Three-year outcomes from the CRADLE study in de novo pediatric kidney transplant recipients receiving everolimus with reduced tacrolimus and early steroid withdrawal

CRADLE was a 36-month multicenter study in pediatric (≥1 to <18 years) kidney transplant recipients randomized at 4 to 6 weeks posttransplant to receive everolimus + reduced-exposure tacrolimus (EVR + rTAC; n = 52) with corticosteroid withdrawal at 6-month posttransplant or continue mycophenolate mofetil + standard-exposure TAC (MMF + sTAC; n = 54) with corticosteroids. The incidence of composite efficacy failure (biopsy-proven acute rejection [BPAR], graft loss, or death) at month 36 was 9.8% vs 9.6% (difference: 0.2%; 80% confidence interval: −7.3 to 7.7) for EVR + rTAC and MMF + sTAC, respectively, which was driven by BPARs. Graft loss was low (2.1% vs 3.8%) with no deaths. Mean estimated glomerular filtration rate at month 36 was comparable between groups (68.1 vs 67.3 mL/min/1.73 m²). Mean changes (z-score) in height (0.72 vs 0.39; P = .158) and weight (0.61 vs 0.82; P = .453) from randomization to month 36 were comparable, whereas growth in prepubertal patients on EVR + rTAC was better (P = .050) vs MMF + sTAC. The overall incidence of adverse events (AEs) and serious AEs was comparable between groups. Rejection was the leading AE for study drug discontinuation in the EVR + rTAC group. In conclusion, though AE-related study drug discontinuation was higher, an EVR + rTAC regimen represents an alternative treatment option that enables withdrawal of steroids as well as reduction of CNIs for pediatric kidney transplant recipients. ClinicalTrials.gov: NCT01544491.     

Symptoms in children of British and of Bangladeshi parents measured by the Rutter B2 questionnaire

Objectives. Bangladeshi children are less frequently referred to a child psychiatric clinic than their British peers. This study aimed to ascertain if teachers observed less psychological symptoms in Bangladeshi than British children.

Method. Teachers completed a Rutter B2 Scale on samples of 113 ‘Bangladeshi’ and 61 British children aged between 5 and 11 years.

Results. Teachers recognised less symptomatology in the Asian children than their British peers. This trend was significant in children under the age of 8, but there was no significant difference in those aged 8–11 years. Only 13% of Bangladeshi children were fully fluent in English.

Conclusions. Two alternate hypotheses are put forward to explain these findings: (a) because more of the younger children could not speak English and communicate freely with their teachers, their symptoms were not noted by teachers; (b) the symptoms of the older children were a response to the pressures both the children and families faced as new immigrants. This study clearly needs to be replicated with a larger sample and also with interviews with both children and parents in order to validate the Rutter B2 questionnaires as an appropriate measure of disturbance in Bangladeshi children. It should be replicated with validated assessments of the children's fluency in English. It is also important to discuss with Bangladeshi parents what support they would like from both the school and from child psychiatric services, to promote their children's psychological health.     

Cannabis laws: an analysis of costs

There is evidence that the use of cannabis is increasing in Australia, with stable black-market prices, despite the 9-year National Campaign Against Drug Abuse, increasing expenditure to enforce the laws against cannabis use, and the seizure of large plantations of cannabis plants. Recent government data are used to estimate the conservative cost of drug-law enforcement against cannabis use as being $329m in 1991-92. Alternatives to the existing regime are examined, including expiation, decriminalization, and legalization.     

Treatment of infected left ventricular assist device using antibiotic-impregnated beads

There is no well-established therapy for treating infections of heart-assist or artificial heart devices, a serious problem with life-threatening consequences. We used a promising new approach in which antibiotic-impregnated polymethylmethacrylate beads were placed around an implanted left ventricular assist device to control an external blood pump infection in a bridge-to-transplant patient. In this case report, we describe the potential of antimicrobial-impregnated polymethylmethacrylate beads for in situ control of infections involving external surfaces of cardiovascular devices.     

Papillary clear cell adenocarcinoma of the groin arising from endometriosis

A 67-year-old woman presented with rapidly enlarging right anterior thigh mass. Clinical impression was of a primary sarcoma, but the histologic analysis of an incisional biopsy specimen showed adenocarcinoma with clear cell differentiation. Initially thought to be a metastasis, the malignant tumor appears to have arisen from extraabdominal endometriosis of the right groin. This case shows clinical, radiographic, and histologic findings that may help the orthopaedic surgeon recognize an unusual complication of extrapelvic endometriosis.     

Long-term effects of finasteride on prostate tissue composition

OBJECTIVES: To determine the long-term effects of finasteride treatment on prostate tissue composition; to relate these effects to clinical outcomes; and to test the hypothesis that finasteride exerts a selective or preferential action on the transition zone. METHODS: Nineteen men with symptomatic benign prostatic hyperplasia (BPH) who completed a 6-month double-blind trial of finasteride were enrolled in a 24-month open-label extension study of drug responders. Magnetic resonance imaging and prostate biopsy for morphometric analysis were performed together 70 times: at baseline (n = 19), after treatment periods of intermediate duration (6 to 18 months, n = 32), and after long-term drug treatment (24 to 30 months, n = 19). At baseline, prostate volume averaged 51 cc, of which 57% was transition zone. RESULTS: Decreases in symptom score, dihydrotestosterone and prostate-specific antigen levels, and prostate volume occurred at 6 months (P <0.01), stabilized, and were maintained without further long-term decreases. Prostate epithelium contracted progressively from baseline (19.2% tissue composition; 6.0-cc volume; 3.2 stroma/epithelial ratio) to intermediate (12.5%, 3.3 cc, and 5.6, respectively) to long-term treatment (6.4%, 2.0 cc, and 17.4, respectively, P <0.01 for all). Percent epithelial contraction was similar in the peripheral and transition zones (P = NS). The transition zone remained a relatively constant proportion (53% to 58%) of whole-prostate volume from baseline to long-term observation. CONCLUSIONS: Long-term finasteride treatment (24 to 30 months) results in a marked involution of the prostate epithelium, which continues to progress for many months after clinical effects stabilize. The effect on the epithelium is similar in the peripheral and transition zones for both morphometric and volumetric changes. Progressive contraction of the prostate epithelium appears to constitute the underlying mechanism for sustained action of finasteride.