The Kaiser Permanente experience with ultrasound-guided percutaneous endovascular abdominal aortic aneurysm repair.

BACKGROUND: This study was conducted to determine the effect of ultrasound (US)-guided percutaneous access for percutaneous endovascular abdominal aortic aneurysm repair (PEVAR) on conversion to open repair by femoral cutdown. We also sought to identify other risk factors associated with failure of percutaneous access and conversion to femoral cutdowns. METHODS: This is a single-center, retrospective review of 101 patients who underwent PEVAR between January 1, 2005 and July 31, 2009 (56 months). Risk factors that were evaluated for unsuccessful PEVAR included gender, age (≤65 and ≥66 years), US-guided percutaneous access, mechanical failure, abdominal aortic aneurysm size, and the following comorbidities: diabetes, hypertension, vessel calcification, and obesity (body mass index: ≥30 kg/m(2)). RESULTS: There were 10 (9.9%) conversions from percutaneous to femoral cutdown, yielding a success rate of 90.1% for a total percutaneous approach. Each converted patient had one groin converted, resulting in a cutdown rate per groin of 10/202 (5%). There were no 30-day mortalities. Univariate analysis showed that hypertension (P = 0.261), age ≥66 years (P = 0.741), current smoking history (P = 0.649), past smoking history (P = .093), diabetes (P = 0.908), vessel calcification (P = 0.8281), and body mass index ≥30 kg/m(2) (P = 0.052) did not significantly predict conversion to endovascular aortic aneurysm repair (EVAR). Mechanical failure significantly predicted conversion to cutdown EVAR (P = 0.0002), whereas US-guided percutaneous access influenced successful PEVAR (P = 0.030). Multivariate analysis showed that mechanical failure significantly predicted conversion to cutdown EVAR (P = 0.003) and US-guided percutaneous access influenced successful PEVAR (P = 0.040) after adjusting for smoking history and obesity. CONCLUSION: PEVAR is a viable option for aortic aneurysm repair that may be improved with US-guided percutaneous access by reducing the rate of femoral cutdowns.

Quantitative ultrasound characterization of therapy response in prostate cancer in vivo.

Quantitative ultrasound (QUS) is a non-invasive imaging modality that permits the detection of tumor response following various cancer therapies. Based on ultrasound signal scattering from the biological system, scatterer size, and concentration of microscopic scatterers, QUS enables the rapid characterization of tumor cell death. In this study, tumor response to ultrasound-stimulated microbubbles (USMB) and hyperthermia (HT) in tumor-bearing mice, with prostate cancer xenografts (PC3), was examined using QUS. Treatment conditions included 1% (v/v) Definity microbubbles stimulated at ultrasound pressures (0, 246, and 570 kPa) and HT treatment (0, 10, 40, and 50 minutes). Three ultrasound backscatter parameters, mid-band fit (MBF), 0-MHz spectral intercept (SI), and spectral slope (SS) were estimated prior to, and 24 hours after treatment. Additionally, histological assessment of tumor cell death and tissue microstructural changes was used to complement the results obtained from ultrasound data. Results demonstrated a significant increase in QUS parameters (MBF and SI) followed combined USMB and HT treatment (P<0.05). In contrast, the backscatter parameters from the control (untreated) group, and USMB only group showed minimal changes (P>0.05). Furthermore, histological data demonstrated increased cell death and prominent changes in cellular and tissue structure, nucleus size, and subcellular constituent orientation followed combined treatments. The findings suggested that QUS parameters derived from the ultrasound backscattered power spectrum may be used to detect HT treatment effects in prostate cancer tumors in vivo.

Bifurcated endograft repair of ilio-iliac arteriovenous fistula secondary to lumbar diskectomy.

Ilio-iliac arteriovenous (AV) fistula is a rare complication after lumbar diskectomy. Endovascular repair of such fistulas is a growing trend in vascular surgery. This is a case report of an endovascular exclusion of an ilio-iliac AV fistula in a 51-year-old male. This man presented with high-output congestive heart failure and ascites. The AV fistula was discovered 17 years after a lumbar diskectomy. Computed topography (CT) revealed a right common iliac artery pseudoaneurysm connecting to the left common iliac vein. The fistula was repaired using a bifurcated Gore Excluder endograft. There were follow-up CT scans at 6 and 10 months confirming exclusion of the AV fistula. Endovascular AV fistula repair offers a safe, effective method for managing ilio-iliac AV fistulas.

Ultrasound microbubble potentiated enhancement of hyperthermia-effect in tumours.

It is now well established that for tumour growth and survival, tumour vasculature is an important element. Studies have demonstrated that ultrasound-stimulated microbubble (USMB) treatment causes extensive endothelial cell death leading to tumour vascular disruption. The subsequent rapid vascular collapse translates to overall increases in tumour response to various therapies. In this study, we explored USMB involvement in the enhancement of hyperthermia (HT) treatment effects. Human prostate tumour (PC3) xenografts were grown in mice and were treated with USMB, HT, or with a combination of the two treatments. Treatment parameters consisted of ultrasound pressures of 0 to 740 kPa, the use of perfluorocarbon-filled microbubbles administered intravenously, and an HT temperature of 43°C delivered for various times (0-50 minutes). Single and multiple repeated treatments were evaluated. Tumour response was monitored 24 hours after treatments and tumour growth was monitored for up to over 30 days for a single treatment and 4 weeks for multiple treatments. Tumours exposed to USMB combined with HT exhibited enhanced cell death (p<0.05) and decreased vasculature (p<0.05) compared to untreated tumours or those treated with either USMB alone or HT alone within 24 hours. Deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL) staining and cluster of differentiation 31 (CD31) staining were used to assess cell death and vascular content, respectively. Further, tumours receiving a single combined USMB and HT treatment exhibited decreased tumour volumes (p<0.05) compared to those receiving either treatment alone when monitored over the duration of 30 days. Additionally, tumour response monitored weekly up to 4 weeks demonstrated a reduced vascular index and tumour volume, increased fibrosis and lesser number of proliferating cells with combined treatment of USMB and HT. Thus in this study, we characterize a novel therapeutic approach that combines USMB with HT to enhance treatment responses in a prostate cancer xenograft model in vivo.

Retrograde superior mesenteric artery stenting for acute mesenteric arterial thrombosis.

Retrograde superior mesenteric artery stenting (ROMS) represents a significant development in the treatment of acute mesenteric ischemia. Compared to traditional surgical mesenteric bypass, ROMS is a less invasive technique that avoids many complications associated with emergent mesenteric bypass. This case report illustrates that retrograde superior mesenteric artery (SMA) stenting is an option for the treatment of acute mesenteric ischemia for patients in extremis.

Psychosocial factors affecting medication adherence among HIV-1 infected adults receiving combination antiretroviral therapy (cART) in Botswana.

As increasing numbers of persons are placed on potentially life-saving combination antiretroviral therapy (cART) in sub-Saharan Africa, it is imperative to identify the psychosocial and social factors that may influence antiretroviral (ARV) medication adherence. Using an 87 question survey, the following data were collected from patients on cART in Botswana: demographics, performance (Karnofsky) score, perceived stigma and level of HIV disclosure, attitudes and beliefs concerning HIV/AIDS, substance and/or drug use, depression, and pharmacy and healthcare provider-related factors. Overall adherence rates were determined by patient self-report, institutional adherence, and a culturally modified Morisky scale. Three hundred adult patients were recruited between April and May 2005. The overall cART adherence rate was 81.3% based on 4 day and 1 month patient recall and on clinic attendance for ARV medication refills during the previous 3 months. Adults receiving cART for 1-6 months were the least adherent (77%) followed by those receiving cART for greater than 12 months (79%). Alcohol use, depression, and nondisclosure of positive HIV status to their partner were predictive of poor adherence rates (p value <0.02). A significant proportion (81.3%) of cART-treated adults were adherent to their prescribed treatment, with rates superior to those reported in resource-rich settings. Adherence rates were poorest among those just starting cART, most likely due to the presence of ARV-related toxicity. Adherence was lower among those who have been treated for longer periods of time (greater than 1 year), suggesting complacency, which may become a significant problem, especially among these long-term cART-treated patients who return to improved physical and mental functioning and may be less motivated to adhere to their ARV medications. Healthcare providers should encourage HIV disclosure to "at-risk" partners and provide ongoing counseling and education to help patients recognize and overcome HIV-associated stigma, alcohol abuse, and depression.

[Intestinal parasitosis in patients with HIV-AIDS]. / Parasitosis intestinal en el paciente con infección VIH-SIDA.

INTRODUCTION: Diarrhea, a common complication and one of the most important causes of malabsorption and malnutrition in AIDS patients. Our objective was to determine the parasitic causes of diarrhea in patients with HIV-AIDS at the Cayetano Heredia National Hospital (Lima, Peru). METHODS: We included 217 HIV-AIDS patients who reported diarrhea between May 2002 and September 2005. We analyzed 1-3 stool samples per patient using six methods to detect oocysts, cysts, eggs and larvae of parasites. RESULTS: The average patients age was 34.5 years (range 15-68); 75.12% were males. Patients with diarrhea during two weeks or more were 149/217 (68.66%). A total of 123 parasites were detected in 103/217 patients (47.5%) 18/217 (8.3%) had mixed parasitic infections. Cryptosporidium spp. was the most frequent parasite detected. It was more prevalent in the group of patients who had diarrhea for two or more weeks than those who had diarrhea for less than two weeks (22.82% vs. 10.29%, p=0.029). Other frequent parasitosis cases were isosporidiasis (10.6%), giardiasis (8.3%) and strongyloidiasis (6.9%). CONCLUSION: Intestinal parasitosis is frequent in HIV-AIDS patients at the Cayetano Heredia National Hospital. The most common opportunistic pathogens were Criptosporidium spp. and Isospora belli and the most frequent non-opportunistic pathogens were Giardia lamblia and Strongyloidiasis stercoralis.

Parasitosis intestinal en el paciente con infección VIH-SIDA / Intestinal diseases parasitic in patients with HIV-AIDS

Introducción: La diarrea es una complicación común y una de las principales causas de malabsorción y desnutrición entre los paciente con SIDA. Nuestro objetivo es determinar las causas parasitarias de diarrea en pacientes con VIH-SIDA del Hospital Nacional Cayetano Heredia (Lima, Perú). MÉTODOS: Fueron incluidos 217 pacientes con VIH-SIDA que reportaron diarrea entre Mayo-2002 y Septiembre-2005. Fueron analizadas 1-3 muestras de heces mediante seis métodos para la detección de ooquistes, quistes, huevos y larvas de parásitos. RESULTADOS: La edad promedio fue 34.5 años (rango 15-68 años), 75.12 por ciento eran hombres. De ellos, 149/217 (68.66 por ciento) presentaron diarrea durante dos o más semanas. Se detectaron 123 parásitos en 103/217 pacientes (47.5 por ciento), presentando 18 de ellos(8.3 por ciento) infecciones parasitarias mixtas. Cryptosporidium spp. fue detectado con más frecuencia, sin embargo fue más prevalente en el grupo que presentaba dos o más semanas de diarrea, siendo esta diferencia estadísticamente significativa (22.82 por ciento vs. 10.29 por ciento, p=0.029). Otras parasitosis frecuentes fueron isosporidiasis (10.6 por ciento), giardiasis (8.3 por ciento) y strongyloidiasis (6.9 por ciento. CONCLUSIÓN: La enteroparasitosis es una condición frecuente entre los pacientes con VIH SIDA que acuden al Hospital Nacional Cayetano Heredia, siendo frecuente la presencia de agentes oportunistas (Cryptosporidium spp. e Isospora belli) y no oportunistas (Giardia lamblia y Strongyloides stercoralis).

Introduction: Diarrhea,a common complication and one of the most important causes of malabsorption and malnutrition in AIDS patients. Our objective was to determine the parasitic causes of diarrhea in patients with HIV-AIDSat the Cayetano Heredia National Hospital (Lima, Perú). METHODS:We included 217 HIV-AIDS patients who reported diarrhea between May 2002 and September 2005. We analyzed 1-3 stool samples per patient using six methods to detect oocysts, cysts, eggs and larvae of parasites. RESULTS: The average patients' age was 34.5 years (range 15-68); 75.12 percent were males. Patients with diarrhea during two weeks or more were149/217(68.66 percent).A total of 123 parasites were detected in 103/217 patients (47.5 percent) 18/217 (8.3 percent) had mixed parasitic infections. Cryptosporidium spp. was the most frequent parasite detected. It was more prevalent in the group of patients who had diarrhea for two or more weeksthan those who had diarrhea for less than two weeks (22.82 percent vs. 10.29 percent, p=0.029). Other frequent parasitosis cases were isosporidiasis (10.6 percent), giardiasis (8.3 percent) and strongyloidiasis (6.9 percent). CONCLUSION:Intestinal parasitosis is frequent in HIV-AIDS patients at the Cayetano Heredia National Hospital. The most common opportunistic pathogens were Criptosporidium spp. and Isospora belli and the most frequent non-opportunisticpathogens were Giardia lamblia and Strongyloidiasis stercoralis.