Comparison of virtual computed tomography enteroscopy using carbon dioxide with small-bowel enteroclysis and capsule endoscopy in patients with small-bowel tuberculosis.

OBJECTIVE: Comparison of virtual CT enteroscopy (VCTE) using carbon dioxide with small-bowel enteroclysis (SBE) and capsule endoscopy (CE) in small-bowel tuberculosis (SBTB). METHODS: This prospective study comprised consecutive patients suspected to have SBTB. VCTE and SBE were performed on the same day and evaluated by independent radiologists. CE was performed within 2 weeks. VCTE was performed following insufflation of carbon dioxide via catheters in the jejunum and anorectum. A contrast-enhanced CT was followed by a delayed non-contrast CT. Image processing was done using virtual colonoscopy software. Findings on VCTE, SBE, and CE were compared. The final diagnosis of SBTB was based on either histopathological or cytological findings, response to antitubercular treatment, or a combination of these. RESULTS: Of the 55 patients in whom VCTE was performed, complete data was available in 52 patients. A final diagnosis of SBTB was established in 37 patients. All patients had VCTE and SBE. CE was performed in 34 patients. Adequate luminal distension was achieved in all patients with SBE and 35 patients with VCTE. SBE showed more strictures in jejunum (10.8%) and ileum (75.7%) compared with VCTE (jejunum, 8.1%, and ileum, 64.9%) and CE (jejunum, 5.9%, and ileum, 61.8%). However, difference was not statistically significant. VCTE revealed a greater length of strictures in both the jejunum and ileum compared with SBE and CE. CONCLUSION: VCTE allows adequate evaluation of the bowel in most patients with SBTB. It allows detection of greater length of abnormality in jejunum and ileum compared with SBE and CE. KEY POINTS: • The use of VCTE using CO2 bowel insufflation in patients with SBTB should be considered. • VCTE allows detection of a greater length of abnormality in the jejunum and ileum.

Patients undergoing recurrent CT exams: assessment of patients with non-malignant diseases, reasons for imaging and imaging appropriateness.

OBJECTIVE: To determine percent of patients without malignancy and ≤ 40 years of age with high cumulative radiation doses through recurrent CT exams and assess imaging appropriateness. METHODS: From the cohort of patients who received cumulative effective dose (CED) of ≥ 100 mSv over a 5-year period, a sub-set was identified with non-malignant disease. The top 50 clinical indications leading to multiple CTs were determined. Clinical decision support (CDS) system scores were analyzed using a widely adopted standard of 1-3 (red) as "not usually appropriate," 4-6 (yellow) "may or may not be appropriate," and 7-9 (green) "usually appropriate." Clinicians reviewed patient records to assess compliance with appropriate use criteria (AUC). RESULTS: 9.6% of patients in our series were with non-malignant conditions and 1.4% with age ≤ 40 years. CDS scores (rounded) were 2% red, 38% yellow, 27% green, and 33% unscored CTs. Clinical society guidelines for CT exams, wherever available, were followed in 87.5 to 100% of cases. AUCs were not available for several clinical indications as also referral guidelines for serial CT imaging. More than half of CT exams were unrelated to follow-up of a primary chronic disease. CONCLUSIONS: We are faced with a situation wherein patients in age ≤ 40 years require or are thought to require many CT exams over the course of a few years but the radiation risk creates concern. There is a fair number of conditions for which AUC are not available. Suggested solutions include development of CT scanners with lesser radiation dose and further development of appropriateness criteria. KEY POINTS: We are faced with a situation wherein patients in age group 0-40 years and with non-malignant diagnosis require or are thought to require many CT exams over the course of a few years. More than half of CT exams were unrelated to follow-up of a primary chronic disease. Imaging guidelines and appropriateness use criteria are not available for many conditions. Wherever available, they are for initial work-up and diagnosis and there is a lack of guidance on serial CT imaging.

A single institution's 1-year experience with uterine fibroid embolization marketing.

PURPOSE: To assess the impact of various marketing techniques on the referral pattern for uterine fibroid embolization (UFE) at an academic interventional radiology practice over a 1-year period. MATERIALS AND METHODS: All referrals to the interventional radiology clinic for UFE from January 1, 2009, to December 31, 2009, were retrospectively reviewed. A standard intake sheet was completed by the interventional clinic secretary at the time of initial patient contact that included the source of the referral (radio, television, newspaper, mailing, Internet, physician, friend, other). All patients who proceeded to consultation were seen in the interventional radiology clinic by attending interventional radiologists in a university-based academic center. The referral pattern was analyzed with respect to the number of patients who contacted the clinic, the number of actual clinic visits, the number of magnetic resonance (MR) imaging examinations performed before and after the procedure, the total number of embolization cases performed, and the subsequent downstream revenue. RESULTS: During the 1-year period, 344 patients contacted the interventional radiology clinic regarding UFE resulting in 171 consultations and 100 pelvic MR imaging examinations performed before the procedure. Sixty-two patients proceeded to UFE, and 32 patients underwent follow-up pelvic MR imaging. These results show a significant increase from eight cases the previous year and are presumably attributable almost entirely to the directed marketing campaign. The marketing initiative consisted primarily of print and radio advertisements, with the latter being the most effective. The total advertising cost for the year was approximately $24,706, of which $20,520 was for radio advertisements. The radio advertisements generated 69% (237 of 344) of the referrals and 69% (43 of 62) of the UFE procedures. Using Medicare reimbursement rates, the radio advertisements generated $281,994 in UFE technical fees and $50,329 in MR imaging technical fees. CONCLUSIONS: Direct patient marketing techniques can promote significant growth for a fibroid embolization practice. In our market, radio advertisements proved to be the most cost-effective strategy.

Modified stent-supported coil embolization for treatment of a splenic artery pseudoaneurysm.

A patient presented 2 weeks after distal pancreatectomy and splenectomy with increased bloody output from his surgical drain. Catheter angiography found an enlarging splenic artery stump pseudoaneurysm. During the procedure, there was concern that nontarget embolization may occur, given the short splenic artery remnant. Pseudoaneurysm thrombosis was subsequently achieved using a variation of stent-supported coil embolization. At 3-month follow-up, the patient had no recurrent bleeding from the surgical site. Although this technique has been described in the treatment of neurovascular and renal artery aneurysms, it is applicable to, and readily adapted for, use in visceral arterial procedures.

Cost determinants of percutaneous and surgical interventions for treatment of intermittent claudication from the perspective of the hospital.

PURPOSE: To identify pretreatment predictors of procedural costs in percutaneous and surgical interventions for intermittent claudication due to aortoiliac and/or femoropopliteal disease. METHODS: A retrospective study was conducted in 97 consecutive patients who underwent percutaneous or surgical interventions over 15 months at a tertiary care center. Nineteen clinical predictive variables were collected at baseline. Procedural costs (outcome) were assessed from the perspective of the hospital by direct calculation, not based on ratios of costs-to-charges. A multivariable regression model was built to identify significant cost predictors. Follow-up information was obtained to provide multidimensional assessment of clinical outcome, including technical success (arteriographic score) and clinical result (changes in ankle-brachial pressure index; cumulative patency, mortality, and complication rates). RESULTS: The linear regression model shows that procedural costs per patient are 25% lower in percutaneous patients (versus surgical), 42% lower for patients without rest pain than for those with, 28% lower if treated lesions are unilateral (versus bilateral), 12% lower if the treated lesion is stenotic rather than occlusive, 34% higher in sedentary patients, and 11% higher in patients with a history of cardiac disease. After a mean clinical follow-up >2 years, between-group differences between percutaneous and surgical patients were small and of limited significance in all dimensions of clinical outcome. CONCLUSION: Predictors of clinical outcome are different from predictors of costs, and one should include both types of variables in the decision-making process. The choice of percutaneous versus surgical strategy, the presence of rest pain, and the bilaterality of the culprit lesions were the main pretreatment determinants of procedural costs. When possible choices of treatment strategy overlap, percutaneous treatment should provide an acceptable result that is less expensive (although not equal to surgery).

Operating expenses for the diagnosis and treatment of peripheral vascular disease in an academic interventional radiology department: cost calculations according to a microeconomic method.

PURPOSE: A correct understanding of the true costs of a procedure is necessary to make informed decisions in cost-effectiveness analyses. The actual comprehensive costs of performing cardiovascular and interventional radiology (CVIR) procedures were analyzed in the present study, as opposed to charges or ratios of costs to charges (RCCs), as often used in the literature. MATERIALS AND METHODS: Costs included labor, equipment, administration, facility establishment and maintenance, overhead, and consumable supplies. Cost identification was initially performed with use of an hourly rate that reflected the cost of operating the CVIR section. This was then combined with the costs of the consumable supplies used during each type of procedure. Eight types of vascular procedures were studied in 235 consecutive patients to determine mean procedure duration and supplies consumption. Costs were then compared with charges and RCCs of these procedures. RESULTS: The hourly rate for operating one angiography suite was 690 dollars. Average cost by procedure, including hourly rate plus consumable supplies, were: aortic arteriogram, 1,442 dollars; aortobifemoral arteriogram, 1,554 dollars; unilateral limb arteriogram, 1,307 dollars; simple iliac or femoropopliteal angioplasty, 2,119 dollars; arterial stent placement, 2,780 dollars; percutaneous thrombectomy, 1,998 dollars; arterial in situ thrombolysis, 3,133 dollars; and arteriogram after thrombolysis, 926 dollars. RCCs calculated for each procedure ranged from 0.39 (thrombectomy) to 1.92 (control arteriography during or after thrombolysis) and were lower than expected based on previous reports. CONCLUSIONS: The average actual costs of several common diagnostic and therapeutic procedures for peripheral vascular occlusive disease were established, allowing determination of the relative importance of different cost components. This methodology may serve as a template for future cost analyses.

Docetaxel/Gemcitabine followed by gemcitabine and external beam radiotherapy in patients with pancreatic adenocarcinoma.

BACKGROUND: Pancreatic cancer remains highly lethal. Previous attempts with neoadjuvant therapy in this disease have been inconclusive, but a potential for benefit exists. We conducted a phase II trial of dose-intense docetaxel and gemcitabine followed by twice-weekly gemcitabine and external beam radiotherapy in patients with pancreatic adenocarcinoma. METHODS: Patients with stage I to III disease were eligible. Docetaxel 65 mg/m(2) intravenously over 1 hour and gemcitabine 4000 mg/m(2) given intravenously over 30 minutes were given on days 1, 15, and 29. On day 43, radiotherapy was begun at 50.4 Gy with gemcitabine 50 mg/m(2) intravenously over 30 minutes twice weekly for 12 doses. After treatment, patients were considered for resection. RESULTS: Twenty-four assessable patients were recruited onto the trial. All but one patient completed a full 12 weeks of therapy. Grade 3 and 4 hematological and nonhematological toxicities were common but manageable, and neutropenic fever did not occur. No patient had local tumor progression. Twelve patients (50%) responded by Response Evaluation Criteria in Solid Tumors Group (RECIST) criteria, including one radiographic complete response. Seventeen patients underwent resection after therapy. Margin-negative resections were performed in 13 patients, including 9 patients whose disease was borderline or unresectable before treatment. A treatment effect was seen in all resection specimens. There have been no local recurrences of tumor, and several patients remain alive without evidence of disease. CONCLUSIONS: Docetaxel/gemcitabine followed by gemcitabine/radiotherapy is active in the treatment of pancreatic adenocarcinoma, with manageable toxicity. Tumor downstaging occurs in some patients to allow complete resection. Further investigation of this regimen is warranted.

Percutaneous radiologic gastrostomy versus percutaneous endoscopic gastrostomy: a comparison of indications, complications and outcomes in 370 patients.

OBJECTIVE: Percutaneous access to the stomach can be achieved by endoscopic or fluoroscopic methods. Our objective was to compare indications, complications, efficacy and outcomes of these two techniques. METHODS: Records of 370 patients with feeding tubes placed either endoscopically by gastroenterology, or fluoroscopically by radiology, at our university-based tertiary care center over a 54-month period were reviewed. RESULTS: 177 gastrostomies were placed endoscopically and 193 fluoroscopically. Nutrition was the most common indication in each group (94 and 92%), but the most common underlying diagnosis was neurologic impairment in the endoscopic group (n=89, 50%) and malignancy in the fluoroscopic group (n=134, 69%) (p<0.001). Complications in the first 30 days were more common with fluoroscopic placement (23% versus 11%, p=0.002), with infection most frequent. Correlates of late complications were inpatient status (OR 0.26, 95%CI: 0.13-0.51) and a diagnosis of malignancy (OR 2.2, 95%CI: 1.03-4.84). Average follow-up time was 108 days in the fluoroscopic group and 174 days in the endoscopic group. CONCLUSIONS: Both endoscopic and fluoroscopic gastrostomy tube placement are safe and effective. Outpatient status was associated with greater early and late complication rates; minor complications such as infection were greater in the fluoroscopic group, while malignancy was associated with late complications.

Frequently asked questions: iodinated contrast agents.

Although iodinated contrast agents are safe and widely used, adverse events occur and questions remain about their use, safety, and interactions. Some questions are easily answered and others still require extensive investigation. For one frequent question--is informed consent necessary before all contrast media injections--the simple answer is no. Another question concerns use of contrast media in patients with prior reactions or allergies. Contrast agents can be safely used in such patients, but special care must be taken to be aware of what the previous reaction was and to be ready to treat any reaction. The protective role of pre-treatment with steroids is well established for minor reactions, but they may not prevent major reactions. It is important to realize that even life-threatening, anaphylactoid reactions are not the result of a true allergy to contrast media. Many questions arise about contrast agent-induced nephropathy. Baseline serum creatinine values should be obtained in patients who are at risk, not all patients. The incidence and natural history of contrast agent-induced nephropathy remain unclear. It occurs only in patients with compromised renal function before contrast agent injection, but even patients with normal serum creatinine levels can have renal dysfunction. Calculated creatinine clearance is a better way to determine risk and to follow this complication. The outcome in almost all patients is benign, with progression to end-stage renal disease being rare. The major risk factors, in addition to renal dysfunction, are long-standing diabetes mellitus, dehydration, and use of other nephrotoxic medications. Recent work in preventing and ameliorating contrast agent-induced nephropathy with N-acetyl cysteine, substitution of an isosmolal nonionic contrast agent, and various hydration regimens has been promising. Another common concern is use of iodinated contrast agents in pregnant or breast-feeding women. In both cases, there is no evidence of harm to the fetus or infant, but it is prudent to weigh the theoretical risks and benefits and avoid contrast agent administration unless it is truly necessary.

Retrospective assessment of risk factors to predict tunneled hemodialysis catheter outcome.

PURPOSE: To identify factors that may influence the function, outcome, and complications associated with tunneled hemodialysis catheters. MATERIALS AND METHODS: Radiology reports and hemodialysis, medical, and Clinical Information System (computerized patient medical record system) records were retrospectively reviewed in 221 consecutive patients who underwent tunneled hemodialysis catheter placement by interventional radiologists between January 11, 1996 and January 13, 2000 at Dartmouth-Hitchcock Medical Center. Various patient characteristics (diabetes, smoking, hypertension, age, sex, atherosclerotic cardiovascular disease, history of cardiac catheterization, coumadin use, functional status, and obesity) were assessed for their relationship to the outcome of hemodialysis catheters. Catheter outcome was examined by calculating infection rate, thrombosis rate, fibrin formation rate, mechanical malfunction rate, and total complication rate. With these patient characteristics and outcome variables, multiple regression analysis was performed with STATA (College Station, TX) statistical analysis software. RESULTS: Of the 221 patients reviewed, 39 patients were lost to follow-up. Among the remaining 182 patients, 427 catheters were placed for a total number of 36994 catheter-days. For overall complication rate, multiple regression analysis revealed a statistically significant positive correlation only for hypertension (P =.032). Total complication rate was 0.76 events per 100 catheter-days (95% CI: 0.53-1.00) for patients with a documented history of hypertension and 0.27 events per 100 catheter-days (95% CI: 0.08-0.45) for patients without (P =.024, paired student t test). For patients with diabetes versus patients without, the infection rates were 0.34 episodes per 100 catheter-days (95% CI: 0.15-0.53) and 0.12 episodes per 100 catheter-days (95% CI: 0.06-0.18), respectively, (P =.011, paired student t test). Thrombosis rate for patients on coumadin was 0.13 events per 100 catheter-days (95% CI: -0.14-0.40), while thrombosis rate for patients not taking coumadin was 0.03 events per 100 catheter-days (95% CI: 0-0.05) (P =.036, paired student t test). CONCLUSION: Hypertension is a risk factor for poor outcome of tunneled hemodialysis catheters as measured by total complication rate requiring catheter removal or exchange. In this retrospective study, no other specific risk factors predicted an increased need for removal or exchange of tunneled hemodialysis catheters.