Objective Aneurysm growth after endovascular aneurysm repair (EVAR) in patients with type II endoleak is associated with adverse outcomes. This study evaluated the long-term success of embolization ...of type II endoleaks in preventing aneurysm sac growth. Methods We retrospectively reviewed outcomes of patients who underwent infrarenal EVAR who were treated for a type II endoleak between 2000 and 2008. Computed tomography scans were evaluated for aneurysm sac growth or shrinkage from the time of treatment of the endoleak. The embolization material used, graft type, target vessel embolized, and comorbidities were evaluated for their association with sac growth or shrinkage. Results Ninety-five patients underwent 140 embolization procedures. The mean time from EVAR to embolization was 26.1 ± 22.2 months, and the average increase in size of the aneurysm sac from EVAR to treatment was 0.7 × 0.5 cm. Patients underwent an average of 1.6 ± 0.8 embolization procedures after EVAR. Thirteen patients underwent initial simultaneous embolization of two targets. Embolization was with glue (61%), coils (29%), glue and coils (7%), and Gelfoam (3%; Pfizer Inc, New York, NY). No abdominal aortic aneurysms (AAA) ruptured. Eight patients (8.4%) underwent graft explant and open repair; 19 (20%) required two or more embolization procedures. There was no difference in the target vessel treated or the treatment used in halting sac expansion (>5 mm). Coil embolization alone resulted in more second procedures. The 5-year cumulative survival was 65% (95% confidence interval CI, 52%-77%), freedom from explant was 89% (95% CI, 81%-97%), freedom from second embolization was 76% (95% CI, 66%-86%), and freedom from sac expansion >5 mm was 44% (95% CI 30%-50%). Univariable analysis identified continued tobacco use (hazard ratio HR, 2.30; 95% CI, 1.02-5.13; P = .04) was associated with continued sac expansion, and hyperlipidemia (HR, 9.64; 95% CI, 2.22-41.86) was associated with patients requiring a second embolization procedure. Conclusions Embolization of type II endoleaks is successful early in preventing aneurysm sac growth and rupture after EVAR. However, a significant number of patients require more than one procedure, and at 5 years, many patients who underwent embolization of a type II endoleak continued to experience sac growth. Patients with hyperlipidemia who undergo coil embolization are more likely to require a second embolization procedure, and patients who smoke have a higher likelihood of AAA sac expansion after embolization. Continued long-term surveillance is necessary in this cohort of patients.
Abstract Background Heterotopic ossification (HO) is a known complication following total hip arthroplasty. Radiation is an effective prophylaxis, but an optimal protocol has yet to be determined. We ...performed a randomized, double-blinded clinical trial in high-risk patients to determine the efficacy of 400 vs 700 cGy doses of radiation. Methods One hundred forty-seven patients undergoing total hip arthroplasty and at high risk for HO at an urban medical center were randomized to receive either a single 400 or 700 cGy dose of radiation postoperatively. High risk was defined as a diagnosis of diffuse idiopathic skeletal hyperostosis, hypertrophic osteoarthritis, ankylosing spondylitis, or history of previous HO. Radiation was administered on the first or second postoperative day. A single blinded reviewer graded radiographs taken immediately postoperatively and at a minimum of 6 months postoperatively using the Brooker classification. Progression was defined as an increase in Brooker classification. Operative data including surgical approach, implant fixation, revision surgery, and postoperative range of motion data were also collected. Results A significantly greater portion of patients who received the 400 cGy dose demonstrated progression of HO than patients who received the 700 cGy dose. There were no wound complications. No preoperative factors were associated with a higher rate of progression. Patients who progressed had less flexion on physical examination than patients who did not progress, but this was not clinically significant. Conclusion Seven hundred centigray was superior to 400 cGy in preventing HO formation following total hip arthroplasty in high-risk patients and may be the more effective treatment in this population. Further studies comparing 700 cGy to dosages between 400 and 700 cGy may help to clarify if a more optimal dose can be identified.
Skin and Digital–The 2024 Narrative du Crest, Dominique; Madhumita, Monisha; Enbiale, Wendemagegn ...
Mayo Clinic Proceedings. Digital health,
September 2024, 2024-09-00, 2024-09-01, Letnik:
2, Številka:
3
Journal Article
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The global burden of skin diseases affects over 3 billion individuals, posing important public health challenges worldwide, with profound impacts in both high-income and low-income and middle-income ...countries. These challenges are exacerbated by widespread disparities in access to dermatologic care and the prevalence of misinformation. This article, derived from the Skin and Digital Summit at the International Master Course on Aging Science critically evaluates how digital technologies such as artificial intelligence, teledermatology, and large language models can bridge these access gaps. It explores practical applications and case studies demonstrating the impact of these technologies in various settings, with a particular focus on adapting solutions to meet the diverse needs of low-income and middle-income countries. In addition, the narrative highlights the ongoing conversation within the dermatologic community about the role of digital advances in health care, emphasizing that this discussion is dynamic and the one that is continuously evolving. Dermatologists play an essential role in this transition, integrating digital tools into mainstream care to complement a patient-centered, culturally sensitive approach. The article advocates for a globally coordinated digital response that not only addresses current disparities in skin health care but also promotes equitable access to digital health resources, making dermatologic care more representative of all skin types and accessible worldwide.
Objective The objective of the study was to determine whether protease inhibitors increase glucose intolerance and insulin resistance in pregnancy. Study Design In this multicenter, prospective, ...observational study, 149 human immunodeficiency virus-1-infected pregnant women had fasting insulin, glucose, and C-peptide measured followed by a 1 hour, 50 g glucose test. Glucose intolerance was defined as a 1 hour glucose greater than 130 mg/dL. Glucose intolerance, homeostasis model assessment of insulin resistance and pancreatic β-cell function, and pregnancy outcomes were compared between those taking protease inhibitors and those not. Results Fifty-seven of 149 subjects (38%) had glucose intolerance. Body mass index, Hispanic ethnicity, and maternal age, but not protease inhibitors, were associated with glucose intolerance. There were no differences in insulin resistance, β-cell function, or pregnancy outcome associated with protease inhibitor use. Conclusions Protease inhibitors do not increase risk of glucose intolerance or insulin resistance among pregnant women.
: The role of peri-transplant radiation therapy (RT) in children with primary brain tumors is unclear. We characterized our institutional practice patterns and patient outcomes.
The cohort included ...all patients treated with high-dose chemotherapy and autologous stem cell transplant for primary brain tumors at our institution from 2011 to 2017. Rates of local control, progression-free survival, overall survival, and radiation-associated injury were assessed.
Of the 37 eligible patients, 29 (78%) received peri-transplant RT. Patients treated with RT were more likely to have metastatic (P = .0121) and incompletely resected (P = .056) disease. Of those treated with RT, 13 (45%) received craniospinal irradiation (CSI) and 16 (55%) received focal RT. The median CSI dose was 23.4 Gy (interquartile range IQR, 18-36 Gy; boost: median, 54 Gy IQR, 53.7-55.8 Gy) and focal RT dose was 50.4 Gy IQR, 50.4-54.5 Gy). Compared with the focal RT group, patients treated with CSI were older (P = .0499) and more likely to have metastatic disease (P = .0004). For the complete cohort, 2-year local control was 82% (95% confidence interval CI, 70%-96%), progression-free survival 63% (95% CI, 49%-81%), and overall survival 65% (95% CI, 51%-82%). These rates did not differ significantly between patients treated with and without peri-transplant RT. Two cases of fatal myelopathy were observed after spinal cord doses within the highest tertile (41.4 cobalt Gy equivalent and 36 Gy).
Peri-transplant RT was used for high-risk disease. Oncologic outcomes after RT were encouraging. However, 2 cases of grade 5 myelopathy were observed. If used cautiously, RT may contribute to durable remission in patients at high risk of relapse.
Aim Determine the clinical course and outcomes in subjects with anomalous aortic origin of coronary arteries (AAOCA), particularly after surgical repair. Methods and Results A single-center, ...retrospective review of patients with AAOCA with right or left interarterial/intramural (IA/IM) or intraconal (IC) course from 1996- 2014. Among 155 patients, median age at diagnosis was 8.5 (range 0.1-50) years, and 65% were male. The AAOCA course was IA/IM in 151 (97%) and IC in 4 (3%). Anomalous right coronary artery (ARCA) was present in 127 (82%), of whom 52 (42%) had repair. Anomalous left coronary artery (ALCA) was present in 28 (18%), of whom 20 (71%) had repair. In the surgical group, 70(97%) had IA/IM CAs; CA unroofing was performed in 62(86%). In univariable analysis, surgical management was associated with ALCA (28% vs. 10%, p =0.003), age > 10 years (median 11 vs. 6 years, p <0.001), symptoms (63% vs. 13%, p <0.001), and exercise restriction at time of diagnosis (47% vs. 13% p <0.001). In multivariable modeling, surgery was associated with chest pain/syncope ( p <0.001) and older age ( p =0.03). Major perioperative complications occurred in 4 cases (6%) and 1 patient had late aortic valve repair. In the surgical group, no patients died; in the observed group, 2 patients with ARCA (2.3%) died of severe non-cardiac comorbidities. Conclusion In our center, surgery for AAOCA was not associated with mortality and surgery was recommended in patients with ALCA with IA/IM course. Rare but serious surgical complications highlight the importance of long-term follow-up of AAOCA patients to develop evidence-based management guidelines.
Objective To test the hypothesis that children and adults with a history of Kawasaki disease (KD) are more likely to have abnormal lipoprotein particle profiles that could place them at increased ...risk for developing atherosclerosis later in life. Study design Fasting serum samples were obtained from 192 children and 63 adults with history of KD and 90 age-similar healthy controls. Lipoprotein particle concentrations and sizes were measured by nuclear magnetic resonance spectroscopy (LipoScience Inc, Raleigh, North Carolina), and serum was assayed for total cholesterol (TC), triglycerides, and high-density lipoprotein (HDL) cholesterol (HDL-C). Low-density lipoprotein (LDL) cholesterol was estimated using the Friedewald formula. Data were analyzed in a least-square means model, with adjustment for age and sex and with the use of Holm correction for multiple comparisons. Results Compared with respective control groups, both adult and pediatric subjects with KD had significantly lower mean very low-density lipoprotein-chylomicron particles, intermediate-density lipoproteins, triglycerides, and TC concentrations. Pediatric subjects with KD had significantly lower LDL particle and LDL cholesterol concentrations and lower mean TC/HDL-C ratio ( P < .001). In contrast, the adult subjects with KD had significantly lower HDL particle, small HDL particle, and HDL-C concentrations ( P < .001), but HDL-C was within normal range. Conclusions Nuclear magnetic resonance lipoprotein particle analysis suggests that pediatric and adult subjects with KD, regardless of their aneurysm status, are no more likely than age-similar, healthy controls to have lipid patterns associated with increased risk of atherosclerosis.
The morbidity and mortality associated with preeclampsia is staggering. The physiology of the Page kidney, a condition in which increased intrarenal pressure causes hypertension, appears to provide a ...unifying framework to explain the complex pathophysiology. Page kidney hypertension is renin-mediated acutely and ischemia-mediated chronically. Renal venous outflow obstruction also causes a Page kidney phenomenon, providing a hypothesis for the increased vulnerability of a subset of women who have what we are hypothesizing is a "renal compartment syndrome" due to inadequate ipsilateral collateral renal venous circulation consistent with well-known variation in normal venous anatomy. Dynamic changes in renal venous anatomy and physiology in pregnancy appear to correlate with disease onset, severity, and recurrence. Since maternal recumbent position is well known to affect renal perfusion and since chronic outflow obstruction makes women vulnerable to the ischemic/inflammatory sequelae, heightened awareness of renal compartment syndrome physiology is critical. The anatomic and physiologic insights provide immediate strategies to predict and prevent preeclampsia with straightforward, low-cost interventions that make renewed global advocacy for pregnant women a realistic goal.
Abstract Background context Plasma-mediated radiofrequency-based ablation (coblation) is an electrosurgical technique currently used for tissue removal in a wide range of surgical applications, ...including lumbar microdiscectomy. In vitro and in vivo studies have shown the technique to alter the expression of inflammatory cytokines in the disc, increasing the levels of interleukin-8 (IL-8), which may promote maturation and remodeling of the disc matrix. Purpose To better understand the effect of coblation treatment, this study characterizes the temporal and spatial pattern of healing after stab injury to the rabbit intervertebral disc, with and without plasma-mediated radiofrequency treatment. Patient sample A total of 23 New Zealand white rabbits. Study design Annular and nuclear stab injuries. Outcome measures Sandwich enzyme-linked immunosorbent assay evaluated the concentrations of cytokines tumor necrosis factor-α, IL-1β, and IL-8. Histopathologic evaluations were performed on whole discs and end plates. Tissue sections were stained with Safranin-O to evaluate nucleus pulposus and annulus fibrosus proteoglycan content and with Alcian blue for extracellular proteoglycan content. Intradiscal leakage pressure was evaluated by injecting methylene blue dye into the nucleus. Methods Animals underwent annular and nuclear stab injuries on three consecutive lumbar discs (L2–L3 to L4–L5). The three levels were randomly assigned into one of the three groups for treatment with a plasma-mediated radiofrequency ablation device (TOPAZ; ArthroCare Corp., Austin, TX, USA): active treatment of the nucleus only (SN); active treatment of both nucleus and annulus (SNA); sham treatment. Unstabbed/untreated discs from L5–L6 (n=5) served as normal controls. Animals were euthanized at 4, 8, and 28 days postsurgery. Results Tumor necrosis factor-α was detected in sham discs at 4 and 8 days, but not in coblation groups (SN or SNA); IL-1β was below detection in all three treatment groups. Interleukin-8 levels increased in all treatment groups at 4 and 8 days compared with normal control, peaking at 4th day for sham and SN groups and 8th day (p>.3) for the SNA group (a 2.5-fold increase). Pressure measurements revealed higher leakage in the SN group, but no statistically significant differences. Histopathology showed higher proteoglycan production by 28 days in the SNA and SN groups compared with sham. All three treatment groups showed ruptured annular fibers from the stab injury, but maintained the overall architecture. Remnants of notochordal tissue within the nucleus were evident in all treatment groups at 4 and 8 days, but were only found in sham group by 28 days. At this time, unlike the normal or sham controls, the nucleus of SN and SNA discs had fibrocartilaginous tissue with chondrocyte-like cells. Significant differences in the disc architecture grade were only noted when comparing normal controls with other groups by 28 days (p<.001). Conclusions Plasma-mediated radiofrequency ablation appears to have an anabolic effect on disc cells, stimulating proteoglycan and IL-8 production and maintaining annulus architecture. Coblation treatment appears to reduce cellular response to proinflammatory stimuli and restore overall disc architecture that may prove beneficial in a number of degenerative disc paradigms. Further studies are encouraged to investigate the therapeutic effect of the technique.
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