Research
Staphylococcus Associated Glomerulonephritis with IgA Mesangial Deposition
The case is that of 52 year Caucasian male with motor vehicle accident, status post open reduction and internal fixation of the left hip. He sustained wound infection with osteomyelitis due to multidrug resistant pseudomonas infection. Extensive debridement of the wound was carried out but the hardware was left in place. He underwent treatment with polymyxin antibiotic for a month then the course was complicated by renal failure which resolved with polymyxin dose adjustment. However, the hard ware was removed after 2 months of treatment. At that time wound culture revealed MRSA infection. He received 4 weeks of Vancomycin and 6 week course of polymyxin after the hardware was removal. He was readmitted to the hospital with increasing pain and persistent drainage from the wound. Imagings were consistent with erosion of the femoral head with joint space loss, and septic arthritis with evidence of osteomyelitis and the presence of sinus tract to the skin surface. Wash out of the wound with debridement was carried out and another course of Vancomycin was instituted.
Acute Kidney Injury and Massive Proteinuria Secondary to Epstein – Barr virus aAssociated Nephrotic Syndrome
The case is that of 69 year old female who went on vacation and fell on her knees. She noticed progressive swelling of both legs over 2 weeks duration. During this period she gained 44 pounds in weight. She presented with sudden onset of edema of the lower extremity and weigh gain. She had 16 g/day of proteinuria. Past medical history is significant of hypertension of unknown duration. She had never seen a doctor in the last year. Her laboratory data showed 30 grams protein in 24 hrs urine, and her serum creatinine was 1.7 mg/dl. The baseline serum creatinine was not known.
Polyarteritis Nodosa Renal Crisis with Malignant Hypertension
A case of 28 years female with no significant past medical history presented with malignant hypertension. She was found to have Polyarteritis nodosa involving the kidney on angiography. She was treated successfully with steroids and cytotoxic drugs and made uneventful recovery. Her kidney function remained stable and her BP was controlled on Po medications. Even though she was negative for hepatitis B infection, the association was strongly confirmed in about 10% of patients. PAN should be suspected in any patients with multisystem involvement with hypertension and minimal findings in urinalysis. Polyneuropathy and high ESR are also red flags for PAN.
Tunnel Hemodialysis Catheter Placement using the Supra-clavicular Approach to Overcome Stenosis of the Internal Jugular Vein At its Origin
A case of ESRD on HD who is referred for placement of tunnel hemodialysis catheter insertion because his arterialvenous fistula is still immature to be used for HD. He had had 3 TDC placed in the right IJ on previous occasions. His angiogram revealed stenosis of the internal jugular vein at its junction with subclavian vein. After 3 failed attempts at right internal jugular vein cannulation the Supraclavicular approach of the SCV cannulation was achieved with ease overcoming the stenosis in the right internal jugular vein. The case is 68 years Caucasian male with end stage renal disease secondary to renal cell carcinoma and hypertension. He had three tunnel hemodialysis catheters (TDC) placed in the right internal jugular vein and failed radialcephalic arterial-venous fistula in the left forearm. He had recently placed brachial-cephalic AVF in the left arm which was not matured to be used in HD. He was referred to the Dialysis Access Center of Pittsburgh, PA for placement of right internal jugular vein tunneled hemodialysis catheter. Three attempts were made to place TDC in the right IJ vein were without avail due to stenosis in the origin of the right IJ at its junction with the sub-clavian vein as illustrated in the angiogram. A decision was made to place the TDC using the supra-clavicular approach as described below to overcome the stenosis in the right IJ. The procedure was accomplished without difficulty using the ultra-sound- guided cannulation of the subclavian vein and the supra-clavicular approach. Supraclavicular placement of tunnel dialysis catheter is easy and safe method to overcome stenosis in the internal jugular vein.
Testosterone and Vitamin D Deficiency as Risk Factors for Hip Fracture Elderly Male Patients: Time for Vitamin D and Testosterone Replacement
Twenty eight male patients with non-pathological fracture neck of femur (FNOF), age range 61-89 years, mean age 74.4 years, presented for surgery for fracture neck of femur to Merlin Park Regional Hospital, Galway Ireland and 28 age and sex matched control patients, age range 60-85 years, mean age 72.4 years who were admitted to the medical ward for chest pain were included in the study. Following a formal written consent blood were collected for CBC, CMP, and total and free testosterone levels, LH, Estradilol, total 25OHD and 1,25(OH)â‚‚D, and PTH levels pre-operatively. Bone mineral density was done within 7 days of the incident fracture on the patients and the control groups. The study is approved by the local IRB. The results were analyzed using T-test for paired data and Chi-square test for the dichotomous data when applicable. The levels of free and total testosterone (<0.001), LH (<0.001), total protein (<0.001), albumin (<0.001), PTH (<0.001), and free estradilol levels (<0.04) were significantly low in patients with hip fracture compared to controls. The BMD of the femoral neck in g/cm2 were also significantly lower in the patient compared to controls (P<0.001). Conclusions: testosterone and vitamin D deficiency are potentially preventable risk factors in elderly male patients with non-pathological hip fracture. Vitamin D deficiency might also be implicated for the rise in PTH levels, secondary hyperparathyroidism and bone mineral disorders. Hormonal treatment may be potential option to prevent osteoporosis and decrease the risk of hip fracture in elderly male patients.
Prevalence of Helicobacter Pylori Infection among the Whole Spectrum of Age and the Performance of the Different Diagnostic Tests
Design, setting, participants & measurements: Three hundred and thirty eight patients were included in the study. They presented to the endoscopy suite at University College Hospital Galway, Ireland (UCHG) with upper gastrointestinal symptoms. The age range is 21-90 years with a median age of 52 years, 62% females, and 24% diabetics. They were divided into 3 groups 18-30 years, 31-60 years, and 61-90 years. The prevalence of H. pylori among the different spectrum of age is calculated using different methods of diagnosing H. pylori. Reliabilities of the diagnostic tests: The sensitivity, specificity, positive and negative predictive values for (i) Rapid urease test (RUT), (ii) ELISA, (iii) Histology and (iv) Culture. The rapid urease test was found to have a high sensitivity and specificity (89.5% and 96.8%), respectively. Although estimation of serum IgG H. pylori antibody by ELISA is relatively non-invasive procedure, unfortunately, it lacks sufficient sensitivity (63%) to be used as a sole diagnostic test for H. pylori infection. Histology on the other hand is widely available in most hospitals and has a relatively high sensitivity (77.4%) and specificity (75%). Culture of H. pylori was found to be highly specific (100%) and sufficiently sensitive (86.2%). Prevalence of H. pylori infection: The prevalence of H. pylori is assessed in the different age groups. There was a substantial increase in the prevalence of H. pylori infection with increasing age up to the age 61 years. In this study the highest prevalence of infection was found in the age group 31-60 years. The overall prevalence of H. pylori infection in patients with upper gastrointestinal symptoms as assessed by histology (73%), culture (53%), serum IgG ELISA (56%), and rapid urease test (65%). Conclusion: The prevalent of Helicobacter pylori infection are worldwide and the infection rate is intimately related to age, ethnicity, and socio-economic factors. The sensitivity and specificity of the different m
Duodenal Brush Border Enzymes in Helicobacter Pylori Infection
Background and Objectives: H. pylori are an accepted cause of chronic active gastritis and commonly associated with both gastric and duodenal ulcer. Moderate to severe gastritis increases the relative risk of developing peptic ulceration and eradication of the bacteria reduces duodenal ulcer recurrence. The effect of H pylori on the duodenal brush border membrane enzymes have not been studied extensively in this infection. This study evaluates the duodenal brush border enzymes between the H. pylori positive and negatives patients. Design, setting, participants & measurements: One hundred and nine patients, age range 20-84 years, mean age 56 years were included in the study. They presented to the endoscopy suite of UCHG with upper gastrointestinal symptoms. The duodenal bulb was entirely normal and with no evidence of inflammation on endoscopic examination. Biopsies from the antrum were processed for histology and bacteriological culture. Two biopsies from the duodenal bulb were taken from each patient and were sealed in Para-film and stored at -20C0 until assayed for brush border enzymes.
Systemic and Local Immune Response to H. Pylori Infection and their Correlation with the Degree of Antral and Duodenal Inflammation
Design, setting, participants & measurements: One hundred and eight patients presented to the University College Hospital Galway, Ireland (UCHG) with upper gastro-intestinal symptoms were included in the study. There were 52 males with age range 18-82 years, mean age 49 years, and 56 females, age range 20-83 years, mean age 52 years. They were grouped according to the endoscopic findings into 4 groups (i) Duodenal Ulcer (DU), (ii) Gastric Ulcer (GU), (iii) Gastritis (GS), & (iv) Non-Ulcer Dyspepsia (NUD). Five milliliter of venous blood was taken in a sterile plain tube; the serum was separated and stored at -70 C0 for ELISA assay. Endoscopy was carried out and at least 4 biopsies were obtained, 2 from the antrum and 2 from the first part of the duodenum (duodenal bulb). One biopsy each from the antrum and duodenum was transferred immediately into a sterile container containing 2 mL of RPMI 1640. The other biopsy specimens one from the antrum and one from the duodenum were processed for histological examination. The serum IgG antibodies to H. pylori and local IgA and IgG were measured by an ELISA test.
The Sensitivity and Specificity of Clinical Examination of the Hemodialysis Arterial-Venous Fistula (AVF) as Compared to Angiography
Background and Objectives: Physical examination of the hemodialysis arterial-venous fistula (AVF) is convenient and inexpensive, and can often detect common problems associated with hemodialysis access. Routine systematic physical examination of the fistula by the dialysis staff with each treatment may allow early detection of problems that are commonly associated with mature fistula. This avoiding missed treatments and emergent situations. Dialysis access stenosis is the most common cause of access dysfunction. Physical examination is an important method in the assessment of stenotic lesions. The purpose of this study is to evaluate the two simple maneuvers in physical examination of the AVF (pulse augmentation and pressure assessment inside the fistula and collapsibility of the fistula on arm elevation) and compare them with the gold standard angiography.
Hormonal and Mineral Changes in Early Stages of Chronic Kidney Diseases
This study evaluates divalent ion abnormalities (DIA) and the hormonal changes throughout the spectrum of early CKD stages (1-4) as defined by K/DOQI. A total of 96 patients (48.96% males, mean age 62±13 yrs) with CKD 1 to 4, were prospectively evaluated and followed-up. There were (20, 27, 32, and 17 patients in CKD-1, 2, 3, and 4 respectively). The diagnosis was confirmed by renal biopsy, Table- 1.Mean serum creatinine (62±32 umol/L). Plasma levels of calcium, phosphorus, calcitriol (CTRL), and parathyroid hormone (PTH) were evaluated among the groups. A 24-hour urinary creatinine, calcium (Uca), phosphorus (Up), creatinine clearance and fractional excretion of calcium (FeCa), and phosphorus (FeP) were also compared. PTH was measured using the standard IRMA test (normal values 10-50 pg/dl), and calcitriol was measured by RIA test (normal values are 74.5 – 169 pmol/l). The exclusion criteria are nephrolithiasis, hypercalcemia, proteinuria >3g/24 hrs, previous renal transplant, and therapy with steroids or anticonvulsants (Phenytoin).
