Is obesity still a risk factor in renal transplantation?

At our center, since 1982, a body mass index (BMI) of less than 30 has been a prerequisite for placing a patient on the waiting list for renal transplantation. This decision was made because obese transplant recipients seemed to have a less than favorable post-transplant outcome. The aim of this study was to evaluate whether this requirement is still justified. Forty-six patients with a BMI above 30 underwent primary cadaveric renal transplantation between 1972 and 1993. For each of these obese patients, five consecutive non-obese (BMI 20–25) control patients were selected. Patient and graft survival, causes of graft loss, and acute rejection rate were evaluated for the two patient groups before and after the year 1982. Within the first 30 post-transplant days, one patient (2 %) and 11 grafts (24 %) were lost in the group of obese patients whereas seven patients (3 %) and 36 grafts (16 %) were lost in the control group. Among the obese patients, renal circulatory complications were a major cause of graft loss. In the period 1973–1981, the 1-year patient survival rate was 65 % among obese patients versus 75 % among controls from 1982 to 1993, this was 90 % versus 93 %. From 1973 to 1981, the 1-year graft survival rate was 25 % among obese patients versus 53 % among controls (P < 0.05); from 1982 to 1993, it was 68 % versus 84 % (P = NS). Multivariate analysis showed that the immunosuppressive regimen, age of the patient, BMI, and cold ischemia time of the graft had a significant influence on graft survival. The acute rejection rate within the first 30 days was 28 % among obese patients and 35 % among controls (P = NS). We conclude that a BMI below or equal to 30 is still justified as a prerequisite for placement on the waiting list for renal transplantation, for despite an overall improvement, the outcome of renal transplantation in obese patients remains worse than that in non-obese patients. Received: 3 February 1997 Received after revision: 4 April 1997 Accepted: 8 April 1997     

Renal allograft immunosuppression: II. A randomized trial of withdrawal of one drug in triple drug immunosuppression

Abstract. A prospective randomized study was conducted to evaluate the impact of four different conversion protocols on graft outcome in long-term follow-up. Between January 1986 and May 1987, 128 patients with first cadaveric kidney allografts were randomized at the time of transplantation to four treatment groups of 32 patients each, to be assigned 10 weeks post-transplantation. During the first 10 weeks, all patients received triple therapy with low-dose azathioprine (Aza), cyclosporin (CyA), and methylprednisolone (MP). After 10 weeks, one group continued with triple therapy (group A) while the three other groups received different combinations of two drugs, namely, Aza and CyA (group B), Aza and MP (group C), or CyA and MP (group D). Withdrawal of MP (group B) or especially of CyA (group C) was associated with 4/29 (14%) and 10/28 (36%) acute rejection episodes, respectively, for 60 days after conversion. All rejections were mild and reversible. There were no rejections after Aza withdrawal or in the group that continued on triple therapy during the corresponding time period. The most common reason for dropping out after withdrawal, for those patients who could not continue on the originally randomized medication, was azathioprine intolerance (n= 12). Five patients were switched back to triple therapy after CyA withdrawal due to rejection. Steroid intolerance was rare and CyA in low doses was very well tolerated. At 1 year there were no statistically significant differences in graft survival between groups A, B, C, and D-81 %, 88%, 88%, and 88%, respectively-or in patient survival-88%, 88%, 88%, and 97%, respectively. For those patients continuing with the originally randomized treatment protocol, there were no differences in patient or graft survival either, the means being 91% and 89%, respectively. The most common cause of death after withdrawal was cardiovascular in nature, and there were no more fatal infections under triple drug treatment than with double drug regimens. There were no statistically significant differences in mean serum creatinine values at 1 year. The median serum creatinine values for groups A, B, C, and D were 112, 132, 133, and 133 μmol/l, respectively. At 1 year the mean CyA dose in the groups that continued with CyA was 3. 5–4. 2 mg/kg per day and CyA concentrations were equal.     

Male suicides and alcohol consumption in the former USSR

A significant decline (34.5%) in the suicide rate occurred in 1984–1988 throughout the USSR. The decline was observed shortly after the introduction of strict restrictions on the sale of alcohol. We tested the hypothesis that the restrictive alcohol policy in the first years of perestroika (June 1985) caused the fall in suicide rates in the former USSR. Data on alcohol consumption, violent death caused by external injury and poisoning (n= 916,315), death due to accidental alcohol poisoning (n= 77,837), suicide (n= 192,305) and death undetermined whether accidentally or purposely (n= 54,253) were analyzed for all former Soviet republics for 1984, 1986, 1988 and 1990. Men were chosen for the analysis, since men are more prone to abuse alcohol than women. Regression analysis with alcohol consumption as the independent variable and suicide rates and violent death rates as dependent variables shows that suicide and alcohol consumption were positively correlated as were violent death and alcohol consumption. In the republics with high alcohol consumption (Slavic and Baltic), suicide rates were also high. In the Caucasian republics, low alcohol consumption was associated with low suicide rates. For most republics, alcohol seems to explain more than 50% of suicides. Alcohol also has considerable explanatory value for violent death. Thus, a restrictive alcohol policy might be a way to reduce suicide and violent death.     

Preoperative risk stratification using gated myocardial perfusion studies in patients with cancer.

Cancer patients frequently have anemia or an altered coagulation state that may affect their risk stratification for perioperative cardiac events. We performed this study to investigate the incidence of perioperative cardiac events in cancer patients who had abnormal stress myocardial perfusion imaging (MPI) results versus cancer patients with normal MPI results. METHODS: We included 394 consecutive cancer patients with normal (n = 201) or abnormal (n = 193) results on MPI studies performed for preoperative risk stratification. MPI was performed within 6 mo before each patient's scheduled operation. All the patients had surgical procedures requiring general anesthesia, except for 18 who had endoscopic or colonoscopic procedures. We retrospectively reviewed their data for the incidence of major cardiac events intraoperatively and for 1 mo postoperatively. We collected data on their cancer type, risk factors for coronary artery disease, MPI findings, risk of operation, and intraoperative or postoperative major cardiac events, which included death, myocardial infarction (MI), and congestive heart failure (CHF). RESULTS: The patients with abnormal MPI results included 97 with ischemia, 80 with scarring, and 16 with mixed scarring and ischemia. The mean left ventricular ejection fraction and end-diastolic volume were 63.8% +/- 9.8% and 82.0 +/- 53.5 mL in the normal MPI group versus 52.1% +/- 13.1% and 118.1 +/- 53.4 mL in the abnormal-MPI group (P < 0.001). There were 9 major intraoperative or postoperative cardiac events (4.7%) in the patients with abnormal MPI results and none in the patients with normal MPI results (P = 0.001). These major events consisted of 3 deaths, 2 acute MIs, 1 non-Q-wave MI, and 3 cases of CHF. Four of these patients had only scarring on their MPI studies, 3 had ischemia, and 2 had scarring and ischemia. CONCLUSION: Normal MPI results have a high negative predictive value for perioperative cardiac events in cancer patients. Abnormal MPI results, whether demonstrating scarring or ischemia, should prompt appropriate perioperative management in patients with cancer to minimize major cardiac events.     

Cystic fibrosis detection in high-risk Egyptian children and CFTR mutation analysis.

BACKGROUND: Knowledge about Cystic Fibrosis (CF) in Egypt is very limited. The objective of this study was to screen for CF in Egyptian children with suggestive clinical features and to identify causative genetic mutations. METHODS: Sixty-one patients from the Chest Unit, Cairo University Children's Hospital, Egypt, were included. Subjects presented with persistent or recurrent respiratory symptoms, failure to thrive, diarrhea and/or steatorrhea and unexplained persistent jaundice. Patients were screened using the CF Indicatortrade mark sweat test system (PolyChrome Medical, Inc., Brooklyn Center, MN). A quantitative sweat testing was conducted on 10 of the 12 positive patients. Seven probands and one sibling underwent molecular analysis by direct DNA sequencing of the coding region and of the intronic sequences adjacent to the 27 exons of the CFTR gene. RESULTS: Of 61 patients, 12 (20%) had positive sweat chloride screening. Ten of the 12 patients underwent quantitative sweat testing and were positive. Eight CFTR sequence changes were identified in seven affected probands and two were confirmed in one sibling by direct DNA sequencing. CONCLUSION: The study results suggest that CF is more common in Egypt than previously anticipated. Larger studies are warranted to identify the incidence, molecular basis and clinical pattern of CF in the Egyptian population.     

Children with psychiatric disorders: the A1 Ain Community Psychiatric Survey.

OBJECTIVE: The prevalence of child psychiatric morbidity in the community is unknown in most developing countries, including those in the Arab region. METHOD: An epidemiologic study was carried out to estimate the prevalence of psychiatric morbidity and to determine the sociodemographic correlates in a sample of children in the community, aged 6 to 18 years, in A1 Ain, United Arab Emirates (UAE). RESULTS: We obtained a prevalence rate of 22.2% for overall morbidity, as classified in the DSM-1V, and 14.3% for those with significant dysfunction, with the most common diagnosis being mood disorders. Female sex, large family size, chronic life difficulties, family history of psychiatric disorder, and alcohol-related problems in a family member were significantly associated with DSM-IV diagnosis. CONCLUSION: Although the prevalence and symptomatology in this Middle East community are similar to those in Western studies, none of these children had received professional help, suggesting serious deficiencies in mental health care services in the country.     

Sexual self views of women with disabilities: The relationship among age-of-onset,nature of disability and sexual self-esteem

The sexual self-esteen of 43 women with mobility impairments was examined on the basis of age-of-onset and nature (fluctuating versus stable health conditions) of disability. Based on past literature, it was hypothesized that women with earlier age-of-onset disabilities would report lower positive levels of sexual self-esteem compared to women with later age-of-onset disabilities. Subjects were acquired through two computer on-line services, two large urban universities, and nationally based disability-related organizations. A hierarchical multiple regression indicated that as age-of-onset of disability increased (i.e. the disability occurred later in life), positive sexual self-esteem decreased significantly. Future research should acquire participants from residential institutions other than rehabilitation facilities and those who remain at home. The necessity of creating psychological scales and tools applicable to this population is discussed.     

Positive and negative symptoms covary during clozapine treatment in schizophrenia

Although negative symptoms were traditionally considered to be unresponsive to neuroleptic medication, recent studies have demonstrated that negative symptoms do improve during neuroleptic treatment and that such improvement tends to occur concurrently with improvement in positive symptoms. Clozapine is an atypical neuroleptic that is effective in a significant proportion of otherwise neuroleptic-nonresponsive schizophrenic patients; in contrast to conventional neuroleptics, clozapine is also purported to possess unique efficacy in the amelioration of negative symptoms. How clozapine-associated reduction in negative symptoms relates to change in positive symptoms is not clear. To study the relationship between change in positive and negative symptoms during clozapine treatment, we monitored symptomatology in 40 DSM-III-R schizophrenic patients before and about 8 weeks after a trial of clozapine. Both positive and negative symptoms improved significantly. There was a significant correlation (r = .63,p <.01) between change in positive symptoms and change in negative symptoms; as with conventional neuroleptics, negative symptoms improved concomitantly with positive symptoms during clozapine treatment. Clozapine's apparent greater efficacy on negative symptoms may be related to its greater efficacy on positive symptoms in otherwise neuroleptic-refractory patients and its lesser propensity to cause extrapyramidal side-effects.