Effect of race on outcome after kidney and kidney-pancreas transplantation in type 1 diabetic patients

OBJECTIVE: The racial impact on graft outcome is not well defined in diabetic recipients. The purpose of this study is to analyze our experience with kidney-alone (A) and kidney-pancreas (KP) transplantation in type 1 diabetic recipients and evaluate the impact of racial disparity on outcome. RESEARCH DESIGN AND METHODS: The records of 217 kidney transplants (118 KA, 99 KP) performed on type 1 diabetic patients between 1985 and 1995 at the Medical University of South Carolina and the University of Texas Medical Branch were reviewed. RESULTS: A total of 53 (31%) white patients and 15 (33%) black patients experienced at least one episode of biopsy-proven acute rejection of the renal graft (NS). Patient survival at 1, 2, and 5 years was similar in white (92, 87, 69%) and black (91, 91, 69%) patients (NS). Kidney graft survival at 1, 2, and 5 years in the KA group was 72, 62, and 42% in blacks, compared with 79, 76, and 53% in whites (NS). Kidney graft survival at 1, 2, and 5 years in the KP group was 92, 92, and 74% in blacks, compared with 83, 77, and 58% in whites (NS). Pancreas graft survival at 1, 2, and 5 years was 81, 81, and 81% in blacks, compared with 81, 75, and 62% in whites (NS). Cox regression analysis revealed that donor age > or = 40 years increased the risk of renal graft failure 6.2-fold (P = 0.0001), whereas the addition of a pancreas transplant to a kidney and a living-related transplant decreased the risk of failure of the kidney graft 0.2 (P = 0.005) and 0.1 times (P = 0.005). CONCLUSIONS: Our results suggest that when compared with whites, there may be a trend toward an improved kidney and pancreas graft outcome in blacks undergoing KP transplants. These findings suggest that diabetes may override the risk factors that account for the pronounced disparity in outcome observed between nondiabetic white and black recipients.     

Reengineering a surgical service line: focusing on core process improvement

Integrating principles from a variety of theory has led to the development of a conceptual framework for reengineering in a clinical care delivery setting to improve the value of services provided to the customer. A conceptual framework involving the identification of three high level core processes to reengineer can provide clarity and focus for clinicians to begin directing reengineering efforts. Those core processes are: clinical management of the patient's medical needs, patient operational processes to support the clinical processes, and administrative decision-making processes to support the implementation of the clinical and operational processes. Improvement in any one of these areas has the potential to increase value, but the concurrent targeting of these core processes for reengineering has provided a synergy that has accelerated the achievement of the desired outcomes in the area of surgical services.     

Tuberculous duodenal obstruction--a case report

Proximal duodenal obstruction due to tuberculosis can masquarade as duodenal ulcer. Although commonest cause of duodenal obstruction is ulcer, other causes must be considered, particularly tuberculosis which is common in tropics.     

Stability of proximal femoral grafts in canine hip arthroplasty

In a canine model, the fixation stability of a prosthesis and proximal bone graft composite were measured relative to the distal femur. One group had the prosthesis graft composite cemented into the distal femur. The second group had the prosthesis graft composite press fit into the distal femur for biologic ingrowth. Displacements of the proximal femoral grafts relative to the host bone in each group were measured after ex vivo (acute with graft) implantation and 4 months after implantation. A third group with no osteotomy (acute intact) simulated perfect graft to host bone union. Relative displacements representing 6 degrees freedom (translation and rotation) were calculated from the displacement values measured by 9 eddy current transducers. Measurements of displacement were used to test the hypothesis that distal press fit fixation equals distal cement fixation at 4 months after implantation. In all cases the measured translations and rotations of the graft to implant construct were small and of a magnitude that should encourage bone ingrowth (< 0.05 mm and < 0.1 degree, respectively). The stability of the press fit group at 4 months was not significantly different from the cemented group in axial and transverse displacement during axial and transverse loading, respectively. There was no difference in stabilities at 4 months between distal press fit and cemented fixation in hip replacements requiring a proximal femoral graft.     

Migration of newly generated neurons upon ependymally derived radial guide cells in explant cultures of the adult songbird forebrain

The adult songbird forebrain undergoes neuronal production throughout adulthood, with the production of new neurons in discrete regions of the neostriatal ventricular zone. Upon mitogenesis, these new neurons migrate into the subjacent brain parenchyma along radially directed guide fibers. In long-term ventricular zone explant cultures, derived from the higher vocal center of the adult canary, newly migratory neurons were found to associate preferentially with a characteristic substrate cell type. These small, parvonuclear substrate cells formed tightly packed epithelioid sheets, in which ciliated ependymal cells were common, as recognized by both live observation and electron microscopy. A subpopulation of these cells was immunostained by monoclonal antibody 3A7, which preferentially stains the guide fiber network of the adult avian brain. These 3A7+ cells included ependymal cells and bipolar radial cells, as well as morphologically defined astrocytes. As they matured in vitro, the 3A7+ bipolar radial cells extended long, unbranching fibers, which ultimately traversed the culture substrate. Like ependymal cells, they supported neuronal migration. These cells were likely homologous to radial guide cells in vivo. Thus, neuronal migration in adult avian forebrain culture occurred upon guide cells of ependymal derivation.     

Psychological interventions to prevent HIV infection are urgently needed: New priorities for behavioral research in the second decade of AIDS.

Behavior change remains the only means for primary prevention of HIV disease. Psychology should take a leading role in efforts to curtail the epidemic, but has not contributed to HIV prevention at a level proportionate to the urgency of the crisis. The authors propose an updated agenda for behavioral research on AIDS-HIV prevention implementing accelerated community trials of promising behavior change models, conducting trials of community-level interventions on a large scale and focused on populations most vulnerable to HIV infections, establishing partnerships between HIV research and community service organizations, integrating efforts from across psychology disciplines to advance and refine HIV prevention interventions, and mobilizing interdisciplinary HIV prevention resources and communication mechanisms to rapidly translate research findings to community and public policy arenas. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Acromioclavicular joint cyst and rotator cuff tear

The role of a depressor factor, atrial natriuretic peptide, in the development of arterial hypertension in adolescents with pubertal hypothalamic syndrome was studied in 52 patients and 13 healthy males aged 13-24 years. The duration of disease was 2-11 years. Radioimmunological methods were used to measure plasma atrial natriuretic peptide, plasma renin activity, and serum aldosterone. Patients with borderline arterial hypertension were found to have a significant reduction in their atrial natriuretic peptide levels, and this correlated directly with the renin-aldosterone system, demonstrating insufficiency of the depressor system in patients with pubertal hypothalamic syndrome and the involvement of atrial natriuretic peptide in the development of arterial hypertension, along with disturbances in the functional relationship between atrial natriuretic peptide and the renin-aldosterone system.     

Transplantation for end stage liver disease related to alpha 1 antitrypsin

Alpha 1 antitrypsin deficiency (AT) is an autosomal recessive disease associated with chronic liver disease in adults and children and emphysema in adults. The disease is one of the most common inherited disorders of the Caucasian population of North Europe and North America and is the most common genetic reason for pediatric orthotopic liver transplantation (OLTx), although it is a rare indication in adults. The natural history of the disease is unpredictable and the pathogenesis of the liver injury unclear. Thirty-five patients with histologically apparent alpha 1 AT accumulation in the liver (22 adults, 13 children) have been transplanted in this center. Clinical features were correlated with the pretransplant phenotype, serum alpha 1 antitrypsin levels and potential precipitating factors. All children were PiZZ homozygotes, most of whom had presented with neonatal hepatitis. The majority of adult patients were heterozygotes presenting with portal hypertension and liver cirrhosis. Current one-year posttransplant survival figures are 73% for adults and 87.5% for children. Replacement of the cirrhotic liver results in acquisition of the donor phenotype, a rise in serum levels of alpha 1 antitrypsin, and apparent prevention of associated disease.     

Gynecologic problems in older women

Regular gynecologic evaluation in older women is an integral part of medical care, just as it is for women of reproductive age. This should be emphasized since older women often neglect early symptoms of gynecologic diseases, some of which are potentially lethal. With this in mind, the health care provider must be cognizant of not only gynecologic problems that affect all women, but also those disease processes which are either specific to or more prevalent in an older population. This article emphasizes these aspects in caring for the older gynecologic patient.