Building knowledge, optimising physical and mental health and setting up healthier life trajectories in South African women (Bukhali): a preconception randomised control trial part of the Healthy Life Trajectories Initiative (HeLTI)

INTRODUCTION

South Africa's evolving burden of disease is challenging due to a persistent infectious disease, burgeoning obesity, most notably among women and rising rates of non-communicable diseases (NCDs). With two thirds of women presenting at their first antenatal visit either overweight or obese in urban South Africa (SA), the preconception period is an opportunity to optimise health and offset transgenerational risk of both obesity and NCDs.

METHODS AND ANALYSIS

Bukhali is the first individual randomised controlled trial in Africa to test the efficacy of a complex continuum of care intervention and forms part of the Healthy Life Trajectories Initiative (HeLTI) consortium implementing harmonised trials in Canada, China, India and SA. Starting preconception and continuing through pregnancy, infancy and childhood, the intervention is designed to improve nutrition, physical and mental health and health behaviours of South African women to offset obesity-risk (adiposity) in their offspring. Women aged 18-28 years (n=6800) will be recruited from Soweto, an urban-poor area of Johannesburg. The primary outcome is dual-energy X-ray absorptiometry derived fat mass index (fat mass divided by height²) in the offspring at age 5 years. Community health workers will deliver the intervention randomly to half the cohort by providing health literacy material, dispensing a multimicronutrient supplement, providing health services and feedback, and facilitating behaviour change support sessions to optimise: (1) nutrition, (2) physical and mental health and (3) lay the foundations for healthier pregnancies and early child development.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Human Ethics Research Committee University of the Witwatersrand, Johannesburg, South Africa (M1811111), the University of Toronto, Canada (19-0066-E) and the WHO Ethics Committee (ERC.0003328). Data and biological sample sharing policies are consistent with the governance policy of the HeLTI Consortium (https://helti.org) and South African government legislation (POPIA). The recruitment and research team will obtain informed consent.

TRIAL REGISTRATION

This trial is registered with the Pan African Clinical Trials Registry (https://pactr.samrc.ac.za) on 25 March 2019 (identifier: PACTR201903750173871).

PROTOCOL VERSION

20 March 2022 (version #4). Any protocol amendments will be communicated to investigators, Institutional Review Board (IRB)s, trial participants and trial registries.

Using 3D-UPLC-DAD and a new method-verification by adding mixture standard compounds to determine the fingerprint and eight active components of Naoluoxintong decoction

Naoluoxintong decoction (NLXTD) is a traditional Chinese formula which has been used for the management of ischemic stroke in China for two hundred years. In this study, we developed a comprehensive and reliable analytical method to qualitatively analyze the components in NLXTD. This novel method was based on three-dimensional ultra-fast high performance liquid chromatography coupled with diode array detector (3D-UPLC-DAD) with an additional component validation method via incorporation of the mixture standard compounds during the verification step. In addition, the relationship between active components and "Monarch drug, Minster drug, Assistant drug, Guide drug" were determined. Our results showed that gradient elution with the mobile phase of 0.02% formic acid and methanol was the optimum condition to separate peaks. A total of 35 common peaks were established by comparing ten batches of NLXTD, and eight components were identified, including Calycosin, Calycosin-7-O-β-d-glucoside and Ononin in Astragali radix (Monarch drug); Ligustrazine in Chuanxiong Rhizoma (Minster drug); 4-Hydroxbenzyl alcohol and Parishin A in Gastrodiae rhizome (Assistant drug); Ferulic acid in Angelicae sinensis radix (Guide drug). The validation method of verification by adding mixture standard compounds combined with 3D-UPLC-DAD method, with the merits of greater resolution, higher speed of analysis and higher sensitivity, provided a semi-quantitative and qualitative analysis method to assess traditional Chinese medicinal prescription consisting of many bio-active components. Finally, our study has provided systemic and scientific evidence to explain the relationship between the bio-active components in the NLXTD and traditional Chinese medicine theory.

Social support needs of Sudanese and Zimbabwean refugee new parents in Canada

Purpose

The purpose of this paper is to examine support needs of African refugee new parents in Canada, and identifies support preferences that may enhance the mental health of refugee parents and children.

Design/methodology/approach

In all, 72 refugee new parents from Zimbabwe (n=36) and Sudan (n=36) participated in individual interviews. All had a child aged four months to five years born in Canada. Refugee new parents completed standardized measures on social support resources and support seeking as a coping strategy. Four group interviews (n=30) with refugee new parents were subsequently conducted. In addition, two group interviews (n=30) were held with service providers and policy influencers.

Findings

Separated from their traditional family and cultural supports, refugee new parents reported isolation and loneliness. They lacked support during pregnancy, birth, and postpartum and had limited interactions with people from similar cultural backgrounds. Refugees required support to access services and overcome barriers such as language, complex systems, and limited financial resources. Support preferences included emotional and information support from peers from their cultural community and culturally sensitive service providers.

Research limitations/implications

Psychometric evaluation of the quantitative measures with the two specific populations included in this study had not been conducted, although these measures have been used with ethnically diverse populations by other researchers.

Practical implications

The study findings can inform culturally appropriate health professional practice, program and policy development.

Originality/value

The study bridges gaps in research examining support needs and support intervention preferences of African refugee new parents.

Balancing selection on MHC class I in wild brown trout Salmo trutta

Evidence is reported for balancing selection acting on variation at major histocompatibility complex (MHC) in wild populations of brown trout Salmo trutta. First, variation at an MHC class I (satr-uba)-linked microsatellite locus (mhc1) is retained in small S. trutta populations isolated above waterfalls although variation is lost at neutral microsatellite markers. Second, populations across several catchments are less differentiated at mhc1 than at neutral markers, as predicted by theory. The population structure of these fish was also elucidated.

Use of computed tomography pulmonary angiography in the diagnosis of pulmonary embolismin patients with an intermediate probability ventilation/perfusion scan

BACKGROUND

Computed tomography pulmonary -angiography (CTPA) plays an increasingly important role in the diagnosis of pulmonary embolism (PE). Although accurate in the detection of large PE, its accuracy in other patient groups is yet to be defined.

AIM

To compare CTPA with pulmonary angiography as a second-line investigation in patients with a ventilation/perfusion (VQ) scan indicating an intermediate probability of PE.

METHODS

We recruited 25 patients over a 17-month period. Subjects were eligible if they: (i). had clinically suspected PE, (ii). had a VQ scan indicating an intermediate probability of PE and (iii). were referred for pulmonary angiography. Subjects underwent CTPA within 36 h of the VQ scan. CTPA was interpreted without knowledge of the results of the pulmonary angiogram by two of the authors.

RESULTS

PE was prevalent (i.e. embolus detected at pulmonary angiography) in seven of 25 subjects (28%). The sensitivity of CTPA was 57% and the specificity was 94%.

CONCLUSIONS

In the setting of intermediate-probability VQ scanning, CTPA may be used to clarify the diagnosis of PE. However, a negative CTPA cannot -definitely exclude PE. Conventional pulmonary angiography may be necessary to determine the presence of PE if CTPA is negative.

Histone tails modulate nucleosome mobility and regulate ATP-dependent nucleosome sliding by NURF

Nucleosome Remodeling Factor (NURF) is an ATP-dependent nucleosome remodeling complex that alters chromatin structure by catalyzing nucleosome sliding, thereby exposing DNA sequences previously associated with nucleosomes. We systematically studied how the unstructured N-terminal residues of core histones (the N-terminal histone tails) influence nucleosome sliding. We used bacterially expressed Drosophila histones to reconstitute hybrid nucleosomes lacking one or more histone N-terminal tails. Unexpectedly, we found that removal of the N-terminal tail of histone H2B promoted uncatalyzed nucleosome sliding during native gel electrophoresis. Uncatalyzed nucleosome mobility was enhanced by additional removal of other histone tails but was not affected by hyperacetylation of core histones by p300. In addition, we found that the N-terminal tail of the histone H4 is specifically required for ATP-dependent catalysis of nucleosome sliding by NURF. Alanine scanning mutagenesis demonstrated that H4 residues 16-KRHR-19 are critical for the induction of nucleosome mobility, revealing a histone tail motif that regulates NURF activity. An exchange of histone tails between H4 and H3 impaired NURF-induced sliding of the mutant nucleosome, indicating that the location of the KRHR motif in relation to global nucleosome structure is functionally important. Our results provide functions for the N-terminal histone tails in regulating the mobility of nucleosomes.

Primary pulmonary botryomycosis: an important differential diagnosis for lung cancer

This is the sixteenth reported case of pulmonary botryomycosis, an uncommon suppurative bacterial infection of the lung. We describe the case of a 69-year-old man who presented with a chronic cough and intermittent haemoptysis and on subsequent chest computed tomographic scan imaging was found to have a right lower lobe mass. He underwent a right lower lobectomy for presumed lung cancer. Histological analysis however revealed a bacterial aetiology. The past literature is reviewed outlining the pathogenesis and difficulties of clinical and radiological diagnosis. Primary pulmonary botryomycosis forms an important curative differential diagnosis for lung cancer.

Short-term implicit memory: visual, auditory, and cross-modality priming

Short-term implicit memory was examined for mixed auditory (A) and visual (V) stimuli. In lexical decision, words and nonwords were repeated at lags of 0, 1, 3, and 6 intervening trials, in four prime-target combinations (VV, VA, AV, AA). Same-modality repetition priming showed a lag x lexicality interaction for visual stimuli (nonwords decayed faster), but not for auditory stimuli (longer lasting smooth decay for both words and nonwords). These modality differences suggest that short-term priming has a perceptual locus, with the phonological lexicon maintaining stimuli active longer than the orthographic lexicon and treating pseudowords as potential words. We interpret these differences in terms of the different memory needs of speech recognition and text reading. Weak cross-modality short-term priming was present for words and nonwords, indicating recoding between perceptual forms.

Can computerization of the exercise test replace the cardiologist?

BACKGROUND

The type of practitioners who use the standard exercise test is changing. Once a tool of the cardiologist, the standard exercise test is now being performed by internists and other noncardiologists. Because this change could be facilitated by computerization similar to the computerized interpretation programs available for the resting electrocardiograph (ECG), we performed this analysis. A secondary aim was to demonstrate the effects of medication status and resting ECG abnormalities on test diagnostic characteristics because these factors affect utility of the exercise test by the generalist.

METHODS AND RESULTS

A retrospective analysis was performed of consecutive patients referred at 2 university-affiliated Veteran's Affairs Medical Centers and a Hungarian Hospital for evaluation of chest pain and possible ischemic heart disease. There were 1384 consecutive male patients without a prior myocardial infarction with complete data who had exercise tests and coronary angiography between 1987 and 1997. Measurements included clinical, exercise test data, and visual interpretation of the ECG recordings as well as more than 100 computed measurements from the digitized ECG recordings and compilation of angiographic data from clinical reports. The computer measurements had similar diagnostic power compared with visual interpretation. Computerized measurements from maximal exercise or recovery were equivalent or superior to all other measurements. Prediction equations applied by computer were superior to single ECG measurements. Beta-blockers had no effect on test characteristics, whereas resting ST depression was associated with decreased specificity and increased sensitivity.

CONCLUSIONS

Computerized exercise ST measurements are comparable to visual ST measurements by a cardiologist; computerized scores that included clinical and exercise test results exhibited the greatest diagnostic power. Applying scores with a computer allows the practicing physician to improve the diagnostic characteristics of the standard exercise test. This approach is successful even when there is resting ST depression, thus lessening the need for more expensive nuclear or imaging studies.

The electrocardiographic exercise test in a population with reduced workup bias: diagnostic performance, computerized interpretation, and multivariable prediction. Veterans Affairs Cooperative Study in Health Services #016 (QUEXTA) Study Group. Quantitative Exercise Testing and Angiography

BACKGROUND

Empirical scores, computerized ST-segment measurements, and equations have been proposed as tools for improving the diagnostic performance of the exercise test.

OBJECTIVE

To compare the diagnostic utility of these scores, measurements, and equations with that of visual ST-segment measurements in patients with reduced workup bias.

DESIGN

Prospective analysis.

SETTING

12 university-affiliated Veterans Affairs Medical Centers.

PATIENTS

814 consecutive patients who presented with angina pectoris and agreed to undergo both exercise testing and coronary angiography.

MEASUREMENTS

Digital electrocardiographic recorders and angiographic calipers were used for testing at each site, and test results were sent to core laboratories.

RESULTS

Although 25% of patients had previously had testing, workup bias was reduced, as shown by comparison with a pilot study group. This reduction resulted in a sensitivity of 45% and a specificity of 85% for visual analysis. Computerized measurements and visual analysis had similar diagnostic power. Equations incorporating nonelectrocardiographic variables and either visual or computerized ST-segment measurement had similar discrimination and were superior to single ST-segment measurements. These equations correctly classified 5 more patients of every 100 tested (areas under the receiver-operating characteristic curve, 0.80 for equations and 0.68 for visual analysis; P < 0.001) in this population with a 50% prevalence of disease.

CONCLUSIONS

Standard exercise tests had lower sensitivity but higher specificity in this population with reduced work-up bias than in previous studies. Computerized ST-segment measurements were similar to visual ST-segment measurements made by cardiologists. Considering more than ST-segment measurements can enhance the diagnostic power of the exercise test.

Aspergillus infection of the respiratory tract after lung transplantation: chest radiographic and CT findings

The objective of our study was to assess radiographic and CT findings in lung transplant patients with evidence of Aspergillus colonization or infection of the airways and correlate the findings with clinical, laboratory, bronchoalveolar lavage, biopsy and autopsy findings. The records of 189 patients who had undergone lung transplantation were retrospectively reviewed for evidence of Aspergillus colonization or infection of the airways. Aspergillus was demonstrated by culture or microscopy of sputum or bronchoalveolar lavage fluid or histologically from lung biopsies or postmortem studies in 44 patients (23 %). Notes and radiographs were available for analysis in 30 patients. In 12 of the 30 patients (40 %) chest radiographs remained normal. In 11 of 18 patients with abnormal radiographs pulmonary abnormalities were attributed to invasive pulmonary aspergillosis (IPA) in the absence of other causes for pulmonary abnormalities (8 patients) or because of histological demonstration of IPA (3 patients). In these 11 patients initial radiographic abnormalities were focal areas of patchy consolidation (8 patients), ill-defined pulmonary nodules (2 patients) or a combination of both (1 patient). In some of the lesions cavitation was demonstrated subsequently. At CT a "halo" of decreased density was demonstrated in some of the nodules and lesion morphology and location were shown more precisely. Demonstration of Aspergillus from the respiratory tract after lung transplantation does not necessarily reflect IPA but may represent colonization of the airways or semi-invasive aspergillosis. The findings in patients with IPA did not differ from those described in the literature in other immunocompromised patients, suggesting that surgical disruption of lymphatic drainage and nervous supply or effects of preservation and transport of the transplant lung do not affect the radiographic appearances.

Vitronectin expression in differentiating neuroblastic tumors: integrin alpha v beta 5 mediates vitronectin-dependent adhesion of retinoic-acid-differentiated neuroblastoma cells

The metastatic potential of undifferentiated neuroblastomas is typically lost when differentiation into ganglioneuroblastomas occurs spontaneously or is induced. Cell adhesion may play a role in metastasis, and we have shown recently that expression of integrin alpha v beta 5 protein and mRNA is up-regulated in ganglioneuroblastomas in vivo. To investigate whether interactions of alpha v beta 5 with matrix components play a role in the loss of metastatic potential, we used immunohistochemical and in situ hybridization to analyze neuroblastic tumors at various stages of differentiation for expression of the alpha v beta 5 ligands, vitronectin and osteopontin, and determined the ability of vitronectin to promote attachment and neurite outgrowth in vitro in a retinoic-acid-differentiated neuroblastoma cell model. We found that vitronectin, but not osteopontin, was expressed in 5 of 5 ganglioneuroblastomas but was absent or weakly expressed in 6 of 6 undifferentiated neuroblastomas. Neuronal cell vitronectin was detected in 7 of 9 ganglioneuromas, 5 of 8 peripheral ganglia, and 14 of 21 adrenal gland medullae, confirming expression of vitronectin in mature peripheral neurons. In vitro, vitronectin promoted attachment of both undifferentiated and retinoic-acid-differentiated neuroblastoma cells, which was inhibited 20 and 60%, respectively, by monoclonal antibody anti-integrin alpha v beta 5. Vitronectin-promoted neurite outgrowth of retinoic-acid-differentiated neuroblastoma cells was not inhibited by monoclonal antibody anti-alpha v beta 5. These data suggest that the synthesis of vitronectin and the ability of integrin alpha v beta 5 to mediate vitronectin adhesion on retinoic-acid-differentiated neuroblastoma cells may promote differentiation of neuroblastoma cells in vivo.

Measurement of health-related quality of life before and after heart-lung transplantation

BACKGROUND

The measurement of the quality of the outcome of treatment as viewed by patients is becoming increasingly recognized as an important aspect of decision making in all health services. This major study, which set out to measure the health-related quality of life outcomes of heart and lung transplantation, developed from the experience gained in the United Kingdom and United States studies of the cost and benefits of heart transplantation in the 1980s.

METHODS

The design was prospective with a cohort of patients completing a variety of generic and specific health-related quality of life questionnaires at intervals before and after heart and lung transplantation. The sample size was not prescribed; one of the aims of the project was to test the feasibility of introducing routine monitoring of health-related quality of life outcomes as an integral part of a developing transplant service.

RESULTS

Before the operation, there was evidence of deterioration over time in all dimensions of the Nottingham Health Profile. In comparing Profile scores at less than 3 months before with those at 3 to 6 months after transplantation, statistically significant improvements were evident (p < 0.001). Mean scores at intervals up to 2 years after transplantation showed little change over time and compared well with those from a general population sample. Hospital Anxiety and Depression Scale scores were reduced significantly (p < 0.01) by 1 year after heart and lung transplantation. In the pretransplantation period, at least 90% of 101 patients had some level of restriction in home and leisure activities, reducing to between 2% and 24% at 1 year after transplantation. Similarly, 79 patients (78%) had chest pain, and 101 (100%) were breathless before transplantation, reducing to 54% and 39%, respectively, at 1 year after surgery; by which time, for 8 of 10 patients, the problem was occasional.

CONCLUSIONS

Highly significant improvements were observed in the physical, social, and emotional dimensions of health-related quality of life of patients after heart-lung transplantation. The advantages and feasibility of combining generic and condition-specific questionnaires are shown together with the need to develop new measures with greater sensitivity to the smaller peaks and troughs of recovery.

Tuberculous pericarditis

A patient with a 5-month history of pericardial effusion and unsuccessful steroid treatment was found at pericardial exploration to have thickened pericardium adhered to the heart. After anterior pericardiectomy, histologic examination revealed severe granulomatous pericarditis resulting from infection with Mycobacterium tuberculosis. Despite the pericardiectomy and antituberculous therapy, the patient continued to have symptoms, including bilateral pleural effusions, 4 days after discharge from the hospital. After a second exploration (after echocardiography revealed decreased left ventricular function and hemodynamic findings showed persistent constriction), anterior and posterior cardiectomy was deemed necessary. Pleural effusion did not recur, and the patient was discharged with antituberculous drug therapy. This rare extrapulmonary form of tuberculosis can have an insidious or sudden onset, and diagnosis is complicated by false-negative tuberculin tests, nonspecific radiographic and echocardiographic findings, and time-consuming bacteriologic culture. Previous high mortality with the disease has been decreased to approximately 40% by the advent of antituberculous drug therapy. The still significant mortality reflects the difficulty in early diagnosis and the serious effects of pericardial effusion and constriction.

Identifying nursing research priorities: general and neuroscience specific at an acute care hospital

As a result of economic and health care changes the role of the nurse continues to expand and research-based practice is changing its focus. Limited resources and staff shortages have revealed new areas for research study. Clinical nurses have valuable questions to share that can form the basis of future nursing research. The purposes of the study were to: (a) Determine the priorities for nursing research within a single acute care teaching hospital; (b) Promote nurses' awareness of the importance of research-based practice; (c) Facilitate the development of future nursing research. It was assumed that nurses who carry out direct and indirect patient care roles are "experts" and therefore, are in a position to identify what they see as important questions and in need of further investigation. Three hundred and sixty-six nurses (24%) responded to round #1 of the open ended survey and submitted a total of 912 clinical practice issues. Initially, issues were broadly categorized into clinical and indirect clinical themes in a series of subcategories. Round #2 was conducted to identify nurses' ratings of the priority of the final 123 research issues for future clinical research and practice improvement efforts. Results of the two rounds will be presented, including issues identified by neuroscience nurses. This information will provide a valuable source for additional neuroscience research at either the local or international level.

Single lung transplantation for end stage emphysema

BACKGROUND

The first successful single lung transplantation was carried out in 1983 for pulmonary fibrosis. Because of the inherent advantages of single lung transplantation, a transplantation programme has been started for patients with end stage lung disease due to emphysema.

METHODS

Between October 1990 and August 1993 25 patients with severe emphysema (15 men, mean age 51 years) received a single lung transplant at our institution. All patients were severely disabled with a mean (SD) 12 minute walking distance of 281 (165) metres. There were five deaths in the series, four in the first 20 days and one on day 503. Two patients suffered graft compression by air trapping in the native lung. Bronchial narrowing requiring insertion of endobronchial stenting occurred in four patients.

RESULTS

Mean (SD) FEV1 improved from a preoperative value of 17.8(13%) predicted to a six month value of 53.6(13)%, and FEV1/FVC from 23.8(12)% to 68.6(15)%. After the transplant 12 patients are in New York Heart Association (NYHA) class I and the rest of the survivors are in NYHA II. Actuarial survival was 82% at one year and 74% at three years.

CONCLUSIONS

Single lung transplantation is an effective treatment for end stage lung disease due to emphysema and carries an acceptable mortality and morbidity.

[Radiological findings in lung transplantation]

Lung transplantation (single-lung transplantation, double-lung transplantation or heart-lung transplantation) may be the only effective therapy in end-stage pulmonary disease. At specialized institutions it has been performed on a routine basis for some years now. Diagnostic imaging plays an important role in the assessment of potential recipients as well as for the postoperative evaluation after transplantation. The aim of this review is to describe the role of imaging procedures of the chest in these patients and to demonstrate characteristic plain radiographic and computed tomographic findings. Normal postoperative findings specific to lung transplant patients as well as typical complications are presented. These include reimplantation response, acute and chronic rejection, and the typical bacterial, viral, and fungal infections as well as the sequelae of transbronchial biopsy.

Isolation and genetic mapping of two novel members of the murine Wnt gene family, Wnt11 and Wnt12, and the mapping of Wnt5a and Wnt7a

The murine Wnt genes are implicated in the control of a variety of developmental processes. Using a PCR-based approach, we have isolated two novel members of the murine Wnt gene family, Wnt11 and Wnt12. These cDNAs display an amino acid sequence identity of between 38 and 49% with all other murine Wnts over the regions that we have isolated. In addition, two previously described Wnt genes, Wnt5a and Wnt7a, were detected in RT-PCR products. Interspecific crosses were used to demonstrate close linkage between Wnt12 and Wnt1 on Chromosome (Chr) 15. Wnt7a was mapped to mouse Chr 6, Wnt5a to the centromeric region of Chr 14, and Wnt11 to Chr7.

Airway stenoses after lung transplantation: management with expanding metal stents

Success in lung transplantation has been hindered by airway complications, usually as a result of anastomotic ischemia and stenosis. We report our experience with expanding metal stents in managing airway stenoses after lung transplantation. From April 1984 through November 1993, 46 single lung, 5 double lung, and 154 heart-lung transplantations were performed at Papworth Hospital. All patients received immunosuppression with azathioprine, cyclosporine, methylprednisolone, and induction antithymocyte globulin. Fourteen patients (nine single lung, two double lung, and three heart-lung) had an airway stenosis requiring a stent. The most common features were shortness of breath, wheezing or stridor, and a fall in pulmonary function tests (11 patients). Three patients had pneumonia. Airway stenosis was diagnosed on bronchoscopy an average of 61 days after transplantation (range 3 to 245 days). Stent placement occurred an average of 18 days after the diagnosis (range 2 to 84 days). One heart-lung transplant recipient received a silicone rubber stent. All other patients received expanding metal stents. Six patients required multiple stent placements. After stent placement the average increase in the forced expiratory volume in 1 second was 117%. Infection complicated the stenoses in 12 patients. Pseudomonas aeruginosa and Aspergillus fumigatus were the most common pathogens, each occurring in six cases. Multiple pathogens were isolated in seven cases. Three patients died as a direct consequence of their airway problems. Two died of pneumonia despite stenting, and a third died of acute occlusion of the silicone rubber stent. Expanding metal stents are an effective treatment of airway stenoses in lung transplant recipients. Patients with suspected airway problems should be referred for early bronchoscopy with the potential for stent placement.

Domino heart transplantation: the Papworth experience

The use of donor hearts from heart-lung recipients, the so-called domino procedure, began at Papworth Hospital in November 1988. Between then and September 1992, 198 heart transplantations and 86 heart-lung transplantations were performed. Fifty-three heart-lung recipients donated their hearts for use in the domino procedure. Thirty-two domino hearts were transplanted at Papworth and 21 were exported to other centers. Institution of the domino procedure allowed us to perform 19% more heart transplantations (166 to 198) than would have been done had the procedure not been used. The ischemic time was significantly shorter for the domino hearts compared with organs from brain dead donors (134 minutes versus 191 minutes; p < 0.001). No difference was found in the 3-month (84% versus 83%) or 1-year (74% versus 76%) survival between domino and nondomino recipients. Other potential advantages of the domino procedure include detailed pretransplantation evaluation of the heart in live donors and the potential for human leukocyte antigen matching. Additionally many heart-lung recipients have elevated pulmonary artery pressures and a "conditioned", hypertrophied right ventricle. The use of such hearts for heart transplantation has theoretic appeal for patients with elevated pulmonary vascular resistance.

Expandable metal stents for tracheobronchial obstruction

We report our experience of the use of endoscopically inserted expanding stainless steel stents in 18 patients over a period of 31 months. Twelve patients had stents inserted for malignant disease causing narrowing of the tracheobronchial tree, and six for airway complications following heart-lung, single lung or double lung transplantation. In all but one case, stents were satisfactorily positioned, and there were no complications related to stent insertion. Seven patients were alive at follow-up, three of whom had stents inserted for malignancy and four as a result of complications following transplantation.

Who waits longest for heart and lung transplantation?

Between August 1982 and December 1992, 260 patients were accepted for heart and lung transplantation, of whom 139 patients underwent transplant surgery. One hundred twenty-one patients have not received transplants, of whom 80 have died, four were transferred to other lists, and 37 were still waiting for suitable organs at the close of the study. Median waiting time for those patients who underwent heart and lung transplantation was 7 months, whereas patients who died waiting spent a median of 5 months on the list. Recipients are matched to donor organs according to blood type, size (total lung capacity), and cytomegalovirus antibody status. These factors, along with age, gender, underlying diagnosis, and Toxoplasma antibody status, were studied to assess their influence on survival after acceptance and time to transplantation. The only characteristic that significantly influenced survival after acceptance was the underlying disease, with patients with Eisenmenger's syndrome having significantly longer survival than the other groups (relative risk = 0.21; p < 0.001). Patients with Eisenmenger's syndrome underwent transplantation at a slower rate than did other patients (relative risk = 0.51; p = 0.012). Patients who had a total lung capacity of more than 6 L underwent transplantation significantly more quickly than did smaller patients (relative risk = 1.98; p = 0.005). Male patients underwent heart and lung transplantation at a quicker rate than did female patients (relative risk = 1.86; p < 0.001), although this was related to size. Patients who had cytomegalovirus-positive antibodies underwent transplantation at almost twice the rate of patients who had cytomegalovirus-negative antibodies (relative risk = 1.92; p < 0.001). Age at acceptance, blood type, and Toxoplasma status did not significantly influence time to heart and lung transplantation. In summary, cytomegalovirus antibody status, patient size, and gender significantly affect the waiting time to heart and lung transplantation. Patients with Eisenmenger's syndrome wait longer than other patients as a result of the natural history of their disease.

Risk factors for survival following combined heart-lung transplantation. The first 100 patients

As the numbers of heart and lung transplant recipients have increased it has become possible to identify major risk factors for early (within 3 months) and later (after 3 months) death after this procedure. For 100 patients receiving organs between April 1984 and February 1991, and followed up until February 1992, patient characteristics, operative details, and early morbidity were assessed for their effects on early and later deaths. Recipient age, sex, and preoperative diagnosis did not have a significant effect on early (within 3 months) or later death. Positive cytomegalovirus antibody status of donor or recipient conferred greater risk of death within 90 days (odds ratio [OR] = 3.24, P = 0.06). Greater than 2 L blood in the first 24 hr after operation (OR = 6.00, P = 0.05), and ventilation for greater than 24 hr (OR = 4.87, P = 0.006) were significant prognostic indicators of early death. After the first 3 months, the main risk factor for death was rejection in the first 3 months (OR = 1.38 per episode, P = 0.008). Early infection in general and CMV infection in particular were associated with a small increase in risk. This study confirms the importance of matching donor and recipient for CMV and shows that difficulties during operation, reflected in postoperative bleeding and ventilation times increased the chance of early death. Later death was associated with early acute rejection. A detrimental effect of infection, including CMV infection, either does not exist, or is too small to be detected in a study of this size.