Biomedical subjects
Publications and source records attributed to S R Mandel.
This report describes a patient who developed cyclosporin-induced thrombotic microangiopathy in a renal allograft. Cyclosporin-induced thrombotic microangiopathy is considered by many as a contraindication to subsequent therapy with cyclosporin. This case is notable for successful treatment with cyclosporin following resolution of thrombotic microangiopathy in a renal allograft.
The surgical approach to bleeding visceral artery aneurysms has a mortality rate of 16-50% that is dependent primarily on anatomic location and underlying cause. Nineteen patients were studied over a 10-year period who were definitively treated by embolization. There was a 79% success rate and no mortality. The cause of the aneurysms was pancreatitis in 13 patients, trauma in four patients, subacute bacterial endocarditis in one patient, and secondary to biliary tract surgery in one patient.
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The pathogenicity of Candida species cultured from peritoneal fluid or from an intra-abdominal abscess is unknown. A review of cultures at NCMH from 1978 to 1983 showed that Candida species were cultured from the peritoneal fluid of 39 patients and from intra-abdominal abscesses in 24 patients. The average age was 49 (range 6 months to 102 years); there were 38 men and 25 women. None of the 39 patients with Candida species grown from the peritoneal fluid was treated with Amphotericin B and only 1 (2.6%) subsequently developed an abscess. This patient was treated by surgical drainage without Amphotericin B and recovered. Twenty-four patients had Candida cultured from an intra-abdominal abscess. Of these, 21 (87.5%) also grew other bacterial organisms. Twenty of these 24 patients were treated with surgical drainage and antibacterial antibiotics without Amphotericin B. Six (30%) died, but only one death was felt to be directly related to the Candida infection. The remaining four were treated with surgical drainage, appropriate antibacterial antibiotics, and Amphotericin B. Two of these four (50%) died; one of the two deaths was related to Candida infection. Candida species grown from the peritoneum were not related to later Candida infection. Treatment of patients with contamination of the peritoneum by Candida with Amphotericin B appears unnecessary and because of Amphotericin renal toxicity, may be potentially harmful. Patients with polymicrobial intra-abdominal abscesses that contain Candida species should be treated with surgical drainage and appropriate antibacterial antibiotics. The value of adding Amphotericin B therapy in patients with polymicrobial abscess containing Candida was not demonstrated in this study, and its role is unclear.
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A graft placed between the popliteal artery and proximal saphenous vein for hemodialysis is an excellent alternative when more conventional arteriovenous fistulas cannot be accomplished. This technique has proved to be safe and reliable. The procedure is easily and rapidly performed. It provides a long segment of material with excellent accessibility.
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Traumatic hemobilia is an uncommon and potentially fatal complication of blunt or penetrating liver trauma. We report two patients who were successfully treated with embolization immediately following diagnosis with selective arteriography. These findings, when added to the experience reported by others, support selective embolization as the therapy of choice in trauma patients who do not require initial surgery, in cases of hemobilia following percutaneous liver biopsy, and in cases of hemobilia with recurrence after surgical treatment.
Opens surgical drainage of intraabdominal, intrahepatic, and mediastinal abscess is well established. Although this may be the procedure of choice when there are indications for treatment of concurrent intraabdominal and mediastinal surgical disease, with the advent of computerized axial tomography and ultrasonography we have identified a patient population best served by percutaneous catheter drainage. The procedure involves precise localization using ultrasound or CAT scanning, fine needle aspiration for confirmation of diagnosis, and injection of radiopaque contrast medium with fluoroscopic observation to localize the abscess. Catheter placement is usually achieved by a Seldinger technique, although a trochar-cannula method is occasionally required. Our experience with 4 patients, as well as review of the world literature provides a cumulative experience of 252 patients, has led us to believe that this approach is successful 83 percent of the time with a minimal incidence of complications. Percutaneous catheter drainage of intrahepatic, intraabdominal, and mediastinal abscess guided by computerized axial tomography is the treatment of choice in patients who do not have other indications for exploration.
Patients with severe factor VIII deficiency hemophilia require recurrent factor VIII infusion for complications of their bleeding diathesis, resulting in depletion of peripheral infusion sites. At the University of North Carolina in Chapel Hill, many hemophiliac patients are seen yearly. Therapy for some of these patients requires recurrent administration of factor VIII concentrates. Recent experience with two patients who had exhausted peripheral venous infusion sites necessitated innovative vascular access. Our favorable experience with subcutaneous bovine heterografts prompted use of this technique. An easily cannulated infusion site resulted and facilitated factor VIII concentrate infusion. Patients with bleeding disorders represent a whole new population who may require vascular access. Our experience suggests that it is practical to expand the scope of access to include these patients.
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The patient with the symptomatic abdominal aortic aneurysm (AAA) presents a management dilemma, ie, emergent, urgent, or elective operation. The mortality for 38 patients with a ruptured AAA prior to 1972 was 61%. That year, a policy of immediate operation was instituted for patients with symptoms that might be referable to a ruptured AAA. It is concluded that an immediate operation on the patient with a symptomatic but intact AAA resulted in an excessively high mortality. Thus, the indications for an immediate operation on these patients should be based on clinical judgment; attempting to differentiate between the patient with the ruptured and the patient with the intact aneurysm. Hemodynamic data (blood pressure hematocrit reading) suggesting a decrease in blood volume dictate an immediate operation. An urgent operation on the well-prepared patient should be performed on all patients with a symptomatic aneurysm in which the clinical and hemodynamic findings do not suggest that it has ruptured.
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Thrombosis of the microvasculature has been recognized at the end product of organ rejection, but the exact biological pathway through which this occurs has not been clarified. Normal, factor VII deficient and heterozygous hemophilic (factor VIII) dogs were grouped to study the intrinsic and extrinsic clotting and platelet mechanisms during unmodified renal allograft rejection. The observed alterations of the hemostatic mechanisms are related to the changes observed in the microvasculature. Six groups of donor-recipient animals were studied: Group I -autografts (control); Group II - normal to normal allografts with bilateral nephrectomy; Group III - heterozygotes for factor VIII deficiency; Group IV - normal to normal allografts with unilateral nephrectomy; Group V - normal to factor VII deficiency without nephrectomy; and Group VI - normal to normal allografts with unilateral nephrectomy and dipyridamole. Each engrafted animal was followed pre- and posttransplantation for change in the blood clotting factors, fibrin split products, platelets, white blood cells, renal function and microvasculature. The animals with factor VII deficiency rejected in a similar fashion as the control animals. The group with impaired factor VIII synthesis and platelet function had longer survival times. These data suggest that the intrinsic clotting pathway and platelets are the primary mechanism through which thrombosis occurs secondary to immune injury.
A 32-year-old morbidly obese woman had bilateral subclavian artery embolism. After embolectomy, a right heart catheterization showed a patent foramen ovale and a right-to-left shunt. Pulmonary angiography revealed multiple pulmonary emboli. Bilateral lower extremity venography demonstrated left ileofemoral thrombi as the probable source. The patient was successfully treated with an inferior vena caval umbrella and anticoagulant drugs.
Vascular access has become the most common operation performed at North Carolina Memorial Hospital, Chapel Hill. Three hundred vascular access procedures performed between 1971 and 1975 were reviewed as to results, costs, and manpower commitment. Subcutaneous radial arterial venous fistula was the procedure of choice, with a 67% two-year patency and the lowest incidence of complications. An average of 1.7 operations per patient was necessary to maintain access. Patients used an average of 19 hospital days per year of dialysis for vascular access and an average of 35 hospital days per year of dialysis for all medical problems. Cost of hospitalization averaged $6,818 per patient per year of dialysis, and for vascular access alone averaged $3,452 per patient per year of dialysis. To create and maintain vascular access, 1,000 hours of operating room time were required, at an expense of $200,000. Vascular access in support of patients undergoing chronic hemodialysis requires a massive commitment of dollars, time, and personnel.
We are reporting the first case, to our knowledge, of a venous embolus to a transplanted kidney. The embolus occurred five days after transplantation of a cadaver kidney in a 31-year-old woman who was receiving estrogen-progesterone therapy for menorrhagia. Five hours after acute onset of left flank pain and anuria, the embolus was identified at the anastomosis of the donor renal vein to the external iliac vein. The embolus was manipulated distally in the external iliac vein and excluded by proximal division of the vein. Recovery was eventually complete, despite two major postoperative complications, acute tubular necrosis and a perirenal hematoma secondary to heparin sodium therapy. Radionuclide scanning was critically important in establishing the diagnosis and in assessing the potential for the kidney to recover from acute tubular necrosis. On the basis of this experience, we believe that prompt surgical intervention is indicated for acute venous occlusion.
Transplantation experiments were utilized to study the possible sites of synthesis of von Willebrand factor (vWF) and factor VIII (F VIII) activities. Three normal kidney and two normal liver allografts were implanted into five swine with von Willebrand's disease (vWD) that survived for 1,6, and 7, and 4 and 9 days, respectively. The correction of the multiple hemostatic defects of vWD by organ transplantation was evaluated using the F VIII procoagulant activity, bleeding time, and platelet aggregating factor (PAF) levels; i.e., vWF levels. Normal kidney allografts produced no changes in the bleeding times or increases in F VIII or PAF. Transfusions for surgical hemostasis produced transient increases in F VIII and PAF. In animals receiving normal liver allografts, the levels of F VIII exceeded 100%, PAF was increased, and sustained correction of the bleeding time and maintenance of hemostasis was observed. These data suggest that the kidney is incapable of synthesizing either the vWF or the F VIII and that cells contained in the liver, possibly the endothelial cells, are one of the sites of synthesis of these factors.