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Infected pancreatic necrosis is a devastating and lethal complication of acute pancreatitis. Late death is usually a result of sepsis. W.A. Altemeier and J.W. Alexander established in 1963 that open drainage of the necrotic pancreas is mandatory for survival (Arch Surg 1963;87:96-105). In 1981, E.D. Davidson and E.L. Bradley III concluded that "marsupialization" is the most effective method of open drainage (Surgery 1981;89:252-6). At our institution, we have a series of 10 patients who have undergone marsupialization for treatment of infected pancreatic necrosis. Our mortality rate was 30 per cent. One death resulted from sepsis after an infected necrotic pancreas was found with a colonic anastomotic leak at emergency exploratory celiotomy. Of note, further debridement was not performed. A second death occurred in a female with idiopathic pancreatitis and leukocytopenia, and we are uncertain whether that played a role in the failure of surgical intervention. The third death was in a young alcoholic with hyperlipidemia and severe pancreatitis who was septic 8 days before surgery. The patient died on postoperative day 1. Of the survivors, some were old, many were septic, and all but one returned for further debridement. Our series supports open debridement of infected pancreatic necrosis as a life-saving maneuver and marsupialization as an effective means of open drainage.
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PMID:Marsupialization of the pancreas for infected pancreatic necrosis. 903 96

Plasmapheresis is the process by which plasma containing components causing or thought to cause disease is removed from the circulation, and the remaining blood components are returned with plasma or a harmless plasma substitute to the donor. It primarily removes protein-bound solutes or high-molecular-weight solutes such as circulating protein-bound toxins, autoantibodies, immune complexes, or other abnormally occurring molecules. Plasmapheresis has been used in the treatment of more than 100 diseases in human medicine, including immune-mediated diseases, neoplasia, infectious diseases, sepsis, hyperlipidemia, thyrotoxicosis, and removal of toxins. In immune-mediated disease, it is most useful to rapidly decrease plasma concentrations of antibodies or immune complexes, whereas other immunosuppressive measures are used to prolong the effect.
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PMID:Therapeutic plasmapheresis. 928 42

A nine-year old girl with T cell acute lymphoblastic leukemia (ALL) had acute severe neurologic complications at the end of the remission-induction chemotherapy course. Thirty-six hours following triple intrathecal (IT) therapy and intravenous (IV) administration of L-asparaginase (L-asp), tetraplegia developed and she became unconscious. She had bouts of hypertension and persistent tachycardia unresponsive to digitalis therapy. Magnetic resonance imaging (MRI) showed multiple brain white matter hyperintensities and filling defects in the saggital sinus, suggesting thrombosis. Over the 40 days, in addition to her neurologic compromise she also had transient diabetes mellitus, severe hyperlipidemia, hypoproteinemia and edema, liver and heart failure and staphylococcus aureus sepsis with prolonged bone marrow depression. Despite, coexistence of all these chemotherapy related complications, her neurologic functions and multiple organ failure improved gradually. After a 70 days' period of interruption, chemotherapy was resumed and continued without any further complications. Although, the etiology of her extensive sensitivity to some drugs remains unclear, we believe that it is important to document these unusual events in this child.
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PMID:Coexistence of life threatening chemotherapy related leukoencephalopathy, saggital sinus thrombosis and multiple organ failure in a child with acute lymphoblastic leukemia: an unusual case with clinical recovery. 932 1

Despite the high rates of rejection, allograft failure, and patient death in the early years of renal transplantation, some patients have done remarkably well. Forty-three (17 living related donor and 26 cadaver donor recipients) such patients with an allograft that functioned for 19 years or more (range, 19 to 29 years) were followed up at this center. The patients included 24 men and 19 women, with a mean age at transplantation of 29 years, of whom 39 were white and four were black. At most recent follow-up, the mean daily dose of azathioprine was 104 mg (range, 50 to 175 mg) and that of prednisone was 10 mg (range, 5 to 20 mg). Mean serum creatinine level was 1.6 mg/dL (range, 0.7 to 5.4 mg/dL). Acute rejection occurred in 14 (33%) patients. Nine patients had one episode and five patients had two episodes of acute rejection. Long-term risks to the recipients appeared in the form of coronary artery disease in 10 (23%) patients; malignancy in 13 (30%) patients, which included nine patients with skin malignancy; and chronic hepatitis C virus (HCV) infection in four patients, two of whom died of complications of liver failure. Other complications included avascular bone necrosis in five patients, which required total hip replacement in two patients; hyperlipidemia requiring treatment in 16 (37%) patients; posttransplantation diabetes mellitus in 10 (23%) patients after a median of 17.5 years (range, 1 to 23 years); and hypertension in 23 (53%) patients. There were seven deaths (three of coronary artery disease, two of liver failure, one each of sepsis and malignancy) and eight graft losses (five to death with function, two to chronic rejection, and one to focal and segmental glomerulosclerosis). Although long-term allograft success results in patients receiving minimal amounts of immunosuppression and having good renal function, long-term renal transplant survivors are at risk for significant morbidity even in the third decade posttransplantation.
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PMID:Characteristics of long-term renal transplant survivors. 966 30

Diabetic ketoacidosis results from insulin deficiency and insulin resistance and is marked by hyperglycaemia, ketoacidosis, dehydration and electrolyte losses. Management includes correction of shock, dehydration, electrolyte deficits, hyperglycaemia, acidosis and sepsis (if present). Warning signs include severe dehydration, shock, pH < 7.0, hypokalaemia, hypernatraemia, hyperosmolality, hyperlipidaemia, deterioration in consciousness and diabetic ketoacidosis in very young patients. The principles of treatment include (i) admission to a unit with paediatric experience, (ii) treatment of shock, (iii) rehydration over 24-36 h, or longer if the osmolality is >360 mmoll(-1), (iv) normal saline for rehydration unless the patient is hypernatraemic, (v) avoidance of bicarbonate unless acidosis is interfering with myocardial contractility, (vi) insulin infusion to achieve a fall in blood glucose levels of 5 mmol h(-1), (vi) potassium, (vii) use of 5% glucose when the blood glucose level falls <12mmoll(-1), (ix) treatment of any complications and (x) change to subcutaneous insulin when diabetic ketoacidosis is controlled.
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PMID:Practical management of diabetic ketoacidosis in childhood and adolescence. 982 96

The incidence of atherosclerosis of the heart transplant in long term survivors is 38% at 5 years. In the present work, myocardial perfusion 201Tl-SPET was assessed as a non-invasive diagnostic method for the detection of postransplant coronary artery disease, as well as its efficiency with regard to other techniques. Twenty patients, aged (47 +/- 9) years old, who underwent heart transplantation at least 3 years earlier, were studied by 201Tl-SPET. Qualitative and quantitative analysis of the images were performed. It was found ischemia in 6 patients, 4 of them asymptomatics. In 5 of the 6 positive cases by SPET coronary stenosis was found by angiography. Kappa coefficient and percent of agreement were k = 0. 76 and Pe = 90%, respectively. There were no relationships among rejection crisis, sepsis by cytomegalovirus and coronary artery disease detected by using 201Tl-SPET (p > 0.05). The most relevant risk factors in the sample were hypertension and hyperlipidemia. Two patients died because of coronary artery disease. It was confirmed by necropsy findings. These results suggest that thallium-201 myocardial perfusion tomography could be useful to detect coronary artery disease in the transplanted heart.
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PMID:[Myocardial perfusion SPET in the detection of coronary artery disease in orthotopic heart transplantation]. 987 29

The development of acute acalculous cholecystitis (AAC) after cardiovascular surgery is an infrequent but devastating complication, the etiology and management of which remains controversial. To evaluate the etiology, treatment, and outcome of patients with AAC, the cases of six patients encountered within an 8-year period who developed AAC after cardiovascular surgery requiring cardiopulmonary bypass (CPB) were reviewed. Atherosclerotic risk factors including diabetes, hyperlipidemia, and smoking were evident in five patients, three of whom had a history of stroke or arteriosclerosis obliterans, while low cardiac output was recognized in three. Percutaneous transhepatic cholecystostomy was performed in five patients, and another required cholecystectomy for peritonitis due to gangrene of the gallbladder. Two patients died of respiratory failure and sepsis after 15 and 82 days of percutaneous drainage, respectively; however, the four survivors had an excellent outcome without any biliary tract disease during a mean follow-up period of 5.3 years. In conclusion, AAC after cardiovascular surgery may result from hypoperfusion of the gallbladder due to various factors including CPB, visceral atherosclerosis, and low cardiac output. We advocate early percutaneous cholecystostomy for patients without peritonitis, while early cholecystectomy is indicated for those with peritonitis.
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PMID:Acute acalculous cholecystitis after cardiovascular surgery. 1087 May 75

We evaluated cardiovascular risk factors, morbidity and mortality in patients with lupus nephritis (LN). We prospectively studied 70 consecutive patients with LN, and 70 age- and sex-matched controls with systemic lupus erythematosus (SLE) but no evidence of nephropathy, from 1988 to 1998. Patients were evaluated at entry for hypertension, diabetes, hyperlipidaemia, smoking, menopause and antiphospholipid syndrome. The LN patients (64 women, 6 men) had a mean age of 35 years (SE 1.7, range 11-67). During the 10 years, 15 (21%) LN patients and 18 (25%) of the controls were lost to follow-up. Compared with controls, LN patients had a higher prevalence of hyperlipidaemia (44% vs. 2%, p<0.001), hypertension (44% vs. 9%, p<0.001) and antiphospholipid antibodies (45% vs. 22%, p=0.01) at study onset. At the last visit, 37 (67%) LN patients had normal plasma creatinine, 13 (24%) had renal failure and only five (9%) end-stage renal failure. Hyperlipidaemia (78% vs. 27%, p<0.001) and hypertension (67% vs. 32%, p=0.01) at study onset were associated with development of renal failure. Nine LN patients and one control died (16% vs. 2%, p=0.02). These patients showed more antiphospholipid syndrome (56% vs. 17%, p=0.03) and hyperlipidaemia (78% vs. 37%, p=0.03) at study onset. The main causes of death in LN patients were vascular complications (cardiovascular or cerebrovascular events) in five patients (four of whom had antiphospholipid antibodies) and sepsis in three.
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PMID:Cardiovascular risk factors and the long-term outcome of lupus nephritis. 1116 Nov 32

The study is retrospective review of the demographic, clinical, angiographic, and operative data of the first 205 consecutive CABG operations performed by Caribbean Heart Care at the Eric Williams Medical Sciences Complex (EWMSC), Trinidad and Tobago, between November 1993 and December 1997. The aim of the study was to determine the in-hospital and intermediate-term follow-up results. The mean age of patients was 59 +/- 10 years and 78% were male. Sixty-four per cent were of East Indian descent, whereas 16% were of African descent. Forty-eight per cent of the patients were hypertensive, 46% were diabetic, 33% had hyperlipidaemia, 20% had a recent history of cigarette smoking and 16% were obese. Sixty-five per cent had a positive family history of ischaemic heart disease. The average time interval between angiography and surgery was 2.3 months. At the time of angiography, 63.5% of patients had Canadian Cardiac Society (CCS) class 3 or 4 angina. The mean ejection fraction was 61 +/- 15%. Wall motion abnormalities were seen in 67% of patients. Significant stenoses of the left anterior descending artery, right circumflex artery, circumflex and ramus coronary arteries were present in 91%, 78%, 54% and 5%, respectively. Many patients (67%) had severe diffuse disease on angiography. The mean intensive care stay was 2.2 +/- 0.8 days. In-hospital mortality was 3.9% (8/205). The most frequent post-operative complication was haemorrhage (2.6%). Acute renal failure occurred in 2.1%; pulmonary collapse, 1.6%; stroke, 1% and cardiac arrest, 1%. Both sternal wound infections and systemic sepsis occurred in 0.5%. Intermediate-term follow-up data were obtained for 92% (189/205). The duration of follow-up ranged from 1 to 5 years (mean 3.7 years). During the follow-up period, 7 patients (3.4%) died. Angina severity was reduced from a mean CCS score of 2.61 +/- 0.95 before CABG to 1.22 +/- 0.55 at the time of follow-up (p < 0.0001). Overall 4-year mortality compared favourably with data from international studies. Among survivors, quality of life improved as evidenced by the reduction in the mean angina score.
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PMID:Coronary artery bypass graft outcome: the Trinidad and Tobago experience. 1121 37

A 65-year-old man presented with an asymptomatic infrarenal abdominal aortic aneurysm of 6 cm in transverse diameter. Five years before he received a cadaveric renal transplant. The patient also had the following risk factors and associated diseases: arterial hypertension, coronary artery disease, previous myocardial infarction, coronary angioplasty and stent, ileal resection secondary to Chron disease, hepatopathy, hyperlipidemia and hepato-renal cystic disease. The ASA classification was III, IV. Considering previous abdominal operations and risk factors, we decided to repair the aneurysm with a minimal aggression. The aneurysm was successfully approached by an endovascular route implanting a 22x10 bifurcated aorto-iliac endovascular prosthesis. The patient died 13 months later after being diagnosed of enterocolitis by cytomegalovirus complicated with sepsis and lung infection. We consider this less invasive modality of treatment a valid and useful alternative in this high-risk group of patients.
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PMID:Endovascular repair of abdominal aortic aneurysm in a renal transplant patient. 1123 76


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