An Incidental Finding of Pulmonary Cement Embolism Four Weeks After Vertebroplasty in a 50-Year-Old Man with Multiple Myeloma.

BACKGROUND Vertebroplasty is a minimally invasive radiological procedure that involves injection of cement to stabilize the fractured vertebra. It has also been increasingly used to relieve pain in patients with bone-incorporated malignancies. The most frequently encountered complication of this procedure is inadvertent cement leakage, which has the potential to embolize. This report presents an incidental finding of cement embolism during fluoroscopy for a peripherally inserted central catheter (PICC) line 4 weeks after vertebroplasty in a 50-year-old man with multiple myeloma. CASE REPORT Our report details the case of a 50-year-old man who presented for progressive sciatic nerve pain and was found on imaging to have an L3 fracture, spinal stenosis, lumbar spinal spondylosis, and diffusely decreased bone density, eventually diagnosed with multiple myeloma. For symptomatic relief and vertebrae stabilization, he underwent a CT-guided fluoroscopic vertebroplasty procedure. Four weeks later, during fluoroscopy for a PICC, he was incidentally found to have radiopaque opacities within the pulmonary arteries. He was diagnosed with a pulmonary embolism due to transvertebral cement leakage from his vertebroplasty. Given the central nature of his embolism, he was treated with anticoagulation and closely monitored. Throughout the treatment period, he remained asymptomatic with normal vital signs and NT-brain natriuretic peptide. CONCLUSIONS This report highlights the association between vertebroplasty and pulmonary cement embolism (PCE), the potential for late detection upon chest imaging even weeks after vertebroplasty, and suggests that some patients with PCE may need therapeutic anticoagulation.

Physician failure to stratify patients hospitalized with acute pulmonary embolism.

OBJECTIVES: In 2011, the AHA recommended risk stratification of patients with acute pulmonary embolism (PE). Failure to risk stratify may cause under recognition of intermediate-risk PE and its attendant short- and long-term consequences. We sought to determine if patients hospitalized with acute PE were appropriately risk stratified according to the 2011 AHA Scientific Statement within our hospital system and whether differences exist in adherence to risk stratification by hospital or treating hospital service. We also wished to know the frequency of in-hospital consultations for acute PE which might assist in the risk stratification process. METHODS: This is a retrospective chart audit of all patients hospitalized with a diagnosis of acute PE between January 2011 and December 2013 at our 937-bed metropolitan, three hospital system comprised of academic University, neuroscience Specialty, and teaching Community hospitals. We evaluated the presence of imaging, laboratory tests, and specialty consultation within 72 h of PE diagnosis by hospital. RESULTS: 701 patients with acute PE were admitted to our hospital system during the study period. 308 patients (43.9%) met criteria for intermediate-risk PE. 347 patients (49.5%) were considered 'Low-Risk - At Risk', patients defined in a low-risk category not having undergone all recommended risk stratification testing and so truly may have been in a higher risk category. No specialty consultations were utilized for 265 patients (37.8%). CONCLUSIONS: Our large metropolitan hospital system inadequately risk stratifies hospitalized patients with acute PE. Because nearly one-half of patients with acute PE did not have all recommended testing, clinicians may be under recognizing patients with intermediate-risk PE and their risk for long-term morbidity. Specialty consultations were underutilized and may help guide medical decision-making.

Patient-Centered Specialty Practice: Defining the Role of Specialists in Value-Based Health Care.

Health care is at a crossroads and under pressure to add value by improving patient experience and health outcomes and reducing costs to the system. Efforts to improve the care model in primary care, such as the patient-centered medical home, have enjoyed some success. However, primary care accounts for only a small portion of total health-care spending, and there is a need for policies and frameworks to support high-quality, cost-efficient care in specialty practices of the medical neighborhood. The Patient-Centered Specialty Practice (PCSP) model offers ambulatory-based specialty practices one such framework, supported by a formal recognition program through the National Committee for Quality Assurance. The key elements of the PCSP model include processes to support timely access to referral requests, improved communication and coordination with patients and referring clinicians, reduced unnecessary and duplicative testing, and an emphasis on continuous measurement of quality, safety, and performance improvement for a population of patients. Evidence to support the model remains limited, and estimates of net costs and value to practices are not fully understood. The PCSP model holds promise for promoting value-based health care in specialty practices. The continued development of appropriate incentives is required to ensure widespread adoption.

Delayed recognition of an uncommon cause of iatrogenic pneumothorax.

The images enclosed from our case report show the subtle radiographic findings on the plain film, less subtle findings on computed tomographic scan, and what we believe is the first to be reported 3-dimensional reconstructed image of an acupuncture needle remaining in the chest after treatment. The case highlights the importance of looking for subtle abnormalities on imaging and the importance of history taking to finally establish a cause. We consider this an instructive case for internists and respirologists who should ask about this potential iatrogenic form of penetrating chest trauma when evaluating a patient for pneumothorax.

Evaluation and management of chronic pulmonary thromboembolic disease.

Pulmonary embolism (PE) is common and the majority of patients survive the acute event. Survivors are at increased risk for adverse outcomes, including persistent thrombi, recurrent embolism, chronic thromboembolic pulmonary hypertension (CTEPH), and death. Anticoagulation protects against recurrence, which has a high mortality rate. The recommended duration of anticoagulation for patients with reversible PE risk factors is 3 months. For patients with idiopathic PE or persistent risk factors, extended duration of anticoagulation is preferred, balanced with an individual patient's risk of hemorrhage, which in itself is a major cause of morbidity and mortality. Among patients with malignancy who develop venous thromboembolism (VTE), low-molecular-weight heparin is preferred over oral vitamin K antagonists in the first 6 months. Thereafter, anticoagulation should be continued indefinitely with either low-molecular-weight heparin or oral vitamin K antagonists. Inferior vena cava filters are not routinely recommended and should only be used in patients who have a contraindication to anticoagulation. Patients who have had VTE and with persistent or recurrent dyspnea should be evaluated for recurrence of VTE or development of CTEPH. Patients with recurrent VTE should be anticoagulated indefinitely. Routine screening for CTEPH in asymptomatic patients is not recommended. Echocardiography often provides the first indication of the presence of pulmonary hypertension. Once presence of CTEPH is established by right-sided heart catheterization and perfusion imaging (ie, ventilation/perfusion scintigraphy, computed tomography angiography, or pulmonary angiography), patients should be referred early to a center with expertise, as it is potentially surgically curable by pulmonary endarterectomy. Those who are deemed inoperable after being evaluated may gain symptomatic benefit from drugs approved for idiopathic pulmonary arterial hypertension. Lung transplantation may also be an option for patients who are not candidates for pulmonary endarterectomy.

Complete tracheal duplication in an adult with thoracic aortic coarctation.

Partial and complete duplication of the trachea have previously been reported as rare causes of respiratory distress in children. We report a case of complete tracheal duplication detected incidentally in an adult during a computed tomography angiogram of the heart performed as part of an evaluation for coarctation of the aorta.