Renal artery stump to inferior vena cava fistula: unusual clinical presentation and transcatheter embolization with the Amplatzer vascular plug

Fistulous communication between the renal artery stump and inferior vena cava following nephrectomy is rare. We describe the case of a 52-year-old man with a fistula detected on investigation for hemolytic anemia in the postoperative period. The patient had had a nephrectomy performed 2 weeks prior to presentation for blunt abdominal trauma. The fistula was successfully occluded percutaneously using an Amplatzer vascular plug. The patient recovered completely and was discharged 2 weeks later.     

Is the Routine Check Nephrostogram Following Percutaneous Antegrade Ureteric Stent Placement Necessary?

Our aim was to review our experience with percutaneous antegrade ureteric stent (PAUS) placement and to determine if the routinely conducted check nephrostogram on the day following ureteric stent placement was necessary. Retrospective review of patients who had undergone PAUS placement between January 2004 and December 2005 was performed. There were 83 subjects (36 males, 47 females), with a mean age of 59.9 years (range, 22–94 years). Average follow-up duration was 7.1 months (range, 1–24 months). The most common indications for PAUS placement were ureteric obstruction due to metastatic disease (n = 56) and urinary calculi (n = 34). Technical success was 93.2% (96/103 attempts), with no major immediate procedure-related complications or mortalities. The Bard 7Fr Urosoft DJ Stent was used in more than 95% of the cases. Eighty-one of 89 (91.0%) check nephrostograms demonstrated a patent ureteric stent with resultant safety catheter removal. Three check nephrostograms revealed distal stent migration requiring repositioning by a goose-snare, while five others showed stent occlusion necessitating permanent external drainage by nephrostomy drainage catheter reinsertion. Following PAUS placement, the serum creatinine level improved or stabilized in 82% of patients. The serum creatinine outcome difference between the groups with benign and malignant indications for PAUS placement was not statistically significant (p = 0.145) but resolution of hydronephrosis was significantly better (p = 0.008) in patients with benign indications. Percutaneous antegrade ureteric stent placement is a safe and effective means of relief for ureteric obstruction. The check nephrostogram following ureteric stent placement was unnecessary in the majority of patients.     

Magnesium Intake in Relation to Systemic Inflammation, Insulin Resistance, and the Incidence of Diabetes

OBJECTIVE

To investigate the long-term associations of magnesium intake with incidence of diabetes, systemic inflammation, and insulin resistance among young American adults.

RESEARCH DESIGN AND METHODS

A total of 4,497 Americans, aged 18–30 years, who had no diabetes at baseline, were prospectively examined for incident diabetes based on quintiles of magnesium intake. We also investigated the associations between magnesium intake and inflammatory markers, i.e., high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), and fibrinogen, and the homeostasis model assessment of insulin resistance (HOMA-IR).

RESULTS

During the 20-year follow-up, 330 incident cases of diabetes were identified. Magnesium intake was inversely associated with incidence of diabetes after adjustment for potential confounders. The multivariable-adjusted hazard ratio of diabetes for participants in the highest quintile of magnesium intake was 0.53 (95% CI, 0.32–0.86; P_trend < 0.01) compared with those in the lowest quintile. Consistently, magnesium intake was significantly inversely associated with hs-CRP, IL-6, fibrinogen, and HOMA-IR, and serum magnesium levels were inversely correlated with hs-CRP and HOMA-IR.

CONCLUSIONS

Magnesium intake was inversely longitudinally associated with incidence of diabetes in young American adults. This inverse association may be explained, at least in part, by the inverse correlations of magnesium intake with systemic inflammation and insulin resistance.Although obesity is an important risk factor for diabetes, certain foods or nutrients may also be associated with an increased risk of diabetes (1). Magnesium, found in whole grains, is an essential cofactor for multiple enzymes involved in glucose metabolism (2). Several cohort studies have investigated magnesium intake in relation to risk of diabetes, but the findings have been inconsistent (3). Some (4–6), but not all (7–9), studies found an inverse association between magnesium intake and diabetes risk. Of note, all previous studies except one (7) used self-reported cases, and all studies were conducted among middle-aged or elderly individuals.In addition, the pathophysiological mechanisms underlying the beneficial effects of magnesium intake on diabetes are not fully understood. Cross-sectional studies have suggested an inverse correlation between magnesium intake and inflammatory markers (10,11), and some clinical and experimental studies have suggested that magnesium may improve insulin sensitivity (12,13). Therefore, we investigated magnesium intake in relation to the incidence of diabetes in a large cohort of young American adults participating in the Coronary Artery Risk Development in Young Adults (CARDIA) study. To explore possible mechanisms, we also examined whether magnesium intake is inversely associated with systemic inflammation markers, i.e., high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), and fibrinogen, and with the homeostasis model assessment of insulin resistance (HOMA-IR).     

Prevalence and significance of unrecognized lower extremity peripheral arterial disease in general medicine practice

OBJECTIVE: To determine the prevalence of unrecognized lower extremity peripheral arterial disease (PAD) among men and women aged 55 years and older in a general internal medicine (GIM) practice and to identify characteristics and functional performance associated with unrecognized PAD. DESIGN: Cross-sectional. SETTING: Academic medical center. PARTICIPANTS: We identified 143 patients with known PAD from the noninvasive vascular laboratory, and 239 men and women aged 55 and older with no prior PAD history from a GIM practice. Group 1 consisted of patients with PAD consecutively identified from the noninvasive vascular laboratory (n = 143). Group 2 included GIM practice patients found to have an ankle brachial index less than 0.90, consistent with PAD (n = 34). Group 3 consisted of GIM practice patients without PAD (n = 205). MEASUREMENTS AND MAIN RESULTS: Leg functioning was assessed with the 6-minute walk, 4-meter walking velocity, and Walking Impairment Questionnaire (WIQ). Of GIM practice patients, 14% had unrecognized PAD. Only 44% of patients in Group 2 had exertional leg symptoms. Distances achieved in the 6-minute walk were 1,130, 1,362, and 1,539 feet for Groups 1, 2, and 3, respectively, adjusting for age, gender, and race (P <.001). The degree of difficulty walking due to leg symptoms as reported on the WIQ was comparable between Groups 2 and 3 and significantly greater in Group 1 than Group 2. In multiple logistic regression analysis including Groups 2 and 3, current cigarette smoking was associated independently with unrecognized PAD (odds ratio [OR], 6.82; 95% confidence interval [95% CI], 1.55 to 29.93). Aspirin therapy was nearly independently associated with absence of PAD (OR, 0.37; 95% CI, 0.12 to 1.12). CONCLUSION: Unrecognized PAD is common among men and women aged 55 years and older in GIM practice and is associated with impaired lower extremity functioning. Ankle brachial index screening may be necessary to diagnose unrecognized PAD in a GIM practice.     

Management of Stage MB Breast Cancer

Systemic treatments with hormones and/or chemotherapy attained outstanding success in producing objective regressions of local and distant metastases of breast cancer. With these demonstrations, similar therapies were employed in the adjuvant setting for stage II patients resulting in improved disease-free and overall survival (1,2). For locally advanced disease, systemic treatments caused substantial shrinkage of unresectable primary tumors (3,4). Because of the poor prognosis of stage III breast cancer, a positive approach to its management has been neglected or at least variable. This has been associated, in part, with the changing of staging systems of breast cancer. Further confusion occurred with clinical trials that incorporated stages IIB and III breast cancer. For clarification in this report, reference will be made to stage IIIB breast cancer (5,6). Stage IIIB breast cancer consists of tumors of any size with direct extension to the chest wall or skin (T4) with axillary node involvement (N1 and N2), but not including internal mammary chain or supraclavicular nodes. Inflammatory carcinoma (T4d) is also included. Distant metastases are not present (5,6). Data for the staging system of the American Joint Committee on Cancer in 1992 reported the 5-year survival of stage IIIB breast cancer was approximately 48% (6).