The impact of surveillance and rapid reduction in immunosuppression to control BK virus‐related graft injury in kidney transplantation

We prospectively screened 609 consecutive kidney (538) and kidney‐pancreas (71) transplant recipients for BK viremia over a 4‐year interval using polymerase chain reaction viral load detection and protocol kidney biopsies. We found that BK viremia is common at our center: total cases 26.7%, cases during first year 21.3% (mean 4 months), and recipients with ≥10 000 copies/ml 12.3%. We found few predictive clinical or demographic risk factors for any BK viremia or viral loads ≥10,000 copies/ml, other than prior treatment of biopsy confirmed acute rejection and/or higher immunosuppressive blood levels of tacrolimus (P = 0.001) or mycophenolate mofetil (P = 0.007). Viral loads at diagnosis (<10 000 copies/ml) demonstrated little impact on graft function or survival. However, rising copy numbers demand early reductions in immunosuppressive drug doses of at least 30–50%. Viral loads >185 000 copies/ml at diagnosis were predictive of BK virus‐associated nephropathy (BKVAN; OR: 113.25, 95% CI: 17.22–744.6, P < 0.001). Surveillance for BK viremia and rapid reduction of immunosuppression limited the incidence of BKVAN to 1.3%. The addition of leflunomide or ciprofloxacin to immunosuppressive dose reduction did not result in greater rates of viral clearance. These data support the role of early surveillance for BK viremia to limit the impact on transplant outcome, although the most effective schedule for screening awaits further investigation.     

Complications in degenerative lumbar disease treated with a dynamic interspinous spacer (Coflex)

Purpose

The purpose of this study was to quantify the intra- and postoperative complications of an interspinous process device (Coflex) in managing degenerative lumbar diseases and to investigate corresponding therapeutic strategies.

Methods

Between January 2008 and December 2012, we retrospectively analysed a total of 131 patients who underwent decompressive surgery along with the Coflex system for the treatment of degenerative lumbar diseases. The related complications were reported, and appropriate measures were taken. Clinical outcomes and radiological data were collected and analysed, and clinical outcomes were evaluated with paired-samples T test.

Results

Related complications occurred in 11 patients. Among them, six cases were found with surgical technique-related complications, including device-related complications in three cases: spinal process fracture (n = 1), Coflex loosening (n = 1), fixed-wing breakage (n = 1), dura mater tear in two cases and superficial wound infection in one case. All of them received corresponding conservative treatment and obtained a good result. The other five cases had non-device-related complications and required additional spinal surgery. The conservative therapy group had apparent improvement of VAS score and ODI, and remained well to final follow-up (P < 0.05). The second operation group also improved postoperatively (each P < 0.05).

Conclusion

The Coflex dynamic interspinous process device shows a low complication and re-operation rate. Standard operation and strict follow-up observation can effectively avoid surgical technique-related complications. The key points to ensure surgical effect and to reduce non-device-related complications are mastering surgical indications and thorough intra-operative decompression.     

Profile and Predictors of Long-term Morbidity in Breast Cancer Survivors

Background

A sound understanding of the benefits of different treatment options and their health-related quality of life (HRQoL) impacts is required for optimal breast cancer care.

Methods

A cross-sectional cohort study was conducted to determine the prevalence and severity of persistent functional decrements and symptoms and identify demographic, clinical and treatment variables associated with poorer outcomes. Four hundred English-speaking women treated for ductal carcinoma-in-situ or stage I to III breast cancer between 1999 and 2009, at least 12 months after surgery and currently disease free, were randomly selected and invited to complete (1) the Breast Cancer Treatment Outcome Scale and (2) the EORTC core Quality of Life Questionnaire, version 3.

Results

The response rate was 85.60 %. Many participants reported moderate to severe decrements in a number of HRQoL domains, including functional well-being (15 %), cosmetic status (32 %) and overall quality of life (21 %). There were significant associations (p < .05) between younger age and poorer HRQoL but none between time since surgery and morbidity (p > .05). Different treatments were associated with different HRQoL impacts. Poorer functional status was predicted by axillary dissection (p = .011), and adjuvant radiotherapy was a significant predictor of breast-specific pain (p < .05).

Conclusions

Many breast cancer survivors report long-term morbidity that is unaffected by time since surgery. The significant associations between the extent of locoregional therapies and poorer HRQoL outcomes emphasize the importance of the safe tailoring of these treatments.     

双封堵器介入治疗多孔性房间隔缺损

目的对双封堵器介入治疗多孔性房间隔缺损(ASD)的可行性与有效性进行临床评估。方法对17例多孔性ASD(12例为2孔,5例为3孔)患者在X线透视和超声心动图监测下植入Amplatzer封堵器,同时闭合2～3个缺损。术后复查ECG、X线平片及TTE以评价其疗效。结果 17例术中超声测量ASD大、中和小缺损直径分别为(13.94±3.21)mm、(9.65±2.64)mm及(4.80±1.92)mm。16例获得成功(16/17,94.12%),1例因第2个ASD不适于封堵而放弃,改行外科手术后痊愈出院。16例植入封堵器32枚,共闭合缺损37个,所植入大、小封堵器直径分别为(20.75±4.07)mm和(16.94±3.75)mm,较术中超声所测大孔及中孔ASD径分别增大(7.06±2.65)mm、(7.44±3.25)mm。术后3例残余微或少量分流(2例为3孔ASD),分别于术后第2、3天及3个月复查时消失。1例发生股动静脉瘘,1个月后消失。随访X线胸片测心胸比及超声测右心室前后径均较术前明显下降(P均<0.01)。结论采用双封堵器介入治疗多孔性ASD安全、有效。     

Properties of the ON bistratified ganglion cell in the rabbit retina

The identity of the types of different neurons in mammalian retinae is now close to being completely known for a few mammalian species; comparison reveals strong homologies for many neurons across the order. Still, there remain some cell types rarely encountered and inadequately described, despite not being rare in relative frequency. Here we describe in detail an additional ganglion cell type in rabbit that is bistratified with dendrites in both sublaminae, yet spikes only at light onset and has no response bias to the direction of moving bars. This ON bistratified ganglion cell type is most easily distinguished by the unusual behavior of its dendritic arbors. While dendrites that arborize in sublamina b terminate at that level, those that ascend to arborize in sublamina a do not normally terminate there. Instead, when they reach the approximate radius of the dendrites in sublamina b, they dive sharply back down to ramify in sublamina b. Here they continue to course even further away from the soma at the same level as the branches wholly contained in sublamina b, thereby forming an annulus of secondary ON dendrites in sublamina b. This pattern of branching creates a bistratified dendritic field of approximately equal area in the two sublaminae initially, to which is then added an external annulus of dendrites only in sublamina b whose origin is entirely from processes descending from sublamina a. It is coupled to a population of wide‐field amacrine cells upon which the dendrites of the ganglion cell often terminate. J. Comp. Neurol. 521:1497–1509, 2013. © 2012 Wiley Periodicals, Inc.     

Clustering of cardiovascular risk factors and stroke: a prospective cohort study in Inner Mongolia

Objective: This study aimed to evaluate the effect of clustering of cardiovascular risk factors (CVRF) on stroke incidence and find some high predictive clusters among Inner Mongolians in China.

Methods: A prospective cohort study was conducted among 2589 participants aged 20 and older from Inner Mongolia, China. The participants were divided into four groups according to the number of CVRFs and followed up from June 2002 to July 2012. Cox proportional hazards model was used to evaluate the clustering of CVRFs on the incidence of stroke. Area under curve was used to compare the effect of every cluster on stroke and find those having higher predictive value.

Results: A total of 124 stroke occurred during the follow-up period. The incident stroke cases tended to be older and male; had higher prevalence of smoking, drinking, and family history of cardiovascular diseases (FHCVD); had greater waist circumference, higher systolic and diastolic blood pressure, and C-reactive protein levels at baseline compared with those who did not experience stroke. Unadjusted hazard ratio (HR) (95% confidence interval) of stroke in the participants with at least three CVRFs was 5.230 (2.646–10.336), compared with those without CVRF. After multiple adjustments, the result remained statistically significant (HR, 3.388; 95% confidence interval: 1.678–6.840). On the basis of FHCVD, clustering of hypertension with other CVRFs and clustering of diabetes with tachycardia had higher predictive value than other clustering.

Conclusion: The clustering of CVRFs increased the risk of stroke. On the basis of FHCVD, the clustering of hypertension with other CVRFs and the clustering of diabetes with tachycardia had higher predictive value for stroke than other cluster.