Sohail Contractor

Role of helical CT in detecting right ventricular dysfunction secondary to acute pulmonary embolism

Objective The purpose of this study was to evaluate the role of helical CT in detecting right ventricular dysfunction (RVD) after acute pulmonary embolism (PE). Methods This was a retrospective study consisting of 25 patients with CT scans positive for acute pulmonary embolism who had either follow-up echocardiography (23 patients) or pulmonary angiography (2 patients). CT scans were reviewed for findings suggestive of RVD. Scans were considered positive for RVD if the right ventricle (RV) was dilated or if the interventricular septum was deviated towards the left ventricle. Results were then correlated with the results of echocardiography or pulmonary angiography to estimate the sensitivity and specificity of CT in detecting RVD associated with PE. Results Within this group of 25 patients with PE, CT demonstrated sensitivity of 78% (7/9), specificity of 100% (16/16), and positive predictive value of 100% (7/7) in detection of RVD. Conclusion CT may be useful in detecting RVD in patients with acute PE.

Readability assessment of internet-based patient education materials related to uterine artery embolization.

PURPOSE To determine the readability of Internet-based patient education materials (IPEMs) created by United States hospitals and universities and clinical practices and miscellaneous health care-associated Web sites regarding uterine artery embolization (UAE) as a marker for IPEMs in general. METHODS AND METHODS Two hundred unique Web sites were evaluated for patient-related articles on UAE. Web sites produced by US hospitals and universities and clinical practices, as well as miscellaneous health care-associated Web sites meeting the Health on the Net Foundation Code of Conduct criteria were included in the database. By using mathematical regression algorithms based on word and sentence length to quantitatively analyze reading materials for language intricacy, readability of 40 UAE-related IPEMs was assessed with four indices: Flesch-Kincaid Grade Level (FKGL), Flesch Reading Ease Score (FRES), Simple Measure of Gobbledygook (SMOG), and Gunning Frequency of Gobbledygook (GFOG). Scores were evaluated against national recommendations, and intergroup analysis was performed. RESULTS None of the IPEMs were written at or below the sixth-grade reading level, based on FKGL. The mean readability scores were as follows: FRES, 43.98; FKGL, 10.76; SMOG, 13.63; and GFOG, 14.55. These scores indicate that the readability of UAE IPEMs is written at an advanced level, significantly above the recommended 6th grade reading level (P<.05) determined by the United States Department of Health and Human Services. CONCLUSIONS IPEMs related to UAE generated by hospitals, clinical practices, and miscellaneous health care-associated Web sites are written above the recommended sixth grade level. IPEMs for other disease entities may also reflect similar results.

Analysis of the Sherlock II tip location system for inserting peripherally inserted central venous catheters.

Peripherally inserted central catheters (PICCs) are frequently placed at the bedside. The purpose of our study was to evaluate the efficacy of the Sherlock II tip location system (Bard Access Systems, Salt Lake City, UT), which offers electromagnetic detection of the PICC tip to assist the operator in guiding the tip to a desired location. We performed a retrospective review of patients who had a bedside PICC using the Sherlock II tip location system. Three hundred seventy-five of 384 patients (97.7%) had the catheter tip positioned appropriately. Our results suggest that the Sherlock II tip location system is an efficacious system for bedside PICC placement.

Coil Embolization as a Treatment Alternative for Dialysis-Associated Steal Syndrome

Steal syndrome is a rare but serious complication of arteriovenous fistulas (AVF) created as well as the angioplasty technique used for its maturation and can have severe consequences if left untreated. Standard treatment options generally lead to loss of fistula access, although newer practices such as coil embolization are being utilized to conserve the AVF. Here we illustrate a case of a 65-year-old man with end-stage renal disease on dialysis, who had a Brescia-Cimino (radiocephalic) AV fistula created and subsequently underwent balloon-assisted maturation for an underdeveloped fistula. One month later, the patient presented with a cold thumb and index finger along with parasthesias in those digits and was treated with coil embolization of the distal radial artery while leaving the AVF functional. Steal syndrome and the novel treatment option of coil embolization are reviewed here.

Cystic artery pseudoaneurysm presenting as a complication of laparoscopic cholecystectomy treated with percutaneous thrombin injection.

A 45-year-old woman status post laparoscopic cholecystectomy 3years ago presented with upper gastrointestinal bleeding. Endoscopy revealed hemobilia. Computed tomographic abdomen demonstrated a 2-cm aneurysm in the gall bladder fossa, consistent with a pseudoaneurysm. Initially, transcatheter coil embolization was attempted but recanalization of the aneurysm with recurrent bleeding in 2 days ensued. The aneurysm was then accessed percutaneously under ultrasound guidance and thrombin was injected into the aneurysm with subsequent complete thrombosis of the aneurysm and cessation of bleeding.

Transient Mediastinal Enlargement: An Unusual Computed Tomographic Manifestation of Pulmonary Venous Hypertension and Congestive Heart Failure

We describe a case of diffuse superior and middle mediastinal enlargement of soft tissue attenuation noted on helical computed tomography (CT) of a patient with clinical and radiographic findings of congestive heart failure (CHF). Upon treatment and improvement of his pulmonary venous hypertension, a repeat CT scan revealed resolution of the mediastinal abnormalities. We, therefore, advocate a search for primary CT signs of CHF in patients with findings of widespread mediastinal distension. If present, repeat CT scanning after resolution of the cardiac condition should be performed before further intervention for the mediastinal abnormality is attempted.

A Phase I trial using local regional treatment, nonlethal irradiation, intratumoral and systemic polyinosinic-polycytidylic acid polylysine carboxymethylcellulose to treat liver cancer: in search of the abscopal effect

Purpose To determine the safety of an approach to immunologically enhance local treatment of hepatocellular cancer (HCC) by combining nonlethal radiation, local regional therapy with intratumoral injection, and systemic administration of a potent Toll-like receptor (TLR) immune adjuvant. Methods Patients with HCC not eligible for liver transplant or surgery were subject to: 1) 3 fractions of 2-Gy focal nonlethal radiation to increase tumor antigen expression, 2) intra-/peri-tumoral (IT) injection of the TLR3 agonist, polyinosinic-polycytidylic acid polylysine carboxymethylcellulose (poly-ICLC), to induce an immunologic “danger” response in the tumor microenvironment with local regional therapy, and 3) systemic boosting of immunity with intramuscular poly-ICLC. Primary end points were safety and tolerability; secondary end points were progression-free survival (PFS) and overall survival (OS) at 6 months, 1 year, and 2 years. Results Eighteen patients with HCC not eligible for surgery or liver transplant were treated. Aside from 1 embolization-related severe adverse event, all events were ≤grade II. PFS was 66% at 6 months, 39% at 12 months, and 28% at 24 months. Overall 1-year survival was 69%, and 2-year survival 38%. In patients <60 years old, 2-year survival was 62.5% vs. 11.1% in patients aged >60 years (P<0.05). Several patients had prolonged PFS and OS. Conclusion Intra-tumoral injection of the TLR3 agonist poly-ICLC in patients with HCC is safe and tolerable when combined with local nonlethal radiation and local regional treatment. Further work is in progress to evaluate if this approach improves survival compared to local regional treatment alone and characterize changes in anticancer immunity.

De Novo Placement of a Tunneled Dialysis Catheter over a Wire with the Single-Incision Technique

The authors describe a technique for the de novo placement of a tunneled dialysis catheter (TDC) over a wire. With use of a micropuncture needle bent into a C shape, the internal jugular vein was accessed under real-time ultrasonographic guidance from the expected catheter exit location in the deltopectoral fossa. The TDC was placed over the wire alone, without the use of a peel-away sheath. Twelve TDCs were successfully placed with this technique without any complications at an average follow-up of 2 months.

Penetration of Günther Tulip filter struts through an introducer sheath: case report and safety concerns.

The authors present a patient who had a Günther-Tulip inferior vena cava filter placed under fluoroscopic guidance. The filter struts were seen to penetrate through the introducer sheath at deployment. This was believed to be secondary to a kink in the sheath at the site of venous entry and was due to the patients nuchal obesity as well as his inability to turn his head to the opposite side. The introducer sheath was then placed through a long reinforced metal sheath through which the filter was then placed without complication.

Incomplete Deployment of the Vena Tech LP Filter—Case Series and Concerns

The Vena Tech LP vena cava filter (B Braun, Evanston, Illinois) has been FDA approved since 2001 and is a permanent vena cava filtration device. It replaced the previous Vena tech LGM filter also manufactured by B Braun. The LGM filter had 2 case series reporting a high incidence of incomplete deployment of the filter, especially when placed from a jugular approach. Design changes were made to this device and the LP filter introduced. The LP filter has also been reported to have incompletely deployed both in peer reviewed literature as well as the FDA MAUDE website. We present here 3 cases of incomplete deployment of the Vena Tech LP filter and review the cases previously described as well as attempt to present possible etiologies for incomplete deployment.