Disseminating health care innovation.
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Diffusion of Innovation↗
Biomedical subjects
James Sayre
Publications and source records attributed to James Sayre.
Influence of large peritumoral vessels on outcome of radiofrequency ablation of liver tumors.
PURPOSE: The effect of large vessels (>/=3 mm) contiguous to hepatic tumors was evaluated with respect to clinical tumor recurrence rates after radiofrequency (RF) ablation. MATERIALS AND METHODS: The first 105 malignant liver tumors treated by RF ablation therapy at our institution with pathologic analysis or a minimum of 6 months of clinical follow-up were reviewed. The original pretreatment imaging studies were reviewed by a radiologist who was blinded to the cases, and, based on lesion contiguity to vessels of at least 3 mm, the lesions were categorized as perivascular or nonperivascular. Treatment outcomes with respect to local tumor recurrence between these two groups were then compared. Logistic regression analysis was performed to take into account other variables and to determine whether this categorization was an independent predictor of treatment outcome. RESULTS: There were 74 nonperivascular tumors and 31 perivascular tumors. Mean tumor size was 2.4 cm and mean follow-up was 11.3 months. Residual or locally recurrent tumors were documented in 20 of 105 cases (19%). In the nonperivascular group, five of 74 (7%) had either incompletely treated tumor (manifested within 6 months) or local recurrence beyond 6 months. In the perivascular group, 15 of 31 (48%) had incompletely treated or locally recurrent tumor (P <.001). Subanalysis of lesion size (61 tumors </=2.5 cm, 33 tumors 2.6-4 cm, and 11 tumors >4 cm), tumor type (40 hepatocellular carcinomas, 48 colorectal metastases, and 17 other metastases), access (53 intraoperative, 52 percutaneous), and RF device (45 Radiotherapeutics electrodes, 18 Rita electrodes, and 42 Radionics electrodes) showed similar results. Multivariate logistic regression analysis showed that presence or absence of a large peritumoral vessel is an independent, and the dominant, predictor of treatment outcome. CONCLUSION: The presence of vessels at least 3 mm in size contiguous to hepatic tumors is a strong independent predictor of incomplete tumor destruction by RF ablation. Modified ablation strategies should be considered to improve destruction of these tumors.
Adult↗
Recurrent pleomorphic adenoma of the parotid gland in pediatric and adult patients: value of multiple lesions as a diagnostic indicator.
OBJECTIVE: Recurrent pleomorphic adenoma of the parotid gland is a significant problem. Rates have been as high as 40% in some series of patients who have undergone surgery for the primary lesion. In the imaging literature, anecdotal case reports show multiple lesions in recurrent pleomorphic adenoma. Our aim was to analyze the imaging of a series of patients to determine the reliability of multiple lesions as a tool in diagnosing recurrent disease. MATERIALS AND METHODS: Medical records of the patients with recurrent pleomorphic adenoma of the parotid gland referred to our institution were retrospectively reviewed. Before the second surgery, MR imaging had been performed in 15 patients. We retrospectively reevaluated and scored the MR imaging studies with particular attention paid to the location and number of the lesions and the remaining parotid gland tissue. RESULTS: On the basis of imaging findings, eight patients underwent enucleation, superficial parotidectomy had been performed in four patients, and three patients underwent total parotidectomy. For our group, the lesions were multiple in 73.3% of patients. CONCLUSION: To our knowledge, we present the first large series of imaging studies in recurrent pleomorphic adenoma of the parotid gland. Our findings show that recurrent pleomorphic adenomas are most likely to be multiple. Such multiplicity of lesions is a reliable diagnostic indicator of recurrent disease.
Adenoma, Pleomorphic↗
Cardiomyocytes undergo apoptosis in human immunodeficiency virus cardiomyopathy through mitochondrion- and death receptor-controlled pathways.
We investigated 18 AIDS hearts (5 with and 13 without cardiomyopathy) by using immunocytochemistry and computerized image analysis regarding the roles of HIV-1 proteins and tumor necrosis factor ligands in HIV cardiomyopathy (HIVCM). HIVCM and cardiomyocyte apoptosis were significantly related to each other and to the expression by inflammatory cells of gp120 and tumor necrosis factor-alpha. In HIVCM heart, active caspase 9, a component of the mitochondrion-controlled apoptotic pathway, and the elements of the death receptor-mediated pathway, tumor necrosis factor-alpha and Fas ligand, were expressed strongly on macrophages and weakly on cardiomyocytes. HIVCM showed significantly greater macrophage infiltration and cardiomyocyte apoptosis rate compared with non-HIVCM. HIV-1 entered cultured neonatal rat ventricular myocytes by macropinocytosis but did not replicate. HIV-1- or gp120-induced apoptosis of rat myocytes through a mitochondrion-controlled pathway, which was inhibited by heparin, AOP-RANTES, or pertussis toxin, suggesting that cardiomyocyte apoptosis is induced by signaling through chemokine receptors. In conclusion, in patients with HIVCM, cardiomyocytes die through both mitochondrion- and death receptor-controlled apoptotic pathways.
Acquired Immunodeficiency Syndrome↗
Minimizing diaphragmatic injury during radio-frequency ablation: efficacy of subphrenic peritoneal saline injection in a porcine model.
PURPOSE: To investigate if a targeted subphrenic peritoneal infusion of normal saline to separate liver from diaphragm before radio-frequency (RF) ablation could minimize or eliminate diaphragmatic injury. MATERIALS AND METHODS: With a 2-cm-diameter, eight-prong RF needle electrode, 37 hepatic dome RF lesions were created in 10 pigs. Seventeen lesions were created before (non-saline group) and 20 lesions after (post-saline group) intraperitoneal infusion of approximately 500 mL of normal saline. Ten non-saline lesions were created deep (centered 1-2 cm from the liver surface) and seven superficially (centered within 1 cm of the capsule). All 20 post-saline lesions were created superficially. Helical enhanced computed tomography was performed 24-48 hours after ablation. The pigs were killed immediately, and the diaphragm was visually inspected and sectioned. Diaphragmatic injury was graded as 0, no injury; 1, injury up to one-third thickness; 2, injury to two-thirds thickness; 3, full-thickness injury. Representative grade 3 injuries and all partial injuries underwent gross and histologic analysis. RESULTS: All 10 deep non-saline RF lesions caused grade 0 injury. All seven superficial non-saline lesions caused grade 3 injury. Of the 20 superficial post-saline lesions, 13 (65%) caused grade 0 injury; four (20%), grade 1; and three (15%), grade 3. The post-saline group caused significantly less diaphragmatic injury (P <.05). CONCLUSION: Intraperitoneal saline infusion may reduce the frequency and severity of diaphragmatic injury when adjacent liver is treated with RF ablation.
Animals↗
Predictors of hemorrhagic transformation in patients receiving intra-arterial thrombolysis.
BACKGROUND AND PURPOSE: Hemorrhagic transformation (HT) is a major complication of intra-arterial (IA) thrombolytic therapy. Identifying significant predictors of hemorrhage after thrombolysis would be useful in guiding patient selection for IA treatment. METHODS: Data were collected retrospectively on consecutive patients with acute focal cerebral ischemia within the anterior or posterior circulation who were treated with combined intravenous (IV)-IA or pure IA thrombolysis over an 8-year period at the UCLA Medical Center. RESULTS: Eighty-nine patients were treated. Median baseline National Institutes of Health Stroke Scale (NIHSS) score was 16, and mean age was 69 years. Twenty-six patients received IA tissue plasminogen activator (tPA) only, 22 received IV-IA tPA, and 41 received IA urokinase only. Asymptomatic HT occurred in 29 patients (33%), minor symptomatic HT (1- to 3-point worsening in NIHSS score) occurred in 10 patients (11%), and major symptomatic HT (> or = 4-point worsening in NIHSS score) occurred in 6 patients (7%). The rate of any HT was similar in patients treated with pure IA thrombolysis (39%) versus combined IV-IA thrombolysis (41%). In pure IA cases, the rate of any HT was 50% with tPA versus 32% with urokinase (P=0.2). Eighty-six percent of the patients with HT versus 39% of the patients without HT were dead or disabled (modified Rankin score >2) at day 7 (P<0.0001). On multivariate analysis, independent predictors of any HT were higher NIHSS score, longer time to recanalization, lower platelet count, and higher glucose level. A model using these variables correctly predicted HT with positive predictive value 70% and overall accuracy 78%. CONCLUSIONS: In this large series of IA thrombolysis, rates of HT were similar to those demonstrated in prior series and clinical trials. Higher NIHSS score, longer time to recanalization, lower platelet count, and higher glucose level were independent predictors of any HT.
Academic Medical Centers↗
Effect of vessel size on creation of hepatic radiofrequency lesions in pigs: assessment of the "heat sink" effect.
OBJECTIVE: The effect of vessels and their size on radiofrequency lesion creation in the liver was evaluated with respect to potential for vascular injury and perfusion-mediated "heat sink" effect. SUBJECTS AND METHODS: Radiofrequency lesions targeted to tissue adjacent to a variety of vessels were created in vivo in the liver of 10 Yorkshire pigs. Postablation contrast-enhanced CT and then histopathologic analysis of the vessels and lesions were performed after sacrifice of the pigs. Degree of vascular injury and viability of perivascular hepatocytes were recorded and tabulated according to vessel size for both CT and histologic data sets. RESULTS: At CT, 42 (95%) of 44 veins greater than 3 mm remained patent, and four (20%) of 20 veins less than 3 mm were occluded. Heat sink effect, indicated by invagination of enhancing tissue between vessel and radiofrequency lesion, was observed in 32 (73%) of 44 veins greater than 3 mm and in zero of 20 veins less than 3 mm. On histopathology, 111 (100%) of 111 vessels less than 3 mm showed at least partial vessel wall injury, characterized by endothelial cell necrosis and luminal thrombus. In 24 vessels greater than 3 mm, the extent of vessel wall injury decreased with increasing vessel diameter. Viable perivascular tissue indicative of heat sink effect was identified in 12 of 24 veins greater than 3 mm, increasing to seven of seven veins greater than 5 mm. None of 96 vessels less than 2 mm and three of 111 vessels less than 3 mm showed any heat sink effect. CONCLUSION: There appears to be a narrow transition zone for hepatic vessels at 2-4 mm, beyond which the heat sink effect was seen consistently and substantial vascular injury was rare.
Animals↗
Accuracy of nonfocused helical CT for the diagnosis of acute appendicitis: a 5-year review.
OBJECTIVE: The clinical usefulness of routine, nonfocused helical CT was evaluated in diagnosing acute appendicitis or providing an alternative diagnosis in patients presenting to the emergency department with acute lower abdominal pain. MATERIALS AND METHODS: We reviewed CT reports and clinical records of 650 consecutive adult patients who presented between January 1996 and December 2000 with right lower quadrant pain or lower abdominal pain and clinical findings suggestive of appendicitis. Helical CT was performed with oral contrast material in 610 cases (93.8%) and IV contrast in 572 cases (88.0%). Both vascular and enteric contrast media were administered in 544 cases (83.7%). Rectal contrast material was administered in 52 cases (8.0%). The abdomen was helically scanned from the dome of the diaphragm to the iliac crests with a collimation of 7 mm, from the iliac crests to the acetabular roof at a 5-mm collimation, from the acetabular roof to the symphysis pubis with a collimation of 5-10 mm. The surgical or clinical record was used for follow-up. RESULTS: Of the 650 patients, 552 (84.9%) had adequate clinical follow-up. There were 137 true-positive, eight false-positive, five false-negative, and 402 true-negative cases. The sensitivity, specificity, and accuracy of nonfocused helical CT were 96.5%, 98.0%, 97.6%, respectively. The positive and negative predictive values were 94.5% and 98.8%, respectively. In patients without acute appendicitis, CT suggested an alternative diagnosis, which clinically explained the patient's acute abdominal pain in 266 patients (66.2%). CONCLUSION: Nonfocused helical CT was highly accurate in diagnosing acute appendicitis or suggesting an alternative diagnosis in patients with acute lower abdominal pain or right lower quadrant pain.
Acute Disease↗
Three-dimensional helical computerized tomography angiography in the diagnosis, characterization, and management of middle cerebral artery aneurysms: comparison with conventional angiography and intraoperative findings.
OBJECT: Middle cerebral artery (MCA) aneurysms can be difficult to detect and characterize. The authors describe the utility and impact of helical computerized tomography (CT) angiography for the evaluation of aneurysms in this location, and compare this modality with digital subtraction (DS) angiography and intraoperative findings. METHODS: Two hundred fifty-one patients with suspected cerebral aneurysms underwent CT angiography. Two-dimensional multiplanar reformatted images and three-dimensional CT angiograms were examined by two independent readers in a blinded fashion. Results were compared with findings on DS angiograms to determine the relative efficacy of these modalities in the detection and characterization of aneurysms. Questionnaires completed by neurosurgeons and endovascular therapists were used to determine the impact of CT angiograms on aneurysm management. Twenty-eight patients harboring 31 MCA aneurysms and 26 patients without aneurysms were identified using CT angiography. The sensitivity of CT angiography and DS angiography for MCA aneurysms was 97%; both techniques showed 100% specificity. In 76% of evaluations, the CT angiography studies provided information not available on DS angiography examinations. For the characterization of aneurysms, CT angiography was rated superior (72%) or equal (20%) to DS angiography in 92% of cases evaluated (p < 0.001). Computerized tomography angiography was evaluated as the only study needed for patient triage in 82% of cases (p < 0.001), and as the only study needed for treatment planning in 89% of surgically treated (p < 0.001) and in 63% of endovascularly treated cases (p < 0.001). The information acquired on CT angiograms changed the initial treatment plan in 24 (67%) of these 36 complex lesions (p < 0.01). The aneurysm appearance intraoperatively was identical or nearly identical to that seen on CT angiograms in 17 (89%) of 19 of the surgically treated cases. CONCLUSIONS: Computerized tomography angiography has unique advantages over DS angiography and is a viable alternative to the latter modality in the diagnosis, triage, and treatment planning in patients with MCA aneurysms.
Adult↗
Detection and characterization of very small cerebral aneurysms by using 2D and 3D helical CT angiography.
BACKGROUND AND PURPOSE: Many cases of subarachnoid hemorrhage are due to rupture of small cerebral aneurysms. Our purpose was to evaluate the usefulness of helical CT angiography (CTA) in the detection and characterization of very small (<5 mm) intracranial aneurysms. METHODS: One hundred eighty consecutive patients underwent CTA for suspected intracranial aneurysms. All aneurysms prospectively detected by CTA were confirmed by digital subtraction angiography (DSA) or at surgery. CT angiograms and digital subtraction angiograms were reviewed by two independent blinded radiologists who performed aneurysm detection, quantitation, and characterization using 2D multiplanar reformatted and 3D volume-rendering techniques. RESULTS: Fifty-one patients harboring 41 very small intracranial aneurysms were included in this series. Eighty-one percent (33 of 41 aneurysms) were </=4 mm in maximal diameter, and 37% (15 of 41 aneurysms) were </=3 mm in maximal diameter. Sensitivity of CTA for very small intracranial aneurysm detection ranged from 98% to 100% (95% confidence intervals, 0.871, 0.999, 0.914, and 1.0), compared with 95% for DSA. The specificity of CTA and DSA for very small intracranial aneurysms was 100% (26 of 26 aneurysms). Positive predictive value ranged from 98% to 100%. Negative predictive value ranged from 96% to 100%. Accuracy of CTA for detection of very small intracranial aneurysms was 99% and 100% (kappa = 0.969 - 1.0 +/- 0.1221). Forty-eight percent of aneurysms were detected in the presence of subarachnoid hemorrhage. CONCLUSION: The sensitivity of CTA for the detection of cerebral aneurysms </=5 mm is higher than that of DSA, with equal specificity and high interoperator reliability. High quality, noninvasive CTA aneurysm detection and characterization can be performed using routine clinical CT scanners and commercially available image processing workstations.
Adult↗
Imaging-Guided Core Needle Biopsy of the Breast: Study of Psychological Outcomes.
The objective of this study was to evaluate and document pain and psychological distress related to imaging-guided core needle biopsy (CNB) of the breast. This prospective study of 52 consecutive patients undergoing CNB of the breast assessed anxiety, pain, acute stress disorder, and activities of daily living both preprocedure and at 24 hours, 5 days, and 30 days postprocedure. Survey instruments included the State-Trait Anxiety Inventory (STAI), a visual analog pain scale, the SF-36 Physical Functioning Scale, and DSM IV criteria for acute stress disorder. Preprocedure the mean scores for self-reported levels of state and trait anxiety were 47.11 (SD = 13.53) and 37.71 (SD = 11.24), respectively. At 24 hours postprocedure, the mean score for self-reported state anxiety was 38.74 (SD = 17.77), a significant reduction from the preprocedure level reported by patients (p < 0.005). Further reductions in state anxiety levels were reported at 5 and 30 days postprocedure. The mean scores for state anxiety fell within the normal range at 30 days postprocedure (mean 32.75, SD = 10.97). However, at 5 days post-CNB, patients with confirmed malignancies reported significantly more anxiety than patients without malignancies (p = 0.002). This difference was not present at 30 days post-CNB (p = 0.17). Patients reported average pain scores of 2.0 (on a scale of 0-10) during the biopsy. This decreased to 1.3 at 24 hours, 0.3 at 5 days, and 0.2 at 30 days. Reported symptoms of acute stress related to the procedure significantly increased over the period between the 5-day interview and the 30-day interview. One (2%) patient reported avoidance of thoughts about CNB 5 days postprocedure and 5 (12%) patients reported this at 30 days postprocedure (p < 0.05). Patients undergoing CNB reported significant levels of state anxiety which were greatest at the time of biopsy. A significant decrease was observed at 24 hours postprocedure, despite the fact that biopsy results were not available to the patients. Self-reported levels of anxiety for the group, regardless of biopsy results, fell within the normal range by 30 days. Further research and interventions are recommended to address the management of anxiety for patients undergoing CNB.
Journal Article↗
MR imaging correlates of survival in patients with high-grade gliomas.
BACKGROUND AND PURPOSE: For patients with malignant gliomas, clinical data-including age, perioperative Karnofsky Performance Status (KPS), and tumor resection-and tumor imaging features-including necrosis and edema-have been found to correlate with survival. The purpose of this study was to assess the validity of these results and determine whether other imaging features are useful in predicting survival. METHODS: We analyzed the relationship between 15 imaging variables obtained from contrast-enhanced MR imaging scans and survival in patients with grade III (n = 43) and grade IV (n = 110) glioblastoma multiforme (GBM) gliomas. Image analysis was performed by 2 neuroradiologists who were blinded to clinical data. The Kaplan-Meier method was used to estimate survival probabilities. Univariable Cox models were used to assess the impact of imaging features on survival. A recursive partitioning analysis also was performed. RESULTS: As expected, age and KPS scores had significant prognostic value for both tumor grades. The extent of resection was not a statistically meaningful predictor of survival. For GBM, univariable analysis revealed the following imaging features to be significant, (hazard ratios in parentheses): noncontrast-enhancing tumor (nCET, 0.55), edema (1.62), satellites (1.74), and multifocality (4.34). For grade III tumors, the Cox hazard ratio for necrosis was 4.43 (P = .014) and correlated with a poor outcome and survival rates comparable to GBM patients. Lack of nCET, multifocality, and satellite lesions also were correlated with shortened survival. CONCLUSION: Of 15 tumor imaging features in GBM patients, only nCET, edema, and multifocality/satellites are statistically significant prognostic indicators. The survival advantage of nCET is a novel finding.
Adult↗