Outcomes following Exchange and Upsizing of Malfunctioning Small-Caliber Double-J Ureteral Stents

PURPOSE

To determine the effectiveness of exchange and upsizing of malfunctioning small-caliber double-J (JJ) ureteral stents.

MATERIALS AND METHODS

Thirty-one patients with malfunctioning cystoscopically placed small-caliber (6 or 7 F) JJ stents underwent transurethral (n = 28) or transrenal (n = 3) exchange and upsizing to a large-caliber (10 F) JJ stent from 2013 to 2022. Ureteral obstruction was malignant in 20 patients (65%) and benign in 11 (35%). Fifteen patients (48%) presented with persistent hydroureteronephrosis and 16 patients (52%) with worsening hydronephrosis. Acute kidney injury (AKI) was present in 19 patients (61%) at the time of stent malfunction. Therapeutic success was defined as resolution of hydronephrosis and AKI, if present.

RESULTS

JJ stent exchange and upsizing was technically successful in 31 patients (100%) with no immediate adverse events. Therapeutic success was achieved in 27 patients (87%). During follow-up (median, 97 days; IQR, 32-205 days), 2 patients who initially achieved therapeutic success had stent malfunction, requiring conversion to percutaneous nephrostomy drainage (2/27, 7%).

CONCLUSIONS

Exchange and upsizing to large-caliber JJ stents can relieve urinary obstruction and resolve AKI in patients with malfunctioning small-caliber JJ stents. Large-caliber JJ stents should be considered as a salvage option for patients who wish to continue internal drainage and avoid percutaneous nephrostomy.

Comparison of Transthoracic Contrast Echocardiography to High-Resolution Chest Computed Tomography after Embolization of Pulmonary Arteriovenous Malformation

PURPOSE

To compare post-embolotherapy follow-up graded transthoracic contrast echocardiography (TTCE) and high-resolution chest CT (HRCT) and to evaluate the use of graded TTCE in the early post-embolization period.

METHODS

Thirty-five patients (6M;29F, mean age 56y, range 27-78y) presenting for post-embolotherapy follow-up between 2017-2021 with concurrent HRCT and graded TTCE were analyzed retrospectively. Untreated PAVMs with a feeding artery > 2 mm were considered treatable.

RESULTS

Ninety-four percent of patients (33/35) did not have treatable PAVMs on HRCT. TTCE was negative (grade 0) in 34% of patients (n=12). Of patients with a positive TTCE (23/35, 66%), 83% had a grade 1 shunt, 13% a grade 2 shunt, and 4% a grade 3 shunt. No patients with a grade 0 or 1 shunt had a treatable PAVM on HRCT. Of the two patients with PAVMs requiring treatment, one had a grade 2 shunt, and one had a grade 3 shunt. TTCE grade was significantly associated with the presence of a treatable PAVM on HRCT (P<0.01).

CONCLUSION

Graded TTCE predicts the need for repeat embolotherapy and does so reliably in the early post-embolotherapy period. This suggests that graded TTCE can be utilized in the post-embolotherapy period for surveillance, which has the potential to lead to a decrease in cumulative radiation in this patient population.

Adrenal Vein Sampling Results and Surgical Outcomes in Patients with a Normal Plasma Aldosterone Concentration

PURPOSE

To determine the utility of adrenal vein sampling (AVS) and outcomes after adrenalectomy in patients with normal plasma aldosterone concentration (PAC) and elevated aldosterone-to-renin ratio (ARR).

MATERIALS AND METHODS

The study sample included 106 patients with ARR greater than 20 and PAC between 5 and 15 ng/dL (normal PAC group) who underwent AVS from 2005 to 2021. These patients were compared with a cohort of 106 patients with ARR >20 and PAC >15 ng/dL (high PAC group) who underwent AVS during the same period. Data regarding baseline clinical characteristics, lateralization indices from AVS, and outcomes after adrenalectomy were analyzed.

RESULTS

AVS was technically successful in 210 patients (210/212, 99%). A smaller proportion of patients in the normal PAC group showed a lateralization index of >4 compared with those in the high PAC group (44% vs 64%, P <.01). A similar proportion of patients in the normal PAC group experienced improved or cured hypertension after adrenalectomy compared with that in the high PAC group (94% vs 88%, P =.31). Hypokalemia was cured in all patients in the normal PAC group after adrenalectomy compared with 98% of patients in the high PAC group (100% vs 98%, P = 1).

CONCLUSIONS

Although lateralization is less frequent for patients with normal PAC, patients who do lateralize show similar blood pressure response and correction of hypokalemia after adrenalectomy, regardless of initial plasma aldosterone levels. Therefore, patients with PAC <15 ng/dL should still be considered for AVS provided the ARR is elevated.

Outcomes after Transgastric Drainage of Pancreatic Duct Leaks

PURPOSE

To determine the outcomes of transgastric drainage (TGD) of pancreatic duct leaks (PDLs), including fluid collections and pancreaticocutaneous fistulae (PCFs).

MATERIALS AND METHODS

Fifty-four patients who underwent attempted TGD of a PDL from 1992 to 2020 were identified. Data regarding patient comorbidities, fluid collection characteristics, technical success, drain exchanges and removals, recurrent collections, and complications were analyzed.

RESULTS

Forty-one patients (41/54, 76%) had a history of pancreatitis. Sixteen patients (16/54, 30%) had a history of recent abdominal surgery. Peripancreatic fluid collections were 11.2 cm ± 4.6 in greatest dimension prior to drainage. Twenty-one collections (21/54, 39%) demonstrated biochemical and/or imaging evidence of an active communication to the pancreatic duct, and 16 (16/54, 30%) of these patients had a PCF due to a direct percutaneous drain prior to TGD. TGD was technically successful in 53 patients (53/54, 98%). During the follow-up period, 46 patients (46/53, 87%) were able to undergo drain removal after resolution of the fluid collection, with a mean catheter indwelling time of 3 months and a median of 1 catheter exchange. There were 2 severe (2/53, 4%) and 4 moderate (4/53, 8%) complications, the most common of which was drain dislodgement requiring repeat transgastric puncture. Recurrent fluid collections were observed in 8 patients (8/53, 15%) after a mean of 5 months following drain removal. There were no recurrent PCFs.

CONCLUSIONS

TGD of PDLs is technically feasible and efficacious in the vast majority of patients with a relatively low complication rate. This technique is effective in preventing or treating the long-term debilitating complication of PCF.

Endovascular IVC Reconstruction in an 18 Year Old Patient with Subtotal IVC Atresia

Introduction

Inferior vena cava (IVC) atresia is an uncommon venous anomaly that is an under recognised cause of unprovoked acute deep venous thrombosis (DVT) in young adults. The purpose of this case report is to highlight endovascular IVC reconstruction as a feasible treatment option, particularly in challenging cases when other therapeutic modalities have failed.

Report

This is the report of an 18 year old patient with near complete IVC atresia and a longstanding history of exertional nausea of unknown aetiology, who presented with extensive acute DVT. He was treated successfully by endovascular IVC reconstruction after failing initial anticoagulation and thrombolysis. Symptom resolution and venous patency were maintained at 2.5 year follow up.

Discussion

IVC atresia is an important aetiology to consider in a young patient presenting with unprovoked DVT. Endovascular stenting can restore venous patency and is feasible even when there is near complete IVC atresia. This case was uniquely challenging in the length of atretic IVC that was reconstructed and also highlights an atypical clinical presentation of IVC atresia.

Infectious Recidivism in Tunneled Dialysis Catheters Removed for Bloodstream Infection in the Intensive Care Unit

PURPOSE

To determine the rate of recurrent infection of ICU patients who underwent tunneled dialysis catheter (TDC) exchange or removal for bloodstream infection.

MATERIALS AND METHODS

Forty seven patients, with a total of 61 TDCs removed for bloodstream infection while admitted in an ICU from 2017-2020, were identified. TDCs were exchanged over a wire or removed and replaced. Thirteen patients (21%) were managed with non-tunneled dialysis catheters (NTDCs) until delayed TDC replacement at ICU departure. Forty seven TDCs were removed for bacteremia (77%), 13 for fungemia (21%), and 1 for both (2%). Thirty TDCs (49%) were exchanged over-the-wire (ICU-exchanged TDCs), and 31 (51%) were removed. Of the patients who underwent TDC removal, 9 had a new TDC placed while still admitted in the ICU (ICU-replaced TDCs), and 7 underwent delayed TDC replacement at ICU departure. Data regarding infection, removal technique, catheter replacement, and patient outcomes were analyzed.

RESULTS

There were 10 instances of recurrent bloodstream infection (infectious recidivism), occurring in 7 ICU-exchanged TDCs (7/30, 23%) and 3 ICU-replaced TDCs (3/9, 33%). Bloodstream infection complicated 22% of NTDCs used in patients undergoing delayed TDC replacement. No cases of TDC infectious recidivism were observed in patients who underwent delayed TDC replacement (0/7, 0%) after ICU departure.

CONCLUSIONS

High rates of infectious recidivism exist in the ICU, meriting further investigation into how to optimally manage these patients. In those in whom TDCs are removed, withholding TDC replacement until ICU departure may help to minimize the rate of recurrent infection.

Timely diagnosis and staging of non-alcoholic fatty liver disease using transient elastography and clinical parameters

Background and Aim

There is no standardized guideline to screen, image, or refer patients with non-alcoholic fatty liver disease (NAFLD) to a specialist. In this study, we used transient elastography (TE) to examine the fibrosis stages at which patients are first diagnosed with NAFLD. Subsequently, we analyzed metabolic markers to establish cut-offs beyond which noninvasive imaging should be considered to confirm NAFLD/non-alcoholic steatohepatitis fibrosis in patients.

Methods

Charts spanning July 2015-April 2018 for 116 NAFLD patients who had TE performed were reviewed. Univariate and multivariate analysis of metabolic markers was conducted.

Results

At the first hepatology visit, TE showed 73% F0-F2 and 27% F3-F4. Univariate analysis showed that high-density lipoproteins (HDL), hemoglobin A1c (A1c), aspartate transaminase (AST), and alanine transaminase (ALT) were significantly different between the F0-F2 and F3-F4 groups. Multivariate analysis showed that AST (P = 0.01) and A1c (P = 0.05) were significantly different. Optimal cut-offs for these markers to detect liver fibrosis on TE were AST >43 U/L and A1c >6.6%. The logistic regression function combining these two variables to reflect the probability (P) of the patient having advanced fibrosis (F3-F4) on TE yielded the formula: P = e ^R /(1 + e ^R ), where R = -8.56 + 0.052 * AST + 0.89 * A1c.

Conclusions

Our study suggested that >25% of patients presenting to a specialist for NAFLD may have advanced fibrosis (F3-F4). Diabetes (A1c >6.6%) and AST >43 U/L were the most predictive in identifying NAFLD patients with advanced fibrosis on imaging. We proposed a formula that may be used to prioritize NAFLD patients at higher risk of having advanced fibrosis for specialist referral and imaging follow-up.

Association of Radioactive Iodine Administration After Reoperation With Outcomes Among Patients With Recurrent or Persistent Papillary Thyroid Cancer

Importance

One-third of patients with papillary thyroid cancer (PTC) develop persistent or recurrent disease after initial therapy. Most patients with persistent or recurrent disease undergo reoperation, but the role of treatment with radioactive iodine (RAI) after reoperation is unclear.

Objective

To determine whether receipt of RAI after reoperation for recurrent PTC is associated with improved outcomes.

Design, Setting, and Participants

This retrospective cohort study included electronic health record data from 102 patients who underwent neck reoperation for persistent or recurrent PTC at a tertiary referral center from April 2006 to January 2016; 50 patients received RAI after reoperation, and 52 did not receive RAI after reoperation. Data analysis was performed from September 1, 2017, to December 1, 2017.

Main Outcomes and Measures

Suppressed thyroglobulin (Tg) levels were compared between patients who underwent reoperation and received RAI and patients who underwent reoperation without receipt of RAI at the following time points: before reoperation (Tg0), after reoperation (Tg1), and after RAI or a comparable time interval among patients whose cases were managed without RAI (Tg2). Outcomes were biochemical response and structural recurrence after reoperation.

Results

The cohort comprised 102 patients who underwent neck reoperation for persistent or recurrent PTC (median age, 44 years [interquartile range, 33-54 years; SD, 14 years]; 67 [66%] female), 50 of whom received treatment with RAI after reoperation. Clinicopathologic characteristics of the patients at the time of the initial surgical procedure were similar between the reoperation with RAI group and the reoperation without RAI group with the exception of tumor (T) stage (T3 and T4, 28 of 50 [56%] vs 19 of 52 [37%]). Although median Tg levels were similar between the reoperation with RAI group and the reoperation without RAI group (Tg0, 3.3 ng/mL vs 2.4 ng/mL; Tg1, 0.6 ng/mL vs 0.2 ng/mL; and Tg2, 0.5 ng/mL vs 0.2 ng/mL; all differences were nonsignificant), the rate of excellent response at Tg1 was lower in the reoperation with RAI group (4 of 33 [12%] vs 24 of 51 [47%]; P = .007). Structural recurrence after reoperation occurred in 18 of 50 patients (36%) in the reoperation with RAI group and 10 of 52 patients (19%) in the reoperation without RAI group. In multivariable analysis accounting for clinicopathologic characteristics and Tg0, receipt of RAI after reoperation was not associated with the rate of a second structural recurrence. In subset analyses limited to patients with incomplete response to reoperation and patients with T3 or T4 tumors, no association between receipt of RAI and the risk of a second recurrence was found.

Conclusions and Relevance

Patients who received RAI after reoperation had outcomes similar to those in patients who underwent reoperation alone. RAI after reoperation was not associated with a significant clinical benefit in this limited series. Larger multicenter studies are required to determine whether receipt of RAI after reoperation improves outcomes among patients with recurrent PTC.

Invasive aspergillosis in patients with systemic lupus erythematosus: a retrospective study on clinical characteristics and risk factors for mortality

Objective

The objective of this paper is to analyze the clinical features, outcomes, mortality risk factors, and all-cause mortalities of invasive aspergillosis (IA) in patients with systemic lupus erythematosus (SLE).

Methods

Medical records were reviewed to identify SLE patients with IA from January 2006 to June 2017, at Taipei Veterans General Hospital, Taiwan. A total of 6714 SLE patients were included. Clinical/laboratory parameters and treatment outcomes were analyzed.

Results

Four patients (19.0%) had definite and 17 had probable (81.0%) IA. Seven patients (33.3%) survived and 14 died (66.7%). Concurrently, there were 19 pneumonias (90.5%), 17 cases of other infections (81.0%), eight bacteremia (38.1%), nine cytomegalovirus (CMV, 42.7%) and six Candida (28.6%) infections. In all 55 blood cultures, 38 (69.1%) yielded gram-negative bacilli, of which carbapenem-resistant A. baumannii accounted for eight (21.1%); 17 (30.9%) yielded gram-positive cocci, of which methicillin-resistant S. aureus accounted for six (35.3%); and vancomycin-resistant Enterococcus accounted for four (23.5%). Daily steroid dose ≥ 20 mg (hazard ratio (HR) 2.00), recent pulse steroid therapy (HR 2.80), azathioprine (HR 2.00), rituximab (HR 2.00), plasmapheresis (HR 2.00), acute respiratory distress syndrome (HR 2.00), concurrent infections (HR 5.667) and CMV viremia (HR 1.75) were higher in the fatality group. All p values were less than 0.05. Septic shock ( n = 7, 50% in the fatality group) is the most common cause of mortality.

Conclusions

High daily steroid dosing, recent pulse steroid therapy, azathioprine, rituximab, concurrent infections, and CMV viremia were mortality risk factors for IA in SLE.

Clinical Factors Influencing the Performance of Gene Expression Classifier Testing in Indeterminate Thyroid Nodules

BACKGROUND

Molecular diagnostic testing is increasingly used in the management of indeterminate thyroid nodules. Limited data exist regarding the influence of clinical factors on gene expression classifier (GEC) test performance. This study examined the positive and negative predictive value of GEC as stratified by nodule size.

METHODS

A prospectively maintained pathology database from a single tertiary referral center was queried from 2012 to 2015 for indeterminate thyroid nodules that underwent GEC testing. Nodule size, patient demographics, Bethesda classification, and Hürthle cell-predominant nodules (HCNs) were evaluated as predictors of GEC performance.

RESULTS

Two hundred and thirty-one patients with 245 indeterminate nodules were examined. Assuming all nodules to be benign unless proven malignant on histopathology, the sensitivity and specificity of GEC testing were 95.2% and 60.1%, respectively. The malignancy rate among resected nodules was 25.3%. The positive predictive value was consistent across nodule sizes: 45.5% for nodules <1 cm, 42.9% for nodules 1-1.9 cm, 36.0% for nodules 2-2.9 cm, 54.2% for nodules 3-3.9 cm, and 50.0% for nodules ≥4 cm. The negative predictive value ranged from 93.3% to 100% and was not affected by nodule size. HCNs had a high rate of GEC suspicious results (77.4% vs. 50.5% for nodules without Hürthle cell predominance, p < 0.01), though this did not correspond to a difference in the rate of malignancy (25.8% vs. 25.3%).

CONCLUSIONS

Nodule size did not affect GEC test performance in the present cohort. GEC benign results remain reliable in large nodules. GEC suspicious nodules >3 cm carry a similar risk of malignancy compared to smaller nodules, and do not warrant more aggressive treatment. GEC testing has limited clinical utility for HCNs due to the high rate of false-positive results.

Trimucytin: a collagen-like aggregating inducer isolated from Trimeresurus mucrosquamatus snake venom

Trimucytin is a potent platelet aggregation inducer isolated from Trimeresurus mucrosquamatus snake venom. Similar to collagen, trimucytin has a run of (Gly-Pro-X) repeats at the N-terminal amino acids sequence. It induced platelet aggregation, ATP release and thromboxane formation in rabbit platelets in a concentration-dependent manner. The aggregation was not due to released ADP since it was not suppressed by creatine phosphate/creatine phosphokinase. It was not either due to thromboxane A2 formation because indomethacin and BW755C did not have any effect on the aggregation even thromboxane B2 formation was completely abolished by indomethacin. Platelet-activating factor (PAF) was not involved in the aggregation since a PAF antagonist, kadsurenone, did not affect. However, RGD-containing peptide triflavin inhibited the aggregation, but not the release of ATP, of platelets induced by trimucytin. Indomethacin, mepacrine, prostaglandin E1 and tetracaine inhibited the thromboxane B2 formation of platelets caused by collagen and trimucytin. Forskolin and sodium nitroprusside inhibited both platelet aggregation and ATP release, but not the shape change induced by trimucytin. In quin-2 loaded platelets, the rise of intracellular calcium concentration caused by trimucytin was decreased by 12-O-tetradecanoyl phorbol-13 acetate, imipramine, TMB-8 and indomethacin. In the absence of extracellular calcium, both collagen and trimucytin caused no thromboxane B2 formation, but still induced ATP release which was completely blocked by R 59022. Inositol phosphate formation in platelets was markedly enhanced by trimucytin and collagen. MAB1988, an antibody against platelet membrane glycoprotein Ia, inhibited trimucytin- and collagen-induced platelet aggregation and ATP release.(ABSTRACT TRUNCATED AT 250 WORDS)

Triwaglerin: a potent platelet aggregation inducer purified from Trimeresurus wagleri snake venom

Trimeresurus wagleri venom is the most potent inducer of platelet aggregation among the seven Trimeresurus snake venoms tested. By means of CM-Sephadex C-50 column chromatography, T. wagleri venom was separated into 19 fractions. Fraction XVI possessed the strongest aggregating activity and was further purified by Sephadex G-75 and on heparin-agarose columns, and finally Triwaglerin, with a molecular weight of 68000, was obtained. Its aggregating and ATP-releasing activity was dose-dependent and 10-times more potent than the crude venom. Triwaglerin was devoid of any of the enzymatic activities possessed by the crude venom. Triwaglerin-induced aggregation was not affected by indomethacin, creatine phosphate/creatine phosphokinase (CP/CPK), platelet-activating factor (PAF) antagonists, verapamil or heparin, but was inhibited completely by mepacrine, imipramine and forskolin and markedly by tetracaine and sodium nitroprusside. Thromboxane B2 formation caused by Triwaglerin was suppressed by mepacrine, imipramine and indomethacin. R59022 and TMB-8 caused a synergistic inhibitory effect against Triwaglerin-induced aggregation. These data suggest that Triwaglerin activates platelets in a unique action which is independent of formation of thromboxane A2 and PAF, or release of ADP.