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Biomedical subjects

D S David

Publications and source records attributed to D S David.

At least 19 recordsLinked to original sources
PubMed1998

Acute vascular rejection: a clinical and morphological study.

We analyzed one special type of acute vascular rejection (AVR), defined as fibrous thickening of the arterial intimal layer that leads to early renal failure. Twenty-one patients who presented this histological pattern were studied among 339 transplanted over 4 years. Patients were separated into two groups. Thirteen patients have restained their kidneys (Group A, 61.9%) and 8 have lost their grafts (Group B, 38%). Diagnosis was made on average 430. POD in GA and at 49 degrees POD in GB on the 43rd postoperative day in group A and on the 49th postoperative day in group B (NS). In group A, mean serum creatinine is 2.2 mg/dl and follow-up time is 29 months. Oliguria was much more frequent in group B (75% versus 15.3%, P = 0.01). These patients were submitted to 91 renal biopsies always because of non-function. Typical vascular lesions began at arcuate arteries and progressed, as seen in sequential biopsies, to interlobular arteries and arterioles. When only arcuate arteries were affected, 22.5% of renal losses were seen, but when arcuate plus interlobular arteries were compromised, 72.2% of patients lost their kidneys (P = 0.006). We did not identify any difference in immunofluorescent staining from biopsies with or without vascular rejection, or between groups A and B. We concluded that about 2.3% of our patients lost their kidneys because of this kind of AVR, diagnosed near the 43rd postoperative day. The only clinical predictive sign of poor reversibility was oliguria. The attack on arcuate plus interlobular arteries meant a poor prognosis. Immunofluorescent staining did not have a prognostic value.

Acute Disease↗
PubMed1998

Post-transplant neutrophilic interstitial nephritis--an important cause of graft dysfunction.

Post-transplant neutrophilic interstitial nephritis (NIN) is characterized by an interstitial infiltrate consisting of polymorphonuclear cells that leads frequently to acute graft dysfunction. In 220 graft biopsies performed because of renal dysfunction over 2 years in our unit, 11 (5%) diagnoses of NIN were made. Only two patients had chronic pyelonephritis as original disease. Four patients had urological problems before transplantation. After transplantation, five patients had urinary tract infection, one had urethral stenosis, two had vesicourethral reflux and one patient had a perinephritic abscess. Seven patients had fever (63%). Only in six patients did urine culture lead to microorganism isolation. After 6 months, only two patients had a serum creatinine level < 1.4 mg/dl, five patients had abnormal function, three had lost their grafts, and one patient had died with sepsis. We conclude that 5% of the biopsies performed in our center disclosed NIN, an entity that causes graft dysfunction and progresses frequently to chronic renal failure. In some cases, no infectious etiology could be detected.

Female↗
PubMed1998

Visceral varicella-zoster after bone marrow transplantation: report of a case series and review of the literature.

OBJECTIVES: Infection with varicella-zoster virus after bone marrow transplantation (BMT) is a common cause of morbidity and mortality. Visceral involvement with varicella-zoster may be incorrectly ascribed to graft-versus-host disease, resulting in delayed diagnosis and misguided therapy. METHODS: A 4-yr retrospective chart review was performed to determine the presenting symptoms and clinical outcome of visceral varicella-zoster virus infection in BMT recipients. RESULTS: Ten BMT recipients who subsequently developed visceral varicella-zoster virus infection were identified. The mean age at diagnosis was 40 yr (range 27-56 yr). Primary hematological malignancies were leukemia (N = 7), myelodysplasia (N = 2), and myelofibrosis (N = 1). Bone marrow transplants in affected patients were autologous (N = 2), related allogeneic (N = 5), or matched unrelated allogeneic (N = 3). The mean time interval from BMT to symptomatic visceral varicella-zoster virus infection was 153 days (range 60-280 days). Presenting symptoms included abdominal pain in all patients, nausea (60%), fever > 38 degrees C (60%), vomiting (50%), pneumonitis (50%), skin rash (40%), and diarrhea (30%). All patients had moderately or profoundly elevated aminotransferases and most had elevated pancreatic enzymes (80%). The mean time interval from the development of abdominal pain to the characteristic skin rash and then diagnosis was 6 and 7 days, respectively (range 4-10 and 4-14 days). Active graft-versus-host disease had previously been documented in five of the eight allogeneic BMT recipients. Immunosuppressive medications were increased at the onset of the abdominal pain in seven of these eight patients for suspected exacerbation of graft-versus-host disease. After recognition of varicella infection, antiviral therapy was promptly initiated; despite this, mortality was still 50%. CONCLUSIONS: Visceral involvement with varicella-zoster virus infection can occur as a late complication after both allogeneic and autologous BMT. In these cases, symptoms of severe abdominal pain with associated nausea, vomiting, and diarrhea and elevated liver and pancreatic enzymes preceded the vesicular skin eruption and were confused with graft-versus-host disease. With the increasing application of high-dose chemotherapy followed by stem cell rescue for both hematological and solid tumors, clinicians should be aware of this potentially treatable and often lethal complication.

Adult↗
PubMed1994

Long term results of subtotal parathyroidectomy in patients with end-stage renal disease.

This is a retrospective, clinical study evaluating the long-term outcome of subtotal parathyroidectomy (PTX) in 60 patients with chronic renal failure and severe secondary hyperparathyroidism. Patients were 41 +/- 2 years old (mean +/- SE) at the time of PTX, and followed for 69 +/- 6 months since the procedure. At the time of PTX, three patients had chronic renal failure, 53 had been on chronic hemodialysis, and four had received successful kidney transplants. In more than 80 per cent of patients, symptoms of hyperparathyroidism (bone pain and muscle weakness) resolved within weeks, and biochemical signs (hypercalcemia, and high plasma alkaline phosphatase and parathyroid hormone concentrations) returned to normal ranges within a year. Subperiosteal resorption, bone fractures, and soft tissue calcification frequently improved. Osteosclerosis (rugger-jersey spine), cystic bone changes, osteopenia, and vascular calcifications were, however, often unchanged or progressive. Five patients (8%) who had either persistent or recurrent hyperparathyroidism required additional surgical procedures, and two had subsequent improvement. Twelve patients who had aluminum associated bone disease diagnosed later continued to progress with a high incidence of bone fractures and severe osteopenia. Cystic bone changes, especially of the carpal bones, in association with carpal tunnel syndrome, probably representing amyloid bone disease, also did not respond to PTX. In conclusion, PTX is an effective surgical procedure to reverse complications of hyperparathyroidism in patients with end-stage renal disease, provided that other causes of osteodystrophy, such as aluminum or amyloid-associated bone diseases, are adequately excluded. We feel that subtotal PTX, leaving a small remnant in place, is the procedure of choice.

Adolescent↗
PubMed1992

Medical malpractice: a nonadversarial suggestion.

BACKGROUND: The current legal system for prosecuting medical malpractice claims has bred widespread discontent. It has increased costs, jeopardized the delivery of necessary medical services, and corroded the physician-patient relationship with mistrust and poor morale. METHODS: Analysis of fairness of compensation awards and deterrence of substandard medical services under the current system. RESULTS: Compensation awards are inconsistent and unfairly contingent on irrational, adventitious factors. The current system does not seem to have had a significant effect on detering poor medical practice or on improving medical practice in general. CONCLUSIONS: An alternative to the current litigation-oriented medical malpractice system should be established and centered around a four-member Medical Malpractice Tribunal composed of a general physician, an expert physician in the specialty area of the claim, an attorney, and a lay person. This tribunal would be empowered to investigate malpractice claims by gathering evidence and taking testimony from parties, experts, and witnesses. The tribunal could employ a table of treatment-related injuries in making findings as to physician liability and victim compensation. Such a system, through predictability, would likely increase malpractice prevention while decreasing legal costs and also costs associated with defensive medicine. Deterrence could be served by giving the tribunal power to recommend sanctions against substandard providers to appropriate licensing and disciplinary bodies and by requiring those found guilty of malpractice to contribute subsidies to a compensation fund.

Insurance, Liability↗
PubMed1980

HLA-A28 and steroid-induced diabetes in renal transplant patients.

Between July 1971 and March 1977, steroid-induced diabetes (SD) developed postoperatively in 31 (10.8%) of 286 nondiabetic adult kidney transplant recipients who were observed for a total of 410 patient transplant years. There was a highly significant association between HLA-A28 and SD. There was no significant association between SD and BB or Bw 15. Age was also associated with SD. However, A28 was associated with SD even when corrected for age. A28 occurred more frequently in blacks than whites, 25.4% and 6.3%, respectively, and accounted for the higher incidence of SD in black adults. There were no significant associations between SD and patients' sex, donor source, number of short-term rejection treatments, or maintenance dose of corticosteroids. Steroid-induced diabetes had no adverse effects on graft or patient survival.

Adult↗
PubMed1979

Parainfluenza type 3 in a transplant unit.

We observed an epidemic of parainfluenza type 3 viral infection in a renal transplantation service among 16 recent transplant recipients. To assess the effect of infection on transplant function, we retrospectively compared the infected patients with a matched, uninfected control group. In addition to symptoms of a mild upper respiratory tract infection associated with the epidemic, there was an increase in the frequency of acute rejection episodes during the period of infection in the infected group. Nevertheless, outcome in terms of patient and graft survival at six months was not affected when compared with the survival rates of the control group.

Acute Disease↗
PubMed1978

Eye findings in the diagnosis of Fabry's disease. Patients with renal failure.

Two patients underwent renal transplantation for what was thought to be glomerulonephritis and chronic pyelonephritis. The diagnosis of Fabry's disease was made as an incidental finding during an ophthalmologic consultation for evaluation of blurred vision. These two cases illustrate the usefulness of an eye examination in the correct diagnosis in patients with the multisystem complaints of Fabry's disease. The correct diagnosis was extremely important in understanding the other manifestations of this disease in the affected patient and in the genetic counseling of the family.

Adult↗
PubMed1978

Pharmacokinetics of essential amino acids in chronic dialysis-patients.

Possible disorders of essential amino acid (EAA) metabolism in maintenance dialysis patients (D) were studied by measuring plasma amino acids before and sequentially after administering a mixture of 8 EAA po and iv. The EAA were in a ratio similar to that required for optimal utilization, and the total dose given was within physiological range. Ten D and six normals (N) received 150 mg/kg po as a 10.5 g/dl solution and 117 mg/kg iv as a 5.1 g/dl solution infused at a constant rate of mg/kg per min. Blood glucose and immunoreactive insulin were also measured. Both D and N were postabsorptive and at least 18 hr postdialysis. The fraction of the oral dose appearing in the systemic circulation was variable for each EAA in both N and D. Total body clearance was significantly lower in D (P less than 0.05) for theronine, phenylalanine, valine, leucine, and isoleucine, and this difference could not be explained by changes in renal excretion. The apparent volume of distribution did not differ between N and D for all EAA except for valine and phenylalanine. Blood glucose insulin varied only slightly in both N and D for all EAA except for valine and phenylalanine. Blood glucose and insulin varied only slightly in both N and D. These studies indicate that there are a variety of significant abnormalities in the metabolism of specific EAA in D. Decreased total body clearance of the branched-chain amino acids, since they are primarily metabolized total body clearance of the brnached-chain amino acids, since they are primarily metabolized by muscle, may result from a defect in muscle metabolism in D.

Administration, Oral↗
PubMed1978

Endophthalmitis following staphylococcal sepsis in renal failure patients.

Endophthalmitis occurred three months following completion of therapy for documented staphylococcal septicemia in two patients on long-term hemodialysis. The indolent course of the endophthalmitis, and its excellent response to systemic and subconjunctival antibiotics and subconjunctival and topical corticosteroid therapy, suggest the possibility that the acute fulminating clinical course of metastatic bacterial endophthalmitis may be modified in this population of patients. The reason for this modified clinical picture is probably the immune incompetence associated with uremia, which favors both the development of metastatic endophthalmitis as well as altering its clinical presentation. While funduscopic examination is suggested in all dialysis patients with eye complaints, this procedure becomes mandatory following episodes of sepsis.

Adult↗
PubMed1978

Acute corneal calcification.

This case report describes acute unilateral calcium deposition in the central cornea of a uremic patient with corneal exposure. A mechanism of calcium deposition is discussed. It is suggested that a high calcium-phosphorus product, combined with local factors secondary to injury of the exposed corneal epithelial cells, helped to trigger rapid and dense calcification. Details of the removal technique are presented. Constant irrigation of freshly prepared chelating agent combined with vigorous and frequent massage of residual deposits is necessary to completely remove dense concentrations of calcium.

Acute Disease↗
PubMed1976

Essential amino acid metabolism in maintenance dialysis patients.

Oral and I.V. administration of a mixture of essential amino acids to normal and dialysis patients revealed: 1. First pass metabolism (FPM) occurred for all administered amino acids in both normal and dialysis patients, and was variable in both populations. however, FPM appeared lower for phenylalanine and higher for methionine in the dialysis group. 2. Net metabolic clearance rate was significantly lower (p less than 0.05) for leucine, isoleucine, threonine and phenylalanine, and tended to be lower for valine and lysine in the dialysis group. 3. With the exception of phenylalanine and valine the apparent volume of distribution did not differ between normals and maintenance dialysis patients. 4. These studies indicate the existence of a variety of significant abnormalities in the metabolism of specific essential amino acids, and suggests a defect in muscle metabolism of branched-chain amino acids in maintenance dialysis patients.

Administration, Oral↗