Vertebral arteriovenous fistula as a result of Swan-Ganz catheter insertion: surgical correction in a symptomatic patient.

A case of a vertebral arteriovenous fistula is reported after being caused by insertion of a Swan-Ganz catheter into the vertebral artery prior to cardiac surgery. The patient's clinical symptoms which precipitated re-admission consisted of multiple episodes of diaphoresis and dizziness. A right carotid bruit was detected in the neck. Four vessel cerebral arteriograms could not accurately identify the origin of the fistula. The proximal carotid artery was considered by several radiologists to be the arterial source of the fistula. During the surgical procedure, a tortuous right vertebral artery was found to be the source of the fistula. Surgical correction of the fistula was successful with preservation of the vertebral artery. Recommendations from a review of the literature are made for the current treatment of this rare complication from an insertion of a Swan-Ganz catheter.

Necrotizing fasciitis in a renal transplant patient.

We have described a 28-year-old diabetic woman who had necrotizing fasciitis of the perineum three years after receiving a living related renal transplant. The diagnosis of necrotizing fasciitis was made early and she was referred to a tertiary care center where she received radical perineal debridement and aggressive medical and surgical follow-up. Necrotizing fasciitis in a transplant patient is rare; review of the literature shows few cases and no survivors. Our patient has returned to a normal life despite continuation of all immunosuppressive therapy throughout the entire hospital course. In addition, she had a good cosmetic result despite the large necrotic perineal infection. Her survival can be attributed to early diagnosis and referral, immediate and extensive debridement, and aggressive protein replacement.

Inhibition of macrophage- and neutrophil-mediated cytotoxicity by verapamil.

Peripheral blood monocyte-derived macrophages and polymorphonuclear leukocytes (PMNs) obtained from normal donors kill tumor cells in vitro. However, if verapamil is added to the macrophages or neutrophil tumor cell suspensions in microgram concentrations (0.1 microgram to 0.1 mg), there is marked inhibition of tumor cell killing. The inhibitory effect for the macrophages resulted from an effect of verapamil on both the effector and target cells. When either the effector cells or target cells were preincubated with verapamil, they became resistant to the effects of the cytotoxic macrophages. Cytotoxicity was also inhibited when 0.1 mg of verapamil was added to the macrophages monolayers either at the time of addition of the tumor cells or 15-30 min after addition of the tumor cells, whereas no inhibition of cytotoxicity occurred when verapamil was added more than 30 min after the initiation of the cytotoxic reaction. For the neutrophils it was observed that the inhibitory activity resulted from an effect of verapamil on the effector cells rather than the target cells. When the effector cells were preincubated with verapamil they became incapable of killing the tumor cells, whereas preincubation of the target cells with verapamil had no effect on their ability to be killed by the neutrophils. Cytotoxicity was also inhibited when 0.1 mg of verapamil was added to the neutrophil monolayers either at the time of addition of the tumor cells or 15-60 min after addition of the tumor cells, whereas no inhibition of cytotoxicity occurred when verapamil was added more than 60 min after the initiation of the cytotoxic reaction.

Pillars in the colon. Crohn's colitis with unusual endoscopic and morphologic appearances: report of a case.

A case of Crohn's colitis with unusual endoscopic and morphologic appearances is reported. The colitis was asymptomatic and discovered incidentally. Histologic confirmation was obtained following segmental colectomy.

Suppressor T cell activity in lymphoid interstitial pneumonia.

A case of lymphoid interstitial pneumonia was investigated for immunological abnormalities. Suppressor T cells were found. The abnormality in the lymphoid system could be corrected in vitro with levamisole. The patient thereafter developed histiocytic lymphoma and soon died without any response to chemotherapy.

Rectus sheath abscess.

I have reported a case in which percutaneous aspiration of a rectus sheath hematoma subsequently led to abscess. The treatment of a rectus sheath hematoma should be conservative after diagnosis by ultrasonography or CT scan. A sterile rectus sheath hematoma should not be aspirated under any circumstance.

Prevention of acute tubular necrosis after transplantation: effect of pretransplantation volume expansion.

We reviewed our experience with 100 consecutive cadaveric transplants of kidneys from satisfactory donors with respect to immediate function after transplantation. The management was the same in all patients except that 66 of them received 1,000 ml of 0.9 N saline IV preoperatively. The overall incidence of acute tubular necrosis (ATN) was 23.2%, but the incidence of ATN in the group of patients who received saline was 7.6%, as compared to 53% in those that did not (P less than .001). There was no other significant difference between the two groups. We conclude that when cadaver kidneys are harvested and preserved under satisfactory conditions, preoperative volume expansion markedly lowers the incidence of posttransplantation ATN, suggesting that the recipient volume status is an important consideration.

Polyps of the gallbladder.

One of the unusual problems associated with gallbladder disease is a polyp discovered by either ultrasonography or by oral cholecystogram. We report a recent experience of two cases of polyps of the gallbladder removed by cholecystectomy. The incidence of gallbladder polyps of any type is quite varied in the medical literature. Eighty percent of polyps occur in females, and these occur after the third decade of life. The polyps can either be cholesterol or inflammatory polyps that are not really benign tumors but just reactions of the gallbladder wall. The true mucosal benign lesions are either adenomyomas or papillomas. The adenomyomas and papillomas have malignant potential. There are case reports of carcinoma in situ and cancer arising from these lesions. The treatment for a gallbladder polyp is a cholecystectomy.

Effects of in vivo treatment with ibuprofen on macrophage function in breast and colon cancer patients.

In this study, the capacity of macrophages from breast and colon cancer patients to become cytotoxic for tumor cells after in vivo administration of the prostaglandin inhibitor, Ibuprofen, has been investigated. Prior to the administration of the drug, each patient's macrophages were tested for their ability to kill tumor cells in the presence and absence of 10(-7) M Ibuprofen. The patients were given 400 mg Ibuprofen 4 times daily for 28 days. At days 14 and 28 after commencing the study, blood samples were drawn and the macrophages were tested for their ability to kill tumor cells in vitro. The patients were divided into 3 groups: Category I, patients possessing non-cytotoxic macrophages in the presence and absence of Ibuprofen; Category II, patients possessing non-cytotoxic macrophages in the absence of the drug and cytotoxic macrophages in the presence of the drug; and Category III, patients possessing cytotoxic macrophages in the absence of the drug and non-cytotoxic macrophages in the presence of the drug. Category I cancer patients generally responded the most effectively to in vivo administration of Ibuprofen at day 28 whereas Category II patients responded the most effectively at day 14. Category II patients became non-responsive when tested again at day 28 and Category I patients became non-responsive when the study was extended to day 42. Category III patients were generally non-responsive at all time points studied.(ABSTRACT TRUNCATED AT 250 WORDS)

Paper bezoar in the stomach.

A toilet paper bezoar caused acute abdominal distention and symptoms of an acute condition of the abdomen in a 5-year-old boy. Simple gastrotomy served to clear the paper bezoar and relieve the gastric obstruction after nonoperative methods failed.

Forearm arterial venous shunt for hemodialysis.

A new technique for creation of an arterial venous shunt for hemodialysis is described. The proximal radial artery is used for the arterial inflow anastomosis site instead of the brachial artery. The technique provides an adequate arterial inflow but avoids all the complications of utilization of the brachial artery in the forearm arterial venous shunt for hemodialysis.

Renal transplantation in Alport's syndrome.

Nineteen patients (3 women and 16 men) with Alport's Syndrome and endstage renal failure received 23 allograft kidneys at two medical centers between 1972 and 1983. Ten patients had pretransplant splenectomies, and four patients had pretransplant thoracic duct drainage. After a mean follow-up time of 49 months, analysis revealed total allograft survival was 65 per cent at 1 year, 50 per cent at 2 years, and 57 per cent at 5 years. Pretransplant splenectomy resulted in 60 per cent allograft survival at 24 months mean follow-up. Pretransplant thoracic duct drainage resulted in 100 per cent allograft survival at 15.6 months mean follow-up. The overall allograft survival was greatest for three and four antigen-matched kidneys and for living related donor kidneys. Data indicated that 50 per cent of all allografts in men were functional at 50.8 months mean follow-up. All allografts in women were functional at 48.3 months mean follow-up. Three of four patients who expired had pretransplant splenectomies. From this study, the authors conclude that renal transplantation is the preferred method of treatment for patients with Alport's Syndrome.

Hazard of a postendarterectomy intimal flap in carotid artery surgery.

A patient with severe bilateral carotid artery stenosis had an intimal flap after removal of the carotid plaque using the plaque cracker. Because use of the plaque cracker in the carotid artery surgery offers no significant advantages and allows the possibility of an intimal flap occurring in the carotid artery, this instrument should not be used in carotid artery surgery. The plaque cracker has been established as a useful instrument in peripheral vascular surgery in selected cases.

Macrophage and polymorphonuclear leukocyte function in patients with Alzheimer disease.

Monocyte derived macrophages and polymorphonuclear leukocytes (PMNs) isolated from the peripheral blood of thirteen patients with Alzheimer disease were studied for their cytotoxic effects on a sensitive allogenic tumor target. PMN cells from 11 of the 13 patients with Alzheimer disease were able to kill the tumor cells. In addition, the macrophages from 12 of the 13 Alzheimer disease patients were cytotoxic towards the tumor targets. Four of these patients possessed a plasma inhibitory factor which was capable of suppressing macrophage mediated cytotoxicity. When the lymphocytes from these patients were studied for their ability to be stimulated with the specific antigen, streptokinase, to produce macrophage activating factor (MAF), only 5 of the 13 patients studied possessed lymphocytes which were capable of producing MAF. Thus, the only immunological defect in Alzheimer disease patients which was observed in this study was in the ability of the lymphocytes to synthesize MAF.

Necrotizing fasciitis.

Necrotizing fasciitis is a synergistic infection caused by aerobic and anaerobic organisms, resulting in liquefaction and necrosis of the fascia. Clinical findings typically include septicemia, anemia and radiographic evidence of gas in the soft tissue. Most patients have a history of diabetes or atherosclerosis. Morbidity and mortality can be reduced by early diagnosis, extensive surgical debridement and aggressive nutritional support.