Thigh bleeding time as a valid indicator of hemostatic competency during surgical treatment of patients with advanced renal disease.

We compared the usefulness of the modified Ivy bleeding time performed in the forearm (arm bleeding time) with that performed in the thigh (thigh bleeding time) as an indicator of hemostatic competence during surgical treatment in 16 patients with chronic renal failure. In 22 normal adults, the arm bleeding time (mean plus or minus standard deviation, 6.6 +/- 1.4 minutes) was significantly longer than the value in the thigh (mean plus or minus standard deviation, 4.1 +/- 1.3 minutes) (p less than 0.001), and there was no correlation between arm and thigh bleeding time. Preoperatively, the arm bleeding time in patients with renal disease was markedly prolonged (greater than 20 minutes) in 15 patients and slightly prolonged in one patient. There was no abnormal perioperative bleeding in 13 patients whose preoperative thigh bleeding time was seven minutes or less. Prolonged and excessive perioperative bleeding was observed in three patients whose thigh bleeding time was 8.0, 9.5 and 26.5 minutes. These findings suggest that thigh bleeding time is a better indicator of competence of primary hemostasis during the operation than the arm bleeding time in patients with advanced renal failure.

Spontaneous clostridial empyema and pyopneumothorax.

Five patients developed pleural empyema due to Clostridium perfringens in the absence of penetration of the thorax; two of the patients presented with pyopneumothorax. Thirteen additional cases from the literature are reviewed. Predisposing factors to the development of pleural empyema appear to include aspiration pneumonia, pulmonary embolization and infarction, and bacteremia from other foci. Pleural disease and pulmonary tuberculosis may also predispose patients to pleural empyema. Treatment consists of drainage and antimicrobial chemotherapy.

The protean manifestations of Legionnaires' disease.

The protean manifestations of Legionnaires' disease are described in an analysis of 12 sporadic cases. Two forms of the disease have been delineated. One variant (Group A) consisted of six patients who had a mild form of non-progressive pneumonia with minimum extra-pulmonary involvement. Six patients (Group B) were differentiated by rapidly progressive pulmonary infiltrates, severe hypoxia and respiratory failure, plus a higher frequency of band neutrophils and extra-pulmonary manifestations. Particularly notable were evidence of severe myositis (elevated creatinine phosphokinase and lactate dehydrogenase), anaemia, and neurological findings which included alterations in the sensorium, meningitis, and convulsions. Cerebrospinal fluid (CSF) abnormalities were seen frequently in patients with neurological manifestations, and necropsy findings in one patient suggested that the Legionnaires' bacillus was capable of producing a fatal leucoencephalitis. Renal findings included haematuria, proteinuria and oliguric renal failure. Hepatic transaminases (SGPT, SGOT) were elevated in six patients and serum bilirubin was abnormal in five. Alkaline phosphatase values were normal to minimally elevated. The gastrointestinal symptoms commonly considered to be a frequent initial manifestation of Legionnaires' disease were rare in this series. Recommendations for instituting empirical therapy, based upon recognition of a clinical syndrome which should suggest the diagnosis of Legionnaires' disease, are included.

Total parathyroidectomy and parathyroid autotransplantation in patients with chronic renal failure.

Sixteen patients with chronic renal failure underwent total parathyroidectomy and parathyroid autotransplantation into the muscle of the forearm. Pertinent preoperative medical history of these patients included renal osteodystrophy, metastatic vascular calcifications, intractable itching and uncontrollable hyperphosphatemia. Efforts to control preoperative serum calcium and elevated serum parathormone levels were unsuccessful. The mass of parathyroid tissue implanted, in most instances, was approximately half that used in other series. Postoperatively, all patients received vitamin D and calcium orally, which were gradually decreased. Fourteen of the 16 patients had relief of symptoms, and all had restoration of parathormone levels to normal or slightly above normal, although in two patients, partial excision of hyperfunctioning tissue from the forearm was subsequently required because of recurring symptoms of secondary hyperparathyroidism. All patients had evidence of functioning grafts six to 40 months postoperatively or until death, attributable to intercurrent causes. The success of total parathyroidectomy and parathyroid autotransplantation in patients with chronic renal failure and symptomatic secondary hyperparathyroidism makes this a viable approach to the disease in such patients.

Clinically silent pericardial effusions in patients on long-term hemodialysis. Pericardial effusions in hemodialysis.

The danger of cardiac tamponade occurring when pericarditis is accompanied by pericardial effusion, as opposed merely to the presence of a friction rub without effusion, has been unclear. Forty patients on hemodialysis were studied by physical examination, chest x-ray film, and echocardiography for evidence of pericarditis and pericardial effusion. Only two patients developed a friction rub during the study and were placed on regional heparin. Ten of 11 patients who were positive on echocardiogram for pericardial effusion had unremarkable physical examinations. These 11 patients had cardiomegaly as noted on chest x-ray examination. Eighteen of 25 patients without effusion also had cardiomegaly on chest x-ray film. No patient remaining on systemic heparin and having a pericardial effusion developed cardiovascular complications during hemodialysis. This study suggests that while many patients on longterm hemodialysis have pericardial effusion undiagnosed on the basis of physical examination, but noted on echocardiogram, special precautions to prevent tamponade during hemodialysis are not necessary. Also, posterior-anterior chest x-ray film showing a normal-sized heart will usually exclude significant pericardial effusion.

Obstructive polyuric renal failure following renal transplantation.

In a previously nephrectomized patient with a well functioning renal allograft, acute renal failure with massive polyuria and hypertension developed. Relief of a periureteric obstruction resulted in rapid correction of all three. Pathogenesis of hypotonic polyuria is thought to be a defect in the collecting duct permeability to water, stimulating nephrogenic diabetes insipidus. Normal urinary dilution and acidification suggest intact function of the ascending loop of Henle and distal convoluted tubules. The quick reversal of polyuria and renal failure after obtaining relief of the obstruction suggest that both the decrease in the glomerular filtration rate and tubular dysfunctions are due to functional changes in the nephron rather than to organic damage, a possibility also borne out by the findings in a renal biopsy specimen showing normal glomeruli and intact tubular epithelial cells. Ureteric obstruction should be considered in any patient with renal failure and polyuria; it may be a correctable cause of hypertension.

Coombs-positive hemolytic uremic syndrome.

Two children presenting typical clinical features of the hemolytic-uremic syndrome had a positive direct Coombs test that remained positive throughout the illness. It is probable that an upper respiratory tract infection precipitated an antigen-antibody reaction that caused the autoimmune hemolytic anemia and immune-complex glomerulonephritis.