Lymphatic Management in Single-Ventricle Patients.

Lymphatic complications in patients with single ventricle include plastic bronchitis, protein-losing enteropathy, and chylous pleural effusion are a source of significant morbidity and mortality with historically limited therapeutic options. Novel lymphatic imaging techniques such as intranodal lymphangiography, dynamic contrast enhanced magnetic resonance lymphangiography and liver lymphangiography have allowed visualization of the lymphatic system and discovery of the pathophysiological mechanism of these conditions. This mechanism includes the combination of 2 factors: increased lymphatic flow in patients with elevated central venous pressure and presence of the lymphatic anatomical variant that allows the lymph to flow in close proximity to the serous (pleural space in chylothorax) or mucosal (plastic bronchitis and protein losing enteropathy) surfaces. Novel minimally invasive lymphatic interventional techniques, such as thoracic duct embolization, interstitial embolization and liver lymphatic embolization have allowed the obliteration of these abnormal lymphatic networks, resulting in resolution of the symptoms. Further refinement of the imaging techniques and interventional methods have subsequently allowed better patient selection and improved long term outcome of these procedures.

Abnormal Pulmonary Lymphatic Flow in Patients With Lymphatic Anomalies and Respiratory Compromise.

BACKGROUND: Pulmonary involvement in lymphatic anomalies (LA) is associated with significant morbidity and mortality. Dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) is capable of imaging the lymphatic system in a variety of pulmonary lymphatic disorders. RESEARCH QUESTION: The objective of this study is to describe the central lymphatic anatomy in patients with LA and pulmonary involvement on DCMRL. STUDY DESIGN AND METHODS: This prospective observational study enrolled 16 patients with LA (mean age, 17 years; range, 6-63 years; ratio of female to male patients, 9:7) with pulmonary involvement. All patients underwent DCMRL. The lymphatic system was assessed for the presence of mediastinal masses, interstitial lung disease, size and tortuosity of the thoracic duct (TD), and presence of abnormal pulmonary lymphatic flow. RESULTS: T2-weighted imaging showed the following: mediastinal soft tissue masses in 10 patients, diffuse pulmonary interstitial thickening in 13 patients, and bone involvement in 15 patients. DCMRL revealed abnormal pulmonary lymphatic flow in 14 of 16 patients. Abnormal pulmonary lymphatic flow originated from the TD in three of 14 patients, the retroperitoneum in six of 14 patients, and both the TD and retroperitoneum in four of 14 patients. In nine of 16 patients, the TD was dilated and tortuous. In two patients the TD was not identified, and in five patients it was normal. INTERPRETATION: Abnormal pulmonary lymphatic flow/perfusion from the TD or retroperitoneum into the lung parenchyma occurred in the majority of patients in this study. These findings can explain the interstitial lung disease and chylothorax resulting in deterioration of respiratory function in these patients. Future studies will determine whether mechanical cessation of this abnormal flow can improve pulmonary function and prolong survival in patients with LA. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov; No.: NCT02744027; URL: www.clinicaltrials.gov.

Postgraduate radiology training in sub-Saharan Africa: a review of current educational resources.

RATIONALE AND OBJECTIVE: Postgraduate training programs in radiology exist in several African nations. The ability of these programs to train radiologists is necessarily affected by local availability of educational resources, including clinical case volume, radiology equipment and maintenance, number of teaching faculty, and library and computer facilities. We sought to determine the current resources of a sample of African radiology education programs. MATERIALS AND METHODS: Site visits were conducted at three separate radiology training programs, one in Ghana and two in South Africa. At each site, the investigator conducted a technology census, assessed library resources, observed daily trainee activities, and interviewed trainees, faculty, and statisticians. RESULTS: African radiology trainees receive considerable training in fluoroscopy, ultrasound, and plain film radiography, but receive considerably less training in nuclear medicine, mammography, magnetic resonance imaging, and interventional radiology. A large amount of equipment in African teaching hospitals is inoperative because of lack of maintenance programs. Faculty to resident ratios in African teaching hospitals are much lower than in American hospitals. Needs of training programs vary greatly from hospital to hospital, and from country to country. CONCLUSION: Radiologists, radiology organizations, and radiology vendors from high-income nations are in a unique position to help Africa's postgraduate radiology training programs fulfill their mission of training Africa's next generation of radiologists. It is desirable that long-term commitments be made to teaching hospitals so that scarce donated resources may be put to the best possible use.