Cutaneous necrosis from calcific uremic arteriolopathy

Calcific uremic arteriolopathy (calciphylaxis) is an uncommon complication of chronic renal failure that is associated with high morbidity and mortality. We report 16 patients (13 female) who presented between 1985 and 1996. All patients developed painful livido reticularis that progressed to cutaneous necrosis and ulceration (11 cases on the proximal extremities and five cases on the distal extremities). Two patients with predominately distal leg disease survived; the cause of death in the other 14 patients was sepsis (six patients), withdrawal from dialysis (three), cardiac arrest (three), and gastrointestinal hemorrhage (two). Mesenteric ischemia from intestinal vascular calcification occurred in two cases. Clinical factors identified included the use of warfarin therapy in seven cases and significant weight loss (>10% body weight) in seven cases in the 6 months preceding the development of calcific uremic arteriolopathy. Skin pathology was studied in 12 cases, with all showing calcific panniculitis and small vessel calcification. Electron microscopic spectral analysis of the mineral content of the calcific lesions in the subcutaneous tissue showed only calcium and phosphorous. In two cases, substitution of low molecular weight heparin for warfarin therapy resulted in clinical improvement. Current theories of pathogenesis and treatment are reviewed. This study confirms the high morbidity and mortality of calcific uremic arteriolopathy producing ischemic tissue necrosis while drawing attention to significant weight loss and warfarin therapy as risk factors for the development of ischemic tissue necrosis. Hyperbaric oxygen therapy warrants further study.     

Evaluation of abdominal trauma by computed tomography

Computed tomography (CT) was used in the evaluation of 100 patients suffering abdominal trauma. The type of trauma was blunt in 78 patients, penetrating in eight, and iatrogenic in 14. Forty per cent of cases had normal CT scans, while 60% showed substantial abdominal or retroperitoneal injuries. Surgery, clinical follow-up, and repeated radiologic examinations confirmed the accuracy of CT, and there were no cases in which medical or surgical management was inappropriately guided by CT. A wide variety of injuries was detected, including 19 splenic, eight hepatic, six pancreatic, 13 renal, 13 retroperitoneal or abdominal wall, and one intraperitoneal. CT has major advantages over plain radiography, radionuclide imaging, and angiography in assessment of trauma-induced injuries.     

Intra‐arterial embolization of lumbar artery pseudoaneurysm following percutaneous nephrolithotomy

The management of a patient with haematuria following percutaneous nephrolithotomy is described. The patient underwent renal angiography to assess the cause of bleeding. A pseudoaneurysm arising from first left lumbar artery was incidentally discovered, which was then successfully embolized using an indigenously fabricated metallic coil and gel foam particles in the same sitting.     

Estimation of bilirubin using BiliChek?, a transcutaneous bilirubin measurement device: Effects of gestational age and use of phototherapy

BACKGROUND

Heel puncture to obtain bilirubin measurements is painful for infants and distressing for parents. Transcutaneous bilirubin measurement using BiliChek (Respironics, USA) is easily performed in any setting. Reliable transcutaneous testing should decrease the number of painful procedures in otherwise well infants, reduce the volume of phlebotomy losses in ill newborns, and reduce the need for hospital or specialized clinic visits after discharge.

OBJECTIVE

To correlate bilirubin measurements using the transcutaneous device BiliChek with ‘gold standard’ serum measurements in well term infants, and in ill term and preterm infants admitted to the authors’ neonatal intensive care unit.

METHODS

The study consisted of two phases. In phase 1, informed consent was obtained from mothers of 99 healthy, full-term infants not receiving phototherapy to perform both serum and transcutaneous bilirubin measurements at the time of heel puncture for routine neonatal screening. In phase 2, 56 infants in the neonatal intensive care unit had a total of 99 transcutaneous readings performed at the time serum bilirubin measurements were ordered for clinical reasons by the attending staff. The operators of the transcutaneous device, who were unaware of the serum bilirubin levels, performed readings within 1 h of the heel puncture.

RESULTS

Using a Bland-Altman comparison in the well term infants, the transcutaneous measurements were −32.2 μmol/L to +31.2 μmol/L (1.96 SD); however, 79 (79.8%) of the transcutaneous measurements were within 15 μmol/L of the serum measurements. The variation in preterm infants was greater at −69.6 μmol/L to +62.0 μmol/L, and only 49 (49.5%) were within 15 μmol/L. For infants receiving phototherapy, the variation was −76.3 μmol/L to +49.5 μmol/L, but improved to −40.4 μmol/L to +31.0 μmol/L if an area of skin was patched for testing, approximating the group not receiving phototherapy.

CONCLUSIONS

Transcutaneous bilirubin measurements obtained with the BiliChek instrument were accurate for measuring bilirubin levels in term jaundiced infants not receiving phototherapy and in those receiving phototherapy if an area of skin was patched. The instrument was not as sensitive in the small sample of preterm infants, and a larger study is required before recommending the use of this instrument in this population.