The joint diabetic-renal clinic in clinical practice: 10 years of data from a District General Hospital.

BACKGROUND: Diabetic nephropathy is the leading cause of end-stage renal failure. Untreated, it causes continuous decline in glomerular function, worsening hypertension and a marked increase in cardiovascular risk. Joint diabetic-renal clinics were established to address these factors and prepare patients for renal replacement therapy. AIM: To determine whether our joint diabetic-renal clinic influenced progression of renal disease, and whether we were able to achieve targets from clinical trials and guidelines in routine practice. DESIGN: Retrospective review. METHODS: We collected data using clinical notes and electronic records for 130 patients attending the clinic over 10 years. RESULTS: Our patients had 62% type 2 and 38% type 1 diabetes. Mean duration of diabetes was 24 years for type 1 and 11 years for type 2 diabetes. At referral, 56% had evidence of vascular disease and 45%, proliferative retinopathy. Baseline median creatinine was 124 micromol/l. Significant improvements were made in systolic BP, diastolic BP and cholesterol (p < 0.001), compared to measurements at presentation. We analysed progression of renal disease by linear regression on 45 patients who had follow-up data for 3 years. Rate of decline of GFR was significantly reduced from 1.09 ml/min/month in the first year to 0.39 ml/min/month in the third year, (p < 0.004). DISCUSSION: Our findings suggest that the rate of deterioration of renal function can be reduced by aggressive management of risk factors. Joint diabetic-renal clinics appear to be useful in achieving targets in routine clinical practice.

Role of computerized tomography (CT) scan of the chest in patients with newly diagnosed head and neck cancers.

Chest metastases and second primaries are not uncommon in patients with head and neck cancer. Early detection of a second site of malignant disease may alter prognosis and management. This study assessed the diagnostic yield of chest radiographs compared with computerized tomography (CT) in a series of patients with head and neck cancer. Forty-four consecutive patients with a head and neck squamous cell carcinoma (SCC) attending the head and neck surgery department of Cumberland Infirmary, Carlisle, between January 2000 and December 2000 were included in this prospective study. Patients with lymphomas and localized cancers of the skin and lip were excluded. Thirty men and 14 women, with a mean age of 67 years, were assessed. All had chest radiographs and chest CT at the same time as the CT scan of the primary site. Only one patient had a true positive finding on chest radiograph. Five patients had an abnormal chest CT. Of these, two had multiple lung metastases, and another patient had biopsy-proved bronchogenic carcinoma and underwent surgical excision. The sensitivity and specificity of CT scan was 100% and 95%, as opposed to 33% and 97% for chest radiograph.

Successful management of coronary artery perforation with helical platinum microcoil embolization.

A case of small coronary artery perforation during coronary intervention is presented. Continued leakage occurred despite prolonged intracoronary balloon inflation, in part probably related to the use of glycoprotein (GP) IIB/IIIA inhibitors. It was successfully managed by microcoil embolization without any sequel, helping avoid surgery in a high-risk patient. Cathet. Cardiovasc. Intervent. 51:320-322, 2000.

Limb-threatening lower extremity ischemia successfully treated with intra-arterial infusion--case reports.

The authors present two patients with acute arterial vasospasm of the lower extremities causing marked ischemia. One patient had a history of Raynaud's disease, the second had been taking Cafergot for migraine headaches. Both patients's were given a test dose of intra-arterial tolazoline (50 mg). The patient with Raynaud's disease demonstrated marked improvement diffusely and was successfully treated with overnight infusion of papaverine. The second patient, taking Cafergot, demonstrated no angiographic response to tolazoline. It was speculated that the arteries of this patient were thrombosed. The patient was successfully treated with urokinase and remained free of pain at the 15-month follow-up.

Is day case tonsillectomy suitable for children in Cumbria?

Day case tonsillectomy has been advocated as a means of reducing health-care costs associated with in-patient care. The authors studied 74 consecutive children undergoing conventional overnight stay tonsillectomy using a parental questionnaire and a retrospective case note review. Medical exclusion criteria for day surgery were present in 21 per cent, and social exclusion criteria in 82 per cent. Overall, only 16 per cent of children satisfied all the criteria for suitability. On the day of surgery, 29 per cent of children were reported as having poorly controlled pain and 31 per cent as having nausea and vomiting, such that unplanned admission would have been likely had they been done as day cases. In total 63 per cent of parents were unhappy or very unhappy with the possibility of same day discharge. The authors do not plan to introduce day case tonsillectomy in Cumbria.

Bronchial arteriovenous malformation in a child with hemoptysis. A case report.

Pulmonary arteriovenous (AV) malformations occur sporadically and in the pediatric population are most commonly associated with hereditary hemorrhagic telangiectasia. Hemoptysis is an infrequent presentation in this age group. Pulmonary angiography is considered to be the definitive diagnostic modality. The authors describe an otherwise healthy eleven-year- old girl who presented with massive hemoptysis secondary to a large bronchial AV malformation unrelated to any congenital anomalies. The pulmonary angiogram appeared normal and the diagnosis was established by digital subtraction aortography. Successful embolotherapy was performed by selective injection of polyvinyl alcohol particles into the culprit bronchial artery.

Thoracic BB injuries in pediatric patients.

Penetrating thoracic injury from BB shot remains an innocuous event in most patients, but factors including location, proximity, gun type, and patient weight may identify groups at risk. The following cases demonstrate morbidity and mortality in two patients, and this experience may suggest the need for reassessment of this injury.

Intravascular stents in the management of acute superior vena cava obstruction of benign etiology.

The purpose of our study was to report our experience with percutaneous placement of intravascular stents to relieve venous occlusion in patients with acute superior vena cava syndrome resulting from benign etiologies. Six patients ranging in age from 39 to 66 years received thrombolysis followed by placement of stents within the superior vena cava or received stent placement alone as emergency treatment for symptoms of acute superior vena cava obstruction. Treatment was successful in all patients, with establishment of a patent lumen angiographically, and patients experienced prompt symptomatic relief. Follow-up examination at intervals of 5 months to 2 years has demonstrated no evidence of reocclusion. Three patients have subsequently had central lines placed across the stented vena cava for vascular access. Percutaneous placement of intravascular stents to treat acute occlusion offered a safe and effective method of treatment in patients with superior vena cava syndrome resulting from benign causes.

Transesophageal echocardiography for diagnosing aortic injury: a case report and summary of current imaging techniques.

Early diagnosis and rapid treatment of lethal aortic injuries associated with blunt trauma remain a challenge for trauma surgeons. The following case demonstrates the use of transesophageal echocardiography for definitive diagnosis of an aortic injury from blunt trauma. A summary of current diagnostic modalities is also presented.

Intrathrombic urokinase reverses neonatal renal artery thrombosis.

A term infant with aortic and renal artery thrombosis is described, in whom the right kidney experienced complete ischemia for 5 days. A continuous intrathrombic urokinase infusion induced complete clot lysis and reperfusion of the right kidney. Follow-up studies of renal function and renal growth have been normal. This is the first report to describe complete pharmacological salvage of a neonatal kidney after prolonged warm ischemia. This case underscores both the ability of the neonatal kidney to recover from prolonged ischemia and the need to effect thrombolysis before irreversible renal injury occurs. The intrathrombic use of fibrinolytic agents in similarly affected infants warrants consideration and further study.

Use of CT for diagnosis of traumatic rupture of the thoracic aorta.

CT imaging of traumatic aortic rupture has been both advocated and disparaged in the current literature as a reliable diagnostic modality. In a retrospective review of blunt chest trauma patients at our institution evaluated by both thoracic CT and arteriography, we found a 17% false negative rate and a 39% false positive rate. Although we feel CT is not sufficiently sensitive at present to evaluate traumatic rupture of the aorta directly, it is an invaluable adjunctive imaging modality for stable blunt chest trauma patients with equivocal chest radiographs or arteriograms.

Hemoptysis complicating AICD patch placement controlled by temporary selective bronchial balloon occlusion.

This is the first reported case of an automatic implantable cardioverter-defibrillator patch placement complicated by hemoptysis. It is also notable because the patient's massive hemoptysis was managed by a balloon occlusion catheter inserted into the segmental bronchus through the endotracheal tube with fluoroscopic guidance.

Percapsular and percutaneous embolization of renal transplant pseudoaneurysm and AV fistula: case report.

Renal allograft arteriovenous (AV) fistula is a known complication of renal biopsies in patients experiencing renal allograft dysfunction. Treatment may include observation, surgery, or intraarterial embolization. We report a case of postbiopsy renal allograft AV fistula and pseudoaneurysm in which intraarterial embolization was technically impossible. Treatment included percapsular embolization of the pseudoaneurysm using intraoperative ultrasound guidance. The embolization coils served as a guide for subsequent percutaneous embolization of the AV fistula in the angiographic suite. Innovative embolization techniques may be necessary in order to preserve optimal renal function.

Brachial plexopathy as a complication of intraarterial cisplatin chemotherapy.

Intraarterial administration of chemotherapeutic agents provides greater local concentration at the tumor site without increased systemic toxicity. Although intravenous infusion of cisplatin is known to cause peripheral neuropathy and intraarterial administration has been reported to cause lumbosacral plexopathy, brachial plexopathy has not been described. We present a case in which infusion of cisplatin into the axillary artery resulted in permanent neurological damage to the posterior cord of the brachial plexus. Proper positioning of the infusion catheter is necessary to minimize potential neural damage.

Pulmonary nodule mimicked by ECG lead artifact.

Recently, a new ECG lead has been introduced that can mimic a pulmonary nodule to the uninitiated. Alternatively, in those institutions where the lead is commonly seen, physicians may dismiss a real finding on the chest x-ray film as a lead "artifact." We describe the appearance of this new chest wall artifact.