Early experience with infectious complications of percutaneous femoral artery closure devices.

Percutaneous femoral artery closure devices are being used routinely after cardiac catheterizations. The use of these devices has been advocated to decrease length of stay, promote early ambulation, and prevent bleeding. We reviewed the use of these devices in our institution and report three cases of infectious complications (two pseudoaneurysms and one infected hematoma). Reports of infected pseudoaneurysms after cardiac catheterization before the implementation of these devices are rare. The use of these devices may be associated with an increased incidence of infected femoral pseudo-aneurysms.

Rapid decomposition of permethrin in the outer fly of an experimental tent in Pakistan.

The residual activity of permethrin on the canvas of an experimental tent, used by nomadic refugees in a malarious area in northern Pakistan, was assessed. A permethrin emulsion sprayed on the inner sheet of a pitched double-fly tent (0.5 g/m2) had an effective residue for at least 6 months in bioassays using the local malaria vectors, Anopheles stephensi and Anopheles culcifacies. However, a high concentration of permethrin (2 g/m2) sprayed on the inner surface of the outer tent, simulating single-fly tents, decomposed within 2 months. These findings were confirmed with chromatographic analysis. Under the conditions found in the study area, the shortened residual effect most likely resulted from photodecomposition, not previously reported to affect operational performance of this insecticide.

Malaria control using permethrin applied to tents of nomadic Afghan refugees in northern Pakistan.

Malaria control among nomadic populations has, in the past, posed serious logistic difficulties. Presented in this article are the results of a pilot study in which permethrin was sprayed on the tents of over 26000 nomadic Afghan refugees in an area of Pakistan where seasonal malaria outbreaks occur. In this area Anopheles culicifacies and A. stephensi are the malaria vectors. Population surveys in the year of the study, before and at the end of the transmission season, showed that the increase in the Plasmodium falciparum prevalence among the Afghan nomads was on average significantly less (increase from 6.4% to 15.3%) than that among the resident Pakistani population (from 3.2% to 45.6%). Surveys at the end of the transmission season among primary schoolchildren the year before and the year of the permethrin trial showed that the P. falciparum prevalence among nomadic children decreased significantly (from 46.9% to 16.3%), whereas an increase was observed among the local Pakistani children. The results show that spraying tents with permethrin was a safe and culturally acceptable intervention for the Afghan refugees and that the findings warrant further investigation.

PIP: During 1989-90, in the North-West Frontier Province of Pakistan, a pilot study was conducted in the remote and politically unstable area of South Waziristan Agency (altitude, 1300-1750 m) to determine the feasibility of spraying about 5600 tents (used by more than 26,000 nomadic Afghan refugees) with permethrin and its effect on malaria prevalence. The researchers compared baseline data on the refugees and data from Pakistani schoolchildren with follow-up data on the nomadic Afghan refugees. The mosquito species harboring malaria parasites in the area were Anopheles culicifacies and A. stephensi. An effective permethrin residue persisted for at least 6 months after spraying. Between seasons, the prevalence of Plasmodium falciparum increased at a significantly lower rate among the Afghan nomads (6.4-15.3%) than the resident Pakistan population (3.2-45.6%). Prevalence decreased significantly among nomadic Afghan children after the permethrin intervention (46.9-16.3%; p 0.002). On the other hand, it increased significantly among the local Pakistani children (11.6-40.7%; p 0.001). There were no reports of adverse effects from permethrin spraying operations. The absence of toxic effects, the immediate impact on flies, and the lack of smell or color of the permethrin emulsion made the spraying operation acceptable among the nomads. These findings suggest that spraying tents with permethrin was a safe and culturally acceptable intervention.

Fenitrothion intoxication during spraying operations in the malaria programme for Afghan refugees in North West Frontier Province of Pakistan.

During the experimental use of fenitrothion to replace malathion for the control of malaria in North West Frontier Province of Pakistan, serious intoxication of Afghan refugee spraymen occurred. A few weeks after commencement of the spraying operations, cholinesterase levels had fallen to 43.8% in personnel mixing the insecticide, and to 60.7% in spraymen, as measured by tintometry. Most of the personnel reported symptoms of overexposure and the spraying operations had to be discontinued. Intoxication of personnel resulted in poor coverage of the target area. High ambient temperatures during Pakistan's spray season discourage the use of full-protective clothing. Fenitrothion intoxication observed in the Afghan refugee programme, and similar experiences in Pakistan in the past, suggest that this insecticide is too toxic for routine use, when the compliance with safety precautions cannot be effectively supervised.

Social influences on the sexual behavior of youth at risk for HIV exposure.

OBJECTIVES: Adolescents are increasingly at risk for infection with human immunodeficiency virus (HIV) and other sexually transmitted diseases, especially in poor urban minority communities. To aid the design of interventions in these communities, this study investigated the role of knowledge, attitudes, perceived parental monitoring, and peer behavior in the onset and progression of sexual behavior in children at risk for exposure to HIV. METHODS: A computerized personal interview was administered to 300 African-American 9- to 15-year-old children living in six public housing developments in a large US city. RESULTS: Although children's knowledge about the hazards of sex increased with age, their sexual activity also increased (from 12% sexually experienced at 9 years of age to more than 80% experienced at 15 years of age). Parental monitoring appeared able to influence sexual activity. However, the perceived behavior of friends was associated with the rate at which sexual activity progressed with age and the degree to which condom use was maintained with age. CONCLUSIONS: The early onset and prevalence of sexual behavior and the importance of peer group influence call for early interventions that simultaneously influence the parents and peers in children's social networks.

Tissue penetration of clindamycin in diabetic foot infections.

Serum and tissue samples were obtained during surgery from four diabetics with neuropathy who underwent debridement or amputation for foot infections while receiving clindamycin 600 or 900 mg iv. Clindamycin concentrations were assayed by radioimmunoassay. Clindamycin was detected in all serum and tissue samples (range: 0.04-2.8 mg/kg in tissues and 1.1-11.1 mg/L in serum). In nine of the eleven tissue samples the clindamycin concentration exceeded the MICs reported for many pathogens commonly involved in such infections. In only a single instance was the ratio of tissue to serum concentration < 0.13.

Current role of cryoamputation.

Cryoamputation or physiologic amputation has been used at our institution for more than 30 years. From 1971 through 1989, 891 major lower extremity amputations were performed in 750 patients. With the use of dry ice or mechanical refrigeration, 320 (36%) physiologic amputations were performed in 292 patients. After physiologic amputation, the initially elevated white blood cell count and temperature decreased. Complications of physiologic amputation were unusual; 3% of patients developed minor freezing above the tourniquet, which did not alter the amputation level, while 1% had purulence at the level of surgical amputation that required delayed stump closure. The overall operative mortality rate in patients who underwent physiologic amputation was 11%, which was equivalent to the rate in patients undergoing primary amputation. Revision was required in 9% of amputations after preliminary physiologic amputation compared with 17% of primary amputations. Physiologic amputation is a simple technique, controls local infection, avoids emergency surgery, and allows for medical stabilization prior to surgery. Amputation revision after physiologic amputation is required less often than after primary amputation, while the mortality rate is comparable to that of patients undergoing primary amputation.

Perigraft pseudocyst complicating repair of ruptured aortic aneurysm: successful treatment by percutaneous aspiration.

Occurring rarely after aortic surgery, post-operative pancreatitis is often complicated and carries a high mortality rate. We have reported a case of pancreatic pseudocyst involving a polytef aortic prosthesis used to repair a ruptured abdominal aortic aneurysm. The pseudocyst was treated successfully by repeated percutaneous aspiration, and removal of the aortic prosthesis was not required. Although less successful than operative drainage, percutaneous approaches to pancreatic pseudocysts are an important option for patients who are poor surgical candidates.

Computerized axial tomography (CT) as an aid in the diagnosis of hepatic portal venous gas: a case report.

The radiologic finding of hepatic portal venous gas and its surgical implications have been documented previously in the literature. More than 67 cases have been reported. Branching tubular lucencies that extend from the porta hepatis to the edge of the liver are characteristic. In general, air in the biliary tree is central in location, but the distinction may not always be clear. We present a case in which computerized axial tomography was extremely helpful in localizing extraluminal gas to the liver and differentiating between air in the biliary tree and hepatic portal venous gas.

Potential drug interactions in surgical patients.

The incidence and frequency of potentially serious drug interactions were evaluated in hospitalized surgical patients. Drug profiles of patients on the general surgical service of a tertiary-care teaching hospital were retrospectively reviewed for two six-month periods to determine how often drugs that are known for major interactions were prescribed concurrently. Interactions were studied that were relatively well documented and potentially harmful to the patients. A total of 1825 patient profiles were reviewed (21,888 patient days). At least one potential drug interaction was found in 17% of the patients. Interactions were found to occur at the rate of 1 for every 59 patient days. Digoxin and cimetidine were the potential interacting drugs in almost 90% of the cases. Hospitalized surgical patients require close monitoring because they frequently receive potentially interacting drugs.

Intraoperative ceforanide pharmacokinetics and protein binding.

The pharmacokinetics and protein binding of ceforanide were studied in 15 patients undergoing cholecystectomies. Each patient received ceforanide (20 mg/kg) intravenously on arrival in the operating room, after which serial blood samples were collected during the elimination phase for determination of total and free ceforanide concentrations in the serum. A high-pressure liquid chromatography assay was used, with a centrifugal filtration system for free-drug determinations. Serum concentration data for each individual were subjected to linear regression to determine the elimination rate constants (total and free drug), volumes of distribution, and systemic clearances. The mean elimination rate constants were 0.41 and 0.50 h-1 for total and free ceforanide, respectively. The mean percentage of ceforanide bound to serum protein was 87.9%. The relationship of the free ceforanide concentration to the total concentration appeared to be linear. The data were fit to double-reciprocal and half-reciprocal relationships with good agreement, showing one binding site and an association constant range of 1.6 X 10(7) to 1.9 X 10(7) at these in vivo concentrations. The mean volume of distribution and mean systemic clearance of total drug were 100 ml/kg and 45.9 ml/min per 1.73 m2, respectively. Ceforanide consistently produced higher intraoperative total drug concentrations compared with those of cefazolin and cefoxitin from similar studies.

Spinal cord ischemia following surgery for aortoiliac occlusive disease.

A 70-year-old man had aortobifemoral bypass for severe aortoiliac occlusive disease. He developed spinal cord ischemia with anterior spinal artery syndrome. He had minimal recovery of muscle function, multiple postoperative complications, and 11 months postoperatively he died. Spinal cord ischemia is a rare and unpredictable complication of abdominal aortic surgery. It most often has occurred following surgery for aneurysm but can also occur after apparently routine surgery for occlusive disease.

Presentation of unknown primary cancer with metastatic liver disease--management and natural history.

Initial blind liver biopsy established a histological diagnosis of metastatic cancer in 27 out of 34 patients who presented with clinical signs of liver metastases and no obvious primary tumour. Twenty-two of the patients had metastatic adenocarcinoma, and a primary tumour site was identified before death in only four patients.

Effect of intraarterial injection of heparin on the complications of percutaneous arterial catheterization in infants and children.

Thrombotic complications of percutaneous arterial catheterization still remain a significant and serious problem in infants and children. Systemic heparinization has been recommended for prevention of these complications. The purpose of this study was to evaluate the effect of intraarterial injection of heparin in reducing thrombotic complications following percutaneous femoral artery catheterization. One hundred sixteen consecutive patients (ages four months to 20 years) studied by the Desilets-Hoffman modification of Seldinger's technique of femoral artery catheterization were randomly allocated to the control or heparin groups using a double-blind technique. At the completion of the catheterization, 0.1 mg/kg of placebo or heparin (1,000 units/ml) was injected into the common iliac artery prior to removal of the catheter and sheath. Segmental plethysmography was performed in both lower extremities prior to and after the catheterization, and a plethysmography index (PI) was calculated. The age and sex distribution, diagnoses, number, type, and site of previous catheterization, hemoglobin, platelet count, the amount of flush solution and the heparin contained therein, size of the catheter and sheath used, number of arterial punctures, and the length of the time in the artery were similar in the two groups (P greater than 0.1). Thrombin time and activated partial thromboplastin time were measured prior to the use of flush solution and prior to angiography, and these remained essentially unchanged in the two groups. The PI in the control group (97.5 +/- 320 was not significantly different (P greater than 0.1) from that of the heparin group (97.7 +/- 32). Similarly, the six to 24 month of postcatheterization plethysmography data show no differences (P greater than 0.1). The number of patients with reduced ipsilateral posterior tibial and dorsalis pedis pulses was also similar (P greater than 0.1). None of the patients in either group required thrombectomy. The low low incidence of arterial complications in our patients when compared with other studies may be related in part to the use of a sheath, which is not called for in original Seldinger technique. The data suggest that full-dose heparin administration does not significantly alter arterial complications following percutaneous femoral artery catheterization, especially in children over five years of age.

The use of intravenous hydrochloric acid in the treatment of thirty-four patients with metabolic alkalosis.

Since 1972, 34 patients with refractory metabolic alkalosis have been treated with intravenous hydrochloric acid at the teaching hospitals of the Medical College of Georgia. Intravenous hydrochloric acid lacks some of the problems associated with alternative methods of therapy. The acid must always be given through a central vein, and its effects should be monitored closely. The use of intravenous hydrochloric acid is a safe, effective way of preventing the deleterious effcts of severe metabolic alkalosis.

Treatment of metabolic alkalosis with intravenous hydrochloric acid.

Severe alkalosis requires aggressive treatment. Twenty patients at the Talmadge Memorial Hospital have been treated for metabolic alkalosis by infusion of dilute hydrochloric acid through a central venous line. The treatment was effective and there were no major complications. Intravenous hydrochloric acid is preferred to other modes of therapy for refractory alkalosis, especially in the presence of hepatic or renal failure.

Bilateral internal carotid artery aneurysms.

Two patients were treated for bilateral internal carotid artery aneurysms. One had resection and restoration of continuity on the right side nine years after ligation of the left internal carotid artery. The second had sequential resection and reconstruction of both vessels. Complications of carotid aneurysms include embolization, rupture, and thrombosis. Preferred treatment is resection with reconstitution of the flow. Patients with carotid aneurysms should be investigated for similar lesions on the opposite side. Patients who have had one carotid aneurysm treated should be followed up for the possible occurrence of a contralateral aneurysm.