Impact of Etiologic Factors and APACHE II and POSSUM Scores in Management and Clinical Outcome of Acute Intestinal Ischemic Disorders after Surgical Treatment

Background Acute intestinal ischemic disorder (AIID) is an uncommon vascular disease with high mortality. According to etiology, it can be categorized into three groups: arterial occlusive mesenteric ischemia (AOMI), mesenteric venous thrombosis (MVT), and nonocclusive mesenteric ischemia (NOMI). This study analyzes the effect of classification on surgical outcome. Patients and Methods All AIID patients who underwent operative treatment at National Cheng Kung University Hospital between January 1989 and August 2003 were enrolled in this study. Preoperative information on these patients was compared to find predictors of outcome. Results Data from 77 patients (49 men and 28 women, median age 70 years) were analyzed. The etiology was AOMI in 30 patients, MVT in 19 patients, and NOMI in 28 patients. Median age was younger in MVT (54 years) than in AOMI (70 years) or NOMI (72 years). In addition, MVT usually involved the jejunum (74%, versus 31% in AOMI and 46% in NOMI), whereas both AOMI and NOMI involved ileum and colon. The patients with AOMI had shorter duration of symptoms and higher ratio of underlying hypertension than those with MVT. The overall mortality rate was 53.2% (41/77). The day 1 and day 30 mortality were 0% and 10.5% in MVT, 16.7% and 30% in AOMI, and 42.9% and 67.9% in NOMI, respectively (P < 0.05). Both the etiology and the APACHE II scores were significant risk factors for day 30 and long-term mortality. The patients with NOMI had higher POSSUM physiologic scores than patients with MVT. The P-POSSUM regression equation can accurately predict mortality. Conclusions Patients with MVT had a more favorable prognosis, whereas those with NOMI had the worst outlook. The APACHE II and POSSUM scoring systems are useful in predicting the clinical outcome. Early diagnosis and classification of AIID patients are useful for aggressive treatment to improve the clinical outcome.     

Early Presumptive Therapy with Fluconazole for Occult Candida Infection after Gastrointestinal Surgery

The objective of this retrospective comparative study was to improve the outcome of patients with suspected occult Candida infection after gastrointestinal surgery by early presumptive therapy. It was conducted in the National Cheng Kung University Hospital in Taiwan. A total of 36 patients with prolonged ileus with fever after gastrointestinal tract surgery between January 1995 and December 2002 were examined for two time periods: those treated before and those treated after January 1999. One set of patients did not receive early presumptive therapy (EPT) until Candida infection was confirmed, and they were designated EPT(−). Another group of patients with suspected occult Candida infection received EPT and were designated EPT(+). Fluconazole, 400 mg/day, was given as EPT. Urine, wound, intraperitoneal drainage, and blood specimens were obtained from patients for fungus culture before starting treatment and weekly until symptoms subsided. The primary endpoints were the frequency of candidiasis and the persistence of candidemia; the secondary endpoint was the efficiency of EPT in the clinical outcome. There was no difference in Candida peritonitis, wound colonization, or urine colonization in the two treatment groups. Candida albicans accounted for 87.5%% of the isolated Candida species: 84.6%% in the EPT(+) group and 89.5%% in the EPT(−) group. In the EPT(+) group, the positive blood culture rate was 66.7%%. The fever subsided rapidly in 17 patients (94%%), the hospital stay and intensive care unit stay were shorter, and the mortality decreased significantly: 11%% vs. 78%%, P < 0.001. Persistent gastrointestinal ileus was the main cause of breakthrough candidemia. We concluded that EPT with fluconazole improves the prognosis of patients with occult Candida infection after gastrointestinal surgery. Surgical intervention was required in patients with breakthrough candidemia.     

Alveolar ridge preservation using a bioactive glass particulate graft in extraction site defects

This article describes the application of a bioactive glass particulate graft and placement of an expanded polytetrafluoroethylene barrier into extraction sites to preserve the residual ridge and to develop the site prior to fixed prosthetic replacement. Extraction site development can enhance and facilitate the position and shape of the pontics while maximizing the natural contour of the soft tissues.     

An incomplete form of pachydermoperiostosis. Diagnosis of finger clubbing

INTRODUCTION: The finger clubbing is most of the time associated with cardiovascular and pulmonary diseases. Pachydermoperiostosis also known as osteodermopathic syndrome, an hereditary disorder, is a rare cause of finger clubbing which might be difficult to diagnose in an incomplete form. EXEGESIS: We report a 36 years old black man presenting over many years polyarthralgias, broadening of fingers and clubbing of the fingers and toes extremities. This was mentioned on other family members. The physical examination was otherwise unremarkable. There were no skin thickening, no psoriasis-like and cardio-pulmonary disease features. These following exams were normal; Hemogram, fibrinogen, C reactive protein, rheumato?d factor, serum calcium and phosphorus, thyroid hormones, growth hormone, chest X-ray, gastroduodenoscopy, electrocardiogram. The skeletal X-ray documented a widespread bone formation, a sacro-iliac osteosclerosis and interosseous ossifications betwen tibias and fibulas. CONCLUSION: Pachydermoperiostosis diagnosis was set up on 3 out of the 4 Borochowitz criteria. The absence of pachyderma defines this incomplete form. The osteoarticular manifestations lead mainly to differential diagnosis with the secondary hypertrophic osteoarthropathy and chronic inflammatory rheumatisms. The underlying pathogenic mechanism of this disease remains still unclear.     

The impact of AIDS on state public health legislation in the United States: a critical review

This article reviews and analyzes the current public health legislation in 17 states and the District of Columbia in the United States. These states were selected and grouped into high, medium, and low incidence based on their annual AIDS incidence rates. Data were collected through a combination of library research and direct communications with the various state health departments. Four major areas of legislation were reviewed: HIV antibody testing and reporting; confidentiality and partner notification; personal control measures: and AIDS antidiscrimination laws. In general, majority of the states have treated the AIDS epidemic as a public health problem and not as a moral or criminal issue. Some states with higher incidence such as New York and California have developed the least restrictive laws and responded with stronger AIDS antidiscrimination legislation. The states with medium incidence have more restrictive measures and the low incidence states have less legislation and fewer regulations related to AIDS. AIDS educators should be aware of the implications of the varied legislation and regulations on AIDS education and prevention. They should play a strong advocacy role in promoting the development and application of measures that will facilitate the prevention and control of AIDS.     

A study of the causes of staghorn calculi

A thorough metabolic evaluation of all staghorn stone patients seems justified, considering the results obtained by the study of 27 such cases. Pak's ambulatory screening test, slightly modified, was used. This allowed the finding of a hypercalciuria in more than 50% of the cases, a hyperuricosuria in 63% of the cases and a hyperoxaluria in one case out of five. A metabolic anomaly was not detected in two patients. Although urinary tract infection, present in 75% of the cases is essential to the genesis of a staghorn stone, the question raises whether metabolic anomalies are not the primary cause of the stone formation.     

In vitro growth inhibition of Plasmodium falciparum by sera from different regions of the Philippines

Sera from different malaria endemic regions of the Republic of the Philippines were compared for their ability to inhibit growth of Plasmodium falciparum in vitro. Dialyzed serum was added to synchronous cultures containing schizonts for either the total 48 hr test period or only the last 24 hr in order to analyze the effects on erythrocytic invasion and intraerythrocytic growth, respectively. Reduction in 3H-hypoxanthine uptake was used to determine the percent of inhibition compared to nonimmune serum. One hundred seventy sera from Mindanao and Palawan in the South, the centrally located island of Mindoro, and Luzon in the North, were tested against 4 P. falciparum strains from the Philippines and 1 from Africa. Indirect fluorescent antibody titers were not predictive of inhibition. Inhibition of merozoite invasion rather than intraerythrocytic parasite growth is suggested by this study. Generally, sera were more inhibitory to parasite strains from the same geographical area than to those from more remote areas.     

Congestive heart failure secondary to an arteriovenous fistula from cardiac catheterization and angioplasty

Arteriovenous (AV) fistulae are well known to cause high output cardiac failure. AV fistulae from cardiac catheterization are as rare as 0.01% in the transfemoral approach. We describe here what we believe is the first reported case of high output cardiac failure from an AV fistula due to percutaneous transluminal coronary angioplasty (PTCA). The patient had reversal of the congestive heart failure with surgical correction of the fistula.     

Human defensin 5 expression in intestinal metaplasia of the upper gastrointestinal tract

BACKGROUND: Upper gastrointestinal tract intestinal metaplasia (IM) is termed Barrett's oesophagus (BO) or gastric intestinal metaplasia (GIM), depending on its location. BO and GIM are associated with chemical exposure resulting from gastro-oesophageal reflux and chronic Helicobacter pylori infection, respectively. Paneth cells (PCs), characterised by cytoplasmic eosinophilic granules, are found in a subset of IM at these sites, but histology may not accurately detect them. AIM: To determine human defensin 5 (HD5; an antimicrobial peptide produced by PCs) expression in BO and GIM, and to investigate its association with H pylori infection. METHODS: Endoscopic biopsies from 33 patients with BO and 51 with GIM, and control tissues, were examined by routine histology and for H pylori infection and HD5 mRNA and protein expression. RESULTS: In normal tissues, HD5 expression was specific for PCs in the small intestine. Five patients with BE and 42 with GIM expressed HD5, but few HD5 expressing cells in IM had the characteristic histological features of PCs. Most HD5 positive specimens were H pylori infected and most HD5 negative specimens were not infected. CONCLUSIONS: HD5 immunohistochemistry was often positive in IM when PCs were absent by conventional histology. Thus, HD5 immunohistochemistry may be superior to histology for identifying metaplastic PCs and distinguishing GIM from BO. The higher frequency of HD5 expression in GIM than in BO is associated with a higher frequency of H pylori infection, suggesting that in IM PCs may form part of the mucosal antibacterial response.