Chronic mesenteric ischaemia: 28-year experience of endovascular treatment

Objective

To report the outcomes associated with endovascular therapy for patients with chronic mesenteric ischemia (CMI).

Methods

A retrospective review of patients who underwent endovascular therapy for CMI between April 1981 and September 2009 at a single institution was performed. Procedural details, mesenteric arteries treated, technical and clinical success rates, outcomes per patient and per vessel were assessed.

Results

In 166 patients treatment was attempted using a variety of balloon and stent platforms during the 28-year period. The technical success rate was 97% per patient and 94% per vessel. The technical success rate of stenting (99.4%) was higher than for percutaneous transluminal angioplasty (PTA; 86%; P = 0.0001). Immediate clinical improvement was seen in 146 out of 166 (88.2%). The type of guidewire or device platform, brachial vs. femoral artery access, balloon and/or stent diameters used, and stenosis vs. occlusion had no statistical impact on mortality or the primary patency of any mesenteric artery outcomes. The outcome of the superior mesenteric artery (SMA) with PTA appears to be superior to that of stenting (P = 0.014).

Conclusion

Technical success rates are improved with the use of stents; however, PTA use in the SMA seems to offer better primary patency rates.

Key Points

• Superior mesenteric artery (SMA) stenosis is often responsible for ischaemic symptoms.

• Treatment with percutaneous transluminal angioplasty (PTA) seems superior to stenting

• Although technical success rates are improved with the use of stents.

• Higher mortality in the elderly and those presenting with nausea/vomiting/bloody stools.

     

Two giant cavernous hemangioma caused cavernous transformation of the portal vein in a pregnant woman.

We report a case with two giant hemangiomas of the liver that caused cavernous transformation of the portal vein in a 45-yr-old full term pregnant woman. The patient had no serious complaints other than a mass and slight pain in the right upper quadrant and there were no abnormalities in laboratory values. Delivery was performed without complication. In the six month follow-up period, no changes were seen in the lesions.     

FDG PET/CT imaging in the diagnosis of osteomyelitis in the diabetic foot

Purpose

Osteomyelitis, the most serious complication of the diabetic foot, occurs in about 20?% of patients. Early diagnosis is crucial. Appropriate treatment will avoid or decrease the likelihood of amputation. The objective of this study was to assess the value of FDG PET/CT in diabetic patients with clinically suspected osteomyelitis.

Methods

Enrolled in this prospective study were 39 consecutive diabetic patients (29 men and 10 women, mean age 57?years, range 28–71?years) with 46 suspected sites of foot infection. Of these 39 patients, 38 had type 2 and 1 type 1 diabetes for 4–25?years, and 28 were receiving treatment with insulin. FDG PET/CT was interpreted for the presence, intensity (SUVmax) and localization of increased FDG foci. Final diagnosis was based on histopathology and bacteriology of surgical samples, or clinical and imaging follow-up.

Results

Osteomyelitis was correctly diagnosed in 18 and excluded in 21 sites. Of 20 lesions with focal bone FDG uptake, 2 were false-positive with no further evidence of osteomyelitis. Five sites of diffuse FDG uptake involving more than one bone on CT were correctly diagnosed as diabetic osteoarthropathy. FDG PET/CT had a sensitivity, specificity and accuracy of 100?%, 92?% and 95?% in a patient-based analysis and 100?%, 93?% and 96?% in a lesion-based analysis, respectively, for the diagnosis of osteomyelitis in the diabetic foot.

Conclusion

FDG PET/CT was found to have high performance indices for evaluation of the diabetic foot. The PET component identified FDG-avid foci in sites of acute infection which were precisely localized on fused PET/CT images allowing correct differentiation between osteomyelitis and soft-tissue infection.     

Is antibiotic prophylaxis necessary in elective soft tissue hand surgery?

Antibiotic prophylaxis for clean soft tissue hand surgery is not yet defined. Current literature focuses on overall orthopedic procedures, traumatic hand surgery, and carpal tunnel release. However, a paucity of data exists regarding the role of antibiotic prophylaxis in a broader variety of soft tissue hand procedures. The goal of the current study was to evaluate the rates of surgical site infection following elective soft tissue hand surgery with respect to administration of prophylactic antibiotics.A multicenter, retrospective review was performed on 600 consecutive elective soft tissue hand procedures. Procedures with concomitant implant or incomplete records were excluded. Antibiotic delivery was given at the discretion of the attending surgeon. Patient comorbidities were recorded. Outcomes were measured by the presence of deep or superficial infections within 30 days postoperatively. The 4 most common procedures were carpal tunnel release, trigger finger release, mass excision, and first dorsal compartment release. The overall infection rate was 0.66%. All infections were considered superficial, and none required surgical management. In patients who received antibiotic prophylaxis (n=212), the infection rate was 0.47%. In those who did not receive prophylaxis (n=388), the infection rate was 0.77%. These differences were not statistically significant (P=1.00).     

Peripheral nerve injuries following gunshot fracture of the humerus

Current best evidence supports observation for peripheral nerve palsies following a fracture of the humerus unless associated with an open fracture. However, the indications for nerve exploration with humerus gunshot fractures are unclear. All patients aged 18 to 89 years who were treated for a gunshot fracture of the humerus at an academic trauma center between 2004 and 2008 were retrospectively reviewed. Patient demographics, fracture characteristics, fracture healing, nerve injury, and intraoperative findings were examined. Twelve patients were identified, of which 6 had nerve palsies at presentation. Three patients had an isolated single nerve palsy, and all recovered spontaneously within 90 days with observation. The other 3 patients had a concomitant brachial artery laceration, and all required a secondary nerve procedure, including 1 primary nerve repair for a near complete transection and 2 re-explorations with neurolysis due to lack of spontaneous recovery by 90 days. Nerve palsies are common after gunshot fractures of the humerus, but nerve transections are uncommon. We observed 1 nerve transection in 12 cases. However, in all 3 cases with a brachial artery injury, a nerve injury required surgical intervention. Subsequently, we recommend continued observation of isolated nerve palsies associated with gunshot fractures of the humerus. However, consider early nerve exploration of palsies when associated with a concomitant vascular injury.     

Androgen receptor-independent prostate cancer: an emerging clinical entity

Androgen deprivation therapy remains the backbone of prostate cancer treatment given its pivotal role in the pathogenesis of prostate cancer. The growing knowledge of androgen receptor-independent (i.e. AR-null) prostate cancer cells, however, might advance the treatment paradigm of prostate cancer. Here, we examined the results of two recent studies, published in Cancer Cell by Bluemn and Shukla et al., and their impact in the future management of castration-resistant prostate cancer.     

Serum antibodies to gangliosides in Guillain-Barré syndrome

To determine whether antibodies to acidic glycolipids of nervous tissue are present in patients with Guillain-Barré syndrome (GBS), sera from patients with GBS and appropriate control subjects were tested by a thin-layer chromatogram overlay technique. Chromatograms on which the whole ganglioside fractions from peripheral nerve and brain had been separated were overlaid with appropriate dilutions of the patients' sera (1:100 or greater), and antibody binding was revealed with a radiolabeled or peroxidase-labeled second antibody. Antibodies to ganglioside antigens were detected in 5 of 26 patients with GBS. IgG antibodies in 1 patient reacted strongly with LM1 (sialosyl paragloboside), the major ganglioside of human peripheral nervous system myelin, and its hexaose analog (sialosyl lactosaminyl paragloboside), a minor ganglioside of human peripheral nervous system myelin. The antibody titer in this patient fell 8-fold over 6 weeks coincident with clinical improvement. IgG from 2 other patients with GBS reacted with GD1b ganglioside, and the antibody titers in these patients also decreased substantially with clinical improvement. IgM antibodies in the sera from 2 other patients reacted with GD1a and GT1b gangliosides, which have a shared terminal carbohydrate sequence. Antibodies to gangliosides were not detected in the sera from 19 patients with other neurological diseases or from 10 normal subjects, and the frequency with which antiganglioside antibodies occurred in the patients with GBS was significantly greater than that in the combined control subjects (p less than 0.01). The results demonstrate relatively high levels of antibodies to gangliosides in some GBS patients.     

Mouse monoclonal and rabbit polyclonal antibodies prepared to human myelin-associated glycoprotein also react with glycosphingolipids of peripheral nerve

A panel of mouse monoclonal antibodies and rabbit polyclonal antisera that were raised to myelin-associated glycoprotein (MAG) were screened for reactivity with acidic glycolipids from brain and peripheral nerve by enzyme-linked immunosorbent assay (ELISA) and/or a thin-layer chromatogram overlay technique. Seven out of 7 mouse monoclonal antibodies that recognize carbohydrate epitopes in human MAG also reacted with acidic glycolipids from human and cat peripheral nerve, while monoclonal antibodies that react with polypeptide epitopes on MAG did not react with these glycolipids. Rabbit anti-human MAG antisera also strongly reacted with the glycolipids from peripheral nerve, while rabbit antisera raised to rat MAG did not. None of the antibodies reacted with similar glycolipid fractions prepared from adult human brain. Overlay of thin-layer chromatograms revealed that all the mouse and rabbit antibodies showing reactivity with peripheral nerve glycolipids were binding to the same two sphingoglycolipids that react with human anti-MAG IgM paraproteins in neuropathy and with HNK-1 (anti-Leu-7), a mouse IgM monoclonal antibody that identifies a subset of human lymphocytes with natural killer function. Thus, the carbohydrate epitope(s) in MAG which is shared with nerve acidic glycolipids appears to be highly immunogenic in mice and rabbits. Further, it is clear that the antibodies that react with the carbohydrate moieties of human MAG cannot be used as specific probes for this glycoprotein.     

Temporal integration: intentional sound discrimination does not modulate stimulus-driven processes in auditory event synthesis

Objective: Our previous study showed that the auditory context could influence whether two successive acoustic changes occurring within the temporal integration window (approximately 200 ms) were pre-attentively encoded as a single auditory event or as two discrete events (Cogn Brain Res 12 (2001) 431). The aim of the current study was to assess whether top-down processes could influence the stimulus-driven processes in determining what constitutes an auditory event.Methods: Electroencepholagram (EEG) was recorded from 11 scalp electrodes to frequently occurring standard and infrequently occurring deviant sounds. Within the stimulus blocks, deviants either occurred only in pairs (successive feature changes) or both singly and in pairs. Event-related potential indices of change and target detection, the mismatch negativity (MMN) and the N2b component, respectively, were compared with the simultaneously measured performance in discriminating the deviants.Results: Even though subjects could voluntarily distinguish the two successive auditory feature changes from each other, which was also indicated by the elicitation of the N2b target-detection response, top-down processes did not modify the event organization reflected by the MMN response.Conclusions: Top-down processes can extract elemental auditory information from a single integrated acoustic event, but the extraction occurs at a later processing stage than the one whose outcome is indexed by MMN.Significance: Initial processes of auditory event-formation are fully governed by the context within which the sounds occur. Perception of the deviants as two separate sound events (the top-down effects) did not change the initial neural representation of the same deviants as one event (indexed by the MMN), without a corresponding change in the stimulus-driven sound organization.