Long-term,prolonged-release tacrolimus-based immunosuppression in de novo kidney transplant recipients: 5-year prospective follow-up of the ADHERE study patients

The objectives of this study were to assess long-term graft survival, patient survival, renal function, and acute rejections in de novo kidney transplant recipients, treated with once-daily prolonged-release tacrolimus-based therapy. The study was a 5-year non-interventional prospective follow-up of patients from the ADHERE study, a Phase IV 12-month open-label assessment of patients randomized to receive prolonged-release tacrolimus in combination with mycophenolate mofetil (MMF) (Arm 1) or sirolimus (Arm 2). From 838 patients in the randomized study, 587 were included in the long-term follow-up, of whom 510 completed the study at year 5. At 1 year post-transplant, graft and patient survival rates were 93.0% and 97.8%, respectively, and at 5 years were 84.0% and 90.8%, respectively. Cox proportional hazards analysis showed no association between graft loss, initial randomized treatment arm, donor age, donor type, or sex. The 5-year acute rejection-free survival rate was 77.4%, and biopsy-confirmed acute rejection-free survival rate was 86.0%. Renal function remained stable over the follow-up period: mean ± SD eGFR 4-variable modification diet in renal disease formula (MDRD4) was 52.3 ± 21.6 ml/min/1.73 m² at 6 months and 52.5 ± 23.0 ml/min/1.73 m² at 5 years post-transplant. These findings support the role of long-term once-daily prolonged-release tacrolimus-based immunosuppression, in combination with sirolimus or MMF, for renal transplant recipients in routine clinical practice.     

Girl Child Marriage and Its Effect on Fertility in Pakistan: Findings from Pakistan Demographic and Health Survey, 2006–2007

Child marriage (before 18 years) is prevalent in Pakistan, which disproportionately affects young girls in rural, low income and low education households. Our study aims to determine the association between early marriage and high fertility and poor fertility health indicators among young women in Pakistan beyond those attributed to social vulnerabilities. Nationally representative data from Pakistan Demographic and Health Survey, 2006–2007, a cross-sectional observational survey, were limited to ever-married women aged 20–24 years (n = 1,560; 15 % of 10,023) to identify differences in poor fertility outcomes [high fertility (three or more childbirths); rapid repeat childbirth (<24 months between births); unwanted pregnancy (any ever); pregnancy termination (any stillbirth, miscarriage or abortion ever)] by early (<18) versus adult (≥18) age at marriage. Associations between child marriage and fertility outcomes were assessed by calculating adjusted odds ratios (AORs) using logistic regression models after controlling for demographics, social equity indicators (education, wealth index, rural residence), contraception use, marriage duration and culture-specific factors (husband’s desire for more children, son preference). Overall, 50 % of ever-married women aged 20–24 years in Pakistan were married before the age of 18 years. Girl child marriage was significantly (p < 0.001) associated with low social equity indicators (poverty, rural residence, and no formal education). Adjusted logistic regression models showed that girl child marriage was significantly associated with high fertility (AOR 6.62; 95 % CI 3.53–12.43), rapid repeat childbirth (AOR 2.88; 95 % CI 1.83–4.54), unwanted pregnancy (AOR 2.90; 95 % CI 1.75–4.79), and pregnancy termination (AOR 1.75; 95 % CI 1.10–2.78). Girl child marriage affects half of all ever-married women aged 20–24 years in Pakistan, and increases their risk for high fertility and poor fertility health indicators, highlighting the need of increasing the age of marriage among women in Pakistan. Efforts to eliminate girl child marriage by strict law enforcement, promoting civil, sexual and reproductive health rights for women can help eliminate girl child marriage in Pakistan.     

Simultaneous combined use of flexible ureteroscopy and percutaneous nephrolithotomy to reduce the number of access tracts in the management of complex renal calculi

OBJECTIVE: To present early experience in managing complex renal calculi using a combined ureteroscopic and percutaneous approach, as complex and branched renal calculi often require multiple access tracts during percutaneous nephrolithotomy (PNL), and the combined use of flexible ureteroscopy and PNL has the potential to reduce the inherent morbidity of several tracts. PATIENTS AND METHODS: The study included seven patients (mean age 54 years) with multiple, branched, large-volume renal calculi suitable for management with PNL. Preoperative data, including patient demographics, stone location and stone surface area, were recorded. After informed consent, the patients underwent combined PNL and ureteroscopy in one session. Intraoperative data, including the location of PNL puncture sites, operative duration and complications, were analysed. Stone-free rates were determined by follow-up imaging at 3 months. RESULTS: All patients had either two or more stones in separate locations in the collecting system, or staghorn stones involving multiple calyces. The mean stone burden was 666 mm(2). All patients had only one percutaneous access tract. The mean operative duration was 142 min and the mean blood loss 79 mL. Two patients had small residual stones (< 3 mm), that required ureteroscopic intervention as they failed to pass spontaneously by 3 months after the initial combined procedure. The convalescence was similar to that in our current PNL practice; imaging showed that five of the patients were stone-free. CONCLUSIONS: Combined PNL and ureteroscopic management can effectively reduce the number of percutaneous access tracts which would otherwise be required for managing complex and branched renal calculi, as stones in an unfavourable location relative to the access tract can be relocated and fragmented within easy reach of the single nephrostomy tract. This manoeuvre reduces potential patient morbidity and blood loss but with no significant effect on stone-free rates and operative durations.     

Training junior operative residents in laparoscopic suturing skills is feasible and efficacious

BACKGROUND: Laparoscopic suturing has been regarded as an advanced operative task, and courses to develop this skill are aimed at senior trainees and consultants. This study evaluates the role of laparoscopic suturing courses in the modern operative training curriculum. METHODS: The performance of 9 senior operative trainees (course A) was compared to that of 14 junior operative trainees (course B) at identical, 2-day laparoscopic suturing courses. Pre- and post-course assessments measured time taken, dexterity, and quality for the placement of 1 intracorporeal suture on synthetic bowel. Post-course data was compared to the performance of a group of 6 experts. RESULTS: The median number of laparoscopic procedures carried out unassisted was 130 for surgeons on course A, and 0 for those on course B. At the pre-course assessment, senior trainees (course A) were significantly faster, more dexterous, and had higher checklist scores then those on course B. Both groups had improved significantly by the end of each the course. Post-course comparison between the 2 groups showed equivalent path length and checklist scores, although group A remained faster (P = .003) and made fewer movements (P = .033). Senior trainees had similar performance data to the group of expert surgeons, although this was not the case for junior trainees. CONCLUSIONS: Endoscopic suturing is a task that can be learned by operative trainees during short skills courses, regardless of baseline laparoscopic experience. Skills training in laparoscopic suturing should thus not be reserved only for those contemplating advanced laparoscopic operation.