Severe diarrhea in renal transplant patients: results of the DIDACT study.

Diarrhea is common in transplant recipients. While the majority of cases are mild and transient, some are severe and prolonged, which can threaten graft survival through dehydration. While it is known that some immunosuppressive agents can elicit diarrhea, there does not appear to be any consensus on the role that other nonimmunosuppressive causes can play in transplant patients. The aim of the present open, nonrandomized, multicenter study was to identify nonimmunosuppressive factors involved in severe diarrhea in renal transplant patients. Patients (n = 108) with severe diarrhea (>/=3 stools/day for >/=7 days) were enrolled from 16 Belgian transplant centers. Patients were diagnosed according to an agreed flowchart that consisted of identification of possible infections, followed by changes in empirical and immunosuppressive treatment. Approximately 50% of patients experienced resolution of severe diarrhea following treatment for infections, dietary problems or diarrhea-causing concomitant medications. In conclusion, a large proportion of the severe diarrhea observed in renal transplant recipients is not associated with immunosuppressive therapy and can be treated through anti-infectives, changes to concomitant medication and other empirical treatments. Correct diagnosis of the cause of severe diarrhea in such patients should help to protect graft survival in transplant recipients.

[Clinical case of the month. A recurrent chylothorax in Bourneville tuberous sclerosis]. / Le cas clinique du mois. Un chylothorax récidivant dans un contexte de sclérose tubéreuse de Bourneville.

Bourneville's disease, first described in 1862, is a phacomatosis that is either autosomal dominant or sporadic. Its typical clinical signs include mental retardation, epilepsy and cutaneous adenomas. The pulmonary form is rare, less than 1%, and is secondary to occlusion of the bronchus, vascular and lymphatics by immature smooth muscle cells. Chylothorax may appear in more than 50% of all cases. No guidelines currently exist for treatment of recurrent chylothorax. However, several possibilities are described in the literature.

Efegatran sulfate as an adjunct to streptokinase versus heparin as an adjunct to tissue plasminogen activator in patients with acute myocardial infarction. ESCALAT Investigators.

BACKGROUND: Previous clinical studies have shown that direct antithrombins can accelerate clot lysis after treatment with streptokinase in acute myocardial infarction (MI). Efegatran is a new direct antithrombin, which in experimental animals has been shown to enhance thrombolysis, reduce rate of reocclusion, and limit infarct size. This study was designed to compare the efficacy of efegatran plus streptokinase versus heparin plus accelerated tissue plasminogen activator (TPA) in coronary reperfusion in acute MI. METHODS AND RESULTS: In this randomized, dose-finding study (n = 245), we initially explored 4 doses of efegatran sulfate in combination with streptokinase (1.5 million U) given intravenously within 12 hours of symptom onset. The optimal dosage group of 0.5 mg/kg per hour was expanded and compared with heparin plus accelerated TPA. The primary end point was complete patency (Thrombolysis In Myocardial Infarction [TIMI] grade 3) at 90 minutes after thrombolytic therapy, assessed in a core angiographic laboratory. Infarct-related vessel patency (TIMI grade 2 or 3) and complete patency (TIMI grade 3) were 73% and 40% in the efegatran/streptokinase group versus 79% and 53% in the heparin/TPA group (P = not significant). In-hospital mortality rate was 5% for the efegatran/streptokinase group versus 0% for the heparin/TPA group (P = not significant). Major bleeding occurred in 23% of patients in the efegatran/streptokinase group versus 11% in the heparin/TPA group (P = not significant). No intracranial hemorrhage occurred. CONCLUSIONS: The combination of efegatran plus streptokinase is not superior to the current therapy of heparin and accelerated TPA in achieving early patency. In addition, there is no indication that this experimental treatment can achieve better clinical outcome.

Coronary steal by IMA bypass graft side-branches: a novel therapeutic use of a new detachable embolization coil.

Coronary artery steal syndromes following coronary artery bypass grafting (CAB) may occur as a result of the presence of large side-branches arising from the internal mammary artery (IMA). We report the first successful deployment of a new detachable vascular embolization coil device to occlude the IMA side-branches in two patients. Optimal positioning is easily obtained with the unique operator-controlled, safety-release protected mechanism of this device. Complete retraction is possible, with safe and efficient removal of the coil even after deployment. This feature was appreciated during one procedure in which the initially selected coil was found to be oversized, requiring immediate removal. Acute thrombo-occlusion of the IMA side-branches in both patients was observed. We conclude that IMA bypass graft side-branches causing coronary steal can be safely and effectively occluded using this new technique. However, due to observed delayed partial recanalization noted on distant follow-up angiography, we recommend placement of multiple coils at the time of initial embolization.

[Clinical case of the month. Galloping nephropathy in a patient with type 2 diabetes]. / Le cas clinique du mois. Une néphropathie galopante chez un patient diabétique de type 2.

We report the case of a patient with insulin-requiring type 2 diabetes who exhibited a rapid deterioration of his renal function leading to haemodialysis in a few months. Various diagnosis were considered to explain this rapid deterioration, excluding diabetic nephropathy as major etiology. The exploration, especially renal biopsy, demonstrated the presence of a glomerulonephritis due to the deposition of immune complexes associated to active hepatitis C rather than diabetic glomerulosclerosis. A treatment with interferon-alpha allowed to partially restore renal function, this recovery permitting the interruption of hemodialysis, with a current follow-up of more than 6 months.

Bedside videoscopic placement of feeding tubes: development of fiberoptics through the tube.

OBJECTIVE: Transpyloric small intestine feeding tube placement can be difficult and tedious. Currently accepted techniques are associated with disadvantages and risk. The purpose of this study is to describe the development of a new technique: bedside videoscopic placement using fiberoptics through the tube. DESIGN: Prospective, descriptive case study. SETTING: Intensive care unit in a teaching hospital. PATIENTS: Subjects were divided into two groups: a) group 1: eight healthy volunteers (seven male, one female); b) group 2: nine critically ill patients (six male, three female; eight of these patients were intubated). INTERVENTIONS: Standard 12-Fr (4.0-mm) feeding tubes (n = 19) were placed. Two patients from group 2 had feeding tubes placed on two separate occasions. The feeding tubes were inserted by the oral (n = 8) or nasal (n = 11) route under direct vision, using a 6.7-Fr (2.2-mm) fiberoptic scope through the feeding tube. MEASUREMENTS AND MAIN RESULTS: We visualized enteric structures clearly through the feeding tube in all subjects and patients. Based on visual landmarks, we advanced the feeding tube through the pylorus and into the duodenum in all individuals. Transpyloric tube placement was confirmed videoscopically (n = 19) and radiographically (n = 18). In three subjects from group 1, the feeding tube entered the first part of the duodenum, while, in the remainder of the subjects, the tube passed into or beyond the second portion of the duodenum. In eight (73%) of 11 attempts on the nine critically ill patients from group 2, the feeding tubes were advanced to the distal duodenum or jejunum. The time required for placement in group 2 ranged from 2 to 43 mins (mean 18 +/- 12 [SD]). The feeding tubes remained in place 10 +/- 4 days and patients met their estimated caloric needs within 24 hrs. Residual volumes of nutrition in the small bowel were < 5 mL. There were no documented episodes of aspiration. CONCLUSION: This new technique has the potential for rapid, accurate, and safe feeding tube placement in patients requiring nutritional support.

Beneficial impact of aorto-coronary graft markers on post-operative angiography.

OBJECTIVE: When coronary and graft angiography is required for patients with prior coronary artery bypass (CAB) graft surgery, it is often difficult to localize the proximal aorto-coronary graft anastamosis. Our goal was to quantify the potential benefit during subsequent angiography if the proximal anastamosis is marked by an aorto-coronary graft marker at the time of CAB. METHODS: Retrospective review of 414 angiograms that were performed for patients with prior CAB. Cohorts with an without graft markers were compared. RESULTS: In the group with aorto-coronary graft markers and > or = 2 aorto-coronary grafts, there were significant reductions in fluoroscopy time (30.5%, p < 0.0001), contrast volume (21.7%, p < 0.0001), and numbers of angiographic catheters used (17.0%, p = 0.0001). If only one aorto-coronary graft was placed and marked, a trend toward reduced fluoroscopy time was observed (23.8%, p = 0.07). CONCLUSIONS: This study demonstrates the objective benefit supporting routine placement of circumferential aorto-coronary graft markers during CAB, particularly if > 1 graft is required.

Polyamines and Pectins (I. Ion Exchange and Selectivity).

The ion-binding and -exchange properties of putrescine, spermidine, and spermine on purified walls of carrot (Daucus carota L.) cell suspensions were investigated by producing ion-exchange isotherms and comparing them with the behavior of Na+, Mg2+, and Ca2+. The cation exchange capacity of the carrot cell walls was 0.8 equivalent kg-1 dry matter, and the ionic selectivity sequence of the walls for polyamines followed the sequence spermine4+ > spermidine3+ [almost equal to] Ca2+ > putrescine2+. The polyamines were subjected to only electroselectivity and probably did not induce any favorable supramolecular conformation of pectin like the one induced by Ca2+. Triangular ion exchanges were also performed with three diamines: ethanediamine, butanediamine, and octanediamine. The shorter the diamine, the higher the total adsorption and selectivity of the exchange. The lower selectivity of the cell wall for putrescine was partly attributed to its inability to access and displace Ca2+ from higher affinity sites within dimerized pectic sequences. The polyamine adsorption and exchange on pectic sequences could result in pectic signal modulation in pathogenesis and in differentiation.

Transcatheter occlusion of patent ductus arteriosus.

This article reviews the current status of transcatheter technology, which has been applied to close the patent ductus arteriosus (PDA). Pioneering work in this field was performed by Porstmann in the 1960s and Rashkind in the 1970s. Devices which have been implanted in the PDA have basic designs as plugs, umbrellas, or coils. The experience reported with each type of device is detailed. Issues and controversies are examined. It appears that coils should be the preferred method for closing smaller PDAs (3-mm diameter or smaller), and Rashkind or similar devices, if available, should be reserved for larger PDAs (> 3-mm diameter). Surgery is necessary for neonatal and for rare large PDAs. Transcatheter technology is still evolving and may become more effective and cheaper.

Percutaneous closure of the small patent ductus arteriosus using occluding spring coils.

OBJECTIVES: This report summarizes our experience with the use of occluding spring coils to close the small patent ductus arteriosus. BACKGROUND: Several patent ductus arteriosus occluders (most notably the Rashkind device) have been developed and studied. Occluding spring coils have been used to close abnormal vessels and vascular connections. We previously reported the use of occluding spring coils to close the small patent ductus arteriosus in a small group of patients. This report describes our series of patients having patent ductus arteriosus closure with occluding spring coils. METHODS: Between June 1990 and June 1993, 30 patients underwent cardiac catheterization to have patent ductus arteriosus closure by occluding spring coils. Selection criteria were age > 6 months and narrowest patent ductus arteriosus internal dimension < or = 3.0 mm by color flow imaging. Definitive selection was based on review of aortograms performed at catheterization. A 5.2F coronary catheter was used to deliver one or two standard occluding spring coils. A loop was delivered in the main pulmonary artery, and the remainder of the coil was delivered across the patent ductus arteriosus and into the aortic diverticulum. Patent ductus arteriosus closure was confirmed by aortography or color flow imaging, or both. Follow-up after coil placement occurred at 6 weeks and 6 months and included two-view chest radiography, echocardiography and color flow imaging. RESULTS: Of the 30 patients, 29 had successful implantation by one (27 patients) or two (2 patients) occluding spring coils. Of these 29 patients, 19 had a clinically apparent and 10 had a silent patent ductus arteriosus. Average ductus minimal internal dimension was 1.7 mm (range 1.0 to 3.0). Complete closure of the ductus was confirmed in 27 patients by aortography or color flow imaging or both (in 24 within 4 h, in 2 after 6 weeks and in 1 after 6 months). Six weeks after implantation, two patients had a tiny residual patent ductus arteriosus noted on color flow imaging. One patient did not have successful implantation. This patient had a 3.2-mm ductus, and two coils migrated to the distal left pulmonary artery and could not be retrieved. There were no deaths or any significant complications noted during early or late follow-up in these patients. CONCLUSIONS: Occluding spring coils may have additional application in closing the small patent ductus arteriosus.

[Arthroscopic acromioplasty. Medium results after more than a year]. / Acromioplasties arthroscopiques. Résultats moyens supérieurs à 1 an.

Sixty-nine arthroscopic acromioplasties were evaluated with an average follow-up of 18 months (6 to 38 months), with the UCLA score. The UCLA scores evolved from an average of 9.9 preoperatively (minimum 5, maximum 18) to 30.2 (minimum 18, maximum 35) postoperatively. There were 26% excellent results (34 to 35 points on the UCLA score), 55% good results (28 to 33 points), 14.5% poor results (21 to 27 points) and 4.3% bad results (0 to 20 points), i.e. 81% good and excellent results. There was no relationship between the duration of the complaints and the results, nor was there between the age and the results. The best results were seen in patients without rupture of the rotator cuff. Calcification without rupture of the cuff had no influence on the results. Pain, the most important complaint, was diminished much more than the complaints about restricted range of motion, which is better tolerated.

Post-atherectomy coronary artery aneurysm.

A 52-year-old man underwent an uneventful directional atherectomy of the left anterior descending coronary artery. Four months after the procedure unstable angina developed and on angiogram an aneurysm of the left anterior descending coronary artery was noted. The patient underwent bypass of the left anterior descending coronary artery. An attempt to exclude the aneurysm resulted in hemodynamic compromise and was discontinued. Follow-up angiogram 2 months after operation showed the aneurysm to be smaller. The patient is doing well 6 months after operation.

Release of Small Polyuronides from Nitella Cell Walls during Ionic Exchange.

Mono-divalent ion exchange in isolated cell walls of Nitella flexilis (L.) Ag. induces a marked loss of wall polymers and a decrease in the wall cationic exchange capacity. These data correlate with the replacement in the walls of adsorbed Mn(2+) by Na(+) ions. Boiling wall samples in methanol for 1 h or keeping the ionic solutions chilled to 4 degrees C does not inhibit the cell wall polymer leakage but modifies the kinetics both of the ionic exchange and of the released polymers. These data are more compatible with physical rather than enzymic induced processes. The extracted polymers in the successively renewed NaCl solutions initially belong to the wall protein and pectin fractions and mainly to pectic fractions subsequently. Determination of the average degree of polymerization shows that the average molecular size of the lost acidic polysaccharides increases with extraction time up an average polymerization degree of 25. Enzyme-linked immunosorbent assay inhibition tests show the presence of homopolymer blocks equal to or higher than 10 in the released polymer fragments. Compositional analysis of released polysaccharides suggests that the pectin lost by action of monovalent ions was largely composed of rhamnogalacturonans whose acidic residue fraction is approximately 60% in association with galactose chains. Small quantities of glucuronylated xylans are also found.

Diagnostic criteria of analgesic nephropathy in patients with end-stage renal failure: results of the Belgian study.

Diagnostic criteria of analgesic nephropathy with well-defined sensitivity and specificity are not available. During a 2-year period all new patients (n = 273) starting renal replacement therapy in 13 Belgian dialysis units were investigated aiming to select diagnostic criteria of analgesic nephropathy with acceptable performance. Using several interview techniques, a history of analgesic abuse was found in 31% of the patients. Analgesic abusers presenting a clear non-analgesic-related renal diagnosis were excluded from analysis (n = 25). Comparing the remaining abusers (n = 60) and patients without a history of analgesic abuse (n = 188) it was found that renal imaging investigations (sonography plus tomography), showing a decrease in length combined with bumpy contours of both kidneys, presented a sensitivity of 90% and a specificity of 95%. The additional finding of signs of renal papillary necrosis resulted in an overall sensitivity of 72% and a specificity of 97%, giving a positive predictive value of 92%. Other signs frequently mentioned in the literature (hypertension, anaemia, sterile pyuria, bacteriuria, proteinuria) showed insufficient sensitivity and/or specificity to be of help for diagnosing analgesic nephropathy in end-stage renal failure (ESRF) patients starting renal replacement therapy.

Immunocytochemical demonstration of the lysosomal enzyme alpha-glucosidase in the brush border of human intestinal epithelial cells.

In investigations on the intracellular transport route(s) of lysosomal enzymes in polarized epithelial cells, we used immunocytochemical methods to localize lysosomal alpha-glucosidase in human small-intestinal epithelial cells. Two monoclonal antibodies which can discriminate between different biosynthetic forms of this enzyme were used. One monoclonal antibody, 43D1, which recognizes all forms of the enzyme, showed labeling of the Golgi apparatus, the lysosomes and, unexpectedly, of the brush border of the cells. Multivesicular bodies were free of label. In contrast, monoclonal antibody 43G8, which recognizes all forms except the 110,000 Da precursor of alpha-glucosidase, showed labeling of the lysosomes only. This leads us to conclude that the 110,000 Da precursor form of alpha-glucosidase is present in the Golgi apparatus and the brush border of human small-intestinal epithelial cells. Moreover, biochemical experiments show that this precursor copurifies with sucrase, a typical brush-border marker, when a partially purified microvilli fraction is prepared.

Pharmacokinetics and thrombolytic properties of a nonglycosylated mutant of human tissue-type plasminogen activator, lacking the finger and growth factor domains, in dogs with copper coil-induced coronary artery thrombosis.

The pharmacokinetics and thrombolytic properties of a variant of human tissue-type plasminogen activator (t-PA), obtained by deletion mutagenesis of the NH2-terminal fibronectin-like finger (F) and epidermal growth factor (E) domains, and substitution of the three known glycosylated Asn residues by Gln (t-PA-delta FE3X), were studied in dogs with a copper coil-induced thrombosis of the left anterior descending coronary artery. Bolus injections were given during 2 min to groups of three dogs. Injection of 0.15 mg/kg resulted in peak antigen levels in plasma of 1.58 +/- 0.72 micrograms/ml (mean +/- SEM) and caused reperfusion within 14 +/- 6 min. With 0.075 mg/kg, corresponding values of 0.81 +/- 0.20 micrograms/ml and 31 +/- 15 min were obtained. A bolus of 0.038 mg/kg yielded plasma peak levels of 0.43 +/- 0.20 micrograms/ml but did not cause coronary recanalization within 3 h. A bolus injection of natural t-PA (Mel-t-PA) at a dose of 0.1 mg/kg in four dogs resulted in plasma peak levels of 0.46 +/- 0.09 micrograms/ml and caused partial coronary artery reperfusion within 3 h in one of four dogs (after 31 min). None of these injections caused a significant decrease of the fibrinogen level. Pharmacokinetic parameters for t-PA-delta FE3X were alpha half-life (t1/2) 14-18 min, beta t1/2 72-125 min, and plasma clearance 21-36 ml/min. For Mel-t-PA, the corresponding values were 3 min, 8 min, and 520 ml/min. We conclude that the variant t-PA-delta FE3X has a markedly longer plasma t1/2 than does Mel-t-PA and, when administered as a bolus injection, a higher thrombolytic efficacy.

Treatment of prosthetic tricuspid valve thrombosis with recombinant tissue-type plasminogen activator.

Recombinant tissue-type plasminogen activator (rt-PA) was administered intravenously to a 64-years old female with thrombotic malfunction of a Björk-Shiley prosthetic tricuspid valve. 150 mg of single-chain rt-PA was infused over 8 hours followed by an additional dose of 50 mg over the next 8 hours. At the end of the first infusion, restoration of normal valve function was demonstrated by fluoroscopic and echo-Doppler examinations. Mild systemic activation of the fibrinolytic system occurred, with a decrease of fibrinogen and alpha 2-antiplasmin to 53% and 33%, respectively, of the preinfusion value at the nadir.