Medical Imaging Decision And Support (MIDAS):Study protocol for a multi-centre cluster randomized trial evaluating the ESR iGuide

Objectives: Medical imaging plays an essential role in healthcare. As a diagnostic test, imaging is prone to substantial overuse and potential overdiagnosis, with dire consequences to patient outcomes and health care costs. Clinical decision support systems (CDSSs) were developed to guide referring physicians in making appropriate imaging decisions. This study will evaluate the effect of implementing a CDSS (ESR iGuide) with versus without active decision support in a physician order entry on the appropriate use of imaging tests and ordering behaviour. Methods: A protocol for a multi-center cluster-randomized trial with departments acting as clusters, combined with a before-after-revert design. Four university hospitals with eight participating departments each for a total of thirty-two clusters will be included in the study. All departments start in control condition with structured data entry of the clinical indication and tracking of the imaging exams requested. Initially, the CDSS is implemented and all physicians remain blinded to appropriateness scores based on the ESR imaging referral guidelines. After randomization, half of the clusters switch to the active intervention of decision support. Physicians in the active condition are made aware of the categorization of their requests as appropriate, under certain conditions appropriate, or inappropriate, and appropriate exams are suggested. Physicians may change their requests in response to feedback. In the revert condition, active decision support is removed to study the educational effect. Results/conclusions: The main outcome is the proportion of inappropriate diagnostic imaging exams requested per cluster. Secondary outcomes are the absolute number of imaging exams, radiation from diagnostic imaging, and medical costs. Trial registration number: Approval from the Medical Ethics Review Committee was obtained under protocol numbers 20–069 (Augsburg), B 238/21 (Kiel), 20–318 (Lübeck) and 2020–15,125 (Mainz). The trial is registered in the ClinicalTrials.gov</p

Mechanical rotational thrombectomy in long femoropopliteal artery and bypass occlusions: risk factors for periprocedural peripheral embolization

PURPOSEWe aimed to examine lesion characteristics influencing technical outcome and periprocedural peripheral embolization (PPE) during percutaneous mechanical rotational thrombectomy (PMT) of long femoropopliteal artery and bypass occlusions.METHODSRetrospectively, 65 consecutive patients (43 male patients, mean age 70±12 years; Rutherford category I–III), undergoing PMT (Rotarex®, Straub Medical AG) with acutely/subacutely occluded femoropopliteal arteries/bypasses were included. Occlusions (mean length, 217±98 mm) were treated by PMT followed by percutaneous transluminal angioplasty (PTA) plus drug-coated balloon or PTA plus stenting/stentgrafting. Technical success was defined as residual stenosis 200 mm (15%; 6/39; OR 4.5; 95% CI, 0.5–40; p = 0.014) and thrombus density ≤45 HU (20%; 2/10; OR 3.0; 95% CI, 0.2–38.9; p = 0.05). No significant relation between risk factors and technical success was found.CONCLUSIONPMT followed by PTA or implantation of stent (grafts) appears to be effective and safe for revascularization of acute/subacute long occlusions. Thrombus density <45 HU and lesion length above 20 cm represent risk factors for PPE during PMT

Serpentinization in the trench-outer rise region offshore of Nicaragua: constraints from seismic refraction and wide-angle data

Recent seismic evidence suggested that most oceanic plate hydration is associated with trench-outer rise faulting prior to subduction. Hydration at trenches may have a significant impact on the subduction zone water cycle. Previous seismic experiments conducted to the northwest of Nicoya Peninsula, Northern Costa Rica, have shown that the subducting Cocos lithosphere is pervasively altered, which was interpreted to be due to both hydration (serpentinization) and fracturing of the crustal and upper-mantle rocks. New seismic wide-angle reflection and refraction data were collected along two profiles, running parallel to the Middle American trench axis offshore of central Nicaragua, revealing lateral changes of the seismic properties of the subducting lithosphere. Seismic structure along both profiles is characterized by low velocities both in the crust and upper mantle. Velocities in the uppermost mantle are found to be in the range 7.3–7.5 km s−1; thus are 8–10 per cent lower than velocities typical for unaltered peridotites and hence confirm the assumption that serpentinization is a common process at the trench-outer rise area offshore of Nicaragua. In addition, a prominent velocity anomaly occurred within the crust beneath two seamounts. Here, velocity reduction may indicate increased porosity and perhaps permeability, supporting the idea that seamounts serve as sites for water percolation and circulation

Should Radiologists and Cardiologists work together more?

Kardio-CT und -MRT werden in Leitlinien bei diversen Herzerkrankungen als Diagnostik empfohlen. Bislang haben sie jedoch keinen Eingang gefunden in den Regelleistungskatalog der gesetzlichen Krankenversicherung. Im Gesprach fuhren ein Kardiologe und ein Radiologe aus, weshalb diese Diagnostik so wichtig ist und warum eine interdisziplinare Zusammenarbeit hier wunschenswert ware

The Diagnosis of Chronic Coronary Heart Disease

Background: Chronic coronary heart disease (CHD) and acute myocardial infarction are endemic conditions. In Germany, an estimated 900 000 cardiac catheterizations were performed in the year 2014, and a percutaneous intervention was carried out in 40% of these procedures. It would be desirable to lessen the number of invasive diagnostic procedures while preserving the reliability of diagnosis. In this article, we present the updated recommendations of the German National Care Guideline for Chronic CHD with regard to diagnostic evaluation. Methods: Updated recommendations for the diagnostic evaluation of chronic CHD were developed on the basis of existing guidelines and a systematic literature review and approved by a formal consensus process. Results: 8-11% of patients with chest pain who present to a general practitioner and 20-25% of those who present to a cardiologist have chronic CHD. General practitioners should estimate the probability of CHD with the Marburg Heart Score. Specialists can use detailed tables for determining the pre-test probability of CHD; if this lies in the range of 15% to 85%, then non-invasive tests should be primarily used for evaluation and treatment planning. If the pretest probability is less than 15%, other potential causes should be ruled out first. If it is over 85%, the presence of CHD should be presumed and treatment planning should be initiated. Coronary angiography is needed only if therapeutic implications are expected (revascularization). Psychosocial risk factors for the development and course of CHD and the patient's quality of life should be regularly assessed as well. Conclusion: Non-invasive testing and invasive coronary angiography should be used only if their findings are expected to have therapeutic implications. Psychosocial risk factors, the quality of life, and adherence to treatment are important components of these patients' diagnostic evaluation and long-term care

Coronary Computed Tomography and Magnetic Resonance Imaging

Cardiac computed tomography and magnetic resonance are relatively new imaging modalities that can exceed the ability of established imaging modalities to detect present pathology or predict patient outcomes. Coronary calcium scoring may be useful in asymptomatic patients at intermediate risk. Computed tomographic coronary angiography is a first-line indication to evaluate congenitally abnormal coronary arteries and, along with stress magnetic resonance myocardial perfusion imaging, is useful in symptomatic patients with nondiagnostic conventional stress tests. Cardiac magnetic resonance is indicated for visualizing cardiac structure and function, and delayed enhancement magnetic resonance is a first-line indication for assessing myocardial viability. Imaging plaque and molecular mechanisms related to plaque rupture holds great promise for the presymptomatic detection of patients at risk for coronary events but is not yet suitable for routine clinical use