Katherine Kaproth-Joslin

Dalteparin thromboprophylaxis in cancer patients at high risk for venous thromboembolism: A randomized trial

BACKGROUND Ambulatory cancer patients at high-risk for venous thromboembolism (VTE) can be identified using a validated risk score (Khorana score). We evaluated the benefit of outpatient thromboprophylaxis with dalteparin in high-risk patients in a multicenter randomized study. METHODS Cancer patients with Khorana score≥3 starting a new systemic regimen were screened for VTE and if negative randomized to dalteparin 5000units daily or observation for 12weeks. Subjects were screened with lower extremity ultrasounds every 4weeks on study and with chest CT at 12weeks. The primary efficacy endpoint was all VTE over 12weeks and primary safety endpoint was clinically relevant bleeding events over 13weeks. The study was terminated early due to low accrual. RESULTS Of 117 enrolled patients, 10 (8.5%) had VTE on baseline screening and were not randomized. Of 98 randomized patients, VTE occurred in 12% (N=6/50) of patients on dalteparin and 21% (N=10/48) on observation (hazard ratio, HR 0.69, 95% CI 0.23-1.89). Major bleeding was similar (N=1) in each arm but clinically relevant bleeding was higher in dalteparin arm (N=7 versus 1 on observation) (HR=7.0, 95% CI 1.2-131.6). There was no difference in overall survival. CONCLUSIONS Thromboprophylaxis is associated with a non-significantly reduced risk of VTE and significantly increased risk of clinically relevant bleeding in this underpowered study. The Khorana score successfully identifies patients with high incidence of VTE both at baseline and during treatment. Future studies should continue to focus on risk-adapted approaches to reduce the burden of VTE in cancer. TRIAL REGISTRATION clinicaltrials.gov identifier: NCT00876915.

Imaging of female infertility: a pictorial guide to the hysterosalpingography, ultrasonography, and magnetic resonance imaging findings of the congenital and acquired causes of female infertility.

Hysterosalpingography is the gold standard in assessing the patency of the fallopian tubes, which is among the most common causes of female factor infertility, making this technique the most frequent first-choice imaging modality in the assessment of female infertility. Ultrasonography and magnetic resonance imaging are typically used for evaluation of indeterminate or complicated cases of female infertility and presurgical planning. Imaging also plays a role in the detection of the secondary causes of ovarian factor infertility, including endometriosis and polycystic ovarian syndrome.

The History of US: From Bats and Boats to the Bedside and Beyond: RSNA Centennial Article

The article traces the emergence of modern US from knowledge accumulated gradually over 2 centuries from scientific observation, including experiments with flying bats, underwater church bells, iceberg detection devices, and imaging systems that required the patient to be submerged in a tank of water.

The essentials of extracranial carotid ultrasonographic imaging.

In this article, the standard ultrasonographic scanning techniques and Doppler settings necessary to produce reliable and reproducible carotid imaging are discussed. The normal carotid anatomy is reviewed, including grayscale, color Doppler, and spectral Doppler imaging appearances, is reviewed. The vascular abnormalities caused by atherosclerosis are examined, including plaque morphology characterization as well as waveform and velocity changes caused by stenosis, are examined. In addition, special situations are explored, such as imaging in the presence of an arrhythmia or cardiac assist devices. Imaging after carotid intervention is discussed, including the complications associated with these procedures.

Resident and Fellow Education Feature: US Assessment of Acute Female Pelvic Pain: Test Your Knowledge

1From the Department of Imaging Sciences (K.K.J., R.S., S.B., S.V., P.F., V.D., D.R.), University of Rochester, 601 Elmwood Ave, PO Box 648, Rochester, NY 14642. Received April 11, 2013; revision requested July 31 and received November 20; accepted March 14, 2014. All authors have disclosed no relevant relationships. Address correspondence to K.K.J. (e-mail: katherine_kaproth-joslin@urmc.rochester.edu). The full digital presentation is available online.

Contrast opacification on thoracic CT angiography: challenges and solutions

AbstractContrast flow and enhancement patterns seen on thoracic CT angiography (CTA) can often be challenging and may often reveal more than is immediately apparent. A non-diagnostic CTA following the initial contrast injection can be secondary to many causes; these include both extrinsic factors, such as injection technique/equipment failure (iv cannula, power injector), and intrinsic, patient-related factors. Contrast pressure and flow graphs often contain useful information regarding the etiology of a non-diagnostic scan. Understanding these graphs will help the radiologist plan a repeat contrast injection to overcome the deficiencies of the first injection and thus obtain a diagnostic scan. The current review article outlines normal and abnormal intravenous contrast dynamics, discusses how to recognize etiologies of non-diagnostic scans, and ultimately addresses techniques to overcome obstacles towards obtaining normal contrast opacification of the target vessel. In addition, there are some life-threatening findings, which unless sought for, may remain hidden in plain sight. Key Points • Using contrast enhancement and flow patterns to identify the cause of a non-diagnostic CTA.• Recognize life threatening causes of altered contrast dynamics such as cardiac asystole.• Non-target vessel opacification may hold key to underlying pathophysiology.

Imaging of the oesophagus: beyond cancer

Non-malignant oesophageal diseases are critical to recognize, but can be easily overlooked or misdiagnosed radiologically. In this paper, we cover the salient clinical features and imaging findings of non-malignant pathology of the oesophagus. We organize the many non-malignant diseases of the oesophagus into two major categories: luminal disorders and wall disorders. Luminal disorders include dilatation/narrowing (e.g. achalasia, scleroderma, and stricture) and foreign body impaction. Wall disorders include wall thickening (e.g. oesophagitis, benign neoplasms, oesophageal varices, and intramural hematoma), wall thinning/outpouching (e.g. epiphrenic diverticulum, Zenker diverticulum, and Killian-Jamieson diverticulum), wall rupture (e.g. iatrogenic perforation, Boerhaave Syndrome, and Mallory-Weiss Syndrome), and fistula formation (e.g. pericardioesophageal fistula, tracheoesophageal fistula, and aortoesophageal fistula). It is the role of the radiologist to recognize the classic imaging patterns of these non-malignant oesophageal diseases to facilitate the delivery of appropriate and prompt medical treatment.Teaching Points• Nonmalignant oesophageal disease can be categorised by the imaging appearance of wall and lumen.• Scleroderma and achalasia both cause lumen dilatation via different pathophysiologic pathways.• Oesophageal wall thickening can be inflammatory, neoplastic, traumatic, or vascular in aetiology.

Every second counts: signs of a failing heart on thoracic CT in the ED

Impending cardiac failure is often difficult to recognize and requires a multidisciplinary approach. Upon arrival in the emergency department, patients are promptly screened for potentially life-threatening conditions through a history and physical examination. In many cases, the diagnosis is not clear until confirmatory laboratory or imaging tests are performed. Unfortunately, patients can rapidly decompensate as this diagnostic information is being obtained. Emergent CT plays a key role in identifying conditions that may result in cardiovascular collapse, including severe congestive heart failure, myocardial infarction, cardiac tamponade, and impending cardiac failure. Characteristic imaging findings can prompt the physician to take immediate action and prepare for resuscitation.

Scrotal mass in a 13 year old with history of trauma.

CLINICAL HISTORY A 13-year-old previously healthy boy presented to the emergency department for left testicular swelling and pain after being kicked in the groin 1 week ago. His symptoms had increased significantly for the first 2 days after trauma. At that time, the patient had been seen at an outside hospital, where a testicular ultrasound examination demonstrated good testicular blood flow; however, 2 extratesticular masses in the left scrotal sac were also identified. The patient was sent home with a follow-up appointment to be seen by urology service. Four days later, the patient’s symptoms had not resolved, and therefore, the patient visited our emergency department for further evaluation. The patient reported constant pain, which worsened with sitting. The patient denied problems with urination or bowel movements and reported a normal appetite. On physical examination, the patient’s left hemiscrotum was firm, swollen, and tender to palpation. There was a cordlike swelling in the left inguinal region as well. The right hemiscrotum was nontender but appeared slightly swollen. The remainder of the physical examination was normal. The emergency department physician requested a scrotal ultrasound examination for further assessment.