Reduction of venous thrombosis complicating phlebography

Patients who underwent radiographic phlebography were studied to determine the frequency of postphlebographic venous thrombosis. In a group of 23 patients who had negative phlebograms performed with standard contrast agent (60% sodium methylglucamine diatrizoate), nine had positive 125I-fibrinogen leg scans. On repeat phlebography, three had confirmed deep vein thrombosis, six overall developed deep or superficial thrombosis, and three had positive scans without demonstrable thrombi. In a second group of 34 patients studied with the contrast material diluted to 45%, only three developed positive scans, one due to deep venous thrombosis and two to superficial thrombosis. There was also a reduction in the incidence of postphlebographic symptoms of pain, tenderness, and erythema, but no apparent sacrifice in diagnostic accuracy.     

Computerized tomography scan for diagnosis and staging of renal cell carcinoma

A comparison of computerized tomography and arteriography for the diagnosis and staging of renal cell carcinoma was done in 45 patients during a 2-year interval. Compared to arteriography, computerized tomography was more accurate in the diagnosis of renal cell carcinoma (95 versus 85 per cent), equivalent in the determination of renal vein involvement and superior in the determination of regional nodal involvement. Because of the increased diagnostic accuracy, better delineation of the local extent of the tumor and less invasive nature we recommend computerized tomography as the preferred procedure for diagnosis and staging of renal cell carcinoma. However, in patients with questionable findings arteriography and/or inferior venacavography should be used as complementary studies.     

Effects of a new nonionic and a conventional ionic contrast agent on coronary sinus ionized calcium and left ventricular hemodynamics in dogs

Transient myocardial depression associated with intracoronary injections of contrast medium has been attributed to hypertonicity and to calcium binding. To further assess the importance of calcium binding, a new technique for continuous monitoring of coronary sinus ionized calcium with an intravascular calcium-selective electrode was used. With this calcium-selective electrode the effects of intracoronary injection in dogs of a conventional ionic contrast agent, sodium meglumine diatrizoate (Renografin-76), and a new nonionic agent, iohexol, were assessed and compared. Left ventricular pressure was measured with a micromanometer catheter. After bolus injection of 0.2 ml/kg body weight of Renografin-76 (n = 10), coronary sinus pCa increased by 0.27 from 2.98 +/- 0.02 to 3.25 +/- 0.03, indicating a decrease in ionized calcium from 2.0 to 1.1 mEq/liter. With iohexol (n = 9), pCa increased by only 0.05 +/- 0.01 (p less than 0.001), indicating a decrease in ionized calcium from 2.0 to 1.8 mEq/liter. Peak changes occurred approximately 6 seconds after injection. Renografin-76 caused a marked decrease in left ventricular systolic pressure (140 +/- 7 to 106 +/- 8 mm Hg) and in heart rate (122 +/- 7 to 101 +/- 5 beats/min) with an increase in end-diastolic pressure (5 +/- 1 to 12 +/- 1 mm Hg), whereas iohexol did not significantly alter these variables. Using Renografin-76 with calcium added to achieve an ionized calcium level of 2 (n = 4), 4 (n = 4) or 6 (n = 4) mEq/liter, the changes in coronary sinus pCa were abolished and the hemodynamic changes attenuated. These findings indicate that Renografin-76 results in greater myocardial depression than the new nonionic agent iohexol.(ABSTRACT TRUNCATED AT 250 WORDS)     

New York City social workers after 9/11: their attachment, resiliency, and compassion fatigue

This study examines the relationship between attachment classification, resiliency, and compassion fatigue in New York social workers following 9/11. We used single occasion, quasi-random sampling, surveying 481 social workers living in Manhattan. Hierarchical regression analyses revealed that secure attachment is predictive of the ability to cope with secondary traumatic stress as well as capacity for resilience, explaining approximately 7% of the variance in both compassion fatigue and resiliency. These findings suggest that secure attachment may serve as a source of resilience for social workers, immunizing them from significant compassion fatigue. Such findings have significant implications for clinicians working with traumatized populations.     

Percutaneous radiologic gastrostomy versus percutaneous endoscopic gastrostomy: a comparison of indications, complications and outcomes in 370 patients

OBJECTIVE: Percutaneous access to the stomach can be achieved by endoscopic or fluoroscopic methods. Our objective was to compare indications, complications, efficacy and outcomes of these two techniques. METHODS: Records of 370 patients with feeding tubes placed either endoscopically by gastroenterology, or fluoroscopically by radiology, at our university-based tertiary care center over a 54-month period were reviewed. RESULTS: 177 gastrostomies were placed endoscopically and 193 fluoroscopically. Nutrition was the most common indication in each group (94 and 92%), but the most common underlying diagnosis was neurologic impairment in the endoscopic group (n=89, 50%) and malignancy in the fluoroscopic group (n=134, 69%) (p<0.001). Complications in the first 30 days were more common with fluoroscopic placement (23% versus 11%, p=0.002), with infection most frequent. Correlates of late complications were inpatient status (OR 0.26, 95%CI: 0.13-0.51) and a diagnosis of malignancy (OR 2.2, 95%CI: 1.03-4.84). Average follow-up time was 108 days in the fluoroscopic group and 174 days in the endoscopic group. CONCLUSIONS: Both endoscopic and fluoroscopic gastrostomy tube placement are safe and effective. Outpatient status was associated with greater early and late complication rates; minor complications such as infection were greater in the fluoroscopic group, while malignancy was associated with late complications.     

Contrast venography of the leg: diagnostic efficacy, tolerance, and complication rates with ionic and nonionic contrast media

A prospective, three-center study of two contrast agents for leg venography was performed to evaluate both the relative frequency of adverse effects and whether low-osmolality agents provided significant advantages for this procedure. Fifty-four patients were studied with the standard preparation (iothalamate meglumine) and 57 with a nonionic agent (iopamidol). Both were used at an iodine concentration of 200 mg/mL, and there were no differences in volume of contrast material, duration of infusion, percentage of positive studies, or overall diagnostic adequacy. Patient discomfort was less with iopamidol than with iothalamate (18% vs. 44%), although discomfort was generally mild in both groups. By objective follow-up studies, the frequency of postvenographic thrombosis was not significantly different in the two groups (8% vs. 9%). Contrast venography, then, had a low frequency of complications when either a dilute conventional or a low-osmolality agent was employed. Although the frequency of postvenographic thrombosis was low with both agents, patient discomfort was less with the low-osmolality formulation.     

Complications of transluminal angioplasty

Four hundred fifty-three percutaneous transluminal angioplasties in 352 patients were reviewed to determine the frequency, distribution, and cause of complications. The primary success rate was 89% (81%-82% for renal and distal runoff vessels, 91%-95% for the iliofemoral arteries). Fifty-nine complications occurred in 53 patients, including 20 puncture site complications, the most frequent being hematoma. The most important angioplasty complication was acute occlusion of the arterial lumen attributed to acute thrombosis (2%). Subintimal passage of the guide wire/catheter (2%) may also cause luminal compromise. Arterial dissection following balloon dilatation (1%) and distal emboli (1.5%) were less important clinically, and vessel wall rupture was rare (0.4%). Complications were two to four times more frequent for renal and distal popliteal/tibial compared with iliofemoral angioplasties; the lower success and higher complication rates are attributed to greater technical difficulty and the increased importance of spasm. Operator experience and technical refinements play an important role in reducing occurrence of serious complications. The frequency and severity of angioplasty complications compare favorably with the alternative surgical procedure.     

Utility of Covered Stents for Revision of Aging Failing Synthetic Hemodialysis Grafts: A Report of Three Cases

Three aging failing hemodialysis polytetrafluoroethylene bypass shunts, average age 44 months, previously percutaneously revised with balloon angioplasty, presented with pseudoaneurysms and recurrent thrombosis. All were treated with percutaneous covered stent placement within their affected limbs. One graft was ligated 1 month after treatment for infected overlying skin ulcer, though this graft was subsequently surgically revised with interposition graft and the covered stent portion remains functional at 19 month follow-up. The 18- and 13- month follow- up of the remaining 2 patients shows that the covered stents remained patent and they are functional and being successfully and routinely punctured for dialysis. In this elderly population, the use of covered stents may prolong the functional life of failing hemodialysis bypass grafts, reducing the number of percutaneous and surgical interventions and further sparing other vascular access sites.