SummaryBackground and objectives Comparisons of fistulas and grafts often overlook the high primary failure rate of fistulas. This study compared cumulative patency (time from access creation to permanent failure) of fistulas and grafts.Design, setting, participants, & measurements Vascular accesses of 1140 hemodialysis patients from two centers (Toronto and London, Ontario, Canada, 200022010) were analyzed. Cumulative patency was compared between groups using Kaplan-Meier survival curves and log-rank tests. Hazard ratios (HRs) for fistula failure relative to grafts and 95% confidence intervals (95% CIs) are reported.Results There were 1012 (88.8%) fistulas and 128 (11.2%) grafts. The primary failure rate was two times greater for fistulas than for grafts: 40% versus 19% (P,0.001). Cumulative patency did not differ between fistulas and grafts for the patients' first access (median, 7.4 versus 15.0 months, respectively [HR, 0.99; 95% CI, 0.7921.23; P=0.85]) or for 600 with a subsequent access (7.0 versus 9.0 months [HR, 0.93; 95% CI, 0.7721.13; P=0.39]). However, when primary failures were excluded, cumulative patency became significantly longer for fistulas than for grafts for both first and subsequent accesses (61.9 versus 23.8 months [HR, 0.56; 95% CI, 0.4320.74; P,0.001] and 42.8 versus 15.9 months [HR, 0.56; 95% CI, 0.4420.72; P,0.001]). Results were similar for forearm and upper-arm accesses. Compared with functioning fistulas, grafts necessitated twice as many angioplasties (1.4 versus 3.2/ 1000 days, respectively; P,0.001) and significantly more thrombolysis interventions (0.06 versus 0.98/1000 days; P,0.001) to maintain patency once matured and successfully used for dialysis.Conclusions Cumulative patency did not differ between fistulas and grafts; however, grafts necessitated more interventions to maintain functional patency.

OBJECTIVEHyperbaric oxygen therapy (HBOT) is used for the treatment of chronic diabetic foot ulcers (DFUs). The controlled evidence for the efficacy of this treatment is limited. The goal of this study was to assess the efficacy of HBOT in reducing the need for major amputation and improving wound healing in patients with diabetes and chronic DFUs. RESEARCH DESIGN AND METHODSPatients with diabetes and foot lesions (Wagner grade 2-4) of at least 4 weeks' duration participated in this study. In addition to comprehensive wound care, participants were randomly assigned to receive 30 daily sessions of 90 min of HBOT (breathing oxygen at 244 kPa) or sham (breathing air at 125 kPa). Patients, physicians, and researchers were blinded to group assignment. At 12 weeks postrandomization, the primary outcome was freedom from meeting the criteria for amputation as assessed by a vascular surgeon. Secondary outcomes were measures of wound healing. RESULTSOne hundred fifty-seven patients were assessed for eligibility, with 107 randomly assigned and 103 available for end point adjudication. Criteria for major amputation were met in 13 of 54 patients in the sham group and 11 of 49 in the HBOT group (odds ratio 0.91 [95% CI 0.37, 2.28], P = 0.846). Twelve (22%) patients in the sham group and 10 (20%) in the HBOT group were healed (0.90 [0.35, 2.31], P = 0.823). All other indices of wound healing were also not statistically significantly different between groups. CONCLUSIONSHBOT does not offer an additional advantage to comprehensive wound care in reducing the indication for amputation or facilitating wound healing in patients with chronic DFUs.

The Toll-like receptor 4 (TLR4) has recently been shown to function as the major upstream sensor for LPS. In this study, a rodent model of lung injury following resuscitated hemorrhagic shock was used to examine the regulation of TLR4 gene and protein expression in vivo and in vitro. Intratracheal LPS alone induced a rapid reduction in whole lung TLR4 mRNA, an effect which is also observed in recovered alveolar macrophages. This effect appeared to be due to a lowering of TLR4 mRNA stability by ∼69%. By contrast, while shock/resuscitation alone had no effect on TLR4 mRNA levels, it markedly altered the response to LPS. Specifically, antecedent shock prevented the LPS-induced reduction in TLR4 mRNA levels. This reversal was explained by the ability of prior resuscitated shock both to prevent the destabilization of TLR4 mRNA by LPS and also to augment LPS-stimulated TLR4 gene transcription compared with LPS alone. Oxidant stress related to shock/resuscitation appeared to contribute to the regulation of TLR4 mRNA, because supplementation of the resuscitation fluid with the antioxidant N-acetylcysteine reversed the ability of shock/resuscitation to preserve TLR4 mRNA levels following LPS. TLR4 protein levels in whole lung mirrored the changes seen for TLR4 mRNA. Considered in aggregate, these data suggest that levels of tlr4 expression are controlled both transcriptionally as well as posttranscriptionally through altered mRNA stability and that antecedent shock/resuscitation, a form of global ischemia/reperfusion, might influence regulation of this gene.

Radiofrequency puncture is a viable alternative to needle or laser punctures for in situ fenestration during TEVAR. Early clinical results suggest technical feasibility and acceptable early outcomes.