The Huntsville Hospital Health System, also known as Huntsville Hospital, is a public, not-for-profit hospital organization consisting of several sites and buildings originating in the downtown area of Huntsville, Alabama. The Huntsville Hospital Health System has evolved and now owns or works with several other hospitals in Alabama. It has around 13,000 employees, 2,000 nurses and 650 physicians.The hospital has no official ties to any college or university. It is only used for clinical rotations by students from the UAB School of Medicine, their family practice residency program, and local nursing and pharmacy students.
Factor Xa inhibitor (FXaI)–associated major bleeding presents a critical management challenge. Although andexanet alfa is the targeted reversal agent, its limited availability and high cost has sustained the use of prothrombin complex concentrates (PCCs). Activated PCC (aPCC) may provide effective reversal at lower doses due to its inclusion of activated factor VII. This study compared the effectiveness and safety of aPCC versus 4-factor PCC (4 F-PCC) for reversal of apixaban- and rivaroxaban-associated major bleeding. A retrospective cohort study was conducted at Huntsville Hospital. Adult patients who received aPCC or 4 F-PCC for major bleeding while on apixaban or rivaroxaban were included. Major bleeding and clinical hemostasis were defined using International Society on Thrombosis and Haemostasis (ISTH) criteria. The primary outcome was hemostatic effectiveness; the secondary outcome was in-hospital thromboembolic complications. Among 293 patients (252 aPCC, 41 4 F-PCC), baseline characteristics were similar except for more intracranial hemorrhage in the 4 F-PCC group (75.6
BACKGROUND:The ACR Diagnostic Fluoroscopy Dose Index Registry (DIR-Fluoro) is expanding to include diagnostic fluoroscopy. Variations in dose reference points and overhead radiography events may introduce unique challenges for benchmarking. PURPOSE:To survey the technological status and dosimetric performance of fluoroscopes participating in the DIR-Fluoro pilot project, focusing on longitudinal stability and variability of fluoroscopic dose reporting accuracy across multiple institutions and vendors. METHODS:Sixty-six fluoroscopic systems from nine institutions (24 facilities) were surveyed for facility type, fluoroscope type, image receptor type, age, dose reporting capabilities, and other key features. Of these, 56 were evaluable. Semi-annual measurements assessed reference air kerma (Ka,r) and air kerma area product (PKA) accuracy. Linear mixed-effects models evaluated changes in dose accuracy over time, incorporating system-specific random effects; models were compared using likelihood ratio testing. Radiation Dose Structured Reports (RDSR) contents were investigated to understand the challenges in benchmarking diagnostic fluoroscopy dose indices. RESULTS:Nearly 80% of units were tube-under-table fluoroscopes. Average age was 9.6 ± 5.2 years. Sixty-four percent of the units produced RDSRs. Median deviations for Ka,r and PKA were 1%-4%. Accuracy of PKA and Ka,r remained stable, with no significant time-dependent drift for RDSR-capable systems (p > 0.05). Incorporating detector type significantly improved performance for PKA measurements (p < 0.05 for all datasets); Ka,r models were generally best fit by simpler models (p > 0.05 for 3 of 4 datasets). Major discrepancies in RDSRs were observed, including differences in Ka,r reference point definitions and in event-level data. Overhead radiography exposures were not well distinguished from fluoroscope exposures. These issues resulted in inconsistencies in reported Ka,r values. CONCLUSION:Fluoroscopic dose indices were accurate and stable over time. Differences in RDSR availability result in data biased to newer systems with flat panel detectors. Discrepancies in RDSR content and inconsistent reference point definitions necessitate use of PKA as the primary benchmark metric.
BACKGROUND:The impact of intravenous (IV) thrombolysis on the outcomes of aspiration thrombectomy as the primary endovascular approach to stroke in patients with large vessel occlusion is unknown. METHODS:The Imperative Trial was a prospective, investigational device exemption, multicenter trial of first-line aspiration thrombectomy that assessed the safety and efficacy of the Zoom System, including a novel 0.088 inch aspiration catheter in patients with stroke within 8 hours of onset. We compared procedural, technical, and clinical outcomes of aspiration thrombectomy based on whether patients had received IV thrombolytics prior to the intervention. RESULTS:Among the 260 patients treated with front-line aspiration thrombectomy using the Zoom System, 125 (48%) received IV thrombolysis prior to aspiration. Rates of modified Thrombolysis in Cerebral Infarction (mTICI) ≥2b achieved with the Zoom System were higher in the aspiration-only group than in the combined group (92% vs 81%, P=0.016). Rates of mTICI ≥2c and first pass effect were similar. The use of rescue devices to achieve mTICI ≥2b was less frequent in the aspiration-only group than in the combined group (2% vs 10%, P=0.008). The rates of functional independence (modified Rankin Scale (mRS) score 0-2) in the aspiration-only group and the combined group were 50% and 59%, respectively (P=0.16). Univariate (P=0.30) and multivariate (P=0.47) ordinal regression analyses showed no significant correlation of mRS 0-2 with IV thrombolysis. Both groups had similar safety outcomes including rates of symptomatic intracranial hemorrhage and 90-day mortality. CONCLUSIONS:Aspiration thrombectomy alone may result in higher rates of successful reperfusion and reduce the need for rescue devices compared with the combined approach with IV thrombolysis.
Abstract Introduction Right ventricular (RV) infarction is an uncommon but serious complication of inferior wall myocardial infarction (IWMI), often causing severe hemodynamic compromise and increased mortality. The American Heart Association identifies RV involvement in IWMI as an independent predictor of in-hospital death. Acute RV dysfunction can elevate right-sided pressures, reopening a patent foramen ovale (PFO) and producing right-to-left shunting with refractory hypoxemia. We present a case of recurrent right coronary artery thrombosis resulting in RV infarction, PFO-mediated shunting, and rapid progression to multi-organ failure despite intervention. Case Presentation A 72-year-old woman with diabetes mellitus presented with severe retrosternal chest pain radiating to the jaw and left arm, preceded by intermittent exertional discomfort for two months. She was initially hemodynamically stable. Laboratory evaluation showed creatinine 1.4 mg/dL, BNP 4,500 pg/mL, and high-sensitivity troponin I 3,056 ng/L (down-trending). ECG and chest radiography were unremarkable. Coronary angiography demonstrated complete occlusion of the proximal right coronary artery (RCA) distal to the sinus node branch, with distal filling via left-to-right collaterals. Aspiration thrombectomy was performed, followed by tandem stent placement, restoring flow. Dual antiplatelet therapy with aspirin and ticagrelor was initiated. Echocardiography showed preserved left ventricular ejection fraction (LVEF 55%) with mild mitral and tricuspid regurgitation. On hospital day two, she developed sudden pallor, diaphoresis, and profound bradycardia (heart rate in the 30s) while straining on the toilet. ECG confirmed complete atrioventricular block. Emergent catheterization revealed acute in-stent thrombosis; additional stents were placed in the proximal and distal RCA extending into the posterolateral branch, and a temporary transvenous pacemaker was inserted. She subsequently developed acute hypoxemic respiratory failure refractory to BiPAP and mechanical ventilation, requiring vasopressor support. Repeat echocardiography showed new LV dysfunction (EF 35-40%), severe RV hypokinesis, and a PFO with right-to-left shunting consistent with elevated right atrial pressures secondary to RV infarction. Her condition rapidly deteriorated, resulting in multi-organ failure; goals of care were transitioned, and she died hours later. Discussion RV infarction complicates a significant subset of IWMI and can precipitate hemodynamic collapse when right-sided pressures exceed left-sided pressures, promoting PFO-mediated shunting and refractory hypoxemia. In patients with suspected RV involvement who demonstrate persistent hypoxemia despite oxygenation and ventilation, early echocardiographic assessment for intracardiac shunt is essential. This case emphasizes the importance of recognizing RV failure physiology and considering early mechanical support strategies when revascularization alone does not restore adequate RV function. Color Doppler on TTE demonstrating right to left flow across a PFO. This abstract is funded by: None
BACKGROUND:Recent observational studies have suggested that early treatment (<12 hours from diagnosis) of intermediate risk pulmonary embolism (PE) with catheter-based therapies may reduce morbidity and mortality. However, the effect of early versus late mechanical thrombectomy on acute pulmonary hemodynamics and right ventricular mechanics is less well defined. METHODS:Patients enrolled in SYMPHONY-PE were divided into one of 2 groups based on the time from baseline CT pulmonary angiography to mechanical thrombectomy: Early <12 hours versus late ≥12 hours. The primary safety end point was the rate of major adverse events within 48 hours, as adjudicated by an academic independent safety board. The primary efficacy end point was the core-lab assessed mean change in right ventricle-to-left ventricle ratio from baseline to 48 hours. RESULTS:Early thrombectomy was performed in 44% (48/109) of patients and was associated with a larger reduction, approaching statistical significance, in right ventricle-to-left ventricle ratio (0.52±0.50 versus 0.37±0.34; P=0.071). Mean pulmonary artery pressure decreased significantly more in patients receiving early thrombectomy (8.6±5.2 versus 5.8±5.0 mm Hg; P=0.006). The major adverse events rate was similar (P=0.431) between groups, and there were no mortalities. The differences in efficacy outcomes were greatest in higher-risk patients per the Composite Pulmonary Embolism Shock score. CONCLUSIONS:Early mechanical thrombectomy was associated with larger reductions in right ventricle-to-left ventricle ratio and mean pulmonary artery pressure, with no significant differences in safety event rates compared with patients who underwent late thrombectomy. Randomized trials are needed to test these associations. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT06062329.
