A Clinically Optimal Protocol for the Imaging of Enteric Tubes: On the Basis of Radiologist Interpreted Diagnostic Utility and Radiation Dose Reduction.

RATIONALE AND OBJECTIVES: The purpose of this study was to develop and evaluate a patient thickness-based protocol specifically for the confirmation of enteric tube placements in bedside abdominal radiographs. Protocol techniques were set to maintain image quality while minimizing patient dose. MATERIALS AND METHODS: A total of 226 pre-intervention radiographs were obtained to serve as a baseline cohort for comparison. After the implementation of a thickness-based protocol, a total of 229 radiographs were obtained as part of an intervention cohort. Radiographs were randomized and graded for diagnostic quality by seven expert radiologists based on a standardized conspicuity scale (grades: 0 non-diagnostic to 3+). Basic patient demographics, body mass index, ventilatory status, and enteric tube type were recorded and subgroup analyses were performed. Effective dose was estimated for both cohorts. RESULTS: The dedicated thickness-based protocol resulted in a significant reduction in effective dose of 80% (p-value < 0.01). There was no significant difference in diagnostic quality between the two cohorts with 209 (92.5%) diagnostic radiographs in the baseline and 221 (96.5%) diagnostic radiographs in the thickness-based protocol (p-value 0.06). CONCLUSION: A protocol optimized for the confirmation of enteric tube placements was developed. This protocol results in lower patient effective dose, without sacrificing diagnostic accuracy. The technique chart is provided for reference. The protocol development process outlined in this work could be readily generalized to other imaging clinical tasks.

Assessment of complication rates based on time of feeding initiation in radiologically guided gastrostomy tubes: a retrospective study.

PURPOSE: We aimed to assess the association between complication rate and time to feeding in a cohort of patients undergoing radiologically guided placement of gastrostomy tubes. METHODS: A retrospective study was conducted of all patients receiving pull-type and push-type gastrostomy tubes placed by interventional radiologists between January 1st, 2017 and December 31st, 2018 at a single institution. Primary outcomes included procedural and tube-related complications per medical chart review with a follow-up interval of 30 days. Exclusion criteria were enteral nutrition delayed more than 48 hours, no feeding information, and tubes placed for venting (n=20). Overall, 303 gastrostomy tubes (pull-type, n=184; push-type, n=119) were included. The most common indications for placement included head and neck carcinoma for push-type tubes (n=76, 63.9%) and cerebral vascular accident for pull-type tubes (n=78, 42.4%). RESULTS: In a multiple regression analysis, there was no statistically significant association between complications and time to feeding (p = 0.096), age (p = 0.758), gender (p = 0.127), indication for tube placement (p = 0.206), or type of tube placed (p = 0.437). Average time to initiation of enteral nutrition was 12.3 hours for the pull-type and 21.7 hours for the push-type cohort (p < 0.001). Additional multiple regression analyses of pull-type tubes and push-type tubes separately also did not find any significant association between complications and the above factors (p > 0.05). CONCLUSION: There was no statistically significant correlation between time to feed and complications, suggesting that there is no clinical difference between early and late feeding following gastrostomy tube placement.

Increasing Volume of Bone Marrow Biopsies by Radiology Providers: Evaluation of Trends by Physician Specialty and Practice Setting.

PURPOSE: The aim of this study was to evaluate trends in bone marrow biopsies performed in the United States by physician specialty and practice setting. METHODS: The CMS Medicare Physician Supplier Procedure Summary database was queried from 2005 to 2016 for bone marrow biopsies and aspirations (BMBs). Data were categorized according to the largest subspecialty groups (medicine, surgery, radiology, pathology, and other) and encounter setting (office, inpatient hospital, and outpatient hospital). Trends in procedure volume by specialty and practice setting were evaluated. RESULTS: Between 2005 and 2016, an annual average of 11,417 BMBs were performed (range, 10,380-14,204), with no significant year-over-year change in volume. Medicine was the largest provider of BMBs by specialty, although their market share over this time period declined from 60.2% to 36.6%. Radiology saw the greatest growth in BMB market share from 4.1% to 16.2%. The compound annual growth rate (CAGR) of BMBs performed by medicine subspecialists demonstrated a decrease in year-over-year procedural volume at -5.16% (P < .001). Both surgery and radiology demonstrated positive trends in the number of BMBs performed, with CAGRs of 6.20% (P < .001) and 12.43% (P < .001), respectively. Independent of physician specialty, there was a decrease in the number of biopsies performed in the office setting, decreasing by a CAGR of -5.59% (P < .001). CONCLUSIONS: From 2005 to 2016, medicine has remained the primary provider of BMBs, although their market share has declined. Radiology has experienced the greatest rate of growth in this time period and now represents the third largest individual specialty providing this service.

Prognosticating Outcomes in Interstitial Lung Disease by Mediastinal Lymph Node Assessment. An Observational Cohort Study with Independent Validation.

RATIONALE: Mediastinal lymph node (MLN) enlargement on chest computed tomography (CT) is prevalent in patients with interstitial lung disease (ILD) and may reflect immunologic activation and subsequent cytokine-mediated immune cell trafficking. OBJECTIVES: We aimed to determine whether MLN enlargement on chest CT predicts clinical outcomes and circulating cytokine levels in ILD. METHODS: MLN measurements were obtained from chest CT scans of patients with ILD at baseline evaluation over a 10-year period. Patients with sarcoidosis and drug toxicity-related ILD were excluded. MLN diameter and location were assessed. Plasma cytokine levels were analyzed in a subset of patients. The primary outcome was transplant-free survival (TFS). Secondary outcomes included all-cause and respiratory hospitalizations, lung function, and plasma cytokine concentrations. Cox regression was used to assess mortality risk. Outcomes were assessed in three independent ILD cohorts. MEASUREMENTS AND MAIN RESULTS: Chest CT scans were assessed in 1,094 patients (mean age, 64 yr; 52% male). MLN enlargement (≥10 mm) was present in 66% (n = 726) and strongly predicted TFS (hazard ratio [HR], 1.53; 95% confidence interval [CI], 1.12-2.10; P = 0.008) and risk of all-cause and respiratory hospitalizations (internal rate of return [IRR], 1.52; 95% CI, 1.17-1.98; P = 0.002; and IRR, 1.71; 95% CI, 1.15-2.53; P = 0.008, respectively) when compared with subjects with MLN <10 mm. Patients with MLN enlargement had lower lung function and decreased plasma concentrations of soluble CD40L (376 pg/ml vs. 505 pg/ml, P = 0.001) compared with those without MLN enlargement. Plasma IL-10 concentration >45 pg/ml predicted mortality (HR, 4.21; 95% CI, 1.21-14.68; P = 0.024). Independent analysis of external datasets confirmed these findings. CONCLUSIONS: MLN enlargement predicts TFS and hospitalization risk in ILD and is associated with decreased levels of a key circulating cytokine, soluble CD40L. Incorporating MLN and cytokine findings into current prediction models might improve ILD prognostication.

Hering's Law in Congenital Ptosis: Evaluation of the Contralateral Response to Unilateral Congenital Ptosis Repair.

PURPOSE: To determine the applicability and clinical relevance of Hering's law for the eyelids in cases of congenital ptosis. METHODS: A retrospective chart review and digital photograph analysis of patients who underwent unilateral congenital ptosis repair at a tertiary, university-based, Oculoplastics clinic was conducted. Pre- and postoperative eyelid height (marginal reflex distance), upper eyelid symmetry, and brow position were determined using ImageJ analysis software. Changes in these values, and the relationship between the change in ipsi- and contralateral eyelid heights and brow positions, were determined. RESULTS: In 51 patients, the mean change in contralateral upper eyelid position (marginal reflex distance) following unilateral repair was -0.5 mm with 29% (n = 15) demonstrating a greater than 1 mm contralateral descent. The contralateral brow position remained stable with a mean change of +0.1 mm. No significant differences were seen between the 15 patients who demonstrated a contralateral upper eyelid descent greater than 1 mm and the remainder of the cohort in terms of amblyopia rate (p = 0.71), mean preoperative marginal reflex distance (p = 0.14), mean change in ipsilateral marginal reflex distance (p = 0.32), mean change in contralateral brow position (p = 0.44), or mean postoperative upper eyelid asymmetry (1.3 mm vs. 1.2 mm). Overall, the mean upper eyelid asymmetry improved from 2.6 mm preoperatively to 1.2 mm postoperatively. None of the 51 patients underwent subsequent contralateral ptosis repair. CONCLUSIONS: Hering's law for the eyelids applies to cases of congenital ptosis but has little clinical significance due to improved upper eyelid asymmetry following unilateral surgery.