Chronically occluded inferior venae cavae: endovascular treatment.

PURPOSE: To report the results of endoluminal recanalization and stent placement in patients with chronic occlusions of the inferior vena cava (IVC). MATERIALS AND METHODS: Seventeen consecutive patients (12 male, five female patients; mean age, 40.6 years; age range, 15-77 years) with chronic IVC occlusions were treated during a 6-year period. The mean duration of symptoms was 32 months. Underlying active malignancy was the cause of occlusion in four patients. Five patients with superimposed acute thrombus underwent catheter-directed thrombolysis prior to IVC recanalization. Clinical patency was defined as absence or improvement of symptoms. Clinical follow-up was supplemented with ultrasonography, vena cavography, or both in 10 patients. RESULTS: Technical success was achieved in 15 (88%) patients. Additional thrombolytic therapy and stent placement was needed in two patients to maintain patency at 4 and 6 months after the procedure. Twelve patients had IVCs that remained patent after a mean follow-up of 19 months for a primary patency rate of 80%. The primary assisted patency rate was 87% (13 of 15). There were four deaths owing to underlying disease 6-21 months after the procedures. There were no procedure-related complications. CONCLUSION: Endoluminal recanalization and stent placement in chronically occluded IVCs has a good intermediate-term outcome and should be considered in patients who have symptoms and who often do not have adequate alternative therapy.

Pelvic arterial embolization for control of obstetric hemorrhage: a five-year experience.

OBJECTIVE: Obstetric hemorrhage is a significant cause of maternal morbidity and death. Postpartum hemorrhage that cannot be controlled by local measures has traditionally been managed by bilateral uterine artery or hypogastric artery ligation. These techniques have a high failure rate, often resulting in hysterectomy. In contrast, endovascular embolization techniques have a success rate of >90%. An additional benefit of the latter procedure is that fertility is maintained. We report our experience at Stanford University Medical Center in which this technique was used in 6 cases within the past 5 years. STUDY DESIGN: Six women between the ages of 18 and 41 years underwent placement of arterial catheters for emergency (n = 3) or prophylactic (n = 3) control of postpartum bleeding. Specific diagnoses included cervical pregnancy (n = 1), uterine atony (n = 3), and placenta previa and accreta (n = 2). RESULTS: Control of severe or anticipated postpartum hemorrhage was obtained with transcatheter embolization in 4 patients. A fifth patient had balloon occlusion of the uterine artery performed prophylactically, but embolization was not necessary. In a sixth case, bleeding could not be controlled in time, and hysterectomy was performed. The only complication observed with this technique was postpartum fever in 1 patient, which was treated with antibiotics and resolved within 7 days. CONCLUSIONS: Uterine artery embolization is a superior first-line alternative to surgery for control of obstetric hemorrhage. Use of transcatheter occlusion balloons before embolization allows timely control of bleeding and permits complete embolization of the uterine arteries and hemostasis. Given the improved ultrasonography techniques, diagnosis of some potential high-risk conditions for postpartum hemorrhage, such as placenta previa or accreta, can be made prenatally. The patient can then be prepared with prophylactic placement of arterial catheters, and rapid occlusion of these vessels can be achieved if necessary.

Role of microtubules in the adaptive response to low phosphate of Na/Pi cotransport in opossum kidney cells.

The role of microtubules and actin microfilaments in adaptive changes of the apical Na-dependent transport of phosphate (Pi) was investigated in opossum kidney (OK) cells. Up-regulation of Na/Pi cotransport was achieved by incubating OK cells in a medium containing 0.1 mM Pi; down-regulation of Na/Pi cotransport was provoked by refeeding adapted cells with 2 mM Pi. Up-regulation of Na/Pi cotransport was found to be inhibited by approximately 50% after a pretreatment of the cells with the microtubule disrupting agents nocodozole and colchicine; indirect immunofluorescence indicated complete depolymerization of the microtubular network. No inhibition of the adaptive response was observed after treatment of the cells with cytochalasin B to depolymerize actin microfilaments. In adapted cells, depolymerization of microtubules by nocodozole led to a reversibility of Na/Pi cotransport similar to that observed after refeeding adapted cells with 2 mM Pi. No effects of the microtubule disrupting drugs were observed on Na/L-glutamic acid transport. Depolymerization of microtubules did not prevent parathyroid-hormone-mediated inhibition of Na/Pi cotransport. It is concluded that microtubules are (at least in part) involved in the correct insertion of newly synthesized apical Na/Pi cotransport systems and that microtubules are not involved in the internalization of Na/Pi cotransport systems.

Left ventricular filling dynamics by Doppler echocardiography in dilated cardiomyopathy: one-year follow-up in patients treated with captopril compared to placebo.

The role of impaired diastolic function in determining the pathophysiology of congestive cardiomyopathy was only recently appreciated. In the present study, echocardiography and Doppler cardiography were used to determine changes in cardiac size and transmitral filling dynamics over a 1-year period in patients with congestive cardiomyopathy and determine the effect of captopril on these changes. The study population consisted of 27 patients with congestive heart failure in spite of therapy with digitalis and diuretics (NYHA class 3.2). Fifteen patients were started on placebo and 12 on captopril. Noninvasive evaluation was performed at 6-month intervals. Left ventricular size and left ventricular ejection fraction did not change significantly in either group. Forward stroke volume improved significantly only in patients on captopril compared to placebo (p < 0.05). No significant changes in transmitral flow dynamics were observed in the placebo group whereas the captopril-treated group showed a decrease in the peak velocity, flow velocity integral and rate of rapid filling wave (E) and an increase in the peak, integral and rate of filling during atrial contraction (A). The E/A ratio did not change significantly over time in the placebo group, whereas a reduction in the ratio was noted in the captopril-treated patients. These changes are sustained over 1 year with concomitant improvement in stroke volume, exercise duration and functional class.

Cognition in Parkinson disease: an event-related potential perspective.

Auditory event-related potentials (ERP) elicited in a target detection stimulus paradigm and pattern-shift visual ERPs were studied in 20 male patients with idiopathic Parkinson disease (PD) and 20 age-matched normal controls. Patients showed significantly increased latencies for both the P200 and P300 components of the auditory ERP. Patients and controls showed no significant differences in latency of the visual ERP but patients showed significantly decreased amplitude. Only one of five neuropsychological measures, the Symbol Digit Modalities test (SDMT), showed a significant negative correlation with P300 latency. The significant association between the two measures that showed impairments in the PD patients (P300 latency and SDMT scores) suggested that these measures reflect a common, disrupted aspect of cognitive function in PD.

Relationship of motor symptoms to intellectual deficits in Parkinson disease.

We studied 60 patients with idiopathic Parkinson disease with motor and neuropsychologic tests to ascertain whether the severity of motor symptoms was associated with the degree of neuropsychologic deficity. Significant correlations were found between the severity of brady kinesia and impaired performance on tests assessing visual-spatial reasoning and psychomotor speed. More severe tremor was associated with better performance on a spatial orientation memory test. There relationships remained when age, age at onset, and self-rated depression were controlled. The findings suggested that cognitive impairment may result from the same subcortical lesions that cause motor symptoms.

Parkinson's disease: Cogentin with Sinemet, a better response.

1. A randomized, placebo controlled, double-blind cross-over study was conducted to evaluate the clinical efficacy of the anticholinergic agent, benztropine mesylate (CogentinR) in 29 patients with mild to moderate, idiopathic Parkinson disease. 2. Patients were maintained on a stable, therapeutically optimal dosage and schedule of levadopa-carbidopa (Sinemet) throughout the study. 3. Both the neurologist's and the patient's global assessments of treatment efficacy indicated that Sinemet plus benztropine mesylate resulted in significantly greater improvement than Sinemet plus placebo. 4. Qualitative and quantitative evaluations of relevant neurologic functions showed small, but statistically significant improvements for rigidity, finger tapping speed and activities of daily living in patients during the Sinemet plus benztropine mesylate treatment period. 5. At the completion of the study 16 patients chose to continue taking benztropine mesylate as an adjuvant to Sinemet. 6. No important adverse side effects occurred during the study.

Dementia in Parkinson disease: a neuropsychological analysis.

An extensive set of neuropsychological measures was administered to 60 Parkinson's disease patients and age-, sex-, and education-matched controls in order to investigate the nature and prevalence of the cognitive deficit in the disease. Parkinsonian patients performed significantly poorer on all measures with the exception of tests for apraxia and object recognition, and on a test of vocabulary knowledge. Discriminant analysis of the test data revealed that over 93% of patients are impaired relative to matched controls, but that assigning a prevalence rate for dementia in the disease may be difficult due to the continuous distribution of cognitive deficits.

Oculomotor reaction time in dementia reflects degree of cerebral dysfunction.

The effects of diffuse cerebral dysfunction on oculomotor reaction time were assessed in patients with dementia of presumed Alzheimer's etiology and in normal age-matched control subjects. Patients were classified into mild, moderate, and severe groups on the basis of independent neurological, neuropsychological, and neuroradiological ratings for disease severity. Saccadic latencies to targets appearing in parafoveal and near peripheral vision showed significant increases from the normal controls to dementia groups, with each severity subdivision clearly differentiated from the others in terms of mean oculomotor reaction time. These data offer strong evidence for a direct relationship between degree of cortical structural integrity and simple oculomotor reaction time and suggest a higher cortical regulatory role in sensory-motor integration.

Decreased verbal memory associated with anticholinergic treatment in Parkinson's disease patients.

The effects of chronic administration of the anticholinergic agent, benztropine mesylate (CogentinTM), on specific verbal memory were investigated as part of a placebo-controlled randomized double-blind crossover study to determine the clinical efficiency of CogentinTM as an adjuvant therapy with SinemetTM in Parkinson's disease. Twenty-nine males with clinically definite idiopathic Parkinson's disease participated in the trial. They were tested for acquisition of new word lists, and on four other cognitive tests before, during, between, and after two 10-week trial periods when they received either increasing doses of CogentinTM (maximum 2 mg) or placebo while on a maintenance dose of SinemetTM. Patients showed a statistically significant decrease (5--10%) in word list acquisition while on CogentinTM. The anticholinergic memory effect was unrelated to the degree of improved clinical efficacy of CogentinTM for the Parkinsonism, and to initial word list acquisition ability. Verbal memory findings indicate that chronic administration of an anticholinergic in even low therapeutic dosage may play an important role in memory function.

Simple and choice reaction time in dementia: clinical implications.

The present study investigated differences between normal elderly subjects matched for age and education and patients with dementia of the Alzheimer's type (DAT) on two measures of reaction time (RT). Statistically significant group differences clearly demonstrate that normal elderly subjects have faster RT than subjects with senile dementia on all RT tasks. The DAT patients were most clearly differentiated in terms of overall group means and clinical classification from their age-matched counterparts on the choice of RT task. Eleven of 12 (92%) DAT patients displayed choice RT's 2 or more standard deviations above those of age-matched normals. While both RT measures were discriminative between patients and normals, the overall results argue for increased sensitivity when choice is required in RT in accessing the cognitive deficits in DAT.