In-Hospital Mortality Benefit of Inferior Vena Cava Filters in Patients With Pulmonary Embolism and Congestive Heart Failure.

OBJECTIVE: Pulmonary embolism (PE) is associated with a higher mortality rate in patients with congestive heart failure (CHF) than in those without heart failure. The purpose of this study was to evaluate if inferior vena cava (IVC) filter placement provides any mortality benefit in patients admitted with CHF and PE. MATERIALS AND METHODS: The 2005-2014 Nationwide Inpatient Sample (NIS) was used for this study. Adults (≥ 18 years old) with PE were identified using International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) diagnosis codes. Patients with CHF were identified using the Elixhauser comorbidity variable (CM_CHF) in the NIS database. IVC filter placement was identified using the ICD-9-CM procedure code 38.7 (interruption of the vena cava). A multivariate logistic regression model was used to determine the association of IVC filter placement with in-hospital mortality. The model was adjusted for demographics, hospital characteristics, comorbidities, and PE severity indexes (pressor dependence, mechanical ventilation, nonseptic shock, and use of thrombolytic therapy). RESULTS: During the study years, 425,877 patients with a comorbidity of CHF were hospitalized with PE (44% male; mean age, 71.5 years old). Of them, 67,237 patients (15.8%) received an IVC filter during the admission, and 50,338 (11.8%) died during the hospital stay. The all-cause in-hospital mortality rate among patients who received an IVC filter was 9.7% (6541 of 67,237 patients) compared with 12.2% (43,796 of 358,638 patients) among those without an IVC filter (p < 0.001), with an absolute risk reduction of 2.5%. The multivariate adjusted hazard ratio of in-hospital mortality associated with IVC filter placement was 0.535 (95% CI, 0.518-0.551; p < 0.001). CONCLUSION: A lower all-cause mortality rate was observed in patients with CHF and PE who received an IVC filter while hospitalized. In the absence of data from randomized controlled trials, this study suggests that IVC filters could help prevent in-hospital death among patients admitted with PE and CHF.

Metastatic laryngeal large cell neuroendocrine carcinoma: A rare case of presentation and extreme tumor burden.

Large cell neuroendocrine carcinoma (LCNEC) of the larynx is an aggressive form of neuroendocrine carcinoma that affects smokers at an average age of 60 years. LCNEC is characterized by large cells with round to ovoid nuclei distributed in a trabecular or nested growth pattern. Previously, laryngeal LCNEC and atypical carcinoid tumors were considered identical; however, laryngeal LCNEC has been shown to have higher mitotic rates and worse prognosis, which has led to laryngeal LCNEC's being separated from atypical carcinoid and classified as a poorly differentiated neuroendocrine carcinoma in the most recent World Health Organization classification. We present a case of a 56-year-old female who presented with painful subcutaneous skin lesions that were diagnosed as metastatic carcinoma at an outside facility. Subsequent workup revealed a primary epiglottic lesion. Over the next 4 years, she continued to develop over 100 similar subcutaneous nodules. Additional workup confirmed neuroendocrine differentiation, thus clarifying the diagnosis of metastatic LCNEC. Review of literature has revealed only 1 reported case of LCNEC with skin metastasis. This is the first reported case in which skin metastasis was the initial presenting symptom; moreover, our case is unique with regard to the heavy metastatic burden to the skin.

Novel use of noninvasive high-intensity focused ultrasonography for intercostal nerve neurolysis in a swine model.

BACKGROUND: High-intensity focused ultrasound (HIFU) is a noninvasive thermal ablation technique. High-intensity focused ultrasound has been used in small-animal models to lesion neural tissue selectively. This study aimed to evaluate the efficacy of HIFU in a large-animal model for ablation of nerves similar in size to human nerves. METHODS: Twelve acute magnetic resonance-guided HIFU ablation lesions were created in intercostal nerves in a swine model. In a second pig, as a control, 4 radiofrequency ablation and 4 alcohol lesions were performed on intercostal nerves under ultrasound guidance. Preprocedural and postprocedural magnetic resonance imaging was then performed to evaluate radiologically the lesion size created by HIFU. Animals were euthanized 1 hour postprocedure, and necropsy was performed to collect tissue samples for histopathologic analysis. RESULTS: On gross and histological examination of the intercostal nerve, acute HIFU nerve lesions showed evidence of well-demarcated, acute, focally extensive thermal necrosis. Four intercostal nerves ablated with HIFU were sent for histopathologic analysis, with 2 of 4 lesions showing pathologic damage to the intercostal nerve. Similar results were shown with radiofrequency ablation technique, whereas the intercostal nerves appeared histologically intact with alcohol ablation. CONCLUSIONS: High-intensity focused ultrasound may be used as a noninvasive neurolytic technique in swine. High-intensity focused ultrasound may have potential as a neuroablation technique for patients with chronic and cancer pain.