Safe endovascular retrieval of a vena cava filter after duodenal perforation.

The use of vena cava filters (VCF) is a common procedure utilized in the prevention of pulmonary embolism (PE), yet VCFs have some significant and known complications, such as strut penetration and migration. Deep vein thrombosis (DVT) and PE remain a major cause of morbidity and mortality in the United States. It is estimated that as many as 900,000 individuals are affected by these each year with estimates suggesting that nearly 60,000-100,000 Americans die of DVT/PE each year. Currently, the preferred treatment for DVT/PE is anticoagulation. However, if there are contraindications to anticoagulation, an inferior vena cava (IVC) filter can be placed. These filters have both therapeutic and prophylactic indications. Therapeutic indications (documented thromboembolic disease) include absolute or relative contraindications to anticoagulation, complication of anticoagulation, failure of anticoagulation, propagation/progression of DVT during therapeutic anticoagulation, PE with residual DVT in patients with further risk of PE, free-floating iliofemoral IVC thrombus, and severe cardiopulmonary disease and DVT. There are also prophylactic indications (no current thromboembolic disease) for these filters. These include severe trauma without documented PE or DVT, closed head injury, spinal cord injury, multiple long bone fractures, and patients deemed at high risk of thromboembolic disease (immobilized or intensive care unit). Interruption of the IVC with filters has long been practiced and is a procedure that can be performed on an outpatient basis. There are known complications of filter placement, which include filter migration within the vena cava and into various organs, as well as filter strut fracture. This case describes a 66-year-old woman who was found to have a filter migration and techniques that were utilized to remove this filter.

"Death Knell" for Prophylactic Vena Cava Filters? A 20-Year Experience with a Venous Thromboembolism Guideline.

The role of prophylactic vena cava filters (pVCFs) in trauma patients remains controversial. After 20 years of data collection and experience, we reviewed our venous thromboembolism guideline for the efficacy of pVCFs in preventing pulmonary embolism (PE). A retrospective cohort study was performed using our Level I trauma center registry from January 1997 thru December 2016. This population was then divided by the presence of pVCFs. Univariate analysis was performed comparing the incidence of PEs, deep vein thrombosis, and mortality between those with and without a pVCF. There were 35,658 patients identified, of whom 2 per cent (n = 847) received pVCFs. The PE rate was 0.4 per cent in both groups. The deep vein thrombosis rate for pVCFs was 3.9 per cent compared with 0.6 per cent in the no-VCF group (P < 0.0001). Given that there was no difference in the rates of PEs between the cohorts, the subset of patients with a PE were analyzed by their risk factors. Only ventilator days > 3 were associated with a higher risk in the no-pVCF group (0.2 vs 1.5%, P = 0.033). pVCFs did not confer benefit reducing PE rate. In addition, despite their intended purpose, pVCFs cannot eliminate PEs in high-risk trauma patients, suggesting a lack of utility for prophylaxis in this population.

Voluntary exercise improves hypothalamic and metabolic function in obese mice.

Exercise plays a critical role in regulating glucose homeostasis and body weight. However, the mechanism of exercise on metabolic functions associated with the CNS has not been fully understood. C57BL6 male mice (n=45) were divided into three groups: normal chow diet, high-fat diet (HFD) treatment, and HFD along with voluntary running wheel exercise training for 12 weeks. Metabolic function was examined by the Comprehensive Lab Animal Monitoring System and magnetic resonance imaging; phenotypic analysis included measurements of body weight, food intake, glucose and insulin tolerance tests, as well as insulin and leptin sensitivity studies. By immunohistochemistry, the amount changes in the phosphorylation of signal transducer and activator of transcription 3, neuronal proliferative maker Ki67, apoptosis positive cells as well as pro-opiomelanocortin (POMC)-expressing neurons in the arcuate area of the hypothalamus was identified. We found that 12 weeks of voluntary exercise training partially reduced body weight gain and adiposity induced by an HFD. Insulin and leptin sensitivity were enhanced in the exercise training group verses the HFD group. Furthermore, the HFD-impaired POMC-expressing neuron is remarkably restored in the exercise training group. The restoration of POMC neuron number may be due to neuroprotective effects of exercise on POMC neurons, as evidenced by altered proliferation and apoptosis. In conclusion, our data suggest that voluntary exercise training improves metabolic symptoms induced by HFD, in part through protected POMC-expressing neuron from HFD and enhanced leptin signaling in the hypothalamus that regulates whole-body energy homeostasis.

Colonoscopy is superior to neostigmine in the treatment of Ogilvie's syndrome.

BACKGROUND: Colonic pseudo-obstruction in critically ill patients may lead to devastating colonic perforation. Neostigmine is often the first-line intervention, because colonoscopy is more invasive and labor intensive. METHODS: A retrospective 10-year review at a tertiary medical center identified 100 patients with Ogilvie's syndrome, in whom treatment course and clinical and radiographic response were evaluated. RESULTS: Colonoscopy was significantly more successful than neostigmine (defined as no further therapy) after 1 or 2 interventions (75.0% vs 35.5%, P = .0002, and 84.6% vs 55.6%, P = .0031, respectively). One colonoscopy was more effective than 2 neostigmine administrations (75.0% vs 55.6%, P = .044). Clinical response (poor, fair, or good) was significantly better after colonoscopy than neostigmine after 1 or 2 interventions (P = .0028 and P = .00079). Cecal diameters decreased significantly more after colonoscopy than neostigmine (from 10.2 ± .5 cm to 7.1 ± .4 cm vs from 10.5 ± .5 cm to 8.8 ± .5 cm, P = .026). Neostigmine administration before colonoscopy did not affect outcomes. There were 3 perforations (3.7%): 1 each after colonoscopy, neostigmine, and no intervention. Neostigmine dose or repetition did not affect radiographic (P = .41) or clinical (P = .31) response. CONCLUSIONS: Colonoscopy is superior to neostigmine for Ogilvie's syndrome and should be considered first-line therapy, although neostigmine is useful in select patients and repeat interventions.

Signal suppression/enhancement in HPLC-ESI-MS/MS from concomitant medications.

This paper presents a study of the signal suppression and enhancement effects in assays based on HPLC-ESI-MS/MS detection. The major focus was to investigate the effect of signal suppression/enhancement of typical co-administered (concomitant) medications, i.e. naproxen and ibuprofen. The results demonstrate that the analyte and internal standard can experience signal enhancement up to a factor of ca 2.9 if the test analyte or internal standard co-elute with concomitant. Experimental results also demonstrate that the analyte and internal standard signal increased by a factor of ca 2.0 in the negative ion mode at physiological relevant levels of naproxen (100 microg/mL) and by a factor of ca 1.6 in the negative ion mode at physiological relevant level of ibuprofen (10 microg/mL) in both neat and plasma samples. Signal enhancement significantly increased when concomitant medications ionized in the same ion mode as the analyte and internal standard. To overcome signal enhancement or potential suppression from concomitant medications, a comprehensive HPLC method needs to be developed with sufficient separation of concomitant medication from the analyte and internal standard. Other means to reduce signal enhancement or potential suppression include switching ionization polarity and performing comprehensive sample clean-up to remove concomitant medications before analysis.

Quantitative characterization of differential ion suppression on liquid chromatography/atmospheric pressure ionization mass spectrometric bioanalytical methods.

Ion suppression is a known phenomenon in atmospheric pressure ionization mass spectrometry. These suppression effects have been shown to adversely affect the accuracy and precision of quantitative bioanalytical methods. This paper presents a simple procedure for determining the impact of differential ion suppression on bioanalytical methods that utilize atmospheric pressure ionization mass spectrometric (APIMS) detection. This procedure was applied to the assessment of two potential internal standards, and to determine selectivity issues for another analyte which was to be measured in multiple species.

The relationship of clinical QT prolongation to outcome in the conscious dog using a beat-to-beat QT-RR interval assessment.

QT interval prolongation of the electrocardiogram has been associated with the occurrence of life-threatening fatal ventricular arrhythmias. To understand the relationship between preclinical cardiac conduction assessment to clinical outcome, comparisons of free (unbound)-plasma drug concentrations and their associated effects in the conscious mongrel dog were made to the free plasma concentrations in humans reported to produce QT prolongation. E-4031 (an experimental class III antiarrhythmic), cisapride, terfenadine, terodiline, and verapamil all affect cardiac repolarization and can produce QT prolongation in humans. In the conscious dog, the QT interval was assessed on a beat-to-beat basis in relation to each preceding RR interval at concentrations approximating the same unbound human concentrations. E-4031, cisapride and terodiline statistically increased the QT(RR1000) interval [the QT interval at a 60 beats/min (bpm) heart rate] 23, 8, and 9 ms, respectively, at concentrations 0.3 to 15.8 times their relevant clinical level. Increases were not observed for terfenadine or verapamil (p > 0.05 at all doses). Inspection of individual dog QT versus RR interval relationships showed clear QT interval responses specific to each treatment but not readily apparent when data are averaged at a heart rate of 60 bpm. For specific rectifier K(+) current (IKr) blockers, robust effects on mean QT prolongation can be detected. However, for drugs that affect repolarization through multiple channels, the effect on the mean QT interval may be more difficult to detect. Inspection of the beat-to-beat QT-RR interval relationship in an individual animal can increase the sensitivity for more accurate clinical prediction.