Pregnancy-associated large pelvic desmoid tumor: A case report of fetal-protective strategies and fertility preservation.

•Desmoid fibromatoses grow rapidly during the high estrogen-state of pregnancy.•Mass effect on the bladder is a complication of abdominal desmoid fibromatoses.•Cryoablation, doxorubicin, and post-partum prolactin are fetal-protective treatments.•Desmoid tumors can be effectively treated with fetal-protective strategies.

Utility of Cone-Beam CT for Bronchial Artery Embolization and Chemoinfusion: A Single-Institution Retrospective Case Series.

PURPOSE: To describe the technique and document utility of adjunctive cone-beam CT (CBCT) in patients undergoing bronchial artery embolization (BAE) or chemoinfusion (BAC). MATERIALS AND METHODS: Between August 2010 and February 2021, 26 patients (62 bronchial arteries) were evaluated with CBCT in addition to the usual digital subtraction angiography (DSA) during BAE or BAC. 19 patients (43 arteries) underwent BAE for hemoptysis; 7 patients (19 arteries) had BAC for palliation of lung malignancy. Retrospective review of procedural reports and the archived DSA and CBCT images was assessed for (1) whether CBCT findings added unique diagnostic information prior to treatment of target arteries compared to DSA alone; and (2) whether these unique CBCT findings led to modification of embolization or chemoinfusion technique. RESULTS: In 61 of 62 (98%) interrogated bronchial arteries, CBCT provided additional unique diagnostic information over planar DSA, primarily cross-sectional assessment of the spinal canal for spinal arteries. In 46/62 (74%) of the bronchial arteries the unique information did not lead to a change in therapeutic technique. In 15 bronchial arteries (24%), the added information from CBCT led to change in embolization and/or chemoinfusion technique. Embolization of one small unrecognized spinal artery branch (1.6%), which was missed intra-procedurally but retrospectively seen on CBCT led to transient spinal cord ischemia. CONCLUSIONS: These results suggest that adjunctive use of CBCT technique may improve diagnostic confidence from information provided by DSA in nearly all cases of BAE and BAC leading to improved therapeutic targeting or change in technique of embolization or chemoinfusion.

Duplicate inferior vena cava complicating the evaluation of primary aldosteronism.

A 64-year-old man with a known duplicate inferior vena cava (D-IVC) and resistant hypertension presented to our emergency department in a hypertensive crisis. He had a longstanding history of hypertension and unexplained hypokalemia treated with oral potassium supplementation. The patient was diagnosed with primary aldosteronism and MRI of the abdomen revealed a left-sided adrenal adenoma. Adrenal venous sampling (AVS) lateralised aldosterone hypersecretion to the left adrenal gland. The patient subsequently underwent an uncomplicated laparoscopic left adrenalectomy. The patient's postoperative course was uneventful, and he was discharged on a single antihypertensive medication on postoperative day 1. D-IVC is one of several rare IVC anatomical variants that have been well described in the literature. Knowledge of this patient's unique abdominal venous anatomy enabled successful AVS and appropriate surgical management. It is necessary to identify potential anatomical variants of abdominal venous anatomy that may complicate these invasive procedures.

CT urography: how to optimize the technique.

PURPOSE: Computed tomography urography (CTU) has emerged as the modality of choice for imaging the urinary tract within the past few decades. It is a powerful tool that enables detailed anatomic evaluation of the urinary tract in order to identify primary urothelial malignancies, benign urinary tract conditions, and associated abdominopelvic pathologies. As such, there have been extensive efforts to optimize CTU protocol. METHODS: This article reviews the published literature on CTU protocol optimization, including contrast bolus timing, dose reduction, reconstruction algorithms, and ancillary practices. CONCLUSION: There have been many advances in CTU techniques, which allow for imaging diagnosis of a wide spectrum of diseases while minimizing radiation dose and maximizing urinary tract distension and opacification.

Characterization of intramuscular calf vein thrombosis on routine knee MRI.

OBJECTIVE: Literature regarding intramuscular calf vein thrombosis (IMCVT) or infrapopliteal deep vein thrombosis (DVT) evaluation by magnetic resonance imaging (MRI) is limited, particularly with regard to routine unenhanced knee examinations. We attempt to correlate routine unenhanced MRI findings with ultrasound evaluations of the lower extremity deep venous system. MATERIALS AND METHODS: The radiology information system was searched, yielding a total of 67 patients who had undergone both routine knee MRI and duplex ultrasound examinations within 14 days. The MRI examination findings recorded were the presence and pattern of edema, segmental vein dilation, intraluminal signal on fluid-sensitive sequences, and abnormal hyperintense signal on axial T1-weighted sequences. The presence and extent of thrombus more centrally (i.e., intramuscular calf vein thrombosis with or without extension into the popliteal vein) was reassessed on ultrasound. RESULTS: When comparing patients with positive (n = 13) and negative (n = 54) ultrasound, there were significant differences in each of these parameters: perivascular edema, intramuscular edema, focal vein dilation, and abnormal fluid-sensitive signal. In the subset of patients with popliteal extension of the intramuscular calf vein thrombosis compared with those without any deep vein thrombosis, there was a statistically significant increase in peripopliteal edema, abnormal fluid-sensitive signal, and abnormal hyperintense T1 signal. CONCLUSION: Imaging findings on routine unenhanced MRI have a high rate of concordance with duplex ultrasound performed through the calf in the detection of intramuscular calf vein thrombosis.

Influence of lipopolysaccharide-binding protein on pulmonary inflammation in gram-negative pneumonia.

Lipopolysaccharide-binding protein (LBP) is upregulated as part of the acute-phase response. Lipopolysaccharide-binding protein has a known multifunctional role in potentiating the recognition, clearance, and killing of gram-negative bacteria. In a Klebsiella pneumonia model, we previously demonstrated that LBP gene-deficient mice (LBP-/-) mice experience increased mortality when compared with wild-type (Wt) mice (98% vs. 59%). We hypothesize that LBP is essential to bacterial clearance from the lung, and its absence leads to alteration of the pulmonary inflammatory response to pneumonia. Twelve- to 16-week-old female C57Bl/6 Wt mice and age-matched LBP-/- mice were administered 1 × 10(3) colony-forming units of Klebsiella pneumoniae by intratracheal injection. Animals were euthanized at 6, 12, 24, or 36 h after inoculation. Lung tissue and bronchoalveolar lavage samples were obtained. Lung homogenate samples were assayed to determine quantitative bacterial load per whole lung, proinflammatory cytokine concentrations, myeloperoxidase activity, and assessment of pulmonary leukocyte populations. In vitro production of inflammatory mediators were also assayed after LPS stimulation of peritoneal macrophages isolated from Wt, Toll-like receptor 4 (TLR4)-deficient, and LBP-/- mice. The LBP-/- mice demonstrated significantly elevated levels of bacteria in the lung at 24 and 36 h when compared with Wt controls. The average lung levels of proinflammatory cytokines interleukin-1ß (IL-1ß), IL-6, keratinocyte-derived chemokine, and macrophage-inflammatory protein-2 were greater in the LBP mice and remained elevated longer when compared with those in the Wt mice. Myeloperoxidase activity, an indicator of neutrophil content, was significantly increased at time 36 h in the LBP mice. After in vitro stimulation of peritoneal macrophages with LPS, production of IL-1ß, IL-6, IL-10, keratinocyte-derived chemokine, and macrophage-inflammatory protein-1α were suppressed in LBP and TLR4-deficient mice compared with that in Wt. Absence of a functional LBP-/- gene results in diminished clearance of gram-negative bacteria from the pulmonary system. Failure to recognize and clear gram-negative bacteria via the LBP/TLR4 axis results in an initial delayed inflammatory response. This delay in LBP-/- mice is followed by excessive amplification and prolonged elevation of proinflammatory mediators and neutrophil sequestration within the lungs.

Topical nanoemulsion therapy reduces bacterial wound infection and inflammation after burn injury.

BACKGROUND: Nanoemulsions are broadly antimicrobial oil-in-water emulsions containing nanometer-sized droplets stabilized with surfactants. We hypothesize that topical application of a nanoemulsion compound (NB-201) can attenuate burn wound infection. In addition to reducing infection, nanoemulsion therapy may modulate dermal inflammatory signaling and thereby lessen inflammation following thermal injury. METHODS: Male Sprague-Dawley rats underwent a 20% total body surface area scald burn to create a partial-thickness burn injury. Animals were resuscitated with Ringer's lactate solution and the wound covered with an occlusive dressing. At 8 hours after injury, the burn wound was inoculated with 1 x 10(6) colony-forming units (CFUs) of Pseudomonas aeruginosa. NB-201, NB-201 placebo, 5% mafenide acetate solution, or 0.9% saline (control) was applied onto the wound at 16 and 24 hours after burn injury. Skin was harvested 32 hours postburn for quantitative wound culture and determination of inflammatory mediators in tissue homogenates. RESULTS: NB-201 decreased mean bacterial growth in the burn wound by 1,000-fold, with only 13% (3/23) of animals having P. aeruginosa counts greater than 10(5) CFU/g tissue versus 91% (29/32) in the control group (P < .0001). Treatment with NB-201 attenuated neutrophil sequestration in the treatment group as measured by myeloperoxidase assay and by histology. It also significantly decreased levels of proinflammatory cytokines (interleukin [IL]-1beta and IL-6) and the degree of hair follicle cell apoptosis in skin compared to saline-treated controls. CONCLUSION: Topical NB-201 substantially decreased bacterial growth in a partial-thickness burn model. This decrease in the level of wound infection was associated with an attenuation of the local dermal inflammatory response and diminished neutrophil sequestration. NB-201 represents a novel potent antimicrobial and anti-inflammatory treatment for use in burn wounds.

Duration of antibiotic therapy for ventilator-associated pneumonia in burn patients.

Shorter compared with longer courses of antibiotic therapy for ventilator-associated pneumonia (VAP) in mixed medical-surgical intensive care units (ICUs) have been reported to produce equivalent outcomes. There have been few studies on the duration of antibiotic therapy for VAP in the burn population. We hypothesized that a shorter duration of antibiotic therapy for VAP would produce similar outcomes in our burn ICU. All burn patients from July 2001 to December 2006 admitted to the burn ICU requiring mechanical ventilation were studied. VAP was diagnosed prospectively by our Infection Control Liaison using bronchoalveolar lavage for cultures. Patients were cohorted into two groups: before July 1, 2004, antibiotic therapy duration was directed by the discretion of the attending physician (preprotocol), and after, the goal was 8 days of appropriate therapy or longer based on physician discretion (postprotocol). There were 98 patients treated for VAP with similar rates of inhalation injury, %TBSA burn size, age, and need for mechanical ventilation between the groups. The incidence of recurrent VAP was the same: 17% for the preprotocol and 15% for the postprotocol periods. The overall duration of antibiotic therapy did not change from 11 +/- 4 to 12 +/- 6 days. For patients treated longer than the target of 8 days, 66% had positive respiratory cultures at 4 days after initiation of antibiotic therapy. For the majority of patients with aspiration-type organisms or nonvirulent strains, there were fewer antibiotic days overall at 10 +/- 5 days (P < .05), with no episodes of recurrent VAP with the same bacteria. Despite a focused effort to decrease antibiotic usage for VAP in burn patients, the overall duration of therapy did not change. The majority of patients with virulent organisms such as methicillin-resistant Staphylococcus aureus or nonfermenting Gram-negative rods still had clinical signs of pneumonia and positive cultures, leading clinicians to continue antibiotics. In patients without virulent pathogens, a shorter antibiotic course was well-tolerated without recurrences.

Intensive insulin therapy is associated with reduced infectious complications in burn patients.

BACKGROUND: Intensive insulin therapy to control blood glucose levels has reduced mortality in surgical, but not medical, intensive care unit (ICU) patients. Control of blood glucose levels has also been shown to reduce morbidity in surgical ICU patients. There is very little data for use of intensive insulin therapy in the burn patient population. We sought to evaluate our experience with intensive insulin therapy in burn-injured ICU patients with regard to mortality, morbidity, and use of hospital resources. STUDY DESIGN: Burn patients admitted to our American College of Surgeons verified burn center ICU from 7/1/2004 to 6/30/2006 were studied. An intensive insulin therapy protocol was initiated for ICU patients admitted starting 7/1/2005 with a blood glucose target of 100-140 mg/dL. The 2 groups of patients studied were control (7/1/2004 to 6/30/2005) and intensive insulin therapy (7/1/2005 to 6/30/2006). All glucose values for the hospitalization were analyzed. Univariate and multivariate analyses were performed. RESULTS: Overall, 152 ICU patients admitted with burn injury were available for study. No difference in mortality was evident between the control and intensive insulin therapy groups. After adjusting for patient risk, the intensive insulin therapy group was found to have a decreased rate of pneumonia, ventilator-associated pneumonia, and urinary tract infection. In patients with a maximum glucose value of greater than 140 mg/dL, the risk for an infection was significantly increased (OR 11.3, 95% CI 4-32, P-value < .001). The presence of a maximum glucose value greater than 140 mg/dL was associated with a sensitivity of 91% and specificity of 62% for an infectious complication. CONCLUSION: Intensive insulin therapy for burn-injured patients admitted to the ICU was associated with a reduced incidence of pneumonia, ventilator-associated pneumonia, and urinary tract infection. Intensive insulin therapy did not result in a change in mortality or length of stay when adjusting for confounding variables. Measurement of a blood glucose level greater than 140 mg/dL should heighten the clinical suspicion for the presence of an infection in patients with burn injury.

Mean glucose values predict trauma patient mortality.

BACKGROUND: Tight glycemic control in a mixed surgical intensive care unit patient population has been associated with improved survival. We postulated targeted therapy to achieve glucose levels <140 mg/dL would reduce infectious complications and mortality in trauma patients admitted to the intensive care unit (ICU). METHODS: Adult trauma patients admitted to our American College of Surgeons Level I Trauma Center ICU from July 2004 through June 30, 2006 were studied. Insulin therapy was instituted for ICU patients admitted after July 1, 2005 with glucose >140 mg/dL. Data on infections and all glucose values were collected. Multivariate analysis adjusting for age, Injury Severity Score, Glasgow Coma Scale Score, admit blood pressure, and intubation status was performed. RESULTS: Five thirty-one ICU patients were admitted with a mean Injury Severity Score of 23 +/- 13 and mean age of 45 years +/- 19 years. The admission, mean, and maximum glucoses were 141, 129, and 192 respectively. In multivariate analyses, increases in all three glucose values were associated with a significantly higher mortality, with the best model achieved using mean glucose with a receiver operating curve of 0.90. For mean glucose categories of >200 mg/dL, 141 mg/dL to 200 mg/dL, and