[Embolization of acute abdominal and thoracic hemorrhages with ethylene vinyl alcohol copolymer (Onyx): initial experiences with arteries of the body trunk]. / Embolisation akuter abdomineller und thorakaler Blutungen mit Ethylen-Vinyl-Alkohol-Kopolymer (Onyx®): erste Erfahrungen im arteriellen Gefäßgebiet des Körperstamms.

During the last years most embolizations with the liquid agent Onyx have been performed in the field of neuroradiological interventions. There is minimal experience with arterial embolizations of the body trunk. 23 patients suffering from acute abdominal or thoracic bleeding underwent 28 embolizations with Onyx (17 male, 6 female, mean age 69 years). 27 interventions were technically and clinically successful. One patient with rebleeding from a jejunal artery aneurysm underwent surgery. Onyx embolizations were performed in renal, hepatic, iliac and bronchial arteries and esophageal varices. Compared with prior embolisation agents Onyx offers advantages due to good controllability. Fast arterial occlusion improves time management of patients. In comparison with prior techniques we observed a significant reduction of fluoroscopy time. Quantitative measurements demonstrated a significant higher embolisation agent contrast.

An established extracorporeal membrane oxygenation protocol promotes survival in extreme hypothermia.

BACKGROUND: Historical reports indicate that active rewarming with extracorporeal membrane oxygenation (ECMO) can salvage a patient after hypothermic cardiac arrest. We created a protocol that includes ECMO for extreme hypothermia to guide rewarming of the hypothermic patient. METHODS: A retrospective review of the ECMO rewarming protocol (2004-2006) was conducted. RESULTS: The active rewarming protocol is a flowchart that is available on our hospital intranet and can be accessed in the trauma bay. A severely hypothermic patient triggers the activation of a TRAUMA ONE-OP ECMO response. During the 2-year period, there were 5 activations of the system and 4 children were placed on ECMO. Two of the 4 were dramatically salvaged and eventually discharged neurologically intact. All 5 children were found pulseless at the scene before transport. The average time from the injury occurrence to arrival was 94 minutes (range, 41-181 minutes). Mean cardiopulmonary resuscitation time was 78.2 minutes (range, 37-152 minutes). The mean core temperature on arrival was 25.4 degrees C (range, 20.4 degrees C-28.6 degrees C). The average time from arrival to ECMO cannulation was 25.5 minutes (range, 16-37 minutes). CONCLUSION: A preemptive strategy for the severely hypothermic patient provides an organized approach and prompt response. Expeditious rewarming can make the difference in an opportunity for survival.

[Clinical results with a detachable temporary vena cava filter]. / Erfahrungen mit einem abwerfbaren temporären Vena cava Filter.

PURPOSE: Evaluation of the feasibility of implantation and explantation and evaluation of the efficacy of a detachable and retrievable temporary vena cava filter. MATERIALS AND METHOD: The temporary vena cava filter "OptEase" (Cordis) is a nitinol filter derived from the "TrapEase" (Cordis) permanent filter, which is implantable transjugularly or transfemorally. In contrast to other temporary filters, this type can be detached and is not fixed on a catheter during implantation. Therefore, it is usable as a temporary as well as a permanent filter which can be retrieved up to 12 days after detachment with a special catheter using the loop technique. The "OptEase" filter was implanted in 11 patients ranging in age from 19 to 82 (mean age 30 years). In 10 patients the filter was transfemorally implanted and explanted. In 1 patient implantation was performed transjugularly prior to surgery and explantation was performed transfemorally after surgery. All patients had a deep vein thrombosis or iliac vein thrombosis. In 3 patients the filter was implanted prior to surgery. In 2 patients pulmonary embolism was identified. In 5 patients the filter was implanted prophylactically because of deep vein thrombosis according to interdisciplinary diagnosis. RESULTS: No pulmonary embolism occurred during implantation. All filters were able to be retrieved without complications using the loop technique on the 6th, 8th, 12th and 13th day. No captured thrombus material was in the filter. CONCLUSIONS: This new vena cava filter type is an easily implantable and retrievable system. Since this filter type is detachable without a need for venous access during implantation, there are no sterility problems. The filter can be left in the vena cava as a permanent system if explantation is not indicated.

[Quality assurance with teleradiology]. / Qualitätssicherung mit Teleradiologie.

Teleradiology offers many applications for quality assurance in medicine. The spectrum reaches from electronic consultations in emergency or special cases and double reading--along with new models of cooperative work and medical networks--to technical quality assurance and integration into interinstitutional and patient controlled health records. Regional teleradiology networks based on server concepts can fulfill the developing technical and organisational requirements. The increasing mobility arising from smaller radiological equipment and improved accessibility to experts with minimized visualisation and reporting systems will change the radiological world of tomorrow, especially in combination with the usage of knowledge based systems in reference data bases and computer assisted diagnosis (CAD). Teleradiology by itself must be liable to quality assurance measurements to prevent unnecessary radiation exposure or danger to the doctor patient relation.

[The future of teleradiology: results of Teleradiology Expert Meeting of the Health Network Congress 2001]. / Die Zukunft der Teleradiologie: Ergebnisse des Expertentreffens Teleradiologie des Gesundheitsnetzkongresses 2001.

Legal prerequisites have substantial influence on the development of teleradiology. At an expert meeting (Mannheim, 8.6.2001) a proposal for a teleradiology article in the new German x-ray ordinance has been set up. An exception of the demand for a doctor trained in radiation protection at the point of examination shall be established for emergency cases. To realize the intended improvement of patient care measurements for quality assurance concerning the medical personnel and processes are necessary. Along with other current developments the basis of secure regional teleradiology networks is now built up.

The clinical presentation of pediatric pelvic fractures.

BACKGROUND: Few studies have addressed the presentation and clinical impact of pediatric pelvic fractures. We sought to describe pediatric blunt trauma patients with pelvic fracture (PF) and to evaluate the sensitivity and specificity of physical examination at presentation for diagnosis. METHODS: Retrospective analysis of all PF and control (NPF) patients from our pediatric institution over an 8-year period. RESULTS: A total of 174 patients (88 PF, 86 NPF) were included. Median patient age was 8 years (range, 3 months to 18 years), with 54% males. The most common mechanisms of injury for PF patients were automobile-related accidents (75%). There were 140 patients (87%) who were transported by air or ground medical services. At presentation, approximately 16% of PF patients had a Glasgow Coma score of <15, a mean Revised Trauma Score of 7.49, and a median Injury Severity Score (ISS) of 9. Thirty-one PF patients (35%) had an ISS of >15 indicating severe, multiple injuries. Sixty-eight PF patients (77%) had severe isolated injuries (Abbreviated Injury Scale 1990 value of >3); 11% of PF patients required transfusions, and 2% died. Fifteen PF patients (17% ) had no pelvic ring disruption; 39 (43%) had a single pelvic ring fracture, 22 (2%) had two pelvic ring fractures, 2 (2%) had acetabular fractures, and 10 (11%) had a combination of pelvic fractures. An abnormal physical examination of the pelvis was noted in 81 patients with PF (92% sensitivity, 95% confidence interval [CI] = 0.89-0.95), 15 NPF patients had an abnormal examination (79% specificity, 95% CI = 0.74-0.84). The positive predictive value of the pelvis examination was 0.84, and the negative predictive value was 0.89. The most common abnormal pelvis examination finding was pelvic tenderness in 65 PF patients (73%). A total of seven PF patients had a normal examination of the pelvis; four had a depressed level of consciousness (defined as GCS <15), and six patients had a distracting injury. CONCLUSIONS: Pediatric blunt trauma patients with pelvic fracture represent a severely injured population but generally have lower transfusion rates and mortality than noted in adult studies. The pelvis examination appears to be sensitive and specific in this retrospective study. However, an altered level of consciousness and/or distracting injuries may affect examination sensitivity and specificity. Based on this retrospective study, we cannot advocate eliminating pelvic radiographs in the severely injured, blunt trauma patient. Prospective studies are recommended.

Teleradiology requirements and aims in Germany and Europe: status at the beginning of 2000.

Specific radiological requirements have to be considered for realization of telemedicine. In this article the goals and requirements for an extensive implementation of teleradiology are defined from the radiological user's point of view. Necessary medical, legal and professional prerequisites for teleradiology are presented. Superior requirements, such as data security and privacy or standardization of communication, must be realized. Application specific requirements, e. g. quality and extent of teleradiological functions as well as technological alternatives, are discussed. Each project must be carefully planned in relation to one's own needs, extent of functions and system selection. Topics like legal acceptance of electronic documentation, reimbursement of teleradiology and liability must be clarified in the future.

Appendiceal perforation in children diagnosed in a pediatric emergency department.

OBJECTIVE: To determine the incidence of appendiceal perforation (AP) among children with acute appendicitis (AA) and determine factors associated with AP. DESIGN: Retrospective chart review. SETTING: Emergency department (ED) of Primary Children's Medical Center (PCMC). PATIENTS: 131 children less than 17 years of age with AA diagnosed in the PCMC ED. RESULTS: The overall rate of AP was 47%. One hundred eleven (85%) children with AA were correctly diagnosed on their first ED visit. Patients with AP had a significantly (P < 0.05) lower median age (8.0 vs 11.0 years), longer duration of illness (3.0 vs 1.4 days), greater incidence of vomiting and fever by history (91% vs 69% and 83% vs 58%, respectively), higher median temperatures (39.0 degrees vs 38.3 degrees C), and higher proportions of leukocyte (WBC) band forms (14% vs 5%). Patients with AP did not differ from those without AP with respect to total WBC count, hour of arrival, or number of ED visits. CONCLUSIONS: The rate of AP among pediatric patients with AA is greater among younger children and is associated with vomiting, prolonged illness, and higher body temperatures. Unexpectedly, patients with AP did not have higher total WBC values, more frequent late night arrivals, a longer time interval prior to surgery, or more ED visits prior to diagnosis. These findings suggest that efforts to decrease the rate of AP should be directed toward heightening awareness among primary care physicians regarding the high rate of AP in children, with an emphasis on early ED and surgical referral.

Risks of intravenous administration of hypotonic fluids for pediatric patients in ED and prehospital settings: let's remove the handle from the pump.

Fluid resuscitation of infants and children is a common management problem in prehospital and emergency department care. We present two cases of children who received 5% dextrose in water as the initial resuscitation fluid. Bolus administration of hypotonic fluid contributed to fatal outcomes in these cases. Recommendations are made for eliminating hypotonic fluids as stock items in both the prehospital and emergency department settings.

Applying outpatient protocols in febrile infants 1-28 days of age: can the threshold be lowered?

The purpose of this study was to determine the applicability of two accepted outpatient management protocols for the febrile infant 1-2 months of age (Boston and Philadelphia protocols) in febrile infants 1-28 days of age. We retrospectively reviewed charts of patients 1-28 days of age with a temperature greater than or equal to 38.0 degrees C. Criteria from each of the above-cited management protocols were applied to the patients to determine their applicability in screening for serious bacterial infection (SBI). An SBI was defined as bacterial growth in cultures from blood, urine, cerebrospinal fluid (CSF), stool, or any aspirated fluid. Overall, 372 febrile infants were included in the study. Ages ranged from 1 to 28 days of age. The mean age was 15 days. SBI occurred in 45 patients (12%). The mean age of the patients with an SBI was 13 days. Thirty-two infants (8.6%) had a urinary tract infection; 12 (3.2%), bacteremia; five (1.3%), bacterial meningitis; three (0.8%), cellulitis; one (0.3%), septic arthritis; one (0.3%), bacterial gastroenteritis; and one (0.3%), pneumonia. Ten infants had more than one SBI. Of 372 patients, 231 (62%) met the Boston's laboratory low-risk criteria; eight (3.5%) would have been sent home with an SBI with these criteria. Philadelphia's laboratory low-risk criteria would have been met by 186 patients (50%); six (3.2%) would have been sent home with an SBI with these criteria. The negative predictive value of both the Boston and Philadelphia protocols for excluding an SBI was 97%. We conclude that current management protocols for febrile infants 1-2 months of age when applied to febrile infants 1 to 28 days of age would allow 3% of febrile infants less than 28 days of age to be sent home with an SBI. Current guidelines recommending admitting all febrile infants less than 28 days of age should be followed until the outcome of those 3% of febrile infants with an SBI treated as outpatients can be determined.

[Lymph node imaging with ultra-rapid 3D MR angiography]. / Lymphknotendarstellung bei ultraschneller 3D-MR-Angiographie.

PURPOSE: A report on observations of lymph node images obtained by gadolinium-enhanced 3D MR angiography (MRA). METHODS: Ultrarapid MRA (TR, TE, FA-5 or 6.4 ms, 1.9 or 2.8 ms, 30-40 degrees) with 0.2 mmol/kg BW Gd-DTPA and 20 ml physiological saline. Start after completion of injection. Single series of the pelvis-thigh as well as head-neck regions by use of a phased array coil with a 1.5 T Magnetom Vision or a 1.0 T Magnetom Harmony (Siemens, Erlangen). We report on lymph node imaging in 4 patients, 2 of whom exhibited benign changes and 2 further metastases. In 1 patient with extensive lymph node metastases of a malignant melanoma, color-Doppler sonography as color-flow angiography (CFA) was used as a comparative method. RESULTS: Lymph node imaging by contrast medium-enhanced ultrarapid 3D MRA apparently resulted from their vessels. Thus, arterially-supplied metastases and inflammatory enlarged lymph nodes were well visualized while those with a.v. shunts or poor vascular supply in tumor necroses were poorly imaged. CONCLUSIONS: Further investigations are required with regard to the visualization of lymph nodes in other parts of the body as well as a possible differentiation between benign and malignant lesions.

Effect of a pediatric trauma response team on emergency department treatment time and mortality of pediatric trauma victims.

OBJECTIVE: Delay in the provision of definitive care for critically injured children may adversely effect outcome. We sought to speed care in the emergency department (ED) for trauma victims by organizing a formal trauma response system. DESIGN: A case-control study of severely injured children, comparing those who received treatment before and after the creation of a formal trauma response team. SETTING: A tertiary pediatric referral hospital that is a locally designated pediatric trauma center, and also receives trauma victims from a geographically large area of the Western United States. SUBJECTS: Pediatric trauma victims identified as critically injured (designated as "trauma one") and treated by a hospital trauma response team during the first year of its existence. Control patients were matched with subjects by probability of survival scores, and were chosen from pediatric trauma victims treated at the same hospital during the year preceding the creation of the trauma team. INTERVENTIONS: A trauma response team was organized to respond to pediatric trauma victims seen in the ED. The decision to activate the trauma team (designation of patient as "trauma one") is made by the pediatric emergency medicine (PEM) physician before patient arrival in the ED, based on data received from prehospital care providers. Activation results in the notification and immediate travel to the ED of a pediatric surgeon, neurosurgeon, emergency physician, intensivist, pharmacist, radiology technician, phlebotomist, and intensive care unit nurse, and mobilization of an operating room team. Most trauma one patients arrived by helicopter directly from accident scenes. OUTCOME MEASURES: Data recorded included identifying information, diagnosis, time to head computerized tomography, time required for ED treatment, admission Revised Trauma Score, discharge Injury Severity Score, surgical procedures performed, and mortality outcome. Trauma Injury Severity Score methodology was used to calculate the probability of survival and mortality compared with the reference patients of the Major Trauma Outcome Study, by calculation of z score. RESULTS: Patients treated in the ED after trauma team initiation had statistically shorter times from arrival to computerized tomography scanning (27 +/- 2 vs 21 +/- 4 minutes), operating room (63 +/- 16 vs 623 +/- 27 minutes) and total time in the ED (85 +/- 8 vs 821 +/- 9 minutes). Calculation of z score showed that survival for the control group was not different from the reference population (z = -0.8068), although survival for trauma-one patients was significantly better than the reference population (z = 2.102). CONCLUSION: Before creation of the trauma team, relevant specialists were individually called to the ED for patient evaluation. When a formal trauma response team was organized, time required for ED treatment of severe trauma was decreased, and survival was better than predicted compared with the reference Major Trauma Outcome Study population.

Economic analysis of teleradiology applications with KAMEDIN.

The teleradiology system KAMEDIN (German Telekom), installed on HP-Unix- and NT-Workstations, was evaluated in different scenarios and a cost-benefit-analysis was performed. CT examinations were transferred from a PACS workstation (GE) to KAMEDIN using DICOM-3 protocol. Teleconferences were realized with an intensive care unit by LAN, with a radiology department at 5 km. distance by ISDN, and with an on duty radiologist 22 km. away by ISDN. On average, 36 CT slices per patient were transferred. Overall costs (costs for hardware, software, support, ISDN-fees, and staff) were compared to possible cost reduction, mainly concerning transportation and films. These three scenarios could be realized during daily routine work. Differing in their amount of transportation cost reduction, two applications (intensive care unit, radiologist on duty) showed a break-even at 1817, respectively 528 teleconferences/year. Improvement of cost-effectiveness can be obtained on the conditions that existing hardware will be used and that the automatic data transfer will be improved. Combining all optimisation factors, the break-even decreased to a minimum of 167, respectively 77 teleconferences/year. The optimisation of patient management is an additional--but in this study, not yet counted--advantage of teleradiology.

A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages.

STUDY OBJECTIVE: To compare historical features, physical examination findings, and testicular color Doppler ultrasound in pediatric patients with epididymitis, testicular torsion, and torsion of appendix testis. METHODS: A retrospective review of patients with the diagnosis of epididymitis, testicular torsion, or torsion of appendix testis. RESULTS: Ninety patients were included in the study (64 with epididymitis, 13 with testicular torsion, and 13 with torsion of appendix testis). Historical features did not differ among groups except for duration of symptoms. Of 13 patients with testicular torsion all had a tender testicle and an absent cremasteric reflex. When compared with the testicular torsion group, fewer patients with epididymitis had a tender testicle (69%) or an absent cremasteric reflex (14%). 62 (97%) patients with epididymitis had a tender epididymis and 43 (67%) had scrotal erythema/edema. By comparison, 3 (23%) and 5 (38%) patients with testicular torsion had a tender epididymis or scrotal erythema/edema, respectively. Doppler ultrasound showed decreased or absent blood flow in 8 patients, 7 of whom were diagnosed with testicular torsion. Ten out of 13 patients with testicular torsion had a salvageable testicle at the time of surgery. CONCLUSION: The physical examination is helpful in distinguishing among epididymitis, testicular torsion, and torsion of appendix testis. Patients presenting with a tender testicle and an absent cremasteric reflex were more likely to have a testicular torsion rather than epididymitis or torsion of appendix testis. An absent cremasteric reflex was the most sensitive physical finding for diagnosing testicular torsion. Color Doppler ultrasound is a useful adjunct in the evaluation of the acute scrotum when physical findings are equivocal.

Teleradiology: results of a questionnaire of German radiologists.

A questionnaire was sent by mail to 4400 radiologists (i.e. to at least 1000 radiological institutions). The response rate was about 5%. The results showed that 47% of respondents felt well informed about teleradiology, 49% not enough and 3% not at all. Image and report transfer as well as interfaces to reference databases, educational applications, technical quality surveillance and product support (maintenance) were considered to be increasingly important areas. Smaller institutions (1-3 doctors) judged expert consultation as more important than bigger institutions. Standardization, system stability and data security were demanded as well as guidelines, for example concerning the linking of report and image, correct documentation and required image quality. Technically most demands can be fulfilled today but this technology is not yet commonly included in teleradiology systems.

[Goals, requirements and prerequisites of teleradiology. An assessment of current status]. / Ziele, Anforderungen und Rahmenbedingungen der Teleradiologie. Eine Bestandsaufnahme.

Specific radiological requirements have to be considered for the realization of telemedicine. In this article the goals and requirements for an extensive introduction of teleradiology will be defined from the radiological user's point of view. Necessary medical, legal and professional prerequisites for teleradiology are presented. Essential requirements, such as data security, maintenance of personal rights and standardization, must be realized. Application-specific requirements, e.g. quality and extent of teleradiological functions, as well as technological alternatives, are discussed. Each project must be carefully planned in relation to one's own needs, extent of functions and system selection. Topics, such as acknowledgement of electronic documentation, reimbursement of teleradiology and liability, must be clarified. Legal advice and the observance of quality guidelines are recommended.

[Possible applications of the KAMEDIN teleradiology system with special reference to an economic analysis]. / Einsatzmöglichkeiten des KAMEDIN-Teleradiologiesystems unter besonderer Berücksichtigung einer Wirtschaftlichkeitsanalyse.

INTRODUCTION: Different concepts and applications of teleradiology systems have been realised. However, their cost-effectiveness is still questionable. Therefore, a cost-benefit analysis of three different scenarios of the new teleradiology system Kamedin (Kooperatives Arbeiten und rechnergestützte Medizinische Diagnostik auf innovativen Netzen der Deutschen Telekom) was performed. METHODS: CT examinations were transmitted from an Advantage Windows (GE) workstation to a Kamedin workstation using DICOM 3 protocol. Afterwards a teleconference was established with a Kamedin workstation in the intensive care unit within the hospital via FDDI/Ethernet, with an external workstation in a radiology department 6 km away via ISDN and with a Kamedin PC located with radiologist on duty 22 km away via ISDN. On average, 36 CT slices per patient were transferred. A break-even analysis was performed with respect to costs of hardware, software, support, use of ISDN and staff, as well as benefits like the decrease in transportation or film documentation costs. RESULTS: Owing to the different reductions in transportation costs, two applications (intensive care unit and external PC) showed a break-even of 1817 and 528 teleconferences/year, respectively. Further optimisation of cost-effectiveness is possible on condition that existing hardware can be used and an automatic data transfer without staff control is available. When all optimisation factors were combined, the break-even decreased to a minimum of 167 and 77 teleconferences/ year, respectively. CONCLUSION: Teleconferences with high image quality can be set up between workstations and PCs using the Kamedin system. Depending on the possible decrease in transportation costs, teleconferencing is cost-effective under certain conditions. Teleradiology has additional advantages, such as the acceleration and optimisation of patient management.

Evaluating the effectiveness of a pediatric trauma educational program in Central America.

OBJECTIVE: To evaluate the effectiveness of a pediatric trauma course taught in a developing country. STUDY DESIGN: A pediatric trauma course was designed with didactic presentations and reinforced with small group case discussions. Subjects included a general trauma overview, head trauma, airway/chest trauma, cervical spine trauma, abdominal trauma, shock, burns, and orthopedic injuries. Evaluation consisted of a pre- and post-course test and questionnaire assessing the participants' knowledge and level of comfort in managing trauma. Nine months after the course, the participants were evaluated with the same post-course test. Also a questionnaire was given to physician and nurse co-workers from the participating institutions, who themselves had not participated in the course, to assess the perceptual and attitudinal impact of the pediatric trauma course. SETTING: Guatemala City, Guatemala. PARTICIPANTS: Forty-three physicians from Central America. RESULTS: Initial and nine-month post-test scores showed uniform improvement (P value < 0.05) when compared to pretest results using the Wilcoxon signed-ranks test. Analysis of the pre- and post-course questionnaires indicated that all participants felt more comfortable (scale 1 to 5) after the course managing pediatric trauma patients. All participants "strongly agreed" the course provided information that would improve their management of the pediatric trauma victim. Nine months after the course, 100% of their medical co-workers perceived physicians who participated in the pediatric trauma course to have better resuscitative skills, and 92% perceived these physicians to have a higher level of confidence. CONCLUSION: This course, when presented to physicians in a developing country, appears to be effective in improving their knowledge base regarding pediatric trauma and increasing their comfort level in managing major pediatric trauma.