A comparison of recipient renal outcomes with laparoscopic versus open live donor nephrectomy

BACKGROUND

Laparoscopic donor nephrectomy (laparoNx) has the potential to increase living kidney donation rates by reducing the pain and suffering of the donor. However, renal function outcomes of a large series of recipients of laparoNx have not been studied.

METHODS

We retrospectively reviewed the records of 132 recipients of laparoNx done at our center between 3/96 and 11/97 and compared them to 99 recipients of kidneys procured by the open technique (openNx) done between 10/93 and 3/96.

RESULTS

Significantly more patients in the laparoNx group (25.2%) were taking tacrolimus within the first month than those in the openNx group (2.1%). Mean serum creatinine was higher in laparoNx compared with openNx at 1 week (2.8+/-0.3 and 1.8+/-0.2 mg/dl, respectively; P=0.005) and at 1 month (2.0+/-0.1 and 1.6+/-0.1 mg/dl, P=0.05) after transplant. However, by 3 and 6 months, the mean serum creatinine was similar in the two groups (1.7+/-0.1 versus 1.5+/-0.05 mg/dl, and 1.7+/-0.1 versus 1.7+/-0.1, respectively). By 1 year posttransplant, the mean serum creatinine for laparoNx was actually less than that for openNx (1.4+/-0.1 and 1.7+/-0.1 mg/dl, P=0.03). Although patients in the laparoNx compared to the openNx group were more likely to have delayed graft function (7.6 versus 2.0%) and ureteral complications (4.5 versus 1.0%), the rate of other complications, as well as hospital length of stay, patient and graft survival rates were similar in the two groups.

CONCLUSION

Although laparoNx allografts have slower initial function compared with openNx, there was no significant difference in longer term renal function.

Gender differences in the effects of bereavement-related psychological distress in health outcomes

BACKGROUND

This study examined whether traumatic grief, depressive and anxiety symptoms formed three distinct factors for widows and widowers. In addition, we examined whether high symptom levels of traumatic grief, depression and anxiety predicted different mental and physical health outcomes for widows and widowers.

METHOD

Ninety-two future widows and 58 future widowers were interviewed at the time of their spouse's hospital admission and then at 6 weeks, 6, 13 and 25 month follow-ups. Principal axis factor analyses tested the distinctiveness of traumatic grief, depressive and anxiety symptoms, by gender. Repeated measures ANOVA tested for gender differences and changes over time in mean symptom levels of traumatic grief, depression and anxiety. Linear and logistic regression models estimated the effects of high symptom levels of traumatic grief, depression and anxiety at 6 months on health outcomes at 13 and 25 months post-intake by gender.

RESULTS

Three distinct symptom clusters (i.e. traumatic grief, depressive and anxiety symptoms) were found to emerge for both widows and widowers. Widows had higher mean levels of traumatic grief, depressive and anxiety symptoms. High symptom levels of traumatic grief measured at 6 months predicted a physical health event (e.g. cancer, heart attack) at 25 months post-intake for widows. High symptom levels of anxiety measured at 6 months predicted suicidal ideation at 25 months for widowers.

CONCLUSIONS

The results suggest that there are gender differences in the levels of psychological symptoms resulting from bereavement and in their effects on subsequent mental and physical health for widows and widowers.

Ten dimensions of public-sector managed care

Managed care in the public sector remains a poorly defined concept. It is currently understood largely through case examples, an approach of limited usefulness because each managed care initiative is shaped by local forces and is constantly changing. The authors describe ten key dimensions on which such initiatives vary and suggest that they can be used to examine essential characteristics of the initiatives and core differences between them. The dimensions are objectives, scope, organizational structures and authority, enrollment, benefit package, strategies for managing utilization, best practices, financing, quality management and outcomes measurement, and the impact of the initiative on the public mental health system. Using these dimensions to assess existing initiatives, the authors conclude that most focus on one principal dimension to the exclusion of other critical dimensions. The authors argue for a comprehensive approach to planning and implementing managed care projects that should ultimately lead to better care for public-sector populations.

Correction of diabetic nod mice with insulinomas implanted within Baxter immunoisolation devices

Insulin replacement by injection is clearly not a cure for Insulin Dependent Diabetes Mellitus (IDDM). Replacement of the destroyed islets by pancreas or islet allograft transplantation can achieve the good metabolic control required to prevent diabetic complications, but tissue supply is limited. The problem of islet supply to treat the 1 million IDDM patients in the USA could be overcome by using immortalized islet beta-cells as a donor source. However, before either allogeneic or xenogeneic immortalized beta-cells are used, some major problems have to be overcome: control of immortalized cell growth, allograft or xenograft rejection and recurrence of autoimmunity. To tackle these problems we have used a cell impermeable immunoisolation device containing mouse insulinoma cells. Transplantation of devices with insulinomas from NOD mice carrying the Rat-insulin promoter regulated SV40 T-Antigen transgene (RIP-TAg), normalized the blood glucose levels of diabetic NOD mice. Insulinomas from allogeneic CBA/NOD-RIP-TAg mice were also capable of normalizing diabetic NOD mice. Not only were non-fasting blood glucoses normalized but when given an intraperitoneal injection of glucose, the corrected mice had a near normal clearance of glucose from the blood. When the devices were removed from normalized mice they became diabetic again, demonstrating that the immunoisolation device was capable of protecting against both alloimmune and autoimmune destruction. The results with allogeneic mouse beta-cells suggest the possibility that immortalized human beta-cells could be an effective source of tissue to correct diabetes in IDDM patients without the use of immunosuppression.

Laparoscopic living donor nephrectomy and multiple renal arteries

BACKGROUND

Laparoscopic donor nephrectomy (LDN) is a new technique. While the short-term recipient renal function is equivalent to that of the traditional open nephrectomy (ODN), long-term function and potential exclusion criteria, such as the presence of multiple renal arteries, are as yet unknown.

METHODS

Retrospective review of 124 consecutive LDN performed from March 1996 to September 1997 with 117 ODN as historical controls.

RESULTS

The 1-year actuarial graft and patient survival for LDN kidneys were 94% and 95%, respectively. These were not statistically different from that of the ODN controls. The presence of multiple renal arteries did not alter graft and patient survival or prevalence of immunologic events. The number of recipient ureteral complications in the LDN group was 11.2% compared with 3.4% in ODN (P < 0.01). Following correction for a learning curve with accompanying technical modifications, the prevalence of recipient ureteral complications has decreased to 7% in the last 94 patients (P = nonsignificant versus ODN).

CONCLUSIONS

LDN represents a viable alternative to ODN for living renal transplants. Advantages for the donor are matched by equivalent functional results for the recipients.

Effects of therapy with nifedipine GITS or atenolol on mental stress-induced ischemic left ventricular dysfunction

OBJECTIVES

We sought to determine the effect of nifedipine gastrointestinal therapeutic system (GITS) or atenolol on ischemic left ventricular dysfunction induced by mental stress.

BACKGROUND

The efficacy of conventional antianginal therapy in preventing myocardial ischemia induced by mental stress is unknown.

METHODS

Nifedipine GITS, atenolol and placebo were administered to 15 subjects with stable angina in a double-blind crossover trial. Subjects underwent a series of mental stressors at the end of each treatment. Radionuclide ventriculography was performed at baseline and at peak mental stress. Other measured variables included time to ischemia on exercise treadmill testing, ischemia on 48-h ambulatory electrocardiogram (ECG) monitoring, and resting and mental stress-induced levels of plasma catecholamines, tissue plasminogen activator antigen, plasminogen activator inhibitor-1 and platelet aggregability.

RESULTS

Mental stress resulted in a significant increase in plasma epinephrine and norepinephrine levels during each treatment phase. Atenolol therapy was associated with lower baseline and postmental stress rate-pressure product compared with nifedipine or placebo. Therapy with either nifedipine GITS or atenolol prevented the development of wall-motion abnormalities and the decline in regional ejection fraction (EF) in the segment with the largest deterioration in wall motion during placebo therapy. Both medications prevented the decrease in global EF in subjects who demonstrated at least a 5% fall in global EF on placebo therapy. No therapy exerted a statistically significant benefit on exercise performance or frequency of ischemia during ambulatory ECG monitoring.

CONCLUSIONS

Both nifedipine GITS and atenolol are effective at preventing mental stress-induced wall-motion abnormalities, although the mechanisms may be different.

Advanced nursing practice in New Zealand: 1998

In the last decade, change in the health sector has often seemed to deny and thwart the professionalism and expertise of nurses. However, in the first half of 1998, a number of positive initiatives have come to fruition, which support the development of clinical and educational structures for advanced practice nursing in New Zealand. Within one month of each other the Nursing Council published its framework for post-registration nursing education, and the Nurse Executives of New Zealand published a proposal for the development of advanced practice roles: clinical nurse specialist and nurse practitioner. This article will explore these initiatives, and will examine the proposed clinical nurse specialist and nurse practitioner roles in light of experience in the United States in developing advanced or expanded nursing practice.

The mouse ADP-ribosylation factor-like 4 gene: two separate promoters direct specific transcription in tissues and testicular germ cell

ADP-ribosylation factor-like protein 4 (ARL4) is a Ras-related GTPase that has been cloned from the 3T3-L1 preadipocyte cell line as an adipocyte-specific cDNA [Schürmann, Breiner, Becker, Huppertz, Kainulainen, Kentrup and Joost (1994) J. Biol. Chem. 269, 15683-15688]. The Arl4 gene maps to the proximal region of mouse chromosome 12 linked to Lamb1-1, Hfhbf1 and Sos2. Compared with all other known genes of Ras-related GTPases, the genomic organization of Arl4 is unusual in that its entire coding region, the 3' untranslated region (UTR) and most of the 5' UTR are located on a single exon. This structure suggests that Arl4 has evolved by retroposition of an Arf (ADP-ribosylation factor) or Arf-like gene. Isolation of the 5' UTR by rapid amplification of cDNA ends (RACE)-PCR revealed heterogeneous transcription initiation sites in alternative exons 1. Both 5'-flanking regions exhibited promoter activity when expressed in COS-7 cells, indicating that the expression of Arl4 is directed by two separate promoters. mRNA transcribed under the control of the downstream promoter was isolated by RACE-PCR from all investigated tissues. In contrast, the upstream promoter seems to drive specifically the expression of Arl4 in adult testis. Hybridization of rat testis in situ indicated that Arl4 is expressed in germ cells of puberal and adult testis, but not in prepuberal testis, suggesting that Arl4 is involved in sperm production.

Genomic organization and partial duplication of the human alpha7 neuronal nicotinic acetylcholine receptor gene (CHRNA7)

The human alpha7 neuronal nicotinic acetylcholine receptor gene (HGMW-approved symbol CHRNA7) has been characterized from genomic clones. The gene is similar in structure to the chick alpha7 gene with 10 exons and conserved splice junction positions. The size of the human gene is estimated to be larger than 75 kb. A putative promoter 5' of the translation start in exon 1 has been cloned and sequenced. The promoter region lacks a TATA box and has a high GC content (77%). Consensus Sp1, AP-2, Egr-1, and CREB transcription factor binding sites appear to be conserved between bovine and human genes. The alpha7 nAChR gene was found to be partially duplicated, with both loci mapping to the chromosome 15q13 region. A yeast artificial chromosome contig was constructed over a genetic distance of 5 cM that includes both alpha7 loci and the region between them. Four novel exons are described, located in genomic clones containing the partially duplicated gene. The duplicated sequences, including the novel exons, are expressed in human brain.

Isolation and characterization of a novel human bladder cancer cell line: BK10

Molecular studies of bladder carcinomas have aided in determining causative genetic events and the prognosis of cancers endowed with certain abnormalities. In vitro bladder cancer characterization of key cytogenetic alterations is useful for study of molecular changes that may promote oncogenic events. In our laboratory, a novel human bladder cancer cell line, BK10, has been established in vitro and passaged for more than 20 mo. This new bladder cancer cell line (BK10) was derived from bladder tissue containing grade III-IV/IV transitional cell carcinoma. Bladder cancer tissue was obtained at the time of radical cystoprostatectomy extirpation. Cell cultures derived from this surgical sample exhibited an epithelial morphology and expressed epithelial cytokeratins. Immunostains of BK10 were negative for prostate specific antigen (PSA), fibronectin, smooth muscle actin alpha, and desmin. Karyotypic analysis revealed an aneuploid chromosomal content <4n> with many numerical and structural abnormalities previously linked to bladder oncogenesis. Translocations occurred in chromosomes 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 13, 14, 15, 16, 17, 19, 20, 21, 22, X and Y. G-banding analysis revealed rearrangements involving chromosomes 9q and 17p, and the location of the ab11 oncogene and the p53 gene, respectively. The availability of this bladder cancer cell line will provide a useful tool for the further study of bladder carcinoma oncogenesis and gene therapy.

A post hoc comparison of paroxetine and nortriptyline for symptoms of traumatic grief

BACKGROUND

This report presents the results of an open-trial pilot study of paroxetine for symptoms of traumatic grief, compared with the effects of nortriptyline in an archival contrast group.

METHOD

Data are presented on 15 subjects (4 men, 11 women), ranging in age from 40 to 79 years (mean age = 57 years), who experienced the loss of a spouse (N = 8), child (N =5), grandchild (N = 1), or parent (N = 1). Subjects were required to have a baseline score on the Inventory of Complicated Grief (ICG) of > or = 20. Treatment with paroxetine began at a median of 17 months (range, 6-139 months) after the loss. Paroxetine-treated subjects received a psychotherapy tailored for traumatic grief. Depressive symptoms were assessed by using the Hamilton Rating Scale for Depression (HAM-D). The ICG and the HAM-D were administered weekly over 4 months of paroxetine treatment (median dose = 30 mg/day). The group receiving paroxetine were then compared with a group (N = 22) participating in a separate trial of nortriptyline (median dose = 77.5 mg/day) for treatment of bereavement-related major depressive episodes.

RESULTS

Level of traumatic grief symptoms (ICG) decreased by 53%, and depression ratings (HAM-D) decreased by 54% in paroxetine-treated subjects. Nortriptyline showed clinical effects comparable to those of paroxetine.

CONCLUSION

Paroxetine may be an effective agent in the treatment of traumatic grief symptoms. A comparison of the paroxetine-treated group with a nortriptyline-treated group suggests that both agents have comparably beneficial effects on the symptoms of traumatic grief (as well as those of depression). However, the higher rate of diagnostic comorbidity in the paroxetine-treated group, together with the greater chronicity of their symptoms and the greater safety of paroxetine in overdose, leads us to favor paroxetine over nortriptyline for traumatic grief symptoms in general psychiatric practice. Further controlled evaluation of paroxetine for traumatic grief is necessary.

The 'Bodywise' initiative

Young people want access to good information in suitable settings so they can discuss sexual matters openly. Services are needed to bridge the gap between paediatric and adult health services. Interprofessional collaboration can provide effective, integrated and supportive services for users and providers. Static and outreach services are essential to facilitate young people's access to the services.

Validation parameters for a novel biosensor assay which simultaneously measures serum concentrations of a humanized monoclonal antibody and detects induced antibodies

This report documents the validation of an assay using BIAcore 2000 that, with a single injection of mouse serum, allows the quantitation of a humanized monoclonal antibody and can also detect the presence of antibodies directed against this humanized antibody. The important components required for the validation of biosensor assays including precision, accuracy, linearity, stability of the immobilized ligand, specificity and sensitivity are addressed. The tandem assay that is used as a model for biosensor validations is accomplished by flowing each sample across the surface of two flowcells in sequence. The first flowcell has the antigen that the humanized mAb was generated against immobilized while the humanized mAb itself is immobilized on the second flowcell. The quantitation component of this assay is precise and accurate with a limit of quantitation of 1 microg/ml in mouse serum samples. Any antibodies directed against the humanized mAb can be detected and also characterized as to isotype. This unique assay can be performed with as little as 10 microl of serum which is then diluted ten-fold prior to analysis. The small sample requirement allows analysis of individual mouse serum samples rather than requiring the use of pooled samples from multiple mice. A further advantage of this assay is the automation capability which allows unattended operation.

Adrenal function predicts demoralization after losses

Stressful experiences can cause disturbances in the hypothalamic-pituitary-adrenocortical axis and the sympathetic-adrenomedullary system. The authors hypothesized that assessments of adrenal function made in the circumstances of stressful losses would predict outcome 1 or 2 years later. The authors collected 24-hour urinary free cortisol, serum cortisol, and 24-hour urinary catecholamines 2 months after intake and used these measures as predictors of depression, anxiety, hopelessness/helplessness, unresolved grief, self-rated health, and help-seeking behavior on follow-up at 13 and 25 months. Adrenal function in the circumstances of a loss predicted only demoralization scores (hopelessness/helplessness) on follow-up.

Comparison of open and laparoscopic live donor nephrectomy

OBJECTIVE

This study compares an initial group of patients undergoing laparoscopic live donor nephrectomy to a group of patients undergoing open donor nephrectomy to assess the efficacy, morbidity, and patient recovery after the laparoscopic technique.

SUMMARY BACKGROUND DATA

Recent data have shown the technical feasibility of harvesting live renal allografts using a laparoscopic approach. However, comparison of donor recovery, morbidity, and short-term graft function to open donor nephrectomy has not been performed previously.

METHODS

An initial series of patients undergoing laparoscopic live donor nephrectomy were compared to historic control subjects undergoing open donor nephrectomy. The groups were matched for age, gender, race, and comorbidity. Graft function, intraoperative variables, and clinical outcome of the two groups were compared.

RESULTS

Laparoscopic donor nephrectomy was attempted in 70 patients and completed successfully in 94% of cases. Graft survival was 97% versus 98% (p = 0.6191), and immediate graft function occurred in 97% versus 100% in the laparoscopic and open groups, respectively (p = 0.4961). Blood loss, length of stay, parenteral narcotic requirements, resumption of diet, and return to normal activity were significantly less in the laparoscopic group. Mean warm ischemia time was 3 minutes after laparoscopic harvest. Morbidity was 14% in the laparoscopic group and 35% in the open group. There was no mortality in either group.

CONCLUSIONS

Laparoscopic live donor nephrectomy can be performed with morbidity and mortality comparable to open donor nephrectomy, with substantial improvements in patient recovery after the laparoscopic approach. Initial graft survival and function rates are equal to those of open donor nephrectomy, but longer follow-up is necessary to confirm these observations.

Traumatic grief as a risk factor for mental and physical morbidity

OBJECTIVE

The aim of this study was to confirm and extend the authors' previous work indicating that symptoms of traumatic grief are predictors of future physical and mental health outcomes.

METHOD

The study group consisted of 150 future widows and widowers interviewed at the time of their spouse's hospital admission and at 6-week and 6-, 13-, and 25- month follow-ups. Traumatic grief was measured with a modified version of the Grief Measurement Scale. Mental and physical health outcomes were assessed by self-report and interviewer evaluation. Survival analysis and linear and logistic regressions were used to determine the risk for adverse mental and physical health outcomes posed by traumatic grief.

RESULTS

Survival and regression analyses indicated that the presence of traumatic grief symptoms approximately 6 months after the death of the spouse predicted such negative health outcomes as cancer, heart trouble, high blood pressure, suicidal ideation, and changes in eating habits at 13- or 25-month follow-up.

CONCLUSIONS

The results suggest that it may not be the stress of bereavement, per se, that puts individuals at risk for long-term mental and physical health impairments and adverse health behaviors. Rather, it appears that psychiatric sequelae such as traumatic grief are of critical importance in determining which bereaved individuals will be at risk for long-term dysfunction.

Using research for successful Medicare and Medicaid risk marketing

Medicare/Medicaid risk marketing is a vital business challenge, one that countless managed care organizations are facing right now. Early entry into new markets and aggressive participation in existing markets are essential to meet competitive pressures. Health plans intent on success in government risk programs should conduct research to learn the medical needs, wants, and desires of older persons in the geographic area they serve. Original, market-specific research yields critical marketing and clinical data that can be used to improve care and member satisfaction along with customer loyalty and retention.

Assessment of the agreement between cardiac output measured by bolus thermodilution and continuous methods, with particular reference to the effect of heart rhythm

Cardiac output (CO) is a fundamentally important haemodynamic parameter and its continuous measurement has the potential to enable early recognition of haemodynamic trends and earlier therapeutic response. A method of continuous cardiac output (CCO) monitoring is now available for clinical use. The accuracy and reliability of this method has been confirmed in clinical trials but not, to our knowledge, in the presence of abnormal heart rhythms. A comparison was made between CCO and bolus thermodilution methods, to determine if there is a greater difference between their respective determinations of CO when heart rhythm is abnormal. A convenience sample of 38 intensive care patients was used to obtain 410 comparisons of CCO and bolus CO determinations. Heart rhythm associated with each comparison was determined. The comparison produced a measurement bias of -0.07 l/min and limits of agreement of -1.77 to 1.63 l/min. The bias of the two measurements was -0.35 l/min for sinus rhythm, -0.19 l/min for sinus tachycardia and -0.12 l/min for atrial flutter/fibrillation. Increased temperature and heart rate did not affect measurement agreement. In conclusion, the agreement between the bolus and continuous methods is clinically acceptable and is unaffected by the heart rhythms of sinus rhythm, sinus tachycardia and atrial flutter/fibrillation.