Split-liver transplantation in two adult recipients: evaluation of feasibility in 100 consecutive cadaver liver grafts

AIM: To evaluate the feasibility of splitting a liver graft for transplantation in two adult patients. PATIENTS AND METHODS: We retrospectively collected data on the harvesting of 100 consecutive liver grafts. Data were separated into 4 groups to establish feasibility criteria, according to the chronological steps of harvesting: 1) initial criteria about the donor (age, weight, biological tests), 2) criteria concerning the liver graft at the time of harvesting (macroscopic appearance, graft weight, hemodynamic state of donor), (3) anatomical criteria and (4) histological criteria. RESULTS: If our criteria for the feasibility of splitting a liver graft for transplantation in two adults had been applied, 47 grafts would have been rejected based on initial criteria, 34 at the time of harvesting and 6 because of anatomical or histological evaluation. Finally, 13 liver grafts would have been accepted for splitting and then transplantation in two adults. CONCLUSIONS: Split-liver transplantation for two adult recipients could increase the graft pool by 13%. This procedure requires technical changes in organ harvesting and coordination among centers.     

Deliberate self-poisoning in Oman

OBJECTIVE: To describe the demographics, precipitating factors, substances and methods used for deliberate self-harm in Oman. METHODS: Data were extracted from the Accident and Emergency (A & E) records of patients treated at the A & E units in Muscat from 1993 to 1998. Data were obtained form the history, and clinical findings resulting form deliberate self-harm. RESULTS: During the 5-year study period, 123 persons presented to various hospitals in the Muscat area with injuries that resulted form deliberate self-harm. Most of these cases were women, students and unemployed. There was a high incidence of family, marital and psychiatric or social problems. The methods of self-harm were most often analgesics (such as paracetamol) and non-pharmaceutical chemicals. CONCLUSIONS: The rate of self-injurious behaviour is low in Oman, compared with other countries, including other Islamic countries. The data illustrate a rising rate and a tendency to ingest toxic doses of analgesics or non-pharmaceutical chemicals.     

Peritoneal pseudomyxoma: two case reports and review of the literature

In this article, we present two cases of peritoneal pseudomyxoma suspected on abdominal CT Scan and then confirmed on pathologic examination. A mucinus carcinoma was the primary lesion in the two cases, appendicular in the first case and with an undeterminate origin in the second. The prognosis was bad in these cases despite the debulking surgery and the systemic and intraperitoneal chemotherapy.     

Neoral rescue therapy in transplant patients with intolerance to tacrolimus

BACKGROUND: The calcineurin inhibitors, cyclosporine and tacrolimus, are the mainstay of current immunosuppressive regimens for the prevention of acute rejection in organ transplantation. The choice of the individual agent used often depends on the preference of the Transplant Center and patient type. Adverse effects associated with tacrolimus may impact its clinical utility in many patients. This study characterizes the clinical outcomes of transplant recipients who experienced adverse effects from tacrolimus and were converted to cyclosporine-microemulsion-based (Neoral([cyclosporine, USP] MODIFIED) therapy. METHODS: Hepatic or renal allograft recipients unable to maintain adequate immunosuppression with a tacrolimus-based regimen for reasons of toxicity or efficacy were recruited for this study and converted to cyclosporine-microemulsion-based therapy. Data were collected on drug dosing, trough concentrations, and treatment duration, as well as detailed information on tacrolimus-associated toxicities that prompted rescue with cyclosporine-microemulsion. Furthermore, clinical and laboratory data related to the clinical course of the patients after conversion to cyclosporine-microemulsion were recorded for up to 1 yr following conversion. RESULTS: One hundred and fifty-seven transplant recipients were enrolled in this study. Predominant reasons for discontinuation of tacrolimus were neurotoxicity (55%), diabetes (24%), nephrotoxicity (15%), and gastrointestinal intolerance (24%). Patients frequently had multiple symptoms prompting rescue therapy with cyclosporine-microemulsion. Over 70% of subjects had improvement or resolution of their tacrolimus-associated adverse symptoms within 3 months post-conversion. Acute rejection episodes occurred in 27% of patients converted to cyclosporine-microemulsion. CONCLUSIONS: Cyclosporine-microemulsion rescue therapy in patients experiencing adverse clinical effects associated with tacrolimus is an effective treatment option which leads to resolution of these adverse effects in the majority of patients, and allows for satisfactory clinical outcomes.     

Safety and risk of microelectrode recording in surgery for movement disorders

There is an ongoing controversy about whether it is necessary to use microelectrode recording (MER) techniques in stereotactic surgery for Parkinson's disease and other movement disorders. This paper consists of a critical review of the published literature in order to analyze the value of MER in providing safe, efficient and accurate functional stereotactic surgery. Review of the literature revealed that MER techniques do not necessarily improve targeting accuracy or clinical results, compared to techniques using impedance monitoring and macrostimulation. In terms of safety for the patients, however, MER techniques are relatively safe, but non-Mer techniques, based on macrostimulation-guided surgery, are at least five times safer.     

The inter-role confidentiality conflict in recruitment for clinical research

Recruiting patients into clinical research is essential for the advancement of medical knowledge. However, when the physician undertaking the care of the patient is also responsible for recruitment into clinical research, a situation arises of an inter-role breach of confidentiality which is distinguishable from other conflicts of interest. Such discord arises as the physician utilizes confidential information obtained within the therapeutic relationship beyond its primary objective, and safeguards ought to be observed in order to avert this important, and generally overlooked, problem. The moral worth of the pledge of confidentiality is based not on its innate value but on its being a promise on which subsequent interactions and disclosures are founded. Within the patient-doctor interaction, confidentiality is an important facet of the promised fidelity and, as such, a loose interpretation of the notion threatens the essence of the relationship, and any violation thereof requires compelling moral justification. To avoid conflict, patients' confidential information ought not be used for the purpose of recruitment, which needs to be undertaken through general education and non-directed appeals, and a preliminary consent to be approached for research should be obtained from the patient prior to her being identified as a suitable research subject. Securing this prior consent would avoid one source of potential, albeit unintended, coercion.     

Transcranial doppler measurement of cerebral velocity indices as a predictor of preeclampsia

OBJECTIVE: We have previously shown that women with preeclampsia demonstrate cerebral hyperperfusion and abnormal cerebrovascular autoregulation. In the current study, we tested the hypothesis that abnormal cerebrovascular function can be detected before the clinical onset of preeclampsia. STUDY DESIGN: Transcranial Doppler ultrasonography was performed for 166 women in the second trimester of pregnancy to measure peak, end-diastolic, and mean velocities in the middle cerebral arteries. Preeclampsia developed in 10 patients who were initially normotensive. In a nested case-controlled design, each patient with preeclampsia who was initially normotensive was matched for gestational age at the time of initial examination, maternal age, and parity with two pregnant women who remained normotensive and who were delivered at term. All measurements were performed with the subject in the left lateral position at baseline, during 5% carbon dioxide inhalation, and during a 2-minute isometric handgrip test. Blood pressure, heart rate, oxygen saturation, and end-tidal PCO (2) were recorded with each Doppler measurement. The mean pulsatility index, resistance index, and cerebral perfusion pressure at each time were calculated and compared. Statistical significance was set at a probability value of <.05. RESULTS: The studies were performed at 19 to 28 weeks of gestation. Preeclampsia developed an average of 13.6 +/- 1.0 weeks after the study. Baseline mean blood pressure and heart rate were similar, but middle cerebral arteries pulsatility and resistance indices were lower in the women with preeclampsia who were initially normotensive compared with the pregnant women who were normotensive (0.83 and 0.54 vs 0.73 and 0.50, respectively; P <.05). Both maneuvers caused a significant reduction in the pulsatility and resistance indices. With the use of baseline values as covariates, no significant differences were noted in the response to either carbon dioxide inhalation or handgrip between the group of women who remained normotensive and the group of women with preeclampsia who were initially normotensive. CONCLUSION: Normotensive pregnant women who later have preeclampsia demonstrate lower baseline pulsatility and resistance indices but normal vasodilatory responses to challenge tests. These findings suggest that women who are destined to have preeclampsia experience cerebral hemodynamic changes that predate the development of overt preeclampsia symptoms.     

An economic analysis of midwifery training programmes in South Kalimantan, Indonesia

In order to improve the knowledge and skills of midwives at health facilities and those based in villages in South Kalimantan, Indonesia, three in-service training programmes were carried out during 1995-98. A scheme used for both facility and village midwives included training at training centres, peer review and continuing education. One restricted to village midwives involved an internship programme in district hospitals. The incremental cost-effectiveness of these programmes was assessed from the standpoint of the health care provider. It was estimated that the first scheme could be expanded to increase the number of competent midwives based in facilities and villages in South Kalimantan by 1% at incremental costs of US$ 764.6 and US$ 1175.7 respectively, and that replication beyond South Kalimantan could increase the number of competent midwives based in facilities and villages by 1% at incremental costs of US$ 1225.5 and US$ 1786.4 per midwife respectively. It was also estimated that the number of competent village midwives could be increased by 1% at an incremental cost of US$ 898.1 per intern if replicated elsewhere, and at a cost of US$ 146.2 per intern for expanding the scheme in South Kalimantan. It was not clear whether the training programmes were more or less cost-effective than other safe motherhood interventions because the nature of the outcome measures hindered comparison.