Guidance Of Interventional Procedures Research Articles

Sonographic imaging of the genicular nerves of the knee

Introduction: The genicular nerves are sensory nerves around the knee. With the improvements in ultrasound imaging resolution, these nerves can be identified sonographically. Topic description: Due to their small size, genicular nerves are often underappreciated and overlooked during routine sonographic imaging. Chronic pain associated with knee osteoarthritis, or postsurgical knee pain can be relieved by ultrasound-guided radiofrequency ablations or nerve blockades targeting the genicular nerves. Discussion: To sonographically image these nerves, or guide nerve blocks or ablations, knowledge of the sonographic anatomy, technique and normal appearances of the genicular nerves and their surrounding structures is required and is unpacked in this pictorial essay. Conclusion: Enhanced knowledge of the anatomy and a systematic approach to sonographically image and assess the genicular nerves of the knee can enhance the diagnosis of pathology, nerve injury or entrapment, and sonographic guidance of interventional procedures for pain relief.

Deformable motion compensation in interventional cone-beam CT with a context-aware learned autofocus metric.

Interventional Cone-Beam CT (CBCT) offers 3D visualization of soft-tissue and vascular anatomy, enabling 3D guidance of abdominal interventions. However, its long acquisition time makes CBCT susceptible to patient motion. Image-based autofocus offers a suitable platform for compensation of deformable motion in CBCT, but it relies on handcrafted motion metrics based on first-order image properties and that lack awareness of the underlying anatomy. This work proposes a data-driven approach to motion quantification via a learned, context-aware, deformable metric, , that quantifies the amount of motion degradation as well as the realism of the structural anatomical content in the image. The proposed was modeled as a deep convolutional neural network (CNN) trained to recreate a reference-based structural similarity metric-visual information fidelity (VIF). The deep CNN acted on motion-corrupted images, providing an estimation of the spatial VIF map that would be obtained against a motion-free reference, capturing motion distortion, and anatomic plausibility. The deep CNN featured a multi-branch architecture with a high-resolution branch for estimation of voxel-wise VIF on a small volume of interest. A second contextual, low-resolution branch provided features associated to anatomical context for disentanglement of motion effects and anatomical appearance. The deep CNN was trained on paired motion-free and motion-corrupted data obtained with a high-fidelity forward projection model for a protocol involving 120kV and 9.90mGy. The performance of was evaluated via metrics of correlation with ground truth and with the underlying deformable motion field in simulated data with deformable motion fields with amplitude ranging from 5 to 20mm and frequency from 2.4 up to 4 cycles/scan. Robustness to variation in tissue contrast and noise levels was assessed in simulation studies with varying beam energy (90-120kV) and dose (1.19-39.59mGy). Further validation was obtained on experimental studies with a deformable phantom. Final validation was obtained via integration of on an autofocus compensation framework, applied to motion compensation on experimental datasets and evaluated via metric of spatial resolution on soft-tissue boundaries and sharpness of contrast-enhanced vascularity. The magnitude and spatial map of showed consistent and high correlation levels with the ground truth in both simulation and real data, yielding average normalized cross correlation (NCC) values of 0.95 and 0.88, respectively. Similarly, achieved good correlation values with the underlying motion field, with average NCC of 0.90. In experimental phantom studies, properly reflects the change in motion amplitudes and frequencies: voxel-wise averaging of the local across the full reconstructed volume yielded an average value of 0.69 for the case with mild motion (2mm, 12 cycles/scan) and 0.29 for the case with severe motion (12mm, 6 cycles/scan). Autofocus motion compensation using resulted in noticeable mitigation of motion artifacts and improved spatial resolution of soft tissue and high-contrast structures, resulting in reduction of edge spread function width of 8.78% and 9.20%, respectively. Motion compensation also increased the conspicuity of contrast-enhanced vascularity, reflected in an increase of 9.64% in vessel sharpness. The proposed , featuring a novel context-aware architecture, demonstrated its capacity as a reference-free surrogate of structural similarity to quantify motion-induced degradation of image quality and anatomical plausibility of image content. The validation studies showed robust performance across motion patterns, x-ray techniques, and anatomical instances. The proposed anatomy- and context-aware metric poses a powerful alternative to conventional motion estimation metrics, and a step forward for application of deep autofocus motion compensation for guidance in clinical interventional procedures.

Dual-modality rigid endoscope for photoacoustic imaging and white light videoscopy.

There has been significant interest in the development of miniature photoacoustic imaging probes for a variety of clinical uses, including the in situ assessment of tumors and minimally invasive surgical guidance. Most of the previously implemented probes are either side viewing or operate in the optical-resolution microscopy mode in which the imaging depth is limited to . We describe a forward-viewing photoacoustic probe that operates in tomography mode and simultaneously provides white light video images. We aim to develop a dual-modality endoscope capable of performing high-resolution PAT imaging and traditional white light videoscopy simultaneously in the forward-viewing configuration. We used a Fabry-Pérot ultrasound sensor that operates in the 1500 to 1600nm wavelength range and is transparent in the visible and near infrared region (580 to 1250nm). The FP sensor was optically scanned using a miniature MEMs mirror located at the proximal end of the endoscope, resulting in a system that is sufficiently compact (10mm outer diameter) and lightweight for practical endoscopic use. The imaging performance of the endoscope is evaluated, and dual-mode imaging capability is demonstrated using phantoms and abdominal organs of an ex vivo mouse including spleen, liver, and kidney. The proposed endoscope design offers several advantages including the high acoustic sensitivity and wide detection bandwidth of the FP sensor, dual-mode imaging capability, compact footprint, and an all-optical distal end for improved safety. The dual-mode imaging capability also offers the advantage of correlating the tissue surface morphology with the underlying vascular anatomy. Potential applications include the guidance of laparoscopic surgery and other interventional procedures.

Imaging in interventional oncology, the better you see, the better you treat.

Imaging and image processing is the fundamental pillar of interventional oncology in which diagnostic, procedure planning, treatment and follow-up are sustained. Knowing all the possibilities that the different image modalities can offer is capital to select the most appropriate and accurate guidance for interventional procedures. Despite there is a wide variability in physicians preferences and availability of the different image modalities to guide interventional procedures, it is important to recognize the advantages and limitations for each of them. In this review, we aim to provide an overview of the most frequently used image guidance modalities for interventional procedures and its typical and future applications including angiography, computed tomography (CT) and spectral CT, magnetic resonance imaging, Ultrasound and the use of hybrid systems. Finally, we resume the possible role of artificial intelligence related to image in patient selection, treatment and follow-up.

Cardiac Adipose Tissue Segmentation via Image-Level Annotations.

Automatically identifying the structural substrates underlying cardiac abnormalities can potentially provide real-time guidance for interventional procedures. With the knowledge of cardiac tissue substrates, the treatment of complex arrhythmias such as atrial fibrillation and ventricular tachycardia can be further optimized by detecting arrhythmia substrates to target for treatment (i.e., adipose) and identifying critical structures to avoid. Optical coherence tomography (OCT) is a real-time imaging modality that aids in addressing this need. Existing approaches for cardiac image analysis mainly rely on fully supervised learning techniques, which suffer from the drawback of workload on labor-intensive annotation process of pixel-wise labeling. To lessen the need for pixel-wise labeling, we develop a two-stage deep learning framework for cardiac adipose tissue segmentation using image-level annotations on OCT images of human cardiac substrates. In particular, we integrate class activation maps with superpixel segmentation to solve the sparse tissue seed challenge raised in cardiac tissue segmentation. Our study bridges the gap between the demand for automatic tissue analysis and the lack of high-quality pixel-wise annotations. To the best of our knowledge, this is the first study that attempts to address cardiac tissue segmentation on OCT images via weakly supervised learning techniques. Within an in-vitro human cardiac OCT dataset, we demonstrate that our weakly supervised approach on image-level annotations achieves comparable performance as fully supervised methods trained on pixel-wise annotations.

Comprehensive classifications for the endovascular recanalization of vertebral artery stump syndrome

Backgroundand purpose: To share our single-center vertebral artery stump syndrome (VASS) treatment experience and assess the role of comprehensive classification based on anatomic development, proximal conditions, and distal conditions (PAD). Materials and methodsData were retrospectively collected from patients who underwent endovascular thrombectomy (EVT) at the Stroke Center of the First Hospital of Jilin University between January 2016 and December 2021. Among patients with acute ischemic stroke in the posterior circulation, those with acute occlusion of the intracranial arteries and occlusion at the origin of the vertebral artery confirmed by digital subtraction angiography were selected. The clinical data were summarized and analyzed. ResultsFifteen patients with VASS were enrolled in the study. The overall success rate of surgical recanalization was 80%. The successful proximal recanalization rate was 70.6%, and the recanalization rates for P1, P2, P3, and P4 were 100%, 71.4%, 50%, and 66.67%, respectively. The mean operation times for the A1 and A2 types were 124 and 120 ​min, respectively. The successful distal recanalization rate was 91.7%, and the recanalization rates for types D1, D2, D3, and D4 were 100%, 83.3%, 100%, and 100%, respectively. Five patients experienced perioperative complications (incidence rate: 33.3%). Distal embolism occurred in three patients (incidence rate: 20%). No dissection or subarachnoid hemorrhage occurred in any patient. ConclusionEVT is a technically feasible treatment for VASS, and comprehensive PAD classification can, to a certain extent, help initially estimate the difficulty of surgery and provide guidance for interventional procedures.

AIUM Official Statement: Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers and Equipment Between Patients as Well as Safe Handling and Use of Ultrasound Coupling Gel.

AIUM Official Statement: Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers and Equipment Between Patients as Well as Safe Handling and Use of Ultrasound Coupling Gel.

OP92 Impact Of Real-World Evidence On Health Technology Assessment And National Guidance For Interventional Procedures: A UK Perspective

IntroductionThe National Institute for Health and Care Excellence (NICE) interventional procedures programme (IPP) issues guidance on the safety and efficacy of new interventional procedures (IPS). The IPP considers a range of evidence from randomized controlled trials (RCTs) to case series to make final recommendations. Real-world evidence (RWE) can provide additional information on long-term outcomes and patient population characteristics that are not easily captured by RCTs. This study explores the impact of RWE in complementing RCTs on long-term safety and efficacy for national guidance development.MethodsWe review the impact of RWE in IPS guidance (IPG) updates and change in guidance recommendations in the last 5 years. This is done by analyzing NICE guidance updates and supporting evidence. A range of RWE was considered in the supporting evidence, for example, registries and clinical audits.ResultsThe addition of RWE evidence to IPP guidance update has led to significant changes in the recommendations. For example, in one recent IPG, standard arrangements recommendation based on short-term RCT evidence was changed to a research recommendation when RWE showed an increase in long-term adverse effects. In another recent IPG update, special arrangements recommendation based on short-term RCT evidence was changed to a research recommendation when RWE reported long-term inferior efficacy and safety for the new intervention compared to current standard of care. A complete overview of results of the last 5 years will also be presented at the meeting.ConclusionsThese findings indicate that increased availability of RWE in HTA has the potential to impact national guidance recommendations. In addition, it shows how RWE can fill the evidence base gaps created by RCTs. Such data can confirm or contradict the findings of RCTs, or generate questions needing further research, or support disinvestment in non-effective technologies.

Intraoperative Needle Tip Tracking with an Integrated Fibre-Optic Ultrasound Sensor.

Ultrasound is an essential tool for guidance of many minimally-invasive surgical and interventional procedures, where accurate placement of the interventional device is critical to avoid adverse events. Needle insertion procedures for anaesthesia, fetal medicine and tumour biopsy are commonly ultrasound-guided, and misplacement of the needle may lead to complications such as nerve damage, organ injury or pregnancy loss. Clear visibility of the needle tip is therefore critical, but visibility is often precluded by tissue heterogeneities or specular reflections from the needle shaft. This paper presents the in vitro and ex vivo accuracy of a new, real-time, ultrasound needle tip tracking system for guidance of fetal interventions. A fibre-optic, Fabry-Pérot interferometer hydrophone is integrated into an intraoperative needle and used to localise the needle tip within a handheld ultrasound field. While previous, related work has been based on research ultrasound systems with bespoke transmission sequences, the new system-developed under the ISO 13485 Medical Devices quality standard-operates as an adjunct to a commercial ultrasound imaging system and therefore provides the image quality expected in the clinic, superimposing a cross-hair onto the ultrasound image at the needle tip position. Tracking accuracy was determined by translating the needle tip to 356 known positions in the ultrasound field of view in a tank of water, and by comparison to manual labelling of the the position of the needle in B-mode US images during an insertion into an ex vivo phantom. In water, the mean distance between tracked and true positions was 0.7 ± 0.4 mm with a mean repeatability of 0.3 ± 0.2 mm. In the tissue phantom, the mean distance between tracked and labelled positions was 1.1 ± 0.7 mm. Tracking performance was found to be independent of needle angle. The study demonstrates the performance and clinical compatibility of ultrasound needle tracking, an essential step towards a first-in-human study.

Apport de la fusion d'images de scanner en salle de cathétérisme

Fusion imaging is developing fast, allowing improvements in interventional cardiology procedures workup and guidance. Computed-tomography (CT) scan and fluoroscopy fusion guidance used in procedures such as left appendage occlusion or perivalvular leak closure permit prediction and simulation of the appropriatedevice, as well as implantation guidance. In the era of tailored medicine, CT/fluoroscopy fusion imaging guidance is an interesting tool for individualizing and adapting the devices implanted to each patient, as well as improving the outcomes and safety of each procedure.

State-of-the-art imaging for lymphatic evaluation in children.

The lymphatic system has been poorly understood and its importance neglected for decades. Growing understanding of lymphatic flow pathophysiology through peripheral and central lymphatic flow imaging has improved diagnosis and treatment options in children with lymphatic diseases. Flow dynamics can now be visualized by different means including dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL), the current standard technique to depict central lymphatics. Novel imaging modalities including intranodal, intrahepatic and intramesenteric DCMRL are quickly evolving and have shown important advances in the understanding and guidance of interventional procedures in children with intestinal lymphatic leaks. Lymphatic imaging is gaining importance in the radiologic and clinical fields and new techniques are emerging to overcome its limitations.

Overview of Lung Ultrasound in Pediatric Cardiology.

Lung ultrasound (LUS) is increasing in its popularity for the diagnosis of pulmonary complications in acute pediatric care settings. Despite the high incidence of pulmonary complications for patients with pediatric cardiovascular and congenital heart disease, especially in children undergoing cardiac surgery, the use of LUS remains quite limited in these patients. The aim of this review is to provide a comprehensive overview and list of current potential applications for LUS in children with congenital heart disease, post-surgery. We herein describe protocols for LUS examinations in children, discuss diagnostic criteria, and introduce methods for the diagnosis and classification of pulmonary disease commonly encountered in pediatric cardiology (e.g., pleural effusion, atelectasis, interstitial edema, pneumothorax, pneumonia, and diaphragmatic motion analysis). Furthermore, applications of chest ultrasounds for the evaluation of the retrosternal area, and in particular, systematic search criteria for retrosternal clots, are illustrated. We also discussed the potential applications of LUS, including the guidance of interventional procedures, namely lung recruitment and drainage insertion. Lastly, we analyzed current gaps in knowledge, including the difficulty of the quantification of pleural effusion and atelectasis, and the need to differentiate different etiologies of B-lines. We concluded with future applications of LUS, including strain analysis and advanced analysis of diaphragmatic mechanics. In summary, US is an easy, accurate, fast, cheap, and radiation-free tool for the diagnosis and follow-up of major pulmonary complications in pediatric cardiac surgery, and we strongly encourage its use in routine practice.

Thermal Ablation of Liver Tumors Guided by Augmented Reality: An Initial Clinical Experience.

Simple SummaryWe report the first clinical use of Endosight, a new guidance system for percutaneous interventional procedures based on augmented reality, to guide percutaneous thermal ablations. The new system was demonstrated to be precise and reliable, with a targeting accuracy of 3.4 mm. Clinically acceptable, rapid setup and procedural times can be achieved.Background: Over the last two decades, augmented reality (AR) has been used as a visualization tool in many medical fields in order to increase precision, limit the radiation dose, and decrease the variability among operators. Here, we report the first in vivo study of a novel AR system for the guidance of percutaneous interventional oncology procedures. Methods: Eight patients with 15 liver tumors (0.7–3.0 cm, mean 1.56 + 0.55) underwent percutaneous thermal ablations using AR guidance (i.e., the Endosight system). Prior to the intervention, the patients were evaluated with US and CT. The targeted nodules were segmented and three-dimensionally (3D) reconstructed from CT images, and the probe trajectory to the target was defined. The procedures were guided solely by AR, with the position of the probe tip was subsequently confirmed by conventional imaging. The primary endpoints were the targeting accuracy, the system setup time, and targeting time (i.e., from the target visualization to the correct needle insertion). The technical success was also evaluated and validated by co-registration software. Upon completion, the operators were assessed for cybersickness or other symptoms related to the use of AR. Results: Rapid system setup and procedural targeting times were noted (mean 14.3 min; 12.0–17.2 min; 4.3 min, 3.2–5.7 min, mean, respectively). The high targeting accuracy (3.4 mm; 2.6–4.2 mm, mean) was accompanied by technical success in all 15 lesions (i.e., the complete ablation of the tumor and 13/15 lesions with a >90% 5-mm periablational margin). No intra/periprocedural complications or operator cybersickness were observed. Conclusions: AR guidance is highly accurate, and allows for the confident performance of percutaneous thermal ablations.

Current Practice of Imaging-Guided Interventional Procedures in Rheumatic and Musculoskeletal Diseases: Results of a Multinational Multidisciplinary Survey.

Objectives: To investigate opinion and routine practice of specialists from different disciplines on imaging techniques for interventional procedures related to rheumatic and musculoskeletal diseases (RMDs).Methods: An English-language questionnaire was developed by an international working group and distributed to health care providers of various disciplines involved in the care of people with RMDs via an online survey tool (SoSci Survey®) from December 2019 to May 2020.Results: A total of 1,105 respondents from 56 countries completed the survey, over 60% of participants were rheumatologists. The majority of respondents (88%) performed interventional procedures in RMDs patients and 90% of them used imaging guidance. Ultrasonography was the most frequently used technique, particularly among rheumatologists. X-ray and computed tomography were mainly used by radiologists. A discrepancy emerged between the importance assigned to certain items such as the availability of a second operator and their actual implementation in clinical practice. Local barriers, lack of resources and facilities were mentioned as the most relevant obstacles in this regard. Lack of training on imaging and/or imaging guided procedures did not emerge as a barrier to perform such interventions; in fact, 19% of respondents performing the procedures indicated not to have received adequate training in this field.Conclusions: This is the first multinational multidisciplinary survey exploring in detail the opinions and practice on imaging guidance for interventional procedures in RMDs. A harmonization of protocols based on international guidelines, along with adequate training programmes and interventions on barriers at national/local levels are the main unmet needs requiring attention.

New developments in rare vulvar and vaginal cancers.

To provide the latest insight on the rare vulvar and vaginal malignancies, able to impact on clinical practice, and to outline new potential research developments. Many efforts are being made to produce technical and scientific advances in the fields of vulvar and vaginal carcinoma, including imaging work-up, interventional procedures and minimally invasive surgical approach, as well as molecular profiling and identification of new target treatments. In the evaluation of lymph node status, ultrasound has demonstrated promising results because of high predictive value, low risk and low cost. Positron Emission Tomography-Computed Tomography is confirmed to be reliable and should be prospectively investigated for its potential applications in radiomics, whilst Fusion-US could allow a precision guidance in diagnostics and interventional procedures. Regarding interventional procedure, surgery is becoming less invasive with the aim to increase quality of life; in carefully selected patients it would be possible to overcome the current strict criteria in the use of sentinel node biopsy. Future research should focus on potential target therapy, on the basis of tumor-specific biological features.Rare cancers should be referred to experienced centers with a high case flow, able to offer a full range of diagnostic and therapeutical options and a multidisciplinary approach. Networking should be encouraged to promote research opportunities and enable data sharing and multicenter trials.

Abstract No. 135 Point-of-care ultrasound (POCUS) versus conventional ultrasound imaging quality

To compare the quality of point-of-care-ultrasound (POCUS) imaging guidance for interventional procedures compared to that of conventional ultrasound (US) imaging Intra-procedural US images from the first 119 procedures in 108 patients using POCUS following its integration into our practice were uploaded to a HIPAA compliant cloud. When conventional US imaging from these cases was also captured and stored on our picture archival system (PACS) for quality assurance and documentation, these images were also evaluated. 119 comparable procedures in patients with similar body mass indices and matched procedural type where conventional US was utilized were identified. Studies were reviewed by the P.I. and the intra-procedural images stripped of PHI and proprietary ultrasound unit graphics or annotations. Representative images from each case were imported into a PowerPoint (Microsoft Corp. Redmond, WA) presentation, 1-2 images per slide, for a total of 331 case slides (123 POCUS-guided procedures with 101 correlative images taken with conventional US imaging, and 107 matched procedures performed with conventional US imaging). Slides were assorted using a random sequence generator. The PowerPoint presentation was then stored in an electronic folder on the Departmental share-drive for review by three blinded co-investigators for image quality on a 10-point Likert scale (inadequate ≤ 4.9; adequate 5.0-6.9; good 7.0-8.9; excellent 8.0-10). Scores were compared between procedures completed with the two different US technologies (POCUS versus conventional) and across procedural categories. 331 total observations were made. Overall quality of the POCUS images was rated as 5.7, compared with 7.0 for conventional US images of the same cases and 6.8 for the other conventional US-guided cases. For POCUS cases, all procedural categories had images rated as adequate (5.0-5.8) except vascular access which was rated as good (6.8) and conversely nephrostomy access which was rated as 4.7. This compares to conventional US images, which were rated as good for all categories (6.4-7.9), except nephrostomy access which was rated as 5.7. In 10 cases, two of three of the reviewers deemed the image quality ≥ adequate for procedural guidance compared to the third reviewer; 9 of these cases were in the POCUS group. Point-of-care ultrasound pocket-sized imaging was rated as “adequate“ for guidance of most vascular access and non-vascular procedures compared to “good“ for conventional ultrasound imaging.

Irreversible pancreatic electroporation, first institutional experience, case report and literature review

Presenter: Victor Manuel Correa Santillan MD | Instituto Jalisciense de Cancerología / Hospital Civil de Guadalajara Background: Pancreatic cancer is one of the pathologies that determine a poor prognosis, since it presents advanced stages at the time of diagnosis, with an overall 5-year survival < 5%. It is estimated that there was 495,773 new cases worldwide and many of these patients had ECOG 0-2 at the time of diagnosis.(1) Efforts have been made to develop new treatments to improve the care of patients with locally advanced pancreatic cancer, as a result of this, we have novel alternatives such as irreversible electroporation, which consists of inserting special needles into the tumor; Short electrical pulses of a high voltage current are then passed through the needles. The goal is to destroy cancer cells.(2) Methods: Describe the results of treatment of a patient with locally advanced pancreatic cancer using irreversible transurgical electroporation. In our institution for the first time. Results: A 58-year-old male presented as an outpatient with a 6-week history of progressive jaundice and weight loss of more than 8 kg. His laboratory test was CA 19-9 of 615U/ml, total bilirubin 19mg/dl, direct bilirubin 11.18 mg/dl, alkaline phosphatase 481U/L, gamma-glutamyl transferase of 849U/L. The cholangioresonance showed intra- and extrahepatic bile duct dilation with a 2cm mass in the head of the pancreas, with infiltration of the portal vein. The ERCP confirms the finding of a pancreatic head tumor, brush cytology is done, and drainage of the bile duct is achieved with a 16 Fr biliary stent. The cytology analysis shows inflammatory changes with atypia. Induction chemotherapy is started with six cycles of FOLFIRINOX; 8 weeks later, a Whipple procedure is attempted, during surgery infiltration of more than 180 degrees of the vena cava is seen; therefore, the surgery is aborted. Four weeks later, irreversible pancreatic electroporation is scheduled with three needles, two cycles, and two fields of trans-surgical depth, which was completed without complications. After the procedure, the chemotherapy continued with FOLFOX for four cycles and changed to XELOX / CAPEOX for six cycles due to gastrointestinal intolerance. Four months after chemotherapy completion, a PET-CT scan showed retroperitoneal lymph node activity without evidence of the pancreatic tumor; due to these findings, thirty sessions of Intensity-Modulated Radiotherapy was started. Conclusion: The evidence supporting the use of this technology reports a benefit in overall survival from 28 months to 85 months and overall progression-free periods up to 12 months, with a solid base of safety reporting a mortality rate of 2% to 3% to 90 days. And this is reflected in stable ECOGs for a longer time. (2,3) Although in Mexico there is the possibility of using this type of technology, they are limited by their high cost, even so, The Instituto Jalisciense de Cancerología is a pioneer in the comprehensive management of locally advanced pancreatic cancer, positioning itself as a reference center in the country. Bibliography 1. International Agency for Research on Cancer. GLOBOCAN 2020 2. National institute for Hearth and Care Excellence, Irreversible electroporation for treating pancreatic cancer, Interventional procedures guidance, 3. Balaban E and Col, 2016 Locally Advanced, Unresectable Pancreatic Cancer

Ultrasound-guided musculoskeletal interventional procedures around the elbow, hand and wrist excluding carpal tunnel procedures.

Ultrasound is a fast, reliable and radiation-free method for the assessment of a wide range of pathological conditions, as well as for the guidance of percutaneous interventional procedures around the elbow, hand and wrist. Intraarticular and periarticular interventional procedures can be easily performed under continuous ultrasound monitoring to ensure correct needle positioning and medication delivery to a specific target. The most common ultrasound-guided procedures performed around the elbow, wrist, and hand are described in this review, excluding carpal tunnel procedures. Specifically, elbow steroid injections are performed in patients with inflammatory disorders, while hyaluronic acid can be administered in case of osteoarthritis. Septic olecranon bursitis requires percutaneous drainage for diagnosis and appropriate treatment. Dry needling and injection of regenerative medications, such as blood derivatives, are among the treatment options for lateral epicondylosis. Steroid injections are performed to give symptom relief in patients with ulnar neuropathy at the elbow. Hand and wrist steroid injections are performed in case of osteoarthritis, subsequently followed by hyaluronic acid injections, and in inflammatory disorders. Wrist ganglia can be safely aspirated and injected with steroids under ultrasound guidance. De Quervain’s tenosynovitis and trigger finger are chronic tenosynovitides of the wrist and digits, respectively, which can be treated with steroid injections, subsequently followed by hyaluronic acid injections. In conclusion, proper knowledge of the musculoskeletal disorders around the elbow, hand and wrist, as well as US-guided treatment options and operator training, are prerequisites to achieve good outcomes.

Evaluation of the impact of patient input in health technology assessments at NICE.

Accounts of patient experiences are increasingly used in health technology assessment (HTA) processes. However, we know little about their impact on the decision-making process. This study aims to assess the level and the type of impact of patient input to highly specialised technologies (HSTs) and interventional procedures (IPs) guidance at the National Institute for Health and Care Excellence (NICE). A questionnaire was developed to capture quantitative and qualitative data on the amount and type of impact of patient input into NICE HTAs. It was completed by committee members of the guidance-producing programs after a discussion of the considered topics. The data were analyzed by topic and overall, for each program, and compared across programs. Patient input was assessed on ten pieces of HST guidance published between January 2015 and November 2019, and on twenty-six pieces of IP guidance scoped between February 2016 and October 2018. A total of 96 responses were collected for HST and 440 for IP. The level of impact of patient input was higher for HST than for IP. For HST, no respondents stated that it had no impact, whereas in IP, 35 percent of respondents did. The most common types of impact found for HST and IP were that it helped interpret the other evidence and that it provided new evidence. The impact of patient input is not necessarily explicit in changing recommendations, but it provides context, reassurance, and new information to the committee for the decision-making process in HTAs.

Practical setting and potential applications of interventions guided by PET/MRI.

Multimodality imaging has emerged from a vision thirty years ago to routine clinical use today. Positron emission tomography (PET)/magnetic resonance imaging (MRI) is still relatively new in this arena and particularly suitable for clinical research and technical development. PET/MRI-guidance for interventions opens up opportunities for novel treatments but at the same time demands certain technical and organizational requirements to be fulfilled. In this work, we aimed to demonstrate a practical setting and potential application of PET/MRI guidance of interventional procedures. The superior quantitative physiologic information of PET, the various unique imaging characteristics of MRI, and the reduced radiation exposure are the most relevant advantages of this technique. As a noninvasive interventional tool, focused ultrasound (FUS) ablation of tumor cells would benefit from PET/MRI for diagnostics, treatment planning and intervention. Yet, technical limitations might impeed preclinical research, given that PET/MRI sites are per se not designed as interventional suites. Nonetheless, several approaches have been offered in the past years to upgrade MRI suites for interventional purposes. Taking advantage of state of the art and easy-to-use technology it is possible to create a supporting infrastructure that is suitable for broad preclinical adaption. Several aspects are to be addressed, including remote control of the imaging system, display of the imaging results, communication technology, and implementation of additional devices such as a FUS platform and an MR-compatible robotic system for positioning of the FUS equipment. Feasibility could be demostrated with an examplary experimental setup for interventional PET/MRI. Most PET/MRI sites could allow for interventions with just a few add-ons and modifications, such as comunication, in room image display and sytems control. By unlocking this feature, and driving preclinical research in interventional PET/MRI, translation of the protocol and methodology into clinical settings seems feasible.