Engaging nurse practitioners and physician assistants to improve patient care and drive productivity in a radiology consult practice at a comprehensive cancer center.

BACKGROUND: The demand for health care in the United States is increasing because of an aging population and an increase in the number of individuals insured. This has led to requests to revamp the primary care infrastructure fundamentally. LOCAL PROBLEM: The optimal use of nurse practitioners (NPs) and physician assistants (PAs) is still a subject of debate, but recently, it was reported that for many medical conditions, NP and PA-managed care outcomes are consistent with physician-managed care outcomes. METHODS: Radiologists' productivity was measured according to relative value units (RVUs)/shift and professional billing changes. Patient care metrics measured were prescribed protocol to patient appointment lead time and number of same-day prescribed imaging protocol changes. INTERVENTIONS: The focus was on radiologists' productivity and patient care for three months before and three months after integrating NP and PA into our abdominal radiology consult service. RESULTS: We observed significant increases in the mean RVUs/shift (15.2 ± 0.9 vs. 6.2 ± 1.8; p = .02), studies read per shift (10.1 ± 0.5 vs. 4.4 ± 1.5; p = .003), revenue per shift hour ($756.20 ± 55.40 vs. $335.40 ± 32.60; p = .007), and protocol prescription to patient appointment lead time (39.3 ± 6.7 days vs. 16.3 ± 2.9 days; p = .005) and saw significant decreases in the mean prescribed CT (19.3 ± 0.6 vs. 3.3 ± 0.6; p = .001) and MRI (11.7 ± 0.6 vs. 8.30 ± 0.12; p = .011) same day protocol changes in NP and PA integrated workflow. CONCLUSIONS: These findings suggest that NP and PA can be effectively integrated into the abdominal radiology consult service, increasing radiologists' productivity and enhancing clinical care.

PAs and NPs improve patient care and productivity in a radiology consult practice.

OBJECTIVE: To evaluate the effects on efficiency and patient care of the addition of physician assistants (PAs) and NPs to the abdominal radiology consult service. METHODS: We obtained radiologist productivity and patient care metrics for 3 months before and 3 months after the integration of PAs and NPs into our consult service. RESULTS: Integrating PAs and NPs into the workflow led to a significant increase in mean RVUs/shift (15.2 ± 0.9 versus 6.2 ± 1.8; P = .02), number of studies read per shift (10.1 ± 0.5 versus 4.4 ± 1.5; P = .003), revenue per shift hour ($756.20 ± $55.40 versus $335.40 ± $132.60; P = .007), protocol prescription to patient appointment lead time (39.3 ± 6.7 versus 16.3 ± 2.9 days; P = .005), and significant decreases in mean CT (19.3% ± 0.6 versus 3.3% ± 0.6; P = .001) and MRI (11.7% ± 0.6 versus 8.3% ± 0.12; P = .011) same-day protocol changes as patient appointments. CONCLUSIONS: PAs and NPs can be effectively integrated into abdominal radiology consult service, increasing the productivity of radiologists, and enhancing clinical care.

In vitro and in vivo investigation of a zonal microstructured scaffold for osteochondral defect repair.

Articular cartilage is comprised of zones that vary in architecture, extracellular matrix composition, and mechanical properties. Here, we designed and engineered a porous zonal microstructured scaffold from a single biocompatible polymer (poly [ϵ-caprolactone]) using multiple fabrication strategies: electrospinning, spherical porogen leaching, directional freezing, and melt electrowriting. With this approach we mimicked the zonal structure of articular cartilage and produced a stiffness gradient through the scaffold which aligns with the mechanics of the native tissue. Chondrocyte-seeded scaffolds accumulated extracellular matrix including glycosaminoglycans and collagen II over four weeks in vitro. This prompted us to further study the repair efficacy in a skeletally mature porcine model. Two osteochondral lesions were produced in the trochlear groove of 12 animals and repaired using four treatment conditions: (1) microstructured scaffold, (2) chondrocyte seeded microstructured scaffold, (3) MaioRegen™, and (4) empty defect. After 6 months the defect sites were harvested and analyzed using histology, micro computed tomography, and Raman microspectroscopy mapping. Overall, the scaffolds were retained in the defect space, repair quality was repeatable, and there was clear evidence of osteointegration. The repair quality of the microstructured scaffolds was not superior to the control based on histological scoring; however, the lower score was biased by the lack of histological staining due to the limited degradation of the implant at 6 months. Longer follow up studies (e.g., 1 yr) will be required to fully evaluate the efficacy of the microstructured scaffold. In conclusion, we found consistent scaffold retention, osteointegration, and prolonged degradation of the microstructured scaffold, which we propose may have beneficial effects for the long-term repair of osteochondral defects.

A multilayered scaffold for regeneration of smooth muscle and connective tissue layers.

Tissue regeneration often requires recruitment of different cell types and rebuilding of two or more tissue layers to restore function. Here, we describe the creation of a novel multilayered scaffold with distinct fiber organizations-aligned to unaligned and dense to porous-to template common architectures found in adjacent tissue layers. Electrospun scaffolds were fabricated using a biodegradable, tyrosine-derived terpolymer, yielding densely-packed, aligned fibers that transition into randomly-oriented fibers of increasing diameter and porosity. We demonstrate that differently-oriented scaffold fibers direct cell and extracellular matrix (ECM) organization, and that scaffold fibers and ECM protein networks are maintained after decellularization. Smooth muscle and connective tissue layers are frequently adjacent in vivo; we show that within a single scaffold, the architecture supports alignment of contractile smooth muscle cells and deposition by fibroblasts of a meshwork of ECM fibrils. We rolled a flat scaffold into a tubular construct and, after culture, showed cell viability, orientation, and tissue-specific protein expression in the tube were similar to the flat-sheet scaffold. This scaffold design not only has translational potential for reparation of flat and tubular tissue layers but can also be customized for alternative applications by introducing two or more cell types in different combinations.

First-in-Human Study with Eight Patients Using an Absorbable Vena Cava Filter for the Prevention of Pulmonary Embolism.

PURPOSE: To prospectively evaluate the initial human experience with an absorbable vena cava filter designed for transient protection from pulmonary embolism (PE). MATERIALS AND METHODS: This was a prospective, single-arm, first-in-human study of 8 patients with elevated risk of venous thromboembolism (VTE). Seven absorbable IVC filters (made of polydioxanone that breaks down into H2O and CO2 in 6 mo) were placed prophylactically before orthopedic (n = 5) and gynecologic (n = 2) surgeries, and 1 was placed in a case of deep vein thrombosis. Subjects underwent CT cavography and abdominal radiography before and 5, 11, and 36 weeks after filter placement to assess filter migration, embolization, perforation, and caval thrombosis and/or stenosis. Potential PE was assessed immediately before and 5 weeks after filter placement by pulmonary CT angiography. RESULTS: No symptomatic PE was reported throughout the study or detected at the planned 5-week follow-up. No filter migration was detected based on the fixed location of the radiopaque markers (attached to the stent section of the filter) relative to the vertebral bodies. No filter embolization or caval perforation was detected, and no caval stenosis was observed. Throughout the study, no filter-related adverse events were reported. CONCLUSIONS: Implantation of an absorbable vena cava filter in a limited number of human subjects resulted in 100% clinical success. One planned deployment was aborted as a result of stenotic pelvic veins, resulting in 89% technical success. No PE or filter-related adverse events were observed.

Evaluation of Cancer Patients With Suspected Pulmonary Embolism: Performance of the American College of Physicians Guideline.

BACKGROUND: Accurate risk stratification of pulmonary embolism (PE) can reduce unnecessary imaging. We investigated the extent to which the American College of Physicians (ACP) guideline for evaluation of patients with suspected PE could be applied to cancer patients in the emergency department of a comprehensive cancer center. MATERIALS AND METHODS: Data from cancer patients who underwent CT pulmonary angiography (CTPA) between August 1, 2015, and October 31, 2015, were collected. We assessed each patient's diagnostic workup for its adherence to the ACP guideline in terms of clinical risk stratification and age-adjusted d-dimer level and the degree to which these factors were associated with PE. RESULTS: Of the 380 patients identified, 213 (56%) underwent CTPA indicated per the ACP guideline, and 78 (21%) underwent CTPA not indicated per the guideline. Only one of the patients who underwent nonindicated CTPA had a PE. Fifty-seven patients underwent unnecessary d-dimer evaluation, and 71 patients with negative d-dimer test results underwent nonindicated CTPA. PEs were found in 6 of 108 (6%) low-risk patients, 22 of 219 (10%) intermediate-risk patients, and 13 of 53 (25%) high-risk patients. The ACP guideline had negative predictive value of 99% (95% confidence interval: 93%-100%) and sensitivity of 97% (95% confidence interval: 86%-100%) in predicting PE. CONCLUSION: The ACP guideline has good sensitivity for detecting PE in cancer patients and thus can be applied in this population. Compliance with the ACP guideline when evaluating cancer patients with suspected PE could reduce the use of unnecessary imaging and laboratory studies.

A step toward engineering thick tissues: Distributing microfibers within 3D printed frames.

Microfiber mats for tissue engineering scaffolds support cell growth, but are limited by poor cell infiltration and nutrient transport. Three-dimensional printing, specifically fused deposition modeling (FDM), can rapidly produce customized constructs, but macroscopic porosity resulting from low resolution reduces cell seeding efficiency and prevents the formation of continuous cell networks. Here we describe the fabrication of hierarchical scaffolds that integrate a fibrous microenvironment with the open macropore structure of FDM. Biodegradable tyrosine-derived polycarbonate microfibers were airbrushed iteratively between layers of 3D printed support structure following optimization. Confocal imaging showed layers of airbrushed fiber mats supported human dermal fibroblast growth and extracellular matrix development throughout the scaffold. When implanted subcutaneously, hierarchical scaffolds facilitated greater cell infiltration and tissue formation than airbrushed fiber mats. Fibronectin matrix assembled in vitro throughout the hierarchical scaffold survived decellularization and provided a hybrid substrate for recellularization with mesenchymal stromal cells. These results demonstrate that by combining FDM and airbrushing techniques we can engineer customizable hierarchical scaffolds for thick tissues that support increased cell growth and infiltration.

Randomized Controlled Study of an Absorbable Vena Cava Filter in a Porcine Model.

PURPOSE: To compare the safety and efficacy of an absorbable inferior vena cava (IVC) filter and a benchmark IVC filter in a porcine model. MATERIALS AND METHODS: A randomized controlled Good Laboratory Practice study was performed in Domestic Yorkshire cross swine. Sixteen swine were implanted with an absorbable IVC filter (test device; Adient Medical, Pearland, Texas); 8 were implanted with a benchmark metal IVC filter (control device; Cook Medical, Bloomington, Indiana). All animals underwent rotational digital subtraction pulmonary angiography and cavography (anteroposterior and lateral) before filter deployment and 5 and 32 weeks after deployment. Terminal procedures and necropsy were performed at 32 weeks. The IVC, heart, lungs, liver, and kidneys were harvested at necropsy. The reported randomized controlled GLP animal study was conducted at Synchrony Labs, Durham, North Carolina. RESULTS: One animal died early in the test cohort of a recurring hemorrhage at the femoral access site resulting from a filter placement complication. All other animals remained clinically healthy throughout the study. No pulmonary embolism was detected at the 5- and 32-week follow-up visits. The absorbable filter subjects experienced less caval wall perforation (0% vs 100%) and thrombosis (0% vs 75%). The control device routinely perforated the IVC and occasionally produced collateral trauma to adjacent tissues (psoas muscle and aorta). The veins implanted with the absorbable filter were macroscopically indistinguishable from normal adjacent veins at 32 weeks except for the presence of radiopaque markers. Nontarget tissues showed no device-related changes. CONCLUSIONS: Implantation of the absorbable IVC filter in swine proved safe with no pulmonary emboli detected. There was complete to near-complete resorption of the filter polymer by 32 weeks with restoration of the normal appearance and structure of the IVC.

A method to deliver patterned electrical impulses to Schwann cells cultured on an artificial axon.

Information from the brain travels back and forth along peripheral nerves in the form of electrical impulses generated by neurons and these impulses have repetitive patterns. Schwann cells in peripheral nerves receive molecular signals from axons to coordinate the process of myelination. There is evidence, however, that non-molecular signals play an important role in myelination in the form of patterned electrical impulses generated by neuronal activity. The role of patterned electrical impulses has been investigated in the literature using co-cultures of neurons and myelinating cells. The co-culturing method, however, prevents the uncoupling of the direct effect of patterned electrical impulses on myelinating cells from the indirect effect mediated by neurons. To uncouple these effects and focus on the direct response of Schwann cells, we developed an in vitro model where an electroconductive carbon fiber acts as an artificial axon. The fiber provides only the biophysical characteristics of an axon but does not contribute any molecular signaling. In our "suspended wire model", the carbon fiber is suspended in a liquid media supported by a 3D printed scaffold. Patterned electrical impulses are generated by an Arduino 101 microcontroller. In this study, we describe the technology needed to set-up and eventually replicate this model. We also report on our initial in vitro tests where we were able to document the adherence and ensheath of human Schwann cells to the carbon fiber in the presence of patterned electrical impulses (hSCs were purchased from ScienCell Research Laboratories, Carlsbad, CA, USA; ScienCell fulfills the ethic requirements, including donor's consent). This technology will likely make feasible to investigate the response of Schwann cells to patterned electrical impulses in the future.

Hypothermia in adults: A strategy for detection and Tx.

Whether hypothermia is a result of environmental exposure or illness, it's important to identify predictable patterns of physiologic response and focus on proper Tx.

"Ruffled border" formation on a CaP-free substrate: A first step towards osteoclast-recruiting bone-grafts materials able to re-establish bone turn-over.

Osteoclasts are large multinucleated giant cells that actively resorb bone during the physiological bone turnover (BTO), which is the continuous cycle of bone resorption (by osteoclasts) followed by new bone formation (by osteoblasts). Osteoclasts secrete chemotactic signals to recruit cells for regeneration of vasculature and bone. We hypothesize that a biomaterial that attracts osteoclasts and re-establishes BTO will induce a better healing response than currently used bone graft materials. While the majority of bone regeneration efforts have focused on maximizing bone deposition, the novelty in this approach is the focus on stimulating osteoclastic resorption as the starter for BTO and its concurrent new vascularized bone formation. A biodegradable tyrosine-derived polycarbonate, E1001(1k), was chosen as the polymer base due to its ability to support bone regeneration in vivo. The polymer was functionalized with a RGD peptide or collagen I, or blended with ß-tricalcium phosphate. Osteoclast attachment and early stages of active resorption were observed on all substrates. The transparency of E1001(1k) in combination with high resolution confocal imaging enabled visualization of morphological features of osteoclast activation such as the formation of the "actin ring" and the "ruffled border", which previously required destructive forms of imaging such as transmission electron microscopy. The significance of these results is twofold: (1) E1001(1k) is suitable for osteoclast attachment and supports osteoclast maturation, making it a base polymer that can be further modified to optimize stimulation of BTO and (2) the transparency of this polymer makes it a suitable analytical tool for studying osteoclast behavior.

Culturing functional pancreatic islets on α5-laminins and curative transplantation to diabetic mice.

The efficacy of islet transplantation for diabetes treatment suffers from lack of cadaver-derived islets, islet necrosis and long transfer times prior to transplantation. Here, we developed a method for culturing mouse and human islets in vitro on α5-laminins, which are natural components of islet basement membranes. Adhering islets spread to form layers of 1-3 cells in thickness and remained normoxic and functional for at least 7 days in culture. In contrast, spherical islets kept in suspension developed hypoxia and central necrosis within 16 h. Transplantation of 110-150 mouse islets cultured on α5-laminin-coated polydimethylsiloxane membranes for 3-7 days normalized blood glucose already within 3 days in mice with streptozotocin-induced diabetes. RNA-sequencing of isolated and cultured mouse islets provided further evidence for the adhesion and spreading achieved with α5-laminin. Our results suggest that use of such in vitro expanded islets may significantly enhance the efficacy of islet transplantation treatment for diabetes.

Advancing biomaterials towards biological complexity.

3D printing has the potential for on-demand, patient-specific devices with high structural complexity. However, the tools and biomaterials most widely available for 3D printing are largely limited to fused deposition modelling (FDM) with commodity plastics that lack cell-scale resolution and biological cues. The lack of biologically active materials, also called 'bioinks,' is a key issue that limits the ability to produce engineered tissues, tissue interfaces and functional organs. While advances are being made in the field of biomaterials, current technologies can be combined into hybrid systems that overcome the limitations of a single technique or material, as described in this article.

Time Is Not on Our Side: How Radiology Practices Should Manage Customer Queues.

As health care shifts toward patient-centered care, wait times have received increasing scrutiny as an important metric for patient satisfaction. Long queues form when radiology practices inefficiently service their customers, leading to customer dissatisfaction and a lower perception of value. This article describes a four-step framework for radiology practices to resolve problematic queues: (1) analyze factors contributing to queue formation; (2) improve processes to reduce service times; (3) reduce variability; (4) address the psychology of queues.

Safety and Efficacy of an Absorbable Filter in the Inferior Vena Cava to Prevent Pulmonary Embolism in Swine.

Purpose To evaluate the immediate and long-term safety as well as thrombus-capturing efficacy for 5 weeks after implantation of an absorbable inferior vena cava (IVC) filter in a swine model. Materials and Methods This study was approved by the institutional animal care and use committee. Eleven absorbable IVC filters made from polydioxanone suture were deployed via a catheter in the IVC of 11 swine. Filters remained in situ for 2 weeks (n = 2), 5 weeks (n = 2), 12 weeks (n = 2), 24 weeks (n = 2), and 32 weeks (n = 3). Autologous thrombus was administered from below the filter in seven swine from 0 to 35 days after filter placement. Fluoroscopy and computed tomography follow-up was performed after filter deployment from weeks 1-6 (weekly), weeks 7-20 (biweekly), and weeks 21-32 (monthly). The infrarenal IVC, lungs, heart, liver, kidneys, and spleen were harvested at necropsy. Continuous variables were evaluated with a Student t test. Results There was no evidence of IVC thrombosis, device migration, caval penetration, or pulmonary embolism. Gross pathologic analysis showed gradual device resorption until 32 weeks after deployment. Histologic assessment demonstrated neointimal hyperplasia around the IVC filter within 2 weeks after IVC filter deployment with residual microscopic fragments of polydioxanone suture within the caval wall at 32 weeks. Each iatrogenic-administered thrombus was successfully captured by the filter until resorbed (range, 1-4 weeks). Conclusion An absorbable IVC filter can be safely deployed in swine and resorbs gradually over the 32-week testing period. The device is effective for the prevention of pulmonary embolism for at least 5 weeks after placement in swine. © RSNA, 2017.

Preventing tissue fibrosis by local biomaterials interfacing of specific cryptic extracellular matrix information.

Matrix metalloproteinases (MMPs) contribute to the breakdown of tissue structures such as the basement membrane, promoting tissue fibrosis. Here we developed an electrospun membrane biofunctionalized with a fragment of the laminin ß1-chain to modulate the expression of MMP2 in this context. We demonstrate that interfacing of the ß1-fragment with the mesothelium of the peritoneal membrane via a biomaterial abrogates the release of active MMP2 in response to transforming growth factor ß1 and rescues tissue integrity ex vivo and in vivo in a mouse model of peritoneal fibrosis. Importantly, our data demonstrate that the membrane inhibits MMP2 expression. Changes in the expression of epithelial-to-mesenchymal transition (EMT)-related molecules further point towards a contribution of the modulation of EMT. Biomaterial-based presentation of regulatory basement membrane signals directly addresses limitations of current therapeutic approaches by enabling a localized and specific method to counteract MMP2 release applicable to a broad range of therapeutic targets.

Quality and Value of Subspecialty Reinterpretation of Thoracic CT Scans of Patients Referred to a Tertiary Cancer Center.

INTRODUCTION: Patients referred to tertiary cancer centers often present with imaging studies performed and interpreted at other health care institutions. Although reinterpretation of imaging performed at another health care institution can reduce repeat imaging, unnecessary radiation dose, and cost, the benefit is uncertain. The purpose of this study is to evaluate the quality of initial imaging studies of patients seeking a second opinion at a tertiary cancer center, to compare the accuracy of initial interpretations to reinterpretations performed by subspecialty trained radiologists at a tertiary oncologic center, and to determine the potential impact on patient management. METHODS: An institutional review board-approved retrospective, single-institution database review was performed in 120 new patients presenting to the thoracic surgery clinics at our institution from 2010 through 2013, with initial chest CTs performed at another institution. Two thoracic radiologists blinded to the interpretation independently assessed the quality and performed a reinterpretation of 52 CTs. Fisher's exact tests were used to compare the frequency with which clinically important staging parameters appeared in the reinterpretations and initial reports. Discrepancies between the reinterpretations and initial interpretations were adjudicated independently by two thoracic radiologists at different tertiary cancer institutions to determine which interpretations were more accurate. The impact of discrepancies on clinical management was evaluated based on National Comprehensive Cancer Network guidelines. RESULTS: Of the 52 CTs, 32 (62%) were of inadequate image quality for staging. In 17 of 52 (33%), discrepancies were identified between reinterpretations and initial interpretations. For discrepancies, the reinterpretation was judged to be more accurate for staging than the initial interpretation. In nine of these patients, staging parameters were omitted in the initial interpretations that precluded adequate staging. In the remaining eight patients, six were upstaged, one was downstaged, and one was unchanged by the reinterpretation. CONCLUSIONS: Imaging studies from outside institutions are of variable image quality and often not adequate for appropriate staging of thoracic malignancies. Reinterpretation can decrease repeat imaging and associated technical costs. Additionally, the accuracy of staging is improved by reinterpretation of CTs by subspecialty trained radiologists and can significantly impact clinical management.

Use of an Online Education Platform to Enhance Patients' Knowledge About Radiation in Diagnostic Imaging.

PURPOSE: The aim of this study was to compare the impact of a digital interactive education platform and standard paper-based education on patients' knowledge regarding ionizing radiation. METHODS: Beginning in January 2015, patients at a tertiary cancer center scheduled for diagnostic imaging procedures were randomized to receive information about ionizing radiation delivered through a web-based interactive education platform (interactive education group), the same information in document format (document education group), or no specialized education (control group). Patients who completed at least some education and control group patients were invited to complete a knowledge assessment; interactive education patients were invited to provide feedback about satisfaction with their experience. RESULTS: A total of 2,226 patients participated. Surveys were completed by 302 of 745 patients (40.5%) participating in interactive education, 488 of 993 (49.1%) participating in document education, and 363 of 488 (74.4%) in the control group. Patients in the interactive education group were significantly more likely to say that they knew the definition of ionizing radiation, outperformed the other groups in identifying which imaging examinations used ionizing radiation, were significantly more likely to identify from a list which imaging modality had the highest radiation dose, and tended to perform better when asked about the tissue effects of radiation in diagnostic imaging, although this difference was not significant. In the interactive education group, 84% of patients were satisfied with the experience, and 79% said that they would recommend the program. CONCLUSIONS: Complex information on a highly technical subject with personal implications for patients may be conveyed more effectively using electronic platforms, and this approach is well accepted.