Primary Patency Rates of AV Fistulae and the Effect of Patient Variables

Background

DOQI (The Dialysis Outcomes Quality Initiative) recommend 40% of prevalent renal failure patients should be undergoing hemodialysis (HD) using autogenous arteriovenous fistulae (AVF). The aim of this study is to assess the primary patency rates of wrist and elbow fistulae, and to examine how patient variables influence the success of a fistula. In addition, an attempt has been made to address the main issue of survival rates in this high risk patient population.

Methods

A retrospective study was performed on all patients in the University Hospital of North Staffordshire who underwent creation of a wrist or elbow fistula for HD. During the study period 289 primary AVFs were created. In all, 210 AVF were sited at the wrist and 79 at the elbow. Follow-up ranged from 3 months to 4 yrs. Primary patency and patient death, transplant and transfer were taken as end points. Patient survival was defined as time of fistula creation to patient death. Actuarial survival was calculated using Kaplan-Meier survival analyses, with differences between groups determined using log rank analysis, and statistical significance obtained using X2 tests.

Results

Primary patency for wrist fistulae was 49, 41 and 32% at 6, 12 and 24 months, respectively, and 57, 51 and 38% for elbow fistulae. Regression analysis showed fistula survival to be significantly greater in males than in females (p=0.023). Fistula survival rates in non-diabetics patients were higher than in patients with diabetes however, this was not significant (p=0.11); (54, 48 and 34% in diabetics compared to 45, 35 and 26% in non-diabetics at 6, 12 and 24 months, respectively). Age did not influence fistula survival; however, it did affect patient survival. Patient survival was 90, 74 and 56% at 1, 2 and 3 yrs, respectively, and in >60s fell to 86, 71 and 50%. Overall 74/245 (30%) patients died.

Conclusion

These results suggest that overall primary patency rates for wrist and elbow fistulae are comparable to similar studies at 6, 12 and 24 months. Fistula survival after this period is dictated by poor patient survival. Our findings suggest that creation of primary vascular access at the elbow in older females and diabetics may be associated with better results.

A Stuck Hemodialysis Central venous Catheter

Background

A growing number of hemodialysis patients are dependent upon central venous catheters (CVCs) for long-term vascular access. Although many complications of CVCs have been documented, the phenomenon of the stuck catheter is described relatively infrequently.

Case report

We describe a case where attempts to remove the line by exploration of the jugular insertion site in theater were unsuccessful and the line was internalized.

Discussion

The case is then discussed with all available cases in the literature to suggest principles of managing and preventing the stuck catheter phenomenon.

MED13L-related intellectual disability: involvement of missense variants and delineation of the phenotype

Molecular anomalies in MED13L, leading to haploinsufficiency, have been reported in patients with moderate to severe intellectual disability (ID) and distinct facial features, with or without congenital heart defects. Phenotype of the patients was referred to "MED13L haploinsufficiency syndrome." Missense variants in MED13L were already previously described to cause the MED13L-related syndrome, but only in a limited number of patients. Here we report 36 patients with MED13L molecular anomaly, recruited through an international collaboration between centers of expertise for developmental anomalies. All patients presented with intellectual disability and severe language impairment. Hypotonia, ataxia, and recognizable facial gestalt were frequent findings, but not congenital heart defects. We identified seven de novo missense variations, in addition to protein-truncating variants and intragenic deletions. Missense variants clustered in two mutation hot-spots, i.e., exons 15-17 and 25-31. We found that patients carrying missense mutations had more frequently epilepsy and showed a more severe phenotype. This study ascertains missense variations in MED13L as a cause for MED13L-related intellectual disability and improves the clinical delineation of the condition.

Role of Gamma Knife® Radiosurgery for the Treatment of Brain Metastases from Gynecological Cancers

Objective: Gamma Knife^® (GK) (Elekta Instruments, Stockholm, Sweden) radiosurgery is well established for treatment of brain metastases. There are limited data on patients treated with GK from gynecological cancers. The authors sought to determine the effectiveness of the GK in patients with brain metastases from gynecological cancers.

Methods: An IRB-approved database was queried for patients with gynecologic cancers treated with GK between June 1996 and May 2016. Imaging studies were reviewed post-SRS (stereotactic radiosurgery) to evaluate local control (LC) and distant brain control (DC). Overall survival (OS), local control, and distant brain control were calculated using the Kaplan-Meier (KM) method and log-rank test. 

Results: Thirty-three patients underwent SRS for 73 separate cranial lesions. The median age was ­58.5 years, and 17 (52%) also had extracranial metastases. Ten (30%) patients had previously received whole brain radiotherapy (WBRT), and 11 (33%) underwent concurrent WBRT. The median tumor volume was 0.96 cm³. Median radiographic follow-up was 11 months. At the time of treatment, 39% of patients were categorized as recursive partitioning analysis (RPA) Class I, 55% as RPA Class II, and 6% as RPA Class III. The local failure rate was 8%. Five patients (15%) developed new brain lesions outside the radiation field with a median progression-free survival (PFS) of seven (range: 3-9) months. Median OS was 15 months from GK treatment. One-year OS was 72.9% from GK treatment. Primary cancer histology was a significant predictor of OS, favoring ovarian and endometrial cancer (p = 0.03).

Conclusions: Gamma Knife stereotactic radiosurgery for gynecologic brain metastases leads to excellent control rates of treated lesions. Primary histology may have a significant impact on OS following GK, with improved survival seen with ovarian and cervical cancer following Gamma Knife radiosurgery (p = 0.03).

Combined cognitive-behavioural and mindfulness programme for people living with dystonia: a proof-of-concept study

OBJECTIVES

To design and test the delivery of an intervention targeting the non-motor symptoms of dystonia and pilot key health and well-being questionnaires in this population.

DESIGN

A proof-of-concept study to test the delivery, acceptability, relevance, structure and content for a 3-day group residential programme for the management of dystonia.

SETTING

Participants were recruited from a single botulinum toxin clinic. The intervention was delivered in the community.

PARTICIPANTS

14 participants consented to take part (2 withdrew prior to the starting of intervention). The average age was 60 years (range 44-77), 8 of whom were female. After drop-out, 9 participants completed the 3-day programme.

INTERVENTION

A 3-day group residential programme.

PRIMARY AND SECONDARY OUTCOME MEASURES

Process evaluation and interviews were carried out before and after the intervention to explore participant's views and expectations, as well as experiences of the intervention. Select questionnaires were completed at baseline, 1-month and 3-month follow-up.

RESULTS

Although participants were not sure what to expect from the programme, they found it informative and for many this together with being in a group with other people with dystonia legitimised their condition. Mindfulness was accepted and adopted as a coping strategy. This was reflected in the 1-month follow-up.

CONCLUSIONS

We successfully delivered a 3-day residential programme to help those living with dystonia manage their condition. Further improvements are suggested. The quantitative outcome measures were acceptable to this group of patients with dystonia.

Randomized clinical trial of the use of glyceryl trinitrate patches to aid arteriovenous fistula maturation

BACKGROUND

Arteriovenous fistulas are critical for haemodialysis, but maturation rates remain poor. Experimental and anecdotal evidence has supported the use of transdermal glyceryl trinitrate (GTN) patches. The aim of this RCT was to determine whether use of a GTN patch aids arteriovenous fistula maturation.

METHODS

Patients referred for arteriovenous fistula formation were eligible. The GTN or placebo patch was applied immediately after surgery and left in situ for 24 h. The primary outcome measure was the change in venous diameter at 6 weeks after fistula formation. The secondary outcome measure was clinical fistula patency at 6 weeks.

RESULTS

Of 200 patients recruited (533 screened), 101 were randomized to the placebo group and 99 to the GTN group. Of these, 81 and 86 respectively completed surgery, and had follow-up data available at 6 weeks. Improvements in venous diameter were similar in the two groups: mean(s.d.) increase 2·3(1·9) mm in the placebo group compared with 2·2(1·8) mm in the GTN group (P = 0·704). The fistula failure rate did not differ significantly between the two groups: 23 per cent for placebo and 28 per cent for GTN (P = 0·596).

CONCLUSION

GTN transdermal patches used for 24 h after surgery did not improve arteriovenous fistula maturation.

REGISTRATION NUMBER

NCT01685710 (http://www.clinicaltrials.gov).