Endovascular Embolisation of Pulmonary Arteriovenous Malformation Using Amplatzer Vascular Plugs.

Pulmonary arteriovenous malformation (PAVMs) are abnormal communications between pulmonary arteries and veins. The rarity of their occurrence, coupled with the risks they pose, including brain abscess, embolic stroke, and myocardial infarction, mandates that they should not be overlooked in the differential diagnosis of patients presenting with haemoptysis, dyspnea, clubbing, cyanosis, hypoxemia, or epistaxis. We present the case of a 41-year-old local female who presented to our hospital as an outpatient with decreased oxygen saturation (SpO2) of 70%-80% for the past two years with a final diagnosis of PAVM. The initial baseline workup showed polycythemia with a hemoglobin level of 19 mg/dL and raised hematocrit. She had extensive workup in the past two years for her polycythemia including gene mutation testing and cardiac workup which all turned out normal. Her chest X-ray (CXR) showed right lung opacity which was initially considered to be infective but it did not respond to antibiotic treatment. Later on, a CT scan of the chest was performed and findings were typical of a large PAVM which had two feeding arteries. The patient was referred to a cardiothoracic surgeon who sent the patient to the interventional radiology section for endovascular management. The embolization procedure was then performed and both feeders were successfully embolised. After the procedure, the patient's SpO2 levels were restored to 95%-96%, and no post-procedure complications were noted.

Value of Periappendiceal Fat Sign on Ultrasound in Acute Appendicitis.

Introduction Acute right lower quadrant abdominal pain is one of the most common surgical presentations to the emergency department with acute appendicitis being the topmost differential diagnosis. Although computed tomography (CT) is the gold standard in diagnosing appendicitis, in our setup ultrasound is often the initial imaging modality available in urgent care settings especially for children and pregnant females. On ultrasound, an inflamed appendix has a diameter of 6 mm or more and is non-compressible. Increased periappendiceal fat echogenicity is an important ancillary sign of acute appendicitis that supports the sonographic diagnosis of acute appendicitis. To determine the association of periappendiceal fat echo sign (PFES) on ultrasound in surgically proven cases of acute appendicitis. Methods This cross-sectional study was held at the Department of Radiology at the Aga Khan University Hospital in Karachi, Pakistan. Periappendiceal fat echogenicity was assessed and prospectively graded in 59 patients. These patients had sonographic features of acute appendicitis which was later confirmed by surgery. Data were collected on a proforma and later analyzed. Frequency of increased periappendiceal fat echogenicity in acute appendicitis was calculated. Association of PFES with gender and ascites was evaluated with Fischer's exact test and with patient's age and appendiceal diameter was assessed using analysis of variance (ANOVA). Results Increased periappendiceal fat echogenicity was seen in 89.8% of patients with acute appendicitis. 10.2% of patients had acute appendicitis with normal surrounding fat. Mean appendiceal diameter in patients with grade 3 PFES was significantly more than those with grade 2 or grade 1 PFES. PFES had no association with age and gender of the patient or with ascites. Conclusion Increased periappendiceal fat echogenicity is an important ancillary sign of acute appendicitis that helps support its sonographic diagnosis.

Evaluation of Radiology Request Forms in a Tertiary Care Hospital: An Audit With a Focus on the Impact of Technological Intervention.

Radiology request forms are the basis of communication between referring physicians and radiologists. These are the sole documents on the basis of which a justification to carry out a radiological procedure is carried out. However, across the globe, there is a problem of inadequately filled radiology request forms. Several interventions like standardization and the use of technology have been proposed worldwide to overcome the shortcomings of inadequately filled radiology request forms. We carried out a two-phase audit assessing the impact of a technological intervention on the quality of radiology requests with the results showing marked improvement in key parameters. A subset analysis was also done to highlight the importance of radiology request forms by following the patients' treatment course. The remaining shortcomings highlight the importance of training sessions and refresher courses for junior doctors in order to familiarize them with the importance of adequately filled radiology request forms.

Image-guided Percutaneous Radiofrequency Ablation for Osteoid Osteoma: Experience from a Developing Nation.

Objective The purpose of this study is to report our experience in using image-guided percutaneous radiofrequency ablation (RFA) for the treatment of osteoid osteoma (OO) and the subsequent duration of pain relief over a period of about six years (May 2013-March 2019; 70 months) at a tertiary-care hospital in a developing nation. Methods A retrospective study was performed at the radiology department of Aga Khan University, Karachi, Pakistan. All patients who had undergone image-guided percutaneous RFA for OO between May 2013-March 2019 were included. All cases had been performed with CT-guidance under general anesthesia, with an additional local anesthesia injection also administered to the patients. A soloist needle had been used for RFA. The primary success rates, complications, symptom-free intervals, and follow-ups were evaluated. Results In total, 15 patients (11 males, 4 females) of a mean age of 13.93 years (range: 5-25 years; median age: 14.5 years) with OO underwent image-guided percutaneous RFA during a period of 70 months. Eleven lesions were located in the femur, three in the tibia, and one in the humerus. The mean nidus size was 8.1 x 5.73 mm [range: (4.9-11.5) x (3.8-9.1) mm]. All patients were successfully treated and experienced resolution of pain in 2.36 months (range: 1-4 months). During the follow-up period (range: 3-40 months; mean: 13.85 months; median: nine months), none of the patients experienced any relapse or persistent symptoms. No major complications were reported. Conclusion Image-guided percutaneous RFA is a minimally invasive and safe treatment option with high efficiency and a high rate of technical success for the treatment of OO. The risk of recurrence is remote with all patients achieving independent recovery.

Empiric Transcatheter Arterial Embolization for Massive or Recurrent Gastrointestinal Bleeding: Ten-year Experience from a Single Tertiary Care Center.

Purpose In patients with massive or recurrent gastrointestinal bleeding (GIB) which is not amenable to endoscopic therapy, angiographic interventions are often employed. We report our ten-year experience of empiric transcatheter arterial embolization (TAE) for patients with massive or recurrent GIB. Methods All patients who had undergone empiric TAE at our hospital between March 2004 and June 2015 were identified using the institutional radiology information system. A retrospective chart review was performed using a structured pro forma. Technical success rate, 30-day clinical success rate, 30-day mortality rate, and rate of procedural complications were computed. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 20. Results A total of 32 patients had undergone empiric TAE for GIB during the study period. The median age of subjects was 56 years and two-thirds of them were male (68.7%). Gastroduodenal (n=24), ileocolic (n=3), left gastric (n=2), right gastroepiploic (n=1), and branches of superior and middle rectal arteries (n=1) were embolized using microcoils (n=25), polyvinyl alcohol particles (n=25), and gelatin sponge (n=3)--either alone or in combination. Technical and 30-day clinical success rates were 96.9% (31/32) and 71.9% (23/32), respectively. The 30-day mortality rate for our cohort was 21.9% (7/32). One patient developed re-bleeding at two days after the initial procedure and required repeat embolization. Coil migration (n=3) and access site hematoma (n=1) were the observed procedural complications. Conclusion Empiric TAE can be a useful treatment option for selected patients with massive or recurrent GIB that is not amenable to endoscopic therapy.

Interobserver Agreement on Focused Assessment with Sonography for Trauma in Blunt Abdominal Injury.

Introduction Trauma constitutes a major public health problem. Ninty percent of world's fatalities on road occur in low and middle-income countries. Focused assessment with sonography in trauma (FAST) has a key role in trauma investigation, altering subsequent management in a significant number of patients. There is a rising trend of introducing FAST examination to non-radiologists and junior members of healthcare team to hasten triage of trauma patients. Objective To determine interobserver agreement on focused assessment with sonography for trauma in blunt abdominal injury between senior and junior residents. Methods This cross-sectional study was conducted at Aga Khan University Hospital. Three hundred patients with blunt abdominal trauma meeting inclusion criteria were enrolled. FAST was performed using standard curvilinear 3.5-5 MHz transducer. Agreement between junior and senior residents was measured and Kappa statistic was calculated. Results Mean age of the patients included in the study was 30.04 ± 18.09 years. Among these 237 (79%) were male and 63 (21%) were female. Sixteen (5.3%) were positive for intraperitoneal free fluid while the remaining 284 (94.7%) were negative. A total of 19 FAST examinations were reported positive by junior residents, of which 15 (78.9%) were confirmed by a senior resident to be correct, while four (21.05%) were falsely labeled positive by a junior resident. A total of 281 negative FAST examinations were reported by junior residents, of which 280 (99.6%) were confirmed by a senior resident, while only one (0.003%) was falsely labeled negative. Kappa statistic was calculated for inter-observer agreement on FAST examination findings, which showed a kappa value of 0.84 (very good agreement), with a p-value of <0.001. Conclusion Our study suggests very good interobserver agreement on FAST examination between senior and junior resident in patients with blunt trauma to the abdomen. Results suggest that FAST can be easily learnt with minimal radiology training and may have greater applicability in trauma.