Transgender and gender diverse (TGD) people experience health disparities, and many avoid necessary medical care because of fears of discrimination or mistreatment. Disparate care is further compounded by limited understanding of gender-affirming hormone therapy (GAHT) and gender-affirming surgery among the medical community. Specific to radiology, TGD patients report more negative imaging experiences than negative general health encounters, highlighting the need for guidance and best practices for inclusive imaging care. A patient's imaging journey provides numerous opportunities for improvement. Inclusive practice in a radiology department starts with ordering and scheduling the examination, facilitated by staff education on appropriate use of a patient's chosen name, gender identity, and pronouns. Contemporary electronic health record systems have the capacity for recording detailed sexual orientation and gender identity data, but staff must be trained to solicit and use this information. A welcoming environment can help TGD patients to feel safe during the imaging experience and may include institutional nondiscrimination policies, gender-neutral signage, and all-gender single-user dressing rooms and bathrooms. Image acquisition should be performed using trauma-informed and patient-centered care. Finally, radiologists should be aware of reporting considerations for TGD patients, such as avoiding the use of gender in reports when it is not medically relevant and using precise, respectful language for findings related to GAHT and gender-affirming surgical procedures. As a field, radiology has a range of opportunities for improving care delivery for TGD patients, and the authors summarize recommended best practices. See the invited commentary by Stowell in this issue. © RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Purpose: Retrievable inferior vena cava filters (IVCF) have been increasingly used for mechanical pulmonary embolism prophylaxis since their development. The Captus Vascular Retrieval System (Avantec Vascular, Sunnyvale, California) is a new device developed for retrieval of IVCF. This study compared the safety and efficacy of the new Captus device against the existing EnSnare Endovascular Snare System (Merit Medical, South Jordan, Utah) for IVCF retrieval. Methods: Patients undergoing IVCF retrieval at a single institution between July 2015 and July 2020 were retrospectively identified. All adult patients (>18 years) undergoing filter retrieval with either Captus or Ensnare were included. Technical success and complications were compared by device. A complexity score was assigned to each case to adjust for selection bias. Logistic regression was used to model the association between device type and primary technical success. Results: 99 IVCF retrievals met inclusion criteria, 59 with Captus and 40 with Ensnare. The majority of the cohort consisted of low complexity cases (n = 51, 86% Captus versus n = 31, 78% Ensnare; p = 0.28). Technical success for low and medium complexity retrievals was 88% and 62% with Captus and 96% and 33% with Ensnare. There was no significant association between device type and technical success, adjusting for case complexity (Captus OR 0.55, 95% CI 0.08-2.72, p = 0.49). There were no device-related complications. Conclusion: No statistically significant difference in device technical success or complications between the Ensnare and Captus devices for uncomplicated IVCF retrieval. Precis: The Captus Vascular Retrieval System is a new device for IVC filter retrieval which has similar technical success to the existing EnSnare.

BACKGROUND:Intranasal sphenopalatine ganglion (SPG) block has been shown to be an effective treatment for headaches. Multiple therapeutic agents have been studied, although the wide availability and low cost of lidocaine and bupivacaine have made them attractive treatment options. To the authors knowledge, no study has yet demonstrated superiority of one anesthetic over the other.OBJECTIVE:To determine the efficacy of lidocaine versus bupivacaine when performing intranasal sphenopalatine ganglion (SPG) block for the treatment of headaches.STUDY DESIGN:Retrospective cohort study.SETTING:A single tertiary care academic institutionMETHODS: This retrospective study identified patients who underwent SPG block at a single institution from January 1, 2014 to December 20, 2017. Patients were included if they were treated with either lidocaine or bupivacaine and had both pre- and post-procedure pain scores recorded on a 0-10 scale. Patients were excluded if they were less than 18 years of age.RESULTS:386 total procedures were performed. 303 (78.5%) were lidocaine delivered via the SphenoCath device, and 83 (21.5%) were bupivacaine delivered via the Tx360 device. 90.2% of treatments (n = 348) decreased the patient's pain level. Of the treatments performed with lidocaine, 89.1% (n = 270) resulted in improvement of the patient's pain level with a mean decrease in pain level of 3.1 (SD ± 2.3). Of the treatments performed with bupivacaine, 94.0% (n = 78) resulted in improvement of the patient's pain level, with a mean decrease in pain level of 3.0 (SD ± 1.9). No statistically significant difference was found between the 2 anesthetics.LIMITATIONS:The retrospective study design may introduce selection bias. Both lidocaine and bupivacaine were administered by different devices (Sphenocath and Tx360 respectively) which may account for differences in initial treatment success. There were differences in the size of the two groups, which may also introduce error.CONCLUSIONS:This study demonstrates similar efficacy of SPG block performed with lidocaine or bupivacaine. While no difference was found, the particular advantages and disadvantages of the intranasal delivery device may influence physician choice.KEY WORDS:Sphenopalatine ganglion nerve block, lidocaine, bupivacaine, sphenocath, Tx360, pain intervetnio, headache, miimally invasive therapy.

Transjugular intrahepatic portosystemic shunt (TIPS) creation is an effective intervention to address complications of decompensated portal hypertension, most commonly variceal hemorrhage and refractory ascites. While TIPS is con-sidered challenging, reported technical success rate is high at 95%. 1,2 Variant anatomy and relative contraindications such as portal vein thrombosis pose additional challenges and can reduce likelihood of success. 3,4 Most operators consider puncture of the portal vein to be the technically dif fi cult part of TIPS creation, which frequently requires multiple needle passes. Existing methods for the guidance of a needle pass into the portal vein do not provide real-time feedback and multiple needle passes are not without risk. Indirect portal venogram via injection of contrast or CO 2 increases risk of hepatic laceration and air embolus, respectively. Direct venogram via percutaneous needle puncture of the portal system carries a heightened risk of hemorrhage. 3,5,6 Needle passes without real-time imaging guidance can lead to complications such as extrahepatic portal vein puncture, extracapsular puncture, hemoperitoneum, and hemobilia. Intracardiac

Gender-affirming surgeries expand the options for physical transition among transgender patients, those whose gender identity is incongruent with the sex assigned to them at birth. Growing medical insight, increasing public acceptance, and expanding insurance coverage have improved the access to and increased the demand for gender-affirming surgeries in the United States. Procedures for transgender women, those patients with feminine gender identity, include breast augmentation using implants and genital reconstruction with vaginoplasty. Some transgender women receive medically unapproved silicone injections for breast augmentation or other soft-tissue contouring procedures that can lead to disfigurement, silicone pulmonary embolism, systemic reactions, and even death. MRI is preferred over CT for postvaginoplasty evaluation given its superior tissue contrast resolution. Procedures for transgender men, patients with a masculine gender identity, include chest masculinization (mastectomy) and genital reconstruction (phalloplasty or metoidioplasty, scrotoplasty, and erectile device implantation). Urethrography is the standard imaging modality performed to evaluate neourethral patency and other complications, such as leaks and fistulas. Despite a sizeable growth in the surgical literature about gender-affirming surgeries and their outcomes, detailed descriptions of the imaging features following these surgeries remain sparse. Radiologists must be aware of the wide variety of anatomic and pathologic changes unique to patients who undergo gender-affirming surgeries to ensure accurate imaging interpretation. Online supplemental material is available for this article. ©RSNA, 2019

Arteriovenous malformations (AVMs) of the toe are a rare entity. To the author's knowledge, there are only 2 published case reports, and both patients underwent amputation of the affected digits. Little is known about the optimal treatment of AVMs involving the toe. The authors present the case of a 20-year-old male with a large AVM of the second toe, which was successfully treated with intra-arterial sodium tetradecyl sulfate. Percutaneous treatment of these lesions is possible and should be considered before amputation.

Transgender and gender-diverse (TGD) persons experience an inner sense of gender that does not align with the sex assigned to them at birth [ 1 James S.E. Herman J.L. Rankin S. Keisling M. Mottet L. Anafi M. The report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality, Washington, District of Columbia2016 Google Scholar ]. Although TGD persons are included within the broader social classification of lesbian, gay, bisexual, transgender, and queer (LGBTQ) people, gender identity and sexual orientation are separate constructs (ie, TGD people may have any sexual orientation) (Table 1). A rising prevalence of TGD persons in the United States (an estimated 1.4 million or 1 in 250 adults) coupled with increasing desire and insurance coverage for TGD health services has fueled a need for knowledgeable providers of gender-affirming hormonal and surgical therapies [ 1 James S.E. Herman J.L. Rankin S. Keisling M. Mottet L. Anafi M. The report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality, Washington, District of Columbia2016 Google Scholar ]. Table 1Glossary of select accepted terminology used in reference to gender-diverse populations 1 James S.E. Herman J.L. Rankin S. Keisling M. Mottet L. Anafi M. The report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality, Washington, District of Columbia2016 Google Scholar Term Meaning Gender identity Inner sense of masculinity or femininity Sex Identification of male, female, or intersex at birth on the basis of phenotype and/or genetics Sexual orientation Individual preference for sexual intimacy with others Transgender Person whose gender identity differs from the sex assigned at birth Gender diverse (also gender nonconforming, nonbinary, gender queer) Person whose gender identity differs from the sex assigned at birth but whose gender identity may not be confined to a binary male/female understanding of gender; may use pronouns such as they/them or others Cisgender Person whose gender identity aligns with one’s assigned sex at birth Trans man Person with male gender identity who was assigned female at birth Trans woman Person with female gender identity who was assigned male at birth Transmasculine, transfeminine Terms to describe directionality of gender identity or expression on the spectrum of gender-diverse persons Gender dysphoria Distress caused by incongruence of gender identity and sex assigned at birth Gender-affirming hormone therapy Hormonal regimens designed to induce phenotypic characteristics of the affirmed gender and suppress those of the birth-assigned sex Gender-affirming surgery Surgeries to align one’s anatomy with one’s gender identity; “gender reassignment” and “sex change” are considered offensive and no longer used Open table in a new tab Re: “Serving the Needs of Transgender and Gender-Diverse Persons in Radiology”Journal of the American College of RadiologyVol. 16Issue 9PreviewI compliment the authors of the timely and informative article, “Serving the Needs of Transgender and Gender-Diverse Persons in Radiology” [1]. Full-Text PDF

Transgender (TG) people are individuals who experience an incongruity between their gender and the sex they were assigned at birth. Constituting 0.5%-2% of the population, TG individuals experience greater rates of discrimination, even in health care. Up to 23% of transgender people report having been refused basic medical care based on their gender identity, leading many to avoid seeking care. Familiarity of health care providers with TG issues and terminology has been shown to improve the experience of TG individuals in health care. This article aims to familiarize interventional radiologists with the TG community and provide actionable goals for creating an affirming, inclusive department.

Purpose: To determine whether treating benign biliary strictures via a stricture protocol reduced the probability of developing symptomatic recurrence and requiring surgical revision compared to nonprotocol treatment. Materials and Methods: A stricture protocol was designed to include serial upsizing of internal/external biliary drainage catheters to a target maximum dilation of 18-French, optional cholangioplasty at each upsizing, and maintenance of the largest catheter for at least 6 months. Patients were included in this retrospective analysis if they underwent biliary ductal dilation at a single institution from 2005 to 2016. Forty-two patients were included, 25 women and 17 men, with an average age of 51.9 years (standard deviation +/- 14.6). Logistic regression models were used to determine the probability of symptomatic recurrence and surgical revision by stricture treatment type. Results: Twenty-two patients received nonprotocol treatment, while 20 received treatment on a stricture protocol. After treatment, 7 (32%) patients in the nonprotocol group experienced clinical or laboratory recurrence of a benign stricture, whereas only 1 patient in the stricture protocol group experienced symptom recurrence. Patients in the protocol group were 8.9 times (95% confidence interval [CI] = 1.4-175.3) more likely to remain symptom free than patients in the nonprotocol group. Moreover, patients in the protocol group had an estimated 89% reduction in the probability of undergoing surgical revision compared to patients receiving nonprotocol treatment (odds ratio = .11, 95% CI = .01-.73). Conclusions: Establishing a stricture protocol may decrease the risk of stricture recurrence and the need for surgical revision when compared to a nonprotocol treatment approach.

Needle track seeding following image guided needle biopsy is a known but uncommon complication in the workup of hepatocellular carcinoma. We present the case of a 55 year-old male who was found to have a recurrent hepatocellular carcinoma in the rectus sheath five years following a CT guided biopsy with the biopsy needle passing through the anterior abdominal wall muscles.

Chronic lymphocytic leukemia (CLL) is the most prevalent hematologic malignancy of adults in the western hemisphere. Involvement of the spleen is not uncommon, often presenting as diffuse enlargement due to infiltration of neoplastic cells. A case is presented of an 81-year-old woman with a past medical history of CLL who was incidentally found to have multiple, focal splenic infiltrates on sonography. The patient had a normal sized spleen, which is a less common occurrence with splenic invasion by CLL. As current CLL guidelines discourage imaging but rely on evidence of organ involvement, this finding was critical in staging the patient properly. The sonographic appearance of this rare condition is described, and the advantages of sonography in its evaluation are discussed.

Chronic lymphocytic leukemia (CLL) is the most prevalent hematologic malignancy of adults in the western hemisphere. Involvement of the spleen is not uncommon, often presenting as diffuse enlargement due to infiltration of neoplastic cells. A case is presented of an 81-year-old woman with a past medical history of CLL who was incidentally found to have multiple, focal splenic infiltrates on sonography. The patient had a normal sized spleen, which is a less common occurrence with splenic invasion by CLL. As current CLL guidelines discourage imaging but rely on evidence of organ involvement, this finding was critical in staging the patient properly. The sonographic appearance of this rare condition is described, and the advantages of sonography in its evaluation are discussed.

Pneumocystis jirovecii is ubiquitous in the environment and is best known as the cause of Pneumocystis pneumonia (PCP) in immune-suppressed hosts. Extrapulmonary P. jirovecii is a rare complication of this opportunistic infection primarily seen in patients with immune-deficient states. Nephritis due to P. jirovecii was first described by Bargman in 1991 in a patient with atypical nephrocalcinosis found on conventional radiography. This case report presents a patient with Pneumocystis nephritis and describes the sonographic appearance as well as the advantages of sonography in the early detection of this uncommon condition.

Gastrin-releasing peptide receptors (GRPr) and prostate-specific membrane antigen (PSMA) are two identifying biomarkers expressed in very high numbers on prostate cancer cells and could serve as a useful tool for molecular targeting and diagnosis of disease via positron-emission tomography (PET). The aim of this study was to produce the multipurpose, bivalent [DUPA-6-Ahx-(Cu-64-NODAGA)-5-Ava-BBN(7-14)NH2] radioligand for prostate cancer imaging, where DUPA = (2-[3-(1,3-dicarboxypropyl)-ureido]pentanedioic acid), a small-molecule, PSMA-targeting probe, 6Ahx = 6-aminohexanoic acid, 5-Ava = 5-aminovaleric acid, NODAGA = [2-(4,7-biscarboxymethyl)-1,4,7-(triazonan-1-yl)pentanedioic acid] (a derivative of NOTA (1,4,7-triazacyclononane-1,4,7-triacetic acid)), and BBN(7-14)NH2 = bombesin, a GRPr-specific peptide targeting probe.Methods: The PSMA/GRPr dual targeting ligand precursor [DUPA-6-Ahx-K-5-Ava-BBN(7-14)NH2], was synthesized by solid-phase and manual peptide synthesis, after which NODAGA was added via manual conjugation to the epsilon-amine of lysine (K). The new bivalent GRPr/PSMA targeting vector was purified by reversed-phase high performance liquid chromatography (RP-HPLC), characterized by electrosprayionization mass spectrometry (ESI-MS), and metallated with (CuCl2)-Cu-64 and (CuCl2)-Cu-nat. The receptor binding affinity was evaluated in human, prostate, PC-3 (GRPr-positive) and LNCaP (PSMA-positive) cells and the tumor-targeting efficacy determined in severe combined immunodeficient (SCID) and athymic nude mice bearing PC-3 and LNCaP tumors. Whole-body maximum intensity microPET/CT images of PC-3/LNCaP tumor-bearing mice were obtained 18 h post-injection (p.i.).Results: Competitive binding assays in PC-3 and LNCaP cells indicated high receptor binding affinity for the [DUPA-6-Ahx-(Cu-nat-NODAGA)-5-Ava-BBN(7-14)NH2] conjugate. MicroPET scintigraphy in PC-3/LNCaP tumor-bearing mice indicated that xenografted tumors were visible at 18 h p.i. with collateral, background radiation also being observed in non-target tissue.Conclusions: DUPA-6-Ahx-(Cu-64-NODAGA)-5-Ava-BBN(7-14)NH2] targeting vector, as described herein, is the first example of a dual GRPr-/PSMA-targeting radioligand for molecular of imaging prostate tumors. Detailed in vitro studies and microPET molecular imaging investigations of [DUPA-6-Ahx-(Cu-64-NODAGA)-5-Ava-BBN(7-14)NH2 in tumor-bearing mice indicate that further studies are necessary to optimize uptake and retention of tracer in GRPr- and PSMA-positive tissues. Published by Elsevier Inc.