Primary forearm arteriovenous fistula for hemodialysis access--an integrated approach to improve outcomes.

PURPOSE: Maximizing the ratio of primary arteriovenous fistula (PAVF) over bridge graft fistula (BGF) for hemodialysis access is a primary recommendation of the National Kidney Foundation published as Dialysis Outcomes Quality Initiative (DOQI). Imaging, anesthetic and surgical techniques were taken into account to achieve this and other goals, including extensive use of forearm vessels to lower immediate and early failure rates and prolong the useful life of PAVFs. DESIGN: Prospective non-randomized study. METHODS: High-resolution duplex ultrasonography (DUS) was added to careful clinical assessment in planning and follow-up of the dialysis access. Brachial plexus block, which allowed the use of an arterial tourniquet and gave a postoperative sympathectomy type effect, was used for anesthesia, and together with meticulous surgical technique, prevented spasm. Access puncture, post-operative follow-up and surgical revisions were planned in close cooperation with the nephrology team. FINDINGS: Ninety (57.3%) of the 157 fistulas constructed for new hemodialysis access between August 1998 and March 2000 were PAVFs. Seventy-three (81.1%) of these were confined to the forearm and comprise the study population, with a mean follow-up of 8.4+/-4.4 months. There were no immediate failures in the study group. The early failure rate (1 month) was 6.8% and revisions based on DUS were easily accomplished in all cases. The one year assisted primary patency rate was 81.8% and the secondary patency rate at 18 months was 98.6%. CONCLUSIONS: DUS for planning and follow-up of PAVF along with careful surgical technique under a brachial plexus blockade can achieve a PAVF/BGF ratio well above 50% with a low early failure rate and a high secondary patency rate. Algorithms are presented to achieve these goals.

Influence of thoracic sympathectomy on cardiac induced oscillations in tissue blood volume.

The photoplethysmographic (PPG) signal, which measures cardiac-induced changes in tissue blood volume by light transmission measurements, shows spontaneous fluctuations. In this study, PPG was simultaneously measured in the right and left index fingers of 16 patients undergoing thoracic sympathectomy, and, from each PPG pulse, the amplitude of the pulse (AM) and its maximum (BL) were determined. The parameter AM/BL is proportional to the cardiac-induced blood volume increase, which depends on the arterial wall compliance. AM/BL increased after the thoracic sympathectomy treatment (for male patients, from 2.60+/-1.49% to 4.81+/-1.21%), as sympathetic denervation decreases arterial tonus in skin. The very low-frequency (VLF) fluctuations of BL or AM showed high correlation (0.90+/-0.11 and 0.92+/-0.07, respectively) between the right and left hands before the thoracic sympathectomy, and a significant decrease in the right-left correlation coefficient (to 0.54+/-0.22 and 0.76+/-0.20, respectively) after the operation. The standard deviation of the BL or AM VLF fluctuations also reduced after the treatment, indicating sympathetic mediation of the VLF PPG fluctuations. The study also shows that the analysis of the PPG signal and the VLF fluctuations of the PPG parameters enable the assessment of the change in sympathetic nervous system activity after thoracic sympathectomy.

Caracterização farmacognóstica do jambolão (Syzypiam cumini (L. ) Skeels)

A padronização de um fitoterápico é etapa imprescindível para garantia da qualidade de medicamentos contendo plantas medicinais. Objetivou-se padronizar Syzygiam cumini (L.) Skeels e para tanto se estabeleceram parametros tais como, avaliação morfoanatômica das folhas, morfológica das flores e dos frutos, avaliação granulométrica da droga rasurada (frutos), determinação da umidade, avaliação dos processos de secagem, determinação do teor de extrativos e do teor de taninos (monômeros e polimeros). O estudo anatômico das folhas revelou a inexistência de pêlos no sistema dérmico, assim como a ocorrência de glândulas secretoras, drusas, colênquima e esclerênquima. As flores são hermafroditas, com androceu polistêmone e gineceu com ovário ínfero, gamocarpelar, bilocular com placentação axial. Observou-se elevado teor extrativo (38,57 por cento). O diâmetro médio de partícula dos frutos secos moídos ficou em 0,630 mm. O processo de secagem dos frutos influenciou o teor de taninos totais. O teor de taninos determinado ficou em 5,10 por cento para monômeros e 11,30 por cento para os polimeros.

The phytotherapics standardization is an important step for the warranty of the quality of the drugs contends medicinal plants. The aim of this paper was to standardize and establish parameters seeking the characterization of the drug, according to technical pharmacopoeias and in some cases, other techniques were developed. Morphologic description of leaves, flowers and fruits, granulometric analysis of the ground drugs, dry residues, evaluations in the drying methods, determination of the extractive drift and tannins values (monomers and polymers) were executed, being the monomers in the range of 5,10 percent and 11,30 percent for the polymeric ones.