Changes in peripheral hemodynamics after percutaneous transluminal angioplasty

We measured ankle/arm pressure indexes and blood flow rates before and after performing percutaneous transluminal angioplasty in 36 extremities. Flow rates through the leg were determined with a magnetic resonance blood flow scanner. All patients had claudication; one had gangrene, another had an ulcer, and two complained of rest pain. The median age was 65 years, and 72% were men. There were 25 dilations of the iliac artery, 12 of the superficial femoral artery, and eight of the popliteal arteries; nine patients had two arterial segments dilated. Nineteen legs had ankle/arm pressure indexes before percutaneous transluminal angioplasty of less than 0.80 (range 0.51 to 0.75); their flow rates averaged 40 +/- 20 (SD) ml/min. After percutaneous transluminal angioplasty flow and pressure increased significantly in 14 of these 19 legs, and three had no hemodynamic improvement; in one leg only pressure and in another only flow increased significantly. The remaining 17 extremities had ankle/arm pressure indexes before percutaneous transluminal angioplasty ranging from 0.81 to 1.09; their flow rates averaged 53 +/- 27 (SD) ml/min. Abnormal flow rates were detected in 15 of these 17 extremities. With near-normal ankle/arm pressure indexes no significant increase in pressure was anticipated. Flow rates augmented to 75 +/- 28 (SD) ml/min after percutaneous transluminal angioplasty; a significant increase in flow was noted in 12 legs (71%). For patients with ankle/arm indexes before percutaneous transluminal angioplasty of less than 0.80, either pressure or flow measurements should corroborate the benefits of the operation, whereas if the ankle arm index is greater than 0.80, flow measurements are most likely to substantiate changes in peripheral hemodynamics.     

Exploring Minority Stress and Resilience in a Polyamorous Sample

Polyamory is a type of consensual non-monogamy (CNM) in which participants engage in multiple simultaneous romantic and often sexual relationships with the knowledge and consent of all involved. CNM practitioners in general, and polyamorous people in specific, appear to be highly stigmatized due to their relational practices, and to experience acts of CNM-related discrimination, harassment, and violence. Conceptualizing this dynamic via minority stress theory predicts that this stigma and discrimination will lead to negative mental health effects for polyamorous individuals. However, recent research has begun to identify possible sources of resilience within polyamorous populations that may ameliorate these negative effects. This study investigated these hypotheses in a sample of 1176 polyamorous American adults utilizing structural equation modeling. Four constructs were assessed as potential resilience factors: mindfulness, cognitive flexibility, a positive CNM identity, and connection to a supportive CNM community. Results indicate that CNM-related minority stress was positively related to increased psychological distress, such as higher self-reported depression and anxiety symptoms. Mindfulness was found to have both direct and moderating effects on the relationship between minority stress and psychological distress, such that higher mindfulness attenuated the negative impact of minority stress. Cognitive flexibility also displayed direct and moderating effects, but in the opposite than predicted direction. Clinical and research implications of these findings are discussed, with an emphasis on expanding understanding of how anti-CNM stigma affects practitioners and improving clinical cultural competence with this unique and under-served population.

     

Cardiac Lead Extraction with a Novel Locking Stylet

Extraction of chronically implanted pacing and defibrillator leads is facilitated by using specialized locking stylets placed in the lead to allow application of traction and to stabilize the lead during sheath dissection of fibrotic tissue. We report the initial multicenter series of cases using a novel lead locking device (LLD). In 57 consecutive patients presenting at 6 institutions for lead extraction, 99 leads were treated using the LLD. After removing the pulse generator, leads were severed, the inner coil dilated and an LLD was successfully inserted and locked in the inner lumen of 95/99 (96±%) leads. With traction applied to the LLD, a variety of sheaths were advanced over the lead body to separate it from adhesions. In 97/99 (98±%) leads, all or most of the lead was removed via the implant vein; 2 leads were removed via the femoral vein. No major complications were observed. The LLD deploys safely and reliably, and provides stable support for advancement of dissecting sheaths.     

Technical aspects of total revascularization in off-pump coronary bypass via sternotomy approach

Background. Cardiopulmonary bypass and cardioplegic arrest result in known physiologic inflammatory, coagulopathic, and embolic states that may result in end-organ damage. Interest in off-pump complete coronary revascularization using sternotomy exposure is therefore increasing.

Methods. Using specific surgical and anesthetic techniques, we have been able to achieve total revascularization using off-pump coronary artery bypass grafting procedures (OP-CAB) through a sternotomy approach. Exposure techniques and local stabilization are tailored to individual vessels and cardiac regions. Vascular control is achieved with silicone-elastomer loops, occluders, and shunts. Poor ventricular function, advanced age, and other comorbid conditions, in and of themselves, were not considered contraindications to OP-CAB. Cardiomegaly or situations of small, intramyocardial, or heavily calcified vessels were relative contraindications to OP-CAB.

Results. Of 141 sternotomy OP-CAB cases, 132 (93.6%) were completely off-pump. The mean number of OP-CAB grafts per patient in the cases that were completely off-pump was 3.3 (range, 1 to 6). The 30-day operative mortality was 0%. There were four instances of intraoperative cardiac arrest, precipitated by vascular occlusion of the right coronary artery or manipulating a cardiomegalic heart. Advanced age (≥ 80 years) or profound ventricular dysfunction (ejection fraction ≤ 0.25) was present in a considerable percentage of patients (10.6% and 9.9%, respectively).

Conclusions. Off-pump coronary artery bypass grafting is successful for total revascularization in large numbers of patients. Anatomic factors, including cardiomegaly and small, intramyocardial, or heavily calcified vessels are possible contraindications to OP-CAB. Patients at highest risk for undergoing cardiopulmonary bypass, including those of advanced age and having ventricular dysfunction, are precisely the ones in whom OP-CAB may be the most useful.     

Biliary ascariasis: CT, MR cholangiopancreatography, and navigator endoscopic appearance—report of a case of acute biliary obstruction

A case of acute common bile duct obstruction caused by a roundworm in a 6-year-old girl is reported. Computed tomography (CT) and magnetic resonance imaging (MRI) showed “bull's-eye” and “eye-glass” appearances of the ascaris in the common bile duct. On reformation of the transverse CT and coronal MR images, the tubular Ascaris was better depicted. MRI and navigator endoscopic demonstrations of the common bile duct ascaris have not been described previously in the literature. These CT and MRI findings may be helpful in the diagnosis of Ascaris. Received 6 November 1998/Accepted 14 December 1998     

The extended-short nail system, a novel concept in the management of proximal femur fractures

In light of recent health care reform and the aging US Medicare population, it is becoming increasingly important for orthopedic surgeons to use effective and efficient strategies for hip fracture surgery. The Extended-Short Nail System (ES nail) is a US Food and Drug Administration-approved titanium nail which is locked at the same location as the locking hole of a short intramedullary (IM) nail. The ES nail takes advantage of an "extended-short" hybrid design combining the mechanical characteristics of a long IM nail with the surgical ease of use offered with a short IM nail.     

Effect of abiraterone acetate plus prednisone on the pharmacokinetics of dextromethorphan and theophylline in patients with metastatic castration-resistant prostate cancer

Purpose

To assess the effect of abiraterone acetate plus prednisone on the pharmacokinetics of dextromethorphan HBr (CYP2D6 substrate) and theophylline (CYP1A2 substrate) in patients with metastatic castration-resistant prostate cancer (mCRPC).

Methods

Men with progressive metastatic mCRPC who failed gonadotropin-releasing hormone therapy and ≥1 lines of chemotherapy were enrolled. Patients received two doses of dextromethorphan HBr-30 mg (n = 18; group A) or theophylline-100 mg (n = 16; group B) under fasting conditions; one dose on cycle 1, day ?8, and the other dose on cycle 1, day 8. Only patients with extensive CYP2D6 metabolizing status were assigned to group A. All patients received continuous daily oral abiraterone acetate (1,000 mg) plus prednisone (10 mg) starting on cycle 1, day 1.

Results

Coadministration of abiraterone acetate plus prednisone increased the systemic exposure of dextromethorphan by approximately 100 %. Ratios of geometric means for maximum plasma concentration (C _max) (275.36 %) and area under plasma concentration–time curves from time 0 to 24 h (AUC _24h) (268.14 %) of dextromethorphan were outside the bioequivalence limit. The pharmacokinetics of theophylline was unaltered following coadministration of abiraterone acetate plus prednisone. Ratios of geometric means [C _max; 102.36 % and AUC _24h; 108.03 %] of theophylline exposure parameters were within the bioequivalence limit. The safety profile of abiraterone acetate was consistent with reported toxicities.

Conclusion

Abiraterone acetate plus prednisone increased the exposure of dextromethorphan, suggesting a need for caution when coadministrating with known CYP2D6 substrates. The pharmacokinetics of theophylline was unaffected when coadministered with abiraterone acetate plus prednisone.