The application of the combined corticotropin-releasing hormone plus desmopressin stimulation during petrosal sinus sampling is both sensitive and specific in differentiating patients with Cushing's disease from patients with the occult ectopic adrenocorticotropin syndrome.

CONTEXT: Although bilateral inferior petrosal sinus sampling (BIPSS) with CRH stimulation is the most accurate procedure for the differential diagnosis of ACTH-dependent Cushing's syndrome (CS), 4-15% of patients with Cushing's disease (CD) fail to demonstrate diagnostic gradients. Preliminary data suggest that a more potent stimulation by the combined administration of CRH plus desmopressin during BIPSS may provide some diagnostic advantage. A crucial issue, however, is whether such an amplified stimulation may affect the specificity of the procedure, and this was the main aim of the present study. OBJECTIVE: We investigated the diagnostic accuracy of BIPSS performed by CRH plus desmopressin stimulation. DESIGN AND SETTING: A retrospective analysis was conducted at a single tertiary care center. PARTICIPANTS: Fifty-four patients were admitted for the investigation of ACTH-dependent CS. CD was diagnosed in 47 patients; occult ectopic ACTH syndrome (oEAS) was histologically confirmed in seven patients. INTERVENTION(S): All patients underwent BIPSS with CRH plus desmopressin administration. Additional noninvasive tests included CRH test, high-dose dexamethasone suppression test, desmopressin test, and pituitary magnetic resonance imaging. MAIN OUTCOME MEASURES: Gradients of inferior petrosal sinus (IPS) to peripheral (IPS/P) ACTH were calculated before and after stimulation with CRH plus desmopressin. RESULTS: The sensitivity for a basal IPS/P gradient greater than 2 was 61.7%, with 100% specificity and a diagnostic accuracy of 66.7%. After stimulation with CRH plus desmopressin, receiver operating characteristic (ROC) curve analysis showed that a cutoff gradient of more than 2 offers the best test performance. In total, 46 of 47 patients with CD had an IPS/P gradient greater than 2, but none of the patients with oEAS, resulting in a sensitivity of 97.9%. The specificity was 100%, diagnostic accuracy was 98.2%, and the positive and negative predictive values were 100 and 87.5%, respectively. A subgroup of 18 patients (16 with CD and two with oEAS) had contradictory responses to routine tests with CRH and/or high-dose dexamethasone suppression test; sensitivity, specificity, and accuracy of BIPSS in this subgroup were 100%. CONCLUSIONS: The application of a combined stimulation with CRH plus desmopressin during BIPSS is associated with a high sensitivity but no loss of specificity.

Complications of percutaneous nephrostomy, percutaneous insertion of ureteral endoprosthesis, and replacement procedures.

PURPOSE: The aim of the present study was to record and identify the frequency of complications following percutaneous nephrostomy, replacement of nephrostomy drains and percutaneous insertion of ureteral endoprostheses. METHODS: During a 10-year period 341 patients were referred to our department with indications for percutaneous nephrostomy and/or percutaneous insertion of a ureteral endoprosthesis, and a total of 1036 interventional procedures were performed (nephrostomy, catheter change, stenting). RESULTS: There were three major complications (0.29%): two patients died during the first 30 days after the procedure, due to aggravation of their condition caused by the procedure, and one patient had retroperitoneal bleeding requiring surgery. There were 76 complications of intermediate severity (7.33%): catheter or stent displacement (n = 37, 3.57%) catheter occlusion (n = 18, 1.73%), hematuria (n = 12, 1.16%), and urinary tract infection (n = 9, 0.87%). The 55 minor complications (5.3%) comprised inflammation of the skin at the site of insertion of the percutaneous catheter. CONCLUSION: The small number of complications observed during acts of interventional uroradiology prove transcutaneous manipulations to be safe medical procedures.

The application of a combined stimulation with CRH and desmopressin during bilateral inferior petrosal sinus sampling in patients with Cushing's syndrome.

BACKGROUND: Bilateral inferior petrosal sinus sampling (BIPSS) is a useful investigative technique in the differential diagnosis of ACTH-dependent Cushing's syndrome (CS). The diagnostic sensitivity of this procedure is improved by the administration of CRH to stimulate ACTH secretion. It has been reported recently that the combined administration of CRH and desmopressin is a more potent stimulus for ACTH release from corticotroph adenomas. We therefore hypothesized that the combined stimulation of ACTH secretion with CRH plus desmopressin may further improve the diagnostic outcome of this procedure. AIMS: To report our experience of the application of combined stimulation with CRH and desmopressin during BIPSS in patients with ACTH-dependent Cushing's syndrome, and to compare these results to those obtained in patients who have undergone BIPSS with CRH stimulation alone. PATIENTS: We studied 34 patients with ACTH-dependent CS: 30 with Cushing's disease (CD) and four with occult ectopic ACTH syndrome (oEAS). A combined stimulation with CRH (100 micrograms i.v.) plus desmopressin (10 micrograms i.v.) during BIPSS was performed in 15 patients with CD, while in a different group of 15 patients with CD, BIPSS was performed with CRH stimulation alone (100 micrograms i.v.). In the patients with oEAS, BIPSS was performed with CRH stimulation in three and CRH plus desmopressin in one patient. RESULTS: In patients with CD the mean peak ACTH levels from the dominant petrosal sinus samples were significantly higher in the group given a combined stimulus than in the group who had only CRH stimulation (mean +/- SD: 1649 +/- 938 vs. 692 +/- 561 ng/l, P < 0. 05). Dominant inferior petrosal sinus/peripheral (IPS/P) ACTH ratios greater than 2 were observed in 15/15 (100%) patients following the combined stimulation with CRH and desmopressin and 13/15 (87%) patients undergoing stimulation with CRH alone. No patient with oEAS had an IPS/P ratio greater than 2. It is of note that the single patient with oEAS studied following a combined stimulation during BIPSS had a IPS/P ratio of less than 2, despite a significant peripheral ACTH and cortisol response. CONCLUSIONS: A combined stimulus using CRH and desmopressin appears to induce a higher ACTH output from pituitary corticotroph adenomas during BIPSS, which may improve the diagnostic sensitivity of this procedure.

Long-term follow-up in patients with malignant biliary obstruction after percutaneous placement of uncovered wallstent endoprostheses.

PURPOSE: Evaluation of the treatment of malignant obstructive jaundice by percutaneous insertion of uncovered stents. MATERIAL AND METHODS: 51 patients (35 men, 16 women) with inoperable malignant biliary obstruction underwent percutaneous placement of uncovered Wallstent biliary endoprostheses. A total of 65 endoprostheses were inserted. RESULTS: The technical success rate was 98%, and the procedure-related complications rate was 10%. Early complications rate within the first 30 days was 2%. The clinical success rate within the first 30 days was 98% and the 30-day mortality rate was 2%. The late complications rate was 16%. The overall stent occlusion rate was 18% at a mean of 288.4 days. Mean survival time of the 50 patients was 214 days, and the mean total duration of hospital stay was 9.8 days. CONCLUSIONS: The advantages of uncovered Wallstent endoprostheses justify their placement in patients with inoperable malignant obstructive jaundice since patients' quality of life is markedly improved. Stent insertion is associated with a low complication rate, most stents remain patent longer than the patients' survival time and patients' hospital stay is relatively short.

Percutaneous metallic self-expandable endoprostheses in biliary obstruction caused by metastatic cancer.

BACKGROUND/AIMS: Up to now, all reports about metallic stents concerned mostly patients with obstructive jaundice due to primary cancer although some of these series included a small number of patients with metastatic disease as a cause of occlusion of the bile ducts. The question of whether they should be used in patients with biliary obstruction due to metastatic disease, and consequently have a limited life expectancy, is investigated. PATIENTS AND METHODS: Between January 1994 and April 1995, we inserted percutaneously 20 metallic self-expandable endoprostheses in 14 patients with obstructive jaundice due to metastatic disease. RESULTS: Twelve patients died with a mean survival of 144.6 (range 25-338) days without any evidence of biliary reobstruction. For 2 patients, we have followup no longer than 30 days. Thirty day mortality was 7.2% (1/14). Jaundice reoccurred in one patient but wasn't related to stent obstruction, and he died during the first 30 days. We had 2 cases with moderate hemobilia. CONCLUSION: We believe that the use of metal stents in patients with obstructive jaundice due to metastatic disease is justified. Their high initial cost is offset by their prolong patency, decreased complication rate and shorter hospitalization.

Bilateral ureteral involvement in polyarteritis nodosa.

A case of polyarteritis nodosa with bilateral ureteral changes in IVU is reported, because of the rarity of ureteric involvement in this entity. The urographic findings were unilateral ureteral stricture with hydronephrosis and irregular ureter outlines bilaterally. All lesions subsided after treatment.