Central thrombi in pulmonary arterial hypertension detected by MR imaging

Differentiation of thrombi from slow flow in the pulmonary arteries, sometimes observed in the presence of pulmonary arterial hypertension, can be equivocal. Magnetic resonance (MR) imaging was performed in a patient with chronic pulmonary thromboembolism and pulmonary arterial hypertension using an electrocardiographically gated technique that allowed visualization of the pulmonary arteries at the end of diastole and multiple times during systole. These images were compared with those of a patient with primary pulmonary hypertension and those of healthy subjects. Thrombi were discrete structures, seen throughout the cardiac cycle on both the first and second spin-echo images, and decreased in signal intensity on the second image. Slow flow increased in signal intensity and changed in structure during the cardiac cycle and was seen best on the second image. MR may play an important role in excluding large central thrombi as the cause of pulmonary arterial hypertension. It is a noninvasive method for defining pulmonary arterial wall thickness and for direct visualization of chronic pulmonary thrombus.     

Pulmonary manifestations of AIDS: review of 106 episodes

We reviewed the clinical records and chest radiographs of all patients admitted to our institution between 1982 and 1984 who had pulmonary disease and who were later proved to have acquired immunodeficiency syndrome (AIDS) (95 patients). Diffuse parenchymal lung disease was the most common finding. These infiltrates were usually interstitial and caused by Pneumocystis carinii pneumonia or P. carinii combined with cytomegalovirus infection. Focal, multilobar, interstitial infiltrates were also often seen and usually caused by P. carinii or P. carinii and cytomegalovirus infections. Rarely, well-defined, multiple, interstitial nodules less than 10 mm in diameter were the only or predominant characteristic and were seen only in association with Mycobacterium tuberculosis or Cryptococcus neoformans infections or Kaposi sarcoma. Hilar or mediastinal adenopathy occurred in 17 of the 21 patients with M. tuberculosis or C. neoformans infections. In contrast, only 4% of patients with P. carinii infections presented with these findings. We also found that hilar or mediastinal adenopathy was not significantly associated with peripheral adenopathy. Lung cavitation, pleural effusion, or a normal chest radiograph was uncommon.     

Ultrastructural changes of ischemic injury due to coronary artery occlusion in the porcine heart

Using the ultrastructural criteria established by Schaper et al. 1979 [27] for distinguishing between different degrees of ischemic change in dog myocardium, slight ischemic changes are observed in the pig suboendocardium as early as 1 min after occlusion of the LAD artery. Moderate change throughout the thickness of the myocardium is seen after 6 to 12 min of ischemia and continues to be found up until 20 min after commencement of the ischemic period. 20 to 30 min ischemia produces severe ischemic damage and more than 30 min leads to irreversible damage. The changes are uniform at all stages of ischemia and there is no evidence of a transmural gradient of ultrastructural damage. Of particular interest in the early part of the ischemic period is the observation of ultrastructural changes in the subendocardial specialized conducting tissue. In these specialized cells, although morphological features consistent with slight and moderate ischemia are found as early as 1 to 2 min after occlusion, spontaneous recovery occurs and is complete by 15 min. This biphasic time course parallels the electro-physiological changes known to occur in ischemic Purkinje fibres.     

Regional block and DVT prophylaxis

The last few years have seen increasing concerns among anaesthetistsabout the risks of pharmacological prophylaxis for thromboembolicdisease. Increased bleeding during or after surgery is one concern,but of greater significance is the possibility of an increasedpredisposition to haematoma formation when regional block isused. Most of the recent consideration of this problem has beenin relation to vertebral canal haematoma formation after centralnerve block. Some thought must be given also to the possibilityof haematoma formation after peripheral techniques when thetarget nerve is deeply placed so that pressure cannot be usedto control bleeding after needle insertion. However, this reviewwill be focused on vertebral canal haematoma.     

Initiation of osteoporosis assessment in the fracture clinic results in improved osteoporosis management: a randomised controlled trial

Summary

Osteoporosis management post fragility fracture has traditionally been deficient with up to 60–90 % of patients remaining untreated for osteoporosis in some studies. Efforts have been made to address this deficiency with some successes reported.

Introduction

The aim of this study was to assess the efficacy of two different models of screening for osteoporosis in a community fracture clinic setting.

Methods

A prospective randomised clinical trial was conducted to assess the DXA scan and treatment rates in patients with fragility fractures when assessment for osteoporosis had been initiated in the fracture clinic compared with the “usual care” of assessment initiation by the participant’s general practitioner.

Results

Sixty-six patients were enrolled in the study. Thirty-three patients each were in the control and intervention groups. The assessment rate (DXA scan rate) was significantly better in the intervention group where participants were referred for assessment from fracture clinic compared to the control group where participants were referred for assessment by their general practitioner (68 vs 36 %, respectively; p?<?0.05). For patients who were assessed for osteoporosis, treatment rates were similar in both the control and intervention groups (100 vs 88 %, p?>?0.05).

Conclusion

This study demonstrates that screening for osteoporosis initiated in fracture clinic results in improved osteoporosis management compared to screening initiated in primary care. Orthopaedic surgeons and other specialists need to be more active in managing osteoporosis in patients who present with fragility fractures and should at the very least initiate assessment in the fracture clinic setting.     

Endothelial-Derived miR-17∼92 Promotes Angiogenesis to Protect against Renal Ischemia-Reperfusion Injury

BackgroundDamage to the renal microvasculature is a hallmark of renal ischemia-reperfusion injury (IRI)–mediated AKI. The miR-17∼92 miRNA cluster (encoding miR-17, -18a, -19a, -20a, -19b-1, and -92a-1) regulates angiogenesis in multiple settings, but no definitive role in renal endothelium during AKI pathogenesis has been established.MethodsAntibodies bound to magnetic beads were utilized to selectively enrich for renal endothelial cells from mice. Endothelial-specific miR-17∼92 knockout (miR-17∼92^endo−/−) mice were generated and given renal IRI. Mice were monitored for the development of AKI using serum chemistries and histology and for renal blood flow using magnetic resonance imaging (MRI) and laser Doppler imaging. Mice were treated with miRNA mimics during renal IRI, and therapeutic efficacies were evaluated.ResultsmiR-17, -18a, -20a, -19b, and pri–miR-17∼92 are dynamically regulated in renal endothelial cells after renal IRI. miR-17∼92^endo−/− exacerbates renal IRI in male and female mice. Specifically, miR-17∼92^endo−/− promotes renal tubular injury, reduces renal blood flow, promotes microvascular rarefaction, increases renal oxidative stress, and promotes macrophage infiltration to injured kidneys. The potent antiangiogenic factor thrombospondin 1 (TSP1) is highly expressed in renal endothelium in miR-17∼92^endo−/− after renal IRI and is a target of miR-18a and miR-19a/b. miR-17∼92 is critical in the angiogenic response after renal IRI, which treatment with miR-18a and miR-19b mimics can mitigate.ConclusionsThese data suggest that endothelial-derived miR-17∼92 stimulates a reparative response in damaged renal vasculature during renal IRI by regulating angiogenic pathways.     

Active surveillance is superior to radical nephrectomy and equivalent to partial nephrectomy for preserving renal function in patients with small renal masses: Results from the DISSRM registry

Purpose

We compared renal function outcomes among patients in the surveillance and intervention arms of the DISSRM registry.