Angioplasty versus stenting for subclavian artery stenosis.

BACKGROUND: The subclavian arteries are two major arteries of the upper chest, below the collar bone, which come from the arch of the aorta. Endovascular treatment for stenosis of the subclavian arteries includes angioplasty alone, and with stenting. There is insufficient evidence to guide the use of stents following angioplasty for subclavian artery stenosis. This is the second update of a review first published in 2011. OBJECTIVES: The aim of this review was to determine whether stenting was more effective than angioplasty alone for stenosis of the subclavian artery. SEARCH METHODS: For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and LILACS databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 2 February 2021. SELECTION CRITERIA: We searched for randomised controlled trials of endovascular treatment of subclavian artery lesions that compared angioplasty alone and stent implantation. DATA COLLECTION AND ANALYSIS: Two review authors independently evaluated studies to assess eligibility. Discrepancies were resolved by discussion. If there was no agreement, we asked a third review author to assess the study for inclusion. We planned to undertake data collection and analysis in accordance with recommendations described in the Cochrane Handbook for Systematic Reviews of Interventions, and assess the certainty of the evidence using a GRADE approach. MAIN RESULTS: To date, we have not identified any completed or ongoing randomised controlled trials that compare percutaneous transluminal angioplasty and stenting for subclavian artery stenosis. AUTHORS' CONCLUSIONS: There is currently insufficient evidence to determine whether stenting is more effective than angioplasty alone for stenosis of the subclavian artery.

Impact of PSA density of transition zone as a potential parameter in reducing the number of unnecessary prostate biopsies in patients with psa levels between 2.6 and 10.0 ng/mL.

PURPOSE: To assess the accuracy of prostate-specific antigen (PSA) adjusted for the transition zone volume (PSATZ) in predicting prostate cancer by comparing the ability of several PSA parameters in predicting prostate cancer in men with intermediate PSA levels of 2.6 - 10.0 ng/mL and its ability to reduce unnecessary biopsies. MATERIALS AND METHODS: This study included 656 patients referred for prostate biopsy who had a serum PSA of 2.6 - 10.0 ng/mL. Total prostate and transition zone volumes were measured by transrectal ultrasound using the prolate ellipsoid method. The clinical values of PSA, free-to-total (F/T) ratio, PSA density (PSAD) and PSATZ for the detection of prostate cancer were calculated and statistical comparisons between biopsy-positive (cancer) and biopsy-negative (benign) were conducted. RESULTS: Cancer was detected in 172 patients (26.2%). Mean PSA, PSATZ, PSAD and F/T ratio were 7.5 ng/mL, 0.68 ng/mL/cc. 0.25 ng/mL/cc and 0.14 in patients with prostate cancer and 6.29 ng/mL, 0.30 ng/mL/cc, 0.16 ng/mL/cc and 0.22 in patients with benign biopsies, respectively. ROC curves analysis demonstrated that PSATZ had a higher area under curve (0,838) than F/T ratio (0,806) (P<0.001) and PSAD (0,806) (P<0.001). With a cut-off value of 0.22 ng/mL/cc, PSATZ had 100% of sensitivity and could have prevented 24% of unnecessary biopsies. CONCLUSIONS: PSATZ may be useful in enhancing the specificity of serum PSA. Compared to other PSA related parameters, it was better in differentiating between prostate cancer and benign prostatic enlargement. Also, PSATZ could reduce a significant number of unnecessary biopsies.

Health-related quality of life, cognitive screening, and functional status in a randomized phase III trial (EF-14) of tumor treating fields with temozolomide compared to temozolomide alone in newly diagnosed glioblastoma.

We characterized health-related quality of life (HRQoL), cognitive, and functional status in newly diagnosed glioblastoma (GBM) patients receiving Tumor treating fields (TTFields) with temozolomide (TMZ) versus TMZ alone in a planned interim analysis of a randomized phase III trial [NCT00916409], which showed significant improvement in progression-free and overall survival with TTFields/TMZ. After radiotherapy with concomitant TMZ, newly diagnosed GBM patients were randomized (2:1) to TTFields/TMZ (n = 210) or TMZ (n = 105). Interim analysis was performed in 315 patients with ≥18 months of follow-up. HRQoL, a secondary endpoint, was evaluated in per-protocol patient population and expressed as change from baseline (CFB) at 3, 6, and 9 months for each subscale in the EORTC QLQ-C30/BN20. Karnofsky performance scores (KPS) and Mini-Mental State Examination scores (MMSE) were assessed. CFB in HRQoL was balanced in treatment groups at the 12-month time point. Initially, HRQoL improved in patients treated with TTFields/TMZ (CFB3: 24% and CFB6: 13%) versus TMZ (CFB3: -7% and CFB6: -17%), though this difference was no longer evident at the 9-month point. General scales, including physical and social functioning, showed no difference at 9 and 12 months. TTFields/TMZ group reported higher concerns of "itchy skin". KPS over 12 months was just below 90 in both groups. Cognitive status (MMSE) was stable over time. HRQoL, KPS, and MMSE were balanced in both groups over time. There was no preliminary evidence that HRQoL, cognitive, and functional status is adversely affected by the continuous use of TTFields.

Microsurgical treatment of recurrent coiled aneurysms.

The number of endovascularly-treated aneurysms has steadily increased over the past two decades. A small but significant number of recurrent or partially recanalized aneurysms have been identified. If repeat endovascular therapies are not feasible due to anatomical or technical considerations, surgical clipping may be considered. The technical challenges in the microsurgical treatment include coils interfering with the clip application; the possibility of an aneurysm that is less collapsible and less easy to manipulate; and intraluminal thrombus formation requiring thrombus and coil removal. The video presents the technical steps and nuances for clipping. The technical issues for coil removal are illustrated in two cases. The video can be found here: http://youtu.be/NvhSDVT4iuE.

Angioplasty versus stenting for subclavian artery stenosis.

BACKGROUND: There is insufficient evidence to guide stent usage following angioplasty in subclavian artery stenosis. This is an update of a review first published in 2011. OBJECTIVES: The aim of this review was to determine whether stenting is more effective than angioplasty alone for stenosis of the subclavian artery. SEARCH METHODS: For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched February 2014) and CENTRAL (2014, Issue 1). There was no restriction on language. SELECTION CRITERIA: Randomised controlled trials of endovascular treatment of subclavian artery lesions comparing angioplasty alone and stent implantation. DATA COLLECTION AND ANALYSIS: Two authors independently evaluated studies to assess eligibility. Discrepancies were resolved by discussion. If there was no agreement, the third author was asked to assess the study for inclusion. MAIN RESULTS: To date we have not identified any completed or ongoing randomised controlled trials comparing percutaneous transluminal angioplasty and stenting for subclavian artery stenosis. AUTHORS' CONCLUSIONS: There is currently insufficient evidence to determine whether stenting is more effective than angioplasty alone for stenosis of the subclavian artery.

Microsurgical Management of Internal Carotid Artery Bifurcation Aneurysm After Failure of Endovascular Coiling and Flow Diversion: 2-Dimensional Operative Video.

We describe the case of a 51-year-old woman who underwent craniotomy and surgical clipping of a large internal carotid bifurcation aneurysm that was refractory to treatment with 2 rounds of endovascular coiling and internal carotid artery (ICA) to middle cerebral artery pipeline placement. The patient initially presented in 2004 with a 3-week history of sudden-onset headache with associated nausea. Computed tomography and lumbar puncture on presentation in 2004 were negative for subarachnoid hemorrhage. Digital subtraction angiography, however, demonstrated a large left ICA bifurcation aneurysm. The decision was made to proceed with endovascular coiling of the aneurysm. Six-month and 1-year follow-up imaging showed incomplete resolution of the aneurysm, and retreatment coiling was completed in 2005. After recoiling in 2005, the patient was lost to follow-up. During this period, she underwent pipeline placement from the ICA to the middle cerebral artery across the A1 segment at a different institution. Two years after flow diversion, the patient was referred back to our institution with further worsening of the aneurysm. Our surgical team opted for craniotomy and surgical clipping given the limited management options that this extremely complex case now presented. The patient consented to the procedure. Postoperative imaging demonstrated marked improvement in aneurysm severity. Although the current neurosurgical trend favors endovascular treatment over craniotomy, this case shows the vital importance of craniotomy and aneurysm clipping in the treatment of select patients. We also provide high-quality operative video of aneurysm clipping.1-7.

Evaluation of the Minimum Segment Width and Fluence Smoothing Tools for Intensity-modulated Techniques in Monaco Treatment Planning System.

Purpose: This study aims to minimize monitor units (MUs) of intensity-modulated treatments in the Monaco treatment planning system while preserving plan quality by optimizing the "Minimum Segment Width" (MSW) and "Fluence Smoothing" parameters. Materials and Methods: We retrospectively analyzed 30 prostate, 30 gynecological, 15 breast cancer, 10 head and neck tumor, 11 radiosurgery, and 10 hypo-fractionated plans. Original prostate plans employed "Fluence Smoothing" = Off and were reoptimized with Low, Medium, and High settings. The remaining pathologies initially used MSW = 0.5 cm and were reoptimized with MSW = 1.0 cm. Plan quality, including total MU, delivery time, and dosimetric constraints, was statistically analyzed with a paired t-test. Results: Prostate plans exhibited the highest MU variation when changing "Fluence Smoothing" from Off to High (average ΔMU = -5.1%; P < 0.001). However, a High setting may increase overall MU when MSW = 0.5 cm. Gynecological plans changed substantially when MSW increased from 0.5 cm to 1.0 cm (average ΔMU = -29%; P < 0.001). Organs at risk sparing and planning target volumes remained within 1.2% differences. Replanning other pathologies with MSW = 1.0 cm affected breast and head and neck tumor plans (average ΔMU = -168.38, average Δt = -11.74 s, and average ΔMU = -256.56, average Δt = -15.05 s, respectively; all with P < 0.004). Radiosurgery and hypofractioned highly modulated plans did not yield statistically significant results. Conclusions: In breast, pelvis, head and neck, and prostate plans, starting with MSW = 1.0 cm optimally reduces MU and treatment time without compromising plan quality. MSW has a greater impact on MU than the "Fluence Smoothing" parameter. Plans with high modulation might present divergent behavior, requiring a case-specific analysis with MSW values higher than 0.5 cm.

National-scale geodatabase of catchment characteristics in the Philippines for river management applications.

Quantitative descriptions of stream network and river catchment characteristics provide valuable context for enabling geomorphologically-informed sustainable river management. For countries where high-quality topographic data are available, there are opportunities to enable open access availability of baseline products from systematic assessment of morphometric and topographic characteristics. In this study, we present a national-scale assessment of fundamental topographic characteristics of Philippine river systems. We applied a consistent workflow using TopoToolbox V2 to delineate stream networks and river catchments using a nationwide digital elevation model (DEM) acquired in 2013 and generated through airborne Interferometric Synthetic Aperture Radar (IfSAR). We assessed morphometric and topographic characteristics for 128 medium- to large-sized catchments (catchment area > 250 km2) and organised the results in a national-scale geodatabase. The dataset realises the potential of topographic data as part of river management applications, by enabling variations in hydromorphology to be characterised and contextualised. The dataset is used to reveal the diversity of stream networks and river catchments in the Philippines. Catchments have a continuum of shapes (Gravelius compactness coefficient ranges from 1.05 to 3.29) with drainage densities that range from 0.65 to 1.23 km/km2. Average catchment slope ranges from 3.1 to 28.1° and average stream slope varies by more than an order of magnitude from 0.004 to 0.107 m/m. Inter-catchment analyses show the distinctive topographic signatures of adjacent river catchments; examples from NW Luzon highlight topographic similarity between catchments whereas examples from Panay Island shown marked topographic differences. These contrasts underline the importance of using place-based analyses for sustainable river management applications. By designing an interactive ArcGIS web-application to display the national-scale geodatabase, we improve data accessibility and enable users to freely access, explore and download the data (https://glasgow-uni.maps.arcgis.com/apps/webappviewer/index.html?id=a88b9ca0919f4400881eab4a26370cee). The national-scale geodatabase provides a baseline understanding of fundamental topographic characteristics in support of varied geomorphological, hydrological and geohazard susceptibility applications.

Hepatic fibrosis: a manifestation of the liver disease evolution in patients with Ataxia-telangiectasia.

BACKGROUND: Ataxia-telangiectasia (A-T) is a DNA repair disorder characterized by changes in several organs and systems. Advances in clinical protocols have resulted in increased survival of A-T patients, however disease progression is evident, mainly through metabolic and liver changes. OBJECTIVE: To identify the frequency of significant hepatic fibrosis in A-T patients and to verify the association with metabolic alterations and degree of ataxia. METHODS: This is a cross-sectional study that included 25 A-T patients aged 5 to 31 years. Anthropometric data, liver, inflammatory, lipid metabolism and glucose biomarkers (oral glucose tolerance test with insulin curve-OGTT) were collected. The Cooperative Ataxia Rating Scale was applied to assess the degree of ataxia. The following were calculated: Homeostasis Model Assessment-Insulin Resistance, Homeostasis Model Assessment-Adiponectin (HOMA-AD), Matsuda index, aspartate aminotransferase (AST): platelet ratio index, nonalcoholic fatty liver disease fibrosis score and BARD score. Liver ultrasonography and transient liver elastography by FibroScan® were performed. RESULTS: Significant hepatic fibrosis was observed in 5/25 (20%). Patients in the group with significant hepatic fibrosis were older (p < 0.001), had lower platelet count values (p = 0.027), serum albumin (p = 0.019), HDL-c (p = 0.013) and Matsuda index (p = 0.044); and high values of LDL-c (p = 0.049), AST (p = 0.001), alanine aminotransferase (p = 0.002), gamma-glutamyl transferase (p = 0.001), ferritin (p = 0.001), 120-min glycemia by OGTT (p = 0.049), HOMA-AD (p = 0.016) and degree of ataxia (p = 0.009). CONCLUSIONS: A non-invasive diagnosis of significant hepatic fibrosis was observed in 20% of A-T patients associated with changes in liver enzymes, ferritin, increased HOMA-AD, and the severity of ataxia in comparison with patients without hepatic fibrosis.

A Transcriptomic Comparative Study of Cranial Vasculature.

In genetic studies of cerebrovascular diseases, the optimal vessels to use as controls remain unclear. Our goal is to compare the transcriptomic profiles among 3 different types of control vessels: superficial temporal artery (STA), middle cerebral arteries (MCA), and arteries from the circle of Willis obtained from autopsies (AU). We examined the transcriptomic profiles of STA, MCA, and AU using RNAseq. We also investigated the effects of using these control groups on the results of the comparisons between aneurysms and the control arteries. Our study showed that when comparing pathological cerebral arteries to control groups, all control groups presented similar responses in the activation of immunological processes, the regulation of intracellular signaling pathways, and extracellular matrix productions, despite their intrinsic biological differences. When compared to STA, AU exhibited upregulation of stress and apoptosis genes, whereas MCA showed upregulation of genes associated with tRNA/rRNA processing. Moreover, our results suggest that the matched case-control study design, which involves control STA samples collected from the same subjects of matched aneurysm samples in our study, can improve the identification of non-inherited disease-associated genes. Given the challenges associated with obtaining fresh intracranial arteries from healthy individuals, our study suggests that using MCA, AU, or paired STA samples as controls are feasible strategies for future large-scale studies investigating cerebral vasculopathies. However, the intrinsic differences of each type of control should be taken into consideration when interpreting the results. With the limitations of each control type, it may be most optimal to use multiple tissues as controls.

Assessment of nurses' knowledge about magnetic resonance imaging in a university hospital in Sao Paulo.

The aims of this descriptive study were to determine the academic profile of nurses in a university hospital, assess their level of knowledge about magnetic resonance imaging (MRI) and verify whether this knowledge was acquired during their undergraduate or graduate education. Ninety randomly selected nurses working in inpatient wards and outpatient units of a university hospital participated in the study. Data were collected through a questionnaire completed by the participants between August and October 2009. Most nurses were females who have received specialized education. The participants had a limited knowledge about MRI, which was restricted to the procedures to prepare patients for MRI examination and MRI contraindications. Most of the nurses acquired information about MRI during the professional practice. The majority of nurses showed interest to know more about the MRI examination, especially regarding the exam environment, conditions and contraindications, in order to prevent accidents.

Retroperitoneal Laparoscopic Resolution of Posas Abscess: Case Reports and Review of the Literature.

INTRODUCTION: Psoas abscess is a rare pathological entity being retroperitonescopy an unusual therapeutic modality for its resolution. MATERIALS AND METHODS: The objective is to present and describe five patients with a diagnosis of psoas abscess that were resolved by retroperitoneoscopy in our institution and then carried out a non-systematic review of the literature. RESULTS: The mean age was 58.8 years and 80% were male. All patients had back pain and none had therapeutic resolution with conservative treatment. 60% of the patients had a methicillin sensitive Staphyylococus Aureus. In the follow-up with a mean of 10.2 months, no recurrence was observed. CONCLUSIONS: Early diagnosis of psoas abscess is important for its correct resolution. In our small series of patients, retroperitoneoscopy was an effective treatment.

Analysis of Trifecta Results in a Single-Center Experience with Retroperitoneoscopic Partial Nephrectomy: An Observational Study.

OBJECTIVE: To analyze the trifecta results in patients with T1a and T1b renal tumors treated with retroperitoneoscopic partial nephrectomy (RPN). MATERIAL AND METHODS: A cross-sectional prospective observational study was conducted on 106 patients with cT1 renal tumor submitted to RPN. Trifecta was reported as no ≥ 2 Clavien-Dindo complications, warm ischemia time (WIT) ≤ 25 minutes, ≤ 15% postoperative ΔGFR, and nonpositive margins. RESULTS: The mean age was 58 years (SD ± 12). The median (Q1; Q3) tumor size was 3.5 (2.2; 4.5) cm. Of the treated patients, 33% had a ventral tumor. R.E.N.A.L nephrometry score was low complexity in 54% of cases and high complexity in 4%. WIT median (Q1; Q3) was 20 (14; 23) minutes. Estimated blood loss median (Q1; Q3) was 50 (0; 100) ml. There were no conversions to open surgery. ΔGFR was >15% in 17.5% of patients. There were no postoperative complications in 84% of cases. Nonpositive margins were observed. Sixty-eight percent were pT1a and 32% were pT1b. Seventy-two percent of patients presented trifecta. A statistically significant difference was found between trifecta and tumor size (3 cm vs. 4.4 cm; p<0.001), complexity (low complexity 90% vs. intermediate complexity 56%; p<0.0001), and pT (T1a 81% vs. T1b 53%; p<0.003). CONCLUSION: RPN is a safe and effective treatment modality for T1a and T1b renal tumors. Trifecta rate was 72%. Tumor size, tumor complexity, and pT were found to be an associated factor for trifecta.

Somatic Variants in SVIL in Cerebral Aneurysms.

Background and Objectives: While somatic mutations have been well-studied in cancer, their roles in other complex traits are much less understood. Our goal is to identify somatic variants that may contribute to the formation of saccular cerebral aneurysms. Methods: We performed whole-exome sequencing on aneurysm tissues and paired peripheral blood. RNA sequencing and the CRISPR/Cas9 system were then used to perform functional validation of our results. Results: Somatic variants involved in supervillin (SVIL) or its regulation were found in 17% of aneurysm tissues. In the presence of a mutation in the SVIL gene, the expression level of SVIL was downregulated in the aneurysm tissue compared with normal control vessels. Downstream signaling pathways that were induced by knockdown of SVIL via the CRISPR/Cas9 system in vascular smooth muscle cells (vSMCs) were determined by evaluating changes in gene expression and protein kinase phosphorylation. We found that SVIL regulated the phenotypic modulation of vSMCs to the synthetic phenotype via Krüppel-like factor 4 and platelet-derived growth factor and affected cell migration of vSMCs via the RhoA/ROCK pathway. Discussion: We propose that somatic variants form a novel mechanism for the development of cerebral aneurysms. Specifically, somatic variants in SVIL result in the phenotypic modulation of vSMCs, which increases the susceptibility to aneurysm formation. This finding suggests a new avenue for the therapeutic intervention and prevention of cerebral aneurysms.

Incidence and predictors of intracranial hemorrhage after minor head trauma in patients taking anticoagulant and antiplatelet medication.

BACKGROUND: The yield of head computed tomography (CT) for patients who suffered head trauma with a presenting Glasgow Coma Scale (GCS) score of 15 has been reported to be low, even in patients who are anticoagulated or on antiplatelet therapy. We undertook this study to (1) determine the frequency of intracranial hemorrhage in anticoagulated patients and patients on antiplatelet therapy and its impact on clinical management, (2) identify predictors of positive imaging findings, and (3) assess potential differences between anticoagulation and antiplatelet therapy. METHODS: We conducted a retrospective review of the trauma registry at our institution, a Level II trauma center. All trauma registry patients with a minor head injury registered between the years 2004 and 2006 who were taking warfarin or clopidogrel, had a presenting GCS score of 15, and underwent head CT were included in this study. Intracranial hemorrhage on head CT was considered a positive result. RESULTS: One hundred forty-one patients (male, n=67; female, n=74), mean age 79 years (range, 36-101 years), were included in this study. Forty-one patients (29%) were diagnosed with intracranial hemorrhage. Thirty-nine (95%) of these 41 patients underwent reversal and/or discontinuation of clopidogrel and/or warfarin. Five patients required surgical evacuation of an intracranial hemorrhage. Four patients died. Loss of consciousness (Wald=7.468, ß=1.179, p=0.008) predicted a positive CT result. Type of medication (warfarin, aspirin, or clopidogrel) did not reach statistical significance as a predictor of positive result. CONCLUSION: Despite a presenting GCS score of 15, patients with minor head injury from the trauma registry at our institution taking anticoagulation or antiplatelet therapy have a high incidence of intracranial hemorrhage especially after reported loss of consciousness.

Acute Myelopathy: Vascular and Infectious Diseases.

Vascular and infectious causes are rare but important causes of spinal cord injury. High suspicion for these processes is necessary, as symptoms may progress over hours to days, resulting in delayed presentation and diagnosis and worse outcomes. History and clinical examination findings can assist with localization of the affected vascular territory and spinal level, which will assist with focusing spinal imaging. Open and/or endovascular surgical management depends on the associated vascular abnormality. Infectious myelopathy treatment consists of targeted antimicrobial therapy when possible, infectious source control, and again, close monitoring for systemic complications.

Perceptions of senior nursing students regarding clinical decision-making.

OBJECTIVES: to understand the perceptions of senior students in an undergraduate nursing course at a nursing college in Lisbon regarding skills related to clinical decision-making learned during their initial training. METHODS: qualitative study, of an exploratory and descriptive nature. Data collection occurred by carrying out a focus group with eight senior students in an undergraduate nursing course. Data treatment applied content analysis, performed with twebQDA® software. RESULTS: data were analyzed according to the four dimensions of Tanner's model of clinical judgment, and noticing and interpreting stood out as the most influential in clinical decision-making. Theoretical and clinical knowledge, validation of care planning, prioritization, and capacity to discuss and debate about situations emerged as the most representative skills. FINAL CONSIDERATIONS: students make decisions by means of a complex process by using the knowledge and skills learned during their training.

Use of color Doppler ultrasonography for the prediction of malignancy in follicular thyroid neoplasms: systematic review and meta-analysis.

OBJECTIVE: The purpose of this systematic review was to obtain summary estimates of the diagnostic accuracy of color Doppler ultrasonography (CDU) in predicting malignancy in thyroid follicular neoplasms (FNs). METHODS: We searched Medical Subject Headings together with the search terms "follicular," "thyroid," and "Doppler" in the MEDLINE, Web of Science, and Excerpta Medica databases as well as the Latin American and Caribbean Health Sciences Literature database, after which we performed manual searches of the reference lists to locate additional studies. There were no language restrictions. We included studies that assessed the diagnostic accuracy of CDU in identifying malignancy in thyroid FNs. The assessments of the quality and extraction of data were performed by 3 independent reviewers. RESULTS: We included 4 studies, which collectively evaluated 457 thyroid FNs, 67 of which had been classified as malignant based on the evaluation of surgical biopsy samples. Moderate, rich, predominant, or exclusive internal flow on CDU of thyroid FNs was considered indicative of malignancy. The overall sensitivity of CDU was 85% (95% confidence interval [CI], 74%-93%), with an overall specificity of 86% (95% CI, 82%-89%). The overall prevalence was 14.7%, and the positive and negative predictive values were 51% and 97%, respectively. The positive likelihood ratio was 6.07, and the negative likelihood ratio was 0.18. CONCLUSIONS: Predominant internal flow seen on CDU is associated with malignancy of thyroid FNs. Absence of internal flow or predominantly peripheral flow indicates a low probability of thyroid FN malignancy.

Spontaneous bladder rupture: Laparoscopic management of rare complications after nontraumatic vaginal delivery.

INTRODUCTION: Spontaneous bladder rupture is a rare condition, especially after a nontraumatic vaginal delivery. CASE PRESENTATION: A 32-year-old patient who had had a nontraumatic vaginal delivery presented to the emergency room with abdominal pain and anuria. Computed tomography showed free fluid in the peritoneal cavity. An exploratory laparoscopy revealed a perforation on the bladder dome that was laparoscopically sutured. CONCLUSION: In the presence of an acute abdominal pain with free fluid in the peritoneal cavity after a nontraumatic vaginal delivery, a differential diagnosis should be a spontaneous rupture of the bladder.

Endothelial markers in schistosomiasis patients with or without portal hypertension.

PURPOSE: To evaluate the serum levels of von Willebrand factor (vWF), vascular endothelial growth factor (VEGF), endothelin-1 (ET-1), and endothelin-3 (ET-3) in patients with the isolated, inactive form of Schistosomiasis mansoni. Patients were classified into two groups: 10 patients without (SM group) and 18 with (PH group) portal hypertension. RESULTS: Serum albumin, VEGF, and vWF levels did not differ between the two groups (P > 0.05). The prothrombin time (INR), number of platelets, spleen size, splenic vein diameter, and endothelin levels differentiated the PH group, which showed decreased ET-1 (SM = 22.4 +/- 2.4 pg/ml and PH = 16.4 +/- 1.5 pg/ml; P = 0.034) and increased ET-3 (SM = 2.1 +/- 0.1 ng/ml and PH = 3.2 +/- 0.1 ng/ml; P = 0.000) levels. CONCLUSIONS: In patients with schistosomiasis and portal hypertension (presinusoidal type), the levels of VEGF and ET-1 differ from those reported in patients with cirrhosis.