Development of Research Agenda in Prostate Artery Embolization: Summary of Society of Interventional Radiology Consensus Panel

PurposeTo summarize the Society of Interventional Radiology Foundation’s Research Consensus Panel development of a research agenda on prostate artery embolization (PAE).Materials and MethodsPAE for the treatment of lower urinary tract symptoms has been shown to be safe and effective in decreasing symptoms and prostate size. Lack of randomized controlled trials (RCTs) on PAE in the United States has prevented inclusion in American Urologic Association guideline recommendations for treatment of lower urinary tract symptoms resulting from benign prostatic hyperplasia. Recognizing the need for well-designed trials, the SIR Foundation funded a Research Consensus Panel to prioritize a research agenda. The panel included interventional radiologists, urologists, SIR Foundation leadership, and industry representatives. The goal of the meeting was to discuss weaknesses with current data and study design for development of US trials to report long-term outcomes data.ResultsFinal consensus on a research design could not be made because the group was split on 3 research designs: (i) RCT of PAE versus sham with crossover of the sham group. (ii) RCT of PAE versus simple prostatectomy. (iii) RCT of PAE versus holmium laser enucleation of the prostate/thulium laser enucleation of the prostate. The panel recommended a nonindustry-funded registry to obtain real-world data.ConclusionsLevel 1 data are required to be included in the American Urologic Association guidelines for treatment of benign prostatic hyperplasia. Because of concerns with all 3 study designs, the panel did not reach a consensus. Further meetings are planned with the panel to select among these research designs.     

慢性便秘继发肠系膜上动脉压迫综合征(李氏三联征)的诊断与治疗

目的归纳按“李氏三联征”概念指导诊断和治疗慢性便秘继发肠系膜上动脉压迫综合征(SMAS)的经验。方法“李氏三联征”的概念包括:(1)临床症状:便秘、营养不良、上消化道梗阻(呕吐、进食困难)三联症状;(2)解剖学表现:具有横结肠下垂、脾曲升高和肠系膜上动脉压迫三联解剖异常;(3)治疗:均给予肠内营养支持、胸膝位、菌群移植三联治疗。根据“李氏三联征”概念,采用描述性病例系列研究方法,前瞻性纳入2014年6月至2018年11月期间,同济大学附属第十人民医院和东部战区总医院收治的78例慢性便秘继发SMAS患者的病例资料,包括基本信息、症状体征、影像学资料、营养指标、胃肠生活质量指数和Wexner排粪评分,按上述“李氏三联征”的标准进行评估和治疗,对临床症状和解剖学特征指标进行随访,记录治疗后1、3、6和12个月的变化。结果治疗前所有患者均有“李氏三联征”特征,均存在严重便秘、营养不良及上消化道梗阻的临床表现,均具有肠系膜上动脉压迫征象和明显的脾曲升高的解剖学表现。经肠内营养支持、胸膝位及菌群移植三联治疗后,69例(88.5%)症状明显改善,9例治疗无效行手术治疗。69例非手术患者经12个月随访,结果显示,所有患者均恢复正常进食,1个月后便秘相关指标改善,至12个月后时,每周自主排粪次数从治疗前(1.0±0.8)次增加至(5.0±1.6)次,胃肠生活质量指数由治疗前(52.7±8.5)分增加至(93.2±7.5)分,Wexner排粪评分由治疗前(19.1±2.5)分下降至(6.2±2.1)分,差异均有统计学意义(均P<0.001)。随访1个月后营养指标改善,至12个月后时,体质指数从治疗前(17.9±1.8)kg/m2增加至(21.0±1.3)kg/m2,总蛋白由(65.2±5.7)g/L增加至(68.3±4.2)g/L,白蛋白从(32.1±5.1)g/L增加至(40.4±3.0)g/L,纤维蛋白原从(1.9±0.5)g/L增加至(2.4±0.5)g/L,前白蛋白从(163.2±5.3)mg/L增加至(259.1±45.6)mg/L;差异均有统计学意义(均P<0.001)。上消化道造影及肠系膜上动脉成像均显示十二指肠受压征象解除,肠系膜上动脉与腹主动脉夹角从治疗前(17.4±3.8)°增加至(37.8±5.8)°(t=-22.26,P<0.001)。结论慢性便秘继发SMAS患者具有“李氏三联征”的异常三联临床症状和解剖学表现时,应给予肠内营养支持、胸膝位及菌群移植三联治疗。     

Carotid Artery-Related Perioperative Stroke Following Anterior Cervical Spine Surgery: A Series of 3 Cases and Literature Review

Background

Vascular complications following anterior cervical spine surgery are rare but potentially devastating. Complications associated with the carotid artery are even more disastrous but largely anecdotal, with no more than 4 reported cases.

Feasibility of coronary artery calcium scoring on virtual unenhanced images derived from single-source fast kVp-switching dual-energy coronary CT angiography

BackgroundDual-energy CT technology enables acquisition of virtual unenhanced (VUE) images from contrast-enhanced scans.ObjectiveTo assess the feasibility of coronary artery calcium (CAC) scoring on VUE images derived from fast kVp-switching dual-energy coronary CT angiography.MethodsTwenty-seven patients underwent true noncontrast CAC-scoring CT followed by routine single-energy (120-kVp) and fast kVp-switching dual-energy coronary CT angiography, in a random acquisition order on the same day. We calculated the CAC scores on true noncontrast and VUE images. The image noises and the signal-to-noise and contrast-to-noise ratios of the aorta and coronary arteries were measured on both the single-energy coronary CT angiography images and dual-energy coronary CT angiography images (70 keV virtual monochromatic spectral images). The Pearson correlation coefficient test and paired t test were used for statistical analysis.ResultsExcellent correlation was observed between the CAC scores on the true noncontrast and those on the VUE images (r = 0.88; P < .001). Compared with single-energy coronary CT angiography, dual-energy coronary CT angiography showed significantly reduced image noise and increased signal-to-noise and contrast-to-noise ratios in all regions (all P < .001). The effective dose of dual-energy coronary CT angiography (4.3 ± 0.3 mSv) was significantly lower than that of true noncontrast CAC-scoring CT plus single-energy coronary CT angiography (5.4 ± 0.7 mSv; P < .0001).ConclusionsExcellent correlation was observed between the CAC scores on the VUE images and true noncontrast images. Thus, fast kVp-switching dual-energy coronary CT angiography could allow prediction of the true CAC scores, potentially reducing the total radiation exposure and image acquisition time by obviating the need for true noncontrast CAC-scoring CT.     

Acute myocardial infarction due to simultaneous spasm of 3 coronary arteries that worsened over time

Coronary artery spasm (CAS) rarely worsens from single-vessel to simultaneous multivessel CAS naturally, and simultaneous multivessel CAS leads to serious conditions such as cardiopulmonary arrest (CPA). A 77-year-old Japanese man who took medications for CAS was transferred to our hospital due to persistent chest pain. On arrival, his vital signs were stable, but his electrocardiogram (ECG) showed ST-segment elevation in leads II, III and aVF. Ventricular fibrillation developed suddenly. Although routine cardiopulmonary resuscitation (CPR) including intravenous administration of epinephrine was performed immediately, he could not be resuscitated. After initiation of percutaneous cardiopulmonary support (PCPS), there was a return of spontaneous circulation. His ECG showed exacerbation of myocardial ischemia with ST-segment elevation in leads I, II, III, aVL, aVF and V3–V6. Emergency coronary angiography revealed severe CAS of the right and left coronary arteries, which was relieved completely by intracoronary administration of nitrates. He was diagnosed with acute myocardial infarction due to simultaneous 3-vessel CAS that progressed over time. About 6 h after arrival, he developed hemodynamic instability and died. CAS worsened from single-vessel to simultaneous 3-vessel spasm, and intracoronary administration of nitrates was effective in relieving CAS, which was documented by the ECG and coronary angiogram. Since CAS can progress over time, nitrates must be administered immediately. When CAS leads to CPA, epinephrine may be ineffective in CPR because of its vasoconstrictive effect on coronary arteries; therefore, PCPS should be initiated, and intracoronary nitrates should be administered.     

Paraaortic dissection in “total mesopancreas excision” and “mesopancreas-first resection” pancreaticoduodenectomies for pancreatic cancer: Useless,optional, or necessary?A systematic review

The mesopancreas does not have well-defined boundaries but is continuous and connected through its components with the paraaortic area. The mesopancreatic resection margin has been indicated as the primary site for R1 resection after PD in pancreatic head cancer and total mesopancreas excision has been proposed to achieve adequate retropancreatic margin clearance and to minimize the likelihood of R1 resection. However, the anatomy of the mesopancreas requires extended dissection of the paraaortic area to maximize posterior clearance. The artery-first surgical approach has been developed to increase local radicality at the mesopancreatic resection margin. During PD, the artery-first approach begins with dissection of the connective tissues around the SMA. However, the concept of the mesopancreas as a boundless structure that includes circumferential tissues around the SMA, SMV, and paraaortic tissue highlights the need to shift from artery-first PD to mesopancreas-first PD to reduce the risk of R1 resection. From this perspective the “artery-first” approach, which allows for the avoidance of R2 resection risk, should be integrated into the “mesopancreas-first” approach to improve the R0 resection rate.In total mesopancreas excision and mesopancreas-first pancreaticoduodenectomies, the inclusion of the paraaortic area and circumferential area around the SMA in the resection field is necessary to control the tumour spread along the mesopancreatic resection margin rather than to control or stage the spread in the nodal basin.     

Radiographic study to assess the reliability of the Gillies approach for biopsy of the superficial temporal artery

Biopsy of the superficial temporal artery is often used in the diagnosis of giant cell arteritis, but at traditional sites there is a risk of injury to the facial nerve. Recently the Gillies incision has been suggested as an alternative means of access for the biopsy, but the anatomical basis of this has not been fully elucidated. We therefore undertook a radiographic review of 150 patients, and examining 300 vessels, to find out. Our results indicated that there is considerable variability in the position of the bifurcation of the superficial temporal artery, and so a Gillies approach may not be reliable, particularly if access to the bifurcation is required.     

The metabolic syndrome and risk of coronary artery disease in patients with chronic schizophrenia or schizoaffective disorder in a chronic mental institute

The prevalence rate of metabolic syndrome (MS) and coronary artery disease (CAD) has been found to be high in patients with chronic schizophrenia. Current evidence shows that CAD is underdiagnosed in this group. Our study evaluated the prevalence of MS and the risk of CAD in patients with chronic schizophrenia in a chronic care mental hospital in southern Taiwan. We included all patients with the diagnosis of schizophrenia or schizoaffective disorder. We collected all laboratory, physical examination, psychiatric interview, and chart review data. We also evaluated the risk of CAD in these patients using the Framingham point system. There was no significant age difference in the MS prevalence rate in these patients. The young patients with schizophrenia in our study tended to have a higher prevalence of MS than the general population. In addition, female patients had a higher prevalence rate of MS than males. Based on the Framingham point system, we found the 10-year risk of CAD to be higher among the patients with schizophrenia than in the general population. Our study highlights the importance of the high risk of MS in both younger and older patients with schizophrenia, without a significant relationship to the use of antipsychotics. More complete cohort studies are needed to confirm these findings. Psychiatrists may want to establish more specific and detailed clinical guidelines for patients with chronic schizophrenia with comorbid physical diseases, especially MS and CAD.