The Incremental Cost of Incompatible Living Donor Kidney Transplantation: A National Cohort Analysis

Incompatible living donor kidney transplantation (ILDKT) has been established as an effective option for end‐stage renal disease patients with willing but HLA‐incompatible living donors, reducing mortality and improving quality of life. Depending on antibody titer, ILDKT can require highly resource‐intensive procedures, including intravenous immunoglobulin, plasma exchange, and/or cell‐depleting antibody treatment, as well as protocol biopsies and donor‐specific antibody testing. This study sought to compare the cost and Medicare reimbursement, exclusive of organ acquisition payment, for ILDKT (n = 926) with varying antibody titers to matched compatible transplants (n = 2762) performed between 2002 and 2011. Data were assembled from a national cohort study of ILDKT and a unique data set linking hospital cost accounting data and Medicare claims. ILDKT was more expensive than matched compatible transplantation, ranging from 20% higher adjusted costs for positive on Luminex assay but negative flow cytometric crossmatch, 26% higher for positive flow cytometric crossmatch but negative cytotoxic crossmatch, and 39% higher for positive cytotoxic crossmatch (p < 0.0001 for all). ILDKT was associated with longer median length of stay (12.9 vs. 7.8 days), higher Medicare payments ($91 330 vs. $63 782 p < 0.0001), and greater outlier payments. In conclusion, ILDKT increases the cost of and payments for kidney transplantation.     

Integrating political-societal concerns in psychotherapy

Despite growing publicity and public concern about the serious nature of the nuclear, societal, and environmental problems in our increasingly globally conscious world, and despite the fact that a majority of psychotherapists share this concern, most psychotherapists state that their patients never mention such matters in psychotherapy. Some possible reasons for this scarcity of discussion in psychotherapy are offered. These include the often unstated understanding that political-societal matters are not to be discussed by patients in therapy, therapists not hearing such content or hearing it only as a way of talking about early, intrapsychic fears, therapists' concerns about influencing their patients, the fear of talking about "ordinary death" much less the death of all life now and in the future via nuclear or environmental disaster, and the impact of modern Western civilization's overemphasis of individualism on much of psychotherapy theory and practice. An approach in which questions about political-societal concerns are raised early in treatment is described and discussed. The results of this approach include an increased dialogue about death, the meaning of life, and connectedness to the world of others.     

Amyotrophische Lateralsklerose und Bulbärparalyse nach Betriebsunfall

Ohne Zusammenfassung     

Iron overload in patients with chronic hepatitis C: A clinicopathologic study

Recent studies suggest that increased hepatic iron may impair the response to interferon therapy in patients with chronic hepatitis C. We reviewed the records and liver biopsies of 72 patients with chronic hepatitis C to determine the prevalence of iron overload and to evaluate whether there is a correlation between serum and hepatic iron concentrations and activity of liver disease. Patients with other causes of liver disease or iron overload were excluded. Necroinflammatory activity and fibrosis were evaluated using modified Knodell score. Hepatic iron was assessed using Brissot's grading system. Increased serum iron and ferritin levels were found in 29% and 43% patients, respectively. Hepatic iron grades 0, I, II, III, and IV were present in 37%, 35%, 25%, 3%, and 0% of patients, respectively. A significant correlation was found between hepatic iron grade and serum ferritin (P = .0001). There was no correlation between hepatic iron grade and histological activity index or fibrosis score. In summary, we found a high proportion of patients with chronic hepatitis C had mild to moderate increase in hepatic iron content even when patients with alcoholism and recurrent transfusions were excluded. However, very few patients had severely increased iron load.     

False-negative results by polymerase chain reaction due to contamination by glove powder

The polymerase chain reaction (PCR) technique has become an important, widely employed method for the detection and quantitation of the nucleic acid sequences used in the diagnosis and monitoring of genetic and infectious diseases. Much attention has been directed at the problem of false-positive PCR results, which are generally attributed to low-level laboratory contamination of amplified sequences ("carryover"). In contrast, few investigators have commented on the somewhat less frequent, but equally problematic, false-negative PCR results. Investigation of the source of sporadic false-negative PCR reactions found that glove powder, inadvertently introduced into tubes when gloves are changed in an effort to reduce false-positive results, can nonspecifically inhibit each of the major steps in the PCR detection process. Methodologic precautions are recommended to minimize this problem.     

Dissection following balloon angioplasty of aortic coarctation: review of the literature

Balloon angioplasty of the coarctation of the aorta can result in intimal or medial or even adventitial dissections as demonstrated by in vitro studies and animal experiments. As a typical sign of stretching of the aortic wall, patients complain of pain during the angioplasty procedure. In the literature, aortic wall rupture and ventricular fibrillation during the procedure are reported. Additional sudden deaths can occur within 40 hours after the procedure. Mortality ranges from 0.1% to 2.5%. By transesophageal echocardiography, monitoring of balloon angioplasty, control of the positioning of the balloon, and control of the results and detection of complications are possible. Intimal as well as medial dissections can be detected with observed healing for intimal but also medial dissections. In order to avoid the patient's discomfort, intraaortic ultrasound will be used in the future, when major methodological improvements are done. Computed tomography demonstrates medial dissections but is not able to visualize intimal dissections. Using computed tomography and magnetic resonance after angioplasty of the coarctation of the aorta, irregularities are described in up to 17% of the patients. For angiography, a low detection rate of medial dissections has to be expected, when not biplane angiographies of the whole thoracic aorta are performend. Medial dissections can be seen, but intimal dissections are missed. In conclusion, a review of the literature demonstrates a high incidence of intimal and medial dissections after angioplasty of the coarctation of the aorta with spontaneous healing in most patients. As is the way with coronary angioplasty, aortic wall ruptures are rare, but stand-by surgery is necessary.     

Characterization of l-2-Amino-4-Phosphonobutanoate Action Following Sensitization by Quisqualate in Rat Hippocampal Slice Cultures

An excitatory action of l-2-amino-4-phosphonobutanoate (l-AP4), a glutamate analogue, is observed following pre-exposure of tissue to quisqualate. We have studied the mechanism of sensitization of l-AP4 responses by quisqualate in voltage-clamped CA3 pyramidal cells in rat hippocampal slice cultures in the presence of tetrodotoxin. Prior to quisqualate addition, CA3 cells did not respond to l-AP4 (50 - 1000 microM). Following brief application of quisqualate (500 nM for 30 s), l-AP4 (50 - 200 microM) induced a complex excitatory response which could be obtained for >1 h. l-AP4 caused an ionotropic inward current associated with a conductance increase. This response was in part sensitive to 6-cyano-7-nitro-quinoxaline-2,3-dione (CNQX) and in part sensitive to d-2-amino-5-phosphonovalerate (d-AP5) and Mg2+ ions. At depolarizing potentials, in the presence of CNQX and d-AP5, l-AP4 caused excitation by depressing K+ currents, mimicking the metabotropic action of glutamate. This indicates that the action of l-AP4 is mediated by three different receptor types: N-methyl-d-aspartate (NMDA) receptors, alpha-amino-3-hydroxy-5-methyl-isoxazole-4-propionate (AMPA) receptors, and glutamatergic metabotropic receptors. The l-AP4 response persisted in solutions containing low Ca2+ and high Mg2+ concentrations or 100 - 200 microM Cd2+, suggesting that it is independent of extracellular Ca2+. We were unable to identify any substance other than quisqualate capable of sensitizing the l-AP4 action. This effect also occurred when quisqualate was applied in Ca2+-free solution or in solutions containing low concentrations of Na+ or Cl-. Sensitization of l-AP4 responses by quisqualate was not observed in acutely dissociated pyramidal cells recorded by means of the whole-cell recording mode, although ionotropic quisqualate responses were present. Sensitization was readily reversed by short applications of the endogenous excitatory amino acids glutamate, aspartate and homocysteate at concentrations of 10 - 100 microM. Our data are consistent with the hypothesis that the excitatory action of l-AP4 results from a Ca2+-independent release of endogenous excitatory amino acids from some presynaptic neuronal or glial site.     

The value of inflammatory markers to diagnose and monitor diabetic foot osteomyelitis

In this study, we assessed the effectiveness of inflammatory markers to diagnose and monitor the treatment of osteomyelitis in the diabetic foot. We evaluated 35 consecutive patients admitted to our hospital with infected foot ulcers. Patients were divided in two groups based on the results of bone culture and histopathology: osteomyelitis and no osteomyelitis. The erythrocyte sedimentation rate (ESR), C‐reactive protein (CRP), procalcitonin (PCT), interleukin‐6 (IL‐6), interleukin‐8 (IL‐8), tumor necrosis factor alpha (TNFα), monocyte chemotactic protein‐1 (MCP‐1) and macrophage inflammatory protein‐1 alpha (MIP1α) were measured at baseline after 3 and 6 weeks of standard therapy. PCT levels in the osteomyelitis group were significantly higher at baseline than in the group with no osteomyelitis (P = 0·049). There were no significant differences between the two groups in the levels of the other markers. CRP, ESR, PCT and IL‐6 levels significantly declined in the group with osteomyelitis after starting therapy, while MCP‐1 increased (P = 0·002). TNFα and MIP1α levels were below range in 80 out of 97 samples and therefore not reported. Our results suggest that PCT might be useful to distinguish osteomyelitis in infected foot ulcers. CRP, ESR, PCT and IL‐6 are valuable when monitoring the effect of therapy.