Access to kidney transplantation in France of non-French patients and French patients living in overseas territories

BACKGROUND: In France, foreign patients, whether resident or not in France, can register on the national waiting list under certain conditions. We compared waiting time to kidney transplantation, the level of HLA matching and graft cold ischemia time between foreign patients and French patients living in mainland France or in French overseas territories (FOT). METHODS: We performed a retrospective cohort survey using the nationwide registry. Between 1996 and 2003, 18,595 patients were registered on the French waiting list. Of these, 9.9% were of non-French nationality (0.7% Greek, 1.4% Italian, 1.5% other European, 3.7% North African, 1.8% sub-Saharan African and 0.9% other), and 3.8% were French nationals living in FOT. RESULTS: Median waiting time differed significantly between groups, from 13.8 months for mainland French patients to 39.5 months for sub-Saharan African patients. After adjustment for other factors significantly linked to waiting time, French residents of FOT (RR=0.83; P<0.001) and patients from sub-Saharan Africa (RR=0.75; P<0.0001) were found to wait significantly longer than other patients. HLA matching level, particularly HLA-A and HLA-B, was worse for African patients. After adjustment for the transplant team, cold ischemia time was found to be longer for Greeks (30.4 hr, P<0.0001) and French patients living in FOT (33.3 hr, P<0.0001) than for mainland French patients (21.2 hr). CONCLUSIONS.: Programs promoting organ donation aimed at minorities of African origin should improve their access to transplantation in France. We also need to strengthen international cooperation programs in certain countries to assist access to transplantation and to increase graft quality.     

The pharmacokinetics of anesthetic drugs and adjuvants during cardiopulmonary bypass

The institution of cardiopulmonary bypass during cardiac surgery has profound effects on the plasma concentration of drugs and thus their therapeutic effectiveness. These changes occur through acute hemodilution, altered plasma protein binding, hypotension, as well as the use of hypothermia and heparin administration. Isolation of the lungs from the circulation and the possible sequestration of drugs in the bypass circuit also affect drug plasma concentrations on bypass. The individual characteristics of the drug in question are also important in determining the final plasma concentration: Lipid soluble drugs with a high volume of distribution may be more readily taken up by bypass equipment, but the initial fall in concentration at the start of cardiopulmonary bypass may be more readily counteracted by back diffusion into plasma, if large tissue stores have accumulated. The extent of the drug's plasma protein binding is of importance as the effective free fraction in plasma for highly bound drugs will be sensitive to changes in plasma protein binding brought on by factors such as hemodilution, heparin administration as well as alpha, acid-glycoprotein binding. Clearly the fate of drugs administered before or on bypass is complex and can only be accurately determined by specific studies evaluating drug plasma concentrations. This review updates the available data on anesthetics and drugs used during cardiac surgery in order that anesthetists may predict better the likely effect of drugs administered before or during cardiopulmonary bypass.     

Mallory-Weiss tear following cardiac surgery: transoesophageal echoprobe or nasogastric tube?

A case of fatal upper gastrointestinal bleeding from a Mallory–Weisstear after transoesophageal echocardiography during cardiacsurgery is reported. After the echocardiographic examination,which is considered a safe procedure, a nasogastric tube wasinserted which immediately revealed bright red blood. Eventuallythe patient lost 9 litres of blood. The role of the echoprobeand the nasogastric tube in causing the Mallory–Weisstear is discussed. Although this case is not conclusive aboutthe mechanism of oesophageal damage, it is suggested that thesafety recommendations for transoesophageal echocardiographyalso apply for instrumentation of the oesophagus with a nasogastrictube after the transoesophageal echocardiographic examination.     

Predisposing and provoking factors in childhood headache

Objective.–To study the differences in predisposing and provoking factors between childhood migraine and nonmigrainous headache.
Background.–Information on the predisposing and provoking factors of headache could help to find ways to prevent it. Differences in predisposing and provoking factors between migraine and nonmigrainous headache are largely unknown.
Methods.–An unselected, population-based, prospective, follow-up study on the occurrence of headache in schoolchildren was carried out in 1290 children aged from 8 to 9 years. The children who had reported headache during the 6 months prior to the study ( n = 725) were sent a more detailed questionnaire about factors that might give rise to headache. Six hundred twenty-two (86%) children returned questionnaires that were completed to an acceptable degree.
Results.–The occurrence of familial paroxysmal headache and unhappiness in the family independently predicted the occurrence of migraine in children, but this was not the case for nonmigrainous headache.
Conclusions.–In particular, the family occurrence of paroxysmal headache increases the risk of migraine in a child. The risk is still greater if their living conditions are experienced as unsatisfactory by the family.     

Congenital radial head dislocation with a progressive cubitus valgus: a case report

Congenital dislocation of the radial head is rare, although it is the most common congenital anomaly of the elbow. A concomitant progressive cubitus valgus of the elbow has not previously been described in literature. We describe a case of an 8-year-old girl with an unilateral congenital radial head dislocation with a progressive cubitus valgus of 35°, caused by a prematurely closing physis of the lateral humeral condyle. This might be caused by an increased pressure on the lateral physis by the anteriorly dislocated radial head. As no complaints or limitations were present, treatment was non-operative with clinical observation, with satisfactory results after a follow-up of 18 months. A concomitant progressive cubitus valgus can be present in patients with a congenital radial head dislocation. Non-operative treatment can provide satisfactory results.