Distal revascularization-interval ligation: a durable and effective treatment for ischemic steal syndrome after hemodialysis access

PURPOSE: The treatment of hemodialysis access-induced ischemic steal syndrome is challenging. Despite promising early results with the distal revascularization-interval ligation (DRIL) procedure, the operation has not been widely adopted because of concerns about its complexity and long-term efficacy. The purpose of this report was to determine the efficacy and durability of the DRIL procedure in relieving hand ischemia and in maintaining access patency in the setting of hemodialysis access-induced ischemia. METHODS: A retrospective review was performed of all patients who underwent the DRIL procedure for access-induced ischemia. Demographic information was compiled, as were data regarding access and bypass patency, limb salvage, and patient survival. Arteriovenous access and brachial artery bypass patency rates were determined with life-table methods. RESULTS: Between 1995 and 2001, we performed 55 DRIL procedures in 52 patients (35 women and 17 men; mean age, 60.8 years; range, 30 to 86 years). The indications for surgery were ischemic pain in 27 patients, tissue loss in 20 patients, loss of neurologic function in four patients, and pain on hemodialysis in one patient. Most patients (92%) had diabetes. The mean interval from access placement to DRIL was 7.4 months (range, 1 to 84 months). The mean follow-up interval was 16 months (range, 1 to 67 months). The brachial artery bypass primary patency rate was 80% at 4 years, and the arteriovenous access primary patency rate was 83% at 1 year. Forty-seven of 52 patients (90%) had substantial or complete relief of ischemic hand symptoms, and 15 of 20 patients with digital ischemic lesions have healed completely. CONCLUSION: DRIL is a durable and effective procedure that reliably accomplishes the twin goals in the treatment of angioaccess-induced ischemia: persistent relief of hand ischemia and continued access patency.     

Splanchnic artery aneurysms and pseudoaneurysms: transcatheter embolization

Over the past 7 years, eight patients with splanchnic artery aneurysms and pseudoaneurysms were studied and treated. Transcatheter embolization resulted in occlusion of the lesions in all eight patients. Potentially risky and difficult surgery was avoided completely in four patients. Three patients had elective surgery at a later date when their condition was more stable. The remaining patient had definitive surgery after embolization. Transcatheter embolization should be the initial treatment of choice in splanchnic artery aneurysms and pseudoaneurysms.     

Impact of clinical history on fracture detection with radiography

The effect of knowledge of localizing symptoms and signs in the detection of fractures was studied. Forty radiographs of the extremities were examined twice by seven radiologists; the sessions were separated by 4 months. In 26 cases, a subtle fracture was present; 14 cases were normal. In half of the cases at each session, the precise location of pain, tenderness, or swelling was provided. The observer was asked to determine if the case was normal or abnormal (provide the exact location of the fracture) and to indicate the degree of confidence in the diagnosis. Responses were converted to a numeric scale for analysis. Analysis of receiver operator characteristic parameters indicates that clues regarding location of trauma facilitate detection of fractures. The improvement is based largely on an increased true-positive rate without an increased false-positive rate, regardless of the decision criteria of the radiologist (overall willingness to "overread" or "underread"). This has direct clinical applicability and reinforces the plea of radiologists for precise clinical information.     

Generation of CD1+RelB+ dendritic cells and tartrate-resistant acid phosphatase-positive osteoclast-like multinucleated giant cells from human monocytes

We previously showed that granulocyte-macrophage colony-stimulating factor (GM-CSF) and macrophage colony-stimulating factor (M-CSF) stimulate the differentiation of human monocytes into two phenotypically distinct types of macrophages. However, in vivo, not only CSF but also many other cytokines are produced under various conditions. Those cytokines may modulate the differentiation of monocytes by CSFs. In the present study, we showed that CD14+ adherent human monocytes can differentiate into CD1+relB+ dendritic cells (DC) by the combination of GM-CSF plus interleukin-4 (IL-4) and that they differentiate into tartrate-resistant acid phosphatase (TRAP)-positive osteoclast-like multinucleated giant cells (MGC) by the combination of M-CSF plus IL-4. However, the monocyte-derived DC were not terminally differentiated cells; they could still convert to macrophages in response to M-CSF. Tumor necrosis factor-alpha (TNF-alpha) stimulated the terminal differentiation of the DC by downregulating the expression of the M-CSF receptor, cfms mRNA, and aborting the potential to convert to macrophages. In contrast to IL-4, interferon-gamma (IFN-gamma) had no demonstrable effect on the differentiation of monocytes. Rather, IFN- gamma antagonized the effect of IL-4 and suppressed the DC and MGC formation induced by GM-CSF + IL-4 and M-CSF + IL-4, respectively. Taken together, these results provide a new aspect to our knowledge of monocyte differentiation and provide evidence that human monocytes are flexible in their differentiation potential and are precursors not only of macrophages but also of CD1+relB+DC and TRAP-positive MGC. Such a diverse pathway of monocyte differentiation may constitute one of the basic mechanisms of immune regulation.     

Human herpesvirus 6 and multiple sclerosis: systemic active infections in patients with early disease.

By means of immunohistochemical staining, cells actively infected with human herpesvirus 6 (HHV-6) were found in central nervous system tissues from 8 (73%) of 11 patients with definite multiple sclerosis (MS). Interestingly, 17 (90%) of 19 tissue sections showing active demyelination were positive for HHV-6-infected cells compared with only 3 (13%) of 23 tissue sections free of active disease (P<.0001). Central nervous system tissues from 2 of 28 normal persons and patients with other inflammatory demyelinative diseases were positive for HHV-6-infected cells (P<.0001), and the 2 positive cases were diagnosed as having HHV-6 leukoencephalitis. By use of a rapid culture assay, blood samples from 22 (54%) of 41 patients with definite MS were found to contain active HHV-6 infections, compared with 0 of 61 normal controls (P<.0001). No significant difference was found between HHV-6 viremia-positive and HHV-6 viremia-negative MS patients with respect to type of disease (relapsing/remitting or progressive). In contrast, patients with active HHV-6 viremia were significantly younger and had shorter durations of disease than did HHV-6 viremia-negative patients.     

Blood Pressure Variations During a Working Day at Age 28: Effects of Different Types of Work and Blood Pressure Level at Age 18

Abstract

During an ordinary work day blood pressure was self-monitored once every hour in two samples of asymptomatic nonmedicating 28-year-old men. They were selected on the basis of previous compulsory blood pressure recordings made at the age of 18 when they had been drafted for military service. Subjects in the ?original hypertensive sample” with ?strain” occupations (hectic and uncontrollable, such as waiter, driver and cook) had more marked elevations of systolic blood pressure during work hours than other subjects.     

Bcp1, a gene required for male fertility in Arabidopsis.

Male fertility in flowering plants is dependent on production of viable pollen grains within the anther. Genes expressed exclusively in the anther are likely to include those that control male fertility. On the basis of their tissue specificity, such genes have been isolated, yet in none of them has this function been demonstrated. Here we report that one such gene, Bcp1, is active in both diploid tapetum and haploid microspores and is required for pollen fertility. Perturbation of this gene in either tapetum or microspores prevents production of fertile pollen in transgenic Arabidopsis plants. When tapetum expression of this gene is perturbed, mature anthers contain dead shriveled pollen. On the other hand, when microspore expression is perturbed, anthers show 1:1 segregation of viable/aborted pollen. These findings identify a class of sporophytic/gametophytic genes controlling male fertility and, hence, reproduction in flowering plants.