Systemic Vibrio infection presenting as necrotizing fasciitis and sepsis. A series of thirteen cases

BACKGROUND: Vibrio species are an uncommon cause of necrotizing fasciitis and primary septicemia, which are likely to occur in patients with hepatic disease, diabetes mellitus, adrenal insufficiency, and immunocompromised conditions. These organisms are found in warm sea waters and are often present in raw oysters, shellfish, and other seafood. The purposes of the present report were to describe a series of patients who had this potentially lethal infection and to identify clinical features associated with a poor prognosis. METHODS: We retrospectively reviewed the records of thirteen patients (ten men and three women) who had necrotizing fasciitis and sepsis caused by Vibrio species. All patients had a history of contact with seawater or raw seafood. Eight patients had a hepatic disease such as hepatitis or cirrhosis of the liver, three had diabetes mellitus (without hepatic disease), and two had chronic renal or adrenal insufficiency (without hepatic disease). RESULTS: Twelve patients underwent fasciotomy or limb amputation. Five patients (38%) died within two to six days after admission, and eight patients survived. Patients with a systolic blood pressure of < or =90 mm Hg and leukopenia in the emergency room had a significantly higher mortality rate (p < 0.05). CONCLUSIONS: The diagnosis of Vibrio necrotizing fasciitis should be suspected when a patient has the appropriate clinical findings and a history of contact with seawater or raw seafood. The treatment should begin as early as possible, essentially when the patient has symptoms of sepsis. Although emergency fasciotomy or limb amputation did not reduce the mortality rate in this series, we consider such operations to be an important aspect of treatment.     

Effects of and predictors for tacrolimus rescue therapy among renal transplant patients under cyclosporine-based immunosuppression

BACKGROUND: Though cyclosporine has dramatically decreased rejection rates and improved graft survival rates of renal allografts, there is still a remarkable rate of acute rejection and progressive deterioration of renal function after transplantation. Rescue therapy with tacrolimus has been used for allografts failing under cyclosporine-based treatment in order to get some renal functional recovery or stabilization. The aim was to evaluate tacrolimus rescue therapy for failing allografts under cyclosporine-based immunosuppression for possible prediction factors for success. PATIENTS AND METHODS: Thirty-five renal allograft recipients with failing transplants under cyclosporine-based immunosuppression were enrolled into this study. Renal function was evaluated by reciprocal serum creatinine level (1/Cr) and calculated CCr. The slope of changes in 1/Cr and CCr were calculated before and after tacrolimus therapy. The possible risk factors that affect the outcome of tacrolimus rescue therapy were analyzed. RESULTS: Nineteen patients showed improved renal function (group 1) and 16 patients, persistent deterioration (group 2) after rescue therapy. Group 1 showed positive slopes of changes of 1/Cr and CCr after rescue therapy. Group 2 patients showed persistent negative slopes although less negative than before rescue therapy. Only the posttransplant time was the significant predictive factor for successful tacrolimus therapy (P = .018). CONCLUSION: Tacrolimus rescue therapy improved or stabilized renal function in some patients with failing grafts under cyclosporine-based immunosuppression. To assure a successful rescue effect, it should be given early after transplantation, if there is a tendency toward deterioration of renal function.     

Gyrus plasmasect: is it better than monopolar transurethral resection of prostate?

INTRODUCTION: This randomized prospective study was conducted to compare the efficacy and safety of the Gyrus Plasmasect loop bipolar transurethral resection of prostate (TURP) and conventional monopolar TURP in the treatment of benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: A total of 117 men were enrolled in this study. Fifty-eight patients underwent Gyrus Plasmasect TURP and 59 patients underwent monopolar TURP. They were followed up for 3 months after surgery. RESULTS: Significant improvements were seen postoperatively in both the Gyrus and monopolar groups in terms of prostatic volume, International Prostate Symptom Score, quality of life score, peak flow rate, and post-void residual urine volume. However, the degree of improvement was not statistically different between the 2 groups. Significantly less blood loss, shorter postoperative catheterization time and length of hospital stay were seen in the Gyrus group. CONCLUSIONS: Gyrus Plasmasect TURP yielded comparable results to monopolar TURP; however, this is only a preliminary study and follow-up is necessary to assess its long-term efficacy.     

Extended trapezius myocutaneous free flap for the reconstruction of a foot defect lacking adjacent recipient vessels

Foot reconstruction requires tissue that is durable and can withstand the extremes of pressure and stress. The trapezius myocutaneous flap has not been used previously as a free flap for foot reconstruction. In this report, the trapezius was used as an extended myocutaneous free flap for the reconstruction of a foot wound lacking adjacent and adequate recipient vessels. The extended trapezius flap may be one of the longest free flaps that can be harvested. The indications for the use of this flap are limited. In an extremity that lacks adequate recipient vessels adjacent to the defect, this flap can be extended such that more proximal vessels in the leg can be used as the recipient vessels without the need for vein grafts to bridge the distance. The donor-site morbidity of this flap is minimal when the superior fibers of the trapezius muscle and its innervation are preserved.     

Bifurcated abdominal aorta, with a coarctation over the right branch of the bifurcated abdominal aorta and aberrant renal arteries originating from the left branch of the bifurcated abdominal aorta

This study describes an unusual case of secondary hypertension in a young female patient presenting with severe hypertension and abdominal bruits. Gadolinium-enhanced MRA revealed a clearly bifurcated abdominal aorta, with a coarctation over the right branch of the bifurcated abdominal aorta and aberrant renal arteries originated from the left branch of the bifurcated abdominal aorta. Of interest is conventional angiography had failed to reveal these vascular abnormalities. This study mentions both embryologic and clinical aspects of this developmentally abnormal bifurcated abdominal aorta, coarctation of abdominal aorta and aberrant renal arteries.     

Liver transplant for hepatocellular cancer: a treatment for the select few

Hepatocellular cancer (HCC) is increasing in incidence and liver transplant (LT) is likely the best treatment for long-term survival and decreased recurrence in those with localized disease. Optimal treatment for HCC is limited by advanced stage at presentation and available donors. We retrospectively reviewed 232 cases of HCC from 1993 to 2002 referred to our medical center, which also has the only transplant program in the state. Demographic data, risk factors, stage, previous treatment, candidacy for LT, and outcome were noted. Stage distribution was as follows: stage I - nine patients, II - 115 patients, III - 31 patients, and IV - 76 patients. Mean age was 61.1 yr and 62 patients were over the age of 70 yr. Thirty-five patients (15.1%) were offered LT evaluation. Nineteen patients (8.2%) eventually underwent LT, five are currently on a transplant waiting list, three were on a list but removed due to death or progression of disease, six were evaluated but not listed, and two refused evaluation. Five patients were transplanted because implementation of the Model of End-stage Liver Disease (MELD) system for organ allocation. Of 19 patients who underwent LT, 14 are still alive 3-52 months post-transplant, three developed recurrent HCC, and two died of lung cancer. Although LT may be the best treatment for HCC, a relatively small number of patients (15%) will qualify for this therapy. About half of those who qualify will actually undergo LT. This further emphasizes the need for other strategies such as vaccination, chemoprevention, and early detection to improve survival from HCC.     

Antineutrophil cytoplasmic antibody-associated glomerulonephritis in Taiwanese

AIMS: This retrospective study defined the clinical features and outcome of antineutrophil cytoplasmic antibody-associated glomerulonephritis in 18 seropositive Taiwanese patients (11 male, seven female; median age 64 years; range 21-82 years) with biopsy-proven pauci-immune necrotizing crescentic glomerulonephritis. RESULTS: Fourteen patients had a diagnosis of systemic vasculitis including 10 with microscopic polyangiitis and four with Wegener's granulomatosis; the remaining four had only glomerulonephritis. At onset, 100% of the systemic vasculitis patients had pulmonary lesions with or without haemoptysis, and 29% presented with seizure in the absence of a defined brain lesion. Median serum creatinine concentration was 362.4 micromol/L (range 61.9-857.5 micromol/L) and dialysis therapy was needed in six patients. During follow up (median 16.5 months; range 2-72 months), treatment included cyclophosphamide and corticosteroids (n = 8) or corticosteroids alone (n = 7). In some patients, treatment improved (n = 4) or stabilized (n = 4) renal function. But chronic dialysis was needed in the other 10 patients. Follow-up death occurred because of sepsis (n = 3) and haemorrhage (n = 2). Patient survival rates were 78% (1 year) and 72% (5 years). Renal survival rates were 56 and 39% at 1 and 5 years, respectively. Of the candidate clinical and pathological parameters, chronic glomerular lesions in renal biopsy were the only determinant of poor renal outcome (P = 0.006). CONCLUSION: Antineutrophil cytoplasmic antibody-associated glomerulonephritis should be considered in nephritic patients with extrarenal manifestations, especially pulmonary infiltrate, unexplained seizure, and fever of an unknown origin in Taiwanese patients. Renal biopsy should be performed before initiating immunosuppressive therapy because the most common cause of mortality was sepsis.     

Microfluidic Flow Switching Design Using Volume of Fluid Model

In this study, a volume of fluid (VOF) model was employed for microfluidic switch design. The VOF model validity in predicting the interface between fluid streams with different viscosities co-flowing in a microchannel was first verified by experimental observation. It was then extended to microfluidic flow switch design. Two specific flow switches, one with a guided fluid to one of five desired outlet ports, and another with a guided fluid flows into one, two, or three outlet ports equally distributed along the outlet channel of a Y-shaped channel. The flow switching was achieved by controlling the flow rate ratios between tested and buffer fluids. The numerical results showed that the VOF model could successfully predict the flow switching phenomena in these flow switches. The numerical results also showed that the flow rate ratio required for flow switching depends on the viscosity ratio between the tested and buffer fluids. The numerical simulation was verified by experimental study and the agreement was good.     

Oxygen distribution and respiration by the microcirculation

Longitudinal and radial oxygen gradients in the microcirculation due to oxygen release from arterioles show that in some tissues oxygen is primarily supplied by arterioles and secondarily by capillaries. In several tissues, the arteriolar rate of oxygen exit is too large to be explained by diffusion alone, indicating that in these tissues oxygen consumption of the arteriolar wall in vivo is much greater than that shown in in vitro studies of endothelium and vascular smooth muscle, a phenomenon that may be related to the synthesis autocoids by the endothelium in vivo. The functional significance of the high metabolic rate of the arteriolar vessels may be related to the need of providing a metabolic barrier for protecting the parenchymal tissue from high oxygen levels in arterial blood, thus reducing formation of oxygen free radicals in the perivascular tissue, a supposition supported by the finding that the radial oxygen gradient at the microvascular wall and therefore its rate of oxygen consumption are proportional to local blood oxygen partial pressure (pO(2)). Oxygen consumption by the endothelium and/or smooth muscle is also a factor in causing terminal lymphatic pO(2) to have the lowest oxygen level in the tissue, rendering this compartment most vulnerable in hypoxic conditions.