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Clements W, Bolger M, Varma DK. Immediate Angiography after Major Trauma: Establishing Feasibility Through Systems, Governance, and Infrastructure. Cardiovasc Intervent Radiol 2024; 47:481-482. [PMID: 38498067 DOI: 10.1007/s00270-024-03688-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 02/16/2024] [Indexed: 03/19/2024]
Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia.
- Department of Surgery, Monash University, Clayton, Australia.
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Australia.
| | - Mark Bolger
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Dinesh K Varma
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia
- Department of Surgery, Monash University, Clayton, Australia
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Australia
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Clements W, Chenoweth A, Morphett L, Billington E, Nandurkar R, Phan T, Venn GA, Lukies MW. A cost outcome study of varicocoele embolisation and future pregnancy in an Australian public hospital setting. J Med Imaging Radiat Oncol 2024; 68:282-288. [PMID: 38437182 DOI: 10.1111/1754-9485.13629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 02/21/2024] [Indexed: 03/06/2024]
Abstract
INTRODUCTION Varicocoele is commonly encountered in males with infertility. Studies have shown that varicocoele repair (surgery or embolisation) can improve the rate of subsequent pregnancy. In Australia, there have been no studies assessing the cost of varicocoele embolisation and current practice is based on international data. This study aimed to assess the cost of varicocoele embolisation and estimate the treatment cost per pregnancy. METHODS Retrospective cost-outcome study of patients treated by embolisation between January 2018 and 2023. A bottom-up approach was used to calculate procedure costs whereas a top-down approach was used to calculate costs for all other patient services, including direct and indirect costs. To calculate cost per pregnancy, costs were adjusted according to existing published data on the rate of pregnancy after embolisation. RESULTS Costing data from 18 patients were included, of median age 33.5 years (range 26-60) and median varicocoele grade 2.5 (range 1-3). All patients had unilateral treatment, most commonly via right internal jugular (16 patients, 89%) and using a 0.035″ system (17 patients, 94%). The median cost for the entire treatment including procedural, non-procedural, ward and peri-procedural costs was AUD$2208.10 (USD$1405 or EUR€1314), range AUD$1691-7051. The projected cost to the healthcare system per pregnancy was AUD$5387 (USD$3429 or EUR€3207). CONCLUSION Total varicocoele embolisation cost and the cost per-pregnancy were lower than for both embolisation and surgical repair in existing international studies. Patients undergoing varicocoele treatment should have the option to access an interventional radiologist to realise the benefits of this low-cost pinhole procedure.
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Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University Central Clinical School, Melbourne, Victoria, Australia
- National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Abigail Chenoweth
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
| | - Laura Morphett
- Department of Finance, Alfred Health, Melbourne, Victoria, Australia
| | - Eliza Billington
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
| | - Rohan Nandurkar
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
| | - Tuan Phan
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University Central Clinical School, Melbourne, Victoria, Australia
| | - Georgina A Venn
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
| | - Matthew W Lukies
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Medical Imaging, Monash Health, Melbourne, Victoria, Australia
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Clements W, Lukies M, Zia A, Fitzgerald M, Kavnoudias H. Let's settle the controversy-gelfoam is a safe intravascular embolic agent. Br J Radiol 2024:tqae047. [PMID: 38402518 DOI: 10.1093/bjr/tqae047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 02/08/2024] [Accepted: 02/21/2024] [Indexed: 02/26/2024] Open
Abstract
OBJECTIVES A 2021 safety alert restricted endovascular gelfoam use in Australia and resulted in an embargo on gelfoam sales to IR departments. This study aimed to show that gelfoam is safe in a population of trauma patients with pelvic injury, and discuss the basis of the recent controversies. METHODS Retrospective cohort study between 1 January 2010 and 21 May 2021 of patients who underwent gelfoam embolisation for pelvic arterial haemorrhage. Primary outcome was the rate of adverse events related to intravascular gelfoam administration. RESULTS Inclusion criteria met in 50 patients, comprising 58% males median age 59.9 years, and median injury severity score 31. There were 0 complications related to gelfoam use and 100% technical success. 35 patients (70%) received a non-targeted embolisation approach. All-cause mortality was observed in 5 patients (10%), unrelated to gelfoam. CONCLUSIONS Gelfoam is a safe and effective embolic agent in pelvic trauma. Patients are in urgent need of universal on-label registration of endovascular gelfoam products, as it is life-saving in major haemorrhage after trauma. ADVANCES IN KNOWLEDGE Endovascular gelfoam is mandatory for a high-quality trauma service, and this study shows that it is safe to use intentionally in the endovascular space. Companies should work with interventional radiologists, sharing and collaborating to ensure positive outcomes for patients.
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Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Health, Melbourne, Australia
- Department of Surgery, Monash University, Australia
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Australia
| | - Matthew Lukies
- Department of Radiology, Alfred Health, Melbourne, Australia
| | - Adil Zia
- Department of Radiology, Alfred Health, Melbourne, Australia
| | - Mark Fitzgerald
- Department of Surgery, Monash University, Australia
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Australia
- Department of Trauma, Alfred Health, Melbourne, Australia
| | - Helen Kavnoudias
- Department of Radiology, Alfred Health, Melbourne, Australia
- Department of Surgery, Monash University, Australia
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Clements W. How Important is Low-Cost to the Overall Value of Interventional Radiology? Cardiovasc Intervent Radiol 2024; 47:158-160. [PMID: 38147154 DOI: 10.1007/s00270-023-03637-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/24/2023] [Indexed: 12/27/2023]
Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia.
- Department of Surgery, Monash University Central Clinical School, Melbourne, Australia.
- National Trauma Research Institute, Melbourne, Australia.
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Lukies M, Clements W. Splenic artery embolisation for splenic injury during colonoscopy: A systematic review. United European Gastroenterol J 2024; 12:44-55. [PMID: 38047383 PMCID: PMC10859723 DOI: 10.1002/ueg2.12498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 09/21/2023] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND Splenic injury due to colonoscopy is rare, but has high mortality. While historically treated conservatively for low-grade injuries or with splenectomy for high-grade injuries, splenic artery embolisation is increasingly utilised, reflecting modern treatment guidelines for external blunt trauma. This systematic review evaluates outcomes of published cases of splenic injury due to colonoscopy treated with splenic artery embolisation. METHODS A systematic review was performed of published articles concerning splenic injury during colonoscopy treated primarily with splenic artery embolisation, splenectomy, or splenorrhaphy from 1977 to 2022. Datapoints included demographics, past surgical history, indication for colonoscopy, delay to diagnosis, treatment, grade of injury, splenic artery embolisation location, splenic preservation (salvage), and mortality. RESULTS The 30 patients treated with splenic artery embolisation were of mean age 65 (SD 9) years and 67% female, with 83% avoiding splenectomy and 6.7% mortality. Splenic artery embolisation was proximal to the splenic hilum in 81%. The 163 patients treated with splenectomy were of mean age 65 (SD 11) years and 66% female, with 5.5% mortality. Three patients treated with splenorrhaphy of median age 60 (range 59-70) years all avoided splenectomy with no mortality. There was no difference in mortality between splenic artery embolisation and splenectomy cohorts (p = 0.81). CONCLUSIONS Splenic artery embolisation is an effective treatment option in splenic injury due to colonoscopy. Given the known benefits of splenic salvage compared to splenectomy, including preserved immune function against encapsulated organisms, low cost, and shorter hospital length of stay, embolisation should be incorporated into treatment pathways for splenic injury due to colonoscopy in suitable patients.
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Affiliation(s)
- Matthew Lukies
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, Melbourne, Victoria, Australia
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Clements W, Dunne T, Clare S, Lukies M, Fitzgerald M, Mathew J, Kavnoudias H, Zia A, Ban EJ, Skelley A, Koukounaras J. A retrospective observational study assessing mortality after pelvic trauma embolisation. J Med Imaging Radiat Oncol 2024. [PMID: 38294148 DOI: 10.1111/1754-9485.13623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 01/17/2024] [Indexed: 02/01/2024]
Abstract
INTRODUCTION Trauma to the pelvic ring and associated haemorrhage represent a management challenge for the multidisciplinary trauma team. In up to 10% of patients, bleeding can be the result of an arterial injury and mortality is reported as high as 89% in this cohort. We aimed to assess the mortality rate after pelvic trauma embolisation and whether earlier embolisation improved mortality. METHODS Retrospective study at single tertiary trauma and referral centre, between 1 January 2009 and 30 June 2022. All adult patients who received embolisation following pelvic trauma were included. Patients were excluded if angiography was performed but no embolisation performed. RESULTS During the 13.5-year time period, 175 patients underwent angiography and 28 were excluded, leaving 147 patients in the study. The all-cause mortality rate at 30-days was 11.6% (17 patients). The median time from injury to embolisation was 6.3 h (range 2.8-418.4). On regression analysis, time from injury to embolisation was not associated with mortality (OR 1.01, 95% CI 0.952-1.061). Increasing age (OR 1.20, 95% CI 1.084-1.333) and increasing injury severity score (OR 1.14, 95% CI 1.049-1.247) were positively associated with all-cause 30-day mortality, while non-selective embolisation (OR 0.11, 95% CI 0.013-0.893) was negatively associated. CONCLUSION The all-cause mortality rate at 30-days in or cohort was very low. In addition, earlier time from injury to embolisation was not positively associated with all-cause 30-day mortality. Nevertheless, minimising this remains a fundamental principle of the management of bleeding in pelvic trauma.
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Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Talulla Dunne
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Radiology, St James' Hospital, Dublin, Ireland
| | - Steven Clare
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
| | - Matthew Lukies
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Diagnostic and Interventional Imaging, KK Women's and Children's Hospital, Singapore City, Singapore
| | - Mark Fitzgerald
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Trauma, Alfred Health, Melbourne, Victoria, Australia
| | - Joseph Mathew
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Trauma, Alfred Health, Melbourne, Victoria, Australia
| | - Helen Kavnoudias
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Adil Zia
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
| | - Ee Jun Ban
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Trauma, Alfred Health, Melbourne, Victoria, Australia
| | - Annabelle Skelley
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
| | - Jim Koukounaras
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
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Clements W, Fitzgerald M, Chennapragada SM, Mathew J, Groombridge C, Ban EJ, Lukies MW. A systematic review assessing incorporation of prophylactic splenic artery embolisation (pSAE) into trauma guidelines for the management of high-grade splenic injury. CVIR Endovasc 2023; 6:62. [PMID: 38103054 PMCID: PMC10725392 DOI: 10.1186/s42155-023-00414-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/05/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Splenic artery embolisation (SAE) has become a vital strategy in the modern landscape of multidisciplinary trauma care, improving splenic salvage rates in patients with high-grade injury. However, due to a lack of prospective data there remains contention amongst stakeholders as to whether SAE should be performed at the time of presentation (prophylactic or pSAE), or whether patients should be observed, and SAE only used only if a patient re-bleeds. This systematic review aimed to assess published practice management guidelines which recommend pSAE, stratified according to their quality. METHODS The study was registered and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Medline, PubMed, Cochrane, Embase, and Google Scholar were searched by the study authors. Identified guidelines were graded according to the Appraisal of Guidelines Research and Evaluation II (AGREE-II) instrument. RESULTS Database and internet searches identified 1006 results. After applying exclusion criteria, 28 guidelines were included. The use of pSAE was recommended in 15 guidelines (54%). This included 6 out of 9 guidelines that were high quality (66.7%), 4 out of 9 guidelines that were moderate quality (44.4%), and 3 out of 10 (30%) guidelines that were low quality, p = 0.275. CONCLUSIONS This systematic review showed that recommendation of pSAE is more common in guidelines which are of high quality. However, there is vast heterogeneity of recommended practice guidelines, likely based on individual trauma systems rather than the available evidence. This reflects biases with interpretation of data and lack of multidisciplinary system inputs, including from interventional radiologists.
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Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Hospital, 55 Commercial Rd, Melbourne, VIC, 3004, Australia.
- Department of Surgery, Monash University Central Clinical School, Melbourne, Australia.
- National Trauma Research Institute, Melbourne, Australia.
| | - Mark Fitzgerald
- Department of Surgery, Monash University Central Clinical School, Melbourne, Australia
- National Trauma Research Institute, Melbourne, Australia
- Department of Trauma, Alfred Health, Melbourne, Australia
| | - S Murthy Chennapragada
- Discipline of Child and Adolescent Health, Sydney Medical School, Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
- Department of Medical Imaging, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Joseph Mathew
- Department of Surgery, Monash University Central Clinical School, Melbourne, Australia
- National Trauma Research Institute, Melbourne, Australia
- Department of Trauma, Alfred Health, Melbourne, Australia
| | - Christopher Groombridge
- Department of Surgery, Monash University Central Clinical School, Melbourne, Australia
- National Trauma Research Institute, Melbourne, Australia
- Department of Trauma, Alfred Health, Melbourne, Australia
| | - Ee Jun Ban
- National Trauma Research Institute, Melbourne, Australia
- Acute General Surgical Unit, Alfred Health, Melbourne, Australia
| | - Matthew W Lukies
- Department of Radiology, Alfred Hospital, 55 Commercial Rd, Melbourne, VIC, 3004, Australia
- Department of Surgery, Monash University Central Clinical School, Melbourne, Australia
- National Trauma Research Institute, Melbourne, Australia
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Hogarty J, Jassal K, Ravintharan N, Adhami M, Yeung M, Clements W, Fitzgerald M, Mathew JK. Twenty-year perspective on blunt traumatic diaphragmatic injury in level 1 trauma centre: Early versus delayed diagnosis injury patterns and outcomes. Emerg Med Australas 2023; 35:842-848. [PMID: 37308166 DOI: 10.1111/1742-6723.14255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/25/2023] [Accepted: 05/14/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Blunt traumatic diaphragmatic injury (TDI) is typically associated with severe trauma and concomitant injuries. It is a diagnostic challenge in the setting of blunt trauma and can be easily overlooked especially in the acute phase often dominated by concurrent injuries. METHODS A retrospective review was conducted of patients with blunt-TDI identified from a level 1 trauma registry. Variables associated with early versus delayed diagnosis as well as non-survivor and survivor groups were collected to examine factors associated with delayed diagnosis. RESULTS A total of 155 patients were included (mean age 46 ± 20, 60.6% male). Diagnosis was made <24 h in 126 (81.3%), and >24 h in 29 (18.7%). Of the delayed diagnosis group, 14 (48%) were diagnosed >7 days. Overall, 27 (21.4%) patients had a diagnostic initial CXR and 64 (50.8%) had a diagnostic initial CT. Fifty-eight (37.4%) patients were diagnosed intraoperatively. Of the delayed diagnosis group, 22 (75.9%) had no initial signs on CXR or CT, 15 (52%) of this group had persistent pleural-effusions/elevated-hemidiaphragm leading to further investigation and diagnosis. No significant difference in survival was observed between early and delayed diagnoses, no clinically significant injury patterns to predict delayed diagnoses were noted. CONCLUSION The diagnosis of TDI is challenging. Without frank signs of herniation of abdominal contents on CXR or CT, the diagnosis is often not made on initial imaging. In patients with the evidence of blunt traumatic injury in the lower-chest/upper-abdomen, a high degree of clinical suspicion should be held and follow-up CXRs/CTs arranged.
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Affiliation(s)
- Joseph Hogarty
- Alfred Health Trauma Service, Alfred Hospital, Melbourne, Victoria, Australia
| | - Karishma Jassal
- Alfred Health Trauma Service, Alfred Hospital, Melbourne, Victoria, Australia
- National Trauma Research Institute, Alfred Hospital, Melbourne, Victoria, Australia
| | | | | | - Meei Yeung
- Alfred Health Trauma Service, Alfred Hospital, Melbourne, Victoria, Australia
- National Trauma Research Institute, Alfred Hospital, Melbourne, Victoria, Australia
| | - Warren Clements
- National Trauma Research Institute, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Mark Fitzgerald
- Alfred Health Trauma Service, Alfred Hospital, Melbourne, Victoria, Australia
- National Trauma Research Institute, Alfred Hospital, Melbourne, Victoria, Australia
| | - Joseph K Mathew
- Alfred Health Trauma Service, Alfred Hospital, Melbourne, Victoria, Australia
- National Trauma Research Institute, Alfred Hospital, Melbourne, Victoria, Australia
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Clements W, So J, Koukounaras J, Lau G, Lukies MW. Research output of radiologists in Australia and New Zealand: Strengths, weaknesses and future directions. J Med Imaging Radiat Oncol 2023; 67:697-702. [PMID: 37302986 DOI: 10.1111/1754-9485.13548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 06/03/2023] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Clinical radiology is a popular career. However, academic radiology in Australia and New Zealand (ANZ) has not traditionally been a strength of the specialty which has a focus on clinical medicine and has been influenced by corporatisation of the specialty. The aim of this study was to review the source(s) of radiologist-led research in Australia and New Zealand, to identify areas of relative deficiency and propose plans to improve research output. METHODS A manual search was performed of all manuscripts in seven popular ANZ journals, where the corresponding or senior author was a radiologist. Publications between January 2017 and April 2022 were included. RESULTS There were 285 manuscripts from ANZ radiologists during the study period. This equates to 10.7 manuscripts per 100 radiologists based on RANZCR census data. Radiologists in Northern Territory, Victoria, Western Australia, South Australia and the Australian Capital Territory all produced manuscripts above the corrected mean incidence rate of 10.7 manuscripts per 100 radiologists. However, locations including Tasmania, New South Wales, New Zealand and Queensland were below the mean. The majority of manuscripts arose from public teaching hospitals with accredited trainees (86%), and there were a higher proportion of manuscripts published by female radiologists (11.5 compared to 10.4 per 100 radiologists). CONCLUSION Radiologists in ANZ are academically active; however, interventions aimed at increasing output could be targeted at certain locations and/or areas within a busy private sector. Time, culture, infrastructure and research support are vital, but personal motivation is also extremely important.
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Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Joanne So
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
| | - Jim Koukounaras
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Gabes Lau
- Radiology Department, Dunedin Public Hospital, Dunedin, New Zealand
| | - Matthew W Lukies
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Diagnostic and Interventional Imaging, KK Women's and Children's Hospital, Singapore City, Singapore
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Narita C, Clements W, Varma D. Assessing the necessity of intravenous contrast for computed tomography in the acute undifferentiated abdomen. J Med Imaging Radiat Oncol 2023; 67:710-716. [PMID: 37403895 DOI: 10.1111/1754-9485.13559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/27/2023] [Indexed: 07/06/2023]
Abstract
INTRODUCTION Undifferentiated abdominal pain in the emergency setting is frequently investigated with an intravenous contrast enhanced CT as a first line diagnostic test. However, global contrast shortages restricted the use of contrast for a period in 2022, altering standard practice with many scans performed without intravenous contrast. Whilst IV contrast can be useful to assist with interpretation, its necessity in the setting of acute undifferentiated abdominal pain is not well described, and its use comes with its own risks. This study aimed to assess the shortcomings of omitting IV contrast in an emergency setting, by comparing the rate of CT scans with "indeterminate" findings with and without the use of IV contrast. METHODS Data from presentations to a single centre emergency department for undifferentiated abdominal pain prior to and during contrast shortages in June 2022 were retrospectively compared. The primary outcome was the rate of diagnostic uncertainty, where the presence or absence of intra-abdominal pathology could not be ascertained. RESULTS 12/85 (14.1%) of the unenhanced abdominal CT scans provided an uncertain result, compared with 14/101 (13.9%) of control cases performed with intravenous contrast (P = 0.96). There were also similar rates of positive and negative findings between the groups. CONCLUSION Omitting intravenous contrast for abdominal CT in the setting of undifferentiated abdominal pain demonstrated no significant difference in the rate of diagnostic uncertainty. There are significant potential patient, fiscal and societal benefits as well as potential improvements to emergency department efficiency with the reduction of unnecessary intravenous contrast administration.
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Affiliation(s)
- Callum Narita
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University Central Clinical School, Melbourne, Victoria, Australia
- National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Dinesh Varma
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University Central Clinical School, Melbourne, Victoria, Australia
- National Trauma Research Institute, Melbourne, Victoria, Australia
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Clements W, Koukounaras J. Complications in Interventional Radiology: the role of clinical governance and iterative hospital systems in quality improvement. CVIR Endovasc 2023; 6:38. [PMID: 37542625 PMCID: PMC10404211 DOI: 10.1186/s42155-023-00388-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/30/2023] [Indexed: 08/07/2023] Open
Abstract
As modern Interventional Radiology (IR) evolves, and expands in scope and complexity, it will push the boundaries of existing literature. However, with all intervention comes risk and it is the shared judgement of the risk-benefit analysis which underpins the ethical and legal principles of care in IR.Complications in medicine are common, said to occur in 9.2% of in-hospital healthcare interactions. Healthcare complications also come at considerable cost. It is estimated that in the UK, prolonging hospital stays to manage complications can cost ₤2 billion per year.However, complications can't be viewed in isolation. Clinical governance is the umbrella within which complications are viewed. It can be defined as a broadly integrated and systematic approach to clinical care and accountability, that seeks to focus on quality of healthcare. This concept incorporates complications but acknowledges their interplay within a complex healthcare system in which negative adverse events are influenced by a range of intrinsic and extrinsic factors. It also includes the processes that result from monitoring and learning from complications, with feedback leading to systems-based improvements in care moving forward. The reality is that complications are uncommonly the result of medical negligence, but rather they are an unfortunate by-product of a healthcare industry with inherent risk.It is also important to remember that complications are not just a number on an audit sheet, but a potentially life-changing event for every patient that is affected. The events that follow immediately from an adverse outcome such as open disclosure are vital, and have implications for how that patient experiences healthcare and trusts healthcare professionals for the rest of their life. We must ensure that the patient and their family maintain trust in healthcare professionals into the future.Credentialling and accreditation are imperative for Interventional Radiologists to meet existing standards as well deal with challenging situations. These should integrate and align within the structure of an organization that has a safety and learning culture. It is the many layers of organisational clinical governance that arguably play the most important role in IR-related complications, rather than apportioning blame to an individual IR.
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Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Health, 55 Commercial Rd, Melbourne, 3004, Australia.
- Department of Surgery, Monash University Central Clinical School, Melbourne, Australia.
- National Trauma Research Institute, Melbourne, Australia.
| | - Jim Koukounaras
- Department of Radiology, Alfred Health, 55 Commercial Rd, Melbourne, 3004, Australia
- Department of Surgery, Monash University Central Clinical School, Melbourne, Australia
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Varma D, Brown P, Clements W. Importance of the Mechanism of Injury in Trauma Radiology Decision-Making. Korean J Radiol 2023; 24:522-528. [PMID: 37271206 DOI: 10.3348/kjr.2022.0966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/22/2023] [Accepted: 04/18/2023] [Indexed: 06/06/2023] Open
Affiliation(s)
- Dinesh Varma
- Department of Radiology, Alfred Health, Melbourne, Australia
- Department of Surgery, Monash University Central Clinical School, Melbourne, Australia
- National Trauma Research Institute, Melbourne, Australia.
| | - Patrick Brown
- Department of Radiology, Alfred Health, Melbourne, Australia
| | - Warren Clements
- Department of Radiology, Alfred Health, Melbourne, Australia
- Department of Surgery, Monash University Central Clinical School, Melbourne, Australia
- National Trauma Research Institute, Melbourne, Australia
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13
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Findakly S, Zia A, Kavnoudias H, Mathew J, Varma D, Di Muzio B, Lee R, Moriarty HK, Joseph T, Clements W. The use of whole-body trauma CT should be based on mechanism of injury: A risk analysis of 3920 patients at a tertiary trauma centre. Injury 2023:110828. [PMID: 37225543 DOI: 10.1016/j.injury.2023.05.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 04/27/2023] [Accepted: 05/13/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Mechanism of injury (MOI) plays a significant role in a decision to perform whole-body computed tomography (CT) imaging for trauma patients. Various mechanisms have unique patterns of injury and therefore form an important variable in decision making. METHODS Retrospective cohort study including all patients >18 years old who received a whole-body CT scan between 1 January 2019 and 19 February 2020. The outcomes were divided into CT 'positive' if any internal injuries were detected and CT 'negative' if no internal injuries were detected. The MOI, vital sign parameters, and other relevant clinical examination findings at presentation were recorded. RESULTS 3920 patients met the inclusion criteria, of which 1591 (40.6%) had a positive CT. The most common MOI was fall from standing height (FFSH), accounting for 23.0%, followed by motor vehicle accident (MVA), accounting for 22.4%. Covariates significantly associated with a positive CT included age, MVA >60 km/h, motor bike, bicycle, or pedestrian accident >30 km/h, prolonged extrication >30 min, fall from height above standing, penetrating chest or abdominal injury, as well as hypotension, neurological deficit, or hypoxia on arrival. FFSH was shown to reduce the risk of a positive CT overall, however, sub-analysis of FFSH in patients >65 years showed a significant association with a positive CT (OR 2.34, p < 0.001) compared to <65 years. CONCLUSIONS Pre-arrival information including MOI and vital signs have significant impact on identifying subsequent injuries with CT imaging. In high energy trauma, we should consider the need for whole-body CT based on MOI alone regardless of the clinical examination findings. However, for low-energy trauma, including FFSH, in the absence of clinical examination findings which support an internal injury, a screening whole-body CT is unlikely to yield a positive result, particularly in the age group <65yo.
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Affiliation(s)
- Salam Findakly
- Department of Radiology, Alfred Health, Melbourne, Australia. https://twitter.com/https//twitter.comSalamfindalky
| | - Adil Zia
- Department of Radiology, Alfred Health, Melbourne, Australia. https://twitter.com/https//twitter.comAdilFZia
| | - Helen Kavnoudias
- Department of Radiology, Alfred Health, Melbourne, Australia; Department of Surgery, Monash University, Australia
| | - Joseph Mathew
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Australia; Department of Trauma, Alfred Health, Melbourne, Australia. https://twitter.com/https//twitter.comtrauma_jm
| | - Dinesh Varma
- Department of Radiology, Alfred Health, Melbourne, Australia; Department of Surgery, Monash University, Australia; National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Australia
| | - Bruno Di Muzio
- Department of Radiology, Alfred Health, Melbourne, Australia
| | - Robin Lee
- Department of Radiology, Alfred Health, Melbourne, Australia
| | - Heather K Moriarty
- Department of Radiology, Cork University Hospital, Cork, Ireland. https://twitter.com/https//twitter.comHeatherKateIR
| | - Tim Joseph
- Department of Radiology, Alfred Health, Melbourne, Australia
| | - Warren Clements
- Department of Radiology, Alfred Health, Melbourne, Australia; Department of Surgery, Monash University, Australia; National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Australia.
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14
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Janko N, Majeed A, Clements W, Fink MA, Lubel J, Goodwin M, Nicoll A, Strasser SI, Sood S, Bollipo S, Bate J, Bowers KA, George J, Kemp W, Roberts SK. Wide variation in pre-procedural blood product transfusion practices in cirrhosis: a national multidisciplinary survey. Hepatol Commun 2023; 7:02009842-202305010-00014. [PMID: 37102761 PMCID: PMC10146548 DOI: 10.1097/hc9.0000000000000147] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 02/16/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND AND AIMS Recent guidelines recognize the limitations of standard coagulation tests in predicting bleeding and guiding pre-procedural blood component prophylaxis in cirrhosis. It is unclear whether these recommendations are reflected in clinical practice. We performed a nationwide survey to investigate pre-procedural transfusion practices and opinions of key health care stakeholders involved in managing cirrhosis. METHODS We designed a 36-item multiple-choice questionnaire to investigate the international normalized ratio and platelet cutoffs utilized to guide pre-procedural transfusion of fresh frozen plasma and platelets in patients with cirrhosis undergoing a range of low and high-risk invasive procedures. Eighty medical colleagues from all mainland States involved in managing patients with cirrhosis were invited by email to participate. RESULTS Overall, 48 specialists across Australia completed the questionnaire: 21 gastroenterologists, 22 radiologists, and 5 hepatobiliary surgeons. 50% of respondents reported that their main workplace did not have written guidelines relating to pre-procedural blood component prophylaxis in patients with cirrhosis. There was marked variation in routine prophylactic transfusion practices across institutions for the different procedures and international normalized ratio and platelet cutoffs. This variation was present both within and between specialty groups and held for both low and high-risk procedures. For scenarios where the platelet count was ≤ 50 × 109/L, 61% of respondents stated that prophylactic platelet transfusions would be given before low-risk and 62% before high-risk procedures at their center. For scenarios where the international normalized ratio was ≥2, 46% of respondents stated that prophylactic fresh frozen plasma would be routinely given before low-risk procedures and 74% before high-risk procedures. CONCLUSION Our survey reveals significant heterogeneity of pre-procedural prophylactic transfusion practices in patients with cirrhosis and discrepancies between guidelines and clinical practice.
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Affiliation(s)
- Natasha Janko
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Ammar Majeed
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Warren Clements
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Michael A Fink
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Australia
- Department of Surgery, Austin Health, The University of Melbourne, Melbourne, Australia
| | - John Lubel
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Mark Goodwin
- Department of Radiology, Interventional Radiology Service, Austin Hospital, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Amanda Nicoll
- Department of Gastroenterology, Eastern Health, Melbourne, Victoria, Australia
| | - Simone I Strasser
- AW Morrow Gastroenterology and Liver Center, Royal Prince Alfred Hospital and University of Sydney, NSW, Australia
| | - Siddharth Sood
- Department of Medicine, The University of Melbourne, Melbourne, Australia
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Australia
| | - Steven Bollipo
- Department of Gastroenterology, John Hunter Hospital, Newcastle, Australia
- School of Medicine & Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - John Bate
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, South Australia, Australia
| | - Kaye A Bowers
- Department of Hepatobiliary Surgery, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Jacob George
- Storr Liver Centre, Westmead Institute for Medical Research, University of Sydney, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - William Kemp
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Stuart K Roberts
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
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15
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Dix C, Clements W, Gibbs H, So J, A Tran H, D McFadyen J. Venous anomalies and thromboembolism. Thromb J 2023; 21:45. [PMID: 37081466 PMCID: PMC10116765 DOI: 10.1186/s12959-023-00484-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/31/2023] [Indexed: 04/22/2023] Open
Abstract
Patients with venous anomalies are at increased risk of developing venous thromboembolism (VTE) and subsequent complications, but they are often under-recognised. While unprovoked VTE may trigger testing for inherited thrombophilias and malignancy screening, anatomic variants are considered less often. Venous anomalies increase the risk due to venous flow disturbance, resulting in hypertension, reduced flow velocity and turbulence. Recognition is important as endovascular or surgical intervention may be appropriate, these patients have a high rate of VTE recurrence if anticoagulation is ceased, and the anomalies can predispose to extensive VTE and severe post-thrombotic syndrome (PTS). In this case series, we present representative cases and radiological images of May-Thurner syndrome (MTS), inferior vena cava (IVC) variants and venous aneurysms, and review the available literature regarding optimal diagnosis and management in each condition.
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Affiliation(s)
- Caroline Dix
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, VIC, 3004, Australia.
| | - Warren Clements
- Department of Radiology, The Alfred Hospital, Melbourne, VIC, 3004, Australia
| | - Harry Gibbs
- Department of General Medicine, Alfred Health, Melbourne, VIC, 3004, Australia
| | - Joanne So
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, VIC, 3004, Australia
| | - Huyen A Tran
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, VIC, 3004, Australia
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
| | - James D McFadyen
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, VIC, 3004, Australia
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
- Atherothrombosis and Vascular Biology Laboratory, Baker Heart and Diabetes Institute, Melbourne, 3004, Australia
- Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Australia
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16
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Clements W, Lukies MW. Management of Spontaneous Retroperitoneal Haemorrhage Emphasises the Need for Nuanced Clinical Decision Making in Interventional Radiology. Cardiovasc Intervent Radiol 2023; 46:701-702. [PMID: 37043077 DOI: 10.1007/s00270-023-03431-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 03/24/2023] [Indexed: 04/13/2023]
Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia.
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia.
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Australia.
| | - Matthew W Lukies
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia
- Department of Diagnostic and Interventional Imaging, KK Women's and Children's Hospital, Singapore, Singapore
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17
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Clements W. Commentary on "Post-Embolization Hemoglobin Changes: When to Consider Re-intervention". Cardiovasc Intervent Radiol 2023; 46:626-627. [PMID: 37039864 DOI: 10.1007/s00270-023-03432-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 03/24/2023] [Indexed: 04/12/2023]
Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia.
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia.
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Australia.
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18
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Lee DYL, Clements W, Lukies M. Atraumatic versus cutting needles in fluoroscopic lumbar puncture. Br J Radiol 2023; 96:20220993. [PMID: 37017612 DOI: 10.1259/bjr.20220993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023] Open
Abstract
OBJECTIVES Atraumatic needles are known to reduce complication rates of blind lumbar punctures (LP), however, their use in fluoroscopically guided LP is less studied. This study assessed the comparative difficulty of performing fluoroscopic lumbar puncture with atraumatic needles. METHODS Single-centre retrospective case-control study comparing atraumatic and conventional or 'cutting' needles using fluoroscopic time and radiation dose (Dose Area Product or DAP) as surrogate markers. Patients were assessed from two comparable eight-month periods before and after a policy change to primary use of atraumatic needles. RESULTS 105 procedures with a cutting needle were performed in the group prior to the policy change. Median fluoroscopy time was 48 sec and median DAP was 3.14. Of 102 procedures performed in the group after the policy change, 99 were performed with an atraumatic needle and three with a cutting needle after initial attempt with an atraumatic needle. Median fluoroscopy time was 41 sec and median DAP was 3.28. The mean number of attempts was 1.02 in the cutting needle group and 1.05 in the atraumatic needle group. There was no significant difference in median fluoroscopy time, median DAP, or mean number of attempts. CONCLUSION Fluoroscopic screening time, DAP and mean number of attempts were not significantly increased with primary use of atraumatic needles for LP. Use of atraumatic needles should be considered in fluoroscopic LP given the lower complication rates. ADVANCES IN KNOWLEDGE This study provides new data showing that the use of atraumatic needles does not increase the difficulty of fluoroscopically guided LP.
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Affiliation(s)
- Dana Yen Lin Lee
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University Central Clinical School, Melbourne, Victoria, Australia
- National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Matthew Lukies
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
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19
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Lukies M, Moriarty H, Clements W. Which caval diameter? Clarification manufacturer's instructions for inferior vena cava filter use and implications for practice. Clin Radiol 2023; 78:310-314. [PMID: 36746721 DOI: 10.1016/j.crad.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 11/24/2022] [Accepted: 01/04/2023] [Indexed: 01/24/2023]
Abstract
AIM To clarify manufacturer's instructions for inferior vena cava (IVC) filter use and implications for practice. MATERIALS AND METHODS Three vendors of IVC filters were contacted for clarification, with all stating that caval diameter limits are to be true maximum and true minimum cross-sectional diameters. To determine the implications of this, measurements were performed on 302 abdominal computed tomography studies in four transaxial dimensions perpendicular to the long axis including true maximum and minimum diameters, and measurements reflecting those typically taken on fluoroscopic cavography. RESULTS Based on the true maximum and true minimum caval diameter limits as clarified by vendors, 22% of patients who would typically be considered suitable for IVC filter insertion based on frontal and lateral fluoroscopic cavography would be contraindicated, and 40% of patients who would typically be considered suitable for IVC filter insertion based on only frontal fluoroscopic cavography (as lateral projection is often not performed) would be contraindicated. CONCLUSION There is a marked discordance between the vendor-clarified caval diameter limits of three common IVC filter devices and real-world caval geometry. Given the rarity of complications, this suggests a pressing need for revision of manufacturers' instructions for use statements to better reflect current safe routine clinical use, particularly from a medicolegal perspective.
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Affiliation(s)
- M Lukies
- Department of Radiology, Alfred Health, Melbourne, VIC, Australia; Department of Diagnostic and Interventional Imaging, KK Women Women's and Children's Hospital, Singapore, Singapore.
| | - H Moriarty
- Department of Radiology, Alfred Health, Melbourne, VIC, Australia; Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland
| | - W Clements
- Department of Radiology, Alfred Health, Melbourne, VIC, Australia; Department of Surgery, Monash University, Melbourne, VIC, Australia; National Trauma Research Institute, Melbourne, VIC, Australia
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20
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Clements W. Implementation of lasting changes to sustainability in Interventional Radiology is a top-down governance challenge. CVIR Endovasc 2023; 6:22. [PMID: 37004624 PMCID: PMC10067772 DOI: 10.1186/s42155-023-00371-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/24/2023] [Indexed: 04/04/2023] Open
Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia.
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia.
- National Trauma Research Institute, Melbourne, Australia.
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21
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Clements W, Cheung A, Brown N. A new subsection within JMIRO: Acknowledging the importance of Interventional Radiology and Interventional Neuroradiology research in Australia and New Zealand. J Med Imaging Radiat Oncol 2023. [PMID: 36738131 DOI: 10.1111/1754-9485.13514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 01/24/2023] [Indexed: 02/05/2023]
Affiliation(s)
- Warren Clements
- Department of Radiology, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Andrew Cheung
- Department of Interventional Radiology, Liverpool Hospital, Sydney, New South Wales, Australia.,Neurointervention, Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,South West Sydney Clinical Campuses, UNSW Sydney, Sydney, New South Wales, Australia
| | - Nicholas Brown
- The University of Queensland, Brisbane, Queensland, Australia.,Wesley Hospital, Brisbane, Queensland, Australia.,The Prince Charles Hospital, Brisbane, Queensland, Australia
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22
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Schlegel RN, Fitzgerald M, Lim A, O'Reilly GM, Clements W, Goh GS, Groombridge CJ, Johnny C, Noonan MP, Ban EJ, Mathew J. Injury patterns, management and outcomes of retroperitoneal haemorrhage caused by lower intercostal arterial bleeding at a level-1 trauma centre: A 10-year retrospective review. Emerg Med Australas 2023; 35:56-61. [PMID: 35953075 DOI: 10.1111/1742-6723.14054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/14/2022] [Accepted: 07/24/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Haemorrhagic shock is a life-threatening complication of trauma, but remains a preventable cause of death. Early recognition of retroperitoneal haemorrhage (RPH) is crucial in preventing deleterious outcomes including mortality. Injury to the 9-11th intercostal arteries (i.e. arteries of the lower thoracic region) are complicit in RPH. However, the associated injuries, implications and management of such bleeds remain poorly characterised. METHODS We performed a retrospective review of the medical records of patients diagnosed with RPH who presented to our level-1 trauma centre (2009-2019). We described the associated injuries, management and outcomes relating to RPH of the lower thoracic region (the 9-11th intercostal arteries) from this cohort to identify potential predictors and evaluate the impact of early identification and management of non-cavitary bleeds. RESULTS Haemorrhage of the lower intercostal arteries (LIA) into the retroperitoneal space is associated with an increased number of posterior lower rib fractures and pneumothorax/haemothorax. A higher proportion of patients in the LIA group required massive transfusion, angioembolisation or surgical ligation when compared to other causes of RPH. CONCLUSION The present study highlights the importance of injury patterns, particularly posterior lower rib fractures, as predictors for early recognition and management of RPH in the prevention of deleterious patient outcomes. RPH secondary to bleeding of the LIA may require early and aggressive management of haemorrhage through massive transfusion, and angioembolisation or surgical ligation when compared to RPH because of other causes.
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Affiliation(s)
- Richard N Schlegel
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Mark Fitzgerald
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Andrew Lim
- National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Gerard M O'Reilly
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Warren Clements
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Department of Radiology, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University Central Clinical School, Melbourne, Victoria, Australia
| | - Gerard S Goh
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Department of Radiology, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University Central Clinical School, Melbourne, Victoria, Australia
| | - Christopher J Groombridge
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Cecil Johnny
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Michael P Noonan
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Ee-Jun Ban
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Joseph Mathew
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
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23
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Newman C, Nandurkar R, Holcdorf D, Gerstenmaier J, Tagkalidis P, Clements W. Role of CT angiography and therapeutic anticoagulation in patients presenting to the emergency department with acute gastrointestinal bleeding. J Med Imaging Radiat Oncol 2023; 67:37-44. [PMID: 35394116 DOI: 10.1111/1754-9485.13410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 02/24/2022] [Accepted: 03/23/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Acute gastrointestinal bleeding (GIB) is associated with morbidity and mortality. There can be a low threshold for practitioners to assess for active GIB and computed tomography angiography (CTA) examinations are performed frequently, even for stable patients and those who are therapeutically anticoagulated. We aimed to assess the predictive value of CTA for acute GIB and the influence of CTA on treatment. METHODS Retrospective single-centre study over a 2-year period. RESULTS A total of 227 patients with mean age 67.7 years (SD 17.86), 58.6% male. 84.4% were for lower GIB. 49 patients were on therapeutic anticoagulation (21.6%). 45 CTAs were positive (19.8%). 22 patients received embolisation, and 15 received acute endoscopic treatment. CTA sensitivity was 68.6% and specificity 89.1%. The PPV was 53.3% and NPV 93.9%. The odds ratio of a positive CTA requiring treatment for patients on therapeutic anticoagulation was 1.1 (P = 0.932) compared with the odds of patients not taking therapeutic anticoagulation 21.5 (P < 0.001). The risk ratio for requiring treatment if not taking anticoagulation was 6.2. A total of 19 patients (9.1%) met the definition of CI-AKI as a result of the CTA. A pre-existing eGFR of less than 20 was associated with significantly increased odds of developing CI-AKI (OR 3.95, P = 0.031, 95%CI 1.135-13.782). CONCLUSIONS The presence of anticoagulation has a significant impact on the decision not to perform interventional treatments on patients with acute GIB when CTA is positive. Anticoagulant reversal and volume resuscitation are important front-line measures, and CTA may have a role for those anticoagulated who are haemodynamically unstable after resuscitation.
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Affiliation(s)
- Chris Newman
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Rohan Nandurkar
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - David Holcdorf
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jan Gerstenmaier
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Peter Tagkalidis
- Department of Gastroenterology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University Central Clinical School, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
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24
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Lukies M, Gipson J, Tan SY, Clements W. Spontaneous Retroperitoneal Haemorrhage: Efficacy of Conservative Management and Embolisation. Cardiovasc Intervent Radiol 2023; 46:488-495. [PMID: 36720738 PMCID: PMC9888734 DOI: 10.1007/s00270-023-03359-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 01/03/2023] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the efficacy of conservative management and embolisation in patients with spontaneous retroperitoneal haemorrhage. METHODS Single-centre retrospective case-control study of patients with spontaneous retroperitoneal haemorrhage treated conservatively or with embolisation. Patients aged ≥ 18 years were identified from CT imaging reports stating a diagnosis of retroperitoneal haemorrhage or similar and images reviewed for confirmation. Exclusion criteria included recent trauma, surgery, retroperitoneal vascular line insertion, or other non-spontaneous aetiology. Datapoints analysed included treatment approach (conservative or embolisation), technical success, clinical success, and mortality outcome. RESULTS A total of 54 patients met inclusion criteria, who were predominantly anticoagulated (74%), male (72%), older adults (mean age 69 years), with active haemorrhage on CT (52%). Overall mortality was 15%. Clinical success was more likely with conservative management (36/38) than embolisation (9/16; p < 0.01), and all-cause (1/38 vs 7/16; p < 0.01) and uncontrolled primary bleeding (1/38 vs 5/16; p < 0.01) mortality were higher with embolisation. However, embolised patients more commonly had active bleeding on CT (15/38 vs 13/16; p < 0.01), shock (5/38 vs 6/16; p < 0.04), and higher blood transfusion volumes (mean 2.2 vs 5.9 units; p < 0.01). After one-to-one propensity score matching, differences in clinical success (p = 0.04) and all-cause mortality (p = 0.01) remained; however, difference in uncontrolled primary bleeding mortality did not (p = 0.07). CONCLUSION Conservative management of SRH is likely to be effective in most patients, even in those who are anticoagulated and haemodynamically unstable, with variable success seen after embolisation in a more unstable patient group, supporting the notion that resuscitation and optimisation of coagulation are the most vital components of treatment.
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Affiliation(s)
- Matthew Lukies
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004 Australia ,Department of Diagnostic and Interventional Imaging, KK Women’s and Children’s Hospital, Singapore, Singapore
| | - Jacob Gipson
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004 Australia
| | - Sia Yang Tan
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004 Australia
| | - Warren Clements
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004 Australia ,Department of Surgery, Monash University, Melbourne, VIC Australia ,National Trauma Research Institute, Melbourne, VIC Australia
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Stevens H, Bortz H, Chao S, Ramanan R, Clements W, Peter K, McFadyen JD, Tran H. Improving the rate of inferior vena cava filter retrieval through multidisciplinary engagement. Res Pract Thromb Haemost 2023; 7:100040. [PMID: 36852111 PMCID: PMC9958400 DOI: 10.1016/j.rpth.2023.100040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 11/20/2022] [Accepted: 11/24/2022] [Indexed: 01/09/2023] Open
Abstract
Background The placement of retrievable inferior vena cava (IVC) filters occurs commonly, but retrieval rates remain low. Consequently, there is an unmet clinical need to ensure appropriate follow-up and retrieval of these devices. Objectives To determine the association between an IVC filter surveillance team with filter retrievals or a documented filter plan, time to retrieval, and incidence of filter complications or recurrent venous thromboembolism. Methods Ambidirectional cohort study evaluating consecutive IVC filter insertions before and after the implementation of a multidisciplinary surveillance team (MDST). We report an odds ratio (OR) with 95% CIs, adjusted by age, sex, weight, and malignancy status. Results Overall, 453 patients were included, with 272 individuals in the pre-MDST cohort and 181 individuals in the post-MDST cohort. The MDST was associated with a higher composite primary outcome of IVC filter retrieval or a documented filter plan from 79.4% in the pre-MDST cohort to 96.1% in the post-MDST cohort (OR, 6.44; 95% CI, 3.06-15.84). Compared with the pre-MDST cohort, IVC filter retrieval rates were higher in the post-MDST cohort (52.6%-73.5%, respectively; (OR, 2.50; 95% CI, 1.67-3.78). The MDST was associated with a shorter median time-to-filter retrieval (187-150 days, hazard ratio, 1.78; 95% CI, 1.39-2.29), but there was no significant difference when comparing symptomatic or clinically significant IVC filter complications, recurrent venous thromboembolism, or mortality. Conclusion Our study demonstrates the importance of a structured program to ensure timely IVC filter retrieval and ultimately improve patient care.
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Affiliation(s)
- Hannah Stevens
- Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia,Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia,Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia,Correspondence Hannah Stevens, Department of Clinical Haematology, The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia. @hannahpstevens
| | - Hadley Bortz
- Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia,Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia
| | - Sharon Chao
- Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Radha Ramanan
- Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia,Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Health, Melbourne, Australia,Department of Surgery, Monash University Central Clinical School, Melbourne, Australia,National Trauma Research Institute, Melbourne, Australia
| | - Karlheinz Peter
- Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia,Department of Cardiology, Alfred Hospital, Melbourne, Melbourne, Australia,Baker Department of Cardiometabolic Health, The University of Melbourne, Victoria, Australia
| | - James D. McFadyen
- Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia,Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia,Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia,Baker Department of Cardiometabolic Health, The University of Melbourne, Victoria, Australia
| | - Huyen Tran
- Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia,Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
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Schlegel RN, Fitzgerald M, O'Reilly G, Clements W, Goh GS, Groombridge C, Johnny C, Noonan M, Ban J, Mathew J. The injury patterns, management and outcomes of retroperitoneal haemorrhage caused by lumbar arterial bleeding at a Level-1 Trauma Centre: A 10-year retrospective review. Injury 2023; 54:145-149. [PMID: 35948513 DOI: 10.1016/j.injury.2022.07.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 07/13/2022] [Accepted: 07/26/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE Haemorrhagic shock remains a leading preventable cause of death amongst trauma patients. Failure to identify retroperitoneal haemorrhage (RPH) can lead to irreversible haemorrhagic shock. The arteries of the middle retroperitoneal region (i.e., the 1st to 4th lumbar arteries) are complicit in haemorrhage into the retroperitoneal space. However, predictive injury patterns and subsequent management implications of haemorrhage secondary to bleeding of these arteries is lacking. MATERIALS AND METHODS We performed a retrospective cohort study of patients diagnosed with retroperitoneal haemorrhage who presented to our Level-1 Trauma Centre (2009-2019). We described the associated injuries, management and outcomes relating to haemorrhage of lumbar arteries (L1-4) from this cohort to assess risk and management priorities in non-cavitary haemorrhage compared to RPH due to other causes. RESULTS Haemorrhage of the lumbar arteries (LA) is associated with a higher proportion of lumbar transverse process (TP) fractures. Bleeding from branches of these vessels is associated with lower systolic blood pressure, increased incidence of massive transfusion, higher shock index, and a higher Injury Severity Score (ISS). A higher proportion of patients in the LA group underwent angioembolisation when compared to other causes of RPH. CONCLUSION This study highlights the injury patterns, particularly TP fractures, in the prediction, early detection and management of haemorrhage from the lumbar arteries (L1-4). Compared to other causes of RPH, bleeding of the LA responds to early, aggressive haemorrhage control through angioembolisation. These injuries are likely best treated in Level-1 or Level-2 trauma facilities that are equipped with angioembolisation facilities or hybrid theatres to facilitate early identification and management of thoracolumbar bleeds.
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Affiliation(s)
- R N Schlegel
- Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia; Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia.
| | - M Fitzgerald
- Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia; National Trauma Research Institute (NTRI), Melbourne, VIC, Australia
| | - G O'Reilly
- Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia; National Trauma Research Institute (NTRI), Melbourne, VIC, Australia; Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - W Clements
- National Trauma Research Institute (NTRI), Melbourne, VIC, Australia; Department of Radiology, The Alfred Hospital, Melbourne, VIC, Australia; Department of Surgery, Monash University Central Clinical School, Australia
| | - G S Goh
- National Trauma Research Institute (NTRI), Melbourne, VIC, Australia; Department of Radiology, The Alfred Hospital, Melbourne, VIC, Australia; Department of Surgery, Monash University Central Clinical School, Australia
| | - C Groombridge
- Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia; National Trauma Research Institute (NTRI), Melbourne, VIC, Australia; Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - C Johnny
- Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia; National Trauma Research Institute (NTRI), Melbourne, VIC, Australia; Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - M Noonan
- Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia; National Trauma Research Institute (NTRI), Melbourne, VIC, Australia; Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - J Ban
- Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia
| | - J Mathew
- Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia; National Trauma Research Institute (NTRI), Melbourne, VIC, Australia; Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
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Clements W, Zia A, Srinivas A, Davis J, Goh GS. A prospective cross-sectional study assessing teaching of interventional radiology across 20 Australian medical schools, endorsed by the Australian Medical Students Association. CVIR Endovasc 2022; 5:66. [PMID: 36536064 PMCID: PMC9763521 DOI: 10.1186/s42155-022-00344-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Existing literature from around the world has shown that teaching of Interventional Radiology (IR) to medical students remains suboptimal. Despite calls for improvement at a "grass-roots" level, most IRs find that junior doctors have limited or no knowledge of IR, and thus reduced awareness of potential IR treatments for their patients or contemplating IR as a future career. The aim of this study was to survey current medical students to assess perception of whether a wider variety of medical schools are integrating IR into their curriculum, from universities all across Australia. This was a prospective cross-sectional study of members of the Australian Medical Students Association (AMSA) from across Australia. Students were given a 14-question survey of current university teaching and students' knowledge of the discipline of IR. The primary outcome was perception of current teaching and knowledge of IR. Secondary outcomes include awareness of technical, clinical, and other duties of IRs. RESULTS Surveys were sent in a newsletter and posted on the AMSA Facebook page to their members. 82 responses were received via students from 20 out of 23 Australian medical schools. 61% of students described poor or no knowledge of IR. Teaching of IR was significantly worse than diagnostic radiology (p < 0.001), only 12% suggested that current IR teaching was adequate, and 99% suggested that IR teaching could be improved. Only 11% of students would consider a career in IR. CONCLUSIONS Medical student perception of exposure to IR is poor compared to diagnostic radiology. Better awareness may lead to improved referral patterns for patients and more career interest in IR.
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Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Health, 55 Commercial Rd, Melbourne, VIC 3004 Australia ,grid.1002.30000 0004 1936 7857Department of Surgery, Monash University Central Clinical School, Melbourne, Australia ,grid.511499.1National Trauma Research Institute, Melbourne, Australia
| | - Adil Zia
- Department of Radiology, Alfred Health, 55 Commercial Rd, Melbourne, VIC 3004 Australia
| | - Abhishekh Srinivas
- Department of Radiology, Alfred Health, 55 Commercial Rd, Melbourne, VIC 3004 Australia ,Australian Medical Students Association, Australian Capital Territory, Barton, Australia
| | - Jasmine Davis
- Australian Medical Students Association, Australian Capital Territory, Barton, Australia
| | - Gerard S. Goh
- Department of Radiology, Alfred Health, 55 Commercial Rd, Melbourne, VIC 3004 Australia ,grid.1002.30000 0004 1936 7857Department of Surgery, Monash University Central Clinical School, Melbourne, Australia ,grid.511499.1National Trauma Research Institute, Melbourne, Australia
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Clements W, Marshall E, Lukies M, Joseph T, Tran H, Ban EJ, Koukounaras J. A retrospective cohort study assessing the incidence of inferior vena cava (IVC) occlusion following prophylactic IVC filter insertion: Is anticoagulation necessary during filter dwell? Injury 2022; 53:2763-2767. [PMID: 35773022 DOI: 10.1016/j.injury.2022.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/13/2022] [Accepted: 06/22/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Inferior vena cava (IVC) filters play a role in preventing venous thromboembolism after major trauma where deep venous thrombosis (DVT) risk is up to 80%. It has been suggested that IVC filters are thrombogenic and many patients are therefore placed on therapeutic anticoagulation during IVC filter dwell citing concern of in situ IVC thrombosis, even in the absence of existing DVT. METHODS Between 1 June 2018 and 31 December 2021, this retrospective study assessed the incidence of IVC thrombosis following prophylactic IVC filter insertion. Groups were defined according to the presence or absence of therapeutic anticoagulation during filter dwell. The primary outcome was the presence or absence of IVC thrombus at retrieval. RESULTS A total of 124 patients were included. Anticoagulation was prescribed in 29 and anticoagulation was not prescribed in 63. A further 32 patients developed a new thrombosis episode after the prophylactic IVC filter was placed, and 29 were prescribed anticoagulation part-way during filter dwell as a result of this diagnosis. No cases of IVC occlusion were observed in any patient group. CONCLUSIONS Caval thrombosis was not observed after prophylactic filter placement, with or without the prescription of anticoagulation. While prospective trials are needed to increase the level of evidence, based on these results the use of therapeutic anticoagulation during IVC filter dwell should not be dictated by the presence of an IVC filter alone but rather by the presence of a related thrombosis event.
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Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Health, Melbourne, Australia; Department of Surgery, Monash University, Australia; National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Australia.
| | - Elissa Marshall
- Department of Radiology, Alfred Health, Melbourne, Australia
| | - Matthew Lukies
- Department of Radiology, Alfred Health, Melbourne, Australia
| | - Tim Joseph
- Department of Radiology, Alfred Health, Melbourne, Australia
| | - Huyen Tran
- Australian Centre for Blood Diseases, Clinical Haematology Department, Monash University, Melbourne, Australia
| | - Ee Jun Ban
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Australia; Department of Trauma, Alfred Health, Melbourne, Australia
| | - Jim Koukounaras
- Department of Radiology, Alfred Health, Melbourne, Australia; Department of Surgery, Monash University, Australia
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Moriarty HK, Ban EJ, Schlegel RN, Goh GS, Matthew JK, Clements W. Ten-year incidence and treatment outcomes of closed degloving injuries (Morel-Lavallee lesions) in a level 1 trauma centre. J Med Imaging Radiat Oncol 2022; 67:260-266. [PMID: 35906779 DOI: 10.1111/1754-9485.13459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/12/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Morel-Lavallée lesions (MLL), also referred to as closed degloving injuries, result from traumatic shearing forces with separation of the subcutaneous fat from the underlying fascia. The aim of this study was to determine the incidence and treatment of MLLs at a level 1 trauma centre. METHODS Single-centre retrospective cross-sectional study of consecutive patients with an imaging diagnosis of a Morel-Lavallee lesion from 1/1/2010-31/12/2019. Demographic data, mechanism of injury, volume of lesion, management and outcome data were collated. RESULTS Sixty-six MLLs were identified in 63 patients (64% Male) with a median age of 49.5 years (19-94 years). Mechanism of injury were road traffic accidents in the majority (66%). Median injury severity score (ISS) was 17 (range 1-33). Patients on oral anti-coagulants had significantly larger lesions (181.9 cc v 445.5 cc, P = 0.044). The most common lesion location was the thigh (60.5%). Patients that underwent imaging within 72 h of injury had significantly larger lesions than those imaged more than 72 h after the inciting trauma (65 cc v 167 cc, P < 0.05). Management data were documented in 59% of lesions (39/66) in which 66.6% (n = 26) had invasive treatment. In the 31 patients where follow-up was available, 64.5% (n = 20) were persistent but decreasing in size. There was no significant difference in follow-up size for those who had invasive compared to conservative treatment (P = 0.3). CONCLUSION The diagnosis of MLL should be considered for soft-tissue swelling in the context of shearing trauma. A variety of management options have been employed, with good overall outcomes.
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Affiliation(s)
- Heather K Moriarty
- Department of Radiology, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia.,Department of Radiology, Cork University Hospital, Cork, Ireland
| | - Ee-Jun Ban
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Richard N Schlegel
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Gerard S Goh
- Department of Radiology, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Joseph K Matthew
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
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Clements W, Brown N, Buckley B, Rogan C, Kok HK, Liang E. Quality care guidelines for uterine artery embolisation in women with symptomatic uterine fibroids in Australia and New Zealand: According to the AGREE-II checklist and endorsed by the Interventional Radiology Society of Australasia. J Med Imaging Radiat Oncol 2022; 66:819-825. [PMID: 35785440 PMCID: PMC9545349 DOI: 10.1111/1754-9485.13455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/21/2022] [Indexed: 12/03/2022]
Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University Central Clinical School, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Nicholas Brown
- The University of Queensland, St Lucia, Queensland, Australia.,Wesley Hospital, Auchenflower, Queensland, Australia
| | - Brendan Buckley
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Chris Rogan
- Royal Prince Alfred Hospital, Camperdown, Sydney, New South Wales, Australia.,Chris O'Brien Lifehouse, Camperdown, Sydney, New South Wales, Australia.,Sydney Adventist Hospital, Wahroonga, Sydney, New South Wales, Australia
| | - Hong Kuan Kok
- Department of Radiology, Northern Health, Melbourne, Victoria, Australia
| | - Eisen Liang
- Sydney Fibroid Clinic, Sydney, New South Wales, Australia
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Hau E, Clements W, Sia J. Immunotherapy, radiation oncology and radiology: An alliance into the future. J Med Imaging Radiat Oncol 2022; 66:475-477. [PMID: 35666008 DOI: 10.1111/1754-9485.13421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/27/2022] [Indexed: 11/28/2022]
Abstract
AUTHOR BIOGRAPHIES A/Prof Eric Hau is a clinician-scientist with interest in lung and CNS tumours. His clinical and laboratory research focuses on understanding the mechanisms of radiation resistance and investigating drugs which may be utilised for radiation sensitisation to improve outcomes for patients. Associate Professor Warren Clements is an Interventional Radiologist at Alfred Health and has an Adjunct appointment with the Department of Surgery, Central Clinical School, Monash University. A/Prof Clements completed post-fellowship subspecialty training in Interventional Radiology, consolidated by completion of the EBIR certification. A/Prof Clements is actively involved in medical research with over 80 peer-reviewed publications, and has presented his research at national and international conferences. He is an Associate Editor for JMIRO and editorial board member of both CVIR and CVIR Endovascular. He volunteers his time for RANZCR as a member of the Interventional Radiology Committee and as an editorial board member for RANZCR's Inside Radiology website. A/Prof Clements has a keen interest in education and training, and is the supervisor of Intern Training in the Radiology Department. Dr. Joseph (Joe) Sia is a Consultant Radiation Oncologist at the Peter MacCallum Cancer Centre, Melbourne, Australia. He obtained his medical degree from the University of Otago, New Zealand and completed his radiation oncology training in Melbourne in 2017. He then undertook a laboratory-based PhD in tumour immunology at the University of Melbourne, which was awarded in 2020.
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Affiliation(s)
- Eric Hau
- Sydney West Radiation Oncology, Sydney, New South Wales, Australia.,Centre for Cancer Research, Westmead Institute of Medical Research, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Warren Clements
- Department of Radiology, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Joseph Sia
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
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Gipson J, Tang V, Seah J, Kavnoudias H, Zia A, Lee R, Mitra B, Clements W. Diagnostic accuracy of a commercially available deep-learning algorithm in supine chest radiographs following trauma. Br J Radiol 2022; 95:20210979. [PMID: 35271382 PMCID: PMC10996416 DOI: 10.1259/bjr.20210979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 03/01/2022] [Accepted: 03/04/2022] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES Trauma chest radiographs may contain subtle and time-critical pathology. Artificial intelligence (AI) may aid in accurate reporting, timely identification and worklist prioritisation. However, few AI programs have been externally validated. This study aimed to evaluate the performance of a commercially available deep convolutional neural network - Annalise CXR V1.2 (Annalise.ai) - for detection of traumatic injuries on supine chest radiographs. METHODS Chest radiographs with a CT performed within 24 h in the setting of trauma were retrospectively identified at a level one adult trauma centre between January 2009 and June 2019. Annalise.ai assessment of the chest radiograph was compared to the radiologist report of the chest radiograph. Contemporaneous CT report was taken as the ground truth. Agreement with CT was measured using Cohen's κ and sensitivity/specificity for both AI and radiologists were calculated. RESULTS There were 1404 cases identified with a median age of 52 (IQR 33-69) years, 949 males. AI demonstrated superior performance compared to radiologists in identifying pneumothorax (p = 0.007) and segmental collapse (p = 0.012) on chest radiograph. Radiologists performed better than AI for clavicle fracture (p = 0.002), humerus fracture (p < 0.0015) and scapula fracture (p = 0.014). No statistical difference was found for identification of rib fractures and pneumomediastinum. CONCLUSION The evaluated AI performed comparably to radiologists in interpreting chest radiographs. Further evaluation of this AI program has the potential to enable it to be safely incorporated in clinical processes. ADVANCES IN KNOWLEDGE Clinically useful AI programs represent promising decision support tools.
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Affiliation(s)
- Jacob Gipson
- Department of Radiology, Alfred Health,
Melbourne, Victoria, Australia
| | - Victor Tang
- Department of Radiology, Alfred Health,
Melbourne, Victoria, Australia
- Faculty of Medicine, University of Queensland,
Brisbane, Queensland,
Australia
| | - Jarrel Seah
- Department of Radiology, Alfred Health,
Melbourne, Victoria, Australia
- Harrison.ai, Sydney, NSW,
Australia
| | - Helen Kavnoudias
- Department of Radiology, Alfred Health,
Melbourne, Victoria, Australia
- Department of Surgery, Monash University,
Melbourne, Victoria, Australia
| | - Adil Zia
- Department of Radiology, Alfred Health,
Melbourne, Victoria, Australia
| | - Robin Lee
- Department of Radiology, Alfred Health,
Melbourne, Victoria, Australia
| | - Biswadev Mitra
- National Trauma Research Institute,
Melbourne, Victoria, Australia
- Emergency & Trauma Centre, The Alfred
Hospital, Melbourne, Victoria,
Australia
- School of Public Health & Preventive Medicine, Monash
University, Melbourne, Victoria,
Australia
| | - Warren Clements
- Department of Radiology, Alfred Health,
Melbourne, Victoria, Australia
- Department of Surgery, Monash University,
Melbourne, Victoria, Australia
- National Trauma Research Institute,
Melbourne, Victoria, Australia
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Lukies M, Clements W. Current Strategies for Prevention of Infection After Uterine Artery Embolisation. Cardiovasc Intervent Radiol 2022; 45:911-917. [PMID: 35578034 PMCID: PMC9225967 DOI: 10.1007/s00270-022-03158-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 04/12/2022] [Indexed: 11/28/2022]
Abstract
Uterine artery embolisation (UAE) is a safe and effective procedure for symptomatic uterine fibroids with an estimated rate of post-operative intra-uterine infection of 0.9-2.5%. While rates of infection have remained low over the past two decades, there is variation in infection prevention practices. Intra-uterine infection after UAE may occur via access site haematogenous spread or ascension of vaginal flora through the cervical canal. Although the evidence base is immature, risk factors for infection including previous pelvic infection, hydrosalpinx, endocervical incompetence, diabetes, smoking, obesity, respiratory disease, and immunosuppression should be assessed during the pre-operative consultation with the interventional radiologist to tailor a plan for minimising infection, which may include optimisation of any modifiable risk facts and prophylactic antibiotics.
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Affiliation(s)
- Matthew Lukies
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Warren Clements
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia. .,Department of Surgery, Monash University, Melbourne, VIC, Australia. .,National Trauma Research Institute, Melbourne, VIC, Australia.
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Lukies M, Zia A, Kavnoudias H, Bosco JJ, Narita C, Lee R, Joseph T, Clements W. Immune Function After Splenic Artery Embolization for Blunt Trauma: Long-Term Assessment of CD27 + IgM B-Cell Levels. J Vasc Interv Radiol 2022; 33:505-509. [PMID: 35489783 DOI: 10.1016/j.jvir.2022.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/08/2022] [Accepted: 02/02/2022] [Indexed: 12/18/2022] Open
Abstract
Splenic artery embolization (SAE) plays a critical role in the treatment of high-grade splenic injury not requiring emergent laparotomy. SAE preserves splenic tissue, and growing evidence demonstrates preserved short-term splenic immune function after SAE. However, long-term function is less studied. Patients who underwent SAE for blunt abdominal trauma over a 10-year period were contacted for long-term follow-up. Sixteen participants (sex: women, 10, and men, 6; age: median, 34 years, and range, 18-67 years) were followed up at a median of 7.7 years (range, 4.7-12.8 years) after embolization. Splenic lacerations were of American Association for the Surgery of Trauma grades III to V, and 14 procedures involved proximal embolization. All individuals had measurable levels of IgM memory B cells (median, 14.30 as %B cells), splenic tissue present on ultrasound (median, 122 mL), and no history of severe infection since SAE. In conclusion, this study quantitatively demonstrated that long-term immune function remains after SAE for blunt abdominal trauma based on the IgM memory B cell levels.
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Affiliation(s)
- Matthew Lukies
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
| | - Adil Zia
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia; Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Helen Kavnoudias
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
| | - Julian J Bosco
- Department of Respiratory Medicine-Allergy, Asthma and Clinical Immunology, Alfred Health, Melbourne, Victoria, Australia; Central Clinical School, Faculty of Medicine Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Callum Narita
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
| | - Robin Lee
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia; Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Timothy Joseph
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia; Department of Surgery, Monash University, Melbourne, Victoria, Australia; National Trauma Research Institute, Melbourne, Victoria, Australia.
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Clements W, Thong L, Zia A, Moriarty H, Goh G. A Prospective Study Assessing Patient Perception of the Use Of Artificial Intelligence in Radiology. APJHM 2022. [DOI: 10.24083/apjhm.v17i1.861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective: Radiology has been at the forefront of medical technology including the use of artificial intelligence (AI) and machine learning. However, there remains scant literature on the perspective of patients regarding clinical use of this technology. This study aimed to assess the opinion of radiology patients on the potential involvement of AI in their medical care.
Design: A survey was given to ambulatory outpatients attending our hospital for medical imaging. The survey consisted of questions concerning comfort with radiologist reports, comfort with entirely AI reports, comfort with in-part AI reports, accuracy, data security, and medicolegal risk.
Setting: Tertiary academic hospital in Melbourne, Australia.
Main outcome measures: Patients’ were surveyed for their overall comfort with the use of AI in their medical imaging using a Likert scale of 0 to 7.
Results: 283 patient surveys were included. Patients rated comfort in their imaging being reported by a radiologist at mean of 6.5 out of 7, compared with AI alone at mean 3.5 out of 7 (p<0.0001), or in-part AI at mean 5.4 out of 7 (p<0.0001). Patients felt AI should have an accuracy of mean 91.4% to be able to be used in a clinical environment. Patients rated their current comfort with data security at mean 5.5 out of 7 however comfort with data security using AI at mean 4.4 out of 7, p<0.0001.
Conclusions: Patients are trusting of the holistic role of a radiologist however, remain uncomfortable with clinical use of AI as a standalone product including accuracy and data security. If AI technology is to evolve then it must do so with appropriate involvement of stakeholders, of which patients are paramount.
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Tibballs J, Clements W. Immunotherapy and Transarterial therapy of HCC: What the interventional radiologist needs to know about the changing landscape of HCC treatment? J Med Imaging Radiat Oncol 2022; 66:478-482. [PMID: 35357076 PMCID: PMC9311219 DOI: 10.1111/1754-9485.13405] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/10/2022] [Accepted: 03/15/2022] [Indexed: 02/06/2023]
Abstract
Hepatocellular carcinoma (HCC) is the fourth most common cancer worldwide and its incidence is increasing in Australia. Transarterial therapy, predominantly transarterial chemoembolization (TACE) but increasingly transarterial radioembolization (TARE), plays an important role in patients with intermediate‐stage disease and preserved liver function. However, despite advances in TACE, TARE and adjunctive procedures, overall survival has only modestly increased over the last 20 years. Immunotherapy has emerged as a newer cancer treatment and uses antibodies directed at checkpoint inhibitors to upregulate T‐cell mediated tumour‐specific death. These drugs have been shown to increase survival in patients with HCC and have changed the landscape for advanced disease. Trials are now ongoing combining transarterial therapy and immunotherapy. This manuscript introduces these trials and interventional radiologists should be aware of the changing landscape so that they can partner with immunotherapy and remain relevant in the HCC multidisciplinary group as immunotherapy use increases.
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Affiliation(s)
- Jonathan Tibballs
- Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Warren Clements
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University Central Clinical School, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
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Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia. .,Department of Surgery, Monash University, Melbourne, Australia. .,National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Australia.
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Moriarty HK, Clements W, Zia A, Connor B, Goh GS. The gender imbalance in Interventional Radiology in Australia and New Zealand. J Med Imaging Radiat Oncol 2022; 67:146-154. [PMID: 35261169 DOI: 10.1111/1754-9485.13397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 02/07/2022] [Accepted: 02/15/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION There are few female Interventional Radiologists worldwide and this is a significant issue for many countries. There is little known about the current status and attitudes to women in Interventional Radiology in Australia and New Zealand. The purpose of this study was to explore the gender balance, workforce challenges and perceptions towards women in Interventional Radiology in Australia and New Zealand. METHODS An anonymised voluntary survey exploring the current demographics of Interventional Radiologists and opinions on multiple gender issues in Interventional Radiology was conducted. The survey was sent to all members of the Interventional Radiology Society of Australasia. Statistical analysis was performed using independent samples t-tests, the non-parametric Mann-Whitney U testing and proportions of binary variables using logistic regression. RESULTS Seventy seven responses were received, 83% males and 17% females. The majority of participants worked full time (83%) and identified as an Interventional Radiologist with/without some sessions of diagnostic radiology per week (83%). There was general consensus in many issues; however, males tended to disagree more than females that female IRs are treated differently than male IRs (p < 0.037), and that male IRs are paid more than female IRs (P = 0.020). Females agreed it was harder for female IRs to gain academic or clinical promotion; however, males disagreed (P < 0.001). CONCLUSION There is a clear gender imbalance in Interventional Radiology in Australia and New Zealand. Multiple issues should be investigated and addressed by the major stakeholders such as the Royal Australian and New Zealand College of Radiologists and the Interventional Radiology society of Australasia.
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Affiliation(s)
- Heather K Moriarty
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University Central Clinical School, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University Central Clinical School, Melbourne, Victoria, Australia.,National Trauma Research Institute, Monash University Central Clinical School, Melbourne, Victoria, Australia
| | - Adil Zia
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Neuroscience, Monash University Central Clinical School, Melbourne, Victoria, Australia
| | | | - Gerard S Goh
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University Central Clinical School, Melbourne, Victoria, Australia.,National Trauma Research Institute, Monash University Central Clinical School, Melbourne, Victoria, Australia
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Lim SS, Phan TD, Law M, Goh GS, Moriarty HK, Lukies MW, Joseph T, Clements W. Non-radiologist perception of the use of artificial intelligence (AI) in diagnostic medical imaging reports. J Med Imaging Radiat Oncol 2022; 66:1029-1034. [PMID: 35191186 PMCID: PMC10078783 DOI: 10.1111/1754-9485.13388] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/17/2021] [Accepted: 01/27/2022] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Incorporating artificial intelligence (AI) in diagnostic medical imaging reports has the potential to improve efficiency. Although perception of radiologists, radiographers, medical students and patients on AI use in image reporting has been explored, there is limited literature on non-radiologist clinicians' opinion on this topic. METHOD Single-centre online survey targeting non-radiologist medical staff conducted from May to August 2021 at a tertiary referral hospital in Melbourne, Australia. Survey questions revolved around clinicians' level of comfort acting on AI-generated reports with varying levels of radiologist involvement and scan complexity, opinion on medicolegal responsibility for erroneous AI-issued reports and perception of data privacy and security. RESULTS Eighty-eight responses were collected, including 47.9% of consultants. Non-radiologist clinicians across all seniorities and specialties felt significantly less comfortable acting on AI-issued reports compared with radiologist-issued reports (mean comfort radiologist 6.44/7, mean comfort AI 3.35/7, P < 0.001) but felt equally comfortable with an AI-hybrid model of care (mean comfort hybrid 6.38/7, P = 0.676). Non-radiologist clinicians believed that medicolegal responsibility with errors in AI-issued reports mostly lay with hospitals or health service providers (65.9%) and radiologists (54.5%). Regarding data privacy and security, non-radiologist clinicians felt significantly less comfortable with AI issuing image reports instead of radiologists (P < 0.001). CONCLUSION A hybrid AI-generated radiologist-confirmed method of image reporting may be the ideal way of integrating AI into clinical practice based on the perception of our referring non-radiologist medical colleagues. Formal guidelines on medicolegal responsibility and data privacy should be established prior to utilising AI in the clinical setting.
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Affiliation(s)
- Sophie Soyeon Lim
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Tuan D Phan
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Meng Law
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Electrical and Computer Systems Engineering, Monash University, Melbourne, Victoria, Australia.,Department of Neuroscience, Monash University Central Clinical School, Melbourne, Victoria, Australia
| | - Gerard S Goh
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University Central Clinical School, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Heather K Moriarty
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University Central Clinical School, Melbourne, Victoria, Australia
| | - Matthew W Lukies
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Timothy Joseph
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University Central Clinical School, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
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Clements W, Venn G, McGiffin D, Moriarty HK, Joseph T, Goh GS, Whitford H, Keating D. Chronic Thromboembolic Pulmonary Hypertension (CTEPH) and massive hemoptysis: The rationale for bronchial artery embolization. Respir Med 2022; 195:106784. [DOI: 10.1016/j.rmed.2022.106784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 01/16/2022] [Accepted: 02/20/2022] [Indexed: 11/26/2022]
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Slater SJ, Lukies M, Kavnoudias H, Zia A, Lee R, Bosco JJ, Joseph T, Clements W. Immune function and the role of vaccination after splenic artery embolization for blunt splenic injury. Injury 2022; 53:112-115. [PMID: 34565618 DOI: 10.1016/j.injury.2021.09.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 09/08/2021] [Accepted: 09/12/2021] [Indexed: 02/02/2023]
Abstract
The spleen is the most commonly injured solid organ following blunt abdominal trauma. Over recent decades, splenic artery embolization (SAE) has become the mainstay treatment for haemodynamically stable patients with high-grade blunt splenic trauma, with splenectomy the mainstay of treatment for unstable patients. Splenic function is complex but the spleen has an important role in immune function, particularly in protection against encapsulated bacteria. Established evidence suggests that following splenectomy immune function is impaired resulting in increased susceptibility to overwhelming post-splenectomy infection, however, immune function may be preserved following SAE. This review will discuss the current state of the literature on immune function following different treatments of blunt splenic injury, and the controversies surrounding what constitutes a quantitative test of splenic immune function.
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Affiliation(s)
- Samuel J Slater
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Matthew Lukies
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Helen Kavnoudias
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, Monash University Central Clinical School, Australia
| | - Adil Zia
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Robin Lee
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Julian J Bosco
- Department of Respiratory medicine, Allergy, asthma and Clinical Immunology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Tim Joseph
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, Monash University Central Clinical School, Australia; National Trauma Research Institute, Monash University Central Clinical School, Melbourne, Australia.
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Erskine B, Bradley P, Joseph T, Yeh S, Clements W. Comparing the accuracy and complications of peripherally inserted central catheter (PICC) placement using fluoroscopic and the blind pushing technique. J Med Radiat Sci 2021; 68:349-355. [PMID: 34343419 PMCID: PMC8655624 DOI: 10.1002/jmrs.533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/20/2021] [Accepted: 07/23/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Peripherally inserted central catheters (PICCs) offer a convenient long-term intravenous access option. Different methods exist for insertion including the use of continuous fluoroscopy for guidance, or bedside insertion techniques. The blind pushing technique is a bedside approach which involves advancing a PICC through the access sheath without imaging guidance, before taking a mobile chest radiograph to confirm tip position. Obtaining optimal position is a critical aim of PICC placement as malpositioned lines have been associated with higher complications including death. We aimed to assess the accuracy of PICC placement by comparing the tip position and complications for lines placed under fluoroscopic guidance to those placed without fluoroscopic guidance. METHODS The Radiology Information System was used to identify 100 continuous PICC insertions in each group (fluoroscopic and blind pushing) between 1 January and 12 May 2019. Patients were excluded if there was a known history of central venous occlusion/stenosis. RESULTS In the fluoroscopic-guided group, 0% of the lines were malpositioned compared with 60% of the lines placed using the blind pushing technique, P < 0.001. Fluoroscopic-guided PICC insertions were in place for a total of 2446 days and demonstrated 6 complications (2.45 complications per 1000 catheter days). This compared with blind pushing technique PICC insertions which were in place for a total of 1521 days and demonstrated 18 complications (11.83 complications per 1000 catheter days), P = 0.004. CONCLUSION The use of fluoroscopy for PICC placement leads to significant improvements in tip accuracy than for PICCs placed using the blind pushing technique. While the use of these imaging resources incurs cost and time, these factors should be balanced in order to offer patients the safest and most accurate method of line insertion.
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Affiliation(s)
- Brendan Erskine
- Department of RadiologyAlfred HospitalMelbourneVictoriaAustralia
| | - Pierre Bradley
- Department of Anaesthesia and Perioperative MedicineAlfred HospitalMelbourneVictoriaAustralia
- Department of Anaesthesia Teaching and ResearchMonash University Central Clinical SchoolMelbourneVictoriaAustralia
| | - Tim Joseph
- Department of RadiologyAlfred HospitalMelbourneVictoriaAustralia
| | - Sabrina Yeh
- Department of RadiologyAlfred HospitalMelbourneVictoriaAustralia
| | - Warren Clements
- Department of RadiologyAlfred HospitalMelbourneVictoriaAustralia
- Department of SurgeryMonash University Central Clinical SchoolMelbourneVictoriaAustralia
- National Trauma Research InstituteAlfred HospitalMelbourneVictoriaAustralia
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Gipson J, Lee R, Clements W. Impact of COVID-19 lockdowns on registrar reporting volumes in a Melbourne teaching hospital. J Med Imaging Radiat Oncol 2021; 66:115-116. [PMID: 34796653 PMCID: PMC8652562 DOI: 10.1111/1754-9485.13353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jacob Gipson
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
| | - Robin Lee
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia.,Department of Surgery, Monash University Central Clinical School, Melbourne, Victoria, Australia
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Thompson C, Karunadasa H, Varma D, Schoenwaelder M, Clements W. Impact of COVID vaccination rollout on the use of computed tomography venography for the assessment of cerebral venous sinus thrombosis. J Med Imaging Radiat Oncol 2021; 65:883-887. [PMID: 34729931 PMCID: PMC8652448 DOI: 10.1111/1754-9485.13345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 10/17/2021] [Indexed: 11/07/2022]
Abstract
Introduction Cerebral venous sinus thrombosis (CVST) is rare; however, it has been observed in patients with vaccine‐induced immune thrombotic thrombocytopaenia syndrome (VITT) following the use of adenovirus vector vaccines against COVID‐19. Adverse vaccine effects have been heavily addressed in mainstream media, likely contributing to vaccination anxiety. This study aimed to assess how the vaccine rollout and media coverage has influenced the use of computed tomography venography (CTV) in an acute care setting of a tertiary hospital. Method Single‐centre retrospective cohort study from 30 March 2021 to 13 June 2021. Direct comparison to same calendar dates in the preceding 3 years. Results In 2021, 57 patients received CTV with headache being the reason in 48 (84%) and 40 (70%) had received ChAdOx1 nCov‐19 (AstraZeneca COVID‐19 vaccination). Only 20 of these patients received CTV after platelets and D‐Dimer had returned, and only three patients met existing guidelines for imaging. Zero cases were positive. The number of CTV studies was 5.2 times than in 2020 and 2.7 times the mean number for the 3 preceding years. Conclusion The use of CTV in patients with headache has markedly increased at our centre since negatively biased vaccination influence of mainstream media. Headache is a common vaccine‐related side effect and VITT is exceptionably rare. With the rates of vaccination increasing in the community, these results highlight the importance of strict adherence to established evidence‐based guidelines. Otherwise, critical care capacity, and in particular imaging resources already under pressure will be strained further.
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Affiliation(s)
- Corey Thompson
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | | | - Dinesh Varma
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University Central Clinical School, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Mark Schoenwaelder
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University Central Clinical School, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
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Schlegel RN, Clements W, Koukounaras J, Goh GS, Joseph T, Phan T, Moriarty HK. A 10-year retrospective review of management and outcomes of pseudoaneurysms at a tertiary referral centre. J Med Imaging Radiat Oncol 2021; 66:603-608. [PMID: 34490983 DOI: 10.1111/1754-9485.13325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/26/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Pseudoaneurysms are uncommon but potentially life-threatening. Treatment may involve a variety of interventions including observation, manual compression, ultrasound-guided thrombin injection and a variety of endovascular and surgical techniques. Current treatments are largely based on observational data and there is no consensus on management. This study aimed to provide evidence for guiding clinical decisions regarding visceral artery pseudoaneurysm and peripheral artery pseudoaneurysm management. METHODS Retrospective single-centre review of patients diagnosed with visceral and peripheral artery pseudoaneurysms at a tertiary hospital (2010-2020). RESULTS There were 285 patients included in this study. A total of 86 patients were diagnosed with a visceral artery pseudoaneurysm, and 49 of these (57%) were caused by trauma. A total of 199 patients were identified with a peripheral pseudoaneurysm; 76 of these (38%) were caused by trauma and 69 (35%) were due to access site complication during an endovascular procedure. Initial technical success was achieved in 266 patients (93.3%) with 19 requiring an additional treatment to achieve success. Conservative treatment (100% success), endovascular treatment (98.1%) and surgery (100%) were more successful than ultrasound-guided compression (63.6%) and thrombin injection (83.8%). The median time from diagnosis to intervention was <9 h for visceral artery pseudoaneurysms and 24 h for peripheral artery pseudoaneurysms. There was no change in survival outcomes with respect to time from diagnosis and intervention. CONCLUSION In this study, pseudoaneurysms were treated with a high degree of success by observation or by using an endovascular approach, and those requiring endovascular intervention did not need to be treated immediately in an emergent setting.
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Affiliation(s)
- Richard N Schlegel
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jim Koukounaras
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Gerard S Goh
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Tim Joseph
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Tuan Phan
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Heather K Moriarty
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
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Moriarty HK, Clements W, Phan T, Wang S, Goh GS. Occupational radiation exposure to the lens of the eye in interventional radiology. J Med Imaging Radiat Oncol 2021; 66:34-40. [PMID: 34342393 DOI: 10.1111/1754-9485.13307] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/15/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Cataract formation is a tissue reaction effected by radiation exposure. The purpose of this study was to evaluate the occupational exposure to the lens of the eye of interventional radiologists (IR's) and interventional radiology staff, with and without lead glasses. METHODS Ethical approval was provided by the hospital research and ethics committee. A prospective cohort study was performed over 1 year, doses recorded, lifetime dose (estimated at working 5 days in angiography, for 30 years) was estimated and dose compared to current guidelines. Thermoluminescent dosimeters (TLDs; Landauer, Glenwood, USA) Hp(3) were placed on both the exterior and interior side of the personal lead glasses worn by three interventional radiologists and two radiographers. They were monitored during all procedures performed within 1 year. Lead glasses (AttenuTech® Microlite® , Florida, USA) with specifications were 0.75 mm lead equivalent front shield, and Side shield 0.3 mm Pb equivalent. A control TLD was placed in the storage location of the lead glasses when not in use. Yearly dose was measured and lifetime dose was calculated from the data obtained. Calculation of dose received per day(s) spent performing procedures for both annual and lifetime exposure was performed. In addition a record of occurrence of splashes on glasses was made after each case. RESULTS Eye doses without protection were double the recommended limits for both annual and lifetime dose. For interventional radiologists working between 3 and 4 or more days in the lab per week, annual dose thresholds would be exceeded (20 mSv/year averaged over 5 years, no more than 50 mSv in 1 year). If interventional radiologists worked between 3 and 4 or more days in the lab, lifetime dose thresholds would be exceeded (500 mSv lifetime dose). Lead glasses reduced radiation exposure by an average of 79%. If lead glasses were worn no interventional radiologists would exceed annual or lifetime dose thresholds to the eyes even if working 5 days per week as the primary operator. Radiographers would not exceed annual or lifetime dose thresholds even without lead glasses. Splash incidents occurred for all interventional radiologists and one radiographer. CONCLUSION The use of lead glasses even in this small study resulted in a decreased dose of radiation to the lens of the eye. Regular use of radiation protection eyewear will reduce eye dose for primary proceduralists to well below yearly and lifetime thresholds.
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Affiliation(s)
- Heather K Moriarty
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Tuan Phan
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Sherry Wang
- University of Utah, Salt Lake City, Utah, USA
| | - Gerard S Goh
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia
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Venn GA, Clements W, Moriarty H, Goh GS. Proximal splenic embolisation versus distal splenic embolisation for management of focal distal arterial injuries of the spleen. J Med Imaging Radiat Oncol 2021; 65:869-874. [PMID: 34142762 DOI: 10.1111/1754-9485.13263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/28/2021] [Accepted: 05/25/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION To compare the outcomes of proximal (pSAE) versus distal (dSAE) splenic artery embolisation for management of focal distal arterial splenic injuries secondary to blunt splenic trauma. METHOD Ethical approval was granted by the hospital research and ethics committee, Project 389/19. All patients who underwent splenic artery embolisation secondary to blunt abdominal trauma from 1 January 2009 to 1 January 2019 were reviewed. Patients with a tandem embolisation (both proximal and distal embolisations) or those with no acute vascular injury on angiography were excluded. Patient demographics, injury type/ AAST grade (2018 classification), technique of embolisation and outcomes were collected. Complications and splenectomy rates up to 30 days were recorded. RESULTS 136 out of 232 patients had an embolisation performed for a distal vascular injury including active arterial bleeding, pseudoaneurysm or arteriovenous fistula. Mean age was 41 (range 16-84). Mean AAST grade was 4 (range 3-5). Mean Injury Severity Score was 22. pSAE was performed in 79.4% (n = 108) and dSAE in 20.6% (n = 28). Major complications occurred in 12 patients (pSAE n = 12, 11.1%; dSAE n = 0, P > 0.05); 6 pSAE required splenectomy (n = 6, 5.6%). There was no significant difference in outcomes between the two groups or when based on AAST grading. CONCLUSION No significant difference was observed between proximal and distal embolisation techniques for blunt trauma patients with a distal vascular injury in terms of technical and clinical success.
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Affiliation(s)
| | - Warren Clements
- Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Central Clinical School, Monash University, Clayton, Victoria, Australia.,National Trauma Research Institute, Monash University, Clayton, Victoria, Australia
| | - Heather Moriarty
- Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Central Clinical School, Monash University, Clayton, Victoria, Australia
| | - Gerard S Goh
- Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Central Clinical School, Monash University, Clayton, Victoria, Australia.,National Trauma Research Institute, Monash University, Clayton, Victoria, Australia
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Clements W, McMahon GA, Joseph T, Goh GS, Kuang RJ, Smit DV, Varma D. Risk stratification of emergency department patients with acute pulmonary thromboembolism: Is chest pain a reason to investigate? J Med Imaging Radiat Oncol 2021; 65:864-868. [PMID: 34132053 DOI: 10.1111/1754-9485.13262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/25/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study aimed to risk-stratify chest pain as a presenting symptom in patients with a diagnosis of pulmonary thromboembolism (PE) to assess for any association. In addition, this study aimed to assess traditionally acknowledged PE risk factors in an Australian population. METHODS This was a retrospective single-centre cohort study assessing patients who presented to our emergency department during the period of 1 January 2019 to 1 January 2020. 730 consecutive patients who went on to computed tomography pulmonary angiography (CTPA) examination after presentation were included. RESULTS The rate of CTPA being positive in this study was 11.6% (85/730). Chest pain was associated with a non-significant reduction in the odds of PE (OR 0.774, P = 0.327). Univariate analysis showed significantly increased odds of a diagnosis of PE with presentation for leg pain/swelling (OR 6.670, P < 0.001). Multivariate analysis showed increasing age (OR 1.018, 95% CI 1.002-1.034, P = 0.024), clinical signs of a DVT (OR 3.194, 95% CI 1.803-5.657, P < 0.001) and positive D-dimer (OR 1.762, 95% CI 1.011-3.071, P = 0.046) were associated with increased odds of PE. CONCLUSION In this study, Emergency Department presentation with chest pain, whilst the most common reason to perform a CTPA, resulted in reduced odds with regard to the diagnosis of pulmonary thromboembolism. The use of CTPA in this setting may be rationalised according to other factors such as localised leg pain as a symptom, signs of DVT, increasing age or positive D-dimer.
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Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia.,National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - George Al McMahon
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Tim Joseph
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Gerard S Goh
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia.,National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Ronny Jd Kuang
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - De Villiers Smit
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Emergency Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Dinesh Varma
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia.,National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Kuang RJ, Beale AL, Bloom JE, Clements W. Paradoxical Cerebral Embolism Secondary to Superior Vena Cava Occlusion and Development of a Systemic Right-to-Left Shunt. Journal of Clinical Interventional Radiology ISVIR 2021. [DOI: 10.1055/s-0041-1730104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
AbstractParadoxical cerebral embolism, although rare, can be secondary to acquired causes such as superior vena cava (SVC) occlusion and development of a mediastinal right-to-left shunt. Such shunts allow undisturbed passage of thromboemboli to bypass the pulmonary circulation and enter the systemic circulation. This report presents a case of paradoxical cerebral embolism due to a right-to-left shunt originating from occlusion of the SVC. The etiology of the SVC occlusion stems from a prior central venous access line used for treatment of lymphoma. The patient underwent endovascular treatment with successful coil embolization of the mediastinal shunt.
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Affiliation(s)
- Ronny J.D. Kuang
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Anna L Beale
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jason E Bloom
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, Melbourne, Victoria, Australia
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50
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Clements W, Joseph T, Koukounaras J. UK NICE Guidelines for EVAR: Cost Implications for Post-COVID Australian Public Health. Cardiovasc Intervent Radiol 2021; 44:1286-1288. [PMID: 33884459 DOI: 10.1007/s00270-021-02832-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/24/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia. .,Department of Surgery, Monash University Central Clinical School, Melbourne, 3004, Australia. .,National Trauma Research Institute, Melbourne, 3004, Australia.
| | - Tim Joseph
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Jim Koukounaras
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia.,Department of Surgery, Monash University Central Clinical School, Melbourne, 3004, Australia
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