Patient Radiation Doses in IR Procedures: The American College of Radiology Dose Index Registry-Fluoroscopy Pilot.

PURPOSE: To update normative data on fluoroscopy dose indices in the United States for the first time since the Radiation Doses in Interventional Radiology study in the late 1990s. MATERIALS AND METHODS: The Dose Index Registry-Fluoroscopy pilot study collected data from March 2018 through December 2019, with 50 fluoroscopes from 10 sites submitting data. Primary radiation dose indices including fluoroscopy time (FT), cumulative air kerma (Ka,r), and kerma area product (PKA) were collected for interventional radiology fluoroscopically guided interventional (FGI) procedures. Clinical facility procedure names were mapped to the American College of Radiology (ACR) common procedure lexicon. Distribution parameters including the 10th, 25th, 50th, 75th, 95th, and 99th percentiles were computed. RESULTS: Dose indices were collected for 70,377 FGI procedures, with 50,501 ultimately eligible for analysis. Distribution parameters are reported for 100 ACR Common IDs. FT in minutes, Ka,r in mGy, and PKA in Gy-cm2 are reported in this study as (n; median) for select ACR Common IDs: inferior vena cava filter insertion (1,726; FT: 2.9; Ka,r: 55.8; PKA: 14.19); inferior vena cava filter removal (464; FT: 5.7; Ka,r: 178.6; PKA: 34.73); nephrostomy placement (2,037; FT: 4.1; Ka,r: 39.2; PKA: 6.61); percutaneous biliary drainage (952; FT: 12.4; Ka,r: 160.5; PKA: 21.32); gastrostomy placement (1,643; FT: 3.2; Ka,r: 29.1; PKA: 7.29); and transjugular intrahepatic portosystemic shunt placement (327; FT: 34.8; Ka,r: 813.0; PKA: 181.47). CONCLUSIONS: The ACR DIR-Fluoro pilot has provided state-of-the-practice statistics for radiation dose indices from IR FGI procedures. These data can be used to prioritize procedures for radiation optimization, as demonstrated in this work.

Patient Radiation Doses in Interventional Radiology Procedures: Comparison of Fluoroscopy Dose Indices between the American College of Radiology Dose Index Registry-Fluoroscopy Pilot and the Radiation Doses in Interventional Radiology Study.

PURPOSE: To compare radiation dose index distributions for fluoroscopically guided interventions in interventional radiology from the American College of Radiology (ACR) Fluoroscopy Dose Index Registry (DIR-Fluoro) pilot to those from the Radiation Doses in Interventional Radiology (RAD-IR) study. MATERIALS AND METHODS: Individual and grouped ACR Common identification numbers (procedure types) from the DIR-Fluoro pilot were matched to procedure types in the RAD-IR study. Fifteen comparisons were made. Distribution parameters, including the 10th, 25th, 50th, 75th, and 95th percentiles, were compared for fluoroscopy time (FT), cumulative air kerma (Ka,r), and kerma area product (PKA). Two derived indices were computed using median dose indices. The procedure-averaged reference air kerma rate (Ka,r¯) was computed as Ka,r / FT. The procedure-averaged x-ray field size at the reference point (Ar) was computed as PKA / (Ka,r × 1,000). RESULTS: The median FT was equally likely to be higher or lower in the DIR-Fluoro pilot as it was in the RAD-IR study, whereas the maximum FT was almost twice as likely to be higher in the DIR-Fluoro pilot than it was in the RAD-IR study. The median Ka,r was lower in the DIR-Fluoro pilot for all procedures, as was median PKA. The maximum Ka,r and PKA were more often higher in the DIR-Fluoro pilot than in the RAD-IR study. Ka,r¯ followed the same pattern as Ka,r, whereas Ar was often greater in DIR-Fluoro. CONCLUSIONS: The median dose indices have decreased since the RAD-IR study. The typical Ka,r rates are lower, a result of the use of lower default dose rates. However, opportunities for quality improvement exist, including renewed focus on tight collimation of the imaging field of view.

The Use of the Transfemoral Transcaval Liver Biopsy Technique for Biopsies of Hepatic Masses.

The purpose of this study was to investigate the safety and effectiveness of the transfemoral transcaval (TFTC) liver biopsy technique in patients with hepatic masses with relative contraindications to percutaneous biopsy and/or mass location abutting the inferior vena cava. The medical records of 16 patients (56% men; age range, 21-88 years) who underwent TFTC biopsy of hepatic masses (ranging in diameter from 2.1 to 13.2 cm) from September 2015 to August 2021 were reviewed. Histopathologic diagnoses were made in 15 of 17 (88%) procedures. Two adverse events were noted: worsened preexisting hemobilia requiring embolization in 1 patient, and a decrease in hematocrit level in another patient, requiring only observation. In conclusion, this report showed that the TFTC technique is a relatively safe and effective method for sampling hepatic masses in select cases.

A Retrospective Multi-Site Academic Center Analysis of Pneumothorax and Associated Risk Factors after CT-Guided Percutaneous Lung Biopsy.

PURPOSE: To assess the risk factors, incidence and significance of pneumothorax in patients undergoing CT-guided lung biopsy. METHODS: Patients who underwent a CT-guided lung biopsy between August 10, 2010 and September 19, 2016 were retrospectively identified. Imaging was assessed for immediate and delayed pneumothorax. Records were reviewed for presence of risk factors and the frequency of complications requiring chest tube placement. 604 patients were identified. Patients who underwent chest wall biopsy (39) or had incomplete data (9) were excluded. RESULTS: Of 556 patients (average age 66 years, 50.2% women) 26.3% (146/556) had an immediate pneumothorax and 2.7% (15/556) required chest tube placement. 297/410 patients without pneumothorax had a delayed chest X-ray. Pneumothorax developed in 1% (3/297); one patient required chest tube placement. Pneumothorax risk was associated with smaller lesion sizes (OR 0.998; 95% CI (0.997, 0.999); [p = 0.002]) and longer intrapulmonary needle traversal (OR 1.055; 95% CI (1.033, 1.077); [p < 0.001]). Previous ipsilateral lung surgery (OR 0.12; 95% CI (0.031, 0.468); [p = 0.002]) and longer needle traversal through subcutaneous tissue (OR 0.976; 95% CI (0.96, 0.992); [p = 0.0034]) were protective of pneumothorax. History of lung cancer, biopsy technique, and smoking history were not significantly associated with pneumothorax risk. CONCLUSION: Delayed pneumothorax after CT-guided lung biopsy is rare, developing in 1% of our cohort. Pneumothorax is associated with smaller lesion size and longer intrapulmonary needle traversal. Previous ipsilateral lung surgery and longer needle traversal through subcutaneous tissues are protective of pneumothorax. Stratifying patients based on pneumothorax risk may safely obviate standard post-biopsy delayed chest radiographs.

The value of a machine learning algorithm to predict adverse short-term outcome during resuscitation of patients with in-hospital cardiac arrest: a retrospective study.

Background and importance Guidelines recommend that hospital emergency teams locally validate criteria for termination of cardiopulmonary resuscitation in patients with in-hospital cardiac arrest (IHCA). Objective To determine the value of a machine learning algorithm to predict failure to achieve return of spontaneous circulation (ROSC) and unfavourable functional outcome from IHCA using only data readily available at emergency team arrival. Design Retrospective cohort study. Setting and participants Adults who experienced an IHCA were attended to by the emergency team. Outcome measures and analysis Demographic and clinical data typically available at the arrival of the emergency team were extracted from the institutional IHCA database. In addition, outcome data including the Cerebral Performance Category (CPC) score count at hospital discharge were collected. A model selection procedure for random forests with a hyperparameter search was employed to develop two classification algorithms to predict failure to achieve ROSC and unfavourable (CPC 3-5) functional outcomes. Main results Six hundred thirty patients were included, of which 390 failed to achieve ROSC (61.9%). The final classification model to predict failure to achieve ROSC had an area under the receiver operating characteristic curve of 0.9 [95% confidence interval (CI), 0.89-0.9], a balanced accuracy of 0.77 (95% CI, 0.75-0.79), an F1-score of 0.78 (95% CI, 0.76-0.79), a positive predictive value of 0.88 (0.86-0.91), a negative predictive value of 0.61 (0.6-0.63), a sensitivity of 0.69 (0.66-0.72), and a specificity of 0.84 (0.8-0.88). Five hundred fifty-nine subjects experienced an unfavourable outcome (88.7%). The final classification model to predict unfavourable functional outcomes from IHCA at hospital discharge had an area under the receiver operating characteristic curve of 0.93 (95% CI, 0.92-0.93), a balanced accuracy of 0.59 (95% CI, 0.57-0.61), an F1-score of 0.94 (95% CI, 0.94-0.95), a positive predictive value of 0.91 (0.9-0.91), a negative predictive value of 0.57 (0.48-0.66), a sensitivity of 0.98 (0.97-0.99), and a specificity of 0.2 (0.16-0.24). Conclusion Using data readily available at emergency team arrival, machine learning algorithms had a high predictive power to forecast failure to achieve ROSC and unfavourable functional outcomes from IHCA while cardiopulmonary resuscitation was still ongoing; however, the positive predictive value of both models was not high enough to allow for early termination of resuscitation efforts.

Umbilical hernia simulating recurrent carcinoid on octreoscan.

Physiologic bowel activity on In-111 octreotide imaging is commonly seen. However, on occasion, normal bowel activity may mimic lesions in the abdomen, which can be very difficult to differentiate, particularly after surgical intervention. We report a case of focal bowel activity simulating a lesion in a patient who had an In-111 octreotide scan (Octreoscan), postoperatively, looking for recurrent carcinoid. SPECT/CT demonstrated that the uptake was localized in the anterior abdomen, and corresponded to a loop of bowel within a ventral hernia at the site of surgical incision. The correlation with CT as well as the precise localization made possible by the fusion images helped avoid misinterpretation of this finding as possible recurrent carcinoid.

Chest radiographs are valuable in demonstrating clinically significant pacemaker complications that require reoperation.

PURPOSE: To evaluate the utility of chest radiography in demonstrating clinically significant pacemaker complications that required reoperation. METHODS: In this retrospective case-controlled series, we identified 14 consecutive adults who required pacemaker reoperation and who had chest radiographs available for review (6 men, 8 women; mean age, 71 years [range, 43-95 years]). Ten patients had pacemakers implanted at our institution, and 4 were referred for reoperation. Forty-two controls, 3 for each patient, had postoperative chest radiographs and normal device function (25 men, 17 women; mean age 76 years [range, 37-96 years]). All postoperative chest radiographs, including 1-year follow-ups, were blindly reviewed by at least 2 of 4 radiologists for lead perforation and position of right atrial and right ventricular leads. Follow-up radiographs were assessed for lead perforation, lead displacement, and lead fracture. Data were analysed by using the Fisher exact test. RESULTS: Of the patients, 1.7% (10/581) required reoperation for pacemaker dysfunction (noncapture, oversensing, abnormal atrial and ventricular thresholds, failing impedance), extracardiac stimulation, and lead perforation and/or displacement. There were no lead fractures. Chest radiographs demonstrated pacemaker complications in 57% of patients (8/14) at a median of 2 days (<1-32 days) after implantation and in 5% of the controls (2/42) (P < .0001). None of the abnormalities were noted on the official reports. Among subgroups, chest radiographs were abnormal for the following indications: pacemaker dysfunction in 4 of 7 patients versus 0 of 21 controls (P = .0017), extracardiac stimulation in 1 of 3 patients vs 0 of 9 controls (P = .25), and lead perforation and/or displacement in 3 of 4 patients vs 2 of 12 controls (P = .06). CONCLUSIONS: Chest radiographs are useful after pacemaker placement and demonstrate the majority of complications that require reoperation. Familiarity with the expected normal position of the leads, appearances of pacemaker complications, and comparison with prior radiographs is crucial in rendering a correct diagnosis that guides patient management.

Online survey of radiologic ordering practices by pediatric trainees.

OBJECTIVE: The ACR has developed appropriateness criteria to ensure that patients are receiving appropriate imaging studies. The purpose of this study was to compare the imaging ordering practices of pediatric residents in specific clinical scenarios with the ACR Appropriateness Criteria. MATERIALS AND METHODS: A multiple-choice questionnaire was created using 10 clinical scenarios excerpted from the ACR Appropriateness Criteria. The questionnaire was sent to 69 pediatric residents (postgraduate years 1-3) at Children's Hospital of New York at Columbia University Medical Center (CHONY) and then to 75 pediatric residents at The Children's Hospital at Montefiore Medical Center (CHAM). The responses were compared with the ACR Appropriateness Criteria. RESULTS: Seventy-five and 69 pediatric residents from the CHAM and CHONY, respectively, were invited to participate in the survey. Thirty-nine individual responses (52%) were received from CHAM, and 41 (59%) were received from CHONY. A total of 27 responses were received from first-year residents, 28 from second-year residents, and 25 from third-year residents. The average number of questions answered incorrectly by first-year residents was 4.1, by second-year residents was 4.4, and by third-year residents was 4.5. CONCLUSIONS: This study demonstrates that residents appreciate the value of an imaging workup, but these examinations are often ordered without the consultation of a radiologist. The decision each resident makes reflects individual training. To improve residents' ability to make decisions regarding imaging examinations, radiologists must educate pediatric residents with uniform case-based and didactic sessions.

Prevalence and characterization of asymptomatic pacemaker and ICD lead perforation on CT.

BACKGROUND: Pacemakers and implantable cardiac defibrillators (ICDs) are widely used for the management of cardiac arrhythmias and congestive heart failure (CHF). Acute implantation complication rates range from 3% to 7%. The aim of this study is to describe the incidence of lead perforation on computed tomography (CT), and correlate these findings with electrophysiologic data. METHODS: Images of 100 consecutive patients with permanent pacemakers (n = 72) or ICDs (n = 28) who underwent multidetector CTs of the chest were identified. Cases were reviewed by 2 cardiothoracic radiologists, and a third if there was disagreement. Each CT was reviewed for device and fixation type, tip position, and presence of pericardial effusion. Results were correlated with lead impedance and pacing threshold, when available [79% (79/100)]. A cardiac electrophysiologist interpreted device data. RESULTS: All 100 patients had right ventricular leads (58 passive, 42 active) and 61 had right atrial leads (12 passive, 49 active). 15% (15/100) of patients had a lead perforation. Perforation rates were 15% (9/61) for atrial and 6% (6/100) for ventricular leads (P < 0.05, chi square). Four of 28 (14%) right ventricular ICD leads and 2 of 72 (3%)right ventricular pacemaker leads were perforated (P < 0.05, chi square). 12% (6/49) of active right atrial leads, and 25% (3/12) of passive right atrial leads perforated (P = NS, chi square). 7% (3/42) of active right ventricular leads, and 5% (3/58) of passive ventricular leads perforated (P = NS, chi square). Electrophysiologic parameters did not differ significantly between perforated and nonperforated leads. CONCLUSION: Asymptomatic perforation is a common phenomenon and rarely resulting in electrophysiologic consequences. Atrial leads perforated more frequently than ventricular leads, and ventricular ICD leads perforated more frequently than ventricular pacemaker leads.

Barrett's esophagus: clinical characteristics.

Barrett's metaplasia develops in 6-14% of individuals with gastroesophageal reflux. Barrett's adenocarcinomas are increasing in epidemic proportions for as yet unknown reasons, approximately 0.5-1% of patients with Barrett's will develop adenocarcinoma. Heartburn duration and frequency (but not severity), male gender, and Caucasian race are major risk factors for developing cancer. Obesity and smoking are weak risk factors. Survival is determined by depth of tumor invasion (stage). Once invasion of the muscularis propia occurs, the vast majority of patients will have developed widespread metastasis, even when clinical staging studies are negative. No currently available therapy results in prolonged survival once metastases develop. Thus, the more widespread use of effective surveillance strategies is the only currently available means for reducing the morbidity and mortality associated with Barrett's adenocarcinoma.