Tips and techniques for optimal stent graft placement in angulated aneurysm necks

An increasing number of patients with severely angulated abdominal aortic aneurysm (AAA) necks are being treated by endovascular aneurysm repair (EVAR). Optimal preprocedural planning and investigation of the AAA morphology is essential to achieve a successful EVAR in these patients. In this article, we discuss specific problems that can be encountered during preoperative planning in relation to periprocedural stent graft deployment in patients with angulated AAA necks and offer potential solutions for these problems

Clinical Outcome of Intra-Arterial Embolization for Treatment of Patients with Pelvic Trauma

Purpose. To analyse the technical success of pelvic embolization in our institution and to assess periprocedural hemodynamic status and morbidity/mortality of all pelvic trauma patients who underwent pelvic embolization. Methods. A retrospective analysis of patients with a pelvic fracture due to trauma who underwent arterial embolization was performed. Clinical data, pelvic radiographs, contrast-enhanced CT-scans, and angiographic findings were reviewed. Subsequently, the technical success and peri-procedural hemodynamic status were evaluated and described. Results. 19 trauma patients with fractures of the pelvis underwent arterial embolization. Initially, 10/19 patients (53%) were hemodynamically unstable prior to embolization. Technical success of embolization was 100%. 14/19 patients (74%) were stable after embolization, and treatment success was high as 74%. Conclusion. Angiography with subsequent embolization should be performed in patients with a pelvic fracture due to trauma and hemodynamic instability, after surgical intervention or with a persistent arterial blush indicative of an active bleeding on CT

A ruptured aneurysm after stent graft puncture during computed tomography-guided thrombin injection

Type II endoleaks occur in 5% to 10% of patients who are treated by endovascular aneurysm repair. A persistent type II endoleak combined with documented aneurysm expansion is generally considered an indication for intervention. Thrombin injection directly into the aneurysm sac is described as a safe and efficient treatment option. We present a patient with a ruptured aneurysm caused by a puncture of the stent graft during computed tomography-guided thrombin injection. This case highlights a possible harmful complication of thrombin injection and emphasizes the need for caution while performing such a procedure

Therapist alliance building behavior and treatment adherence for dutch children with mild intellectual disability or borderline intellectual functioning and externalizing problem behavior

BACKGROUND: Psychological interventions targeting children with mild intellectual disability or borderline intellectual functioning (MID-BIF) are suggested to be effective in reducing their externalizing problem behavior, but less is known about the specific treatment processes that may be associated with these effects. AIMS: The current study investigated whether the treatment processes of observed treatment adherence (i.e., the degree to which a therapist sticks to the protocol of a treatment and provides the treatment as intended) and observed therapist alliance-building behavior (TA-BB; i.e., behavior contributing to the affective bond between the therapist and the client) predicted treatment outcomes in a group behavioral parent training combined with group child cognitive behavior therapy targeting externalizing problem behavior in children with MID-BIF. METHODS AND PROCEDURES: Seventy-two children (aged 9-18; Mage = 12.1) and their parents in The Netherlands received the intervention program. They reported on children's externalizing behavior, parenting practices and the parent-child relationship by questionnaires at pre-test and post-test, and the observed treatment processes were coded by audio tapes of therapeutic sessions. OUTCOMES AND RESULTS: The results showed high levels of both treatment adherence (M = 2.49; SD = 0.20; range 1 - 3) and TA-BB (M = 4.11; SD = 0.32; range 1 - 5). Additionally, repeated measures analyses revealed that levels of treatment adherence significantly predicted the improvement of the parent-child relationship (F(1, 66) = 5.37; p = .024) and that levels of TA-BB significantly predicted the decrease of parent reported externalizing problem behavior (F(1, 66) = 9.89; p = .002). CONCLUSIONS AND IMPLICATIONS: The current study suggested that optimal treatment processes are important for treatment outcomes in an intervention targeting children with MID-BIF

Optimizing the Timing of Highest Hydrocortisone Dose in Children and Adolescents With 21-Hydroxylase Deficiency

CONTEXT: Hydrocortisone treatment of young patients with 21-hydroxylase deficiency (21OHD) is given thrice daily, but there is debate about the optimal timing of the highest hydrocortisone dose, either mimicking the physiological diurnal rhythm (morning), or optimally suppressing androgen activity (evening). OBJECTIVE: We aimed to compare 2 standard hydrocortisone timing strategies, either highest dosage in the morning or evening, with respect to hormonal status throughout the day, nocturnal blood pressure (BP), and sleep and activity scores. METHODS: This 6-week crossover study included 39 patients (aged 4-19 years) with 21OHD. Patients were treated for 3 weeks with the highest hydrocortisone dose in the morning, followed by 3 weeks with the highest dose in the evening (n = 21), or vice versa (n = 18). Androstenedione (A4) and 17-hydroxyprogesterone (17OHP) levels were quantified in saliva collected at 5 am; 7 am; 3 pm; and 11 pm during the last 2 days of each treatment period. The main outcome measure was comparison of saliva 17OHP and A4 levels between the 2 treatment strategies. RESULTS: Administration of the highest dose in the evening resulted in significantly lower 17OHP levels at 5 am, whereas the highest dose in the morning resulted in significantly lower 17OHP and A4 levels in the afternoon. The 2 treatment dose regimens were comparable with respect to averaged daily hormone levels, nocturnal BP, and activity and sleep scores. CONCLUSION: No clear benefit for either treatment schedule was established. Given the variation in individual responses, we recommend individually optimizing dose distribution and monitoring disease control at multiple time points

Quantitative analysis of the anterolateral ossification mass in diffuse idiopathic skeletal hyperostosis of the thoracic spine

Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic condition leading to ossification of spinal ligaments and has been shown to behave similarly to ankylosing spondylitis (AS) often leading to unstable hyperextension fractures. Currently, no quantitative data are available on the spatial relationship between the bridging anterolateral ossification mass (ALOM) and the vertebral body/intervertebral disc to explain the propensity in DISH to fracture through the vertebral body instead of through the intervertebral disc as more often seen in AS. Furthermore, no reasonable explanation is available for the typical flowing wax morphology observed in DISH. In the current study, a quantitative analysis of computed tomography (CT) data from human cadaveric specimens with DISH was performed to better understand the newly formed osseous structures and fracture biomechanics. Additionally, the results were verified using computed tomography angiography data from ten patients with DISH and ten controls. Transverse CT images were analyzed to obtain ALOM area and centroid angle relative to the anteroposterior axis; intervertebral disc and adjacent cranial and caudal levels. The ALOM area at the mid-vertebral body level averaged 57.9 ± 50.0 mm2; at the mid-intervertebral disc space level it averaged 246.4 ± 95.9 mm2. The mean ALOM area at the adjacent level caudal to the mid-vertebral body level was 169.6 ± 81.3 mm2; at the adjacent cranial level, it was 161.7 ± 78.2 mm2. The main finding was the significant difference between mean ALOM area at the mid-vertebral body level and other three levels (p < 0.0001). The subsequent verification study showed the presence of vertebral segmental arteries at the mid-vertebral body level in nearly all images irrespective of the presence of DISH. A larger area of ALOM seemed associated with increased counter-clockwise rotation (away from the aorta) of the centroid relative to the anteroposterior axis. The results from the present study suggest a predisposition for fractures through the vertebral body and a role for the arterial system in the inhibition of soft tissue ossification

Seasonal and Nonseasonal Longitudinal Variation of Immune Function

Different components of the immune response show large variability between individuals, but they also vary within the same individual because of host and environmental factors. In this study, we report an extensive analysis of the immune characteristics of 56 individuals over four timepoints in 1 single year as part of the Human Functional Genomics Project. We characterized 102 cell subsets using flow cytometry; quantified production of eight cytokines and two chemokines in response to 20 metabolic, bacterial, fungal, and viral stimuli; and measured circulating markers of inflammation. Taking advantage of the longitudinal sampling, both seasonal and nonseasonal sources of variability were studied. The circulating markers of inflammation IL-18, IL-18 binding protein, and resistin displayed clear seasonal variability, whereas the strongest effect was observed for alpha-1 antitrypsin. Cytokine production capacity also showed strong seasonal changes, especially after stimulation with the influenza virus, Borrelia burgdorferi, and Escherichia coli. Furthermore, we observed moderate seasonality effects on immune cell counts, especially in several CD4(+)/CD8(+) T cell subpopulations. Age of the volunteers was an important factor influencing IFN-gamma and IL-22 production, which matched the strong impact of age on several T cell subsets. Finally, on average, genetics accounted for almost 50% of the interindividual variance not already explained by age, sex, and body mass index, although this varies strongly for different parameters. In conclusion, seasonality is an important environmental factor that influences immune responses, in addition to specific genetic and nongenetic host factors, and this may well explain the seasonal variation in the incidence and severity of immune-mediated diseases

Small bowel motility affects glucose absorption in a healthy man

WSTĘP. Celem pracy było wyjaśnienie związku pomiędzy motoryką dwunastnicy i jelita cienkiego a wchłanianiem glukozy oraz ustalenie wpływu zmiany motoryki jelita cienkiego na wchłanianie glukozy po zastosowaniu substancji prokinetycznej - cizaprydu. MATERIAŁ I METODY. W badaniu wzięło udział 7 zdrowych mężczyzn, których średnia wieku wynosiła 22 lata. W sposób randomizowany badani otrzymywali cizapryd 10 mg 3 razy dziennie lub placebo, przez 3 dni. Po 2 tygodniach powtarzano próbę z drugim preparatem. Rano 3 dnia badania wykonywano manometrię z użyciem 18-kanałowego cewnika, wprowadzonego do dwunastnicy. Przez 30 minut badani otrzymywali przez cewnik płynną odżywkę (3 kcal/min), a następnie bolus analogu glukozy (3-OMG, 3-O-metyloglukozę). W celu oceny kinetyki wchłaniania oznaczano w osoczu stężenia 3-OMG. WYNIKI. Pole pod krzywą stężenia 3-OMG w pierwszych 30 minutach po podaniu dojelitowym było zależne od liczby ruchów robaczkowych rozchodzących się ortodromowo (r = 0,49, p < 0,05), ale nie wykazano związku ze stężeniem szczytowym, czasem do osiągnięcia stężenia szczytowego ani frakcją wchłoniętą. Średnia amplituda ruchów robaczkowych była wyższa przy podawaniu cizaprydu niż placebo (p < 0,05), ale powrót motoryki w okresie międzyposiłkowym, liczba ruchów robaczkowych i ich propagacja oraz charakterystyka wchłaniania 3-OMG były podobne przy stosowaniu cizaprydu i placebo. W obu typach leczenia propagacja ruchów robaczkowych w ponad 60% wynosiła jedynie 1,5 cm. WNIOSKI. Absorpcja glukozy w jelicie cienkim człowieka wiąże się z propagacją aktywności skurczowej jelita w zakresie krótkich odcinków. Cizapryd zwiększa amplitudę ruchów robaczkowych, ale nie wpływa na ich organizację ani na wchłanianie 3-OMG.INTRODUCTION. To investigate the relationship between duodenojejunal motor activity and glucose absorption and to evaluate the effect of modification of duodenojejunal motility on glucose absorption by using the prokinetic drug cisapride. MATERIAL AND METHODS. We examined seven healthy males, mean age 22 years, who were treated with cisapride 10 mg t.i.d. and placebo during 3 days in a randomized order, with a 2-week time interval. Duodenojejunal manometry was performed after each treatment on the morning of day 3, using an 18-lumen catheter. A liquid nutrient (3 kcal/min) was administered intraduodenally for 30 min, followed by a bolus of the glucose analog 3-O-methylglucose (3-OMG). Plasma 3-OMG concentrations were measured to assess absorption kinetics. RESULTS. The area under the 3-OMG concentration curve in the first 30 min after infusion was related to the number of antegrade propagated pressure waves (r = 0.49, P < 0.05), but not to the peak concentration, time to peak, and absorption fraction. The mean amplitude of pressure waves was higher during cisapride than placebo (P < 0.05), but the reoccurrence of interdigestive motility, numbers of pressure waves, and propagated pressure waves, as well as 3-OMG absorption characteristics, were not significantly different between the two treatments. During both treatments > 60% of antegrade propagated pressure waves were propagated over a very short distance (1.5 cm). CONCLUSIONS. Glucose absorption in the human small intestine is related to short-traveling propagated intestinal contractile activity. Cisapride increases the amplitude of pressure waves, but does not affect the organization of pressure waves or the absorption of 3-OMG