bluuebunny/crossref_metadata_2025 huggingface dataset:
The Importance of Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL) Certification for Noninvasive Peripheral Vascular Tests: The Tennessee Experience
Authors: Stanley David G.
Published: March 2018

Introduction

Accurate, safe, and cost-effective noninvasive vascular tests (NIVTs) upon which vascular specialists can confidently base recommendations for treatment decisions are critically important for optimal patient care. Vascular surgeons are referred patients from many sources. These patients often present with NIVTs performed at a variety of facilities. A vascular specialist must be aware of the accuracy of NIVTs from his vascular lab as well as those sent from other facilities in order to make correct treatment recommendations. Without this knowledge, the consultant must either repeat the NIVT in a vascular lab with known quality assurance (QA) statistics or order arteriograms or other tests.

Methods

In order to determine the accuracy of studies from other facilities, the Vascular Diagnostic Center of Oak Ridge (VDC) and the vascular surgeons that practice at the Methodist Medical Center of Oak Ridge (MMC) developed an ongoing quality assurance program to address the quality and accuracy of NIVTs from other facilities. Since 1985, duplex vascular studies from other vascular laboratories, hospitals, and physician offices have been carefully compared with NIVTs performed at the VDC. We also compared all studies from VDC and other facilities to arteriograms and to pathology demonstrated in the operating room at MMC in patients who underwent surgery.

Conclusions

In the QA experience of VDC, studies from Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL)-accredited laboratories were accurate in 83% of reviewed cases, whereas studies from facilities without ICAVL accreditation generated much lower correlation to quality and accuracy indices. This information is clearly valuable to physicians, patients, and third-party payers.
Are There Long-Term Consequences of Iliac Artery Trauma during Endograft Implantation? Results of Serial Duplex Ultrasound Follow-up
Authors: Mendoza Bernardo , Meier George H. , Carter Kathleen , Nelms Courtney , Chaler Dulcie , Beedie Felicia , Sprouse L. Richard
Published: March 2018

Purpose

The implantation of abdominal aortic endografts requires the insertion of large devices that have the potential to traumatize the iliac arteries, particularly on the ipsilateral side, where the main body of the endograft is introduced. The consequences of this potential trauma are unknown, but the possibility for significant injury remains. For this reason, a prospective measurement of iliac intimal medial thickness by serial duplex ultrasound was undertaken to determine the effect of endograft placement on iliac arteries.

Methods

A total of 117 patients had duplex evaluation of their iliac arteries after aortic endograft placement at an average follow-up of 18.8 months (range, 0 to 71 months). Ancure devices were used in 89, AneuRx in 11, Endologix in 12, Vanguard in 1, and unknown devices in 4. All endografts were scanned using Philips/ ATL HDI 5000 or ATL 3000 ultrasound machines with 7–4 MHz transducers and a standard protocol, with additional iliac artery measurements performed for the specifics of this study. Of these 117 patients, bilateral intimal medial thickness (IMT) was measured with a clearly determined ipsilateral (larger diameter sheath) implantation side defined in 66 patients. In these patients the ratio of ipsilateral (main introducer) IMT to contralateral (smaller diameter sheath) IMT was determined.

Results

Of the 66 patients with complete data available for review, the mean ipsilateral to contralateral IMT ratio was 1.41 (range, 0.3 to 16.4). Nonetheless, when evaluated more closely, only two patients had IMT ratios exceeding 2.0 (12.0 and 16.4). When these two patients are excluded, the IMT ratio averaged 1.01, suggesting an absence of significant intimal trauma secondary to aortic endograft implantation. If we presume that the cause of this increased intimal thickness is iliac trauma secondary to endograft placement, then the maximum incidence is 2/66 (3.0%). Analysis by follow-up intervals suggests no duration effect of significance.

Conclusions

Iliac artery trauma resulting in intimal hyperplasia or premature atherosclerosis appears to be a rare event after endograft abdominal aortic aneurysm repair. With current devices and current clinical selection, iliac artery pathology after endograft placement is not a significant concern.
Technical Aspects of Infrainguinal Arterial Duplex Guided Balloon Angioplasty
Authors: Marks Natalie , Ascher Enrico , Hingorani Anil , Schutzer Richard
Published: March 2018

Purpose

Duplex-guided balloon angioplasty (DGBA) has been reported in patients with short stenoses. We attempted to perform this procedure in patients with impaired renal function.

Methods

Over the course of 16 months, 37 lower-extremity DGBAs were performed at our institution in patients with renal insufficiency. Disabling claudication was the indication in 24 cases (65%) and critical ischemia in 13 cases. After duplex-guided common femoral artery (CFA) cannulation, a guide wire was directed into the origin of the superficial femoral artery, across the diseased segment and into the popliteal artery with the help of a guiding catheter under direct ultrasound visualization. The diseased segment was then dilated using a balloon. The balloon diameter and length were chosen according to arterial measurements obtained by duplex. Whenever indicated, stents were placed under duplex guidance.

Results

Thirty-day survival was 100%. Overall immediate technical success was achieved in all cases. Placement of intraluminal stents were deemed appropriate in 23 of 37 (62%) cases. The 1-month patency and limb salvage rates were 100%.

Conclusion

DGBA appears to be a feasible, safe, and effective technique for patients with renal insufficiency. Other advantages include guided puncture, accurate balloon and stent selection, and hemodynamic confirmation of the technique adequacy.
A Comparative Study of Ultrasound and Computed Tomography Scan for the follow-up of Abdominal Aortic Aneurysms after Endovascular Repair
Authors: Nerlekar Ruta , Warrier Ranjana , de Ryke Rex , Miller Robert , Hewitt Peter M. , Scott Alan
Published: March 2018

Objective

To date, computed tomography (CT) scanning has been the gold standard for follow-up of abdominal aortic aneurysms (AAA) after endovascular repair (EVR). However, with increasing durability of the minimally invasive procedure and longer survival of patients, there is concern over the expense of CT and its associated risks. For this reason, many now believe that ultrasound (US) may be an adequate substitute for surveillance of patients after EVR. The aim of this study was to compare ultrasound and CT scan in our practice to ascertain whether ultrasound alone would be sufficient for follow-up of AAA patients after EVR.

Materials and Methods

A total of 121 patients underwent EVR of AAAs during a 6-year period. All patients were followed up annually using both CT scanning and US. The parameters assessed included the presence/absence of endoleaks, as well as diameters of the aneurysm sac and neck. Results were plotted graphically to determine the change in size of aneurysms over time, and patients with endoleaks were compared with those who had no endoleaks. The sensitivity, specificity, positive, and negative predictive values for detecting endoleaks was also calculated for US and CT. Normally distributed data were analyzed using the Student's t-test and the Wilcox-signed rank test was used for nonparametric data.

Results

A total of 573 (CT and US) scans were analyzed. Of these, 391 scans (91 patients) did not show endoleaks. There were 64 scans (18 patients) in which both CT and US detected endoleaks; 6 scans (6 patients) in which CT detected leaks and US did not; and 5 scans (4 patients) in which US detected leaks and CT did not. The aneurysm sac size increased over time in the endoleak group and decreased over time in the nonendoleak group, whereas neck sizes did not change in either patient group. The sensitivity, specificity, positive, and negative predictive values of US and CT scan for detecting endoleak were 92.7%, 98.5%, 91.4%, and 98.7%; and 91.4%, 98.7%, 92.7%, and 98.5% respectively.

Conclusion

In our practice, US was comparable with CT scan for the detection of endoleaks, and similar trends were seen over time with regard to changes in aneurysm neck and body sizes for both modalities. We believe that US should be the primary modality for follow-up of patients after EVR and that CT scan should be reserved for confirmation of endoleak where this is suspected.
Ultrasonography in Saphenous Vein Conduit Selection
Authors: Cohn Joseph D. , Korver Keith F.
Published: March 2018

Objective

There are anatomic, histologic, and physiologic differences between great saphenous veins (GSVs) and accessory saphenous veins (ASVs). The GSV is deep to the saphenous fascia. ASVs are superficial to this layer and have thin walls with diminished muscle cells and elastic fiber. This study reviews the ultrasound characteristics of these veins, changes associated with varicose vein disease, and venous anomalies that impact on saphenous vein conduit selection.

Methods

Intraoperative ultrasound studies were performed before coronary artery bypass surgery in 83 patients without known venous disease, in 25 limbs with telangiectases, and in 25 limbs with varicosities. Vein characteristics and segment caliber in the proximal and distal thigh and calf were recorded.

Results

GSV segments of caliber and length suitable for use as coronary artery conduits are more common in men than women in the distal thigh (70% vs. 50%, p = 0.037), proximal calf (68% vs. 40%, p = 0.005), and distal calf (88% vs. 70%, p = 0.017). Dilated GSV segments are identified in 5% of normal limb segments, 21% in limbs with telangiectases ( p < 0.001), and 22% in limbs with varicosities ( p < 0.001). The incidence of absent or hypoplastic GSV segments is increased in limbs with varicosities compared with normal limbs (33% vs. 21%, p = 0.006).

Conclusions

GSVs are not uniform in caliber and gender differences are present. GSVs in limbs with telangiectases and varicosities have an increase in dilated and hypoplastic vein segments. Intraoperative ultrasound studies identify GSV segments for use as coronary conduits, avoiding ASVs and abnormal venous structures.
Acute and Isolated Dissection of the Superior Mesenteric Artery: Presentation and follow-up with Duplex Ultrasound
Authors: Oglesby Beverly , Sorrell Kathyrn
Published: March 2018

Introduction

Isolated dissection of the superior mesenteric artery (SMA) is a rare and often-fatal condition. Currently, only 47 cases of SMA dissection, in the absence of aortic dissection, have been reported in the literature. This report describes a case wherein the use of duplex ultrasound (DU) established the initial diagnosis and was used aggressively in follow-up care.

Case Report

A 51-year-old man presented to the emergency department (ED) complaining of severe abdominal pain. A DU of the mesenteric vessels was normal with the exception of a focal dilatation noted near the origin of the SMA that was later confirmed by computed tomography. Two days after admission, a second DU revealed a further increase in diameter of the proximal SMA and an intimal flap present in this segment. The patient was managed conservatively and discharged. Approximately 1 year later, the patient returned to the ED complaining of nausea and diarrhea for 3 weeks. DU revealed chronic dissection of the SMA as well as a stenosis in the celiac artery and inferior mesenteric artery (IMA). A stent was placed into the origin of the IMA to ensure collateral blood flow and anticoagulant therapy was continued. Before discharge, another DU was performed, which showed a patent IMA and well-perfused proximal SMA. One week later, the patient was asymptomatic and discharged home.

Conclusions

The use of DU provided a prompt and accurate diagnosis for a rare and unsuspected abnormality in the SMA that proved to be very beneficial in follow-up management decisions.
An Unusual Case: CCA Occlusion with Retrograde ICA Flow
Authors: Dick Jim , Hannon Kathleen , Jaff Michael R.
Published: March 2018

The detection of flow disturbances, occlusions, and stenosis of the extracranial carotid arteries with duplex imaging is painless and well tolerated by the majority of the population. A unique case presented to our Intersocietal Commission for the Accreditation of Vascular Laboratories-accredited vascular laboratory that demonstrated common carotid artery occlusion, antegrade external carotid artery flow with a rare finding of retrograde internal carotid artery flow. Using measures such as comparing the arterial flow to venous flow direction, the temporal tap maneuver, lowering pulse repetition frequency, and power Doppler, we were able to delineate this patient's unusual carotid hemodynamics.
Predictors of a Technically Limited Renal Artery Duplex Study: A Retrospective Analysis
Authors: Lee Eugene S. , DelPizzo David , Murray Kristen , Harris Sean , Kuskowski Michael A. , Pevec William C. , Dawson David L.
Published: March 2018

Objective

A renal artery duplex study is the screening study to evaluate for renal artery stenosis. A nondiagnostic study from a renal artery duplex study can be frustrating and labor intensive, with diminished revenue for the vascular laboratory. The purpose of this study is to evaluate patient and environmental factors in predicting a limited study.

Methods

A retrospective chart review of patients who underwent a renal artery duplex study in an Intersocietal Commission for the Accreditation of Vascular Laboratories-accredited vascular laboratory from July 2005 through June 2008 was performed. Patient age, body mass index, technologist experience, and the patient location where imaging was performed (inpatient versus outpatient) were collected and evaluated. A univariate and multivariate analyses were performed by use of the continuous and proportional measures. A p value of less than 0.05 was considered significant.

Results

A total of 390 patients had a renal artery duplex performed during this time period. Of the 390 duplex studies that were performed, 66% (258/390) were considered complete studies. The average age of patients with complete studies was 62 ± 16 versus incomplete 62 ± 15 ( p = NS). In the univariate analysis, complete studies were more likely to be performed by experienced technicians ( p = 0.04), in an outpatient setting ( p < 0.001), in patients with a lower body mass index ( p = 0.01). In the multivariate analysis, only body mass index ( p = 0.01) and outpatient status ( p = 0.002) were found to be significant predictors of a complete study.

Conclusions

One-third of the renal artery duplex studies were limited in our retrospective review. Experience of the ultrasound technician, lower body mass index of the patient, and the outpatient setting for the study appear to play a crucial role in obtaining a complete study. A prospective analysis of the factors will be necessary to confirm these findings.
Post Catheterization Inferior Epigastric Artery to Common Femoral Vein Fistula: Complimentary Role of Duplex Sonography and Computed Tomographic Angiography
Authors: Riggs Kristin D. , Kindhart Jennifer , Lee Savina , Keefer Mary , Gupta Kamal
Published: March 2018

Introduction

Iatrogenic arteriovenous fistulas (AVF) are usually formed between the common femoral artery (CFA) and the common femoral vein (CFV). Diagnosis is confirmed with duplex sonography (DS). They are usually treated conservatively or with surgery. AVF arising from the inferior epigastric (IEA) branch of the CFA are rare and present unique challenges, as DS usually cannot differentiate AVF origin from CFA or IEA.

Case Study

A 21-year-old woman presented with mild groin discomfort and bruit after an electrophysiological procedure via the right CFV. DS confirmed an AVF, but computed tomography angiography was performed to assess the origin. A small fistula was seen from the proximal right IEA to CFV. This offered an opportunity to percutaneously close the fistula by coiling the IEA if clinically indicated. However, a repeat DS 6 weeks later demonstrated spontaneous AVF closure.

Conclusion

DS is usually the only diagnostic study performed for evaluation of AVF. Diagnosis is usually made on the basis of relatively low resistance flow in the CFA, increased pulsatile CFV flow, and high-velocity, disturbed pulsatile flow in the tract. Occasionally, turbulent flow results in soft-tissue vibrations (perivascular speckling) that obscure visualization of AVF tract. Computed tomography angiography defined the exact origin of the fistula from proximal IEA and offers a complimentary role in assessment of AVF and their management.
Timeliness in Notification of Critical Vascular Laboratory Test Results is Part of Quality Assurance
Authors: Satiani Bhagwan , Kiser Dennis
Published: March 2018

Introduction

Regulatory and accrediting bodies, including Intersocietal Commission for the Accreditation of Vascular Laboratories, require a policy for timely notification of caregivers with potentially life-threatening or “critical” findings on vascular laboratory (VL) testing. However, the timeliness of notification with reference to VL tests is often not specified.

Objective

To audit all “critical” results as defined by our written policy requiring notification within 120 minutes of completion of a test.

Methods

The VL database, when queried for results between August 1, 2008, and December 31, 2009, showed that “critical” results constituted 6.1% (988/16,168) of all VL tests performed during that period. Reporting time was the time between test completion and contact with an appropriate caregiver. The type of test, indication, in or out-patient status, and after-hour or regular work hours testing was recorded during a separate focused audit.

Results

A focused audit performed during December 2009 showed 3.49% (31/888) of all tests reported as critical. The majority of critical results were abnormal venous studies (93.5%), performed in inpatients (61%), and during regular working hours (93.5%). The time to notification was a mean of 11.92 minutes (SD 9.51; range, 1–40 minutes).

Conclusions

Promptness of notification of “critical” VL results to caregivers must be part of an audit quality assurance program. A well-established protocol for communication and documentation of critical results must be instituted in all VLs.
The Findings of a Retrospective Audit of Clinical Indications and Outcomes Related to Renal Artery Duplex Ultrasounds Performed during a 2-Year Period
Authors: Pemble Lucia , Gibbs Harry
Published: March 2018

Introduction

In this retrospective audit of renal artery duplex ultrasounds (RADU), performed on 791 patients during a 2-year period, we analyze the clinical indications for testing, the patient cohort characteristics, and RADU results and outcomes.

Results

We found RADU to be sensitive and specific for the detection of renal artery stenosis with limitations in some instances attributable to physical interactions between ultrasound and body tissues and the variable presence of accessory renal arteries, even when performed by qualified experienced vascular sonographers. The results show the wide range of clinical indications for the performance of the test and document the multiple co morbidities of the patient population. Results show the majority of renal artery lesions are atherosclerotic in nature and that few patients go on to have renal artery intervention. The interventions do result in improvement of blood pressure but no change in resistive index.

Conclusion

The future role of RADU will be determined by medical research that provides evidence-based outcomes of the natural history of renal artery stenosis in the context of hypertension, allowing algorithms to be developed that best identify the medical versus interventional therapies for individual patients attempting to optimize renal function and blood pressure control while modifying associated risk factors. This will then allow more selective use of this diagnostic tool to answer more specified clinical questions on a case-by-case basis.
Case Series of Subclavian Artery Aneurysms in the Noninvasive Vascular Laboratory
Authors: Casanegra Ana I. , Whitelaw Susan M. , Greenberg Roy K. , Kashyap Vikram , Gornik Heather L.
Published: March 2018

Introduction

Subclavian artery aneurysm (SAA) is an uncommon entity, and there is little information in the vascular ultrasound literature regarding this disorder.

Methods

Query of a single-center noninvasive vascular laboratory database for all duplex examinations performed from January 1, 2000, to December 31, 2009 with a diagnosis of SAA. Medical records, archived ultrasound images, and correlative imaging studies were reviewed.

Result

A total of 12 patients with SAA were identified. Median age 56 years (range, 24–86 years), 58% male. The etiology of SAA was as follows: atherosclerosis (3/12), thoracic outlet syndrome (TOS; 3/12), connective tissue disorder (3/12), trauma (2/12), and vasculitis (1/12). All patients with SAA not caused by TOS had additional peripheral arterial or aortic aneurysm(s) previously or subsequently documented on imaging studies. Ten patients had symptoms at the time of diagnosis, most commonly arm and neck pain, arm claudication, and neurological findings. Aneurysms were equally distributed between right and left sides. The majority of SAA (9/12) were located at the origin or proximal subclavian artery; 3 were dissecting aneurysms. The median aneurysm maximal diameter was 2.35 cm (range, 1.5–6.4 cm), and the median contiguous normal artery diameter was 0.85 cm. Three patients had significant velocity shifts noted within the aneurysm. Vertebral artery flow was abnormal in one-third of SAA (4/12). Marked tortuosity of either internal carotid artery was a common related finding among these patients (6/12). Correlative computed tomography scan was available for 5 patients. A total of 75% of subjects in this series underwent open or endovascular aneurysm repair, whereas the remaining patients were followed with no intervention.

Conclusion

Duplex ultrasound is a useful tool for diagnosis and characterization of subclavian artery aneurysms. Among patients with SAA who have no evidence of TOS, careful evaluation for co-existent aortic and peripheral aneurysms is critical.
The Role of Duplex Ultrasound in the Detection of Celiac Aneurysm
Authors: Roberts Jason , Alonso Claudia , Khatib Yazan
Published: March 2018

Celiac trunk aneurysms are a rare and unusual pathology, accounting for roughly 4% of all splanchnic aneurysms; fewer than 180 cases have been reported since 1745. Early recognition of splanchnic aneurysms is crucial because of the operative mortality rate associated with ruptured splanchnic aneurysms. Duplex ultrasound in this case study has proven to be sensitive and specific in the detection of celiac aneurysms.
Hold the Stroke Alert! Acute Axillary Artery Embolus Unmasked by Emergency Bedside Ultrasound
Authors: Strony Robert
Published: March 2018

Objective

—To describe a case of axillary artery embolus detected by emergency physician- performed bedside ultrasound.

Case Report

—A patient presented with a possible stroke but was diagnosed correctly with acute axillary artery embolus. The axillary artery embolus was detected by the emergency physician by the use of bedside ultrasound.

Results

—An acute axillary artery embolus was detected rapidly by emergency physician-performed bedside ultrasound. This led to rapid definitive vascular surgical care.

Conclusion

—Rapid bedside emergency ultrasound of the upper extremity arterial system can accurately detect life- and limb-threatening pathology and expedite, as this case demonstrates, definitive limb-saving surgical care.
Use of Duplex Ultrasound for Evaluation of Complex Aortic Arch Vessel Re-routing for Thoracic Endovascular Aneurysm Repair
Authors: Liu Anyi , Wartak Siddharth , Srivastava Sunita , Roselli Eric E. , Whitelaw Susan , Gornik Heather L.
Published: March 2018

Introduction

Technological advances have increased availability of endovascular therapies for complex aortic disease. Endovascular repair of thoracic aortic aneurysms (TEVAR) involving the arch and proximal descending thoracic aorta is challenging with respect to the proximal landing zone for fixation of the endograft and prevention of endoleak. In such cases, additional vascular procedures may be necessary for re-routing of arch vessels.

Patient Description

An 88 year-old man was treated for chronic type B aortic dissection with aneurysm and rapid growth, including involvement of the distal aortic arch (arch 6.5 cm, descending thoracic aorta 6.2 cm). He underwent a left common carotid artery (CCA) to subclavian artery (SCA) bypass followed by a second bypass procedure communicating the right CCA to the left CCA–SCA graft. A thoracic endograft was placed which covered the origin of the left SCA and left CCA with distal fixation just above the celiac artery. Two weeks after the surgery, he developed confusion and a carotid duplex study was conducted using a Philips iU22 with a 9-3 MHz linear transducer.

Findings

Both synthetic bypass grafts were well visualized and were widely patent with no velocity shifts indicative of stenosis. The right to left graft ran behind the esophagusbefore its anastomosis to the left CCA–SCA graft. A dissection flap and small, partially thrombosed pseudoaneurysm were visualized at the right internal carotid artery (ICA) origin consistent with prior carotid dissection, but there was no evidence of stenosis. A plaque was visualized in the left ICA with a velocity shift noted consistent with moderate stenosis. The vertebral arteries were patent with antegrade flow, although flow in the left vertebral artery had a delayed upstroke, likely reflecting the long re-routing of blood flow.

Conclusion

Vascular technologists may be called to assist in the care of patients who have undergone re-routing of the aortic arch vessels for TEVAR. The complex anatomy of these cases emphasizes the importance of preparation for the examination, including review of operative reports and communication with referring clinicians.
Ship infrared image edge detection based on an improved adaptive Canny algorithm
Authors: Liu Lisang , Liang Fenqiang , Zheng Jishi , He Dongwei , Huang Jing
Published: March 2018

Influenced by light reflection and water fog interference, ship infrared images are mostly blurred and have low signal-to-noise ratio. In this paper, an improved adaptive Canny edge detection algorithm for infrared image of ship is proposed, which aims to solve the threshold of the traditional Canny cannot be adjusted automatically and the shortcomings of sensitivity to noise. The contrast limited adaptive histogram equalization algorithm is adopted to enhance the infrared image, the morphological filter replaces the Gauss filter to smooth the image, and the OTSU algorithm is utilized to adjust the high and low thresholds dynamically. The experimental results show that the improved Canny algorithm, which can not only improve the contrast of the image and automatically adjust the threshold but also reduce the background sea clutter and false edges, is an effective edge detection method.
A case of sarcoidosis‐associated pulmonary hypertension masquerading as chronic thromboembolic pulmonary hypertension
Authors: Bazmpani Maria Anna , Arsos Georgios , Zarogoulidis Paul , Doumas Argyrios , Dimitroulas Theodoros , Sianos George , Hadjimiltiades Stavros , Kouskouras Konstantinos , Mayer Eckhard , Karvounis Haralambos , Giannakoulas George
Published: March 2018

Occlusive vasculopathy due to the development and accumulation of granulomas at the level of intima of large vessels, as well as mediastinal lymph nodes and fibrosing mediastinitis secondary to sarcoidosis, causing extrinsic compression of mediastinal vascular structure are uncommon mechanisms of sarcoidosis‐associated pulmonary hypertension. We present a case of a 62‐year‐old woman with a rare manifestation of sarcoidosis, which was misclassified and treated as chronic thromboembolic pulmonary hypertension for a long period. Fluorine‐18‐fluorodeoxyglucose positron emission tomography played a major role in accessing final diagnosis. Mechanisms that lead to development of pulmonary hypertension, the contribution of novel imaging modalities, and treatment options are discussed.
Metabolic syndrome and the risk of adverse cardiovascular events after an acute coronary syndrome
Authors: Cavallari Ilaria , Cannon Christopher P , Braunwald Eugene , Goodrich Erica L , Im KyungAh , Lukas Mary Ann , O’Donoghue Michelle L
Published: March 2018

Background

The incremental prognostic value of assessing the metabolic syndrome has been disputed. Little is known regarding its prognostic value in patients after an acute coronary syndrome.

Design and methods

The presence of metabolic syndrome (2005 International Diabetes Federation) was assessed at baseline in SOLID-TIMI 52, a trial of patients within 30 days of acute coronary syndrome (median follow-up 2.5 years). The primary endpoint was major coronary events (coronary heart disease death, myocardial infarction or urgent coronary revascularization).

Results

At baseline, 61.6% ( n = 7537) of patients met the definition of metabolic syndrome, 34.7% (n = 4247) had diabetes and 29.3% had both ( n = 3584). The presence of metabolic syndrome was associated with increased risk of major coronary events (adjusted hazard ratio (adjHR) 1.29, p < 0.0001) and recurrent myocardial infarction (adjHR 1.30, p < 0.0001). Of the individual components of the definition, only diabetes (adjHR 1.48, p < 0.0001) or impaired fasting glucose (adjHR 1.21, p = 0.002) and hypertension (adjHR 1.46, p < 0.0001) were associated with the risk of major coronary events. In patients without diabetes, metabolic syndrome was numerically but not significantly associated with the risk of major coronary events (adjHR 1.13, p = 0.06). Conversely, diabetes was a strong independent predictor of major coronary events in the absence of metabolic syndrome (adjHR 1.57, p < 0.0001). The presence of both diabetes and metabolic syndrome identified patients at highest risk of adverse outcomes but the incremental value of metabolic syndrome was not significant relative to diabetes alone (adjHR 1.07, p = 0.54).

Conclusions

After acute coronary syndrome, diabetes is a strong and independent predictor of adverse outcomes. Assessment of the metabolic syndrome provides only marginal incremental value once the presence or absence of diabetes is established.
The Impact of Absolute CD4 Count and Percentage Discordance on Pneumocystis Jirovecii Pneumonia Prophylaxis in HIV-Infected Patients
Authors: Anyimadu Henry , Pingili Chandra , Sivapalan Vel , Hirsch-Moverman Yael , Mannheimer Sharon
Published: March 2018

Current guidelines suggest that HIV-infected patients should receive chemoprophylaxis against Pneumocystis jirovecii pneumonia (PJP) if they have a cluster determinant 4 (CD4) count <200 cells/mm3 or oropharyngeal candidiasis. Persons with CD4 percentage (CD4%) below 14% should also be considered for prophylaxis. Discordance between CD4 count and CD4% occurs in 16% to 25% of HIV-infected patients. Provider compliance with current PJP prophylaxis guidelines when such discordance is present was assessed. Electronic medical records of 429 HIV-infected individuals who had CD4 count and CD4% measured at our clinic were reviewed. CD4 count and percentage discordance was seen in 57 (13%) of 429. Patients with CD4 count >200 but CD4% <14 were significantly less likely to be prescribed PJP prophylaxis compared with those who had CD4 count <200 and CD4% >14 (29% versus 86%; odds ratio = 0.064, 95% confidence interval: 0.0168-0.2436; P < .0001). We emphasize monitoring both the absolute CD4 count and percentage to appropriately guide PJP primary and secondary prophylaxis.
iwCLL guidelines for diagnosis, indications for treatment, response assessment, and supportive management of CLL
Authors: Hallek Michael , Cheson Bruce D. , Catovsky Daniel , Caligaris-Cappio Federico , Dighiero Guillermo , Döhner Hartmut , Hillmen Peter , Keating Michael , Montserrat Emili , Chiorazzi Nicholas , Stilgenbauer Stephan , Rai Kanti R. , Byrd John C. , Eichhorst Barbara , O’Brien Susan , Robak Tadeusz , Seymour John F. , Kipps Thomas J.
Published: March 2018

The previous edition of the consensus guidelines of the International Workshop on Chronic Lymphocytic Leukemia (iwCLL), published in 2008, has found broad acceptance by physicians and investigators caring for patients with CLL. Recent advances including the discovery of the genomic landscape of the disease, the development of genetic tests with prognostic relevance, and the detection of minimal residual disease (MRD), coupled with the increased availability of novel targeted agents with impressive efficacy, prompted an international panel to provide updated evidence- and expert opinion–based recommendations. These recommendations include a revised version of the iwCLL response criteria, an update on the use of MRD status for clinical evaluation, and recommendations regarding the assessment and prophylaxis of viral diseases during management of CLL.
Bis-Indole–Derived NR4A1 Ligands and Metformin Exhibit NR4A1-Dependent Glucose Metabolism and Uptake in C2C12 Cells
Authors: Mohankumar Kumaravel , Lee Jehoon , Wu Chia Shan , Sun Yuxiang , Safe Stephen
Published: March 2018

Treatment of C2C12 muscle cells with metformin or the NR4A1 ligand 1,1-bis(3′-indolyl)-1-(p-hydroxyphenyl)methane (DIM-C-pPhOH) induced NR4A1 and Glut4 messenger RNA and protein expression. Similar results were observed with buttressed (3- or 3,5-substituted) analogs of DIM-C-pPhOH, including 1,1-bis(3′-indolyl)-1-(3-chloro-4-hydroxy-5-methoxyphenyl)methane (DIM-C-pPhOH-3-Cl-5-OCH3), and the buttressed analogs were more potent than DIM-C-pPhOH NR4A1 agonists. Metformin and the bis-indole substituted analogs also induced expression of several glycolytic genes and Rab4, which has previously been linked to enhancing cell membrane accumulation of Glut4 and overall glucose uptake in C2C12 cells, and these responses were also observed after treatment with metformin and the NR4A1 ligands. The role of NR4A1 in mediating the responses induced by the bis-indoles and metformin was determined by knockdown of NR4A1, and this resulted in attenuating the gene and protein expression and enhanced glucose uptake responses induced by these compounds. Our results demonstrate that the bis-indole–derived NR4A1 ligands represent a class of drugs that enhance glucose uptake in C2C12 muscle cells, and we also show that the effects of metformin in this cell line are NR4A1-dependent.
PUF-8 facilitates homologous chromosome pairing by promoting proteasome activity during meiotic entry in C. elegans
Authors: Kumar Ganga Anil , Subramaniam Kuppuswamy
Published: March 2018

Pairing of homologous chromosomes is essential for genetic recombination during gametogenesis. In many organisms, chromosome ends are attached to cytoplasmic dynein, and dynein-driven chromosomal movements facilitate the pairing process. Factors that promote or control the cytoskeletal tethering of chromosomes are largely unknown. Here, we show that the conserved RNA-binding protein PUF-8 facilitates the tethering and pairing processes in the C. elegans germline by promoting proteasome activity. We have isolated a hypomorphic allele of pas-1, which encodes a proteasome core subunit, and find that the homologous chromosomes fail to pair in the puf-8; pas-1 double mutant due to failure of chromosome tethering. Our results reveal that the puf-8; pas-1 meiotic defects are caused by the loss of proteasome activity. The axis component HTP-3 accumulates prematurely in the double mutant, and reduction of its activity partially suppresses some of the puf-8; pas-1 meiotic defects, suggesting that HTP-3 might be an important target of the proteasome in promoting early meiotic events. In summary, our results reveal a role for the proteasome in chromosome tethering and identify PUF-8 as a regulator of proteasome activity during early meiosis.
Matrix elasticity regulates mesenchymal stem cell chemotaxis
Authors: Saxena Neha , Mogha Pankaj , Dash Silalipi , Majumder Abhijit , Jadhav Sameer , Sen Shamik
Published: March 2018

Efficient homing of human mesenchymal stem cells (hMSCs) is likely to be dictated by a combination of physical and chemical factors present in the microenvironment. However, crosstalk between the physical and chemical cues remains incompletely understood. Here, we address this question by probing the efficiency of epidermal growth factor (EGF)-induced hMSC chemotaxis on substrates of varying stiffness (3, 30 and 600 kPa) inside a polydimethylsiloxane (PDMS) microfluidic device. Chemotactic speed was found to be the sum of a stiffness-dependent component and a chemokine concentration-dependent component. While the stiffness-dependent component scaled inversely with stiffness, the chemotactic component was independent of stiffness. Faster chemotaxis on the softest 3 kPa substrates is attributed to a combination of weaker adhesions and higher protrusion rate. While chemotaxis was mildly sensitive to contractility inhibitors, suppression of chemotaxis upon actin depolymerization demonstrates the role of actin-mediated protrusions in driving chemotaxis. In addition to highlighting the collective influence of physical and chemical cues in chemotactic migration, our results suggest that hMSC homing is more efficient on softer substrates.
Light exposure enhances urea absorption in the fluted giant clam,Tridacna squamosa, and up-regulates the protein abundance of a light-dependent urea active transporter, DUR3-like, in its ctenidium
Authors: Chan Christabel Y. L. , Hiong Kum C. , Boo Mel V. , Choo Celine Y. L. , Wong Wai P. , Chew Shit F. , Ip Yuen K.
Published: March 2018

Giant clams live in nutrient-poor reef waters of the Indo-Pacific and rely on symbiotic dinoflagellates (Symbiodinium spp., also known as zooxanthellae) for nutrients. As the symbionts are nitrogen deficient, the host clam has to absorb exogenous nitrogen and supply it to them. This study aimed to demonstrate light-enhanced urea absorption in the fluted giant clam, Tridacna squamosa, and to clone and characterize the urea active transporter, DUR3-like, from its ctenidium (gill). Results indicate that T. squamosa could absorb exogenous urea, and the rate of urea uptake in light was significantly higher than that in darkness. The DUR3-like coding sequence obtained from its ctenidium comprised 2,346 bp, encoding a protein of 782 amino acids and 87.0 kDa. DUR3-like was expressed strongly in the ctenidium, outer mantle and kidney. Twelve hours of exposure to light had no significant effect on the transcript level of ctenidial DUR3-like. However, between hour 3 and hour 12 h of light exposure, the DUR3-like protein abundance increased progressively in the ctenidium, and became significantly greater than the control at hour 12. The DUR3-like had an apical localization in the epithelia of the ctenidial filaments and tertiary water channels. Taken together, these results indicate that the DUR3-like might participate in light-enhanced urea absorption in the ctenidium of T. squamosa. When made available to the symbiotic zooxanthellae that are known to possess urease, the absorbed urea can be metabolized to NH3 and CO2 to support amino acid synthesis and photosynthesis, respectively, during insolation.
Prolonged Effects of Elevated 17β-Estradiol on Physical Activity after Orchidectomy
Authors: STOTT NICOLE L. , ABREU MITCHELL R. , CATES BRITTANY E. , DILLARD BRYCE M. , FOSTER BRITTANY R. , HASKETT MYRRHANDE J. , LEE JAMES C. , SIMÕES HELEN G. , SPIVEY THOMAS P. , BOWEN ROBERT S.
Published: March 2018

The biological mechanisms regulating physical activity patterns appear to be linked to the sex hormones. Elucidation of these regulatory mechanisms may enhance individual physical activity patterns producing positive gains in health.

Purpose

The purpose of this study was to evaluate the prolonged effects of estrogen on wheel running distance, duration, and speed in orchidectomized mice.

Methods

The physical activity patterns of 9-wk-old C57BL/6j male mice (n = 28) were observed. Wheel running distance, duration, and speed were assessed under physiological conditions for 7 d. Next, physical activity patterns were evaluated after bilateral orchidectomy (n = 14) or sham orchidectomy (n = 14) for an additional 7 d. Orchidectomized mice were provided estrogen containing capsules for three additional weeks; control mice were provided estrogen-free capsules. Wheel running distance, duration, and speed were analyzed by three two-way (treatment group–phase of study) analysis of variance tests.

Results

Wheel running speed was unaffected by sex hormone status. Distance (mean ± SD = 6.74 ± 2.13 km at baseline) decreased significantly after orchidectomy (2.27 ± 1.55 km) and remained low after initial estrogen treatment (3.04 ± 1.05 km). Prolonged estrogen exposure sustained a significant elevation of daily distance (4.47 ± 1.87 km). Prolonged estrogen exposure recovered and significantly sustained wheel running duration (baseline, 248 ± 60 min; postorchidectomy, 102 ± 53 min; prolonged exposure, 170 ± 63 min).

Conclusions

Wheel running behavior was reduced significantly after orchidectomy and remained low after initial treatment with estrogens, but recovered to near control levels after 2 wk of exposure to estrogens. The estrogenic mechanism regulating wheel running behavior in male mice appears to induce an extensive but slow acting biological mechanism. Understanding the biological drive behind this mechanism may aid in developing useful therapeutic strategies to combat health issues related to physical inactivity.
Intravenous Iron Does Not Augment the Hemoglobin Mass Response to Simulated Hypoxia
Authors: GARVICAN-LEWIS LAURA A. , VUONG VICTOR L. , GOVUS ANDREW D. , PEELING PETER , JUNG GRACE , NEMETH ELIZABETA , HUGHES DAVID , LOVELL GREG , EICHNER DANIEL , GORE CHRISTOPHER J.
Published: March 2018

Purpose

Iron is integral for erythropoietic adaptation to hypoxia, yet the importance of supplementary iron compared with existing stores is poorly understood. The aim of the present study was to compare the magnitude of the hemoglobin mass (Hbmass) in response to altitude in athletes with intravenous (IV), oral, or placebo iron supplementation.

Methods

Thirty-four, nonanemic, endurance-trained athletes completed 3 wk of simulated altitude (3000 m, 14 h·d−1), receiving two to three bolus iron injections (ferric carboxymaltose), daily oral iron supplementation (ferrous sulfate), or a placebo, commencing 2 wk before and throughout altitude exposure. Hbmass and markers of iron regulation were assessed at baseline (day −14), immediately before (day 0), weekly during (days 8 and 15), and immediately, 1, 3, and 6 wk after (days 22, 28, 42, and 63) the completion of altitude exposure.

Results

Hbmass significantly increased after altitude exposure in athletes with IV (mean % [90% confidence interval (CI)], 3.7% [2.8–4.7]) and oral (3.2% [2.2–4.2]) supplementation and remained elevated at 7 d postaltitude in oral (2.9% [1.5–4.3]) and 21 d after in IV (3.0% [1.5–4.6]) supplementation. Hbmass was not significantly higher than baseline at any time point in placebo.

Conclusions

Iron supplementation appears necessary for optimal erythropoietic adaptation to altitude exposure. IV iron supplementation during 3 wk of simulated live high–train low altitude training offered no additional benefit in terms of the magnitude of the erythropoietic response for nonanemic endurance athletes compared with oral supplementation.
Impact of a Multicenter, Mentored Quality Collaborative on Hospital‐Associated Venous Thromboembolism
Authors: Jenkins Ian , O'Bryan Tamra , Holdych Janet , Maynard Gregory
Published: March 2018

BACKGROUND

Reliable prophylaxis of hospital‐associated venous thromboembolism (HA‐VTE) is not achieved in many hospitals. Efforts to improve prophylaxis have had uneven results.

OBJECTIVE

To reduce HA‐VTE with a scalable quality improvement collaborative.

DESIGN

A prospective, unblinded, open‐intervention study with historical controls.

PARTICIPANTS AND SETTING

All adult inpatients at 35 community hospitals in California, Arizona, and Nevada.

INTERVENTIONS

A centrally supported collaborative implementing standardized VTE risk assessment and prophylaxis. Protocols were developed with 9 “pilot” sites, which received individualized mentoring. Finished protocols were disseminated to 26 “spread” sites, which received improvement webinars without mentoring. Active surveillance for real‐time correction of suboptimal prophylaxis was funded in pilot sites and encouraged in spread sites. Planning and minimal improvement work began in 2011; most implementation occurred in 2012 and 2013.

MEASUREMENTS

Rates of per‐protocol prophylaxis (at pilot sites), and compliance with The Joint Commission VTE measures (all sites), were monitored starting in January 2012. The International Classification of Diseases, 9th Edition‐Clinical Modification codes were used to determine the rates of HA‐VTE within 30 days of discharge, heparin‐induced thrombocytopenia, and anticoagulation adverse events; preimplementation (2011) rates were compared with postimplementation (2014) rates.

RESULTS

Protocol‐appropriate prophylaxis rates and The Joint Commission measure compliance both reached 97% in 2014, up from 70% to 89% in 2012 and 2013. Five thousand three hundred and seventy HA‐VTEs occurred during 1.16 million admissions. Four hundred twenty‐eight fewer HA‐VTEs occurred in 2014 than in 2011 (relative risk 0.78; 95% confidence interval, 0.73‐0.85). HA‐VTEs fell more in pilot sites than spread sites (26% vs 20%). The rates of adverse events were reduced or unchanged.

CONCLUSIONS

Collaborative efforts were associated with improved prophylaxis rates and fewer HA‐VTEs.
Lichen planus in children
Authors: Agel Mona , Al-Chihabi Mamdouh , Zaitoun Halla , Thornhill Martin H , Hegarty Anne M
Published: March 2018

Abstract: Lichen Planus (LP) is a chronic, inflammatory disease of the skin and mucous membranes. It is more frequently seen in the middle-aged and elderly population but can be present in children, although this is relatively rare. This paper describes the presentation and management of lichen planus in children, illustrated by seven cases seen within the Paediatric Dentistry Unit. Dentists should be aware of the condition and understand when referral to a specialist centre is required and the need for multidisciplinary management of complex cases.

CPD/Clinical Relevance: Although oral lichen planus is rare in children, it is important that dentists are able to identify its clinical presentation and abnormal changes to the oral mucosa, as well as being aware of possible local and systemic causes of the condition so that reassurance and correct management pathways can be implemented in primary care practice.