Contemporary management and outcomes of infective tunnelled haemodialysis catheter-related right atrial thrombi: a case series and literature review
SINGAPORE MEDICAL JOURNAL
Authors: Yew, Min Sen; Leong, Andrew Michael Weng Meng
Abstract
INTRODUCTION Infective haemodialysis catheter-related right atrial thrombus (CRAT) is a complication of tunnelled catheter use. Management recommendations are based mainly on published case series prior to 2011. We report our institution's recent experience in managing infective haemodialysis CRAT and correlate treatment with outcomes. METHODS We conducted a retrospective analysis of haemodialysis CRAT cases diagnosed on transthoracic echocardiography between 1 January 2011 and 31 December 2017. Clinical outcomes, including mortality at 180 days post diagnosis and thrombus resolution, were traced from electronic medical records. RESULTS There were 14 cases identified. The median age was 59 (range 47-88) years and 11 (78.6%) were male. Sepsis was the most common reason for hospitalisation (71.4%). Blood cultures identified Staphylococcus aureus in seven cases, of which two were methicillin-resistant. Three had coagulase-negative Staphylococcus . All cases received antibiotics with infectious disease physician input. Seven were treated with catheter removal alone, of which three died within 180 days. Both cases treated with catheter removal plus anticoagulation survived at 180 days. Of the two cases who had anticoagulation without catheter removal, one died within 180 days and the other did not have thrombus resolution. Three underwent surgical thrombus removal, of which two died postoperatively and the last required repeated operations and prolonged hospitalisation. Mortality at 180 days post diagnosis was 42.9%. CONCLUSION Catheter removal and anticoagulation are modestly effective. Surgery is associated with poor outcomes. Despite contemporary management, infective haemodialysis CRAT still results in high mortality. Prospective studies are needed to identify the optimal management.
Distributional changes in gene-specific methylation associated with temperature
ENVIRONMENTAL RESEARCH
Authors: Bind, Marie-Abele C.; Coull, Brent A.; Baccarelli, Andrea; Tarantini, Letizia; Cantone, Laura; Vokonas, Pantel; Schwartz, Joel
Abstract
Temperature has been related to mean differences in DNA methylation. However, heterogeneity in these associations may exist across the distribution of methylation outcomes. This study examined whether the association between three-week averaged of temperature and methylation differs across quantiles of the methylation distributions in nine candidate genes. We measured gene-specific blood methylation repeatedly in 777 elderly men participating in the Normative Aging Study (1999-2010). We fit quantile regressions for longitudinal data to investigate whether the associations of temperature on methylation (expressed as %5mC) varied across the distribution of the methylation outcomes. We observed heterogeneity in the associations of temperature across percentiles of methylation in F3, TLR-2, CRAT, iNOS, and ICAM-1 genes. For instance, an increase in three-week temperature exposure was associated with a longer left-tail of the F3 methylation distribution. A 5 degrees C increase in temperature was associated with a 0.15%5mC (95% confidence interval (CI): -0.27, -0.04) decrease on the 20th quantile of F3 methylation, but was not significantly related to the 80th quantile of this distribution (Estimate:0.06%5mC, 95%Cl: -0.22, 0.35). Individuals with low values of F3, TLR-2, CRAT, and iNOS methylation, as well as a high value of IGAM-1 methylation, may be more susceptible to temperature effects on systemic inflammation. (C) 2016 Elsevier Inc. All rights reserved.