Complete Clinical Success Research Articles

Role of percutaneous computed tomography-guided radiofrequency ablation in treatment of osteoid osteoma.

Aim:The aim of the study was to evaluate efficacy of percutaneous computed tomography (CT)-guided radiofrequency ablation (RFA) of nidus in osteoid osteoma (OO).Materials and Methods:RFA was performed on fifty patients with clinically and radiologically diagnosed OO. RFA was done in the department of radio-diagnosis in our institute (a tertiary care providing institute in Ahmedabad, Western India). Ablation was performed by putting at an electrode tip (3–5 mm) into nidus under CT guidance with targeted temperature of 90°C for 3 min.Results:All procedures were technically successful. No immediate major or minor complications were observed. Complete clinical success was achieved in 46 patients. Only four patients required second intervention.Conclusion:Our experience indicates a 98% success rate. No major complications were noted.

Transvenous lead extraction at the time of cardiac implantable electronic device upgrade: Complexity, safety, and outcomes

The practice of lead abandonment at the time of cardiac implantable electronic device upgrade remains a controversial topic but is affecting an increasing number of patients. Inherent risks include high-risk extractions of redundant leads when extraction is required at a later date. We aimed to report our experience with transvenous lead extraction (TLE) at the time of device upgrade. All consecutive TLE procedures at the time of device upgrade at the Cleveland Clinic between January 1, 1996 and December 31, 2012 were included (n = 503). Success and complications were defined according to the Heart Rhythm Society consensus document on TLE. There were a total of 984 leads in place, and 719 were targeted with extraction (589 pacer and 130 defibrillator leads, 63 of them being dual-coil leads). In all patients, TLEs aimed to avoid abandoning leads. Concomitant lead management issues included lead malfunction (15%), previously abandoned leads (9%), vascular access occlusion (6%), or leads on advisory (3%). In most procedures (75.4%), special extraction tools were needed. The complete procedural and clinical success rates were 96.6% and 97.2%, respectively. During planned extractions, damage of coexisting leads occurred in 19 patients (3.8%), eventually requiring extraction. The major and minor complication rates were 1% and 1.4%, respectively. In a high-volume center, TLEs at the time of device upgrade were successful in the vast majority of patients with a low complication rate.

Outcomes after adrenalectomy for unilateral primary aldosteronism: an international consensus on outcome measures and analysis of remission rates in an international cohort

Although unilateral primary aldosteronism is the most common surgically correctable cause of hypertension, no standard criteria exist to classify surgical outcomes. We aimed to create consensus criteria for clinical and biochemical outcomes and follow-up of adrenalectomy for unilateral primary aldosteronism and apply these criteria to an international cohort to analyse the frequency of remission and identify preoperative determinants of successful outcome. The Primary Aldosteronism Surgical Outcome (PASO) study was an international project to develop consensus criteria for outcomes and follow-up of adrenalectomy for unilateral primary aldosteronism. An international panel of 31 experts from 28 centres, including six endocrine surgeons, used the Delphi method to reach consensus. We then retrospectively analysed follow-up data from prospective cohorts for outcome assessment of patients diagnosed with unilateral primary aldosteronism by adrenal venous sampling who had undergone a total adrenalectomy, consecutively included from 12 referral centres in nine countries. On the basis of standardised criteria, we determined the proportions of patients achieving complete, partial, or absent clinical and biochemical success in accordance with the consensus. We then used logistic regression analyses to identify preoperative factors associated with clinical and biochemical outcomes. Consensus was reached for criteria for six outcomes (complete, partial, and absent success of clinical and biochemical outcomes) based on blood pressure, use of antihypertensive drugs, plasma potassium and aldosterone concentrations, and plasma renin concentrations or activities. Consensus was also reached for two recommendations for the timing of follow-up assessment. For the international cohort analysis, we analysed clinical data from 705 patients recruited between 1994 and 2015, of whom 699 also had biochemical data. Complete clinical success was achieved in 259 (37%) of 705 patients, with a wide variance (range 17-62), and partial clinical success in an additional 334 (47%, range 35-66); complete biochemical success was seen in 656 (94%, 83-100) of 699 patients. Female patients had a higher likelihood of complete clinical success (odds ratio [OR] 2·25, 95% CI 1·40-3·62; p=0·001) and clinical benefit (complete plus partial clinical success; OR 2·89, 1·49-5·59; p=0·002) than male patients. Younger patients had a higher likelihood of complete clinical success (OR 0·95 per extra year, 0·93-0·98; p<0·001) and clinical benefit (OR 0·95 per extra year, 0·92-0·98; p=0·004). Higher levels of preoperative medication were associated with lower levels of complete clinical success (OR 0·80 per unit increase, 0·70-0·90; p<0·001). These standardised outcome criteria are relevant for the assessment of the success of surgical treatment in individual patients and will allow the comparison of outcome data in future studies. The variable baseline clinical characteristics of our international cohort contributed to wide variation in clinical outcomes. Most patients derive clinical benefit from adrenalectomy, with younger patients and female patients more likely to have a favourable surgical outcome. Screening for primary aldosteronism should nonetheless be done in every individual fulfilling US Endocrine Society guideline criteria because biochemical success without clinical success is by itself clinically important and older women and men can also derive post-operative clinical benefit. European Research Council; European Union's Horizon 2020; Else Kröner-Fresenius Stiftung; Netherlands Organisation for Health Research and Development-Medical Sciences; Japanese Ministry of Health, Labour and Welfare; Ministry of Health, Slovenia; US National Institutes of Health; and CONICYT-FONDECYT (Chile).

Cardiac Implantable Electronic DeviceInfections: Added Complexity and Suboptimal Outcomes WithPreviouslyAbandoned Leads.

This study sought to assess the impact of previously abandoned leads on the clinical management of cardiac device infections, notably transvenous lead extraction and subsequent clinical course. The population of patients with cardiac implantable electronic devices continues to grow with a disproportionate increase in device infections, which are invariably life threatening. A potentially complicating issue is the widely practiced strategy of device lead abandonment at the time of system revision, change, or upgrade, which is affecting an increasing number of patients. The study assessed the impact of previously abandoned leads in a prospectively maintained registry of consecutive patients undergoing percutaneous extraction of infected cardiac devices at the Cleveland Clinic between August 1996 and September 2012. The primary clinical endpoint was complete procedural and clinical success defined as the successful removal of the device and all lead material from the vascular space, in the absence of a major complication. Of 1,386 patients with infected cardiac devices, 323 (23.3%) had previously abandoned leads. Failure to achieve the primary endpoint occurred more frequently in patients with abandoned leads (13.0% vs. 3.7%; p< 0.0001). This was primarily due to retention of lead material (11.5% vs. 2.9%; p< 0.0001), which was associated with poor clinical outcomes including higher rates of 1-month mortality (7.4% vs. 3.5% in those without lead remnants). Lead extraction procedures in patients with previously abandoned leads were longer (p< 0.0001), with longer fluoroscopy times (p<0.0001), and more likely to require specialized extraction tools (94.4% vs. 81.8%; p< 0.0001) or adjunctive rescue femoral workstations (14.9% vs. 2.9%; p< 0.0001). Procedural complications occurred more frequently in patients with previously abandoned leads (11.5% vs. 5.6%; p= 0.0003), which was true for both major (3.7% vs. 1.4%; p= 0.009) and minor complications (7.7% vs. 4.4%; p= 0.02). Previously abandoned leads complicate the management of cardiac device infections, leading to worse clinical outcomes.

Transvenous removal of cardiac implantable electronic device leadsTransvenous removal of cardiac implantable electronic device leads

Introduction and ObjectiveThe number and complexity of cardiac implantable electronic devices (CIEDs) have increased, as has the number of related complications, often leading to removal of the implanted system. The aim of this study was to characterize transvenous explantation/extraction of CIED leads in a reference center. MethodsThis was a descriptive observational study of patients consecutively admitted from January 2009 to May 2014 for transvenous lead extraction. ResultsThe sample consisted of 109 patients, with a mean age of 64.6±16.62 years, 73.1% male. The main indication for lead extraction was CIED infection. The mean time from first implantation to lead removal was 5.6±4.89 years. Blood cultures were positive in 32.8% of cases and 29% of patients had vegetations on echocardiography. A total of 228 cardiac leads were removed, of which 58.8% were ventricular, 32.4% atrial and 8.8% coronary sinus. Complete clinical success was achieved in 97.2% of cases, while procedural success was complete in 93.4% and partial in 5.3%. The complications reported were three cases of significant pocket hematoma, one of subclavian vein thrombosis and three of cardiac tamponade, effectively treated by pericardiocentesis. ConclusionsTransvenous explantion or extraction of CIED leads was highly effective. A high level of experience is an essential factor in the success and safety of the procedure.

Extração transvenosa de eletrocateteres de dispositivos eletrónicos cardíacos implantáveis

Introduction and ObjectiveThe number and complexity of cardiac implantable electronic devices (CIEDs) have increased, as has the number of related complications, often leading to removal of the implanted system. The aim of this study was to characterize transvenous explantation/extraction of CIED leads in a reference center. MethodsThis was a descriptive observational study of patients consecutively admitted from January 2009 to May 2014 for tranvenous lead extraction. ResultsThe sample consisted of 109 patients, with a mean age of 64.6±16.62 years, 73.1% male. The main indication for lead extraction was CIED infection. The mean time from first implantation to lead removal was 5.6±4.89 years. Blood cultures were positive in 32.8% of cases and 29% of patients had vegetations on echocardiography. A total of 228 cardiac leads were removed, of which 58.8% were ventricular, 32.4% atrial and 8.8% coronary sinus. Complete clinical success was achieved in 97.2% of cases, while procedural success was complete in 93.4% and partial in 5.3%. The complications reported were three cases of significant pocket hematoma, one of subclavian vein thrombosis and three of cardiac tamponade, effectively treated by pericardiocentesis. ConclusionsTransvenous explantion or extraction of CIED leads was highly effective. A high level of experience is an essential factor in the success and safety of the procedure.

Lead extractions: the Zwolle experience with the Evolution mechanical sheath.

The Evolution sheath (Cook, USA) is a power sheath with a cutting screw tip operated by mechanical rotation. It has been reported to be an effective tool for chronic lead extraction. We evaluated the safety and efficacy of this system. From 2009 to 2014, all lead extractions requiring the use of an Evolution sheath were prospectively examined. In 77 patients, 111 leads were extracted. The first 57 leads were extracted with the original unidirectional sheath, and since 2013, 54 leads were extracted with the bidirectional R/L type. According to the current guidelines, complete procedural success was defined as the removal of all targeted lead material. Clinical success was the retention of a small portion of the lead, and failure was the inability to achieve either complete procedural or clinical success or the development of any permanently disabling complication. The Evolution sheath was used to extract 111 leads in 77 patients. The median age of the lead at time of extraction was 8.0 years (median 6.9, interquartile range 6.4, minimum: 0.6 and maximum: 34.4), with a clinical success rate of 98% and a complete procedural success of 88%. Complete procedural success was higher for the R/L type Evolution sheath (96 vs. 80%, P = 0.006). There were 21 (19%) implantable cardioverter defibrillator leads, 22 (20%) right ventricular pacing leads, 60 (54%) right atrial leads, and 8 (7%) left ventricular leads. There were no major complications and six (8%) minor complications. There was no need for the usage of a femoral tool or snares. Use of Evolution for lead extractions seems to be safe and effective, with a high clinical success rate.

High‐Risk Lead Removal by Planned Sequential Transvenous Laser Extraction and Minimally Invasive Right Thoracotomy

Transvenous pacemaker or implantable cardioverter defibrillator (ICD) lead extraction via mechanical or excimer laser sheath is typically safe and effective. Longer duration from implant, presence of large vegetations or thrombi, fractured leads, and prior failed extraction are risk factors predicting higher complication rates or incomplete or failed lead removal. Techniques developed for minimally invasive valve surgery were used in conjunction with laser extraction to refine a "hybrid" technique for lead extraction. We assessed the outcomes of high-risk lead extraction using this hybrid lead extraction technique. Retrospective assessment of clinical parameters and procedural outcomes in patients undergoing planned hybrid lead extraction from February 2008 to September 2012 was performed. We report 8 cases of hybrid lead extraction performed at our institution. We extracted 21 leads with average lead age of 13.8 years since implant. All leads were removed with complete clinical and radiographic success. There were no intraprocedure complications. One patient died of continued sepsis and 1 other had symptoms consistent with pulmonary embolism. Hybrid lead extraction using this technique is a safe and effective approach for removal of high-risk chronic pacemaker or ICD leads. This method extends the range of approachable leads resulting in complete removal without median sternotomy. Hybrid lead extraction can be scheduled electively facilitating complete lead removal with a low complication rate and short postoperative recovery time, mitigating the risks inherent in midline sternotomy or emergent cardiac surgical rescue.

Management of Postbiopsy Arteriovenous Fistulas in Transplanted Kidneys and Effectiveness of Endovascular Treatment: A Single-center Experience

We sought to evaluate the best therapeutic management of postbiopsy arteriovenous fistulas (AVFs) in transplanted kidneys. Between January 2005 and December 2011, we observed 17 cases of postbiopsy AVF in transplanted kidneys (9 asymptomatic; 8 symptomatic). Asymptomatic cases were managed conservatively, while patients with symptomatic AVF underwent endovascular treatment. We used a technique that consisted in a superselective transcatheter embolization of the afferent branch. We evaluated the technical success (postoperative closure of AVF), the immediate clinical efficacy (cessation of symptoms), and clinical efficacy at follow-up (measurement of serum creatinine at 7 days and 6 and 12 months compared with preoperative levels using t-tests). Asymptomatic AVFs resolved spontaneously, while the endovascular treatment in symptomatic AVFs showed a complete technical and clinical success with prompt remission of the presented symptoms. We observed a statistically significant reduction in serum creatinine at 7 days and 6 and 12 months postoperatively (mean creatinine--preoperative: 3.23 ± 1.4 mg/dL; 7 days: 2.25 ± 0.8 mg/dL; 6 months: 1.65 ± 0.28 mg/dL; 12 months: 1.4 ± 0.26 mg/dL; in all cases P < 0.05). In our experience, asymptomatic AVFs could be managed conservatively with close follow-up while the endovascular treatment for symptomatic AVFs is both safe and effective in the short- and long-term.

Interventional radiology in the treatment of early postoperative biliary complications

We sought to evaluate the feasibility and efficacy of percutaneous treatment of early postoperative biliary complications. The primary aims were to evaluate clinical and technical success and complications and perioperative mortality, and secondary aims were to evaluate treatment duration and recurrence rate. Between March 2007 and March 2010, 75 patients (42 men and 33 women; age range, 17-88 years; mean age, 60.8 years) underwent interventional radiology procedures to treat early postoperative biliary complications of biliary and pancreatic-duodenal surgery with biliodigestive anastomosis (37.7%), laparoscopic cholecystectomy (30.6%), hepatic resection (21.1%) and several other surgical procedures (10.6%). Complications included fistulas (73%), stenoses (20%) and complete bile duct transections (7%). Interventional radiology achieved complete clinical success in 74 cases (85.9%) and in particular in 95.2% of fistulas, 76.5% of stenoses and 33.3% of complete bile duct transections. Mean indwelling catheter time was 34.9 days, with an average of 4.1 procedures. There were two cases of severe haemobilia (2.3%). Minor complications occurred in 7% of cases. Perioperative mortality rate was 1.2% and overall recurrence rate 6.7% (range, 1-18 months; mean, 10 months), with recurrences occurring predominantly in stenoses. All patients were retreated successfully. Percutaneous procedures are feasible, effective and safe for treating early postoperative biliary complications. They provide a valuable alternative to presendoscopy, which is precluded in many of these patients, and to surgery, which has higher morbidity and mortality rates.

Nonvariceal Upper Gastrointestinal Bleeding: the Usefulness of Rotational Angiography after Endoscopic Marking with a Metallic Clip

ObjectiveWe wanted to assess the usefulness of rotational angiography after endoscopic marking with a metallic clip in upper gastrointestinal bleeding patients with no extravasation of contrast medium on conventional angiography.Materials and MethodsIn 16 patients (mean age, 59.4 years) with acute bleeding ulcers (13 gastric ulcers, 2 duodenal ulcers, 1 malignant ulcer), a metallic clip was placed via gastroscopy and this had been preceded by routine endoscopic treatment. The metallic clip was placed in the fibrous edge of the ulcer adjacent to the bleeding point. All patients had negative results from their angiographic studies. To localize the bleeding focus, rotational angiography and high pressure angiography as close as possible to the clip were used.ResultsOf the 16 patients, seven (44%) had positive results after high pressure angiography as close as possible to the clip and they underwent transcatheter arterial embolization (TAE) with microcoils. Nine patients without extravasation of contrast medium underwent TAE with microcoils as close as possible to the clip. The bleeding was stopped initially in all patients after treatment of the feeding artery. Two patients experienced a repeat episode of bleeding two days later. Of the two patients, one had subtle oozing from the ulcer margin and that patient underwent endoscopic treatment. One patient with malignant ulcer died due to disseminated intravascular coagulation one month after embolization. Complete clinical success was achieved in 14 of 16 (88%) patients. Delayed bleeding or major/minor complications were not noted.ConclusionRotational angiography after marking with a metallic clip helps to localize accurately the bleeding focus and thus to embolize the vessel correctly.

Intrapericardial triamcinolone for acute pericarditis after electrophysiologic procedures

The use of intrapericardial triamcinolone for acute pericarditis after electrophysiologic procedures in three patients is described. Treatment for idiopathic pericarditis and viral pericarditis, which account for about 85% of cases, focuses on pain management and decreasing pericardial inflammation. This is oftentimes achieved with nonsteroidal antiinflammatory drugs (NSAIDs). Colchicine may be used in combination with NSAIDs, specifically in postmyocardial infarction pericarditis and recurrent pericarditis. Because oral corticosteroid use has been shown to be an independent risk factor in pericarditis recurrence, their use in patients with refractory pericarditis is reserved as a last-resort option. Intrapericardial triamcinolone is an uncommon treatment approach, although it is recommended in select situations of pericarditis according to guidelines developed by the European Society of Cardiology. In this retrospective case series, three patients with pericarditis, tamponade, or both as a complication of radiofrequency ablation or implantable cardioverter defibrillator implantation received triamcinolone. The drug was instilled intrapericardially, with doses ranging from 50 to 200 mg. In two patients, the need for pain medication and the perceived pain score decreased dramatically after triamcinolone administration. In the third patient, triamcinolone administration decreased the need for supportive therapy but was not deemed a complete clinical success. Additional study is necessary to better define the use of intrapericardial triamcinolone and determine long-term outcomes associated with this therapy. Other factors, including past medical history and renal function, also need to be taken into account when choosing the proper dosing regimen. Intrapericardial administration of triamcinolone acetonide may be an effective treatment for patients with acute pericarditis after electrophysiologic procedures.

233 Indication, technique and results of Radio-frequency ablation of premature ventricular beats

radio-frequency (RF) ablation of premature ventricular beats (PVB) has been only reported as isolated cases or in short series. 34 successive pts (25 men, 53 ± 18 yo) underwent RF ablation of frequent or symptomatic isolated PVB at our institution from 2005 to 2009. Indication, technique and results were reported. 43 RF ablation of PVB was performed for post-ischemic electrical storm in 7 pts (6 men), for symptomatic PVB in 7 (3 men) and for suspected VPB-induced tachycardiomyopathy in 20 (16 men) with 1,2 procedure/pt. RF was performed in each case using pace mapping and activation mapping with conventional technique. RF ablation of PVB during intractable post-ischemic electrical storm was initially successful in each pt but fatal electrical storm recurred in 4 during the following days. PVB were targeted in the left septal Purkinje network. 10 procedures were performed in 7 pts for palpitations or syncope, leading to complete or partial clinical success in 6 (PVB reduction 9400 ± 12200 to 420 ± 610 /24h, NS). 25 procedures were performed for suspected VPB-induced tachycardiomyopathy in 20 pts leading to complete success in 9 pts and to significant decrease in VPB in 5 pts. Mean VPB/24h was 17800 ± 8600 before and 3410 ± 8150 after and 125 ± 230 at 11 ± 6 months follow-up (p=0,0005). EF increase from 41 ± 8 to 53 ± 7% (p<0,0001). Main locations of the PVB were RVOT, right or left aortic cusps, left basal septum, LVOT and laterobasal LV. Complications were asymptomatic mild pericardial effusion in one pt, transient AV block in one and transient ischemic stroke in one. RF ablation of PVB may be indicated if highly symptomatic, for electrical storm or for suspected tachycardiomyopathy with good although imperfect success rate

Initial Experience using N-butyl Cyanoacrylate for Embolization of Lower Gastrointestinal Hemorrhage

To report initial experience using N-butyl cyanoacrylate (n-BCA) to control lower gastrointestinal hemorrhage (LGIH). From May 2005 to March 2009, 14 patients with LGIH underwent mesenteric angiography and transcatheter arterial embolization using n-BCA. Candidacy was primarily based on the patient's hemodynamic stability and the risk for future LGIH, determined by the presence of at least one of the following risk factors: more than one arterial feeder supplying the bleeding vessel, underlying coagulopathy, or need to resume anticoagulation after embolization. Outcome measures included technical success (immediate postembolic hemostasis confirmed with completion angiography showing no further extravasation of contrast medium), clinical success (postembolic hemostasis in the absence of complications 30 days after the procedure), and clinical failure (recurrence of LGIH necessitating repeat embolization or surgical treatment). Fourteen patients with active LGIH were treated with n-BCA, with 100% technical success. Two patients had rebleeds resulting in bowel resection. One patient experienced a minor rebleed that spontaneously resolved. One patient died secondary to multiorgan failure in the setting of multiple medical problems. The remaining 10 patients had complete clinical success, experiencing no signs of rebleeding or infarction. The results suggest that n-BCA can be a useful alternative embolic agent for the treatment of hemodynamically unstable patients with LGIH when standard microcoiling techniques fail or are not feasible and in patients with coagulopathy.

Nd:YAG Laser Biostimulation in the Treatment of Bisphosphonate-Associated Osteonecrosis of the Jaw: Clinical Experience in 28 Cases

To research an efficient treatment for the management of bisphosphonate-associated osteonecrosis. Necrosis of the jawbone has recently been described in association with systemic bisphosphonate therapy with drugs including zoledronic acid, pamidronate, and alendronate. The extent and clinical characteristics of bisphosphonate-associated osteonecrosis (BON) of the jaw are extremely variable, and range from the presence of fistulae in the oral mucosa or orofacial tissues, to large exposed areas of necrotic bone within the oral cavity. Clinical signs and symptoms commonly reported include pain, swelling, the presence of pus, loose teeth, ill-fitting dentures, and paresthesias of the inferior alveolar nerve when the necrosis affects the mandible. Fractures have also been reported. The treatment of BON of the jaw is still controversial since no therapy has proven to be efficacious as shown by the literature on the subject. In this study we report results achieved with 28 patients affected by BON of the jaw, who received treatment with the Nd:YAG laser alone or in combination with conventional medical or surgical treatment. Clinical variables such as severity of symptoms, presence of pus, and closure of mucosal flaps before and after therapy were evaluated to establish the effectiveness of laser irradiation. The 28 patients with BON were subdivided into four groups: eight patients were treated with medical therapy only (antibiotics with or without antimycotics and/or antiseptic rinses), six patients were treated with medical and surgical therapy (necrotic bone removal and bone curettage), six patients were treated with medical therapy associated with laser biostimulation, and eight patients were treated with medical therapy associated with both surgical therapy and laser biostimulation. Of the 14 patients who underwent laser biostimulation, nine reported complete clinical success (no pain, symptoms of infection, or exposed bone or draining fistulas), and three improved their symptomatology only, with a follow-up of between 4 and 7 mo. While the results reported in this study are not conclusive, they indicate that laser therapy has potential to improve management of BON.

Neurosyphilis in a young adult: very early tertiary syphilis?

A rare episode of early neurosyphilis occurred in a 34-year-old, otherwise healthy, woman. Based on an isolated positive Borrelia burgdorferi serology (later interpreted as a cross-reaction), early ceftriaxone was initiated, in the suspect of Lyme borreliosis. Even after the diagnosis was corrected into that of a neurosyphilis, ceftriaxone administration was continued, until it achieved complete clinical and microbiological success after 24 days of treatment in a day-hospital setting, and three-weekly penicillin administrations. When considering the differential diagnosis, a luetic aetiology should not be underestimated when facing young patients with signs-symptoms of a meningoencephalitis. Our case report was characterized by an extremely low patient's age, compared with the occurrence of tertiary neurosyphilis, more than three years after the last sexual contacts. The diagnosis was confirmed by highly positive treponemal and non-treponemal serum and cerebrospinal fluid serology, and several suggestive clinical manifestations: seizures, altered mentation, cognitive impairment, lip drop, and anisochoria. These concomitant findings, together with a neuroradiological report indicating a diffuse meningoencephalitis, allowed us to confirm the diagnosis of neurosyphilis, together with a demonstrated cross-reaction of B. burgdorferi serology. Although ceftriaxone benefits from its once-daily administration (and can be easily delivered on outpatient basis), it is not the firstline treatment of neurosyphilis. However, our experience demonstrated a favourable and rapid response to ceftriaxone, in the absence of toxicity and disease sequelae.

Superselective Microcoil Embolization for the Treatment of Lower Gastrointestinal Hemorrhage

To evaluate the safety and effectiveness of superselective microcoil embolization for the treatment of lower gastrointestinal (LGI) hemorrhage. A retrospective review of LGI superselective microcoil embolization data for a 10-year period was performed. During this period, twenty-two patients with evidence on angiography of LGI bleeding underwent superselective microcoil embolization. Hemorrhage was treated in the colon (n = 19) and jejunum (n = 3). Ivalon was used adjunctively in two patients and gelfoam was used as a secondary agent in two additional patients. Postembolization ischemia was evaluated objectively in 14 patients by colonoscopy (n = 10), surgical specimen (n = 3), and barium enema (n = 1). All patients were followed for clinical evidence of bowel ischemia. Four patients died before further follow-up could be performed. Additionally, 122 cases of LGI hemorrhage treated with superselective microcoil embolization were identified in a review of the literature. A meta-analysis was then performed, combining the data in this study and the data from the literature, to estimate the rate of major and minor ischemic complications on a total of 144 superselective microcoil embolizations. Immediate hemostasis was achieved in all 22 patients in this study. Complete clinical success was achieved in 86% of patients (19 of 22 patients). Rebleeding occurred in 14% of patients (3 of 22 patients) and each underwent colonoscopic intervention with success. Postembolization objective follow-up was performed in 64% of patients (14 of 22 patients). Ten patients underwent follow-up colonoscopy; one patient received a follow-up barium enema; and three patients underwent subsequent surgery. Colonic resection (one partial and one total) was performed in two patients. The partial colectomy was performed in a patient who had been diagnosed with colonic polyps and dysplasia. The total colectomy was performed on a patient with history of chronic LGI bleeding complicated by long-term anticoagulation therapy and a history of tubular adenoma resection. The third surgical patient (16 months old) underwent a follow-up exploratory laparotomy after embolization of a proximal jejunal branch of the superior mesenteric artery. None of the three patients who underwent surgery were found to have postembolic ischemic changes in the bowel specimen. Four patients in this study died, for reasons unrelated to hemorrhage or embolization, before further follow-up could be performed. The last four patients were followed clinically and experienced no symptoms of intestinal ischemia. A minor ischemic complication was reported in 4.5% of patients (1 of 22 patients), and there were no major ischemic complications (0%) in this series. A review of the data from 122 cases of LGI superselective microcoil embolization in the literature is also presented. Combined with the data in this study, the minor complication rate was 9% (13 of 144 patients), and the major complication rate was 0% (0 of 144 patients). Superselective microcoil embolization is a safe and effective treatment for LGI hemorrhage.

Initial Experience with the Combination of Reteplase and Abciximab for Thrombolytic Therapy in Peripheral Arterial Occlusive Disease: A Pilot Study

To report the efficacy of catheter-directed thrombolysis with a combination of a thrombolytic agent (reteplase) and a glycoprotein (GP) IIb/IIIa platelet receptor antagonist (abciximab) in peripheral arterial occlusive disease. Fifteen patients with lower extremity arterial thromboses (age range, 40-96 y; mean, 73 y) were prospectively enrolled in a protocol approved by the Institutional Review Committee. Nine patients had native arterial occlusions, three (33%) of whom had subacute symptoms (>14 d) and one of whom had chronic symptoms (>3 mo). Four patients had acute arterial graft thromboses. Two patients with lower extremity bypass grafts presented with subacute limb ischemia. All patients received catheter-directed infusion of reteplase (0.5 U/h) in combination with intravenous administration of abciximab (0.25-mg/kg bolus followed by 0.125 microg/kg/min infusion) for 12 hours without systemic heparinization. The thrombolytic success was studied by Doppler ultrasonography (US) and angiography. Complete thrombolysis and clinical success was achieved in 14 of the 15 patients (93%). One patient with unsuccessful thrombolysis underwent major amputation. The mean thrombolysis time per Doppler US procedure was 6.8 hours (range, 2-30 h). Angiographic patency was achieved at a mean of 17.5 hours (range, 4-36 h) corresponding to a mean dose of reteplase of 8.8 U. The mean increase in ankle-brachial index was 0.52 (range, 0-0.9). No major hemorrhagic complications occurred. The 30-day primary patency rate was 93%. The combination of reteplase and abciximab in catheter-directed arterial thrombolysis is feasible and effective. This combination therapy pilot study suggests short thrombolysis times and minimal adverse effects in catheter-directed thrombolytic therapy for peripheral arterial occlusive disease.

Lower respiratory infections treated with cephacetrile

The study is concerned with the pharmacological and clinical evaluation of cephacetrile as given by the results obtained in 23 patients with lower respiratory infections. The criteria employed comprised not only pharmacokinetic parameters such as serum and urine concentrations and the serum half-life, but also bacteriological and clinical data obtained in the course of careful examinations carried out before, during, and after treatment. The studies conducted for this purpose included various laboratory tests, as well as differential blood counts, tests of respiratory function, sputum investigations, and tests of hepatic and renal function. In the patients under review, most of whom were old (average age 62 years) and in moderate or poor condition, treatment with cephacetrile (1 g twice daily i. m.) enabled a complete clinical success to be achieved in 69 % of cases, a partial success being obtained in a further 13 %. The bacteriological and laboratory findings (e.g. improvement in the sputum characteristics) correlated well with the clinical response. Cephacetrile was well tolerated; in particular, it appeared to have no nephrotoxic properties.

Recent advances in the study and restoration of fecal continence.

Important advances in clinical and experimental studies of fecal continence have been reviewed. In some respects, the results of these studies are contradictory, and much remains to be learned. Although complete clinical success remains elusive, methods for the restoration of both reservoir continence and sphincteric continence appear to be at hand.