Delayed superficialization of brachiobasilic fistula: technique and initial experience.

HYPOTHESIS: Angioaccess procedures for dialysis have varied patency rates with frequent need for intervention. A superficialized arteriovenous brachiobasilic fistula created as a 2-step procedure will have good long-term patency with minimal complication. DESIGN: Retrospective medical record review and patient interview. SETTING: Tertiary referral university hospital. PATIENTS: Twelve patients who underwent delayed superficialization of brachiobasilic fistula from September 1994 to April 2000. MAIN OUTCOME MEASURES: Patency of fistula for dialysis, and major and minor complications, including revisions. RESULTS: Delayed superficialization of brachiobasilic fistula was performed in 12 patients. Fistulas have been used for a mean duration of 22.4 months (range, 10-59 months). Two patients required alternate access owing to thrombosis of brachiobasilic fistula. CONCLUSIONS: The delayed superficialized brachiobasilic arteriovenous fistula has a good initial patency rate with minimal complications. It should be considered early in patients if radiocephalic fistula is unavailable.

The 'sweet killer'. Can you recognize the symptoms of ethylene glycol poisoning?

Ingested ethylene glycol is readily absorbed and metabolized into toxic metabolites that can cause CNS depression, cardiopulmonary failure, and renal failure. Thorough history taking, physical examination, and laboratory testing are essential for diagnosis. Careful differential diagnosis is important because symptoms of ethylene glycol poisoning are similar to those of other intoxicants. Early, aggressive treatment with appropriate therapies, such as ethanol therapy, hemodialysis, vitamin cofactors, and antidotal agents, is necessary to prevent permanent disability or death.

Reversal of the histology of bone after parathyroidectomy in patients with hyperparathyroidism.

Hyperparathyroidism is commonly seen in patients with end-stage renal disease and less commonly in the primary form. The skeletal manifestations of hyperparathyroidism are the same in both forms and are well described in the literature. We treated a patient from each category. Multiple bony lesions and pathologic fractures were observed. The clinical presentations and radiologic and histologic findings confirmed the diagnosis of hyperparathyroidism and osteitis fibrosa cystica in both patients. Subtotal excisions of the parathyroid glands were done in both patients. Appropriate treatment of the bony lesions and pathologic fractures resulted in healing. Histologic evaluation of the bony lesions indicated an osteoblastic or healing response. The reversal of the histologic pattern in just 5 days and 16 days after parathyroidectomy was noted. In treating such patients, physicians should consider parathyroidectomy as an aid in the overall management of patients.

Atheroembolic renal disease: experience with 22 patients.

Atheroembolic renal disease (ARD) following an arteriographic procedure developed in 17 patients over a 107-month period in which 14,998 procedures were performed at two hospitals. The incidence of ARD per arteriographic procedure was 0.1%. A review of all nephrology consults during this same period identified five patients with ARD unrelated to a procedure (spontaneous disease). ARD was diagnosed 5.3 +/- 0.9 weeks following an arteriographic procedure. Patients most likely to be diagnosed with ARD were those recently undergoing arteriography (77%), the elderly (mean 69.9 years), males (73%), Caucasians (95%) and patients with renal insufficiency prior to arteriography. In the patients who had arteriography, the baseline serum creatinine increased significantly from a mean of 3.0 +/- 0.6 mg/dl to 6.6 +/- 1.1 mg/dl at the time of diagnosis (P < .05). The mortality rate of 16 patients who progressed to end stage renal disease was significantly greater (75%) than 6 patients who recovered renal function (17%; P < .05).

Sexuality and menopause.

Postmenopausal sexuoerotic health is multivariately determined by both intrinsic and extrinsic variables, some of which may predate the menopause. In a pilot study of 20 postmenopausal women, even when deterioration in sexual well-being was anticipated beforehand, it did not inevitably materialize, but if it did so, it was not inevitably correlated with diminished partner availability. Postmenopausal ratings of erotosexual ideation, imagery, and practices indicated nondeterioration markedly more often than they did deterioration. There is increasing professional agreement that androgen maintains erotosexual functioning in women as well as men; and that, in minimal nonmasculinizing dosage, it can be included with good therapeutic effect in postmenopausal steroid replacement therapy.

Pseudomonas aeruginosa infections in the podiatric patient.

Pseudomonal infections of the skin, soft tissue, bone, and toe web may often be very difficult to treat. This article reviews the microbiology, pathogenesis, and treatment of pseudomonal infections that are related to podiatric medicine and surgery.

Antimicrobial activity of cefmetazole compared with those of other cephalosporins.

The antimicrobial activity of cefmetazole was compared with those of cefmenoxime, ceftizoxime, cefamandole, cefoperazone, cefotaxime, cephalothin, and latamoxef. In general, the activity of cefmetazole was less than those of the other cephalosporins. The in vitro activity of cefmetazole suggests that it will not prove useful as a broad-spectrum antimicrobial against gram-positive and gram-negative pathogens.

Comparative efficacy of four antibiotics in anaerobic pulmonary infection. An experimental model in rabbits.

The efficacy of cefoxitin, mezlocillin, latamoxef and metronidazole in anaerobic lung infection was studied using a rabbit model. A mixture of Bacteroides fragilis, Peptococcus morbillorum, Eubacterium lentum and Fusobacterium nucleatum was inoculated transtracheally to produce infection within the lung. Mezlocillin was most effective, achieving bacteriologic cure in 5 out of 8 animals. With cefoxitin therapy, 4 out of 8 became bacteriologically sterile. Severe diarrhea with elevated titers of Clostridium difficile toxin was noted in most cefoxitin-treated animals. Latamoxef- and metronidazole-treated animals had apparently healed lesions, but cultures were positive in 6 and 7 out of 8 in each group, respectively. The commonest pathogen isolated in the last two groups was P. morbillorum. The therapeutic superiority of mezlocillin over metronidazole and latamoxef was statistically significant (p less than or equal to 0.05).

Mitogenic responses of hamsters infected with Treponema pertenue Lack of correlation with passive transfer of resistance.

Infection of the CB/Ss Lak hamster with Treponema pertenue is characterised by chronic cutaneous lesions and lymph nodes teeming with treponemes. Throughout the course of infection lymph node and spleen cells responded poorly to the mitogens concanavalin A, phytohaemagglutinin, and lipopolysaccharide. This impairment preceded clinical signs of infection and correlated well with the chronicity of framboesial infection. High concentrations of antigen from T pertenue, but not from the non-pathogenic Treponema phagedenis, depressed the mitogenic response of normal lymphoid cells. After framboesial hamsters were treated with penicillin the mitogenic activities of their lymph node and spleen cells were similar to or slightly raised above those of controls. No significant differences were detected among recipients of framboesial immune cells with or without mitogenic activity. Recipients of immune lymph node and spleen cells from penicillin-treated or non-penicillin-treated animals had no cutaneous lesions 21 days after infection and had significantly lower lymph node weights and fewer treponemes per node than recipients of cells from normal penicillin-treated or non-penicillin-treated animals. Since lymphocyte transformation in vitro does not correlate with in-vivo treponemicidal activity, it is not a valid approach to assess the protective immune capacity of the framboesial host.

Rapid detection of simulated bacteremia by centrifugation and filtration.

A centrifugation-filtration procedure was developed to expedite the recovery of microorganisms from blood. Fresh whole human blood was inoculated with various aerobic and facultatively anaerobic microorganisms (3 to 18 per ml). The seeded blood was carefully overlaid on a Ficoll-Hypaque gradient (density, 1.114 g/ml) and centrifuged (400 x g) for 45 min at ambient temperature. The entire gradient (plasma, leukocytes, and Ficoll-Hypaque) was removed and filtered through a 0.22-micrometer membrane filter. The filters were then placed on chocolate agar and incubated at 35 degrees C in humidified air containing 5% CO2. No statistically significant differences were detected between the numbers of microorganisms recovered by filtration and by direct culture of the original inoculum. Most microorganisms were detected within 18 h after filtration. This system has excellent sensitivity and negligible toxicity.

Evidence for depletion of Ia+ macrophages and associated immunosuppression in African trypanosomiasis.

The percentage of Ia antigen-bearing (Ia+) macrophages was significantly lower in mice infected with Trypanosoma rhodesiense than in normal controls. The degree of difference varied with the source of macrophages and time course of infection. The percentage of Ia+ macrophages isolated from spleens 10 days after infection was 71% of that in the controls, and depletion continued until Ia+ macrophages were almost undetectable 30 days after infection. The rate of depletion was slower in the peritoneal cavity. In contrast, Ia+ macrophages were not significantly depleted from the lymph nodes until 30 days after infection. The ability of macrophages from trypanosome-infected mice to present listerial antigen to sensitized T cells was significantly lower than in controls. Immune T cells had significantly less ability (43% of controls) to incorporate thymidine when exposed to splenic macrophages from infected mice during the early stage of disease. This loss of antigen presentation increased during the course of infection. Peritoneal macrophages also exhibited an early loss of ability to present antigen, but no significant decline occurred thereafter. No significant loss of antigen had occurred in the lymph node macrophages 10 days after infection, but during the later stages of the disease a significant loss was detected. Treatment of macrophages from infected and control mice with anti-Iab serum and complement inhibited their ability to present antigen. Our results demonstrate that Ia+ macrophages and their distribution can influence the ability of infected animals to process antigens and may therefore account in part for the immunosuppression observed in trypanosomiasis.

Use of CB hamsters in the study of Treponema pertenue.

The CB/Ss LAK strain of inbred hamster was used as a model for studies of infection with Treponema pertenue and of acquired resistance to it. When infected, this strain developed cutaneous lesions which lasted for six to seven months, even in the presence of peak titres of antitreponemal antibody. The rate of appearance and resolution of these lesions varied with the size of the inoculum. The infected hamsters' inguinal lymph nodes increased significantly in weight and teemed with treponemes for several weeks. Animals infected for eight or 10 weeks obtained quick resolution of their lesions by treatment with penicillin and were thereafter resistant to reinfection.

Endemic syphilis: passive transfer of resistance with serum and cells in hamsters.

Serum or spleen cells from hamsters immune to infection with Treponema pallidum strain Bosnia A conferred partial protection against syphilitic infection by the same strain on recipient hamsters. Cutaneous lesions did not develop, and in the lymph nodes the average weight and number of treponemes detected were significantly lower than in normal and control hamsters. Treatment of the immune spleen cells with antithymocyte serum and complement abolished their ability to transfer resistance. This is the first direct evidence that thymus-derived cells are involved in resistance to syphilitic infection.

Evaluation of ten anaerobic blood culture media.

Selection of an anaerobic blood culture based upon clinical findings that have compared the isolation rates of bacteremic agents from different blood culture media. No agreement has been reached as to which of the commercially available blood culture media is optimal for detection of bacteremia. The purpose of this study was to determine the rates of recovery of anaerobic microorganisms from various anaerobic blood culture media. The blood culture media were inoculated with a small inoculum of microorganisms in the presence or absence of an erythrocyte-serum mixture. The results demonstrated that the type of medium and the erythrocyte-serum mixture influenced the ability of blood culture media to support the growth of microorganisms. The majority of the media failed to support the growth of 87% or more of the microorganisms within four days after inoculation. Pre-reduced brain-heart infusion broth supported the growth of a larger proportion of microorganisms than the other types of blood culture media.

Recovery of Haemophilus influenzae from twenty-three blood culture media.

Haemophilus influenzae is an important agent of bacteremia and has fastidious growth requirements. The purpose of this investigation was to determine the ability of commercial blood culture media to support the growth of this fastidious microorganism. Twenty-three types of blood culture media were inoculated with individual suspensions of eight strains of H. influenzae in the presence or absence of an erythrocyte-serum mixture. The rates of recovery of the H. influenzae strains from the various types of blood culture media were compared. The results demonstrated that the type of medium, the manufacturer, the erythrocyte-serum mixture, and the strain of H. influenzae influenced the recovery rates of H. influenzae. Optimal recovery of the strains of H. influenzae was obtained from brain heart infustion blood culture medium (GIBCO). Trypic soy broth (GIBCO) and supplemental peptone of Becton, Dickinson and Co. also were found to be superior to the remaining types of media tested for the recovery of H. influenzae.

Evaluation of twenty-three blood culture media.

Several investigators have evaluated clinically a variety of commercially available blood culture media. No agreement has been reached as to which of these media is optimal for detection of bacteremia. The purpose of this study was to determine the rate of recovery of microorganisms from various blood culture media. A total of 23 blood culture media were inoculated with 7 to 15 microorganisms per bottle in the presence or absence of an erythrocyte-serum mixture. The results demonstrated that blood culture media differed in their ability to support the growth of microorganisms. At 4 days after inoculation, only 10 of the 23 blood culture media supported the growth of 91% (10 of the 11) or more of the test microorganisms. The recovery rate of microorganisms depended not only upon the type of medium but also upon the manufacturer of the type of blood culture medium. The addition of an erythrocyte-serum mixture to the blood culture media did not influence the difference in the recovery rate of microorganisms among media and the same type of medium prepared by different manufacturers. The majority (15 of the 23) of the blood culture media supplemented with the erythrocyte-serum mixture failed to support the growth of 91% or more of the test microorganisms at 4 days after inoculation. These results have demonstrated that blood culture media need to be improved. Better quality control measures should also be implemented to evaluate commercial blood culture media.

Passive transfer of resistance to frambesial infection in hamsters.

The immune mechanism by which hamsters acquire resistance to infection with Treponema pertenue, the causative agent of frambesia, or yaws, has not been elucidated. Serum or cells (spleen or lymph node) obtained from hamsters resistant to frambesial infection were transferred to normal syngenic recipients, who are subsequently infected with T. pertenue. The following parameters were used to measure the ability of immune serum of cells to confer resistance on recipient hamsters to frambesial infection: inhibition of the development of cutaneous lesions, decreased weight, and number of treponemes in the inguinal lymph nodes. This investigation demonstrated that immune serum conferred protection on recipient hamsters infected with T. pertenue. Discontinuation of the administration of immune serum (18 days after frambesial infection) did not result in the development of cutaneous lesions. Since the inguinal lymph nodes contained a sizeable number of treponemes (2.6 X 10(5)), immune serum failed to prevent frambesial infection. Recipients of immune spleen or lymph node cells initially developed frambesial lesions 9 days after infection. The frambesial lesions began to resolve 12 to 14 days after infection and by day 21 had completely regressed. These results illustrated that humoral factors and cells are involved in resistance of the hamster to frambesial infection.