Management of left ventricular assist device infection with heart transplantation

BACKGROUND

Left ventricular assist devices (LVADs) are being used as bridges to heart transplantation (HT). Infection of the LVAD in this patient population represents a serious complication, as simple LVAD removal or delaying HT may result in death. To improve outcomes in this group of patients, we performed HT in the presence of LVAD infection.

METHODS

Eighteen patients underwent LVAD implantation followed by HT. Ten underwent HT in the absence of LVAD infection (group 1); and 8, in the presence of LVAD infection (group 2). All patients were treated similarly except for modification of immunosuppression in group 2 patients.

RESULTS

Infectious and noninfectious complications were equivalent between the two groups. There was no difference between groups in regard to intraoperative deaths (one versus none), long-term survival (8/10 versus 7/8), wound complications (three versus none), and mean length of hospital stay after HT (21 versus 26 days).

CONCLUSIONS

Patients with LVAD infection are too seriously ill to allow LVAD removal or delay of HT. Transplantation in the face of infection is an effective treatment option.

The impact of elevated serum IgA and race on primary recipient renal allograft survival

This study correlated overall serum IgA levels in pretransplant (preTx) sera with graft survival. IgA levels, determined by nephelometry, were normally distributed, with a mean level of 255 +/- 139 mg/dl and a median of 234 mg/dl in 631 adult primary kidney allograft recipients and a mean level of 213 +/- 123 mg/dl with a median of 196 mg/dl for 100 retransplant recipients. Improved 3-year survival was associated with a high preTx IgA serum level in primary recipients (Kaplan-Meier analysis, P = 0.01), but not in retransplant patients. After stratifying by race, IgA correlated with graft survival in Caucasian, Hispanic, and "other" (Middle Eastern, Indian subcontinent, and Asian) primary recipients (P < or = 0.04), but not in African Americans. Higher survival rates were not associated with IgA in primary recipients stratified for rejection episodes, blood transfusions, or HLA-DR mismatches. Graft survival was improved in patients with > 2 HLA-AB mismatches and serum IgA above the median. PreTx IgA level and IgA alpha-HLA activity were significantly associated in preTx sera of primary renal allograft recipients (chi 2 = 7.145, P = 0.01), although only 9% (12/133) of sera tested displayed IgA anti-HLA class I reactivity. Thus, enhanced graft survival mediated by elevated serum IgA levels may due in part to competition for allograft HLA class I binding with deleterious Ig subclasses or immune effector cells. Elevated serum IgA may also reflect an altered immunoregulatory state. The results suggest that, depending on the racial group, preTx serum IgA levels are a prognostic indicator of graft survival in primary renal allograft recipients.

Raynaud's phenomenon in the emergency department

Raynaud's phenomenon manifests as triphasic color changes of the digits, induced by exposure to low temperature or emotional stress. It is a relatively common disorder, estimated to affect 5% to 10% of the general population and 25% to 30% of otherwise healthy women. Although usually self-limiting, it can be severely painful and debilitating, and complicated by ulcerations and tissue necrosis. For the emergency physician treating a patient with an acute presentation of the phenomenon, the main challenges are to achieve adequate pain control, reverse vasospasm, and maintain viable tissue. Emergency treatment can also extend to patient education and arrangement of appropriate referrals and follow-up care.

Renal transplantation

Renal transplantation is the treatment of choice for patients with end-stage renal disease. The authors present a rational approach to the pre-, intra-, and postoperative care required for successful patient management.

Influence of sleep deprivation on learning among surgical house staff and medical students

BACKGROUND

Sleep deprivation as a result of in-house night call may alter capacity to learn. Surgical residents and medical students, in both sleep-deprived and rested states, read surgical journal articles and later answered questions regarding their content as a measure of ability to learn while participating in scheduled night call.

METHODS

Medical students (n = 35) and residents (n = 21) rotating on surgical services kept logs of hours slept during a 4-week study period. Subjects read six selected articles at separate early morning sittings during weeks 1 and 3. A multiple choice test was given 1 week after each session to assess short-term recall, and all tests were given again 3 months later to assess retention of information over the longer term. Scores were compared with the sleep data. Subjective measures of fatigue and motivation elicited from subjects also were evaluated.

RESULTS

Sleep deprivation (4 hours or less uninterrupted sleep per night) resulted in increased fatigue and decreased motivation among medical students and residents (p < 0.05, t test). Objective scores on tests administered 1 week and 3 months after reading did not show an effect attributable to sleep deprivation (p > 0.05, t test).

CONCLUSIONS

Sleep deprivation leads to subjective feelings of increased fatigue and decreased motivation. Residents and medical students, however, whether sleep deprived or not, obtain comparable scores on objective tests measuring both short-term and long-term retention of newly learned material. The ability to learn medically relevant information does not appear to be significantly altered by the degree of sleep deprivation associated with clinical rotations on surgical services.

Internal displacement of a gastrostomy button: an unusual case of gastric outlet obstruction

Gastric outlet obstruction caused by gastrostomy tube migration should not occur in patients who have gastrostomy buttons. This is the first reported case of gastric outlet obstruction caused by internal displacement of a gastrostomy button.

A prospective randomized comparison of quadruple versus triple therapy for first cadaver transplants with immediate function

In January 1988, we initiated a prospective, randomized comparison of prophylactic antilymphoblast globulin (ALG; quadruple therapy) versus no prophylactic ALG (triple therapy) in the setting of immediate graft function (defined by a brisk diuresis and a 20% decline in serum creatinine within 24 hr). Recipients were stratified according to presence of diabetes and age greater or less than 50 years. Recipients on quadruple therapy (n = 61) received 7 days of prophylactic Minnesota ALG (5 mg/kg on day 1, 10 mg/kg on day 2, 20 mg/kg on days 3-7). CsA, 10 mg/kg/day, began on day 6. AZA began at 2.5 mg/kg/day and was adjusted according to white blood cell count. Recipients on triple therapy (n = 60) began immediate CsA, 10 mg/kg/day orally and AZA, 5 mg/kg/day, tapering to 2.5 mg/kg/day by day 8. Both groups received identical prednisone tapers beginning at 1 mg/kg/day, decreasing to 0.5 mg/kg/day by 2 weeks and to 0.15 mg/kg/day by 6 months. Demographic characteristics between groups were not different with respect to diabetes, age, sex, race, per cent panel-reactive antibodies (PRA), or HLA matching. Follow-up ranged from 2 to 4.5 years. Patient survival was 93% for the quadruple therapy group and 90% for triple therapy. Actuarial graft survival was 79% in the quadruple group and 72% in the triple group (P = 0.18). Graft loss due to rejection occurred in 6/61 receiving ALG versus 7/60 in the immediate CsA group. Three of 4 high PRA recipients in the immediate CsA group lost their grafts within 30 days compared with none in the ALG group. The mean time to graft loss was significantly longer for the quadruple therapy group (17 +/- 8 months) compared with the triple therapy group (4 +/- 5 months), P = 0.006. The total number of rejection episodes was similar for both groups (29/61 vs. 31/60), as was the number who were rejection free (51% vs. 47%). The use of OKT3 was also similar between groups (28% vs. 30%). The quadruple therapy group had a higher incidence of CMV infection: 20% vs. 7% (P < 0.05), but no grafts or patients were lost as a result. Serum Cr was not different at 1 and 12 months (1.5 and 1.6 vs. 1.6 and 1.7, respectively), nor were Cr clearances (63 and 68 vs. 60 and 63). Conclusion. Early initiation of oral CsA in the setting of immediate graft function is not associated with significant nephrotoxicity.(ABSTRACT TRUNCATED AT 400 WORDS)

Pin sensation as a predictor of extensor carpi radialis recovery in spinal cord injury

The purpose of this prospective study was to determine if initial preservation of C5 pin sensation could predict extensor carpi radialis (ECR) motor recovery in the zone of partial preservation after spinal cord injury (SCI). The study compared initial C5 pin sensation and initial ECR strength as predictors of ECR motor recovery after C4 and C5 SCI. The initial motor and sensory evaluation was done less than seven days after injury. Motor power was graded from absent (0/5) to normal strength (5/5). Pin sensation was graded as absent (0/2) decreased (1/2) or normal (2/2). The manual muscle test was performed weekly to four weeks and than at three, six, and 12 months after injury. An ECR muscle grade of > or = 3/5 was defined as recovery. C5 pin sensation at the lateral antecubital fossa significantly correlated with ECR recovery to > or = 3/5 (p < 0.001). Only two of nine subjects with absent C5 pin sensation recovered ECR to > or = 3/5, whereas 14 of 15 subjects with 1/2 or 2/2 C5 pin sensation had ECR motor recovery to > or = 3/5. All ten subjects with 1/5 or 2/5 initial ECR strength had ECR motor recovery. Five of six subjects with 0/5 initial ECR strength and subsequent ECR recovery to > or = 3/5 were found to have C5 pin preservation. In conclusion the presence of 1/5 to 2/5 initial ECR strength or 1/2 or 2/2 C5 pin sensation were highly significant predictors of ECR motor recovery to > or = 3/5 in C4 and C5 motor complete quadriplegic subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Selective adrenergic agonists and colon motility in monkeys

Sympathetic stimulation during and after laparotomy and other surgical procedures may be a factor inducing postoperative ileus. In experiments conducted in fasting monkeys, the effects of the selective sympathetic agonists alpha 1 (phenylephrine), alpha 2 (ST-91), beta 1 (dobutamine), and beta 2 (terbutaline) on colon contractile activity were measured. Strain gauges were implanted on the colon. Recordings were made for 1 hour (control) and then for an additional hour during continuous infusion by one of a range of doses of each drug (experimental). The drug doses were chosen to cover both physiologic and pharmacologic concentrations. All of the sympathetic agonists caused a dose-dependent decrease in the frequency of colon contractions. The beta-agonists did so at a concentration that is sufficiently low to support a hypothesis that beta-stimulation leading to inhibition of smooth-muscle contraction may play an important role in the genesis of postoperative ileus.

Electrical injuries and lightning

Prolonged cardiopulmonary resuscitation is key to the resuscitation of lightning strike victims. Multiple accounts exist of successful revival of victims thought to be "dead" or in patients who have what is often believed to be unresuscitatable cardiac dysrhythmia. Victims of lightning injury may, in addition to their electrical injury, have secondary injuries that require expedient care if significant morbidity is to be avoided. They should be treated as any victim of trauma, that is, with a complete and thorough evaluation including hospitalization if warranted. In the absence of a cardiac arrest or serious secondary injury, care for the lightning strike victim is generally supportive in nature.

Small bowel transplantation promotes bacterial overgrowth and translocation

Alterations in the symbiotic relationship between immunocompromised hosts and their resident gut microflora may lead to serious complications following small bowel transplantation (SBT). This study examined the effects of SBT and cyclosporine (CsA) immunosuppression on gut bacterial populations and translocation to the mesenteric lymph nodes. Sixty adult male meat-fed Lewis rats were divided into six groups: normal controls, CsA alone (24 mg/kg im qod), CsA carrier vehicle alone, isografts, isografts given CsA, and allografts given CsA. Rats were killed after 3 weeks and segments of small bowel and colon were harvested for quantitative tissue culture. Mesenteric lymph nodes and blood were cultured to identify translocation. Transplantation alone led to an increase in gram-negative aerobes from 2.6 to 4.6 colony forming units/100 mg tissue (P less than 0.05) in the distal ileum (transplanted segment). Eighty-four percent of transplanted animals receiving CsA had bacteria recovered from their mesenteric lymph nodes compared to none in controls (P less than 0.001) and 20% in isografts not receiving CsA (P less than 0.02). Intestinal transplantation alone appears to promote gram-negative overgrowth while the addition of CsA therapy facilitates translocation to the mesenteric lymph nodes and may predispose to gut-associated sepsis following SBT.

Quantitative serum toxic screening in the management of suspected drug overdose

Data were collected on 176 consecutive cases of drug overdose evaluated in an emergency department. Quantitative serum toxic screening (TS) was performed for 164 (93%) of these patients; positive results were noted for 133 patients (81%). Six classes of drugs (ethanol, benzodiazepines, salicylates, acetaminophen, barbiturates, and tricyclic antidepressants) were responsible for nearly 70% of all drug detections and were associated with 80% of all admissions in this patient sample. Only two patients (1%) had drug-specific treatment initiated because of TS results. In 12 patients (7%), TS confirmed substances for which specific treatments had been initiated on clinical grounds. Four patients (2%) had drug-specific treatment discontinued because of TS results. Thirty-two patients (19%) were admitted to a medical service; however, only seven patients (4%) were admitted primarily because of TS results. All other patients were admitted because of clinical abnormalities that required inpatient care. It is concluded that only a few drugs are responsible for most drug overdoses. Moreover, TS results rarely change the treatment or disposition of overdose patients; these decisions are typically based on clinical parameters.

Arterial injury from a high pressure water jet: case report

We report the case of a patient who sustained a high-pressure water jet injury to the thigh while cleaning industrial piping. The patient presented with a puncture wound to the anterior thigh and a pulseless foot. Emergency arteriography was performed that revealed complete disruption of the superficial femoral artery. The patient underwent surgical exploration and debridement, and a successful repair of the disrupted artery was performed with a prosthetic arterial graft. A discussion of high-pressure water jet injuries and their management is presented.

Deep venous thrombosis of the upper extremity: diagnosis and treatment

Deep vein thrombosis of the upper extremity was long thought to be a benign disease, rarely complicated by pulmonary embolism and associated with minimal long-term morbidity. More recent observations have demonstrated however, that a significant number of patients will continue to have disabling symptoms after treatment with conservative measures and standard anticoagulation therapy, and that pulmonary embolism can occur in the course of the disease. Because of its significant morbidity and increasing incidence, an aggressive emergency department approach to diagnosis and early consideration of fibrinolytic therapy are recommended.

Acute cholecystitis in the emergency department

Acute cholecystitis is a frequent consideration in patients presenting to the emergency department with the challenging complaint of upper abdominal pain. It is estimated that 20% of American adults have gallstones, and of these a large percentage (about one-third) will at some point develop acute cholecystitis. The epidemiology and associated risk factors of acute cholecystitis are briefly reviewed along with the pathogenesis and clinical presentation of the disease. Finally, an approach to the diagnosis in the emergency department and suggested management is discussed including a comparison of the strengths and weaknesses of ultrasonography and hepatobilary scintigraphy.

Late postpartum eclampsia

A case of new-onset seizures occurring 12 days postpartum is described. The patient presented with headache, hypertension, and proteinuria. Postpartum eclampsia was diagnosed and IV magnesium sulfate was administered. The patient had no further seizures and did not require long-term anticonvulsants. Medical and neurologic evaluations failed to reveal any other etiology for the seizures.

Esophageal spasm following propranolol overdose relieved by glucagon

A case of propranolol overdose complicated by esophageal spasm preventing extrication of an orogastric lavage tube and relieved by intravenous glucagon is presented. Esophageal spasm is an infrequent complication of beta-adrenergic over-dose. Possible mechanisms of esophageal spasm and its relief with glucagon are discussed.

Coronary artery spasm. Part II

Coronary artery spasm can occur in several settings, often combined with coronary artery disease and thrombosis. Calcium channel blockers and beta-blockers are primary treatment modalities. The role of alpha-blocking agents remains unconfirmed.