Improved survival of children with sepsis and purpura: effects of age,gender, and era

Background  

To gain insight into factors that might affect results of future case-control studies, we performed an analysis of children with sepsis and purpura admitted to the paediatric intensive care unit (PICU) of Erasmus MC-Sophia Children's Hospital (Rotterdam, The Netherlands).     

New composite tissue allograft model of vascularized bone marrow transplant: the iliac osteomyocutaneous flap

Vascularized bone marrow transplant (VBMT) induces donor-specific chimerism in experimental models across the major histocompatibility barrier. An experimental model for immunotolerance studies should sustain a high antigenicity with low morbidity. Accordingly, we introduced an iliac bone osteomusculocutaneous (IBOMC) transplant model in rat. It consists of a large skin component and an abundant bone marrow cells (BMC) population. We tested this model with isograft transplantations between Lewis rats (RT1^l) and with allograft transplantation between Lewis-Brown Norway (LBN RT1^l + n) donors and Lewis (RT1^l) recipients under low dose of cyclosporine A monotherapy. Immunologic responses were tested for donor cell engraftment and chimerism induction. All isografts survived indefinitely and allografts were viable at 200 days post-transplant under low dose of cyclosporine A. Microangiography of the graft revealed preservation of skin, muscle, and bone components. Histologic examination confirmed viability of all allograft components without signs of rejection. Long-term engraftment of donor-origin (RT1ⁿ) BMC was confirmed by donor-specific chimerism (1.2%) in peripheral blood and bone marrow (1.65%) compartments and by engraftment into lymphoid organs of recipients. The IBOMC transplant proved to be a reliable composite tissue allotransplantation (CTA) model. Moreover, because of its robust bone marrow component and large skin component, it is applicable to studies on immunologic responses in CTA.     

Normalization of endothelial dysfunction following renal transplantation is accompanied by a reduction of circulating visfatin/NAMPT. A novel marker of endothelial damage?

Abstract:  Endothelial dysfunction is strongly linked to cardiovascular disease and outcome of patients with chronic kidney disease. We hypothesized that decreased inflammatory activity and increased adiponectin following transplantation could be one mechanism for a better endothelial health. Fifty-eight living donor kidney transplant non-diabetic recipients, 31 (23 male, 29 ± 5 yr) on cyclosporine A and 27 (10 male, 26 ± 5 yr) on tacrolimus immunsupression, were studied longitudinally. Visfatin, adiponectin, high sensitive C-reactive protein (hsCRP) levels, brachial artery flow mediated dilatation (FMD) and nitroglycerine mediated dilatation were measured before transplantation and on the 30th and 90th day after transplantation. Pre-transplantation visfatin, adiponectin and FMD values of patients were significantly higher than those of the controls (p < 0.001 for all). All values decreased significantly 30 and 90 d post-transplantation. Plasma visfatin and adiponectin, correlated negatively with FMD levels 90 d both before and after kidney transplantation (p < 0.001 for both). Endothelial function improved during the first month after transplantation, and the degree of improvement correlated to reductions in circulating visfatin, adiponectin and hsCRP levels. Of interest, the intracellular enzyme visfatin was the strongest predictor of FMD both before and after kidney transplantation and may thus reflect endothelial cell damage directly.     

Predictors and clinical significance of angiographically detected distal embolization after primary percutaneous coronary interventions

OBJECTIVES: The aim of this study was to investigate clinical, angiographic and procedural predictors of distal embolization (DE) on angiography after primary percutaneous coronary intervention (PCI). The impact of DE on outcome in the first 30 days was also assessed. METHODS: Between January 2004 and April 2006, primary PCI was performed in 212 consecutive patients with acute myocardial infarction (AMI) of < or = 12-h duration. RESULTS: Distal embolization was present in 27 patients (12.7%) and more often observed in female sex (27.5 vs. 10.4%, P=0.01), in patients with right coronary artery involvement (52 vs. 28%, P=0.02), prerevascularization thrombolysis in myocardial infarction flow < or = 1 (89 vs. 69%, P=0.03), in the presence of high thrombus burden (92.6 vs. 39.5%, P=0.0009), and a long target lesion in the infarct-related artery (>14.5 mm, 74 vs. 29%, P<0.0001). By multiple stepwise logistic regression analysis, only the presence of high thrombus burden before the PCI procedure [odds ratio (OR)=5.2, 95% confidence interval (CI)=1.09-24.97, P=0.03)] and target lesion length (>14.5 mm, OR=3.9, 95% CI=1.45-10.60, P=0.007) were found independent predictors of DE. Patients with DE had an increased risk of target vessel revascularization (26 vs. 5%, P=0.001) and short-term mortality (29.6 vs. 7.5%, P=0.002) when compared with patients without angiographic signs of embolization. CONCLUSIONS: In patients who undergo primary PCI, high thrombus burden on angiography before PCI and/or a long target lesion in the infarct-related artery increase the risk of DE and subsequent short-term mortality.     

Multicentric malignant peripheral nerve sheath tumor

We present a case of malignant peripheral nerve sheath tumor of multicentric origin, an extremely rare condition. A 25-year-old man was admitted to hospital with presenting symptoms of cough, dyspnea and left lateral back pain. Computed tomography and magnetic resonance imaging revealed extrapleural masses in the left hemithorax in addition to synchronous left inguinal mass. After surgical resection of the masses from the thoracic and inguinal regions, histological examination confirmed the preoperative diagnosis of malignant peripheral nerve sheath tumor.     

Doctor-patient communication with people with intellectual disability - a qualitative study

Background

Patients' priorities and views on quality care are well-documented in Western countries but there is a dearth of research in this area in the East. The aim of the present study was to explore Chinese patients' views on quality of primary care consultations in Hong Kong and to compare these with the items in the CARE measure (a process measure of consultation quality widely used in the UK) in order to assess the potential utility of the CARE measure in a Chinese population.

Methods

Individual semi-structured interviews were conducted on 21 adult patients from 3 different primary care clinics (a public primary healthcare clinic, a University health centre, and a private family physician's clinic). Topics discussed included expectations, experiences, and views about quality of medical consultations. Interviews were typed verbatim, and a thematic approach was taken to identify key issues. These identified issues were then compared with the ten CARE measure items, using a CARE framework: Connecting (Care Measure items 1–3), Assessing (item 4), Responding (items 5,6), and Empowering (items 7–10).

Results

Patients judged doctors in terms of both the process of the consultation and the perceived outcomes. Themes identified that related to the interpersonal process of the consultation fitted well under the CARE framework; Connecting and communicating (18/21 patients), Assessing holistically (10/21 patients), Responding (18/21 patients) and Empowering (19/21 patients). Patients from the public clinic, who were generally of lower socio-economic status, were least likely to expect holistic care or empowerment. Two-thirds of patients also judged doctors on whether they performed an adequate physical examination, and three-quarters on the later outcomes of consultation (in terms of relief or cure and/or side-effects of prescribed drugs).

Conclusion

These findings suggest that Chinese patients in Hong Kong value engaged, empathic primary care doctors and judge the quality of consultations largely on these human skills and the attitudes and values that underpin them, as well as on the perceived outcomes of treatment. The match between themes relating to consultation process and the CARE Measure items suggests utility of this measure in this population, but further quantitative validation is required.