Early experience with enteric-coated mycophenolate sodium in de novo kidney transplant recipients

INTRODUCTION: We sought to evaluate the efficacy of enteric-coated mycophenolate sodium (EC-MPS) and the gastrointestinal (GI) adverse events in de novo kidney transplant recipients. METHODS: This noncontrolled, retrospective review includes 22 de novo kidney transplant recipients. All patients received a standard course of basiliximab and were maintained on triple-drug therapy with EC-MPS, cyclosporine microemulsion (CsA), and prednisolone. The follow-up lasted 7.9 +/- 1.2 months. The incidence of GI adverse effects were compared with those of historical mycophenolate mofetil (MMF) studies. RESULTS: The serum creatinine was maintained within 1.4 +/- 0.7 mg/dL. The 2-hour CsA postdose level was 1080 +/- 327 ng/mL initially and gradually tapered to 851 +/- 435 ng/mL. The daily EC-MPS dose was 1404 +/- 180 mg initially and gradually tapered to 1098 +/- 288 mg. The GI adverse effects at the daily dose of EC-MPS 1422 +/- 126 mg included dyspepsia 27%, acid regurgitation 18.2%, epigastralgia 9%, nausea 9%, vomiting 4.5%, and poor appetite 4.5%. In comparison those from historical MMF 2 g/d studies included dyspepsia 3.1% to 40%, epigastralgia 10%, nausea 3.7% to 34%, and vomiting 0.6% to 10.7%. CONCLUSION: Immunosuppression with CsA, EC-MPS, and steroids maintains stable graft functions. Minimal dose reduction of EC-MPS decreases GI adverse events but without significance. EC-MPC and MMF have respective GI side effects; they can be used alternatively in patients with individual GI intolerance.     

Treatment of cytomegalovirus infection or disease in solid organ transplant recipients with valganciclovir

Valganciclovir (VGC) has proved efficacious and safe for the prophylaxis against cytomegalovirus (CMV) in high-risk transplant recipients and for the treatment of CMV retinitis in AIDS patients. We used VGC for the treatment of CMV infection (viremia without symptoms) or disease (CMV syndrome or tissue-invasive disease) in kidney, heart, and lung transplant recipients. Fourteen transplant recipients were treated: five for asymptomatic CMV infection and nine for CMV disease. VGC was administered in doses adjusted to renal function for 4 to 12 weeks (induction and maintenance therapy). Clinically, all nine patients with CMV disease responded to treatment. Microbiologically, treatment with VGC turned blood culture negative for CMV within 2 weeks in all patients and was associated with a > or =2 log decrease in blood CMV DNA within 3 weeks in 8 of 8 tested patients. With a follow-up of 6 months (n = 12 patients), asymptomatic recurrent CMV viremia was noted in five cases, and CMV syndrome noted in one case (all cases in the first 2 months after the end of treatment). VGC was clinically well tolerated in all patients; however, laboratory abnormalities occurred in three cases (mild increase in transaminases, thrombocytopenia, and pancytopenia). This preliminary experience strongly suggests that therapy with VGC is effective against CMV in organ transplant recipients; however, the exact duration of therapy remains to be determined: a longer course may be necessary to prevent early recurrence.     

Perioperative blood transfusions. Value, risks, and guidelines

Surgical blood loss and trauma are the major causes of allogeneic blood transfusions, which still bear considerable risks. After the correction of hypovolemia, the anesthesiologist often has to deal with normovolemic anemia. The clinical relevance of this isolated decrease in hemoglobin concentration consists in an eventually compromised global or regional oxygen supply with the development of tissue hypoxia below a critical threshold. This is an individual threshold for each patient and depends on his or her capacity to compensate the decrease in blood oxygen content. Therefore, physiologic transfusion triggers should primarily be applied and not rigid numeric transfusion triggers, such as hemoglobin concentration, which do not take into account each patient's individual reserve.     

Prophylaxis of thromboembolic events during urologic surgery

Few scientific evidences are available in the literature, and the methodologic quality of the studies is often under average. Nevertheless, the conclusions are the following. Nephrectomy, renal transplantation, open surgery of the lower urinary tract and lumbar or pelvic lymph nodes dissection are at high risk for thromboembolic events. Other open or endoscopic urological procedures are at low risk. The laparoscopic approach doesn't change the risk associated with the procedure itself. Thromboprophylaxis is recommended in high-risk procedures. There was no evidence to recommend starting the prophylaxis before more than after the procedure. The use of low molecular weight heparin is recommended for prophylaxis. It can be associated with compressive stockings. It is recommended to treat for around seven days after the procedure. In case of cancer surgery, prophylaxis could be needed for four to six weeks.     

Pseudosyndactyly and musculoskeletal contractures in inherited epidermolysis bullosa: experience of the National Epidermolysis Bullosa Registry, 1986-2002

Mitten deformities of the hands and feet occur in nearly every patient with the most severe subtype (Hallopeau-Siemens) of recessive dystrophic epidermolysis bullosa, and in at least 40-50% of all other recessive dystrophic epidermolysis bullosa patients. Smaller numbers of patients with dominant dystrophic, junctional, and simplex types of epidermolysis bullosa are also at risk of this complication. Surgical intervention is commonly performed to correct these deformities, but recurrence and the need for repeated surgery are common. Higher numbers of epidermolysis bullosa patients also develop musculoskeletal contractures in other anatomic sites, further impairing overall function. Lifetable analyses not only better project the cumulative risk of mitten deformities and other contractures but also emphasize the need for early surveillance and intervention, since both of these musculoskeletal complications may occur within the first year of life.     

Antibiotic susceptibility of 65 isolates of Burkholderia pseudomallei and Burkholderia mallei to 35 antimicrobial agents

OBJECTIVES: Fifty isolates of Burkholderia pseudomallei and 15 isolates of Burkholderia mallei were tested for their susceptibilities to 35 antimicrobial agents, including agents not previously tested against these bacteria. METHODS: MICs were determined by agar dilution in Mueller-Hinton medium. RESULTS: Among the antibiotics tested, lower MICs were obtained with imipenem, ceftazidime, piperacillin, piperacillin/tazobactam, doxycycline and minocycline. Fluoroquinolones and aminoglycosides had poor activities. A single clinical isolate of B. pseudomallei was resistant to ceftazidime, co-amoxiclav and doxycycline but remained susceptible to imipenem. CONCLUSIONS: Although B. mallei MICs are often lower, the overall results underline the importance of resistance in both species. The susceptibilities measured are consistent with the current recommendations for the treatment of B. pseudomallei and B. mallei infections.     

Parkinson's disease as a model of aging: prospective analysis of gait discorders

Falls are a dramatic consequence of the age-related gait disorders. There are few prospective studies on falls predictive of the biomechanical features of gait. According to the literature, there are similarities between the gait observed in older people and in parkinsonian subjects. The objective of this study was to apply multiparametric gait analysis to demonstrate changes of the neuromotor gait pattern connected with falls. This prospective study included two groups of 16 subjects aged more than 60 years, who had not fallen during the previous year. One group included 16 minimally disabled parkinsonian patients off drugs, and the other group 16 healthy people. Gait recordings were obtained with a three-dimensional optoelectronic movement analysis system coupled with 2 force platforms in all persons who were followed for 1 year to collect data on all new events, particularly falls. Data analysis concerned spatiotemporal stride and three-dimensional power peaks developed in each lower limb joint. Cluster analysis of the 32 persons was used to determine various infraclinic neuromotor gait patterns. A post hoc analysis of variance was then applied to identify discriminating parameters. Three groups of subjects were identified with 3 different neuromotor gait patterns, independently of the presence of Parkinson disease. There were no fallers in first group (n=18). The second group (n=8) had 20 p.cent fallers and the third group (n=4) 100 p.cent fallers. The groups differed by 4 spatiotemporal parameters and 3 joint power peaks in the sagittal plane. Functional capacity was good in the first group with no falls recorded. This group of subjects had characteristics reported in the literature corresponding to a category of persons who compensate well for the phenomena of aging. Functional capacity was intermediary in the second group (20 p. cent were fallers). The kinematic pattern appeared to be less successful, revealing a tendency for stiff posture. The third group (100 p. cent fallers) exhibited inferior functional capacity. In this group, the kinematic pattern appeared to be disrupted. The subjects were unable to adapt satisfactorily to situations other than by stereotypical neuromotor reactions. In conclusion this study demonstrated a close determinism between physiological neuromotor aging and Parkinson's disease. The prospective follow-up demonstrated that falls that occurred were related to changes in neuromotor gait patterns. Three phases of gait pattern were also identified from minimal to major risk of falls.     

Coverage of heel tissue loss by two pediculated flaps in a single procedure

We report the case of a traffic accident victim who suffered major tissue loss of the heal. We used two pediculated flaps to close the gap in a single procedure. The remaining tissue presented zones of necrosis from the plantar aspect to the posterior half of the calcaneum, up to the insertion of the calcaneus tendon, extending 5 cm on the posterior aspect of the heal. We decided to combine a medial plantar flap with a lateral supramalleolar flap. The thick medial plantar flap allowed cover of the calcaneum and sensitivity. The calcaneus tendon was covered with the lateral supramalleolar flap. The thickness of the flap was adapted to match the tissue defect. At six months, the patient had recovered walking function with satisfactory weight bearing on the heal. Flap sensitivity was satisfactory with no slipping phenomenon.