Proportion Of Patients In Group Research Articles

Growth factor plus preemptive (‘just-in-time’) plerixafor successfully mobilizes hematopoietic stem cells in multiple myeloma patients despite prior lenalidomide exposure

Lenalidomide is associated with suboptimal autologous hematopoietic stem cell (AHSC) mobilization. We hypothesized that growth factor plus preemptive plerixafor is an effective strategy for AHSC mobilization in multiple myeloma (MM) despite prior exposure to lenalidomide. We retrospectively reviewed patient characteristics and mobilization outcomes of 89 consecutive MM patients undergoing first mobilization with filgrastim or pegfilgrastim +/- preemptive plerixafor using a previously validated algorithm based on day 4 peripheral blood CD34+ cell count (PB-CD34+) and mobilization target. Outcomes were analyzed according to the extent of prior exposure to lenalidomide: no prior exposure (group A, n=40), 1- 4 cycles (group B, n=30) and >4 cycles (group C, n=19). Multivariate analysis yielded only age and number of cycles of lenalidomide as negatively associated, and mobilization with pegfilgrastim as positively associated with higher PB-CD34+. Only 45% of patients in group A required plerixafor vs 63% in groups B and 84% in C, P=0.01. A higher proportion of patients in group A (100%) met the mobilization target than in groups B (90%) or C (79%), P=0.008. All patients yielded at least 2 × 10(6) CD34+/kg. Growth factor mobilization with preemptive plerixafor is an adequate upfront mobilization strategy for MM patients regardless of prior exposure to lenalidomide.

Conventional combination treatment versus biological treatment in methotrexate-refractory early rheumatoid arthritis: 2 year follow-up of the randomised, non-blinded, parallel-group Swefot trial

Analysis of the Swedish Farmacotherapy (Swefot) trial at 12 months showed that the addition of an anti-tumour-necrosis-factor agent gave an improved clinical outcome compared with the addition of conventional disease-modifying antirheumatic drugs in patients with methotrexate-refractory early rheumatoid arthritis. Here we report the 2 year follow-up assessment. In this randomised, non-blinded, parallel-group trial, we enrolled adult patients older than 18 years with rheumatoid arthritis and a symptom duration of less than 1 year from 15 rheumatology units in Sweden between December, 2002 and December, 2006. All patients were started on methotrexate. After 3-4 months, those who failed treatment were randomly assigned (1:1) to group A (conventional treatment; additional sulfasalazine and hydroxychloroquine) or group B (biological treatment; additional infliximab). Randomisation was done with a computer-generated sequence. We analysed clinical outcomes at months 18 and 24 by the response criteria of the American College of Rheumatology and the European League Against Rheumatism, and radiographs of patients' hands and feet at months 12 and 24 using the Van der Heijde modification of the Sharp score. Analysis was by intention to treat. This trial is registered with www.ClinicalTrials.gov, number NCT00764725. Of 493 screened individuals, we enrolled 487, of whom 258 were randomly allocated to treatment. The proportion of patients in group B who received a EULAR-defined good response was non-significantly greater than it was in group A at 18 months (49 of 128 [38%] vs 38 of 130 [29%]) and at 24 months (49 of 128 [38%] vs 40 of 130 [31%]; p=0·204). After 24 months, radiological disease progression was greater in patients in group A than it was in those in group B (mean 7·23 [SD 12·72] vs 4·00 [10·0]; p=0·009). We recorded three serious adverse events: an extended generalised illness in group A, an extended febrile episode in group B, and a generalised illness in group B. Additional biological treatment is a valid option for patients who fail initial methotrexate treatment. However, improved clinical outcomes after 12 months and better radiographical results after 24 months should be weighed against the absence of a convincing clinical difference at 24 months and substantially higher costs. Therefore, for many patients who fail initial methotrexate treatment, add-on treatment with disease-modifying antirheumatic drugs is an appropriate treatment option. Swedish Rheumatism Association, Stockholm County, and Schering-Plough/Merck Sharp and Dohme.

99 Osteopenia/osteoporosis in patients with calcium nephrolithiasis

The objective of this study is to analyze the alterations in bone mineral density and bone and calcium–phosphorus metabolism in patients with calcium nephrolithiasis. We designed a study with 182 patients who were distributed among three groups: group O, 56 patients without nephrolithiasis; group A, 67 patients with calcium nephrolithiasis and mild lithogenic activity; and group B, 59 patients with calcium nephrolithiasis and severe lithogenic activity. Metabolic parameters of blood and urine that were related to calcium–phosphorous and bone metabolism and bone densitometry were assessed in all patients. A comparative study was performed on the variables of bone and calcium–phosphorus metabolism and bone densitometry as well as the presence or absence of osteopenia/osteoporosis. The patients in group B had a greater loss of bone mineral density, measured by the T-score, than the patients in groups O and A. Moreover, the proportion of patients in group B with osteopenia/osteoporosis was statistically significantly higher than the proportion of patients in groups O and A. We observed higher values of calciuria, fasting calcium/creatinine ratio, and 24-h calcium/creatinine among the patients in group B compared to the other two groups. Calciuria, citraturia, and fasting calcium/creatinine were independent factors that showed a relationship with severe lithogenic activity compared to the control group, and β-crosslaps is an independent factor that has a relationship with severe lithogenic activity as compared to mild lithogenic activity. Patients with calcium lithiasis and severe lithogenic activity have a greater loss in bone mineral density and therefore a greater risk of osteopenia/osteoporosis.

Children with Oligoarticular Juvenile Idiopathic Arthritis are at Considerable Risk for Growth Retardation

To assess linear growth in patients with persistent oligoarticular juvenile idiopathic arthritis (JIA) treated by intra-articular corticosteroid injections (IACSI). Data were obtained from a retrospective review of the charts of 95 patients with persistent oligoarticular JIA (69 females). The mean age at first visit was 4.9 ± 3.4 years, with follow-up of 6 ± 3.7 years. The height SDS for chronologic age (z-score) was correlated with the clinical course of the disease and compared among patients treated by IACSI alone (group I) or by a combination of disease-modifying antirheumatic drugs (DMARDs) (group II). Growth retardation was found in 35.8% of patients (Δ z-score <-0.3), including 11.6% with severe growth retardation (Δ z-score <-1.0). Growth retardation was found in a smaller proportion of patients in group I (any growth retardation, 30.6%; severe growth retardation, 6.5%) than in patients in group II (any growth retardation, 44.4%; severe growth retardation, 21.2%; P < .05). Elevated erythrocyte sedimentation rate values (≥ 40 mm/1sth) indicated a significantly higher risk for growth retardation. All other clinical variables had no association with growth retardation. A significant proportion of patients with persistent oligoarticular JIA have growth retardation and a minority have severe growth retardation. Only elevated erythrocyte sedimentation rate values were proven to be a good predictor of risk for growth retardation.

Resection leads to less recurrence than strictureplasty in a paediatric population with obstructive crohn's

IntroductionResection and Strictureplasty are used to treat patients with obstructive Crohn's disease. Strictureplasty is considered preferable in adults as it preserves bowel length. This study aims to identify differences in...

Extended treatment with lamivudine and adefovir dipivoxil in chronic hepatitis B patients with lamivudine resistance

We and others have reported that adding adefovir dipivoxil (adefovir) to lamivudine results in virological and biochemical improvement in cases of lamivudine resistance. The current study assessed the efficacy and safety of combined therapy after 104weeks of combined treatment and analyzed the frequency of persistent lamivudine resistant HBV. A total of 78 patients with compensated CHB (Group A) were maintained on either adefovir 10mg daily (n=38) or placebo (n=40) while continuing lamivudine. An additional 38 patients with decompensated cirrhosis or post liver transplantation (Group B) received lamivudine plus adefovir. The primary endpoint was HBV DNA response at year 2. At week 104 of therapy, a significantly greater proportion of patients in Group A on combination therapy (76%) had a decline in serum HBV DNA to ≤10(5) copies or >2 log(10) reduction from baseline compared to those receiving lamivudine alone (13%; p<0.001). Fifty-two percent of Group A patients on combination treatment continued to have the M204V/I HBV mutation compared to 92% receiving lamivudine alone (p=0.0013). Virologic response occurred less frequently in patients expressing persistent lamivudine resistant HBV. In Group B, 87% of patients had HBV DNA response at week 104 (median change from baseline of -5.84 log(10) copies/mL). The combination of lamivudine and adefovir for 2years generally proved effective in lamivudine-resistant cases, but there was a persistently high rate of detection of lamivudine resistant mutants and impaired virologic response in compensated patients.

Acute diverticulitis in younger patients: Any rationale for a different approach?

To compare the natural history and course of acute diverticulitis in a younger age group with an older population and to evaluate whether younger patients should be managed differently. This study was a retrospective review of 157 patients treated with acute diverticulitis between January 1, 2004 and December 31, 2007. Diverticulitis was stratified according to the Hinchey classification. Patients were divided into 2 populations: group A ≤ 50 years (n = 31); group B > 50 years (n = 126). Mean patient follow-up was 15 mo. The median age was 60 years. A significantly higher proportion of patients in group B presented with complicated diverticulitis (36.5% vs 12.9%, P = 0.01). Recurrence was more frequent in group A (25.8% vs 11.1%, P = 0.03) and the mean time-to-recurrence was shorter (12 mo vs 28 mo, P = 0.26). The most severe recurrent episodes of acute diverticulitis were classified as Hinchey stage I and none of the patients required emergency surgery. In multivariate analysis, only age (P = 0.024) was identified as an independent prognostic factor for recurrence. Based on the results of this study, the authors recommend that diverticulitis management should be based on the severity of the disease and not on the age of the patient.

Cinacalcet Effectively Reduces Parathyroid Hormone Secretion and Gland Volume Regardless of Pretreatment Gland Size in Patients with Secondary Hyperparathyroidism

Cinacalcet is effective in reducing serum parathyroid hormone (PTH) in patients with secondary hyperparathyroidism. However, it has not been proven whether parathyroid gland size predicts response to therapy and whether cinacalcet is capable of inducing a reduction in parathyroid volume. This 52-week, multicenter, open-label study enrolled hemodialysis patients with moderate to severe secondary hyperparathyroidism (intact PTH >300 pg/ml). Doses of cinacalcet were adjusted between 25 and 100 mg to achieve intact PTH <180 pg/ml. Ultrasonography was performed to measure the parathyroid gland size at baseline, week 26, and week 52. Findings were also compared with those of historical controls. Of the 81 subjects enrolled, 56 had parathyroid glands smaller than 500 mm(3) (group S) and 25 had at least one enlarged gland larger than 500 mm(3) (group L). Treatment with cinacalcet effectively decreased intact PTH by 55% from baseline in group S and by 58% in group L. A slightly greater proportion of patients in group S versus group L achieved an intact PTH <180 pg/ml (46 versus 32%) and a >30% reduction from baseline (88 versus 78%), but this was not statistically significant. Cinacalcet therapy also resulted in a significant reduction in parathyroid gland volume regardless of pretreatment size, which was in sharp contrast to historical controls (n = 87) where parathyroid gland volume progressively increased with traditional therapy alone. Cinacalcet effectively decreases serum PTH levels and concomitantly reduces parathyroid gland volume, even in patients with marked parathyroid hyperplasia.

Referral pattern for epilepsy surgery after evidence-based recommendations

Class I evidence for surgical effectiveness in refractory temporal lobe epilepsy (TLE) in 2001 led to an American Academy of Neurology practice parameter in 2003 recommending "referral to a surgical epilepsy center on failing appropriate trials of first-line antiepileptic drugs." We examined whether this led to a change in referral patterns to our epilepsy center. We compared referral data for patients with TLE at our center for 1995 to 1998 (group 1, n = 83) and 2005 to 2008 (group 2, n = 102) to determine whether these recommendations resulted in a change in referral patterns for surgical evaluation. Patients with brain tumors, previous epilepsy surgery evaluations, or brain surgery (including epilepsy surgery) were excluded. We did not find a difference between the groups in the duration from the diagnosis of habitual seizures to referral (17.1 +/- 10.0 vs 18.6 +/- 12.6 years, p = 0.39) or the age at the time of evaluation (34.1 +/- 10.3 vs 37.0 +/- 11.8 years, p = 0.08). However, there was a difference in the distributions of age at evaluation (p = 0.03) and the duration of pharmacotherapy (p = 0.03) between the groups, with a greater proportion of patients in group 2 with drug-resistant epilepsy both earlier and later in their treatment course. Nonepileptic seizures were referred significantly earlier than TLE in either group or when combined. Our analysis does not identify a significantly earlier referral for epilepsy surgery evaluation as recommended in the practice parameter, but suggests a hopeful trend in this direction.

Efficacy and Tolerability of Split-Dose Magnesium Citrate: Low-Volume (2 Liters) Polyethylene Glycol vs. Single- or Split-Dose Polyethylene Glycol Bowel Preparation for Morning Colonoscopy

Preparation regimens for morning colonoscopy are suboptimal. The aim of this study was to test the efficacy and tolerance of a split-dose magnesium citrate-low-volume (2 liters) polyethylene glycol (PEG) regimen for morning colonoscopy. A total of 232 patients were randomly assigned to receive 4 liters PEG (day before procedure; group 1, n=79), 2 liters PEG (day before procedure) followed by another 2 liters PEG (day of procedure; group 2, n=80), or magnesium citrate (250 ml, day before procedure) followed by 2 liters PEG (day of procedure; group 3, n=73). The quality of bowel cleansing, tolerability, and adverse effects in group 3 were compared with those in groups 1 and 2. Satisfactory bowel preparation was more frequently reported for group 3 than for group 1 (75% vs. 51%, P=0.001) and was similar to that for group 2 (75% vs. 76%, P=0.896). A significantly greater proportion of patients in group 3 graded their overall satisfaction as satisfactory compared with group 1 (43% vs. 23%, P=0.010), and the proportion was similar to that in group 2 (43% vs. 35%, P=0.133). Patients in group 3 were more willing to repeat the same preparation regimen, if necessary, than those in group 1 (93% vs. 48%, P<0.001) or group 2 (93% vs. 62%, P<0.001). The split-dose magnesium citrate-low-volume (2 liters) PEG regimen was more efficient than and preferred to the conventional regimen of 4 liters of PEG, and it was equally efficient as, but, again, preferred to the split-dose (2+2 liters) regimen for morning colonoscopy.

Intraoperative Distal Vasal Flushing—Does It Improve the Rate of Early Azoospermia Following No-scalpel Vasectomy? A Prospective, Randomized, Controlled Study

To assess the impact of intraoperative distal vasal flushing during no-scalpel vasectomy on hastening the sperm clearance from the vas deferens and subsequent postvasectomy time to azoospermia. A total of 906 men undergoing vasectomy at our center from October 2007 to August 2008 were included in this prospective, randomized, controlled study. Patients were alternately allocated to 1 of 2 groups. Group A were patients who underwent no scalpel vasectomy alone; Group B patients, in addition to no scalpel vasectomy, underwent flushing of the distal vasal segment with 30 mL of sterile water. Postvasectomy semen analysis was done at 4, 8, and 12 weeks. The age, operative time, number of ejaculations, and proportion of patients' azoospermic at 4, 8, and 12 weeks after vasectomy were compared between the 2 groups. A total of 727 men were available for final analysis. A significantly higher proportion of patients in group B were azoospermic at 4 and 8 weeks when compared with group A (group B: 53.40% and 80.68%; group A: 33.86% and 49.6% at 4 and 8 weeks, respectively). There was no statistically significant difference in the mean age, operative time, and number of ejaculations between the 2 groups. Distal vasal flushing with 30 mL of sterile water may shorten the time to azoospermia for between 20% and 30% of vasectomy patients. Thus, this procedure may be an option for some who choose the vasal flush to avoid the long duration of postvasectomy alternate contraceptive methods.

THE RELATIONSHIP BETWEEN THE PROXIMITY OF LEFT VENTRICULAR LEAD POSITIONS TO THE LATEST SITE OF ACTIVATION AND RESPONSE TO CARDIAC RESYNCHRONIZATION THERAPY: HOW CLOSE DO YOU NEED TO BE?

Abstract Category: Cardiac PacingPresentation Number: 1024-130Authors: Fakhar Z. Khan, Munmohan S. Virdee, Philip A. Read, Peter J. Pugh, Simon P. Fynn, David P. Dutka, Addenbrooke’s Hospital, Cambridge, United Kingdom, Papworth Hospital, Cambridge, United Kingdom Background: Left ventricular (LV) lead placement is an important determinant of response to cardiac resynchronization therapy (CRT). We aimed to investigate the relationship between LV lead proximity to the latest site of activation and CRT response.Methods: Sixty seven patients (age 69 +/- 8 yrs, NYHA III 92%, EF 23 +/- 7%, QRS width 154 +/- 9 ms) were assessed before and 3 months after CRT. The latest site of activation was determined with speckle tracking radial strain prior to CRT and the LV lead position defined by biplane fluoroscopy as either anterior, lateral, posterior or inferior. Patients were classified into one of three groups according to the relation of the LV lead position to the latest site: Concordant (C - lead position at latest site), Adjacent (A - within one segment) or Remote (R - 2 or more segments away from latest site). CRT response was defined as a >15% reduction in LV end systolic volume (LVESV) at 3 months.Results: The proportions of patients in group C, A and R were 42% (n=28), 31% (21) and 27% (18) respectively. The baseline characteristics between all three groups were similar. There were no differences in either the extent of LVESV reduction from baseline between groups C and A (23.1 vs 20.4%, p=0.49) or response rates (78.6 vs 61.9%, p=0.20). There were significant differences between groups C and R and groups A and R in both the extent of reduction of LVESV (C vs R: 23.1 vs 6.8%, p<0.01, A vs R: 20.4 vs 6.8%, p<0.01) and response rates (C vs R: 78.6 vs 20.1%, p<0.01, A vs R: 61.9 vs 20.1%, p<0.01). Conclusions: Similar extents of LV reverse remodeling are seen in patients with an LV lead position either concordant or adjacent to the latest site of activation. This suggests that the target area for optimal LV lead placement is potentially quite large and requires further study in prospective trials.

Cardioprotective Role of Remote Ischemic Periconditioning in Primary Percutaneous Coronary Intervention: Enhancement by Opioid Action

We sought to determine the potential of remote ischemic periconditioning (RIPC), and its combination with morphine, to reduce reperfusion injury in primary percutaneous coronary interventions. Remote ischemic post-conditioning is implemented by applying cycles of ischemia and reperfusion on a remote organ, which result in release of circulating factors inducing the effects of post-conditioning on the myocardium. A total of 96 patients (59 men) were enrolled. The patients were randomized to groups as follows: 33 to each treatment group (Group A: RIPC; Group B: RIPC and morphine) and 30 to the control group (Group C). Measures of efficacy were achievement of full ST-segment resolution (primary), and reduction of ST-segment deviation score and peak troponin I during hospitalization. A higher proportion of patients in Groups A (73%) and B (82%) achieved full ST-segment resolution after percutaneous coronary intervention, compared with control patients (53%) (p = 0.045). Peak troponin I was lowest in Group B, 103.3 +/- 13.3 ng/ml, in comparison to peak levels in Group A, 166.0 +/- 28.0 ng/ml, and the control group, 255.5 +/- 35.5 ng/ml (p = 0.0006). ST-segment deviation resolution was 87.3 +/- 2.7% in Group B, compared with 69.9 +/- 5.1% in Group A and 53.2 +/- 6.4% in the control group (p = 0.00002). In paired comparisons between groups, Group B did better than the control group in terms of both ST-segment reduction (p = 0.0001) and peak troponin I (p = 0.004), whereas Group A differences from the control group did not achieve statistical significance (p = 0.054 and p = 0.062, respectively). These findings demonstrate a cardioprotective effect of RIPC and morphine during primary percutaneous coronary intervention for the prevention of reperfusion injury. This is in agreement with observations that the beneficial effect of RIPC is inhibited by the opioid receptor blocker naloxone.

Comparison of outcomes after hand-sewn versus stapled ileal pouch-anal anastomosis in 3,109 patients

The aim of this study was to compare outcomes after primary hand-sewn versus stapled ileal pouch-anal anastomosis (IPAA). Patients undergoing a primary IPAA (1983-2007) were identified from a prospective pelvic pouch database. Differences between group A (hand-sewn) and group B (stapled) for pre-operative and peri-operative factors, complications, functional outcomes, and quality of life (QOL) were investigated. Of 3,382 patients with a primary IPAA, 3,109 were included. Median follow-up was 7.1 years (0.1-24). Mean age was 37.9 +/- 13.2 years. Overall, 1,741 patients (56%) were male. Group A (n = 474) and group B (n = 2635) had similar age (P = .28), sex (P = .8), albumin level (P = .74), prior colectomy (P = .98), and use of steroids (P = .1). Group A had a greater use of ileostomy (P = .001) and a longer duration of stay (P < .001). Group B had a greater body mass index (P < .001) and J-pouch (P < or = .001). Wound infection (P = .42) and pouchitis (P = .59) were similar. Anastomotic stricture (P = .002), septic complications (P = .019), bowel obstruction (P = .027), and pouch failure (P < .001) were greater in group A. At most recent follow-up, bowel frequency (P = .74) and rate of urgency were similar (P = .71). A greater proportion of patients in group A described incontinence (P < .001), seepage (P < .001), pad usage (P < .001), dietary (P < .001), social (P < .001), and work restrictions (P = .025). The Cleveland Global QOL score (P = .018) was greater in group B. Patients undergoing a stapled IPAA had better outcomes and QOL than those undergoing a hand-sewn IPAA.

Functional reading acuity and performance: Comparison of 2 accommodating intraocular lenses

To compare functional reading acuity and speed with 2 models of accommodating intraocular lenses (IOLs). Four of 12 investigative sites in a U.S. Food and Drug Administration (FDA) clinical study. In this observational study, which was part of an ongoing FDA clinical trial, the MNRead functional reading test was used to compare the reading performance of patients with bilateral Tetraflex IOLs (Group 1) and a consecutive series of patients with bilateral Crystalens IOLs (Group 2) presenting at approximately 1 year postoperatively at 4 ophthalmic practices. The 2 groups were well matched for age, sex, mean postoperative time, and mean level of postoperative corrected distance visual acuity. All examinations were scored at a central reading center. Group 1 comprised 96 patients and Group 2, 55 patients. Patients in Group 1 read better than those in Group 2 at print sizes of 20/63 (P = .004), 20/50 (P = .002), 20/40 (P = .001), 20/32 (P = .003), and 20/25 (P = .001). A statistically significantly higher proportion of patients in Group 1 than in Group 2 read 80 words per minute or more throughout the range of print sizes (P = .002). Near reading ability was better with the Tetraflex accommodating IOL than with the Crystalens accommodating IOL at all print sizes between 20/25 and 20/63.

The Effects of Timing of Pediatric Knee Ligament Surgery on Short-term Academic Performance in School-Aged Athletes

Background Orthopaedic injuries negatively affect the academic lives of children. Hypothesis The timing of anterior cruciate ligament (ACL) and medial patellofemoral ligament (MPFL) reconstructions affects academic performance in school-aged athletes. Study Design Cohort study; Level of evidence, 2. Methods Records of patients ≤18 years old who underwent ACL or MPFL reconstructions from 2001-2007 were reviewed retrospectively. Subjects had been administered a unique questionnaire to evaluate school life in the immediate postoperative period as well as International Knee Documentation Committee (IDKC), Lysholm, and Kujala knee-specific questionnaires. Patients were in 1 of 3 study cohorts: group A (surgery during school year), group B (surgery during school holiday), and group C (surgery during summer break). Results There were 62 subjects (53 ACL and 12 MPFL reconstructions). A higher proportion of patients in group A required being driven to school (88.5%) than groups B (63.6%) or C (64.7%) (P < .05). A lower proportion of patients in group A returned to school immediately after surgery (3.8%) than groups B (36.4%) or C (88.2%) (P < .005). Among children who had never failed a test before surgery, a higher proportion of patients in group A failed a test (36.4%) after return to school than groups B (0%) or C (0%) (P < .05). Patients in group C had higher mean Likert scores (4.5) than groups A (3.8) or B (3.7) (P = .05) in response to the question “my grades suffered in my classes.” Delay in surgery was negatively correlated with IKDC, Lysholm, and Kujala questionnaire scores (P < .05). Conclusion In school-aged athletes with ligamentous knee injuries receiving operative treatment, surgery on a school day causes more academic difficulties than surgery during a holiday or summer break. Academic benefits of delaying surgery during the school year must be weighed against potentially worse outcomes encountered with prolonged surgical delay.

Angioscanographie thoracique au gadolinium en TDM multicoupe du thorax : analyse rétrospective de la qualité image et de la tolérance chez 45 patients évalués antérieurement à la description de la fibrose systémique néphrogénique: Gadolinium-enhanced thoracic CTA: retrospective analysis of image quality and tolerability in 45 patients evaluated prior to th edescription of nephrogenic systemic fibrosis

To assess the accuracy and torerability of gadolinium-enhanced thoracic CTA using a 64 MDCT compared to a 16 MDCT. Because this study was started prior to the description of NSF, particular attention was paid to long-term follow-up of the patient population.The study protocol was approved by the ethics committee of our institution and informed consent was obtained from all patients. Fourteen patients (Group 1) (9 males and 5 females; mean age: 64.3 years) with contraindication to the administration of iodinated contrast material underwent thoracic CTA (collimation: 32 x 2 x 0.6 mm; pitch: 1.2) with gadolinium administration (0.5 mml/ml) at 0.4 mmol/kg injected at 6 ml/sec with evaluation of clinical and biological tolerability of the gadolinium based contrast agent. Results from this patient population were compared to results from a population of 31 patients (21 males; 10 females; mean age: 63.2 years) (Group 2) imaged on a 16 MDCT. All patients were folloowed-up for a mean time of 22.6 months.Using a mean contrast volume (standard deviation) that was not significantly different (Group 1: 54.8+/-11 ml; Group 2: 53.4+/-6.9 ml) (p=0.94), patients in Group 1 underwent complete thoracic CTA whereas patients in Group 2 underwent CTA of only the middle third of the thoracic region. All CTA examinations were diagnostic for Group 1 and Group 2 patients; however, evaluation of subsegmental vessels was possible in a significantly larger proportion of patients in Group 1 (10/14; 72%) compared to Group 2 (6/31; 19%) (p=0.003). Mean attenuation values within pulmonary arterial branches were similar for Groups 1 and 2 (central arteries: 194.5+/-51.3 HU vs 180.6+/-53.8 HU; p=0.38) (lobar arteries: 208.5+/-52.5 HU vs 189.9+/-60.1 HU; p=0.33) (segmental arteries: 220.4+/-50.4 HU vs 201.5+/-54.7 HU; p=0.42). Transient alteration of renal function was recorded in one patient from Group 1 with severe pre-existing chronic renal failure. No change in renal function was observed for Group 2 patients. No case of NSF was reported in patients with pre-existing renal failure at the time of enrollment.The use of gadolinium-based contrast agent for thoracic CTA using a 64 MDCT provides diagnostic quality examinations in all patients with improved image quality compared to a 16 MDCT. No complication other than transient alteration of renal function was observed. Because the likelihood of developing NSF may vary with the type of gadolinium-based contrast agent used, the least toxic agent should be used.

Lateral Subfascial Endoscopic Perforating Vein Surgery as Treatment for Lateral Perforating Vein Incompetence and Venous Ulceration

The aim of this study was to evaluate the clinical results of lateral subfascial endoscopic perforating vein surgery (SEPS). Our study was conducted from February 2002 to January 2007. Sixty-three patients with lateral incompetent perforating veins (IPVs) and venous ulceration were allocated to two groups. Group 1 comprised 31 patients (33 limbs) who underwent only routine surgery (saphenofemoral or saphenopopliteal ligation, stripping, phlebectomies, endovascular laser treatment [EVLT], medial SEPS, and skin grafting). Group 2 comprised 32 patients (35 limbs) who underwent our routine surgery with the addition of lateral SEPS. Bidirectional ultrasonography was performed before the operation, and 6 weeks, 6 months, and 1 year after surgery. Clinical score and disability score were collected at the same time. Twenty-nine (87.9%) of 33 limbs with active ulcers in group 1 healed, with recurrence in four (12.1%) limbs at follow-up at 25.9 +/- 10.0 months. All 35 limbs in group 2 healed, with recurrence in 0 (0.0%) limbs at follow-up at 25.4 +/- 10.1 months. Lateral SEPS could reduce the rate of recurrence of ulcers (Kaplan-Meier analysis). Patients in group 2 also showed improvement in clinical and disability scores, although they were not statistically significant differences (t test, p > 0.05). A significantly higher proportion of patients in group 1 had IPVs on the lateral aspect of the lower leg on ultrosonography imaging. Lateral SEPS could contribute to ulcer healing and reduce ulcer recurrence. The addition of lateral SEPS to routine surgery did reduce the number of IPVs. Lateral SEPS may be safe and effective for lateral perforating vein incompetence and venous ulceration.

Incidence and Clinical Predictors of Gastric Retention in Video Capsule Endoscopy (VCE)

Purpose: VCE is an established technique for examination of the small bowel and has become an important diagnostic tool. The approximate incidence of incomplete small bowel studies due to transit delay is 25%, however, the incidence of gastric retention is not known. Many patients with incomplete studies require a second VCE which often is placed into the small bowel under endoscopic assistance. In this study we sought to assess the incidence of gastric capsule retention in patients undergoing VCE and elucidate specific clinical factors predicting gastric retention in those patients who have had incomplete capsule studies. Methods: We performed a retrospective chart review of 1200 patients undergoing VCE between 2002–2007. Cases had gastric retention of the capsule and controls were patients who had had completed VCE studies. Controls were matched in a 1:1 fashion for age, gender and indication for VCE. Results: There was gastric retention of VCE in 16 patients out of 1200 patients who underwent an initial VCE (1.3%). There was no difference in demographic features between group I and II including race and BMI. There was no difference in gastrointestinal symptoms such as bloating, GERD symptoms, epigastric pain, or nausea/vomiting. Patients with retained VCE did not have increased prevalence of DM or hypothyroidism. There was no difference between the two groups with respects to use of anti-inflammatory, narcotic, prokinetic, antispasmodic, anti-cholinergic and/or anti-secretory medications. A significant proportion of patients in group I had a history of prior gastric or bowel surgery compared to none in group II [56% vs. 0%; P < 0.001]. In 5 of 16 patients a gastric emptying study (GES) was performed and all studies were positive for delayed gastric emptying. After initial gastric retention of VCE, a second VCE was performed in 11/16 patients, 7 of whom underwent EGD-assisted placement of the capsule. In 2/4 cases where EGD assistance was not used there was recurrent gastric retention of capsule. Conclusion: 1. Gastric retention of VCE occurs in approximately 1% of patients undergoing VCE. 2. While there was no significant difference in clinical features nor prescription drug use in cases compared to controls, patients with a history of gastric or bowel surgery and/or delayed gastric emptying on GES are more likely to have gastric retention of VCE. 3. In a patient with prior gastric retention of the video capsule or evidence of delayed gastric emptying on GES, repeat VCE should be done with EGD assistance because of high frequency of recurrence of gastric capsule retention.

External cardioversion of atrial fibrillation: The role of electrode position on cardioversion success

The optimal method to perform external electrical cardioversion of atrial fibrillation has not been fully determined yet. In order to define the effects of different pad positions on cardioversion success rates, shock energy requirements and serum myocardial proteins levels we studied 62 patients with persistent atrial fibrillation who underwent elective external electrical cardioversion using a standardized step-up protocol of increasing energy levels. Electrode positions were randomly assigned as anterolateral (Group A) or anteroposterior (Group B). After all shocks were delivered there was no difference in the cardioversion success rate between the two groups. However, a significantly greater proportion of patients in group B were restored to sinus rhythm after the second shock of 300 J was delivered ( p = 0.005). Mean shock energy requirements and peak serum creatine kinase levels were lower for group B than for group A ( p = 0.049 and p = 0.021 respectively). Troponin T serum levels were not increased after the cardioversion attempts in either group. We conclude that an anteroposterior electrode position is more effective in achieving restoration of sinus rhythm in lower energy shock levels compared to the anterolateral position.