CXCR2 expression during melanoma tumorigenesis controls transcriptional programs that facilitate tumor growth.

BACKGROUND: Though the CXCR2 chemokine receptor is known to play a key role in cancer growth and response to therapy, a direct link between expression of CXCR2 in tumor progenitor cells during induction of tumorigenesis has not been established. METHODS: To characterize the role of CXCR2 during melanoma tumorigenesis, we generated tamoxifen-inducible tyrosinase-promoter driven BrafV600E/Pten-/-/Cxcr2-/- and NRasQ61R/INK4a-/-/Cxcr2-/- melanoma models. In addition, the effects of a CXCR1/CXCR2 antagonist, SX-682, on melanoma tumorigenesis were evaluated in BrafV600E/Pten-/- and NRasQ61R/INK4a-/- mice and in melanoma cell lines. Potential mechanisms by which Cxcr2 affects melanoma tumorigenesis in these murine models were explored using RNAseq, mMCP-counter, ChIPseq, and qRT-PCR; flow cytometry, and reverse phosphoprotein analysis (RPPA). RESULTS: Genetic loss of Cxcr2 or pharmacological inhibition of CXCR1/CXCR2 during melanoma tumor induction resulted in key changes in gene expression that reduced tumor incidence/growth and increased anti-tumor immunity. Interestingly, after Cxcr2 ablation, Tfcp2l1, a key tumor suppressive transcription factor, was the only gene significantly induced with a log2 fold-change greater than 2 in these three different melanoma models. CONCLUSIONS: Here, we provide novel mechanistic insight revealing how loss of Cxcr2 expression/activity in melanoma tumor progenitor cells results in reduced tumor burden and creation of an anti-tumor immune microenvironment. This mechanism entails an increase in expression of the tumor suppressive transcription factor, Tfcp2l1, along with alteration in the expression of genes involved in growth regulation, tumor suppression, stemness, differentiation, and immune modulation. These gene expression changes are coincident with reduction in the activation of key growth regulatory pathways, including AKT and mTOR.

Characteristic findings of cervical Papanicolaou tests from transgender patients on androgen therapy: Challenges in detecting dysplasia.

INTRODUCTION: The characteristic features of Papanicolaou (Pap) tests collected from female-to-male (FTM) transgender patients on androgen therapy have not been well defined in the literature. FTM transgender patients require cervical cancer screening with the same recommended frequency as cis-gender females. Dysplasia remains challenging to differentiate from atrophy. Without pertinent history, the atrophic findings in younger transgender patients can be misinterpreted as high-grade dysplasia. METHODS: A review of all cervical Pap tests of transgender patients receiving androgen therapy (2010-2017) was performed. Bethesda diagnosis, cytomorphological features, HPV testing and cervical biopsy results were reviewed. RESULTS: Eleven transgender patients receiving androgen therapy were identified with 23 cervical Pap tests, 11 HPV tests and five cervical biopsies performed. A review of the Pap tests demonstrated: 57% negative for intraepithelial lesion; 13% unsatisfactory; 13% atypical squamous cells of undetermined significance; 13% atypical squamous cells - cannot exclude high-grade squamous intraepithelial lesion; and 4% high-grade squamous intraepithelial lesion. The rates of abnormal tests were higher than our age-matched cis-gender atrophic cohort rates of unsatisfactory (0.5%), atypical squamous cells of undetermined significance (7%), atypical squamous cells-cannot exclude high-grade squamous intraepithelial lesion (0%) and high-grade squamous intraepithelial lesion (0.5%). The cytological findings from liquid-based preparations included dispersed and clustered parabasal-type cells, scattered degenerated cells, smooth evenly dispersed chromatin, and occasional mild nuclear enlargement and irregularity. Dysplastic cells had larger nuclei, hyperchromatic clumped chromatin, and more irregular nuclear contours. CONCLUSIONS: The evaluation of dysplasia can be challenging on Pap tests from transgender patients on androgen therapy. The cohort evaluated had higher rates of unsatisfactory and abnormal Pap tests. Pathologists should be familiar with the distinctive cytomorphological changes in the Pap tests from patients on androgen therapy to evaluate them appropriately.

Combination antimicrobial therapy in patients with Staphylococcus aureus bacteraemia-a post hoc analysis in 964 prospectively evaluated patients.

OBJECTIVES: The evidence for using combination antimicrobial therapy (CoRx) in Staphylococcus aureus bacteraemia (SAB) is limited. We aimed to investigate whether CoRx is associated with higher survival or lower SAB-related late complications. METHODS: We performed a post hoc analysis of a prospective SAB cohort study. CoRx was defined as a cell wall-active antistaphylococcal agent plus either rifampicin, a fluoroquinolone, fosfomycin or an aminoglycoside. To adjust for survivor bias multivariable Cox models that included CoRx as a time-dependent covariable were calculated. RESULTS: Of 964 evaluable patients, 512 (53%) received CoRx, most of them (301/512, 59%) rifampicin-containing CoRx. All-cause mortality after 30 and 90 days was similar for the two groups, although the patients in the CoRx group had more often endocarditis, deep-seated or disseminated infections and severe sepsis/septic shock. For the entire cohort, only age, comorbidity and severe sepsis/septic shock were associated with a higher mortality and infectious disease consultation, but not CoRx with a lower mortality. However, in the subgroup of patients with implanted foreign bodies or devices CoRx was independently associated with a lower mortality at 30 days (hazard ratio 0.6, 95% confidence interval 0.3-1.1) and at 90 days (hazard ratio 0.6, 95% confidence interval 0.4-0.9). SAB-related late complications in this subgroup occurred in 15 (10.6%) of 142 patients in the monotherapy group vs. nine (4.5%) of 202 patients in the CoRx group (p 0.03). CONCLUSIONS: In a setting of optimized management of adult patients with SAB secured by infectious disease consultations, this observational study could not prove CoRx to be independently associated with improved survival or reduced late complications in the entire cohort. However, administration of CoRx may be associated with lower mortality and fewer SAB-related late complications in the subgroup of patients with implanted foreign bodies or devices. Prospective randomized trials should be performed to prove this benefit.

[The use of benzodiazepines and Z-drugs for patients with sleeping problems - A survey among hospital doctors and nurses]. / Benzodiazepine und Z-Substanzen als Schlaf- und Beruhigungsmittel in einem Krankenhaus.

Aim | Benzodiazepines and Z-drugs are frequently prescribed sleep medications in spite of their poor risk-benefit ratio when used over a longer period of time. The aim of the study was to find out how the medical and nursing staff in a general hospital estimated the frequency of use for these drugs, and the risk-benefit ratio for elderly patients as well as the factors which positively influence the perceived use of these drugs. Methods | All members of the medical and nursing staff of a hospital received a questionnaire about their use of, and attitudes towards, benzodiazepines and Z-drugs. Absolute and relative frequencies were calculated to estimate the perceived frequency of use and the risk-benefit ratio. Multiple logistic regressions were used to analyze which factors are associated with a perceived high use of benzodiazepines or Z-drugs for insomnia. Results | More nurses than hospital doctors believed that they dispensed benzodiazepines often or always (57 % vs. 29 %) to patients with insomnia; this was also the case for Z-drugs (66 % vs. 29 %). Nearly half of the hospital doctors and 29 % of the nurses perceived more harms than benefits for benzodiazepines in the elderly. The following factors were associated with a high perceived usage of Z-drugs: working as a nurse (OR: 13,95; 95%-CI: 3,87-50,28), working in a non-surgical department (5,41; 2,00-14,61), having < 5 years of professional experience (4,90; 1,43-16,81) and feeling that the benefits of Z-drugs outweigh the risks for elderly patients (5,07; 1,48-17,35). For benzodiazepines, only the perceived positive risk-benefit ratio had an influence on the perceived use (3,35; 1,28-8.79). Conclusion | The medical and nursing staff perceived the frequency of prescription of benzodiazepines and Z-drugs and the risk-benefit ratio in different ways. Other aspects, such as working in a non-surgical department or having a smaller amount of working experience may also influence the decision to use Z-drugs.

Age cut-off for reporting endometrial cells on a Papanicolaou test: 50 years may be more appropriate than 45 years.

OBJECTIVE: The 2001 Bethesda System for Reporting Cervical Cytology includes documenting 'endometrial cells in women ≥40 years of age' (E40) to help identify endometrial carcinoma (EC) on a Papanicolaou (Pap) test. The 2014 Bethesda System for Reporting Cervical Cytology raises the threshold to ≥45 years of age (E45). As many of these women are menstruating, routine biopsy after E40, or even E45, may lead to unnecessary procedures for benign endometrial cells. Establishing a different age threshold in combination with other clinical findings may help to guide management. METHODS: A retrospective chart review was performed on consecutive EC specimens and E40 Pap tests. Clinical, pathological data such as age, biopsy diagnosis, FIGO grade and the time of the last Pap test, Pap test diagnosis and resection diagnosis, depth of invasion, stage and metastases were recorded. RESULTS: Sixty-three EC cases had prior Pap smears, with the following diagnoses: negative for an intraepithelial lesion or malignancy (n = 27), atypical glandular cells, not otherwise specified (AGC, NOS) (n = 14), adenocarcinoma (n = 10) and E40 (n = 1; 51 years). Six hundred and forty-two E40 cases had 138 (21.5%) biopsies and/or hysterectomies. Out of the 138 cases, two (1.4%) had EC (both 51 years; postmenopausal), one had complex hyperplasia with atypia (52 years; abnormal uterine bleeding), and eight had hyperplasia without atypia. CONCLUSIONS: In asymptomatic women less than 50 years, E40 correlated with benign, non-hyperplastic endometrium. However, post-menopausal women with E40 had a risk of EC. Perhaps endometrial cells should only be reported in post-menopausal women or women greater than or equal to 50 years of age.

[Is the validated ICIQ-SF suitable for evaluation of OAB patients? A data analysis of intravesicular botulinum toxin therapy]. / Ist der validierte ICIQ-SF zur Evaluation bei OAB-Patientinnen geeignet? : Eine Datenanalyse im Rahmen der intravesikalen Botulinumtoxin-Therapie.

BACKGROUND: The following data analysis studied the aspects of patient satisfaction following onabotulinum toxin A (BTX-A) treatment including modification of certain parameters, such as frequency of micturition and the use of pads and in particular, the applicability of the international consultation on incontinence questionnaire short form (ICIQ-SF) and the urgency perception scale (UPS) in patients with an overactive bladder (OAB). PATIENTS AND METHOD: In this study 40 female patients were questioned in the form of validated questionnaires (extended ICIQ-SF and UPS) before and after being injected with 300 IU of BTX-A in each detrusor muscle. The average age of the patients was 66 years. All patients experienced anticholinergic refractory, non-neurogenic OAB. RESULTS: The recommendation rate and related patient satisfaction was 82.5 %. A significant decrease in the frequency of micturition by 50.9 % (p < 0.01) was reported as well as a significant reduction in the use of pads by 66.7 % (p < 0.01). The average number of ICIQ-SF points could be significantly (p < 0.01) reduced via BTX-A from 15.9 to 7.3. Moreover, BTX-A demonstrated a significant improvement in the urgency to urinate, which was illustrated through the UPS. CONCLUSION: Treatment with BTX-A achieves significant improvements in female patients with anticholinergic refractory OAB with regard to the individual symptoms of OAB (e.g. pollakisuria, nocturia, undesired urination and urgency). The use of the ICIQ-SF as the only questionnaire in OAB diagnostics proved to be unsuitable as it does not include female patients with dry OAB to an adequate degree. A combination of various validated questionnaires, such as ICIQ-SF and UPS, proved to be useful.

Disposition of midazolam in asphyxiated neonates receiving therapeutic hypothermia--a pilot study.

Moderate hypothermia has become an established therapy for asphyxiated neonates. Midazolam is a frequently used sedative for this indication, although it has never been investigated how therapeutic hypothermia and asphyxia influence midazolam metabolism in neonates.9 asphyxiated newborns were treated with whole body hypothermia of 32-34°C for 72 h and all of them received continuous midazolam infusion for sedation. Serum concentrations of midazolam and its metabolites 1-hydroxy-midazolam and 4-hydroxy-midazolam were measured during hypothermia and the rewarming period. Renal and hepatic parameters were assessed to take into account the influence of asphyxia related renal or hepatic impairment.We found a high interindividual variability of serum midazolam concentrations in asphyxiated neonates with therapeutic hypothermia; median midazolam concentration was 369.3 ng/ml (minimum 36.6; maximum 3 218.6 ng/ml). The population pharmacokinetic model revealed a midazolam clearance of 2.57 ml/kg/min, comparable to midazolam clearances observed in normothermic critically ill neonates. However, midazolam clearance was significantly decreased in patients with asphyxia related renal and hepatic impairment.It seems that isolated hypothermia does not significantly influence midazolam metabolism. However, neonates with asphyxia related hepatic and renal impairment are at risk of generating unexpectedly high serum midazolam concentrations. In addition pronounced interindividual variability of midazolam metabolism may contribute to dangerously high midazolam concentrations.

[Randomly discovered enlargement in the region of sella turcica]. / Náhodne zjistené expanze v selární oblasti.

Computer tomography (CT) and magnetic resonance imaging (MRI) quite often detect unexpected cases of enlargement in the hypothalamus-hypophysial region, without the above methods being indicated for clinical manifested symptomatology provoked by the tumour. This is not surprising if we consider that autopsies show the presence of hypophysial adenomas of 10-15% of population on an average. X ray, CT or MRI are indicated in the case of head traumas, lateral nasal cavity inflammations, headaches, strokes, neurological diseases and other disorders. A number of tumours of diverse etiology occur in the hypothalamus-hypophysial region, but hypophysial adenomas are by far the most frequent among all (above 90 %). Among other primary enlargements, the most frequent are craniopharyngeomas and meningeomas, while other enlargements are by fare less common. Such randomly detected tumours are mostly asymptomatic, but targeted anamnesis may show some of the symptoms quite clearly. The symptomatology can be linked with possible slight hormonal overproduction of hypophysial adenomas, a deficit of hypophysial hormones or local manifestations of expansion. Exact assessment of MRI results, of hormonal activity of the enlargement, of the relation to surrounding structures, especially the optic nerves, and the assessment of hypophysial functions are important for the therapeutic decision. Depending on the type and extension of the tumour the options considered are pharmacotherapy (the treatment of choice in the case of prolactinomas), surgery, radiotherapy (today prevailingly using the gamma knife), and if no intervention is necessary, follow up with regular MRI examinations. Tumorous growth is more often observed in "macroadenomas" than in "microadenomas" (up to 10 mm).

Plasma levels of total and active ghrelin in acromegaly and growth hormone deficiency.

Ghrelin is an endogenous growth hormone (GH) secretagogue recently isolated from the stomach. Although it possesses a strong GH releasing activity in vitro and in vivo, its physiological significance in endogenous GH secretion remains unclear. The aim of this study was to characterize plasma ghrelin levels in acromegaly and growth hormone deficiency (GHD). We investigated plasma total and active ghrelin in 21 patients with acromegaly, 9 patients with GHD and 24 age-, sex- and BMI-matched controls. In all subjects, we further assessed the concentrations of leptin, soluble leptin receptor, insulin, IGF-I, free IGF-I and IGFBP-1, 2, 3 and 6. Patients with acromegaly and GHD as well as control subjects showed similar levels of total ghrelin (controls 2.004+/-0.18 ng/ml, acromegalics 1.755+/-0.16 ng/ml, p=0.31, GHD patients 1.704+/-0.17 ng/ml, p=0.35) and active ghrelin (controls 0.057+/-0.01 ng/ml, acromegalics 0.047+/-0.01 ng/ml, p=0.29, GHD patients 0.062+/-0.01 ng/ml, p=0.73). In acromegalic patients plasma total ghrelin values correlated negatively with IGF-I (p<0.05), in GHD patients active ghrelin correlated with IGF-I positively (p<0.05). In the control group, total ghrelin correlated positively with IGFBP-2 (p<0.05) and negatively with active ghrelin (p=0.05), BMI (p<0.05), WHR (p<0.05), insulin (p=0.01) and IGF-I (p=0.05). Plasma active ghrelin correlated positively with IGFBP-3 (p=0.005) but negatively with total ghrelin and free IGF-I (p=0.01). In conclusion, all groups of the tested subjects showed similar plasma levels of total and active ghrelin. In acromegaly and growth hormone deficiency plasma ghrelin does not seem to be significantly affected by changes in GH secretion.

[Transparency in patient care -- survey of bedsores on communal level to promote quality assurance]. / Transparenz in der Pflege -- Dekubituserfassung auf Landkreisebene als Instrument der Qualitätssicherung.

The medical diagnosis of bedsores often applies to open wounds. These wounds are caused by constant pressure to the skin of seniors who cannot change their position in bed or wheelchair without help. In severe cases these wounds extend through all layers of the skin with involvement of muscle and underlying bone. These ulcers can be very painful, so the mobility and quality of life of seniors is thoroughly reduced. Treatment of ulcers costs annually millions of Euro in Germany alone. Primary prevention of bedsores has not yet been established neither in Germany nor in Europe. The first step to improve the situation in a scientific manner has been to set up a comparable database. In order to change that, the German community of Ostalbkreis (part of the German Federal state of Baden-Wurttemberg) developed a process of nursing quality assurance as a project of the local agenda 21, initiated and supported by the health office of the community. Annual networked and anonymous survey from 2001 to 2003, each lasting three months every year, proved that the rate of non stratified prevalence could be reduced. For example the rate of all day spent with bedsores within the community could be reduced from 1.96 % in 2001, to 1.74 % in 2002 and finally to 1.62 % in 2003. During the survey as an additional bonus cooperation of community-organized nursing was optimised and quality assurance in nursing became a pole position of the community. During the QM-process a software was developed to process the survey: it is internet-based, published in the nursing-guide of Ostalbkreis, easy to manage and to establish in any nursing institution or community.

Effects of industrial and urban pollution on the benthic macrofauna in the Bay of Muggia (industrial port of Trieste, Italy).

The benthic macrofauna of the Bay of Muggia and its evolution in time was analysed in order to assess the impact of man-made pollution in this port area. The north and NE zones are totally industrialised while the southern zone is mainly used for tourism and aquaculture. The most important anthropic impacts were stagnation and direct urban and industrial discharges, which operated until the beginning of the 1990s. Forty-four stations were sampled in 1981, 12 of which were monitored over time (1975, 1981 and 1994). From 172 taxa 11783 organisms were identified. Polychaetes were the richest group, followed by molluscs, crustaceans and echinoderms. The dominant species was Corbula gibba (39.5%) followed by Pectinaria koreni (9%). Uni- and multivariate analyses showed a declining pattern for the fauna along a gradient of environmental stress. The very high concentrations of heavy metals in the Bay's sediments, especially Pb, contrasted with the diversity and biological index values found, indicating that many species could survive these conditions. The enforcement of the Italian ecological laws regarding water pollution control benefited the local macrofauna and evidenced the resilience of the system. C. gibba constituted a good biological indicator of zones of high instability (especially sedimentary) and of intermediate levels of pollution.

[Total body composition in adult patients with growth hormone deficiency before and after its administration]. / Celkové telesné slození dospelých pacientu s deficitem rustového hormonu pred a po jeho podávání.

Effect of growth hormone (GH) on the growth and development of children is generally known. Effects of GH in adults are favorable, though. The aim of the work was to verify effects of GH administration on body composition in adult patients with GH deficit (GHD). The authors examined 15 adult patients with GHD originated in 13 of them in adulthood and in two of them in childhood. Their mean age was 43.9 +/- 11.3 years, the mean body mass was 80.0 +/- 15.2 kg. The GH deficit was verified by the stimulation insulin tolerance test. For the period of 12 months, they were subcutaneously administered recombinant human GH in a substitution dose of 0.5 to 1.5 IU/m2 body surface/day. A stable substitution of the hormone was applied for the period of at least six months in all these patients provided any deficit of other hormones had not been demonstrated. The examination by whole-body dosimeter Lunar DPX-L was made in the patients before the GH treatment began and after 12 months of therapy. It enabled to determine the amount of lean body mass (LBM) and fatty mass. After 12 months of GH treatment the mean level of insulin-like growth factor (IGF-I) was increased (P = 0.002). A statistically significant increase of total LBM (48.6 +/- 9.8 vs. 50.8 +/- 9.9 kg, P = 0.004) developed, the fatty mass did not change. Nine of these 15 patients were further followed and the administration of GH proceeded for six months. The densitometric examination was repeated, but no change of LBM was observed. The administration of GH was halted and after the period of 12 months the whole-body densitometric examination was done. The increase of LBM lasted. The amount of fat mass did not change, a decrease of fatty mass was observed after the GH administration ended. After 12 months of GH treatment there was also an increase of maximal output reached on bicycle ergometer (157.3 +/- 34.2 vs. 197.5 +/- 68.1 W, P = 0.006). A positive correlation between LBM and maximal output reached on bicycle ergometer before GH administration (r = 0.58, P = 0.02) was observed. A favorable effect of the substitution dose of GS administered to adult patients with GHD on the increase of LBM and physical output was confirmed.

[Incidental findings of expansive processes in the sellar region]. / Náhodne zjistené expanzivní procesy selární oblasti.

The technologic advancement of imaging techniques especially computed tomography (CT) and magnetic resonance (MRI) is associated with an increasing number of incidentally discovered sellar masses. The endocrinologists are facing the problem to distinguish between benign and clinically often insignificant non-functioning pituitary adenomas (pituitary incidentalomas) and other pituitary or sellar and parasellar masses, which require further therapy. This paper gives an overview about different types of pituitary or sellar and parasellar masses, their aetiology and basic symptoms arising from either endocrine disturbances or as a result of mass effect of an enlarging tissue. Further, the paper shortly characterises most common pituitary and non-pituitary sellar masses that are necessary to distinguish. Finally, the basic diagnostic approach to the patients with sellar and parasellar masses is described.

Epidural analgesia in patients with chronic obstructive pulmonary disease undergoing transperitoneal abdominal aortic aneurysmorraphy--a multi-institutional analysis.

INTRODUCTION: Patients with chronic obstructive pulmonary disease (COPD) are more likely to develop pulmonary morbidity following major abdominal surgery. The purpose of this study was to examine the utility of epidural analgesia in patients with COPD who underwent elective transperitoneal abdominal aortic aneurysm (AAA) repair. METHODS: During a 7-year period, all patients diagnosed with COPD undergoing elective AAA repair (n=425) from three hospitals were reviewed. Inclusion criteria were an FEV(1)/FVC ratio <75% and/or a PaCO(2)>45 mmHg. Clinical outcomes were compared between those who received epidural analgesia (epidural group) and those who did not (control group). Primary endpoints measured were duration of intubation, ICU stay, hospital days, and pulmonary complications. RESULTS: Strict inclusion criteria were met by 131 patients, which included 86 patients in the epidural group and 45 patients in the control group. When comparing the epidural vs. control group, the mean AAA size was 6.3+/-0.9 cm vs. 6.0+/-1.5 cm (NS), FEV(1) was 57.2+/-24.7% vs. 49.0+/-10.3% (NS), and the mean FEV(1)/FVC ratio was 52.0+/-11.4% vs. 50.6+/-6.7% (NS), respectively. The epidural group had a significantly lower incidence of post-operative ventilator dependency and ICU stay (p<0.05), as well as a decreased trend in pulmonary complications when compared to the control group. The overall hospital stay remained similar between the two groups. The relative risk of developing a pulmonary complication in the absence of epidural analgesia was 2.3. CONCLUSIONS: Perioperative epidural analgesia is beneficial in patients with COPD undergoing AAA repair by reducing both the post-operative ventilator duration and ICU stay. Epidural analgesia should be considered in all COPD patients undergoing elective transperitoneal AAA repair.

[New avenues to quality assurance--a model project for recording bedsore incidence]. / Neue Wege der Qualitätssicherung - Modellprojekt Dekubituserfassung im Ostalbkreis.

Bedsores can usually be avoided by adequate care and preventive measures. In the context of the local agenda process a local district office (Landratsamt) and inspection units initiated a variety of activities to promote sensitisation in health institutions and contribute to an increase in life quality of the persons concerned. Nearly all nursing care homes, domiciliary services and hospitals participated in a pilot study which was accompanied by the Fraunhofer IAO in Stuttgart. Objectives of the pilot study were to implement internal quality assurance to sensitise for persons the topic and to collect comparable data to achieve benchmarking. Software-tool institutions recorded data on care days, days spent with bedsores according to care level from July till September 01. Major result was that - although institutions had already a decreasing incidence in bedsores since the start of discussing the project - bedsore quotas could be further decreased from 2.15 to 1.84 %.

Surgical intervention for complications caused by femoral artery catheterization in pediatric patients.

PURPOSE: This study evaluated the risk factors and surgical management of complications caused by femoral artery catheterization in pediatric patients. METHODS: From January 1986 to March 2001, the hospital records of all children who underwent operative repairs for complications caused by femoral artery catheterization were reviewed. A prospective cardiac data bank containing 1674 catheterization procedures during the study period was used as a means of determining risk factors associated with iatrogenic femoral artery injury. RESULTS: Thirty-six operations were performed in 34 patients (age range, 1 week-17.4 years) in whom iatrogenic complications developed after either diagnostic or therapeutic femoral artery catheterizations during the study period. Non-ischemic complications included femoral artery pseudoaneurysms (n = 4), arteriovenous fistulae (n = 5), uncontrollable bleeding, and expanding hematoma (n = 4). Operative repairs were performed successfully in all patients with non-ischemic iatrogenic femoral artery injuries. In contrast, ischemic complications occurred in 21 patients. Among them, 14 patients had acute femoral ischemia and underwent surgical interventions including femoral artery thrombectomy with primary closure (n = 6), saphenous vein patch angioplasty (n = 6), and resection with primary anastomosis (n = 2). Chronic femoral artery occlusion (> 30 days) occurred in seven patients, with symptoms including either severe claudication (n = 4) or gait disturbance or limb growth impairment (n = 3). Operative treatments in these patients included ileofemoral bypass grafting (n = 5), femorofemoral bypass grafting (n = 1), and femoral artery patch angioplasty (n = 1). During a mean follow-up period of 38 months, no instances of limb loss occurred, and 84% of children with ischemic complications eventually gained normal circulation. Factors that correlated with an increased risk of iatrogenic groin complications that necessitated surgical intervention included age younger than 3 years, therapeutic intervention, number of catheterizations (>or= 3), and use of 6F or larger guiding catheter. CONCLUSION: Although excellent operative results can be achieved in cases of non-ischemic complications, acute femoral occlusion in children younger than 2 years often leads to less satisfactory outcomes. Operative intervention can provide successful outcome in children with claudication caused by chronic limb ischemia. Variables that correlated with significant iatrogenic groin complications included a young age, therapeutic intervention, earlier catheterization, and the use of a large guiding catheter.

Late recurrence of lupus nephritis in a renal transplant recipient: response to mycophenolate mofetil.

Clinically significant recurrence of lupus nephritis in the renal allograft is low, with an incidence of 1 to 3%, and usually occurs within the first 6 years after transplantation. We report an unusual case of a patient with end-stage renal disease caused by lupus nephritis who received a kidney transplant from a living relative; 13 years later, the patient had a severe recurrence of diffuse proliferative lupus nephritis. The patient relapsed after receiving intravenous cyclophosphamide therapy and had a partial response to oral mycophenolate mofetil. In this report we review the risk factors for the recurrence of the systemic lupus erythematosus in the kidney graft and the anti-lupus activity of mycophenolate mofetil.

Early experience with the bifurcated Excluder endoprosthesis for treatment of the abdominal aortic aneurysm.

PURPOSE: This report describes our initial experience with the modular, bifurcated Excluder endoprosthesis and its safety and efficacy in the primary endovascular repair of infrarenal abdominal aortic aneurysms (AAAs). METHODS: AAAs (mean diameter, 58.2 +/- 14.3 mm) were repaired in 19 patients with this device between March 1999 and January 2000. The mean age of patients was 71.8 +/- 8.4 years (range, 57-86 years). This modular device was inserted through an 18F introducer sheath placed in one femoral artery, and the contralateral artery was cannulated with a 12F introducer sheath. All procedures were performed in a standard operating room with angiographic capabilities. RESULTS: Endograft deployment was successful in all patients. The average surgical time was 135 +/- 37 minutes, with a mean blood loss of 229 +/- 138 mL. In eight patients, the use of either aortic or iliac extenders was required for enhanced sealing or additional length. An external iliac artery dissection occurring at the time of endograft insertion was successfully treated with a Wallstent. Type II leaks initially found to be present by means of intraoperative completion angiography had spontaneously thrombosed by the 1-month follow-up computed tomography scan. There was one perioperative death (5.3%). Complications included superficial wound infections (n = 3) and a nonfatal myocardial infarction (n = 1). The mean length of hospital stay was 2.9 +/- 1.2 days, and only six patients required intensive care. Endoleaks were seen in four patients (21%) by means of the 30-day computed tomography scan; three of these endoleaks had spontaneously sealed at the time of the 6-month follow-up examination (5.5% 6-month endoleak rate). Aneurysm size did not increase in the patients with leaks. CONCLUSION: The Excluder endoprosthesis was an effective means of excluding an infrarenal AAA from the systemic circulation in this selected group of patients. The smaller sheath sizes may increase the pool of potential candidates. Further study of this device is warranted, and continued assessment of the long-term durability of the device will be necessary.

Detection of isolated hook fractures 36 months after implantation of the Ancure endograft: a cautionary note.

Two cases of delayed (36-month) Ancure hook fracture are reported in patients who experienced a decrease in aneurysm size and no evidence of endoleak. Both devices used redesigned hooks and are otherwise identical to those devices currently used in clinical practice. Notably, hook fractures were not visualized on all abdominal radiographic views, nor were they noted on the final "institutional" report by the reviewing radiologist. Careful clinical follow-up with multiple-view abdominal radiographs remains essential for all patients treated with an endovascular graft, with particular attention directed to the integrity of the metal components. The broader clinical significance of this observation with respect to the Ancure endograft remains to be defined.