Fostering research in pediatric interventional radiology: needs assessment and suggestions for support

BACKGROUND

Due to the rarity of pediatric diseases, collaborative research is the key to maximizing the impact of research studies. A research needs assessment survey was created to support initiatives to foster pediatric interventional radiology research.

OBJECTIVE

To assess the status of pediatric interventional radiology research, identify perceived barriers, obtain community input on areas of research/education/support, and create metrics for evaluating changes/responses to programmatic initiatives.

MATERIALS AND METHODS

A survey link was sent to approximately 275 members of the Society for Pediatric Interventional Radiology (SPIR) between May and October 2020. Data was collected using a web-based interface. Data collected included practice setting, clinical role, research experience, research barriers, and suggestions for future initiatives.

RESULTS

Fifty-nine surveys were analyzed with a staff physician survey response rate of 28% (56/198). A wide range of practice sizes from 15 countries were represented. Respondents were predominantly staff physicians (95%; 56/59) with an average of 11 years (range: 1-25 years) of clinical experience working at academic or freestanding children's hospitals. A total of 100% (59/59) had research experience, and 70% (41/58) had published research with a mean of 30 peer-reviewed publications (range: 1-200). For job security, 56% (33/59) of respondents were expected or required to publish, but only 19% (11/58) had research support staff, and 42% (25/59) had protected research time, but of those, 36% (9/25) got the time "sometimes or never." Lack of support staff, established collaborative processes, and education were identified as top barriers to performing research.

CONCLUSIONS

The needs assessment survey demonstrated active research output despite several identified barriers. There is a widespread interest within the pediatric interventional radiology community for collaborative research.

Use of glue embolization in management of traumatic bile leak: A case report

Blunt abdominal trauma is a common cause of solid organ injury in children. Nonoperative management has been established as the standard of care for suspected liver and spleen injuries without peritonitis. Major ductal injury with resultant biloma is a rare complication of nonoperative management of blunt liver injury. Endoscopic retrograde cholangiopancreatography (ERCP) and/or percutaneous drain placement are considered to be safe adjuncts in the management of these bile leaks. However, in the rare cases of persistent bile leak, further nonoperative alternatives have not been reported. In this case report we present a novel multidisciplinary approach to managing persistent bile leaks in blunt liver injury.

Formulation development and characterization of lumefantrine nanosuspension for enhanced antimalarial activity

Variable and low oral bioavailability (4-11%) of lumefantrine (LUF), an anti-malarial agent, is characterized by very low solubility in aqueous vehicle. Thus, the present study was intended to formulate lyophilized nanosuspensions of LUF to resolve its solubility issues for the improvement of oral bioavailability. A three level 3² factorial design was applied to analyze the influence of independent variables, concentration of polysorbate 80 (X₁) and sonication time (X₂) on the responses for dependent variables, particle size (Y₁) and time to 90% release of LUF (t₉₀) (Y₂). Optimized formulation (F3) has shown to possess lowest particle size (95.34 nm) with minimum t₉₀ value (⁓3 mins), which was lyophilized to obtain the dry powder form of the nanosuspension. The characterization parameters confirmed the amorphous form of LUF with good stability and no chemical interactions of the drug with the incorporated components. Further, saturation solubility study revealed increased solubility of the LUF nanosuspension (1670 µg/mL) when compared to the pure drug (212.33 µg/mL). Further, rate of dissolution of LUF from the nanosuspension formulations were found to be significantly (p < 0.05) higher when compared to the pure drug. Fabricated lyophilized nanosuspension was found to be stable at 25 ± 2 °C/60 ± 5% RH and 40 ± 2 °C/75 ± 5% RH for the duration of three months. In conclusion, lyophilized nanosuspension showed ∼8-folds increase in drug release, which indicated a better way to offer higher release of LUF in controlling malaria.

Single-stage embolization with n-butyl cyanoacrylate and surgical resection of venous malformations

PURPOSE

Sclerotherapy or surgical resection is options for symptomatic venous malformations (VM). Sclerotherapy may require repetitive intervention and resection is often avoided due to operative morbidity. The purpose of this study was to report use of single-stage n-butyl cyanoacrylate glue embolization and surgical resection of focal VM.

METHODS

A review of patients with focal VM who underwent glue embolization followed by resection at a single tertiary care vascular malformations center was performed. All embolizations were performed with ultrasound and fluoroscopy under the same anesthetic as resection. Patient characteristics and outcomes were evaluated.

RESULTS

Fifteen procedures were performed in 12 patients with a total of 20 VM addressed, as several patients had multiple VM. Mean age was 16 ± 9 years. Malformation locations included scalp, hip, gluteal, labial, toe, finger, face, lip, chest, and foot and size ranged from 1.0 to 10.5 cm. Median (range) of prior sclerotherapy treatments was 3 (0-5) and three patients previously underwent surgical resection. Median blood loss was zero (0-10) mL. Surgical complications occurred after five procedures (33%) including superficial wound dehiscence and cellulitis. No complications required readmission or reoperation. At a median follow up of 195 (103-266) days, no patients have required additional treatment.

CONCLUSION

Glue embolization and resection of focal VM of variable size and location appears to have durable results and low surgical morbidity. This single-stage procedure, often performed as an outpatient, may be utilized as upfront treatment for symptomatic malformations or for VM refractory to other treatments.

Transarterial radioembolization with yttrium-90 of unresectable primary hepatic malignancy in children

BACKGROUND

Primary malignant liver tumors are rare, accounting for 1% to 2% of all childhood cancers. When chemotherapy fails, transarterial radioembolization with yttrium-90 (TARE-Y90) may offer an alternative therapy as a bridge to surgical resection or liver transplant or for palliation.

METHODS

We conducted a retrospective review of 10 pediatric patients with histologically confirmed primary liver malignancy who received treatment with TARE-Y90.

RESULTS

The median age at treatment was 5.5 years (range, 2-18 years). Median patient survival from initial diagnosis was 12.5 months (range, 10-28 months), and median patient survival after TARE-Y90 was 4 months (range, 2-20 months). Retreatment was well tolerated in three of 10 patients, with these patients demonstrating the longest survival times (range, 17-20 months). One patient was transplanted 6 weeks after TARE-Y90. By RECIST 1.1 criteria of all target lesions, eight of nine patients had stable disease, and one of nine had progressive disease. By mRECIST criteria (requiring postcontrast arterial phase imaging), two of seven patients had a partial response, four of seven had stable disease, and one of seven had progressive disease.

CONCLUSION

TARE-Y90 of unresectable primary liver malignancy is both technically feasible and demonstrates an anticancer effect, and retreatment is well tolerated. TARE-Y90 could be considered as adjunctive therapy in pediatric patients with unresectable hepatic malignancies and could be used as a bridge to surgical resection or liver transplant. More research is required to determine the efficacy of this treatment in children and to define the clinical scenarios where benefit is likely to be optimized.

CT-guided localization of pulmonary nodules in children prior to video-assisted thoracoscopic surgical resection utilizing a combination of two previously described techniques

BACKGROUND

Pulmonary nodules in pediatric oncology patients can present a diagnostic and treatment dilemma. Imaging findings are often nonspecific and tissue diagnosis may be required for appropriate treatment. The smaller subpleural nodules may not be visualized and cannot be palpated during video-assisted thoracoscopic surgical (VATS) resection. Preoperative localization has been beneficial in obtaining an adequate pathological specimen.

OBJECTIVE

This study presents experience in a large pediatric hospital using CT-guided preoperative localization of pulmonary nodules combining two previously utilized techniques, hook wire and methylene blue blood patch localization.

MATERIALS AND METHODS

A search of the electronic medical record utilizing a medical record search application was performed to identify all patients who underwent preoperative lung nodule localization during a 12.5-year period (July 1999 through January 2012). A retrospective chart review of these patients was then performed. Pre- and postoperative imaging, interventional radiology procedural images and reports, surgical reports, and pathology reports were obtained and evaluated.

RESULTS

Thirty-five patients, with 40 nodules, who underwent preoperative CT-guided lung nodule localization were identified. Patients ranged in age from 8 months to 21 years. The pulmonary nodules ranged in size from 1.4 mm to 18 mm. Twelve nodules were localized using a Kopans breast lesion localization needle with hook wire, 4 were localized using a methylene blue blood patch, and 24 were localized using the combination of these two techniques. The technical success rate of all procedures was 100%. A pathological diagnosis was determined in 39 patients (97.5%). There were 6 (15.0%) minor complications and no major complications.

CONCLUSION

CT-guided lung nodule localization using the combined techniques of methylene blue blood patch and hook wire is safe, technically feasible and successful in children. Using this combination of techniques will consistently yield a pathological diagnosis, is currently the preferred technique at our tertiary pediatric hospital and could be considered the new best practice.

Comparison of complications between pediatric peripherally inserted central catheter placement techniques

BACKGROUND

Peripherally inserted central catheter (PICC) is among the most common procedures performed in children in the hospital setting. PICC insertion can be simplified with the use of a sheathed needle as an alternative to the modified Seldinger technique.

OBJECTIVE

To retrospectively evaluate PICC placement for the technique used and the incidence of complications at a large pediatric tertiary care center.

MATERIALS AND METHODS

We retrospectively reviewed all PICC placements at a single institution over a 4-year period. We reviewed patient records for demographic data, PICC placement technique, catheter size and number of lumens, and the incidence of complications (i.e. multiple attempted puncture sites, phlebitis and vessel thrombosis). We analyzed complication rates between two placement techniques using a chi-square test.

RESULTS

We identified 8,816 successful PICC placements, 4,749 (53.9%) in males and 4,067 (46.1%) in females. The average age of the patients for which a line was placed was 5.6 years (range 1 day to 45 years). A direct sheathed needle puncture technique was used in 8,362 (94.9%) placements and a modified Seldinger technique was used in 454 (5.1%). Complications occurred in 312 (3.7%) of direct sheathed needle puncture placements versus 17 (3.7%) of modified Seldinger placements (P = 0.99). Multiple puncture sites were required in 175 (2.1%) attempted direct sheathed needle puncture placements compared with 8 (1.7%) attempted modified Seldinger placements (P = 0.63). Phlebitis occurred in 94 (1.1%) direct sheathed needle puncture lines versus 5 (1.1%) modified Seldinger placed lines (P = 0.96). Vessel thrombosis occurred in 43 (0.5%) direct sheathed needle puncture lines versus 4 (0.9%) modified Seldinger placed lines (P = 0.30).

CONCLUSION

The direct peel-away sheathed needle vessel puncture technique and the modified Seldinger technique used to place PICC lines in children have similar complication rates.

2014 Revised Classification of Vascular Lesions from the International Society for the Study of Vascular Anomalies: Radiologic-Pathologic Update

Since the publication of the seminal work on the histology-based classification of vascular anomalies by Mulliken and Glowacki in 1982 and the subsequent adoption of an expanded and modified version in 1996 by the International Society for the Study of Vascular Anomalies, an increasing number of vascular lesions have been recognized as histologically distinct entities. Furthermore, there have been significant advances in detailing the behavior and underlying genetics of previously identified lesions. These developments have required restructuring and expansion of the classification scheme so that appropriate therapies may be studied and implemented in affected patients. The new classification retains the broad categories of neoplasms and malformations but now divides the tumor group into benign, locally aggressive or borderline, and malignant, with the malformation group being divided into simple, combined, those of major named vessels, and those associated with other anomalies. Additionally, a category has been created for lesions in which the histology and behavior do not yet allow clear separation into neoplasm or malformation (thus named "provisionally unclassified vascular anomalies"). The known clinical courses and imaging, histologic, and genetic findings of the most common and/or clinically relevant lesions in the newly adopted revised system are reviewed in this article. (©)RSNA, 2016.

Use of rotational fluoroscopy and 3-D reconstruction for pre-operative imaging of complex cloacal malformations

Complex cloacal malformations are associated with a wide spectrum of anatomic defects involving the gastrointestinal, urinary, and gynecologic tracts; the variety and complexity of these defects complicate surgical planning and repair. Rotational fluoroscopy with 3-D reconstruction provides precise anatomic detail, particularly regarding length of the common channel, appearance/location of the vagina(s) and bladder, which facilitates surgical planning and determination of prognosis.

Efficacy and Safety of Sirolimus in the Treatment of Complicated Vascular Anomalies

BACKGROUND AND OBJECTIVES

Complicated vascular anomalies have limited therapeutic options and cause significant morbidity and mortality. This Phase II trial enrolled patients with complicated vascular anomalies to determine the efficacy and safety of treatment with sirolimus for 12 courses; each course was defined as 28 days.

METHODS

Treatment consisted of a continuous dosing schedule of oral sirolimus starting at 0.8 mg/m(2) per dose twice daily, with pharmacokinetic-guided target serum trough levels of 10 to 15 ng/mL. The primary outcomes were responsiveness to sirolimus by the end of course 6 (evaluated according to functional impairment score, quality of life, and radiologic assessment) and the incidence of toxicities and/or infection-related deaths.

RESULTS

Sixty-one patients were enrolled; 57 patients were evaluable for efficacy at the end of course 6, and 53 were evaluable at the end of course 12. No patient had a complete response at the end of course 6 or 12 as anticipated. At the end of course 6, a total of 47 patients had a partial response, 3 patients had stable disease, and 7 patients had progressive disease. Two patients were taken off of study medicine secondary to persistent adverse effects. Grade 3 and higher toxicities attributable to sirolimus included blood/bone marrow toxicity in 27% of patients, gastrointestinal toxicity in 3%, and metabolic/laboratory toxicity in 3%. No toxicity-related deaths occurred.

CONCLUSIONS

Sirolimus was efficacious and well tolerated in these study patients with complicated vascular anomalies. Clinical activity was reported in the majority of the disorders.

Ultrasound-Guided Botulinum Toxin Type A Salivary Gland Injection in Children for Refractory Sialorrhea: 10-Year Experience at a Large Tertiary Children's Hospital

BACKGROUND

Sialorrhea is problematic for neurologically impaired children, and botulinum toxin A salivary gland injection has been reported as effective in reducing sialorrhea. This article assesses the success and safety of ultrasound-guided weight-based botulinum toxin A injection for the management of sialorrhea in children.

METHODS

A total of 111 patients (63 males; 48 females; average age 7 years) with refractory sialorrhea were treated with ultrasound-guided botulinum toxin type A salivary gland injections (144 procedures) from July 1, 2004, to July 1, 2014, using a single weight-based protocol. Patient history, procedural records, and clinical follow-up documents were retrospectively reviewed. Clinical data were compared with reported effectiveness and complications using odds ratios.

RESULTS

A total of 144 procedures were performed in 111 patients with refractory sialorrhea. Cerebral palsy was the most common underlying etiology for sialorrhea (29%), whereas others included encephalopathy (5%), anoxic brain injury (4%), and a variety of chromosomal anomalies (5%). There was a 100% technical success rate. Overall treatment effectiveness was 68%. Repeat injections were not associated with increased clinical success. No procedure-related deaths or major complications were identified; the minor complication rate was less than 2%.

CONCLUSIONS

The protocol used for ultrasound-guided injection of botulinum toxin A proved to be safe and effective in children suffering from sialorrhea. Image guidance technique may lead to a reduction in rates of adverse events reported in other series. Subsequent procedures do not improve upon initial efficacy.

Comparison of pediatric radiation dose and vessel visibility on angiographic systems using piglets as a surrogate: antiscatter grid removal vs. lower detector air kerma settings with a grid - a preclinical investigation

The purpose of this study was to reduce pediatric doses while maintaining or improving image quality scores without removing the grid from X‐ray beam. This study was approved by the Institutional Animal Care and Use Committee. Three piglets (5, 14, and 20 kg) were imaged using six different selectable detector air kerma (Kair) per frame values (100%, 70%, 50%, 35%, 25%, 17.5%) with and without the grid. Number of distal branches visualized with diagnostic confidence relative to the injected vessel defined image quality score. Five pediatric interventional radiologists evaluated all images. Image quality score and piglet Kair were statistically compared using analysis of variance and receiver operating curve analysis to define the preferred dose setting and use of grid for a visibility of 2nd and 3rd order vessel branches. Grid removal reduced both dose to subject and imaging quality by 26%. Third order branches could only be visualized with the grid present; 100% detector Kair was required for smallest pig, while 70% detector Kair was adequate for the two larger pigs. Second order branches could be visualized with grid at 17.5% detector Kair for all three pig sizes. Without the grid, 50%, 35%, and 35% detector Kair were required for smallest to largest pig, respectively. Grid removal reduces both dose and image quality score. Image quality scores can be maintained with less dose to subject with the grid in the beam as opposed to removed. Smaller anatomy requires more dose to the detector to achieve the same image quality score.

PACS numbers: 87.53.Bn, 87.57.N‐, 87.57.cj, 87.59.cf, 87.59.Dj

Robot-assisted laparoscopic simple anatomic prostatectomy

Management options for men with symptomatic benign prostatic hyperplasia have increased in recent years. Surgery is recommended for patients who have renal insufficiency secondary to benign prostatic hyperplasia (BPH), who have recurrent urinary tract infections, bladder stones or gross hematuria caused by BPH, and those who have lower urinary tract symptoms refractory to other therapies. Technology is improving, and the use of endoscopic techniques with lasers has gained popularity. The use of robotics overcomes the limitations of pure laparoscopy. Robotic assistance helps in quicker skills acquisition. This article describes techniques for robotic-assisted laparoscopic simple anatomic prostatectomy in a step-by-step manner.

Endovascular venous thrombolysis in children younger than 24 months

PURPOSE

To evaluate the technical feasibility and safety of percutaneous endovascular thrombolysis for extremity deep venous thrombosis (DVT) in children < 24 months old.

MATERIALS AND METHODS

A retrospective chart review of a clinical and imaging database was performed for pediatric patients who underwent endovascular therapy for DVT between January 2010 and July 2013. Indications, techniques, technical and clinical success, and complications were reviewed. Techniques for thrombolysis included catheter-directed therapy (CDT) using alteplase infusion via a multi-side hole catheter, mechanical thrombectomy, and angioplasty. Short-term outcomes were assessed using surgical and imaging follow-up examinations for patency of the targeted vessel. Patients included 11 children (mean age, 9 mo; range, 3 wk-23 mo) who consecutively underwent endovascular thrombolysis for upper extremity (n = 6) or lower extremity (n = 5) DVT. The most common indication was preservation of venous access for future cardiac surgery or medical therapy.

RESULTS

The most common risk factor was the presence of a central venous catheter (10 of 11 patients). All patients with upper extremity DVT had congenital heart disease. CDT and angioplasty were performed in all patients. Venous patency was established in all patients. A grade III (95%-100%) thrombolysis response was achieved in seven patients, and a grade II (50%-95%) thrombolysis response was achieved in four patients. A major complication of pulmonary embolism occurred in one patient with upper extremity thrombolysis and was managed by intravenous systemic alteplase and heparin. No recurrence of thrombosis was found on average follow-up of 11.8 months (range, 1-41 mo).

CONCLUSIONS

Percutaneous endovascular thrombolysis for extremity DVT is safe and technically feasible in children < 24 months old.

Clinically useful dilution factors for iodine and gadolinium contrast material: an animal model of pediatric digital subtraction angiography using state-of-the-art flat-panel detectors

BACKGROUND

Iodinated and gadolinium contrast agents pose some risk for certain pediatric patients, including allergic-like reactions, contrast-induced nephropathy (CIN) and nephrogenic systemic fibrosis (NSF). Digital flat-panel detectors enhance image quality during angiography and might allow use of more dilute contrast material to decrease risk of complications that might be dose-dependent, such as CIN and NSF.

OBJECTIVE

To assess the maximum dilution factors for iodine- and gadolinium-based contrast agents suitable for vascular imaging with fluoroscopy and digital subtraction angiography (DSA) on digital flat-panel detectors in an animal model.

MATERIALS AND METHODS

We performed selective catheterization of the abdominal aorta, renal artery and common carotid artery on a rabbit. In each vessel we performed fluoroscopy and DSA during contrast material injection using iodinated and gadolinium contrast material at 100%, 80%, 50%, 33% and 20% dilutions. An image quality score (0 to 3) was assigned by each of eight evaluators. Intracorrelation coefficient, paired t-test, one-way repeated analysis of variance, Spearman correlation and receiver operating characteristic curve analysis were applied to the data.

RESULTS

Overall the image quality scores correlated linearly with dilution levels. For iodinated contrast material, the optimum cut-off level for DSA when a score of at least 2 is acceptable is above 33%; it is above 50% when a score of 3 is necessary. For gadolinium contrast material, the optimum cut-off for DSA images is above 50% when a score of at least 2 is acceptable and above 80% when a score of 3 is necessary.

CONCLUSION

Knowledge of the relationship between image quality and contrast material dilution might allow a decrease in overall contrast load while maintaining appropriate image quality when using digital flat-panel detectors.

Intrathyroidal thymic tissue mimicking a thyroid nodule in a 4-year-old child

A 4 year-old girl was referred for CT of her neck for suspected submental lymphadenopathy and was found to have an incidental low-attenuation thyroid mass. Subsequent thyroid ultrasound showed a heterogeneous thyroid mass with punctate areas of increased echogenicity. Cytologic examination was consistent with ectopic intrathyroidal thymic nodule. We review the presentation of ectopic thymic tissue, especially in the thyroid gland.

Synthesis, characterization, and evaluation of five coordinated copper(II) complexes as antibacterial, artificial nuclease, and SOD mimics

The copper(II) complexes with ciprofloxacin (CFLH), levofloxacin (LFLH), norfloxacin (NFLH), and neutral bidentate ligands have been synthesized and characterized. The complexes have been evaluated for their antibacterial activity against selective species. Complexes have been also checked for their interacting behavior with DNA, and were found to have two different modes of interaction, classical and partial intercalation. Tested complexes were found to be better antioxidants with their IC(50) values ranging from 0.51 to 0.97 μM.

Complex cloacal malformations: use of rotational fluoroscopy and 3-D reconstruction in diagnosis and surgical planning

A cloacal malformation is a congenital malformation in which the urinary tract, gynecological system and distal rectum fail to separate and form a common channel with a single perineal opening. Precise anatomical information is required to plan surgery and predict prognosis for children with this abnormality. Conventional fluoroscopic studies provide limited information, primarily due to the overlap of structures and inability to make accurate measurements. Rotational fluoroscopy and 3-D reconstruction help clarify overlapping structures and allow for precise measurement of the common channel, thereby helping to predict the complexity of the surgical case as well as the long-term prognosis regarding bowel, bladder and sexual function.

Tissue engineering of the penis

Congenital disorders, cancer, trauma, or other conditions of the genitourinary tract can lead to significant organ damage or loss of function, necessitating eventual reconstruction or replacement of the damaged structures. However, current reconstructive techniques are limited by issues of tissue availability and compatibility. Physicians and scientists have begun to explore tissue engineering and regenerative medicine strategies for repair and reconstruction of the genitourinary tract. Tissue engineering allows the development of biological substitutes which could potentially restore normal function. Tissue engineering efforts designed to treat or replace most organs are currently being undertaken. Most of these efforts have occurred within the past decade. However, before these engineering techniques can be applied to humans, further studies are needed to ensure the safety and efficacy of these new materials. Recent progress suggests that engineered urologic tissues and cell therapy may soon have clinical applicability.

Fetal MRI clues to diagnose cloacal malformations

BACKGROUND

Prenatal US detection of cloacal malformations is challenging and rarely confirms this diagnosis.

OBJECTIVE

To define the prenatal MRI findings in cloacal malformations.

MATERIALS AND METHODS

We performed a retrospective study of patients with cloacal malformations who had pre- and post-natal assessment at our institution. Fetal MRI was obtained in six singleton pregnancies between 26 and 32 weeks of gestation. Imaging analysis was focused on the distal bowel, the urinary system and the genital tract and compared with postnatal clinical, radiological and surgical diagnoses.

RESULTS

The distal bowel was dilated and did not extend below the bladder in five fetuses. They had a long common cloacal channel (3.5-6 cm) and a rectum located over the bladder base. Only one fetus with a posterior cloacal variant had a normal rectum. Three fetuses had increased T2 signal in the bowel and two increased T1/decreased T2 signal bladder content. All had renal anomalies, four had abnormal bladders and two had hydrocolpos.

CONCLUSION

Assessment of the anorectal signal and pelvic anatomy during the third trimester helps to detect cloacal malformations in the fetus. The specificity for this diagnosis was highly increased when bowel fluid or bladder meconium content was identified.

Robotic-assisted partial nephrectomy: Has it come of age?

Surgical resection is the gold standard for the treatment of renal cell carcinoma, and partial nephrectomy (PN) is the treatment of choice for tumors smaller than 4 cm in size. A laparoscopic PN is a viable alternative to a traditional open PN, demonstrating good oncologic and functional outcomes. A laparoscopic PN is a challenging procedure, particularly performing intracorporeal suturing under the time constraints of warm ischemia. The introduction of the da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA) with wristed instruments and magnified, 3-dimensional vision may facilitate the technical challenges of a minimally invasive PN. The technique of robotic partial nephrectomy (RPN) is still evolving and a number of institutions have recently reported their results. In this article, we present a review of the literature and our technique for robotic PN using a transperitoneal approach.

DNA interactions and promotion in antibacterial activities of ciprofloxacin drug due to formation of mixed-ligand complexes of oxovanadium(IV)

Mixed-ligand complexes of oxovanadium(IV) of the type [VOAL]*2H(2)O [where A = ciprofloxacin and L = uninegative bidentate ligands] have been synthesized and characterized using infrared spectra, electronic spectra, magnetic measurements, elemental analyses, thermal investigation, and mass spectroscopy. Here, we tried to increase an antibacterial activity of ciprofloxacin drug due to formation of mixed-ligand complexes. The complexes were found to be more potent compare to some standard drugs, ligands and metal salt against selective gram(+ve) and gram(-ve) organisms. Binding of the complexes with DNA have been investigated by spectroscopic absorption titration and viscometric techniques. The mixed-ligand complexes show good binding ability. The cleavage efficacy has been determined using gel electrophoresis method and complexes were found to be more active compared to parental ligands and metal salt.

Maximizing console surgeon independence during robot-assisted renal surgery by using the Fourth Arm and TilePro

PURPOSE

We describe multiple uses of the fourth robotic arm and TilePro on the da Vinci S surgical system to maximize console surgeon independence from the assistant during robot-assisted renal surgery.

MATERIALS AND METHODS

We prospectively evaluated the use of the fourth robotic arm and TilePro on the da Vinci S during robot-assisted radical nephrectomy (RRN) and robot-assisted partial nephrectomy (RPN). The fourth robotic arm was used to provide kidney retraction, place the renal hilum on stretch, control vascular structures, apply and remove bulldog clamps during partial nephrectomy, and secure renal capsular stitches. TilePro was used to project intraoperative ultrasonography and preoperative CT images onto the console screen.

RESULTS

From January 2006 to June 2008, 90 robot-assisted kidney procedures were performed, of which the fourth robotic arm was used in 46 cases (RRN, 18; RPN, 24; nephroureterectomy, 4). The fourth robotic arm facilitated consistent kidney retraction for dissection of the renal hilum and mobilization of the kidney. The robotic Hem-o-Lok clip applier effectively controlled renal hilar vessels during eight RPN cases and secured renal capsular stitches during two RPN cases. Bulldog clamps were successfully applied to the renal artery during RPN using the fourth arm in two cases. TilePro was used during 22 RPN cases to project intraoperative ultrasonographic images and preoperative CT images onto the console screen as a picture-on-picture image to guide tumor resection.

CONCLUSIONS

Robotic instruments used with the fourth robotic arm may give the console surgeon greater independence from the assistant during robot-assisted kidney surgery by facilitating steps such as kidney retraction, hilar dissection, and vascular control. The TilePro feature of the da Vinci S can be used to project intraoperative ultrasonography and preoperative imaging onto the console screen, potentially guiding tumor localization and resection during RPN without the need to leave the console to view external images.

Description of a novel technique for suture ligation of the renal vessels during robotic nephrectomy

Minimally invasive techniques are frequently used for surgical treatment of suspected malignant renal masses. We previously reported on our experience with robotic nephrectomy and the feasibility of performing suture ligation of the renal vessels using robotic needle drivers. We describe a novel technique for suture ligation of the renal vessels during robotic nephrectomy utilizing the robotic hook and a suture with loops at each end. Our technique for suture ligation of the renal vessels recapitulates the open technique without the need for exchanging the robotic working instruments for robotic needle drivers and without the need for endovascular staplers.

Retroperitoneal robotic renal surgery: technique and early results

We describe a robotic retroperitoneal approach to renal surgery, optimized in porcine and cadaveric models, and applied to human patients. A retroperitoneal approach for robotic kidney surgery was developed in nonsurvival porcine and a fresh cadaver models, and then utilized in ten patients (three partial nephrectomy, three radical nephrectomy, two simple nephrectomy, one pyeloplasty, one cryoablation). Retroperitoneal access was successfully achieved for robotic renal procedures in six pigs and a human cadaver. Ten human patients (mean age 56 years, range 36-72 years) then underwent a successful retroperitoneal approach for robotic renal surgery. Mean console time was 166 (120-300) min. Mean blood loss was 82 (50-100) ml and average hospital stay was 2.6 (1-5) days. Pathology demonstrated clear cell renal cell carcinoma (four), papillary renal cell carcinoma (two), and xanthogranulomatous pyelonephritis (two). One patient with xanthogranulomatous pyelonephritis required open conversion for failure to progress due to dense adhesions. A retroperitoneal approach is a safe and feasible alternative to a transperitoneal approach for robotic renal surgery, including radical nephrectomy, partial nephrectomy, pyeloplasty, and cryoablation.

Combined robotic-assisted laparoscopic partial nephrectomy and radical prostatectomy

A 59-year-old man with a history of prostate cancer and clear-cell renal-cell carcinoma of the kidney underwent a combined robot-assisted laparoscopic partial nephrectomy and radical prostatectomy. We describe the initial report of a combined robot-assisted operation for both procedures concurrently with a port strategy allowing reuse of ports.

In-vitro biological evaluation of some ONS and NS donor Schiff's bases and their metal complexes

Complexes of Mn(II), Co(II), Ni(II), Cu(II), Zn(II) and Cd(II) with the Schiff bases salicylidene-o-aminothiophenol (H2L) and thiophene-o-carboxaldeneaniline (SB) have been synthesized and characterized by elemental analyses, magnetic measurements, thermogravimetric analyses as well as infrared spectra and reflectance spectra. The nature of the bonding has been discussed on the basis of IR spectral data. Magnetic susceptibility measurements and electronic spectral data suggest a six-coordinated octahedral structure for these complexes. The complexes of Mn(II), Co(II), Ni(II), Cu(II) are paramagnetic, while Zn(II) and Cd(II) are diamagnetic in nature. The complexes were tested for their antimicrobial activities against Salmonella typhi, Escherichia coli and Serratia marcescens using the "Disc Diffusion Method". The results are compared with the standard drug (tetracycline) and show moderate activity.

Iron(III) complexes: preparation, characterization, antibacterial activity and DNA-binding

Iron(III) have been combined to well known quinolones (ciprofloxacin) and some Schiff bases with the help of coordination approach. Characterization of these compounds have been done using elemental analysis, magnetic measurements, thermogravimetric analysis, IR, UV-VIS, (1)H NMR and (13)C NMR spectral investigation. Analytical studies suggest that the iron(III)-quinolone complexes assume a six-coordinated dimeric distorted octahedral geometry. All the compounds show a good antibacterial activity against broad range of bacteria like Bacillus cereus, Staphylococcus aureus, Escherichia coli, Bacillus subtilis, Salmonella typhi and Serratia marcescens, whereas no significant inhibition towards growth of fungal strains like Aspergillus Niger, Aspergillus flavus and Lasiodiplodia theobromae. Analyses of all these compounds show effective sperm herring DNA inhibition.

Efficacy of a radiation safety education initiative in reducing radiation exposure in the pediatric IR suite

BACKGROUND

The use of ionizing radiation is essential for diagnostic and therapeutic imaging in the interventional radiology (IR) suite. As the complexity of procedures increases, radiation exposure risk increases. We believed that reinforcing staff education and awareness would help optimize radiation safety.

OBJECTIVE

To evaluate the effect of a radiation safety education initiative on IR staff radiation safety practices and patient radiation exposure.

MATERIALS AND METHODS

After each fluoroscopic procedure performed in the IR suite during a 4-month period, dose-area product (DAP), fluoroscopy time, and use of shielding equipment (leaded eyeglasses and hanging lead shield) by IR physicians were recorded. A lecture and article were then given to IR physicians and technologists that reviewed ALARA principles for optimizing radiation dose. During the following 4 months, those same parameters were recorded after each procedure.

RESULTS

Before education 432 procedures were performed and after education 616 procedures were performed. Physician use of leaded eyeglasses and hanging shield increased significantly after education. DAP and fluoroscopy time decreased significantly for uncomplicated peripherally inserted central catheters (PICC) procedures and non-PICC procedures after education, but did not change for complicated PICC procedures.

CONCLUSION

Staff radiation safety education can improve IR radiation safety practices and thus decrease exposure to radiation of both staff and patients.

Utility of follow-up renal sonography in children with vesicoureteral reflux and normal initial sonogram

OBJECTIVE

The purpose of this study was to determine the value of follow-up renal sonography in children who presented with urinary tract infection and were found to have a voiding cystogram diagnosis of vesicoureteral reflux while having a normal initial renal sonogram.

METHODS

We retrospectively reviewed the medical records of 64 consecutive children who presented for follow-up renal sonography with a voiding cystogram diagnosis of vesicoureteral reflux and a normal initial sonogram conducted as part of the routine evaluation after urinary tract infection. Data recorded included gender, age, initial grade of reflux, time to follow-up sonogram, and abnormalities on follow-up sonogram. Children with conditions that may predispose to vesicoureteral reflux were excluded.

RESULTS

Children who were studied (7 boys, 57 girls) ranged in age from 1 month to 10 years, 10 months (mean: 35.6 months; median: 24 months). Ninety-four (73.4%) of 128 renal units demonstrated vesicoureteral reflux on voiding cystogram; 89 (94.7%) of 94 of them were grade 1 to 3. The mean time to follow-up was 22 months (range: 4 months to 5 years, 2 months; median: 18 months). All 128 (95% confidence interval: 0%-2.8%) renal units were normal on follow-up sonography.

CONCLUSION

Routine performance of repeat sonography seems unnecessary among children, particularly girls, with low- to medium-grade vesicoureteral reflux, who have had a previous normal sonogram and no conditions that predispose to vesicoureteral reflux.

2-methoxyestradiol does not inhibit superoxide dismutase

It has been reported in the literature that the endogenous estrogen metabolite 2-methoxyestradiol (2-ME) inhibits both manganese and copper,zinc superoxide dismutases (Mn and Cu,Zn SODs) and that this mechanism is responsible for 2-ME's ability to kill cancer cells. In fact, as demonstrated using several SOD assays including pulse radiolysis, 2-ME does not inhibit SOD but rather interferes with the SOD assay originally used. Nevertheless, as confirmed by aconitase inactivation measurements and lactate dehydrogenase release in human leukemia HL-60 cells, 2-ME does increase superoxide production in these cells and is more toxic than its non-O-methylated precursor 2-hydroxyestradiol. Other mechanisms previously suggested in the literature may explain 2-ME's ability to increase intracellular superoxide levels in tumor cells.

Fatty acid composition of Heterorhabditis sp. during storage

The fatty acid composition of three North West European isolates of Heterorhabditis sp. from different geographical origins, UK211 (England), HF85 (The Netherlands) and EU17 (Estonia) was assessed directly after harvest and, for UK211 and HF85, after 5 weeks storage in water at 20 degrees C. Lipid represented 34-43% of the dry weight of fresh nematodes. Of this, neutral lipid (NL) comprised from 70% (HF85) to over 90% (UK211, EU17). The fatty acid patterns were similar between the three isolates. Oleic (C18:In-9), palmitic (C16:0), and linoleic (C18:2n-6) acid predominated with 51, 13 and 12%, respectively in the total lipid (TL) of fresh nematodes (average for the three isolates). Levels of unsaturation (U.I.) of fresh nematodes were on average 110, 112, 113 and 152 for the TL, NL, phospholipid and free fatty acid fractions, respectively. EU17 had a slightly lower U.I than the other two strains, despite its more northern origin. Changes in fatty acid composition due to storage were most significant in the NL fraction. The U.I. for the NL fraction increased during storage, suggesting a preferential use of saturated fatty acids.

The ultrastructure of the cuticle and sheath of infective juveniles of entomopathogenic steinernematid nematodes

The ultrastructure of the cuticle of infective juveniles (IJs) of Steinernema carpocapsae (newly emerged and 80-day-old) and newly emerged IJs of S. riobravis, S. feltiae and S. glaseri was examined using transmission electron microscopy. The thickness of four distinctive layers of the cuticle was measured: epicuticle, cortical and median layer, striated layer and fibrous mat. The thickness of the cuticle was correlated with the size of the IJ. In the case of newly emerged IJs, the smallest species, S. carpocapsae, had a cuticle thickness of c. 270 nm compared with c. 460 nm for S. glaseri, the largest of the four species. The overall thickness of the cuticle or the thickness of the cuticle layers was not correlated with the ability of the IJs of the four species to survive desiccation per se. The major difference between newly emerged IJs of the four species was that S. carpocapsae had a proportionately thicker striated layer compared with the other three species. The significance of this is not known but it may be an adaptation involving the nictation behaviour of this species. A substantial change was observed in the cuticle of aged (80-day-old) IJs of S. carpocapsae, whereby the thickness of the cortical and median layer increased by more than 100% and the overall thickness of the cuticle increased by about 50%. Two possible explanations for this increase are: (i) new material was synthesized; or (ii) the fluid content of this layer increased due to an increase in the permeability of the outer layers of the cuticle. The ultrastructure of the sheaths of S. feltiae and S. glaseri was also examined and, apart from S. glaseri having a thicker sheath, the structure of the sheath in both species was similar, with the epicuticle and striated layer still visible.

Phospholipids and their fatty acids in infective juveniles of entomopathogenic steinernematid nematodes

The composition of phospholipids and their fatty acids was investigated in the infective juveniles (IJs) of four species of entomopathogenic nematodes: Steinernema carpocapsae (strain All), S. riobravis (strain Biosys 355), S. feltiae (strain UK76) and S. glaseri (strain NC). In newly emerged IJs of the four species, phospholipids comprised 15-18% dry weight of the total lipids (or 5-6% dry weight of the nematode), and phosphatidylethanolamine and phosphatidylcholine constituted about 40 and 30%, respectively, of the total phospholipids, with phosphatidylserine (PS) and phosphatidylinositol (PI) collectively accounting for about 25%. Qualitatively, the four species had identical total phospholipid (combined non-acidic and acidic fractions) fatty acid profiles, although there were some differences in the relative proportions (mol%) of specific fatty acids. The fatty acid composition of the total phospholipids in newly emerged IJs was dominated by C16 fatty acids, specifically C16:0 (14-18%), C16:1n-7 (up to 20%) and C16:4 (up to 26%), whereas the major C18 fatty acid was C18:1n-9 (20-23%). Polyunsaturated C20 fatty acids collectively made up 8-13% of the total composition. When newly emerged IJs were stored in distilled water at 25 degrees C, the proportions of C16:0 and C16:4 decreased with storage time, whereas C16:3n-3 increased (by 30-fold in S. glaseri). These changes were mostly observed in the acidic phospholipid fraction (mainly PI and PS). No evidence was found for a correlation between the fatty acid composition of the phospholipids and the relative ability of the IJs of the four Steinernema species to survive desiccation stress.

Fatty acid composition of neutral lipid energy reserves in infective juveniles of entomopathogenic nematodes

The fatty acid composition of neutral lipids from infective juveniles (IJs) of Steinernema carpocapsae strain All, S. riobravis strain Biosys 355, S. feltiae strain UK76, and S. glaseri strain NC stored in distilled water at 25 degrees C was determined. Newly emerged IJs of all four species had similar neutral lipid fatty acid profiles and of the 18 fatty acids identified, C18:1n-9 (43-49 mol %), C16:0 (18-23%), C18:2n-6 (8-14%) and C18:0 (4-8%) were the most abundant. Unsaturated fatty acids predominated, with about 50% being monoene and 14-22% polyene; the unsaturation index ranged from 91.6 in S. glaseri to 111.6 in S. carpocapsae. The fatty acid composition of the total lipid and the free fatty acid fraction mirrored that of the neutral lipids. During storage, the relative levels (%) of C16:0, C18:0, and C18:ln-9 in the neutral lipids declined significantly, suggesting they were preferentially utilised.

Glycogen: its importance in the infectivity of aged juveniles of Steinernema carpocapsae

Infective juveniles (IJs) of Steinernema carpocapsae (All) are able to remain relatively highly infective even when they have almost exhausted their neutral lipid reserves. This is not seen in other steinernematid species so we proposed that carbohydrate may be important for infectivity in aging IJs of S. carpocapsae. The present study investigated glycogen utilization in IJs of 4 entomopathogenic nematodes, S. carpocapsae, S. riobravis (Biosys 355), S. feltiae (UK76) and S. glaseri (NC), stored in distilled water at 25 degrees C. The 4 species had appreciable amounts of glycogen; from ca. 8% dry weight in S. riobravis to ca. 18% in S. glaseri. Infective juveniles of S. carpocapsae and S. riobravis survived for 120-135 days and utilized ca. 90% of their glycogen reserve at an almost constant rate during a 112-day storage period. Steinernema feltiae and S. glaseri lived for much longer (> 450 days) and during a 250-day storage period their glycogen content decreased by 27 and 40%, respectively. In contrast to the other 3 species, the rate of lipid decline preceded that of glycogen in S. carpocapsae. The rate of glycogen decline in S. carpocapsae IJs incubated with the glycolytic inhibitor, iodoacetamide (10(-4) M) was significantly reduced (P < 0.05) compared with untreated nematodes, and the infectivity of inhibitor-treated aged (> 80 days) IJs was reduced compared with controls. Incubating aged (80-day) IJs of S. carpocapsae (mean neutral lipid content ca. 10% of initial level) with 10(-4) M iodoacetamide for 24 h significantly reduced (P < 0.05) their infectivity compared with freshly harvested inhibitor-treated IJs and untreated controls. Following an 11-day recovery period, the infectivity of inhibitor-treated aged IJs recovered significantly (P < 0.05). The evidence suggests that glycogen is an important source of energy for maintaining infectivity in aged IJs of S. carpocapsae.