Independent risk factors predicting acute graft rejection in cardiac transplant recipients treated by triple drug immunosuppression

To assess independent risk factors predicting the occurrence of clinically significant acute rejection episodes in the first 6 months after cardiac transplantation, we performed a multivariate stepwise logistic regression analysis. Forty-three recipients, undergoing transplantation between September 1986 and May 1988, were eligible for analysis and received standardized, low-dose triple drug maintenance immunosuppression with cyclosporine, azathioprine, and prednisolone. Immunoprophylaxis was supplemented perioperatively with either a polyclonal (antithymocyte globulin, N = 26) or a monoclonal (OKT3, N = 17) anti-T-cell antibody. Investigated, conceivable risk factors comprised recipient and donor age, ischemic time, perioperative anti-T-cell antibody prophylaxis, recipient preoperative status, underlying disease, previous cardiac operation, and histocompatibility parameter (mismatches for HLA-A, HLA-B, HLA-DR, HLA-B+DR, HLA-A+B+DR, and Rh0[D] antigen, HLA-DRw6 positive recipient, and identify for ABO system). Univariate analysis suggested significant influence of the type of antibody used perioperatively (p = 0.0024) and the number of mismatches for HLA-A+B+DR (p = 0.0037) and for HLA-B+DR (p = 0.0043). Stepwise logistic regression yielded the number of mismatches for HLA-B+DR (p = 0.0029) and the type of antibody used perioperatively (p = 0.0031) as being highly significant predictors of acute cardiac rejection. Six-month freedom from rejection was 100%, 41%, and 27% for recipients with two, three, and four mismatches for HLA-B+DR and 59% versus 22% for recipients with polyclonal versus monoclonal antibody prophylaxis. Similar to results with kidney transplantation, these results indicate that a poor donor/recipient match for combined HLA-B+DR loci constitutes an independent risk factor for acute graft rejection in low-dose triple drug immunosuppressed cardiac recipients, which stimulates the potential concept of prospective HLA matching. In our experience OKT3 prophylaxis provides significantly less effective prevention of acute rejection than a comparable course of antithymocyte globulin.     

The effects of ‘in-use’ surgical handwashing on the pre- and postoperative fingertip flora during cardiothoracic and orthopaedic surgery

Two operating teams (25 persons) were followed for two months with fingerprint samples taken preoperatively; before and after ‘in-use’ surgical handwashing; and immediately postoperatively, with and without surgical gloves. The mean time for handwashing for the cardiothoracic team (CT) was 2 min and for the orthopaedic team (OT) was 3·5 min. A closer observation of 10 persons revealed a great individual variation in washing techniques, in spite of standard guidelines. The CT team performed eight, and the OT team nine sterile operations with an average duration of 3 h and 20 min and 2 h and 40 min, respectively. Surgical handwashing resulted in fingertip sterility in 111/118 (94·1%) cases; in 61/66 (92·4%) samples from the surgeons and in 50/52 (96·2%) samples from the assistants. Postoperative fingerprinting with gloves on showed sterile conditions in 85/91 (93·4%) samples; 57/59 (96·6%) from the surgeons and 28/32 (87·5%) from the assistants. Immediately after removal of the gloves, 43/67 (64·2%) of fingerprint samples from the surgeons and 13/48 (27·1%) from the assistants were still sterile. Coagulase-negative staphylococci (CNS) and Bacillus species predominated in fingerprint samples. Of the 105 CNS strains tested, 11·4% were methicillin resistant. Only five strains of Staphylococcus aureus were isolated; in 4/5 cases from the OT. This study illustrates that in spite of standard guidelines, there is great individual variation in surgical handwashing. However, in most instances, the bacteria are eradicated from the fingertips. Even after surgery for 2–3 h, there may still be a residual effect of the hand disinfecting agent in half of the cases.     

Regulation and kinetics of platelet-activating factor and leukotriene C4 synthesis by activated human basophils

BACKGROUND: Allergic disease is the result of an interplay of many different cell types, including basophils and mast cells, in combination with various inflammatory lipid mediators, such as platelet-activating factor (PAF) and leukotrienes (LT). LTC4 synthesis by human basophils has been studied quite extensively. However, not much is known about the synthesis of PAF by human basophils. OBJECTIVE: In this study, we have made a comprehensive comparison between the kinetics of PAF and LTC4 synthesis, in highly purified basophils, activated with different stimuli or with combinations of stimuli. METHODS : Synthesis of PAF and LTC4 by human basophils was determined with commercially available assay kits. The basophils were activated with C5a, fMLP, PMA, allergen or anti-IgE, in the absence and presence of IL-3 and/or in combination with elevation of cytosolic free Ca2+ by the sarcoplasmic reticulum Ca2+-ATPase inhibitor thapsigargin. RESULTS: Most stimuli were found to induce both PAF and LTC4 synthesis. PAF synthesis and LTC4 release were enhanced by preincubation of the basophils with IL-3 or by elevation of cytosolic free Ca2+ by thapsigargin. Incubation of human basophils with IL-3 alone or thapsigargin alone did not result in detectable synthesis of PAF and LTC4, whereas the combination of the two resulted in high amounts of PAF and LTC4 synthesis. Depending on the stimulus used, LTC4 release was 5-100-fold higher than PAF synthesis. In addition, PAF, but not LTC4, was transiently detected, probably due to PAF degradation. LTC4 and PAF synthesis was strongly blocked by inhibitors of cytosolic phospholipase A2, indicating that this enzyme is involved in PAF and LTC4 synthesis by activated human basophils. CONCLUSION: This study provides a first comprehensive comparison of PAF and LTC4 synthesis in highly purified human basophils, stimulated with a variety of stimuli.     

Menkes Kinky Hair Disease with ''Ragged Red'' Fibers

A 30-month-old infant with Menkes kinky-hair disease died, with prominent vascular, cerebral and cerebellar degeneration. Increased numbers of mitochondria containing homogeneous dense bodies were seen on electron-microscopic examination of Purkinje cells. Subsarcolemmal aggregates of mitochondria ('ragged red' fibers) were present in skeletal muscle. These mitochondrial alterations support the hypothesis that copper deficiency results in mitochondrial encephalomyopathy.     

Acquired renal cysts in maintenance dialysis patients

Ultrasonographic examination of the kidneys of 111 patients on long term maintenance hemodialysis was performed. None of the patients had genuine polycystic kidney disease. In many patients acquired cysts were found. Frequency and volume of these cysts were the same on the right and left side. There was no correlation between the age of the patients and the number of cysts. There were no differences concerning sex and type of primary renal disease. There was a significant positive correlation between time on maintenance hemodialysis and number of cysts but no correlation between number of cysts and hemoglobin concentration. This is in contrast to data in the literature. Clinical relevance of acquired kidney cysts in dialysis patients concerns hematuria, retroperitoneal bleeding, kidney stone formation, septicemia and malignancy.     

Accuracy of implant‐supported prostheses in the edentulous jaw. Analysis of precision of fit between cast gold‐alloy frameworks and master casts by means of a three‐dimensional photogrammetric technique.

Distortions of 15 routine implant‐supported prostheses were measured in relation to the master casts after completion by means of a 3‐dimensional (3‐D) photogrammetric technique. All prostheses were designed as one‐piece gold‐alloy castings with resin teeth. Five of the prostheses were placed in the edentulous maxilla, and the remaining were placed in the lower jaw. Distortion of the cylinders was mostly observed in the horizontal plane (x‐and y‐axis) while the vertical aspect seemed to be more stable. The mean 3‐D center point distortion was 42 (SD 15) and 74 (SD 38)μm for the upper and lower jaws, respectively. The measurements revealed a range of3‐D center point distortion from 16 to 80 and 15 to 165 μm for the different jaws, respectively. The corresponding 3‐D mean angular distortion of the cylinders was 51 (SD 35)μm in lower and 70 (SD 75)μm in the upper jaws. A correlation was found between 3‐D center point distortion and the width as well as the curvature of the implant arch, indicating more displacement the wider and the more curved the arch was. The 3‐D center point distortion was also significantly higher in the upper jaws which could possibly be explained by the curvature of the implant arch and higher numbers of implants in the upper jaws. Further problems with the fit of upper jaw castings could be related to more alloy in the 1 castings and poor alignment of implants.     

Effect of epidural vs. general anesthesia on breastfeeding

In a prospective interview study, two groups each consisting of 28 sectio caesarea patients were compared concerning the course of breastfeeding. The women in the two groups were delivered under either epidural analgesia or general anesthesia. The two groups were identical with respect to age, parity, participation in antenatal preparatory courses and former breastfeeding. A significantly higher breastfeeding frequency and longer breastfeeding periods were were found after epidural analgesia than after general anesthesia.     

Endocrinology: Insulin resistant and non-resistant polycystic ovary syndrome represent two clinical and endocrinological subgroups

We studied the clinical and endocrine features of 35 patientswith polycystic ovary syndrome (PCOS) who are either insulinresistant or non-insulin resistant. The occurrence of insulinresistance was determined by measuring insulin and glucose concentrationsfollowing a standard 75 g oral glucose load. All patients wereevaluated by anthropometric measurements: body mass index (BMI),percentage of body fat (BCF) and waist-to-hip ratio (W/H), degreeof hirsutism (Ferriman-Gallwey method) and endocrine profile.Fourteen patients had insulin resistance of unknown origin whereasfour were due to a type A insulin receptor mutation, and 17were non-insulin resistant. The insulin resistant patients weresignificantly more obese (higher BMI P < 0.0001, BCF P <0.002 and W/H ratio P < 0.005) and were more hirsute (P <0.002) than the non-insulin resistant patients. Testosteroneconcentrations were significantly higher in the insulin resistantgroup than in the non-insulin resistant group (2.65 versus 1.37nmol/l; P < 0.027), whereas sex hormone-binding globulinwas lower in insulin resistant patients (30.61 versus 19.48nmol/l; P < 0.02). Non-insulin resistant patients showeda high luteinizing hormone to follicle stimulating hormone ratio,while a normal ratio was found in the insulin resistant subpopulation(2.94 versus 1.34; P < 0.0001). We concluded that PCOS comprisestwo subpopulations, one with insulin resistance of differentaetiologies and the other which has no insulin resistance. Thesetwo groups differ in their anthropometric and endocrine features.The diagnosis of insulin resistance in PCOS can be easily determinedby the insulin response to an oral glucose tolerance test.