DXPLAIN--demonstration and discussion of a diagnostic clinical decision support system.
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Artificial Intelligence↗
Biomedical subjects
B H Forman
Publications and source records attributed to B H Forman.
Percutaneous gastrostomy with gastropexy: experience in 125 patients.
We report our experience with radiologically guided percutaneous tube gastrostomy in 125 patients by using a gastropexy technique in which the anterior gastric wall is nonsurgically sutured to the anterior abdominal wall with percutaneously placed T-fasteners before catheter insertion. Short-term follow-up of up to 2 weeks was available in all patients. In 63 patients, long-term follow-up (greater than 4 weeks; average, 3.5 months; maximum, 1 year) was available. Catheter placement was successful in 124 (99%) of 125 patients, including three patients with anatomic changes after Bilroth II hemigastrectomy and two patients with failed endoscopic attempts. There were no deaths related to the procedure, and no patients required surgical intervention for complications attributable to the gastrostomy procedure. The 30-day mortality rate was 11% (n = 7). These deaths were due to cardiorespiratory arrest and were not attributable to the gastrostomy procedure. Major complications occurred in 1.6% (n = 1) and minor complications in 9.5% (n = 6). These results indicate that percutaneous gastrostomy with gastropexy is a safe and effective technique for placement of catheters in the stomach.
Adult↗
New universal precaution aspiration tray.
A new tray has been designed for use during procedures involving needles and other sharp objects. The tray includes a foam adhesive pad, marked into 10 sections, into which the sharp objects can be placed point first. After the procedure, the objects can be safely withdrawn by their handles and then discarded. The tray has been used in more than 250 procedures.
Accident Prevention↗
Image-guided pleural biopsies: indications, technique, and results in 23 patients.
Twenty-six pleural biopsies were performed on 23 patients over a 3-year period. Twenty-three biopsies were performed guided with ultrasound; one, with computed tomography; and two, with fluoroscopy. Indications for an image-guided pleural biopsy were (a) pleural masses or thickening that were either not seen on chest radiographs or seen only on one view and (b) small or loculated pleural effusions of unknown cause with no mass seen. If only pleural fluid was present, reverse bevel needles were used for biopsy (n = 15). If a discrete pleural mass or thickening was seen with cross-sectional imaging, standard (16-20 gauge) biopsy needles were used (n = 11). In the 23 patients, biopsy results were true positive in ten (nine with malignancy, one with tuberculous pleurisy), true negative in ten (confirmed either at subsequent thoracotomy or clinical follow-up), and false negative in three. Complications were few, with a significant pneumothorax occurring in two patients (8.7%). Image-guided biopsy of small pleural lesions and small pleural effusions can be performed by the radiologist who understands the special needles and techniques involved.
Biopsy, Needle↗
Thoracic empyema: management with image-guided catheter drainage.
Forty-three patients with thoracic empyema were treated by means of image-guided catheter drainage. In 40 patients, image-guided catheter drainage was the primary treatment method; in three it was used after conventional, surgical chest tube placement failed. Drainage was performed with ultrasound guidance in 30 patients (69.8%), computed tomography in eight (18.6%), and fluoroscopy in five (11.6%). A combination of guidance modalities was used in six patients. Image-guided catheter drainage alone was successful in 31 of 43 patients (72.1%). In three patients (7%), empyemas were initially drained, but a thoracotomy was ultimately required because of a persistent pleural peel. In eight patients (18.6%), the procedure failed, predominantly due to tube clogging, persistent pneumothorax, or progressive development of a pleural peel. In one patient, drainage was successful but he died 10 days later of complications of renal failure. No major complications were encountered. Treatment of these patients requires a thorough understanding of the pathogenesis of pleural space infection, principles of empyema drainage, techniques of abscess drainage under image guidance, and the use of a pleural drainage system.
Adult↗
Differentiation of hepatic metastases from hepatic hemangiomas and cysts by using MR imaging.
T1-weighted and T2-weighted pulse sequences were employed for MR imaging of hepatic metastatic tumors (98 patients), hemangiomas (24 patients), and cysts (seven patients); a 0.6-T superconducting magnet was used. In a retrospective study, signal intensity and morphology were used to establish criteria for differentiating metastases from hemangiomas and cysts. The signal intensity of the lesion alone failed to be an etiologic discriminator because over 96% of all masses had a signal intensity less than that of liver on T1-weighted sequences, and at least 90% had a signal intensity greater than that of liver on T2-weighted sequences. Morphologic features depicted on T2-weighted images were more specific than those depicted on T1-weighted images in differential diagnosis. Amorphous, target, and halo signs and a change in morphology were present only in metastatic disease, with a frequency of 45%, 27%, 13%, and 12%, respectively. Two other morphologic patterns--doughnut and lightbulb signs--were found to have overlapping causes. Overall, at least one of the specific signs was observed in 92% of patients with metastatic disease. These data suggest that T2-weighted pulse sequences are essential for discriminating between hepatic metastases and hepatic hemangiomas and cysts. MR imaging is a promising technique for distinguishing these lesions.
Cysts↗
Severe acute pancreatitis after percutaneous biopsy of the pancreas.
A retrospective review of 184 pancreatic biopsies in 178 patients was performed to assess the prevalence of severe postbiopsy pancreatitis. The size, contour, and pathology of the lesions biopsied; the course of the needle (i.e., through bowel or other viscera); the size of the needle; the number of needle passes made; and the guidance technique used were analyzed. Severe pancreatitis developed in five cases (five patients) 5/184 or 3% of the biopsies), usually within 24-48 hr. Three of the five patients who developed pancreatitis had true-negative biopsies (normal pancreas) proved either at surgery (two) or at clinical follow-up (one). The diagnoses for the two remaining patients were adenocarcinomas. In four of the five patients, the diagnosis of severe pancreatitis was made by inspection at surgery. The fifth case was diagnosed by CT. Three patients who underwent surgery and one patient who had percutaneous drainage recovered from the pancreatitis. The fifth patient died despite surgical intervention. All five patients with pancreatitis had masses 3 cm or smaller as compared with the overall group, in which 71 (39%) of the 184 biopsies performed had masses smaller than 3 cm. Overall, 18% of the biopsies were true negative, compared with the 60% true-negative rate in the pancreatitis group. The bowel was transgressed in 21% of all 178 patients, including three of the five pancreatitis patients. We conclude that although the risk of pancreatitis is exceedingly small in percutaneous needle biopsies, it may occur, and at a higher rate than previously reported.
Acute Disease↗
Poorly differentiated ("insular") carcinoma of the thyroid gland: an aggressive subset of differentiated thyroid neoplasms.
Four patients with a histologically distinctive thyroid carcinoma--which recently has been referred to as poorly differentiated ("insular") carcinoma--are reported. This study confirms the previous conclusions that patients with this neoplasm often experience an aggressive clinical course, with focal recurrences and distant metastases common, which results in death in the majority of patients. Such aggressive behavior may occur even when the insular component accounts for only a small percentage of an otherwise well-differentiated carcinoma, as seen in one of our patients. After subtotal or total thyroidectomy, three of the four patients have experienced local recurrence (1) and metastases to lung (3), mediastinum (1), and bone (1). All three of these patients died within 2 years of the diagnosis of insular carcinoma. The remaining patient is alive without evidence of disease 1 year after total thyroidectomy. Histologically, this neoplasm is characterized by well-defined nests (insulae) that are composed of relatively small, uniform cells and sometimes associated with small, thyroglobulin-containing follicles. Tumor necrosis is often present. Insular carcinoma may comprise the entire neoplasm (2 patients) or be associated with well-differentiated follicular (1 patient) or papillary (1 patient) carcinoma. The rapid and often fatal course associated with insular carcinoma warrants aggressive treatment at the time of initial diagnosis, including total thyroidectomy and node dissection (if involved), as well as possible iodine-131, external beam irradiation and chemotherapy.
Adult↗
ACTH-secreting pheochromocytoma.
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Adrenal Gland Neoplasms↗
The diagnosis and management of pituitary tumors.
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Humans↗
Steroid profile in a case of adrenal carcinoma with severe hypertension.
The case of a young boy who had Cushing's syndrome and severe hypertension in association with metastatic adrenal carcinoma is described. Marked elevation of the mineralocorticoid 11-deoxycorticosterone was demonstrated in the plasma. 11-Deoxycortisol, 17alpha-hydroxyprogesterone, and urinary tetrahydro-11-deoxycortisol and pregnanetriol were also elevated. Aldosterone excretion was low. The data implicate defective 11beta hydroxylation and suggest that excessive 11-deoxycorticosterone production may have been responsible for the hypertension.
17-Hydroxycorticosteroids↗
Effects of an angiotensin inhibitor on adrenocortical response to angiotensin II, ACTH, and K.
A competitive inhibitor of angiotensin II has been studied in nephrectomized dogs treated with dexamethasone to suppress ACTH secretion. The inhibitor, [1-sarcosine, 8-alanine]angiotensin II (P113), has been shown by previous investigators to inhibit the pressor action of angiotensin II but not the pressor effect of other pressor agents. The present experiments demonstrate that P113 inhibits the stimulation of aldosterone secretion by angiotensin II but not by ACTH or potassium infusions. Therefore, P113 appears to be a specific inhibitor of angiotensin's action on both vascular and adrenocortical tissue. In this dog preparation, P113 has a mild nondose-related agonistic action on the blood pressure and a nonsignificant action on aldosterone secretion, although in some dogs P113 appears to have a definite agonist effect.
Adrenal Cortex↗
Ectopic ACTH syndrome due to pheochromocytoma: case report and review of the literature.
A 51-year-old female was diagnosed preoperatively to have a pheochromocytoma producing ACTH. This diagnosis was based upon her paroxysmal hypertension, hyperpigmentation, and hypokalemia. Elevated levels of serum and urine corticosteroids, plasma ACTH, urinary VMA, and catecholamines fell after a right adrenal pheochromocytoma was removed. Subsequently this tumor was found to have a high content of ACTH. Review of the literature indicates a mortality rate of 57% for this syndrome. Proper preoperative recognition and management can result in total cure.
Adrenal Gland Neoplasms↗