Improving pancreas graft utilization through importation

Background

We analyze our outcomes utilizing imported allografts as a strategy to shorten wait list time for pancreas transplantation.

Methods

This is an observational retrospective cohort of 26 recipients who received either a locally procured (n = 16) or an imported pancreas graft (n = 10) at our center between January 2014 and May 2017. Wait list times of this cohort were compared to UNOS Region 9 (New York State and Western Vermont). Hospital financial data were also reviewed to analyze the cost‐effectiveness of this strategy.

Results

Imported pancreas grafts had significantly increased cold ischemia times (CIT) and peak lipase (PL) levels compared to locally procured grafts (CIT 827 vs 497 minutes; P = .001, PL 563 vs 157 u/L; P = .023, respectively). There were no differences in graft or patient survival. The median wait time was significantly lower for simultaneous kidney‐pancreas transplants at our center (518 days, n = 21) compared to Region 9 (1001 days, n = 65) P = .038. Despite financial concerns, the cost of transport for imported grafts was offset by lower standard acquisition costs.

Conclusions

Imported pancreas grafts may be a cost‐effective strategy to increase organ utilization and shorten wait times in regions with longer waiting times.     

Immunohistochemistry for hMLH1 and hMSH2: a practical test for DNA mismatch repair-deficient tumors.

Inactivation of deoxyribonucleic acid (DNA) mismatch repair genes, most commonly human mutL homologue 1 (hMLH1) or human mutS homologue 2 (hMSH2), is a recently described alternate pathway in cancer development and progression. The resulting genetic instability is characterized by widespread somatic mutations in tumor DNA, and is termed high-frequency microsatellite instability (MSI-H). Although described in a variety of tumors, mismatch repair deficiency has been studied predominantly in colorectal carcinoma. Most MSI-H colorectal carcinomas are sporadic, but some occur in patients with hereditary nonpolyposis colorectal cancer (HNPCC), and are associated with germline mutations in mismatch repair genes. Until now, the identification of MSI-H cancers has required molecular testing. To evaluate the role of immunohistochemistry as a new screening tool for mismatch repair-deficient neoplasms, the authors studied the expression of hMLH1 and hMSH2, using commercially available monoclonal antibodies, in 72 formalin-fixed, paraffin-embedded tumors that had been tested previously for microsatellite instability. They compared immunohistochemical patterns of 38 MSI-H neoplasms, including 16 cases from HNPCC patients with known germline mutations in hMLH1 or hMSH2, with 34 neoplasms that did not show microsatellite instability. Thirty-seven of 38 MSI-H neoplasms were predicted to have a mismatch repair gene defect, as demonstrated by the absence of hMLH1 and/or hMSH2 expression. This included correspondence with all 16 cases with germline mutations. All 34 microsatellite-stable cancers had intact staining with both antibodies. These findings clearly demonstrate that immunohistochemistry can discriminate accurately between MSI-H and microsatellite-stable tumors, providing a practical new technique with important clinical and research applications.     

An IgG complexed form of vitamin B12 is a common cause of elevated serum concentrations

ObjectivesTo report detailed investigations in a case of elevated serum B₁₂ due to the presence of an IgG–B₁₂ complex, to determine the prevalence of this phenomenon and to review the literature.Design and methods431 samples with elevated B₁₂ (median 1250 ng/L, range 901–114,480 ng/L) were treated with polyethylene glycol to precipitate immunoglobulin complexes. Samples with > 50% of precipitable B₁₂ (PPB₁₂) were further investigated by protein G adsorption, gel filtration chromatography and measurement of B₁₂ on different analytical platforms.ResultsMedian PPB₁₂ was 22.6%, but in 35 samples (8.1%), median PPB₁₂ was more than 50%. Investigation of 27 of these samples with protein G-Sepharose confirmed the presence of an IgG–B₁₂ complex in 24, and in 15 cases, B₁₂ fell to within the reference range. After treatment of serum with reagents releasing B₁₂ from binding proteins, immunoreactivity co-eluted with free B₁₂. Immunoreactivity of the IgG-bound form of B₁₂ was confirmed using five B₁₂ assays in common use in the UK.ConclusionsAt least 8% of samples with elevated vitamin B₁₂ contain an immunoglobulin complexed form of circulating B₁₂; this possibility should be considered in the interpretation of results.     

Delivering Child Community Psychology Services in the Community: Experiences from the NIPPERS Project

Background: The NIPPERS (Nursery Intervention Project for Parents & Education Related Services) was a novel community psychology service based in nursery settings in socio‐economically disadvantaged, inner‐city areas in London. Method: The service included consultation work with nursery staff, structured parenting groups and individual sessions for parents. Results: The delivery of the clinical service and research evaluation underwent several changes in the first phase of the project, in particular to ensure that the service was acceptable and accessible to families and staff. Although take‐up of community services was higher than in the local clinic‐based services, it was not taken up by some 40% of parents. Due to the allocation design, it was not possible to measure the effectiveness of the intervention. Conclusions: The NIPPERS service was successful in delivering a community child psychology service to families with high levels of early child behavioural problems at high risk for continuing difficulties.     

A randomized controlled trial of fall prevention strategies in old peoples' homes

BACKGROUND: Falls are a major cause of morbidity in old age. A small number of fall prevention trials in cognitively intact community-dwelling older people have been effective. This study set out to examine the preventability of falls in older people living in institutional care. OBJECTIVE: To evaluate the effectiveness of falls risk factor assessment/modification and seated balance exercise training in reducing falls among elderly people living in residential care. METHODS: 133 residents with a mean age of 84+/- (SD) 6.8 years were allocated at random by home to receive either a 6-month falls risk factor assessment/modification and seated balance exercise training programme (n = 77) or 6 months of reminiscence therapy (n = 56). The risk factors targeted were postural hypotension, polypharmacy, visual acuity, and ambient lighting levels. Falls risk factor assessments and recommendation for modifications were performed at baseline in the intervention group and assessments repeated at 6 months. Functional reach, reaction time, timed up-and- go, grip strength, spinal flexibility, and Philadelphia Geriatric Centre Morale Scale and Mini-Mental State Examination scores were determined at baseline and at 6 months by a 'blind' observer. Falls and fractures were then monitored in both groups during a 7- to 12-month falls-monitoring follow-up period. RESULTS: Only 90 of 133 (67.7%) residents completed the 6-month intervention period, and 84 (63.2%) completed the 7- to 12-month falls-monitoring follow-up period. Both prevalence of postural hypotension (p = 0.0005) and poor visual acuity (p = 0.04) were reduced in the intervention group. There was no difference between the groups in the number of falls sustained, the risk of falling [odds ratio 0.45 (95% CI 0.19-1.14)], or in the risk of recurrent falling [odds ratio 1.07 (95% CI 0.40-2.97)]. No significant differences were found between the groups with regard to change in other outcome measures. CONCLUSIONS: The high drop-out rate reduced the power of this study to detect any effect of the interventions used. It is possible that either the exercises were not sufficiently vigorous or that to improve balance exercises must be performed standing. Further research is required to identify effective fall prevention strategies for elderly people in residential settings.     

Evaluation of an experimental system for the in vitro assessment of ultrasonic contrast agents

The ultrasonic properties of microbubble contrast agents need to be fully understood if reproducible images and quantitative results are to be produced. Additional aspects of the physical and chemical environment into which the contrast agents are introduced also need to be taken into account, and their effect on contrast agent performance evaluated. A setup that provides an accurate and reproducible data-acquisition system is presented and evaluated in this paper. The linear range of this system is assessed, as well as its accuracy and precision. A new approach to the investigation of contrast agents, based on normalised backscatter, is discussed. Also, a common technique of degassing, widely used in other areas, is described and evaluated to determine its appropriateness to contrast agent studies.     

Detection and speciation of Cryptosporidium spp. in environmental water samples by immunomagnetic separation, PCR and endonuclease restriction

Current methods for the detection of Cryptosporidium oocysts in water samples are both time-consuming and subject to variation in sensitivity. A genus-specific PCR assay was designed for the specific amplification of a 552-bp region of the 18S rRNA gene. Postamplification endonuclease restriction generated unique digest patterns that enabled differentiation between the three species, C. muris, C. baileyi and C. parvum, the major human pathogen. Theoretical restriction profiles for other Cryptosporidium species were also predicted. The assay routinely detected 10 oocysts in 10-ml purified oocyst preparations, but sensitivity was found to be 10(3)-10(4) -fold lower in environmental water samples. The use of Chelex resin and an immunomagnetic separation procedure overcame this inhibition. This provided detection levels of 10(1)-10(3) oocysts, depending on water turbidity. Rapid and sensitive pathogen detection methods are essential for the water industry. The results of this study demonstrate that PCR has the potential to improve current detection capabilities greatly by differentiating the major human pathogens from non-pathogenic species. This will greatly facilitate a closer examination of the epidemiology of this important pathogen.     

Ultrasonic features of pyogenic and amoebic hepatic abscesses

Pyogenic liver abscesses are not infrequent in some developing countries. Amoebic abscesses may also occur in endemic areas and differentiation may be difficult. The ultrasonic data of proven cases of both conditions were compared and we are now more more confident in predicting the aetiology of these lesions.     

Mucin-secreting Wilms' tumor. Report of two cases

Two children, ages 7 years and 14 months, with mucin-secreting Wilms' tumor were treated at the Red Cross War Memorial Children's Hospital in 1987. In both cases, examination of peripheral blood films disclosed the characteristic appearance of circulating mucin. In each case the blood film appearances returned to normal following nephrectomy. Both patients are in good health and apparently tumor free at 16 and 18 months follow-up.