Using an Assumed Lung Mass Inaccurately Estimates the Lung Absorbed Dose in Patients Undergoing Hepatic 90Yttrium Radioembolization Therapy.

RATIONALE: Currently, the estimated absorbed radiation dose to the lung in 90Y radioembolization therapy is calculated using an assumed 1 kg lung mass for all patients. The aim of this study was to evaluate whether using a patient-specific lung mass measurement for each patient rather than a generic, assumed 1 kg lung mass would change the estimated lung absorbed dose. METHODS: A retrospective analysis was performed on 68 patients who had undergone 90Y radioembolization therapy at our institution. Individualized lung volumes were measured manually on CT scans for each patient, and these volumes were used to calculate personalized lung masses. The personalized lung masses were used to recalculate the estimated lung absorbed dose from the 90Y therapy, and this dose was compared to the estimated lung absorbed dose calculated using an assumed 1 kg lung mass. RESULTS: Patient-specific lung masses were significantly different from the generic 1 kg when compared individually for each patient (p < 0.0001). Median individualized lung mass was 0.71 (IQR: 0.59, 1.02) kg overall and was significantly different from the generic 1 kg lung mass for female patients [0.59 (0.50, 0.68) kg, (p < 0.0001)] but not for male patients [0.99 (0.71, 1.14) kg, (p = 0.24)]. Median estimated lung absorbed dose was 4.48 (2.38, 11.71) Gy using a patient-specific lung mass and 3.45 (1.81, 6.68) Gy when assuming a 1 kg lung mass for all patients. The estimated lung absorbed dose was significantly different using a patient-specific versus generic 1 kg lung mass when comparing the doses individually for each patient (p < 0.0001). The difference in the estimated lung absorbed dose between the patient-specific and generic 1 kg lung mass method was significant for female patients as a subgroup but not for male patients. CONCLUSIONS: The current method of assuming a 1 kg lung mass for all patients inaccurately estimates the lung absorbed dose in 90Y radioembolization therapy. Using patient-specific lung masses resulted in estimated lung absorbed doses that were significantly different from those calculated using an assumed 1 kg lung mass for all patients. A personalized dosimetry method that includes individualized lung masses is necessary and can warrant a 90Y dose reduction in some patients with lung masses smaller than 1 kg. LEVEL OF EVIDENCE: Level 3, Retrospective Study.

Omission of Planning CT Reduces Patient Radiation Exposure during CT-Guided Bone Marrow Biopsy and Aspiration.

The purpose of this study is to evaluate the impact of eliminating a preprocedural planning computed tomography during CT-guided bone marrow biopsy on the technical aspects of the procedure, including patient dose, sample quality, procedure time, and CT fluoroscopy usage. Retrospective analysis of 109 patients between 1 June 2018 and 1 January 2021 was performed. Patients were grouped based on whether they received a planning CT scan. Relative radiation exposure was measured using dose-length product (DLP). Secondary metrics included number of CT fluoroscopic acquisitions until target localization, total number of CT fluoroscopic acquisitions, biopsy diagnostic yield, and procedure time. A total of 43 bone marrow biopsies with planning CT scans (Group 1) and 66 bone marrow biopsies without planning CT scans (Group 2) were performed. The average total DLP for Group 1 and Group 2 was 268.73 mGy*cm and 50.92 mGy*cm, respectively. The mean radiation dose reduction between the groups was 81% (p < 0.0001). Significantly more CT fluoroscopy acquisitions were needed for needle localization in Group 2 than Group 1 (p < 0.0001). Total number of CT fluoroscopy acquisitions was four for Group 1 and eight for Group 2 (p = 0.0002). There was no significant difference between the groups in procedure time or diagnostic yield. Patients without a planning CT scan received more fluoroscopic CT acquisitions but overall were exposed to significantly less radiation without an increase in procedure time.

Interventional radiology procedural volume changes during COVID-19 initial phase: A tertiary level Midwest health system experience.

BACKGROUND: To evaluate Interventional Radiology (IR) procedural volume changes at a large Midwest health system between March 17, 2020 and April 30, 2020 following a state-mandated shutdown of nonessential procedures during the initial phase of COVID-19. METHODS: IR procedural volumes were compiled, stratified by location and compared with Diagnostic Radiology (DR) volumes during the same timeframe. Procedure volume was categorized by type, including oncology, dialysis interventions, and drainage procedures with comparisons made using Z-score test for proportions. IR and system-wide surgical procedural volume was compared with baseline values. RESULTS: System-wide IR procedural volume decreased by 35%, with a 41% decrease in outpatient and a 25% decrease in inpatient volume during the state-mandated order. DR volume decreased by 45%, with a 57% decrease in outpatient and a 22% decrease in inpatient volume. Total IR procedural volume during the mandate was 1077 versus 1518 during the preceding six weeks. The proportion of Interventional Oncology and dialysis interventions showed no significant change (p > 0.05) while that of drainage procedures increased (p < 0.05). Compared to baseline values, system-wide procedural volumes for IR, Vascular Surgery, Urology, General Surgery, Gastroenterology and Gynecology decreased by 3%, 11%, 25%, 20%, 38% and 31% in March 2020 and 25%, 47%, 68%, 63%, 79% and 73% in April 2020 respectively. CONCLUSION: Outpatient IR volumes were less impacted compared to DR during the initial phase of COVID-19. Oncology, dialysis and drainage interventions may be considered essential procedures due to their stability. IR volumes were less affected compared to other procedural specialties.

Author Correction: Variable water input controls evolution of the Lesser Antilles volcanic arc.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Variable water input controls evolution of the Lesser Antilles volcanic arc.

Oceanic lithosphere carries volatiles, notably water, into the mantle through subduction at convergent plate boundaries. This subducted water exercises control on the production of magma, earthquakes, formation of continental crust and mineral resources. Identifying different potential fluid sources (sediments, crust and mantle lithosphere) and tracing fluids from their release to the surface has proved challenging1. Atlantic subduction zones are a valuable endmember when studying this deep water cycle because hydration in Atlantic lithosphere, produced by slow spreading, is expected to be highly non-uniform2. Here, as part of a multi-disciplinary project in the Lesser Antilles volcanic arc3, we studied boron trace element and isotopic fingerprints of melt inclusions. These reveal that serpentine-that is, hydrated mantle rather than crust or sediments-is a dominant supplier of subducted water to the central arc. This serpentine is most likely to reside in a set of major fracture zones subducted beneath the central arc over approximately the past ten million years. The current dehydration of these fracture zones coincides with the current locations of the highest rates of earthquakes and prominent low shear velocities, whereas the preceding history of dehydration is consistent with the locations of higher volcanic productivity and thicker arc crust. These combined geochemical and geophysical data indicate that the structure and hydration of the subducted plate are directly connected to the evolution of the arc and its associated seismic and volcanic hazards.

Management of patients with hepatocellular carcinoma and portal vein tumour thrombosis: comparing east and west.

Portal vein tumour thrombosis is common among patients with advanced hepatocellular carcinoma. Tremendous differences exist in the management of hepatocellular carcinoma with portal vein tumour thrombosis between the east and the west, which derive from heterogeneities in its epidemiology, causes, pathology, comorbidities, prognosis, and other demographics. These divergences between the east and the west are not only caused by hepatocellular carcinoma itself, but are also affected by many variables including social factors, physician preferences, accessibility to costly or novel treatments, and reimbursement schemes. In this Review, we compare and contrast the management of hepatocellular carcinoma with portal vein tumour thrombosis in the east and in the west in terms of systemic and surgical treatments, radiotherapy, transcatheter arterial therapies, and portal vein revascularisation. We conclude that a personalised, data-driven approach to care with active management from a multidisciplinary team, as well as increased communication and collaboration between clinicians and researchers based in east and the west, could help to reduce the differences in management and optimise treatment strategies.

Evidence from plutonic xenoliths for magma differentiation, mixing and storage in a volatile-rich crystal mush beneath St. Eustatius, Lesser Antilles.

Quantifying the storage conditions and evolution of different magmatic components within sub-volcanic plumbing systems is key to our understanding of igneous processes and products. Whereas erupted magmas represent a portion of the eruptible volcanic system, plutonic xenoliths provide a complementary record of the mushy roots of the plumbing system that cannot be mobilised easily to form lavas and consequently offer a unique record of magma diversity within the sub-volcanic plumbing system. Here, we present a detailed petrological and geochemical study of erupted plutonic xenoliths from the island of Sint Eustatius (Statia), in the northern Lesser Antilles volcanic arc. The plutonic xenoliths are predominantly gabbroic, but vary in texture, mineral assemblage and crystallisation sequence. We report major, trace and volatile (H2O and CO2) concentrations of xenolith-hosted melt inclusions (MIs) and interstitial glass. The MIs have a very large range in major element (49-78 wt% SiO2 and 0.1-6.1 wt% MgO) and trace element concentration (72-377 ppm Sr, 32-686 ppm Ba, 39-211 ppm Zr). Their chemistry varies systematically with host phase and sample type. Significantly, it shows that (1) plutonic xenoliths record a complete differentiation sequence from basalt to rhyolite (2) apatite, but not zircon, saturation was reached during crystallisation, (3) amphibole breakdown reactions play a role in the genesis of shallow gabbronorite assemblages, and (4) mixing between crystal cargos and multiple discrete bodies occurred. Residual melt volatile contents are high (≤ 9.1 wt% H2O and ≤ 1350 ppm CO2), returning volatile saturation pressures of 0-426 MPa. Multiple reaction geobarometry and experimental comparisons indicate that equilibration took place in the upper-middle crust (0-15 km). We infer that the Statia plutonic xenoliths represent portions of a large heterogeneous crystal mush within which a great diversity of melts was stored and mixed prior to eruption. Our data show that compositional variations in magmatic plumbing systems exceed those observed in volcanic products, a likely consequence of the blending that occurs prior to and during eruption.

Imaging work-up and endovascular treatment options for aorto-enteric fistula.

Aorto-enteric fistula (AEF) is a rare life-threatening condition. Early recognition and diagnosis are of paramount importance to improve outcome. In this article four cases of AEF with relevant pre- and post-procedural images are presented to demonstrate the utility of cross-sectional imaging in the work-up of AEF. The literature is reviewed to describe the typical presentation of AEF, the diagnostic work-up of AEF, and the different methods used to treat AEF. Endovascular repair of AEF is gaining increasing attention due to its decreased short-term mortality compared to open surgical techniques.

Comparison of Local Injection of Fresh Frozen Plasma to Traditional Methods of Hemostasis in Minimally Invasive Procedures.

RATIONALE AND OBJECTIVES: To evaluate different techniques for reducing hemorrhagic complications in coagulopathic patients with elevated international normalized ratio having an image-guided percutaneous invasive procedure; techniques included systemic transfusion of fresh frozen plasma (FFP), local injection of FFP, percutaneous injection of gelatin sponge, and percutaneous placements of angiographic coils. MATERIALS AND METHODS: Retrospective review of 232 consecutive patients with known coagulopathy undergoing image-guided minimally invasive procedures were selected. Ninety-one patients had local FFP injected, 40 patients underwent local synthetic gelatin injection, 16 patients had percutaneous coil embolization, and 85 patients received systemic FFP. The number of bleeds, complications related to bleeds, and systemic complications were recorded. A 30 cc threshold was used to delineate significant bleeding. RESULTS: No patients experienced clinically significant or insignificant bleeding with local FFP injection (P value <.05). Other local hemostatic methods (Gelfoam, systemic FFP, and coil embolization) were associated with higher levels of bleeding (12.5%, 17.1%, 37.5%, respectively) and complications (7.5%, 31.4%, 37.5%, respectively). Systemic FFP infusion was associated with respiratory, infectious, and mortal complications. CONCLUSIONS: Local injection of blood products provides a safe and efficacious hemostatic agent to reduce the incidence of postprocedural bleeding. The technique is associated with lower rates of bleeding and systemic complications when compared to other local and systemic techniques. Further randomized prospective studies with a larger patient cohort need to be performed to corroborate these initial findings.

Andean surface uplift constrained by radiogenic isotopes of arc lavas.

Climate and tectonics have complex feedback systems which are difficult to resolve and remain controversial. Here we propose a new climate-independent approach to constrain regional Andean surface uplift. 87Sr/86Sr and 143Nd/144Nd ratios of Quaternary frontal-arc lavas from the Andean Plateau are distinctly crustal (>0.705 and <0.5125, respectively) compared to non-plateau arc lavas, which we identify as a plateau discriminant. Strong linear correlations exist between smoothed elevation and 87Sr/86Sr (R2 = 0.858, n = 17) and 143Nd/144Nd (R2 = 0.919, n = 16) ratios of non-plateau arc lavas. These relationships are used to constrain 200 Myr of surface uplift history for the Western Cordillera (present elevation 4200 ± 516 m). Between 16 and 26°S, Miocene to recent arc lavas have comparable isotopic signatures, which we infer indicates that current elevations were attained in the Western Cordillera from 23 Ma. From 23-10 Ma, surface uplift gradually propagated southwards by ~400 km.

The Radiologist Is in, but Was it Worth the Wait? Radiology Resident Note Quality in an Outpatient Interventional Radiology Clinic.

Preprocedural evaluation of patients in an interventional radiology (IR) clinic is a complex synthesis of physical examination and imaging findings, and as IR transitions to an independent clinical specialty, such evaluations will become an increasingly critical component of a successful IR practice and quality patient care. Prior research suggests that preprocedural evaluations increased patient's perceived quality of care and may improve procedural technical success rates. Appropriate documentation of a preprocedural evaluation in the medical record is also paramount for an interventional radiologist to add value and function as an effective member of a larger IR service and multidisciplinary health care team. The purpose of this study is to examine the quality of radiology resident notes for patients seen in an outpatient IR clinic at a single academic medical center before and after the adoption of clinic note template with reminders to include platelet count, international normalized ratio, glomerular filtration rate, and plan for periprocedural coagulation status. Before adoption of the template, platelet count, international normalized ratio, glomerular filtration rate and an appropriate plan for periprocedural coagulation status were documented in 72%, 82%, 42%, and 33% of patients, respectively. After adoption of the template, appropriate documentation of platelet count, international normalized ratio, and glomerular filtration rate increased to 96%, and appropriate plan for periprocedural coagulation status was documented in 83% of patients. Patient evaluation and clinical documentation skills may not be adequately practiced during radiology residency, and tools such as templates may help increase documentation quality by radiology residents.

Minimally invasive treatments for venous compression syndromes.

The management of venous compression syndromes has historically been reliant on surgical treatment when conservative measures fail. There are, however, several settings in which endovascular therapy can play a significant role as an adjunct or even a replacement to more invasive surgical methods. We explore the role of minimally invasive treatment options for three of the most well-studied venous compression syndromes. The clinical aspects and pathophysiology of Paget-Schroetter syndrome (PSS), nutcracker syndrome, and May-Thurner syndrome are discussed in detail, with particular emphasis on the role that interventionalists can play in minimally invasive treatment.

Plutonic xenoliths from Martinique, Lesser Antilles: evidence for open system processes and reactive melt flow in island arc crust.

The Lesser Antilles Volcanic Arc is remarkable for the abundance and variety of erupted plutonic xenoliths. These samples provide a window into the deeper crust and record a more protracted crystallisation history than is observed from lavas alone. We present a detailed petrological and in situ geochemical study of xenoliths from Martinique in order to establish their petrogenesis, pre-eruptive storage conditions and their contribution to construction of the sub-volcanic arc crust. The lavas from Martinique are controlled by crystal-liquid differentiation. Amphibole is rarely present in the erupted lavas, but it is a very common component in plutonic xenoliths, allowing us to directly test the involvement of amphibole in the petrogenesis of arc magmas. The plutonic xenoliths provide both textural and geochemical evidence of open system processes and crystal 'cargos'. All xenoliths are plagioclase-bearing, with variable proportions of olivine, spinel, clinopyroxene, orthopyroxene and amphibole, commonly with interstitial melt. In Martinique, the sequence of crystallisation varies in sample type and differs from other islands of the Lesser Antilles arc. The compositional offset between plagioclase (~An90) and olivine (~Fo75), suggests crystallisation under high water contents and low pressures from an already fractionated liquid. Texturally, amphibole is either equant (crystallising early in the sequence) or interstitial (crystallising late). Interstitial amphibole is enriched in Ba and LREE compared with early crystallised amphibole and does not follow typical fractionation trends. Modelling of melt compositions indicates that a water-rich, plagioclase-undersaturated reactive melt or fluid percolated through a crystal mush, accompanied by the breakdown of clinopyroxene, and the crystallisation of amphibole. Geothermobarometry estimates and comparisons with experimental studies imply the majority of xenoliths formed in the mid-crust. Martinique cumulate xenoliths are inferred to represent crystal mushes within an open system, through which melt can both percolate and be generated.

Management of ureteral obstruction in crossed fused renal ectopia: A case report.

Crossed fused renal ectopia is a rare congenital malformation. We describe a case in which a 58-year-old male with left-sided crossed fused renal ectopia presented with urinary bladder outlet obstruction due to metastatic prostate adenocarcinoma. Glomerular filtration rate (GFR) was 13 mL/min, creatinine 4 mg/dL, and blood urea nitrogen (BUN) 58 mg/dL. The patient underwent successful image-guided placement of percutaneous nephrostomy tubes which were later converted to nephroureteral stents. Labs improved to a GFR of 28 mL/min, creatinine of 2.4 mg/dL, and BUN of 41 mg/dL. In this case standard image-guided renal decompression techniques were effective in treating a patient with crossed fused renal ectopia.