Symptomatic hemodialysis arteriovenous fistula with associated subclavian stenosis and a normal fistulogram.

While arteriovenous fistulas (AVFs) are the optimal route of access for hemodialysis in terms of duration of patency and infection rates, they can still fail due a variety of reasons. Most commonly, AVF failure is due to venous stenotic lesions, resulting in reduced blood flow rate across the fistula. Fistulograms are often used to investigate cases of symptomatic or poor fistula function. This case discusses a 71-year-old man with a mature brachiocephalic AVF who presented with severe right upper extremity edema, and had a negative fistulogram, despite a severe stenosis in his AVF.

Rate of Curative Surgery in Real-world Patients with Unresectable Metastatic Colorectal Cancer Treated with FOLFOXIRI ± Bevacizumab: A Western Canadian Province Experience.

BACKGROUND: Recent evidence from randomized trials suggests that FOLFOXIRI (fluorouracil, oxaliplatin, and irinotecan) ± bevacizumab is associated with higher response rates, with the potential for conversion of unresectable to resectable disease in metastatic colorectal cancer (mCRC). However, limited evidence is available on the efficacy and safety of this regimen in real-world patients with mCRC. The current study aims to evaluate the conversion rate and safety of FOLFOXIRI ± bevacizumab in real-world patients with unresectable mCRC. METHODS: In this retrospective multicenter population-based cohort study, patients who were diagnosed with unresectable mCRC between January 2015 and December 2018 in Saskatchewan and received FOLFOXIRI ± bevacizumab were assessed. Kaplan-Meier survival methods and the log-rank test were performed. RESULTS: A total of 28 eligible patients with a median age of 51 years (interquartile range 39-60) and a male:female ratio of 11:17 were identified; 39% had rectal cancer, 46% had extrahepatic disease, and 46% had bilobar liver metastases. Overall, 63% of the patients had a positive response to FOLFOXIRI ± bevacizumab and 53% underwent metastasectomy. Of all patients 60% had grade 3/4 toxicity and 32% required hospital admission. No treatment-related mortality was noted. After 4 years, 50% of the patients were alive. Median progression-free survival of patients who underwent surgery was 18 months (95% CI 11.3-24.7) versus 11 months (4-18.1) without surgery (p = 0.28). Median overall survival of patients with surgery was 33 months (17.5-48.5) versus 16 months (8.3-23.7) without surgery (p = 0.03). CONCLUSION: The current study suggests that FOLFOXIRI ± bevacizumab therapy in real-world patients with mCRC is associated with a high rate of conversion from unresectable to resectable metastatic disease. Patients with metastasectomy had better survival.

Imaging of the unstable plaque.

Atherosclerosis is now considered a systemic inflammatory disorder affecting the arterial tree. Inflammation plays a role in all stages of the disease, from the initiation of the fatty streak to the final stage of plaque rupture. Atherosclerotic plaques that demonstrate the features of active inflammation are more likely to become symptomatic. In addition to having a higher risk of developing adverse cardiovascular events, patients who have higher indices of inflammation may be more likely to develop restenosis after endovascular stenting. Thus, the identification of the 'inflamed plaque' is the subject of intense research. The detection of the inflamed plaque by the conventional modalities of ultrasound, magnetic resonance imaging, computed tomography and nuclear medicine as well as the novel imaging modalities of optical coherence tomography, near-infrared spectroscopy, thermography and angioscopy will be examined.

CT vs conventional angiography in unselected patients with suspected coronary heart disease.

BACKGROUND: To provide confirmatory evidence that the accuracy of MSCT coronary angiography is comparable to that of conventional coronary angiography. METHOD: 19 patients who had both MSCT and conventional coronary angiography were included in our study. The mean age of our patients was 62.3 (SD 7.7) and 42% of our patients were female. The coronary vascular tree was subdivided into 13 segments (modified from the 16-segment AHA classification). The grade of disease was classified into 1 of 6 categories; (1)0-50% stenosis; (2) 50-75% stenosis; (3) 75-99% stenosis; (4) Occluded; (5) aneurysmal; (6) fistula. The results of the imaging studies were analysed by two radiologists, who were blinded to the clinical data. RESULTS: A total of 172 coronary artery segments were visualised on both CT and conventional angiography. There is excellent statistical correlation between the appearance of the coronary arteries on MSCT and conventional angiography, as determined by Spearmans test (r=0.727, P<0.0001). MSCT coronary angiography had a sensitivity of 80.0%, specificity of 95.9%, NPV of 97.9% and PPV of 66.7%. CONCLUSION: The specificity and NPV from our study are similar to those obtained by previous researchers. This study confirms that a negative CT coronary angiogram is useful to rule out the presence of significant coronary heart disease.

Platelets, atherosclerosis and the endothelium: new therapeutic targets?

One of the major causes of morbidity and mortality in the developed world is atherosclerosis. Recent research has suggested that the interaction of platelets with the endothelium is important in both the progression of atherosclerosis and the development of the acute complications of the disease. Both of these cells secrete various signalling molecules and express adhesion molecules, which can influence the development of pathological states. Certainly, there may be a vicious cycle in which platelet activation promotes atherosclerosis; a process involving inflammation and the activation of many other cell types (for example, leukocytes and smooth muscle cells), which causes further platelet activation. Therefore, intense effort has been made to develop therapeutic agents that can modulate the function of these cells, with the ultimate aim to retard (or even reverse) the progression of atheroma growth.

Factor X inhibitors.

Factor X plays a central role in coagulation, being the point of convergence of the extrinsic and intrinsic pathways of blood clotting. It may also act as one of the links between the coagulation and inflammatory pathways. These findings suggest that factor X may represent an attractive target for a new antithrombotic drug. Indeed, a factor X inhibitor, fondaparinux, has already been approved for clinical use to prevent post-operative deep vein thrombosis. Factor X inhibitors are also being evaluated for use in the treatment of the acute coronary syndromes, pulmonary embolism and deep vein thrombosis. Oral factor X inhibitors are also being developed, which may be of use in the outpatient prevention and/or treatment of stroke and thromboembolism.