Retained broken needles (RBNs) in patients is a potentially underreported complication of intravenous drug use (IVDU) in people who inject drugs. Identification of RBNs poses a challenge for radiologists and clinicians due to subtle appearance on imaging and the complexities of patient presentations. A single-center case-control study was performed between January 1, 2021, and December 31, 2021. The cases included all patients with a history of IVDU who presented to the emergency department (ED) with RBNs. Data collected on the study population included RBN location and size, complications, and imaging modality. A control group of 2:1 matched on age, gender, and race/ethnicity with the cases was generated from patients with a history of IVDU from the same time period who had no RBNs. A total of 3920 total patients presented to ED with a history of IVDU and 70 patients were found to have RBN (1.8%). RBNs were most observed in the foot/ankle (32.9%) forearm (18.6%), and neck (17.1%). RBNs were found to be incidental in 82.9% (58 out of 70) of patients. Radiography located needle fragments (55.7%) slightly more often than CT (44.3%). Overall, among all the cases and controls combined, 33.8% had positive blood cultures. In the group of patients with a RBN, 47.1% presented with positive bacterial blood cultures during the hospital admission, whereas the group without an RBN showed 27.1% ( P = .004). The RBN group showed significantly higher rates of abscess (72.9% vs 48.6%), cellulitis (70.0% vs 46.4%), and osteomyelitis (37.1% vs 13.6%) than the non-RBN group (all P ≤ .001). This study suggests that RBNs are likely underreported and patients with RBNs are at an increased risk of infectious complications. Increasing the awareness and refining our understanding of RBNs is crucial to mitigating these complications.

Pulmonary embolism (PE) is a very common clinical entity with clinical symptoms that range from no symptom to complete hemodynamic collapse, sometimes with similar-appearing clot burden on computed tomographic pulmonary angiogram. Given highly variable clinical presentation, the authors wanted to investigate if there is clinical correlation based on the age of a clot with microscopic examination to clinical presentation. Thirteen thrombectomy aspirates from patients with an acute PE were microscopically analyzed. The goal was to age the thrombus based on histologic features and correlate it to clinical course.

Introduction:Right ventricular dysfunction (RVD) is a key component in the process of risk stratification in patients with acute pulmonary embolism (PE). Echocardiography remains the gold standard for RVD assessment, however, measures of RVD may be seen on CTPA imaging, including increased pulmonary artery diameter (PAD). The aim of our study was to evaluate the association between PAD and echocardiographic parameters of RVD in patients with acute PE. Methods:Retrospective analysis of patients diagnosed with acute PE was conducted at large academic center with an established pulmonary embolism response team (PERT). Patients with available clinical, imaging, and echocardiographic data were included. PAD was compared to echocardiographic markers of RVD. Statistical analysis was performed using the Student's t test, Chi-square test, or one-way analysis of variance (ANOVA); P < 0.05 was considered statistically significant. Results:270 patients with acute PE were identified. Patients with a PAD >30 mm measured on CTPA had higher rates of RV dilation (73.1% vs 48.7%, P < 0.005), RV systolic dysfunction (65.4% vs 43.7%, P < 0.005), and RVSP >30 mmHg (90.2% vs 68%, P = 0.004), but not TAPSE ≤1.6 cm (39.1% vs 26.1%, P = 0.086). A weak increasing linear relationship between PAD and RVSP was noted (r = 0.379, P = 0.001). Conclusions:Increased PAD in patients with acute PE was significantly associated with echocardiographic markers of RVD. Increased PAD on CTPA in acute PE can serve as a rapid prognostic tool and assist with PE risk stratification at the time of diagnosis, allowing rapid mobilization of a PERT team and appropriate resource utilization.

Objective Although systemic thrombolysis (ST) is the standard of care in the treatment of high-risk pulmonary embolism (PE), large variations in real-world usage exist, including its use to treat intermediate-risk PE. A paucity of data is available to define the outcomes and practice patterns of the ST dose, duration, and treatment of presumed and imaging-confirmed PE. Methods We performed a multicenter retrospective study to evaluate the real-world practice patterns of ST use in the setting of acute PE (presumed vs imaging-confirmed intermediate- and high-risk PE). Patients who had received tissue plasminogen activator for PE between 2017 and 2019 were included. We compared the baseline clinical characteristics, tissue plasminogen activator practice patterns, and outcomes for patients with confirmed vs presumed PE. Results A total of 104 patients had received ST for PE: 52 with confirmed PE and 52 with presumed PE. Significantly more patients who had been treated for presumed PE had experienced cardiac arrest (n = 47; 90%) compared with those with confirmed PE (n = 23; 44%; P < .01). Survival to hospital discharge was 65% for the patients with confirmed PE vs 6% for those with presumed PE (P < .01). The use of ST was contraindicated for 56% of the patients with confirmed PE, with major bleeding in 26% but no intracranial hemorrhage. Conclusions The in-hospital mortality of patients with confirmed acute PE has remained high (35%) in contemporary practice for those treated with ST. A large proportion of these patients had had contraindications to ST, and the rates of major bleeding were significant. Those with confirmed PE had had a higher survival rate compared with those with presumed PE, including those with cardiac arrest. This observation suggests a limited role for empiric thrombolysis in cardiac arrest situations.

Background The impact of pulmonary embolism response teams (PERTs) on treatment choice and outcomes of patients with acute pulmonary embolism (PE) is still uncertain. Objective To determine the effect of PERTs in the management and outcomes of patients with PE. Methods PubMed, Embase, Web of Science, CINAHL, WorldWideScience and MedRxiv were searched for original articles reporting PERT patient outcomes from 2009. Data were analysed using a random effects model. Results 16 studies comprising 3827 PERT patients and 3967 controls met inclusion criteria. The PERT group had more patients with intermediate and high-risk PE (66.2%) compared to the control group (48.5%). Meta-analysis demonstrated an increased risk of catheter-directed interventions, systemic thrombolysis and surgical embolectomy (odds ratio (OR) 2.10, 95% confidence interval (CI) 1.74-2.53; p<0.01), similar bleeding complications (OR 1.10, 95% CI 0.88-1.37) and decreased utilisation of inferior vena cava (IVC) filters (OR 0.71, 95% CI 0.58-0.88; p<0.01) in the PERT group. Furthermore, there was a nonsignificant trend towards decreased mortality (OR 0.87, 95% CI 0.71-1.07; p=0.19) with PERTs. Conclusions The PERT group showed an increased use of advanced therapies and a decreased utilisation of IVC filters. This was not associated with increased bleeding. Despite comprising more severe PE patients, there was a trend towards lower mortality in the PERT group.

Objective Pulmonary infarction is a common clinical and radiographic finding in acute pulmonary embolism (PE), yet the clinical relevance and prognostic significance of pulmonary infarction remain unclear. The study aims to investigate the clinical features, radiographic characteristics, impact of reperfusion therapy and outcomes of patients with pulmonary infarction. Design, setting and participants A retrospective cohort study of 496 adult patients (≥18 years of age) diagnosed with PE who were evaluated by the PE response team at a tertiary academic referral centre in the USA. We collected baseline characteristics, laboratory, radiographic and outcome data. Statistical analysis was performed by Student’s t-test, Mann-Whitney U test, Fischer’s exact or χ2 test where appropriate. Multivariate logistic regression was used to evaluate potential risk factors for pulmonary infarction. Results We identified 143 (29%) cases of pulmonary infarction in 496 patients with PE. Patients with infarction were significantly younger (52±15.9 vs 61±16.6 years, p<0.001) and with fewer comorbidities. Most infarctions occurred in the lower lobes (60%) and involved a single lobe (64%). The presence of right ventricular (RV) strain on CT imaging was significantly more common in patients with infarction (21% vs 14%, p=0.031). There was no significant difference in advanced reperfusion therapy, in-hospital mortality, length of stay and readmissions between groups. In multivariate analysis, age and evidence of RV strain on CT and haemoptysis increased the risk of infarction. Conclusions Radiographic evidence of pulmonary infarction was demonstrated in nearly one-third of patients with acute PE. There was no difference in the rate of reperfusion therapies and the presence of infarction did not correlate with poorer outcomes.

Acute pulmonary embolism management is centered on the presence of right ventricular (RV) strain. Patients with RV strain have a greater than twofold increase in 30-day mortality (1, 2). RV strain is pre-sent in > 25 % in patients with pulmonary embolism (3). This is associated with adverse outcomes even in patients with low pulmonary embolism severity index RV dilation on computed tomography pulmonary angiography with increased 30-day mortality in patients with acute pulmonary embolism

Introduction Acute pulmonary embolism (PE) remains a common cause for morbidity and mortality in patients over 65 years. Given the increased risk of bleeding in the elderly population with the use of systemic thrombolysis, catheter-directed therapy (CDT) is being increasingly used for the treatment of submassive PE. Nevertheless, the safety of CDT in the elderly population is not well studied. We, therefore, aimed to evaluate the safety of CDT in our elderly patients.Methods We conducted a retrospective observational study of consecutive patients aged >65 years with a diagnosis of PE from our Pulmonary Embolism Response Team database. We compared the treatment outcomes of CDT versus anticoagulation (AC) in elderly. Propensity score matching was used to construct two matched cohorts for final outcomes analysis.Results Of 346 patients with acute PE, 138 were >65 years, and of these, 18 were treated with CDT. Unmatched comparison between CDT and AC cohorts demonstrated similar in-hospital mortality (11.1% vs 5.6%, p=0.37) and length of stay (LOS) (3.81 vs 5.02 days, p=0.5395), respectively. The results from the propensity-matched cohort mirrored results of the unmatched cohort with no significant difference between CDT and AC in-hospital mortality (11.8% vs 5.9%, p=0.545) or median LOS (3.76 vs 4.21 days, p=0.77), respectively.Conclusion In this observational study using propensity score-matched analysis, we found that patients >65 years who were treated with CDT for management of acute PE had similar mortality and LOS compared with those treated with AC. Further studies are required to confirm these findings.

Supplemental Digital Content is available in the text Abstract The value of chest radiography (CXR) in detection and as an outcome predictor in the management of patients with coronavirus disease-2019 (COVID-19) has not yet been fully understood. To validate a standardized CXR scoring system and assess its prognostic value in hospitalized patients found to have COVID-19 by imaging criteria and to compare it to computed tomography (CT). In this cross-sectional chart review study, patients aged 18-years or older who underwent chest CT at a single institution with an imaging-based diagnosis of COVID-19 between March 15, 2020 to April 15, 2020 were included. Each patient's CXR and coronal CT were analyzed for opacities in a 6-zonal assessment method and aggregated into a “Sextus score.” Inter-reader variability and correlation between CXR and coronal CT images were investigated to validate this scoring system. Univariable and multiple logistic regression techniques were used to investigate relationships between CXR scores and clinical parameters in relation to patient outcomes. One hundred twenty-four patients (median [interquartile range] age 58.5 [47.5–69.0] years, 72 [58%] men, 58 [47%] Blacks, and 35 [28%] Hispanics) were included. The CXR Sextus score (range: 0–6) was reliable (inter-rater kappa = 0.76; 95% confidence interval [CI]: 0.69–0.83) and correlated strongly with the CT Sextus score (Spearman correlation coefficient = 0.75, P < .0001). Incremental increases of CXR Sextus scores of 2 points were found to be an independent predictor of intubation (adjusted odds ratio [95% CI]: 4.49 [1.98, 10.20], P = .0003) and prolonged hospitalization (≥10 days) (adjusted odds ratio [95% CI]: 4.06 [1.98, 8.32], P = .0001). The CXR Sextus score was found to be reproducible and CXR-CT severity scores were closely correlated. Increasing Sextus scores were associated with increased risks for intubation and prolonged hospitalization for patients with COVID-19 in a predominantly Black population. The CXR Sextus score may provide insight into identifying and monitoring high-risk patients with COVID-19.

The COVID-19 pandemic has created unprecedented challenges in healthcare including pressure to provide efficient and timely patient care while maintaining a safe environment for physicians and staff. Radiology plays a vital role as part of a multidisciplinary team in the care of these patients. We address the experiences of our radiology residency at a large urban US academic institution with an underserved population in our fight against COVID-19. The unprecedented challenges faced during this pandemic has created monumental impacts on our training and allowed for development of skills and resources in order to better handle future situations.

We present the characteristics and outcomes of the first 2 cases of catheter-directed thrombolysis performed in patients presenting with coronavirus disease-2019 (COVID-19)-related iliocaval thrombosis. (Level of Difficulty: Beginner.)

BACKGROUND:Infection with the novel severe acute respiratory syndrome coronavirus 2 has been associated with a hypercoagulable state. Emerging data from China and Europe have consistently shown an increased incidence of venous thromboembolism (VTE). We aimed to identify the VTE incidence and early predictors of VTE at our high-volume tertiary care center. METHODS:We performed a retrospective cohort study of 147 patients who had been admitted to Temple University Hospital with coronavirus disease 2019 (COVID-19) from April 1, 2020 to April 27, 2020. We first identified the VTE (pulmonary embolism [PE] and deep vein thrombosis [DVT]) incidence in our cohort. The VTE and no-VTE groups were compared by univariable analysis for demographics, comorbidities, laboratory data, and treatment outcomes. Subsequently, multivariable logistic regression analysis was performed to identify the early predictors of VTE. RESULTS:The 147 patients (20.9% of all admissions) admitted to a designated COVID-19 unit at Temple University Hospital with a high clinical suspicion of acute VTE had undergone testing for VTE using computed tomography pulmonary angiography and/or extremity venous duplex ultrasonography. The overall incidence of VTE was 17% (25 of 147). Of the 25 patients, 16 had had acute PE, 14 had had acute DVT, and 5 had had both PE and DVT. The need for invasive mechanical ventilation (adjusted odds ratio, 3.19; 95% confidence interval, 1.07-9.55) and the admission D-dimer level ≥1500 ng/mL (adjusted odds ratio, 3.55; 95% confidence interval, 1.29-9.78) were independent markers associated with VTE. The all-cause mortality in the VTE group was greater than that in the non-VTE group (48% vs 22%; P = .007). CONCLUSIONS:Our study represents one of the earliest reported from the United States on the incidence rate of VTE in patients with COVID-19. Patients with a high clinical suspicion and the identified risk factors (invasive mechanical ventilation, admission D-dimer level ≥1500 ng/mL) should be considered for early VTE testing. We did not screen all patients admitted for VTE; therefore, the true incidence of VTE could have been underestimated. Our findings require confirmation in future prospective studies.

SESSION TITLE: Wednesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM PURPOSE: PE is 3rd leading cause of death in hospitalized patients. There are well validated clinical scores (Wells, Geneva score) and laboratory test like d-dimer to rule out PE as potential diagnosis. Unfortunately, implementation of such algorithm remains poor and under-utilized in busy clinical practice. The rate of CT pulmonary angiogram (CTPA) has significantly increased over number of years. CTPA has several disadvantages such as contrast induced nephropathy and potentially renal failure. Many patients also have contrast allergy and chronic kidney disease where CTPA can't be performed. Alternative is nuclear medicine ventilation perfusion (V/Q) scan that is time consuming and often not readily available. Given, above reasons we feel there is potentially role of CT and fluoroscopy based 4Dx CFPA and 4DxV analysis in diagnosis and follow up for patients presenting with PE. Our hypothesis is CFPA technology will reduce overuse of CTPA and serve as an follow up imaging modality that is simple and doesn't involve contrast METHODS: We are currently performing P&F study evaluating 4Dx CFPA technology in diagnosis of PE. As per our IRB-approved protocol total of 30 de-identified images of CTPA (15 positive and 15 negative) will be selected. First 4 cases (2 positive and 2 negative) will be utilized to standardize and validate CFPA analysis of pulmonary vessel caliber at 4DX. Next 26 cases (13 positive and 13 negative) will be blinded to research team at 4DX and clinical team at Temple University will have full clinical information. Primary Objective – Determine if 4DX CFPA technology can identify the patients with PE as compared to gold standard CTPA. Secondary Objective – Determine if 4Dx CFPA technology can identify degree of vasculature abnormality compared to CTPA. RESULTS: We are reporting result of first 4 unblinded cases (two cases with PE and two without PE). 4Dx software derives non-contrast image from de-identified CTPA imaging for measuring vessel caliber that are color coded as large [Red (>10 mm)], medium [Yellow/Green/Orange (5-10 mm)] and small [Blue (< 5 mm)]and scaled according to vessel diameter. There are significant global changes in cross sectional vessel area (mm2) and volume (mm) in cases of pulmonary embolism vs those without. CONCLUSIONS: Our initial results demonstrate contrast-free qualitative and quantitative analysis of vessel caliber in PE vs non-PE subjects. We aim to further validate CFPA technique in in next phase, where research staff will be blinded to original CTPA results. This study will be followed by future prospective study where CFPA will be validated prior to performance of CTPA. CLINICAL IMPLICATIONS: A) Reduce over utilization of CTPA. B) Reduce chances of contrast induced nephropathy. C) Simple, effective way of rapid diagnosis of PE and reduce time to therapeutic anti-coagulation. D) CFPA can be used as follow up testing following acute PE. DISCLOSURES: No relevant relationships by Ryan Cobb, source=Web Response No relevant relationships by Gary Cohen, source=Web Response No relevant relationships by Chandra Dass, source=Web Response Employee $100000 Added 06/16/2019 by Jonathan Dusting, source=Web Response, value=Salary Owner/Founder relationship with 4Dx Please note: >$100000 Added 06/21/2019 by Andreas Fouras, source=Web Response, value=Ownership interest No relevant relationships by Joseph Panaro, source=Web Response No relevant relationships by Parth Rali, source=Web Response Employee relationship with 4Dx Limited Please note: >$100000 Added 06/20/2019 by Neeraj Vij, source=Web Response, value=Salary

Patients with liver disease and portal hypertension who have had surgical formation of an abdominal stoma are at risk of developing peristomal varices. These varices have a predilection for bleeding. Ideally, portal decompression via TIPS procedure is performed, with or without direct embolization of the bleeding varix. When TIPS is not an appropriate option due to significant liver disease and hepatic encephalopathy there are other approaches to treat peristomal variceal hemorrhage. We report the embolization of such a varix via direct percutaneous puncture under ultrasound guidance when portal decompression was not an appropriate option.

OBJECTIVE:The purpose of this article is to describe the injury patterns observed in the 2015 Philadelphia Amtrak train derailment.CONCLUSION:Fractures accounted for most observed injuries, but uncommon and potentially serious injuries included posterior sternoclavicular dislocation and mesenteric contusion. Imaging plays a critical role in the triage of patients during mass-casualty events, and familiarity with the injury patterns associated with high-velocity unrestrained blunt force trauma will aid diagnosis in any future similar occurrence.

Diagnostic imaging options for localization of lower gastrointestinal bleeding (LGIB) prior to conventional catheter directed angiography have historically included a Tc99m tagged red blood cell scan, and more recently, computed tomography angiography (CTA). It has been well documented that CTA sensitivity in identifying LGIB is inferior to nuclear scintigraphy (0.1 ml/min for scintigraphy versus 0.35 ml/min for CTA). As a result, CTA can frequently be negative in patients who are clinically found to have a GI bleed.

As the transition from fee-for-service to value-based reimbursement continues, there is an increasing financial incentive for hospitals and health care systems to provide high-quality and efficient health care. Hospitals and health care systems are now faced with reimbursements tied to quality metrics and fixed bundle payments for health services provided and are at risk for the cost and quality of care. This is a significant change from the fee-for-service model, in which radiology departments were incentivized to maximize volume without regard for appropriateness or quality. Michael Porter [ 1 Porter M.E. What is value in health care?. N Engl J Med. 2010; 363: 2477-2481 Crossref PubMed Scopus (3246) Google Scholar ] defined value as health outcomes achieved per dollar spent. Implicit in this definition is the collective nature of value delivery. The health outcomes achieved are the result of the combined efforts of many people, processes, and systems.

Purpose It is not uncommon for patients with lower gastrointestinal bleeding (LGIB) to have underlying chronic kidney disease (CKD). Computed tomography angiography (CTA) has recently become the initial diagnostic imaging study in localization of LGIB. However, practitioners are often wary of ordering CTAs for patients with pre-existing renal impairment due to the perceived significant risk of contrast-induced nephropathy (CIN). This clinical dilemma may result in delay of appropriate diagnostic management or perhaps unnecessary more invasive diagnostic tests.