Robert T. Mcmillan

Preoperative vancomycin prophylaxis decreases incidence of postoperative hemodialysis vascular access infections

The role of vancomycin in the treatment of infected arteriovenous chronic dialysis access is well established. However, the role of preoperative vancomycin administration in preventing infection in newly placed, revised, or surgically thrombectomized grafts has not been determined. We performed a prospective randomized study to examine whether vancomycin prophylaxis can decrease the incidence of postoperative graft infections. Over a 5-year period, 206 patients undergoing 408 permanent vascular access procedures were randomized into two groups. Group 1 (206 procedures) received a single intravenous dose of 750 mg of vancomycin approximately 6 to 12 hours before vascular access placement procedures, while group 2 (202 procedures) did not. Patients were evaluated for access infection within the following 30 days and before use of the access for chronic dialysis. Access infection developed in two patients (1%) in group 1 and in 12 patients (6%) in group 2 (P = 0.006). All 14 infections occurred in upper extremity polytetrafluoroethylene grafts. We conclude that the use of preoperative single-dose intravenous vancomycin prophylaxis for hemodialysis vascular graft procedures reduces the risk of postoperative access infection.

Factors affecting germination and stand establishment ofphyllanthus Amarus (Euphorbiaceae)

Interest inPhyllanthus amarus (Euphorbiaceae) has been generated by reports of antiviral activity and wide usage in traditional medicine. Attempts at cultivation resulted in poor stands. The objectives of these studies were to determine the effects of light, storage temperature, age of seeds, time ofdehiscence, and a scarification procedure on the germination ofP. amarus. Seeds ofP. amarus require light to germinate, and thus should not be covered at sowing. Freezing did not significantly affect the germination of dry seeds compared to seeds stored at ambient room temperature or higher, but storage at 10°C was deleterious. Percent germination was typically less than 50% and significantly decreased with time. Germination of freshly harvested seeds was slower than older seeds. Seeds from the first capsules to dehisce had a higher percent germination. A scarification procedure rendered seeds inviable. These results helped explain poor stands seen infield plots. In a previously planted plot, the re-established stand by natural reseeding was equivalent to that following intentional reseeding procedures.RésuméSegún se ha informado el interés en cuanto a Phyllanthus amarus (Euphorbiaceae) es debido a su actividad antiviral y su uso en la medicina tradicional. Al intentar su cultivo, la post-germinación fue menos de lo esperado. Los objetivos de estos estudios fueron probar los efectos de la luz, la temperatura de almacenamiento, la edad de las semillas, el periodo de la apertura de las cápsulas conteniendo las semillas y un procedimiento de escarificación en la germinación deP. amarus. Las semillas deP. amarus necesitan luz para germinar; es por eso que no se las debe cubrir al sembrar. Temperaturas de congelamiento no afectaron significativamente la germinación de las semillas secas al compararlas con las semillas mantenidas bajo temperatura ambiental o más aha, pero sin embargo el almacenamiento a 10°C sí afectó severamente la viabilidad. El porcentaje de viabilidad por lo general fue bajo, generalmente menos de 50%, y disminuyó con el tiempo. Las semillas nuevas germinaron más lentas que las semillas más viejas. Las primeras semillas que salieron de las cápsulas mostraron un mayor porcentaje de germinación. El procedimiento de escarificación que seprobó dio semillas inviables. Estos resultados ayudan a explicar la baja post-germinación observada en el campo. En terrenos anteriormente sembrados, la post-germinación de siembra natural fue equivalente a los procedimientos intencionales de siembra.

LIVER TRANSPLANTATION : WHEN IS IT INDICATED AND WHAT CAN BE EXPECTED AFTERWARDS ?

Preview How many months of documented abstinence are required before a patient with alcoholic cirrhosis can be considered for liver transplantation? What is the role of liver transplantation as treatment for primary hepatocellular cancer? What are the possible causes of elevated liver enzyme levels following transplantation? Which patients with neurologic injury are potential organ donors? The authors answer these and other questions primary care physicians may have about this lifesaving procedure.

Kidney Outcomes in Patients with Liver Cirrhosis and Chronic Kidney Disease Receiving an Orthotopic Liver Transplant Alone

Kidney transplant in patients with liver cirrhosis and nondialysis chronic kidney disease (CKD) is controversial. We report 14 liver cirrhotic patients who had persistently low MDRD‐6 estimated glomerular filtration rate (e‐GFR) <40 mL/min/1.73 m2 for ≥3 months and underwent either liver transplant alone (LTA; n=9) or simultaneous liver‐kidney transplant (SLKT; n=5). Pretransplant, patients with LTA compared with SLKT had lower serum creatinine (2.5±0.73 vs 4.6±0.52 mg/dL, P=.001), higher MDRD‐6 e‐GFR (21.0±7.2 vs 10.3±2.0 mL/min/1.73 m2, P=.002), higher 24‐hour urine creatinine clearance (34.2±8.8 vs 18.0±2.2 mL/min, P=.002), lower proteinuria (133.2±117.7 vs 663±268.2 mg/24 h, P=.0002), and relatively normal kidney biopsy and ultrasound findings. Post‐LTA, the e‐GFR (mL/min/1.73 m2) increased in all nine patients, with mean e‐GFR at 1 month (49.8±8.4), 3 months (49.6±8.7), 6 months (49.8±8.1), 12 months (47.6±9.2), 24 months (47.9±9.1), and 36 months (45.1±7.3) significantly higher compared to pre‐LTA e‐GFR (P≤.005 at all time points). One patient developed end‐stage renal disease 9 years post‐LTA and another patient expired 7 years post‐LTA. The low e‐GFR alone in the absence of other markers or risk factors of CKD should not be an absolute criterion for SLKT in patients with liver cirrhosis.