Renal arteriovenous fistulas after renal biopsy. Percutaneous embolization

PURPOSE: We report our experience relative to transcatheter percutaneous embolization of post-biopsy renal intraparenchymal arteriovenous fistulas in patients with chronic renal insufficiency. MATERIAL AND METHODS: We observed 5 patients affected with post-bioptic fistulas for possible embolization. In three cases the symptoms were represented by intermittent macro-microhematuria; one patient had hypertension of nephrovascular origin and one patient was asymptomatic. In all cases we performed angiography and it was possible to catheterize the peripheral afferent branch of the fistula with a superselective technique using a hydrophilic guide of 0.035 F and a hydrophilic Cobra catheter of 4-5 F. The occlusion was obtained by the positioning of Granturco metal coils: in 1 case we adapted a coil of 3 mm diameter and 1 cm length; in 3 cases 2 coils of 3 mm and in 1 case 2 coils of 3 mm and 1 coil of 5 mm diameter and 1 cm length were necessary. The success of the procedure was always checked with an immediate angiogram and color Doppler US after 48 hrs. RESULTS: The diagnosis of arteriovenous fistulas was always confirmed by a preliminary angiography that demonstrated the normal anatomic disposition of the renal arteries except in one case in which the fistula was fed by a peripheral branch originating from an inferior polar artery. All the lesions were localized in the inferior pole, the site of biopsy, and ranged from 3 mm to 2.5 cm in diameter. We never had any difficulties in the positioning and placement of the coils. The arterial occlusion and exclusion of the fistula was accomplished in all cases. The induced parenchymal loss ranged from 10 to 30% of the renal volume. There was a complete disappearance of symptoms in 3 of the patients, with hematuria without any modification of the blood pressure values in the patient with hypertension. Considering the patient status renal function did not worsen after the embolization. Each patient was followed-up with color Doppler US every two months. CONCLUSIONS: The intrarenal arteriovenous fistula represents a relative frequent complication of renal needle biopsy in patients with arterial hypertension and nephroangiosclerosis as risk factors. Embolization is a valid alternative therapeutic option to surgical treatments. The use of small size catheters permits the successful embolization also of peripheral lesions, reducing the induced parenchymal ischemia. We believe that among the embolization material available metal coils represent a valid solution as they are easily positioned and permit definitive occlusion without any risks of systemic venous microembolization.     

Appropriateness of hospital utilisation in Italy

The purpose of this study was to determine the extent of inappropriate hospital admission and inappropriate days of stay and the effect of variables on such inappropriateness on an adult population in Italy. A review was made of medical records of patients admitted to any one of the following specialities: medicine, surgery, gynaecology or traumatology/orthopaedics at one of five hospitals located respectively in Siena, Frosinone, Rome and Catanzaro, and who were in-patients during one of four pre-selected index days. To determine the appropriateness of hospital admission and length of hospitalisation, a retrospective application was made using the Italian version of Appropriateness Evaluation Protocol (AEP). A total of 1299 patient days were reviewed.14.2% of the hospital admissions and 37.3% of the number of hospitalisation days were judged to be inappropriate. Multiple logistic regression analysis showed that inappropriate admission was significantly increased with relation to: greater distance from hospital to patient's home; admission to a medical ward; planned admissions; and admission over a weekend. Multiple logistic regression analysis indicated that the inappropriate number of days of hospitalisation was significantly higher for medicine and for patients who were inappropriately admitted.The main reason for categorising an admission as inappropriate was that the patient's problems could be treated on an out-patient basis, and, for inappropriate days of care, the physician was overtly cautious in the management of a patient.Changing the physicians' behaviour and the organisation of hospital activities may be effective in improving the quality and efficiency of hospital care. Public Health (2000) 114, 9–14.     

Intimate Partner Relationships,Work-Life Factors,and Their Associations With Burnout Among Partnered Pediatric Residents

Background

Burnout is prevalent among pediatric residents, and reducing burnout is a priority for pediatric residency programs. Understanding residents’ personal circumstances, including relationship satisfaction and perceived work-life conflict, may identify novel determinants of burnout.

Clinical, hormonal and cytogenetic evaluation of 46,XX males and review of the literature

The main factor influencing the sex determination of an embryo is the genetic sex determined by the presence or absence of the Y chromosome. However, some individuals carry a Y chromosome but are phenotypically female (46,XY females) or have a female karyotype but are phenotypically male (46,XX males). 46,XX maleness is a rare sex reversal syndrome affecting 1 in 20,000 newborn males. Molecular analysis of sex-reversed patients led to the discovery of the SRY gene (sex-determining region on Y). The presence of SRY causes the bipotential gonad to develop into a testis. The majority of 46, SRY-positive XX males have normal genitalia; in contrast SRY-negative XX males usually have genital ambiguity. A small number of SRY-positive XX males also present with ambiguous genitalia. Phenotypic variability observed in 46,XX sex reversed patients cannot be explained only by the presence or absence of SRY despite the fact that SRY is considered to be the major regulatory factor for testis determination. There must be some other genes either in the Y or other autosomal chromosomes involved in the definition of phenotype. In this article, we evaluate four patients with 46,XX male syndrome with various phenotypes. Two of these cases are among the first reported to be diagnosed prenatally.     

Influence of carbohydrate and age on lymphocyte function following a marathon

The influence of 6% carbohydrate ingestion and age on PHA-induced lymphocyte proliferation and in vitro cytokine production was studied in 48 runners following a competitive marathon. Runners were randomly assigned to carbohydrate (C; n = 23) and placebo (P; n= 25) groups, with blood samples taken before, immediately after, and 1.5 hr post-race. C versus P ingestion resulted in higher plasma glucose, lower plasma cortisol, reduced neutrophilia, and monocytosis during recovery, but had no effect on the post-exercise reduction in T-lymphocytes or NK cells, or on race times. No group differences were observed for PHA-induced lymphocyte proliferation or cytokine production. However, for all subjects combined, lymphocyte proliferation and IFN-gamma secretion decreased significantly below pre-race values by 1.5 hr of recovery, and these were negatively correlated with plasma cortisol. Young (<50 years; n = 36) and old (>or=50 years; n = 12) runners exhibited parallel post-race declines in lymphocyte proliferation and IFN-gamma secretion, with the older group exhibiting a 33-59% lower proliferation at each time point. In conclusion, PHA-induced lymphocyte proliferation and cytokine production decreased significantly following a marathon, and this decrease was strongly linked to cortisol and only partially linked to T-cell changes. This decrease occurred in both younger and older runners and was not influenced by carbohydrate.     

Visceral leishmaniasis and HIV co-infection: a rare case of pulmonary and oral localization

Visceral leishmaniasis (VL) has increased as a complicating infection in subjects with human immunodeficiency virus (HIV) in countries bordering the Mediterranean sea. The clinical course as well as organ involvement of VL are often atypical in HIV positive subjects. In this study a case of VL with pulmonary and oral mucose localisation in a patient with acquired immune deficiency syndrome (AIDS), is reported. These findings, together with the presence of the parasite in the peripheral blood smear, confirm that in HIV positive patients the impaired immune system allows the spreading and the atypical localisation of the Leishmania amastigotes more easily than in immuno-competent individuals. In endemic areas and in HIV positive subjects a systemic and careful parasitological follow-up is necessary to ensure that any clinical form of leishmaniasis is not overlooked.     

Pediatric pre-hospital advanced life support care in an urban setting

OBJECTIVE: To describe pediatric advanced life support (PALS) in a single urban environment and clarify educational priorities for ALS pre-hospital providers and pediatric medical control physicians. METHODS: Retrospective observational review of all pediatric pre-hospital PALS transport and medical control records of the two-tiered, unified, municipal emergency medical service of the City of Boston (catchment area 590,000) over a 1-year period. RESULTS: Of the 555 pediatric patients receiving ALS transport, 38% were for respiratory emergencies, 24% for nonrespiratory medical emergencies, 19% for traffic-related blunt trauma, and 10% for penetrating trauma. Two percent involved cardiac arrests. The most frequent procedures performed were intravenous (IV) cannulation (n = 184, 33%), bag-mask ventilation (n = 28, 5%) and intubation (n = 15, 3%). Intraosseous access was only performed in three patients (0.5%). Fifty ALS providers in the EMS system averaged pediatric IV cannulation 3.7 times, intubation 0.3 times, and intraosseous access 0.06 times per provider per year. On-line medical control was requested in 28 % of PALS transports. The chief complaints managed by medical control closely mirrored the distribution of all ALS transports. The most frequent medication ordered by on-line medical control was additional nebulized albuterol after standing orders (off-line medical control) had been exhausted. CONCLUSIONS: A limited number of chief complaints make up the majority of PALS transports. Initial and continuing education for ALS providers needs to reflect the importance of these critical entities. Education for urban pre-hospital providers should reflect that certain procedures will be only executed every few years (eg, pediatric intubation) or once in the career of an ALS pre-hospital provider (eg, intraosseous access). With a limited amount of pediatric teaching time, paramedic education will have to strike a careful balance between teaching about the chief complaints most frequently encountered and teaching rare, high-risk procedures that could provide maximal support for the uncommon critically ill child. On-line medical control physicians need to be prepared to direct and support the management by ALS pre-hospital providers for the chief complaints most frequently seen in pediatric patients.     

Occupational risk factors for the sporadic form of Creutzfeldt-Jakob disease

Some case reports among European farmers and a few case-control studies suggested the hypothesis of an increased risk of the sporadic form of CJD (sCJD) associated with livestock farming or work as a butcher. Also, the discovery of the possibility of transmission of the disease via blood or by contact following corneal or dura madre transplant suggested that health occupations might also run higher sCJD risks. However, a meta-analysis of three case-control studies and a multicentre European study did not find any positive association between sCJD and health-related jobs or occupational contact with livestock, such as cattle and sheep, or animal products. To explore possible occupational risk factors for Creutzfeldt-Jakob disease (CJD), we used a publicly available US database including about 6 million deaths in 24 states during 1984-95. Cases were 636 deaths (300 men and 336 women) with CJD (ICD-9 code 046.1) as the underlying cause of death. Controls were 3,180 deaths randomly selected from among those who died from all other diseases except those affecting the central nervous system. CJD cases represented a wide variety of occupations (159) and industries (147). Among occupations and industries, for which previous reports suggested potential exposure to a transmissible spongiform encephalopathy (TSE) agent, the OR for CJD was significantly increased among butchers (OR = 6.8, 95% C.I. 1.5, 30.1, based on 4 cases and 3 controls), and persons working in offices of physicians (OR = 4.6, 95% C.I. 1.2, 17.6 based on 5 cases and 4 controls). Nine other occupations and seven other industries, for which no previous suggestion existed in the literature, also showed significant associations. Overall, our results suggest that occupational exposures are not an important source of sCJD infection. However, as the excess among butchers and some workers in health occupations was consistent with previous reports, more indepth research is warranted to address the hypothesis.