Telerobotic Sonography for Remote Diagnostic Imaging: Narrative Review of Current Developments and Clinical Applications.

Access to sonographers and sonologists is limited in many communities around the world. Telerobotic sonography (robotic ultrasound) is a new technology to increase access to sonography, providing sonographers and sonologists the ability to manipulate an ultrasound probe from a distant location and remotely perform ultrasound examinations. This narrative review discusses the development of telerobotic ultrasound systems, clinical studies evaluating the feasibility and diagnostic accuracy of telerobotic sonography, and emerging use of telerobotic sonography in clinical settings. Telerobotic sonography provides an opportunity to provide real-time ultrasound examinations to underserviced rural and remote communities to increase equity in the delivery of diagnostic imaging.

Randomized Clinical Trial Evaluating Complications and Complication-Related Removal of Arm-Situated Power-Injectable and Non-Power-Injectable Totally Implanted Venous Access Devices among Cancer Patients.

PURPOSE: To evaluate the hypothesis that power-injectable (PI) totally implanted venous access devices (TIVADs) situated in the arm are associated with more frequent complications and complication-related removal than non-power-injectable (NPI) arm TIVADs among adult cancer patients. MATERIALS AND METHODS: In this single-center trial, 211 adult chemotherapy patients were randomized to receive either a PI or a NPI arm TIVAD. Follow-up involved a standardized telephone interview 1 week after insertion, followed by a chest X-ray, arm X-ray, and Doppler ultrasound at 3 months and 12 months. Online complication reporting was also provided by patients and care providers for a minimum of 1 year. The primary end point was removal for port-related complications; the secondary end point was the occurrence of any port-related complication. RESULTS: Forty-two complications occurred (19.9% of patients), precipitating the removal of 6 PI ports and 7 standard ports. Time-to-removal did not differ between TIVAD types (hazard ratio 0.75, 95% confidence interval [CI] 0.25-2.24; P = .61). Complications were related to thrombosis, infection, or mechanical issues, with no statistical difference between groups for overall occurrence (23.1% vs 17.0%, odds ratio 1.47, 95% CI 0.74-2.92; P = .27); however, by type of complication, thrombosis occurred more frequently among PI TIVAD patients (15.2% vs 6.1%, odds ratio 2.79, 95% CI 1.04-7.44; P = .03). CONCLUSIONS: There was no difference in port-related complication occurrence or complication-related removal when using the arm PI port compared with the NPI port among cancer patients.

Satisfaction and Quality of Life Related to Chemotherapy With an Arm Port: A Pilot Study.

PURPOSE: Placement of arm ports, or totally implanted venous access devices, is a common practice in our interventional radiology suite. We implant a miniaturized port in the upper arm for the provision of long-term chemotherapy. We hypothesized that there was general satisfaction with these arm ports and they have a minimal negative impact on quality of life. In this study we aimed to assess our hypotheses. METHODS: We surveyed subjects, who having previously received an arm port for chemotherapy to treat a malignancy, attended the interventional room for its removal. The survey assessed the port's effect on lifestyle, the degree of device-related pain, the acceptance of the port, and the willingness to have another port in the future. RESULTS: Survey responses from 77 subjects were reviewed. On a scale of 1 (most negative) to 10 (most positive), respondents indicated that the port system was a very positive enhancement to their treatment (satisfaction = 9.2 ± 2.0 and positivity = 8.8 ± 2.2). The port had little impact on daily activities. The mean score for the likelihood of choosing to have another port placed if additional treatment was required was 9.1 ± 2.1. DISCUSSION: The arm port in this study did not negatively impact subject satisfaction and quality of life for this cohort. Most subjects rated the device utility highly and felt that the port was a positive enhancement to their treatment, one that they would possibly utilise again in future, if need be.

Radiological errors in the Canadian Journal of Emergency Medicine.

OBJECTIVES: To systematically evaluate the accuracy of text descriptions and labeling of radiologic images published in the Canadian Journal of Emergency Medicine (CJEM). Error detection by radiologists and emergency physicians and the clinical significance and educational value of these errors were assessed. Errors were also correlated with radiologist involvement in publication and imaging modality. METHODS: Thirty-three issues of CJEM were examined from January 2003 to May 2008. Electronic copies of all radiologic images published were obtained with their caption and description from the text. Identifying information was removed to present images in an anonymous fashion. Images were presented to two radiologists who, working in consensus, critically appraised each image and accompanying text. Images were then presented to two emergency department physicians who, working in consensus, critically appraised each image and accompanying text. All images with errors detected by either radiology or emergency physicians were then discussed to determine if errors would have affected clinical management or educational value. The emergency physicians also identified "underlabeled" images where it was felt that further labeling would enhance their educational value. RESULTS: Forty-five articles with 82 images were obtained. At least one error was observed in 18 (40%) articles and 20 (24%) images. Two errors were present in three images, resulting in 23 errors. Of the 23 errors, 17 were image description errors and 6 were labeling errors. Five errors were detected by both radiology and emergency physicians, whereas 15 were detected only by radiologists and 3 were detected only by emergency physicians. Of these errors, 12 (52%) were rated as potentially affecting both clinical management and educational value, 5 (22%) as only affecting educational value, and 6 (26%) as nonsignificant. Radiologists were involved in six articles, including 12 images that contained no errors. There was no official radiologist involvement in 39 articles, including 70 images, 18 (26%) of which contained errors. In addition, 26 images were identified by emergency physicians as potentially benefiting from enhanced labeling to improve educational value. CONCLUSIONS: Radiologic images published in the CJEM are generally of high quality; however, 23 errors were found in 82 images, 18 (78%) of which were rated as potentially affecting clinical management, educational value, or both. Radiologist involvement in the publication process may be of assistance as no errors were seen in articles that included radiologists as authors.

Catheter fracture and embolization associated with arm implantation of the cook vital port.

PURPOSE: To determine the frequency of arm port catheter fracture and embolization related to the Cook Vital Port Mini Titanium. MATERIALS AND METHODS: A retrospective audit of our Cerner Radiology Information System was performed between June 1, 2006, and June 30, 2011, to determine the number of Cook arm venous ports implanted and the frequency of foreign body retrievals related to catheter fracture for these arm ports. RESULTS: A total of 691 arm implantations of the Cook Vital Port during the 5-year time frame were analysed. Eleven of these patients (1.6%) required intravenous foreign body retrieval in the interventional radiology suite related to catheter fracture and embolization. Three of these fractured catheters were retrieved from the peripheral venous system upstream of the pulmonary circulation, whereas 8 embolized to the pulmonary arteries. All were successfully extracted with an intravenous snare by interventional radiology. CONCLUSION: We discovered a 1.6% frequency of catheter fracture and embolization associated with arm implantation of the Cook Vital Port. All the catheters fractured at the vein entry site and did not detach from the port housing. The cause for catheter fracture and embolization is uncertain. Pulmonary embolization of the fractured catheters puts the patients at risk for possible further complications. No patients had ancillary complications related to catheter embolization or to catheter extraction procedures. Further investigation is required in an attempt to determine the circumstances that may result in catheter fracture and embolization related to this venous access device.

Pneumoperitoneum post-fluoroscopic percutaneous gastrojejunostomy insertion: computed tomography and clinical evaluation.

INTRODUCTION: To assess the incidence and clinical significance of pneumoperitoneum after radiologic percutaneous gastrojejunostomy (PGJ) tube insertion. METHODS: Sixteen subjects were prospectively assessed after imaging-guided PGJ tube insertion to discern the incidence of pneumoperitoneum related to specific clinical signs and symptoms. Computed tomography of the abdomen and the pelvis was performed immediately after PGJ insertion. A clinical evaluation, including history, general and abdominal physical examination, temperature, complete blood cell count, abdominal pain, and abdominal tension, was performed on days 1 and 3, and at the discretion of the nutritional support team on day 7 after PGJ insertion. RESULTS: Fifteen of the 16 subjects demonstrated imaging findings of pneumoperitoneum after the PGJ-tube insertion. Only a small amount of pneumoperitoneum was demonstrated in 10 of the subjects, whereas a large volume of gas was detected in 2 of the subjects. The only altered clinical findings encountered were increased white blood cell count and fever. These abnormal clinical data were most frequently seen immediately after feeding-tube placement. DISCUSSION: Pneumoperitoneum was a common finding after PGJ-tube placement in our study population. There were no statistically significant abnormal clinical parameters, in the presence or absence of pneumoperitoneum, for any of the subjects after PGJ-tube insertion. Conservative management of pneumoperitoneum after PGJ is warranted.

Comparison of post-operative lordosis with the PEEK cage and the cervical plate.

OBJECTIVE: The maintenance of post-operative lordosis has been shown to be a key factor in decreasing adjacent level disc stress. Previous studies of the PEEK (polyether ketone) cage have used intervertebral bony fusion as the primary measure of surgical success; however, little is known about its effects on spinal curvature. Our objective was to compare the PEEK cage to the cervical plate with respect to the maintenance of cervical lordosis at one year. Secondary outcomes included fusion and complication rates. METHODS: We performed a retrospective study of patients who underwent ACDF (anterior cervical discectomy and fusion) by two different methods; 13 patients were treated with the PEEK cage, and 22 with allograft and plating. RESULTS: Patient and treatment characteristics were similar in both groups. Average global lordotic curvature (C2-C7) was increased by 1.7 degrees for the PEEK cage and decreased by 1.6 degrees for the plate after an average follow-up of 12.46 and 14.95 months, respectively. Regional lordosis for the PEEK cage and plate was decreased by 2.5 and 2.1 degrees, respectively for the same time period. These differences did not achieve statistical significance. Bony fusion was observed in all patients. One patient in each group developed persistent mild dysphagia. CONCLUSIONS: The PEEK cage is comparable to the anterior cervical plate in the maintenance of post-operative cervical lordosis.

Comparison of computed tomography 3-dimensional volumetric analysis of ventricular size to visual radiological assessment.

OBJECTIVES: Interpretation of ventricular volume on computed tomography scans of hydrocephalus patients is usually subjective. The objective of this study was to determine whether radiological assessment of interval change correlates better with an objective calculated volume change or with other objective 2-dimensional estimates of ventricle volume change. METHODS/SAMPLE: Ventricular volume, Evans ratio, and frontal and occipital Horn ratio were retrospectively assessed on 95 pairs of scans from patients with a ventriculoperitoneal shunt. To determine ventricle volume, all voxels of cerebrospinal fluid density were isolated on a 3-dimensional reconstructed computed tomography scan. Voxels of fluid density contiguous with one another in the ventricular system were isolated. Radiological assessments of interval change were divided into 5 groups based on reported findings in the radiology report. The 95% mean confidence intervals were developed for changes in the measured parameters, given a particular radiological assessment. Multinomial regression was subsequently performed to determine which parameter was most closely correlated with the radiological assessment. RESULTS: Significant overlap was found in the confidence intervals for objectively calculated volume change between the different categories of radiological assessment. The frontal and occipital Horn ratio had the most consistent correlation with the radiological assessment, followed by the Evans ratio. Objectively calculated volume change correlated poorly with radiological assessment. CONCLUSIONS: Radiological interpretation does not correlate well with objectively calculated volume changes, but correlates better with other parameters that approximate volume and are likely used to visually evaluate interval change. We recommend that ventricle volume be objectively measured to increase consistency between radiological interpretation and actual interval changes.

Percutaneous subclavian artery stent-graft placement following failed ultrasound guided subclavian venous access.

BACKGROUND: Ultrasound guidance for central and peripheral venous access has been proven to improve success rates and reduce complications of venous cannulation. Appropriately trained and experienced operators add significantly to diminished patient morbidity related to venous access procedures. We discuss a patient who required an arterial stent-graft to prevent arterial hemorrhage following inadvertent cannulation of the proximal, ventral, right subclavian artery related to unsuccessful ultrasound guided access of the subclavian vein. CASE PRESENTATION: During pre-operative preparation for aortic valve replacement and aorto-coronary bypass surgery an anesthetist attempted ultrasound guided venous access. The ultrasound guided attempt to access the right jugular vein failed and the ultrasound guided attempt at accessing the subclavian vein resulted in inappropriate placement of an 8.5 F sheath in the arterial system. Following angiographic imaging and specialist consultations, an arterial stent-graft was deployed in the right subclavian artery rather than perform an extensive anterior chest wall resection and dissection to extract the arterial sheath. The patient tolerated the procedure, without complication, despite occlusion of the right internal mammary artery and the right vertebral artery. There were no neurologic sequelae. There was no evidence of hemorrhage after subclavian artery sheath extraction and stent-graft implantation. CONCLUSION: The attempted ultrasound guided puncture of the subclavian vein resulted in placement of an 8.5 F subclavian artery catheter. Entry of the catheter into the proximal subclavian artery beneath the medial clavicle, the medial first rib and the manubrium suggests that the operator, most likely, did not directly visualize the puncture needle enter the vessel with the ultrasound. The bones of the anterior chest impede the ultrasound beam and the vessels in this area would not be visible to ultrasound imaging. Appropriate training and supervised experience in ultrasound guided venous access coupled with quality ultrasound equipment would most likely have significantly diminished the likelihood of this complication. The potential for significant patient morbidity, and possible mortality, was prevented by implantation of an arterial stent-graft.

West Nile Virus: a case report with flaccid paralysis and cervical spinal cord: MR imaging findings.

We present a case of serologically proved West Nile virus (WNV) flaccid paralysis of the right upper extremity. Radiologic correlation revealed striking T2 hyperintensities in the anterior horns of the cervical spinal cord, similar to those seen in cases of poliomyelitis. Recognition of the MR imaging findings in cases of WNV flaccid paralysis can provide early evidence of infection.

Experience with a modified Gray-St. Louis catheter for percutaneous gastrojejunostomy.

PURPOSE: To determine if design modifications to the Gray-St. Louis gastrojejunostomy catheter would improve its deployment and utilization characteristics. METHODS: A modified catheter and the Gray-St. Louis catheter were alternately inserted in consecutive patients requiring gastrojejunostomy. At the time of insertion, the anatomic locations of the fenestrated end of the catheter and the Cope retention loop were recorded. At the time of removal or exchange, catheters were assessed for the position of the fenestrated end and the retention loop, the presence of catheter tears, leakage of injected contrast medium and evidence of catheter blockage. RESULTS: Of the 250 catheters we assessed in a 3-year period, 141 (56%) were modified catheters and 109 (44%) were Gray-St. Louis catheters. At insertion, the retention loop of the modified catheter was in the duodenum in 132 (94%) patients, whereas the retention loop of the Gray-St. Louis Catheter reached the duodenum in 29 (27%) (p < 0.05). At the time of catheter removal or exchange, the retention loop of the modified catheter was in the duodenum in 72 (60%) patients, whereas the retention loop of the Gray-St. Louis catheter was in the duodenum in 13 (14%) (p < 0.05). CONCLUSION: The design modifications to the Gray-St. Louis catheter improved the likelihood of the retention loop residing in the duodenum, while continuing to allow the fenestrated portion of the catheter to reside in the jejunum.

Synovial chondromatosis and chondrosarcoma: a diagnostic dilemma.

PURPOSE: The progression of synovial chondromatosis to chondrosarcoma is very rare. Distinction between these two entities may be difficult on histology alone, and should be based on clinical, radiographic and microscopic evidence. Immunohistochemical markers that would facilitate differentiation between synovial chondromatosis and chondrosarcoma are currently being investigated. PATIENTS: We describe the cases of two patients who presented with synovial chondromatosis and progression to synovial chondrosarcoma during periods of 7 and 11 years. Several biopsies and resected specimens demonstrated synovial chondromatosis before a diagnosis of chondrosarcoma was made. METHOD: We have examined five markers (Bcl2, Ki67, p27, p16, and p53) in all specimens from these cases, as well as known cases of chondromatosis and chondrosarcoma for control purposes. RESULTS: We found increased expression of Bcl2 in benign chondromatosis compared to synovial or central chondrosarcomas. DISCUSSION: Distinction between chondromatosis and its progression to low grade chondrosarcoma is difficult at histological level, and must involve incorporation of clinical and radiographical data. Although preliminary, our study suggests that reduced or absent expression of Bcl2 is associated withmalignant transformation of chondromatosis.