Mycophenolate Mofetil Use Is Associated with Decreased Risk of Late Acute Rejection in Adult Liver Transplant Recipients

Mycophenolate mofetil (MMF) used in a triple-drug regimen has been shown to decrease acute rejection rates, compared to a double-drug regimen. The impact of MMF on late acute rejection (LAR) episodes has not been well described. To investigate the risk of LAR (rejection > or = 6 months post-transplantation) data from the Scientific Registry of Transplant Recipients (SRTR) were used. We studied adult primary liver transplant recipients transplanted between June 1, 1995, and April 30, 2004, with hepatitis C virus (HCV) (n = 3356), hepatitis B virus (HBV) (n = 550) or a nonviral (n = 5740) primary cause of liver disease who were recorded as receiving continuous 3-(MMF + Tacro + steroids) versus 2-drug (Tacro + steroids) therapy for at least 6 months immediately post transplantation. Kaplan-Meier analysis showed significantly lower LAR rates 4 years post-transplant in 3- versus 2-drug HCV, HBV and nonviral disease patients. Multivariate regression confirmed 3- versus 2-drug therapy to be associated with a decreased risk of LAR. Late graft survival was significantly lower at 4 years post-transplant for patients with LAR 6-12 months post-transplantation versus patients with early rejection (78.0% vs. 87.0%, p < 0.001) and no rejection (88.1%, p < 0.001). Three-drug versus 2-drug therapy for a minimum of 6 months may offer a better treatment strategy to avoid the consequences and expense of LAR episodes.     

胶囊内镜与常规上消化道内镜检查诊断食管静脉曲张准确性的比较：一项前瞻性、3中心先导性研究

背景与研究目的：静脉曲张破裂出血是肝硬化的一个主要并发症，与6周内20％的死亡率有关。目前国际指南推荐肝硬化患应常规行上消化道内镜检查（食管胃十二指肠内镜检查，EGD）来筛查是否有食管静脉曲张。新近出现的食管胶囊内镜在对胃食管反流和Barrett食管的研究中已经显示出准确的诊断效应。该研究比较胶囊内镜和EGD对肝硬化患食管胃底静脉曲张和门脉高压性胃病的检出率。患与方法：在3个中心进行了先导试验。有进行EGD临床指征的肝硬化患，在EGD检查后48h内用胶囊内镜来筛查或监视食管静脉曲张。研究采用盲法，即由1名事先不知道患病史和EGD检查结果的研究评估胶囊视频成像。结果：在32例纳入的患中，EGD和胶囊内镜检查发现有食管静脉曲张23例患。有1例患经胶囊内镜发现有轻度静脉曲张，但EGD未检出。胶囊内镜和EGD诊断食管静脉曲张和门脉高压性胃病的总体一致性分别为96．9％和90．6％。没有与胶囊内镜相关的不良事件。     

颈椎旋转、半失稳在椎动脉型、交感型、神经根型颈椎病间的相关研究

目的:探讨椎动脉型颈椎病、交感型颈椎病、神经根型颈椎病之间颈椎旋转、半失稳的关系。方法:本组112例,其中椎动脉型38型、交感型36例、神经根型38例,应用图像存档和传输系统(picture archiving and communication systems,PACS)在X线正位片上测量患者每个颈椎椎体的旋转度和在侧位片上测量椎体半失稳的位移距离。结果:在C6旋转度上,椎动脉型颈椎病和交感型颈椎病均与神经根型颈椎病有统计学差异(P<0·01),椎动脉型颈椎病和交感型颈椎病间的C2旋转度有统计学差异(P<0·05),椎动脉型颈椎病和神经根型颈椎病间的C4旋转度有统计学差异(P<0·05)。在椎体半失稳的位移距离和椎体半失稳率上,椎动脉型颈椎病和交感型颈椎病均与神经根型颈椎病有统计学差异(P<0·01)。结论:在椎动脉型颈椎病和交感型颈椎病中椎体半失稳和颈椎旋转是它们发病的一个重要因素,而在神经根型颈椎病中不是发病的重要因素。     

Repetitive transcranial magnetic stimulation (rTMS): a new therapeutic approach in subjective tinnitus?

Subjective (non-recordable) tinnitus is the conscious perception of a phantom sound, and a very frequent, sometimes disabling, condition. Even if subjective tinnitus is often related to peripheral hearing loss, neurophysiological and functional imaging studies provide increasing evidence for an involvement both auditory and non-auditory central nervous pathways in the generation of tinnitus and related distress. Repetitive transcranial magnetic stimulation (rTMS) has been proposed to relieve tinnitus by reducing auditory cortex hyperexcitability associated with this condition. This paper will review the first clinical results reported in auditory cortex rTMS studies, with special reference to the pathophysiology of tinnitus processing and the mechanisms of action of rTMS. Although rTMS appears to be a very promising tool for the diagnosis and the treatment of tinnitus patients, available knowledge is still very limited at the moment. Further basic research and clinical studies are needed in order to optimize the parameters of stimulation (stimulus frequency, cortical target definition) and to validate the application of this technique in the management of patients with disabling tinnitus.     

Sociodemographic characteristics of the neighborhood and depressive symptoms in older adults: using multilevel modeling in geriatric psychiatry.

OBJECTIVE: Neighborhood sociodemographic characteristics may be important to the mental health of older adults who have decreased mobility and fewer resources. Our objective was to examine the association between neighborhood context and level of depressive symptomatology in older adults in a diverse geographic region of central North Carolina. METHODS: The sample included 2,998 adults 65 or older residing in 91 census tracts. Depressive symptoms were measured using the Center for Epidemiologic Studies-Depression scale (CES-D). Neighborhoods were characterized by five census-based characteristics: socioeconomic disadvantage, socioeconomic advantage, racial/ethnic heterogeneity, residential stability, and age structure. RESULTS: In ecologic level analyses, level of census tract socioeconomic disadvantage was associated with increased depressive symptoms. To determine whether neighborhood context was associated with depressive symptoms independently of individual characteristics, the authors used multilevel modeling. The authors examined the ability of each of five neighborhood (level 2) characteristics to predict a level 1 outcome (CES-D symptoms) controlling for the effects of individual (level 1) characteristics. Younger age, being widowed, lower income, and having some functional limitations were associated with increased depression symptoms conditional on census tract random effects. However, none of the neighborhood characteristics was significantly associated with depression symptoms, conditional on census tract random effects, either unadjusted or adjusted for individual characteristics. CONCLUSION: Any observed association between neighborhood sociodemographic characteristics and individual depressive symptoms in our sample may reflect the characteristics of the individuals who reside in the neighborhood rather than the neighborhood characteristics themselves. The use of multilevel modeling is important to separate these effects.     

Towards performance measurement in reconstructive surgery: a multicentre pilot study of free and pedicled flap procedures.

OBJECTIVES: To pilot the acceptability and feasibility of clinical audit in free and pedicled flap reconstruction. To establish a baseline flap failure rate in participating units, so that a sample size calculation could be performed for future national audit. METHODS: A proforma was piloted over a 3-month period in four participating units, during which time data on 93 reconstructive procedures involving free and pedicled flaps was collected. The patients included those where large transfers of tissue were required such as for coverage of grade IIIb compound tibial fractures and breast reconstruction after mastectomy, and also smaller flap transfers such as after skin cancer excision. RESULTS: The proforma was found to be acceptable to clinicians and the feasibility of the data collection process was established. Overall there was a total flap survival of 89% and secondary operations to the donor or recipient sites were required in 11% of patients. CONCLUSIONS: This study demonstrates the feasibility of comparative audit for free and pedicled flap procedures using the methods proposed. Based on the incidence of flap failure observed in this pilot study, at least 18 months of prospective data collection on consecutive patients is required to fulfil the statistical requirements of comparative audit. The establishment of a routinely collected minimum dataset is proposed as one means of meeting these requirements.     

Posttraumatic stress disorder and associated risk factors in Canadian peacekeeping veterans with health-related disabilities.

OBJECTIVES: This study investigates posttraumatic stress disorder (PTSD) and its associated risk factors in a random, national, Canadian sample of United Nations peacekeeping veterans with service-related disabilities. METHODS: Participants included 1016 male veterans (age < 65 years) who served in the Canadian Forces from 1990 to 1999 and were selected from a larger random sample of 1968 veterans who voluntarily and anonymously completed a general health survey conducted by Veterans Affairs Canada in 1999. Survey instruments included the PTSD Checklist-Military Version (PCL-M), Center for Epidemiological Studies-Depression Scale (CES-D), and questionnaires regarding life events during the past year, current stressors, sociodemographic characteristics, and military history. RESULTS: We found that rates of probable PTSD (PCL-M score > 50) among veterans were 10.92% for veterans deployed once and 14.84% for those deployed more than once. The rates of probable clinical depression (CES-D score > 16) were 30.35% for veterans deployed once and 32.62% for those deployed more than once. We found that, in multivariate analyses, probable PTSD rates and PTSD severity were associated with younger age, single marital status, and deployment frequency. CONCLUSIONS: PTSD is an important health concern in the veteran population. Understanding such risk factors as younger age and unmarried status can help predict morbidity among trauma-exposed veterans.     

Social phobia, fear of negative evaluation and harm avoidance.

This naturalistic, prospective investigation examined the role of fear of negative evaluation and the personality trait of harm avoidance in the anxiety levels of treated social phobia patients. One hundred and fifty-seven patients with DSM-IV social phobia were assessed before starting treatment and were then followed for up to two years. As expected, greater fear of negative evaluation and higher scores of harm avoidance were associated with greater anxiety at the 6 month follow-up, and harm avoidance remained a significant predictor at 24 months. However, no evidence was found for an interaction between the personality and cognitive variables examined. The findings are discussed in terms of the relative independence of these factors, as well as their potential implications for the treatment of this disorder.