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121 9. Summárý Purpose: This study was designed to evaluate the role of interventional radiology in liver transplantation programme. The aim is to present our experience, technical outcomes and long-term clinical results with chemoembolization of hepatocellular carcinoma in patients before liver transplantation and with percutaneous treatment of vascular and biliary complication after orthotopic liver transplantation. Methods: Twenty five patients (17 men, 8 women, mean age 57.76 years) with HCC were scheduled for TACE prior to liver transplantation from 2008 to 2012. Twenty three procedures were performed, 7 c-TACE in 2008 and 16 DEB TACE in next years. Thirty patients (13 men, 17 women, mean age 46.4 years) with biliary strictures after liver transplantation without endoscopic access possibility were treated with balloon dilatation and biliary duct drainage from 1996 and 2010. Twenty patients (13 men, 7 women, mean age 45.25 years) were treated with PTA/stent due to hepatic artery stenosis after liver transplantation between 1996 and 2011. Stents were placed to the hepatic/celiac artery in 16 PTAs, balloon dilatation alone was performed in 7 stenosis due to tortuosity of the vessel. Results: Liver transplantation was performed to 20 patients after TACE. Only one patient (4.5 %) was excluded from waiting...

Die akustische Rhinometrie ist in der Humanmedizin eine etablierte, nicht-invasive Methode zur Bestimmung von Nasenhöhlenvolumina und definierten Querschnittsflächen in nasalen Atemwegen beim Menschen. Sie basiert auf dem Vergleich beziehungsweise der Analyse der Amplituden von Schallwellen (definiert über die Querschnittsflächen) als Funktion der Zeit (definiert durch den Abstand in die Nasenhöhle), die durch Reflexionen einer Ausgangs-schallwelle in der Nasenhöhle entstehen. Das Ziel dieser Studie war es, erstmals den Nutzen der akustischen Rhinometrie für die klinische Veterinärmedizin bei Hunden zu überprüfen. Die Hauptschwerpunkte lagen in der Quantifizierung des geometrischen Aufbaus der Nasenhöhle von gesunden (n=15) und kranken (n=32) Hunden über die Auswertung der Flächenabstandskurven, der Definition von minimalen Querschnittsflächen (MCA1, MCA2) und Zuordnung zu anatomischen Landmarken auf CT-Schnittbildern. Für die Messungen wurde das Rhinometer SRE 2000 (RhinoMetrics, Dänemark) verwendet. Voruntersuchungen zu Wiederholbarkeit und Genauigkeit der Messmethode erfolgten an zylindrischen Stufenmodellen (n=3). Für jeden Beagle konnte eine deutliche Korrelation der ersten minimalen Querschnittsflächen zur Spitze der Concha nasalis ventralis nachgewiesen werden. Die zweite minimale Querschnittsfläche ließ sich keiner anatomischen Landmarke zuordnen. Es bestand kein statistisch signifikanter Unterschied in Nasenhöhlenvolumina, Auftreten der MCA1 und MCA2 und ihrer entsprechenden Dimension der jeweils rechten und linken Nasenhöhle im Gruppenvergleich. Nach lokaler Applikation von Xylometazolin lag die Größenzunahme des Volumens der rechten Nasen-höhle bei 19,4% [3,9-24,7%] (n=13) und der Linken bei 23,7% [15,4-36,4%] (n=12). Von insgesamt 32 untersuchten Hunden zeigten acht Hunde eindeutig einseitige Veränderungen (25%) in den CT-Schnittbildern. Anhand der Kurvensymmetrie ließ sich die pathologisch veränderte Nasenhöhlenseite nur in vier von acht Fällen zweifellos zuordnen. Besonders bei Erkrankungen mit Rhinorrhoe oder Ansammlungen von Sekret innerhalb der Nasenhöhle kam zu Fehlinterpretationen der Flächenabstandskurven. Oszillationen traten bei 22% der Patienten auf. Die Ergebnisse lassen Rückschlüsse zu, dass sich die akustische Rhinometrie aufgrund einer guten Wiederholbarkeit und einfachen Anwendung für wissenschaftliche Studien eignet, bei denen der Schwerpunkt auf intraindividuellen Vergleichen liegt. Obwohl die Daten objektiv ermittelt werden, ist die Anwendung dieser Methode in der klinischen Veterinärmedizin bei Hunden nur in Kombination mit anderen Untersuchungsmodalitäten sinnvoll. Fehlmessungen treten bereits bei einfach strukturierten Modellen auf; am caninen Patienten nehmen sie durch die ansteigende Diskrepanz zum idealen theoretischen Modell weiter zu. Primäre pathologische Veränderungen in der Nasenhöhlengeometrie werden nicht erkannt oder durch sekundäre Veränderungen maskiert. Verschiedene Krankheitsbilder weisen gleiche oder ähnliche strukturelle Veränderungen in der Nasenhöhle auf und können durch Messungen mit akustischen Schallwellen nicht unterschieden werden. Die Interpretation von Absolutwer-ten ist kritisch. Die Quantifizierung einer intranasalen Stenose ist nicht möglich.

Background:Lower back pain is one of the most common health-related complaints in the adult population. Thirty percent of Americans 65 years and older reported symptoms of lower back pain in 2004. With an aging population, the proportion of people over the age of 65 is expected to reach 20% by the year 2030. Because of this increase in older adults, lumbar spinal stenosis (LSS) associated with arthritic changes will also likely increase. In older adults, lower back pain is most often caused by degenerative lumbar spinal stenosis. Stenosis is the narrowing ofthe spinal canal, causing pressure on the nerve roots and is frequently treated surgically. Lumbar spinal stenosis is one of the most common reasons for back surgery in patients 65 years and older 2. However, risks associated with surgery increase with age 3-5 and older patients may choose non-surgical treatment for their lower back pain, including injection treatment. Injection treatment, usually consisting of anti-inflammatory medications and analgesics, has improved since the mid-1990's when fluoroscopic guidance was developed. Information about injection treatment for lower back pain is limited, especially in the older population. An extensive review of published literature regarding injection treatment revealed a paucity of information about older adults diagnosed with lumbar spinal stenosis. In this study, three aims were designed to gain more information about the effectiveness of injection treatment in older patients with lumbar spinal stenosis. In the first (retrospective) study, information about receipt of second injections and time between injections was collected to examine injection usage. In the second and third (prospective) studies, information about pain relief and functional return following injection treatment was collected to examine the effectiveness of injection treatment in patients age 60 and older diagnosed with lumbar spinal stenosis. To our knowledge, such results have not been repolted for this population in the literature. Objective:Injection treatment is a commonly used non-surgical procedure to alleviate lower back pain in older adults. However, older patients do not have enough information about how long pain relief will last after treatment or the amount of pain relief and functional return they will experience. These studies focused on three topics: 1) usage of injection treatment; 2) effectiveness of injection treatment on pain relief; 3) effectiveness of injection treatment on functional return. In addition, the variations of the effectiveness were examined by selected patient attributes. Methods:In a retrospective study, medical records of patients aged 60 years or older from a high volume dedicated spine center at the University of Massachusetts Memorial Hospital were retrospectively reviewed. This study included those diagnosed with degenerative LSS, who had not received an injection for lower back pain within six months, and whom were treated between June I, 2006 and May 31, 2007. In two prospective studies, patients scheduled for lumbar injection treatment between January 1 and June 30, 2008 were selected from the University of Massachusetts Memorial Hospital Spine Center. Selection criteria included patients age 60 and over, diagnosed with degenerative lumbar spinal stenosis and no previous lumbar injection within 6 months or lumbar surgery within 2 years. The Pain sub-score of the SF-36 questionnaire was used to measure pain at baseline and at one and three months post injection. The Physical Component Score (PCS) of the SF-36 questionnaire and the Oswestry Disability Index (ODI) were used to measure function at baseline and at one and three months post injection. Variations in longitudinal changes in scores by patient characteristics were analyzed in both unadjusted (univariate) analyses using one-way analysis of variance (ANOVA), and adjusted (multiple regression) analyses using linear mixed effects models. Results: In the retrospective cohort, the mean age of the cohort was 68, 64% were female, 59% were married, with a mean Body Mass index of 32 kg/m2. Of 92 eligible patients, 57% returned for a second injection within six months of the first. The mean number of months between injections was 4.8 for all patients, ranging from 1 to 22 months. When patient characteristics were examined, the only variable that showed a statistically significant difference was age. Patients aged 70 years and older were found to be 67% less likely to return for a second injection when compared to patients age 60-69 (OR=0.33 (0.12 - 0.94)p In the prospective cohort, information was collected on 62 patients. Mean Pain scores improved significantly from baseline to one month (14.1 points), and from baseline to three months (8.3 points). Post injection changes in Pain scores varied by Body Mass Index (BMI) and baseline emotional health. Based on a linear mixed effects model analysis, higher baseline emotional health, as measured by the SF-36 Mental Component Score (MCS>50), was associated with greater reduction in pain over three months when compared to lower emotional health (MCS Conclusion: Patients over age 70 do not return for repeat injection as frequently as patients age 60-69. In addition, each year a patient ages over age 60, they are 10% less likely to return for a repeat injection. Lower back pain in older adults with LSS is clinically significantly alleviated after injection treatment. In addition, injection treatment for LSS is associated with return of lost function needed for daily living activities in older adults. Pain relief and functional return varies by patient personal and clinical characteristics. Higher emotional health was associated with more pain relief and more functional return experienced over three months following injection treatment. Additional information is needed about why older patients do not return for second injections at the same rate as younger patients and how emotional health affects response to injection treatment in older adults.

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Le rétrécissement aortique calcifie (RAC) est la valvulopathie la plus fréquente dans les pays occidentaux et touche environ 2% des sujets de plus de 65 ans. Initialement considérée comme une dégénérescence passive de la valve aortique liée à l’âge, le RAC est actuellement considéré comme une pathologie complexe et hautement régulée et qui aboutit à un épaississement et à une calcification des feuillets valvulaires aortiques. A ce jour les mécanismes initiateurs et favorisant la progression du RAC ne sont pas complètement élucidés, et d’autre part, aucun traitement ne s’est avéré efficace pour ralentir ou stopper son évolution. Le remplacement valvulaire aortique (chirurgical ou percutané) reste le seul traitement en cas de rétrécissement aortique serré. D’autre part, il n’existe aucun modèle animal fiable et reproductible du RAC permettant de mieux comprendre la physiopathologie de cette valvulopathie et de tester de nouvelles cibles thérapeutiques. Dans le laboratoire, nous avons fait l’hypothèse que la dysfonction de l’endothélium valvulaire jouait un rôle important dans l’initiation et la progression du RAC, et nous souhaitons utiliser un modèle animal permettant d’évaluer l’effet de nouvelles thérapeutiques. Ce travail porte donc sur l’évaluation du rôle du système endothélinergique dans la sténose aortique calcifiée et le développement d’un nouveau modèle animal murin de RAC. Dans notre première étude, nous nous sommes intéressés au modèle de souris EgfrWa2/Wa2. Ce modèle est induit par la substitution du résidu amine glycine par une valine. Les souris EgfrWa2/Wa2 homozygotes pour la mutation voient leur activité tyrosine kinase diminuée de 90%. Ce modèle induit un épaississement fibreux des feuillets valvulaires avec peu de calcifications. Cependant, l’augmentation du flux transaortique n’est pas liée a un RAC mais a une insuffisance aortique (IA). Nous avons évalué dans ce modèle l’effet d’un régime enrichi en graisse et d’une supplémentation en vitamine D3. Malgré une augmentation des taux sériquesdu cholestérol, de la vitamine D3 et de la calcémie, nous n’avons pas observé d’augmentation de la calcification. Le modèle EgfrWa2/Wa2 reste essentiellement un modèle d’IA avec le développement d’un RAC qui reste rare ou absent. Dans notre seconde étude, nous avons évalué le rôle du système endothélinergique dans des cultures primaires de cellules valvulaires interstitielles (hVICs) et endothéliales (hVECs) humaines, prélevées lors d’un remplacement valvulaire aortique chirurgical chez des patients ayant un RAC serré. Les valves de patients traités par une intervention de Bentall ont été utilisées comme groupe contrôle. Nous avons tout d’abord observé, par RT-PCR quantitative, que les hVECs issues de valves sténosées présentaient une augmentation non significative de l’ARNm codant pour l’endothéline et une augmentation significative de l’ARNm codant pour le récepteur ET-B, ainsi qu’une diminution significative de l’enzyme de conversion de l’endothéline dans les hVECs par rapport aux hVECs issues de valves contrôles. Le récepteur ET-B était également surexprimé dans les hVICs par rapport aux valves contrôles. En revanche, nous n’avons pas retrouvé de variation d’expression du récepteur ET-A dans les hVICs. Nous avons ensuite évalué l’effet de l’endotheline-1 (ET-1) dans les hVICs. Nous avons retrouvé que les hVICs calcifient lorsqu’elles sont en présence d’ET-1. Ces données suggèrent une implication du système endothélinergique dans la calcification valvulaire aortique. Des études complémentaires sont nécessaires pour mieux comprendre son implication, notamment en évaluant l’effet d’antagoniste des récepteurs de l’endothéline dans des cultures de hVICs puis dans un modèle animal fiable mimant cette pathologie. / Aortic stenosis (AS) is the most common valvulopathy in Western countries and affects approximately 2% of subjects over 65 years of age. Originally considered a passive age-related degeneration of the aortic valve, AS is currently considered a complex and highly regulated pathology that results in thickening and calcification of aortic valve leaflets. To date the mechanisms initiating and promoting the progression of AS are not completely understood and secondly, no treatment has been effective to slow or stop its evolution. Aortic valve replacement (surgical or percutaneous) remains the only treatment for severe aortic stenosis. On the other hand, there is no reliable and reproducible animal model of AS to better understand the pathophysiology of this valvulopathy and to test new therapeutic targets. In the laboratory, we hypothesized that valvular endothelial dysfunction plays an important role in the initiation and progression of AS and we wish to use an animal model to evaluate the effect of new therapeutics. This work focuses on assessing the role of the endothelinergic system in AS and the development of a novel mouse animal model of AS. First, we used the EgfrWa2/Wa2 mouse model. This model is induced by the substitution of the amino glycine residue by a valine. The EgfrWa2/Wa2 mice homozygous for the mutation have their tyrosine kinase activity decreased by 90%. This model induces fibrous thickening of the leaflets with little calcification, but the increase in transaortic flow is not related to AS but to aortic regurgitation (AR). In this model we evaluated the effect of a fat-enriched diet and vitamin D3 supplementation. Despite increased serum levels of cholesterol, vitamin D3 and serum calcium, we did not observe an increase in calcification. The EgfrWa2/Wa2 model remains essentially a model of AR whereas AS remains rare or absent. Second, we evaluated the role of the endothelinergic system in primary cultures of human interstitial valvular (hVICs) and endothelial (hVECs) cells, obtained from AS patients treated by surgical aortic valve replacement. The valves of patients treated by a Bentall procedure were used as a control group. We first observed, by quantitative RT-PCR, that stenotic valves showed an increase in mRNA encoding endothelin and for its ET-B receptor and a decrease in the endothelin converting enzyme in the hVECs compared to the control valves. The ET-B receptor was also overexpressed in the hVICs compared to the control valves. We did not find any variation in expression of its ET-A receptor in hVICs. We then assessed the effect of endothelin-1 (ET-1) in the hVICs. We found that hVICs calcify when they are in the presence of ET-1. These data suggest involvement of the endothelinergic system in aortic valve calcification. Further studies are needed to better understand its involvement, notably by evaluating the effect of endothelin receptor antagonist in hVICs cultures and then in a reliable animal model mimicking this pathology

Background: The use of manual therapy for the management of lumbar spinal stenosis (LSS) has not been adequately systematically reviewed in an attempt to determine its effectiveness on patients with LSS. The lack of evidence in support ofcommonly used conservative interventions continues to result in a lack of clarity regarding what interventions should be used to manage patients with LSS. Objective: To use a randomized comparative trial to compare the functional clinical outcomes achieved by patients with LSS receiving two different physical therapy interventions. Methods: In this randomized controlled trial, a total of40 participants diagnosed with LSS were randomized into two groups. Both groups received 6 weeks of treatment. Participants assigned to group 1 (EX Group) received impairment-based exercises. Participants assigned to group 2 (EXMT Group) received impairment-based exercises as well as manual physical therapy techniques. The evaluation parameters included (1) McGill Pain Questionnaire, (2) the original version of the Oswestry Low Back Pain Disability Questionnaire (ODQ), (3) double inclinometer measurement for measuring thoracolumbar flexion and extension, (4) self-pace walking test, (5) hip abductor and extensor strength, and (6) hip external rotation and extension range of motion. All participants were evaluated before starting treatment, once at the end of 6 weeks of treatment, and again at 6 weeks following the completion of treatment. Results: In terms of overall treatmentefficacy, there were notable improvements observed over time regardless of treatment group. Results indicated significant improvement in perceived disability using ODQ in the EXMT treatment group in comparison to the EX group at follow-up. For the EXMT group, there were notable improvements in comparison to the EX group in multiple objective functional improvement measures. Conclusion: Results of this study suggest that a multimodal approach using manual therapy and therapeutic exercises is an effective treatment option for providing clinically significant short-term reduction in back pain and disability, as well as improvements in back mobility in patients with LSS. Physical therapists should strongly consider the impairment-based approachof manual therapy and specific exercises program for lumbar spine and hips as a treatment option for patients with lumbarspinal stenosis.

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OBJECTIVES: Despite numerous studies in which various methods for arteriotomy closure after carotid endarterectomy (CEA) have been addressed, the optimum surgical technique to reduce complications and late carotid restenosis has yet to be firmly established. The purpose of this study was to prospectively compare the results of the eversion CEA technique with those of conventional CEA with either primary closure or carotid patch angioplasty, and to determine under clinical conditions whether eversion CEA influences the results and restenosis rate. PATIENTS AND METHODS: Over a 3-year period, 322 CEAs performed on 296 consecutive patients were concurrently evaluated. This study included 118 eversion CEAs, 97 CEAs with primary closure, and 107 CEAs with patch angioplasty. There were no differences in demographics, in surgical indications, or in the severity of carotid disease (not significant [NS]). The choice of CEA technique was not randomized because of technical considerations and surgeon preference. After entry into the protocol, no patients were excluded or withdrawn. Carotid restenosis was defined as a > 60% lumen reduction at the CEA site with established duplex ultrasonography criteria. RESULTS: The mean operative time for eversion CEA was 31 minutes, for CEA-primary closure it was 39 minutes, and for CEA-patch angioplasty it was 46 minutes (P <.01). The operative mortality rate for eversion CEA was 0.8% (1 patient), for CEA-primary closure it was 1.0% (1 patient), and for CEA-patch angioplasty it was 2.8% (3 patients) (NS). The postoperative stroke rate was 0.8% after eversion CEA, 1.0% after CEA-primary closure, and 2.8% after CEA-patch angioplasty (NS). The combined stroke and death rate in each group was thus 0.8% for eversion CEA (1 stroke-death), 1% for CEA with primary closure (1 stroke-death), and 5% for CEA with patch angioplasty (1 stroke-death, 2 fatal myocardial infarctions, and 2 nonfatal strokes) (NS). Transient ischemic attacks occurred in 2.5% after eversion CEA, in 5.2% after CEA-primary closure, and in 2.9% with CEA-patch angioplasty (NS). The mean clinical follow-up for all three groups was 23 months (range, 6-42 months) (NS). The restenosis rate was 1.7% after eversion CEA, 9.3% after CEA-primary closure, and 6.5% after CEA-patch angioplasty (P <.05). CONCLUSIONS: This prospective, nonrandomized clinical study indicates that eversion CEA is an effective surgical option comparable to conventional CEA with either primary arteriotomy closure or carotid patch angioplasty. No differences were found between eversion CEA and these more widely accepted CEA closure techniques with respect to operative morbidity and mortality. These data indicate, however, that eversion CEA has a lower restenosis rate than conventional CEA closure techniques and thus superior long-term durability.