Management of Nephrolithiasis in Pregnancy: Multi-Disciplinary Guidelines From an Academic Medical Center.

Introduction: The management of nephrolithiasis during pregnancy can be stressful for urologists due to concerns for investigations and treatments that may pose risk of fetal harm, and unfamiliarity with optimal management of these complex patients. In response, we created multi-disciplinary evidence-based guidelines to standardize the care for obstetric patients presenting with flank pain and suspicion for nephrolithiasis. Methods: A multi-disciplinary team involving Urology, Obstetric Anesthesiology, Obstetrics and Gynecology, Diagnostic Radiology, and Interventional Radiology from a single academic medical center was assembled. A PubMed search was performed using keywords of pregnancy/antepartum, nephrolithiasis/calculi/kidney stones, ureteroscopy, non-obstetric surgery, complications, preterm delivery, MRI, computerized tomography, renal bladder ultrasound (RBUS), and anesthesia to identify relevant articles. Team members reviewed their respective areas to create a comprehensive set of guidelines. One invited external expert reviewed the guidelines for validation purposes. Results: A total of 54 articles were reviewed for evidence synthesis. Four guideline statements were constructed to guide diagnosis and imaging, and seven statements to guide intervention. Guidelines were then used to create a diagnostic and intervention flowchart for ease of use. In summary, RBUS should be the initial diagnostic study. If diagnostic uncertainty still exists, a non-contrast CT scan should be obtained. For obstetric patients presenting with a septic obstructing stone, urgent decompression should be achieved. We recommend ureteral stent placement as the preferred intervention if local factors allow. Conclusions: We present a standardized care pathway for the management of nephrolithiasis during pregnancy. Our aim is to standardize and simplify the clinical management of these complex scenarios for urologists.

The Concordance Between Imaging and Adrenal Vein Sampling Varies With Aldosterone-Driver Somatic Mutation.

BACKGROUND: Correct subtyping of primary aldosteronism (PA) is critical for guiding clinical management. Adrenal imaging is less accurate than adrenal vein sampling (AVS); nonetheless, AVS is invasive, technically challenging, and scarcely available. OBJECTIVE: To identify predictors of concordance between cross-sectional imaging and lateralized AVS in patients with PA that could help circumvent AVS in a subset of patients. METHODS: We retrospectively studied all patients with PA who underwent AVS in a tertiary referral center from 2009 to 2019. AVS was performed before and after cosyntropin stimulation. Patients with lateralized AVS in at least one condition were included. Aldosterone synthase-guided next-generation sequencing was performed on available adrenal tissue. Logistic regression was implemented to identify predictors of imaging-AVS lateralization concordance. RESULTS: A total of 234 patients (62% men), age 20 to 79 years, 73% white, 23% black, and 2% Asian were included. AVS lateralization was found: 1) both pre- and post-cosyntropin (Uni/Uni) in 138 patients; 2) only at baseline (Uni/Bi) in 39 patients; 3) only after cosyntropin stimulation (Bi/Uni) in 29 patients. Catheterization partially failed in 28 patients. AVS-imaging agreement was higher in patients with KCNJ5 versus other aldosterone-driver somatic mutations (90.3% versus 64.6%; P < 0.001); in Asian and white versus black Americans (75%, 70%, and 36%, respectively); in younger patients; and those with left adrenal nodules and contralateral suppression. Conversely, AVS-imaging agreement was lowest in Uni/Bi patients (38% vs. 69% in Uni/Uni, and 62% in Bi/Uni; P = 0.007). CONCLUSIONS: While AVS-imaging agreement is higher in young white and Asian patients, who have KCNJ5-mutated aldosterone producing adenomas, no predictor confers absolute imaging accuracy.

Percutaneous Transesophageal Access for Enteral Feeding Tube Placement.

BACKGROUND: The purpose of this study was to describe our experience with percutaneous transesophageal enteral feeding tube placement when percutaneous gastrostomy tube placement is not feasible. MATERIALS AND METHODS: A retrospective review was performed from July 2018 to March 2019. Thirteen patients (9 females, 4 males), (age range 22-80 years; mean age, 55 years; mean body mass index of 24.6) underwent placement of 14 percutaneous transesophageal enteral feeding tubes. Relative contraindications to standard gastrostomy tube placement included: prior gastric surgery (5 patients), severe contractures/large body habitus (2), abdominal mesh (1), high riding stomach (1), interposition of bowel (1), ascites (1), and refractory gastrostomy tract leak (1). Patients were evaluated for functionality of the tube, complications, and patients' satisfaction with physical examination at 24 h, review of electronic medical record and phone interviews at 1 month, and 3-month follow-up. Complications were classified according to the CIRSE guidelines. RESULTS: Technical success rate was 100% with placement of seven percutaneous transesophageal gastrostomy tubes and seven percutaneous transesophageal jejunostomy tubes. One patient underwent tube placement twice after dislodgement. At 3-month follow-up, two patients had died, one patient was lost to follow-up, and 11 patients had properly working tubes. No major complications occurred. Minor complication rate was 43% (6/14). Patient's satisfaction scores ranged from "poor" 2/11 (18%) or "neutral" 4/11 (36.4%) to "satisfied/very satisfied" 5/11 (45.3%). CONCLUSION: Percutaneous transesophageal enteral feeding tube placement is feasible with a low complication rate. A majority of patients were either satisfied or neutral with the transesophageal enteral tube.

Comprehensive Analysis of Steroid Biomarkers for Guiding Primary Aldosteronism Subtyping.

Adrenal vein sampling (AVS) is required to distinguish unilateral from bilateral aldosterone sources in primary aldosteronism (PA), and cortisol is used for AVS data interpretation, but cortisol has several pitfalls. In this study, we present the utility of several other steroids in PA subtyping, both during AVS, as well as in peripheral serum. We included patients with PA who underwent AVS at University of Michigan between 2012 and 2018. We used mass spectrometry to simultaneously quantify 17 steroids in adrenal veins (AV) and periphery, both at baseline and after cosyntropin administration. PA was classified as unilateral or bilateral based on a lateralization index ≥ or <4, respectively, separately for baseline and post-cosyntropin administration. Of 131 participants, AV catheterizations was deemed failed in 28 (21 %) patients (36 AVs) at baseline. Eight steroids demonstrated higher AV/periphery ratios than cortisol (P<0.01 for all); 11ß-hydroxyandrostenedione, 11-deoxycortisol, and corticosterone rescued most failed baseline catheterizations. Lateralization was generally consistent when using these alternative steroids. Based on pre- and post-cosyntropin data, the remaining 103 patients were classified as: U/U, 37; B/B, 32; U/B, 20; B/U, 14. Discriminant analysis of multi-steroid panels from peripheral serum showed distinct profiles across the 4 groups, with highest aldosterone, 18-oxocortisol and 11-deoxycorticosterone in U/U patients. In conclusion, 11ß-hydroxyandrostenedione and 11-deoxycortisol are superior to cortisol for AVS data interpretation. Single assay multi-steroid panels measured in peripheral serum are helpful in stratified PA subtyping and have the potential to circumvent AVS in a subset of patients with PA.

Three Discrete Patterns of Primary Aldosteronism Lateralization in Response to Cosyntropin During Adrenal Vein Sampling.

CONTEXT: Cosyntropin [ACTH (1-24)] stimulation during adrenal vein (AV) sampling (AVS) enhances the confidence in the success of AV cannulation and circumvents intraprocedure hormonal fluctuations. Cosyntropin's effect on primary aldosteronism (PA) lateralization, however, is controversial. OBJECTIVES: To define the major patterns of time-dependent lateralization, and their determinants, after cosyntropin stimulation during AVS. METHODS: We retrospectively studied patients with PA who underwent AVS before, 10, and 20 minutes after cosyntropin stimulation between 2009 and 2018. Unilateral (U) or bilateral (B) PA was determined on the basis of a lateralization index (LI) value ≥4 or <4, respectively. Available adrenal tissue underwent aldosterone synthase-guided next-generation sequencing. RESULTS: PA lateralization was concordant between basal and cosyntropin-stimulated AVS in 169 of 222 patients (76%; U/U, n = 110; B/B, n = 59) and discordant in 53 patients (24%; U/B, n = 32; B/U, n = 21). Peripheral and dominant AV aldosterone concentrations and LI were highest in U/U patients and progressively lower across intermediate and B/B groups. LI response to cosyntropin increased in 27% of patients, decreased in 33%, and remained stable in 40%. Baseline aldosterone concentrations predicted the LI pattern across time (P < 0.001). Mutation status was defined in 61 patients. Most patients with KCNJ5 mutations had descending LI, whereas those with ATP1A1 and ATP2B3 mutations had ascending LI after cosyntropin stimulation. CONCLUSION: Patients with severe PA lateralized robustly regardless of cosyntropin use. Cosyntropin stimulation reveals intermediate PA subtypes; its impact on LI varies with baseline aldosterone concentrations and aldosterone-driver mutations.

The occlusion balloon reduction technique for de novo placement and salvage of malpositioned enteric tubes.

PURPOSE: Nasoenteric, gastrojejunostomy, and jejunostomy tubes are methods of enteral nutrition in patients with functioning gastrointestinal tracts who cannot maintain adequate oral intake. Current placements; however, may be complicated by redundant wire and catheter loops within the stomach preventing operators from optimal feeding tube placement and predisposing patients to feeding tube prolapse. This report describes the occlusion balloon reduction technique for salvage of malpositioned tubes and placement of new enteric tubes in the setting of redundant loops. MATERIALS AND METHODS: Five patients underwent the occlusion balloon reduction technique for jejunostomy (n = 3), gastrojejunostomy (n = 1), or nasojejunal tube placement (n = 1). All patients (n = 5) had redundant wires coiled within the stomach. In all patients (n = 5), a 9-French × 32 mm × 120 cm Coda balloon was inserted over the wire and passed into the small bowel. The balloon was inflated after which reduction of redundancy in the upper gastrointestinal tract was performed. Feeding tubes were then placed with tips in the distal jejunum. Technical success of the occlusion balloon reduction technique, successful placement of enteric tube, complications, and follow-up were recorded. RESULTS: The occlusion balloon reduction was technically successful in all patients (n = 5). Feeding tube placement was successful in all patients (n = 5). No minor or major complication occurred. Mean follow-up was 56 days. CONCLUSION: The occlusion balloon reduction technique provides a method for reduction of redundant wire and catheter loops within the stomach during enteric tube placement or repositioning.

Ambulatory Tubeless Mini-Percutaneous Nephrolithotomy Using Moses Technology and Dusting Technique.

OBJECTIVE: To demonstrate the use of the Moses technology for holmium laser lithotripsy in conjunction with mini-percutaneous nephrolithotomy (PCNL) to treat a lower pole stone. The Moses technology is a pulse modulation method that can reduce stone retropulsion, which may have advantages when used during mini-PCNL. METHODS: A 63-year-old patient with a right-sided 1.5 cm lower pole stone (1300 Hounsfield Unit) underwent mini-PCNL using a 120W holmium laser (MosesP120, Lumenis). Moses has 2 modes-"Contact" and "Distance"-optimized for operation at 0-1 and 2-3 mm from the stone surface, respectively. Percutaneous access was obtained into the lower pole while the patient was in prone position. Using the medium (17.5F) mini-PCNL set (Karl Storz), the stone was fragmented using dusting settings with a 230 µm Moses fiber (0.3 J × 20-30 Hz; Moses Contact and Distance modes). RESULTS: The video demonstrates the capabilities of treating a lower pole stone with a dusting technique using Moses modes. Dusting, to decrease the stone size so that it can fit within the sheath, in combination with fragment expulsion with the Venturi effect, as well as extraction with graspers/baskets resulted in complete stone removal. Following placement of an antegrade ureteral stent (tubeless technique) and sealing of the tract with FloSeal, the patient was discharged from the recovery unit. There were no adverse events. The stent was removed after 7 days, and follow-up KUB at 2 weeks showed no residual fragment. CONCLUSION: Due to the miniaturization of equipment, the holmium laser serves as an ideal energy source for fragmentation. In our early experience, the Moses technology with mini-PCNL allows a combination of dusting and stone extraction. As mini-PCNL offers smaller tract dilatation, for lower pole stones it can be performed in an ambulatory setting and is an alternative to ureteroscopy or shockwave lithotripsy with the potential for complete stone clearance.

Adrenal Vein Sampling Lateralization Despite Mineralocorticoid Receptor Antagonists Exposure in Primary Aldosteronism.

Context: Many antihypertensive medications modulate the renin-angiotensin-aldosterone system, possibly skewing the diagnosis and subtyping of primary aldosteronism (PA). Particularly, mineralocorticoid receptor antagonists (MRA) might raise renin and stimulate aldosterone synthesis from nonautonomous areas, potentially obscuring lateralization on adrenal vein sampling (AVS). Withdrawal of MRA in severe PA, however, can precipitate hypokalemia and/or hypertension and therefore is not always practical. Objective: To assess the effects of MRA on the interpretation of AVS data. Design and Participants: A cohort study of all PA patients who underwent AVS at University of Michigan between January 2009 and January 2018 was conducted. Demographics, diagnostic, AVS, surgical pathology, and follow-up data were collected retrospectively. Results: Of 191 patients who underwent AVS, 51 (27%) were exposed to MRA at the time of the procedure. Plasma aldosterone concentration and the daily defined dose of antihypertensives were higher in patients taking vs those not taking MRA. Unilateral PA was more frequent in the MRA group, both precosyntropin and postcosyntropin (P < 0.05). The MRA group included two patients with unsuppressed renin, who demonstrated unequivocal AVS lateralization. To date, 86 patients underwent unilateral adrenalectomy, including 30 patients taking MRA during AVS. The proportion of clinical and biochemical success was not statistically different between patients exposed to and those not exposed to MRA during AVS (P = 0.17 and 0.65, respectively). Conclusion: Our data suggest that conclusive AVS lateralization is often achieved in patients with severe PA despite MRA use.

Removal of T-Fasteners Immediately After Percutaneous Gastrostomy Tube Placement: Experience in 488 Patients.

OBJECTIVE: The purpose of this article is to evaluate the safety of T-fastener removal immediately after percutaneous gastrostomy tube placement by assessing difference in complication rates between early and delayed gastropexy removal. MATERIALS AND METHODS: A retrospective review was performed of the electronic medical records of all patients who underwent percutaneous gastrostomy at our institution from January 2015 to June 2017. A total of 722 patients successfully underwent gastrostomy tube insertion during this period. Two hundred twenty-two patients were excluded from analysis on the basis of our exclusion criteria. Twelve patients were lost to follow-up. The remaining patients were divided into two groups: group 1 included 350 patients who had their T-fasteners released immediately after gastrostomy, and group 2 included 138 patients whose T-fasteners were left in place for 2 weeks. Electronic medical records were reviewed for postprocedure complications for up to 1 month. Complications were classified according to Society of Interventional Radiology classification. Statistical analysis was performed using a logistic regression model with calculation of odds ratios, power, p values, and 95% CIs. RESULTS: Seven (2.0%) major and 24 (6.8%) minor complications occurred in group 1. Two (1.4%) major and 11 (7.9%) minor complications occurred in group 2. There was no statistically significant difference in complication rates between immediate and delayed gastropexy removal. CONCLUSION: In our study, immediate removal of T-fasteners was not associated with a higher complication rate.

Gastrojejunoscopy facilitates placement of a percutaneous transgastric jejunostomy in a patient with a pancreaticoduodenectomy and multiple-failed feeding tube placements.

Enteral access is one of the most common procedures performed in abdominal and interventional radiology. The surgical anatomy of the postoperative stomach may, however, make enteral access challenging. This report describes a patient with a pancreaticoduodenectomy complicated by a gastrojejunostomy leak who underwent 2 unsuccessful transoral endoscopic nasojejunal tube placements and 2 failed percutaneous gastrojejunostomy tube placements. Eventually, a gastrojejunostomy tube was placed utilizing percutaneous techniques with fluoroscopy assistance and gastrojejunoscopy guidance. A combined technique with fluoroscopy and endoscopy, both controlled by interventional radiology, may be useful in patients with complex postsurgical gastrointestinal anatomy who require enteral access.

Percutaneous Cholecystostomy: Long-Term Outcomes in 324 Patients.

PURPOSE: To report technical success and clinical outcome of cholecystostomy tube placement along with timing-and method-of tube removal. MATERIALS AND METHODS: A retrospective review of cholecystostomy tubes placed from January 2010 to September 2017 was performed at a single academic center. This search yielded 1160 patients. Of these patients, 324 (27.9%) met inclusion criteria for cholecystostomy placement, 199 (61.4%) males and 125 (38.6%) females, with mean age of 67 years (range 6-101 years). The indication for cholecystostomy tube placement, technical success, surgical candidacy, medical comorbidities, clinical outcome, tube indwelling time, complications, and follow-up were recorded. RESULTS: Indications for cholecystostomy tube placement included: acute cholecystitis (n = 270; 83.3%), perforated cholecystitis (n = 22; 6.8%), emphysematous cholecystitis (n = 18; 5.6%), and other (n = 14; 4.3%). Technical success was 100%. Many patients had multiple medical comorbidities including (most commonly): debilitation (n = 211; 65.1%), cardiovascular disease (n = 194; 59.9%), multisystem disease (n = 181; 55.9%), and malignancy (n = 131; 40.4%). After tube placement, 96 (29.6%) patients underwent definitive cholecystectomy, 94 expired (29.0%), 36 (11.1%) had a patent cystic duct on follow-up cholangiogram and subsequent cholecystostomy removal, 14 (4.3%) underwent cholecystoscopy with stone removal, and 3 (0.9%) had liver transplantation. Forty-five (13.9%) patients had indwelling tubes at the end of the study period. Mean tube indwelling time was 89 days (range 0-586 days). CONCLUSION: Technical success for cholecystostomy tube placement was 100% with all patients having clinical resolution of acute cholecystitis. Many patients were able to have tubes subsequently removed.

Transnasal Snare Technique for Retrograde Primary Jejunostomy Placement After Surgical Gastrojejunostomy.

PURPOSE: To report a transnasal snare technique for retrograde primary jejunostomy placement after surgical gastrojejunostomy. MATERIALS AND METHODS: Two patients underwent the transnasal snare technique for retrograde primary jejunostomy placement. Patients included two females, age 58 and 62. In both patients, a gooseneck snare was inserted in a transnasal fashion. After insertion of the snare into the jejunum, the location was confirmed with ultrasound. The snare was then targeted using a Chiba needle through which a 0.018-inch wire was advanced and snared through the nose. The wire was exchanged for a 0.035-inch Amplatz wire over which the tract was serially dilated followed by insertion of the jejunostomy catheter through a peel-away sheath. Technical success, complications, and follow-up were recorded. RESULTS: Primary jejunostomy placement was technically successful in both patients. No minor or major complications occurred. Both patients received enteral nutrition the day following placement. Follow-up was at 54 and 38 days for patients 1 and 2, respectively. CONCLUSION: The transnasal snare technique provides a novel alternative for primary jejunostomy insertion allowing for targeting of the jejunum with improved procedural success and no complications.

Discordance between imaging and immunohistochemistry in unilateral primary aldosteronism.

OBJECTIVE: Correct subtyping of primary aldosteronism (PA) is essential for good surgical outcomes. Adrenal vein sampling (AVS) and/or computed tomography (CT) are used for PA subclassification. Clinical and/or biochemical improvement after surgery, however, is not always achieved in patients with presumed unilateral PA. We aimed to identify the pitfalls in PA subclassification leading to surgical treatment failures. PATIENTS AND DESIGN: We retrospectively studied 208 patients who underwent adrenal vein sampling (AVS) for PA subclassification in a tertiary referral centre, between January 2009 and August 2016. Simultaneous bilateral AVS was performed before and after cosyntropin administration. We implemented immunohistochemistry for aldosterone synthase (CYP11B2) and 17α-hydroxylase/17,20 lyase (CYP17A1) in adrenal glands resected from patients without improvement of PA after surgical treatment and from those with limitations in AVS interpretation. RESULTS: Of 55 patients who underwent adrenalectomy, three (5.5%) had no improvement of PA. All three patients underwent partial adrenalectomy to remove a CT-detected nodule present on the same side with AVS lateralization. Immunohistochemistry revealed a CYP11B2-negative nodule in both cases available. All patients who underwent total adrenalectomy based on AVS lateralization benefitted from surgery, including three patients with unilateral unsuccessful AVS and aldosterone suppression in the catheterized side vs inferior vena cava. CONCLUSIONS: Radiographically identified adrenal nodules are not always a source of PA, even when ipsilateral with AVS lateralization. These data caution against reliance on imaging findings, either alone or in conjunction with AVS, to guide surgery for PA.

Adrenal-derived 11-oxygenated 19-carbon steroids are the dominant androgens in classic 21-hydroxylase deficiency.

OBJECTIVE: To comprehensively characterize androgens and androgen precursors in classic 21-hydroxylase deficiency (21OHD) and to gain insights into the mechanisms of their formation. DESIGN: Serum samples were obtained from 38 patients (19 men) with classic 21OHD, aged 3-59, and 38 sex- and age-matched controls; 3 patients with 11ß-hydroxylase deficiency; 4 patients with adrenal insufficiency; and 16 patients (8 men) undergoing adrenal vein sampling. Paraffin-embedded normal (n = 5) and 21OHD adrenal tissues (n = 3) were used for immunohistochemical studies. METHODS: We measured 11 steroids in all sera by liquid chromatography-tandem mass spectrometry. Immunofluroescence localized 3ß-hydroxysteroid dehydrogenase type 2 (HSD3B2) and cytochrome b5 (CYB5A) within the normal and 21OHD adrenals. RESULTS: Four 11-oxygenated 19-carbon (11oxC19) steroids were significantly higher in male and female 21OHD patients than in controls: 11ß-hydroxyandrostenedione, 11-ketoandrostenedione 11ß-hydroxytestosterone, and 11-ketotestosterone (3-4-fold, P < 0.0001). For 21OHD patients, testosterone and 11-ketotestosterone were positively correlated in females, but inversely correlated in males. All 11oxC19 steroids were higher in the adrenal vein than in the inferior vena cava samples from men and women and rose with cosyntropin stimulation. Only trace amounts of 11oxC19 steroids were found in the sera of patients with 11ß-hydroxylase deficiency and adrenal insufficiency, confirming their adrenal origin. HSD3B2 and CYB5A immunoreactivities were sharply segregated in the normal adrenal glands, whereas areas of overlapping expression were identified in the 21OHD adrenals. CONCLUSIONS: All four 11oxC19 steroids are elevated in both men and women with classic 21OHD. Our data suggest that 11oxC19 steroids are specific biomarkers of adrenal-derived androgen excess.

Preoperative splenic artery embolization in klippel-Trenaunay syndrome with massive splenomegaly: A case report.

The authors describe a case of Klippel-Trenaunay syndrome (KTS) with massive splenomegaly in a 29-year-old woman. Preoperative splenic artery embolization using the "double embolization technique" (a combination of distal selective splenic artery embolization and proximal splenic artery occlusion) facilitated open splenectomy.

Detection of synthetic cannabinoids in herbal incense products.

OBJECTIVE: We investigated the ability of clinical drug of abuse tests to detect synthetic cannabinoids. RESULTS: A broad class GC/MS drug screening method detected JWH-018 and JWH-073 in methanolic extracts and teas steeped from herbal incense products in three of four products tested. CONCLUSIONS: Synthetic cannabinoids are present in herbal incense purchased over the internet.

Percutaneous cholecystostomy as a bridge to definitive endoscopic gallbladder stent placement.

BACKGROUND & AIMS: Percutaneous cholecystostomy (PC) is an effective treatment for acute cholecystitis (AC) in patients who are poor surgical candidates, although it is generally used as a bridge to cholecystectomy, given its long-term risks, the need for repeated procedures, and patient dissatisfaction. Ongoing patient comorbidity, however, might preclude cholecystectomy after recovery from the acute illness. METHODS: Four patients with AC who were poor immediate and long-term candidates for cholecystectomy underwent PC as primary therapy for AC, followed by endoscopic placement of a transpapillary gallbladder stent as definitive long-term management. RESULTS: All 4 patients were successfully treated for AC with PC. After recovery, the patients underwent endoscopic gallbladder stent placement and removal of the PC. In 2 cases, endoscopic transpapillary access to the gallbladder was facilitated by advancing a guidewire through the cholecystostomy tract into the duodenum. All patients had favorable outcomes. CONCLUSIONS: PC as a bridge to permanent therapy with endoscopic gallbladder stenting appears to be a viable strategy in the management of patients with AC who are poor immediate and long-term candidates for cholecystectomy.

Serological study of selected vector-borne diseases in shelter dogs in central Spain using point-of-care assays.

We evaluated the prevalence of selected vector-borne diseases in 131 dogs in an animal shelter in central Spain using point-of-care assays (SNAP 4DX and SNAP Leishmania; IDEXX Laboratories, Westbrook, ME). The SNAP 4DX detects Dirofilaria immitis (Di) antigen and antibodies against Ehrlichia canis (Ec), Borrelia burgdorferi (Bb), and Anaplasma phagocytophylum (Aph); the SNAP Leishmania kit detects antibodies against Leishmania infantum (Li). Dogs were classified as healthy or sick based on physical examination, complete blood counts, and serum chemistry profiles. The prevalence of positive test results was as follows: Ec, 5.3% (n = 7); Aph, 19.0% (n = 25); Bb, 0%; Di, 0%; and Li, 5.3% (n = 7). Four dogs (3%) were coexposed to Ec and Aph, and three dogs (2.3%) were coexposed to Aph and Li. There was no statistically significant correlation between positive serology and clinical status (sick vs. healthy) or hematologic/biochemical abnormalities. The prevalence of Aph was the highest and is in agreement with a recent report in a dog shelter in northwestern Spain. These point-of-care assays may be more valuable as epidemiologic than as clinical tools.

Retrievability of optional inferior vena cava filters with caudal migration and caval penetration: report of three cases.

The present report describes the safe retrieval of caudally migrated optional inferior vena cava (IVC) filters with significant IVC penetration. Three patients had optional IVC filters placed for deep vein thrombosis/pulmonary emboli and contraindications for anticoagulation. Subsequent imaging showed caudal migration and penetration of the filter legs through the IVC wall. All filters were removed without major complications. One patient experienced abdominal pain after filter removal, which required no treatment. Caudal migration of optional filters with IVC wall penetration by the filter legs may be more common with new filter designs in which the secondary and primary struts are separated.