Sadhna B. Nandwana

Abdominal Imaging Surveillance in Adult Patients After Fontan Procedure: Risk of Chronic Liver Disease and Hepatocellular Carcinoma

PURPOSE To assess the prevalence of chronic liver disease (CLD) and hepatocellular carcinoma (HCC) in adult patients who had surveillance imaging after Fontan procedure. METHODS Institutional review board-approved, Health Insurance Portability and Accountability Act-compliant retrospective study evaluated electronic medical records including radiology reports and clinical notes for adult patients after Fontan procedure between January 1993 and January 2016. Abdominal ultrasound, computed tomography, and magnetic resonance imaging reports were reviewed for changes of CLD and HCC. Existence of concomitant viral hepatitis was also recorded. RESULTS A total of 145 patients (male: 78 and female: 67) had surveillance imaging after Fontan procedure. In all, 78% (113/145) had ongoing imaging surveillance (median follow-up 3.05 years, IQR: 0.75-5.3 years); 19% (21/113) had an initial normal study and remained normal throughout follow-up; 19% (21/113) had an initial normal study with subsequent imaging reporting changes of CLD; and 62% (71/113) had existing changes of CLD on initial study. HCC was identified in 5 patients (median 22 years post-Fontan, IQR: 10-29 years), 4 of which had a normal initial study. Only 1 patient with HCC had concomitant viral hepatitis C infection. CONCLUSION Radiologists should be aware that CLD is exceedingly common in post-Fontan cardiac physiology, and surveillance imaging is warranted given the risk of HCC.

Radiology Department Preparedness for the Management of Severe Acute Iodinated Contrast Reactions: Do We Need to Change Our Approach?

OBJECTIVE The purpose of this study was to identify opportunities for reducing epinephrine administration errors after a sentinel event entailing an overdose of i.v. epinephrine occurred in a radiology department. MATERIALS AND METHODS A root cause analysis was performed that included review and analysis of current system protocols, a medication audit, and access to treatment algorithms. A proctored three-question multiple-choice test was administered to radiology attending physicians, fellows, residents, and nurses to gauge baseline knowledge of epinephrine use. Chi-square analysis was performed. RESULTS Twelve of 13 radiology department central pharmacy automation system locations lacked epinephrine ampules. As a result, personnel had to access i.v. epinephrine stocked on hospital code carts designed for use during cardiac arrest. This led to errors related to appropriate dosing. Test participants included 46 attending physicians, 23 fellows, 28 residents, and 25 nurses (n = 122). Almost all (99%) correctly identified epinephrine as the medication to administer in this situation. Approximately one half (52%) correctly identified the dose of intramuscular epinephrine, but only 29% knew the dose and rate of administration of i.v. epinephrine (p < 0.001). Attending physicians were more likely to administer i.v. epinephrine correctly than were the other groups (p < 0.0001). CONCLUSION Stocking and routine auditing of medication availability are essential. The use of epinephrine intended for cardiac arrest stocked on code carts should be avoided during contrast reactions. It would be optimal if first-line responders to contrast reactions included attending physicians, but this may not always be the case at academic institutions.

Reassessing medicare trends in diagnostic CT colonography after achieving CPT code category I status

AbstractPurpose Compare national trends in utilization and coverage of diagnostic (non-screening) computed tomography colonography (CTC) in the Medicare population before and after achieving Current Procedural Terminology® (CPT) Category I code status in 2010.MethodsClaims by provider type and location for diagnostic CTC were identified between 2005 and 2013 using Medicare Physician Supplier Procedure Summary Master Files. Frequencies of billed and denied services were used to calculate denial rates for CTC and abdominal computed tomography (CT). PubMed search for articles with “CT colonography” in abstract or title during 1997–2013 was performed. Publications were recorded yearly and matched to CTC denial rates.ResultsAnnual Medicare claims for diagnostic CTC increased 212% during 2005–2009 in Category III status and increased 27.4% during 2009–2013 after implementation of Category I codes. Claims for abdominal CT rose 13.4% over the same overall period. Denial rates decreased from 70% to 32.8% between 2005 and 2009, and fluctuated between 24.7 and 30.6% thereafter. Denial rates for abdominal CT remained constant (4.1%–4.6%). From 2005 to 2013, services grew most in the private office (1678–7293) and hospital outpatient (1644–6449) settings with radiologists performing 93.3% of CTC. 1037 CTC publications were identified which increased 3567% between 1997 (3) and 2008 (107), plateaued until 2010 (114) and declined thereafter (75 in 2013).ConclusionsDiagnostic CTC grew dramatically from 2005 to 2009, but slowed thereafter; even after achieving CPT Category I code status in 2010. Medicare denial rates declined during early years but later stabilized which paralleled a slowing in new peer-reviewed research. CTC continues to be performed predominately by radiologists in the outpatient setting.

Image-Guided Nontargeted Renal Biopsies Performed by Radiology-Trained Nurse Practitioners: A Safe Practice Model

Table 1. Society of Interventional Radiology classification system for complications by outcome DESCRIPTION OF THE PROBLEM Percutaneous biopsy of the kidney is an integral part of the diagnostic workup for medical renal disease and has become the standard of care for the diagnosis of glomerular, vascular, and tubulointerstitial renal disease [1]. Over the years, there has been an increasing trend of radiologists performing image-guided renal biopsies rather than nephrologists [2]. Concomitantly, there has also been an expanding role of nurse practitioners (NPs) as providers of invasive radiologic procedures [3]. At our institution, NPs and radiologists routinely perform medical renal biopsies under CT guidance. However, there is limited understanding of the differences between NPs and radiologists in the performance of these procedures, and many institutions do not have systems in place to routinely compare NPs’ and physicians’ performance. Minor complications A No therapy, no consequence B Nominal therapy, no consequence; includes overnight admission for observation only Major complications C Require therapy, minor hospitalization (<48 h) D Require major therapy, unplanned increase in level of case, prolonged hospitalization (>48 h) E Permanent adverse sequelae F Death WHAT WE DID The radiology report database was searched to identify patients who underwent CT-guided medical renal biopsies from January 1, 2009, through December 31, 2013 at 2 hospital sites within the authors’ academic medical center. Gender,

Comparative Effectiveness of Tumor Response Assessment Methods: Standard of Care Versus Computer-Assisted Response Evaluation

PURPOSE To compare the effectiveness of metastatic tumor response evaluation with computed tomography using computer-assisted versus manual methods. MATERIALS AND METHODS In this institutional review board-approved, Health Insurance Portability and Accountability Act-compliant retrospective study, 11 readers from 10 different institutions independently categorized tumor response according to three different therapeutic response criteria by using paired baseline and initial post-therapy computed tomography studies from 20 randomly selected patients with metastatic renal cell carcinoma who were treated with sunitinib as part of a completed phase III multi-institutional study. Images were evaluated with a manual tumor response evaluation method (standard of care) and with computer-assisted response evaluation (CARE) that included stepwise guidance, interactive error identification and correction methods, automated tumor metric extraction, calculations, response categorization, and data and image archiving. A crossover design, patient randomization, and 2-week washout period were used to reduce recall bias. Comparative effectiveness metrics included error rate and mean patient evaluation time. RESULTS The standard-of-care method, on average, was associated with one or more errors in 30.5% (6.1 of 20) of patients, whereas CARE had a 0.0% (0.0 of 20) error rate ( P < .001). The most common errors were related to data transfer and arithmetic calculation. In patients with errors, the median number of error types was 1 (range, 1 to 3). Mean patient evaluation time with CARE was twice as fast as the standard-of-care method (6.4 minutes v 13.1 minutes; P < .001). CONCLUSION CARE reduced errors and time of evaluation, which indicated better overall effectiveness than manual tumor response evaluation methods that are the current standard of care.

Beyond complications: Comparison of procedural differences and diagnostic success between nurse practitioners and radiologists performing image-guided renal biopsies.

PURPOSE Radiology-trained nurse practitioners (NPs) may perform image-guided medical renal biopsies with computed tomography (CT). This study evaluates the procedural differences and diagnostic success between biopsies performed by NPs compared to radiologists. DATA SOURCES A retrospective study was performed on patients who underwent nontargeted, CT-guided renal biopsy between 2009 and 2014. Provider type (NP or radiologist), number of core specimens obtained, sedation medication dose, CT dose index (CTDI), and diagnostic success were recorded. Categorical and continuous variables were analyzed using χ2 and Students two-tailed t-test, respectively, comparing NPs with radiologists. CONCLUSIONS A total of 386 patients were included; radiologists performed 215 biopsies and NPs performed 171 biopsies. There was no significant difference in diagnostic success, amount of tissue harvested (number of cores), radiation dose, or sedation dosage between NPs and radiologists performing CT-guided renal biopsies. Only 4% were nondiagnostic (n = 7, radiologists; n = 9, NPs; p = .325). Overall mean number of cores obtained was 3.7, mean CTDI was 176.5 mGy, mean fentanyl dose was 86.3 μg, and mean midazolam was dose 1.54 mg without a statistically significant difference between provider types. IMPLICATIONS FOR PRACTICE NPs perform image-guided medical renal biopsies in a similar fashion to radiologists with respect to diagnostic success, amount of tissue harvested, total radiation dose exposure, and administration of sedation.