Retrieval of a Cook Celect inferior vena cava (IVC) filter after prolonged dwell time of 5,117 days: Factors to consider for retrieval of long-dwell IVC filters.

Inferior vena cava (IVC) filters are used in certain patients to help prevent the occurrence of pulmonary embolism (PE). IVC filters are generally recommended to be removed once PE prophylaxis is no longer required. Long-dwelling IVC filters are associated with higher complication rates (Vasa 2020; 49: 449), being more difficult to retrieve and associated with higher retrieval complications (Cardiovasc Diagn Ther 2016; 6: 632). This report describes the pre-procedural work-up and removal of an IVC filter with a prolonged dwell time of 5,117 days (14 years, 3 days) using the loop snare advanced retrieval technique. As far as the authors are aware this case is the longest-described successful retrieval of a Cook Celect IVC filter at 5,117 days.

The gender imbalance in Interventional Radiology in Australia and New Zealand.

INTRODUCTION: There are few female Interventional Radiologists worldwide and this is a significant issue for many countries. There is little known about the current status and attitudes to women in Interventional Radiology in Australia and New Zealand. The purpose of this study was to explore the gender balance, workforce challenges and perceptions towards women in Interventional Radiology in Australia and New Zealand. METHODS: An anonymised voluntary survey exploring the current demographics of Interventional Radiologists and opinions on multiple gender issues in Interventional Radiology was conducted. The survey was sent to all members of the Interventional Radiology Society of Australasia. Statistical analysis was performed using independent samples t-tests, the non-parametric Mann-Whitney U testing and proportions of binary variables using logistic regression. RESULTS: Seventy seven responses were received, 83% males and 17% females. The majority of participants worked full time (83%) and identified as an Interventional Radiologist with/without some sessions of diagnostic radiology per week (83%). There was general consensus in many issues; however, males tended to disagree more than females that female IRs are treated differently than male IRs (p < 0.037), and that male IRs are paid more than female IRs (P = 0.020). Females agreed it was harder for female IRs to gain academic or clinical promotion; however, males disagreed (P < 0.001). CONCLUSION: There is a clear gender imbalance in Interventional Radiology in Australia and New Zealand. Multiple issues should be investigated and addressed by the major stakeholders such as the Royal Australian and New Zealand College of Radiologists and the Interventional Radiology society of Australasia.

Ten-year incidence and treatment outcomes of closed degloving injuries (Morel-Lavallee lesions) in a level 1 trauma centre.

INTRODUCTION: Morel-Lavallée lesions (MLL), also referred to as closed degloving injuries, result from traumatic shearing forces with separation of the subcutaneous fat from the underlying fascia. The aim of this study was to determine the incidence and treatment of MLLs at a level 1 trauma centre. METHODS: Single-centre retrospective cross-sectional study of consecutive patients with an imaging diagnosis of a Morel-Lavallee lesion from 1/1/2010-31/12/2019. Demographic data, mechanism of injury, volume of lesion, management and outcome data were collated. RESULTS: Sixty-six MLLs were identified in 63 patients (64% Male) with a median age of 49.5 years (19-94 years). Mechanism of injury were road traffic accidents in the majority (66%). Median injury severity score (ISS) was 17 (range 1-33). Patients on oral anti-coagulants had significantly larger lesions (181.9 cc v 445.5 cc, P = 0.044). The most common lesion location was the thigh (60.5%). Patients that underwent imaging within 72 h of injury had significantly larger lesions than those imaged more than 72 h after the inciting trauma (65 cc v 167 cc, P < 0.05). Management data were documented in 59% of lesions (39/66) in which 66.6% (n = 26) had invasive treatment. In the 31 patients where follow-up was available, 64.5% (n = 20) were persistent but decreasing in size. There was no significant difference in follow-up size for those who had invasive compared to conservative treatment (P = 0.3). CONCLUSION: The diagnosis of MLL should be considered for soft-tissue swelling in the context of shearing trauma. A variety of management options have been employed, with good overall outcomes.

A Pilot First-in-Human Study of Embrace, a Polyethylene Glycol-Based Liquid Embolic Agent, in the Embolization of Malignant and Benign Hypervascular Tumors.

PURPOSE: To investigate the safety and efficacy of an aqueous polyethylene glycol-based liquid embolic agent, Embrace Hydrogel Embolic System (HES), in the treatment of benign and malignant hypervascular tumors. MATERIALS AND METHODS: A prospective, single-arm, multicenter study included 8 patients, 5 males and 3 females, with a median age of 58.5 years (30-85 years), who underwent embolization in 8 tumors between October 2019 and May 2020. Technical success was defined as successful delivery of HES to the index vessel, with disappearance of >90% of the targeted vascular enhancement or, for portal vein embolization, occlusion of the portal branches to the liver segments for future resection. The volume of HES administered, ease of use (5 point Likert scale), administration time, and adverse events (AEs) were recorded. Evaluation was performed at 7, 30, and 90 days via clinical assessment and blood testing, and follow-up imaging was performed at 30 days. RESULTS: Eight patients were enrolled, and 10 embolizations were performed in 8 lesions. Tumors included hepatocellular carcinoma (n = 4), renal angiomyolipoma (n = 3), and intrahepatic cholangiocarcinoma (n = 1). Technical success was 100%, and the average ease of use was 3.3 ± 1.0 SD. The HES delivery time was 1-28 minutes (median, 16.5 minutes), and the HES volume injected was 0.4-4.0 mL (median, 1.3 mL). All patients reached 30-day follow-up with imaging, and 6 patients reached 90-day follow-up. There were 3 serious AEs in 2 patients that were unrelated to the embolic agent. CONCLUSION: HES resulted in a 100% embolization technical success rate. The product ease of use was acceptable, and no target vessel recanalization was noted on follow-up imaging at 30 days.

Pathogenic variants in the human m6A reader YTHDC2 are associated with primary ovarian insufficiency.

Primary ovarian insufficiency (POI) affects 1% of women and carries significant medical and psychosocial sequelae. Approximately 10% of POI has a defined genetic cause, with most implicated genes relating to biological processes involved in early fetal ovary development and function. Recently, Ythdc2, an RNA helicase and N6-methyladenosine reader, has emerged as a regulator of meiosis in mice. Here, we describe homozygous pathogenic variants in YTHDC2 in 3 women with early-onset POI from 2 families: c. 2567C>G, p.P856R in the helicase-associated (HA2) domain and c.1129G>T, p.E377*. We demonstrated that YTHDC2 is expressed in the developing human fetal ovary and is upregulated in meiotic germ cells, together with related meiosis-associated factors. The p.P856R variant resulted in a less flexible protein that likely disrupted downstream conformational kinetics of the HA2 domain, whereas the p.E377* variant truncated the helicase core. Taken together, our results reveal that YTHDC2 is a key regulator of meiosis in humans and pathogenic variants within this gene are associated with POI.

Non-radiologist perception of the use of artificial intelligence (AI) in diagnostic medical imaging reports.

INTRODUCTION: Incorporating artificial intelligence (AI) in diagnostic medical imaging reports has the potential to improve efficiency. Although perception of radiologists, radiographers, medical students and patients on AI use in image reporting has been explored, there is limited literature on non-radiologist clinicians' opinion on this topic. METHOD: Single-centre online survey targeting non-radiologist medical staff conducted from May to August 2021 at a tertiary referral hospital in Melbourne, Australia. Survey questions revolved around clinicians' level of comfort acting on AI-generated reports with varying levels of radiologist involvement and scan complexity, opinion on medicolegal responsibility for erroneous AI-issued reports and perception of data privacy and security. RESULTS: Eighty-eight responses were collected, including 47.9% of consultants. Non-radiologist clinicians across all seniorities and specialties felt significantly less comfortable acting on AI-issued reports compared with radiologist-issued reports (mean comfort radiologist 6.44/7, mean comfort AI 3.35/7, P < 0.001) but felt equally comfortable with an AI-hybrid model of care (mean comfort hybrid 6.38/7, P = 0.676). Non-radiologist clinicians believed that medicolegal responsibility with errors in AI-issued reports mostly lay with hospitals or health service providers (65.9%) and radiologists (54.5%). Regarding data privacy and security, non-radiologist clinicians felt significantly less comfortable with AI issuing image reports instead of radiologists (P < 0.001). CONCLUSION: A hybrid AI-generated radiologist-confirmed method of image reporting may be the ideal way of integrating AI into clinical practice based on the perception of our referring non-radiologist medical colleagues. Formal guidelines on medicolegal responsibility and data privacy should be established prior to utilising AI in the clinical setting.

Occupational radiation exposure to the lens of the eye in interventional radiology.

INTRODUCTION: Cataract formation is a tissue reaction effected by radiation exposure. The purpose of this study was to evaluate the occupational exposure to the lens of the eye of interventional radiologists (IR's) and interventional radiology staff, with and without lead glasses. METHODS: Ethical approval was provided by the hospital research and ethics committee. A prospective cohort study was performed over 1 year, doses recorded, lifetime dose (estimated at working 5 days in angiography, for 30 years) was estimated and dose compared to current guidelines. Thermoluminescent dosimeters (TLDs; Landauer, Glenwood, USA) Hp(3) were placed on both the exterior and interior side of the personal lead glasses worn by three interventional radiologists and two radiographers. They were monitored during all procedures performed within 1 year. Lead glasses (AttenuTech® Microlite® , Florida, USA) with specifications were 0.75 mm lead equivalent front shield, and Side shield 0.3 mm Pb equivalent. A control TLD was placed in the storage location of the lead glasses when not in use. Yearly dose was measured and lifetime dose was calculated from the data obtained. Calculation of dose received per day(s) spent performing procedures for both annual and lifetime exposure was performed. In addition a record of occurrence of splashes on glasses was made after each case. RESULTS: Eye doses without protection were double the recommended limits for both annual and lifetime dose. For interventional radiologists working between 3 and 4 or more days in the lab per week, annual dose thresholds would be exceeded (20 mSv/year averaged over 5 years, no more than 50 mSv in 1 year). If interventional radiologists worked between 3 and 4 or more days in the lab, lifetime dose thresholds would be exceeded (500 mSv lifetime dose). Lead glasses reduced radiation exposure by an average of 79%. If lead glasses were worn no interventional radiologists would exceed annual or lifetime dose thresholds to the eyes even if working 5 days per week as the primary operator. Radiographers would not exceed annual or lifetime dose thresholds even without lead glasses. Splash incidents occurred for all interventional radiologists and one radiographer. CONCLUSION: The use of lead glasses even in this small study resulted in a decreased dose of radiation to the lens of the eye. Regular use of radiation protection eyewear will reduce eye dose for primary proceduralists to well below yearly and lifetime thresholds.

A 10-year retrospective review of management and outcomes of pseudoaneurysms at a tertiary referral centre.

INTRODUCTION: Pseudoaneurysms are uncommon but potentially life-threatening. Treatment may involve a variety of interventions including observation, manual compression, ultrasound-guided thrombin injection and a variety of endovascular and surgical techniques. Current treatments are largely based on observational data and there is no consensus on management. This study aimed to provide evidence for guiding clinical decisions regarding visceral artery pseudoaneurysm and peripheral artery pseudoaneurysm management. METHODS: Retrospective single-centre review of patients diagnosed with visceral and peripheral artery pseudoaneurysms at a tertiary hospital (2010-2020). RESULTS: There were 285 patients included in this study. A total of 86 patients were diagnosed with a visceral artery pseudoaneurysm, and 49 of these (57%) were caused by trauma. A total of 199 patients were identified with a peripheral pseudoaneurysm; 76 of these (38%) were caused by trauma and 69 (35%) were due to access site complication during an endovascular procedure. Initial technical success was achieved in 266 patients (93.3%) with 19 requiring an additional treatment to achieve success. Conservative treatment (100% success), endovascular treatment (98.1%) and surgery (100%) were more successful than ultrasound-guided compression (63.6%) and thrombin injection (83.8%). The median time from diagnosis to intervention was <9 h for visceral artery pseudoaneurysms and 24 h for peripheral artery pseudoaneurysms. There was no change in survival outcomes with respect to time from diagnosis and intervention. CONCLUSION: In this study, pseudoaneurysms were treated with a high degree of success by observation or by using an endovascular approach, and those requiring endovascular intervention did not need to be treated immediately in an emergent setting.

Premature ovarian insufficiency.

The natural lifespan of the ovary is occasionally interrupted by pathological processes; some are known, but many are unknown. Premature ovarian insufficiency (POI) can be a devastating diagnosis for an adolescent or for someone who has yet to start a family. Common causes of POI include genetic and chromosomal defects, autoimmune damage, and cancer treatments. Knowledge of the pathogenesis of this condition and an awareness of contemporary hormone replacement and fertility options are required to design a multidisciplinary therapeutic approach comprising reproductive medicine, endocrinology, clinical psychology, and assisted fertility expertise.

Risk stratification of emergency department patients with acute pulmonary thromboembolism: Is chest pain a reason to investigate?

BACKGROUND: This study aimed to risk-stratify chest pain as a presenting symptom in patients with a diagnosis of pulmonary thromboembolism (PE) to assess for any association. In addition, this study aimed to assess traditionally acknowledged PE risk factors in an Australian population. METHODS: This was a retrospective single-centre cohort study assessing patients who presented to our emergency department during the period of 1 January 2019 to 1 January 2020. 730 consecutive patients who went on to computed tomography pulmonary angiography (CTPA) examination after presentation were included. RESULTS: The rate of CTPA being positive in this study was 11.6% (85/730). Chest pain was associated with a non-significant reduction in the odds of PE (OR 0.774, P = 0.327). Univariate analysis showed significantly increased odds of a diagnosis of PE with presentation for leg pain/swelling (OR 6.670, P < 0.001). Multivariate analysis showed increasing age (OR 1.018, 95% CI 1.002-1.034, P = 0.024), clinical signs of a DVT (OR 3.194, 95% CI 1.803-5.657, P < 0.001) and positive D-dimer (OR 1.762, 95% CI 1.011-3.071, P = 0.046) were associated with increased odds of PE. CONCLUSION: In this study, Emergency Department presentation with chest pain, whilst the most common reason to perform a CTPA, resulted in reduced odds with regard to the diagnosis of pulmonary thromboembolism. The use of CTPA in this setting may be rationalised according to other factors such as localised leg pain as a symptom, signs of DVT, increasing age or positive D-dimer.

Proximal splenic embolisation versus distal splenic embolisation for management of focal distal arterial injuries of the spleen.

INTRODUCTION: To compare the outcomes of proximal (pSAE) versus distal (dSAE) splenic artery embolisation for management of focal distal arterial splenic injuries secondary to blunt splenic trauma. METHOD: Ethical approval was granted by the hospital research and ethics committee, Project 389/19. All patients who underwent splenic artery embolisation secondary to blunt abdominal trauma from 1 January 2009 to 1 January 2019 were reviewed. Patients with a tandem embolisation (both proximal and distal embolisations) or those with no acute vascular injury on angiography were excluded. Patient demographics, injury type/ AAST grade (2018 classification), technique of embolisation and outcomes were collected. Complications and splenectomy rates up to 30 days were recorded. RESULTS: 136 out of 232 patients had an embolisation performed for a distal vascular injury including active arterial bleeding, pseudoaneurysm or arteriovenous fistula. Mean age was 41 (range 16-84). Mean AAST grade was 4 (range 3-5). Mean Injury Severity Score was 22. pSAE was performed in 79.4% (n = 108) and dSAE in 20.6% (n = 28). Major complications occurred in 12 patients (pSAE n = 12, 11.1%; dSAE n = 0, P > 0.05); 6 pSAE required splenectomy (n = 6, 5.6%). There was no significant difference in outcomes between the two groups or when based on AAST grading. CONCLUSION: No significant difference was observed between proximal and distal embolisation techniques for blunt trauma patients with a distal vascular injury in terms of technical and clinical success.

Relationship and sexual experiences in women with early-onset oestrogen deficiency: Comparison between women with Turner syndrome and premature ovarian insufficiency.

OBJECTIVE: Age at first date and sexual intercourse have been observed to be delayed in women with Turner syndrome (TS), with delayed puberty being the main factor. We sought to assess relationship and sexual experiences comparing women with TS and premature ovarian insufficiency (POI). DESIGN: Cross-sectional observational study. PATIENTS: 302 women with TS and 53 women with karyotypically normal POI (median age 33.0 [15.0-78.4] and 26.3 [17.8-52.3], respectively). MEASUREMENTS: A self-reporting questionnaire was used to collect data on relationship and sexual experiences. RESULTS: Women with TS were older than women with POI (P = .002). Compared to women with POI, a smaller proportion of women with TS had ever had vaginal sexual intercourse (VSI) (40 [78.4%] vs 169 [58.1%], respectively, P = .006) and women with TS exhibited a delay in the median age at first relationship and VSI (POI 19.3 ± 0.4 vs TS 22.2 ± 1.1, P = <.001). Start of oestrogen replacement therapy at ≤ 14 years of age compared with > 14 years did not result in earlier relationship and sexual debut. After adjusting for age and diagnosis, induction of puberty, as opposed to spontaneous puberty, was associated with a delay in the median age at first relationship and VSI and a reduced probability of having VSI (Hazard ratio = 0.44 [95% confidence interval: 0.32-0.60], P = <.001). CONCLUSIONS: Turner syndrome and induction of puberty are associated with a reduced likelihood and a delay in relationship and sexual experiences. Women needing puberty induction and women with TS more than POI have a delayed mean age at first VSI compared to the general population.

Accuracy of dual-bolus CT in the diagnosis of active arterial bleeding in adult pelvic trauma.

INTRODUCTION: A single-phase dual-bolus CT (DB-CT) simultaneously opacifies both arterial and venous systems and can be utilised in the trauma setting to aid in the diagnosis of active bleeding while also allowing for optimal assessment of the abdominal and pelvic viscera. Active bleeding can be venous or arterial, the latter being amenable to angiography and potentially embolisation. We aimed to establish the accuracy of single-phase DB-CT vs commonly performed portal venous CT (PV-CT) in the diagnosis of active bleeding when compared to formal digital subtraction angiography as the gold standard. METHODS: All patients diagnosed with active bleeding on PV-CT or DB-CT at a level 1 tertiary centre over a 6-year period and who subsequently proceeded to digital subtraction angiography (DSA) were included for analysis. The initial CT images were retrospectively reviewed by two consultant interventional radiologists who were blinded to the subsequent outcome of the DSA and to each other's results. The sensitivity, specificity and inter-observer agreement between the two readers was then able to be assessed. RESULTS: A total of 60 patients were included in the analysis. Sensitivity for the diagnosis for any active bleeding was high for both DB-CT and PV-CT (range 88.9%-100%) while diagnosis of specifically arterial bleeding was comparatively lower (51.9%-79%). Inter-observer agreement for the identification of arterial bleeding was better for DB-CT (fair) compared to PV-CT (poor). CONCLUSION: Both PV-CT and DB-CT demonstrate high sensitivity in the diagnosis of any active bleeding though identification of specifically arterial bleeding is lower for both scanning methods. Nevertheless, inter-observer reliability for the identification of arterial bleeding is higher for DB-CT. Multi-phase arterial and venous CT may yield better results and could be a focus for future studies.

Omental apoplexy: Unravelling the mystery.

INTRODUCTION: To describe cases omental haemorrhage and to review the literature on this topic. METHODS: We describe three cases of spontaneous omental haemorrhage and discuss various management strategies, in an attempt to provide direction for similar cases in the future. RESULTS: A number of case reports of spontaneous or idiopathic omental haemorrhage exist in the literature. These cases are often attributed to an underlying vasculopathy, such as segmental arterial mediolysis (SAM). Appropriate resuscitation is paramount for best outcome. Severe bleeding may require surgery or transcatheter arterial embolisation, which is best performed early if required. Endovascular management using selective catheterisation of the bleeding vessel and embolisation is a minimally invasive alternative to emergent operative intervention. In the three cases we present, endovascular embolisation was performed in two patients, and surgical ligation in a third. Segmental arterial mediolysis is considered the likely aetiology in at least 2 of the 3 cases, based on imaging findings. No further episodes of haemorrhage occurred at follow-up (ranging from 6 months to 2 years). CONCLUSIONS: Acute omental haemorrhage is a rare condition; however, it may be associated with significant morbidity and mortality. CT angiography is the imaging of choice. Management strategies include both endovascular and surgical intervention.

No Difference in the Phenotypic Expression of Frailty among Elderly Patients Recently Diagnosed with Cancer Vs Cancer Free Patients.

OBJECTIVES: To examine frailty determinants differences in patients with a recent diagnosis of cancer compared to non-cancer patients among older adult. Revealing those differences will allow us to individualize the exact frailty management in those patients diagnosed with cancer. DESIGN: This is an observational cross-sectional, monocentric study. SETTING: Patients were evaluated at the Geriatric Frailty Clinic (GFC), in the Toulouse University Hospital, France, between October 2011 and February 2016. PARTICIPANTS: 1996 patients aged 65 and older were included (1578 patients without cancer and 418 patients with solid and hematological cancer recently diagnosed). MEASUREMENTS: Frailty was established according to the frailty phenotype. The frailty phenotype measures five components of frailty: weight loss, exhaustion, low physical activity, weakness and slow gait. Frailty phenotype was categorized as robust, pre-frail and frail. RESULTS: In a multinomial logistic regression, cancer, compared to the non-cancer group, is not associated with an increased likelihood of being classified as pre frail (RRR 0.9, 95% CI [0.5 ; 1.6 ], p 0.9) or frail (RRR 1.2, 95% CI [0.7 ; 2.0], p 0.4) rather than robust. When considering each Fried criterion, a significant higher odd of weight loss was observed in older patients with cancer compared to the non-cancer patients (OR 2.3, 95% CI [1.8; 3.0], p <0.001) but no statistically significant differences was found among the four other Fried criteria. Sensitivity analysis on the frailty index showed that cancer was not associated with a higher FI score compared to non-cancer (ß 0.002, 95%CI [-0.009; 0.01], p 0.6). CONCLUSION: In this real-life study evaluating elderly patients with and without cancer, we didn't confirm our hypothesis, in fact we found that cancer was not associated with frailty severity using both a phenotypic model and a deficit accumulation approach. Cancer may contribute, at least additively, to the development of frailty, like any other comorbidity, rather than a global underlying condition of vulnerability.

Treatment of symptomatic fibroid disease using uterine fibroid embolisation: An Australian perspective.

Uterine leiomyomata (fibroids) are symptomatic in up to 35% of women and treatment can be a costly burden to the individual and society. Options for treatment range from non-hormonal, hormonal, minimally invasive, to surgery. While symptoms from smaller fibroids may respond to simple treatment, those with larger fibroids or with a large volume of disease require a more definitive option. Surgery (hysterectomy or myomectomy) are both well-established treatment modalities with good clinical outcomes. Since the 1990s, uterine fibroid embolisation has emerged as a less invasive option for women than for surgical techniques, while level 1 evidence shows that in the short to mid-term, there is a similar improvement in symptom-related quality of life outcomes to surgery, but with reduced hospital stay and reduced cost. However, in the longer term there may be a need for further treatment or retreatment in some patients compared with surgery. Since its introduction, uptake of this procedure in Australia has been low relative to surgical options. This manuscript reviews the current literature surrounding treatment, along with the trends in uptake of embolisation by Australian women, places this in context of current guidelines from major societies, and encourages gynaecologists and interventional radiologists to be aware of the advantages and limitations of embolisation.