Bacteriology laboratories and musculoskeletal tissue banks in Australia

In Australia, there are six Therapeutic Goods Administration–licensed clinical bacteriology laboratories providing bacterial and fungal bioburden testing of allograft musculoskeletal samples sent from 10 tissue banks. Musculoskeletal swab and/or tissue biopsy samples are collected at the time of allograft retrieval and sent to bacteriology laboratories for bioburden testing, in some cases requiring interstate transport. Bacteria and fungi may be present within the allograft at the time of retrieval or contaminated from an external source. The type of organism recovered will determine if the allograft is rejected for transplant, which may include all allografts from the same donor. Bacteriology staff also provides unpaid support of tissue banks through meeting involvement, consultations, licence‐related activities, validations and research funded by their organisation and not part of any contractual agreement. Bacteriology laboratories and tissue banks must be compliant to the Code of Good Manufacturing Practice – Human Blood and Tissues and regulated by the Therapeutic Goods Administration. Clinical bacteriology laboratories also require mandatory accreditation to Standards Australia International Organisation for Standardisation (ISO) 15189:2009 medical laboratories – particular requirements for quality and competence, and may also attain Standards Australia/New Zealand Standard ISO 9001:2000 quality management systems certification. Bacteriology laboratories and musculoskeletal tissue banks are integral partners in providing safe allograft musculoskeletal tissue for transplant.     

Pharmacologic approaches to composite tissue allograft

This article discusses the pharmacologic approaches and the most promising new compounds for composite tissue allograft tolerance. Although some approaches rely on a combination of immunosuppressive agents that act synergistically against rejection, other strategies use immunologic manipulation, including major histocompatibility complex matching, induction of chimerism, and use of monoclonal antibodies to abrogate the immune response. There is still a need, however, to reproduce these findings in species phylogenetically closer to humans. This may be the target of future research efforts, which may overcome the challenge of limb and face transplant rejection.     

同种异体骨与血管组织深低温冷藏的时限研究

目的 研究储藏在液氮中的带血管蒂骨组织保持存活状态的时限，为下一步行带血管蒂的骨移植提供理论依据。方法 对冷藏不同时段的带血管蒂骨组织进行组织学、电镜及琥珀酸脱氢酶(SDH)染色。结果 酚冷藏4个月后的骨组织结构形态学正常，骨细胞SDH染色阳性，而冷藏6个月后的骨组织有线粒体肿胀的超微结构改变，骨细胞SDH染色阴性；冷藏6个月后的血管结构形态学正常，内膜SDH染色阳性。结论存储于液氮中的带血管蒂骨组织维持存活状态的最佳时限为4个月。     

Biopsy of musculoskeletal tumours--beware

BACKGROUND: Biopsy of musculoskeletal tumours is hazardous and, when poorly performed, can compromise limb salvage surgery and patient survival. The aim of the present paper is to examine the early management of such patients referred to the Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Sydney, Australia with particular reference to biopsy. METHODS: We conducted a prospective audit of all patients referred to our musculoskeletal tumour service during 2002. Inclusion criteria were: all patients with primary tumours of the musculoskeletal system. We compared the outcome of patients biopsied prior to referral with that of patients biopsied in a recognized treatment centre. RESULTS: One hundred and forty-two patients were included. The referring surgeon performed biopsies in 29 cases, of which 20 were malignant lesions. The senior author biopsied the remaining 113 cases, of which 57 were malignant. Definitive treatment was hindered by a badly performed biopsy in 38% of patients biopsied by the referring surgeon. In 25% the definitive treatment had to be changed either to a more radical procedure than would have originally been necessary or to palliative rather than curative intent. Patients biopsied elsewhere were more likely to have an incomplete excision requiring re-excision, more likely to require amputation, and more likely to require adjuvant radiotherapy. CONCLUSIONS: There is a high complication rate when patients with musculoskeletal tumours are biopsied by surgeons inexperienced in their management. These patients are better served by early referral to a specialist centre where staging investigations including biopsy can be performed with minimal morbidity.     

Comparison of the risk of viral infection between the living and nonliving musculoskeletal tissue donors in Australia

Screening of musculoskeletal tissue donors with nucleic acid testing (NAT) for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) has been implemented in the United States and other developed nations. However, in contrast to the donor demographics in the United States, the majority of Australian musculoskeletal tissue donations are primarily from living surgical donors. The objective of our study was to determine and compare the risk of viral infection associated with musculoskeletal tissue donation from living and nonliving donors in Australia. We studied serum samples from 12 415 consecutive musculoskeletal tissue donors between 1993 and 2004. This included 10 937 surgical donations, and 1478 donations obtained from postmortem organ donation patients and cadaveric donors. Current mandatory retesting of surgical donors 6 months postdonation reduces the risk of viral infection by approximately 95% by eliminating almost all donors in the window period. The addition of nucleic acid amplification testing for nonliving donors would similarly reduce the window period, and consequently the residual risk by approximately 50% for hepatitis B virus, 55% for HIV, and 90% for HCV. NAT, using appropriately validated assays for nonliving donors, would reduce the residual risk to levels comparable to that in living donors (where the 95% reduction for quarantining pending the 180‐day re‐test is included).     

Use of cidofovir in polyomavirus BK viral nephropathy in two renal allograft recipients

Polyomavirus BK viral allograft nephropathy is a potentially reversible cause of deteriorating function of kidney allografts. Initial treatment involves reducing immunosuppressive medications, with low-dose cidofovir an effective alternative in refractory cases. We describe two cases of BK viral allograft nephropathy responding to low-dose cidofovir after a reduction in immunosuppressive medications failed to clear the virus or stabilize the deterioration in renal function. There were no significant side-effects from this treatment in either patient.     

Validation of 11 kGy as a Radiation Sterilization Dose for Frozen Bone Allografts

A radiation sterilization dose (RSD) of 25 kGy is deleterious to bone allografts. This study aimed to establish a lower RSD for bone allografts using method 1 of International Standard Organisation 11137.2:2006. This provides a database to select an RSD corresponding to an allograft's bioburden, given that the bioburden's gamma resistance is equal to or less than the standard. This can be verified by irradiating 100 allografts at a dose selected to provide a sterility assurance level of 10⁻². The bioburden of our allografts was 0, which prescribed a verification dose of 1.3 kGy. After irradiating 100 allografts, sterility tests returned no positive cultures. We therefore validated an RSD of 11 kGy for allografts with that bioburden. According to the standard, this RSD provides a sterility assurance level of 10⁻⁶ for bone allografts.     

尸体动脉建立动静脉内瘘术

目的 动静脉内瘘是慢性肾功能衰竭血液透析患者的重要“生命线”,但一些长期透析患者,由于多次手术及反复穿刺,上肢前臂已无可供做内瘘吻合的动静脉。我们采用尸体动脉作为移植血管制作动静脉内瘘。方法 将尸体动脉用乙醚及无水乙醇处理,保存于75％乙醇内。将尸体动脉作为移植血管制作动静脉内瘘3例。结果 术后血流通畅,血流量200-275ml·min-1。结论 用尸体动脉作为移植血管制作动静脉内瘘效果满意。     

Significance of subclinical rejection in early renal allograft biopsies for chronic allograft dysfunction

To determine the significance of early subclinical rejection of renal allografts, we reviewed 127 biopsy specimens obtained soon after transplantation. Histological finding was categorized according to a modification of the Banff scheme as: acute rejection (AR), borderline changes (BL); non-specific inflammatory changes, (NI) and no rejection (NR). Subclinical rejection was defined as AR, BL or NI. Patients with BL or NI were divided into two groups; one was treated with high-dose methylprednisolone (MP), the other remained untreated. Freedom from chronic allograft dysfunction (defined as non-doubling of serum creatinine 5 yr after transplantation) was significantly more frequent in the NR group (89%) than in the BL (70%) and AR (64%) groups. At 1 yr after transplantation, mean serum creatinine had increased significantly only in the untreated group (p < 0.05), and re-biopsy showed that interstitial fibrosis had developed to a significantly greater extent in the untreated group than in the treated group (p < 0.01). Subclinical rejection in the early protocol biopsies correlated closely with subsequent allograft dysfunction. High-dose MP treatment for early subclinical rejection may be effective in suppressing the development of interstitial fibrosis at 1 yr after transplantation.     

双钢板联合同种异体骨治疗桡骨远端C型骨折

目的探讨应用双钢板内固定结合植骨填充骨缺损治疗桡骨远端C型骨折的临床疗效。方法对54例闭合性不稳定性桡骨远端骨折患者行桡骨远端解剖钢板恢复桡骨远端解剖结构、微型钢板固定桡骨远端分离骨块,加同种异体骨植骨填充骨缺损治疗。结果患者均获随访,时间12-18个月。植骨均融合良好,无骨不连发生。按ADL腕关节功能评定标准进行评估：优36例,良12例,可4例,差2例,优良率为88.8%。结论对于不稳定的桡骨远端C型骨折,双钢板内固定结合植骨填充骨缺损疗效较好。     

Musculoskeletal tissue banking in Western Australia: review of the first ten years

BACKGROUND: Musculoskeletal tissue allotransplantation has been used as a standard approach for reconstructive surgery. The present study has reviewed the banking of musculoskeletal tissue at the Perth Bone and Tissue Bank (PBTB) and provided evidence of quality assurance on musculoskeletal tissue allotransplantation. METHODS: All donor tissues were processed in accordance with the Therapeutic Goods Administration's relevant codes of good manufacturing practices. Microbiological monitoring at each step of manufacture and postoperative surveying of the musculoskeletal allotransplantations were both conducted. The possible contribution of contaminants in allografts to postoperative infections was also assessed. RESULTS: Of the 5276 donors obtained over the last 10 years, 1672 were rejected, giving an overall donor rejection rate of 32%. Milled femoral heads were the most frequently implanted allografts, followed by whole femoral heads. In the postoperative survey an infection rate of 4.9% was found (113/2321 recipients). The infectious agents were identified in 65 cases but for 60 of these there were no correlations with the positive culture test results for the allografts. The organism most commonly identified in postoperative infections was Staphylococcus species. CONCLUSIONS: The present study shows evidence that musculoskeletal tissue allotransplantation is a safe procedure when accompanied by high standards of quality assurance.     

Delayed function reduces renal allograft survival independent of acute rejection

BACKGROUND: Mechanisms by which delayed allograft function reduces renalallograft survival are poorly understood, This study evaluatedthe relationship of delayed allograft function to acute rejectionand long-term survival of cadaveric allografts. METHODS: 338 recipients of cadaveric allografts were followed until death,resumption of dialysis, retransplantation, loss to follow-up,or the study's end, whichever came first. Delayed allograftfunction was defined by dialysis during the first week followingtransplantation, Multivariate Cox proportional hazards survivalanalysis was used to assess the relationship of delayed allograftfunction to rejection and allograft survival. RESULTS: Delayed allograft function, recipient age, preformed reactiveantibody levels, prior kidney transplantation, recipient race,rejection during the first 30 days and rejection subsequentto 30 days following transplantation were predictive of allograftsurvival in multivariate survival models. Delayed allograftfunction was associated with shorter allograft survival afteradjustment for acute rejection and other covariates (relativerate of failure [RR]=1.72 [95% CI, 1.07, 2.76]). The adjustedRR of allograft failure associated with any rejection duringthe first 30 days was 1.99 (1.23, 3.21), and for rejection subsequentto the first 30 days was 3.53 (2.08, 6.00). The impact of delayedallograft function did not change substantially (RR=1.84 [1.15,2.95]) in models not controlling for acute rejection. Theseresults were stable among several subgroups of patients andusing alternative definitions of allograft survival and delayedallograft function. CONCLUSIONS: This study demonstrates that delayed allograft function andacute allograft rejection have important independent and deleteriouseffects on cadaveric allograft survival. These results suggestthat the effect of delayed allograft function is mediated, inpart, through mechanisms not involving acute clinical rejection.     

Upregulation of connective tissue growth factor in a rat model of chronic allograft nephropathy

AIM: To study the expression of connective tissue growth factor (CTGF) in transplanted rat kidney and its relationship with chronic allograft nephropathy (CAN). METHODS: Kidney transplantation was performed from Lewis to Fisher 344 allogeneic rat strain, and kidney grafts were harvested at the eighth, 12th and 16th week. The morphological changes were studied, and collagen deposition was determined by Masson trichrome stain. Serum creatinine was examined. The fibrotic process and the CAN grades were evaluated according to Banff 97 schema. The expressions of transforming growth factor beta, CTGF and alpha-smooth muscle actin were detected to assess the development of grafted kidney fibrosis and to discuss their relationships. Spearman correlation was used for correlation study between CTGF expression and development of CAN. RESULTS: Serum creatinine was promoted in a time-dependent manner. Morphological changes suggested that the grafted kidneys were under abnormalities. At the end stage, focal segmental glomerulosclerosis was seen; tubular epithelial cells lost their phenotype and interstitial fibrosis was notable. Masson trichrome stain showed significant collagen accumulation in a time-dependent manner. Immunohistochemistry and western blotting results showed that the transforming growth factor beta, CTGF and alpha-smooth muscle actin expression were markedly promoted compared with the control group. CTGF was mainly expressed in the plasm of proximal tubular epithelial cells based on the severity of CAN. CONCLUSION: Connective tissue growth factor might play an important role in the pathological changes of CAN after kidney transplantation. The expression of CTGF in epithelial cells could act as a molecular marker of interstitial fibrosis and CAN.     

Comparison of the biomechanical stability of dense cancellous allograft with tricortical iliac autograft and fibular allograft for cervical interbody fusion

Several choices are available for cervical interbody fusion after anterior cervical discectomy. A recent option is dense cancellous allograft (CS) which is characterized by an open-matrix structure that may promote vascularization and cellular penetration during early osseous integration. However, the biomechanical stability of CS should be comparable to that of the tricortical iliac autograft (AG) and fibular allograft (FA) to be an acceptable alternative to these materials. The purpose of this study was to compare the initial biomechanical stability of CS to that of AG and FA in a one-level anterior cervical discectomy and interbody fusion (ACDF) model. Twelve human cervical spines (C3–T1) were loaded in six modes of motion and evaluated under three conditions: (1) intact, (2) after ACDF using CS, AG, and FA in alternating sequences, and (3) after ACDF with anterior plating. Three reflective markers were placed on the adjacent vertebral bodies. Intervertebral motion was measured with a video-based motion-capture system (MacReflex, Qualisys, Sweden). Torques were applied to a maximum of 2.0 N m. The range-of-motion and neutral-zone values measured in each loading mode were compared. No graft material displayed significant differences in biomechanical stability in any of the tested loading modes, suggesting that the initial stability of CS is comparable to that of AG and FA. Anterior cervical plating significantly increased biomechanical stability in all modes.An erratum to this article can be found at     

Monitoring of human liver and kidney allograft tolerance: a tissue/histopathology perspective

Several factors acting together have recently enabled clinicians to seriously consider whether chronic immunosuppression is needed in all solid organ allograft recipients. This has prompted a dozen or so centers throughout the world to prospectively wean immunosuppression from conventionally treated liver allograft recipients. The goal is to lessen the impact of chronic immunosuppression and empirically identify occasional recipients who show operational tolerance, defined as gross phenotype of tolerance in the presence of an immune response and/or immune deficit that has little or no significant clinical impact. Rare operationally tolerant kidney allograft recipients have also been identified, usually by single case reports, but only a couple of prospective weaning trials in conventionally treated kidney allograft recipients have been attempted and reported. Pre- and postweaning allograft biopsy monitoring of recipients adds a critical dimension to these trials, not only for patient safety but also for determining whether events in the allografts can contribute to a mechanistic understanding of allograft acceptance. The following is based on a literature review and personal experience regarding the practical and scientific aspects of biopsy monitoring of potential or actual operationally tolerant human liver and kidney allograft recipients where the goal, intended or attained, was complete withdrawal of immunosuppression.     

Evaluation of renal allograft function by Doppler spectrum analysis

A decreased renal function is rather common after renal transplantation. The causes of this decreased function are diverse and difficult to differentiate. Yet, duplex examination, and especially quantitative Doppler spectrum analysis of the blood velocities in the renal artery, may be an effective method for differentiating between some of these causes. Forty-five renal transplant recipients were included in this preliminary study. Doppler spectra were recorded from the renal artery to the allograft. Parameters were derived from every Doppler spectrum in order to characterize each spectrum. Renal allograft function was evaluated on the basis of a number of clinical parameters. A significant correlation was found between the clinical parameters and the Doppler spectrum parameters indicative for changes in the peripheral resistance. Patients with a normal renal allograft function showed Doppler spectra with a high diastolic flow, typical of a vascular bed with a low peripheral resistance. Patients with a decreased renal allograft function caused by a stenosis in the renal artery could be distinguished by a low peak velocity and a low pulsatility index. A decreased allograft function caused by allograft rejection or cyclosporin nephrotoxicity also led to characteristic arterial flow disturbances. In these cases, the peripheral resistance was increased, and this was primarily reflected in a decrease in the diastolic blood velocity. We conclude that quantitative analysis of the blood velocities in the renal artery by Doppler spectrum analysis seems to be a useful, noninvasive diagnostic tool that discriminates between some of the causes of a decreased renal allograft function.     

肌肉骨骼超声技术对风湿性疾病的诊断价值

目的探讨肌肉骨骼超声技术在诊断风湿性疾病病情活动中的应用价值。方法选择2016年1月至2018年9月在我院接受治疗的112例风湿性疾病患者,采用肌肉骨骼超声技术对患者进行关节、骨骼、肌肉及软组织扫描,观察治疗前后滑膜厚度、关节积液、骨面缺损、滑膜血流变化、痛风石、双轨征等影像学表现并进行评分比较,评价肌肉骨骼超声技术对风湿性疾病的诊断价值。结果风湿性疾病患者中,有57例(50. 89%)发生类风湿关节炎,超声表现为关节滑膜增厚,关节积液深度增加,形成血管翳,发生骨侵蚀;有29例(25. 89%)发生痛风性关节炎,超声主要表现为痛风石、多点状强回声和双轨征;有26例(23. 21%)发生骨性关节炎,超声主要表现为关节软骨退化、关节滑膜增厚和关节积液。治疗后超声检查显示,除了骨表面缺损和软骨退化以外,其他主要超声观察指标明显改善(P0. 05)。结论肌肉骨骼超声技术能够全面、细致、动态地检测风湿性疾病的组织病变程度及发展情况,对风湿性疾病的影像学诊断和治疗具有很高的应用价值。     

同种肾组织移植治疗慢性肾功能衰竭性贫血的实验研究

以Ｗｉｓｔａｒ雄性大鼠为受体，建立慢性肾功能衰竭动物模型，将鼠婴肾组织声多点植入受体双侧后肢皮下和筋膜下。结果表明，３０天后移植物的体积由１ｍｍ＾３增至４ｍｍ＾３大小，表面血管网丰富；光镜下见肾小球、肾小管结构正常。促红细胞生成素（ＥＰＯ）着色颗粒主要分布在肾小球区，移植组着色程度明显增高。血红蛋白和４促红细胞生成素随移植的时间延长而逐渐升高，实验结果提示，此方法有可能为治疗慢性肾功能衰竭性贫血提