Image quality and safety of automated carbon dioxide digital subtraction angiography in femoropopliteal lesions: Results from a randomized single-center study.

PURPOSE: To evaluate the image quality and the safety of automated carbon dioxide (CO2) digital subtraction angiography (DSA). MATERIALS AND METHODS: Fifty patients receiving DSA for femoropopliteal peripheral arterial disease (PAD) were enrolled in this single-center prospective study. All patients received iodinated contrast media (ICM) and CO2 as a contrast agent in the same target lesion. As a primary endpoint, four raters independently evaluated the angiography images based on overall image quality, visibility of collaterals, and assessment of stenoses/occlusions. Inter-rater agreement was assessed using the intraclass correlation coefficient (ICC) and differences between the raters were evaluated using Friedmann's test. Secondary endpoints were procedure safety and patient pain assessment. RESULTS: Inter-rater agreement between CO2-DSA and ICM-DSA images was fair to excellent for overall image quality (ICC: 0.399-0.748), fair to excellent for the visibility of collaterals (ICC: 0.513-0.691), and poor to excellent for the assessment of stenoses/occlusions (ICC: -0.065-0.762). There were no significant differences between the raters. Two patients had a hematoma, one reported pain related to puncture, one became nauseous, and one vomited. No other adverse events were observed. Reported pain scores were significantly higher for CO2-DSA vs. ICM-DSA (1.25 vs. 0625; p < 0.028). CONCLUSION: CO2-DSA using automated injection system in combination with proprietary post-processing software is safe and comparable diagnostic test compared to ICM-DSA.

Satisfaction and quality of life: a survey-based assessment in patients with a totally implantable venous port system.

The purpose was to assess the satisfaction and quality of life in patients with a totally implantable central venous port system using a questionnaire-based survey. A self-designed questionnaire to assess patient satisfaction and the impact of the port on daily life was dispatched 180 days after implantation. The questionnaire was combined with the commonly used short form (SF)-12 Health Survey quality of life questionnaire. Of the 98 patients who received a port system, 75 were contacted, and 42 (56%) returned the questionnaire. Most of the responding patients reported high overall satisfaction. The impact of the system on daily life was widely perceived not to be negative. The physical component summary (PCS) and the mental component summary (MCS) scores from the SF-12 were 35.5 and 45.23 respectively (general German population: PCS = 49.6, MCS = 52.3). The multiple stepwise regression showed that the cosmetic result was a predictor of overall satisfaction; the cosmetic result and a painful port together were predictors of the MCS. Overall, it was found that the cosmetic result of the implantation procedure was a predictor of satisfaction and quality of life and should thus not be underestimated.

'Low-dose' dopamine worsens renal perfusion in patients with acute renal failure.

'Low-dose' dopamine is frequently used in intensive care units (ICU) for its presumed renoprotective effects, but prospective and retrospective studies have so far not proven prevention or amelioration of renal injury. Data on renal perfusion following dopamine infusion are limited. In order to circumvent the problem of patient heterogeneity in the ICU setting, we used a crossover design in a prospective, double-blind randomized controlled study to investigate the effect of 'low-dose' dopamine on renal resistance indices, as determined by Doppler ultrasound. Forty patients, 10 without and 30 with acute renal failure (ARF, defined as doubling of baseline creatinine or an increase above 2 mg/dl), were included. Dopamine (2 mug/kg min) or placebo was given intravenously in alternating sequence for four subsequent periods of 60 min, starting randomly with either dopamine or placebo. Resistive (RI) and pulsatility index (PI) were closely correlated, positively related to serum creatinine values at baseline and highly reproducible during the two paired infusion periods. Dopamine reduced renal vascular resistance in patients without ARF (median RI/PI from 0.70 to 0.65/1.20 to 1.07, P<0.01) but increased resistance indices in patients with ARF (median RI/PI from 0.77 to 0.81/1.64 to 1.79, P<0.01) in the absence of effects on systemic hemodynamics. Subgroup analysis of patients with ARF revealed that dopamine induced renal vasoconstriction above 55 years (n=22) and in patients not receiving norepinephrine (n=20). In conclusion 'low-dose' dopamine can worsen renal perfusion in patients with ARF, which adds to the rationale for abandoning the routine use of 'low-dose' dopamine in critically ill patients.

[Contrast media pressure injection using a portal catheter system--results of an in vitro study]. / Kontrastmitteldruckinjektion in Portkathetersysteme -- Ergebnisse einer In-vitro-Studie.

PURPOSE: Are implanted central venous port catheters suitable for contrast media pressure (power) injection in computed tomography? MATERIAL AND METHODS: In an in vitro study 100 ml of contrast medium (Ultravist 370, Schering, Berlin, Deutschland) was injected through 20 different port catheter systems using a power injector (Stellant, Medrad, Inianola, USA) with a pressure limit of 325 PSI. The injection rate was increased from 2 ml/s to 10 ml/s in increments of 2 ml/s. The maximum injection pressure and maximum injection rate were assessed. RESULTS: An injection rate of 2 ml/s was possible in all catheter systems. Injection rates of 4 ml/s in 18 systems, 6 ml/s in 13 systems and 8 ml/s in 6 systems were achieved. With a given pressure limit of 325 PSI an injection rate of 10 ml/s was not possible in any of the port catheter systems. There were no catheter ruptures, catheter disconnections or contrast extravasations noted. CONCLUSION: Power injection of contrast media with a pressure limit of 325 PSI seems to be tolerated by port catheter systems. Most of the evaluated port systems allow flow rates suitable for multislice computed tomography requiring rapid contrast injection.

[Long-term central venous lines and their complications]. / Langfristige zentralvenöse Zugänge und deren Komplikationsmanagement.

The implantation of permanent (> 14 days) central venous catheters is constantly increasing, accelerated by a trend toward outpatient therapies. Subcutaneous tunneled and non-tunneled catheters as well as port systems are available. The interventional radiologist plays an important role in the implantation of central venous catheters as well as in detection and treatment of any complications. Various access ways via peripheral and central veins are described and the implantation techniques for the different systems explained. The use of peel-away sheaths allows the radiologist to implant subcutaneous tunneled catheters via the Seldinger technique without surgical preparation. Procedure-related early and late complications may occur, and the radiologist plays an important role in the surveillance and management of catheter-associated complications. This review demonstrates the different catheter systems and implantation techniques.

[Ultrasound- and fluoroscopy-guided implantation of peripherally inserted central venous catheters (PICCs)]. / Ultraschall- und durchleuchtungsgesteuerte Implantation peripher inserierter zentral-venöser Katheter (PICC).

PURPOSE: Evaluation of ultrasound- and fluoroscopy-guided implantation of peripherally inserted central venous catheters (PICCs). MATERIALS AND METHODS: In 32 patients (12 males, 20 females; mean age 64.1 +/- 11.9 years) with clinical indication for long term central venous catheter (chemotherapy: N = 5; parenteral nutrition and fluid substitution: N = 26; parenteral pain therapy: N = 1) a PICC was placed by an interventional radiologist using ultrasound guidance. RESULTS: The placement of the PICC was technically successful in 31 (96.9%) patients, with placement of 20 single-lumen 5F PICCs, 4 double-lumen 6F PICCs and 7 double-lumen 7F PICCs. The mean duration of catheter usage was 28.4 (2 - 161) days with a total of 910 catheter days. No catheter occlusions were recorded. Two patients developed a superficial venous thrombosis of the upper extremity. The resulting thrombotic rate was 2.2 per 1000 catheter days. No catheter associated infection was recorded. CONCLUSION: The ultrasound guided placement of peripherally inserted central venous catheters (PICCs) via a superficial vein of the upper extremity is a practical alternative to central catheters via central veins.

[Methods of process management in radiology]. / Methoden des Prozessmanagements in der Radiologie.

The main emphasis in health care has been on quality and availability but increasing cost pressure has made cost efficiency ever more relevant for nurses, technicians, and physicians. Within a hospital, the radiologist considerably influences the patient's length of stay through the availability of service and diagnostic information. Therefore, coordinating and timing radiologic examinations become increasingly more important. Physicians are not taught organizational management during their medical education and residency training, and the necessary expertise in economics is generally acquired through the literature or specialized courses. Beyond the medical service, the physicians are increasingly required to optimize their work flow according to economic factors. This review introduces various tools for process management and its application in radiology. By means of simple paper-based methods, the work flow of most processes can be analyzed. For more complex work flow, it is suggested to choose a method that allows for an exact qualitative and quantitative prediction of the effect of variations. This review introduces network planning technique and process simulation.

[Conception and data transfer analysis of an open-source digital image archive designed for radiology]. / Aufbau und Datentransferanalyse eines proprietären digitalen Open-Source-Bildarchivs für radiologische Dienstleistungen.

PURPOSE: Implementation of a self-designed, web-based digital image archive incorporating the existing DICOM infrastructure to assure distribution of digital pictures and reports and to optimize work flow. Assessment after three years. MATERIALS AND METHODS: Open-source software was used to guarantee highest reliability and cost effectiveness. In view of rapidly increasing capacity and decreasing costs of hard discs (HDs), HDs were preferred over slower and expensive magneto-optical disk (MOD) or tape storage systems. The number of installed servers increased from one to 12. By installing HDs with increased capacities, the number of servers should be kept constant. Entry and access of data were analyzed over two 4-month periods (after 1.5 and 2 years of continuous operations). RESULTS: Our digital image archive was found to be very reliable, cost effective and suitable for its designated tasks. As judged from the measured access volume, the average utilization of the system increased by 160 %. In the period from January to April 2002, the users accessed 239.8 gigabyte of the stored 873.7 gigabyte image data (27 %). The volume of the stored data added 20%, mainly due to an increase in cross-section imaging. CONCLUSION: The challenge of developing a digital image archive with limited financial resources resulted in a practicable and expandable solution. The utilization, number of active users and volume of transferred data have increased significantly. Our concept of utilizing HDs for image storage proved to be successful.

[Accuracy of the sonographic determination of the splenic weight in comparison with the weight at autopsy]. / Genauigkeit der sonographischen Milzgewichtsbestimmung am Lebenden im Vergleich zum pathologischen Korrelat.

PURPOSE: The weight of the spleen can be easily calculated from sonographic measurements. This study investigates the correlations between the weight of the spleen determined sonographically and the weight measured at autopsy or after splenectomy. MATERIALS AND METHODS: The splenic weight at autopsy or after splenectomy was correlated with the calculated sonographic splenic weight in 55 patients who had a sonographic examination within the preceding three weeks. RESULTS: A significant correlation (r = 0.978) was found between the sonographically calculated splenic weight (460.82 grams) and the measured weight of the removed spleen (average weight 463.18 grams). Spleens weighing more than 1 kg showed a slightly weaker correlation. CONCLUSION: This study proves that the simple formula of length x transverse diameter x vertical diameter x 0.6 provides a reliable calculation of the weight of the spleen.

[Use of portable computed tomography in non-transportable patients on the intensive care unit: preclinical experience]. / Einsatz der mobilen Computertomographie bei nicht transportfähigen Patienten auf der Intensivstation - Ein Erfahrungsbericht.

PURPOSE: To evaluate different concepts of the application of a portable CT (PCT) directly in a patient's ICU room versus in a specially designed interventional suite (IS). METHODS: 13 patients with maximum ICU treatment were examined by PCT and assessed with regard to their health status by ICU scores (TISS 28, MODS). Only patients with a therapeutic intervention scoring system 28 (TISS 28) value of 40 or greater were included in the study. A TISS 28 value of 40 or more characterizes a patient requiring maximal ICU treatment. Patients were examined by PCT either in the patient's room or in the IS on the ICU. Scanning time and personnel resource expense were determined. The multiple organ dysfunction score (MODS) was utilized for patient characterization. RESULTS: An average of 1.4 hours was needed to perform a PCT scan in the interventional room. A minimum of 4.5 hours or up to a maximum of 7.2 hours were required to perform a bedside scan in the patient's room. There is a noticeable difference between patients with respect to TISS 28. Patients examined by bedside CT were more acutely ill than the others by reason of MODS (8 - 18 patient-room group vs. 3 - 12 IS group). CONCLUSIONS: PCT performed on an ICU assures optimal treatment of patients during CT examination. Portable CT had more time exposure and required more personnel resources than examination in the IS. All PCT examinations performed directly in the patient's room demonstrated the diagnostic value and had direct therapeutic consequences.

Single (culprit) vessel disease in octogenarians with acute myocardial infarction and unstable angina.

It is generally thought that coronary artery disease (CAD) in octogenarians would involve multiple vessels. The purpose of the current study was to determine the relative importance of single vessel disease in octogenarians with acute myocardial infarction (AMI) and unstable angina and its outcome from a revascularization procedure such as percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG). Our study included 70 patients (25 men, 45 women) aged 80 or older (mean, 84.5 +/- 0.5) admitted for the first time to the St. Agnes Hospital coronary care unit during 1994 for AMI or unstable angina. Patients admitted primarily for congestive heart failure, cardiogenic shock, hypertensive heart disease, or cardiomyopathy were excluded. Fifty patients (71.4%) had AMI and 20 (28.6%) had unstable angina. Of the 19 patients who had cardiac catheterization done, 10 had single vessel disease, 8 had flow-limiting disease in 2 or more coronary arteries, and 1 had no flow-limiting disease. The mean ejection fraction was 56.5 +/- 6.9 in patients with single vessel disease, 48.0 +/- 3.3 in those with multiple vessel disease, and 38.7 +/- 1.7 in those who did not have cardiac catheterization done. Fourteen PTCA (20%) and 3 CABG (4.3%) were performed without inhospital mortality from the procedures. There were 9 deaths (12.9%) overall: none among 10 patients with single vessel disease, 1 (12.5%) among 8 patients with widespread CAD, and 8 (15.7%) among 51 patients who did not have cardiac catheterization. Study results emphasize the need for recognition and treatment of single vessel disease by revascularization procedures to reduce mortality from CAD in octogenarians.

Maternal and child health in urban Sabah, Malaysia: a comparison of citizens and migrants.

This paper describes selected maternal and child health indicators based on a cross-sectional study of citizens and migrants in Sabah, Malaysia. A total of 1,515 women were interviewed from a multi-stage random sample of households in eight urban centers. Among the 1,411 women in the sample who had experienced a pregnancy before, 76% were local citizens and 24% were migrants. There were statistically significant differences between citizens and migrants in ethnicity, religion, education, household income, and access to treated water supply and sanitary toilet facilities. Significantly fewer migrants practiced any form of contraception and obtained any antenatal care during any pregnancy. Furthermore, citizens tended to initiate care as early as three months but migrants as late as seven months. Despite these differences, only the infant mortality rate, and not pregnancy wastage, was statistically significantly higher among migrants. Pregnancy interval was also similar between the two groups. The influence of several socioeconomic factors on pregnancy wastage and infant mortality was explored.

PIP: Findings from this study conducted in urban Sabah, Malaysia, support the view that migrants, as opposed to natives, are at a disadvantage with regard to education and income and are more exposed to negative environments in Malaysia compared to their home countries. Migrants are found to have less contraceptive use and higher proportions of women who never had prenatal care. Crude birth intervals are found to be similar in both the native population and the migrant population. Migrant women who breast feed are a larger proportion. The comparison of women who used prenatal care suggests that some migrant women use prenatal care late in pregnancy and only register at child health clinics as a means of obtaining citizenship. Pregnancy wastage is similar in both groups of migrant and native women. Infant mortality is higher among births to migrant women, but the differences are not statistically significant. It is suggested that poor living conditions contribute to the higher infant mortality. Logistic models reveal that maternal educational level is a statistically significant predictor of pregnancy wastage and infant mortality. Risk of pregnancy wastage is also significantly affected by household income. Piped water supply and sanitary facilities are insignificant predictors. The lack of a relationship is interpreted as potentially a function of disparity in the time frame of variables. The authors recommend an improvement in access to health care and in living conditions. The study area is primarily rural and the population is scattered, which makes for more difficult delivery and distribution of services. Voluntary use of health care services by migrants needs to be encouraged. Government policy should shift to improving local government capacity to provide health care, improving the responsiveness of relevant public agencies, lowering health care costs, increasing service demand among the poor, promoting private sector cooperation, and encouraging migrant movement to small and intermediate sized cities.

Risk factors for the development of persistent diarrhoea and malnutrition in Burmese children.

To identify socioeconomic and behavioural risk factors for development of persistent diarrhoea and malnutrition in children, a case-control study was carried out in Burma. Cases were 67 children 1-59 months old hospitalized for diarrhoea lasting > 14 days and complicated by severe malnutrition; for each case, a healthy control child was selected who was age- and sex-matched from the same neighbourhood. Homes of cases and controls were visited for interviews and for direct observation of household child-care practices. Risk factors were catalogued and calculations made for relative risk and etiologic fractions. Risk factors that were associated with persistent diarrhoea and malnutrition included low family income, low education of mothers, unhygienic latrines, flies in the house and on the child, dirty appearance of child and mother, mother not using soap and water when washing child's hands, defaecation of child on floor, breastfeeding on demand, child eating food from floor, not feeding recommended weaning foods, and lack of knowledge by mother about causes of diarrhoea and about foods that prevent malnutrition. These results indicated that persistent diarrhoea and malnutrition in Burma is caused by a complex of several interrelated socioeconomic factors, unsanitary behaviour pertaining to personal hygiene, the practice of demand breastfeeding and lack of certain weaning foods, and low education of mothers who showed less knowledge about causes of diarrhoea and prevention of malnutrition.