Volumetric measurements of the brachial and carotid arteries in dialysis grafts: is there evidence of a subclavian-carotid artery steal syndrome?

Dialysis grafts may lead to major hyperperfusion in the graft arm and to hypertrophic, hypervolemic cardiomyopathy. No data have been published concerning the impact of dialysis grafts on the cerebral perfusion in relation to a potential carotid steal syndrome, possibly causing neurologic or neuropsychologic symptoms. In 30 patients (32 to 74 years old) with dialysis grafts we studied the following hemodynamic parameters in the brachial and common carotid arteries bilaterally: Flow velocities (spectral Doppler sonography), diameter (B-mode) and volume flow (color M-mode) with a color duplex system (Philips P700). Volume flow in the brachial arteries of the graft arm averaged 1032 ml/min (range, 158 to 2854 ml/min) as compared to 42 ml/min (range, 15 to 108 ml/min) in the nongraft arm. Almost identical volume flow data could be seen in both common carotid arteries (418 versus 421 ml/min) with no evidence of reduced flow in the carotid arteries in patients with high flow in the graft arm. A tendency toward higher volume flow in both carotid arteries in patients with high volume flow in the graft arm was noted. We found no evidence of shunt-induced cerebral hypoperfusion. Cerebral autoregulation appears to be patent even with high brachial artery shunt volume.

Efficacy of 4 commercially available protective creams in the repetitive irritation test (RIT).

Protective creams (PCs) play their part in the prevention of occupational contact dermatitis, even though efficacy data are frequently lacking. 4 different commercially-available PCs were evaluated against a set of 4 standard irritants (10% sodium lauryl sulfate (SLS), 1% sodium hydroxide (NaOH), 30% lactic acid (LA) and undiluted toluene (TOL)) in the repetitive irritation test (RIT) in humans described by Frosch and Kurte. 20 subjects were tested on the paravertebral skin on the mid-back. Irritation was assessed by visual scoring, transepidermal water loss (TEWL) as an indicator of epidermal barrier function, and colorimetry as a parameter of inflammation. Very different protective effects of the PCs on irritation by chemical substances were detectable. All products were very effective against SLS irritation. No PC provided significant protection against toluene. 3 products showed a partially protective effect against all ionic irritants, while the 4th showed less protection against SLS and NaOH, and even amplification of inflammation by TOL. Considering the range of PC effects from good protection to increased irritation, depending on the irritant, the need for careful selection of PCs for specific workplaces is stressed.

Infiltration of both T cells and neutrophils in the skin is accompanied by the expression of endothelial leukocyte adhesion molecule-1 (ELAM-1): an immunohistochemical and ultrastructural study.

Various inducible adhesion molecules on human endothelial cells like the endothelial leukocyte adhesion molecule-1 (ELAM-1) seem to be the basis of mechanisms that allow peripheral blood leukocytes to enter precisely areas of inflamed tissue. Because in vitro data had shown that ELAM-1 plays a central role in neutrophil as well as memory T-cell endothelium interactions, we analyzed in vivo at the light and electron microscopic level its expression in various benign and malignant skin diseases, which differ in the composition of the cellular infiltrates. The expression of ELAM-1 on endothelial cells at different anatomical sites could be demonstrated independently from the cell type (neutrophils/memory T cells) infiltrating the surrounding tissue. On the ultrastructural level we demonstrate that the expression of ELAM-1 is restricted to certain segments of post-capillary venules exhibiting distinctive morphologic features. The ELAM-1-positive endothelia are identical to those vessels that are currently described to be the preferred sites of lymphocyte trafficking in diseased skin.

Radionuclide bone imaging of femoral prostheses with porous coatings.

Radionuclide bone imaging can be of value in assessing the osseous changes around porous-coated femoral prostheses. Scintimetry appears to be a promising method for determining if radiodensities seen in radiographs of long-term prostheses are indicative of accelerated bone turnover or represent stable osseous structures. In dogs, the periosteal reaction which often occurs within two months of joint surgery masks endosteal-intramedullary osseous changes, including bone ingrowth into the porous coating.

Management of anuric intensive-care patients with arteriovenous hemofiltration.

It may be concluded from our results to date, that arteriovenous hemofiltration is an accurate and reliable method for the management of fluid balance in patients resistant to diuretics. Early use of this method may improve the prognosis of intensive-care patients by decongestion or dehydration of lungs, reduction of cardiac pre-and after-load and unrestricted infusion therapy for prevention of catabolism. In addition, the method has been shown to be useful for compensation of uremia and particularly for hypernatremia. The fact that this method requires no investment costs might be of particular interest to many intensive-care units which cannot afford expensive hemodialysis or hemofiltration machines.

Clinical experience with continuously monitored fluid balance in automatic hemofiltration.

Automatic fluid balancing, as obtained with the hemofiltration machines from Sartorius (Göttingen, West Germany) and Dialysetechnik (Karlsruhe, West Germany), is accurate enough to replace bed scales, which have been necessary in conventional hemodialysis for patients who are confined to beds. Side effects such as hypotension, nausea and muscle cramps during treatment may be reduced with these new machines, compared to conventional methods, provided that the rate of effective fluid withdrawal does not exceed 0.5 L/hr. In particular, the constant weight loss associated with automatic hemofiltration seems to be well tolerated by the patients with fewer side effects.

[Haemofiltration in the treatment of acute left heart failure in anuric patients (author's transl)]. / Die Behandlung der akuten Linksherzinsuffizienz anurischer Patienten mit der Hämofiltration.

Eight patients with acute left heart failure refractory to diuretics were treated by haemofiltration. Used conventionally the filtration membranes need a high pressure gradient. But the hollow-fibre kidney use in the last three patients required merely normal arterial venous pressure gradients. During an average heaemofiltration period of four hours 1000-2300 ml of plasma water were obtained. Pulmonary congestion improved in all patients; in five the arterial pressure returned to normal. Spontaneous diuresis was resumed in three. The clinical course was not influenced by haemofiltration in three instances. The advantages of haemofiltration are: reliable control of volume withdrawal, immediate effectiveness, technical simplicity, and absence of side effects.

[Arteriovenous haemofiltration: a new and simple method for treatment of over-hydrated patients resistant to diuretics]. / Arteriovenäose Hämofiltration: eine neue und einfache Methode zur Behandlung diuretika-resistent überwässerter Patienten.

Fluid withdrawal in over-hydrated patients resistant to diuretics was obtained by means of a capillary haemofilter, using the arterio-venous pressure gradient for blood perfusion at a rate of 100 ml/min. The ultrafiltration rate was 200-600 ml/h and could be maintained as long as 48 h without changing the haemofilter. This method, which needs no technical investment, is easy and simple to handle for the physician, bears only a very low risk for the patient, and ensures a negative fluid balance even at a mean blood pressure of only 60 mm Hg.

Management of uraemic pericarditis.

Of 250 patients undergoing haemodialysis from 1967 to 1974 17 presented with uraemic pericarditis. Seven of these patients who had been transferred early enough to peritoneal dialysis treatment were cured without pericardiectomy (mean survival 18 months (range 6-36); no deaths). Only one patient was cured from his pericarditis by "aggressive haemodialysis." In seven out of 10 patients treated with haemodialysis, pericardiectomy finally had to be performed because of pericardial tamponade (postoperative survival 20 months (range 8-36); one death). Two patients died from pericardial tamponade before surgery. In patients with evidence of uraemic pericarditis frequent peritoneal dialysis with high fluid withdrawal is the treatment of choice, but in cardiac tamponade pericardiectomy should follow a preoperative pericardiocentesis with limited fluid aspiration. Of possible significance in the aetiology of pericarditis were the findings that 10 of the 17 patients had hypertension with cardiac enlargement and that 14 presented with evidence of underdialysis, possibly due to the reuse of dialysis components.