Optimal immunosuppression in teenagers

Adolescence is a difficult time for transplant recipients, who need to cope with the challenges of becoming independent from their parents, as well as taking responsibility for their own behavior and medication. They need to balance their developing sexuality with a body image which may be affected by the side-effects of immunosuppression. It is now anticipated that more than 80% of children will survive their transplant to become teenagers and adults, and it is therefore important to ensure that immunosuppressive medication is acceptable, convenient for drug level monitoring and free of significant long-term side-effects.     

Maternal serum activin A, inhibin A, and follistatin in pregnancies with appropriately grown and small-for-gestational-age fetuses classified by umbilical artery Doppler ultrasound

OBJECTIVE: The purpose of this study was to examine the relationship of maternal serum activin A, inhibin A, and follistatin with fetal growth and placental function. STUDY DESIGN: Inhibin A, activin A, and follistatin were measured in maternal serum that was stored from normally grown (control subjects, n = 50) and small-for-gestational-age pregnancies (n = 49), prospectively classified as normal small-for-gestational-age pregnancy or fetal growth-restricted pregnancy with the use of umbilical artery Doppler ultrasound. RESULTS: Activin A and inhibin A were significantly increased in fetal growth-restricted pregnancies compared with control subjects (activin A: regression coefficient, 0.54, P <.001; inhibin A: regression coefficient, 0.47, P =.003). The activin:follistatin ratio was significantly higher in fetal growth-restricted pregnancies compared with control subjects (P <.001). There were no significant differences between analyte levels of normal small-for-gestational-age pregnancies and control subjects. CONCLUSION: Maternal serum activin A, inhibin A, and activin:follistatin ratio are raised in fetal growth-restricted pregnancies but not in normal small-for-gestational age pregnancies. This provides further evidence of the difference between subgroups within small-for-gestational-age pregnancies and emphasizes the need to stratify for this in research.     

The effect of mode of delivery and gestational age on neonatal outcome of the non-cephalic- presenting second twin

OBJECTIVE: Our purpose was to compare the neonatal morbidity of the non-cephalic- and cephalicpresenting second twin in terms of mode of delivery and gestational age. STUDY DESIGN: A retrospective cohort study of 422 sets of twins with a cephalic-presenting first twin was performed. RESULTS: The non-cephalic-presenting second twin was less likely to be delivered vaginally than the cephalic second twin, odds ratio 0.5 (95% CI 0.3-0.8). There were no significant differences in low Apgar scores at 5 minutes and admission to the neonatal intensive care unit for non-cephalic-presenting compared with cephalic-presenting second twins, adjusted odds ratio 1.1 (95 % CI 0.5-2.2) and 1.4 (0.8-2.6). Delivery by caesarean section was associated with increased admission to the neonatal intensive care unit for cephalic second twins, adjusted odds ratio 3.8 (1.2-12.7). Neonatal morbidity after vaginal delivery was similar for non-cephalic-presenting and cephalic-presenting second twins, particularly at lower gestational ages (24-31 weeks, Apgar score at 5 minutes <7, adjusted odds ratio 0.8 [0.1-11.3]). CONCLUSION: Vaginal delivery for the non-cephalic-presenting second twin appears to be a reasonable management option, particularly at early gestational ages.     

How many is too many? Collaboration of multiple nursing organizations for professional development

Representatives of 11 nursing organizations developed a unique consortium to produce an ongoing series of annual conferences focused on promoting professional nursing leadership among nurses in diverse practice areas including acute care, long-term care, community health, and nursing education. The consortium strategically added members and refined the format of the conferences based on participant feedback. The conferences feature a keynote speaker and practice-based breakout sessions designed to facilitate futuristic thinking among nurses. The conference is associated with a legislative roundtable to support interaction between nurses and legislators. Future expansion of the consortium will include representation of advanced practice nurses. The development of the consortium and its highly efficient methods of operation are described in this article as an example of multi-organizational collaboration to promote professional nursing leadership. Bonds have been formed between the consortium member organizations that are mutually beneficial to the members of all.     

A comparison of independent living outcomes following traumatic brain injury and spinal cord injury

This study compares independent living outcomes in persons with traumatic brain injury (TBI) and spinal cord injury (SCI). Both injuries represent life-altering events that are known to have a negative impact on independent living and are predominantly experienced by members of the same demographic group. However, the types of resultant impairments and disabilities experienced by the two populations differ substantially. The TBI participants were recruited consecutively from Canada's largest tertiary care trauma centre and followed prospectively for four years. The SCI participants were recruited via a mailed survey to members of a provincial branch of the Canadian Paraplegic Association. Independent living outcomes were measured using DeJong and Hughes' (1982) classification system of productivity status, the Reintegration to Normal Living Index, and questions on assistance from environmental supports in the form of wheelchair use and paid/unpaid personal assistance. The TBI group was found to be significantly more productive, have higher levels of satisfaction with their current experience of community integration, and use fewer environmental supports than their SCI counterparts (P相似文献   

Increased angiogenesis in bone marrow of children with acute lymphoblastic leukaemia has no prognostic significance

The importance of angiogenesis for the growth and viability of solid tumours has been established. Similarly, prognostic information may be gained from the extent of angiogenesis in these tumours. Haematopoietic malignancies should have equal requirements for angiogenesis and important prognostic information may be derived from quantification of bone marrow angiogenic activity. We retrospectively investigated 82 bone marrow trephine biopsies from 41 children with acute lymphoblastic leukaemia (ALL) at diagnosis and following treatment. Nine normal bone marrow trephines from age-matched children were also analysed as controls. The microvessels were stained immunohistochemically with anti-Factor VIII-related antigen (antivWF) and antithrombomodulin (anti-THR). Angiogenesis was quantified manually by two independent observers and was highly reproducible (Pearson's r = 0.91). Staining with anti-vWF and anti-THR was highly specific for microvessels and thetwo stains closely correlated (r = 0.68). Microvessel densities (MVD) at presentation were significantly increased in the majority of patients in comparison with controls (P < 0.0001) and MVD dropped towards normal in remission (P < 0.0001). Of interest, the difference in total vessel counts between leukaemic and normal/remission marrows was contributed solely by small microvessels. There was no significant difference in MVD at presentation or remission from children in poor prognostic groups or those who subsequently relapsed. Similarly, we could not find an association with age, sex, cytogenetic abnormality or disease phenotype.     

Venous obstruction in healthy limbs: a model for chronic compartment syndrome?

PURPOSE: Chronic exertional compartment syndrome (CECS) in the anterior tibial (AT) compartment is generally believed to be the result of reduced venous blood flow caused by restrictive compartments and increased intramuscular pressures. If this is so, then restricting venous flow in the muscles of healthy subjects during exercise should mimic CECS. METHODS: This hypothesis was tested in 10 control subjects (aged 19-41 yr, five males) with and without external venous occlusion induced by a sphygmomanometer cuff fitted just below the knee and inflated to 80 mm Hg. Twenty CECS patients (20-39 yr, 16 males) were studied without external occlusion. Subjects performed intermittent, isometric maximal voluntary contractions (MVC) of the AT for 20 min (1.6-s contractions, 0.5 duty cycle). MVC, tetanic force (2 s at 50 Hz), muscle thickness (ultrasound imaging), and pain were measured during exercise and 10 min of recovery. RESULTS: Venous occlusion in the controls induced greater pain, fatigue, and increase in muscle thickness (P < 0.01). Initially the patients fatigued more slowly than the occluded controls, but at the end of exercise, the fatigue and pain were similar in these two groups. The controls showed a greater increase in muscle size (P = 0.01). Recovery was similar in all three groups, although the size of the patients' muscles recovered rather more slowly. CONCLUSION: External venous occlusion of the AT muscles in control subjects induces changes very similar to those of CECS patients, although the different time courses indicate that different processes are involved. The AT compartment of CECS patients is capable of distension.     

Influence of peg design and cement mantle thickness on pull-out strength of glenoid component pegs

Fixation of the glenoid component is critical to the outcome of total shoulder arthroplasty. In an in vitro study, we analysed the effect of surface design and thickness of the cement mantle on the pull-out strength of the polyethylene pegs which are considered essential for fixation of cemented glenoid components. The macrostructure and surface of the pegs and the thickness of the cement mantle were studied in human glenoid bone. The lowest pull-out forces, 20 +/- 5 N, were for cylindrical pegs with a smooth surface fixed in the glenoid with a thin cement mantle. The highest values, 425 +/- 7 N, were for threaded pegs fixed with a thicker cement mantle. Increasing the diameter of the hole into which the peg is inserted from 5.2 to 6.2 mm thereby increasing the thickness of the cement mantle, improved the mean pull-out force for the pegs tested.     

Is there a direct association between age-related eye diseases and mortality? The Rotterdam Study

PURPOSE: To study mortality in subjects with age-related maculopathy (ARM), cataract, or open-angle glaucoma (OAG) in comparison with those without these disorders. DESIGN: Population-based prospective cohort study. PARTICIPANTS: Subjects (n = 6339) aged 55 years and older from the population-based Rotterdam Study for whom complete information on eye disease status was present. MAIN OUTCOME MEASURES: Vital status continuously monitored from 1990 until January 1, 2000. METHODS: The diagnosis of ARM was made according to the International Classification System. Cataract, determined on biomicroscopy, was defined as any sign of nuclear or (sub)cortical cataract, or both, in at least one eye with a visual acuity of 20/40 or less. Aphakia and pseudophakia in at least one eye were classified as operated cataract. Definite OAG was defined as a glaucomatous optic neuropathy combined with a glaucomatous visual field defect. Diagnoses were assessed at baseline. Mortality hazard ratios were computed using Cox proportional hazard regression analysis, adjusted for appropriate confounders (age, gender, smoking status, body mass index, cholesterol level, atherosclerosis, hypertension, history of cardiovascular disease, and diabetes mellitus). RESULTS: The adjusted mortality hazard ratio for subjects with AMD (n = 104) was 0.94 (95% confidence interval [CI], 0.52-1.68), with biomicroscopic cataract (n = 951) was 0.94 (95% CI, 0.74-1.21), with surgical cataract (n = 298) was 1.20 (95% CI, 0.86-1.68), and with definite OAG (n = 44) was 0.39 (95% CI, 0.10-1.55). CONCLUSIONS: Both ARM and cataract are predictors of shorter survival because they have risk factors that also affect mortality. When adjusted for these factors, ARM, cataract, and OAG were themselves not significantly associated with mortality.