The future of imaging in the management of abdominal aortic aneurysm.

The development of endovascular techniques depends on the concomitant development of imaging techniques. Imaging with ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MR) is evolving at rapid pace. Angiography has largely been replaced by these techniques as a diagnostic tool in the clinical setting. New methods, e.g., rotational angiography and intravascular ultrasound, will play an important role in endovascular treatment of vascular disease. It is necessary to have easy access to ultrasonography, CT and MR images in future hybrid angiographic/surgical suites and the operator must be able to do advanced immediate reconstructions in a sterile environment. The combined use of advanced imaging, open and endovascular techniques will further improve the treatment of vascular disease in the future.     

A holistic approach to stylalgia

A follow-up study was performed on 20 patients surgically treated because of stylalgia (Eagle's Syndrome). The aim of the study was to investigate why somatic treatment was often ineffective; furthermore, if there was a psychosomatic background to the complaints. The results of a psychiatric interview in which 11 patients took part clearly showed that most of them were suffering primarily from a psychiatric disorder. The question of stylalgia only as a form of atypical facial pain is discussed.     

Preoperative localization in unilateral parathyroid surgery. A cost-benefit study on ultrasound, computed tomography and scintigraphy

In 50 patients with primary hyperparathyroidism, investigation before initial neck exploration included ultrasonography, computed tomography and 99technetium-201thallium subtraction scintigraphy. The sensitivity for correct preoperative localization was 50%, 54% and 56%, respectively. There was marked inter-observer variation in assessment of ultrasonography and computed tomography, while scintigrams were evaluated by only one person. The scintigraphic sensitivity increased with size of the glands. In cases where correct preoperative localization permitted unilateral parathyroidectomy, the time for surgery and anesthesia was significantly reduced. A cost-benefit analysis, however, revealed that the financial saving from this time reduction was outweighed by the cost of the localization procedures. The authors conclude that investigations for definition of enlarged parathyroid glands are not indicated prior to unilateral parathyroidectomy.     

Nonregressive schizophrenia--a long-term comparative follow-up investigation

A 14-17 year follow-up study of a first admission sample of nonregressive schizophrenic cases revealed a phenomenological and diagnostic consistency over time. Some improved and adapted well in society but a considerable proportion developed into chronic schizophrenic syndromes. Schizophrenic deterioration was also manifested among those who adhered to a nonregressive course without ever revealing frank psychotic decompensation. Treatment consumption and disability were high. Prognosis and outcome were, in the main, similar to a parallel series of regressive schizophrenic first-admission cases of similar sex and age composition. The sex difference noted in the intermediate-term outcome study in 1973, with a more favourable outcome among the women, was no longer present. The findings added further support to the validity of the concept of nonregressive schizophrenia and to the hypothesis of a joint nosology with classical schizophrenia.     

Venous obstruction after pacemaker implantation

BACKGROUND: Central vein leads are known to predispose to venous obstruction. Although usually asymptomatic, obstruction may render electrode removal difficult. This study aimed at quantifying changes in venous calibers in a prospective fashion by intravenous contrast venography (ICV) before and after pacemaker (PM) or cardioverter-defibrillator implantation. METHODS: One hundred and fifty (mean age 67; 61% male) consecutive patients were enrolled, and followed for 6 months. A successful ICV was done at baseline prior to implantation and at 6-month follow-up in 136 (91%) patients. Minimum (D(min)) and maximum (D(max)) vessel diameters were obtained from both ICVs. A new stenosis was defined as a 50% diameter reduction in a venous segment when compared to baseline. We implanted a total of 230 electrodes: 47 (34.6%) single lead, 84 (61.8%) 2-lead, and 5 (3.7%) 3-lead systems. RESULTS: At baseline ICV, 10 patients (7%) were found to have venous anomalies, including 8 patients with obstructive lesions, 1 patient with a persistent left superior vena cava, and 1 patient with double axillary vein. At 6 months, a new obstructive venous lesion had developed in a total of 19 (14%) patients, none of whom exhibited any local symptoms. Of these patients 14 (10%) had a stenosis (mean D(min) 4.6 mm and diameter 38% of baseline), and 5 (3.6%) had a complete venous occlusion. In most cases the new stenosis developed in a location where the vessel was narrowest at baseline. Clinical predictors for the development of stenosis were atrial fibrillation at baseline and biventricular PM implantation. CONCLUSIONS: This is the first systematic study to quantify venous changes after PM or ICD implantation. Our study shows that venous anomalies rendering PM implantation difficult are not infrequent. The incidence of new venous obstruction was 14%. Atrial fibrillation and biventricular PM implantation were independent predictors of venous obstruction.     

Multiple cardiovascular complications in a patient with relapsing polychondritis

Relapsing polychondritis is an uncommon disease of unknown etiology, usually manifested by inflammatory changes of cartilaginous tissues. Cardiovascular complications are rare but have been associated with adverse prognosis. Aortitis, vasculitis of large- and medium-sized arteries with aneurysm formation, valvulitis, pericarditis, and atrioventricular conduction disturbances have been reported as late complications of relapsing polychondritis. We describe a 42-year-old man who developed all the known cardiovascular complications of relapsing polychondritis except for clinically evident pericarditis. This case illustrates the multiple, varied, and potentially fatal cardiovascular complications that can occur with this disorder. Patients with relapsing polychondritis should be monitored closely for development of such complications.     

Local low‐dose lovastatin delivery improves the bone‐healing defect caused by Nf1 loss of function in osteoblasts

Postfracture tibial nonunion (pseudoarthrosis) leads to lifelong disability in patients with neurofibromatosis type I (NF1), a disorder caused by mutations in the NF1 gene. To determine the contribution of NF1 in bone healing, we assessed bone healing in the Nf1 conditional mouse model lacking Nf1 specifically in osteoblasts. A closed distal tibia fracture protocol and a longitudinal study design were used. During the 21‐ to 28‐day postfracture period, callus volume, as expected, decreased in wild‐type but not in Nf1 mice, suggesting delayed healing. At these two time points, bone volume (BV/TV) and volumetric bone mineral density (vBMD) measured by 3D micro–computed tomography were decreased in Nf1 callus‐bridging cortices and trabecular compartments compared with wild‐type controls. Histomorphometric analyses revealed the presence of cartilaginous remnants, a high amount of osteoid, and increased osteoclast surfaces in Nf1 calluses 21 days after fracture, which was accompanied by increased expression of osteopontin, Rankl, and Tgfβ. Callus strength measured by three‐point bending 28 days after fracture was reduced in Nf1 versus wild‐type calluses. Importantly, from a clinical point of view, this defect of callus maturation and strength could be ameliorated by local delivery of low‐dose lovastatin microparticles, which successfully decreased osteoid volume and cartilaginous remnant number and increased callus BV/TV and strength in mutant mice. These results thus indicate that the dysfunctions caused by loss of Nf1 in osteoblasts impair callus maturation and weaken callus mechanical properties and suggest that local delivery of low‐dose lovastatin may improve bone healing in NF1 patients. © 2010 American Society for Bone and Mineral Research     

A health‐economic analysis of porcine islet xenotransplantation

Beckwith J, Nyman JA, Flanagan B, Schrover R, Schuurman H‐J. A health‐economic analysis of porcine islet xenotransplantation. Xenotransplantation 2010; 17: 233–242. © 2010 John Wiley & Sons A/S. Abstract: Background: Islet cell transplantation is a promising treatment for type 1 diabetes. To overcome the shortage of deceased human pancreas donors, porcine islet cell xenotransplantation is being developed as an alternative to allotransplantation. The objective of this study was to perform a cost‐effectiveness analysis of porcine islet transplantation in comparison with standard insulin therapy. The patient population for this study was young adults, ages 20 to 40, for whom standard medical care is inadequate in controlling blood glucose levels (hypoglycemia unawareness). Since trial data were lacking, estimates used extrapolations from data found in the literature and ongoing trials in clinical allotransplantation. Cost estimates were based on the data available in the USA. Methods: Markov modeling and Monte Carlo simulations using software specifically developed for health‐economic evaluations were used. Outcomes data for ongoing clinical islet allotransplantation from the University of Minnesota were used, along with probabilities of complications from the Diabetes Control and Complications Trial. Quality‐adjusted life years (QALYs) were the effectiveness measure. The upper limit of being cost‐effective is $100 000 per QALY. Cost data from the literature were used and adjusted to 2007 US dollars using the medical care portion of the Consumer Price Index. Results: In both Markov modeling and Monte Carlo simulations, porcine islet xenotransplantation was both more effective and less costly over the course of the 20‐yr model. For standard insulin therapy, cumulative cost per patient was $661 000, while cumulative effectiveness was 9.4 QALYs, for a cost of $71 100 per QALY. Transplantation had a cumulative cost of $659 000 per patient, a cumulative effectiveness of 10.9 QALYs, and a cost per QALY of $60 700. Islet transplantation became cost‐effective at 4 yr after transplantation, and was more cost‐effective than standard insulin treatment at 14 yr. These findings are related to relative high costs in the transplantation arm of the evaluation during the first years while those in the insulin arm became higher later in follow‐up. Throughout the follow‐up period, effectiveness of transplantation was higher than that of insulin treatment. In sensitivity analysis, duplication or triplication of one‐time initial costs such as costs of donor animal, islet manufacturing and transplantation had no effect on long‐term outcome in terms of cost‐saving or cost‐effectiveness, but the outcome of transplantation in terms of diabetes complications in cases with partial graft function could affect cost‐saving and cost‐effectiveness conclusions. Conclusion: Despite limitations in the model and lack of trial data, and under the assumption that islet transplantation outcomes for young adult type 1 diabetes patients are not dependent on the source of islet cells, this health‐economic evaluation suggests that porcine islet cell xenotransplantation may prove to be a cost‐effective and possibly cost‐saving procedure for type 1 diabetes compared to standard management.