Correlating Abdominal Wall Thickness and Body Mass Index to Predict Usefulness of Right Lower Quadrant Ultrasound for Evaluation of Pediatric Appendicitis.

OBJECTIVES: To inform selective and efficient use of appendix ultrasound (US) beyond adult parameters of body mass index (BMI) of less than 25 kg/m, we correlate abdominal wall thickness (AWT) with age and BMI to generate parameters for male and female children. Information presented in chart format can aid in the decision to utilize US for the evaluation of appendicitis. METHODS: In this observational study, 1600 pediatric computed tomography scans of the abdomen and pelvis were analyzed to obtain measurements of AWT in the right lower quadrant. Measurements were correlated by patient age, BMI, and sex. Results and consensus-based recommendations were presented in chart format with color-coded groupings to allow for convenient referencing in the clinical setting. RESULTS: One thousand four hundred eighty-eight computed tomography scans and AWT measurements were included. All age groups with BMI of less than 25 kg/m and all male and female groups younger than 6 years regardless of BMI had median AWT of less than 4 cm resulting in strong recommendation for US. Males older than 6 years and all female age groups with BMI of greater than 30 kg/m and female older than 15 years and BMI of greater than 25 kg/m had AWT of more than 5 cm resulting in low recommendation for US. CONCLUSIONS: While the BMI cutoff standard of less than 25 kg/m for usefulness of appendix US holds in the adult population, our data expand the acceptable range in children younger than 9 years regardless of BMI and male children with BMI up to 30 kg/m. Female children younger than 15 years with a BMI up to 30 kg/m may also be amenable to right lower quadrant US based on AWT. These parameters inform selective and efficient use of US for appendix evaluation.

Effect of technical parameters on transjugular intrahepatic portosystemic shunts utilizing stent grafts.

AIM: To assess the effect of technical parameters on outcomes of transjugular intrahepatic portosystemic shunt (TIPS) created using a stent graft. METHODS: The medical records of 68 patients who underwent TIPS placement with a stent graft from 2008 to 2014 were reviewed by two radiologists blinded to the patient outcomes. Digital Subtraction Angiographic images with a measuring catheter in two orthogonal planes was used to determine the TIPS stent-to-inferior vena cava distance (SIVCD), hepatic vein to parenchymal tract angle (HVTA), portal vein to parenchymal tract angle (PVTA), and the accessed portal vein. The length and diameter of the TIPS stent and the use of concurrent variceal embolization were recorded by review of the patient's procedure note. Data on re-intervention within 30 d of TIPS placement, recurrence of symptoms, and survival were collected through the patient's chart. Cox proportional regression analysis was performed to assess the effect of these technical parameters on primary patency of TIPS, time to recurrence of symptoms, and all-cause mortality. RESULTS: There was no significant association between the SIVCD and primary patency (P = 0.23), time to recurrence of symptoms (P = 0.83), or all-cause mortality (P = 0.18). The 3, 6, and 12-mo primary patency rates for a SIVCD ≥ 1.5 cm were 82.4%, 64.7%, and 50.3% compared to 89.3%, 83.8%, and 60.6% for a SIVCD of < 1.5 cm (P = 0.29). The median time to stenosis for a SIVCD of ≥ 1.5 cm was 19.1 mo vs 15.1 mo for a SIVCD of < 1.5 cm (P = 0.48). There was no significant association between the following factors and primary patency: HVTA (P = 0.99), PVTA (P = 0.65), accessed portal vein (P = 0.35), TIPS stent diameter (P = 0.93), TIPS stent length (P = 0.48), concurrent variceal embolization (P = 0.13) and reinterventions within 30 d (P = 0.24). Furthermore, there was no correlation between these technical parameters and time to recurrence of symptoms or all-cause mortality. Recurrence of symptoms was associated with stent graft stenosis (P = 0.03). CONCLUSION: TIPS stent-to-caval distance and other parameters have no significant effect on primary patency, time to recurrence of symptoms, or all-cause mortality following TIPS with a stent-graft.

Practice quality improvement during residency: where do we stand and where can we improve?

RATIONALE AND OBJECTIVES: Completing a systems-based practice project, equivalent to a practice quality improvement project (PQI), is a residency requirement by the Accreditation Council for Graduate Medical Education and an American Board of Radiology milestone. The aim of this study was to assess the residents' perspectives on quality improvement projects in radiology. MATERIALS AND METHODS: Survey data were collected from 154 trainee members of the Association of University Radiologists to evaluate the residents' views on PQI. RESULTS: Most residents were aware of the requirement of completing a PQI project and had faculty mentors for their projects. Residents who thought it was difficult to find a mentor were more likely to start their project later in residency (P < .0001). Publication rates were low overall, and lack of time was considered the greatest obstacle. Having dedicated time for a PQI project was associated with increased likelihood of publishing or presenting the data (P = .0091). Residents who rated the five surveyed PQI steps (coming up with an idea, finding a mentor, designing a project, finding resources, and finding time) as difficult steps were more likely to not have initiated a PQI project (P < .0001 for the first four and P = .0046 for time). CONCLUSION: We present five practical areas of improvement to make PQI a valuable learning experience: 1) Increasing awareness of PQI and providing ideas for projects, 2) encouraging faculty mentorship and publication, 3) educating residents about project design and implementation, 4) providing resources such as books and funds, and 5) allowing dedicated time.

Sealing of type III endoleaks with ethylene vinyl alcohol copolymer in a canine model.

PURPOSE: To test ethylene vinyl alcohol copolymer (EVOH) as a sealing agent for persistent abdominal aortic aneurysm (AAA) endograft leaks. MATERIALS AND METHODS: Twelve dogs underwent creation of AAAs with a Palmaz P4014 stent. A 10-mm x 5-cm Wallgraft endoprosthesis with a 4-mm-diameter hole cut into its side was deployed within the AAA. One week later, computed tomography (CT) and angiography were performed and the aneurysm sac was catheterized through the 4-mm hole. Then, EVOH was injected into the sac and lumbar arteries. Four weeks thereafter, all surviving animals underwent repeat CT scanning and angiography and were then euthanized. The AAA underwent gross and microscopic study. RESULTS: Three dogs died from aortic rupture within 24 hours of AAA creation and the remaining nine dogs survived to receive EVOH. All nine dogs had persistent flow into the sac and lumbar arteries at the time of EVOH delivery. Seven dogs survived to the end of the experiment, and all aneurysm sacs and lumbar arteries remained occluded on angiography and CT. Histologic examination revealed EVOH and thrombus admixed, with thrombus in varying stages of organization filling the aneurysm sac and lumbar arteries. CONCLUSIONS: Embolization of type III endoleaks with EVOH proved to be feasible in a canine model. Further work is warranted to determine its therapeutic utility.