Gastrointestinal bleeding as the initial manifestation of a polyarteritis nodosa-associated hepatic artery aneurysm-duodenal fistula--a case report.

The authors report an unusual case of upper gastrointestinal bleeding from a hepatic artery aneurysm-duodenal fistula in a 21-year-old male. Arteriography revealed multiple visceral artery aneurysms. Biopsy of the hepatic artery aneurysm (HAA) revealed focal areas of necrosis, medial degeneration, fibrosis, and giant cells. The necrotizing vasculitis plus the multiple visceral aneurysms were highly suggestive of polyarteritis nodosa (PAN). This report reviews the pathophysiology and management of PAN and the diagnosis and management of HAA.

Heparin-associated antiplatelet antibodies increase morbidity and mortality in hemodialysis patients.

BACKGROUND: Patients are frequently exposed to heparin during hemodialysis (HD) to prevent thrombosis of the extracorporeal circuit. Other groups with frequent heparin exposures have a high rate of development of heparin-associated antiplatelet antibodies (HAAb). We sought to define the prevalence of HAAb in HD patients and evaluate their effects. METHODS: A chart listing of all patients undergoing HD at our tertiary care institution during a six-year period was obtained. Charts of patients who tested positive for HAAb were reviewed. A cohort of randomly selected HD patients who tested negative for HAAb was analyzed as a control group. RESULTS: In our sample, 3.7% of HD patients were positive for HAAb. Morbidity, as defined by thromboembolic (TEC) or hemorrhagic complications, was higher in the HAAb-positive group compared with the control patients (60% vs 8.7%, P < .05), and the mortality rate (mortality directly related to TECs) was also higher in the HAAb-positive patients (28.6% vs 4.35%, P < .05). CONCLUSIONS: Contrary to reports of HAAb in patients undergoing HD without increased morbidity and mortality, we found significant increases in both morbidity and mortality. The elevated morbidity and mortality may represent ongoing endothelial and platelet activation from repeated heparin exposures. Reduced morbidity and mortality will likely require early recognition of HAAb and alteration of anticoagulation in HD patients.

A camera's view of consumer food-handling behaviors.

OBJECTIVE: To compare consumer food-handling behaviors with the Fight BAC! consumer food-safety recommendations. DESIGN: Subjects were videotaped in their home while preparing a meal. Videotapes were coded according to Fight BAC! recommendations. A food-safety survey was administered and temperature data was collected. SUBJECTS/SETTING: A market research company randomly recruited subjects by telephone. Ninety-nine consumers participated (92 women, seven men). STATISTICAL ANALYSIS PERFORMED: Descriptive statistics were used. RESULTS: Overall, subjects did not follow the Fight BAC! recommendations for safe food handling. Handwashing was inadequate. The average hand wash length was significantly lower than the 20-second recommendation. Only one-third of subjects' hand wash attempts were with soap. Surface cleaning was inadequate with only one-third of surfaces thoroughly cleaned. Moreover, one-third of subjects did not attempt to clean surfaces during food preparation. Nearly all subjects cross-contaminated raw meat, poultry, seafood, eggs, and/or unwashed vegetables with ready-to-eat foods multiple times during food preparation. Unwashed hands were the most common cross-contamination agent. Many subjects undercooked the meat and poultry entrees. Very few subjects used a food thermometer. APPLICATIONS/CONCLUSIONS: Consumers make many food-handling errors during food preparation, increasing their risk of foodborne illness. Dietetics professionals need to familiarize themselves with the Fight BAC! consumer food-safety recommendations; understand where consumers are making food-handling errors; increase food safety awareness; and educate consumers, especially those in high-risk populations, about safe food handling at home.

Heparin-induced thrombocytopenia: twenty-nine years later.

OBJECTIVE: To determine the current frequency, types of patients, indications for testing, morbidity and mortality, and management of heparin-induced thrombocytopenia (HIT). METHODS: Between December 1998 and July 2001, the charts of 102 inpatients that tested positive for heparin-associated antiplatelet antibodies (HAAb) were reviewed. There were 33,941 inpatients, 10,348 of them having received unfractionated or low molecular weight heparins. HAAb were determined by platelet aggregometry. RESULTS: There were 58 males and 44 females with a mean age of 56 years. The majority (72%) of patients were admitted to a surgical service (23% were admitted to medicine, and 5% were admitted to obstetrics/pediatrics). Indications for testing included one or more low platelet counts (n = 51), unexplained arterial (n = 33) or venous (n = 6) thromboses, resistance to anticoagulation (n = 1), prior history of HAAb (n = 3), organ transplant (n = 17), or other indication (n = 4). The HAAb "patterns" were variable, with patients having antibodies only to bovine (n = 7) or porcine heparin (n = 5), bovine and porcine heparins (n = 17), enoxaparin (n = 3), fragmin (n = 7), or all 4 heparins (n = 43). The HIT-related mortality was 6.9%, and the morbidity was 30% with 19 arterial and 7 venous thromboses and 5 bleeding events. Management consisted of discontinuation of heparin in 95 patients. Twenty-five patients did not require continued anticoagulation. When needed, anticoagulation was continued with a direct thrombin inhibitor (n = 32), enoxaparin (n = 16), warfarin (n = 15), or aspirin (n = 7). Seven patients continued to receive unfractionated heparin (n = 4) or low molecular weight heparin (n = 3). CONCLUSIONS: HIT occurs in 0.99% of inpatients receiving heparin and remains an important nondiscriminatory contributor to their morbidity and mortality. Patients receiving any form of heparin who develop a decreasing platelet count, unexplained thrombosis, or resistance to heparin anticoagulation should be tested for HAAb. If HAAb are detected, patients must not receive the sensitizing heparin(s).

Abdominal aortic sarcoma: report of a case with long-term survival and review of the literature.

We present a case of an intimal epitheliod aortic sarcoma. Diagnosis was established after an aortic endarterectomy. The tumor was subsequently resected and an aortic graft was inserted. The patient underwent adjuvant chemotherapy. The patient is alive and free of metastatic disease at 48 months. Aortic tumors are rare, with an extremely poor prognosis and 1-year survival of 0-13%. The diagnosis is usually established postmortem, with metastatic disease being a common finding. The diagnosis should be suspected in patients with symptoms of nonatherosclerotic-related aortic occlusive disease or distal embolic events. Resection followed by adjuvant therapy and close follow-up can offer a prolonged survival for the patient with an extremely lethal aortic sarcoma.