Technique for office-based, ultrasonography-guided percutaneous biopsy of renal cortical neoplasms using a novel transducer for facilitated ultrasound targeting.

OBJECTIVES: To help clarify which small renal cortical neoplasms (RCNs) require surgery by using office-based, ultrasonography-guided percutaneous renal biopsy. PATIENTS AND METHODS: Biopsies were performed using facilitated ultrasound targeting (FUT) technology, which incorporates a needle guide and onscreen beam-steered technology to permit highly precise needle deployment. Patient and tumour characteristics, procedure time, complications and biopsy efficacy were documented. Wong-Baker pain levels were obtained before, during and 1 h after the procedure. RESULTS: Seven patients underwent biopsy, six for RCNs and one for medical renal disease. The mean (range) patient age was 68.5 (54-79) years, and the mean (range) tumour diameter was 2.55 (2.0-2.9) cm. Mean pain levels before, during and 1 h after the procedure were 0, 1.6 and 0.5, respectively. There were no intra- or post-procedural complications. Biopsy results were diagnostic in five of the six RCN cases and in the single case of medical renal disease. CONCLUSIONS: Our preliminary experience shows that office-based percutaneous renal biopsy using a novel transducer for FUT is safe and effective. An international multicentre study is planned to confirm these preliminary results.

An Updated Protocol for Evaluating Chest Pain and Managing Acute Coronary Syndromes.

Clinical pathways can optimize care both across and within institutions, but regular updates to these pathways based on new clinical trials, professional guidelines, and Food and Drug Administration approvals are essential. Herein we describe the most recent revisions to the New York-Presbyterian Hospital (Columbia University Medical Center and Weill Cornell Medical Center) clinical pathway for acute coronary syndromes and chest pain, which incorporates novel data regarding the timing and administration of P2Y12 inhibition (including the intravenous P2Y12 inhibitor cangrelor) and the appropriateness of prolonged (>1 year) dual antiplatelet therapy for the secondary prevention of ischemic events.

Long-Term Safety and Efficacy of Platinum Chromium Everolimus-Eluting Stents in Coronary Artery Disease: 5-Year Results From the PLATINUM Trial.

OBJECTIVES: The authors sought to evaluate the final 5-year safety and effectiveness of the platinum-chromium everolimus-eluting stent (PtCr-EES) in the randomized trial, as well as in 2 single-arm substudies that evaluated PtCr-EES in small vessels (diameter <2.5 mm; n = 94) and long lesions (24 to 34 mm; n = 102). BACKGROUND: In the multicenter, randomized PLATINUM (PLATINUM Clinical Trial to Assess the PROMUS Element Stent System for Treatment of De Novo Coronary Artery Lesions), the PtCr-EES was noninferior to the cobalt-chromium everolimus-eluting stent (CoCr-EES) at 1 year in 1,530 patients undergoing percutaneous coronary intervention. METHODS: Patients with 1 or 2 de novo coronary artery lesions (reference vessel diameter 2.50 to 4.25 mm, length ≤24 mm) were randomized 1:1 to PtCr-EES versus CoCr-EES. All patients in the substudies received PtCr-EES. The primary endpoint was target lesion failure (TLF), a composite of target vessel-related cardiac death, target vessel-related myocardial infarction, or ischemia-driven target lesion revascularization. RESULTS: In the randomized trial, the 5-year TLF rate was 9.1% for PtCr-EES and 9.3% for CoCr-EES (hazard ratio [HR]: 0.97; p = 0.87). Landmark analysis demonstrated similar TLF rates from discharge to 1 year (HR: 1.12; p = 0.70) and from 1 to 5 years (HR: 0.90; p = 0.63). There were no significant differences in the rates of cardiac death, myocardial infarction, target lesion or vessel revascularization, or stent thrombosis. PtCr-EES had 5-year TLF rates of 7.0% in small vessels and 13.6% in long lesions. CONCLUSIONS: PtCr-EES demonstrated comparable safety and effectiveness to CoCr-EES through 5 years of follow-up, with low rates of stent thrombosis and other adverse events. The 5-year event rates were also acceptable in patients with small vessels and long lesions treated with PtCr-EES. (The PLATINUM Clinical Trial to Assess the PROMUS Element Stent System for Treatment of De Novo Coronary Artery Lesions [PLATINUM]; NCT00823212; The PLATINUM Clinical Trial to Assess the PROMUS Element Stent System for Treatment of De Novo Coronary Artery Lesions in Small Vessels [PLATINUM SV]; NCT01498692; The PLATINUM Clinical Trial to Assess the PROMUS Element Stent System for Treatment of Long De Novo Coronary Artery Lesions [PLATINUM LL]; NCT01500434).

Can physicians identify inappropriate nuclear stress tests? An examination of inter-rater reliability for the 2009 appropriate use criteria for radionuclide imaging.

BACKGROUND: We sought to determine inter-rater reliability of the 2009 Appropriate Use Criteria for radionuclide imaging and whether physicians at various levels of training can effectively identify nuclear stress tests with inappropriate indications. METHODS AND RESULTS: Four hundred patients were randomly selected from a consecutive cohort of patients undergoing nuclear stress testing at an academic medical center. Raters with different levels of training (including cardiology attending physicians, cardiology fellows, internal medicine hospitalists, and internal medicine interns) classified individual nuclear stress tests using the 2009 Appropriate Use Criteria. Consensus classification by 2 cardiologists was considered the operational gold standard, and sensitivity and specificity of individual raters for identifying inappropriate tests were calculated. Inter-rater reliability of the Appropriate Use Criteria was assessed using Cohen κ statistics for pairs of different raters. The mean age of patients was 61.5 years; 214 (54%) were female. The cardiologists rated 256 (64%) of 400 nuclear stress tests as appropriate, 68 (18%) as uncertain, 55 (14%) as inappropriate; 21 (5%) tests were unable to be classified. Inter-rater reliability for noncardiologist raters was modest (unweighted Cohen κ, 0.51, 95% confidence interval, 0.45-0.55). Sensitivity of individual raters for identifying inappropriate tests ranged from 47% to 82%, while specificity ranged from 85% to 97%. CONCLUSIONS: Inter-rater reliability for the 2009 Appropriate Use Criteria for radionuclide imaging is modest, and there is considerable variation in the ability of raters at different levels of training to identify inappropriate tests.

Relation of C-reactive protein levels to instability of untreated vulnerable coronary plaques (from the PROSPECT Study).

C-reactive protein (CRP) levels predict adverse coronary events, but it is uncertain if they predict the burden or stability of vulnerable coronary plaques. In the Providing Regional Observations to Study Predictors of Events in the Coronary Tree study, 697 patients with acute coronary syndromes underwent percutaneous coronary intervention followed by 3-vessel angiography, gray-scale intravascular ultrasound (IVUS), and radiofrequency IVUS. Major adverse cardiac events (MACE) during 3 years of follow-up were adjudicated to initially treated culprit lesions or to untreated nonculprit lesions (NCLs). NCLs at greatest risk of causing subsequent MACE had plaque burden ≥70%, minimal luminal area ≤4.0 mm(2), and/or thin-cap fibroatheroma morphology. Here, we examine the interaction of high-risk NCLs with CRP levels, which were measured at presentation, 1 month, and 6 months, then categorized at each time as normal (<3 mg/L), elevated (3 to 10 mg/L), or very elevated (>10 mg/L). We found that patients with elevated CRP levels at any time did not have more high-risk NCLs; however, untreated high-risk NCLs were more likely to cause subsequent MACE in patients with very elevated compared with normal 6-month CRP levels (for thin-cap fibroatheromas, 13.8% vs 1.9%, p = 0.0003; for lesions with minimal luminal area ≤4.0 mm(2), 15.6% vs 2.2%, p <0.0001). As expected, patients with very elevated 6-month CRP levels had higher rates of subsequent NCL-related MACE (19.0% vs 7.2%, p = 0.039). In conclusion, the higher rates of NCL-related MACE in post-acute coronary syndrome patients with very elevated CRP levels may reflect greater instability of high-risk NCLs, rather than a larger burden of such lesions.

Percutaneous renal surgery: use of flexible nephroscopy and treatment of infundibular stenoses.

Abstract Percutaneous nephrolithotomy is now the gold standard for treatment of large renal stones. In this article, we describe the indications for use of antegrade flexible nephroscopy during percutaneous nephrolithotomy, as well as for treatment of infundibular stenosis. We also discuss various new technologies to help in these endeavors, including digital cystoscopes and ureteroscopes and our preferred baskets, as well as our particular techniques for improving stone-free rates. The treatment of infundibular stenosis through percutaneous access is also reviewed.

Clinical evaluation of efficacy of novel optically activated digital endoscope protection system against laser energy damage.

OBJECTIVES: To evaluate the clinical reliability and efficacy of a novel endoscope protection system (EPS) against direct laser energy damage during ureteroscopy. METHODS: We performed an in vivo evaluation of a novel EPS prototype that uses optical feedback from the digital sensor of the Invisio Digital Flexible Ureteroscope (DUR-D) to terminate laser energy on retraction of the fiber. We evaluated 20 consecutive patients undergoing flexible ureteroscopy. In each patient, the laser was retracted into the ureteroscope 4 times during active firing using a fast pull (5 cm/s) and a slow pull (2 cm/s) with the ureteroscope straight and flexed. We documented whether the EPS activated, whether the laser shut down properly, and the length of fiber projecting from the ureteroscope at laser shutdown. RESULTS: The EPS was 100% effective in shutting down the laser before entry into the ureteroscope in all trials (80/80). The mean length of fiber showing from the tip of the ureteroscope at shutdown was 1.55 mm (range 0-2.5) when the ureteroscope was straight and 1.28 mm (range 0-2.0) when it was flexed. EPS laser shutoff occurred in 50% (10/20) of the cases when the laser fiber was still outside the ureteroscope. One DUR-D ureteroscope was damaged during the trial from mechanical damage. CONCLUSIONS: In this clinical evaluation, the novel EPS was highly effective and reliable. No energy-based ureteroscope damage was noted with slow and rapid retractions of the activated laser into the ureteroscope. The EPS can be used to complement, rather than replace, the standard safe laser technique.

High definition in minimally invasive surgery: a review of methods for recording, editing, and distributing video.

The use of high-definition cameras and monitors during minimally invasive procedures can provide the surgeon and operating team with more than twice the resolution of standard definition systems. Although this dramatic improvement in visualization offers numerous advantages, the adoption of high definition cameras in the operating room can be challenging because new recording equipment must be purchased, and several new technologies are required to edit and distribute video. The purpose of this review article is to provide an overview of the popular methods for recording, editing, and distributing high-definition video. This article discusses the essential technical concepts of high-definition video, reviews the different kinds of equipment and methods most often used for recording, and describes several options for video distribution.

Repeated exposure to media violence is associated with diminished response in an inhibitory frontolimbic network.

BACKGROUND: Media depictions of violence, although often claimed to induce viewer aggression, have not been shown to affect the cortical networks that regulate behavior. METHODOLOGY/PRINCIPAL FINDINGS: Using functional magnetic resonance imaging (fMRI), we found that repeated exposure to violent media, but not to other equally arousing media, led to both diminished response in right lateral orbitofrontal cortex (right ltOFC) and a decrease in right ltOFC-amygdala interaction. Reduced function in this network has been previously associated with decreased control over a variety of behaviors, including reactive aggression. Indeed, we found reduced right ltOFC responses to be characteristic of those subjects that reported greater tendencies toward reactive aggression. Furthermore, the violence-induced reduction in right ltOFC response coincided with increased throughput to behavior planning regions. CONCLUSIONS: These novel findings establish that even short-term exposure to violent media can result in diminished responsiveness of a network associated with behaviors such as reactive aggression.