Search

Nutcracker syndrome (NCS) is an extrinsic compression of the left renal vein (LRV) by the superior mesenteric artery (SMA) anteriorly and aorta posteriorly resulting in renal vascular congestion manifesting as hematuria, proteinuria, orthostatic hypotension, pain, or even renal dysfunction. Long-standing venous compression can encourage collateral drainage pathways through gonadal and pelvic veins, which may explain reported symptom and syndrome overlap with pelvic congestion syndrome. Diagnosis can be challenging and variable, frequently involving a combination of ultrasound Doppler, cross-sectional, and invasive imaging. Often, intravascular pressure measurements are required to prove a renocaval pressure gradient to aid in a definitive diagnosis. Conservative management is appropriate, especially in children, who tend to outgrow the disorder. In the interim, medical management with angiotensin converting enzyme inhibitors (ACEIs) is a useful therapy to manage orthostatic hypotension in the pediatric population. In adults, invasive therapies are more frequently pursued. These are aimed at relieving the extrinsic compression on the LRV. The standard of care is renal vein transposition, with renal autotransplantation reserved for recalcitrant cases. Endovascular stenting is a less invasive option. Laparoscopic placement of an exovascular stent is a newer therapy intended to minimize trauma to the LRV. In this review, we will discuss the clinical manifestations, diagnostic criterion, imaging features, and conservative and surgical therapies for this condition.

Context Concussion underreporting leads to delays in diagnosis and treatment, prolonging recovery time. Athletes' self-reporting of concussion symptoms, therefore, reduces risk. Objective To evaluate the effectiveness of 3 concussion-education programs in improving concussion-reporting intention. Design Randomized controlled clinical trial. Setting Three high schools in California. Patients or Other Participants A total of 118 male football players (age = 14.88 ± 1.19 years). Intervention(s) Participants were randomly assigned to receive concussion education via CrashCourse (CC), Centers for Disease Control and Prevention (CDC) video education materials (CDC-Vi), or CDC written education materials (CDC-Wr). Main Outcome Measure(s) The primary outcome was concussion-reporting intention, which was assessed at baseline, immediately after education, and at 1-month follow-up. Secondary outcomes were concussion knowledge, concussion-reporting attitudes, perceived concussion-reporting norms, and perceived behavioral control. Results Across all education formats, a total sample of athletes improved in concussion-reporting intention at immediate and 1-month follow-ups (mean improvements = 6.8% and 11.4%, respectively; F4,224 = 11.1, P < .001). Similar findings were observed across all education formats in secondary analyses examining knowledge, attitudes, and perceived behavioral control. However, we noted differences in concussion-reporting intention by education format and time (F4,224 = 2.8, P = .03). Post hoc analysis showed that athletes who received CC had increased concussion-reporting intentions at immediate and 1-month follow-ups (baseline = 4.7, immediate follow-up = 6.1, 1-month follow-up = 6.0; F16,61.1 = 6.1, P = .007) compared with increases only at 1-month follow-up for CDC-Vi (baseline = 4.3, immediate follow-up = 5.2, 1-month follow-up = 5.8; F1.6,61.6 = 8.4, P = .001) and no improvement for CDC-Wr (P = .10). Secondary analyses indicated differences between CC and both CDC interventions in concussion knowledge and attitudes at immediate and 1-month follow-ups. We identified no differences in perceived behavioral control among interventions (F4,216 = 0.2, P = .93) or perceived concussion-reporting norms across (F4,224 = 0.3, P = .73) or among (F4,224 = 1.7, P = .15) interventions. Conclusions All athletes exhibited an improved intent to report concussions, increased concussion knowledge, better concussion attitudes, and more perceived behavioral control at both immediate and 1-month follow-ups. However, athletes randomized to receive CC reported a greater intent to report concussion, more knowledge, and improved concussion-reporting attitudes when compared with those who received CDC-Vi and CDC-Wr.

The Fistula First Breakthrough Initiative was created to promote arteriovenous fistula creation in patients requiring long-term hemodialysis. Arteriovenous fistulas have been shown to demonstrate greater patency rates and fewer complications than dialysis grafts. Traditionally, arteriovenous fistulas are surgically created and require maturations times which prevent their immediate use. New technology is now available that allows for non-surgical creation of arteriovenous fistulas as well as decreased necessary maturation periods.

Popliteal entrapment syndrome (PES) describes a set of symptoms related to compression of the neurovascular bundle in the popliteal fossa, with popliteal artery involvement the most widely recognized variation. Popliteal vein entrapment is a rare variation which can easily go undiagnosed. This is most commonly due to an anomaly of the medial head of the gastrocnemius muscle, but other etiologies include excess adipose tissue or cysts within the popliteal fossa, popliteal artery aneurysm, fibrous bands, thickened perivenous fascia, compression by the popliteus muscle or muscular hypertrophy independent of anomalous anatomy, or variant origin of the short saphenous vein. However, with improving awareness, it is a condition which should be increasingly considered in patients presenting with unexplained lower extremity swelling or other symptoms of lower extremity thrombosis. The initial test of choice is typically ultrasound with flexion and extension maneuvers. Venography is the gold standard for diagnosis, but MRI offers a noninvasive option for both diagnosis and evaluation of etiology and should be considered in the work-up of popliteal venous entrapment. Management is based on severity and type of symptoms, ranging from conservative management with compression stockings to surgical management if there is popliteal artery involvement or more severe symptoms. Endovascular therapy such as angioplasty or stenting has also been reported with good results.

Recent studies have reported high rates of reintervention after primary stenting for hepatic artery stenosis (HAS) due to the loss of primary patency. The aims of this study were to evaluate the outcomes of primary stenting after HAS in a large cohort with longterm follow-up. After institutional review board approval, all patients undergoing liver transplantation between 2003 and 2017 at a single institution were evaluated for occurrence of hepatic artery complications. HAS occurred in 37/454 (8%) of patients. HAS was defined as >50% stenosis on computed tomography or digital subtraction angiography. Hepatic arterial patency and graft survival were evaluated at annual intervals. Primary patency was defined as the time from revascularization to imaging evidence of new HAS or reaching a censored event (retransplantation, death, loss to follow-up, or end of study period). Primary stenting was attempted in 30 patients (17 female, 57%; median age, 51 years; range, 24-68 years). Surgical repair of HAS prior to stenting was attempted in 5/30 (17%) patients. Endovascular treatment was performed within 1 week of the primary anastomosis in 5/30 (17%) of patients. Technical success was accomplished in 97% (29/30) of patients. Primary patency was 90% at 1 year and remained unchanged throughout the remaining follow-up period (median, 41 months; interquartile range [IQR], 25-86 months). Reintervention was required in 3 patients to maintain stent patency. The median time period between primary stenting and retreatment was 5.9 months (IQR, 4.4-11.1 months). There were no major complications, and no patient developed hepatic arterial thrombosis or required listing for retransplantation or retransplantation during the follow-up period. In conclusion, primary stenting for HAS has excellent longterm primary patency and low reintervention rates.

To evaluate the impact of standardized reduced post-procedure observation time on subsequent healthcare encounters such as emergency department (ED) visits, hospital admissions, and clinic visits. 800 consecutive patients undergoing outpatient non-arterial interventional radiologic procedures within the vascular interventional department between 1 June 2013 and 21 July 2014 were included in this IRB-approved, HIPAA-compliant single center observational retrospective study. Electronic medical records were reviewed for subsequent healthcare encounters, such as ED visits, hospital admissions, and clinic visits. An attending interventional radiologist and radiology resident reviewed, in consensus, medical records for relevance of the encounter to the index procedure. Procedure-related encounters were analyzed to determine relationship to length of observation time, using Matlab for statistical analysis. 397 and 403 patients were in the pre- and post-standardization groups, respectively. Median observation time decreased overall from 1.67 h [interquartile range (IQR) 1.17–2.17] to 1.42 h (IQR 1.08–1.92), p

Objective: Tryptophan hydroxylase is the rate-limiting enzyme in the synthesis of serotonin, and thus its gene, TPH, has been extensively studied as a risk factor for both bipolar disorder and major depressive disorder. The purpose of the present report is to synthesize the available data on these putative associations and derive best estimates of the nature and magnitude of the influence of TPH on risk for mood disorders. Methods: We identified studies that examined the TPH A218C polymorphism in relation to major depressive disorder or bipolar disorder using the PubMed online search engine, ultimately including 10 case-control studies in two meta-analyses. Results: The AA genotype had a significant effect on risk for bipolar disorder in comparison to either the CC or AC genotypes, suggesting that the A allele may increase risk for bipolar disorder in a recessive manner. None of the three genotypes significantly increased risk for major depressive disorder relative to any of the other genotypes. Conclusion: The homozygous recessive genotype of the TPH A218C polymorphism has a significant effect on risk for bipolar disorder but not major depressive disorder. A possible explanation for these results is that the A allele influences mood by permitting or facilitating mania while having no effect on depression. Further replication of these findings in additional large case-control and family-based association is needed before TPH can be designated a risk gene for bipolar disorder.

Purpose To investigate the prevalence and predictors of intraoperative and 90-day postoperative ocular complications associated with cataract surgery performed in the United States Veterans Health Administration (VHA) system. Design Retrospective cohort study. Participants Forty-five thousand eighty-two veterans who underwent cataract surgery in the VHA. Methods The National Patient Care Database was used to identify all VHA patients who underwent outpatient extracapsular cataract surgery and who underwent only 1 cataract surgery within 90 days of the index surgery between October 1, 2005, and September 30, 2007. Data collected include demographics, preoperative systemic and ocular comorbidities, intraoperative complications, and 90-day postoperative complications. Adjusted odds ratios (ORs) of factors predictive of complications were calculated using logistic regression modeling. Main Outcome Measures Intraoperative and postoperative ocular complications within 90 days of cataract surgery. Results During the study period, 53786 veterans underwent cataract surgery; 45082 met inclusion criteria. Common preoperative systemic and ocular comorbidities included diabetes mellitus (40.6%), chronic pulmonary disease (21.2%), age-related macular degeneration (14.4%), and diabetes with ophthalmic manifestations (14.0%). The most common ocular complications were posterior capsular tear, anterior vitrectomy, or both during surgery (3.5%) and posterior capsular opacification after surgery (4.2%). Predictors of complications included: black race (OR, 1.38; 95% confidence interval [CI], 1.28–1.50), divorced status (OR, 1.10; 95% CI, 1.03–1.18), never married (OR, 1.26; 95% CI, 1.14–1.38), diabetes with ophthalmic manifestations (OR, 1.33; 95% CI, 1.23–1.43), traumatic cataract (OR, 1.80; 95% CI, 1.40–2.31), previous ocular surgery (OR, 1.29; 95% CI, 1.02–1.63), and older age. Conclusions In a cohort of United States veterans with a high preoperative disease burden, selected demographic factors and ocular comorbidities were associated with greater risks of cataract surgery complications. Further large-scale studies are warranted to investigate cataract surgery outcomes for non-VHA United States patient populations. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Christine K. Chen, Victoria L. Tseng, Wen-Chih Wu, MD, Paul B. Greenberg, MD Patients having cataract surgery are often on antithrombotic agents, which may increase the risk for perioperative ocular hemorrhage. However, cessation of these medications may increase the risk for thromboembolic events. The American Academy of Ophthalmology’s Preferred Practice Pattern states there is no strong evidence for continuing or discontinuing antithrombotic therapy during cataract surgery. Since the prevailing practices and rationales regarding antithrombotic agents during cataract surgery in the United States are not well established, knowledge of practice patterns would be helpful in understanding the magnitude of differences in management decisions, as well as the rationale behind them. Therefore, we surveyed the chiefs of ophthalmology in the U.S.