Rendezvous endovascular common carotid artery stenting (RECCAS) technique for symptomatic steno-occlusive disease

This report describes a patient who presented with acute but transient right arm weakness and altered sensation secondary to severe stenosis of the left common carotid artery (CCA) origin. Endovascular stenting of the stenosed origin was achieved utilising a novel rendezvous technique through combined retrograde common carotid artery and anterograde transfemoral approaches. This technique has numerous potential advantages over traditional transfemoral endovascular and open retrograde common carotid artery approaches. It allows increased procedural control and success in traversing the stenosis and provides a smooth transition for the stent delivery catheter. An open cutdown procedure or open surgical technique is not required. Our patient recovered well from the procedure with no complications within the three-month follow up period.

Treatment of isolated small renal stones leads to resolution of symptoms and should be routinely offered to patients: retrospective outcomes from a university hospital

INTRODUCTION

Treatment of smaller renal stones and the symptomatic value it offers to patients is often debated. We wanted to analyse surgical outcomes for treatment of small renal stones and whether treatment resulted in symptom resolution.

MATERIALS AND METHODS

All patients who underwent ureterorenoscopy (URS) for isolated symptomatic small renal stones ≤10 mm over a 7-year period were retrospectively included and subdivided into those with stones of ≤7 mm (Group A) and stones of 8-10 mm (Group B). Patients with multiple renal stones, ureteric stones, or combined renal and ureteric stones were excluded. Based on the symptoms, the patient groups were those with pain, urinary tract infection (UTI) and haematuria. Resolution of symptoms was defined as no symptoms during the follow-up period.

RESULTS

A total of 109 patients with a single small renal stone ≤10 mm underwent URS and stone treatment, with mean age of 50 years and a male:female ratio of 1:1.2. The mean operative time was significantly longer in Group B (55.9 min vs 33.07 min, p = 0.001). In total, 97.2% (n = 70) of patients in Group A and 83.7% (n = 31) of patients in Group B were stone free (p = 0.017). Complete resolution of symptoms was seen in 63 (92.6%), 24 (85.7%) and 13 (100%) patients with pain, UTI and haematuria, respectively. There were no statistically significant differences in symptom resolution between patients with stones ≤7 mm and those with stones 8-10 mm in size.

CONCLUSION

Ureteroscopic treatment is a feasible option for small symptomatic stones, since it may lead to symptom resolution. Based on our study we would recommend that patients with symptomatic small renal stones are offered endoscopic treatment.

Evaluation of Sympathetic Vasomotor Fibres in Carpal Tunnel Syndrome Using Continuous Wave Doppler Ultrasonography

Sympathetic vasomotor fibres carried by the median nerve and ulnar nerve innervate their respective sensory territories. The sympathetic vasomotor fibres of the median nerve were evaluated in patients with carpal tunnel syndrome and in healthy volunteers using continuous wave Doppler ultrasonography. The pulsatility index of the radialis indicis artery and the radial palmar digital artery of the little finger were measured at baseline and after stimulation. The maximal increase in the pulsatility index of each artery was measured. This was significantly lower for the radialis indicis artery in the CTS group than in the healthy controls. However, there was no significant difference in the maximal increase in pulsatility index of the radial palmar digital artery of the little finger between both groups. Sympathetic vasomotor fibres of the median nerve are affected in carpal tunnel syndrome. Continuous wave Doppler ultrasonography is easy to use and should be investigated further as a possible diagnostic tool for the confirmation of carpal tunnel syndrome.

A motivation-focused weight loss maintenance program is an effective alternative to a skill-based approach

Objective

Maintaining weight loss is a major challenge in obesity treatment. Individuals often indicate that waning motivation prompts cessation of effective weight management behaviors. Therefore, a novel weight loss maintenance program that specifically targets motivational factors was evaluated.

Design

Overweight women (N=338; 19% African American) with urinary incontinence were randomized to lifestyle obesity treatment or control and followed for 18 months. All participants in lifestyle (N=226) received the same initial six-month group behavioral obesity treatment and were then randomized to 1) a novel motivation-focused maintenance program (N=113) or 2) a standard skill-based maintenance approach (N=113).

Main Outcome Measure

Weight assessed at baseline, 6, and 18 months.

Results

Both treatment groups (motivation-focused and skill-based) achieved comparable 18-month weight losses (−5.48% for motivation-focused vs −5.55% in skill-based, p=0.98), and both groups lost significantly more than controls (−1.51%; p=.0012 in motivation-focused and .0021 in skill-based).

Conclusions

A motivation-focused maintenance program offers an alternative, effective approach to weight maintenance expanding available evidence-based interventions beyond traditional skill-based programs.

Vaginal birth after cesarean in California

OBJECTIVE

To estimate rates at which women were offered and consented to trial of labor in California hospitals with high and low risk-adjusted cesarean delivery rates.

METHODS

From 267 nonfederal acute-care hospitals in California that performed more than 678 deliveries in 1992-1993, 51 hospitals were selected in a stratified sample. Hospitals in the sample were categorized as having high, medium, and low risk-adjusted cesarean rates using a logistic regression model based on data from the California Patient Discharge Data System. We reviewed medical records of women with previous cesareans for evidence of counseling regarding trial of labor, other clinical variables, and method of delivery. Differences in proportions between the three groups of hospitals were compared.

RESULTS

According to records of 369 women with previous cesareans, after excluding contraindications, 312 were potentially eligible for trial of labor. Hospitals with low risk-adjusted cesarean rates documented counseling women for trial of labor in over 99% of records reviewed, compared with 85% and 79%, respectively, of hospitals with intermediate and high rates (P <.001). Rates of completed vaginal births after cesarean were 71% in hospitals with low risk-adjusted cesarean rates, compared with 39% and 31% in hospitals with intermediate and high rates (P <.05).

CONCLUSIONS

California hospitals with high cesarean rates in 1992-1993 had markedly higher rates of repeat elective cesarean delivery without evidence of counseling regarding trial of labor. Informed patient choice is a critical element of the decision for trial of labor or elective repeat cesarean, and lack of documented counseling is cause for concern.

The origin and fate of herniated lumbar intervertebral disc tissue

STUDY DESIGN

In a clinicopathologic study, disc tissue collected from surgery and from cadaveric spines was examined to test an hypothesis about the pathogenesis of herniation.

OBJECTIVES

To determine the origin and fate of herniated lumbar intervertebral disc tissue.

SUMMARY OF BACKGROUND DATA

Previous studies have ascribed herniated disc tissue to the nucleus, anulus, or endplate, or combinations of the three. One study describes it as newly synthesized fibrocartilage. Regardless of its origin, peripheral neovascularization of disc fragments has been described and may be related to pain symptoms.

METHODS

Disc tissue was collected after extrusion and was examined histologically to determine its origin and fate. To test the hypothesis that sequestration results from migration of isolated, degenerate fragments of nucleus pulposus through preexisting tears in the anulus fibrosus, cadaveric lumbar disc were examined in detail.

RESULTS

Ninety-eight percent of sequestrations contained some nuclear material indicating that nucleus pulposus is the principal substance extruded from the disc. None contained anulus alone. Although vascular repair was present in 89% of specimens, it did not correlate with several clinical parameters.

CONCLUSIONS

The autopsy study confirmed the model of nuclear fragmentation, migration, and extrusion along radiating anular clefts. Neovascularization of extruded fragments bore no relationship with duration of sciatic pain symptoms or clinical outcome.

Type 1 fimbrial expression enhances Escherichia coli virulence for the urinary tract

Type 1 fimbriae are adhesion organelles expressed by many Gram-negative bacteria. They facilitate adherence to mucosal surfaces and inflammatory cells in vitro, but their contribution to virulence has not been defined. This study presents evidence that type 1 fimbriae increase the virulence of Escherichia coli for the urinary tract by promoting bacterial persistence and enhancing the inflammatory response to infection. In a clinical study, we observed that disease severity was greater in children infected with E. coli O1:K1:H7 isolates expressing type 1 fimbriae than in those infected with type 1 negative isolates of the same serotype. The E. coli O1:K1:H7 isolates had the same electrophoretic type, were hemolysin-negative, expressed P fimbriae, and carried the fim DNA sequences. When tested in a mouse urinary tract infection model, the type 1-positive E. coli O1:K1:H7 isolates survived in higher numbers, and induced a greater neutrophil influx into the urine, than O1:K1:H7 type 1-negative isolates. To confirm a role of type 1 fimbriae, a fimH null mutant (CN1016) was constructed from an O1:K1:H7 type 1-positive parent. E. coli CN1016 had reduced survival and inflammatogenicity in the mouse urinary tract infection model. E. coli CN1016 reconstituted with type 1 fimbriae (E. coli CN1018) had restored virulence similar to that of the wild-type parent strain. These results show that type 1 fimbriae in the genetic background of a uropathogenic strain contribute to the pathogenesis of E. coli in the urinary tract.

High prevalence of Helicobacter pylori antibodies in an institutionalized population: evidence for person-to-person transmission

OBJECTIVE

To evaluate the prevalence of H. pylori antibodies in mentally and physically handicapped adults living together in a long-term care facility.

METHODS

One hundred twenty-two institutionalized subjects from six living areas were compared to a normal representative Caucasian population obtained by random sampling from the urban population area of Melbourne. Serum samples from 1977 and 1989 from 122 subjects were tested for H. pylori antibody by an ELISA technique. The data were analyzed by Student's t test, chi 2 test and logistic regression.

RESULTS

Ninety-two of the 122 subjects (75%) from whom sera was collected in 1989 were seropositive for H. pylori, compared with only 23% in age- and sex-matched control subjects (p < 0.0001). The prevalence of H. pylori antibodies in 1977 was 34% (42/122). Of the remaining 80 seronegative subjects, 51 (61.4%) converted to became positive in the 12-yr interval. The annual seroconversion rate was 7.4%, with an average of 4.25 newly positive subjects each year. The prevalence of H. pylori in 1989 was significantly higher than in 1977 after adjustment for age (odds ratio 2.39, 95% CI 1.1-5.3, p = 0.03).

CONCLUSIONS

H. pylori antibodies are significantly more prevalent in institutionalized adults compared with controls from the general population. These data support the hypothesis that H. pylori is acquired by either fecal-oral or oral-oral transmission.

Ribotyping of Helicobacter pylori from clinical specimens

Ribotyping is a method used to type strains of bacteria by analyzing the restriction enzyme digestion patterns of the rRNA genes. This method was applied to 126 strains of Helicobacter pylori from 100 unrelated symptomatic patients who had endoscopies done and to 15 strains from 15 infected subjects from seven families. Analysis of the rRNA gene patterns revealed 77 distinct ribotypes from the 100 patients. From 15 of these subjects, isolates were recovered from antral mucosal biopsies at follow-up endoscopy. All follow-up isolates from the same patient, with one exception, yielded identical digest patterns. This patient had strains with two distinct digest patterns obtained from a set of three isolates cultured from biopsy specimens taken at different times. Five patients who had isolates recovered from different sites in the stomach (antrum, gastric body, duodenum, and pyloric channel) showed ribotyping patterns which were identical for each patient yet distinct between patients. In seven family groups studied, identical digest patterns were detected in members of two families, with variability in strains detected among members of the remaining families. This study demonstrates that ribotyping provides a useful, reliable, reproducible, and highly discriminatory typing scheme for the study of H. pylori infection.

A comparison of diagnostic tests to determine Helicobacter pylori infection

Twenty-five Helicobacter pylori positive and 25 H. pylori negative subjects as defined by culture and phase contrast microscopy of antral biopsy specimens obtained from routine upper endoscopy were studied. Antral biopsies were examined by rapid urease test, phase contrast microscopy, culture and histology. Venous blood was tested for H. pylori specific IgG antibodies by an ELISA technique. Within 7 days of endoscopy the patients also had a [14C]-urea breath test. The sensitivity and specificity of the rapid urease test was 92%, the breath test 96% and 100%, histopathology 96% and 91% and serology 96% and 88%, respectively. The [14C]-urea breath test performed over 1 h with sampling of subjects at 0, 0.5 and 1 h was an accurate and reliable method. Results expressed as counts per minute of the expired 14CO2 proved to be a simple method of assessing H. pylori status. A significant correlation between severity of histological antral gastritis and the amount of 14CO2 expired was observed. This study has shown that the non-invasive 14C-urea breath test and serology are highly sensitive and specific for the diagnosis of H. pylori infection.