Balloon-assisted remote external iliac artery endarterectomy: A safe and durable technique for the treatment of iliac artery occlusive disease.

BACKGROUND: Historically, the treatment of iliac artery occlusive disease required a surgical bypass usually consisting of an aortobifemoral bypass or an iliofemoral bypass. With the advent of balloon angioplasty and stenting, these procedures are frequently replaced with endovascular options. However, the treatment of diffuse occlusive disease of the external iliac artery (EIA) using balloon angioplasty and/or stenting does not carry a favorable long-term patency rate. Remote endarterectomy of the EIA using ring dissectors with balloon assistance provides a novel, controlled, safe, and durable treatment of the diseased and/or occluded EIA. METHODS: A retrospective review over the past 6 years was performed at our institution identifying patients treated with balloon-assisted remote endarterectomy of the EIA by the current five practicing vascular surgeons. The technique involves exposure of the ipsilateral common femoral artery. With nonocclusive disease, direct access into the common femoral artery is performed, a wire is traversed through the diseased EIA, and a balloon is inflated at the origin of the vessel providing hemostasis and control. A femoral endarterectomy is performed, and a ring dissector is passed over the endarterectomized material including the wire and balloon catheter and advanced remotely through the EIA up to the balloon. The balloon is briefly deflated, repositioned within the ring dissector, and reinflated, thus cutting the plaque. This allows for retraction of the inflated balloon and cutter, removing the endarterectomized core plaque. The procedure is similar for the treatment of an occluded EIA, but wire access across the occluded vessel is normally achieved with contralateral access. In both cases, the balloon provides control and hemostasis and is critically important in the rare treatment of vessel rupture. RESULTS: A total of 101 vessels were treated in 97 patients. The procedure was successful in 98 vessels (97%) with failure related to vessel rupture requiring conversion to an iliofemoral bypass. The estimated patency rate at three years was 94% with a median follow-up of 20 months. Restenosis/occlusion in four patients seemed to be related to a severe sclerotic response. The EIA was occluded 32% of the time. The common iliac artery (CIA) was diseased requiring angioplasty and stenting 29% of the time and a stent was placed at the transition zone between endarterectomized vessel and nontreated proximal most EIA or distal most CIA 58% of the time. There were no perioperative deaths. CONCLUSIONS: Balloon-assisted remote endarterectomy of the diffusely diseased and/or occluded EIA is a safe and durable option. It precludes the need for a prosthetic conduit and the risk of associated infection. It also involves a single groin incision and negates the need for retroperitoneal exposure of the CIA.

Responses in the rumen microbiome of Bos taurus and indicus steers fed a low-quality rice straw diet and supplemented protein.

Bos indicus typically perform better than Bos taurus when consuming a low-quality diet; however, the response to supplementation is generally greater in B. taurus. The underlying mechanisms supporting these responses have not been fully elucidated. Characterization of differences in rumen prokaryotic populations and their functional role in the two subspecies may provide additional insight. Ten cannulated steers (5 Angus and 5 Brahman) were used in concurrent 5 × 5 Latin squares. Animals were offered ad libitum access to rice straw (4.7% CP). Treatments consisted of an unsupplemented control diet and two levels (50 or 120 mg N/kg BW) of isonitrogenous supplements (30% CP), that were either high (H; 74%) or low (L; 26%) in undegradable intake protein. Rumen samples were collected at 0 and 4 h postfeeding and separated into liquid and solid fractions. Rumen bacterial taxa were sequenced utilizing a Roche 454 platform based on the 16s rRNA gene. At 97% sequence similarity, 97,826 operational taxonomic units were identified, which included 24 phyla, 108 families, and 255 genera. Analysis included SAS PROC mixed model, QIIME, and PICRUSt. Across all samples, Bacteroidetes and Firmicutes accounted for 65% and 28% of total bacterial abundance, respectively. The families Prevotellaceae (P = 0.05) and Ruminococcaceae (P = 0.004) and the genera Prevotellaceae (family; P = 0.003) within the phyla Bacteroidetes differed significantly in relative abundance with added protein when compared to the control. Consistent differences in the relative abundance of family and genus taxa between B. indicus and B. taurus suggest roles the symbiotic rumen microbiome may have in the capacity of B. indicus to utilize low-quality forage over a range of supplement types and levels including (Prevotella, Ruminococcus [family], Sphingobacteriaceae [family], Bacteroidales [order], Pontibacter, Bacteroides, Succiclasticum, Barnesiella, and Xylanibacter). Overall bacterial community diversity differences across parameters were limited. Rice straw is recalcitrant to bacterial digestion because of high levels of silica in the epidermis making this straw more resistant to bacterial attachment. Thus, this analysis represents the bacterial diversity and function of the rumen under conditions depleted CP, recalcitrant fiber matrix and restricted digestibility which appear to limit the microbial population to those capable of attaching and digesting complexed structural carbohydrates, resulting in reduced plasticity, and more evenness in diversity across parameters.

Older adults catch up to younger adults on a learning and memory task that involves collaborative social interaction.

Learning and memory abilities tend to decline as people age. The current study examines the question of whether a learning situation that emphasises collaborative social interaction might help older persons overcome age-related learning and memory changes and thus perform similarly to younger persons. Younger and Older participants (n = 34 in each group) completed the Barrier Task (BT), a game-like social interaction where partners work together to develop labels for a set of abstract tangrams. Participants were also administered standard clinical neuropsychological measures of memory, on which the Older group showed expected inferiority to the Younger group. On the BT, the Older group performed less well than the Younger group early on, but as the task progressed, the performance of the Older group caught up and became statistically indistinguishable from that of the Younger group. These results can be taken to suggest that a learning milieu characterised by collaborative social interaction can attenuate some of the typical memory disadvantages associated with being older.

Chromosome 18 suppresses prostate cancer metastases.

Loss of heterozygosity and allelic imbalance data has shown that there are two distinct regions of loss on chromosome 18q associated with the progression of prostate cancer (CaP). To investigate the functional significance of chromosome 18q loci in CaP, we utilized the technique of microcell-mediated chromosome transfer to introduce an intact chromosome 18 into the human prostate cancer cell line, PC-3. Three of the resulting hybrid lines were compared to the PC-3 cells in vitro and in vivo. The hybrid cell lines, containing an intact copy of the introduced chromosome 18, exhibited a substantial reduction in anchorage-dependent and independent growth in vitro. These hybrid cell lines also made smaller tumors in nude mice following subcutaneous injection compared to PC-3 cells. Because tumor growth was not completely eliminated by introduction of chromosome 18, we assessed the ability of the hybrids to metastasize to bone after intra-cardiac inoculation in a nude mouse model. Mice inoculated with PC-3 hybrids containing intact copies of chromosome 18 had significantly fewer bone metastases and dramatically improved survival compared to PC-3 cells. In addition, the introduction of chromosome 18 significantly reduced tumor burden in extraskeletal sites. This was not because of differences in growth rates because mice bearing hybrids were monitored for metastases over twice as long as mice bearing PC-3 cells. Taken together, these data suggest that chromosome 18 has a functional role in CaP to suppress growth and metastases. Identification of the responsible gene(s) may lead to molecular targets for drug discovery.

Intramural pregnancy in a cesarean section scar. A case report.

BACKGROUND: More than 95% of ectopic pregnancies involve the fallopian tubes. Other sites of ectopic implantation are less frequent, and a pregnancy in the myometrium is extremely rare. CASE: An intramural pregnancy occurred in the uterine scar in a woman who had had two previous cesarean sections. It encompassed the full thickness of the uterine wall, with chorionic villi invading the myometrium. Following conservative surgical treatment, the patient successfully carried the twin pregnancy to term. CONCLUSION: Meticulous examination of all the pelvic organs is important when searching for an ectopic pregnancy.

Efficacy and safety of transurethral alprostadil in patients with erectile dysfunction following radical prostatectomy.

PURPOSE: A retrospective analysis of the MUSE clinical trial was performed to evaluate the efficacy and safety of transurethral alprostadil in patients with erectile dysfunction after radical prostatectomy. MATERIALS AND METHODS: Patients received doses of transurethral alprostadil in the clinic and those for whom a suitable dose was determined were treated at home with active drug or placebo for 3 months. Patients had undergone radical prostatectomy no less than 3 months before study entry. RESULTS: Of the 384 patients in whom radical prostatectomy was identified as a cause of erectile dysfunction 70.3% had an erection believed sufficient for intercourse in the clinic and 57.1% on active medication had sexual intercourse at least once at home. The product of clinic and home success rates (70.3 x 57.1%) was an overall success rate (the likelihood of active treatment to lead to intercourse at home) of 40.1%. The frequency of most adverse effects of radical prostatectomy was comparable to that of other organic etiologies of erectile dysfunction (1,127 patients). The percentage of patients with hypotension in the clinic was lower after radical prostatectomy compared to other erectile dysfunction etiologies (0.8 versus 4.2%, p < 0.001) but the percentage of patients with urethral pain/burning was higher (18.3 versus 10.4%, p = 0.027). No urinary tract infection, fibrosis or priapism occurred in the post-radical prostatectomy patients. CONCLUSIONS: Transurethral alprostadil is a well tolerated and efficacious method of treating erectile dysfunction after radical prostatectomy, although psychological changes associated with cancer and surgery may limit home response. The severe neurovascular deficit associated with prostatectomy neither limits the efficacy of transurethral alprostadil nor increases the risks.

Fatigue in operational settings: examples from the aviation environment.

The need for 24-h operations creates nonstandard and altered work schedules that can lead to cumulative sleep loss and circadian disruption. These factors can lead to fatigue and sleepiness and affect performance and productivity on the job. The approach, research, and results of the NASA Ames Fatigue Countermeasures Program are described to illustrate one attempt to address these issues in the aviation environment. The scientific and operational relevance of these factors is discussed, and provocative issues for future research are presented.

Serum high density lipoprotein cholesterol in patients with abnormal coronary arteries.

Previous studies showing the inverse relationship between high density lipoprotein cholesterol (HDL-C) and coronary artery disease were based on myocardial infarction survivors and presumably normal subjects. To determine whether a similar relationship exists between patients with abnormal coronary arteries (ACA) and those with normal coronary arteries (NCA), the serum HDL-C and other lipoproteins of these patients and those of a group of presumably healthy control subjects (CTL) were determined. The ACA males had lower HDL-C and % HDL-C but higher TG, VLDL-TG, LDL-C/HDL-C and VLDL-C/HDL-C than the NCA and CTL males. They also had higher VLDL-C and % VLDL-C than the CTL males. Adjustment of HDL-C for serum TG eliminated the difference in HDL-C between the ACA and NCA groups but that between ACA and CTL groups remained. The ACA females had lower % HDL-C than the NCA and CTL females. They also had lower HDL-C but higher LDL-C/HDL-C and VLDL-C/HDL-C than the CTL females. The NCA and CTL groups did not differ in any of the lipid variables, although the NCA group values were intermediate to those of the ACA and CTL groups. Using various lipoprotein profiles, it was possible to classify the patients into the 3 groups.

Prevalence of gallstones and gallbladder disease in Canadian Micmac Indian women.

The prevalence of gallstones and gallbladder disease was studied between October 1973 and June 1976 in Canadian Micmac Indian women aged 15 to 50 years in an inland rural community near Shubenacadie, NS. Of 132 women at risk 98 underwent cholecystography, 6 had a history of cholecystectomy (verified from hospital records) and 3 had cholecystectomy because of cholecystitis during the 3 years of the study. Of the 17 abnormal cholecystograms 10 showed radiolucent gallstones, and repeated studies documented gallstones in 6 of the 7 radiographs on which the gallbladder was not visualized. The prevalence of gallstones was found to be 211/1000, and that of gallbladder disease, 240/1000. The peak prevalence was at 30 to 39 years of age. The women with gallbladder disease were significantly more obese and of greater parity than those without gallbladder disease even when age was controlled. The Micmac Indian women of Nova Scotia appear to be at a much higher risk for the development of cholesterol gallstones and gallbladder disease than Caucasian women in Framingham, Massachusetts.

Nutrient intake and meal patterns of Micmac indian and Caucasian women in Shubenacadie, NS.

North American Indians have a higher morbidity from gallbladder disease, diabetes mellitus and obesity than other North Americans; this may result from their food intake. Nutrient intake and meal patterns were compared in 120 Micmac Indian and 115 Caucasian women in Shubenacadie, NS. Findings were compared with the Canadian Dietary Standard (CDS) and the Nutrition Canada national and Indian survey reports. The diet of Indian women had higher carbohydrate, lower protein and lower fibre content than that of Caucasian women, who derived a higher percentage of energy from protein and had a higher intake of vitamin A, niacin and ascorbic acid. Overnight fast was longer among Indian women. A high percentage of all women studied reported diets that did not reach the CDS for total energy intake in kilocalories or for calcium, iron, vitamin A, thiamin or riboflavin.

Heterozygote detection in angiokeratoma corporis diffusum (Anderson-Fabry disease). Studies on plasma, leucocytes, and hair follicles.

Heterozygote detection for angiokeratoma corporis diffusum (Anderson-Fabry disease, ACD), an X-linked disorder of glycosphingolipid metabolism was examined using alpha-galactosidase activity, an alpha-galactosidase/beta-galactosidase activity ratios (alpha/beta ratio) in leucocytes, plasma, and hair follicles; For leucocytes, 22 obligate heterozygotes, 25 suspected heterozygotes, and 47 control subjects were studied, while for plasma, the groups were 17 obligate heterozygotes and 35 controls. The alpha/beta ratio in plasma and leucocytes was clearly a better discriminator between obligate heterozygotes and controls than alpha-galactosidase activity alone, but still failed to detect 3 obligates with leucocytes and 2 with plasma. Discrimination was not improved by joint use of plasma and leucocyte alpha/beta ratios, but was improved by measurement of hair-follicle alpha/beta ratios. The interdecile range of log (alpha-galactosidase/beta-galactosidase activity) in 20 hair follicles from each of 4 obligate and 7 suspected heterozygotes was clearly different from 11 control subjects. Accordingly, for rapid screening for carriers of ACD, we recommend use of leucocyte or plasma alpha/beta ratios which should detect greater than 85% of heterozygotes. When results are equivocal, and ancillary information suggests heterozygous status, the more time-consuming measurement of hair-follicle alpha/beta ratios is a useful additional test.

Self-sufficiency in a regional hospital system.

This article considers measures that indicate the degree of regionalization within a hospital system. In particular, regional independence is characterized with a "self-sufficiency" index. The basis of these measures is the use of facilities in one region by residents of another region, that is, interregional flows. Examples of the use of the suggested measure in the Nova Scotia hospital system are presented.