Increased incidence of gastrointestinal surgical complications in renal transplant recipients with polycystic kidney disease

BACKGROUND: We had the impression that, although our renal transplant recipients with polycystic kidney disease (PKD) had excellent long-term renal graft function, they had an increased incidence of postoperative gastrointestinal (GI) complications. METHODS: Over a 10-year period (1987 through 1996), 1467 renal transplants were performed in 1417 patients; 145 of these transplants involved PKD recipients. In the PKD group, 18 patients (12.4%) developed a posttransplant complication necessitating GI surgery (PKD-GI), an incidence twice that in the non-PKD recipients (73 patients or 6.2%, non-PKD-GI). RESULTS: PKD and non-PKD recipients displayed no significant difference in mortality. The PKD patients had better long-term renal graft survival than the non-PKD patients (P=0.08). There was no difference in mortality (P>0.6) or renal graft survival (P>0.6) between the PKD-GI and PKD-non-GI groups. The PKD-GI group had no increased mortality over the non-PKD-GI patients (P>0.6), despite a higher incidence of GI surgical complications in the PKD group versus the non-PKD group (overall: 12.4 vs. 6.2%, P<0.01; within 90 days of transplant: 7.6 vs. 3.3%, P<0.02) and a greater propensity for small and large bowel complications (overall: 9.0 vs. 2.6%; P< 0.001; less than 90 days: 6.9 vs. 2.0%, P<0.002). The PKD-GI recipients tended toward less long-term graft loss than their non-PKD-GI counterparts (11.1 vs. 27.4%; P=.22). The PKD-GI recipients suffered no acute rejection episodes within 90 days after their GI operation versus 11 of 73 non-PKD-GI recipients (O vs. 15.1%; P=0.075). CONCLUSIONS: PKD recipients of renal grafts should be watched closely early after transplant because of their increased risk of GI complications. These complications resulted in no increase in mortality or graft loss compared to non-PKD recipients with GI complications despite the PKD group's higher incidence of bowel perforation and increased age at time of transplant.     

Current trends in the integration and reimbursement of complementary and alternative medicine by managed care organizations (MCOs) and insurance providers: 1998 update and cohort analysis

OBJECTIVES: To assess the status of managed care and insurance coverage of complementary and alternative medicine (CAM) and the integration of such services into conventional medicine. METHODS: A literature review and information search was conducted to determine which insurers had special policies for CAM. Telephone interviews were conducted with a definitive sample of 9 out of 10 new MCOs or insurers identified in 1998 and a cohort of eight MCOs and insurers who responded both to the original survey in 1997 and again in 1998 to determine trends. RESULTS: This study constitutes the results of the second year of a 3-year ongoing survey. For 1998, 10 MCOs and insurance carriers initiated CAM coverage. Survey results are analyzed for these 10 new providers as well as the results of a cohort of eight insurers surveyed in both 1997 and 1998 to determine current trends. A majority of the insurers interviewed offer some coverage for the following: nutrition counseling, biofeedback, psychotherapy, acupuncture, preventive medicine, chiropractic, osteopathy, and physical therapy. All new MCOs and insurers said that market demand was their primary motivation for covering CAM. Factors determining whether insurers would offer coverage for additional therapies included potential cost-effectiveness, consumer interest, demonstrable clinical efficacy, and state mandates. Among the most common obstacles listed to incorporating CAM into mainstream health care were lack of research on efficacy, economics, ignorance about CAM, provider competition and division, and lack of standards of practice. CONCLUSIONS: Consumer demand for CAM is motivating more MCOs and insurance companies to assess the benefits of incorporating CAM. Outcomes studies for both conventional and CAM therapies are needed to help create a health care system based upon treatments that work, whether they are conventional, complementary, or alternative.     

Parental knowledge about their asthmatic children]

A questionnaire was administered to parents of 171 asthmatic children, and their knowledge of asthma was evaluated using a quantitative score. The mean age of children was 5 yr and the mean duration of their asthma was 3 yr. Each sign of the classical triad "noisy breathing, cough, indrawing" was mentioned by two-thirds of parents. Inhaled agents perceived as triggers of asthma were: animal hair (73.7%), dust (69.6%), pollen (60.2%), tobacco (44.4%), molds (14.6%). Other triggering agents mentioned were: stress (51.5%), infections (38%), exercise (13.5%). Mothers with college or university education knew more clinical signs of an attack (P less than 0.01) and more triggering factors (P less than 0.005). Parents satisfied with previous teaching knew more threatening signs of an attack (P less than 0.01). About 80% of those that used theophylline and 49.4% of those that used inhaled beta-2-agonists knew the correct mode of administration. Parents satisfied with previous teaching had better knowledge of the side-effects of theophylline (P less than 0.005) and beta-2-agonists (P less than 0.02). 58.5% of those that used cromolyn sodium did not know the mean duration of a therapeutic trial and 15% did not use it as prophylaxis. 57.1% of those that used oral corticosteroids did not know any side-effects of the drug. About half of the parents indicated that they would like to receive more information about the causes and the appropriate treatment of asthma. It was concluded that parental teaching should focus more on environmental and therapeutic issues.     

Unusual traumatic rupture of the thoracic aorta with avulsion of the left subclavian artery]

Of the many cases of traumatic rupture of the aorta diagnosed each year at l"H?pital du Sacré-Coeur, Montreal, most patients are already in irreversible shock when seen. However, during the period Oct. 1, 1974 to Sept. 30, 1975, prompt surgical treatment saved six patients. One of these six patients had a complete trans-section of the aortic arch between the left carotid and left subclavian arteries with avulsion and slight retraction of the left subclavian artery. Repair of the aortic arch and left subclavian artery was accomplished without extracorporeal circulation. A sutureless temporary bypass shunt was created by (a) cannulating the ascending and descending aorta, the cannulas being secured with purse-string sutures and joined by a 3/8-inch (94-mm) polyvinyl chloride (PVC) tube connected to a "double T" adapter, and (b) joining two small PVC tubes from the adapter with two straight cannulas, a no. 14 being inserted into the innominate artery and a no. 12 being inserted into the left carotid artery. With this temporary bypass created, the ascending and descending aorta and aortic arch vessels were all clamped. Aortic continuity was re-established with a tubular Dacron graft (diameter, 19 mm) to which was anastomosed a side-arm of knitted Dacron (diameter, 10 mm) to repair the left subclavian artery. Throughout the temporary perfusion the brain, spinal cord and all abdominal viscera were well protected. No sign of ventricular distension was detected. This report is the first in which complete transsection of the aortic arch has been managed by a sutureless bypass shunt allowing perfusion of all aortic arch vessels without extracorporeal circulation.     

Serum ferritin and the iron status of Canadians.

Serum ferritin concentration was determined in 1105 Canadians aged 1 to 90 years. Geometric mean values (ng/ml) were as follows: children 1 to 4 years old, 12; children 5 to 9 years old, 15; adolescent girls, 17; adolescent boys, 18; women 20 to 39 years, 23; women 65 years and older, 52; men 20 to 39 years, 93; and men 40 and older, 92. Ranges were side in all age groups, reflecting variations in size of body iron stores. From analysis of the ferritin values it is highly probably that iron stores were greatly reduced in approximately 25% of children, 30% of adolescents, 30% of menstruating women, 60% of pregnant women and 3% of men. Iron-deficiency anemia was noted in only 2% of subjects. If "normality" requires more than small amounts of storage iron to meet physiologic demands, the study results suggest a high probability of iron deficiency in 60% of the pregnant women and in 19% of the other subjects; but if normality is defined as maintenance of adequate iron stores for erythropoiesis, the prevalence of iron deficiency was zero in the pregnant women and 2% in the other subjects.     

Sensitized immunofixation: a new technique for analyzing the oligoclonal pattern of CSF immunoglobulins

Intrathecal immunoglobulin synthesis is observed in more than 90% of all cases of multiple sclerosis, producing a specific CSF IgG oligoclonal electrophoretic pattern. The consensual method used as reference is isoelectric focusing (IEF). We developed a new CSF Ig analysis method by immunofixation (IF). The method includes an immunoenzymatic detection step performed directly on the gel allowing the use of unconcentrated CSF and avoiding the blotting step. The reliability of this method was established by the analysis of 210 CSF/serum pairs including defined, probable and possible MS, other inflammatory CNS diseases and controls (noninflammatory CNS diseases and peripheral nervous system diseases). Intrathecal IgG synthesis was detected in 95.5% of defined MS cases. The specificity for CNS inflammatory diseases including MS diagnosis, evaluated by comparison with controls, was 98.8%. This new method is quicker and visual interpretation is easier than with IEF. It is a semi-automated method that should be considered for standardization of CSF IgG analysis.