Publications by authors named "Shyamkumar N Keshava"

70 Publications

The "Inside-outside" Sign.

J Clin Imaging Sci 2021 1;11:57. Epub 2021 Nov 1.

Department of Interventional Radiology, Division of Clinical Radiology, Christian Medical College, Vellore, Tamil Nadu, India.

We describe a radiological sign, "inside-outside sign," observed during the cannulation of an expandable contrast-filled tubular structure in the human body. In this optical illusion, a catheter or guidewire appears to be outside the lumen when it is inside the lumen in reality. Knowing this rare optical illusion is essential to avoid mistaking it for a catheter or guidewire outside the lumen.
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http://dx.doi.org/10.25259/JCIS_192_2021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8571281PMC
November 2021

Indian College of Radiology and Imaging (ICRI) Consensus Guidelines for the Early Management of Patients with Acute Ischemic Stroke: Imaging and Intervention.

Indian J Radiol Imaging 2021 Apr 27;31(2):400-408. Epub 2021 Jul 27.

Interventional Radiology, ICRI Director, Interventional Radiology, BLK Super Specialty Hospital, Pusa Road, New Delhi, India.

The medical science has witnessed significant change in the management of acute stroke patients as a result of recent advances in the field of stroke imaging and endovascular mechanical thrombectomy in addition to intravenous thrombolysis and optimization of stroke services in balance with available resources. Despite initial negative trials, we witnessed the publication of five multicenter randomized clinical trials showing superiority of the endovascular approach over standard medical management in patients with large vessel occlusion. The aim of this study is to provide comprehensive set of evidence-based recommendations regarding imaging and endovascular interventions in acute ischemic stroke patients.
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http://dx.doi.org/10.1055/s-0041-1734346DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8448212PMC
April 2021

Radiology Reporting Errors: Learning from Report Addenda.

Indian J Radiol Imaging 2021 Apr 12;31(2):333-344. Epub 2021 Aug 12.

Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India.

The addition of new information to a completed radiology report in the form of an "addendum" conveys a variety of information, ranging from less significant typographical errors to serious omissions and misinterpretations. Understanding the reasons for errors and their clinical implications will lead to better clinical governance and radiology practice. This article assesses the common reasons which lead to addenda generation to completed reports and their clinical implications. Retrospective study was conducted by reviewing addenda to computed tomography (CT), ultrasound, and magnetic resonance imaging reports between January 2018 to June 2018, to note the frequency and classification of report addenda. Rate of addenda generation was 1.1% ( = 1,076) among the 97,003 approved cross-sectional radiology reports. Errors contributed to 71.2% ( = 767) of addenda, most commonly communication (29.3%, = 316) and observational errors (20.8%, = 224), and 28.7% were nonerrors aimed at providing additional clinically relevant information. Majority of the addenda (82.3%, = 886) did not have a significant clinical impact. CT and ultrasound reports accounted for 36.9% ( = 398) and 35.2% ( = 379) share, respectively. A time gap of 1 to 7 days was noted for 46.8% ( = 504) addenda and 37.6% ( = 405) were issued in less than a day. Radiologists with more than 6-year experience created majority (1.5%, = 456) of addenda. Those which were added to reports generated during emergency hours contributed to 23.2% ( = 250) of the addenda. The study has identified the prevalence of report addenda in a radiology practice involving picture archiving and communication system in a tertiary care center in India. The etiology included both errors and non-errors. Results of this audit were used to generate a checklist and put protocols that will help decrease serious radiology misses and common errors.
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http://dx.doi.org/10.1055/s-0041-1734351DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8448237PMC
April 2021

The Status of Interventional Radiology as a Specialty among Medical Students in India-Knowledge, Interest, and Exposure.

Indian J Radiol Imaging 2021 Apr 28;31(2):259-264. Epub 2021 Jul 28.

Division of Vascular Radiology, Department of Radiology, Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom.

Interventional radiology (IR) is a young medical specialty where image guidance is utilized in minimally invasive procedures as a treatment option and/or as a diagnostic tool. There is an exponential increase in awareness and interest in IR amongst medical students. This trend is continuing despite lack of proportionate representation of IR in the current medical curriculum. This study aims to understand the exposure to IR as a specialty amongst medical students in India. Anonymous, voluntary, online questionnaire was sent to medical students from different parts of the country. The survey comprised 15 questions regarding exposure and awareness on IR. The responses were obtained from 1,024 medical students from 98 medical colleges across the country, majority (57.0%) in the clinical years of their training. Thirty-six percent of them were interested in an IR career. Lack of awareness was the most (61.6%) cited reason for not choosing an IR career. Majority (57.9%) would consider IR as a clinical management option and believe that IR holds an important place in medical practice (68.4%). There is an evident under-representation of IR in the medical curriculum. However, an increasing awareness and interest among medical students toward IR as a specialty is demonstrated. Incorporation of IR into current medical curriculum in a systematic way is the need of the hour. This would ultimately benefit a wide cohort of patients across multiple specialties.
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http://dx.doi.org/10.1055/s-0041-1733813DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8448250PMC
April 2021

Utility of spinal angiography and arterial embolization in patients undergoing CT guided alcohol injection of aggressive vertebral hemangiomas.

Neuroradiology 2021 Nov 24;63(11):1935-1945. Epub 2021 Aug 24.

Neurosurgery, Christian Medical College, Vellore, India.

Purpose: The purpose of this study is to evaluate the role of spinal angiography and arterial embolization in avoiding spinal cord ischemia in patients undergoing CT-guided alcohol injection of aggressive vertebral hemangiomas.

Methods: In this retrospective study, patients with vertebral hemangioma who underwent CT-guided direct alcohol injection between January 2007 and October 2018 were identified. Of 28 such patients, 26 had neurological deficits, and 2 had only back pain or radiculopathy. Direct alcohol injection without prior arterial embolization was done in 17 patients. Direct alcohol injection with prior arterial embolization was done in 11 patients. Clinical outcome was assessed immediately after the intervention and at follow-up.

Results: Three patients, who underwent alcohol injection without trans-arterial embolization, had worsening of neurological deficits in the post procedure period due to spinal cord ischemia. No complications related to spinal cord ischemia were noted in the embolization group. There was no significant difference in the outcomes between the two groups if the three patients with complications are excluded (p = 0.34).

Conclusion: While CT-guided direct alcohol injection is effective in the management of symptomatic and aggressive vertebral hemangiomas, spinal angiography and trans-arterial embolization of the blood supply to the vertebral body hemangioma, prior to the direct transpedicular alcohol embolization of the lesion, improves the safety of the procedure.
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http://dx.doi.org/10.1007/s00234-021-02788-7DOI Listing
November 2021

Clinical Radiology Case Presentation: Do's and Don'ts.

Indian J Radiol Imaging 2021 Jan 25;31(1):24-29. Epub 2021 May 25.

Division of Clinical Radiology, Department of Radiodiagnosis, Christian Medical College, Vellore, Tamil Nadu, India.

Clinical case presentation is part of daily routine for doctors to communicate with each other to facilitate learning, and ultimately patient management. Hence, the art of good clinical case presentation is a skill that needs to be mastered. Case presentations are a part of most undergraduate and postgraduate training programs aimed at nurturing oratory and presentation design skills. This article is an attempt at providing a trainee in radiology a guideline to good case presentation skills.
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http://dx.doi.org/10.1055/s-0041-1729489DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8299493PMC
January 2021

Musculoskeletal ultrasound in hemophilia: Results and recommendations from a global survey and consensus meeting.

Res Pract Thromb Haemost 2021 Jul 10;5(5):e12531. Epub 2021 Jul 10.

School of Rehabilitation Science Faculty of Health Science Hamilton Niagara Regional Hemophilia Program Hamilton Health Sciences McMaster University Hamilton ON Canada.

Introduction: For persons with hemophilia, optimization of joint outcomes is an important unmet need. The aim of this initiative was to determine use of ultrasound in evaluating arthropathy in persons with hemophilia, and to move toward consensus among hemophilia care providers regarding the preferred ultrasound protocols for global adaptation.

Methods: A global survey of hemophilia treatment centers was conducted that focused on understanding how and why ultrasound was being used and endeavored to move toward consensus definitions of both point-of-care musculoskeletal ultrasound (POC-MSKUS) and full diagnostic ultrasound, terminology to describe structures being assessed by ultrasound, and how these assessments should be interpreted. Next, an in-person meeting of an international group of hemophilia health care professionals and patient representatives was held, with the objective of achieving consensus regarding the acquisition and interpretation of POC-MSKUS and full diagnostic ultrasound for use in the assessment of musculoskeletal (MSK) pathologies in persons with hemophilia.

Results: The recommendations were that clear definitions of the types of ultrasound examinations should be adopted and that a standardized ultrasound scoring/measurement system should be developed, tested, and implemented. The scoring/measurement system should be tiered to allow for a range of complexity yet maintain the ability for comparison across levels.

Conclusion: Ultrasound is an evolving technology increasingly used for the assessment of MSK outcomes in persons with hemophilia. As adoption increases globally for clinical care and research, it will become increasingly important to establish clear guidelines for image acquisition, interpretation, and reporting to ensure accuracy, consistency, and comparability across groups.
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http://dx.doi.org/10.1002/rth2.12531DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8271584PMC
July 2021

Interventional radiology and COVID-19: How to face the challenge?

Indian J Radiol Imaging 2021 Jan 23;31(Suppl 1):S38-S44. Epub 2021 Jan 23.

Department of Interventional Radiology, BLK Superspeciality Hospital, New Delhi, India.

With the sudden outbreak of Coronavirus disease-19 (COVID-19) in China, and its rapid spread across the continents over a short period of time, healthcare workers are posed with the challenge of managing these patients as well protecting themselves from getting infected. Since interventional radiology deals with both elective and emergency services, wherein close patient contact is a norm, there is a substantial risk of acquiring and transmitting infection. Given the circumstances, it is imperative to develop broadly applicable guidelines to utilize the available resources in an optimal fashion and limit transmission of disease. This brief review deals with infection control measures within the Interventional Radiology department or section and possible recommendations that can be adopted at the institutional level.
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http://dx.doi.org/10.4103/ijri.IJRI_351_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7996698PMC
January 2021

Ultrasound and magnetic resonance imaging for the detection of blood: An ex-vivo study.

Haemophilia 2021 May 29;27(3):488-493. Epub 2021 Mar 29.

Department of Hematology, Christian Medical College, Vellore, India.

Objectives: Early detection of bleeding into a joint is crucial in patients with haemophilia. This study was designed to evaluate the sensitivity of ultrasonography (USG) and magnetic resonance imaging (MRI) to detect the presence of blood in small concentrations in a simulated model to mimic joint bleeding.

Materials And Methods: Different concentrations of blood in plasma, varying from 0.1% to 45%, were collected in 10-ml plastic syringes and imaged using 12 and 18 MHz USG transducers and with 1.5T and 3T MRI scanners, at different intervals of time following dilution. The images were scored for the presence of blood by four experienced radiologists who were blinded to the concentration of blood.

Results: Within the first 2 h, the 18 MHz transducer was able to detect blood consistently up to 0.5%, whereas the 12 MHz transducer could consistently identify blood up to 1.4%. After the first 12 h, both transducers were able to detect blood up to 0.5% concentration. However, at concentrations below 0.5%, there was discordance in the ability to detect blood, with both transducers. There was no correlation between the signal intensities of MRI images and concentration of blood, at different time intervals, irrespective of the magnetic field strength.

Conclusions: Detection of blood using the USG is dependent on variables such as the concentration of blood, frequency of the transducer used and timing of the imaging. As the concentration of blood decreases below 0.5%, the discordance between the observers increases, implying that the detection limit of USG affects its reliability at lower concentrations of blood. Caution is urged while interpreting USG imaging studies for the detection of blood in symptomatic joints.
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http://dx.doi.org/10.1111/hae.14303DOI Listing
May 2021

Imaging criteria to predict Shamblin group in carotid body tumors - revisited.

Diagn Interv Radiol 2021 May;27(3):354-359

Department of Vascular Surgery, Christian Medical College, Vellore, India.

Purpose: This study aims to compare the imaging findings of carotid body tumors on contrast-enhanced computed tomography (CT) with the intraoperative Shamblin grade and to evolve an imaging-based scoring system that can accurately predict the Shamblin grade.

Methods: Preoperative contrast-enhanced CT scans of 40 patients who underwent surgical excision of carotid body tumors in our institution between 2004 and 2017 were retrospectively reviewed. The angle of contact with the internal carotid artery (ICA), tumor volume, presence of peritumoral tuft of veins, loss of tumor adventitia interface and distance from the skull base were assessed and compared with the intraoperative Shamblin grades of the tumor. Ordinal logistic regression was used to determine which parameters could be predictors of the Shamblin grades. Receiver operator characteristic (ROC) curves were used to score the tumor volumes.

Results: Among the 42 tumors evaluated, 6 (14.3%) were surgically classified as Shamblin I, 15 (35.7%) as Shamblin II, and 21 (50%) as Shamblin III tumors. Pairwise comparison between the three Shamblin groups showed a statistically significant difference for angle of contact with ICA, maximum tumor dimension, presence of peritumoral tuft of veins and loss of tumor adventitia interface (p = 0.001, p = 0.001, p = 0.038 and p = 0.003, respectively). However, tumor volumes and distance from skull base were not significantly different between the Shamblin groups (p = 0.136 and p = 0.682). A scoring system, including four of the above mentioned parameters (angle of contact with ICA, tumor volume, presence of peritumoral tuft of veins, and loss of tumor adventitia interface) was developed with a maximum score of 8 and a minimum of 2. A statistically significant difference was found between the final scores among the three Shamblin groups (p < 0.001). Using ROC curves, a final score of ≥6 was found to separate Shamblin grade III tumors from grade I and II tumors (sensitivity, 95.24%; specificity, 71.43%). All patients with documented intraoperative estimated blood loss of >1000 mL had Shamblin grade III tumors. Postoperative complications like stroke, ICA thrombosis and lower cranial nerve palsies were seen only with Shamblin grade II and III tumors.

Conclusion: The simple scoring system we have proposed correlates well with the Shamblin grade and helps in identifying patients who have a higher risk of developing complications.
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http://dx.doi.org/10.5152/dir.2021.20028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8136543PMC
May 2021

Endovascular management of a patient with massive renal arteriovenous fistula: challenges and tricks.

BMJ Case Rep 2021 Feb 1;14(2). Epub 2021 Feb 1.

Department of Urology, Christian Medical College and Hospital, Vellore, India.

We describe the endovascular management of a patient with a massive renal arteriovenous fistula and a huge venous aneurysmal sac, who presented with features of cardiac failure and fever. The challenges faced and the outcomes are discussed with relevant literature review.
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http://dx.doi.org/10.1136/bcr-2020-236358DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7853036PMC
February 2021

Retrieval of retained pigtail in the liver.

Indian J Radiol Imaging 2020 Jul-Sep;30(3):376-378. Epub 2020 Oct 15.

Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India.

The incidence of catheter breakage during percutaneous image-guided treatment of liver hydatid is very rare. A "telescoping" technique was used to retrieve the broken pigtail in this case report. Alternative options for pigtail retrieval are briefly discussed.
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http://dx.doi.org/10.4103/ijri.IJRI_97_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7694720PMC
October 2020

Clinical Profile of Overgrowth Syndromes Consistent with PROS (-Related Overgrowth Syndromes)-A Case Series.

Indian Dermatol Online J 2020 Sep-Oct;11(5):738-746. Epub 2020 Sep 19.

Department of Haematology, Christian Medical College, Vellore, Tamil Nadu, India.

Context: -related overgrowth syndrome (PROS) is characterized by focal and disproportionate growth of acral body structures in a mosaic pattern with varied phenotypes. Clinical diagnostic criteria are available and testing of the mutation is recommended for diagnosis. Cutaneous features described in these conditions include epidermal nevi and vascular malformations which form part of the diagnostic criteria.

Aims: To detail the clinical profile of patients with presumptive PROS.

Settings And Design: We conducted a retrospective study of 15 patients with focal overgrowth of the extremities or macrocephaly who presented to the department of dermatology at a tertiary care hospital in South India.

Subjects And Methods: Data were collected through electronic medical records from July 2012 to April 2018 over 70 months. The criterion proposed by Keppler-Noreuil . was used for classifying them as presumptive PROS in the absence of genetic studies.

Statistical Analysis Used: Descriptive analysis.

Results: There were nine males and six females; mean age of 12.10 years (range: 8 months to 73 years) with clinical features consistent with PROS. There was a higher frequency of vascular malformations (9/15, 60%) and of epidermal nevi (7/15, 46.6%) than that reported in the literature. Unusual features included focal acrochordons, blaschkoid hypopigmentation and linear papillomatous growths in the oral mucosa.

Conclusions: This study provides data on the clinical features of patients with PROS from the Indian subcontinent. In resource-poor settings, clinical criteria may be adequate for diagnosis due to restricted accessibility of technically challenging diagnostic tests.
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http://dx.doi.org/10.4103/idoj.IDOJ_520_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7678549PMC
September 2020

Endografts with mini-cuff-augmented fenestrations for endovascular repair of thoracoabdominal aortic and common iliac artery aneurysms.

Vascular 2021 Apr 17;29(2):163-170. Epub 2020 Aug 17.

Department of Radiology, Christian Medical College, Vellore, India.

Objective: To report a technique of creating mini-cuff-augmented fenestrations in endografts for use in endovascular aneurysm repair.

Methods: Circular fenestrations are made in Dacron thoracic (Valiant Captivia, Medtronic) or tapered iliac limb (Endurant, Medtronic) endografts using thermal cautery and the edges are strengthened with radio-opaque wire sutured on with 6-0 polypropylene. Straight thin-wall expanded polytetrafluoroethylene vascular graft of the same diameter as the fenestration is affixed to its edge with nonlocking 5-0 polypropylene suture, everted, trimmed, balloon-dilated to its nominal diameter and prevented from invaginating by relaxed external stay sutures. Mini-cuff-augmented fenestrations are often pre-cannulated with looped or externalized nitinol guidewires to facilitate catheter crossing. Successful use of mini-cuff-augmented fenestrations is illustrated in a symptomatic patient with Crawford extent-3 thoracoabdominal aortic and bilateral common iliac artery aneurysm undergoing endovascular repair. Seven mini-cuff-augmented fenestrations were created to preserve flow into five visceral arteries (celiac, superior mesenteric, left and dual right renal; all arising from the aneurysm) and both internal iliac arteries (arising at the aneurysm edge).

Results: Effective sealing was achieved immediately at all mini-cuff-augmented fenestrations. At 6-month follow-up there were no endoleaks, all fenestration stents were patent and undistorted, and the aneurysm sac size had decreased.

Conclusion: Mini-cuff-augmented fenestrations accomplish effective fenestration sealing, despite being in aneurysmal zones, while preserving the advantages of fenestrations over cuffed branches.
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http://dx.doi.org/10.1177/1708538120949324DOI Listing
April 2021

Peripheral Arteriovenous Malformations-A Case Series.

Indian Dermatol Online J 2020 May-Jun;11(3):367-372. Epub 2020 May 10.

Department of Radiodiagnosis, Christian Medical College, Vellore, Tamil Nadu, India.

Context: Arteriovenous malformations (AVMs) are aggressive vascular malformations that often result in significant morbidity. Patients may present to a dermatologist due to associated skin changes. Early diagnosis is important as treatment is available to halt their progression toward irreversible destruction of adjacent tissues.

Aims: To study the clinical profile of peripheral AVMs presenting to the dermatologist and to provide a diagnostic algorithm.

Settings And Design: A retrospective study of patients of all age groups with peripheral AVMs who presented to the Department of Dermatology at a tertiary care hospital in India was performed. Syndromic forms were also included.

Subjects And Methods: We conducted a search of patients with peripheral AVMs, which were seen over a period of 51 months, i.e., from July 2014 to September 2018, from electronic medical records and reviewed their clinical details.

Statistical Analysis Used: Descriptive statistics such as frequency, mean, and median were computed.

Results: We report a series of 13 patients with peripheral AVMs, which constituted 6.7% (13/193) of all vascular malformations during this period. Of these, 8.3% (1/12) belonged to Schobinger's stage 1, 41.7% (5/12) to stage 2, 50% (6/12) to stage 3, and one with subcutaneous involvement devoid of cutaneous changes. The most common location was the extremities, which was seen in 53.8% (7/13). Syndromic association was present in 46.2% (6/13). Management included embolization, surgery, and medical treatment.

Conclusions: The proportion of peripheral AVMs out of all vascular malformations was similar to reported studies. The extremities were more frequently involved as compared to the head and neck. The diagnostic algorithm provided will help us to optimize investigations and direct early management.
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http://dx.doi.org/10.4103/idoj.IDOJ_207_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7367563PMC
May 2020

Critical appraisal of the International Prophylaxis Study Group magnetic resonance image scale for evaluating haemophilic arthropathy.

Haemophilia 2020 Jul 4;26(4):565-574. Epub 2020 Jun 4.

Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Canada.

A goal of the International Prophylaxis Study Group (IPSG) is to provide an accurate instrument to measure MRI-based disease severity of haemophilic arthropathy at various time points, so that longitudinal changes in disease severity can be identified to support decisions on treatment management. We review and discuss in this paper the evaluative purpose of the IPSG MRI scale in relation to its development and validation processes so far. We also critically appraise the validity, reliability and responsiveness of using the IPSG MRI scale in different clinical and research settings, and whenever applicable, compare these clinimetric properties of the IPSG MRI scale with those of its precursors, the compatible additive and progressive MRI scales.
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http://dx.doi.org/10.1111/hae.14032DOI Listing
July 2020

Use of ultrasound for assessment of musculoskeletal disease in persons with haemophilia: Results of an International Prophylaxis Study Group global survey.

Haemophilia 2020 Jul 22;26(4):685-693. Epub 2020 May 22.

Department of Medical Imaging, University of Saskatchewan and Saskatchewan Health Authority Saskatoon City Hospital, Saskatoon, SK, Canada.

Aim: The objective of this survey was to understand the global trends of imaging assessments in persons with haemophilia, focusing on point-of-care ultrasound (POCUS). Insights into the barriers impeding its widespread proliferation as a frontline imaging modality were obtained.

Methods: The survey opened in September of 2017 and closed in May of 2018. Haemophilia Treatment Centres (HTCs) treating both paediatric/adult patients were the population of interest. A REDCap survey of 25 questions was disseminated to 232 clinical staff in 26 countries.

Results: The majority of respondents (88.3%, 91/103) reported that POCUS is most useful to confirm or rule out a presumed acute joint bleed. European HTCs reported the highest routine use of POCUS at 59.5% (22/37) followed by HTCs in the "Other" countries of the world at 46.7% (7/15) and North American HTCs at 43.9% (25/57). At the time of the survey, physiotherapists were identified as the clinical staff who perform POCUS 52.8% (28/53) of the time, in contrast with nurses/nurse practitioners who represent only 5.7% (3/53) of users. The greatest perceived barriers to the implementation of POCUS are the lack of trained healthcare professionals who can perform POCUS at 69.2% (74/107) and the overall time commitment required at 68.2% (73/107).

Conclusion: Despite POCUS being used in 49.5% (54/109) of sampled HTCs, it is still utilized almost 30% less globally than full diagnostic ultrasound. A list of barriers has been identified to inform HTCs which challenges they will likely need to overcome should they choose to incorporate this imaging modality into their practice.
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http://dx.doi.org/10.1111/hae.14006DOI Listing
July 2020

Radiation dose reference card for interventional radiology procedures: Experience in a tertiary referral centre.

Indian J Radiol Imaging 2019 Jul-Sep;29(3):247-252. Epub 2019 Oct 30.

Department of Radiology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India.

Background: Fluoroscopy-guided interventions can potentially increase radiation risk to patients, if awareness on angiographic imaging technique and radiation dose is neglected.

Aim: To develop patient radiation dose reference card from standardized imaging techniques for various radiology interventions performed using flat detector based angiography system.

Materials And Methods: Real-time monitoring of angiographic exposure parameters and radiation dose were performed for 16 types of radiological interventions. Effective dose (ED) was estimated from dose area product (DAP) using PCXMC Monte Carlo simulation software. Radiation risk levels were estimated based on Biological Effects of Ionising radiation (BEIR) report VII predictive models for an Asian population.

Results: Pulse rates of 7.5 pps and 0.6 mm Copper filtration during fluoroscopy and 4 frames per second (fps) and 0.1-0.3 mm Cu filtration during image acquisitions were found to reduce radiation dose. Owing to increased number of image acquisitions, DAP was highest during diagnostic spinal angiography 186.7 Gycm (44.0-377.5). This resulted in highest ED of 59.4 mSv with moderate risk levels (1 in 1000 to 1 in 500). Most of the radiological interventions had low radiation risk levels (1 in 10,000 to 1 in 1000).

Conclusion: The patient radiation dose reference card is valuable to the medical community and can aid in patient counselling on radiation induced risk from radiological interventions.
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http://dx.doi.org/10.4103/ijri.IJRI_35_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6857258PMC
October 2019

What makes non-cirrhotic portal hypertension a common disease in India? Analysis for environmental factors.

Indian J Med Res 2019 04;149(4):468-478

Department of Hepatology, Division of GI Sciences, Christian Medical College, Vellore, India.

In India, an unexplained enteropathy is present in a majority of non-cirrhotic intrahepatic portal hypertension (NCIPH) patients. Small intestinal bacterial contamination and tropical enteropathy could trigger inflammatory stimuli and activate the endothelium in the portal venous system. Groundwater contaminated with arsenic is an environmental factor of epidemic proportions in large areas of India which has similar consequences. Von Willebrand factor (a sticky protein) expressed by activated endothelium may promote formation of platelet microthrombi and occlusion of intrahepatic portal vein branches leading to NCIPH. Environmental factors linked to suboptimal hygiene and sanitation, which enter through the gastrointestinal (GI) tract, predispose to platelet plugging onto activated endothelium in portal microcirculation. Thus, NCIPH, an example of poverty linked thrombophilia, is a disease mainly affecting the lower socio-economic strata of Indian population. Public health measures to improve sanitation, provide clean drinking water and eliminate arsenic contamination of drinking water are urgently needed. Till such time as these environmental factors are addressed, NCIPH is likely to remain 'an Indian disease'.
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http://dx.doi.org/10.4103/ijmr.IJMR_1405_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6676844PMC
April 2019

A Study on the Use of Radiation-Protective Apron among Interventionists in Radiology.

J Clin Imaging Sci 2018 24;8:34. Epub 2018 Aug 24.

Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India.

Objective: Radiation-protective aprons are commonly used by interventionists to protect against the harmful effects of ionizing radiation. Choice of appropriate aprons with respect to lead equivalence and weight is necessary for effective protection and reduced physical strain. This study evaluates the knowledge and practice of using radiation-protective aprons by interventionists.

Materials And Methods: Ninety-one interventional radiologists who attended an annual interventional conference were provided with a questionnaire which included age, years of experience, area of expertise, type and weight of apron used, and physical strain caused due to the use of apron.

Results: About 14.3% of the interventionists practiced in an angiographic suite for less than an hour a day, 45% for 2-4 h, 21% for 4-6 h, 10% for 6-10 h, and the rest above 10 h/day. About 68% of the interventionists wore 0.5 mm lead-equivalent (Pb) aprons; 15.4% with 0.25 mm Pb; about 5.5% with 0.35 mm Pb aprons, and the remaining were not aware of the lead equivalence. About 47% reported that they had body aches due to wearing single-sided aprons. Interventionists working more than 10 h/day wearing single-sided lead apron predominantly complained of shoulder pain and back pain.

Conclusion: A large fraction of interventionists reported that they had physical strain. It is suggestive for interventionists to wear correct fit and light-weight aprons with appropriate lead equivalence.
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http://dx.doi.org/10.4103/jcis.JCIS_34_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6118106PMC
August 2018

Percutaneous gastrostomy placement by intervention radiology: Techniques and outcome.

Indian J Radiol Imaging 2018 Apr-Jun;28(2):225-231

Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India.

Background: Interventional radiology (IR) has played an important role in the technical evolution of gastrostomy, from the first surgical, endoscopical to percutaneous interventional procedures.

Aim: This study is done to assess the technical feasibility and outcome of IR-guided percutaneous gastrostomy for patients requiring nutritional support for neuromuscular disorders or head and neck malignancies, as well as to describe simplified and newer technique for pull-type gastrostomy.

Materials And Methods: This is a retrospective study including 29 patients who underwent IR-guided percutaneous gastrostomy over a period of 8 years in a tertiary-level institution. Either pull or push-type gastrostomy was performed in these patients as decided by the interventional radiologist. The procedures were assessed by analyzing the indications, technical aspects, and complications.

Statistical Analysis: Descriptive summary statistics and frequencies were used to assess the techniques and related complications.

Results: The sample consists of 27 patients (93%) with pull technique and 2 patients (7%) with push technique. The technical success rate was 100%. Most of the complications were minor 24% (7/29), including superficial skin infections around the tube site, self-resolving pneumoperitoneum, tube-related complications such as block, leakage, deformation, and dislodgement. Three patients (10.3%) had major complications. One patient (3.4%) developed massive pneumoperitoneum and mild peritonitis due to technical failure in the first attempt and needed re-puncture for successful placement, and other two patients (6.9%) developed peristromal focal abscess. One patient died on the third postoperative day due to type II respiratory failure.

Conclusion: IR-guided percutaneous gastrostomy is a safe and effective procedure in selected patients.
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http://dx.doi.org/10.4103/ijri.IJRI_393_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6038225PMC
July 2018

Correlating MRI with clinical evaluation in the assessment of disease activity of Takayasu's arteritis.

Int J Rheum Dis 2017 Jul 3;20(7):882-886. Epub 2017 Feb 3.

Department of Clinical Immunology and Rheumatology, Christian Medical College Hospital, Vellore, Tamil Nadu, India.

Objectives: To correlate magnetic resonance imaging (MRI) assessment of disease activity in patients with Takayasu's arteritis with the Indian Takayasu's activity score (ITAS).

Design, Materials And Methods: We prospectively assessed 20 patients with Takayasu's arteritis from November 2010 to September 2011.

Results: We found a statistically significant association between MRI assessment of disease activity and ITAS with a P-value of 0.01. The MRI features suggesting active disease included wall thickening and enhancement. We also analyzed the association between MRI and clinical assessment which was also statistically significant at P = 0.037.

Conclusion: Our study suggests that there is an association between MRI assessment of disease activity and the ITAS. MRI evaluation of disease activity of Takayasu's arteritis therefore goes hand in hand with ITAS 2010, ITAS - A, erythrocyte sedimentation rate and C-reactive protein. However this needs further investigation from future studies using serial assessments.
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http://dx.doi.org/10.1111/1756-185X.12967DOI Listing
July 2017

Radiofrequency ablation of osteoid osteoma in common and technically challenging locations in pediatric population.

Indian J Radiol Imaging 2017 Jan-Mar;27(1):88-91

Department of Paediatric Orthopedics, Christian Medical College, Vellore, Tamil Nadu, India.

Context: Percutaneous radiofrequency ablation (RFA) of osteoid osteoma has a high technical and clinical success rate. However, there is limited data on its use in the pediatric population, especially in technically challenging locations.

Objective: To assess the safety and efficacy of computed tomography (CT)-guided percutaneous RFA of osteoid osteoma in pediatric population.

Patients And Methods: From June 2009 to May 2014, 30 patients with osteoid osteoma were treated with CT-guided RFA in common (25 cases) and technically challenging (five cases: four near articular surface and one in sacrum) locations. Therapy was performed under general anesthesia with a three-array expandable RF probe for 6 min at 90°C and power of 60-100 W. The patients were discharged next day under instruction. The treatment success was evaluated in terms of pain relief before and after (1 day, 1 month, and 6 months) treatment.

Results: Technical success was achieved in all patients (100%). Primary clinical success was 96.66% (29 of total 30 patients), despite the pediatric population and atypical location. One patient had persistent pain after 1 month and was treated successfully with a second procedure (secondary success rate was 100%). One patient had immediate complication of weakness of right hand and fingers extension. No delayed complications were observed.

Conclusions: CT-guided RFA is relatively safe and highly effective for treatment of osteoid osteoma in pediatric population, even in technically difficult locations.
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http://dx.doi.org/10.4103/0971-3026.202955DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5385785PMC
May 2017

The current status of pediatric radiology in India: A conference-based survey.

Indian J Radiol Imaging 2017 Jan-Mar;27(1):73-77

Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Canada.

Introduction: Like most other developing countries, India has a large proportion of children among its population. However, the facilities for adequate treatment of this large population is inadequate. The development of pediatric radiology as a subspecialty is still at an infant stage in India. The goal of our study was to assess the awareness about the current status of pediatric radiology in India.

Materials And Methods: A questionnaire was handed over to all attendees of a pediatric radiology conference to assess their opinion regarding the adequacy of pediatric training and practice in India. The questionnaire consisted of 10 multiple-choice and two descriptive questions. Descriptive statistical methods were used for analyzing the results.

Results: Eighty-one out of 400 delegates responded to the questionnaire. Among these 81 respondents, 50 (61.7%) felt that exposure to pediatric cases during postgraduate course was inadequate. Sixty-three out of 81 (77.7%) respondents thought that specialized training is required for practicing pediatric radiology, and 79 respondents (97%) felt that the number of such training programmes should increase. Forty-five out of 81 respondents (55.5%) were interested in pursuing pediatric radiology as a career.

Conclusion: According to the opinion of the respondents of our survey, pediatric radiology remains an underdeveloped speciality in India. Considering the proportion of the population in the pediatric age and the poor health indicators in this age group, elaborate measures, as suggested, need to be implemented to improve pediatric radiology training and the care of sick children in India.
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http://dx.doi.org/10.4103/0971-3026.202965DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5385782PMC
May 2017

Predictors of renal recovery in renal failure secondary to bilateral obstructive urolithiasis.

Arab J Urol 2016 Dec 23;14(4):269-274. Epub 2016 Sep 23.

Department of Urology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India.

Objectives: To identify factors predicting renal recovery in patients presenting with renal failure secondary to bilateral obstructing urolithiasis.

Patients And Methods: Data from electronic records of consecutive adult patients presenting with bilateral obstructing urolithiasis between January 2007 and April 2011 were retrieved. Ultrasonography of the abdomen, and kidney, ureter, bladder (KUB study) X-ray or abdominal non-contrast computed tomography confirmed the diagnosis. Interventional radiologists placed bilateral nephrostomies. Definitive intervention was planned after reaching nadir creatinine. Renal recovery was defined as nadir creatinine of ⩽2 mg/dL.

Results: In all, 53 patients were assessed, 50 (94.3%) were male, and 18 (33.9%) were aged ⩽40 years. Renal recovery was achieved in 20 patients (37.7%). A symptom duration of ⩽25 days ( < 0.01), absence of hypertension ( = 0.018), maximum renal parenchymal thickness of >16.5 mm ( = 0.001), and haemoglobin >9.85 g/dL ( < 0.01) were significant on unadjusted analysis. Symptom duration of ⩽25 days alone remained significant after adjusted analysis. Symptom duration of ⩽25 days (hazard ratio (HR) 13.83, 95% confidence interval (CI) 4.52-42.26;  < 0.01), parenchymal thickness of ⩾16.5 mm (HR 5.91, 95% CI 1.94-17.99;  = 0.002), and absence of hypertension (HR 9.99, CI 95% 1.32-75.37;  = 0.026) were significantly related to time to nadir creatinine. Symptom duration of ⩽25 days (HR 17.44, 95% CI 2.48-122.79;  = 0.004) alone remained significant after adjusted analysis. A symptom duration of ⩽25 days ( = 0.007) was 22-times more likely to indicate renal recovery.

Conclusions: Shorter symptom duration (⩽25 days) is predictive of renal recovery in renal failure secondary to bilateral obstructive urolithiasis.
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http://dx.doi.org/10.1016/j.aju.2016.08.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5122748PMC
December 2016

Femoral Arterial Blowout Post Groin Recurrence in Vulvar Carcinoma - Novel Endovascular Management.

Indian J Surg Oncol 2016 Dec 23;7(4):456-459. Epub 2016 Apr 23.

Department of Gynaecologic Oncology, Christian Medical College, Vellore, Tamil Nadu 632004 India.

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http://dx.doi.org/10.1007/s13193-016-0521-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5097755PMC
December 2016

Cannula-Assisted, Transabdominal Ultrasound-Guided Inferior Vena Cava Recanalization in Inferior Vena Cava Occlusion.

Curr Probl Diagn Radiol 2017 May - Jun;46(3):196-199. Epub 2016 Aug 3.

Department of Radiology, Christian Medical College, Vellore, India.

We describe a novel technique for facilitating recanalization of intrahepatic inferior vena cava (IVC) via the transjugular approach in patients with short segmental hepatic IVC occlusion, where a transjugular liver biopsy cannula provides additional support to the catheter-wire combination and trans-abdominal ultrasound helps in positioning the tip of the cannula at the stump of suprahepatic IVC.
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http://dx.doi.org/10.1067/j.cpradiol.2016.07.003DOI Listing
November 2017

Recurrent hemoptysis: An unusual cause and novel management.

Indian J Radiol Imaging 2016 Apr-Jun;26(2):267-70

Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India.

We report a rare case a 15 year old boy who presented with recurrent hemoptysis. There was past history of pancreatitis. A CT scan of thorax revealed a small collection in the region of the tail of the pancreas and a tract from it extending across the diaphragm into the posterobasal segment of left lower lobe, suggesting a pancreatico-pleuro-pulmonary fistula. The fistula was embolised by percutaneous injection of glue into the collection and fistula, which resulted in good symptom control.
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http://dx.doi.org/10.4103/0971-3026.184412DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4931790PMC
July 2016

Role of endovascular embolization in treatment of acute bleeding complications in haemophilia patients.

Br J Radiol 2016 Aug 21;89(1064):20151064. Epub 2016 Jun 21.

1 Department of Radiology, Christian Medical College, Vellore, India.

Objective:: Bleeding complications either spontaneously or post-operatively are very common in patients with haemophilia. Sometimes these bleeding complications remain unresponsive despite being on high dose of clotting factor replacement. The aim was to assess the role of endovascular embolization in patients with haemophilia in (a) treating haemorrhagic complications due to local causes refractory to clotting factors substitution and (b) reducing intraoperative blood loss in elective pseudotumour surgery.

Methods:: 10 patients seen between January 2000 and April 2015 with severe haemophilia A or B who had unexplained profuse persistent bleeding or required large pseudotumour excision and were taken up for digital subtraction angiography and embolization were included in the study. Data of all these patients were reviewed using the computerized hospital information system and picture archiving and communication system. Details including indications for the procedure, patient preparation for the procedure, imaging findings, details of angiography with intervention, if any, and outcome as well as follow-up data were analyzed.

Results:: In 6 of these 10 cases, bleeding was spontaneous, in 2 cases due to trivial fall and in 2 cases due to post-operative bleeding. Angiography in these patients revealed vascular blush, abnormal hypervascularity or active extravasation. In all 10 patients, an embolization procedure was performed, with bleeding controlled in 8 patients. There were no procedure-related complications during the procedure, post-procedure bleeding or haematoma at the site of arterial access. One patient had recurrence of bleeding for whom surgical exploration was required, and one patient had significant bleeding intraoperatively which was controlled with high-dose clotting factors, blood transfusion and fresh frozen plasma intraoperatively.

Conclusion:: Endovascular embolization is a safe, effective and cost-saving procedure in arresting bleeding in selected patients with severe haemophilia who are unresponsive to adequate clotting factor replacement and where local vascular causes could be contributing to the bleeding. Pre-operative embolization is also a good procedure to reduce intraoperative blood loss in patients with large pseudotumours.

Advances In Knowledge:: Angiography and embolization in patients with haemophilia is technically challenging and should be performed by highly skilled interventional radiologists, which limits its wider use and familiarity among multidisciplinary teams managing haemophilia. By bringing the knowledge of this effective treatment to the specialist groups who care for patients with haemophilia, its wider application may be possible which can save life and/or reduce morbidity.
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http://dx.doi.org/10.1259/bjr.20151064DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5124877PMC
August 2016

Arsenicosis, possibly from contaminated groundwater, associated with noncirrhotic intrahepatic portal hypertension.

Indian J Gastroenterol 2016 May 26;35(3):207-15. Epub 2016 May 26.

Department of Hepatology, Christian Medical College, Vellore, 632 004, India.

Background And Aims: Idiopathic noncirrhotic intrahepatic portal hypertension (NCIPH), a chronic microangiopathy of the liver caused by arsenicosis from use of contaminated groundwater, was reported from Asia. This study aimed to see, if in the twenty-first century, arsenicosis was present in NCIPH patients at our hospital and, if present, to look for groundwater contamination by arsenic in their residential locality.

Methods: Twenty-seven liver biopsy proven NCIPH patients, 25 portal hypertensive controls with hepatitis B or C related cirrhosis and 25 healthy controls, matched for residential locality, were studied. Eighty-four percent to 96 % of study subjects belonged to middle or lower socioeconomic category. Arsenicosis was looked for by estimation of arsenic levels in finger/toe nails and by skin examination. Arsenic levels in nails and in ground water (in NCIPH patients with arsenicosis) was estimated by mass spectrometry.

Results: Nail arsenic levels were raised in five (10 %) portal hypertensive study subjects [two NCIPH patients (both had skin arsenicosis) and three portal hypertensive controls]. All of these five patients were residents of West Bengal or Bangladesh. Skin arsenicosis was noted in three NCIPH patients (11 %) compared to none of disease/healthy controls. Ground water from residential locality of one NCIPH patient with arsenicosis (from Bangladesh) showed extremely high level of arsenic (79.5 μg/L).

Conclusions: Arsenicosis and microangiopathy of liver, possibly caused by environmental contamination continues in parts of Asia. Further studies are needed to understand the mechanisms of such 'poverty-linked thrombophilia'.
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http://dx.doi.org/10.1007/s12664-016-0660-1DOI Listing
May 2016
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