Health insurance as a requirement to undergo cardiac transplantation: a national survey of transplant program practices.

BACKGROUND: Recent limitations in Medicaid coverage of transplantation in Arizona jeopardized transplantation of potential recipients in that state and called attention to financial barriers inherent in the present organ allocation system. Policies of cardiac transplant centers regarding insurance requirements for transplantation have not been previously assessed. We sought to determine the policies of adult cardiac transplant programs nationwide regarding insurance requirements for evaluation and listing for cardiac transplantation. METHODS: From December 15, 2008 to November 16, 2010, all active adult cardiac transplant programs in the United States were surveyed regarding insurance requirements for evaluation and listing for cardiac transplantation. RESULTS: Surveys were completed by 62 of 101 programs, accounting for 71% of adult cardiac transplants in 2007. Only 2% of recipients were uninsured. Insurance was required by 48% of programs to evaluate and 84% to list for transplantation. For uninsured patients, 81% of programs required a large amount of money upfront (median, $200,000; interquartile range, $10,000-$300,000) to list for transplantation and often (84%) educated patients about fundraising to acquire these resources. CONCLUSIONS: Adult cardiac transplant programs generally require candidates to have adequate health insurance to undergo transplantation. Uninsured patients typically need a significant amount of money upfront to be listed for transplantation and often are advised to fundraise to gather such resources.

Association between C-reactive protein, anti-Chlamydia pneumoniae antibodies, and vascular function in healthy adults.

Abnormalities of vascular function occur in patients with risk factors for atherosclerosis before the development of obstructive disease. Our pilot data suggest that elevated serum markers of infection and/or inflammation are associated with functional abnormalities of the vasculature in subjects at otherwise low risk for atherosclerosis.

Experimental pseudomonal posttraumatic endophthalmitis in a swine model. Treatment with ceftazidime, amikacin, and imipenem.

PURPOSE: To compare the intravitreal efficacy of three separately administered antibiotics (imipenem, ceftazidime, and amikacin) in limiting the intraocular inflammation and tissue destruction caused by posttraumatic pseudomonal endophthalmitis. METHODS: Thirty-three Yorkshire pigs each received a surgically induced scleral injury to the right eye. After repair, each eye was injected with 22,000 colony-forming units of live Pseudomonas aeruginosa. Pigs then were randomly grouped into a natural-history-of-infection group in which no treatment was given (n = 9) or into groups treated with the following: intravitreal imipenem (n = 6), ceftazidime (n = 6), amikacin (n = 6), or normal saline (n = 6). Pigs then were observed clinically for 18-24 hours after surgery and enucleated for histopathologic examination. RESULTS: Clinical examinations revealed significantly less posterior segment inflammation in pigs treated with amikacin and imipenem than in pigs in the natural history or saline control groups, based on the Wilcoxon rank sum test (P < .05). Histopathologic examinations showed similar results, with less intraocular inflammation and retinal destruction in pigs treated with amikacin and imipenem, whereas the inflammation in pigs treated with ceftazidime did not differ significantly from that in control pigs. CONCLUSION: Intravitreal antibiotic treatment with imipenem or amikacin appears to limit intraocular inflammation and retinal tissue damage when given early in the course of posttraumatic pseudomonal endopthalmitis. Results with ceftazidime are less conclusive.

Kallistatin in human ocular tissues: reduced levels in vitreous fluids from patients with diabetic retinopathy.

PURPOSE: Kallistatin is a serine proteinase inhibitor, which binds to tissue kallikrein and inhibits its proteolytic activity. This study is to determine the expression, cellular localization and the potential function of kallistatin in the eye. METHODS: Tissue kallikrein-kallistatin complex formation was performed to detect the kallikrein-binding activity in ocular tissues. Immunoreactive kallistatin was detected and quantified by an enzyme-linked immunosorbent assay using polyclonal antibody specific to human kallistatin. In situ hybridization histochemistry was employed to localize the kallistatin mRNA in human eyes using an antisense riboprobe of kallistatin. RESULTS: We have identified active kallistatin in the cornea, ciliary body, sclera, choroid, optic nerve, retina, vitreous and aqeous fluids. Kallistatin binds to tissue kallikrein and forms an SDS-stable complex. Immunoreactive kallistatin was identified in these tissues. Linear dose-dependent curves of the tissue extracts of the retina and choroid are parallel to that of purified human kallistatin, suggesting their immunological identity. The kallistatin mRNA was identified in the ciliary muscle, lens epithelial cells, all the layers of retina cells, optic nerve, choroid and vascular endothelial cells. These cells were not stained by the sense riboprobe under the same conditions, indicating the specificity of the hybridization. We also compared immunoreactive kallistatin levels in vitreous fluids from 18 patients with diabetic retinopathy and 17 non-diabetic subjects. The results show that diabetic subjects have significantly lower kallistatin levels (233.0 +/- 14.6 ng/mg protein) compared to non-diabetic subjects (334.1 +/- 26.9 ng/mg protein). CONCLUSIONS: Kallistatin is produced endogenously in the eye and the decrease in the vitreous kallistatin levels may be involved in diabetic retinopathy.

Subfoveal neovascular membrane removal in patients with traumatic choroidal rupture.

PURPOSE: To describe the clinical outcomes of patients undergoing pars plana vitrectomy to remove subretinal neovascular membranes caused by traumatic choroidal ruptures. METHODS: Three patients with traumatic choroidal rupture in whom subfoveal choroidal neovascularization developed underwent pars plana vitrectomy with surgical excision of the neovascular membrane. Surgical specimens were examined histopathologically in two patients. RESULTS: The choroidal neovascularization was removed completely in each patient. Visual results were excellent with visual acuities improving to 20/30 or better in each patient. Recurrence of choroidal neovascularization has not been observed. Fibrovascular membranes with reactive retinal pigment epithelium were observed in two specimens examined histopathologically. CONCLUSION: Surgical removal of subretinal neovascular membranes emanating from traumatic choroidal ruptures produced an excellent visual outcome in three patients studied. The neovascular membranes, which were removed with minor disturbance to the underlying pigment epithelium, have similar characteristics to those obtained from patients with ocular histoplasmosis syndrome.

Ophthalmic manifestations of Rochalimaea species.

Rochalimaea henselae and R. quintana belong to the order Rickettsiales and are thought to be responsible for trench fever, bacillary angiomatosis, and cat scratch disease. We recently examined four patients with intraocular inflammation of unknown origin. Each patient had either unilateral or bilateral moderate loss of visual acuity ranging from 20/25 to counting fingers. Bilateral intraocular inflammation manifested by anterior and posterior segment cells, retinal lesions, macular exudate, and optic nerve head swelling was present to varying degrees. The R. henselae to R. quintana antibody titers were greater than or equal to 1:256 in each case. Marked improvement in vision occurred after treatment with either oral ciprofloxacin hydrochloride and prednisone or doxycycline hyclate. Rochalimaea species should be considered in the differential diagnosis of intraocular inflammation and inflammatory optic neuropathy. Appropriate treatment may result in marked improvement in visual acuity.

Nocardia asteroides infection following scleral buckling.

We report a case of delayed external ocular Nocardia asteroides infection following scleral buckling for rhegmatogenous detachment. Surgical removal of the exoplant material allowed isolation and identification of the organism. Topical and systemic antibiotic therapy following exoplant removal yielded a favorable result.

Development of a model using polypeptide antibodies for scintigraphy of the pancreas.

A study was designed to develop an agent for pancreatic scintigraphy with greater specificity for the pancreas than selenomethionine. A series of successful experiments was performed using rabbit-produced antibodies to the recently discovered hormone, pancreatic polypeptide. Via hemagglutination and radiolabeled hemagglutination studies, the antibody activity was demonstrated. Gel diffusion studies showed selective uptake by the rat pancreas of intravenously injected antibody and no uptake by the liver and spleen. Immunocytochemical studies on human tissue demonstrated the same selectivity for the pancreas. Also, the titers of different batches of rabbit-produced antibody were quantitated by the enzyme-linked immunospecific assay system. These studies indicate that polypeptide antibody has the potential for carrying a radionuclide selectively to the pancreas.