Procedural comparison of a standard PTA balloon for fistula and graft maintenance procedures with the novel Chameleon™ PTA balloon catheter.

INTRODUCTION: The incidence of cephalic arch (CA) and central venous (CV) stenosis has been reported in the range of 30% in the literature. The purpose of this study is to compare contrast use, fluoroscopy time, and procedure time between standard imaging by injection of contrast through the access sheath versus injection of contrast through a novel PTA balloon with an integrated injection port. METHODS: A multi-centered, retrospective evaluation of consecutive patients treated for CA and CV stenosis was performed. Data captured included demographics, co-morbidities, lesion characteristics/location, procedural details, volume of contrast used, fluoroscopy time, and procedure time. The control group was imaged and treated using standard practice with pre and post imaging performed through the sheath and intervention using standard PTA balloon. Imaging and treatment were performed using the Chameleon™ PTA catheter in the treatment arm. RESULTS: A total of 68 consecutive patients were included. There were 34 patients in Group A and 34 patients in Group B. Average age was 65.2 versus 66.5 (p = 0.284), respectively. There were no significant gender differences between groups. Prevalence of co-morbidities of hypertension, coronary artery disease, and diabetes was similar to national rates in both groups. Contrast volume, fluoroscopy time, and procedure time in Group B were significantly less when compared by multiple regression to Group A, correcting for potential confounders (p = 0.0001, 0.0180, and 0.0008, respectively). CONCLUSION: Use of a PTA balloon with an integrated injection port shows potential for significant reduction in contrast dose, fluoroscopy time, and procedure time.

Results of polidocanol endovenous microfoam in clinical practice.

BACKGROUND: Initial phase III clinical studies with polidocanol endovenous microfoam (PEM) demonstrated its safety and efficacy in the treatment of superficial venous reflux. In those studies, the primary outcome requirement was to assess the improvement in symptoms related to superficial venous disease. The goal of the present study was to evaluate the efficacy of PEM technology in routine clinical practice-specifically, the closure rates after treatment. METHODS: We performed an observational study during which data were prospectively collected from 2 vein centers using an electronic database. Patients with CEAP (clinical, etiologic, anatomic, pathophysiologic) class ≥2 and symptomatic superficial axial reflux (great saphenous vein, anterior accessory saphenous vein, and small saphenous vein) were included and followed up prospectively. PEM was used to treat the saphenous vein and varicosities. The CEAP classification was used to classify chronic venous disease, and the venous clinical severity score (VCSS) was applied to measure the disease severity. Pain and discomfort were assessed using a visual analog scale, and the residual veins were assessed by physical examination. RESULTS: PEM was used to treat superficial reflux in 60 patients. The CEAP classification was C2 for 32 patients, C3 for 14, C4 for 10, and C5 for 4 patients. The average pretreatment VCSS was 7.3. The saphenous vein diameter was 6.5 mm, and the average length was 31 cm. The average volume of PEM used to treat the saphenous veins was 9.3 mL. The closure rate at 3 and 6 months was 93% (54 of 58) and 93% (51 of 55), respectively. The VCSS had improved from 7.3 to 1.4. Complications included 1 case of deep vein thrombosis (1.7%), 5 patients (8.3%) with thrombophlebitis, and 4 patients (6.6%) with skin pigmentation. CONCLUSIONS: PEM is safe and effective for the treatment of saphenous reflux and varicosities. The early closure rates using PEM were maintained at 6 months and are comparable to the results reported with nonthermal, nontumescent technologies and thermal tumescent technologies.

Diagnostic approach to lower limb edema.

Patients with lower limb edema are frequently referred to vascular specialists for evaluation. Multiple etiologies must be considered and often more than one cause may be present. Notably, the role of lymphatic system regardless of the underlying pathology has been underestimated. A thorough history and physical examination and a carefully considered laboratory and imaging evaluation are critical in differentiating causes. In this opinion article, we propose a diagnostic algorithm that incorporates a systematic approach to the patient with leg swelling and provides an efficient pathway for the differential diagnosis for this problem.

Fecal microbiota transplantation in recurrent Clostridium difficile infection: A retrospective single-center chart review.

BACKGROUND AND AIM: Fecal microbiota transplantation (FMT) has been proposed as a treatment option for patients with recurrent Clostridium difficile (C. difficile) infection but remains a novel option. We examined if FMT is an effective means of treating recurrent C. difficile infection. METHODS: A retrospective review of 35 patients who underwent FMT was completed. Demographics and other variables, including the use of proton pump inhibitor therapy and history of inflammatory bowel disease, were collected. RESULTS: Twenty-five patients (71.4%) belonged to a high-risk population (working in a hospital setting, rehabilitation center, or nursing facility) and a total of 74.3% of patients (n = 26 patients) had no history of proton pump inhibitor use. Twenty-five patients (71.4%) had used metronidazole prior to transplantation, 35 patients (100%) had used vancomycin, and 7 patients (20%) had used fidaxomicin for prior infection. Four patients (11.4%) had used all three antibiotics during prior treatment. Of the eight patients who had a history of inflammatory bowel disease, six (75%) experienced resolution of symptoms after transplantation. A total of 30 patients (85.7%) had resolution of their symptoms 6-8 weeks' posttransplant, while 5 patients (14.3%) continued to have symptoms. CONCLUSIONS: Our retrospective chart review supports that patients benefit from FMT in the setting of recurrent C. difficile infection.

Fistuloplasty using a radiation-and-time-saving sheathless balloon catheter.

INTRODUCTION: Sheath placement in dialysis access interventions is traditionally necessary to obtain imaging, guide percutaneous angioplasty, and evaluate results. The aim of this study was to assess the feasibility of performing sheathless Arterio-venous (AV) access interventions using a novel percutaneous angioplasty balloon catheter. METHODS: Between May and September 2017, data on all dialysis access interventions using a novel percutaneous angioplasty balloon with a dedicated injection port were collected. All procedures were performed without a sheath. Success was established as no conversion to sheath placement. Demographic data, location of lesion, time to perform procedure, amount of contrast used, radiation exposure, and access complications were recorded. Ultrasound was used to evaluate access site complications. RESULTS: Sheathless interventions were successful in 24 patients with the mean age of 62 years (29-94). There were 5 PTFE grafts and 19 native fistulas. Lesions were located anywhere from the arterial anastomosis to the cephalic arch. The average balloon size was 6 mm (5-7 mm), and the procedure time was 15.8 min (8-45 min). No access site complications were observed. CONCLUSION: Sheathless intervention is feasible with several potential advantages, including short procedure time, minimal contrast volume, and reduced radiation exposure. Finally, the lower profile at the access site may result in fewer complications.

The staff and patient perspectives on compliance with mechanical prophylaxis for venous thromboembolism.

BACKGROUND: This study evaluated the accuracy of assessment and compliance with proper use of intermittent pneumatic compression (IPC) devices before and after implementation of education, accountability, and oversight measures for health care providers. METHODS: Prospective analysis of randomly selected, emergently hospitalized adult patients was performed (group 1). IPC use was observed by random visual inspections. These patients underwent independent venous thromboembolism (VTE) risk assessments by the admitting service and a VTE consult service. Mechanical prophylaxis orders were subsequently reviewed. Next, strategies to improve compliance were implemented. One year later, prospective analysis of a similar cohort (group 2) was performed, followed by surveys of staff and patients to identify barriers to compliance. RESULTS: In group 1, VTE risk assessments were accurate and IPC was appropriately ordered. Of patients who needed IPC, 24 had IPC correctly applied and 72 did not. In group 2, VTE risk assessments were accurate and IPC was appropriately ordered. Of patients who needed IPC, 26 had IPC correctly applied and 74 did not. Surveys revealed that most providers are aware of the indications, order appropriately, and make efforts to ensure application. Most nurses reported that orders were placed and that IPC was applied. Most patients claimed to have knowledge of VTE and IPC use, but half reported that they were not educated and complained of sleep interference. CONCLUSIONS: Even with implementation of strategies to improve compliance, most patients do not receive adequate mechanical prophylaxis. Health care providers appropriately order prophylactic measures but do not follow up to ensure application. Discomfort and lack of education of the patient were important barriers to prophylaxis.

Mechanochemical ablation for symptomatic great saphenous vein reflux: A two-year follow-up.

Background Several studies have shown comparable early efficacy of mechanochemical ablation to endothermal techniques. The goal of this report was to show if early efficacy is maintained at 24 months. Methods This was a two-year analysis on the efficacy of mechanochemical ablation in patients with symptomatic C2 or more advanced chronic venous disease. Patients with reflux in the great saphenous vein involving the sapheno-femoral junction and no previous venous interventions were included. Demographic information, clinical, and procedural data were collected. The occlusion rate of treated veins was assessed with duplex ultrasound. Patient clinical improvement was assessed by Clinical-Etiology-Anatomy-Pathophysiology (CEAP) class and venous clinical severity score. Results Of the initial 126 patients, there were 65 patients with 24 month follow-up. Of these 65 patients, 70% were female, with a mean age of 70 ± 14 years and an average body mass index (BMI) of BMI of 30.5 ± 6. The mean great saphenous vein diameter in the upper thigh was 7.6 mm and the mean treatment length was 39 cm. Adjunctive treatment of the varicosities was performed in 14% of patients during the procedure. Closure rates were 100% at one week, 98% at three months, 95% at 12 months, and 92% at 24 months. There was one patient with complete and four with partial recanalization ranging from 7 to 12 cm (mean length 9 cm). There was significant improvement in CEAP and venous clinical severity score (P < .001) for all time intervals. Conclusion Early high occlusion rate with mechanochemical ablation is associated with significant clinical improvement which is maintained at 24 months, making it a very good option for the treatment of great saphenous vein incompetence.

Accuracy of venous thromboembolism assessment and compliance to prophylaxis in a tertiary care center.

BACKGROUND: Proper assessment of venous thromboembolism (VTE) risk level in hospitalized patients is vital to providing adequate prophylaxis. Clinical decision support (CDS) tools with electronic medical record (EMR) have been used by institutions to improve assessment and prophylaxis. As such, this study was conducted after implementing such a system to compare admitting service (AS) assessment of VTE risk level to the VTE consult service (CS) assessment. In addition, compliance of ordered prophylaxis based on AS assessment was evaluated. METHODS: At a tertiary care center, we performed a review of randomly selected patients assessed within 18 h of admission for VTE risk over a five-month period. A total of 104 patients were evaluated, four of which were excluded because of VTE presence on admission. Patients were assessed for VTE risk independently, first by the AS, followed by the VTE CS. Prophylaxis orders were then reviewed based on AS assessment compliance to CDS recommendations for prophylaxis based on ACCP guidelines. RESULTS: All 100 patients underwent VTE risk assessment within 18 h from admission. The mean age was 63 years. Comparing AS to CS assessment, 13 patients had incorrect assessments (p < .001). Of these, six patients were under-assessed (p = .029), and seven patients were over-assessed (p = .014). Based on AS assessment there were eight patients who had incorrect prophylaxis ordered. Unnecessary exposure to complications due to inappropriate prophylaxis occurred in five patients. CONCLUSION: Despite the use of EMR CDS tools, there continues to be a significant number of patients that are being under-assessed and under-prophylaxed for VTE resulting in exposing patients to potential harm. Quality programs need to be instituted to further improve VTE assessment and prophylaxis.

Bariatric outcomes are significantly improved in hospitals with fellowship council-accredited bariatric fellowships.

BACKGROUND: With the increasing demand of bariatric surgery, there is a need to train more surgeons, while identifying institutional factors associated with improved outcomes. Little is known regarding the impact of a fellowship training program on institutional outcomes. This study examines the effect of bariatric fellowship program status on perioperative outcomes within New York state. METHODS: Using the New York statewide planning and research cooperative system, 47,342 adult patients in 91 hospitals were identified who underwent a laparoscopic bariatric surgery over a 6-year period. Hospitals with fellowships were identified from the Fellowship Council. Statistical comparison between patient demographics, payer source, comorbidities, bariatric procedure performed, and perioperative outcomes in hospitals with and without fellowship were performed. RESULTS: On univariate analysis, fellowship accreditation status was found to be associated with increased rates of cardiac complications and shock and decreased rates of pneumonia. Overall complication rate was not significantly different in fellowship versus non-fellowship institutions. However, when controlled for patient demographic, payer source, comorbidity, and operative procedure, there were significantly improved bariatric outcomes among institutions with fellowship programs. CONCLUSIONS: The presence of a fellowship program correlates with improved hospital outcomes, mitigating potential concerns about possible negative effects of trainees on hospitals and patients.

Case review and consideration for imaging and work evaluation of the pregnant bariatric patient.

BACKGROUND: There is an increasing trend toward morbid obesity in women of childbearing age and a subsequent increase in number of weight reduction surgeries in these individuals. As a result, special attention needs to be paid to potential postsurgical complications during pregnancy, particularly after Roux-en-Y gastric bypass (RYGB). We are presenting our small case series and our suggestions for management for the pregnant bariatric patient. The aim of this study is to review our institutional experience and present our algorithm to approach pregnant women presenting with abdominal pain and/or emesis after RYGB. METHODS: After Institutional Review Board approval, a retrospective chart review was performed at a single center institution between 2010 and 2013. Data regarding clinical presentation, physical exam findings, laboratory values, radiographic studies, intraoperative findings, and clinical outcomes of both mother and fetus were collected and reviewed for pregnant patients with history of RYGB and abdominal distress. RESULTS: Five patients were identified. Patient age ranged from 22-34 years (mean 28.4). Gestational age ranged from 9-31 months (mean 19.2). Average body mass index at presentation was 30.3 kg/m(2). Of the 5 patients, 4 presented with abdominal pain and one with intractable emesis. Four patients were taken to the operating room. One was successfully discharged. Two of the patients had an obstruction from adhesions, and the other 2 were found to have internal hernia. There was no mortality for either fetus or mother. One patient required premature delivery at 28 weeks. CONCLUSIONS: Pregnant women with history of RYGB who present with abdominal pain should be evaluated urgently for internal hernia or obstruction. A systematic approach is needed to ensure prompt diagnosis.

Unique obstacle race injuries at an extreme sports event: a case series.

Obstacle course endurance events are becoming more common. Appropriate preparedness for the volume and unique types of injury patterns, as well as the effect on public health these events may cause, has yet to be reported in emergency literature. We describe 5 patients who presented with diverse injuries to illustrate the variety of injuries sustained in this competitive event. In particular, 4 of the patients had a history of contact with electrical discharge, an obstacle distinctive to the Tough Mudder experience.

Unusual presentation of a cutaneous bronchogenic cyst in an asymptomatic neonate.

Cutaneous presentations of bronchogenic cysts are rare in all age groups. Previous reports of cutaneous manifestations of bronchogenic cysts have been described as nodular, adherent masses, most frequently with a suprasternal location. We report a unique presentation of an infant with a pedunculated, anterior chest wall mass, which was identified as a bronchogenic cyst.

Copine A is required for cytokinesis, contractile vacuole function, and development in Dictyostelium.

Copines make up a family of soluble, calcium-dependent, membrane binding proteins found in a variety of eukaryotic organisms. In an earlier study, we identified six copine genes in the Dictyostelium discoideum genome and focused our studies on cpnA. Our previous localization studies of green fluorescent protein-tagged CpnA in Dictyostelium suggested that CpnA may have roles in contractile vacuole function, endolysosomal trafficking, and development. To test these hypotheses, we created a cpnA- knockout strain, and here we report the initial characterization of the mutant phenotype. The cpnA- cells exhibited normal growth rates and a slight cytokinesis defect. When placed in starvation conditions, cpnA- cells appeared to aggregate into mounds and form fingers with normal timing; however, they were delayed or arrested in the finger stage. When placed in water, cpnA- cells formed unusually large contractile vacuoles, indicating a defect in contractile vacuole function, while endocytosis and phagocytosis rates for the cpnA- cells were similar to those seen for wild-type cells. These studies indicate that CpnA plays a role in cytokinesis and contractile vacuole function and is required for normal development, specifically in the later stages prior to culmination. We also used real-time reverse transcription-PCR to determine the expression patterns of all six copine genes during development. The six copine genes were expressed in vegetative cells, with each gene exhibiting a distinct pattern of expression throughout development. All of the copine genes except cpnF showed an upregulation of mRNA expression at one or two developmental transitions, suggesting that copines may be important regulators of Dictyostelium development.