Reversal of renal failure and paraplegia after thoracoabdominal aneurysm repair

Repair of ruptured thoracoabdominal aortic aneurysms is complicated by high rates of perioperative paraplegia, renal insufficiency, and mortality. This report describes a patient with a ruptured thoracoabdominal aortic aneurysm in whom preoperative acute renal failure was reversed with hemodialysis, aortic replacement, and renal revascularization. Prompt cerebrospinal fluid drainage reversed delayed-onset postoperative paraplegia and led to immediate, complete neurologic recovery.

Implementation of total quality management after reconfiguration of services on a general hospital unit

In 1992 the New York State Office of Mental Health issued a statewide plan for mental health services to reduce the number of inpatient beds in state-run facilities from approximately 11,000 to between 6,000 and 8,000 by the year 2000. This reduction resulted in at least a 25 percent increase in psychiatric beds at local general hospitals. In 1992 Albany Medical Center Hospital's department of inpatient psychiatry established an interdisciplinary committee to address changes resulting from the reconfiguration of services to chronic mentally ill persons. The committee established procedures to use the principles of total quality management to respond to problems and to continuously improve the therapeutic milieu. The authors describe how these principles were used to create a patient satisfaction survey, to examine and improve part of the hospital admissions procedure, and to review and revise treatment planning documentation. A concurrent review committee reviews patients' records to ensure accuracy of documentation and quality of care.

Multiple recurrent branch retinal artery occlusions associated with varicella zoster virus

PURPOSE

The authors describe an immunocompetent patient who developed multiple recurrent branch retinal artery occlusions (BRAOs) associated with the varicella zoster virus (VZV).

METHODS

A 69-year-old woman with mild bilateral vitritis developed superior and inferior BRAOs in her right eye with decreased visual acuity to 20/40, and a peripheral BRAO inferotemporally in her left eye. One month later, the inferotemporal BRAO progressed proximally in her left eye with a decrease of visual acuity to 20/40. After an extensive negative systemic evaluation, she underwent a diagnostic pars plana vitrectomy of her right eye.

RESULTS

Vitreous fluid was positive for VZV DNA by polymerase chain reaction (PCR). The patient was treated with intravenous acyclovir and systemic oral steroids. After remaining disease free for 3 months, the patient had two recurrences: 1) a mild vitritis and 2) development of a new superior temporal artery occlusion in the left eye. Both recurrences were treated with oral acyclovir and systemic steroids. The patient remained recurrence free for 12 months on a maintenance dose of oral acyclovir, and for 4 additional months without acyclovir.

CONCLUSIONS

Varicella zoster virus can be associated with the syndrome of multiple recurrent BRAOs. The diagnosis of VZV-associated BRAO can be established by PCR of intraocular fluid.

Haemodialysis and ultrafiltration in babies weighing under 1000 g

Until now it has not be feasible to haemodialyse babies with renal failure who weigh less than 1000 g. Three babies weighing 630, 808, and 1140 g are described. They had multiorgan failure and could not be peritoneally dialysed. They were treated with veno-venous ultrafiltration and haemodialysis using a manual syringe driven technique that required only simple equipment. This method is highly labour intensive, but can provide control of fluid volume and plasma biochemistry in these very sick infants. Their prognosis, however, is determined by the underlying cause of their renal failure, and remains poor.

Environmental microbial challenges to an aseptic Blow-Fill-Seal process--a practical study

A Blow-Fill-Seal machine, set to aseptically fill sterile liquid TSB medium into 20 ml plastic containers, was subjected to a series of environmental microbial challenges in order to evaluate the effects of the room environment, and of the actions of persons in the room, on the sterility of the product. Despite a series of relatively severe stresses to the system, none of the units filled (approximately 44,000) were found, following incubation, to display growth.

Surgical considerations for hematogenous osteomyelitis

Surgical treatment of hematogenous osteomyelitis is uncommon in the literature. Indications for surgical decompression, along with a review of the literature, is presented. A case history of a 7-year-old male with hematogenous osteomyelitis of the first metatarsal treated by surgical decompression and 12-month follow-up is discussed.

Linkage analysis of late-infantile neuronal ceroid-lipofuscinosis

The neuronal ceroid-lipofuscinoses (NCL) are a group of neurodegenerative disorders with an autosomal-recessive pattern of inheritance. There are 3 main categories of childhood NCL, namely, infantile, late-infantile, and juvenile NCL. These can be distinguished on the basis of age of onset, clinical course, and histopathology. A number of variant forms of NCL have also been described, and these show symptoms intermediary between the main classical forms. The genes for both the infantile and juvenile forms of NCL have previously been mapped to chromosome areas 1p32 and 16p12, respectively. The gene for late-infantile NCL (LINCL), CLN2, has been excluded from both these loci, but its location is as yet unknown. Recently, CLN5, the gene for the Finnish variant form of LINCL, was mapped to 13q21.1-32. Using the 3 microsatellite markers which were most tightly linked to CLN5, we have excluded CLN2 from this region using a subset of 17 families. Thus, CLN2 represents a fourth distinct genetic locus involved in the pathogenesis of NCL.

What do we mean by "sterility"?

In a "President's Comment" (PDA Newsletter, August 1993) James Akers referred to such numbers, and numerical statements, as: 10(-3), 10(-6), 1cfu/m3, 3cfu/Rodac plate, 90 feet per minute, 0.005 inches of water, 80 degrees C, 20 air changes per hour, and 0.1% with 95% level of confidence. He posed the question "Where did all these numbers come from?" These are, of course all numbers instantly recognisable by those acquainted with the art and science of parenteral manufacture. They are accepted (essential?) parameters of various aspects of this process. But Akers's question carries with it the implicit answer: "They just seemed like a good idea at the time." One might similarly add: 100, 10,000, 100,000, 115 degrees C for 30 minutes, 121 degrees C for 15 minutes, and so on.

Defined chromosomal assignment of CLN5 demonstrates that at least four genetic loci are involved in the pathogenesis of human ceroid lipofuscinoses

We demonstrate here that at least four genetically separate loci are involved in the pathogenesis of human neuronal ceroid lipofuscinoses (NCLs), fatal brain disorders of children. Earlier the assignments of the infantile and juvenile subtypes of NCL to 1p32 and 16p12 had revealed two loci; and here a variant subtype of the late-infantile form of NCL is mapped to a well-defined region on 13q21.1-q32, whereas the clinically similar, classical form of late-infantile NCL was found to represent the fourth, yet-unidentified NCL locus. The linkage disequilibrium was crucial for locus assignment in our highly limited family material, and the data exemplify the significance of this phenomenon in the random mapping of rare human diseases.

Rapid and stable gene expression in hippocampal slice cultures from a defective HSV-1 vector

Stable transfer of genetic information into neurons is a powerful strategy to elucidate specific mechanisms of neurophysiology and to develop therapies for neurological disorders. To evaluate the optimal parameters for efficient gene delivery of defective herpes simplex virus type one (HSV-1) vectors into a specific brain region, an HSV-1 vector expressing E. coli beta-galactosidase was used to infect organotypic cultures of hippocampal slices. beta-Galactosidase was expressed as early as 2 h after infection in a dose-dependent manner as measured on immunoblots, and reached a maximum level after approximately 35 h. Expression of the RNA and the antigen was still evident after the longest time sampled (11-12 days), whereas no beta-galactosidase was ever detected in cultured slices infected with a control virus lacking the reporter gene. Hippocampal cells expressing the reporter gene outlined the contour of the neuronal cell body layers in fields CA3 and dentate gyrus; such correspondence was less evident in field CA1. Anatomical, morphological, and immunohistochemical criteria also confirmed that the majority of these infected cells were neurons. beta-Galactosidase was also detected in the somata and processes of infected interneurons. Tests for synaptic pathology associated with virus infection showed no changes in pre- and postsynaptic markers.

Prognosis in low grade non-Hodgkin's lymphoma: relevance of the number of sites involved, absolute lymphocyte count and serum immunoglobulin level

Eighty-eight patients with low grade non-Hodgkin's lymphoma were followed for a median period of 63 months. Sixty-eight per cent of the group were centrocytic/centroblastic B cell lymphomas by the updated Kiel classification. Fifty-one (58 per cent) of the patients were stage IV by the Ann Arbor classification. In 18 of these patients the bone marrow was the only site of extranodal involvement. Univariate survival analysis showed that the sum of involved sites was more discriminatory than Ann Arbor stage. Analysis by site of involvement showed that the liver and other intraabdominal sites were associated with worse survival than involvement of peripheral lymph nodes. Bone marrow and spleen involvement were not significantly associated with short survival. Increasing age at presentation was strongly associated with shorter survival and was also inversely correlated with serum albumin. Both low absolute lymphocyte count (< 1.0 x 10(9)/l), low serum IgG level (< 10 g/l) and low total immunoglobulins on presentation were significantly associated with short survival. Multivariate analysis showed that age, serum albumin and number of involved sites gave the best survival prediction. The sum of involved sites, immunoglobulin level and absolute lymphocyte count may be useful objective markers of prognosis in low-grade non-Hodgkin's lymphoma.

Non-cardiac benefits of human recombinant erythropoietin in end stage renal failure and anaemia

Recombinant human erythropoietin (r-HuEpo) is now available to correct the anaemia of end stage renal failure. The clinical consequences of increasing the haemoglobin concentration in children on dialysis are incompletely documented; a placebo controlled study is essential when assessing subjective changes, for example in appetite or other aspects of quality of life. A single blind, placebo controlled crossover study in 11 children with end stage renal failure was performed to assess the clinical benefits resulting from correction of anaemia. Ten of the 11 children completed 36 weeks of the study and seven completed both 24 week limbs. Subcutaneous administration of r-HuEpo twice a week resulted in an increase in haemoglobin concentration, from 73 to 112 g/l. This was associated with an objective improvement in exercise tolerance, and a subjective improvement in physical performance and health, and better school attendance. No consistent effect was seen on appetite, growth, psychosocial functioning, biochemical control, or peritoneal dialysis efficiency. A small but clinically unimportant increase in systolic and diastolic blood pressure was seen in five children. One child on antihypertensive treatment required an increase in dosage during r-HuEpo while another child required a reduction in treatment. These findings, together with the important cardiac benefits previously described during r-HuEpo treatment, support the use of r-HuEpo in all children with end stage renal failure and anaemia.

Bioethics: social work's response and training needs

Hospital social workers (N = 255) from ten urban teaching hospitals in seven states were surveyed regarding their practice responses and training needs in bioethics. Responses to twenty-one practice situations in bioethics were analyzed in terms of levels of encountering ethical concerns, clinical participation and preparedness to handle ethical concerns. Whereas worker responses were greater in practice situations appearing more psychosocial than biomedical in nature, training needs were greater in those situations appearing more biomedical than psychosocial in nature. Rationing of health care, the number one training need across service specialties, stands out as the practice situation in which ethical concerns were encountered with the least preparation and participation. Prior training in ethical principles and analysis and service on a hospital ethics committee associated significantly with higher levels of worker responses. Implications for social work education and practice in today's health care environment are presented.

Surgical aspects of chronic peritoneal dialysis in the neonate and infant under 1 year of age

Since 1982 eight patients under 1 year of age with end-stage renal failure have been treated by chronic peritoneal dialysis (CPD) following insertion of an abdominal Tenckhoff catheter. We routinely perform a partial omentectomy now, and in males undertake bilateral exploration of the groins at the time of catheter insertion, with herniotomy or ligation of the patent processus vaginalis as required. Up to January 1990, 19 straight double-cuff catheters had been inserted with a total follow-up of 244.5 patient months. The median age at the initial catheter insertion was 14.6 weeks (range, 2 days to 11 months) and the median weight was 3.89 kg (range, 2.2 to 5.5). Peritonitis was the most common complication, with 46 episodes, representing one episode of peritonitis per 5.3 patient months on dialysis. The frequency of peritonitis has decreased in the last 6 months since all patients have been dialysed by two caregivers. The present rate of peritonitis is 1 episode per 10 patient months on dialysis. One patient has died of septicemia secondary to associated congenital abnormalities, one patient has regained renal function, and two patients have been transplanted, one successfully. Five patients are currently dialysing via their abdominal Tenckhoff catheters and awaiting transplantation. We conclude that neonates and infants under 1 year of age can be treated satisfactorily by CPD to enable successful preparation for transplantation later in childhood.