Predicting failure in polytetrafluoroethylene vascular access grafts for hemodialysis: a pilot study

In order to determine if serial, noninvasive evaluation of polytetrafluoroethylene (PTFE) vascular access grafts could identify a subgroup of patients at risk for thrombosis, the authors studied flow characteristics, using duplex ultrasonic scanning, in 18 hemodialysis patients with forearm loop grafts. On average, five examinations were performed per patient over the 10-month study period. Seven episodes of thrombosis occurred in six patients. The mean Doppler flow in grafts that subsequently thrombosed was significantly lower than in those that did not (544 +/- 218 ml/min versus 843 +/- 391 ml/min, p less than 0.001). The interval from last examination to thrombosis ranged from 13 to 58 days. At a defined cut-off flow of 450 ml/min, this test yielded a sensitivity of 83% and a specificity of 75% for episodes of thrombosis occurring within 2 to 6 weeks. The authors conclude that episodes of thrombosis in PTFE arm loop grafts are usually preceded by significantly lower Doppler-measured flow than grafts that do not thrombose and that it may be possible, by this means, to identify grafts at risk.     

Toxic shock syndrome after inguinal hernia repair. Report of a case with patient survival

A 40-year-old man developed fulminant multisystem failure several days after elective repair of an inguinal hernia. Toxic shock syndrome (TSS) was diagnosed. There was, however, no evidence of wound infection at the time of multisystem failure. Only later in his hospital course did the wound drain. Staphylococcus aureus was cultured from the wound and was the presumed etiologic agent in the patient's life-threatening illness. The patient recovered fully with supportive care, antibiotics, and surgical debridement of the inguinal hernia site. This case is discussed in the context of existing literature on the toxic shock syndrome. The site of infection is typically nonsuppurative, but the systemic manifestations are typically life threatening. The responsible organism is commonly believed to be a strain of S. aureus that expresses a toxin (TSS toxin-1) that effects multisystem failure, but which also diminishes the local inflammatory response and explains the benign appearance of the wound. Although this is a rare clinical entity, elective surgical procedures complicated by fatal TSS have been reported. Surgeons should understand this disease and the management necessary to avert mortality.     

Testicular microlithiasis: sonographic and clinical features.

Eleven cases of bilateral diffuse microlithiasis of the testes were evaluated sonographically. The presence of testicular microlithiasis was coincidental to the presence of testicular neoplasms (n = 2), nontesticular malignant lesion in the abdomen or chest (n = 2), subfertility (n = 2), varicocele (n = 1), epididymitis (n = 1), testicular maldescent (n = 1), scrotal trauma (n = 1), and transient scrotal pain (n = 1). Clinical follow-up suggested that testicular microlithiasis is an asymptomatic nonprogressive condition. Sonographic examination of testicular microlithiasis shows diffuse hyperechoic nonshadowing foci measuring 1-2 mm in diameter throughout both testes. The diagnosis of testicular microlithiasis was pathologically proved in five cases. In six cases, the diagnosis was made on the basis of the sonographic appearance (n = 6), clinical information and follow-up (n = 6), and radiologic demonstration of testicular microcalcifications (n = 3). The sonographic appearance of testicular microlithiasis is specific, and we believe that biopsy or orchiectomy in these cases is unnecessary.     

A leg ulcer as manifestation of metastatic squamous cell vaginal carcinoma

Cutaneous metastasis of vaginal carcinoma is extremely rare. So far, the total number of reported skin metastasis of vaginal carcinoma is only one. We present another case with an unusual manifestation of vagina carcinoma metastasis: skin metastasis presenting as a leg ulcer on the lower leg.