Zachary L. Bercu

Associations between olfactory identification and verbal memory in patients with schizophrenia, first-degree relatives, and non-psychiatric controls

OBJECTIVE Olfactory identification deficits and verbal memory impairments may represent trait markers for schizophrenia. The aims of this study were to: (1) assess olfactory identification in patients, first-degree relatives, and non-psychiatric controls, (2) determine differences in verbal memory functioning in these three groups, and (3) study correlations between olfactory identification and three specific verbal memory domains. METHOD A total of 106 participants-41 patients with schizophrenia or related disorders, 27 relatives, and 38 controls-were assessed with the University of Pennsylvania Smell Identification Test (UPSIT) and the Wechsler Memory Scale-Third Edition. Linear mixed models, accounting for clustering within families and relevant covariates, were used to compare scores across groups and to examine associations between olfactory identification ability and the three verbal memory domains. RESULTS A group effect was apparent for all four measures, and relatives scored midway between patients and controls on all three memory domains. UPSIT scores were significantly correlated with all three forms of verbal memory. Age, verbal working memory, and auditory recognition delayed memory were independently predictive of UPSIT scores. CONCLUSIONS Impairments in olfactory identification and verbal memory appear to represent two correlated risk markers for schizophrenia, and frontal-temporal deficits likely account for both impairments.

TIPS for Refractory Ascites: A 6-Year Single-Center Experience With Expanded Polytetrafluoroethylene -Covered Stent-Grafts

OBJECTIVE. This single-center study evaluated the use of expanded polytetrafluoroethylene (ePTFE)-covered stent-grafts for transjugular intrahepatic portosystemic shunt (TIPS) placement to manage portal hypertension-related refractory ascites. MATERIALS AND METHODS. One hundred patients at a single tertiary care center in a major metropolitan hospital underwent TIPS placement with an ePTFE-covered stent-graft (Viatorr TIPS Endoprosthesis). Patients with portal hypertension-related ascites and preexisting hepatocellular carcinoma or liver transplant were excluded from the analysis. Records were reviewed for demographic characteristics, technical success of the TIPS procedures, and stent follow-up findings. Clinical results were assessed at 90- and 180-day intervals. RESULTS. Immediate technical success of the TIPS procedure was 100%. Of the 61 patients with documented follow-up, 55 (90.2%) had a partial or complete ascites response to TIPS creation. Of these 55 patients, nine experienced severe encephalopathy. Six of 61 patients (9.8%) did not experience a significant ascites response. Overall survival was 78.7% at 365-day follow-up. The 365-day survival was 84.2% for patients with a model for end-stage liver disease (MELD) score of less than 15, 67.0% for those with a score of 15-18, and 53.8% for those with a score of greater than 18 (p = 0.01). For patients with a MELD score of less than 18, the 365-day survival was 88.0% for those with an albumin value of 3 mg/dL or greater and 72.8% for those with an albumin value of less than 3 mg/dL (p = 0.04). CONCLUSION. TIPS placement using an ePTFE-covered stent-graft is an efficacious therapy for refractory ascites. Patients with preserved liver function-characterized by a MELD score of less than 15 or a MELD score of less than 18 and an albumin value of 3 mg/dL or greater-experience the greatest survival benefit.

Percutaneous Mesocaval Shunt Creation in a Patient with Chronic Portal and Superior Mesenteric Vein Thrombosis

AbstractThe creation of a transjugular intrahepatic portosystemic shunt (TIPS) is a critical procedure for the treatment of recurrent variceal bleeding and refractory ascites in the setting of portal hypertension. Chronic portal vein thrombosis remains a relative contraindication to conventional TIPS and options are limited in this scenario. Presented is a novel technique for management of refractory ascites in a patient with hepatitis C cirrhosis and chronic portal and superior mesenteric vein thrombosis secondary to schistosomiasis and lupus anticoagulant utilizing fluoroscopically guided percutaneous mesocaval shunt creation.

Outcomes of Transjugular Intrahepatic Portosystemic Shunts for Ascites

Refractory ascites represents a devastating complication of portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) is an efficacious option for patients for whom transplant is not an immediate option. Techniques to optimize the hepatic venous pressure gradient and the use of covered stents have reduced rates of hepatic encephalopathy and stent occlusion, respectively. Patients with a Model for End-Stage Liver Disease score less than 15, serum creatinine less than 2 mg/dL, and serum bilirubin less than 2 mg/dL are particularly suited for TIPS placement. TIPS is also effective for hepatic hydrothorax and for massive ascites in the posttransplant setting, although future investigations are necessary to elucidate risk factors and establish the effect on transplant-free survival.

Locoregional Therapies in the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy in the world, with over 14 million cases in 2012 and an expected growth to 22 million over the next 20 years [1–3]. It develops secondary to intrinsic liver diseases such as viral hepatitis, alcoholic cirrhosis, steatohepatitis, biliary cirrhosis, or other rarer causes. It represents the third most common etiology of cancer-related deaths in the world and the seventh most common etiology in the United States [3, 4]. As most patients have concomitant chronic liver disease leading to the development of HCC, management of the disease becomes more complicated. Staging and treatment options are impacted not only by the extent of the tumor but also by the patient’s liver function and performance status. Because the majority of patients present with unresectable disease, locoregional therapies, including image-guided percutaneous ablation and image-guided transcatheter tumor therapies, play an important role in the management of patients with HCC.

Understanding patient preferences for femoral central venous catheterization among patients with sickle cell disease

A temporary large-bore central venous catheter (CVC) is placed in patients with sickle cell disease (SCD) to facilitate red blood cell exchange apheresis in order to treat or prevent hemoglobin S-associated complications (1). It has been our observation that some patients strongly prefer the common femoral vein to the internal jugular vein for CVC placement. Limited data exist in the literature on factors that could explain this observation. We aim to explore patient preferences for femoral central venous catheterization among patients with SCD and assess the perceived importance of factors affecting their preferences. From January 2011 to February 2016, 163 consecutive patients underwent a total of 753 procedures of temporary CVC placement at our institution (39% of CVCs placed in the common femoral vein, 59% in the internal jugular vein, and 2% in other sites). The mean age was 34 years (range, 18-69 years). Ninety-two (63%) were females and 53 (37%) were males. We conducted a retrospective survey via telephone interview asking whether they had preferences for the femoral vein versus the internal jugular vein. They rated the importance of various factors in their decisions on a scale of 1 (no importance) to 5 (greatest importance). Logistic regression analysis was performed to evaluate independent clinicodemographic factors associated with preferences. Of the 145 respondents (89% response rate), 42 (29%) reported preferences for the femoral vein. They indicated that the most important factor was concern about possible scar formation at the site of catheterization (mean rating, 4.4). In multivariate analysis, female sex (p<0.001) and known occlusion in the internal jugular vein (p = 0.009) were associated with preferences for femoral central venous catheterization (Tab. I). Patients voiced substantial concerns over scar formation in the neck area if they were to undergo catheter placement in the internal jugular vein. Many sickle cell patients have to undergo multiple repeat procedures of CVC placement whenever needed for red cell exchange apheresis. Taking this into account, scar formation remains a big concern in this young population. Several previous studies reported that femoral central venous catheterization has higher rates of complications such as catheter-related infections and thrombosis with hazard ratios of 2.8-4.2 when compared to internal jugular catheterization (2-5). Despite our on-going, constant efforts to understand patients’ perspectives and educate them on pertinent risks and benefits related to central venous catheterization, some patients still remain poorly informed of potential risks of their preferences. It is our belief that although patient preferences are important, they should be based on well-informed decisions. In conclusion, adult female patients with sickle cell disease often express a preference for the common femoral vein as a placement site of temporary large-bore central venous catheters, with concern about scar formation in the neck being reported as the most important factor. Future studies would be useful in evaluating complications associated with temporary femoral CVC placement in this patient population, and quality improvement studies can be also pursued to optimize patient engagement in shared decision making.

CTA As an Adjuvant Tool for Acute Intra-abdominal or Gastrointestinal Bleeding

Hematemesis and acute postsurgical upper gastrointestinal hemorrhage are common emergent on-call consultations for the interventional radiologist. Upper GI bleleding (UGIB) is a relatively frequent problem. The incidence and mortality vary among patient populations, but studies have shown an overall incidence ranging from 36-172 cases per 100,000 adults per year, with a mortality rate of 5%-14%. The incidence is significantly higher in men. Peptic ulcer disease is the predominant etiology, responsible for 28%-59% of UGIB. Other causes include varices, mucosal erosive disease, Mallory-Weiss syndrome, and malignancy. After assessment of hemodynamic status and airway stability with resuscitative efforts as needed, initial consultation with gastroenterology for endoscopic evaluation and treatment is well regarded as the initial therapeutic strategy. Angiography with embolization and interventional techniques directed at managing variceal hemorrhage have emerged as very capable second-line strategies for patients who have failed endoscopic therapy. In certain circumstances, the interventional radiologist may be called upon as the first line, notably for patients who have had recent surgical intervention or who have extraluminal hemorrhage. As the role of the interventional radiologist in the evaluation and treatment of UGIB continues to evolve, familiarity and knowledge of how to deal with these urgent and emergent clinical scenarios becomes paramount.

Atlas table: a dynamic innovative support device for the coming obesity epidemic

With obesity rates increasing rapidly, the Atlas table, a modular table overlay, was developed to address the unmet medical need of the inability of current interventional tables to support patients weighing more than 450 lbs. Current procedural tables have a posted weight limit of 500 lbs. In practice, this limit is 450 lbs due to the permanent installation of a 50 lb dye injector at the foot of the table. Instability is reported in patients in the range of 250–450 lbs, resulting in the need to modify how the table is placed over the base. Additional weight and mobility limitations exist due to the cantilever beam design of the existing table that allows movement of the C-arm fluoroscope to move around the entire table. A clinical device should bear all of the weight of an 800 lb patient, without failing during emergency chest compressions, which makes the weight capacity necessary 1200 lbs. This must be accomplished without obstructing the movement of the C-arm of the existing table or requiring a more than 2% increase in radiation. Our table overlay design features a lightweight, radiolucent tabletop and four modular height-adjusting legs that move with the existing table and do not require separate controls. The legs clamp to the radiolucent tabletop securely but not permanently so that they can be moved when needed, with buttons that swing out and cause the table to raise or lower by being trigger by contact from the existing table. The proposed design safely holds and lifts 1200 lbs.

Lost in Transition: One Radiology Resident's Transitional Year at a Hospital Lost to the Ages

Admission to a radiology residency requires a year’s clinical experience: an internship. What made mine different from most is that mine was served in a hospital that was scheduled to close at the end of that year: St Vincent’s Medical Center in the West Village of Manhattan (Fig. 1). I began my intern year as all interns do: a novice who was careful yet anxious and slightly overwhelmed. Did my medical school education prepare me well enough to handle the responsibility? Were other interns also nervous about their new roles, or were they somehow more confident? I would be remiss to suggest that any of these sentiments, felt by every intern on that sweltering summer day in July 2009, were unique for my peers and me. I began on the ventilator service, a field to which I had little exposure as a medical student because of a