Intravascular Ultrasound Use in Peripheral Arterial and Deep Venous Interventions: Multidisciplinary Expert Opinion From SCAI/AVF/AVLS/SIR/SVM/SVS.

Percutaneous revascularization is the primary strategy for treating lower extremity venous and arterial disease. Angiography is limited by its ability to accurately size vessels, precisely determine the degree of stenosis and length of lesions, characterize lesion morphology, or correctly diagnose postintervention complications. These limitations are overcome with use of intravascular ultrasound (IVUS). IVUS has demonstrated the ability to improve outcomes following percutaneous coronary intervention, and there is increasing evidence to support its benefits in the setting of peripheral vascular intervention. At this stage in its evolution, there remains a need to standardize the use and approach to peripheral vascular IVUS imaging. This manuscript represents considerations and consensus perspectives that emerged from a roundtable discussion including 15 physicians with expertise in interventional cardiology, interventional radiology, and vascular surgery, representing 6 cardiovascular specialty societies, held on February 3, 2023. The roundtable's aims were to assess the current state of lower extremity revascularization, identify knowledge gaps and need for evidence, and determine how IVUS can improve care and outcomes for patients with peripheral arterial and deep venous pathology.

Results of an American College of Radiology-Society of Interventional Radiology Membership Survey on Exclusive Contracts and the Attitudes of Interventional Radiologists.

PURPOSE: To assess the attitudes of interventional radiologists (IRs) and diagnostic radiologists (DRs) toward exclusive contracts and independently practicing IRs who may request privileges at a hospital where an exclusive contract exists with a different group of radiologists. MATERIALS AND METHODS: A total of 22,400 survey instruments were distributed to 4,490 IRs and 17,910 DRs in the United States. Statistical evaluation included multivariate ordinal logistic regression analysis with calculation of the odds ratios and forest plots. RESULTS: Completed surveys were received from 525 (11.69%) IRs and 401 (2.23%) DRs. Given the low response rate of DRs, data analysis was focused on IRs. Early-career IRs and those in outpatient practices had a more positive attitude toward independent IRs who requested admitting and/or procedural privileges. A supermajority of both IRs and DRs who responded to the survey agreed that the importance of IR to hospital and health system contracts will increase. CONCLUSIONS: This survey identified many interrelated and complex variables that significantly affected the attitudes of IRs in various practice settings toward independent IRs requesting hospital admitting and/or procedural privileges. It will benefit independent IRs seeking admitting privileges to better understand some of the factors that impact the potential willingness of the radiology groups and other IRs with exclusive hospital contracts to work toward mutually beneficial practice paradigms, especially as more clinically oriented IRs complete their training in the new, integrated residency programs.

Bringing the Vascular Lab Inside the Procedure Room.

The advantages of the vascular lab (VL) are a specialized knowledgeable team and a dedicated equipment which is transferrable to the procedure room to facilitate the procedure and gather information about the procedure endpoints. In this article, Registered Vascular Technologists (RVT) from various institutions discuss the basic and the complex ways the VL can be used inside a procedure room. The advantages of the vascular lab (VL) are a specialized knowledgeable team and dedicated equipment which is transferrable to the procedure room to facilitate the procedure and gather information about procedure endpoints. Such expertise may improve imaging guided access, enable complicated lesion crossing, and provide information about the success of the procedure. Below are the reports from practicing registered vascular technologists at the forefront of patient vascular care within institutions that have adopted the mobile intraprocedural VL idea in basic and complex real-world ways.

Real-World Treatment Patterns in Patients with Castrate-Resistant Prostate Cancer and Bone Metastases.

BACKGROUND: Prostate cancer is the most frequently diagnosed cancer in men in the United States. There is scant real-world evidence characterizing the care utilization and clinical outcomes associated with the use of therapies currently approved by the US Food and Drug Administration (FDA) for patients with metastatic castrate-resistant prostate cancer (CRPC). OBJECTIVE: To describe the real-world treatment patterns, healthcare costs, and survival rates of patients with metastatic CRPC and bone metastases who have commercial or Medicare coverage. METHODS: This retrospective observational study was conducted using medical and pharmacy claims from the Humana research database for male patients who had Medicare or commercial coverage and were aged 55 to 89 years at the initiation of treatment for metastatic CRPC. Three inclusion criteria were used to identify appropriate patients for the 2 cohorts, including (1) a diagnosis of prostate cancer (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 185.x); (2) a diagnosis of bone metastasis (ICD-9-CM code 198.5) between 2013 and 2014; and (3) a healthcare insurance claim indicating a prescription for an FDA-approved first-line treatment for metastatic CRPC. Subsequent lines of treatment were also identified through the healthcare claims data. The 2-year survival rate was calculated and controlled for demographic and clinical characteristics, and the total costs (medical plus pharmacy) were calculated for the 6 months postindex. RESULTS: A total of 1855 patients met the study inclusion criteria. Of these patients, 660 (35.6%) received at least 1 medication. The patient count by line of treatment was 660 (100%) who received first-line therapy, 380 (57.6%) who received second-line treatment, 204 (30.9%) who received third-line therapy, and 107 (16.2%) who received fourth-line therapy. The medication distribution by line of treatment (using first-, second-, third-, or fourth-line therapy for each drug) was abiraterone acetate (50.5%, 61.3%, 68.6%, 75.7%); enzalutamide (15.6%, 39.2%, 54.4%, 71.0%); sipuleucel-T (9.2%, 13.9%, 20.1%, 20.6%); radium-223 dichloride (1.7%, 2.6%, 7.4%, 13.1%); cabazitaxel (2.3%, 5.5%, 16.2%, 19.6%); and docetaxel (22.1%, 32.1%, 42.6%, 48.6%). The total monthly unadjusted healthcare costs for patients who received an FDA-approved treatment was much higher ($9435) than for patients with metastatic prostate cancer who did not receive an FDA-approved treatment ($5055), and the 2-year survival rate for patients who received an FDA-approved treatment was 57.1% (25th percentile, 250 days; 50th percentile, 541 days). CONCLUSIONS: The most common first-line treatment for patients with commercial or Medicare coverage who had metastatic CRPC was abiraterone or enzalutamide. Hormone therapies used as monotherapy were the most frequently used treatment, and their concomitant administration with other treatments was the second most common treatment pattern. Additional clinical studies are needed to further elucidate the treatment sequencing for patients with metastatic CRPC.

Interventional Radiology Private Practice Patterns.

Private practice interventional radiology (IR) in the US takes many forms - from specialty coverage withing traditional diagnostic radiology (DR) models and hybrid IR/DR practices, to multispecialty groups and independent IR practitioners. The purpose of this article is to understand the value each of these current IR models offer and predict their future viability.

The relationship between comorbidity medication adherence and health related quality of life among patients with cancer.

BACKGROUND: Studies have demonstrated that comorbidities compound the adverse influence of cancer on health-related quality of life (HRQoL). Comorbidities adversely impact adherence to cancer treatment. Additionally, adherence to medications for comorbidities is positively associated with HRQoL for various diseases. This study used the Center for Disease Control and Prevention's Healthy Days measure of HRQoL to explore the association between HRQoL and adherence to comorbidity medication for elderly patients with cancer and at least one comorbid condition. METHODS: We conducted a cross-sectional survey combined with retrospective claims data. Patients with metastatic breast, lung or colorectal cancer were surveyed regarding their HRQoL, comorbidity medication adherence and cancer-related symptoms. Patients reported the number of physical, mental and total unhealthy days in the prior month. The Morisky Medication Adherence 8-point scale was differentiated into moderate/high (> 6) and low (≤ 6) comorbidity medication adherence. RESULTS: Of the 1847 respondents, the mean age was 69.2 years, most were female (66.8%) and the majority of the sample had Medicare coverage (88.2%). Low comorbidity medication adherence was associated with significantly more total, mental and physical unhealthy days. Low comorbidity medication adherence was associated with the presence of patient-reported cancer-related symptoms. Patients reporting low, as compared to moderate/high, comorbidity medication adherence had 23.4% more unhealthy days in adjusted analysis, P = 0.007. CONCLUSION: The positive association between low comorbidity medication adherence and the number of unhealthy days suggests that addressing barriers to comorbidity medication adherence during cancer treatment may be an avenue for improving or maintaining HRQoL for older patients with cancer and comorbid conditions.

Association of obesity with healthcare utilization and costs in a Medicare population.

OBJECTIVES: To examine the association of obesity with healthcare resource utilization and costs in a Medicare population. METHODS: This study was a retrospective cohort study using Humana Medicare Advantage (MA) claims data. Body mass index (BMI) was assessed using ICD-9-CM status codes (V85 hierarchy) that have been validated in the data source to classify patients into BMI categories: normal (N), overweight (Ow), obese class I (ObI), obese class II (ObII), and obese class III (ObIII). Healthcare resource utilization (HRU) and costs were determined based on claims data. Descriptive statistics were used to examine baseline characteristics and HRU across BMI classes. Multivariable analysis was used to examine the association between BMI class and outcome measures. RESULTS: Among the 172,866 patients aged ≥65 years that were identified, BMI distribution was: N, 21%; Ow 37%; ObI, 24%, ObII, 10%; and ObIII, 9%. Inpatient, emergency department and outpatient utilization increased with greater BMI level, and greater BMI level was associated with higher total healthcare, medical and pharmacy costs. Greater prevalence of several cardiometabolic conditions, total medication use, and use of specific medication classes was observed with increasing BMI class. CONCLUSIONS: Greater BMI was associated with greater HRU and costs and observed increase in prevalence of cardiometabolic conditions. These results reflect an urgent need to address the epidemic of obesity and the resulting excessive clinical and economic burden on the healthcare system.

Healthcare utilization and costs for patients initiating Dabigatran or Warfarin.

BACKGROUND: Novel oral anticoagulants (NOAC) such as dabigatran, when compared to warfarin, have been shown to potentially reduce the risk of stroke in patients with non-valvular atrial fibrillation (NVAF) together with lower healthcare resource utilization (HCRU) and similar total costs. This study expands on previous work by comparing HCRU and costs for patients newly diagnosed with NVAF and newly initiated on dabigatran or warfarin, and is the first study specifically in a Medicare population. METHODS: A retrospective matched-cohort study was conducted using data from administrative health care claims during the study period 01/01/2010-12/31/2012. Cox regression analyses were used to compare all-cause risk of first hospitalizations and emergency room (ER) visits. Medical, pharmacy, and total costs per-patient-per-month (PPPM) were compared between dabigatran and warfarin users. RESULTS: A total of 1110 patients initiated on dabigatran were propensity score-matched with corresponding patients initiated on warfarin. The mean number of hospitalizations (0.92 vs. 1.13, P = 0.012), ER visits (1.32 vs. 1.56, P < 0.01), office visits (21.43 vs. 29.41; P < 0.01), and outpatient visits (10.86 vs. 22.02; P < 0.01) were lower among dabigatran compared to warfarin users. Patients initiated on dabigatran had significantly lower risk of first all-cause ER visits [hazard ratio (HR): 0.84, 95% confidence interval (CI): 0.73-0.98] compared to those initiated on warfarin. Adjusted mean pharmacy costs PPPM were significantly greater for dabigatran users ($510 vs. $250, P < 0.001); however, mean medical costs PPPM ($1912 vs. $1956, P = 0.55) and mean total costs PPPM ($2381 vs. $2183, P = 0.10) were not significantly different compared to warfarin users. CONCLUSIONS: Dabigatran users had significantly lower HCRU compared to warfarin users. In addition, dabigatran users had lower risk of all-cause ER visits. Despite higher pharmacy costs, the two cohorts did not differ significantly in medical or total all-cause costs.

Impact of Out-of-Pocket Costs on Prescription Fills Among New Initiators of Biologic Therapies for Rheumatoid Arthritis.

BACKGROUND: Biologic disease-modifying antirheumatic drug (DMARD) therapies are a mainstay of treatment for rheumatoid arthritis (RA), yet high member out-of-pocket (OOP) costs for such therapies may limit patient access to these therapies. OBJECTIVE: To understand whether there is a relationship between OOP costs and the initial fill and subsequent refills of biologic DMARD treatments for RA members. METHODS: Members of a national Medicare Advantage and Prescription Drug (MAPD) plan with an adjudicated (paid or reversed) claim for a biologic DMARD indicated for RA were identified from July 1, 2007, to December 31, 2012, and followed retrospectively. The first adjudicated claim date was the index date. Members were required to have 180 days of continuous enrollment pre- and post-index and ≥ 1 diagnosis for RA (ICD-9-CM: 714.0 or 714.2) during pre-index or ≤ 30 days post-index. Low-income subsidy and Medicaid-Medicare dual-eligible patients were excluded. The analysis used multivariate regression models to examine associations between initial prescription (Rx) abandonment rates and OOP costs and factors influencing the refill of a biologic DMARD therapy based on pharmacy claims. RESULTS: The final sample size included 864 MAPD members with an adjudicated claim for a biologic DMARD. The majority were female (77.4%) and mean age was 63.5 years (SD = 10.9). Most (78%) had conventional nonbiologic DMARD utilization during pre-index. The overall initial abandonment rate was 18.2% for biologic DMARDs, ranging from 1.3% for the lowest OOP cost group ($0-$250) to 32.7% for the highest OOP cost group (> $550; P < 0.0001 for Cochran-Armitage trend test). ORs for abandonment rose from 18.4 to 32.7 to 41.2 for OOP costs of $250.01-$400.00, $400.01-$550.00, and > $550.00 respectively, relative to OOP costs of ≤ $250.00 (all P < 0.0001). Meeting the catastrophic coverage limit and utilization of a specialty pharmacy for the index claim were both associated with a decreased likelihood of abandoning therapy (OR = 0.29 and OR = 0.14, respectively; both P < 0.05). Among the subset of 533 members with a paid claim, 82.4% had at least 1 refill post-index. The negative association between OOP cost and likelihood of refilling an Rx was highly significant (P < 0.0001). CONCLUSIONS: This study suggests that the higher the member OOP cost, the less likely an MAPD member is to initiate or refill a biologic DMARD therapy for RA. Further research is needed to understand reasons for initial Rx abandonment and lack of refills, including benefit design and adverse events.

Racial/ethnic and gender differences in severity of diabetes-related complications, health care resource use, and costs in a Medicare population.

This retrospective cohort study evaluated associations of race/ethnicity and gender with outcomes of diabetes complications severity, health care resource utilization (HRU), and costs among Medicare Advantage health plan members with type 2 diabetes (T2DM). Medical and pharmacy claims were evaluated for 333,576 members continuously enrolled from January 1, 2010, to December 31, 2011, aged 18-89 years, with ≥1 primary diagnosis medical claim, or ≥2 claims with a secondary diagnosis of T2DM (International Classification of Diseases, Ninth Revision, Clinical Modification code 250.x0 or 250.x2). Complications severity assessment by Diabetes Complications Severity Index ranged from 0 (no complications) to 5+. Mean (SD) all-cause medical, pharmacy, and total costs were reported alongside all-cause HRU by place of service (outpatient, inpatient, emergency room [ER]) and number of visits. Multivariate regression showed being Hispanic, black, or male was associated with higher prevalence of more severe complications. This racial/ethnic disparity was more pronounced among females, among whom odds of having more severe complications were higher for Hispanic and black as compared to white females [(Hispanic vs. white odds ratio [OR], 1.40; 95% confidence interval [CI], 1.32-1.48), and (black vs. white OR, 1.22; 95% CI, 1.19-1.25)]. Regardless of gender, blacks had more ER visits than whites. White females incurred the highest total health care costs (mean annual costs: $13,086; 95% CI, $12,935-$13,240, vs. Hispanic females: $10,732; 95% CI, $10,406-$11,067). These effects held regardless of other demographic and clinical attributes. These findings suggest racial/ethnic and gender differences exist in certain T2DM clinical and economic outcomes.

The burden of diabetes mellitus for medicare beneficiaries.

The objective was to estimate health care costs and utilization for Medicare beneficiaries with type 1 (T1DM) or type 2 (T2DM) diabetes and their respective matched control cohorts. A retrospective claims cohort analysis was used to assess direct health care cost and utilization of health services in 2009 for patients aged 65-89 who were enrolled in a Medicare Advantage Plus prescription drug plan. Patients were matched 1:1 with patients without diabetes. All-cause health care costs for 2009 were calculated as the sum of all medical and pharmacy claims. The analysis included 6562 patients with T1DM and an equal number of matched controls, and 194,775 patients with T2DM and an equal number of matched controls. There were no significant demographic differences between cohorts for matched variables. Patients with T2DM had significantly higher mean Deyo/Charlson Comorbidity Index scores compared with their controls (2.47 versus 0.77; P<0.001), although all groups reported a high rate of costly comorbidities such as hypertension and heart disease. Mean all-cause health care costs per patient per year were significantly higher for patients with T1DM and T2DM versus controls for inpatient hospitalizations; outpatient, office, and emergency room visits; pharmacy expenditures; and total health care costs for 2009 (T1DM group: $20,701±$30,201; T1DM-matched control group: $6,537±$10,441; T2DM group: $10,437±$18,518; T2DM-matched control group: $6,505±$11,140). Diabetes escalates health care costs for Medicare Advantage Plus patients compared with patients in the same plan without diabetes, regardless of comorbidities.

The influence of a postdischarge intervention on reducing hospital readmissions in a Medicare population.

Hospital readmissions in the Medicare population may be related to a number of factors, including reoccurrence of illness, failure to understand or follow physician direction, or lack of follow-up care, among others. These readmissions significantly increase cost and utilization in this population, and are expected to increase with the projected growth in Medicare enrollment. The authors examined whether a postdischarge telephonic intervention for patients reduced 30-day hospital readmissions as compared to a matched control population. Postdischarge telephone calls were placed to patients after discharge from a hospital. Readmissions were monitored through health care claims data analysis. Of 48,538 Medicare members who received the intervention, 4504 (9.3%) were readmitted to the hospital within 30 days, as compared to 5598 controls (11.5%, P<0.0001). A direct correlation was observed between the timing of the intervention and the rate of readmission; the closer the intervention to the date of discharge the greater the reduction in number of readmissions. Furthermore, although emergency room visits were reduced in the intervention group as compared to controls (8.1% vs. 9.4%, P<0.0001), physician office visits increased (76.5% vs. 72.3%, P<0.0001), suggesting the intervention may have encouraged members to seek assistance leading to avoidance of readmission. As a group, overall cost savings were $499,458 for members who received the intervention, with $13,964,773 in savings to the health care plan. Support for patients after hospital discharge clearly affected hospital readmission and associated costs and warrants further development.

Transdermal scopolamine patch with odansetron for the control of nausea after uterine artery embolization compared with odansetron alone: results of a randomized placebo-controlled trial.

PURPOSE: To determine whether the transdermal scopolamine patch in combination with odansetron is more effective than odansetron alone at reducing the nausea that occurs after uterine artery embolization (UAE). MATERIALS AND METHODS: Patients undergoing UAE at a single university medical center were randomly assigned to receive either a scopolamine patch (containing 1.5 mg of scopolamine) or a placebo. All participants and study personnel were blinded as to group assignment. The primary outcome was the degree of nausea in the first 24 hours after UAE as measured on a visual analog scale from 0 to 10. Nausea and pain at 24 and 72 hours after UAE and medication use were recorded. Baseline characteristics and outcomes were also analyzed. RESULTS: A total of 74 patients were enrolled; 37 were randomly assigned to receive scopolamine, and 37 received placebo. Although the overall level of nausea after UAE was low (mean score of 2.6 out of 10), there was a lower level of nausea with those treated with scopolamine compared with placebo during the first 24 hours after embolization; the difference was statistically significant (1.8 vs 3.4, P = .03). Adverse events were more common with the patch, with two patients experiencing episodes of profound disorientation and 71% reporting substantial dry mouth. The only predictor of greater nausea was the increasing severity of pain. CONCLUSIONS: The scopolamine patch provides a moderate reduction in the nausea associated with UAE but is associated with infrequent but notable episodes of patient disorientation.

Bilateral versus unilateral femoral access for uterine artery embolization: results of a randomized comparative trial.

PURPOSE: To determine if uterine embolization via bilateral femoral puncture reduces fluoroscopy time with a similar frequency of puncture site complications compared with unilateral puncture. MATERIALS AND METHODS: Patients presenting for uterine artery embolization (UAE) for leiomyomata at a single institution were randomly assigned to receive unilateral or bilateral femoral punctures. Procedures were performed in a standardized fashion. Patients were blinded to the puncture site with an opaque dressing. Outcome measures included fluoroscopy time, dose-area product (DAP), procedure time, and puncture site pain after treatment. Baseline characteristics of the two groups and outcome measures were compared with the use of t tests, analyses of variance, Pearson chi(2) tests, and nonparametric tests. RESULTS: Fifty-seven patients consented to participate: 22 received bilateral punctures and 35 received unilateral puncture. Bilateral puncture procedures had less fluoroscopy time (13 minutes vs 16.6 minutes; P = .0033), less procedure time (54.9 min vs 62.9 min; P = .026), and fewer angiographic images (46.5 vs 68.3; P < .001). There was no difference in DAP (12,986 muGy/cm(2)for bilateral vs 16,237 muGy/cm(2)for unilateral; P = .35). Groins that were punctured had greater-although still minor-pain than unpunctured groins at 24 hours (visual analog pain scores, 1.45 for punctured groins vs 0 for unpunctured groins; P = .039) and 48 hours (scores of 1 vs 0; P = .018). There were no complications in either group. CONCLUSIONS: Bilateral femoral puncture during UAE was associated with reduced fluoroscopy time and procedure time, minor puncture site pain, and no increase in complications.

CT angiography in the evaluation of acute pulmonary embolus.

OBJECTIVE: The purpose of this study was to assess the appropriate use of CT angiography (CTA) in the diagnostic evaluation of acute pulmonary embolism (PE). MATERIALS AND METHODS: We reviewed a total of 575 CT angiograms obtained to evaluate for PE at a large level 1 trauma teaching hospital from January 2004 through March 2005. Various clinical settings were used for 267 inpatient (46%), 258 emergency department (45%), and 50 outpatient (9%) studies. We excluded CTA performed for other reasons, repeated CTA, and patient records with incomplete clinical data. On the basis of chart review in which the investigators were blinded to final diagnoses, pretest probability of PE according to the Wells criteria was retrospectively assigned to each patient. D-dimer values, when obtained, also were reviewed. The diagnosis of PE was based on final CTA reports. RESULTS: PE was diagnosed in 9.57% of 575 patients. Positivity rates by location were 32 (12%) of the 267 inpatients, 22 (8.5%) of the 258 emergency department patients, and one (2.0%) of the 50 outpatients. Three (< 1%) of the 575 patients had high probability of PE, even though 351 patients had gone directly to CTA. Of the other 572 patients, 158 (28%) had intermediate and 414 (72%) low probability of PE. In the high, intermediate, and low probability groups, two (67%), 24 (15%), and 29 (7%), respectively, of the patients had PE. A D-dimer assay was performed for 224 (39%) of the 575 patients. Thirty-nine (17%) of the 224 patients had normal results (< 0.5 microg/mL); 107 (48%), intermediate results (0.6-2.0 microg/mL); and 78 (35%), abnormal results (> 2.0 microg/mL). In the emergency department cohort, 151 (59%) of 258 patients underwent a D-dimer assay. Thirty-two (21%) of the 151 patients had normal results; 81 (54%), intermediate results; and 38 (25%), abnormal results. Only one patient with a normal D-dimer level and three patients with intermediate D-dimer levels had PE, the equivalent of 3% of each group. The number of CTA examinations ordered for patients with normal and intermediate D-dimer results was 146 (25% of the 575 total studies). Twenty-two (8%) of the 258 emergency department patients had PE, and clinical suspicion of PE was high for 11 (50%), intermediate for 10 (45%), and low for one (5%) of those patients. CONCLUSION: Our data showed suboptimal use of the Wells criteria and subjective overestimation of the probability of PE before ordering of CTA. Although a definitive acceptable PE positivity rate for CTA has not been established, the 10% yield represents overuse of CTA as a screening rather than a diagnostic examination.

The zinc finger transcription factor ZFHX1A is linked to cell proliferation by Rb-E2F1.

ZFHX1A is expressed in proliferating cells in the developing embryo, and in the present study we provide evidence that its expression is confined to proliferating cells through dependence on the Rb (retinoblastoma protein) family/E2F cell cycle pathway. Mutation of the Rb or E2F1 genes lead to induction of ZFHX1A mRNA, implying that the Rb-E2F1 repressor complex is important for repression of ZFHX1A. This repression is associated with recruitment of an E2F-Rb-histone deacetylase repressor complex to the promoter. A dominant-negative form of E2F1 inhibited ZFHX1A expression in p16INK4a- cells where Rb is constitutively hyperphosphorylated and inactive, suggesting that E2F can contribute to ZFHX1A transactivation in the absence of functional Rb. ZFHX1A is an E-box-binding transcription factor whose binding sites overlap with those bound by Snail1 and 2, and ZFHX1B/SIP1 (leading to at least partially overlapping function; for example, each of the proteins can repress E-cadherin expression). We found that expression of Snail1 and ZFHX1B/SIP1 is also regulated by E2Fs, but in contrast with ZFHX1A this regulation is Rb-family-independent. Snail2 expression was unaffected by either E2F or the Rb family. We propose that the differential effects of the Rb family/E2F pathway on expression of these E-box-binding proteins are important in maintaining their distinct patterns (and thus distinct functions) during embryogenesis.

Treatment of inadvertent pericardial placement of a tunneled dialysis catheter by direct thrombin injection.

An inadvertent case of pericardial placement of a central venous catheter was successfully treated by direct thrombin injection.