RESUMEN
BACKGROUND: Previous reports have indicated endovascular repair to be safe and effective in the treatment of complex aortic aneurysms. The endovascular technology evolves rapidly, and continuous evaluation of F/B-EVAR results is critical to detect failing techniques. Our aim was to analyze the outcome after endovascular repair of complex abdominal aortic and thoracoabdominal aneurysms. METHODS: Single-center, retrospective cohort study, of all F/B-EVAR from August 2009 to December 2018. Primary outcomes were branch instability and freedom from reinterventions at 2 years. Secondary outcomes were major adverse events and all-cause mortality at 30 and 90 days. RESULTS: A total of 72 consecutive patients were included, 55 with a complex abdominal aortic aneurysm (AAA) and 17 with a thoracoabdominal aortic aneurysm (TAAA). Two patients were operated on for rupture. A total of 219 vessels were stented through fenestrations (n = 163) or branches (n = 56). Median follow-up was 24 months (IQR 4-24). Fractured bridging stent graft was the most common cause for reintervention, n = 6. All fractures were in vessels stented with first generation BeGrafts, (6/41 BeGraft vs 0/61 other stents, P < 0.01). Freedom from reinterventions at 2 years was 75% and 35%, in the complex AAA and TAAA groups, respectively (P = 0.04) and excluding BeGrafts 79% (cAAA) and 66% (TAAA). The most common major adverse event was spinal cord ischemia (SCI), in total 8.3% with either transient (2.8%) or permanent (5.6%) deficit. Elective mortality at 30 days was 1.4% (1/70) and at 90 days was 2.9% (2/70). CONCLUSIONS: The rate of branch instability and reintervention was high, with a clear relation to fractured first-generation BeGrafts. Mortality and major adverse event rates were low. Long-term close surveillance of bridging stent graft performance is crucial, and the endovascular community should strive to find ways to report failing materials at an early stage to avoid potentially serious complications.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Procedimientos Endovasculares/instrumentación , Falla de Prótesis , Stents , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Masculino , Diseño de Prótesis , Reoperación , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE/BACKGROUND: To describe the risk factor distribution and outcome for patients with critical limb ischemia (CLI) due to infrapopliteal arterial lesions treated by endovascular or open procedures, with special consideration of diabetic patients. METHODS: Data were collected from the Swedish Vascular Registry, Swedvasc, covering all procedures performed on 549 consecutive patients between May 2008 and January 2014 at the Karolinska University Hospital. Diagnosis of ischemic rest pain and/or tissue loss and treatment of infrapopliteal arterial occlusive disease were considered. Analysis was performed on the first procedure during the observation period, "endo" or "open". Amputation rate and death from any cause were recorded as the primary outcome measures. Subgroup analysis was performed on diabetic patients. RESULTS: Patient demographics did not differ between the endo (n = 430) and open (n = 114) cohorts. Wound complications requiring treatment within 30 days were more common in patients treated with open procedures (32% vs. 1% for endo; p < .001), as well as stroke and myocardial infarction. Amputation rates were higher at 30 days in the open group (7% vs. 2%; p = .012) but similar at 1 year (10% vs. 7%; p = .206). Mortality was similar at 30 days (p = .400) and 1 year (p = .860). Median survival at the end of the observation period was 43 months for endo and 56 months for open patients (p = .055). Patients with diabetes treated with open procedures had more complications at 30 days and a higher rate of transfemoral amputations at 1 year compared with non-diabetic patients. CONCLUSION: This non-randomized registry based study shows similar outcomes regarding amputation and survival rate in a large group of patients treated for infrapopliteal CLI with endovascular or open procedures, although more post-operative complications were reported in the open group. These findings support the continued use of both treatments while stressing the importance of minimizing surgical trauma to reduce wound complications.
Asunto(s)
Angioplastia de Balón , Isquemia/cirugía , Enfermedad Arterial Periférica/terapia , Arteria Poplítea/cirugía , Injerto Vascular/métodos , Venas/trasplante , Anciano , Amputación Quirúrgica , Angioplastia de Balón/efectos adversos , Angioplastia de Balón/instrumentación , Angioplastia de Balón/mortalidad , Implantación de Prótesis Vascular , Comorbilidad , Enfermedad Crítica , Diabetes Mellitus/mortalidad , Femenino , Hospitales Universitarios , Humanos , Isquemia/diagnóstico por imagen , Isquemia/mortalidad , Isquemia/fisiopatología , Estimación de Kaplan-Meier , Recuperación del Miembro , Masculino , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/fisiopatología , Arteria Poplítea/diagnóstico por imagen , Arteria Poplítea/fisiopatología , Complicaciones Posoperatorias/etiología , Sistema de Registros , Factores de Riesgo , Stents , Suecia , Factores de Tiempo , Resultado del Tratamiento , Injerto Vascular/efectos adversos , Injerto Vascular/mortalidadRESUMEN
The frequency of GSTT1 and GSTM1 gene deletion polymorphism was determined in a case-control study of full-term Ukrainian newborns including patients with perinatal asphyxia. Multiplex polymerase chain reaction was used for genotyping 245 full-term newborns. The investigated full-term newborns with perinatal asphyxia were subdivided in the subgroups depending of severity of perinatal asphyxia and neonatal outcome. No significant differences in allele frequencies of homorygous null genotypes of GSTT1 and GSTM1 gene were detected among newborns with moderate perinatal asphyxia and healthy control. However, association with the development of severe perinatal asphyxia was detected for the deletion polymorphism in GSTT1 gene and the combination of the GSTT1 absent/GSTM1 absent in the newborns. The study shows that severe perinatal asphyxia may develop in the consequence of genetic predisposition to this condition as compare with moderate.
Asunto(s)
Asfixia Neonatal/genética , Eliminación de Gen , Predisposición Genética a la Enfermedad , Glutatión Transferasa/genética , Polimorfismo Genético , Asfixia Neonatal/enzimología , Estudios de Casos y Controles , Homocigoto , Humanos , Recién Nacido , Reacción en Cadena de la Polimerasa , Índice de Severidad de la EnfermedadRESUMEN
OBJECTIVE: Enhanced expression of CXCL16 has been demonstrated in atherosclerotic plaques and several properties have been attributed to CXCL16 that could influence the atherosclerotic process. CXCL16 exists in transmembrane and soluble forms. The transmembrane form acts as a scavenger receptor for oxidised LDL whereas the soluble form acts a chemoattractant for mainly CD8+ T cells. In addition, the soluble form of CXCL16 influences human aortic smooth muscle cell proliferation in vitro. In the present work, a human molecular genetic approach employing a common polymorphism within exon 4 of CXCL16 (181 Ala>Val) was used to investigate whether CXCL16 may be involved in the development of coronary artery disease. The polymorphism is located within the spacer region between the chemokine and transmembrane region and potentially influences an Ala/Val cleavage site, a site commonly used for the release of chemokines by tumour necrosis factor-alpha converting enzyme. DESIGN AND SUBJECTS: We first genotyped 387 unselected survivors of a first myocardial infarction aged <60 years and 387 sex- and age-matched controls. A subset of patients (n = 236) was evaluated by quantitative coronary angiography. Secondly, a cohort of 468 patients undergoing percutaneous transluminal coronary angioplasty (PTCA) with stent implantation was genotyped. RESULTS: No significant difference in allele frequency between patient and controls of the 181 A>V polymorphism was detected. However, the V-allele was associated with increased severity of coronary stenoses. Secondly, the V-allele was associated with smaller minimal luminal diameter in the coronary segment subjected to intervention in a second cohort of patients undergoing PTCA with stent implantation. CONCLUSIONS: The present work provides evidence that CXCL16 is involved in processes leading to enhanced stenosis in atherosclerotic coronary arteries.
Asunto(s)
Quimiocinas CXC/genética , Estenosis Coronaria/genética , Proteínas de la Membrana/genética , Infarto del Miocardio/genética , Receptores Inmunológicos/genética , Secuencia de Aminoácidos , Análisis de Varianza , Angioplastia Coronaria con Balón , Estudios de Casos y Controles , Quimiocina CXCL16 , Quimiocinas CXC/inmunología , Quimiocinas CXC/metabolismo , Distribución de Chi-Cuadrado , Angiografía Coronaria , Estenosis Coronaria/patología , Femenino , Estudios de Seguimiento , Frecuencia de los Genes , Humanos , Masculino , Proteínas de la Membrana/inmunología , Proteínas de la Membrana/metabolismo , Persona de Mediana Edad , Datos de Secuencia Molecular , Infarto del Miocardio/patología , Infarto del Miocardio/terapia , Polimorfismo Genético , Polimorfismo de Longitud del Fragmento de Restricción , Receptores Inmunológicos/inmunología , Receptores Inmunológicos/metabolismo , Receptores Depuradores , Análisis de Secuencia de ADN , StentsRESUMEN
We sought an animal model able to discriminate metabolic and angiogenic processes in limb ischemia. For that we modified and evaluated a rat model of severe unilateral limb ischemia at rest. A two-stage surgical procedure entailing left femoral artery ligation preceded by interruption of collateral vessels originating from the infra-renal aorta and left iliac arteries was performed in Sprague-Dawley rats. The model was evaluated for up to 8 weeks with a transit-time flow meter, a laser Doppler perfusion imager, microspheres, arteriography and histology. It was found to be well tolerated with low mortality and perfusion in the foot skin was reduced up to 8 weeks, while collaterals were visible after 2 weeks. Histologic signs of ischemia were seen for up to 4 weeks. This rat model of severe limb ischemia at rest lasts up to 8 weeks and seems well suited for longitudinal studies of the pathophysiology of limb ischemia and healing mechanisms like angio- and arteriogenesis.
Asunto(s)
Modelos Animales de Enfermedad , Extremidades/irrigación sanguínea , Isquemia/fisiopatología , Ratas , Angiografía , Animales , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/patología , Isquemia/diagnóstico por imagen , Isquemia/patología , Flujometría por Láser-Doppler , Masculino , Microesferas , Músculo Esquelético/patología , Ratas Sprague-Dawley , Flujo Sanguíneo Regional , Descanso , Índice de Severidad de la EnfermedadRESUMEN
The intramuscular microdialysate lactate concentration during dynamic exercise with various degrees of blood flow restriction and its relation to lactate concentration in skeletal muscle biopsy and venous blood were studied. Nine healthy males performed three one-legged knee extension exercises (Ex 1-3). Blood flow was restricted stepwise by applying supra-atmospheric pressure over the working leg. Microdialysate mean (range) lactate concentrations at the end of the exercise periods were 3.2 (0.5-6.6), 4.4 (1.1-9.8) and 7.9 (1.1-11.6) mmol.l(-1)during unrestricted, moderately restricted and severely restricted blood flow respectively. There was a significant correlation between microdialysate and venous lactate concentrations at the end of all three exercise periods. Microdialysate lactate concentration correlated significantly to skeletal muscle biopsy lactate concentration at the end of Ex 1. In conclusion, microdialysate lactate concentration in the working muscle increased step-wise with increasing blood flow restriction. It showed a better correlation to venous than to muscle biopsy lactate, which is possibly partly explained by the characteristics of diffusion between body compartments and differences in time resolution between the methods used.
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Ácido Láctico/sangre , Músculo Esquelético/irrigación sanguínea , Músculo Esquelético/metabolismo , Esfuerzo Físico/fisiología , Adulto , Biopsia , Glucosa/metabolismo , Glicerol/metabolismo , Humanos , Isquemia/metabolismo , Modelos Lineales , Masculino , Microdiálisis , Músculo Esquelético/citología , Flujo Sanguíneo Regional , Urea/metabolismo , VenasAsunto(s)
Atención a la Salud/organización & administración , Reforma de la Atención de Salud , Participación de la Comunidad , Control de Costos , Sector de Atención de Salud , Humanos , Liderazgo , Mala Praxis/economía , Objetivos Organizacionales , Responsabilidad Social , Estados Unidos , Cobertura Universal del Seguro de SaludAsunto(s)
Atención a la Salud/normas , Internet/organización & administración , Edición/organización & administración , Garantía de la Calidad de Atención de Salud/métodos , Humanos , Internet/estadística & datos numéricos , Programas Controlados de Atención en Salud/normas , Edición/estadística & datos numéricos , Estados UnidosRESUMEN
The aim of a study comprising 607 women working as homecare personnel was to investigate general spinal, joint and segmental mobility, different symptoms (pain and strain) and their relation to various aspects of disability. Joint mobility (mainly peripheral) was estimated using the "Beighton" score and spinal posture and mobility were measured by kyphometer. Passive segmental mobility and pain provocation were estimated manually. Pain intensity and strain during work and leisure were estimated using visual analogue scales for defined anatomical regions. Disability was rated using defined items and two indices. The 7-day prevalence of low back pain was 48%. Peripheral joint mobility, spinal sagittal posture and thoracic sagittal mobility showed low correlations with disability. Lumbar sagittal hypomobility was associated with higher disability. Manually estimated segmental mobility and segmental pain provocation of L4-L5 and L5-S1 correlated with disability; hypo- and hypermobility or positive pain provocation tests at these levels showed higher disability than normal mobility and negative pain provocation tests, respectively. Cluster analysis revealed that the combination of positive pain provocation tests and low lumbar sagittal mobility was associated with particularly high disability levels. In conclusion, positive pain provocation tests were clearly associated with high disability levels.
Asunto(s)
Evaluación de la Discapacidad , Servicios de Atención de Salud a Domicilio , Articulaciones/patología , Dolor de la Región Lumbar/diagnóstico , Región Lumbosacra/patología , Columna Vertebral/patología , Actividades Cotidianas , Adulto , Anciano , Fenómenos Biomecánicos , Análisis por Conglomerados , Personas con Discapacidad , Femenino , Personal de Salud , Humanos , Articulaciones/fisiología , Dolor de la Región Lumbar/epidemiología , Dolor de la Región Lumbar/patología , Persona de Mediana Edad , Índice de Severidad de la Enfermedad , Factores Sexuales , Factores Socioeconómicos , Columna Vertebral/fisiología , Recursos HumanosRESUMEN
OBJECTIVE: to investigate the feasibility of using microdialysate glucose, lactate and pyruvate concentrations for grading the severity of blood flow reduction in patients with critical limb ischaemia. PATIENTS AND METHODS: microdialysis catheters were inserted (two subcutaneously and one intramuscularly) in the symptomatic limb of ten patients. To further reduce limb perfusion, the lower leg was elevated during part of the experiment. RESULTS: elevation reduced ankle and toe blood pressure and transcutaneous oxygen tension. Microdialysate glucose concentration decreased at all three catheter sites, while lactate increased in the intramuscular catheter. Two patients interrupted the elevated position prematurely due to severe pain in the foot. They had among the highest lactate levels in the horizontal position and the most marked increases following provocation. Neither initial metabolite concentrations nor concentration changes during elevation were shown to correlate to conventional methods used to assess limb perfusion. CONCLUSIONS: in patients with critical limb ischaemia microdialysis can be used without complications. A significant decrease in glucose concentration may reflect lowered blood flow in the elevated position. Metabolic response, i.e. increase in lactate concentration during profoundly reduced limb perfusion was heterogeneous, indicating an overestimation of the presence of ischaemia in some patients using current diagnostic methods.
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Glucosa/metabolismo , Isquemia/metabolismo , Ácido Láctico/metabolismo , Pierna/irrigación sanguínea , Microdiálisis , Monitoreo Fisiológico/métodos , Ácido Pirúvico/metabolismo , Arteriopatías Oclusivas/fisiopatología , Velocidad del Flujo Sanguíneo , Presión Sanguínea , Estudios de Factibilidad , Arteria Femoral , Humanos , Isquemia/diagnóstico , Isquemia/fisiopatología , Flujometría por Láser-Doppler , PosturaRESUMEN
UNLABELLED: A lower detection rate of coronary artery disease (CAD) has been reported for SPECT imaging in women, despite the fact that similar numbers of women and men die each year of heart disease. Ruling out instrumentation as a possible source of this low detection rate for CAD in women could be important in determining the root cause of this difference. METHODS: Patients were referred by cardiologists and randomized to PET or SPECT by the imaging center. A total of 210 patients (106 women, 104 men) were enrolled in this study, with 105 imaged by dual-isotope SPECT and 105 imaged by 82Rb PET. Rest/stress scanning was performed using dipyridamole. The effects of sex, prior history of CAD, and instrumentation on the detection of positive scans were determined using multiple logistic regression analysis with positive scans as the endpoint. RESULTS: For the total study population, sex and prior history of CAD are significantly associated with positive scans, whereas imaging modality and age are not. There was no significant interaction between sex and prior history of CAD. Men have 4.1-fold greater odds of having a positive nuclear scan than women, and patients with prior history of CAD have 5.2-fold greater odds of a positive scan after controlling for the confounding effects of age and imaging modality. In the subgroup of patients with no prior history of heart disease, men have 3.9-fold greater odds of a positive scan than women, and the odds ratio of a positive scan is 2.5-fold greater for PET than for SPECT. There was no statistical difference in the number of positive scans by SPECT or PET, or positive scans by sex in patients with documented history of CAD. CONCLUSION: Fewer women than men have positive nuclear cardiology scans by both PET and SPECT, despite similar symptoms. Instrumentation characteristics alone do not account for this sex-based difference and suggest the possibility that early CAD may present differently in women than in men.
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Enfermedad Coronaria/diagnóstico por imagen , Corazón/diagnóstico por imagen , Tomografía Computarizada de Emisión de Fotón Único , Tomografía Computarizada de Emisión , Anciano , Enfermedad Coronaria/epidemiología , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Factores SexualesAsunto(s)
Actitud del Personal de Salud , Atención a la Salud/tendencias , Periodismo Médico , Programas Controlados de Atención en Salud/tendencias , Informática Médica/tendencias , Médicos/psicología , Centros Médicos Académicos/tendencias , American Medical Association , Predicción , Humanos , Publicaciones Periódicas como Asunto , Estados UnidosRESUMEN
The aim of this study was to investigate joint mobility, segmental and general spinal mobility and their interrelationship in 607 women working as homecare personnel. Joint mobility (mainly peripheral) was estimated using the "Beighton" score. Spinal posture and mobility were measured by Debrunner's kyphometer. Passive segmental mobility and pain provocation were estimated manually. Reliability tests between two physiotherapists of segmental mobility and pain provocation (n = 150 subjects) were performed. Positive correlations were found between joint mobility, sagittal thoraco-lumbar mobility and segmental mobility. Hyperlordosis (>39 degrees) was associated with greater lumbar mobility. The reliability of manual segmental mobility and segmental pain provocation was good, especially in the lowest back segments (kappa approximately 0.7). Joint mobility, general mobility and segmental spinal mobility intercorrelated. Segmental mobility manually estimated showed intertester reliability. The good positive correlation between sagittal lumbar mobility and manually tested segmental mobility indicates criterion validity for the latter.
Asunto(s)
Cuidadores , Servicios de Atención de Salud a Domicilio , Articulaciones/fisiología , Columna Vertebral/fisiología , Adulto , Análisis de Varianza , Cuidadores/estadística & datos numéricos , Femenino , Humanos , Modelos Lineales , Dolor de la Región Lumbar/diagnóstico , Dolor de la Región Lumbar/fisiopatología , Persona de Mediana Edad , Movimiento/fisiología , Proyectos Piloto , Postura/fisiología , Reproducibilidad de los Resultados , Curvaturas de la Columna Vertebral/diagnóstico , Curvaturas de la Columna Vertebral/fisiopatología , Encuestas y Cuestionarios , SueciaRESUMEN
In developed countries, clinicians are faced with a plethora of diagnostic tests to apply to patients to guide their clinical management. The quality, effectiveness, and efficiency of patient care should be foremost in the clinician's mind. Laboratory directors should make every effort to guide clinicians in appropriate laboratory test ordering, interpretation, and resulting actions. Medicine, being at its center a moral enterprise grounded in a covenant of trust, and laboratory medicine being a subset of medicine, must first care and advocate for the patient, and consider clinical outcomes as most important.