Thomas K. Egglin

Fibrin sheath stripping versus catheter exchange for the treatment of failed tunneled hemodialysis catheters: randomized clinical trial.

PURPOSE To compare the effectiveness of two treatments for tunneled hemodialysis catheter malfunction: percutaneous fibrin sheath stripping (PFSS) and over-the-wire catheter exchange (EX). MATERIALS AND METHODS Adult patients with poorly functioning tunneled hemodialysis catheters (flow rates < 200 mL/min) were randomly assigned to receive either PFSS or EX. Over the course of 20 months, 30 patients (37 encounters) referred to a single institution met the inclusion criteria and consented to participate. PFSS employed transcatheter snares via femoral vein puncture, whereas EX was performed over a guide wire with use of fluoroscopic guidance. Patients were followed up to determine the duration of continued adequate hemodialysis via manipulated catheters for up to 4 months (primary outcome measure). RESULTS Overall technical success rate was 97%. Mean catheter patency for the PFSS group was 24.5 +/- 29.3 days, and 52.2 +/- 43 days for the EX group (P < .0001). After EX, patency rates at 1, 2, 3, and 4 months were 71%, 33%, 27%, and 27%, compared to 31%, 16%, 7%, and 0% after PFSS (P = .04, logrank test). Exchanged catheters were significantly more likely to be patent for as long as 4 months (23% versus 0%; P < .05, chi2 test). CONCLUSIONS Malfunctioning tunneled hemodialysis catheters treated by means of EX are significantly more likely to remain patent for up to 4 months than are those treated by means of PFSS. According to the results of this trial, PFSS should not be performed as a routine therapy for catheter malfunction.

Utilization Patterns and Diagnostic Yield of 3421 Consecutive Multidetector Row Computed Tomography Pulmonary Angiograms in a Busy Emergency Department

Objective: To compare examination volume and diagnostic yield of computed tomography (CT) pulmonary angiography (CTPA) and ventilation-perfusion (V/Q) scintigraphy for detection of suspected pulmonary embolism (PE) in emergency department patients. Methods: Every CTPA and V/Q scan result for emergency department patients between October 2001 and September 2005 were reviewed. Patients with prior PE and follow-up examinations were excluded. Results: A total of 3421 CTPA examinations and 198 V/Q scans met inclusion criteria. Average CTPA examinations completed per month increased 227%, from 33.4 to 109.2 for the first and last 24-month periods, respectively. Ventilation-perfusion scintigraphy volume decreased 80% (from 6.9 to 1.4 per month). Total diagnoses of PE per month increased 89% from 4.0 to 7.5, whereas the percentage of positive CTPA examinations dropped from 9.8% to 6.8%. Conclusions: Availability of CT in the emergency department and lower physician thresholds for test utilization have increased the use of CT pulmonary angiography and increased detection of PE.

Do Emergency Physicians Use Serum d-Dimer Effectively to Determine the Need for CT When Evaluating Patients for Pulmonary Embolism? Review of 5,344 Consecutive Patients

OBJECTIVE The purpose of our study was to investigate whether D-dimer screening is being used effectively to determine the need for MDCT in diagnosing acute pulmonary embolism (PE) in emergency department patients. MATERIALS AND METHODS We performed a retrospective review of all patients who underwent D-dimer testing or MDCT in the emergency department from January 1, 2003, through October 31, 2005. A D-dimer value of > 0.43 microg/mL was considered positive. Diagnosis of PE was made on the basis of the MDCT. Clinical algorithms for diagnosing PE mandate that patients with a low clinical suspicion for PE undergo D-dimer testing, then MDCT if positive. For patients with a high clinical suspicion for PE, MDCT should be performed without D-dimer testing. RESULTS Of 3,716 D-dimer tests, 1,431 (39%) were positive and 2,285 (61%) were negative. MDCT was performed in 166 (7%) patients with negative D-dimer results and in 826 (58%) patients with positive D-dimer results. The prevalence of PE in patients with a high clinical suspicion and no D-dimer testing was 9% (139/1,628), which was higher than the rate of PE in the positive D-dimer group at 2% (19/826) (p < 0.0001). There was no significant difference in the prevalence of PE in the positive and negative D-dimer groups (2% vs 0.6%, respectively) (p = 0.23). The sensitivity and negative predictive value of D-dimer for PE were 95% (95% CI, 73.1-99.7%) and 99% (95% CI, 96.2-99.9%), respectively. CONCLUSION D-dimer screening is not used according to established diagnostic algorithms to determine the need for MDCT in diagnosing acute pulmonary embolism in our emergency department.

Outcomes in 74 patients with an appendicolith who did not undergo surgery: is follow-up imaging necessary?

The objective of this study was to report the clinical outcome of patients with an appendicolith on computed tomography (CT) who did not undergo appendectomy on initial presentation. Reports from 45,901 abdominal CT examinations performed between March 2000–March 2004 containing the words “appendicolith” or “fecalith” were identified. Patients with appendicoliths not initially undergoing appendectomy were followed to assess re-presentation with abdominal pain ultimately requiring appendectomy. Seventy-four patients had an appendicolith on CT report, were discharged without surgery, and had clinical follow-up. Fifty-two of 74 (70%) patients had no appendiceal symptoms, were given an alternate diagnosis, and did not return with appendicitis. Twenty-two of 74 (30%) patients were discharged without acute appendicitis but with possible appendiceal symptoms. Five of these 22 (23%) patients returned with pathologically proven acute appendicitis, and all had possible appendiceal symptoms at initial presentation. An appendicolith may be a marker of increased risk for appendicitis but is not an indication for appendectomy.

Injuries from ingesting wire bristles dislodged from grill-cleaning brushes — Providence, Rhode Island, 2009–2012 ☆ ☆☆

Foreign object ingestion is a common reason for visiting an emergency department; however, wire grill-cleaning brush bristles are an uncommon foreign object. This report describes a series of twelve cases identified in a single hospital system from July 2009 through June 2012. Patients included six males and six females; ages ranged from 11 to 75 (mean: 47 years). The patients all reported recent outdoor residential food grilling and use of commercially available wire grill-cleaning brushes. The severity of injury ranged from puncture of the soft tissues of the neck, causing severe pain on swallowing, to perforation of the gastrointestinal tract requiring emergent surgery. Before cooking, persons should examine the grill surface carefully for the presence of wire bristles that might have dislodged from the grill brush and could embed in cooked food. Alternative residential grill-cleaning methods or products might be considered.

Prevalence and nature of excluded findings at reduced scan length CT angiography for pulmonary embolism

BACKGROUND Scan length reduction effectively decreases radiation dose at CT pulmonary angiography (CTPA) for pulmonary embolism (PE) but may exclude important incidental scan findings. OBJECTIVE We aimed to determine the prevalence and nature of excluded findings with the use of reduced scan length CTPA. METHODS We reviewed 335 consecutive emergency department CTPA studies performed on 16- or 64-detector row scanners with the use of a standard scan range. A scan length of 14.2 cm that was centered 4.1 cm below the carina has been shown to be adequate for PE diagnosis. Boundary slices for this scan range were determined. All pertinent and incidental findings within and outside the reduced scan range were noted. To determine the significance of newly detected excluded findings, we reviewed medical records and all relevant imaging studies before and 9-11 months after the reference CTPA. RESULTS We found 374 pertinent findings in 192 patients, including 28 (8%) cases of PE. All except 3 (0.8%) were adequately seen with the reduced scan range, among which only one finding altered clinical management. There were a total of 230 incidental findings in 165 patients, 60 (26%) of which were excluded; 23 (10%) of the 60 were newly detected, including 10 thyroid nodules, 6 liver lesions, and an 8-mm pulmonary nodule. The reduced scan length decreased z-axis coverage by 49% ± 6%. CONCLUSION Substantial scan length reduction at CTPA may not compromise the diagnostic yield for pertinent alternative diagnoses.

Scan length optimization for pulmonary embolism at CT angiography: analysis based on the three-dimensional spatial distribution of 370 emboli in 100 patients

AIM To determine the size and three-dimensional spatial distribution of pulmonary emboli (PE) at computed tomography angiography (CTA) to optimize the scan length. MATERIALS AND METHODS Two experienced radiologists jointly reviewed 100 consecutive, positive PE CTA studies performed in the Emergency Department (53 women; age 61±17 years). All studies were conducted on a 16-detector row CT machine. In each case, the number of emboli was counted and the proximal and distal spatial coordinates of each embolus documented. Coordinates of the main pulmonary artery bifurcation (MPAb) and carina were recorded. For normalization, the thoracic cavity height (H)-from inlet to lowest hemidiaphragm-was measured. The minimal scan lengths for (a) capturing all emboli and (b) rendering a positive diagnosis were determined. RESULTS Three hundred and seventy (370) emboli were detected. The average number of PE per patient was 3.7 (maximum 12, minimum 1). Their average length was 2.7 cm. Nine patients had saddle emboli (9%), and 71% of emboli were at or below the MPAb. An 18 cm (0.90×H) scan length, centred 4 cm (0.18×H) below the carina, captures all PE in this dataset while reducing z-axis coverage by 29% (34% for normalized data). Moreover, a 14.2 cm (0.78×H) scan length appropriately centred captures at least one embolus in all patients while reducing coverage by 44% (43%). Decreasing scan length to the lesser of 14.2 cm and 0.78×H per patient reduces coverage by 47%. CONCLUSION Scan length at CTA for PE can be reduced by up to 47% while preserving diagnostic accuracy for PE detection.