A deeply invasive Phoma species infection in a renal transplant recipient.

Phoma sp, a fungus routinely isolated from the soil and a known plant pathogen, was found to be the cause of an aggressive, deep compartment hand infection in a renal transplant recipient. Previous reports have described minimally invasive Phoma sp infections with isolates recovered from the skin or subcutaneous tissue. This case, however, is the first reported in which Phoma sp was found to be both aggressive and deeply invasive. Histologic sections obtained from the synovium of the fourth and fifth dorsal hand compartments revealed invasive hyphal elements. Detailed examination with Grocott-Gomori methenamine-silver staining revealed branching filaments and pycnidia. A Phoma sp was isolated from culture after 2 weeks of incubation. Antifungal agent sensitivity testing found the organism to be sensitive to amphotericin B but resistant to both fluconazole and 5-flucytosine. Treatment required surgical debridement and the use of prolonged systemic amphotericin B therapy in order to effect cure. This is a unique case of a deeply invasive Phoma sp infection, indicating that such processes are not strictly indolent as previously reported.

A decision support simulation model for the management of an elective surgery waiting system.

This paper describes the design of a simulation model to provide decision support for the scheduling of patients waiting for elective surgery in the public hospital system. Patients nominated for surgery by doctors are categorised by urgency and type of operation. The simulation model can be used as an operational tool to match hospital availability and patient need. It can also be used to report upon the performance of the system, and as a planning tool to compare the effectiveness of alternative policies in this multi-criteria decision environment.

Heart transplantation for patients over age 60.

As the proportion of people over age 60 in our society continues to rise, so does the number of potential heart transplant candidates. Advanced recipient age, however, has long been used as an exclusion criterion for transplantation, though the upper age limit remains poorly defined. The purpose of our study was to analyze the outcomes of 31 heart transplant recipients over age 60 at our institution. They were followed with regard to early and late morbidity and mortality. Mean follow-up time was 50 months. The 1- and 5-yr survival rates were 90% and 85%. These rates were not significantly different compared with younger (age 18 to 59) recipients transplanted in the same time period. The older recipients more frequently developed osteoporotic changes as well as cutaneous and visceral malignancies, but had infrequent rejection episodes. Overall, heart transplantation is safe and effective for patients over age 60 with end-stage congestive heart failure. Both 1- and 5-yr survival rates are well within the acceptable range and do not differ significantly from younger recipients. Individualized immunosuppression might help reduce the incidence of malignancy in older recipients, but further studies are needed. Matching donor and recipient age would make the best use of available organs.

Noninvasive diagnosis of cardiac allograft rejection in an orthotopic canine model.

BACKGROUND: A decline in the R wave voltage obtained from surface electrocardiograms once correlated with cardiac allograft rejection. With cyclosporine therapy, however, these electrocardiographic findings became inconsistent, occurring only during severe rejection episodes. Despite cyclosporine use, intramyocardial unipolar peak-to-peak amplitudes obtained from plunge electrodes are reported to be highly sensitive and specific for diagnosing rejection. These reports are based on heterotopic grafts, which atrophy over time, making long-term voltage changes during rejection difficult to interpret. The purpose of this study was to use analysis of unipolar peak-to-peak amplitudes as a prospective monitoring tool for diagnosing orthotopic cardiac allograft rejection. METHODS: Ten adult mongrel dogs underwent orthotopic heart transplantation with the attachment of four intramyocardial leads. The unipolar peak-to-peak amplitudes were measured daily and compared with endomyocardial biopsy results. RESULTS: We found that intramyocardial unipolar peak-to-peak amplitude analysis had a sensitivity and a specificity of 100% for diagnosing rejection. We also found that as the number of myocardial leads increased, the sensitivity of detecting rejection also increased. CONCLUSIONS: We conclude that unipolar peak-to-peak amplitude analysis is an accurate noninvasive means for early detection of cardiac allograft rejection in an orthotopic model. Its success should allow less frequent, more selective use of endomyocardial biopsy.

Mycoplasma hominis infections occurring in cardiovascular surgical patients.

BACKGROUND: Postoperative Mycoplasma hominis sternal would or mediastinal infections are uncommon and difficult to diagnose. Atypical growth characteristics in routine bacterial culture, and the inability to demonstrate the organism on Gram stain, lead to delayed diagnosis of M hominis infections and increased morbidity. METHODS: Postoperative purulent would drainage or acute mediastinitis caused by M hominis developed in 3 cardiovascular surgery patients. These patients were considered along with 9 patients previously reported in the literature. RESULTS: Operative findings included moderately thick, gray purulent fluid with the degree of tissue necrosis related to duration of infection. Intraoperative Gram stain of wound or mediastinal drainage demonstrated no microorganisms, and initial bacterial cultures did not reveal microbial growth. After an average of 4.5 days of culture, minute translucent colonies of M hominis were identified. The institution of appropriate antimycoplasma therapy (doxycycline and clindamycin) was associated with clinical or microbiological cure in all patients. Sternal wound complications developed in 3 patients, and a chronic infection developed in 1 patient. CONCLUSIONS: Empiric therapy for M hominis infection should be considered in patients with mediastinitis or a sternal wound infection in which organisms are not observed on Gram stain and are not readily cultured.

A model of unilateral pulmonary lobar transplantation.

Unilateral lung transplantation has become an accepted treatment for patients with end-stage pulmonary disease. Donor shortage, however, is a major limitation, with up to 87% of patients dying of their pulmonary disease while awaiting transplantation. This is especially true in neonatal and pediatric patient populations. The use of organ segments from cadaveric or living donors may provide a solution. The purpose of this study, therefore, was to evaluate the function and hemodynamic response to pulmonary lobar transplantation using a swine model. Five transplants were performed for acute study, while 10 were performed for 6-week survival. The left lower lobe was harvested from a 70- to 75-kg donor animal. The lobe was then transplanted into a 20 to 25-kg recipient following left pneumonectomy. Graft function was determined by pulmonary arterial and venous blood gas analysis. Cardiac output, pulmonary pressure, and pulmonary vascular resistance were measured under two experimental conditions: (1) baseline and (2) with the right pulmonary artery occluded, forcing the entire cardiac output through the lobar graft. All grafts showed excellent acute and long-term function with regard to gas exchange. The lobar grafts, however, were characterized by high pulmonary vascular resistance both acutely and 6 weeks post-transplant. Contralateral pulmonary artery occlusion resulted in hemodynamic instability and right heart failure. No animal was able to be solely supported by the lobar transplant for more than one hour. These results have prompted a bilateral lobar transplant model and current studies are in progress.

Noninvasive diagnosis of cardiac allograft rejection: the effect of procainamide.

The surface electrocardiogram (ECG) has been used as a noninvasive technique for the diagnosis of cardiac allograft rejection. Alteration in conduction, R-wave amplitude, and rhythm have been associated with rejection. These ECG findings are modulated by the myocyte sodium channel, but are inconsistent and occur only during severe rejection episodes. The purpose of this study was to (1) characterize changes in cardiac electrophysiology during allograft rejection using the highly sensitive intramyocardial electrocardiogram and (2) determine whether pharmacological sodium channel blockade with procainamide enhances subtle ECG changes. Nine mongrel dogs underwent heterotopic heart transplantation in which four intramyocardial leads (one anteriorly and posteriorly on each ventricle) were attached. Leads exited to a subcutaneously placed ECG block which was transcutaneously accessed posttransplant to record direct intramyocardial electrocardiograms. Six animals were treated with procainamide, while three were not and served as controls. Daily measurements included the QRS, QT, and QTc intervals and the R-wave amplitude. Endomyocardial biopsies were performed weekly and also when significant decline in ECG amplitude occurred. Detailed ECG interval analysis failed to establish any correlation between conduction and rejection, even in the procainamide-treated group. Intramyocardial amplitude analysis, however, had a sensitivity of 100% and a specificity of 86% for the diagnosis of rejection. The results indicate that intramyocardial ECG interval analysis is not predictive of rejection even when prolonging conduction with procainamide. Amplitude analysis, however, remains an accurate noninvasive means for the early detection of cardiac allograft rejection and should allow more selective use of endomyocardial biopsy.

Suicide right ventricle after lung transplantation for Eisenmenger syndrome.

Right ventricular outflow tract obstruction, or "suicide right ventricle," rarely has been observed after single or bilateral single-lung transplantation for the treatment of Eisenmenger syndrome. We describe our experience in 2 patients with Eisenmenger syndrome in whom right ventricular outflow tract obstruction developed, in 1 after single-lung transplantation and ventricular septal defect repair and in the other after bilateral single-lung transplantation. Both patients suffered progressive deterioration and hemodynamic instability that was unresponsive to aggressive medical therapy. Diagnosis was confirmed in both patients by transesophageal echocardiography. Operative intervention was undertaken 72 and 24 hours after transplantation, and consisted of myectomy and outflow tract patching. One patient survived; the other died intraoperatively. The index of suspicion for this problem should be high during the intraoperative performance of transesophageal echocardiography, as well as during direct gradient measurement, with consideration of immediate management of severe right ventricular outflow tract obstruction at the time of transplantation.

Characterization and impact of wound infection after pancreas transplantation.

OBJECTIVE: To characterize the incidence, microbial pathogenesis, risk factors, and impact of wound infection after pancreas transplantation. DESIGN: Retrospective analysis. SETTING: A large university hospital. PATIENTS: From January 1, 1990, to September 30, 1993, 197 patients underwent 207 consecutive pancreas transplantation procedures. MAIN OUTCOME MEASURES: Wound infection and patient and allograft survival rates at 1 year. RESULTS: Sixty-nine patients (33%) suffered wound infections: 21 (10%) were superficial; 31 (15%), deep; and 17 (8%), combined. Most (74%) wound infections were monomicrobial. Staphylococcus epidermidis and Candida species were the most common pathogens. Prolonged operating time, older donors, and enteric drainage were associated with higher wound infection rates. Deep and combined wound infections led to allograft loss despite subsequent salvage procedures. Combined wound infection was associated with significantly higher mortality. CONCLUSIONS: A deep wound infection should be an indication for allograft removal. Antifungal prophylaxis, stringent donor criteria, and delayed primary wound closure should lower the incidence of wound infection.

Discrimination Measures Using Contingency Tables.

Discrimination in organizations based on race or sex is a contentious issue. Sensible discussion of the issue will be enhanced by the availability of measures of discrimination enabling comparisons to be made between organizations and across time. Linear models are of limited validity. A contingency table approach is suggested. Given an observed distribution of categorical variables (such as rank, sex and qualifications) loglinear modelling of the odds ratios across ranks enables maximum likelihood measures distinguishing direct and total discrimination to be established. The analogy between item bias and direct discrimination is discussed, and the proposed maximum likelihood measure of direct discrimination is compared with the Mantel-Haenszel estimator and with a measure derived by collapsing fitted subtables. The proposed discrimination measure can be shown to have a chi-square distribution, and therefore can readily be tested for significance. The methods are illustrated by applying them to examine the extent of sex discrimination in the ranks of staff within an Australian university, but can readily be used to measure discrimination in respect of a sub-group in any employment or membership context.

Factor Comparability As A Means Of Determining The Number Of Factors And Their Rotation.

Several methods, mostly based on a consideration of the eigenvalues, have been previously used to determine the number of factors to retain in a factor analysis. This paper shows how split-half factor comparabilities, based on factor scores, can provide a direct and unambiguous method of determining the number of reliable factors that should be retained, and of assessing the appropriate rotation that should be used. The method is particularly appropriate for taxonomic factor analysis, where the factor scores are to be used as summary or classificatory measures. It is shown that, for respondents from non-homogenous populations, split-halves based on the sub-populations should be considered, as well as random split-halves. The discussion is supported by a number of principal components analyses, using synthetic data sets of known factor structure and an actual semantic response data bank.

An investigation of the incidence of cardiac murmurs in young health women.

Healthy women students who asked for oral contraceptives were carefully examined to ascertain whether they had a cardiac murmur. Over 52 per cent of the 509 women examined had such a murmur and of these murmurs 3-4 per cent were thought to have an organic origin.