Randomized Controlled Trial on Adjunctive Lavage for Severe Peritonitis.

Background:In severe peritoneal dialysis (PD)-related peritonitis, patients' response to antibiotic can be poor. We postulated that adjunctive lavage may improve the outcome in severe cases by enhancing the removal of bacteria and inflammatory cells from the peritoneum.Methods:Severe PD peritonitis was defined as poor clinical response to empirical cefazolin/ceftazidime and a PD effluent (PDE) leukocyte count > 1,090/mm3 on day 3. Enrolled patients were randomized into either the lavage group (n = 20) or control group (n = 20). In the lavage group, continuous lavage by an automated PD machine from day 3 to 5 or 6 was performed, whereas the usual PD schedule was maintained in the control group. The primary outcome was treatment success. Post hoc analysis was also performed to compare the outcome between subgroups with different severity.Results:Baseline parameters were similar in the lavage and control groups, including PDE leukocyte count on day 3 (4,871/mm3 vs 4,143/mm3, p = 0.46). Treatment success rates were high in both groups (75% vs 70%, p = 0.72). C-reactive protein (CRP) on day 3 was found to be the only predictor of treatment failure and was used to stratify all patients into tertiles of severity. Whilst a significant decline in treatment success was evident across the tertiles of increasing CRP in the control group (100% vs 85.7% vs 28.6%, p = 0.005), treatment success was relatively maintained in the lavage group (85.7% vs 71.4% vs 66.7%, p = 0.43).Conclusions:Adjunctive lavage did not improve the overall outcome, although it may be beneficial for the more severe peritonitis patients who have high CRP.

Extended Experience in the Use of Antibiotic Lock for Eradication of Biofilm Bacteria on Tenckhoff Catheter.

Whilst antibiotic lock is effective to eradicate biofilm bacteria on hemodialysis catheters, this adjunctive method has scarcely been tested in peritoneal dialysis (PD) patients. After our previous successful experience of its use to salvage two Tenckhoff catheters, we encountered another patient with problematic biofilm-associated PD peritonitis who strongly refused catheter removal. As a result, antibiotic lock was given once daily, initially, with continuation of the usual PD schedule. However, relapsing peritonitis could not be prevented until we administered antibiotic lock without dialysate in the abdomen, which led to successful eradication of biofilm bacteria. To investigate the significance of having "dry abdomen" during antibiotic lock treatment, we injected an equivalent amount of contrast into the Tenckhoff catheter under fluoroscopy. We observed that the catheter lock solution could be retained over a long period of time only with "dry abdomen," whereas rapid dissipation of the lock solution occurred in the presence of dialysate. We concluded that whilst antibiotic lock in a once-daily regimen can be highly effective against biofilm bacteria on a Tenckhoff catheter, it is essential to withhold PD exchanges during the dwell of antibiotic lock to prevent it from dissolving into the surrounding dialysate.

Inflammatory pseudotumors of the central nervous system.

Inflammatory pseudotumor is a disease with unsettled pathogenesis. The brain is a rare site of occurrence. The aim of this study is to investigate ALK-1 protein expression and IgG4-positive plasma cells detection in 4 intracranial inflammatory pseudotumors. Three dural-based and 1 intraventricular inflammatory pseudotumors were retrieved from the hospitals' archive. The data on clinical presentation, radiological findings, procedure undertaken, and patients' progress were collected. Sections from the excised lesions were examined under hematoxylin and eosin, histochemical, and immunohistochemical staining including ALK-1 and IgG4. All 4 cases displayed typical histological features of inflammatory pseudotumor with dense lymphoplasmacytic infiltrate admixed with small number of benign-looking spindle cells in a collagenous stroma. Three cases exhibited high density of IgG4-positive plasma cells per high-power field. ALK-1 was negative. ALK expression was not found in any of our cases. On the contrary, the detection of significant number of IgG4-positive plasma cells in 3 inflammatory pseudotumors suggests that a considerable proportion of intracranial inflammatory pseudotumor may belong to the IgG4-related subgroup. Hence, a trial of corticosteroid after histological confirmation may be valid to avoid unnecessary risk-taking neurosurgical procedures or in cases with incomplete tumor removal.

Cytology of chordoid meningioma: a series of five cases with emphasis on differential diagnoses.

BACKGROUND: Chordoid meningioma is a rare meningioma variant characterised by epithelioid cord-like tumour cells in a myxoid stroma. It is classified as grade II (World Health Organization) tumours, as they have a tendency to behave more aggressively than traditional meningiomas and have a greater likelihood of recurrence. AIMS: To report the features of intraoperative imprint smears of five cases of chordoid meningioma. METHODS: The intraoperative squash smears were reviewed for cellularity, cellular atypia, mitotic figure, cytoplasmic vacuolation, intranuclear inclusion, presence of a cohesive cord of tumour cells, whorl-like structure, psammoma bodies, chronic inflammatory cells (lymphocytes and plasma cells), background mucin and necrosis. RESULTS: All cases were of moderate to high cellularity, with cohesive cords of bland tumour cells possessing uniformly round nuclei with smooth nuclear outline, stippled chromatin and small nucleoli, with cytoplasmic vacuolation and chronic inflammatory cells in the background. Intranuclear inclusions (80%) and whorl-like structures (60%) were also common. Necrotic background, psammoma bodies or mitotic figures were consistently absent. CONCLUSIONS: The cytological features of chordoid mengiomas are distinctive, and intraoperative imprint diagnosis is feasible.