Sirolimus allows renal recovery in lung and heart transplant recipients with chronic renal impairment.

BACKGROUND: Until recently, there has been no practical alternative to the use of calcineurin inhibitors (CIs) as primary immunosuppressants in lung transplantation (LTx) and heart transplantation (HTx). Sirolimus (SRL) is a novel powerful immunosuppressant without renal toxicity, a common post-transplant problem associated with CI therapy. METHODS: SRL was used in 20 LTx and 5 HTx recipients >90 days post-transplant, where serious renal impairment was limiting CI dosing. Patients started on 2 to 5 mg/day orally at a median of 1,185 days post-transplant. Dosage adjustments were made according to trough levels, toxicity and perceived efficacy. With SRL initiation, 48% ceased CI therapy and the remainder decreased their dose substantively. RESULTS: After 30 days, 4 of 5 dialyzed patients ceased dialysis and 15 of 20 patients with an elevated serum creatinine (Cr) (mean Cr 0.29 mmol/liter) improved their Cr. The direction of change in Cr at 30 days predicted longer term Cr. The starting Cr did not predict the 30-day or long-term value. There were two bouts of acute and one bout of chronic rejection. There were 35 infectious complications in 16 patients and 24 episodes of potential SRL-related toxicity in 17 patients. These events generally responded to dose reduction or temporary cessation and were level-related. Fifteen recipients presently remain on the drug. None of the 7 deaths could be directly related to toxicity. CONCLUSION: SRL is a useful alternative immunosuppressant, allowing significant CI withdrawal in transplant recipients with renal impairment. Whether the resulting improvement in Cr can be maintained in the long term probably depends on the balance between the extent of acute and chronic renal damage.     

Platelet activation,aggregation, and life span in calves implanted with axial flow ventricular assist devices

Background. A variety of rotary blood pumps are under development worldwide to serve as chronic ventricular assist devices (VADs). Historically VADs have been associated with thrombotic and thromboembolic complications, yet the ability to evaluate the thrombotic process in preclinical device testing has been limited.

Methods. We have developed and applied flow cytometric assays for activated platelets, platelet microaggregates, and platelet life span and consumption to calves implanted with an axial flow VAD and calves undergoing a sham surgical procedure.

Results. Surgical sham calves had significant increases in circulating activated platelets (p < 0.05) that resolved within 17 days, and no increases in circulating platelet microaggregates. Calves with uneventful VAD implant periods had early transient elevations in platelet microaggregates and prolonged elevations in activated platelets that did not recover to preoperative values during the study. Daily platelet consumption in VAD implanted calves was increased by 20% ± 3%. Calves with thrombotic deposition within the VAD and elevated thromboembolism observed at autopsy experienced increases in circulating activated platelets and microaggregates at the end of the implant period when VAD flow decreased.

Conclusions. This study demonstrates the ability of flow cytometry-based platelet assays to differentiate VAD implant operations from VAD support, and suggests differences that exist between uneventful VAD support and support with complications. These techniques should have value in evaluating other cardiovascular devices undergoing preclinical testing and provide insight into the temporal impact of these devices on the hemostatic system.     

Sperm maturation in the epididymis： a new look at an old problem

The osmotic challenges facing maturing spermatozoa and their responses to them are discussed in relation to the concept of sperm maturation, defined as the increased ability of more distally recovered epididymal spermatozoa to fertilize eggs when inseminated into the female tract. One explanation could be that the more distal cells are better able to regulate their volume, and reach the oviducts, as a consequence of uptake of epididymal osmolytes. Increased motility, zona binding and oolemma fusion capacities are also acquired within the epididymis and are necessary for those cells that finally arrive at the site of fertilization. （Asian J Androl 2007 July; 9： 533-539）     

A bilobed groin flap for coverage of traumatic injury to both the volar and dorsal hand surfaces

BACKGROUND:

There are many methods available for coverage of both the volar and dorsal hand surfaces in traumatic injury. All of these surgical procedures allow for ample coverage of the defect, but have the major drawback of needing multiple donor sites. In the present report, a case of a complex crush injury to the hand in which both volar and dorsal surfaces received traumatic injury is presented. A bilobed groin flap pedicled on the superficial circumflex iliac artery was fashioned to cover the entire defect. Like many other described flaps, the bilobed groin flap resulted in a favourable functional and cosmetic result for the patient, but with the unique advantage of requiring a single donor site.

METHODS:

A bipedicled groin flap was raised from distal to proximal, and the flaps inset onto both the dorsal and volar hand defects.

RESULTS:

The patient regained adequate function of his hand, and was able to return to work full-time as a manual labourer.

CONCLUSION:

The bilobed groin flap appears to be a valuable option for covering complex hand injuries involving both the volar and dorsal surfaces of the hand.     

Closed reduction for treatment of developmental dysplasia of the hip in children

Although many studies have analyzed the success rates of closed reduction and spica casting for the treatment of developmental dysplasia of the hip (DDH) in children, the definition of success for this procedure is not standardized in the literature. We retrospectively reviewed our experience with closed reduction for treatment of DDH in 30 children (35 hips) over an 8-year period to determine the success rates of this procedure on the basis of how success is defined. In only 1 patient (2 hips, 6%) were the hips unable to be concentrically reduced with sufficient stability at the time of closed reduction. In 10 (30%) of the other 33 hips, the acetabulum failed to develop sufficiently after closed reduction, and a secondary surgery was required a mean of 22 months after cast removal. Four (12%) of the 33 hips developed radiographic evidence of avascular necrosis. Therefore, the success rate of closed reduction for DDH varies markedly depending on how success is defined.     

Use of additional treatment for prostate cancer after radical prostatectomy, radiation therapy, androgen deprivation, or watchful waiting

OBJECTIVE. To examine how the use of additional treatment for prostate cancer differs as a function of the initial therapy (radical prostatectomy [RP], radiation therapy [RT], androgen deprivation therapy [ADT], or watchful waiting [WW]) for men with non-metastatic prostate cancer. MATERIAL AND METHODS. A dataset was created that combined information from the Surveillance, Epidemiology, and End Results program and Medicare claims for hospital and physician services. To identify patients receiving additional cancer treatment, we searched the claims for the presence of RP, RT (palliative radiation not included), or ADT. RESULTS. The study population consisted of 12 711 patients: as initial treatment, 3940 (31.0%) had RP, 3950 (31.1%) RT, 1209 (9.5%) ADT, and 3612 (28.4%) WW. The RP group had a less favorable distribution of tumor differentiation than the RT group. Only 54.6% of men who had initial RP had localized cancer. In men who had initial RP, 8.1% had RT and 12.4% ADT during the follow-up period, which was 6-66 months after the initial therapy ended. Among patients who had initial RT or WW, 22.8% and 22.1%, respectively had ADT during the follow-up period. CONCLUSION. Older American men with prostate cancer who are initially treated with RT or simply observed (WW) are more likely than men who undergo RP to receive ADT as a follow-up treatment.     

Donor history of asthma is not a contraindication to lung transplantation: 12-year single-center experience.

BACKGROUND: Donor asthma has been regarded as a contraindication to lung transplantation (LTx) because of concerns that pre-existing airway inflammation will predispose to early and late graft dysfunction. The aim of this study was to describe LTx outcomes in which lungs had been transplanted from donors with a history of asthma. METHODS: A retrospective chart review was undertaken of 743 consecutive donor lung referrals to the Alfred Hospital between 1990 and September 2002. Seventy-four were noted to have a history of asthma, including 18 in whom asthma was the cause of death. Twenty-seven patients became lung donors, of whom 16 were on asthma treatment (on-treatment group) and 11 were not (no-treatment group). RESULTS: From 27 lung donors, 35 LTx procedures were performed (16 double LTx [DLTx], 19 single LTx [SLTx]). Five recipients died at <30 days (including 3 of early graft failure in the no-treatment group), and 7 died at >30 days (only 1 due to BOS). The 30-day, 1-year and 5-year survival rates in the on- and no-treatment donor groups were 90% vs 76%, 74% vs 69% and 74% vs 60%, respectively, and were not significantly different from our overall LTx survival rates. There were no significant differences in percent predicted forced expiratory volume in 1 second, ICU stay or hospital stay overall, or when analyzed according to on treatment vs no treatment and SLTx vs DLTx. Only 2 procedures LTx were performed from fatal asthma donors, both of whom had subsequent graft dysfunction and died on Days 73 and 484, respectively. CONCLUSIONS: The use of lungs from carefully selected lung donors with a history of asthma may increase the donor pool with acceptable long-term outcomes. The use of fatal asthma donors remains problematic.     

Outpatient Vascular Intervention: A Two-Year Experience

PURPOSE: To retrospectively analyze the outcome of a range of interventional vascular procedures performed on outpatients. METHODS: Suitability for outpatient procedures was assessed according to agreed protocols. An episode was defined as any procedure/s through a single access site at one attendance. Retrospective case-note review was performed. RESULTS: There were 693 outpatient episodes between April 1998 and May 2000 (290 interventional, and 403 diagnostic procedures), comprising 25% (693/2,769) of the total workload. Follow-up is available in 214; 38 of these were transfers from outlying hospitals and were excluded from analysis. One hundred and seventy-six were true outpatients. There were 98 iliac and 46 femoropopliteal interventions, 2 aortic stents, 1 renal and 5 upper-limb angioplasties (PTAs), 5 embolizations, 8 Hickman lines, 1 line stripping, 3 atherectomies, 1 dialysis-graft PTA and 6 bypass-graft PTAs. Sixty-eight closure devices were used. Twelve patients were converted to inpatients (6.8%, 12/176). The readmission rate was 3.4% (6/176). The reattendance rate was 1.1% (2/176), both subsequently attending for outpatient duplex ultrasound examination to exclude pseudoaneurysm. The major complication rate was 3.4% and the delayed major complication rate was 1.7%. CONCLUSION: Outpatient vascular intervention is safe with appropriate protocols and with careful patient selection. Local vascular services benefit from the release of inpatient beds.     

Evaluating quantitative proton‐density‐mapping methods

Quantitative magnetic resonance imaging (qMRI) aims to quantify tissue parameters by eliminating instrumental bias. We describe qMRI theory, simulations, and software designed to estimate proton density (PD), the apparent local concentration of water protons in the living human brain. First, we show that, in the absence of noise, multichannel coil data contain enough information to separate PD and coil sensitivity, a limiting instrumental bias. Second, we show that, in the presence of noise, regularization by a constraint on the relationship between T1 and PD produces accurate coil sensitivity and PD maps. The ability to measure PD quantitatively has applications in the analysis of in‐vivo human brain tissue and enables multisite comparisons between individuals and across instruments. Hum Brain Mapp 37:3623–3635, 2016. © 2016 Wiley Periodicals, Inc.