Sildenafil has no effect on portal pressure but lowers arterial pressure in patients with compensated cirrhosis.

BACKGROUND & AIMS: The reduction of portal pressure in patients with early compensated cirrhosis may be more responsive to drugs increasing intrahepatic vasodilatation than those reducing portal venous inflow. The phosphodiesterase-5 (PDE-V) inhibitor sildenafil can potentially reduce portal pressure by decreasing intrahepatic resistance, but its systemic vasodilatory effects may be deleterious. The aim of this study was to evaluate the effect of sildenafil on systemic and portal hemodynamics in an open-label pilot study. METHODS: Twelve patients with compensated cirrhosis and baseline hepatic venous pressure gradient (HVPG) >5 mm Hg received 25 mg of oral sildenafil. Mean arterial pressure (MAP), heart rate (HR), and HVPG were repeated after 30 and 60 minutes in 9/12 patients at 90 minutes (after an additional 25 mg of sildenafil). HVPG tracings were read by 3 blinded observers. RESULTS: All 12 patients were Child A with median MAP of 92 mm Hg (interquartile range, 83-94) and HVPG 10.4 mm Hg (interquartile range, 6.6-13.0). While MAP decreased significantly at all time points, sildenafil had no effect on HVPG. CONCLUSIONS: As shown with other vasodilators in compensated cirrhotic patients, sildenafil at therapeutic doses for erectile dysfunction reduces MAP without reducing portal pressure. The search should continue for specific intrahepatic vasodilators.

Initial clinical experience with a new heparin-coated chronic hemodialysis catheter.

In this paper we wish to report our clinical experience with a new heparin-coated dialysis catheter with a symmetric tip. Over a 16-month period, 60 heparin-coated Tal Palindrome catheters were placed in 57 patients. Catheter patency, catheter-related complications, and reasons for catheter removal were recorded. The patient's initial cause of end-stage renal disease, underlying diseases, and site of access were recorded as well. Patients were specifically followed for development of heparin-induced thrombocytopenia. Patient ages were 34-91 (average 66). Fifty-four percent of patients had a history of diabetes. Sixty catheters were placed for a total of 5353 catheter-days. The average catheter indwell time was 107 days (range of 2-381 days). Catheter-related infection occurred in 6 patients over the study period, with a rate of 1.12/1000 catheter-days. Bacteremia occurred in 3 patients with a rate of 0.56/1000 catheter-days. Six catheters were removed or exchanged due to malfunction. There was no incidence of heparin-induced thrombocytopenia. Initial clinical experience with the heparin-coated Tal Palindrome hemodialysis catheter demonstrated safe, reliable use, and low infection rates.

Clinical outcome of the Tal Palindrome chronic hemodialysis catheter: single institution experience.

PURPOSE: To report the authors' clinical experience with the Tal Palindrome chronic dialysis catheter with a symmetric tip. MATERIALS AND METHODS: During a 39-month period, 126 Palindrome catheters were placed consecutively in 85 patients. Follow-up was available for 115 catheters. Insertion complications, patency, catheter-related bacteremia, exit site infections, and reasons for catheter removal were recorded. The patient's initial cause of end-stage renal disease, underlying diseases, and site of access were recorded as well. RESULTS: Patient ranged in age from 35 to 91 years (median, 69 years). Fifty percent of patients had diabetes. One hundred twenty-six Palindrome catheters were placed for a total of 12,046 catheter-days. The technical success rate of catheter placement was 100%. The average catheter indwell time was 105 days (range, 1-673 days). Catheters were inserted via the right (n = 107) or left (n = 19) jugular vein in all patients without insertional complication. Catheter-related infections occurred in 16 of the 115 catheters (13.9%) during the study period and culture-proved bacteremia occurred in four (3.5%). Seven exit site infections were recorded, and 10 catheters (8.7%) developed fibrin sheaths that necessitated catheter exchanges. CONCLUSIONS: Clinical experience with the Tal Palindrome hemodialysis catheter demonstrated safe and reliable use with low infection rates.

Management of malignant pleural effusions.

Malignant pleural effusions (MPEs) are commonly seen as complications of advanced malignancy, especially in lung cancer and breast cancer. The management will depend on the performance status of the patient, severity of the symptoms, and the primary tumor's response to systemic therapy. Thoracentesis is usually the first step for both diagnostic and therapeutic reasons. Chest tube placement with sclerotherapy is successful in 60 to 90% of cases, but it requires hospitalization for ~1 week. Alternatively, long-term tunneled pleural drainage catheters can be performed on an outpatient basis and are effective in controlling symptoms in 80 to 100% of patients. Additional advantages are the ability to treat trapped lung, large loculated effusions, and bilateral effusions simultaneously, as well as lower charges. Spontaneous pleurodesis can occur in up to 50% of the patients. Tunneled catheters should be considered in all patients with MPE and particularly those who have a reasonable expectancy of being outpatient.

Sindrome de Kallmann / Kallmann's syndromes

Os autores tecem inicialmente algumas considerações sobre a síndrome de Kallmann, sua etilogia, manifestações clínicas, diagnósticos diferenciais e meios de diagnóstico. Em seguida relatam o caso de uma paciente de 18 anos em investigações de amenorréia primária, que apresentava desenvolvimento incompleto dos caracteres sexuais secundários, hábito eunucóide e hiposmia. O diagnóstico se baseou no quadro clínico, exames complementares: dosagem sérica do estradiol teste do LHRH (hormônio liberador de gonadotrofinas) e radiografia de mão e punho esquerdos (idade óssea e 4 metacarpiano curto). Iniciada terapia de reposição hormonal com estrogênio e progesterona com finalidade de completar o desenvolvimento puberal e propiciar catamênios regulares