Future challenges in quality improvement in heart failure.

This is the final installment in a series reporting on the Centers for Medicare & Medicaid Services (CMS) initiatives to improve care for Medicare beneficiaries with heart failure through its Quality Improvement Organization (QIO) contractors during the 1999-2002 contract cycle. Previous columns have reported on a nation-wide hospital-based effort, the National Heart Failure project, and a more limited outpatient-based effort, the Heart Failure Practice Improvement Effort. After 3 years of experience with the National Heart Failure project, it is appropriate to highlight the issues pertinent to future quality improvement initiatives in heart failure care.

Use of nutritional support formula as a gastrointestinal contrast agent for MRI.

The objective of this study was to evaluate the potential utility of a nutritional support formula to serve as a practical means of enhancing the gastrointestinal tract on abdominal MR images. Nutritional support formula (Ensure Plus) was administered to 29 patients prior to abdominal MRI. Standard T1-weighted and T2-weighted pulse sequences were performed, in addition to fat suppression and inversion recovery sequences in selected patients.

Lateral dual-energy radiography: artifact error from rib and pelvic bone.

A lateral projection of the lumbar spine with dual-energy radiography (DER) may be a more sensitive tool for the detection of vertebral demineralization than the standard anterior-posterior (AP) DER measurement. The lateral view allows measurement of the vertebral body and selective measurement of the central trabecular compartment, excluding the majority of the cortical envelope and posterior vertebral elements. The lateral DER typically contains L2-4 in the region of interest.

Opacification of ascitic fluid on delayed contrast computed tomography scans.

Ascitic fluid opacification on delayed intravenous contrast computed tomography scans was observed in eight consecutive patients imaged. This apparently common phenomenon may alter both the sensitivity and the specificity of ascitic fluid detection. It may also serve as a diagnostic aid by making nonascitic intra-abdominal fluid collections (ie, pseudocyst and cystic tumor) more apparent.

Lateral dual energy radiography: a new method for measuring vertebral bone density: a preliminary study.

Dual energy radiography (DER) is a new technique for non-invasive measurement of vertebral bone mineral density, which because of its high precision (1%), is particularly suitable for prospective analyses of time-related changes in bone mass. However, we recently found that DER is less sensitive to demineralization of trabecular bone than quantitative computed tomography (QCT). Since the compact bone of the posterior vertebral elements are included in the standard anterior-posterior DER (APDER), but not in QCT measurements, changes in trabecular bone mass attending the early phases of the osteoporotic process go undetected with the APDER technique due to the preponderance of cortical mass.

The extrapleural fat sign: CT characteristics.

Three cases of medially displaced extrapleural fat are presented. In these cases displacement is secondary to tumor, thoracic wall edema, and hematoma. When significantly displaced, and especially when distorted, the extrapleural fat may present a confusing CT picture.

Dual energy radiography versus quantitative computer tomography for the diagnosis of osteoporosis.

In this study we compared dual energy radiography (DER), a new, highly precise x-ray densitometric technique recently devised for measurements of vertebral mineral density and quantitative computer tomography (QCT), a densitometric technique that selectively measures the trabecular compartment of the vertebra. DER and QCT measurements were obtained in 56 healthy (H) and 48 fractured osteoporotic (OP) women using a Hologic QDR 1000 bone densitometer and a GE 9800 scanner, respectively. DER was significantly correlated with QCT in both the H (r = 0.

The gastric air-fluid sign: aid in CT assessment of gastric wall thickening.

The differentiation of apparent gastric wall thickening due to incomplete gastric distention from true pathologic wall thickening can be difficult on computed tomographic (CT) scanning. We have observed a transition in gastric wall thickening that is often present at or slightly above the gastric air-fluid or air-contrast level. The apparently thickened gastric wall in the dependent portion of the stomach undergoes an abrupt change to normal thickness at or above the air-fluid level.

Dual energy radiography (DER): a preliminary comparative study.

Dual energy radiography (DER) has been recently proposed as a new technique for the non invasive measurement of vertebral mineral density. This preliminary study was undertaken to assess the short-term precision of DER and to compare DER to dual photon absorptiometry (DPA) measurements. Three DER measurements were obtained in 19 healthy volunteers (mean age 34.

Adhesion-related variceal hemorrhage following sclerosis of esophageal varices.

A 78-year-old woman with portal hypertension had recurrent episodes of lower gastrointestinal hemorrhage two months after bleeding esophageal varices had been successfully treated with endoscopic injection sclerosis. Labeled red blood cell scans and mesenteric angiographic examination allowed a preoperative diagnosis of adhesion-related varices as the cause of bleeding. The problem was successfully treated by dividing the adhesion and resecting the involved small intestine.

Single and dual energy tomographic analysis of spinal trabecular bone: a comparative study in normal and osteoporotic women.

To investigate the effects of age on rates of bone loss and the relationship between amount of trabecular bone and clinical severity of osteoporosis, trabecular mineral density of the lumbar spine (VMD) was measured in 55 osteoporotic women and 133 healthy women with both single energy (SE) and dual energy (DE) quantitative computed tomography (QCT). The amount of marrow fat was indirectly estimated by the difference (delta) between DE and SE VMD values. The rate of bone loss in the normal women was 1.

CT findings in thoracic aortic dissection.

Computed tomography (CT) findings in 11 cases of aortic dissection were correlated with aortographic, surgical, or postmortem findings. In another two patients, the CT findings were considered diagnostic of aortic dissection but no further workup was performed. All the CT examinations were made before and after bolus injection of contrast.

Lung carcinoma associated with bullous lung disease in young men.

Over a 6 year period, three cases of pulmonary carcinoma in young men with severe bullous lung disease were seen at Washington University Medical Center. The patients did not have a long cigarette-smoking exposure. It would seem that patients with severe bullous lung disease are at a higher risk for the development of pulmonary neoplasm than the general population.

An improved snare system for the nonsurgical retrieval of intravascular foreign bodies.

We have modified a snare technique originally described for transcolonoscopic removal of colonic polyps for the retrieval of intravascular foreign bodies. The key difference from other snare techniques is the employment of a wire snare with a crimp in its midportion that enables the formation of a loop in a plane perpendicular to the axial direction of the guiding catheter. With this technique we have quickly removed a variety of objects from the right heart and pulmonary arteries in four patients.

Radiographic characteristics of colonic "mucosal bridges": sequelae of inflammatory bowel disease.

Colonic mucosal bridges are a relatively unusual entity occurring in patients with inflammatory disease of the colon. The authors describe two cases in which the pattern of multiple long, linear band-like defects may be easily misinterpreted as thickened mucosal folds, mucous strands, or foreign matter. The possibility of mucosal bridges should be considered if this radiographic pattern is demonstrated, and the patient's history is compatible with their formation.

Alveolar-capillary oxygen disequilibrium in hepatic cirrhosis.

Hypoxemia is a frequent occurrence in patients with severe hepatic disease. Multiple mechanisms have been implicated in the production of such hypoxemia. The case of a 35-year-old man with cyanosis, clubbing, and cirrhosis is presented.