St John's wort: a hidden risk for transplant patients.

Herbal medications may cause prescription drug interactions in transplant recipients. After 2 of our kidney transplant recipients started self-medicating with St John's wort, their cyclosporine concentrations were consistently documented to be subtherapeutic. While on St John's wort, one patient developed acute rejection possibly due to low cyclosporine concentrations. Termination of St John's wort returned both patients' cyclosporine concentrations to therapeutic values. Based on the Naranjo Adverse Drug Reaction Probability Scale, our report would achieve a "probable" score, which supports the existence of a St John's wort-cyclosporine adverse drug interaction. St John's wort may induce cytochrome P-450 3A4 activity and/or P-glycoprotein expression, which are both involved in the metabolism and absorption of cyclosporine. Patients using St John's wort concomitantly with cyclosporine or other medications with similar absorption and/or metabolism to cyclosporine need close monitoring. Transplant coordinators are in a critical position to educate transplant recipients about the potential risks of herbal medication usage.

Primary Gianturco stent placement for inferior vena cava abnormalities following liver transplantation.

PURPOSE: To determine the efficacy of primary Gianturco stent placement for patients with inferior vena caval (IVC) abnormalities following liver transplantation. MATERIALS AND METHODS: From August 1996 through March 1999, nine adult patients developed significant IVC abnormalities following liver transplantation. Patients were referred for vena cavography on the basis of abnormal clinical findings, laboratory values, liver biopsy results, Doppler findings, or a combination. Those patients demonstrating a significant caval or hepatic venous gradient were treated with primary Gianturco stent placement. Patients were followed clinically (nine patients), with duplex ultrasound (nine patients), vena cavography (four patients), and biopsy (seven patients). RESULTS: Original pressure gradients ranged from 3 to 14 mm Hg, with a mean of 9 mm Hg. Gradients were reduced to 3 mm Hg or less in all nine patients; presenting signs and symptoms either resolved or improved in eight of nine patients. The ninth patient required repeated transplantation 2 days later. A second patient died 433 days after stent placement of recurrent hepatitis C. Another initially improved following caval stent placement, but underwent repeated transplantation 7 days later due to hepatic necrosis from hepatic arterial thrombosis. Follow-up for the remaining six patients has averaged 491 days, with no clinical, venographic, or ultrasound evidence for recurrent caval stenosis. CONCLUSIONS: Intermediate term results suggest that primary Gianturco stent placement for IVC stenosis, compression, or torsion resulting after liver transplantation is safe and effective.

Use of endovascular stents for the treatment of abdominal aortic aneurysm.

The conventional open surgical repair of abdominal aortic aneurysms is a well-established and durable procedure. However, as with all other major abdominal surgical operations, there are associated morbidities. Both mortality and morbidity increase significantly with advanced patient age and associated comorbid conditions. Endovascular aortic stent-grafts offer a significantly less invasive alternative to conventional open-surgical repair. Patients previously considered unsuitable for open repair can often receive treatment for aneurysms with endovascular techniques. The US Food and Drug Administration has recently approved two endovascular stent-graft devices for use within the United States.

Resource requirements for interventional radiologic management of long-term ambulatory hemodialysis patients.

OBJECTIVE: The purpose of this study was to determine how many and what type of procedures a vascular and interventional radiology service should provide for patients at ambulatory-patient dialysis centers and to determine the necessary resource requirements. These data may provide a realistic starting point for those engaged in the planning and provision of contractual services to dialysis centers. MATERIALS AND METHODS: Patient records at three dialysis centers for a recent 3-year period were examined, and demographic and clinical data were recorded. Records were cross-correlated with records from the vascular and interventional radiology service that had contractually provided all dialysis-related procedures. These data generated a monthly procedure volume and case mix per 100 dialysis patients. Facility usage times for 121 dialysis-related procedures were obtained prospectively and used to calculate the expected resources needed to service the dialysis patients. RESULTS: The three centers provided 5795 hemodialysis-months to 386 patients. Of the 386 patients over the 36-month period, 101 died and 92 transferred from the centers. Three hundred and sixteen patients required 1580 interventional procedures. Monthly procedure volume per 100 dialysis patients averaged 27.1 procedures. Observed procedure times were used to calculate expected room-time hours required to service the monthly procedural volume and case mix per 100 dialysis patients. CONCLUSION: On average, 500 ambulatory dialysis patients will require the full-time use of an interventional suite and the services of a full-time technologist, nurse, and physician to provide necessary dialysis-related procedures. If resources cannot accommodate this volume, the quality and timeliness of care for these patients is jeopardized.

Pathological jealousy appearing after cerebrovascular infarction in a 25-year-old woman.

OBJECTIVE: To report pathological jealousy (Othello syndrome) occurring in a young woman with a right hemisphere cerebrovascular infarction and to review diagnosis and possible organic mechanisms for the generation of this syndrome. CLINICAL PICTURE: A 20-year-old woman was admitted to hospital with a right hemisphere stroke associated with a history of severe migraine and the use of oral contraceptives. The patient made a good recovery with minimal neurological deficits but 5 years later developed the syndrome of morbid jealousy with depression and a near fatal overdose. TREATMENT AND OUTCOME: Morbid jealousy subsided, almost completely disappearing over a 6-week period of treatment with a selective serotonin re-uptake inhibitor (SSRI). CONCLUSIONS: Case reports of the Othello syndrome and other content specific delusions following right hemisphere cerebrovascular infarction have appeared in geriatric psychiatry literature. The occurrence of a similar association in a young patient lends support to the suggestion of a causal relationship and has implications for diagnosis, clinical care and research.

Disaster mental health services: a personal perspective.

1. Services that may be provided by psychiatric-mental health nurses following a disaster include education, intervention, problem solving, advocacy, and referral. 2. Nurses providing disaster mental health services must be flexible and creative. Strong observational skills and teamwork are also essential characteristics in disaster settings. 3. Psychiatric-mental health nurses who wish to receive training for disaster mental health volunteer opportunities should contact their local chapter of the American Red Cross.

Squamous cell carcinomas that arise in the oral cavity and tongue base: can CT help predict perineural or vascular invasion?

PURPOSE: To determine the ability to use computed tomography (CT) to predict invasion of adjacent nerves or vessels by oral cavity tumors. MATERIALS AND METHODS: Contrast material-enhanced CT scans and histopathologic reports were retrospectively reviewed in 48 patients (36 men, 12 women) aged 38-75 years who underwent gross total resection of squamous cell carcinomas arising in the tongue, the base of the tongue, and the floor of the mouth. CT criteria for diagnosis of perineural or vascular invasion were aggressive tumor margins, invasion of the sublingual space, and direct adjacency of the tumor to the enhanced lingual vasculature in the sublingual space. CT and histopathologic findings of perineural and/or vascular invasion by tumor were correlated in all patients. RESULTS: With the above criteria, CT findings predictive of perineural or vascular invasion had a sensitivity of 88%; specificity, 83%; positive predictive value, 85%; and negative predictive value, 84%. CONCLUSION: CT findings can be used to predict perineural or vascular invasion by oral cavity tumors.

Malignant liver lesions: comparison of spiral CT arterial portography and MR imaging for diagnostic accuracy, cost, and effect on patient management.

We compared two imaging techniques, spiral CT arterial portography (CTAP) and MR imaging, for diagnostic accuracy, procedural cost, and effect on management of 26 patients referred for hepatic surgery for suspected limited malignant liver disease. CTAP and MR imaging were done within a 1-week period (19 within 24 hours); the results of the studies were interpreted prospectively by separate reviewers. Surgical data were evaluated in conjunction with imaging data in 10 patients. Lesion detection and segmental involvement were determined and sensitivity and specificity were calculated. Procedural cost was determined from hospital billing codes. Effect on patient management was determined by the referring oncologic surgeon. CTAP and MR imaging showed 185 and 176 true-positive malignant lesions, 15 and zero false-positive malignant lesions, zero and 18 true-negative malignant lesions, and 13 and 22 false-negative malignant lesions, respectively. CTAP and MR imaging showed 107 and 105 true-positive segments, 11 and zero false-positive segments, 80 and 91 true-negative segments, and four and six false-negative segments, respectively. There was a significant difference in specificity of segmental involvement between MR imaging (1.0 +/- 0) compared with CTAP (0.88 +/- 0.05), P = .03. Total procedural cost was $3,499 for CTAP and $1,224 for MR imaging. CTAP findings did not change patient management over MR imaging findings in any patient, whereas MR imaging findings resulted in a change in patient management over CTAP findings in seven patients (P = .015). The results of our study suggest that MR imaging has higher diagnostic accuracy and greater effect on patient management than CTAP does and is 64% less expensive.

Correlation of perfusion abnormalities on CTAP and immediate postintravenous gadolinium-enhanced gradient echo MRI.

BACKGROUND: The purpose of this study was to evaluate patients with wedge-shaped perfusion defects seen on spiral CT arterial portography for the presence of transient increased wedge-shaped enhancement on dynamic gadolinium-enhanced gradient echo MR images. METHODS: Nineteen patients underwent CTAP and MRI within a 2-week interval. All patients with wedge-shaped perfusion defects on CT arterial portography were evaluated in a separate review session for the presence of transient increased segmental hepatic enhancement on dynamic gadolinium-enhanced spoiled gradient echo (SGE) MR images. RESULTS: Eight patients were identified to have subsegmental, segmental, or lobar wedge-shaped perfusion defects by CT arterial portography. In 8/8 patients, there was transient wedge-shaped increased hepatic enhancement on MR images which corresponded to the perfusion defects identified on CT arterial portography. Transient increased enhancement on MR images was observed on immediate postgadolinium images as high-signal intensity of the involved subsegment, segment, or lobe. This relatively high-signal area faded to near isointensity in all cases on images obtained at 45 s. CONCLUSION: Wedge-shaped perfusion defects demonstrated by CT arterial portography corresponded to wedge-shaped increased hepatic enhancement following gadolinium administration on SGE MR images.

Transitional cell carcinoma of the upper urinary tract: staging by MRI.

BACKGROUND: This study evaluates the ability of MRI to stage transitional cell carcinoma of the upper urinary tract. METHODS: Nine patients who had transitional cell carcinoma of the upper urinary tract detected by other imaging modalities underwent MRI examination at 1.5 T. Imaging included pre- and postgadolinium-DTPA T1-weighted images (9 patients) pre- and postgadolinium chelate T1-weighted fat-suppressed spin echo (7 patients). Postcontrast images were acquired prior to the presence of gadolinium within the collecting system (< 2 min postcontrast), intermediate (2.5-8 min), and late (> 10 min) postcontrast. Images were prospectively interpreted and lesion staging was determined. Correlation with histopathology was obtained in all cases. RESULTS: Transitional cell cancers were demonstrated in 9/9 patients, and tumors ranged in size from 2 to 8 cm (mean = 3.8 cm) in one dimension. Correct tumor staging was performed in 8/9 patients. The staging error in one case occurred because direct tumor extension into the renal parenchyma was not detected. CONCLUSIONS: The results of this preliminary study show that MRI stages transitional cell cancers relatively well; however, MRI is not able to detect superficial invasion of renal parenchyma.