Trough Level of Mycophenolic Acid Did Not Affect De Novo DSA Development in Kidney Transplantation

IntroductionMycophenolate mofetil has improved long-term outcomes of kidney transplantation. However, the impact of mycophenolic acid (MPA) trough level on the development of de novo donor-specific anti-HLA antibody (DSA) is unclear. We examined the relation between MPA trough level and de novo DSA development.MethodWe retrospectively studied 617 kidney recipients whose MPA trough level and de novo DSA data were available. All patients underwent primary kidney transplant from living donors from 2008 to 2014, and were chronically treated with a calcineurin inhibitor, mycophenolate mofetil, and +/- steroids. They were equally divided into 4 groups according to the mean trough level of MPA (mMPA) at 1 year post-transplantation: Group 1, mMPA < 2.14 ng/mL (n = 152); Group 2, mMPA 2.14-2.83 ng/mL (n = 157); Group 3, mMPA 2.83-3.57 ng/mL (n = 153); and Group 4, mMPA ≥ 3.57 ng/mL (n = 155). The groups were compared by incidence rate of de novo DSA, graft survival rate, and renal function.ResultsThe incidence rates of de novo DSA were 33.3% in Group 1, 23.7% in Group 2, 22.9% in Group 3, and 30.3% in Group 4 (P = .158). Although there was no significant difference in graft survival rates, a significant difference of renal functions was noted: the higher the renal function, the lower the MPA trough level.ConclusionThe mMPA trough level at 1 year post-transplantation was not statistically associated with the incidence rate of de novo DSA after kidney transplantation.     

Sildenafil Monotherapy to Treat Portopulmonary Hypertension Before Liver Transplant

Portopulmonary hypertension (PPHTN) is a rare complication of liver cirrhosis. Patients with severe PPHTN are contraindicated for liver transplant because of the associated risk of intraoperative acute right heart failure during reperfusion phase or massive volume infusion. Therefore, it has been recommended that patients with moderate to severe PPHTN undergo medical treatment to lower the pulmonary artery pressure before undergoing transplant. Herein, we report 3 patients with severe PPHTN who underwent sildenafil monotherapy before living donor liver transplant. None of the patients experienced associated adverse effects during sildenafil treatment, and the pulmonary artery pressure was effectively reduced before transplant. The first patient was diagnosed during anesthesia prior to transplant, and the mean pulmonary artery pressure was reduced by 34% after treatment. The second and third patients were followed-up with echography, and the estimated pulmonary artery systolic pressure were reduced by 34% and 47%, respectively. Pretransplant right heart catheterization also confirmed the reduction of the mean pulmonary artery pressure. Intraoperative hemodynamic parameters were stable, and the 3 patients were discharged uneventfully. After transplant, sildenafil was discontinued, and all patients remained in a stable clinical and functional status during follow-up.     

Impact of Incidental Findings During the Evaluation of Live Kidney Donors on Post-Transplant Outcomes: A Single Center Analysis

BackgroundA careful assessment of a living donor is mandatory to minimize the short- and long-term risk related to kidney donation. In this study, we evaluated the incidence of incidental findings (IFs) in a large population of potential living kidney donors. Moreover, this study evaluated if the presence of IFs could influence the chance of living kidney donation and post-transplant outcomes.MethodsOne hundred and sixty consecutive potential prospective living kidney transplant donors, who underwent a multidetector computed tomography angiography (MDCTA), were included in the study. An IF was defined as an incidentally discovered mass or lesion, detected by computed tomography angiography during the imaging evaluation of potential living donors. Clinical outcomes of living donors with IF were compared with those without IF.ResultsIn 10 patients (6.2%) an incidental finding was detected at MDCTA assessment. Among the 10 patients presenting with an IF, 7 patients (4.3%) were excluded from the living donation: 2 patients with an adrenal lesion, 3 patients with cancer, and 2 patients with a large (>8 cm) renal cyst. Graft and patient survival of kidney transplant recipients of donors with IFs were not significantly different to those receiving a kidney from living donors without IFs.ConclusionsIncidental findings are frequently discovered during living kidney donor evaluation. Whereas most are asymptomatic or not clinically relevant, predonation screening could identify potentially life-threatening diseases at an earlier stage, allowing for a more radical treatment.     

Extending endovascular aneurysm repair to more patients without better outcomes

ObjectiveThis study quantifies the survival and outcomes associated with endovascular aneurysm repair (EVAR) patients treated in two eras. We hypothesized that both end points will improve over time.MethodsPatients receiving EVAR between January 2003 and May 2017 contained within the Vascular Quality Initiative data set were examined. Those patients treated between January 2003 and December 2007 were included in the early era, and those treated between January 2012 and December 2015 were considered late era. Baseline demographics, technical variables, and outcomes were compared with appropriate statistical tests. Survival was estimated with Kaplan-Meier life-table analysis. Cox proportional hazards modeling analyzed the relationship between repair era and survival; the repair era's significance was further examined in matched cohorts generated by coarsened exact matching and propensity scoring.ResultsEarly era (n = 787) patients demonstrate decreased estimated survival in comparison to those treated in the late era (n = 20,066; log-rank, P < .001). Repair in the late era was not an independent predictor of survival in the Cox model (hazard ratio, 1.06; 95% confidence interval, 0.23-4.95; P = .94). Three different matching methods confirmed a nonsignificant contribution of treatment era to survival suggested by the initial Cox model (all P > .05). Total hospital stays were longer in the late era (3.1 vs 4.2 days; P < .001). Postoperative myocardial infarction and surgical site infections decreased in frequency in the late group, although postoperative vasopressor use became more frequent (all P < .05). Operations became 20% faster, required 27% less contrast material and 29% less crystalloid, and lost 30% less blood over time (all P < .05).ConclusionsAlthough EVAR volume increased significantly over time, post-EVAR outcomes of patients do not differ between the early era, 2003 to 2007, and the late era, 2012 to 2015. Aspects of surgical performance improved, but this did not translate into a measurable benefit to patients. Length of hospital stay unexpectedly increased over time.     

Are Stems Redundant in Times of Metaphyseal Sleeve Fixation?

BackgroundVarious options exist for implant fixation in revision total knee arthroplasty. One of it is direct cementless metaphyseal sleeve fixation with stems, which has shown excellent short-term and midterm results. Stemless fixation of sleeves is another fixation option for the treatment of specific bone defects; however, so far no data in larger series exist. The objective of this study was, therefore, to analyze the midterm (3-6.5 years) results of stemless sleeve fixation in a larger revision total knee arthroplasty series.MethodsIn this prospective study, 85 patients with 109 stemless sleeves have been assessed with a mean follow-up of 58.2 (36-78) months. An exclusion criterion was uncontained type II and type III defects. Analysis included clinical and radiographic assessment.ResultsThe results showed a survival rate of sleeves in 96% of the tibia (27/28) and 100% of the femur (81/81). This results in an overall survival rate of sleeves of 99% (108/109). So far, 10 patients (11.8%) underwent rerevision during the follow-up period. The main reason for failure was infection (4/85; 4.7%). Range of motion, Oxford Knee Score, Knee Society Score, and Functional Score improved significantly. Mechanical leg alignment was within the 3° corridor in all patients.ConclusionsIn cases with type I and contained type II defects, sleeves without stems are a promising option, with a survival rate of sleeves of 99% after 5 years. Also, the clinical improvement and reconstruction of leg alignment showed excellent results. In uncontained defects and type III defects, however, we do recommend using stems for additional fixation in the diaphysis. Although the midterm results are very promising, long-term data are needed.     

Shoulder and elbow pain in junior high school baseball players: Results of a nationwide survey

BackgroundDespite proposals and guidelines to prevent baseball injuries in young players by societies and organizations, many shoulder and elbow injuries continue to occur among junior high school baseball players. In order to investigate the training conditions of junior high school baseball players and the risk factors for shoulder and elbow pain in the players, we conducted a questionnaire survey among junior high school baseball players throughout the country.MethodsThe questionnaire survey was conducted among junior high school baseball players in September 2016.ResultsA total of 11,134 junior high school baseball players belonging to 495 teams responded to the survey. Among these, 4004 players trained every day of the week and 1151 players played baseball games every month with no off-season. Among 9752 players who did not have shoulder and/or elbow pain in the spring and summer of 2015, 19.2% of players experienced elbow pain over the course of one year, 13.6% of players experienced shoulder pain, and 28.0% complained of shoulder and/or elbow pain. The frequency of elbow pain was more than that of shoulder pain. At risk for shoulder pain were pitchers and catchers and second-year students, while risk factors for elbow pain were playing pitcher and catcher positions, pitching or throwing ≥300 balls per week, playing ≥10 games on average per month and being left-handed.ConclusionRisk factors for shoulder pain were different from those for elbow pain. To prevent elbow pain, coaches should pay attention to pitchers and catchers and left-handed players and not allow players to pitch or throw ≥300 full-power balls per week or participate in ≥10 games per month. They should also pay attention to pitchers and catchers and second-year students to prevent shoulder pain. It is important for coaches to train multiple pitchers and catchers.     

Stride length of elderly patients with lumbar spinal stenosis: Multi-center study using the Two-Step test

BackgroundShort stride length is one of clinical symptoms associated with lumbar spinal stenosis (LSS). Short stride is a risk factor for falls; therefore, identification of factors associated with short stride is critical for fall prevention in LSS patients. Although the Two-Step test can conveniently assess maximal stride length, it has not become widely used; therefore, its data are limited. We identified the potential factors associated with short stride of elderly LSS patients using Two-Step test.MethodsClinical data of patients aged >65 years who planned to undergo surgery for LSS were prospectively collected at multiple institutions. Patients were assessed with the Two-Step test and Timed Up-and-Go Test prior to surgery; 357 consecutive patients were enrolled. We determined the cut-off value of the Two-Step test score for short stride, referring to the Timed Up-and-Go Test score of 13.5 s, used to indicate high risk of falls in elderly individuals. Logistic regression model was constructed to identify factors associated with short stride.ResultsThe Two-Step test score showed moderate-to-strong inverse correlation with that of Timed Up-and-Go Test (r = ?0.65, p < 0.001). Using the tentative Two-Step test cut-off value (0.93) for short stride, multivariable analysis showed that age ≥80 years (OR = 2.3, 95% CI:1.1–4.8), a score of <60 for lumbar function in Japanese Orthopedic Association Back Pain Evaluation Questionnaire (OR = 2.7, 95% CI:1.5–4.7), motor deficit (OR = 2.7, 95% CI:1.2–6.1), and sagittal vertical axis ≥50 mm (OR = 2.1, 95% CI:1.2–3.5) were factors significantly associated with short stride in elderly patients with LSS.ConclusionsUsing the Two-Step test, we found that 80 years old and over, lumbar dysfunction, motor deficit of the lower extremities, and forward-bent posture were associated with short stride in LSS patients. Therefore, elderly LSS patients with these conditions may have a higher risk for falls.