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61.

Background

Endovascular aneurysm sealing (EVAS) represents a novel approach to the treatment of abdominal aortic aneurysms. It uses polymer technology to achieve an anatomic seal within the sac of the aneurysm. This cohort study reports the early clinical outcomes, technical refinements, and learning curve during the initial EVAS experience at a single institution.

Methods

Results from 150 consecutive EVAS cases for intact, infrarenal abdominal aortic aneurysms are reported here. These cases were undertaken between March 2013 and July 2015. Preoperative, perioperative, and postoperative data were collected for each patient prospectively.

Results

The median age of the cohort was 76.6 years (interquartile range, 70.2-80.9 years), and 87.3% were male. Median aneurysm diameter was 62.0 mm (IQR, 58.0-69.0 mm). Adverse neck morphology was seen in 69 (46.0%) patients, including aneurysm neck length <10 mm (17.3%), neck diameter >32 mm or <18 mm (8.7%), and neck angulation >60 degrees (15.3%). Median follow-up was 687 days (IQR, 463-897 days); 37 patients (24.7%) underwent reintervention. The rates of unresolved endoleak are 1.3% type IA, 0.7% type IB, and 2.7% type I. There were no type III endoleaks. There have been seven secondary ruptures in this cohort; all but one of these patients survived after reintervention. Only one rupture occurred in an aneurysm that had been treated within the manufacturer's instructions for use (IFU).

Conclusions

The rate of unresolved endoleaks is satisfactorily low. The incidence of secondary rupture is of concern; however, when the IFU are adhered to, the rate is very low. The results of this study suggest that working within the IFU yields better clinical results.  相似文献   
62.

Background

Spontaneous spinal and intracranial subdural hematomas are rarely reported, especially occurring simultaneously. Anticoagulation use has been associated with spontaneous hemorrhages. Prompt diagnosis is required to prevent permanent neurological sequelae. In this case report, we describe a spontaneous spinal and intracranial subdural hematoma in a woman taking warfarin and initially presenting with severe vaginal pain.

Case Report

A 42-year-old woman who had a history of mechanical valve replacement and was therefore taking warfarin, came to an emergency department for relief of severe vaginal pain. Mild concurrent lumbar pain increased concern about spinal pathology, so magnetic resonance imaging of her spine was performed. It revealed a subdural hematoma extending from L1–S1 with arachnoiditis, which suggested intracranial pathology, though the patient had no complaint of a headache. Computed tomography of her brain demonstrated a large right subdural hemorrhage with midline shift. Subsequent imaging revealed no aneurysm or source of the intracranial bleeding. We concluded that the patient experienced spontaneous anticoagulation-related intracranial hemorrhage resulting in lumbar subdural hematoma and arachnoiditis with referred vaginal pain.

Why Should an Emergency Physician Be Aware of This?

Pelvic, vaginal, or perineal pain may be the presenting symptom in patients with lower spinal pathology. It is important to consider causes other than gynecological ones in the differential diagnosis of these patients, as well as to be cognizant of the relationship between spinal and intracranial subdural hemorrhages. In patients with back pain or radiating lumbar pain, especially coupled with neurological effects, clinicians should consider spinal subdural hemorrhage and arachnoiditis to expedite imaging studies and treatment of these rare entities.  相似文献   
63.

Background

Multiparametric magnetic resonance imaging (mpMRI) undoubtedly affects the diagnosis and treatment of localized prostate cancer (CaP). However, clinicians need a better understanding of its accuracy and limitations in detecting individual CaP foci to optimize management.

Objective

To determine the per-lesion detection rate for CaP foci by mpMRI and identify predictors of tumor detection.

Design, setting, and participants

We carried out a retrospective analysis of a prospectively managed database correlating lesion-specific results from mpMRI co-registered with whole-mount pathology (WMP) prostatectomy specimens from June 2010 to February 2018. Participants include 588 consecutive patients with biopsy-proven CaP undergoing 3-T mpMRI before radical prostatectomy at a single tertiary institution.

Outcome measurements and statistical analysis

We measured mpMRI sensitivity in detecting individual CaP and clinically significant (any Gleason score ≥7) CaP foci and predictors of tumor detection using multivariate analysis.

Results and limitations

The final analysis included 1213 pathologically confirmed tumor foci in 588 patients with primarily intermediate- (75%) or high-risk (12%) CaP. mpMRI detected 45% of all lesions (95% confidence interval [CI] 42–47%), including 65% of clinically significant lesions (95% CI 61–69%) and nearly 80% of high-grade tumors. Some 74% and 31% of missed solitary and multifocal tumors, respectively, were clinically significant. The majority of missed lesions were small (61.1% ≤1 cm); 28.3% were between 1 and 2 cm, and 10.4% were >2 cm. mpMRI missed at least one clinically significant focus in 34% of patients overall, and in 45% of men with multifocal lesions. On multivariate analysis, smaller, low-grade, multifocal, nonindex tumors with lower prostate-specific antigen density were more likely to be missed. Limitations include selection bias in a prostatectomy cohort, lack of specificity data, an imperfect co-registration process, and uncertain clinical significance for undetected lesions.

Conclusions

mpMRI detects less than half of all and less than two-thirds of clinically significant CaP foci. The moderate per-lesion sensitivity and significant proportion of men with undetected tumor foci demonstrate the current limitations of mpMRI.

Patient summary

Magnetic resonance imaging of the prostate before surgical removal for prostate cancer finds less than half of all individual prostate cancer tumors. Large, solitary, aggressive tumors are more likely to be visualized on imaging.  相似文献   
64.
Background and Objective: Although preventable, substance addiction has become one of the most prominent public health problems facing the nation. As a result, treatment programs and centers have focused resources and efforts on aiding individuals on their path to long-term recovery. However, the constant threat, reinforced by high incidence, of relapse presents a major obstacle to long-term recovery. Relapse prevention programs are designed to target social and psychological factors contributing to lapses in sobriety. Yet, the exact factors that can impact long-term recovery and prevent or lower the instances of relapse are not always clear. The current study explores the major contributors to relapse as experienced in a male residential treatment center.

Methods: The data were gathered through 31 in-depth interviews in a residential halfway house treatment facility for substance use recovery.

Results: The results of the study underscored social support and interpersonal relationships as major factors impacting long-term recovery. More specifically, lack of efficacy in managing interpersonal relationships and building new support networks were identified as essential barriers to long-term recovery.

Conclusions: The management of interpersonal relationships seems to be a key to long-term recovery, which emphasizes the need for strategies that underscore the development of positive relationships that will strengthen resistance to relapse and long-term recovery.  相似文献   

65.

Study objectives

The primary objective of this study was to compare Emergency Department patients with first-time versus recurrent acute pancreatitis.

Methods

This study was a retrospective chart review of patients with a diagnosis of acute pancreatitis who presented to a single academic urban emergency department from 2012 to 2016. Criteria for inclusion were clinical symptoms of pancreatitis, age greater than or equal to 18?years, ED diagnosis of acute pancreatitis, and an abdominal CT scan within 24?h of triage. Exclusion criteria were traumatic mechanism and pregnancy. Charts were reviewed by a minimum of two trained abstractors using structured data collection sheets and discrepancies were resolved by a third abstractor. Patients with first time acute pancreatitis versus recurrent acute pancreatitis were compared to determine differences in characteristics, management and disposition.

Results

250 patients were included in the study. Of these, 165 patients had first-time acute pancreatitis and 85 patients had recurrent acute pancreatitis. Demographics, vital signs and initial lab values were the same in both groups. Patients with recurrent acute pancreatitis were more likely to have significant findings on CT (Modified CT Severity Index, 2.09 versus 1.43, p?<?0.05), more likely to require IV opiates (96% versus 75%, p?<?0.001) and less likely to need ICU admission (8% versus 19%, p?=?0.03).

Conclusion

ED patients with recurrent acute pancreatitis demonstrated more significant findings on CT compared to patients with first-time acute pancreatitis but were less likely to require ICU admission.  相似文献   
66.

Objective

Although endovascular repair of abdominal aortic aneurysms (AAAs) has been demonstrated to have favorable outcomes, not all cohorts of patients with AAA fare equally well. Our goal was to investigate perioperative and 1-year outcomes in patients with end-stage renal disease (ESRD) on dialysis, who have traditionally fared worse after vascular interventions, to assess how ESRD affects outcomes in a large modern cohort of endovascular aneurysm repair (EVAR) patients.

Methods

The Vascular Quality Initiative database was queried for all patients undergoing EVAR from 2010 to 2017. ESRD patients were compared with patients not on dialysis. Propensity-matched scoring and multivariable analysis were used to isolate the effects of ESRD.

Results

Of 28,683 EVARs identified, there were 321 (1.12%) patients with ESRD on dialysis. Patients with ESRD had no difference in presenting AAA size (57.5 ± 12.7 mm vs 56.7 ± 17.2 mm; P = .44); however, they had more urgent/emergent repairs (20.6% vs 13.6%; P = .002) than those without ESRD. ESRD patients were more often younger, nonwhite, and nonobese and less likely to have commercial insurance (P < .05). ESRD patients more often had hypertension, coronary artery disease, congestive heart failure, previous lower extremity bypass, aneurysm repair, and carotid interventions (P < .05). There was no difference in the rate of concomitant procedures. Matching based on demographics, comorbidities, and operative details showed that ESRD patients had longer hospital length of stay (4.8 ± 9.4 days vs 4.1 ± 12.6 days; P = .026) and higher 30-day mortality (7% vs 2.4%; P < .001). There was no difference in cardiac, pulmonary, lower extremity, bowel, and stroke complications or return to the operating room. On multivariable analysis, ESRD was associated with 30-day mortality (odds ratio, 4.1; 95% confidence interval, 2.6-6.7; P < .001). Of the 24,750 elective EVARs, 1.04% had ESRD on dialysis. Matched data for elective EVAR show increased postoperative length of stay, hospital mortality, and 30-day mortality for ESRD patients on dialysis compared with those who are not. There was no association with postoperative myocardial infarction or pulmonary complications. At 1 year, patients with ESRD on dialysis had worse survival (78% vs 94%; P < .001), and ESRD was associated with higher mortality (hazard ratio, 3.3; 95% confidence interval, 2.5-4.2; P < .001).

Conclusions

Among patients undergoing EVAR, ESRD is independently associated with higher perioperative and 1-year mortality despite not being associated with higher postoperative complications. This should be taken into account during informed consent for EVAR and risk-benefit considerations in this high-risk population, particularly for elective repair.  相似文献   
67.

Objective

Arteriovenous fistulas created in patients with chronic kidney disease often lose patency and fail to become usable. This prospective trial evaluated the efficacy of vonapanitase, a recombinant human elastase, in promoting radiocephalic fistula patency and use for hemodialysis.

Methods

PATENCY-1 was a double-blind, placebo-controlled trial that enrolled 349 patients on or approaching hemodialysis and being evaluated for radiocephalic arteriovenous fistula creation. Of these, 313 were randomized and 311 treated. Patients were assigned to vonapanitase (n = 210) or placebo (n = 103). The study drug solution was applied topically to the artery and vein for 10 minutes immediately after fistula creation. The primary and secondary end points were primary patency (time to first thrombosis or corrective procedure) and secondary patency (time to abandonment). Tertiary end points included use of the fistula for hemodialysis, fistula maturation by ultrasound, and procedure rates.

Results

The Kaplan-Meier estimates of 12-month primary patency were 42% (95% confidence interval [CI], 35-49) and 31% (95% CI, 21-42) for vonapanitase and placebo (P = .25). The Kaplan-Meier estimates of 12-month secondary patency were 74% (95% CI, 68-80) and 61% (95% CI, 51-71) for vonapanitase and placebo (P = .048). The proportions of vonapanitase and placebo patients were 39% and 25% (P = .035) with unassisted use for hemodialysis and 64% and 44% (P = .006) with unassisted plus assisted use.

Conclusions

Vonapanitase treatment did not significantly improve primary patency but was associated with increased secondary patency and use for hemodialysis. Further research is needed to evaluate these end points.  相似文献   
68.
ABSTRACT

Latinos are less likely to seek health care for eating disorders and more likely to drop out of treatment than members of other ethnic groups, highlighting existing challenges to engagement in traditional mental health care. This study explored the role of family in the treatment of adult Latinas with eating disorders through content analysis of family sessions adjunctive to cognitive behavioral therapy. This study yielded insight into the experiences of 10 Latinas with eating disorders (M age = 39.90 years) and 10 relatives (M age = 39.50) from the Promoviendo una Alimentación Saludable trial who were randomly selected to receive six family enhancement sessions. Data from 53 sessions were analyzed using a qualitative content analysis approach. Family intervention might serve as a valuable adjunct to conventional treatment by positively influencing social, family, and emotional support for Latinas with eating disorders.  相似文献   
69.

Introduction

Today's healthcare policies rely heavily on data that has been gathered from multiple small studies in intrinsically varied populations. We sought to describe the prevalence, comorbidities and outcomes of atrial fibrillation (AF) in the population of a specific region where all healthcare centers have implemented a common information technology (IT) structure.

Methods

The total number of inhabitants was obtained from the healthcare area's IT system. Information pertaining to AF was derived from various datasets in the data warehouse of the Galician regional health service.

Results

In the healthcare area of Santiago de Compostela (n=383 000), the diagnosis of AF was coded in 7990 (2.08%) individuals in 2013. Mean age was 76.83±10.5 years, mean CHA2DS2-VASc score was 3.5, 4056 (50.8%) were female and 72.6% were receiving oral anticoagulants. Up until December 31, 2015, 1361 patients died from all causes (17%), 478 (6%) of them in-hospital, with 30 deaths secondary to intracranial bleeding (0.4%) and 125 to stroke (1.6%). On multivariate analysis, age, gender, heart failure, diabetes, previous thromboembolic events and dementia were independently associated with all-cause mortality. Similarly, age, gender and previous thromboembolic events were associated with future thromboembolic events. Oral anticoagulation was found to be protective against mortality and thromboembolic events.

Conclusions

In this study, we report for the first time the true prevalence of diagnosed AF and its clinical characteristics, treatment and prognosis in a Spanish healthcare area, based on the systematic integration of data available from a universally adopted health IT system within the region.  相似文献   
70.

Background and aims

Heparin-binding EGF-like growth factor (HB-EGF) is a representative EGF family member that interacts with EGFR under diverse stress environment. Previously, we reported that the HB-EGF-targeting using antisense oligonucleotide (ASO) effectively suppressed an aortic aneurysm in the vessel wall and circulatory lipid levels. In this study, we further examined the effects of the HB-EGF ASO administration on the development of hyperlipidemia-associated atherosclerosis using an atherogenic mouse model.

Methods and results

The male and female LDLR deficient mice under Western diet containing 21% fat and 0.2% cholesterol content were cotreated with control and HB-EGF ASOs for 12 weeks. We observed that the HB-EGF ASO administration effectively downregulated circulatory VLDL- and LDL-associated lipid levels in circulation; concordantly, the HB-EGF targeting effectively suppressed the development of atherosclerosis in the aorta. An EGFR blocker BIBX1382 administration suppressed the hepatic TG secretion rate, suggesting a positive role of the HB-EGF signaling for the hepatic VLDL production. We newly observed that there was a significant improvement of the insulin sensitivity by the HB-EGF ASO administration in a mouse model under the Western diet as demonstrated by the improvement of the glucose and insulin tolerances.

Conclusion

The HB-EGF ASO administration effectively downregulated circulatory lipid levels by suppressing hepatic VLDL production rate, which leads to effective protection against atherosclerosis in the vascular wall.  相似文献   
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