A clinical approach to the management of a patient with suspected renovascular disease who presents with leg ischemia.

Atherosclerotic renal artery stenosis (ARAS) may cause hypertension, progressive renal failure, and recurrent pulmonary edema. It typically occurs in high risk patients with coexistent vascular disease elsewhere. Most patients with ARAS are likely to die from coronary heart disease or stroke before end-stage renal failure occurs. Recent controlled trials have shown that most patients undergoing angioplasty to treat renovascular hypertension still need antihypertensive agents 6 or 12 months after the procedure. Nevertheless, the number of antihypertensive agents required to control blood pressure adequately is lower following angioplasty than for medication alone. Trials assessing the value of revascularization for preserving renal function or preventing clinical events are only in the early recruitment phase. Revascularization should be undertaken in patients with ARAS and resistant hypertension or heart failure, and probably in those with rapidly deteriorating renal function or with an increase in plasma creatinine levels during angiotensin-converting enzyme inhibition. With or without revascularization, medical therapy using antihypertensive, hypolipidemic and antiplatelet agents is necessary in almost all cases.     

Ankle-brachial index and extent of atherothrombosis in 8891 patients with or at risk of vascular disease: results of the international AGATHA study.

AIMS: AGATHA (a Global Atherothrombosis Assessment) was designed to assess the extent of atherothrombosis and the use of the ankle-brachial index (ABI) in vascular patients. The principal hypotheses were that (1) in diseased patients, a low ABI was related to the number and site of vascular beds affected and (2) in at-risk patients without disease, a low ABI was related to the number of risk factors present. METHODS AND RESULTS: Patients were recruited consecutively by 482 clinicians in 24 countries and the ABI measurement was performed at a single visit. Of 8891 patients recruited, 1792 were defined as at risk and 7099 as with disease. Of the with-disease patients, 65.2% had one arterial bed affected, 27.6% two and 7.1% all three. Abnormal ABI (< or =0.9) was present in 30.9% of at-risk and 40.5% of with-disease patients. A lower ABI was weakly associated with an increasing number of risk factors in at-risk patients (r=-0.056, P=0.02) and with the site and number of arterial beds affected in with-disease patients (P<0.001). CONCLUSION: This large international study confirms that atherothrombotic disease often occurs at more than one site. The ABI is related to the risk factor profile and to the site and extent of atherothrombosis.     

Emergency Preparedness for Health Professionals in a Statewide AHEC Program: the first two years.

In 2003 through 2005, the California Statewide Area Health Education Centers (AHEC) Program developed an educational delivery system, through partnerships with six AHECs and state organizations concerned with emergency preparedness, to train for public health emergency preparedness the health professionals who practice primarily in the state's medically underserved areas. Four educational modules--General Emergency Preparedness, Bioterrorism, Chemical and Radiologic Agents, and Emerging Infections--were developed and delivered by a trained, multidisciplinary, community-based faculty. The authors discuss the organization, partnerships, curriculum, faculty, characteristics of trainees, outcomes of the program, effects for AHECs, and the evaluation used to commit the organization and program process to the intended program objectives during the two-year period. Over 9,000 health professionals attended one or more of the 462 educational presentations. Approximately one third of attendees were physicians, and 82% of the learners were from sites that typically care for the underserved. Important to the success of the program (which still continues in a revised form) were the types of partnerships, an orientation of the curriculum to all-hazards disaster preparedness, the delivery of educational sessions at clinical sites, and the increased capacities of community AHECs to facilitate continuing professional education. The challenges were the diminished role of a key partner organization, uncertainties within the funding agency, and the widespread geographic area to address.     

Variability of ankle and brachial systolic pressures in the measurement of atherosclerotic peripheral arterial disease.

The aim of this study was to determine the variability of measurements of ankle and brachial systolic pressures and ankle brachial ratios in order to assess their suitability for use in epidemiological studies of arterial disease in the lower limbs. Thirty-six subjects had repeat measurements taken by four observers on two separate days using a Doppler probe and random zero sphygmomanometer. The variability in the measurement of ankle systolic pressure was comparable to that for brachial systolic pressure. The 95% confidence limits of one measurement of the ankle brachial ratio was estimated to be +/- 16%, reducing to +/- 10% for the mean of four measurements taken by two observers on two days. Analysis of variance indicated that the variability in the measurement of ankle brachial ratios attributable to observers, days, timing of measurements on the same day, and repeat measurements was considerably less than the "biological" variability between subjects and between legs. These results suggest that repeatability of the ankle brachial ratio is such that a single measurement is suitable for most epidemiological studies of atherosclerotic peripheral arterial disease.     

Comparison of selective media for isolation of Campylobacter jejuni/coli

A comparison of Skirrow's, Butzler's, Blaser's, Campy-BAP and Preston media for Campylobacter spp was made using human, animal and environmental specimens. Butzler's medium gave the lowest isolation rate and Preston medium, which was the most selective, the highest isolation rate. Enrichment culture using Preston enrichment broth gave a higher isolation rate than direct plating onto Preston medium.     

Meningioma presenting as an intraoral mass in a patient with neurofibromatosis type 1

A 77-year-old woman with neurofibromatosis type 1 presented with ill-fitting dentures due to intraoral extension of a right temporal fossa mass. Computed tomographic scanning demonstrated that the masticator space mass bowed the zygomatic arch and remodeled the lateral orbit and maxillary sinus walls, findings that were consistent with the clinical diagnosis of a neurofibroma with possible malignant transformation. However, light microscopic, immunohistochemical, and ultrastructural examination of tissue from an incisional biopsy specimen were diagnostic of meningioma. This case illustrates that the clinicopathologic differential diagnosis of an enlarging mass in patient with neurofibromatosis should include sporadic, unrelated neoplasms as well as tumors known to be associated with the syndrome.