PATENCY-2 trial of vonapanitase to promote radiocephalic fistula use for hemodialysis and secondary patency

OBJECTIVE

Arteriovenous fistulas created for hemodialysis often fail to become usable and are frequently abandoned. This prospective trial evaluated the efficacy of vonapanitase, a recombinant human elastase, in increasing radiocephalic fistula use for hemodialysis and secondary patency.

METHODS

PATENCY-2 was a randomized, double-blind, placebo-controlled trial in patients on or approaching the need for hemodialysis undergoing radiocephalic arteriovenous fistula creation. Of 696 screened, 613 were randomized, and 603 were treated (vonapanitase n = 405, placebo n = 208). The study drug solution was applied topically to the artery and vein for 10 min immediately after fistula creation. The primary endpoints were fistula use for hemodialysis and secondary patency (fistula survival without abandonment). Other efficacy endpoints included unassisted fistula use for hemodialysis, primary unassisted patency, fistula maturation and unassisted maturation by ultrasound criteria, and fistula procedure rates.

RESULTS

The proportions of patients with fistula use for hemodialysis was similar between groups, 70% vonapanitase and 65% placebo, (p = 0.33). The Kaplan-Meier estimates of 12-month secondary patency were 78% (95% confidence interval [CI], 73-82) for vonapanitase and 76% (95% CI, 70-82) for placebo (p = 0.93). The proportions with unassisted fistula use for hemodialysis were 46% vonapanitase and 37% placebo (p = 0.054). The Kaplan-Meier estimates of 12-month primary unassisted patency were 50% (95% CI, 44-55) for vonapanitase and 43% (95% CI, 35-50) for placebo (p = 0.18). There were no differences in the proportion of patients with fistula maturation or in fistula procedure rates. Adverse events were similar between groups. Vonapanitase was not immunogenic.

CONCLUSIONS

Vonapanitase treatment did not achieve clinical or statistical significance to meaningfully improve radiocephalic fistula surgical outcomes. Outcome in the placebo group were better than in historical controls. Vonapanitase was well-tolerated and safe.

TRIAL REGISTRATION

clinicaltrials.gov: NCT02414841 (https://clinicaltrials.gov/ct2/show/NCT02414841).

Arteriovenous fistula patency in the 3 years following vonapanitase and placebo treatment

OBJECTIVE

This study explored the long-term outcomes of arteriovenous fistulas treated with vonapanitase (recombinant human elastase) at the time of surgical creation.

METHODS

This was a randomized, double-blind, placebo-controlled trial of 151 patients undergoing radiocephalic or brachiocephalic arteriovenous fistula creation who were randomized equally to placebo, vonapanitase 10 μg, or vonapanitase 30 μg. The results after 1 year of follow-up were previously reported. The current analysis occurred when the last patient treated was observed for 3 years. For the current analysis, the primary end point was primary patency; the secondary end points included secondary patency, use of the fistula for hemodialysis, and rate of procedures to restore or to maintain patency.

RESULTS

There was no significant difference in the risk of primary patency loss with vonapanitase 10 μg or 30 μg vs placebo. When seven initial patency loss events related to cephalic arch and central vein balloon angioplasty were excluded, the risk of patency loss was reduced with vonapanitase overall (hazard ratio [HR], 0.63; P = .049) and 30 μg (HR, 0.51; P = .03). In patients with radiocephalic fistulas (n = 67), the risks of primary and secondary patency loss were reduced with 30 μg (HR, 0.37 [P = .02] and 0.24 [P = .046], respectively). The rate of procedures to restore or to maintain fistula patency was reduced with 30 μg vs placebo (0.23 vs 0.72 procedure days/patient/year; P = .03) and also reduced in patients with radiocephalic fistulas with 30 μg vs placebo (0.17 vs 0.85 procedure days/patient/year; P = .048).

CONCLUSIONS

In this study, vonapanitase did not significantly improve primary patency in the primary analysis but did significantly improve primary patency in an analysis that excluded patency loss due to cephalic arch and central vein balloon angioplasty. In patients with radiocephalic fistulas, 30 μg significantly improved primary and secondary patency. Vonapanitase 30 μg decreased the rate of procedures to restore or to maintain patency in the analysis that included all patients and in the subset with radiocephalic fistulas.

Application of human type I pancreatic elastase (PRT-201) to the venous anastomosis of arteriovenous grafts in patients with chronic kidney disease

PURPOSE

To explore the safety and efficacy of PRT-201 applied to the outflow vein of a newly created arteriovenous graft (AVG).

METHODS

Randomized, double-blind, placebo-controlled, single-dose escalation study of PRT-201 (0.01 to 9 mg) applied to the graft-vein anastomosis and adjacent outflow vein immediately after AVG placement. The primary outcome measure was safety. The efficacy measures were intraoperative increases in outflow vein diameter and blood flow rate, primary unassisted patency, and secondary patency by dose groups (placebo, low, medium, high and All PRT-201).

RESULTS

A total of 89 patients were treated (28 placebo and 61 PRT-201). There were no significant differences in the proportion of placebo and PRT-201 patients reporting adverse events. Intraoperative outflow vein diameter increased 5% (p=0.14) in the placebo group compared with 13% (p=0.01), 15% (p=0.07) and 12% (p<0.001), in the low, medium and high groups, respectively. The comparison between the high and placebo groups was marginally statistically significant (p=0.06). The intraoperative blood flow did not change in the placebo group, and increased in the low, medium and high groups by 19% (p=0.34), 36% (p=0.09) and 46% (p=0.02), respectively. The low group had the longest primary unassisted and secondary patency and the fewest procedures to restore or maintain patency; however, the differences between groups were not statistically significant.

CONCLUSIONS

PRT-201 was well tolerated and increased AVG intraoperative outflow vein diameter and blood flow. Low dose tended to increase secondary patency and decrease the rate of procedures to restore or maintain patency. Larger studies with these doses will be necessary to confirm these results.

The impact of cytomegalovirus infection ≥1 year after primary renal transplantation

We studied the impact of a first post-transplant cytomegalovirus (CMV) infection greater than one year after primary kidney transplantation. Risk factors for developing late CMV were acute rejection and donor-recipient CMV status. Of those developing late CMV, 35% were donor (D) positive, recipient (R) negative; however, 23% were D+R+, 22% D-R+, and 15% D-R-. Late CMV was associated with significantly decreased patient and graft survival.

Selective retransplant after graft loss to nonadherence: success with a second chance

Nonadherence (NA) is a difficult posttransplant problem that can lead to graft loss. A retransplant is controversial because of a fear of recurrent NA. We reviewed our center's data base and identified 114 kidney recipients who lost their graft to overt NA; of this group, 35 (31%) underwent a retransplant after a thorough reevaluation. We compared this NA retransplant group to a control group of second transplant recipients who did not lose their first graft to overt NA (non-NA) (n = 552). After 8 years of follow-up, we found no significant differences between the groups in actuarial graft or patient survival rates, renal function, or the incidence of biopsy-proven chronic rejection. However, 5 of 35 (14%) NA recipients versus 10 of 552 (2%) non-NA recipients lost their retransplant to NA (p = 0.0001). Twenty of 35 (57%) of the NA group exhibited repeat NA behavior after retransplant. We conclude that prior graft loss to NA is associated with increased graft loss to NA after retransplant. However, the majority of NA retransplant recipients did well-with overall long-term outcomes similar to those of the non-NA group. With careful patient selection and aggressive intervention, prior overt NA should not be an absolute contraindication to retransplantation.

A Comparison of Cryopreserved Vein Allografts and Prosthetic Grafts for Hemodialysis Access

In hemodialysis patients with insufficient vasculature for creation of a native arteriovenous fistula (AVF), a polytetrafluoroethylene (PTFE) graft is commonly utilized. Because of PTFE complications, our group and others have used cryopreserved cadaver femoral vein allografts (Synergraft [SYN], CryoLife, Marietta, GA) in selected patients. Based on our experience with these allografts, we hypothesized that they were more resistant to thrombosis than PTFE grafts. The purpose of this study was to compare the thrombosis rates of SYN and PTFE grafts in a prospective, randomized fashion. Our study was interrupted when the FDA ordered CryoLife, Inc. to retain certain vascular tissue products, and patient accrual stopped in 2003. Most patients referred for hemodialysis access are evaluated with bilateral, upper extremity Doppler ultrasound. Starting in 2001, those with insufficient vasculature for native AVF were offered randomization into the PTFE or SYN groups. All accesses were placed in the upper extremity, above the elbow. Access patency and complications were recorded, and failure was defined as access removal, abandonment, or replacement of > 50% with a new conduit. Prior to FDA interruption of the study, 27 patients were randomized into each group. Patient characteristics were similar, but there were significantly more males and African-Americans in the SYN group. No significant differences were seen in primary or secondary patency, number of thrombectomies, revisions, or total interventions. Significantly more fistulagrams were performed in the SYN group (p < 0.05). No infections were seen in either group, but 2 aneurysms occurred in the SYN group. Nine (33%) patients in each group died with functioning access. Access failures: In the SYN group, 8 of 27 (30%) failed, with 5 failing from multiple access stenoses unresponsive to balloon angioplasty; in the PTFE group 4 of 27 (18%) failed, with 2 failing from multiple stenoses. In conclusion, for initial hemodialysis access in patients without sufficient vasculature for native AVF, our results do not support the routine use of SYN allografts in the general dialysis population.

Experience with cryopreserved cadaveric femoral vein allografts used for hemodialysis access

The purpose of this study was to review the patency and complications of cryopreserved vein allografts used for hemodialysis access, and to compare them to a group with polytetrafluoroethylene (PTFE) grafts. Patients without adequate vasculature for native fistula were implanted with vein allografts or PTFE grafts at the surgeon's discretion. Only cryopreserved (CRY) veins were used until January 2001, when decellularized, cryopreserved Synergraft (SYN) veins became available. The CRY group had 48 patients; the SYN group, 42 patients; the PTFE group, 100 patients, who were selected from billing records listing PTFE graft insertion. Patient demographics were similar. Primary and secondary patencies were not significantly different at 1 or 2 years between groups. Complications in PTFE versus CRY and SYN groups were as follows: infection, 10 % vs. 0% (p < 0.01); aneurysm, 2% vs. 18% (p < 0.001); and steal syndrome, 12% vs. 12% (p = NS). Significantly more vein allograft patients lost their accesses to aneurysm (p < 0.01) and multiple stenoses (p < 0.05), whereas PTFE patients lost significantly more accesses to infection (p < 0.01) and recurrent thrombosis (p < 0.05). We conclude that cadaver vein allografts have similar patency to PTFE grafts. These allografts are more resistant to infection but significantly more susceptible to aneurysms. When used, vein allografts should be monitored aggressively for the development of aneurysms.

Delayed graft function may not adversely affect short-term renal allograft outcome

INTRODUCTION

Delayed graft function (DGF) is commonly believed to adversely impact both short- and long-term renal allograft function. Because immunosuppressive therapy is commonly altered after DGF is identified, retrospective analyses are difficult to interpret. We therefore prospectively sought to examine the natural history of DGF in a controlled patient population under identical immunosuppressive protocols.

METHODS

Adult patients undergoing cadaveric renal transplantation were treated with sequential triple drug immunotherapy. High-dose steroids were administered in the operating room and rapidly tapered to 20 mg prednisone by post-operative day (POD) 6. Cyclosporine (CsA) microemulsion was begun on POD 1, and dosed asymmetrically at 12-h intervals to reach a daytime Cav of 650 ng/mL (utilizing 2-h and 6-h levels), while PM doses were adjusted to an AM trough of 300 ng/mL. Mycophenolate (1000 mg q12 h) was added on POD 3 in most patients and discontinued after 3 months. No induction agents were used. All patients were followed for at least 6 months.

RESULTS

Sixty consecutive patients received 64 allografts (four double grafts). In all, 17 patients required dialysis and were considered to have DGF. Eight of these patients received marginal organs turned down by at least one other centre. Cold ischaemia time was significantly longer in patients with DGF (24 h vs. 19 h, P < 0.01) All patients were treated as planned and there were no major protocol violations. One patient had primary non-function and was excluded from analysis. CsA trough and Cav values were similar between groups. Mean serum creatinine levels (mg/mL) fell more slowly in patients with DGF but there was no significant difference by 3 months (1.7 vs. 1.5) and the creatinine clearance was not significantly different between the groups after 1 year (71 cm3/min in DGF vs. 61 cm3/min, P = 0.13). Our data demonstrate that alterations in routine immunosuppressive strategies may not be necessary to achieve equivalent outcomes in patients with DGF.

Effect of cyclosporin pharmacokinetics on renal allograft outcome in African-Americans

African-Americans (A-As) experience inferior outcome after transplantation compared with other ethnic groups. Bioavailability of cyclosporin (CsA) has been implicated as a possible contributing factor. This paper describes the outcome of 32 A-A recipients of de novo renal allograft who received CsA-based triple immunotherapy according to individual pharmacokinetic profiles. Patients received CsA-microemulsion q 12 h, dosed initially at 3.5 mg/kg (8 am) and 3.0 mg/kg (8 pm). The am and pm doses were independently adjusted to achieve a 12-h area under the concentration-time curve (AUC0-12) of 6600-7200 nghr/mL and morning trough level (C0) of 250-325 ng/mL, respectively. Mean age was 43 +/- 12 yr, 37% (12) female. Mean AUC0-12 in 1 wk, 1, 3, 6, and 12 months were 7810 +/- 1880 nghr/mL, 9057 +/- 2097 nghr/mL, 7674 +/- 1912 nghr/mL, 7132 +/- 2040 nghr/mL, and 6503 +/- 1410 ngl/h with corresponding C0 of 301 +/- 79 ng/mL, 316 +/- 66 ng/mL, 275 +/- 59 ng/mL, 273 +/- 66 ng/mL, and 224 +/- 49 ng/mL, respectively. Acute rejection occurred in two patients (6%) 1 yr after transplantation. Prospective use of CsA pharmocokinetic profiles improves renal allograft outcome in A-As.

Clinical significance of eosinophils in suspicious or borderline renal allograft biopsies

AIMS

Renal allograft biopsies play a critical role in renal transplantation. Acute rejection characterized by tubulitis and intimitis is of primary concern. There is an association between eosinophilic infiltrates and irreversible acute rejection; however, the significance of eosinophils in biopsies that fall short of the diagnostic threshold for acute rejection has not been well studied. This report describes clinical course, treatment and long-term outcome of 5 transplant recipients with biopsy histology that showed borderline changes associated with eosinophilic infiltrates.

METHODS

Clinical records were selected for review on the basis of biopsy histology satisfying the following criteria: presence of interstitial infiltrates with eosinophils, absence of definitive criteria for acute rejection and absence of findings suggestive of infection or cyclosporine toxicity.

RESULTS

All identified biopsies occurred within the first month of transplantation, and histology showed varying degrees of patchy mononuclear cell infiltrates composed of lymphocytes, with eosinophilic infiltrates, but no evidence of acute rejection based on Banff criteria. These patients were taking trimethoprim-sulfamethoxazole and ranitidine at the time of biopsy. Serum creatinine returned to baseline levels in each case after stopping both drugs, and remained stable during the duration of follow-up without any documented episode of acute rejection. No patient received specific therapy for acute rejection.

CONCLUSION

This report suggests that independent of decisions on treatment with high-dose steroids or anti-lymphocyte antibody preparations, the management algorithm should include stopping drugs associated with acute interstitial nephritis when non-diagnostic biopsies show eosinophilic infiltrates.

Can a pharmacokinetic approach to immunosuppression eliminate ethnic disparities in renal allograft outcome?

Although renal allograft outcome correlates more closely with area under the concentration time curve (AUC) for cyclosporin (CsA) compared with the 12-h trough level (C0), few studies have prospectively evaluated pharmacokinetic monitoring in kidney transplantation. This paper describes a study designed to evaluate the impact of a novel approach to CsA-based immunosuppression on ethnic differences in renal allograft outcome. Sixty (32 African Americans and 28 Caucasians) renal transplant recipients were treated with cyclosporin-based triple therapy. Morning and evening doses were independently adjusted to reach an AUC0-12 of 6600-7200 ng h/mL and a C0 of 250-325 ng/mL, respectively. AUCs were measured within 48 h of starting CsA, and as often as necessary to maintain target levels. Only two patients experienced significant adverse events related to immunosuppression. One (Caucasian) developed haemolytic uremic syndrome and was converted to tacrolimus, while another (African American) developed acute vascular rejection. One graft was lost (Caucasian) due to death with a functioning graft. An average of 8 AUCs (range 5-13) were measured in the first 3 months. AUCs were significantly higher in African Americans compared with Caucasians only in the first and second month. C0 values were similar in both groups throughout the study period. A pharmacokinetic approach to immunosuppression allows individualization of CsA exposure, and appears to reduce ethnic disparities in renal allograft outcome.

Diurnal cyclosporine dosing optimizes exposure and reduces the risk of acute rejection after kidney transplantation

Acute rejection (AR) following transplantation may be due to episodic subtherapeutic cyclosporine (CsA) levels related to diurnal variation of hepatic drug metabolism. We postulated that asymmetrical dosing of CsA based on individualized pharmacokinetic profiles would optimize drug exposure and decrease the risk of AR. We prospectively treated all patients undergoing kidney transplantation with a diurnally split dose of CsA microemulsion given q 12 hours (3.5 mg/kg q a.m., 3.0 mg/kg qPM). Morning doses were adjusted to reach a day-time area under the concentration curve (AUC) of 7,800 ng hour/ml (utilizing 2 hour and 6 hour levels) and evening doses were adjusted to a morning trough of 300 ng/ml. Patients received high-dose steroids tapered to 20 mg prednisone by day 6. CsA was started within 36 hours and mycophenolate mofetil (1000 mg q 12 hour) was added on day 3 in most patients and continued for 3 months. Only one patient received antibody induction. Thirty kidneys (67% cadaveric) were transplanted into 28 adult patients (50% African American, 57% men). Therapeutic targets were reached in all patients prior to discharge and maintained during the study period. At 3 months follow-up, there was not a single episode of documented AR and mean creatinine was 1.5 +/- 0.1 mg/ml. Twelve patients required biopsy for allograft dysfunction; however no histological evidence of AR or CsA-toxicity was identified and the creatinine normalized in each case without altering immunosuppression. Patients continued to require increased CsA doses in the AM compared to the PM (P<0.05) throughout the study to maintain target levels. Diurnal dosing of CsA based on individual pharmacokinetic profiles optimizes CsA exposure and reduces the risk of AR during the first 3 months after transplantation.

Use of plain radiography to screen for cervical spine injuries

STUDY OBJECTIVE

Standard radiographic screening may fail to reveal any evidence of injury in some patients with spinal injury. The purposes of this investigation were to document the efficacy of standard radiographic views and to categorize the frequencies and types of injuries missed on plain radiographic screening of the cervical spine.

METHODS

All patients with blunt trauma selected for radiographic cervical spine imaging at 21 participating institutions underwent a standard 3-view series (cross-table lateral, anteroposterior, and odontoid views), as well as any other imaging deemed necessary by their physicians. Injuries detected with screening radiography were then compared with final injury status for each patient, as determined by review of all radiographic studies.

RESULTS

The study enrolled 34,069 patients with blunt trauma, including 818 patients (2.40% of all patients; 95% confidence interval [CI] 2.40% to 2.40%) having a total of 1,496 distinct cervical spine injuries. Plain radiographs revealed 932 injuries in 498 patients (1.46% of all patients; 95% CI 1.46% to 1.46%) but missed 564 injuries in 320 patients (0.94% of all patients; 95% CI 0.94% to 0.94%). The majority of missed injuries (436 injuries in 237 patients [representing 0.80% of all patients]; 95% CI 0.80% to 0.80%) occurred in cases in which plain radiographs were interpreted as abnormal (but not diagnostic of injury) or inadequate. However, 23 patients (0.07% of all patients; 95% CI 0.05% to 0.09%) had 35 injuries (including 3 potentially unstable injuries) that were not visualized on adequate plain film imaging. These patients represent 2.81% (95% CI 1.89% to 3.63%) of all injured patients with blunt trauma undergoing radiographic evaluation.

CONCLUSION

Standard 3-view imaging provides reliable screening for most patients with blunt trauma. However, on rare occasions, such imaging may fail to detect significant unstable injuries. In addition, it is difficult to obtain adequate plain radiographic imaging in a substantial minority of patients.

Epidemiology of cervical spine injury victims

STUDY OBJECTIVE

We sought to characterize demographics and injury patterns among patients undergoing emergency department cervical spine radiography for blunt traumatic injury.

METHODS

All patients with blunt trauma undergoing cervical spine radiography at 21 centers were enrolled in this prospective, observational study. Patients' date of birth, age, sex, and ethnicity were noted before cervical spine radiography.

RESULTS

Demographic factors associated with cervical spine injury, present in 818 of 33,922 patients, included the following: age of 65 years or older (relative risk [RR] 2.09; 95% confidence interval [CI] 1.77 to 2.59); "other" ethnicity (RR 1.79, 95% CI 1.46 to 2.19); male sex (RR 1.72, 95% CI 1.48 to 2.00); and white ethnicity (RR 1.50, 95% CI 1.31 to 1.72). Hispanic ethnicity (RR 0.64, 95% CI 0.51 to 0.79), female sex (RR 0.58, 95% CI 0.50 to 0.67), black ethnicity (RR 0.55, 95% CI 0.45 to 0.66), and age of less than 18 years (RR 0.39, 95% CI 0.27 to 0.55) were associated with reduced risk of cervical spine injury.

CONCLUSION

Among patients undergoing ED cervical spine radiography, cervical spine injury is more common among the elderly, male subjects, and patients of white or "other" ethnicity. Because cervical spine injury occurs in patients in all demographic categories, however, this information cannot be used to select individual patients who should or should not undergo imaging.

Ranitidine-induced acute interstitial nephritis in a cadaveric renal allograft

Ranitidine frequently is used for preventing peptic ulceration after renal transplantation. This drug occasionally has been associated with acute interstitial nephritis in native kidneys. There are no similar reports with renal transplantation. We report a case of ranitidine-induced acute interstitial nephritis in a recipient of a cadaveric renal allograft presenting with acute allograft dysfunction within 48 hours of exposure to the drug. The biopsy specimen showed pathognomonic features, including eosinophilic infiltration of the interstitial compartment. Allograft function improved rapidly and returned to baseline after stopping the drug.

Cerebral ventricular shunts

Cerebral ventricular shunts are siphoning devices used to treat hydrocephalus. They are placed within cerebral ventricles and peripheral cavities such as the ventricular atrium or peritoneal cavity. Complications include obstruction of cerebral spinal fluid (malfunction) and infection. Morbidity and mortality rates are high when shunt malfunction and infection are not treated emergently. This report summarizes the physical examination of patients with ventricular shunts, reviews the type of shunts commonly used, discusses shunt malfunctions (causing overshunting or undershunting of cerebrospinal fluid) and infections, and makes recommendations concerning empiric antibiotic therapy for shunt infection. The technique of tapping a shunt is presented for management of patients with elevated intracranial pressure that does not respond to non-invasive maneuvers to lower the pressure.

A multidisciplinary approach to chest pain evaluation and management

Chest pain evaluation centers in emergency departments efficiently exclude acute myocardial infarctions but are limited in identifying patients with acute cardiac ischemia (ACI) without infarction. Short-term prognosis is similar for patients discharged with ACI and for those who had an infarction. Subsequently, for suspected ACI, cardiology or primary care is consulted, providing follow-up coronary angiography or stress testing, but often requiring repeat labwork and resulting in significant time delays. A coordinated approach to chest pain management--an early multidisciplinary effort--provides an efficient and cost-effective approach to chest pain evaluation and management, while reducing potentially dangerous delays in identifying ACI.

The role of gender in heart transplantation

BACKGROUND

The effect of donor and recipient gender on the outcome of heart transplantation (HT) remains uncertain.

METHODS

One hundred seventy-four patients who underwent HT were divided into four groups according to donor and recipient gender. Group A consisted of 81 men who received male donor hearts, group B of 18 women who received female donor hearts, group C of 21 women who received male donor hearts, and group D of 54 men who received female donor hearts. All patients were treated by the same group of surgeons according to standard HT protocols. Comparisons were made between groups with regard to short- and long-term outcomes.

RESULTS

Donor gender and recipient gender did not affect outcomes significantly. Overall, donor-recipient gender mismatching significantly increased the number of rejection episodes and reduced creatinine clearance, survival, and censored survival in the first year after HT (p < 0.05). More specifically, among female recipients, donor-recipient gender mismatching significantly increased the number of rejection episodes and decreased creatinine clearance in the first year after HT (p < 0.05); among male recipients, donor-recipient gender mismatching significantly reduced 1-year survival and censored survival to date after HT (p < 0.05).

CONCLUSIONS

Donor-recipient gender matching plays a significant role in determining HT outcomes.

Secondary acute angle closure glaucoma: a complication of AIDS

A 58-year-old man with advanced AIDS presented to the emergency department complaining of headache and decreased vision bilaterally. On evaluation, he was found to have intraocular pressures of 69 and 65 mm Hg. After topical treatment with miotics and apraclonidine, he was given intravenous acetazolamide (Diamox) and peripheral iridotomy was performed. The pressures did not improve significantly. Secondary acute angle closure glaucoma was diagnosed. Emergency physicians should consider this diagnosis when evaluating AIDS patients with visual complaints.

Reengineering the emergency evaluation of chest pain

This article presents strategies for enhancing the emergency department care delivered to patients with chest pain and suspected acute myocardial infarction. It also describes the planning and implementation of an emergency department reengineering project at a university medical center. The establishment of chest pain evaluation centers within emergency departments has been associated with improved clinical outcomes and cost control. Creating such a center requires careful revamping of diagnostic and treatment algorithms, a process that must be based on information from all departments affected by the changes.

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.