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Biomedical subjects

D Picus

Publications and source records attributed to D Picus.

At least 19 recordsLinked to original sources
PubMed1998

Recurrent gastrointestinal bleeding: use of thrombolysis with anticoagulation in diagnosis.

PURPOSE: To determine the safety and diagnostic accuracy of a provocative protocol with heparin and urokinase to induce bleeding and determine the source in patients with chronic gastrointestinal hemorrhage. MATERIALS AND METHODS: Nine patients had gastrointestinal bleeding from an indeterminate source and had negative results from esophagogastroduodenoscopy, colonoscopy, small-bowel examination, and angiography. Ten provocative bleeding studies were performed prospectively. Patients had no clinical evidence of bleeding within 2 days before the study. Intravenous administration of heparin and urokinase was performed systemically during a 4-hour period while scintigraphy was performed continuously. Mesenteric angiography was performed immediately in patients in whom substantial gastrointestinal bleeding was detected at scintigraphy. RESULTS: The provocative protocol was successful in inducing scintigraphically detectable hemorrhage in four (40%) studies within 4 hours. In two of these four studies, the source of hemorrhage was determined and treated with embolization or surgery. Three (30%) studies demonstrated scintigraphic evidence of hemorrhage only at delayed imaging (8-24 hours after initiation of the study). The remaining three (30%) studies did not show active bleeding. No complications occurred, including hemodynamic instability or uncontrollable decreases in hematocrit. CONCLUSION: Since this protocol with heparin and urokinase enabled determination of the bleeding source in only two of 10 studies, protocol modifications are necessary before this intervention is used widely.

Adult↗
PubMed1997

Prospective study of provocative angiograms to localize functional islet cell tumors of the pancreas.

BACKGROUND: Controversy exists concerning the use of preoperative imaging studies in patients with islet cell tumors. Since 1993 we have evaluated the use of provocative angiography in patients with insulinoma or Zollinger-Ellison syndrome (ZES). METHODS: Twelve patients with a working diagnosis of insulinoma (n = 4) or ZES (n = 8) were studied. Of the eight patients with ZES, four were known to have multiple endocrine neoplasia type 1. All patients underwent conventional imaging studies followed by provocative angiography. Angiograms were graded based on the ability to detect tumor and regionalize it within the pancreas. RESULTS: Of the three patients with a working diagnosis of ZES but equivocal results of biochemical studies, none had arteriographic imaging of an islet cell tumor or a positive provocative study result (true negative result). Of the nine patients with documented islet cell tumor, seven (78%) underwent arteriographic imaging of the tumor and eight (89%) had correct regional localization by provocative angiography. Sensitivity and specificity for imaging were 78% and 100%, respectively, and for regional localization 89% and 100%, respectively. CONCLUSIONS: Provocative angiography is the localization study of choice for both gastrinoma and insulinoma. Having few false-negative results, it can be used to corroborate the diagnosis and, having few false-positive results, it detects tumor and biochemically confirms localization in nearly every patient.

Adenoma, Islet Cell↗
PubMed1997

Long-term outcome of flexible ureterorenoscopy in the diagnosis and treatment of lateralizing essential hematuria.

PURPOSE: We identified the long-term outcome of ureterorenoscopic diagnosis and treatment of patients with lateralizing essential hematuria. MATERIALS AND METHODS: We reviewed retrospectively 17 patients with lateralizing essential hematuria treated with flexible ureterorenoscopy (15) or flexible percutaneous nephroscopy (2) with or without biopsy and electrocoagulation. Followup was longer than 24 months (average 60, range 24 to 116) in all patients. RESULTS: At followup 9 of the 17 patients (59%) were cured and 7 (41%) had recurrent bleeding. Discrete lesions occurred in 11 patients (64%), who were treated with electrocoagulation with 9 (82%) cured. All 3 patients (18%) with diffuse lesions had recurrent bleeding as did 2 of 3 (66%, 18% overall) with negative examinations. CONCLUSIONS: Ureterorenoscopy is an effective means of diagnosis and treatment of lateralizing essential hematuria. The majority of patients with lateralizing hematuria will have a discrete lesion that will respond to ureterorenoscopic electrocoagulation in the long-term. However, if the lesions are diffuse or the diagnostic examination is unreliable recurrent bleeding is likely.

Adult↗
PubMed1996

Evaluation of coagulation tests as predictors of angiographic bleeding complications.

PURPOSE: To determine whether prothrombin time (PT), partial thromboplastin time (PTT), and platelet count are useful predictors of postangiographic hematoma. MATERIALS AND METHODS: The authors prospectively studied 1,000 consecutive patients who underwent femoral arterial puncture for a diagnostic or therapeutic vascular procedure. Demographic and procedural variables were recorded, including patient age and sex, history of medications and bleeding, procedure type and length, catheter size, and experience level of radiologist applying compression for hemostasis. RESULTS: Abnormal results of coagulation tests were not correlated with an increased occurrence of hemorrhagic complications, but bleeding complications did occur more often in patients with thrombocytopenia. Hematomas occurred in 8.1% (10 of 123) of patients with any abnormal coagulation test results and 9.7% (85 of 877) of patients with normal test results. A platelet count of less than 100 X 10(9)/L was correlated with a higher occurrence of hematoma (P = .002). CONCLUSION: Abnormal PT and PTTs do not correlate with an increased risk of postangiographic hematoma, but a low platelet count is associated with more bleeding complications.

Adolescent↗
PubMed1995

Subcutaneous urinary diversion utilizing a nephrovesical stent: a superior alternative to long-term external drainage?

OBJECTIVES: The use of external percutaneous nephrostomy drainage in patients with end-stage ureteral obstruction in whom ureteral stenting has failed presents significant compromises in the patient's quality of life. Toward this end, we present the initial experience in the United States with an intracorporeal nephrovesical stent. METHODS: We performed successful subcutaneous urinary diversion in 2 patients with malignant, metastatic periureteral obstruction. Both patients had previously been managed with a chronic percutaneous nephrostomy that was both painful and inconvenient. The nephrovesical stent was inserted utilizing percutaneous access to both the kidney and bladder followed by creation of a subcutaneous tunnel between the two sites. RESULTS: The nephrovesical stents are patent at 6 and 9 weeks postoperatively and both patients have had their nephrostomy tubes removed. Both patients have noted a marked improvement in their overall comfort and quality of life since the stent has been in place. CONCLUSIONS: Subcutaneous urinary diversion with a nephrovesical stent provides effective urinary drainage and may improve the quality of life of patients with malignant metastatic ureteral obstruction. Further long-term studies are needed.

Adult↗
PubMed1995

Dialysis access grafts: anatomic location of venous stenosis and results of angioplasty.

PURPOSE: To determine the distribution of stenoses and results of angioplasty in patients with similar forearm dialysis grafts made of polytetrafluoroethylene (PTFE). MATERIALS AND METHODS: Diagnostic radiographs of the fistula obtained in 215 patients were reviewed; 90 patients had similar, unrevised forearm PTFE loop dialysis grafts. The location, morphology, and results of angioplasty were reviewed for each measurable stenosis. Surgical, radiologic, and dialysis records were reviewed to document the subsequent patency rate of each patient's dialysis access. RESULTS: On the initial diagnostic fistulogram, 93 stenoses were identified. The anatomic distribution included 47% at the venous anastomosis and 11% within 1 cm of the anastomosis. Life table analysis revealed a 6-month patency rate of 63% and a 1-year patency rate of 41% for the first angioplasty in a given graft, and a 6-month patency rate of 44% and a 1-year patency rate of 22% [corrected] for the second angioplasty. CONCLUSION: Performance of serial venous angioplasty procedures may help prolong the life of a graft, but the patency rates diminish with subsequent interventions.

Aged↗
PubMed1995

High-output congestive heart failure following transjugular intrahepatic portal-systemic shunting.

A hyperdynamic circulatory state with elevated cardiac output, decreased peripheral vascular resistance, and sodium retention occurs in patients with portal cirrhosis. Surgical portal-systemic shunts and transjugular intrahepatic portal-systemic shunts (TIPS) have been shown to worsen the high-output state in these patients. However, clinical evidence of high-output congestive heart failure has been reported only rarely to complicate cirrhosis. We describe a patient who developed high-output congestive heart failure with markedly elevated filling pressures after TIPS and had complete resolution of heart failure after liver transplantation.

Cardiac Output, High↗
PubMed1994

Evaluating peer reviews. Pilot testing of a grading instrument.

OBJECTIVE: To measure the reliability and preliminary validity of a grading instrument for editors to evaluate the quality of peer reviews. DESIGN: The consecutive sample design included 53 reviews of 23 manuscripts. Reviews were systematically assigned to interrater reliability (n = 41; power greater than 0.90 to detect a difference of greater than one point) and preliminary criterion-related validity (n = 12) subsamples. Content validity was closely examined. SETTING: Nonclinical. PARTICIPANTS: Three graders evaluated reliability. One individual examined content validity and two editors tested preliminary criterion-related validity. INTERVENTION (INSTRUMENT)--Attributes reflecting two basic dimensions, review content and format, were identified and scored (values are possible points/percent contribution): timeliness, 3/21%; grade sheet, 1/7%; etiquette, 1/7%; sectional narratives, 3/21%; citations, 2/14%; narrative summary, 2/14%; and insights, 2/14%. A scoring guide was provided. MAIN OUTCOME MEASURES: Statistical analyses used to test the interrater reliability of the total score included the intraclass correlation coefficient and analysis of variance with the expectation to uphold the null hypothesis. Kendall's coefficient of concordance was used to test preliminary criterion-related validity. RESULTS: The intraclass correlation coefficient was .84 (P < .001) and a lack of difference between mean scores was demonstrated by analysis of variance (P = .46). Content validity was confirmed and preliminary criterion-related validity was indicated (Kendall's coefficient of concordance = .94, P = .038). CONCLUSIONS: The instrument is reliable. Content validation has been completed, and further criterion-related validation is warranted.

Evaluation Studies as Topic↗
PubMed1994

Peripheral vascular disease: evaluation with stepping DSA and conventional screen-film angiography.

PURPOSE: To prospectively evaluate stepping digital subtraction angiography (S-DSA), which enables peripheral digital subtraction angiography (DSA) of both lower extremities after one injection of contrast material, in comparison with conventional screen-film angiography (SFA) for evaluation of lower-extremity vascular disease. MATERIALS AND METHODS: Fifty consecutive patients were prospectively examined. Each study was performed without knowledge of the findings in the other. Additional stationary DSA images were obtained whenever necessary. All studies were individually evaluated for diagnostic adequacy and then side by side for vascular opacification, timing of contrast enhancement, ease of reading, and overall superiority. RESULTS: The diagnostic adequacy of S-DSA was not statistically different from that of SFA (P > .30). SFA was subjectively considered superior in opacification (P < .003), ease of reading (P < .003), and subjective overall superiority (P < .005). S-DSA was superior in timing of contrast enhancement (P < .001). CONCLUSION: The advantages of S-DSA can be achieved while the diagnostic adequacy of SFA is maintained. However, SFA was considered superior in three of four subjective characteristics.

Aged↗
PubMed1994

Bloodstream infections after interventional procedures in the biliary tract.

PURPOSE: To assess the adequacy of prophylaxis for interventional radiologic biliary procedures and the etiologic organisms of subsequent bloodstream infections. MATERIALS AND METHODS: Data from 148 patients who underwent 480 interventional radiologic biliary procedures were evaluated for evidence of bloodstream infection. Data analyzed included type of procedure performed, whether an antibiotic was used, and evidence of infectious complications occurring during and within 72 hours after the procedure. All culture data obtained before and after the procedure were recorded. RESULTS: Seven cases of new bloodstream infection were identified, five of which were caused by Enterococcus species. No substantial risk factors for bloodstream infection were identified, although it occurred only in patients who had recently undergone biliary surgery or underwent manipulations other than simple cholangiography. Microbial colonization of the bile was associated with older age. Evidence of possible or proved infection after the first interventional procedure was more common in patients with positive bile cultures. CONCLUSION: Although the importance of enterococcal bacteremia is uncertain, current recommendations for cephalosporin prophylaxis for interventional radiologic biliary procedures should be reevaluated.

Bacteremia↗
PubMed1994

Angiographic evaluation and therapy of ureteroarterial fistulas.

OBJECTIVE: Fistulas between the iliac artery and the ureter are extremely uncommon, life-threatening conditions usually seen in patients who have had pelvic irradiation or have indwelling ureteral stents. We describe our experience in the angiographic evaluation and therapy of these fistulas. MATERIALS AND METHODS: We retrospectively reviewed medical records for diagnoses of ureteroarterial fistulas. Patients' records were evaluated for potentially associated etiologic factors, clinical features and course, radiographic evaluation and findings, and therapy. RESULTS: Our review showed that four patients treated at our institution (all since 1990) had ureteroarterial fistulas. All four patients had indwelling ureteral stents and had had irradiation for pelvic cancer. Three had spontaneous brisk hemorrhage in the urinary tract. The fourth had hemorrhage after balloon dilatation of a ureteral stricture. Initial diagnosis was based on findings on iliac arteriography in three patients and on findings on retrograde ureterography in one. Angiographic techniques required to visualize the fistulas included selective arterial catheterization, use of multiple projections, and provocative maneuvers. Treatment of the ureteroarterial fistulas involved surgery in one case, isolated embolotherapy in one case, and a combination of embolotherapy and surgery in two cases. CONCLUSION: Specific angiographic maneuvers are often required to identify ureteroarterial fistulas. Transcatheter embolotherapy (with or without surgical bypass) is an effective form of treatment for this rare abnormality.

Adult↗
PubMed1993

Diagnosis and management of biliary complications of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has become the operation of choice for symptomatic cholelithiasis. However, this operation may result in serious biliary complications. Our aims were to review our experience with biliary complications of laparoscopic cholecystectomy and to document the mechanisms of the injuries and the techniques of managing these complications. We treated 20 patients with biliary complications of laparoscopic cholecystectomy. Symptomatic collections of bile (bilomas) were present in five patients. One of these patients underwent operative ligation of an accessory bile duct in the gallbladder bed, whereas the others had percutaneous or endoscopic therapy. In the remaining 15 patients (of whom 13 were referred from other hospitals), injuries to the major bile ducts were managed by combined radiologic, endoscopic, and operative therapies. In 10 of these patients (67%), the mechanism of injury was the misidentification of the common bile duct as the cystic duct. In 3 of 15 patients, a noncircumferential injury to the lateral aspect of the common bile duct occurred. The Bismuth levels of the remaining bile duct injuries were type I in 3, type II in 4, type III in 3, and type IV in 2. Early outcome of therapy for these bile duct injuries has been favorable. One patient was lost to follow-up, and 2 died of nonbiliary causes, whereas 12 patients are alive and well with normal serum liver enzyme levels at 4 to 19 months postoperatively (mean: 14 months). The most common cause of major bile duct injury during laparoscopic cholecystectomy is mistaking the common bile duct for the cystic duct. Most bilomas can be managed successfully with noninvasive methods. Coordinated efforts by radiologists, endoscopists, and surgeons are necessary to optimize the management of patients with major bile duct injury, suggesting that patients with biliary complications of laparoscopic cholecystectomy should be referred to specialty centers for optimal care.

Abdominal Pain↗
PubMed1993

Intrahepatic portosystemic vascular stents: a bridge to hepatic transplantation.

Refractory esophageal variceal hemorrhage (EVH) remains a formidable problem in patients awaiting liver transplantations. Transjugular intrahepatic portosystemic shunts (TIPS) have provided an alternative approach for managing EVH that may obviate the need for portosystemic shunt surgery. Experience with TIPS placement and subsequent successful hepatic transplantation in patients without previous portosystemic shunt surgery has not been previously reported. Two patients are reported who underwent TIPS placement and subsequent successful hepatic transplantation without previous portosystemic shunt surgery. This experience indicates that (1) TIPS can provide effective control of EVH for at least several weeks, (2) TIPS placement decreases portal hypertension, thus facilitating technical performance of the transplant procedure and minimizing blood loss, (3) TIPS may undergo vascular incorporation, thus requiring that they be accurately positioned so that the lengths of suprahepatic inferior vena cava and portal vein are not compromised at the time of transplantation, (4) TIPS thrombosis can be effectively treated and prolonged patency may be observed, and (5) deterioration in hepatic function and exacerbation of hepatic encephalopathy were not observed after TIPS placement. In summary, TIPS provide an attractive, effective means for managing refractory EVH in patients awaiting liver transplantation.

Esophageal and Gastric Varices↗