Sex Differences in the Development of Anthracycline-Associated Heart Failure.

BACKGROUND: Female sex is frequently cited as a risk factor for anthracycline cardiotoxicity based on pediatric data, but the role of sex in the development of cardiotoxicity has not been clearly established in adults. OBJECTIVES: To assess the effect of female sex on the development of incident heart failure (HF) in adult patients treated with anthracyclines. METHODS: This was a retrospective cohort study of 1525 adult patients with no prior history of HF or cardiomyopathy who were treated with anthracyclines between 1992 and 2019. The primary outcome was new HF within 5 years of the first dose of anthracyclines. The effect of sex was assessed using Cox proportional hazards and competing risk models. RESULTS: Over a median (IQR) follow-up of 1.02 (0.30-3.01) years, 4.78% of patients developed HF (44 men and 29 women). Female sex was not associated with the primary outcome in a multivariable Cox proportional hazards model (HR 0.87; 95% CI 0.53-1.43; P = 0.58). Similar results were observed in a multivariable model accounting for the competing risk of death (HR 0.94; 95% CI 0.39-2.25; P = 0.88). Age, coronary artery disease and hematopoietic stem cell transplant were associated with the primary outcome in a multivariable Cox proportional hazards model. Age and body mass index were associated with the primary outcome in a multivariable competing risk model. CONCLUSIONS: In this large, single-center, retrospective cohort study, female sex was not associated with incident HF in adult patients treated with anthracyclines. CONDENSED ABSTRACT: Female sex is frequently cited as a risk factor for anthracycline cardiotoxicity based on pediatric data, but the role of sex in the development of cardiotoxicity has not been clearly established in adults. In this retrospective cohort study, we assessed the effect of female sex on the development of incident heart failure in adult patients treated with anthracyclines. Using Cox proportional hazards and competing risk regression models, we found that there was no association between female sex and heart failure after treatment with anthracyclines.

Minimizing Radiation Dose Outliers Through Systematic Analysis, Computed Tomography Technologist Education, and Standardized System Solutions.

OBJECTIVES: The aims of the study were to systematically analyze causes for radiation dose outliers in emergency department noncontrast head computed tomographies (CTs), to develop and implement standardized system solutions, and audit program success for an extended period of time. METHODS: This study was performed in a large, tertiary academic center between January 2015 and September 2017. Four phases of radiation dose data collection with and without prior interventions were performed. Outliers from 5 categories were evaluated for appropriateness in consensus by 2 radiologists and a senior CT technologist. RESULTS: A total of 275 ± 15 CTs per period were included. Fifty-seven inappropriate scanning parameters were found in 24 (9%) of 254 CTs during the first analysis, 27 in 21 (7%) of 290 CTs during the second, 11 in 10 (4%) of 276 during the third assessment (P = 0.006). After a year without additional intervention, the number remained stable (14 in 11/281 CTs, 4%). CONCLUSIONS: Combining a dose reporting system, individual case analysis, staff education, and implementation of systemic solutions lead to sustained radiation exposure improvement.

Clinical Outcomes of Patients with Porcelain Gallbladder Diagnosed on CT.

PURPOSE: To evaluate diagnostic accuracy and clinical outcomes of patients with porcelain gallbladder (GB) diagnosed on CT. MATERIALS AND METHODS: In this IRB-approved, HIPAA-compliant study, consecutive patients with porcelain gallbladder reported on CT between December 1, 2000 and August 31, 2017 in a tertiary academic center were included. Two radiologists independently reviewed CT images and confirmed presence of porcelain gallbladder. Discrepant cases were reviewed by a third reader with 15 years of experience in abdominal imaging. Porcelain gallbladder diagnosis was confirmed by surgery/pathology or follow-up imaging. RESULTS: Porcelain gallbladder was reported in 133 CT studies. Radiologist review and pathology results confirmed porcelain gallbladder in 90/133 (68%) patients (age 71.6 ± 13.8 years, 57% female). One third (42/133; 32%) of CT reports were false positive; 1/133 (1%) remained indeterminate. Frequent pitfalls included: stones filling the whole gallbladder lumen in 39/43 (91%), sludge in 3/43 (7%) and mucosal enhancement in 2/43 (5%). In 5/90 (6%) patients, concurrent gallbladder cancer was noted on the initial CT scan. No patient developed subsequent gallbladder cancer during 6.6 ± 4.6 years of follow-up. One third (30/90, 33%) of patients with porcelain gallbladder have deceased during the follow-up period, all from unrelated causes. CONCLUSION: At the time of presentation with porcelain gallbladder, 6% of patients had concurrent gallbladder cancer. No patient with porcelain gallbladder alone diagnosed on CT developed gallbladder cancer during a follow-up of 6.6 ± 4.6 years. Porcelain gallbladder is overcalled on CT, with frequent pitfalls including gallstones filling the whole gallbladder lumen, sludge, and wall enhancement.

Dependent lesion positioning at CT-guided lung biopsy to reduce risk of pneumothorax.

OBJECTIVES: To evaluate the impact of patient positioning during CT-guided lung biopsy on patients' outcomes. METHODS: In this retrospective, IRB-approved, HIPAA-compliant study, consecutive CT-guided lung biopsies performed on 5/1/2015-12/26/2017 were included. Correlation between incidence of pneumothorax, chest tube placement, pulmonary bleeding with patient, and procedure characteristics was evaluated. Lesion-trachea-table angle (LTTA) was defined as an angle between the lesion, trachea, and horizontal line parallel to the table. Lesion above trachea has a positive LTTA. Univariate and multivariate logistic regression analysis was performed. RESULTS: A total of 423 biopsies in 409 patients (68 ± 11 years, 231/409, 56% female) were included in the study. Pneumothorax occurred in 83/423 (20%) biopsies with chest tube placed in 11/423 (3%) biopsies. Perilesional bleeding occurred in 194/423 (46%) biopsies and hemoptysis in 20/423 (5%) biopsies. Univariate analysis showed an association of pneumothorax with smaller lesions (p = 0.05), positive LTTA (p = 0.002), and lesions not attached to pleura (p = 0.026) with multivariate analysis showing lesion size and LTTA to be independent risk factors. Univariate analysis showed an association of increased pulmonary bleeding with smaller lesions (p < 0.001), no attachment to the pleura (p < 0.001), needle throw < 16 mm (p = 0.05), and a longer needle path (p < 0.001). Multivariate analysis showed lesion size, a longer needle path, and lesions not attached to the pleura to be independently associated with perilesional bleeding. Risk factors for hemoptysis were longer needle path (p = 0.002), no attachment to the pleura (p = 0.03), and female sex (p = 0.04). CONCLUSIONS: Interventional radiologists can reduce the pneumothorax risk during the CT-guided biopsy by positioning the biopsy site below the trachea. KEY POINTS: • Positioning patient with lesion to be below the trachea for the CT-guided lung biopsy results in lower rate of pneumothorax, as compared with the lesion above the trachea. • Positioning patient with lesion to be below the trachea for the CT-guided lung biopsy does not affect rate of procedure-associated pulmonary hemorrhage or hemoptysis.

Single-Energy Retrospective Metal Artifact Reduction Using Adaptive Thresholding for Metal Implants in the Abdomen and Pelvis.

OBJECTIVE: To assess impact of single-energy metal artifact reduction (SEMAR) algorithm utilizing retrospective adaptive thresholding in reducing metal artifacts in the abdomen and pelvis. METHODS: In this prospective institutional review board-approved, Health Insurance Portability and Accountability Act-compliant study, 90 patients with various metals (n = 97) on computed tomography of abdomen and pelvis (Canon Medical, Aquilion ONE and PRIME) scanned 07/2017-09/2018 with SEMAR retrospectively applied were included. Density was measured in the near and far field to the metals. Density standard deviation (SD), representing artifact severity, was compared with and without SEMAR applied. Two trained human observers independently evaluated severity of artifacts on a five-point scale (0, no artifact; 5, severe artifact). RESULTS: The SEMAR significantly decreased artifact severity in the near field of high-density metal implants (SD of 204 ± 101HU without vs. 66 ± 40HU with SEMAR, P < 0.001). In the far field, the artifact severity was similar (40 ± 31HU without vs. 36 ± 27HU with SEMAR, P = 0.41). Artifact severity was decreased adjacent to low-density metal in the near field (SD of 86 ± 56HU without vs 49 ± 30HU with SEMAR, P < 0.001). In the far field to the low-density metals artifact severity was similar (33 ± 29HU without vs. 31 ± 27HU with SEMAR, P = 0.79). Subjectively, artifacts severity decreased for high-density metals in near field by 1.3 ± 1.0, and in far field by 0.7 ± 0.7 and for low-density metals in the near field by 0.7 ± 1.0, far field 0.4 ± 0.5, all P < 0.05. CONCLUSIONS: The SEMAR retrospective algorithm with adaptive thresholding subjectively and objectively reduced near-field artifacts generated by high- and low-density metals.

Fluoropyrimidine-Associated Cardiotoxicity: A Retrospective Case-Control Study.

BACKGROUND: The fluoropyrimidines, 5-fluorouracil (5-FU) and capecitabine, are commonly used chemotherapeutic agents that have been associated with coronary vasospasm. METHODS: In this retrospective case-control study, we identified patients at our institution who received 5-FU or capecitabine in 2018. We compared characteristics of patients who experienced cardiotoxicity with controls. We described phenotypes and outcomes of cardiotoxic cases. RESULTS: We identified 177 patients who received fluoropyrimidines. After adjudication, 4.5% of the cohort met the criteria for cardiovascular toxicity. Coronary artery disease was more common among cases than controls (38% vs. 7%, p < .05). There was also a trend toward increased prevalence of cardiovascular risk factors in cases compared with controls. Most cardiotoxic cases had chest pain, although a minority of cases presented with nonischemic cardiomyopathy. CONCLUSION: Cardiotoxicity phenotypes associated with fluoropyrimidine use are not limited to coronary vasospasm. Cardiac risk factors and ischemic heart disease were highly prevalent among patients with cardiotoxicity.

Impact of Preprocedure Time-Out Checklist for Computed Tomography-Guided Procedures on Workflow and Patient Safety.

OBJECTIVE: The objective of this study was to assess the impact of preprocedural time-out on workflow and patient safety in computed tomography (CT)-guided procedures. METHODS: In this institutional review board-approved, Health Insurance Portability and Accountability Act-compliant study, preprocedure time-out was assessed by an independent observer in CT-guided procedures performed from January 16, 2018, to May 15, 2018. Anonymous survey of 302 radiology team members involved in image-guided procedures about preprocedure time-out was performed using REDCap. RESULTS: Preprocedure time-out for 100 CT-guided procedures (biopsies, drainages, ablations) was observed. Procedures were recruited per observer availability and thus were nonconsecutive and nonrandom. Preprocedure time-out was performed in 100 procedures (100%). Median duration was 60 seconds (interquartile range, 60-71 seconds). Scripted checklist was followed in 52 cases (52/100, 52%). Omissions from the preprocedure time-out were identified in 40 cases (40/100, 40%) and were much more frequent when scripted checklist was not used (30/48 [63%] vs 10/52 [19%], P < 0.005). One case (1/100, 1%) was postponed due to abnormal coagulation parameters discovered during the time-out. Three cases (3/100, 3%) were delayed by 3 minutes to address other safety issues. In additional 14 cases (14/100, 14%), safety issues were raised during the time-out, which were resolved in less than 30 seconds.A total of 137 (45%) of 302 survey responses from 54 radiologists (39%), 55 technologists (40%), and 28 nurses (20%) were received. Forty-eight respondents (48/137, 35%) encountered a procedure that was cancelled or delayed as a result of information identified during time-out. Ninety-six percent (131/137) of respondents stated that time-out improves teamwork, 98% (134/137) stated that it enhances communication between the team members, and 93% (127/137) stated that it identifies and resolves problems and ambiguities. CONCLUSIONS: Scripted preprocedure time-out for CT-guided procedures takes approximately 1 minute to execute and detects safety issues in 18% of cases.