Outcomes of HLA-mismatched HSCT with TCRαß/CD19 depletion or post-HSCT cyclophosphamide for inborn errors of immunity.

HLA-mismatched transplants with either in vitro depletion of CD3+TCRαß/CD19 (TCRαß) cells or in vivo T-cell depletion using post-transplant cyclophosphamide (PTCY) have been increasingly used for patients with inborn errors of immunity (IEI). We performed a retrospective multicenter study via the EBMT registry on 306 children with IEI undergoing first transplant between 2010-2019 from an HLA-mismatched donor using TCRαß (n=167) or PTCY (n=139). Median age at HSCT was 1.2 years (range, 0.03-19.6 years). The 3-year overall survival (OS) was 78% (95% confidence interval (CI), 71-84%) after TCRαß and 66% (57-74%) after PTCY (p=0.013). Pre-HSCT morbidity score (hazard ratio (HR) 2.27, 1.07-4.80, p=0.032) and non-Busulfan/Treosulfan conditioning (HR 3.12, 1.98-4.92, p<0.001) were the only independent predictors of unfavorable OS. The 3-year event-free survival (EFS) was 58% (50-66%) after TCRαß and 57% (48-66%) after PTCY (p=0.804). Cumulative incidence of severe acute GvHD was higher after PTCY (15%, 9-21%) than TCRαß (6%, 2-9%, p=0.007), with no difference in chronic GvHD (PTCY, 11%, 6-17%; TCRαß, 7%, 3-11%, p=0.173). The 3-year GvHD-free EFS was 53% (44-61%) after TCRαß and 41% (32-50%) after PTCY (p=0.080). PTCY had significantly higher rates of veno-occlusive disease (14.4% versus TCRαß 4.9%, p=0.009), acute kidney injury (12.7% versus 4.6%, p=0.032) and pulmonary complications (38.2% versus 24.1%, p=0.017). Adenoviraemia (18.3% versus PTCY 8.0%, p=0.015), primary graft failure (10%, versus 5%, p=0.048), and second HSCT (17.4% versus 7.9%, p=0.023) were significantly higher in TCRαß. In conclusion, this study demonstrates that both approaches are suitable options in IEI patients, although characterized by different advantages and outcomes.

Safety and Efficacy of Paclitaxel-Eluting Balloon Angioplasty for Dysfunctional Hemodialysis Access: A randomized trial Comparing with Angioplasty Alone.

PURPOSE: To assess whether angioplasty of hemodialysis access (HA) stenosis with a drug-coated balloon (DCB) would prevent restenosis in comparison with plain-balloon percutaneous transluminal angioplasty (PTA). MATERIALS AND METHODS: This prospective randomized clinical trial enrolled 120 patients with dysfunctional arteriovenous fistulae (n = 109) and grafts (n = 11), due to a ≥50% stenosis between March 2014 and April 2018. All patients underwent high-pressure balloon angioplasty and were then randomized to either DCB (n = 60) or PTA (n = 60). Patients were followed-up for 1 year, and angiography was performed 6 months after angioplasty. The primary endpoint was the late lumen loss (LLL) at 6 months. Secondary endpoints included other angiographic parameters at 6 months and HA failures, adverse event, and mortality at 12 months. Continuous variables were compared with a Student t-test, and Kaplan-Meier curves were used for freedom from HA failure and for mortality. RESULTS: LLL in the DCB and in the PTA group were 0.64 mm ± 1.20 and 1.13 mm ± 1.51, respectively (P = .082, adjusted P = .0498). DCB was associated with lower percentage stenosis (54.2% ± 19.3 vs 61.7% ± 18.2; P = .047) and binary restenosis ≥50% (56.5% vs 81.1%; P = .009) than PTA. The number of HA failures after 12 months was lower for DCB than for PTA (45% vs 66.7%; P = .017). Mortality at 12 months was 10% and 8.3% in the DCB and PTA groups, respectively (P = .75). CONCLUSIONS: Despite LLL improvement that failed to reach statistical significance, this study demonstrated decreased incidence and severity of restenosis with DCB compared with PTA to treat dysfunctional HA.

Eye Lens Dosimetry in Interventional Radiology: Assessment With Dedicated Hp(3) Dosimeters.

PURPOSE: To quantify eye lens dose in interventional radiology and assess whether neck dosimeter is a good surrogate to evaluate eye lens dosimetry. METHODS: Radiation exposure was prospectively measured in 9 interventional radiologists between May and October 2017. Standard Hp(0,07) thermoluminescent dosimeters (TLDs) were worn at the neck outside the lead apron, and 2 dedicated eye lens Hp(3) TLDs were placed just above the eyes, one midline and another at the outer edge of the left eye. Correlations between eye lens and neck TLD doses were assessed with Pearson coefficient, and linear regression was used to predict eye lens dose from neck TLD values. RESULTS: Eye lens dose without eye protection was 0.18 ± 0.11 (mean ± standard deviation; 0.08-0.41) mSv per workday and 35.3 ± 6.6 mSv (16.3-82.9) annually (200 workdays/year). Five (56%) radiologists exceeded the 20 mSv annual eye lens dose limit. Eye lens doses from left and central TLDs were 12.46 ± 3.02 and 9.29 ± 3.38 mSv, respectively (P = .027). Mean eye lens (left and central) and neck TLD doses were 10.87 ± 2.67 and 16.56 ± 5.67 mSv, respectively (P = .008). Pearson correlation coefficient between both eye lens TLD and between mean eye lens TLD and neck TLD doses were 0.91 and 0.92, respectively. Average of eye lens dose was 0.0179 + (0.5971 × neck dose). CONCLUSION: Full-time interventional radiologists are likely to suffer from deterministic radiation effects to the eye lens, especially on the left side. Neck TLD significantly overestimates eye lens dose. However, eye lens doses are highly correlated with neck doses and may be predicted from the neck TLD values.

Percutaneous Thrombectomy with the JETi8 Peripheral Thrombectomy System for the Treatment of Deep Vein Thrombosis.

PURPOSE: This study evaluated the safety and efficacy of the JETi8 peripheral thrombectomy system in treating acute deep vein thrombosis (DVT). MATERIALS AND METHODS: A retrospective study was conducted in 18 consecutive patients (mean age, 41 years old [range, 15-74 years old]; 5 men and 13 women). There were 21 instances of DVTs (9 iliofemoral, 10 axillosubclavian, and 2 portal), which were treated using the JETi8 thrombectomy device between November 2016 and July 2018. Thrombus was laced with recombinant tissue plasminogen activator (r-TPA) (9.3 mg, on average; range, 2-12 mg) in 17 procedures (81%) prior to thrombectomy. Technical success was defined as restoration of antegrade flow using the JETi8 with or without additional treatment of an underlying obstructive lesion. Procedural success was defined as technical success with or without the addition of overnight catheter-directed thrombolysis (CDT) RESULTS: Mean procedure time was 83 minutes (range, 30-160 minutes), and mean thrombus reduction with the JETi8 alone was 92% (range, 60%-100%). Stent placement was required in 6 procedures (29%). Technical success using the JETi8 system alone was 76% (16 of 21 procedures), whereas 5 procedures (24%) required subsequent overnight CDT in the intensive care unit. Procedural success rate was 100% (20 of 20 procedures). Mean aspirated volume was 531 mL (range, 250-1,230 mL). The only adverse event was a subsegmental pulmonary embolism. Seven patients (33%) were discharged the same day. Recurrent thrombosis was observed in 5 patients (24%), of whom 3 were successfully treated with the JETi8 system. CONCLUSIONS: The JETi8 system may be a safe and effective option for thrombectomy of acute DVT.

Clinical Validation of a Semi-Automated Software for Maximal Diameter Measurements for Endovascular Repair Follow-up.

PURPOSE: To compare automated measurements of maximal diameter (Dmax) of abdominal aortic aneurysm (AAA) orthogonal to luminal or outer wall envelope centerline for endovascular repair (EVAR) follow-up. MATERIAL AND METHODS: Eighty-three consecutive patients with AAA treated by EVAR who had at least 1 computed tomography (CT) scan before and 2 CT scans after EVAR with at least 5 months' interval were included. Three-dimensional reconstruction of the AAA was achieved with dedicated segmentation software. Performances of automated calculation algorithms of Dmax perpendicular to lumen or outer wall envelope centerlines were then compared to manual measurement of Dmax on double-oblique multiplanar reconstruction (gold standard). Accuracy of automated Dmax measurements at baseline, follow-up, and progression over time was evaluated by calculation of mean error, Bland-Altman plot, and regression models. RESULTS: Disagreement in Dmax measurements between outer wall envelope algorithm and manual method was insignificant (mean error: baseline, -0.07 ± 1.66 mm, P = .7; first follow-up, 0.24 ± 1.69 mm, P = .2; last follow-up, -0.41 ± 2.74 mm, P = .17); whereas significant discrepancies were found between the luminal algorithm and the manual method (mean error: baseline, -1.24 ± 2.01 mm, P < .01; first follow-up, -1.49 ± 3.30 mm, P < .01; last follow-up, -1.78 ± 3.60 mm, P < .01). Dmax progression results were more accurate with AAA outer wall envelope algorithm compared to luminal method (P = .2). CONCLUSIONS: AAA outer wall envelope segmentation is recommended to enable automated calculation of Dmax perpendicular to its centerline during EVAR follow-up.

Assessment of Response to Transcatheter Arterial Chemoembolization with Doxorubicin-eluting Microspheres: Tumor Biology and Hepatocellular Carcinoma Recurrence in a 5-year Transplant Cohort.

Purpose To assess response to transcatheter arterial chemoembolization (TACE) based on immune markers and tumor biology in patients with hepatocellular carcinoma (HCC) who were bridged to liver transplantation, and to produce an optimized pretransplantation model for posttransplantation recurrence risk. Materials and Methods In this institutional review board-approved HIPAA-compliant retrospective analysis, 93 consecutive patients (73 male, 20 female; mean age, 59.6 years; age range, 23-72 years) underwent TACE with doxorubicin-eluting microspheres (DEB) (hereafter, DEB-TACE) and subsequently underwent transplantation over a 5-year period from July 7, 2011, to May 16, 2016. DEB-TACE response was based on modified Response Evaluation Criteria in Solid Tumors. Imaging responses and posttransplantation recurrence were compared with demographics, liver function, basic immune markers, treatment dose, and tumor morphology. Treatment response and recurrence were analyzed with uni- and multivariate statistics, as well as internal validation and propensity score matching of factors known to affect recurrence to assess independent effects of DEB-TACE response on recurrence. Results Low-grade tumors (grade 0, 1, or 2) demonstrated a favorable long-term treatment response in 87% of patients (complete response, 49%; partial response, 38%; stable disease [SD] or local disease progression [DP], 13%) versus 33% of high-grade tumors (grade 3 or 4) (complete response, 0%; partial response, 33%; SD or DP, 67%) (P < .001). Of the 93 patients who underwent treatment, 82 were followed-up after transplantation (mean duration, 757 days). Recurrence occurred in seven (9%) patients (mean time after transplantation, 635 days). Poor response to DEB-TACE (SD or DP) was present in 86% of cases and accounted for 35% of all patients with SD or DP (P < .001). By using only variables routinely available prior to liver transplantation, a validated model of posttransplantation recurrence risk was produced with a concordance statistic of 0.83. The validated model shows sensitivity of 83.6%, specificity of 82.6%, and negative predictive value of 98.4%, which are pessimistic estimates. Conclusion Response to DEB-TACE is correlated with tumor biology and patients at risk for posttransplantation recurrence, and it may be associated with HCC recurrence after liver transplantation. © RSNA, 2017 Online supplemental material is available for this article.

Effectiveness and Safety of Sclerotherapy for Treatment of Low-Flow Vascular Malformations of the Oropharyngeal Region.

PURPOSE: To evaluate the efficacy and safety of sclerotherapy with sodium tetradecyl sulfate (STS) and bleomycin for treatment of venous malformations (VMs) of the oropharyngeal region. MATERIALS AND METHODS: A retrospective study of 33 patients with 46 VMs of the buccal and pharyngolaryngeal cavity associated with impairment of eating, respiration, or elocution was performed. Individual lesions were divided based on their anterior or posterior location, using the base of the tongue as an anatomic landmark. Lesion size was estimated with the use of orthogonal measurements on magnetic resonance or ultrasound images before and after treatment to assess radiologic response. Sclerotherapy sessions were performed under ultrasound, fluoroscopic, and, if needed, endoscopic guidance. Clinical response was assessed with the use of the Manchester Orofacial Pain Disability Scale. Methods for airway management were also compiled. RESULTS: Following sclerotherapy, average VM diameter was reduced by 31.4% (P < .0001) on a per-patient basis and by 30.8% (P < .0001) on a per-lesion basis. The Manchester score improved by an average of 37.0% (P = .013). Four patients reported a worsening of symptoms, and 11 patients experienced symptomatic recurrence. Complications include pneumonia (5 patients) and urgent placement of a post-procedure tracheostomy (4 patients). Patients with posterior malformations experienced more complications (emergency tracheostomies in 4 and pneumonias in 4). CONCLUSIONS: Sclerotherapy using STS is an efficient treatment for venous malformations of the buccal and pharyngolaryngeal cavity but can lead to significant complication for posterior lesions. Careful assessment of the airway is needed before treatment, and prophylactic tracheotomy should be considered in patients with posterior lesions.

Results of a randomized clinical trial of external beam radiation to prevent restenosis after superficial femoral artery stenting.

OBJECTIVE: The objective of this study was to evaluate the safety and efficacy of external beam radiation (EBR) in preventing restenosis after superficial femoral artery (SFA) stenting in comparison with a control group treated with SFA stenting only. METHODS: In this Institutional Review Board-approved study, patients who provided written informed consent were randomly assigned to 0 Gy or 14 Gy of EBR to the stent site 24 hours after SFA stenting. The primary end point was the angiographic binary restenosis rate 2 years after stenting. Categorical and continuous end points were respectively analyzed using logistic regression models and Wilcoxon tests. End points expressed as time to event were analyzed using a log-rank test. RESULTS: The study included 155 patients, 46 women and 109 men (mean age, 66 years; range, 45-85 years). In the 0 and 14 Gy groups, binary restenosis was present, respectively, in 44% (34/77) and 68% (52/76; P = .003) 2 years after stenting. Stent thrombosis occurred in 13% (10/78) of the 0 Gy group and in 33% (25/77) of the 14 Gy group (P = .003). Target lesion revascularization at 2 years was 26% (25/78) in the 0 Gy group and 30% (23/77) in the 14 Gy group (P = .56). There were no significant differences in total walking distances change from baseline to 2 years (46 ± 100 and 26 ± 79 m, respectively, in the 0 Gy and 14 Gy group; P = .25). There were no procedure-related deaths and no major amputations. CONCLUSIONS: A single 14 Gy dose of EBR to the SFA stenting site did not prevent in-stent restenosis.

Adrenal Vein Sampling in Primary Aldosteronism: Sensitivity and Specificity of Basal Adrenal Vein to Peripheral Vein Cortisol and Aldosterone Ratios to Confirm Catheterization of the Adrenal Vein.

PURPOSE: To assess the sensitivity and specificity for ratios of adrenal vein cortisol level (Ca) to peripheral vein cortisol level (Cp), adrenal vein aldosterone level (Aa) to peripheral vein aldosterone level (Ap), and combined cortisol and aldosterone levels ("combined ratio") for the detection of successful adrenal vein catheterization ("selectivity") in adrenal vein sampling (AVS) without adrenocorticotropic hormone (ACTH) injection at different cutoff values. MATERIALS AND METHODS: This retrospective study was approved by the institutional review board, and informed consent was waived. AVS was performed in 160 consecutive patients (49 women and 111 men; mean age, 53.6 years) between December 1989 and January 2014. Cortisol and aldosterone levels were measured in samples from the adrenal veins and left iliac vein every 5 minutes, two times before (basal) and three times after intravenous cosyntropin (ACTH 1-24) injection. Selectivity was defined by Ca/Cp or Aa/Ap ratio of at least 5 in at least one sampling after ACTH administration. Sensitivity and specificity for the detection of selective adrenal vein catheterization were calculated for basal Ca/Cp ratio, Aa/Ap ratio, and combined ratios for three cutoff values reported in the literature. The McNemar test was used to assess differences in sensitivity and specificity to detect selective adrenal vein catheterization. RESULTS: The sensitivity and specificity for the cutoff values of at least 3, at least 2, and at least 1.1 for the detection of AVS selectivity were respectively 50.4% and 100%, 70.8% and 100%, and 98.5% and 76.9% for Ca/Cp ratio; 61.3% and 100%, 70.8% and 100%, and 94.2% and 53.8% for Aa/Ap ratio; and 75.2% and 100%, 88.3% and 100%, and 99.3% and 46.2% for combined ratios (sensitivity at the ≥2 cutoff value: P < .0001 for combined ratio vs Ca/Cp ratio and for combined ratio vs Aa/Ap ratio). CONCLUSION: Basal combined ratio has the best sensitivity for the detection of AVS selectivity at all cutoff values, and for all ratios, the cutoff value of at least 2 has the best sensitivity for 100% specificity.

Source of errors and accuracy of a two-dimensional/three-dimensional fusion road map for endovascular aneurysm repair of abdominal aortic aneurysm.

PURPOSE: To evaluate the accuracy and source of errors using a two-dimensional (2D)/three-dimensional (3D) fusion road map for endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm. MATERIALS AND METHODS: A rigid 2D/3D road map was tested in 16 patients undergoing EVAR. After 3D/3D manual registration of preoperative multidetector computed tomography (CT) and cone beam CT, abdominal aortic aneurysm outlines were overlaid on live fluoroscopy/digital subtraction angiography (DSA). Patient motion was evaluated using bone landmarks. The misregistration of renal and internal iliac arteries were estimated by 3 readers along head-feet and right-left coordinates (z-axis and x-axis, respectively) before and after bone and DSA corrections centered on the lowest renal artery. Iliac deformation was evaluated by comparing centerlines before and during intervention. A score of clinical added value was estimated as high (z-axis < 3 mm), good (3 mm ≤ z-axis ≤ 5 mm), and low (z-axis > 5 mm). Interobserver reproducibility was calculated by the intraclass correlation coefficient. RESULTS: The lowest renal artery misregistration was estimated at x-axis = 10.6 mm ± 11.1 and z-axis = 7.4 mm ± 5.3 before correction and at x-axis = 3.5 mm ± 2.5 and z-axis = 4.6 mm ± 3.7 after bone correction (P = .08), and at 0 after DSA correction (P < .001). After DSA correction, residual misregistration on the contralateral renal artery was estimated at x-axis = 2.4 mm ± 2.0 and z-axis = 2.2 mm ± 2.0. Score of clinical added value was low (n = 11), good (n= 0), and high (n= 5) before correction and low (n = 5), good (n = 4), and high (n = 7) after bone correction. Interobserver intraclass correlation coefficient for misregistration measurements was estimated at 0.99. Patient motion before stent graft delivery was estimated at x-axis = 8 mm ± 5.8 and z-axis = 3.0 mm ± 2.7. The internal iliac artery misregistration measurements were estimated at x-axis = 6.1 mm ± 3.5 and z-axis = 5.6 mm ± 4.0, and iliac centerline deformation was estimated at 38.3 mm ± 15.6. CONCLUSIONS: Rigid registration is feasible and fairly accurate. Only a partial reduction of vascular misregistration was observed after bone correction; minimal DSA acquisition is still required.

Cone-beam CT: an additional imaging tool in the interventional treatment and management of low-flow vascular malformations.

PURPOSE: To evaluate the impact of cone-beam computed tomography (CT) during sclerotherapy of low-flow vascular malformations. MATERIALS AND METHODS: Eighty-seven cone-beam CT examinations were acquired during 81 sclerotherapy treatments of low-flow malformations in 48 patients: 81 were performed to evaluate sclerosing agent diffusion and six were performed to evaluate needle or catheter positioning before injection of therapeutic agent. Image quality was rated by two observers. Clinical impact of cone-beam CT in the assessment of therapeutic agent diffusion, needle or catheter positioning, subsequent treatment planning, and complication detection was evaluated. The κ-statistic was used to assess interobserver reliability and proportions, with associated 95% confidence intervals (CIs). RESULTS: All cone-beam CT images were successfully acquired. Image quality was rated as excellent or good for the majority of studies, with substantial interobserver reliability (κ = 0.648). Cone-beam CT studies improved assessment of therapeutic agent diffusion in 83% of cases (67 of 81; 95% CI, 75%-91%) for observer 1, who had access to ultrasound, fluoroscopic, and digital subtraction angiographic (DSA) imaging, and in 95% of cases (77 of 81; 95% CI, 90%-100%) for observer 2, who had access to only stored fluoroscopic spot radiographs and DSA images. Cone-beam CT impacted planning of the next treatment session in 49% of cases (40 of 81; 95% CI, 38%-60%). In 7% of cases (six of 81; 95% CI, 1%-13%), complications such as migration of therapeutic agent or compression of upper airways were detected that were not seen with other imaging. CONCLUSIONS: Cone-beam CT can be a useful adjunctive imaging tool, providing information to help decision-making during percutaneous sclerotherapy and ongoing management of low-flow vascular malformations.

Management of Pancreatico-duodenal arterio-venous malformation.

PURPOSE: To describe the interventional management and clinical outcome of pancreatico-duodenal arterio-venous malformations (PDAVMs). MATERIAL AND METHODS: Seven patients presenting a PDAVM (6 women, 1 male; mean age: 61) were retrospectively reviewed. Technical, clinical success and complications of embolization and surgical management of symptomatic PDAVMs were assessed. Technical success was defined as a complete occlusion of the PDAVM and clinical success as no clinical symptom or recurrence during follow-up. Patients with asymptomatic PDAVMs were followed clinically, by Doppler ultrasound and CT-angiography. RESULTS: Mean follow-up time was 69 months (15-180). Five symptomatic patients presented with upper gastrointestinal bleeding (n=3), ascites (n=1), and abdominal pain (n=1). Two patients were asymptomatic. The PDAVMs were classified as follow: Yakes I (1), IIIa (2), IIIb (3) and IV (1). Five symptomatic patients were treated with 9 embolization sessions with arterial approach (onyx®, glue, coils) in 7 and venous approach in 2 (plugs, coils, covered stents, STS foam and onyx®). Technical success of embolization was 60% (3/5). Devascularization was incomplete for 2 Yakes IIIB patients. Clinical success of embolization was estimated at 80% (4/5) as one patient required additional surgery (Whipple) because of persistent bleeding. One splenic vein thrombosis was treated successfully by mechanical thrombectomy and heparin. No recurrence occurred during follow-up. No progression was documented in asymptomatic patients. CONCLUSION: Embolization of symptomatic PDAVMs is effective and surgery should be performed in second intention. Complete devascularization is more difficult to obtain in Yakes III PDAVM.

Percutaneous embolization of iatrogenic arterial kidney injuries: safety, efficacy, and impact on blood pressure and renal function.

PURPOSE: To evaluate the efficacy and safety of percutaneous renal artery embolization (RAE) of iatrogenic vascular kidney injuries and the effects of RAE on renal function and arterial blood pressure (BP). MATERIALS AND METHODS: Over a 12-year period, 50 consecutive patients with severe hemorrhage after iatrogenic arterial kidney injuries underwent RAE. Technical success was defined as occlusion of the bleeding site, and clinical success was defined as complete bleeding cessation. The effects on renal function and arterial BP were assessed by comparing the estimated glomerular filtration rate (eGFR), renal function stage (National Kidney Foundation scale), systolic BP, and BP stage (European Society of Hypertension classification) before and after RAE. RESULTS: RAE was technically successful in 49 patients (98%). Two patients were lost to follow-up after RAE. Clinical success was obtained in 40 (83%), 45 (94%), and 47 patients (98%), respectively, at 24, 48, and 96 hours after RAE. Three patients (6%) had minor complications, and one patient (2%) died within 30 days after RAE. Follow-up renal function data (mean, 4 mo) were available for 33 patients (66%). No statistically significant differences in eGFR (P = .186) or renal function stage (P = .183) were apparent after RAE. Follow-up BP data (mean, 3 mo) were available for 28 patients (56%). There were no significant differences in systolic BP (P = .233) or BP stage (P = .745) after RAE. CONCLUSIONS: Embolization of iatrogenic renal artery injuries is safe and associated with high technical and clinical success rates. It is not associated with a significant worsening of renal function or increase in BP.

Comparison of prognosis for men with type 2 diabetes mellitus and men with cardiovascular disease.

BACKGROUND: People with type 2 diabetes mellitus are at high risk for cardiovascular disease. In some studies, the mortality rate among people with this condition has been equivalent to that among people with cardiovascular disease. We compared cardiovascular mortality between incident cases of diabetes and cardiovascular disease. METHODS: The study population was part of a random sample of 4376 men from Quebec, Canada, aged 35 to 64 years, who did not have cardiovascular disease in 1974 and who were followed until 1998. Three groups of incident cases were identified: diabetes without cardiovascular disease, first cardiovascular event (myocardial infarction, unstable angina or stroke) without diabetes, and both cardiovascular disease and diabetes. These cases were age-matched to a control group without diabetes or cardiovascular disease. RESULTS: During the 24-year follow-up period, new diabetes without cardiovascular disease was documented in 137 men. A first cardiovascular event without diabetes was documented in 527 men. Relative to the 627 controls, men with 1 of the 2 diseases of interest had higher cardiovascular mortality (age-adjusted relative risk [RR] 3.11, 95% confidence interval [CI] 1.96-4.92) for those with diabetes and 4.46 (95% CI 3.15-6.30) for those with cardiovascular disease). However, within the first 5 years after diagnosis, men with cardiovascular disease had higher cardiovascular mortality than men with diabetes (age-adjusted RR 2.03, 95% CI 1.01-4.08). INTERPRETATION: Men with isolated type 2 diabetes and men with isolated cardiovascular disease had similar cardiovascular mortality rates several years after initial diagnosis of either condition. These findings reinforce the need to prevent and optimally manage diabetes and cardiovascular disease.

Silver Diamine Fluoride and Potassium Iodide Disruption of In Vitro Streptococcus mutans Biofilm.

Purpose: The purpose of this study was to investigate the inhibitory in vitro effects of silver diamine fluoride (SDF) with and without a saturated solution of potassium iodide (SSKI) on established Streptococcus mutans biofilm.Methods: Fifty µl of an overnight S. mutans culture (106 CFU per mL) in Tryptic Soy Broth (TSB) and three ml of fresh TSB supplemented with one percent sucrose (TSBS) were incubated for 24 hours to establish an S. mutans biofilm in six-well tissue culture plates. Four treatments (SDF, SSKI, SDF plus SSKI, and untreated control) were used to disrupt the biofilm. The biofilm groups were each treated with reagent and washed; the biofilm was collected, diluted, and spiral-plated onto blood agar plates; and an automated counting machine was used to determine the bacterial colony forming units (CFU).Results: The control had significantly more CFU than the SSKI, SDF, and SDF plus SSKI groups (P<.0001). The SSKI group had significantly more CFU than the SDF and SDF plus SSKI groups (P<.0001). The SDF group had significantly fewer CFU than the SDF plus SSKI group (P=.02). The reduction from the control was more than seven-fold for SDF, four-fold for SDF plus SSKI, and two-fold for SSKI.Conclusions: SDF alone, SDF plus SSKI, and SSKI disrupted an established S. mutans biofilm. SDF alone had the greatest overall disruption.

New Treatment Approaches to Arteriovenous Malformations.

Arteriovenous malformations (AVMs) are high-flow vascular anomalies that have demonstrated a very high recurrence rate after endovascular treatment, surgical treatment, or a combination of both. Surgical treatments have shown good response when they are small and well localized but a poor response when diffuse. A better understanding of the nature of the lesion has led to a better response rate and a safer treatment for these patients. This has been accomplished through a detailed understanding of the angioarchitecture of the lesion, enabling a tailored approach in reaching and targeting the nidus of the AVM with different liquid embolic agents, more specifically ethanol. Flow reduction techniques help in exposing the nidus to sclerosant agents. A clinical classification, the Schobinger classification, will help determine the appropriate time to start or to pursue therapy.

Intraarterial Liver-Directed Therapies: The Role of Interventional Oncology.

BACKGROUND: Since the early 1990s, the minimally invasive image-guided therapies used in interventional oncology to treat hepatocellular carcinoma have continued to evolve. Additionally, the range of applications has been expanded to the treatment of hepatic metastases from colorectal cancer, neuroendocrine tumors, cholangiocarcinoma, breast cancer, melanoma, and sarcoma. METHODS: We searched the literature to identify publications from 1990 to the present on various image-guided intraarterial therapies and their efficacy, as well as their role in the management of primary and secondary liver malignancies. RESULTS: Chemoembolization and radioembolization are considered a standard of care in treating, delaying progression of disease, and downstaging to bridge to liver transplantation. Progression-free survival and overall survival outcomes are promising in patients with colorectal cancer and neuroendocrine tumors with liver metastases. Applications in the treatment of hepatic metastases from cholangiocarcinoma, breast cancer, melanoma, and sarcoma also show potential. CONCLUSION: Interventional oncology and its image-guided intraarterial therapies continue to gain recognition as treatment options for primary and secondary liver cancers. Growing evidence supports their role as a standard of care alongside medical oncology, surgery, and radiation oncology.

Adrenal vein sampling in primary aldosteronism: concordance of simultaneous vs sequential sampling.

OBJECTIVE: Many investigators believe that basal adrenal venous sampling (AVS) should be done simultaneously, whereas others opt for sequential AVS for simplicity and reduced cost. This study aimed to evaluate the concordance of sequential and simultaneous AVS methods. DESIGN AND METHODS: Between 1989 and 2015, bilateral simultaneous sets of basal AVS were obtained twice within 5 min, in 188 consecutive patients (59 women and 129 men; mean age: 53.4 years). Selectivity was defined by adrenal-to-peripheral cortisol ratio ≥2, and lateralization was defined as an adrenal aldosterone-to-cortisol ratio ≥2, the contralateral side. Sequential AVS was simulated using right sampling at -5 min (t = -5) and left sampling at 0 min (t = 0). RESULTS: There was no significant difference in mean selectivity ratio (P = 0.12 and P = 0.42 for the right and left sides respectively) and in mean lateralization ratio (P = 0.93) between t = -5 and t = 0. Kappa for selectivity between 2 simultaneous AVS was 0.71 (95% CI: 0.60-0.82), whereas it was 0.84 (95% CI: 0.76-0.92) and 0.85 (95% CI: 0.77-0.93) between sequential and simultaneous AVS at respectively -5 min and at 0 min. Kappa for lateralization between 2 simultaneous AVS was 0.84 (95% CI: 0.75-0.93), whereas it was 0.86 (95% CI: 0.78-0.94) and 0.80 (95% CI: 0.71-0.90) between sequential AVS and simultaneous AVS at respectively -5 min at 0 min. CONCLUSIONS: Concordance between simultaneous and sequential AVS was not different than that between 2 repeated simultaneous AVS in the same patient. Therefore, a better diagnostic performance is not a good argument to select the AVS method.