[Effectiveness of pre-emptive hemodialysis with high-flux membranes for the treatment of life-threatening alcohol poisoning]

Alcohol intoxication (methanol, ethanol and ethylene glycol) may result in metabolic acidosis with increased anion gap, increased serum osmolal gap, and neurologic abnormalities ranging from drunkenness to coma, and death. The mortality and morbidity rates remain very high despite intensive care therapy. The toxicity of methanol and ethylene glycol is clearly correlated to the degree of metabolic acidosis. The established treatment of severe methanol and ethylene glycol intoxication is ethanol administration and hemodialysis (HD). By inhibiting the main metabolic pathway of methanol and ethylene glycol (alcohol dehydrogenase), ethanol prevents the formation of major toxic metabolites (formic acid, glycolic acid and oxalic acid). Conventional HD can reduce serum methanol, ethanol and ethylene glycol and its metabolites rapidly, but high-flux membranes should be capable of removing more toxic per hour of HD. In this report, we describe 14 cases of life-threatening alcohol intoxication (11 methanol, 1 ethanol, and 2 ethylene glycol) who were treated successfully with supportive care, ethanol infusion (methanol and ethylene glycol), and early HD with a high-flux dialyser. The median pH was 7.04 +/- 0.06 (range 6.60-7.33), median bicarbonate 9.9 +/- 1.9 mmol/l (range 1.4-25), and median base deficit 18.4 +/- 2.6 mmol/l (range 2-33). The median anion gap was 29.1 +/- 2.3 mmol/l (range 16-45) and the median osmolal gap was 119 +/- 47 mOsm/l (range 16-402). On admission there was an excellent linear correlation between the serum toxic alcohol concentrations and the osmolal gaps (R2 = 0.98, p = 0.0006). In all cases early HD corrected metabolic acidosis and osmolal abnormalities. The mortality was 7 % (1 from 14). We conclude that pre-emptive HD should be performed in severe intoxications to remove both the parent compound and its metabolites. The HD prescription should include a large surface area dialyser with high-flux membrane, a blood flow rate in excess of 250 ml/min, a modified bicarbonate bath enriched with phosphorus and potassium, and a long time session. The phosphorus and potassium-enriched bicarbonate-based dialysis solution used in patients with normal phosphorus and potassium serum levels avoided HD-induced hypophosphatemia and hypopotassemia. HD as implemented in these cases is a safe and very effective approach to the management of alcohol poisoning.

[Nephropathia caused by hantavirus puumala: a case report]

We present a patient from Germany with Hantavirus infection, admitted in the Emergency room of our hospital, with fever, thrombocytopenia, acute renal failure, oliguria, mild proteinuria and hematuria. Percutaneous renal biopsy revealed an acute interstitial nephritis without medulla haemorrhages. The virus infection confirmation was made by detection of IgM against Hantavirus Puumala. This infection should be considered in patients with thrombocytopenia, fever and acute renal failure, over all if they are from North and Central Europe.

[Influence of early or late referral to nephrologist over morbidity and mortality in hemodialysis]

OBJECTIVE

We studied the influence of early vs late referral to nephrologist of patients with chronic renal failure over clinical situation at the onset of hemodialysis and outcome.

SUBJECTS AND METHODS

From january 1994 to december 1998, 139 patients started hemodialysis for end-stage renal disease at the Hospital General de Albacete, all of them included in the study and clinical follow-up concluded in december 2001. Patients with rapidly progressive glomerulonephritis were excluded. Early (ER) and late referral (LR) were defined by the time of first nephrology encounter greater than or less than 6 months respectively, before iniciation of hemodialysis.

RESULTS

106 patients (76.25%) were referred early; mean follow-up time 6.3 +/- 4.5 years. 33 patients (23.74%) had late referral, follow-up time was less then six months, 18 patients were followed during less than 4 weeks. There were no differences in demographic data and comorbid conditions between LR and ER patients (age, cardiac and vascular disease, diabetes, neoplasia...). Mean plasma concentration of creatinine and urea was significantly greater, whereas hematocrit and albumin were less in the LRA than the ER group. Emergency dialysis through central vein catheterisation was more frequent in the LR group. Number of admissions and duration of hospital stay were higher in the LR group. No significant differences in nutrition, dialysis doses or anemia were found between the two groups after 6 and 12 months of hemodialysis. Long term outcome was similar in both groups: no significant differences were found in percentage of patients transplanted or deceased after 3 years of treatment. Survival analysis failed to show a difference between ER and LR groups (mean survival time was 73.6 +/- 4.3 months and 73.0 +/- 6 months respectively).

CONCLUSION

Late referral to the nephrologist is associated with increased early morbidity vs early referral, although long term outcome is not worse if predialysis comorbid conditions are comparable and dialysis care achieve equal results in dialysis doses, nutrition and anemia in both groups in the first months of treatment. Improvement of outcome of patients referred early to the nephrologist will depend on the adoption of preventive measures over comorbidity factors that should be applied in early stages of renal disease.

[Monitoring dermatomal somatosensory evoked potentials at the ERB point, the cervical spinal cord and the cerebral cortex in the diagnosis of cervical radiculopathy]

INTRODUCTION

Recording at various levels of the somatosensory pathway is often used in somatosensory evoked potentials to mixed nerve stimulation (SEP), but not in dermatomal somatosensory evoked potentials (DSEP) in which only the cortical potential is usually recorded. The aim of our study was to compare the recordings of upper limb DSEP at Erb point, cervical cord, and subcortical and cortical levels with SEP recordings in healthy subjects and patients with cervical radiculopathy.

PATIENTS AND METHODS

17 patients with clinical history, MRI and electromyography consistent with cervical radiculopathy and 17 healthy subjects were included. Median and ulnar nerves were stimulated at the wrist; and C6, C7 and C8 dermatomes at the 1st, 3rd and 5th fingers respectively. All the potentials obtained with SEP and DSEP were compared between controls and patients by t test for independent samples. We also used Pearson s correlation for height/latencies, weight/amplitude and age/peripheral nerve conduction velocity (PNCV).

RESULTS

DSEP potentials were of similar morphology of those observed in SEP but had longer latencies and smaller amplitudes. We found a positive correlation between height and latencies, and a negative association of weight with amplitude of peripheral potential, and age/PNCV. No difference between controls and the neurological intact segments of patients was found. 13 patient had DSEP altered while only 5 of them had altered SEP recorded. The most common finding was prolongation of the conduction time of the segment N9 N13 on DSEP recordings.

CONCLUSION

We found that it is possible to record and to identify all the potentials in DSEP as observed in the SEP. On cervical radiculopathy, DSEP with the present technique increase the sensitivity and give some additional and useful information regarding the extension and localization of the pathology. Besides, DSEP recording is a non invasive technique, non traumatic and well tolerated for our patients.

Mouse microglial cell lines differing in constitutive and interferon-gamma-inducible antigen-presenting activities for naive and memory CD4+ and CD8+ T cells

We developed a panel of non-virus transformed cell lines derived from individual microglial precursors residing in the brains of normal mice. These colony stimulating factor-1-dependent cell lines are B7-1+ (CD80), Mac-1+, Mac-2+, Mac-3+, CD45+, MHC class I+, colony stimulating factor-1 receptor+, and they ingest antibody-coated particles. However, the cell lines differ in their expression of B7-2 (CD86), F4/80, Ly-6C and MHC class II molecules. They also differ in their ability to constitutively process and present antigens to naive CD4+ and CD8+ T cells, memory CD4+ and CD8+, and in the manner by which interferon gamma modulates their antigen-presenting activities. These cell lines should be valuable as models for studies on the immunobiology of the microglia.

A subset of splenic macrophages process and present native antigen to naive antigen-specific CD4+ T-cells from mice transgenic for an alpha beta T-cell receptor

The progeny of individual macrophage precursors from mouse spleen were examined for their ability to constitutively process and present native pigeon cytochrome c or a peptide fragment of this antigen to naive CD4+ T-cells from mice transgenic for a V alpha 11/V beta 3 TCR that recognizes an epitope in the antigen fragment. The results show that constitutive Ag processing and presentation is a stable characteristic restricted to the progeny of approximately 20% of splenic macrophage precursors. This property does not appear to be randomly acquired, but to reflect the ability of certain macrophages to produce IL-12.

Use of the Pannell-Milstein roller bottle apparatus to produce high concentrations of the CSF-1, the mouse macrophage growth factor

A simple roller bottle apparatus for growing B cell hybridomas in dialysis tubing yields high concentrations of monoclonal antibodies (Pannell and Milstein, J. Immunol. Methods (1992) 146, 43-48). Here we describe an adaptation of this apparatus for the simple production of high concentrations of the mouse macrophage specific growth factor, CSF-1. This apparatus appears to have general applicability for the production of other secreted cytokines.

[Hypermineralcorticism syndrome secondary to topical application of 9-alpha-fluoroprednisolone (author's transl)]

A patient is reported who presented with severe arterial hypertension and pronounced hypokalemic metabolic alkalosis along with suppression of 17-hydroxicorticoids, plasma renin activity and urinary aldosterone excretion, in relation to topical application of 9-alpha-fluoroprednisolone, 300 mg weekly. The clinical picture changed after discontinuation of the steroid preparation. Whenever topical steroids are prescribed for extensive chronic skin the development of systemic side-effects must be watched. Depending on the type of steroid employed, Cushing's syndrome or a hypermineralcorticism state may appear. The differential diagnosis of a hypermineralcorticism syndrome without aldosteronism should include the possible topical application of fluorated steroids.

Reduction of methemerythrin-anion adducts by dithionite ion

The reduction by dithionite ion (in excess) of methemerythrin-anion adducts, Hr+X-, to deoxyhemerythrin, Hr degree, has been examined at 25 degrees and pH 6.3 and 8.2. The results accord with the scheme: S2O42- in equilibrium 2SO2- rapid Hr+X- in equilibrium Hr++X- k-1, k1 Hr++SO2- leads to PRODUCT k2 with X- = Br-, HCO2-, CNO-, and F-, k2[SO2-] greater than k1[X-], and the pseudo first-order rate constant, kobs (= k-1), is independent of [X-] and [S2O42-]. Only with X- = NCS- is k2[SO2-] approximately k1[X-] and kobs = a[S2O42-]1/2 (b[NCS-] + [S2OR2-]1/2)-1. Values at pH 6.3 of k-1 (sec-1) and k1 (M-1 sec-1), obtained by anation and anion displacement reactions, are 2.3 x 10(-3), 1.6 x 10(-2) (Br-); 1.5 x 10(-3), 1.2 x 10(-2) (HCO2-); 1.3 x 10(-4), 0.52 (CNO-) and approximately 2 x 10(-4), 3.3 x 10(-3) (CN-, pH 7.0). Values of k-1 from reduction and displacement methods are in good agreement with each other. The value of k2 (1.6 x 10(5) M-1 sec-1, pH 6.3) in somewhat smaller than that for reduction of the met form of hemoproteins. There is only a small effect of pH on rates. Direct reduction of Hr+CN- does not occur, in contrast with Mb+CN-.

Reduction of metmyoglobin derivatives by dithionite ion

The rate constants for reduction by dithionite of a number of metmyoglobin species Mb+X(X=H2O, imidazole, OH-, F-, N3-, CNO-, SCN-, HCO2-, NO2-, and CN-) were measured at 25 degrees by stopped flow spectrophotometry. The dependence of the rate was [S2O42-]1/2, and the SO2- radical was considered to be the active reductant. Except for X=imidazole and CN-, reduction occurred through dissociation of Mb+X. Values for the dissociative rate constant obtained from dithionite reduction were in good agreement with those obtained directly. Reduction of the dissociated fragment (assumed Mb+H2O) by SO2- is 3+/-1 X 10(6) M-1S-1 at pH 8.2 for all Mb+X species examined. Reduction of Mb+ imidazole and Mb+CN- occurs directly with SO2-, and Mb0CN- (Mb0, deoxymyoglobin) is characterized as an intermediate in reduction of the latter.