Chemoattractant properties of Corynebacterium parvum and pyran copolymer for human monocytes and neutrophils.

Both pyran copolymer and the Burroughs-Wellcome vaccine of Corynebacterium parvum were able to elicit a migratory response by human neutrophils or monocytes when incubated with serum. However, in the absence of serum, neither agent elicited such a response. The generation of the chemotactic factor by pyran was dependent on heat-labile components in the serum, while suggested involvement of the complement sequence. Conversely, the migratory response of C. parvum in heated serum was equivalent to that in normal serum. No specificity for either monocytes or neutrophils was observed.

Selective elimination of the delayed-type hypersensitivity response by extracorporeal thoracic duct filtration.

Calves were sensitized to tuberculin and histoplasmin. The delayed-type hypersensitivity skin response to these antigens was produced and the diameter of induration measured. Repeated skin tests prior to filtration demonstrated that the amount of induration produced by these skin tests was closely reproducible. Histoplasmin or tuberculin-coated columns were then introduced into a closed circuit extracorporeal thoracic duct circulation. A significant (P is less than 0.01) reduction or ablation of the delayed-type hypersensitivity response was obtained to the antigen used to coat the column. In contrast, no significant reduction occurred in the skin test response to the other antigen. Repeated skin tests to both antigens after the cessation of filtration showed a gradual rise toward prefiltration levels in the skin test to the filtered antigen. The results of these experiments indicate that a selective population of T lymphocytes can be removed from an in vivo system. The removal of these cells can selectively reduce a delayed-type hypersensitivity skin test response to a particular antigen. These results are consistent with the hypothesis that a type of in vivo selective immunosuppression can be produced by antigen-coated columns when they are placed in an extracorporeal thoracic duct lymph circulation system.

The late adverse effect of splenectomy on patient survival following cadaveric renal transplantation.

Kidney and patient survival of 351 consecutive patients undergoing first cadaveric renal transplants since 1968 were reviewed to determine the effects of splenectomy on outcome. Special emphasis was given to analysis of 106 splenectomized and 102 nonsplenectomized patients treated since 1975. During the first two years after transplant, kidney survival was better in the splenectomized patients, with no adverse effect on patient survival. However, after the first two years, patient survival became significantly worse in splenectomized patients (35.5% vs. 60.5% at 84 months). Of the deaths, infection was the cause in 26.7% of nonsplenectomized patients compared with 50% of splenectomized patients (P less than 0.07). Of patients alive at one year posttransplant, death rates were not different in patients splenectomized before 1975 or after 1975. Timing of splenectomy (prior vs. concurrent) had no effect on outcome. The adverse effect of splenectomy on mortality appeared to be more pronounced in younger (less than or equal to 45 year-old) than in older (greater than 45 year-old) patients. Splenectomy should not be performed routinely in preparation for a cadaveric transplant because of an unacceptably high late mortality that is primarily from sepsis.

A thoracic benign mesenchymoma in association with hemihypertrophy.

A thoracic benign mesenchymoma was removed from an 18-year old caucasian male who also had hemihypertrophy. The very large benign mesenchymoma which was removed was found to consist of an admixture of cytologically mature vascular spaces, adipose tissue, and smooth muscle. After removal of the tumor, the patient has had no recurrence with one year of follow-up. Patients with hemihypertrophy appear to be at high risk to develop neoplasms. Malignant neoplasms of the adrenal gland, kidney, and liver are most common. It is suggested that patients with hemihypertrophy should be followed periodically for their entire life because of their propensity to develop tumors.

Eosinophilic occlusive pulmonic panarteritis associated with long-term antibiotic therapy.

The administration of antibiotics through central catheters for short periods of time frequently is encountered clinically. This report is an in vivo experimental study of long-term bolus administration of antibiotics through a central catheter inserted in the external jugular vein. Approximately 30 calves, which weighed between 180 and 225 kg, had silicone-rubber catheters inserted for protracted periods of time. Various concentrations of either penicillin, cephalothin, or streptomycin were given intravenously in bolus doses. Minimal doses given for long periods of time or large doses given over short periods of time did not produce any pulmonary vascular lesions. Large doses of antibiotics administered for long experimental periods routinely produced a pulmonary vascular lesion in the medium-size and small-size pulmonary arterioles. The vasculitis consists of a diffuse eosinophilic infiltrate located perivascularly and throughout the intima and media. Associated with the vasculitis was a diffuse hyperplasia of the intima and media which frequently stenosed the vascular lumen. These studies suggest an association between large bolus dosages of antibiotics given over a prlonged period via a central catheter and a constrictive pulmonary arteriolar eosinophilic panvasculitis.

Hazard of percutaneous transluminal dilation in renal transplant arterial stenosis.

Percutaneous transluminal dilation of a transplant renal artery was attempted in a patient. The renal artery was perforated by the balloon catheter during the procedure. Despite prompt surgical intervention, the kidney was lost because of irreversible ischemia. This experience is a warning that irreversible ischemia can occur with a transplant kidney if an occlusive complication occurs after percutaneous transluminal dilation. Since the warm ischemic time can exceed the surgical approach and repair, the renal transplant can be lost, and treatment of the patient will resume with long-term hemodialysis. Surgical correlation is a more predictable method, which still must be considered as the treatment of a renal allograft artery stenosis.

Autotransplantation and ex vivo surgery for renovascular disease.

Renal transplantation and preservation techniques permit the use of vascular and microvascular surgical procedures for the reconstruction of renal vessels in situations where the size or location of involved renal vessels does not permit the application of standard in situ techniques. Six cases with renal vascular lesions were studied, one each of intimal fibromuscular hyperplasia, medial arterial fibroplasia, renal artery aneurysm, atherosclerosis, iatrogenic arteriovenous fistula, and traumatic venous laceration, that were repaired by ex vivo surgery and autotransplantation under cold storage or continuous hypothermic perfusion protection, which preserved renal tissue. We believe these techniques should be considered before nephrectomy is undertaken, especially in the patient with one kidney.

Transplantation of microbially contaminated cadaver kidneys.

Bacterial cultures of graft perfusion fluid were taken on 514 renal perfusions during a ten-year period. A total of 22 positive cultures were found. Two sets of kidneys were discarded because of the bacteriology report. Only two possible wound infections were found that could be attributable to the preoperative contamination even though 19 of 24 patients with "contaminated" kidneys received no antibiotics. No loss of kidneys or life was found. Of the 22 contaminated perfusates, 18 (80%) originated from other institutions although only 144 (28%) of the total kidneys that were perfused came from other institutions. The majority of cultures indicated that the organisms were skin contaminants or organisms of low virulence. Microbial contamination of perfused cadaver kidneys is uncommon (1.2% in local kidneys and 9.3% in shared kidneys). Contaminated kidneys are not a major source of infection in renal transplant recipients. Kidneys that are contaminated with frequently virulent Gram-negative bacteria, such as Escherichia coli, should be discarded. Contamination of kidneys with Gram-positive organisms should not be a contraindication for transplantation, but the patients should probably be given prophylactic antibiotics.

Repair of a subvalvular left ventricular aneurysm following mitral valve replacement.

Left ventricular aneurysms are a frequent complication of myocardial infarction. Some aneurysms occur secondary to trauma, previous operation, or infection. This report presents the case of a patient with a posterior submitral left ventricular aneurysm, which occurred following mitral valve replacement. The complete obliteration of the pericardial sac due to previous cardiac operation and the posterior location made external dissection of the aneurysmal wall technically impossible. Closure of the defect through the valve orifice by placing a patch over the neck of the aneurysm was found to be a relatively simple and safe technique combined with replacement of the prosthetic valve. The possibility of injury to the circumflex coronary artery was reduced using this surgical approach.

Early diagnosis, nutritional support, and immediate extensive debridement improve survival in necrotizing fasciitis.

Thirty patients with necrotizing fasciitis were analyzed. The first 20 patients were reviewed from the patient records of the University of Cincinnati Medical Center (Group A). An additional 10 patients from the University of Cincinnati Medical Center and the Medical University of South Carolina were more recently treated (Group B). The 20 patients in Group A had a mortality rate of 50 percent, whereas no deaths occurred in Group B. The age range and race and sex ratios were essentially identical between the groups. The most common site of infection in both groups was the leg or perirectal-perioneal area. Hemolytic streptococcus, Escherichia coli, and Staphylococcus aureus were the most frequently isolated organisms in Group B patients. The most common organisms isolated from patients in Group A were identical to those found in Group B, with the addition of Bacteriodes. The clinical manifestations in Group A patients were most commonly fever, edema, crepitus, gangrene, cellulitis, and pus in the involved area. In Group B patients clinical signs of fever, crepitus, skin anesthesia, and roentgenographic evidence of gas were the most common clinical manifestations. Ninety percent of patients in Group B were found to have roentgenographic evidence of soft tissue gas. Diabetes and atherosclerotic vascular disease occurred in more than 75 percent of all patients in both groups. Patients in Groups A and B were identical in nutritional status at the time of admission to the hospital. The improvement in the rate of survival in patients in Group B can be attributed to earlier diagnosis and referral, immediate and extensive debridement of all involved tissue, and aggressive protein replacement.

Macrophage and polymorphonuclear leukocyte function in patients with Alzheimer disease.

Monocyte derived macrophages and polymorphonuclear leukocytes (PMNs) isolated from the peripheral blood of thirteen patients with Alzheimer disease were studied for their cytotoxic effects on a sensitive allogenic tumor target. PMN cells from 11 of the 13 patients with Alzheimer disease were able to kill the tumor cells. In addition, the macrophages from 12 of the 13 Alzheimer disease patients were cytotoxic towards the tumor targets. Four of these patients possessed a plasma inhibitory factor which was capable of suppressing macrophage mediated cytotoxicity. When the lymphocytes from these patients were studied for their ability to be stimulated with the specific antigen, streptokinase, to produce macrophage activating factor (MAF), only 5 of the 13 patients studied possessed lymphocytes which were capable of producing MAF. Thus, the only immunological defect in Alzheimer disease patients which was observed in this study was in the ability of the lymphocytes to synthesize MAF.

Forearm arterial venous shunt for hemodialysis.

A new technique for creation of an arterial venous shunt for hemodialysis is described. The proximal radial artery is used for the arterial inflow anastomosis site instead of the brachial artery. The technique provides an adequate arterial inflow but avoids all the complications of utilization of the brachial artery in the forearm arterial venous shunt for hemodialysis.

Pancreatic trauma.

The early diagnosis of pancreatic injuries depends on a high degree of clinical suspicion. During laparotomy, exploration of the pancreas and duodenum for suspected injury should be thorough and orderly. In managing these injuries, one should select the simplest procedure that will re-establish the integrity of the upper gastrointestinal tract and control the free escape of pancreatic juices into the surrounding tissue. In general, resection of the distal portion of the body and tail of the pancreas for severe injuries in that area and duodenal diverticularization for injuries involving the pancreatic head are the procedures of choice for preservation of functioning pancreatic tissue.

Effect of antibiotics on the in vitro neutrophil chemotactic response.

Polymorphonuclear neutrophilic leukocyte chemotaxis was examined in vitro in the presence of the following antibiotics: tetracycline, chloramphenicol, erythromycin, gentamicin, methicillin, sulfadiazine, cephalothin, oxacillin, nafcillin and clindamycin. Results indicate that high concentrations (1 mg/ml) of tetracycline, nafcillin, erythromycin and sulfadiazine inhibited the chemotactic response of neutrophils. Tetracycline produced an inhibition at concentrations as low as 1mug/ml. A stimulation of the neutrophil chemotactic response was observed in the presence of chloramphenicol in all concentrations. The results are discussed with particular emphasis on the implications to host immunity.

Vascular complications as a result of intra-aortic balloon pumping.

Intra-aortic balloon conterpulsation (IABP) was used to assist 109 patients with extensive myocardial infarcts, unstable angina, cardiogenic shock, and unstable cardiodynamic states after cardiopulmonary bypass over a six year period. Severe vascular occlusion occurred in three patients (3%) which required an above the knee amputation. Each patient had a long history of smoking. Obesity, atherosclerotic disease of the femoral vessels, and extensive coronary artery disease were additional contributing factors. Two of the three patients survived, but both survivors had extensive postoperative myocardial infarctions. A low flow cardiac state and the presence of atherosclerotic changes in the legs must be precipitating factors for the vascular complications. Several possible methods to minimize complications of this nature include 1) angiographic examination of the lower aorta and femoral arteries at the time of cardiac catheterization, 2) frequent monitoring with ultrasound equipment, and 3) use of anticoagulation during and after the period of counterpulsation.

Renal transplantation in Alport's syndrome.

Nineteen patients (3 women and 16 men) with Alport's Syndrome and endstage renal failure received 23 allograft kidneys at two medical centers between 1972 and 1983. Ten patients had pretransplant splenectomies, and four patients had pretransplant thoracic duct drainage. After a mean follow-up time of 49 months, analysis revealed total allograft survival was 65 per cent at 1 year, 50 per cent at 2 years, and 57 per cent at 5 years. Pretransplant splenectomy resulted in 60 per cent allograft survival at 24 months mean follow-up. Pretransplant thoracic duct drainage resulted in 100 per cent allograft survival at 15.6 months mean follow-up. The overall allograft survival was greatest for three and four antigen-matched kidneys and for living related donor kidneys. Data indicated that 50 per cent of all allografts in men were functional at 50.8 months mean follow-up. All allografts in women were functional at 48.3 months mean follow-up. Three of four patients who expired had pretransplant splenectomies. From this study, the authors conclude that renal transplantation is the preferred method of treatment for patients with Alport's Syndrome.

Action of cefoxitin and cefamandole on human neutrophil function.

Polymorphonuclear neutrophilic leukocyte chemotaxis was examined in vitro in the presence to two new antibiotics: cefamandole and cefoxitin. Results indicate that cefamandole inhibited neutrophil chemotaxis to a significant degree only at high antibiotic concentrations of 100 microgram/ml (P less than 0.01) and has no significant effect at normal serum therapeutic range. Cefoxitin was found to produce a 43% inhibition (P less than 0.01) of human in vivo neutrophil chemotaxis at antibiotic concentrations of 100 microgram/ml and have a minimal inhibitory effect (1 approximately 9%) at low concentrations (1 approximately 5 microgram/ml). Both cefamandole and cefoxitin had no significant effect on opsonophagocytosis.

Vertebral arteriovenous fistula as a result of Swan-Ganz catheter insertion: surgical correction in a symptomatic patient.

A case of a vertebral arteriovenous fistula is reported after being caused by insertion of a Swan-Ganz catheter into the vertebral artery prior to cardiac surgery. The patient's clinical symptoms which precipitated re-admission consisted of multiple episodes of diaphoresis and dizziness. A right carotid bruit was detected in the neck. Four vessel cerebral arteriograms could not accurately identify the origin of the fistula. The proximal carotid artery was considered by several radiologists to be the arterial source of the fistula. During the surgical procedure, a tortuous right vertebral artery was found to be the source of the fistula. Surgical correction of the fistula was successful with preservation of the vertebral artery. Recommendations from a review of the literature are made for the current treatment of this rare complication from an insertion of a Swan-Ganz catheter.