Implementation of a 4-dimensional computed tomography protocol for parathyroid adenoma localization

PurposeTo present the results of our implementation of a four-dimensional computed tomography- (4DCT) based parathyroid localization protocol for primary hyperparathyroidism at a safety net hospital.MethodsWe performed a retrospective review of all patients who underwent parathyroidectomy for primary hyperparathyroidism at Elmhurst Hospital Center from June 2016 – September 2019. Patients treated prior to the implementation of 4DCT during October 2018 served as historical controls for comparison. Imaging-related costs and hospital charges were obtained from the Radiology Department for each patient.ResultsForty-two patients underwent parathyroid surgery during the study period. Twenty patients had undergone 4DCT while 22 had nuclear medicine studies with or without ultrasonography. The sensitivity and specificity of 4DCT was 90.4% and 100% respectively, compared to 63% and 93.7% for nuclear imaging studies and 41% and 95% for ultrasound. The mean number of glands explored was significantly less in the 4DCT group, 1.8 ± 1.19 versus 2.77 ± 1.26 (p = 0.01). There was no increase in infrastructure or personnel costs associated with 4DCT implementation.Conclusions4DCT represents an increasingly common imaging modality for pre-operative parathyroid localization. Here we demonstrate that 4DCT is associated with a reduction in the number of glands explored and enables minimally invasive parathyroid surgery. 4DCT is a cost-effective and clinically sound localization study for parathyroid localization in an urban safety-net hospital.     

An Easily Assembled,Low-Cost Model for Lateral Canthotomy Education

BackgroundLateral canthotomy is a vision-saving procedure. However, the low incidence of orbital compartment syndrome and the expense of simulators to practice this procedure can lead to low confidence and delays in the performance of the procedure by emergency physicians.DiscussionWe used a simple, inexpensive, easily assembled eye model for lateral canthotomy education at a residency program and a national conference obtaining feedback from simulation participants. Residents rated procedure laboratories that included the lateral canthotomy model as 4.9 to 5 (on a 5-point Likert scale, with 5 being the best score). National conference participants rated the model a 9 as a useful training model for practitioners on a 10-point Likert scale.ConclusionThis simple task trainer is practical, inexpensive, quickly assembled, and useful as a tool for practicing emergency medicine providers.     

Does Tweeting Improve Citations? One-Year Results From the TSSMN Prospective Randomized Trial

1. Download : Download high-res image (181KB)
2. Download : Download full-size image

     

Recent Administration of Iodinated Contrast Renders Core Infarct Estimation Inaccurate Using RAPID Software

BACKGROUND AND PURPOSE:Automated CTP software is increasingly used for extended window emergent large-vessel occlusion to quantify core infarct. We aimed to assess whether RAPID software underestimates core infarct in patients with an extended window recently receiving IV iodinated contrast.MATERIALS AND METHODS:We reviewed a prospective, single-center data base of 271 consecutive patients who underwent CTA ± CTP for acute ischemic stroke from May 2018 through January 2019. Patients with emergent large-vessel occlusion confirmed by CTA in the extended window (>6 hours since last known well) and CTP with RAPID postprocessing were included. Two blinded raters independently assessed CT ASPECTS on NCCT performed at the time of CTP. RAPID software used relative cerebral blood flow of <30% as a surrogate for irreversible core infarct. Patients were dichotomized on the basis of receiving recent IV iodinated contrast (<8 hours before CTP) for a separate imaging study.RESULTS:The recent IV contrast and contrast-naïve cohorts comprised 23 and 15 patients, respectively. Multivariate linear regression analysis demonstrated that recent IV contrast administration was independently associated with a decrease in the RAPID core infarct estimate (proportional increase = 0.34; 95% CI, 0.12–0.96; P = .04).CONCLUSIONS:Patients who received IV iodinated contrast in proximity (<8 hours) to CTA/CTP as part of a separate imaging study had a much higher likelihood of core infarct underestimation with RAPID compared with contrast-naïve patients. Over-reliance on RAPID postprocessing for treatment disposition of patients with extended window emergent large-vessel occlusion should be avoided, particularly with recent IV contrast administration.

Quantifying core infarction versus viable ischemic penumbra is at the crux of patient selection for mechanical thrombectomy (MT) in the setting of anterior circulation emergent large-vessel occlusion (ELVO). While patients with large infarcts tend to demonstrate worse clinical outcomes following reperfusion, successful recanalization of sizable ischemic penumbra, indicative of salvageable tissue, may result in drastic clinical improvement.¹ Segregation of core infarction from ischemic penumbra is particularly relevant for extended window ELVOs (>6 hours since last known well [LKW]).^2,3The semiquantitative ASPECTS system is highly predictive of clinical outcome with ELVO but demonstrates high inter- and intrareader variability.^4,5 Additionally, ASPECTS regions are volumetrically weighted unequally; consequently, patients with the same ASPECTS may have different core infarct volumes depending on the regions involved. The automated quantitative RApid processing of PerfusIon and Diffusion (RAPID; iSchemaView) CTP platform offers standardized and numeric estimation of core infarct and ischemic penumbra, lessening reliance on neuroradiologic ASPECTS interpretation. RAPID estimates a variety of perfusion parameters indicative of cerebral hemodynamics at the moment of scanning. Accordingly, RAPID may predict tissue fate in the hyperacute setting (<1 hour since LKW). NCCT, however, is dependent on parenchymal hypoattenuation, which becomes apparent at least several hours from symptom onset.RAPID software has been validated in multiple clinical trials, notably in DAWN (DWI or CTP Assessment with Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention with Trevo) and DEFUSE-3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3), both using RAPID for patient selection for MT in extended window ELVOs. Patients allocated to MT versus best medical therapy alone in the DAWN and DEFUSE-3 trials demonstrated markedly better clinical outcomes with unprecedented numbers needed to treat (NNT) of 2.8 and 4, respectively, to achieve functional independence at 90 days.^2,3Through more ubiquitous RAPID use, we encountered a recurrent phenomenon in which transfer patients with extended window ELVO demonstrated MCA territory hypoattenuation on NCCT but with disproportionately small and, in some instances, zero RAPID estimated core infarct. Essentially, all ELVO transfers to our institution are recent recipients of IV iodinated contrast. Given this imaging incongruity and our ongoing need to optimize patient selection for MT, we aimed to assess whether RAPID software underestimated core infarct volume in patients who received recent (<8 hours) IV contrast for a separate imaging study, most commonly CTA ± CTP at an outside hospital before transfer.     

Modified diagnostic criteria,grading classification and newly elucidated pathophysiology of hepatic SOS/VOD after haematopoietic cell transplantation

Sinusoidal obstruction syndrome (SOS), previously known as hepatic veno-occlusive disease (VOD), remains a multi-organ system complication following haematopoietic cell transplantation (HCT). When SOS/VOD is accompanied by multi-organ dysfunction, overall mortality rates remain >80%. However, the definitions related to the diagnosis and grading of SOS/VOD after HCT are almost 25 years old and require new and contemporary modifications. Importantly, the pathophysiology of SOS/VOD, including the contribution of dysregulated inflammatory and coagulation cascades as well as the critical importance of liver and vascular derived endothelial dysfunction, have been elucidated. Here we summarise new information on pathogenesis of SOS/VOD; identify modifiable and unmodifiable risk factors for disease development; propose novel, contemporary and panel opinion-based diagnostic criteria and an innovative organ-based method of SOS/VOD grading classification; and review current approaches for prophylaxis and treatment of SOS/VOD. This review will hopefully illuminate pathways responsible for drug-induced liver injury and manifestations of disease, sharpen awareness of risk for disease development and enhance the timely and correct diagnosis of SOS/VOD post-HCT.