Timing of Pregnancy After Kidney Transplantation and Risk of Allograft Failure.

The optimal timing of pregnancy after kidney transplantation remains uncertain. We determined the risk of allograft failure among women who became pregnant within the first 3 posttransplant years. Among 21 814 women aged 15-45 years who received a first kidney-only transplant between 1990 and 2010 captured in the United States Renal Data System, n = 729 pregnancies were identified using Medicare claims. The probability of allograft failure from any cause including death (ACGL) at 1, 3, and 5 years after pregnancy was 9.6%, 25.9%, and 36.6%. In multivariate analyses, pregnancy in the first posttransplant year was associated with an increased risk of ACGL (hazard ratio [HR]: 1.18; 95% confidence interval [CI] 1.00, 1.40) and death censored graft loss (DCGL) (HR:1.25; 95% CI 1.04, 1.50), while pregnancy in the second posttransplant year was associated with an increased risk of DCGL (HR: 1.26; 95% CI 1.06, 1.50). Pregnancy in the third posttransplant year was not associated with an increased risk of ACGL or DCGL. These findings demonstrate a higher incidence of allograft failure after pregnancy than previously reported and that the increased risk of allograft failure extends to pregnancies in the second posttransplant year.

The survival benefit of kidney transplantation in obese patients.

Obese patients have a decreased risk of death on dialysis but an increased risk of death after transplantation, and may derive a lower survival benefit from transplantation. Using data from the United States between 1995 and 2007 and multivariate non-proportional hazards analyses we determined the relative risk of death in transplant recipients grouped by body mass index (BMI) compared to wait-listed candidates with the same BMI (n = 208 498). One year after transplantation the survival benefit of transplantation varied by BMI: Standard criteria donor transplantation was associated with a 48% reduction in the risk of death in patients with BMI ≥ 40 kg/m(2) but a ≥ 66% reduction in patients with BMI < 40 kg/m2. Living donor transplantation was associated with ≥ 66% reduction in the risk of death in all BMI groups. In sub-group analyses, transplantation from any donor source was associated with a survival benefit in obese patients ≥ 50 years, and diabetic patients, but a survival benefit was not demonstrated in Black patients with BMI ≥ 40 kg/m(2). Although most obese patients selected for transplantation derive a survival benefit, the benefit is lower when BMI is ≥ 40 kg/m(2), and uncertain in Black patients with BMI ≥ 40 kg/m(2).

Quantification of the early risk of death in elderly kidney transplant recipients.

To inform decision making regarding transplantation in patients ≥ 65 years, we quantified the early posttransplant risk of death by determining the time to equal risk and equal survival between transplant recipients and wait-listed dialysis patients in the United States between 1995 and 2007 (total n = 25 468). Survival was determined using separate multivariate nonproportional hazards analyses in low-, intermediate- and high-risk cardiovascular risk patients. Compared to wait-listed patients with similar cardiovascular risk, standard criteria (SCD) and expanded criteria (ECD) recipients had a higher risk of death in the perioperative and early-posttransplant period. In contrast, low and intermediate risk living donor (LD) recipients had an immediate survival advantage compared to similar risk wait-listed patients. In all risk groups, transplantation was associated with a long-term survival advantage compared to dialysis, but there were marked differences in time to equal risk of death, and time to equal survival by donor type. For example, survival in high-risk recipients of an LD, SCD and ECD transplant became equal to that in similar risk wait-listed patients 130, 368 and 521 days after transplantation. Early posttransplant mortality risk is eliminated in low- and intermediate-risk patients, and markedly reduced in high-risk patients with LD transplantation.

Income of living kidney donors and the income difference between living kidney donors and their recipients in the United States.

Disincentives for living kidney donation are common but are poorly understood. We studied 54 483 living donor kidney transplants in the United States between 2000 and 2009, limiting to those with valid zip code data to allow determination of median household income by linkage to the 2000 U.S. Census. We then determined the income and income difference of donors and recipients. The median household income in donors and recipients was $46 334 ±$17 350 and $46 439 ±$17 743, respectively. Donation-related expenses consume ≥ 1 month's income in 76% of donors. The mean ± standard deviation income difference between recipients and donors in transplants involving a wealthier recipient was $22 760 ± 14 792 and in 90% of transplants the difference was <$40 000 dollars. The findings suggest that the capacity for donors to absorb the financial consequences of donation, or of recipients to reimburse allowable expenses, is limited. There were few transplants with a large difference in recipient and donor income, suggesting that the scope and value of any payment between donors and recipients is likely to be small. We conclude that most donors and recipients have similar modest incomes, suggesting that the costs of donation are a significant burden in the majority of living donor transplants.

The impact of pancreas transplantation on kidney allograft survival.

Whether pancreas after kidney transplantation (PAK) compromises kidney allograft survival, and what pre-PAK glomerular filtration rate (GFR) should be used to select patients for PAK is unclear. We analyzed all (n = 2776) PAK recipients in the United States between 1989 and 2007 and compared their risk of kidney failure to a comparator group of n = 13 635 young adult diabetic kidney only transplant recipients during the same time after accounting for selection bias by the use of a propensity score for PAK in a multivariate time to event analysis. In a secondary analysis, we determined the association of pre-PAK GFR with subsequent kidney allograft survival. Despite an increased risk of death early after pancreas transplantation, PAK recipients had a decreased long-term risk of kidney allograft failure compared to diabetic kidney only transplant recipients HR = 0.89; 95% CI: [0.78-1.00]; p = 0.05. An association of pre-PAK GFR with kidney survival was not evident until 3 years after pancreas transplantation, and patients with a pre-PAK GFR of 30-39 mL/min still attained 10-year post-PAK kidney survival of 69%. We conclude that PAK is associated with improved kidney allograft survival, and pre-PAK GFR 30-39 mL/min should not preclude PAK. Expanded use of PAK is warranted.

A community-based long-term follow up of women undergoing obstetric fistula repair in rural Ethiopia.

OBJECTIVES: To assess urinary and reproductive health and quality of life following surgical repair of obstetric fistula. DESIGN: Follow-up study. SETTING: A newly established fistula clinic (2004) at Gimbie Adventist Hospital, a 71-bedded district general hospital in West Wollega Zone, in rural Western Ethiopia. POPULATION: Thirty-eight women (86%) of 44 who had undergone fistula repair were identified in their community. METHODS: Community-based structured interviews 14-28 months following fistula repair, using a customised questionnaire addressing urinary health, reproductive health and quality of life. MAIN OUTCOME MEASURES: Urinary health at follow up was assessed as completely dry, stress or urge incontinence, or fistula. King's Health Questionnaire was modified and used for the quality-of-life assessment. RESULTS: At follow up, 21 women (57%) were completely dry, 13 (35%) suffered from stress or urge incontinence and three (8%) had a persistent fistula. Surgery improved quality of life and facilitated social reintegration to a level comparable to that experienced before fistula development for both women who were dry and those with residual incontinence (P = 0.001). For women still suffering from fistula no change was seen (P = 0.1). Four women became pregnant following their surgery, among which there was one maternal death, three stillbirths and one re-occurrence of fistula. CONCLUSION: Community-based, long-term follow up after fistula repair succeeded in Western rural Ethiopia. Despite one-third still suffering stress or urge incontinence, the women reported improved quality of life and social reintegration after fistula closure.

Nephrectomy after transplant failure: current practice and outcomes.

The role of transplant nephrectomy after transplant failure is uncertain. We report the use and consequences of transplant nephrectomy among 19 107 transplant failure patients between 1995 and 2003 in the United States. Among 3707 patients with early transplant failure (graft survival <12 m), nephrectomy was performed in 56%, and was associated with an increased risk of death (HR 1.13, 95% CI 1.01-1.26). In contrast, among 15,400 patients with late transplant failure (graft survival > or =12 m), nephrectomy was performed in 27%, and was associated with a decreased risk of death (HR 0.89, 95% CI 0.83-0.95). In early transplant failure patients, nephrectomy was associated with a lower risk of repeat transplant failure (HR 0.72, 95% CI 0.56-0.94), while among late transplant failure patients; nephrectomy was associated with a higher risk of repeat transplant failure (HR 1.20, 95% CI 1.02-1.41). Definitive conclusions are not possible from this observational study. The role of nephrectomy in the management of dialysis treated transplant failure patients, and the implications of nephrectomy for repeat transplantation should be further studied in prospective studies.

A long-term study of the development of N2O controls at a pediatric dental facility.

A review is given of National Institute for Occupational Safety and Health (NIOSH) efforts to control N2O at a pediatric dental operatory from 1978 to the present. Measurements of N2O concentrations were made on four occasions before and after installation of different controls, using an infrared analyzer. Air velocity and volumetric flow measurements also were taken, Video imaging was done in some cases simultaneously with real-time N2O measurements to correlate work practices with exposure data. An infrared imaging system was used to identify sources of N2O. Critical components of resulting recommendations for control include monitoring of N2O concentrations; use of engineering controls, such as a scavenging mask, an effective dilution ventilation system, and auxiliary exhaust; good work practices; maintenance of the equipment; and worker education. Data presented strongly supports the hypothesis that better implementation of controls leads to reduction of N2O exposures. N2O concentrations were reduced by a factor of 61 from their initial levels. The current NIOSH recommended exposure limit of 25 ppm TWA during the time of N2O administration appears to be achievable.

Control of ethyl methacrylate exposures during the application of artificial fingernails.

In 1990 six cases of physician-diagnosed occupational asthma in cosmetologists working with artificial fingernails prompted the Colorado Department of Health to request the assistance of National Institute for Occupational Safety and Health (NIOSH) researchers in the evaluation and control of nail salon technician exposure. A commercially available recirculating downdraft table with charcoal filters was purchased and evaluated. Researchers from NIOSH made modifications to the table that included increasing the downdraft air volume; enlarging the plenum for more consistent airflow rates at the face of the table; removing the charcoal filters while incorporating a ventilation system to the outdoors; and putting an extension around the duct leading to the perforated plate at the downdraft face of the table. An evaluation was performed using the following two configurations: the modified table with the downdraft ventilation on (vented) and without the downdraft ventilation on (unvented). Each of the two configurations was sampled for 3 days in random order. Testing included the use of XAD-2 solid sorbent tubes for determining ethyl methacrylate and methyl methacrylate concentrations. Relative concentrations of organics were examined and used to analyze work practices. The geometric mean ethyl methacrylate exposure for personal breathing zone samples when using the modified table for approximately 6 hours was 0.6 ppm; when using the unventilated conventional table, the geometric mean exposure was 8.7 ppm. The difference in the values is statistically significant (p = 0.0045). Methyl methacrylate concentrations were nondetectable on all sorbent tubes.

Nitrous oxide control in the dental operatory: auxiliary exhaust and mask leakage, design, and scavenging flow rate as factors.

Two new local exhaust systems, intended primarily to control patient mouth emissions of N2O, were installed in a dental operatory, and resulting exposure concentrations to dental personnel were observed. The exposures were found to be typically unaffected by the presence and operation of these new controls. Laboratory testing on a head form, in conjunction with the operatory observations, established that mask leakage due to poor fit was the primary cause of N2O emissions. An improved mask fit and the addition of a slotted skirt around the outer mask shell individually resulted in greatly reduced leakage rates in the laboratory tests. Also, exhaust systems placed on the chin, on the chest, or in the mouth proved effective in capturing mouth emissions simulated by a breathing machine and head form.

Antihypertensive effects of an aromatase inhibitor in inbred salt-sensitive rats.

Rats susceptible to the hypertensive effect of dietary salt (SS/Jr) have excess urinary 19-nordeoxycorticosterone compared with salt-resistant control rats (SR/Jr). 19-Nordeoxycorticosterone is a hypertensinogenic mineralocorticoid, but whether it contributes to the salt sensitivity of SS/Jr is unknown. This study sought to evaluate the contribution of 19-nordeoxycorticosterone to the salt sensitivity of SS/Jr by lowering its production with an aromatase inhibitor, 10-propargyl-androst-4-ene,3,17-dione (19-acetylenic-androstenedione, 19-AA). This aromatase inhibitor also preferentially inhibits nonaromatizing adrenal 19-hydroxylation, an essential step in the formation of 19-nordeoxycorticosterone. To test this hypothesis, inhibitor (120 mg) or vehicle pellets were implanted into male and female weanling SS/Jr at 42 days of age. A high salt diet (8% NaCl) was started and two additional pellets were implanted at 52 and 62 days of age. Systolic blood pressure was measured in all animals and urinary corticosteroids in males. Compared with vehicle, the inhibitor lowered blood pressure at 50 days of age (when it could first be measured) until 64 days of age in females and 71 days of age in males. Corticosterone and aldosterone levels were not different between 19-AA- and vehicle-treated SS/Jr. 19-Nordeoxycorticosterone levels, however, were mildly reduced with the inhibitor (0.05 less than p less than 0.10). After 28 days of high salt diet all 23 of the 19-AA-treated SS/Jr were alive, whereas almost one half of the control animals had died. These data demonstrate that 19-AA attenuates the hypertension in SS/Jr; this effect may be through reduction in 19-nordeoxycorticosterone production.(ABSTRACT TRUNCATED AT 250 WORDS)

Poorly coordinated children: a survey of 95 cases.

Screening of 717 5-year-olds and 757 7-year-olds, found 55 of the former and 77 of the latter possibly to be poorly coordinated. Further diagnostic testing with the McCarthy Motor Scales confirmed the problem in a total of 95 children, a prevalence of 6.4%. Neurological examination showed 43% of the 5-year-olds and 21% of the 7-year-olds to have choreiform movements. Of the total 95, proprioception was abnormal in 40%, but abnormal muscle tone present in only 4%. An increased prevalence of hearing loss and obesity and a history of developmental delays was found. Low birth weights, prematurity, post-maturity and perinatal problems were significantly associated with poor coordination. Socioeconomic status was not a significant factor. The difficulties of testing and measuring poor coordination and the need for more precise measures are discussed. Follow-up of at risk children at age 5 with tests of motor coordination is recommended.

Poor co-ordination in 5 year olds: a screening test for use in schools.

A simple standardized screening test (South Australian Motor Co-ordination Screening Test, SAM Test) was developed to screen for poor co-ordination in 5 year olds. This SAM Test, which can be used by teachers, nurses and doctors, has explicit pass/fail criteria and has classified correctly 90% of children. The McCarthy Motor Scales, which are time consuming and limited to use by psychologists, were used to categorize 60 poorly co-ordinated and 60 normal children. The 120 children thus selected were tested on 19 items covering gross and fine motor skills. Statistical analysis to determine which items best discriminated between the two groups found the following five gross motor items to be most effective: one leg balancing, hopping, heel-toe walking on line, jumping over ribbon and dropping ball and catching.

Retrovesical leiomyoma.

Primary tumors arising in the retrovesical area are rare. We recently treated by primary excision a large retrovesical leiomyoma in a forty-five-year-old man. The smooth muscle nature of the tumor was confirmed by electron microscopy. Recognizing this entity is important, since treatment consists only of surgical removal, and the prognosis should be excellent.

Control of wood dust from horizontal belt sanding.

An auxiliary ventilation system has been developed to reduce the wood dust emission from horizontal belt sanders. This system consists of two devices: a hood and a jet stripper. The hood is a narrow low-volume, high-velocity slot hood located between a belt surface and a worktable; the push device is a jet stripper located inside a driven pulley hood opposite the operator site. In combination with a standard sander hood, both devices significantly reduced the wood dust emission into the workroom. Laboratory data were confirmed by field tests conducted at an oscillating edge belt sander at a wood furniture manufacturing plant. These devices work independently of each other and do not interfere with the operator's sanding activity. They do not require special maintenance and are economically feasible.