Predictors of endobronchial forceps utilization for inferior vena cava filter retrieval: when snare retrieval fails.

BACKGROUND: Endobronchial forceps are commonly used for complex IVC filter removal and after initial attempts at IVC filter retrieval with a snare have failed. Currently, there are no clear guidelines to help distinguish cases where primary removal should be attempted with standard snare technique or whether attempts at removal should directly be started with forceps. This study is aimed to identify clinical and imaging predictors of snare failure which necessitate conversion to endobronchial forceps. METHODS: Retrospective analysis of 543 patients who underwent IVC filter retrievals were performed at three large quaternary care centers from Jan 2015 to Jan 2022. Patient demographics and IVC filter characteristics on cross-sectional images (degree of tilt, hook embedment, and strut penetration, etc.) were reviewed. Binary multivariate logistic regression was used to identify predictors of IVC filter retrieval where snare retrieval would fail. RESULTS: Thirty seven percent of the patients (n = 203) necessitated utilization of endobronchial forceps. IVC filter hook embedment (OR:4.55; 95%CI: 1.74-11.87; p = 0.002) and strut penetration (OR: 56.46; 95% CI 20.2-157.7; p = 0.001) were predictors of snare failure. In contrast, total dwell time, BMI, and degree of filter tilt were not associated with snare failure. Intraprocedural conversion from snare to endobronchial forceps was significantly associated with increased contrast volume, radiation dose, and total procedure times (p < 0.05). CONCLUSION: IVC filter hook embedment and strut penetration were predictors of snare retrieval failure. Intraprocedural conversion from snare to endobronchial forceps increased contrast volume, radiation dose, and total procedure time. When either hook embedment or strut penetration is present on pre-procedural cross-sectional images, IVC filter retrieval should be initiated using endobronchial forceps. LEVEL OF EVIDENCE: Level 3, large multicenter retrospective cohort.

Stroke Nurse Triage: Effects on Time Metrics at a Regional Stroke Center.

INTRODUCTION: Optimization of time metrics in the management of acute stroke is a priority. Nurses with special training in stroke management may contribute to enhanced delivery of care. This study analyzes the effects of initiating a nurse-led stroke triage program at a regional stroke center on time metrics of acute stroke. METHODS: In retrospective review, stroke metrics 25 months prior to the start of the triage program and 23 months after the start of the program were analyzed, including time from arrival to: emergency department assessment, neurologist assessment, head computed tomography (CT) scan, start of tissue plasminogen activator (tPA) administration, and puncture for mechanical thrombectomy. RESULTS: The study included 1,019 patients presenting with symptoms of acute stroke. Significant decrease was found between means for the time measures of arrival to emergency department (ED) physician assessment (pre-program: 6.2 minutes, post-program: 5.7 minutes, p= 0.0036), and CT start (pre-program: 21.3 minutes, post-program: 19.8 minutes, p= 0.0001). Time from arrival to ED physician assessment and CT start showed an increase in the proportion of cases meeting goal times: ED physician assessment increased from 82 percent to 84.4 percent of cases meeting the goal time (p= 0.3543), and CT start increased from 55.3 percent to 63.2 percent (p= 0.0481) of cases meeting the goal time. Significant increase was found between means for time from arrival to neurologist assessment (pre-program: 11.6 minutes, post-program: 17.1 minutes, p= 0.0015), and the proportion of cases meeting the goal time for arrival to neurologist assessment decreased (88.8 percent pre-program, 75.8 percent post-program). No significant differences were found for times from arrival to tPA administration and mechanical thrombectomy, or between Modified Rankin Scores (mRS) at discharge. CONCLUSIONS: Certain time-sensitive metrics of acute stroke care were improved after implementation of the stroke nurse triage program, particularly those related to immediate patient assessment within the ED. Time metrics related to the direct administration of stroke therapies were unaffected, indicating the need for recognition of additional factors affecting timely stroke management. Incorporating specially trained stroke nurses in acute stroke management may be an important component in efforts to improve time metrics of acute stroke.

A Case of Pituitary Macroadenoma Presenting as Aseptic Meningitis.

Pituitary adenomas are a common brain tumor that are frequently asymptomatic but may initially present with vision deficits or very rarely as meningitis thought to be due to cerebrospinal fluid leakage. In this case report we discuss the initial presentation of a pituitary macroadenoma as aseptic meningitis, particularly in the absence of an identifiable cerebrospinal fluid leak. We also discuss the workup and diagnostic challenges associated with this atypical presentation, including findings on imaging and pertinent laboratory results.

Intraperitoneal Extravasation of TPN and Associated Hepatic Hemorrhage as a Complication of a Malpositioned UVC in a Preterm Neonate.

Extravasation of total parenteral nutrition (TPN) from a malpositioned umbilical venous catheter (UVC) is a rare cause of ascites in neonates. The gross appearance of the aspirated peritoneal fluid may mimic congenital chylous ascites, delaying an accurate diagnosis of the causative source. UVC malpositioning is associated with complications of various organs as related to the position of the UVC tip. TPN from laterally positioned UVC tips may penetrate into the liver and provoke hepatic damage with subsequent peritoneal fluid accumulation. Factors including biochemical characteristics of the peritoneal fluid, radiographic findings with specific attention to the location of the UVC tip, and clinical timing of ascites presentation have been associated with TPN extravasation from UVCs. This report presents a case of a preterm neonate with intraperitoneal extravasation of TPN and associated hepatic hemorrhage due to a malpositioned UVC while highlighting the cumulative clinical, radiographic, and laboratory findings that should prompt consideration of this complication as the cause of ascites in neonates.

Cushing's Syndrome in a Pregnant Patient Secondary to Adrenal Adenoma: Treatment With Unilateral Adrenalectomy.

BACKGROUND: A pregnant woman presented with Cushing's syndrome (CS) secondary to adrenal adenoma and was treated with laparoscopic-assisted right adrenalectomy during the second trimester of pregnancy. SUMMARY: Our patient is a 33-year-old woman who presented with hypertension and cushingoid appearance at 21 weeks gestational age. Laboratory evidence indicated CS was likely, and imaging found a 2.3 x 3.0 cm right adrenal nodule as a suggested cause. Laparoscopic-assisted right adrenalectomy was performed at 23 weeks 4 days gestation without complication. Pathology of the removed specimen revealed an adrenal gland containing a 3.0 x 3.0 x 2.0 cm well-circumscribed proliferation of adrenal cortical cells without significant atypia. This report describes the rare occurrence of CS during pregnancy and subsequent successful surgical management. We review the diagnosis of CS during pregnancy and surgical considerations. CONCLUSION: CS, while a rare entity in the general population, is even more unique in the setting of pregnancy due to the negative effects of hypercortisolism on fertility. CS during pregnancy presents a diagnostically complicated scenario, along with specific considerations necessary for successful surgical management.

Incorporation of Women's Health Maintenance Screening in the USD Coyote Clinic.

INTRODUCTION: The Coyote Clinic is a student-run clinic that provides free services to Sioux Falls residents without insurance. It has not historically provided routine women's health screenings. The project addressed this lack of preventative care. We aimed to increase the percentage of female patients that are up to date on Papanicolaou (Pap) smears, mammograms, and human papillomavirus (HPV) vaccines through the implementation of screening questions. METHODS: A screening questionnaire was created and asked to female patients between the ages of 18-65 about the dates and results of their last Pap smear, mammogram, and the administration of any HPV vaccine. RESULTS: 27 patients answered the questions. Fifty-two percent were Caucasian, 26 percent Hispanic, 15 percent African American, and 7 percent Middle Eastern. Two patients were eligible for HPV vaccination: one had not received the vaccination and the other was unknown. All 27 women were eligible for Pap smears. Seventy-six percent had normal results, 19 percent were unsure of their results, and 5 percent had abnormal results. Eight patients were eligible for mammograms: five were up to date, two were tested in the last three years, and one had an unknown test date. CONCLUSIONS: The majority of eligible female patients were up to date on Pap smears and mammograms. The health maintenance questionnaire was a valuable resource for patient care, patient health literacy, and medical student education.

Effectiveness of Radiofrequency Ablation in the Treatment of Painful Osseous Metastases: A Correlation Meta-Analysis with Machine Learning Cluster Identification.

A systematic review and meta-analysis of pain response after radiofrequency (RF) ablation over time for osseous metastases was conducted in 2019. Analysis used a random-effects model with GOSH plots and meta-regression. Fourteen studies comprising 426 patients, most with recalcitrant pain, were identified. Median pain reduction after RF ablation was 67% over median follow-up of 24 weeks (R2 = -.66, 95% confidence interval -0.76 to -0.55, I2 = 71.24%, fail-safe N = 875) with 44% pain reduction within 1 week. A low-heterogeneity subgroup was identified with median pain reduction after RF ablation of 70% over 12 weeks (R2 = -.75, 95% confidence interval -0.80 to -0.70, I2 = 2.66%, fail-safe N = 910). Addition of cementoplasty after RF ablation did not significantly affect pain scores. Primary tumor type and tumor size did not significantly affect pain scores. A particular, positive association between pain after RF ablation and axial tumors was identified, implying possible increased palliative effects for RF ablation on axial over appendicular lesions. RF ablation is a useful palliative therapy for osseous metastases, particularly in patients with recalcitrant pain.

Acute Flaccid Myelitis in an Adult.

INTRODUCTION: Acute flaccid myelitis (AFM) is a condition causing acute onset flaccid limb weakness primarily in children. Correlations with specific viral illnesses have been found, however, specific pathogenesis remains unknown. CASE REPORT: A 21-year-old female individual presented with progressive weakness provoking multiple falls, severe fatigue, headaches, and body aches after an upper respiratory illness. Deep tendon reflexes were absent, and cerebrospinal fluid analysis was remarkable for lymphocytic pleocytosis and elevated protein. Magnetic resonance imaging revealed T2 hyperintensity extending from C1-T2 predominantly involving the anterior horns. Weakness continued to increase before subtly improving over the course of a 10-day hospital stay. Functional improvements had been achieved by the patient at 1-year follow-up with intensive physical therapy. CONCLUSIONS: AFM should be included in the differential for the presentation of acute weakness in adults and pediatric patients. As the incidence of AFM continues to rise, awareness of the condition and prompt obtainment of specimens in suspected patients is crucial to aid in the investigation.

Prolonged Peripheral Hypoperfusion Promotes Neuroprotection in Ischemic Stroke.

Objectives Sublethal, transient occlusion of peripheral vessels, called remote ischemic preconditioning (RIPC), induces a neuroprotective state against brain infarction. Recent studies suggest chronic hypoperfusion in patients with peripheral vascular disease (PVD) has analogous effects. We hypothesized a positive correlation between the severity of chronic hypoperfusion and the extent of neuroprotection. To determine if this correlation exists, we compared stroke volumes and clinical measures of modified ranking scale (mRS) and National Institute of Health Stroke Scale (NIHSS) between cases with and without PVD, subgrouping PVD cases by ankle-brachial-index (ABI) values. Patients and methods Cases of ischemic stroke with and without PVD were sampled retrospectively from a local institutional data base. Charts were manually reviewed for demographics (age, sex, ethnicity), comorbidities (diabetes, hypertension, hyperlipidemia, coronary artery disease, smoking, and stroke history), clinical measures (admission NIHSS, prior mRS, three-month mRS, and survival) and stroke volumes in each case. Those diagnosed with PVD and ABI indicating active disease were grouped as PVD cases; those not diagnosed with PVD or having ABI indicating absence of disease were used as controls. PVD cases were subgrouped by disease severity per ABI values: mild (ABI 0.8-0.9), moderate (ABI 0.5-0.9) and severe (ABI < 0.5). Data were analyzed in R using adjusted logarithmic-multivariate models. Adjusted cox proportional hazards models were used to estimate associations between survival and PVD. Results A total of 105 patients, 50 PVD cases and 55 controls, were collected. Mean age was 72.54 years, 51.4% were males and 48.6% females, and 94% were Caucasian. There were 17 mild, 22 moderate, and 11 severe cases of PVD. A higher incidence of comorbidities was present in PVD cases. The mean admission NIHSS was 4.44 and did not differ significantly between groups. Stroke volumes were significantly lower (p = .021) in PVD cases (4.39 ± 8.97 ml) compared to controls (19.33 ± 44.31 ml). There was also a significant difference (p = .04) between volumes of mild (3.86 ± 5.47 ml) and severe (0.63 ± 0.76 ml) PVD cases. There were significant differences (p = .012) in the incidence of good outcomes in moderate to severe PVD cases (100%) compared to controls (83.3%). There was no difference in survival between groups (p = .538). Conclusion Increasing degrees of hypoperfusion related to PVD have a potential neuroprotective effect in acute ischemic stroke quantified by lower stroke volumes and better clinical outcomes at three months as seen in other preclinical models of RIPC.

Antidepressant Use for Improving Functional Ischemic Stroke Outcomes.

Objective To assess the effect of antidepressants on functional post-stroke recovery, we conducted a retrospective analysis among acute ischemic stroke patients with a subgroup analysis of severe stroke cases, assessing outcomes through 18 months. Methods A retrospectively gathered ischemic stroke population was obtained from an institutional database. Grouping was via intention-to-treat with antidepressant use post-stroke or lack thereof. Patients with severe stroke (NIHSS ≥ 21) were further analyzed independently. The primary and secondary outcomes were modified Rankin scale (mRS) and survival over 18 months, respectively. Patient demographics and NIHSS were obtained. Data were analyzed in R using adjusted logarithmic-multivariate models. Adjusted Cox proportional hazards models were used to estimate associations between survival and antidepressants. Results Eight-hundred six patients (52 severe strokes) received antidepressants post-stroke while 948 (56 severe) did not. The antidepressant group was more female (56% to 43.5%) and had significantly better survival rates (88% vs. 79%, HR 0.62, p < 0.01) but not mRS scores (2.13 vs 2.24, p = 0.262) by the end of the study period. Among severe stroke cases, those receiving antidepressants showed better survival rates (79% vs. 60%, HR 0.36, p=0.026) and most recent mRS score (3.9 vs 5, p < 0.01). The analysis controlling for demographics variables retained significance. Conclusion Antidepressant use post-stroke may improve functional outcomes in patients suffering from severe stroke and may decrease all-cause mortality for strokes of any severity.

Effects on Stroke Metrics and Outcomes of a Nurse-led Stroke Triage Team in Acute Stroke Management.

Background Timely administration of healthcare in acute stroke, congruent with national stroke metrics, relates to better patient outcomes. A nurse-led stroke triage team instituted at our facility was hypothesized to improve metrics and outcomes. To evaluate the effect of the nurse-led stroke triage team we compared specific stroke metrics and patient outcomes before and after the program initiation.  Methods In retrospective review, we analyzed stroke metrics one year prior to the start of the triage program (controls) and one year after the start of the program (cases), including the following metrics: patient arrival, emergency department assessment, neurology contact, head computed tomography (CT) scan, and delivery of tissue plasminogen activator (tPA) or puncture for mechanical thrombectomy. Primary outcome measures were improved metric times.  Results Ninety-five acute stroke events were analyzed: 26 controls and 69 cases. Cohort demographics included means of age 72.82 years, National Institutes of Health Stroke Scale (NIHSS) 15.96, discharge and 90-day mRS 3.71 and 3.55 respectively, and length of stay 5.98 days. There were significantly different improvements in metrics between arrival time to CT start, emergency room physician evaluation to CT start, neurology contact to CT start, and neurology contact to tPA initiation for cases post-triage team institution. No significant differences during this period were seen for other metrics. Multivariate analysis controlling for age, sex and NIHSS found no significant difference for discharge or 90-day mRS scores.  Conclusions An interdisciplinary approach to acute stroke management can impact stroke metrics. These data support the integration of specially trained stroke nurses in acute stroke triage for quality improvement efforts.