Surviving complications of retroperitoneal fibrosis with intermittent relapses over a period of 20 years: case report and literature review / Sobrevivir a las complicaciones de la fibrosis retroperitoneal con recaídas intermitentes durante un período de 20 años: reporte de un caso y revisión de la literatura

Idiopathic retroperitoneal fibrosis is a rare fibro-inflammatory disease of varied etiology which usually originates around aorta and spreads caudally along Iliac vessels into adjacent retroperitoneum causing ureteral obstruction as the most frequent complication.A 53-year-old male patient presented with complaint of mild pain in both the legs off and on. On investigating further, we found that he had been struggling with intermittent relapses every 3-4 years for last 20 years since he was first diagnosed with Idiopathic Retroperitoneal Fibrosis. He was 33-year-old when he first developed the symptoms of anuria for 48 hours and was diagnosed with Idiopathic retroperitoneal fibrosis. This was followed by atrophy of left kidney and hypertension 6 years later, then hypothyroidism after another 3years and finally involvement of Inferior Vena Cava and acute Deep Vein Thrombosis of lower limbs after another 3-4 years. His deep vein thrombosis was well managed in time. He was put on glucocorticoids everytime he had a relapse and a complication.We did a review of literature to understand recent advances about its pathogenesis, diagnosis, investigations and management. We searched in PubMed using terms like retroperitoneal fibrosis alone and in combination with related terms such as Inferior Vena Cava thrombosis, Deep Vein Thrombosis, Tamoxifen, Methotrexate. This case is unique as it is very rare to find acute Deep Vein Thrombosis in Idiopathic retroperitoneal fibrosis without development of any collaterals when Inferior Vena Cava lumen is compromised to almost complete obstruction.After a follow up of 20 years patient is doing well in terms of physical activity and psychological wellbeing with anti-hypertensives, thyroxine and anti-coagulants. Is the disease-free interval actually free of the disease or it just subsided with immunosuppressants to become active after some time?

La fibrosis retroperitoneal idiopática es una enfermedad fibroinflamatoria rara, de etiología variada que generalmente se origina alrededor de la aorta y se propaga caudalmente a lo largo de los vasos ilíacos en retroperitoneo adyacente causando obstrucción ureteral como la complicación más frecuente.Reportamos el caso de un paciente varón de 53 años que se presentó con un dolor leve en ambas piernas. Al investigar más a fondo, descubrimos que había estado luchando con recaídas intermitentes cada 3-4 años durante los últimos 20 años desde que se le diagnosticó por primera vez fibrosis retroperitoneal idiopática. Tenía 33 años cuando desarrolló por primera vez los síntomas de anuria durante 48 horas y se le diagnosticó fibrosis retroperitoneal idiopática. Esto fue seguido por atrofia del riñón izquierdo e hipertensión 6 años después, luego hipotiroidismo después de otros 3 años y finalmente afectación de la vena cava inferior y trombosis venosa profunda aguda de las extremidades inferiores después de otros 3-4 años. Su trombosis venosa profunda se controló bien a tiempo. Le recetaron glucocorticoides cada vez que tenía una recaída y una complicación.Hicimos una revisión de la literatura para comprender los avances recientes sobre su patogenia, diagnóstico, investigaciones y manejo. Se realizaron búsquedas en PubMed utilizando términos como fibrosis retroperitoneal sola y en combinación con términos relacionados como trombosis de la vena cava inferior, trombosis venosa profunda, tamoxifeno, metotrexato. Este caso es único, ya que es muy raro encontrar trombosis venosa profunda aguda en fibrosis retroperitoneal idiopática sin desarrollo de colaterales cuando la luz de la vena cava inferior está comprometida hasta una obstrucción casi completa.Después de un seguimiento de 20 años, el paciente se encuentra bien en términos de actividad física y bienestar psicológico con antihipertensivos, tiroxina y anticoagulantes. ¿El intervalo libre de enfermedad está realmente libre de la enfermedad o simplemente disminuyó con inmunosupresores para activarse después de algún tiempo?

Preservation of Post-Infarction Cardiac Structure and Function via Long-Term Oral Formyl Peptide Receptor Agonist Treatment.

Dysregulated inflammation following myocardial infarction (MI) promotes left ventricular (LV) remodeling and loss of function. Targeting inflammation resolution by activating formyl peptide receptors (FPRs) may limit adverse remodeling and progression towards heart failure. This study characterized the cellular and signaling properties of Compound 43 (Cmpd43), a dual FPR1/FPR2 agonist, and examined whether Cmpd43 treatment improves LV and infarct remodeling in rodent MI models. Cmpd43 stimulated FPR1/2-mediated signaling, enhanced proresolution cellular function, and modulated cytokines. Cmpd43 increased LV function and reduced chamber remodeling while increasing proresolution macrophage markers. The findings demonstrate that FPR agonism improves cardiac structure and function post-MI.

Outcome after internal fixation of intraarticular distal humerus (AO type B & C) fractures: Preliminary results with anatomical distal humerus LCP system.

PURPOSE: The treatment of intraarticular fractures of the distal humerus is challenging and involves the risk of complications and bad functional results. Anatomical and stable internal fixation with early postoperative mobilization is expected to improve the functional outcomes. The objective of this study was to evaluate the functional and radiological results, along with the complications associated, of open reduction and internal fixation using precontoured anatomical locking LCP plate system for intraarticular distal humerus fractures in adult patients. METHODS: This prospective study consist of 31 patients with a mean age of 41.2 years (range 19-62) were treated with open reduction and angular stable internal fixation. All underwent posterior transolecranon surgical approach. Mean follow-up to the final interview was 10 months (from 6 to 20 months). All operated patients were available at the time of last followup. AO classification showed 26 C-fractures (9*13C 1, 12*13C2,5* 13C3) and 5 B-fracture (1* 13B1,1* 13B2,3* 13B3). There were 25 closed fractures and 6 open grade 1 fractures. The clinical followup using Mayo elbow performance score (MEPS) and radiographic follow up with elbow anterior-posterior and lateral view X-rays were performed postoperatively. RESULTS: The mean MEPS was 87.9 points out of 100 (range 55-100) with 61% Excellent, 29% good and 10% fair and poor scores. Mean elbow flexion of 115.8° (range 85°-150°). The mean deficit in extension was 19° (range 5°-35°). All olecranon osteotomy were united .Nonunion of distal humerus fracture occurred in 2 cases. Other complications were hardware prominence in 3 cases, superficial infection in 4 cases and Ulnar nerve neuropraxia in 1 case which was recovered uneventfully. Revision surgery was not required in any complication. CONCLUSION: Open reduction and internal fixation with precontoured distal humerus anatomical locking plate system is a good method of treatment for complex Supra- intercondylar fracture of distal humerus with good functional outcome and low rates of complications. Even though early results are promising, longer term investigations and larger patient groups are necessary to confirm the presented data.

Role of α2-adrenoceptors in electrical field stimulation-induced contraction of pig nasal mucosa and pharmacologic characterization of a novel α2C-adrenoceptor agonist.

BACKGROUND: Blood vessels of the nasal mucosa are richly innervated by sympathetic nerves and neural mechanism is of great interest in upper respiratory tract disorders. This study was designed to determine the role of α2-adrenoceptors and, more specifically, α2C-adrenoceptors, on neurogenic sympathetic vasoconstrictor responses in pig nasal mucosa, and to define the pharmacologic profile of a novel selective α2C-adrenoreceptor agonist. METHODS: Electrical field stimulation (EFS) was applied to nasal mucosa strips placed in an organ bath and attached to force displacement transducers for continuous recording of isometric tension. The affinity and functional activity of compound B for α2C-adrenoceptors were determined by binding analysis and the ability of compound B to stimulate [(35)S]GTPγS binding to the receptors. Compound B was also tested in a postjunctional α2C-adrenoreceptor bioassay. RESULTS: EFS-induced contractions were partly blocked by the α2-adrenoreceptor antagonist yohimbine (41.1%) and the α2C-adrenoreceptor antagonist JP-1302 had no effect. The α2-adrenoreceptor agonist clonidine, but not compound B, exerted a significant blockade (70.6%). Compound B had high affinity (K(i) = 18 nM), produced potent agonist (EC50 = 279 nM) and good efficacy (E(max) = 73%) responses at the α2C-adrenoceptors, and displayed good functional agonist potency in the human saphenous vein α2C-adrenoreceptor bioassay (pD2 = 6.2). CONCLUSION: (1) Neurogenic vasomotor contractility is largely regulated through an α-adrenergic mechanism; (2) pig nasal mucosa possesses post- and prejunctional α2-adrenoceptors; (3) the α2C-adrenoreceptor subtype does not seem to be involved; and (4) compound B is a novel, highly selective, and potent α2C-adrenoreceptor agonist.

Pharmacological characterization of a novel α2C-adrenoceptor agonist N-[3,4-dihydro-4-(1H-imidazol-4-ylmethyl)-2H-1, 4-benzoxazin-6-yl]-N-ethyl-N'-methylurea (compound A).

We define the pharmacological and pharmacokinetic profiles of a novel α(2C)-adrenoceptor agonist, compound A [N-[3,4-dihydro-4-(1H-imidazol-4-ylmethyl)-2H-1,4-benzoxazin-6-yl]-N-ethyl-N'-methylurea]. This compound has high affinity (K(i)) for the human α(2C)-adrenoceptor (K(i) = 12 nM), and 190- to 260-fold selectivity over the α(2A)- and α(2B)-adrenoceptor subtypes. In cell-based functional assays, compound A produced good agonist (EC(50) = 166 nM) and efficacy (E(max) = 64%) responses at the α(2C)-adrenoceptor, much lower potency and efficacy at the α(2A)-adrenoceptor (EC(50) = 1525 nM; E(max) = 8%) and α(2B)-adrenoceptor (EC(50) = 5814 nM; E(max) = 21%) subtypes, and low or no affinity and functional activity at the α(1A)-, α(1B)-, and α(1D)-adrenoceptor subtypes. In the human saphenous vein postjunctional α(2C)-adrenoceptor bioassay, compound A functions as a potent agonist (pD(2) = 6.3). In a real-time contraction bioassay of pig nasal mucosa, compound A preferentially constricted the veins (EC(50) = 108 nM), and the magnitude of arteriolar contraction reached only 50% of the maximum venular responses. Compound A exhibited no effect on locomotor activity, sedation, and body temperature in mice (up to 100 mg/kg) and did not cause hypertension and mydriasis (30 mg/kg) in conscious rats. Compound A is orally bioavailable (24%) with good plasma exposure. This compound is a substrate for the efflux P-glycoprotein transporter, resulting in very low central nervous system (CNS) penetration. In summary, compound A is a highly selective, orally active, and non-CNS-penetrating α(2C)-adrenoceptor agonist with desirable in vitro and in vivo pharmacological properties suitable for the treatment of nasal congestion.

Novel TNF-α converting enzyme (TACE) inhibitors as potential treatment for inflammatory diseases.

Our research on hydantoin based TNF-α converting enzyme (TACE) inhibitors has led to an acetylene containing series that demonstrates sub-nanomolar potency (K(i)) as well as excellent activity in human whole blood. These studies led to the discovery of highly potent TACE inhibitors with good DMPK profiles.

Biaryl substituted hydantoin compounds as TACE inhibitors.

We disclose further optimization of hydantoin TNF-alpha convertase enzyme (TACE) inhibitors. SAR with respect to the non-prime region of TACE active site was explored. A series of biaryl substituted hydantoin compounds was shown to have sub-nanomolar K(i), good rat PK, and good selectivity versus MMP-1, -2, -3, -7, -9, and -13.

Time to hemostasis after traction removal of tunneled cuffed central venous catheters.

PURPOSE: Many patients undergo placement of tunneled cuffed central venous catheters (TCCVCs) for indications including administration of medical therapy and hemodialysis. They are removed when no longer needed or if there is a device complication. There is no consensus regarding the necessity of routine preremoval coagulation studies or platelet count, so this study was performed to determine if abnormal coagulation status affects the time to hemostasis (TH) after traction removal of TCCVCs. MATERIALS AND METHODS: Adult patients referred to our group for removal of a TCCVC placed via a jugular or subclavian route were considered candidates for inclusion. Blood was submitted for evaluation of prothrombin time (PT) and International Normalized Ratio (INR), activated partial thromboplastin time (aPTT), and platelet count. Catheters were removed with the traction technique, and presence of hemostasis was assessed at 5-minute intervals of manual compression. RESULTS: Between November 19, 2001, and April 20, 2004, 179 subjects were enrolled and completed the study. There were 165 subjects in whom TH was within the first 5-minute interval and 14 in whom more than 5 minutes was required. Statistically significant factors associated with prolonged TH were primary diagnosis of end-stage renal disease (P = .005), use of antiplatelet agents (P = .03), and procedure performed by a "low-volume" operator (P = .002). CONCLUSIONS: Routine preremoval evaluation of coagulation parameters is not necessary. Patients who are likely to have abnormal platelet function but not abnormal platelet number appear to be at risk for prolonged TH, but even in those cases, the THs are rarely more than 15 minutes.

The synthesis of substituted bipiperidine amide compounds as CCR3 ligands: antagonists versus agonists.

Structure-activity relationship study of bipiperidine amide 1 has identified the reverse bipiperidine amide 4a as a CC chemokine-3 (CCR3) receptor antagonist. Optimization of the structure-activity relationship of compound 4a has resulted in the identification of a CCR3 antagonist 4i as well as a CCR3 agonist 13.

The synthesis of substituted bipiperidine amide compounds as CCR3 antagonists.

Bipiperidine amide 1 has been identified as a CC chemokine receptor 3 (CCR3) antagonist. Optimization of its structure-activity relationship has resulted in the identification of cis (R,R)-4-[(3,4-dichlorophenyl)methyl]-3-hydroxymethyl-1'(6-quinolinylcarbonyl)-1,4'-bipiperidine 14n, which exhibits potent receptor affinity and inhibition of both calcium flux and eosinophil chemotaxis.

Suspected acute pulmonary embolism: evaluation with multi-detector row CT versus digital subtraction pulmonary arteriography.

PURPOSE: To determine diagnostic accuracy of four-channel multi-detector row computed tomography (CT) in emergency room and inpatient populations suspected of having acute pulmonary embolism (PE) who prospectively underwent both CT and pulmonary arteriography (PA). MATERIALS AND METHODS: Patients referred for PA to assess suspected PE were eligible. Institutional review board approval and written informed consent were obtained. All patients underwent CT and PA within a 48-hour period. For CT, 4 x 2.5-mm collimation was used. Three readers independently evaluated each study for PE presence. PE status, vessel level, and lobar location were determined by means of majority rule, and interobserver agreement (kappa) was calculated for PE status, as assessed with each modality. Sensitivity and specificity of CT were calculated by using PA as the reference standard. Two radiologists later reviewed false-positive CT studies. RESULTS: The study group comprised 93 patients (median age, 56 years; range, 19-88 years). Sensitivity, specificity, and accuracy of CT were 100%, 89%, and 91%, respectively. kappa values were 0.71 and 0.83 for CT and PA, respectively, and were not significantly different between modalities. At PA, 18 patients (19%) had PE at 50 vessel levels (five main and/or interlobar, 24 segmental, and 21 subsegmental), 17 (94%) of which had PE at multiple sites. At CT, 26 patients (28%) had PE at 71 vessel levels (24 main and/or interlobar, 33 segmental, and 14 subsegmental). Twenty patients (77%) had PE at multiple sites. Review of eight false-positive CT studies showed an appearance highly suggestive of acute PE in three patients, chronic PE in one, and no PE in three; one study was inconclusive. CT better demonstrated large-level vessel involvement (P < .01), while PA better demonstrated small-level vessel involvement (P < .01). CONCLUSION: Multi-detector row CT has an accuracy of 91% in the depiction of suspected acute PE when conventional PA is used as the reference standard.

Embolization of large gastric varices using vena cava filter and coils.

A 40-year-old male with alcoholic cirrhosis and portal hypertension presented with acute variceal hemorrhage. Abdominal CT scan and endoscopy revealed large gastric varices. The patient underwent a TIPS procedure. Portal venography demonstrated persistent filling of the large gastric varices with associated high-flow spontaneous splenorenal shunt. Because of the large size of the varices, a Simon-Nitinol filter was used in conjunction with multiple embolization coils to enable successful occlusion of the varices.

Catalytic activity of human ADAM33.

ADAM33 (a disintegrin and metalloproteinase) is an asthma susceptibility gene recently identified through a genetic study of asthmatic families (van Eerdewegh et al. (2002) Nature 418, 426-430). In order to characterize the catalytic properties of ADAM33, the metalloproteinase domain of human ADAM33 was expressed in Drosophila S2 cells and purified. The N-terminal sequence of the purified metalloproteinase was exclusively (204)EARR, indicating utilization of one of three furin recognition sites. Of many synthetic peptides tested as potential substrates, four peptides derived from beta-amyloid precursor protein (APP), Kit-ligand-1 (KL-1), tumor necrosis factor-related activation-induced cytokine, and insulin B chain were cleaved by ADAM33; mutation at the catalytic site, E346A, inactivated catalytic activity. Cleavage of APP occurred at His(14)/Gln(15), not at the alpha-secretase site and was inefficient (k(cat)/K(m) (1.6 +/- 0.3) x 10(2) m(-1) s(-1)). Cleavage of a juxtamembrane KL-1 peptide occurred at a site used physiologically with a similar efficiency. Mutagenesis of KL-1 peptide substrate indicated that the P3, P2, P1, and P3' residues were critical for activity. In a transfected cell-based sheddase assay, ADAM33 functioned as a negative regulator of APP shedding and mediated some constitutive shedding of KL-1, which was not regulated by phorbol 12-myristate 13-acetate activation. ADAM33 activity was sensitive to several hydroxamate inhibitors (IK682, K(i) = 23 +/- 7 nm) and to tissue inhibitors of metalloproteinase (TIMPs). Activity was inhibited moderately by TIMP-3 and TIMP-4 and weakly inhibited by TIMP-2 but not by TIMP-1, a profile distinct from other ADAMs. The identification of ADAM33 peptide substrates, cellular activity, and a distinct inhibitor profile provide the basis for further functional studies of ADAM33.

Mouse ADAM33: two splice variants differ in protein maturation and localization.

We compared the tissue mRNA prevalence and protein maturation of two splice variants of mouse ADAM33, a metalloprotease implicated in airway hyperresponsiveness. These variant cDNAs, designated 914 (alpha) and 906 (beta), encode membrane-bound forms that differ primarily in 26 residues (exon 17) between the cysteine-rich and epidermal growth factor-like domains. Proteins of approximately 120 and 103 kD, detectable by anti-ADAM33 antibodies, were expressed in 914-transfected HEK293 cells. The time-dependent appearance of the approximately 100-kD form and its inhibition by a peptidyl chloromethylketone, or the calcium ionophore, A23187, indicated that this was mature ADAM33, which was processed by a furin-like convertase. One form, approximately 110 kD, was detected in 906-transfected cell lysates. Trypsin and biotinylation treatment of transfected cells demonstrated that all of the mature approximately 100-kD, a minority of the approximately 120-kD pro-form, and none of the 906-expressed 110-kD form localized to the cell surface. The mature form was resistant to endoglycosidase H(f). The approximately 110-kD form was endoglycosidase H(f)-sensitive, indicating retention proximal to the trans-Golgi, consistent with a lack of maturation. Quantitation of transcripts demonstrated that those containing exon 17 predominate, whereas those lacking exon 17 are negligible in the mouse lung, although detectable at low levels in mouse testis, heart, and brain. Thus, potential dominant-negative effects exerted by the nonprocessed 906-encoded beta splice variant are unlikely to occur in mouse lung.

Human ADAM33 messenger RNA expression profile and post-transcriptional regulation.

We examined transcript expression and post-transcriptional regulation of human ADAM33, a recently identified asthma gene. A detailed messenger RNA (mRNA) expression profile was obtained using Northern, reverse transcription polymerase chain reaction, and in situ hybridization analyses. ADAM33 mRNA was expressed significantly in smooth muscle-containing organs, minimally in immune organs and hematopoietic cells, and highly in repairing duodenal granulation tissue. Expression was seen in asthmatic subepithelial fibroblasts and smooth muscle but not in respiratory epithelium. In all tissues, transcripts of approximately 5 kb predominated over those of approximately 3.5 kb by 2- to 5-fold. The effect of the 3' untranslated region (UTR) on ADAM33 protein expression and maturation was examined. The presence of the 3'UTR in untagged full-length constructs promoted prodomain removal, detected as mature approximately 100 kD protein by ADAM33-reactive antibodies; in its absence, maturation was 2- to 3-fold less in HEK293 cells. His-tagged and untagged constructs lacking the 3'UTR demonstrated that lack of maturation was not a result of tag-mediated effects. Minimal maturation of ADAM33 occurred in primary lung and MRC5 fibroblasts following adenoviral-mediated expression of ADAM33 lacking the 3'UTR. In contrast, prodomain removal was observed with plasmids and adenovirus encoding only the pro- and catalytic domains. Thus, the 3'UTR of ADAM33 and domains downstream of the catalytic domain regulate potential ADAM33 activity. Mechanisms of regulation of ADAM33, distinct from closely related ADAMs, thus include mRNA localization and processing and protein maturation.

Human ADAM33: protein maturation and localization.

ADAM33 (a disintegrin and metalloprotease) was recently found to be a novel asthma susceptibility gene. Domain-specific antibodies were used to study its expression and processing. When the pro-domain and catalytic domain were expressed by a stable-transfected cell line, the pro-domain was removed by cleavage within a putative furin cleavage site. The catalytic domain was active in an alpha(2)-macroglobulin complex formation assay and mutation of the catalytic site glutamic acid (E346A) eliminated activity. In transient transfections using the full-length protein, a pro-form and mature form were detectable and alternate glycosylation was demonstrated at sites within the catalytic domain. ADAM33 was detected on the cell surface, with the majority of protein detected intracellularly. The E346A mutation had no significant effect on protein processing. Endogenous ADAM33 was detected in bronchus tissue, bronchial smooth muscle cells, and MRC-5 fibroblasts, consistent with a role in the pathophysiology of asthma.

Identification of full, partial and inverse CC chemokine receptor 3 agonists using [35S]GTPgammaS binding.

Study of the CC chemokine receptor 3 (CCR3) has been limited to using radiolabeled agonist chemokines. A small molecule CCR3 antagonist, 2-[(6-amino-2-benzothiazolyl)thio]-N-[1-[(3,4-dichlorylphenyl)methyl]-4-piperidinyl]acetamide, Banyu (I), was tritiated and used for pharmacological studies. Banyu (I) has a K(d) of 5.0+/-0.4 and 4.3+/-1.8 nM on human CCR3 transfectants and eosinophils, and noncompetitively inhibits [125I]eotaxin binding and eotaxin-induced [35S]guanosine-5'-O-(3-thiotriphosphate) ([35S]GTPgammaS) binding. The proportion of [125I]eotaxin: [3H]Banyu (I) binding sites in eosinophils or transfectants was 35% or 13%, although both binding sites were overexpressed in transfectants. CCR3 spontaneously couples to G-proteins in CCR3 transfectants, demonstrated by changes in basal and eotaxin-induced [35S]GTPgammaS binding under reduced NaCl and GDP concentrations. Consequently, Banyu (I) was identified as an inverse agonist. In contrast, CCL18 and I-TAC (interferon-inducible T cell alpha-chemoattractant) were neutral antagonists, inhibiting eotaxin-induced [35S]GTPgammaS binding, with minimal effect on basal coupling of CCR3 to G proteins. Eotaxin, eotaxin-2 and monocyte chemoattractant protein (MCP)-4 are full agonists inducing [35S]GTPgammaS binding; eotaxin-3, MCP-3, RANTES (regulated on activation normal T cell expressed and secreted), vMIP-I (Kaposi's sarcoma-associated herpesvirus macrophage inflammatory protein-) and vMIP-II are partial agonists, indicating that this is a sensitive method to quantitate agonist efficacy.

Randomized comparison of split tip versus step tip high-flow hemodialysis catheters.

BACKGROUND: Our purpose was to compare the function and complications of two high-flow polyurethane hemodialysis catheters. METHODS: This prospective, randomized trial compared the Ash-Split (MedComp) and Opti-Flow (Bard Access Systems) catheters. All patients referred for tunneled hemodialysis catheter placement were offered entry in the study, provided they met inclusion criteria. Catheters were placed by interventional radiologists using ultrasound and fluoroscopic guidance. Procedure time and initial complications were recorded. Effective (QbEff) catheter flow rates and recirculation were studied at baseline, one month, three and six months using ultrasonic dilution (Transonic) at various pump speeds (Qb). Episodes of catheter malfunction and infection were recorded. Catheter removal or six months was the study endpoint. RESULTS: A total of 132 patients were enrolled in the trial. The groups did not differ as to age, sex distribution, height or weight (P> 0.05). Initial complications included kinking resulting in catheter failure (Optiflow N = 3), and tunnel bleeding (Optiflow N = 1; Ash N = 3). Adjusted mean flow rates (QbEff) at Qb300 were 299 mL/min Ash and 305 mL/min Optiflow (P = 0.06), at Qb400 were 365 mL/min Ash and 382 mL/min Optiflow (P = 0.01), and at QbMax were 414 mL/min Ash and 433 mL/min Optiflow (P = 0.03). Recirculation was significantly higher with the Optiflow catheter at most measurement points. Total late complications were lower in the Ash group (P = 0.04), and catheter survival was significantly higher in the Ash group (P = 0.02). CONCLUSIONS: Both catheters can deliver flow rates well beyond those recommended by the Dialysis Outcomes Quality Initiative. While the Optiflow delivered higher flow rates at some measurement points, this was offset by higher recirculation. The Ash catheter showed a long-term survival advantage and fewer late complications.

Use of balloon-expandable stents in transjugular intrahepatic portosystemic shunts in cases of Wallstent endoprosthesis technical failure and revision of shunt stenosis.

Thirteen patients underwent placement of a balloon-expandable stent either at initial transjugular intrahepatic portosystemic shunt (TIPS) creation (n = 3) because of immediate technical failure of the Wallstent or at shunt revision because of failure of the Wallstent to reduce the portosystemic gradient

Percutaneous imaging-guided access for the treatment of calculi in continent urinary reservoirs.

PURPOSE: To describe our long-term experience with percutaneous access to continent urinary reservoirs for calculus removal. PATIENTS AND METHODS: A retrospective study of 13 procedures in 10 patients was performed. In 2 of the 13 procedures, access and calculus removal was performed in a single session. In the other 11 procedures, initial access was obtained using ultrasonography, fluoroscopy, and/or computed tomography. The patients then returned at a later date for a second step where the access was dilated and the calculi were removed. RESULTS: Access was achieved successfully in all cases with no complications. At mean follow-up time of 13.6 months (range 1-94 months) one patient had died of complications unrelated to her continent urinary reservoir. Another patient had been placed on suppressive antibiotics for recurrent calculi. The remaining patients were stone free and without late complication. CONCLUSIONS: Percutaneous removal of reservoir calculi can be performed safely, avoiding potential injury to the continence valve mechanism by a direct cystoscopic approach. We propose a two-stage procedure using CT guidance for initial access as the preferred technique.