Immunosuppression in renal transplantation: Long-term clinical trial of a double versus triple therapy regimen

Summary: Sixty-nine renal allograft recipients were randomized to two immunosuppressive regimens: 35 patients received cyclosporine A and prednisolone (PC) while 34 patients received low dose cyclosporine A, prednisolone and short term azathioprine (PCA). the data of 66 patients (34 in PC and 32 in PCA groups) were analysed. the median follow-up periods were 62 months for the PC group and 60 months for the PCA group. There was no difference in graft survival between the two groups but five patients died in the PC group compared to none in the PCA group (graft survival: 88 vs 90% at 1 year and 82 vs 82% at 5 years, P = not significant at any time point; patient survival: 90 vs 100% at 1 year and 88 vs 100% at 5 years, P = 0.05 at 5 years). There was a trend for patients in the PCA group to develop earlier and more frequent rejections (not significant; P = 0.106 and P = 0.062, respectively). There were also more episodes of acute cyclosporine A nephrotoxicity and cytomegalovirus (CMV) infection in the PC group. the mean serum creatinine at 5 years was significantly higher in the PCA group when compared to the PC group (179.8 ± 76.5 μmol/L vs 154.7 ± 41.0 μmol/L; P =0.05). We found that both therapeutic regimens were effective in preventing renal allograft rejections. However, double therapy was associated with higher patient mortality secondary to infection. Patients on triple therapy, on the other hand, were more prone to develop rejections in the early post-transplant period and were associated with less favourable renal function in the long run.     

Percutaneous cholecystostomy: an alternative to surgical cholecystostomy for acute cholecystitis?

Emergency percutaneous cholecystostomy was successfully performed in 39 of 40 attempted procedures in 37 hospitalized patients with possible acute cholecystitis. All cholecystostomies were performed with ultrasound guidance and preferentially with the transhepatic route, and all but four were performed at the patient's bedside. The patients had been hospitalized an average of 27 days before the procedure. Twenty-two of the 37 patients (59%) eventually died during hospitalization because of other medical or surgical problems. Only minor complications related to percutaneous cholecystostomy placement occurred in this series: catheter dislodgment without sequelae (n = 2) and significant abdominal pain (n = 2). Technical problems included guide-wire buckling during catheter insertion (n = 1) and failed attempted cholecystostomy (n = 1). Percutaneous cholecystostomy is a safe alternative to surgical cholecystostomy in the treatment of patients suspected of having acute cholecystitis.     

Validation and comparison of luminex multiplex cytokine analysis kits with ELISA: determinations of a panel of nine cytokines in clinical sample culture supernatants

PROBLEM: Analyses of the expression pattern of multiple cytokines are frequently required for characterization of the status of the immune system as it pertains to Th type bias and intrinsic levels of inflammation. Classically, analysis of cytokine expression patterns has been performed by enzyme-linked immunosorbent assays (ELISA) for each separate analyte. A new technology, Luminex MAP, facilitates the simultaneous evaluation of multiple immune mediators with advantages of higher throughput, smaller sample volume, and lower cost. Validation of this technology has been limited to small sample sets, limited use of clinical study specimens, and use of non-commercial reagents. METHODS: Ninety-six specimens from women over the course of their respective pregnancies were evaluated for cytokine concentrations using commercially available ELISA kits and commercially available Luminex MAP kits according to the manufacturers' directions. Correlations between data sets were evaluated using Pearson's correlation coefficient (r). RESULTS: Excellent correlations were demonstrated for IL-1 beta, IL-4, IL-5, IL-6, IL-10, IFN gamma, and TNF alpha, in contrast to IL-12 p 70 and IL-13. CONCLUSIONS: Luminex multiplex technology has distinct advantages and is a valid alternative method to ELISA for the evaluation of the majority of cytokines tested and for the characterization of immune system status.     

The influence of in-pregnancy smoking cessation programmes on partner quitting and women's social support mobilization: a randomized controlled trial [ISRCTN89131885]

Background  

Smoking cessation interventions in pregnancy could influence a woman's social behaviour and her partner's smoking behaviour, but this has not been examined in any published randomized trials.     

Peri-operative outcomes for pancreatoduodenectomy in India: a multi-centric study

Background:

There have been an increasing number of reports world-wide relating improved outcomes after pancreatic resections to high volumes thereby supporting the idea of centralization of pancreatic resectional surgery. To date there has been no collective attempt from India at addressing this issue. This cohort study analysed peri-operative outcomes after pancreatoduodenectomy (PD) at seven major Indian centres.

Materials and Methods:

Between January 2005 and December 2007, retrospective data on PDs, including intra-operative and post-operative factors, were obtained from seven major centres for pancreatic surgery in India.

Results:

Between January 2005 and December 2007, a total of 718 PDs were performed in India at the seven centres. The median number of PDs performed per year was 34 (range 9–54). The median number of PDs per surgeon per year was 16 (range 7–38). Ninety-four per cent of surgeries were performed for suspected malignancy in the pancreatic head and periampullary region. The median mortality rate per centre was four (range 2–5%). Wound infections were the commonest complication with a median incidence per centre of 18% (range 9.3–32.2%), and the median post-operative duration of hospital stay was 16 days (range 4–100 days).

Conclusions:

This is the first multi-centric report of peri-operative outcomes of PD from India. The results from these specialist centers are very acceptable, and appear to support the thrust towards centralization.     

Keeping pace: video communications in a managed care environment. Interview by Thomas A. Rasmussen

A number of health care provider organizations, particularly those with geographically dispersed personnel, are utilizing the video medium to improve organizational performance. The key attributes of the video medium are uniformity of education delivery to multiple sites, the ability to deliver information in a timely manner, the ability to visually portray best practices for all to see, and the convenience for end-users. While the executives interviewed for this article aren't aware of any published research specifically documenting the linkage between video education and improved organizational performance, the panelists believe that informed health care professionals inherently contribute to improved organizational performance and that video education is a prudent investment of resources.     

Vector Databank in the Indian Armed Forces

Background

Medical intelligence of disease vectors deals with understanding vector distribution and control.

Methods

An entomological baseline survey using standard vector sampling techniques was done as a pilot study to map the vectors of defence importance in two cantonments of Pune with a view to establish a vector databank and impart training to armed forces personnel in vector surveillance.

Result

The project trained 142 armed forces personnel in surveillance techniques in three years. Seventeen species of mosquitoes comprising of eight vector species were collected. Three other vectors viz. Rhipicephalus sanguineus, Xenopsylla cheopis and Leptotrombidium deliense are reported.

Conclusion

The study emphasizes the need for vector mapping /surveillance in each area for preventing morbidity and mortality amongst troops. It also focuses on indigenous fabrication of vector sampling tools and training of personnel for capacity building which in turn will enable such surveys to be undertaken in other units and deployment areas.Key Words: Leptotrombidium, Mosquitoes, Rhipicephalus, Surveillance, Xenopsylla     

Primary, secondary, and tertiary interventions to reduce the morbidity and mortality of preterm birth

Interventions to reduce the morbidity and mortality of preterm birth can be primary (directed to all women), secondary (aimed at eliminating or reducing existing risk), or tertiary (intended to improve outcomes for preterm infants). Most efforts so far have been tertiary interventions, such as regionalised care, and treatment with antenatal corticosteroids, tocolytic agents, and antibiotics. These measures have reduced perinatal morbidity and mortality, but the incidence of preterm birth is increasing. Advances in primary and secondary care, following strategies used for other complex health problems, such as cervical cancer, will be needed to prevent prematurity-related illness in infants and children.     

Epidemiology and causes of preterm birth

This paper is the first in a three-part series on preterm birth, which is the leading cause of perinatal morbidity and mortality in developed countries. Infants are born preterm at less than 37 weeks' gestational age after: (1) spontaneous labour with intact membranes, (2) preterm premature rupture of the membranes (PPROM), and (3) labour induction or caesarean delivery for maternal or fetal indications. The frequency of preterm births is about 12-13% in the USA and 5-9% in many other developed countries; however, the rate of preterm birth has increased in many locations, predominantly because of increasing indicated preterm births and preterm delivery of artificially conceived multiple pregnancies. Common reasons for indicated preterm births include pre-eclampsia or eclampsia, and intrauterine growth restriction. Births that follow spontaneous preterm labour and PPROM-together called spontaneous preterm births-are regarded as a syndrome resulting from multiple causes, including infection or inflammation, vascular disease, and uterine overdistension. Risk factors for spontaneous preterm births include a previous preterm birth, black race, periodontal disease, and low maternal body-mass index. A short cervical length and a raised cervical-vaginal fetal fibronectin concentration are the strongest predictors of spontaneous preterm birth.