Adverse Events from Fluoroscopic versus Portable Placement of Peripherally Inserted Central Catheters and Central Venous Catheters in Pediatric Patients.

PURPOSE: To compare the outcomes of fluoroscopic versus portable placement of peripherally inserted central catheters (PICCs) and central venous catheters (CVCs) in pediatric patients. MATERIALS AND METHODS: This is a single-center, retrospective review of 346 upper-extremity PICC placements (286 fluoroscopic and 60 portable; mean age, 9.83 years [SD ± 5.58]; 49.1% female) and 138 tunneled femoral CVC placements (56 fluoroscopic and 82 portable; mean age, 0.23 years [SD ± 0.36]; 57.0% female). Portable placements used mobile plain-film radiography. All lines were placed by board-certified interventional radiologists. RESULTS: Fluoroscopic PICC placements had a lower procedure time (43.9 vs 57.9 minutes; P < .001), radiation dosage (342 vs 590 mGy·cm2; P < .001), incidence of technical failure (0% vs 3.3%; P = .029), and incidence of catheter malfunction (1.7% vs 12.1%; P < .001) compared with portable PICC placements. Fluoroscopic CVC placements had a lower procedure time (42.6 vs 54.8 minutes; P < .001) and radiation dosage (63.8 vs 405 mGy·cm2; P < .001) compared with portable CVC placements. No technical failures were found in either CVC groups and the difference was nonsignificant for catheter malfunction (0% vs 7.3%; P = .081). Fluoroscopic placements of PICCs and CVCs had a lower incidence rate of central line-associated bloodstream infection compared with portable placements (0.71 vs 2.22 cases per 1,000 line-days; P = .046). Overall, fluoroscopic placements of PICCs and CVCs had fewer adverse events compared with portable placements (3.2% vs 14.8%; P < .001). Portable procedure setting was the only significant factor associated with adverse events (odds ratio, 33.77; 95% CI, 4.56-757.01). CONCLUSIONS: Fluoroscopic placements of PICCs and CVCs are associated with lower procedure time, radiation dose, and risk of adverse events compared with portable placements in pediatric patients.

Investigating the Underutilization of Uterine Fibroid Embolization by Surveying Practice Preferences of Obstetricians/Gynecologists.

This study aimed to survey the practice preferences of obstetricians/gynecologists (OB/GYNs) that may be contributing to the underutilization of uterine fibroid embolization (UFE) in the treatment of symptomatic uterine fibroids (SUFs). A 22-question survey was created using the Qualtrics XM software and distributed to an obstetrics/gynecology-specific social media group of resident or attending OB/GYNs practicing in the United States. One hundred twelve responses met the inclusion criteria. For patients with SUFs, UFE was offered as a first-choice option <2% of the time. For patients with SUFs seeking to maintain fertility, UFE was recommended only 1% of the time after medical therapy (54%) and myomectomy (42%). Respondents reported lower rates of confidence (selecting "strongly agree" or "agree") regarding risks and benefits of UFE (77%) in comparison with those of myomectomy (99%) or hysterectomy (100%). Because UFE was seldom recommended by respondents, further, more robust polling of OB/GYNs is warranted.

Percutaneous Lung Biopsy in Immunocompromised Pediatric Patients.

PURPOSE: To determine the diagnostic yield and safety of image-guided lung biopsies in immunocompromised pediatric patients. MATERIALS AND METHODS: This was a retrospective pediatric cohort study conducted from June 2000 to April 2017. Subjects were 0-17 years of age (median, 10 years of age). There were 46 males (48%). A total of 73 consecutive image-guided lung biopsies were performed in 68 patients (weight range, 4.9-97.3 kg [median, 25.3 kg]). The indication for biopsy was to isolate an organism to tailor medical therapy. All patients were immunocompromised with an underlying history of bone marrow transplantation (n = 50), primary immunodeficiency (n = 14), and solid organ transplantation (n = 4). Patient and technical factors were analyzed for rates of complication. RESULTS: Overall diagnostic yield was 43 of 73 patients (60%). There were 14 minor (19%) and 8 major (11%) complications. Major complications included pneumothorax or hemoptysis requiring intervention (n = 6), and death (n = 2). The histological diagnosis was an infectious cause in 5 of 8 major complications (63%). There were statistically significant differences between the rates of complications with the imaging modality used (P = .02) and the use of fine needle aspiration (P = .02). CONCLUSIONS: Image-guided percutaneous lung biopsy can be helpful in isolating an organism to tailor therapy. Biopsies performed in immunosuppressed patients result in an elevated complication risk of up to 30% and demonstrate lower diagnostic yield and increased mortality, which should warrant detailed discussion with the primary team and family.

Fluoroscopic percutaneous brush cytology, forceps biopsy and both in tandem for diagnosis of malignant biliary obstruction.

OBJECTIVES: To evaluate percutaneous brush cytology, forceps biopsy and a tandem procedure consisting of both, in the diagnosis of malignant biliary obstruction. METHODS: A retrospective review of consecutive patients who underwent biliary brush cytology and/or forceps biopsy between 01/2010 and 09/2014 was performed. The cytology and pathology results were compared to the composite outcome (including radiological, pathological and clinical data). Cost for tandem procedure compared to brush cytology and forceps biopsy alone was calculated. RESULTS: A total of 232 interventions in 129 patients (70.8 ± 11.0 years) were included. Composite outcome showed malignancy in 94/129 (72.9%) patients. Sensitivity for brush cytology, forceps biopsy and tandem procedure was 40.6% (95% CI 32.6-48.7%), 42.7% (32.4-53.0%) and 55.8% (44.7-66.9%) with 100% specificity, respectively. There were 9/43 (20.9%) additional cancers diagnosed when forceps biopsy was performed in addition to brush cytology, while there were 13/43 (30.2%) more cancers diagnosed when brush cytology was performed in addition to forceps biopsy. Additional costs per additionally diagnosed malignancy if tandem approach is to be utilised in all cases was $704.96. CONCLUSION: Using brush cytology and forceps biopsy in tandem improves sensitivity compared to brush cytology and forceps biopsy alone in the diagnosis of malignant biliary obstruction. KEY POINTS: • Tandem procedure improves sensitivity compared to brush cytology and forceps biopsy. • Brush cytology may help to overcome "crush artefacts" from forceps biopsy. • The cost per diagnosed malignancy may warrant tandem procedure in all patients.

Catheter-Directed Thrombolysis in a Child with Bilateral Renal Artery Graft Thrombosis.

A 5-year-old boy with midaortic syndrome who had undergone aortic bypass and bilateral renal artery grafts presented to the emergency department 1 year after surgery with symptoms of nausea, vomiting, and abdominal pain. Because of delay in diagnosis of bilateral renal artery thrombosis, his condition progressed to anuric renal failure. He underwent catheter-directed thrombolysis 7 days after presentation with administration of tissue plasminogen activator and heparin infusion over a 24-hour period. There was successful resolution of thrombus and complete recovery of renal function to baseline. The patient had normal renal function at 6-month follow-up.

Temporal Evolution and Management of Fast Flow Vascular Anomalies in PTEN Hamartoma Tumor Syndrome.

Phosphatase and tensin homolog (PTEN) hamartoma tumor syndrome (PHTS) is characterized by formation of recurrent benign tumors described as PTEN hamartoma of soft tissue that may contain fast flow vascular anomalies (FFVA). The purpose of this study is to review the temporal evolution and management of FFVA in PHTS. A retrospective review of 22 patients (9 males), age 1 to 18 (median 9) years diagnosed with PHTS at a tertiary care pediatric hospital between October 2002 and August 2017 revealed 4 patients with FFVA. Imaging, management, and treatment complications were reviewed. During median follow-up of 8 (range: 4-13) years, ultrasound and magnetic resonance imaging performed for recurrent pain, showed progressive increase in the size of hamartomas and development of new FFVA in three-fourth patients. Medical management included pain medications, oral sirolimus, and physical and psychiatric therapy. Surgical excision of hamartoma ( n = 1) resulted in recurrence within 3 months. Between 4 and 24 (average 1.5/year) embolizations were performed per patient. Pain related to FFVA responded well to embolization. Pain secondary to PTEN hamartoma responded poorly to percutaneous sclerosant injection, but demonstrated improvement with sirolimus. There was no correlation between serum sirolimus levels and frequency/timing of recurrence of FFVA/hamartoma. Complications included sclerosant migration into digital arteries ( n = 1), subclavian vein stenosis due to glue migration ( n = 1), oral mucositis ( n = 4), and elevated triglycerides ( n = 4). Patients with PHTS present with recurrent pain requiring life-long management with a multi-disciplinary team. Pain due to FFVA responds to embolization, and pain due to hamartoma responds to sirolimus. This improves quality of life, but does not prevent disease progression.

Neurite outgrowth on well-characterized surfaces: preparation and characterization of chemically and spatially controlled fibronectin and RGD substrates with good bioactivity.

Study of axonal growth and ligand-receptor interactions requires specificity and careful characterization of the biomaterial substrates to which the neurons bind. It would be impossible to predict the effects of important variables such as composition, surface density, spatial distribution, and conformation of the ligands on axonal growth of a neuron without highly specific surface characterization. Here, we compare two methods of surface modification (hereafter referred to as "Heterobifunctional Crosslinker" and "Pluronics" methods) used for immobilization of fibronectin (FN) and FN-derived, RGD-containing peptides to the substrates. We also characterized their performance in neurite outgrowth experiments. Various surface analytical techniques such as contact angle measurement, XPS, and time-of-flight secondary ion mass spectrometry (TOF-SIMS) were used for the analysis of the substrates at each step of the two different chemistries involved. FN-patterned surfaces were created by micro-contact printing methods and confirmed by imaging TOF-SIMS, and AFM techniques. After immobilization of FN and/or FN-derived RGD-containing peptide, including the formation of micron-scale patterns of FN, the modified surfaces were plated with neurons from postnatal rat dorsal root ganglia (DRG) and incubated in serum-free medium. Both the peptide- and/or protein-modified substrates supported significantly greater neurite outgrowth than controls, and outgrowth on both substrate chemistries was inhibited by the addition of soluble RGD peptide. Patterned FN surfaces were successful in spatially controlling the neuron attachment and outgrowth.