A CT-Derived Measurement of Sarcopenia Fails to Predict Falls

Sarcopenia and frailty have both emerged as risk factors for elderly falls. We investigated whether radiologic sarcopenia or frailty are associated with falls in a high-risk geriatric outpatient population. We reviewed 114 patients followed at the Center for Healthy Senior Living who had undergone a computerized tomography (CT) of the abdomen and pelvis for any reason from 2013 to 2019. Sarcopenia was determined by psoas muscle cross-sectional area at L3 on CT scan. Their individual frailty score was calculated. The primary outcome was admission to hospital for falls. There were no statistical differences in frailty score or sarcopenia between the 2 groups (left/right psoas muscle: no hospital admission = 6.8 ± 2.4/6.4 ± 2.5 vs falls requiring hospital admission 6.5 ± 2.3/6.5 ± 2.3 cm²). We concluded that neither frailty score nor sarcopenia predicted the occurrence of falls in our high-risk geriatric outpatient population.

O07 Sarcoidosis: it's bone deep

Case report - Introduction

This is a report of a Caucasian patient with sarcoidosis presenting as groin pain.

Case report - Case description

A 58-year-old Caucasian female from South Africa self-referred for physiotherapy following sudden onset right groin pain. Pelvic Xray was normal, but MRI pelvis showed lytic lesions in the acetabulum and proximal femur. The presence of night sweats suggested haematological malignancy leading to haematology referral. PET CT showed widespread metabolically active soft tissue lesions, lymph nodes and skeletal foci. Bone marrow trephine biopsy showed well-formed granulomata. An extensive infection screen was negative. A cervical lymph node biopsy and CT guided biopsy of pelvic and femoral lesions confirmed non-necrotising granulomas suggestive of sarcoidosis. Lung function tests were normal. Treatment with 30mg prednisolone for one month was poorly tolerated and steroids were rapidly weaned. She was unable to tolerate even low dose prednisolone. Severe pelvic pain and night sweats continue despite methotrexate, hydroxychloroquine and IV zoledronate (given for osteoporosis).

Case report - Discussion

This patient presented with groin pain, fatigue and night sweats, no demonstrable extra-osseous organ abnormality and normal plain radiography. Our diagnostic strategy was to first exclude malignancy and infection, particularly TB, but the unusual presentation created significant diagnostic uncertainty. Treatment is challenging due to intrusive side effects of steroids and hydroxychloroquine, and neutropenia induced by methotrexate.

Osseous involvement is rare and has been reported in 1-15% of sarcoidosis patients. It is usually accompanied by skin lesions. There were no features on history or examination to suggest sarcoidosis and the diagnosis was based on bone biopsies.

In a case series of 20 patients with osseous sarcoidosis, bone lesions were found on imaging during the initial presentation in 60% of cases. Ten patients were symptomatic, and all had multiple joint involvement. Axial involvement, primarily pelvis and lumbar spine was seen in 90% of cases. Lesions were detected on plain radiographs in 2 cases and were identified on MRI in 13 cases, PET-CT in 9 cases, CT in 4 cases and technetium-99m bone scintigraphy in 1 case. 55% of the cases required no treatment and 45% were treated most commonly with prednisolone, methotrexate, or hydroxychloroquine. Two cases required treatment with tumour necrosis factor inhibitors for refractory disease.

Case report - Key learning points

Osseous sarcoidosis can mimic many conditions including multiple myeloma and lymphoma, due to presentation with lytic lesions. Even pulmonary presentations can be atypical with predominant ground glass opacity or cavitating consolidation and parenchymal masses. Histopathological diagnosis is of critical importance, particularly in patients with atypical presentations. 

Assessment of organ involvement and disease extent is important in monitoring of treatment response. Plain radiographs tend to be normal in these cases and advanced imaging, including MRI, PET-CT, and CT, is often required. 

Symptomatic osseous disease may respond to steroids and conventional immunosuppression; a minority of refractory cases require TNF inhibition.

Consensus Recommendations on the Use of 18F-FDG PET/CT in Lung Disease

PET with ¹⁸F-FDG has been increasingly applied, predominantly in the research setting, to study drug effects and pulmonary biology and to monitor disease progression and treatment outcomes in lung diseases that interfere with gas exchange through alterations of the pulmonary parenchyma, airways, or vasculature. To date, however, there are no widely accepted standard acquisition protocols or imaging data analysis methods for pulmonary ¹⁸F-FDG PET/CT in these diseases, resulting in disparate approaches. Hence, comparison of data across the literature is challenging. To help harmonize the acquisition and analysis and promote reproducibility, we collated details of acquisition protocols and analysis methods from 7 PET centers. From this information and our discussions, we reached the consensus recommendations given here on patient preparation, choice of dynamic versus static imaging, image reconstruction, and image analysis reporting.

Fulminating deep tissue space infection with Streptococcus constellatus presenting initially as a sore throat

Management of sore throat requires robust decision-making to balance successfully the conflicting risks of unnecessary antibiotic use against those of untreated bacterial infection. We present a case of fulminant sepsis caused by Streptococcus constellatus, presenting as a sore throat, initially managed conservatively. Despite subsequent appropriate anti-microbial therapy and surgical drainage, contiguous spread ultimately involved the deep neck spaces, mediastinum and thoracic wall, and was complicated by severe aspiration pneumonia, pharyngocutaneous and bronchopleural fistulation. The complexity and widespread extent of the infected spaces, in conjunction with the catabolic response to sepsis, created a life-threatening situation. Surgical closure of the pharyngeal defect, using a pectoralis-major pedicle flap, was successfully undertaken to ensure source control of the infection and heralded a complete recovery. We describe our management of this case, discuss the current approach to the management of patients presenting with a sore throat, and review the literature on S. constellatus infections.

Protocol for the EARCO Registry: a pan-European observational study in patients with α1-antitrypsin deficiency

Rationale and objectives

Alpha-1 antitrypsin deficiency (AATD) is a genetic condition that leads to an increased risk of emphysema and liver disease. Despite extensive investigation, there remain unanswered questions concerning the natural history, pathophysiology, genetics and the prognosis of the lung disease in association with AATD. The European Alpha-1 Clinical Research Collaboration (EARCO) is designed to bring together researchers from European countries and to create a standardised database for the follow-up of patients with AATD.

Study design and population

The EARCO Registry is a non-interventional, multicentre, pan-European, longitudinal observational cohort study enrolling patients with AATD. Data will be collected prospectively without interference/modification of patient's management by the study team. The major inclusion criterion is diagnosed severe AATD, defined by an AAT serum level <11 µM (50 mg·dL⁻¹) and/or a proteinase inhibitor genotype ZZ, SZ or compound heterozygotes or homozygotes of other rare deficient variants. Assessments at baseline and during the yearly follow-up visits include lung function testing (spirometry, body plethysmography and diffusing capacity of the lung), exercise capacity, blood tests and questionnaires (symptoms, quality of life and physical activity). To ensure correct data collection, there will be designated investigator staff to document the data in the case report form. All data will be reviewed by the EARCO database manager.

Summary

The EARCO Registry aims to understand the natural history and prognosis of AATD better with the goal to create and validate prognostic tools to support medical decision-making.

The EARCO Registry is a non-interventional, multicentre, pan-European, longitudinal observational cohort study enrolling patients with AATD to elucidate the natural history, pathophysiology, genetics and prognosis of this conditionhttp://bit.ly/369ScCc

European Respiratory Society statement: diagnosis and treatment of pulmonary disease in α1-antitrypsin deficiency

α1-antitrypsin deficiency (AATD) is the most common hereditary disorder in adults. It is associated with an increased risk of developing pulmonary emphysema and liver disease. The pulmonary emphysema in AATD is strongly linked to smoking, but even a proportion of never-smokers develop progressive lung disease. A large proportion of individuals affected remain undiagnosed and therefore without access to appropriate care and treatment.

The most recent international statement on AATD was published by the American Thoracic Society and the European Respiratory Society in 2003. Since then there has been a continuous development of novel, more accurate and less expensive genetic diagnostic methods. Furthermore, new outcome parameters have been developed and validated for use in clinical trials and a new series of observational and randomised clinical trials have provided more evidence concerning the efficacy and safety of augmentation therapy, the only specific treatment available for the pulmonary disease associated with AATD.

As AATD is a rare disease, it is crucial to organise national and international registries and collect information prospectively about the natural history of the disease. Management of AATD patients must be supervised by national or regional expert centres and inequalities in access to therapies across Europe should be addressed.

Influence of exercise duration on cardiorespiratory responses, energy cost and tissue oxygenation within a 6 hour treadmill run

Purpose

The physiological mechanisms for alterations in oxygen utilization (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$\dot {\mathrm{V }}{\mathrm{O}}_{2}$\end{document}V ˙O2) and the energy cost of running (C_r) during prolonged running are not completely understood, and could be linked with alterations in muscle and cerebral tissue oxygenation.

Methods

Eight trained ultramarathon runners (three women; mean ± SD; age 37 ± 7 yr; maximum \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$\dot {\mathrm{V }}{\mathrm{O}}_{2}$\end{document}V ˙O2 60 ± 15 mL min⁻¹ kg⁻¹) completed a 6 hr treadmill run (6TR), which consisted of four modules, including periods of moderate (3 min at 10 km h⁻¹, 10-CR) and heavy exercise intensities (6 min at 70% of maximum \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$\dot {\mathrm{V }}{\mathrm{O}}_{2}$\end{document}V ˙O2, HILL), separated by three, 100 min periods of self-paced running (SP). We measured \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$\dot {\mathrm{V }}{\mathrm{O}}_{2}$\end{document}V ˙O2, minute ventilation (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}${\dot {\mathrm{V }}}_{\mathrm{E}}$\end{document}V ˙E), ventilatory efficiency (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}${\dot {\mathrm{V }}}_{\mathrm{E}}:\dot {\mathrm{V }}{\mathrm{O}}_{2}$\end{document}V ˙E:V ˙O2), respiratory exchange ratio (RER), C_r, muscle and cerebral tissue saturation index (TSI) during the modules, and heart rate (HR) and perceived exertion (RPE) during the modules and SP.

Results

Participants ran 58.3 ± 10.5 km during 6TR. Speed decreased and HR and RPE increased during SP. Across the modules, HR and \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$\dot {\mathrm{V }}{\mathrm{O}}_{2}$\end{document}V ˙O2 increased (10-CR), and RER decreased (10-CR and HILL). There were no significant changes in \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}${\dot {\mathrm{V }}}_{\mathrm{E}}$\end{document}V ˙E, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}${\dot {\mathrm{V }}}_{\mathrm{E}}:\dot {\mathrm{V }}{\mathrm{O}}_{2}$\end{document}V ˙E:V ˙O2, C_r, TSI and RPE across the modules.

Conclusions

In the context of positive pacing (decreasing speed), increased cardiac drift and perceived exertion over the 6TR, we observed increased RER and increased HR at moderate and heavy exercise intensity, increased \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$\dot {\mathrm{V }}{\mathrm{O}}_{2}$\end{document}V ˙O2 at moderate intensity, and no effect of exercise duration on ventilatory efficiency, energy cost of running and tissue oxygenation.

Influence of lung CT changes in chronic obstructive pulmonary disease (COPD) on the human lung microbiome

BACKGROUND

Changes in microbial community composition in the lung of patients suffering from moderate to severe COPD have been well documented. However, knowledge about specific microbiome structures in the human lung associated with CT defined abnormalities is limited.

METHODS

Bacterial community composition derived from brush samples from lungs of 16 patients suffering from different CT defined subtypes of COPD and 9 healthy subjects was analyzed using a cultivation independent barcoding approach applying 454-pyrosequencing of 16S rRNA gene fragment amplicons.

RESULTS

We could show that bacterial community composition in patients with changes in CT (either airway or emphysema type changes, designated as severe subtypes) was different from community composition in lungs of patients without visible changes in CT as well as from healthy subjects (designated as mild COPD subtype and control group) (PC1, Padj = 0.002). Higher abundance of Prevotella in samples from patients with mild COPD subtype and from controls and of Streptococcus in the severe subtype cases mainly contributed to the separation of bacterial communities of subjects. No significant effects of treatment with inhaled glucocorticoids on bacterial community composition were detected within COPD cases with and without abnormalities in CT in PCoA. Co-occurrence analysis suggests the presence of networks of co-occurring bacteria. Four communities of positively correlated bacteria were revealed. The microbial communities can clearly be distinguished by their associations with the CT defined disease phenotype.

CONCLUSION

Our findings indicate that CT detectable structural changes in the lung of COPD patients, which we termed severe subtypes, are associated with alterations in bacterial communities, which may induce further changes in the interaction between microbes and host cells. This might result in a changed interplay with the host immune system.

Quantification of Lung PET Images: Challenges and Opportunities

Millions of people are affected by respiratory diseases, leading to a significant health burden globally. Because of the current insufficient knowledge of the underlying mechanisms that lead to the development and progression of respiratory diseases, treatment options remain limited. To overcome this limitation and understand the associated molecular changes, noninvasive imaging techniques such as PET and SPECT have been explored for biomarker development, with ¹⁸F-FDG PET imaging being the most studied. The quantification of pulmonary molecular imaging data remains challenging because of variations in tissue, air, blood, and water fractions within the lungs. The proportions of these components further differ depending on the lung disease. Therefore, different quantification approaches have been proposed to address these variabilities. However, no standardized approach has been developed to date. This article reviews the data evaluating ¹⁸F-FDG PET quantification approaches in lung diseases, focusing on methods to account for variations in lung components and the interpretation of the derived parameters. The diseases reviewed include acute respiratory distress syndrome, chronic obstructive pulmonary disease, and interstitial lung diseases such as idiopathic pulmonary fibrosis. Based on review of prior literature, ongoing research, and discussions among the authors, suggested considerations are presented to assist with the interpretation of the derived parameters from these approaches and the design of future studies.

Quantitative computed tomography-derived clusters: redefining airway remodeling in asthmatic patients

BACKGROUND

Asthma heterogeneity is multidimensional and requires additional tools to unravel its complexity. Computed tomography (CT)-assessed proximal airway remodeling and air trapping in asthmatic patients might provide new insights into underlying disease mechanisms.

OBJECTIVES

The aim of this study was to explore novel, quantitative, CT-determined asthma phenotypes.

METHODS

Sixty-five asthmatic patients and 30 healthy subjects underwent detailed clinical, physiologic characterization and quantitative CT analysis. Factor and cluster analysis techniques were used to determine 3 novel, quantitative, CT-based asthma phenotypes.

RESULTS

Patients with severe and mild-to-moderate asthma demonstrated smaller mean right upper lobe apical segmental bronchus (RB1) lumen volume (LV) in comparison with healthy control subjects (272.3 mm(3) [SD, 112.6 mm(3)], 259.0 mm(3) [SD, 53.3 mm(3)], 366.4 mm(3) [SD, 195.3 mm(3)], respectively; P = .007) but no difference in RB1 wall volume (WV). Air trapping measured based on mean lung density expiratory/inspiratory ratio was greater in patients with severe and mild-to-moderate asthma compared with that seen in healthy control subjects (0.861 [SD, 0.05)], 0.866 [SD, 0.07], and 0.830 [SD, 0.06], respectively; P = .04). The fractal dimension of the segmented airway tree was less in asthmatic patients compared with that seen in control subjects (P = .007). Three novel, quantitative, CT-based asthma clusters were identified, all of which demonstrated air trapping. Cluster 1 demonstrates increased RB1 WV and RB1 LV but decreased RB1 percentage WV. On the contrary, cluster 3 subjects have the smallest RB1 WV and LV values but the highest RB1 percentage WV values. There is a lack of proximal airway remodeling in cluster 2 subjects.

CONCLUSIONS

Quantitative CT analysis provides a new perspective in asthma phenotyping, which might prove useful in patient selection for novel therapies.

The EvA study: aims and strategy

The EvA study is a European Union-funded project under the Seventh Framework Programme (FP7), which aims at defining new markers for chronic obstructive pulmonary disease (COPD) and its subtypes. The acronym is derived from emphysema versus airway disease, indicating that the project targets these two main phenotypes of the disease. The EvA study is based on the concept that emphysema and airway disease are governed by different pathophysiological processes, are driven by different genes and have differential gene expression in the lung. To define these genes, patients and non-COPD controls are recruited for clinical examination, lung function analysis and computed tomography (CT) of the lung. CT scans are used to define the phenotypes based on lung density and airway wall thickness. This is followed by bronchoscopy in order to obtain samples from the airways and the alveoli. These tissue samples, along with blood samples, are then subjected to genome-wide expression and association analysis and markers linked to the phenotypes are identified. The population of the EvA study is different from other COPD study populations, since patients with current oral glucocorticoids, antibiotics and exacerbations or current smokers are excluded, such that the signals detected in the molecular analysis are due to the distinct inflammatory process of emphysema and airway disease in COPD.

Outcomes for COPD pharmacological trials: from lung function to biomarkers

The American Thoracic Society/European Respiratory Society jointly created a Task Force on "Outcomes for COPD pharmacological trials: from lung function to biomarkers" to inform the chronic obstructive pulmonary disease research community about the possible use and limitations of current outcomes and markers when evaluating the impact of a pharmacological therapy. Based on their review of the published literature, the following document has been prepared with individual sections that address specific outcomes and markers, and a final section that summarises their recommendations.

Epidemiology and host- and variety-dependent characteristics of infection due to Cryptococcus neoformans in Australia and New Zealand. Australasian Cryptococcal Study Group

A prospective population-based study was conducted in Australia and New Zealand during 1994-1997 to elucidate the epidemiology of cryptococcosis due to Cryptococcus neoformans var. neoformans (CNVN) and C. neoformans var. gattii (CNVG) and to relate clinical manifestations to host immune status and cryptococcal variety. The mean annual incidence per 10(6) population was 6.6 in Australia and 2.2 in New Zealand. Of 312 episodes, CNVN caused 265 (85%; 98% of the episodes in immunocompromised hosts) and CNVG caused 47 (15%; 44% of the episodes in immunocompetent hosts). The incidence of AIDS-associated cases in Australia declined annually (P<.001). Aborigines in rural or semirural locations (P<.001) and immunocompetent males (P<.001) were at increased risk of CNVG infection. Cryptococcomas in lung or brain were more common in immunocompetent hosts (P< or =.03) in whom there was an association only between lung cryptococcomas and CNVG. An AIDS-associated genetic profile of CNVN serotype A was confirmed by random amplification of polymorphic DNA analysis. Resistance to antifungal drugs was uncommon. The epidemiology of CNVN infection has changed substantially. Clinical manifestations of disease are influenced more strongly by host immune status than by cryptococcal variety.

Psychophysiological stress responses, muscle tension, and neck and shoulder pain among supermarket cashiers

This study examined psychological and physiological stress, as well as muscle tension and musculoskeletal symptoms, among 72 female supermarket cashiers. Stress levels were found to be significantly elevated at work, as reflected in the catecholamines, blood pressure, heart rate, electromyographic (EMG) activity, and self-reports. Fifty cashiers (70%) suffering from neck-shoulder pain (trapezius myalgia) were found to have higher EMG activity at work and reported more tension after work. Women who kept a diary for 1 week and reported more musculoskeletal pain (above the median) were older, had higher blood pressure, and reported more work stress and psychosomatic symptoms. The elevated stress levels at work are consistent with data from workers involved in other types of repetitive tasks and can be important for the high prevalence of neck and shoulder symptoms among the cashiers.

Psychophysiological stress responses, muscle tension, and neck and shoulder pain among supermarket cashiers

This study examined psychological and physiological stress, as well as muscle tension and musculoskeletal symptoms, among 72 female supermarket cashiers. Stress levels were found to be significantly elevated at work, as reflected in the catecholamines, blood pressure, heart rate, electromyographic (EMG) activity, and self-reports. Fifty cashiers (70%) suffering from neck-shoulder pain (trapezius myalgia) were found to have higher EMG activity at work and reported more tension after work. Women who kept a diary for 1 week and reported more musculoskeletal pain (above the median) were older, had higher blood pressure, and reported more work stress and psychosomatic symptoms. The elevated stress levels at work are consistent with data from workers involved in other types of repetitive tasks and can be important for the high prevalence of neck and shoulder symptoms among the cashiers.

Acanthamoeba keratitis in New Zealand, including two cases with in vivo resistance to polyhexamethylene biguanide

BACKGROUND

Acanthamoeba keratitis is an uncommon corneal infection that can run a protracted course with, at times, serious visual results. Eighty-five per cent of cases occur in soft contact lens wearers. The first New Zealand case occurred in 1990 and only seven cases have been identified in New Zealand to the end of 1996.

METHODS

We surveyed the ophthalmologists looking after these seven cases of acanthamoeba keratitis as to time to diagnosis, treatment and outcome.

RESULTS

New Zealand has a low incidence of this disease. All cases were soft contact lens wearers with defective care in every instance. After an initial two late-diagnosed cases, the time to diagnosis for four of the five other cases has been within 2 weeks. Medical treatment has varied over this series, but since the introduction of the cationic antiseptics polyhexamethylene biguanide (PHMB) and chlorhexidine in 1992, the last five cases were all treated with PHMB. One case diagnosed within 2 weeks ran a devastating course, despite intensive PHMB, and a second case remained culture positive after 1 year of PHMB and the late addition of chlorhexidine. Debridement, 0.1% PHMB and hexamidine eventually settled this eye.

CONCLUSIONS

For treatment PHMB, hexamidine rather than propamidine and surgical debridement are favoured. While all Acanthamoeba isolates show good in vitro sensitivity to PHMB, the in vivo response is not always proportionate. A bacterial endosymbiont may have been a factor in the favourable outcome of one protracted case.

Pythium insidiosum keratitis

A case of Pythium insidiosum keratitis is described. It is an unusual organism that is difficult to isolate. Cases in animals and humans have been reported from tropical and subtropical parts of the world but this is the first case from a temperate region and was acquired from a hot pool. Although resembling a fungus, it is insensitive to all antifungals and requires wide surgical excision for cure.

Percutaneous balloon-assisted aspiration thrombectomy of clotted hemodialysis access grafts

PURPOSE

To present experience with percutaneous balloon-assisted aspiration thrombectomy (BAT) for the treatment of patients with clotted hemodialysis access grafts.

MATERIALS AND METHODS

BAT was performed with use of 7-F intravascular sheaths and a Fogarty balloon catheter. It was tested with an in vitro flow-circuit model. Twenty consecutive BAT procedures were performed in 15 patients with clotted grafts. The balloon catheter was advanced through the sheath to the arterial anastomosis. The balloon was inflated and withdrawn while suction was applied from the sideport to recover thrombus. The procedure was repeated for the venous limb. BAT was used alone in 12 procedures and in combination with urokinase in eight procedures.

RESULTS

Almost complete thrombectomy was achieved in all tubes (in vitro), with very low venous and arterial embolic fractions. Technical success (restored graft thrill and almost complete thrombectomy) was achieved in 18 cases (90%). Clinical success (patency after 1 week of dialysis) was achieved in 17 cases (85%).

CONCLUSION

Percutaneous BAT is feasible in recently clotted dialysis grafts.

Evidence for nosocomial transmission of Candida albicans obtained by Ca3 fingerprinting

The moderately repetitive sequence Ca3 was used to fingerprint Candida albicans isolates from 32 patients hospitalized for more than 3 days, 17 recent admissions or outpatients, and 8 recently readmitted patients and 10 commensal isolates from the community in Wellington, New Zealand, plus isolates from 21 hospitalized patients, 26 outpatients or recent admissions, 4 recently readmitted patients, and 10 healthy individuals in the community in Auckland, New Zealand. In Wellington, isolates from patients hospitalized in Wellington Hospital for more than 3 days were genetically significantly less diverse than were isolates from outpatients or recent admissions or isolates from healthy individuals in the community. In addition, two clusters of genetically similar strains were isolated from hospitalized patients significantly more often than from other individuals. These observations provide evidence (albeit indirectly) for nosocomial transmission of hospital-specific C. albicans strains. In contrast, no indication of hospital-specific transmission of C. albicans was found in Auckland Hospital. Since these results were obtained under conditions in which no candidiasis outbreak occurred in either hospital, they also suggest that Ca3 fingerprinting may be a useful tool in preventive nosocomial infection control programs, allowing assessment of the extent of C. albicans transmission occurring in a hospital.

The Auckland skin clinic tinea pedis and erythrasma study

Three hundred consecutive patients attending the Auckland Hospital dermatology clinic were examined clinically and microbiologically for evidence of interdigital or plantar mycological or bacterial infection. One hundred and nine patients were shown by laboratory investigation to have an infection. Of these, only 89 displayed clinical signs of infection. Erythrasma, a desquamative condition caused by Corynebacterium minutissimum, was the commonest infection in this study. The commonest dermatophyte isolated was Trichophyton mentagrophytes var interdigitale. There was a significant rise in the incidence of both types of infection with age.