RESUMEN
We report disseminated coccidioidomycosis in 3 transplant recipients from a donor in an endemic area found to have unrecognized meningeal coccidioidomycosis. All 3 transplant recipients presented within 3 weeks of receipt of their organ. Only 1 organ recipient survived the acute presentation of coccidioidomycosis. Serologic testing for Coccidioides immitis infection should be considered for organ donors residing in endemic areas.
Asunto(s)
Coccidioides/aislamiento & purificación , Coccidioidomicosis/transmisión , Fungemia/microbiología , Trasplante de Corazón/efectos adversos , Trasplante de Riñón/efectos adversos , Trasplante de Hígado/efectos adversos , Adulto , Anciano , Coccidioidomicosis/diagnóstico , Coccidioidomicosis/tratamiento farmacológico , Femenino , Fungemia/diagnóstico , Fungemia/tratamiento farmacológico , Humanos , Masculino , Persona de Mediana Edad , Donantes de Tejidos , Recolección de Tejidos y Órganos , Trasplantes/efectos adversos , Adulto JovenRESUMEN
Due to increasing use of allografts from donation after cardiac death (DCD) donors, we evaluated DCD liver transplants and impact of recipient and donor factors on graft survival. Liver transplants from DCD donors reported to UNOS were analyzed against donation after brain death (DBD) donor liver transplants performed between 1996 and 2003. We defined a recipient cumulative relative risk (RCRR) using significant risk factors identified from a Cox regression analysis: age; medical condition at transplantation; regraft status; dialysis received and serum creatinine. Graft survival from DCD donors (71% at 1 year and 60% at 3 years) were significantly inferior to DBD donors (80% at 1 year and 72% at 3 years, p < 0.001). Low-risk recipients (RCRR < or = 1.5) with low-risk DCD livers (DWIT < 30 min and CIT < 10 h, n = 226) achieved graft survival rates (81% and 67% at 1 and 3 years, respectively) not significantly different from recipients with DBD allografts (80% and 72% at 1 and 3 years, respectively, log-rank p = 0.23). Liver allografts from DCD donors may be used to increase the cadaveric donor pool, with favorable graft survival rates achieved when low-risk grafts are transplanted in a low-risk setting. Whether transplantation of these organs in low-risk recipients provides a survival benefit compared to the waiting list is unknown.
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Rechazo de Injerto/epidemiología , Supervivencia de Injerto , Trasplante de Hígado , Donantes de Tejidos , Cadáver , Muerte , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Obtención de Tejidos y ÓrganosRESUMEN
OBJECTIVE: To evaluate the authors' experience with periduodenal perforations to define a systematic management approach. SUMMARY BACKGROUND DATA: Traditionally, traumatic and atraumatic duodenal perforations have been managed surgically; however, in the last decade, management has shifted toward a more selective approach. Some authors advocate routine nonsurgical management, but the reported death rate of medical treatment failures is almost 50%. Others advocate mandatory surgical exploration. Those who favor a selective approach have not elaborated distinct management guidelines. METHODS: A retrospective chart review at the authors' medical center from June 1993 to June 1998 identified 14 instances of periduodenal perforation related to endoscopic retrograde cholangiopancreatography (ERCP), a rate of 1.0%. Charts were reviewed for the following parameters: ERCP findings, clinical presentation of perforation, diagnostic methods, time to diagnosis, radiographic extent and location of duodenal leak, methods of management, surgical procedures, complications, length of stay, and outcome. RESULTS: Fourteen patients had a periduodenal perforation. Eight patients were initially managed conservatively. Five of the eight patients recovered without incident. Three patients failed nonsurgical management and required extensive procedures with long hospital stays and one death. Six patients were managed initially by surgery, with one death. Each injury was evaluated for location and radiographic extent of leak and classified into types I through IV. CONCLUSIONS: Clinical and radiographic features of ERCP-related periduodenal perforations can be used to stratify patients into surgical or nonsurgical cohorts. A selective management scheme is proposed based on the features of each type.
Asunto(s)
Colangiopancreatografia Retrógrada Endoscópica , Duodeno/lesiones , Duodeno/cirugía , Complicaciones Intraoperatorias/terapia , Esfinterotomía Endoscópica , Adulto , Anciano , Duodeno/diagnóstico por imagen , Duodeno/patología , Femenino , Humanos , Complicaciones Intraoperatorias/diagnóstico , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
A major obstacle that limits the potential of human gene therapy is the inefficiency of gene delivery to appropriate sites in vivo. Previous studies demonstrated that the physiological surveillance function performed by von Willebrand factor (vWF) could be incorporated into retroviral vectors by molecular engineering of the MuLV ecotropic envelope (Env) protein. To advance the application of vWF targeting technology beyond laboratory animals, we prepared an extensive series of Env proteins bearing modified vWF-derived matrix-binding sequences and assembled these chimeric proteins into targeted vectors that are capable of transducing human cells. Initially, a dual envelope configuration was utilized, which required coexpression of a wild-type amphotropic Env. Subsequently, streamlined "escort" Env proteins were constructed wherein the inoperative receptor-binding domain of the targeting partner was replaced by the vWF-derived collagen-binding motif. Ultimately, an optimal construct was developed that exhibited properties of both extracellular matrix (ECM)-targeting and near wild-type amphotropic infectivity, and could be arrayed as a single envelope on a retroviral particle. On intraarterial instillation, enhanced focal transduction of neointimal cells (approximately 20%) was demonstrated in a rat model of balloon angioplasty. Moreover, transduction of tumor foci (approximately 1-3%) was detected after portal vein infusion of a matrix-targeted vector in a nude mouse model of liver metastasis. We conclude that the unique properties of these targeted injectable retroviral vectors would be suitable for improving therapeutic gene delivery in numerous clinical applications, including vascular restenosis, laser and other surgical procedures, orthopedic injuries, wound healing, ischemia, arthritis, inflammatory disease, and metastatic cancer.