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BACKGROUND: We investigated the effect of clinical and subclinical T cell-mediated rejection (C-TCMR and SC-TCMR) on allograft histology, function, and progression. METHODS: Adult kidney recipients with 2 protocol biopsies were divided into No-TCMR on biopsies (n = 104), SC-TCMR (n = 56), and C-TCMR (n = 32) in at least 1 biopsy. Chronicity (ci + ct + cg + cv) scores, renal function, and the burden of renal disease measured by area under the curve (serum creatinine, mg mo/dL) were compared. RESULTS: Baseline characteristics were similar except for mean donor age and Kidney Donor Profile index scores. Patients with C-TCMR had higher mean serum creatinine, lower mean estimated glomerular filtration rate, and higher area under the curve with 95% confidence interval (75.2 [67.7-82.7]) as opposed to patients with SC-TCMR and No-TCMR (58.3 [53.6-62.9], 65.1 [58.8-71.5]), P = 0.0004. Chronicity scores were higher at 3 months in C-TCMR (2.30 ± 1.58) compared with SC-TCMR (2.02 ± 1.42) and No-TCMR (1.31 ± 1.18), P = 0.0001 and also at 12 months. At last follow-up, 18.8% patients with C-TCMR had ≥50% decline in estimated glomerular filtration rate from 3 months compared with 7% and 1% among No-TCMR and SC-TCMR groups (P = 0.038). Multivariate analyses revealed higher odds of Δ-creatinine ≥ 0.5 mg/dL from 3 months to last follow-up for C-TCMR (3.39 [95% confidence interval, 1.25-9.20]) versus No-TCMR (P = 0.016). CONCLUSIONS: Kidney transplant recipients with C-/SC-TCMR have heightened early allograft chronicity and worse renal function compared with those with No-TCMR. Progressive renal dysfunction was noted among patients with C-TCMR as opposed to SC-TCMR and No-TCMR.
Assuntos
Rejeição de Enxerto/imunologia , Imunidade Celular , Nefropatias/imunologia , Transplante de Rim/efeitos adversos , Rim/imunologia , Linfócitos T/imunologia , Adulto , Biópsia , Creatinina/sangue , Progressão da Doença , Feminino , Taxa de Filtração Glomerular , Rejeição de Enxerto/diagnóstico , Rejeição de Enxerto/fisiopatologia , Humanos , Rim/patologia , Rim/fisiopatologia , Nefropatias/diagnóstico , Nefropatias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Medição de Risco , Fatores de Risco , Transdução de Sinais , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: Study the prevalence of otologic disease in a pediatric post-palatoplasty population with no prior ear tube placement in resource-deprived countries and assess patient characteristics associated with these abnormal results. DESIGN: Retrospective data review. PARTICIPANTS: Ecuadorian and Chinese children identified during humanitarian cleft lip and palate repair trips with cleft palates undergoing palatoplasty from 2007 to 2010. INTERVENTIONS: Tympanometry and otoacoustic emission (OAE) testing performed following palatoplasty. Patients' parents administered surveys regarding perceived hearing deficits. MAIN OUTCOME MEASURES: Age, gender, Veau classification, follow-up time, laterality, and country of origin were evaluated for possible association with type B tympanogram, "Refer" Otoacoustic results, and presence of hearing difficulty as identified by a parent. Significant predictors were further evaluated with multivariate analysis. RESULTS: The cohorts included 237 patients (129 Ecuadorian, 108 Chinese); mean age: 3.9 years; mean follow-up: 4.2 years. Thirty-nine percent scored type B, 38% failed OAE testing, and 8% of parents noted hearing deficits. The country of origin and a younger age were identified as predictive variables regarding type B tympanogram. Follow-up time, country of origin, and bilateral OAE "Refer" results all significantly predicted parental questionnaire results. Subsequent multivariable analysis further demonstrated effect modification between the 2 variables of age at palatoplasty and country of origin when predicting type B vs type A tympanometry. CONCLUSION: Without otologic intervention, cleft palate children in resource-deprived settings suffer type B tympanometry and failed OAE results with similar to increased incidences to other studied cleft palate populations with otologic interventions available.
Assuntos
Fissura Palatina/cirurgia , Otopatias/etiologia , Complicações Pós-Operatórias/etiologia , Testes de Impedância Acústica , Pré-Escolar , China/epidemiologia , Otopatias/diagnóstico , Otopatias/epidemiologia , Equador/epidemiologia , Feminino , Humanos , Masculino , Missões Médicas , Emissões Otoacústicas Espontâneas , Complicações Pós-Operatórias/epidemiologia , Prevalência , Estudos Retrospectivos , Inquéritos e Questionários , Resultado do TratamentoRESUMO
Substantial strides have been made in improving the short-term success after kidney transplantation. Although there has been some progress, there has not been a robust improvement with respect to long-term outcomes. However, there remain many potentially modifiable transplant-specific risks to long-term patient and graft survival. In this chapter, we detail the current state of five important short-term transplant-specific clinical events. The early post-transplant events that negatively impact long-term survival discussed in this chapter are: acute T cell mediated rejection, acute antibody mediated rejection, delayed graft function, post-transplant viral infections, and recurrent and de novo diseases after transplantation. This chapter focuses on unmet needs and outlines important goals, specific to each of the topics, that hold promise for achieving better long-term graft survival in kidney transplant patients. Consistent across all five areas are: the need for better standardization and improvement in diagnosis and testing, identification of relevant clinical surrogate markers in the design of new studies, newer immunosuppressive agents, anti-viral agents and targeted therapy for certain diseases, and innovative newer clinical trials. A multifaceted approach will further enhance long-term kidney transplant survival.
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BACKGROUND: International organizations have performed palatoplasties in low- and middle-income countries for decades, often working with local providers. Few studies report long-term outcomes, especially for palatal fistulas. A fistula after palatoplasty may affect speech, socialization, and nutrition. Fistula rates on surgical missions have not been compared with rates at U.S. craniofacial centers nor have the rates of the visiting and local surgeons working on missions been compared. METHODS: Fistula rates for two Ecuadorian cohorts were compared with fistula rates for a craniofacial center in the United States. In Ecuador, North American surgeons repaired one cohort (n = 46) and Ecuadorians the other (n = 82) during 2000 through 2005. Ecuadorian patients were evaluated during 2007 and 2008. The center's clinical database (n = 189) provided U.S. cohort data. RESULTS: On missions, the fistula rates were 57 percent (95 percent CI, 46 to 68 percent) for Ecuadorian surgeons and 54 percent (95 percent CI, 39 to 69 percent) for North American surgeons. The rate was 2.6 percent (95 percent CI, 0.8 to 6.0 percent) at the U.S. craniofacial center. There was no difference between the two Ecuadorian cohorts' rates (p = 0.75), but they were significantly higher than those of the U.S. cohort (p < 0.001). Having a cleft lip together with cleft palate was associated with fistula formation, whereas surgeon nationality and older age at surgery were not. CONCLUSIONS: The fistula rate on Ecuadorian missions, regardless of the surgeon's nationality, was significantly higher than in the United States. Further investigation into the causes of this higher fistula rate in this population is needed. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
Assuntos
Fenda Labial/cirurgia , Fissura Palatina/cirurgia , Fístula/epidemiologia , Missões Médicas , Palato/cirurgia , Complicações Pós-Operatórias/epidemiologia , Pré-Escolar , Estudos de Coortes , Equador , Feminino , Hospitais Especializados , Humanos , Lactente , Masculino , Estudos Retrospectivos , Estados UnidosRESUMO
Occlusion or stenosis of a parent vessel or its distal branches is a major cause of poor patient outcome after cerebral aneurysm surgery. Despite great attempts to preserve patency at the time of clip application, intraoperative visual observation may not reveal arterial compromise or occlusion. Quantitative measurement of blood flow in cerebral vessels during aneurysm surgery can help prevent ischaemia and improve patient outcome. We report a case of a large complex middle cerebral artery (MCA) aneurysm in which perivascular microflow probes were used to measure blood flow quantitatively in MCA and its branches before and after aneurysm clipping. Following aneurysm clipping, blood flow in the MCA branches were significantly reduced to less than its initial baseline value with occlusion of the inferior M2 segment. Prompt detection of compromised blood flow gave the surgeon the opportunity to adjust the clip. This adjustment was performed several times until restore MCA flow to its preclipping values. Intraoperative quantitative vessel-flow measurements were safe and may have prevented cerebral ischaemia and neurological deficit to this patient.
Assuntos
Encéfalo/irrigação sanguínea , Aneurisma Intracraniano/cirurgia , Monitorização Intraoperatória/métodos , Instrumentos Cirúrgicos , Ultrassom , Adulto , Angiografia Cerebral , Humanos , Masculino , Monitorização Intraoperatória/instrumentação , Fluxo Sanguíneo Regional/fisiologia , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
A medida quantitativa do fluxo sanguíneo nos vasos cerebrais durante a cirurgia de aneurisma pode ajudar na prevenção de eventos isquêmicos e, portanto, melhorar os resultados. Relatamos o caso de paciente portador de aneurisma grande e complexo da bifurcação da artéria de cerebral média (ACM), no qual foram usadas micro-sondas ultrasônicas perivasculares para medir o fluxo de sangue quantitativamente na ACM e nos seus ramos antes e depois da clipagem do aneurisma. Após a clipagem do aneurisma, o fluxo de sangue diminuiu em todos os ramos, fazendo-se necessário o reajuste do clipe. Após vários ajustes na posição do clipe, o fluxo sanguíneo nos segmentos da ACM foi restabelecido. A descoberta imediata da alteração do fluxo de sangue proporcionou a oportunidade ao cirurgião de ajuste do clipe e conseqüentemente o restabelecimento do fluxo a valores compatíveis àqueles antes da clipagem. O uso de micro-sondas ultrasônicas perivasculares para medida do fluxo sanguíneo durante a cirurgia de aneurisma pode prevenir eventos isquêmicos e eventualmente déficits neurológicos.
Assuntos
Adulto , Humanos , Masculino , Encéfalo/irrigação sanguínea , Aneurisma Intracraniano/cirurgia , Monitorização Intraoperatória/métodos , Instrumentos Cirúrgicos , Ultrassom , Angiografia Cerebral , Monitorização Intraoperatória/instrumentação , Fluxo Sanguíneo Regional/fisiologia , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
OBJECTIVE: To determine in black and white youths the degree to which fatness and cardiovascular fitness (CVF) explained independent proportions of the variance in fasting insulin concentrations. STUDY DESIGN: Youths 14 to 18 years of age (n = 278) were studied. Insulin was measured after a 12-hour fast. Percent body fat (%BF) was measured with dual-energy x-ray absorptiometry. CVF was determined with a multistage treadmill test. RESULTS: Girls had higher %BF and lower CVF than boys. Whites were higher in CVF than blacks. There was a race by sex interaction for fasting insulin concentration, such that black girls had the highest and white girls had the lowest concentrations. When %BF and CVF was controlled statistically, this interaction was no longer significant. Multiple regression models that controlled for race, sex, and their interaction showed that (1) both higher %BF and lower CVF were significantly associated with higher insulin concentrations; (2) there were significant interactions with sex, such that the deleterious effects of low CVF and high %BF were greater in boys than in girls; (3) there was a significant CVF-%BF interaction, such that youths who were both fit and lean had especially low insulin concentrations; and (4) sex-specific regressions showed that both %BF and CVF explained significant independent proportion of the insulin variance for the boys but that only %BF did so for the girls. CONCLUSIONS: Interventions to prevent hyperinsulinemia in youths should be designed both to minimize fatness and maximize CVF.