Improved Upper Limit on the Neutrino Mass from a Direct Kinematic Method by KATRIN

We report on the neutrino mass measurement result from the first four-week science run of the Karlsruhe Tritium Neutrino experiment KATRIN in spring 2019. Beta-decay electrons from a high-purity gaseous molecular tritium source are energy analyzed by a high-resolution MAC-E filter. A fit of the integrated electron spectrum over a narrow interval around the kinematic end point at 18.57 keV gives an effective neutrino mass square value of (-1.0_{-1.1}^{+0.9})  eV^{2}. From this, we derive an upper limit of 1.1 eV (90% confidence level) on the absolute mass scale of neutrinos. This value coincides with the KATRIN sensitivity. It improves upon previous mass limits from kinematic measurements by almost a factor of 2 and provides model-independent input to cosmological studies of structure formation.

Feasibility of photoelectron sources with sharp lines of stable energy between 20 and 80 keV

Photo-absorption of γ-rays in thin Al, Co, Ti, and Mo convertors was examined with the aim to produce quasi monoenergetic photoelectrons having an energy spread of 0.5-4.7eV about mean kinetic energies at discrete values between 18632 and 80321eV. The photoelectron rates were estimated for commercial photon sources of (241)Am, (119m)Sn, (125m)Te and (109)Cd with activities of 0.55-3.7GBq. Photoelectrons ejected by (241)Am γ- and X-rays from Co convertors were measured with two different electron spectrometers and obtained energy spectra were compared with Monte Carlo predictions.

Quantification of elastic recoil after balloon angioplasty in the iliac arteries

PURPOSE

Elastic recoil of the arterial wall has been shown to be responsible for a significant loss of luminal area after balloon angioplasty in the coronary arteries, but it has not been well studied in the peripheral arteries. Because elastic recoil depends on the presence of elastin in the arterial wall, and the amount of elastin varies by artery and proximity to the aorta, the importance of this response to angioplasty may be different in peripheral arteries. The purpose of this study is to document the degree of elastic recoil in the iliac arteries, and analyze variables that might influence the results.

MATERIALS AND METHODS

A series of 19 patients with 25 iliac artery stenoses underwent balloon angioplasty followed by placement of a Palmaz stent with the same-sized angioplasty balloon. The minimum luminal diameter of the lesion was measured before treatment, immediately after balloon angioplasty, and again after stent placement. The arterial diameter after stent placement was defined as the diameter of the inflated balloon. The degree of recoil was correlated with nine variables: patient age and sex, lesion location and length, lesion severity (as percent stenosis), the balloon:artery ratio, and three factors related to lesion morphology--complex versus simple, eccentric versus concentric, and calcified versus noncalcified.

RESULTS

Elastic recoil averaged 36% +/- 11% and ranged from 19% to 54% in this series of patients. The only variable that significantly influenced the degree of elastic recoil was the balloon:artery ratio (P =.039), which was directly related.

CONCLUSION

Elastic recoil is a significant limitation of balloon angioplasty in the iliac arteries. This study illustrates the importance of techniques that limit recoil, such as vascular stents, in angioplasty of the iliac arteries.

A validation of the 10-meter incremental shuttle walk test as a measure of aerobic power in cardiac and rheumatoid arthritis patients

OBJECTIVE

To validate a simple, clinically relevant, and inexpensive test of aerobic power-the 10-meter incremental shuttle walk test (SWT)--in 2 separate patient populations.

DESIGN

Two-sample validity study.

SETTING

Physiotherapy department of major hospital in the United Kingdom.

PATIENTS

Convenience samples of rheumatoid arthritis (RA) patients (n = 10) and cardiac patients (n = 10).

INTERVENTION

Subjects were attached to a portable respiratory gas analyzer to measure oxygen uptake. They walked around an oval 10-meter course, starting at 0.5m/s, with velocity gradually increased by .17m/s increments for as long as they could, for up to 12 minutes.

MAIN OUTCOME MEASURES

A subject's maximal rate of oxygen uptake during exercise (V(O)(2)max) established with linear extrapolation was regressed against the number of shuttles completed (distance walked). An earlier study (n = 28) showed high levels of reliability and validity with linear extrapolation.

RESULTS

No significant linear relationship was found between V(O)(2)max and the number of shuttles completed (R(2); RA subjects = 9.7%, cardiac subjects = .03%, p > .05).

CONCLUSION

These results do not support use of the SWT as a representative measure of aerobic power. Despite this finding, the advantages of developing a clinically viable alternative to costly laboratory testing warrants further study of the SWT in patient groups.

Accuracy and safety of carbon dioxide inferior vena cavography

PURPOSE

The purpose of this study was to assess the accuracy of carbon dioxide compared to iodinated contrast material for determining inferior vena cava (IVC) diameter prior to filter placement, and to assess the safety of CO2 when used for this purpose.

PATIENTS AND METHODS

Consecutive patients undergoing inferior vena cavography prior to filter placement were prospectively evaluated with use of both CO2 and iodinated contrast material. The diameter of the IVC was measured and compared in the same four locations in each patient for both agents. The diameter was corrected for magnification and pin-cushion distortion. The ability of CO2 to correctly classify IVC diameter as < or =28 mm or >28 mm, based on the IVC diameter with iodinated contrast material, was determined. A consensus panel assessed renal vein visualization with CO2 and iodinated contrast material. Blood pressure and arterial oxygen saturation were measured immediately before and after CO2 injection.

RESULTS

Among 30 patients, there was no significant difference in the measured diameter of the IVC with CO2 versus iodinated contrast material after correction for magnification and pin-cushion distortion. One of 30 patients (3.3%) in this study was misclassified as having an IVC < or =28 mm with CO2 when, in fact, the IVC diameter was >28 mm based on iodinated contrast material. This could be clinically significant for certain IVC filters. Forty-seven percent of renal veins identified on contrast venography were identified by CO2 vena cavography. There was no significant difference in the blood pressure or oxygen saturation values measured before and after CO2 injection. However, one patient with pulmonary artery hypertension did experience transient, symptomatic hypotension after CO2 injection.

CONCLUSIONS

In most patients, CO2 vena cavography accurately evaluated IVC diameter prior to filter placement. In 3.3% of patients, the discrepancy in measurements between CO2 and iodinated contrast material could be clinically significant, depending on the type of filter placed. CO2 was less accurate than iodinated contrast material in identifying renal veins. Although CO2 vena cavography is safe in the majority of patients, it should be used with caution in patients with pulmonary hypertension.

Placenta accreta: comparison of cases managed with and without pelvic artery balloon catheters

OBJECTIVE

To describe our experience with the use of prophylactic pelvic artery balloon catheters in cases of placenta accreta diagnosed by antenatal ultrasound and to compare these cases with contemporary controls.

METHODS

In this prospective study, all patients seen at our institution between January 1994 and August 1997 with the antenatal sonographic diagnosis of placenta accreta were offered prophylactic preoperative pelvic artery balloon catheterization. Patients who were delivered by cesarean hysterectomy for unsuspected placenta accreta in our institution during the same time interval served as controls. Five patients with the sonographic diagnosis of placenta accreta underwent prophylactic pelvic artery balloon catheterization. Surgical outcomes in patients who received balloon catheters were compared with those managed without them. Statistical analysis was performed using the Mann-Whitney U test.

RESULTS

Five patients with placenta accreta or one of its variants were correctly identified with antenatal ultrasonography. Of the five patients who underwent pelvic artery balloon catheterization, all had placenta accreta and four required cesarean hysterectomy. The mean estimated blood loss, transfusion requirement, and length of hospitalization in patients undergoing hysterectomy managed with and without the balloon catheters was not different (P > 0.06).

CONCLUSIONS

Antenatal sonographic diagnosis of placenta accreta enables preoperative planning. In our experience, use of pelvic artery balloon occlusion catheters in patients requiring a cesarean hysterectomy for placenta accreta did not improve surgical outcomes compared with patients managed without them. These preliminary findings are based on a small number of patients; therefore, further investigation is needed.

Intravascular ultrasound as an alternative to positive-contrast vena cavography prior to filter placement

PURPOSE

In a nonconsecutive series of patients, intravascular ultrasound (IVUS) was investigated for safety and efficacy as an alternative to positive-contrast vena cavography for evaluating the inferior vena cava (IVC) prior to filter placement.

MATERIALS AND METHODS

In a 6.5-year period, 30 patients (15 women, 15 men) ranging in age from 22 to 98 years old (mean, 56 years) underwent vena cava filter placement without conventional positive-contrast vena cavography, after IVUS evaluation of the IVC with use of a 6.2-F, 12.5- or 20-MHz monorail catheter system. The rationale for using IVUS included contraindications to iodinated contrast material in 14 patients with renal insufficiency and in four patients with previous life-threatening anaphylactoid reaction to iodinated contrast material; limitations to radiation exposure in four pregnant patients; and inability to otherwise image the IVC of eight morbidly obese patients who exceeded the weight limits of available angiographic equipment. IVUS completely replaced positive-contrast vena cavography, although not fluoroscopy in the four pregnant patients and in the 18 patients with contrast material contraindications. In two of the eight obese patients, IVUS was the only imaging modality.

RESULTS

In all 30 patients, IVUS successfully determined the patency of the filter delivery route veins and the vena cava, the absence of thrombus, the location of renal veins, the absence of anatomical variants, and the vena cava diameter at the desired filter deployment level. Successful filter placement was confirmed in all 30 patients either with plain film alone (n = 12), IVUS alone (n = 3), computed tomography alone (n = 1), external ultrasound alone (n = 1), IVUS and another imaging modality (n = 10), or by combinations of other imaging modalities (n = 3). There were no complications.

CONCLUSIONS

IVUS is a safe and effective alternative to conventional positive-contrast vena cavography for imaging the IVC prior to filter placement in patients with contraindications to iodinated contrast material or ionizing radiation.

Feasibility of three-dimensional intravascular ultrasonography: preliminary clinical studies

The aim of this study was to demonstrate the clinical utility of reconstructed three-dimensional intravascular ultrasonography using a voxel-based volume rendering technique. Three-dimensional reconstruction of intravascular ultrasonographic data was performed in 12 patients with various vascular abnormalities during interventional radiology procedures. A stepping motor device was used to pull either a 12.5 or a 20 MHz catheter-based transducer through the lumen of a variety of vessels at a rate of 1.5 mm/s. Images were downloaded to a Life Imaging System for three-dimensional reconstruction. The value of three-dimensional ultrasonographic imaging was evaluated in comparison to conventional intravascular ultrasonography. A variety of abnormalities were demonstrated in reconstructed three-dimensional ultrasound imaging, including arterial atheroma and plaque, aneurysm and pseudoaneurysm, aortic dissection and stenosis (May-Thurner syndrome). The vascular branches and accessory vessels, as well as their relationships to each other, were easily demonstrated on three-dimensional imaging by selecting an appropriate angle, plane, and section of the image. The dimensions and shapes of the vascular lumen were determined in the longitudinal view. Three-dimensional information proved useful for determining the distribution and type of plaque in vessels. Reconstructed three-dimensional imaging allows for global evaluation of the dissection entry site, extent of the flap, and the false lumen of a pseudoaneurysm. Intravascular three-dimensional ultrasonography provides information complementary to that obtained with two-dimensional imaging. It supplies information about spatial relationships of anatomic structures that cannot be evaluated using conventional imaging methods.

Carbon dioxide as a contrast agent to guide vascular interventional procedures

OBJECTIVE

The purpose of this study was to assess the value and limitations of carbon dioxide (CO2) as a contrast agent to guide vascular interventional procedures.

SUBJECTS AND METHODS

Twenty-two adults underwent 26 vascular interventional procedures (21 arterial, five venous). We aimed to use only CO2 if possible because these patients had renal insufficiency (n = 21; mean creatinine level, 2.8 mg/dl) or were allergic to contrast material (n = 1). Arterial procedures performed included renal angioplasty or stent (n = 6), iliac angioplasty or stent (n = 5), infrainguinal angioplasty (n = 5), arterial bypass graft angioplasty (n = 3), and thrombolysis (n = 2). Venous procedures included transjugular intrahepatic portosystemic shunt recanalization (n = 3), angioplasty of the venous anastomosis of a thigh dialysis graft (n = 1), and angioplasty of the inferior vena cava (n = 1).

RESULTS

Twenty-five of the 26 procedures were successfully performed. Of the 26 procedures, eight required no iodinated contrast material and 11 required less than or equal to 20 ml of contrast material. CO2 proved to be inadequate for the remaining seven procedures. Iliac artery angioplasty or stent placement required an average of 9 ml of iodinated contrast material; infrainguinal angioplasty required an average of 22 ml of iodinated contrast material.

CONCLUSION

CO2 can be successfully used as a contrast agent in a variety of vascular interventional procedures. Such procedures can usually be performed in the iliac and infrainguinal arteries using minimal supplemental iodinated contrast material. However, CO2 failed to provide satisfactory guidance in half of the intraabdominal procedures in our study.

1998 SCVIR Gary J. Becker Young Investigator Award. Endovascular repair of arterial pseudoaneurysms with use of a perfusion balloon catheter

PURPOSE

Pseudoaneurysms represent contained disruption of the arterial wall. Iatrogenic pseudoaneurysms frequently complicate complex endovascular procedures. With use of an animal model, the authors attempted to determine the safety and efficacy of using a perfusion balloon catheter (PBC) to thrombose surgically created pseudoaneurysms.

MATERIALS AND METHODS

An in vitro system measured maximum flow volume through a 5-F PBC. Pseudoaneurysms were created in domestic swine with use of a jugular vein patch anastomosed to a femoral arteriotomy. The PBC was inflated across the pseudoaneurysm neck for 30-minute intervals until thrombosis was confirmed by ultrasound. Completion arteriography was performed to evaluate for vascular complications.

RESULTS

Maximum flow through the PBC was 62.6 mL/min measured at a constant pressure gradient of 120 mm Hg. Five pseudoaneurysms were created in four animals. The PBC completely thrombosed all five lesions. The mean treatment duration was 129 minutes (+/- 39 minutes SD). No native arterial injury, in situ thrombus, or distal embolization occurred. Partial recanalization of three of the five treated pseudoaneurysms was identified on follow-up arteriography and gross sectioning (n = 2 and n = 1, respectively).

CONCLUSION

The PBC safely and effectively thrombosed surgically created pseudoaneurysms. Partial recanalization of treated pseudoaneurysms was demonstrated. Clinical trials are warranted.

Comparison of conventional angioplasty with the Palmaz stent in the treatment of abdominal aortic stenoses from the STAR registry. SCVIR Transluminal Angioplasty and Revascularization

PURPOSE

To retrospectively compare the safety and short-term efficacy of conventional percutaneous transluminal angioplasty (PTA) and PTA with the Palmaz balloon-expandable intravascular stent for the treatment of infrarenal abdominal aortic atherosclerotic stenoses.

PATIENTS AND METHODS

The records of 25 patients with infrarenal aortic stenoses treated by means of percutaneous techniques were retrieved from the SCVIR Transluminal Angioplasty and Revascularization (STAR) Registry and analyzed. Thirteen patients were treated with PTA alone and 12 were treated with the Palmaz intravascular stent.

RESULTS

Technical success was achieved in 92% of patients treated with PTA alone and in 100% of those treated with the Palmaz stent. Significant improvements in lesion morphology, hemodynamics, clinical status, and ankle arm indexes were shown in both groups. There was no statistically significant difference in percent stenosis reduction, decrease in trans-stenotic gradient, or initial clinical outcome between the group treated by means of PTA and the group treated by means of PTA with the Palmaz stent.

CONCLUSIONS

PTA and intravascular stent placement of atherosclerotic stenoses involving the infrarenal aorta are both safe and efficacious therapeutic modalities. At present, it does not appear that primary stent placement confers any short-term benefits over technically successful PTA in aortic stenoses.

Biliary-pleural fistulas without biliary obstruction: percutaneous catheter management

OBJECTIVE

Our purpose was to report the use of percutaneous catheter drainage as a therapeutic option in the management of three patients with biliary-pleural fistulas without biliary obstructions.

CONCLUSION

In the proper clinical setting, the CT findings of liver dome laceration or abscess, diaphragm disruption, and pleural effusion should suggest biliary-pleural fistula. Percutaneous catheter management can be curative or serve a temporizing function before surgery.

Evaluation of a new percutaneous stainless steel Greenfield filter

PURPOSE

To evaluate a new percutaneous Greenfield filter with an alternating hook design and over-the-wire delivery system.

MATERIALS AND METHODS

The alternating hook stainless steel Greenfield filter was evaluated in a prospective clinical trial between March 10, 1994, and January 27, 1995. Filters were placed in 75 patients in nine clinical centers and follow-up with radiographs and ultrasound scans was carried out at 30 days.

RESULTS

Clinical trial results revealed successful placement in all patients. There were four cases of filter limb asymmetry (5.3%) without clinical sequelae, with one incidence of failure to span the cava. No significant migration was found. There were no clinically suspected pulmonary emboli, but one instance of probable caval penetration (1.7%) did occur. Caval occlusion was documented in three patients (5%).

CONCLUSION

The percutaneous stainless steel Greenfield filter provides ease of insertion and improved deployment while maintaining the high standards of efficacy and safety associated with the standard and titanium Greenfield filters.

Malignant biliary duct obstruction: long-term experience with Gianturco stents and combined-modality radiation therapy

PURPOSE

To evaluate the effect of combined-modality therapy including intraluminal iridium-192 on stent patency and survival in patients with malignant biliary obstruction treated with Gianturco stents.

MATERIALS AND METHODS

Twenty-two patients with unresectable biliary obstruction caused by cholangiocarcinoma (n = 11) or by secondary extrahepatic bile duct malignant tumors (n = 11) were treated with percutaneous biliary drainage followed by intraluminal Ir-192 wire placement (mean dose, 25 Gy) before insertion of Gianturco metal stents. Eleven patients also received external-beam radiation therapy, and 13 patients received chemotherapy. Patency was defined as absence of jaundice or cholangitis that necessitated hospitalization, or as seen on hepatobiliary scans. Survival was determined from the time of stent insertion after brachytherapy.

RESULTS

Patients with cholangiocarcinoma had extended mean stent patency of 19.5 months (range, 2-46 months) and mean survival of 22.6 months (range, 2-72 months). Patients with secondary malignant tumors had a mean patency of 4.8 months (range, 1.5-8 months) and a mean survival of 5.3 months (range, 2-9 months).

CONCLUSION

Radiation therapy including intraluminal Ir-192 appears to extend stent patency and survival in patients with inoperable cholangiocarcinoma treated with Gianturco metal stents compared with patients with other extrahepatic bile duct malignant diseases and patients treated without combined-modality therapy in other studies.

Participation by radiologists and other specialists in percutaneous vascular and nonvascular interventions: findings from a seven-state database

PURPOSE

To determine the relative degree of participation by radiologists and other specialists in percutaneous interventional procedures.

MATERIALS AND METHODS

By using 1992 Medicare Part B claims data that covered seven states, the specialty of the physician provider was determined for all services performed within various percutaneous vascular and nonvascular interventional procedure codes.

RESULTS

Radiologists' performance of interventional procedures in descending percentage of participation was as follows: renal cyst aspiration (92.7%), biliary decompression (90.5%), abdominal or retroperitoneal mass biopsy (87.7%), lung or mediastinal biopsy (84.2%), noncardiac angioplasty (76.8%), pancreatic biopsy (75.2%), upper urinary tract decompression (73.7%), liver biopsy (43.7%), renal biopsy (38.4%), certain types of abscess drainages (38.2%), and thoracentesis with tube insertion (29.4%). They had only small roles in thoracentesis for aspiration (4.7%) and tube thoracostomy (1.7%).

CONCLUSION

Despite controversy between radiologists and other specialists over who should perform percutaneous interventions, radiologists have maintained strong predominance in many types of these procedures. In others, they have a shared, but still major, role.

Venography with carbon dioxide as a contrast agent

PURPOSE

The purpose of this study was to evaluate the feasibility, safety, and potential role of carbon dioxide (CO2) as a contrast agent for venography.

METHODS

Consecutive patients with contraindications to iodinated contrast agents or with unsatisfactory iodinated contrast studies underwent CO2 digital subtraction venography. The images were rated by three experienced angiographers. Image quality and complications were assessed.

RESULTS

Over a 14-month period, 66 vein segments were studied in 21 patients. There was good correlation between experienced angiographers on CO2 image quality (Ri = 0.80) and good agreement on diagnosis (k = 0.62). In 91% of the vein segments evaluated with C02 there was interobserver agreement on the diagnosis. Upper extremity veins were adequately imaged with CO2 alone in all (6/6) patients with contraindications to iodinated contrast. Following suboptimal iodinated contrast studies in six patients, CO2 produced significantly better quality upper extremity central vein images (p < 0.05). Pain following injection into peripheral veins was the only CO2-related complication. Inferior vena cava (IVC) filters were successfully deployed with CO2 alone in 78% (7/9) of patients; two required iodinated contrast.

CONCLUSIONS

Based upon initial experience, CO2 venography can be recommended in patients with contraindications to iodinated contrast or unsatisfactory iodinated contrast studies.

Arterial abnormalities following orthotopic liver transplantation: arteriographic findings and correlation with Doppler sonographic findings

OBJECTIVE

We studied the findings on conventional arteriography in patients who had suspected graft ischemia after orthotopic liver transplantation to determine the value of a single Doppler signal in predicting these lesions.

MATERIALS AND METHODS

We retrospectively reviewed selective visceral arteriograms with abnormal findings from 20 adults who had suspected graft ischemia after orthotopic liver transplantation and a single Doppler signal from the hepatic artery at the porta hepatis on sonograms obtained before arteriography. Arteriographic abnormalities were categorized according to morphology and location as follows: stenosis of recipient's hepatic artery, occlusion or stenosis of the transplanted extrahepatic artery, and occlusion or stenosis of the transplanted intrahepatic artery.

RESULTS

Twenty-three arteriographic abnormalities were detected: four recipient celiac axis stenoses, seven extrahepatic occlusions, nine extrahepatic stenoses, and two occlusions and one stenosis of the transplanted intrahepatic artery. Six of the extrahepatic occlusions, two of the extrahepatic stenoses, and none of the recipient artery stenoses or the intrahepatic occlusions or stenoses were correctly diagnosed on the basis of Doppler findings. One patient with both an extrahepatic stenosis and an extrahepatic occlusion was thought to have an intrahepatic occlusion, and two patients with mild (< 50%) extrahepatic stenoses and one with an intrahepatic occlusion were thought to have an extrahepatic occlusion.

CONCLUSION

A wide spectrum of abnormalities in the recipient's celiac axis or the transplanted arteries that may be associated with graft ischemia after orthotopic liver transplantation are often not detected or findings are misinterpreted on routine Doppler examination. In patients with suspected graft ischemia, visceral arteriography should be performed promptly to confirm the diagnosis and to allow early intervention.

Transrectal sonographically guided drainage of deep pelvic abscesses

OBJECTIVE

As an alternative to traditional surgical transrectal and transgluteal drainage, we have examined the efficacy of transrectal sonographically guided drainage for deep pelvic abscesses not accessible by percutaneous transabdominal or transvaginal routes.

SUBJECTS AND METHODS

In nine patients (five males and four females) 5-51 years old, sonography or CT showed pelvic abscesses that were deemed unapproachable by percutaneous transabdominal or transvaginal routes because of interposed bowel (five patients), presacral location (two patients), or inability of the pediatric vagina to accommodate a transvaginal probe (one patient). One patient refused both transvaginal and transgluteal routes in preference to transrectal drainage. IV sedation (adults) or general anesthesia (children) was used for all drainages. A 7.5-MHz end-fire transrectal sonographic probe fitted with a biopsy guide was inserted into the rectum, and the collection was localized. With sonographic guidance, an 18-gauge needle and then a guidewire were advanced into the collection. Then with fluoroscopic guidance, a self-retaining drainage catheter was placed by using the Seldinger technique.

RESULTS

All nine collections were successfully accessed and effectively drained without complication. Catheters were removed after 1-24 days (mean, 7 days; median, 5 days) without recurrent abscesses.

CONCLUSION

Transrectal sonographically guided drainage of deep pelvic abscesses is a safe, well-tolerated, effective alternative to the more traditional surgical transrectal drainage or transgluteal approach, especially in pelvic abscesses that cannot be safely drained via a percutaneous transabdominal or transvaginal route.

Fallopian tube recanalization in an unrestricted patient population

PURPOSE

To review the effectiveness of fallopian tube recanalization (FTR) when performed without restriction based on history or tubal condition.

MATERIALS AND METHODS

From October 1989 to July 1992 in 37 consecutive women, aged 22-44 years (mean, 35 years), 42 FTRs were performed (five patients each underwent two FTRs). Water-soluble contrast material and selective ostial salpingography and/or microcatheter technique were used exclusively. Eighty tubes were evaluated, since four patients had previously undergone unilateral salpingectomy. Sixty-three tubes (79%) were occluded at the outset of the procedure.

RESULTS

Complete recanalization was achieved in 45 of 63 (71%) occlusions. Adhesions were present in 25 of 80 (31%) tubes, salpingitis isthmica nodosa in 12 (15%), and hydrosalpinx in nine (11%). The 42 procedures resulted in 14 (33%) conceptions, nine (64%) of which involved pathologic tubes. Eleven intrauterine pregnancies resulted in five spontaneous first-trimester abortions, five full-term deliveries, and one continuing pregnancy.

CONCLUSION

Favorable conception and live birth rates can be achieved with FTR, despite a high prevalence of tubal disease.

Water quality, waterborne disease and enteric disease in Israel, 1976-92

Israel experienced a large number of waterborne disease outbreaks between 1975 and 1985, followed by a steep decline in the period 1986-92. Large-scale community waterborne disease outbreaks occurred primarily in the late 1970s, and in 1985 (the Krayot, four small towns neighboring Haifa), but substantial outbreaks occurred as late as 1989, with 4 during 1986-90, and 1 during 1991-92. New water standards, including mandatory chlorination of all community water supplies, came into effect in late 1988. Water quality, as monitored by the Ministry of Health, showed a marked improvement even when measured by the more stringent standards of the 1988 regulations. Long-term trends in the total of reported enteric infectious diseases from all sources, including typhoid, hepatitis, Shigella and Salmonella in Israel are examined. Typhoid, which has been declining since the 1960s, peaked in 1985 with the large waterborne disease episode of the Krayot. Shigella and total hepatitis incidence increased slowly up to the mid-1970s, followed by large increases during the 1975-85 period, then by a rapid decline up to 1991. Shigella, from childhood contacts in kindergartens, increased in 1992. Salmonella incidence continues to increase steadily. Mandatory chlorination and more stringent water standards have had an important impact on water quality and on waterborne disease outbreaks in Israel. Empiric evidence suggests that improving water quality may also be a factor in the changing patterns of some enteric diseases and the total burden of enteric disease in Israel.

Hemodynamics of failing dialysis grafts

Pressures were measured in the graft and the central vein during 104 consecutive angiographic examinations of failing hemodialysis grafts. Stenosis severity greater than 40% led to a statistically significant rise in graft pressure. In grafts in which all stenoses were of 40% or less severity, the systolic pressures in the venous and arterial limbs of the grafts were 31% +/- 16 and 45% +/- 17, respectively, of systemic systolic pressure. In grafts in which the highest grade of stenosis was greater than 40%, pressures in the venous and arterial limbs of the grafts were 53% +/- 25 and 75% +/- 24, respectively, of systemic systolic pressure. Graft thrombosis tended to occur at a higher degree of lumen reduction (but at similar pressures) with central vein stenoses compared with venous anastomotic stenoses. Dialysis graft pressures can help determine the hemodynamic importance of stenoses and the need for intervention. Percutaneous intervention should achieve arterial and venous limb pressures of less than 50% and 33% of systemic pressure, respectively.

Measles control in developing and developed countries: the case for a two-dose policy

Despite major reductions in the incidence of measles and its complications, measles control with a single dose of the currently used. Schwarz strain vaccine has failed to eradicate the disease in the developed countries. In developing countries an enormous toll of measles deaths and disability continues, despite considerable efforts and increasing immunization coverage. Empirical evidence from a number of countries suggests that a two-dose measles vaccination programme, by improving individual protection and heard immunity can make a major contribution to measles control and elimination of local circulation of the disease. Cost-benefit analysis also supports the two-dose schedule in terms of savings in health costs, and total costs to society. A two-dose measles vaccination programme is therefore an essential component of preventive health care in developing, as well as developed countries for the 1990s.

Intraarterial chemotherapy with limb-sparing resection of large soft-tissue sarcomas of the extremities

Fifteen patients with large (average, 15-cm), high-grade soft-tissue sarcomas of the extremities received prolonged selective intraarterial infusions of chemotherapeutic agents in an attempt to permit limb-sparing resection of these tumors, which would otherwise have required amputation. There were seven malignant fibrous histiocytomas, four liposarcomas, two fibrosarcomas, one leiomyosarcoma, and one rhabdomyosarcoma; 73% were grade III. Seven patients underwent two catheterizations, for a total of 22 infusions, which averaged 11.3 days each. There were four catheterization-related complications, including catheter occlusion or dislodgement in one patient each and two cases of arterial thromboembolism in patients in whom anticoagulant dose was not adequate. Both of the latter patients required thrombectomy; one developed gangrene, which precluded limb-sparing surgery. Thirteen of the 15 patients underwent limb-sparing resections, and two underwent amputations. No wound complications occurred. With a median follow-up of 36 months (mean, 34 months), life-table analysis indicates overall and disease-free survivals of 72% and 59%, respectively, at 2 years and 64% and 59% at 3 years. In comparison to other reported therapies, this technique permits limb salvage in most patients without the high wound complication rate associated with preoperative radiation therapy, with equivalent local disease control and survival.

Recanalization of an occluded aortoiliac bypass graft with Palmaz stents

Four tandem Palmaz balloon-expandable vascular stents were used to recanalize the completely occluded limb of an aortoiliac bypass graft after failure of thrombolysis and conventional angioplasty. The resting peak-systolic pressure gradient across the occluded limb was reduced from 68 to 13 mm Hg. The patient's rest pain resolved, and the ankle-brachial index rose from 0.54 to 0.78. No embolization or stent-related complications occurred. The graft remains patent as determined with noninvasive studies obtained 8 months later.

Results of a multicenter study of the modified hook-titanium Greenfield filter

Initial efforts to modify the stainless steel Greenfield filter for percutaneous insertion led to development of a titanium Greenfield filter, which could be inserted by use of a 12F carrier. This device functioned well as a filter but had an unacceptable 30% rate of migration, tilting, and penetration. Therefore a titanium Greenfield filter with modified hooks was developed and has been tested in 186 patients at 10 institutions. Successful placement occurred in 181 (97%); placement of the remainder was precluded by unfavorable anatomy. A contraindication to anticoagulation was the most frequent indication for insertion (75%). All but two were inserted percutaneously, predominantly via the right femoral vein (70%). Initial incomplete opening was seen in four patients (2%), which was corrected by guide wire manipulation and asymmetry of the legs in 10 (5.4%). Insertion site hematoma occurred in one patient, and apical penetration of the cava during insertion occurred in a second patient. Both events were without sequelae. Follow-up examinations were performed at 30 days at which time 35 deaths had occurred. Recurrent embolism was suspected in six patients (3%) and two of three deaths were confirmed by autopsy. Filter movement greater than 9 mm was seen in 13 patients, (11%) and increase in base diameter greater than or equal to 5 mm was seen in 17 patients (14%). CT scanning showed evidence of caval penetration in only one patient (0.8%). Insertion site venous thrombosis was seen in 4/46 (8.7%) patients screened. The modified hook titanium Greenfield filter is inserted percutaneously or operatively through a sheath, eliminating concern for misplacement from premature discharge.(ABSTRACT TRUNCATED AT 250 WORDS)

Transhepatic laser lithotripsy of choledocholithiasis: initial clinical experience

Three patients with symptomatic intra- and extrahepatic choledocholithiasis who were not good candidates for retrograde endoscopy, surgery, or extracorporeal shock wave lithotripsy (ESWL) were treated successfully with endoscopically guided tunable dye laser lithotripsy via a 12-F transhepatic sheath. There were no complications secondary to the use of the laser. On the basis of this initial experience, transhepatic laser lithotripsy is a technically feasible and safe alternative when choledocholithiasis cannot be managed with retrograde endoscopy, ESWL, or surgery. Its role in the management of choledocholithiasis relative to other transhepatic techniques remains to be determined.

Efficacy of thrombolysis in infrainguinal bypass grafts

The initial outcome of a consecutive series of 43 intra-arterial urokinase infusions for thrombosed infrainguinal grafts in 37 patients was analyzed. There was an 88% (38/43) technical success rate (complete clot lysis) and a 74% (32/43) clinical success rate. Complications occurred in 10 patients (23%) and were related to bleeding in four patients (9%). Patient age, graft age, location, material, and the duration of occlusion did not significantly influence the initial outcome, although there was a trend toward a higher bleeding complication rate among grafts less than or equal to 1 month of age at the time of thrombolysis. A second group of 43 infrainguinal grafts successfully recanalized using regional infusions of thrombolytic agents were followed for long-term patency. This group included 32 grafts successfully treated with urokinase and 11 grafts recanalized with streptokinase. By life-table analysis there was a 55.6% 1-year patency, which fell to 42.4% at 4 years. Vein grafts had significantly (p = 0.01) better long-term patency than prosthetic grafts (69.3% versus 28.6% at 30 months). Grafts with flow-limiting lesions identified and corrected by angioplasty or surgery also had significantly (p = 0.01) better long-term patency than those without such lesions (79.0% versus 9.8% at 2 years). Based on the results of our study compared with a survey of long-term results following secondary surgical procedures for thrombosed infrainguinal grafts, thrombolysis can be recommended in several circumstances. Thrombolysis is indicated for thrombosed vein grafts or when thrombus is present in distal runoff vessels. Thrombosed prosthetic grafts should be replaced by autogenous vein grafts whenever possible.(ABSTRACT TRUNCATED AT 250 WORDS)

Extremity osteosarcomas: intraarterial chemotherapy and limb-sparing resection with 2-year follow-up

Twenty-eight consecutive patients with extremity osteosarcoma (24 stage II, four stage III) received their entire preoperative course of chemotherapy intraarterially in order to maximize local drug concentration and tumor shrinkage to facilitate limb-sparing resection. Eighteen tumors were located in the femur, seven in the tibia, two in the humerus, and one in the fibula. Most patients underwent two catheterizations; thus there was a total of 51 procedures. The average duration of each infusion was 10.4 days. There were eight procedure-related complications, but none precluded completion of intraarterial chemotherapy. Limb-sparing surgery was performed on 25 patients. At a mean follow-up of over 2 years, there was one local recurrence. Among limb-salvage patients with stage II disease, 90% (18 of 20) survived and 75% (15 of 20) are disease-free. Compared with patients from previous studies, this technique permits a high percentage of patients with osteosarcoma to undergo limb-sparing resection without compromise of local disease control or survival.

Selective arterial stimulation of secretin in localization of gastrinomas

In two patients with malignant gastrinoma and the Zollinger-Ellison syndrome, we were able to use selective arterial stimulation with secretin as a technique to localize the lesions accurately, allowing resection. The technique of selected arterial secretin stimulation is one of measuring variations in gastrin levels in both the hepatic vein and a peripheral artery at specified times after injection of secretin into a specific artery. When the criteria for localization have been met, one can plot the presence of the gastrinoma within the blood supply of the injected artery and, using angiograms, thus accurately localize the lesion. This method promises to be a valuable additional tumor-localizing procedure, particularly when gastrinomas are extrapancreatic.

Palmaz vascular stent: initial clinical experience

The safety and efficacy of the Palmaz balloon-expandable vascular stent and its effect on the results of percutaneous transluminal angioplasty (PTA) were assessed in a prospective study. Technical success was achieved in the placement of 34 of 35 stents (97%) in 27 common and external iliac artery lesions in 19 patients (23 limbs) who presented with disabling claudication, rest pain, or gangrene. Stent placement improved the angiographic results achieved by PTA alone in all 19 patients. Seventeen of 23 limbs (74%) had significant (greater than 20%) elevation of the ankle-arm index after combined angioplasty and stent placement, including nine limbs with occlusive outflow lesions. All 10 patients with continuous runoff distal to the stent and one patient with discontinuous runoff had resolution of their symptoms, remaining unchanged at a mean follow-up time of 6 months. There were three complications: One significantly altered the patient's hospital course, but none detracted from the achieved stent result. Stent placement is effective and does not significantly increase the complication rate of conventional iliac PTA. The current delivery system, however, may limit its utility.

Acceleration of thrombolysis with a high-dose transthrombus bolus technique

The rate of complication and the time necessary to achieve thrombolysis remain major disadvantages of regional thrombolytic therapy. By lacing the entire length of arterial or arterial bypass graft occlusions in the lower extremities of 49 patients with one of two different bolus doses of urokinase (mean, 52,000 International U in 35 infusions = low-dose group [28 patients]; mean, 230,000 U in 23 infusions = high-dose group [21 patients]) prior to identical continuous infusions, it was possible to demonstrate a decrease in the time needed to complete thrombolysis from 33.6 hours in the low-dose group to 10.4 hours in the high-dose group (P less than .001). The total urokinase dose necessary for successful thrombolysis was also significantly less in the high-dose group (P less than .001). The major complication rate was 22.9% in the low-dose group and 8.7% in the high-dose group, although the difference was not statistically significant. The use of urokinase and a high-dose transthrombus bolus injection technique significantly accelerates thrombolysis, decreases the total urokinase dose needed, and may lower the major complication rate.