Grasp-and-Fold Technique for Complex Inferior Vena Cava Filter Retrieval.

This study evaluated the use of the grasp-and-fold technique for complex forceps retrieval of inferior vena cava (IVC) filters. A retrospective study of 14 patients (12 women and 2 men) who had either deeply tip-embedded or severely distorted IVC filters was performed at a single institution over 10 years. In this technique, endobronchial forceps were used to fold the filter in half to remove it through the sheath because the filter tip could not be accessed by dissection. The grasp-and-fold technique successfully removed all 14 filters. One patient had retained filter struts, which were present before the procedure. One mild and 5 moderate adverse events (AEs), including fracture fragment embolization requiring retrieval and self-limited IVC extravasation, occurred. No severe AEs occurred. In this small patient cohort, the grasp-and-fold forceps technique successfully retrieved deeply tip-embedded or distorted IVC filters with inaccessible tips.

Iatrogenic Renal Artery Injury in 90 Cases: Arteriographic Findings and Outcomes after Embolization for Bleeding.

PURPOSE: To evaluate differences in arteriographic findings and outcomes after embolization among patients with a suspected iatrogenic renal arterial injury (IRAI). MATERIALS AND METHODS: Patients at the authors' institution who underwent renal arteriography for suspected IRAIs after partial nephrectomy, biopsy, or percutaneous access over a 20-year period were included. Records, imaging, and outcomes were reviewed. Data analysis was performed using the Fisher exact or Kruskal-Wallis test. RESULTS: Ninety arteriograms were performed on 83 patients after partial nephrectomy (n = 32), biopsy (n = 27), or percutaneous access (n = 24), including for nephrostomy/ureterostomy and stone removal. The median number of days between the index procedure and arteriogram was highest (15 days) after partial nephrectomy and lowest (5 days) after biopsy (P = .0001). Embolization was performed during 76% of arteriograms. If prearteriographic imaging showed positive results for IRAIs, embolization was performed in 67% versus 33% if imaging showed negative results (P = .005). The transfusion rate was higher after biopsy than after partial nephrectomy or percutaneous access (P = .002). Acute kidney injury after arteriogram occurred in 7% of patients; however, all returned to baseline by 1 week. CONCLUSIONS: Despite the different mechanism of IRAIs in partial nephrectomy, biopsy, and percutaneous access, arteriographic findings and outcomes were overall similar among groups. Prearteriographic imaging can help identify IRAIs but cannot supersede the clinical judgment regarding indication for embolization. IRAIs can present acutely or after a long interim, although patients who underwent biopsy presented earlier and more frequently required a blood transfusion. IRAIs can be treated with embolization without permanent deleterious effects on renal function.

A 5-Year Update on the IR Residency Match: 2022 National Survey Results of Program Directors and Matched Applicants Compared with 2017.

PURPOSE: To characterize the experiences of matched applicants (MAs) and program directors (PDs) in the 2022 interventional radiology (IR) residency Match and compare with 2017 data. METHODS: Surveys were distributed to IR PDs and MAs from the 2022 Match. Findings were compared with those of 2017 using the 2-sample t test and Fisher exact test. RESULTS: In total, 68 MAs (40%) and 47 PDs (52%) responded. Collected demographic traits were similar, including ongoing male predominance (77% of MAs, 83% of PDs). Moreover, 86% of MAs and 87% of PDs were "satisfied" with Match outcomes. Compared with those in 2017, MAs applied to more IR programs (P < .001). MAs reported more research (P = .003) and abstracts/publications (P < .001) and ranked these as more important than PDs did (P < .001 for both). Approximately 82% of PDs gave special attention to candidates who completed a visiting rotation at their institution; 60% of MAs and 95% of PDs believed virtual interviews resulted in overinterviewing (P < .001); both agreed they provided convenience and accessibility. Furthermore, 63% of MAs believed a Step 1 pass/fail system will be less equitable for applicants. Additional data on demographics, medical school experiences, applications, interviews, intern year, and rank process were reported. CONCLUSIONS: Satisfaction with Match results remained high from 2017 to 2022, although efforts are needed to improve applicants' ability to navigate the application process, address overapplying, and evaluate concerns regarding the Step 1 pass/fail system. These survey findings will help inform applicants and PDs for future match cycles.

Stem cell-related knowledge and attitudes among physicians in Jordan.

BACKGROUND: Rapid advancement of stem cell (SC) therapies provides both opportunities and risks for patients and physicians alike. Physicians have a role in counselling patients about unproven SC therapies, requiring a basic level of knowledge and access to information about SCs. OBJECTIVE: This study sought to assess SC-related knowledge of and attitudes among physicians in Jordan to elucidate areas of deficiency that can be addressed. METHODS: A cross-sectional survey, comprising questions on demographics and SC knowledge and attitudes, was designed as a scoring system to evaluate physicians' knowledge and attitudes. Participants were recruited from 10 major hospitals in Jordan over 3 months between February and April 2019. The internal consistency of the scoring scales was calculated using Cronbach's alpha reliability coefficient. Gender differences were evaluated with an independent t-test. RESULTS: In total, 382 physicians in Jordan completed the survey (59.9% response rate). They demonstrated a low/moderate level of overall SC knowledge (51.3%), but most lacked confidence in their ability to answer patients' questions about SC therapies (64.7%). However, the total attitude score was moderate/high positive (66.8%) and most were interested in learning more about SCs (80.8%). Male physicians reported significantly more knowledge than females (P < .0001). CONCLUSIONS: This study reveals Jordanian physicians' hesitancy to counsel patients about SC therapies, largely because of gaps in knowledge. However, overall attitudes toward SC research and therapies are positive. The results of this study demonstrate a need to cover SC-related information in medical curricula in Jordan, as well as to support initiatives to regulate SC tourism in Jordan.

Spontaneous Dislodgement of Tunneled Dialysis Catheters after De Novo versus Over-The-Wire-Exchange Placement.

PURPOSE: To evaluate dislodgement of tunneled dialysis catheters (TDCs) in de novo (DN) placement with ultrasound versus over-the-wire exchange (OTWE). MATERIALS AND METHODS: Data were collected retrospectively on all TDC placements at this institution from 2001 to 2019 and were excluded if no removal date was recorded or if dwell time was more than 365 days. Information on TDC brand, placement, insertion/removal, and removal reason were collected. Multiple logistic regression evaluated factors associated with TDC dislodgement. DN placement and OTWE were compared for rate of dislodgement (generalized estimating equations method) and TDC dwell time (survival analysis). RESULTS: In total, 5328 TDCs were included with 66% (3522) placed DN and 32% (1727) via OTWE. Mean dwell time was 65 ± 72 days, and dislodgement occurred in 4% (224). TDC dislodgement rates in the DN and OTWE groups were 0.48 and 0.93 per 1000 catheter days, respectively. Brand (Ash Split vs. VectorFlow), placement technique (OTWE vs. DN), laterality (left vs. right), and site (left vs. right internal jugular vein) were significant predictors of dislodgement. OTWE placement exhibited 1.7 times the odds of dislodgement (95% confidence interval, 1.2-2.6; P = .004) compared to DN and had significantly higher probability of dislodgement across time (hazard ratio = 2.0; P < .001) compared to DN. Dislodgement rates for OTWE vs. DN were 8% vs. 3% (3 months), 13% vs. 6% (6 months), and 38% vs. 17% (1 year). CONCLUSIONS: TDC spontaneous dislodgement rates were significantly and consistently higher after OTWE compared to DN placement. These data support more careful attention to catheter fixation after OTWE placement.

Low Utility of Screening Hematologic Testing for Image-Guided Biopsies in Patients Without Bleeding Risks.

OBJECTIVE. This study evaluates the prevalence of an abnormal international normalized ratio (INR) and platelet count before image-guided percutaneous needle biopsies over a 10-year period, comparing data from patients with and those without known conditions predisposing to coagulopathy. MATERIALS AND METHODS. A review of electronic medical records identified patients who were scheduled for a biopsy in a single institution's radiology department for the period of 2007-2016. The following information was recorded: demographic data, patient history of conditions that predispose to bleeding (e.g., liver disease, anticoagulant therapy, history of coagulopathy), and INR and platelet values within 30 days before biopsy. Data were stratified by biopsies that were performed versus those that were cancelled. RESULTS. Over 10 years, 3864 percutaneous biopsies were performed, and 6371 were cancelled. Approximately half of the biopsies (48.2%) were performed in patients without a predisposing condition; of those patients, 0.8% and 0.1% had an INR greater than 1.5 and greater than 1.8, respectively, and 0.4% had a platelet count of 50,000/µL or less (≤ 50 × 109/L). In patients with no known predisposing condition, 0.6% and 0.0% of biopsies cancelled were in patients who had an INR greater than 1.5 and greater than 1.8, respectively, and 0.1% of biopsies cancelled were in patients who had a platelet count of 50,000/µL or less. Ordering prebiopsy testing of patients with no predisposing conditions for the 1864 percutaneous biopsies performed over the 10-year study period resulted in more than $850,000 in laboratory-related health care costs. Our results suggest that the cost of identifying one abnormal INR is nearly $700,000. CONCLUSION. For patients without any known bleeding risks who are scheduled to undergo image-guided percutaneous biopsies, identifying an abnormal INR or abnormal platelet count is rare. Eliminating this testing in patients without predisposing conditions has the potential to create savings in costs and time for both physicians and patients.

Gender-Specific Factors Influencing Medical Students' Career Choice of IR.

The authors conducted an anonymous survey to assess positive and negative factors that may affect medical students' decisions to pursue a career in interventional radiology (IR). The survey was sent to registrants for the Midwest IR Student Symposium in 2016 and/or 2017, with a response rate of 13%; male and female responses were then compared. Female and male medical students shared similar rankings of factors affecting their decisions about choosing IR as a career, such as concern about lifestyle and excitement about therapeutic applications. Access to female IR mentors and diversification of the currently male-dominated workplace were important, gender-specific concerns.

Public-private divide: cultural and social factors in women's attitudes toward cord blood banking in Jordan.

BACKGROUND: Private cord blood (CB) banking is more widespread than public banking in Jordan, contributing to misinformation and unequal access to resources. This study elucidates unique perspectives of women in Jordan toward CB banking for the purpose of national and international policymaking, ethics, and education. STUDY DESIGN AND METHODS: The authors developed and disseminated a questionnaire to women in maternity outpatient clinic waiting rooms in five different hospitals in Jordan. A total of 899 surveys were collected with 100% return rate: 464 surveys from private hospitals and 435 from public ones. Data were reported as frequency distributions, chi-square and Fisher's exact test statistics, and odds ratios. RESULTS: Patient demographics, self-reported knowledge, and opinions about CB banking differed significantly between women at private versus public hospitals. Women at private hospitals had higher levels of awareness and communication with a health care professional about CB banking, which is associated with more positive viewpoints on CB banking and a self-reported higher likelihood of participating in CB banking in the future. Furthermore, religious approval and father-only consent for CB banking must be considered as unique factors in CB storage in Jordan. CONCLUSION: This analysis aids in identifying discrepancies in knowledge, resources, and communication, as well as unique population preferences. Comprehensive culturally attuned educational campaigns for patients and physicians should be a national priority to ensure ethical practice, informed decision making, and sustainable programs before the opening of Jordan's first public CB bank in 2017.

Ischemic Optic Neuropathy in Cardiac Surgery: Incidence and Risk Factors in the United States from the National Inpatient Sample 1998 to 2013.

BACKGROUND: Ischemic optic neuropathy is the most common form of perioperative visual loss, with highest incidence in cardiac and spinal fusion surgery. To date, potential risk factors have been identified in cardiac surgery by only small, single-institution studies. To determine the preoperative risk factors for ischemic optic neuropathy, the authors used the National Inpatient Sample, a database of inpatient discharges for nonfederal hospitals in the United States. METHODS: Adults aged 18 yr or older admitted for coronary artery bypass grafting, heart valve repair or replacement surgery, or left ventricular assist device insertion in National Inpatient Sample from 1998 to 2013 were included. Risk of ischemic optic neuropathy was evaluated by multivariable logistic regression. RESULTS: A total of 5,559,395 discharges met inclusion criteria with 794 (0.014%) cases of ischemic optic neuropathy. The average yearly incidence was 1.43 of 10,000 cardiac procedures, with no change during the study period (P = 0.57). Conditions increasing risk were carotid artery stenosis (odds ratio, 2.70), stroke (odds ratio, 3.43), diabetic retinopathy (odds ratio, 3.83), hypertensive retinopathy (odds ratio, 30.09), macular degeneration (odds ratio, 4.50), glaucoma (odds ratio, 2.68), and cataract (odds ratio, 5.62). Female sex (odds ratio, 0.59) and uncomplicated diabetes mellitus type 2 (odds ratio, 0.51) decreased risk. CONCLUSIONS: The incidence of ischemic optic neuropathy in cardiac surgery did not change during the study period. Development of ischemic optic neuropathy after cardiac surgery is associated with carotid artery stenosis, stroke, and degenerative eye conditions.

Assessing women's knowledge and attitudes toward cord blood banking: policy and ethical implications for Jordan.

BACKGROUND: Despite the global expansion of umbilical cord blood (CB) banking, little is known about public opinion and awareness, especially among Arab Muslim populations. CB banking raises policy questions about funding sustainability and quality standards, as well as ethical debates about profitability, informed consent, and medical justification. This study is the first of its kind in the Arab world, and Jordan has a unique, understudied, yet highly relevant setting, especially as a regional medical hub with advanced medical and health policy infrastructures. In addition, the first private and public CB banks are expected to open in 2016. STUDY DESIGN AND METHODS: The authors developed and administered, over a 5-month period, an anonymous survey to investigate public opinion and knowledge about CB banking in Jordan. The survey was administered to women in maternity outpatient clinic waiting rooms at five different hospitals. RESULTS: More than 75% of respondents indicated they knew nothing about CB banking in Jordan, and more than 50% had never heard of CB banking before. However, overall public opinion about CB storage is positive. Important factors related to public opinion were also identified, demonstrating that most women want more information on CB banking, especially from their obstetrician. CONCLUSION: This widespread lack of awareness is likely contributing to misinformation, lack of knowledge, and unfavorable perspectives toward CB donation and research. The results have important implications for the development of national and regional policies and educational campaigns on CB banking targeting both physicians and patients.

Cord Blood Banking in the Arab World: Current Status and Future Developments.

Umbilical cord blood transplants are now used to treat numerous types of immune- and blood-related disorders and genetic diseases. Cord blood (CB) banks play an important role in these transplants by processing and storing CB units. In addition to their therapeutic potential, these banks raise ethical and regulatory questions, especially in emerging markets in the Arab world. In this article, the authors review CB banking in five countries in the region, Jordan, Saudi Arabia, Egypt, Qatar, and the United Arab Emirates, selected for their different CB banking policies and initiatives. In assessing these case studies, the authors present regional trends and issues, including religious perspectives, policies, and demographic risk factors. This research suggests strong incentives for increasing the number of CB units that are collected from and available to Arab populations. In addition, the deficit in knowledge concerning public opinion and awareness in the region should be addressed to ensure educated decision-making.

Structural and biochemical analyses of alanine racemase from the multidrug-resistant Clostridium difficile strain 630.

Clostridium difficile, a Gram-positive, spore-forming anaerobic bacterium, is the leading cause of infectious diarrhea among hospitalized patients. C. difficile is frequently associated with antibiotic treatment, and causes diseases ranging from antibiotic-associated diarrhea to life-threatening pseudomembranous colitis. The severity of C. difficile infections is exacerbated by the emergence of hypervirulent and multidrug-resistant strains, which are difficult to treat and are often associated with increased mortality rates. Alanine racemase (Alr) is a pyridoxal-5'-phosphate (PLP)-dependent enzyme that catalyzes the reversible racemization of L- and D-alanine. Since D-alanine is an essential component of the bacterial cell-wall peptidoglycan, and there are no known Alr homologs in humans, this enzyme is being tested as an antibiotic target. Cycloserine is an antibiotic that inhibits Alr. In this study, the catalytic properties and crystal structures of recombinant Alr from the virulent and multidrug-resistant C. difficile strain 630 are presented. Three crystal structures of C. difficile Alr (CdAlr), corresponding to the complex with PLP, the complex with cycloserine and a K271T mutant form of the enzyme with bound PLP, are presented. The structures are prototypical Alr homodimers with two active sites in which the cofactor PLP and cycloserine are localized. Kinetic analyses reveal that the K271T mutant CdAlr has the highest catalytic constants reported to date for any Alr. Additional studies are needed to identify the basis for the high catalytic activity. The structural and activity data presented are first steps towards using CdAlr for the development of structure-based therapeutics for C. difficile infections.

Uterine Vascular Anomalies: Management and Treatment Overview.

Uterine vascular anomalies (UVAs), while rare, can result in severe, life-threatening hemorrhage. An understanding of the presentation and management options for UVAs is important for interventional radiologists to appropriately evaluate and care for these patients. The authors propose a standardized terminology for UVAs to avoid confusion and conflating congenital from acquired vascular lesions, which have a different pathophysiology. Limited high-level evidence and no definitive guidelines for UVA management exist, although endovascular treatment with uterine artery embolization has generally become the first-line approach for symptomatic or persistent UVAs with high technical and clinical success rates. There is also no consensus on the optimal embolization technique; the authors propose an initial approach to first embolize the dominant uterine artery supplying the UVA with gelatin sponge, with the option to embolize the contralateral side at the time of initial embolization if there is persistent supply (avoiding bilateral empiric embolization). Repeat embolization is feasible and recommended in the setting of recurrence, and both clinical and imaging follow-up is important. Ultimately, a multidisciplinary approach with individualized patient management is needed, particularly in the face of a lack of consensus guidelines for the management of symptomatic UVAs.

A Practical Guide for Left Adrenal Vein Sampling in Patients with Left Renal Vein Variants.

BACKGROUND: The presence of left renal vein (LRV) variants can increase the complexity of adrenal vein sampling (AVS), an already technically demanding procedure. While AVS literature often focuses on the right adrenal vein, an understanding of common LRV variants, their relationship with the left adrenal vein, and principles for successful catheterization can facilitate AVS. This guide provides practical, technical tips for AVS for duplicated (Du), circumaortic (Ca), and retroaortic (Ra) LRVs. METHODS: AVS cases were identified at a single institution (June 2009-March 2023) based on adrenophrenic trunk drainage relative to variant LRVs. Available cross-sectional imaging was reviewed to evaluate LRV anatomy pre-procedure. Twenty-seven cases (1 DuLRV, 13 CaLRVs, and 13 RaLRVs) were identified. Diagnostic AVS was confirmed by a threshold selectivity index. Literature on LRV anatomic variants was also reviewed. RESULTS: Based on the authors' experience and literature review, the following principles can guide AVS in the setting of LRV variants. In the presence of DuLRV or CaLRV, the left adrenal vein invariably drains into a normally positioned, pre-aortic LRV limb, so AVS can proceed as expected with a Simmons as the catheter of choice. In contrast, a LAV draining into a RaLRV may require a hockey stick-like catheter, or in rare cases a microcatheter, for selecting and sampling, due to the longer RaLRV course, which usually drains into the IVC more inferiorly and can be stenotic where the aorta crosses. CONCLUSION: Knowing the presence and understanding the anatomy of LRV variants can facilitate an efficient AVS.

Understanding Race-Based Medicine and Its Impact on Radiology.

Although race is widely accepted as a social construct, the practice of medicine is embedded with the assumption of race as a genetic marker that explains differences in disease prevalence, presentation, and health outcomes and encourages the "correction" for race in interpreting certain test results and values. This false premise, which is fundamental to the theory of race-based medicine, is integrated into clinical practice and has resulted in inequitable care among communities of color. The impact of race-based medicine in radiology might be less apparent but is nonetheless considerable because it affects the entire continuum of radiology practice. In this review, we discuss historical perspectives, examine various incriminated scenarios relevant to radiology, and offer mitigation strategies.

Mixed-integer quadratic programming approach for noninvasive estimation of respiratory effort profile during pressure support ventilation.

Information about respiratory mechanics such as resistance, elastance, and muscular pressure is important to mitigate ventilator-induced lung injury. Particularly during pressure support ventilation, the available options to quantify breathing effort and calculate respiratory system mechanics are often invasive or complex. We herein propose a robust and flexible estimation of respiratory effort better than current methods. We developed a method for non-invasively estimating breathing effort using only flow and pressure signals. Mixed-integer quadratic programming (MIQP) was employed, and the binary variables were the switching moments of the respiratory effort waveform. Mathematical constraints, based on ventilation physiology, were set for some variables to restrict feasible solutions. Simulated and patient data were used to verify our method, and the results were compared to an established estimation methodology. Our algorithm successfully estimated the respiratory effort, resistance, and elastance of the respiratory system, resulting in more robust performance and faster solver times than a previously proposed algorithm that used quadratic programming (QP) techniques. In a numerical simulation benchmark, the worst-case errors for resistance and elastance were 25% and 23% for QP versus <0.1% and <0.1% for MIQP, whose solver times were 4.7 s and 0.5 s, respectively. This approach can estimate several breathing effort profiles and identify the respiratory system's mechanical properties in invasively ventilated critically ill patients.