Antimicrobial Resistance as Risk Factor for Recurrent Bacteremia after Staphylococcus aureus, Escherichia coli, or Klebsiella spp. Community-Onset Bacteremia

We investigated links between antimicrobial resistance in community-onset bacteremia and 1-year bacteremia recurrence by using the clinical data warehouse of Europe's largest university hospital group in France. We included adult patients hospitalized with an incident community-onset Staphylococcus aureus, Escherichia coli, or Klebsiella spp. bacteremia during 2017-2019. We assessed risk factors of 1-year recurrence using Fine-Gray regression models. Of the 3,617 patients included, 291 (8.0%) had >1 recurrence episode. Third-generation cephalosporin (3GC)-resistance was significantly associated with increased recurrence risk after incident Klebsiella spp. (hazard ratio 3.91 [95% CI 2.32-6.59]) or E. coli (hazard ratio 2.35 [95% CI 1.50-3.68]) bacteremia. Methicillin resistance in S. aureus bacteremia had no effect on recurrence risk. Although several underlying conditions and infection sources increased recurrence risk, 3GC-resistant Klebsiella spp. was associated with the greatest increase. These results demonstrate a new facet to illness induced by 3GC-resistant Klebsiella spp. and E. coli in the community setting.

Primary Invasive Cutaneous Fusariosis in Patients with STAT3 Hyper-IgE Syndrome

Dominant negative (DN) mutations in signal transducer and activator of transcription 3 (STAT3) are known to cause hyper-IgE syndrome, a rare primary immunodeficiency. STAT3 DN patients are prone to develop fungal infections, including chronic mucocutaneous candidiasis due to impaired IL-17-mediated immunity, and pulmonary aspergillosis. Despite having preserved phagocyte functions, STAT3 DN patients present connective tissue abnormalities and a defect in the immunological skin barrier. Fusarium species are ubiquitous molds, whose potential to infect humans depends on the host's innate and cellular immune status. Our aim was to describe four STAT3 DN patients with fusariosis confined to the skin. Medical records were reviewed and summarized. Four patients, aged 4, 11, 30, and 33 years, presented with chronic skin lesions which started in the extremities. Two patients had remote lesions, and none had systemic involvement. Skin biopsies showed mycelial threads with deep inflammatory-occasionally granulomatous-infiltrates, reaching the dermis; cultures grew Fusarium solani. Response to treatment was heterogeneous, often requiring multimodal therapies, including topical antifungal preparations. In this work, we describe primary invasive cutaneous fusariosis as a syndromic entity in four STAT3 DN patients.

Antimicrobial Resistance and Mortality in Hospitalized Patients with Bacteremia in the Greater Paris Area from 2016 to 2019

PURPOSE

Antibiotic-resistant bacteremia is a leading global cause of infectious disease morbidity and mortality. Clinical data warehouses (CDWs) allow for the secure, real-time coupling of diverse data sources from real-world clinical settings, including care-based medical-administrative data and laboratory-based microbiological data. The main purpose of this study was to assess the contribution of CDWs in the epidemiological study of antibiotic resistance by constructing a database of bacteremia patients, BactHub, and describing their main clinico-microbiological features and outcomes.

PATIENTS AND METHODS

Adult patients with bacteremia hospitalized between January 1, 2016 and December 31, 2019 in 14 acute care university hospitals from the Greater Paris area were identified; their first bacteremia episode was included. Data describing patients, episodes of bacteremia, bacterial isolates, and antimicrobial resistance were structured.

RESULTS

Among 29,228 patients with bacteremia, 41% of episodes were community-onset (CO) and 59% were hospital-acquired (HA). Thirty-day and ninety-day mortality rates were 15% and 20% in CO episodes, and 18% and 36% in HA episodes. Overall resistance rates were high, including third-generation cephalosporin resistance among Klebsiella pneumoniae (CO 21%, HA 37%) and Escherichia coli (CO 13%, HA 17%), and methicillin resistance among Staphylococcus aureus (CO 11%, HA 14%). Annual incidence rates increased significantly from 2017 to 2019, from 20.0 to 20.9 to 22.1 stays with bacteremia per 1000 stays (p < 0.0001).

CONCLUSION

The Bacthub database provides accurate clinico-microbiological data describing bacteremia across France's largest hospital group. Data from Bacthub may inform surveillance and the clinical decision-making process for bacteremia patients, including choice of antimicrobial therapy. The database also offers opportunities for research, including analysis of hospital care pathways and significant patient outcomes such as mortality and recurrence of infection.

Vasculitis and familial Mediterranean fever: Description of 22 French adults from the juvenile inflammatory rheumatism cohort

Objective

The frequency of vasculitis may be increased in patients with Familial Mediterranean Fever (FMF), according to several studies. Our aim was to assess the characteristics of French adult patients with both diseases.

Methods

Patients with vasculitis were selected from patients followed for FMF in the French JIR-cohort.

Results

Twenty-two patients were included [polyarteritis nodosa (PAN) n = 10, IgA vasculitis n = 8, unclassified vasculitis n = 2, granulomatosis with polyangiitis n = 1, and microscopic polyangiitis n = 1]. Pathogenic mutations in exon 10 were found in all 21 patients (96%) for which MEFV testing results were available, and 18 (82%) had two pathogenic mutations. Histology showed vasculitis in 59% of patients. Most patients with FMF-associated PAN were HBV-negative and had an inactive FMF before PAN onset, and 40% had a peri-renal or central nervous system bleeding. Most patients with FMF-associated IgA vasculitis had an active FMF before vasculitis onset, and 25% had digestive bleeding. Both patients with unclassified vasculitis had ischemic and/or hemorrhagic complications.

Conclusion

This study confirms the predominance of PAN and IgA vasculitis in patients with FMF and the high frequency of bleeding in FMF-associated PAN. FMF should be considered in case of persistent symptoms and/or inflammatory syndrome despite vasculitis treatment in Mediterranean patients.

Antimicrobial stewardship in high-risk febrile neutropenia patients

BACKGROUND

The 2011 4th European Conference on Infections in Leukemia (ECIL4) guidelines recommend antibiotics de-escalation/discontinuation in selected febrile neutropenia (FN) patients. We aimed to assess the impact of an antimicrobial stewardship (AMS) program based on these guidelines on antibiotics use and clinical outcomes in high-risk FN patients.

METHODS

We conducted an observational study in the hematology department of Cochin University Hospital in Paris, France. An ECIL4-based antibiotics de-escalation and discontinuation strategy was implemented jointly by the hematologists and the AMS team. The pre-intervention (January-October 2018) and post-intervention (January-October 2019) periods were compared. We retrospectively collected clinical and microbiological data. We compiled antibiotics consumptions via hospital pharmacy data and standardized them by calculating defined daily doses per 1000 patient-days. We analyzed the two-monthly antibiotic consumption using an interrupted time series method and built a composite endpoint for clinical outcomes based on transfer to the intensive care unit (ICU) and/or hospital death.

RESULTS

Overall, 273 hospital stays (164 patients) in the pre-intervention and 217 (148 patients) in the post-intervention periods were analyzed. Patients were mainly hospitalized for intensive chemotherapy for acute leukemia or autologous stem-cell transplant for myeloma. Patients were slightly younger in the pre-intervention compared to the post-intervention period (median age 60.4 vs 65.2 years, p = 0.049), but otherwise comparable. After implementation of the AMS program, glycopeptide and carbapenem use decreased by 85% (p = 0.03) and 72% (p = 0.04), respectively. After adjustment on confounders, the risk of transfer to the ICU/death decreased significantly after implementation of the AMS program (post-intervention period: odds-ratio = 0.29, 95% Confidence Interval: 0.15-0.53, p < 0.001).

CONCLUSION

Implementation of a multidisciplinary AMS program for high-risk neutropenic patients was associated with lower carbapenem and glycopeptide use and improved clinical outcomes.

An Educational Game Evening for Medical Residents: A Proof of Concept to Evaluate the Impact on Learning of the Use of Games

Insufficient knowledge of bacteria and antimicrobials leads to the emergence of multidrug-resistant-bacterium infections. Diversification of the teaching forms, such as the use of games, could be a solution. We organized an event around 3 games (Bacteria Game, KROBS, and Dawaa) to collect student feedback on the evening and assess their knowledge before and after the evening using multiple-choice questions. The preliminary results suggest a positive effect of this event, but due to the low number of participants, we see this report more as a proof of concept to assess the impact of games on the learning.

Abdominal adiposity assessed using CT angiography associates with acute kidney injury after trans-catheter aortic valve replacement

AIM

To determine if there is an association between area-based visceral abdominal adipose tissue (VAT), subcutaneous abdominal adipose tissue (SAT), and abdominal circumference measured on computed tomography (CT) angiography before trans-catheter aortic valve replacement (TAVR) and post-TAVR acute kidney injury (AKI).

MATERIALS AND METHODS

In this retrospective cohort study of 106 TAVR patients, SAT and VAT areas and abdominal circumference was measured on a single CT section at L4 vertebral level. Univariate comparisons between patients who did and did not develop AKI were undertaken for radiological measurements. Multivariable logistic regression was used to assess association between CT measurements and the development of post-TAVR AKI.

RESULTS

Post-TAVR AKI occurred in 20 of 106 patients (19%). In univariate comparisons, body mass index (BMI) did not differ significantly between patients who did and did not develop AKI (p=0.14); however, VAT+SAT (443.2±163.7 versus 351±168.7 cm²; p=0.03), VAT (213.9±110.6 versus 153.9±96.1 cm²; p=0.03), and outer abdominal circumference (100.2±14.4 cm versus 91.8±13.3 cm; p=0.02) were significantly higher in the patients who did not develop post-TAVR AKI. These three measures on pre-TAVR CT angiogram remained significantly associated with reduced post-TAVR AKI with a lower incidence of post-TAVR AKI after multivariable adjustment for pre-TAVR estimated glomerular filtration rate and patient height (p<0.05).

CONCLUSION

This study found that increased abdominal obesity as assessed by measures on pre-TAVR CT angiogram is associated with a significantly lower incidence of AKI.

Variable impact of an antimicrobial stewardship programme in three intensive care units: time-series analysis of 2012-2017 surveillance data

BACKGROUND

Preprescription authorization (PPA) and postprescription review with feedback (PPRF) were successively implemented in 2012 and 2016 in our 1500-bed hospital.

AIM

The impact of PPA and PPRF on carbapenems use and resistance levels of Pseudomonas aeruginosa was assessed in three intensive care units (ICUs).

METHODS

Carbapenems use (in DDDs/1000 occupied bed-days) and resistance of P. aeruginosa (percentage of non-susceptible (I+R) isolates to imipenem and/or meropenem) were analysed using a controlled interrupted time-series method. Two periods were compared: 2012-2015 (PPA) and 2016-2017 (PPA+PPRF). Models were adjusted on the annual incidence of extended-spectrum β-lactamase-producing enterobacteriacae.

FINDINGS

Carbapenem use was stable over the PPA period in all ICUs, with a significant change of slope over the PPA+PPRF period only in ICU1 (β2 = -12.8, 95% confidence interval (CI) = -19.5 to -6.1). There was a switch from imipenem to meropenem during the PPA period in all three units. Resistances of P. aeruginosa were stable over the study period in ICU1 and ICU2, and significantly decreased over the PPA+PPRF period in ICU3 (β2 = -0.18, CI = -0.3 to -0.03).

CONCLUSION

In real-life conditions and with the same antimicrobial stewardship programme (AMSP) led by a single team, the impact of PPRF was heterogeneous between ICUs. Factors driving the impact of AMSPs should be further assessed in comparable settings through real-life data, to target where they could prove cost-effective.

Anti-RNP positivity in primary Sjögren's syndrome is associated with a more active disease and a more frequent muscular and pulmonary involvement

Objectives

To describe and compare the clinical and biological characteristics of subjects with primary Sjögren’s syndrome (pSS) with and without anti-RNP antibodies.

Methods

Patients fulfilling the American College of Rheumatology (ACR)/EULAR 2016 criteria for pSS and having anti-RNP antibodies, without other connective tissue disease diagnosed and no anti-dsDNA antibodies were retrieved from the database from our French National Reference Center. These patients were compared with all other patients with pSS with negative anti-Sm, anti-RNP and anti-dsDNA antibodies.

Results

Overall, 21 patients with pSS positive for anti-RNP antibodies and 446 negative for anti-RNP antibodies were retrieved. Anti-RNP-positive patients had a lower median age at onset of pSS symptoms (41.0 vs 50.0 years, p=0.01), a higher median EULAR Sjögren’s syndrome disease activity index at inclusion (8.0 vs 3.0, p<0.01), more frequently constitutional symptoms (14.3% vs 0.01%, p<0.01), myositis (19.0% vs 2.3%, p<0.01) and pulmonary (19.0% vs 5.7%, p=0.04) involvement. Moreover, anti-RNP-positive patients had higher median gammaglobulin levels (22.5 vs 13 g/L, p<0.01), more frequently anti-SSA antibodies (90.5% vs 67.1%, p=0.03), but less frequent lymphocytic sialadenitis with a focus score ≥1 (66.7% vs 85.5%, p=0.03). If the analysis is restricted to anti-SSA-positive patients, anti-RNP positivity is associated with the same clinicobiologic features except the pulmonary involvement.

Conclusion

Patients with pSS with anti-RNP antibodies displayed a more active systemic disease, with more frequent muscular and pulmonary involvement, and increased gammaglobulin level, compared with anti-RNP-negative patients.

Association of Vasculitis and Familial Mediterranean Fever

Certain types of vasculitis occur more frequently and present differently in patients with familial Mediterranean fever (FMF). We assessed the characteristics of patients with FMF and systemic vasculitis through a systematic review of the literature. Medline was searched by two independent investigators until December 2017. We screened 310 articles and selected 58 of them (IgA vasculitis n = 12, polyarteritis nodosa (PAN) n = 25, Behçet's disease (BD) n = 7, other vasculitis n = 14). Clinical case reports were available for 167 patients (IgA vasculitis n = 46, PAN n = 61, BD n = 46, other vasculitis n = 14), and unavailable for 45 patients (IgA vasculitis n = 38, PAN n = 7). IgA vasculitis was the most common vasculitis in FMF patients with a prevalence of 2.7-7%, followed by PAN with a prevalence of 0.9-1.4%. Characteristics of FMF did not differ between patients with and without vasculitis. Patients with FMF and IgA vasculitis displayed more intussusception (8.7%) and possibly less IgA deposits on histological analysis than patients with IgA vasculitis alone. Patients with FMF and PAN had a younger age at vasculitis onset (mean age = 17.9 years), as well as more perirenal hematomas (49%) and CNS involvement (31%) than patients with PAN alone. Glomerular involvement was noted in 33% of patients diagnosed with PAN, suggesting an alternative diagnosis. Sequencing of the MEFV gene confirmed the presence of two pathogenic variants in 73% of FMF patients with IgA vasculitis or PAN. The majority of patients with BD were from one case series, and presented more skin, gastrointestinal, and CNS involvement than patients with isolated BD. In conclusion, FMF, particularly when supported by two pathogenic MEFV mutations, could predispose to IgA vasculitis, or a PAN-like vasculitis with more perirenal bleeding and CNS involvement.

Impact of a multimodal strategy combining a new standard of care and restriction of carbapenems, fluoroquinolones and cephalosporins on antibiotic consumption and resistance of Pseudomonas aeruginosa in a French intensive care unit

This study aimed to assess whether post-prescription review and feedback (PPRF) of all antibiotics, with restriction of carbapenems, fluoroquinolones and third-generation cephalosporins (3GCs), along with a change in medical standard of care impacted antibiotic consumption and bacterial antimicrobial resistance in a French medical/surgical intensive care unit (ICU). A 4-year before (2007-2010) and after (2011-2014) retrospective comparative study was performed. Antibiotic consumption was evaluated in defined daily doses per 1000 patient-days. The rates of Pseudomonas aeruginosa resistance to piperacillin, ceftazidime, ciprofloxacin, imipenem and amikacin and of AmpC-hyperproducing group 3 Enterobacteriaceae were assessed. Consumption of fluoroquinolones decreased by -85%, carbapenems by -58%, 3GCs by -50% and glycopeptides by -66% (P ≤ 0.0001). Consumption of penicillins with and without β-lactamase inhibitors increased by +72% and +78%, sulfonamides by +172% and macrolides by +267% (P < 0.0001). Pseudomonas aeruginosa resistance rates for all antibiotics tested and the proportion of AmpC-hyperproducing group 3 Enterobacteriaceae decreased (P ≤ 0.01). The median length of stay, use of vasopressors and invasive mechanical ventilation decreased, and the use of renal replacement therapy increased (P < 0.05). The initial severity score (SAPS II) increased (P < 0.01) due to changes in practice, with no impact on in-hospital mortality (P = 0.07). In conclusion, changes in medical care along with PPRF and a restriction of high ecological impact antibiotics were associated with a shift towards the consumption of low ecological impact antibiotics in an ICU. Rates of resistant P. aeruginosa and of AmpC-hyperproducing group 3 Enterobacteriaceae decreased simultaneously.

CT coronary imaging-a fast evolving world

Computed tomography (CT) has become an important modality in the evaluation of coronary artery disease (CAD). The tremendous technological advances in CT in the last two decades has made it possible to obtain high quality images of coronary arteries with high spatial and temporal resolutions. Multiple trials have confirmed the accuracy of CT compared to invasive catheter angiography. CT is also able to evaluate beyond the lumen in characterizing and quantifying atherosclerotic plaques, including evaluation of high risk features. Although CTA has low specificity in identification of lesion-specific ischemia, functional techniques are now possible such as CT myocardial perfusion and CT-fractional flow reserve (FFR) which evaluate the hemodynamic significance of stenosis and help with revascularization strategies. Multi-energy CT provides additional information beyond what is possible with a conventional CT and is useful in variety of clinical applications, including myocardial perfusion imaging, lesion characterization and low contrast studies. Large trials have confirmed the ability of CT to predict major adverse cardiovascular events and recent trials have even demonstrated improved clinical outcomes by using CT for the evaluation of CAD. CT is also useful in structural heart disease and 3 D printing is now increasingly used for surgical/interventional planning. Machine learning is evolving rapidly and is likely to impact diagnosis and management.

Symptomatic muscular sarcoidosis: Lessons from a nationwide multicenter study

Objectives

To describe clinicopathologic features of muscular sarcoidosis and the associated sarcoidosis phenotype through a nationwide multicenter study.

Methods

Patients were included if they had histologically proven sarcoidosis and symptomatic muscular involvement confirmed by biological, imaging, or histologic examinations.

Results

Forty-eight patients (20 males) were studied, with a median age at muscular symptoms onset of 45 years (range 18–71). Four patterns were identified: a nodular pattern (27%); smoldering phenotype (29%); acute, subacute, or progressive myopathic type (35%); and combined myopathic and neurogenic pattern (10%). In all patterns, sarcoidosis was multivisceral with a median of 3 extramuscular organs involved (mostly lungs, lymph nodes, eyes, and skin) and a prolonged course with long-term use of corticosteroids and immunosuppressive drugs. Muscular patterns differed according to clinical presentation (myalgia, nodules, or weakness), electromyographic findings, muscular MRI, and response to sarcoidosis treatment. The myopathic and neuromuscular patterns were more severe.

Conclusion

This nationwide study of muscular sarcoidosis allowed the identification of 4 patterns of granulomatous myositis, which differed by phenotypes and the clinical course.

[Familial Mediterranean fever]

Familial Mediterranean Fever (FMF) is the most frequent monogenic auto-inflammatory disease. FMF is an autosomal recessive disease, which affects populations from Mediterranean origin and is associated with MEFV gene mutations encoding for the protein pyrin. Pyrin activation enhances the secretion of interleukin 1 by myelo-monocytic cells. Main features of the disease are acute attacks of serositis mainly located on the abdomen, less frequently on chest and joints, accompanied by fever and biological inflammatory markers elevation. Usually attacks last 1 to 3 days and spontaneously stop. A daily oral colchicine intake of 1 to 2mg/day is able to prevent attack's occurrence, frequency, intensity and duration among most patients. Colchicine is also able to prevent the development of inflammatory amyloidosis, the most severe complication of FMF. This state of the art article will focus on the diagnosis of FMF, the treatment and an update on the pathophysiology including the recent described dominant form of MEFV-associated new auto-inflammatory diseases.

Feasibility of a radiation dose conserving CT protocol for myocardial function assessment

OBJECTIVE

Assessment of myocardial function can be performed at higher noise levels than necessary for coronary arterial evaluation. We evaluated image quality and radiation exposure of a dose-conserving function-only acquisition vs retrospectively electrocardiogram(ECG)-gated coronary CTA with automatic tube current modulation.

METHODS

Of 26 patients who underwent clinically indicated coronary CTA for coronary and function evaluation, 13 (Group I) underwent prospectively ECG-triggered coronary CTA, followed by low-dose retrospectively ECG-gated scan for function (128-slice dual-source, 80 kVp; reference tube current, 100 mA; 8-mm-thick multiplanar reformatted reconstructions) performed either immediately (n = 6) or after 5- to 10-min delay for infarct assessment (n = 7). 13 corresponding controls (Group II) underwent retrospectively ECG-gated protocols (automatic tube potential selection with CARE kV/CARE Dose 4D; Siemens Healthcare, Forchheim, Germany) with aggressive dose modulation. Image quality assessment was performed on the six Group I subjects who underwent early post-contrast dedicated function scan and corresponding controls. Radiation exposure was based on dose-length product.

RESULTS

Contrast-to-noise ratio (CNR) was preserved throughout the cardiac cycle in Group I and varied according to dose modulation in Group II. Visual image quality indices were similar during end systole but were better in Group II at end diastole. Although the total radiation exposure was equivalent in Group I and Group II (284 vs 280 mGy cm), the median radiation exposure associated with only the dedicated function scan was 138 mGy cm (interquartile range, 116-203 mGy cm).

CONCLUSION

A low-dose retrospective ECG-gated protocol permits assessment of myocardial function at a median radiation exposure of 138 mGy cm and offers more consistent multiphase CNR vs traditional ECG-modulation protocols. This is useful for pure functional evaluation or as an adjunct to single-phase scan modes.

ADVANCES IN KNOWLEDGE

Radiation exposure can be limited with a tailored myocardial function CT protocol while maintaining preserved images.

[Prevalence and clinical significance of incidental cardiac findings in non-ECG-gated chest CT scans]

BACKGROUND

The purpose of this study was to evaluate the prevalence and clinical significance of incidental cardiac findings in non-ECG-gated chest CT.

PATIENTS AND METHODS

Non-ECG-gated chest CT examinations of 300 patients were retrospectively analyzed for incidental cardiac findings. Subsequently, these findings were evaluated for their clinical relevance by a cardiologist.

RESULTS

A total of 107 out of 300 examined patients had 174 incidental cardiac findings including coronary calcification (90), aortic/mitral valve calcification (42), iatrogenic changes (23), pericardial effusion (6), dilatation of the heart (4), myocardial changes (3), thrombus in the left ventricle (2), constrictive pericarditis (2) and atrial myxoma (1). Of the cardiac findings 51% were described in the written report and in 53 out of the 107 patients the cardiac findings were unknown. Newly detected incidental findings from 8 patients were rated as clinically significant: pericardial effusion (4), constrictive pericarditis (1), thrombus in the left ventricle (1), atrial myxoma (1) and dilatation of the heart (1).

CONCLUSION

Incidental cardiac findings are frequent in non-ECG-gated chest CT and may have a high clinical relevance.

The use of CTA in the chest pain center: a perspective

Suitable imaging methods to reliably rule out coronary artery disease as the underlying condition might be beneficially applied in the workup of patients with acute chest pain. The temporal and spatial resolution of computed tomgraphy and electron beam computed tomography has seen continuous improvements over the past years. Current scanner generations permit relatively reliable visualization of the coronary arteries and several studies have demonstrated a high negative predictive value to rule out coronary artery stenoses. Even though applications in the context of acute coronary syndromes have not yet been specifically evaluated, it seems likely that computed tomography imaging may develop into a tool that can be integrated into the workflow in chest pain centers once appropriate studies have been performed.

Uterine artery embolization: reduced radiation with refined technique

PURPOSE

To determine the estimated absorbed ovarian dose (EAOD) and absorbed skin dose (ASD) that occurs during uterine artery embolization (UAE) using pulsed fluoroscopy and a refined procedure protocol.

MATERIALS AND METHODS

The absorbed dose was measured in 20 patients who underwent UAE procedures. Radiation was limited by using low frequency pulsed fluoroscopy, bilateral catheter technique with simultaneous injections for embolization as well as pre-and postembolization exposures and focus on limitation of magnified and oblique fluoroscopy. Lithium fluoride dosimeters were placed both in the posterior vaginal fornix and on the skin at the beam entrance site. The vaginal dose was used to approximate the EAOD. Fluoroscopy time and exposures were recorded. The mean values for all patients were calculated and compared to our previous results obtained with conventional fluoroscopy and to threshold doses for the induction of deterministic skin injury.

RESULTS

Mean fluoroscopy time was 10.95 min. (range 6-21.3 min.) and the mean number of angiographic exposures was 20.9 (range 14-53). The mean EAOD was 9.5 cGy (range 2.21-23.21 cGy) and the mean ASD was 47.69 cGy (range 10.83-110.14 cGy). This compares to previous results with non-pulsed fluoroscopy of an EAOD of 22.34 cGy (range 4.25-65.08 cGy) and an ASD of 162.32 cGy (range 66.01-303.89 cGy) as well as threshold doses for induction of deterministic radiation injury to the skin (400-500 cGy).

CONCLUSION

When pulsed fluoroscopy is used with emphasis on dose reduction techniques, the EAOD and ASD can be substantially reduced to less than 1/2 (P = .017) and 1/3 (P < .0001) when compared to UAE performed with nonpulsed fluoroscopy. These radiation reduction tools should therefore be applied whenever possible.

[The sacral perineural system--are there radiological criteria for an indication for surgery? First results and literature survey]

PURPOSE

To establish recommendations for diagnostic imaging of cystic lesions of the sacral region and to evaluate for potential predictors of therapeutic outcome.

METHODS

Conventional imaging of the lumbar spine, conventional CT, myelography, post myelo-CT and MRI were performed in 7 symptomatic [corrected] patients. All patients underwent operative decompression and histological examination. The radiographic examinations were reevaluated retrospectively and correlated with the postoperative outcome.

RESULTS

In one patient the differential diagnosis of a neurinoma could not be excluded with CT and CT-myelography alone. In all 7 patients MRI provided a definite diagnosis and a precise presentation of the cyst extension. A complete postoperative remission of symptoms was noticed in 4, a partial remission in three cases. The correlation of cyst extension, cyst shape, and the communication with the subarachnoid space did not provide predictive information concerning operative outcome.

CONCLUSION

MR can be used as the sole imaging tool for demonstration of cystic lesions. Relevant disadvantages in comparison to myelography and myelo-CT were not evident. No imaging modality could predict the value of surgical intervention.

Influence of radiographic technique and equipment on absorbed ovarian dose associated with uterine artery embolization

PURPOSE

To evaluate the influence of pulsed fluoroscopy (PF), nonpulsed fluoroscopy (NPF), and various fluoroscopic techniques on the absorbed ovarian dose (AOD) associated with uterine artery embolization (UAE) of leiomyomata.

MATERIAL AND METHODS

Ovarian location was estimated from preprocedural pelvic magnetic resonance images of 23 patients previously treated by means of UAE. The AOD was measured with thermoluminescent dosimeters (TLD) placed into an anthropomorphic phantom at the determined ovarian location. The following measurements from PF and NPF were obtained: 21.89 minutes of nonmagnified posterior-anterior fluoroscopy, 10 minutes of nonmagnified oblique fluoroscopy, 10 minutes of posterior-anterior magnified fluoroscopy, 10 minutes of combined oblique magnified fluoroscopy, and 47 simulated angiographic exposures. Numbers for nonmagnified posterior-anterior fluoroscopy time and exposure numbers were chosen from the average values from previous UAE procedures. AOD from pulsed and nonpulsed nonmagnified posterior-anterior fluoroscopy was compared to measurements from oblique magnified, posterior-anterior magnified, and oblique fluoroscopy.

RESULTS

AOD from NPF was, on average, 1.7 times higher than from PF. When compared with nonmagnified posterior-anterior fluoroscopy, the AOD from oblique magnified fluoroscopy was 1.9 times greater; the AOD from nonmagnified oblique fluoroscopy was 1.1 times greater. The AOD from oblique magnified fluoroscopy was 1.5 times higher on the side closer to the x-ray tube than on the contralateral side. AOD from serial angiographic exposures contributed only less than 7% to the total AOD for the average UAE procedure.

CONCLUSIONS

The AOD associated with UAE can best be reduced by limiting fluoroscopy time and the use of oblique or magnified fluoroscopy. Contribution of angiographic exposures to AOD is much less significant.

Patient radiation dose associated with uterine artery embolization

PURPOSE

To evaluate the estimated absorbed radiation doses to the ovaries and skin entrance during uterine artery embolization (UAE) for leiomyomas.

MATERIALS AND METHODS

Radiation dose was measured in 20 patients who underwent UAE for leiomyomas. Measurements were obtained by placing lithium fluoride dosimeters both into the posterior fornix of the vagina and on the skin at the beam entrance site. Patient doses were obtained with thermoluminescent dosimeters.

RESULTS

The mean fluoroscopic time was 21.89 minutes, and the mean number of angiographic exposures was 44. The mean estimated absorbed ovarian dose was 22.34 cGy, and the mean absorbed skin dose was 162.32 cGy. These values compare to published values for the assessed absorbed ovarian dose during hysterosalpingography (0.04-0.55 cGy), fallopian tube recanalization (0.2-2.75 cGy), computed tomography of the trunk (0.1-1.9 cGy), and pelvic irradiation for Hodgkin disease (263-3,500 cGy).

CONCLUSION

The estimated absorbed ovarian dose during UAE is greater than that during common fluoroscopic procedures. On the basis of the known risks of pelvic irradiation for Hodgkin disease, the dose associated with UAE is unlikely to result in acute or long-term radiation injury to the patient or to a measurable increase in the genetic risk to the patient's future children.

[Diagnosis and therapy of second aortoenteric fistulas: results of 16 patients]

From January 1977 to July 1997, 16 patients with aorto/iliac-enteric fistulas underwent repair. The fistula became apparent at a mean of 51 months. Gastrointestinal bleeding was the main symptom in 11 cases, 4 patients had a cutaneous fistula, and 1 developed retroperitoneal bleeding. The preoperative diagnosis was established in one-half of the cases. Three patients had to be treated surgically on an emergency basis without a preoperative diagnosis because of bleeding, 7 patients were semi-urgent and 6 had elective surgery. In 3 cases treatment consisted only of local repair. In 6 patients we performed extra-anatomic revascularization and in 7 patients we achieved restoration by in situ replacement after removal of all infected prosthetic material. Eight of 16 patients survived the perioperative period. Local repair alone cannot be recommended. All 3 patients died. The mortality rates between extra-anatomic revascularization and in situ reconstruction are comparable.