Insurance Status Correlates with Access to Procedural Therapy for Patients with Early-Stage Hepatocellular Carcinoma: A Retrospective Cohort Study of the National Cancer Database.

PURPOSE: To compare access to specific procedural therapies across insurance types for patients with American Joint Commission on Cancer (AJCC) Stage I or II hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Using the National Cancer Database, patients diagnosed with Stage I or II HCC between 2004 and 2019 were identified. Parametric and nonparametric testing was used to compare the rates of procedural modalities and time to therapy across insurance types. Univariate and multivariate logistic regression analyses were used to identify the likelihood of receiving specific procedural therapy based on insurance status. RESULTS: In total, 105,703 patients with AJCC Stage I or II HCC were identified. The rates of ablative therapy were similar across insurance types (18.1% total, 17.2% private insurance, 15.3% uninsured, 18.1% Medicaid, and 18.8% Medicare). In the logistic regression analysis, patients with private insurance were more likely to receive a transplant or undergo resection or procedural therapy of any kind. Patients with Medicare insurance were more likely to undergo ablation (odds ratio, 1.11; 95% confidence interval, 1.07-1.15; P < .001) than those with private insurance. CONCLUSIONS: Patients with private insurance were more likely to receive most forms of procedural therapy for early-stage HCC, with the notable exception of ablative therapy, which patients with Medicare were slightly more likely to receive.

Percutaneous transhepatic cholangioscopy-guided lithotripsy and retrieval of vascular coils eroded into the biliary tree.

Endovascular coil erosion into the biliary system after hepatic artery embolization is a rare complication which may result in inflammation, strictures, choledocholithiasis, biliary colic, and cholangitis. Removal of coils may result in cessation of these symptoms, but is challenging in patients who cannot undergo removal via standard endoscopic approaches. This case report describes the retrieval of coils placed across a hepatic artery pseudoaneurysm, which over several years eroded into the biliary tree, resulting in calculi formation and post-prandial pain. Using combined fluoroscopy and cholangioscopy via percutaneous transhepatic accesses, the calculi were fragmented and the coils were retrieved, resulting in cessation of symptoms.

High-fidelity simulation training improves resident knowledge of contrast reaction management, especially for junior residents.

Rationale and objectives: Contrast reactions are rare but serious events, frequently managed independently by Radiology Residents, who are likely underprepared to lead the acute event response. At our tertiary care center, Radiology Residents are the first responders to contrast reaction scenarios, and previously had didactic only training. We sought to create a High-Fidelity Simulation Training, and to assess whether this improved resident knowledge in managing contrast reactions. Materials and methods: In September of 2020, we administered a didactic only contrast reaction training to 20 residents, with an anonymous 20 question multiple choice pre- and post-test. In January of 2022, we administered a 4-hour, 4-station contrast reaction High-Fidelity Simulation Training to 22 residents, with the same 20 question multiple choice pre- and post-test. Results: The average number of residents answering each question correctly did not significantly improve following the didactic only training (p = 0.116). Following high-fidelity simulation training, however, there was a significant improvement by a mean of 2.45 (p = 0.028), as well as a mean improvement in individual scores of 10.45% (p = 0.0001). Comparing junior and senior residents, there was a significant difference in pre-test scores, with senior residents scoring on average 9.67% better (p = 0.0364); however on post-test scores, there was no significant difference. Conclusion: High-fidelity simulation training improves resident knowledge of contrast reaction management, and allows inexperienced junior residents to attain senior resident level proficiency in these high-stress scenarios.

The evolution of performing a kidney biopsy: a single center experience comparing native and transplant kidney biopsies performed by interventional radiologists and nephrologists.

BACKGROUND: Kidney biopsy is the most vital tool guiding a nephrologist in diagnosis and treatment of kidney disease. Over the last few years, we have seen an increasing number of kidney biopsies being performed by interventional radiologists. The goal of our study was to compare the adequacy and complication rates between kidney biopsies performed by interventional radiology versus nephrology.  METHODS : We performed a single center retrospective analysis of a total of all kidney biopsies performed at our Institution between 2015 and 2021. All biopsies were performed using real-time ultrasound. Patients were monitored for four hours post biopsy and repeat ultrasound or hemoglobin checks were done if clinically indicated. The entire cohort was divided into two groups (Interventional radiology (IR) vs nephrology) based on who performed the biopsy. Baseline characteristics, comorbidities, blood counts, blood pressure, adequacy of the biopsy specimen and complication rates were recorded. Multivariable logistic regression was used to compare complication rates (microscopic hematuria, gross hematuria and need for blood transfusion combined) between these two groups, controlling for covariates of interest. ANCOVA (analysis of variance, controlling for covariates) was used to compare differences in biopsy adequacy (number of glomeruli per biopsy procedure) between the groups. RESULTS: 446 kidney biopsies were performed in the study period (229 native and 147 transplant kidney biopsies) of which 324 were performed by IR and 122 by nephrologist. There was a significantly greater number of core samples obtained by IR (mean = 3.59, std.dev. = 1.49) compared to nephrology (mean = 2.47, std.dev = 0.79), p < 0.0001. IR used 18-gauge biopsy needles while nephrologist exclusively used 16-gauge needles. IR used moderate sedation (95.99%) or general anesthesia (1.85%) for the procedures more often than nephrology, which used them only in 0.82% and 0.82% of cases respectively (p < 0.0001). Trainees (residents or fellows) participated in the biopsy procedures more often in nephrology compared to IR (97.4% versus 69.04%, p < 0.0001). The most frequent complication identified was microscopic hematuria which occurred in 6.8% of biopsies. For native biopsies only, there was no significant difference in likelihood of complication between groups, after adjustment for covariates of interest (OR = 1.01, C.I. = (0.42, 2.41), p = 0.99). For native biopsies only, there was no significant difference in mean number of glomeruli obtained per biopsy procedure between groups, after adjustment for covariates of interest (F(1,251) = 0.40, p = 0.53). CONCLUSION: Our results suggest that there is no significant difference in the adequacy or complication rates between kidney biopsies performed by IR or nephrology. This conclusion may indicate that kidney biopsies can be performed safely with adequate results either by IR or nephrologists depending on each institution's resources and expertise.

Transcatheter coil embolization of a complex pulmonary artery pseudoaneurysm with thyrocervical trunk-pulmonary arterial fistulization in a patient with cystic fibrosis and massive hemoptysis.

Pulmonary artery pseudoaneurysm (PAP) is a rare cause of life-threatening hemoptysis and tends to develop in the setting of infection, neoplasm, or trauma. Successful endovascular coil embolization has demonstrated effectiveness in treating PAPs and is now the treatment of choice for these patients. Vascular supply to PAPs is highly variable and often requires embolization of both the systemic and pulmonary feeding vessels. This is a case report of a successful transcatheter coil embolization of a complex PAP with a thyrocervical trunk-pulmonary arterial fistula in a patient with massive hemoptysis in the setting of advanced cystic fibrosis.

Formation of a traumatic air cyst and ensuing hemopneumothorax during CT angiography in a patient with Ehlers-Danlos syndrome.

Ehlers-Danlos syndrome (EDS) refers to a rare group of genetic disorders that makeup part of the connective tissue disorders consortium. It is characterized by clinical features such as skin hyperextensibility, joint hypermobility, and tissue fragility. A vascular subtype (EDS IV) exists, that predisposes affected patients to vascular injury and is well-known and documented. However, other manifestations of EDS IV are less commonly understood and reported. Though spontaneous pneumothorax has been described in several cases, formation of traumatic air cysts/pneumatoceles with little to no inciting factors has not. This can eventually lead to pulmonary hemorrhage or hemopneumothorax. We present a case of spontaneous formation of a traumatic air cyst with ensuing large-volume hemopneumothorax occurring in a time period of under 3 minutes, between pre- and post-contrast-media administration during CT angiography of the chest.

Cholecystostomy as an Exclusive Access to Remove Cystic, Common Hepatic, and Common Bile Duct Stones.

OBJECTIVE. The purpose of this article was to evaluate the feasibility and efficacy of percutaneous fluoroscopic-guided stone retrieval from the cystic duct and antegrade common bile duct (CBD) stone advancement into the duodenum exclusively through a cholecystostomy tube. MATERIALS AND METHODS. Twenty-one patients with acute cholecystitis and choledocholithiasis or an impacted cystic duct stone who underwent percutaneous cholecystostomy tube placement were retrospectively enrolled in this study. The patients had a contra-indication for cholecystectomy (17 patients because of comorbidities and one who declined surgery) or had failed endoscopic retrograde stone removal attempts (three patients). RESULTS. The 21 patients underwent subsequent percutaneous CBD (17 patients) and cystic duct (nine patients) stone removal on follow-up sessions through the percutaneous cholecystostomy track using moderate sedation. A total of 32 stone removal procedures were performed. Seventeen patients underwent balloon dilatation sphincterotomy, after which the CBD stones were pushed forward into the duodenum using a compliant balloon. Seven patients also had stone removal from the cystic duct by a stone retrieval basket. The primary technical success rate for removal of all CBD and cystic duct stones was 76%. The secondary technical success rate was 100%. The clinical success rate was 74%. All patients tolerated the procedures well without major complication. The clinical follow-up interval ranged from 2 to 2310 days (median, 30 days), with no incidence of postprocedural complications. CONCLUSION. Percutaneous transcholecystic common bile and cystic duct stone removal through an existing cholecystostomy access is a safe and effective procedure that is well tolerated.

Creation of a neoinfundibulum and serial balloon dilations for the treatment of the excluded calyx: Two cases describing a novel technique.

An excluded calyx is a rare, acquired urologic condition where there is discontinuity between a portion of the renal collecting system with the remainder of the collecting system. Re-establishment of reliable long-term communication between the excluded calyx and the remaining collecting system is crucial for preservation of renal function and possible relief of symptoms. In this manuscript, we discuss two such cases where a previously undescribed novel procedure is used for treatment of this uncommon condition, where percutaneous antegrade transcatheter techniques were used to establish long-term urinary drainage. The first case discusses an excluded calyx in a 17-year-old male who suffered left renal injury after a high speed motor vehicle accident, where the kidney was divided by the injury and subsequently required creation of a neoinfundibulum in order to maintain continuity of the collecting system. The second case involves a 39-year-old female who underwent resection of a renal cell carcinoma, later developing an excluded calyx where radiofrequency wire recanalization was performed and the neoinfundibular track underwent serial retrograde balloon dilation, resulting in a continuous collecting system. Both patients have done well for more than 2 years after neoinfundibulum creation, showing that this novel technique should be considered a viable and safe procedure in the treatment of this rare condition.

A randomized controlled trial of intravenous aminophylline for atropine-resistant out-of-hospital asystolic cardiac arrest.

OBJECTIVES: Myocardial ischemia, during cardiopulmonary arrest, can lead to atropine-resistant bradyasystole from interstitial accumulation of endogenous adenosine. Aminophylline is a nonspecific adenosine receptor antagonist capable of reversing ischemia-induced bradyasystole in a variety of settings. The hypothesis of this study was that aminophylline improves the rate of return of spontaneous circulation (ROSC) in atropine-resistant asystolic out-of-hospital cardiac arrest when used early in the resuscitation effort. METHODS: This was a prospective, randomized, double-blinded, placebo-controlled trial set in an urban emergency medical services system serving a population of 250,000. All non-pregnant, normothermic adults suffering nontraumatic out-of-hospital cardiac arrest (February 1999 to August 2000) with asystole were eligible. Patients remaining in asystole after initial doses of epinephrine and atropine received either aminophylline 250 mg or matching placebo as a bolus injection through a peripheral intravenous line. All other aspects of the attempted resuscitation proceeded in accordance with standard Advanced Cardiac Life Support (ACLS) guidelines. A sample size of 102 patients was calculated to yield a power of 80% to show an absolute improvement of 25% in ROSC. The aminophylline and control groups were compared by calculating 95% confidence intervals (95% CIs) and the data were modeled using logistic regression. RESULTS: The investigators enrolled 112 consecutive patients. One subject was dropped prior to analysis because of missing data. Data for 111 patients were analyzed on an intention-to-treat basis. Baseline characteristics were similar for the two groups. Comparing the control and aminophylline groups, ROSC was achieved in 15.6% (95% CI = 6% to 29%) and 22.7% (95% CI = 13% to 35%), while reversal of asystole occurred in 26.7% (95% CI = 15% to 42%) and 40.9% (95% CI = 29% to 54%), respectively. Group allocation had an odds ratio of 1.8 (95% CI = 0.6 to 5.3) for ROSC. Witnessed arrest was an independent predictor of outcome with an odds ratio of 3.8 (95% CI = 1.3 to 11.2). CONCLUSIONS: Addition of aminophylline appears to be a promising new intervention in the ACLS treatment of atropine-resistant asystolic out-of-hospital cardiac arrest.