What happens after graft loss? A large,long-term,single-center observation

The number of patients returning to dialysis after graft failure increases. Surprisingly, little is known about the clinical and immunological outcomes of this cohort. We retrospectively analyzed 254 patients after kidney allograft loss between 1997 and 2017 and report clinical outcomes such as mortality, relisting, retransplantations, transplant nephrectomies, and immunization status. Of the 254 patients, 49% had died 5 years after graft loss, while 27% were relisted, 14% were on dialysis and not relisted, and only 11% were retransplanted 5 years after graft loss. In the complete observational period, 111/254 (43.7%) patients were relisted. Of these, 72.1% of patients were under 55 years of age at time of graft loss and only 13.5% of patients were ≥65 years. Age at graft loss was associated with relisting in a logistic regression analysis. In the complete observational period, 42 patients (16.5%) were retransplanted. Only 4 of those (9.5%) were ≥65 years at time of graft loss. Nephrectomy had no impact on survival, relisting, or development of dnDSA. Patients after allograft loss have a high overall mortality. Immunization contributes to long waiting times. Only a very limited number of patients are retransplanted especially when ≥65 years at time of graft loss.     

Management des blutenden Patienten mit Immunthrombozytopenie

Die Anaesthesiologie - Die Immunthrombozytopenie (ITP) ist eine seltene, erworbene Thrombozytopenie mit einer Inzidenz von 2–4/100.000 Personen und Jahr. Sie wird durch eine Thrombozytenzahl...     

Time course of the effect of intravenous dimetindene maleate

Summary In order to evaluate the time course of its effects, dimetindene maleate has been investigated in a histamine provocation model in man. Eight healthy male volunteers were treated i. v. with 4 mg dimetindene maleate or sodium chloride solution in a double blind, cross over study. Intracutaneous histamine injections were given at –1, 2, 5, 14, 17, 20, 23, 26, and 29 h following drug administration and the areas of flares and wheals were measured after 5, 10, 20, and 30 min. There was strong inhibition of the development both of flares and wheals, which was more pronounced for the former. Baseline adjusted areas under the curve differed significantly following drug and placebo treatment. The maximum effect was observed at 2 h.The mean residence time of the inhibitory effect was calculated to be 13 h compared to the mean residence time of dimetindene in blood of 5 h, which indicates a non-linear relationship between blood level and effect.     

Clinical Concept-Based Radiology Reports Classification Pipeline for Lung Carcinoma

Rising incidence and mortality of cancer have led to an incremental amount of research in the field. To learn from preexisting data, it has become important to capture maximum information related to disease type, stage, treatment, and outcomes. Medical imaging reports are rich in this kind of information but are only present as free text. The extraction of information from such unstructured text reports is labor-intensive. The use of Natural Language Processing (NLP) tools to extract information from radiology reports can make it less time-consuming as well as more effective. In this study, we have developed and compared different models for the classification of lung carcinoma reports using clinical concepts. This study was approved by the institutional ethics committee as a retrospective study with a waiver of informed consent. A clinical concept-based classification pipeline for lung carcinoma radiology reports was developed using rule-based as well as machine learning models and compared. The machine learning models used were XGBoost and two more deep learning model architectures with bidirectional long short-term neural networks. A corpus consisting of 1700 radiology reports including computed tomography (CT) and positron emission tomography/computed tomography (PET/CT) reports were used for development and testing. Five hundred one radiology reports from MIMIC-III Clinical Database version 1.4 was used for external validation. The pipeline achieved an overall F1 score of 0.94 on the internal set and 0.74 on external validation with the rule-based algorithm using expert input giving the best performance. Among the machine learning models, the Bi-LSTM_dropout model performed better than the ML model using XGBoost and the Bi-LSTM_simple model on internal set, whereas on external validation, the Bi-LSTM_simple model performed relatively better than other 2. This pipeline can be used for clinical concept-based classification of radiology reports related to lung carcinoma from a huge corpus and also for automated annotation of these reports.

     

Diurnal patterns of cocaine and heroin self-administration in rhesus monkeys responding under a schedule of multiple daily sessions

A number of non-pharmacological factors have been shown to influence drug self-administration in experimental animals. This report examines diurnal changes in drug self-administration by rhesus monkeys trained to self-administer food (1gm fruit-flavored pellets) and cocaine (0.01 or 0.032mg/kg/injection) under a second order FR4 (VR16:S) schedule during four daily food and drug self-administration sessions. Saline, different unit doses of cocaine (0.001-0.1mg/kg/injection) or different unit doses of heroin (0.0001-0.01mg/kg/injection) were substituted for the maintenance dose of cocaine during drug sessions. Dose-effect curves relating unit dose of cocaine or heroin to the number of injections per session displayed an inverted U-shape during each of the four daily drug sessions. When 0.032mg/kg/injection cocaine or 0.0032mg/kg/injection heroin were available, monkeys usually self-administered the maximum number of injections during all four drug sessions. Substitution of saline or lower unit doses of cocaine (0.001-0.01mg/kg/injection) or heroin (0.0001-0.001mg/kg/injection) decreased the number of injections/session; however, these decreases were consistently greater during the evening (20.00-21.00h) and morning (07.00-08.00h) sessions than during the afternoon sessions (12.00-13.00h and 16.00-17.00h). As a result, the ascending limbs of the cocaine and heroin dose-effect curves for the evening and morning sessions were shifted to the right of the ascending limbs of the dose-effect curves for the afternoon sessions. Moreover, when saline was substituted for cocaine for only two sessions per day, drug self-administration decreased more during the evening and morning sessions even when the cocaine was available during those sessions. These findings suggest a diurnal variation in cocaine and heroin self-administration. Specifically, drug self-administration during the evening and morning sessions appears to be more sensitive to a decrease in reinforcer magnitude than responding during the afternoon sessions. These findings confirm and extend previous reports of the influence of non-pharmacological factors on drug self-administration.     

Whipple's disease in a man with weight loss and diarrhea

In a 45-year-old man with diarrhoea, upper abdominal pain and malabsorption Whipple's disease was diagnosed by gastroduodenoscopy with small bowel biopsies. The disease is rare and can present with gastrointestinal problems but also with cardiac or neurological complaints. Tropheryma whippelii, the aetiological organism, can be demonstrated by pathological investigation of biopsies and with the polymerase chain reaction (PCR). Treatment with trimethoprim-sulfamethoxazole 160-800 mg twice daily is the therapy of choice: it must be continued for a year, otherwise there is a high possibility of relapse. Correct diagnosis, based mostly on gastroduodenoscopy, can lead to the right therapy and recovery of the patient.     

Correlations in uncertainty analysis for medical decision making: an application to heart-valve replacement.

A Monte Carlo uncertainty analysis with correlations between parameters is applied to a Markov-chain model that is used to support the choice of a replacement heart-valve. The objective is to quantify the effects of uncertainty in and of correlations between probabilities of valve-related events on the life expectancies of four valve types. The uncertainty in the logit- and log-transformed parameters-mostly representing probabilities and durations-is modeled as a multivariate normal distribution. The univariate distributions are obtained through values for the median and the 0.975 quantile of each parameter. Correlations between parameters are difficult to quantify. A sensitivity analysis is suggested to study their influences on the uncertainty in valve preference prior to further elicitation efforts. The results of the uncertainty analysis strengthen the conclusions from a preceding study, which did not include uncertainty in the model parameters, where the homograft turned out to be the best choice. It is concluded that the influence of correlations is limited in most cases. Preference statements become more certain when the correlation between valve types increases.     

Supine Bicycle Exercise Echocardiography: A Potent Immediately Available Tool for Detection and Localization of Myocardial Ischemia for the Initial Cardiologist

Background: Exercise echocardiography (EE) is being used increasingly as an investigative technique now that dynamic images can be captured digitally. Its equivalent reliability with scintigraphic methods has been demonstrated in a hospital setting. This study analyzes its impact on daily practice. Materials and Methods: Standardized progressive stress was produced by supine bicycle ergometry. Echocardiographic images of complete cardiac cycles were obtained in standard apical and parasternal short-axis views before, during, and after maximum effort, and digitized for simultaneous analysis of synchronized images at rest and during exercise. Two hundred sixteen patients (175 men and 41 women; mean age 58 ± 10 years) were studied. Results: Image quality was suboptimal in 4 cases. In the remaining 212 cases, ischemia was detected in 91 cases, and the test was negative in 114 cases and doubtful in 7 cases. Control by selective coronary angiography, as indicated by the clinical situation, was performed in 52 cases. In this particular group, EE showed 87% sensitivity, which is significantly higher than the 59% recorded for conventional exercise testing (P > 0.0001). Conclusions: EE by bicycle ergometer in the supine position is a valid, noninvasive investigative technique that can be used in an outpatient situation (feasibility 95%) since it is readily available. Its value appears to be greatest in cases in which exercise ECG is not conclusive. A negative result enables the initial cardiologist to reassure the patient immediately, which has been demonstrated in the literature to have favorable prognostic value.