Learning Curve for Flow Diversion of Posterior Circulation Aneurysms: A Long-Term International Multicenter Cohort Study.

BACKGROUND AND PURPOSE: Flow diversion has gradually become a standard treatment for intracranial aneurysms of the anterior circulation. Recently, the off-label use of the flow diverters to treat posterior circulation aneurysms has also increased despite initial concerns of rupture and the suboptimal results. This study aimed to explore the change in complication rates and treatment outcomes across time for posterior circulation aneurysms treated using flow diversion and to further evaluate the mechanisms and variables that could potentially explain the change and outcomes. MATERIALS AND METHODS: A retrospective review using a standardized data set at multiple international academic institutions was performed to identify patients with ruptured and unruptured posterior circulation aneurysms treated with flow diversion during a decade spanning January 2011 to January 2020. This period was then categorized into 4 intervals. RESULTS: A total of 378 procedures were performed during the study period. Across time, there was an increasing tendency to treat more vertebral artery and fewer large vertebrobasilar aneurysms (P = .05). Moreover, interventionalists have been increasingly using fewer overlapping flow diverters per aneurysm (P = .07). There was a trend toward a decrease in the rate of thromboembolic complications from 15.8% in 2011-13 to 8.9% in 2018-19 (P = .34). CONCLUSIONS: This multicenter experience revealed a trend toward treating fewer basilar aneurysms, smaller aneurysms, and increased usage of a single flow diverter, leading to a decrease in the rate of thromboembolic and hemorrhagic complications.

Diabetes mellitus and other underlying conditions in patients with coronavirus disease 2019 associated rhino-orbito-cerebral mucormycosis: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to compute the pooled prevalence of diabetes mellitus and other underlying conditions in patients with coronavirus disease 2019 associated rhino-orbito-cerebral mucormycosis. METHOD: A systematic literature review was performed in PubMed, Scopus, Web of Science, Embase and Google Scholar. The cross-sectional studies that reported the frequency of diabetes mellitus in patients with coronavirus disease 2019 associated rhino-orbito-cerebral mucormycosis were included. RESULTS: Eighteen eligible studies with a total number of 3718 patients were included in the current study. The pooled prevalence of diabetes in patients with coronavirus disease 2019 associated rhino-orbito-cerebral mucormycosis was 89 per cent and with new-onset diabetes was 32 per cent. The pooled prevalence of steroid use was high (79 per cent) too. The all-cause mortality rate was 24 per cent. CONCLUSION: Diabetes mellitus was the most frequent underlying condition in patients with coronavirus disease 2019 associated rhino-orbito-cerebral mucormycosis. The second most frequent underlying condition was steroid use during coronavirus disease 2019 infection. The appropriate control of hyperglycaemia and rational prescription of steroids during the treatment of coronavirus disease 2019 associated rhino-orbito-cerebral mucormycosis is recommended.

Endothelialization following Flow Diversion for Intracranial Aneurysms: A Systematic Review.

BACKGROUND: The underlying mechanism of action of flow diverters is believed to be the induction of aneurysm thrombosis and simultaneous endothelial cell growth along the device struts, thereby facilitating aneurysm exclusion from the circulation. Although extensive attention has been paid to the role of altered cerebrovascular hemodynamics using computational fluid dynamics analyses, relatively less emphasis has been placed on the role of the vascular endothelium in promoting aneurysm healing. PURPOSE: Our aim was to systematically review all available literature investigating the mechanism of action of flow diverters in both human patients and preclinical models. DATA SOURCES: A systematic search of PubMed, Cochrane Central Register of Controlled Trials MEDLINE, EMBASE, and the Web of Science electronic data bases was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. STUDY SELECTION: We selected articles assessing the role of endothelialization in flow-diverter treatment of cerebral aneurysms, including both preclinical and clinical studies. DATA ANALYSIS: Ten articles were eligible for inclusion in this review. Two assessed endothelialization in human patients, while the other 8 used preclinical models (either rabbits or pigs). DATA SYNTHESIS: Methods used to assess endothelialization included optical coherence tomography and scanning electron microscopy. LIMITATIONS: A limitation was the heterogeneity of studies. CONCLUSIONS: Current data regarding the temporal relationship to flow-diverter placement has largely been derived from work in preclinical animal models. Whether these cells along the device struts originate from adjacent endothelial cells or are the result of homing of circulating endothelial progenitor cells is equivocal.

Investigation of the potential utility of a linomide analogue for treatment of choroidal neovascularization.

The aim of this study was to test the selectivity, in-vivo effectiveness, and potential mechanism of action of a linomide analogue (N-phenyl-1,2-dihydro-4-hydroxyl-2-oxo-quinoline-3-carboxamide, Lin05) for inhibition of choroidal neovascularization. The selectivity of Lin05 was tested in cell proliferation assays with human umbilical vein endothelial cells (HUVEC) and a retinal pigmented epithelial cell line(ARPE-19). In-vivo anti-angiogenic effect of Lin05 was investigated utilizing an experimental laser-induced choroidal neovascularization (ECNV) model in adult Brown Norway rats. Western blot and/or reverse transcriptase-PCR was used to test the effect of Lin05 on potential targets. Our results indicate that Lin05 is at least an 8-fold more selective inhibitor of endothelial cell proliferation compared to RPE cells. Systemic administration of Lin05 in an ECNV model was associated with a significant decrease in both vascular leakage on fluorescein angiography and lesion size by histopathology (p = 0.02). No systemic toxicity was detected for Lin05 in major organs such as the liver, lung and kidneys. Lin05 did not inhibit VEGF-induced VEGFR2 (KDR) phosphorylation in HUVEC nor was associated with decreased VEGF gene expression. Also it did not inhibit insulin-like growth factor (IGF-1) and Epidermal Growth Factor (EGF) induced activation of p42/p44 MAPK activation. It inhibited both PDGF- and bFGF-induced p42/p44 MAPK phosphorylation. However, the effect on PDGF was variable in different HUVEC cells. In conclusion, Lin05 is a potential anti-angiogenic agent for the treatment of eye diseases associated with pathological neovascularization. The anti-angiogenic effect of Lin05 is likely through inhibition of bFGF but not through inhibition of the VEGF/KDR pathway.

[Vitiligo. What is new?]. / Vitiligo. Was ist neu?

Vitiligo occurs in Northern Europe in one of 200 people. The disease can cause significant psychological stress for the affected individual. These patients generate and accumulate massive amounts of H(2)O(2)- and peroxynitrite in the epidermal compartment. Consequently many proteins are oxidized or nitrated, leading in turn to partial or complete loss of functionality. Moreover, presence of DNA damage in the skin as well as in plasma has been shown, while apoptosis is not enhanced. Induction of DNA repair is associated with up-regulated functioning p53 protein. Considering possible genetic predisposition and /or spontaneous mutations, autoimmune reactions in the disease are put forward in the context of oxidative stress. In addition a review of recent and novel treatment modalities including the role of oxidative stress reduction and combined climatotherapy at the Dead Sea in a group are discussed.

Management of symptomatic cholelithiasis in pregnancy.

BACKGROUND: Symptomatic cholelithiasis occurs in pregnancy in our patient population, some of whom are diabetic. But its management remains controversial. How common is the problem? Is our current policy of management appropriate for our patients? PATIENTS AND METHODS: The management of 162 pregnant patients admitted over a ten-year period with symptomatic cholelithiasis was evaluated in a retrospective study. The patients were divided into two groups: Group A, 58 patients with diabetes mellitus, and Group B, 104 nondiabetic patients. RESULTS: Symptomatic cholelithiasis occurred in only 0.3% of our pregnant patients. Of 162 patients, 148 (91.4%) had successful conservative (nonsurgical) management. There was no fetal loss, premature birth, maternal morbidity or mortality. Fourteen patients who had failure of conservative treatment had surgical management. When the postpartum cholecystectomy hospitalization days were added to the total days of admission for the nonoperative cases, there was a significant difference in the mean total number of days of hospitalizations between the surgical cases, 12.4 days, and the nonsurgical cases, 20.5 days (P<0.001), but not in the mean number of hospitalizations, 2.3 versus 3.3. CONCLUSION: Our current policy of conservative management seems optimal. It has, however, been achieved at the price per patient of 8 extra days of hospitalization. In keeping with recent improvements in surgery and the advent of laparoscopic surgery, a more cost-efficient approach would suggest a more aggressive policy.

Predictors of left ventricular outflow obstruction following single-stage repair of interrupted aortic arch and ventricular septal defect.

This study looked at echocardiographic predictors of left ventricular outflow obstruction after primary neonatal repair of interrupted aortic arch and ventricular septal defect. Results of this study indicate that the only significant independent predictor of left ventricular outflow obstruction is aortic valve diameter; all patients with an aortic valve diameter <4.5 mm (Z score <-5) subsequently developed obstruction, whereas patients with annuli >4.5 mm (Z score >-5) remained free from obstruction.

Atrial natriuretic factor in oliguric acute renal failure. Anaritide Acute Renal Failure Study Group.

Atrial natriuretic peptide (ANP), an endogenous hormone synthesized by the cardiac atria, has been shown to improve renal function in multiple animal models of acute renal failure. In a recent multicenter clinical trial of 504 patients with acute tubular necrosis (oliguric and nonoliguric), ANP decreased the need for dialysis only in the oliguric patients. In the present study, 222 patients with oliguric acute renal failure were enrolled into a multicenter, randomized, double-blind, placebo-controlled trial designed to assess prospectively the safety and efficacy of ANP compared with placebo. Subjects were randomized to treatment with a 24-hour infusion of ANP (anaritide, 0.2 microgram/kg/min; synthetic form of human ANP) or placebo. Dialysis and mortality status were followed up for 60 days. The primary efficacy end point was dialysis-free survival through day 21. Dialysis-free survival rates were 21% in the ANP group and 15% in the placebo group (P = 0.22). By day 14 of the study, 64% and 77% of the ANP and placebo groups had undergone dialysis, respectively (P = 0.054), and 9 additional patients (7 patients, ANP group; 2 patients, placebo group) needed dialysis but did not receive it. Although a trend was present, there was no statistically significant beneficial effect of ANP in dialysis-free survival or reduction in dialysis in these subjects with oliguric acute renal failure. Mortality rates through day 60 were 60% versus 56% in the ANP and placebo groups, respectively (P = 0.541). One hundred two of 108 (95%) versus 63 of 114 (55%) patients in the ANP and placebo groups had systolic blood pressures less than 90 mm Hg during the study-drug infusion (P < 0.001). The maximal absolute decrease in systolic blood pressure was significantly greater in the anaritide group than placebo group (33.6 versus 23.9 mm Hg; P < 0.001). This well-characterized population with oliguric acute renal failure had an overall high morbidity and mortality.

Treatment of hypertension in the hemodialysis patient: beneficial or not?

Hypertension is common in the hemodialysis population. Although hypertension in the general population has been shown to reduce survival and to accelerate atherosclerosis, leading to serious cardiac and cerebrovascular morbidity, its effects are less clear in those undergoing dialysis. This review focuses on recent studies showing a favorable outcome in hypertensive hemodialysis patients when compared with those with lower blood pressure. The possible explanations for this paradoxic relationship are examined, and practical suggestions are given for the management of hypertension in the patient undergoing hemodialysis. We also present information on the morbiditiy associated with hypertension in the hemodialysis population.

Hypertension in the haemodialysis population: any relationship to 2-years survival?

BACKGROUND: Few studies have quantified the effect of hypertension on survival in the haemodialysis (HD) population. We have previously reported lack of adverse effect of hypertension on 1-year mortality in a cohort of 649 haemodialysis patients (Am J Kidney Dis 1996; 28: 737-744). We report here the effect of hypertension on 2-year survival in the same cohort of patients. METHODS: We reviewed the complete computerized files on 649 HD patients enrolled in 10 haemodialysis centres in the state of Mississippi, USA. One-month dialysis records for each patient from mid-October 1994 to mid-November 1994 were reviewed. Predialysis mean arterial pressure was calculated as immediate predialysis diastolic pressure plus one-third the difference between systolic and diastolic pressure. Patients were classified as hypertensive if their average pre-MAP was more than 114 mmHg or they were receiving antihypertensive drugs during the study period. Normotensives had a pre-MAP < 114 and were not receiving any antihypertensives. We followed these patients for 2 years to determine their survival and the effect of their BP status, as determined in October 1994, on 2-year mortality. RESULTS: In univariate analysis, hypertension was associated with improved 2-years survival (relative risk 0.64, P=0.08 compared to normotensives). Furthermore, among the hypertensives, good blood pressure control (less than 140/90) was associated with increased relative risk of death at 2 years (RR 1.86, P=0.004). In multivariate analysis, taking age, race, serum albumin, and diabetic status into consideration, there was a 27% reduction in mortality among hypertensives compared to normtensives (RR 0.73, P=0.06). Other factors of significance in multivariate analysis were age (RR 1.03/year, P=0.02), serum albumin (RR 0.36/g, P<0.0001), diabetes mellitus (RR 1.35, P=0.07), and race (RR 0.64, P=0.05). CONCLUSIONS: Our study suggests that hypertension has no adverse effect on survival at 2 years in the haemodialysis population.

[The complications of wound healing after an operation for ventral hernia and their prevention]. / Oslozhneniia zazhivleniia rany posle operatsii po povodu gryzhi zhivota i ikh profilaktika.

For abdominal hernia 982 patients were operated. The complications had occurred in 18.6% of patients due to chronic inflammation and the presence of "sleeping" infection in the hiatal gates margins. Application of the elaborated prophylaxis complex of measures had permitted to lower the frequency of the wound healing complications down to 9%.

Comparison of laparoscopic and open cholecystectomy at Prince Abdulrahman Al Sudairy Hospital, Saudi Arabia.

The initial 300 patients whose symptomatic cholelithiasis was managed by laparoscopic cholecystectomy (LC) were matched to and compared with 300 patients managed by open cholecystectomy (OC) during the 30 months prior to the introduction of LC. Of the 300 LC attempted 292 (97.3%) were successful with conversion to OC rate of 2.7%. Besides the obviously better cosmetic results, LC patients had less post operative pain, mean doses of opiates needed 0.01 versus 5 for OC (p < 0.0001), were discharged earlier from the hospital, mean 3.1 days versus 8 days for OC (p < 0.001) and had less postoperative complications 4% versus 11% for OC. We conclude that not only is LC a better operation than OC, but also that in the regional referral centres such as ours, LC can safely supplant OC as the preferred modality for the management of symptomatic cholelithiasis.

Hyperparathyroidism in the hemodialysis population: a survey of 612 patients.

There are no epidemiologic studies documenting the prevalence of hyperparathyroidism in the US hemodialysis population. We looked at a random sample of 612 hemodialysis patients enrolled in 10 outpatient dialysis units in Mississippi. Fifty percent of the patients surveyed had an intact serum parathyroid hormone (PTH) level more than three times normal (mean, 622 pg/mL). Another 25% had a less than normal PTH level (mean, 33 pg/mL), suggesting adynamic bone disease. Abnormal serum calcium was also common. Seventeen percent of patients were hypocalcemic and 14% were hypercalcemic. These high point prevalences occurred despite widespread use of calcium supplements and/or vitamin D (used in 90% of the patients surveyed). Black patients tended to have a lower serum calcium and higher PTH level than white patients. We also found that diabetic patients are less likely to have an elevated PTH level than nondiabetic patients. Elevated serum phosphorus was the most important factor correlating with the development of secondary hyperparathyroidism. Causes of inadequate control of hyperparathyroidism in this population require further study.

Effects of one year of hemodialysis on weight and blood pressure in 434 patients.

Excess volume is thought to be the major mechanism leading to hypertension in the hemodialysis population. Blood pressure measurements and volume parameters were obtained in 434 hemodialysis patients in 1994 and compared to their 1993 data. Equal numbers of patients were receiving antihypertensive treatment in both 1993 and 1994. The predialysis mean arterial pressure (pre-MAP) did not significantly change after 1 year of dialysis. The lack of change in blood pressure was evident in those who either lost or maintained body weight. There was no correlation between changes in interdialytic weight and changes in pre-MAP over 1 year. Volume sensitivity (described as the percentage decrease in blood pressure immediately after dialysis) was not different in 1993 from 1994. We conclude that irrespective of weight changes, the average hemodialysis patient does not show a significant change in blood pressure (BP) after 1 year of dialysis. This lack of improvement was evident regardless of age, sex, race, dialysis duration, or etiology of end-stage renal disease.

Acidosis and coma after hemodialysis.

Ethylene glycol poisoning is a rare yet potentially fatal illness seen most commonly in association with ingestion by alcoholics or in suicide attempts. It is characterized by an elevated anion gap metabolic acidosis, osmolal gap, calcium oxalate crystals in the urine, and a well-defined clinical picture. Prompt treatment is crucial because effective intervention can prevent the neurologic, cardiac, pulmonary, and renal sequelae associated with ethylene glycol poisoning. Hemodialysis offers rapid clearance of ethylene glycol and its toxic metabolites. In this article, the case of a hemodialysis patient who suffered contamination of the dialysate solution with ethylene glycol, leading to altered mental status, coma, and severe anion gap metabolic acidosis, is reported. Despite prolonged dialysis and correction of the acidosis, the patient remained comatose and subsequently died.

Hypertension in the hemodialysis population: any relation to one-year survival?

Few studies have quantified the effect of hypertension on survival in the hemodialysis population. We report the effect of hypertension on 1-year survival in 649 hemodialysis patients (89% black). In univariate analysis, hypertension was associated with improved 1-year survival (relative risk [RR], 0.48; P = 0.002 compared with normotensive patients). This effect of hypertension was mostly caused by the associated antihypertensive treatment because untreated hypertensive patients had survival rates equal to normotensive patients (RR, 0.87; P = 0.70). On the other hand, treated hypertensive patients fared better than normotensive patients (RR, 0.41; P = 0.0006). This was also true in multivariate analysis, in which antihypertensive treatment was associated with reduced RR (RR, 0.55; P = 0.02) whereas the level of blood pressure per se was insignificant (RR, 0.99; P = 0.63 per 1 mm Hg increase in predialysis mean arterial pressure). Other factors of significance in multivariate analysis included age (RR, 1.03/y; P = 0.0004), serum albumin (RR, 0.38/g; P = 0.002), and diabetes mellitus (RR, 1.58; P = 0.06). Our study suggests that antihypertensive treatment has a favorable effect on survival in the hemodialysis population irrespective of the level of blood pressure control.

Hypertension in the hemodialysis population: a survey of 649 patients.

Accurate information on prevalence and status of blood pressure control among US hemodialysis patients is lacking. We have surveyed the status of blood pressure control in 649 hemodialysis patients (89.8% black) from 10 dialysis units in Mississippi. Our results show a hypertension prevalence of 72% (hypertension defined as mean arterial pressure prior to dialysis session > or = 114 mm Hg). This mean arterial pressure did not differ among black patients compared with white patients (P = 0.51). The majority of hypertensive patients (80%) had elevation of both systolic and diastolic blood pressure. Isolated systolic hypertension was present in only 20% of hypertensive patients and was not different between black and white patients (P = 0.10). Three hundred eighty-one patients (58.7% of the total population and 81.5% of the hypertensive patients) were receiving antihypertensives. Age was the only significant factor that correlated with blood pressure: older patients (> 65 years) had lower blood pressure (P < 0.0001). Race, time on dialysis, etiology of end-stage renal disease, adequacy of dialysis, and several excess volume parameters had no influence on the blood pressure level. Treated hypertensive patients had a predialysis mean blood pressure only 3 mm Hg less than the untreated hypertensive patients. No differences were found among four classes of antihypertensives with regard to the degree of blood pressure control. Patients with hypertension requiring more than one antihypertensive did not achieve a lower blood pressure than the untreated patients. There was no correlation between use of antihypertensives and the magnitude of decrease in blood pressure after dialysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Potassium adaptation in hypothyroidism: changes in transport adenosinetriphosphatases.

To evaluate whether hypothyroidism alters the adaptive responses of renal transport adenosine-triphosphatases (ATPases) to modifications in dietary K content, we examined the activities of Na-K pump and H-K pump in hypothyroid rats under basal conditions and after dietary K changes. Hypothyroidism led to a decline in Na-K pump activity in all three nephron segments examined [proximal convoluted tubule from 2,333 +/- 103 to 1,099 +/- 32, medullary thick ascending limb from 4,344 +/- 119 to 1,613 +/- 61, and cortical collecting tubule (CCT) from 1,133 +/- 45 to 640 +/- 38 pmol.mm-1 x h-1; all P < 0.01 vs. euthyroid] along with morphological changes manifest in a decrease in tubule diameter. K loading led to an increase in Na-K pump activity in the CCT of both euthyroid (from 1,133 +/- 45 to 2,269 +/- 74, pmol.mm-1 x h-1, P < 0.01) and hypothyroid (from 640 +/- 38 to 1,118 +/- 67 pmol.mm-1 x h-1, P < 0.01) animals. Furthermore, in euthyroid rats, 3 wk of K depletion led to a major increase in H-K pump activity in both the CCT (from 203 +/- 14 to 331 +/- 22 pmol.mm-1 x h-1, P < 0.01) and medullary collecting tubule (MCT, from 137 +/- 9 to 210 +/- 14 pmol.mm-1 x h-1, P < 0.01). Hypothyroidism was associated with a decline in H-K pump activity in the CCT and MCT (to 94 +/- 6 and 55 +/- 5 pmol.mm-1 x h-1, respectively; both P < 0.01 vs. euthyroid).(ABSTRACT TRUNCATED AT 250 WORDS)

Gaps in the anion gap.

OBJECTIVE: To review limitations of the use of serum anion gap in clinical practice. DATA SOURCES: Original reports and reviews. STUDY SELECTION: Sources containing the most recent pertinent information. DATA SYNTHESIS: Theoretical and practical limitations beset the use of serum anion gap. Awareness of these limitations reduces but does not eliminate wrong diagnoses based on the anion gaps. CONCLUSIONS: Serum anion gap has a limited value in the differential diagnosis of acid-base disorders and can be misleading.