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BACKGROUND: Anticoagulation is a cornerstone in atrial fibrillation (AF) management for stroke prevention. Studies showed that oral anticoagulants (OAC), previously limited to warfarin, were underused. Recently, non-vitamin K oral anticoagulants (NOACs) have seen widespread adoption, but it has not been well studied whether there has been a subsequent increase in OAC usage in AF patients. METHODS: We quantified OAC rates in AF patients in a large multispecialty health system in the Northeast United States. A total of 351,795 patients seen in the network over the preceding 18 months were reviewed. RESULTS: Of these patients, 8727 (2.5%) carried a diagnosis of AF, and, of the 6933 patients with a CHA2DS2-VASc score of 2 or higher, 5576 (80.4%) had an OAC listed as an active medication or had received a left atrial appendage occlusion device. Of the 6605 patients treated with an OAC, 5308 (80.4%) were treated with a NOAC and 1295 (19.6%) were prescribed warfarin. A higher percentage of patients with CHA2DS2-VASc ≥ 2 who had seen a cardiologist were treated with an OAC vs. those who had not seen a cardiologist in the prior 18 months (83.95% vs. 67.43%, p < 0.01). CONCLUSIONS: We show dramatically increased OAC usage among patients with AF and that NOACs comprise the large majority of OACs compared with previous studies. This suggests an association between widespread adoption of NOACs and increased oral anticoagulation rates. Future directions include assessing barriers to oral anticoagulation and developing interventions to reduce disparity in OAC use between clinics.

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Differentiating stroke from stroke mimics is a diagnostic challenge in every day practice. Posterior Reversible Encephalopathy Syndrome (PRES) is an important stroke mimic with nonspecific symptomatology, making prompt and accurate diagnosis challenging. Baseline neuroimaging plays a pivotal role in detection and differentiation of stroke from many common mimics and is thus critical in guiding appropriate management. In particular, MR perfusion (MRP) imaging modalities provide added value through detection and quantification of multiple physiological parameters. Arterial Spin Labeling (ASL) is a non-contrast, noninvasive MRP technique increasingly used in clinical practice; however, there is limited description of ASL in PRES in the existing literature. In this single center retrospective pilot study, we investigate the added value of ASL in detecting PRES in the largest series to date. We hope this study can serve as the basis for larger scale investigations exploring the utility of ASL in detecting stroke mimics such as PRES for accurate and efficient management of such patients.

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RATIONALE AND OBJECTIVES: The coronavirus disease of 2019 (COVID-19) pandemic has challenged the educational missions of academic radiology departments nationwide. We describe a novel cloud-based HIPAA compliant and accessible education platform which simulates a live radiology workstation for continued education of first year radiology (R1) residents, with an emphasis on call preparation and peer to peer resident learning. MATERIALS AND METHODS: Three tools were used in our education model: Pacsbin (Orion Medical Technologies, Baltimore, MD, pacsbin.com), Zoom (Zoom Video Communications, San Jose, CA, zoom.us), and Google Classroom (Google, Mountain View, CA, classroom.google.com). A senior radiology resident (R2-R4) (n = 7) driven workflow was established to provide scrollable Digital Imaging and Communications in Medicine (DICOM) based case collections to the R1 residents (n = 9) via Pacsbin. A centralized classroom was created using Google Classroom for assignments, reports, and discussion where attending radiologists could review content for accuracy. Daily case collections over an 8-week period from March to May were reviewed via Zoom video conference readout in small groups consisting of a R2-R4 teacher and R1 residents. Surveys were administered to R1 residents, R2-4 residents, and attending radiologist participants. RESULTS: Hundred percent of R1 residents felt this model improved their confidence and knowledge to take independent call. Seventy-eight percent of the R1 residents (n = 7/9) demonstrated strong interest in continuing the project after pandemic related restrictions are lifted. Based on a Likert "helpfulness" scale of 1-5 with 5 being most helpful, the project earned an overall average rating of 4.9. Two R2-R4 teachers demonstrated increased interest in pursuing academic radiology. CONCLUSION: In response to unique pandemic circumstances, our institution implemented a novel cloud-based distance learning solution to simulate the radiology workstation. This platform helped continue the program's educational mission, offered first year residents increased call preparation, and promoted peer to peer learning. This approach to case-based learning could be used at other institutions to educate residents.

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STUDY DESIGN: Retrospective radiological review and analysis of 79 patients who underwent primary anterior cervical discectomy and fusion (ACDF) of 2 or 3 levels between 2011 and 2013. PURPOSE: This study aimed to determine the effect of the local placement of a steroid-soaked gelatin sponge after ACDF on prevertebral soft tissue swelling. OVERVIEW OF LITERATURE: Although ACDF has become a popular choice for cervical fusion, the surgical involvement of the delicate anatomy of the neck frequently results in tissue irritation and edema. Swelling of the prevertebral soft tissue may consequently lead to mild-to-severe complications, ranging from dysphonia to dyspnea. METHODS: Out of the 79 patients who underwent primary ACDF, 52 received a gelatin sponge soaked with 40 mg of Depo-Medrol placed adjacent to the operated cervical levels. Prevertebral soft tissue swelling was detected using postoperative lateral X-ray. The radiographic values were compared to those of 27 patients who did not receive the treatment. RESULTS: Soft tissue swelling was markedly decreased in patients who received the placement of the steroid-soaked gelatin sponge next to their fused levels after surgery compared with that in patients who did not receive it. No complications were documented with the use of steroids. CONCLUSIONS: The placement of a steroid-soaked gelatin sponge markedly reduces postoperative soft tissue swelling following 2- or 3-level primary ACDF.

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PURPOSE: Wound infection after spine surgery is a debilitating complication. Local placement of vancomycin powder into the surgical wounds prior to closing of the fascia has been introduced as a method to reduce deep infection rates. METHODS: The infection rates of all the patients who were treated with intra-operative local vancomycin between June 2012 and June 2013 were compared to all cases that were not treated with vancomycin between January 2009 and December 2010. Patients for both groups were operated by four senior, fellowship-trained spine surgeons with a combined experience of 55 years of practice at a referral orthopedic center. Patients' charts and microbiology reports were reviewed. RESULTS: 1224 cases were performed with the use of vancomycin. The average age was 56.3 years (SD -13.2; NS). The male to female ratio was 1:1.12 (NS). 2253 cases were performed without the use of vancomycin. The average patient age was 57.1 years (SD 14.5). The male to female ratio was 1:1.14. There were 30 cases of deep infections needing a surgical irrigation and debridement without vancomycin versus 5 when vancomycin was used (P = 0.04). Infections in patients treated with vancomycin were not vancomycin-resistant bacteria. CONCLUSION: In conclusion, the use of vancomycin reduces the rate of deep wound infections and irrigation and debridement procedures after spine surgery in a referral center among surgeons with a high surgical volume.

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BACKGROUND: Parkinson disease is the second most common neurodegenerative condition. The literature on patients with Parkinson disease and spine surgery is limited, but increased complications have been reported. METHODS: All patients with Parkinson disease undergoing lumbar spine surgery between 2002 and 2012 were identified. Patients' charts, radiographs, and outcome questionnaires were reviewed. Parkinson disease severity was assessed with use of the modified Hoehn and Yahr staging scale. Complications and subsequent surgeries were analyzed. Risk for reoperation was assessed. RESULTS: Ninety-six patients underwent lumbar spine surgery. The mean patient age was 63.0 years. The mean follow-up duration was 30.1 months. The Parkinson disease severity stage was <2 in thirteen patients, 2 in thirty patients, 2.5 in twenty-three patients, and ≥3 in thirty patients. The primary indication for surgery was spinal stenosis in seventy-two patients, spondylolisthesis in seventeen patients, and coronal and/or sagittal deformity in seven patients. There were nineteen early complications, including postoperative infections requiring surgical irrigation and debridement and long-term antibiotics in ten patients. The visual analog scale for back pain improved from 7.4 cm preoperatively to 1.8 cm postoperatively (p < 0.001). The visual analog scale for lower-limb pain improved from 7.7 cm preoperatively to 2.3 cm postoperatively (p < 0.001). The Oswestry Disability Index score dropped from 54.1 points to 17.7 points at the time of the latest follow-up (p < 0.001). The Short Form-12 Physical Component Summary score improved from 26.6 points preoperatively to 30.5 points postoperatively (p < 0.05). Twenty patients required revision surgery. Risks for further surgery included a Parkinson disease severity stage of ≥3 (p < 0.05), a history of diabetes mellitus, treatment for osteoporosis, and a combined anterior and posterior approach. CONCLUSIONS: Despite a higher rate of complications than in the general population, the overall outcome of spine surgery in patients with mild to moderate Parkinson disease is good, with improvement of spine-related pain. A larger prospective study is warranted.

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Controversy exists among the orthopedic community regarding the treatment of gunshot injuries. No consistent treatment algorithm exists for treatment of low energy gunshot wound (GSW) trauma. The purpose of this study was to critically examine the wound contamination following low velocity GSW based upon bullet caliber and clothing fiber type found within the injury track. Four types of handguns were fired at ballistic gel from a 10-foot distance. Various clothing materials were applied (denim, cotton, polyester, and wool) circumferentially around the tissue agar in a loose manor. A total of 32 specimens were examined. Each caliber handgun was fired a minimum of 5 times into a gel. Regardless of bullet caliber there was gross contamination of the entire bullet track in 100% of specimens in all scenarios and for all fiber types. Furthermore, as would be expected, the degree of contamination appeared to increase as the size of the bullet increased. Low velocity GSWs result in significant contamination regardless of bullet caliber and jacket type. Based upon our results further investigation of low velocity GSW tracks is warranted. Further clinical investigation should focus on the degree to which debridement should be undertaken.

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PURPOSE: To determine whether combining acetic acid instillation before radiofrequency (RF) ablation can improve local tissue electrical conductivity, RF energy deposition, intratumoral heating, and tumor necrosis in a large animal model. MATERIALS AND METHODS: Multiple hypovascular canine venereal sarcomas were implanted in 11 mildly immunosuppressed dogs (25 mg/kg cyclosporin A twice daily). Tumors were incubated for 8-12 weeks to 4.2 cm +/- 0.6 in diameter. Treatment strategies included 10% and 15% acetic acid diluted in distilled water, 10% and 15% acetic acid diluted in saturated NaCl solution, 50% acetic acid, and 100% ethanol, with 6 mL of each injected alone or in combination with RF ablation (internally cooled, 1-cm tip; 12 minutes). Two additional control groups were studied in which tumors received either RF alone or distilled water injected alone. Comparisons were also made with groups treated with 36% NaCl with and without RF ablation. Resultant coagulation for these ablative strategies, along with local temperatures and RF parameters such as impedance, current, and power, were compared. RESULTS: Increasing coagulation was observed with increasing acetic acid concentrations (1.7 cm +/- 0.4, 2.8 cm +/- 0.6, and 3.5 cm +/- 0.3 for 10%, 15%, and 50% acetic acid alone, respectively; P <.01). The combination of RF ablation with acetic acid resulted in greater coagulation than with either therapy alone (P <.05). However, maximum heating and coagulation were observed with 10% acetic acid diluted in NaCl, with which the entire tumor (diameter, 4.5 cm +/- 0.4) was completely ablated in every case. This was equivalent to results for tumors treated with 36% NaCl combined with RF. RF with a 50% acetic acid concentration resulted in coagulation measuring only 3.7 cm +/- 0.3 (P <.01). Significantly greater RF heating (89.7 degrees C +/- 12.3 at 10 mm) was observed when the tumors were pretreated with 10% or 15% acetic acid in saturated NaCl, compared with 67.9 degrees C +/- 13.7 observed when acetic acid was diluted in water (P <.02). RF combined with ethanol produced less coagulation (2.8 cm +/- 0.3) than combinations with acetic acid because rapid and irreversible impedance increases were observed. CONCLUSION: Addition of acetic acid injections to RF ablation substantially increases tumor destruction compared with RF or injection therapy alone. However, lower acetic acid concentrations in saturated NaCl produced greater tumor coagulation, suggesting that, in this hypovascular tumor model, alterations in electrical conductivity play a more important role in increasing tumor ablation efficiency than do the additional ablative effects of acetic acid.

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PURPOSE: The authors have recently developed a small-diameter, thin, flexible ultrasonic catheter device that permits the removal of thrombus by low-power transverse ultrasonic cavitation energy. In this study, the authors sought to determine whether this device could be used to eliminate portal vein thrombosis in an animal model. MATERIALS AND METHODS: In five anesthetized pigs, a total of six occlusions of the left portal vein were achieved with use of autologous clot with (n = 2) or without (n = 4) thrombin injection (250 U) introduced via a 7-F transhepatic catheter/sheath system. Angiographic examination documented complete occlusion of this vessel. The 75-cm-long, 21-gauge ultrasonic catheter (Resolution) was introduced into the clot under angiographic guidance via the transhepatic sheath. Transverse-wave ultrasonic energy was then delivered from the distal 5 cm of the probe at 3.5 W +/- 10% power for up to 6 minutes. Repeat angiographic studies were performed to document patency. After the procedure, gross and histopathologic examinations were performed. RESULTS: Restoration of patency of the main left portal vein was documented in all cases at angiography, with no evidence of residual clot fragments in the major branches. However, side branches demonstrated small thrombotic plugs on pathologic examination. No complications such as perforation of the vessel adjacent to the active ultrasonic tip were encountered. Virtually all thrombolysis was documented to occur within the first minute of energy application. At gross pathologic examination, there was no evidence of damage to the portal vein, and histopathologic examination demonstrated minimal intimal disruption without damage to the media. CONCLUSIONS: This preliminary animal study suggests the feasibility of a percutaneous transhepatic approach to the treatment of portal vein thrombosis with use of low-power ultrasonic cavitation energy. With further study, this method may have potential for the treatment of thrombotic disease, thereby offering novel therapy to patients with thrombotic vascular occlusions.

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PURPOSE: To determine whether pretreatment with local NaCl injection can increase radiofrequency (RF)-induced coagulation in a large animal model. MATERIAL AND METHODS: Multiple canine venereal sarcomas (n = 25) were implanted subcutaneously in eight mildly immunosuppressed dogs (25 mg/kg cyclosporin A twice daily). Tumors were incubated for 8-12 weeks to a diameter of 4.2-6.3 cm (5.1 cm +/- 0.7). Internally cooled RF ablation (1-cm tip; 12 min; pulsed technique; 2,000-mA maximum) was performed. Tumors were pretreated with 6 mL of 18%, 24%, or 36% NaCl injected intratumorally under direct ultrasound guidance after RF electrode insertion, and this treatment was compared to RF treatment without NaCl injection and to 36% NaCl injection without RF ablation. Impedance measurements and remote thermometry were performed. These measurements and resultant coagulation were compared. RESULTS: Significantly greater RF heating (73 degrees C +/- 11 degrees C at 20 mm) was observed when the tumors were treated with 24% or 36% NaCl pretreatment, compared to the 47 degrees C +/- 5 degrees C observed when 18% or no NaCl was injected (P <.02). In the 36% NaCl group, the entire tumor (5.2 cm +/- 0.8 diameter) was completely ablated in every case, with coagulation extending several centimeters into the surrounding tissues. By comparison, control tumors (without NaCl injection) contained coagulation measuring 3.1 cm +/- 0.2, surrounded by viable, well-perfused tumor (P <.01), and 36% NaCl alone produced 2.7 cm +/- 0.6 of patchy necrosis. CONCLUSIONS: Pretreatment with intratumoral injection of small volumes of highly concentrated NaCl markedly increases RF heating and coagulation in a large animal tumor model. The complete destruction of tumors 5 cm in diameter or larger suggests that this substantial increase may be achieved for tumor ablation in clinical practice.

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