Favorable outcome of Fournier gangrene in two patients with diabetes mellitus on continuous peritoneal dialysis.

Fournier gangrene (FG), a form of necrotizing fasciitis of the perineum and genitals, with high morbidity and mortality in the general population, carries the additional risk of involvement of the peritoneal catheter tunnel and peritoneal cavity in patients on chronic peritoneal dialysis (PD). We describe two men with diabetes who developed FG in the course of PD. Computed tomography showed no extension of FG to the abdominal wall, and spent peritoneal dialysate was clear in both patients. Broad-spectrum antibiotic therapy with anaerobic coverage and early aggressive debridement followed by negative-pressure wound therapy and repeated debridement led to improvements in clinical status in both cases. Surgical closure and healing of the wound was achieved in one patient; the wound of the second patient is healing, but remains open. Both patients experienced prolonged hospitalization, with a serious decline in nutrition status. In patients on PD, FG can be treated successfully. However, additional measures are required to evaluate for potential involvement of the PD apparatus and the peritoneal cavity in the infectious process; and prolonged hospitalization, worsening nutrition, and multiple surgical interventions can result.

Increase in serum creatinine in a patient on continuous peritoneal dialysis: potential mechanisms and management.

A large elevation in serum creatinine (S(Cr)) on an unchanged peritoneal dialysis (PD) schedule is usually caused by a decrease in total creatinine clearance (C(Cr)), but may also reflect an increase in creatinine (Cr) production. A meticulously compliant 43-year-old man with lupus nephritis on automated nocturnal PD plus an additional daytime exchange developed a rise in S(Cr) to 16.73 mg/dL from 8.06 mg/dL after starting fenofibrate, while total C(Cr) decreased only to 61.5 L/1.73 m2 from 77.4 m2 weekly. Creatinine excretion was 16.4 mg/(kg x 24 h) pre-fenofibrate. It increased to a high of 26.2 mg/(kg x 24 h) during the period of fenofibrate intake and returned to 21.9 mg/ (kg x 24 h) 2 months after discontinuation of that drug. The patient's age, weight, height, body mass index, 24-h drain and urine volumes, total Kt/V urea, serum urea nitrogen, urea nitrogen excretion, and (for the pre-fenofibrate period) S(Cr), Cr excretion, estimated Cr production, and measured-to-predicted Cr excretion (using a formula developed in PD patients) were within the 95% confidence intervals (CIs) obtained in a control group of 24 other men on similar PD schedules. The patient's Cr excretion and production were above the 95% CIs of the control group while he was on fenofibrate, and they returned toward or within the 95% CIs after cessation of the drug. The patient's serum creatine phosphokinase was not elevated while he was taking fenofibrate. A thorough investigation of the potential mechanisms of a rise in S(Cr) during the course of PD is warranted to determine if the rise is disproportional to any fall in total C(Cr). In the latter case, Cr excretion and production should be evaluated, and if elevated, conditions potentially causing the rise in Cr production (fenofibrate in this patient) should be sought, and appropriate therapeutic interventions should be implemented.

Imaging of peritoneal catheter tunnel infection using positron-emission tomography.

Imaging by ultrasonography or scintigraphy may assist in the diagnosis and management of tunnel infections of the peritoneal dialysis (PD) catheter. Here, we report a case of tunnel infection in which imaging with positron-emission tomography (PET) correctly predicted failure of conservative management. A 61-year-old man with diabetic nephropathy commenced PD in January 2008. He developed erythema and drainage at the exit site, with negative cultures in February 2008, and frank exit-site infection (ESI) with purulent drainage growing methicillin-sensitive Staphylococcus aureus [MSSA (treated with 3 weeks of oral dicloxacillin)] in August 2008. Subsequently, MSSA-growing purulent drainage from the exit site persisted. Systemic antibiotics were not administered, but there was gradual improvement with gentamicin ointment alone. In November 2008, the patient developed partial extrusion of the outer cuff of the PD catheter. In January 2009, a new ESI developed. Despite a week of treatment with cefazolin and gentamicin, the patient still developed his first episode of peritonitis with coagulase-negative Staphylococcus. He then received intraperitoneal vancomycin with good response. Although the ESI appeared to have responded to the treatment, PET imaging showed increased fludeoxyglucose (FDG) activity in the whole abdominal wall portion of the PD catheter. The patient resisted removal of the catheter and had no further signs of infection until June 2009. At that time he presented with exuberant inflammatory tissue ("proud flesh") at the exit site. Repeated PET imaging again showed increased FDG activity along the abdominal wall portion of the catheter. The PD catheter was removed and found to be infected. The patient was placed on temporary hemodialysis. This case demonstrates that PET imaging, in addition to other imaging techniques, may be useful for diagnosing and managing PD catheter infections.

Scrotal edema secondary to fluid imbalance in patients on continuous peritoneal dialysis.

In addition to local causes--for example, leak of dialysate into an inguinal hernia sac or into the anterior abdominal wall through the track of the catheter for continuous peritoneal dialysis (CPD)--scrotal edema in CPD patients may result from generalized volume retention. We present 2 CPD patients with scrotal edema, illustrating the diagnosis and management of the mechanisms of volume retention. A man with hypertensive nephrosclerosis developed isolated scrotal edema 14 months after an uneventful course of continuous ambulatory peritoneal dialysis (CAPD). After repair of a ventral hernia and of a communicating hydrocele, he started continuous cycling peritoneal dialysis (CCPD), plus 2 daytime CAPD exchanges. After 4 months, he again developed isolated scrotal edema, which decreased at night. Peritoneal scintigraphy showed no dialysate leaks, and peritoneal equilibration test (PET) revealed high-average transport with a residual volume above, and an ultrafiltration volume below, the expected range. Abdominal radiography revealed migration of the CPD catheter. Malposition of the CPD catheter with positional retention of dialysate was diagnosed. The patient was treated with nightly peritoneal dialysis and no daytime exchanges. On this regimen, ultrafiltration improved and the scrotal edema disappeared with no recurrence for 5 months, at which point the patient underwent kidney transplantation. A man with diabetic nephropathy developed poor dialysate return, volume gain, and pronounced edema of the scrotum, penis, and both legs soon after starting CAPD. Peritoneal scintigraphy was negative, and abdominal radiography confirmed the appropriate position of the CPD catheter tip in the right lower abdominal quadrant. PET revealed high peritoneal solute transport, appropriate residual volume, and appropriate for the transport category, but relatively low (0.1 L), ultrafiltration volume. He was treated with a change in the CPD procedure to CCPD, plus 1 daytime icodextrin exchange and instruction to reduce salt intake. This patient has remained free of scrotal edema for 6 months. In men on CPD, scrotal edema can develop from generalized volume gain secondary to either CPD catheter malfunction or imbalance between total fluid removal and salt and water intake. Proper interpretation of PET findings is critical in the evaluation of scrotal edema not resulting from internal dialysate leaks in CPD.

Effect of community coalition structure and preparation on the subsequent implementation of cancer control activities.

PURPOSE: The purpose of this paper is to identify factors within a three-phase community coalition development model that influence short-term success in cancer control coalitions based on the cumulative number of educational and screening activities conducted by the coalitions. DESIGN: This study was a nonrandomized community intervention trial involving four autonomous, independently funded multistate projects aimed at using coalitions to increase cancer screening and early detection. SETTING: The study was conducted in medically underserved, rural counties of Appalachia. SUBJECTS: Sixty-three coalitions involved 1725 members representing 71 counties within 10 states. Intervention. A network of local and regional community cancer control coalitions throughout rural Appalachia delivered culturally sensitive cancer control messages to women, with the long-term goal of increasing the early detection of breast cancer ANALYSIS: County-level coalitions were the unit of analysis for this study. Multiple linear regression was used to determine if three classes of variables corresponding to the developmental history of coalitions--formation, preparation for implementation, and implementation--were associated with the number of educational and screening activities conducted by the coalitions. RESULTS: The presence of a paid coordinator and formal organizational structure were both strongly associated with the number of activities conducted, accounting for 71% of the variability in coalition activities. Other variables positively associated with number of activities were the preparation of written community assessments and the modification of implementation plans. The same factors (structure, written plans) were associated with activities in coalitions without paid organizers (r2 = .57), as was the number of meetings. However, such coalitions produced an average of only 2.2 activities vs. 21.7 activities in coalitions with paid coordinators. CONCLUSION: The ALIC study would seem to indicate that community-based coalitions with paid coordinators and formal structures are capable of generating significantly higher levels of activity than those without either a paid coordinator or formal structure.

Examination of the relationship between community support and tobacco control activities as a part of youth empowerment programs.

Through the American Legacy Foundation's Statewide Youth Movement Against Tobacco Use (SYMATU), programs aimed at empowering youths to take action against tobacco use were funded. It is believed that the activities these groups undertake result in changes at the community level. This article examines the relationships between community support of tobacco control and the number and types of tobacco control-related activities these local youth groups conduct. Regression analyses examine the influence that different levels and sources of community support have on the quantity and focus of a group's activities. The influences of community support are briefly explored to understand if certain group characteristics have an impact on the quantity or sources of support for tobacco control. A deeper understanding of the importance and impact of community support will help groups understand the need for building community support networks and how these networks can assist them with implementation of program activities.

Women's perspectives on smoking and pregnancy and graphic warning labels.

OBJECTIVES: To explore women's knowledge, attitudes, and beliefs about adverse outcomes associated with smoking during pregnancy and which outcomes might motivate cessation; to explore reactions to graphic warnings depicting 2 adverse outcomes. METHODS: Twelve focus groups were conducted with women of childbearing age who were current smokers. RESULTS: Participants had low to moderate awareness of many outcomes and believed it was acceptable to smoke in the first trimester before knowledge of pregnancy. Perceived susceptibility to outcomes was low. Motivators included risk-focused information, especially serious risks to the baby (eg, stillbirth, SIDS). Graphic warnings produced strong reactions, especially the warning with a real photo. CONCLUSIONS: Despite barriers to reducing rates of smoking during pregnancy, educational information and photos depicting babies' risks could motivate women to quit.

Assessment of the status of a National Action Plan for Cancer Survivorship in the USA.

PURPOSE: There are currently more than 12 million cancer survivors in the USA. Survivors face many issues related to cancer and treatment that are outside the purview of the clinical care system. Therefore, understanding and providing for the evolving needs of cancer survivors offers challenges and opportunities for the public health system. In 2004, the Centers for Disease Control and Prevention and the Lance Armstrong Foundation, now the Livestrong Foundation, partnered with national cancer survivorship organizations to develop the National Action Plan for Cancer Survivorship (NAPCS). This plan outlines public health strategies to address the needs of cancer survivors. To date, no assessment of NAPCS strategies and their alignment with domestic cancer survivorship activities has been conducted. METHODS: The activities of five national organizations with organized public health agendas about cancer survivorship were assessed qualitatively during 2003-2007. Using the NAPCS as an organizing framework, interviews were conducted with key informants from all participating organizations. Interview responses were supplemented with relevant materials from informants and reviews of the organizations' websites. RESULTS: Strategies associated with surveillance and applied research; communication, education, and training; and programs, policy, and infrastructure represent a large amount of the organizational efforts. However, there are gaps in research on preventive interventions, evaluation of implemented activities, and translation. CONCLUSIONS: Numerous NAPCS strategies have been implemented. Future efforts of national cancer survivorship organizations should include rigorous evaluation of implemented activities, increased translation of research to practice, and assessment of dissemination efforts. IMPLICATIONS FOR CANCER SURVIVORS: The results of this descriptive assessment provide cancer survivors, cancer survivorship organizations, researchers, providers, and policy makers with initial information about cancer survivorship public health efforts in the USA. Additionally, results suggest areas in need of further attention and next steps in advancing the national cancer survivorship public health agenda.

Striving to be in the profession and of It: the African American experience in physical education and kinesiology.

This study analyzes the experiences of African Americans in the physical education and kinesiology profession since the late 1850s. Using a variety of primary and secondary source material, we place special emphasis on the experiences of African American physical educators in higher education and in the American Alliance for Health, Physical Education, Recreation and Dance and its southern, regional, and state chapters. Apparent from this examination is that African Americans have experienced various forms of racially discriminatory practices in physical education and kinesiology and have found it extraordinarily difficult to assume leader ship positions in the profession and be acknowledged for their scholarly and academic accomplishments.