Low-dose Thymoglobulin vs Basiliximab Induction Therapy in Low-Risk Living Related Kidney Transplant Recipients: A Prospective Randomized Trial

ContextThymoglobulin is used effectively as induction agent in kidney transplantation but the optimal dose is not well established.ObjectiveDemonstrate that low-dose thymoglobulin (3 mg/kg) has similar efficacy and safety compared to basiliximab induction in low-risk kidney transplantation under standard maintenance immunosuppressionDesign, Setting, ParticipantsProspective randomized study in kidney transplant patients (12/2016-05/2018). Inclusion criteria: Recipients > 18 years, first living donor transplant. Exclusion criteria: Second and multiorgan transplant, ABO incompatibility, positive cross-match, panel reactive antibodies (PRA) > 30%, positive donor-specific antibody, human immunodeficiency virus, hepatitis B surface antigen, hepatitis C virus positive, white blood cells < 2000 cells/mm³, platelets < 75,000 cells/mm³ and malignancy.InterventionGroup A: basiliximab (20 mg D0 and D4). Group B: thymoglobulin (3 mg/kg total). Maintenance immunosuppression: tacrolimus, mycophenolate mofetil, and steroids.Main Outcome MeasuresBiopsy-proven acute rejection (BPAR), delayed graft function, slow graft function, leukopenia, infections, adverse events, graft loss, estimated glomerular filtration rate, and death within 12 months.Results100 patients (basiliximab, n = 53) (thymoglobulin, n = 47) were included. Donor and recipient characteristics were similar except for longer dialysis (basiliximab), PRA class I (1.2% basiliximab, 4.5% thymoglobulin), HLA match (basiliximab 2.8, thymoglobulin 2.2), and cytomegalovirus status. BPAR rate was basiliximab 3.8% and thymoglobulin 6.4% (P = ns). Delayed graft function (basiliximab 3.8%; thymoglobulin 4.3%), slow graft function, and 12-month leukopenia (basiliximab 11.3%, thymoglobulin 21.3%) were similar between groups (P = ns). There was no difference in infections and adverse events between groups. Patient and graft survival were as follows: basiliximab 98.1% and 92.5%, thymoglobulin 100% and 93.6% (P = ns).ConclusionLow-dose thymoglobulin induction (3 mg/kg) can be used effectively and safely in low-risk kidney transplantation with good results during the first year post-transplant.     

Documento de consenso de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Sociedad Española de Medicina Interna (SEMI) y Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) para la definición de competencias mínimas de ecografía en Cuidados Intensivos y Urgencias y la obtención del Diploma acreditativo

The use of ultrasound as a clinical diagnostic tool and guide of bedside procedures has become an indispensable examination in the acute critically ill patient. The training of professionals in minimum skills of knowledge, management and indications of use of ultrasound required to be defined by the Scientific Societies. The Intensive Care Ultrasound Working Group of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), of the Spanish Society of Internal Medicine (SEMI) and the Spanish Society of Emergency Medicine (SEMES) has developed this consensus document in which the recommended training program and the minimum competencies to be achieved with regard to the use of Ultrasound in Intensive Care, Anesthesia and Emergency medicine are defined.This document defines the training program and the skills to acquire in order to achieve the diploma in lung, abdominal and vascular ultrasound. This document can serve as a guide to define the skills to be acquired in the training programs of residents (MIRs) of specialists working in intensive care, anesthesia, and emergency medicine.     

Donor Choriocarcinoma Transmission From Solid Organ Transplantation: A Case Report

Transplantation of any organ has some inherent risk of disease transmission, such as infection and malignancy. The present study aims to describe 2 cases of choriocarcinoma transmission after kidney and liver transplantation originating from the same patient. The donor was a 17-year-old woman who died of cerebral hemorrhage. Both organ recipients died of metastatic choriocarcinoma few months after the transplantation, within days after starting chemotherapy. Retrospective hCG (human chorionic gonadotropin hormone) analysis in donor's blood stored at the time of donation had a result of 9324 mIU/mL. Despite its rarity, clinicians should be aware of the risk of transplant-related choriocarcinoma from female donors in childbearing age. In some cases, hCG dosage should be performed before donation.     

Cross-Cultural Adaptation and Validation of the Pain Scale for Plantar Fasciitis to Spanish

The aim of this study was the validation and transcultural adaptation of the Pain Scale for Plantar Fasciitis to Spanish, following the steps defined by “Guidelines for the process of cross-cultural adaptation of self-report measures.” A cross-sectional study was driven in 153 patients with unilateral plantar fasciitis diagnosis. Statistical analysis measured the internal consistency, the test-retest reliability, the construct validity with the Spanish version of Foot and Function Index, and a factorial analysis. The questionnaire Pain Scale for Plantar Fasciitis was also given to a group of 10 people who received a physiotherapy treatment based on manual therapy, therapeutic exercise, and health education, which aim was to determine the questionnaire's sensitivity to changes. The questionnaire showed high internal consistency and test-retest reliability (Cronbach's α = 0.99, intraclass correlation coefficient = 0.98 [0.97-0.98]), good convergent validity with a moderate correlation with the Foot and Function Index (rho = 0.677, p < .0001) and no floor or ceiling effects were detected. The factorial analysis revealed that the first 3 factors showed 42.47% of variance, finding only 1 latent feature. Statistically significant differences were found in those patients who received physiotherapy treatment after 1 month, revealing that the questionnaire was sensitive to changes in the symptoms of subjects with plantar fasciitis. The Spanish version of Pain Scale for Plantar Fasciitis has proved to be a valid, reliable, and change-sensitive tool for patients with plantar fasciitis.     

Mesh repair for lateral inguinal hernias: a non-evidence-based practice

Introduction

The EHS clinical guidelines recommend the use of mesh to repair symptomatic primary inguinal hernias (PIH) in adult males but, in spite of this, it begs the question as to why there is still place for tissue techniques. Lack of stratification of patients according to risk of recurrence in RCTs might be a cause of results disparity, since medial and mixed are hernias with higher risk of recurrence (HRRH), whereas lateral hernias present a lower risk (LRRH).

Objective

To determine whether the lack of stratification may lead to questionable conclusions regarding the protective effect of mesh techniques and to identify other methodological flaws.

Methods

In the RCTs included in the clinical guidelines that addressed recurrences of PIH after mesh and non-mesh techniques, we assessed the type of hernias classification used, the number needed to treat in LRRH and HRRH and the statistical power.

Results

Most of trials were underpowered; five studies classified the hernia types; in the three studies that compared the recurrence rates of LRRH and HRRH the effect of mesh techniques was small; only two trials record data needed to calculate the NNT in LRRH (46 y 84 patients, respectively).

Conclusion

The idea that mesh techniques reduce the recurrence rate in all PIHs is not supported by high level of evidence. The NNT for pure lateral hernias was very high and should be interpreted taking into account chronic pain rates and costs.

     

Histologic and microbiological findings of the defunctionalized loop in sleeve gastrectomy with jejunal bypass

BackgroundBariatric surgery produces anatomic changes in the digestive tract that can affect the intestinal microbiome and, in some cases, can cause small intestinal bacterial overgrowth. Since the inception of the sleeve gastrectomy with jejunal bypass (SGJB) in 2004, there has been discussion regarding the possible development of those complications associated with the now abandoned jejunoileal bypass (JIB) procedure.ObjectivesThe primary endpoint was to characterize the bacteriologic and histopathologic findings in the defunctionalized jejunal loop after the SGJB procedure and to analyze the liver profile. The secondary endpoint was to report SGJB conversions or reversions and to review the differences between SGJB and JIB.SettingAcademic medical center.MethodsWe conducted a prospective study of patients who underwent laparoscopy for any reason, having previously had an SGJB. A 5-cm segment at the proximal end of the excluded limb was resected. Luminal liquid and tissue samples were taken from this segment for aerobic and anaerobic cultures, and pathologic examination of the bowel wall was performed to evaluate trophism and signs of chronic inflammation. Other variables were liver function and pre- and postoperative status. Finally, we retrospectively reviewed the causes of revisional surgery in the prospective database.ResultsEleven patients underwent laparoscopy. The median time after SGJB was 14 months (range, 10–144 months). There were no complications from the procedure. Eight (72.7%) of the procedures were cholecystectomies. None of the patients showed histologic alterations or signs of chronic infection. The liquid and tissue cultures were negative. The liver tests and the laparoscopic morphology of the liver were normal in all patients, except in 1 with previously documented liver cirrhosis. The number of SGJB revisions was 19 of 1074 (1.8 %), and all of them were converted to Roux-en-Y gastric bypass for severe gastroesophageal reflux.ConclusionsIn this study, we were unable to demonstrate the presence of symptoms or histologic alterations that would suggest that patients undergoing SGJB develop small intestinal bacterial overgrowth in the short- and medium-term follow-up, unlike those who have undergone JIB. The study constitutes an initial step toward establishing what happens to the defunctionalized jejunal limb as a result of this surgical technique.     

Cytomegalovirus DNAemia and risk of mortality in allogeneic hematopoietic stem cell transplantation: Analysis from the Spanish Hematopoietic Transplantation and Cell Therapy Group

The net impact of cytomegalovirus (CMV) DNAemia on overall mortality (OM) and nonrelapse mortality (NRM) following allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains a matter of debate. This was a retrospective, multicenter, noninterventional study finally including 749 patients. CMV DNA monitoring was conducted by real-time polymerase chain reaction (PCR) assays. Clinical outcomes of interest were OM and NRM through day 365 after allo-HSCT. The cumulative incidence of CMV DNAemia in this cohort was 52.6%. A total of 306 out of 382 patients with CMV DNAemia received preemptive antiviral therapy (PET). PET use for CMV DNAemia, but not the occurrence of CMV DNAemia, taken as a qualitative variable, was associated with increased OM and NRM in univariate but not in adjusted models. A subcohort analysis including patients monitored by the COBAS Ampliprep/COBAS Taqman CMV Test showed that OM and NRM were comparable in patients in whom either low or high plasma CMV DNA threshold (<500 vs ≥500 IU/mL) was used for PET initiation. In conclusion, CMV DNAemia was not associated with increased OM and NRM in allo-HSCT recipients. The potential impact of PET use on mortality was not proven but merits further research.