Therapeutic alternatives for subacute peripheral arterial occlusion. Comparison by outcome, length of stay, and hospital charges.

Thrombolytic therapy using streptokinase or urokinase has been shown to be a viable alternative to surgical thrombectomy in patients with subacute peripheral arterial occlusion. Urokinase is associated with higher success and lower complication rates than streptokinase, but the cost of urokinase is at least seven times higher. To address questions of utility and effectiveness in the treatment of subacute peripheral arterial occlusions, the authors designed a retrospective study of patients treated either by surgical thrombectomy (n = 70), thrombolysis with streptokinase (n = 19), or thrombolysis with urokinase (n = 22). Outcome of therapy, length of hospital stay, and total hospital charges in the three groups were examined. Treatment successes in the three groups, defined as complete clearing of the occluded segment with patency maintained for 60 days, were 76% for thrombectomy, 32% for streptokinase, and 64% for urokinase. Total duration of hospitalization was 21.1, 21.3, and 11.5 days (P less than .05), respectively. Mean charges for thrombolytic agents were $690 for streptokinase and $6429 for urokinase. Mean total hospital charges, however, were $25,978 for streptokinase, $22,203 for urokinase, and $25,336 for thrombectomy (P = NS). The higher cost of urokinase, then, accounted for the similar total charges, despite the shortened length of stay. These results suggest that urokinase is cost-effective compared to streptokinase for subacute peripheral arterial occlusion. Compared to thrombectomy, thrombolysis with urokinase has a marginally lower patency rate at 60 days, but a significantly shorter length of hospital stay.     

Selection of contrast media

The pathophysiologic mechanisms of contrast-induced nephropathy (CIN) have been reviewed by Persson and Tepel. They focus on the renal response to contrast media (CM). In this section, we focus on the CM itself. Aspects of importance with regard to CIN include the route of administration, the volume of CM, the manner of X-ray attenuation, and the specific chemical structure of the CM.     

Primary intestinal lymphomas

Summary The histology and immunohistology of twenty-seven malignant non-Hodgkin's lymphomas of the intestinal tract were studied. Nine of these cases were in the small intestine, ten in the ileocaecal region, two in the appendix and four in the large intestine. In one case, several locations in the gastrointestinal tract were involved. The so-called Kiel-Classification was applied. We have found thirteen lymphomas with low grade (lymphocytic, lymphoplasmacytic, centrocytic, centroblastic/centrocytic) and fourteen with high grade of malignancy (centroblastic, lymphoblastic, immunoblastic). For most of the lymphoplasmacytic and immunoblastic lymphomata a monoclonal pattern of intracellular immunoglobulin (IgM/kappa) was identified by the immunoperoxidase method. Tumour cells of lymphocytic, centrocytic, centroblastic/centrocytic, centroblastic and lymphoblastic lymphomas were always Ig-negative. The immunoperoxidase technique helped considerably in distinguishing between (monoclonal) malignant lymphomas and (polyclonal) lympho- or immunoproliferative processes.Six out of twenty-seven malignant lymphomas had developed from immuno-inflammatory diseases of the gut. Four of these were complications of coeliac disease. One had developed from a malabsorptive dermatitis herpetiformis Duhring, and one from a complication of a long-standing ulcerative colitis. In two patients with coeliac sprue and malabsorptive dermatitis herpetiformis Duhring respectively the ulcerating small intestinal lymphomas were initially misinterpreted as benigne ulcerative non-granulomatous jejunitis. The evidence from the literature summarized suggests strongly that the benign non-granulomatous jejunoileitis, lymphomatous ulcer, intestinal pseudolymphoma and malignant lymphoma, when associated with villous atrophy of adjacent mucosa and malabsorption symptoms, are all one condition, namely, malignant lymphoma.This study was supported by a grant from the Deutsche Forschungsgemeinschaft (Ot 53/4-6)     

Ueber die Hautaffectionen der Hysterischen und den atypischen Zoster

Ohne Zusammenfassung     

Outcomes and performance of the Tesio twin catheter system placed for hemodialysis access.

PURPOSE: To assess the effectiveness of and outcomes with a twin catheter system. MATERIALS AND METHODS: The authors retrospectively reviewed the medical records, hemodialysis records, and clinical information system data from 132 consecutive patients who were referred for placement of a tunneled catheter for hemodialysis access. A commercially available twin catheter system was placed in all patients. Outcomes evaluated included infection rate, complication rate, and catheter malfunction and failure rates. Performance parameters evaluated included blood flow rates, urea reduction percentages, and recirculation percentages. RESULTS: One hundred eighty-four twin catheter systems were placed in 132 patients from January 11, 1996, to October 23, 1997. The initial technical success rate was 100%. There were four immediate procedural complications: Air emboli occurred in two patients, and prolonged bleeding necessitating intervention occurred in two. The total number of days a catheter was in place was 13,200 (mean, 74.6 days). Thirty-one infections occurred in 20 patients (total infection rate, 0.23 episodes per 100 catheter days). Sixty-five catheters malfunctioned during the study period, 19 of which necessitated removal, for a rate of 0.14 episodes per 100 catheter days. The average blood flow rate was 281.4 mL/min (range, 117.1-405.6 mL/min; median, 295.2 mL/min). Mean and median urea reductions were both 61%. Mean and median recirculation was 6.1% and 3.5%, respectively (range, 0%-31%). CONCLUSION: Percutaneous placement of the tunneled twin catheter system can be performed with excellent technical success and safety and acceptable catheter performance and outcomes for effective intermediate- to long-term hemodialysis.