Strengthening the Capacity of Emergency Medical Services in Low and Middle Income Countries using Dispatcher-Coordinated Taxis

International standards recommend provision of 1 ambulance for every 50,000 people to fulfil demand for transporting patients to definitive care facilities in Low and Middle Income Countries (LMICs). Governments' consistent attempt to build capacity of emergency medical services (EMS) in LMICs has been financially demanding. This study is an attempt to assess the feasibility of capacity building of existing EMS in Delhi, India by using taxis as an alternative mode of transport for emergency transportation of road traffic crash victims to enable improvement in response time for road traffic crashes where time criticality is deemed important. Performance of the proposed system is evaluated based on response time, coverage and distance. The system models the performance and quantifies the taxi - ambulance configuration for achieving EMS performance within international standards.

Short-tem Post Renal Trasplant Follow-up at Madinah Al Munawarah

We reviewed the records of the renal transplant patients followed at our hospital to determine short-term outcome and complications. Sixty-five renal transplant patients, follow-up for two years were included in this study. Of these patients 40 (61.5%) were males, 33 (50.7%) were Saudis with mean age of 37.2 +/- 11.7 years. Donors were living related (LRD) in 23 (35%), living non-related (LNRD) in 27 (42%) and cadaveric (CAD) in 15 (23%). Thirty-two transplants were carried out at Medinah, 21 in India and the rest in other centers inside Saudi Arabia. Immunosuppression was based on a triple therapy (Cyclosporin, Azathioprine, and Prednisone). At two years, 52 (80%) patients were alive, with functioning graft in 31 (58%). Causes of death among 13 patients (11 LNRD & 2 CAD) were infections in 7 (54%), immediate post transplant in three (22.7%), acute myocardial infarction in two (15.7%), CVA in one (7.6%). Complications encountered were acute rejection (23 episodes) in 18 923.6%) patients, infections in 19 (25%), chronic rejection in 16 (21.5%), surgical in 13 917.1%), diabetes mellitus in 5 (6.5%) primary non-function in three (3.8%) and Kaposi Sarcoma in two (2.4%). Twenty-six (81.25%) out of 32 transplants performed in Madinah were functioning, four (12.5%) patients returned to dialysis and two (6.25%) patients died. Among the 21 transplants done in India 11 (52%) patients died, six (28.6%) returned to dialysis, and four (19.4%) had function deteriorated in all patients. We conclude that despite limitations, results of renal transplantation carried out at Madinah are encouraging on short-term basis. Live related transplant has a very good outcome, while commercial transplantation carries poor prognosis.

Predictive value of intraoperative biopsies and liver function tests for preservation injury in orthotopic liver transplantation

Eighty liver allografts were studied to determine the predictive value of intraoperative biopsies and postoperative liver function tests for the development of preservation injury (PI). Peak transaminase (aspartate transaminase [AST] and alanine transaminase [ALT]) and prothrombin time (PT) values achieved by each patient during postoperative days (POD) 1 through 7 were determined. PI in day 0 preperfusion biopsies (0Pre) (obtained immediately before implantation) and postperfusion biopsies (0Post) (obtained immediately after revascularization) was categorized by histological criteria as present or absent. PI in biopsies taken during POD 2 through 14 was histologically graded as either moderate-to-severe, mild, or absent. Of the 80 allografts, 8 were omitted because of primary nonfunction or postoperative complications. 0Pre and 0Post biopsies were available on 25 of 72 (35%) and 69 of 72 (96%) allografts, respectively. Only 2 (8%) of the 0Pre biopsies showed histological PI compared with 48 (70%) of the 0Post biopsies. Fifty-nine patients were biopsied between POD 2 through 14. Of these, 15, 28, and 16 patients developed moderate-to-severe, mild, or no evidence of PI, respectively. The presence of PI in the 0Post biopsy strongly correlated with the development of PI during POD 2 through 14 (P < .0005). Peak AST and ALT values in patients with moderate-to-severe PI on POD 2 through 14 were significantly elevated compared with those patients with either mild (P = .01 and .03) or no PI (P = .02 and .006). Because of extensive overlap in AST and ALT values between the three groups, however, transaminase values were not useful in predicting the presence or absence of PI in the individual case. The development of PI during POD 2 through 14 correlated with advanced donor age (P = .06) but was unassociated with 0Pre biopsy findings, cold ischemia time, or peak PT values. We conclude that the 0Post biopsy is a valuable tool for the prediction of subsequent PI in the early postoperative period. In contrast, 0Pre biopsy findings and peak AST and ALT values are not useful in the assessment of PI.

Renal transplantation at the jeddah kidney center

Renal transplantation is the optimal treatment for patients with end-stage renal failure. During the period 1991 to 1995, a total of 279 renal transplantations were performed at the Jeddah Kidney Center. They included 115 kidneys from cadaveric donors and 164 living related donor transplants. There were 160 males and 119 females; age of the patients ranged between 4 and 45 years. During the follow-up period, 32 grafts were lost and 26 patients died. The overall 5-year graft and patient survival rates were 79.2% and 90.7% respectively. Sepsis and pulmonary embolism constituted the common causes of death.

Orthotopic liver transplantation at king faisal specialist hospital and research center: 1994-1995

Over the last decade, orthotopic liver transplantation (OLT) has become an established therapy for end-stage liver disease of various etiologies. The early experience with orthotopic liver transplantation in the Kingdom was in 1990 in the Military Hospital when a man with sclerosing cholangitis received a new liver successfully. Intensive effort was done at King Faisal Specialist Hospital and Research Center (KFSH & RC) to start liver transplantation and that was achieved in March 1994 when a man with an end-stage liver failure secondary to hepatitis C was transplanted successfully. Since then, forty four (44) more liver transplantations were done at KFSH & RC. The age of the patients transplanted ranged from 9-65 years old; there were more males than females, (26 males, 15 females). The waiting time until transplantation was up to one year. All patients received a combination of cyclosporin and prednisolone as an induction therapy +/- Azathioprime. The majority of patients developed minor complications like wound infection and acute mild cellular rejection. In the second year, 3 out of 18 patients also developed primary non-function. Also in the first year, the majority of the patients developed primary dysfunction; however, this decreased significantly in the second year. The majority of the patients who were transplanted for hepatitis C had mild recurrence. None of them lost their livers because of recurrence of hepatitis C. Several patients developed biliary complications including bile leak and stricture at duct-to-duct anastomosis.

Renal transplant experience at king fahad national guard hospital

Between September 1988 and end of 1995, 170 renal transplantations were performed at the King Fahad National Guard Hospital, Riyadh. There were 102 cadaver donor (CAD) and 68 living related donor (LRD) transplants. All patients received triple drug immunosuppression. Patients with delayed graft function received anti-thymocyte globulin instead of cyclosporin until recovery of graft function. The 1,3 and 5 year graft survival was as follows: all transplants 83.5%, 77.6%, 74.7% respectively; LRD transplants, 89.7%, 85.2%, 80.9% respectively; CAD transplants, 81.0%, 72.5%, 70.5% respectively. The commonest cause of graft loss was chronic rejection. The 1,3 and 5 year patient survival was as follows: all transplants, 97.0%, 94.7%, 93.5% respectively; LRD transplants, 98.5%, 97.0%, 95.5% respectively; CAD transplants, 96.0%, 93.0%, 92.0% respectively. The overall results in our center are comparable to those published from other centers in Saudi Arabia and abroad.

Need for reduction of cyclosporin dosage in renal transplant patients with hypertriglyceridemia but not hypercholesterolemia

Currently there is a paucity of data regarding the influence of high serum triglyceride levels on cyclosporin A (CyA) levels and dosing. We therefore undertook a retrospective study to determine the relationship of serum lipid levels to CyA levels and CyA dosages. Renal transplant patients at a 0.5-to-3-year post-transplant stage, with a stable CyA dosage, who were not on medications that affect CyA metabolism or renal function, were entered into the study. The CyA dosage was adjusted by clinicians to maintain whole blood. 12-h CyA trough levels between 200 and 250 ng/ml (monoclonal TDX method, which measures the parent compound). Forty-four patients qualified for the study. The data clearly indicated that high cholesterol levels (> 300 mg/dl and with normal triglyceride levels) did not influence the CyA levels or the dosages. Conversely, high triglyceride levels ( > 500 mg/dl) significantly reduced the amount of CyA required. A decreased clearance of CyA in the presence of hypertriglyceridemia led to high CyA levels in some patients. Reducing the CyA dosage to achieve levels between 200 and 250 ng/ml improved renal allograft function and decreased other side effects attributed to CyA toxicity. These studies indicate that high triglyceride levels, but not high cholesterol levels, increase CyA levels, which can lead to CyA toxicity.

Spontaneous rupture of renal allograft

Spontaneous rupture of a renal allograft was encountered in 3 male patients among 75 consecutive renal transplants over a three-year period. In 1 patient, the transplant was from a living related donor, while the other two were cadaveric kidneys from pediatric donors. In 2 patients, allograft rupture followed steroid-resistant rejection, while in the third with cadaveric kidney transplant, the rupture was associated with renal vein thrombosis. Two patients presented with classic symptoms of renal allograft rupture: sudden onset of severe pain and swelling over the allograft and hypotension, while in the third the rupture was found during exploration of the allograft with clinical diagnosis of renal artery thrombosis. Transplant nephrectomy was done in 2 patients, while successful surgical repair was performed in the third patient with living related transplant.