Automated detection of IVC filters on radiographs with deep convolutional neural networks

PURPOSE

To create an algorithm able to accurately detect IVC filters on radiographs without human assistance, capable of being used to screen radiographs to identify patients needing IVC filter retrieval.

METHODS

A primary dataset of 5225 images, 30% of which included IVC filters, was assembled and annotated. 85% of the data was used to train a Cascade R-CNN (Region Based Convolutional Neural Network) object detection network incorporating a pre-trained ResNet-50 backbone. The remaining 15% of the data, independently annotated by three radiologists, was used as a test set to assess performance. The algorithm was also assessed on an independently constructed 1424-image dataset, drawn from a different institution than the primary dataset.

RESULTS

On the primary test set, the algorithm achieved a sensitivity of 96.2% (95% CI 92.7-98.1%) and a specificity of 98.9% (95% CI 97.4-99.5%). Results were similar on the external test set: sensitivity 97.9% (95% CI 96.2-98.9%), specificity 99.6 (95% CI 98.9-99.9%).

CONCLUSION

Fully automated detection of IVC filters on radiographs with high sensitivity and excellent specificity required for an automated screening system can be achieved using object detection neural networks. Further work will develop a system for identifying patients for IVC filter retrieval based on this algorithm.

Non-operative management of biliary complications after Liver Transplantation in pediatric patients: A 30-year experience

BACKGROUND

To evaluate the efficacy of percutaneous and endoscopic therapeutic interventions for biliary strictures and leaks following LT in children.

METHODS

Retrospective analysis of 49 consecutive pediatric liver transplant recipients (27 girls, 22 boys, mean age at transplant 3.9 years) treated at our institution from 1989 to 2019 for biliary leak and/or biliary stricture was performed. Minimally invasive approach was considered clinically successful if it resulted in patency of the narrowed biliary segment and/or correction of the biliary leak.

RESULTS

Forty-two patients had a stricture at the biliary anastomosis; seven had a biliary leak. After an average 13.8 years of follow-up, long-term clinical success with minimally invasive treatment (no surgery or re-transplant) was achieved for 24 children (57%) with biliary stricture and 4 (57%) with biliary leaks. Eight patients required re-transplant; however, only one was due to failure of both percutaneous and surgical management. For biliary strictures, failure of non-surgical management was associated with younger age at stricture diagnosis (p < .02).

CONCLUSIONS

Percutaneous and endoscopic management of biliary strictures and leaks after LT in children is associated with a durable result in >50% of children.

Prospective Phase II trial of drug-eluting bead chemoembolization for liver transplant candidates with hepatocellular carcinoma and marginal hepatic reserve

Purpose: To determine whether chemoembolization using drug-eluting beads (DEB-TACE) is safe and effective for liver transplantation candidates with liver-limited hepatocellular carcinoma (HCC) without vascular invasion and baseline hepatic dysfunction.

Materials and methods: Seventeen adult liver transplantation candidates (median age 66 years, range 58–73 years; 13 men) with HCC were treated with DEB-TACE as a part of Stage 1 of a prospective single-institution Phase II trial. All patients had marginal hepatic reserve based on at least one of the following criteria: ascites (n=14), bilirubin between 3 and 6 mg/dL (n=5), AST 5–10 times upper normal limit (n=1), INR between 1.6 and 2.5 (n=4), portal vein thrombosis (n=2), and/or portosystemic shunt (n=2). Primary study objectives were safety and best observed radiographic response.

Results: Thirty-seven DEB-TACE procedures were performed. Objective response rate and disease control rate were 63% and 88%, respectively. HCC progression was observed in 12 patients. Median time to progression was 5.6 months (range 0.9–13.6 months). Within 1 month following DEB-TACE, 13 patients (76%) developed grade 3 or 4 AE attributable to the procedure. Four patients (all within Milan Criteria) were transplanted (2.7–6.9 months after DEB-TACE), and 12 patients died (1.8–32 months after DEB-TACE). All deaths were due to liver failure that was either unrelated to HCC (n=5), in the setting of metastatic HCC (n=5), or in the setting of locally advanced HCC (n=2). Mortality rate at 1 month was 0%.

Conclusions: DEB-TACE achieves tumor responses but carries a high risk of hepatotoxicity for liver transplant candidates with HCC and marginal hepatic reserve.

Uterine Artery Embolization following Cesarean Delivery but prior to Hysterectomy in the Management of Patients with Invasive Placenta

PURPOSE

To evaluate outcomes of patients with placenta accreta spectrum (PAS) disorders who underwent uterine artery embolization (UAE) following cesarean delivery but before hysterectomy.

MATERIALS AND METHODS

A retrospective review of patients with PAS treated with cesarean-hysterectomy (C-hyst) was performed. Patients in the UAE group underwent UAE after cesarean delivery but before hysterectomy; patients in the control group underwent C-hyst alone. Estimated blood loss (EBL), transfusion requirements, length of intensive care unit (ICU) stay, and adverse events were evaluated.

RESULTS

The study included 31 patients, 7 in the UAE group and 24 in the control group. Median EBL, transfusion requirements, and length of ICU stay in the UAE group compared with control group were 1,500 mL (range, 500-2,000 mL) vs 2,000 mL (range, 1,000-4,500 mL) (P = .04), 150 mL (range, 0-650 mL) vs 550 mL (range, 0-3,125 mL) (P = .10), and 0 d (range, 0-1 d) vs 0.5 d (range, 0-2 d) (P = .07). All patients in the UAE group had placenta increta; patients in the control group had placenta accreta (29%), increta (54%), and percreta (17%) (P = .10). Subgroup analysis of patients with placenta increta demonstrated that the UAE group had a significant decrease in median EBL (P = .004), transfusion requirements (P = .009), and length of ICU stay (P = .04). No adverse events following UAE were noted.

CONCLUSIONS

UAE following cesarean delivery but before hysterectomy in patients with placenta increta appears to be safe and effective in decreasing EBL, transfusion requirements, and length of ICU stay compared with C-hyst alone.

Automated detection of moderate and large pneumothorax on frontal chest X-rays using deep convolutional neural networks: A retrospective study

BACKGROUND

Pneumothorax can precipitate a life-threatening emergency due to lung collapse and respiratory or circulatory distress. Pneumothorax is typically detected on chest X-ray; however, treatment is reliant on timely review of radiographs. Since current imaging volumes may result in long worklists of radiographs awaiting review, an automated method of prioritizing X-rays with pneumothorax may reduce time to treatment. Our objective was to create a large human-annotated dataset of chest X-rays containing pneumothorax and to train deep convolutional networks to screen for potentially emergent moderate or large pneumothorax at the time of image acquisition.

METHODS AND FINDINGS

In all, 13,292 frontal chest X-rays (3,107 with pneumothorax) were visually annotated by radiologists. This dataset was used to train and evaluate multiple network architectures. Images showing large- or moderate-sized pneumothorax were considered positive, and those with trace or no pneumothorax were considered negative. Images showing small pneumothorax were excluded from training. Using an internal validation set (n = 1,993), we selected the 2 top-performing models; these models were then evaluated on a held-out internal test set based on area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and positive predictive value (PPV). The final internal test was performed initially on a subset with small pneumothorax excluded (as in training; n = 1,701), then on the full test set (n = 1,990), with small pneumothorax included as positive. External evaluation was performed using the National Institutes of Health (NIH) ChestX-ray14 set, a public dataset labeled for chest pathology based on text reports. All images labeled with pneumothorax were considered positive, because the NIH set does not classify pneumothorax by size. In internal testing, our "high sensitivity model" produced a sensitivity of 0.84 (95% CI 0.78-0.90), specificity of 0.90 (95% CI 0.89-0.92), and AUC of 0.94 for the test subset with small pneumothorax excluded. Our "high specificity model" showed sensitivity of 0.80 (95% CI 0.72-0.86), specificity of 0.97 (95% CI 0.96-0.98), and AUC of 0.96 for this set. PPVs were 0.45 (95% CI 0.39-0.51) and 0.71 (95% CI 0.63-0.77), respectively. Internal testing on the full set showed expected decreased performance (sensitivity 0.55, specificity 0.90, and AUC 0.82 for high sensitivity model and sensitivity 0.45, specificity 0.97, and AUC 0.86 for high specificity model). External testing using the NIH dataset showed some further performance decline (sensitivity 0.28-0.49, specificity 0.85-0.97, and AUC 0.75 for both). Due to labeling differences between internal and external datasets, these findings represent a preliminary step towards external validation.

CONCLUSIONS

We trained automated classifiers to detect moderate and large pneumothorax in frontal chest X-rays at high levels of performance on held-out test data. These models may provide a high specificity screening solution to detect moderate or large pneumothorax on images collected when human review might be delayed, such as overnight. They are not intended for unsupervised diagnosis of all pneumothoraces, as many small pneumothoraces (and some larger ones) are not detected by the algorithm. Implementation studies are warranted to develop appropriate, effective clinician alerts for the potentially critical finding of pneumothorax, and to assess their impact on reducing time to treatment.

High-Throughput Classification of Radiographs Using Deep Convolutional Neural Networks

The study aimed to determine if computer vision techniques rooted in deep learning can use a small set of radiographs to perform clinically relevant image classification with high fidelity. One thousand eight hundred eighty-five chest radiographs on 909 patients obtained between January 2013 and July 2015 at our institution were retrieved and anonymized. The source images were manually annotated as frontal or lateral and randomly divided into training, validation, and test sets. Training and validation sets were augmented to over 150,000 images using standard image manipulations. We then pre-trained a series of deep convolutional networks based on the open-source GoogLeNet with various transformations of the open-source ImageNet (non-radiology) images. These trained networks were then fine-tuned using the original and augmented radiology images. The model with highest validation accuracy was applied to our institutional test set and a publicly available set. Accuracy was assessed by using the Youden Index to set a binary cutoff for frontal or lateral classification. This retrospective study was IRB approved prior to initiation. A network pre-trained on 1.2 million greyscale ImageNet images and fine-tuned on augmented radiographs was chosen. The binary classification method correctly classified 100 % (95 % CI 99.73–100 %) of both our test set and the publicly available images. Classification was rapid, at 38 images per second. A deep convolutional neural network created using non-radiological images, and an augmented set of radiographs is effective in highly accurate classification of chest radiograph view type and is a feasible, rapid method for high-throughput annotation.

Radiation Dose Reduction during Uterine Fibroid Embolization Using an Optimized Imaging Platform

PURPOSE

To assess radiation dose reduction during uterine fibroid embolization (UFE) using an optimized angiographic processing and acquisition platform.

MATERIALS AND METHODS

Radiation dose data for 70 women (mean age, 46 y; range, 34-67 y) who underwent UFE were retrospectively analyzed. Twenty-one patients underwent UFE using the baseline fluoroscopic and angiographic image acquisition platform, and 49 underwent UFE after implementing an optimized imaging platform in otherwise identical angiography suites. Cumulative kerma-area product (CKAP), cumulative air kerma (CAK), total fluoroscopy time, and image exposure number were collected for each procedure. Image quality was assessed by 3 interventional radiologists blinded to the platform used for image acquisition and processing.

RESULTS

Patients undergoing UFE using the new x-ray fluoroscopy platform had significantly lower CKAP and CAK indicators than patients for whom baseline settings were used. Mean CKAP decreased by 60% from 438.5 Gy · cm² (range, 180.3-1,081.1 Gy · cm²) to 175.2 Gy · cm² (range, 47.1-757.0 Gy · cm²; P < .0001). Mean CAK decreased by 45% from 2,034.2 mGy (range, 699.3-5,056.0 mGy) to 1,109.8 mGy (range, 256.6-4,513.6 mGy; P = .001). No degradation of image quality was identified through qualitative evaluation.

CONCLUSIONS

Significant reduction in patient radiation dose indicators can be achieved with use of an optimized image acquisition and processing platform.

Radioembolization with 90Y glass microspheres for the treatment of unresectable metastatic liver disease from chemotherapy-refractory gastrointestinal cancers: final report of a prospective pilot study

BACKGROUND

This prospective pilot single-institution study was undertaken to document the feasibility, safety, and efficacy of radioembolization of liver-dominant metastatic gastrointestinal cancer using ⁹⁰Y glass microspheres.

METHODS

Between June 2010 and October 2013, 42 adult patients (26 men, 16 women; median age 60 years) with metastatic chemotherapy-refractory unresectable colorectal (n=21), neuroendocrine (n=11), intrahepatic bile duct (n=7), pancreas (n=2), and esophageal (n=1) carcinomas underwent 60 lobar or segmental administrations of ⁹⁰Y glass microspheres. Data regarding clinical and laboratory adverse events (AE) were collected prospectively for up to 5.5 years after radioembolization. Radiographic responses were evaluated using Response Evaluation Criteria in Solid Tumors (RECIST), version 1.1. Time to maximum response, response duration, progression-free survival (PFS) (hepatic and extrahepatic), and overall survival (OS) were measured.

RESULTS

Median target dose and activity were 109.4 Gy and 2.6 GBq per treatment session, respectively. Majority of clinical AE were grade 1 or 2 in severity. Patients with colorectal cancer had hepatic objective response rate (ORR) of 25% and a hepatic disease control rate (DCR) of 80%. Median PFS and OS were 1.0 and 4.4 months, respectively. Patients with neuroendocrine tumors (NET) had hepatic ORR and DCR of 73% and 100%, respectively. Median PFS was 8.9 months for this cohort. DCR and median PFS and OS for patients with cholangiocarcinoma were 86%, 1.1 months, and 6.7 months, respectively.

CONCLUSIONS

⁹⁰Y glass microspheres device has a favorable safety profile, and achieved prolonged disease control of hepatic tumor burden in a subset of patients, including all patients enrolled in the neuroendocrine cohort.

Catheter directed interventions for acute deep vein thrombosis

Venous thromboembolism (VTE) is an extremely common form of vascular disease and impacts a great number of patients worldwide. Acute deep vein thrombosis (DVT) is a subset of VTE and is traditionally been treated with anticoagulation. There is good quality data which suggests the use of catheter directed interventions for the treatment of acute DVT with the aim of reducing post-thrombotic syndrome (PTS). The present review will discuss the various therapies available for acute DVT, focusing on catheter directed interventions, ranging from traditional anticoagulation to the most novel forms of aspiration thrombectomy.

Emphysematous pyelonephritis: the impact of urolithiasis on disease severity

Background

Emphysematous pyelonephritis is a severe infection of the kidney associated with formation of gas in the renal parenchyma and/or collecting system. The purpose of this study was to evaluate outcomes of patients with emphysematous pyelonephritis in a contemporary cohort and to evaluate the impact of urolithiasis on disease severity.

Methods

A search of all imaging reports at University of California San Francisco (UCSF) for the term “emphysematous pyelonephritis” was undertaken from 2003–2014. Patients were included if there was clinical evidence of infection, no recent urologic instrumentation, and computerized tomography (CT) demonstrating gas in the renal parenchyma or collecting system. Clinical and laboratory variables were obtained from medical records.

Results

A total of 14 cases were identified. The majority of patients (57%) had gas confined to the collecting system. Three patients (21%) had gas in the renal parenchyma and 3 patients (21%) had gas extending into perirenal tissues. A total of 8 patients (57%) had concomitant urolithiasis. Seven patients (50%) were managed with antibiotic therapy alone while 6 patients (43%) required percutaneous drainage. No patients required immediate nephrectomy. There were no deaths. Patients with urolithiasis had less severe emphysematous pyelonephritis than patients without urolithiasis (P<0.05).

Conclusions

The majority of patients in this study had gas contained within the collecting system and were treated successfully with antibiotics alone. Percutaneous drainage was successfully utilized in patients with more advanced disease. No patients required emergent nephrectomy. Emphysematous pyelonephritis in patients with urolithiasis was less severe than in patients without urolithiasis.

Periprocedural Patient Care

Periprocedural care of patients who undergo image-guided interventions is a task of monumental importance. As physicians who perform procedures, radiologists rely on their noninterpretive skills to optimize patient care. At the center of periprocedural care is proper patient identification. It is imperative to perform the indicated procedure for the correct patient. It is also of great importance to discuss with the patient the nature of the procedure. This conversation should include the indications, risks, benefits, alternatives, and potential complications of the procedure. Once the patient agrees to the procedure and grants informed consent, it is imperative to stop and confirm that the correct procedure is being performed on the correct patient. This universal time-out policy helps decrease errors and improves patient care. To optimize our interpretative and procedural skills, it may be necessary to provide the patient with sedation or anesthesia. However, it is important to understand the continuum of sedation and be able to appropriately monitor the patient and manage the sedation in these patients. To minimize the risks of infection, periprocedural care of patients relies on aseptic or, at times, sterile techniques. Before the procedure, it is important to evaluate the patient's coagulation parameters and bleeding risks and correct the coagulopathy, if needed. During the procedure, the patient's blood pressure and at times the patient's glucose levels will also require monitoring and management. After the procedure, patients must be observed in a recovery unit and deemed safe for discharge. The fundamental components of periprocedural care necessary to enhance patient safety, satisfaction, and care are reviewed to familiarize the reader with the important noninterpretive skills necessary to optimize periprocedural care.

Phytoplankton production and taxon-specific growth rates in the Costa Rica Dome

During summer 2010, we investigated phytoplankton production and growth rates at 19 stations in the eastern tropical Pacific, where winds and strong opposing currents generate the Costa Rica Dome (CRD), an open-ocean upwelling feature. Primary production (¹⁴C-incorporation) and group-specific growth and net growth rates (two-treatment seawater dilution method) were estimated from samples incubated in situ at eight depths. Our cruise coincided with a mild El Niño event, and only weak upwelling was observed in the CRD. Nevertheless, the highest phytoplankton abundances were found near the dome center. However, mixed-layer growth rates were lowest in the dome center (∼0.5-0.9 day^-1), but higher on the edge of the dome (∼0.9-1.0 day^-1) and in adjacent coastal waters (0.9-1.3 day^-1). We found good agreement between independent methods to estimate growth rates. Mixed-layer growth rates of Prochlorococcus and Synechococcus were largely balanced by mortality, whereas eukaryotic phytoplankton showed positive net growth (∼0.5-0.6 day^-1), that is, growth available to support larger (mesozooplankton) consumer biomass. These are the first group-specific phytoplankton rate estimates in this region, and they demonstrate that integrated primary production is high, exceeding 1 g C m^-2 day^-1 on average, even during a period of reduced upwelling.

Biomass and composition of protistan grazers and heterotrophic bacteria in the Costa Rica Dome during summer 2010

We investigated biomass and composition of heterotrophic microbes in the Costa Rica Dome during June-July 2010 as part of a broader study of plankton trophic dynamics. Because picophytoplankton (<2 μm) are known to dominate in this unique upwelling region, we hypothesized tight biomass relationships between size-determined predator-prey pairs (i.e. picoplankton-nano-grazers, nanoplankton-micro-grazers) within the microbial community. Integrated biomass of heterotrophic bacteria ranged from 180 to 487 mg C m^-2 and was significantly correlated with total autotrophic carbon. Heterotrophic protist (H-protist) biomass ranged more narrowly from 488 to 545 mg C m^-2, and was comprised of 60% dinoflagellates, 30% other flagellates and 11% ciliates. Nano-sized (<20 μm) protists accounted for the majority (57%) of grazer biomass and were positively correlated with picoplankton, partially supporting our hypothesis, but nanoplankton and micro-grazers (>20 μm) were not significantly correlated. The relative constancy of H-protist biomass among locations despite clear changes in integrated autotrophic biomass, Chl a, and primary production suggests that mesozooplankton may exert a tight top-down control on micro-grazers. Biomass-specific consumption rates of phytoplankton by protistan grazers suggest an instantaneous growth rate of 0.52 day^-1 for H-protists, similar to the growth rate of phytoplankton and consistent with a trophically balanced ecosystem dominated by pico-nanoplankton interactions.

Net biogenic silica production and the contribution of diatoms to new production and organic matter export in the Costa Rica Dome ecosystem

We determined the net rate of biogenic silica (bSiO₂) production and estimated the diatom contribution to new production and organic matter export in the Costa Rica Dome during summer 2010. The shallow thermocline significantly reduces bSiO₂ dissolution rates below the mixed layer, leading to significant enhancement of bSiO₂ relative to organic matter (silicate-pump condition). This may explain why deep export of bSiO₂ in this region is elevated by an order of magnitude relative to comparable systems. Diatom carbon, relative to autotrophic carbon, was low (<3%); however, the contribution of diatoms to new production averaged 3 and 13% using independent approaches. The 4-old discrepancy between methods may be explained by a low average C:Si ratio (∼1.4) for the net produced diatom C relative to the net produced bSiO₂. We speculate that this low production ratio is not the result of reduced C, but may arise from a significant contribution of non-diatom silicifying organisms to bSiO₂ production. The contribution of diatoms to organic matter export was minor (5.7%). These results, and those of the broader project, suggest substantial food-web transformation of diatom organic matter in the euphotic zone, which creates enriched bSiO₂ relative to organic matter within the exported material.

The biological pump in the Costa Rica Dome: an open-ocean upwelling system with high new production and low export

The Costa Rica Dome is a picophytoplankton-dominated, open-ocean upwelling system in the Eastern Tropical Pacific that overlies the ocean's largest oxygen minimum zone. To investigate the efficiency of the biological pump in this unique area, we used shallow (90-150 m) drifting sediment traps and 234Th:238U deficiency measurements to determine export fluxes of carbon, nitrogen and phosphorus in sinking particles. Simultaneous measurements of nitrate uptake and shallow water nitrification allowed us to assess the equilibrium balance of new and export production over a monthly timescale. While f-ratios (new:total production) were reasonably high (0.36 ± 0.12, mean ± standard deviation), export efficiencies were considerably lower. Sediment traps suggested e-ratios (export/14C-primary production) at 90-100 m ranging from 0.053 to 0.067. ThE-ratios (234Th disequilibrium-derived export) ranged from 0.038 to 0.088. C:N and N:P stoichiometries of sinking material were both greater than canonical (Redfield) ratios or measured C:N of suspended particulates, and they increased with depth, suggesting that both nitrogen and phosphorus were preferentially remineralized from sinking particles. Our results are consistent with an ecosystem in which mesozooplankton play a major role in energy transfer to higher trophic levels but are relatively inefficient in mediating vertical carbon flux to depth, leading to an imbalance between new production and sinking flux.

Phytoplankton production and grazing balances in the Costa Rica Dome

We investigated phytoplankton production rates and grazing fates in the Costa Rica Dome (CRD) during summer 2010 based on dilution depth profiles analyzed by flow cytometry and pigments and mesozooplankton grazing assessed by gut fluorescence. Three community production estimates, from ¹⁴C uptake (1025 ± 113 mg C m^-2 day^-1) and from dilution experiments analyzed for total Chla (990 ± 106 mg C m^-2 day^-1) and flow cytometry populations (862 ± 71 mg C m^-2 day^-1), exceeded regional ship-based values by 2-3-fold. Picophytoplankton accounted for 56% of community biomass and 39% of production. Production profiles extended deeper for Prochlorococcus (PRO) and picoeukaryotes than for Synechococcus (SYN) and larger eukaryotes, but 93% of total production occurred above 40 m. Microzooplankton consumed all PRO and SYN growth and two-third of total production. Positive net growth of larger eukaryotes in the upper 40 m was balanced by independently measured consumption by mesozooplankton. Among larger eukaryotes, diatoms contributed ∼3% to production. On the basis of this analysis, the CRD region is characterized by high production and grazing turnover, comparable with or higher than estimates for the eastern equatorial Pacific. The region nonetheless displays characteristics atypical of high productivity, such as picophytoplankton dominance and suppressed diatom roles.

Patterns of microbial community biomass, composition and HPLC diagnostic pigments in the Costa Rica upwelling dome

We investigated biomass, size-structure, composition, depth distributions and spatial variability of the phytoplankton community in the Costa Rica Dome (CRD) in June-July 2010. Euphotic zone profiles were sampled daily during Lagrangian experiments in and out of the dome region, and the community was analyzed using a combination of digital epifluorescence microscopy, flow cytometry and HPLC pigments. The mean depth-integrated biomass of phytoplankton ranged 2-fold, from 1089 to 1858 mg C m^-2 (mean ± SE = 1378 ± 112 mg C m^-2), among 4 water parcels tracked for 4 days. Corresponding mean (±SE) integrated values for total chlorophyll a (Chl a) and the ratio of autotrophic carbon to Chl a were 24.1 ± 1.5 mg Chl a m^-2 and 57.5 ± 3.4, respectively. Absolute and relative contributions of picophytoplankton (∼60%), Synechococcus (>33%) and Prochlorococcus (17%) to phytoplankton community biomass were highest in the central dome region, while >20 µm phytoplankton accounted for ≤10%, and diatoms <2%, of biomass in all areas. Nonetheless, autotrophic flagellates, dominated by dinoflagellates, exceeded biomass contributions of Synechococcus at all locations. Order-of-magnitude discrepancies in the relative contributions of diatoms (overestimated) and dinoflagellates (underestimated) based on diagnostic pigments relative to microscopy highlight potential significant biases associated with making community inferences from pigments.

Techniques for Transjugular Intrahepatic Portosystemic Shunt Reduction and Occlusion

Transjugular intrahepatic portosystemic shunts (TIPS) effectively lower portal pressure and are commonly used to manage selected patients with variceal bleeding. Unfortunately, significant consequences are not infrequently encountered as a result of this diversion of portal venous flow. These consequences include disabling hepatic encephalopathy as well as hepatic decompensation. To manage these complications, therapeutic options include TIPS reduction and TIPS occlusion. TIPS reduction is the favored technique because of the potential for venous thrombosis and recurrent variceal hemorrhage after acute TIPS occlusion. Techniques and indications for TIPS reduction and TIPS occlusion are reviewed.

Crossed legs: an unexpected occurrence during an ALN filter placement

Inferior vena cava (IVC) filter placement is indicated for patients with pulmonary embolism and/or deep venous thrombosis when anticoagulation therapy is contraindicated. IVC filter placement, however, is not without complications. In this case, we noted crossing of the filter struts immediately after deployment of the ALN IVC filter (ALN Implants Chirurgicaux Ghisonaccia, France). The filter was then successfully removed.

The inferior emissary vein: a reliable landmark for right adrenal vein sampling

BACKGROUND

Right adrenal vein (RAV) catheterization can be a very challenging step in adrenal venous sampling (AVS). Visualization of the inferior emissary vein (IEV) may be an indication of successful RAV catheterization.

PURPOSE

To compare the rate of successful RAV sampling in the presence of the IEV.

MATERIAL AND METHODS

Retrospective review of all consecutive patients with PA who underwent AVS between April 2009 and April 2012 was performed. A total of 30 patients were identified. Procedural images, cortisol, and aldosterone values obtained from sampling of the RAV and inferior vena cava (IVC) were reviewed. Cortisol measurements obtained from RAV samples were divided by measurements from the infra-renal IVC blood samples in order to calculate the selectivity index (SI). An SI >3 was considered indicative of technically successful RAV sampling.

RESULTS

RAV sampling was considered technically successful in 29 out of 30 cases (97%). In cases of successful RAV sampling (29 patients), the IEV was identified in 25 patients (86%). The IEV was visualized in isolation in 16 patients (64%), and in conjunction with visualization of the RAV or right adrenal gland stain in nine patients (36%). The IEV was not visualized in the one case of unsuccessful RAV sampling. Visualizing the IEV had a sensitivity of 86.2% for successful RAV sampling.

CONCLUSION

The IEV may serve as a reliable landmark for the RAV during RAV sampling.

Implications of discordant findings between hepatic angiography and cross-sectional imaging in transplant candidates with hepatocellular carcinoma

The goal of this study was to determine whether the detection of discordant numbers of hypervascular foci at hepatic angiography versus contrast-enhanced (CE) cross-sectional imaging [computed tomography (CT) or magnetic resonance imaging (MRI)] is associated with adverse clinical outcomes in patients with hepatocellular carcinoma (HCC) who are listed for liver transplantation. We retrospectively reviewed the records of 218 consecutive patients with HCC who were listed for a liver transplant and who underwent transarterial chemoembolization at our institution between January 1, 2006 and December 31, 2010. Patients were grouped into 3 categories: (1) the number of nodules at CT/MRI was concordant with the number of hypervascular foci detected at angiography (n=136), (2) the number of nodules at CT/MRI was greater than the number of hypervascular foci at angiography (n=45), and (3) the number of nodules at CT/MRI was fewer than the number of hypervascular foci at angiography (n=37). The study outcomes were liver transplantation and tumor recurrence after transplantation. The detection of at least 3 more hypervascular foci at angiography versus the number of HCC nodules on CT/MRI was associated with a significantly lower rate of transplantation [multivariate subhazard ratio (SHR), 0.39; 95% confidence interval (CI), 0.17-0.92]. The detection of fewer hypervascular foci at angiography versus the number of HCC nodules on CT/MRI was associated with a significantly higher rate of tumor recurrence after transplantation (multivariate SHR, 3.49; 95% CI, 1.27-9.56). In conclusion, liver transplant candidates with HCC who demonstrate discordant findings between angiography and CE CT or MRI may be at a higher risk for dropout from the transplant list and for tumor recurrence after transplantation.

Clinical outcomes of percutaneous drainage of breast fluid collections after mastectomy with expander-based breast reconstruction

PURPOSE

To determine clinical outcomes of patients who underwent imaging-guided percutaneous drainage of breast fluid collections after mastectomy and breast reconstruction.

MATERIALS AND METHODS

A retrospective review was performed including all consecutive patients who underwent percutaneous drainage of fluid collections after mastectomy with tissue expander-based reconstruction between January 2007 and September 2012. During this period, 879 mastectomies (563 patients) with expander-based breast reconstruction were performed. Fluid collections developed in 28 patients (5%), which led to 30 imaging-guided percutaneous drainage procedures. The median follow-up time was 533 days. Patient characteristics, surgical technique, microbiology analysis, and clinical outcomes were reviewed.

RESULTS

The mean age of patients was 51.5 years (range, 30.9-69.4 y), and the median time between breast reconstruction and drainage was 35 days (range, 4-235 d). Erythema and swelling were the most common presenting symptoms. The median volume of fluid evacuated at the time of drain placement was 70 mL. Drains were left in place for a median 14 days (range, 6-34 d). Microorganisms were detected in the fluid in 12 of 30 drainage procedures, with Staphylococcus aureus being the most common microorganism. No further intervention was needed in 21 of 30 drainage procedures (70%). However, surgical intervention (removal of expanders) was needed after 6 (20%) drainage procedures, and additional percutaneous drainage procedures were performed after 3 (10%) drainage procedures.

CONCLUSIONS

Percutaneous drainage is an effective means of treating postoperative fluid collections after expander-based breast reconstruction and can obviate the need for repeat surgery in most cases.

Creation of a percutaneous mesocaval shunt to control variceal bleeding in a child

Although transjugular intrahepatic portosystemic shunt (TIPS) placement is the standard procedure for the treatment of portal hypertension, it is often impossible to perform in patients with extrahepatic portal vein occlusion. In these patients, options for decompressing the liver are few. In this report, we present a novel solution for managing gastro-esophageal hemorrhage in a child with portal hypertension and extrahepatic portal vein occlusion, through the creation of a percutaneous mesocaval shunt.

Efficacy of TACE in TIPS patients: comparison of treatment response to chemoembolization for hepatocellular carcinoma in patients with and without a transjugular intrahepatic portosystemic shunt

PURPOSE

To compare treatment response after transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) in patients with and without a transjugular intrahepatic portosystemic shunt (TIPS).

MATERIALS AND METHODS

A retrospective review of patients who underwent conventional TACE for HCC between January 2005 and December 2009 identified 10 patients with patent TIPS. From the same time period, 23 patients without TIPS were selected to control for comparable Model for End-Stage Liver Disease and Child-Pugh-Turcotte scores. The two groups showed similar distribution of Barcelona Clinic Liver Cancer and United Network of Organ Sharing stages. Target HCC lesions were evaluated according to the modified response evaluation criteria in solid tumors (mRECIST) guidelines. Transplantation rate, time to tumor progression, and overall survival (OS) were documented.

RESULTS

After TACE, the rate of complete response was significantly greater in non-TIPS patients compared with TIPS patients (74 vs. 30 %, p = 0.03). Objective response rate (complete and partial response) trended greater in the non-TIPS group (83 vs. 50 %, p = 0.09). The liver transplantation rate was 80 and 74 % in the TIPS and non-TIPS groups, respectively (p = 1.0). Time to tumor progression was similar (p = 0.47) between the two groups. OS favored the non-TIPS group (p = 0.01) when censored for liver transplantation.

CONCLUSION

TACE is less effective in achieving complete or partial response using mRECIST criteria in TIPS patients compared with those without a TIPS. Nevertheless, similar clinical outcomes may be achieved, particularly in TIPS patients who are liver-transplantation candidates.

A late haemorrhagic complication in an arteriovenous malformation cured with radiosurgery. Case report

Radiosurgery is a recognized safe form of treating and usually curing arteriovenous malformations (AVMs). Complications related to radiosurgery, especially late sequelae, are rare. Such sequelae may be secondary to incomplete treatment of the original lesion such as haemorrhage, or secondary to the radiation damage to the tissue, or both. Sometimes treatment may induce new lesions. We report a patient who had an AVM cured with radiosurgery, but developed hemisensory loss acutely and had changes on MRI in keeping with a haematoma. We discuss the possible differential diagnosis that should be considered.

The management of very small/blister internal carotid artery aneurysms

Blood blister aneuryms are uncommon lesions that have a poor natural history. Because there is no clear aneurysmal sac to treat they remain challenging lesions to manage whether the approach is endovascular or surgical. Although the management of intracranial cerebral aneurysms has changed subsequent to the results published by the ISAT trial, there still exist groups of aneurysms which do not lend themselves to endovascular management. There are recent reports of successful endovascular management using flow diverting approaches but experience is limited and relying on flow change may be insufficient to prevent re-rupture. Surgery when possible offers the advantage of immediate vessel wall reconstruction.

Relationship of the dietary phytochemical index to weight gain, oxidative stress and inflammation in overweight young adults

BACKGROUND

Phytochemicals are bioactive nutrients that help reduce disease risk. A high intake of these compounds is important for optimal health and prevention of disease, but quantification of these nutrients in vivo is costly and time consuming. The present examined whether an alternative, simple 'phytochemical index' (PI) ratio calculation (PI = the ratio of the energy from high-nutrient phytochemical-rich foods to overall daily energy consumed [kJ phytochemical rich foods/total kJ consumed]) was related to several precursors of future disease: annual weight gain, adiposity, oxidative stress and inflammation.

METHODS

This was a cross-sectional, quantitative, descriptive study (n = 54, age range 18-30 years). Participants were stratified into normal weight and overweight groups. Three-day dietary records were analysed for food items, food groups, energy and the PI score at repeated time points. Blood plasma samples were analysed by colorimetric or an enzyme-linked immunoabsorbent assay for cholesterol subfractions, glycated haemoglobin, total antioxidant status, lipid hydroperoxides, cytokines (interleukins-1beta and -6) and C-reactive protein).

RESULTS

PI values were higher in the overweight-obese group. Correlation values between the PI score and body mass index, waist circumference, waist-to-hip ratio and plasma oxidative stress were significant. The PI score did not correlate with any cytokine levels. The PI score was a significant contributor to yearly weight gain.

CONCLUSIONS

The PI is inversely related to adiposity and oxidative stress in healthy young adults, and is responsive to body weight changes. This simple, easy to administer index might be useful as a dietary target for appropriate proportion consumption of nutrient-rich foods in weight reduction or management programmes.

Biomarkers and potential mechanisms of obesity-induced oxidant stress in humans

OBJECTIVE

Oxidative stress may be the unifying mechanism underlying the development of comorbidities in obesity. Evidence suggests that a clustering of sources of oxidative stress exists in obesity: hyperglycemia, hyperleptinemia, increased tissue lipid levels, inadequate antioxidant defenses, increased rates of free radical formation, enzymatic sources within the endothelium, and chronic inflammation.

METHOD

This review provides a summary of the available evidence on systemic oxidative stress in humans and specific metabolic pathways by which obesity may elevate systemic oxidant stress. The authors suggest possible methods of reducing oxidative stress such as antioxidant supplementation, caloric restriction and/or physical activity and surgical intervention to combat free radicals and reduce adipose tissue.

RESULTS

Obesity is associated with oxidative stress and can be reduced with weight loss (regardless of exercise or surgery induced weight loss), caloric restriction or antioxidant rich diets.

CONCLUSION

Oxidative stress levels are elevated in human obesity, and these levels are modifiable with various lifestyle modifications and surgical interventions.

Development of transplantable nervous tissue constructs comprised of stretch-grown axons

Pursuing a new approach to nervous system repair, fasciculated axon tracts grown in vitro were developed into nervous tissue constructs designed to span peripheral nerve or spinal cord lesions. We optimized the newfound process of extreme axon stretch growth to maximize the number and length of axon tracts, reach an unprecedented axon growth-rate of 1cm/day, and create 5cm long axon tracts in 8 days to serve as the core component of a living nervous tissue construct. Immunocytochemical analysis confirmed that elongating fibers were axons, and that all major cytoskeletal constituents were present across the stretch-growth regions. We formed a transplantable nervous tissue construct by encasing the elongated cells in an 80% collagen hydrogel, removing them from culture, and inserting them into a synthetic conduit. Alternatively, we induced axon stretch growth directly on a surgical membrane that could be removed from the elongation device, and formed into a cylindrical construct suitable for transplant. The ability to rapidly create living nervous tissue constructs that recapitulates the uniaxial orientations of the original nerve offers an unexplored and potentially complimentary direction in nerve repair. Ideally, bridging nerve damage with living axon tracts may serve to establish or promote new functional connections.

Traumatic axonal injury induces proteolytic cleavage of the voltage-gated sodium channels modulated by tetrodotoxin and protease inhibitors

We demonstrated previously that dynamic stretch injury of cultured axons induces structural changes and Ca2+ influx modulated by tetrodotoxin (TTX)-sensitive voltage-gated sodium channels (NaChs). In the present study, we evaluated potential damage to the NaCh alpha-subunit, which can cause noninactivation of NaChs. In addition, we explored the effects of pre-injury and post-injury treatment with TTX and protease inhibition on proteolysis of the NaCh alpha-subunit and intra-axonal calcium levels ([Ca2+]i) over 60 min after trauma. After stretch injury, we found that [Ca2+]i continued to increase in untreated axons for at least 60 min. We also observed that the III-IV intra-axonal loop of the NaCh alpha-subunit was proteolyzed between 5 and 20 min after trauma. Pre-injury treatment of the axons with TTX completely abolished the posttraumatic increase in [Ca2+]i and proteolysis of the NaCh alpha-subunit. In addition, both pre-injury and post-injury inhibition of protease activity attenuated long-term increases in [Ca2+]i as well as mitigating degradation of the NaCh alpha-subunit. These results suggest a unique "feed-forward" deleterious process initiated by mechanical trauma of axons. Na+ influx through NaChs resulting from axonal deformation triggers initial increases in [Ca2+]i and subsequent proteolysis of the NaCh-subunit. In turn, degradation of the alpha-subunit promotes persistent elevations in [Ca2+]i, fueling additional pathologic changes. These observations may have important implications for developing therapeutic strategies for axonal trauma.

Paget's disease complicated by hydrocephalus and syringomyelia

The authors report a case of Paget's disease involving the skull with the rare but severe complications of hydrocephalus and syringomyelia related to basilar impression. Complications of Paget's disease of the skull are briefly discussed and current treatment strategies outlined.

A dissecting aneurysm of the posterior inferior cerebellar artery. A case report

SUMMARY

Dissecting aneurysms occur when blood extrudes into the wall of a vessel. Posterior circulation dissections are recognised as an important cause of cerbral infarction and subarachnoid haemorrhage(SAH), however posterior inferior cerebellar artery (PICA) aneurysmal dissections are rare. A 49-year-old man who presented with SAH was found to have a left PICA dissection on cerebral angiography. The lesion was treated with surgical clipping proximal to the dissection and a distal PICA to PICA anastomosis. The pathology, diagnosis, presentation and treatment of these difficult lesions is discussed.

Advantages of delayed VP shunting in post-haemorrhagic hydrocephalus seen in low-birth-weight infants

The optimal timing of ventriculo-peritoneal (VP) shunt insertion in a neonate with post-haemorrhagic hydrocephalus (PHH) is uncertain. During the 8-year period from January 1989 to December 1996, 41 patients had VP shunts inserted for PHH at Red Cross War Memorial Children's Hospital. Data on 36 patients were sufficient for review in order to determine whether the timing of surgery in any way influenced the complication incidence of this intervention. Nine of the 36 patients had a serious complication, either infection or mechanical shunt obstruction, during their initial hospital admission (early period). Nineteen patients had surgery performed before day 35 after birth and all those with early complications were in this group. Seventeen patients had surgery delayed until after day 35, and none of these patients had an early complication. In this study a higher complication incidence was noted when a VP shunt was inserted prior to day 35 (Chi-square test P < 0.01). This most probably correlates with a high concentration of blood breakdown products in the cerebrospinal fluid during the first month after intra-ventricular haemorrhage.

Static magnetic fields for treatment of fibromyalgia: a randomized controlled trial

OBJECTIVE

To test effectiveness of static magnetic fields of two different configurations, produced by magnetic sleep pads, as adjunctive therapies in decreasing patient pain perception and improving functional status in individuals with fibromyalgia.

DESIGN

Randomized, placebo-controlled, 6-month trial conducted from November 1997 through December 1998.

SETTING AND SUBJECTS

Adults who met the 1990 American College of Rheumatology criteria for fibromyalgia were recruited through clinical referral and media announcements and evaluated at a university-based clinic.

INTERVENTIONS

Subjects in Functional Pad A group used a pad for 6 months that provided whole-body exposure to a low, uniform static magnetic field of negative polarity. Subjects in the Functional Pad B group used a pad for 6 months that exposed them to a low static magnetic field that varied spatially and in polarity. Subjects in two Sham groups used pads that were identical in appearance and texture to the functional pads but contained inactive magnets; these groups were combined for analysis. Subjects in the Usual Care group continued with their established treatment regimens.

OUTCOME MEASURES

Primary outcomes were the change scores at 6 months in the following measures: functional status (Fibromyalgia Impact Questionnaire), pain intensity ratings, tender point count, and a tender point pain intensity score.

RESULTS

There was a significant difference among groups in pain intensity ratings (p = 0.03), with Functional Pad A group showing the greatest reduction from baseline at 6 months. All four groups showed a decline in number of tender points, but differences among the groups were not significant (p = 0.72). The functional pad groups showed the largest decline in total tender point pain intensity, but overall differences were not significant (p = 0.25). Improvement in functional status was greatest in the functional pad groups, but differences among groups were not significant (p = 0.23).

CONCLUSIONS

Although the functional pad groups showed improvements in functional status, pain intensity level, tender point count, and tender point intensity after 6 months of treatment, with the exception of pain intensity level these improvements did not differ significantly from changes in the Sham group or in the Usual Care group.

Use of binaural beat tapes for treatment of anxiety: a pilot study of tape preference and outcomes

CONTEXT

Recent studies and anecdotal reports suggest that binaural auditory beats can affect mood, performance on vigilance tasks, and anxiety.

OBJECTIVE

To determine whether mildly anxious people would report decreased anxiety after listening daily for 1 month to tapes imbedded with tones that create binaural beats, and whether they would show a definite tape preference among 3 tapes.

DESIGN

A 1-group pre-posttest pilot study.

SETTING

Patients' homes.

PARTICIPANTS

A volunteer sample of 15 mildly anxious patients seen in the Clinique Psyché, Montreal, Quebec.

INTERVENTION

Participants were asked to listen at least 5 times weekly for 4 weeks to 1 or more of 3 music tapes containing tones that produce binaural beats in the electroencephalogram delta/theta frequency range. Participants also were asked to record tape usage, tape preference, and anxiety ratings in a journal before and after listening to the tape or tapes.

MAIN OUTCOME MEASURES

Anxiety ratings before and after tape listening, pre- and post-study State-Trait Anxiety Inventory scores, and tape preferences documented in daily journals.

RESULTS

Listening to the binaural beat tapes resulted in a significant reduction in the anxiety score reported daily in patients' diaries. The number of times participants listened to the tapes in 4 weeks ranged from 10 to 17 (an average of 1.4 to 2.4 times per week) for approximately 30 minutes per session. End-of-study tape preferences indicated that slightly more participants preferred tape B, with its pronounced and extended patterns of binaural beats, over tapes A and C. Changes in pre- and posttest listening State-Trait Anxiety Inventory scores trended toward a reduction of anxiety, but these differences were not statistically significant.

CONCLUSIONS

Listening to binaural beat tapes in the delta/theta electroencephalogram range may be beneficial in reducing mild anxiety. Future studies should account for music preference among participants and include age as a factor in outcomes, incentives to foster tape listening, and a physiologic measure of anxiety reduction. A controlled trial that includes binaural beat tapes as an adjunctive treatment to conventional therapy for mild anxiety may be warranted.

Responsiveness of fibromyalgia clinical trial outcome measures

OBJECTIVE

To assess the responsiveness of the Fibromyalgia Impact Questionnaire (FIQ), patient ratings of pain intensity, number of tender points, and total tender point pain intensity score to perceived changes in clinical status in patients with fibromyalgia (FM).

METHODS

Using data from a randomized placebo controlled study evaluating efficacy of magnetic therapy in patients with FM, the ability of primary outcomes to detect clinically meaningful changes over a 6 month period was assessed by: (1) degree of association between outcome change scores and patient global ratings of symptom change (Spearman rank-order correlations); (2) ability of these scores to discriminate among groups of patients whose perceived health status had changed to varying degrees (ANOVA); (3) ability of these scores, individually and jointly, to discriminate between patients who had reported improvement and those who did not (logistic regression); (4) effect size, standardized response mean, and Guyatt's statistic were calculated to quantify responsiveness.

RESULTS

Correlations showed the outcome measures were moderately responsive to perceived symptomatic change. For FIQ, pain intensity ratings and number of tender points, differences in change scores between globally improved and unchanged groups and between globally improved and worsened groups were significant; for total tender point pain intensity, the globally improved differed from worsened group. FIQ outperformed the other measures in discriminating between patients who reported improvement from those who did not. Summary statistics were consistent with discriminatory analyses, indicating the measures were sensitive to improvement, but relatively unresponsive to decline.

CONCLUSION

The FIQ was the most responsive measure to perceived clinical improvement and we recommend its inclusion as a primary endpoint in FM clinical trials.

Complementary and alternative medicine and psychologic factors: toward an individual differences model of complementary and alternative medicine use and outcomes

CONTEXT

Complementary and alternative medicine (CAM) is in widespread use. Study of the psychologic factors associated with CAM use may provide descriptions of subgroups of health care consumers and give further insight into the reasons for using alternative therapies.

OBJECTIVES

To see if the use of CAM is associated with psychologic factors in two outpatient samples and one community sample.

SETTING

The University of Virginia Hospital and Charlottesville community.

PATIENTS

Patients at the Cancer Center (60) and Pain Management Center (63) and adults from the Charlottesville community (63) for a total of 186 participants.

DESIGN

A survey of CAM with psychologic assessment.

MAIN MEASURES

Level of CAM use, effectiveness ratings of CAM, positive affect, negative affect, and the Absorption Scale, which measures a personality factor associated with the capacity for focused attention and mind-body awareness.

RESULTS

Participants using six or fewer CAM scored an average of 13.9 on the Absorption Scale compared to participants using seven or more CAM, who scored an average of 21.4 on Absorption (F = 48.73, p < .0001). Higher effectiveness ratings of CAM were associated with greater positive affect. Pain Center patients rated alternative therapies as least effective, and reported lower positive affect and greater negative affect compared with the Cancer Center patients and community adults.

CONCLUSIONS

Above average use of CAM is associated with higher education, greater well-being and higher Absorption. The personality traits associated with alternative therapies are compatible with participation in these therapies and may facilitate the capacity to benefit from them.