Plasma levels of Asymmetric Di Methyl Arginine and endothelial dysfunction in diabetic subjects with neuropathic foot ulcer.

OBJECTIVE: Asymmetric dimethyl arginine (ADMA) is an amino acid that acts as an endogenous competitive inhibitor of Nitric oxide synthase, leading to endothelial dysfunction (ED). The aim of this study was to evaluate the relationship between plasma ADMA (p-ADMA) level and ED in diabetic subjects with neuropathic foot ulcer (NFU), and the possible predictors of p-ADMA level. MATERIALS AND METHODS: 80 diabetic subjects of matched age, sex and BMI were included; 40 with NFU (G1), 20 with peripheral nerve dysfunction (PND) (G2) and 20 without PND (G3), plus 20 matched healthy subjects (G4). Flow-mediated-dilatation (FMD) of brachial artery and Carotid-intima-media-thickness (CIMT) were measured to evaluate ED and subclinical atherosclerosis, respectively. RESULTS: G1&2 had a significantly lower FMD than G3&4 [-5.09 (-22.5 to 22.92), 4.67 (-15 to 23.91) vs. 15.74 (8.33-36.59) and 20.1 (10.0-46.15)%, respectively] (p < 0.001), and higher CIMT [0.9 (0.6-1.5), 0.9 (0.6-1.3) vs. 0.6 (0.5-0.8) and 0.7 (0.5-0.9) cm, respectively] (p < 0.001, r = 0.237, p = 0.034, r = 0.330, p = 0.003, respectively), with no significant correlation with FMD (r = -0.176, p = 0.118). FMD was inversely and strongly related to CIMT (r = -0.520, p < 0.001). p-ADMA levels were significantly higher in uncontrolled hypertensive patients in comparison to controlled and normotensive subjects [717 (286-3611) vs. 648 (335-874) and 686 (526-857) ng/L, respectively] (p = 0.026). Metformin users and hypertensive subjects on ACEIs or ARBs had the lowest p-ADMA levels than the non-users (p < 0.001, p = 0.007, respectively). CONCLUSION: The remarkable ED in diabetic subjects with NFU is unlikely to be due to alteration in p-ADMA. Further studies are needed in order to conclude a causal association between p-ADMA and ED in this group of patients.

Prognostic value of vascular endothelial growth factor in both conventional and drug eluting beads transarterial chemoembolization for treatment of unresectable hepatocellular carcinoma in HCV patients.

OBJECTIVES: This work aimed to measure serum vascular endothelial growth factor (VEGF) levels before and after Conventional transarterial chemoembolization (cTACE) versus drug-eluting beads (DEB)-TACE and evaluate its efficacy in predicting response to therapy and tumor recurrence. METHODS: 114 patients with unresectable hepatocellular carcinoma complicating hepatitis C virus-related cirrhosis were included. They underwent cTACE (58) or DEB-TACE (56). VEGF serum levels were measured before and on days 1 and 30 after TACE. Patients with complete response (CR) after TACE were followed-up for one year. Statistical analysis was done. RESULTS: VEGF level was higher than baseline after cTACE (P < 0.001), and DEB-TACE (P = 0.004). It was also significantly higher in patients with progressive disease (P < 0.001). VEGF level at cut off values of 97.3, 149.8, and 104.1 pg/ml could discriminate disease progression from treatment success with area under ROC curves of 0.806, 0.775, and 0.771, respectively. The sensitivity was 88.9%, 88.9%, and 77.8% and specificity was 62.5%, 64.6 and 66.7%, respectively. However, no relation to tumor recurrence in CR group could be detected after one year. CONCLUSION: VEGF serum levels may predict response to therapy in patients treated by DEB-TACE or cTACE but it has no relation to tumor recurrence.

Factors Affecting the Degree of Angular Remodeling in Stent-Assisted Coiling of Bifurcation Aneurysms.

BACKGROUND: Stent-assisted coiling (SAC) leads to significant changes in the vascular angle altering the bifurcation geometry and the hemodynamics at the bifurcation apex. It is believed that the stent alone exerts this effect, but other possible factors have not been studied. PURPOSE: To study the factors contributing to angular remodeling following SAC of bifurcation aneurysms including the anatomical, stent-related, and coil-related factors. MATERIALS AND METHODS: We reviewed 43 basilar and carotid bifurcation aneurysms treated by SAC using Neuroform EZ (n = 28), Enterprise (n = 8), and Lvis Jr. (n = 7) stents. The bifurcation angle between the mother and stented daughter vessel was measured in 4 settings: pretreatment, poststenting, postcoiling, and at delayed follow-up (6-12 months). The degree of stent-induced angular remodeling was calculated by subtracting the poststenting bifurcation angle from the pretreatment one, while the coil-induced angular remodeling was calculated as the difference between the postcoiling and poststenting bifurcation angle. The immediate postprocedural degree of angular remodeling is the sum of the stent- and coil-induced angular remodeling. We studied the effect of several factors including the pretreatment bifurcation angle, aneurysm site, diameter of parent vessel, stent type, stent length in the daughter vessel, postoperative actual in situ coil size, and packing density. RESULTS: The mean degree of stent-induced and coil-induced angular remodeling was 10.2 (0-47) and 4.53 (-7 to 30), respectively. The immediate postprocedural and delayed angular remodeling was 14.8 (-4 to 47) and 4.75 (-12 to 40), respectively. The degree of immediate remodeling was significantly affected by the actual in situ coil size (p = 0.017), and the pretreatment bifurcation angle (p = 0.024). Linear regression was carried out and the pretreatment bifurcation angle was defined as a predictor. The degree of delayed remodeling is significantly affected only by the pretreatment bifurcation angle (p = 0.011). CONCLUSION: Immediate angular remodeling following SAC of bifurcation aneurysms can happen after stenting or coiling or both. This is the first study reporting the role of the coils as an additional factor beside the stent in inducing immediate angular changes; this effect is correlated to the size of the coils. The pretreatment bifurcation angle is the most consistent factor affecting the degree of both immediate and delayed angular remodeling.

Diagnostic Accuracy of Multiparametric Magnetic Resonance Imaging for Differentiation Between Parotid Neoplasms.

PURPOSE: This study was designed to evaluate the role of multiparametric magnetic resonance imaging (MRI) for differentiation of parotid gland neoplasms. METHODS: Prospective study was conducted upon 52 consecutive patients (30 men, 22 women; aged 24-78 years; mean, 51 years) with parotid tumours that underwent multiparametric MRI using combined static MRI, dynamic contrast enhanced (DCE) MRI, and diffusion-weighted imaging (DWI). The static MRI parameter, time signal intensity curves (TIC) derived from DCE-MRI, and apparent diffusion coefficient (ADC) values of parotid tumours were correlated with histopathological findings. RESULTS: Static MRI revealed a significant difference between both benign and malignant lesions in regards to margin definition (P < .001) and T2 hypointensity (P < .013), with a diagnostic accuracy 95% and 78.33% respectively. Study of the TIC type on DCE-MRI revealed statistically significant difference between benign and malignant lesions (P < .001) and diagnostic accuracy 96.55%. There was no statistically significant difference (P = .181) between the ADC values of benign and malignant lesions. ROC curve analysis revealed that by using ADC cut-off value of 1 × 10-3 mm2/s had accuracy of 84.62% respectively for differentiating Warthin from malignant tumours that could be modified to higher value (94.28%) by excluding lymphoma from malignant lesions. By using cutoff value of 1.3 × 10-3 mm2/s to differentiate pleomorphic adenoma from malignancy, ROC curve analysis had high accuracy of 97.06%. CONCLUSION: Multiparametric MRI can be used for differentiation of malignant from benign parotid tumours and characterization of some benign parotid tumours.

Uterine artery occlusion for treatment of symptomatic uterine myomas.

OBJECTIVE: To compare the effectiveness and safety of uterine artery occlusion by laparoscopy versus embolization as a treatment modality for symptomatic uterine fibroids. METHODS: Ninety-six premenopausal women with symptomatic uterine leiomyomata were studied. None of them desired further pregnancy. They were randomized to treatment either by laparoscopic occlusion (group 1) or by radiologic embolization of uterine arteries (group 2). The primary outcome measure was patient satisfaction as regards menstrual blood loss compared with pretreatment loss. Secondary outcome measures included postoperative pain, complications, secondary interventions, and failures. RESULTS: Ninety women were followed for 1, 3, 6, and 12 months after both procedures. The primary outcome was comparable between the 2 groups (86.7% after laparoscopic occlusion versus 88.8% after embolization, with no statistically significant difference). After 12 months of follow-up, more patients resumed heavy periods in the uterine artery occlusion group [4/45 patients, 8.8% in occlusion group compared with 3/45 (6.6%) in embolization group, P=0.044]. CONCLUSION: Both laparoscopic occlusion and superselective embolization of uterine arteries improved clinical symptoms in the majority of patients. At 12-month follow-up, embolization might be more effective.

Partial splenic embolization versus splenectomy for the management of hypersplenism in cirrhotic patients.

BACKGROUND: Hypersplenism occurs in patients with chronic liver disease, and splenectomy is the definitive treatment. However, the operation may be hazardous in patients with poor liver function. In recent years, partial splenic embolization (PSE) has been widely used in patients with hypersplenism and cirrhosis. This study was conducted to assess the safety and efficacy of PSE compared to splenectomy in the management of hypersplenism in cirrhotic patients. METHODS: This study comprised 40 patients with hypersplenism secondary to cirrhosis. They were divided into two groups, each including 20 patients. The first group of patients were treated by PSE using polyvinyl alcohol particles to achieve embolization of at least 50% of the distal branches of the splenic artery. Postembolization arteriography and computed tomography were performed to document the extent of devascularization. Patients in the second group were treated by splenectomy with or without devascularization and left gastric ligation according to the presence or absence of esophageal varices. RESULTS: There was marked improvement in platelet and leukocytic counts in both groups, and the counts remained at appropriate levels during the follow-up period. All patients in the first group had problems related to postembolization syndrome that abated by the first week. One patient in the first group died from myocardial infarction. No deaths occurred in the second group. Asymptomatic portal vein thrombosis developed in one patient in the first group that was treated with anticoagulation, and another patient developed splenic abscess treated by splenectomy with a good outcome. In the second group, three patients developed portal vein thrombosis, one of them being readmitted 4 months postoperatively with mesenteric vascular occlusion; that patient underwent a resection anastomosis with good outcome. CONCLUSIONS: Partial splenic embolization is an effective therapeutic modality for the treatment of hypersplenism secondary to chronic liver disease. It is a simple, rapid procedure that is easily performed under local anesthesia; and it allows preservation of adequate splenic tissue to safeguard against overwhelming infection.

Preoperative isolated limb infusion of Doxorubicin and external irradiation for limb-threatening soft tissue sarcomas.

BACKGROUND: At present, limb-sparing surgery is the most appropriate and acceptable treatment option for soft tissue sarcomas of the extremities. To increase the number of limb-sparing resections in the treatment of locally advanced soft tissue sarcomas of the extremities, preoperative radiotherapy and/or chemotherapy are often used. Isolated limb perfusion of cytostatic agents is an effective alternative option but technically complex. Isolated limb infusion, essentially a low-flow isolated limb perfusion without oxygenation via a percutaneous catheter, had been developed as a simple alternative. OBJECTIVE: The objective of this study was to achieve limb-sparing surgery in patients with locally advanced soft tissue sarcomas of the extremities that would otherwise have required an amputation or a functionally mutilating surgery by performing preoperative isolated limb infusion with doxorubicin and external beam irradiation to obtain local control and make limb-sparing surgery feasible. METHODS: A total of 40 patients with locally advanced soft tissue sarcomas of the extremities were evaluated between 2002 and 2005. Tumors were located in the lower limb in 28 patients (70%) and in the upper limb in 12 patients (30%). All of these patients were felt to be unresectable and were referred because amputation was considered the only available treatment option. They underwent preoperative isolated limb infusion with doxorubicin (0.7 and 1.4 mg/kg for the upper and lower limbs, respectively). Preoperative external beam radiotherapy started within 3-7 days after isolated limb infusion was administered. The total dose was 35 Gy in ten fractions. After 3-7 weeks, surgery was performed aiming at limb preservation. RESULTS: Tumor response was seen in 85% of patients, rendering these large sarcomas resectable in most cases. The mean values of pretreatment tumor volume and post-treatment volume were 2797 cm(3) and 1781 cm(3), respectively, with a significant p value of 0.0001. Histologic response was seen in 80% of patients. At a median followup of 15 months (range = 5-35), limb salvage was achieved in 82.5%. Procedure-related complications were limited and easily managed. CONCLUSION: Isolated limb infusion with doxorubicin is a simple and safe method of regional chemotherapy. The addition of preoperative external beam irradiation helped to increase the rate of limb salvage in patients with large and/or high-grade soft tissue sarcomas of the extremities.

Endoscopic-assisted midfacial degloving approach for type III juvenile angiofibroma.

BACKGROUND: Open surgery is the mainstay treatment for juvenile angiofibromas (JAF). Midfacial degloving approach provides good exposure to the target area with excellent cosmoses. Endoscopic techniques have been used for the removal of some small JAF. OBJECTIVES/HYPOTHESIS: To evaluate the efficacy and outcome of endoscopic-assisted midfacial degloving approach as a route for removal of type III juvenile angiofibroma. PATIENTS AND METHODS: Fifteen young male patients with type III JAF (based on Fisch classification by computed tomography (CT) and magnetic resonance imaging (MRI) or both), were operated on by endoscopic-assisted midfacial degloving approach. Pre-operative angiography and embolization were performed in two patients. The surgical technique is described in details. RESULTS: Apart from a case developed cerebrospinal fluid (CSF) rhinorrhea intraoperatively there were neither major operative nor post-operative complications. CSF leak was repaired through the same approach successfully in the same set. Thirteen patients had complete tumor clearance with no residual or recurrence during the follow-up period which ranged from 6 months to 6 years. Recurrence was detected early by endoscopic examination in two cases (3 and 8 months post-operatively) and confirmed by CT and MRI. Endoscopic transnasal removal of the recurrent JAF was done successfully under local anesthesia in the first patient and under general anesthesia in the second with no recurrence during the follow-up period. CONCLUSIONS: Endoscopic-assisted midfacial degloving approach for removal of type III JAF enables the surgeon to gain the advantages of midfacial degloving approach with extensive exposure of the surgical field. Employing an endoscope, offers safe dealing with serious intraoperative complications like CSF leak. Post-operative follow-up by endoscopic nasal examination can detect early recurrence, which can be confirmed by CT and MRI.