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300 Section 14: Lymphology
lymphatic trunks and aids in differentiating various possible causes of lymphatic obstruction in
secondary lymphedema. Magnetic resonance imaging lymphography (MRL) with intracutaneous administration of an MR contrast agent allows for assessment of both superficial and deep
lymphatic channels. However, interpretation of MRL may be compounded by venous uptake of
a gadolinium-based agent. The differential diagnosis includes lipedema, a type of lipodystrophy
which results in uniform and symmetrical enlargement in both lower extremities but there is
sparing of the feet. Systemic causes such as hepatic failure, renal failure, congestive heart failure, constrictive pericarditis, hypoproteinemia, malnutrition, and myxedema can also lead to
leg swelling. Chronic venous insufficiency with venous stasis manifests as hemosiderin deposits
in the skin, which leads to brownish pigmentation near the ankle. In contrast to lymphedema,
which is painless (unless there is an associated infection), venous hypertension results in
significant pain and venous claudication manifested as throbbing pain when walking. Chronic
inf lammation in subcutaneous tissue in patients with venous insufficiency may cause destruction of lymph channels with a mixed picture of venous and lymphatic edema.
Correct Answer B MRI
Reference
Mills, M., van Zanten, M., Borri, M., et al. (2021). Systematic review of magnetic resonance ly mphangi-
ography from a technical perspective. J Magn Reson Imaging, 53(6), 1766–1790. PMID: 33625795
15. RATIONALE
Conservative management of lymphedema can be burdensome, and the main reason for failure
is the need for lifelong treatment which can lead to noncompliance. Attention to daily skin
hygiene on the part of patient i.e., washing limbs regularly with soap and avoiding trauma,
as this can be a potential source of infection. Patients with a history of fungal infection such
as Candida and Tinea should be treated with topical antifungal medications like miconazole
cream or clotrimazole cream. Walking and performing exercises such as aerobic exercises augment lymphatic flow. Exercise helps to decrease the swelling from lymphedema. During muscle
contraction, the lymph flow is propelled to an alternative lymph node via the lymphatic vessels.
Lymphatic circulation is not driven by a central pump such as the heart. Exposure to cold or
heat should be avoided. Diuretics have a very limited role in the management of lymphedema,
as they can worsen the condition by increasing the concentration of interstitial proteins.
Correct Answer D Daily hygiene and skin care, weight loss, and aerobic exercises
Reference
Baddour, L. M. (2000). Cellulitis syndromes: an update. Int J Antimicrob Agents, 14(2), 113–116. PMID:
10720800
16. RATIONALE
Complex decongestive therapy should be the first line of therapy for stage II and stage III
lymphedema. It is a multimodal approach for the management of lymphedema. The program
combines four main elements: Compression therapy, manual lymphatic drainage (MLD),
exercise, and skin care. CDT can acutely reduce limb volume and provide long-term benefits
through the acceleration of lymph drainage in the edematous limb and the dispersal of accumulated protein. CDT is administered in two phases: An intensive initial reductive phase and
Section 14: Lymphology 301
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a maintenance phase. CDT is labor intensive and is effective for both primary and secondary
lymphedema and can be used in both children and adults. Manual lymphatic drainage is safe
and beneficial when combined with compression bandaging. Its benefit is more pronounced in
patients with mild-to-moderate lymphedema. Each session usually takes 40–60 minutes and
should be performed by a physical therapist with specialized training. Massaging techniques
using low pressure (30–40 mmHg) and low frequency are intended to enhance lymphatic contractility and redirect lymph flow through the non-obstructed cutaneous lymphatics. During
the initial phase of CDT, non-elastic, high-grade (40–80 mmHg) compressive wrappings should
be applied after each session of manual lymphatic drainage to prevent reaccumulation of fluid
and to promote lymph flow.
Correct Answer D Stage II and III lymphedema
Reference
Finnane, A., Janda, M., & Hayes, S. C. (2015). Review of the evidence of lymphedema treatment effect.
Am J Phys Med Rehabil, 94(6), 483–498. PMID: 25741621
17. RATIONALE
In the initial phase of CDT a multilayer low-stretch bandage can be left on the affected area
overnight for 24 hours. The multilayer bandage consists of a single protective layer of cotton
bandage next to the skin and a soft synthetic wool (or foam) underpadding. Compression is
provided by an outer layer of at least two short-stretch extensible bandages. The compression
garment must be continuously used during the day and removed at night as long as the legs
are kept elevated. They should have graduated compression that increases from the distal to
proximal segment. A minimum pressure of 40 mmHg is required for compression. Garments
should preferably be custom fit and need to be replaced in 3–6 months, as they may lose their
elasticity. Pneumatic compression devices surround the limb with a sleeve containing air-filled
chambers. The chambers are gradually filled with air to provide active sequential compression
from distal to proximal and should be used for at least 2 hours daily. The advanced pneumatic
compression device (APCD) delivers programmable external pneumatic compression though
multiple inflatable compartments. APCDs are designed for home use and are intended to
stimulate the labor-intensive MLD performed by the physical therapist.
Correct Answer D Improvement of the lymphatic flow and venous return, reduction of accumulated protein debris and decreased volume, and maintenance of skin integrity
Reference
Karaca-Mandic, P., Hirsch, A. T., Rockson, S. G., & Ridner, S. H. (2015). The cutaneous, net clinica l, and
health economic benefits of advanced pneumatic compression devices in patients with lymphedema. JAMA Dermatol, 151(11), 1187–1193. PMID: 26444458
18. RATIONALE
In lymphovenous anastomosis (LVA), subdermal lymphatics are anastomosed to adjacent
venules using indocyanine green near-infrared lymphangiography to visualize fluorescent
images and mark visible lymphatic pathways and incision sites. Lymphazurin is injected into
the web spaces in the extremity (feet); the next step is to take down the subdermal postobstruction dissection down to venous and lymphatic channels. Use of microsurgical
302 Section 14: Lymphology
connection to reestablish lymph flow with end-to-end anastomosis is next. End-to-side anastomosis can be used when veins are larger than the lymphatic channels. The patency of the shunt
is confirmed by the presence of Lymphazurin into the vein. In a series of 100 patients undergoing LVA, improvement of symptoms was noted in 96% of patients with improvement in volume
deferential in 74%.
The effectiveness of vascularized groin lymph node transfer (VLNT) is based on: The lymphatic
“wick” of the bridge of proximal and distal lymphatic vessels in the recipient site and lymphangiogenesis is stimulated by growth factors produced by the lymph nodes; and the lymphatic
“pump” which stems from lymphovenous communication with the lymph nodes of the transferred f lap. During vascularized groin lymph node transfer, an elliptical skin paddle from the
lateral to femoral pulse is harvested with the superficial circumflex iliac vessels at the recipient
site using a transverse incision, and a microvascular anastomosis to the recipient artery and
vein is performed. VLNT results in improvement in swelling in 86%–90% of patients with volume difference on an average of 22%.
Correct Answer D LVA and VLNT are effective in early stages of lymphedema and debulking
procedures in the later stages with a combination of conservative therapy immediately after any
surgical procedure
Reference
Campisi, C., & Boccardo, F. (2004). Microsurgical techniques for lymphedema treatment: derivative
lymphatic-venous microsurgery. World J Surg, 28(6), 609–613. PMID: 15366754
19. RATIONALE
Surgical circumferential liposuction has been introduced during the last 3 decades for postmastectomy lymphedema and is useful in addressing large adipose tissue deposits. It is safe
and quick and allows for immediate decrease in volume and pressure of the lymph fluid, thus
promoting better lymphatic flow. It is usually indicated when excess volume is greater than
500 mL. Contraindications include metastatic disease, open wound, presence of more than
pitting edema, and coagulation disorders. Risks include lidocaine toxicity, fat emboli,
hematoma, and seroma. Excess volume reduction of 96.6% has been reported.
The Charles procedure is an aggressive approach including radical excision of the skin and subcutaneous tissue down to muscle fascia. The excised skin is used for grafting on the fascia, or
other donor sites can be used. This approach is indicated for severe cases and carries a high risk
of complications including infection, ulceration, hyperpigmentation, and unstable scar.
The Sistrunk procedure is a planned, staged excision of the affected subcutaneous tissue and
involves burying dermal flaps within the skin flaps. Long-term results indicate a reduction of
at least half of the affected tissue in 76% of patients. Groin lymph node dissection can result in
secondary lymphedema.
Correct Answer D Groin lymph node dissection
Reference
Chang, D. W., Masia, J., Garza, R., et al. (2016). Lymphedema: surgical and medical therapy. Plast
Reconstr Surg, 138(3 Suppl), 209s–218s. PMID: 27556764
SECTION 15: DIALYSIS ACCESS
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MCQs 1–34
Q1. According to the Centers for Medicare
and Medicaid Services, the percentages
of patients using a tunneled hemodialysis
catheter as their primary vascular access
is approximately:
A. 10%
B. 15%
C. 20%
D. 25%
Q2. The desired blood flow rate for hemo-
dialysis treatment with a hemodialysis
catheter is:
A. 200–250 cc
B. 250–300 cc
C. 300–500 cc
D. Greater than 500 cc
Q3. The hemodialysis nurse reports an inad-
equately functioning tunneled catheter
placed 6 weeks earlier. Cath flow (tPA)
was unsuccessful. The next best
option is:
A. Chest X-ray to determine the position of
the tip of the catheter and to rule out a
kink in the catheter
B. Insert a new catheter on the contralateral
side
C. Reverse the blood lines
D. Schedule a tunneled hemodialysis cath-
eter exchange in the intervention suite
Q4. The suboptimal rates of blood flow in tun-
neled hemodialysis catheters have been
reported in:
A. 20% of patients
B. 25% of patients
C. 30% of patients
D. 35% of patients
Q5. The incidence of hemodialysis access
infection per 100 patients is highest in:
A. Autologous fistula
B. Prosthetic graft
C. Non-tunneled hemodialysis catheter
D. Tunneled hemodialysis catheter
Q6. The National Kidney Foundation Kidney
Disease Outcomes Quality Initiative
(NKFKDOQI) states all of the following
except:
A. Arteriovenous fistulas have the lowest
rate of thrombosis and require the fewest
interventions
B. Cost of AV fistula use and maintenance is
the lowest
C. Fistulas have the highest rates of infection
D. Fistulas are associated with the highest
survival and lowest hospitalization rates
Q7. Vascular hemodialysis access is impli-
cated in what percentage of all bacteremias in patients on hemodialysis:
A. 20%–33%
B. 30%–40%
C. 40%–63%
D. 48%–73%
Q8. Management of catheter-related bacte-
remia is initial empiric antimicrobial
therapy followed by:
A. Catheter removal with immediate
replacement
B. Catheter exchange over a guide wire in
the same tunnel
C. Catheter exchange over a guide wire with
creation of a new tunnel
D. Catheter removal with delayed replace-
ment after defervescence in patients with
severe clinical symptoms
DOI: 10.1201/9781003389897-15
304 Section 15: Dialysis Access
Q9. The incidence of 30-day graft infection
rate with use of a PTFE conduit for an AV
graft is:
A. Less than 1%
B. 1%–3%
C. 4%–5%
D. 6%
Q10. Diagnosis of dialysis access (fistula/graft)
infection is usually made by:
A. Tagged leukocyte scan
B. Duplex ultrasound
C. CT scan
D. Clinical exam
Q11. Autologous AV access infection localized to
the access site in patients undergoing hemodialysis should initially be treated with:
A. Removal of AV access and immediate
tunneled hemodialysis catheter insertion
B. Removal of AV access and delayed
(2–3 days) placement of tunneled
hemodialysis catheter
C. Antibiotics
D. Conversion of autologous AV access to
AV graft
Q12. The HeRO graft is relatively contraindicated
in patients with all of the following except:
A. Inflow artery diameter less than 3 mm
B. Systolic blood pressure less than 100 mmHg
or ejection fraction less than 20%
C. Active infection
D. Prior multiple upper extremity access
procedures
Q13. A radial artery-cephalic vein direct wrist
access fistula (Brescia Cimino) has a
2-year patency of:
A. 50%–60%
B. 55%–89%
C. 60%–95%
D. 65%–95%
Q14. The most common cause of failure of arte-
riovenous fistula and arteriovenous grafts
for hemodialysis access is:
A. Low ejection fraction
B. Arterial inflow occlusive disease
C. Venous outflow obstruction
D. Use of inadequate vein for fistula creation
Q15. The most common site of stenosis in the
dialysis circuit is:
A. At the needle insertion
B. Central outflow tract
C. Arterial inflow tract
D. Venous outflow tract adjacent to the
anastomosis
Q16. The best test for the diagnosis of a stenosis
in a hemodialysis circuit is:
A. Duplex ultrasound
B. Fistulogram/shuntogram
C. CTA
D. Catheter-based arteriography
Q17. The most prevalent time for neointimal
hyperplasia in dialysis access fistula/graft
occurs in:
A. Within a few weeks of index operation
B. Within 3 months of index operation
C. Within first year of index operation
D. Within first 2 years of index operation
Q18. The most important reason for thrombo-
sis of the hemodialysis access-fistula/
graft is:
A. Hypercoagulability
B. Vessel injury resulting in endothelial
dysfunction
C. Patients with diabetes mellitus
D. Significant stenosis secondary to neo-
intimal hyperplasia at the venous
anastomosis
Q19. The following statement best reflects
the results of percutaneous versus open
surgical thrombectomies for thrombosed
hemodialysis access:
A. Percutaneous thrombectomies have
a higher rethrombosis rate but better
assisted primary patency rate than open
surgical thrombectomies
B. Percutaneous thrombectomies have
a lower rethrombosis rate but worse
assisted primary patency rate than open
surgical thrombectomies
C. Percutaneous thrombectomies have
a lower rethrombosis rate and better
assisted primary patency rate than open
surgical thrombectomies
Section 15: Dialysis Access 305
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D. Percutaneous thrombectomies have
a higher rethrombosis rate and worse
assisted primary patency rate as compared to open surgical thrombectomies
Q20. Pseudoaneurysms at the anastomotic site of
the AV fistula/graft are most often due to:
A. Poor surgical technique with inadequate
depth of sutures
B. Excessive tension at the anastomotic site
C. Infectious complications
D. Inadequate depth of sutures at the
anastomotic site, excessive tension at
the anastomotic site, and infectious
complications
Q21. The incidence of upper extremity isch-
emia in dialysis patients is up to:
A. 1%
B. 2%
C. 4%
D. 5%
Q22. Ischemic Rest pain in the hand as a
symptom of steal syndrome following
hemodialysis arteriovenous access reconstruction is graded as:
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
Q23. The diagnosis of dialysis access–associated
steal syndrome (DASS) is confirmed by:
A. Catheter-based arteriography
B. EMG and nerve conduction velocity
study
C. Doppler ultrasonography with digital
pressures and tracings with and without
AV access compression
D. Clinical examination with and without
AV access compression
Q25. There are several causes of peripheral
neuropathy in patients on hemodialysis;
the most serious is:
A. Entrapment causing peripheral nerve
compression
B. Uronic neuropathy
C. Diabetic polyneuropathy
D. Ischemic monomelic neuropathy
Q26. Ischemic monomelic neuropathy differs
from ischemic syndrome in all except it is:
A. Reversible
B. Exhibits no tissue necrosis
C. Warm hand
D. Palpable pulse or audible Doppler signal
Q27. What percentage of patients have central
venous stenosis/occlusion (CVS) detected
on venography for failing access and
edema of the extremity?
A. Less than 5%
B. 5%–10%
C. 11%–16%
D. 17%–26%
Q28. During balloon angioplasty for venous
stenosis near the distal anastomosis of
the AV graft, there is a residual stenosis of
approximately 30%. The next best option is:
A. Covered stent
B. Open patch angioplasty
C. Cutting balloon or high-pressure balloon
angioplasty
D. Bare-metal stent
Q29. Treatment of symptomatic venous
hypertension secondary to central venous
stenosis/occlusion (CVS) is:
A. Open surgical management
B. Endovascular angioplasty
C. Bare-metal stent
D. Covered stent
Q24. Treatment of symptomatic steal syndrome
(stage IV and selected patients with stage
III) is:
A. Ligation of the access
B. Banding
C. Endoluminal-assisted revision
D. Distal revascularization with interval
ligation (DRIL) procedure
Q30. Tapered arteriovenous grafts in upper
extremity dialysis access over nontapered grafts provide:
A. Better patency protection against
ischemic steal syndrome
B. Less arm swelling
C. Similar primary patency
D. Less endovascular operative reintervention
306 Section 15: Dialysis Access
Q31. The optimal treatment of bleeding in the
dialysis patient with platelet dysfunction
is:
A. Maintenance of hematocrit >36
B. Change the permanent access to tun-
neled dialysis catheter
C. Tranexamic acid
D. Desmopressin
Q32. A 74-year-old woman on hemodialysis
with AV graft in the left upper arm not
on any anticoagulation medication for
the past 18 months presents to the ER
with pulsatile bleeding from the needle
puncture site during dialysis, which could
not be controlled by local pressure by the
dialysis access team. The optimal management is:
A. Immediately take the patient to the OR
and perform a new interposition graft
through healthy tissues
B. Immediate shuntogram
C. Compression Ace bandage
D. Direct pressure for 30–40 minutes; if
bleeding persists, place a suture over
the bleeding site and administer desmopressin; then evaluate the shunt by
shuntogram followed by the appropriate
management strategy
Q33. Access flow in patients with high-output
heart failure as a complication of arteriovenous fistula/graft is greater than:
A. 1000 mL/min
B. 1200 mL/min
C. 1500 mL/min
D. >2000 mL/min
Q34. The advantages of arterio-arterial grafts
as a prosthetic loop are:
A. No change in cardiac output
B. No change in peripheral perfusion
C. Axillo-axillary loop grafts are preferred to
femoral artery loop grafts
D. No change in cardiac output or periph-
eral perfusion with preference for axilloaxillary loop grafts
Section 15: Dialysis Access 307
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RATIONALE 1–34
1. RATIONALE
In the United States, most patients (75%) begin hemodialysis treatment with a central venous
catheter as their initial vascular access. Most patients will have a tunneled hemodialysis catheter inserted into the internal jugular vein. According to the Centers for Medicare and Medicaid
Services, the percentage of patients using a tunneled hemodialysis catheter as their primary
vascular access was 29% in 2007 and 24% in 2010. The majority of patients who begin hemodialysis treatment using a central venous catheter will transition to an arteriovenous fistula
or a prosthetic graft as their permanent vascular access. According to the National Kidney
Foundation Kidney Disease Outcomes Quality Initiative (DOQI) guidelines, each patient should
have a graft within 90 days of starting chronic hemodialysis treatment. However, a significant
number of patients will continue to use a tunneled hemodialysis catheter for the first 6–12
months after start of the hemodialysis treatment.
Correct Answer D 25%
Reference
Vesely, T. (2013). The challenge of hemodialysis catheter use. Endovasc Today, 60–62.
2. RATIONALE
Hemodialysis catheter dysfunction is commonly defined as the inability to aspirate blood, a blood
flow rate of less than 300 mL/min, and increased arterial or venous pressure or inability to deliver
an adequate hemodialysis. Catheter dysfunction has been reported during 7% of hemodialysis
sessions, and the median time to the first episode of catheter dysfunction was 95 days. Sixty-three
percent of patients had at least one episode of catheter dysfunction, and 30% of patients had
≥1 episode of catheter dysfunction per month. If the desired flow rate is not achieved, the underlying cause needs to be determined. Early dysfunction is usually associated with kinking of the
catheter or a poor position, while late dysfunction is more commonly associated with thrombosis
or a fibrin sheath around the distal end of the catheter with or without thrombi.
Correct Answer C 300–500 cc
Reference
Frankel, A. (2006). Temporary access and central venous catheters. Eur J Vasc Endovasc Surg, 31(4),
417–422. PMID: 16360326
3. RATIONALE
In an inadequately functioning non-tunneled hemodialysis catheter, the patient’s position
should first be altered. The catheter should then be flushed with normal saline using a 10-cc
syringe; obtaining a chest X-ray in tunneled hemodialysis catheter dysfunction helps in determining the position of the tip of the catheter. It also rules out a kink in the catheter. Several
clinical studies have demonstrated that the performance and durability of hemodialysis catheters are improved if the tip is positioned within the right atrium. The majority of hemodialysis
catheters are inserted in the anterior chest wall via the right internal jugular vein while the
patient is in a supine position. When the patient moves to the standing position, the anterior
chest wall will move inferiorly due to gravity. In the supine position, the mediastinal structures,
308 Section 15: Dialysis Access
including central veins, are compressed by the abdominal contents. When the patient moves to
the upright position, the abdominal contents descend, the central veins lengthen, and the right
atrium expands. This lengthening of the mediastinal structure will result in upward retraction
of the catheter into the superior vena cava. A correctly placed catheter tip usually undergoes a
2- to 3-cm movement between the superior vena cava and the upper right atrium.1 It has been
reported that left-sided catheters terminating in the SVC or pericavoatrial junction had significantly more catheter-related dysfunction and infection as compared to right-sided catheters.
2
Kink in left IJ tunneled dialysis catheter.
Correct Answer A Chest X-ray to determine the position of the tip of the catheter and to rule
out a kink in the catheter
References
1. Kowalski, C. M., Kaufman, J. A., Rivitz, S. M., Geller, S. C., & Waltman, A. C. (1997). Migration of
central venous catheters: implicat ions for initial cat heter tip posit ioning. J Vasc Interv Radiol, 8(3),
443–447. PM ID: 9152919
2. Engstrom, B. I., Horvath, J. J., Stewart, J. K., et al. (2013). Tunneled internal jugular hemodialysis
catheters: impact of laterality and tip position on catheter dysfunction and infection rates. J Vasc
Interv Radiol, 24(9), 1295–1302. PMID: 23891045
4. RATIONALE
A prospective study of 102 patients with tunneled hemodialysis catheters reported that 35%
of catheters have suboptimal rates of blood flow, leading to reversal of the arterial and venous
blood lines, which often improves the rate of blood f low though the catheter. However, this
maneuver may be associated with significant access recirculation. Access recirculation occurs
when dialyzed blood exiting the outflow lumen directly re-enters the inflow lumen, thereby
bypassing the systemic circulation. Recirculation reduces the effective clearance of the solute
by diluting the inf low concentration, thereby reducing the driving force of diffusion across the
Section 15: Dialysis Access 309
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dialyzer membrane. A hemodialysis catheter recirculation rate of >10% reduces the adequacy of
hemodialysis treatment. The arterial and venous end holes, located at the distal tip of the catheter, are separated (1–3 cm) to minimize recirculation of blood during hemodialysis treatment.
The average recirculation for a tunneled hemodialysis catheter with distal tip position in the
upper right atrium should be <5%.
Correct Answer D 35% of patients
Reference
Depner, T. A. (2001). Catheter performance. Semin Dial, 14 (6), 425–431. PMID: 11851927
5. RATIONALE
The major complication of hemodialysis catheters is infection. Numerous studies have confirmed
that the risk of both local and blood-borne infection is highest in non-tunneled hemodialysis
catheters. Catheter-associated infection can result in septic central vein thrombosis, infective
endocarditis, osteomyelitis, and septic arthritis. The incidence of access infections per 100 patient
months was reported with the type of access: Fistula 0.56, prosthetic graft 1.35, tunneled dialysis catheter 8.42, and non-tunneled dialysis catheter 11.98. The high rate of infection not only
increases morbidity and mortality but also has a significant economic implication, as infection is
the most common reason for admission of a patient on chronic hemodialysis to the hospital.
Correct Answer C Non-tunneled hemodialysis catheter
Reference
Frankel, A. (2006). Temporary access and central venous catheters. Eur J Vasc Endovasc Surg, 31(4),
417–422. PMID: 16360326
6. RATIONALE
Arteriovenous fistula for hemodialysis access has the lowest rate of thrombosis requiring the
least number of interventions at the lowest cost. Patients with fistulas are associated with the
highest survival and lowest hospitalization rates, with the lowest rate of infection. The literature
review indicates that there are growing numbers of studies reporting that creating an arteriovenous fistula in some patients is less likely to be successful in the presence of certain comorbidities. In addition, certain patient groups may have less incremental benefit from an AV fistula
relative to an AV graft. By adjusting the fistula rates for patient characteristics and comorbidities
associated with low AV fistula success rate, this measure accounts for some patients where an
AV graft or even a tunneled dialysis catheter may be a more appropriate option.
Correct Answer C Fistulas have the highest rates of infection
Reference
Lok, C. E., Huber, T. S., Lee, T., et al. (2020). KDOQI clinical practice guideline for vascular access: 2019
update. Am J Kidney Dis, 75(4 Suppl 2), S1–S164. PMID: 32778223
7. RATIONALE
Numerous reports implicate the vascular access in up to 48%–73% of all bacteremias in the
hemodialysis population. The majority of these bacteremias are caused by staphylococcal
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