A Proposed Intervention to Decrease Resident-Performed Cataract Surgery Cancellation in a Tertiary Eye Care Center.

BACKGROUND: Cataracts are the leading cause of preventable blindness globally. As a result, competence in cataract surgery is an important component of ophthalmology residency training. Residency programs must optimize the number of cataract surgery cases to train proficient physicians. However, the rate of cataract surgery cancellations is high, and some are canceled because of preventable causes. OBJECTIVE: To evaluate the effect of mandatory on-site preadmission testing, including having a physical examination, on resident-performed cataract surgery cancellation rates. METHODS: For this study, patients scheduled for cataract surgery at the Wills Eye Hospital resident cataract clinic between January 2015 and November 2015 were enrolled and randomized into 2 groups: usual care or intervention. The patients randomized to the usual care group were instructed to complete preadmission testing and to have a physical examination with their primary care physician. The patients randomized to the intervention group were escorted to a Wills Eye Hospital-affiliated cardiologist to complete preadmission testing and to have a physical examination. Patients in both groups received a reminder call before the cataract surgery. RESULTS: A total of 441 patients were included in the study-240 patients in the usual care group and 201 patients in the intervention group. The overall cataract surgery cancellation rate was 14.5%; the rate was 12.4% in the intervention group and 16.3% in the usual care group (P = .28). The patients receiving the intervention were more likely to have preadmission testing and a physical examination than the patients in the usual care arm (P <.001). CONCLUSIONS: Facilitating the completion of preadmission testing for patients decreased the rates of resident-performed cataract surgery cancellation at a Wills Eye Hospital resident clinic and has the potential to improve patient outcomes and prevent blindness.

Novel partial anomalous pulmonary venous connection associated with brain abscess.

BACKGROUND: Right-to-left vascular shunts are associated with brain abscess. CASE REPORT: We present a 47-year-old female with a cryptogenic left thalamic abscess on which Streptococcus mitis grew upon aspiration. Computed tomography of the chest with contrast agent revealed an anomalous connection between the left superior pulmonary and brachiocephalic veins. A right-to-left shunt was confirmed in a transthoracic echocardiogram study in which bubbles were injected into the left arm; this shunt had not previously been noted upon right-arm injection. CONCLUSIONS: We recommend aggressive evaluation for right-to-left shunts in patients who present with cryptogenic brain abscesses. In addition to imaging, this should include a bubble-based study with left-arm saline injection.

Left atrial volume: comparison of 2D and 3D transthoracic echocardiography with ECG-gated CT angiography.

RATIONALE AND OBJECTIVES: Left atrial volume (LAV) measurement by conventional two-dimensional (2D) transthoracic echocardiography (TTE) may be limited by the geometric model, by suboptimal definition of left atrial endocardium, or by chamber foreshortening. Three-dimensional (3D) TTE is posited to eliminate chamber foreshortening, and LAV measurement by 3D TTE should be more reflective of true LAV. The aim of this study was to compare conventional 2D TTE and newer 3D TTE for measurements of LAV to multidetector computed tomographic (MDCT) measurements using automated chamber reconstruction (ACR). MATERIALS AND METHODS: Twenty-two subjects consented to undergo 2D TTE and 3D TTE immediately prior to or following coronary computed tomographic angiography. LAV was calculated from 2D TTE using the area-length method (ALM) and from 3D TTE with the ALM as well as with a 3D model. Electrocardiographically gated coronary computed tomographic angiography was performed in helical mode. LAV was measured using the ALM as well as ACR. RESULTS: LAV was significantly smaller by 2D TTE (80 ± 21 mL) and 3D-TTE (90 ± 24 mL with the ALM, 61 ± 16 mL with the 3D model) compared to MDCT ACR (120 ± 30 mL) (P < .01). Correlation between MDCT ALM and MDCT ACR was excellent (mean Δ = -1.4 ± 14 mL, r = 0.91). Correlation with MDCT ACR was no better for 3D TTE (r = 0.80) than for 2D TTE (r = 0.80). CONCLUSIONS: LAV is underestimated by both 2D TTE and 3D TTE relative to coronary computed tomographic angiography. Excellent agreement between the ALM and ACR with MDCT imaging suggests that the geometric model plays a negligible role in the underestimation of LAV. Underestimation of LAV by echocardiography is likely related to suboptimal definition of left atrial contour.

Underestimation of left atrial size measured with transthoracic echocardiography compared with 3D MDCT.

OBJECTIVE: High-resolution 64-MDCT images of the beating heart can be used for measurement of left atrial volume with 3D chamber reconstruction. The purpose of this study was to correlate measurements of left atrial volume obtained with clinical transthoracic echocardiography (TTE) and measurements obtained with 64-MDCT 3D reconstructions of the left atrium. MATERIALS AND METHODS: Patients who underwent TTE and MDCT within 3 days were identified. TTE images were graded as excellent, good, or suboptimal. Two independent observers calculated estimates of left atrial volume from TTE and 64-MDCT images using 3D chamber reconstructions and conventional geometric assumptions on MDCT echocardiographic views. RESULTS: MDCT estimates of phantom volume on 3D chamber reconstructions agreed with actual volumes within 1.5%. The TTE images of 37 of the 52 patients were judged to be of good or excellent quality and were included in the analysis. Mean left atrial volume measured on 3D chamber reconstructions was 61 +/- 14 mL/m(2). Estimates of left atrial volume obtained with TTE were significantly lower (28 +/- 12 mL/m(2)) than similar estimates obtained with MDCT echocardiographic views (53 +/- 15 mL/m(2)) (p < 0.001). TTE left atrial volume and 3D chamber reconstruction left atrial volume exhibited moderate correlation (r = 0.60-0.70), but the correlation improved when analysis was limited to the 26 studies with excellent-quality TTE images (r = 0.71). MDCT echocardiographic estimates of left atrial volume with the area-length method had excellent correlation (r = 0.89) with and were closest to estimates made on 3D chamber reconstructions. CONCLUSION: Left atrial volume is significantly underestimated on TTE images, and TTE estimates have moderate correlation with left atrial volume measured with MDCT. Measured and estimated left atrial volumes at MDCT can provide important additive prognostic information in the care of patients undergoing MDCT for other reasons. Future studies are needed to obtain normative MDCT measurements of left atrial volume.

Decision analytic model for evaluation of suspected coronary disease with stress testing and coronary CT angiography.

RATIONALE AND OBJECTIVES: The aim of this study was to apply a decision analytic model for the evaluation of coronary artery disease (CAD) to define the optimal utilization of coronary computed tomographic angiography (cCTA) and stress testing. MATERIALS AND METHODS: The model tested in this study assumes that CAD is evaluated with a stress test and/or cCTA and that a patient with positive evaluation results undergoes cardiac catheterization. On the basis of values of sensitivity, specificity, and radiation dose from the published literature and test costs from the Medicare fee schedule, a decision tree model was constructed as a function of disease prevalence. RESULTS: The false-negative rate is lowest when cCTA is used as an isolated test. The false-positive rate is minimized when cCTA is used in combination with stress echocardiography. Effective radiation is minimized by use of stress electrocardiography or stress echocardiography alone or prior to cCTA. When the pretest probability of CAD is low, a strategy that uses stress echocardiography followed by cCTA minimizes the false-positive rate and effective radiation exposure, with relatively low imaging costs and with a false-negative rate only slightly higher than a strategy including stress myocardial scintigraphy. As the pretest probability of CAD increases above 20%, the false-negative rate of stress echocardiography followed by cCTA increases by >5% relative to cCTA alone. CONCLUSION: Effective radiation dose and imaging costs for the workup of CAD may be minimized by an appropriate combination of stress testing and cCTA. A strategy that uses stress echocardiography followed by cCTA is most appropriate for the evaluation of low-risk patients with CAD with a pretest probability < 20%, while cCTA alone may be more appropriate in intermediate-risk patients.