Compliance: the patient, the doctor, and the medication?

Noncompliance can be defined as covert nonadherence to prescribed medication used for the prophylaxis of allograft rejection and threatening impaired kidney histology or function. It is an increasingly significant long-term problem in transplantation as the failure rates from other causes have diminished. Formal approaches to diagnosis, prophylaxis, and treatment, together with a greater understanding of what should be regarded as a syndrome, are thus increasingly important components of reducing the chronic attrition of graft function and survival. It is possible to classify noncompliant behavior using four facets of the syndrome: timing, frequency, origin, and diagnostic certainty. There are a number of different ways of approaching diagnosis, such as observation of behavior through pill counting or electronic measurements of pill container opening; blood level measurement of relevant drugs; physical examination; and observation of the consequences. However, the only certainty of diagnosis comes from direct patient admission of nonadherence to the prescribed immunosuppression. It is possible to define the highest risk patients through assessment of a number of patient-, drug-, and physician-associated variables, and then to influence the outcome through education, compliance monitoring, and simplified regimens targeted to the highest risk patients. It is important for all transplant units to address the issues raised by noncompliance if the chronic loss of allografts is to be reduced.     

The future: surgery of the spinal cord?

Surgery of the spinal cord is still experimental, and outcomes must be confirmed by more cases. In this field, knowledge and research are still figuratively in the Stone Age. Nevertheless, the author is confident that in the future, with the improvement of surgical and resuscitation techniques and with the introduction of new biotechnologic drugs and molecules that favor axon regeneration and inhibitor blocking, CNS-peripheral nerve connections can be performed with some functional improvement, even in tetraplegia.     

Simulation-based endovascular skills assessment: the future of credentialing?

OBJECTIVES: Simulator-based endovascular skills training measurably improves performance in catheter-based image-guided interventions. The purpose of this study was to determine whether structured global performance assessment during endovascular simulation correlated well with trainee-reported procedural skill and prior experience level. METHODS: Fourth-year and fifth-year general surgery residents interviewing for vascular fellowship training provided detailed information regarding prior open vascular and endovascular operative experience. The pretest questionnaire responses were used to separate subjects into low (<20 cases) and moderate (20 to 100) endovascular experience groups. Subjects were then asked to perform a renal angioplasty/stent procedure on the Procedicus Vascular Intervention System Trainer (VIST) endovascular simulator (Mentice Corporation, Gothenburg, Sweden). The subjects' performance was supervised and evaluated by a blinded expert interventionalist using a structured global assessment scale based on angiography setup, target vessel catheterization, and the interventional procedure. Objective measures determined by the simulator were also collected for each subject. A postsimulation questionnaire was administered to determine the subjects' self-assessment of their performance. RESULTS: Seventeen surgical residents from 15 training programs completed questionnaires before and after the exercise and performed a renal angioplasty/stent procedure on the endovascular simulator. The beginner group (n = 8) reported prior experience of a median of eight endovascular cases (interquartile range [IQR], 6.5-17.8; range, 4-20), and intermediate group (n = 9) had previously completed a median of 42 cases (IQR, 31-44; range, 25-89, P = .01). The two groups had similar prior open vascular experience (79 cases vs 75, P = .60). The mean score on the structured global assessment scale for the low experience group was 2.68 of 5.0 possible compared with 3.60 for the intermediate group (P = .03). Scores for subcategories of the global assessment score for target vessel catheterization (P = .02) and the interventional procedure (P = .05) contributed more to the differentiation between the two experience groups. Total procedure time, fluoroscopy time, average contrast used, percentage of lesion covered by the stent, placement accuracy, residual stenosis rates, and number of cine loops utilized were similar between the two groups (P > .05). CONCLUSION: Structured endovascular skills assessment correlates well with prior procedural experience within a high-fidelity simulation environment. In addition to improving endovascular training, simulators may prove useful in determining procedural competency and credentialing standards for endovascular surgeons.     

Xenotransplantation: back to the future?

The field of xenotransplantation has fluctuated between great optimism and doubts over the last 50 years. The initial clinical attempts were extremely ambitious but faced technical and ethical issues that prompted the research community to go back to preclinical studies. Important players left the field due to perceived xenozoonotic risks and the lack of progress in pig‐to‐nonhuman‐primate transplant models. Initial apparently unsurmountable issues appear now to be possible to overcome due to progress of genetic engineering, allowing the generation of multiple‐xenoantigen knockout pigs that express human transgenes and the genomewide inactivation of porcine endogenous retroviruses. These important steps forward were made possible by new genome editing technologies, such as CRISPR/Cas9, allowing researchers to precisely remove or insert genes anywhere in the genome. An additional emerging perspective is the possibility of growing humanized organs in pigs using blastocyst complementation. This article summarizes the current advances in xenotransplantation research in nonhuman primates, and it describes the newly developed genome editing technology tools and interspecific organ generation.     

Xenotransplantation: is this the future?

The modern era of xenotransplantation, ie, transplantation across species, involving use of genetically modified pigs as potential organ and tissue donors for human recipients, is now more than 5 years old but remains essentially an experimental and controversial procedure. The status of the field is reviewed with regard to immunologic barriers, especially delayed xenograft rejection, infectious risks, biocompatibility issues, and associated problems. The case is made that robust clinical application is still at least a decade away although in the interim knowledge developing from the experimental approaches under investigation is proving of unexpected use in several areas of medicine.     

Lactose: the hidden culprit in medication intolerance?

Although reports are rare, lactose-containing medications may cause patient discomfort and subsequently affect medication adherence.