Radiation Exposure During Diagnostic and Therapeutic Angiography of Carotid-cavernous Fistula

Purpose The aim of this study was to determine local diagnostic reference levels (DRLs) during endovascular diagnostics and therapy of carotid-cavernous fistulas (CCF). Methods In a retrospective study design, DRLs, achievable dose (AD) and mean values were assessed for all patients with CCF undergoing diagnostic angiography (I) or embolization (II). All procedures were performed with the flat-panel angiography system Allura Xper (Philips Healthcare). Interventional procedures were differentiated according to the type of CCF and the type of procedure. Results In total, 86 neurointerventional procedures of 48 patients with CCF were executed between February 2010 and July 2021. The following DRLs, AD and mean values could be determined: (I) DRL 215 Gy ∙ cm2, AD 169 Gy ∙ cm2, mean 165 Gy ∙ cm2; (II) DRL 350 Gy ∙ cm2, AD 226 Gy ∙ cm2, mean 266 Gy ∙ cm2. Dose levels of embolization were significantly higher compared to diagnostic angiography (p < 0.001). No significant dose difference was observed with respect to the type of fistula or the embolization method. Conclusion This article reports on diagnostic and therapeutic DRLs in the management of CCF that could serve as a benchmark for the national radiation protection authorities. Differentiation by fistula type or embolization method does not seem to be useful.

Share and Share Alike: How Inner Source Can Help Create New Digital Platforms

Many organizations are eager to develop a digital platform. Yet, it is not clear how to realize this ambition, especially for large companies with complex existing structures. This study demonstrates how the growing trend of “Inner Source” (adopting internal open-source/crowdsourcing practices within large organizations) can help companies become more platform-based. This article studies three large organizations—Zalando, Philips Healthcare, and PayPal—and identifies a four-stage model that explains how Inner Source helped them develop their internal and external platforms. It details six recommendations for large organizations wishing to follow a strategy of Inner Source-driven platformization.

Precision Infection Prevention (PIP) as a New Standard of Practice Within Longitudinal Infection Prevention and Surveillance

Background: Infection prevention and control (IPC) workflows are often retrospective and manual. New tools, however, have entered the field to facilitate rapid prospective monitoring of infections in hospitals. Although artificial intelligence (AI)–enabled platforms facilitate timely, on-demand integration of clinical data feeds with pathogen whole-genome sequencing (WGS), a standardized workflow to fully harness the power of such tools is lacking. We report a novel, evidence-based workflow that promotes quicker infection surveillance via AI-assisted clinical and WGS data analysis. The algorithm suggests clusters based on a combination of similar minimum inhibitory concentration (MIC) data, timing of sample collection, and shared location stays between patients. It helps to proactively guide IPC professionals during investigation of infectious outbreaks and surveillance of multidrug-resistant organisms and healthcare-acquired infections. Methods: Our team established a 1-year workgroup comprised of IPC practitioners, clinical experts, and scientists in the field. We held weekly roundtables to study lessons learned in an ongoing surveillance effort at a tertiary care hospital—utilizing Philips IntelliSpace Epidemiology (ISEpi), an AI-powered system—to understand how such a tool can enhance practice. Based on real-time case discussions and evidence from the literature, a workflow guidance tool and checklist were codified. Results: In our workflow, data-informed clusters posed by ISEpi underwent triage and expert follow-up analysis to assess: (1) likelihood of transmission(s); (2) potential vector(s) identity; (3) need to request WGS; and (4) intervention(s) to be pursued, if warranted. In a representative sample (spanning October 17, 2019, to November 7, 2019) of 67 total isolates suggested for inclusion in 19 unique cluster investigations, we determined that 9 investigations merited follow-up. Collectively, these 9 investigations involved 21 patients and required 115 minutes to review in ISEpi and an additional 70 minutes of review outside of ISEpi. After review, 6 investigations were deemed unlikely to represent a transmission; the other 3 had potential to represent transmission for which interventions would be performed. Conclusions: This study offers an important framework for adaptation of existing infection control workflow strategies to leverage the utility of rapidly integrated clinical and WGS data. This workflow can also facilitate time-sensitive decisions regarding sequencing of specific pathogens given the preponderance of available clinical data supporting investigations. In this regard, our work sets a new standard of practice: precision infection prevention (PIP). Ongoing effort is aimed at development of AI-powered capabilities for enterprise-level quality and safety improvement initiatives.Funding: Philips Healthcare provided support for this study.Disclosures: Alan Doty and Juan Jose Carmona report salary from Philips Healthcare.

3D advanced imaging overlay with rapid registration in CHD to reduce radiation and assist cardiac catheterisation interventions

Novel commercially available software has enabled registration of both CT and MRI images to rapidly fuse with X-ray fluoroscopic imaging. We describe our initial experience performing cardiac catheterisations with the guidance of 3D imaging overlay using the VesselNavigator system (Philips Healthcare, Best, NL). A total of 33 patients with CHD were included in our study. Demographic, advanced imaging, and catheterisation data were collected between 1 December, 2016 and 31 January, 2019. We report successful use of this technology in both diagnostic and interventional cases such as placing stents and percutaneous valves, performing angioplasties, occlusion of collaterals, and guidance for lymphatic interventions. In addition, radiation exposure was markedly decreased when comparing our 10–15-year-old coarctation of the aorta stent angioplasty cohort to cases without the use of overlay technology and the most recently published national radiation dose benchmarks. No complications were encountered due to the application of overlay technology. 3D CT or MRI overlay for CHD intervention with rapid registration is feasible and aids decisions regarding access and planned angiographic angles. Operators found intraprocedural overlay fusion registration using placed vessel guidewires to be more accurate than attempts using bony structures.

1248. Genomic Sequencing and Clinical Data Integration for Next-Generation Infection Prevention

Background Typical Infection Prevention to detect pathogen transmission in hospitals has relied on observation of (1) uncommon pathogen phenotypes or (2) greater than expected number of pathogen phenotypes in a given timeframe and/or location. Genome sequencing of targeted organisms in conjunction with routine patient geo-temporal information and antibiotic susceptibility data holds promise in identifying transmissions with greater sensitivity and specificity, saving time and effort in reviewing for transmission events. Methods In an on-going genomic sequencing surveillance effort in a tertiary care hospital, drug-resistant clinical isolates from the “ESKAPE” pathogens were routinely sequenced in 2017. In parallel, potential clusters were identified for 2017 through conventional Infection Prevention approaches. Groups identified by their genetic distances along with visualizations on antimicrobial susceptibilities, and patient location histories and dates were displayed in an interactive interface, Philips IntelliSpace Epidemiology (PIE), and reviewed by Infection Prevention. Results Among 656 patients, 1,239 drug-resistant ESKAPE samples were sequenced. Thirty-eight genetically related groups involving 196 patients were identified. Groups ranged in size from two to 44 patients, primarily consisting of VRE and MRSA. Notably, a review of the 38 groups identified 20 groups where the information at hand suggested a concern for transmission. 16 of the 20 were not previously identified by Infection Prevention. Using PIE to review all 38 groups identified from 1 year’s worth of data required 3 hours of time by an Infection Prevention professional, averaging less than 5 minutes per cluster, less than 1 minute per patient, and 11 minutes of review time per actionable opportunity. By conventional means, approximately 23 hours would have been required to review the genomic groups without the aid of the PIE tool. Conclusion The use of PIE’s genomic-defined groups, along with the integrated clinical data platform, allows for a greater ability, certainty, and speed to detect clusters of organisms representing transmission in the hospital setting. Applied prospectively, PIE can detect transmissions sooner than by conventional means for potential patient safety gains and cost savings. Disclosures D. Chen, Philips: Scientific Advisor, Consulting fee. M. Fortunato-Habib, Philips Healthcare: Collaborator and Employee, Salary. A. Hoss, Philips: Employee, Salary. R. Kolde, Philips: Employee, Salary. A. Dhand, Merck: Speaker’s Bureau, Speaker honorarium. Astellas: Scientific Advisor, Consulting fee. R. Sussner, Philips: Scientific Advisor, Consulting fee. J. Carmona, Philips Healthcare: Employee, Salary. B. Gross, Philips Healthcare: Employee, Investigator, Research Contractor, Scientific Advisor and Shareholder, Salary. J. Fallon, Philips Healthcare: Investigator, Research support.

Augmented 3D venous navigation for neuroendovascular procedures

BackgroundEndovascular venous access is increasingly used for the treatment of many cerebrovascular diseases. The quality of venous roadmapping through arterial injection can be problematic because of contrast media dilution, slow flow velocity, and unilateral opacification of the venous system.ObjectiveTo describe our experience with the VesselNavigator (Philips Healthcare, Best, The Netherlands) in performing live 3D roadmapping for intracranial venous procedures.Material and methodsLive 3D roadmapping is an image-processing technique that allows dynamic roadmapping of vessels with immediate adaptation to the C-arm movements without the need for contrast injection. For this purpose, 3D MR venography is overlaid on live fluoroscopy images after semiautomatic coregistration. The technique was applied to cases of idiopathic venous stenosis and arteriovenous fistula.ResultsThe process of coregistration was performed by the principal operator in <5 min, just before the treatment. The accuracy was controlled peroperatively and was judged satisfactory. Three illustrative cases demonstrate the use of this software for venous navigation and pressure measurement (case 1), venous stenting (case 2), and transvenous embolization of a carotid-cavernous fistula (case 3).ConclusionOur preliminary experience suggests that it is a feasible and safe technique for intracranial venous navigation and procedures. The potential lowering of overall radiation dose and contrast media use needs to be verified with further studies.

Führunsgwechsel: Eva Braun verlässt Philips Healthcare

Paukenschlag in der Hamburger Zentrale von Philips Deutschland: Eva Braun, bislang Leiterin der Philips Healthcare-Sparte für die Region Deutschland, Österreich und Schweiz (DACH) verlässt das Unternehmen zum 31. März 2017.

Utility of Routine Genomic Sequencing for Infection Control Surveillance

Background Recent work indicates that comprehensive genomic sequencing can be a highly effective tool in defining the transmission of microbial pathogens. We have studied the utility of the routine use of genomic sequencing for infection control surveillance in an academic medical center. Methods The genomes of inpatient and emergency department isolates of Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Enterococcus faecium were sequenced. Within each species, single-nucleotide polymorphisms (SNP) were identified in the core genome for all isolates using alignment-based methods. The number of SNP differences between isolate pairs was determined and used, in combination with the patient’s electronic medical records to identify potential transmission events. Results Between September 2016 and March 2017, 388 S. aureus, 66 P. aeruginosa, 48 K. pneumoniae, and 29 E. faecium isolates were sequenced from 373 patients. There was variation in the distribution of SNP differences between intrapatient isolates for the four pathogens; with the least variability for E. faecium and greatest for P. aeruginosa. The majority of the bacterial isolates from separate patients appeared to be genetically unique exhibiting marked SNP differences from other isolates. There were 19 sets of isolates where the SNP variation between interpatient isolates was either comparable to that of intrapatient variation (12) and suggestive of recent transmission events, or with SNP variation somewhat greater than the intrapatient SNP variation (7) suggesting relative relatedness. Only one of the highly related sets had been previously identified by standard infection control surveillance. Likely transmissions appeared to have occurred both in the inpatient and outpatient settings, and the transmission routes were not always apparent. Conclusion The routine use of genomic sequencing analysis identified previously unrecognized likely transmission events within the institution’s patient population that are of relevance to infection control surveillance. This capacity should significantly enhance our understanding of the epidemiology of hospital acquired infections, and assist in developing and implementing new prevention strategies. Disclosures R. T. Ellison III, Philips Healthcare: Consultant and Grant Investigator, Consulting fee and Research grant; A. Hoss, Philips: Employee, Salary; J. Mathew, Philips Healthcare: Investigator, Research grant; J. Halperin, Philips Healthcare: Employee and Shareholder, Salary; B. Gross, Philips: Employee and Shareholder, Salary; D. V. Ward, Philips Healthcare: Consultant, Investigator and Research Contractor, Consulting fee, Research support and Salary