Seth Toomay

Predictors of early versus late timing of pulmonary embolus after traumatic injury

OBJECTIVE To identify risk factors predictive of pulmonary embolus (PE) timing after a traumatic injury. METHODS One hundred eight traumatic injury patients with a confirmed diagnosis of PE were classified as early PE (≤4 days, n = 54) or late PE (>4 days, n = 54). Independent predictors of early versus late PE were identified using multivariate logistic regression. RESULTS Half the PEs were diagnosed ≤4 days of injury. Only long bone fractures independently predicted early PE (odds ratio 2.8; 95% confidence interval, 1.1-7.1). Severe head injuries were associated with late PE (odds ratio 11.1; 95% confidence interval, 3.9-31). Established risk factors such as age did not affect timing. CONCLUSIONS Half the PEs were diagnosed ≤4 days after injury. The risk of early PE appeared highest in patients with long bone fractures, and the benefits of immediate prophylaxis may outweigh risks. Patients with severe head injuries appear to have later PE events. Prospective interventional trials in these injury populations are needed.

Update on Treatment of Liver Metastases: Focus on Ablation Therapies

There is substantial and growing interest in the use of local therapies to treat patients with metastatic cancer, especially those deemed to have “oligometastatic” disease. Much of the literature to date consists of reports on metastasectomy for liver and lung metastases. Non-surgical minimally or non-invasive treatments including thermal ablation, irreversible electroporation, and high-dose radiation therapy (stereotactic ablative radiation therapy) can also be used in the treatment of primary and secondary tumors, including in the treatment of liver metastases. In this review, we discuss the rationale for using these ablative treatments in the treatment of liver metastases including similarities and differences between them.

Myelography: A Primer

Despite recent trends toward evaluation of back and neck pain with magnetic resonance imaging, myelography and postmyelography computed tomography continue to play an important role in the workup of many patients with spinal pathology. We present techniques for the safe and efficient performance of myelography, lumbar, and cervical puncture, which remain important skills to be mastered by radiology residents and fellows.

Implementation of an Online Screening and Check-In Process to Optimize Patient Workflow Before Outpatient MRI Studies

BACKGROUND/SUMMARY OF THE PROBLEM The long examination times in MRI create the need to reduce access time and implement an efficientmodel to reduce patient turnaround time to a minimum [1]. A commonly encountered cause of delay is the screening process, an essential and indispensable step to ensure patient safety and delivery of high-quality care [2,3]. Traditionally, the MRI screening process is completed with a paper questionnaire, which is then scanned into the electronic medical record (EMR) or uploaded to the PACS for documentation purposes. The MRI screening process is commonly completed after patient arrival for an MRI appointment. If a patient reports a positive pertinent history during MRI screening (eg, placement of a medical device or presence of foreign bodies), further investigation is required, for example, obtaining specific information about the make and model of an implanted device before “clearing” the patient [2-6]. This process has several challenges. First,many patients are unaware of the specifics of their implanted device or may not be aware of the need or may simply forget to bring device-specific documentation to their MRI

Acute pulmonary embolism: Endovascular therapy

Pulmonary embolism (PE) is a leading cause of morbidity and mortality worldwide. PE is a complex disease with a highly variable presentation and the available treatment options for PE are expanding rapidly. Anticoagulation (AC), systemic lysis, surgery, and catheter-directed thrombolysis (CDT) play important roles in treating patients with PE. Thus, a multidisciplinary approach to diagnosis, risk stratification, and therapy is required to determine which treatment option is best for a given patient with this complex disease.

Angiography in Complex Regional Pain Syndrome

Figure 3 A 53-year-old woman with a history of injury to the distal second digit 4 months prior presented with pain disproportionate to injury, including paresthesia, hyperesthesia, numbness, redness, and coolness. Angiography was unremarkable on early arterial phase (Fig 1) with arteriovenous shunting in the distal tuft on late arterial phase (Fig 2, arrows). Appropriate vasoconstriction was lacking after topical application of ice (Fig 3, arrow; ice applied only to digits 2–5), suggesting lack of autoregulation. Angiographic findings and correlation of symptoms with the Budapest Criteria suggested complex regional pain syndrome. This syndrome

Agile co-development for clinical adoption and adaptation of innovative technologies

Even the most innovative healthcare technologies provide patient benefits only when adopted by clinicians and/or patients in actual practice. Yet realizing optimal positive impact from a new technology for the widest range of individuals who would benefit remains elusive. In software and new product development, iterative rapid-cycle “agile” methods more rapidly provide value, mitigate failure risks, and adapt to customer feedback. Co-development between builders and customers is a key agile principle. But how does one accomplish co-development with busy clinicians? In this paper, we discuss four practical agile co-development practices found helpful clinically: (1) User stories for lightweight requirements; (2) Time-boxed development for collaborative design and prompt course correction; (3) Automated acceptance test driven development, with clinician-vetted specifications; and (4) Monitoring of clinician interactions after release, for rapid-cycle product adaptation and evolution. In the coming wave of innovation in healthcare apps ushered in by open APIs to EHRs, learning rapidly what new product features work well for clinicians and patients will become even more crucial.

Safety and Effectiveness of the Denali Inferior Vena Cava Filter Intermediate Follow-Up Results

Purpose: The purpose of the study is to evaluate the clinical safety and effectiveness of the Denali (Bard, Tempe, Arizona) retrievable inferior vena cava (IVC) filter. Materials and Methods: In this retrospective study, authors reviewed the data of Denali IVC filters placed at their institution between 2013 and 2015. The clinical presentation, indications, and procedure-related complications during placement and retrieval were evaluated. The frequency of post filter pulmonary embolism (PE) and filter-related complications was assessed. Results: Denali filters were placed in 87 patients (47 males; mean age: 56 years). Twenty patients presented with PE, 45 with deep vein thrombosis (DVT), and 21 with both PE and DVT, 1 filter was placed prophylactically before surgery. Indications for filter placement included contraindications to anticoagulation (AC; n = 80), failure of AC (n = 4), and complications of AC (n = 3). No patients had PE on follow-up imaging after filter placement. Retrieval was attempted in 31 patients after a mean period of 125 days (range: 34-324 days). The filter was successfully removed in 31 (100%) patients. Follow-up imaging, available in 71 (82%) patients (range: 2-538 days), demonstrated penetration of 15 legs in 5 patients, caval thrombus in 3, 1 resulting in caval occlusion, <15° filter tilt in 5, and no leg fractures or crossed legs. Conclusion: The Denali filter is safe during deployment and readily retrievable. The overall safety following deployment is similar to those reported in the literature, and the incidence of filter fractures and migration appears to be less than the previous generation of Bard devices.

Approaching the Practice Quality Improvement Project in Interventional Radiology

An important component of maintenance of certification and quality improvement in radiology is the practice quality improvement (PQI) project. In this article, the authors describe several methodologies for initiating and completing PQI projects. Furthermore, the authors illustrate several tools that are vital in compiling, analyzing, and presenting data in an easily understandable and reproducible manner. Last, they describe two PQI projects performed in an interventional radiology division that have successfully improved the quality of care for patients. Using the DMAIC (define, measure, analyze, improve, control) quality improvement framework, interventional radiology throughput has been increased, to lessen mediport wait times from 43 to 8 days, and mediport infection rates have decreased from more than 2% to less than 0.4%.