Double renal transplants from marginal donors: 2-year results

PURPOSE

Marginal cadaveric renal transplant donors represent a potential source for expansion of the donor pool but these kidneys have generally demonstrated significantly poorer survival compared to those from conventional donors. A strategy to provide sufficient renal mass for adequate nephron dosing and subsequent improved survival is the use of both kidneys for a single recipient. We present our 2-year experience with double renal transplants from marginal donors.

MATERIALS AND METHODS

During an 8-year period 28 patients received double renal transplants (group 1) and 31 received a single transplant (group 2) from marginal donors. Donors were older than 55 years, or had diabetes mellitus, hypertension, greater than 15% glomerulosclerosis on biopsy, increasing creatinine or intrinsic renal parenchymal disease.

RESULTS

Both groups were of similar age and the number of rejection episodes per year was similar but followup time differed (22.4+/-14.6 months for group 1 versus 43.7+/-20.5 for group 2). Male-to-female ratio, cold ischemia time, terminal creatinine and pre-transplant biopsy rates were similar for donors in both groups. Average donor age was younger in group 1 (48.9+/-15.8 versus 57.5+/-8.2 years, p = 0.01), and incidence of intrinsic renal disease and increasing donor creatinine was greater (12 versus 2, p = 0.002 and 4 versus 0, p = 0.04, respectively). Incidence of primary nonfunction (1 group 1 versus 5 group 2 patients) and delayed graft function (6 versus 7) was similar. The 1 and 2-year graft survival rates of 96% and 96%, respectively, for group 1 were significantly higher than those for group 2 (77% and 73%, p = 0.02).

CONCLUSIONS

Our experience to date with double kidney transplants from marginal donors demonstrates acceptable 1 and 2-year survival rates significantly superior to the outcome using only 1 marginal kidney. This finding has important implications in the decision to use marginal donors in regard to cost-effectiveness and patient survival compared to the alternative of continued hemodialysis until an ideal donor organ becomes available.

Outcome in recipients of dual kidney transplants: an analysis of the dual registry patients

BACKGROUND

A novel but controversial method to increase the utilization of aged donor kidneys is the transplantation of both kidneys as a dual transplant. Initial single-center reports demonstrated outcomes similar to single kidneys from younger donors. In this report, we compare outcome in recipients of kidneys from donors > or =54 years of age who received a single kidney transplant reported to the United Network for Organ Sharing Scientific Registry versus a dual kidney transplant reported to the Dual Kidney Registry.

METHODS

A retrospective analysis was performed, comparing four donor and nine recipient and outcome variables between recipients of a single versus a dual transplant between March 1993 and March 1999.

RESULTS

Dual versus single transplants from donors > or =54 years of age have a significantly decreased incidence of delayed graft function, and lower serum creatinines up to 2 years after transplant despite having kidneys from significantly older donors with poorer HLA matching.

CONCLUSIONS

Dual kidney transplants improve graft performance and outcome in recipients of kidneys from donors > or =54 years of age.

Mental health services in faith communities: the role of clergy in black churches

A small but growing literature recognizes the varied roles that clergy play in identifying and addressing mental health needs in their congregations. Although the role of the clergy in mental health services delivery has not been studied extensively, a few investigations have attempted a systematic examination of this area. This article examines the research, highlighting available information with regard to the process by which mental health needs are identified and addressed by faith communities. Areas and issues where additional information is needed also are discussed. Other topics addressed include client characteristics and factors associated with the use of ministers for personal problems, the role of ministers in mental health services delivery, factors related to the development of church-based programs and service delivery systems, and models that link churches and formal services agencies. A concluding section describes barriers to and constraints against effective partnerships between churches, formal services agencies, and the broader practice of social work.

Tandem Intermolecular - Intramolecular Carbolithiation: A Versatile Method for Synthesis of Cyclopentanes

Polysubstituted cyclopentanes from readily available starting materials? A versatile anionic [3+2] approach is offered by the reaction of difunctional organolithium reagents 1 with alkenes 2 in a tandem intermolecular - intramolecular carbolithiation (see scheme). This convergent sequence is especially attractive as, not only are the precursors readily available, but the products provide valuable synthetic building blocks.

Dental service provision in private general practice for an insured population in New South Wales, Australia

OBJECTIVE

To determine patterns of dental services provided to a cohort of the insured population 18 years and over, in private general practice in New South Wales, Australia.

BASIC RESEARCH DESIGN

A cohort study using the person-years method and Poisson regression for analysis.

SETTING

Data were derived from claims records submitted by members of a health insurance fund (Government Employees Health Fund-GEHF) for rebates during the study period 1 January 1992-31 December 1995.

PARTICIPANTS

There were 133,467 members aged 18 years and over from New South Wales.

MAIN OUTCOME MEASURES

To determine, by age group, for those members who used private general practice and made a claim (referred to as 'patients') the annual number of visits, total number of services received per year and number of services received at a visit.

RESULTS

The mean number of visits per patient was 2.4 per year with patients under 45 years making fewer visits than the 45-54 age group reference category. Mean number of services utilised per patient-year was 5.9, with services provided increasing from 3.5 for the 18-24-year-old group, reaching a plateau of approximately 6.2 for those aged 45 years or more. The number of services received per visit was 2.4 and there were no differences by age. Service mix was dominated by restorative (35%), diagnostic (27%), and preventive services (18%); with age specific variations observed.

CONCLUSIONS

Age was found to be an important determinant in the use of dental services, independent of membership duration and gender.

The farnesyltransferase inhibitor manumycin A is a novel trypanocide with a complex mode of action including major effects on mitochondria

Eukaryotes modify numerous proteins, including small GTPases of the ras superfamily, with isoprenes as a mechanism for membrane attachment. Inhibition of farnesylation of ras has been successfully exploited to control cell growth, with promise in the clinic for treatment of human tumours. Using an in vitro screen of mammalian farnesyltransferase inhibitors, we have identified manumycin A as potently active against growth of both bloodstream and procyclic forms of Trypanosoma brucei. Other structural classes of farnesyltransferase inhibitors were far less effective. Exposure of T. brucei for brief periods to lethal concentrations of manumycin A resulted in subsequent cell death whilst the concentration required to achieve killing was dependent on serum concentration, suggesting partitioning of manumycin A into hydrophobic cellular sites. Manumycin A did not affect trypanosomal protein and DNA synthesis or cell cycle progression but altered incorporation of prenyl groups into several polypeptides indicating a specific effect on the prenylation without effect on other mevalonate pathway products, most importantly prenyl pyrophosphate levels. Morphological analysis indicated that manumycin A caused significant mitochondrial damage suggesting an additional site of action. Structural analogues of manumycin A containing a quinone were also highly trypanocidal and altered mitochondrial morphology, suggesting interference with electron/proton transport systems. Furthermore, manumycin A also elicited mitochondrial alterations in mammalian cells indicating that the effect is not confined to lower eukaryotes. Manumycin A is well tolerated in vivo but failed to cure experimental trypanosomiasis in mice.

Ramberg-Bäcklund Approaches to the Synthesis of C-Linked Disaccharides

Readily available S-glycoside dioxides were utilized in a Ramberg-Bäcklund rearrangement for the construction of C-linked disaccharides. This approach is ideally suited to analogue synthesis simply by variation of the alkylating agent, and is illustrated here by the synthesis of beta,beta-C-trehalose (see reaction scheme), a higher homologue of C-trehalose, and methyl C-gentiobioside. Bn=benzyl.

A comparison of sub-bandage pressures produced with two multi-layer bandaging systems

Fourteen nurses with experience in the use of high-compression bandaging were asked to bandage the same limb with two different bandaging systems: the 'Charing Cross' four-layer regimen (System A), and a modified system incorporating two new bandages (System B). A sub-bandage pressure monitor was used to quantify the efficacy of the resulting bandaging for the two systems. The results indicated that there was no significant difference between site sub-bandage pressures achieved using the two bandaging systems. Sub-bandage pressure profiles, however, fluctuated with patient posture, the best profiles being obtained with System B and the patient in the sitting position.

Tumor localization and systemic absorption of intravesical instillation of radio-iodinated iododeoxyuridine in patients with bladder cancer

PURPOSE

We evaluated tumor uptake and systemic distribution of intravesically instilled iododeoxyuridine (IUdR) in patients with superficial bladder cancer.

MATERIALS AND METHODS

We performed 24 intravesical instillation studies in 11 patients with a mean age of 71 years. Radio-iodinated IUdR was administered through a Foley catheter. Gamma camera imaging was done after instillation and after 5 to 7 bladder irrigations. Tumor uptake was estimated by region of interest analysis. Bladder biopsy samples and surgical tumor specimens were tested for acid insoluble (deoxyribonucleic acid incorporated) radioactivity. Blood samples were obtained and analyzed for systemic absorption.

RESULTS

Imaging was positive in all patients with bladder cancer. Average tumor uptake plus or minus standard deviation was 0.185+/-0.120% of the instilled dose. Preferential uptake of IUdR in the tumor was observed in all 6 patients undergoing tissue analysis. The tumor-to-normal bladder ratio ranged from 3.2 to 74,000 (median 202). Systemic absorption of IUdR was minimal. Blood sample analysis performed after intravesical instillation in all 11 cases revealed an average uptake of 3.2x10(-5)% instilled dose per ml. (range 0.69x10(-5) to 6.7x10(-5)) in the systemic circulation. Instillation within 24 hours after transurethral bladder tumor resection in 5 cases resulted in a higher but not dangerous average systemic uptake of 7.3x10(-4)% instilled dose per ml. (range 1.3x10(-5) to 2.6x10(-3)). Instillation 1 to 4 weeks after transurethral surgery in 8 cases resulted in no increased systemic absorption with an average blood level of 3.4+/-1.8x10(-5)% instilled dose per ml. There was no detectable distribution of radioactivity into other organs, including the thyroid. We noted no evidence of systemic toxicity in the study.

CONCLUSIONS

Intravesical instillation of radio-iodinated IUdR achieves selective localization in the bladder tumor with minimal uptake by the normal bladder and minimal systemic absorption. The use of intravesical IUdR therapy for bladder cancer appears to be promising and requires further study.

A computerised leg ulcer database with facilities for reporting and auditing

A review of a new computerised reporting and auditing system.

The design, synthesis, and evaluation of novel conformationally rigid analogues of sialyl Lewis(x)

The design and synthesis of a series of analogues of sialyl Lewis(x)(1) which incorporate conformationally rigid tetralin and naphthalene ring systems(2-4) has led to novel compounds which have similar potency to 1 as inhibitors of cell adhesion.

Pupil-sparing third nerve palsy associated with sildenafil citrate (Viagra)

PURPOSE

To report unilateral pupil-sparing third nerve palsy after use of sildenafil citrate (Viagra).

METHOD

Case report.

RESULTS

A 56-year-old man with a history of tobacco abuse was treated for erectile dysfunction. Viagra, 50 mg, was taken once without adverse effect. Three weeks later, the patient took a second dose of Viagra (50 mg); 36 hours later he experienced a complete pupil-sparing third nerve palsy. Erythrocyte sedimentation rate, blood glucose level, magnetic resonance imaging, and magnetic resonance angiography were normal.

CONCLUSION

In a patient with microvascular disease, use of sildenafil may be associated with pupil-sparing third nerve palsy.

Interval breast cancers in an Australian mammographic screening program

OBJECTIVE

To determine the incidence of interval cancers which occurred in the first 12 months after mammographic screening at a mammographic screening service.

DESIGN

Retrospective analysis of data obtained by crossmatching the screening Service and the New South Wales Central Cancer Registry databases.

SETTING

The Central & Eastern Sydney Service of BreastScreen NSW.

PARTICIPANTS

Women aged 40-69 years at first screen, who attended for their first or second screen between 1 March 1988 and 31 December 1992.

MAIN OUTCOME MEASURES

Interval-cancer rates per 10000 screens and as a proportion of the underlying incidence of breast cancer (as estimated by the underlying rate in the total NSW population).

RESULTS

The 12-month interval-cancer incidence per 10000 screens was 4.17 for the 40-49 years age group (95% confidence interval [CI], 1.35-9.73) and 4.64 for the 50-69 years age group (95% CI, 2.47-7.94). Proportional incidence rates were 30.1% for the 40-49 years age group (95% CI, 9.8-70.3) and 22% for the 50-69 years age group (95% CI, 11.7-37.7). There was no significant difference between the proportional incidence rate for the 50-69 years age group for the Central & Eastern Sydney Service and those of major successful overseas screening trials.

CONCLUSION

Screening quality was acceptable and should result in a significant mortality reduction in the screened population. Given the small number of cancers involved, comparison of interval-cancer statistics of mammographic screening programs with trials requires age-specific or age-adjusted data, and consideration of confidence intervals of both program and trial data.

Results of the double-blind, randomized, multicenter, phase III clinical trial of Thymoglobulin versus Atgam in the treatment of acute graft rejection episodes after renal transplantation

BACKGROUND

Thymoglobulin, a rabbit anti-human thymocyte globulin, was compared with Atgam, a horse anti-human thymocyte globulin for the treatment of acute rejection after renal transplantation.

METHODS

A multicenter, double-blind, randomized trial with enrollment stratification based on standardized histology (Banff grading) was conducted. Subjects received 7-14 days of Thymoglobulin (1.5 mg/kg/ day) or Atgam (15 mg/kg/day). The primary end point was rejection reversal (return of serum creatinine level to or below the day 0 baseline value).

RESULTS

A total of 163 patients were enrolled at 25 transplant centers in the United States. No differences in demographics or transplant characteristics were noted. Intent-to-treat analysis demonstrated that Thymoglobulin had a higher rejection reversal rate than Atgam (88% versus 76%, P=0.027, primary end point). Day 30 graft survival rates (Thymoglobulin 94% and Atgam 90%, P=0.17), day 30 serum creatinine levels as a percentage of baseline (Thymoglobulin 72% and Atgam 80%; P=0.43), and improvement in posttreatment biopsy results (Thymoglobulin 65% and Atgam 50%; P=0.15) were not statistically different. T-cell depletion was maintained more effectively with Thymoglobulin than Atgam both at the end of therapy (P=0.001) and at day 30 (P=0.016). Recurrent rejection, at 90 days after therapy, occurred less frequently with Thymoglobulin (17%) versus Atgam (36%) (P=0.011). A similar incidence of adverse events, post-therapy infections, and 1-year patient and graft survival rates were observed with both treatments.

CONCLUSIONS

Thymoglobulin was found to be superior to Atgam in reversing acute rejection and preventing recurrent rejection after therapy in renal transplant recipients.

A comparison of standard and a modified method of two resuscitator adult cardiopulmonary resuscitation: description of a new system for research into advanced life support skills

The study compares two methods of Advanced Life Support by a pair of resuscitators using a bag-valve-mask (BVM) technique. Standard two resuscitator cardiopulmonary resuscitation (CPR) was compared with a modified method of two resuscitator CPR. During the modified CPR one resuscitator held the face mask while the other resuscitator alternates between squeezing the self inflating bag and performing simulated cardiac compressions. Standard CPR was performed at a ventilation:compression ratio of 1:5 while modified CPR was performed at a ventilation:compression ratio of 2:15. Comparisons were made during induction of anaesthesia in 30 ASA I and II patients. Modified CPR produced a greater tidal volume (TV) (P < 0.001), a slower respiratory rate (RR) (P < 0.001) and a faster compression rate (CR) (P < 0.01) (means with (S.D.): modified CPR: TV 990 (220) ml, RR 6 (1) min(-1), CR 82 (8) min(-1); standard CPR: TV 570 (190) ml, RR 10 (2) min(-1), CR 65 (11) min(-1)). A new method for the simultaneous computerised recording of simulated cardiac compressions together with mask pressure and expired gas composition in anaesthetised patients is described.

Preoperative hyperbaric oxygen therapy for radiation induced injuries

PURPOSE

We present our experience with preoperatively administered hyperbaric oxygen therapy to patients who have sustained significant therapeutic radiation induced soft tissue injuries and subsequently undergo planned abdominal intervention/surgery.

MATERIALS AND METHODS

From February 1993 to May 1997, 5 patients with a history of complications following therapeutic radiation were prospectively treated with hyperbaric oxygen before a planned abdominal operation.

RESULTS

All patients had uneventful hospital courses. An additional procedure was eventually necessary in 2 patients but with fewer radiation related problems following hyperbaric oxygenation.

CONCLUSIONS

Hyperbaric oxygenation may improve postoperative outcomes when given before planned open operations in patients with previous therapeutic pelvic irradiation and a history of radiation related complications.

Audit of populations in general practice: the creation of a national resource for the study of morbidity in Scottish general practice

STUDY OBJECTIVE

To create a national data resource for studying morbidity in Scottish general practice, complementary to existing information systems and available for management and research purposes at national and local levels.

DESIGN

The Department of General Practice, University of Aberdeen has worked since 1988 to collect and analyse computerised information at practice, regional, and national levels by distribution of a floppy disk-based software program, which extracts a predetermined dataset from each general practice computer system.

SETTING

Almost 100% of patients in Scotland are registered with a general practitioner. Scotland has a national computer system, General Practice Administration System for Scotland (GPASS), used by over 75% of all Scottish practices. Escalating costs of health care and demographic changes in the national population emphasise the monetary value of the gatekeeper role of general medical practice. General practitioners' increasing involvement in the provision and purchasing of care has raised the importance of the management of populations as well as the care of individual patients.

PATIENTS

Collection of major morbidity and prescribing data from up to 2.4 million patients, approximately half the population of Scotland, takes place biannually. A subset of practices (population 282,700 patients; 52 practices) are continuously collecting doctor/patient contact information (symptoms or diagnoses).

MAIN RESULTS

The data collected provide information at the level of the individual patient. Morbidity, prescribing, screening, and administrative data can be linked by patient, date or postcode. The sample population studied is representative by age, sex, deprivation, and sparsity (using the postcode) of the national population. Large sub-populations of patients satisfying a selected criteria can be extracted for further study of needs assessment or of epidemiological research.

CONCLUSIONS

The gatekeeping role of Scottish general practice and the predominance of GPASS favours standardisation of methods of data capture and the construction of large regional, national, and Continuous Morbidity databases. Analysis by geographical, demographic, and temporal distributions allows the changing patterns of illness and provision of health care to be studied in substantial detail to the benefit of patients, doctors, and the national health service.

Color Doppler ultrasound assessment of urethral artery location: potential implication for technique of visual internal urethrotomy

PURPOSE

We assessed the location of urethral arteries in patients with urethral stricture using color Doppler ultrasound.

MATERIALS AND METHODS

We performed 41 color ultrasound studies of the urethra in 33 patients 17 to 76 years old. The linear array transducer was placed on the ventral surface of the penis and perineum to image the urethra and periurethral structures. In addition to evaluating the extent of stricture disease, color Doppler ultrasound determined the location of the urethral arteries at the segment with stricture.

RESULTS

The number and site of the urethral arteries vary among individuals. Contrary to the common belief that these arteries are located at the 3 and 9 o'clock positions, we have found that in the bulbous urethra the arteries are at the 1 to 2 o'clock positions in 14% of cases, 3 to 4 in 22%, 5 to 6 in 17%, 7 to 8 in 18%, 9 to 10 in 18% and 11 to 12 in 11%. The arteries may be close to the surface of the urethral lumen, especially in patients who have undergone previous urethral procedures. Preoperative evaluation of urethral artery location may be helpful for preventing arterial bleeding at visual internal urethrotomy.

CONCLUSIONS

Color Doppler ultrasound can effectively assess the extent of stricture disease and urethral artery sites. Because the location of the urethral arteries varies among patients, individual preoperative assessment is advisable. Color Doppler ultrasound is currently our imaging method of choice for evaluating strictures of the pendulous and bulbous urethra.

Construction and calibration of a low-cost bandage pressure monitor

This study describes the construction and calibration of a three-channel bandage pressure monitor and evaluates its in-service use. The monitor was constructed from a range of commercially available, relatively inexpensive components consisting of a pressure sensor, piezoresistive transducer, differential amplifier and liquid crystal display. The pressure sensors show a good ratio of thickness to surface area (< 10%) and are sufficiently robust and flexible to conform to most anatomical profiles. The transducers are internally calibrated and temperature-compensated to provide an accurate and stable measurement of gauge pressure relative to atmospheric pressure. During laboratory assessment and in-service use, the system has proved to be reliable, accurate (typically < +/- 0.5 mmHg) and reproducible over repeated calibration.

Renal transplantation: surgical aspects, complications and results

Despite the fact that kidney transplants have routinely been successfully performed for over 30 years there continues to be challenges for the transplant surgeon. These include a static donor pool, growing recipient list, declining number of ideal donors and greater reliance on marginal donors. Innovative methods to deal with these problems continue to be sought.

Using a bandage pressure monitor as an aid in improving bandaging skills

This prospective study used a bandage pressure monitor to assess the bandaging skills of 16 nurses caring for patients with venous leg ulcers. Baseline measurements showed that only 50% of the nurses demonstrated bandaging skills that were adequate to good. However, by the end of the feedback/post-training session, 81% of those examined had reached this standard and this figure rose to 86% on recall. These data seem to support the view that the use of a pressure monitor is a useful adjunct in the teaching of bandaging skills.