A Case of Acute Reversible Encephalopathy with Neuronal Intranuclear Inclusion Disease Diagnosed by a Brain Biopsy: Inferring the Mechanism of Encephalopathy from Radiological and Histological Findings

A 75-year-old man presented with headache and disturbance of consciousness. Magnetic resonance imaging revealed edema localized mainly in the cortex and linear contrast enhancement. A brain biopsy revealed numerous astrocytes with inclusion, and genetic testing demonstrated prolonged GGC repeats in NOTCH2NLC. The present case provided two novel insights into the mechanism underlying encephalopathy associated with neuronal intranuclear inclusion disease. First, the histological findings at a site with contrast enhancement on magnetic resonance imaging did not demonstrate any organic association, such as the presence of inflammation or ischemic changes. Second, the imaging and cerebrospinal fluid findings demonstrated increased cerebral blood flow and opening of the blood-brain barrier, indicating the cause of the cerebral swelling.

Misuse of Discharge Antimicrobial Prescription in the Emergency Department: An Observational Study at a Tertiary Care Center

We conducted a restrospective cohort study of patients discharged from the emergency department at a tertiary care center with an antimicrobial prescription. More than half of the prescribed antimicrobials were misused and frequently inappropriate for various infectious diseases. In this study, we analyzed the physician-related and environment-related factors predicting misuse.

1843. Prescribers’ Characteristics and Unnecessary/Inappropriate Antimicrobial Prescription in the Emergency Department: An Observational Study at a Tertiary Care Center

Background

Antimicrobials are commonly prescribed in the emergency department despite the fact that a large proportion of these drugs are misused. However, comprehensive studies of factors leading to the misuse of antimicrobials in the emergency department (ED) are few. Understanding current practice of antimicrobial use in the ED is important for developing an effective antimicrobial stewardship program for this setting.

Methods

We performed a 1-year cohort study of patients discharged from the ED in a tertiary care center with a prescription for oral antimicrobial agents. A retrospective audit of the appropriateness of antimicrobial prescription using prespecified criteria was performed by two infectious disease physicians. Patterns in antimicrobial prescription and the physician-, patient-, and environment-related factors predicting unnecessary/inappropriate antimicrobial prescription were evaluated.

Results

Of the 36,308 annual visits to the ED, 1,555 patients (4.3% of visit) received oral antimicrobial prescriptions upon discharge. Pneumonia (18.2% [283/1,555]) was the most common indication for antimicrobial prescription. Of the 1,555 antimicrobial prescriptions issued, 852 (52.9%) were considered inappropriate. Factors significantly associated with unnecessary/inappropriate antimicrobial prescription included the lack of comorbidities (adjusted odds ratio [aOR]: 1.39; 95% confidence interval [CI]: 1.03–1.87), late-night visit (aOR: 1.48 95%; CI: 1.05–2.09), the spring-summer season (aOR: 1.13 95%; CI: 1.03–1.25), higher postgraduate year (>10 years) (aOR: 1.77 95%; CI: 1.24–2.52), and physicians in surgical subspecialties (aOR: 4.51 95%; CI: 3.34–6.09).

Conclusion

More than half of oral antimicrobial prescriptions in the ED were inappropriate. Unnecessary or inappropriate antimicrobial prescriptions were frequently issued during the late-night shift, and by older physicians and physicians in surgical subspecialties.

Disclosures

All authors: No reported disclosures.

Case study of paired cadaver renal allografts from the same donor: influence of local DIC kidney and concomitant acute rejection on early graft outcome

We report the clinical course of 2 recipients whose renal allografts were obtained from the same cadaver donor after cardiac arrest. The recipients showed different outcomes after transplantation. Graft biopsy after reperfusion revealed disseminated intravascular coagulation (so-called DIC kidney) and severe acute tubular necrosis (ATN) in both recipients. While one graft showed primary nonfunction, the other graft became functional after a post-operative anuric period. Serial graft biopsies performed during the oligo-anuric period revealed recovery of ATN and no intra-glomerular fibrin thrombi, but development of acute rejection was detected in both recipients. The left kidney graft showed more severe local DIC kidney than the right kidney, as well as more severe acute rejection in the oligo-anuric period. Despite aggressive anti-rejection therapy, the left kidney graft showed primary nonfunction. Therefore, severe acute rejection leading to primary nonfunction might have been related to more severe ischemic injury and more extensive local DIC kidney in the left kidney.

Surgical significance of supernumerary parathyroid glands in renal hyperparathyroidism

In secondary hyperparathyroidism (2HPT) fundamentally all parathyroid glands, including supernumerary glands, become hyperplastic, and stimulation of parathyroid glands continues after parathyroidectomy (PTx). Therefore supernumerary glands have special significance during surgery for 2HPT, whether persistent or recurrent HPT. In the present study 570 patients underwent initial total PTx with a forearm autograft. The frequency, type, location, histopathology, and clinical significance of the supernumerary glands were evaluated. At the initial operation 90 supernumerary glands were removed from 82 to 570 patients (14.4%); 12 patients (2.1%) required extirpation of supernumerary glands for persistent/recurrent HPT. Altogether 104 supernumerary glands were identified at operation in 94 of the 570 patients (16.5%). Among these 104 glands, 25 (24.0%) were of the rudimentary, or split, type and 79 (76.0%) of the proper type. Supernumerary glands were most frequently identified in the thymic tongue (53/104, 51.0%); 32 (60.4%) of these 53 glands were identified only microscopically. In 6 of the 570 cases (1.1%), reoperation was required for persistent HPT due to supernumerary glands located in the mediastinum, and 6 patients underwent neck reexploration for recurrence. Histopathologically, 61 of 104 (58.7%) supernumerary glands, including 36 glands recognized only microscopically, showed diffuse hyperplasia, and 43 (41.3%) displayed nodular hyperplasia. Residual small supernumerary glands with diffuse hyperplasia have the potential to be transformed to nodular hyperplasia during long-term hemodialysis. Therefore all parathyroid glands including supernumerary glands should, if possible, be removed at the initial operation. Routine removal of the thymic tongue and careful examination of the regions surrounding the lower poles of the thyroid, especially on the left side, are important steps in the surgical treatment.

Beneficial effect of donor pretreatment with thromboxane A2 synthase inhibitor on the graft survival in pig liver transplantation

With a known evidence that thromboxane A2 (TxA2) is elevated in the perfusate of the liver transplant (LTx) recipient, TxA2 is likely to play a role in the pathogenesis of preservation reperfusion injury. In this study, effectiveness of donor pretreatment with TxA2 synthase inhibitor, sodium ozagrel (SO), in the prevention of primary nonfunction (PNF) was investigated. LTx was performed for eight pigs which received the grafts treated with SO during harvest surgery (treatment group). Eight other animals were the control group. All of the animals in the treatment group survived longer than 7 days, whereas 37.5% (three of eight) of the control group died from PNF within 3 days postoperative. Significantly lower serum LDH levels were noted in the treatment group than control. Serum thromboxane B2 (TxB2) and 6-keto-PGF1 alpha were both elevated in the control group. However, a significant decrease in TxB2 was noted in the treatment group after reperfusion of the liver graft. Polymorphonuclear leukocyte (PMN) infiltration in the graft after reperfusion was significantly greater in the control group than in the treatment group. Hepatocyte microsteatosis was prominent in the control group after reperfusion. Donor pretreatment with SO was effective in the prevention of PNF after LTx. The beneficial effects of this drug are improvement in microcirculation allowing better perfusion of cold preservative and the blocking effect of platelet-PMN-endothelial interaction which is thought to be a primary etiology in reperfusion injury.

Effect of prolonged delayed graft function on long-term graft outcome in cadaveric kidney transplantation

One-hundred-and-twenty-six cadaveric renal transplantations were analyzed for the effect of post-transplant renal function on graft outcome. Thirty-one grafts functioned immediately after transplantation (Group 1), 54 grafts failed to function temporarily up to 8 posttransplant days as evidenced by urine output < 400 ml/day or hemodialysis support (Group 2), 33 grafts showed temporary nonfunction > 8 days (Group 3) and 8 grafts never functioned (group 4). Five-year graft failure rates were 6.5% (2/31), 13.0% (7/54), 42.4% (14/33) and 100% (8/8) for Groups 1, 2, 3 and 4, respectively. Actuarial 5-year graft survivals were 89.4%, 84.8%, 50% and 0% for Groups 1, 2, 3 and 4, respectively (p < 0.05). The most common cause of graft failure was the chronic rejection in 13, of which 9 were in Group 3. Acute rejection episodes during the first 3 months post-transplant in Group 3 (15 of 33, 45.5%) was slightly higher than that in Group 1 (10 of 30, 33.3%) or Group 2 (19 of 54, 35.2%) but the differences were not significant. Acute rejection episodes were associated with graft loss only 1 of 19 (5.3%) patients in Group 2 whereas 9 of 15 (47.4%) were seen in Group 3. The authors conclude that prolonged DGF is associated with a higher incidence of graft failure, particularly secondary to chronic rejection after 1 year posttransplant. Moreover, acute rejection based on prolonged DGF probably plays a major role in the development of chronic rejection.

Ten-year experience in the use of double balloon catheter for kidney procurement from non-heart beating donors in cadaveric kidney transplantation

One-hundred-and-twenty patients underwent first cadaveric kidney transplantation from the non-heart beating donors. All of the organs were procured with the use of double balloon catheter for in situ cooling. The mean warm ischemic time and cold ischemic time were 10.7 +/- 17.0 minutes and 18.9 +/- 11.4 hours, respectively. One- and 5-year graft survival rates were 85.0 and 72.7%, respectively. Among 120 recipients, 30 (25%) grafts functioned immediately (immediate function), 82 (68.3%) grafts functioned after varying length of oliguric periods (delayed function) and 8 (6.7%) grafts never functioned (non-function). The mean age of the donors in the group of immediate function (31.5 +/- 16.1 yr) was significantly lower than those of other two groups. The mean warm ischemic time in the group of immediate function (6.0 +/- 11.2 min) was significantly shorter than that of delayed function. However, there was no significant difference in donor hypotensive episode, types of preservation fluid and cold ischemic time between the groups. The conclusion is that the ultimate result of cadaveric kidney transplant from the non-heart beating donors with the use of double lumen catheter is acceptable despite a relatively high incidence of delayed graft function.

HLA-DRB1 matching as a recipient selection criterion in cadaveric renal transplantation

We retrospectively examined the effect of HLA-DRB1 matching at the DNA level compared with serological HLA-DR matching on acute rejection and graft survival in patients who underwent primary cadaveric renal transplantation. For patients with serological HLA-DR zero mismatch, the incidence of acute rejection in patients with zero DRB1 mismatch (3/20; 15%) was significantly lower than in those with one or two DRB1 mismatches (10/21; 48%). Five-year graft survival in patients with zero DRB1 mismatch was 100%, whereas that in those with one or two DRB1 mismatches was 76%, although the difference was not statistically significant. The fact that HLA-DRB1 matching at the DNA level influenced incidence of graft rejection after cadaveric renal transplantation is analogous to results in living-related renal transplantation. It is suggested that avoidance of mismatching for DRB1 alleles at the DNA level in recipient selection of cadaveric renal transplantation leads to an improvement of graft outcome.

Total parathyroidectomy with forearm autograft for secondary hyperparathyroidism in chronic renal failure

One hundred twenty-eight patients with chronic renal failure and secondary hyperparathyroidism underwent total parathyroidectomy with forearm autograft. Postoperative clinical improvement was remarkable. In all cases, the grafted tissue functioned well, and reimplantation of the cryopreserved parathyroid tissues was unnecessary. Intact 1-84 parathyroid hormone was more sensitive than C-terminal parathyroid hormone in parathyroid hormone level (PTH) gradient assays of grafted and nongrafted forearm. The study of hypocalcemia was also helpful in obtaining more distinct PTH gradients. Five of 119 patients had supernumerary parathyroid glands (4.2%), which preoperative noninvasive image diagnosis of parathyroid glands was helpful in detecting.