Effect of preoperative sonographic mapping on vascular access outcomes in hemodialysis patients

Effect of preoperative sonographic mapping on vascular access outcomes in hemodialysis patients.BackgroundCurrent DOQI guidelines encourage placing arteriovenous (AV) fistulas in more hemodialysis patients. However, many new fistulas fail to mature sufficiently to be useable for hemodialysis. Preoperative vascular mapping to identify suitable vessels may improve vascular access outcomes. The present study prospectively evaluated the effect of routine preoperative vascular mapping on the type of vascular accesses placed and their outcomes.MethodsDuring a 17-month period, preoperative sonographic evaluation of the upper extremity arteries and veins was obtained routinely. The surgeons used the information obtained to plan the vascular access procedure. The types of access placed, their initial adequacy for dialysis, and their long-term outcomes were compared to institutional historical controls placed on the basis of physical examination alone.ResultsThe proportion of fistulas placed increased from 34% during the historical control period to 64% with preoperative vascular mapping (P < 0.001). When all fistulas were assessed, the initial adequacy rate for dialysis increased mildly from 46 to 54% (P = 0.34). For the subset of forearm fistulas, the initial adequacy increased substantially from 34 to 54% (P = 0.06); the greatest improvement occurred among women (from 7 to 36%, P = 0.06) and diabetic patients (from 21 to 50%, P = 0.055). In contrast, the initial adequacy rate of upper arm fistulas was not improved by preoperative vascular mapping (59 vs. 56%, P = 0.75). Primary access failure was higher for fistulas than grafts (46.4 vs. 20.6%, P = 0.001), but the subsequent long-term failure rate was higher for grafts than fistulas (P < 0.05). Moreover, grafts required a threefold higher intervention rate (1.67 vs. 0.57 per year, P < 0.001) to maintain their patency. The overall effect of this strategy was to double the proportion of patients dialyzing with a fistula in our population from 16 to 34% (P < 0.001).ConclusionsRoutine preoperative vascular mapping results in a marked increase in placement of AV fistulas, as well as an improvement in the adequacy of forearm fistulas for dialysis. This approach resulted in a substantial increase in the proportion of patients dialyzing with a fistula in our patient population. Fistulas have a higher primary failure rate than grafts, but have a lower subsequent failure rate and require fewer procedures to maintain their long-term patency

HST/WFC3 Observations of an Off-Nuclear Superbubble in Arp 220

We present a high spatial resolution optical and infrared study of the circumnuclear region in Arp 220, a late-stage galaxy merger. Narrowband imaging using HST/WFC3 has resolved the previously observed peak in H$\alpha$+[NII] emission into a bubble-shaped feature. This feature measures 1.6" in diameter, or 600 pc, and is only 1" northwest of the western nucleus. The bubble is aligned with the western nucleus and the large-scale outflow axis seen in X-rays. We explore several possibilities for the bubble origin, including a jet or outflow from a hidden active galactic nucleus (AGN), outflows from high levels of star formation within the few hundred pc nuclear gas disk, or an ultraluminous X-ray source. An obscured AGN or high levels of star formation within the inner $\sim$100 pc of the nuclei are favored based on the alignment of the bubble and energetics arguments.Comment: Accepted for publication in ApJ. 12 pages, 10 figure

Segmentations of MRI images of the female pelvic floor: A study of inter- and intra-reader reliability

Purpose: To describe the inter- and intra-operator reliability of segmentations of female pelvic floor structures. Materials and Methods: Three segmentation specialists were asked to segment out the female pelvic structures in 20 MR datasets on three separate occasions. The STAPLE algorithm was used to compute inter- and intra-segmenter agreement of each organ in each dataset. STAPLE computed the sensitivity, specificity, and positive predictive values (PPV) for inter- and intra-segmenter repeatability. These parameters were analyzed using intra-class correlation analysis. Correlation of organ volume to PPV and sensitivity was also computed. Results: Mean PPV of the segmented organs ranged from 0.82 to 0.99, and sensitivity ranged from 33 to 96%. Intra-class correlation ranged from 0.07 to 0.98 across segmenters. Pearson correlation of volume to sensitivity were significant across organs, ranging from 0.54 to 0.91. Organs with significant correlation of PPV to volume were bladder (−0.69), levator ani (−0.68), and coccyx (−0.63). Conclusion: Undirected manual segmentation of the pelvic floor organs are adequate for locating the organs, but poor at defining structural boundaries. J. Magn. Reson. Imaging 2011;33:684–691. © 2011 Wiley-Liss, Inc.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/83166/1/22478_ftp.pd

The Influence of Sylvatic Plague on North American Wildlife at the Landscape Level, with Special Emphasis on Black-footed Ferret and Prairie Dog Conservation

Prairie-dogs are distributed over a large part of the Great Plains and Rocky Mountain regions. Their colonies often number thousands of individuals, and their destruction of grasses and other forage plants makes them of considerable economic importance. Drastic measures are frequently necessary to prevent the destruction of crops of grain and hay. The Biological Survey is exterminating these rodents in national forests and in the public domain. The information in this report, in regards to the several species and their distribution, as indicated by maps, will aid materially in efforts, national or state, to control or exterminate them, said Henry W. Henshaw in 1915 (Hollister 1916)

Ergonomic vs. ergonomics: acknowledging the etymology

Ergonomic vs. ergonomics: acknowledging the etymolog

Racial Differences in Pelvic Anatomy by Magnetic Resonance Imaging

To use static and dynamic magnetic resonance imaging (MRI) to compare dimensions of the bony pelvis and soft tissue structures in a sample of African-American and white women

Magnetic resonance assessment of pelvic anatomy and pelvic floor disorders after childbirth

To compare pelvic anatomy, using magnetic resonance imaging (MRI), between women with or without pelvic floor disorders 6-12 months after a first delivery

Pyruvate kinase M2 activation may protect against the progression of diabetic glomerular pathology and mitochondrial dysfunction

Diabetic nephropathy (DN) is a major cause of end-stage renal disease, and therapeutic options for preventing its progression are limited. To identify novel therapeutic strategies, we studied protective factors for DN using proteomics on glomeruli from individuals with extreme duration of diabetes (≥ 50 years) without DN and those with histologic signs of DN. Enzymes in the glycolytic, sorbitol, methylglyoxal and mitochondrial pathways were elevated in individuals without DN. In particular, pyruvate kinase M2 (PKM2) expression and activity were upregulated. Mechanistically, we showed that hyperglycemia and diabetes decreased PKM2 tetramer formation and activity by sulfenylation in mouse glomeruli and cultured podocytes. Pkm-knockdown immortalized mouse podocytes had higher levels of toxic glucose metabolites, mitochondrial dysfunction and apoptosis. Podocyte-specific Pkm2-knockout (KO) mice with diabetes developed worse albuminuria and glomerular pathology. Conversely, we found that pharmacological activation of PKM2 by a small-molecule PKM2 activator, TEPP-46, reversed hyperglycemia-induced elevation in toxic glucose metabolites and mitochondrial dysfunction, partially by increasing glycolytic flux and PGC-1α mRNA in cultured podocytes. In intervention studies using DBA2/J and Nos3 (eNos) KO mouse models of diabetes, TEPP-46 treatment reversed metabolic abnormalities, mitochondrial dysfunction and kidney pathology. Thus, PKM2 activation may protect against DN by increasing glucose metabolic flux, inhibiting the production of toxic glucose metabolites and inducing mitochondrial biogenesis to restore mitochondrial function