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Cholestasis Post Liver Transplantation. IN: Lindor, K.; Talwalkar, J., eds. Cholestatic Liver Disease. Totowa, NJ: Humana Press. 2008. pp 171-182.

This chapter on cholestasis that occurs after liver transplantation is from a book that offers health care providers an overview of cholestatic liver disease; cholestasis is defined as a liver disorder characterized by impaired bile flow. The chapter covers biliary complications, preservation or reperfusion injury and ABO incompatibility, small-for-size syndrome, hepatic artery thrombosis, infectious complications, drug-induced acute cellular rejection, chronic rejection, and recurrent disease, including primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), and viral hepatitis. The authors caution that cholestasis can occur anytime throughout the posttransplant period, may be intrahepatic or extrahepatic in origin, and has a very broad differential diagnosis. Careful diagnostic imaging of the biliary tree is an important first step in the workup, followed by liver biopsy if clinically indicated. 1 table. 50 references.

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Disorders of the Kidneys. IN: Tanagho, E.; McAninch, J., eds. Smith’s General Urology. 17th ed. Columbus, OH: McGraw Hill. 2008. pp 506-520.

This chapter about disorders of the kidneys is from an updated edition of a comprehensive textbook about urology that offers an overview of the diagnosis and treatment of diseases and disorders common to the genitourinary tract. The author begins with a consideration of congenital anomalies of the kidneys, including agenesis, hypoplasia, supernumerary kidneys, dysplasia and multicystic kidney, adult polycystic kidney disease (PKD), simple or solitary cyst, renal fusion, and ectopic kidney. For most conditions, the author reviews the etiology and pathogenesis, the pathology, clinical findings, differential diagnosis, complications, treatment, and prognosis. The chapter goes on to describe acquired lesions of the kidneys, including aneurysm of the renal artery, renal infarcts, thrombosis of the renal vein, arteriovenous fistula, arteriovenous aneurysm, renoalimentary fistula, and renobronchial fistula. The chapter is illustrated with numerous black-and-white drawings and photographs. The chapter concludes with an extensive list of references, categorized by topic. 9 figures. 34 references. 17 ..MJ.- Kidney Diseases. Congenital Anomalies. Acquired Disorders. Diagnosis. Symptoms. Etiology. Therapy. Patient Care Management.

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Value of a Team Approach to Monitoring. Nephrology News & Issues. 22(6): 34-36. May 2008.

This article discusses the use of a team approach to the monitoring required for patients who have arteriovenous (AV) fistulae for hemodialysis vascular access. This team is usually composed of dialysis nurses, a vascular access coordinator, nephrologists, interventionalists, and the surgeon who placed the fistula. The authors review suggested methods of surveillance and the diagnostic techniques that can add valuable information to monitoring efforts. The authors maintain that the examination and surveillance techniques they describe can reduce the incidence of complete access thrombosis, a disruptive complication that can be disturbing for the patient. Incorporating these methods into routine dialysis care can increase access survival and thus reduce hospital days, missed treatments, and catheter use. A chart summarizes the clues of an access failure, the recommended physical examination of the access, the periodic surveillance tools to use, how to handle suspected access malfunction, stenosis or thrombosis, and the interventions for salvage of the access. 1 figure. 14 references.

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ABC of Clinical Hematology. Williston, VT: Blackwell Publishing Inc. 2007. 99 p.

This book on clinical hematology is from a series of resource books written by specialists for nonspecialists. The book is designed to be easy to use and covers the symptoms, investigations, treatment, and management of conditions presenting in day-to-day practice. The book includes fifteen chapters covering iron deficiency anemia, macrocytic anemias, hereditary anemias, polycythemia, essential thrombocythemia and myelofibrosis, chronic myeloid leukemia, the acute leukemias, platelet disorders, the myelodysplastic syndromes, multiple myeloma and related conditions, bleeding disorders, thrombosis and anticoagulation, lymphoproliferative disorders including chronic lymphocytic leukemia, stem cell transplantation, hematological disorders at the extremes of life, hematological emergencies, and the impact of molecular biology and gene therapy on the field of hematology. The book includes full-color photographs and illustrations. Each chapter concludes with a list of references, and a detailed subject index appears at the end of the text.

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Antiphospholipid Syndrome. IN: Hematology 2007. Washington, DC: American Society of Hematology. 2007. pp.136-142.

This chapter, from the annual Hematology 2007, describes the antiphospholipid syndrome (APS), an autoimmune thrombophilic condition that is marked by the presence of antibodies that recognize phospholipid-binding proteins. Patients with APS tend to present with vascular thrombosis and pregnancy complications, especially recurrent, spontaneous miscarriages. The author focuses on updated diagnostic and therapeutic approaches to this disorder. The author recommends that testing for antiphospholipid (aPL) antibodies should usually be restricted to patients who have had thrombosis, embolism, or pregnancy complications that may be attributable to APS, and to patients with systemic lupus erythematosus (SLE) even if they have not had these manifestations. An initial venous thromboembolism (VTE) in patients with confirmed APS should be treated with warfarin. Recurrence of VTE in the face of standard treatment should be treated with higher intensity coagulation or in selected situations with a form of low-molecular-weight heparin (LMWH). For pregnant patients with VTE, the author recommends treatment with prophylactic dose heparin plus low-dose aspirin (81 milligrams daily), with modification of administration for delivery, followed by resumption of prophylactic anticoagulation. 2 figures. 3 tables. 41 references.

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Aspirin and Clopidogrel Resistance. IN: Hematology 2007. Washington, DC: American Society of Hematology. 2007. pp. 114-120.

This chapter, from the annual Hematology 2007, reviews the use of aspirin and clopidogrel in patients with cardiovascular disease, focusing on patients who experience aspirin and clopidogrel “resistance.” The authors caution that this term infers a lack of therapeutic response and a single underlying mechanism, which is misleading. The incidence of “resistance” detected in clinical studies varies with the definition applied and assay used to measure response. Rather than true resistance, however, there is a variable patient response that reflects the unique pharmacology and pharmacokinetics of each drug, the clinical significance of which remains to be established. The authors discuss true “aspirin resistance” in which, despite 95 percent inhibition of serum thromboxane B2 by aspirin, residual platelet aggregation is detected in some cases. They consider whether heritable factors directly and indirectly related to platelet cyclooxygenase may influence aspirin response. The authors conclude that, in contrast to aspirin, the response to clopidogrel is highly variable and reflects the bioavailability of the active metabolite and not “resistance” of the receptor to inhibition. 2 tables. 46 references.

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Bleeding And Thrombosis Risks in Plasma Cell Dyscrasias. IN: Hematology 2007. Washington, DC: American Society of Hematology. 2007. pp.158-164.

This chapter, from the annual Hematology 2007, considers the bleeding and thrombosis, or clotting, risks in patients with plasma cell dyscrasias, including multiple myeloma, Waldenstrom macroglobulinemia, and other B cell malignancies. The author notes that overt bleeding is relatively uncommon in these patients, despite frequent abnormal screening hemostasis tests. However, acquired von Willebrand deficiency and light-chain (AL) amyloidosis, and amyloidosis complicating multiple myeloma can present with serious hemorrhagic complications that are challenging to manage. The author notes that present understanding is incomplete regarding the complex interactions among malignant plasma cells, inflammatory and hemostasis pathways, and treatment modalities that combine to produce thrombotic complications. The author concludes by calling for additional research to assist clinicians in providing venous thromboembolism (VTE) prophylaxis to patients with plasma cell dyscrasias. 1 figure. 4 tables. 67 references.

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Bleeding Disorders, Thrombosis and Anticoagulation. IN: Provan, D., ed. ABC of Clinical Haematology. Williston, VT: Blackwell Publishing Inc. 2007. pp. 52-56.

Blood within the circulation must remain fluid, but if a blood vessel is damaged, localized coagulation must take place to prevent blood loss. This complex interacting system can be disturbed by inherited or acquired factors, resulting in bleeding or thrombotic disorders. This chapter about bleeding disorders, thrombosis, and anticoagulation is from a book on clinical hematology, written by specialists for nonspecialists. The book is designed to be easy to use and covers the symptoms, investigations, treatment, and management of conditions presenting in day-to-day practice. In this chapter, the author outlines the approach to a patient with a suspected bleeding disorder, which should include a medical history, examination, coagulation screening tests, and specialist coagulation tests. The chapter also covers congenital bleeding disorders, acquired bleeding disorders, venous thromboembolism, the inherited thrombophilias, and treatment strategies for venous thromboembolism. The chapter is illustrated with full-color photographs, drawings, and charts. 3 figures. 7 tables. 6 references.

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Catheter-Related Complications of Total Parenteral Nutrition. American Journal of Gastroenterology. 102: S97-S101. 2007.

This article describes the catheter-related complications that can occur with the use of total parenteral nutrition (TPN), focusing on the two major complications related to catheters: occlusion and infection. Topics include nonthrombotic catheter occlusion, catheter-related infection, catheter sepsis and its diagnosis, and exit site and tunnel infections. In each category, the author reviews the typical and atypical symptoms, diagnostic considerations, and treatment options. The author notes that most thrombotic disease actually occurs around, rather than within, the catheter. However, catheter thrombosis is a relatively uncommon occurrence. The greatest risk for developing catheter thrombosis is a previous catheter thrombosis in the absence of catheter malposition. Many catheter occlusions are related to mechanical problems. In long-term patients, most infections occur at the hub, primarily as a result of contamination and improper cleaning of the catheter. 5 figures. 31 references.

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Catheter-Related Complications of Total Parenteral Nutrition. American Journal of Gastroenterology. 102: S97-S101. 2007.

This article describes the catheter-related complications that can occur with the use of total parenteral nutrition (TPN), focusing on the two major complications related to catheters: occlusion and infection. Topics include nonthrombotic catheter occlusion, catheter-related infection, catheter sepsis and its diagnosis, and exit site and tunnel infections. In each category, the author reviews the typical and atypical symptoms, diagnostic considerations, and treatment options. The author notes that most thrombotic disease actually occurs around, rather than within, the catheter. However, catheter thrombosis is a relatively uncommon occurrence. The greatest risk for developing catheter thrombosis is a previous catheter thrombosis in the absence of catheter malposition. Many catheter occlusions are related to mechanical problems. In long-term patients, most infections occur at the hub, primarily as a result of contamination and improper cleaning of the catheter. 5 figures. 31 references.

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Chronic Myeloproliferative Diseases. IN: Sekeres, M.; Kalaycio, M.; Bolwell, B., eds. Clinical Malignant Hematology. Columbus, OH: McGraw Hill. 2007. pp 445-502.

This section about chronic myeloproliferative disorders (CMPDs) is from a comprehensive reference book that covers the full spectrum of cancers in the blood, bone marrow, and lymphatic system, including leukemia, lymphoma, and myeloma. CMPDs are characterized by the chronic proliferation of one or more of the three hematopoietic cell lines or by marrow stromal cells, in various proportions. The CMPDs include polycythemia vera, idiopathic myelofibrosis, chronic myelogenous leukemia (CML), and essential thrombocytosis (ET). This section offers six chapters: epidemiology, risk factors, and classification; molecular biology, pathology, and cytogenetics; clinical features and making the diagnosis; the recommended treatment approach to polycythemia vera and essential thrombocythemia; the recommended approach to chronic idiopathic myelofibrosis, with extramedullary hematopoiesis; and the management of chronic myelomonocytic leukemia and other rare myeloproliferative disorders. The chapters are illustrated with black-and-white clinical pictures and photomicrographs. Each chapter concludes with an extensive list of references.

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Coagulation in the Pathophysiology of Hemolytic Anemias. IN: Hematology 2007. Washington, DC: American Society of Hematology.2007. pp 74-78.

This chapter, from the Hematology 2007 monograph, reviews coagulation in the pathophysiology of hemolytic anemias (HA). The author focuses on three hemolytic disorders: sickle cell disease and beta-thalassemia, paroxysmal nocturnal hemoglobinuria (PNH), and thrombotic microangiopathies (TMA). In sickle cell disease and in ß-thalassemia, a thrombophilic status has been well documented as multifactorial involving hemostatic changes and activation of the coagulation cascade. Other evidence points to the involvement of endothelial activation in vascular occlusion. The main clinical manifestation of paroxysmal nocturnal hemoglobinuria (PNH) is HA, and the most common complications are thrombosis, pancytopenia, and myelodysplastic syndrome or acute leukemia. The author notes that the mechanism responsible for the increased incidence of thrombotic events in PNH remains unclear. Recent advances have been made in understanding the coagulation involvement TMA, a heterogeneous group of diseases characterized by microangiopathic HA and thrombocytopenia due to platelet clumping in the microcirculation, leading to ischemic organ dysfunction with neurologic symptoms and renal impairment. The author concludes by discussing the three ways that hemolysis contributes to coagulation abnormalities in HA: red blood cell membrane alterations, erythrocyte/endothelium interaction, and nitric oxide (NO) deficiency. 1 figure. 38 references.

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Double Hazard of Thrombophilia And Bleeding in Leukemia. IN: Hematology 2007. Washington, DC: American Society of Hematology. 2007. pp.151-157.

This chapter, from the annual Hematology 2007, considers the association between thrombosis and cancer, notably the incidence of thrombosis in malignant hematologic disorders such as leukemia. The author notes that thrombotic, or clotting, complications in acute leukemia are often overlooked because bleeding complications generally dominate the clinical picture. Yet, the patient is at risk for both. The factors in patients with leukemia that may contribute to thrombosis include hyperleukocytosis, increased expression of tissue factor and its activation in leukemic cells, and the prothrombotic adverse effects of therapeutic agents and vascular access catheters. In addition, comorbid conditions including hereditary thrombophilia, infection, endothelial cell activation by cytokines, antiphospholipid syndrome and acquired activated protein C resistance are major contributory factors. Factors that increase the bleeding risk include thrombocytopenia, disseminated intravascular coagulation, and excessive fibrinolysis, which is enhanced by increased expression of annexin II by leukemic cells. The author concludes by cautioning readers to keep these factors in mind and to consider earlier application of prophylactic measures for patients at risk. 1 figure. 3 tables. 44 references.

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Growth Factors in Short-Bowel Syndrome Patients. Gastroenterology Clinics of North America. 36(1): 109-122. 2007.

This article, from a special issue of Gastroenterology Clinics of North America that covers nutrition in gastrointestinal illness, discusses growth factors in patients with short-bowel syndrome. The author notes that malabsorption of nonessential and essential nutrients, fluids, and electrolytes, if not compensated for by increased intake, is a key finding in patients with short-bowel syndrome. Dependence on parenteral nutritional (PN) support significantly impairs the quality of life in these patients and is associated with complications, including recurrent infections, increased risk of venous thrombosis, and PN-associated liver failure. The author focuses on selected factors responsible for the morphologic and functional changes in the adaptive processes and presents results of clinical trials that use either growth hormone or glucagon-like peptide (GLP)-2 to facilitate a condition of hyperadaptation in short-bowel patients. Intestinal adaptation refers to the progressive recovery from intestinal insufficiency or failure that follows a loss of intestinal length. The author concludes that the effects of high doses of growth hormone are related to the wet-weight absorption (or fluid retention) and mainly in patients with a preserved colon, whereas the effects on energy absorption are minimal. 1 figure. 1 table. 54 references.

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Haematological Disorders at the Extremes of Life. IN: Provan, D., ed. ABC of Clinical Haematology. Williston, VT: Blackwell Publishing Inc. 2007. pp. 72-77.

This chapter about hematological disorders at infancy and old age is from a book on clinical hematology, written by specialists for nonspecialists. The book is designed to be easy to use and covers the symptoms, investigations, treatment, and management of conditions presenting in day-to-day practice. In this chapter, the authors first discuss hematological disorders in infants, including anemia, hemolytic disease of the fetus and newborn, hemoglobinopathies, thalassemia, sickle cell disease, enzyme deficiencies, membrane defects, sepsis, bleeding and thrombotic disorders, prematurity, thrombocytopenia, neonatal alloimmune thrombocytopenia, transfusion in this age group, neutropenia, polycythemia, and leukemia. A final section covers iron deficiency anemia, megaloblastic anemia, anemia of chronic disease, and malignancies of the blood in people older than 70 years. The authors caution that anemia in the neonate results in reduced tissue oxygenation, metabolic acidosis, and ultimately growth retardation and many other sequelae. Neonatal thrombosis and thrombocytopenia are potentially lethal and prompt diagnosis and management are essential. At the other end of life, elderly people are more susceptible to the effects of anemia, which is often multifactorial and should be investigated and treated appropriately. The chapter is illustrated with full-color photographs, drawings, and charts. 4 figures. 14 tables. 8 references.

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Haemophilia and Haemostasis: A Case-Based Approach to Management. Williston, VT: Blackwell Publishing Inc. 2007. 229 p.

This book compiles a breadth of questions relating to perplexing or complicated management questions in the fields of hemophilia and hemostasis. The contributing authors have provided practical, hands-on answers to the questions sent in by practitioners in the field. The book is organized into seven sections: hemophilia A and hemophilia B, Von Willebrand disease, factor deficiencies, rare platelet and coagulation disorders, acquired bleeding diatheses, miscellaneous questions, and thrombotic disorders. Specific topics covered include the hemophilic ankle and knee, hemophilia with HIV, pregnancy in women with hemophilia, hemophilia and scuba diving, hemodialysis, hepatitis in people with hemophilia, VWD and pregnancy, Factor VIII deficiency, Factor X deficiency, Gardner-Diamond syndrome, cocaine and DDAVP, selective serotonin reuptake inhibitors (SSRIs) and clotting disturbances, the work-up for children with intracranial bleeding, treatment of antithrombin deficiency, recurrent thrombosis, and thromboembolic disease. Most sections include references, and a detailed subject index concludes the volume.

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Management of Pregnant Women With Thrombophilia or a History of Venous Thromboembolism. IN: Hematology 2007. Washington, DC: American Society of Hematology. 2007. pp.143-150.

This chapter, from the annual Hematology 2007, considers the management of pregnant women with thrombophilia or a history of venous thromboembolism. The author reminds readers that pregnancy is associated with an increased risk of venous thromboembolism (VTE), and this condition remains an important cause of maternal morbidity and mortality. Recent studies suggest there is a link between thrombophilia and pregnancy loss, as well as with other gestational vascular complications. The author reviews the management and prevention of VTE and other complications related to the heritable thrombophilias during pregnancy. This area remains particularly challenging because of the potential for anticoagulant-related fetal as well as maternal complications and the paucity of good-quality data upon which to base clinical decisions. The author concludes that treatment that prevents fetal loss may not prevent other complications and, at present, data on the effect of antithrombotic interventions in other adverse pregnancy outcomes in women with hereditary thrombophilia are insufficient to provide any recommendations. 6 tables. 53 references.

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Management of Thrombohemorrhagic Syndromes (THS) in Hematologic Malignancies. IN: Hematology 2007. Washington, DC: American Society of Hematology. 2007. pp. 165-171.

This chapter, from the annual Hematology 2007, describes the recommended management of thrombohemorrhagic syndromes (THS) in patients with hematologic malignancies such as leukemia or lymphoma. The authors caution that chemotherapy and antiangiogenic drugs increase the thrombotic risk in patients with lymphomas, acute leukemias, and multiple myeloma (MM). Patients with hematologic malignancies often present with a hypercoagulable state or chronic disseminated intravascular coagulation (DIC) in the absence of active thrombosis and/or bleeding. Some of the factors for clotting activation in hematologic malignancies include malignant cell procoagulant properties, cytotoxic therapies, and concomitant infections. In acute leukemia, clinical manifestations range from localized venous or arterial thrombosis to a diffuse, life-threatening THS. Randomized controlled trials (RCTs) of different prophylactic regimens to prevent VTE or THS in hematologic malignancies are urgently needed, particularly in patients with lymphoma or MM during chemotherapy and in patients with acute promyelocytic leukemia (APL). The authors stress that anticoagulant therapy is a particular challenge in patients with hematologic malignancies because these patients are at very high risk for hemorrhage. No guidelines are presently available for the prophylaxis or treatment of VTE.

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Pathophysiologic Changes Occur in Women Years Before Clinical Diagnosis of Type 2 Diabetes. Review of Endocrinology. 1(3): 40-44. July 2007.

This article explores the traditional and emerging cardiovascular risk factors that may predict the progression from normoglycemia to prediabetes, as well as any gender differences in the risk factor distributions. The authors briefly report on their epidemiologic case-control study of alcohol intake patterns and risk of cardiovascular disease (CVD); the full report was published previously (Stranges, S., et al. Hypertension. 2005). Compared with controls, the prediabetic women were older and had a higher mean waist circumference after adjustment for age, ethnicity, and year of study enrollment. The results demonstrated higher levels of markers of endothelial dysfunction and thrombosis as well as hypertension in women who progressed from normoglycemia to prediabetes. The authors conclude that this shows pathophysiologic changes begin long before the clinical diagnosis of diabetes is made. Clinicians are encouraged to assess each patient’s risk for developing diabetes and coronary artery disease and implement interventions as early as possible with lifestyle modification to prevent or delay type 2 diabetes and CVD. 4 tables. 23 references.

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Platelet Disorders. IN: Provan, D., ed. ABC of Clinical Haematology. Williston, VT: Blackwell Publishing Inc. 2007. pp. 33-39.

Platelets, produced from bone marrow megakaryocytes, are important in the formation of platelet plugs during normal hemostasis. This chapter about platelet disorders is from a book on clinical hematology, written by specialists for nonspecialists. The book is designed to be easy to use and covers the symptoms, investigations, treatment, and management of conditions presenting in day-to-day practice. In this chapter, the authors first review normal hemostasis and then discuss congenital abnormalities, including Fanconi’s anemia, thrombocytopenia with absent radii (TAR syndrome), Wiskott-Aldrich syndrome, MYH9-related thrombocytopenias, disorders of the surface membrane, and platelet storage pool diseases; acquired abnormalities, including decreased production of platelets, increased consumption of platelets, idiopathic thrombocytopenic purpura, post-transfusion purpura, neonatal alloimmune thrombocytopenia, heparin-induced thrombocytopenia, thrombotic thrombocytopenic purpura, microangiopathic thrombocytopenia, disseminated intravascular coagulation, massive blood transfusion, massive splenomegaly, drug-induced platelet disorders, bleeding in patients with uremia, and thrombocytosis; diagnostic tests used to confirm a suspected platelet disorder; and the management of congenital and acquired disorders. The chapter is illustrated with full-color photographs, drawings, and charts. 9 figures. 5 tables. 7 references.

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Polycythaemia, Essential Thrombocythaemia and Myelofibrosis. IN: Provan, D., ed. ABC of Clinical Haematology. Williston, VT: Blackwell Publishing Inc. 2007. pp. 17-21.

The myeloproliferative disorders (MPDs) comprise polycythemia vera (PV), essential thrombocythemia (ET), and idiopathic myelofibrosis (IMF). This chapter about MPDs is from a book on clinical hematology, written by specialists for nonspecialists. The book is designed to be easy to use and covers the symptoms, investigations, treatment, and management of conditions presenting in day-to-day practice. In this chapter, the authors cover diagnosis and treatment of each of these disorders, as well as secondary polycythemia, apparent polycythemia, presentation and prognosis of patients with ET, and the progression and management of IMF. The authors note that appropriately treated PV and ET are compatible with long-term survival, but life expectancy is significantly reduced in IMF. They caution that MPDs have an inherent risk of progression to acute leukemia, a risk that is highest in patients with IMF. The chapter is illustrated with full-color photographs, drawings, and charts. 7 figures. 7 tables. 5 references.

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Portal Vein Aneurysm: Case Report and Review of Literature. Gastroenterology and Hepatology. 3(4): 296-300. April 2007.

This article presents a case report and review of the literature regarding portal vein aneurysm, an unusual condition that seems to be due to hereditary weakness or a developmental anomaly of the portal vein. The authors note that the portal vein is a unique vessel because of the presence of capillaries on both ends and the absence of valves. The authors review the different types of portal vein aneurysms and how they might develop and then discuss diagnostic and treatment approaches. They note that the management of portal vein aneurysms remains controversial, as most remain asymptomatic, but serious complications can occur with thrombosis or rupture. The case report is a 57-year-old Caucasian man who was known to have a portal vein aneurysm for more than 10 years. The patient was followed with conservative care, including serial imaging, for more than 4 years; the aneurysm has remained stable and there have been no associated complications. Attached to the article is a commentary from Dr. Marcos Mucenic. 2 figures. 90 references.

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Surveillance Techniques: Mathematical Model Shows Frequent Testing Needed During Graft Surveillance. Nephrology News & Issues. 21(12): 35-36. November 2007.

This article briefly summarizes two recent studies on the main methods of hemodialysis synthetic graft surveillance: blood flow and dialysis venous pressure (VP) measurements. The author participated in the research on blood flow and VP, using duplex ultrasound to determine the diameters of arteries and veins of 94 patients. The first study showed that as stenosis progresses, blood flow is initially unchanged but then rapidly decreases. As the artery becomes narrower, flow resistance increases. The author cautions that if flow measurements are performed only monthly on patients, critical stenosis can be reached and thrombosis may occur before the next flow measurement is taken. The second study investigated the impact of artery and vein diameters on the ability of VP to detect stenosis. Once again, relatively narrow arteries were shown to have a large impact on VP surveillance. The author concludes that the current standard of monthly or even twice monthly surveillance measurements is inadequate. 2 figures. 2 references.

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Thrombocytosis and Thrombosis. IN: Hematology 2007. Washington, DC: American Society of Hematology. 2007. pp 363-369.

This review article covers current diagnostic approaches to and classification of patients presenting with thrombocytosis. The authors focus on specific molecular abnormalities in chronic myeloproliferative disorders (CMPD), which represent the most common cause of primary thrombocytosis. Specifically, the JAK2V617F and the MPLW515L/K mutations have been found in patients with essential thrombocythemia, polycythemia vera, and primary myelofibrosis, and they have been found less frequently in other myeloproliferative disorders complicated by thrombocytosis. However, neither mutation is disease specific nor is it universally present in patients with elevated platelet counts due to a CMPD. The authors stress that distinguishing between reactive and primary forms of thrombocytosis, as well as among the different clinical entities that constitute the CMPD, requires a multifaceted diagnostic approach, starting with the accurate evaluation of bone marrow histology. The authors discuss the role of elevated platelet counts in thrombosis, which represent the predominant complication of CMPD, significantly affecting prognosis and quality of life. The review concludes with a discussion of the established and novel potential risk factors for thrombosis, including the clinical relevance of the JAK2V617F mutation, and current management strategies for thrombocytosis. 2 figures. 2 tables. 53 references.

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Thromboembolic Disease in Inflammatory Bowel Disease. Practical Gastroenterology. 31(7): 26, 31-36. July 2007.

This article reviews the relationship between thromboembolic disease and inflammatory bowel disease (IBD). Patients with IBD are approximately three times more likely than the general population to have a thromboembolic event. Although active disease is a risk factor, even patients with quiescent disease have an increased risk of deep vein thrombosis or pulmonary embolism. The authors encourage physicians who manage patients with IBD to remain aware of this risk because thromboembolic events have a high associated mortality. At least some of these events may be preventable by use of antithrombotic measures including low-molecular-weight heparin in immobile patients in hospital and long-term care settings. 2 tables. 13 references.

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Thrombophilia: Common Questions on Laboratory Assessment and Management. IN: Hematology 2007. Washington, DC: American Society of Hematology. 2007. pp.127-135.

This chapter, from the annual Hematology 2007, answers common questions on the laboratory assessment and management of patients with thrombophilia. Thrombophilia is an inherited or acquired predisposition to thrombosis. The author reviews the clinical manifestations of thrombophilia and discusses the potential indications for thrombophilia testing, who should be tested, what tests should be requested, when testing should be performed, and how the test results affect primary prevention, acute therapy, and secondary prophylaxis of thrombosis. The author cautions that because there is no single laboratory assay or simple set of assays that will identify all thrombophilias, a battery of complex and potentially expensive assays is usually required. For patient management, the risks of recurrent venous thromboembolism must be weighed against the risks of anticoagulant-related bleeding. The author stresses the importance of reevaluating patients on anticoagulants because the need for secondary prophylaxis tends to change over time. 3 figures. 7 tables. 59 references.

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Thrombotic Disorders. IN: Roberts, H.R., ed. Haemophilia and Haemostasis: A Case-Based Approach to Management. Williston, VT: Blackwell Publishing Inc. 2007. pp 193-221.

This chapter about thrombotic disorders is from a book that compiles a breadth of questions relating to perplexing or complicated management questions in the fields of hemophilia and hemostasis. The contributing authors have provided practical, hands-on answers to the questions sent in by practitioners in the field. This section discusses genetic differences between Asians and Westerners with regard to venous thromboembolism (VTE), treatment of antithrombin deficiency, anticardiolipin antibody questions, pediatric antiphospholipid syndrome and recurrent thrombosis, anticoagulation for deep venous thrombosis in the presence of an intracranial hemorrhage, clinical probability assessment for thromboembolic disease, progestins and thrombosis, and unknown thrombophilia and surgery. Much of the information is presented through case studies. 42 references.

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Classification, Diagnosis and Management of Myeloproliferative Disorders in the JAK2V617F Era. Washington, DC: American Society of Hematology. 2006. pp. 240-245.

This article reviews the classification, diagnosis, and management of myeloproliferative disorders now that JAK2V617F, has been identified. JAK2V617F , a somatic gain-of-function mutation involving the JAK2 tyrosine kinase gene, occurs in nearly all patients with polycythemia vera (PV) but also in a variable proportion of patients with other myeloid disorders. The mutation frequency is estimated at approximately 50 percent in both essential thrombocythemia (ET) and myelofibrosis (MF), up to 20 percent in certain subcategories of atypical myeloproliferative disorder (atypical MPD), less than 3 percent in de novo myelodysplastic syndrome (MDS) or acute myeloid leukemia, and 0 percent in chronic myeloid leukemia (CML). The author presents the case for grouping PV, ET, and MF together in a distinct MPD category that is separate from chronic myeloid leukemia (CML), MDS, and atypical MPD. The author concludes that the presence of JAK2V617F strongly suggests an underlying MPD and it is therefore reasonable to consider JAK2V617F-based laboratory tests for the evaluation of polycythemia, primary thrombocytosis, unexplained leukocytosis, bone marrow fibrosis, or abdominal vein thrombosis. A patient care algorithm is also included. 1 figure. 3 tables. 41 references.

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Essential Haematology. 5th ed. Williston, VT: Blackwell Publishing Inc. 2006. 380 p.

This hematology textbook offers a comprehensive look at the biochemical, physiological, and immunological processes involved in normal blood cell formation and function and the disturbances that may occur in different diseases. The book is designed to help medical students grasp the essential features of modern clinical and laboratory hematology. The book includes 28 chapters on hemopoiesis, erythropoiesis and general aspects of anemia, hypochromic anemias and iron overload, megaloblastic anemias and other macrocytic anemias, hemolytic anemias, genetic disorders of hemoglobin, granulocytes and monocytes, lymphocytes and their benign disorders, the spleen, the etiology and genetics of hematological malignancies, the management of hematological malignancy, acute leukemias, chronic myeloid leukemia, myelodysplasia, the chronic lymphoid leukemias, Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, multiple myeloma and related disorders, myeloproliferative disorders, aplastic anemia and bone marrow failure, stem cell transplantation, platelets and blood coagulation, bleeding disorders caused by vascular and platelet abnormalities, coagulation disorders, thrombosis and antithrombotic therapy, hematological changes in systemic disease, blood transfusion, and pregnancy and neonatal hematology. Each chapter includes full-color photographs and illustrations and concludes with a list of references. The book concludes with three appendices and a detailed subject index.

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Extraintestinal Manifestations of Inflammatory Bowel Diseases. Journal of Clinical Gastroenterology. 40(6): 467-475. July 2006.

This article reports on a literature review that focused on the extraintestinal manifestations of inflammatory bowel diseases (IBD), including Crohn's disease and ulcerative colitis. The author notes that extraintestinal manifestations of IBD occur in approximately 20 to 40 percent of patients and can involve nearly every organ system in the body. The article first reviews pathogenesis, including genetic factors and immunological mechanisms, then discusses musculoskeletal, dermatologic, ocular, oral, hepatobiliary, hematologic, renal and urologic, pulmonary, neurologic, and cardiovascular manifestations. Specific conditions covered include peripheral arthropathy, osteoporosis, osteonecrosis, episcleritis, keratitis, retinitis, erythema nodosum, pyoderma gangrenosum, Sweet syndrome, erythema multiforme, aphthous stomatitis, pyostomatitis vegetans, orofacial granulomatosis, primary sclerosing cholangitis, hepatic steatosis, anemia, thrombocytosis, nephrolithiasis, obstructive uropathy, interstitial nephritis, bronchiectasis, pleuritis, interstitial fibrosis, peripheral neuropathy, myopathy, myelopathy, and secondary amyloidosis. The author concludes by encouraging clinicians who care for patients with IBD to stay cognizant of various systemic complications of the disease, as failure to diagnose and treat them early may result in major morbidity. 6 figures. 2 tables. 92 references.

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Hypercogulable States. IN: Nilsson, K.R.; Piccini, J.P., eds. Osler Medical Handbook. Philadelphia, PA: Saunders. 2006. pp. 526-536.

This chapter on hypercoagulable states is from a handbook that provides the essentials of diagnosis and treatment, as well as the latest in evidence-based medicine, for residents working bedside, in-patient care. The chapter begins with a presentation of essential Fast Facts and concludes with Pearls and Pitfalls useful to the practicing internist. The body of the chapter is divided into sections: Epidemiology, Clinical Presentation, Diagnosis, and Management. Specific topics covered in this chapter include the most important primary (factor V Leiden and prothrombin gene mutation) and secondary (surgery, malignancy, peripartum state) hypercoagulable states; the causes of most thrombotic events, which in most patients require the presence of both a primary and secondary stimulus (such as surgery in patients with inherited thrombophilia); the risk of venous thrombosis in hypercoagulable states; conditions that predispose to both venous and arterial thrombosis, including antiphospholipid antibody syndrome, hyperhomocysteinemia, malignancy, heparin-induced thrombocytopenia and thrombotic syndrome (HIT-TS), and dysfibrinogenemia; and the management of thrombotic events, generally with anticoagulation for at least 3 months. The chapter concludes with a list of references, each labeled with a 'strength of evidence' grade to help readers determine the type of research available in that reference source. 3 figures. 3 tables. 26 references.

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Neonatal Kidney Problems. IN: Hogg, R., ed. Kidney Disorders in Children and Adolescents: A Global Perspective of Clinical Practice. New York, NY: Informa Healthcare USA. 2006. pp 53-66.

This chapter about neonatal kidney problems is from a textbook that presents a global perspective of clinical practice regarding kidney disorders in children and adolescents. The author reviews maturation during fetal life, postnatal maturation, symptoms and signs of renal disease in the neonate, gross hematuria, malformation syndromes, diagnostic tests used to confirm kidney and urologic disorders in the neonate, blood pressure and hypertension, renal function during neonatal respiratory disorders, acute renal failure (ARF), acquired diseases, and drugs and the neonatal kidney, including drugs administered to the mother during pregnancy. Acquired diseases discussed include urinary tract infection; renal venous thrombosis; cortical, medullary, and papillary necrosis; Bartter’s syndrome; nephrogenic diabetes insipidus; and oligonephropathy. The chapter includes black-and-white illustrations and photographs and concludes with an extensive list of references. 6 figures. 16 tables. 24 references.

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New Insights into Paroxysmal Nocturnal Hemoglobinuria. IN: Hematology 2006. Washington, DC: American Society of Hematology. 2006. pp. 24-28.

This article brings readers up-to-date on paroxysmal nocturnal hemoglobinuria (PNH), an uncommon intravascular hemolytic anemia that results from the clonal expansion of hematopoietic stem cells harboring somatic mutations in an X-linked gene, termed PIG-A. PIG-A mutations block glycosylphosphatidylinositol (GPI) anchor biosynthesis, resulting in a deficiency or absence of all GPI-anchored proteins on the cell surface. Intravascular hemolysis leads to release of free hemoglobin, which contributes to many of the clinical manifestations of PNH including fatigue, pain, esophageal spasm, erectile dysfunction and possibly thrombosis. The author also reports on the recent development of a humanized monoclonal antibody directed against the terminal complement protein C5 that has been shown to reduce hemolysis and greatly improve symptoms and quality of life for PNH patients. 2 figures. 40 references.

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Obesity, Diabetes and Endothelial Dysfunction. IN: Obesity and Diabetes. Totowa, NJ: Humana Press. 2006. pp. 213-220.

The prevalence of obesity is increasing globally and is associated with an increased risk of coronary artery disease (CAD), hypertension, dyslipidemia, and type 2 diabetes, all of which combine to an increased risk for cardiovascular disease (CVD). Endothelial dysfunction is an early event in atherogenesis and has been shown to precede by several years the development of clinically detectable atherosclerotic plaques in the coronary arteries. This chapter on obesity, diabetes, and endothelial dysfunction is from a comprehensive textbook on obesity and diabetes. The authors note that the vascular endothelium is no longer viewed as an inert lining of blood vessels, rather, it plays a vital role in vascular homeostasis, vascular tone regulation, vascular smooth muscle cell proliferation, leukocyte migration, thrombosis, and thrombolysis. Endothelial dysfunction is described as a state in which factors that favor a vasoconstrictive, growth-promoting, procoagulant, and proinflammatory state become predominant. Research shows that exercise improves endothelial function; in individuals with risk factors for CVD, exercise appears to be even more beneficial. The authors conclude with a brief discussion on the potential impact of macronutrient modifications (such as the use of olive oil or soy protein) on endothelial function. 56 references.

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Pregnancy and Neonatal Haematology. IN: Hoffbrand, A.V.; Moss, P.A.H.; Pettit, J.E. Essential Haematology. 5th ed. Williston, VT: Blackwell Publishing Inc. 2006. pp. 352-359.

Pregnancy places extreme stresses on the hematological system, thus an understanding of the physiological changes of pregnancy is essential to best care for pregnant women. This chapter on pregnancy and neonatal hematology is from a hematology textbook that offers a comprehensive look at the biochemical, physiological, and immunological processes involved in normal blood cell formation and function and the disturbances that may occur in different diseases. The first section discusses physiological anemia, iron deficiency anemia, folate deficiency, thrombocytopenia, hemostasis and thrombosis, and the treatment of thrombosis in the mother. The neonatal hematology section covers normal blood count, anemia in the neonate, anemia of prematurity, neonatal polycythemia, fetomaternal alloimmune thrombocytopenia, and coagulation. The final section considers hemolytic disease of the newborn (HDN), notably Rh HDN, which occurs when an Rh D-negative woman has a pregnancy with an Rh D-positive fetus. The chapter features full-color photographs and illustrations. 7 figures. 6 references.

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Renal Transplantation in Childhood. IN: Hogg, R., ed. Kidney Disorders in Children and Adolescents: A Global Perspective of Clinical Practice. New York, NY: Informa Healthcare USA. 2006. pp 243-252.

This chapter about renal transplantation in childhood is from a textbook that presents a global perspective of clinical practice regarding kidney disorders in children and adolescents. The author notes that in recent years, graft and patient survival have increased due to improvements in the care of young patients and advances in pharmacologic immunosuppression. The author focuses on providing information for primary care physicians on the care of a child who has received a kidney transplant for end-stage renal disease (ESRD). Topics include the results of transplantation with a living related donor versus a cadaveric donor; graft survival; antirejection medications, including corticosteroids, azathioprine, mycophenolate mofetil, cyclosporine, tacrolimus, rapamycin, and antilymphocyte antibodies; complications of renal transplantation, including delayed graft function, vascular thrombosis, rejection, hypertension, infections, recurrence of primary disease, malignancy, and noncompliance with treatment; growth after renal transplantation; and preparation for renal transplantation. 33 references.

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Role of JAK-STAT Signaling in the Pathogenesis of Myeloproliferative Disorders. IN: Hematology 2006. Washington, DC: American Society of Hematology. 2006. pp 233-239.

This article outlines the role of JAK–STAT signaling in the pathogenesis of myeloproliferative disorders (MPD). The authors contend that the identification of JAK2V617F mutations in polycythemia vera (PV), essential thrombocytosis (ET), and myelofibrosis (MF) represents an important advance in our understanding of these myeloproliferative disorders (MPD). Most, if not all, patients with PV and a significant number of patients with ET and MF are JAK2V617F positive, and the mutation likely arises in the hematopoietic stem cell compartment. The authors review animal studies that support the central role of JAK2V617F in the pathogenesis of MPD. They conclude that, despite these advances, many questions remain regarding the role of a single disease allele in three phenotypically distinct MPD and the potential clinical efficacy of JAK2 inhibitors. 1 table. 58 references.

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Think of HIT. Washington, DC: American Society of Hematology. 2006. pp. 408-414.

This article reviews the condition of heparin-induced thrombocytopenia (HIT), a problem that can present in many ways, ranging from isolated thrombocytopenia, venous thromboembolism, or acute limb ischemia to less common but specific presentations such as necrotizing skin lesions at heparin injection sites, post-bolus acute systemic reactions, and adrenal hemorrhagic necrosis—secondary to adrenal vein thrombosis. HIT is an acquired, transient, prothrombotic disorder that, ironically, is caused by the anticoagulant heparin and is characterized by mild or moderate thrombocytopenia. HIT that begins after stopping heparin—"delayed-onset HIT"—is increasingly recognized. The author reviews factors influencing the risk of HIT include type of heparin—unfractionated heparin holds a greater risk than low-molecular-weight heparin, type of patient—surgical patients have a greater risk than medical patients, and gender—females have a greater risk than males. Since timely diagnosis and treatment of HIT may reduce the risk of adverse outcomes, the author focuses on those clinical circumstances that should prompt the clinician to consider the presence of HIT. The author cautions that coumarin anticoagulants such as warfarin are ineffective in acute HIT and can even be deleterious by predisposing to micro-thrombosis via protein C depletion. Thus, it is important to avoid or postpone coumarin while managing HIT hypercoagulability, using instead agents that inhibit thrombin directly—lepirudin, algarroba—or that inhibit its generation—danaparoid, fondaparinux. 4 figures. 3 tables. 40 references.

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Thrombosis and Antithrombotic Therapy. IN: Hoffbrand, A.V.; Moss, P.A.H.; Pettit, J.E. Essential Haematology. 5th ed. Williston, VT: Blackwell Publishing Inc. 2006. pp. 303-319.

This chapter on thrombosis and antithrombotic therapy is from a hematology textbook that offers a comprehensive look at the biochemical, physiological, and immunological processes involved in normal blood cell formation and function and the disturbances that may occur in different diseases. Thrombi are solid masses or plugs formed in the circulation from blood components, primarily platelets and fibrin. Symptoms arising from these clots result from ischemia, or lack of blood flow, from either local vascular obstruction or distant embolization. Thrombosis, both arterial and venous, is more common as age increases and is associated with certain risk factors such as surgery or pregnancy. The authors discuss arterial thrombosis, venous thrombosis, investigation of thrombophilia, diagnosis of venous thrombosis, anticoagulant drugs, heparin, oral anticoagulants, graduated compression stockings, inferior vena cava filter, fibrinolytic agents, and antiplatelet drugs. The chapter features full-color illustrations. 8 figures. 10 tables. 27 references.

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Thrombosis in Infants and Children. IN: Hematology 2006. Washington, DC: American Society of Hematology. 2006. pp 86-96.

This article reviews thromboembolism (TE) in childhood, still considered a rare event. During the last decade much progress has been made toward better understanding of the underlying reasons causing thromboembolism in children, and better understanding of diagnostics and therapy has followed suit. A considerable number of acquired and hereditary thrombotic risk factors have been identified which may also have an impact on therapeutic decisions and prognosis concerning outcome and the risk of a second event. However, indications for therapeutic interventions, such as thrombolysis and prophylactic anticoagulation with respect to the different clinical conditions and their combination with other risk factors, are not yet well defined. The authors describe the causes, epidemiology, clinical presentation, and management of thrombosis in neonates, infants, and older children, focusing on the most clinically relevant conditions, including the management of thrombosis in children with cancer. 2 figures. 5 tables. 65 references.

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Treatment of the 5q-Syndrome. Washington, DC: American Society of Hematology. 2006. pp. 192-198.

This article reviews treatment of the 5q- syndrome, a specific type of myelodysplastic syndrome (MDS) that presents with particular characteristics, including severe anemia, frequent thrombocytosis, typical dysmegakaryopoiesis, and favorable outcome. The pathogenesis of the 5q- syndrome remains uncertain, in particular the role of inactivation of gene(s) situated in 5q. The authors note that, until the advent of lenalidomide, repeated red blood cell (RBC) transfusions were generally the only treatment of the 5q- syndrome, which was resistant to other therapeutic approaches. Lenalidomide can lead to RBC transfusion independence in at least two-thirds of cases of the 5q- syndrome, with two-thirds of those responses persisting after 2 years of treatment. Not only reversal of anemia but also frequent complete pathological and cytogenetic responses are obtained. The authors caution that Grade 3 or 4 neutropenia and thrombocytopenia, especially during the first 6 to 8 weeks of treatment, are the major side effect of lenalidomide, so patients should have close monitoring of blood counts and regular physician visits. 3 tables. 39 references.

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Vascular Access for the Patient Receiving Parenteral Nutrition. IN: Buchman, A., ed. Clinical Nutrition in Gastrointestinal Disease. Thorofare, NJ: Slack Incorporated. 2006. pp 409-416.

This chapter about vascular access for parenteral nutrition (PN) is from a comprehensive textbook that compiles available data, clinical experience, and research on the role of nutrition in the management of patients with disorders that affect the gastrointestinal (GI) tract. The authors note that the effective administration of PN, whether given to the patient in the hospital or at home, depends on obtaining and maintaining safe, prolonged vascular access. Complications associated with vascular access device insertion and maintenance can be serious or even life threatening. The chapter covers device selection, the use of peripheral catheters, central venous catheters, different devices for hospital and home use, the morbidity of central venous catheters, complications of central line insertion, catheter infections, catheter occlusion, catheter-associated thrombosis, and the role of the interventional radiologist in difficult vascular access situations. The authors conclude that obtaining and maintaining safe vascular access requires the cooperative expertise of interventional radiologists, surgeons, nurses, and experienced physicians; the involvement of these team members can minimize complications associated with vascular access insertion. 2 figures. 2 tables. 56 references.

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Vascular Diseases Involving the Liver. IN: Lichtenstein, G.; Reddy, K.R.; Faust, T., eds. Clinician’s Guide to Liver Disease. Thorofare, NJ: Slack Incorporated. 2006. pp 161-186.

This chapter about vascular diseases involving the liver is from a user-friendly reference book that provides gastroenterologists with an overview of the management of acute and chronic liver disease. The authors outline the physiology and anatomy of the hepatic circulation, noting that clinical characteristics of the vascular diseases of the liver are largely dependent on five factors: the nature of the pathologic process, that is, partial or complete obstruction; the extent of segmental versus diffuse hepatic involvement; the rate of evolution of the pathology; the amount of the accompanying liver parenchymal necrosis; and specific vascular involvement. The chapter discusses specific vascular disease, including Budd-Chiari syndrome (BCS), veno-occlusive disease (VOD), the liver in heart disease, portal vein thrombosis (PVT), and peliosis hepatis. For each condition, the authors discuss pathophysiology, clinical presentation, diagnostic tests, patient care management, and prognosis. The chapter includes tables and two patient care algorithms and concludes with a list of references. 5 figures. 9 tables. 119 references.

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Anticoagulation in Patients on Hemodialysis. In: Clinical Dialysis. 4th ed. New York, NY: McGraw-Hill. 2005. pp. 127-152.

This chapter on anticoagulation in patients on hemodialysis is from a textbook on the clinical management of dialysis patients. The author notes that, despite continuing advances, the goal of finding a satisfactory method for preventing clotting in hemodialysis circuits remains elusive. The relative risks of bleeding and thrombosis tend to be different for acute and chronic dialysis situations but have to be assessed for each individual patient. The choice of an anticoagulation prescription for hemodialysis must be based also on several other considerations, including knowledge of hemostatic mechanisms and their status in uremic patients, the pharmacology and practical aspects of each of the available methods, and the empiric results that have been achieved with respect to effectiveness and complications. The author discusses the coagulation status of patients with renal failure, the mechanisms of thrombosis in hemodialysis circuits, approaches to maintaining the patency of hemodialysis circuits, the pharmacology of heparin, the use of heparin for intermittent hemodialysis, nonheparin methods of anticoagulation and their use for intermittent hemodialysis, and anticoagulation for continuous renal replacement therapy (CRRT). 1 figure. 4 tables. 312 references.

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Diagnostic Imaging in Kidney Transplantation. IN: Danovitch, G.M. Handbook of Kidney Transplantation. Philadelphia, PA: Lippincott Williams and Wilkins. 2005. pp. 347-368.

The clinician evaluating a patient with renal transplant dysfunction has the choice of a variety of imaging procedures, including ultrasound (US), nuclear medicine (NM) or molecular imaging, computed tomography (CT), magnetic resonance imaging (MRI), and excretory urography. This chapter on diagnostic imaging in kidney transplantation is from a handbook that offers a practical guide for health care providers who manage kidney transplant patients. In this chapter, the authors focus on the use of US and NM techniques in kidney transplantation. They also note that CT, MRI, and urography may, on occasion, be the optimal imaging modalities for certain clinical problems encountered in renal transplant recipients. Specific topics include the radiologic evaluation of the living donor; radiologic techniques in the early posttransplant period (up to 3 months), including that for hematomas, urinomas, lymphoceles, abscesses, and acute rejection; nuclear medicine imaging of graft function and dysfunction; posttransplantation vascular complications, including arterial thrombosis, infarction, renal vein thrombosis, chronic rejection, renal artery stenosis, arteriovenous fistulas, and pseudoaneurysms; and measurement of glomerular filtration rate. 13 figures. 1 table. 13 references.

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Hematologic Complications of Transplantation. In: Medical Management of Kidney Transplantation. Philadelphia, PA: Lippincott Williams and Wilkins. 2005. pp. 305-323.

The current success of kidney transplantation is largely due to advances in the manipulation of the immune component of the hematologic system and surgical techniques. This chapter on the hematologic complications of transplantation is from a textbook that provides a compendium of the latest advances and understandings regarding the complex medical problems seen in kidney transplant patients. The authors of this chapter summarize the hematologic changes after transplantation but focus on disorders of erythropoiesis and thrombosis due to increasing evidence of their importance on determining outcomes in transplant patients. Other topics include the diagnosis and treatment of posttransplant anemia; disorders of white blood cells in transplantation, including leukocytosis and leukopenia; hypercoagulable disorders in transplantation; and thrombotic microangiopathies following transplantation. 3 figures. 6 tables. 201 references.

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How to Interpret and Pursue an Abnormal Complete Blood Cell Count in Adults. Mayo Clinic Proceedings. 80(7): 923-936. July 2005.

A complete blood cell count (CBC) is one of the most common laboratory tests in medicine. This article provides practical diagnostic algorithms that address frequently encountered conditions associated with CBC abnormalities. These conditions include anemia (decreased hemoglobin, the oxygen-carrying compound of the blood), thrombocytopenia (decreased platelets in the blood), leukopenia (decreased white blood cells), polycythemia (increased erythrocytes, which are the red blood cells), thrombocytosis (increased platelets in the blood), and leukocytosis (increased white blood cells). The objective is to help the nonhematologist recognize when a subspecialty consultation is reasonable and when it may be foregone, thus allowing a cost-effective and intellectually rewarding practice. The authors conclude that, in general, it is prudent to perform a PBS (peripheral blood smear) in most instances of abnormal CBC, along with basic tests that are dictated by the type of CBC abnormalities encountered. The latter may include, for example, serum ferritin in patients with microcytic anemia or lymphocyte immunophenotyping by flow cytometry in patients with lymphocytosis. However, a prompt hematology consultation is encouraged in patients with severe cytopenia, pancytopenia, or extreme cytosis of any type or when a PBS report suggests thrombotic thrombocytopenic purpura (TTP) or acute leukemia. 6 figures. 4 tables. 114 references.

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Kidney and Pancreas Transplantation in Diabetic Patients. IN: Danovitch, G.M. Handbook of Kidney Transplantation. Philadelphia, PA: Lippincott Williams and Wilkins. 2005. pp. 390-413.

Diabetes mellitus is the leading cause of end-stage renal disease (ESRD) and one of the primary diseases that most commonly leads to kidney transplantation. This chapter on kidney and pancreas transplantation in patients with diabetes is from a handbook that offers a practical guide for health care providers who manage kidney transplant patients. The authors focus on the management issues associated with kidney and pancreas transplantation in patients with diabetes and the pros and cons of the different forms of pancreas transplantation. The first section discusses kidney transplantation, including the preoperative assessment, patients with coronary artery disease, predialysis transplantation, insulin requirements, preoperative preparation, postoperative complications, graft dysfunction, and long-term complications, such as peripheral vascular disease, retinopathy, neuropathy, diabetic gastropathy, neurogenic bladder, blood pressure considerations, bone disease, recurrent diabetic nephropathy, and pregnancy. The second section describes kidney-pancreas dual transplantation, including surgical options, surgical techniques, complications (enzyme and urine leaks, graft pancreatitis, vascular thrombosis, intra-abdominal abscess, and complications specific to bladder-drained pancreas transplants), immunosuppressive therapy, the diagnosis of rejection, the effect of pancreas transplantation on secondary diabetes complications, and choice of procedure. An additional section covers the transplantation of pancreas islets, including the process of islet isolation and recipient selection. 5 figures. 3 tables. 15 references.

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Platelets and Thrombosis in Myeloproliferative Diseases. IN: Hematology 2005. Washington, DC: American Society of Hematology. 2005. pp. 409-415.

This article reviews the role of platelets and thrombosis in myeloproliferative diseases (MPD), which include chronic myeloid leukemia, polycythemia vera (PV), idiopathic myelofibrosis (IMF), and essential thrombocythemia (ET). The author covers thrombosis and hemorrhage, the pathogenesis of thrombosis, platelets and their contribution to thrombotic risk, platelet number, platelet receptors, platelet activation, platelet interaction with leukocytes and the endothelium, hematocrit, risk factors for thrombosis, and the prevention of thrombosis through the use of phlebotomy, aspirin, hydroxyurea, anagrelide, or interferon. The author cautions that the clinical course of the predominant MPDs is characterized by thrombotic and hemorrhagic events that significantly impact prognosis and quality of life. 1 figure. 2 tables. 40 references.

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POEMS Syndrome. IN: Hematology 2005. Washington, DC: American Society of Hematology. 2005. pp. 360-367.

This article describes POEMS syndrome, a condition defined by the presence of a peripheral neuropathy (P), a monoclonal plasma cell disorder (M), and other paraneoplastic features, the most common of which include organomegaly (O), endocrinopathy (E), skin changes (S), papilledema, edema, effusions, ascites, and thrombocytosis. Virtually all patients will have either sclerotic bone lesion(s) or co-existent Castleman’s disease. The author stresses that not all features of the disease are required to make the diagnosis, and early recognition is important to reduce morbidity. Clues to an early diagnosis include thrombocytosis and sclerotic bone lesions on plain skeletal radiographs. Treatments that may be effective in patients with CIDP and MGUS associated peripheral neuropathy, such as intravenous gammaglobulin and plasmapheresis, are not effective in patients with POEMS. Instead, the mainstays of therapy for patients with POEMS include irradiation, corticosteroids, and alkylator-based therapy, including high-dose chemotherapy with peripheral blood stem cell transplantation. Radiation therapy produces substantial improvement of the neuropathy in more than half of the patients who have a single lesion or who have multiple lesions in limited areas. 3 figures. 5 tables. 40 references.

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Recommendations for Management of Diabetes During Ramadan. Diabetes Care. 28(9): 2305-2311. September 2005.

Muslims who fast during Ramadan must abstain from eating, drinking, use of oral medications, and smoking from predawn to after sunset; however, there are no restrictions on food or fluid intake between sunset and dawn. This article outlines recommendations for patients with diabetes who follow the fasting requirements of the Muslim season of Ramadan. The Koran specifically exempts the sick from the duty of fasting, especially if fasting might lead to harmful consequences for the individual. Patients with diabetes fall under this category because their chronic metabolic disorder may place them at high risk for various complications if the pattern and amount of their meal and fluid intake is markedly altered. However, many patients with diabetes insist on fasting during Ramadan. The authors note their goals as threefold: to invite an open dialogue on this important topic; to offer a set of medical opinions and suggestions; and to identify topics of research needed to answer important medical questions regarding fasting during Ramadan. The authors emphasize that fasting, especially for patients with type 1 diabetes with poor glycemic (blood glucose) control, is associated with multiple risks. These risks include hypoglycemia (low blood glucose levels), hyperglycemia (high blood glucose levels), diabetic ketoacidosis (a metabolic complication that can result in coma), and dehydration and thrombosis (the development of clots). The authors conclude by stressing that a patient's decision to fast should be made after ample discussion with his or her physician concerning the risks involved. Patients who insist on fasting should undergo pre-Ramadan assessment and receive appropriate education and instructions related to physical activity, meal planning, glucose monitoring, and dosage and timing of medications. Close follow-up is essential to reduce the risk for complications. 3 tables. 30 references.

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Transplant Operation and Its Surgical Complications. IN: Danovitch, G.M. Handbook of Kidney Transplantation. Philadelphia, PA: Lippincott Williams and Wilkins. 2005. pp. 193-211.

Kidney transplantation is an elective or semi-elective surgical procedure performed in patients who have undergone careful preoperative assessment and preparation. Chronic dialysis enables patients to be maintained in optimal condition and provides time to address potentially complicating medical and surgical issues. The authors of this chapter discuss these preparations. The chapter, on the transplant operation and its surgical complications, is from a handbook that offers a practical guide for health care providers who manage kidney transplant patients. Specific topics include immediate preoperative preparations, operative techniques, surgical considerations in young children, intraoperative fluid management, dual-kidney transplantation, and the surgical complications of kidney transplantation, including wound infection, lymphocele, bleeding, graft thrombosis, the need for perioperative anticoagulation, renal artery stenosis, urine leaks, and ureteral obstruction. An additional section discusses allograft nephrectomy (removal of prior kidney transplants that have failed). 6 figures. 2 tables. 14 references.

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Vascular Access for Hemodialysis. In: Clinical Dialysis. 4th ed. New York, NY: McGraw-Hill. 2005. pp. 27-46.

Successful hemodialysis requires access to large blood vessels capable of supporting rapid extracorporeal blood flow. This chapter on vascular access (VA) for hemodialysis is from a textbook on the clinical care of dialysis patients. There are three general situations in which hemodialysis is required: acute renal failure, poisonings, and end stage renal disease (ESRD). In the first two situations, immediate and perhaps only temporary access to the circulation system is required. These requirements are best met by the percutaneous insertion of dual-lumen hemodialysis catheters into large central veins. In ESRD, reliable, long-term access to the circulation system is essential for adequate dialysis therapy. Long-term access is best accomplished by the construction of an endogenous arteriovenous fistula. The authors discuss patient care management, surgical techniques, and the complications of VA, which can include thrombosis, infection of native and synthetic fistulas, cuffed catheter-related infection, problems with antibiotics, congestive heart failure, hand ischemia, aneurysms and pseudoaneurysms, and venous stenoses. The authors conclude that the morbidity of a maintenance hemodialysis patient is in large part determined by the ability of the nephrologists, vascular surgeon, and vascular radiologist to establish and maintain adequate vascular access. 7 figures. 143 references.

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Why Is There More Cardiovascular Disease in Diabetes?. Practical Diabetology. 25(4): 10-15. December 2005.

Cardiovascular disease is of major importance for patients with diabetes. This article considers some of the controversies in this area while presenting information about why there is more cardiovascular disease in people with diabetes. The author focuses on the vascular endothelium as the final common pathway of all risk factors that accompany cardiovascular disease in people with diabetes. The vascular endothelium is no longer considered to be only a passive lining but rather is an active endocrine organ, playing a critical role in normal vascular function. The author discusses nutrient dynamics and endothelial function, glycemia and cardiovascular disease, hypertension, lipid abnormalities, enhanced thrombosis in diabetes, the risk levels in people with type 1 diabetes, enhanced inflammation in diabetes, and inflammatory markers. The author reminds readers that dyslipidemia and hypertension are both risk factors for increased macrovascular risk in people with and without diabetes. Until the data are clearer on why there is so much macrovascular disease in diabetes, patients must continue to strive for near-normal blood glucose levels and healthy levels of blood lipids and blood pressure as the best way to stave off cardiovascular disease. 14 references.

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Acute Mesenteric Venous Thrombosis. In: Kelly, K.A.; Sarr, M.G.; Hinder, R.A., eds. Mayo Clinic Gastrointestinal Surgery. St. Louis, MO: Elsevier Science. 2004. p. 447-455.

Mesenteric venous thrombosis is a rare severe form of acute mesenteric ischemic (lack of blood flow in the main arteries of the intestines). The clinical presentation is frequently insidious; signs and symptoms of the disease may be nonspecific, and delay in diagnosis is frequent, resulting in substantial mortality. The main causes of death in this condition are bowel infarction with peritonitis leading to septic shock and short-bowel syndrome after extensive resection. This chapter on acute mesenteric venous thrombosis is from a book that focuses on the major diseases treated by gastrointestinal surgeons, from the esophagus to the anal canal. The presentation has a definite clinical orientation and a major emphasis on practical applications as they are applied at the Mayo Clinic. The authors of this chapter review the incidence, pathogenesis, and clinical presentation of acute mesenteric venous thrombosis. The authors discuss the difficulty in reaching an early diagnosis, review the accuracy of available imaging studies, and discuss nonsurgical and surgical treatment options and results. The authors conclude with an algorithm for optimal management of patients who have this potentially lethal condition. The chapter is illustrated with line drawings and black-and-white photographs. 7 figures. 4 tables. 52 references.

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Mayo Clinic Gastrointestinal Surgery. St. Louis, MO: Elsevier Science. 2004. 1020 p.

This book focuses on the major diseases treated by gastrointestinal surgeons, from the esophagus to the anal canal. The presentation has a definite clinical orientation and a major emphasis on practical applications as they are applied at the Mayo Clinic. Sections on etiology, pathophysiology, pathology, and diagnosis are also included by are purposely not the emphasis of the chapters. The book offers 49 chapters: the experience of being a Mayo Clinic surgeon; gastroesophageal reflux disease (GERD) and esophageal hiatal hernia; achalasia and other esophageal motility disorders; epiphrenic esophageal diverticula; cancer of the esophagus; gastric adenocarcinoma, primary gastric lymphoma; peptic ulcer; disorders of gastrointestinal motility and emptying after gastric operations; morbid obesity; hepatocellular carcinoma and intrahepatic cholangiocarcinoma; hepatic metastases from extrahepatic cancers; benign tumors and cysts of the liver; liver diseases necessitating liver transplantation; biliary stone disease; benign biliary strictures; cancer of the gallbladder; pancreatic and periampullary carcinoma; islet cell tumors; acute and chronic pancreatitis; pancreas transplantation after complications of diabetes mellitus; cystic tumors of the pancreas; thrombocytopenia and other hematologic disorders; malignant tumors of the small intestine; villous tumors of the duodenum; small intestinal diverticula; Crohn's disease; small bowel obstruction; acute mesenteric ischemia; acute mesenteric venous thrombosis; chronic mesenteric ischemia; visceral artery aneurysms; colonic motor disorders (constipation); diverticular disease of the colon; colon cancer; ischemic colitis; appendicitis; chronic ulcerative colitis; colonic volvulus; familial adenomatous polyposis; cancer of the rectum; common anorectal problems; rectal prolapse and solitary rectal ulcer syndrome; abdominal trauma; unclosable abdomen and the dehisced wound; ventral and incisional hernias; open repair of inguinal hernia; endoscopic inguinal hernia repair; and common pediatric gastrointestinal disorders. Each chapter is illustrated with line drawings, black and white photographs, and some color plates. References are provided with each chapter and a detailed subject index concludes the text.

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Arteriovenous Fistula. Journal of the American Society of Nephrology. 14(6): 1669-1680. June 2003.

Recent guidelines on the care of kidney disease patients requiring hemodialysis have recommended the use of AV fistulae over PTFE grafts, as outcomes are generally better with the AV fistula. However, there are often high primary failure rates with the AV fistula. This article provides insight into the cellular biology and pathophysiology underlying the vascular adaptation to the creation of an AV fistula. The authors describe some small, often neglected, but important technical details that determine the success of the procedure. The authors state that primary failure rates can be substantially improved by attention to small but important details of surgical technique. They conclude that there is no single standard approach and surgical management must be individualized. One key to success is early referral and early establishment of a vascular access after preoperative assessment using ultrasonography. Regular monitoring of the fistula is indicated, and fistula flow should be assessed in critical cases as the single most important predictor of fistula thrombosis. 11 figures. 2 tables. 74 references.

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Budd-Chiari Syndrome. In: PDxMD. PDxMD Gastroenterology. St. Louis, MO: Elsevier Science. 2003. p. 15-41.

Budd-Chiari syndrome is characterized by an impediment of venous blood flow from the liver, caused by thrombosis (clotting), external compression, or venous malformation. The consequences of this syndrome include portal hypertension, cirrhosis (scarring of the liver), and liver failure. Treatment includes thrombolytic therapy, re-establishing venous flow by shunting or stenting, and in fulminant cases, orthotopic liver transplantation. This chapter on Budd-Chiari syndrome is from a book on gastroenterology that offers concise, action-oriented recommendations for primary care medicine. The chapter covers summary information and background on the condition, and comprehensive information on diagnosis, treatment, outcomes, and prevention. Specific topics covered include the ICD9 code, urgent action, synonyms, cardinal features, causes (etiology), epidemiology, differential diagnosis, signs and symptoms, associated disorders, investigation of the patient, appropriate referrals and consultations, diagnostic considerations, clinical tips, treatment options, patient management issues, drug therapies, prognosis, complications, and how to prevent recurrence. The information is provided in outline and bulleted format for ease of accessibility. The final section of the chapter offers resources, including related associations, key references, and the answers to frequently asked questions (FAQs). 5 references.

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Hemorrhoidal Symptom Complex. In: Stein, E. Anorectal and Colon Diseases: Textbook and Color Atlas of Proctology. New York, NY: Springer-Verlag. 2003. p. 71-106.

Hemorrhoids are found on proctoscopic examination in about 70 percent of adults over 30 years of age. This high percentage makes clear that the vast majority of individuals with hemorrhoids are asymptomatic. However, when there is impaired blood flow in the sinusoidal cushions associated with inflammation and spread to adjacent tissues, then pain, discharge, bleeding, and other symptoms may occur (the hemorrhoidal symptom complex). This chapter on the hemorrhoidal symptom complex is from a multidisciplinary reference book and atlas that covers all aspects of anorectal and colon disease (proctology). Topics in this chapter include hemorrhoids, anal tags, perianal thrombosis (clotting), anal prolapse, rectal prolapse, cryptitis and papillitis, hypertrophic anal papillae, anal rhagades and erosions, anal fissure, anorectal abscess, and fistulas. For each condition, the author discusses etiology, clinical features, diagnosis, and therapy. The chapter includes full-color and black-and-white illustrations and photographs, to support the heavily-visual aspects of proctology. Each section concludes with a list of references. 20 figures. 1 table. 157 references.

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Inflammatory Bowel Diseases. St. Louis, MO: Elsevier Science. 2003. 856 p.

This comprehensive textbook serves as a reference for scientists, physicians, and surgeons involved in all aspects of Crohn's disease and ulcerative colitis (inflammatory bowel diseases, IBD). The text offers 49 chapters in six sections: historical review and perspectives, pathogenesis, clinical presentation and diagnosis of IBD, medical treatment, surgical treatment, and complications and clinical problems in IBD. Specific topics include epidemiology of IBD, genetics, microbial factors, intestinal permeability and mucosal defense, the immune system, animal models and their relevance to human IBD, symptoms, differential diagnosis, imaging studies, histopathology, natural history, prognosis, induction and maintenance of remission, fulminant ulcerative colitis, biological therapies, pharmacogenetics, nutrition and diet in IBD, probiotics, surgical techniques, minimally invasive surgery, stoma management, pouchitis and pouch dysfunction, intestinal complications, hepatobiliary disease, osteoporosis, thrombosis, anemia, extraintestinal manifestations, IBD in children, IBD in pregnancy, IBD in the elderly, and quality of life considerations. Each chapter includes a learning goal, a list of key points, a brief list of key references, figures and tables, and a lengthy list of references. The text concludes with a detailed subject index.

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Long-Term Results of Renal Transplantation Using Kidneys Harvested From Non-Heartbeating Donors: a 15-Year Experience. Journal of Urology. 169(1): 28-31. January 2003.

This article reports on an organ procurement program of non-heartbeating donors that was developed to expand the pool of suitable organ donors. The authors compare graft survival in patients receiving renal transplants procured from non-heartbeating with recipients of kidneys from heartbeating donors over a period of 15 years. In the study, there were 60 renal transplantations selected from 70 non-heartbeating donors based on age younger than 50 years, warm ischemia (no blood flow) less than 30 minutes, creatinine less than 200, and no hypertension or major histological lesions. Long-term results of graft survival and complications were compared with a series of 1,065 renal (kidney) transplantations performed during the same period with kidneys procured from heartbeating donors. Mean age of the recipients was statistically different as non-heartbeating donors were older. However, the 10 year graft survival rates were similar in both groups. Incidence of ureteral stenosis (narrowing) and fistula, arterial stenosis and thrombosis (clotting) was not statistically different in both groups. On the other hand, delay graft function was more frequent in non-heartbeating donors. The authors conclude that despite a high rate of acute tubular necrosis (ATN, tissue death of some of the kidney tubules), kidneys harvested from non-heartbeating donors had the same graft survival rates as those procured from heartbeating donors. 2 figures. 1 table. 20 references.

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Sirolimus Does Not Increase the Risk for Postoperative Thromboembolic Events Among Renal Transplant Recipients. Transplantation. 76(2): 318-323. July 2003.

Deep venous thrombosis (DVT) tends to occur in greater frequency among cyclosporine (CsA) treated renal (kidney) transplant recipients. This article reports on a study undertaken to assess the impact of a combination regimen (CsA and sirolimus) on the incidence, predisposing factors, and consequences of postoperative DVT, transplant renal vein or artery thrombosis, and pulmonary embolus. The authors retrospectively evaluated two cohorts of renal transplant recipients: CsA or prednisone plus or minus azathioprine (n = 136, group A) or sirolimus plus CsA plus prednisone (n = 354, group B). The 7 of 136 (5.1 percent) incidence of thrombotic events in group A was similar to the 20 of 354 (5.6 percent) incidence in group B. No patient lost a graft as a complication of DVT, nor did these events produce other lasting adverse effects. The authors conclude that addition of sirolimus to a CsA and prednisone regimen does not increase the incidence of postoperative thrombotic events among renal transplant recipients. 1 figure. 5 tables. 26 references.

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Vascular Diseases of the Liver. In: Textbook of Gastroenterology. 4th ed. [2-volume set]. Hagerstown, MD: Lippincott Williams and Wilkins. 2003. p. 2517-2525.

This chapter on vascular diseases of the liver is from a comprehensive gastroenterology textbook that provides an encyclopedic discussion of virtually all the disease states encountered in a gastroenterology practice. In this chapter, the author discusses systemic circulatory disease, Budd-Chiari syndrome, obstruction of the inferior vena cava, portal vein thrombosis, sinusoidal obstruction syndrome (hepatic venoocclusive disease), nodular regenerative hyperplasia, and peliosis hepatis. The chapter is illustrated with black-and-white graphs and drawings. 1 figure. 4 tables. 95 references.

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Case Against Chronic Venous Hemodialysis Access. JASN. Journal of the American Society of Nephrology. 13(8): 2195-2197. August 2002.

The provision of adequate hemodialysis is dependent on repeated and reliable access to the central circulation of the patient's body. This access to the circulation is best provided by primary arteriovenous fistulas (AVF) and to a lesser extent by AV grafts (AVG). However, due to changing patient demographics, reliance on less desirable modes of vascular access such as synthetic (PTFE) grafts and tunneled, cuffed catheters (CVC) has increased. These latter two types of access are more prone to both thrombosis (clotting) and infection. Venous access in particular has emerged as a substantial cause of hemodialysis morbidity and mortality. This editorial serves as an introduction to two articles in this issue that deal with these dilemmas. The editorial first considers the development of these types of problems and the guidelines for medical care regarding vascular access practice. The authors then summarize the two articles and conclude that the best way to deal with these venous access problems is by finding mechanisms to limit venous hemodialysis complications with new techniques and devices, but also to use venous access less and for shorter periods of time. 22 references.

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Circulating Platelet-Derived Microparticles With Procoagulant Activity May be a Potential Cause of Thrombosis in Uremic Patients. Kidney International. 62(5): 1757-1763. November 2002.

Clinical experience indicates that bleeding and thrombotic (clotting) tendencies coexist in uremic patients. Numerous studies have shown that platelet functional defects contribute to the bleeding tendency in uremic patients. In contrast, there are no solid studies clarifying the pathogenesis (development) of the prothrombotic state in uremic patients. This article reports on a study that considered the role of platelet-derived microparticles (PMPs) which are small vesicles with procoagulant activity released from activated platelets and are thought to be involved in clinical thrombogenesis. The study included predialyzed patients, patients on hemodialysis, or continuous ambulatory peritoneal dialysis (CAPD) patients, and age-matched healthy controls. Results showed that PMP counts were significantly greater in each uremic group than in controls. The PMP counts were not different among three types of uremic groups. PMP counts were significantly higher in uremic patients with thrombotic events than in those without thrombotic events. The hemodialysis procedure and existence of an arteriovenous (AV) fistula (for access) did not affect PMP counts, but erythropoietin (rHuEPO) treatment possibly enhanced the PMP release in these patients. The authors conclude that elevated PMP counts may trigger thrombosis in uremic patients. The primary cause of PMP elevation in uremia was not clarified in this study. 5 figures. 2 tables. 35 references.

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Homocysteine and Vascular Access Thrombosis in Hemodialysis Patients. Renal Failure. 24(2): 215-222. 2002.

Vascular access (VA) remains the Achilles' heel of successful hemodialysis, and thrombosis (clotting) is the leading cause of VA failure. Hyperhomocystinemia (high levels of homocysteine in the blood) is common in patients on hemodialysis and is associated with venous and arterial thrombosis in patients without end stage renal disease (ESRD). In this article, the authors report on a study of 65 hemodialysis patients with native arteriovenous fistulae. Two groups of patients were defined: group A including 45 patients with their VA either never or only once thrombosed, and group B including 20 patients with two or more thromboses of their vascular access. The authors determined serum concentrations of total homocysteine in these patients. In 63 patients (96.9 percent), hyperhomocystinemia was present. There was no statistically significant difference between groups A and B regarding age, gender, and duration of hemodialysis treatment. Total homocysteine concentrations were higher in group A than in group B patients but the difference was small and not statistically significant. These results suggest that thrombosis of native arteriovenous fistulae may not be caused by hyperhomocystinemia in these patients. 40 references.

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Improving Dialysis Access Management. Seminars in Nephrology. 22(6): 507-514. November 2002.

Renal replacement therapy requires either placement of a functional hemodialysis vascular access or peritoneal dialysis catheter. This article reviews the current literature on the planning of dialysis access, with particular emphasis on issues pertaining to vascular access. Early provision of a dialysis access improves patient care with reduction in morbidity and reduces the economic burden incurred as a result of delayed access placement. Vascular access dysfunction, including thrombosis (clotting) and infection, poses the greatest burden on the end stage renal disease (ESRD) population. The authors highlight current concepts used to maximize access patency and to efficiently manage vascular access complications. 1 table. 59 references.

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Infection in Vascular Access Procedures. In: Wilson, S.E. Vascular Access: Principles and Practice. 4th ed. St. Louis, MO: Mosby, Inc. 2002. p. 189-203.

This chapter on infection in vascular access (VA) procedures is from a text that reviews the principles and practice of vascular access, including that used for hemodialysis and for critical care, chemotherapy, and nutrition. Infection is the most common complication of vascular access surgery after thrombosis (clotting) and is a frequent cause of hospitalization of hemodialysis patients. Infection of surgical sites or graft material may prematurely end the function of autogenous or prosthetic fistulas and threatens life, through hemorrhage or systemic sepsis, and jeopardizes limb, through disruption of arterial supply. The authors review the pathogenesis of vascular access infection in the hemodialysis patient and discuss its presentation, prevention, and management. Other topics include altered immune response, altered natural barriers to infection, altered bacterial flora, role of the access type and site, bacteriology, clinical features (symptoms), prevention, treatment of sepsis, the effect of human immunodeficiency virus (HIV), and hemodialysis equipment. 4 figures. 144 references.

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Pancreaticoportal Fistula in Association with Antiphospholipid Syndrome Presenting as Ascites and Portal System Thrombosis. Canadian Journal of Gastroenterology. 16(9): 601-605. September 2002.

Fistulous communication (an abnormal opening) between the pancreas and the portal venous system is extremely rare and is usually a complication of chronic pancreatitis or pancreatic pseudocysts. In this article, the authors describe a patient who presented with abdominal pain and ascites (fluid accumulation) secondary to a pancreaticoportal fistula and portal system thrombosis. The diagnosis was made by endoscopic retrograde cholangiopancreatography (ERCP) and confirmed by immediate postprocedure computed tomographic scanning (CT scan). Laboratory studies identified concomitant antiphospholipid syndrome. The patient responded favorably to supportive medical therapy. 5 figures. 32 references.

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Permanent Hemodialysis Vascular Access Survival in Children and Adolescents with End-Stage Renal Disease. Kidney International. 62(5): 1864-1869. November 2002.

Transplantation is the optimal therapy for children with end stage renal disease (ESRD), but in a subset of patients with peritoneal membrane failure, failed transplants, or poor social situations, chronic hemodialysis (HD) remains the only option. Long-term survival of arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) in pediatric patients has not been well described. This article reports on a study of the survival of permanent vascular access in 34 pediatric ESRD patients treated with chronic HD between 1989 and 1995 and followed through 2000. Twenty-four AVFs and AVGs were created in 19 and 23 patients, respectively. Mean age and weight at insertion were 15.1 years (range 7.1 to 20.9 years) and 46 kilograms (18 to 81 kilograms) for AVFs and 13.3 years (3.8 to 21.1 years) and 41.5 kilograms (10.5 to 145 kilograms) for AVGs. Excluding primary failures, 1-year, 3-year, and 5-year patency rates for AVFs and AVGs were not significantly different. Patency did not correlate with patient weight or age at access creation. Primary access failure occurred more often in AVFs (8 of 24) than in AVGs (1 of 28). Access thrombosis (clotting), stenosis (narrowing), and infection occurred more frequently in AVG. The authors conclude that both AVF and AVG function well even in small pediatric patients and have survival rates equivalent to adult series and longer than cuffed venous catheters in pediatric patients. Both AVFs and AVGs are preferable for long-term HD access in pediatrics. 1 figure. 3 tables. 17 references.

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Surgical Techniques in Right Laparoscopic Donor Nephrectomy. Journal of the American College of Surgeons. 195(1): 131-137. July 2002.

The benefits of laparoscopic donor nephrectomy (LDN, removal of a donated kidney using laparoscopic, rather than open surgery, techniques) have been well described, but limitations in the technical performance of LDN of the right kidney have isolated its performance to only a few advanced laparoscopic centers. This article reviews the technical challenges of right LDN and offers several approaches for improving the right LDN technique. Topics include port placement and liver retraction, inferior vena caval dissection, arterial mobilization, division of the renal vessels, and anticipated results of the procedure. The authors conclude by noting that a considerable proportion of living donors should undergo right rather than left donor nephrectomy for anatomical reasons, including multiple renal arteries, smaller right kidney, or undiagnosed lesions within the right donor kidney. The ability to perform right LDN allows the inclusion of those donors with only right kidneys suitable for donation. When the operation is performed with attention to potential complications, right LDN can provide kidneys without increased risk for thrombosis or other technical complications. 1 table. 6 figures. 13 references.

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Vascular Access: Anatomy, Examination, Management. Seminars in Nephrology. 22(3): 183-194. May 2002.

A systematic approach to managing vascular access (VA) problems in hemodialysis patients is the key to reducing current high rates of access thrombosis (clotting) and failure. This article describes this systematic approach that consists of anatomy, examination, and management. The approach begins with a thorough knowledge of vascular access anatomy that, when combined with the physical examination, can help optimize access planning and maintenance. Because of the high complication rate of synthetic grafts, there has been increased emphasis on creating autogenous (from the patient herself or himself) arteriovenous (AV) fistulae, which, once established, are more trouble-free. The benefit of increased fistula creation will not be realized, however, until the high rate of early fistula failure is reduced. It is widely recommended that graft surveillance programs be implemented and that stenosis (narrowing) be corrected when accompanied by graft dysfunction. Graft blood flow is the preferred surveillance method, but has a poor accuracy in predicting thrombosis. The authors conclude that the most important factor in access survival may be a team approach with an organized commitment to access planning, followed by recognition and treatment of access problems. 2 figures. 7 tables. 64 references.

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Vascular Access: Principles and Practice. 4th ed. St. Louis, MO: Mosby, Inc. 2002. 289 p.

This text reviews the principles and practice of vascular access, including that used for hemodialysis and for critical care, chemotherapy, and nutrition. The text features 25 chapters that cover: the development of vascular access (VA) surgery, planning and patient assessment, anesthesia, surgical anatomy for VA procedures, physiology for the arteriovenous fistula, biologic properties of VA devices, biologic response to prosthetic dialysis grafts, epidemiology of chronic renal (kidney) failure (CRF) and guidelines for the initiation of hemodialysis, autologous arteriovenous fistulas, basilic vein transposition, vascular interposition (bridge fistulas) for hemodialysis, central venous cannulation for hemodialysis access, vascular access in the neonatal and pediatric patient, revision and outcome of VA procedures for hemodialysis, radiologic intervention and instrumentation for the salvage of hemodialysis access grafts, axillosubclavian vein thrombosis (clotting), thrombosis, venous hypertension, arterial steal, and neuropathy (nerve disease or damage), complications of VA procedures, care and use of VA devices, cardiovascular consequences of rapid hemodialysis, peritoneal dialysis, socioeconomic implications of VA surgery, placement of indwelling VA systems, VA for trauma and emergency surgery, and complications of percutaneous VA procedures and their management. Each chapter includes black and white illustrations and a list of references; a subject index concludes the volume.

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Chronic Pancreatitis. In: Beckingham, I.J., ed. ABC of Liver, Pancreas and Gallbladder. London, UK: BMJ Publishing Group. 2001. p.37-40.

Chronic pancreatitis is usually caused by alcohol misuse and it mainly affects men aged 40 to 50 years. There is no uniform threshold for alcohol toxicity, but the quantity and duration of alcohol consumption correlates with the development of chronic pancreatitis. This chapter on chronic pancreatitis is from an atlas of the liver, pancreas and gallbladder. Topics include natural course, symptoms and signs, diagnosis, treatment options (for pain, steatorrhea, and diabetes), endoscopic procedures, surgery, and complications of chronic pancreatitis, including pseudocysts, biliary stricture, gastroduodenal obstruction, and splenic vein thrombosis. The authors note that early diagnosis of chronic pancreatitis is often difficult and relies on appropriate clinical history and imaging. Stopping alcohol intake is essential to reduce attacks of pain, preserve pancreatic function, and aid management of complications. Patients often require opiate analgesics (painkillers), and pain is best managed in a multidisciplinary setting. Surgery should be reserved for patients with intractable pain or with complications. The chapter concludes with summary points of the concepts discussed. 7 figures. 2 tables. 3 references.

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Clinical Outcomes and Insulin Secretion After Islet Transplantation with the Edmonton Protocol. Diabetes. 50(4): 710-719. April 2001.

This article provides further data on 12 patients with type 1 diabetes who have had successful islet transplantations. Details of metabolic control, acute complications associated with islet transplantation, and long term complications related to immunosuppression therapy and diabetes were noted. Insulin secretion, both acute and over 30 minutes, was determined after intravenous glucose tolerance tests (IVGTTs). The median follow up was 10.2 months, and the longest was 20 months. Glucose control was stable, with pretransplant fasting and meal tolerance stimulated glucose levels of 12.5 plus or minus 1.9 and 20.0 plus or minus 2.7 mmol per liter, respectively, but decreased significantly, with posttransplant levels of 6.3 plus or minus 0.3 and 7.5 plus or minus 0.6 mmol per liter, respectively. All patients had sustained insulin production, as evidenced by the most current baseline C-peptide levels of 0.66 plus or minus 0.06 nmol per liter, increasing to 1.29 plus or minus 0.25 nmol per liter after the meal tolerance test. The mean glycosylated hemoglobin (HbA1c) level decreased from 8.3 plus or minus 0.5 percent to the current level of 5.8 plus or minus 0.1 percent. Four patients had normal glucose tolerance, five had impaired glucose tolerance, and three had postislet transplant diabetes. Three patients had a temporary increase in their liver function tests. One patient had thrombosis of a peripheral branch of the right portal vein, and two of the early patients had bleeding from the hepatic needle puncture site; however, these problems were resolved. Two patients had transient vitreous hemorrhages. The two patients with elevated creatinine levels posttransplant had a significant increase in serum creatinine in the long term, although the mean serum creatinine of the group was unchanged. Cholesterol increased in five patients, and lipid lowering therapy was required for three patients. No patient has developed cytomegalovirus infection or disease, posttransplant lymphoproliferative disorder, malignancies, or serious infection to date. None of the patients have been sensitized to donor antigen. In 11 of the 12 patients, insulin independence was achieved after 9,000 islet equivalents (IEs) per kilogram were transplanted. The acute insulin response and the insulin area under the curve (AUC) after IVGTT were consistently maintained over time. The insulin AUC from the IVGTT correlated to the number of islets transplanted, but more closely correlated when the cold ischemia time was taken into consideration. Islet transplantation has successfully corrected labile type 1 diabetes and problems with hypoglycemia, and results show persistent insulin secretion. After a minimum of 9,000 IEs per kilogram are provided, insulin independence is usually attained. An elevation of creatinine appears to be a contraindication to this immunosuppressive regimen. When considering islet transplantation for people with labile type 1 diabetes that is difficult to control, the risk to benefit ratio should be in favor of islet transplantation. 6 figures. 35 references. (AA-M).

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Diabetes and Atherosclerosis. In: Johnstone, M.T. and Veves, A. Diabetes and Cardiovascular Disease. Totowa, NJ: The Humana Press, Inc. 2001. p. 169-194.

With over ten million diagnosed patients and another five million undiagnosed, diabetes mellitus and its complications is a major public health problem that will assume epidemic proportions as the population grows older. This chapter on diabetes and atherosclerosis (hardening and narrowing of the arteries) is from a textbook that offers physicians practical knowledge about cardiovascular disease and diabetes. This chapter is in Part I, which focuses on pathophysiology, including the mechanisms and risk factors for diabetic cardiovascular disease. The author notes that macrovascular (large vessel) disease is the leading cause of mortality (death) and morbidity (illness) in diabetes. The author discusses endothelial (the cells that line the body cavity and the cardiovascular system) dysfunction, the mechanisms of foam cell formation, the role of humoral immunity and macrophage activation, abnormalities in platelet function, coagulation, and fibrinolysis, particularly as they contribute to thrombus (clot) formation. The author provides updated information concerning factors associated with diabetes that may accelerate the development of atherosclerosis and thrombosis and contribute to acute clinical events. 1 figure. 227 references.

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Diabetes and Cardiovascular Disease. Totowa, NJ: The Humana Press, Inc. 2001. 458 p.

With over ten million diagnosed patients and another five million undiagnosed, diabetes mellitus and its complications is a major public health problem that will assume epidemic proportions as the population grows older. This textbook offers practicing physicians the day to day practical knowledge about cardiovascular disease and diabetes. The 24 chapters in the book focus on either clinical or basic aspects of diabetes and cardiovascular disease. Part I, pathophysiology, reviews the mechanisms and risk factors for diabetic cardiovascular disease. Specific topics include the effects of insulin on the vascular system, vascular abnormalities in the prediabetic state, diabetes and advanced glycation end products, diabetes and hypertension (high blood pressure), the renin-angiotensin system, diabetes and dyslipidemia (disordered levels of fats in the blood), diabetes and thrombosis (blood clotting), diabetes and atherosclerosis (hardening and narrowing of the arteries), and nitric oxide and its role in diabetes mellitus. Part II focuses on the heart in diabetes mellitus, including coronary artery disease and congestive heart failure, including the preoperative assessment and perioperative management of the surgical patient with diabetes mellitus. Part III, the peripheral vascular system, addresses epidemiology (incidence and prevalence), mechanisms, methods of assessment, and treatment of this macrovascular disease. Specific topics include diabetes and arterial stiffness, methods for assessing large vessel pathophysiology, and peripheral vascular disease in patients with diabetes mellitus. And Part IV reviews the different microvascular effects in individuals with diabetes mellitus, including retinopathy (eye disease), nephropathy (kidney disease), neuropathy (nerve disease), and microcirculation of the diabetic foot. Each chapter includes extensive references and a subject index concludes the text.

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Diabetes and Thrombosis. In: Johnstone, M.T. and Veves, A. Diabetes and Cardiovascular Disease. Totowa, NJ: The Humana Press, Inc. 2001. p. 149-168.

With over ten million diagnosed patients and another five million undiagnosed, diabetes mellitus and its complications is a major public health problem that will assume epidemic proportions as the population grows older. This chapter on diabetes and thrombosis (clotting) is from a textbook that offers physicians practical knowledge about cardiovascular disease and diabetes. This chapter is in Part I, which focuses on pathophysiology, including the mechanisms and risk factors for diabetic cardiovascular disease. The authors note that complications of macrovascular disease, referred to by some as atherothrombosis, are responsible for 50 percent of the deaths in patients with type 2 diabetes mellitus, 27 percent of the deaths I patients with type 1 diabetes for 35 years or less, and 67 percent of the deaths in patients with type 1 diabetes for 40 years or more. The authors focus on type 2 diabetes in their discussion of thrombosis and atherosclerosis, platelet function in subjects with diabetes mellitus, the coagulation system and diabetes mellitus, mechanisms responsible for a prothrombotic state associated with diabetes, diabetes and fibrinolysis, mechanisms responsible for the overexpression of PAI (plasminogen activator inhibitor) in diabetes, fibrinolysis and arterial mural proteolysis, and therapeutic implications. The authors conclude that subjects with diabetes mellitus have a high prevalence and rapid progression of coronary artery, peripheral vascular, and cerebral vascular disease secondary in part to increased platelet reactivity, increased thrombotic activity and decreased activity of antithrombotic factors, and decreased fibrinolytic system capacity. Therapy designed to reduce insulin resistance decreases concentrations in blood not only of insulin but also of PAI-1. Thus, the treatment of subjects with diabetes, and particularly type 2 diabetes, should focus not only on improved metabolic control but also on reduction of insulin resistance and hyperinsulinemia. Treatment designed to treat both the hormonal and metabolic abnormalities of diabetes is likely to reduce hyperactivity of platelets, decrease the intensity of the prothrombotic state, and normalize activity of the fibrinolytic system in blood and in vessel walls, thereby reducing the rate of progression of macrovascular disease and its complications. 2 tables. 114 references.

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Enteral vs. Parenteral Nutrition Support: Part One. Today's Dietitian. 3(8): 10-12. August 2001.

Advances in both enteral (through the digestive tract) and parenteral (outside the digestive tract) products and devices have made clinical nutrition a most exciting and rewarding area of practice. This article, the first of two in a continuing education series for dietitians, explores the pros and cons of parenteral support. Total parenteral nutrition (TPN) provides nutrients to a patient via vascular (blood vessel) access and can provide most of the necessary nutrients to patients unable to utilize their gastrointestinal (GI) tract effectively. Guidelines for the use of TPN include massive small bowel resection (surgical removal), severe diarrhea (if unresponsive to other treatments), intractable vomiting, acute pancreatitis, and malnutrition (if the patient is unable to use the GI tract for seven to 10 days). The authors describe access issues for TPN, formula preparation, fats, monitoring the TPN patient, and complications. Complications of TPN include phlebitis (inflammation of a vein) at the access site, pneumothorax (collapsed lung) during the insertion of the central line, thrombosis (clotting) of the vein, and infection of the venous access line. And because parenteral nutrition is much more complex and expensive than enteral nutrition therapies, its use must be closely monitored. 2 figures. 10 references.

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Hepatobiliary Diseases: Pathophysiology and Imaging. Malden, MA: Blackwell Science, Inc. 2001. 764 p.

This textbook aims to familiarize the reader with various imaging modalities, the information they provide, and with the merits of each, in order to facilitate the combined use of different imaging techniques in the diagnosis and management of hepatobiliary (liver and bile tract) diseases. The book includes 47 chapters in seven sections: progress in imaging, anatomy and gross changes in the liver, diffuse liver diseases, vascular disease, space-occupying lesions, other liver diseases, and biliary tract disease. Specific topics include computed tomography (CT scan) and magnetic resonance imaging (MRI); harmonic ultrasound; anatomy of the liver; acute hepatitis and acute hepatic failure; chronic hepatitis; cirrhosis (liver scarring); fatty liver (steatosis); alcoholic liver disease; iron overload; Wilson's disease; amyloidosis, metabolic diseases, drug-induced and chemical-induced liver injuries; vascular anatomy of the liver and vascular anomalies; portal hypertension (high blood pressure); thrombosis (clotting) affecting the liver; Budd-Chiari syndrome; primary malignant tumors of the liver (liver cancer); benign liver lesions; cysts of the liver; liver abscess; blunt hepatic trauma; parasitic diseases; infections and the liver; transplantation; anatomy of the biliary tract; congenital anomalies and dilatation; Caroli's disease; stone disease (gallstones); biliary tract stenosis; primary sclerosing cholangitis; cholecystitis and Mirizzi syndrome; tumors of the gallbladder; adenomyomatosis and cholesterolosis; Hilar carcinoma; and tumors of the common bile duct and papilla of Vater. Each chapter includes black and white reproductions of imaging techniques and a list of references. The book includes a color plate section and a detailed subject index.

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Highlights for Nephrology Nurses from the Updated NKF-K/DOQI Guidelines. Nephrology Nursing Journal. 28(1): 45-50. February 2001.

This article reviews for nephrology nurses the updated National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF DOQI), published in January 2001. The updated guidelines (renamed the K DOQI) have been expanded in coverage from a focus on dialysis to a focus on kidney disease in all its stages, including those that occur well before dialysis becomes necessary. Nephrology nurses were active members of the groups that updated the K DOQI; in this article, nephrology nurses from the four content area work groups provide highlights of the revisions. Regarding hemodialysis adequacy, the new guidelines emphasize that institutions should make sure that the dialysis dose is measured consistently, that Kt per V is calculated using blood urea nitrogen (BUN) measurements taken at defined pre and postdialysis blood draws, and that patient comfort is considered, particularly in its effect on adherence (compliance with recommended dialysis amounts). Recommendations for improving peritoneal dialysis include lowering the creatinine clearance requirements for patients with low transport status, considering early initiation of dialysis in patients with poor nutritional status, and making preservation of residual renal function a goal. Recommendations for improving vascular access outcomes include using native arteriovenous (AV) fistulas where possible, considering use of bridge devices while AV fistulas mature, improving monitoring programs to prevent access complications (such as thrombosis), and referring patients for fistulograms to diagnose low flow rate problems. Recommendations for improving anemia management include using hemoglobin rather than hematocrit as anemia endpoint, considering the use of sodium ferric gluconate complex in sucrose injection, waiting 1 week (rather than 2) after the last dose of intravenous iron to measure iron indices, administering erythropoietin subcutaneously when possible, and watching for the effect of ACE inhibitors and C reactive protein on erythropoietin responsiveness. 4 tables. 49 references.

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Kidney Transplantation in Young Children: Should There be a Minimum Age?. Pediatric Nephrology. 16(12): 941-945. December 2001.

The optimal age in transplantation in children with end stage renal disease (ESRD) remains controversial. Many centers have adopted a policy of waiting until such children reach a certain minimum age or weight, maintaining them on chronic dialysis until then. However, the authors of this article note that with proper donor selection and recipient care, comparable results can be achieved in very young age groups. This article presents results with kidney transplantation in children less than 1 year old. Between January 1984 and December 1999, the authors performed 321 kidney transplants at the University of Minnesota in children younger than 13 years old. The authors analyzed results in three age groups: less than 1 year (n = 30), 1 through 4 years (n = 122), and 5 through 13 years (n = 169). The authors found no significant differences in patient or graft survival rates between the three groups. Almost all infant (less than 1 year) recipients underwent primary transplants from living donors (LDs). However, even when comparing the results only of primary LD transplants between the three groups, there were no significant differences. To date, all the infant recipients are alive and well, 24 (80 percent) with a functioning original graft. Causes of the 6 graft losses were chronic rejection (n = 3), vascular thrombosis (n = 2), and recurrent disease (n = 1). Infants had significantly lower incidences of acute and chronic rejection compared with older recipients, but a tendency to higher incidences of delayed graft function and vascular thrombosis (clotting). The authors conclude that kidney transplant results in very young children can be comparable to those in older children. The timing of the transplant should not be based on age or size alone. 4 figures. 2 tables. 14 references.

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Liver Transplantation. In: Okuda, K., ed.,et al. Hepatobiliary Diseases: Pathophysiology and Imaging. Malden, MA: Blackwell Science, Inc. 2001. p. 599-612.

Liver transplantation is the treatment of choice for patients with irreversible liver failure. This chapter on liver transplantation is from a textbook that familiarizes the reader with various imaging modalities, the information they provide, and the merits of each, in order to facilitate the combined use of different imaging techniques in the diagnosis and management of hepatobiliary (liver and bile tract) diseases. The authors stresses that successful liver transplantation is dependent on accurate radiological imaging. As a member of the transplantation team, the radiologist must be familiar with the surgical anatomy of liver transplantation and the complex imaging of liver transplant patients. The radiological assessment includes the preoperative evaluation of patients with liver failure, accurate hepatic imaging of living donors, and rapid and accurate diagnosis of postoperative complications. The author discusses preoperative imaging, anatomy and normal postoperative findings, and post transplantation complications, including vascular complications, biliary complications, fluid collections, rejection, and post transplant malignancy (cancer). The preoperative assessment includes both technical aspects such as liver volume determination, and accurate diagnosis of conditions affecting transplantation, such as vessel thrombosis and liver cancer. The postoperative evaluation centers of rapid and accurate detection of complications. The author concludes that in many instances, accurate and prompt radiological assessment can play an important role in implementing treatments that prevent graft failure. 26 figures. 44 references.

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Open Donor, Laparoscopic Donor and Hand Assisted Laparoscopic Donor Nephrectomy: A Comparison of Outcomes. Journal of Urology. 166(4): 1270-1274. October 2001.

In experienced hands, laparoscopic surgery has been shown to be safe for procuring kidneys for transplantation that function identically to open nephrectomy (surgical removal of a kidney) controls. This article reports on a study of allograft function in patients (n = 48) with greater than 1 year followup who underwent open donor, classic laparoscopic, and hand assisted laparoscopic nephrectomy. Of these patients, 34 underwent consecutive laparoscopic live donor nephrectomy and 14 underwent open donor nephrectomy. Mean patient age was 36.5 years (plus or minus 8.4 years) for donors and 29 years (plus or minus 17 years) for recipients at transplantation (range of 13 months to 69 years). In the laparoscopic group, 11 patients underwent the transperitoneal technique, and 23 underwent hand assisted laparoscopic nephrectomy. Total operating time was significantly reduced with the hand assisted laparoscopic technique, as was the time from skin incision to kidney removal and warm ischemic (without blood flow) time. No blood transfusions were necessary. Complications included adrenal vein injury in 1 patient, small bowel obstruction in 2 patients, abdominal hernia at the trocar site in 1 patient, and deep venous thrombosis in 1 patient. The authors conclude that both classic laparoscopic donor and hand assisted laparoscopic donor nephrectomies appear to be safe procedures for harvesting kidneys. The recipient graft function is similar in the laparosocpic and open surgery groups. An editorial comment is appended to the article. 2 figures. 3 tables. 14 references.

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Platelet Dysfunction in Type 2 Diabetes. Diabetes Care. 24(8): 1476-1485. August 2001.

This review article examines the hypothesis that platelet and neurovascular dysfunction are integral parts of the metabolic syndrome and coexist with features of the syndrome. Platelets are essential for hemostasis, and knowledge of their function is basic to understanding the pathophysiology of vascular disease in diabetes. Intact healthy vascular endothelium is central to the normal functioning of smooth muscle contractility as well as its normal interaction with platelets. What is not clear is the role of hyperglycemia in the functional and organic microvascular deficiencies and platelet hyperactivity in people with diabetes. The entire coagulation cascade is dysfunctional in diabetes. Increased levels of fibrinogen and plasminogen activator inhibitor 1 favor both thrombosis and defective dissolution of clots once formed. Platelets in people with type 2 diabetes adhere to vascular endothelium and aggregate more readily than those in healthy people. Loss of sensitivity to the normal restraints exercised by prostocyclin (PGI2) and nitric oxide (NO) generated by the vascular endothelium presents as the major defect in platelet function. Insulin is a natural antagonist of platelet hyperactivity. It sensitizes the platelet to PGI2 and enhances endothelial generation of PGI2 and NO. Thus, the defects in insulin action in diabetes create a milieu of disordered platelet activity conducive to macrovascular and microvascular events. 3 figures. 1 table. 108 references. (AA-M).

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Refractory Pancreatitis Secondary to Ruptured Hepatocellular Carcinoma into the Common Bile Duct. Digestive Diseases and Sciences. 46(5): 1029-1033. May 2001.

Hepatocellular carcinoma (HCC, liver cancer) is a common disease worldwide and continues to be the leading cause of death of males in Taiwan (from where this article originates). Jaundice is present in 19 to 44 percent of cases of HCC at the time of diagnosis and is usually attributed to the preexisting liver cirrhosis (scarring) or extensive hepatic parenchymal (the liver body) destruction by tumor. Icteric hepatoma (a type of liver tumor) is characterized by intermittent obstructive jaundice with associated complications, such as cholangitis (inflammation of the bile ducts) and hemobilia. In this article, the authors report the first case of icteric hepatoma that initially presented as pancreatitis in addition to obstructive jaundice. The 59 year old man was admitted with a 2 week history of tea colored urine, intermittent tarry stool, vomiting, and postprandial epigastralgia (pain in the stomach after meals) with radiation to his back. He denied alcohol abuse and drugs consumption and he had never experienced pancreatitis. After 8 days of hospital treatment, the patient was released and able to eat a normal diet at an outpatient visit one month later. However, he was rehospitalized 8 weeks later with another episode of pain; surgical treatment was implemented. The patient died of multisystem organ failure on the 32nd postoperative day. For this case, the treatment was focused on two goals. First, the consequences of the biliary obstruction including the pancreatitis should be resolved by nonoperative methods, if available. Second, the origin of the migrating tumor should be eradicated either by transarterial chemoembolization or hepatic (liver) resection. The present case was not suitable for hepatic resection or hepatic artery ligation because of intrahepatic metastasis of both lobes and portal vein thrombosis (clotting) seen at exploration. Although palliation could be satisfactorily given, the prognosis continues to be dismal. 4 figures. 11 references.

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Systemic Vasculitis: A Difficult Diagnosis in the Elderly. Physician Assistant. 25(1): 37-38, 47-53. January 2001.

Illnesses in geriatric (aging) patients are often difficult to diagnose because the patients may not present with the typical pattern for many common diseases. This article reviews the diagnosis of systemic vasculitis in the elderly. Vasculitis is a group of heterogeneous disorders characterized by inflammation of blood vessels. The inflammation may cause narrowing, thrombosis (clotting), or occlusion (blockage) and necrosis (death) of the vessels. Vasculitis can also cause aneurysm or rupture, which will result in an inadequate blood supply and damage to the tissues of the differing organ systems involved. The author notes that the atypical presentation in the elderly, compounded by the fact that vasculitides present with vague symptomatology, have nonspecific diagnostic testing, and are difficult to differentiate because of their overlapping presentations, makes the diagnosis of systemic vasculitis difficult for the clinician. Additionally, geriatric patients often delay seeing the physician because they attribute their symptoms to the aging process. This article provides the clinician with tools to enhance the diagnosis of systemic vasculitis in a more timely and systematic fashion in the geriatric patient. Specific subtypes discussed include giant cell arteritis, polyarteritis nodosa, microscopic polyangiitis, and Wegener's granulomatosis. Nonspecific constitutional complaints, combined with those from multiple organ systems in the geriatric patient, should bring the suspicion of vasculitis. Once vasculitis is suspected, the clinician must move quickly to rule out the mimics of this systemic illness, including malignancies and infections. The diagnosis of a specific vascular syndrome is based on clinical symptoms, angiography, biopsy results, ANCA (antineutrophil cytoplasmic autoantibodies), and viral testing. Appropriate treatment with corticosteroids, cytotoxic agents, and antiviral therapy should begin as soon as possible to improve the patient's prognosis. 3 tables. 17 references.

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Toxic Megacolon: Role of CT in Evaluation and Detection of Complications. Journal of Clinical Imaging. 25(5): 349-354. September-October 2001.

This study was undertaken to determine the role of computed tomography (CT) in the evaluation of patients with toxic megacolon (including the detection of complications). A retrospective analysis of CT findings of 18 consecutive patients with toxic megacolon was performed. Underlying etiology included 12 patients with pseudomembranous colitis (PC), four patients with ulcerative colitis (UC), and two patients with cytomegalovirus colitis. Eleven patients were HIV positive. CT features, correlation with severity of disease, and development of complications were analyzed. Colonic dilatation with intraluminal and or fluid with a distorted colonic contour or an ahaustral pattern was seen in all patients. In four patients (22 percent), CT depicted complications: two colonic perforations and two septic thrombosis (clots) of the portal system (the vascular system of the liver). Six patients died (33 percent), three of whom had the above complications. The presence and degree of submucosal edema (fluid accumulation), wall thickening, degree of dilatation, nodular contour, and ascites did not correlate with clinical outcome. Two thirds of patients with toxic megacolon had PC as the underlying etiology. CT was helpful in depicting diffuse colitis, and it was instrumental in detecting life-threatening abdominal complications, contributing to the management of these patients. The authors conclude that CT abnormalities cannot be used to predict the clinical outcome unless complications develop. 4 figures. 25 references.

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Complications of Dialysis in Diabetic Patients. In: Lameire, N. and Mehta, R.L., eds. Complications of Dialysis. New York, NY: Marcel Dekker, Inc. 2000. p. 697-704.

Dialysis patients with diabetes mellitus comprise the largest subgroup of patients in end stage renal disease (ESRD) treatment programs in developed countries. This patient population is unfortunately also subject to greater morbidity and mortality when compared to nondiabetic dialysis patients. This chapter on the complications of dialysis in patients with diabetes is from a book that offers a comprehensive, multidisciplinary resource for the nephrologist and caregiver providing dialysis, covering all aspects of dialysis therapies and their complications. The authors of this chapter note that older age at the time of dialysis initiation and the presence of often advanced microvascular and macrovascular disease account for this excess rate of complications and death on dialysis. The management of dialysis patients with diabetes requires an aggressive, preemptive, multidisciplinary, and patient education oriented approach, which must often be led by the nephrologist (kidney specialist) who has the most frequent contact with the patient. Peripheral vascular, cardiovascular, and cerebrovascular disease, retinopathy (eye disease), gastropathy, and dialysis associated complications are the major contributors to co-morbidity in diabetic dialysis patients. Hemodialysis related complications include hypotension (low blood pressure), hypertension (high blood pressure), high interdialytic weight gain, vascular access problems, access thrombosis (clotting), ischemic monomelic neuropathy, and venous hypertension. Other problems discussed include bone disease, diabetic retinopathy, undernutrition, and hyperglycemia (high blood sugar levels). The complications of peritoneal dialysis in patients with diabetes including peritonitis, underdialysis, undernutrition, and hyperglycemia. The authors conclude by noting that the increasing prevalence of type 2 diabetes will require that nephrologists target the problems prevalent in this population in order to reduce morbidity (illness) and mortality (death). 2 tables. 46 references.

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Complications of Vascular Access. In: Lameire, N. and Mehta, R.L., eds. Complications of Dialysis. New York, NY: Marcel Dekker, Inc. 2000. p. 1-27.

This chapter on the complications of vascular access is from a book that offers a comprehensive, multidisciplinary resource for the nephrologist and caregiver providing dialysis, covering all aspects of dialysis therapies and their complications. Vascular access is essential for hemodialysis; without effective access, dialysis can not take place. However, access also accounts for many of the complications seen in hemodialysis patients. The author discusses the three types of vascular access and the complications associated with each type: tunneled cuffed catheters (TCC), prosthetic bridge grafts (PBG), and autologous native fistulas (AVF). Topics include complications of initial placement, catheter thrombosis, infection, venous stenosis (narrowing), graft thrombosis, graft infection, pseudoaneurysm formation, PBG related ischemia, and inadequate development of the AVF. The author concludes that the hemodialysis community has a great need for a better solution for the management of vascular access and for an organized strategy to decrease the incidence of complications and to handle them appropriately when they occur. At a minimum, this strategy must include a plan to maximize the use of native fistulae, a policy for appropriate use of dialysis catheters, a quality assurance program to detect the access at risk, implementation of procedures to increase access longevity, and a system to manage graft thrombosis effectively and efficiently. 5 figures. 9 tables. 191 references.

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Increasing the Hematocrit Has a Beneficial Effect on Quality of Life and Is Safe in Selected Hemodialysis Patients. JASN. Journal of the American Society of Nephrology. 11(2): 335-342. February 2000.

Target hematocrit and hemoglobin values in dialysis patients are still controversial. This article reports on a 6 month prospective study conducted by the Spanish Cooperative Renal Patients Quality of Life Study Group (including 34 hemodialysis units) on the effect of patient functional status and quality of life using epoetin to achieve normal hematocrit in hemodialysis patients with anemia. The possible adverse effects of increased hematocrit, patient hospitalization, and epoetin requirements were also studied. The study included 156 patients (age range, 18 to 65 years). Quality of life was measured with the Sickness Impact Profile (SIP) and Karnofsky scale. Patients completed questionnaires at home at onset and conclusion of the 6 month study. Mean hematocrit increased from 30.9 to 38.4 percent and hemoglobin from 10.2 to 12.5 g per dl during the study. Health indicator scores improved significantly; functional status and quality of life improved with increased hematocrit. No deaths occurred. Three patients (2 percent) were censored for hypertension and nine (5.7 percent) for thrombosis of the vascular access. The number of patients hospitalized decreased and hospital lengths of stay were shorter during the study period than in the same patients in the 6 month period preceding the study. The authors conclude that normalization of hematocrit in selected hemodialysis patients, i.e. nondiabetic patients without severe cardiovascular or cerebrovascular comorbidities, improves quality of life and decreases morbidity without significant adverse effects. 2 figures. 5 tables. 37 references.

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Ischemic Nephropathy: Clinical Characteristics and Treatment. American Journal of Kidney Diseases. 36(5): 883-893. November 2000.

Ischemic nephropathy (kidney damage due to lack of adequate blood flow in the organ) is a long term cause of hypertension (high blood pressure) and renal (kidney) failure. Although its real incidence is unknown, ischemic nephropathy is growing because of the increased mean age of the population and the greater prevalence of populations with hypertension or diabetes mellitus. This review article describes the typical clinical profile of afflicted patients. The authors note that atherosclerosis in different vascular beds is common in these patients. The evolution of ischemic nephropathy is generally progressive, although some patients present with acute renal failure (ARF), either secondary to the administration of ACE inhibitors or caused by thrombosis of the renal arteries. Resvascularizing surgery may stabilize or improve renal function, even in patients with nonfunctioning kidneys. The results obtained with intraluminal angioplasty are worse, with a high percentage of re-stenosis. Placement of an endoprosthesis is recommended when the lesions affect the ostium or proximal third of the artery. The authors caution that this complex disease typically affects multiple organs, thus making individual patient assessment essential. 4 figures. 6 tables. 94 references.

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Levin and O'Neal's the Diabetic Foot. 6th ed. St. Louis, MO: Mosby, Inc. 2000. 828 p.

This book serves as a guide for the interdisciplinary team treating people who have diabetes, focusing on the medical, surgical, psychosocial, and medicolegal aspects of care. The first section explores the foundations of diabetic foot management. Chapters discuss old assumptions and new realities about diabetes, the epidemiology of foot ulcers and amputations, neuropathic problems of the lower extremities, atherosclerosis and thrombosis, the principles and concepts of hemorheology, the biomechanics of the foot in diabetes, cutaneous aspects of diabetes, nutritional issues, and the pathogenesis and management of foot lesions. The section concludes with an overview of diabetic foot care throughout the world. The next section deals with nonsurgical management of diabetic foot problems. Chapters focus on a method for staging and classifying foot lesions, diabetic foot ulcer care, total contact casting, alternative weight redistribution, imaging of the diabetic foot, and noninvasive vascular testing. Other chapter topics include radiologic intervention in diabetic peripheral vascular disease, wound healing, adjunctive hyperbaric oxygen therapy, footwear for injury prevention, Charcot neuroarthropathy of the foot, and infectious problems of the foot. The third section addresses the surgical aspects of diabetic foot care. Chapters discuss the surgical pathology of the foot and clinicopathologic correlations, medical management of diabetic patients during the perioperative period, vascular surgery, plastic surgical reconstruction of the foot, Charcot neuropathy of the foot, lower limb amputation, and rehabilitation of the amputee. The next section is devoted to the team approach to diabetic foot care. Topics include patient education, the role of the wound care nurse and the podiatrist, psychological aspects, and improvements in diabetic foot care. The final section addresses the medicolegal issues relevant to clinicians providing diabetic foot care. Numerous figures. Numerous tables. Numerous references.

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Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia. In: Narayan, P. Benign Prostatic Hyperplasia. London, England: Churchill Livingstone. 2000. p. 355-367.

Transurethral resection of the prostate (TURP) is a procedure used to prevent unnecessary damage to the bladder and kidneys of men with benign prostatic hyperplasia (BPH). This chapter on TURP in the clinical management of BPH is from a textbook that compiles data and commentary from the world's leading experts in this field. The author considers the indications for TURP; the need for informed consent, particularly addressing the potential problems of retrograde ejaculation and erectile dysfunction (impotence); contraindications to transurethral resection; patient preparation, including position on the operating table; equipment, including irrigating fluid, diathermy, avoiding deep venous thrombosis, and anesthesia; the techniques used for TURP, including preliminary cystourethroscopy, internal urethrotomy, preliminary diathermy of the prostatic arteries, finding the landmarks, resecting the left lateral lobe, the capsule, hemostasis, the second lateral lobe, completing the procedure, and catheterization; complications that may be encountered during the procedure, including hemorrhage, perforation, and erection; postoperative complications, including reactionary hemorrhage, secondary hemorrhage, the transurethral resection syndrome, and incontinence; and dealing with the long term aftermath of cardiac disease. Each step of the surgical procedure is illustrated with line drawings. 24 figures. 41 references.

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Vascular Access Procedures for American Indian Dialysis Patients. IHS Primary Care Provider. 25(10): 153-158. October 2000.

More than 300,000 patients are currently receiving treatment for chronic renal failure with chronic dialysis in the United States. Access complications are the leading cause for hospitalizations in this population. This article examines renal (kidney) failure and the complications of dialysis access in two groups of patients from two southwestern Native American tribes. As in the general population, comorbid conditions (illnesses in addition to the kidney disease) were common. In the group from Tribe A, 84 percent had diabetes and 97 percent had hypertension (high blood pressure). In the Tribe B group, 66 percent had diabetes and 80 percent had hypertension. Renal failure associated with diabetes mellitus and hypertension is largely preventable by maintaining strict control of serum glucose and blood pressure. There are three general treatment options for end stage renal disease (ESRD): no therapy (which results in death), peritoneal dialysis, and hemodialysis. In this article, the authors review results from 60 patients from Tribe A who had 81 primary dialysis access procedures over a 6 year period, and from 58 patients from Tribe B who had 94 primary dialysis access procedures over a three year period. The authors discuss the types of grafts and fistulas used, and the complications that can be encountered, including thrombosis (clotting), infection, and arterial insufficiency. In the groups covered in this paper, arteriovenous fistulas had a higher initial failure rate than PTFE (polytetrafluoroethylene) grafts in both patient populations, but those that last a year have longer patency than grafts. The primary and secondary patency rates for Tribe B are less than those for Tribe A patients for PTFE grafts. Radiologic thrombectomy with angioplasty has as good results as surgical revisions as a treatment for graft thrombosis. The authors conclude that early placement of access in patients with progressive ESRD reduces the need for temporary access procedures and may reduce the incidence of subclavian vein stenosis. 5 figures. 3 tables. 28 references.

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