Ian Hammond

Spherical versus Conventional Polyvinyl Alcohol Particles for Uterine Artery Embolization

PURPOSE To compare the efficacy of spherical polyvinyl alcohol (PVA) particles versus conventional PVA particles for uterine artery embolization (UAE). MATERIALS AND METHODS Of 149 patients with 1-year follow-up after UAE, 96 received conventional PVA particles and 53 received spherical PVA particles. Severity of symptoms was ranked on an 11-point numeric rating scale (0-10). The changes in severity of symptoms after embolization, blood hemoglobin level, and the size of the dominant tumor depicted by ultrasonography were used to assess the efficacy of the two types of particles. The number of hysterectomies and myomectomies in each group was also recorded as evidence of UAE failure. RESULTS On 1-year follow-up, patients treated with conventional PVA showed average numeric rating scale score improvements of 4.6 in menorrhagia, 2.9 in dysmenorrhea, 3.7 in pressure sensation, and 3.4 in urinary frequency. With spherical PVA, the average improvements were 3.0 in menorrhagia, 2.4 in dysmenorrhea, 3.1 in pressure sensation, and 2.0 in urinary frequency. Except in dysmenorrhea, all differences were significant (P < .001). With conventional PVA, there was an 8-mg/mL increase in blood hemoglobin level versus a 3-mg/mL increase with spherical PVA (P < .05). With conventional PVA, there was a 28-mm (34%) average reduction in diameter of the dominant tumor versus a 15.7-mm (19%) reduction with spherical PVA (P = .01). Eight of 96 patients (8%) treated with conventional PVA underwent hysterectomy or myomectomy during the entire length of the study, versus six of 53 patients (11%) treated with spherical PVA (P = .6). No patient underwent multiple embolizations. CONCLUSIONS In comparison with conventional PVA particles, UAE with the use of spherical PVA particles resulted in less fibroid tumor shrinkage and less improvement in clinical symptoms.

Superior hypogastric nerve block for pain control in outpatient uterine artery embolization

PURPOSE To assess the efficacy of the superior hypogastric nerve block (SHNB) in permitting uterine artery embolization (UAE) to be performed as a routine outpatient procedure. MATERIALS AND METHODS One hundred thirty-nine patients who underwent UAE in a prospective single-arm clinical trial in an academic institution underwent SHNB from an anterior abdominal approach to control acute postprocedural pain, in addition to conventional conscious sedation. They were discharged and prescribed one of two drug combinations started during the in-hospital recovery period. Regimen A included short-acting morphine tablets and indomethacin rectal suppositories and regimen B included long-acting morphine tablets for baseline pain supplemented with short-acting morphine tablets for breakthrough pain, and naproxen rectal suppositories. All patients were contacted by phone on the third and fifth postprocedural days and their peak pain experience was recorded on a scale of 0 to 10. RESULTS All patients were able to be discharged the day of the procedure. Seven patients (5%) returned to the hospital because of pain. One was discharged after undergoing a second SHNB and four were discharged after receiving intravenous analgesics; two required longer admission for intravenous analgesia. The mean (+/-SD) peak pain score in the first 5 days after the procedure for all patients was 4.8 +/- 2.6. There was a significant difference between regimens A (mean pain score, 5.7 +/- 2.2) and B (mean pain score, 2.7 +/- 2.5; Mann-Whitney, 5.94; P < .01). CONCLUSION The addition of SHNB to the more conventional post-UAE pain management methodology enhances pain control, enabling the procedure to be offered with minimum pain on a routine outpatient basis.

Answer to Case of the Month #150: Right Iliac Fossa Abscess Secondary to Cecal Perforation by Toothpick

A 55-year-old woman presented to the emergency department with a 10-day history of right lower quadrant pain that was associated with nausea and vomiting only on the first day of symptoms. Her abdomen was mildly distended with marked tenderness and localized guarding in the right lower quadrant. Routine laboratory work including white blood cell count was normal. Images from ultrasound (Figure 1) and computed tomography (CT) (Figures 2 and 3) of the right lower quadrant are presented.

Computed Tomography and Magnetic Resonance Imaging in the Differentiation of Osteoporotic Fractures From Neoplastic Metastatic Fractures

Determining whether a low-intensity vertebral fracture in an older person, particularly one with a history of cancer, is due to osteoporosis (OP) or is the result of a metastasis, is a not infrequent clinical problem that has important prognostic and therapeutic implications. The 2 types of fracture are usually indistinguishable on plain radiographs and require higher order imaging for diagnosis. Magnetic resonance imaging is the modality of choice because of its unique ability to depict the bone marrow, which becomes transiently edematous in an acute OP fracture. Preservation of at least part of the normal marrow signal, the visualization of a fracture line parallel to the end plates, the presence of an intravertebral cleft, lack of pedicle involvement, and no extra-osseous mass all favor a benign OP fracture. Absence of the preceding signs, particularly if there is complete replacement of the normal bone marrow and a convex posterior contour of the vertebral body, favors a fracture of malignant origin. Non-routine magnetic resonance sequences using diffusion-weighted imaging and/or chemical shift imaging may be helpful in difficult cases.

Vertebral Pseudolesion on Lateral Chest Radiograph

OBJECTIVE The purpose of this study was to describe and explain the basis for the lateral chest radiographic finding of a pseudolesion simulating a sclerotic vertebral lesion. CONCLUSION Superimposition of the scapula on the upper thoracic spine causes a vertebral pseudolesion that simulates a sclerotic lesion.

The Pursuit of Impalpable Thyroid Nodules: Are We Using Scarce Resources Wisely?

Thyroid nodules are very common in the general population, with an estimated prevalence in the adult population of 4% as detected by palpation, 50% as detected at autopsy, and as high as 67% as detected by ultrasonography [1]. We can reasonably conclude that millions of Canadians have thyroid nodules, the vast majority of which are impalpable. With the widespread use of medical imaging, many of these nodules, some as small as 2e3 mm in diameter are detected incidentally when patients undergo imaging studies of the neck, often for reasons unrelated to the thyroid gland, hence the descriptor ‘‘thyroid incidentalomas.’’ Unless a nonpalpable thyroid nodule is causing thyrotoxicosis, its clinical significance derives from the possibility that it is an occult cancer [2]. It is thought that approximately 9% 13% of thyroid nodules, whether palpable or nonpalpable, single or multiple, are cancers [3,4]. Most of these are welldifferentiated papillary carcinomas, the most common subtype of thyroid cancer. In contrast to occult disease, clinically apparent thyroid cancer is not common, nor is it usually aggressive. The most recent Canadian cancer statistics estimate a 2.5% incidence of thyroid cancer in 2008, with an estimated 0.23% of all cancer deaths from this neoplasm [5]. Of the 17 types of cancer reported upon, thyroid cancer has the highest estimated 5-year survival ratio of 98%. The same document notes that the incidence rate of thyroid cancer has risen

Splenic Artery Embolization in Blunt Trauma: A Single-Center Retrospective Comparison of the Use of Gelatin Sponge Versus Coils

OBJECTIVE The purpose of this study was to compare the efficacy of gelatin sponge with that of coils for splenic artery embolization in the treatment of blunt splenic injury. MATERIALS AND METHODS A single-center retrospective review was performed with the records of 63 patients (45 men, 18 women; mean age, 45.5 years; range, 16-84 years) with blunt splenic injury treated at a tertiary care trauma center by splenic artery embolization with gelatin sponge (n = 30 patients) or metallic coils (n = 33 patients) between 2005 and 2014. The two groups had comparable median American Association for the Surgery of Trauma grades of IV and comparable angiographic appearances regarding active extravasation and pseudoaneurysm formation at preembolization splenic arteriography (p = 0.32). Clinical outcomes and procedure-related outcomes were evaluated. RESULTS The success rates were similar in the two groups: splenic artery embolization failed in 6.6% (2/30) of patients in the gelatin sponge group and 12.1% (4/33) in the coil embolization group (p = 0.45; 95% CI, -30.1% to 19.2%). Major complications occurred in six patients (20.0%) in the gelatin sponge group and in six patients (18.1%) in the coil group (p = 0.85; 95% CI, -23.0% to 26.6%). Minor complications occurred in three patients (10.0%) in the gelatin sponge group and seven patients (21.2%) in the coil group (p = 0.21; 95% CI, -35.4% to 14.0%). Procedure time was significantly shorter in the gelatin sponge group (median, 32 minutes; interquartile range, 18-48 minutes) than in the coil group (median, 53 minutes; interquartile range, 30-76 minutes) (p = 0.01). CONCLUSION Splenic artery embolization with gelatin sponge appears to be as effective and as safe as coil embolization and can be completed in a shorter time.

Imaging of Osteoporotic Fractures on XR, CT, and MR

The evaluation of skeletal health has progressed from diagnostic labeling (normal-low bone mass-osteoporosis) to quantifying future fracture risk. Thus, the recognition of prevalent and incident fractures has increased in importance because they influence risk assessment. Non-spinal osteoporotic fractures rarely pose diagnostic problems, although those of the proximal femur and pelvis may require computed tomography (CT) and/or magnetic resonance imaging for diagnosis. Spinal fractures remain a paradox. Whereas radiological diagnosis in general benefits increasingly from powerful diagnostic tools to examine disease, many osteoporotic spinal fractures are asymptomatic, and their recognition is often incidental to chest radiography or body CT. Moreover, there are no uniformly agreed criteria by which to decide if a vertebra is fractured. Lastly, it has become apparent that some osteoporosis treatments may themselves contribute to so-called atypical femoral fractures.

Outpatient Uterine Artery Embolization for Symptomatic Fibroids: Short- and Long-Term Single Institution-Based Outcomes

OBJECTIVE To assess the short- and long-term efficacy and safety of uterine artery embolization (UAE) in the management of uterine fibroids, and to assess patient satisfaction with this procedure when performed on an outpatient basis. METHODS One hundred one patients who had undergone UAE for symptomatic uterine fibroids in the past five years were interviewed over the telephone, using a standard uterine fibroid symptom and quality-of-life questionnaire. The severity of post-procedural pain, occurrence of adverse reactions, complications, need for subsequent hysterectomy or myomectomy, and overall patient satisfaction were also recorded. RESULTS UAE resulted in a mean 39.1 point improvement in fibroid symptom scores and a mean rise of health-related quality of life score to 93.6, which is near normal. The mean pain score was highest (3.7/10) on the first night after the procedure. Ten patients returned to the hospital in the first 48 hours after UAE, but of these only one required admission because of sepsis. The only other major complication was spontaneous fibroid expulsion in one patient. Fourteen patients remained hypermenorrheic, 78 had regained normal or light menses, five reported spotting, and four became amenorrheic. Six patients underwent subsequent hysterectomy and one a subsequent myomectomy. Six patients found the procedure less than satisfactory. CONCLUSION UAE is a safe, effective, and durable alternative to hysterectomy and myomectomy in women with symptomatic fibroids who wish to avoid surgery. It can be performed safely on an outpatient basis.

Vertebral Fractures and Morphometric Deformities: LETTER TO THE EDITOR

Dear Dr. Civitelli, In discussing such advances, they include spinal morphometry, and specifically refer to and illustrate the Genant semi-quantitative (GSQ) paradigm,2 although also referring to the algorithm-based qualitative (ABQ) method3 of vertebral evaluation in the diagnosis of osteoporotic vertebral fractures (OVF). Although in its day the GSQ method was a credible attempt at structured reporting, recent data suggest that GSQ Grade 1 lesions, the most common, relate less well to bone density and fracture risk than comparable fractures diagnosed using the ABQ tool. This article is protected by copyright. All rights reserved.