COVID-19 classification of X-ray images using deep neural networks.

OBJECTIVES: In the midst of the coronavirus disease 2019 (COVID-19) outbreak, chest X-ray (CXR) imaging is playing an important role in diagnosis and monitoring of patients with COVID-19. We propose a deep learning model for detection of COVID-19 from CXRs, as well as a tool for retrieving similar patients according to the model's results on their CXRs. For training and evaluating our model, we collected CXRs from inpatients hospitalized in four different hospitals. METHODS: In this retrospective study, 1384 frontal CXRs, of COVID-19 confirmed patients imaged between March and August 2020, and 1024 matching CXRs of non-COVID patients imaged before the pandemic, were collected and used to build a deep learning classifier for detecting patients positive for COVID-19. The classifier consists of an ensemble of pre-trained deep neural networks (DNNS), specifically, ReNet34, ReNet50¸ ReNet152, and vgg16, and is enhanced by data augmentation and lung segmentation. We further implemented a nearest-neighbors algorithm that uses DNN-based image embeddings to retrieve the images most similar to a given image. RESULTS: Our model achieved accuracy of 90.3%, (95% CI: 86.3-93.7%) specificity of 90% (95% CI: 84.3-94%), and sensitivity of 90.5% (95% CI: 85-94%) on a test dataset comprising 15% (350/2326) of the original images. The AUC of the ROC curve is 0.96 (95% CI: 0.93-0.97). CONCLUSION: We provide deep learning models, trained and evaluated on CXRs that can assist medical efforts and reduce medical staff workload in handling COVID-19. KEY POINTS: • A machine learning model was able to detect chest X-ray (CXR) images of patients tested positive for COVID-19 with accuracy and detection rate above 90%. • A tool was created for finding existing CXR images with imaging characteristics most similar to a given CXR, according to the model's image embeddings.

Cystic Duct Embolization with Chemical Gallbladder Ablation for the Treatment of Acute Calculous Cholecystitis in High-Risk Patients: A Prospective Single-Center Study.

PURPOSE: To demonstrate the feasibility of cystic duct embolization and chemical gallbladder ablation as an alternative to cholecystectomy in high-risk patients with calculous cholecystitis who were not candidates for surgery. MATERIALS AND METHODS: This prospective study included 10 patients with acute cholecystitis (7 males and 3 females) aged 70-91 years (average age, 81.6 years) between 2013 and 2019. A cholecystostomy catheter was inserted during the acute phase, followed by cystic duct coil embolization performed via the existing drainage tube tract. Once asymptomatic, 3% aethoxysklerol was injected into the gallbladder, and the drain was removed upon sonographic confirmation that the gallbladder remained contracted. Each phase of the procedure was performed with an interval of 2-3 weeks. Clinical, cholangiographic, and sonographic data were collected before and after drain removal at 1-month follow-up. RESULTS: Cystic duct embolization was technically successful in all patients, with no immediate post-procedure complications. Gallbladder ablation performed in 10 patients was technically successful in all of them (median follow-up, 11 months). One patient required repeat ablation at 14 months, and the prolonged biliary excretions of 1 other patient ceased only at 8 months. CONCLUSIONS: Cystic duct embolization with gallbladder ablation is a feasible procedure for patients in whom cholecystectomy is contraindicated.

Prothrombin Complex Concentrate before Urgent Surgery in Patients Treated with Rivaroxaban and Apixaban.

INTRODUCTION: Patients treated with direct Xa inhibitors may require urgent surgery. Administration of prothrombin complex concentrate (PCC) in this setting is common; however, it is based on limited experience in healthy volunteers. OBJECTIVE: To characterize the population receiving PCC for apixaban/rivaroxaban reversal prior to an urgent surgery and evaluate its efficacy and safety. METHODS: This was a retrospective study in 2 tertiary hospitals. Bleeding was evaluated based on surgical reports, hemoglobin drop, and the use of blood products or additional PCC during 48 h. Safety measures were thrombotic complications and 30-day mortality. RESULTS: Sixty-two patients aged 80.7 ± 9 years, treated with apixaban (39.63%) or rivaroxaban (23.37%), received PCC before an urgent surgery/procedure. Most underwent abdominal operation (61%), orthopedic surgery (13%), or transhepatic cholecystostomy insertion (10%). Bleeding during surgery was reported in 3 patients (5%), no patient required additional PCC, and 16 patients (26%) received packed cells (median: 1 unit, range: 1-5). The 30-day mortality and thrombosis rates were 21% (n = 13) and 3% (n = 2), respectively. The cause of death was related to the primary disease, most commonly sepsis. No patient died due to bleeding/thrombosis. CONCLUSIONS: Our results support the use of PCC to achieve hemostasis in patients treated with Xa inhibitors prior to an urgent surgery.

How Prevalent is Hydronephrosis Secondary to Acute Appendicitis: A Cross-Sectional Study.

BACKGROUND: Right hydronephrosis secondary to acute appendicitis is an under-reported phenomenon with only several case reports published. OBJECTIVES: To assess the incidence of this phenomenon in our database of patients diagnosed with acute appendicitis. METHODS: Data were collected on 1092 patients who underwent surgery due to acute appendicitis between 2003 and 2007 in our tertiary medical center. The data entailed demographic, surgical, and hospitalization parameters including ultrasound or computed tomography examinations and presence of right hydronephrosis prior to surgery. RESULTS: Out of 1092 patients, appendicitis was eventually diagnosed in 87.4% of the patients. Only 594 (54%) had preoperative imaging performed prior to surgery (ultrasound or computed tomography). Out of these 594 patients, 21 (3.5%) had a new right hydronephrosis diagnosed and all had appendicitis with 15/21 (71%) having a retrocecal appendix. Of those with retrocecal appendix, 10 were pregnant women (48%). Erythrocyturia was present in 15/21 patients (71%) and in 10/11 of patients (91%) after excluding those who were pregnant. No significant differences were seen in patients with hydronephrosis regarding age, hospitalization, and surgery time. In all patients, an ultrasound was performed 2 weeks after surgery demonstrating the disappearance of hydronephrosis. Median follow-up time was 41.7 months (range 14.8-118.4 months). CONCLUSIONS: Our study shows that 3.5% of our cohort had right hydronephrosis secondary to acute appendicitis. Although this presentation is very rare, physicians should be aware of this phenomenon and the risk for delayed diagnosis and treatment of acute appendicitis.

Radiological Evaluation of Artificial Stone Silicosis Outbreak: Emphasizing Findings in Lung Transplant Recipients.

OBJECTIVE: The aim of this study was to describe the computed tomography (CT) findings and correlate pulmonary function tests (PFTs) of silicosis patients with emphasis on the findings in lung transplantation (LTX) recipients. METHODS: We studied the chest CT scans from 82 marble workers exposed to artificial stone dust and who had a diagnosis of silicosis, of whom 13 patients underwent LTX. Silicosis-associated findings were graded and correlated to concomitant PFT. RESULTS: A statistically significant inverse relationship was found between chest CT scores and PFT including forced expired volume in the first second (r = -0.54, P < 0.0001), total lung capacity (r = -0.4, P < 0.0001), and diffusion capacity for carbon monoxide single breath % (r = -0.6, P < 0.0001) parameters. Progressive massive fibrosis indicating advanced and complicated silicosis was found in 85% of LTX patients, as compared with 40% in patients with maintained pulmonary function. Ground-glass opacities were seen in some LTX patients with or without signs of progressive massive fibrosis. Two of these patients had silicoproteinosis diagnosed within the resected lung, indicating an acute or accelerated form of silicosis. CONCLUSIONS: This silicosis current outbreak is important because of the worldwide use of this and similar high-silica-content, artificial stone products, which can cause progressive severe forms of silicosis. Along with standard clinical assessment and PFT, CT parameters are indicative measures of the disease severity.

Retrievable Inferior Vena Cava Filters: Indications, Indwelling Time, Removal, Success and Complication Rates.

BACKGROUND: Various vena cava filters (VCF) are designed with the ability to be retrieved percutaneously. Yet, despite this option most of them remain in the inferior vena cava (IVC). OBJECTIVES: To report our experience in the placement and retrieval of three different types of VCFs, and to compare the indications for their insertion and retrieval as reported in the literature. METHODS: During a 5 year period three types of retrievable VCF (ALN, OptEase, and Celect) were inserted in 306 patients at the Rabin Medical Center (Beilinson and Hasharon hospitals). Indications, retrieval rates, median time to retrieval, success and complication rates were viewed and assessed in the three groups of filter types and were compared with the data of similar studies in the literature. RESULTS: Of the 306 VCFs inserted, 31 (10.1%) were retrieved with equal distribution in the three groups. In most patients the reason for filter insertion was venous thromboembolic events (VTE) and contraindications to anticoagulant therapy. Mean age was 68.38 ± 17.5 years (range 18-99) and was noted to be significantly higher compared to similar studies (53-56 years) (P < 0.0001). Multi-trauma patients were significantly older (71.11 ± 14.99 years) than post-pulmonary embolism patients (48.03 ± 20.98 years, P < 0.0001) and patients with preventive indication (26.00 ± 11.31, P < 0.0001). The mean indwelling time was 100.6 ± 103.399 days. Our results are comparable with the results of other studies, and there was no difference in percentage of retrieval or complications between patients in each of the three groups. CONCLUSIONS: In 1 of 10 patients filters should be removed after an average of 3.5 months. All three IVC filter types used are safe to insert and retrieve.

Stercoral colitis: a lethal disease-computed tomographic findings and clinical characteristic.

OBJECTIVE: The aim of this study was to describe the radiographic findings in stercoral colitis. METHODS: The computed tomographic scans and abdominal radiographs of 13 patients with surgically and pathologically confirmed stercoral colitis from 4 affiliated hospitals were reviewed by a board-certified abdominal radiologist blinded to the official imaging, surgical, and pathologic findings. RESULTS: The median age was 66 years. The patients presented mainly with constipation (100%) and an acute inflammatory process (85%); 5 patients (38%) had frank septic shock. Mortality was 46%. Imaging scans showed that the colon dilated proximally to the impaction site in 6 patients (50%). Other findings included fat stranding (100%), mucosal sloughing (58%), mesenteric hyperemia (58%), and extraluminal gas (17%). CONCLUSIONS: Computed tomography is an important diagnostic modality for stercoral colitis. The presence of a large fecaloma with distention of the affected colon and wall thickening and pericolonic fat stranding should alert radiologists and surgeons to the presence of this potentially fatal condition.

Predictors of poor outcome following liver biopsy for the investigation of new hepatic space occupying lesion/s.

BACKGROUND: Ultrasound-guided percutaneous liver biopsy (UPLB) is currently performed mainly to determine if new hepatic space occupying lesions (SOL) represent benign, primary malignant, or metastatic disease. This study sought to investigate the outcome of UPLB in this setting. METHODS: In a retrospective study, patients with a new hepatic SOL who underwent UPLB during 1/2006-12/2016 were included and followed to 12/2018. Clinical data and pathology reports were reviewed. Mortality within 60 days and no change in patients' management following UPLB were defined as medically futile. RESULTS: Included 140 patients, 50% male, mean age 68.8 ± 11.5 years; 112 patients died, all of malignant disease. 32 patients (23%) died within 60 days of UPLB. Median post-UPLB survival was 151 days. Survival was significantly shorter in patients with >1 hepatic lesion (n = 108) or an extrahepatic malignant lesion (n = 77) (p = 0.0082, p = 0.0301, respectively). On Cox Proportional Hazards analysis, significant predictors of mortality within 60 days of UPLB were: age as a continuous variable, (HR 1.070, 95% CI 1.011-1.131, p = 0.018), serum albumin <2.9 g/dL, (HR 4.822 95% CI 1.335-17.425, p = 0.016) and serum LDH >1500 U/L (HR 9.443, 95% CI 3.404-26.197, p < 0.0001). CONCLUSIONS: In patients with these features or with disseminated disease, liver biopsy should be carefully reconsidered.

Retrospective comparison of mechanical percutaneous thrombectomy of hemodialysis arteriovenous grafts with the Arrow-Trerotola device and the lyse and wait technique.

OBJECTIVE: The purpose of our study was to determine whether pharmacologic thrombolysis with urokinase in the lyse and wait (L&W) technique compared with mechanical declotting using the Arrow-Trerotola percutaneous thrombectomy device is more efficient, safer, or less expensive in treating thrombosed hemodialysis grafts. MATERIALS AND METHODS: The files of 157 patients who underwent arteriovenous graft declotting from 2000 to 2007 at one tertiary care center were reviewed. The study group included 83 women and 74 men with a mean age of 68 +/- 12 years (range, 27-95 years). A total of 563 procedures were performed: 427 with the L&W technique and 136 with mechanical percutaneous thrombectomy using the percutaneous thrombectomy device. The two types of procedures were compared for success rate, complications, average patency time, and cost. RESULTS: There were no statistically significant differences between the pharmacologic and mechanical procedures in immediate success rate (99% and 98%, respectively) or average patency time (5.44 months and 5.40 months, respectively). The L&W technique was considerably less expensive. CONCLUSION: Given its lower cost and equal efficacy and safety, L&W appears to be preferable to mechanical thrombolysis with a percutaneous thrombectomy device for initial arteriovenous hemodialysis graft declotting.

Step-and-Shoot: a new low radiation coronary computed tomography angiography technology: our initial experience with 125 consecutive asymptomatic patients.

BACKGROUND: Coronary CTangiography is an accurate imaging modality; however, its main drawback is the radiation dose. A new technology, the "step and shoot," which reduces the radiation up to one-eighth, is now available. OBJECTIVES: To assess our initial experience using the "step-and-shoot" technology for various vascular pathologies. METHODS: During a 10 month period 125 consecutive asymptomatic patients (111 men and 14 women aged 25-82, average age 54.9 years) with various clinical indications that were appropriate for step-and-shoot CCTA (regular heart rate < 65 beats/minute and body weight < 115 kg) were scanned with a 64-slice multidetector computed tomography Brilliance scanner (Philips, USA). The preparation protocol for the scan was the same as for regular coronary CTA. All examinations were interpreted by at least one experienced radiologist and one experienced interventional cardiologist. The quality of the examinations was graded from 1 (excellent imaging quality of all coronary segments) to 4 (poor quality, not diagnostic). There were 99 patients without a history of coronary intervention, 13 after coronary stent deployment (19 stents) and 3 after coronary artery bypass graft. RESULTS: Coronary interpretation was obtained in 122 examinations (97.6%). The imaging quality obtained was as follows: 103 patients scored 1 (82.4%), 15 scored 2 (12%), 4 scored 3 (3.2%) and 3 scored 4 (2.4%). The grades were unrelated to cardiac history or type of previous examinations. Poor image quality occurred because of sudden heart rate acceleration during the scan (one patient), movement and respiration (one patient), and arrhythmia and poor scan timing (in one). Two patients were referred to percutaneous coronary intervention based on the CCTA findings, which correlated perfectly. CONCLUSIONS: Step-and-shoot CCTA is a reliable technique and CCTA algorithm comparable to regular CCTA. This technique requires the lowest radiation dose, as compared to other coronary imaging modalities, that can be used for all CCTA indications based on the inclusion criteria of low (> 65 bpm) and stable heart rate.

Computed tomography study of the effect of orlistat on visceral adipose tissue volume in obese subjects.

BACKGROUND: Obesity has become a major public health problem worldwide. OBJECTIVES: To examine the effect of orlistat in promoting weight loss and its specific effect on visceral adipose tissue and subcutaneous adipose tissue as evaluated by computed tomography. METHODS: A prospective case series study of 10 obese subjects was conducted. The 6 women and 4 men, age 50-67 years (mean 59 +/- 8 years), had a mean body mass index of 34.1 +/- 3.2 kg/m2. All subjects were prescribed a mildly hypocaloric diet (600 kcal/day deficit). In addition, all subjects were treated with orlistat 120 mg 3 times a day for 20.1 +/- 7 weeks. RESULTS: The subjects had lost approximately 8.2 kg each, or 8.4% of their initial body weight. Mean body weight decreased from 98 +/- 13 to 89.8 +/- 13.6 kg at the last followup visit (P = 0.0001); mean BMI decreased from 34.1 +/- 3.2 to 30.3 +/- 3.9 kg/m2 (P = 0.0001), and mean waist circumference from 113.8 +/- 11.4 to 107.6 +/- 10 cm (P = 0.0006). Mean total abdominal adipose tissue volume, evaluated by computed tomography, decreased from 426 +/- 104.3 to 369.8 +/- 99.6 mm3 (P = 0.0001). Mean abdominal SAT volume decreased from 251.1 +/- 78.8 to 224 +/- 81.1 mm3 (P = 0.006), and mean abdominal VAT volume decreased from 176 +/- 76.7 to 141.6 +/- 67 mm3 (P = 0.0001). Thus, the total abdominal adipose tissue volume for the whole group decreased by 15.4%, and most of this decrease was attributable to the reduction in VAT (24.8%) as opposed to SAT (only 12% reduction) (P = 0.03). The weight reduction that occurred during the study was accompanied by a statistically significant reduction in levels of total cholesterol, low density lipoprotein-cholesterol, triglycerides, and fasting blood glucose. CONCLUSIONS: Our results demonstrate the effect of orlistat in reducing human visceral adipose tissue as evaluated by CT. The benefit of the treatment is further supported by the statistically significant reduction in cardiovascular risk factors.

Endovascular interventions of juxtaanastomotic stenoses and thromboses of hemodialysis arteriovenous fistulas.

PURPOSE: To assess the primary and secondary patency rates for juxtaanastomotic stenoses, with or without superimposed thromboses, of arteriovenous hemodialysis fistulas treated with angioplasty and to compare it with National Kidney Foundation Dialysis Outcomes Quality Initiative treatment guidelines for stenosed and occluded arteriovenous fistulas (50% primary patency rate at 12 months). MATERIALS AND METHODS: This study was a retrospective analysis, covering a period of 5(1/2) years. Forty-three hemodialysis patients were referred due to secondary fistula dysfunction, and angiography was diagnostic of a juxtaanastomotic lesion. Interventions consisted of standard angioplasty techniques along with thrombolysis and/or thrombectomy and intravascular stent placement as needed. Follow-up was performed at the attending dialysis center, and repeat angiography was performed as clinically required. RESULTS: Immediate postprocedural angiography demonstrated an angiographic success rate of 98%. Clinical success, with at least one session of normal dialysis, occurred in 95% of interventions. Primary patency rates at 12 months for the stenosed and stenosed/thrombosed fistulas were 56% and 64%, respectively. Secondary patency rates at 12 months were 64% and 63%, respectively. Half of the stenosed fistulas were patent at 1.5 years, 28% were patent at 4 years, and 13% remained patent at 6 years. No major complications were documented. Four minor complications, which did not require therapy, were noted. CONCLUSIONS: The results achieved are comparable to those reported for interventions at nonjuxtaanastomotic sites and exceed those quoted by the National Kidney Foundation Dialysis Outcomes Quality Initiative guidelines. Angioplastic interventions in a juxtaanastomatic area of arteriovenous fistulas are safe, promote prolonged patency, and postpone the need for surgical intervention or creation of a new fistula.

Endovascular diagnosis and intervention in patients with isolated hyperammonemia, with or without ascites, after liver transplantation.

Hyperammonemia with or without ascites with normal synthetic liver functions after liver transplantation might indicate the presence of anastomotic stenosis of the portal or hepatic vein or the existence of a patent portosystemic shunt. The authors describe six patients, three children after split-liver transplantation and three adults after cadaver liver transplantation, who presented with hyperammonemia. Three patients had ascites. All lesions were successfully treated percutaneously; stents were placed in patients with anastomotic stenoses and coil embolization was performed in patients with patent portosystemic shunts--with either transhepatic or transjugular approaches according to the site of the abnormality. Ammonia levels returned to normal, and ascites had regressed completely for at least 3 months.

Angiographic findings and clinical outcomes in asymptomatic patients with severe obstructive atherosclerosis on computed tomography angiography.

BACKGROUND: Cardiac computed tomography angiography is a relatively new imaging modality to detect coronary atherosclerosis. OBJECTIVES: To explore the diagnostic value of CTA in assessing coronary artery disease among asymptomatic patients. METHODS: In this retrospective single-centered analysis, 622 consecutive patients underwent CTA of coronary arteries between November 2004 and May 2006 at the Mor Institute for Cardiovascular Imaging in Bnei Brak, Israel. All patients were asymptomatic but had at least one risk factor for atherosclerotic CAD. The initial 244 patients were examined with the 16-slice Brilliance CT scanner (Philips, Cleveland, OH, U.S.A.), and in the remaining 378 patients the 64-slice scanner (GE Healthcare, The Netherlands) with dedicated cardiac reconstruction software and electrocardiography triggering was used. Scanning was performed in the cranio-caudal direction. Images reconstructed in different phases of the cardiac cycle using a retrospective ECG-gated reconstruction algorithm were transferred to a dedicated workstation for review by experienced CT radiologists and cardiologists. RESULTS: Of 622 patients, 52 (8.4%) had severe obstructive atherosclerosis (suspected > or = 75% stenosis) according to CTA interpretation. Invasive coronary angiography was performed in 48 patients while 4 patients had no further procedure. A non-significant CAD (e.g., diameter stenosis < 70%) was identified in 6 of 48 patients (12%) by selective coronary angiography. Forty-two patients showed severe CAD with at least one lesion of 70% stenosis. Percutaneous coronary intervention was performed in 35 patients and coronary artery bypass grafting surgery in the other 4 patients. Angioplasty procedures were successful in all 35 patients and stents were utilized in all cases without complications. No further complications occurred among the study cohort undergoing either PCI or surgery. The 6 month survival rate in these patients was 100%. CONCLUSIONS: Non-invasive coronary CTA appears to be a reliable technique, with reasonably high accuracy, to detect obstructive atherosclerosis in asymptomatic high risk patients for atherosclerotic CAD.

Modified Doppler-guided laser procedure for the treatment of second- and third-degree hemorrhoids.

BACKGROUND: Hemorrhoids are a common anorectal condition with a major medical and socioeconomic impact. Owing to the high incidence of symptomatic hemorrhoids in the adult population together with the risk of complications of traditional surgery, researchers are seeking less invasive methods of hemorrhoidal treatment.The aim of this study was to present our experience with the mini-invasive Doppler guided hemorrhoidal laser procedure (HeLP) in symptomatic 2nd and 3rd degree hemorrhoids with absent or minimal mucosal prolapse. METHODS: The cohort included 62 patients with symptomatic hemorrhoids who underwent the HeLP at a tertiary medical center in 2014-2016. Data were collected on clinical and perioperative characteristics and outcome. Findings were compared between patients with second- and third-degree hemorrhoids. RESULTS: The cohort included 41 male and 21 female patients of mean age 41.5 years. Fifty-one had bleeding and 11 had hemorrhoidal syndrome. Mean operative time was 16.6 ± 3.7 minutes. A total of 8-12 arterial branches were treated. Patients were discharged home within a mean of 91.95 ± 20.48 minutes and allowed to resume normal activities. Compared to patients with second-degree hemorrhoids, patients with third-degree hemorrhoids had a significantly higher rate of recto-anal repair (18.2% vs 0, p < 0.05), intraoperative bleeding (11.3% vs 5%, p < 0.05), and thrombus formation in the hemorrhoids (11.3 % vs 0, p < 0.01). At the six-month follow-up, no complications were reported, and there was significant improvement in symptoms.Using the visual analog scale, no pain was reported by 82.3% of patients at one week after surgery and 95.2% of patients at one month after surgery. CONCLUSION: Patients with hemorrhoids treated with Doppler-guided laser had an excellent outcome in terms of resolution of symptoms and postoperative pain. Only Minor short-term complications were noted. Doppler-guided laser seems to be an effective and painless technique for the treatment of symptomatic second- to third grade hemorrhoids with minimal mucosal prolapse.

Prevalence and clinical predictors of atherosclerotic coronary artery disease in asymptomatic patients undergoing coronary multidetector computed tomography.

OBJECTIVE: We examined the prevalence and clinical predictors of atherosclerotic coronary artery disease in asymptomatic patients undergoing multidetector computed tomography BACKGROUND: In recent years multidetector computed tomography imaging has taken a leading role in the detection of subclinical atherosclerosis, even before its clinical manifestation. We examined the prevalence and clinical predictors of atherosclerotic coronary artery disease in asymptomatic patients undergoing multidetector computed tomography of the coronary arteries. METHODS: A total of 244 consecutive asymptomatic patients (190 men and 54 women aged 53.8+/-7.9 years) with at least one atherogenic risk factor underwent multidetector computed tomography angiography of the coronary arteries. The severity and extent of coronary atherosclerosis were graded and evaluated against clinical and laboratory parameters. RESULTS: Multidetector computed tomography identified significant obstructive coronary artery disease (>50% luminal stenosis) in 13 patients (4.9%), mild or moderate nonobstructive disease (<50% stenosis) in 124 patients (50.8%), and no atherosclerosis in 108 patients (44.3%). On multivariate logistic regression analysis, significant independent clinical predictors of coronary artery disease were male sex (odds ratio, 1.6, P<0.0047), family history of coronary artery disease (odds ratio, 1.4, P<0.0099), low-density lipoprotein cholesterol >130 mg/dl (OR 1.3, P<0.027), hypertension (odds ratio, 1.27, P<0.05), and noninsulin-dependent diabetes mellitus (odds ratio, 1.6, P<0.006). On the basis of the multidetector computed tomography results, pharmacological treatment was initiated or intensified in 40% of patients (statins in 31% and aspirin in 9%). Twenty-two patients (9%) were referred for complementary exercise testing and five (2%) for catheterization. CONCLUSIONS: (i) Occult atherosclerosis is not uncommon in asymptomatic patients with a risk profile for coronary artery disease. (ii) Conventional risk factors independently correlate with imaging findings of coronary atherosclerosis. (iii) Risk management could be intensified in a significant proportion (approximately 40%) of patients based on the multidetector computed tomography findings. (iv) In approximately 5% of patients at clinical risk, multidetector computed tomography might detect obstructive atherosclerosis that mandates further investigation.

Peripheral cutting balloon in the management of resistant benign ureteral and biliary strictures: long-term results.

PURPOSE: To report the long-term follow-up results of peripheral cutting balloon incision and dilatation (PCBID) after failed high-pressure balloon dilatation in patients with benign ureteral and biliary strictures. MATERIALS AND METHODS: The study included 9 patients (5 males and 4 females) who underwent successful PCBID procedures. Of these, 4 patients had biliary strictures; 2 of them had choledocho-choledochal anastomosis after liver transplantation, one at the choledocho-jejunal anastomosis, and the other at the papilla of Vater after failed endoscopic papillotomy. Of the 5 patients with ureteral strictures, 2 occurred following kidney transplantation, one after local radiation, and 2 had pelvic metastases compressing the urinary tract. The duration of follow-up, both clinical and radiological, was 24 months. RESULTS: The 9 patients who underwent successful PCBID procedures represented 82% of the original group treated by PCBID, which we reported in a previous publication. There were no periprocedural complications. The rate of primary patency, which was confirmed clinically and ultrasonographically at the end of follow- up, was 55% (5/9), and the secondary patency rate was 78% (7/9). Choledocho-choledochal restenosis occurred in 2 patients, 5 and 9 months after liver transplantation, who were treated percutaneously; one by balloon angioplasty (secondary patency for 19 months) and the other by PCBID (patency for 15 months). The remaining 2 patients (both with pelvic metastases) had restenosis 5 and 6 months postprocedure and were successfully treated by the insertion of double-J ureteral stents. CONCLUSION: PCBID is a simple and safe option for the treatment of ureteral and biliary strictures after failed high-pressure balloon dilatation, which demonstrated a two-year primary patency rate of 55% and a secondary patency rate of 78%.

Yield of magnetic resonance cholangiopancreatography for the investigation of bile duct dilatation in asymptomatic patients.

BACKGROUND: Biliary dilatation in the asymptomatic patient is a frequent incidental finding in the work-up for which there are no current guidelines. OBJECTIVES: The purpose of this study was to determine the yield of magnetic resonance cholangiopancreatography (MRCP) in asymptomatic patients with an incidental finding of biliary duct dilatation. METHODS: The study included 68 consecutive patients for evaluation of biliary duct dilatation found incidentally on computed tomography (CT) or ultrasound (US). MRCP scans were reviewed, and data were retrospectively collected on demographics and laboratory work-up. Patients were divided by the presence of a significant or non-significant MRCP findings explaining the biliary duct dilatation and compared for normal or abnormal liver function. RESULTS: Liver function was normal in 47 patients and abnormal in 21 patients. MRCP identified the cause of the bile duct dilatation in 41 patients (60.3%). Rates of insignificant causes were 51% in the normal-liver-function group and 7% in the abnormal-function group. Corresponding rates of significant causes were 27.7% and 61.9% (p = 0.007). CONCLUSIONS: MRCP is a valuable tool in the work-up of biliary duct dilatation. Although significantly more significant causes of bile dilatation are identified in patients with abnormal liver function, almost one-third of patients with normal liver function need further work-up. This has important implications for establishing criteria for the use of MRCP in asymptomatic patients with biliary dilatation.

Treatment of large incisional abdominal wall hernias, using a modified preperitoneal prosthetic mesh repair.

Very large and complex incisional hernias, especially those with loss of abdominal wall, can be a very interesting and perplexing problem, which present a particular challenge to the surgeon. The reported technique was developed and refined by one of our surgeons, between 1998 and 1999 for the repair of incisional hernias in a selected group of patients with large defects, often with a major loss of abdominal wall, overweight and previous attempts for incisional hernia repair. The technique involves a modified preperitoneal approach and was used on 43 eligible patients between 1999 and 2002. There were 30 females and 13 males at a mean age of 61 years. The median ASA score of the group was 2, with a mean BMI of 30.4 and a mean hernia surface area of 162 cm(2). One-third of the patients had one or more previous incisional hernia repair. Mean operating time was 190 min with an average hospital stay of 5.7 days. Postoperative complications occurred in 28% of the patients, most of which were minor and did not necessitate admission to the intensive care unit. None of the patients died. Wound infections occurred in 9.3%, was associated with an increased risk for cutaneous sinus formation, but not for mesh removal or hernia recurrence. A recurrence rate of 12.5% was found after a mean follow-up period of 46 months. We advocate this procedure for the repair of large, complex incisional hernias with loss of abdominal domain in patients with significant risk factors for recurrence.

Amplatzer Vascular Plugs Versus Coils for Embolization of Pulmonary Arteriovenous Malformations in Patients with Hereditary Hemorrhagic Telangiectasia.

PURPOSE: Coil embolization of pulmonary arteriovenous malformations (PAVMs) has a high re-canalization/re-perfusion rate. Embolization with Amplatzer plugs has been previously described, but the long-term efficacy is not established. This study reports the experience of a referral medical center with the use of coils and Amplatzer plugs for treating PAVMs in patients with hereditary hemorrhagic telangiectasia. METHODS: The study was approved by the Institutional Review Board with waiver of informed consent. The cohort included all patients who underwent PAVM embolization in 2004-2014 for whom follow-up imaging scans were available. The medical files were retrospectively reviewed for background data, embolization method (coils, Amplatzer plugs, both), and complications. Re-canalization of treated PAVMs was assessed from intrapulmonary angiograms (following percutaneous procedures) or computed tomography angiograms. Fisher's exact test and Pearson Chi-squared test or t test were used for statistical analysis, with significance at p < 0.05. RESULTS: 16 patients met the study criteria. Imaging scans were available for 63 of the total 110 PAVMs treated in 41 procedures. Coils were used for embolization in 37 PAVMs, Amplatzer plugs in 21, and both in five. Median follow-up time was 7.7 years (range 1.4-18.9). Re-canalization was detected in seven vessels, all treated with coils; there were no cases of re-canalization in plug-occluded vessels (p = 0.0413). CONCLUSION: The use of Amplatzer plugs for the embolization of PAVMs in patients with hemorrhagic telangiectasia is associated with a significantly lower rate of re-canalization of feeding vessels than coils. Long-term prospective studies are required to confirm these findings.