Hidden Intruder: A Rare Encounter of Dirofilaria Masquerading as a Breast Lump.

Dirofilaria, commonly known as heartworm, is a parasitic nematode that primarily infects canines. However, human infections have been reported and can present as subcutaneous nodules in different parts of the body. We present a case of a 43-year-old female who presented with a breast lump that was ultimately diagnosed as a Dirofilaria infection, a rare occurrence in humans. This case report shows that considering parasites in unusual presentations is of utmost importance, especially in regions known to have a high prevalence of such infections.

The effect of earlier or automatic collision notification on traffic mortality by survival analysis.

OBJECTIVE: This article explores the effects of earlier emergency medical services (EMS) or automatic collision notification (ACN) and EMS arrival on passenger/driver survivability within the short time frame following traffic crashes. METHODS: Survival analysis techniques are used extensively in this study, because traffic crash and EMS data are closely associated with time. The Kaplan-Meier estimator and life curves are applied to compare the survival rates between 2 or more conditions (e.g., earlier verus late EMS notification); The Weibull model with 3 parameters is used to predict mortality over time; furthermore, the Cox proportional hazard model explores multiple risk factors related to traffic mortality. RESULTS: Based on Fatality Analysis Reporting System (FARS) data from 2005 to 2009, Kaplan-Meier life curves clearly showed the benefits associated with earlier notifications (approximately 1.84% fatality reduction within a time frame of 6 h after a crash) and earlier arrivals, and the Weibull model with 3 parameters reasonably predicted the fatality trends. The relative risks (RRs) associated with collision notification, arrival, location, and age were obtained from a multiple Cox regression model, and the relatively higher fatality hazard (2.4% higher) associated with the later notification of more than 1 min was studied in detail. CONCLUSIONS: This article obtains the driver/passenger survival probability differences over time under different conditions of collision notifications, EMS arrivals, and crash locations; furthermore, this analysis provides an estimation of the lives that could potentially be saved (approximately 154 to 290 per year) due to earlier ACN.

Predicting blood pressure improvement in hypertensive patients after renal artery stent placement: renal fractional flow reserve.

BACKGROUND: Renal stent placement improves or cures hypertension in only 60-70% of patients with renal artery stenosis (RAS) and uncontrolled hypertension. There is a need to better identify patients who are likely to respond to percutaneous renal revascularization. We investigated whether an abnormal renal fractional flow reserve (FFR) would predict blood pressure improvement in patients undergoing renal artery stent placement. METHODS: We prospectively enrolled 17 patients with unilateral RAS and medically refractory hypertension (BP > 140/90 mm Hg). Renal FFR was measured at maximal hyperemia induced by papaverine followed by renal stent placement. Blood pressure improvement was defined as a blood pressure of

Diabetes mellitus does not preclude stabilization or improvement of renal function after stent revascularization in patients with kidney insufficiency and renal artery stenosis.

OBJECTIVE: To assess the impact of stent revascularization on the renal function of diabetic and nondiabetic patients with renal insufficiency. BACKGROUND: Renal artery revascularization has been shown to stabilize or improve renal function in patients with significant renal artery stenosis and impaired renal function. However, some studies have suggested negligible or no benefit of renal function in diabetic patients with the same condition. METHODS: We retrospectively compared data from 50 consecutive patients undergoing renal artery stent placement with renal insufficiency (serum creatinine > or = 1.5-4.0 mg/dl) and global ischemia (bilateral or solitary [single] kidney renal artery stenosis) There were 17 diabetic (DM) and 33 nondiabetic (NDM) patients. The endpoints included the follow-up measurements of renal function, blood pressure, and number of antihypertensive medications. RESULTS: After stent placement, at a mean follow-up of 42 +/- 18 months (range: 6-62 months), 79% NDM (N = 26), and 76% DM patients (N = 13) (P = NS) had improvement in the slope of the reciprocal of creatinine (1/SCr), indicating a beneficial effect in renal function in many patients. CONCLUSION: Renal artery stent placement appears to be equally beneficial in preserving renal function in DM and NDM patients with ischemic nephropathy and global renal ischemia.

Renal fractional flow reserve: a hemodynamic evaluation of moderate renal artery stenoses.

The objective of this study was to perform a hemodynamic evaluation of moderate (50-90%) renal artery stenosis (RAS) under conditions of rest and maximum hyperemia. Identifying patients with RAS who have hemodynamically significant stenoses and are most likely to benefit from revascularization is clinically important. Current methods used to evaluate RAS, including angiography, have limitations. Physiologic evaluation of RAS may have a role in identifying patients with hemodynamically significant stenosis. Patients with suspected renovascular hypertension due to aorto-ostial RAS were included in the study. Hyperemia was induced by administration of intrarenal papavarine. Translesional pressure gradients were measured and renal fractional flow reserve (FFR) was calculated using a 0.014'' pressure guidewire. Thirteen patients and 14 arteries with moderately severe (50-90%) RAS were studied. The mean translesional pressure gradient rose from a baseline of 6.3 +/- 3.9 to 17.5 +/- 10.8 mm Hg with maximal hyperemia. The renal FFR ranged from 0.58 to 0.95. There was a poor correlation between angiographic stenosis measurement and the renal FFR (r = -0.18; P = 0.54) and the hyperemic translesional mean pressure gradient (r = 0.22; P = 0.44). There was an excellent correlation between renal FFR and the resting mean translesional pressure gradient (r = -0.76; P = 0.0016) and the hyperemic mean translesional pressure gradient (r = -0.94; P < 0.0001). Selective renal arterial papavarine administration induces maximum hyperemia, permitting the calculation of renal FFR in renal arteries with aorto-ostial stenoses. The renal FFR correlates well with other hemodynamic parameters of lesion severity, but poorly with angiographic measures of lesion severity.

Catheter-based treatment for patients with acute ischemic stroke ineligible for intravenous thrombolysis.

BACKGROUND AND PURPOSE: We present our single-center experience using catheter-based therapy for acute ischemic stroke patients who were not candidates for intravenous thrombolytic therapy. METHODS: Neurologic outcomes were assessed in patients with acute ischemic stroke, ineligible for intravenous thrombolysis, treated with an emergent catheter-based therapy. RESULTS: Nonparametric analysis of neurological outcomes demonstrated a benefit in National Institutes of Health Stroke Scale (NIHSS) at long-term follow-up (P=0.036). Independence in daily activities and improvement in NIHSS of > or =4 points were achieved in 38% and 56% of patients, respectively. Four patients (25%) died, including 2 patients (12.5%) who died from intracranial hemorrhage. CONCLUSIONS: Catheter-based treatment offers a promising treatment strategy in patients with acute ischemic stroke ineligible for intravenous thrombolysis.

Nonhealing wound resulting from a foreign-body reaction to a radial arterial sheath.

Several patients developed sterile inflammation at their radial arterial access site. Pathologic examination of biopsy material from one patient demonstrated a foreign-body reaction to material most likely from the gel-coated arterial access sheath. Surgical excision of the inflamed tissue resulted in healing.

Vertebral and intracranial artery angioplasty.

Cerebral ischemia is due to either embolic or cerebrovascular occlusive disease, which most commonly occurs as a manifestation of atherosclerosis. Although carotid endarterectomy has been proven more effective than medical therapy in the treatment of cervical carotid disease, there are no effective surgical strategies for the management of vertebral artery or intracranial carotid disease. Management of patients with these conditions is well suited to a multidisciplinary team with the combined skills to provide optimal care. Percutaneous revascularization techniques with balloon angioplasty and stenting can be used to successfully treat occlusive disease of the vertebral and intracranial arteries. Percutaneous revascularization of intracranial and vertebral vessels with angioplasty and stenting is an effective strategy. The outcomes in this difficult to manage cohort of patients appears to be markedly improved over the natural history of this disease with medical therapy alone.

Endovascular Treatment for Vertebrobasilar Insufficiency.

Endovascular management of supra-aortic atherosclerotic vascular disease is becoming relatively common in the innominate, subclavian, and carotid arteries. However, revascularization of vertebral artery disease is an infrequently used treatment option due to several reasons: 1) stroke etiology and prevention is generally considered with respect to carotid disease as posterior circulation ischemia is poorly defined; 2) the limited success and excessive morbidity have made surgery an unattractive option for vertebral artery revascularization; 3) routine screening for posterior circulation disease as an etiology for stroke is rarely performed; and 4) endovascular treatment of vertebrobasilar insufficiency is not routinely performed in peripheral interventional programs. Randomized data comparing medical therapy, endovascular treatment, or surgical treatment do not exist. Due to infrequent identification of vertebral artery disease as the etiology of posterior circulation symptomatology, randomized comparisons will be difficult to obtain. Balloon angioplasty alone, provisional stenting, or primary stent placement for the treatment of vertebral artery stenosis is associated with low restenosis rates and high success rates. The available literature demonstrates angioplasty with stent placement of posterior circulation, symptomatic, vertebrobasilar atherosclerotic disease is a safe and effective approach that avoids the morbidity associated with major surgery. We believe primary stent placement is the treatment of choice for vertebral artery revascularization due to the high technical success rate, low incidence of morbidity and mortality, and long-term durability.

Mechanical interventions and thrombolytic therapy in venous thrombosis and pulmonary embolism.

Venous thromboembolism is associated with significant morbidity and mortality. Anticoagulation with heparin and warfarin has favorably altered the natural history of untreated venous thromboembolism. The role of thrombolysis and interventional therapy in the management of venous thromboembolism is less well appreciated. This review evaluates the role of thrombolytic therapy and mechanical interventions in the management of deep vein thrombosis and pulmonary embolism.