White Paper: Best Practices in the Communication and Management of Actionable Incidental Findings in Emergency Department Imaging.

PURPOSE: Actionable incidental findings (AIFs) are common in radiologic imaging. Imaging is commonly performed in emergency department (ED) visits, and AIFs are frequently encountered, but the ED presents unique challenges for communication and follow-up of these findings. The authors formed a multidisciplinary panel to seek consensus regarding best practices in the reporting, communication, and follow-up of AIFs on ED imaging tests. METHODS: A 15-member panel was formed, nominated by the ACR and American College of Emergency Physicians, to represent radiologists, emergency physicians, patients, and those involved in health care systems and quality. A modified Delphi process was used to identify areas of best practice and seek consensus. The panel identified four areas: (1) report elements and structure, (2) communication of findings with patients, (3) communication of findings with clinicians, and (4) follow-up and tracking systems. A survey was constructed to seek consensus and was anonymously administered in two rounds, with a priori agreement requiring at least 80% consensus. Discussion occurred after the first round, with readministration of questions where consensus was not initially achieved. RESULTS: Consensus was reached in the four areas identified. There was particularly strong consensus that AIFs represent a system-level issue, with need for approaches that do not depend on individual clinicians or patients to ensure communication and completion of recommended follow-up. CONCLUSIONS: This multidisciplinary collaboration represents consensus results on best practices regarding the reporting and communication of AIFs in the ED setting.

Anion-exchange membranes with internal microchannels for water control in CO2 electrolysis.

Electrochemical reduction of carbon dioxide (CO2R) poses substantial promise to convert abundant feedstocks (water and CO2) to value-added chemicals and fuels using solely renewable energy. However, recent membrane-electrode assembly (MEA) devices that have been demonstrated to achieve high rates of CO2R are limited by water management within the cell, due to both consumption of water by the CO2R reaction and electro-osmotic fluxes that transport water from the cathode to the anode. Additionally, crossover of potassium (K+) ions poses concern at high current densities where saturation and precipitation of the salt ions can degrade cell performance. Herein, a device architecture incorporating an anion-exchange membrane (AEM) with internal water channels to mitigate MEA dehydration is proposed and demonstrated. A macroscale, two-dimensional continuum model is used to assess water fluxes and local water content within the modified MEA, as well as to determine the optimal channel geometry and composition. The modified AEMs are then fabricated and tested experimentally, demonstrating that the internal channels can both reduce K+ cation crossover as well as improve AEM conductivity and therefore overall cell performance. This work demonstrates the promise of these materials, and operando water-management strategies in general, in handling some of the major hurdles in the development of MEA devices for CO2R.

A New American University Model for Training the Future MCH Workforce Through a Translational Research Team.

OBJECTIVES: To describe the process of developing and implementing experiential learning through translational research teams that engage diverse undergraduate and graduate students. METHODS: After a college redesign, translational research teams were developed to foster multidisciplinary research and better integrate students with faculty research, community, and clinical activities. Three primary approaches were used to engage undergraduate and graduate students in the maternal and child health translational research team (MCH TrT). These included an undergraduate experiential learning course; participation in translational research team meetings and events; and mentorship activities including graduate student theses and supplementary projects. RESULTS: Since 2019, a total of 56 students have engaged with the MCH translational research team. The majority (64%) of students engaging in translational research were undergraduates. Racial and ethnic diversity was evident with 16% Latinx, 14% Black/African American, 12% Asian, 10% two or more races, and 4% Native American or Native Hawaiian. A large proportion (42%) of students indicated that they were first-generation college students, while 24% indicated they had a disability. Five themes emerged from student feedback about their involvement in the experiential learning course: the value of translational research, development of research skills, collaboration, practice development, and value for community partners. CONCLUSIONS FOR PRACTICE: Through an MCH translational research team, we have established a pathway to enhance diversity among the MCH workforce which will increase recruitment and retention of underrepresented groups, and ultimately improve MCH research and practice.

The impact of regional STEMI systems on protocol use and quality improvement initiatives in community hospitals without cardiac catheterization laboratories.

Study objective: Since the 1990s, national guidelines have recommended hospitals develop STEMI treatment protocols and monitor quality. A 2003 survey of Minnesota hospitals without cardiac catheterization laboratories (CCL) found <2/3 had STEMI protocols, <50% had a quality assessment (QA) process, and protocols in existence were incomplete. We evaluated temporal changes in STEMI processes in relationship to changes in mortality. Design setting and participants: Follow-up surveys were mailed to emergency departments at 108 Minnesota hospitals without CCL. Results: Among 87% of responding hospitals, 89% had formal protocols or guidelines for STEMI management compared to 63% in 2003 (p < 0.001). In 2010, 67% of hospitals had triage/transfer criteria and 15% of hospitals used protocols for transfer decisions, compared to only 8% (p < 0.001) and 1% (p = 0.098), respectively, in 2003. The percentage of hospitals transferring patients with STEMI from the emergency department increased from 23% in 2003 to 56% in 2010 (p < 0.001). During this time, age-adjusted acute MI mortality rate in Minnesota decreased 33% and was more pronounced in areas with regional STEMI systems. Conclusions: Since 2003, utilization of STEMI guidelines, protocols, and standing orders in Minnesota hospitals without CCL has markedly improved with <10% of hospitals lacking specific STEMI management protocols. The majority of hospitals routinely transfer patients with STEMI for primary PCI and have comprehensive QA processes. This improvement was stimulated by regional STEMI systems, further supporting the current class I recommendation for STEMI systems of care in current guidelines. The decline in Minnesota STEMI mortality paralleled the growth of regional STEMI systems.

Revealing Nanoscale Chemical Heterogeneities in Polycrystalline Mo-BiVO4 Thin Films.

The activity of polycrystalline thin film photoelectrodes is impacted by local variations of the material properties due to the exposure of different crystal facets and the presence of grain/domain boundaries. Here a multi-modal approach is applied to correlate nanoscale heterogeneities in chemical composition and electronic structure with nanoscale morphology in polycrystalline Mo-BiVO4 . By using scanning transmission X-ray microscopy, the characteristic structure of polycrystalline film is used to disentangle the different X-ray absorption spectra corresponding to grain centers and grain boundaries. Comparing both spectra reveals phase segregation of V2 O5 at grain boundaries of Mo-BiVO4 thin films, which is further supported by X-ray photoelectron spectroscopy and many-body density functional theory calculations. Theoretical calculations also enable to predict the X-ray absorption spectral fingerprint of polarons in Mo-BiVO4 . After photo-electrochemical operation, the degraded Mo-BiVO4 films show similar grain center and grain boundary spectra indicating V2 O5 dissolution in the course of the reaction. Overall, these findings provide valuable insights into the degradation mechanism and the impact of material heterogeneities on the material performance and stability of polycrystalline photoelectrodes.

Heterogenized Pyridine-Substituted Cobalt(II) Phthalocyanine Yields Reduction of CO2 by Tuning the Electron Affinity of the Co Center.

Conversion of CO2 to reduced products is a promising route to alleviate irreversible climate change. Here we report the synthesis of a Co-based phthalocyanine with pyridine moieties (CoPc-Pyr), which is supported on a carbon electrode and shows Faradaic efficiency ∼90% for CO at 490 mV of overpotential (-0.6 V vs reversible hydrogen electrode (RHE)). In addition, its catalytic activity at -0.7 V versus RHE surpasses other Co-based molecular and metal-organic framework catalysts for CO2 reduction at this bias. Density functional theory calculations show that pyridine moieties enhance CO2 adsorption and electron affinity of the Co center by an inductive effect, thus lowering the overpotential necessary for CO2 conversion. Our study shows that CoPc-Pyr reduces CO2 at lower overpotential and with higher activity than noble metal electrodes, such as silver.

Electrocatalysis at Organic-Metal Interfaces: Identification of Structure-Reactivity Relationships for CO2 Reduction at Modified Cu Surfaces.

The limited selectivity of existing CO2 reduction catalysts and rising levels of CO2 in the atmosphere necessitate the identification of specific structure-reactivity relationships to inform catalyst development. Herein, we develop a predictive framework to tune the selectivity of CO2 reduction on Cu by examining a series of polymeric and molecular modifiers. We find that protic species enhance selectivity for H2, hydrophilic species enhance formic acid formation, and cationic hydrophobic species enhance CO selectivity. ReaxFF reactive molecular dynamics simulations indicate that the hydrophilic/hydrophobic modifiers influence the formation of surface hydrides, which yield formic acid or H2. These observations offer insights into how these modifiers influence catalytic behavior at the non-precious Cu surface and may aid in the future implementation of organic structures in CO2 reduction devices.

Resource utilization and outcome among patients with selective versus nonselective troponin testing.

OBJECTIVE: In patients with suspected acute coronary syndrome (ACS), troponin testing is effective for diagnosis and prognosis. Troponin testing has now expanded to include patients without suspected ACS. This nonselective troponin testing has unknown consequences for resource utilization and outcome. Therefore, we examined selective versus nonselective troponin testing with respect to patient characteristics, resource utilization, and outcome. METHODS: This retrospective 1-year study included all patients with troponin testing at a U.S. emergency department. Testing was classified as selective (ACS) or nonselective (non-ACS) based on admission ICD-9 codes. Troponin upper reference limit (URL) was ≥99th percentile. RESULTS: Among 47,053 patients, troponin was measured in 9109 (19%) of whom 5764 were hospitalized. Admission diagnosis was non-ACS in 4427 (77%) and ACS in 1337 (23%). Non-ACS patients were older, 71±17 versus 65±16 years, with longer hospital stay, 77 versus 32 h, and greater 1-year mortality 22% versus 6.7%; P<.001. In patients with troponin ≥URL, revascularization was performed in 64 (4.7%) of non-ACS versus 213 (48%) of ACS; P<.001. In patients with troponin 80% of the non-ACS population CONCLUSIONS: Contemporary troponin testing is frequently nonselective. The non-ACS and ACS populations differ significantly regarding clinical characteristics, revascularization rates, and outcomes. Troponin elevation is a powerful predictor of 1-year mortality in non-ACS, this association reveals an opportunity for risk stratification and targeted therapy. KEY QUESTIONS: In patients with suspected acute coronary syndrome (ACS), troponin testing is effective for diagnosis and prognosis. However, troponin testing has now expanded to include patients without suspected ACS. This nonselective troponin testing has unknown consequences for hospital resource utilization and patient outcome. Our findings demonstrate contemporary troponin testing is largely nonselective (77% of testing was performed in patients without acute coronary syndrome). In comparison to patients with acute coronary syndrome, those with non-acute coronary syndrome are older, with longer hospital stay, lower revascularization rates, and greater 1-year mortality. Troponin elevation identifies a high-risk population in both acute coronary syndrome and non-acute coronary syndrome populations, yet effective treatment for the latter is lacking.

New or presumed new left bundle branch block in patients with suspected ST-elevation myocardial infarction.

AIMS: Using a comprehensive large prospective regional ST-elevation myocardial infarction (STEMI) system database, we evaluated the prevalence, clinical and angiographic characteristics, and outcomes in patients with ischemic symptoms and new or presumed new left bundle branch block (LBBB). We then tested a new hierarchical diagnosis and triage algorithm to identify more accurately new LBBB patients with an acute culprit lesion. METHODS AND RESULTS: From March 2003 to June 2013, 3903 consecutive STEMI patients were treated using the Minneapolis Heart Institute regional STEMI protocol including 131 patients (3.3%) with new LBBB. These patients had fewer culprit arteries (54.2% vs. 86.4%; P<0.001), were older, more commonly women, with a lower ejection fraction, and more frequently presented with cardiac arrest or heart failure than those without new LBBB. At 1 year follow-up, all-cause mortality accounting for baseline differences was higher in patients with new LBBB (hazard ratio 1.73, 95% confidence interval 1.17-2.58; P=0.007). The new algorithm yielded high sensitivity (97%) and negative predictive value (94%) for identification of a culprit lesion. Using the definition of new LBBB with either hemodynamically unstable features or Sgarbossa concordance criteria on electrocardiogram (ECG), 45% of new LBBB patients would have been treated as 'STEMI equivalent'. CONCLUSION: Patients with acute ischemic symptoms and new LBBB represent a high-risk population with unique clinical challenges. If validated in an independent dataset, the new algorithm may improve the diagnostic accuracy regarding reperfusion therapy for new LBBB patients.

Mechanistic insights into chemical and photochemical transformations of bismuth vanadate photoanodes.

Artificial photosynthesis relies on the availability of semiconductors that are chemically stable and can efficiently capture solar energy. Although metal oxide semiconductors have been investigated for their promise to resist oxidative attack, materials in this class can suffer from chemical and photochemical instability. Here we present a methodology for evaluating corrosion mechanisms and apply it to bismuth vanadate, a state-of-the-art photoanode. Analysis of changing morphology and composition under solar water splitting conditions reveals chemical instabilities that are not predicted from thermodynamic considerations of stable solid oxide phases, as represented by the Pourbaix diagram for the system. Computational modelling indicates that photoexcited charge carriers accumulated at the surface destabilize the lattice, and that self-passivation by formation of a chemically stable surface phase is kinetically hindered. Although chemical stability of metal oxides cannot be assumed, insight into corrosion mechanisms aids development of protection strategies and discovery of semiconductors with improved stability.

Reperfusion Options for ST Elevation Myocardial Infarction Patients with Expected Delays to Percutaneous Coronary Intervention.

Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for ST elevation myocardial infarction (STEMI). However, only one-third of hospitals in the US have PCI availability 24/7. For non-PCI hospitals, transfer remains the optimal strategy. For expected delays of greater than 120 minutes, a pharmacoinvasive strategy is recommended. In patients with evidence of failed reperfusion or hemodynamic instability, immediate rescue PCI should be performed. All other patients should undergo routine cardiac catheterization and PCI within 24 hours after fibrinolysis. A pharmacoinvasive strategy is best implemented within an organized regional STEMI system with prospective standardized transfer protocols.

False Activations for ST-Segment Elevation Myocardial Infarction.

First-medical-contact-to-device (FMC2D) times have improved over the past decade, as have clinical outcomes for patients presenting with ST-elevation myocardial infarction (STEMI). However, with improvements in FMC2D times, false activation of the cardiac catheterization laboratory (CCL) has become a challenging problem. The authors define false activation as any patient who does not warrant emergent coronary angiography for STEMI. In addition to clinical outcome measures for these patients, STEMI systems should collect data regarding the total number of CCL activations, the total number of emergency coronary angiograms, and the number revascularization procedures performed.

"No culprit" ST-elevation myocardial infarction: role of cardiac magnetic resonance imaging.

Patients with presumed ST-elevation myocardial infarction (STEMI) have no clear culprit artery in approximately 10-15% of cases. We examined the value of cardiac magnetic resonance (CMR) for diagnosis in patients with "no culprit" STEMI. Data from a comprehensive prospective registry of STEMI patients were reviewed from March 2003 to December 2009. "No culprit" patients were followed for diagnosis and clinical outcome. CMR was performed at the discretion of the attending cardiologist. Of 2728 consecutive presumed STEMI patients, 412 (15%) had no clear culprit artery. Of these, 202 (49%) had abnormal cardiac biomarkers with a definitive diagnosis in 157 (78%). Diagnoses in this group included myocardial infarction without a culprit lesion (24%), myopericarditis (22%), and stress cardiomyopathy (21%). In 210 (51%) patients with normal biomarkers, only 84 (40%) received a definitive diagnosis. Diagnoses in this group included myopericarditis (27%), noncardiac causes (21%), and cardiomyopathy (14%). CMR was performed in 123 (30%) "no culprit" patients. Patients who had CMR were more likely to have a definitive diagnosis than those who did not (95/123 [77%] vs. 144/289 [50%]; P=0.01). In particular, "no culprit" patients with abnormal biomarkers were more likely to have a definitive diagnosis with CMR. CMR led to a diagnosis different from the presumptive clinical diagnosis in 53% of all cases. CMR is a valuable diagnostic tool to improve diagnostic accuracy in patients with "no culprit" STEMI.

Outcomes of primary percutaneous coronary intervention in ST-segment elevation myocardial infarction patients with previous coronary bypass surgery.

OBJECTIVES: This study sought to determine the contemporary clinical characteristics and outcomes of patients with ST-segment elevation myocardial infarction (STEMI) and previous coronary artery bypass graft (CABG), including those with a saphenous vein graft culprit lesion. BACKGROUND: The outcome of STEMI patients with previous CABG is reported to be inferior to those without previous CABG, but limited data is available from the primary percutaneous coronary intervention era. METHODS: Data was extracted from a large, regional STEMI system's prospective database, which contained 3,542 unique STEMI episodes from March 4, 2003 through April 22, 2012. RESULTS: Previous CABG was present in 249 patients (7%). Despite higher comorbidity, patients with versus those without previous CABG had similar in-hospital (4.8% vs. 5.2%; p = 0.82) and 1-year (10.8% vs. 9.1%; p = 0.36) mortality, but 5-year (24.9% vs. 14.2%; p < 0.001) mortality was higher. Patients with previous CABG have similar door-to-balloon times. The culprit vessel was the saphenous vein graft in 84 patients (34%), a native vessel in 104 (42%), with no clear culprit in 59 (24%). The left internal mammary artery graft was not a culprit in any patient. Mortality at 30 days (8.3% vs. 3.9% vs. 1.7%, p = 0.19) and 1 year (14.3% vs. 9.0% vs. 6.8%; p = 0.35) was higher (but not statistically) with a saphenous vein graft culprit and was equivalent at 5 years (25.0% vs. 26.0% vs. 20.3%; p = 0.71). CONCLUSIONS: Patients with previous CABG treated in a regional STEMI system have similar outcomes as patients without previous CABG, although 5-year mortality is higher. The most common culprit location was a native vessel (42%). Outcomes have improved significantly compared with historical reports.

Satisfaction with emergent transfer for percutaneous coronary interventions on patients with ST-segment-elevation myocardial infarction and their families.

BACKGROUND: Transfer for primary percutaneous coronary intervention (PCI) is superior to fibrinolysis if performed in a timely manner but frequently requires dislocation of patients and their families from their local community. Although patient satisfaction is increasingly viewed as an important quality indicator, there are no data on how emergent transfer for PCI affects patients with ST-segment-elevation myocardial infarction and their families. METHODS AND RESULTS: The Minneapolis Heart Institute's Level 1 Regional ST-Segment-Elevation Myocardial Infarction program is designed to facilitate emergent transfer for PCI in patients with ST-segment-elevation myocardial infarction from 31 rural and community hospitals. To determine the effect of emergent transfer, questionnaires were given to 152 patients and their families who survived to hospital discharge with a 65.8% response rate (mean age, 63.9 years; 29% women). Ninety-five percent of patients felt the reasons and process of transfer were well explained, and 97% felt transfer for care was necessary. Despite this, 15% of patients would have preferred to stay in their local hospital. The majority of the families felt the transfer process (88%) and family member's condition (94%) were well explained. Although 99% felt it was necessary for their family member to be transferred for specialized care, 11% of families still would have preferred that their family members remain at the local community hospital. CONCLUSIONS: Our results suggest that ST-segment-elevation myocardial infarction patients and families can be informed, even in time-critical situations, about the transfer process for PCI and understand the need for specialized care. Still, a significant minority would prefer to stay at their local hospital, despite acknowledging transfer for PCI provided optimal care.

Minimizing electrostatic charging of an aperture used to produce in-focus phase contrast in the TEM.

Microfabricated devices designed to provide phase contrast in the transmission electron microscope must be free of phase distortions caused by unexpected electrostatic effects. We find that such phase distortions occur even when a device is heated to 300 °C during use in order to avoid the formation of polymerized, carbonaceous contamination. Remaining factors that could cause unwanted phase distortions include patchy variations in the work function of a clean metal surface, radiation-induced formation of a localized oxide layer, and creation of a contact potential between an irradiated area and the surround due to radiation-induced structural changes. We show that coating a microfabricated device with evaporated carbon apparently eliminates the problem of patchy variation in the work function. Furthermore, we show that a carbon-coated titanium device is superior to a carbon-coated gold device, with respect to radiation-induced electrostatic effects. A carbon-coated, hybrid double-sideband/single-sideband aperture is used to record in-focus, cryo-EM images of monolayer crystals of streptavidin. Images showing no systematic phase error due to charging are achievable under conditions of low-dose data collection. The contrast in such in-focus images is sufficient that one can readily see individual streptavidin tetramer molecules. Nevertheless, these carbon-coated devices perform well for only a limited length of time, and the cause of failure is not yet understood.

Comparison of functional recovery following percutaneous coronary intervention for ST elevation myocardial infarction in three age groups (<70, 70 to 79, and ≥80 years).

Functional outcomes of elderly patients ≥80 years who undergo percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) are unknown. Registry data indicate that up to 55% of elderly patients with STEMI do not receive reperfusion therapy despite a suggested mortality benefit, and only limited data are available regarding outcomes in elderly patients treated with primary PCI. Therefore, prospective data from a regional STEMI transfer program were analyzed to determine major adverse cardiac events, length of stay, and discharge status of consecutive patients with STEMI ≥80 years from March 2003 to November 2006. Of the 1,323 consecutive patients with STEMI treated in this regional STEMI system from March 2003 to November 2006, 199 (15.0%) were ≥80 years old. In-hospital mortality in elderly patients was 11.6%, with a 1-year mortality rate of 25.6%. Of the 166 patients with age ≥80 who lived independently or in assisted living before hospital admission and survived, 150 (90.4%) were discharged to a similar living situation or projected to such a living situation after temporary nursing home care. The median length of hospital stay was 4 days for these patients. In conclusion, elderly patients with age ≥80 receiving PCI for STEMI in a regional STEMI program have short hospital stays and excellent functional recovery on the basis of a very high rate of return to a similar previous living situation.

Are the results of a regional ST-elevation myocardial infarction system reproducible?

Primary percutaneous coronary intervention (PCI) is the preferred reperfusion method in patients with ST-elevation myocardial infarction (STEMI) if it can be performed in a timely manner in high-volume centers. Regional STEMI networks improve timely access to PCI but are frequently criticized for being single center. To determine if results of regional STEMI systems could be replicated and achieve similar outcomes in 2 separate geographic regions, we examined the prospective databases of 2 large regional STEMI networks that use identical standardized protocols and integrated transfer systems. The Minneapolis Heart Institute (MHI) database included 2,266 patients with STEMI from 31 hospitals (498 at the PCI hospital, 1,033 transferred from 11 hospitals <60 miles away, and 735 transferred from 19 hospitals 60 to 210 miles away). The Iowa Heart Center (IHC) database included 1,206 patients with STEMI from 24 hospitals (710 at the PCI hospital, 266 transferred from 10 hospitals <60 miles away, and 230 transferred from 13 hospitals 60 to 120 miles away). Median total door-to-balloon times for the PCI hospital, zone 1, and zone 2 patients were 64, 95, and 123 minutes for the MHI and 59, 102, and 136 for the IHC (p <0.05 for each comparison between MHI and IHC). Overall in-hospital, 30-day, and 1-year mortalities was 4.8%, 5.4%, and 8.0% respectively (p = NS for each comparison between MHI and IHC). In conclusion, the use of identical protocols in 2 large regional STEMI systems in geographically separate locations produced nearly identical outcomes, adding to evidence that regional STEMI centers expand timely access to PCI.