Jason W. Mitchell

Quality Improvement Guidelines for Transarterial Chemoembolization and Embolization of Hepatic Malignancy

From the Division of In ment of Radiology, Un 1740 West Taylor Stree Interventional Radiolog Northwestern Memoria (D.B.B.), Vanderbilt Univ Interventional Radiolog Therapy (S.G.), Massa Boston, Massachusetts Israel, New York, New Hospital, Barrie, Onta (A.M.E.), University of ventional Radiology (M Interventional Radiolog University School of M Radiology (S.A.P.), Dep at University of Californ Radiology (T.J.W.), Flor Radiology (J.L.W.), Dep Center, Boston, Massa Medical Center, Albany 2017. Address corres Fair Ridge Dr., Suite 40

Analysis of the Tibial Epiphysis in the Skeletally Immature Knee Using Magnetic Resonance Imaging: An Update of Anatomic Parameters Pertinent to Physeal-Sparing Anterior Cruciate Ligament Reconstruction

Background: Physeal-sparing anterior cruciate ligament (ACL) reconstruction is being performed increasingly in skeletally immature knees. Purpose: To determine normal values for the maximum oblique length and “safe” physeal-sparing length and their corresponding angular trajectories across the tibial epiphysis on reconstructed magnetic resonance images (MRIs) in children and adolescents. Study Design: Cross-sectional study; Level of evidence, 3. Methods: An electronic search for pediatric knee MR examinations from April 2003 to April 2013 was performed at our institution. A 3-dimensional system viewer was used to measure the maximum oblique length, physeal-sparing length, and their corresponding angular trajectories on reconstructed MRIs. Knees were stratified by age into 2 groups: group 1 consisted of boys <13 years and girls <12 years and group 2 consisted of older boys (13-14 years) and girls (12-14 years). Each cohort was further stratified by sex. Group 1 consisted of 36 knees (mean age, 10.9 years) and group 2 consisted of 59 knees (mean age, 13.6 years). Results: Significant differences existed for the maximum oblique length and its angular trajectory for the younger versus older cohort (22.2 ± 2.7 vs 23.8 ± 2.7 mm, P = .007; 42.0° ± 4.0° vs 39.4° ± 4.2°, P = .003) and for the physeal-sparing length and its angular trajectory (19.4 ± 2.8 vs 21.3 ± 2.9 mm, P = .001; 30.1° ± 4.1° vs 28.2° ± 4.5°, P = .042). In group 2, females had shorter maximal oblique length and physeal-sparing length than boys (22.7 ± 2.3 vs 25.0 ± 2.7 mm, P < .001; 20.3 ± 2.6 vs 22.4 ± 2.9 mm, P = .004). Conclusion: The maximum oblique length across the tibial epiphysis is shorter than previously believed, measuring approximately 22 mm and approximately 24 mm for high- and intermediate-risk knees, respectively. However, “safe” physeal-sparing lengths were only approximately 19 mm and 21 mm for the younger and older cohorts, respectively. The angles corresponding to the maximum and safe lengths are more acute than commonly thought, measuring approximately 40° and 30°, respectively. All prepubescent knees and intermediate-risk females should receive careful attention before ACL reconstruction due to the relative smaller size of their tibial epiphyses. Clinical Relevance: Physeal-sparing ACL reconstruction is gaining acceptance as a surgical option for complete ACL tear in skeletally immature knees. Iatrogenic growth disturbance after violation of an open growth remains a real concern for surgeons tasked with providing operative management for the unstable pediatric knee. Inadvertent iatrogenic growth plate injury to the tibial physis has been shown to occur more commonly than surgeons would intend during physeal-sparing ACL reconstruction.

Adult and Pediatric Antibiotic Prophylaxis during Vascular and IR Procedures: A Society of Interventional Radiology Practice Parameter Update Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Association for Interventional Radiology

Monzer A. Chehab, MD, Avnesh Thakor, MD, PhD, Sheryl Tulin-Silver, MD, Bairbre L. Connolly, MB, MCh, FRCPC, FRCSI, Anne Marie Cahill, MD, Thomas J. Ward, MD, Siddharth A. Padia, MD, Maureen P. Kohi, MD, Mehran Midia, MD, Gulraiz Chaudry, MBChB, FRCR, Joseph J. Gemmete, MD, Jason W. Mitchell, MD, MPH, MBA, Lynn Brody, MD, John J. Crowley, MD, Manraj K.S. Heran, MD, Jeffrey L. Weinstein, MD, Boris Nikolic, MD, MBA, Sean R. Dariushnia, MD, Alda L. Tam, MD, MBA, and Aradhana M. Venkatesan, MD

Obstruction of the Biliary and Urinary System

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