Zeev Korzets

Increased sodium concentrations in drinking water increase blood pressure in neonates.

Background In a previous study, we found that increased sodium concentrations in the drinking water led to an increase in mean arterial pressure (MAP) and systolic blood pressure (SBP) in fourth- and fifth-grade school children. Milk powder formulae have a low content of sodium, almost identical to that of breast milk. However, the final sodium concentration in the milk formula depends upon the concentration of sodium in the diluting water, which varies remarkably. Objective To evaluate changes in blood pressure during the first 2 months of life in neonates receiving low-sodium mineral water (LSMW), high-sodium tap water (HSTW), or breast milk. Design A randomized, prospective study in a teaching hospital. Methods Fifty-eight Jewish term infants maintained on milk formula were randomly assigned to two groups. Group 1 consisted of 25 infants whose formula was diluted with LSMW (Eden Spring Mineral Water) having a sodium concentration of 32 mg/l (1.4 mmol/l). Group 2 contained 33 infants whose formula was diluted with HSTW having a sodium concentration of 196 mg/l (8.5 mmol/l). Fifteen breastfed babies served as the control group (group 3). Weekly weight, height, head circumference, heart rate, and systolic (SBP), diastolic (DBP) and mean (MAP) blood pressures were recorded for each infant for 8 consecutive weeks after birth. After 8 weeks, group 1 reverted to a diet similar to that of group 2. At 6 months of age (week 24), a follow-up blood pressure measurement was performed in 11, 20 and seven infants in groups 1, 2 and 3, respectively. Blood pressure was measured during sleep. Urinary sodium : creatinine ratio was determined monthly during the initial 2 months. Results Increases in weight and height were equal in all groups. Heart rate did not differ between groups during the entire study period. From the age of 6 weeks until week 8, MAP, SBP and DBP were found to be significantly greater in the group 2 (HSTW). In parallel, the urinary sodium : creatinine ratio was significantly greater in this group. At week 24, blood pressure values in group 1 increased towards those of group 2. Conclusions Diluting milk formula with tap water containing a high concentration of sodium will result in the infant being fed a high-salt diet. To equilibrate with breast milk, formula should be diluted with low-salt water. Blood pressure in the neonate is increased by a high sodium intake via drinking water.

Acute brachial artery thrombosis as the initial manifestation of human immunodeficiency virus infection

Thrombosis of upper extremity arteries is most commonly due to atherosclerosis of the proximal subclavian artery, trauma, or catheter‐related injury. In the absence of an identifiable cause, a search for a hypercoagulable state is indicated. Hematologic manifestations of human immunodeficiency virus (HIV) infection and AIDS are frequent occurrences (Coyle TE. Med Clin N Am 1997;81:449–476). The most important of these are cytopenias (anemia, neutropenia, and thrombocytopenia). The incidence and severity of cytopenia are generally correlated to the stage of the HIV infection. In addition, various coagulation abnormalities have been reported in HIV‐infected patients. Apart from thrombocytopenia, these have included a prolonged APTT due to the presence of lupus anticoagulant, an increased prevalence of protein S and heparin cofactor II deficiency, and hypoalbuminemia‐related fibrin polymerization defects (Toulon P. Ann Bio Clin (Paris) 1998;56:153–160). HIV infection has also been associated with endothelial dysfunction. Although for the most part asymptomatic, elevated d‐dimer levels have been found in HIV‐infected patients, suggesting the existence of a prethrombotic state. In fact, clinical thrombosis eventuates in 2% of these patients (Toulon, 1988). Documented thromboses have involved both veins and arteries. We hereby present a patient who developed an acute thrombosis of his brachial artery as the initial manifestation of HIV infection. Am. J. Hematol. 64:137–139, 2000.

Successful treatment of Finnish congenital nephrotic syndrome with captopril and indomethacin

Two infants with biopsy-proven microcystic Finnish congenital nephrotic syndrome (onset at birth) were treated with a combination of captopril and indomethacin for 2 1/2 and 2 years, respectively; they had a marked reduction of urinary protein excretion without further need for albumin infusions. One infant has end-stage renal disease; the other infants glomerular filtration rate has remained within normal limits.

In vitro effect of advanced glycation end-products on human polymorphonuclear superoxide production

Background Advanced glycation end‐products (AGEs) are elevated in the sera of diabetic patients. The latter are prone to severe bacterial infections. Advanced glycation end‐products have been shown to modulate immune competent cell activities. In this study we examined the in vitro effect of advanced glycation end‐products on superoxide anion generation by human polymorphonuclear leukocytes.

Frequent involvement of the internal cuff segment in CAPD peritonitis and exit-site infection—an ultrasound study

BACKGROUND The extent of involvement of the subcutaneous Tenckhoff catheter tract in CAPD peritonitis and catheter-related infections is of major therapeutic importance. By definition, both peritonitis and exit-site infections do not involve the catheter tract. However, diagnosis of these infections as well as the more sinister tunnel infection is based mainly on clinical signs. METHODS We examined the usefulness of ultrasound examination (US) of the catheter tract in delineating catheter-related (exit-site and tunnel) infections, and their relationship to each other and to peritonitis. CAPD patients with no evidence of peritonitis or catheter-related infections for 6 months prior to examination served as controls. US were performed by one of two experienced radiologists using the Acuson 128XP/10 scanner with a 7-MHz linear transducer. A positive US was defined as an area of hypoechogenicity (indicative of fluid collection) >2 mm in width along any portion of the catheter tract. Findings were localized into segments(S) as follows: S1, limited to external cuff; S2, intercuff segment adjacent to the external cuff; S3, intercuff segment adjacent to the internal cuff; S4, limited to the internal cuff; and S5, involvement extending throughout the catheter tract. RESULTS Between March 1993 and January 1995, 39 CAPD patients, all with a double-cuff straight Tenckhoff catheter with the exit site situated above the point of entry into the peritoneum were studied. A total of 56 US were performed divided among 26 episodes of peritonitis, four tunnel infections, 13 exit-site infections,and 13 controls. There were 30 positive US distributed among 16 peritonitis, four tunnel, eight exit site infections and two control patients. The two positive controls went on to develop peritonitis within 1 month of the US. The majority of the US findings (13/16 in episodes of peritonitis and 5/8 exit site infections were localized to segment 4, that is, to the internal cuff region. Apart from a significant increase in width in all infected segments versus a normal tunnel, no differences in size were seen between peritonitis, exit-site, or tunnel infections, nor were there any differences in size and localization in these infections when comparing the offending organism (Gram-positive, negative, or culture negative). CONCLUSIONS We conclude that peritonitis and exit-site infections are frequently accompanied by involvement of the catheter tract. The localization of infection to the internal cuff region in cases of exit-site infection probably occurred as a result of downward migration along the catheter tract. This supports the notion that ideally the exit site should be pointing caudally or that the peritoneal catheter have a swan-neck configuration. With regard to peritonitis, infection within the peritoneal cavity appears to extend and involve the internal cuff region. Thus both the internal and external cuffs do not seem to pose an effective barrier against the spread of infection.. Based on our data, we recommend that US be performed as a routine investigation in all cases of exit-site infection and in cases of refractory or relapsing peritonitis.

Urinary Kallikrein in Normal Pregnancy, Pregnancy with Hypertension, and Toxemia

The 24-hour urinary excretion of kallikrein (K) and prostaglandin E2 (PGE2), which reflects their intrarenal synthesis, was measured in 7 normal women (NW), 10 women with essential hypertension (EH), 26 normal pregnant women (NP), 12 women with hypertension in pregnancy (HP), and 4 women with toxemia. All pregnant women were in the last trimester of their pregnancy (week 24-40). K was raised in NP (99.6 +/- 8.1 KU/24 h) and HP (106.5 +/- 8 KU/24 h) compared to NW (57 +/- 8.23 KU/24 h) (p less than 0.05). PGE2 excretion was decreased in EH (403.25 +/- 90.6 ng/24 h) compared to NW (508.6 +/- 80.26 ng/24 h). During pregnancy PGE2 was increased to 1,088 +/- 93.2 ng/24 h in NP and significantly more in HP, 1,885 +/- 40 ng/24 h (p less than 0.002). In this regard it differed from K. These data may suggest that, in addition to K, other factors (as angiotensin II and/or antidiuretic hormone) possibly activate renal PGE2 production in HP. In toxemia, K (23 +/- 6.1 KU/24 h) and PGE2 (583 +/- 172.83 ng/24 h) were markedly decreased. The above results suggest that the renal kallikrein-kinin and prostaglandin systems may play a role in sodium homeostasis during pregnancy. Their exact influence on the pathogenesis of hypertension in nonpregnant, pregnant, and toxemic subjects awaits further investigation.

Prevalence of cholelithiasis in non-diabetic haemodialysis and continuous ambulatory peritoneal dialysis patients

Haemodialyzed (HD) patients have been found to have an increased bile cholesterol level and an increased saturation index in bile. These changes were markedly enhanced in the presence of a low-protein diet. To evaluate whether such changes influence the prevalence of cholelithiasis in patients with end-stage renal failure, real-time sonography was performed to detect the presence of gallstones (GS) in 54 HD (28 males, 26 females, mean age 52.4 ± 15.4 years) and 39 continuous ambulatory peritoneal dialysis (CAPD; 22 males, 17 females, mean age 59.1 ± 14.9 years) patients. No patient had diabetes. The patients’ charts were reviewed for the following data: age, sex, primary renal disease, obesity (20% above ideal weight), history suggestive of gallbladder disease or previous cholecystectomy, duration of dialysis, and serum cholesterol levels. Overall, cholelithiasis was documented in 12 of 93 (12.9%) patients, 7 HD and 5 CAPD. When comparing the factors outlined above, no significant difference was found between HD and CAPD patient groups, either with or without cholelithiasis. Gallbladder disease was asymptomatic in all except 1 patient who required cholecystectomy. Using a healthy control group consisting of local age- and sex-matched inhabitants, GS were found in 8 of 134 (6%) of them (p > 0.05). We conclude that the prevalence rate of GS in our dialysis population (HD and CAPD) is similar to that of a local general population following a western-style diet, irrespective of dialysis mode.

Nonocclusive Mesenteric Infarction in Continuous Ambulatory Peritoneal Dialysis

Nonocclusive mesenteric infarction has recently been diagnosed with increasing frequency in dialysis patients. Although most reports have concerned patients on hemodialysis, the condition has also been reported to occur in patients on continuous ambulatory peritoneal dialysis. This report describes such a case developing in a woman whose end-stage renal failure was due to adult polycystic kidney disease. Associated predisposing factors were the presence of orthostatic hypoxemia, postural hypotension and extensive atheromatous changes of the abdominal aorta. In keeping with the known difficulty of establishing the diagnosis of mesenteric ischemia, the diagnosis in our patient was also delayed. She was initially thought to suffer from an episode of peritonitis and/or colonic perforation secondary to the performance of a cleansing enema. Only upon showing pneumatosis coli of the right colon on abdominal computerized tomography was the correct diagnosis made. Laparotomy revealed extensive necrosis of the ascending and transverse colon. A total colectomy and ileorectal anastomosis were performed. The patient died on the 17th day following surgery. This case serves to illustrate that mesenteric infarction should be considered in predisposed patients on continuous ambulatory peritoneal dialysis. The presence of peritonitis may mask the underlying pathology and waylay the unwary physician.

Delayed carotid artery rupture in advanced cervical cancer--a dilemma in emergency management.

Abstract Carotid artery rupture in the setting of advanced carcinoma of the head and neck constitutes a surgical emergency. This report details three such patients, two of whom presented with profuse bleeding, the other with imminent rupture. Notably, our first patient ruptured 27 years after having had radiotherapy for carcinoma of the larynx. This patient had had no previous surgery and at operation no recurrent tumor was evident. In the other two patients, previous surgery had demonstrated tumor invasion of the carotid artery. The choice of therapy in this calamitous condition is controversial, the question being whether to resect and reconstruct or ligate the ruptured artery. Our three patients underwent ligation with no recurrence of bleeding and no neurological sequelae for a follow-up period of 5–36 months. Of paramount importance is the hemodynamic stabilization of the patient prior to being submitted to surgery. Our results favor ligation rather than resection and reconstruction as the procedure of choice in this difficult predicament.

Increased prevalence of HCV antibodies in dialyzed Ashkenazi Jews—a possible ethnic predisposition

BACKGROUND The prevalence of hepatitis C (HCV) antibodies in dialysis patients is considerably higher than that found among healthy blood donors. This increased seroprevalence has been correlated to increased duration of dialysis, mode of dialysis and to the number of blood transfusions administered. However, factors other than nosocomial ones also seem to play a part in disease transmission. The role of the patients ethnic origin, possibly reflecting on his/her genetic makeup has received scant attention. In this study, HCV seroprevalence in our dialysis population, which consists of three major ethnic subgroups (Ashkenazi Jews, Sephardi Jews and Arabs), was examined. METHODS AND RESULTS Altogether HCV seropositivity was determined in 120 dialysed patients--65 males/55 females (76 hemodialysis, 44 CAPD), using second generation ELISA confirmed by RIBA-2. Mean age was 59.7 +/- 15.7 (range 16-86 years). Patients had to have been on dialysis for a minimum of 3 months (mean duration 45.2 +/- 44.5 months). Patients whose end-stage renal disease was due to diabetic nephropathy (DN) or those who had previously been transplanted (TP) were considered as separate groups and compared to the group as a whole. Of the 120 patients, there were 49 Ashkenazi Jews (40.8%), 57 Sephardi Jews (47.5%) and 14 Arabs (11.7%). Overall HCV prevalence was 21.7% (26/120) with a significantly greater prevalence in HD compared to CAPD (30.3 vs. 6.8%, P < 0.01). Respective values for Ashkenazi Jews, Sephardi Jews and Arabs were 30.6, 15.8, and 14.3% (P < 0.01, Ashkenazi Jews vs. Sephardi Jews and Arabs). DN had a lower 3.7% while TP had a higher 46.1% prevalence compared to the group as a whole (P < 0.01). In general, the increased frequency of anti HCV antibodies was significantly correlated to the duration of dialysis and the number of blood transfusions administered. This, however, was not the case in the greater prevalence of HCV found in Ashkenazi Jews compared to Sephardi Jews and Arabs which was independent of the above factors and the mode of dialysis. CONCLUSION Our results showing increased HCV seropositivity in Ashkenazi Jews compared to Sephardi Jews and Arabs, suggest that ethnic factors might predispose to HCV transmission and infectivity.