Treatment of iron deficiency in predialysis state by low molecular weight iron dextran high doses intravenously

Anemia is a common complication of chronic kidney disease (CKD) in predialysis stage. Iron deficiency is more common than in normal patients and plays a key role in the genesis of anemia. Its correction avoids the use of erythropoiesis stimulating agents (ESA) or reduces their dosage. Treatment with oral iron is often poorly tolerated and ineffective, necessitating the use of intravenous iron. New forms of injectable iron allow the use of high doses and correct iron deficiency in a single administration with consequent preservation of venous capital and lower costs. We studied the effectiveness of iron dextran of low molecular weight (LMWID) in high doses to correct iron deficiency and treat anemia in predialysis CKD patients. Twenty-nine doses of 500 to 1600 mg were administered to 25 patients followed for CKD (GFR between 60 and 10 ml/min per 1.73 m²), selected on biological criteria of iron deficiency defined by a ratio of transferrin saturation (TSAT) < 20% and/or serum ferritin of less than 100 μg/L. Patients received treatment by ESA in 16 cases out of 29. One month after treatment, hemoglobin (Hb) increased significantly (11.4 ± 1.6 vs 10.4 ± 1.4 g/dL, P = 0.0003) along with a significant increase in TSAT (21.3 ± 7.3 vs 13.3 ± 3.8%, P = 0.000003) and serum ferritin (286 ± 253 vs 91 ± 60 μg/L, P = 0.00005). Six patients had a serum ferritin greater than 500 μg/L after treatment, which may put them at risk of iron overload. Their serum ferritin was higher than the rest of the population before treatment, while the TSAT was no different, reflecting a functional deficiency. Their hemoglobin did not increase after treatment in contrast to the rest of the population suggesting the unavailability of iron for erythropoiesis with accumulation in the reticuloendothelial system. Renal function did not change significantly and there were no cases of acute renal failure. No immediate side effect was observed. Three patients presented delayed reactions to such self-limiting myalgia and arthralgia. No venous inflammatory reaction was noted. The administration of high doses of LMWID is effective in treating anemia of CKD in the predialysis stage with a satisfactory tolerance, without affecting kidney function and helps preserve the venous capital. It should be reserved for patients whose serum ferritin is less than or equal to 150 μg/L.     

Flow diversion treatment: intra-aneurismal blood flow velocity and WSS reduction are parameters to predict aneurysm thrombosis

Background

To evaluate the haemodynamic changes induced by flow diversion treatment in cerebral aneurysms, resulting in thrombosis or persisting aneurysm patency over time.

Method

Eight patients with aneurysms at the para-ophthalmic segment of the internal carotid artery were treated by flow diversion only. The clinical follow-up ranged between 6?days and 12?months. Computational fluid dynamics (CFD) analysis of pre- and post-treatment conditions was performed in all cases. True geometric models of the flow diverter were created and placed over the neck of the aneurysms by using a virtual stent-deployment technique, and the device was simulated as a true physical barrier. Pre- and post-treatment haemodynamics were compared, including mean and maximal velocities, wall-shear stress (WSS) and intra-aneurysmal flow patterns. The CFD study results were then correlated to angiographic follow-up studies.

Results

Mean intra-aneurysmal flow velocities and WSS were significantly reduced in all aneurysms. Changes in flow patterns were recorded in only one case. Seven of eight aneurysms showed complete occlusion during the follow-up. One aneurysm remaining patent after 1?year showed no change in flow patterns. One aneurysm rupturing 5?days after treatment showed also no change in flow pattern, and no change in the maximal inflow velocity.

Conclusions

Relative flow velocity and WSS reduction in and of itself may result in aneurysm thrombosis in the majority of cases. Flow reductions under aneurysm–specific thresholds may, however, be the reason why some aneurysms remain completely or partially patent after flow diversion.     

Biphasic bone substitute and fibrin sealant for treatment of benign bone tumours and tumour-like lesions

Purpose  

Bone defects resulting from tumour resection or curettage are most commonly reconstructed with autologous bone graft which is associated with limited availability and donor site morbidity. Recent research has focussed on synthetic biomaterials as bone graft substitutes. The aim of this study was to assess the safety and efficiency of a bone substitute as an alternative for autologous bone in the treatment of benign bone tumours and tumour-like lesions.     

A new method to measure ligament balancing in total knee arthroplasty: laxity measurements in 100 knees

Background

Ligament balancing is considered a prerequisite for good function and survival in total knee arthroplasty (TKA). However, there is no consensus on how to measure ligament balance intra-operatively and the degree of stability obtained after different balancing techniques is not clarified.

Purpose

This study presents a new method to measure ligament balancing in TKA and reports on the results of a try-out of this method and its inter-observer reliability.

Methods

After the implantation of the prosthesis, spatulas of different thickness were used to measure medial and lateral condylar lift-off in flexion and extension in 70 ligament-balanced knees and in 30 knees were ligament balancing was considered unnecessary. Inter-observer reliability for the new method was estimated and the degree of medial–lateral symmetry in extension and in flexion, and the equality of the extension gaps and flexion gaps were calculated.

Results

The method was feasible in all operated knees, and found to be very reliable (intraclass correlation coefficient?=?0.88). We found no statistically significant difference in condylar lift-off between the ligament-balanced and the non ligament-balanced group, however, there was a tendency to more outliers in flexion in the ligament-balanced group.

Conclusions

Our method for measuring ligament balance is reliable and provides valuable information in assessing laxity intra-operatively. This method may be a useful tool in further research on the relationship between ligament balance, function and survival of TKA.     

Role of iron deficiency and anemia in cardio-renal syndromes

Chronic heart failure is a common disorder associated with unacceptably high mortality rates. Chronic renal disease and anemia are two important comorbidities that significantly influence morbidity and mortality in patients with chronic heart failure (CHF). Progress in CHF again may cause worsening of kidney function and anemia. To describe this vicious cycle, the term cardio-renal anemia syndrome has been suggested. Iron deficiency is part of the pathophysiology of anemia in both CHF and chronic kidney disease, which makes it an interesting target for treatment of anemia in cardio-renal anemia syndrome. Recently, studies have highlighted the potential clinical benefits of treating iron deficiency in patients with CHF, even if these patients are nonanemic. This article summarizes studies investigating the influence of iron deficiency with or without anemia in chronic kidney disease and CHF and gives an overview of preparations of intravenous iron currently available.     

Distribution of substance-P nerves inside the infrapatellar fat pad and the adjacent synovial tissue: a neurohistological approach to anterior knee pain syndrome

Introduction The purpose of the study was to determine the distribution and number of nerves inside the infrapatellar fat pad and the adjacent synovium, in particular with regards to nociceptive substance-P nerves.Materials and methods The infrapatellar fat pad of the knee was resected from 21 patients (4 male, 17 female, mean age 69 years) during the course of standard total knee arthroplasty operations performed in our clinic. The fat pad was dissected into five standardized segments, fixed in formalin and embedded in paraffin. Immunohistochemical techniques using antibodies against S-100 protein and substance-P (SP) were employed to determine and specify the nerves.Results Studying all the detectable nerves present in 50 observation fields (200-fold magnification), we found an average of 106 S-100 versus 25 SP nerves (24%) in the synovium and 27 S-100- versus 7 SP nerves (26%) in the interior of the fat pad. The total nerve count was significantly ( P <0.001) higher in the synovium than in the fat pad for both marker types. The number of S-100 nerves was significantly ( P <0.05) higher in the central and lateral segments of the fat pad, while SP nerves were equally distributed throughout all segments of the fat-pad. SP nerves were significantly more frequently associated with blood vessels inside the fat pad (43%, P <0.05) than in the synovial tissue (28%).Conclusion The occurrence and distribution of SP nerves inside the infrapatellar fat pad suggest a nociceptive function and a neurohistological role in anterior knee pain syndrome. The data support the hypothesis that a neurogenous infection of the infrapatellar fat pad could contribute to anterior knee pain syndrome.     

Reduced Field-of-View Diffusion-Weighted Magnetic Resonance Imaging of the Pancreas: Comparison with Conventional Single-Shot Echo-Planar Imaging

ObjectiveTo investigate the image quality (IQ) and apparent diffusion coefficient (ADC) of reduced field-of-view (FOV) di-ffusion-weighted imaging (DWI) of pancreas in comparison with full FOV DWI.ResultsOn qualitative analysis, reduced FOV DWI showed better anatomic structure visualization (2.76 ± 0.79 at b = 0 s/mm² and 2.81 ± 0.64 at b = 400 s/mm²), lesion conspicuity (3.11 ± 0.99 at b = 0 s/mm² and 3.15 ± 0.79 at b = 400 s/mm²), IQ score (8.51 ± 2.05 at b = 0 s/mm² and 8.79 ± 1.60 at b = 400 s/mm²), and higher clinical utility (3.41 ± 0.64), as compared to full FOV DWI (anatomic structure, 2.18 ± 0.59 at b = 0 s/mm² and 2.56 ± 0.47 at b = 500 s/mm²; lesion conspicuity, 2.55 ± 1.07 at b = 0 s/mm² and 2.89 ± 0.86 at b = 500 s/mm²; IQ score, 7.13 ± 1.83 at b = 0 s/mm² and 8.17 ± 1.31 at b = 500 s/mm²; clinical utility, 3.14 ± 0.70) (p < 0.05). Artifacts were significantly improved on reduced FOV DWI (2.65 ± 0.68) at b = 0 s/mm² (full FOV DWI, 2.41 ± 0.63) (p < 0.001). On quantitative analysis, there were no significant differences between the 2 DWI sequences in ADCs of various pancreatic lesions and parenchyma (p > 0.05). ADCs of adenocarcinomas (1.061 × 10^-3 mm²/s ± 0.133 at reduced FOV and 1.079 × 10^-3 mm²/s ± 0.135 at full FOV) and neuroendocrine tumors (0.983 × 10^-3 mm²/s ± 0.152 at reduced FOV and 1.004 × 10^-3 mm²/s ± 0.153 at full FOV) were significantly lower than those of parenchyma (1.191 × 10^-3 mm²/s ± 0.125 at reduced FOV and 1.218 × 10^-3 mm²/s ± 0.103 at full FOV) (p < 0.05).ConclusionReduced FOV DWI of the pancreas provides better overall IQ including better anatomic detail, lesion conspicuity and subjective clinical utility.     

Absolute myocardial flow quantification with 82Rb PET/CT: comparison of different software packages and methods

Purpose

In clinical cardiac ⁸²Rb PET, globally impaired coronary flow reserve (CFR) is a relevant marker for predicting short-term cardiovascular events. However, there are limited data on the impact of different software and methods for estimation of myocardial blood flow (MBF) and CFR. Our objective was to compare quantitative results obtained from previously validated software tools.

Methods

We retrospectively analyzed cardiac ⁸²Rb PET/CT data from 25 subjects (group 1, 62?±?11 years) with low-to-intermediate probability of coronary artery disease (CAD) and 26 patients (group 2, 57?±?10 years; P?=?0.07) with known CAD. Resting and vasodilator-stress MBF and CFR were derived using three software applications: (1) Corridor4DM (4DM) based on factor analysis (FA) and kinetic modeling, (2) 4DM based on region-of-interest (ROI) and kinetic modeling, (3) MunichHeart (MH), which uses a simplified ROI-based retention model approach, and (4) FlowQuant (FQ) based on ROI and compartmental modeling with constant distribution volume.

Results

Resting and stress MBF values (in milliliters per minute per gram) derived using the different methods were significantly different: using 4DM-FA, 4DM-ROI, FQ, and MH resting MBF values were 1.47?±?0.59, 1.16?±?0.51, 0.91?±?0.39, and 0.90?±?0.44, respectively (P?<?0.001), and stress MBF values were 3.05?±?1.66, 2.26?±?1.01, 1.90?±?0.82, and 1.83?±?0.81, respectively (P?<?0.001). However, there were no statistically significant differences among the CFR values (2.15?±?1.08, 2.05?±?0.83, 2.23?±?0.89, and 2.21?±?0.90, respectively; P?=?0.17). Regional MBF and CFR according to vascular territories showed similar results. Linear correlation coefficient for global CFR varied between 0.71 (MH vs. 4DM-ROI) and 0.90 (FQ vs. 4DM-ROI). Using a cut-off value of 2.0 for abnormal CFR, the agreement among the software programs ranged between 76 % (MH vs. FQ) and 90 % (FQ vs. 4DM-ROI). Interobserver agreement was in general excellent with all software packages.

Conclusion

Quantitative assessment of resting and stress MBF with ⁸²Rb PET is dependent on the software and methods used, whereas CFR appears to be more comparable. Follow-up and treatment assessment should be done with the same software and method.     

Reoperation, myocardial infarction and mortality after transurethral and open prostatectomy: a nation-wide, long-term analysis of 23,123 cases

OBJECTIVE: To analyse long-term rates of reoperation, myocardial infarction and mortality after transurethral (TURP) and open prostatectomy (open PE) in a nation-wide analysis. MATERIAL AND METHODS: Patients who underwent TURP (n=20,671) or open PE (n=2452) in Austria between 1992 and 1996 entered this study and were followed for up to 8 years. Actuarial cumulative incidences of reoperation (TURP, urethrotomy, bladder neck incision), myocardial infarction and death after 1, 5 and 8 years were calculated. Data were provided by the Austrian Health Institute (OBIG). RESULTS: Actuarial cumulative incidences of a secondary TURP after primary TURP at 1, 5 and 8 years were 2.9%, 5.8% and 7.4%; the respective numbers after open PE 1.0%, 2.7% and 3.4%. The overall incidence of a secondary endourological procedure (TURP, urethrotomy, bladder neck incision) within 8 years was 14.7% after TURP and 9.5% after open PE. The 8 years incidence of myocardial infarction was identical after TURP (4.8%) and open PE (4.9%). In parallel, mortality rates at 90 days (TURP: 0.7%; open PE: 0.9%), one year (2.8% vs. 2.7%), 5 years (12.7% vs. 11.8%) and 8 years (20% vs. 20.9%) was identical after TURP and open PE. CONCLUSIONS: This large-scale, contemporary, nation-wide analysis confirms the higher reoperation rate after TURP compared to open PE. We observed no excess risk of myocardial infarction or death after TURP compared to open PE.     

Risk stratification with cardiac troponin I in patients undergoing elective coronary artery bypass surgery.

OBJECTIVE: Cardiac troponin I (cTnI) is a highly sensitive and specific marker for postoperative prediction of patients outcome after coronary artery bypass surgery (CABG). Whether preoperatively elevated cTnI levels similarly predict the outcome in patients scheduled for elective CABG is currently unknown. METHODS: Therefore, a possible correlation between preoperative cTnI levels and perioperative major adverse events and in-hospital mortality after CABG was investigated. CTnI was measured within 24h before surgery in 1405 out of 3124 consecutive elective CABG patients. Out of these patients, 1178 had a preoperative cTnI level below 0.1ng/ml (group 1), 163 patients had a cTnI level between 0.11 and 1.5ng/ml (group 2), and 64 patients had a cTnI level above 1.5ng/ml (group 3). CTnI levels, electrocardiograms, clinical data, adverse events and in-hospital mortality were recorded prospectively. Patients with ST-elevation myocardial infarction less than 7 days before surgery were excluded from the study. RESULTS: Perioperative myocardial infarction (PMI) occurred in 69/1178 patients (5.9%) in group 1, 14/163 patients (8.6%; odds ratio (OR) 1.5, 95% confidence interval (CI): 0.8-2.8) in group 2, and 11/64 patients (17.2%; OR 3.3, CI: 1.6-7.0) in group 3 (overall: P<0.001, Cochran-Armitage trend test). Low cardiac output syndrome (LCOS) occurred in 19/1178 patients (1.6%), 9/163 (5.5%; OR 3.6, CI: 1.5-8.5), and 7/64 patients (10.9%; OR 7.5, CI: 2.7-19.8) (overall: P<0.001, group 1 vs. group 2: P<0.002), respectively. In-hospital mortality was 1.7% in group 1 and 3.1% in group 2, but 6.3% (OR 3.9, CI: 1.1-12.5) in group 3 (overall: P<0.01, group 1 vs. group 2: P=NS). Intensive care and hospital stay were significantly longer in group 3 compared to groups 1 and 2. Univariate and multivariate logistic regression analysis confirmed the statistically significant relationship between cTnI and PMI, LCOS and in-hospital mortality, respectively (P<0.001). CONCLUSIONS: Risk stratification by measurement of cTnI levels within 24h before elective CABG clearly identifies a subgroup of patients with increased risk for postoperative adverse outcome and in-hospital mortality.