Living donor kidney transplants: personal reflections

Short- and long-term living kidney donor morbidity and mortality are discussed herein. The analysis includes over 3000 living donor kidney transplants from 1963 through 2002 at a single institution. The category of living donors includes living related donors, such as fathers, mothers, siblings, offspring, and other genetically related donors, as well as living unrelated donors, such as spouses, friends, or altruistic strangers. Graft and patient survival rates with living related and unrelated living donors are compared to rates with cadaveric donors. Donor risks are discussed, including short-term surgical risks as well as long-term risks of impaired renal function, possible hypertension, and psychological risks. Finally, early and late donor mortality statistics are presented. In addition, the benefits to potential donors are reviewed. Donors are carefully screened before donation. During this screening process, a significant number of donors have been found to have abnormal renal function--some had undisclosed hypertension and others had unknown cardiovascular disease. In addition, six malignancies were found, eventually resulting in curative resection. A secondary benefit to donors was reported in a study from Norway and Sweden, which showed that donors had improved long-term survival versus the general population. Our own long-term studies involving follow-up of 20 to 30 years after kidney donation have shown no significant difference in donor renal function, blood pressure, and incidence of proteinuria, as compared with their nondonor siblings. We also found donors to be perfectly normal in all other categories; several had even undergone normal pregnancies after donation. Most donors reported a high quality of life, with a boost in self-esteem and an increased sense of well-being: 96% felt it was a positive experience. In conclusion, living kidney donation has a very low mortality rate. Long-term follow-up shows minimal impact after donation. Donor quality of life is reported as excellent.     

The pursuit of excellence in graduate surgical education: Visions of the arizona experience

A unique experiment in graduate surgical education is described. The premise is set forth that there exists a discipline called human biology worthy of formal graduate study, most logically carried out in a department of surgery. Study in this program was specifically goal-oriented rather than time-oriented, with goals individually tailored to each student. Emphasis was on flexibility of progression, individual achievement, original thought and rigorous logical analysis of fundamental problems in surgical biology. The purpose of such a program was to produce life-time students of human biology rather than mere residents hurdling a demoralizing obstacle. Although long-term data are not available, the conviction of those who participated in the experiment is that such a purpose was and can be uniquely fulfilled. Wider acceptance of these principles should lead to higher standards of surgical care.     

Review article: Teaching, learning, and the pursuit of excellence in anesthesia education

Purpose

Excellence in anesthesia education has been advocated to meet the future needs and direction of the specialty. The purpose of this article is twofold: first, to review the current medical education literature and theory in order to inform teaching and learning in anesthesia; and second, to advocate for excellence in anesthesia education.

Source

This review considers the general education, educational psychology, and medical education literature based on a search of the MEDLINE and ERIC databases, educational Web sites, and library catalogues.

Principal findings

Excellent teaching is considered that which facilitates and maximizes learning. A conceptual framework of learning as a convergence of teacher, learner, assessment, and context is proposed. The contribution of each component to learning is examined in order to enable anesthesia teachers to choose and adapt the most appropriate educational approaches for their particular contexts. The relationship of excellent teaching, scholarly teaching, and the scholarship of teaching is explored. Strategies for promoting excellence in anesthesia education are suggested.

Conclusions

The call for excellence in anesthesia has become an important theme, particularly with respect to education. While excellent teaching is a goal to which all anesthesia faculty should aspire, scholarly teaching and scholarship in teaching should also be promoted in order to advance anesthesia education for the benefit of the profession and ultimately for patient care.     

In pursuit of the unknown primary

The case histories of sixty-seven patients were reviewed to evaluate the contribution made by various x-ray and laboratory studies to the diagnosis and treatment of systemic metastases from unknown primary tumors. When used as screening procedures, radiographic contrast studies were rarely helpful unless the test was indicated by appropriate symptoms. The large number (8 of 27) of misleading ultrasonic scans rendered that study a major source of confusion. Inadequate tissue samples were another cause of confusion and delay. Even with adequate tissue samples, a definitive pathologic diagnosis could be assigned to only forty-five of the sixty-five patients who underwent biopsy. After extensive diagnostic evaluations, only thirty-one of the sixty-seven patients received chemotherapy for specific diagnoses. Objective remissions were seen in four of thirty-one recipients of specific chemotherapy and one of five patients treated without a primary diagnosis. The same patients would have received the same therapy had the diagnostic workup been limited to x-ray studies of symptomatic systems, adequate tissue sampling, and appropriate pathologic examinations followed by treatment of the "most treatable" disease.     

From the pursuit of excellence to the quest for significance: promotion of a Childsafe South Africa

Trauma represents a major burden of disease in South Africa. Children are disproportionately affected by trauma; rightly, childhood trauma can be referred to as 'the neglected childhood killer disease'. Unlike the field of infectious diseases, where vaccinations and prevention are the norm, paediatric trauma is usually ignored and prevention strategies are scarce. In this article, we review paediatric trauma and its effect on our society in light of the development of more effective child safety promotion strategies.     

Complex urethral disruptions: In pursuit of a successful reconstruction

OBJECTIVES: We analyzed the methods and outcomes of urethroplasty in men with complex urethral disruptions. METHODS: The medical records of 40 men with complex urethral disruptions were analyzed. Surgical methods were individualized according to stricture location, severity and length of the stricture, bladder neck characteristics and presence of complicating factors. Patients were divided into four groups based on the above characteristics. RESULTS: End-to-end urethroplasty performed in six patients with short bulbar strictures (<3 cm) was successful in all. Elaborated perineal repair was performed in 10 patients with intermediate (3-6 cm) strictures with or without complicating factors. Elaborated perineal repair with urethral substitution was performed in nine patients with long segment stricture (>6 cm). Abdominal transpubic repair was successfully applied to patients with rectourethral fistula or lacerated bladder neck. Success rate of anastomotic urethroplasty was 95% while over all success rate was 85%. CONCLUSION: Guidelines for urethral reconstruction of complex urethral disruptions are predicated on stricture length, location, bladder neck characteristics and associated complicating factors. End-to-end urethroplasty with stricture excision is highly reliable for short strictures for which previous operative repair have failed. Elaborated perineal repair is extremely versatile for intermediate and longer strictures with associated complicating factors. Abdominal transpubic urethroplasty is effective for patients with rectourethral fistula or lacerated bladder neck.