Complications in CT-guided Procedures: Do We Really Need Postinterventional CT Control Scans?

Purpose

The aim of this study is twofold: to determine the complication rate in computed tomography (CT)-guided biopsies and drainages, and to evaluate the value of postinterventional CT control scans.

Methods

Retrospective analysis of 1,067 CT-guided diagnostic biopsies (n = 476) and therapeutic drainages (n = 591) in thoracic (n = 37), abdominal (n = 866), and musculoskeletal (ms) (n = 164) locations. Severity of any complication was categorized as minor or major. To assess the need for postinterventional CT control scans, it was determined whether complications were detected clinically, on peri-procedural scans or on postinterventional scans only.

Results

The complication rate was 2.5 % in all procedures (n = 27), 4.4 % in diagnostic punctures, and 1.0 % in drainages; 13.5 % in thoracic, 2.0 % in abdominal, and 3.0 % in musculoskeletal procedures. There was only 1 major complication (0.1 %). Pneumothorax (n = 14) was most frequent, followed by bleeding (n = 9), paresthesia (n = 2), material damage (n = 1), and bone fissure (n = 1). Postinterventional control acquisitions were performed in 65.7 % (701 of 1,067). Six complications were solely detectable in postinterventional control acquisitions (3 retroperitoneal bleeds, 3 pneumothoraces); all other complications were clinically detectable (n = 4) and/or visible in peri-interventional controls (n = 21).

Conclusion

Complications in CT-guided interventions are rare. Of these, thoracic interventions had the highest rate, while pneumothoraces and bleeding were most frequent. Most complications can be detected clinically or peri-interventionally. To reduce the radiation dose, postinterventional CT controls should not be performed routinely and should be restricted to complicated or retroperitoneal interventions only.     

Radial force and wall apposition of balloon-expandable vascular stents in eccentric stenoses: an in vitro evaluation in a curved vessel model

PURPOSE: Important criteria for optimized stent implantation are high radial force and complete apposition of the stent itself. The aim of this study was to develop a simple method to assess these parameters under controlled experimental conditions and to compare vascular stents of different designs with regard to these parameters. MATERIALS AND METHODS: Five balloon-expandable stents of different designs (Jostent Flex, MAC stent, ML-Tristar, ML-Ultra, and S670) were tested. Fourteen stents of each type were implanted in a curved plastic vessel model (curve radius, 10 mm; lumen diameter, 3.5 mm) with use of a balloon inflation pressure of 12 atm. Part of the model was a nonflexible eccentric stenosis which was 2 mm or 8 mm in length. After stent implantation, a stenosis of 10%-70% was induced and radial force of the stent struts was measured at the site of the stenosis. The apposition of the stent to the vessel wall was imaged by high-resolution radiography. RESULTS: Analysis of variance showed significant differences of radial force between the tested stents (P <.001). The ML-Tristar and ML-Ultra stents had the highest radial force with maximum mean values of 687 cN and 846 cN at a stenosis of 70% in the model with the long stenosis. The radial force of the S670 stent was the lowest whereas the MAC stents showed an intermediate radial force. Radial force of the ML-Ultra stent was as much as 3.8 times higher than the force of the S670 stent (P <.001). Fifty percent of the ML-Tristar and ML-Ultra stents did not expand sufficiently to touch the vessel surface at the outer curvature. With an inflation pressure of 17 atm, complete apposition of these stents was achieved. The highest number of apposition irregularities was found in the S670 group (13 of 14 stents), whereas the MAC stents revealed the lowest number of irregular appositions (three of 14 stents). A significant correlation was found between the number of interconnecting struts and the number of irregular apposition events (P <.01). CONCLUSIONS: This model allows an accurate in vitro evaluation of different stent parameters, such as apposition to the vessel wall and radial force. None of the investigated stents showed optimal results with respect to both parameters. The apposition behavior was significantly influenced by the architecture of the stents.     

Correction to: Force delivery modification of removable thermoplastic appliances using Hilliard precision thermopliers for tipping an upper central incisor

Clinical Oral Investigations -     

Diabetes and antenatal milk expressing: a pilot project to inform the development of a randomised controlled trial

Objective

infants of women with diabetes in pregnancy are at increased risk of hypoglycaemia. If the infant's blood glucose is low and the mother is unable to breast feed/provide sufficient expressed breast milk, infants are often given formula. Some hospitals encourage women with diabetes to express breast milk before birth. However, there is limited evidence for this practice, including its impact on labour and birth, e.g. causing premature birth may be a concern. A pilot study was undertaken to establish the feasibility of conducting an adequately powered randomised controlled trial to evaluate this practice.

Design

consecutive eligible women with pre-existing or gestational diabetes (requiring insulin), planning to breast feed and attending the study hospital were offered participation. Inclusion criteria: 34-36 weeks of gestation; singleton pregnancy; cephalic presentation; and able to speak, read and write in English. Exclusion criteria: history of spontaneous preterm birth, antepartum haemorrhage, placenta praevia and suspected fetal compromise. Women were encouraged to express colostrum twice a day from 36 weeks of gestation, and advised how to store the colostrum, which was frozen for their infant's use after birth. They were asked to keep a diary documenting their expressing. Data: demographic questionnaire, telephone interview at six and 12 weeks postpartum and medical record data.

Setting

a public, tertiary, women's hospital in Melbourne, Australia.

Participants

43 women with diabetes in pregnancy (requiring insulin).

Findings

cardiotocographs were undertaken after the first expressing episode and none of the infants showed any sign of fetal compromise. Forty per cent of infants received formula in the 24 hours postpartum. The proportion of infants receiving any breast milk at six weeks was 90%, and this decreased to 75% at 12 weeks. No women showed evidence of hypoglycaemia post expressing. The intervention was positively received by most women; 95% said that they would express antenatally again if the practice proved to be beneficial. The amount of colostrum varied according to the number of expressions, the length of time in the study and the time spent expressing, with a median of 14 days expressing and 39.6 ml of colostrum obtained.

Key conclusions

the small number of women in this pilot was not an adequate number to examine safety or efficacy, but this study does provide evidence that it would be feasible and desirable to conduct a randomised controlled trial of antenatal milk expressing for women with diabetes requiring insulin in pregnancy.

Implications for practice

it is important that this widespread practice undergoes rigorous evaluation to assess both efficacy and safety. Until such evidence is available, the authors suggest that the routine encouragement of antenatal milk expressing in women with diabetes in pregnancy should cease.     

An aggressive systemic juvenile xanthogranuloma clonally related to a preceding T‐cell acute lymphoblastic leukemia

Juvenile xanthogranuloma (JXG) is a disorder of disputed origin thought to be related to the dermal/interstitial macrophage. A 5‐year‐old female presented with an aggressive systemic JXG that developed 5 months after the diagnosis of T‐cell acute lymphoblastic leukemia (T‐ALL). Examination of the T‐cell receptor gamma (TCR‐γ) rearrangement in T‐ALL blasts, JXG infiltrated lymph node biopsies and micro‐dissected JXG histiocytes revealed an identical bi‐allelic TCR‐γ rearrangement in all samples, thus providing evidence for a clonal relationship between T‐ALL and JXG in this case. Pediatr Blood Cancer 2011;56:859–862. © 2011 Wiley‐Liss, Inc.     

Mother/daughter relationships during pregnancy and the transition to motherhood of women with pre-existing diabetes: raising some issues

In pregnancies complicated by pre-existing diabetes, there is a higher incidence of adverse pregnancy outcome. Several reports including the Confidential Enquiry into Maternal and Child Health, Diabetes in Pregnancy—are we providing the best care? (2007) highlighted the need for family involvement before/during pregnancy and in early motherhood with the aim of making pregnancy and the transition to motherhood a positive and fulfilling experience. Exploring the midwifery, sociological and diabetes literature may assist in gaining a better understanding of the complexities surrounding conception, pregnancy, childbirth and motherhood within the context of diabetes.     

The use of transcutaneous electrical nerve stimulation (TENS) for pain relief in labour: a review of the evidence

Objective

to assess the effects of transcutaneous electrical nerve stimulation (TENS) for pain relief in labour.

Search methods

studies were identified from a search of the Cochrane Pregnancy and Childbirth Group’s Trials Register (November 2008).

Selection criteria

randomised controlled trials comparing women receiving TENS for pain relief in labour vs routine care or placebo devices. All types of TENS machines were included.

Data collection and analysis

two review authors assessed all trials identified by the search strategy, carried out data extraction and assessed risk of bias.

Results

14 studies including 1256 women were included: 11 examined TENS applied to the back, two to acupuncture points and one to the cranium. Overall, there was little difference in satisfaction with pain relief or in pain ratings between TENS and control groups, although women receiving TENS to acupuncture points were less likely to report severe pain (risk ratio 0.41, 95% confidence interval 0.32–0.55). The majority of women using TENS would use it again in a future labour. There was no evidence that TENS had any impact on interventions and outcomes in labour. There was little information on outcomes for mothers and infants. No adverse events were reported.

Conclusions

there is only limited evidence that TENS reduces pain in labour and it does not seem to have any impact on other outcomes for mothers or infants. The use of TENS at home in early labour has not been evaluated. Although the guidelines of the National Institute for Health and Clinical Excellence recommend that TENS should not be offered to women in labour, women appear to be choosing it and midwives are supporting them in their choice. Given the absence of adverse effects and the limited evidence base, it seems unreasonable to deny women that choice. More robust studies of effectiveness are needed.