Association Between Waiting Times for Kidney Transplantation and Rates of Live Donation

A deceased donor (DD) allocation system incorporating net life survival benefit has been proposed. In this system, many kidneys will be shifted to younger recipients, thereby decreasing their waiting times. The goal of this study was to determine the potential effects of altering waiting times on the likelihood of live donor kidney transplantation (LDKT). We analyzed 93,727 waiting list candidates to determine the association of various patient factors with likelihood of LDKT. The proportion of patients receiving LDKT was compared by the median DD waiting time at that patient's transplant center for someone of that patient's age category and race. LDKT was consistently higher as waiting times became longer. After adjusting for all other factors associated with likelihood of LDKT, waiting time remained a significant, independent predictor. Patients with the longest DD waiting times had 2.3-fold higher odds of LDKT (95% CI 2.11-2.58, p < 0.001). In planning the new DD allocation policy, we must account for resulting alterations in LDKT. It is possible that shifting DD kidneys to younger recipients may decrease LDKT or shift it to older recipients, net effects not consistent with the goal of net life survival benefit.     

Survival after gastric adenocarcinoma resection: Eighteen-year experience at a single institution

Gastric adenocarcinoma is the second leading cause of cancer death worldwide. In Western series, survival rates vary widely and are generally lower than those reported from Eastern series. We performed a retrospective analysis of cases operated on at the Johns Hopkins Hospital over the past 18 years and collected data on demographics, tumor characteristics, pathologic stage, treatment methods, complications, survival time, and other relevant factors. Survival according to stage of disease, Lauren tumor type, tumorlocation,time period, andadministration of adjuvant therapy wasanalyzed, andresultswerecompared with those of other Western series. During this period, 436 patients with gastric adenocarcinoma underwent resection. We have shown a statistically significant association between survival and margin status, stage of disease, and Lauren tumor type. Overall 5-year survival was 26%, and 5-year survival after R0 resection was 33%. No significant difference was detected between survival and tumor location, time period of treatment, or administration of adjuvant therapy. Analysis of various Western series reveals major differences between the cohorts under study, such as stage of disease, extent of resection, tumor type, and tumor location. Many of the reported differences among Western series may be due to cohort differences, such as stage of disease, extent of resection, tumor type, and tumor location.     

An open access technique to create pneumoperitoneum in laparoscopic surgery.

BACKGROUND: An open access technique might reduce severe vascular and visceral injuries. An open access technique through the umbilical cicatrix tube has been developed as a routine method with the goal to be easy, safe and used by all surgeons in patients without a previous midline incision. AIM: To evaluate the open technique in a prospective study in 100 consecutive laparoscopic operations regarding time for entrance, surgeons experience and BMI of the patients. METHODS: A midline incision from the linea alba up into the inverted umbilicus was performed in the cicatrix tube and the peritoneum was penetrated allowing air to flow into the abdominal cavity followed by a blunt trocar insertion. RESULTS: Time for access was median 93 seconds. Entrance time in patients with BMI >30 (n=18) was 100 sec and with BMI <30 it was 90 sec (p = 0.71). The median time for consultants was 88 sec and for residents 120 sec (p = 0.003). No gas leakage was seen. Prolonged time for access was seen in three patients; two equipment failures and one obese patent. CONCLUSION: The open access technique is applicable in all patients without a former midline incision. It is fast, easy to learn with very few associated problems.     

A randomized controlled trial of electromagnetic therapy in the primary care management of venous leg ulceration

OBJECTIVE: The aim was to establish the potential efficacy, tolerabilityand side-effect profile of electromagnetic therapy as an adjunctto conventional dressings in the treatment of venous leg ulcers. METHOD: A prospective, randomized, double blind controlled clinicaltrial was carried out in a dedicated leg ulcer clinic basedin one urban general practice. Nineteen patients with leg ulcersof confirmed venous aetiology were assessed. The main outcomemeasures were rate and scale of venous leg ulcer healing, changesin patient-reported pain levels, quality of life, degree ofmobility, side effect profile and acceptability to patientsand staff. RESULTS: Sixty-eight per cent of patients attending this dedicated clinicachieved improvements in the size of their ulcer (4, 21%, healedfully) and in reduced pain levels (P < 0.05) during the trial,despite the chronicity of ulcer histories. Patients treatedwith electromagnetic therapy at 800 Hz were found at day 50to have significantly greater healing (P < 0.05) and paincontrol (P < 0.05) than placebo therapy or treatment with600 Hz. All patients reported improved mobility at the end ofthe study. The electromagnetic therapy was well tolerated bypatients, with no differences between groups in reporting adverseevents, and proved acceptable to staff. CONCLUSION: Despite the small numbers in this pilot study, electromagnetictherapy provided significant gains in the healing of venousleg ulcers and reduction in pain. Keywords. Electromagnetic therapy, RCT, leg ulcers, primary care.     

A placebo controlled trial of remoxipride in the prevention of relapse in chronic schizophrenia

Sixty-two DSM III chronic schizophrenic inpatients were selected for a double-blind, placebo controlled, multi-centre, relapse prevention study of remoxipride, a selective dopamine (D₂)-receptor antagonist. After a 1 month placebo washout, 23 patients had relapsed and were withdrawn. Of the remaining patients 19 were randomised to remoxipride (150–300 mg daily) and 20 to placebo. Their median age was 58 years, 26 were male, and the median duration of illness was 33 years. After 24 weeks a further total of 8 remoxipride and 17 placebo patients had been withdrawn. Excluding three patients withdrawn for reasons other than relapse, the comparative relapse rates were 37% and 75%, respectively (P=0.015). Efficacy analyses using clinical global impression (P=0.04) and change in BPRS scores (P=0.016) were in favour of remoxipride. Extrapyramidal symptoms were minimal in both groups. Treatment emergent adverse events were similar in the two groups. Remoxipride is therefore of potential value as a safe drug which is both effective and well tolerated in the long term management of chronic schizophrenic patients.     

Impact of clinical history on fracture detection with radiography

The effect of knowledge of localizing symptoms and signs in the detection of fractures was studied. Forty radiographs of the extremities were examined twice by seven radiologists; the sessions were separated by 4 months. In 26 cases, a subtle fracture was present; 14 cases were normal. In half of the cases at each session, the precise location of pain, tenderness, or swelling was provided. The observer was asked to determine if the case was normal or abnormal (provide the exact location of the fracture) and to indicate the degree of confidence in the diagnosis. Responses were converted to a numeric scale for analysis. Analysis of receiver operator characteristic parameters indicates that clues regarding location of trauma facilitate detection of fractures. The improvement is based largely on an increased true-positive rate without an increased false-positive rate, regardless of the decision criteria of the radiologist (overall willingness to "overread" or "underread"). This has direct clinical applicability and reinforces the plea of radiologists for precise clinical information.     

Evidence that background GABAergic tone and possible ligand release may alter the action of the 'neutral' benzodiazepine-receptor antagonist, Ro 15-1788, in hypothalamic self-stimulation

Upward or downward shifts in the level of brain GABAergictransmission have been held to be necessary and sufficient to promote release of endogenous ligands ('endocoids') for the benzodiazepine (BZD) recognition site. To investigate this possibility, variable-interval self-stimulation performance was used to monitor 'intrinsic' benzodiazepine-like and anti- benzodiazepine activity by the 'neutral' benzodiazepine-receptor antagonist, Ro 15-1788 (flumazenil) (10 or 30 mg/kg intraperitoneally). Rats were pretreated with either a GABA synthesis blocking agent (isoniazid, 130 mg/kg subcutaneously), or with a GABA agonist (progabide, 30 or 100 mg/kg intraperitoneally). The lower dose of Ro 15-1788 (10 mg/kg), without pretreatment, did not affect self-stimulation; higher doses (30 mg/kg) caused a brief (<20 min) depression. Isoniazid (130 mg/kg) depressed self-stimulation, but did not modify the activity of Ro 15-1788. In rats pretreated with progabide (100 mg/kg), low doses of Ro 15- 1788 (10 mg/kg) that were previously without effect now caused a sharp fall in responding. These findings can be interpreted as showing that even low doses of Ro 15-1788 may affect self-stimulation under certain conditions, and that they do so by competing with an endogenous ligand for the benzodiazepine site, released by upward shifts in GABAergic activity. Alternative explanations in terms of altered receptor function seem less feasible. The results imply that the action of the endogenous ligand would not resemble that of a typical benzodiazepine, but that of an inverse agonist (that is, proconflict and proconvulsant); this conclusion agrees with recent biochemical evidence.