Mina S. Makary

Design-of-Experiments Approach to Improving Inferior Vena Cava Filter Retrieval Rates

PURPOSE The association of retrievable inferior vena cava filters (IVCFs) with adverse events has led to increased interest in prompt retrieval, particularly in younger patients given the progressive nature of these complications over time. This study takes a design-of-experiments (DOE) approach to investigate methods to best improve filter retrieval rates, with a particular focus on younger (<60 years) patients. METHODS A DOE approach was executed in which combinations of variables were tested to best improve retrieval rates. The impact of a virtual IVCF clinic, primary care physician (PCP) letters, and discharge instructions was investigated. The decision for filter retrieval in group 1 was determined solely by the referring physician. Group 2 included those patients prospectively followed in an IVCF virtual clinic in which filter retrieval was coordinated by the interventional radiologist when clinically appropriate. In group 3, in addition to being followed through the IVCF clinic, each patients PCP was faxed a follow-up letter, and information regarding IVCF retrieval was added to the patients discharge instructions. RESULTS A total of 10 IVCFs (8.4%) were retrieved among 119 retrievable IVCFs placed in group 1. Implementation of the IVCF clinic in group 2 significantly improved the retrieval rate to 25.3% (23 of 91 retrievable IVCFs placed, P < .05). The addition of discharge instructions and PCP letters to the virtual clinic (group 3) resulted in a retrieval rate of 33.3% (17 of 51). The retrieval rates demonstrated more pronounced improvement when examining only younger patients, with retrieval rates of 11.3% (7 of 62), 29.5% (13 of 44, P < .05), and 45.2% (14 of 31) for groups 1, 2, and 3, respectively. CONCLUSIONS DOE methodology is not routinely executed in health care, but it is an effective approach to evaluating clinical practice behavior and patient quality measures. In this study, implementation of the combination of a virtual clinic, PCP letters, and discharge instructions improved retrieval rates compared with a virtual clinic alone. Quality improvement strategies such as these that augment patient and referring physician knowledge on interventional radiologic procedures may ultimately improve patient safety and personalized care.

Conventional versus Drug-Eluting Bead Transarterial Chemoembolization for Neuroendocrine Tumor Liver Metastases

PURPOSE To compare outcomes of conventional transarterial chemoembolization with drug-eluting bead (DEB) chemoembolization for treatment of neuroendocrine tumor liver metastases. MATERIALS AND METHODS This single-center, retrospective study evaluated 177 transarterial chemoembolization treatments (78 conventional chemoembolization treatments using ethiodized oil-based cisplatin, mitomycin C, and doxorubicin and 99 DEB chemoembolization treatments using doxorubicin-loaded 100-300 μm DEBs) from 2012 to 2015. Hepatic disease distribution was 93% bilobar for both groups with largest lesion size 5.0 cm ± 2.7. No difference was noted in regard to lesion size or distribution, carcinoid syndrome, or pancreastatin production. Clinical outcomes including complications; liver function tests (LFTs); and radiologic (modified Response Evaluation Criteria in Solid Tumors), biochemical (pancreastatin levels), and symptomatic responses were evaluated at 1-month follow-up. RESULTS Higher symptomatic response (complete and partial) was identified with conventional transarterial chemoembolization compared with DEB chemoembolization (47% vs 30%; P < .05). Patients receiving DEB transarterial chemoembolization experienced lower elevation of LFTs (aspartate aminotransferase, 39 U/L vs 122 U/L; alanine aminotransferase, 20 U/L vs 93 U/L; bilirubin, 0.001 mg/dL vs 0.123 mg/dL; P < .05) and less postembolization syndrome (50% vs 67%; P < .05). Patients undergoing first-time DEB transarterial chemoembolization had lower periprocedural octreotide maximum rate requirements (58 μg/h vs 66 μg/h; P < .05). No difference was observed in biochemical (P = .60) or radiologic (P < .20) responses. CONCLUSIONS Conventional transarterial chemoembolization yields better symptomatic response and may be preferred for patients experiencing carcinoid symptoms. DEB transarterial chemoembolization, with lower LFT elevations and postembolization syndrome incidence, may be preferred for patients with poor liver function.

Venous extravasation and polymethylmethacrylate pulmonary embolism following fluoroscopy-guided percutaneous vertebroplasty

Percutaneous vertebroplasty has gained widespread popularity and demonstrated clinical efficacy in the treatment of spinal osteoporotic compression fractures and pathologic osteolytic lesions. Despite its rapid pain relief and safety, this minimally invasive intervention has exhibited some rare complications over the past decade. In this case study, we describe a patient with an uncommon complication of polymethylmethacrylate (PMMA) cement pulmonary embolism following fluoroscopy-guided percutaneous vertebroplasty for treatment of pain associated with an osteoporotic vertebral fracture. We present this case to highlight that vertebroplasty is not risk-free and that knowledge of such potentially severe complication is necessary for prevention and optimal operative outcomes.

Tumefactive demyelinating disease with isolated spinal cord involvement

Tumefactive multiple sclerosis (TMS) is an unusual variant of demyelinating disease. TMS has a variable and unknown progression and presents with features similar to a neoplasm making the determination a diagnostic challenge to clinicians. This report presents one of the very few reported cases of isolated spinal cord TMS, and the second case to describe TMS of the lower spinal cord, given that the lesions are typically cervical. This case study presents a diagnostic approach based on clinical, laboratory, and imaging characteristics, as well as sheds some light on the response to therapy and disease evolution.

Institutional Interventional Radiology Symposium Increases Medical Student Interest and Identifies Target Recruitment Candidates

OBJECTIVES To assess and raise medical student interest in interventional radiology (IR); and to evaluate student response across gender, level of training, and surgical vs nonsurgical specialty interest. MATERIALS AND METHODS All Ohio medical students were invited to an IR Symposium held by a large academic medical center in central Ohio. The program encompassed didactic lectures, hands-on simulation models, and a networking luncheon with faculty, trainees, and industry partners. All attendees completed an anonymous, 5-point Likert scaled survey preattending and postattending the event to assess their awareness of IR as a specialty, understanding of the current training pathways, and level of interest. RESULTS A total of 46 participants (M:F 60%:40%, MS1-53%, MS2-36%, and MS3-11%) attended the symposium. The cohort demonstrated increased interest in pursuing a career in IR following the symposium (4.12 vs 3.70, P < 0.001). Students with an interest in a nonsurgical specialty showed an increased interest in IR (4.20 vs 3.68, P < 0.001), whereas surgically oriented students did not demonstrate a significant increase (4.00 vs 3.71, P = 0.375). No statistically significant differences were noted across gender or level of training. The symposium experience significantly increased understanding of the IR training pathways (4.51 vs 2.94, P < 0.001). Students rated lectures (57%) and endovascular simulators (41%) as the most useful experiences. CONCLUSIONS This study demonstrated the role of symposia in improving medical student awareness of IR and training pathways. Findings were validated across gender and training level, and identified the subset of students with nonsurgical interests as most responsive to such intervention and potential recruitment.

Implementation of an Innovative Tablet-based Curriculum for Radiology Resident Education

RATIONALE AND OBJECTIVES The aim of this study was to prospectively examine the impact of a tablet-based curriculum on the radiology resident educational experience. MATERIALS AND METHODS A comprehensive tablet-based curriculum was developed by creating subspecialty modules with appropriate content level for each required rotation at our diagnostic radiology residency program. Daily assignments included key learning points, readings, and reference presentation slides, covering all objectives published by the ABR Core Exam Study Guide. Residents were provided with iPad devices preconfigured with the curriculum and online access to most major radiology textbooks available in our institutional digital library. Assessment surveys were administered at baseline and 12 months following curriculum implementation. RESULTS Twenty-two residents completed both surveys. In comparing the pre versus postsurvey results, 32% versus 73% residents agreed or strongly agreed that study resources were well-organized, 41% versus 91% agreed or strongly agreed that study resources were easily accessible, 27% versus 77% agreed or strongly agreed that the modules encouraged active learning, 18% versus 82% agreed or strongly agreed that resources motivate them to study daily, 36% versus 82% agreed or strongly agreed that the resources adequately prepared the resident for the radiology board exam, and 36% versus 82% agreed or strongly agreed that they were satisfied with the resources provided by the residency program (p < 0.05). CONCLUSION Our study demonstrated the positive impact of implementing a complete tablet-based curriculum on radiology resident motivation, satisfaction, and engagement. Use of mobile tablet devices has the potential to dramatically transform content delivery in residency education.