Background/Aims: The diagnostic potential of magnetic resonance cholangiopancreaticography (MRCP) has improved as a result of evolving technique. MRCP has the advantage of negligible morbidity and mortality in contrast to endoscopic retrograde cholangiopancreatography (ERCP). This study was performed to evaluate MRCP as a replacement for diagnostic ERCP for the suspicion of common bile duct (CBD) stones. Methods: From 1998 to 2001, MRCP was performed in 202 patients with a suspicion of CBD stones based on medical history (MH), cholestatic liver function tests (CL), both MH and CL or other reasons. ERCP was performed in all patients where MRCP indicated the presence of CBD stones and in those patients with a persistent strong clinical suspicion for CBD stones despite a negative MRCP. Results: In 25 patients, MRCP suggested CBD stones which were proven with ERCP in 24 patients. Despite a negative MRCP, 27 patients had a subsequent ERCP. None of these patients appeared to have CBD stones. In this group, MRCP resulted in 100% sensitivity and 96% specificity in detecting CBD stones. Follow-up of all patients revealed 5 more patients with persistent clinical suspicion or cholestatic liver function values. Assuming CBD stones in these patients, MRCP had a sensitivity of 83 % and a specificity of 99% for this diagnosis. Conclusion: In the case of CBD stone suspicion, MRCP should be the diagnostic procedure of choice.

Introduction: Thoracolumbar spine fractures are common osteoporotic fractures among elderly patients. Several studies suggest that these fractures can be treated successfully with a nonoperative management. The aim of this study is to evaluate the conservative treatment of elderly patients with a vertebral fracture. Methods: This study is a retrospective cohort study, which included all patients with an age of 65 years and older, who were diagnosed with a vertebral fracture and where therefore admitted to the Geriatric Fracture Center over a period of 2 years. Primary outcome was the level of functioning 6 weeks and 3 months after admission. Results: We included 106 patients with 143 vertebral fractures, of which 61 patients were evaluated after 3 months. In our population, 53% of the patients had a fracture involving both middle and anterior columns. The majority of the patients functioned sufficiently 6 weeks and 3 months after admission. Analysis showed that age <80 years is an independent predictor of a sufficient level of functioning after 6 weeks. Discussion: The nonoperative treatment of elderly patients with a vertebral fracture leads to a sufficient level of functioning 6 weeks and 3 months after admission. In our population, only age <80 years is an independent predictor for a sufficient level of functioning 6 weeks after admission. The level of functioning at 6 weeks predicts the level of functioning 3 months after admission. On comparison, the level of functioning after early ambulation is equal to the level of functioning after immobilization. Where immobilization may lead to complications, early ambulation was not associated with new complications or neurological damage. Based on these advantages, the treatment of elderly patients with a fracture involving both middle and anterior columns may be altered from immobilization to mobilization in the future.

Objectives: The impact of national quality initiatives aiming at limiting lower extremity amputations (AMPS) in diabetics remains uncertain. Therefore, we explored trends in AMPS among Medicare diabetics with a focus on those at highest risk.Methods: The Diabetes Analytic File, an enhanced sample of all diabetics from the Medicare 5% sample, was used to study the national incidence of AMPS in diabetics. Within a cohort of ϳ5 million diabetics between 1999-2006, we compared the incidence of AMPS in high-risk (ESRD or Ͼ 3 comorbidities) and low-risk groups, and by race.Results: A total of 23,976 AMPS were performed between 1999 and 2006; 11,558 in high risk and 12,418 in low risk patients. The rate of AMPS declined over time (4.8 per 1000 in 1999, 4.4 in 2006, pϽ0.001). Over time, high-risk patients represented a growing proportion of all AMPS (33% in 1999, 50% in 2006; pϽ0.001) despite representing a minority of all diabetics (4% in 1999 to 10% in 2006, pϽ0.001). The incidence of AMPS was 10 fold higher in the high-risk group (29.6 per 1000) versus low-risk patients (2.7 per 1000, pϽ0.001), and African Americans had higher rates of AMPS, in both high and low-risk groups (Figure 1).Conclusions: Although high-risk patients represent a minority of Medicare diabetics, they account for 50% of all AMPS, and this effect is magnified in African Americans. Future QI efforts should focus on high-risk patients and African Americans.

Purpose: The aim of this study was to assess the initial experience, technical success, and clinical benefit of AneuFix (TripleMed, Geleen, the Netherlands), a novel biocompatible and non-inflammatory elastomer that is directly injected into the aneurysm sac by a translumbar puncture in patients with a type II endoleak and a growing aneurysm. Materials and Methods: A multicenter, prospective, pivotal study was conducted (ClinicalTrials.gov:NCT02487290). Patients with a type II endoleak and aneurysm growth (>5 mm) were included. Patients with a patent inferior mesenteric artery connected to the endoleak were excluded for initial safety reasons. The endoleak cavity was translumbar punctured with cone-beam computed tomography (CT) and software guidance. Angiography of the endoleak was performed, all lumbar arteries connected to the endoleak were visualized, and AneuFix elastomer was injected into the endoleak cavity and short segment of the lumbar arteries. The primary endpoint was technical success, defined as successful filling of the endoleak cavity with computed tomography angiography (CTA) assessment within 24 hours. Secondary endpoints were clinical success defined as the absence of abdominal aortic aneurysm (AAA) growth at 6 months on CTA, serious adverse events, re-interventions, and neurological abnormalities. Computed tomography angiography follow-up was performed at 1 day and at 3, 6, and 12 months. This analysis reports the initial experience of the first 10 patients treated with AneuFix. Results: Seven men and 3 women with a median age of 78 years (interquartile range (IQR), 74-84) were treated. Median aneurysm growth after endovascular aneurysm repair (EVAR) was 19 mm (IQR, 8–23 mm). Technical success was 100%; it was possible to puncture the endoleak cavity of all treated patients and to inject AneuFix. Clinical success at 6 months was 90%. One patient showed 5 mm growth with persisting endoleak, probably due to insufficient endoleak filling. No serious adverse events related to the procedure or AneuFix material were reported. No neurological disorders were reported. Conclusion: The first results of type II endoleak treatment with AneuFix injectable elastomer in a small number of patients with a growing aneurysm show that it is technically feasible, safe, and clinically effective at 6 months. Clinical Impact Effective and durable embolization of type II endoleaks causing abdominal aortic aneurysms (AAA) growth after EVAR is challenging. A novel injectable elastic polymer (elastomer) was developed, specifically designed to treat type II endoleaks (AneuFix, TripleMed, Geleen, the Netherlands). Embolization of the type II endoleak was performed by translumbar puncture. The viscosity changes from paste-like during injection, into an elastic implant after curing. The initial experience of this multicentre prospective pivotal trial demonstrated that the procedure is feasible and safe with a technical success of 100%. Absence of AAA growth was observed in 9 out of 10 treated patients at 6 months.

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