Leo P. Lawler

Working formulation for the standardization of definitions of infections in patients using ventricular assist devices

In 2009, the International Society for Heart and Lung Transplantation (ISHLT) recognized the importance of infectionrelated morbidity and mortality in patients using ventricular assist devices (VADs) and the growing need for a consensusbased expert opinion to provide standard definitions of infections in these patients. The aim of these standard definitions is to improve clinical-investigator communication, allowing meaningful comparison in practice and outcomes between different centers and different VAD devices. In 2010, a core group of experts, including infectious diseases specialists, cardiologists, pathologists, radiologists, and cardiothoracic surgeons, formed an ISHLT Infectious Diseases Working Group to develop agreed criteria for definitions of infections in VAD patients. These definitions have been created by adapting and expanding on existing standardized definitions, which are based on the pathophysiology of equivalent infectious processes in prosthetic devices, such as cardiac prosthetic valve infections, intravascular catheter-related infections, and prosthetic joint infections. These definitions have been divided into 3 sections: VAD-specific infections, VAD-related infections, and non-VAD infections. Owing to the constant shortage of donor organs, new allocation systems, and improved medical therapies for congestive cardiac failure, the overwhelming trend in cardiac transplantation has been toward listing principally the most critically ill patients, that is, those requiring inpatient inotropic therapy for mechanical circulatory support (MCS). The ventricular assist device (VAD) has an expanding role in the management of these patients, both as a bridge to transplantation and as a destination therapy (ie, alternative to transplantation). According to United Network of Organ Sharing (UNOS) registry data, 9,000 transplant candidates have undergone MCS since 1999, comprising 33% of all listed patients and 75% of all listed inpatients. 1

A 2010 working formulation for the standardization of definitions of infections in cardiothoracic transplant recipients

Shahid Husain, MD, MS, Martha L. Mooney, MD, MS, FACP, Lara Danziger-Isakov, MD, MPH, Frauke Mattner, MD, PhD, Nina Singh, MD, Robin Avery, MD, FIDSA, Michael Ison, MD, MS, Atul Humar, MD, MSc, Robert F. Padera, MD, PhD, Leo P. Lawler, MD, FRCR, Andy Fisher, PhD, FRCP, Richard J. Drew, MD, Kate F. Gould, MBBS, MRCP, FRCP, Amparo Sole, MD, PhD, Sean Studer, MD, MSc, Patricia Munoz, MD, Lianne G. Singer, MD, FRCPC, and Margaret Hannan, MD, FRCP, FRCPath, for the ISHLT Infectious Diseases Council Working Group on Definitions From the Division of Infectious Diseases, Transplant Infectious Diseases, University Health Network, University of Toronto, Toronto, Ontario, Canada; Eastern Virginia Medical School, Sentara Norfolk Transplant Center, Norfolk, Virginia; Center for Pediatric Infectious Diseases, Department of Infectious Disease, Medicine Institute, The Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio; Infection Control and Hospital Epidemiology, Institute for Medical Microbiology, Hannover Medical School, Hannover, Germany; Division of Infectious Diseases, Veteran Affairs Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania; Divisions of Infectious Diseases and Organ Transplantation, Northwestern University, Feinberg School of Medicine, Chicago, Illinois; Department of Medicine, Division of Infectious Diseases, University of Alberta, Edmonton, Alberta, Canada; Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; Respiratory Transplant Medicine, Newcastle University, Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, UK; Mater Misericordiae University Hospital, Dublin, Ireland; Health Protection Agency Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK; Hospital Universitario La Fe, Valencia, Spain; Division of Pulmonary & Critical Care, Newark Beth Israel Medical Center, Newark, New Jersey; and Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Maranon, Universidad Complutense, Madrid, Spain.

Bronchopleural Cutaneous Fistula after Pulmonary Radiofrequency Ablation: Treatment with Low-Adherent Paraffin Gauze Dressing

useful during chemoembolization procedures but has been difficult to incorporate into clinical workflow. C-arm CT using flat panel detectors can produce three-dimensional images using the same angiographic unit as used for DSA (3,4), simplifying the process. The advantages of C-arm CT are of particular importance in patients with lesions in the watershed regions, where identifying multiple tumor-supplying vessels and assessing completeness of lipiodol uptake are difficult using projectional imaging alone. Although use of C-arm CT can increase the single-procedure radiation dose to the patient, complete treatment of a tumor may allow avoidance of subsequent procedures, resulting in a net decrease in radiation and nephrotoxic contrast medium exposure (5). In conclusion, the use of C-arm CT during superselective chemoembolization can provide critical information, especially for tumors in watershed territories served by a bilobar segmental supply. Evaluation of completeness of lipiodol uptake can trigger interrogation of additional vessels if indicated, increasing the operator’s confidence of definitive treatment.

Water-enhanced antegrade MR pyelography in pregnancy: a novel radiation-free approach

Our aim was to determine if water-enhanced antegrade magnetic resonance (MR) pyelography can be an alternative to conventional antegrade pyelography in pregnant patients who require percutaneous nephrostomy placement for urosepsis and/or obstructive uropathy. The pregnant patient was placed supine in a 1.5-T MRI scanner seven days after percutaneous nephrostomy placement using ultrasound. Serial axial and coronal T2-weighted echo-planar fast spin-echo sequences were performed before and after injection of the catheter. The right nephrostomy catheter hub was sterilised using chlorhexidine. Sixty millilitres of sterile water were slowly injected. No Gd-based contrast agent was utilised due to safety concerns for the foetus. MR antegrade pyelography demonstrated the level of ureteric obstruction and the absence of renal calculi using sterile water as a contrast medium injected through a percutaneous nephrostomy followed by T2-weighted imaging. Air bubbles in the injected solution were differentiated from calculi due to their mobility on serial scans and their anti-dependent position. Water-enhanced antegrade MR pyelography was a safe and effective method of imaging the pregnant patient. It served as an alternative to conventional antegrade pyelography and minimised potential risks to the foetus.

Bring Back ‘Permanent’ Filters

To the Editor, It is time to remove ‘temporary’ and ‘retrievable’ descriptors from the vernacular of IVC filter placement. Neither practitioner nor company could ever claim complete control over the many factors that determine retrievability. Such terminology misleads referrers and patients alike. By raising unrealistic expectations, it also unnecessarily gifts a novel caseload to an already adversarial medico-legal system. Although an innovation of good intention, these redundant discriminators have been hijacked through marketing, misinformation, and misinterpretation to the detriment of this common vital practice. Patients should only be offered a ‘permanent’ filter albeit with a design that may permit, but never guarantee, a method of removal. The moniker ‘permanent’ filter better articulates the risk that it may well be and better focuses all minds on the threshold for justified use based on clinical indications and patient reservations. It is better for all to offer a permanent filter that is potentially retrievable than vice versa. Clear communication is a basic tenet of patient care, so for the good of all, let us make this simple language change in our practice and our literature and re-educate the world on filters.

Loss of renal India ink artifact—a useful radiological sign for obstructive hydronephrosis in pregnancy☆

Magnetic resonance imaging is a useful tool for investigating causes of abdominal pain in pregnancy. Differentiating between physiologic hydronephrosis of pregnancy and pathologic hydronephrosis can be challenging for clinicians and radiologists. This report describes loss of the India ink artifact around the obstructed kidney as a novel and potentially useful radiological sign, which may be of value in the evaluation of abdominal pain and hydronephrosis in pregnancy.

Frequency of Nonthromboembolic Imaging Abnormalities in Pregnant Women Referred for Computed Tomography Pulmonary Arteriography

Purpose The study sought to determine the frequency of nonthromboembolic imaging abnormalities in pregnant women referred for computed tomography pulmonary arteriography (CTPA). Materials and Methods CTPA studies on 100 consecutive pregnant women performed over a 5-year period were reviewed independently by 2 radiologists, with conflicts resolved by consensus. Age range was 18-43 years (mean 28 years). The presence or absence of pulmonary embolism and of nonthromboembolic imaging abnormalities was recorded. These were graded as A if the abnormalities were thought to provide potential alternative explanations for acute symptoms, B if findings were incidental that required clinical or radiologic follow-up, and C if the findings did not require further action. Results Pulmonary embolism was seen in 5 women. In 2 of these additional findings of consolidation and infarction were seen. Ninety-five women did not have pulmonary embolism. Eleven women (12%) had grade A abnormalities; 6 cases of consolidation, 2 cases of lobar collapse, and 3 cases of heart failure with pleural effusions. One woman had a grade B abnormality due to the presence of pulmonary nodules. Ten women had incidental grade C abnormalities. Conclusion Pulmonary embolism occurs in 5% of pregnant women referred for CTPA. In pregnant women without embolism on CTPA, potential alternative causes for patient symptoms are seen on CT in 12% of cases.