Anand Narayan

A Comparison of Clinical Outcomes with Retrievable and Permanent Inferior Vena Cava Filters

PURPOSE To compare the clinical effectiveness of retrievable and permanent inferior vena cava (IVC) filters. MATERIALS AND METHODS A retrospective cohort study of consecutive patients who received retrievable or permanent IVC filters from January 2002 through December 2006 was conducted. Patient characteristics and clinical outcomes were compared with nonparametric and parametric statistics. RESULTS IVC filters were placed in 702 patients: 427 (60.8%) received a retrievable filter (RF) and 275 (39.2%) received a permanent filter (PF). Overall, the mean duration of follow-up was 11.5 months: 10.4 months for RF recipients and 13.1 months for PF recipients (P = .025). PF recipients were older (60.6 y +/- 17.0 vs 55.4 y +/- 17.2; P < .0001) and more likely to have underlying cancer (45.8% vs 29.3%; P < .0001). Symptomatic pulmonary embolism (PE) occurred in 11 PF recipients and 20 RF recipients who were receiving ongoing filtration (4.0% vs 4.7%; P = .67). Patients with PFs and RFs with ongoing filtration experienced symptomatic deep vein thrombosis (11.3% vs 12.6%; P = .59) and symptomatic IVC thrombosis (1.1% vs 0.5%; P = .39) at a comparable frequency. Sixty-six RF recipients (15.5%) underwent attempted retrieval, which was successful in 46 (69.7%). No RF recipients experienced a new PE after retrieval during a mean follow-up of 12.0 months. CONCLUSIONS In this retrospective cohort study, RFs and PFs provided similar protection from PE with comparable complication rates. Clinicians should select an IVC filter based on the projected duration of filtration needed at the time of placement rather than filter type.

Iliac vein compression as risk factor for left- versus right-sided deep venous thrombosis: case-control study.

PURPOSE To determine if compression of the left common iliac vein (LCIV) by the right common iliac artery is associated with left-sided deep venous thrombosis (DVT). MATERIALS AND METHODS This institutional review board-approved case-control study was performed in a cohort of 230 consecutive patients (94 men, 136 women; mean age, 57.5 years; range, 10-94 years) at one institution who had undergone contrast material-enhanced computed tomography of the pelvis prior to a diagnosis of unilateral DVT. Demographic data and information on risk factors were collected. Two board-certified radiologists determined iliac vein compression by using quantitative measures of percentage compression {[1 minus (LCIV diameter at point of maximal compression/distal right common iliac vein diameter)] times 100%}, as well as qualitative measures (none, mild, moderate, severe), with estimates of measurement variability. Logistic regression analysis was performed (independent variable, left vs right DVT; dependent variable, iliac vein compression). Cutpoints of relevant compression were evaluated by using splines. Means (with 95% confidence intervals [CIs]) and odds ratios (ORs) (and 95% CIs) of left DVT per 1% increase in percentage compression were calculated. RESULTS Patients with right DVT were more likely than those with left DVT to have a history of pulmonary embolism. Overall, in all study patients, mean percentage compression was 36.6%, 66 (29.7%) of 222 had greater than 50% compression, and 16 (7.2%) had greater than 70% compression. At most levels of compression, increasing compression was not associated with left DVT (adjusted ORs, 1.00, 0.99, 1.02) but above 70%, LCIV compression may be associated with left DVT (adjusted ORs, 3.03, 0.91, 10.15). CONCLUSION Increasing levels of percentage compression were not associated with left-sided DVT up to 70%; however, greater than 70% compression may be associated with left DVT. SUPPLEMENTAL MATERIAL http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12111580/-/DC1.

Uterine artery embolization versus abdominal myomectomy: a long-term clinical outcome comparison.

PURPOSE To assess long-term clinical effectiveness of uterine artery embolization (UAE) compared with abdominal myomectomy. MATERIALS AND METHODS Women who received UAE (n = 87) or abdominal myomectomy (n = 98) for symptomatic uterine leiomyomata between 2000 and 2002 at a single institution were consecutively enrolled in this study. Patients whose procedures were performed within 5 years before the study were included. Symptom evaluations with symptom severity scores, pregnancy rates, and satisfaction with the procedures were obtained via institutional review board-approved questionnaires. Chart reviews were performed to supplement analyses. RESULTS The retrospective cohort included 185 patients, of whom long-term follow-up was completed by 89 patients (48.1%), 48 being treated with UAE, and 41 with myomectomy. Follow-up ranged from 50 to 83 months. A higher but not statistically significant number of patients received repeat interventions after abdominal myomectomy (14%) versus UAE (8%; P = .204). Significantly higher symptom severity score improvements were seen in patients treated with UAE versus abdominal myomectomy (34 vs 31; P = .02). UAE recipients were less likely to attempt to get pregnant (P = .02), but those who did had a 66.7% success rate compared with 58.8% for patients who underwent myomectomy. Similar numbers of patients between groups were satisfied with the procedure (P = .57), reported effectiveness of symptom relief (P = .43), and would recommend the procedure to others (P = .37). CONCLUSIONS UAE results in long-term clinical success with outcomes comparable or superior to those of abdominal myomectomy.

Quality Measurements in Radiology: A Systematic Review of the Literature and Survey of Radiology Benefit Management Groups

PURPOSE As the US health care system transitions toward value-based reimbursement, there is an increasing need for metrics to quantify health care quality. Within radiology, many quality metrics are in use, and still more have been proposed, but there have been limited attempts to systematically inventory these measures and classify them using a standard framework. The purpose of this study was to develop an exhaustive inventory of public and private sector imaging quality metrics classified according to the classic Donabedian framework (structure, process, and outcome). METHODS A systematic review was performed in which eligibility criteria included published articles (from 2000 onward) from multiple databases. Studies were double-read, with discrepancies resolved by consensus. For the radiology benefit management group (RBM) survey, the six known companies nationally were surveyed. Outcome measures were organized on the basis of standard categories (structure, process, and outcome) and reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS The search strategy yielded 1,816 citations; review yielded 110 reports (29 included for final analysis). Three of six RBMs (50%) responded to the survey; the websites of the other RBMs were searched for additional metrics. Seventy-five unique metrics were reported: 35 structure (46%), 20 outcome (27%), and 20 process (27%) metrics. For RBMs, 35 metrics were reported: 27 structure (77%), 4 process (11%), and 4 outcome (11%) metrics. The most commonly cited structure, process, and outcome metrics included ACR accreditation (37%), ACR Appropriateness Criteria (85%), and peer review (95%), respectively. CONCLUSIONS Imaging quality metrics are more likely to be structural (46%) than process (27%) or outcome (27%) based (P < .05). As national value-based reimbursement programs increasingly emphasize outcome-based metrics, radiologists must keep pace by developing the data infrastructure required to collect outcome-based quality metrics.

A Comparative Study of Conventional Mammography Film Interpretations with Soft Copy Readings of the Same Examinations

An acceptable mammography film digitizer must provide high-quality images at a level of diagnostic accuracy comparable to reading conventional film examinations. The purpose of this study was to determine if there are significant differences between the interpretations of conventional film-screen mammography examinations and soft copy readings of the images produced by a mammography film digitizer. Eight radiologists interpreted 120 mammography examinations, half as original films and the other half as digital images on a soft copy work station. No radiologist read the same examination twice. The interpretations were recorded in accordance with the Breast Imaging Reporting and Data System and included other variables such as perceived image quality and diagnostic difficulty and confidence. The results provide support for the hypothesis that there are no significant differences between the interpretations of conventional film-screen mammography examinations and soft copy examinations produced by a mammography film digitizer.

Extracranial, peritoneal seeding of primary malignant brain tumors through ventriculo-peritoneal shunts in children: Case report and review of the literature

Introduction Ventriculoperitoneal shunts (VPS) have been implicated as a source of the extraneural spread of a wide variety of central nervous system tumors. The purpose is to review the literature on peritoneal seeding of central nervous system tumors from VPS in the context of a case report. Methods Medline was searched using the phrase ‘peritoneal seeding ventriculoperitoneal shunt’. Inclusion criteria included patients (<18 years) with evidence of peritoneal seeding from VPS. Results Search of the literature revealed a final total of 22 articles and a total of 28 patients. Case report A 7-year-old boy presented with intermittent vomiting, headaches, photophobia; a 4.4 cm left thalamic mass (glioblastoma multiforme) was found. Occipital VPS catheters were placed for increasing hydrocephalus and the patient developed increased abdominal distention and pain. Computed tomography revealed diffuse ascites with carcinomatosis and the patient was diagnosed clinically with peritoneal metastases. Discussion Our case report and literature review revealed 28 cases of central nervous system tumors demonstrating evidence of extraneural spread associated with VPS in children in a wide variety of tumors. Larger studies are required to evaluate VPS as potential risk factors for peritoneal seeding and familiarity with potential VPS-related peritoneal seeding is important for diagnostic consideration.

Histogram Analysis of Diffusion Tensor Imaging Parameters in Pediatric Cerebellar Tumors

Apparent diffusion coefficient (ADC) values have been shown to assist in differentiating cerebellar pilocytic astrocytomas and medulloblastomas. Previous studies have applied only ADC measurements and calculated the mean/median values. Here we investigated the value of diffusion tensor imaging (DTI) histogram characteristics of the entire tumor for differentiation of cerebellar pilocytic astrocytomas and medulloblastomas.

The Impact of Cancer on the Clinical Outcome of Patients After Inferior Vena Cava Filter Placement: A Retrospective Cohort Study.

Objectives:Inferior vena cava (IVC) filters are placed to prevent pulmonary embolism, however, some studies have suggested that IVC filters are associated with exacerbated risks of deep vein/IVC thrombosis in cancer patients. The purpose of this study is to determine if cancer patients develop higher than expected rates of venous thromboembolism complications after filter placement compared with noncancer patients. Materials and Methods:A retrospective cohort study of consecutive patients who received filters (2002 to 2006) at Johns Hopkins was conducted. Exposures and outcomes were obtained by chart review. Relative risks (RR, 95% confidence interval [CI]) for outcomes in cancer versus noncancer patients were estimated using multistate models. Results:The cohort included 702 patients—246 with cancer and 456 without cancer. Cancer patients were older, more likely to be white and have filters placed for contraindications to anticoagulation (P<0.01). The most common cancers were lung (11.8%) and colorectal (10.6%). Cancer patients had an increase in venous thromboembolism (RR 1.9 [95% CI, 1.1, 3.2]) due to more deep venous thrombosis/IVC thrombosis (RR 1.7 [95% CI, 1.0, 3.0]). Higher pulmonary embolism rates in cancer were not statistically significant (RR 2.2 [95% CI, 0.8, 5.8]). Conclusions:Cancer patients have elevated risks of thrombotic complications compared with noncancer patients; however, these risks are not higher than expected based on historical controls.

Impact of medicare shared savings program accountable care organizations at screening mammography: A retrospective cohort study

Purpose To evaluate the impact of accountable care organizations (ACOs) on use of screening mammography in the Medicare Shared Savings Program (MSSP), the largest value-based reimbursement program in U.S. HISTORY Materials and Methods Institutional review board approval was waived, as the study used publicly available unidentifiable data. Medicare data were retrospectively obtained for participating ACOs from 2012 to 2014. Baseline information and the ACO-20 measure (percentage of women aged 40-69 years who underwent screening mammography within 24 months) were obtained. Negative binomial regression models were used to evaluate baseline and longitudinal mammography use, with stratified analyses performed for year of entry into the ACO, number of beneficiaries, and geographic region. Results A total of 333 ACOs with 5 329 831 Medicare beneficiaries (mean size, 16 006 beneficiaries) participated in the MSSP. Screening use varied across ACOs (median, 63.0%; range, 8.8%-90.3%), with differences found across regions (use was highest in the Midwest [66.6%] and lowest in the South [58.2%], P = .038). A total of 208 ACOs reported longitudinal outcomes, with mean change in screening mammography use of +2.6% (range, -33.2% to +42.2%), with 128 (61.6%) ACOs reporting improvements (incidence rate ratio, 1.04; 95% confidence interval: 1.02, 1.07) (P = .002). No longitudinal differences in use were seen across regions (P = .078), year of entry (P = .902), number of beneficiaries (P = .814), or total composite quality score (P = .324), nor was there a difference between ACOs that saved money and those that did not (P = .391). Conclusion ACOs in the MSSP have produced small significant improvements in screening mammography use.

Fostering Longitudinal Involvement in State Chapter Resident and Fellow Sections: The Maryland Experience

INTRODUCTION As residents and fellows, we are training at a time of tremendous political and economic upheaval, when radiologists are increasingly required to demonstrate our value to health care systems and society as a whole. As these changes develop, it will become increasingly important to foster clinical and nonclinical habits that allow us to provide valuewithin thehealth care system. One of the best venues by which residents and fellows can actively engage in these issues is through state chapter resident and fellow sections (RFSs). Prior reports have described the importance of participation of trainees in established RFSs,but therehavebeen limitedreports on fostering longitudinal involvement in RFSs [1]. This article provides practical suggestions on engaging residents and fellows, on the basis of the experience of the recently founded Maryland RFS, which was established in 2013.