Precision imaging of cardiac function and scar size in acute and chronic porcine myocardial infarction using ultrahigh-field MRI.

BACKGROUND: 7 T cardiac magnetic resonance imaging (MRI) studies may enable higher precision in clinical metrics like cardiac function, ventricular mass, and more. Higher precision may allow early detection of functional impairment and early evaluation of treatment responses in clinical practice and pre-clinical studies. METHODS: Seven female German Landrace pigs were scanned prior to and at three time points (3-4 days, 7-10 days, and ~60 days) post myocardial infarction using a whole body 7 T system and three radiofrequency (RF) coils developed and built in-house to accompany animal growth. RESULTS: The combination of dedicated RF hardware and 7 T MRI enables a longitudinal study in a pig model of acute and chronic infarction, providing consistent blood tissue contrast and high signal-to-noise ratio (SNR) in measurements of cardiac function, as well as low coefficients of variation (CoV) for ejection fraction (CoVintra-observer: 2%, CoVinter-observer: 3.8%) and infarct size (CoVintra-observer: 8.4%, CoVinter-observer: 3.8%), despite drastic animal growth. CONCLUSIONS: Best results are achieved via manual segmentation. We define state-of-the-art procedures for large animal studies at 7 T.

In magnetic resonance imaging (MRI), scanners use magnets to generate detailed images of structures in the body, such as the heart. Stronger magnets can produce stronger magnetic fields, which can be leveraged for better image quality and developing new methods for disease diagnosis. In clinical practice, such systems using strong magnets are not yet used for imaging of the heart and some safety aspects remain challenging. We apply such an imaging approach in pigs, in which heart structure and function are similar to humans. We focus on the most important clinical imaging aspects following a heart attack, namely heart function and scar detection. We demonstrate that the high magnetic strength system enabled consistent image quality and accuracy. These findings may help to guide future developments in MRI of the heart, for example in patients who have had a heart attack.

Cardiac function in a large animal model of myocardial infarction at 7 T: deep learning based automatic segmentation increases reproducibility.

Cardiac magnetic resonance (CMR) imaging allows precise non-invasive quantification of cardiac function. It requires reliable image segmentation for myocardial tissue. Clinically used software usually offers automatic approaches for this step. These are, however, designed for segmentation of human images obtained at clinical field strengths. They reach their limits when applied to preclinical data and ultrahigh field strength (such as CMR of pigs at 7 T). In our study, eleven animals (seven with myocardial infarction) underwent four CMR scans each. Short-axis cine stacks were acquired and used for functional cardiac analysis. End-systolic and end-diastolic images were labelled manually by two observers and inter- and intra-observer variability were assessed. Aiming to make the functional analysis faster and more reproducible, an established deep learning (DL) model for myocardial segmentation in humans was re-trained using our preclinical 7 T data (n = 772 images and labels). We then tested the model on n = 288 images. Excellent agreement in parameters of cardiac function was found between manual and DL segmentation: For ejection fraction (EF) we achieved a Pearson's r of 0.95, an Intraclass correlation coefficient (ICC) of 0.97, and a Coefficient of variability (CoV) of 6.6%. Dice scores were 0.88 for the left ventricle and 0.84 for the myocardium.

Complementary analysis of specific absorption rate safety for an 8Tx/16Rx array with central symmetry of elements for magnetic resonance imaging of the human heart and abdominopelvic organs at 7 T.

A complementary safety assessment of the specific absorption rate (SAR) of the electromagnetic energy was performed in a prototype 8Tx/16Rx RF array for cardiac magnetic resonance imaging (MRI) at 7 T. The study aimed to address two critical aspects of 7-T SAR safety not always explicitly examined by coil vendors: (i) the influence of an RF-array position on a peak SAR value, and (ii) the risk of exceeding the permitted maximal SAR in the tissue surrounding conductive passive implants. The full-wave 3D electromagnetic simulations for the thorax with shifted array position and the whole-body volume in the presence of a dental retainer, an intrauterine contraceptive device (IUD), and a hip joint implant, were performed for two human voxel models. The effect of the array displacement on the SAR was simulated for seven array locations on the thorax shifted from the central position in different directions on 50 mm. The peak SAR values for both models were analyzed for the three phase-only transmit vectors optimized for B1 + homogeneity and transmit efficiency. Peak SAR values due to the shifts of the array position increase up to ≈50%. The worst-case peak SAR value for a dental retainer was found to be in the range of 10% of the maximal SAR in the tissue within the array's borders. For the IUD and artificial hip joint implants the effect was found to be negligible (peak SAR < 1% of the SAR within array borders). In addition to simulations for cardiac MRI, we performed a preliminary B1 + shimming and SAR-safety analysis for the same RF-array at various positions lower on the body trunk to assess a potential application in imaging abdominopelvic organs (prostate, kidney, and liver). The most promising target for an ad hoc alternative application of the array was found to be the prostate.

Ultra-high field cardiac MRI in large animals and humans for translational cardiovascular research.

A key step in translational cardiovascular research is the use of large animal models to better understand normal and abnormal physiology, to test drugs or interventions, or to perform studies which would be considered unethical in human subjects. Ultrahigh field magnetic resonance imaging (UHF-MRI) at 7 T field strength is becoming increasingly available for imaging of the heart and, when compared to clinically established field strengths, promises better image quality and image information content, more precise functional analysis, potentially new image contrasts, and as all in-vivo imaging techniques, a reduction of the number of animals per study because of the possibility to scan every animal repeatedly. We present here a solution to the dual use problem of whole-body UHF-MRI systems, which are typically installed in clinical environments, to both UHF-MRI in large animals and humans. Moreover, we provide evidence that in such a research infrastructure UHF-MRI, and ideally combined with a standard small-bore UHF-MRI system, can contribute to a variety of spatial scales in translational cardiovascular research: from cardiac organoids, Zebra fish and rodent hearts to large animal models such as pigs and humans. We present pilot data from serial CINE, late gadolinium enhancement, and susceptibility weighted UHF-MRI in a myocardial infarction model over eight weeks. In 14 pigs which were delivered from a breeding facility in a national SARS-CoV-2 hotspot, we found no infection in the incoming pigs. Human scanning using CINE and phase contrast flow measurements provided good image quality of the left and right ventricle. Agreement of functional analysis between CINE and phase contrast MRI was excellent. MRI in arrested hearts or excised vascular tissue for MRI-based histologic imaging, structural imaging of myofiber and vascular smooth muscle cell architecture using high-resolution diffusion tensor imaging, and UHF-MRI for monitoring free radicals as a surrogate for MRI of reactive oxygen species in studies of oxidative stress are demonstrated. We conclude that UHF-MRI has the potential to become an important precision imaging modality in translational cardiovascular research.

High-resolution imaging of the excised porcine heart at a whole-body 7 T MRI system using an 8Tx/16Rx pTx coil.

INTRODUCTION: MRI of excised hearts at ultra-high field strengths ([Formula: see text]≥7 T) can provide high-resolution, high-fidelity ground truth data for biomedical studies, imaging science, and artificial intelligence. In this study, we demonstrate the capabilities of a custom-built, multiple-element transceiver array customized for high-resolution imaging of excised hearts. METHOD: A dedicated 16-element transceiver loop array was implemented for operation in parallel transmit (pTx) mode (8Tx/16Rx) of a clinical whole-body 7 T MRI system. The initial adjustment of the array was performed using full-wave 3D-electromagnetic simulation with subsequent final fine-tuning on the bench. RESULTS: We report the results of testing the implemented array in tissue-mimicking liquid phantoms and excised porcine hearts. The array demonstrated high efficiency of parallel transmits characteristics enabling efficient pTX-based B1+-shimming. CONCLUSION: The receive sensitivity and parallel imaging capability of the dedicated coil were superior to that of a commercial 1Tx/32Rx head coil in both SNR and T2*-mapping. The array was successfully tested to acquire ultra-high-resolution (0.1 × 0.1 × 0.8 mm voxel) images of post-infarction scar tissue. High-resolution (isotropic 1.6 mm3 voxel) diffusion tensor imaging-based tractography provided high-resolution information about normal myocardial fiber orientation.

Effects of image homogeneity on stenosis visualization at 7 T in a coronary artery phantom study: With and without B1-shimming and parallel transmission.

BACKGROUND: To investigate the effects of B1-shimming and radiofrequency (RF) parallel transmission (pTX) on the visualization and quantification of the degree of stenosis in a coronary artery phantom using 7 Tesla (7 T) magnetic resonance imaging (MRI). METHODS: Stenosis phantoms with different grades of stenosis (0%, 20%, 40%, 60%, 80%, and 100%; 5 mm inner vessel diameter) were produced using 3D printing (clear resin). Phantoms were imaged with four different concentrations of diluted Gd-DOTA representing established arterial concentrations after intravenous injection in humans. Samples were centrally positioned in a thorax phantom of 30 cm diameter filled with a custom-made liquid featuring dielectric properties of muscle tissue. MRI was performed on a 7 T whole-body system. 2D-gradient-echo sequences were acquired with an 8-channel transmit 16-channel receive (8 Tx / 16 Rx) cardiac array prototype coil with and without pTX mode. Measurements were compared to those obtained with identical scan parameters using a commercially available 1 Tx / 16 Rx single transmit coil (sTX). To assess reproducibility, measurements (n = 15) were repeated at different horizontal angles with respect to the B0-field. RESULTS: B1-shimming and pTX markedly improved flip angle homogeneity across the thorax phantom yielding a distinctly increased signal-to-noise ratio (SNR) averaged over a whole slice relative to non-manipulated RF fields. Images without B1-shimming showed shading artifacts due to local B1+-field inhomogeneities, which hampered stenosis quantification in severe cases. In contrast, B1-shimming and pTX provided superior image homogeneity. Compared with a conventional sTX coil higher grade stenoses (60% and 80%) were graded significantly (p<0.01) more precise. Mild to moderate grade stenoses did not show significant differences. Overall, SNR was distinctly higher with B1-shimming and pTX than with the conventional sTX coil (inside the stenosis phantoms 14%, outside the phantoms 32%). Both full and half concentration (10.2 mM and 5.1 mM) of a conventional Gd-DOTA dose for humans were equally suitable for stenosis evaluation in this phantom study. CONCLUSIONS: B1-shimming and pTX at 7 T can distinctly improve image homogeneity and therefore provide considerably more accurate MR image analysis, which is beneficial for imaging of small vessel structures.

High-resolution simulation of B0 field conditions in the human heart from segmented computed tomography images.

B0 inhomogeneity leads to imaging artifacts in cardiac magnetic resonance imaging (MRI), in particular dark band artifacts with steady-state free precession pulse sequences. The limited spatial resolution of MR-derived in vivo B0 maps and the lack of population data prevent systematic analysis of the problem at hand and the development of optimized B0 shim strategies. We used readily available clinical computed tomography (CT) images to simulate the B0 conditions in the human heart at high spatial resolution. Calculated B0 fields showed consistency with MRI-based B0 measurements. The B0 maps for both the simulations and in vivo measurements showed local field inhomogeneities in the vicinity of lung tips with dominant Z3 spherical harmonic terms in the field distribution. The presented simulation approach allows for the derivation of B0 field conditions at high spatial resolution from CT images and enables the development of subject- and population-specific B0 shim strategies for the human heart.

A novel antisymmetric 16-element transceiver dipole antenna array for parallel transmit cardiac MRI in pigs at 7 T.

To improve parallel transmit (pTx) and receive performance for cardiac MRI (cMRI) in pigs at 7 T, a dedicated transmit/receive (Tx/Rx), 16-element antisymmetric dipole antenna array, which combines L-shaped and straight dipoles, was designed, implemented, and evaluated in both cadavers and animals in vivo. Electromagnetic-field simulations were performed with the new 16-element dipole antenna array loaded with a pig thorax-shaped phantom and compared with an eight-element array of straight dipoles. The new dipole array was interfaced to a 7 T scanner in pTx mode (8Tx/16Rx). Imaging performance of the novel array was validated through MRI measurements in a pig phantom, an 85 kg pig cadaver, and two pigs in vivo (74 and 81 kg). Due to the improved decoupling between interleaved L-shaped and straight dipole elements, the 16-element dipole array fits within the same outer dimensions as an eight-element array of straight dipoles. This provides improvement of both transmit and receive characteristics and additional degrees of freedom for B1+ shimming. The antisymmetric dipole array demonstrated efficient suppression of destructive interferences in the B1+ field, with up to 25% improvement in the B1+ homogeneity achieved using static pTx-RFPA B1+ shimming in comparison with the hardware-adjusted state, which was optimized for single transmit. High-resolution (0.5 × 0.5 × 4 mm3 ) anatomical images of the heart after cardiac arrest proved good transmit and receive characteristics of the novel array design. Parallel imaging with an acceleration factor up to R = 6 was possible while maintaining a mean g factor of 1.55 within the pig heart. CINE images acquired in vivo in two pigs demonstrated SNR and parallel imaging capabilities similar to those of a reference 8Tx/16Rx dedicated loop array for cMRI in pigs.

Global optimization of default phases for parallel transmit coils for ultra-high-field cardiac MRI.

The development of novel multiple-element transmit-receive arrays is an essential factor for improving B1+ field homogeneity in cardiac MRI at ultra-high magnetic field strength (B0 > = 7.0T). One of the key steps in the design and fine-tuning of such arrays during the development process is finding the default driving phases for individual coil elements providing the best possible homogeneity of the combined B1+-field that is achievable without (or before) subject-specific B1+-adjustment in the scanner. This task is often solved by time-consuming (brute-force) or by limited efficiency optimization methods. In this work, we propose a robust technique to find phase vectors providing optimization of the B1-homogeneity in the default setup of multiple-element transceiver arrays. The key point of the described method is the pre-selection of starting vectors for the iterative solver-based search to maximize the probability of finding a global extremum for a cost function optimizing the homogeneity of a shaped B1+-field. This strategy allows for (i) drastic reduction of the computation time in comparison to a brute-force method and (ii) finding phase vectors providing a combined B1+-field with homogeneity characteristics superior to the one provided by the random-multi-start optimization approach. The method was efficiently used for optimizing the default phase settings in the in-house-built 8Tx/16Rx arrays designed for cMRI in pigs at 7T.

On the way to routine cardiac MRI at 7 Tesla - a pilot study on consecutive 84 examinations.

INTRODUCTION: Cardiac magnetic resonance (CMR) at ultrahigh field (UHF) offers the potential of high resolution and fast image acquisition. Both technical and physiological challenges associated with CMR at 7T require specific hardware and pulse sequences. This study aimed to assess the current status and existing, publicly available technology regarding the potential of a clinical application of 7T CMR. METHODS: Using a 7T MRI scanner and a commercially available radiofrequency coil, a total of 84 CMR examinations on 72 healthy volunteers (32 males, age 19-70 years, weight 50-103 kg) were obtained. Both electrocardiographic and acoustic triggering were employed. The data were analyzed regarding the diagnostic image quality and the influence of patient and hardware dependent factors. 50 complete short axis stacks and 35 four chamber CINE views were used for left ventricular (LV) and right ventricular (RV), mono-planar LV function, and RV fractional area change (FAC). Twenty-seven data sets included aortic flow measurements that were used to calculate stroke volumes. Subjective acceptance was obtained from all volunteers with a standardized questionnaire. RESULTS: Functional analysis showed good functions of LV (mean EF 56%), RV (mean EF 59%) and RV FAC (mean FAC 52%). Flow measurements showed congruent results with both ECG and ACT triggering. No significant influence of experimental parameters on the image quality of the LV was detected. Small fractions of 5.4% of LV and 2.5% of RV segments showed a non-diagnostic image quality. The nominal flip angle significantly influenced the RV image quality. CONCLUSION: The results demonstrate that already now a commercially available 7T MRI system, without major methods developments, allows for a solid morphological and functional analysis similar to the clinically established CMR routine approach. This opens the door towards combing routine CMR in patients with development of advanced 7T technology.

B0 shimming of the human heart at 7T.

PURPOSE: Inhomogeneities of the static magnetic B0 field are a major limiting factor in cardiac MRI at ultrahigh field (≥ 7T), as they result in signal loss and image distortions. Different magnetic susceptibilities of the myocardium and surrounding tissue in combination with cardiac motion lead to strong spatio-temporal B0 -field inhomogeneities, and their homogenization (B0 shimming) is a prerequisite. Limitations of state-of-the-art shimming are described, regional B0 variations are measured, and a methodology for spherical harmonics shimming of the B0 field within the human myocardium is proposed. METHODS: The spatial B0 -field distribution in the heart was analyzed as well as temporal B0 -field variations in the myocardium over the cardiac cycle. Different shim region-of-interest selections were compared, and hardware limitations of spherical harmonics B0 shimming were evaluated by calibration-based B0 -field modeling. The role of third-order spherical harmonics terms was analyzed as well as potential benefits from cardiac phase-specific shimming. RESULTS: The strongest B0 -field inhomogeneities were observed in localized spots within the left-ventricular and right-ventricular myocardium and varied between systolic and diastolic cardiac phases. An anatomy-driven shim region-of-interest selection allowed for improved B0 -field homogeneity compared with a standard shim region-of-interest cuboid. Third-order spherical harmonics terms were demonstrated to be beneficial for shimming of these myocardial B0 -field inhomogeneities. Initial results from the in vivo implementation of a potential shim strategy were obtained. Simulated cardiac phase-specific shimming was performed, and a shim term-by-term analysis revealed periodic variations of required currents. CONCLUSION: Challenges in state-of-the-art B0 shimming of the human heart at 7 T were described. Cardiac phase-specific shimming strategies were found to be superior to vendor-supplied shimming.

Longitudinal assessment of tissue properties and cardiac diffusion metrics of the ex vivo porcine heart at 7 T: Impact of continuous tissue fixation using formalin.

In this study we aimed to assess the effects of continuous formalin fixation on diffusion and relaxation metrics of the ex vivo porcine heart at 7 T. Magnetic resonance imaging was performed on eight piglet hearts using a 7 T whole body system. Hearts were measured fresh within 3 hours of cardiac arrest followed by immersion in 10% neutral buffered formalin. T2* and T2 were assessed using a gradient multi-echo and multi-echo spin echo sequence, respectively. A spin echo and a custom stimulated echo sequence were employed to assess diffusion time-dependent changes in metrics of cardiac diffusion tensor imaging. SNR was determined for b = 0 images. Scans were performed for 5 mm thick apical, midcavity and basal slices (in-plane resolution: 1 mm) and repeated 7, 15, 50, 100 and 200 days postfixation. Eigenvalues of the apparent diffusion coefficient (ADC) and fractional anisotropy (FA) decreased significantly (P < 0.05) following fixation. Relative to fresh hearts, FA values 7 and 200 days postfixation were 90% and 80%, while respective relative ADC values at those fixation stages were 78% and 92%. Statistical helix and sheetlet angle distributions as well as respective mean and median values showed no systematic influence of continuous formalin fixation. Similar to changes in the ADC, values for T2 , T2* and SNR dropped initially postfixation. Respective relative values compared with fresh hearts at day 7 were 64%, 79% and 68%, whereas continuous fixation restored T2 , T2* and SNR leading to relative values of 74%, 100%, and 81% at day 200, respectively. Relaxation parameters and diffusion metrics are significantly altered by continuous formalin fixation. The preservation of microstructure metrics following prolonged fixation is a key finding that may enable future studies of ventricular remodeling in cardiac pathologies.

A Novel Mono-surface Antisymmetric 8Tx/16Rx Coil Array for Parallel Transmit Cardiac MRI in Pigs at 7T.

A novel mono-surface antisymmetric 16-element transmit/receive (Tx/Rx) coil array was designed, simulated, constructed, and tested for cardiac magnetic resonance imaging (cMRI) in pigs at 7 T. The cardiac array comprised of a mono-surface 16-loops with two central elements arranged anti-symmetrically and flanked by seven elements on either side. The array was configured for parallel transmit (pTx) mode to have an eight channel transmit and 16-channel receive (8Tx/16Rx) coil array. Electromagnetic (EM) simulations, bench-top measurements, phantom, and MRI experiments with two pig cadavers (68 and 46 kg) were performed. Finally, the coil was used in pilot in-vivo measurements with a 60 kg pig. Flip angle (FA), geometry factor (g-factor), signal-to-noise ratio (SNR) maps, and high-resolution cardiac images were acquired with an in-plane resolution of 0.6 mm × 0.6 mm (in-vivo) and 0.3 mm × 0.3 mm (ex-vivo). The mean g-factor over the heart was 1.26 (R = 6). Static phase [Formula: see text] shimming in a pig body phantom with the optimal phase vectors makes possible to improve the [Formula: see text] homogeneity by factor > 2 and transmit efficiency by factor > 3 compared to zero phases (before RF shimming). Parallel imaging performed in the in-vivo measurements demonstrated well preserved diagnostic quality of the resulting images at acceleration factors up to R = 6. The described hardware design can be adapted for arrays optimized for animals and humans with a larger number of elements (32-64) while maintaining good decoupling for various MRI applications at UHF (e.g., cardiac, head, and spine).

Spin echo based cardiac diffusion imaging at 7T: An ex vivo study of the porcine heart at 7T and 3T.

Purpose of this work was to assess feasibility of cardiac diffusion tensor imaging (cDTI) at 7 T in a set of healthy, unfixed, porcine hearts using various parallel imaging acceleration factors and to compare SNR and derived cDTI metrics to a reference measured at 3 T. Magnetic resonance imaging was performed on 7T and 3T whole body systems using a spin echo diffusion encoding sequence with echo planar imaging readout. Five reference (b = 0 s/mm2) images and 30 diffusion directions (b = 700 s/mm2) were acquired at both 7 T and 3 T using a GRAPPA acceleration factor R = 1. Scans at 7 T were repeated using R = 2, R = 3, and R = 4. SNR evaluation was based on 30 reference (b = 0 s/mm2) images of 30 slices of the left ventricle and cardiac DTI metrics were compared within AHA segmentation. The number of hearts scanned at 7 T and 3 T was n = 11. No statistically significant differences were found for evaluated helix angle, secondary eigenvector angle, fractional anisotropy and apparent diffusion coefficient at the different field strengths, given sufficiently high SNR and geometrically undistorted images. R≥3 was needed to reduce susceptibility induced geometric distortions to an acceptable amount. On average SNR in myocardium of the left ventricle was increased from 29±3 to 44±6 in the reference image (b = 0 s/mm2) when switching from 3 T to 7 T. Our study demonstrates that high resolution, ex vivo cDTI is feasible at 7 T using commercial hardware.

The impact of reduction of testing at a Preoperative Evaluation Clinic for elective cases: Value added without adverse outcomes.

STUDY OBJECTIVE: Protocol changes at Vanderbilt have been adopted with the intention of reducing unnecessary preoperative testing. We sought to evaluate their success and association with clinical decisions. DESIGN: Retrospective Observational Study SETTING: Vanderbilt's Preoperative Evaluation Clinic MEASUREMENTS: We reviewed and identified a key interval of change on clinical workup protocols which led to a reduction in preoperative testing. We queried Data Warehouse for preoperative chemistry tests, complete blood counts, coagulation blood draws, electrocardiograms, and chest x-rays done before and after these intervals. Chi-square, univariate and mixed effect multivariable regressions were performed to determine the significance of testing reduction and tendency of readmission rates and length-of-stay; Welch's t-test with Freeman-Tukey transformation was conducted to identify the differences in case cancellation rates. MAIN RESULTS: We analyzed 56,425 anesthetic cases and there was a statistically significant downward trend in all preoperative testing performed: electrocardiograms (61.90% to 31.66% [OR 0.151; 95% CI 0.144 to 0.159]), coagulation blood draws (37.57% to 29.74% [OR 0.392; 95% CI 0.370 to 0.416]), basic metabolic panels (70.64% to 51.29% [OR 0.294; 95% CI 0.280 to 0.309]), blood cell counts (71.38% to 51.42% [OR 0.264; 95% CI 0.251 to 0.277]) and chest x-rays (11.80% to 6.04% [OR 0.417; 95% CI 0.384 to 0.452], to 3.13% [OR 0.473; 95% CI 0.431 to 0.519]) after protocol changed. The changes didn't induce a significant increase in case cancellations, length-of-stay, readmission or most DOS testing; except for BMPs (0.28% to 0.66% [OR 1.307; 95% CI 1.104 to 1.549]). CONCLUSIONS: A net reduction in preoperative testing was seen at our institution from 2012 to 2015 due to anesthesia protocol changes intended to limit routine ordering of labs and imaging. While there was a significant increase in DOS testing for BMPs, these increases were not enough to offset the decrease in testing observed preoperatively.

Compliance Is Contagious: Using Informatics Methods to Measure the Spread of a Documentation Standard From a Preoperative Clinic.

PURPOSE: Preoperative documentation is essential to coordinated care and has the potential for standardization, which may facilitate downstream clinical management. DESIGN: An observational pre/post standardization design was used. METHODS: We analyzed the implementation of a preoperative documentation standardization intervention in Vanderbilt's Preoperative Evaluation Clinic (VPEC) and its impact outside VPEC. A phased intervention consisted of clinician education with monthly feedback, followed by the development of a compliance dashboard and inclusion in Ongoing Professional Performance Evaluation system by VPEC. A follow-up survey was administered to measure the impact on clinical management. FINDINGS: Adherence to standardization was improved with the addition of electronic feedback. Implementation of this system in the preoperative clinic had significant impact outside VPEC. Trainee status was a significant predictor of adoption of the standardized format. CONCLUSIONS: Adoption of a preoperative documentation standard in a clinic had a positive impact on standardization practices in a perioperative system.

Electronically self-assessed functional capacity and exercise testing: A comparison of the Duke Activity Status Index and Patient-Reported Outcomes Measurement Information System tools.

PURPOSE: Electronic screening tools, such as Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short-Form 12a (PF-SF12a), may aid in the assessment of functional capacity. However, PROMIS PF-SF12a has not been validated against exercise capacity, or compared with established questionnaires, including the Duke Activity Status Index (DASI). We compared the DASI and PROMIS PF-SF12a to the maximum metabolic equivalents (METs) achieved during exercise stress testing. METHODS: DASI and PROMIS PF-SF12a were electronically administered to 100 adult patients (median age 56years, 61% male) immediately before exercise stress testing. DASI-predicted METs and PROMIS T score were calculated. Correlations with exercise METs with and without age adjustment were examined. Linear regression lines were derived and adjusted r2 statistic was calculated. We compared models with the Davidson-Mackinnon J test. RESULTS: The median (interquartile range) DASI-predicted METs, PROMIS Tscore, and exercise METs were 8.97 (7.61-9.89), 47.90 (43.33-52.40), and 10.10 (10.10-12.80), respectively. In unadjusted correlation analyses, PROMIS accounted for 26% of the variance in exercise METs compared with 38% with DASI. With age adjustment, the r2values increased to 0.36 (PROMIS) and 0.46 (DASI). In both unadjusted and age-adjusted analyses, inclusion of DASI improved prediction of exercise METs beyond PROMIS T score (P<.0001). In contrast, PROMIS T score did not improve exercise MET prediction compared with DASI alone (P>.10). CONCLUSION: Among patients undergoing clinically indicated exercise stress testing, DASI outperformed PROMIS PF-SF12a as a predictor of exercise METs.

Reproducibility and comparison of oxygen-enhanced T1 quantification in COPD and asthma patients.

T1 maps have been shown to yield useful diagnostic information on lung function in patients with chronic obstructive pulmonary disease (COPD) and asthma, both for native T1 and ΔT1, the relative reduction while breathing pure oxygen. As parameter quantification is particularly interesting for longitudinal studies, the purpose of this work was both to examine the reproducibility of lung T1 mapping and to compare T1 found in COPD and asthma patients using IRSnapShotFLASH embedded in a full MRI protocol. 12 asthma and 12 COPD patients (site 1) and further 15 COPD patients (site 2) were examined on two consecutive days. In each patient, T1 maps were acquired in 8 single breath-hold slices, breathing first room air, then pure oxygen. Maps were partitioned into 12 regions each to calculate average values. In asthma patients, the average T1,RA = 1206ms (room air) was reduced to T1,O2 = 1141ms under oxygen conditions (ΔT1 = 5.3%, p < 5⋅10-4), while in COPD patients both native T1,RA = 1125ms was significantly shorter (p < 10-3) and the relative reduction to T1,O2 = 1081ms on average ΔT1 = 4.2%(p < 10-5). On the second day, with T1,RA = 1186ms in asthma and T1,RA = 1097ms in COPD, observed values were slightly shorter on average in all patient groups. ΔT1 reduction was the least repeatable parameter and varied from day to day by up to 23% in individual asthma and 30% in COPD patients. While for both patient groups T1 was below the values reported for healthy subjects, the T1 and ΔT1 found in asthmatics lies between that of the COPD group and reported values for healthy subjects, suggesting a higher blood volume fraction and better ventilation. However, it could be demonstrated that lung T1 quantification is subject to notable inter-examination variability, which here can be attributed both to remaining contrast agent from the previous day and the increased dependency of lung T1 on perfusion and thus current lung state.

A Perioperative Systems Design to Improve Intraoperative Glucose Monitoring Is Associated with a Reduction in Surgical Site Infections in a Diabetic Patient Population.

BACKGROUND: Diabetic patients receiving insulin should have periodic intraoperative glucose measurement. The authors conducted a care redesign effort to improve intraoperative glucose monitoring. METHODS: With approval from Vanderbilt University Human Research Protection Program (Nashville, Tennessee), the authors created an automatic system to identify diabetic patients, detect insulin administration, check for recent glucose measurement, and remind clinicians to check intraoperative glucose. Interrupted time series and propensity score matching were used to quantify pre- and postintervention impact on outcomes. Chi-square/likelihood ratio tests were used to compare surgical site infections at patient follow-up. RESULTS: The authors analyzed 15,895 cases (3,994 preintervention and 11,901 postintervention; similar patient characteristics between groups). Intraoperative glucose monitoring rose from 61.6 to 87.3% in cases after intervention (P = 0.0001). Recovery room entry hyperglycemia (fraction of initial postoperative glucose readings greater than 250) fell from 11.0 to 7.2% after intervention (P = 0.0019), while hypoglycemia (fraction of initial postoperative glucose readings less than 75) was unchanged (0.6 vs. 0.9%; P = 0.2155). Eighty-seven percent of patients had follow-up care. After intervention the unadjusted surgical site infection rate fell from 1.5 to 1.0% (P = 0.0061), a 55.4% relative risk reduction. Interrupted time series analysis confirmed a statistically significant surgical site infection rate reduction (P = 0.01). Propensity score matching to adjust for confounders generated a cohort of 7,604 well-matched patients and confirmed a statistically significant surgical site infection rate reduction (P = 0.02). CONCLUSIONS: Anesthesiologists add healthcare value by improving perioperative systems. The authors leveraged the one-time cost of programming to improve reliability of intraoperative glucose management and observed improved glucose monitoring, increased insulin administration, reduced recovery room hyperglycemia, and fewer surgical site infections. Their analysis is limited by its applied quasiexperimental design.

Nondepolarizing Neuromuscular Blocking Agents, Reversal, and Risk of Postoperative Pneumonia.

BACKGROUND: Residual postoperative paralysis from nondepolarizing neuromuscular blocking agents (NMBAs) is a known problem. This paralysis has been associated with impaired respiratory function, but the clinical significance remains unclear. The aims of this analysis were two-fold: (1) to investigate if intermediate-acting NMBA use during surgery is associated with postoperative pneumonia and (2) to investigate if nonreversal of NMBAs is associated with postoperative pneumonia. METHODS: Surgical cases (n = 13,100) from the Vanderbilt University Medical Center National Surgical Quality Improvement Program database who received general anesthesia were included. The authors compared 1,455 surgical cases who received an intermediate-acting nondepolarizing NMBA to 1,455 propensity score-matched cases who did not and 1,320 surgical cases who received an NMBA and reversal with neostigmine to 1,320 propensity score-matched cases who did not receive reversal. Postoperative pneumonia incidence rate ratios (IRRs) and bootstrapped 95% CIs were calculated. RESULTS: Patients receiving an NMBA had a higher absolute incidence rate of postoperative pneumonia (9.00 vs. 5.22 per 10,000 person-days at risk), and the IRR was statistically significant (1.79; 95% bootstrapped CI, 1.08 to 3.07). Among surgical cases who received an NMBA, cases who were not reversed were 2.26 times as likely to develop pneumonia after surgery compared to cases who received reversal with neostigmine (IRR, 2.26; 95% bootstrapped CI, 1.65 to 3.03). CONCLUSIONS: Intraoperative use of intermediate nondepolarizing NMBAs is associated with developing pneumonia after surgery. Among patients who receive these agents, nonreversal is associated with an increased risk of postoperative pneumonia.