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To determine the incidence of malignancy for radial scars (RS)/radial sclerosing lesions (RSL) without associated atypia or malignancy identified at needle biopsy. Retrospective review of the pathology data base from January 2004 to July 2013 yielded 100 needle biopsies diagnosed as RS/RSL without associated atypia/malignancy. The RS/RSL was considered "incidental" if the target was calcifications and "targeted" if imaging revealed a mass, architectural distortion, or suspicious magnetic resonance imaging enhancement. The electronic medical record was used to identify surgical pathology, follow-up imaging, and clinical course; all pathology slides and imaging were reviewed by a board-certified pathologist and radiologist, respectively. Patient age, laterality, RS/RSL size, microcalcifications, and associated benign lesions were recorded. Among 100 cases, 54 were "incidental" and 46 were "targeted." In the incidental group, 14 underwent excision, 30 had imaging follow-up, and 10 were lost to follow-up. In the targeted group, 27 underwent excision, 11 had imaging follow-up, and 8 were lost to follow-up. Atypia was identified in four excisions: three from the incidental group and one from the targeted group. Among these, three had negative imaging follow-up (mean 45 months; range 15-60 months); the fourth patient (one of the incidental group) underwent excision alone. One of the 27 "targeted" patients who underwent excision developed ductal carcinoma in situ of the contralateral breast at 96 months. There have been no ipsilateral malignancies. We found no evidence of associated malignancy at excision for either incidental or targeted biopsies of RS/RSL without atypia. Our study suggests that close imaging follow-up is adequate for patients with RS/RSL without associated atypia/malignancy on needle biopsy.

Rationale and Objectives This study aimed to evaluate the effectiveness of an iPad app for teaching healthcare economics milestones. Materials and Methods Institutional review board-approved, Health Insurance Portability and Accountability Act-compliant survey assessment of radiology residents' knowledge of healthcare economics before and following review of the Healthcare Economics iPad app was undertaken at two residencies. Residents received an electronic link to the pre survey, answered 13 general knowledge questions, rated their knowledge of healthcare economics milestones, and reported any prior economics/business background. During the conference, residents reviewed the app on their iPads. They then received a link to the post survey. Responses were entered using REDCap and a unique yet anonymous code was used to link each resident's pre and post results. A follow-up survey was completed at 3 months using REDCap. Results Sixty-two of 69 (90%) residents completed the pre survey. Mean and median age was 30 years. Thirty-two of 62 (52%) were men and 30/62 (48%) were women. Twenty-nine percent (18/62) were postgraduate year (PGY) 2, 24% (15/62) PGY 3, 19% (12/62) PGY 4, 26% (16/62) PGY 5, and 1.6% (1/62) PGY 6. Thirty-four percent (21/62) reported some economics/business background. Residents' mean self-assessment of their knowledge of healthcare economics milestones was fair on the pre survey, significantly improved on the post survey, and plateaued at 3 months. Fifty-nine residents completed the post survey; 60 completed the 3-month follow-up. Residents demonstrated a significant increase in healthcare economics knowledge on post survey. At 3-month follow-up, significant decreases in gained knowledge were observed only in residents for whom the material was not integrated into the curriculum. Conclusions Teaching with iPad apps offers an alternative, effective way to teach basics of healthcare economics milestones.

The objective of the study was to determine if time to positive (TTP), defined as the time from the start of (99m)Tc-labeled RBC scanning to the appearance of a radionuclide blush (considered to be a positive finding for acute lower gastrointestinal bleeding [LGIB]), and lag time (LT), defined as the time from the appearance of a radionuclide blush to the start of catheter angiography (CA), affected the yield of CA for the detection of acute LGIB.TTP and LT were retrospectively evaluated in 120 patients who had positive findings for acute LGIB on (99m)Tc-labeled RBC scanning and subsequently underwent CA for the diagnosis and localization of gastrointestinal bleeding. Two nuclear medicine fellowship-trained radiologists independently reviewed the (99m)Tc-labeled RBC scans. Two fellowship-trained interventional radiologists independently reviewed the angiograms. All data were analyzed using SAS software.When a TTP threshold of ≤ 9 minutes was used, the sensitivity, specificity, positive predictive value, and negative predictive value for a positive CA study were 92%, 35%, 27%, and 94%, respectively. In addition, the odds of detecting bleeding on CA increased 6.1-fold with a TTP of ≤ 9 minutes relative to a TTP of9 minutes (p = 0.020). A significant inverse relationship was found between LT and a positive CA study (p = 0.041).TTP and LT impact the rate of positive CA studies. A TTP threshold of ≤ 9 minutes allows the detection of almost all patients who would benefit from CA for treatment and allows a reduction in unnecessary negative CA studies. The likelihood of positive findings on CA decreases with a delay in the performance of CA.

BACKGROUND Intracerebral hemorrhage (ICH) volumes are frequently used for prognostication and inclusion of patients in clinical trials. We sought to compare the original ABC/2 method and sABC/2, a simplified version with the planimetric method. METHODS We retrospectively reviewed admission head CT scans of consecutive ICH patients admitted to a single academic center from July 2012 to April 2013. We assessed ICH volume on the admission. In ABC/2 method, A = greatest hemorrhage diameter by CT, B = diameter perpendicular to A, C = the approximate number of CT slices with hemorrhage multiplied by the slice thickness. C is weighted by area as 75%. However, in the sABC/2 method, C is the total number of cuts with ICH without any weighting. Bland–Altman plots were generated for both the ABC/2 and sABC/2 methods in comparison to the planimetric method. RESULTS One hundred thirty-five patients with spontaneous ICH were included in the final analysis. Bland–Altman analysis illustrated that both ABC/2 and sABC/2 were concordant with the planimetric method. ABC/2 had more bias than sABC/2 (47% vs. 5%, respectively) with no evidence of a linear trend. For differentiating a volume threshold of 30 mL, ABC/2 was less sensitive but more specific than sABC/2 (P < .0001). Concordance between planimetry, ABC/2, and sABC/2 was high, evidenced by most coefficients exceeding .90. CONCLUSION Simplified ABC/2 (sABC/2) method performs better than ABC/2 in calculating ICH volumes. Moreover, it is better in differentiating a volume threshold of 30 mL. These findings may have implications for outcomes prediction and clinical trials inclusion.

Rationale: Recent studies have focused on the role of female sex and estradiol (E2) in pulmonary arterial hypertension (PAH), but it is not known whether sex hormones are risk factors for PAH in men.Objectives: We performed a case-control study to determine whether hormone levels (E2, dehydroepiandrosterone-sulfate [DHEA-S], and testosterone) are associated with PAH in men.Methods: Plasma sex hormone levels in men with idiopathic, heritable, or connective tissue disease–associated PAH were compared with those from age- and body mass index–matched men without clinical cardiovascular disease.Measurements and Main Results: There were 23 cases with PAH (70% had idiopathic PAH, 65% were functional class III/IV) and 67 control subjects. Higher E2 and E2/testosterone levels were associated with the risk of PAH (odds ratio per 1 ln[E2:testosterone], 6.0; 95% confidence interval, 2.2–16.4; P = 0.001), whereas higher levels of DHEA-S were associated with a reduced risk (odds ratio per 1 ln[DHEA-S], 0.1; 95% confide...

Aims Extracellular vesicles (EVs) from mice with monocrotaline (MCT)-induced pulmonary hypertension (PH) induce PH in healthy mice, and the exosomes (EXO) fraction of EVs from mesenchymal stem cells (MSCs) can blunt the development of hypoxic PH. We sought to determine whether the EXO fraction of EVs is responsible for modulating pulmonary vascular responses and whether differences in EXO-miR content explains the differential effects of EXOs from MSCs and mice with MCT-PH. Methods and results Plasma, lung EVs from MCT-PH, and control mice were divided into EXO (exosome), microvesicle (MV) fractions and injected into healthy mice. EVs from MSCs were divided into EXO, MV fractions and injected into MCT-treated mice. PH was assessed by right ventricle-to-left ventricle + septum (RV/LV + S) ratio and pulmonary arterial wall thickness-to-diameter (WT/D) ratio. miR microarray analyses were also performed on all EXO populations. EXOs but not MVs from MCT-injured mice increased RV/LV + S, WT/D ratios in healthy mice. MSC-EXOs prevented any increase in RV/LV + S, WT/D ratios when given at the time of MCT injection and reversed the increase in these ratios when given after MCT administration. EXOs from MCT-injured mice and patients with idiopathic pulmonary arterial hypertension (IPAH) contained increased levels of miRs-19b,-20a,-20b, and -145, whereas miRs isolated from MSC-EXOs had increased levels of anti-inflammatory, anti-proliferative miRs including miRs-34a,-122,-124, and -127. Conclusion These findings suggest that circulating or MSC-EXOs may modulate pulmonary hypertensive effects based on their miR cargo. The ability of MSC-EXOs to reverse MCT-PH offers a promising potential target for new PAH therapies.

Selection of the most appropriate modality for image guidance is essential for procedural success. We identified specific factors contributing to failure of ultrasound-guided procedures that were subsequently performed using CT guidance. This single-center, retrospective study included 164 patients who underwent a CT-guided biopsy, aspiration/drainage, or ablation after initially having the same procedure attempted unsuccessfully with ultrasound guidance. Review of the procedure images, reports, biopsy results, and clinical follow-up was performed and the reasons for inability to perform the procedure with ultrasound guidance were recorded. Patient cross-sectional area and depth to target were calculated. Differences in area and depth were compared using general linear modeling. Depth as a predictor of an unfavorable body habitus designation was modeled using logistic regression. US guidance was successful in the vast majority of cases (97%). Of the 164 procedures, there were 92 (56%) biopsies, 63 (38%) aspirations/drainages, and 9 (5%) ablations. The most common reason for procedure failure was poor acoustic window (83/164, 51%). Other reasons included target lesion being poorly discerned from adjacent tissue (61/164, 37%), adjacent bowel gas (34/164, 21%), body habitus (27/164, 16%), and gas-containing collection (22/164, 13%). Within the biopsy subgroup, patients for whom body habitus was a limiting factor were found to have on average a larger cross-sectional area and lesion depth relative to patients whose body habitus was not a complicating factor (p

PURPOSE: To develop a deep learning approach to bone age assessment based on a training set of developmentally normal pediatric hand radiographs and to compare this approach with automated and manual bone age assessment methods based on Greulich and Pyle (GP). METHODS: In this retrospective study, a convolutional neural network (trauma hand radiograph–trained deep learning bone age assessment method [TDL-BAAM]) was trained on 15 129 frontal view pediatric trauma hand radiographs obtained between December 14, 2009, and May 31, 2017, from Children’s Hospital of New York, to predict chronological age. A total of 214 trauma hand radiographs from Hasbro Children’s Hospital were used as an independent test set. The test set was rated by the TDL-BAAM model as well as a GP-based deep learning model (GPDL-BAAM) and two pediatric radiologists (radiologists 1 and 2) using the GP method. All ratings were compared with chronological age using mean absolute error (MAE), and standard concordance analyses were performed. RESULTS: The MAE of the TDL-BAAM model was 11.1 months, compared with 12.9 months for GPDL-BAAM (P = .0005), 14.6 months for radiologist 1 (P < .0001), and 16.0 for radiologist 2 (P < .0001). For TDL-BAAM, 95.3% of predictions were within 24 months of chronological age compared with 91.6% for GPDL-BAAM (P = .096), 86.0% for radiologist 1 (P < .0001), and 84.6% for radiologist 2 (P < .0001). Concordance was high between all methods and chronological age (intraclass coefficient > 0.93). Deep learning models demonstrated a systematic bias with a tendency to overpredict age for younger children versus radiologists who showed a consistent mean bias. CONCLUSION: A deep learning model trained on pediatric trauma hand radiographs is on par with automated and manual GP-based methods for bone age assessment and provides a foundation for developing population-specific deep learning algorithms for bone age assessment in modern pediatric populations. Supplemental material is available for this article. © RSNA, 2020 See also the commentary by Halabi in this issue.

Objective Over 40% of combat Veterans report exposure to at least one type of morally injurious experience (MIE). While moral injury (MI) is described among Veterans with posttraumatic stress disorder (PTSD), MI has not been studied in Veterans with psychogenic nonepileptic seizures (PNES). We sought to identify MI in a clinical sample of Veterans with PNES and describe differences between those with MI and those without. Methods We conducted a retrospective cross-sectional study of 82 male and female Veterans with video-electroencephalography (EEG)-confirmed PNES consecutively seen in a Veterans Administration neuropsychiatry clinic. Identification of MI (witnessed or experienced events that conflict with one's moral compass) was made based by an independent observer using a survey of MIEs. Comorbidities, trauma history, and symptom scales were compared among those with and without MI. Results Twelve of 82 Veterans with PNES had MI. Those with MI reported higher guilt, depression symptoms and were of younger average age. There were no significant differences for categorical PTSD diagnosis, abuse history, or other demographic variables between those with and without MI. Summary In this sample of Veterans with PNES, MI was present in 14.6%. Those with MI had more guilt and depressive symptoms than those without. An increased understanding of this condition may aid in the development of diagnostic screenings and therapy options for those with PNES.

Point-of-care (POC) Hemoglobin A1C (HbA1C) testing is frequently used to assess glycemic control in diabetes management. Studies are lacking on the comparison of POC with high performance liquid chromatography (HPLC) when the POC HbA1C is ≥ 14%.Retrospective chart review of children with T1DM at Rhode Island Hospital from 2007-2013. Primary objective was to delineate the range of HPLC HbA1C values when the POC is ≥ 14% and characterize these patients.There were 72 patients, 5-21 years old, with corresponding POC and HPLC tests. Nineteen children, mean age 16.1 years, had a POC HbA1C ≥ 14%. Their mean HPLC value was 14.1% (95% CI [13.4, 14.8]), with range 11.1-16.3 and standard deviation 1.4%.There is wide variation when POC HbA1C values are ≥ 14%. We suggest routine central HbA1C testing when the POC is ≥ 14% for proper counseling and follow-up of glycemic control. Tracking relative changes in HbA1C at subsequent clinic visits is important as it allows clinicians to gauge whether or not interventions are effective. Additionally, knowledge that their HbA1C is trending down may provide positive reinforcement to adolescents.

Despite largely unproven clinical effectiveness, incentive spirometry (IS) is widely used in an effort to reduce postoperative pulmonary complications. The objective of the study is to evaluate the financial impact of implementing IS. The amount of time nurses and RTs spend each day doing IS-related activities was assessed utilizing an online survey distributed to the relevant national nursing and respiratory therapists (RT) societies along with questionnaire that was prospectively collected every day for 4 weeks at a single 10-bed cardiothoracic surgery step-down unit. Cost of RT time to teach IS use to patients and cost of nurse time spent reeducating and reminding patients to use IS were used to calculate IS implementation cost estimates per patient. Per-patient cost of IS implementation ranged from $65.30 to $240.96 for a mean 9-day step-down stay. For the 566 patients who stayed in the 10-bed step-down in 2016, the total estimated cost of implementing IS ranged from $36 959.80 to $136 383.36. Using national survey workload data, per-patient cost of IS implementation costed $107.36 (95% confidence interval [CI], $97.88-$116.98) for a hospital stay of 4.5 days. For the 9.7 million inpatient surgeries performed annually in the United States, the total annual cost of implementing postoperative IS is estimated to be $1.04 billion (95% CI, $949.4 million-$1.13 billion). The cost of implementing IS is substantial. Further efficacy studies are necessary to determine whether the cost is justifiable.

Infectious disease (ID) consultation in patients with Staphylococcus aureus bacteremia who were at low risk for endocarditis and who had no secondary site of infection was associated with a longer course of antibiotics (median duration of intravenous antimicrobial therapy of 31 days and 15 days in those with and without ID consultation, respectively; P ≤ .01), and based on Kaplan-Meier survival analysis, reduced in-hospital mortality (P = .2), and reduced 30-day mortality after discharge (P = .4). ID consultation was also associated with a higher readmission rate within 90 days of discharge: 46% and 34% with and without ID consultation, respectively (P = .2).

BackgroundFollowing the results of randomized clinical trials supporting the use of mechanical thrombectomy (MT) with tissue plasminogen activator for emergent large vessel occlusion (ELVO), our state Stroke Task Force convened to: update legislation to recognize differences between Primary Stroke Centers (PSCs) and Comprehensive Stroke Centers (CSCs); and update Emergency Medical Services (EMS) protocols to triage direct transport of suspected ELVO patients to CSCs.PurposeWe developed a single-session training curriculum for EMS personnel focused on the Los Angeles Motor Scale (LAMS) score, its use to correctly triage patients as CSC-appropriate in the field, and our state-wide EMS stroke protocol. We assessed the effect of our training on EMS knowledge.MethodsWe assembled a focus group to develop a training curriculum and assessment questions that would mimic real-life conditions under which EMS personnel operate. Ten questions were formulated to assess content knowledge before and after training, and scores were compared using generalized mixed models.ResultsTraining was provided for 179 EMS providers throughout the state.Average pre-test score was 52.4% (95% CI 49% to 56%). Average post-test score was 85.6% (83%–88%, PConclusionsA brief educational intervention results in substantial improvements in EMS knowledge of prehospital stroke severity scales and severity-based field triage protocols. Further study is needed to establish whether these gains in knowledge result in improved real-world performance.

Objectives Mechanical thrombectomy is the standard of care for stroke caused by an emergent large vessel occlusion in the anterior circulation, and the ability to rapidly review CTA is one hurdle in minimizing the time from diagnosis to intervention. We evaluated the diagnostic accuracy and confidence in review of stroke CTA for ELVO via a smartphone-based application as compared to PACS workstation. Patients and Methods Seventy-six head and neck CTA studies performed for stroke from one comprehensive and seven primary stroke centers were independently reviewed remotely on smartphone by two blinded interventional neuroradiologists in actual-use circumstances. The presence and location of large vessel occlusion(s), diagnostic quality, and confidence in interpretation were recorded. Comparison was made to blinded PACS workstation review performed at a delayed interval. Weighted Kappa and Kendall’s Tau statistics were calculated to evaluate intra- and inter-observer reliability. Results Of the 76 studies, 20 (26%) had a large vessel occlusion. 14 M1 segment occlusions (18%); 2 ICA terminus (3%); 2 tandem carotid and M1 (3%); and 2 basilar artery (3%). There was 100% diagnostic accuracy by both PACS workstation and smartphone review (p = .9999) with high inter- and intra-rater reliability for assessments of both image quality and diagnostic confidence. Conclusion In actual-use circumstances, experienced neuroradiologists can diagnose ELVOs on CTA using a smartphone application as accurately as on PACS workstation without degradation of confidence. These findings support the use of mobile electronic devices by stroke centers to rapidly triage patients for mechanical thrombectomy.

High oestradiol (E2) and low dehydroepiandrosterone-sulfate (DHEA-S) levels are risk factors for pulmonary arterial hypertension (PAH) in men, but whether sex hormones are related to PAH in women is unknown.Post-menopausal women aged ≥55 years with PAH were matched by age and body mass index to women without cardiovascular disease. Plasma sex hormone levels were measured by immunoassay.Lower levels of DHEA-S (p−1) decrease in DHEA-S was associated with a doubling in the risk of death (hazard ratio 2.0, 95% CI 1.5–2.7; pHigh E2 and low DHEA-S levels are associated with the risk and severity of PAH in post-menopausal women. Hormonal modulation should be studied as a treatment strategy in PAH.

Introduction: Higher rates of recanalization following thrombectomy are associated with better clinical outcomes. Specifically, patients with TICI 2c or 3 recanalization have higher degrees of functional independence as compared with TICI 2b recanalization. Older age is also associated with worse outcomes. We sought to determine if the magnitude of difference in outcomes between TICI 2c/3 and 2b is affected by age. Methods: We identified 157 consecutive patients with anterior circulation LVO over 24 months at a single center. Angiograms were reviewed blinded to clinical outcome. In 24 patients, TICI 2b or greater recanalization could not be achieved. This left 133 patients for analysis, with TICI 2c/3 recanalization in 72, and TICI 2b in 61. Primary outcome measures were independence (defined as mRs 0-2 at 90 days), and Utility weighted Rankin at 90 days. We analyzed the relationship between age and outcomes, comparing the TICI 2c/3 vs. 2b groups. Results: Patient age ranged from 19 to 92, median 73 (IQR 61-82). Median NIHSS was 17 (IQR 13-20). Median [IQR] time from imaging to reperfusion was 106 [80-141.5] minutes in the TICI 2c/3 group and 124 [86-150] minutes in the TICI 2b group, and did not increase with age. When comparing the relationship between age and outcomes, there was a greater decrease in functional outcome in those with TICI 2b versus TICI 2c/3 reperfusion. In patients younger than 70, 19/29 (66%) with TICI 2b achieved independence at 90 days, as compared with 19/26 (73%) in the TICI 2c/3 group. In patients 70 and older, 9/32 (28%) with TICI 2b achieved independence at 90 days, as compared with 26/46 (57%) in the TICI 2c/3 group, a significant difference (p=.02). The relationship between age and utility weighted Rankin at 90 days is highly significant (p=.0067) and summarized in the figure. Conclusions: The additional benefit of TICI 2c/3 over TICI 2b increases significantly with age. Higher levels of recanalization may benefit older patients to a greater extent.

Introduction: Neurology led Stroke Teams are becoming imperative in recent care models of acute stroke management. Advanced Practice Providers (APP) are important members of these stroke teams. Code Stroke simulations allow (APP) to gain valuable experience in the evaluation and treatment of a potential stroke patient without compromising patient care. We hypothesized that simulation training would increase advanced practice provider confidence, comfort level and preparedness in leading a Code Stroke similar to neurology residents. Methods: Nine advanced practice providers and nine neurology residents each took turns leading a Code Stroke simulation to determine need for intravenous thrombolysis, thrombectomy and blood pressure management on three cases with standardized patients. Emergency medicine physicians and neurologists were preceptors and gave feedback. APPs and residents completed a survey before and after the simulation. Generalized mixed modeling assuming a binomial distribution was used to evaluate change. Results: On a 5-point Likert scale (1 - Strongly disagree and 5 - Strongly agree), confidence in leading a Code Stroke significantly increased from (2.8 to 4.5, p Conclusion: Simulation training is a beneficial part of medical education for advanced practice providers and should be considered in addition to traditional didactics and clinical training.

Introduction: Treatment for large vessel occlusion is profoundly time dependent. Two potential mechanisms to reduce time to treatment are optimizing transfers from Primary Stroke Centers (PSC) and transporting selected patients directly to a Comprehensive Stroke Center (CSC). In our region, we sequentially implemented both interventions. We sought to evaluate the impact of 1) Optimization of PSC transfer protocols and 2) implementation of a severity based EMS triage protocol on times to treatment and outcomes. Methods: All thrombectomy patients in our state treated over 24 months were retrospectively reviewed. We included patients with anterior circulation LVO, presenting within 6 hours, with an NIHSS of 6 or higher. An EMS protocol was introduced such that patients with a field LAMS score of 4 or higher, within 30 minutes of the CSC, would be directly transported to the CSC. Patients from adjacent states (where the EMS protocol would not apply) as well as inpatient strokes were excluded. We examined the proportion of patients who were directly transported to the CSC, as well as trends in time to treatment with IV tPA and thrombectomy from the time of first hospital arrival (PSC or CSC). Time periods were as follows: 7/1/2015 to 12/31/2015 (Pre-optimization and pre-triage); 1/1/2016 to 12/31/2016 (PSC optimization; pre-triage) and 1/1/2017 to 6/30/2017 (PSC optimization and triage). Primary outcome measures were times to treatment, discharge to home, and in-hospital mortality. Results: The results are summarized in the table below. Marked decreases in median time from first hospital arrival to recanalization were seen, from 156 to 109 minutes over time. In addition, there were increases in discharge home, and decreases in in-hospital mortality across each of the time periods. Conclusions: Through a combination of field triage and optimization of PSC workflow, it is possible to reduce times to thrombectomy and improve outcomes across an entire region.

Introduction: All eligible patients receive IV tPA prior to thrombectomy, but the effect of IV tPA on recanalization prior to and following thrombectomy remains unclear. The purpose of this analysis was to determine the effect of IV tPA on early recanalization obviating the need for thrombectomy, as well as the effect of tPA on recanalization rates. Methods: All patients with a CTA-proven LVO in the ICA, M1, proximal M2, or basilar artery in whom thrombectomy was planned over a 24 month period were included. CTA was performed at the first presenting hospital, whether PSC or CSC, and not repeated on arrival for transfer patients. We defined “successful” treatment with IV tPA as TICI 2b or 3 reperfusion, such that thrombectomy was not performed. Time from tPA to start of angiography was divided into 30 minute intervals. We also examined the effect of transfer status and the relationship between tPA and overall recanalization after thrombectomy. Results: We identified 310 patients, 190 who received tPA prior to planned thrombectomy and 120 who did not. Of all patients, 178 (57%) were transfers, including 111/190 (58%) in the tPA group. The rates of recanalization with IV tPA are summarized in Table below. Overall rates of successful recanalization (TICI 2b or better) before thrombectomy are low, especially when time between IV tPA and start of angiography is minimized. Successful tPA recanalization rates were 11.7% for transfer patients and 6.3% for non-transfer patients, likely due to faster workflow at the comprehensive stroke center. The rates of overall successful recanalization (TICI 2b or better) were 77.4% in the tPA group (23.8% TICI 2b; 53.6% TICI 2c/3) and 83.6% (22.4% TICI 2b; 61.2% TICI 2c/3) in the no tPA group. Conclusion: Early recanalization rate following IV tPA prior to thrombectomy is low, especially when workflow is optimized to minimize time between tPA bolus and start of angiography. Pre-treatment with IV tPA did not increase recanalization rates after thrombectomy.

Introduction: We have previously shown that a transfer protocol for patients with suspected large vessel occlusion (LVO) stroke which includes early vessel imaging at the Primary Stroke Center (PSC) is associated with decreased onset to recanalization times driven entirely by improved initial hospital processes at the PSC and reflected in the PSC Door-in Door-out (DIDO) time. In this study, we examined the association between DIDO and outcomes. Methods: We collected prospective data on 195 patients transferred to our Comprehensive Stroke Center (CSC) with PSC-confirmed LVO between July 1, 2015 and June 30, 2017. The patients were accepted from 2 states and 16 different PSCs (only 2 of which were part of our hospital system) and the furthest PSC being 56 miles away. We included all patients with LVO stroke (ICA, M1, Basilar) with an NIHSS of 6 or higher. We examined PSC workflow factors associated with shorter DIDO times. Outcomes were examined by DIDO using generalized mix modeling assuming a binomial distribution with SAS 9.4. Results: The median [IQR] age and NIHSS of the 195 ELVO transfers was 75 [62-84] and 17 [12-22]. IV tpA was administered to 64% of patients. Regarding specific workflow metrics, Median [IQR] times (in minutes) for PSC door to CT was 12 [9-20], PSC door to CTA 26 [19-50], PSC door to tPA 58 [46-78], DIDO 87 [68-113], PSC door to CSC groin puncture 140 [115-179], and PSC door to CSC recanalization of 169 [136-216]. As can be seen in the Figure, longer DIDO were associated with more deleterious scores on discharge NIHSS (p=0.04), discharge mRS (p=0.009) and 90d mRS (p=0.002). Full execution of the PSC LVO protocol and “hold, drip and go” strategy for EMS transport were associated with shorter DIDO times. Conclusion: For patients diagnosed with LVO at a PSC, longer DIDO time appears to have a deleterious effect on outcome at discharge from the CSC and at 90 days. All PSCs should take measures to decrease DIDO and use it as a quality metric.

Background: Following the results of randomized clinical trials supporting the use of mechanical thrombectomy (MT) with tPA for large vessel occlusion (LVO) stroke, our state Stroke Task Force convened to 1) update legislation to recognize differences between Primary Stroke Centers (PSCs) and Comprehensive Stroke Centers (CSCs) and (2) update EMS protocols to triage direct transport of suspected LVO patients to CSCs. Objectives: Develop an assessment and single-session training curriculum to assess EMS knowledge before and knowledge gained after training on Los Angeles Motor Scale (LAMS) score, its use to correctly triage patients as CSC-appropriate, and our state-wide EMS protocol for stroke. We also aim to share our specific approach and its efficacy with others so our work can be disseminated and implemented elsewhere. Methods: We assembled a focus group to develop assessment questions that would mimic real-life conditions EMS personnel operate under. Ten identical pre-post training questions were formulated to assess content provided during the trainings. Content validity was established by ensuring that questions exclusively tested the content of the slides in the training. Results: Trainings were provided for 354 EMS professionals throughout the state. Average pre-test score was 52.4% (95% CI 49%-56%). Average post-test score was 85.6% (83%-88%), representing a significant increase. Each of the 10 questions were individually assessed and all showed significant gains in EMS knowledge after training (Figure 1, p Conclusions: Structured EMS education can improve knowledge of stroke triage protocols. As EMS protocols are changed to improve triage of suspected LVO patients to CSCs, such educational efforts will be critical to improve compliance.

Introduction: Since the treatment effect of mechanical thrombectomy (MT) is profoundly time-dependent, we created an optimized Comprehensive Stroke Center-Large Vessel Occlusion (CSC-LVO) protocol focusing on three key steps: early vessel imaging on all code stroke patients, standardizing the MT procedure, and integrating a team of stroke-dedicated advanced practice clinicians (APCs) to manage patients across the continuum of initial hospital care. Methods: All direct to CSC (“mothership”) LVO patients treated during the following time periods (Epochs) were retrospectively reviewed: 1/1/2015 to 6/30/2015 (Pre-optimization); 1/1/2016 to 6/30/2016 (Early Vessel Imaging and MT standardization) and 1/1/2017 to 6/30/2017 (Early Vessel Imaging, MT standardization, APC integration). Epochs were separated by 6 months to minimize any “ramp-up” effect. We included all patients who presented with large vessel occlusion stroke (ICA, M1, Basilar), within six hours from symptom onset, and with an NIHSS of 6 or higher. During Epoch 3, APCs were available for 12h/day and 7 days a week. For all cases, the neurointerventional team was activated only after the CTA confirmed large vessel occlusion. To measure efficiency of initial hospital processes, we compared CSC door to CT, door to CTA, door to IV t-PA, door to groin puncture, and door to recanalization across time Epochs. Results: All results are summarized in the table below and there was a marked decrease in median time from CSC arrival to recanalization from 186 to 100 minutes. Within Epoch 3, when APCs were in-house (n=29/44 or 70% of cases), the median [IQR] Door to t-PA, door to groin puncture, and door to recanalization times were lowest 27 [23-31], 53 [42-73], and 86 [72-118] minutes, respectively. Conclusions: A CSC-LVO protocol including early vessel imaging, procedural standardization, and integrating a team of stroke-dedicated APCs enables CSCs to achieve median door to recanalization times in less than 90 minutes.

Purpose To compare screening mammography recall rate, cancer detection rate (CDR), and positive predictive values (PPVs) for digital mammography before and after radiologist experience with digital breast tomosynthesis (DBT). Materials and Methods This retrospective study was approved by the institutional review board and compliant with HIPAA. The authors reviewed screening mammography audit data obtained from 2009 to 2014, during which 108 276 digital mammographic examinations were performed (50 062 before and 58 214 after experience with DBT). Recall rate, CDR, PPV of positive screening result (PPV1), PPV of biopsy recommendation (PPV2), and PPV of biopsies performed (PPV3) of digital mammography for six radiologists were compared before (2009-2011) and after (2012-2014) experience with DBT. Radiologists worked in both a community setting, in which only digital mammography was available, and in two tertiary breast imaging centers, where they interpreted DBT images starting in 2012. Data were examined by using generalized linear mixed modeling wherein observations were nested for each radiologist over time. P < .05 was considered indicative of a statistically significant difference; 95% confidence intervals (CIs) were calculated. Results The average recall rate was 6.8% (range, 3.6%-9.7%) before experience with DBT and 7.9% (range, 5.5%-9.5%) after (P = .0316). Before experience with DBT, the recall rate increased only 0.01% for each year from 2009 to 2011 (P = .9727). After experience with DBT, the recall rate increased 0.65% for each year from 2012 to 2014 (P < .0127). CDR increased from 2.5 per 1000 examinations (95% CI: 2.2, 2.9) to 3.5 per 1000 examinations (95% CI: 3.0, 4.0; P = .0203). PPV2 and PPV3 increased significantly after experience with DBT, from 26.9% (95% CI: 19.9%, 35.3%) to 36.1% (95% CI: 31.7%, 40.7%; P = .0212) for PPV2 and from 31.2% (95% CI: 24.0%, 39.3%) to 40.0% (95% CI: 35.5%, 44.6%; P = .0290) for PPV3. Conclusion Recall rate, CDR, PPV2, and PPV3 of digital mammography increased after radiologist experience with DBT. © RSNA, 2017.

Purpose To establish, in a large cohort, the diagnostic performance of a staged algorithm involving ultrasonography (US) followed by conditional unenhanced magnetic resonance (MR) imaging for the imaging work-up of pediatric appendicitis. Materials and Methods A staged imaging algorithm in which US and unenhanced MR imaging were performed in pediatric patients suspected of having appendicitis was implemented at the authors' institution on January 1, 2011, with US as the initial modality followed by unenhanced MR imaging when US findings were equivocal. A search of the radiology database revealed 2180 pediatric patients who had undergone imaging for suspected appendicitis from January 1, 2011, through December 31, 2012. Of the 2180 patients, 1982 (90.9%) were evaluated according to the algorithm. The authors reviewed the electronic medical records and imaging reports for all patients. Imaging reports were reviewed and classified as positive, negative, or equivocal for appendicitis and correlated with surgical and pathology reports. Results The frequency of appendicitis was 20.5% (407 of 1982 patients). US alone was performed in 1905 of the 1982 patients (96.1%), yielding a sensitivity of 98.7% (386 of 391 patients) and specificity of 97.1% (1470 of 1514 patients) for appendicitis. Seventy-seven patients underwent unenhanced MR imaging after equivocal US findings, yielding an overall algorithm sensitivity of 98.2% (400 of 407 patients) and specificity of 97.1% (1530 of 1575 patients). Seven of the 1982 patients (0.4%) had false-negative results with the staged algorithm. The negative predictive value of the staged algorithm was 99.5% (1530 of 1537 patients). Conclusion A staged algorithm of US and unenhanced MR imaging for pediatric appendicitis appears to be effective. The results of this study demonstrate that this staged algorithm is 98.2% sensitive and 97.1% specific for the diagnosis of appendicitis in pediatric patients.

Purpose To assess the readability of online patient education materials (OPEM) related to common diseases treated by and procedures performed by interventional radiology (IR). Materials and Methods The following websites were chosen based on their average Google search return for each IR OPEM content area examined in this study: Society of Interventional Radiology (SIR), Cardiovascular and Interventional Radiological Society of Europe (CIRSE), National Library of Medicine, RadiologyInfo, Mayo Clinic, WebMD, and Wikipedia. IR OPEM content area was assessed for the following: peripheral arterial disease, central venous catheter, varicocele, uterine artery embolization, vertebroplasty, transjugular intrahepatic portosystemic shunt, and deep vein thrombosis. The following algorithms were used to estimate and compare readability levels: Flesch-Kincaid Grade Formula, Flesch Reading Ease Score, Gunning Frequency of Gobbledygook, Simple Measure of Gobbledygook, and Coleman-Liau Index. Data were analyzed using general mixed modeling. Results On average, online sources that required beyond high school grade–level readability were Wikipedia (15.0), SIR (14.2), and RadiologyInfo (12.4); sources that required high school grade–level readability were CIRSE (11.3), Mayo Clinic (11.0), WebMD (10.6), and National Library of Medicine (9.0). On average, OPEM on uterine artery embolization, vertebroplasty, varicocele, and peripheral arterial disease required the highest level of readability (12.5, 12.3, 12.3, and 12.2, respectively). Conclusions The IR OPEM assessed in this study were written above the recommended sixth-grade reading level and the health literacy level of the average American adult. Many patients in the general public may not have the ability to read and understand health information in IR OPEM.

To compare recall rate, types of abnormalities recalled, additional imaging required, biopsy positive predictive value (PPV), and cancer detection rate before and after implementation of screening digital breast tomosynthesis (DBT).This retrospective analysis was approved by the institutional review board and complied with HIPAA. The requirement to obtain informed consent was waived. Results from all screening digital mammography (DM) examinations performed without tomosynthesis from March 1, 2011, through February 29, 2012, and DBT examinations performed from March 1, 2012, through February 28, 2013, were reviewed to identify all Breast Imaging Reporting and Data System (BI-RADS) category 0 examinations (needs additional imaging). Radiology and pathology reports were reviewed. The recall rate, biopsy PPV, and cancer detection rate were calculated. Statistical analysis was performed by using a two-proportions z test.The recall rate was 9.3% (1175 of 12 577 examinations; 95% confidence interval [CI]: 8.8%, 9.9%) for DM and 6.4% (827 of 12 921 examinations; 95% CI: 6.0%, 6.8%) for DBT, an overall reduction of 31% (P.00001). The recall rate was lower with DM than with DBT for masses (8.9% vs 26.8%, respectively), distortions (0.6% vs 5.3%), and calcifications (13.4% vs 20.3%) (P.0001 for all). The recall rate was lower with DBT than with DM for asymmetries (13.3% vs 32.2%, respectively) and focal asymmetries (18.2% vs 32.2%) (P.0001 for both). Diagnostic evaluation with ultrasonography (US) increased with DBT at the time of additional imaging (2.6% for DM vs 28.3% for DBT, P.0001). There was no significant difference between DM and DBT with regard to biopsy PPV (30.2% vs 23.8%, P = .21) or cancer detection rate per 1000 patients (5.4 vs 4.6, P = .44).With DBT, the recall rate decreased and the biopsy PPV and cancer detection rate did not decrease. The distribution of recalled abnormalities changed, and more patients were evaluated with US only.

Background The National Institutes of Health (NIH) recommend that health materials be written at a grade 6-7 reading level, which has generally not been achieved in online reading materials. Up to the present time, there have not been any assessments focused on the reading level of online educational materials across the most popular consumer Web sites for common internal medicine diagnoses. In this study, we examined the readability of open-access online health information for 9 common internal medicine diagnoses. Methods Nine of the most frequently encountered inpatient and ambulatory internal medicine diagnoses were selected for analysis. In November and December 2014, these diagnoses were used as search terms in Google, and the top 5 Web sites across all diagnoses and a diagnosis-specific site were analyzed across 5 validated reading indices. Results On average, the lowest reading grade-level content was provided by the NIH (10.7), followed by WebMD (10.9), Mayo Clinic (11.3), and diagnosis-specific Web sites (11.5). Conversely, Wikipedia provided content that required the highest grade-level readability (14.6). The diagnoses with the lowest reading grade levels were chronic obstructive pulmonary disease (10.8), followed by diabetes (10.9), congestive heart failure (11.7), osteoporosis (11.7) and hypertension (11.7). Depression had the highest grade-level readability (13.8). Discussion Despite recommendations for patient health information to be written at a grade 6-7 reading level, our examination of online educational materials pertaining to 9 common internal medicine diagnoses revealed reading levels significantly above the NIH recommendation. This was seen across both diagnosis-specific and general Web sites. There is a need to improve the readability of online educational materials made available to patients. These improvements have the potential to greatly enhance patient awareness, engagement, and physician–patient communication.

OBJECTIVE To examine surgical case volume characteristics in certifying urologists to evaluate practice patterns, given the long-standing understanding but unproven hypothesis that non-fellowship trained female general urologists perform more urogynecologic procedures compared with their equally trained male counterparts. MATERIALS AND METHODS Case log data from certifying and recertifying urologists from 2000 to 2015 were obtained from the American Board of Urology. Thirty-seven Current Procedural Terminology (CPT) codes were chosen to represent traditionally urogynecologic cases. Logistic regression analysis models were used to determine the percentage of total CPT codes logged during the certification period made up by traditionally urogynecologic cases. Male and female non-fellowship trained, self-described general urologists were compared. RESULTS The case logs of 4032 non-fellowship trained general urologists were reviewed from 2000 to 2015, 297 of whom were female and 3735 of whom were male. Urogynecologic cases made up 1.27% of the total CPT codes logged by the women and 0.59% of those codes logged by the men (P

Mandated college students (those in violation of a campus alcohol policy) are heterogenous with respect to alcohol consumption. Thus, when universities consider required treatment for mandated students, one promising option is to match treatment intensity according to level of alcohol involvement. The present study evaluates such an approach with minimal resources.Mandated students (N = 285) were required to complete a baseline assessment. Participants identified as high-risk (5+ past month alcohol problems AND 2+ past month heavy drinking episodes) received a one session individual Brief Motivational Intervention (I-BMI) whereas those identified as low-risk (all others) received a one session group Brief Motivational Intervention (G-BMI). I-BMI and G-BMI sessions were delivered by doctoral students in Clinical Psychology. Follow-up assessments were collected 1 month post-intervention (response rate = 73%).The vast majority of students complied with their requirement. Participants assigned to I-BMI reported an 82% reduction in drinks per week, a 58% reduction in heavy episodic drinking, and a 74% reduction in alcohol-related problems at a 1 month follow-up. Participants assigned to G-BMI reported a 61% reduction in drinks per week and a 42% reduction in alcohol-related problems at follow-up relative to baseline. Conclusion/Importance: We demonstrate that matching intervention intensity on baseline alcohol involvement with mandated students is feasible and associated with short-term reductions in alcohol use and consequences. Universities may wish to consider the procedure outlined here as a way of allocating more resources to those who drink at problematic levels.

The purpose of this study was to describe a new, broadly applicable radiology report categorization (RADCAT) system that was developed collaboratively between radiologists and emergency department (ED) physicians, and to establish its usability and performance by interobserver variation.In collaboration with our ED colleagues, we developed the RADCAT system for all imaging studies performed in our level-1 trauma center, including five categories that span the spectrum of normal through emergent life-threatening findings. During a pilot phase, four radiologists used the system real-time to categorize a minimum of 400 reports in the ED. From this pool of categorized studies, 58 reports were then selected semi-randomly, de-identified, stripped of their original categorization, and recategorized based on the narrative radiology report by 12 individual reviewers (6 radiologists, and 6 ED physicians). Interobserver variation between all reviewers, radiologists only, and ED physicians only was calculated using Cohen's Kappa statistic and Kendall's coefficient of concordance.Altogether, agreement among radiologists and ED physicians was substantial (κ = 0.73, p 0.0001) and agreement for each category was substantial (all κ 0.60, p 0.0001). The lowest agreement was observed with RADCAT-3 (κ 0.61, p 0.0001) and the highest agreement with RADCAT-1 (κ 0.85, p 0.0001). A high trend in agreement was observed for radiologists and ED physicians and their combination (all W 0.90, p 0.0001).Our RADCAT system is understandable between radiologists and ED physicians for categorizing a wide range of imaging studies, and warrants further assessment and validation. Based upon these pilot results, we plan to adopt this RADCAT scheme and further assess its performance.

While prehospital triage to the closest comprehensive stroke center (CSC) may improve the delivery of care for patients with suspected emergent large-vessel occlusion (ELVO), efficient systems of care must also exist for patients with ELVO who first present to a primary stroke center (PSC).To describe the association of a PSC protocol focused on 3 key steps (early CSC notification based on clinical severity, vessel imaging at the PSC, and cloud-based image sharing) with the efficiency of care and the outcomes of patients with suspected ELVO who first present to a PSC.In this retrospective cohort study, 14 regional PSCs unfamiliar with the management of patients with ELVO were instructed on the use of the following protocol for patients presenting with a Los Angeles Motor Scale score 4 or higher: (1) notify the CSC on arrival, (2) perform computed tomographic angiography concurrently with noncontract computed tomography of the brain and within 30 minutes of arrival, and (3) share imaging data with the CSC using a cloud-based platform. A total of 101 patients were transferred from regional PSCs to the CSC between July 1, 2015, and May 31, 2016, and received mechanical thrombectomy for acute ischemic stroke. The CSC serves approximately 1.7 million people and partners with 14 PSCs located between 6.4 and 73.6 km away. All consecutive patients with internal carotid artery or middle cerebral artery occlusions transferred over an 11-month period were reviewed, and they were divided into 2 groups based on whether the PSC protocol was partially or fully executed.The primary outcomes were efficiency measures including time from PSC door in to PSC door out, time from PSC door to CSC groin puncture, and 90-day modified Rankin Scale score (range, 0-6; scores of 0-2 indicate a good outcome).Although 101 patients were transferred, only 70 patients met the inclusion criteria during the study period. The protocol was partially executed for 48 patients (68.6%) (mean age, 77 years [interquartile range, 65-84 years]; 22 of the 48 patients [45.0%] were women) and fully executed for 22 patients (31.4%) (mean age, 76 years [interquartile range, 59-86 years]; 13 of the 22 patients [59.1%] were women). When fully executed, the protocol was associated with a reduction in the median time for PSC arrival to CSC groin puncture (from 151 minutes [95% CI, 141-166 minutes] to 111 minutes [95% CI, 88-130 minutes]; P .001). This was primarily related to an improvement in the time from PSC door in to door out that reduced from a median time of 104 minutes (95% CI, 82-112 minutes) to a median time of 64 minutes (95% CI, 51-71.0 minutes) (P .001). When the protocol was fully executed, patients were twice as likely to have a favorable outcome (50% vs 25%, P .04).When fully implemented, a standardized protocol at PSCs for patients with suspected ELVO consisting of early CSC notification, computed tomographic angiography on arrival to the PSC, and cloud-based image sharing is associated with a reduction in time to groin puncture and improved outcomes.

To compare interobserver variability (IOV), reader confidence, and sensitivity/specificity in detecting architectural distortion (AD) on digital mammography (DM) versus digital breast tomosynthesis (DBT).This IRB-approved, HIPAA-compliant reader study used a counterbalanced experimental design. We searched radiology reports for AD on screening mammograms from 5 March 2012-27 November 2013. Cases were consensus-reviewed. Controls were selected from demographically matched non-AD examinations. Two radiologists and two fellows blinded to outcomes independently reviewed images from two patient groups in two sessions. Readers recorded presence/absence of AD and confidence level. Agreement and differences in confidence and sensitivity/specificity between DBT versus DM and attendings versus fellows were examined using weighted Kappa and generalised mixed modeling, respectively.There were 59 AD patients and 59 controls for 1,888 observations (59 × 2 (cases and controls) × 2 breasts × 2 imaging techniques × 4 readers). For all readers, agreement improved with DBT versus DM (0.61 vs. 0.37). Confidence was higher with DBT, p = .001. DBT achieved higher sensitivity (.59 vs. .32), p .001; specificity remained high (.90). DBT achieved higher positive likelihood ratio values, smaller negative likelihood ratio values, and larger ROC values.DBT decreases IOV, increases confidence, and improves sensitivity while maintaining high specificity in detecting AD.• Digital breast tomosynthesis decreases interobserver variability in the detection of architectural distortion. • Digital breast tomosynthesis increases reader confidence in the detection of architectural distortion. • Digital breast tomosynthesis improves sensitivity in the detection of architectural distortion.

Background and purpose: The Thrombolysis in Cerebral Infarction (TICI) 2b classification is defined as “near complete” recanalization for acute ischemic stroke. While this category has historically combined with TICI 3 (“complete reperfusion”) as “successful recanalization”, recent studies have suggested that TICI 3 and a proposed intermediate TICI 2c (“near complete reperfusion except for slow flow or distal emboli”) should be distinguished from TICI 2b due to differences in outcomes. In this study, we examined if early neurologic improvement differed significantly between patients with TICI 2b, TICI 2c, and TICI 3 recanalization for emergent large vessel occlusions treated with mechanical thrombectomy (MT). Methods: Retrospective analysis was performed using data from 133 consecutive patients with middle cerebral artery or internal carotid artery occlusions treated with MT from January 2015 to June 2016. Patient angiograms were graded independently and blinded to clinical data by two experienced readers based on original TICI (oTICI), modified TICI (mTICI), and modified TICI with TICI 2c (mTICI 2c) grading scales. Early neurologic improvement was assessed using change in NIHSS by discharge. General linear modeling was used to evaluate difference in NIHSS delta scores between TICI scales with SAS/PROC GLIMMIX. Multiple comparisons were evaluated using Tukey corrections with significance established at the .05 level. Results: Without the TICI 2c category, there was not a significant difference in change in NIHSS observed between TICI 3 and TICI 2b for both the oTICI (delta 1.4, p=0.355) and mTICI scales (delta 2.1, p=0.190). However, when an additional category (TICI 2c) was added, there was a significant difference in change in NIHSS observed between TICI 3 and TICI 2b (delta 3.8, p= 0.026) as well as between TICI 2c and TICI 2b (delta 3.7, p=0.019). Conclusion: Utilizing a TICI recanalization grading system that adds an additional category beyond TICI 2b allows for improved prediction of neurological improvement in patients treated with MT. Higher levels of recanalization are associated with greater neurologic improvement.

Introduction: Since mechanical thrombectomy was established as the gold standard for treatment of stroke caused by an emergent large vessel occlusion (ELVO), comprehensive stroke centers have worked to streamline their workflow and minimize time-to-intervention; the ability to rapidly review CT angiography (CTA) is one hurdle in that process. To that end, we evaluated the diagnostic accuracy and confidence in review of CTA of the head and neck for ELVO via a smartphone-based application (LifeImage) as compared to review on a PACS workstation. Methods: Seventy-six head and neck CTA studies performed for potential stroke from one comprehensive and seven primary stroke centers were independently reviewed remotely on smartphone by two blinded neurointerventional radiologists in actual-use circumstances. The presence and location of large vessel occlusion(s), diagnostic quality, and confidence in interpretation were recorded. Comparison was made to blinded review of these studies on a PACS workstation performed at a delayed interval. Kappa statistics were calculated to evaluate intra- and inter-observer reliability. Results: Over 76 studies, occlusion of the M1 segment was demonstrated in 14 (18%); carotid artery in 2 (3%); tandem carotid and M1 in 2 (3%); basilar artery in 2 (3%); and no large vessel occlusion in 56 (73%). There was complete agreement between CTA interpretations on smartphone and on PACS with excellent intra- and inter-observer reliability (Table 1). No ELVOs were missed on smartphone review of these studies. Conclusion: In actual-use circumstances, experienced neurointerventional radiologists are able to utilize a smartphone application to diagnose an ELVO on CTA as accurately as on a PACS workstation with similar levels of confidence. These findings support the use of mobile electronic devices by stroke networks to rapidly triage patients for mechanical thrombectomy.

Background: Although it is generally thought that patients with distal middle cerebral artery (MCA) occlusion have a favorable outcome, it has previously been demonstrated that a substantial minority will have a poor outcome by 90 days. We sought to determine whether the infarct location information encoded in the Alberta Stroke Program Early CT Score (ASPECTS) allows for defining distinct ASPECTS regions that are associated with a poor outcome to improve outcome prediction in in these patients. Methods: We retrospectively analyzed patients with isolated acute distal MCA occlusion admitted to a single academic center between January 2010 to August 2012. Infarct regions were defined according to ASPECTS system on the initial head CT. Discriminant function analysis was used to define specific ASPECTS regions that are predictive of the 90 day functional outcome. In addition, logistic regression was used to model the relationship between each individual ASPECT region with poor outcome; for evaluation and comparison, odds ratios, c-statistics, and Akaike information criterion values were estimated for each region. Results: 90 patients with isolated distal MCA were included in the final analysis. ASPECTS score ≤ 6 predicted poor outcome in this cohort (sensitivity=0.591, specificity=0.838, p Conclusion: ASPECTS regions M3 and M6 are key predictors of functional outcome following isolated distal MCA infarction. These findings will be helpful in stratifying outcomes if validated in future studies.

Introduction: We created an optimized ELVO transfer protocol for PSCs focused on three key steps: early CSC notification based on clinical severity threshold, obtaining vessel imaging at the PSC, and cloud-based image sharing without the use of telemedicine. Methods: Our regional PSC spokes were educated to execute the following protocol for patients presenting with a Los Angeles motor score ≥4: 1) notify the CSC on arrival 2) obtain CTA at time of initial NCCT and within 30 minutes of PSC arrival, and 3) implement a secure cloud-based remote viewing platform (LifeIMAGE). We reviewed all ICA and/or M1 occlusions transferred over an 11 month period, and divided the patients into two groups: those for whom the protocol was executed and those for whom it was not. Time from PSC arrival to start of angiogram was modeled using Kaplan-Meier estimation, with Wilcoxon test given no observations were censored. Favorable outcome (mRs 0-2 at 90 days) was modeled by protocol using a generalized linear model with a binary distribution. Results: Between 7/1/15 to 5/31/16 there were 70 patients transferred for thrombectomy. When executed, the PSC ELVO protocol reduced the median time for PSC arrival to CSC groin puncture from 151 [141.0, 166.0] to 111 [88.0, 130.0] minutes, a significant reduction of 40 minutes, p Conclusion: A standardized process at PSCs for suspected ELVO patients consisting of early CSC notification, CTA on arrival to the PSC and image sharing is easily implemented and significantly reduces the time to CSC groin puncture and improves outcomes.

Background and purpose: We compared the value of Alberta Stroke Program Early Computed Tomographic scoring using CT (CT ASPECTS), collateral score on CT angiography (CTA), ASPECTS using diffusion-weighted MRI (DWI ASPECTS), DWI lesion volume, and DWI volume with National Institute of Health Stroke Scale (NIHSS) in determining candidacy of patients who presented >6 hours from stroke onset. Methods: Decision to treat was first determined for each test alone and then with knowledge from other tests. A dismantling design was used to determine the additive effects of each test. Any discrepancy between the first and subsequent decisions to treat, in terms of sensitivity and specificity, is the impact of gained knowledge and was assessed using a generalized mixed-model assuming a binary distribution with PROC GLIMMIX/SAS. Inter-rater reliability was examined using weighted-Kappa. Results: We identified 39 patients between December 1st, 2015 and June 30th 2016. Median time from last-known normal to non-contrast CT was 492 minutes. Median interval between non-contrast CT and CTA was 7 minutes, and between CTA and MRI, 75.5 minutes. For sensitivity, effect of knowledge gained from successive tests was not significant (Table 1; Fig. 1). However, significant gains in specificity were observed from successive tests (63% to 84%; p Conclusion: CT, CTA and MRI each have the ability to correctly determine ELVO patients who would be candidates for embolectomy. However, identification of poor candidates for endovascular therapy was significantly improved using diffusion-weighted MRI.

Breast lymphoscintigraphy using 99mTc-sulfur colloid (99mTc-SC) is well established in clinical practice for staging patients with breast carcinoma. Nearly all patients report having pain during the procedure. However, techniques used to minimize pain during breast lymphoscintigraphy are highly variable across institutions. Our study was to determine whether anesthetizing the skin with sodium bicarbonatehether–buffered lidocaine before performing breast lymphoscintigraphy reduced the pain experienced by the patients. The second objective of this study was to evaluate whether anesthetizing the skin with buffered lidocaine changed visualization of lymph nodes. Methods: This prospective, patient-masked and randomized study involved performing breast lymphoscintigraphy in a control group and experimental group of female breast cancer patients. The control group did not receive skin anesthetic before 99mTc-SC injections, whereas the experimental group first underwent skin anesthesia with an injection of 2% sodium bicarbonate–buffered lidocaine. All patients were asked to rate their pain levels, using the National Institutes of Health pain scale, before the procedure and immediately after the injections. The change in pain from baseline was compared between the 2 groups. After the injections, scintigraphic imaging of the axilla was performed, and the number of axillary lymph nodes visualized was recorded. Results: No significant difference was found in preprocedural baseline pain from the control group, compared with the experimental group. There was a statistically significant difference in the increase in pain experienced during the procedure between the control group and the experimental group (P = 0.009). There was no significant difference in the detection of lymph nodes between the control and experimental groups (P = 0.56). Conclusion: The results from our study indicate that injecting subcutaneous buffered lidocaine before intradermal injection of 99mTc-SC for breast lymphoscintigraphy significantly decreases patient pain without interfering with lymph node visualization.

To identify demographic and ultrasonographic (US) features associated with malignancy after initially nondiagnostic results of fine-needle aspiration (FNA) to help clarify the role of repeat FNA, surgical excision, or serial US in these nodules.This study was HIPAA compliant and institutional review board approved; informed consent was waived. Thyroid nodules (n = 5349) that underwent US-guided FNA in 2004-2012 were identified; 393 were single nodules with nondiagnostic FNA results but adequate cytologic, surgical, or US follow-up. Demographic information and diameters and volume at US at first biopsy were modeled with malignancy as outcome through medical record review. Exact logistic regression was used to model malignancy outcomes, demographic comparisons with age were made (Student t test, Satterthwaite test), and proportion confidence intervals (CIs) were estimated (Clopper-Pearson method).Of 393 nodules with initially nondiagnostic results, nine malignancies (2.3%) were subsequently diagnosed with repeat FNA (n = 2, 0.5%) or surgical pathologic examination (n = 7, 1.8%), 330 (84.0%) were benign, and 54 (13.7%) were stable or decreased in size at serial US (mean follow-up, 3.0 years; median, 2.5 years; range, 1.0-7.8 years). Patients with malignancies were significantly older (mean age, 62.7 years; median, 64 years; range, 47-77 years) than those without (mean age, 55.4 years; median, 57 years; range, 12-94 years; P = .0392). Odds of malignancy were 4.2 times higher for men versus women (P = .045) and increased significantly for each 1-cm increase in anteroposterior, minimum, and mean nodule diameter (1.78, 2.10, and 1.96, respectively). In 393 nodules, no malignancies were detected in cystic or spongiform nodules (both, n = 11, 2.8%; 95% CI: 1.4%, 5.0%), nodules with eggshell calcifications (n = 9, 2.3%; 95% CI: 1.1%, 4.3%), or indeterminate echogenic foci (n = 39, 9.9%; 95% CI: 7.2%, 13.3%).Very few malignancies were diagnosed with repeat FNA following nondiagnostic FNA results (two of 336, 0.6%); therefore, clinical and US follow-up may be more appropriate than repeat FNA following nondiagnostic biopsy results.

PURPOSE Ablation device-associated computed tomography beam hardening artifacts can make tumor margin visualization and its relationship to the ablation applicator tip challenging. Determine optimal scanning conditions for currently-used applicators. MATERIALS AND METHODS Eleven applicators were placed in ex vivo cow livers with implanted mock tumors, surrounded by bolus gel. Various computed tomography scans were performed at 440 mA with 5 mm thickness changing kVp (80, 100, 120, 140), scan time (0.5, 0.7, 1.0, 2.0 seconds), adaptive statistical iterative reconstruction (ASiR) (30, 60, 90), scan type (helical, axial), pitch (0.5, 0.94, 1.37, 1.75), and reconstruction algorithm (soft, standard, lung). Two radiologists blindly scored the images for image quality and artifact quantitatively. RESULTS Cool-tip single (CTS) RF electrode (Covidien) performed significantly better than all other devices in both perceived image quality and artifact while Boston Scientific 4.0 RF electrode (Boston Scientific) underperformed (all P < 0.001), when not controlling for any other factors. An effect for artifact (P < 0.001) was found for kVp and device: for most conditions, 80 kVp was rated significantly lower than all other levels, whereas 120 and 140 performed significantly better than 100 and 80. No significant effect with ASiR level and device was found for the artifact. There was an effect observed for artifact (P < 0.001) between scan time and probe: for most devices, 0.5 seconds was rated significantly lower than all other scan times, but CTS was resilient-showing no difference from other scan times. Algorithm did not show any significant effects. Taking into account ASiR, kVp, and time, CTS outperformed all other devices. CONCLUSIONS Higher kVp and scan times reduce device artifacts. It appears that CTS performs the best, even when considering ASiR, kVp, pitch, scan type, and scan time.

The primary challenge in thermal ablation of liver tumors (e.g. hepatocellular carcinoma and hepatic colorectal cancer) is the relatively high recurrence rate (~30%) for which incomplete ablation at the periphery of the tumor is the most common reason. In an attempt to overcome this, we have developed a novel thermal accelerant (TA) agent capable of augmenting microwave energy from a distance normally unattainable by a single microwave ablation antenna. This cesium-based block co-polymer compound transforms from a liquid to a gel at body temperature and is intrinsically visible by computed tomography. Using an agarose phantom model, herein we demonstrate that both the rate and magnitude of temperature increase during microwave ablation were significantly greater in the presence of TA when compared with controls. These results suggest robust augmentation of microwave energy, and may translate into larger ablation zone volumes within biologic tissues. Further work using in vivo techniques is necessary to confirm these findings.

Background Although it is generally thought that patients with distal middle cerebral artery (M2) occlusion have a favorable outcome, it has previously been demonstrated that a substantial minority will have a poor outcome by 90 days. We sought to determine whether assessing the Alberta Stroke Program Early CT Score (ASPECTS) infarct location allows for identifying patients at risk for a poor 90-day outcome. Methods We retrospectively analyzed patients with isolated acute M2 occlusion admitted to a single academic center between January 2010 and August 2012. Infarct regions were defined according to ASPECTS system on the initial head computed tomography. Discriminant function analysis was used to define specific ASPECTS regions that are predictive of the 90-day functional outcome as defined as a modified Rankin Scale score of 3–6. In addition, logistic regression was used to model the relationship between each individual ASPECT region with poor outcome; for evaluation and comparison, odds ratios, c-statistics, and Akaike information criterion values were estimated for each region. Results Ninety patients with isolated M2 were included in the final analysis. ASPECTS score ≤6 predicted poor outcome in this cohort (sensitivity = 0.591, specificity = 0.838, p

Incentive spirometers (ISs) were developed to reduce atelectasis and are in widespread clinical use. However, without IS use adherence data, the effectiveness of IS cannot be determined.To evaluate the effect of a use-tracking IS reminder on patient adherence and clinical outcomes following coronary artery bypass grafting (CABG) surgery.This randomized clinical trial was conducted from June 5, 2017, to December 29, 2017, at a tertiary referral teaching hospital and included 212 patients who underwent CABG, of whom 160 participants were randomized (intent to treat), with 145 completing the study per protocol. Participants were stratified by surgical urgency (elective vs nonelective) and sex (men vs women).A use-tracking, IS add-on device (SpiroTimer) with an integrated use reminder bell recorded and timestamped participants' inspiratory breaths. Patients were randomized by hourly reminder "bell on" (experimental group) or "bell off" (control group).Incentive spirometer use was recorded for the entire postoperative stay and compared between groups. Radiographic atelectasis severity (score, 0-10) was the primary clinical outcome. Secondary respiratory and nonrespiratory outcomes were also evaluated.A total of 145 per-protocol participants (112 men [77%]; mean age, 69 years [95% CI, 67-70]; 90 [62%] undergoing a nonelective procedure) were evaluated, with 74 (51.0%) in the bell off group and 71 (49.0%) in the bell on group. The baseline medical and motivation-to-recover characteristics of the 2 groups were similar. The mean number of daily inspiratory breaths was greater in bell on (35; 95% CI, 29-43 vs 17; 95% CI, 13-23; P .001). The percentage of recorded hours with an inspiratory breath event was greater in bell on (58%; 95% CI, 51-65 vs 28%; 95% CI, 23-32; P .001). Despite no differences in the first postoperative chest radiograph mean atelectasis severity scores (2.3; 95% CI, 2.0-2.6 vs 2.4; 95% CI, 2.2-2.7; P = .48), the mean atelectasis severity scores for the final chest radiographs conducted before discharge were significantly lower for bell on than bell off group (1.5; 95% CI, 1.3-1.8 vs 1.8; 95% CI, 1.6-2.1; P = .04). Of those with early postoperative fevers, fever duration was shorter for bell on (3.2 hours; 95% CI, 2.3-4.6 vs 5.2 hours; 95% CI, 3.9-7.0; P = .04). Having the bell turned on reduced noninvasive positive pressure ventilation use rates (37.2%; 95% CI, 24.1%-52.5% vs 19.2%; 95% CI, 10.2%-33.0%; P = .03) for participants undergoing nonelective procedures. Bell on reduced the median postoperative length of stay (7 days; 95% CI, 6-9 vs 6 days; 95% CI, 6-7; P = .048) and the intensive care unit length of stay for patients undergoing nonelective procedures (4 days; 95% CI, 3-5 vs 3 days; 95% CI, 3-4; P = .02). At 6 months, the bell off mortality rate was higher than bell on (9% vs 0%, P = .048) for participants undergoing nonelective procedures.The incentive spirometer reminder improved patient adherence, atelectasis severity, early postoperative fever duration, noninvasive positive pressure ventilation use, ICU and length of stay, and 6-month mortality in certain patients. With the reminder, IS appears to be clinically effective when used appropriately.ClinicalTrials.gov identifier: NCT02952027.

Purpose Primary revision amputation is the most common treatment method for traumatic digit amputations in the United States. Few studies have reported secondary revision rates after primary revision amputation. The primary aim of our study was to identify risk factors for secondary revision within 1 year of the index procedure. Secondarily, we describe the incidence and timing of complications requiring secondary revision. Methods Our institution's emergency department (ED) database was reviewed for traumatic digit amputations over a 6-year period. Patients were reviewed for demographic characteristics, comorbidities, site of treatment (ED versus operating room), and complications requiring secondary revision. Conditional Cox Proportional Hazard regression was used to model hazard of revision within 1 year of index procedure relative to site of initial management, mechanism of injury, injury characteristics, and patient demographics. Results Five hundred and thirty-seven patients with 677 digits were managed with primary revision amputation. Five hundred and eighty-six digits (86.6%) were revised in the ED, and 91 (13.4%) in the operating room. Ninety-one digits required secondary revision, including 83 within 1 year. No increased risk of secondary revision amputation within 1 year of the index procedure was observed for patients treated in the ED compared with the operating room. Relative to crush injuries, bite and sharp laceration amputations had 4.8 times and 2.6 times increased risk of secondary revision, respectively. The index finger had a 5.3-fold increased risk of revision with the thumb as the reference digit. Work-related injuries had a 1.9-fold increased risk of secondary revision compared with non–work-related injuries. Conclusions No evidence was found indicating that traumatic digit amputations primarily revised in the ED had an increased risk of secondary revision. Patients may be counseled on the risk of secondary procedures based on the mechanism of injury, injury characteristics and demographics, as well as the timing of complications. Type of study/level of evidence Therapeutic IV.