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Intraprocedural Cone Beam CT (CBCT) is assessed to examine if use improves diagnosis and embolization rates of acute lower GI bleed (LGIB) and if automatic vessel detection (AVD) software can identify feeding vessels (FV) for embolization.Patients with inconclusive DSA findings had CBCT and retrospective analysis with AVD software (Innova 3100, GE Company, USA). Technical success was defined as the ability to detect a lower GIB site while clinical success was defined as successful embolization without evidence of rebleeding or death within 30 days. AVD technical success was defined by the ability to identify the FV on both CTA and CBCT upon independent review by 3 blinded IRs, who also assigned a degree of certainty on a 5-point Likert scale.74 patients in total were treated for lower GI bleed of which 34 had indeterminate DSA. Of those, 10 patients received DSA only, of which 1 was super selective. 24 patients with GIB on pre-procedural CTA and inconclusive DSA underwent CBCT. Use of CBCT identified 9 bleeds not seen on DSA and an additional source artery in 1 case representing a 42% change in intraprocedural management as all findings were embolized. When a bleed could not be identified on CBCT, but the FV could be identified on CTA, the same suspected FV could be selected on AVD 62% of the time with an average certainty of 4.0.CBCT is useful in the intraprocedural detection of GIB when DSA is indeterminate. Furthermore, AVD software can feasibly be utilized to accurately identify FVs for empiric treatment when intraprocedural imaging is inconclusive.Level III, therapeutic study.

Biliary obstruction is a common indication for referral to interventional radiology, particularly when endoscopic retrograde cholangiopancreatography has failed or is not possible due to postsurgical anatomy. The standard approach to percutaneous transhepatic biliary drainage involves gaining needle access to a peripheral bile duct, followed by advancement of a guidewire and drainage catheter across the obstruction and into bowel to allow internal drainage. While most cases of biliary obstruction are managed successfully with this conventional approach, in some situations it is not possible to traverse the occlusion with a guidewire and catheter, and thus advanced techniques may be required. This article has reviewed the available strategies for managing the impassable biliary obstruction.

Rationale and Objectives Limited exposure to radiology by medical students can perpetuate negative stereotypes and hamper recruitment efforts. The purpose of this study is to understand medical students’ perceptions of radiology and how they change based on medical education and exposure. Materials and Methods A single-institution mixed-methods study included four groups of medical students with different levels of radiology exposure. All participants completed a 16-item survey regarding demographics, opinions of radiology, and perception of radiology stereotypes. Ten focus groups were administered to probe perceptions of radiology. Focus groups were coded to identify specific themes in conjunction with the survey results. Results Forty-nine participants were included. Forty-two percent of participants had positive opinions of radiology. Multiple radiology stereotypes were identified, and false stereotypes were diminished with increased radiology exposure. Opinions of the impact of artificial intelligence on radiology closely aligned with positive or negative views of the field overall. Multiple barriers to applying for a radiology residency position were identified including board scores and lack of mentorship. COVID-19 did not affect perceptions of radiology. There was broad agreement that students do not enter medical school with many preconceived notions of radiology, but that subsequent exposure was generally positive. Exposure both solidified and eliminated various stereotypes. Finally, there was general agreement that radiology is integral to the health system with broad exposure on all services. Conclusion Medical student perceptions of radiology are notably influenced by exposure and radiology programs should take active steps to engage in medical student education.

Our diagnostic radiology (DR) program lacked a formalized, structured process for residents to learn from errors. Prior DR residency Accreditation Council for Graduate Medical Education (ACGME) survey results additionally demonstrated opportunity for improvement in resident evaluation, resources, and patient safety/teamwork. Our project's purpose was to implement and evaluate a new resident-oriented radiology morbidity and mortality (MM) conference to enhance resident education.All DR residents (n = 48) were surveyed regarding a new didactic MM consisting of quarterly resident-led and faculty-moderated MMs. Cases for potential review were collected and stored in a REDCap database via an anonymous survey, from which resident-selected faculty curators would select 4-6 for presentation. Residents presented these cases and the group discussed applicable improvements. An anonymous survey of residents followed each conference. Relevant questions from ACGME survey data were extracted from the two years preceding the didactic MM and the pilot year.Before implementation, 86% of responding residents (n = 29; 60% of resident complement) supported the program, 90% expressed willingness to share their own mistakes, and 79% preferred faculty involvement. Respondents favored careful selection of faculty to promote education. At one year, 100% of respondents (n = 17; 35% of resident complement) approved of adding the didactic MM and endorsed program continuance. All respondents expressed a willingness to share their own mistakes. There was also coincident improvement in ACGME survey data in the domains of evaluation, resources, and patient safety/teamwork.We designed and implemented a resident-oriented MM conference that resulted in increased resident confidence and impacted ACGME survey results in evaluation, resources, and patient safety/teamwork.Implementation of a structured, resident-oriented radiology MM conference can increase resident confidence and impact ACGME survey results in the domains of evaluation, resources, and patient safety/teamwork.

Purpose To assess ischemic adverse events following particle embolization when used as a second-line embolic to coil embolization for treatment of acute lower gastrointestinal bleeding(LGIB). Materials and Methods This single-institution retrospective study examined 154 procedures where embolization was attempted for LGIB. In 122 patients (64 males, mean age 69.9 years), embolization was successfully performed using microcoils in 73 procedures, particles in 34 procedures, and both microcoils and particles in 27 procedures. Particles were used as second-line only when coil embolization was infeasible or inadequate. Technical success was defined as angiographic cessation of active extravasation after embolization. Clinical success was defined as absence of recurrent bleeding within 30 days of embolization. Results Technical success for embolization of LGIB was achieved in 87.0% of cases (134/154), and clinical success was 76.1%(102/134) among technically successful cases. Clinical success was 82.2%(60/73) for coils alone and 68.9%(42/61) for particles +/- coils. Severe adverse events involving embolization-induced bowel ischemia occurred in 3 of 56 patients who underwent particle embolization +/- coils (5.3%) versus zero out of 66 patients when coils alone were used (P=0.09). In patients who had colonoscopy or bowel resection within 2 weeks of embolization, ischemic findings attributable to the embolization were found in 3 of 15 who underwent embolization with coils alone, versus 8 of 18 who underwent embolization with particles +/- coils (p=0.27). Conclusion Particle embolization for treatment of LGIB as second line to coil embolization was associated with a 68.9% clinical success rate and a 5.3% rate of ischemia-related adverse events.

Background Adenomyosis is a common gynecologic pathology that relies on diagnostic imaging to guide treatment. Accuracy of both pelvic ultrasound and magnetic resonance imaging (MRI) when specifically evaluating for the presence of adenomyosis is high. However, the accuracy of reported rates in clinical practice is less well understood. Purpose To demonstrate the accuracy in reporting of adenomyosis on pelvic ultrasound and MRI compared to histopathology in common clinical practice. Basic procedures An institutional database was searched for women with a pelvic ultrasound and a pelvic MRI with a subsequent hysterectomy. Findings were extracted from radiology and pathology reports, and the documented presence or absence of adenomyosis was recorded for each modality. Blinded radiologists viewed each imaging pair to directly evaluate for adenomyosis. Main findings Compared to prior published data, imaging had lower accuracy in clinical practice when adenomyosis was not specifically evaluated for. For the finding of adenomyosis, pelvic ultrasound had a sensitivity of 10.9%, a specificity of 98.3%, positive predictive value (PPV) of 77.8%, negative predictive value (NPV) of 66.7%, an accuracy of 67.2%, and a diagnostic odds ratio (DOR) of 7. Pelvic MRI had a sensitivity of 29.7%, specificity of 85.3%, PPV of 52.8%, NPV of 68.8%, an accuracy of 65.6%, and DOR of 2.5. Overall accuracy of MRI improved when adenomyosis was directly evaluated for (82.4% vs 65.6%). Principle conclusions Without direct communication to evaluate for adenomyosis, pelvic ultrasound and MRI may underestimate or misreport adenomyosis. Providers should be aware of these discrepancies when relying on radiology reports to guide treatment and potential interventions when diagnosing and managing adenomyosis.

Purpose To quantify the financial effect of delayed reporting of new moderate sedation (MS) Current Procedural Terminology (CPT) codes at an academic radiology practice, and to identify barriers to timely reporting. Materials and Methods Billing and reimbursement data was collected for a 28-month period (January 1, 2017-April 30, 2019). Reporting of new MS codes was identified and compared to the number of procedures performed by radiology over the study period. Using the number of procedures performed and payment data, losses were estimated. A root cause analysis was then performed to further understand delayed reporting. Results MS was reported with 2.5% of cases in 2017, 47.8% of cases in 2018 and 69.1% of cases in 2019. Appropriate coding was not achieved until June 2018, equating to a 17-month lag in implementation. Lost revenue from inaccurate reporting of MS alone was $21,357 ± $3,945 per month. Primary barriers to an efficient transition included (1) updating billing systems, (2-5) coder, nursing, technologist, and operator education and coordination, and (6) drafting and vetting new procedural report templates. Conclusions Delayed reporting of the new moderate sedation codes resulted in a $363,069 ± $67,065 loss of procedural revenue at an academic radiology practice. Primary drivers of the delay were lags in education and coordination at multiple points in the reporting chain. As healthcare policy shifts and changes to coding become more frequent and significant, timely adoption becomes more salient for radiologists.

This study explores the relationship between the development of uterine fibroids and hemoglobin SS sickle cell disease (SCD) by examining the prevalence of uterine fibroids as detected by pelvic magnetic resonance imaging (MRI) in African American (AA) women with and without SCD.A single-center, retrospective review was performed of all adult AA women at a large, academic medical center who received pelvic MRI from January 1, 2007 to December 31, 2018. Propensity score matching conditional on age and ZIP code evaluated the differences in fibroid prevalence between the two groups. Subanalyses by age in 10-year intervals were also performed.Twenty-one (23.9%) of 88 patients with SCD had fibroids on pelvic MRI versus 1493 (52.1%) of 2868 patients without SCD (p value0.001). After propensity score matching, 21 (24.7%) of 85 patients with SCD compared to 52 (61.2%) of 85 patients without SCD had fibroids (p value0.001). Subanalyses in 10-year age intervals showed significance for patients between 30 and 39 years old in which 4 (13.8%) of 29 SCD patients versus 374 (65.3%) of 573 no SCD patients had fibroids (p value0.001), and for patients between 40 and 49 years old in which 9 (42.9%) of 21 SCD patients versus 667 (73.8%) of 904 no SCD patients had fibroids (p value = 0.002).These findings indicate an overall significantly lower prevalence of uterine fibroids in AA women with SCD, suggesting that SCD may be protective against the development of uterine fibroids in these patients.

Radiology education is essential in medical school; however, developing an integrated and comprehensive curriculum remains a challenge. Many novel methods have been implemented with varying outcomes. In this study, the authors sought to examine published pedagogical methods of radiology instruction and query US academic faculty members on their current use within radiology education.A literature search for current and novel pedagogical methods of radiology instruction was performed and studies were assessed for positive educational outcomes. Educational approaches were grouped according to encountered themes. A survey was distributed to faculty members of the Alliance of Medical Student Educators in Radiology to ascertain the prevalence of these pedagogical methods in the radiology education of medical students.The following themes were encountered: supplemental instruction of anatomy and pathology; radiology-clinical correlation electives; flipped classrooms; hands-on and simulation training; peer-to-peer learning; e-learning; adaptive tutorials; and asynchronous learning. Of the survey respondents, 90% reported that their institution offers a formal radiology clerkship. The majority of respondents reported the use of flipped classrooms (70%) and e-learning (78%); however, few reported offering hands-on clinical experiences (31%) and simulation-based training (36%). Only 5% reported use of adaptive tutorials.In the review of the literature, a combination of hands-on, case-based, team-based, and didactic training, in addition to other forms of active learning within an integrated curriculum, was found to be highly effective and preferred by students and faculty. Virtual and in-person learning incorporating modern technology was found to either increase knowledge and skills or yield similar outcomes as traditional in-person instruction. These methods are currently heterogeneously used across the US medical schools represented by survey respondents, with utilization ranging from 5% to 78%.

Purpose Proton pump inhibitor (PPI) use is a potential risk factor for hepatic encephalopathy (HE), but few studies have examined the effect on post-TIPS HE. The purpose of this study was to determine whether PPIs are associated with increased rates of post-TIPS HE in an independent patient cohort. Materials and methods This single-institution retrospective study analyzed 86 patients (54 male, mean age 58.2) following TIPS from 1/1/2017 to 12/31/2019. Dates of PPI usage and episodes of new or worsening HE were recorded. Poisson regression with generalized estimating equations was used to test for association between PPI use and post-TIPS HE and to test for dose dependence. Post-TIPS HE was also analyzed using the Andersen-Gill survival model for recurrent events. Results There were 1.88 episodes of new or worsening post-TIPS HE per person-year among 35 patients on uninterrupted PPIs therapy, 1.95 on PPIs and 0.94 off PPIs among 35 patients on intermittent therapy, and 0.47 among 16 patients never on PPIs. PPI use was significantly associated with post-TIPS HE in both univariable (incidence rate ratio (IRR) = 2.62; CI = 1.41–4.84; p = 0.002) and multivariable (IRR = 2.31; CI = 1.37–3.89; p = 0.002) regression. Analysis of only those patients on PPIs showed increased rates of HE with higher doses (IRR = 1.17 per 10 mg omeprazole equivalent; CI = 1.04–1.33; p = 0.011). Recurrent events survival analysis supported the association between PPI use and HE in univariable (hazard ratio (HR) = 2.17; CI = 1.19–3.95; p = 0.011) and multivariable (HR = 1.87; CI = 1.12–3.13; p = 0.017) analysis. Conclusion In an independent patient cohort PPI use was associated with increased rates of new or worsening post-TIPS HE.

Decreasing radiology reimbursement is a major challenge faced by academic radiology practices in the United States. The consequent increased workload from reading more radiological studies can lead to job dissatisfaction, burnout and adverse impact on research, innovation, and education. Thriving successfully in an academic practice despite low reimbursement requires modification of radiology business models and culture of the practice. In this article, we review the financial and operational strategies to mitigate low reimbursement and strategies for thriving in academic radiology without burnout.

The health care sector is a resource-intensive industry, consuming significant amounts of water and energy, and producing a multitude of waste. Health care providers are increasingly implementing strategies to reduce energy use and waste. Little is currently known about existing sustainability strategies and how they may be supported by radiology practices. Here, we review concepts and ideas that minimize energy use and waste, and that can be supported or implemented by radiologists.

OBJECTIVE: To understand how women and historically underrepresented minority medical students perceive radiology as a potential career choice. METHODS: Medical students representing a broad spectrum of radiology exposure from a single institution were invited to participate in a mixed-methods study. Participants completed a 16-item survey about demographics and perceptions of radiology. Ten focus groups were administered to probe decision making regarding career selection. The themes influencing women and historically underrepresented minority students are presented. RESULTS: Forty-nine medical students, including 29 (59%) women and 17 (35%) underrepresented minorities, participated. Most participants (28/48, 58%) reported men outnumbered women in radiology. Female participants reported a lack of mentorship and role models as major concerns. Outreach efforts focused on the family friendly nature of radiology were viewed as patronizing. Demographic improvements in the field were viewed as very slow. Forty-six percent (22/48) of participants indicated that radiology had a less underrepresented racial/ethnic workforce than other medical specialties. Minority participants especially noted a lack of radiology presence in mainstream media so students have few preconceived biases. A failure to organically connect with the mostly white male radiologists due to a lack of shared background was a major barrier. Finally, participants described a hidden curriculum which pushes minority medical students away from specialty fields like radiology and towards primary care fields to address underserved communities and healthcare disparities. DISCUSSION: Women and historically underrepresented minority medical students perceive major barriers to choosing a career in radiology. Radiology departments must develop sophisticated multilevel approaches to improve diversity.

Biofluorescence has been detected in several nocturnal-crepuscular organisms from invertebrates to birds and mammals. Biofluorescence in mammals has been detected across the phylogeny, including the monotreme duck-billed platypus (Ornithorhyncus anatinus), marsupial opossums (Didelphidae), and New World placental flying squirrels (Gluacomys spp.). Here, we document vivid biofluorescence of springhare (Pedetidae) in both museum specimens and captive individuals—the first documented biofluorescence of an Old World placental mammal. We explore the variation in biofluorescence across our sample and characterize its physical and chemical properties. The striking visual patterning and intensity of color shift was unique relative to biofluorescence found in other mammals. We establish that biofluorescence in springhare likely originates within the cuticle of the hair fiber and emanates, at least partially, from several fluorescent porphyrins and potentially one unassigned molecule absent from our standard porphyrin mixture. This discovery further supports the hypothesis that biofluorescence may be ecologically important for nocturnal-crepuscular mammals and suggests that it may be more broadly distributed throughout Mammalia than previously thought.

To evaluate the technical success and safety of a steerable coaxial sharp recanalization technique that utilizes routine needles in patients with refractory thoracic central venous occlusions. This retrospective study was performed on 36-attempted sharp recanalizations in 35 patients (mean age 50 years, 23 male) performed via a supraclavicular approach. In all cases, an 18-gauge trocar needle was custom curved to provide directional control during fluoroscopic triangulation. A 22-gauge Chiba needle was then advanced coaxially across the occlusion. A tractogram was performed to assess for traversal of unintended structures. Procedures were completed by catheter placement, angioplasty, or stenting follow successful recanalizations. Sharp recanalization using this steerable coaxial needle technique demonstrated a technical success rate of 94% (34/36). The mean occlusion length was 30 mm (range 3–53 mm). In 11 patients, success was achieved using this technique after failure of other advanced techniques. In five procedures, stent interstices were traversed. Sharp recanalization was the direct cause of one major complication consisting of pleural transgression causing mild hemothorax treated successfully with a stent graft. The proposed technique is effective and safe for patients who have failed traditional blunt recanalization techniques. Level 4, Case Series.

To compare early totally implantable central venous port catheter-related infection rates after inpatient vs outpatient placement and to determine whether the risk associated with inpatient placement is influenced by length of hospital stay.In this single-institution retrospective study, 5,301 patients (3,618 women; mean age 57 y) underwent port placement by interventional radiologists between October 2004 and January 2018. The 30-day infection rate was compared between inpatients and outpatients using survival analysis. Among inpatients, the effect of time from admission to port placement and from placement to discharge was analyzed using a survival regression tree.The 30-day infection rate was 3.6% (95% confidence interval [CI] = 1.9%-6.1%) among 386 inpatients and 1.0% (95% CI = 0.7%-1.3%) among 4,915 outpatients (hazard ratio [HR] = 3.6, 95% CI = 2.0-6.6, P.001). Inpatient placement was a significant risk factor after accounting for covariates in multivariate analysis (HR = 2.2, 95% CI = 1.0-4.7, P = .05) and controlling for demographic differences by propensity score matching (HR = 2.8, 95% CI = 1.0-7.8, P = .04). Infection rate was 11% (95% CI = 4.7%-22%) among 65 inpatients in whom time from admission to placement was ≥ 7 days, 5.1% (95% CI = 1.9%-11%) among 129 inpatients in whom admission to placement was7 days and time to discharge was3 days, and 0% (95% CI = 0%-2.1%) among 192 inpatients in whom admission to placement was7 days and time to discharge was ≤ 3 days (P.001).Inpatient port placement was associated with a higher risk of early infection. However, a clinical decision tree based on shorter length of stay before and after placement may identify a subset of hospitalized patients not at increased risk for infection.

Study design Retrospective review. Objective To ascertain impact of preprocedural magnetic resonance imaging (MRI) or nuclear medicine Tc99m-DMP scintigraphy on the treatment plan when compared with plain films and/or computed tomography prior to vertebral augmentation procedures. Summary of background data Over 1 million vertebral compression fractures (VCFs) occur in the United States annually with over 150,000 individuals hospitalized each year. Physical examination and history are essential to the workup of VCFs, but imaging remains necessary for confirming the diagnosis. VCFs can be imaged with various modalities and there is limited data on the comparative effectiveness of different imaging modalities. Methods Six hundred fifty consecutive patients treated with vertebral augmentation at a single institution between May of 2013 and April of 2018 were reviewed. Preprocedure imaging of the spine obtained within 30 days prior to the procedure were reviewed. Preprocedure imaging results were cross-referenced against the levels treated by vertebral augmentation to determine whether there was a change in the levels treated after receiving an MRI or NM imaging study. Results Three hundred sixty-three patients had adequate imaging for inclusion. One hundred fifty-four of these 363 patients (42.4%) had an alteration of their treatment plan based upon the MR or NM imaging. Fewer vertebral levels were treated in 33, different levels were treated in 41, and more levels were treated in 80 patients. Conclusion MRI or nuclear medicine bone scan imaging prior to vertebral augmentation altered the location and number of levels treated in a large percentage of patients, adding specificity to treatment over findings on radiographs or computed tomography alone. Level of evidence 3.

OBJECTIVE. The purpose of this study was to assess the impact of relative sarcopenia with excess adiposity on mortality after transjugular intrahepatic portosystemic shunt (TIPS) creation. MATERIALS AND METHODS. In this single-institution retrospective study, patients underwent abdominal CT scans within 100 days before or 30 days after TIPS creation. Subcutaneous and visceral adipose tissue and muscle were segmented at the L3 vertebral level. Relative sarcopenia with excess adiposity was defined as the lowest sex-specific quartile of muscle area divided by muscle plus adipose. Dates of death, liver transplantation, TIPS occlusion, and hepatic encephalopathy (HE) after TIPS creation were identified. Mortality was evaluated using competing risks survival analysis. Number of HE episodes and time to first episode were analyzed using negative binomial regression and competing risks survival analysis, respectively. RESULTS. A total of 141 patients (91 men; mean age, 56 years) were included in this study. In univariate analyses, Model for End-Stage Liver Disease (MELD) score (hazard ratio [HR], 1.09 per point; CI, 1.05-1.13; p < 0.001) and relative sarcopenia with excess adiposity (HR, 2.70; CI, 1.55-4.69; p < 0.001) were significant risk factors for shorter survival after TIPS. In multivariate analysis, both MELD score (HR, 1.09; CI, 1.03-1.15; p = 0.003) and relative sarcopenia with excess adiposity (HR, 2.65; CI, 1.56-4.51; p < 0.001) were significant predictors of worse survival. The C-index at 30 days was 0.71 for MELD score, 0.72 for relative sarcopenia with excess adiposity, and 0.80 for a model including both. There was no association between relative sarcopenia with excess adiposity and number of HE episodes (incidence rate ratio, 1.08; CI, 0.49-2.40; p = 0.84) or time to first HE episode (HR, 0.89; CI, 0.51-1.54; p = 0.67). CONCLUSION. Relative sarcopenia with excess adiposity is a risk factor for mortality after TIPS and contributes additional prognostic information beyond MELD score.

Purpose There is increasing interest in the distal radial artery in the anatomic snuffbox as an alternative arterial access point, but the durability of the distal radial artery to support repetitive accesses over multiple procedures is not well established. The purpose of this study was therefore to evaluate success rates for repeated left-sided distal transradial access (ldTRA) in the anatomic snuffbox. Methods In this single institution retrospective study, all patients undergoing radioembolization treatments from January 1st, 2019 to May 1st, 2020 were prospectively evaluated for ldTRA. ldTRA was performed by 15 different operators. Exclusion criteria were a left radiocephalic hemodialysis fistula, inability to properly position the arm, Barbeau D waveform, or failed prior ldTRA due to tortuosity. Barbeau patterns, arterial sizes, and success rates at the first, second, and third ldTRA were compared. Results Fifty patients were evaluated for ldTRA and 44, 39, and 10 underwent one, two, and three ldTRA attempts for a total of 93 procedures. There was no significant change in Barbeau patterns between the first and second (p = 0.13) or first and third (p = 1.0) ldTRA. There was no significant change in artery size between the first (mean, 2.3 mm; range, 1.5-3.4 mm) and second (mean, 2.3 mm; range, 1.6-3.3 mm) (p = 0.59) and first and third (mean, 2.4 mm; range, 1.9-3.3) (p = 0.45) ldTRA. The success rate was not significantly different between the first (93%, 41/44, 95% CI 81%-99%), second (95%, 37/39, 95% CI 83%-99%), and third (100%, 10/10, 95% CI 69%-100%) procedure (p = 1.0). The asymptomatic occlusion rate was 4.1% (2/49, 95% CI 0%-14%), and subsequent ldTRA was successfully completed in both patients with occlusions. There were no hemorrhagic or ischemic complications. Conclusion Success rates are indistinguishable among first, second, and third time ldTRA suggesting that this is a durable access point.

The occurrence of biofluorescence across Mammalia is an area of active study. We examined three specimens of the platypus (Ornithorhynchus anatinus) from Tasmania and New South Wales, Australia, housed in the Field Museum of Natural History (Chicago, Illinois, USA) and the University of Nebraska State Museum (Lincoln, Nebraska, USA) under visible light and ultraviolet (UV) light. The pelage of the animals appeared uniformly brown under visible light and green or cyan under UV light, due to fluoresced wavelengths that peaked around 500 nm. Our observations are the first report of biofluorescence in a monotreme mammal.

Rationale and Objectives Requests for gastrostomy tube placement in patients on aspirin (ASA) 325 mg are common, particularly in patients following reconstructive surgery for head and neck cancer, but periprocedural guidelines and recommendations regarding management of high dose aspirin are inconsistent. The purpose of this study was to assess the bleeding risk of percutaneous gastrostomy tube placement in patients on ASA 325 mg. Materials and Methods This retrospective study of 213 patients who underwent image-guided “push” percutaneous gastrostomy tube placement compared rates of significant bleeding and other secondary outcomes (including all-cause mortality within 30 days, procedure-related mortality, bowel perforation, abdominal abscess, peritonitis, aspiration pneumonia, intraprocedural airway complications, and tube dislodgement) between patients maintained on ASA 325 mg and patients not on antiplatelet or anticoagulation therapy. Results No significant bleeding episodes occurred in patients on ASA 325 mg, compared to three episodes in patients not on ASA 325 mg (p = 0.37). A patient in each group had aspiration pneumonia possibly related to tube placement. There were no other notable secondary outcomes, including intraprocedural airway complications in this population with complex head and neck anatomy. Conclusion These findings suggest that holding ASA 325 mg in patients undergoing percutaneous gastrostomy tube placement is not necessary, especially in patients in whom holding ASA would pose considerable risk. Further multi-institutional longitudinal study is warranted to validate these results.

Objective Lung shunt fraction studies using technetium-99 m macro aggregated albumin are routinely performed before yttrium-90 radioembolization regardless of underlying liver malignancy type. This study evaluates the role of lung shunt fraction studies in hepatocellular carcinoma compared to non-hepatocellular carcinoma liver tumors. Methods A single-institution retrospective analysis of all pre-yttrium-90 technetium-99 m macro aggregated albumin lung shunt fraction studies between November 2012 to March 2018 was performed. Patient variables including age, underlying malignancy, laboratory values, lung shunt fraction, and severity of liver disease were compared between hepatocellular carcinoma and non-hepatocellular carcinoma cases. Results A total of 734 technetium-99 m macro aggregated albumin studies were identified in 653 patients. Among these cases, the liver tumor was hepatocellular carcinoma in 368 (50.1%), colorectal cancer in 112 (15.3%), neuroendocrine tumor in 89 (12.1%), cholangiocarcinoma in 59 (8.0%), breast cancer in 27 (3.7%), and other metastatic malignancies in 79 (10.7%). The mean lung shunt fraction for non-hepatocellular carcinoma cases was 7.4%, which was significantly lower than the mean lung shunt fraction, 11.7%, for hepatocellular carcinoma cases (P = 0.0001). In only one non-hepatocellular carcinoma case was yttrium-90 radioembolization not pursued due to high lung shunt fraction (69.3%), wherein large scale shunting was grossly apparent on angiography in a patient with metastatic gastrointestinal stromal tumor. In comparison, the lung shunt fraction was too high to pursue radioembolization in 37 hepatocellular carcinoma cases (mean lung shunt fraction 35.1%). Conclusion Lung shunt fraction appears low among patients with non-hepatocellular carcinoma liver malignancies. Further analysis examining the necessity of pre-Y90 technetium-99 m macro aggregated albumin lung shunt fraction studies in patients with non-hepatocellular carcinoma malignancies is warranted, since a consolidated yttrium-90 radioembolization without prior lung shunt fraction evaluation could reduce resource consumption, improve workflows, and patient access.

Fluorescence of visible wavelengths under ultraviolet (UV) light has been previously detected in a wide range of birds, reptiles, and amphibians and a few marsupial mammals. Here, we report the discovery of vivid UV fluorescence of the pelage in Glaucomys, the New World flying squirrels. Fluorescence in varying intensities of pink was observed in females and males of all extant species (G. oregonensis, G. sabrinus, and G. volans) across all sampled geographic areas in North and Central America and a temporal range of 130 years. We observed fluorescence in museum specimens (n = 109) and wild individuals (n = 5) on both dorsal and ventral surfaces. Museum specimens of three co-occurring, diurnal sciurid species (Sciurus carolinensis, S. niger, and Tamiasciurus hudsonicus) were also examined but did not fluoresce. The ecological significance of this trait in the nocturnal–crepuscular flying squirrels warrants further investigation.

To compare survival after transjugular intrahepatic portosystemic shunt (TIPS) creation versus serial large volume paracenteses (LVP) in patients with refractory ascites and higher Model for End-Stage Liver Disease (MELD) scores.In this retrospective study, from 1/1/2013 to 10/1/2018, 478 patients (294 male; mean age 58, range 23-89) underwent serial LVP (n = 386) or TIPS (n = 92) for ascites. Propensity-matched cohorts were constructed based on age, MELD, Charlson comorbidity index, varices, and hepatic encephalopathy. Survival was analyzed using a Cox proportional hazards model in which MELD score and TIPS were treated as time-dependent covariates. An interaction term was used to assess the impact of TIPS versus serial LVP on survival as a function of increasing MELD.In the overall patient sample, higher MELD score predicted worse survival after either serial LVP or TIPS [hazard ratio (HR) = 1.13; p 0.001], but there was no significant interaction between TIPS and higher MELD score conferring worse survival (HR = 1.01; p = 0.55). In 92 propensity-matched serial LVP and 92 TIPS patients, higher MELD score predicted worse survival after either serial LVP or TIPS (HR = 1.19; p 0.001), but there was no significant survival interaction between TIPS and higher MELD (HR = 0.97; p = 0.22). In 30 propensity-matched serial LVP patients and 30 TIPS patients with baseline MELD greater than 18, TIPS did not predict worse survival (HR = 0.97; p = 0.94).Higher MELD predicts poorer survival after either serial LVP or TIPS, but TIPS creation is not associated with worse survival compared to serial LVP in patients with higher MELD scores LEVEL OF EVIDENCE: Level 4, case series.

The purpose of this study is to compare the motivations of interventional radiology (IR) residency, IR fellowship, and diagnostic radiology (DR) applicants.A questionnaire was distributed to IR integrated residency and IR fellowship applicants for the 2018 National Resident Matching Program (NRMP) Match. Survey respondents scored the influence of 13 aspects of IR on their career decision. These results were combined with a previously published survey of DR residency applicants from 2016 who were asked the same questions. Pairwise comparisons to survey responses were made between IR residency and IR fellowship as well as IR residency and DR residency respondents.There were 202 of 657 DR residency respondents (response rate 30.7%), 114 of 295 IR residency respondents (response rate 38.6%), and 70 of 169 IR fellowship respondents (response rate 41.4%). Compared with DR respondents, IR residency respondents rated the following factors more positively: influence of a mentor (P = .030), perceived job satisfaction (P.001), job market (P .001), salary (P.001), intellectual stimulation (P = .030), the use of emerging or advanced technology (P.001), and the visual nature of the field (P .001). In contrast, DR residency respondents rated flexible work hours (P.001), physics (P.001), and competitiveness of the application process (P.001) more positively than IR respondents. Compared with IR fellowship respondents, IR residency respondents rated flexible work hours (P = .002), the job market (P = .020), physics (P.001), and salary (P.001) more positively, and competitiveness (P = .002) was felt to be more negative for residency applicants.The motivations for pursuing IR residency differ from both DR residency and IR fellowship. Understanding these motivations can help to recruit top quality IR residency applicants.

A 43-year-old woman presented with postpartum haemorrhage necessitating uterine artery embolisation. Prior to embolisation, angiography demonstrated the presence of a persistent sciatic artery (PSA). Due to the possibility of embolic particles inadvertently traveling to the lower extremity via this variant arterial pathway, care was taken to only embolise the uterine artery. PSAs are uncommon but important vascular pathways to screen for during pelvic intervention and are associated with other genitourinary anomalies.

1. Arboreal camera trapping is a burgeoning method providing a novel and effective technique to answer research questions across a variety of ecosystems, and it has the capacity to improve our understanding of a wide range of taxa. However, while terrestrial camera trapping has received much attention, there is little guidance for dealing with the unique challenges of working in the arboreal realm. 2. Our review draws on the expertise of researchers from six continents and the broader literature to investigate the advantages and disadvantages of arboreal camera trapping, and challenges to consider when using this technology. We also include mini-guides with detailed information on the current arboreal camera trap literature, mounts used to install arboreal cameras, tree climbing pointers and safety tips, methods for deploying cameras without climbing, and tips for managing interference with camera function. 3. We find that arboreal camera traps have been most commonly used in the study of mammals in forests, however there is potential for this method to be applied to a broad range of habitats including urban areas, and taxa such as birds, amphibians, invertebrates, and plants. Methods in arboreal camera trapping could be improved by developing a greater understanding of the factors affecting detection of species. The most common challenges of arboreal camera trapping are camera placement and camera site access. These can be overcome by understanding correct camera orientation, managing potential sources of interference in front of cameras, utilizing appropriate cameras mounts, and training researchers properly. 4. Given the benefits and opportunities presented by arboreal camera trapping, it is likely to become an ever-more popular method of studying arboreal species and systems. The information synthesized in this review provides guidance for future studies to help direct more reliable and robust ecological inferences from arboreal camera trapping.

Interventional radiology continues to evolve into a more robust and clinically dynamic specialty underpinned by significant advancements in training, education, and practice. This article, prepared by members of the 2020-2021 Association of University Radiologists' task force of the Radiology Research Alliance, will review these developments, highlighting the evolution of interventional radiology pathways with attention to growing educational differences, interrelation to diagnostic radiology training, post-training practice patterns, distribution of procedures and future trends, amongst other key features important to those pursuing a career in interventional radiology as well as those in practice.

PURPOSE To determine whether socioeconomic status (SES) is associated with hepatic encephalopathy (HE) risk after transjugular intrahepatic portosystemic shunt (TIPS) creation. MATERIALS AND METHODS This single-institution retrospective study included 368 patients (mean age = 56.7 years; n = 229 males) from 5 states who underwent TIPS creation. SES was estimated using the Agency for Healthcare Research and Quality SES index, a metric based on neighborhood housing, education, and income statistics. Episodes of new or worsening HE after TIPS creation, defined as hospitalization for HE or escalation in outpatient medical therapy, were identified from medical records. Multivariable ordinal regression, negative binomial regression, and competing risks survival analysis were used to identify factors associated with SES quartile, the number of episodes of new or worsening HE per unit time after TIPS creation, and mortality after TIPS creation, respectively. RESULTS There were 83, 113, 99, and 73 patients in the lowest, second, third, and highest SES quartiles, respectively. In multivariable regression, only older age (β = 0.04, confidence interval [CI] = 0.02-0.05; P < .001) and white, non-Hispanic ethnicity (β = 0.64, CI = 0.07-1.21; P = .03) were associated with higher SES quartile. In multivariable regression, lower SES quartile (incidence rate ratio [IRR] = 0.80, CI = 0.68-0.94; P = .004), along with older age, male sex, higher model for end-stage liver disease score, nonalcoholic steatohepatitis, and proton pump inhibitor use were associated with higher rates of HE after TIPS creation. Ethnicity was not associated with the rate of HE after TIPS creation (IRR = 0.77, CI = 0.46-1.29; P = .28). In multivariable survival analysis, neither SES quartile nor ethnicity predicted mortality after creation of a TIPS. CONCLUSION Lower SES is associated with higher rates of new or worsening HE after TIPS creation.

To identify whether technically modifiable factors during gastrojejunostomy (GJ) tube insertion are predictive of retrograde jejunal limb migration into the stomach.Retrospective review of our procedural database over a 5-year period revealed 988 successful primary GJ tube insertions. Medical records and imaging were reviewed for cases of retrograde jejunal limb migration. Primary analysis was performed on 74 patients with retrograde tip migration within 3 months after placement (37 males, mean age = 57). Comparison was performed on 67 control patients (34 males, mean age = 51) who had radiologically confirmed GJ tube stability for at least 6 months. Procedural fluoroscopic images were analyzed for multiple GJ tube configuration parameters. The stomach was designated into antrum, body, and fundus. Predictors of retrograde tip migration were analyzed with univariate and multivariate logistic regression analysis.A total of 110 patients (11.1%) had retrograde jejunal limb migration, with 74 (7.5%) occurring within 3 months of placement. On multivariate analysis, the factors associated with a significantly lower risk of tip malposition included gastric puncture site in the antrum (OR: 0.27, 95% CI: 0.13-0.56, p 0.001) and GJ tract angle less than 30 degrees away from the pylorus (OR: 0.35, 95% CI: 0.16-0.76, p = 0.008). No patient in either cohort had a major complication within 30 days of procedure.To minimize the risk of retrograde tip migration, GJ tubes should be inserted into the gastric antrum with an entry tract oriented as directly towards the pylorus as possible.

To evaluate the technical success and safety of a steerable coaxial sharp recanalization technique that utilizes routine needles in patients with refractory thoracic central venous occlusions.This retrospective study was performed on 36-attempted sharp recanalizations in 35 patients (mean age 50 years, 23 male) performed via a supraclavicular approach. In all cases, an 18-gauge trocar needle was custom curved to provide directional control during fluoroscopic triangulation. A 22-gauge Chiba needle was then advanced coaxially across the occlusion. A tractogram was performed to assess for traversal of unintended structures. Procedures were completed by catheter placement, angioplasty, or stenting follow successful recanalizations.Sharp recanalization using this steerable coaxial needle technique demonstrated a technical success rate of 94% (34/36). The mean occlusion length was 30 mm (range 3-53 mm). In 11 patients, success was achieved using this technique after failure of other advanced techniques. In five procedures, stent interstices were traversed. Sharp recanalization was the direct cause of one major complication consisting of pleural transgression causing mild hemothorax treated successfully with a stent graft.The proposed technique is effective and safe for patients who have failed traditional blunt recanalization techniques.Level 4, Case Series.

Patients with a gastrojejunal anastomosis pose challenging anatomy for percutaneous gastrojejunostomy (GJ)-tube placement. A retrospective review of 24 patients (mean age 67.8 years, 13 males) with GJ anastomoses who underwent attempted GJ tube placement revealed infeasible placement in 6 patients (25%) due to an inadequate window for puncture. When a gastric puncture was achieved, GJ tube insertion was technically successful in 83% (15/18) of attempts, resulting in an overall technical success rate of 63% (15/24). The most common tube-related complication was the migration of the jejunal limb into the stomach, which occurred in 40% (6/15) of successful cases. No major procedure related complications were encountered.

Retrospective review.To ascertain impact of preprocedural magnetic resonance imaging (MRI) or nuclear medicine Tc99m-DMP scintigraphy on the treatment plan when compared with plain films and/or computed tomography prior to vertebral augmentation procedures.Over 1 million vertebral compression fractures (VCFs) occur in the United States annually with over 150,000 individuals hospitalized each year. Physical examination and history are essential to the workup of VCFs, but imaging remains necessary for confirming the diagnosis. VCFs can be imaged with various modalities and there is limited data on the comparative effectiveness of different imaging modalities.Six hundred fifty consecutive patients treated with vertebral augmentation at a single institution between May of 2013 and April of 2018 were reviewed. Preprocedure imaging of the spine obtained within 30 days prior to the procedure were reviewed. Preprocedure imaging results were cross-referenced against the levels treated by vertebral augmentation to determine whether there was a change in the levels treated after receiving an MRI or NM imaging study.Three hundred sixty-three patients had adequate imaging for inclusion. One hundred fifty-four of these 363 patients (42.4%) had an alteration of their treatment plan based upon the MR or NM imaging. Fewer vertebral levels were treated in 33, different levels were treated in 41, and more levels were treated in 80 patients.MRI or nuclear medicine bone scan imaging prior to vertebral augmentation altered the location and number of levels treated in a large percentage of patients, adding specificity to treatment over findings on radiographs or computed tomography alone.3.

PurposeSickle cell disease is the most common monogenic disorder. All the elements of Virchow’s triad – hypercoagulability, endothelial dysfunction and impaired blood flow – are present in sickle cell disease patients, and can lead to thrombosis and vaso-occlusive crises. Central venous catheters are commonly used in sickle cell disease patients for rapid transfusion to avoid a vaso-occlusive crisis or for treatment after crises onset. However, central venous catheters themselves are an additional source for thrombus formation. We investigate a single day thrombolysis protocol for the treatment of catheter related thrombosis.Materials and MethodsWe present an Institutional Review Board approved retrospective analysis spanning from June 2016 to April 2018 evaluating upper extremity thrombolysis in the setting of catheter related thrombosis. All patients underwent a similar protocol involving peripheral upper extremity access, pharmomechanical thrombolysis, and angioplasty, which is described in detail. In 33% of the procedures, a recalcitrant stenosis was then stented. Maximal balloon size and stent sizes are included for reference.ResultsIn follow up, one patient had a severe complication possibly related to the large thrombus burden, and expired. One patient who did not initially have recalcitrant stenosis and therefor did not have a stent placed during the initial procedure, had recurrent stenosis and thrombosis 6 months after the initial procedure, and had repeat pharmomechanical thrombolysis performed, with stent placement at that time. The other procedures were without complication, and the upper extremity and central venous systems remained patent at most recent follow-up, up to 30 months post procedure.ConclusionsIn the circumstance of severe catheter related thrombosis, we present a protocol which can be considered for therapeutic use without further intervention required in 78% of cases at 2 years.

Rationale and Objectives Historically, patients undergoing image-guided percutaneous gastrostomy tube placement have been admitted overnight with feeds commencing 12–24 hours postprocedure. With new expedited feeding protocols starting 3–4 hours postprocedure, same-day discharge is now possible. The purpose of this study was to evaluate the safety and cost of image-guided percutaneous gastrostomy tube placement as an outpatient procedure. Materials and Methods In this retrospective study, 131 patients (age 63.9 ± 11.6; 34% female) underwent gastrostomy tube placement as an outpatient procedure with expedited feeding protocol versus 40 patients (age 61.3 ± 12.6; 38% female) who were hospitalized overnight with feeds starting at 12–24 hours, primarily based on operator preference. The two groups were compared regarding complications within 90 days of procedure. Using a subgroup of 33 consecutive patients, procedural costs (total combined insurer and patient payments for professional and hospital services) for outpatients vs. hospitalized patients were compared. Results Complication rates were similar (p = 0.64) for gastrostomy tubes placed on outpatients (0.17 complications/procedure: 4 bleeding, 2 aspiration pneumonia, 1 abdominal abscess, 4 significant pain, 6 cellulitis, 1 surgical consult, 4 malpositioned/fractured tubes) and hospitalized patients (0.20 complications/procedure: 1 aspiration pneumonia, 1 significant pain, 3 cellulitis, 1 surgical consult, 2 fractured tubes). Total combined insurer and patient payments were similar ($2193/outpatient vs $2701/hospitalized patient; p= 0.52). Conclusion Outpatient image-guided percutaneous gastrostomy tube placement with an expedited feeding protocol is a safe and cost-comparable alternative to historic overnight hospitalization. Further prospective investigation with a larger sample is warranted.

Purpose To report initial clinical experience with intravascular ultrasound (US)-guided transvenous biopsy (TVB) for perivascular target lesions in the abdomen and pelvis using side-viewing phased-array intracardiac echocardiography catheters. Materials and Methods In this single-institution, retrospective study, 48 patients underwent 50 intravascular US-guided TVB procedures for targets close to the inferior vena cava or iliac veins deemed difficult to access by conventional percutaneous needle biopsy (PNB). In all procedures, side-viewing phased-array intracardiac echocardiography intravascular US catheters and transjugular liver biopsy sets were inserted through separate jugular or femoral vein access sheaths, and 18-gauge core needle biopsy specimens were obtained under real-time intravascular US guidance. Diagnostic yield, diagnostic accuracy, and complications were analyzed. Results Intravascular US-guided TVB was diagnostic of malignancy in 40 of 50 procedures for a diagnostic yield of 80%. There were 5 procedures in which biopsy was correctly negative for malignancy, with a per-procedure diagnostic accuracy of 90% (45/50). Among the 5 false negatives, 2 patients underwent repeat intravascular US-guided TVB, which was diagnostic of malignancy for a per-patient diagnostic accuracy of 94% (45/48). There were 1 (2%) mild, 2 (4%) moderate, and 1 (2%) severe adverse events, with 1 moderate severity adverse event (venous thrombosis) directly attributable to the intravascular US-guided TVB technique. Conclusions Intravascular US-guided TVB performed on difficult-to-approach perivascular targets in the abdomen and pelvis resulted in a high diagnostic accuracy, similar to accepted thresholds for PNB. Complication rates may be slightly higher but should be weighed relative to the risks of difficult PNB, surgical biopsy, or clinical management without biopsy.

Trauma is a significant contributor to mortality, especially in the young. Pelvic trauma with pelvic ring fractures may result in associated arterial injury, necessitating endovascular intervention. As a result, interventional radiology plays a critical role in partnering with trauma providers in the care of these patients. Management is determined by the acuity of the patient's clinical status, radiographs, ultrasound, and the results of computed tomography imaging when available. Numerous embolic agents are available for treatment of arterial hemorrhage.

Trauma is a leading cause of death in patients under the age of 45 and generally associated with a high kinetic energy event such as a motor vehicle accident or fall from extreme elevations. Blunt trauma can affect every organ system and major vascular structure with potentially devastating effect. When we consider abdominal solid organ injury from blunt trauma, we usually think of the liver, spleen, and kidneys. However, all of the abdominal organs, including the pancreas and adrenal glands, may be involved. Blunt hepatic trauma is more commonly associated with venous bleeding rather than arterial injury. Stable venous injury is often managed conservatively; when the patient is hemodynamically unstable from venous hepatic injury, operative management should be first-line therapy. When the injury is arterial, endovascular therapy should be initiated. Blunt trauma to the spleen is the most common cause of traumatic injury to the spleen. Management is controversial. In our institution unstable patients are taken to the operating room, and stable patients with Grades IV-V injuries and patients with active arterial injury are taken for endovascular treatment. Renal injuries are less common, and evidence of arterial injury such as active extravasation or pseudoaneurysm is warranted before endovascular therapy. Pancreatic trauma is uncommon and usually secondary to steering wheel/handlebar mechanism injuries. Adrenal injuries are rare in the absence of megatrauma or underlying adrenal abnormality.

Biliary and urinary obstructions can be managed endoscopically or cystoscopically, surgically or by percutansous intervention or drainage. If the obtructed system is infected, emergent decompression is needed. Early recognition and treatment is paramount in both conditions. Acute cholangitis can present many different ways, from mild symptoms to fulminant sepsis. It is usually a result of ascending bacterial colonization and biliary obstruction resulting in bacterial overgrowth. Therefore, those patients with recent biliary instrumentation or previous biliary modification are at higher risk. Charcot's triad of fever, right upper quadrant abdominal pain, and jaundice is only seen in 50%-70% of patients. Fever is seen in over 90% of cases, pain is seen in 70% of cases, and jaundice is seen in 60% of cases. Altered mental status and hypotension are associated with severe cases. All 5 symptoms of fever, right upper quadrant abdominal pain, jaundice, altered mental status, and hypotension are referred to as Reynold's Pentad. Acute pyonephrosis can also present many different ways, from minimal symptoms to fulminant sepsis. Fever, chills, and flank pain are the classic symptoms, although some patients may be relatively asymptomatic. Pyonephrosis may present with a classic triad of fever, flank pain, and hydronephrosis, or simply hydronephrosis and sepsis. Pyonephrosis usually occurs as a result of urinary obstruction with either an ascending infection of the urinary tract or hematogenous spread of a bacterial pathogen as the culprit. Up to 75% of cases are related to urinary stone disease. Patients are at increased risk for pyonephrosis when they haven anatomic urinary tract obstruction, certain chronic diseases (diabetes meliitus and AIDS), or are immunosuppressed due to immunodeficiency or medications, (chronic steroid therapy).