Treatment of vascular non-iatrogenic injuries of upper and lower extremities in tertiary vascular center.

BACKGROUND: The purpose of this study was to examine demographic and baseline characteristics of patients with vascular injuries of extremities and to define the most relevant factors which influenced an early outcome, as well as limb salvage after the management of vascular trauma. METHODS: This study used the database that included 395 patients with peripheral arterial injuries, who were treated in the tertiary vascular university center in the period between 2005-2020. Exclusion criteria were isolated thoracic, abdominal and neck injuries as well as iatrogenic injuries and injuries of intravenous addicts. Univariate binary logistic regression analysis and multiple logistic regression were used to determine risk factors for lomb loss (after vascular reconstruction) or mortality. Decision to perform primary amputation (without vascular reconstruction) was based on surgeons' preference and experience. RESULTS: Out of 395 vascular injuries treated in the period 2005-2020, 210 (53.2%) presented with non-iatrogenic vascular injuries of upper and lower extremities were analyzed. According to the univariate regression analysis, hemorrhage as the main clinical manifestation on admission (P=0.035) and early reintervention (P=0.048) increased, while an early patency of repaired artery (0.010) significantly decreased a 30-day amputation rate. Multivariate logistic regression analysis of these three variables showed that only early patency of repaired artery significantly decreased the early amputation rate (P=0.009). CONCLUSIONS: Based on presented experience, the patency of vascular reconstruction plays a crucial role in limb salvage in patients with non-iatrogenic peripheral vascular injuries. All factors that might influence the patency should be in focus of improvement.

First-year profile of biomarkers for early detection of renal injury in infants with congenital urinary tract obstruction.

BACKGROUND: Diagnosis of renal function impairment and deterioration in congenital urinary tract obstruction (UTO) continues to be extremely challenging. Use of renal biomarkers in this setting may favor early renal injury detection, allowing for a reliable choice of optimal therapeutic options and prevention or minimization of definitive renal damage. METHODS: This longitudinal, prospective study analyzed the first-year profile of two serum renal biomarkers: creatinine (sCr) and cystatin C (sCyC); and six urinary renal biomarkers: neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), transforming growth factor beta-1 (TGF-ß1), retinol-binding protein (RBP), cystatin C (uCyC), and microalbuminuria (µALB) in a cohort of 37 infants with UTO divided into three subgroups: 14/37 with unilateral hydro(uretero)nephrosis, 13/37 with bilateral hydro(uretero)nephrosis, and 10/37 patients with lower urinary tract obstruction (LUTO), compared with 24 healthy infants matched by gestational age and birth weight. RESULTS: All urine biomarkers showed significantly higher values at the first month of life (p ≤ 0.009), while NGAL (p = 0.005), TGF-ß1 (p < 0.001), and µALB (p < 0.001) were high since birth compared to controls. Best single biomarker performances were RBP in bilateral hydronephrosis and LUTO subgroups and KIM-1 in unilateral hydronephrosis subgroup. Best biomarker combination results for all subgroups were obtained by matching RBP with TGF-ß1 or KIM-1 and NGAL with CyC ([AUC] ≤ 0.934; sensitivity ≤ 92.4%; specificity ≤ 92.8%). CONCLUSIONS: RBP, NGAL, KIM-1, TGF-ß1, and CyC, alone and especially in combination, are relatively efficient in identifying surgically amenable congenital UTO and could be of practical use in indicating on-time surgery.

Open repair of ruptured abdominal aortic aneurysm with associated horseshoe kidney.

BACKGROUND: Ruptured abdominal aortic aneurysms (RAAA) with concomitant horseshoe kidney (HK) present a unique challenge at the time of repair. The aim of this article was to propose the most rationale strategy during open repair (OR) of RAAA in the presence of HK. METHODS: We identified and analyzed all patients treated at the clinic due to RAAA and HK. An extensive search was performed on all articles published up to August of 2017 describing open and endovascular repair of RAAA with concomitant horseshoe kidney. The following data were extracted and analyzed: patient number, number of renal arteries, Crawford classification of horseshoe kidney vascularization, type of aortic reconstruction, management with renal arteries, 30-day kidney failure and outcome. RESULTS: Transperitoneal approach followed by supraceliac aortic cross clamping without the division of the renal isthmus occurred in all our six cases. Four of them required additional procedures with accessory renal arteries after aortic replacement. Three of patients (50%) died during the first 30 postoperative days, while one developed transitory renal insufficiency. The renal isthmus was preserved in 43.90% and divided in 46.34% of cases. Crawford type I of HK vascularization was presented in 21.95% of cases, type II also in 39.02%, while the type III in 19.51% of cases. In 46.33% of cases a procedure with renal arteries was necessary. In 26.82% accessory renal arteries were ligated, while in 19.51% preserved (reattachment or aorto-renal bypass). Thirty-day mortality was 21.95%, while the incidence of postoperative renal failure was also 21.95%. There was not significant correlation between the renal artery ligation and the postoperative renal failure (r=-0.81, P=0.59). CONCLUSIONS: Transperitoneal approach should be preferred during urgent OR of RAAA with concomitant HK. A supraceliac aortic cross clamping and the placement of occlusive Fogarty catheters into both iliac arteries are recommended for proximal and distal bleeding control. Preservation of accessory renal arteries that are larger than 3 mm in diameter or supply more than 30% of renal parenchima is recommended. The division of the renal isthmus should be avoided if vascularized. It seems that renal arteries could be covered in emergency EVAR without any implications on postoperative kidney function, allowing broader aplication of endovascular treatment for thesse patients.

Combined Impact of Chronic Kidney Disease and Contrast Induced Acute Kidney Injury on Long-term Outcomes in Patients with Acute Lower Limb Ischaemia.

INTRODUCTION: Acute lower limb ischaemia (ALI) is the sudden onset of decreased arterial perfusion with imminent threat to limb viability. Contrast induced acute kidney injury (CI-AKI) is one of the complications that increases mortality in patients who undergo contrast imaging in coronary procedures. The goal of this study is to evaluate the impact of chronic kidney disease (CKD) and CI-AKI on long-term clinical outcomes in patients with ALI undergoing lower limb revascularisation. METHODS: A total 1017 consecutive patients with acute lower limb ischaemia who were admitted between July 1, 2006, and January 1, 2017, were retrospectively reviewed. Patients who had end stage renal disease, those who had end stage heart and malignant disease and died within 7 days of limb revascularisation, and those who did not undergo angiography were excluded. Thus 546 patients were included in the final analysis. Patients were classified as with or without CKD and were then subdivided according to the presence or absence of the development of CI-AKI, defined as an increase in serum creatinine of ≥0.5 mg/dL or by ≥25% from the baseline value within the first 72 h after contrast exposure. The primary end point was all cause mortality and secondary major adverse limb event (MALE). RESULTS: Both CKD and CI-AKI were associated with the highest rate of all cause mortality (chi square = 55.77, d.f. = 1, p < .01, log rank test) and MALE (chi square = 79.07, d.f. = 1, p < .01, log rank test). The presence of CKD and CI-AKI were significant risk factors associated with long-term all cause mortality (HR = 2.61, p < .01) and MALE (HR = 2.87, p < .01). CONCLUSION: In patients with ALI undergoing lower limb revascularisation, both CKD and CI-AKI were significantly associated with poor long-term outcomes compared with either CKD or CI-AKI alone. Further studies are required to assess this association and to confirm the combined effect of CKD and CI-AKI on long-term clinical outcomes.

A First-in-Human Phase I Study of OPB-111077, a Small-Molecule STAT3 and Oxidative Phosphorylation Inhibitor, in Patients with Advanced Cancers.

LESSONS LEARNED: OPB-111077 is a novel inhibitor of STAT3 and mitochondrial oxidative phosphorylation that exhibited promising anticancer activity in preclinical models.In this first-in-human phase I study of OPB-111077 in unselected advanced cancers, treatment-emergent adverse events, most frequently nausea, fatigue, and vomiting, were generally mild to moderate in intensity and could be medically managed.Overall, only modest clinical activity was observed after OPB-111077 given as monotherapy. Notable antitumor activity was seen in a subject with diffuse large B-cell lymphoma. BACKGROUND: OPB-111077 is a novel inhibitor of STAT3 and mitochondrial oxidative phosphorylation with promising anticancer activity in preclinical models. METHODS: Open-label, phase I trial of OPB-111077 in advanced cancers with no available therapy of documented benefit. Initial dose escalation in unselected subjects was followed by dose expansion. Patients received oral OPB-111077 daily in 28-day cycles until loss of clinical benefit. RESULTS: Eighteen subjects enrolled in dose escalation, and 127 in dose expansion. Dose-limiting toxicities were observed at 300 mg and 400 mg QD; maximum tolerated dose was defined as 250 mg QD. Frequently reported treatment-emergent adverse events (TEAEs) included nausea, fatigue, and vomiting. TEAEs were generally mild to moderate and could be medically managed. OPB-111077 reached micromolar drug concentrations, had an elimination half-life of approximately 1 day, and reached steady-state by day 8. A durable partial response was observed in one subject with diffuse large B-cell lymphoma. Seven subjects with diverse tumor types had stable disease or minor responses for at least eight treatment cycles (224 days). CONCLUSION: OPB-111077 is generally well tolerated, and its pharmacokinetic profile is sufficient for further clinical development. Notable clinical activity was observed in a subject with diffuse large B-cell lymphoma. Overall, modest efficacy was observed against unselected tumors.

Effects of atmospheric pressure dynamics on abdominal aortic aneurysm rupture onset.

BACKGROUND: The effect of atmospheric pressure (AP) on the onset of abdominal aorta aneurysm rupture (RAAA) remains an unanswered question. We have investigated the seasonal variation and the effect of AP dynamics on RAAA by analysing the largest series of intraoperatively confirmed RAAA. PATIENTS AND METHODS: To realize this study we have performed a retrospective analysis of 546 patients with RAAA, operated within 503 days at the Clinic for vascular and endovascular surgery CCS between 1.1.2003 and 31.12.2012. AP data for Belgrade city were obtained from meteorological yearbooks published by the Republic Hydrometeorological Service of Serbia measured at the hydrometeorological station "Belgrade Observatory". Only patients with a residence within the extended Belgrade region, exposed to the similar AP values, were included in the analysis of the AP effect on RAAA. RESULTS: RAAA were observed more frequently during winter and autumn months but without significant difference in comparison to other seasons. Months with higher AP values were associated with a higher RAAA rate (p = 0.0008, R2 = 0.665). A similar trend was observed for the monthly AP variability (p = 0.0311, R2 = 0.374). Average AP values did not differ between days with and without RAAA. However, during the three and seven days periods preceding RAAA AP variability parameters were greater and AP was rising. CONCLUSIONS: Although these pressure differences are very small, higher AP values over longer periods of time as well as greater variability are associated with RAAA. The exact mechanism behind this association remains unclear. The postulation that low AP may precipitate RAAA based on the Laplace law should be discarded.

Severity of memory impairment in the elderly: Association with health care resource use and functional limitations in the United States.

INTRODUCTION: Dementia is a prevalent condition in older adults associated with decline in cognitive and functional abilities and substantial burden. This study assessed the prevalence and impact of subjective memory impairment in the United States. METHODS: The 2011 to 2014 National Health and Nutrition Examination Survey, a population-based, nationally representative survey, was analyzed. Data included medical examinations, self-reported cognitive and functional limitations, and health care utilization over 1 year. Participants were aged ≥65 years and completed both interview and medical examination components. Descriptive analyses of patient characteristics were performed, and complex survey regression models were used to test associations. RESULTS: Of 2431 survey participants included, 53.1% had no memory impairment, 40.1% had early-stage memory impairment, and 6.6% had late-stage memory impairment. In adjusted analyses, late-stage versus no impairment was associated with more functional limitations (odds ratio [OR] = 7.26, P < .001), greater health care utilization (OR = 2.46, P < .001), and higher likelihood of seeing a mental health specialist (OR = 3.06, P = .001). DISCUSSION: Consistent with previous research, individuals with late-stage memory impairment had significantly greater functional limitations and higher health care utilization versus individuals with early-stage or no memory impairment.

Blood groups and acute aortic dissection type III.

INTRODUCTION: Acute aortic type III dissection is one of the most catastrophic events, with in-hospital mortality ranging between 10% and 12%. The majority of patients are treated medically, but complicated dissections, which represent 15% to 20% of cases, require surgical or thoracic endovascular aortic repair (TEVAR). For the best outcomes adequate blood transfusion support is required. Interest in the relationship between blood type and vascular disease has been established. The aim of our study is to evaluate distribution of blood groups among patients with acute aortic type III dissection and to identify any kind of relationship between blood type and patient's survival. MATERIAL AND METHODS: From January 2005 to December 2014, 115 patients with acute aortic type III dissection were enrolled at the Clinic of Vascular and Endovascular Surgery in Belgrade, Serbia and retrospectively analyzed. Patients were separated into two groups. The examination group consisted of patients with a lethal outcome, and the control group consisted of patients who survived. RESULTS: The analysis of the blood groups and RhD typing between groups did not reveal a statistically significant difference (p = 0.220). CONCLUSIONS: Our results indicated no difference between different blood groups and RhD typing with respect to in-hospital mortality of patients with acute aortic dissection type III.

Bilateral Internal Carotid Artery Occlusion, External Carotid Artery Stenosis, and Vertebral Artery Kinking: May It Be Asymptomatic?

The clinical spectrum of internal carotid artery occlusion ranges from being a completely asymptomatic occlusion to a devastating stroke or death. The prevalence of asymptomatic internal carotid artery occlusion is unknown, particularly for bilateral occlusion. The distal branches of the external carotid artery anastomose with distal branches of the internal carotid artery provide important sources of collateral circulation to the brain. Stenosis of the external carotid artery with ipsilateral/bilateral internal occlusion may result in ischemic sequelae. Coiling or kinking of the vertebral artery is a rare morphological entity that is infrequently reported because it remains asymptomatic and has no clinical relevance. Currently, there is little evidence to support management strategies for this disease entity and no official recommendations for asymptomatic bilateral carotid artery occlusion. We present a case of a 62-year-old female with asymptomatic bilateral internal carotid artery occlusion, bilateral external carotid artery stenoses, and bilateral kinking of the vertebral artery at the V2 segment, who has been successfully managed conservatively for over 5 years. An individualized approach to management of patients with bilateral internal carotid artery occlusion, especially in combination with external carotid artery stenosis and elongation malformations of the vertebral artery is key to a successful strategy.

Carotid replacement with Dacron graft in 292 patients.

INTRODUCTION: In case of highly atherosclerotic carotid process, carotid graft replacement might be a potential solution for successful procedure. Many studies evaluated the results of vein and polytetrafluorethilen (PTFE) graft usage at the carotid bifurcation, while the experience on the Dacron graft due to extensive atherosclerotic process is missing. The aim of our study was to evaluate 30-day and long-term results of the Dacron graft on carotid artery used in patients with extensive atherosclerotic disease. MATERIAL AND METHODS: This retrospective study analysed early and long-term neurological outcome as well as Dacron graft patency in patients operated with carotid reconstruction. Early results were confirmed by follow-up clinical examination, whereas late results were assessed by follow-up clinical examination as well as duplex sonographic examination at least 1 year after the surgery. As for statistical methods we used descriptive analysis tests, Chi-square test, and logistic regression. RESULTS: Carotid graft replacement was performed in 292 patients, before endarterectomy in 155 (53.09%), or after already attempted unsuccessful eversion endarterectomy in 137 (46.91%). Nineteen (6.5%) patients had a stroke due to ipsilateral and contralateral ischaemia or haemorrhagic in 17 (5.8%), 1 (0.3%) and 1 (0.3%) patients, respectively. Significantly higher rate of strokes occurred when the graft reconstruction was used after the failure of endarterectomy (8.5% vs. 3.5%, p = 0.029). Stroke and death rate was 7.19%. Factors that increased risk of early stroke were the length of plaque in the internal carotid artery measured intraoperatively (p = 0.025) and the surgical tactic to perform graft reconstruction after attempted extensive endarterectomy (p = 0.029). CONCLUSION: Low number of patients with carotid stenosis has extensive atherosclerotic process longer than 4 cm that might jeopardise eversion endarterectomy. Carotid graft replacement with Dacron graft provide early results that are comparable with other conduits; however, in such patients reconstruction should be selected individually based on surgical experience and anatomical distribution of stenotic disease. Due to high risk of stroke, only symptomatic patients with such extensive atherosclerotic disease should be operated.

Global Trends in Alzheimer Disease Clinical Development: Increasing the Probability of Success.

PURPOSE: Alzheimer disease (AD) is a growing global health and economic issue as elderly populations increase dramatically across the world. Despite the many clinical trials conducted, currently no approved disease-modifying treatment exists. In this commentary, the present status of AD drug development and the grounds for collaborations between government, academia, and industry to accelerate the development of disease-modifying AD therapies are discussed. METHODS: Official government documents, literature, and news releases were surveyed by MEDLINE and website research. FINDINGS: Currently approved anti-AD drugs provide only short-lived symptomatic improvements, which have no effect on the underlying pathogenic mechanisms or progression of the disease. The failure to approve a disease-modifying drug for AD may be because the progression of AD in the patient populations enrolled in clinical studies was too advanced for drugs to demonstrate cognitive and functional improvements. The US Food and Drug Administration and the European Medicines Agency recently published draft guidance for industry which discusses approaches for conducting clinical studies with patients in early AD stages. For successful clinical trials in early-stage AD, however, it will be necessary to identify biomarkers highly correlated with the clinical onset and the longitudinal progress of AD. In addition, because of the high cost and length of clinical AD studies, support in the form of global initiatives and collaborations between government, industry, and academia is needed. IMPLICATIONS: In response to this situation, national guidance and international collaborations have been established. Global initiatives are focusing on 2025 as a goal to provide new treatment options, and early signs of success in biomarker and drug development are already emerging.

Efficacy and safety of aripiprazole once-monthly in obese and nonobese patients with schizophrenia: a post hoc analysis.

PURPOSE: To assess the efficacy and safety of aripiprazole once-monthly 400 mg (AOM 400), an extended-release injectable suspension of aripiprazole, in obese and nonobese patients. PATIENTS AND METHODS: This post hoc analysis of a 38-week randomized, double-blind, active-controlled, noninferiority study (NCT00706654) compared the clinical profile of AOM 400 in obese (body mass index [BMI] ≥30 kg/m(2)) and nonobese (BMI <30 kg/m(2)) patients with schizophrenia for ≥3 years. Patients were randomized 2:2:1 to AOM 400, oral aripiprazole 10-30 mg/d, or aripiprazole once-monthly 50 mg (AOM 50 mg) (subtherapeutic dose). Within obese and nonobese patient subgroups, treatment-group differences in Kaplan-Meier estimated relapse rates at week 26 (z-test) and in observed rates of impending relapse through week 38 (chi-square test) were analyzed. Treatment-emergent adverse events (TEAEs) (>10% in any treatment group) were summarized. RESULTS: At baseline of the randomized phase, obesity rates were similar among patients randomized to AOM 400 (n=95/265, 36%), oral aripiprazole (n=95/266, 36%), and AOM 50 mg (n=43/131, 33%). In both obese and nonobese patients, relapse rates through week 38 for patients randomized to AOM 400 (obese, 7.4%; nonobese, 8.8%) were similar to those in patients on oral aripiprazole (obese, 8.4%; nonobese, 7.6%), whereas relapse rates were significantly lower with AOM 400 versus AOM 50 mg (obese, 27.9% [P=0.0012]; nonobese, 19.3% [P=0.0153]). The most common TEAEs with AOM 400 in obese and nonobese patients were insomnia (12.6% and 11.2%), headache (12.6% and 8.2%), injection site pain (11.6% and 5.3%), akathisia (10.5% and 10.6%), upper respiratory tract infection (10.5% and 4.7%), weight increase (10.5% and 8.2%), and weight decrease (6.3% and 11.8%). Within the AOM 400 group, 7.6% of patients who were nonobese at baseline became obese, and 17.9% of obese patients became nonobese during randomized treatment. CONCLUSION: The clinical profile of AOM 400 was similar in obese and nonobese patients.

Initiation of aripiprazole once-monthly in patients with schizophrenia.

OBJECTIVE: This article provides rationale for recommendations on how to initiate aripiprazole once-monthly 400 mg (AOM 400), an injectable suspension, in patients with schizophrenia, supported by pharmacokinetic (PK) data and based on clinical studies. METHODS: An overview of data from a PK study, PK simulations, controlled clinical trials, and a naturalistic study is presented. RESULTS: Pharmacokinetic data support 400 mg as the starting and maintenance dose of AOM; the plasma concentration profile of aripiprazole after initiating AOM 400 was consistent with therapeutic concentrations observed with oral aripiprazole 10 to 30 mg/d. PK simulations and observed data from a single-dose clinical trial indicate that median aripiprazole plasma concentrations reach therapeutic levels within 7 days of initiating AOM 400. Because of interpatient variability, a 14-day overlap with oral aripiprazole or another antipsychotic medication is considered sufficient to ensure therapeutic concentrations. In clinical studies, when patients initiated AOM 400 with concomitant oral aripiprazole (10-15 mg/d based on stabilized dose) or continued their previous antipsychotic for ≤14 days, mean aripiprazole plasma concentration after 4 weeks (93 to 112 ng/mL) was in range of the therapeutic window established for aripiprazole (94.0-534.0 ng/mL). In clinical studies, the 400-mg starting dose of AOM was efficacious and well tolerated. Across studies of variable duration and design, 1296/1439 (90.1%) patients initiated AOM 400 and required no dose change. Overall rates of discontinuation due to lack of efficacy across clinical studies were low in patients treated with AOM 400 (range, 2.3%-10.0%). In a post hoc analysis from a naturalistic study, cross-titration from other oral antipsychotic therapies to oral aripiprazole before initiating AOM 400 was better tolerated with a >1- to 4-week cross-titration period versus a ≤1-week period, as evidenced by lower rates of discontinuation due to adverse events during cross-titration (2.7% [7/239] vs 10.4% [5/48]). The efficacy and safety of AOM 400 in the month after initiation in the pivotal maintenance studies were comparable between subpopulations of patients previously stabilized on 10- or 30-mg doses of oral aripiprazole. CONCLUSIONS: Findings from PK data, PK simulations, and clinical studies all support that 400 mg is the appropriate initiation dose of AOM for patients with schizophrenia. When switching to oral aripiprazole before initiating AOM 400, tapering the prior oral antipsychotic while titrating up the oral aripiprazole dose (target dose 10-30 mg/d) over >1 to 4 weeks may be an effective strategy. The efficacy, safety, and tolerability of AOM 400 were comparable regardless of whether patients were previously stabilized on oral aripiprazole 10 or 30 mg/d or other antipsychotic therapy and continued to receive the same oral antipsychotic for the first 14 days after initiating AOM 400.

A tailored approach to operative repair of extracranial carotid aneurysms based on anatomic types and kinks.

BACKGROUND: To present outcomes following an operative approach of extracranial carotid artery aneurysm (ECAAs) based on anatomic types and associated kinks. METHODS: This study represents retrospective analysis of anatomic type based approach to operative repair of 84 patients with ECAA from 1994 to 2011, 28 (33.3%) with associated kinking. Patients were followed for neurological ischemic events, hematoma, cranial nerve injury, myocardial infarction, neurological, and overall mortality. The results are presented as early, within 30 days after the surgery, and long term during the follow-up. RESULTS: In the early postoperative period, there were no strokes or mortalities, cranial nerve injury rate was 2.4% while 1 patient had myocardial infarction (1.2%). During the follow-up, 4 patients (4.8%) had stroke, out of which 2 patients died (2.3%), while overall mortality was 4.6%. The average 5-year survival rate was 96 ± 3%. CONCLUSION: Excellent outcomes can be obtained with surgical repair of ECAA, which should be tailored to the anatomic types and presence of kinks.

Clinical course of patients with hyponatremia and decompensated systolic heart failure and the effect of vasopressin receptor antagonism with tolvaptan.

BACKGROUND: Patients with decompensated heart failure, volume overload, and hyponatremia are challenging to manage. Relatively little has been documented regarding the clinical course of these patients during standard in-hospital management or with vasopressin antagonism. METHODS AND RESULTS: The Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan database was examined to assess the short-term clinical course of patients hospitalized with heart failure and hyponatremia and the effect of tolvaptan on outcomes. In the placebo group, patients with hyponatremia (serum Na(+) <135mEq/L; n = 232), compared with those with normonatremia at baseline (n = 1785), had less relief of dyspnea despite receiving higher doses of diuretics (59.2% vs 69.2% improved; P < .01) and worse long-term outcomes. In the hyponatremia subgroup from the entire trial cohort (n = 475), tolvaptan was associated with greater likelihood of normalization of serum sodium than placebo (58% vs 20% and 64% vs 29% for day 1 and discharge, respectively; P < .001 for both comparisons), greater weight reduction at day 1 and discharge (0.7 kg and 0.8 kg differences, respectively; P < .001 and P = .008), and greater relief of dyspnea (P = .03). Among all hyponatremic patients, there was no effect of tolvaptan on long-term outcomes compared with placebo. In patients with pronounced hyponatremia (<130 mEq/L; n = 92), tolvaptan was associated with reduced cardiovascular morbidity and mortality after discharge (P = .04). CONCLUSIONS: In patients with decompensated heart failure and hyponatremia, standard therapy is associated with less weight loss and dyspnea relief, and unfavorable longer-term outcomes compared to those with normonatremia. Tolvaptan is associated with more favorable in-hospital effects and, possibly, long-term outcomes in patients with severe hyponatremia.

Syndactylization as a technique in treatment of infectious limb following aortobifemoral reconstruction.

The infection in vascular surgery is a nightmare of every vascular surgeon. There are numerous ways of treatment but neither one is definitive. We present the case of the patient with infectious limb following aortobifemoral reconstruction treated by partial graft extirpation and with re-implantation of the superficial femoral artery into deep femoral artery.