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There has been increasing debate around how or if race and ethnicity should be used in medical research-including the conceptualization of race as a biological entity, a social construct, or a proxy for racism. The objectives of this narrative review are to identify and synthesize reported racial and ethnic inequalities in obstetrics and gynecology (ob/gyn) and develop informed recommendations for racial and ethnic inequity research in ob/gyn. A reproducible search of the eight highest impact ob/gyn journals was conducted. Articles published between January 1, 2010, and June 30, 2023 containing keywords related to racial and ethnic disparities, bias, prejudice, inequalities, and inequities were included (n=318). Data were abstracted and summarized into four themes: 1) access to care, 2) adherence to national guidelines, 3) clinical outcomes, and 4) clinical trial diversity. Research related to each theme was organized topically under the headings i) obstetrics, ii) reproductive medicine, iii) gynecologic cancer, and iv) other. Additionally, interactive tables were developed. These include data on study timeline, population, location, and results for every article. The tables enable readers to filter by journal, publication year, race and ethnicity, and topic. Numerous studies identified adverse reproductive outcomes among racial and ethnic minorities as compared to white patients, that persist despite adjusting for differential access to care, socioeconomic or lifestyle factors, and clinical characteristics. These include higher maternal morbidity and mortality among Black and Hispanic/Latinx patients; reduced success during fertility treatments for Black, Hispanic/Latinx, and Asian patients; and lower survival rates and lower likelihood of receiving guideline concordant care for gynecological cancers for non-white patients. We conclude that many racial and ethnic inequities in ob/gyn cannot be fully attributed to patient characteristics or access to care. Research focused on explaining these disparities based on biological differences incorrectly reinforces the notion of race as a biological trait. More research that deconstructs race and assesses efficacy of interventions to reduce these disparities is needed.
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CONTEXT: Patients with PCOS are at high risk of depression, anxiety, and metabolic syndrome (MetSyn), a key predictor of cardiovascular disease. The impact of depression and/or anxiety on MetSyn is unknown in this population. OBJECTIVE: To compare the risk of developing MetSyn in patients with PCOS with and without a history of depression and/or anxiety. DESIGN: Retrospective longitudinal cohort study (2008-2022) with median follow-up of 7 years. SETTING: Tertiary care ambulatory practice. PATIENTS OR OTHER PARTICIPANTS: Patients with hyperandrogenic PCOS and at least 2 evaluations for MetSyn ≥3 years apart (n=321). INTERVENTION(S): N/A. MAIN OUTCOME MEASURE(S): The primary outcome was risk of developing MetSyn. We hypothesized that this risk would be higher with a history of depression and/or anxiety. RESULTS: At the first visit, 33.0% had a history of depression and/or anxiety, with a third prescribed antidepressants or anxiolytics. Depression and/or anxiety increased risk of developing MetSyn during the study period (adjusted hazard ratio [aHR] 1.45, 95% CI 1.02-2.06, p=0.04) with an incidence of MetSyn of 75.3 compared to 47.6 cases per 100 person-years among those without (p=0.002). This was primarily driven by depression (aHR 1.56, 95% CI 1.10-2.20, p=0.01). CONCLUSIONS: Patients with PCOS and depression and/or anxiety have a high risk of developing MetSyn, with a stronger association between depression and MetSyn. Our findings highlight the urgent need for guideline-directed screening for depression and anxiety at time of diagnosis of PCOS as well as screening at subsequent visits to facilitate risk stratification for metabolic monitoring and early intervention in this high-risk group.
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For over two centuries, clinicians have been aware of various conditions affecting white matter which had come to be grouped under the umbrella term multiple sclerosis. Within the last 20 years, specific scientific advances have occurred leading to more accurate diagnosis and differentiation of several of these conditions including, neuromyelitis optica spectrum disorders and myelin oligodendrocyte glycoprotein antibody disease. This new understanding has been coupled with advances in disease-modifying therapies which must be accurately applied for maximum safety and efficacy.
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Neuromielite Óptica , Humanos , Neuromielite Óptica/diagnóstico por imagem , Glicoproteína Mielina-Oligodendrócito/metabolismo , Aquaporina 4 , Imageamento por Ressonância Magnética/métodos , AutoanticorposRESUMO
Toxic leukoencephalopathy and myelopathy are common neurologic complications of a wide range of chemotherapeutic and substance abuse agents. During the last decade, there has been a significant change in the profile of white matter toxins, primarily driven by the development and usage of new chemotherapeutic and immunotherapeutic agents and by the continuous increase in illicit drug abuse with contaminants. Neuroimaging in the form of MR imaging forms the cornerstone in the diagnosis of these entities, many of which are reversible and amenable to rapid correction. Chronic white matter changes are also seen with these toxins with gradually progressive clinicoradiological findings.
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Leucoencefalopatias , Imageamento por Ressonância Magnética , Humanos , Imageamento por Ressonância Magnética/métodos , Encéfalo/diagnóstico por imagem , Leucoencefalopatias/induzido quimicamente , Leucoencefalopatias/diagnóstico por imagem , NeuroimagemRESUMO
BACKGROUND AND PURPOSE: Suppurative retropharyngeal lymphadenitis is a retropharyngeal space infection almost exclusively seen in the young (4-8 years old) pediatric population. It can be misdiagnosed as a retropharyngeal abscess, leading to unnecessary invasive treatment procedures. This retrospective study aims to assess radiology residents' ability to independently identify CT imaging findings and make a definitive diagnosis of suppurative retropharyngeal lymphadenitis in a simulated call environment. MATERIALS AND METHODS: The Wisdom in Diagnostic Imaging Emergent/Critical Care Radiology Simulation (WIDI SIM) is a computer-aided emergency imaging simulation proven to be a reliable method for assessing resident preparedness for independent radiology call. The simulation included 65 cases across various imaging modalities of varying complexity, including normal studies, with one case specifically targeting suppurative retropharyngeal adenitis identification. Residents' free text responses were manually scored by faculty members using a standardized grading rubric, with errors subsequently classified by type. RESULTS: A total of 543 radiology residents were tested in three separate years on the imaging findings of suppurative retropharyngeal lymphadenitis using the Wisdom in Diagnostic Imaging simulation web-based testing platform. Suppurative retropharyngeal lymphadenitis was consistently underdiagnosed by radiology residents being tested for call readiness irrespective of the numbers of years in training. On average, only 3.5% of radiology residents were able to correctly identify suppurative retropharyngeal lymphadenitis on a contrast-enhanced computed tomography (CT). CONCLUSIONS: Our findings underscore a potential gap in radiology residency training related to the accurate identification of suppurative retropharyngeal lymphadenitis, highlighting the potential need for enhanced educational efforts in this area.
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Internato e Residência , Linfadenite , Radiologia , Humanos , Criança , Pré-Escolar , Estudos Retrospectivos , Radiologia/educação , Competência Profissional , Linfadenite/diagnóstico por imagemRESUMO
Epstein-Barr Virus (EBV) is a ubiquitous herpes type virus that is associated with post-transplant lymphoproliferative disorder (PTLD). Usual management includes reduction or cessation of immunosuppression and in some cases chemotherapy including rituximab. However, limited therapies are available if PTLD is refractory to rituximab. Several clinical trials have investigated the use of EBV-directed T cells in rituximab-refractory patients; however, data regarding response is scarce and inconclusive. Herein, we describe a patient with EBV-PTLD refractory to rituximab after orthotopic heart transplantation (OHT) requiring EBV-directed T-cell therapy. This article aims to highlight the unique and aggressive clinical presentation and progression of PTLD with utilization of EBV-directed T-cell therapy for management and associated pitfalls.
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Infecções por Vírus Epstein-Barr , Transplante de Coração , Transplante de Células-Tronco Hematopoéticas , Transtornos Linfoproliferativos , Humanos , Pré-Escolar , Herpesvirus Humano 4 , Rituximab/uso terapêutico , Infecções por Vírus Epstein-Barr/terapia , Infecções por Vírus Epstein-Barr/tratamento farmacológico , Transtornos Linfoproliferativos/diagnóstico , Transtornos Linfoproliferativos/etiologia , Transtornos Linfoproliferativos/terapia , Terapia Baseada em Transplante de Células e TecidosRESUMO
BACKGROUND AND OBJECTIVES: The rational for the Somaliland national harmonised curriculum (NHC) was driven by shared concern about the quality of medical education. PROCESS: The Ministry of Education and Science and the Ministry of Health Development produced a Medical Education Policy 2018. Policy objectives included the development of the NHC and accreditation for medical schools that met the standards of the World Federation for Medical Education (WFME). Two bodies were asked to oversee these aims: the National Health Professions' Commission (NHPC) and the National Commission of Higher Education (NCHE). Between 2018 and 2020, a collaborative approach between the Somaliland government, medical school stakeholders, King's Global Health Partnership's (KGHP) volunteers and the Tropical Health Education Trust (THET) team was used to design the 6-years NHC. The NHC structure, content and delivery were grounded by WFME standards, health needs of the local population, student focused and active learning methods, and feasibility of implementation in medical schools. OUTCOMES: The NHC comprises details about the educational outcomes, curriculum model and framework, educational principles, instructional and learning methods, core as well as optional content, and assessment strategy. CONCLUSIONS: The approach used to develop the NHC ensured it is bespoken for Somaliland. Ongoing evaluation of patient and population needs, each medical school's review of programme implementation and outcomes will inform continuous revision and renewal.
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Progressive multifocal leukoencephalopathy (PML) is a central nervous system disease caused by the human polyomavirus 2 that usually occurs in a setting of immunodeficiency. PML without overt immunosuppression is considered a rare occurrence but has been described in multiple previous case reports and series. Its prevalence, overall frequency, and prognosis are largely unknown. This is a single-center retrospective review of all University of Florida cases with the ICD10 PML diagnosis code (A81.2). PML without overt immunosuppression was defined as absence of human immunodeficiency virus (HIV) infection, hematological malignancy, immunomodulatory/-suppressive medications, autoimmune conditions with a propensity for PML (sarcoidosis, systemic lupus erythematosus). Cases that did not fulfill criteria for clinically or histologically definite PML were excluded. Of 52 patients with the ICD10 code A 81.2, 17 fulfilled definite diagnostic criteria for PML. Overt immunosuppression was identified in 15/17 (88.2%) cases (10/17 (58.8%): human immunodeficiency virus; 5/17 (29.4%): immunomodulatory/-suppressive medication). Two/seventeen (11.8%) cases were consistent with PML without overt immunosuppression. Possible contributing factors were a preceding dog bite and mild hypogammaglobulinemia M (39 mg/dL) in case 1 and significant alcohol use without evidence for liver disease in case 2. Both cases were fatal within 6 (case 1) and 2 (case 2) months. The results suggest that PML without overt immunosuppression may be more common than previously described. Therefore, PML should be considered even in the absence of overt immunosuppression if clinical and radiographic findings are suggestive of the diagnosis.
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Doenças Autoimunes , Infecções por HIV , Leucoencefalopatia Multifocal Progressiva , Lúpus Eritematoso Sistêmico , Animais , Cães , Humanos , Doenças Autoimunes/complicações , Infecções por HIV/complicações , Tolerância Imunológica , Leucoencefalopatia Multifocal Progressiva/diagnóstico , Leucoencefalopatia Multifocal Progressiva/etiologia , Lúpus Eritematoso Sistêmico/tratamento farmacológicoRESUMO
BACKGROUND: A major challenge in the study of high-impact, low-frequency procedures in trauma is the lack of accurate data for time-sensitive processes of care. Trauma video review offers a possible solution, allowing investigators to collect extremely granular time-stamped data. Using resuscitative thoracotomy as a model, we compared data collected using review of audiovisual recordings to data prospectively collected in real time with the hypothesis that data collected using video review would be subject to less missingness and bias. METHODS: We conducted a prospective cohort study of patients undergoing resuscitative thoracotomy at a single urban academic level 1 trauma center. Key data on the timing and completion of procedural milestones of resuscitative thoracotomy were collected using video review and prospective collection. We used McNemar's test to compare proportions of missing data between the 2 methods and calculated bias in time measurements for prospective collection with respect to video review. Statistical analyses were performed using Stata v. 15.0 (College Station, TX). RESULTS: We included 51 subjects (88% Black, 82% male, 90% injured by gunshot wounds) over the study period. Missingness in resuscitative thoracotomy procedural milestone time measurements ranged from 34% to 63% for prospective collection and 0 to 8% for video review and was less missing for video review for all key variables (P < .001). When not missing, bias in data collected by prospective collection was 10% to 43% compared with data collected by video review. CONCLUSIONS: The data collected using video review have less missingness and bias than prospective collection data collected by trained research assistants. Audiovisual recording should be the gold standard for data collection for the study of time-sensitive processes of care in resuscitation.
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Toracotomia , Ferimentos por Arma de Fogo , Coleta de Dados , Feminino , Humanos , Masculino , Estudos Prospectivos , Ressuscitação/métodos , Centros de TraumatologiaRESUMO
BACKGROUND: The identification of immunoglobulin G antibodies against the aquaporin-4 channel (AQP-IgG) in the majority of adult patients differentiates neuromyelitis optica as a distinct disease entity. The high specificity of AQP4-IgG for neuromyelitis optica has allowed the identification of seropositive patients with atypical presentations of this disease. Neuromyelitis optica spectrum disorder has been increasingly recognized in children who demonstrate patterns of clinical involvement beyond the traditional boundaries of the optic pathways and spinal cord. METHODS: This is a single-center, retrospective review comparing demographic, clinical/paraclinical, and laboratory features of children and adults with a serologically confirmed diagnosis of AQP4-IgG-positive neuromyelitis optica spectrum disorder. RESULTS: Of 151 reviewed patient charts, 12 pediatric-onset and 31 adult-onset patients had AQP4-IgG-positive neuromyelitis optica spectrum disorder. The mean age of pediatric-onset neuromyelitis optica spectrum disorder was 12 ± 3.58 years with a female predilection (3:1). Pediatric patients showed more frequent involvement of the brainstem (6/12 [50%]); P = .008) and diencephalon (3/12 [25%]; P = .018). A preceding infection was identifiable in only 3 of 12 (25%) pediatric-onset patients. Moreover, disability as calculated on the expanded disability status scale was less severe in pediatric-onset cases compared to adult-onset cases in their most recent assessment (0 [0-9]) vs 6.5 [0-10]; P = .005). Pediatric-onset patients were also more likely to respond to treatment of acute episodes with corticosteroids ± intravenous immunoglobulin and/or plasmapheresis (Clinical Global Impression-Change scale: 2.5 [1-4] vs 4 [1-6], P = .009). INTERPRETATION: This retrospective study was able to compare and contrast pediatric- and adult-onset neuromyelitis optica spectrum disorder. Relative to their adult counterparts, pediatric-onset neuromyelitis optica spectrum disorder patients were more likely to respond to treatment and less likely to be disabled from their disease at follow-up. Therefore, pediatric-onset disease may represent a less virulent form of neuromyelitis optica spectrum disorder.
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Aquaporina 4 , Autoanticorpos , Imunoglobulina G , Neuromielite Óptica , Adolescente , Adulto , Idade de Início , Aquaporina 4/imunologia , Autoanticorpos/sangue , Criança , Feminino , Humanos , Imunoglobulina G/sangue , Masculino , Neuromielite Óptica/diagnóstico por imagem , Neuromielite Óptica/imunologia , Estudos Retrospectivos , Testes SorológicosRESUMO
ABSTRACT: A 72-year-old man suffering with severe depression with psychotic symptoms, marked apathy, and psychomotor retardation was treated with electroconvulsive therapy (ECT) after resistance to treatment with psychotropic medications. His age, comorbidities, and dysexecutive syndrome prompted consideration of a diagnosis of frontotemporal dementia (FTD), and a 99mTechnetium-labeled hexamethyl propylene amine oxime single-photon emission computed tomography (SPECT) brain perfusion scan showed bilateral perfusion defects that were most pronounced in the frontal regions of the brain. The scan was judged to be abnormal and in keeping with a neurodegenerative dementia. We reasoned that the fluctuation in symptoms was inconsistent with a diagnosis of FTD and that his severe depression could be improved with ECT even if he had FTD, so we decided to proceed with this treatment. A course of 12 sessions of ECT resulted in remission of his psychiatric symptoms and improvement in cognitive performance. A repeat SPECT scan 5 weeks after the last ECT demonstrated a substantial improvement in cerebral blood flow, favoring the diagnosis of depression, rather than dementia. Similar case reports from the literature suggest that ECT does reverse brain hypoperfusion in severe cases of depression and catatonia. Clinicians should be aware that abnormal SPECT findings are nonspecific and can be caused by various conditions, including psychiatric illness, and are not necessarily diagnostic of a neurodegenerative disease.
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Catatonia , Transtorno Depressivo Maior , Eletroconvulsoterapia , Demência Frontotemporal , Doenças Neurodegenerativas , Idoso , Catatonia/complicações , Catatonia/terapia , Depressão/complicações , Depressão/terapia , Humanos , MasculinoRESUMO
BACKGROUND: Glioblastoma (GBM) is the most common primary brain malignancy, but much remains unknown about the histogenesis of these tumors. In the great majority of cases, GBM is a purely glial tumor but in rare cases the classic-appearing high-grade glioma component is admixed with regions of small round blue cells with neuronal immunophenotype, and these tumors have been defined in the WHO 2016 Classification as "glioblastoma with a primitive neuronal component." METHODS: In this paper, we present two cases of GBM-PNC with highly divergent clinical courses, and review current theories for the GBM cell-of-origin. RESULTS AND CONCLUSIONS: GBM-PNC likely arises from a cell type competent to give rise to glial or neuronal lineages. The thesis that GBM recapitulates to some extent normal neurodevelopmental cellular pathways is supported by molecular and clinical features of our two cases of GBM-PNC, but more work is needed to determine which cellular precursor gives rise to specific cases of GBM. GBM-PNC may have a dramatically altered clinical course compared to standard GBM and may benefit from specific lines of treatment.
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Neoplasias Encefálicas , Glioblastoma , Glioma , Encéfalo , Neoplasias Encefálicas/diagnóstico por imagem , Glioblastoma/diagnóstico por imagem , HumanosRESUMO
BACKGROUND: The discovery of two immunoglobulin G (IgG) antibodies against aquaporin 4 (anti-AQP4) and myelin oligodendrocyte glycoprotein (anti-MOG) has led to the distinction of the disorders anti-AQP4 immunoglobulin G positive neuromyelitis spectrum disorder (AQP4-IgG+ NMOSD) and anti-MOG associated disorder (MOGAD). Different clinical and radiological features have been proposed to distinguish these two demyelinating CNS diseases. METHODS: This is a single-center retrospective review at the University of Florida (UF) including all patients with the diagnostic code ICD G36 ("other acute disseminated demyelination") from October 2015 to January 2020 (n=141) and all charts included in the clinical NMOSD database of the UF Division of Neuroimmunology (n=36). A total of 151 cases were reviewed for presence of anti-MOG and anti-AQP4 antibodies and NMOSD diagnostic criteria. Differences in MOGAD and AQP4-IgG+ NMOSD were compared. RESULTS: Of the 151 reviewed patient charts, 11 were consistent with MOGAD and 43 with AQP4-IgG+ NMOSD. Patients with MOGAD were significantly younger at symptom onset compared to patients with AQP4-IgG+ NMOSD (14 [1-33] years vs. 37 [6-82] years; p=0.005). In comparison with AQP4-IgG+ NMOSD, optic neuritis in MOGAD was more frequently associated with bilateral optic nerve involvement: (6/11 [54.5%] vs. 6/43 [13.9%]; p=0.009) and fundoscopic presence of optic disc edema (5/11 [45.5%] vs. 3/43 [7%]; p=0.006). Perineuritis was a common radiological feature in MOGAD (present in 4 cases). In case of myelitis, there was more frequent involvement of the conus medullaris in MOGAD (4/11 [36.4%] vs. 2/43 [4.7%]; p=0.012). Symptomatic cerebral syndrome with supratentorial white matter lesions was seen in MOGAD patients with pediatric onset (pediatric onset: 4/6 [66.7%] vs. adult onset: 0/5 [0%]. In MOGAD, evidence for combined central and peripheral demyelination and increased intracranial pressure was present in one patient each. A preceding inciting event (illness/postpartum) was more frequently identifiable in MOGAD (4/11 [36.4%] vs. 4/43 [7%]; p=0.045). Disability as calculated on the Expanded Disability Status Scale was less severe in MOGAD compared to AQP-IgG+ NMOSD (most severe presentation: 5 [2-7] vs. 7 [1-10]; p=0.015; most recent assessment: 2 [0-5] vs. 5 [0-10]; p=0.045) and patients were more likely to respond to treatment of acute attacks with corticosteroids and/or plasmapheresis (Clinical Global Impression-Global Change scale: 1 [1-4] vs. 3 [1-6]; p=0.001). INTERPRETATION: The study confirms that simultaneous bilateral optic neuritis, presence of optic disc edema, transverse myelitis with conus involvement and a less severe disease course are distinctive features of MOGAD.
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Neuromielite Óptica , Adulto , Aquaporina 4 , Autoanticorpos , Criança , Feminino , Humanos , Imunoglobulina G , Glicoproteína Mielina-Oligodendrócito , Neuromielite Óptica/diagnóstico por imagem , Estudos RetrospectivosRESUMO
OBJECTIVES: The purpose of this study was to compare the effectiveness of metal artifact reduction using Single Energy Metal Artifact Reduction (SEMAR) and Dual Energy CT (DECT). MATERIALS AND METHODS: Six cadavers containing metal implants in the head, neck, abdomen, pelvis, and extremities were scanned with Standard, SEMAR, and DECT protocols on a 320-slice CT scanner. Four specialized radiologists blinded to acquisition methods rated severity of metal artifacts, visualization of anatomic structures, diagnostic interpretation, and image preference with a 5-point grading scale. RESULTS: Scores were significantly better for SEMAR than Standard images in the hip, knee, pelvis, abdomen, and maxillofacial scans (3.25⯱â¯0.88 versus 2.14⯱â¯0.93, pâ¯<â¯0.001). However, new reconstruction artifacts developed in SEMAR images that were not present in Standard images. Scores for severity of metal artifacts and visualization of smooth structures were significantly better for DECT than Standard images in the cervical spine (3.50±0.50 versus 2.0±0.58, pâ¯<â¯0.001) and was preferred over Standard images by one radiologist. In all other cases, radiologists preferred the Standard image over the DECT image due to increased image noise and reduced low-contrast resolution with DECT. In all cases, SEMAR was preferred over Standard and DECT images. CONCLUSION: SEMAR was more effective at reducing metal artifacts than DECT. Radiologists should be aware of new artifacts and review both the original and SEMAR images. When the anatomy or implant is relatively small, DECT may be superior to SEMAR without additional artifacts. However, radiologist should be aware of a reduction in soft tissue contrast.
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Artefatos , Tomografia Computadorizada por Raios X , Algoritmos , Cadáver , Humanos , Próteses e ImplantesRESUMO
BACKGROUND: Cerebral amyloid angiopathy - related inflammation (CAA-ri) is an uncommon manifestation of CAA. METHODS: Single-center, retrospective review of all charts with ICD-code I68.0 (CAA) from 2/2/2016-1/1/2020. RESULTS: Of 152 CAA cases, 13 (8.6%) were consistent with CAA-ri. Corticosteroid-treatment led to short-term reduction in modified Rankin Scale scores (2.6 ± 1.4 vs. 1.6 ± 1.5; p = 0.01) and T2/FLAIR lesion volume (78.1 ± 52.2 cm3 vs. 30 ± 30.9 cm3, p < 0.01) as well as short-term improvement in post-treatment Clinical Global Impression - Global Change scores compared to pre-treatment scores (clinical: 6 ± 1 vs. 2.6 ± 1.3, p = 0.03; radiological: 4.6 ± 1.9 vs. 1.2 ± 0.4, p = 0.03). INTERPRETATION: Corticosteroid-treatment leads to clinical and radiological short-term improvement (class IV evidence).
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Corticosteroides/uso terapêutico , Angiopatia Amiloide Cerebral/complicações , Inflamação/tratamento farmacológico , Metilprednisolona/uso terapêutico , Prednisolona/uso terapêutico , Idoso , Encéfalo/efeitos dos fármacos , Encéfalo/patologia , Feminino , Humanos , Inflamação/etiologia , Inflamação/patologia , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
Hyperintense reperfusion marker (HARM) on post-contrast magnetic resonance imaging (MRI) fluid attenuated inversion recovery (FLAIR) represents gadolinium contrast extravasation in the setting of acute ischemic stroke and is a common finding after revascularization therapies. Clinically, it is a marker of blood brain barrier (BBB) disruption, predictor of hemorrhagic transformation, and predictor of poor clinical outcome in ischemic stroke. Here, we describe a case where a patient underwent mechanical thrombectomy and was later found to have evidence of contrast extravasation on CT imaging, in the same locations found on the post-contrast FLAIR MRI, demonstrating that MRI-HARM and CT contrast extravasation may mimic similar phenomena. Thus, this case demonstrates that we may be able to extrapolate what we know about HARM detected on MRI to a CT imaging biomarker that would be more readily obtainable in most stroke patients.
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Meios de Contraste/administração & dosagem , Extravasamento de Materiais Terapêuticos e Diagnósticos/diagnóstico por imagem , Infarto da Artéria Cerebral Média/terapia , Trombectomia/efeitos adversos , Tomografia Computadorizada por Raios X , Idoso , Circulação Cerebrovascular , Extravasamento de Materiais Terapêuticos e Diagnósticos/etiologia , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/fisiopatologia , Imageamento por Ressonância Magnética , Valor Preditivo dos Testes , Resultado do TratamentoRESUMO
RATIONALE AND OBJECTIVES: To describe our full-resolution simulation of critical care imaging coupled with posthoc grading of resident's interpretations and present results from the fixed effects terms in a comprehensive mixed regression model of the resulting scores. MATERIALS AND METHODS: The system delivered full resolution DICOM studies via clinical-grade viewing software integrated with a custom built web-based workflow and reporting system. The interpretations submitted by participating residents from 47 different programs were graded (scores of 0-10) on a case by case basis by a cadre of faculty members from our department. The data from 5 yearly (2014-2018) cycles consisting of 992 separate 65 case, 8 hour simulation sessions were collated from the transaction records. We used a mixed (hierarchical) statistical model with nine fixed and four random independent variables. In this paper, we present the results from the nine fixed effects. RESULTS: There were 19,916/63,839 (27.0%, CI 26.7%-27.4%) scores in the 0-2 range (i.e., clinically significant miss). Neurological cases were more difficult with adjusted scores 2.3 (CI 1.9-3.2) lower than body/musculoskeletal cases. There was a small (0.3, CI 0.20-0.38 points) but highly significant (p<0.0001) decrease in score for the final 13/65 cases (fifth quintile) as evidence of fatigue during the last hour of an 8 hour shift. By comparing adjusted scores from mid-R1 (quarter 3) to late-R3 (quarter 12) we estimate the training effect as an increase of 2.2 (CI 1.90-2.50) points. CONCLUSION: Full resolution simulation based evaluation of critical care radiology interpretation is being conducted remotely and efficiently at large scale. Analysis of the resulting scores yields multiple insights into the interpretative process.