Routine Cyclosporine concentration - C2 level Monitoring. Is it helpful during the early post Transplant Period?

Background

Pre dose or trough blood cyclosporine (CSA) concentration is routinely monitored and the result is used to alter patient''s drug dosing. Patients with identical pre dose blood CSA may have very different systemic exposure to the drug. Recently CSA 2 hour post dose level [C2] has been reported to correlate better with drug exposure. We undertook this study to evaluate the influence of trough and C2, CSA concentration monitoring on short-term renal allograft outcomes.

Methods

25 patients of renal transplant receiving a triple drug regimen of CSA micro emulsion (Panacea Biotec) 8mg/kg, azathioprine 1mg/kg and prednisolone 0.5mg/kg were analyzed prospectively for graft outcomes. CSA levels were monitored in whole blood by radioimmunoassay using monoclonal antibodies, at 72 hours after the transplant.

Results

The mean age of patients was 37.08 + 9.1 years. There were 20 males and 5 females. The mean age of donors was 40.2 + 8.2 years. There were 11 related donors with at least a haplomatch, 4 spousal and 10 unrelated donors with a nil antigen match. The mean pre dose CSA concentration was 289.22 + 171.9ng/ml; range (98.8 + 783.41ng/ml). The CSA concentration at 2 hours after the CSA administration was 838 + 310.87ng/ml (range, 169 + 1268ng/ml). 3 (12%) patients had acute rejection. In these patients the mean pre dose CSA concentration was 328.67ng/ml and the mean C2, CSA concentration was 1006.26ng/ml. CSA induced hemolytic uraemic syndrome was diagnosed in one patient. The trough and C2, CSA concentration levels were 174 and 870.83ng/ml respectively in this patient.

Conclusion

In our study CSA levels, trough and peak showed significant inter patient variability. The trough and C2 concentration levels did not correlate with the episodes of acute rejection. We conclude that in a triple drug regimen with fixed dosing schedules routine trough CSA level monitoring is not helpful in the acute post renal transplant period.Key Words: Cyclosporine levels, Cyclosporine trough levels, C2 levels     

Sonovue improves endocardial border detection and variability in assessing wall motion score and ejection fraction during stress echocardiography

Background Stress echocardiography is useful for assessing patients with coronary artery disease unable to undergo formal exercise testing. Considerable skill is required to avoid large intra- and inter-observer variability due to poor endocardial definition. Intravenous ultrasound contrast agents are now available which may improve this variability. Aim To study intravenous Sonovue in assessing wall motion score and ejection fraction (EF) during stress echocardiography. Methods Thirty-eight patients undergoing arbutamine stress echocardiography for known or suspected coronary artery disease were studied. Echocardiographic analysis of wall motion score index, endocardial border detection (EBD) and EF was performed at rest and at peak stress before and after intravenous injection of Sonovue, by experienced and inexperienced observers. Results All three observers noted an improvement in endocardial border definition following Sonovue (p=<0.001). At baseline, there was a significant difference in wall motion score index between experienced and inexperienced observers at rest (p=0.01) and at peak stress (p=0.001). Following Sonovue administration this was no longer significant (p=0.07, p=0.114). Intra-observer variability of end diastolic, end systolic volumes (ESV) and EF improved following contrast (p<0.05) at rest and during stress. Conclusion Sonovue significantly improved EBD and reduced intra-observer variability of EF at rest and during peak arbutamine infusion.     

Allelic structures at hypervariable minisatellite B6.7 in Japanese show population specificity

Human minisatellite B6.7 shows extensive allele length and structural variability in north Europeans. We analysed this locus in the Japanese population. Allele size distributions showed that Japanese retain extensive allele length variability but have significantly smaller alleles compared with north Europeans. In contrast, there is very little variation in flanking DNA, with only one single-nucleotide polymorphism (SNP) near the minisatellite. Ninety-two Japanese alleles were further characterised by minisatellite variant repeat mapping by polymerase chain reaction (MVR-PCR). These alleles showed a wide variety of internal MVR structures, despite their relative shortness, with most alleles observed only once in the sample. The true heterozygosity is estimated at 99.95%, with well in excess of 2000 different alleles existing in the Japanese population. Dot matrix analysis showed that groups of related alleles sharing structural motifs could be identified within Japanese and in north Europeans, and that these groups are population specific with no examples of significant similarity between any Japanese and north European alleles. Minisatellite B6.7 therefore shows huge allele variability and fast repeat turnover in Japanese as well as north European populations, and provides novel lineage markers for exploring very recent events in human population history. Received: January 29, 2002 / Accepted: February 12, 2002     

Evaluating enrichment program study groups: academic outcomes,psychological outcomes,and variables influencing retention

The purpose of this study was to describe and evaluate select aspects of an enrichment program (EP) for students who participated in peer mentor/tutor (PMT) led study groups throughout the semester. The evaluation addressed three areas related to the underlying conceptual framework: (1) academic outcomes; (2) psychological outcomes (satisfaction); and (3) variables influencing retention. Overall, study group participants achieved higher pass rates, lower withdrawal rates, and positive psychological outcomes (satisfaction). Students perceived that environmental variables were more influential than academic variables in influencing retention. Social integration variables were perceived as greatly supportive. Implications for nurse educators are discussed.     

Informed Consent

There have been significant changes in the doctor patient relationship with the impact of technology in day-to-day practice. More and more patients are aware of their rights and are keen to make free choice and decision on their treatment. This helps them to choose the treatment of their choice from the options available and to select a physician of their choice. Doctor's decisions are being questioned regarding their correctness and there is a need to educate the patient, on what one offers by way of treatment. In some procedures and types of treatment, patient needs to be educated and informed of the merits and demerits of the treatment available. This will help the patient to make appropriate choice and also to accept some adverse outcome of treatment. Towards this end, all countries are looking afresh at the necessity of Informed Consent. Methods adopted by some countries are highlighted to help our physicians practice them in an appropriate way. A lot of remedial work needs to be done to minimize future litigation, as many doctors misunderstand their legal obligations and haven't caught up with the change in judge's thinking.     

Immediate food hypersensitivity reactions on the first known exposure to the food

We report 8 infants with immediate hypersensitivity reactions to foods (milk, egg, or peanut), occurring at the first-known exposure. Each developed symptoms within the first hour, but these generally settled within 2 hours. Sensitisation to the food concerned was demonstrated by positive immediate allergen skin prick tests in every case. Symptoms experienced included irritability, erythematous rash, urticaria, angio-oedema, vomiting, rhinorrhoea, and cough. Five infants were being followed prospectively and 4 were clinically tolerant of the food by age 16 months. The most likely route of sensitisation was via breast milk. None of the infants experienced similar reactions while being breast fed, suggesting that the reaction was dose dependent. As 5 out of a group of 80 infants being followed prospectively developed an immediate reaction at their first known exposure to a food, this appeared to be a not uncommon presentation of food hypersensitivity in infancy.     

Angiotensin‐converting enzyme inhibition increases glucose‐induced insulin secretion in response to acute restraint

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Ethnic differences in cause specific mortality among hospitalised patients with diabetes: a linkage study in New Zealand

STUDY OBJECTIVE: To describe patterns of excess mortality among patients with diabetes in three ethnic groups. DESIGN: A linkage study of national hospital discharge records to death records. SETTING: New Zealand. PARTICIPANTS: The study included 74 847 patients (11,268 Māori, 5730 Pacific, and 57,849 non-Māori/non-Pacific) aged over 25 years with a hospital discharge diagnosis of diabetes between 1988 and 2001. By the end of 2001, 29,295 (39%) of the cohort had died. Based on the underlying cause of death, standardised mortality ratios (SMRs) (95% confidence intervals) were calculated for each ethnic group and sex. MAIN RESULTS: Comparing the mortality patterns of patients with diabetes to the general population of the same ethnic group, adjusting for age and calendar period, all cause SMRs were higher for Māori women and men: 3.80 (95% CI: 3.64 to 3.97) and 3.44 (95%CI: 3.30 to 3.58) than for Pacific (men: 2.41 (95%CI: 2.21 to 2.61); women: 2.23 (95%CI: 2.06 to 2.41)) and non-Māori/non-Pacific (men: 2.98 (95%CI: 2.93 to 3.04); women: 2.99 (95%CI: 2.93 to 3.04)) people. SMRs were significantly raised for several causes of death, including cardiovascular disease and many site specific cancers. CONCLUSIONS: The pattern of excess mortality among Māori with diabetes may relate to severity of disease. This needs further investigation, as the excess mortality may be amenable to intervention.