Management of an acquired renal arteriovenous fistula with a vein-covered stent

A patient is presented who developed a renal arteriovenous fistula as a result of a percuta-neous nephrolithotomy procedure.This was successfully treated with the pereutaneous,intra-arterial insertion of vein covered 6 mm Pahnaz stents.The advantage of this technique is the preservation ofnormal renal parenehyma otherwise lost using intra-arterial embolization or surgery.     

Is there an indication for embolic protection in renal artery intervention?

The role of endovascular treatment of atherosclerotic renal artery disease is uncertain, particularly after the publication of the Angioplasty and Stenting for Renal Artery Lesions trial and other randomized trials. These trials have shown that nonselective treatment of patients with renal artery stenosis does not result in a benefit when compared with best medical therapy. However, all trials have identified a subgroup of patients who do respond favorably to revascularization. In particular, patients with a degree of chronic renal insufficiency, critical renal artery stenosis, and a recent decline in renal function are likely to respond positively to revascularization. Endovascular treatment of renal artery stenosis must be performed safely, particularly in the high-risk patient group with background chronic renal insufficiency. Atheroembolization occurs during renal artery revascularization, as demonstrated by ex vivo studies and the high embolic yield obtained in published series of protected renal artery revascularization. The evidence supporting embolic protection includes single-center series wherein excellent results for renal function preservation have been reported. One small, randomized, controlled trial demonstrated a significant benefit if both embolic protection and abciximab were used. There are unique demands on an embolic protection device in the renal artery circulation and a dedicated device has not been developed. Both distal filters and occlusion balloons have been successfully used. Both devices can normally be primarily passed through the stenosis, allowing the remainder of the procedure to be protected. Filters have the advantage of maintaining renal perfusion throughout the procedure. Distal occlusion balloons can capture embolic particles of all sizes although the clinical advantage is uncertain.     

Endovascular management of visceral artery aneurysms: When to watch,when to intervene?

Visceral artery aneurysms (VAA) include splanchnic and renal artery aneurysms. They represent a rare clinical entity, although their detection is rising due to an increased use of cross-sectional imaging. Rupture is the most devastating complication, and is associated with a high morbidity and mortality. In addition, increased percutaneous endovascular interventions have raised the incidence of iatrogenic visceral artery pseudoaneurysms (VAPAs). For this reason, elective repair is preferable in the appropriately chosen patient. Controversy still exists regarding their treatment. Over the past decade, there has been steady increase in the utilization of minimally invasive, non-operative interventions, for vascular aneurysmal disease. All VAAs and VAPAs can technically be fixed by endovascular techniques but that does not mean they should. These catheter-based techniques constitute an excellent approach in the elective setting. However, in the emergent setting it may carry a higher morbidity and mortality. The decision for intervention has to take into account the size and the natural history of the lesion, the risk of rupture, which is high during pregnancy, and the relative risk of surgical or radiological intervention. For splanchnic artery aneurysms, we should recognize that we are not, in reality, well informed about their natural history. For most asymptomatic aneurysms, expectant treatment is acceptable. For large, symptomatic or aneurysms with a high risk of rupture, endovascular treatment has become the first-line therapy. Treatment of VAPAs is always mandatory because of the high risk of rupture. We present our point of view on interventional radiology in the splanchnic arteries, focusing on what has been achieved and the remaining challenges.     

Can exercise renography be an alternative to ACE inhibitor renography in hypertensive patients who are suspicious for renal artery stenosis?

The aim of this study was to evaluate the value of Tc-99m ethylenedicysteine exercise renography in patients with hypertension who were suspicious for renal artery stenosis and compare the results with captopril renography. METHODS: Twenty-nine patients with hypertension who were highly suspect for having renal artery stenosis were included in the study. Basal captopril exercise renograms were performed within 1 week in all patients with Tc-99m EC. Exercise was performed with a bicycle ergometer as described in the literature. Interpretations of renograms were made according to the consensus report on angiotensin converting enzyme (ACE) inhibitor renography as high, low, or intermediate probability. The sensitivity, specificity, and positive and negative predictive values were also obtained on both the kidneys and a patient basis. The results were compared with renal angiography in 19 patients. RESULTS: Twenty of 29 patients had concordant results with both captopril and exercise studies. All discordant tests were normal with captopril but positive with exercise renograms. Nineteen patients with 38 kidneys were included for statistical data analysis. Nine kidneys, which were either atrophic or abnormal during the basal study, were excluded from the kidney-based analysis. With contrast angiography, 8 patients had renal artery stenosis. When evaluated on a kidney basis, the sensitivity, specificity, and positive and negative predictive values for captopril scans were 87%, 100%, 100%, and 95%, and for the exercise scans were 100%, 90%, 80%, and 100% respectively. When calculated on a patient basis with regard to the captopril scans, the sensitivity, specificity, and positive and negative predictive values were 87%, 81%, 77%, and 88%, and for exercise scans were 100%, 54%, 61%, and 100% respectively. There were 2 false-positive exercise scans that were found to be the result of dilated minor collecting systems and changes in kidney contours as a result of motion during exercise. CONCLUSIONS: These results indicate that exercise renography has a similar sensitivity but lower specificity compared with captopril scintigraphy in the diagnosis of renal artery stenosis. Because of the lower specificity, its use in the screening of renovascular hypertension may be limited. Exercise renography may be more useful as an investigative tool for essential hypertension.     

Are flexible flat feet associated with proximal joint problems in children?

The role of flexible flat feet (FF) in the development of musculoskeletal symptoms at joints proximal to the ankle is unclear. We undertook an observational study to investigate the relationship between foot posture and the proximal joints in children. It was hypothesised that reduced arch height would be associated with proximal joint symptoms and altered gait kinematics and kinetics particularly in the transverse plane at the hip and knee. Ninety-five children between the ages of 8–15 were recruited into this ethically approved study. Foot posture was classified using the arch height index (AHI). The frequency of knee and hip/back pain was documented, and each child underwent three dimensional gait analysis. Reduced arch height was associated with increased odds of knee symptoms (p < 0.01) and hip/back symptoms (p = 0.01). A flat foot posture was also significantly associated with a reduction in the second peak of the vertical ground reaction force (p = 0.03), which concomitantly affected late stance hip and knee moments. A reduced AHI was also associated with increased pelvic retraction and increased knee valgus in midstance. No kinematic and kinetic parameter associated with a flat foot posture related to increased proximal joint symptoms in the FF group. Children with a flatter foot posture are more likely to have pain or discomfort at the knee, hip and back; however, the mechanisms by which this occurs remain unclear. Treating FF without explicit understanding of how it relates to symptoms is difficult, and further work in this area is required.     

Are flow-mediated vasodilatation and intima-media thickness of the brachial artery associated with restenosis after endovascular treatment of peripheral arterial occlusive disease?

Objective:

Restenosis after percutaneous angioplasty of peripheral arteries is still an unsolved matter. Previous studies reported an association between flow-mediated dilatation (FMD), a marker of endothelial dysfunction, and restenosis after coronary angioplasty. This study evaluates the influence of FMD and brachial intima-media thickness (B-IMT) on restenosis after angioplasty of peripheral arteries.

Methods:

One hundred and eighty-four patients (124 male) with claudication related to peripheral arterial disease participated in this trial. FMD and B-IMT were assessed before endovascular revascularisation. In a 12-month follow-up duplex ultrasound examinations were performed to detect restenosis. Finally 128 patients (91male, 37 female) were eligible for statistical analysis.

Results:

Restenosis was found in 54 patients (42.2%). Mean FMD was 3.53?±?3.56%, with no difference between the patients with restenosis (3.55?±?3.64%) and those without (3.52?±?3.48%; p?=?0.716). B-IMT had a mean value of 0.326?±?0.134 mm. B-IMT significantly differed between the patients with restenosis (0.326?±?0.134 mm) and those without (0.256?±?0.133 mm; p?=?0.007). We confirmed that a B-IMT over 0.21 mm was an independent risk factor for restenosis [OR 2.9 (1.3–6.3)].

Conclusion:

Endothelial dysfunction is not associated with restenosis. Conversely patients with enlarged B-IMT are at risk of restenosis after angioplasty of peripheral arteries.     

Are overground or treadmill runners more likely to sustain tibial stress fracture?

BACKGROUND: Repetitive high bone strain and/or strain rates, such as those that occur during running, contribute to stress fractures as well as promoting maintenance of or increase in bone mass. Kinematic differences are known to exist between overground and treadmill running and these may be reflected in different bone strains and strain rates during the two running techniques. Aim: To measure in vivo strains and strain rates in human tibia during treadmill and overground running and determine if there are significant differences in strain and strain rate levels between the two running techniques. METHODS: A strain gauged bone staple was mounted percutaneously along the axial direction in the mid diaphysis of the medial tibia in three subjects, and in vivo tibial strains were measured during treadmill and overground running at 11 km/h. RESULTS: Axial compression strains (p<0.0001), tension strains (p<0.001), compression strain rates (p<0.0001), and tension strain rates (p<0.0001) were 48-285% higher during overground running than during treadmill running. CONCLUSIONS: On the basis of lower in vivo strains and strain rates, treadmill runners are at lower risk of developing tibial stress fractures, but less likely to achieve tibial bone strengthening, than overground runners.     

Are evidence-based protocols which identify vascular injury associated with knee dislocation underutilized?

A concerning number of patients referred to our clinic with knee dislocations have not been thoroughly evaluated for popliteal injury. The objective of this study is to present our experience and attempt to identify possible causes for this trend. Thirty-one consecutive patients with knee dislocations referred over a 1-year period were evaluated. Patients were assigned to either of two groups: Group I included all patients initially evaluated with an evidence-based protocol for identifying clinically significant vascular injury associated with knee dislocation, and Group II included all patients who had not received an evidence-based evaluation. The main outcome measure was delay in the diagnosis of a limb threatening vascular injury (>8 h) within each group. Six out of the 31 patients referred, were evaluated for vascular injury without an evidence-based protocol. These patients were significantly more likely to have had a delay in the diagnosis of their vascular injury beyond 8 h (P = 0.032) and were less likely to have been evaluated at a level I trauma center (P < 0.001). As expected, evidence-based protocols are superior when compared to initial pedal pulse examination alone for identifying surgically significant vascular injury within 8 h. The consequences of a delay in diagnosis beyond 8 h can be catastrophic and one patient in this series required an above-knee amputation. This is not new information, however, a significant number of patients with knee dislocations continue to be evaluated solely by initial pedal pulse examination. Though effective protocols exist, orthopedic surgeons must work to facilitate the implementation of these protocols at their referring institutions.     

Radioiodine therapy in patients with pulmonary metastases of thyroid cancer: when to treat,when not to treat?

Ohne Zusammenfassung     

Is it necessary to study accessory arteries when screening the renal arteries for renovascular hypertension?

PURPOSE: To determine the prevalence of isolated hemodynamically significant stenoses of accessory renal arteries when the main renal arteries are patent. MATERIALS AND METHODS: In 68 adults (24 men, mean age, 67 years +/- 10; 44 women, mean age, 67 years +/- 12), angiograms that fulfilled the following criteria were studied: (a) technically adequate renal angiograms obtained to evaluate suspected renovascular hypertension and (b) angiographically documented hemodynamically significant stenosis of any renal artery. The percentage of kidneys and the percentage of patients with hemodynamically significant isolated stenoses of accessory renal arteries were calculated. RESULTS: Eighty-seven kidneys in 68 patients had hemodynamically significant renal artery stenoses. Fifteen kidneys had 16 accessory renal arteries. Four accessory arteries in three patients had hemodynamically significant stenoses. Only one of 68 patients (1.5%) had an accessory artery stenosis unaccompanied by a main renal artery stenosis in either kidney; this patient had bilateral hemodynamically significant accessory artery stenoses. Two patients had coexistent hemodynamically significant stenoses of accessory and main renal arteries. CONCLUSION: The prevalence of a hemodynamically significant stenosis isolated to an accessory renal artery was 1.5% in our study. Thus, failure to detect accessory renal arteries should not unduly affect the utility of a noninvasive test for detecting renovascular hypertension.     

Are men with erectile dysfunction able to ejaculate? – A survey

ObjectiveThe study aims to show that men complaining of ‘impotence’ or erectile dysfunction (ED) can ejaculate.MethodsAttendees at a clinic for ED were asked to fill in a questionnaire to assess the severity of their ED and establish how often they were able to ejaculate.ResultsNinety-two percent of the men with ED were able to ejaculate at least a few times during sexual stimulation or intercourse.ConclusionMen with even severe ED claim they can ejaculate during sexual stimulation or intercourse.     

Are radiogallium-labelled DOTA-conjugated somatostatin analogues superior to those labelled with other radiometals?

Purpose Gallium-68 is a metallic positron emitter with a half-life of 68 min that is ideal for the in vivo use of small molecules, such as [⁶⁸Ga-DOTA,Tyr³]octreotide, in the diagnostic imaging of somatostatin receptor-positive tumours. In preclinical studies it has shown a striking superiority over its ¹¹¹In-labelled congener. The purpose of this study was to evaluate whether third-generation somatostatin-based, radiogallium-labelled peptides show the same superiority. Methods Peptides were synthesised on solid phase. The receptor affinity was determined by in vitro receptor autoradiography. The internalisation rate was studied in AR4-2J and hsst-HEK-transfected cell lines. The pharmacokinetics was studied in a rat xenograft tumour model, AR4-2J. Results All peptides showed high affinities on hsst2, with the highest affinity for the Ga^III-complexed peptides. On hsst3 the situation was reversed, with a trend towards lower affinity of the Ga^III peptides. A significantly increased internalisation rate was found in sst2-expressing cells for all ⁶⁷Ga-labelled peptides. Internalisation into HEK-sst3 was usually faster for the ¹¹¹In-labelled peptides. No internalisation was found into sst5. Biodistribution studies employing [⁶⁷Ga-DOTA,1-Nal³]octreotide in comparison to [¹¹¹In-DOTA,1-Nal³]octreotide and [⁶⁷Ga-DOTA,Tyr³]octreotide showed a significantly higher and receptor-mediated uptake of the two ⁶⁷Ga-labelled peptides in the tumour and somatostatin receptor-positive tissues. A patient study illustrated the potential advantage of a broad receptor subtype profile radiopeptide over a high-affinity sst2-selective radiopeptide. Conclusion This study demonstrates that ^67/68Ga-DOTA-octapeptides show distinctly better preclinical, pharmacological performances than the ¹¹¹In-labelled peptides, especially on sst2-expressing cells and the corresponding animal models. They may be excellent candidates for further development for clinical studies.     

Are children with higher self-reported wellbeing and perceived motor competence more physically active? A longitudinal study

ObjectivesSelf-perceptions such as perceived motor competence and psychosocial wellbeing have been identified as important to children’s physical activity. The study’s purpose was to explore whether perceived motor competence and psychosocial wellbeing were determinants of physical activity, one year after a baseline assessment.DesignLongitudinal study.MethodsA total of 134 children (65.7% boys, 34.3% girls) aged 6–7 years at baseline (2016), and 7–8 years at follow-up (2017) were included in this study. Pearson’s correlations assessed associations at baseline and follow-up between moderate- to vigorous-intensity physical activity (MVPA) (accelerometers) and (i) total perceived motor competence and subdomains (the pictorial scale of Perceived Movement Skill Competence) and (ii) psychosocial wellbeing and sub-domains — KidKINDL KINDer Lebensqualitätsfragebogen: Children Quality of Life Questionnaire (KINDL^R). Variables identified as significant in Pearson’s correlations were included in mixed model analyses, adjusting for accelerometer wear time, sex and age.ResultsBaseline perceived object control skills was associated with MVPA at follow-up (r = 0.38, p < 0.001), but perceived locomotor skills were not. Self-esteem was the only subdomain of psychosocial wellbeing that demonstrated significant association with MVPA at baseline (r = 0.21, p < 0.05). Perceived object control (B = 1.36, p = 0.019, 95% CI [0.23, 2.50]) and self-esteem (B = 0.32, p = 0.001, 95% CI [0.13, 0.50]) positively predicted MVPA; albeit with small effects.ConclusionsFocusing on improving children’s perceived object control and self-reported self-esteem may contribute to children’s physical activity participation.     

Are former female elite athletes more likely to experience urinary incontinence later in life than non-athletes?

The aim of the present study was to investigate whether former female elite athletes are more likely to experience urinary incontinence (UI) later in life than non-athletes and to assess possible risk factors for UI in athletes. Three hundred and thirty-one former elite athletes (response rate 81%) and 640 controls replied to a postal questionnaire including validated questions on UI. While competing in sport, 10.9% and 2.7% of the former elite athletes reported stress urinary incontinence (SUI) and urge incontinence, respectively. Presently, 36.5% of the former elite athletes and 36.9% of the controls reported SUI. 9.1% and 9.4% reported urge incontinence. Among former elite athletes, those with two or three children were more likely than nulliparous women to have UI now. Also, among former athletes, UI was more common in women with vs those without UI while competing (odds ratio 8.57, 95% confidence interval: 3.55–20.71). Age, menopause and being regularly physically active now were not associated with UI in either group. Based on this study, the prevalence of UI does not seem to be higher in former athletes than in controls. However, the results indicate that UI early in life, as reported during elite sport, is a strong predictor of UI later in life.