Incidence, risk factors, and outcomes of delayed graft function in deceased donor kidney transplantation in a Brazilian center.

BACKGROUND: A high incidence of delayed graft function (DGF) after deceased donor kidney transplantation occurs in Brazil. The reasons for such have not been adequately studied. METHODS: We performed a retrospective cohort study of 346 kidney transplant recipients from deceased donors. DGF risk factors related to the recipient, donor, and transplantation surgery were analyzed and correlated with graft outcomes. A logistic regression analysis was used to identify independent risk factors and patient and graft survival were assessed using Kaplan-Meier curves. RESULTS: The incidence of DGF was 70.8% (245 cases). Our final model of multivariate analysis showed that DGF is associated (P < .05) with donor final serum creatinine (relative risk [RR], 1.84; 95% confidence interval [CI], 1.26-2.70), donor age (RR, 1.02 [1.0-1.033]), receiving a kidney from national offer (RR, 2.44 [1.06-5.59]), and need for antibody induction (RR, 2.87 [1.33-6.18]). Outcomes that were associated with DGF were longer length of hospital stay (32.5 ± 20.5 vs 18.8 ± 16.3 days; P = .01), higher incidence of acute rejection (37.8 vs 12.9%; P < .01), worse graft survival at 1 year (83.5% vs 93.9%; P < .01), and higher levels of serum creatinine at 3, 6, and 12 months (P < .05). There was no difference in patient survival and the occurrence of acute rejection did not influence the survival of patients or grafts. CONCLUSION: DGF was associated with higher donor final serum creatinine, donor age, receiving a kidney from the national supply, and need for antibody induction. Most importantly, DGF was associated with worse outcomes.

Cerebral uptake of morphine in the pig calculated from arterio-venous plasma concentration gradients: an alternative to tissue microdialysis.

The aim of this study was to characterize the reversible cerebral uptake of morphine in the pig by measuring the changing arterio-venous plasma concentration gradient over the brain. Seven pigs were anaesthetized by continuous infusions of ketamine and pancuronium and ventilated with oxygen in nitrous oxide. During and after 5-min intravenous infusions of morphine hydrochloride, blood samples were drawn from a central artery and from the internal jugular vein. Concomitantly, cerebral blood flow (CBF) was repeatedly measured as clearance of 133Xe from the brain after intracarotid injection. Plasma concentrations of morphine and, in samples from two animals, morphine glucuronides were assayed by high-performance liquid chromatography. Drug flux (Jnet) from arterial blood to brain was calculated from the arterio-venous plasma concentration gradients, the blood:plasma concentration ratio and CBF. Uptake of morphine from arterial blood to brain was very rapid, with a maximal Jnet typically at 3 min after the beginning of the infusion. The initial cerebral extraction of morphine was close to 50%. When the arterial and jugular venous concentration curves crossed, 1-5 min after the end of the infusion, the initially rapid uptake of morphine changed into a slow and steady release. The cerebral extraction of morphine glucuronides was comparable to that of morphine, however, Jnet was lower due to lower plasma concentrations at time of maximal extraction. The findings demonstrate how the cerebral uptake and release of morphine and its metabolites can be studied with a method that is entirely non-invasive to the brain and permits very flexible sampling. Uptake and release of drug is observed directly and need not be inferred from cerebral concentration curves.

Cerebral pharmacodynamics of anaesthetic and subanaesthetic doses of ketamine in the normoventilated pig.

There are still divergent opinions regarding the pharmacodynamic effects of ketamine on the brain. In this study, the cerebral blood flow (CBF), cerebral metabolic rate for oxygen (CMRO2) and electroencephalographic (EEG) activity were sequentially assessed over 80 min in 17 normoventilated pigs following rapid i.v. infusions of anaesthetic (10.0 mg.kg-1; n = 7) or subanaesthetic (2.0 mg.kg-1; n = 7) doses of ketamine or of its major metabolite norketamine (10.0 mg.kg-1; n = 3). The animals were continuously anaesthetized with fentanyl, nitrous oxide and pancuronium. CBF was determined by the intra-arterial 133Xe technique. Ketamine (10.0 mg.kg-1) induced an instant, gradually reverting decrease in CBF, amounting to -26% (P < 0.01) at 1 min and -13% (P < 0.05) at 10 min, a delayed increase in CMRO2 by 42% (P < 0.01) at 10 min and a sustained rise in low- and intermediate-frequency EEG voltage by 87% at 1 and 97% at 10 min (P < 0.0001). It is concluded that metabolically formed norketamine does not contribute to these effects. Considering the dissociation of CBF from CMRO2 found 10-20 min after ketamine (10.0 mg.kg-1) administration, it is suggested that ketamine should be used with caution for anaesthesia in patients with suspected cerebral ischaemia in order not to increase the vulnerability of brain tissue to hypoxic injury. Ketamine (2.0 mg.kg-1) had no significant effects on CBF, CMRO2 or EEG. It therefore seems that up to one fifth of the minimal anaesthetic i.v. dose can be used safely for analgesia, provided that normocapnaemia is preserved.

A course component to teach interviewing skills in informing and motivating patients.

In the present study, the authors implemented and evaluated a course component to teach three types of interviewing skills: giving information to patients, handling emotions on the part of patients, and motivating patients. The authors developed a seven-week course for second-year students that included identification and demonstration of explicit interviewing skills, practice with simulated patients, and feedback in a small-group setting. Thirty of the 104 students in the course were randomly selected for evaluation before and after the course. They showed statistically significant increases in their interviewing skills, based on ratings of videotaped interviews with simulated patients after the course, but did not change significantly in self-assessment of their level of confidence in aspects of conducting the interviews.

Trends in civilian vascular trauma during 30 years. A Swedish perspective.

Vascular injuries operated on during a 30-year period (1955-1984) were analyzed. There has been significant increase of such injuries, particularly the iatrogenic types. The total incidence per 100,000 population and year rose from 11.0 to 26.6. Various angiographic and catheterization techniques were responsible for the iatrogenic increase. The noniatrogenic vascular injuries not infrequently were part of multiple trauma, with fractures and a variety of penetrating wounds. Numerous operative techniques were used, increasingly with reconstructive surgery. The mortality rate did not change in the study period, but the rate of amputations and of various long-term sequelae diminished.

Extraanatomic vascular reconstruction in patients with aorto-iliac arteriosclerosis.

During an 11-year period 117 extraanatomic reconstructions were made for aorto-iliac arteriosclerosis; 36 axillofemoral and 81 femorofemoral crossover bypasses. The patients were old and had several factors making them poor risks for surgery. Axillofemoral grafts were more often used in patients with malignant disease. Postoperative mortality was 10% without difference between the two types of reconstruction. Both early and late complications were significantly more frequent in patients with axillofemoral bypass. Reoperations for occlusion and symptoms from the donor side also were significantly more common among axillofemoral patients. Life table analysis showed a higher survival and patency rate among patients with crossover grafts.

Pediatric interviewing skills taught by nonphysicians.

We cannot assume that medical students develop, through unstructured educational happenings, the skills of interviewing a mother about her child. Teaching these skills requires extensive one-to-one faculty-student involvement, which is almost prohibitive if pediatricians are expected to do this teaching. This article describes (1) a current pediatric interviewing teaching program that uses nonphysicians as teachers; (2) the selection and training of nonphysicians to teach the skill of pediatric interviewing to third-year medical students; and (3) an assessment of these teachers by comparing their techniques with those of three pediatric faculty members. The nonphysician teachers fared most favorably when their teaching methods were compared with those of three pediatricians. Acceptance of the program by the students, faculty, and administration has been most encouraging.