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Bedbug (Cimex lectularis) infestation is becoming a worldwide epidemic due to the emergence of insecticide-resistant strains. Pyrethroids are approved by the US Environmental Protection Agency for use against bedbugs and are considered minimally toxic to humans, with known respiratory, neurologic, and gastrointestinal effects. We present the first reported case of pyrethroid-induced toxic acute tubular necrosis (ATN). A 66-year-old healthy woman receiving no prior nephrotoxic medications presented with extreme weakness, decreased urine output, and acute kidney injury. She had administered multiple applications of a bedbug spray (permethrin) and a fogger (pyrethrin), exceeding the manufacturer's recommended amounts. She was found to have severe nonoliguric acute kidney injury associated with profound hypokalemia. Kidney biopsy revealed toxic ATN with extensive tubular degenerative changes and cytoplasmic vacuolization. With conservative management, serum creatinine level decreased from 13.0 mg/dL (estimated glomerular filtration rate, 3 mL/min/1.73 m(2)) to 1.67 mg/dL (estimated glomerular filtration rate, 37 mL/min/1.73 m(2)) within 6 weeks. Literature review uncovered no prior report of pyrethroid insecticide-induced ATN in humans, although there are reports of ATN with similar tubular vacuolization in rats exposed to this agent. Bedbug insecticides containing pyrethroids should be used with caution due to the potential development of toxic ATN after prolonged exposure., (Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

The authors evaluated the self-reported quality of life in patients with systemic arterial hypertension and assessed whether clinicians and normotensive respondents from the general public appreciate the impact that hypertension has on health-related quality of life. A quality-of-life questionnaire was completed by 385 individuals: persons with hypertension (n=188), normotensive persons (n=148), and clinicians (n=49). A utility score, which represents one's self-perceived health-related quality of life, was generated for each group by using standardized time tradeoff questionnaires. Quality of life with hypertension was judged to be significantly higher according to affected individuals (mean utility score, 0.980), compared with normotensive persons (mean utility score, 0.948) and clinicians (mean utility score, 0.942), who were asked to assume that they had hypertension (p<0.0005). Clinicians and normotensive individuals tend to overemphasize the impact that hypertension has on quality of life, as compared to affected patients. The relatively low impact that hypertensive individuals indicate high blood pressure has on their quality of life may contribute to their lack of compliance with treatment regimens., (Copyright 2002 Le Jacq Communications, Inc.)

Background: Algorithms for preoperative cardiac evaluation prior to noncardiac surgery use indices of the metabolic equivalent of activities of daily living (METs). We evaluated METs as a predictor of cardiac complications following elective, noncardiac surgery., Methods: A study was performed in an outpatient university preadmission center METs were estimated prospectively for 5,939 inpatients admitted for elective, noncardiac surgery who underwent a preanesthetic assessment within two months prior to surgery. Cardiac outcomes were retrieved retrospectively from relational databases. Outcomes included death, myocardial infarction, acute congestive failure, arrhythmias, cardiac arrest, acute ischemia, acute renalfailure, stroke, respiratory failure, severe hypertension, peripheral vascular occlusion, and pericardial effusion. Adverse outcomes were correlated with age, gender, surgical procedure, activities, and the American Society of Anesthesiologist's Physical Status (ASA-PS) using receiver operator characteristic curve analysis., Results: 94 of 5,939 (1.6 percent) patients had cardiac complications; 16 died, six from their cardiac complication. 38.3 percent of complications occurred following vascular surgery. Using a multinomial logistic regression analysis, both age and physical status were highly significant predictors (p < 0.001) but METs was not (p = 0. 793). Receiver operator characteristic (ROC) curves were usedfor predictive value of variables. Area of the curves for age versus cardiac complications and death were 0.814 and 0.782; for physical status, 0.744 and 0.803; for METs, 0.664 and 0.524., Conclusions: METs are not a reliable index for the prediction of adverse cardiac events following elective, noncardiac surgery. Age and physical status are more predictive. Adverse cardiac outcomes are most frequent following vascular surgery.

Objective: To query a clinical data repository (CDR) for answers to clinical questions to determine whether different types of fields (coded and free text) would yield confirmatory, complementary, or conflicting information and to discuss the issues involved in producing the discrepancies between the fields., Methods: The appropriate data fields in a subset of a CDR (5,135 patient records) were searched for the answers to three questions related to surgical procedures. Each search included at least one coded data field and at least one free-text field. The identified free-text records were then searched manually to ensure correct interpretation. The fields were then compared to determine whether they agreed with each other, were supportive of each other, contained no entry (absence of data), or were contradictory., Results: The degree of concordance varied greatly according to the field and the question asked. Some fields were not granular enough to answer the question. The free-text fields often gave an answer that was not definitive. Absence of data was most logically interpreted in some cases as lack of completion of data and in others as a negative answer. Even with a question as specific as which side a hernia was on, contradictory data were found in 5 to 8 percent of the records., Conclusions: Using the data in the CDR to answer clinical questions can yield significantly disparate results depending on the question and which data fields are searched. A database cannot just be queried in automated fashion and the results reported. Both coded and textual fields must be searched to obtain the fullest assessment. This can be expected to result in information that may be confirmatory, complementary, or conflicting. To yield the most accurate information possible, final answers to questions require human judgment and may require the gathering of additional information.

We performed a retrospective study to compare the sensitivity, specificity, predictive value, and diagnostic accuracy of appendiceal ultrasonography performed by unsupervised technicians during the nighttime hours with studies performed during the day by supervised technicians. Fifty-nine percent of the 163 sonographic examinations were done during the day, and 41% were performed at night. The sensitivity during the day (61%) was significantly higher than at night (26%), as was the positive predictive value (93% day, 71% night). We conclude that ultrasonography is an operator-dependent study. Its sensitivity is so diminished when not performed by an experienced radiologist or technician that a negative examination is not reliable.

Background: The study of anastomotic leaks is critically important to surgeons because morbidity and mortality increase many fold in the aftermath of an anastomotic disruption. Previous studies that have attempted to identify significant factors contributing to leakage of intestinal anastomoses used animal models or have analyzed retrospective data using univariate analysis. Our objective was to identify factors contributing to leakage of intestinal anastomoses., Study Design: We conducted a retrospective, multivariate analysis of 764 patients who underwent 813 intestinal anastomoses., Results: The overall rate of anastomotic leakage was 3.4 percent. No difference was found in rates of leakage among different techniques of anastomosis or among different anastomotic locations. Colonic anastomoses leaked no more frequently than anastomoses of the small intestine. Proximal fecal diversion did not decrease the frequency of leaks. Multivariate analysis identified six significant predictive variables: a serum albumin level of less than 3.0 g/L, use of corticosteroids, peritonitis, bowel obstruction, chronic obstructive pulmonary disease, and perioperative transfusion of more than 2 U packed red blood cells. The in-hospital mortality rate in patients with and without leaks was 39.3 percent and 7 percent, respectively. Multivariate analysis showed that anastomotic leaks were an independent predictor of mortality., Conclusions: Factors predictive of anastomotic leaks include chronic obstructive pulmonary disease, peritonitis, bowel obstruction, malnutrition, use of corticosteroids, and perioperative blood transfusion.

Objective: To determine the efficacy of supplemental 25% albumin in reducing morbidity and mortality rates in the surgical intensive care unit (ICU)., Design: Prospective, randomized, unblinded clinical study., Setting: Surgical ICU in a community hospital., Patients: Two hundred nineteen patients with admission circulating albumin concentrations of < 3.0 g/dL (< 30 g/L). The groups were well matched regarding age, sex, Acute Physiology and Chronic Health Evaluation II scores and initial circulating albumin concentrations., Interventions: The treatment group (n = 116) received 37.5 g/day of albumin until the circulating albumin concentration increased to > 3.0 g/dL (> 30 g/L). The control group (n = 103) received no supplemental albumin. Both groups received standard nutritional support., Measurements and Main Results: The complication rate was 44% in the albumin group vs. 36.9% in the controls (p = .29). The albumin patients had a mortality rate of 10.3% vs. 5.8% in the control group (p = .22). There were no significant differences between the groups in the number of days spent receiving mechanical ventilation or in the tolerance to tube feedings., Conclusions: Routine supplemental administration of 25% albumin is expensive and offers no apparent outcome advantage and should be abandoned in the treatment of patients in the surgical ICU.

Jeune's syndrome is a rare autosomal disorder characterized by osseous dysplasia, fetal respiratory distress, and renal failure in later life. We describe a 27-year-old man with Jeune's syndrome who underwent renal transplantation and 6 years later developed a sarcoma (primitive neuroectodermal tumor [PNET]) in the soft tissue of the chest wall, a principal site of dysplasia in this disorder.

A retrospective study was done with 325 patients who had preadmission testing prior to ambulatory surgery. At least one laboratory abnormality was noted in 84% of the patients. The serial multiple analysis (SMA)-7 was abnormal 63% of the time. Abnormalities were seen in 54% of the SMA-12 panels and 38% of the urinalyses performed. Twenty-four percent of the patients treated had an abnormal electrocardiogram (ECG). An abnormal chest roentgenogram was found in 19% of the patients. Only three (1%) patients potentially benefited from preadmission testing. Ninety-six percent of the abnormal laboratory results were ignored by the attending physicians. Therefore, we conclude that preadmission testing should be done on a selective basis. Patients older than 50 years of age should have an ECG. A hematocrit should be obtained only if major blood loss is anticipated. All other tests should be ordered based on the history and physical examination.

Human serum has been shown to be bactericidal for most strains of Yersinia enterocolitica. Systemic Y enterocolitica infections have been reported in iron-overloaded hemodialysis patients treated with deferoxamine. Both iron and deferoxamine are known to enhance the growth of Y enterocolitica. We inoculated sera from 12 hemodialysis patients whose serum ferritin levels ranged from 26 to 6,855 micrograms/mL (ng/mL), as well as three controls, with Yersinia organisms. After latencies of 0 to 24 hours, inoculated sera were then plated on blood agar. Bactericidal activity was demonstrated in all sera and the degree of activity did not correlate with ferritin levels. Bactericidal activity was also demonstrated in sera from three deferoxamine treated patients. We conclude that in vitro, sera of end-stage renal failure patients, with and without iron overload, are as bactericidal as control sera for Y enterocolitica and that deferoxamine therapy does not interfere with that bactericidal activity.

The precise diagnosis of the etiology of jaundice is of considerable value to the clinician in caring for the icteric patient. A series of twenty-three patients who underwent minilaparotomy (open transhepatic cholangiogram) is presented. This procedure allows for inspection, biopsy, cholangiography and omental venography under direct visualization and at minimal risk to the patient. In this series the cause of jaundice was successfully determined in 96% of the cases. Cholangiography was used to visualize the ducts in 20 patients and in 2 others, the diagnosis was made by inspection and liver biopsy. The literature on alternative diagnostic methods is reviewed and compared to other procedures the minilaparotomy has relatively few contraindications and many advantages. It is a useful and safe technique in the face of abnormal clotting factors, obstructive jaundice, ascites or hepatitis. By using the multiple diagnostic modalities available in a minilaparotomy, the rate of successful diagnosis equals or exceeds that of the other procedures. It is therefore recommended that this approach be considered as a diagnostic tool in the evaluation of jaundice.

The radiographic spectrum of emphysematous cholecystitis can be divided into three stages. Diagnosis on plain abdominal film is difficult in the first stage. Two cases are presented in which a circular gas filled structure in the right upper quadrant led to a correct diagnosis in the earliest stage. This was confirmed by obtaining contrast studies to rule out other etiologies.

Functional and morphologic glomerular alterations induced by antiglomerular basement membrane (anti-GBM) nephritis were investigated in spontaneously hypertensive rats (SHR) and normotensive Wistar Kyoto controls (WKY) for assessment of the role of systemic hypertension in immunologically mediated renal injury. Over a 6-week period serial measurements of systolic blood pressure (BP), serum creatinine (SCreat), creatinine clearance (CCreat), and urinary albumin excretion (UAlbV) were obtained with inulin clearances (CInulin) at the end of the study. Renal tissue was examined by light microscopy (LM), electron microscopy, immunofluorescence, flash 3H-thymidine autoradiography (AR), and staining for nonspecific esterase (NSE). Immunologic humoral response was evaluated by measurement of rat anti-rabbit IgG antibody production. At all time periods studied, SHR and WKY rats with anti-GBM nephritis demonstrated comparable elevations in SCreat and UAlb V as well as diminution of CCreat and CInulin as compared with non-nephritic control rats of each strain. In nephritic WKY rats mild hypertension developed, whereas in nephritic and control SHR rats marked elevations in BP developed. Morphologic injury as assessed by percent glomerular crescents and hypercellularity on LM, numbers of monocyte macrophages by NSE staining, immunofluorescence for IgG, C3, fibrinogen and Ia positivity, and numbers of glomerular 3H-thymidine-labeled cells by AR was notably comparable in both nephritic strains. Humoral antibody responses were also shown to be similar in all rats studied. These results demonstrate that the 5-week course of experimental anti-GBM nephritis is not exacerbated by systemic hypertension. Glomerular autoregulatory capacity may be important in determining the extent of immune-mediated renal injury.

Pneumoperitoneum was observed in five patients with acute perforative appendicitis (APA). In each case this radiographic observation led to an incorrect diagnosis. Free intraperitoneal gas is found in a small number of patients with APA and has no apparent effect on the course or prognosis of the disease.

Metoclopramide hydrochloride is an antiemetic and gastric motility stimulant with a wide variety of extrapyramidal side effects, including parkinsonism. We describe two patients with end-stage renal disease secondary to diabetes mellitus treated with hemodialysis who developed extrapyramidal symptoms during treatment with metoclopramide. One patient with preexisting, well-controlled Parkinson's disease developed increasing rigidity and bradykinesia that became completely refractory to treatment with L-dopa and bromocriptine while taking metoclopramide for diabetic gastroparesis. A second patient with no history of Parkinson's disease developed a resting tremor and facial dyskinesia during treatment with metoclopramide. In both cases, discontinuation of metoclopramide therapy led to prompt improvement of symptoms.

A series of 168 patients who underwent minilaparotomy was analyzed. Twenty of these patients underwent omentoportography only and 148, open transhepatic cholangiogram. Diagnosis was obtained in 92 per cent of those undergoing evaluation of jaundice, and cholangiography was successful in 99 per cent of those with dilated ducts and in 91 per cent of the over-all group. tthe complications of the procedure have been infrequent and have included sepsis, wound infection and renal failure and, early in the series, bile leak and bleeding. The relative merits of this procedure compared with those percutaneous transhepatic cholangiography and endoscopic retrograde cholangiography were evaluated.

Over an 8-month period, all requests for imaging tests on an acute care surgical ward were discussed and approved by a radiologist who made daily rounds with the surgical staff. Compared with an equivalent interval before the start of the consultation service, the number of sonograms, CT scans, scintigrams, and barium studies decreased significantly, while the number of endoscopic procedures remained constant. The average length of stay was shortened by 2.8 days during the experimental period.

Modern medical practice demands increased patient participation in decision making and an effort to provide economical, safe care. It is recommended that performing breast biopsies as an ambulatory procedure under local anesthesia fulfills these criteria. We present a series of 50 ambulatory breast biopsies, eight of whom had cancer. Of the 50 patients, 94 per cent said they would have it done this way again. Those without cancer went home reassured and those with cancer appreciated time to consider definitive therapy. At our hospital, there is a savings of $750.00 per patient when compared to an inpatient biopsy. It is therefore recommended that patients be given a choice of ambulatory or inpatient biopsy. Ambulatory biopsy avoids general anesthesia, reduces medical costs, and provides opportunity for discussion and planning should further surgery be necessary.

The relationship between acute angiotensin II (AII)-induced functional changes of the kidney and mesangial localization of macromolecules was investigated in rats utilizing native horse spleen ferritin as an exogenous tracer. One group of rats received a 30-minute infusion of a pressor dose of AII. Ten minutes before sacrifice they were injected with a single intravenous dose of ferritin. In the other group the injection of ferritin was followed by an 80-minute infusion of AII. Serial measurements of systolic blood pressure (BP), inulin clearance (CIN), p-aminohippuric acid (PAH) clearance (CPAH), filtration fraction (FF), and excretion of albumin (UAlb V) and ferritin (UFe V) were obtained. Although AII-treated rats showed significant increases of BP, FF, UAlb V and UFe V over controls, they were not different from controls with respect to plasma ferritin concentrations, renal delivery of ferritin, CPAH, and CIN. Semiquantitative evaluation of renal tissue by immunofluorescence and electron microscopy revealed that at 10 minutes no differences in the early and mild deposition of ferritin in the mesangium were appreciable. In contrast, at 80 minutes, AII-treated rats had markedly enhanced mesangial localization of ferritin when compared with controls. In the animals infused with AII for 80 minutes, the amount of glomerular ferritin deposition correlated strongly with UAlb V and UFe V. Combining the results of both, AII and controls at 80 minutes, these correlations were still present, in addition to weaker yet significant correlations of glomerular ferritin with BP and absolute changes of FF during the treatment period. The results show that, over a time interval of 80 minutes, AII augments the mesangial accumulation of ferritin in the presence of normal tracer delivery to the kidney. The enhanced mesangial localization of ferritin is observed under circumstances where overall increases in glomerular capillary permeability to albumin and ferritin are present. Although the precise mechanisms underlying these effects are not identified, AII-induced changes of glomerular microcirculatory forces and permeability properties of the glomerular capillary appear to be involved.

The differential Doppler method used for measuring flow velocities and velocity fluctuations calls for the presence of particles suspended in the flow which act as scattering centers. Experiments conducted with shock waves allowed us to investigate the behavior of these particles at very high accelerations. It would be shown that under normal conditions, particles 0.1-1 micro in diameter are capable of following within a few microseconds velocity variations in flows of at least 200 m/sec.