Sunnybrook Health Sciences Centre Research Articles

Articles That May Change Your Practice: Crew Resource Management

To err is human. Human factors refer to environmental, organizational, and job factors and individual characteristics that influence behavior and affect performance and safety. Human factors account for many of the adverse events and errors in both medicine and aviation. In 1979, crew recourse management (CRM) was introduced for aviation personnel after a number of accidents in which human factors were identified as the cause. CRM led to a decrease in events and has been shown to be essential in effective decision making during time-critical emergencies. Human factors have the same impact on patient care in clinical medicine. This is particularly true in areas in which an interprofessional workforce undertakes decisions and procedures in a time-sensitive manner. Russell D. MacDonald, MD, MPH, FCFP, FRCPC, is the medical director and chair of the Quality Care Committee at Orange Transport Medicine; an associate professor at the University of Toronto; and an attending staff member at Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada. He can be reached at [email protected] .

Use of the Derriford Appearance Scale 59 to assess patient-reported outcomes in secondary cleft surgery

Background Secondary rhinoplasty, one of the final procedures in addressing the stigma of the cleft lip and palate (CLP), has both functional and aesthetic objectives. The way in which physicians evaluate outcomes in surgery concerning aesthetics is changing. Well-designed patient-reported outcome measures to assess health-related quality of life improvements attributable to surgery are increasingly being used. The Derriford Appearance Scale 59 (DAS-59) is currently the only available validated patient-reported outcome measure that assesses concern about physical appearance. Methods Twenty patients with CLP presenting between May 2009 and May 2013 for secondary rhinoplasty to Sunnybrook Health Sciences Centre (Toronto, Ontario) were recruited. DAS-59 measures were administered both preoperatively and at least six months after surgery. Pre- and postoperative measures were scored and compared. Item-by-item analysis of the measure was also performed. Results Total scores for this CLP group indicated greater concern about appearance than the general population. Across all subscales of the measure, there was a reduction in scores after secondary rhinoplasty suggesting less patient concern with appearance and a positive effect of surgery on patient quality of life. Item-by-item analysis suggested relatively few items in the measure were driving overall change in total scores. Conclusion Comparison of pre- and postoperative scores with the DAS-59 in secondary cleft rhinoplasty suggests there is less concern with appearance after surgery. However, a small number of items within this generic scale contributing to this difference may suggest the need for a more patient specific measure for assessment of surgical outcomes in the cleft population.

Research Highlights

Kathleen Kwan Katipunan, BSc, MD, Dermatology Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada. Tiffany Parsons, BHSc, MD, Dermatology Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada. The authors declare no conflict of interest. Correspondence concerning this article should be addressed to Kathleen Kwan Katipunan, BSc MD, Dermatology Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Suite M1-700, Toronto, ON M4N 3M5. E-mail: [email protected]

Patient Characteristics and Outcomes of Outpatient Parenteral Antimicrobial Therapy: A Retrospective Study.

Outpatient parenteral antimicrobial therapy (OPAT) is a safe and effective alternative to hospitalization for many patients with infectious diseases. The objective of this study was to describe the OPAT experience at a Canadian tertiary academic centre in the absence of a formal OPAT program. This was achieved through a retrospective chart review of OPAT patients discharged from Sunnybrook Health Sciences Centre within a one-year period. Between June 2012 and May 2013, 104 patients (median age 63 years) were discharged home with parenteral antimicrobials. The most commonly treated syndromes included surgical site infections (33%), osteoarticular infections (28%), and bacteremia (21%). The most frequently prescribed antimicrobials were ceftriaxone (21%) and cefazolin (20%). Only 56% of the patients received follow-up care from an infectious diseases specialist. In the 60 days following discharge, 43% of the patients returned to the emergency department, while 26% required readmission. Forty-eight percent of the return visits were due to infection relapse or treatment failure, and 23% could be attributed to OPAT-related complications. These results suggest that many OPAT patients have unplanned health care encounters because of issues related to their infection or treatment, and the creation of a formal OPAT clinic may help improve outcomes.

Use of the Derriford Appearance Scale 59 to assess patient-reported outcomes in secondary cleft surgery.

Secondary rhinoplasty, one of the final procedures in addressing the stigma of the cleft lip and palate (CLP), has both functional and aesthetic objectives. The way in which physicians evaluate outcomes in surgery concerning aesthetics is changing. Well-designed patient-reported outcome measures to assess health-related quality of life improvements attributable to surgery are increasingly being used. The Derriford Appearance Scale 59 (DAS-59) is currently the only available validated patient-reported outcome measure that assesses concern about physical appearance. Twenty patients with CLP presenting between May 2009 and May 2013 for secondary rhinoplasty to Sunnybrook Health Sciences Centre (Toronto, Ontario) were recruited. DAS-59 measures were administered both preoperatively and at least six months after surgery. Pre- and postoperative measures were scored and compared. Item-by-item analysis of the measure was also performed. Total scores for this CLP group indicated greater concern about appearance than the general population. Across all subscales of the measure, there was a reduction in scores after secondary rhinoplasty suggesting less patient concern with appearance and a positive effect of surgery on patient quality of life. Item-by-item analysis suggested relatively few items in the measure were driving overall change in total scores. Comparison of pre- and postoperative scores with the DAS-59 in secondary cleft rhinoplasty suggests there is less concern with appearance after surgery. However, a small number of items within this generic scale contributing to this difference may suggest the need for a more patient specific measure for assessment of surgical outcomes in the cleft population.

Antibiotic Use and Need for Antimicrobial Stewardship in Long-Term Care.

Antimicrobial stewardship may be important in long-term care facilities because of unnecessary or inappropriate antibiotic use observed in these residents, coupled with their increased vulnerability to health care-associated infections. To assess antibiotic use in a long-term care facility in order to identify potential antimicrobial stewardship needs. A retrospective descriptive study was conducted at the Veterans Centre, a long-term care facility at Sunnybrook Health Sciences Centre, Toronto, Ontario. All residents taking one or more antibiotics (n = 326) were included as participants. Antibiotic-use data for patients residing in the facility between April 1, 2011, and March 31, 2012, were collected and analyzed. Totals of 358 patient encounters, 835 antibiotic prescriptions, and 193 positive culture results were documented during the study period. For 36% (302/835) of antibiotic prescriptions, the duration was more than 7 days. Cephalosporins (30%; 251/835) and fluoroquinolones (28%; 235/835) were the most frequently prescribed antibiotic classes. Urine was the most common source of samples for culture (60%; 116/193). Characteristics of antimicrobial use at this long-term care facility that might benefit from further evaluation included potentially excessive use of fluoroquinolones and cephalosporins and potentially excessive duration of antibiotic use for individual patients.

Management Challenges of Prosthetic Joint Infections at Sunnybrook Health Sciences Centre

Management Challenges of Prosthetic Joint Infections at Sunnybrook Health Sciences Centre

Prostate Cancer Patients' Preferences for Intermittent vs. Continuous Androgen Deprivation—A Pilot Institutional Study

IntroductionWith locally advanced, recurrent, and metastatic prostate cancer patients, patient preference between intermittent (IAD) and continuous (CAD) androgen deprivation therapy has not been investigated. The goal of the study was to determine patients' preference for IAD vs. CAD therapy. The secondary aim was to elucidate demographic or treatment variables that may affect a patient's preference for one type of hormonal treatment. Materials and MethodsUsing a tradeoff model that demonstrates the difference in outcome between IAD and CAD, a survey questionnaire was developed and administered to prostate cancer patients at the Odette Cancer Centre at Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada. Only patients who had (1) locally advanced prostate cancer, (2) been previously treated for prostate cancer with relapsing prostate-specific antigen, or (3) slow metastatic disease were asked to participate. Data related to patients' demographic information and their decisional preference factors were collected. Results and ConclusionsOverall, 36 of 53 (68%) patients completed the survey. Most patients favoured IAD (n = 32) over CAD (n = 4). Patients currently on radical treatment (adjuvant hormone therapy and radiation therapy) preferred CAD compared with patients who were not on radical treatment (P = .044). Patients with high (>20 ng/L) pretreatment prostate-specific antigen showed preference for CAD; however, this was not statistically significant (P = 0.07). Patients from both groups viewed quality of life as the strongest influence on their treatment preference, but had diverging opinions on side effects and general well being. The results of this pilot study could serve as a guide for future studies; a larger study combined with qualitative methodology may better address patients' needs and minimize any regret over their hormonal treatment.

Impact of hospital length of stay on the distribution of Gram negative bacteria and likelihood of isolating a resistant organism in a Canadian burn center

RationaleThe impact of hospital length of stay (LOS) on the distribution and susceptibility of Gram negative bacteria (GNB) causing infection in burn patients remains unexplored. Knowledge of causative pathogens is important in guiding empiric antibiotic therapy. ObjectivesTo characterize the distribution of GNB causing infection and to identify changes in susceptibility with LOS in a tertiary care burn center. MethodsA retrospective review of all admissions to the Ross Tilley Burn Centre at Sunnybrook Health Sciences Centre with clinical cultures yielding GNB (duplicates excluded) between March 12, 2010 to July 17, 2013 was completed. Positive cultures were categorized into 5 clinically relevant time periods (in days) based on specimen collection date relative to the patient's date of admission: 0–7, 7–14, 14–21, 21–28, >28. Chi-square for proportions was used to compare the time periods. ResultsThe proportion of patients with clinical cultures for P. aeruginosa increased with hospital LOS (0–7 days: 8% vs. >28 days: 55%; p<0.05). Conversely, clinical cultures for H. influenzae occurred primarily within the first 7 days of hospitalization (0–7 days: 36% vs. >28 days: 0.7%; p<0.05). Enterobacteriaceae isolation was highest between 7 and 14 days of hospitalization (7–14 days: 62% vs. >28 days: 38%; p<0.05). Antibiotic resistance was directly proportional to hospital LOS (% patients with multidrug resistant GNB increased from 6% [LOS 0–7days] to 44% [LOS>28 days]; p<0.05). ConclusionsThis study provides objective data documenting changes in species and resistance patterns of GNB causing infection in patients admitted to a burn center as a function of hospital LOS; which may support delaying the use of broad spectrum antibiotics (e.g. carbapenems and beta-lactam/beta-lactamase inhibitors) in clinically stable patients.

Utilization of Percutaneous Needle Biopsy for Breast Diagnosis in a Comprehensive Breast Center: Implications for Development of Quality Indicators.

Percutaneous needle biopsy (PNB) is the standard of care for diagnosis of breast lesions. Rates of excisional biopsy for breast diagnosis in North America have been reported at approximately 35%, although significant regional variation exists. A target rate of PNB for diagnosis of breast abnormalities is needed to facilitate quality improvement. We sought to describe the use of PNB in a referral practice, the clinical scenarios prompting PNB or surgical biopsy (SB), and the accuracy and rate of PNB to inform the ultimate development of a benchmark rate of PNB in breast diagnosis. Female patients age 18-90years, referred to Sunnybrook Health Sciences Centre, a large teaching hospital affiliated with the University of Toronto, with a breast lesion prompting tissue diagnosis with SB and/or PNB between 2002 and 2009 were studied. Each biopsied lesion was characterized by method of biopsy: PNB, SB, or PNB followed by SB. For each lesion, we collected data on patient demographics and breast cancer risk, reason for referral, imaging characteristics (breast imaging-reporting and data system classification, full description, final impression before biopsy), and pathology from each biopsy method. We report concordance between the final impression pre-biopsy and the PNB diagnosis with final surgical diagnosis where applicable. One thousand and twenty-six lesions were biopsied, 987 (96%) with PNB. The benign:malignant ratio for the entire cohort was 1.2:1. Final impression was concordant with final pathology in 674/862 (78%) and PNB diagnosis was concordant with SB pathology in 487/556 (88%). The reasons for SB without PNB were required pathologic evaluation of the entire lesion (n=19), patient choice (n=5), other biopsy technique used (n=6), technical (n=4), planned mastectomy (n=3), and enlarging mass (n=2). 155/559 (28%) of lesions without evidence of malignancy on PNB ultimately underwent SB. Papillary lesions and radial scars were more likely to undergo SB with or without prior PNB. Lesions deemed to be suspicious or malignant on final impression were more likely to be excised after a benign diagnosis at PNB. The vast majority of lesions requiring tissue diagnosis can be accurately diagnosed with PNB. Benchmarks for rates of PNB of 90% or greater may be considered for performance measurement in appropriate populations.

Validating the diagnostic code for acne in a tertiary care dermatology centre.

Administrative databases provide valuable patient data and are used to conduct population-based studies. However, no studies have been conducted to validate the codes for dermatological conditions. To evaluate the validity of ICD 9 code 706 for acne. This was a retrospective chart review of patients seen in dermatology clinics at Sunnybrook Health Sciences Centre between March 1 and May 31, 2013. The billing code for a clinic visit was compared to the diagnosis documented in the medical chart. There were 4,248 participants; 201 with an ICD-9 code of acne. This code had a PPV and sensitivity with 95% confidence intervals (CI) of 84.58% (78.67-89.13%) and 86.29% (80.51-90.62%), respectively. The specificity was 99.20% (98.86-99.45%). We showed that ICD-9 code 706 can be used to accurately identify patients with acne in a dermatology setting. This information can be applied to future epidemiologic studies.

A Metric for Reducing False Positives in the Computer-Aided Detection of Breast Cancer from Dynamic Contrast-Enhanced Magnetic Resonance Imaging Based Screening Examinations of High-Risk Women.

Magnetic resonance imaging (MRI)-enabled cancer screening has been shown to be a highly sensitive method for the early detection of breast cancer. Computer-aided detection systems have the potential to improve the screening process by standardizing radiologists to a high level of diagnostic accuracy. This retrospective study was approved by the institutional review board of Sunnybrook Health Sciences Centre. This study compares the performance of a proposed method for computer-aided detection (based on the second-order spatial derivative of the relative signal intensity) with the signal enhancement ratio (SER) on MRI-based breast screening examinations. Comparison is performed using receiver operating characteristic (ROC) curve analysis as well as free-response receiver operating characteristic (FROC) curve analysis. A modified computer-aided detection system combining the proposed approach with the SER method is also presented. The proposed method provides improvements in the rates of false positive markings over the SER method in the detection of breast cancer (as assessed by FROC analysis). The modified computer-aided detection system that incorporates both the proposed method and the SER method yields ROC results equal to that produced by SER while simultaneously providing improvements over the SER method in terms of false positives per noncancerous exam. The proposed method for identifying malignancies outperforms the SER method in terms of false positives on a challenging dataset containing many small lesions and may play a useful role in breast cancer screening by MRI as part of a computer-aided detection system.

Research Highlights

Michael Stevens, BSc, BSc, PT, MD, Dermatology Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada. Andrea Lam BSc, MD, Dermatology Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada. The authors declare no conflicts of interest. Correspondence concerning this article should be addressed to Michael Stevens, BSc, BSc, PT, MD, Dermatology Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Suite M1-700, Toronto, ON M4N 3M5, Canada. E-mail: [email protected]

Research Highlights

Michael Stevens, BSc, BSc PT, MD, Dermatology Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON. Andrea Lam, BSc, MD, Dermatology Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON. The authors declare no conflict of interest. Correspondence concerning this article should be addressed to Michael Stevens, BSc, BSc PT, MD, 2075 Bayview Avenue, Suite M1-700, Toronto, ON M4N 3M5. E-mail: [email protected]

Update on the management of chemotherapy-induced nausea and vomiting - focus on palonosetron.

PurposeNausea and vomiting are major adverse effects of chemotherapy and can greatly impact patients’ quality of life. Although chemotherapy-induced nausea and vomiting (CINV) prevalence is high, treatment remains difficult. Palonosetron is a 5-hydroxytryptamine receptor antagonist (5-HT3RA) approved for treatment of CINV. The purpose of this review is to discuss existing and emerging therapeutic options, and examine studies focusing on palonosetron with regards to efficacy, pharmacology, tolerability, safety, and patient-derived outcomes.MethodsA literature search was conducted using Ovid MEDLINE and EMBASE to identify relevant studies using palonosetron alone or in combination with other antiemetics. Studies were extracted if they included complete response (CR), complete control (CC), no nausea, no vomiting, and no rescue medications as an endpoint. Studies were also included if safety endpoints were examined.ResultsPalonosetron alone has been shown to improve CR and CC rates for patients receiving low, moderate, or high emetogenic chemotherapy. Rates were further improved with the addition of dexamethasone, a corticosteroid. Furthermore, the addition of neurokinin-1 receptor antagonists, such as netupitant markedly improved efficacy profiles compared to palonosetron alone. Aprepitant is an antiemetic that has exhibited positive results in combination with palonosetron. Recently, a new drug consisting of netupitant and palonosetron (NEPA) has demonstrated significantly more efficacious prevention of CINV. Regardless of the combination, palonosetron has been well tolerated. The most common adverse events were constipation, headache, fatigue, and dizziness, with the majority of patients describing them as only mild or moderate.ConclusionPalonosetron, alone or with other antiemetics, has improved CINV treatment due to its ability to significantly reduce delayed phases of CINV, compared to similar 5-HT3RAs. Palonosetron is both more effective than first generation 5-HT3RAs and safer, as it results in a smaller prolongation of the QTc interval, compared to other 5-HT3RAs.

Value of reflex testing based on hypogammaglobulinemia as demonstrated in serum protein electrophoresis

ObjectivesHypo-gammaglobulinemia (hypoGG) in serum protein electrophoresis (SPE) reflects, variably, reduced serum immunoglobulin (Ig) concentrations, which may be caused by hematological neoplasms, among other causes. HypoGG in the absence of a discernible M-spike (MC) has been the basis of reflexive testing e.g., by immunofixation electrophoresis (IFE). However, the utility of this practice has not been fully evaluated. Thus, we aimed to (1) determine the predictive power of hypoGG for reduced Ig levels, (2) compare the IFE positive rates and sensitivity between hypoGG and non-hypoGG patients, and (3) examine the M-protein isotype distributions. MethodsWe retrospectively analyzed 3974 matched SPE and IFE results at the Sunnybrook Health Sciences Centre from January 2010 to June 2013. SPE and IFE were performed on the Sebia Capillarys™ 2 and Hydrasys™ systems respectively. Results2723/3974 (68.5%) patients were SPE negative, 246/2723 (9%) had hypoGG and 192 (7.1%) were IFE positive. HypoGG predicted 93.1% cases with at least one Ig reduction. Among SPE-negative patients, the IFE positive rate and sensitivity in hypoGG were 12.2% and 15.6% respectively, compared to 6.4% and 77.1% in normo-GG. Proportion of non-IgG isotypes in both groups were comparable but fewer MC were detected in hypoGG. ConclusionsBoth the 7% false negative rate of SPE and the poor sensitivity (16%) of reflex testing based on hypoGG should be taken into consideration when devising a screening strategy based on SPE.

Research Highlights

Andrea Lam, BSc, MD, Dermatology Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON. Michael Stevens, BSc, BSc. PT, MD, Dermatology Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON. The authors declare no conflicts of interest. Correspondence concerning this article should be addressed to Andrea Lam, BSc, MD, Dermatology Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Suite M1-700, Toronto, ON M4N 3M5. E-mail: [email protected]

Acoustic Angiography: High-Resolution Contrast-Enhanced Ultrasound Imaging of the Microvasculature

Presenting Author: Paul A. Dayton1 Co-authors: Co-authors: Sarah Shelton1, Brooks Lindsey1, Ryan Gessner1, Yueh Z. Lee4, Stephen Aylward2, Mike Lee3, Emmanuel Cherin3, F. Stuart Foster3 Joint Graduate Department of Biomedical Engineering, University of North Carolina and North Carolina State University, NC, USA Kitware Medical Imaging, 101 East Weaver Street, Carrboro, NC Department of Medical Biophysics, Sunnybrook Health Sciences Centre,Toronto, ON, Canada Department of Neuroradiology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 Contrast enhanced ultrasound is FDA approved in the US for cardiology applications, and has demonstrated substantial utility off-label and in preclinical research studies. However, to date, contrast enhanced ultrasound in patients is largely performed at low frequencies and does not provide sufficient resolution or tissue suppression to visualize structural details of microvasculature blood flow. Through the use of new dual-frequency ultrasound transducer technology, contrast enhanced ultrasound can be performed with unprecedented resolution and contrast-to-tissue ratio, albeit at shallow penetration depths. This imaging technique enables the visualization of microvascular architecture without signal from background tissues, and can simultaneously provide anatomical information for registration. The resulting images are similar to x-ray angiography, and provide a new means to assess microvascular density and structure. Initial results indicate this new imaging modality can provide non-invasive insight into angiogenic processes involved in tumor growth and progression. We demonstrate the application of this imaging technique in evaluation of cancer angiogenesis in pre-clinical models, and provide a report of first in-human use. Presenting Author: Paul A. Dayton1 Co-authors: Co-authors: Sarah Shelton1, Brooks Lindsey1, Ryan Gessner1, Yueh Z. Lee4, Stephen Aylward2, Mike Lee3, Emmanuel Cherin3, F. Stuart Foster3 Joint Graduate Department of Biomedical Engineering, University of North Carolina and North Carolina State University, NC, USA Kitware Medical Imaging, 101 East Weaver Street, Carrboro, NC Department of Medical Biophysics, Sunnybrook Health Sciences Centre,Toronto, ON, Canada Department of Neuroradiology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 Contrast enhanced ultrasound is FDA approved in the US for cardiology applications, and has demonstrated substantial utility off-label and in preclinical research studies. However, to date, contrast enhanced ultrasound in patients is largely performed at low frequencies and does not provide sufficient resolution or tissue suppression to visualize structural details of microvasculature blood flow. Through the use of new dual-frequency ultrasound transducer technology, contrast enhanced ultrasound can be performed with unprecedented resolution and contrast-to-tissue ratio, albeit at shallow penetration depths. This imaging technique enables the visualization of microvascular architecture without signal from background tissues, and can simultaneously provide anatomical information for registration. The resulting images are similar to x-ray angiography, and provide a new means to assess microvascular density and structure. Initial results indicate this new imaging modality can provide non-invasive insight into angiogenic processes involved in tumor growth and progression. We demonstrate the application of this imaging technique in evaluation of cancer angiogenesis in pre-clinical models, and provide a report of first in-human use.

Increased defibrillator therapies during influenza season in patients without influenza vaccines

BackgroundThe association between influenza vaccination and implantable cardiac defibrillator (ICD) therapies during influenza season is not known and is described in this study. Understanding this association is important since reduction in ICD therapies during influenza season via use of influenza vaccination would benefit patients physically and psychologically. MethodsPatients presenting to the Sunnybrook Health Sciences Center ICD clinic between September 1st, 2011 and November 31st, 2011 were asked to complete a survey evaluating their use of the influenza vaccine. The number of patients with any ICD therapy and the total number of ICD therapies in the six months before and the three months during the 2010–2011 influenza season were determined. Poisson regression analysis was employed to assess differences in the average number of ICD therapies received during the influenza season based on vaccine status (vaccinated vs. unvaccinated). The analysis was repeated after limiting the cohort to patients with a left ventricular ejection fraction ≤35%. ResultsA total of 229 patients completed the survey, 78% of whom received the influenza vaccine. Four patients had more than one ICD shock during the study period. Electrical storm was rare (n=2). A trend toward more ICD therapies (unadjusted incident rate ratio (IRR)=3.2; P=0.07) and appropriate ICD shocks (unadjusted IRR=9.0; P=0.17) was noted for unvaccinated compared to vaccinated patients. This association persisted when analysis was limited to patients with a left ventricular ejection fraction ≤35% (all ICD therapies: unadjusted IRR=5.8; P=0.045; adjusted IRR=2.6; P=0.33). No patient who received the influenza vaccine, and had a reduced ejection fraction, received an approprite ICD shock during influenza season (unadjusted P<0.002). ConclusionA trend toward more ICD therapies during influenza season was observed in patients who did not receive the influenza vaccine compared to those who did. The association was stronger in patients who received appropriate ICD shocks and in patients with left ventricular systolic dysfunction. Further work to confirm these findings is recommended.

Abstract No. 350 - Cone-beam CT during prostatic artery embolization: a necessary adjunct to DSA to prevent complication

No. 352 Transcatheter arterial embolization for chest wall injury: 10 year experience C. Tingerides, G. Annamalai, S. Kaduri, C. Dey, R. Pugash, E. David; Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, ON, Canada Purpose: To present our experience in Transcatheter Arterial Embolization (TAE) for hemorrhage following chest wall injury, both traumatic and iatrogenic. We provide a pictorial summary of the full range of angiographic findings and embolization techniques utilized. Materials and Methods: Retrospective review of all patients treated with TAE for this indication in a period of 10 years: from August 2004 to August 2014 in our institution, a level I trauma centre. Data was obtained from electronic records, preand post-procedural imaging, procedure reports and laboratory results. Results: A total of thirteen patients were treated during this period. Seven patients had blunt trauma to the chest wall. Four patients had penetrating injury (two stabbings and two gunshot wounds). In four cases the injuries were iatrogenic (three due to chest tube insertion and one blunt injury from cardiopulmonary JVIR ’ Posters and Exhibits S157