Special Considerations and Techniques of Interventions in Lung Transplant Recipients.

Lung transplant remains an important treatment option for patients with end-stage lung diseases providing improvement in survival rates and quality of life. Specialized considerations should be applied with interventions of lung transplant recipients as they host specific anatomic variations and high risk towards certain complications. In this article, we highlight the role of interventional radiology for lung transplant recipients along with discussion of interventional techniques. Specific emphasis is placed on describing and explaining the techniques pertained to the points of anastomosis, diagnosis and treatment of malignancies, and management of complications in lung transplant recipients.

Are disparities in emergency department imaging exacerbated during high-volume periods?

PURPOSE: Evaluate if disparities in the emergency department (ED) imaging timeline exist, and if disparities are altered during high volume periods which may stress resource availability. METHODS: This retrospective study was conducted at a four-hospital healthcare system. All patients with at least one ED visit containing imaging from 1/1/2016 to 9/30/2020 were included. Peak hours were defined as ED encounters occurring between 5 pm and midnight, while all other ED encounters were non-peak hours. Patient-flow data points included ED length of stay (LOS), image acquisition time, and diagnostic image assessment time. RESULTS: 321,786 total ED visits consisted of 102,560 during peak hours and 219,226 during non-peak hours. Black patients experienced longer image acquisition and image assessment times across both time periods (TR = 1.030; p < 0.001 and TR = 1.112; p < 0.001, respectively); Black patients also had increased length of stay compared to White patients, which was amplified during peak hours. Likewise, patients with primary payer insurance experienced significantly longer image acquisition and image assessment times in both periods (TR > 1.00; p < 0.05 for all). Females had longer image acquisition and image assessment time and the difference was more pronounced in image acquisition time during both peak and non-peak hours (TR = 1.146 and TR = 1.139 respectively with p < 0.001 for both). CONCLUSION: When measuring radiology time periods, patient flow throughout the ED was not uniform. There was unequal acceleration and deceleration of patient flow based on racial, gender, age, and insurance status. Segmentation of patient flow time periods may allow identification of causes of inequity such that disparities can be addressed with targeted actions.

Vascular anomalies of the head and neck: diagnosis and treatment.

Vascular malformations and vascular tumors comprise the two specific subsets of vascular anomalies that arise as a result of disorganized angiogenesis and neoplasm, respectively. Malformations are separate entities from vascular tumors (e.g., hemangiomas) and are recognized by the International Society for the Study of Vascular Anomalies (ISSVA) as such. Vascular malformations are classified into four main groups: simple, combined, anomalies of major vessels, and those associated with other vascular anomalies. Vascular tumors are neoplastic growths of blood vessels and are morphologically and molecularly distinct from malformations but can arise in the head and neck and have syndromic association. Head and neck vascular anomalies are not uncommon in the pediatric population and require special care in the workup, diagnostic imaging and clinical care. The purpose of this manuscript is to discuss the diagnosis and management of the most common intracranial and extracranial vascular malformations and tumors in the head and neck in children and adolescents.

Contemporary Management of Pediatric Blunt Splenic Trauma: A National Trauma Databank Analysis.

PURPOSE: To quantify changes in the management of pediatric patients with isolated splenic injury from 2007 to 2015. MATERIALS AND METHODS: Patients under 18 years old with registered splenic injury in the National Trauma Data Bank (2007-2015) were identified. Splenic injuries were categorized into 5 management types: nonoperative management (NOM), embolization, splenic repair, splenectomy, or a combination therapy. Linear mixed models accounting for confounding variables were used to examine the direct impact of management on length of stay (LOS), intensive care unit (ICU) days, and ventilator days. RESULTS: Of included patients (n = 24,128), 90.3% (n = 21,789), 5.6% (n = 1,361), and 2.7% (n = 640) had NOM, splenectomy, and embolization, respectively. From 2007 to 2015, the rate of embolization increased from 1.5% to 3.5%, and the rate of splenectomy decreased from 6.9% to 4.4%. Combining injury grades, NOM was associated with the shortest LOS (5.1 days), ICU days (1.9 days), and ventilator days (0.5 day). Moreover, splenectomy was associated with longer LOS (10.1 days), ICU days (4.5 days), and ventilator days (2.1 days) than NOM. The average failure rate of NOM was 1.5% (180 failures/12,378 cases). Average embolization failure was 1.3% (6 failures/456 cases). Splenic artery embolization was associated with lower mortality than splenectomy (OR: 0.10, P <.001). No statistically significant difference was observed in mortality between embolization and NOM (OR: 0.96, P = 1.0). CONCLUSIONS: In pediatric splenic injury, NOM is the most utilized and associated with favorable outcomes, most notably in grades III to V pediatric splenic injury. If intervention is needed, embolization is effective and increasingly utilized most significantly in lower grade injuries.

Management of Splenic Trauma in Contemporary Clinical Practice: A National Trauma Data Bank Study.

BACKGROUND: To evaluate the utilization and efficacy of various treatments for management of adult patients with splenic trauma, highlighting the evolving role of splenic artery embolization. MATERIALS AND METHODS: The National Trauma Data Bank (NTDB) was queried for patients who sustained splenic trauma between 2007 and 2015, excluding those with death on arrival and selected nonsplenic high-grade injuries. Patients were categorized into (1) nonoperative management (NOM), (2) embolization, (3) splenectomy, (4) splenic repair, and (5) combined treatment groups. Evaluated outcomes included hospital length of stay (LOS), intensive care unit LOS, mortality, and NOM and embolization failures. RESULTS: Overall, 117,743 patients with splenic predominant trauma were included in this study. Over the 9-year study period, 85,793 (72.9%) were treated with NOM, 21,999 (18.9%) with splenectomy, 3895 (3.3%) with embolization, and 2131 (1.8%) with splenic repair. From 2007 to 2015, mortality rates declined from 7.6% to 4.7%. The rate of NOM did not significantly change over time, while embolization increased 369% (1.3%-4.8%). Failure of NOM was 4.4% in 2007 and decreased to 3.4% in 2015. Across all injury grades, NOM had the shortest LOS (8.3 days), followed by splenic repair (12.3), embolization (12.6), and splenectomy (13.8) (p < 0.001). When adjusted for various clinical factors including severity of splenic injury, mortality rates were 7.1% for splenectomy, 3.2% for embolization, and 2.5% for NOM. CONCLUSION: Most patients with splenic-dominant blunt trauma are managed with NOM. Over time, the use of embolization has increased while open surgery has declined, and mortality has improved for all treatment methods. Compared to splenectomy, embolization is associated with shorter hospital LOS but is still used relatively infrequently.

Using Point-of-Care Patient Photographs With Musculoskeletal Radiography to Identify Errors of Laterality in Emergency Department Imaging.

PURPOSE: To evaluate the utility of point-of-care patient photographs accompanying musculoskeletal (MSK) radiography to identify errors in laterality. MATERIALS AND METHODS: In this Institutional Review Board-approved study, 347 consecutive MSK radiograph-photograph combinations and corresponding radiography provider orders between October 1, 2018 and January 31, 2019, were retrospectively reviewed. Photographs were obtained simultaneously with the radiographs using the PatCam System (Camerad Technologies, Decatur, GA). In each case, laterality was recorded for all photographs, radiograph side markers, and radiography orders, and any laterality discrepancy among these variables was recorded. The side indicated on the provider order was taken as the gold standard. RESULTS: Three hundred and forty-seven consecutive MSK radiograph-photograph combinations from 253 unique patients consisted of 129 upper extremity and 218 lower extremity radiographs. Two discrepancies (0.58%) in laterality were identified. The first discrepant case consisted of a left foot radiograph, which was labeled as "R" on the radiograph and left on the order. In this case, the patient photograph confirmed with certainty that the incorrect side marker was placed. The second discrepant case was a hip radiograph, in which 1 of 3 images had discrepant L/R labeling; the patient was covered with a sheet, both hips were included in the photograph, but a monitoring device on the patient's left side in the photograph also included on the radiographs determined which film was incorrectly labeled. CONCLUSIONS: Patient photographs obtained concurrently with MSK radiographs can provide a valuable quality tool in identifying errors of laterality. In our study, over 1 in 200 patients was identified as having such an error.

Imaging review of sickle cell disease for the emergency radiologist.

Sickle cell disease (SCD), one of the most common inherited genetic syndromes in the USA, is characterized by recurring episodes of acute illness and progressive multisystem organ injury. Individuals with SCD frequently present to the emergency department for a spectrum of complications, such as vaso-occlusive crises, infection, cholecystitis, and stroke. Imaging correlates for most of these presentations exist, positioning the emergency radiologist to play a pivotal role in facilitating patient care. Using a systems-based approach, we describe the acute and chronic imaging manifestations of SCD that an emergency radiologist can expect to encounter in most practice settings, highlighting the unique pathophysiology of this disorder that typically underlies the imaging findings.

Traumatic Chylothorax: Approach and Outcomes.

Traumatic chylothorax occurs more often now than in historic reports. In part, this is due to the increased ability to perform more advanced and aggressive thoracic resections and cardiovascular surgeries as well as the improved mortality of cancer patients. If untreated, chylothorax can result in significant morbidity and mortality, particularly in patients with underlying malignancy. Thoracic duct embolization for chylothorax was the first successful lymphatic intervention and has been performed for over 20 years. An overview of the clinical and technical approach to thoracic duct embolization for traumatic chylothorax is presented in addition to a review of outcomes.

Contemporary Management of Hepatic Trauma: What IRs Need to Know.

Trauma remains one of the leading causes of death in the United States in patients younger than 45 years. Blunt trauma is most commonly a result of high-speed motor vehicular collisions or high-level fall. The liver and spleen are the most commonly injured organs, with the liver being the most commonly injured organ in adults and the spleen being the most affected in pediatric blunt trauma. Liver injuries incur a high level of morbidity and mortality mostly secondary to hemorrhage. Over the past 20 years, angiographic intervention has become a mainstay of treatment of hepatic trauma. As there is an increasing need for the interventional radiologists to embolize active hemorrhage in the setting of blunt and penetrating hepatic trauma, this article aims to review the current level of evidence and contemporary management of hepatic trauma from the perspective of interventional radiologists. Embolization techniques and associated outcome and complications are also reviewed.

Shared Decision Making: Radiology's Role and Opportunities.

OBJECTIVE. The purpose of this article is to present a targeted literature review describing the current state of radiology initiatives in support of shared decision making and gaps that offer opportunities for innovation and improvement. CONCLUSION. Breaking down the shared decision-making process into its four major components (access to information, comprehension of the information, appraisal of the information, application of knowledge in care decisions) reveals the role of radiologists in the decision-making process and opportunities for expanding this role.

Inactivation of Tm6sf2, a Gene Defective in Fatty Liver Disease, Impairs Lipidation but Not Secretion of Very Low Density Lipoproteins.

A missense mutation (E167K) in TM6SF2 (transmembrane 6 superfamily member 2), a polytopic protein of unknown function, is associated with the full spectrum of fatty liver disease. To investigate the role of TM6SF2 in hepatic triglyceride (TG) metabolism, we inactivated the gene in mice. Chronic inactivation of Tm6sf2 in mice is associated with hepatic steatosis, hypocholesterolemia, and transaminitis, thus recapitulating the phenotype observed in humans. No dietary challenge was required to elicit the phenotype. Immunocytochemical and cell fractionation studies revealed that TM6SF2 was present in the endoplasmic reticulum and Golgi complex, whereas the excess neutral lipids in the Tm6sf2(-/-) mice were located in lipid droplets. Plasma VLDL-TG levels were reduced in the KO animals due to a 3-fold decrease in VLDL-TG secretion rate without any associated reduction in hepatic apoB secretion. Both VLDL particle size and plasma cholesterol levels were significantly reduced in KO mice. Despite levels of TM6SF2 protein being 10-fold higher in the small intestine than in the liver, dietary lipid absorption was only modestly reduced in the KO mice. Our data, taken together, reveal that TM6SF2 is required to mobilize neutral lipids for VLDL assembly but is not required for secretion of apoB-containing lipoproteins. Despite TM6SF2 being located in the endoplasmic reticulum and Golgi complex, the lipids that accumulate in its absence reside in lipid droplets.