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Summary Background Previous catheter-based renal denervation studies have reported variable efficacy results. We aimed to evaluate safety and blood pressure response after renal denervation or sham control in patients with uncontrolled hypertension on antihypertensive medications with drug adherence testing. Methods In this international, randomised, single-blind, sham-control, proof-of-concept trial, patients with uncontrolled hypertension (aged 20–80 years) were enrolled at 25 centres in the USA, Germany, Japan, UK, Australia, Austria, and Greece. Eligible patients had an office systolic blood pressure of between 150 mm Hg and 180 mm Hg and a diastolic blood pressure of 90 mm Hg or higher; a 24 h ambulatory systolic blood pressure of between 140 mm Hg and 170 mm Hg at second screening; and were on one to three antihypertensive drugs with stable doses for at least 6 weeks. Patients underwent renal angiography and were randomly assigned to undergo renal denervation or sham control. Patients, caregivers, and those assessing blood pressure were masked to randomisation assignments. The primary efficacy endpoint was blood pressure change from baseline (measured at screening visit two), based on ambulatory blood pressure measurements assessed at 6 months, as compared between treatment groups. Drug surveillance was used to assess medication adherence. The primary analysis was done in the intention-to-treat population. Safety events were assessed through 6 months as per major adverse events. This trial is registered with ClinicalTrials.gov, number NCT02439775, and follow-up is ongoing. Findings Between July 22, 2015, and June 14, 2017, 467 patients were screened and enrolled. This analysis presents results for the first 80 patients randomly assigned to renal denervation (n=38) and sham control (n=42). Office and 24 h ambulatory blood pressure decreased significantly from baseline to 6 months in the renal denervation group (mean baseline-adjusted treatment differences in 24 h systolic blood pressure −7·0 mm Hg, 95% CI −12·0 to −2·1; p=0·0059, 24 h diastolic blood pressure −4·3 mm Hg, −7·8 to −0·8; p=0.0174, office systolic blood pressure −6·6 mm Hg, −12·4 to −0·9; p=0·0250, and office diastolic blood pressure −4·2 mm Hg, −7·7 to −0·7; p=0·0190). The change in blood pressure was significantly greater at 6 months in the renal denervation group than the sham-control group for office systolic blood pressure (difference −6·8 mm Hg, 95% CI −12·5 to −1·1; p=0·0205), 24 h systolic blood pressure (difference −7·4 mm Hg, −12·5 to −2·3; p=0·0051), office diastolic blood pressure (difference −3·5 mm Hg, −7·0 to −0·0; p=0·0478), and 24 h diastolic blood pressure (difference −4·1 mm Hg, −7·8 to −0·4; p=0·0292). Evaluation of hourly changes in 24 h systolic blood pressure and diastolic blood pressure showed blood pressure reduction throughout 24 h for the renal denervation group. 3 month blood pressure reductions were not significantly different between groups. Medication adherence was about 60% and varied for individual patients throughout the study. No major adverse events were recorded in either group. Interpretation Renal denervation in the main renal arteries and branches significantly reduced blood pressure compared with sham control with no major safety events. Incomplete medication adherence was common. Funding Medtronic.

Summary Background Previous randomised renal denervation studies did not show consistent efficacy in reducing blood pressure. The objective of our study was to evaluate the effect of renal denervation on blood pressure in the absence of antihypertensive medications. Methods SPYRAL HTN-OFF MED was a multicentre, international, single-blind, randomised, sham-controlled, proof-of-concept trial. Patients were enrolled at 21 centres in the USA, Europe, Japan, and Australia. Eligible patients were drug-naive or discontinued their antihypertensive medications. Patients with an office systolic blood pressure (SBP) of 150 mm Hg or greater and less than 180 mm Hg, office diastolic blood pressure (DBP) of 90 mm Hg or greater, and a mean 24-h ambulatory SBP of 140 mm Hg or greater and less than 170 mm Hg at second screening underwent renal angiography and were randomly assigned to renal denervation or sham control. Patients, caregivers, and those assessing blood pressure were blinded to randomisation assignments. The primary endpoint, change in 24-h blood pressure at 3 months, was compared between groups. Drug surveillance was done to ensure patient compliance with absence of antihypertensive medication. The primary analysis was done in the intention-to-treat population. Safety events were assessed at 3 months. This study is registered with ClinicalTrials.gov, number NCT02439749. Findings Between June 25, 2015, and Jan 30, 2017, 353 patients were screened. 80 patients were randomly assigned to renal denervation (n=38) or sham control (n=42) and followed up for 3 months. Office and 24-h ambulatory blood pressure decreased significantly from baseline to 3 months in the renal denervation group: 24-h SBP −5·5 mm Hg (95% CI −9·1 to −2·0; p=0·0031), 24-h DBP −4·8 mm Hg (−7·0 to −2·6; p Interpretation Results from SPYRAL HTN-OFF MED provide biological proof of principle for the blood-pressure-lowering efficacy of renal denervation. Funding Medtronic.

Paget Schroetter syndrome, or effort thrombosis of the axillosubclavian venous system, is distinct from other forms of upper limb deep vein thrombosis. It occurs in younger patients and often is secondary to competitive sport, music, or strenuous occupation. If untreated, there is a higher incidence of disabling venous hypertension than was previously appreciated. Anticoagulation alone or in combination with thrombolysis leads to a high rate of rethrombosis. We have established a multidisciplinary protocol over 15 years, based on careful patient selection and a combination of lysis, decompressive surgery, and postoperative percutaneous venoplasty. During the past 10 years, a total of 232 decompression procedures have been performed. This article reviews the literature and presents the Exeter Protocol along with practical recommendations for management.

•. This paper discusses biopsy of the gall bladder, spleen, pancreas, kidney, adrenal gland and lymph nodes, and the complications associated with these procedures.•. Bleeding tendencies should be corrected prior to biopsy.•. Antibiotic cover is useful if the biopsied organ is infected.•. There are specific circumstances in each organ that produce added risk, e.g. catecholamine crisis whilst biopsying a phaeochromocytoma, pneumothorax during upper abdominal biopsies.

•. Increasing sophistication of cross‐sectional techniques (CT, MRI and ultrasound) has resulted in a move towards non‐invasive diagnosis of vascular diseases.•. Percutaneous transluminal angioplasty ± stenting is a well established treatment of focal aorto‐iliac occlusion/stenosis and clinically significant proximal renal artery stenosis. (Surgery remains the treatment of choice in mesenteric ischaemia, although interventional techniques may challenge this as techniques improve.)•. Exciting developments in endovascular techniques for aortic aneurysm repair (EVAR) are taking place, to provide a less invasive procedure in patients with appropriate anatomical prerequisites.•. Inferior vena cava (IVC) filters are becoming an established prophylactic treatment in selected patients with recurrent pulmonary embolism. Stents are also being used successfully for IVC compression syndromes.

BACKGROUND--Palliative treatments for obstruction of the superior vena cava all have disadvantages. The use of a fine braided wire self expanding stent (Wallstent, Schneider (Europe) AG) in patients with malignant and benign causes of superior vena cava obstruction is reported. METHODS--Five patients with obstruction of the superior vena cava were treated with balloon angioplasty of the stricture and the percutaneous insertion of an expandable Wallstent endoprosthesis across the site of the stricture. Four patients had advanced mediastinal malignancy previously treated by radiotherapy and one patient had fibrosing mediastinitis. RESULTS--All patients experienced rapid symptomatic relief and, in three cases, complete palliation was achieved during survival times of seven weeks, nine weeks, and 24 weeks, respectively. Two surviving patients (with a recurrent thymoma and fibrosing mediastinitis) were free of symptoms when followed up at eight and nine months respectively. CONCLUSIONS--Initial experience with the Wallstent endoprosthesis suggests that it is a valuable treatment alternative once conventional therapy has failed and gives rapid relief of symptoms to patients with obstruction of the superior vena cava.

Malignant tracheal stenosis presents a considerable challenge to the head and neck surgeon. The use of intraluminal stents has been previously described, but current literature notes a paucity of supportive physiological data. We describe the use of a self-expanding metallic Wallstent in the palliation of a case of papillary thyroid carcinoma. This is accompanied by significant improvement in quantitative pulmonary function.

Urinary fistula is an acknowledged complication of partial nephrectomy. We describe a case of a urinary fistula that failed to respond to conventional treatment and the subsequent use of percutaneous Hystoacryl® glue to achieve its resolution.

Oesophageal carcinoma is a relatively common disease with approximately 3500 new cases presenting in the United Kingdom every year. In more than 50% of patients curative resection is inappropriate and only palliative therapy is possible [1]. The aim of palliative treatment is to improve the patient's quality of life, making oral feeding possible with speed and safety, and without the need for long or repeated hospital admissions [2, 3]. Traditional methods have had limited success in achieving this aim and have included surgery [4], radiotherapy [5–7] and plastic endoprostheses [8–10].

Inferior vena caval obstruction (IVCO) is an occasional cause of lower limb oedema in palliative care patients with metastatic malignancy. We present five cases who underwent IVC stenting for symptomatic relief. Four of the five cases had significant reduction in their oedema but three of these four patients died within two weeks of the procedure. The procedure itself is described and the appropriateness of this intervention in patients with end-stage disease is discussed.

Functional and anatomical imaging methods are currently the standard approach to the evaluation of carcinoid tumor extent. Due to the nature of carcinoid tumors ,there is not a single imaging procedure that is sufficient to detect the malignancy. The aim of the study was to compare the value of CT, MR and functional imaging study with(111) In-Octreotide (SRS) in carcinoid detection and evaluation of its extent as well as to work out the imaging studies diagnostic algorithm that could enhance diagnostic efficacy.A total of 34 patients with carcinoid tumor confirmed clinically,biochemically and/or histopathologically were enrolled into the study. Computed tomography (CT) examinations of the abdomen and pelvis were performed before and after administration of a contrast medium, the triple-phase liver scanning included. Magnetic Resonance Imaging (MRI)of the liver was performed according to the standardized protocol before and after administration of a contrast medium .Planar scintigraphy with(111) In Octreotide and SPECT were performed. In each case liver as well as lymph node metastases in the abdomen and pelvis were searched for. All results were reviewed independently. Clinical picture at follow-up and further imaging and/or histological studies confirmed or excluded the diagnosis of the disease.Twenty nine patients were diagnosed with carcinoid tumor. Liver metastases were found in 26 patients and lymph node metastases were detected in 18 of them. Complete diagnostic conformity as far as the diagnosis and extent of the disease are concerned was obtained only in 7 cases. Incorrect assessment of the disease extent was the source of discrepancy between the imaging studies results in most of the remaining 22 patients. The SRS and MR results of liver metastases detection were mostly consistent with one another. Both imaging modalities evaluated the extent of hepatic metastases incorrectly in 22%of the patients,as compared to 43% of the patients for CT. The highest proportion percentages of incorrect results of lymphatic involvement detection were 41%, 29%and 43%for MR, SRS and CT, respectively.The results of our study have indicated that application of a complex imaging algorithm enables higher accuracy of hepatic and lymph nodes metastases detection in carcinoid tumor patients. Combining the results of MR and SRS in evaluating the extent of the carcinoid disease seems to represent higher diagnostic value than relying on one of this method in combination with CT images.

PURPOSE: The prognosis for advanced pancreatic cancer remains poor. Gastrin acts as a growth factor for pancreatic cancer. We describe the first study of the antigastrin immunogen G17DT in pancreatic cancer. Our aims were to determine the antibody response, safety, tolerability, and preliminary evidence of efficacy of G17DT in advanced pancreatic cancer. PATIENTS AND METHODS: Thirty patients with advanced pancreatic cancer were immunized with three doses of either 100 μg or 250 μg of G17DT. RESULTS: In the whole group, 20 (67%) of 30 patients produced an antibody response. The 250-μg dose resulted in a significantly greater response rate of 82% compared with 46% for the 100-μg group (P = .018). The most significant side effects, seen in three patients, were local abscess and/or fever. The median survival for the whole group from the date of the first immunization was 187 days; median survival was 217 days for the antibody responders and 121 days for the antibody nonresponders. The difference in survival between the antibody responders and nonresponders was significant (P = .0023). CONCLUSION: Patients with advanced pancreatic cancer are able to mount an adequate antibody response to G17DT. The 250-μg dose is superior to the 100-μg dose, and it appears to be generally well tolerated. Antibody responders demonstrate significantly greater survival than antibody nonresponders. Phase III studies are currently underway in order to determine efficacy.

The objectives of this study were (i) to identify patterns of angiographic disease in scleroderma patients with and without other vascular risk factors and (ii) to define patients with scleroderma in whom angiography and angioplasty is useful. The records of 26 patients with scleroderma who underwent angiography and angioplasty over an 8-year period were reviewed. Angiographic disease patterns were assessed using a modified Brewster classification. Angiography of the upper limb demonstrated distal disease alone in 86% of patients, both with and without other vascular risk factors such as smoking. In the lower limb there was a highly significant association between the presence of other vascular risk factors and macrovascular disease potentially amenable to angioplasty, and conversely between the absence of other vascular risk factors and distal disease in the lower limb. Good early but poor late clinical results were achieved in three of five patients who underwent angioplasty. Angiography of the upper limb is likely to demonstrate distal disease alone, and angiography and angioplasty of the lower limb may be useful only if other vascular risk factors are present.

Carcinoid tumours are often indolent asymptomatic tumours. However, a small but significant proportion are malignant and difficult to manage. Multiple endocrine neoplasia type 1 (MEN-1) may be associated with carcinoid tumours and should therefore be considered in the investigation of these patients. This review puts into context the use of newer imaging modalities, including octreotide scintigraphy. The therapeutic treatment options are discussed, including the use of octreotide, the role of receptor-targeted therapy, hepatic-artery embolisation, and the arguments against chemotherapy. We review the need for careful patient selection when considering curative and palliative surgery, including liver transplantation. We conclude that there are now better diagnostic tools and therapeutic options available for those patients with malignant carcinoid tumours, and that these patients are best managed by a multidisciplinary approach. Earlier detection and treatment of these tumours should lead to improved quality of life and survival, which, ideally, should be assessed in formal trials.

In patients with malignant biliary obstruction it is important to assess the patient clinically, biochemically, and radiologically using ultrasonography (US) and/or computed tomography (CT). The most common causes of malignant obstruction of the bile duct are carcinoma of the pancreas, cholangiocarinoma, and secondary hilar deposits. Histological confirmation of malignancy and identification of the cell type are important, as the prognosis is slightly different in each case, and are also helpful in planning further management. Cross-sectional imaging may provide information concerning the level and probable cause instances, in order to assess tumour resectability and plan the most appropriate approach to surgical or non-surgical biliary decompression, direct cholangiography is often required, either percutaneous transhepatic cholangiography (PTC) or endoscopic retrograde cholangiography (ERC).

Gastrostomy for nutritional support or relief of bowel obstruction can be performed surgically or via percutaneous nonsurgical techniques. The nonsurgical techniques, either endoscopic or fluoroscopically guided, have recently increased in popularity due to their decreased morbidity and reduced cost. The percutaneously guided fluoroscopic approach was first described in 1983, and the efficacy and safety has since been proven in several series. We describe our experience in 100 cases of tube placement under radiological guidance, which is the preferred choice of treatment in our institution by surgeons, gastroenterologists and radiologists.

Transvenous liver biopsy is performed on patients with contraindications to percutaneous biopsy. Transfemoral liver biopsy has not been widely reported, and we present our experience of 104 consecutive procedures. During a 30-month period, 88 patients underwent 104 transfemoral liver biopsies. Under fluoro-scopic guidance a 9 Fr curved introducer catheter is passed into the right hepatic vein via a standard femoral sheath. A 7 Fr biopsy forceps is then passed into the liver, opened and wedged. Prior to biopsy, the image intensifier is rotated so the relation of the capsular surface to the biopsy site is verified and capsular perforation avoided. Tissue samples obtained in 97 of 104 procedures (93%) were adequate for diagnosis in 83 (80%). Complications occurred in six procedures (6%) including two capsular perforations; the latter two were treated by coil embolization. We found transfemoral liver biopsy using forceps to be a safe, well-tolerated procedure with a high diagnostic yield and it is a technically easy alternative to the transjugular approach using large needles.

Choledochal cysts are an unusual cause of biliary obstruction with up to 85% of reported cases being of the type I variety, that is, fusiform dilations of the common bile duct. Recommended management of this type I cyst is complete surgical excision; however, difficulties arise in type IVa cysts when the cystic dilation extends up into the intrahepatic biliary tree. The purpose of this study is to review the management of choledochal cysts with particular reference to the type IVa variety. Statistical analysis of outcome differences was undertaken using Fisher's exact test. A total of 23 consecutive patients with choledochal cysts seen at our institution in a 5-year period were reviewed: 8 patients had type I cysts, 1 patient had a type III cyst, and 14 patients had type IVa cysts. All type I cysts underwent complete cyst excision with hepaticojejunostomy and modified Houston loop formation. Of 14 patients with type IVa cysts, 13 underwent complete excision of the extrahepatic portion of the cyst with hepatico- and cystojejunostomy and modified Hutson loop formation. One patient required hepatic lobectomy. With a mean follow-up of 33 months, 4 patients with type IVa choledochal cyst have had episodes of recurrent cholangitis, with access to the library tree being achieved via the Hutson loop in 3 of the 4 patients. Three of these cases represented anastomotic strictures that were treated nonoperatively. We concluded that recurrent cholangitis and anastomotic stricture after resection of type IVa choledochal cysts is frequent and recommend Hutson loop formation at the time of primary resection.

The authors describe a 35-year-old man who has had benign mucous membrane pemphigoid from the age of 12 years. Upper esophageal stricture, a rare complication of the syndrome, developed when he was 24 years old. This recurrent condition has been followed for 11 years. It was treated initially, for 6 years, with esophagoscopy and bougie dilatation. Balloon dilatation under fluoroscopic guidance was then substituted for bougienage; this procedure has been performed successfully 10 times over the last 5 years and remains the patient's preferred treatment. The mean period for recurrence of symptoms has been 5 months. Several previous reports of this condition describe treatment with esophagoscopy and bougie dilatation, but there has been no previous report of interventional radiology with balloon dilatation.

This paper outlines some of the properties of alloys produced from atomized powders of nickel-chromium-cobalt and nickel-chromium-cobalt-molybdenum and describes certain aspects of further development work on sintered high-temperature alloys.

Powders having compositions selected in accordance with the results of earlier work have been processed under conditions simulating industrial practice. The properties that can be obtained under such conditions are described.

(1958). ATOMIZATION OF METAL AND ALLOY POWDERS. Powder Metallurgy: Vol. 1, No. 1-2, pp. 13-23.