DrSclafani answers some questions

[Cece]

i am recovering nicely, my nail beds are slightly pink instead of white

We often tell your patients that they are in excellent hands.
Now we will say, "You're in excellent hands, with slightly pink nail beds."

Keep up the good work with recovering.

[drsclafani]

I guess I should have made that clear; I can drive fine now. I'm not expecting a miracle, just hoping to be in no worse shape when I leave than when I came in. The plan is to drive home from Chicago the day after the procedure. I guess that will work.

BTW You would be at the top of my list for IRs, but I refuse to fly anymore and New York is just too long a drive from Detroit.

thanks. Must be the roads. Ironically, a growing percentage of my patients are now coming from Europe, Asia and Australia/New Zealand.

[Robnl]

Yes, it is possible to measure pressures either directly or via a number of surrogates, like varioius MRI, CT ultrasound imaging techniques. I am thinking that you are suggesting is a flowmeter that is real time and can be used during the intervention. Such devices do exist. There is one that combines IVUS imaging and flow and pressure measurements. I havent used it yet, nor explored its economics.

I dont think that the focus has really changed. Dilating obstructions is always about improving flow. Currently, i think lots of talk is lots of talk only. I dont see any good measures of flow being discussed. Looking at the images and the flow appearance are not particularly accurate and without focusing on detecting and correcting obstructions there will be no change in flow.

your proposal has great merit and i would not be surprised when techniques change to measure this.

I was thinking about patients that do not improve after treatment; maybe the IR resolved stenosis on the left, but did not see the stenosis at the right (just an example), maybe the flow is not improved...by measuring this could be determined.

ah, iike you said it; if the technique-guy has some spare moments

[HappyPoet]

DrS, is there a certain percentage of restenosis that is optimal for a second procedure? >50%, >75%, >90%, or some other percentage?

Well, i dont have any real knowledge about what constitutes a significant stenosis in a jugular vein. I think many of us, myself included, think that the arbitrary 50% stenosis is an artificial, and probably erroneous threshhold. I think venous pressure gradients as low as 3 mm may be significant and it could take less than 50% stenosis to cause this.

I think that the indication for a second procedure has nothing to do with %ages. it has to do with return of symptoms, new symptoms, and other signs and symptoms that we havent yet recognized. I have done second procedure after only two days based upon clinical symptom changes.

Thank you, DrS. Restating my question in terms of return of symptoms: Is there an optimal point on the self-rated scale of 1-10 (where 10 = full return of symptoms) when a patient should seek a second procedure? Of course, going too early is more preferable than going too late!

[drsclafani]

DrS, is there a certain percentage of restenosis that is optimal for a second procedure? >50%, >75%, >90%, or some other percentage?

Well, i dont have any real knowledge about what constitutes a significant stenosis in a jugular vein. I think many of us, myself included, think that the arbitrary 50% stenosis is an artificial, and probably erroneous threshhold. I think venous pressure gradients as low as 3 mm may be significant and it could take less than 50% stenosis to cause this.

I think that the indication for a second procedure has nothing to do with %ages. it has to do with return of symptoms, new symptoms, and other signs and symptoms that we havent yet recognized. I have done second procedure after only two days based upon clinical symptom changes.

Thank you, DrS. Restating my question in terms of return of symptoms: Is there an optimal point on the self-rated scale of 1-10 (where 10 = full return of symptoms) when a patient should seek a second procedure? Of course, going too early is more preferable than going too late!

That is going to depend upon which symptoms return, how severe those symptoms are, how important those functions are. This is not yet been stablished that it makes a difference early or late.

It also depends upon the results of noninvasive imaging. In some instances when postprocedure doppler findings are positive, patient is doing quite well. I will wait. Othertimes patient has some symptoms, not overwhelming with a normal doppler.

Finally it has to do with economics. sometimes patients need to accumulate the funds to move forward with another venogram and must wait it out or actually be unable to continue care.

. That is why I have reduced the rate for a seond procedure by almost half. It really sucks to treat a patient and then not be able to continue care because patient does not have funds

[Cece]

Finally it has to do with economics. sometimes patients need to accumulate the funds to move forward with another venogram and must wait it out or actually be unable to continue care.

With an illness this terrible, and with stenoses that can be imaged and seen, I would want to see patients afforded the same care that anyone else with a central venous stenosis would receive, without having to self-pay. It's a terrible situation, for now.

As an insured patient, there is the opposite pressure, to choose to have a repeat procedure sooner rather than later in case insurance is going to pull out the rug from under and stop covering the procedure.

On a separate note: Is plethysmography something you would consider using clinically? Dr. Zamboni suggested at ISET that plethysmography might be of use for post-procedure follow-up monitoring. Dr. Simka is doing a study comparing plethysmography, MRI, and doppler. If that study showed that plethysmography was equal or better than doppler, would you have access to a plethysmography machine? Are they expensive? I do not think there is much training needed. It might be better than doppler at quantifying changes in outflow from before, immediately after, and later follow-ups.

[drsclafani]

On a separate note: Is plethysmography something you would consider using clinically? Dr. Zamboni suggested at ISET that plethysmography might be of use for post-procedure follow-up monitoring. Dr. Simka is doing a study comparing plethysmography, MRI, and doppler. If that study showed that plethysmography was equal or better than doppler, would you have access to a plethysmography machine? Are they expensive? I do not think there is much training needed. It might be better than doppler at quantifying changes in outflow from before, immediately after, and later follow-ups.

Of course, assuming it was validated, that i would opt for plethysmography, even though it is more difficult to spell than doppler.

I discuss with Dr Zamboni what great value this might have DURING a procedure as a safe, simple and inexpensive method of assessing improvement. Of course, we now have to validate it...But what is the Gold STandard by which it is going to be assessed. for specificity, sensitivey and positive and negative predictive value?
S

[David1949]

"plethysmography"???

Well if nothing else MS has certainly caused me to expand my vocabulary.

[tiltawhirl]

"plethysmography"???

Well if nothing else MS has certainly caused me to expand my vocabulary.

You think it's tough now, wait until mid beer study, sir. ;)

tilt

[Cece]

During the procedure! Meaning it might contribute to the decision of whether or not to accept an endpoint.

But what is the Gold STandard by which it is going to be assessed. for specificity, sensitivey and positive and negative predictive value?

Now there's a vocab test....
I'd have to go back and reread to remember the difference between specificity and sensitivity (and I will be going back to reread that). But what is the difference between something that has positive predictive value and something that has negative predictive value? It predicts the positive or it predicts the negative.

In statistics and diagnostic testing, the positive predictive value, or precision rate is the proportion of subjects with positive test results who are correctly diagnosed.

http://en.wikipedia.org/wiki/Positive_predictive_value

[Negative predictive power] is defined as the proportion of subjects with a negative test result who are correctly diagnosed.

http://en.wikipedia.org/wiki/Negative_predictive_value

I will just learn this chart. Statistics!


(Tiltawhirl has the right name for a discussion of plethysmography: it is essentially a blood pressure cuff for the neck, that measures change in neck volume as the patient is abruptly tilted from a flat position to an upright position. Dr. Zamboni started talking about it a year and a half ago and that is a long time to wait for more on the subject, considering its potential. http://www.thisisms.com/forum/chronic-c ... 14742.html )

[Cece]

"plethysmography"???

Well if nothing else MS has certainly caused me to expand my vocabulary.

You think it's tough now, wait until mid beer study, sir. ;)

tilt

We were waiting??? : oops : :hiccup:

[tiltawhirl]

(Tiltawhirl has the right name for a discussion of plethysmography: it is essentially a blood pressure cuff for the neck, that measures change in neck volume as the patient is abruptly tilted from a flat position to an upright position. Dr. Zamboni started talking about it a year and a half ago and that is a long time to wait for more on the subject, considering its potential. http://www.thisisms.com/forum/chronic-c ... 14742.html )

Actually it was David, whom I was quoting, so he gets the vocabulary star this time.

tilt

[tiltawhirl]

"plethysmography"???

Well if nothing else MS has certainly caused me to expand my vocabulary.

You think it's tough now, wait until mid beer study, sir. ;)

tilt

We were waiting??? : oops : :hiccup:

tilt

[Cece]

no, no, I meant your name was appropriate for a discussion of a method that involved abruptly tilting a patient...plethsymography is essentially a tiltawhirl!

[tiltawhirl]

no, no, I meant your name was appropriate for a discussion of a method that involved abruptly tilting a patient...plethsymography is essentially a tiltawhirl!

ah.

tilt