FABRICATION OF MULTILUMEN MICROFLUIDIC TUBING FOR EX SITU DIRECT LASER WRITING.

Among the numerous additive manufacturing or "three-dimensional (3D) printing" techniques, two-photon Direct Laser Writing (DLW) is distinctively suited for applications that demand high geometric versatility with micron-to-submicron-scale feature resolutions. Recently, "ex situ DLW (esDLW)" has emerged as a powerful approach for printing 3D microfluidic structures directly atop meso/macroscale fluidic tubing that can be manipulated by hand; however, difficulties in creating custom esDLW-compatible multilumen tubing at such scales has hindered progress. To address this impediment, here we introduce a novel methodology for fabricating submillimeter multilumen tubing for esDLW 3D printing. Preliminary fabrication results demonstrate the utility of the presented strategy for resolving 743 µm-in-diameter tubing with three lumens-each with an inner diameter (ID) of 80 µm. Experimental results not only revealed independent flow of discrete fluorescently labelled fluids through each of the three lumens, but also effective esDLW-printing of a demonstrative 3D "MEMS" microstructure atop the tubing. These results suggest that the presented approach could offer a promising pathway to enable geometrically sophisticated microfluidic systems to be 3D printed with input and/or output ports fully sealed to multiple, distinct lumens of fluidic tubing for emerging applications in fields ranging from drug delivery and medical diagnostics to soft surgical robotics.

Intraoperative Neuromonitoring during Peripheral Arteriovenous Malformation Embolization.

PURPOSE: To evaluate whether intraoperative neuromonitoring (IONM), including pre-embolization lidocaine injection challenge ("provocative testing") is associated with reduced risk of irreversible nerve injury during embolization of peripheral arteriovenous malformations (AVMs). MATERIALS AND METHODS: Medical records of patients with peripheral AVMs who underwent embolotherapy with IONM with provocative testing between 2012 and 2021 were reviewed retrospectively. Data collected included patient demographic characteristics, AVM location and size, embolic agent used, IONM signal changes after lidocaine and embolic agent injections, postprocedural adverse events, and clinical outcomes. Decisions regarding whether embolization would proceed at specific locations were based on IONM findings after the lidocaine challenge and as embolization proceeded. RESULTS: A cohort of 17 patients (mean age, 27 years ± 19; 5 women) who underwent 59 image-guided embolization procedures with adequate IONM data was identified. No permanent neurologic deficits occurred. Transient neurologic deficits were observed in 3 patients (4 sessions), comprising skin numbness (2 patients), extremity weakness (1 patient), and extremity weakness and numbness (1 patient). All neurologic deficits resolved by postoperative day 4 without additional treatment. CONCLUSIONS: IONM, including provocative testing, during AVM embolization may minimize potential nerve injury.

Venous malformation may be a feature of EXT1-related hereditary multiple exostoses: A report of two unrelated probands.

Hereditary multiple exostoses (HME), also known as hereditary multiple osteochondroma (HMO), is an autosomal dominant disorder caused by pathogenic variants in exostosin-1 or -2 (EXT1 or EXT2). It is characterized by the formation of multiple benign growing osteochondromas (exostoses) that most commonly affect the long bones; however, it may also occur throughout the body. Although many of these lesions are clinically asymptomatic, some can lead to chronic pain and skeletal deformities and interfere with adjacent neurovascular structures. Here, we report two unrelated probands that presented with a clinical and molecular diagnosis of HME with venous malformation, a clinical feature not previously reported in individuals with HME.

Responsiveness of the Patient-Reported Outcome Measure for Vascular Malformation Questionnaire in Patients with Low-Flow Vascular Malformations.

PURPOSE: To assess the responsiveness, defined as the ability to detect change in a patient's health or function, of the Patient-Reported Outcome Measure for Vascular Malformation (PROVAM) questionnaire in a cohort of patients with low-flow vascular malformations (VMs). MATERIALS AND METHODS: PROVAM was previously developed to assess symptoms, functional limitations, and social/emotional effects experienced by patients with VMs. This is a prospective cohort study of 56 patients with venous and lymphatic VMs who completed at least 2 PROVAM questionnaires, of whom 43 had undergone treatment with sclerotherapy in the interim between questionnaires. External responsiveness was assessed using a receiver operating characteristic (ROC) curve to ascertain whether a change in the total PROVAM score predicts whether patients reported symptom improvement and by correlating the change in the total PROVAM score and change in symptoms reported during clinic visit. Internal responsiveness was evaluated using Wilcoxon signed rank test, Cohen d effect size (ESp), and standard response mean difference (SRM). RESULTS: The total PROVAM score demonstrated excellent discrimination for symptom improvement with an area under the ROC curve of 0.856. There was a statistically significant, moderate positive correlation between the change in the total PROVAM score and the change in patient symptoms as determined from clinical visits (Spearman correlation coefficient [rs] = 0.67, P < .001). The total PROVAM score and all subdomain scores improved significantly after treatment (all P < .05). ESp and SRM were 0.80 and 0.83, respectively. CONCLUSIONS: PROVAM is responsive to improvement after treatment and may be useful to assess health-related quality of life in patients treated for VMs.

Racial, Ethnic, and Socioeconomic Disparities in Multiple Measures of Blue and Green Spaces in the United States.

BACKGROUND: Several studies have evaluated whether the distribution of natural environments differs between marginalized and privileged neighborhoods. However, most studies restricted their analyses to a single or handful of cities and used different natural environment measures. OBJECTIVES: We evaluated whether natural environments are inequitably distributed based on socioeconomic status (SES) and race/ethnicity in the contiguous United States. METHODS: We obtained SES and race/ethnicity data (2015-2019) for all U.S. Census tracts. For each tract, we calculated the Normalized Different Vegetation Index (NDVI) for 2020, NatureScore (a proprietary measure of the quantity and quality of natural elements) for 2019, park cover for 2020, and blue space for 1984-2018. We used generalized additive models with adjustment for potential confounders and spatial autocorrelation to evaluate associations of SES and race/ethnicity with NDVI, NatureScore, park cover, and odds of containing blue space in all tracts (n=71,532) and in urban tracts (n=45,338). To compare effect estimates, we standardized NDVI, NatureScore, and park cover so that beta coefficients presented a percentage increase or decrease of the standard deviation (SD). RESULTS: Tracts with higher SES had higher NDVI, NatureScore, park cover, and odds of containing blue space. For example, urban tracts in the highest median household income quintile had higher NDVI [44.8% of the SD (95% CI: 42.8, 46.8)] and park cover [16.2% of the SD (95% CI: 13.5, 19.0)] compared with urban tracts in the lowest median household income quintile. Across all tracts, a lower percentage of non-Hispanic White individuals and a higher percentage of Hispanic individuals were associated with lower NDVI and NatureScore. In urban tracts, we observed weak positive associations between percentage non-Hispanic Black and NDVI, NatureScore, and park cover; we did not find any clear associations for percentage Hispanics. DISCUSSION: Multiple facets of the natural environment are inequitably distributed in the contiguous United States. https://doi.org/10.1289/EHP11164.

Postembolization Persistence of Pulmonary Arteriovenous Malformations: A Retrospective Comparison of Coils and Amplatzer and Micro Vascular Plugs Using Propensity Score Weighting.

BACKGROUND. Endovascular embolization of pulmonary arteriovenous malformations (PAVMs) was historically performed with embolic coils. The Amplatzer Vascular Plug device (AVP) was introduced for this purpose in 2007 and the Micro Vascular Plug device (MVP) in 2013. OBJECTIVE. The purpose of this study was to compare coils, AVPs, and MVPs in terms of risk of persistence after PAVM embolization by use of propensity score weighting to account for biases in device selection. METHODS. This retrospective study included 112 patients (78 women and girls, 34 men and boys; mean age, 45 years) who underwent embolization of 393 PAVMs with a single device type (coil, MVP, or AVP) from January 2003 to January 2020. Persistence was defined as less than 70% reduction in PAVM sac size or contrast enhancement of the sac on follow-up pulmonary CTA. A Cox proportional hazards regression model was used to assess associations between embolic device selection and PAVM persistence. Inverse propensity score weighting was used to account for differences in embolic device selection based on patient and PAVM characteristics. RESULTS. The median postembolization follow-up period was 1.5 years (IQR, 0.3-5.6 years). Persistence was found in 10% (41/393) of PAVMs, including 16% (34/207) of those treated with coils, 8% (7/88) of those treated with AVPs, and 0% (0/98) of those treated with MVPs. Variables associated with embolization device (p < .25) were age, sex, pediatric versus adult status, smoking status, PAVM complexity, PAVM laterality, number of feeding arteries, and feeding artery diameter. The Cox regression model incorporated inverse propensity score weighting to account for the differences between treatment groups in these variables and incorporated feeding artery diameter because of imbalance remaining after weighting. With coils as the referent, MVPs had a hazard ratio for persistence of less than 0.01 (95% CI, < 0.01 to < 0.01; p < .001), and AVPs had a hazard ratio of 0.37 (95% CI, 0.16-0.90; p = .03). CONCLUSION. The risk of persistence after PAVM embolization was significantly lower for MVPs alone than for coils or AVPs alone. In addition, the risk of persistence was lower for AVPs than for coils. CLINICAL IMPACT. The findings support the clinical use of MVPs as the preferred device for PAVM embolization over coils and polytetrafluoroethylene-covered plugs.

Does Intraprocedural CT Improve the Success Rate of Adrenal Venous Sampling? A Systematic Review and Meta-Analysis of Data from 809 Patients.

PURPOSE: To perform a systematic review and meta-analysis to quantify the technical success rate of adrenal venous sampling (AVS) with and without intraprocedural computed tomography (CT). METHODS: A systematic search of the Medline, Scopus, EMBASE, and Web of Science databases for comparative studies using intraprocedural CT was undertaken. More than 1,000 records were screened using titles and abstracts. Full texts of 121 studies were reviewed and 14 eligible studies were identified. Nine studies had adequate comparative data and were included in the meta-analysis. RESULTS: A research synthesis was performed and data from 809 patients were pooled in multiple random effect models. Overall success rate of AVS without and with intraprocedural CT was 72.7% (59.3-83.0%) and 92.5% (86.6-95.9), respectively. The addition of intraprocedural CT increased the technical success rate by 19.8% (P < 0.001), with an odds ratio (OR) of 5.5 (3.3-9.2; P < 0.01). In meta-regression, odds of success with intraprocedural CT was associated with younger age (beta: 0.16 ± 0.05; P:0.001), higher body mass index (BMI; beta:0.08 ± 0.03; P:0.002), and higher selectivity index (defined as the ratio of cortisol in the adrenal vein to that in the inferior vena cava; beta:0.35 ± 0.08, P < 0.001). We found a linear inverse association between operator's success without CT and improved success with intraprocedural CT (R2: 0.86). CONCLUSIONS: Intraprocedural CT is not required for every case, but can be performed in difficult cases or when operators' success is limited. The benefit was more pronounced in younger patients with higher BMI, female gender, and with higher selectivity. LEVEL OF EVIDENCE: III Systematic review and meta-analysis of non-randomized clinical trials.

Characteristics and Outcomes of Percutaneous Biliary Interventions in the United States.

OBJECTIVE: To explore baseline characteristics, comorbidities, and clinical diagnoses in the prediction of outcomes for inpatient percutaneous biliary interventions in the United States. METHODS: Hospitalizations for percutaneous transhepatic cholangiography and percutaneous biliary drainage were studied using the National Inpatient Sample 2012 to 2015. Associations between baseline characteristics, comorbidities, clinical diagnoses, and outcomes were analyzed using multivariable regression modeling. Regional variations were studied in an exploratory analysis. RESULTS: Hospitalizations for percutaneous biliary interventions had average inpatient mortality of 3.8% ± 0.8% and length of stay of 7.6 ± 0.3 days. Hypertension was the most common comorbidity (50.5% ± 0.8%), and paralysis was associated with the highest inpatient mortality (19.1% ± 5.7%) and length of stay (11.4 ± 1.3 days). Compared with nonmalignant biliary-pancreatic disorders, sepsis was associated with the highest inpatient mortality (6.5% ± 1.1%; adjusted odds ratio [aOR]: 5.2 [3.9-7.0]) and length of stay (9.0 ± 3.0 days; aOR: 2.2 [1.9-2.5]), followed by underlying malignancy (mortality of 5.5% ± 0.6%; aOR: 2.3 [1.7-3.0]; length of stay of 8.3 ± 0.2 days; aOR: 1.6 [1.4-1.8]). The observed associations were independent of baseline characteristics and comorbidities. With regard to regional variations, the Middle Atlantic states had the lengthiest hospital stays (38.8% ± 2.0% >8 days) and the East South Central states had the highest inpatient mortality (6.6% ± 1.6%) while having the highest frequency of malignancy (37.9% ± 3.7%) and the lowest frequency of postoperative cases (15.2% ± 2.4%). CONCLUSION: In addition to baseline characteristics and comorbidities, sepsis and malignancy were determinants of higher mortality and increased length of stay in hospitalizations for percutaneous biliary interventions. We observed significant regional variations in clinical diagnoses and outcomes across the United States.

Transcatheter and Endoscopic Treatment of Gastric and Duodenal Bleeding: Population-Based Analysis of National Inpatient Trends and Outcomes in the United States.

BACKGROUND: Upper gastrointestinal (GI) bleeding is a common cause of hospital admission in the United States and is frequently treated by endoscopy. Recent studies have shown an increasing role for treatment using transcatheter embolization. METHODS: Data from the national inpatient sample (1993-2015) were used for trend analysis and to compare patient characteristics, comorbidities, and outcomes for endoscopic and transcatheter treatments of gastric and duodenal bleeding. RESULTS: Despite the continued decline in the rate of hospitalization for upper GI bleeding (-43% since 1993, P < .01), admissions for embolization (21.1% per year since 2005, P < .01) and endoscopic treatments (1.2%-6.1% per year since 1993, P < .01) have increased in the past decade. Patients with multiple comorbidities that include coagulopathy (25.6% versus 11.9%, P < .05), liver disease (16.0% versus 10.7%, P < .05), fluid and electrolyte disorder (51.0% versus 35.4%, P < .05), and metastatic cancer (6.9% versus 2.4%, P < .05) were more likely to receive embolization. Embolization was associated with higher crude risk of death (9.2% versus 2.1%, P < .01), lengthier hospital stays (9.1 days versus 5.1 days, P < .01), and greater average total hospital charges (US$135,000 versus US$46,000). The association between embolization (versus endoscopy) and mortality and length of stay diminished after controlling for disease severity and other procedures in propensity score-matched groups and by covariate adjustment. DISCUSSION: Though endoscopy remains the main treatment of upper GI bleeding, embolization is associated with comparable mortality and length of stay after accounting for disease severity and the need for additional procedures.

Vertebroplasty and kyphoplasty in the USA from 2004 to 2017: national inpatient trends, regional variations, associated diagnoses, and outcomes.

BACKGROUND: To explore the national inpatient trends, regional variations, associated diagnoses, and outcomes of vertebral augmentation (vertebroplasty and kyphoplasty) in the USA from 2004 to 2017. METHODS: Data from the National Inpatient Sample were used to study hospitalization records for percutaneous vertebroplasty and kyphoplasty. Longitudinal projections of trends and outcomes, including mortality, post-procedural complications, length of stay, disposition, and total hospital charges were analyzed. RESULTS: Following a period of decreased utilization from 2008 to 2012, hospitalizations for vertebroplasty and kyphoplasty plateaued after 2013. Total hospital charges and overall financial burden of hospitalizations for vertebroplasty and kyphoplasty increased to a peak of $1.9 billion (range $1.7-$2.2 billion) in 2017. Overall, 8% of procedures were performed in patients with a history of malignancy. In multivariable modeling, lung cancer (adjusted OR (aOR) 2.6 (range 1.4-5.1)) and prostate cancer (aOR 3.4 (range 1.2-9.4)) were associated with a higher risk of mortality. The New England region had the lowest frequency of routine disposition (14.1±1.1%) and the lowest average hospital charges ($47 885±$1351). In contrast, 34.0±0.8% had routine disposition in the West Central South region, and average hospital charges were as high as $99 836±$2259 in the Pacific region. The Mountain region had the lowest number of procedures (5365±272) and the highest mortality rate (1.2±0.3%). CONCLUSION: National inpatient trends of vertebroplasty and kyphoplasty utilization remained stable after a period of decline from 2008 to 2012, while the financial burden of hospitalizations increased. Despite recent improvements in outcomes, significant regional variations persisted across the USA.

ACR Appropriateness Criteria® Radiologic Management of Infected Fluid Collections.

Infected fluid collections are common and occur in a variety of clinical scenarios throughout the body. Minimally invasive image-guided management strategies for infected fluid collections are often preferred over more invasive options, given their low rate of complications and high rates of success. However, specific clinical scenarios, anatomic considerations, and prior or ongoing treatments must be considered when determining the optimal management strategy. As such, several common scenarios relating to infected fluid collections were developed using evidence-based guidelines for management. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Bariatric Embolization: A Narrative Review of Clinical Data From Human Trials.

Bariatric arterial embolization (BAE) is a novel technique that is investigated as an alternative, often supplementary, method for weight management. BAE reduces blood perfusion to the gastric fundus, and thus, reduces the production of appetite-inducing hormones. No randomized controlled trial has evaluated the efficacy of BAE to date. Available evidence from published studies include retrospective evaluations of patients undergoing left gastric artery embolization for gastrointestinal bleeding, and early prospective, single-arm clinical trials. Review of clinical data from human trials suggest an average weight loss of about 8-9 kg (ranging 7.6-22.0 kg), corresponding to 8-9% (ranging 4.8-17.2%) of the patients' baseline weight. Common complications include superficial gastric ulcers. Though uncommon, gastric perforation and splenic infarct are important major complication that may arise after left gastric artery embolization. Overall, BAE is an effective, relatively safe procedure that may be associated with clinically significant weight loss in patients with obesity.

Qualitative study of patients with venous malformations: symptom experiences and content validity of patient-reported outcome measures.

PURPOSE: To determine important symptoms and functional effects of venous malformations (VMs) to assess the content validity of commonly used patient-reported outcome (PRO) measures for use with VM patients. METHODS: This cross-sectional, qualitative study involved cognitive interviews with participants with VM aged ≥ 14 years. From February to June 2016, 11 participants (8 female) with a mean (± standard deviation) age of 31 ± 15 years were recruited from three clinical sites. The following subgroups were evaluated: 5 adults (aged ≥ 18) with trunk/extremity VMs; 3 adolescents (aged 14-17) with trunk/extremity VMs; and 3 adults with head/neck VMs. We evaluated the content validity of the Worst Pain Numeric Rating Scale (NRS), Patient-Reported Outcomes Measurement Information System (PROMIS®) Pain Interference 8-item short form, and PROMIS Physical Function 8-item short form. RESULTS: The most common participant-reported VM symptoms were swelling (n = 10), skin discoloration (n = 8), acute episodic pain (n = 8), chronic pain (n = 7), numbness (n = 7), and tingling/burning (n = 6). Participants reported that VMs affected their physical function (n = 10), appearance (n = 10), relationships/social activities (n = 7), and emotional health (n = 3). The Worst Pain NRS and PROMIS Pain Interference measures were relevant to all participants' VM experience. Only adults with head/neck VMs found the PROMIS Physical Function measure to be irrelevant. The assessed PRO measures did not address several symptoms commonly reported by VM patients (swelling, skin discoloration, numbness, and appearance). CONCLUSION: These results suggest that several VM symptoms are not assessed fully by commonly used PRO measures, and that the relevance of functional limitation questions may vary by VM location.