Parag J. Patel

Neutrophil chemokine production in the skin following scald injury

The present study was conducted to determine whether local production of neutrophil chemoattractant cytokines preceded the influx of neutrophils following dermal scald injury. To accomplish this, dermal tissue was examined for inflammatory infiltrate and the level of KC, a murine homolog of human interleukin-8, at various time points after scald injury. The studies reveal that there was a largely neutrophilic infiltrate at 1 day post-injury which persisted for 4 days. Dermal KC levels increased significantly at 4 h, returned to baseline at 8 h and were elevated again from 1 to 3 days post-burn (P < 0.01). At 3 days post-burn, KC was elevated 15-fold above the level in sham treated mice (P < 0.01). These observations demonstrate that the influx of neutrophils into the skin follows the expression of KC in the skin. This suggests that it should be possible to alter neutrophil accumulation at the wound site by manipulating the local chemokine signal.

Patterns of Venous Reflux and Obstruction in Patients With Skin Damage Due to Chronic Venous Disease

Identified were characteristics of individuals with skin damage related to chronic venous disease. Patients with chronic venous disease (n = 164) were evaluated with duplex ultrasound imaging and were placed in classes 4, 5, and 6 according to the CEAP classification. Their findings were compared with 100 class 2 controls. The prevalence of deep venous thrombosis was higher in the study group (23.7%) versus controls (5.1%; P < .0001), as was the prevalence of deep, perforator, and combined patterns of disease (P < .0001, P < .0007, and P < .0001). The mean duration of disease in controls 2 was shorter compared with the study group (P = .0019). The prevalence of reflux and obstruction within the study group was higher than in controls (P = .0021). Skin changes accurately reflect severity of chronic venous disease. Superficial and perforator vein reflux is the major cause of disease.

Effect of Acute Ethanol Exposure on the Dermal Inflammatory Response After Burn Injury

BACKGROUND More than 100,000 people each year are admitted to U.S. hospitals for severe burn injury. Strikingly, ethanol use prior to injury is apparent in nearly 50% of burn patients, rendering them six times more likely to die from infection than patients not exposed to ethanol. We previously reported that the kinetics and magnitude of neutrophil chemokine production and subsequent accumulation of neutrophils in the lung was dramatically altered when ethanol exposure preceded injury. Here, we tested whether burn injury and ethanol exposure combined, altered susceptibility to infection, neutrophil chemoattractant production, and neutrophil accumulation at the site of the burn wound. METHODS Male B(6)D(2)F1 mice were administered a dose of ethanol designed to achieve 90-100 mg/dl circulating levels and 30 min later subjected to a 15% total body surface area dorsal scald injury. Susceptibility to topically applied Pseudomonas aeruginosa was examined. At various times after injury, burn wound and normal tissues were collected for assessments of neutrophil counts, myeloperoxidase quantitation, and neutrophil chemoattractant (KC and MIP-2) production. RESULTS Ethanol exposure prior to burn injury enhanced susceptibility to infection after burn and was associated with significantly elevated production of KC, but not MIP-2, at the wound site. Despite the enhanced elevation of KC, neutrophil accumulation in the wounds of ethanol exposed, burn injured mice did not differ from those that received burn injury alone. TNFalpha (a potent activator of neutrophils), however, was found to be significantly elevated in the wounds of mice that received only burn injury, but not in those that received injury in combination with prior ethanol exposure. CONCLUSION In the presence of ethanol, neutrophils are adequately recruited to the site of burn injury, but their host defense functions are impaired, perhaps due to the lack of proinflammatory cytokines such as TNFalpha.

The Reentry Catheter: A Second Chance for Endoluminal Reentry at Difficult Lower Extremity Subintimal Arterial Recanalizations

From January 2005 to July 2008, a retrospective study was conducted at a single institution to investigate technical success of the use of a reentry device (Outback LTD reentry catheter) in aortoiliac and femoropopliteal artery recanalization in 34 patients (18 men; mean age +/- SD, 72 years +/- 11) in whom the conventional guide wires and catheters failed to reenter the true lumen. True lumen reentry was achieved in 87% (n = 23) and 91% (n = 11) of patients with femoropopliteal and aortoiliac occlusions, respectively. The overall technical success rate with the device was 88% (n = 34). The device success rate in Transatlantic Inter-Society Consensus II class D lesions was significantly lower than in lower lesion classes (71.4% vs 100%; P < .05). No procedure-related complications were encountered. In conclusion, the use of the reentry catheter enhances the likelihood of successful subintimal recanalization of chronic occlusions in femoropopliteal and aortoiliac arteries.

Optimal Management of the Splenic Vein at the Time of Venous Resection for Pancreatic Cancer: Importance of the Inferior Mesenteric Vein

BackgroundResection of the superior mesenteric vein (SMV)-portal vein (PV)-splenic vein (SV) confluence during pancreatectomy for pancreatic cancer requires management of the SV.DiscussionSimple SV ligation can result in sinistral portal hypertension if the inferior mesenteric vein (IMV) enters the confluence and is thereby resected, or if the IMV is insufficient to drain the SV. We describe herein three patients whose clinical course confirms the importance of the IMV decompressing the SV to avoid sinistral hypertension.

Ciliated hepatic cyst leading to squamous cell carcinoma of the liver – A case report and review of the literature

INTRODUCTION Ciliated hepatic foregut cysts (CHFC) are rare, typically benign liver lesions. Primary squamous cell carcinoma (SCC) of the liver is also a rare entity with only approximately 25 reported cases in the literature. Recently, there have been four reports of malignant transformation of CHFC into primary squamous cell carcinoma of the liver. Here we report a fifth with unique presentation and review the literature. PRESENTATION OF CASE A 34 year-old man, with a history of ulcerative colitis, was incidentally found to have a 10 cm lesion in the right anterior sector plus left medial section of the liver on computerized tomography (CT) scan. The patient was asymptomatic at presentation and neoplastic markers were not elevated. Sequential transarterial chemoembolization (TACE) and portal vein embolization (PVE) allowed for left lateral section plus segment 1 hypertrophy and subsequent resection. Histology later revealed the cyst to be a CHFC and showed its malignant transformation. At 6 month follow-up, the patient has lung and abdominal recurrence. DISCUSSION With now the fifth case of malignant transformation of CHFC being reported, approximately 5% of all reported CHFC have undergone malignant transformation. This frequency, taken together with the aggressive disease course and poor prognosis, suggests that CHFC must not be presumed benign and should be regarded with clinical suspicion. CONCLUSION Accurate diagnosis of CHFC is mandatory given its potential malignant transformation. Even in asymptomatic CHFC, surgical excision is recommended. In addition, in cases of otherwise unresectable lesions, sequential TACE and PVE may provide optimal hypertrophy of future liver remnant.

A Single-Center Experience in Capturing Inpatient Evaluation and Management for an IR Practice

PURPOSE To demonstrate that interventional radiologists can capture work relative value units (wRVUs) for the work that is already being performed providing evaluation and management (E&M) clinical services. MATERIALS AND METHODS A team approach was implemented to optimize revenue capture for inpatient E&M. Structured templates were created for inpatient documentation to ensure that maximum wRVUs were captured. Inpatient billing was audited from fiscal year 2011 (1 year before meeting and structured template creation) through fiscal year 2014. Specifically, data were collected on total charges, collections, wRVUs and total number of inpatient E&M encounters, and the level of the billed encounter. RESULTS Retrospective annual audits revealed that overall inpatient E&M billing charges increased by 722%, whereas collections increased by 831% from 2011 to 2014. The wRVUs increased in 2011 from 181.74 to 1,396.9 (669% increase) in 2014, and the number of inpatient E&M encounters billed increased from 130 to 693 (433% increase) over that same time period. Lower level billing (level I) declined from 30% to 19%, and complex billing levels (level II or higher) increased from 70% to 81%. CONCLUSIONS By implementing a systems approach to revenue management, which includes physician and billing staff meetings and the use of structured templates, billing capture from inpatient E&M services can be improved.

Percutaneous Revascularization of Chronic Total Occlusions

Many patients with severe intermittent claudication (IC) or critical limb ischemia (CLI) have chronic total occlusions (CTO) in their lower extremity vascular bed. The successful treatment of these lesions is becoming increasingly more important as the population ages and the prevalence of diseases such as diabetes mellitus and its consequences increases. Many of these patients have significant comorbidities and may benefit from less invasive treatment options. Several endovascular techniques have now become well established in the treatment of these lesions. Additionally, several new adjunctive tools have been developed to enhance the technical success of CTO revascularization. These tools and techniques offer a minimally invasive alternative for limb salvage in this compromised patient population and have become an established practice in many centers. Although some concerns about procedure durability and lower rates of primary patency exist, particularly when compared to surgical bypass, the limb salvage and amputation-free survival rates are much more encouraging. Advantages of these techniques compared to surgical bypass are reduced morbidity and mortality, reduced anesthesia requirements, and potential reductions in length of hospital stay and cost. In addition, bypass options are typically preserved after endovascular treatment. The more conventional and some newer endovascular treatment approaches, some of the adjunctive tools and techniques used in CTO revascularization as well as their clinical results will be discussed in this review.

Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis: A Failed Concept

In 2009 Paolo Zamboni et al. implicated that chronic cerebral venous congestion lead to the development of multiple sclerosis. In this review, we examined the role of chronic cerbrospinal venous insufficiency in multiple sclerosis and the proposed therapy entailing venous angioplasty and stenting of extracranial veins with available evidence to date.

Evaluation of catheter infection rates in converted dialysis catheters versus de novo placement in the setting of chlorhexidine use.

Purpose Prior studies have reported infection rates of converting non-tunneled dialysis catheters (NTDCs) to tunneled dialysis catheters (TDCs) versus de novo placement of TDCs using povidone-iodine. Chlorhexidine, per the Center of Disease Control guidelines, has been exclusively used in our institution since 2005. Therefore, our study aims to determine whether there is a difference in infection rates between conversion and de novo placement when utilizing chlorhexidine. Materials and Methods A retrospective analysis from 1/1/2009 to 8/10/2012 was performed of patients who underwent placement of NTDCs, which were subsequently converted to TDCs and those who underwent de novo TDC placement. To assess the rate of infection, the following data points were collected: date of procedure(s), indication, outcomes, site of catheter insertion, pre- and post-procedure laboratory values, complications, infection rates within the life of the initially placed catheter, catheter days, and survival. Results The conversion cohort was composed of 205 patients, 135 of whom were lost to follow-up, leaving 70 patients. The de novo cohort included 70 randomly selected patients. Of the 70 patients who underwent conversion, 23 developed a catheter-related infection, with an infection rate of 0.26 events per 100 catheter days. Of the 70 de novo catheters, 20 developed infection with an infection rate of 0.25 events per 100 catheters days. Conclusion In this series, there is no difference in infection rates between conversion and de novo TDC placement when utilizing chlorhexidine as the sterilization agent. However, these infection rates are superior to those reported when using povidone-iodine.