Are Cuffed Peripherally Inserted Central Catheters Superior to Uncuffed Peripherally Inserted Central Catheters? A Retrospective Review in a Tertiary Pediatric Center

PurposeTo assess the use of cuffed peripherally inserted central catheters (PICCs) compared with uncuffed PICCs in children with respect to their ability to provide access until the end of therapy.Materials and MethodsA retrospective review of PICCs inserted between January 2007 and December 2008 was conducted. Data collected from electronic records included patient age, referring service, clinical diagnosis, inserting team (pediatric interventional radiologists or neonatal intensive care unit [NICU] nurse–led PICC team), insertion site, dates of insertion and removal, reasons for removal, and need for a new catheter insertion. A separate subset analysis of the NICU population was performed. Primary outcome measured was the ability of the PICCs to provide access until the end of therapy.ResultsCuffed PICCs (n = 1,201) were significantly more likely to provide access until the end of therapy than uncuffed PICCs (n = 303) (P = .0002). Catheter removal before reaching the end of therapy with requirement of placement of a new PICC occurred in 26% (n = 311) of cuffed PICCs and 38% (n = 114) of uncuffed PICCs. Uncuffed PICCs had a significantly higher incidence of infections per 1,000 catheter days (P = .023), malposition (P = .023), and thrombus formation (P = .022). In the NICU subset analysis, cuffed PICCs had a higher chance of reaching end of therapy, but this was not statistically significant.ConclusionsIn this pediatric population, cuffed PICCs were more likely to provide access until the end of therapy. Cuffed PICCs were associated with lower rates of catheter infection, malposition, and thrombosis than uncuffed PICCs.     

Peripherally Inserted Central Catheter Thrombosis—Reverse Tapered versus Nontapered Catheters: A Randomized Controlled Study

PurposeTo compare the thrombosis rate, ease of insertion, bleeding rate, and complications of a nontapered peripherally inserted central catheter (PICC) versus a reverse tapered PICC.MethodsThis was a prospective randomized, controlled trial conducted in single center. All patients 18–90 years old requiring PICC insertion were considered for the study. All patients were followed until PICC removal. Ultrasound examination of the arm was performed at PICC removal or at 28 days. There were 332 patients randomly assigned—164 to the nontapered PICC group and 168 to the reverse tapered PICC group.ResultsThe overall thrombosis rate was 71.9%. The thrombosis rate was 70.4% in the nontapered PICC group and 73.4% in the reverse tapered PICC group (P = .58). The symptomatic thrombosis rate was 4.3% in the nontapered PICC group and 3.6% in the reverse tapered PICC group (P = .75). The complete thrombosis rate was 15.6% in the nontapered PICC group compared with 20.8% in the reverse tapered PICC group (P = .44). There was a statistically significantly higher thrombosis rate in patients with cancer (71.9% vs 66.7%, P = .002).ConclusionsThis study showed a high incidence of thrombosis of peripheral veins used for PICC insertion. The implication of this thrombosis is significant in light of the morbidity and potential mortality associated with this condition. A difference in thrombosis rate between devices could not be detected in this study.     

How Long Should Peripherally Inserted Central Catheterization Be Delayed in the Context of Recently Documented Bloodstream Infection?

The risk of relapsing bacteremia was assessed retrospectively among a cohort of 348 patients who underwent peripherally inserted central catheter (PICC) insertion within 6 weeks of a documented bacteremia. The overall risk of relapsing bacteremia was low (three of 348; 0.9%) when PICC insertion was performed in the context of a recent bloodstream infection. The relapse risk was higher when PICCs were inserted within 2 days (two of 31; 6.5%) versus at least 3 days (one of 317; 0.3%) after documentation of bacteremia (P = .02).     

Evaluation of a Device Combining an Inferior Vena Cava Filter and a Central Venous Catheter for Preventing Pulmonary Embolism Among Critically Ill Trauma Patients

Purpose

To evaluate efficacy and safety of a novel device that combines an inferior vena cava (IVC) filter and central venous catheter (CVC) for prevention of pulmonary embolism (PE) in critically ill patients.

Comparison of Ultrasound-Accelerated versus Pigtail Catheter–Directed Thrombolysis for the Treatment of Acute Massive and Submassive Pulmonary Embolism

Purpose

To compare the technical and clinical effectiveness of ultrasound-accelerated endovascular thrombolysis (USAT) versus pigtail catheter–directed thrombolysis (PCDT) for the treatment of acute pulmonary embolism (PE).

Infrared pupillography in routine police traffic checks

Background

In order to evaluate the ability of traffic participants to drive, standardized and objective measurement methods are needed. In recent analyses it was shown that pupil function is a significant indicator of being under the influence of substances acting on the central nervous system.

Objective

The aim of this study was to answer the question whether it is possible to detect if a person is under the influence of drugs or medication based on pupil function.

Material and methods

In total 121 subjects were exposed to different light stimuli and an infrared pupillographic investigation of the eyes was carried out. The study cohort consisted of 41 healthy test subjects and 80 subjects under the influence of drugs or medication. Several neural network models with different network architectures were trained in a learning group, further analyzed in a verification sample and most importantly tested in an independent test sample. Specificity, sensitivity, negative and positive predictive values as well as the percentage of correctly predicted subjects were analyzed. A 95?% confidence interval (CI) was included for all performance measurements.

Results

A neural network model was found which performed with a specificity of 91?% (95% CI, 78–98?%), sensitivity 90?% (95% CI, 81–96?%), negative predictive value 85?% (95% CI, 72–94?%), positive predictive value 94?% (95% CI, 86–98?%) and a correct prediction was made for 90?% (95% CI, 83–95?%) of the subjects.

Conclusion

The results of this study clearly show that infrared pupillography provides excellent discrimination between healthy subjects and persons under the influence of drugs or medication in this specific setting.

     

Potential Mechanisms of Vascular Thrombosis after Microwave Ablation in an in Vivo Liver

Purpose

To evaluate potential biologic and thermal mechanisms of the observed differences in thrombosis rates between hepatic vessels during microwave (MW) ablation procedures.

Bacteriophage K Antimicrobial-Lock Technique for Treatment of Staphylococcus aureus Central Venous Catheter–Related Infection: A Leporine Model Efficacy Analysis

PurposeTo determine whether a bacteriophage antimicrobial-lock technique can reduce bacterial colonization and biofilm formation on indwelling central venous catheters in a rabbit model.Materials and MethodsCuffed central venous catheters were inserted into the jugular vein of female New Zealand White rabbits under image guidance. Catheters were inoculated for 24 hours with broth culture of methicillin-sensitive Staphylococcus aureus. The inoculum was aspirated, and rabbits were randomly assigned to two equal groups for 24 hours: (i) untreated controls (heparinized saline lock), (ii) bacteriophage antimicrobial-lock (staphylococcal bacteriophage K, propagated titer > 10⁸/mL). Blood cultures were obtained via peripheral veins, and the catheters were removed for quantitative culture and scanning electron microscopy.ResultsMean colony-forming units (CFU) per cm² of the distal catheter segment, as a measure of biofilm, were significantly decreased in experimental animals compared with controls (control, 1.2 × 10⁵ CFU/cm²; experimental, 7.6 × 10³; P = .016). Scanning electron microscopy demonstrated that biofilms were present on the surface of five of five control catheters but only one of five treated catheters (P = .048). Blood culture results were not significantly different between the groups.ConclusionsIn a rabbit model, treatment of infected central venous catheters with a bacteriophage antimicrobial-lock technique significantly reduced bacterial colonization and biofilm presence. Our data represent a preliminary step toward use of bacteriophage therapy for prevention and treatment of central venous catheter–associated infection.     

Twins in spirit part II: DOTATATE and high-affinity DOTATATE—the clinical experience

Purpose

Over recent decades interest in diagnosis and treatment of neuroendocrine tumours (NET) has steadily grown. The basis for diagnosis and therapy of NET with radiolabelled somatostatin (hsst) analogues is the variable overexpression of hsst receptors (hsst1–5 receptors). We hypothesized that radiometal derivatives of DOTA-iodo-Tyr³-octreotide analogues might be excellent candidates for somatostatin receptor imaging. We therefore explored the diagnostic potential of ⁶⁸Ga-DOTA-iodo-Tyr³-octreotate [⁶⁸Ga-DOTA,3-iodo-Tyr³,Thr⁸]octreotide (⁶⁸Ga-HA-DOTATATE; HA, high-affinity) compared to the established ⁶⁸Ga-DOTA-Tyr³-octreotate (⁶⁸Ga-DOTATATE) in vivo.

Methods

The study included 23 patients with known somatostatin receptor-positive metastases from NETs, thyroid cancer or glomus tumours who were investigated with both ⁶⁸Ga-HA-DOTATATE and ⁶⁸Ga-DOTATATE. A patient-based and a lesion-based comparative analysis was carried out of normal tissue distribution and lesion detectability in a qualitative and a semiquantitative manner.

Results

⁶⁸Ga-HA-DOTATATE and ⁶⁸Ga-DOTATATE showed comparable uptake in the liver (SUV_mean 8.9?±?2.2 vs. 9.3?±?2.5, n.s.), renal cortex (SUV_mean 13.3?±?3.9 vs. 14.5?±?3.7, n.s.) and spleen (SUV_mean 24.0?±?6.7 vs. 22.9?±?7.3, n.s.). A somewhat higher pituitary uptake was found with ⁶⁸Ga-HA-DOTATATE (SUV_mean 6.3?±?1.8 vs. 5.4?±?2.1, p?<?0.05). On a lesion-by-lesion basis a total of 344 lesions were detected. ⁶⁸Ga-HA-DOTATATE demonstrated 328 lesions (95.3 % of total lesions seen), and ⁶⁸Ga-DOTATATE demonstrated 332 lesions (96.4 %). The mean SUV_max of all lesions was not significantly different between ⁶⁸Ga-HA-DOTATATE and ⁶⁸Ga-DOTATATE (17.8?±?11.4 vs. 16.7?±?10.7, n.s.).

Conclusion

Our analysis demonstrated very good concordance between ⁶⁸Ga-HA-DOTATATE and ⁶⁸Ga-DOTATATE PET data. As the availability and use of ⁶⁸Ga-HA-DOTATATE is not governed by patent restrictions it may be an attractive alternative to other ⁶⁸Ga-labelled hsst analogues.     

Have CT and MR Angiography Replaced Catheter Angiography in Diagnosing Peripheral Arterial Disease?

PurposeTo determine whether MR angiography (MRA) and CT angiography (CTA) have replaced diagnostic catheter angiography (DCA) in diagnosing peripheral arterial disease.MethodsMedicare Part B databases for 2002–2013 were reviewed. Current Procedural Terminology codes for extremity MRA, CTA, and DCA were selected. Physician specialty codes were used to classify providers as radiologists, cardiologists, or surgeons. Utilization rates per 100,000 Medicare beneficiaries were calculated.ResultsAmong all specialties, the combined utilization rate of all 3 types of angiography increased from 917 per 100,000 in 2002 to 1,261 in 2006 (+38%), after which it remained stable until 2010, and then declined to 1,010 in 2013. The overall rate of MRA and CTA together increased from 89 in 2002 to 440 in 2006 (+394%), after which it leveled off, and then gradually decreased to 331 in 2013. In 2013, 33% of the total procedures were MRA or CTA, up from 10% in 2002. Radiologists performed >85% of MRA and CTA examinations. Among radiologists, the DCA utilization rate decreased by 75% from 2002 to 2013, whereas among cardiologists and surgeons together, the overall DCA utilization rate increased by 64% from 2002 to 2010 before dropping somewhat in 2011.ConclusionsAmong radiologists, MRA and CTA have replaced DCA in diagnosing peripheral arterial disease. Although overall utilization of DCA has remained steady, it has risen sharply among cardiologists and surgeons, while dropping sharply among radiologists. Given the increased utilization of DCA among cardiologists and surgeons despite noninvasive alternatives, self-referral continues to be of concern in the setting of increasing health care costs.     

How to improve femoral component rotational alignment in computer-assisted TKA

Purpose

Although several anatomical landmarks have been proposed to obtain adequate femoral component alignment in total knee arthroplasty (TKA), there is still no consensus regarding the best way to correctly position the prosthetic component on the horizontal plane. A previous computed tomography (CT)-based study has demonstrated anatomical transepicondylar axis (aTEA) to be externally rotated relative to surgical transepicondylar axis (sTEA) of approximately 4.5°. In this study, it is described a new methodological approach to femoral component rotational positioning through the use of previously reported CT scan information and navigation.

Methods

Eight consecutive patients scheduled for navigated TKA were selected. Rotational placement of the femoral component was performed using navigation system. The femoral component was implanted setting 4.5° of internal rotation relative to the aTEA. Within 1 week from surgery, all patients underwent a CT scan, and the posterior condylar angle (PCA) was measured. A PCA of 0.0°, meaning component placement parallel to sTEA, was set as femoral rotational alignment target. Clinical evaluation was performed at a mean 14.3 months of follow-up with KOOS questionnaire.

Results

The mean PCA measured on post-operative CT images was 0.4° (SD 1.3°), meaning that the femoral component was averagely implanted with 0.4° of internal rotation relative to the sTEA. Seven out of eight cases (87.5 %) resulted to have within 1° deviation from the rotational alignment target. All patients but one reported good clinical results.

Conclusions

Relevant finding of the present study was that the use of navigation and aTEA as a reference demonstrated to be accurate to set up femoral component rotational positioning on the horizontal plane in TKA. Further study should be performed to confirm this conclusion.

Level of evidence

III.     

Quality control of involved field radiotherapy in the HD 13 and HD 14 trials

Introduction

As part of the foundation of the German Hodgkin Study Group (GHSG) in 1978, a central radiotherapy (RT) reference centre was established to evaluate and to improve the quality of treatment. During the study generations, the quality assurance programs (QAP) were continued and adapted to the demands of each study. The purpose of this article is to demonstrate the results of the fifth study generation and to compare them to the previous findings.

Methods

With the start of the fourth GHSG study generation (HD10–12), a central prospective review of all diagnostic images was established to create an individual treatment plan for each early stage study patient. The quality of involved field RT was retrospectively evaluated by an expert panel of radiation oncologists. In the fifth study generation (HD13–15), the retrospective review of radiotherapy performed was refined and the results were compared with the findings of the fourth generation.

Results

The expert panel analyzed the RT planning and application of 1037 (28?%) patients (HD13 n = 465, HD14 n = 572). Simulation films were available in 85?% of cases and verification films in 87?%. RT was assessed as major violation in 46?% (HD13 = 38?%, HD14 = 52?%), minor violation in 9?% (HD13 = 9?%, HD14 = 9?%) and according to the protocol in 45?% (HD13 = 52?%, HD14 = 38?%).

Conclusion

The value for QAP of RT within the GHSG trials is well known. Still there were several protocol violations. In the future, the QAP program has to be adapted to the requirements of “modern RT” in malignant lymphoma.

     

Environmental Factors Predictive of No-Show Visits in Radiology: Observations of Three Million Outpatient Imaging Visits Over 16 Years

PurposeTo evaluate the impact of environmental and socioeconomic factors on outpatient cancellations and “no-show visits” (NSVs) in radiology.Materials and MethodsWe conducted a retrospective analysis by collecting environmental factor data related to outpatient radiology visits occurring between 2000 and 2015 at our multihospital academic institution. Appointment attendance records were joined with daily weather observations from the National Oceanic and Atmospheric Administration and estimated median income from the US Census American Community Survey. A multivariate logistic regression model was built to examine relationships between NSV rate and median income, commute distance, maximum daily temperature, and daily snowfall.ResultsThere were 270,574 (8.0%) cancellations and 87,407 (2.6%) NSVs among 3,379,947 scheduled outpatient radiology appointments and 575,206 unique patients from 2000 to 2015. Overall cancellation rates decreased from 14% to 8%, and NSV rates decreased from 6% to 1% as median income increased from $20,000 to $120,000 per year. In a multivariate model, the odds of NSV decreased 10.7% per $10,000 increase in median income (95% confidence interval [CI]: 10.3%-11.1%) and 2.0% per 10°F increase in maximum daily temperature (95% CI: 1.3%-1.6%). The odds of NSV increased 1.4% per 10-mile increase in commute distance (95% CI: 1.3%-1.6%) and 4.5% per 1-inch increase in daily snowfall (95% CI: 3.6%-5.3%). Commute distance was more strongly associated with NSV for those in the two lower tertiles of income than the highest tertile (P < .001).ConclusionEnvironmental factors are strongly associated with patients’ attendance at scheduled outpatient radiology examinations. Modeling of appointment failure risk based on environmental features can help increase the attendance of outpatient radiology appointments.     

First-Pass Contrast-Enhanced MR Angiography in Evaluation of Treated Spinal Arteriovenous Fistulas: Is Catheter Angiography Necessary?

BACKGROUND AND PURPOSE:Catheter angiography is typically used for follow-up of treated spinal AVFs. The purpose of this study was to determine the diagnostic performance and utility of first-pass contrast-enhanced MRA in the posttreatment evaluation of spinal AVFs compared with DSA.MATERIALS AND METHODS:A retrospective review was performed of all patients at our tertiary referral hospital (from January 2000 to April 2015) who underwent spine MR imaging, first-pass contrast-enhanced MRA, and DSA after surgical and/or endovascular treatment of a spinal AVF. Presence of recurrent or residual fistula on MRA, including vertebral level of the recurrent/residual fistula, was evaluated by 2 experienced neuroradiologists blinded to DSA findings. Posttreatment conventional MR imaging findings were also evaluated, including presence of intramedullary T2 hyperintensity, perimedullary serpentine flow voids, and cord enhancement. The performance of MRA and MR imaging findings for diagnosis of recurrent/residual fistula was determined by using DSA as the criterion standard.RESULTS:In total, 28 posttreatment paired MR imaging/MRA and DSA studies were evaluated in 22 patients with prior spinal AVF and 1 patient with intracranial AVF with prior cervical perimedullary venous drainage. Six image sets of 5 patients demonstrated recurrent/residual disease at DSA. MRA correctly identified all cases with recurrent/residual disease with 1 false-positive (sensitivity, 100%; specificity 95%; P < .001), with correct localization in all cases without interobserver disagreement. Conventional MR imaging parameters were not significantly associated with recurrent/residual spinal AVF.CONCLUSIONS:First-pass MRA demonstrates high sensitivity and specificity for identifying recurrent/residual spinal AVFs and may potentially substitute for DSA in the posttreatment follow-up of patients with spinal AVFs.

Spinal AVFs (SAVFs) can cause radicular/perimedullary venous reflux and present with progressive myelopathy due to cord congestion. The goal of treatment is to disconnect the refluxing vein to protect the cord from further damage. The most common vascular lesion to present in this fashion is the spinal dural AVF. However, similar clinical and radiologic appearances can occur with intracranial dural fistulas draining into the spinal venous system, epidural fistulas with intrathecal venous reflux as well as perimedullary and filum terminale fistulas. Prevalence of recurrent or residual fistulas after treatment of SAVFs ranges from 3.4% to 27.8% and is associated with progressive myelopathy and morbidity.¹ Fistula recurrence may occur early within 1 month after treatment or present in delayed fashion years after successful treatment.¹ Conventional spine MR imaging findings of SAVF, including perimedullary flow voids, intramedullary T2 hyperintensity, and cord enhancement, are not reliable markers of residual/recurrent fistula.^2,3 Using clinical symptoms alone to assess for residual or recurrent disease may result in delayed diagnosis and irreversible progression of symptoms.⁴ Therefore, posttherapy evaluation of patients with previously treated SAVF is commonly performed to ensure complete fistula occlusion. DSA remains the criterion standard test; however, it is an invasive test associated with some procedural risks.⁵ Spine MRA may be a useful noninvasive tool for initial posttreatment evaluation of SAVFs and may have the potential to be a substitute for DSA for this indication.^3,4,6 In this study, we evaluated the performance of MRA for identifying recurrent/residual SAVF posttreatment, compared with DSA and conventional MR imaging findings.     

The role of pharmacological stress testing in women

Pharmacological stress is an alternative method to dynamic exercise that combined with noninvasive imaging allows the detection of flow-limiting coronary artery disease (CAD). It represents the stress procedure of choice in patients who cannot exercise appropriately. In women, pharmacological stress combined with myocardial perfusion scintigraphy (MPS) has demonstrated to be highly accurate for the detection of obstructive CAD and a valuable tool that helps separate patients at low cardiac risk from those with an adverse prognosis. Pharmacological stress with positron emission tomographic (PET) imaging is increasingly used in the investigation of suspected obstructive CAD; available evidence shows that the diagnostic profile and prognostic value of stress PET imaging is similar to that of stress MPS in women.