Transplantation in the 21st century

Remarkable results have been achieved in the field of organ transplantation over the past 40 years, perhaps inconceivable in the pioneering days of the 1950's. Factors which have contributed to these results include better immuno-suppression, matching for HLA, better preservation, and resolution of most of the technical problems associated with organ transplantation. Nevertheless, major problems still remain to be resolved. Chronic rejection leads to a steady attrition of all solid organ grafts. In addition, the penalty of our more potent immunosuppression is becoming evident with the ever-increasing incidence of cardiovascular disease and malignancy in long-surviving patients. These problems would be solved by the achievement of tolerance to an organ graft. However, there will never be sufficient human organs or tissues to meet the demand, which has led to a revival of interest in xenotransplantation, but enormous immunological and infectious problems have still to be resolved. New immunosuppressive agents, both drugs and biological agents, are being evaluated continually in the laboratory and some are going on to clinical trials. The explosion in molecular biology is allowing new approaches, such as genetic engineering, to be taken in the achievement of tolerance as well as solving some of the problems of xenotransplantation. Cloning of tissues and perhaps even organs may become possible in the future. Undoubtedly transplantation will look very different in twenty years' time as we enter the "Dawn of the New Millennium".     

Smallpox in the 21st century

The viral disease, smallpox, was well known through the end of the 20th Century. Because it has been eradicated from natural populations, the present clinical experience with managing the disease is limited. Similarly, research in the pathophysiology, treatment, and prevention of the disease has recently become a priority. Concerns regarding smallpox as a weapon of bioterrorism have led to the implementation of a new prophylactic vaccine program, a renewal in variola vaccine research, and treatment regimens against variola infection.     

Research priorities in surgical simulation for the 21st century

BackgroundLaryngeal complications occur in thyroidectomies as a result of several factors, but especially because of nerve damage. We compared intraoperative stimulation neuromonitoring (IONM) with intraoperative continuous electromyographic neuromonitoring (IEM) to evaluate their ability to identify postoperative laryngeal complications.MethodsThis prospective clinical trial included 174 patients (348 nerves) who had both IONM and IEM. We recorded age, sex, pathology, vocal fold motility, and complications.ResultsIONM identified 334 nerves, whereas IEM identified 348. Five patients had transient laryngeal complications, 2 bilateral, and 3 unilateral recurrent laryngeal nerve paresis. In addition, in 2 patients IEM showed placement of the tracheal tube balloon on the vocal folds, which led to correction. Sensitivity and specificity were 96.48% and 100% for IONM and 100% and 100% for IEM, respectively. IONM had a positive predictive value of 100% and a negative predictive value of 36.84%. The positive and negative predictive values of IEM were 100%.ConclusionsBoth techniques identify recurrent laryngeal nerve injuries; however, IEM seems to have an advantage concerning the nonsurgical laryngeal complications and may play a role in preventing morbidity.     

The impact of the 21st century on rugby injuries

STUDY DESIGN: This is a review article concerning rugby injuries resulting in tetraplegia between the years of 1965 and 2000. It is based on a review of worldwide literature. OBJECTIVES: The objective is to evaluate research that has taken place in the last 10 years. SETTING: The author first became interested in this problem in 1965 when there were few papers on the subject. Understanding of these injuries has changed decade by decade and the number of spinal injuries has increased dramatically. For the first three decades the author was actively engaged in gathering material particularly at the National Spinal Injuries Centre. During the last 10 years there has been a greater understanding in the mechanism of these injuries. METHODS: The following subjects were reviewed in the literature: (1). mechanism of injury; (2). the diameter of the spinal canal; (3). arthritis; (4). treatment; (5). fitness and (6). medico-legal aspects. RESULTS: These injuries are no longer regarded as an Act of God or bad luck but mechanisms of injury have been clearly defined. CONCLUSION: To prevent these injuries occurring there is a need for: (1). better statistics; (2). enforcement of the laws; (3). improved standards of refereeing; (4). higher standards of fitness and training in particular to de-power the set scrum; (5). study of the cervical spine to look for abnormalities which would predispose the player to tetraplegia; (6). the use of MRI and CT scans to monitor the spinal cord anatomy; (7). the importance of pathology and the status of the cervical spine; (8). the awareness of the dangers to the cord of congenital and acquired abnormalities that could prejudice spinal cord function and (9). the awareness of the necessity for comprehensive insurance.     

The 21st century burn care team

The 21st century burn care team epitomises integrated multidisciplinary care. The physical, psychological and socials needs of burn victims necessitates the close collaboration of a broad spectrum of health care professionals. The ultimate aim is to return the patient to the optimal level of physical and psychological health and social function.     

Drug development in the 21st century

Drug development has evolved from workbench chemical synthesis to an automated and in some cases virtual process in which massive numbers of structures can be simulated, synthesized, evaluated and, in most cases, discarded. Ultimately, all effective compounds must be tried in animal models and subsequently in man and these two stages remain the bottleneck in drug development. Future advances will further reduce the use of animals and optimize clinical trials to increase compound throughput, shorten the time between chemical synthesis and marketing and lead to the early identification of ineffective compounds.