Assessment of the clinical features of rheumatoid arthritis-related interstitial lung diseases: a retrospective evaluation.

OBJECTIVE: Rheumatoid Arthritis (RA) stands as the most prevalent form of inflammatory arthritis, affecting approximately 1% of the population. Among individuals diagnosed with RA, a notable proportion, ranging from 10% to 40%, also experience Rheumatoid Arthritis-Associated Interstitial Lung Disease (RA-ILD). This coexistence of RA and ILD has been identified as a detrimental factor contributing to increased mortality rates. Furthermore, RA-ILD often exhibits an insidious nature, posing challenges in its timely detection and management. Hence, our objective was to conduct a retrospective analysis of the clinical characteristics observed in patients who underwent evaluation for RA-ILD. PATIENTS AND METHODS: A total of 87 patients who were evaluated for RA-ILD within one year were included in the study. This study was conducted retrospectively using a cross-sectional and descriptive approach to analyze the demographic and clinical data of the included patients. RESULTS: Among the 87 patients, eight were diagnosed with RA-ILD, with four being male and four being female. Of the eight patients, two had non-specific interstitial pneumonia, five had usual interstitial pneumonia, and one had nodules consistent with RA. Subpleural fibrosis increased the likelihood of RA-ILD by 6.9 times. In the group with ILD, the residual volume and total capacity were found to be lower compared to the other group. Among the eight patients diagnosed with RA-ILD, five had used methotrexate before the diagnosis. CONCLUSIONS: In order to mitigate the risk of delayed diagnosis of RA-ILD, which can lead to increased mortality and has a subtle onset, it is recommended that patients with RA who possess certain risk factors undergo regular monitoring. It is advisable for RA patients to undergo annual assessments involving carbon monoxide diffusion capacity and spirometry function tests. In cases, where deemed necessary, more advanced investigations such as high-resolution computed tomography should be conducted.

Intraperitoneal Administration of Low Dose Aluminium in The Rat: How Good is It to Produce a Model for Alzheimer Disease.

Since neurotoxicity of aluminium (Al) resembles the progressive neurodegeneration observed in Alzheimer Disease (AD), Al administration in several ways has been used to produce AD model. Intraperitoneal (ip) low dose (4.2 mg/ kg) Al injection in rats for long periods is the preferred method by some researchers. In this paper, the efficiency of this method for producing an AD model was evaluated. In this study, we looked at the neuropathology of Al and the characteristic lesions of AD by histological and immunohistochemical techniques and determined oxidative stress markers in the brains of Al-treated and control rats. We also made electrophysiological recordings at the hippocampus and evaluated possible behavioural changes by Morris water maze test. However, no pathologic changes occurred in the animals except for an impairment in long-term potentiation (LTP) in the hippocampus (e.g. the LTPs of population spike (PS) amplitude at 15 min post-tetanus were measured as 217±27% in Al-treated rats and as 240±42% in sham-treated rats, of baseline PS amplitude). According to the findings of the present study, low dose of ip Al in rats is not sufficient to produce a good AD model. Higher doses (≥10 mg/kg) should be used.

Can Doppler flow parameters of carotid stenosis predict the occurrence of new ischemic brain lesions detected by diffusion-weighted MR imaging after filter-protected internal carotid artery stenting?

BACKGROUND AND PURPOSE: Carotid angioplasty and stent placement are increasingly being used for the treatment of symptomatic and asymptomatic carotid artery disease. Carotid angioplasty and stent placement carry an inherent risk of distal cerebral embolization, precipitating new brain ischemic lesions and neurologic symptoms. Our purpose was to evaluate the frequency of new ischemic lesions found on diffusion-weighted imaging after protected carotid angioplasty and stent placement and to determine the association of new lesions with ICA Doppler flow parameters. MATERIALS AND METHODS: Fifty-two patients (mean age, 68 ± 11 years) with 50%-69% (n = 20, group 1) and ≥70% (n = 32, group 2) internal carotid artery stenosis underwent carotid angioplasty and stent placement with distal filter protection. DWI was performed before and 48 hours after carotid angioplasty and stent placement. RESULTS: Thirty-three (63.4%) patients showed new lesions. The average number of new postprocedural lesions was 3.4 per patient. Most of the postprocedural lesions were <5 mm (range, 3-23 mm), cortical and corticosubcortical, and clinically silent. Group 2 had a significantly higher number of new lesions compared with group 1 (P < .001). A significant relationship was found between ICA Doppler flow parameters and the appearance of new lesions. CONCLUSIONS: The appearance of new ischemic lesions was significantly related to the Doppler flow parameters, particularly peak systolic velocity.

A rare cause of intraabdominal hematoma: rupture of mesenteric artery branch aneurysm.

Superior mesenteric artery (SMA) aneurysm is the third most common splanchnic artery aneurysm. Unlike other splanchnic artery aneurysm, isolated aneurysms of the SMA branches are rare. They are usually asymptomatic and difficult to detect until they rupture and cause abdominal pain and hypovolemic shock. Thus, most cases are diagnosed after the occurrence of complications. In this report, we described a 76-year-old woman who had two saccular aneurysms in the superior mesenteric arterial branch(es). One of them was ruptured and partly thrombosed. The patient had acute renal failure secondary to massive intraabdominal hemorrhage.

Abdominal actinomycosis: a report of two cases.

Actinomyces spp. cause a chronic suppurative, granulomatous disease which is characterized clinically by extensive abscess formation, recurrent draining of sinuses and fistulae and histologically by the presence of the so-called "sulphur granules". Colonic actinomycosis is a relatively rare infection and its diagnosis is difficult. We report the case of a female patient who was operated on for ovarian cyst and the case of another female patient operated on for a mass in the transverse colon. In both cases the pathology of the excised tissues revealed actinomycosis. Actinomycosis must be considered in the differential diagnosis of patients who present with abdominal pain, fever, leucocytosis and intestinal wall thickness and/or abdominal mass.

Initial steps in the unifying theory of the pathogenesis of artery aneurysms.

OBJECTIVES: The objective of this study was to investigate the changes in histology and proteolysis and the role of apoptosis in the development of peripheral artery aneurysms. METHODS: Eighteen popliteal, 6 abdominal aortic, 10 iliac, 2 carotid, and 6 femoral artery aneurysm specimens were obtained from patients undergoing elective surgical repair. All were males with ages 48 to 93 (mean 71 years). Normal controls were obtained from patients matched for age, sex, and major risk factors. Vascular smooth muscle cells (VSMC), macrophages, T lymphocytes, and apoptosis-regulating molecules were detected immunohistochemically. Detection of apoptosis was by TUNEL assay. Proteolytic activity was determined by 10% gelatin gel zymography. RESULTS: Paucity of VSMCs, increased amount of inflammatory infiltrate, and fragmentation of elastic lamellae were observed in aneurysmal tissues as compared to normal arteries (P < 0.02). There is increased gelatinolytic activity at 92, 84, 72, and 67 kDa in the aneurysmal tissues. There are fewer CD68+ macrophages and T cells in the media of controls than in the aneurysms (P = 0.01). Apoptosis is significantly high in aneurysm tissues (P < 0.01) and the degree of apoptosis was in the order AAA>FAA>PAA>IAA>CAA. There is increased expression of Bax, CPP-32, Fas, and p53 in PAA specimens as compared to normal popliteal arteries (P < 0.05). CONCLUSIONS: These data confirm the apparent architectural disruption and loss of VSMCs that are hallmarks of aneurysm development, in peripheral artery aneurysms. Apoptosis and signaling molecules capable of initiating cell death may play a significant role in the pathogenesis of all aneurysms. Our data suggest a common etiology between the various types of aneurysms.

Combined upper and lower extremity deep venous thrombosis.

In order to elucidate the natural history of upper extremity deep venous thrombosis (UEDVT), we compared the morbidity and mortality of patients with UEDVT and that of patients with both UEDVT and lower extremity deep venous thrombosis (LEDVT). Between 1993 and 1996, 21 patients presented to our institution with both LEDVT and UEDVT (Group 1). During the same time period, 144 patients were diagnosed with UEDVT alone (Group 2). The diagnosis was confirmed by duplex scanning in all patients. In Group 1, there were 14 females (67%) and 7 males (23%) with ages ranging from 25 to 97 yr old [mean 73 yr old +/-17 yr (SD)]. In Group 2, there were 84 females (58%) and 60 males (42%) with ages ranging from 9 to 101 yr old [mean 67 yr old +/-17 yr (SD)]. Differences in age and sex between the two groups were not statistically significant. In Group 1, systemic anticoagulation was implemented in 17 patients (81%). Two patients (9.5%) required placement of a SVC and IVC filters due to contraindication to anticoagulation. One patient did not receive anticoagulation, and one patient was only started on aspirin. In Group 2, treatment consisted of systemic anticoagulation in 94 patients (65%). The remainder of the patients were treated with aspirin in three patients (2%) or no anticoagulation in 31 patients (19%). Sixteen patients (11%) underwent placement of a SVC filter either due to failure of anticoagulation to prevent pulmonary embolism (two patients) or contraindication to anticoagulation (14 patients). Pulmonary emboli were documented by ventilation/perfusion lung scan in two patients (9.5%) in Group 1 and in 16 patients (11%) in Group 2. In the first group, 8 of the 21 patients (38%) were dead within 1 month of the diagnosis of UEDVT, and 11 of 21 patients (52%) were dead within 2 months of the diagnosis of UEDVT. In the second group, 20 of 144 patients (14%) were dead within 1 month of the diagnosis of UEDVT and 38 of 144 patients (26%) were dead within 2 months of diagnosis (P<0.02). Our data suggest that patients with both UEDVT and LEDVT have a higher mortality than patients with UEDVT alone. As the risk for pulmonary embolism is similar in both groups, we speculate that the severity of medical illness in patients with both UEDVT and LEDVT may contribute to the higher mortality. This is the first study to examine the mortality of this group of patients.

Expression of molecular mediators of apoptosis and their role in the pathogenesis of lower-extremity varicose veins.

PURPOSE: In an earlier study, we observed a significant decrease in apoptosis in varicose veins, as compared with healthy veins, indicating that deregulated apoptosis plays a role in the pathogenesis of varicosities. In addition, significant differences were noted in the expression and subcellular localization of the cell cycle regulatory protein, cyclin D1 in varix tissues, as compared with controls. Because cell cycle checkpoint controls are linked to the signaling and execution of apoptotic cascades, we examined the expression of bcl-2 family members bax and bcl-x, known molecular mediators of apoptosis, and that of poly (ADP-ribose) polymerase (PARP), a downstream substrate of DNA cleavage. METHODS: Twenty varicose vein specimens were retrieved from 20 patients (10 men, 10 women; mean age, 53.6 +/- 4.7 years) undergoing lower-extremity varicose vein excision. Healthy greater saphenous vein segments (n = 27) were obtained from 27 patients (14 men, 13 women; mean age, 59.5 +/- 2.4 years) undergoing infrainguinal arterial bypass grafting surgery. All tissues were distal portions. As per CEAP classification for chronic lower-extremity venous disease, most of the patients were in class 2 for clinical signs (n = 11); some patients were in class 3 (n = 4) or class 4 (n = 4), and only one patient was in class 5. Five 5-microm thick sections from formalin-fixed, paraffin-embedded specimens were used as a means of immunohistochemically localizing the expression of bax, bcl-x, and PARP, and 10 random high-power fields per section were evaluated by two independent reviewers blinded to the clinical findings. Statistical analyses were conducted by means of chi(2), analysis of variance, Student and Fisher exact t tests with StatView software. RESULTS: Immunoreactivity to pro-apoptotic bax was significantly higher in the normal veins (P <.001). Cytoplasmic expression of bcl-x was prominent in the cells of the vasa vasorum in both varicose and healthy veins. PARP expression was diminished in the varicose vein group, with 2.8 +/- 0.7 (P =.01) and 1.4 +/- 0.5 (P =.05) cells per high-power field in the intima and media, respectively. Neither bax nor PARP was noted in the adventitia of varicose veins, although their expression was detected in this layer of the control group (P <.001). CONCLUSION: The entry of smooth muscle cells into the apoptotic pathway may be regulated by the induction of bax in this model, because there is significant presence of this pro-apoptotic protein in healthy veins. Both bax and PARP are downregulated in varicose veins, as compared with healthy veins, and this may play a significant role in the pathogenesis of varicose veins.

Differential proteolytic activity and induction of apoptosis in fibrous versus atheromatous plaques in carotid atherosclerotic disease.

PURPOSE: Atherosclerotic plaque instability may be a contributing factor to plaque complications, such as rupture, thrombosis, and embolization. Of the two types of plaques, atheromatous and fibrous, the atheromatous type has been reported to be vulnerable and unstable. This instability may be related to changes in the cell cycle and extracellular matrix degradation. Apoptosis may weaken the plaque structurally. In addition, alteration of the cellular component may lead to imbalances in associated proteolytic activity. Our study was designed to compare the two types of plaques in terms of apoptosis, apoptosis-inducing factors, namely Fas/CD95/APO-1 and CPP-32/YAMA/caspase-3, and proteolytic activity. METHODS: Carotid artery plaques were obtained from patients undergoing endarterectomy and were classified as either atheromatous or fibrous on the basis of established criteria. Histologic study included hematoxylin and eosin staining, Verhoeff's van Gieson elastin staining, and trichrome staining. Detection of apoptosis was performed with the TUNEL assay. Immunohistochemical studies were performed to localize the expression of CPP-32/YAMA and Fas/CD95. Gelatin gel zymography was used to compare proteolytic activity levels in the two types of plaque. RESULTS: Apoptosis was significantly higher (P <.001) in atheromatous plaques (4.90% +/- 1.27% [SEM]) as compared with fibrous plaques (0.86% +/- 0.46% [SEM]). Zymography demonstrated elevated levels of proteinases in atheromatous plaques. Immunohistochemistry revealed significant increases in the expression of Fas/CD95 (P <.04) and CPP-32/YAMA (P <.001) in atheromatous plaques as compared with that in fibrous plaques. CONCLUSIONS: This is the first study comparing molecular factors that render atheromatous plaques more susceptible to rupture than fibrous plaques. The higher number of apoptotic cells seen in atheromatous plaques as compared with fibrous plaques could contribute to their greater instability. Immunoreactivity to cytoplasmic death domain, Fas/CD95 and CPP-32/YAMA, a prominent mediator of apoptosis, was consistent with the numbers of apoptotic cells detected. The increased levels of proteolytic activity in atheromatous plaques may make these plaques more prone to rupture. These data identifying some of the molecular events and biochemical pathways associated with plaque vulnerability may help in the development of new strategies to prevent plaque rupture.

Von Hippel-Lindau gene therapy: a novel strategy in limiting endothelial cell proliferative activity.

There is evidence that loss of function of the von Hippel-Lindau (VHL) gene causes transcriptional activation of the vascular endothelial growth factor (VEGF) gene, which in turn may lead to increased proliferation of vascular endothelial cells. We hypothesized that transfer of VHL gene, a tumor suppressor gene, into vascular endothelial cells could cause loss of viability and suppression of its proliferative ability. Human aortic endothelial cells (HAEC) were grown as monolayers and transfected with varying titers of adenovirus containing the VHL cDNA (AdVHL). The negative controls used were adenovirus containing green fluorescent protein (AdGFP), vector alone (AdNull), and infection medium without virus. Adenovirus encoding p53 (Adp53) was used as positive control. Cell viability and proliferation were determined by trypan blue dye exclusion and by a tetrazolium-based colorimetric assay. All experiments were performed in triplicate. Our results showed that proliferative activity in HAEC can be blocked and viability of HAEC reduced by adenovirus-mediated gene transfer of VHL gene. This is the first time that VHL gene has been effectively transferred to HAEC. VHL gene transfer into the vascular endothelium may have potential in limiting proliferative processes, including intimal hyperplasia.

The value and limitations of the arm cephalic and basilic vein for arteriovenous access.

The National Kidney Foundation has identified the use arteriovenous grafts (AVG) and the interventions required to maintain their patency as two major causes of increased expenditure in the management of hemodialysis access in end-stage renal disease patients. They have issued an appeal for the increased use of native arteriovenous fistulae (AVF). Although the radialcephalic AVF is considered to be the procedure of choice for these patients, other veins should be sought after to maintain an all-autogenous AVF policy. We examined our experience of using arm veins that were transposed to the brachial artery. Over the last 2.5 years, 109 brachiocephalic AVF (BCAVF) and 63 brachiobasilic AVF (BBAVF) were placed in 163 patients with chronic renal failure. In each group, 40 and 25 patients were males, respectively. Ages ranged from 29 to 88 years (mean 67+/-1.4 years) and 37 to 84 years (mean 69+/-2.0 years) in each group. Diabetic patients comprised 56 and 65% of each group and hypertensive patients comprised 73 and 75% of each group. Data collection was via chart review, personal interviews, and review of the dialysis records. Patency was assessed by life-table analysis. The log-rank test was performed in conjunction with Kaplan-Meier survival analysis. Our results showed that the use of BCAVF and BBAVF appears to be a viable alternative to prosthetic arteriovenous grafts. On the basis of our experience, an algorithm for placement of AVF is suggested.

Posterior transverse plication technique for treatment of redundant internal carotid artery during endarterectomy.

PURPOSE: Posterior transverse plication (PTP) has gained popularity as a technique to correct redundancy of the internal carotid artery during endarterectomy. The safety of this technique in large series of patients has not been extensively studied. We investigated 876 primary carotid endarterectomies (CEAs) performed at our institution over the last six years to determine the safety of this technique. METHODS: Indication for surgery was carotid stenosis >/=70% in 341 (39%) symptomatic and 535 (61%) asymptomatic cases. Preoperative imaging consisted of duplex ultrasound alone or combined with magnetic resonance angiography. Patients were divided into four groups related to surgical technique: CEA+PTP+8mm patch (group Ia), CEA+PTP+10mm patch (group Ib), CEA+patch (group II) and CEA+primary closure (group III). There were 43, 39, 581 and 213 patients in groups Ia, Ib, II and III, respectively. No statistical differences in age, sex or risk factors for atherosclerotic disease were noted among the groups. Postoperative duplex ultrasonography was used at 2weeks and every 6months thereafter to evaluate the adequacy of the repair and presence of complications such as pseudoaneurysm formation and extrinsic compression by the excluded carotid segment. RESULTS: The 30-day mortality was 1.2%, 0.6% and 0.3% for groups I, II and III, respectively. Stroke rates for the same period were 0%, 0.6% and 0.8% for groups I, II and III, respectively. Duplex ultrasonography demonstrated significant stenosis (>/=50%) in two (5%) patients in group Ia at 12months. No restenosis was observed in group Ib. For groups II and III the rates of restenosis were 1.5% and 0.8%. One patient in group II developed a pseudoaneurysm after 7months. CONCLUSION: Posterior transverse plication safely corrects redundancy of the internal carotid artery during endarterectomy without causing early significant restenosis. Continued follow-up in a larger group of patients to determine long-term efficacy and correlation between patch size and restenosis rate is warranted.

Lessons learned from a 6-year clinical experience with superior vena cava Greenfield filters.

PURPOSE: Therapy to prevent pulmonary embolism (PE) resulting from upper extremity deep venous thrombosis (UEDVT) remains controversial despite an increasing incidence of DVT of upper extremity origin. The purpose of this study was to evaluate the results of 72 superior vena cava Greenfield filters (SVC-GFs) placed in patients at risk for PE arising from UEDVT. METHODS: During the past 78 months, we placed SVC-GFs in 72 patients with UEDVT in whom anticoagulation was either deemed contraindicated (n = 67) or proved ineffective in preventing recurrent PE (n = 4) or extension of the thrombus (n = 1). There were 25 male (35%) and 47 (65%) female patients whose ages ranged from 25 to 99 years (mean, 74 years). Follow-up ranged from 10 days to 78 months (mean, 7.8 months). Sequential chest radiographs revealed no filter migration or displacement in 26 patients. RESULTS: Thirty-four patients died in the hospital of causes unrelated to the SVC filter or recurrent thromboembolism (mean time to death, 20 days). Follow-up of the surviving 38 patients ranged from 1 month to 78 months (mean, 22 months); none of these patients were seen with any evidence of PE. One SVC-GF was incorrectly discharged into the innominate vein and left in place. This vein remains patent 2 months after insertion without evidence of filter migration. CONCLUSIONS: We think that insertion of SVC-GFs is a safe, efficacious, and feasible therapy and may prevent recurrent thromboembolism in patients with UEDVT who are resistant to anticoagulation or have contraindications to anticoagulation.

Upper extremity deep venous thrombosis: an underrecognized manifestation of a hypercoagulable state.

Although lower extremity deep venous thrombosis (LEDVT) has been associated with a hypercoagulable state, there are scant data available for patients presenting with upper extremity deep venous thrombosis (UEDVT). Therefore, we conducted a prospective study to determine whether such an association exists for UEDVT. Fifty-two patients who presented with UEDVT at our institution from August 1996 to June 1997 underwent a hematological profile consisting of activated protein C (APC) resistance, antithrombin III (ATIII) level and activity, factor V mutation (arginine 506 to glycine), protein C level and activity, protein S level and activity, factors II and X activity, lupus anticoagulant, and cardiolipin antibody. This represented 68% (52/76) of the total number of patients in whom the diagnosis of UEDVT was made by duplex ultrasonography during this time period. The ages ranged from 9 to 97 (mean 63 +/- 23 years). There were 22 males and 30 females. Twenty-five patients (48%) had a central venous line in place, 4 patients (8%) had a pacemaker, 14 patients (27%) had a history of neoplasm, and 7 patients (13%) had concomitant LEDVT. The results of our study showed that a hypercoagulable state may be an underappreciated contributing factor in the development of UEDVT. Contrary to prior belief that three sets of tests are needed to confirm the presence of a hypercoagulable state, these data also suggest that only two tests may be needed.

Lower-extremity revascularisation without preoperative contrast arteriography in 185 cases: lessons learned with duplex ultrasound arterial mapping.

PURPOSE: we have previously reported our experience with lower-extremity duplex-ultrasound arterial mapping (DUAM) compared to contrast arteriography (CA) to predict lower-extremity bypass sites. The present study evaluates arterial revascularisation procedures for chronic limb ischaemia based on DUAM. MATERIALS AND METHODS: from January 1998 to July 1999, 195 patients (128 men, 67 women) underwent 211 lower-extremity revascularisation procedures based on DUAM. Indications for surgery were tissue loss, severe claudication, rest pain and popliteal aneurysm in 57%, 25%, 14% and 4% of the limbs, respectively. The mean age was 72+/-12 years and risk factors such as diabetes, hypertension, tobacco use, coronary artery and end-stage renal disease were present in 53%, 58%, 53%, 50% and 12% of the patients, respectively. Previous revascularisation procedures had been performed in 23% of the limbs. Preoperative evaluation consisted of DUAM alone (185) or of a combination of DUAM and CA (29 limbs). CA was deemed necessary due to a combination of technical difficulties that jeopardized adequate sonographic imaging and presence of disadvantaged run-off for medico-legal reasons. DUAM consisted of direct imaging of all major arteries from the distal aorta to the pedal circulation. Optimal inflow and outflow bypass anastomotic sites were selected according to a diagram based on DUAM. Adequacy of the inflow was additionally assessed by common-femoral-artery waveform and confirmed by intraoperative pressure measurements. Post-bypass CA was obtained to verify patency of the run-off. RESULTS: DUAM procedure time averaged 75+/-26 min. For patients who underwent only DUAM, the distal anastomosis was to the popliteal artery in 91 cases and to tibial or pedal arteries in 58 cases. Distal anastomosis was proximal to a significant lesion in two cases that required jump grafts. Cumulative patency rates at 1 and 3 months for popliteal bypasses were 96% and 90%, and for infrapopliteal bypasses 90% and 83%, respectively. Inflow procedures to the femoral artery, patch and balloon angioplasties accounted for the remaining 40 cases. Four primary amputations were performed after CA confirmed DUAM findings. CONCLUSIONS: contrary to general belief, these data show that high-quality arterial ultrasonography represents a safe alternative to preoperative CA, even for infrapopliteal bypasses. This non-invasive approach may be especially useful for patients with contrast allergy or impaired renal function.

Changes in the practice of angioaccess surgery: impact of dialysis outcome and quality initiative recommendations.

PURPOSE: Recommendations recently published by the National Kidney Foundation-Dialysis Outcome and Quality Initiative (DOQI) included an appeal for increased use of native arteriovenous fistulas (NAVFs) to improve overall patency and contain angioaccess costs. We evaluated the impact of the DOQI recommendations on angioaccess surgery and its outcome at our institution. METHODS: From June 1996 to April 1999, 483 angioaccess procedures were performed on 247 patients. There were 133 men and 114 women, with an average age ranging from 28 to 95 years (mean age, 69 +/- 0.59 years). Risk factors included smoking in 143 patients (58%), diabetes mellitus in 135 patients (55%), hypertension in 150 patients (61%), and coronary artery disease in 98 patients (40%). The patients were divided in two groups. Group I (pre-DOQI) included patients who had angioaccess procedures between June 1996 and November 1997, and group II (post-DOQI) included patients who had angioaccess procedures between December 1997 and April 1999. The types of procedures performed included placement of arteriovenous grafts (AVGs) in 122 patients (25%), creation of NAVFs in 99 patients (20%), revision of AVGs in 123 patients (25%), and temporary access procedures in 135 patients (28%). Forty-seven of the NAVF procedures were radial-cephalic fistulas (47%), 22 were brachial-cephalic fistulas (23%), and 30 were brachial-basilic fistulas (30%). Patients underwent serial ultrasonography scanning and physical examinations; the mean follow-up period was 9 months. Choice of angioaccess procedures and patency rates before and after implementation of the DOQI recommendations were compared. RESULTS: There was a significant increase in the use of NAVFs after implementing DOQI recommendations (5% vs 68%, P <.001). The 1-year primary patency rate of AVGs was less than that of arteriovenous fistulas (54% vs 85%, P <.001). During the study period, the percentage of AVGs placed at our institution that required revision (59%; 72 of 123) was higher than that of NAVFs that required revision (4%; 4 of 99; P <.001). There was no significant difference in the maturation rates of radial-cephalic fistulas (75%), brachial-cephalic fistulas (91%), and brachial-basilic fistulas (87%). CONCLUSION: By adopting the DOQI recommendations, we used NAVFs more often. This resulted in superior patency rates, compared with synthetic grafts. The liberal use of preoperative duplex venous mapping further increased NAVF use, surpassing the DOQI expectations for primary arteriovenous fistulas. Additionally, fewer revisions were required.

Programmed cell death (Apoptosis) and its role in the pathogenesis of lower extremity varicose veins.

The etiology of varicose veins remains elusive. We hypothesized that abnormal cell cycle events in the vein wall may contribute to changes in its structural integrity predisposing to varicosity development. Since cell cycle checkpoint controls are linked to the signaling and execution of apoptotic cascades, possibly apoptosis is a contributing factor in the pathophysiology of varicosities. The present study was designed to investigate whether programmed cell death varies in varicosities as compared to normal veins. Twenty-seven normal greater saphenous vein specimens were obtained from patients undergoing infrainguinal arterial bypass surgery, and 20 varicose vein specimens were retrieved from patients undergoing varicose vein excision. Apoptosis was detected by TUNEL assay. Expression of bcl-2 and cyclin D1 was noted by standard immunohistochemical techniques. Apoptotic cells were identified in 32 of the 47 specimens. Forty-eight percent of normal vein specimens displayed >3 apoptotic cells per 100 cells in the adventitia; 15% of the specimens of the varicose vein group showed such magnitude of apoptosis (p < 0.03). This increased apoptotic activity was not observed in media or intima of either vein group (p < 0.001). No significant difference in immunoreactivity to bcl-2 protein was observed in varicose vein specimens as compared to controls. Varicose vein specimens demonstrated increased nuclear expression of cyclin D1 whereas its cytoplasmic expression was significantly diminished (p

The spleen at risk after penetrating trauma.

UNLABELLED: In contrast to blunt splenic trauma where nonsurgical management is an option, splenorrhaphy is the current preferred approach for penetrating trauma. Splenectomy, however, may be required because of hemodynamic instability, the extent of the trauma, or when a pancreatic injury requires distal pancreatectomy. We evaluated our attempts at splenic preservation in 69 patients (1988-1992) in whom the spleen was at risk for removal. Fifty-seven patients had penetrating injury to the spleen and 12 patients had distal pancreatectomy. Splenic Trauma (n = 57): 6 patients (mean Abdominal Trauma Index 45) died within 24 hours of extensive injuries. All had splenectomy. Thirty-seven of the remaining 51 (72.5%) had successful splenorrhaphy, 85% with stab wounds (SWs) and 65.5% with gunshot wounds (GSWs). Splenic salvage was 100%, 100%, 92%, 37%, and 0%, respectively, for grades I-V injuries. Absorbable mesh splenorrhaphy improved splenic salvage in grade III and IV injuries from 67% and 0% in previous years (1983-1987) to 92% and 37% in recent years (1988-1992), p < 0.01. The use of the mesh did not increase septic complications, even in the presence of enteric perforation. Distal Pancreatectomy (n = 12): 1 died intraoperatively. The spleen was not injured in 6 and was preserved in all 6. The overall 54.5% splenic salvage rate was achieved without increasing morbidity or the number of transfusions. CONCLUSIONS: (1) Splenorrhaphy should be possible in the great majority of stable patients after penetrating trauma. (2) Absorbable mesh is a valuable adjunct that may facilitate the repair of more severe grades of splenic trauma.(ABSTRACT TRUNCATED AT 250 WORDS)