The combined impact of donor age and acute rejection on long-term cadaver renal allograft survival

BACKGROUND: Acute rejection (AR) is an important risk factor for long-term renal graft loss. Furthermore, donor age is also associated with graft outcome. We analyzed the combined effects of cadaver donor age and AR on long-term graft survival. METHODS: A retrospective review was made of 112 cadaver renal transplants at a single center. Only grafts functioning at least 3 months were included in this analysis. RESULTS: The 3-year survival of AR-free grafts was superior to that of grafts with AR (98% vs 67%, P < .001). Within the AR cohort donor age > 50 years (P < .05) had an additional negative impact on graft survival. The 3-year survival of an older donor graft with AR was 33% versus 82% for a younger donor graft with AR. CONCLUSIONS: AR was a significant predictor of long-term graft loss. Older donor kidneys with AR had poorer graft survival than did younger donor kidneys with AR.     

The effect of age and pre-light melatonin concentration on the melatonin sensitivity to dim light.

The hormone melatonin is secreted at night from the pineal gland, with light being a potent inhibitor of its secretion. Age related decreases in plasma melatonin concentrations have indicated that this may be related to pineal calcification with aging. Recently, it was shown that the melatonin sensitivity to light may be a biological marker of bipolar disorder. However, on average, patients were older than the control group in most studies, and it is not known if age has an effect on the melatonin suppression by light. To test this hypothesis, the present study investigated the effect of age on the melatonin sensitivity to dim light (200 lux). Participants were grouped into three age groups. On the testing night, they were placed in a dark room from 21.00 h to 02.30 h. Light exposure was for an hour from midnight to 01.00 h. Blood samples were collected at regular intervals for measurement of plasma melatonin. No significant differences were found in the percentage suppression of melatonin within the age groups defined in the present study (P > 0.5). No correlation was also found between age and percentage suppression of melatonin (r2 = 0.007; P > 0.1). Our results suggest that the melatonin suppression by light (200 lux) is not affected by age.     

Reboxetine: a double-blind comparison with fluoxetine in major depressive disorder

The aim of this study was to compare the efficacy and tolerability of reboxetine, a uniquely selective noradrenaline reuptake inhibitor, with the selective serotonin reuptake inhibitor, fluoxetine. A double-blind, randomized, parallel-group, multicentre design was employed. One hundred and sixty-eight patients with acute major depressive episodes were randomized to receive oral reboxetine (8-10 mg/day) or oral fluoxetine (20-40 mg/day). The treatment period was 8 weeks. Reboxetine and fluoxetine were similarly effective as assessed by the mean reduction in total Hamilton Depression Rating Scale score, the percentage of responders and patients in remission, Clinical Global Impression severity of illness and global improvement scores and Montgomery-Asberg Depression Rating Scale. A sub-analysis of patients with severe depression indicated that reboxetine had superior efficacy compared with fluoxetine. Both treatments resulted in some improvement in Social Adaptation Self-evaluation Scale total scores and this was more evident for those patients treated with reboxetine who achieved remission. Both treatments were well tolerated. The results indicate that reboxetine is an effective and well tolerated antidepressant, being more effective than fluoxetine in patients with severe depression, and more effective in terms of social functioning in those patients who achieved remission.     

Cerebral blood flow velocity after mannitol infusion in children

Purpose

There is conflicting evidence as to whether the effect of mannitol on brain bulk arises from haemodynamic, rheologic, or osmotic mechanisms. If mannitol alters cerebral haemodynamics by inducing vasoconstriction, this change should be reflected in cerebral blood flow velocity (CBFV) in the middle cerebral artery (MCA). The purpose of this study was to evaluate the effect of mannitol on CBFV in children.

Methods

Children scheduled for intracranial surgery were enrolled. After a loading dose of 10 μg · kg^?1 of fentanyl, general anaesthesia was maintained with fentanyl (3 μg · kg^?1 · hr^?1), 66% nitrous oxide, and isoflurane (0.2–0.5% inspired). Mean and systolic CBFV (Vm and Vs) and pulsatility index (PI) were recorded with a transcranial Doppler (TCD) directed at the M1 segment of the MCA. Mannitol was administered, 1 gm · kg^?1 iv over 15 min. The osmolality (Osm), haematocrit (Hct), mean arterial pressure (MAP), heart rate (HR), and TCD variables were recorded before and 15, 30, 45, and 60 min after the mannitol infusion.

Results

Mannitol infusion resulted in an increase in Osm and decrease in Hct (P < 0.05). Heart rate, MAP and arterial carbon dioxide tensions did not change (P > 0.05) during the measuring period. The Vm did not vary from baseline. The Vs and P1 both increased briefly (P < 0.01 at 15 min and P < 0.05 at 30 min) after the mannitol, suggesting an increase in resistance distal to the MCA.

Conclusion

The time course of CBFV changes produced by mannitol corresponds with previous animal data concerning cerebrovascular tone. Our results suggest that mannitol briefly increases cerebrovascular resistance and thereby diminishes cerebral blood volume.     

Stability of the intra-operative arterial to end-tidal carbon dioxide partial pressure difference in children with congenital heart disease

The purpose of this study was to evaluate the stability of the arterial PCO2 (PaCO2) to end-tidal PCO2 (PETCO2) partial pressure difference (Pa-ETCO2) during surgery using PETCO2 monitoring, in children with congenital heart disease (CHD). Forty children with CHD were studied: ten children with no interchamber communication and normal pulmonary blood flow (PBF) (normal group); ten acyanotic children with increased PBF (acyanotic-shunting group); ten cyanotic children with mixing type lesions and normal or increased PBF (mixing group), and ten cyanotic children with right-to-left intracardiac shunts demonstrating decreased and variable PBF (cyanotic-shunting group). Simultaneous PaCO2 recordings and PETCO2 measurements were obtained for each patient during five intraoperative events: (1) control time, arterial line placement under anaesthesia; (2) time 1, patient preparation; (3) time 2, immediately after sternotomy; (4) time 3, after heparin administration; and (5) time 4, immediately after aortic cannulation. Initially, cyanotic children demonstrated a greater Pa-ETCO2 compared with acyanotic children (P less than 0.05). There was no difference in the Pa-ETCO2 over time in the control, acyanotic-shunting, or mixing groups. The Pa-ETCO2 in the children with cyanotic-shunting lesions at times 2 and 3 was greater (P less than 0.05) than at their control times. We conclude that the Pa-ETCO2 of children with acyanotic-shunting and mixing congenital heart lesions is stable intraoperatively, although patients with mixing congenital heart lesions may demonstrate large individual variations. In children with cyanotic-shunting congenital heart lesions, the Pa-ETCO2 is not stable. The PETCO2 cannot be used during surgery to estimate reliably the PaCO2 in children with cyanotic CHD.     

Rating scales as predictors of response to tricyclic antidepressants.

Fifty-three patients suffering from depressive illness were classified as 'responders' or 'non-responders' on the basis of an "amelioration score" of the Hamilton Rating Scale for depression after six weeks treatment with nortriptyline hydrochloride at 150 mgs. daily. A multivariate analysis of variance was performed on the four psychological rating scale scores used, to determine whether rating scales could predict treatment response to tricyclis antidepressants was found to be at 75% probability.ic anti-depressants was found to be at 757. probability.ic antidepressants. There was a significant difference between the two groups after adjustment for age. Subjects were then classified as 'non-responders' and 'responders' on the basis of their discriminant scores. The prediction of response to tricycl     

Childhood moyamoya disease: hemodynamic MRI

Background. Childhood moyamoya disease is a rare progressive cerebrovascular disease. Objective. To evaluate cerebral hemodynamics using dynamic Gd-DTPA-enhanced imaging in children with moyamoya disease. Materials and methods. Eight children (2–11 years of age) with the clinical and angiographic findings typical of moyamoya disease, before and/or after surgical intervention (pial synangiosis), underwent conventional MR imaging (MRI) and hemodynamic MR imaging (HMRI). HMRI used a spoiled gradient-echo with low flip angle (10 deg) and long TE (TR/TE = 24/15 ms) to minimize T 1 effects and emphasize T 2^* weighting. Raw and calculated hemodynamic images were reviewed. Three-dimensional time-of-flight MR angiography (MRA) and perfusion brain single photon emission computed tomography (SPECT) were also performed. Results. Abnormal hemodynamic maps resulting from vascular stenosis or occlusion and basal collaterals were observed in six patient studies. HMRI depicted perfusion dynamics of affected cerebrovascular territories, detected cortical perfusion deficits, and complemented conventional MRI and MRA. HMRI findings were consistent with those of catheter angiography and perfusion SPECT. Conclusion. Our preliminary experience suggests that HMRI may be of value in the preoperative and postoperative evaluation of surgical interventions in moyamoya disease. Received: 20 February 1996 Accepted: 4 February 1997     

Reflex sympathetic dystrophy in a 12-year-old twin with comorbid conversion disorder in both twins

A case of reflex sympathetic dystrophy is presented in a 12-year-old girl with comorbid conversion disorder. Her identical twin also had a conversion disorder. This is the first reported case of coexistence of reflex sympathetic dystrophy and conversion disorder. It is important for clinicians to be aware that these conditions may coexist since the presentation of symptoms differ, even though there are shared features of treatment.