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To compare radioembolization treatment zone volumes from mapping cone beam CT (CBCT) versus planning CT/MRI and to model their impact on dosimetry. Y90 cases were retrospectively identified in which intra-procedural CBCT angiograms were performed. Segmental and lobar treatment zone volumes were calculated with semi-automated contouring using Couinaud venous anatomy (planning CT/MRI) or tumor angiosome enhancement (CBCT). Differences were compared with a Wilcoxon signed-rank test. Treatment zone-specific differences in segmental volumes by volumetric method were also calculated and used to model differences in delivered dose using medical internal radiation dosimetry (MIRD) at 200 and 120 Gy targets. Anatomic, pathologic, and technical factors likely affecting segmental volumes by volumetric method were evaluated. Forty segmental and 48 lobar CBCT angiograms and corresponding planning CT/MRI scans were included. Median Couinaud- and CBCT-derived segmental volumes were 281 and 243 mL, respectively (p = 0.005). Differences between Couinaud and CBCT lobar volumes (right, left) were not significant (p = 0.24, p = 0.07). Couinaud overestimated segmental volumes in 28 cases by a median of 98 mL (83%) and underestimated in 12 cases by median 69 mL (20%). At a 200 Gy dose target, Couinaud estimates produced median delivered doses of 367 and 160 Gy in these 28 and 12 cases. At a 120 Gy target, Couinaud produced doses of 220 and 96 Gy. Proximal vs. distal microcatheter positioning, variant arterial anatomy, and tumor location on or near segmental watersheds were leading factors linked to volumetric differences. Use of CBCT-based volumetry may allow more accurate, personalized dosimetry for segmental Y90 radioembolization.

OBJECTIVE. The purpose of this study was to report national utilization trends and outcomes after percutaneous cholecystostomy, cholecystectomy, or no intervention among patients admitted to hospitals with acute cholecystitis. MATERIALS AND METHODS. The Nationwide Inpatient Sample was queried from 2005 to 2014. Admissions were identified and stratified into treatment groups of percutaneous cholecystostomy, cholecystectomy, and no intervention on the basis of International Classification of Diseases, 9th revision, codes. Outcomes, including length of stay, inpatient mortality, and complications including hemorrhage and bile peritonitis, were identified. Multivariate analysis was performed to identify mortality risk by treatment type after adjustment for baseline comorbidities and risk of mortality. RESULTS. Among 2,550,013 patients (58.6% women, 41.4% men; mean age, 55.9 years) admitted for acute cholecystitis over the study duration, 73,841 (2.9%) patients underwent percutaneous cholecystostomy, 2,005,728 (78.7%) underwent cholecystectomy, and 459,585 (18.0%) did not undergo either procedure. Use of percutaneous cholecystostomy increased from 2985 procedures in 2005 to 12,650 in 2014. The percutaneous cholecystostomy cohort had a higher mean age (70.6 years) than the other two groups (cholecystectomy, 53.8 years; no intervention, 62.5 years), a higher mean comorbidity index (cholecystostomy, 3.74; cholecystectomy, 1.77; no intervention, 2.65), and a higher mean risk of mortality index (cholecystostomy, 2.88; cholecystectomy, 1.45; no intervention, 2.07) (p < .05). Unadjusted inpatient all-cause mortality was 10.1% in the percutaneous cholecystostomy, 0.8% in the cholecystectomy, and 5.2% in the no intervention cohorts. After adjustment for baseline mortality risk, percutaneous cholecystostomy (odds ratio, 0.78; 95% CI, 0.76-0.81) and cholecystectomy (odds ratio, 0.42; 95% CI, 0.41-0.43) were associated with reduced mortality compared with no intervention. CONCLUSION. Use of percutaneous cholecystostomy is increasing among patients admitted with acute cholecystitis. After adjustment for baseline comorbidities, percutaneous cholecystostomy is associated with improved odds of survival compared with no intervention.

Gastrointestinal interventions have continuously evolved since the inception of interventional radiology. This article will review major milestones in this evolution including the introduction of new tools, the development of new procedures, and the establishment of interventional radiology as its own clinical specialty. Together, these milestones have helped shape how interventional radiologists perform gastrointestinal interventions today.

To compare survival outcomes (all-cause, cancer-specific, and disease-free) for small hepatocellular carcinomas (HCCs), less than or equal to 5 cm, after ablation (AB) and surgical resection (SR) after adjusting for key confounders. Secondarily, to understand differential survival outcomes of liver transplant (TR) compared with SR and AB.Using Surveillance, Epidemiology, and End Results Program-Medicare, HCCs less than 5 cm that were treated with AB, SR, or TR in 2009 to 2016 (n = 1,215) were identified using Healthcare Common Procedure Coding System codes through Medicare claims. The TR group was subdivided into two groups: TR with prior treatment and TR without prior treatment. All-cause survival, cancer-specific survival, and disease-free survival were analyzed using Kaplan-Meier curves and compared between groups using log-rank tests and Cox regression analyses. Propensity score-matched comparison of AB and SR groups was performed, with groups matched on demographics, social determinants of health, medical comorbidities, and liver disease severity prognostic indicators.Median study follow-up time was 2.71 years (interquartile range 1.25-3.83). Unadjusted 1-, 3-, and 5-year cancer-specific survivals were 85.9%, 67.6%, and 56.3% for the AB group; 91.7%, 82.6%, and 81.7% for the SR group; 93.5%, 88.7%, and 79.4% for TR without prior treatment group; and 96.4%, 93.2%, and 93.2% for TR with prior treatment group (P.0001). With SR as the reference group, the propensity-matched hazard ratios for AB were 2.04 (95% confidence interval: 1.51-2.77) for all-cause mortality, 2.44 (95% confidence interval: 1.56-3.80) for cancer-specific mortality, and 2.12 (95% confidence interval: 1.61-2.78) for disease recurrence.SR is superior to AB for small HCCs in a large, nationally representative, modern cohort, and in secondary analysis TR was superior to both.

Hepatocellular carcinoma (HCC) is a leading cause of morbidity and mortality worldwide, with rising clinical and economic burden as incidence increases. There are a multitude of evolving treatment options, including locoregional therapies which can be used alone, in combination with each other, or in combination with systemic therapy. These treatment options have shown to be effective in achieving remission, controlling tumor progression, improving disease free and overall survival in patients who cannot undergo resection and providing a bridge to transplant by debulking tumor burden to downstage patients. Following locoregional therapy (LRT), it is crucial to provide treatment response assessment to guide management and liver transplant candidacy. Therefore, Liver Imaging Reporting and Data Systems (LI-RADS) Treatment Response Algorithm (TRA) was created to provide a standardized assessment of HCC following LRT. LI-RADS TRA provides a step by step approach to evaluate each lesion independently for accurate tumor assessment. In this review, we provide an overview of different locoregional therapies for HCC, describe the expected post treatment imaging appearance following treatment, and review the LI-RADS TRA with guidance for its application in clinical practice. Unique to other publications, we will also review emerging literature supporting the use of LI-RADS for assessment of HCC treatment response after LRT.

To understand portal vein embolization (PVE), associated liver partition and portal vein ligation (ALPPS) and radiation lobectomy (RL) outcomes in hepatocellular carcinoma (HCC) patients. Systematic reviews of future liver remnant (FLR) percent hypertrophy, proportion undergoing hepatectomy and proportion with major complications following PVE, ALPPS, and RL were performed by searching Ovid MEDLINE, Ovid EMBASE, The Cochrane Library, and Web of Science. Separate meta-analyses using random-effects models with assessment of study heterogeneity and publication bias were performed whenever allowable by available data. Of the 10,616 articles screened, 21 articles with 636 subjects, 4 articles with 65 subjects, and 4 articles with 195 subjects met the inclusion criteria for systematic reviews and meta-analyses for PVE, ALPPS, and RL, respectively. The pooled estimate of mean percent FLR hypertrophy was 30.9% (95%CI: 22–39%, Q = 4034.8, p < 0.0001) over 40.3 +/− 26.3 days for PVE, 54.9% (95%CI: 36–74%, Q = 73.8, p < 0.0001) over 11.1 +/− 3.1 days for ALPPS, and 29.0% (95%CI: 23–35%, Q = 56.2, p < 0.0001) over 138.5 +/− 56.5 days for RL. The pooled proportion undergoing hepatectomy was 91% (95%CI: 83–95%, Q = 43.9, p = 0.002) following PVE and 98% (95%CI: 50–100%, Q = 0.0, p = 1.0) following ALPPS. The pooled proportion with major complications was 5% (95%CI: 2–10%, Q = 7.3, p = 0.887) following PVE and 38% (95%CI: 18–63%, Q = 10.0, p = 0.019) following ALPPS. Though liver hypertrophy occurs following all three treatments in HCC patients, PVE balances effective hypertrophy with a short time frame and low major complication rate.

To examine the effect of a clinic workflow intervention on follow-up for routine ercutaneous nephrostomy tube (PCN) exchanges.An intervention consisting of automated electronic tracking for all PCN placements and exchanges followed by phone call reminders to schedule a follow-up exchange 60 days post-procedure was introduced on March 19, 2019. All PCN exchanges performed from March 19, 2018 to September 18, 2019 were identified through a local electronic database search to assess the impact of intervention as a quality improvement project. Basic demographic information and procedure details were collected. Routine follow-up at our institution is recommended every 90 days. The exchange rates within 90 days were compared between groups using a Chi-squared test.A total of 160 PCN placements or exchanges were performed pre-intervention and 69 PCN exchanges were performed post-intervention. Pre-intervention, 75/160 (46.3%) were exchanged within 90 days compared to 47/69 (68.1%) exchanged within 90 days post-intervention. The remainder had delayed follow-up due to loss to follow-up or scheduling delays. Post-intervention, there was a significantly improved rate of compliance for PCN exchanges within the recommended 90 days at our institution (p-value = 0.002).Automated tracking and phone call follow-up at 60 days post-procedure is a simple and effective intervention that can improve compliance for routine PCN exchanges and reduce the number of patients that are lost to follow-up.

The optimal medical management of patients following endovascular deep venous interventions remains ill-defined. As such, the Society of Interventional Radiology Foundation (SIRF) convened a multidisciplinary group of experts in a virtual Research Consensus Panel (RCP) to develop a prioritized research agenda regarding antithrombotic therapy following deep venous interventions. The panelists presented the gaps in knowledge followed by discussion and ranking of research priorities based on clinical relevance, overall impact, and technical feasibility. The following research topics were identified as high priority: 1) characterization of biological processes leading to in-stent stenosis/rethrombosis; 2) identification and validation of methods to assess venous flow dynamics and their effect on stent failure; 3) elucidation of the role of inflammation and anti-inflammatory therapies; and 4) clinical studies to compare antithrombotic strategies and improve venous outcome assessment. Collaborative, multicenter research is necessary to answer these questions and thereby enhance the care of patients with venous disease.

This retrospective analysis reviews five patients with transjugular intrahepatic portosystemic shunt (TIPS) who underwent percutaneous microwave ablation of hepatocellular carcinoma between January 2017 and September 2020. Mean tumor diameter was 2.0 cm (range 1.3-2.9 cm), and mean tumor distance from TIPS was 2.3 cm (range 1.5-3.3 cm). There were no major adverse events, and the TIPS patency was 100% post-ablation. The technical success rate was 100%, and the complete response rate was 100%. In this small study, percutaneous microwave ablation appears safe and effective for the treatment of hepatocellular carcinoma in patients with TIPS in the short-term follow-up period.

Purpose To compare procedure characteristics and outcomes when TIPS is performed under intracardiac echocardiography guidance (iTIPS) compared to conventional fluoroscopic guidance (cTIPS). Materials and methods A retrospective propensity-matched study of 30 iTIPS and 30 cTIPS procedures from January 2014 to March 2017 at a single US high volume academic medical center was performed. iTIPS and cTIPS cases were propensity score matched using predictive variables: age, race, gender, etiology of liver disease, indication for TIPS, MELD score, and portal vein patency. Procedure characteristics and post- procedure outcomes were compared between propensity-matched groups including: total procedure time, technical success, radiation dose, contrast volume, complication rate, 30- day mortality, and revision rate within 3 months. Results Radiation dose (875.3 vs 457.4 mGY, p = 0.039) and contrast volume (141 vs 103 mL, p = 0.005) were significantly decreased in the iTIPS versus the cTIPS group. There was no significant difference in procedure time (81.5 cTIPS vs 84 min iTIPS) or rate of TIPS revisions within 3 months. Average operator experience in the iTIPs group was 4.2 years and cTIPS group 11.0 years (p = 0.0004). All procedures were technically successful with no mortalities within 30 days. Conclusion iTIPS resulted in significantly reduced radiation dose and contrast volume. However, there was no difference in total procedure time or overall outcomes despite greater operator experience in the cTIPS group.

BACKGROUND/AIM To compare overall survival (OS) and liver cancer-specific survival (LCSS) of Surveillance, Epidemiology and End Results (SEER) hepatocellular carcinoma (HCC) database patients treated with cryoablation (cryo) or radiofrequency ablation (RFA). MATERIALS AND METHODS This was a retrospective review of Stage I or II HCC patients from the SEER database treated with cryo and RFA from 2004-2013. Kaplan-Meier and Cox regressions were performed on pooled and propensity-matched cohort. RESULTS Out of 3,239 patients, RFA showed a significant survival advantage over cryo in liver cancer specific survival (LCSS) (HR=1.634 p=0.0004). A total of 91 propensity-matched pairs had similar OS (HR=1.006 p=0.9768), but no difference in LCSS was observed between the groups [HR=1.412 (95%CI=0.933-2.137) p=0.1023]. Survival Cox models did not reveal treatment type as an independent prognostic factor. CONCLUSION Propensity-matched cohort showed no significant difference in terms of OS and LCSS was found for patients treated with either cryo or RFA for localized HCC.

Objectives The aim of this study was to investigate the contemporary trends and comparative effectiveness of adjunctive inferior vena cava filter (IVCF) placement in patients undergoing catheter-directed thrombolysis (CDT) for treatment of proximal lower extremity or caval deep vein thrombosis. Background CDT is being increasingly used in the management of proximal deep vein thrombosis. Although a significant number of patients treated with CDT undergo adjunctive IVCF placement, the benefit of this practice remains unknown. Methods The National Inpatient Sample database was used to identify all patients with proximal or caval deep vein thrombosis who underwent CDT (with and without adjunctive IVCF placement) in the United States between January 2005 and December 2013. A propensity score–matching algorithm was then used to derive 2 matched groups of patients (IVCF and no IVCF) for comparative outcomes (mortality and major and minor bleeding) and resource use analysis. Results Of the 7,119 patients treated with CDT, 2,421 (34%) received IVCFs. There was no significant difference in in-hospital mortality (0.7% vs 1.0%; p = 0.20), procedure-related hemorrhage (1.4% vs. 1.0%; p = 0.23), or intracranial hemorrhage (0.7% vs. 0.6%; p = 0.70) between the IVCF (n = 2,259) and no-IVCF (n = 2,259) groups, respectively. Patients undergoing IVCF placement had higher rates of hematoma (3.4% vs 2.1%; p = 0.009), higher in-hospital charges ($104,049 ± 75,572 vs. $92,881 ± 80,194; p Conclusions This nationwide observational study suggests that one-third of all patients undergoing CDT receive IVCFs. IVCF use was not associated with a decrease in in-hospital mortality but was associated with higher inpatient charges and longer length of stay.

Minimally invasive techniques in the treatment of cancer continue to develop at a rapid pace. Although surgical resection currently remains the only option for a complete cure, not all diseases are amenable to complete removal. This leaves opportunities to develop effective downstaging techniques as well as palliative care. In the realm of minimally invasive oncologic techniques, catheter-based therapies are an attractive option because malignancies require a blood supply to remain active. The intra-arterial (IA) delivery of specific tumoricidal drugs has been shown to be a successful delivery method in a variety of different cancers, and it is currently a progressive area of research. There is work both to increase the delivery specificity of oncologic drugs, including SW43 sigma receptor ligand and nanoparticle research. In addition, oncolytic viral therapy and 3-bromopyruvate have become increasingly more attractive tumoricidal drug prospects. In the future, the success of these therapies will ultimately determine the degree to which IA delivery will compete with the systemic delivery of drugs in the treatment of cancer.

The presence of cancer increases the risk of deep vein thrombosis (DVT), DVT recurrence, and treatment-related bleeding, and therefore offers distinctive clinical considerations when planning treatment. Anticoagulation with a low-molecular-weight heparin is the preferred initial and long-term therapy in cancer patients. Inferior vena cava filters may be used judiciously for patients with cancer-related DVT who have contraindications to anticoagulation or who exhibit breakthrough pulmonary embolism (PE) despite anticoagulation, but should be removed when the PE risk is felt to subside. Because moderate-quality evidence suggests that the use of catheter-directed thrombolysis (CDT) can prevent the postthrombotic syndrome, cancer patients with acute iliofemoral DVT, low expected bleeding risk, and good functional status may reasonably be considered for CDT if DVT-related sequelae are likely to be a dominant contributor to the patient's clinical condition, functional status, and quality of life. In selected patients who have chronic venous symptoms from mass/nodal compression of the pelvic veins, endovascular stent placement may provide symptom relief. As current recommendations are based on very limited data, further studies would be welcome to better delineate the most appropriate use of endovascular therapies in patients with cancer.

BACKGROUND AND PURPOSE: CT angiography and perfusion imaging is an important prognostic tool in the management of patients with aneurysmal subarachnoid hemorrhage. The purpose of this study was to perform a cost-effectiveness analysis of advanced imaging in patients with SAH, incorporating the risks of radiation exposure from CT angiography and CT perfusion imaging. MATERIALS AND METHODS: The risks of radiation-induced brain cancer and cataracts were incorporated into our established decision model comparing the cost-effectiveness of CT angiography and CT perfusion imaging and transcranial Doppler sonography in SAH. Cancer risk was calculated by using National Cancer Institute methodology. The remaining input probabilities were based on literature data and a cohort at our institution. Outcomes were expected quality-adjusted life years gained, costs, and incremental cost-effectiveness ratios. One-way, 2-way, and probabilistic sensitivity analyses were performed. RESULTS: CT angiography and CT perfusion imaging were the dominant strategies, resulting in both better health outcomes and lower costs, even when incorporating brain cancer and cataract risks. Our results remained robust in 2-way sensitivity analyses varying the prolonged latency period up to 30 years, with either brain cancer risk up to 50 times higher than the upper 95% CI limit or the probability of cataracts from 0 to 1. Results were consistent for scenarios that considered either symptomatic or asymptomatic patients with SAH. Probabilistic sensitivity analysis confirmed our findings over a broad range of selected input parameters. CONCLUSIONS: While risks of radiation exposure represent an important consideration, CT angiography and CT perfusion imaging remained the preferred imaging compared with transcranial Doppler sonography in both asymptomatic and symptomatic patients with SAH, with improved health outcomes and lower health care costs, even when modeling a significantly higher risk and shorter latency period for both cataract and brain cancer than that currently known.

Purpose To assess the accessibility and content of query Interventional Radiology (IR) fellowship program websites and determine the impact of these websites on applicants. Materials and methods All IR fellowship programs were individually evaluated, and all IR fellowship applicants to our institution were surveyed. Results In 2015, 44.3% of programs had an appropriate functional link to the fellowship website. Most provided a program description and application information. In our survey, applicants reported that website quality was moderately important to their overall impression of a fellowship. The most important aspects were didactics and facilities information. Conclusion Fellowship website content and quality are important to applicants.

Pleural effusions are frequently encountered in the clinical setting, affect thousands of patients annually, and have numerous etiologies. The interventional radiologist has an important set of tools available for the treatment of pleural effusions, ranging from image-guided chest tube placement to thoracic duct (TD) embolization. Knowledge of these nonvascular percutaneous interventions is an essential part of the basic and advanced toolset for every practicing interventional radiologist. An understanding of the pathophysiology of various pleural pathologies, the appropriate indications for small-caliber tube thoracostomy placement, and the management of chest tubes in the periprocedural setting is vital for appropriate patient care. In this chapter, the etiologies, management protocols, and techniques for treatment of several types of pleural effusions are reviewed, with a special look at the lymphatic system.

Imaging is reliant upon the contrast between different body elements, which may be present naturally or may require the introduction of extrinsic contrast agents. Since the 1920s, the use of contrast agents has been refined to enhance the diagnostic potential of multiple imaging modalities. Contrast agents are a vital part of diagnosis and treatment algorithms involving image guidance. Given the wealth of contrast agents on the market, a basic understanding of the various types is critical for budding interventional radiologists who need to use such agents judiciously on a daily basis. Such contrast agents may be administered intravenously, intraarterially, intrathecally, orally, via inhalation, transrectally, or via indwelling tubes or catheters cannulating a specific viscus. In this chapter, we review the key categories, contraindications, and alternatives for such agents, with special attention to their use in an interventional radiology (IR) practice.

Aim To compare toxicity, response, and survival outcomes of patients with hepatic metastases from breast cancer who underwent transarterial chemoembolization (TACE) or radioembolization (TARE). Materials and methods A retrospective review was carried out of all patients who underwent TACE or TARE for liver-dominant breast cancer metastases between January 2006 and March 2016 at an academic medical center in the United States. Results Seventeen patients in the TACE group and 30 patients in the TARE group received 32 TACE and 49 TARE treatments, respectively. Median follow-up was 9 months. Both groups had similar background variables. More all-grade adverse events were seen in the TACE group (71% vs. 44%; p=0.02). Median overall survival in the TACE group was 4.6 months compared to 12.9 months in the TARE group (p=0.2349). Treatment type was not an independent prognostic factor. Conclusion TARE is better tolerated than TACE for the treatment of liver-dominant breast cancer metastasis. There was a trend towards improved survival with TARE; however, it did not approach statistical significance. Larger studies are needed to validate these findings.

Aim: To compare the overall survival (OS) and liver cancer-specific survival of advanced-stage hepatocellular carcinoma (HCC) patients who received transarterial radioembolization (TARE) with those who received nonoperative/interventional treatment (NOT). Materials & methods: A total of 12,520 HCC patients from the Surveillance, Epidemiology and End Results database were categorized by treatment with either radioembolization or NOT. Kaplan–Meier and multivariate Cox regression were conducted. Results: The TARE group had both a significantly longer median overall survival than the NOT group (TARE = 9 months; NOT = 2 months; p Conclusion: TARE appears to provide a significant survival advantage over the NOT population in advanced HCC patients.

Public awareness of inferior vena cava (IVC) filter-related controversies has been elevated by the Food and Drug Administration (FDA) safety communication in 2010.To examine population level trends in IVC filter utilization, complications, retrieval rates, and subsequent pulmonary embolism (PE) risk.A retrospective cohort study.Patients receiving IVC filters during 2005-2014 in New York State.IVC filter-specific complications, new PE occurrences and IVC filter retrievals were evaluated as time-to-event data using Kaplan-Meier analysis. Estimated cumulative risks were obtained at various timepoints during follow-up.There were 91,873 patients receiving IVC filters between 2005 and 2014 in New York State included in the study. The average patient age was 67 years and 46.6% were male. Age-adjusted rates of IVC filter placement increased from 48 cases/100,000 in 2005 to 52 cases/100,000 in 2009, and decreased afterwards to 36 cases/100,000 in 2014. The estimated risks of having an IVC filter-related complication and filter retrieval within 1 year was 1.5% [95% confidence interval (CI), 1.4%-1.6%] and 3.5% (95% CI, 3.4%-3.6%). One-year retrieval rate was higher post-2010 when compared with pre-2010 years (hazard ratio, 2.70; 95% CI, 2.50-2.91). Among the 58,176 patients who did not have PE events before or at the time of IVC filter placement, the estimated risk of developing subsequent PE at 1 year was 2.0% (95% CI, 1.9%-2.1%).Our findings suggest that FDA communications may be effective in modifying statewide clinical practices. Given the 2% observed PE rate following prophylactic IVC filter placement, large scale pragmatic studies are needed to determine contemporary safety and effectiveness of IVC filters.

The aim of this study was to investigate the contemporary trends and comparative effectiveness of adjunctive inferior vena cava filter (IVCF) placement in patients undergoing catheter-directed thrombolysis (CDT) for treatment of proximal lower extremity or caval deep vein thrombosis.CDT is being increasingly used in the management of proximal deep vein thrombosis. Although a significant number of patients treated with CDT undergo adjunctive IVCF placement, the benefit of this practice remains unknown.The National Inpatient Sample database was used to identify all patients with proximal or caval deep vein thrombosis who underwent CDT (with and without adjunctive IVCF placement) in the United States between January 2005 and December 2013. A propensity score-matching algorithm was then used to derive 2 matched groups of patients (IVCF and no IVCF) for comparative outcomes (mortality and major and minor bleeding) and resource use analysis.Of the 7,119 patients treated with CDT, 2,421 (34%) received IVCFs. There was no significant difference in in-hospital mortality (0.7% vs 1.0%; p = 0.20), procedure-related hemorrhage (1.4% vs. 1.0%; p = 0.23), or intracranial hemorrhage (0.7% vs. 0.6%; p = 0.70) between the IVCF (n = 2,259) and no-IVCF (n = 2,259) groups, respectively. Patients undergoing IVCF placement had higher rates of hematoma (3.4% vs 2.1%; p = 0.009), higher in-hospital charges ($104,049 ± 75,572 vs. $92,881 ± 80,194; p 0.001) and increased length of stay (7.3 ± 5.6 days vs. 6.9 ± 6.9 days; p = 0.046) compared with the no-IVCF group.This nationwide observational study suggests that one-third of all patients undergoing CDT receive IVCFs. IVCF use was not associated with a decrease in in-hospital mortality but was associated with higher inpatient charges and longer length of stay.

A pilot study was performed to evaluate the use of carbon dioxide (CO2) as a contrast medium for C-arm computed tomography (CT). C-arm CT using CO2 was performed during embolization procedures in12 patients with hepatic malignancies and severe iodine allergy or high risk for nephrotoxicity. C-arm CT using gadolinium or iodinated contrast medium was performed for comparison. Of segmental arteries identified by conventional contrast enhancement, 96% were also seen with CO2 enhancement, but subsegmental arteries were not reliably depicted. CO2 enhancement identified 60% of tumors. Small, hypovascular, and infiltrative tumors were difficult to detect. CO2 is a promising alternative intraarterial contrast agent for C-arm CT.

Aims: To determine the rate of diffusion of myoglobin and bovine serum albumin (BSA) through the human cornea. These small proteins have hydrodynamic diameters of approximately 4.4 and 7.2 nm, and molecular weights of 16.7 and 66 kDa, for myoglobin and BSA, respectively. Meth ods: Diffusion coefficients were measured using a diffusion chamber where the protein of interest and balanced salt solution were in different chambers separated by an ex vivo human cornea. Protein concentrations in the balanced salt solution chamber were measured over time. Diffusion coefficients were calculated using equations derived from Fick’s law and conservation of mass in a closed system. Results: Our experiments demonstrate that the diffusion coefficient of myoglobin is 5.5 ± 0.9 × 10–8 cm2/s (n = 8; SD = 1.3 × 10–8 cm2/s; 95% CI: 4.6 × 10–8 to 6.4 × 10–8 cm2/s) and the diffusion coefficient of BSA is 3.1 ± 1.0 × 10–8 cm2/s (n = 8; SD = 1.4 × 10–8 cm2/s; 95% CI: 2.1 × 10–8 to 4.1 × 10–8 cm2/s). Conclusions: Our study suggests that molecules as large as 7.2 nm may be able to passively diffuse through the human cornea. With applications in pharmacotherapy and the development of an artificial cornea, further experiments are warranted to fully understand the limits of human corneal diffusion and its clinical relevance.

Acute cholecystitis is a common cause of abdominal pain in the Western world. Unless treated promptly, patients with acute cholecystitis may develop complications such as gangrenous, perforated, or emphysematous cholecystitis. Because of the increased morbidity and mortality of complicated cholecystitis, early diagnosis and treatment are essential for optimal patient care. Nevertheless, complicated cholecystitis may pose significant challenges with cross-sectional imaging, including sonography and computed tomography (CT). Interpreting radiologists should be familiar with the spectrum of sonographic findings seen with complicated cholecystitis and as well as understand the complementary role of CT. Worrisome imaging findings for complicated cholecystitis include intraluminal findings (sloughed mucosa, hemorrhage, abnormal gas), gallbladder wall abnormalities (striations, asymmetric wall thickening, abnormal gas, loss of sonoreflectivity and contrast enhancement), and pericholecystic changes (echogenic fat, pericholecystic fluid, abscess formation). Finally, diagnosis of complicated cholecystitis by sonography and CT can guide alternative treatments including minimally invasive percutaneous and endoscopic options.

Purpose To evaluate factors associated with positive online patient ratings and written comments regarding hand surgeons. Methods We randomly selected 250 hand surgeons from the American Society for Surgery of the Hand member directory. Surgeon demographic and rating data were collected from 3 physician review Web sites (www.HealthGrades.com, www.Vitals.com, and www.RateMDs.com). Written comments were categorized as being related to professional competence, communication, cost, overall recommendation, staff, and office practice. Online presence was defined by 5 criteria: professional Web site, Facebook page, Twitter page, and personal profiles on www.Healthgrades.com and/or www.Vitals.com. Results A total of 245 hand surgeons (98%) had at least one rating among the 3 Web sites. Mean number of ratings for each surgeon was 13.4, 8.3, and 1.9, respectively, and mean overall ratings were 4.0 out of 5, 3.3 out of 4, and 3.8 out of 5 stars on www.HealthGrades.com, www.Vitals.com, and www.RateMDs.com, respectively. Positive overall ratings were associated with a higher number of ratings, Castle Connolly status, and increased online presence. No consistent correlations were observed among online ratings and surgeon age, sex, years in practice, practice type (ie, private practice vs academics), and/or geographic region. Finally, positive written comments were more often related to factors dependent on perceived surgeon competence, whereas negative comments were related to factors independent of perceived competence. Conclusions Physician review Web sites featured prominently on Google, and 98% of hand surgeons were rated online. This study characterized hand surgeon online patient ratings as well as identified factors associated with positive ratings and comments. In addition, these findings highlight how patients assess care quality. Clinical relevance Understanding hand surgeon online ratings and identifying factors associated with positive ratings are important for both patients and surgeons because of the recent growth in physician-rating Web sites.

National health care reform and scrutiny on rising health care costs have created a climate in which health care providers must improve the value, or quality per cost,[1][1] of patient care. Radiology in particular is at an important crossroads given the heavy use of imaging and the associated large

ACO : Accountable Care Organization The landscape of health care is quickly changing, with new legislation and economic factors driving health care reform. Yet, fundamentally many health care delivery professionals, including physicians, remain unaware of the changing landscape and its

To assess the relative afferent pupillary defect (RAPD) by swinging flashlight as a potentially useful screening test for glaucomatous optic neuropathy.One hundred seven subjects prospectively recruited from a mixed population of glaucomatous and nonglaucomatous patients were examined for a RAPD by 1 individual masked with regard to disease presence. All subjects underwent a swinging flashlight test with, when necessary, the aid of neutral density filters, to determine whether or not a RAPD was present. A determination of glaucoma diagnosis, as well as classification of disease stage, was subsequently assessed based upon review of history and ophthalmic examination. This clinical information regarding glaucomatous disease was ascertained without knowledge of study RAPD status. The acquisition of such clinical information and performance of swinging flashlight testing for RAPD was conducted by different individuals with the latter being a nonophthalmologist.Statistical analysis demonstrated an odds ratio of 9.71 (95% CI, 3.72-25.40) for glaucomatous disease if a RAPD was present, with a sensitivity of 66.7% and a specificity of 82.9%. Subanalysis of patients who had not previously undergone cataract surgery revealed an odds ratio of 17.05 (95% CI, 4.73-61.44) for glaucomatous disease if a RAPD was present, with a sensitivity of 68.8% and a specificity of 88.6%.RAPD screening by a swinging flashlight test with neutral density filters was moderately sensitive and strongly specific for glaucoma. Sensitivity, specificity, and predictive value improved when patients who had previously undergone cataract surgery were removed from the analysis.

To determine the incidence of neonatal endogenous endophthalmitis in the United States between 1998 and 2006 and to identify associated risk factors.Retrospective cohort study.We used the Nationwide Inpatient Sample database, a 20% representative sample of all hospital discharges in the United States, to help refine our understanding of this condition. International Classification of Diseases, ninth edition, codes for endophthalmitis, sepsis, and suspected endophthalmitis risk factors in hospitalized infants and neonates were searched in the database and were tracked over time. The main outcome measure was incidence of neonatal endophthalmitis over the study period.Of 3.64 million live births in 1998, 317 newborns were identified with endophthalmitis (8.71 cases per 100 000 live births). Of 4.14 million live births in 2006, only 183 newborns were identified with endophthalmitis (4.42 cases per 100 000 live births) by comparison. The incidence of endophthalmitis decreased at a rate of 6% per year (P = .01130) between 1998 and 2006. Neonates with endophthalmitis were more likely to have systemic bacteremia (odds ratio, 21.114; P.0001), Candidemia (odds ratio, 2.356; P.0001), a birth weight of less than 1500 g (odds ratio, 1.215; P.0001), and retinopathy of prematurity (odds ratio, 2.052; P.0001).We objectively validated the commonly held belief that Candidemia, bacteremia, retinopathy of prematurity, and low birth weight are significant risk factors for endophthalmitis development in infants, which seems to have had a decreasing incidence in recent years.

This study evaluates the effects of exposure duration, beam diameter, and power on the safety, selectivity, and healing of retinal lesions created using a continuous line scanning laser. A 532 nm laser (PASCALTM) with retinal beam diameters of 40 and 66 μm was applied to 60 eyes of 30 Dutch-Belted rabbits. Retinal exposure duration varied from 15 to 60 μs. Lesions were acutely assessed by ophthalmoscopy and fluorescein angiography (FA). RPE flatmounts were evaluated with live-dead fluorescent assay (LD). Histological analysis was performed at 1 hour, 1 and 3 days, 1 and 2 weeks, and 1 and 2 months following laser treatment. Ophthalmoscopic visibility (OV) of the lesions corresponded to photoreceptor damage on histological analysis at 1 hour. In subvisible lesions, FA and LD yielded similar thresholds of RPE damage. The ratios of the threshold of rupture and of OV to FA visibility (measures of safety and selectivity) increased with decreasing duration and beam diameter. Above the threshold of OV, histology showed focal RPE damage and photoreceptor loss at one day without inner retinal effects. By one week, continuity of photoreceptor and RPE layers was restored. By 1 month, photoreceptors appeared normal while hypertrophy and hyperpigmentation of the RPE persisted. Retinal therapy with a fast scanning continuous laser achieves selective targeting of the RPE and, at higher power, of the photoreceptors. The damage zone in the photoreceptor layer is quickly filled-in, likely due to photoreceptor migration from adjacent zones. Continuous scanning laser can treat large retinal areas within standard eye fixation time.

Purpose To compare optical coherence tomography with fluorescein angiography in 11 patients (21 eyes) with central foveal damage from solar retinopathy. Methods Retrospective, observational case series of 11 patients with solar retinopathy. Dilated funduscopic examination was performed as well as photographic, fluorescein angiography, optical coherence tomography, and Humphrey visual field assessment. Results Significant foveal pathology was identified in each of the 21 eyes (11 patients). Visual acuity in affected eyes ranged from 20/25 to 20/200. Optical coherence tomography demonstrated foveal atrophy associated with a characteristic defect at the level of the inner and outer segment junction of the photoreceptors in all 21 affected eyes, whereas fluorescein angiography identified classic window defects in 19 eyes (10 of 11 patients). There was a modest correlation between foveal thickness and visual acuity. Conclusion Fluorescein angiography did not detect lesions characteristic of solar retinopathy in all patients with a definitive history of sungazing and visual loss. Conversely, optical coherence tomography did detect significant foveal atrophy in all affected eyes and a characteristic defect at the photoreceptor-retinal pigment epithelium junction. Optical coherence tomography improves the diagnosis and assessment of the degree and nature of foveal damage in patients with solar retinopathy and may be an important tool in identifying foveal damage not detected by standard fluorescein angiography.

Purpose Hairy cell leukemia (HCL) is a rare disorder that occasionally has visual symptoms after diagnosis. The authors present a case of HCL in which bilateral visual symptoms led to the initial diagnosis. Methods Observational case report. Results Bilateral decreased vision to 20/30 in the right eye and 20/40 in the left due to intraretinal and pre-retinal hemorrhages with no other systemic signs or symptoms prompted a hematologic evaluation in which HCL was found to be the causative disorder in a previously healthy 41-year-old man. Conclusions The authors present a rare case in which bilateral visual complaints led to the diagnosis of HCL. Thus, though uncommon, HCL should be considered in the differential diagnosis of otherwise unexplained retinal hemorrhages.