Developing a Clinical Pediatric Interventional Practice: A Joint Clinical Practice Guideline from the Society of Interventional Radiology and the Society for Pediatric Radiology

Efficacy of standardizing fibrinolytic therapy for parapneumonic effusion

BACKGROUND

While chest tube placement with pleural fibrinolytic medication is the established treatment of pediatric empyema, treatment failure is reported in up to 20% of these children.

OBJECTIVE

Standardizing fibrinolytic administration among interventional radiology (IR) physicians to improve patient outcomes in pediatric parapneumonic effusion.

MATERIALS AND METHODS

We introduced a hospital-wide clinical pathway for parapneumonic effusion (1-2 mg tissue plasminogen activator [tPA] twice daily based on pleural US grade); we then collected prospective data for IR treatment May 2017 through February 2020. These data included demographics, co-morbidities, pediatric intensive care unit (PICU) admission, pleural US grade, culture results, daily tPA dose average, twice-daily dose days, skipped dose days, pleural therapy days, need for chest CT/a second IR procedure/surgical drainage, and length of stay. We compared the prospective data to historical controls with IR treatment from January 2013 to April 2017.

RESULTS

Sixty-three children and young adults were treated after clinical pathway implementation. IR referrals increased (P = 0.02) and included higher co-morbidities (P = 0.005) and more PICU patients (P = 0.05). Mean doses per day increased from 1.5 to 1.9 (P < 0.001), twice-daily dose days increased from 38% to 79% (P < 0.001) and median pleural therapy days decreased from 3.5 days to 2.5 days (P = 0.001). No IR patients needed surgical intervention. No statistical differences were observed for gender/age/weight, US grade, need for a second IR procedure or length of stay. US grade correlated with greater positive cultures, need for chest CT/second IR procedure, and pleural therapy days.

CONCLUSION

Interventional radiology physician standardization improved on a clinical pathway for fibrinolysis of parapneumonic effusion. Despite higher patient complexity, pleural therapy duration decreased. There were no chest tube failures needing surgical drainage.

A critical appraisal of the quality of guidelines for radiation protection in interventional radiology using the AGREE II tool: A EuroAIM initiative

PURPOSE

To systematically review and assess the methodological quality of guidelines for radiation protection in interventional radiology.

MATERIALS AND METHODS

On April 15^th, 2021, a systematic search for guidelines on radiation protection in interventional radiology was performed using MEDLINE, EMBASE, National Guideline Clearinghouse, and National Institute for Health and Clinical Excellence databases. Among retrieved guidelines, we then excluded those not primarily focused on radiation protection or on interventional radiology. Authors' professional role and year of publication were recorded for each included guideline. Guideline quality evaluation was performed independently by three authors using the six-domain tool "AGREE II", with an overall guideline quality score divided into three classes: low (<60%), acceptable (60-80%), and good quality (>80%).

RESULTS

Our literature search identified 106 citations: after applying exclusion criteria, 11 guidelines published between 2009 and 2018 were included, most of their authors being interventional radiologists (168/224, 75%). Overall quality of included guidelines was acceptable (median 72%, interquartile range 64-83%), with only one guideline (9%) with overall low quality and four guidelines (36%) with overall good quality. Among AGREE II domains, "Scope and Purpose", "Clarity of Presentations", and "Editorial Independence" had the best results (87%, 76%, and 75% respectively), while "Applicability", "Rigor of Development", and "Stakeholder Involvement" the worst (46%, 49%, and 52% respectively).

CONCLUSION

Considering all guidelines, the overall methodological quality was acceptable with one third of them reaching the highest score class. The "Applicability" domain had the lowest median score, highlighting a practical implementation gap to be addressed by future guidelines.

Adherence to the RIGHT statement in Society of Interventional Radiology guidelines

Context

The Reporting Items for Practice Guidelines in Health Care (RIGHT) Statement was developed by a multidisciplinary team of experts to improve reporting quality and transparency in clinical practice guideline development.

Objective

To assess the quality of reporting in clinical practice guidelines put forth by the Society of Interventional Radiology (SIR) and their adherence to the RIGHT statement checklist.

Methods

In March 2018, using the 22 criteria listed in the RIGHT statement, two researchers independently documented adherence to each item for all eligible guidelines listed by the SIR by reading through each guideline and using the RIGHT statement elaboration and explanation document as a guide to determine if each item was appropriately addressed as listed in the checklist. To qualify for inclusion in this study, each guideline must have met the strict definition for a clinical practice guideline as set forth by the National Institute of Health and the Institute of Medicine, meaning they were informed by a systematic review of evidence and intended to direct patient care and physician decisions. Guidelines were excluded if they were identified as consensus statements, position statements, reporting standards, and training standards or guidelines. After exclusion criteria were applied, the two researchers scored each of the remaining clinical practice guidelines (CPGs) using a prespecified abstraction Google form that reflected the RIGHT statement checklist (22 criteria; 35 items inclusive of subset questions). Each item on the abstraction form consisted of a “yes/no” option; each item on the RIGHT checklist was recorded as “yes” if it was included in the guideline and “no” if it was not. Each checklist item was weighed equally. Partial adherence to checklist items was recorded as “no.” Data were extracted into Microsoft Excel (Microsoft Corporation) for statistical analysis.

Results

The initial search results yielded 129 CPGs in the following areas: 13 of the guidelines were in the field of interventional oncology; 16 in neurovascular disorders; five in nonvascular interventions; four in pediatrics; 25 in peripheral, arterial, and aortic disease; one in cardiac; one in portal and mesenteric vascular disease; 37 in practice development and safety; three in spine and musculoskeletal disorders; 14 in venous disease; five in renal failure/hemodialysis; and five in women’s health. Of the 46 guidelines deemed eligible for evaluation by the RIGHT checklist, 12 of the checklist items showed less than 25% adherence and 13 showed more than 75% adherence. Of 35 individual RIGHT statement checklist items, adherence was found for a mean (SD) of 22.9 items (16.3). The median number of items with adherence was 21 (interquartile range, 7.5–38).

Conclusion

The quality of reporting in interventional radiology guidelines is lacking in several key areas, including whether patient preferences were considered, whether costs and resources were considered, the strength of the recommendations, and the certainty of the body of evidence. Poor adherence to the RIGHT statement checklist in these guidelines reveals many areas for improvement in guideline reporting.

Percutaneous Nephrostomy in the Neonatal Period: Indications, Complications, and Outcome-A Single Centre Experience

PURPOSE

The purpose of this study was to evaluate the indications, technique for percutaneous nephrostomy (PCN) insertion, the complications related to PCN, duration of PCN, and outcome following PCN removal regarding the kidney function.

MATERIAL AND METHODS

Medical charts of 31 neonates (22 boys and 9 girls, mean age 13.9 days) treated with 43 PCN were reviewed. Collected data included indications for PCN, PCN complications, duration of PCN, and outcome of these patients by analysing the kidney function.

RESULTS

The indications for PCN insertion were obstructive urinary tract dilation in 24 neonates (four with associated infection), and non-obstructive urinary tract dilation with urosepsis or pyonephrosis in seven cases. Primary technical success of PCN placement using Seldinger technique was 97.7%. The following complications were reported: self-limited post-procedural bleeding into the pelvicalyceal system in two, chronic microscopic haematuria in five, and clinically manifested urinary tract infection in five children. Four PCN were dislocated. Cellulitis was present at the skin entry of 5 PCN, urinary leak in 5 PCN, and mechanical damage of 5 PCN. Eight PCN had to be replaced. Mean duration of PCN was 5 months. Kidney insufficiency was detected in 5/29 children with the mean follow-up of 3.9 years.

CONCLUSIONS

PCN is a safe, effective transient solution in neonates with pyonephrosis or when surgery of obstructed urinary system has to be postponed. The rate of minor complications increased with PCN duration. If kidney insufficiency is present after PCN removal, it is related to the complexity of kidney anomalies.

Non-vascular interventional radiology in the paediatric alimentary tract

Paediatric interventional radiology is an evolving speciality which is able to offer numerous minimally invasive treatments for gastrointestinal tract pathologies. Here we describe interventions performed by paediatric interventional radiologists on the alimentary tract from the mouth to the rectum. The interventions include sclerotherapy, stricture management by dilation, stenting and adjunctive therapies such as Mitomycin C administration and enteral access for feeding, motility assessment and administration of enemas.

Quality and readability of online patient information regarding sclerotherapy for venous malformations

BACKGROUND

Patients often use the internet as a source of information about their condition and treatments. However, this information is unregulated and varies in quality.

OBJECTIVE

To evaluate the readability and quality of online information for pediatric and adult patients and caregivers regarding sclerotherapy for venous malformations.

MATERIALS AND METHODS

"Venous malformation sclerotherapy" was entered into Google, and results were reviewed until 20 sites that satisfied predefined inclusion criteria were identified. Scientific and non-patient-focused web pages were excluded. Readability was assessed using the Flesch Reading Ease Score and American Medical Association reading difficulty recommendations and quality was assessed using Journal of the American Medical Association standards and assessing if the site displayed HONcode (Health on the Net Code) certification. Assessment of the breadth of relevant information was made using a predefined checklist.

RESULTS

Forty-nine search engine results were reviewed before 20 sites were identified for analysis. Average Flesch Reading Ease Score was 44 (range: 24.2-70.1), representing a "fairly difficult" reading level. None of the sites had a Flesch Reading Ease Score meeting the American Medical Association recommendation of 80-90. Only one site met all four Journal of the American Medical Association quality criteria (average: 2.1). None of the sites displayed a HONcode seal. The information most frequently found was: sclerotherapy is performed by radiologists, multiple treatments may be needed and surgery is an alternative treatment.

CONCLUSION

Online information regarding sclerotherapy for venous malformations is heterogeneous in quality and breadth of information, and does not meet readability recommendations for patient information. Radiologists should be aware of and account for this when meeting patients.

Pediatric interventional radiology clinic - how are we doing?

BACKGROUND

Development of a pediatric interventional radiology clinic is a necessary component of providing a pediatric interventional radiology service. Patient satisfaction is important when providing efficient, high-quality care.

OBJECTIVE

To analyze the care provided by a pediatric interventional radiology clinic from the perspective of efficiency and parent satisfaction, so as to identify areas for improvement.

MATERIALS AND METHODS

The prospective study was both quantitative and qualitative. The quantitative component measured clinic efficiency (waiting times, duration of clinic visit, nurse/physician time allocation and assessments performed; n = 91). The qualitative component assessed parental satisfaction with their experience with the pediatric interventional radiology clinic, using a questionnaire (5-point Likert scale) and optional free text section for feedback (n = 80). Questions explored the family's perception of relevance of information provided, consent process and overall satisfaction with their pediatric interventional radiology clinic experience.

RESULTS

Families waited a mean of 11 and 10 min to meet the physician and nurse, respectively. Nurses and physicians spent a mean of 28 and 21 min with the families, respectively. The average duration of the pediatric interventional radiology clinic consultation was 56 min. Of 80 survey participants, 83% were satisfied with their experience and 94% said they believed providing consent before the day of the procedure was helpful. Only 5% of respondents were not satisfied with the time-efficiency of the interventional radiology clinic.

CONCLUSION

Results show the majority of patients/parents are very satisfied with the pediatric interventional radiology clinic visit. The efficiency of the pediatric interventional radiology clinic is satisfactory; however, adherence to stricter scheduling can be improved.