Rates of Epidural Blood Patch following Lumbar Puncture Comparing Atraumatic versus Bevel-Tip Needles Stratified for Body Mass Index.

BACKGROUND AND PURPOSE: Postdural puncture headache, a known complication of lumbar puncture, typically resolves with conservative management. Symptoms persist in a minority of patients, necessitating an epidural blood patch. One method of decreasing rates of postdural puncture headache is using atraumatic, pencil-point needles rather than bevel-tip needles. To the best of our knowledge, this is the first study comparing epidural blood patch rates between pencil- and bevel-tip needles with a subgroup analysis based on body mass index. MATERIALS AND METHODS: This single-institution retrospective study identified 4435 patients with a recorded body mass index who underwent a lumbar puncture with a 22-ga pencil-tip Whitacre needle, a 20-ga bevel-tip Quincke needle, or a 22-ga Quincke needle. The groups were stratified by body mass index. We compared epidural blood patch rates between 22-ga pencil-tip Whitacre needles versus 22-ga Quincke needles and 22-ga Quincke needles versus 20-ga bevel-tip Quincke needles using the Fischer exact test and χ2 test. RESULTS: Postdural puncture headache necessitating an epidural blood patch was statistically more likely using a 22-ga Quincke needle in all patients (P < .001) and overweight (P = .03) and obese (P < .001) populations compared with using a 22-ga pencil-tip Whitacre needle. In the normal body mass index population, there was no statistically significant difference in epidural blood patch rates when using a 22-ga pencil-tip Whitacre needle compared with a 22-ga Quincke needle (P = .12). There was no significant difference in epidural blood patch rates when comparing a 22-ga Quincke needle versus a 20-ga bevel-tip Quincke needle in healthy (P = .70), overweight (P = .69), or obese populations (P = .44). CONCLUSIONS: Using a 22-ga pencil-tip Whitacre needle resulted in lower epidural blood patch rates compared with a 22-ga Quincke needle in all patients. Subgroup analysis demonstrated a statistically significant difference in epidural blood patch rates in overweight and obese populations, but not in patients with a normal body mass index.

Development of a conceptual model of cancer caregiver health literacy.

Caregivers play a vital role in caring for people diagnosed with cancer. However, little is understood about caregivers' capacity to find, understand, appraise and use information to improve health outcomes. The study aimed to develop a conceptual model that describes the elements of cancer caregiver health literacy. Six concept mapping workshops were conducted with 13 caregivers, 13 people with cancer and 11 healthcare providers/policymakers. An iterative, mixed methods approach was used to analyse and synthesise workshop data and to generate the conceptual model. Six major themes and 17 subthemes were identified from 279 statements generated by participants during concept mapping workshops. Major themes included: access to information, understanding of information, relationship with healthcare providers, relationship with the care recipient, managing challenges of caregiving and support systems. The study extends conceptualisations of health literacy by identifying factors specific to caregiving within the cancer context. The findings demonstrate that caregiver health literacy is multidimensional, includes a broad range of individual and interpersonal elements, and is influenced by broader healthcare system and community factors. These results provide guidance for the development of: caregiver health literacy measurement tools; strategies for improving health service delivery, and; interventions to improve caregiver health literacy.

Biliary cast syndrome following liver transplantation: Predictive factors and clinical outcomes.

Biliary cast syndrome (BCS), the presence of biliary casts and debris causing biliary obstruction, occurs in 4%-18% of orthotopic liver transplant (OLT) recipients. Potential consequences include cholangitis and graft damage or loss. Limited data exist regarding the etiology and outcomes of BCS. The purpose of this study was to evaluate donor and recipient risk factors and determine the impact of BCS. A retrospective review of 355 OLT cases identified 9 BCS patients (2.5%) diagnosed by cholangiography. Twenty-six matched controls were also identified. The warm ischemic time was significantly longer in BCS patients. Other recipient and donor preoperative and intraoperative characteristics, including the donor risk index, revealed no significant differences. Overall patient survival showed a trend toward worse outcomes at 6, 12, and 18 months and end of follow-up in the BCS group. Overall graft survival was also worse in the BCS group at all time periods, with statistical significance demonstrated at 18 months and end of follow-up. The number of therapeutic biliary procedures and hospital readmissions was significantly higher in the BCS group. Twenty-two percent of the BCS patients required repeat OLT versus none of the control patients. In conclusion, BCS is an uncommon complication of OLT. Except for a longer warm ischemic time, recipient and donor factors did not predict the occurrence of BCS. BCS patients showed a significantly worse graft survival, as well as a trend toward worse patient survival. Given the negative impact of BCS on liver transplant outcomes, further studies appear justified.

Recurrent hepatitis C after liver transplantation: a nonrandomized trial of interferon alfa alone versus interferon alfa and ribavirin.

Liver transplant recipients with recurrent hepatitis C virus (HCV) infection often have histological hepatitis, and in some patients, graft failure develops. The aim of this nonrandomized study is to determine the efficacy and tolerability of interferon alfa (IFN alfa) alone and IFN alfa and ribavirin combination therapy in such patients. Forty transplant recipients with recurrent hepatitis were initiated on therapy with IFN alfa-2b at 3 million units (MU) three times weekly for 1 month followed by 5 MU three times weekly for 5 months. Twenty patients were administered IFN alfa-2b, 3 MU three times weekly for 1 month followed by 5 MU three times weekly for 11 months, and ribavirin, 600 mg, twice daily orally for 12 months concurrently. The primary end point was sustained clearance of serum HCV RNA, and secondary end points were serum alanine aminotransferase (ALT) level normalization and histological improvement. Thirty patients completed 6 months of IFN-alfa monotherapy and 15 patients completed 12 months of IFN alfa and ribavirin combination therapy. End-of-treatment biochemical responses were similar in the two groups (IFN alfa, 20% v combination therapy, 25%); however, viral clearance was greater in the combination-therapy group (40% v 15%; P = .04). Six months after the completion of therapy, only 1 patient (2.5%) in the IFN-alfa group and 4 patients (20%) in the combination-therapy group were HCV RNA negative (P = .03). Serum ALT and HCV RNA levels declined significantly in both groups during therapy. There was no improvement in inflammatory grade, and fibrosis score was worse in both groups. Ten patients (25%) in the IFN-alfa group and 5 patients (20%) in the combination-therapy group withdrew because of adverse effects. We conclude that in liver allograft recipients with recurrent hepatitis C, combination therapy with IFN alfa and ribavirin is more efficacious than treatment with IFN alfa alone. However, the efficacy is limited by tolerability.

Methoprene and 20-OH-ecdysone affect male production in Daphnia pulex.

Exposure of Daphnia pulex to the insecticide and juvenile hormone-mimic methoprene resulted in a decrease in the incidence of all-male broods and an increase in the incidence of all-female broods compared with controls. These effects were observed at nominal concentrations of 10 and 100 microg/L, within the upper range of concentrations at which methoprene is applied in the environment. Because methoprene has been found to bind to the mammalian retinoid X receptor, we also tested the effects of retinoic acid on Daphnia reproduction. Neither 9-cis-retinoic acid nor all-trans-retinoic acid had any observable effect. Because juvenile hormone and ecdysteroids interact in many insect systems, we also exposed Daphnia to 20-OH-ecdysone. Exposure to the crustacean hormone 20-OH-ecdysone at levels of 1 and 10 microg/L resulted in an increase in all-male broods and a decrease in all-female broods, but 100 microg/L 20-OH-ecdysone resulted in a decrease in all-male broods and an increase in all-female broods. Our results suggest that juvenile hormone and ecdysteroids might play a role in the Daphnia sex determination system.

Internal hernia: clinical and imaging findings in 17 patients with emphasis on CT criteria.

PURPOSE: To review the clinical and radiologic features of internal hernia and to derive useful radiographic and CT criteria to assist in diagnosis. MATERIALS AND METHODS: Retrospective review of medical records revealed 17 patients with surgically proved internal hernia (three paraduodenal, 14 transmesenteric) who had 15 computed tomographic (CT) scans and three small-bowel follow-through (SBFT) images. RESULTS: CT signs common to all types of internal hernia included evidence of small-bowel obstruction; clustering of small bowel; stretched, displaced, crowded, and engorged mesenteric vessels; and displacement of other bowel segments, especially the transverse colon and fourth portion of the duodenum. Left-sided paraduodenal hernias demonstrated a sac-like mass of small-bowel loops interposed between the stomach and pancreatic tail and a posterior mass effect on the stomach. All three paraduodenal hernias were diagnosed confidently at retrospective review of CT and SBFT findings. Transmesenteric hernias demonstrated clustered small-bowel loops adjacent to the abdominal wall without overlying omental fat and central displacement of colon and were frequently complicated by small-bowel volvulus (five of 14) and bowel ischemia (six of 14). CT demonstrated signs of volvulus in four of six patients with ischemia. CT findings considered definitive or suggestive of internal hernia were demonstrated in 15 patients. CONCLUSION: Internal hernia is an important and underdiagnosed condition. Transmesenteric hernia is most common in our experience and is usually related to prior abdominal surgery, especially with creation of a Roux-en-Y anastomosis. CT may allow confident diagnosis in most patients.

Long-term survival after liver transplantation in 4,000 consecutive patients at a single center.

OBJECTIVE: To evaluate the long-term survival outcomes of a large cohort of liver transplant recipients and to identify static and changing factors that influenced these outcomes over time. SUMMARY BACKGROUND DATA: Liver transplantation has been accepted as a therapeutic option for patients with end-stage liver disease since 1983, with continual improvements in patient survival as a result of advances in immunosuppression and medical management, technical achievements, and improvements in procurement and preservation. Although many reports, including registry data, have delineated short-term factors that influence survival, few reports have examined factors that affect long-term survival after liver transplantation. METHODS: Four thousand consecutive patients who underwent liver transplantation between February 1981 and April 1998 were included in this analysis and were followed up to March 2000. The effect of donor and recipient age at the time of transplantation, recipient gender, diagnosis, and year of transplantation were compared. Rates of retransplantation, causes of retransplantation, and cause of death were also examined. RESULTS: The overall patient survival for the entire cohort was 59%; the actuarial 18-year survival was 48%. Patient survival was significantly better in children, in female recipients, and in patients who received transplants after 1990. The rates of retransplantation for acute or chronic rejection were significantly lower with tacrolimus-based immunosuppression. The risk of graft failure and death was relatively stable after the first year, with recurrence of disease, malignancies, and age-related complications being the major factors for loss. CONCLUSION: Significantly improved patient and graft survival has been observed over time, and graft loss from acute or chronic rejection has emerged as a rarity. Age-related and disease-related causes of graft loss represent the greatest threat to long-term survival.

Prevention of de novo hepatitis B infection after liver transplantation with allografts from hepatitis B core antibody positive donors.

The frequent scarcity of organ donors has made it necessary to consider transplantation of organs that may have the potential to transmit hepatitis B virus (HBV) to the recipient. Previous reports have documented the probability of infection of particular recipient populations with transplanted livers from hepatitis B core antibody (anti-HBc) positive donors. Results have varied depending on the status of the recipients with respect to antibodies directed at the virus. Anti-HBc-positive and anti-HBs-positive recipients were generally resistant to hepatitis B infection, with the former infected at a low rate and the latter not at all. However, the probability of de novo HBV infection in naive recipients (anti-HBc-negative and anti-HBs-negative) was quite high (about 70%). The survival rate for infected patients is similar to those who are uninfected, but a significant percentage of infected patients will develop chronic hepatitis and a small percentage will develop allograft failure. Also reported here is a protocol designed to prevent the adverse consequences to naive recipients receiving livers from anti-HBc-positive donors. Hepatitis B immunoglobulin (HBIg) and lamivudine were utilized to prevent transmission of the hepatitis B virus. This combination has prevented de novo infections in all patients tested thus far. There are indications that HBIg or lamivudine may not be as effective when administered separately.

Lamivudine after hepatitis B immune globulin is effective in preventing hepatitis B recurrence after liver transplantation.

The prevention of recurrent hepatitis B virus (HBV) infection after orthotopic liver transplantation (OLT) with hepatitis B immunoglobulin (HBIG) is expensive and requires indefinite parenteral administration. Lamivudine is a nucleoside analogue capable of inhibiting HBV replication. The aim of this study is to determine the efficacy of lamivudine in the prevention of recurrent HBV infection after a course of HBIG in patients who were hepatitis B surface antigen (HBsAg) positive and hepatitis Be antigen (HBeAg) negative before OLT. Patients at high risk for recurrent HBV infection (HBeAg positive and HBV DNA positive) were excluded. Thirty HBsAg-positive, HBeAg-negative patients underwent OLT from January 1993 to June 1997. All 30 patients were administered HBIG after OLT and, after 2 years, were given the option of continuing with HBIG or switching to lamivudine. Five patients were excluded: 3 patients were lost to follow-up and 2 patients died of technical complications. Three patients terminated HBIG therapy at 8, 24, and 29 months after OLT, and reinfection with HBV occurred in 1 patient. Six patients elected to continue HBIG therapy for life; 1 patient died of melanoma and the remaining 5 patients are HBsAg negative, with an average follow-up of 73 months. Sixteen patients were converted to lamivudine after a course of HBIG, and all 16 patients are HBsAg negative, with an average follow-up of 51 months after OLT. Five patients have been on lamivudine monotherapy for more than 24 months. These results suggest that lamivudine administered after a posttransplantation course of HBIG can effectively prevent the recurrence of HBV infection in patients who are HBsAg positive and HBeAg negative before OLT.

Genetic relatedness of Salmonella isolates from nondomestic birds in Southeastern United States.

Salmonella infections have been implicated in large-scale die-offs of wild birds in the United States. Although we know quite a bit about the epidemiology of Salmonella infection among domestic fowl, we know little about the incidence, epidemiology, and genetic relatedness of salmonellae in nondomestic birds. To gain further insight into salmonellae in these hosts, 22 Salmonella isolates from diseased nondomestic birds were screened for the presence of virulence and antibiotic resistance-associated genes and compared genetically using pulsed-field gel electrophoresis (PFGE) and random amplified polymorphic DNA analysis. Of the 22 Salmonella isolates examined, 15 were positive for the invasion gene invA and the virulence plasmid-associated genes spvC and pef. Most (15 of 22) were generally sensitive to antibiotics. However, two Salmonella isolates from pet birds were identified as Salmonella enterica serovar Typhimurium DT104. Despite the general susceptibility of these Salmonella isolates to most antimicrobial agents, antibiotic resistance-associated genes intI1, merA, and aadA1 were identified in a number of these isolates. Five distinct XbaI and nine distinct BlnI DNA patterns were observed for the 22 Salmonella isolates typed by PFGE. PFGE analysis determined that Salmonella isolates from passerines in Georgia and Wyoming were genetically related.

Clinical and virologic outcomes of hepatitis B and C viral coinfection after liver transplantation: effect of viral hepatitis D.

Hepatitis B (HBV) and C viral (HCV) dual-infection-associated liver disease is an uncommon indication for liver transplantation. The clinical and virologic outcomes in such patients have not been well studied. We retrospectively studied 13 patients with hepatitis B surface antigen (HBsAg) and antibody to HCV positivity who underwent orthotopic liver transplantation (OLT) and survived at least 30 days post-OLT. Antibody to hepatitis delta virus (HDV) was negative in 8 patients (group I) and positive in 5 patients (group II). Eleven of the 13 patients received standard hepatitis B immune prophylaxis, and they all remained HBsAg negative. All group I patients were HCV RNA positive after transplantation; in contrast, all group II patients were HCV RNA negative. Serum alanine aminotransferase levels were elevated in 88% (7 of 8) of the patients in group I compared with 20% (1 of 5 patients) in group II. None of the patients had graft loss from chronic rejection or recurrent hepatitis. Three patients had unsuspected hepatocellular carcinoma in the explant. We conclude that among liver transplant recipients with HBV and HCV coinfection, HDV infection is associated with the suppression of HCV replication and mild inflammatory activity after OLT.

Temporal changes in the population genetics of Salmonella pullorum.

Salmonella pullorum is the cause of pullorum disease, which is characterized by white diarrhea and a high mortality rate in poultry. During the 1990s, the serologic "pullorum" test has occasionally failed to detect infected birds during the early stage of disease. To determine if any recent genetic changes have taken place in S. pullorum to account for poor seroconversion sometimes observed in infected flocks, S. pullorum from 1990s outbreaks and strains isolated prior to the 1980s were typed by random amplified polymorphic DNA (RAPD). Of 40 S. pullorum isolates typed by this method, eight distinct DNA patterns were identified with one of three RAPD polymerase chain reaction primers. Sixty-two percent of S. pullorum isolates shared the same RAPD DNA pattern, and a major proportion of these strains were from recent flock infections. The RAPD patterns for S. pullorum were clearly distinct from the avian Salmonella group B isolates included in this analysis. The distribution of Salmonella virulence genes among avian Salmonella isolates was also examined. Eighty-five percent of the S. pullorum isolates had both the virulence plasmid gene, spvB, and the invasion gene, invA, with the same percentage positive for the Salmonella enteriditis fimbrial gene, sef. However, significant variability was observed among S. pullorum in their ability to invade avian epithelial cells, despite the presence of the Salmonella invasion gene in these isolates.

Prevention of de novo hepatitis B infection in recipients of hepatic allografts from anti-HBc positive donors.

BACKGROUND: The shortage of donor organs occasionally mandates the use of hepatic allografts from anti-HBc+ donors in recipients who are susceptible to de novo hepatitis B virus (HBV) infection. The efficacy of hepatitis B immune globulin and lamivudine to prevent de novo HBV infection in anti-HBs negative recipients of allografts from anti-HBc+ donors has not been investigated. METHODS: After liver transplantation with an allograft from a donor positive for anti-HBc, recipients who were anti-HBs-, HbsAg- received hepatitis B immune globulin (HBIG) 10,000 IU i.v. daily for 7 days and monthly for 6 months. After 6 months, 1000 IU of HBIG was given IM. every 2 weeks for 18 months. Patients transplanted after 4/1/97 were given lamivudine 150 mg daily starting postoperative day 1. RESULTS: Between 8/14/96 and 6/10/98, 264 orthotopic liver transplants were performed and 16 anti-HBs-, HbsAg- patients received an hepatic allograft from a donor positive for anti-HBc. HBIG mono-therapy was administered to one patient. HBIG and lamivudine combination therapy was administered to 15 patients. Of the 16 patients, 8 were positive only for anti-HBc before transplant, and 8 were naive (anti-HBs-, anti-HBc-). The single patient who received HBIG monotherapy became HbsAg+ at 6 months. All patients receiving combination therapy with HBIG and lamivudine have remained HbsAg-. The average follow-up is 459 days (range 170-754). Two patients died from unrelated causes. CONCLUSIONS: Combination therapy with HBIG and lamivudine may prevent de novo HBV infection in anti-HBs-, HbsAg- recipients of hepatic allografts from anti-HBc+ donors.

The structure and correlates of kanashibari.

The present research is an examination of the parameters and correlates of kanashibari, operationally defined as being unable to move upon awakening or before falling asleep. Nonclinical Japanese individuals (N = 720), 34% of whom reported an experience of kanashibari at least once, were administered D. I. Templer's (1970) Death Anxiety Scale, R. Brown's (1990) Locus of Control Scale, and a questionnaire devised by the authors to collect information about kanashibari. The results showed that the kanashibari experience was positively correlated with death anxiety, with being a woman, and with external-other locus of control; this last measure assessed the extent to which these individuals felt that their lives were determined by fate, good luck, or chance.

Dieldrin reduces male production and sex ratio in Daphnia galeata mendotae.

We used the sex ratio of neonate Daphnia, as well as the more standard endpoints of adult survivorship and fecundity and neonatal morphology, as an assay for detecting the effects of the insecticides endosulfan and dieldrin. Dieldrin caused a decrease in sex ratio (number of males/number of males plus females); we observed no endosulfan effect. We estimated (by extrapolation) that the sex ratio was reduced by dieldrin from concentrations of about 30 ppb and higher, based on a linear decrease in sex ratio with log dieldrin concentrations from 50 to 600 ppb. Neither insecticide significantly affected adult survival or clutch size. Because sex ratio changed but total neonate production did not change, the data suggest that the effect of dieldrin was on the sex-determining system during embryogenesis. Neither insecticide caused morphological abnormalities. Mixtures of the two pesticides produced only additive effects.

The hepatopulmonary syndrome.

The hepatopulmonary syndrome is a disease entity seen in association with liver failure and other disease entities. It is a devastating consequence of liver failure that results in a significant morbidity for affected patients. Currently, there are no identified medications that ameliorate the symptoms of hypoxemia in this disease state. Recent research, however, has begun to unravel the pathobiology of the vascular dilations that arise in the lungs of patients with liver failure. In this article, a compendium of current knowledge is presented, as well as the contemporary methods for identifying and treating patients.

Liver transplantation for chronic viral hepatitis.

A better understanding of the mechanism of viral replication and of viral transmission has led to improved results with OLTx for patients with end-stage liver disease caused by viral hepatitis. Patients with hepatitis-B-related liver disease who are HBV-DNA negative can expect excellent survival after OLTx with long-term HBIG therapy. Patients coinfected with HDV who are HBV-DNA negative can also expect an excellent rate of survival. HBV-DNA-positive patients may benefit from the addition of lamivudine to the prophylactic regimen both before and after OLTx. De novo HBV infections generally have a very benign course. Lamivudine has proven to be very effective in the treatment of both de novo and recurrent HBV infection after OLTx; however, resistance can develop. Allografts from donors with antibodies to HBV can be used most effectively when directed to recipients who also harbor HBV antibodies. The recurrence of HCV infection after OLTx is universal; however, the 5-year survival rate in patients who received OLTx for HCV-related liver disease is not diminished. Although a few patients experience an aggressive recurrence of HCV infection after OLTx, prognostic indicators have not been determined to allow for identification of these patients. Alpha-interferon does not seem to be effective in the treatment of recurrent HCV infection after OLTx. Trials with combination alpha-interferon-ribavirin are underway. Retransplantation for HCV-related allograft failure can be performed safely in patients if performed before the onset of other organ system failure. Finally, anti-HCV-positive recipients of allografts from anti-HCV-positive donors have an excellent 5-year survival rate.