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PURPOSE: To characterize the effectiveness, safety, and length of stay (LOS) associated with pulmonary cryoablation for management of primary lung malignancies in patients aged ≥80 years. MATERIALS AND METHODS: A retrospective single-center database was compiled of all consecutive patients aged ≥80 years who underwent percutaneous computed tomography-guided cryoablation using modified triple-freeze protocol (1-3 ablation probes) for Stage IA-IIB primary lung malignancies between March 2017 and March 2020 (n = 19; 53% women; mean age, 85 years ± 3.5; range, 80-94 years). Follow-up imaging was assessed for local recurrence. Adverse events and LOS were recorded from chart review. Kaplan-Meier analysis was performed to assess both overall and local recurrence-free survival. RESULTS: Mean patient follow-up period was 21.6 months ± 10.8, and mean imaging follow-up period was 19.2 months ± 9.6. Overall survival at 3 years was 94% (95% CI, 81%-100%). Local recurrence-free survival was 100% throughout the imaging follow-up period. Intraprocedural pneumothorax occurred in 37% (7 of 19) of patients; pneumothorax risk was significantly associated with increased tumor distance from pleura (odds ratio, 1.2; P = .018). Sixty-three percent (12 of 19) of patients were discharged on the day of the procedure, with a mean LOS of 7.7 hours ± 1.6, whereas 37% of patients required overnight observation (2 of 19) or admission (5 of 19), with a mean LOS of 48.1 hours ± 19.4. Overall LOS for all patients was 22.6 hours ± 22.9. CONCLUSIONS: Percutaneous cryoablation of primary pulmonary malignancies can be performed in select octogenarians and nonagenarians with high 3-year overall and recurrence-free survival. Despite nonnegligible risk of pneumothorax, most patients are discharged on the day of the procedure.
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Criocirurgia , Neoplasias Pulmonares , Pneumotórax , Idoso de 80 Anos ou mais , Humanos , Feminino , Masculino , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pulmonares/cirurgia , Nonagenários , Octogenários , Estudos Retrospectivos , Criocirurgia/métodos , Resultado do Tratamento , Pneumotórax/etiologiaRESUMO
PURPOSE: To evaluate ablation zone sizes in patients undergoing pulmonary tumor cryoablation with 14-gauge cryoablation probes. MATERIALS AND METHODS: A single-center retrospective analysis of all consecutive patients who underwent cryoablation of pulmonary tumors with 1 or more 14-gauge probes (August 2017 to June 2020) was performed. Intraprocedural and 1-2-month postprocedural chest computed tomography (CT) scans were evaluated to characterize pulmonary lesions, ice balls, and ablation zones. Single-probe 14-gauge ablation zone volumes were compared with manufacturer reference isotherms and single- and 2-probe ablation zones from a prior investigation of 17-gauge probes. Overall survival and local recurrence-free survival were calculated to 3 years. RESULTS: Forty-seven pulmonary malignancies in 42 patients (women, 50%; mean age, 75.2 years ± 11.5) underwent cryoablation with 1 (n = 35), 2 (n = 10), or 3 (n = 2) cryoablation probes. One- to 2-month follow-up CT images were available for 30 of the 42 patients. The mean cryoablation zone volumes at 1-2 months when 1 (n = 21), 2 (n = 8), and 3 (n = 1) probes were used were 5.0 cm3 ± 2.3, 37.5 cm3 ± 20.5, and 28.4 cm3, respectively. The mean single-probe follow-up ablation zone volume was larger than that previously reported for 17-gauge probes (3.0 cm3 ± 0.3) (P < .001) but smaller than manufacturer-reported isotherms (11.6 cm3 for -40 °C isotherm) and the 2-probe ablation zone volume with 17-gauge devices (12.9 cm3 ± 2.4) (for all, P < 001). The 3-year overall survival and local recurrence-free survival were 69% (95% confidence interval [CI], 53%-89%) and 87% (95% CI, 74%-100%), respectively. CONCLUSIONS: Fourteen-gauge probes generate larger ablation volumes than those generated by 17-gauge probes. Manufacturer-reported isotherms are significantly larger than actual cryoablation zones. Cryoablation can attain low rates of local recurrence.
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Criocirurgia , Neoplasias Pulmonares , Humanos , Feminino , Idoso , Estudos Retrospectivos , Resultado do Tratamento , Criocirurgia/métodos , Tomografia Computadorizada por Raios X , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pulmonares/cirurgia , Neoplasias Pulmonares/patologiaRESUMO
PURPOSE: To determine whether subtherapeutic anticoagulation regimens are noninferior to therapeutic anticoagulation regimens following stent placement for nonthrombotic lower extremity venous disease. MATERIALS AND METHODS: Fifty-one consecutive patients (88% women; mean age, 44 years) who underwent stent placement for nonthrombotic lower extremity venous disease between 2002 and 2016 were retrospectively identified. The patients were divided into 2 cohorts: those who received prophylactic enoxaparin or no anticoagulation (subtherapeutic) after the procedure and those who received therapeutic doses of anticoagulation with enoxaparin, warfarin, and/or rivaroxaban (therapeutic) after the procedure. Baseline demographic characteristics, procedure characteristics, and outcomes were compared between the 2 groups using the Student t test, Fisher exact test, and χ2 test. The subtherapeutic and therapeutic anticoagulation groups did not differ significantly in the baseline demographic characteristics (eg, sex, race, and age) or procedure characteristics (eg, number of stents placed, stent brand, stent diameter, etc). RESULTS: The mean clinical follow-up time was 4.4 years (range, 0-16.3 years). There were no thrombotic adverse events or luminal obstructions due to in-stent restenosis in either group. There were 5 minor bleeding adverse effects in the therapeutic group and no bleeding adverse effects in the subtherapeutic group (P = .051). There were no statistically significant differences in subjective symptom improvement (P = .75). CONCLUSIONS: In this retrospective cohort, the subtherapeutic and therapeutic anticoagulation regimens produced equivalent outcomes in terms of adverse event rates, reintervention rates, and symptomatic improvement, suggesting that therapeutic doses of anticoagulation do not improve outcomes compared with subtherapeutic anticoagulation regimens following nonthrombotic venous stent placement.
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Veia Ilíaca , Trombose Venosa , Adulto , Anticoagulantes/efeitos adversos , Feminino , Humanos , Veia Ilíaca/diagnóstico por imagem , Extremidade Inferior , Masculino , Estudos Retrospectivos , Stents , Resultado do Tratamento , Grau de Desobstrução Vascular , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/terapiaRESUMO
PURPOSE: An automated segmentation technique (AST) for computed tomography (CT) venography was developed to quantify measures of disease severity before and after stent placement in patients with left-sided nonthrombotic iliac vein compression. MATERIALS AND METHODS: Twenty-one patients with left-sided nonthrombotic iliac vein compression who underwent venous stent placement were retrospectively identified. Pre- and poststent CT venography studies were quantitatively analyzed using an AST to determine leg volume, skin thickness, and water content of fat. These measures were compared between diseased and nondiseased limbs and between pre- and poststent images, using patients as their own controls. Additionally, patients with and without postthrombotic lesions were compared. RESULTS: The AST detected significantly increased leg volume (12,437 cm3 vs 10,748 cm3, P < .0001), skin thickness (0.531 cm vs 0.508 cm, P < .0001), and water content of fat (8.2% vs 5.0%, P < .0001) in diseased left limbs compared with the contralateral nondiseased limbs, on prestent imaging. After stent placement in the left leg, there was a significant decrease in the water content of fat in the right (4.9% vs 2.7%, P < .0001) and left (8.2% vs 3.2%, P < .0001) legs. There were no significant changes in leg volume or skin thickness in either leg after stent placement. There were no significant differences between patients with or without postthrombotic lesions in their poststent improvement across the 3 measures of disease severity. CONCLUSIONS: ASTs can be used to quantify measures of disease severity and postintervention changes on CT venography for patients with lower extremity venous disease. Further investigation may clarify the clinical benefit of such technologies.
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Angiografia por Tomografia Computadorizada , Veia Ilíaca/diagnóstico por imagem , Síndrome de May-Thurner/diagnóstico por imagem , Flebografia , Adulto , Constrição Patológica , Bases de Dados Factuais , Feminino , Humanos , Veia Ilíaca/fisiopatologia , Interpretação de Imagem Assistida por Computador , Masculino , Síndrome de May-Thurner/fisiopatologia , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudo de Prova de Conceito , Estudos Retrospectivos , Índice de Gravidade de DoençaRESUMO
PURPOSE: To study short-term and long-term outcomes of lower extremity venous stents placed at a single center and to characterize changes in vein diameter achieved by stent placement. MATERIALS AND METHODS: A database of all patients who received lower extremity venous stents between 1996 and 2018 revealed 1,094 stents were placed in 406 patients (172 men, 234 women; median age, 49 y) in 513 limbs, including patients with iliocaval stents (9.4% acute thrombosis, 65.3% chronic thrombosis, 25.3% nonthrombotic lesions). Primary, primary assisted, and secondary patency rates were assessed for lower extremity venous stents at 1, 3, and 5 years using Kaplan-Meier analyses and summary statistics. Subset analyses and Cox regression were performed to identify risk factors for patency loss. Vein diameters and Villalta scores before and up to 12 months after stent placement were compared. Complication and mortality rates were calculated. RESULTS: Primary, primary assisted, and secondary patency rates at 5 years were 57.3%, 77.2%, and 80.9% by Kaplan-Meier methods and 78.6%, 90.3%, and 92.8% by summary statistics. Median follow-up was 199 days (interquartile range, 35.2-712.0 d). Patency rates for the subset of patients (n = 46) with ≥ 5 years of follow-up (mean ± SD 9.1 y ± 3.4) were nearly identical to cohort patency rates at 5 years. Patients with inferior vena cava stent placement (hazard ratio 2.11, P < .0001) or acute thrombosis (hazard ratio 3.65, P < .0001) during the index procedure had significantly increased risk of losing primary patency status. Vein diameters were significantly greater after stent placement. There were no instances of stent fracture, migration, or structural deformities. In patients with chronic deep vein thrombosis, Villalta scores significantly decreased after stent placement (from 15.7 to 7.4, P < .0001). Perioperative mortality was < 1%, and major perioperative complication rate was 3.7%. CONCLUSIONS: Cavo-ilio-femoral stent placement for venous occlusive disease achieves improvement of vein disease severity scores, increase in treated vein diameters, and satisfactory long-term patency rates.
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Procedimentos Endovasculares/instrumentação , Veia Ilíaca , Extremidade Inferior/irrigação sanguínea , Stents , Veia Cava Inferior , Trombose Venosa/terapia , Adulto , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Veia Ilíaca/diagnóstico por imagem , Veia Ilíaca/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular , Veia Cava Inferior/diagnóstico por imagem , Veia Cava Inferior/fisiopatologia , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/mortalidade , Trombose Venosa/fisiopatologiaRESUMO
We developed a code and data-driven system (learning healthcare system) for gleaning actionable clinical insight from interventional radiology (IR) data. To this end, we constructed a workflow for the collection, processing and analysis of electronic health record (EHR), imaging, and cancer registry data for a cohort of interventional radiology patients seen in the IR Clinic at our institution over a more than 20-year period. As part of this pipeline, we created a database in REDCap (VITAL) to store raw data, as collected by a team of clinical investigators and the Data Coordinating Center at our university. We developed a single, universal pre-processing codebank for our VITAL data in R; in addition, we also wrote widely extendable and easily modifiable analysis code in R that presents results from summary statistics, statistical tests, visualizations, Kaplan-Meier analyses, and Cox proportional hazard modeling, among other analysis techniques. We present our findings for a test case of supra versus infra-inguinal ligament stenting. The developed pre-processing and analysis pipelines were memory and speed-efficient, with both pipelines running in less than 2 min. Three different supra-inguinal ligament veins had a statistically significant improvement in vein diameters post-stenting versus pre-stenting, while no infra-inguinal ligament veins had a statistically significant improvement (due either to an insufficient sample size or a non-significant p value). However, infra-inguinal ligament stenting was not associated with worse restenosis or patency outcomes in either a univariate (summary-statistics and Kaplan-Meier based) or multivariate (Cox proportional hazard model based) analysis.
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Sistema de Aprendizagem em Saúde , Humanos , Veia Ilíaca , Radiologia Intervencionista , Estudos Retrospectivos , Fatores de Risco , Stents , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
BACKGROUND: It has been hypothesized that prisons serve as amplifiers of general tuberculosis (TB) epidemics, but there is a paucity of data on this phenomenon and the potential population-level effects of prison-focused interventions. This study (1) quantifies the TB risk for prisoners as they traverse incarceration and release, (2) mathematically models the impact of prison-based interventions on TB burden in the general population, and (3) generalizes this model to a wide range of epidemiological contexts. METHODS AND FINDINGS: We obtained individual-level incarceration data for all inmates (n = 42,925) and all reported TB cases (n = 5,643) in the Brazilian state of Mato Grosso do Sul from 2007 through 2013. We matched individuals between prisoner and TB databases and estimated the incidence of TB from the time of incarceration and the time of prison release using Cox proportional hazards models. We identified 130 new TB cases diagnosed during incarceration and 170 among individuals released from prison. During imprisonment, TB rates increased from 111 cases per 100,000 person-years at entry to a maximum of 1,303 per 100,000 person-years at 5.2 years. At release, TB incidence was 229 per 100,000 person-years, which declined to 42 per 100,000 person-years (the average TB incidence in Brazil) after 7 years. We used these data to populate a compartmental model of TB transmission and incarceration to evaluate the effects of various prison-based interventions on the incidence of TB among prisoners and the general population. Annual mass TB screening within Brazilian prisons would reduce TB incidence in prisons by 47.4% (95% Bayesian credible interval [BCI], 44.4%-52.5%) and in the general population by 19.4% (95% BCI 17.9%-24.2%). A generalized model demonstrates that prison-based interventions would have maximum effectiveness in reducing community incidence in populations with a high concentration of TB in prisons and greater degrees of mixing between ex-prisoners and community members. Study limitations include our focus on a single Brazilian state and our retrospective use of administrative databases. CONCLUSIONS: Our findings suggest that the prison environment, more so than the prison population itself, drives TB incidence, and targeted interventions within prisons could have a substantial effect on the broader TB epidemic.
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Prisões , Tuberculose Pulmonar/prevenção & controle , Brasil/epidemiologia , Infecções Comunitárias Adquiridas/epidemiologia , Infecções Comunitárias Adquiridas/prevenção & controle , Infecções Comunitárias Adquiridas/transmissão , Feminino , Humanos , Incidência , Tuberculose Latente/epidemiologia , Tuberculose Latente/prevenção & controle , Tuberculose Latente/transmissão , Masculino , Modelos Estatísticos , Prisões/organização & administração , Prisões/estatística & dados numéricos , Modelos de Riscos Proporcionais , Características de Residência , Fatores de Tempo , Tuberculose Pulmonar/epidemiologia , Tuberculose Pulmonar/transmissãoRESUMO
[This corrects the article DOI: 10.1371/journal.pmed.1002737.].
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Vigabatrin is a highly effective antiseizure medication, but its use is limited due to concerns about retinal toxicity. One proposed mechanism for this toxicity is vigabatrin-mediated reduction of taurine. Herein we assess plasma taurine levels in a retrospective cohort of children with epilepsy, including a subset receiving vigabatrin. All children who underwent a plasma amino acid analysis as part of their clinical evaluation between 2006 and 2015 at Stanford Children's Health were included in the analysis. There were no significant differences in plasma taurine levels between children taking vigabatrin (n = 16), children taking other anti-seizure medications, and children not taking any anti-seizure medication (n = 556) (analysis of variance [ANOVA] p = 0.841). There were, however, age-dependent decreases in plasma taurine levels. Multiple linear regression revealed no significant association between vigabatrin use and plasma taurine level (p = 0.87) when controlling for age. These results suggest that children taking vigabatrin maintain normal plasma taurine levels, although they leave unanswered whether taurine supplementation is necessary or sufficient to prevent vigabatrin-associated visual field loss. They also indicate that age should be taken into consideration when evaluating taurine levels in young children.
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Anticonvulsivantes/uso terapêutico , Epilepsia/sangue , Epilepsia/tratamento farmacológico , Taurina/sangue , Vigabatrina/uso terapêutico , Fatores Etários , Análise de Variância , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , MasculinoRESUMO
CONTEXT: High-income country (HIC) trainees are undertaking global health experiences in low- and middle-income country (LMIC) host communities in increasing numbers. Although the benefits for HIC trainees are well described, the benefits and drawbacks for LMIC host communities are not well captured. OBJECTIVES: This study evaluated the perspectives of supervising physicians and local programme coordinators from LMIC host communities who engaged with HIC trainees in the context of the latter's short-term experiences in global health. METHODS: Thirty-five semi-structured interviews were conducted with LMIC host community collaborators with a US-based, non-profit global health education organisation. Interviews took place in La Paz, Bolivia and New Delhi, India. Interview transcripts were assessed for recurrent themes using thematic analysis. RESULTS: Benefits for hosts included improvements in job satisfaction, local prestige, global connectedness, local networks, leadership skills, resources and sense of efficacy within their communities. Host collaborators called for improvements in HIC trainee attitudes and behaviours, and asked that trainees not make promises they would not fulfil. Findings also provided evidence of a desire for parity between the opportunities afforded to US-based staff and those available to LMIC-based partners. CONCLUSIONS: This study provides important insights into the perspectives of LMIC host community members in the context of short-term experiences in global health for HIC trainees. We hope to inform the behaviour of HIC trainees and institutions with regard to international partnerships and global health activities.
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Atitude do Pessoal de Saúde , Estágio Clínico/métodos , Saúde Global/educação , Intercâmbio Educacional Internacional/tendências , Estudantes de Medicina , Bolívia , Países em Desenvolvimento , Educação Médica , Feminino , Humanos , Índia , Cooperação Internacional , Entrevistas como Assunto , Satisfação no Emprego , Liderança , MasculinoRESUMO
Faeces-mediated transmission of Trypanosoma cruzi (the aetiological agent of Chagas disease) by triatomine insects is extremely inefficient. Still, the parasite emerges frequently, and has infected millions of people and domestic animals. We synthesize here the results of field and laboratory studies of T. cruzi transmission conducted in and around Arequipa, Peru. We document the repeated occurrence of large colonies of triatomine bugs (more than 1000) with very high infection prevalence (more than 85%). By inoculating guinea pigs, an important reservoir of T. cruzi in Peru, and feeding triatomine bugs on them weekly, we demonstrate that, while most animals quickly control parasitaemia, a subset of animals remains highly infectious to vectors for many months. However, we argue that the presence of these persistently infectious hosts is insufficient to explain the observed prevalence of T. cruzi in vector colonies. We posit that seasonal rains, leading to a fluctuation in the price of guinea pig food (alfalfa), leading to annual guinea pig roasts, leading to a concentration of vectors on a small subpopulation of animals maintained for reproduction, can propel T. cruzi through vector colonies and create a considerable force of infection for a pathogen whose transmission might otherwise fizzle out.
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Doença de Chagas/veterinária , Cobaias , Insetos Vetores/parasitologia , Doenças dos Roedores/transmissão , Triatoma/parasitologia , Trypanosoma cruzi/fisiologia , Animais , Doença de Chagas/epidemiologia , Doença de Chagas/parasitologia , Doença de Chagas/transmissão , Estudos Transversais , Reservatórios de Doenças/parasitologia , Reservatórios de Doenças/veterinária , Insetos Vetores/fisiologia , Parasitemia/epidemiologia , Parasitemia/parasitologia , Parasitemia/transmissão , Parasitemia/veterinária , Peru/epidemiologia , Dinâmica Populacional , Prevalência , Doenças dos Roedores/epidemiologia , Doenças dos Roedores/parasitologia , Triatoma/fisiologiaRESUMO
Modern cities represent one of the fastest growing ecosystems on the planet. Urbanization occurs in stages; each stage characterized by a distinct habitat that may be more or less susceptible to the establishment of disease vector populations and the transmission of vector-borne pathogens. We performed longitudinal entomological and epidemiological surveys in households along a 1900 × 125 m transect of Arequipa, Peru, a major city of nearly one million inhabitants, in which the transmission of Trypanosoma cruzi, the aetiological agent of Chagas disease, by the insect vector Triatoma infestans, is an ongoing problem. The transect spans a cline of urban development from established communities to land invasions. We find that the vector is tracking the development of the city, and the parasite, in turn, is tracking the dispersal of the vector. New urbanizations are free of vector infestation for decades. T. cruzi transmission is very recent and concentrated in more established communities. The increase in land tenure security during the course of urbanization, if not accompanied by reasonable and enforceable zoning codes, initiates an influx of construction materials, people and animals that creates fertile conditions for epidemics of some vector-borne diseases.
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Doença de Chagas/epidemiologia , Doença de Chagas/transmissão , Insetos Vetores , Fatores Socioeconômicos , Animais , Reservatórios de Doenças , Humanos , Insetos Vetores/parasitologia , Estudos Longitudinais , Peru/epidemiologia , Animais de Estimação , Triatoma/parasitologia , Trypanosoma cruzi , UrbanizaçãoRESUMO
We analyzed a comprehensive telephone log of pest infestation reports to assess the spatial and temporal trends in Cimex lectularius L. (bed bug) reporting throughout Philadelphia, PA. Citywide spatial analyses of reports from September 2011 to June 2012 revealed several statistically significant bed bug hotspots. However, these were small and diffuse. Temporal analyses of reports from December 2008 to May 2011 detected prominent seasonality in bed bug reporting, peaking in August and reaching a nadir in February each year. Controlling for seasonal cycling, the number of bed bug reports in Philadelphia increased steadily at a rate of approximately 4.5% per month (or 69.45% per year) from December 2008 to May 2011. While it may be difficult to spatially target citywide bed bug control measures because of the insects' widespread migration, interventions informed by seasonal trends may enhance efforts to curb the recent increases in urban bed bug populations.
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Percevejos-de-Cama , Animais , Gatos , Cães , Camundongos , Philadelphia , Dinâmica Populacional , RatosRESUMO
PURPOSE: To characterize how the adoption of virtual residency interviews (2020-2021 cycle) has impacted the geographic distribution of radiology resident matches. METHODS: University-based interventional (IR) and diagnostic radiology (DR) residency programs from 2017 to 2021 were identified using a national residency database (FRIEDA). Public applicant data were obtained from official residency program websites. Medical schools and residency programs were categorized by US census regions. Geographic applicant distribution before and after the initiation of virtual interviews was statistically assessed using Chi-square tests. The effect of virtual interviews on the probability of matching within the same geographic region as one's medical school was evaluated with multivariate logistic regression. RESULTS: 4358 radiology residents (88% diagnostic, 12% interventional) matched at 102 radiology programs during the study period. 71% (n = 3115 residents) had data available for analysis. 56.3% of DR and 49.3% of IR residents matched in the same geographic region as their medical school. The geographic distribution of applicants who matched at Southern IR residency programs significantly changed after implementation of virtual interviews (p < 0.0001). Virtual interviews did not increase the odds of matching in the same region as one's medical school for IR (OR 1.11, p = 0.08) or DR (OR 1.01, p = 0.58) applicants. Top-20 ranked DR programs had lower odds of in-region matches (OR 0.87, p < 0.001). CONCLUSION: With few exceptions, shifting to virtual residency interviews did not significantly affect the geographic distribution of IR or DR residency matches. Top-ranked DR programs match more regionally diverse applicants.
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Internato e Residência , Radiologia , Humanos , Faculdades de Medicina , Bases de Dados FactuaisRESUMO
PURPOSE: Non-operative management of hepatic trauma with adjunctive hepatic arterial embolization (HAE) is widely accepted. Despite careful patient selection utilizing CTA, a substantial proportion of angiograms are negative for arterial injury and no HAE is performed. This study aims to determine which CT imaging findings and clinical factors are associated with the presence of active extravasation on subsequent angiography in patients with hepatic trauma. MATERIALS AND METHODS: The charts of 243 adults who presented with abdominal trauma and underwent abdominal CTA followed by conventional angiography were retrospectively reviewed. Of these patients, 49 had hepatic injuries on CTA. Hepatic injuries were graded using the American association for the surgery of trauma (AAST) CT classification, and CT images were assessed for active contrast extravasation, arterial pseudoaneurysm, sentinel clot, hemoperitoneum, laceration in-volving more than 2 segments, and laceration involving specific anatomic landmarks (porta hepatis, hepatic veins, and gallbladder fossa). Medical records were reviewed for pre- and post-angiography blood pressures, hemoglobin levels, and transfusion requirements. Angiographic images and reports were reviewed for hepatic arterial injury and performance of HAE. RESULTS: In multivariate analysis, AAST hepatic injury grade was significantly associated with increased odds of HAE (Odds ratio: 2.5, 95% CI 1.1, 7.1, p = 0.049). Univariate analyses demonstrated no significant association between CT liver injury grade, CT characteristics of liver injury, or pre-angiographic clinical data with need for HAE. CONCLUSION: In patients with hepatic trauma, prediction of need for HAE based on CT findings alone is challenging; such patients require consideration of both clinical factors and imaging findings.
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Embolização Terapêutica , Lacerações , Ferimentos não Penetrantes , Adulto , Humanos , Estudos Retrospectivos , Ferimentos não Penetrantes/cirurgia , Fígado/cirurgia , Artéria Hepática/lesõesRESUMO
Objective: Genicular artery embolization (GAE) is a novel, minimally invasive procedure for treatment of knee osteoarthritis (OA). This meta-analysis investigated the safety and effectiveness of this procedure. Design: Outcomes of this systematic review with meta-analysis were technical success, knee pain visual analog scale (VAS; 0-100 scale), WOMAC Total Score (0-100 scale), retreatment rate, and adverse events. Continuous outcomes were calculated as the weighted mean difference (WMD) versus baseline. Minimal clinically important difference (MCID) and substantial clinical benefit (SCB) rates were estimated in Monte Carlo simulations. Rates of total knee replacement and repeat GAE were calculated using life-table methods. Results: In 10 groups (9 studies; 270 patients; 339 knees), GAE technical success was 99.7%. Over 12 months, the WMD ranged from -34 to -39 at each follow-up for VAS score and -28 to -34 for WOMAC Total score (all p â< â0.001). At 12 months, 78% met the MCID for VAS score; 92% met the MCID for WOMAC Total score, and 78% met the SCB for WOMAC Total score. Higher baseline knee pain severity was associated with greater improvements in knee pain. Over 2 years, 5.2% of patients underwent total knee replacement and 8.3% received repeat GAE. Adverse events were minor, with transient skin discoloration as the most common (11.6%). Conclusions: Limited evidence suggests that GAE is a safe procedure that confers improvement in knee OA symptoms at established MCID thresholds. Patients with greater knee pain severity may be more responsive to GAE.
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Venous malformations, the most common type of vascular malformation, are slow-flow lesions resulting from disorganized angiogenesis. The International Society for the Study of Vascular Anomalies (ISSVA) classification offers a categorization scheme for venous malformations based on their genetic landscapes and association with congenital overgrowth syndromes. Venous malformations present as congenital lesions and can have broad physiologic and psychosocial sequelae depending on their size, location, growth trajectory, and tissue involvement. Diagnostic evaluation is centered around clinical examination, imaging evaluation with ultrasound and time-resolved magnetic resonance imaging, and genetic testing for more complex malformations. Interventional radiology has emerged as first-line management of venous malformations through endovascular treatment with embolization, while surgery and targeted molecular therapies offer additional therapeutic options. In this review, an updated overview of the genetics and clinical presentation of venous malformations in conjunction with key aspects of diagnostic imaging and treatment are discussed.
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90 Yttrium (Y90) radioembolization has been shown to improve outcomes for primary and metastatic liver cancers, but there is limited understanding of the optimal timing and safety of combining systemic therapies with Y90 treatment. Both therapeutic effects and toxicities could be synergistic depending on the timing and dosing of different coadministration paradigms. In particular, patients with liver-only or liver-dominant metastatic disease progression are often on systemic therapy when referred to interventional radiology for consideration of Y90 treatment. Interventional radiologists are frequently asked to offer insight into whether or not to hold systemic therapy, and for how long, prior to and following transarterial therapy. This study reviews the current evidence regarding the timing and safety of systemic therapy with Y90 treatment for hepatocellular carcinoma, metastatic colorectal carcinoma, intrahepatic cholangiocarcinoma, metastatic neuroendocrine tumors, and other hepatic metastases. A particular focus is placed on the timing, dosing, and toxicities of combined therapy.
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OBJECTIVE: To retrospectively evaluate the performance of two commonly used Doppler ultrasound parameters, namely, venous flow phasicity and response to Valsalva maneuver, in detecting iliocaval obstruction. METHODS: All imaging studies of patients seen by interventional radiology for lower extremity venous disease at a single institution from 1996 to 2018 were retrospectively identified. Lower extremity ultrasounds with a concurrent magnetic resonance, computed tomography, or conventional venogram performed within the next 7 days, which served as gold standard, were further identified (n = 192 examinations, including 313 limbs). Iliocaval obstruction were assessed by two ultrasound criteria: (1) nonphasic flow and/or (2) nonresponsive flow to Valsalva in the common femoral vein. The sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) for diagnosing iliocaval obstruction were calculated for each ultrasound criterion, and also for when the two criteria were assessed jointly. RESULTS: Of the 313 limbs assessed for venous flow phasicity, 133 (42.5%) had an iliocaval obstruction confirmed on subsequent venography. Nonphasic flow demonstrated a sensitivity of 69.2%, specificity of 82.8%, NPV of 78.4%, and PPV of 74.8% for diagnosing iliocaval obstruction. Of the 212 limbs assessed for Valsalva response, 88 (41.5%) had a confirmed iliocaval obstruction. Nonresponsive flow to Valsalva demonstrated a sensitivity of 13.6%, specificity of 97.6%, NPV of 61.6%, and PPV of 80.0% for diagnosing iliocaval obstruction. Joint assessment using phasicity and Valsalva criteria demonstrated a sensitivity of 68.2%, specificity of 87.2%, NPV of 79.6%, and PPV of 78.9%. CONCLUSIONS: In this tertiary care setting, Doppler ultrasound examination was not a reliable diagnostic tool for detecting iliocaval obstruction.
Assuntos
Veia Ilíaca/diagnóstico por imagem , Extremidade Inferior/diagnóstico por imagem , Ultrassonografia Doppler , Doenças Vasculares/diagnóstico por imagem , Adulto , Constrição Patológica , Feminino , Humanos , Veia Ilíaca/fisiopatologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos , Manobra de Valsalva , Doenças Vasculares/fisiopatologiaRESUMO
OBJECTIVE: The objective of this study was to characterize the average maximum diameters of widely patent lower extremity vein segments in patients with underlying venous disease and the demographic factors that affect these diameters. METHODS: Maximum axial diameters of each deep vein segment from the diaphragm to the knee were measured from computed tomography venography studies for all patients who underwent venous stent placement during a 20-year period at a single quaternary venous referral institution. Limbs containing only widely patent, unstented vein segments without variant anatomy were identified for inclusion. The final analysis involved diameter measurements from 870 imaging studies of 266 patients. Multivariate linear regression was used to identify factors associated with vein segment diameters. RESULTS: Average vein segment diameters ranged from 7.8 mm for the left and right femoral veins to 27.9 mm for the long axis of the suprarenal inferior vena cava. Multivariate linear regression demonstrated that women had larger IVC, common iliac vein, and external iliac vein diameters, whereas men had larger common femoral veins. Laterality, height, weight, and sex also had statistically significant associations with the diameters of select vein segments. CONCLUSIONS: This study provides an estimate of the average diameters of widely patent deep vein segments in the lower extremities from the diaphragm to the knees in patients with underlying venous disease and characterizes covariates that significantly affect vein diameter. These findings may help interventionalists better select devices for endovascular intervention.