Guide wire directed manipulation of malfunctioning peritoneal dialysis catheters: a critical analysis

PURPOSE

To evaluate patency rates after guide wire directed manipulation of malfunctioning continuous ambulatory peritoneal dialysis (CAPD) catheters.

MATERIALS AND METHODS

During a 58-month period, 23 patients underwent 34 outpatient guide wire directed manipulations of their CAPD catheter to improve function (n = 30) or reduce pain and improve function (n = 4) during dialysis. Catheter patency rates were subsequently determined by review of departmental, hospital, and dialysis center charts; procedural reports; and patient telephone interviews.

RESULTS

Among 12 patients who underwent a single guide wire directed manipulation, long-term (> 30 days) catheter patency was achieved in seven (58%). With use of the Kaplan-Meier survival method, the 3-, 6-, and 12-month probability of patency after a single guide wire manipulation was 0.61, 0.54, and 0.11, respectively. The mean duration of patency achieved in this group was 131 days (range, 2-421 days). In those patients (n = 8) who underwent multiple catheter manipulations (n = 19), 11 (58%) procedures resulted in long-term patency, with each patient (100%) achieving at least one such period. The Kaplan-Meier survival method determined the probability of patency in this group at 3, 6, and 12 months to be 0.75, 0.69, and 0.54, respectively. The mean secondary catheter patency was 235 days (range, 2-646 days). Overall, 75% of patients followed up achieved at least one period of long-term catheter patency during the time of this study. One (3%) episode of postprocedure peritonitis occurred.

CONCLUSION

Guide wire directed CAPD catheter manipulation is a relatively simple outpatient procedure that restores long-term catheter function for most patients with minimal risk for a major complication. Patients with nonfunctioning CAPD catheters who do not have peritonitis or sepsis will most likely benefit from at least one attempt at radiologic manipulation of their catheter.

Role of protein kinase C in beta 2-adrenoceptor function in cultured rat proximal tubule epithelial cells

Renal sodium excretion is regulated by the adrenergic system. We recently demonstrated the presence of functional beta 2-adrenoceptors (beta 2-AR) in cultured rat proximal tubule epithelial cells beta 2-AR activation resulted in increases in Na-K-adenosinetriphosphatase (Na-K-ATPase) activity and transcellular sodium transport as a consequence of increased apical sodium entry. The purpose of this study was to determine the role of protein kinase C (PKC) on beta 2-AR-dependent increases in Na-K-ATPase activity and sodium transport in proximal tubules. To determine the effect of PKC on basal function, cultured rat proximal tubule cells were exposed to phorbol 12-myristate 13-acetate (PMA). PMA increased apical Na entry (+/-80%), decreased Na-K-ATPase activity (+/-25%), and prevented increases in Na-K-ATPase activity after sodium entry facilitation with monensin. Decreases in Na-K-ATPase activity were associated with decreases in sodium transport (+/-30%). To determine whether beta 2-AR function was transduced by PKC, PKC activity was measured in cells exposed to the selective beta 2-AR agonist metaproterenol. Metaproterenol caused increases in PKC activity, which were blocked by a beta 2-AR but not by a beta 1-AR-receptor antagonist. beta 2-AR-dependent increases in apical Na entry, Na-K-ATPase activity, and sodium transport were blocked by calphostin C or staurosporine. To determine whether PKC had additional effects on beta 2-AR function, cells were exposed to metaproterenol and PMA. Metaproterenol-induced increases in Na-K-ATPase activity and sodium transport were blocked by PMA. In conclusion, beta 2-AR-mediated increases in Na-K-ATPase activity and sodium flux are transduced by PKC acting through increases in apical Na entry. However, activation of PKC by phorbol esters inhibits beta 2-AR-dependent increases in Na-K-ATPase activity and sodium transport.

Inheritance of wing feather development rate in guinea fowl (Numida meleagris)

1. A study of primary wing feather development rate in guinea fowl revealed genetic control through a single pair of sex-linked alleles. The allele for slow feathering (K) was dominant over that for rapid feathering (k+). 2. Wing feather sexing showed 94% accuracy in 10-d-old keets. 3. Incidence of rapid feathering allele (k+) was higher in the population selected for high body weight compared to the unselected population.

Multiple neoplasms of the salivary gland and the lung

We describe a patient who presented with Warthin's tumour of the salivary gland which was followed by a bronchial carcinoid and subsequently by a squamous cell carcinoma of the lung. Such a presentation of three neoplasms in an individual is an uncommon occurrence.

Two stage reconstruction for the Shepherd's crook deformity in a case of polyostotic fibrous dysplasia

Polyostotic fibrous dysplasia leads to progressive and disabling deformity involving the proximal femur. Conventional methods of treatment have been ineffective in controlling this problem. Two stage reconstruction was carried out in a case of polyostotic fibrous dysplasia with bilateral shepherd's crook deformity. Bilateral subtrochanteric osteotomies with intramedullary fixation in the first stage and intertrochanteric osteotomies in the second stage with nail plate fixation was done to provide definitive control of the deformity. Bone graft was not used.

Keratoderma hereditaria mutilans (vohwinkel's syndrome)

We report two cases of Vohwinkel's syndrome in son and mother presenting with a progressive palmoplantar keratoderma with 'honeycomb' appearance associated with constricting bands encircling digits of hands and feet along with keratotic plaques on dorsum of hands and feet. Both had associated sensorineural deafness.

Genetic studies on primary antibody response to sheep erythrocytes in guinea fowl

1. The primary antibody response to sheep erythrocytes was determined by haemagglutination test in guinea fowl. The effects of various genetic and non-genetic factors on immune response to sheep RBCs in guinea fowl were also estimated. 2. The immune response to sheep RBCs was normally distributed in guinea fowl with mean titre at 1.534 +/- 0.014. 3. In guinea fowl, effects on titre values of sire and variety (feather colour) were significant whereas sex and sex x variety interaction effects were non-significant. 4. The estimate of heritability for immune response to sheep RBCs in guinea fowl was 0.35 +/- 0.17.

PU.1 functions in a cell-autonomous manner to control the differentiation of multipotential lymphoid-myeloid progenitors

Transcription factor PU.1 is required for the development of lymphoid and myeloid progenitors during fetal hematopoiesis. By generating chimeric animals using PU.1-/- ES cells or PU.1(-/-) hematopoietic progenitors, we demonstrate that PU.1 functions in an exclusively cell-autonomous manner to regulate the development of the lymphoid-myeloid system. Multipotential lymphoid-myeloid progenitors (AA4.1+, Lin-) are significantly reduced in PU.1(-/-) embryos and fail to differentiate into B lymphoid or myeloid cells in vitro. These results suggest that the lymphoid and myeloid lineages develop in the fetal liver from a common hematopoietic progenitor not shared with erythrocytes and megakaryocytes. Finally, the Ikaros gene is expressed in PU.1 mutant embryos, suggesting that PU.1 and Ikaros are independently required for specification of embryonic lymphoid cell fates.

Western blot analysis of serological response in Helicobacter pylori in acid peptic diseases

A prospective study was undertaken in 70 patients presenting with acid peptic disease with the objective of characterising the serological response to Helicobacter pylori and finding antigens specific for the serodiagnosis of H. pylori infection. H. pylori status was assessed by smear microscopy, rapid urease activity, culture and histopathology of endoscopic gastric antral biopsy specimens. Serological characterisation was carried out by using western blotting of various antigenic components of H. pylori and subsequent enzymatic detection of antibodies against them. Four reactive bands in the molecular weight range of 45-65 kDa were present in all subjects irrespective of H. pylori status. Four to six immunoreactive bands in the molecular weight range of 21-45 kDa were found only in patients with positive H. pylori status and histopathologically proven gastritis. These immunoreactive components may be valuable in specific immunodiagnosis of H. pylori infection.

Perioperative anaesthetic considerations for patients undergoing lung transplantation

PURPOSE

Five thousand, two hundred and eight lung transplants were performed worldwide before April, 1996. This review will discuss lung transplantation from an historical perspective, its indications, donor and recipient selection criteria, donor lung preparation, surgical considerations, perioperative anaesthetic management, and associated morbidity and mortality.

SOURCE

Recent literature on perioperative anaesthetic management of lung transplantation and experience from international centres including the Toronto Lung Transplant Group and the St. Louis Lung Transplant Group.

PRINCIPAL FINDINGS

Lung transplantation comprises of a family of operations, including single lung transplant, bilateral single lung transplant, lobar transplant and block heart-lung transplant. Improved donor lung preservation techniques have increased the duration of cold ischaemic time. The advent of bilateral single lung transplant has decreased the requirement for cardiopulmonary bypass, and airway complications have been reduced by adoption of the telescoping bronchial anastomoses. Advances in perioperative monitoring (including transoesophageal echocardiography), pulmonary vasodilators (e.g., nitric oxide and prostaglandin E1), cardiopulmonary bypass and ventilatory management, and a better understanding of the pathophysiological processes during the procedure have improved perioperative anaesthetic management. Also, advances in broad spectrum antibiotics and immunosuppressant drugs have improved the outcome by better management of the complications of infection and rejection.

CONCLUSION

Lung transplantation improves the quality of life with marginal improvement in life expectancy of the recipients. It is an expensive procedure requiring continued resources for long term management of these patients.

Effects of ketorolac versus bupivacaine coadministration during patient-controlled hydromorphone epidural analgesia after thoracotomy procedures

We studied the comparative effects of ketorolac versus bupivacaine supplementation of hydromorphone (HM) patient-controlled epidural analgesia (PCEA) on the HM requirement, postoperative pain, and pulmonary function in 62 consenting patients after thoracotomy procedures. Patients were randomly assigned to receive one of three different combinations of analgesic medications after the operation according to a double-blind, placebo-controlled study. The treatment groups consisted of: Group 1 (n = 23): PCEA HM 3-mL (0.15 mg) bolus doses + saline 1 mL intravenously (IV) q6h, Group 2 (n = 20): PCEA HM (0.15 mg) in 0.125% bupivacaine 3-mL bolus doses + saline 1 mL IV q6h, and Group 3 (n = 19): PCEA HM 3-mL (0.15 mg) bolus doses + ketorolac 1 mL (30 mg) IV q6h. Epidural HM and supplemental analgesic requirements, pain visual analog scale (VAS) scores, the incidence of nonincisional pain, and side effects were recorded at 24 and 48 h after surgery. Bedside pulmonary function tests were performed using a Puritan Bennett 100TM (Puritan-Bennett Corp., Wilmington, MA) spirometer before and 24 and 48 h after surgery. IV ketorolac supplementation of HM PCEA significantly reduced the incidence of nonincisional pain and the HM requirement over 48 h compared with the HM PCEA alone group (7% vs 26%; 3 +/- 1.6 mg vs 5.3 +/- 2.8 mg). Both ketorolac and bupivacaine supplementation of HM PCEA reduced the severity of pain on coughing and on movement compared with HM PCEA alone on postoperative day (POD) 1. Significant reductions in forced vital capacity, forced expiratory volume in 1 s, forced expiratory flow 25%-75% of the vital capacity, and peak expiratory flow rate (PEFR) were noted on PODs 1 and 2 in all three treatment groups. The decrease in PEFR on PODs 1 and 2 was significantly less with ketorolac compared with bupivacaine supplementation. We conclude that ketorolac supplementation of HM PCEA reduces the incidence of nonincisional pain and HM requirement compared with HM PCEA alone and may have a beneficial effect on pulmonary function compared with bupivacaine supplementation of HM PCEA in postthoracotomy patients.

Isolation of Salmonella senftenberg bacteriophages

A total of 61 bacteriophages were isolated from 100 strains of Salmonella senftenberg. Six bacteriophages were selected for typing purposes which were specific for S. senftenberg. Five phages, SasL1 to SasL5 were morphologically similar; phage SasL6 was morphologically different from the others. These phages fall into two morphological groups none of which correspond to the known tailed enterobacterial phage species. Hence, two new phage species represented by SasL1 and SasL6 are proposed.

Cytochromes P450 (CYP) in tropical fishes: catalytic activities, expression of multiple CYP proteins and high levels of microsomal P450 in liver of fishes from Bermuda

Hepatic microsomes prepared from 10 fish species from Bermuda were studied to establish features of cytochrome P450 (CYP) systems in tropical marine fish. The majority (7/10) of the species had total P450 content between 0.1 and 0.5 nmol/mg, and cytochrome b5 content between 0.025 and 0.25 nmol/mg. Ethoxycoumarin O-deethylase (ECOD) and aminopyrine N-demethylase (APND) rates in these 7 species were 0.23-2.1 nmol/min/mg and 0.5-11 nmol/min/mg, respectively, similar to rates in many temperate fish species. In contrast to those 7 species, sergeant major (Abudefduf saxatilis) and Bermuda chub (Kyphosus sectatrix) had microsomal P450 contents near 1.7 nmol/mg, among the highest values reported in untreated fish, and had greater rates of ECOD, APND, ethoxyresorufin O-deethylase (EROD) and pentoxyresorufin O-depentylase than did most of the other species. Freshly caught individuals of all species had detectable levels of EROD and aryl hydrocarbon hydroxylase (AHH) activities. Those individuals with higher rates of EROD activity had greater content of immunodetected CYP1A protein, consistent with Ah-receptor agonists acting to induce CYP1A in many fish in Bermuda waters. Injection of tomtate and blue-striped grunt with beta-naphthoflavone (BNF; 50 or 100 mg/kg) induced EROD rates by 25 to 55-fold, suggesting that environmental induction in some fish was slight compared with the capacity to respond. AHH rates were induced only 3-fold in these same fish. The basis for disparity in the degree of EROD and AHH induction is not known. Rates of APND and testosterone 6 beta- and 16 beta-hydroxylase were little changed by BNF, indicating that these are not CYP1A activities in these fish. Antibodies to phenobarbital-inducible rat CYP2B1 or to scup P450B, a putative CYP2B, detected one or more proteins in several species, suggesting that CYP2B-like proteins are highly expressed in some tropical fishes. Generally, species with greater amounts of total P450 had greater amounts of proteins related to CYP2B. These species also had appreciable amounts of CYP3A-like proteins. Thus, many fishes in Bermuda appear to have induced levels of CYP1A; some also have unusually high levels of total P450 and of CYP2B-like and CYP3A-like proteins. These species may be good models for examining the structural, functional and regulatory properties of teleost CYP and the environmental or ecological factors contributing to high levels of expression of CYP in some fishes.

Electroencephalographic bispectral index correlates with intraoperative recall and depth of propofol-induced sedation

The bispectral (BIS) index and 95% spectral edge frequency (SEF) of the electroencephalograph (EEG) have been used to study the anesthetic and sedative effects of intravenously (i.v.) administered drugs. This prospective study was designed to evaluate the effectiveness of the BIS index and 95% SEF for assessing the level of propofol-induced sedation and amnesia during regional anesthesia. Ten consenting adult patients undergoing surgery with regional anesthesia were administered propofol in increments of 10-20 mg i.v., every 5-10 min until they became unresponsive to tactile stimulation (i.e., mild prodding or shaking). The BIS index and 95% SEF were continuously recorded from a bifrontal montage (Fp1-Cz and Fp2-Cz) using the Aspect B500 monitor. The depth of sedation was assessed clinically at 5- to 10-min intervals using the observer's assessment of alertness/sedation (OAA/S) scale, with 1 = no response to tactile stimulation to 5 = wide awake. Each patient was shown a picture of an animal (cat) prior to administration of an initial dose of propofol, 40 mg i.v.. Subsequently, patients were administered intermittent bolus doses of propofol, 10-20 mg i.v., and shown different pictures upon achieving OAA/S scores of 4, 3, and 2 during the onset of and recovery from propofol-induced sedation. Picture recall was tested upon arrival of the patient in the postanesthesia care unit (PACU). Of the two EEG variables studied, the BIS index exhibited a better correlation with the OAA/S scores during both the onset (Spearman's rho = 0.744) and recovery (Spearman's rho = 0.705) phases of propofol-induced sedation. With the increasing depth of sedation, there was a progressive decrease in the BIS index (OAA/S score of 5, BIS = 94.5 +/- 2.9; 4, 93.3 +/- 3.3; 3, 89 +/- 6.1; 2, 80.1 +/- 8.7; 1, 75.6 +/- 7.5; mean +/- SD). Conversely, there was a progressive increase in the BIS value during recovery from propofol sedation (OAA/S score of 1, BIS = 75.6 +/- 7.5; 2, 82.4 +/- 10.5; 3, 84.9 +/- 5.9; 4, 93.8 +/- 0.8). Although the changes in the 95% SEF values were less consistent during the onset phase, this EEG variable increased from 16.4 +/- 5.0 to 19.3 +/- 5.6 as the OAA/S score increased from 1 to 4 during the recovery phase. Patient recall of the intraoperative pictures decreased with increasing depth of sedation and decreasing BIS values (OAA/S:% BIS:% recall = 5:94.5 +/- 2.9:100%; 4:93.4 +/- 3:63%; 3:87.3 +/- 6.1:40%; 2:80.8 +/- 8.3:0%; 1:75.6 +/- 7.5:0%). The BIS index appears to be a useful variable for assessing the depth of propofol-induced sedation. Increasing depth of sedation was associated with a significant decrease in intraoperative picture recall.

The changing profile of Plasmodium falciparum malaria

Resurgence of malaria has been noted in the Rohtak district (Haryana, India) after the recent floods. The profile of 66 patients of P. falciparum infection who were admitted to our hospital over one month in October 1995 is reported. While only a minority of cases (< 15%) presented with an uncomplicated course, all others developed one or more complication(s), some of them very rare. The usual manifestations viz, cerebral malaria, black water fever and algid malaria seen in the past were observed in less than half the patients. The remaining presented with unusual complications like haemolytic anaemia (46.2%), severe anaemia (37.9%), thrombocytopaenia (18.2%), pancytopaenia (6%), adult respiratory distress syndrome (4.5%) often not seen in sporadic cases of falciparum malaria which occurred in the past in this district. Similarly all deaths (15.1%) were noted in patients with rarer manifestations and only one patient died of cerebral malaria. This study confirms the occurrence of severe and complicated falciparum malaria in this part of the country.

Evidence of two catalytically active carnitine medium/long chain acyltransferases in rat liver peroxisomes

Peroxisomal matrix proteins were extracted from the highly purified peroxisomes with sodium pyrophosphate, and the membranes were sedimented by high speed centrifugation. Biochemical marker enzyme analyses revealed a quantitative release of a number of well-known peroxisomal matrix proteins from the purified peroxisomes. In contrast, carnitine medium/long chain acyltransferase activity, assayed with decanoyl-CoA and palmitoyl-CoA as substrates, was equally distributed in the membrane and the matrix fractions. The matrix and the membrane enzyme activities were differentially affected by a number of detergents. The enzyme in the membrane fraction showed higher malonyl-CoA sensitivity compared to the enzyme in the matrix fraction. The enzyme(s) from the purified peroxisomes or the peroxisomal membranes was quantitatively solubilized by sodium cholate, and the cholate-solubilized enzyme retained malonyl-CoA sensitivity. The membrane enzyme was separated from the matrix enzyme by hydroxylapatite column chromatography. The separation of the membrane enzyme or the matrix enzyme by hydroxylapatite column chromatography resulted in loss of malonyl-CoA sensitivity. The partially purified membrane and the matrix enzymes showed broad substrate specificity, and the highest enzyme activities for both were observed with decanoyl-CoA. In contrast to the matrix enzyme, the membrane enzyme was strongly inhibited by high concentrations (> or = 50 microM) of acyl-CoAs (> 10 carbons in length). The matrix enzyme showed a 2.5-fold lower Km for carnitine compared to the membrane enzyme. The catalytic properties of the partially purified matrix enzyme appear to be similar to the well-characterized peroxisomal carnitine octanoyltransferase, though we find highest activity with decanoyl-CoA rather than octanoyl-CoA as a substrate. The data presented clearly indicate that the membrane and the matrix enzyme activities are due to different proteins.