Feasibility of pulmonary valve imaging using transesophageal echocardiography upper esophageal view.

BACKGROUND: The present study designed to evaluate feasibility of transesophageal echocardiographic (TEE) imaging of the pulmonary valve (PV) at the transaortic upper esophageal (TAUE) window. We hypothesized that patients with larger aorta would be more likely to have visualization of the PV from this TAUE window. METHODS: 2D TEE images of the PV were prospectively acquired by one operator at the TAUE window looking through the aortic arch. Patients were divided into four groups based on image quality of PV (group 1, not visualized; group 2, barely visualized; group 3, sufficient visualization; group 4, excellent visualization). Clinical, echocardiographic, and radiologic parameters were collected. RESULTS: A total of 212 consecutive patients (54 ± 14 years, 63.7% male) were enrolled. Group distribution was as follows: group 1, n = 60 (28.3%); group 2 n = 39 (18.4%); group 3, n = 27 (12.7%); group 4, n = 86 (40.6%). There were no differences between groups' baseline clinical characteristics. There was a weak although statistically negative correlation between PV image quality and aortic arch dimension (r = -0.17 P = 0.01). There was a stronger positive correlation between PV thickness (r = 0.38 P < 0.001) and PV image quality. Retrospective subgroup analysis of 76 patients with recent chest CT showed similar, but not significant trends as by TEE. CONCLUSION: The use of 2D TEE TAUE results in diagnostic image quality of the PV in the majority of patients and outstanding image quality in a subset of patients. PV image quality is negatively affected by increasing aorta diameter and positively affected by PV thickness.

Thoracic diseases associated with HIV infection in the era of antiretroviral therapy: clinical and imaging findings.

The human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) pandemic has entered its 4th decade. Since the introduction of combination antiretroviral therapy (ART) in 1996, the number of AIDS-related deaths has plateaued worldwide. Today, owing to the effectiveness of ART, the HIV-infected population is aging and HIV infection has become a chronic illness. Non-AIDS comorbidities are increasing, and the spectrum of HIV-related thoracic diseases is evolving. In developed countries, bacterial pneumonia has become more common than Pneumocystis pneumonia. Its imaging appearance depends on the responsible organism, most commonly Streptococcus pneumoniae. Mycobacterium tuberculosis continues to be a major threat. Its imaging patterns vary depending on CD4 count. Primary lung cancer and Hodgkin lymphoma are two important non-AIDS-defining malignancies that are increasingly encountered at chest imaging. Human herpesvirus 8, also known as Kaposi sarcoma-associated herpesvirus (KSHV), is strongly linked to HIV-related diseases, including Kaposi sarcoma, multicentric Castleman disease, KSHV inflammatory cytokine syndrome, and primary effusion lymphoma. Immune reconstitution inflammatory syndrome is a direct complication of ART whose manifestations vary with the underlying disease. Given the high rate of smoking among HIV-infected patients, chronic obstructive pulmonary disease is another important cause of morbidity and mortality. A high degree of suspicion is required for the early diagnosis of pulmonary arterial hypertension and lymphocytic interstitial pneumonia, given their nonspecific manifestations. Finally, multilocular thymic cyst manifests as a cystic anterior mediastinal mass. Recognition of the clinical and radiologic manifestations of these less traditional HIV-related diseases can expedite diagnosis and treatment in the ART era.

Ultrasound artifacts: classification, applied physics with illustrations, and imaging appearances.

Ultrasound has become a widely used diagnostic imaging modality in medicine because of its safety and portability. Because of rapid advances in technology, in recent years, sonographic imaging quality has significantly increased. Despite these advances, the potential to encounter artifacts while imaging remains.This article classifies both common and uncommon gray-scale and Doppler ultrasound artifacts into those resulting from physiology and those caused by hardware. A brief applied-physics explanation for each artifact is listed along with an illustrated diagram. The imaging appearance of artifacts is presented in case examples, along with strategies to minimize the artifacts in real time or use them for clinical advantage where applicable.

Internal versus external moonlighting by radiology trainees: differences in roles and responsibilities.

RATIONALE AND OBJECTIVES: Recent survey data have suggested that the paid extracurricular activities of radiology trainees (known as "moonlighting") are more diverse than has been previously recognized. The purpose of this study is to examine these activities in further detail and to assess for differences between clinical duties performed at institutions affiliated with residents' training programs ("internal moonlighting") versus those performed at unaffiliated institutions ("external moonlighting"). MATERIALS AND METHODS: Electronic survey data were collected from trainee members of the Association of University Radiologists regarding their extracurricular clinical work, with an emphasis on their responsibilities when working in institutions that are affiliated with their training program versus work done in unaffiliated institutions. Descriptive and analytic statistics were used to examine these data. RESULTS: Survey respondents represented 61 unique institutions (of 173 Association of University Radiologists member-programs, a 35% institutional response rate). Trainees engage in moonlighting activities at nearly three-fourths of these programs. Although the incidence of duty hour violations appears to be low ("probably" or "definitely" occurring at three of 44, or 7%, of represented programs with moonlighting trainees), these violations go largely undocumented. Residents participating in external moonlighting were significantly more likely to provide final interpretations of diagnostic imaging studies when compared with residents moonlighting internally (odds ratio 13.84, P < .05). Of the 27 programs with residents that moonlight externally, five respondents (19%) indicated that their external moonlighting duties include the unsupervised performance of invasive procedures. There were no reports of unsupervised procedures performed by trainees moonlighting internally. CONCLUSIONS: Many resident physicians view moonlighting as a highly desirable, or even financially necessary, component of their clinical training. Although external moonlighting may be a useful means of garnering additional experience and income, certain ethical and medicolegal implications must be considered. The moonlighting trainee should seek opportunities for extracurricular work that do not compromise patient safety or the trainee's own long-term professional interests. Department administrators might facilitate this process by providing opportunities for internal moonlighting, while simultaneously developing competency-based systems for assessing trainee readiness for progressive clinical independence.

Pediatric abdominal and pelvic trauma: safety and efficacy of arterial embolization.

PURPOSE: Although transcatheter embolization is a well established technique to treat adults in the trauma setting, evidence is lacking in the pediatric population. This study assesses the safety and efficacy of arterial embolization for blunt abdominal and pelvic trauma in the pediatric population. MATERIALS AND METHODS: A retrospective review of abdominal and pelvic angiograms in 97 pediatric patients with blunt trauma was conducted over an 11-year period. Abdominal angiography and embolization was performed for ongoing hepatic, renal, splenic, or nonvisceral retroperitoneal injury. Pelvic angiography was performed in the setting of pelvic fracture with ongoing pelvic hemorrhage. Complications and clinical success rates of these procedures were assessed. RESULTS: Of the 97 pediatric patients who underwent angiography for acute abdominal or pelvic trauma, 54 (56%) required embolization involving 62 separate sites. Injury severity score greater than 15 was present in 94% of patients. Targets of embolization included the pelvis (n = 39), liver (n = 8), kidney (n = 7), spleen (n = 6), and retroperitoneum (n = 2). Effective hemorrhage control was achieved in 47 patients (87%). Overall mortality rate was 22% (12 of 54), with most deaths related to traumatic brain injury. Five complications occurred in four patients (7%), including three major complications (hepatic abscess, bile leak, and urinary incontinence). CONCLUSIONS: Angiography and embolization is relatively safe and potentially effective in the setting of abdominal and pelvic trauma in the pediatric population. Angiography with embolization should be considered in the treatment algorithm for this patient population.

Business of radiology: financial fundamentals for radiologists.

OBJECTIVE: The purposes of this article are to provide a primer on financial statements and to review several financial concepts that are at the foundation of the business of medicine. CONCLUSION: For radiologists to effectively contribute to the leadership and management of their practices, it is imperative that they understand the business aspects of radiology. Radiologists' understanding and participation in practice management may also facilitate job satisfaction and assist the provision of optimal patient care.

Arterial closure device to achieve hemostasis in children following percutaneous femoral arterial puncture.

BACKGROUND: Percutaneous arterial closure devices have increasingly entered clinical practice to assist in achieving femoral arterial access site hemostasis. Prior studies have demonstrated the safety and efficacy of several arterial closure devices in adults. OBJECTIVE: To evaluate the efficacy of using an arterial closure device in children. MATERIALS AND METHODS: A retrospective review of all children (defined as younger than 18 years) undergoing device-assisted closure of their percutaneous femoral arterial access site was conducted. Patient demographics, the clinical indications for use of the arterial closure device and pre-procedural laboratory parameters were noted. The accessed common femoral artery diameter and largest procedural sheath size were recorded. The technical success rate for device deployment and rates of immediate and delayed complications including hemorrhage, access site or retroperitoneal hematoma, access site infection, arterial thromboembolism, pseudoaneurysm or arteriovenous fistulae were documented. RESULTS: Between June 2009 and June 2011, an arterial closure device was deployed with intent to achieve hemostasis in percutaneous femoral arterial access punctures in 38 consecutive children. The mean common femoral artery diameter was 0.70 ± 0.13 cm. Device deployment was technically successful in 37/38 (97.4%) procedures. There was a single complication (2.6%), a small access site hematoma. No other immediate or delayed complications occurred. CONCLUSION: The use of a percutaneous arterial closure device can be an efficacious method for achieving immediate femoral arterial access site hemostasis with few complications in children who have undergone percutaneous femoral arterial access procedures.

The nature and scope of moonlighting by radiology trainees.

RATIONALE AND OBJECTIVES: The practice of moonlighting by trainees is a longstanding controversy; however, the resident point of view remains distinctly underrepresented in the radiology literature. We report the resident perspective on the moonlighting practices of radiology trainees. METHODS: Survey data were collected from resident members of the Association of University Radiologists representing 84 training programs in the United States to assess their routine and extracurricular clinical responsibilities. Descriptive statistics were used to analyze these data. RESULTS: Moonlighting is practiced by radiology trainees at nearly three-fourths of the programs represented in this survey. Interpreting diagnostic imaging (85.5%) and monitoring contrast administrations (72.6%) are the most common duties performed. Twenty-one percent of moonlighting trainees perform procedures (excluding diagnostic fluoroscopy) in their extracurricular positions; of these, most (61.5%) are without attending supervision. Most trainees that moonlight spend 1 to 10 hours weekly doing so while averaging a 59-hour workweek at their primary jobs. CONCLUSIONS: The clinical duties of moonlighting trainees may be more diverse than has been previously recognized. Although major discrepancies between overnight radiology trainee interpretations and attending final interpretations have been shown to be infrequent, the consequences of trainees performing procedures and monitoring adverse contrast reactions without attending supervision are unknown. The financial and professional benefits of moonlighting must be weighed against the potential for harm. Our data suggest that most moonlighting radiology trainees operate within the Accreditation Council for Graduate Medical Education-mandated 80-hour weekly work limit; the mandatory 8-hour break between shifts and 24-hour continuous duty limit may pose logistical challenges.

Percutaneous drainage of intra-abdominal abscess in children with perforated appendicitis.

BACKGROUND: Because the surgical management of perforated appendicitis remains controversial, percutaneous catheter drainage (PCD) has gained favor for managing periappendiceal abscess in hemodynamically stable children. OBJECTIVE: To determine the safety and effectiveness of PCD in children with perforated appendicitis and to identify any variables of prognostic value. MATERIALS & METHODS: We retrospectively evaluated clinical data and imaging features for 33 children undergoing PCD for periappendiceal abscess from October 2006 to February 2010. Those with preprocedural CT studies were assigned to one of three risk categories based on imaging features. RESULTS: Appendectomy was successfully postponed for all patients. Our technical success rate was 87.9%, with three recurrences (two requiring repeat drainage, one managed conservatively) and one possible complication (enterocutaneous fistula formation). Children with large and diffuse abscesses had a 50% rate of technical failure, which was significantly increased when compared to children with large but localized abscesses (P < 0.028). Extraluminal appendicolith, extraluminal gas, leukocytosis, ileus/obstruction and procedural variables were not reliable predictors of outcome. CONCLUSION: PCD can be effective for managing perforated appendicitis in children. Children with large and ill-defined abscess might be at increased risk for complication or recurrence.

Case report: Concurrent congenital complete atrioventricular block, Meckel's diverticulum and cerebral palsy in a 19-year-old male.

A case report is described of a patient with cerebral palsy and Meckel's diverticulum presenting with congenital atrioventricular (AV) block. There is limited information of congenital heart block in adults, because most literature has been devoted to congenital heart block in childhood. This unique case is discussed with other patient groups' with congenital AV block. Long-term follow-up of congenital heart block is reviewed together with the concept of prophylactic pacemaker placement in symptom-free adults.