IgM in human immunity to Plasmodium falciparum malaria.

Most studies on human immunity to malaria have focused on the roles of immunoglobulin G (IgG), whereas the roles of IgM remain undefined. Analyzing multiple human cohorts to assess the dynamics of malaria-specific IgM during experimentally induced and naturally acquired malaria, we identified IgM activity against blood-stage parasites. We found that merozoite-specific IgM appears rapidly in Plasmodium falciparum infection and is prominent during malaria in children and adults with lifetime exposure, together with IgG. Unexpectedly, IgM persisted for extended periods of time; we found no difference in decay of merozoite-specific IgM over time compared to that of IgG. IgM blocked merozoite invasion of red blood cells in a complement-dependent manner. IgM was also associated with significantly reduced risk of clinical malaria in a longitudinal cohort of children. These findings suggest that merozoite-specific IgM is an important functional and long-lived antibody response targeting blood-stage malaria parasites that contributes to malaria immunity.

The effect of antibiotic timing on culture yield in paediatric osteoarticular infection.

PURPOSE: To assess the influence of antibiotic timing on surgical culture yield in paediatric patients with haematogenous osteoarticular infection. METHODS: All patients aged 0 to 15 years admitted to a National Children's Hospital with the diagnosis of acute, haematogenous, osteoarticular infection (osteomyelitis and/or septic arthritis) between June 1997 and December 2016 were retrospectively analyzed. Only patients with positive blood cultures undergoing surgery for culture and debridement were included. Patients were allocated into pre-treatment and post-treatment groups, according to whether they received antibiotics before or after surgical cultures were obtained. Outcomes measured included baseline variables, treatment characteristics and surgical culture yield. RESULTS: A total of 131 patients were included; 107 patients in the pre-treatment group and 24 patients in the post-treatment group. There was no significant difference with respect to patient age (p = 0.870), white blood cell count (p = 0.197), ethnicity (p = 0.203) or infection multi-focality (p = 0.883) between the two groups.The administration of systemic antibiotics prior to obtaining surgical cultures had no clinically significant effect on surgical culture yield (rate of positive surgical cultures, 85% (pre-treatment) versus 54.2% (post-treatment); p = 0.002). Within the pre-treatment group, there was no significant difference in duration of pre-surgical antibiotic treatment between patients who had positive or negative surgical cultures (mean duration, 45.9 hours (positive cultures) versus 47.9 hours (negative cultures); p = 0.743). CONCLUSION: In paediatric patients with acute, haematogenous, osteoarticular infection, antibiotic administration before surgery does not decrease surgical culture yield. Our results suggest that paediatric patients presenting with suspected osteoarticular infection should receive appropriate systemic antibiotics promptly after blood cultures are obtained. LEVEL OF EVIDENCE: Level III - retrospective case-control study.

Removal of the syndesmotic screw after the surgical treatment of a fracture of the ankle in adult patients does not affect one-year outcomes: a randomised controlled trial.

Our aim was to compare the one-year post-operative outcomes following retention or removal of syndesmotic screws in adult patients with a fracture of the ankle that was treated surgically. A total of 51 patients (35 males, 16 females), with a mean age of 33.5 years (16 to 62), undergoing fibular osteosynthesis and syndesmotic screw fixation, were randomly allocated to retention of the syndesmotic screw or removal at three months post-operatively. The two groups were comparable at baseline. One year post-operatively, there was no significant difference in the mean Olerud-Molander ankle score (82.4 retention vs 86.7 removal, p = 0.367), the mean American Orthopedic Foot and Ankle Society ankle-hindfoot score (88.6 vs 90.1, p = 0.688), the mean American Academy of Orthopedic Surgeons foot and ankle score (96.3 vs 94.0, p = 0.250), the mean visual analogue pain score (1.0 vs 0.7, p = 0.237), the mean active dorsiflexion (10.2° vs 13.0°, p = 0.194) and plantar flexion (33.6° vs 31.3°, p = 0.503) of the ankle, or the mean radiological tibiofibular clear space (5.0 mm vs 5.3 mm, p = 0.276) between the two groups. A total of 19 patients (76%) in the retention group had a loose and/or broken screw one year post-operatively. We conclude that removal of a syndesmotic screw produces no significant functional, clinical or radiological benefit in adult patients who are treated surgically for a fracture of the ankle.

Listening styles of undergraduate health students.

BACKGROUND: Concerns about poor communication in the medical and other healthcare professions are common in the empirical literature, with studies showing direct relationships between practitioners' effective listening and patients' satisfaction and less risk of litigation. Furthermore, people do not simply listen or not listen, rather they adopt particular listening styles, making the understanding and investigation of practitioner communication a complex topic. The objective of this study was to identify the listening styles of undergraduate health science students enrolled at one Australian university. METHODS: A cross-sectional study using a paper-based version of the Listening Styles Profile (LSP-16) was administered to a cohort of students enrolled in undergraduate education programs in eight different health disciplines: emergency health (paramedics), nursing, midwifery, occupational therapy, physiotherapy, nursing/emergency health dual degree, health science and nutrition and dietetics. The LSP-16 is a validated and reliable scale that assesses participants' preferences for each of four distinct listening style constructs. There were 1459 health students eligible for inclusion in the study. Ethics approval was granted. RESULTS: A total of 860 students participated in the study (response rate of 58%), of whom 87.2% (n=750) were female. Across the group, a strong preference was shown for the People Listening Style (LS), which is a listening style characterised by a concern for people's feelings and emotions. Otherwise, an unexpected amount of homogeneity in preferred listening style was found within the group of health science students. Female students reported a slightly stronger preference for the People LS, whereas males reported slightly stronger preferences for the Action LS and Content LS. There were no statistical differences in preference for LS by students' age or year level of undergraduate enrolment. CONCLUSION: The health professional student participants of this study reported a preference for a range of listening styles, which is appropriate for many healthcare settings. However, a strong preference for the People LS and a moderate preference for the Content LS were evident. This study should be replicated with practicing professionals to establish if the demands of the workplace affect practitioners' listening style(s).

Review of procedures for investigation of anaesthesia-associated anaphylaxis in Newcastle, Australia.

The procedures, results and outcomes of investigation of 50 patients with clinical episodes of anaesthesia-associated anaphylaxis were retrospectively reviewed. Assessment was performed by measurement of serum tryptase and specific IgE and a combination of skin prick and intradermal skin testing. Testing was performed both for agents received during the anaesthetic and for agents the patient may encounter in future procedures. Twenty of 50 patients underwent a subsequent procedure after assessment. Sensitisation to neuromuscular blocking agents was identified in 18 patients (36%). Sensitisation to propofol (14 patients; 28%) and latex (four patients; 8%) was also frequently identified. No precise cause was identified in 11 cases (22%). Reactivity to more than one agent was identified in 14 patients (28%). Serum tryptase was measured within six hours of the episode in only 28 of the 50 cases. All the patients with elevated serum tryptase had clinically severe reactions. One patient initially found to be sensitised to propofol had another reaction during a second procedure, prompting further assessment where chlorhexidine reactivity was identified. Subsequent surgery in that patient and in 19 other patients where agents implicated in the testing were avoided, proceeded without incident. The results reaffirm that neuromuscular blocking agents are the most common cause of anaphylaxis during anaesthesia. The importance of serum tryptase measurement at the time of the acute episode needs to be emphasised. Investigation should include screening for chlorhexidine and latex in all patients, as exposure to both these agents is common and may be overlooked.

Impact of hydroxychloroquine therapy on chronic urticaria: chronic autoimmune urticaria study and evaluation.

BACKGROUND: Chronic urticaria (CU) imposes profound impairment on quality of life. Up to 60% of idiopathic CU is associated with autoimmune phenomena, and may respond to immunomodulation. Hydroxychloroquine offers potential efficacy for CU and is relatively benign compared with most other therapeutic approaches. OBJECTIVE: The aim of the chronic autoimmune urticaria study and evaluation was to evaluate the efficacy of hydroxychloroquine in patients with chronic idiopathic urticaria. METHODS: Twenty-one patients referred to the Immunology and Allergy Unit at John Hunter Hospital, New South Wales, Australia, with idiopathic CU were randomised to receive treatment with standard urticaria therapies (corticosteroids, H2-antihistamines, H1--antihistamines, doxepin) with or without hydroxychloroquine. Markers of autoimmunity, thyroid disease and mast-cell autoreactivity (autologous serum skin-prick testing (ASPT)) were assessed. Measures of urticaria control were compared at baseline and at 12 weeks for the 18 individuals who completed the study. These included urticaria scores, medication scores and quality-of-life indices. RESULTS: The hydroxychloroquine-treated group achieved significant improvements in quality of life as assessed by the global symptom severity score and the LAMY-7 (a quality of life index designed by Lamy, 7th revision) at 12 weeks (P < 0.01 and P < 0.05, respectively). No significant treatment effect on medication requirements or urticaria score was detected, although differences between treatment groups approached statistical significance for urticaria score and medication requirements (0.05 < P < 0.10). ASPT-reactivity did not correlate to hydroxychloroquine-responsiveness. Hydroxychloroquine was well tolerated. CONCLUSION: Immunomodulation with hydroxychloroquine is safe and appears to offer some efficacy as an intervention in CU.

The peripherally inserted central catheter (PICC): a prospective study of its natural history after cubital fossa insertion.

A prospective cohort study was undertaken to describe the natural history of the cubital fossa peripherally inserted central catheter (PICC), determine which factors influenced the hazard of complication and develop a standard methodology for evaluation of a PICC service. A total of 4349 patient days of PICC observation were analysed using survival analysis techniques. The median time to PICC removal for a complication was 60 days. The most common complications were phlebitis, malposition and tip migration. Complications usually occurred during the first week. There was only one episode of line-related sepsis. Size 3 French gauge catheters had a complication rate of 7.3 per 1,000 line days compared to 14.2 for 4 French catheters (hazard rate 1.26 90% CI 1.02 to 1.55). PICCs requiring two or more attempts at insertion were more likely to develop complications than those inserted at the first attempt: 20 per 1,000 line days vs 10.5 but the confidence intervals were wide (hazard rate 1.91, 90% CI 0.90 to 4.05). Operator (amongst the four experienced operators who inserted all PICCs), arm of placement, or medial or lateral placement in the cubitalfossa did not influence PICC survivaL

Neoadjuvant therapy for esophageal cancer: standard of care or elusive myth?

Although surgical resection as the sole treatment modality for esophageal carcinoma has historically been associated with poor survival rates, improvements have recently been reported using varied neoadjuvant chemo-radiation protocols. This study evaluates the outcome of patients undergoing surgery for esophageal carcinoma at the University of Miami/Jackson Memorial Hospital between July 1991 and June 1996. Seventy-two patients underwent esophageal resection; 51 males and 21 females with a median age of 62.5 years (range = 42-82). Histology was equally distributed between adenocarcinoma (36 patients; 50%) and squamous cell carcinoma (36 patients; 50%). Pathological stage distribution consisted of 6 stage 0 (8%), 10 stage I (14%), 23 stage II (32%), 31 stage III (43%), and 2 stage IV (3%) lesions. Patients were divided into three groups according to the type of preoperative treatment; Group 1 (n = 44); surgery alone; Group 2 (n = 18); neoadjuvant 5-fluorouracil based chemotherapy, and Group 3 (n = 9); neoadjuvant 5-fluorouracil based chemotherapy in conjunction with external beam radiation (XRT). One patient received preoperative XRT alone. All survivors were followed for a minimum of 1 year and statistical analysis was performed using Kaplan-Meier curves, log-rank, and chi-square tests. In the 28 patients receiving any form of neoadjuvant therapy only one patient had a pathological complete response (CR) (3.5%). The overall 5 year and median survival rates were 18 per cent and 20.5 months (range = 0-73), respectively. Individual treatment group survival rates at 5 years were 28% for Group 1; 21% for Group 2; and 0% for Group 3, showing no survival difference between Groups 1 and 2; Group 3 fared significantly worse than the other two, probably as a result of the high operative mortality in this group. These results indicate that surgical resection continues to be an important treatment modality for esophageal carcinoma. Neoadjuvant chemotherapy in our experience failed to improve these survival rates and pre-operative chemoradiation was associated with a high perioperative mortality rate. Chemotherapy regimens with higher CRs may further improve these survival rates.

Internal hemipelvectomy for solitary pelvic thyroid cancer metastases.

BACKGROUND AND OBJECTIVES: Radioactive iodine (RAI) therapy remains a primary treatment modality for metastatic thyroid carcinoma, but poor tumor uptake of the agent can limit its usefulness. While offering effective palliation, radiation therapy is not curative, and chemotherapy is even less useful. Surgical resection occasionally remains the only hope of offering a long-term cure in the case of isolated metastases. METHODS: We describe 3 cases of thyroid cancer metastatic to the pelvic girdle that were unresponsive to RAI and other nonoperative therapies, which presented over a 15-year time period. The pelvic disease was the only site of active disease in all cases, and all 3 patients were suffering considerable pain. All 3 patients underwent internal hemipelvectomy with reconstruction in 2 cases using a pelvic bone allograft. RESULTS: All 3 experienced symptomatic relief and early mobilization. While the infection rate was 100%, these all responded completely to operative debridement, irrigation, and antibiotics. One patient, found postoperatively to have a positive surgical margin, developed a local recurrence at 4 months and died. A second patient developed a local recurrence at 11 months and died. The third patient underwent a revision of her hip arthroplasty because of acetabular loosening after a fall 21 months postoperatively. She is alive, disease-free, and ambulatory with the aid of a cane 32 months after the original procedure. CONCLUSIONS: We propose this surgical procedure in selected patients with metastatic pelvic thyroid cancer. It provides symptomatic relief with a chance for prolonged disease-free survival some patients.

Adjuvant radiation after modified radical mastectomy for breast cancer fails to prolong survival.

Recent literature has reported improved local disease control and overall survival in premenopausal node-positive (stage II, and III) breast cancer patients undergoing modified radical mastectomy (MRM) using radiation therapy (RT) combined with chemotherapy. To assess the efficacy of postoperative RT in our own community, we analyzed all patients undergoing MRM for carcinoma utilizing an extensive database from the three major teaching hospitals in Tulsa, OK, between 1965 and 1993. A total of 5257 patients underwent MRM during this time period. One hundred thirty-seven patients were excluded for insufficient data or because they were found to be at stage IV, leaving a total study population of 5125. Overall survival (OS), overall mean survival (MS), disease-free survival (DFS), and locoregional DFS (LRDFS) were analyzed for all patients and were further analyzed according to stage, lymph node involvement, and menopausal status. Median follow-up was 103 months. Statistical analysis was performed using Kaplan-Meier and t-tests. The DFS at 10 years was 65 per cent in the RT group and 80 per cent in the patients who did not receive RT (P = 0.00). No improved DFS was obtained in the radiation-treated patients, regardless of stage, lymph node involvement, or menopausal status. Similarly, the LRDFS at 10 years was 91 per cent in the RT group and 96 per cent in the patients who did not receive RT (P = 0.00). No improved LRDFS was obtained in the radiation-treated patients, regardless of stage, lymph node involvement, or menopausal status. The overall MS was 97 months in the RT group and 104 months in the patients who did not receive RT (P = 0.00). Comparisons of overall MS rates revealed apparent survival benefits from RT in the premenopausal node-negative group, postmenopausal one to four-positive-node group, and all stage I patients. This apparent survival advantage was not confirmed by Kaplan-Meier curves of OS. No other overall MS differences were detected according to stage, lymph node, or menopausal status. Using Kaplan-Meier survival curves, the OS in the RT group at 10 years was 46 per cent, and 63 per cent in the patients who did not receive RT (P = 0.00). No improved OS was obtained in the radiation-treated patients, regardless of stage, lymph node involvement, or menopausal status. These findings from a large breast cancer database failed to demonstrate any meaningful benefit from RT after MRM and serve to further question the efficacy of this treatment modality in postmastectomy breast cancer patients.

Phyllodes tumors of the breast: a review of 32 cases.

Most general surgeons involved in breast cancer care have limited experience with phyllodes tumors. We analyzed a comprehensive database incorporating 8567 breast cancer cases treated surgically in the Tulsa, Oklahoma, region between 1969 and 1993. This yielded 32 cases of phyllodes tumors (0.37%) in 31 patients. The median age was 57 years (range, 18-91). There were 9 low-grade (28%), 2 intermediate-grade (6%), and 21 high-grade (66%) lesions. Size distribution consisted of 23 (72%) lesions 5 cm or less and 9 (28%) greater than 5 cm (mean, 3; range, 1.2-17.5 cm). Of 137 resected nodes in 13 patients, none were positive for metastatic disease. Surgical management consisted of wide excision or mastectomy. No patients received adjuvant chemoradiation therapy. The disease-free, locoregional disease-free, and overall mean survival rates were 80, 81, and 97 months, respectively. Ten-year disease-free survival (DFS), locoregional disease-free survival (LRDFS), and overall survival (OS) rates were 66, 72, and 55 per cent, respectively. Although there was a tendency toward a higher rate of locoregional recurrences and metastases with high-grade lesions, this was not statistically significant and did not affect DFS, LRDFS, or OS rates. Similarly, size of lesion did not affect DFS, LRDFS, or OS rates. Three patients (9.6%) had metastatic disease at presentation, and a further two (6.4%) developed metastases during follow-up. Overall, nine (28.1%) recurrences developed in eight patients, seven locoregional and two distant. Four patients (12.9%) died with evidence of disease. These findings indicate prolonged survival in this patient population with cystosarcoma phyllodes. Wide local excision of primary and recurrent lesions remains the mainstay of therapy. Neither regional lymph node dissection nor adjuvant chemoradiation adds significant benefit.

Transhiatal versus transthoracic esophagectomy: complication and survival rates.

The classic approach for esophagectomy is via a combined thoracic and abdominal approach. Concerns persist regarding the adequacy of this approach as a cancer operation. A study was carried out to compare these approaches, with particular reference to complication rates and long-term survival. The charts of all adult patients undergoing esophagectomy for carcinoma at the University of Miami/Jackson Memorial Hospital between July 1991 and June 1996 were reviewed. Patients who had transabdominal resections alone or colon interpositions were excluded. Of 65 esophageal resections, 38 (58%) were performed transhiatally (THE) and 27 (42%) were performed via the transthoracic (TTE) route. Treatment groups were matched for age and site, stage, and histology of tumor. Similarly, the treatment groups were homogeneous with respect to distribution of neoadjuvant chemotherapy/radiation. The number of patients experiencing any postoperative complication was similar in both treatment groups, occurring in 22 THE (58%) and 17 TTE (63%) patients (P>0.05). Anastomotic leak occurred in five THE patients (13%) and one TTE patient (4%) (P>0.05). The single TTE patient with a leak died within 3 months without leaving the hospital. All five THE patients who developed a leak left the hospital. Although there was a tendency toward a higher percentage of patients in the TTE group to suffer respiratory failure and sepsis and a higher percentage of THE patients to experience anastomotic leak, these did not reach statistical significance. Again, although perioperative mortality tended to be higher in the TTE group, this did not reach statistical significance. Four and 5-year survival rates were similar in both groups. Whereas a 4-year cumulative survival difference of 42% for THE patients and 31% in TTE patients extended at 58 months to 28% and 8%, respectively, these did not reach statistical significance. Similarly, analysis by stage and preoperative treatment type (+/- neoadjuvant chemotherapy/radiation) failed to demonstrate any survival difference between the two groups. These findings demonstrate that there is little difference in operative morbidity and mortality between THE and TTE routes. Anastomotic leaks that occur after cervical anastomosis tend to run a more benign course. Survival data do not support routine TTE as a superior oncological operation, despite the theoretical benefit of better lymphatic clearance. We continue to advocate THE because it allows a cervical anastomosis without thoracotomy and we feel it is better tolerated by patients.

15AU81, a prostacyclin analog, enhances donor-specific hepatocytes to prolong the survival of rat heart but not small bowel allografts.

Prostacyclin analogs have previously been shown to have not only cytoprotective but also independent immunosuppressive effects. The effect of one such analog, 15AU81, to enhance the immunosuppressive effects of liver was investigated. We have previously demonstrated that cyclosporine (CsA) in conjunction with rapamycin (RAPA) potentiates class I+, class II- donor-specific hepatocytes to prolong rat cardiac and small bowel allograft survival. Brown Norway (BN; RT1n) hepatocytes alone (5 x 10(7)/kg, administered intrasplenically) failed to prolong the survival of BN heart allografts in Wistar Furth (WFu; RT1u) recipients, beyond that of untreated controls (MST = 7.2 +/- 0.8 days). Survival of BN hearts was increased to 11.4 +/- 1.7 days in WFu recipients treated with BN hepatocytes and 50 microg/kg/day 15AU81 administered by continuous s.c. infusion for 14 days using osmotic pumps (p < 0.05). The further addition of RAPA 0.0075 mg/kg/day and CsA 0.375 mg/kg/day delivered for 14 days by continuous i.v. infusion (CIVI) using osmotic pumps (a combination that alone prolonged BN heart allografts in WFu hosts to 18.4 +/- 1.3 days and in conjunction with BN hepatocytes prolonged survival to 27.2 +/- 1.9 days) prolonged allograft survival to 35.2 +/- 5.2 days. In contrast, the survival of small bowel allografts was not enhanced by 15AU81 administration. Survival of BN small bowel transplants in LEW recipients treated with hepatocytes alone (MST = 11.6 +/- 1.5 days) or hepatocytes plus 15AU81 (MST = 10.0 +/- 1.0 days) was similar to controls (MST = 10.2 +/- 1.9 days). Treatment with hepatocytes and RAPA/CsA increased survival to 21.2 +/- 1.5 days. The further addition of 15AU81 failed to augment this (MST = 17.0 +/- 1.9 days). In vitro WFu lymphocyte proliferative responses from animals pretreated with BN hepatocytes, 15AU81, or both treatments, for 2 weeks prior to harvesting, exhibited a reduction of at least 50%, compared to untreated controls upon allostimulation with irradiated BN or ACI spleen cells. These findings demonstrate that 15AU81 interacts favorably with hepatocytes either alone or in conjunction with RAPA and CsA to enhance their immunosuppressive effects on rat heart allograft survival. The failure to enhance small bowel allograft survival may be explained by the inability at this low dosage of 15AU81 to influence the intense graft versus host reaction elicited by small bowel transplants.

Intrasplenic liver parenchymal cells in conjunction with low-dose rapamycin and cyclosporine induce a unique and specific prolongation of rat cardiac and small bowel allograft survival.

These experiments investigated the immunosuppressive properties of liver tissue. Brown Norway (BN; RT1n) rat heart allografts survived in untreated control Wistar Furth (WFu; RTl(u)) rat recipients for 6.2 +/- 1.5 days, while allografts in animals that received rapamycin (RAPA) 0.0075 mg/kg/day and cyclosporine (CsA) 0.375 mg/kg/day delivered for 14 days by continuous intravenous infusion (civi) using osmotic pumps in conjunction with intrasplenic (i.s.) saline survived to 18.4 +/- 1.3 days. i.s. addition of 3 M-KCl extracted BN hepatic antigen or unpurified BN hepatocytes (liver parenchymal cells-5 x 10(7)/kg), which exhibited a 4.8% class II antigen expression, and which alone failed to prolong allograft survival (MST = 6.0 +/- 1.4 days), increased heart allograft survival to 25.3 +/- 2.3 and 27.2 +/- 1.9 days, respectively (p < 0.01). Hepatocyte purification using Dynabeads and Percoll reduced class II expression to 0.9% and increased allograft survival to 32.8 +/- 1.6 days (p < 0.01). In contrast, the effect of 5 x 10(8)/kg BN erythrocytes, exhibiting only 0.1% class II expression, was much less (23.8 +/- 1.9 days). Administration i.s. of BN splenocytes or nonparenchymal liver cells, demonstrated by flow cytometry to exhibit a 47.3 or 55.1% expression of class II antigen, respectively, failed to induce any significant increase in allograft survival (18.4 +/- 4.6 and 19.4 +/- 0.5 days, respectively). Survival of BN rat small bowel allografts was increased in Lewis (LEW; RTl1) rat recipients treated with RAPA, CsA, and unfractionated BN hepatocytes from 10.2 +/- 1.9 to 21.2 +/- 1.5 days. Pretreatment with i.s. BN hepatocytes, 14 days prior to harvesting, reduced WFu lymphocyte responses to allogeneic stimulation with BN or ACI spleen cells by 75 and 70%, respectively. Addition of 1 x 10(5) unpurified donor-specific BN or third-party Buffalo (BUF; RTl(b)) hepatocytes, but not supernatant, to the responder wells of MLCs resulted in a 61 and 40% suppression, respectively, of the WFu lymphocyte response induced by BN allogeneic stimulation. These findings suggest that while class I MHC expression has a significant role to play in exerting the immunosuppressive effects of hepatocytes, other influences more specific to liver may also prevail.

Experience using the Quinton Permcath for haemodialysis in the Irish Republic.

BACKGROUND: The Quinton Permcath has been widely used for temporary vascular access in patients requiring haemodialysis. Placement under direct vision into the internal jugular vein minimizes the complication rate. This access modality is being used more and more for long-term access in the elderly and in patients where other access modalities are unavailable or have failed. METHODS: We reviewed the results of 50 central venous Permcaths inserted under direct vision in 61 patients, over a 4-year period. The overall survival and complication rates are estimated. A detailed description of the catheter insertion and removal is provided. RESULTS: Seventy-six per cent of patients were successfully managed using the Permcath for a median duration of 105 days. In addition, nine patients (18%) had catheters functioning without complications for over 1 year. Twenty-six (42.6%) catheters were removed for complications. Seven patients had a single and two had second catheter reinsertion during the course of the study. CONCLUSIONS: The Quinton Permcath remains a reliable method for short-term vascular access. When other access modalities are unavailable, it may offer a valuable alternative for long-term haemodialysis.