Starting a crossover kidney transplantation program in the Netherlands: ethical and psychological considerations

On April 15th, 2003, the first crossover kidney transplantation took place in The Netherlands. In September of the same year, a national database was established to facilitate kidney exchange between two donor-recipient couples. During 2004, kidneys from living donors will be exchanged between the seven university medical centers in The Netherlands. One of the conditions for successfully implementing this program was the need to address the ethical and psychologic implications involved. In this article we will discuss the ethical and psychologic considerations that are accompanying the practical preparations for the first Dutch crossover transplantation program. We identified five topics of interest: the influence of "donation by strangers" on the motivation and willingness of donor-patient couples, the issue of anonymity, the loss of the possibility of "medical excuses" for unwilling donors, the view that crossover is a first step to commercial organ trade, and the interference with existing organ donation programs. We concluded that whether viewed separately or in combination, these issues do not impede the efficient organization of a crossover program or raise worrying ethical issues.     

Ischemia times and donor serum creatinine in relation to renal graft failure

BACKGROUND: The results of renal transplantation are dependent on many variables. To simplify the decision process related to a kidney offer, the authors wondered which variables had the most important influence on the graft failure risk. METHODS: All transplant patients (n=1,124) between January 1981 and July 2000 were included in the analysis (2.6% had missing values). The variables included were donor and recipient age and gender, recipient original disease, race, donor origin, current smoking, cardiovascular disease, body weight, peak and current panel reactive antibody (PRA), number of preceding transplants, type and duration of renal replacement therapy, and time since failure of native kidneys. Also, human leukocyte antigen (HLA) identity or not, first and second warm and cold ischemia times, left or right kidney and fossa, donor kidney anatomy, donor serum creatinine and proteinuria, and transplantation year were included. RESULTS: In a multivariate model, cold ischemia time and its time-dependent variable significantly influenced the graft failure risk censored for death (P<0.0001) independent of any of the other risk factors. The influence primarily affected the risk in the first week after transplantation; thereafter, it gradually disappeared during the first year after transplantation. Donor serum creatinine also significantly influenced the graft failure risk in a time-dependent manner (P<0.0001). The risk of a high donor serum creatinine is already enlarged in the immediate postoperative phase and increases thereafter; the curve is closely related to the degree of the elevation. The other variables with a significant influence on the graft failure rate were, in order of decreasing significance, recipient age, donor gender, donor age, HLA identity, transplantation year, preceding transplantations, donor origin, and peak PRA. CONCLUSIONS: Donor serum creatinine and cold ischemia time are important time-dependent variables independently influencing the risk of graft failure censored for death. The best strategy for improving the results of cadaveric transplantations is to decrease the cold ischemia time and to allocate kidneys from donors with an elevated serum creatinine to low-risk recipients.     

29例筛窦癌的放射治疗

筛窦癌发病率低,就诊时病期晚,５年无瘤生存率为３０％～５０％。由于解剖部位的限制以及局部浸润,放射和手术均有一定难度。作者回顾性分析皇家Ｍａｒｇｒｅｔ医院１９７６～１９９４年收治的２９例浸润性筛窦癌根治性放射治疗的疗效和影响预后因素。男性２４例,女性４例,中位年龄６２岁,中位随访时间４年。常有鼻出血、鼻塞、疼痛及视力改变等。起病到确诊的平均时间为９个月。２７例吸烟,１０例从事伐木或镍的开采与提炼。　　治疗前均经临床及影像学检查。仅３例局限于筛窦,余侵犯鼻腔、蝶窦、眼眶、上颌窦、额窦及脑内等。Ｔ１…     

Epidermal cyst of the breast: Detection in a screening programme

Two cases of epidermal cyst of the breast, a rare benign condition, were detected during a 3-year period in a mammographic screening programme, from 57 954 screening examinations. It is not uncommon for epidermal cysts to be initially misdiagnosed. The mammographic, ultrasound and histological features are presented. It is recommended that these lesions be resected because they possibly have malignant potential.     

Lactobezoar and cows' milk protein intolerance

A baby girl of an atopic family who developed eczema, asthma, and cows' milk protein intolerance was found to have a gastric lactobezoar at age 9 1/2 months. She responded well to the removal of the bezoar and to the appropriate dietary treatment.     

Lymphomatous superficial lymph nodes: US detection

Superficial adenopathy is the most frequent clinical manifestation of lymphoma, both at initial workup and later when disease recurs. Data obtained by means of physical examination and ultrasonography (US) of the cervicosupraclavicular, axillary, and inguinal regions were compared for 120 patients, 60 at the time of initial staging and 60 during follow-up for a previously treated lymphoma. Twenty-nine in the second group had recurrent disease, as confirmed with histologic examination. For all 120 patients, US revealed clinically impalpable lesions in an average of 10.8% of cases for the cervicosupraclavicular region, 17.9% for the axillary region, and 4.1% for the inguinal region. Eight of the 29 relapses were not detected at physical examination, and three were demonstrated solely with US. These findings emphasize the value of US exploration of the superficial node-bearing regions in patients with lymphoma, during both initial staging and follow-up.     

Performance of colposcopy in five sub-Saharan African countries

Objective  The performance of colposcopy provided in a screening study in five African countries was evaluated.
Design  Cross-sectional study.
Setting  Burkina Faso, Congo Brazzaville, Guinea Conakry, Mali and Niger.
Population  Women aged 25–59 years.
Methods  A total of 29 294 women participated in a cervical screening study in the five study sites, and newly trained local doctors performed colposcopy and directed biopsies as indicated. Using meta-analytical tools, four measures of colposcopy performance at different thresholds of colposcopic abnormalities were assessed. Sources of heterogeneity were also assessed.
Main outcome measures  Proportions of women receiving biopsies, adequate biopsies and women diagnosed with cervical intraepithelial neoplasia (CIN).
Results  Among 28 553 women with satisfactory colposcopy, 3101 had a colposcopic diagnosis of probable low-grade or worse lesions and 1128 probable high-grade or worse lesions. Overall, the measures that reached the set standards were proportion of biopsy taken at colposcopy threshold of probable high-grade or worse lesions (95%, 95% CI 90–100%) and proportion of adequate biopsy samples. The set standards were not met for the proportions of women diagnosed with CIN at different colposcopic abnormality thresholds. Detection of CIN2 or worse lesions increased with increasing colposcopic abnormality.
Conclusions  The performance of colposcopy in some of the African sites studied was comparable to that previously observed in other studies. With appropriate training, monitoring, continuing practice and quality assurance, adequate standards of colposcopy can be attained in sub-Saharan Africa.