Percutaneous nephrostomy drainage in the management of neonatal anuria secondary to renal candidiasis

We report a case of anuria in a premature neonate secondary to bilateral ureteropelvic junction obstructions related to Candida bezoars. Percutaneous decompression and drainage of both kidneys contributed significantly to the successful management of renal candidiasis in this patient. A review of the literature is presented.     

A novel mutation in the last exon of ATRX in a patient with α-thalassemia myelodysplastic syndrome

Abstract:  We describe a patient with acquired alpha-thalassemia myelodysplastic syndrome (ATMDS). A previously healthy 66-year-old man presented with hemoglobin of 9.3 g/dL, mean corpuscular volume 59 fL, and a bone marrow aspirate with increased erythroid precursors and hypolobulated megakaryocytes. Hemoglobin H inclusions were seen in most red cells after 1% brilliant cresyl blue supravital stain of the peripheral blood. At the molecular level, we identified of a novel mutation in the most 3' exon of the ATRX gene ( C GA→ T GA substitution in codon 2407) resulting in a premature termination codon (p.R2407X). This case provides further evidence for a link between ATRX mutations and ATMDS, and suggests a possible role for the conserved Q-box element in ATRX function.     

Efficacy of the dorsal pedal bypass for limb salvage in diabetic patients: short-term observations

Limbs of diabetic patients with distal tibial disease are frequently considered unreconstructible; however, when studied with intraarterial digital subtraction angiography, the dorsal pedal artery is frequently found to be patent. We have reviewed our recent experience with 96 patients, 94% of whom had diabetes and had 97 bypasses placed to the dorsal pedal artery. All procedures were for limb salvage. Superimposed infection was present in 42.3%. In 92 instances where intraarterial digital subtraction angiography successfully visualized the dorsal pedal artery, 91 bypasses were placed. In 12 other cases where the dorsal pedal artery was not visualized by intraarterial digital subtraction angiography but audible with the continuous-wave Doppler, bypasses were completed successfully in six. All procedures were performed with vein. Inflow was taken from the femoral artery in 48, popliteal artery in 45, tibial artery in 2, and from a femoral tibial graft in 2. Perioperative mortality was 1.92%. Actuarial graft patency, limb salvage, and patient survival were 82%, 87%, and 80%, respectively at 18 months. We conclude that bypass grafting to the dorsal pedal artery can be reliably performed with acceptable short-term results. An attempt should always be made to visualize the foot vessels angiographically, especially in diabetic patients, so that this valuable option in arterial reconstruction will not be overlooked.     

Role of nuclear cardiology for determining management of patients with stable coronary artery disease

Both radionuclide angiography and myocardial perfusion imaging provide important insights that determine the management of patients with stable coronary artery disease. Both nuclear cardiology procedures have clearly demonstrated use in the noninvasvie identification of severe (left main or three-vessel) coronary artery disease and the noninvasive assessment of prognosis and thereby determine which patients should be sent to coronary angiography. Both radionuclide angiography and myocardial perfusion imaging provide prognostic information that is independent of resting left ventricular function and coronary anatomy and thereby influence the decision regarding which patients should be sent to coronary revascularization. This review considers the evidence supporting the uses of these nuclear cardiology procedures and provides suggestions regarding their cost-effective application.     

Use of twenty-four hour infusions of intracoronary tissue plasminogen activator to increase the application of coronary angioplasty.

Coronary arteries occluded by long lengths of thrombus are usually considered unattractive for angioplasty. Nine patients (8 male, mean age 50.1 years) undergoing angiography for unstable angina were found to have single vessel disease considered unsuitable for angioplasty as the vessel was occluded by a long length of thrombus. These patients were treated with 24 hr intracoronary infusions of 100 mg tPA in an attempt to make angioplasty feasible. Marked thrombolysis occurred in 7 patients who received uncomplicated infusions. One case was unsuccessful due to catheter displacement, while another had the infusion ceased due to an intracerebral bleed from a previously silent A-V malformation. This was the only major complication. Angioplasty was attempted in 6 of 7 cases where lysis had been achieved, with success in all lesions attempted. This reports shows that intracoronary tPA infused over prolonged periods produces excellent thrombolysis, making angioplasty feasible in some patients who were previously unsuitable.     

Critical care elements in a rehabilitation nursing course.

This article describes a specialized rehabilitation education program, based on adult learning theory, that was developed to promote retention of rehabilitation nurses at MetroHealth Center for Rehabilitation in Cleveland. The curriculum encompasses the skills required to care for rehabilitation patients needing both advanced rehabilitation nursing and critical care nursing. Critical care and rehabilitation nurses collaborated in the presentation of topics and were guided by the course coordinators. Learners were chosen based on experience in rehabilitation, with priority given to those certified in rehabilitation nursing. A variety of evaluation methods elicited positive responses. A 6-month postcourse survey also was completed to assess the long-term effects of the course.     

Female pseudohermaphroditism in a neonate born to a mother with polycystic ovarian disease

A newborn with female pseudohermaphroditism (profound masculinization of the external genitalia and preservation of the internal female genitalia) is presented. During pregnancy progressive hirsutism was noted in the mother, and polycystic ovaries were found at cesarean section. The serum testosterone level in the cord blood was elevated markedly (1,232 ng./dl). After birth the serum testosterone levels of the mother and newborn decreased dramatically. Over-all it appears that the polycystic ovaries were the source of the excessive androgen secretion that caused maternal and fetal masculinization during the pregnancy.     

An assessment of intrarenal hydrostatic pressure measurements in the diagnosis of acute renal allograft rejection

Postoperative intrarenal pressure measurements may be an aid to the diagnosis of acute renal transplant rejection, especially in patients treated with cyclosporine. Serial measurements of intrarenal pressure were made in 38 recipients using a fine-needle technique. Thirty-two intraoperative and 207 postoperative measurements were made, and 39 clinical rejection episodes (23 confirmed by biopsy) monitored. Intraoperative pressures in grafts with immediate function (37.4 +/- 4.0 mmHg, mean +/- SEM) were not significantly different from those with delayed function (30.9 +/- 4.8 mmHg), whereas postoperative pressures were greater (P less than 0.01) in kidneys with acute tubular necrosis (29.4 +/- 1.9 mmHg) than in functioning grafts (20.4 +/- 0.9 mmHg). Pressures recorded during clinical rejection episodes (44.3 +/- 2.3 mmHg) exceeded (P less than 0.001) those during quiescent periods (23.6 +/- 1.0 mmHg). During rejection episodes, higher pressures (P less than 0.01) were recorded from tender or palpably enlarged grafts (52.5 +/- 3.0 mmHg) than in the absence of these signs (36.3 +/- 3.1 mmHg), and patients whose transplants biopsies showed cellular rejection tended to have greater pressures (50.1 +/- 4.1 mmHg) than those with concomitant vasculopathy (36.4 +/- 3.9 mmHg), but the latter did not reach statistical significance. In 7 cases of cyclosporine toxicity the intrarenal pressure was 17.8 +/- 4.2 mmHg. Using a diagnostic cut off point of 40 mmHg, the investigation failed to recognize 26% of acute rejection episodes--and, in the presence of acute tubular necrosis, it wrongly categorized 21% of nonrejectors. While its predictive capacity was limited, the test may occasionally be helpful in the differentiation of cyclosporine toxicity and rejection in functioning kidneys.