Publications

PURPOSE: To determine clinical and radiographic parameters predictive of interventions and adverse outcomes in patients with spontaneous rectus sheath hematoma.

METHODS: This retrospective, institutional review board approved study identified 261 patients with spontaneous rectus sheath hematoma from January 2000 to August 2021 through CT report searches. Demographics, clinical presentation, comorbidities, medications, and laboratory values were collected. CT scans were reviewed for hematoma characteristics including size, location, density, and active contrast extravasation. The primary outcome was the invasive intervention; and the secondary outcomes included transfusion requirements, length of hospital stay, acute kidney injury, readmission, and mortality. Categorical variables were compared using Fisher's exact test, while continuous variables were analyzed using Student's t-test or Mann-Whitney U test as appropriate based on normality assessment.

RESULTS: The cohort comprised 261 patients (median age 71 (IQR, 60-78) years, 59% female). Invasive treatments were performed in 41 patients (15.7%): 35 underwent angiography with embolization; 6 had surgical exploration. Invasive treatment was significantly more frequent among patients with trans-umbilical extension (25.7% vs 9.4%; p < 0.001), active contrast extravasation (46.7% vs 33.0%, p < 0.001), and hematoma volume > 443.5 cc (31.8% vs 9.6%, p < 0.001)." These patients had higher red blood cell transfusion requirements (85.4% vs. 47.7%, p < 0.001) and longer hospital stays (7 vs. 4 days, p < 0.001). The overall in-hospital mortality was 6.9%, with 1.9% attributable to rectus sheath hematoma.

CONCLUSION: While most rectus sheath hematomas are managed conservatively, specific CT findings-trans-umbilical extension, larger volume, and active contrast extravasation-predict invasive intervention and guide clinical decision-making.

The central principle of the theory of constraints is that in any complex system there are only a few constraints that limit the performance (ie, "throughput") of the system. These constraints are rate-limiting steps to throughput. Once the constraint or bottleneck is identified, resources are used to improve the utilization rate at the point of the constraint to make the process as productive as possible. Others in the organization also must work to maintain the high utilization rate at the constraint. Strategies such as buffers are used to increase throughput at the constraints. Although it was initially developed in manufacturing, the theory of constraints has been applied to many industries. By using the theory of constraints to evaluate the radiologic workflow, constraints can be identified through targeted process improvement projects for optimization at steps that affect the total throughput of the system. Constraints can be physical, such as equipment or space (eg, imaging units or recovery room beds), or related to personnel. Because radiology is currently in a resource-constrained environment, targeted interventions with highly effective processes could improve productivity or flow. Given the workforce shortages in radiology, determining whether the constraint is equipment- or personnel-related may lead to different improvement projects.

PURPOSE: Hepatocellular carcinoma (HCC) is a major cause of cancer mortality in sub-Saharan Africa, with most cases arising from chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infections. Despite Rwanda's national hepatitis guidelines recommending biannual surveillance with abdominal ultrasound (US) and alpha-fetoprotein (AFP) testing, the extent of adherence remains unknown. This study aimed to assess adherence to HCC surveillance guidelines among HBV- and HCV-infected patients at a national referral hospital in Rwanda.

METHODS: We conducted a retrospective descriptive study of HBV- and HCV-infected patients attending the Rwanda Military Referral and Teaching Hospital between January 2022 and December 2024. Surveillance adherence was assessed based on the proportion of time covered by abdominal US and AFP testing, with coverage categorized as optimal (100%), intermediate (50%-99%), or poor (<50%).

RESULTS: Among 388 patients (mean age, 41.9 years; 73.4% male), 82.7% were HBV-infected. Over one third (31.4%) and nearly half (44.6%) of the patients never received an US or AFP test, respectively. Only 15.5% achieved optimal US coverage, and 12.1% had optimal AFP coverage. Surveillance coverage was worse in patients age 31-50 years and those residing in Kigali. Paradoxically, patients from rural provinces demonstrated better adherence. Thirteen patients (3.4%) had liver lesions detected on US, although lesion status was undocumented in 44.6% of cases.

CONCLUSION: Adherence to HCC surveillance guidelines in Rwanda is suboptimal, with significant gaps across age groups and regions. These findings underscore the need for integrating HCC surveillance into routine hepatitis care and leveraging Rwanda's decentralized health system to improve early cancer detection.

BACKGROUND: Calciprotein particles (CPP) are nanoparticles that play an important role in the pathogenesis of chronic kidney disease-mineral and bone disorder (CKD-MBD).

HYPOTHESIS/OBJECTIVES: Identification of plasma CPP and preliminary exploration of the relationships among CPP concentrations, calcification propensity (T50), and CKD-MBD variables in cats with azotemic CKD.

ANIMALS: Cats with azotemic CKD (n = 52) stabilized on a phosphate-restricted diet (PRD).

METHODS: Total CPP (T-CPP), low-density CPP (L-CPP), and high-density CPP (H-CPP) were measured in heparinized plasma using a fluorescent bisphosphonate (OsteoSense) after gel filtration. Standardized linear regression models evaluated associations among CPP, T50, and CKD-MBD variables. Generalized estimating equations compared preprandial and postprandial CPP concentrations. Calciprotein particle changes (ΔCPP) between visits were compared between cats with different ionized calcium (iCa) trajectories using independent samples t-test or Mann-Whitney U tests.

RESULTS: Fibroblast growth factor-23 (standardized coefficient [sβ], 0.35; P = .04) and parathyroid hormones (sβ, -0.34; P = .042) were significantly associated with preprandial T-CPP concentrations in cats fed a PRD, whereas phosphate was significantly associated with postprandial T-CPP (sβ, 0.72; P = .003) and L-CPP (sβ, 0.75; P = .003) concentrations before dietary phosphate restriction. ΔT-CPP was significantly greater in cats with CKD with uptrend iCa compared to those with downtrend iCa after PRD stabilization (14 105 ± 36 299 AU vs -29 495 ± 49 664 AU; P = .036).

CONCLUSIONS AND CLINICAL IMPORTANCE: Calciprotein particle measurement is possible in cats and adds to the assessment of CKD-MBD, particularly the risk of soft tissue mineralization. The trajectory of iCa after PRD might influence CPP concentrations in cats with CKD.

BACKGROUND: New-onset postoperative atrial fibrillation (POAF) complicates 30% of cardiac surgeries. Although POAF is often transient, structured follow-up care of patients with POAF may identify those with paroxysmal or persistent atrial fibrillation (AF) who will benefit from evidence-based therapies.

METHODS: This retrospective study includes patients seen in a clinic dedicated to patients with POAF after cardiac surgery between 2020 and 2024. Per the clinic's operating procedure, patients wore a 14-day continuous ambulatory electrocardiogram (ECG) monitor fpr 2 months after surgery and were assessed thereafter in clinic. The primary outcome was recurrent AF lasting ≥ 30 seconds, captured by 14-day continuous ambulatory ECG or during clinical care.

RESULTS: The cohort included 881 patients, with a mean age of 68 ± 9 years, and a median Congestive Heart Failure, Hypertension, Age ≥ 75 Years, Diabetes Mellitus, Stroke, Vascular Disease, Age 65 to 74 Years, Sex Category (CHA2DS2-VASc) score of 2 (interquartile range [IQR] 1-3); 529 patients (60.0%) underwent isolated coronary artery bypass grafting. At discharge, 798 patients (90.6%) were prescribed amiodarone, and 435 (49.4%) were prescribed oral anticoagulation. The mean time between discharge and 14-day continuous ambulatory ECG monitor was 72 days (IQR 61-84). AF recurrence was detected in 94 patients (10.7%); 30 patients (36.1%) were not receiving oral anticoagulation at the time of recurrence. Among patients with recurrence detected by 14-day continuous ambulatory ECG, the median duration was 10 hours (IQR 2-253). Left atrial volume index was the only independent predictor of AF recurrence. Following the clinic visit, oral anticoagulation was continued in 122 patients (28.2%).

CONCLUSIONS: Among patients with POAF following cardiac surgery, 1 in 10 have AF recurrence, as determined by a structured 14-day continuous ambulatory ECG monitor utilized 2-3 months postoperatively.

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a progressive, fatal lung disease leading to end-stage lung disease (ESLD). Single lung transplantation (SLT) is the primary treatment option for IPF; however, the native lung continues to influence post-transplant outcomes.

OBJECTIVES: To determine whether the native lung continues to deteriorate under post-transplantation immunosuppression treatment by assessing chest computed tomography (CT) and perfusion scans.

METHODS: We conducted a single-center retrospective analysis of patients who underwent SLT for IPF between 2016 and 2023. Serial chest CT scans assessed native lung changes. CT signs of fibrosis were scored for severity according to published criteria for defining pulmonary fibrosis disease progression. Lung volumes and perfusion were calculated.

RESULTS: Among 57 patients (mean age 57 years; 33% female), 42% died during follow-up (median survival 95 months). The most common immunosuppressive regimen (54% of patients) included prednisone, calcineurin inhibitor, and mycophenolate mofetil. CT analysis demonstrated that in 41/57 (72%) patients, fibrosis signs continued to deteriorate. There was also a significant correlation decline in native lung volume and perfusion scans over time (P = 0.0003, P < 0.0001, respectively) (r = 0.82, P = 0.03).

CONCLUSIONS: Fibrotic progression in the native lung persists after SLT as demonstrated by both chest CT and nuclear perfusion scan, thus highlighting the importance of ongoing monitoring for accuracy and complications assessment, integrating it into routine surveillance, and ensuring it is consistently considered in post-transplant assessments.

Group 3 medulloblastoma (G3MB) is a devastating disease of the central nervous system (CNS) that primarily affects infants and children. Chimeric antigen receptor (CAR) T cell therapy holds the promise to improve outcomes for CNS malignancies, but few studies have focused specifically on G3MB. We used publicly available datasets to demonstrate EphA2 and B7-H3 expression in primary G3MB and validated expression in patient-derived cell lines. EphA2-CAR T cells had greater cytolytic activity, persistence, and TH1 cytokine production than B7-H3-CAR T cells in coculture assays with MYC-driven G3MB cell lines in vitro. In vivo, EphA2-CAR T cells demonstrated superior tumor control and improved survival compared to B7-H3-CAR T cells in 2 of 3 orthotopic G3MB models. B7-H3-CAR T cells outperformed EphA2-CAR T cells in one model in which the antigen density of EphA2 was 5-fold lower than for B7-H3. The limited antitumor activity of EphA2-CAR T cells could be overcome with second genetic modifications that increase T cell functionality including deletion of DNMT3A or the expression of a constitutively active IL-18 chimeric cytokine receptor. Thus, our study nominates EphA2-CAR T cells as a promising alternative to B7-H3-CAR T cells, which are actively being explored in clinical studies for medulloblastoma.

PURPOSE: This study aims to evaluate the safety and effectiveness of TIPS-PVR in patients with cirrhosis with acute PVT.

MATERIALS AND METHODS: A retrospective analysis of cirrhotic patients with acute PVT who underwent TIPS-PVR at a single academic institution. Patients were categorized by PVT etiology and thrombus extent according to AASLD criteria. Outcomes assessed included technical success, one-year patency of the TIPS and porto-mesenteric venous system, need for TIPS reintervention, symptom recurrence, and overall survival. Overall survival was defined as the time from TIPS-PVR to death or last follow-up.

RESULTS: Fifty cirrhotic patients underwent TIPS-PVR for acute PVT. Technical success was 100%. Superior mesenteric vein (SMV) involvement was seen in 30/50 (60%), and splenic vein in 11/50 (22%). At one year, 32 patients had follow-up. Primary patency was 75% (24/32), primary-assisted patency 94% (30/32) for TIPS and 97% (31/32) for the portal vein. Patency rates improved at one year: Main portal vein from 18 to 97% (p < 0.001), SMV from 50 to 91% (p < 0.001), splenic vein from 78 to 100% (p = 0.0108). 9 patients underwent liver transplantation after TIPS-PVR. There were no grade 4 or grade 5 CIRSE adverse events. There were five Grade 6 events after the procedure. Overall survival was 78% at 12 months, with 95% CI 64-87%.

CONCLUSIONS: TIPS-PVR appears to be a safe and effective procedure for cirrhotic patients with acute PVT, offering a viable option for restoring portal venous flow.