Primary postpartum hemorrhage: outcome of pelvic arterial embolization in 251 patients at a single institution

Purpose: To evaluate the safety and efficacy of pelvic arterial embolization (PAE) for the treatment of primary postpartum hemorrhage (PPH) and to determine the factors associated with clinical outcomes. Materials and Methods: This retrospective single-center study was institutional review board approved, and informed consent was waived. Outcomes were analyzed in 251 patients who underwent PAE for primary PPH between January 2000 and February 2011. Mode of delivery, causes of bleeding, detailed laboratory and treatment records, and clinical outcomes were recorded. Clinical success was defined as cessation of bleeding after initial session of PAE without the need for additional PAE or surgery. Univariate and multivariate analyses were performed to determine the factors related to clinical outcomes. Results: The clinical success rate was 86.5% (217 of 251). Among the 34 failed cases, 12 underwent repeat PAE, 16 underwent additional surgery, and three recovered with conservative management. Overall bleeding control was achieved in 98.0% (246 of 251) of the patients. Overall mortality was 2% (five of 251) after the first (n = 3) or second (n = 1) session of PAE or additional surgery (n = 1). Among the 113 patients with long-term follow-up, 110 (97.3%) maintained a regular menstrual cycle and 11 had successful pregnancies. Univariate analysis showed that cesarean section delivery, disseminated intravascular coagulation (DIC), and massive transfusion of more than 10 red blood cell units were related to failed PAE. Multivariate analysis showed that DIC (odds ratio, 0.36; P = .04) and massive transfusion (odds ratio, 0.10; P < .001) were significantly related to clinical failure. Conclusion: PAE is safe and effective for managing primary PPH. Patients with DIC and massive transfusion were likely to have poor results after PAE. ? RSNA, 2012.     

原发性产后大出血:251例病人盆腔动脉栓塞术的疗效观察

摘要目的评价盆腔动脉栓塞术(PAE)用于治疗原发性产后大出血(PPH)的安全性及有效性,并确定其与临床疗效相关的因素。材料与方法伦理委员会批准了该项回顾性单中心研究并确定无需进行知情同意的确认。     

Mushroom-cage gastrostomy tube placement in patients with amyotrophic lateral sclerosis: a 5-year experience in 104 patients in a single institution

To review our experience of placement of a mushroom-cage gastrostomy tube (Entristar®, Tyco Healthcare, Mansfield, MA), using radiological guidance, in patients with amyotrophic lateral sclerosis (ALS). All procedures were performed under local anaesthesia without sedation. Complications were recorded as peri-procedural, early (<24 h), late (>24 h), major or minor. Deaths were recorded as related to the underlying ALS or secondary to radiological-inserted gastrostomy (RIG) placement. Replacement RIG tube rate was recorded. Over a 5-year period RIG tubes were placed in 104 patients with ALS (male n?=?52, female n?=?52), with a median age of 62 years (range 34-86 years). All procedures were technically successful. Of the RIG procedures, 21/104 (20.2%) were performed with respiratory support. The 30-day mortality rate was 7/104 (6.7%); no patient died as a result of the procedure. There were 23/104 (22.1%) complications overall; 20/104 (19.2%) were minor and 3/104 (2.9%) major, requiring surgery (n?=?2) and radiological-guided abscess drainage (n?=?1). A median interval between replacement RIG procedures in 20/104 (19.2%) patients was 141.5 days (range 43-537 days). A mushroom-cage RIG tube may be safely and effectively inserted in a ‘one-step’ radiological procedure and may replace endoscopic-inserted gastrostomy tubes in the nutritional management of ALS.     

CrossFit and rhabdomyolysis: A case series of 11 patients presenting at a single academic institution

ObjectivesCrossFit is an increasingly popular high intensity work out program geared towards high repetition and intensity done in short intervals. Recently, documented cases of rhabdomyolysis (muscle necrosis and extreme muscle breakdown) after CrossFit participation have become increasingly concerning to physicians and participants alike.DesignRetrospective cohort study.MethodsAll patients who presented to the main hospital at a major academic center complaining of an injury sustained performing CrossFit between June 2010 and June 2016 were identified by the key phrases ‘CrossFit’, ‘crossfit’, ‘Crossfit’ or ‘cross fit’.Results523 patients incurred injuries associated with CrossFit activities. 11 patients presented to our institution ultimately received a diagnosis of rhabdomyolysis (2.1%). The average age of Rhabdomyolysis patient was 34.9 years, with 81.9% of patients being male. The average BMI was 24.2, and the average experience level was beginner (54.5%). The most common presenting symptom was dark urine (90.9%), followed by upper extremity pain (54.5%). Average symptom duration was 2.9 days with 81.8% of patients presenting initially to the ED. The average hospital stay was roughly 2.9 days, and patients had an average of 1.44 clinical follow up visits.ConclusionCrossFit participation poses significant risks to participants including exercise induced rhabdomyolysis. Further study is needed in order to raise awareness of this issue and further quantify risk factors that may promote injury during participation.     

Endovascular intervention for management of pancreatitis-related bleeding: a retrospective analysis of thirty-seven patients at a single institution

PURPOSE

The aim of this study was to assess the outcome of endovascular intervention for pancreatitis-related hemorrhage at a single institution.

METHODS

From January 2000 to October 2012, thirty-seven patients underwent endovascular intervention for the management of pancreatitis-related hemorrhage. The underlying etiology of the disease, clinical symptoms and laboratory findings, abnormalities seen on computed tomography, and details regarding the endovascular procedures were assessed, as were the outcome of each procedure and procedure-related complications.

RESULTS

A total of 41 endovascular procedures were performed in 37 patients. The splenic artery (34.8%) was the most commonly treated artery, and pseudoaneurysm was the most commonly detected abnormality on digital subtraction angiography (78.3%). Transcatheter embolization was performed in the majority of patients (95.1%), while two patients were treated with stent-grafts. Successful hemostasis without rebleeding was achieved in 34 patients (91.9%). Two cases of rebleeding were successfully treated by reintervention. Focal splenic infarction, which developed in eight patients, was either asymptomatic or accompanied by mild, transient fever. Splenic abscess was the only major complication occurring in three patients. Two of these patients died from resulting sepsis, while the third recovered after antibiotic treatment.

CONCLUSION

Endovascular management is effective for achieving hemostasis in patients with pancreatitis-related bleeding and demonstrates low recurrence and mortality rates.Serious bleeding complications have been reported to occur in up to 14.5% of patients with acute and exacerbated chronic pancreatitis and are potentially fatal when left untreated (1). Computed tomography (CT) serves an important role in the diagnosis of pancreatitis-related hemorrhage, demonstrating radiologic features such as the presence of hematomas, hemorrhagic pseudocysts, extravasation of contrast media or the formation of arterial pseudoaneurysms. Timely intervention, either surgical or endovascular, is essential in this clinical setting, especially for active bleeding or pseudoaneurysm formation. Even though the latter may sometimes be clinically silent, arterial pseudoaneurysms are widely considered to be life-threatening “time-bombs” due to their risk of rupture (2–4). The mortality rate of bleeding pseudoaneurysms has been reported to reach as high as 40% when managed conservatively (5).Endovascular treatment has advantages over surgery for managing complications related to pancreatitis. It is less invasive and can be performed in patients with comorbidities who are contraindicated for surgery. Even for those without surgical contraindications, surgery is often difficult owing to severe inflammatory change around the pancreas. Traditionally, the mainstay of endovascular treatment has been transcatheter embolization. More recently, stent-graft placement for exclusion of arterial rupture and pseudoaneurysms has gained popularity. Current literature suggests that such endovascular techniques are effective in achieving hemostasis in patients, and the outcomes are comparable or superior to those of surgery (2, 6, 7). However, despite the widespread popularity of endovascular treatment, the literature is mostly limited to case reports and small case series. We have performed a web-based search of the literature and have found a surprisingly limited number of publications comprising more than a handful of patients in a single study. By performing this retrospective, single-center study, we aim to provide firmer evidence in support of endovascular intervention as the first-line treatment for the management of pancreatitis-related hemorrhage.     

Chronic interstitial pneumonia in young patients undergoing lung transplantation or autopsy: clinico-radiologic-pathologic observations from a single institution

Purpose

To retrospectively evaluate high-resolution computed tomography (HRCT) findings and clinical diagnoses of chronic interstitial pneumonia (IP) with a poor prognosis in young patients (≤50 years).

Materials and methods

HRCT images of 8 men and 7 women (mean age 34.8 years) obtained before lung transplantation or autopsy were reviewed. After reviewing whole lung specimens and pathologic diagnoses, all patients were clinically diagnosed according to the 2010 idiopathic pulmonary fibrosis/usual interstitial pneumonia (IPF/UIP) consensus statement.

Results

HRCT images revealed intralobular reticular opacity, air cysts, ground glass opacity, traction bronchiectasis, and interlobular septal thickening. Intralobular reticular opacity was the most extensive finding. Abnormal findings existed predominantly in both the peripheral and lower lung zones in only 1 patient. Classifications of HRCT patterns were “UIP” (n = 2), “inconsistent with UIP” (n = 11), and “indeterminate UIP” (n = 2). Multidisciplinary diagnoses were “IPF/UIP” (n = 1), “possible IPF/UIP” (n = 1), “IP with connective tissue disease” (n = 7), “fibrotic nonspecific IP” (n = 1), and “unclassified IP” (n = 5).

Conclusion

The most extensive HRCT finding was intralobular reticular opacity. Most HRCT images differed from typical IPF/UIP, and IPF/UIP was uncommon in young patients with chronic IP with a poor prognosis.

     

Transcatheter arterial chemoembolization in unresectable cholangiocarcinoma: initial experience in a single institution

PURPOSE: Unresectable cholangiocarcinoma carries a dismal prognosis, with median survival times ranging from 6 to 12 months from the time of diagnosis. Palliative therapies have been disappointing and have not been shown to significantly prolong survival. Conversely, transcatheter arterial chemoembolization (TACE) has been effective in prolonging the lives of patients with hepatocellular carcinoma but has not been used against cholangiocarcinoma. Therefore, the purpose of the present study was to assess the safety and efficacy (ie, survival) of TACE in patients with unresectable intrahepatic cholangiocarcinoma. MATERIALS AND METHODS: Seventeen patients with unresectable cholangiocarcinoma were treated with one or more cycles of TACE between 1995 and 2004 at our institution. Follow-up imaging was performed on all patients 4-6 weeks after each TACE procedure to determine tumor response and need for further treatment. Survival was calculated with use of the Kaplan-Meier survival curve. RESULTS: The median survival for 17 patients treated with TACE was 23 months. Two patients with previously unresectable disease underwent successful resection after TACE. The procedure was well tolerated by 82% of the patients, who experienced no side effects or mild side effects that quickly resolved with conservative therapy alone. Two patients had minor complications (12%), which were managed successfully, and one had a major complication that resulted in a fatal outcome. This patient had a rapidly declining course from the time of diagnosis and died shortly after TACE. CONCLUSIONS: The results suggest that TACE was effective at prolonging survival of patients with unresectable cholangiocarcinoma. Therefore, for these patients, TACE may be an appropriate palliative therapy.     

Towards quality assurance of the sentinel node procedure in malignant melanoma patients: a single institution evaluation and a european survey

The status of the regional lymph node (LN) is a critical component in staging patients with malignant melanoma. Biopsy of the first tumour-draining LN (sentinel node, SN) may replace routine elective LN dissection. However, until now, the applied methods have differed widely. Therefore, the aim of this study was to formulate recommendations for the pre-operative identification and intra-operative retrieval of the SN. We present the results of an independent survey of the clinical practice of the SN procedure via a postal questionnaire among 136 nuclear physicians in different institutes throughout 16 European countries. Moreover, the results of the SN procedure in our institution in an open prospective intervention trial in 80 patients with malignant melanoma without palpable LNs are also presented. In our protocol, on average, 6 h prior to surgery, 80 MBq technetium-99m nanocolloid was injected intracutaneously around the circumference of the diagnostic excision scar of the primary melanoma. No additional blue dye procedure was used to judge the accuracy of the radioguided SN procedure on its own. For successful identification of the radiolabelled SN, dynamic and static images were performed and the skin projection of the detected SN was marked with a cobalt-57 source. For intra-operative mapping a hand-held gamma probe was used. Forty of the 83 respondents of the European-wide questionnaire (48%) performed the SN procedure. Although many different regimens are used, the following recommendations could be deduced for the SN procedure in patients with malignant melanoma and non-palpable LNs: (1) local, intradermal injection of 40 MBq ^99mTc-nanocolloid around the diagnostic excision scar of the primary melanoma; (2) two-phase LS: dynamic imaging (20 frames of 60 s, 128×128 matrix, LEAP collimator) followed by static images 1–2 h later (180 s per record); (3) intra-operative retrieval of the SN with a gamma probe; (4) histopathological examination of the SN on serial sections. In our trial, surgical retrieval of the SN was successful in 95% of the cases. Dynamic lymphoscintigraphy (LS) contributed to the SN procedure by showing anatomically unpredictable lymph flow to extra-regional SNs (10% of the patients in this study) and multiple SNs. Of the 77 retrieved SNs, 13 contained metastatic disease (17%). Consequently, these patients underwent a formal LN dissection of the affected basin. In conclusion, the SN concept is a rational approach to select patients who could, theoretically, benefit from early LN dissection of the affected basin. Standardisation of the SN procedure will improve the results of this approach, and could be useful for quality control and for making comparisons with other countries in coming years. Received 28 October 1998     

TIPS for treatment of variceal hemorrhage: clinical outcomes in 128 patients at a single institution over a 12-year period

PurposeTo assess clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) treatment of variceal hemorrhage.Materials and MethodsA total of 128 patients (82 men and 46 women; mean age, 52 y) with liver cirrhosis and refractory variceal hemorrhage underwent TIPS creation from 1998 to 2010. Mean Child-Pugh and Model for End-stage Liver Disease (MELD) scores were 9 and 18, respectively. From 1998 to 2004, 12-mm Wallstents (n = 58) were used, whereas from 2004 to 2010, 10-mm VIATORR covered stent-grafts (n = 70) were used. Technical success, hemodynamic success, complications, shunt dysfunction, recurrent bleeding, and overall survival were assessed.ResultsTechnical and hemodynamic success rates were 100% and 94%, respectively. Mean portosystemic gradient reduction was 13 mm Hg. Complications at 30 days included encephalopathy (14%), renal failure (5.5%), infection (1.6%), and liver failure (0.8%). Shunt patency rates were 93%, 82%, and 60% at 30 days, 1 year, and 2 years, respectively. Dysfunction, or loss of TIPS primary patency, occurred more with Wallstent versus VIATORR TIPSs (29% vs 11%; P = .009). Recurrent bleeding incidences were 9%, 22%, and 29% at 30 days, 1 year, and 2 years, respectively, and were similar between Wallstent and VIATORR TIPSs (19% vs 19%; P = .924). Variceal embolization significantly reduced recurrent bleeding rates (5% vs 25%; P = .013). Overall survival rates were 80%, 69%, and 65% at 30 days, 1 year, and 2 years, respectively, and were similar between Wallstent and VIATORR TIPSs (35% vs 26% mortality rate; P = .312). Advanced MELD score was associated with increased mortality on multivariate analysis.ConclusionsWallstent and VIATORR TIPSs effectively treat variceal hemorrhage, particularly when accompanied by variceal embolization. Although TIPS with a VIATORR device showed improved shunt patency, patient survival is similar to that with Wallstent TIPS. These results further validate TIPS creation for refractory variceal bleeding.     

Pulsed-dose-rate brachytherapy for uterine cervix carcinoma: 10 years of experience with 226 patients at a single institution

PurposeTo analyze the long-term results of pulsed-dose-rate (PDR) brachytherapy (BT) in cervical carcinoma patients treated at a single institution.Methods and MaterialsAll patients with histopathologically proven Stages IB–IVA cervical carcinoma, treated at our institution with PDR intracavitary BT between April 1996 and November 2007, were included in this retrospective analysis. All patients underwent primary pelvic radiotherapy (45 Gy) with concomitant chemotherapy from 1999 and PDR intracavitary BT (16 Gy to the clinical target volume), followed by hysterectomy in 124 patients.ResultsTwo hundred twenty-six patients received radiochemotherapy and BT. With a median followup of 81.7 months, the 5-year overall survival, disease-free survival, and local control (LC) were 67%, 65%, and 80%, respectively; seventy-seven relapses were observed including 38 local recurrences. Multivariate analysis showed earlier FIGO (International Federation of Gynecology and Obstetrics) stage and absence of nodal involvement to be associated with better overall and disease-free survivals. Use of three-dimensional image-guided BT planning and absence of nodal involvement were associated with better LC in the multivariate analysis. Late Grade ≥3 toxicity was experienced by 22 patients (9.7%), consisting of gastrointestinal toxicity for 6 patients, urinary tract for 10 patients, lymphatics for 3 patients, and vaginal toxicity for 3 patients.ConclusionsThis study demonstrates excellent LC rates with few late side effects with PDR BT for cervix carcinoma, similar to those reported in the literature with historical standard low-dose-rate BT.     

Effectiveness and safety of computed tomography-guided radiofrequency ablation of renal cancer: a 14-year single institution experience in 203 patients

Objectives

To define effectiveness and safety of CT-guided radiofrequency ablation (RFA) of renal tumours and prognostic indicators for treatment success.

Methods

Patients with a single treatment of a solitary, biopsy-proven renal tumour with intent to cure over a 14-year period were included (n?=?203). Probability of residual disease over time, complication rates and all-cause mortality were assessed in relation to multiple variables.

Results

Mean tumour size was 2.5 cm (range 1.0–6.0). Mean follow-up was 34.1 months (range 1–131). There was an increase in likelihood of residual disease for tumours ≥3.5 cm (P?<?0.05), clear cell subtype of renal cell carcinoma (P?≤?0.005) and maximum treatment temperature ≤70 °C (P?<?0.05). There was a decrease in likelihood of residual disease for exophytic tumours (P?=?0.01) and no difference based on age, gender, tumour location or type of radio freqency (RF) electrode used. Major complications occurred in 3.9 %. Median post-treatment survival was 7 years for patients with tumours <4 cm, and 5-year overall survival was 80 %. Probability of minor complication increased with tumour size (P?=?0.03), as did all-cause mortality (P?=?0.005).

Conclusions

CT-guided RFA is safe and effective for early-stage renal cancer, particularly for exophytic tumours measuring <3.5 cm. Overall 5-year survival with tumours <4 cm is comparable to partial nephrectomy.

Key points

? Prognostic indicators for success of CT-guided RFA of renal tumours are reported. ? Tumour size ≥3.5 cm confers an increased risk for residual tumour. ? Clear cell renal cell carcinoma subtype confers increased risk for residual tumour. ? Tmax <70 °C within the ablation zone confers increased risk for residual tumour. ? Exophytic tumours have a lower probability of residual disease.

     

Sonographically guided compression repair of pseudoaneurysms: further experience from a single institution

OBJECTIVE: Our purpose was to perform a comprehensive review of our experience with compression of postcatheterization groin pseudoaneurysms. MATERIALS AND METHODS: Two hundred eighty-one patients underwent 306 sonographically guided compression procedures on 297 groin pseudoaneurysms after femoral artery catheterization. The medical records, cardiac catheterization reports, and sonographic images were reviewed to determine patient demographics, type of catheterization procedure performed, sheath size, access site, interval from sheath removal to compression, anticoagulation status, pseudoaneurysm dimensions, complications, and follow-up information. Statistical analysis was performed using Pearson's chi-square and Kendall tau tests. RESULTS: The success rate for the initial compression attempt was 72.1%. Of the 83 failed compression attempts, 12 patients underwent a second attempt, of which seven attempts were successful. Therefore, counting both first and second attempts, the success rate was 74.4%. A strong negative correlation existed between anticoagulation status and success, with a 70% failure rate in patients with anticoagulated blood. Smaller pseudoaneurysm size was strongly correlated with success. Of the 83 failed cases, 49 ultimately underwent surgical repair. Eleven complications (3.6%) occurred, including three patients with rupture during compression. No deaths occurred as a result of compression repair. CONCLUSION: We conclude that sonographically guided pseudoaneurysm compression repair is an effective alternative to surgical repair, though nearly one third of compression attempts will fail and most of those patients will ultimately require surgery. The procedure is less effective when the patient's blood is anticoagulated and when the pseudoaneurysm is large. The procedure carries an overall complication rate of 3.6% and a risk for rupture of 1%.     

Initial diagnosis of HIV/AIDS in patients presenting to the emergency department: Imaging and clinical findings at a single institution

PurposeTo evaluate the clinical, laboratory, and imaging findings along with treatment and outcomes associated with patients presenting to the emergency department (ED) who were subsequently diagnosed with HIV/AIDS.Methods591 patients with HIV and available imaging studies presenting to our hospital's ED between 2004 and 2019 were identified in the medical record. Following initial review, we identified 19 patients who were diagnosed with HIV within one week after an initial ED visit and also had received CT imaging during the ED visit. Demographic, clinical, treatment, imaging, and outcome data were reviewed and recorded for each patient.ResultsAmong this 19-patient cohort, the most common indication for HIV testing was oral/esophageal candidiasis (n = 8, 42%). 12 patients presented with an AIDS-defining illness upon initial diagnosis; the most common were esophageal candidiasis (4) and Pneumocystis jiroveci pneumonia (PJP) (3). 10 patients (59%) presented with CD4+ counts <200 cells/L. The most common imaging findings were liver abnormalities (n = 9, 47%). Five of the 19 patients were confirmed deceased at the time of this study, with the median time from diagnosis to death of 5.6 months (range 8 days-14 months).ConclusionOur series demonstrates the breadth of potential imaging findings and clinical presentations of late-stage HIV in the emergency setting, including common AIDS-defining illnesses such as PJP and PML. Although the incidence of these conditions is decreasing, maintaining awareness of their clinical and imaging findings, as well as the potential for multi-organ involvement, is essential due to the possibility of rapid decline in these patients.     

Stress injuries to bone in college athletes: a retrospective review of experience at a single institution

BACKGROUND: No comprehensive studies have been published on stress injuries to bone in college athletes. PURPOSE: To review, in a college athlete population, the epidemiologic aspects of stress injuries to bone, and to examine a subset of patients who were treated with a uniform protocol for return to activities, with magnetic resonance imaging as the primary tool for diagnosis. STUDY TYPE: Retrospective review. METHODS: Ten years of medical records from a Division I college institution were reviewed. Location and grade of stress injury to bone and duration of disability were recorded. All injured athletes followed the same treatment program, with the exception of football players, who were excluded from the return to sport analyses. RESULTS: Seventy-four athletes had lower extremity symptoms consistent with stress injury to bone. Diagnosis was confirmed in 68 of these athletes, 61 via magnetic resonance imaging, 6 via positive radiographs only, and 1 via bone scan only. Distance runners accounted for the most stress injuries to bone for both men and women. The tibia (37%) was the most frequently involved bone; however, as an anatomic region, the foot (44%) was the site of the most stress injuries. There was a significant correlation between grade of injury and time to full return to activity. CONCLUSIONS: The grading system used at this institution is a standardized tool that can be used to predict time to return to sport. A standardized rehabilitation protocol allowed for an appropriate plan to return the athletes to pain-free competition.