Predicting quality of deceased donor kidneys: the harvesting surgeon as a prognostic factor?

INTRODUCTION: The quality of donor organs is a crucial factor with regard to graft survival and function in kidney transplant recipients. The prognostic importance of surgeon-related factors during organ harvesting on graft quality has been almost unknown. Our aim was to find out whether surgical expertise as reflected by the time required for kidney retrieval influences graft survival. METHODS: In this retrospective study, we analyzed the records of 200 patients who received a cadaveric renal graft at our institution between 2000 and 2005. Graft survival and function were examined at discharge and after 1, 2, 3, and 5 years post-transplantation with the estimated glomerular filtration rate (GFR) using the Cockroft-Gault formula as a surrogate marker. We gathered the pertinent data on harvesting procedures from Eurotransplant donor reports. We correlated the length of time from cold organ perfusion to nephrectomy with graft survival. Statistical evaluation was performed using correlation analysis. RESULTS: There was no statistically significant correlation between the time the surgeon needed for kidney retrieval (starting from cold perfusion) and the outcome of transplantation. CONCLUSION: It would seem to be obvious that the longer a cadaveric donor kidney remains in the donor's body after cold perfusion, the worse the outcome will be. Our findings, however, did not prove this hypothesis even when looking at abdominal and combined abdominal and thoracic harvesting procedures separately.

Dimensional ridge alterations following socket preservation using a nanocrystalline hydroxyapatite paste: a histomorphometrical study in dogs.

The aim of the study was to evaluate the histological response and dimensional ridge alterations following application of a nanocrystalline hydroxyapatite paste (NHA) into fresh extraction sockets in dogs. Immediately following vertical tooth separation and extraction, NHA was inserted in the extraction socket of the second molar in the lower jaws of 10 dogs. Untreated extraction sites on the opposite side served as controls. Wounds were closed using resorbable sutures after vertical flap elevation. After three and six months, 5 animals were killed. Lingual and buccal bone height, alveolar wall and total bone width 1, 3 and 5mm underneath the top of the crest were evaluated. Histological analysis revealed a high variability of NHA resorption and osteoconductive properties with different rates of material resorption. No statistically significant differences could be observed between the corresponding aspects of test and control sites. Both groups revealed higher alveolar wall resorption on the buccal than on the lingual side at both time periods. NHA does not seem to be useful for socket preservation procedures since it failed to prevent dimensional ridge alterations while revealing osseous integration but unpredictable material resorption. The role of non-resorbed hydroxyapatite remnants for implant placement is unclear and requires further investigation.

Specificity of computerized physician order entry has a significant effect on the efficiency of workflow for critically ill patients.

BACKGROUND: Critically ill patients require rapid care, yet they are also at risk for morbidity from the potential complications of that care. Computerized physician order entry (CPOE) is advocated as a tool to reduce medical errors, improve the efficiency of healthcare delivery, and improve outcomes. Little is known regarding the essential attributes of CPOE in the intensive care unit (ICU). OBJECTIVE: To assess the effect of CPOE on ICU patient care. DESIGN: Retrospective before and after cohort study. SETTING: An academic ICU. PATIENTS: Patients admitted to the ICU during use of the initial CPOE application and those admitted after its modification. INTERVENTIONS: Comprehensive order interface redesign improving clarity, specificity, and efficiency. MEASUREMENTS: Orders for complex ICU care were compared between the two groups. In addition, the use of higher-efficiency CPOE order paths was tracked. RESULTS: Patients treated with both the initial and modified CPOE system were similar for all measured characteristics. With the modified CPOE system, there were significant reductions in orders for vasoactive infusions, sedative infusions, and ventilator management. There was also a significant increase in orders executed through ICU-specific order sets after system modifications. LIMITATIONS: This retrospective study cannot assess issues related to learner expertise and is meant to only suggest the importance of developing CPOE systems that are appropriate for specialty care environments. CONCLUSION: Appropriate CPOE applications can improve the efficiency of care for critically ill patients. The workflow requirements of individual units must be analyzed before technologies like CPOE can be properly developed and implemented.

Feasibility and accuracy of transthoracic Doppler echocardiographic estimation of pulmonary capillary wedge pressure applying different methods.

BACKGROUND: Pulmonary wedge pressure (PWP) is an established index of cardiac function and an essential component in the management of patients with congestive heart failure and in critically ill patients. AIM: To evaluate feasibility and accuracy of non-invasive prediction of PWP by Doppler echocardiography in daily clinical practice. METHODS: Agreement was assessed between values predicted by Doppler vs. invasively measured PWP. Forty-five consecutive patients [mean (S.D.) age 62 (10) years] with CAD (44%), DCMP (40%) and without structural heart disease (16%) were studied (EF< or =40% in 58% of the patients). Doppler transmitral and pulmonary venous flow velocity profiles were recorded. For binary and quantitative prediction of PWP, four different methods and five different linear equations, suggested previously in the literature, were evaluated. RESULTS: Predictive values to identify elevated PWP were highest for pulmonary venous flow reversal exceeding the duration of forward mitral flow during atrial systole (PPV 1 and NPV 0.96). Likewise, agreement with measured PWP was highest for equations comprising both transmitral and pulmonary venous flow variables (relative mean difference 0.11, S.D.+/-4.01 mmHg for the most accurate equation). Feasibility was slightly, but not statistically, lower when pulmonary venous flow was considered vs. transmitral flow parameters alone for binary prediction (87 vs. 93%) as well as for quantitative assessment (82 vs. 93%). CONCLUSION: Semiquantitative prediction of elevated PWP by Doppler echocardiography is feasible as well as accurate in daily clinical practice. However, accuracy of numeric estimates is limited. Hence, invasive measurement of PWP is still necessary in certain clinical settings.

Carcinogenic potential of silicone breast implants: a Connecticut statewide study.

To clarify the carcinogenic potential of silicone breast implants, 680 implant procedures performed on women in Connecticut with no prior history of cancer were correlated with the subsequent development of primary breast and nonbreast cancers. Neoplastic events after the placement of silicone breast implants during the 13-year interval from October 1, 1980, through September 30, 1993, were quantified using a retrospective, linked-registry method. ICD-9-CM discharge codes contained in the Uni formed Hospital Discharge Data Sets (UHDDS) from 34 hospitals across Connecticut were linked to procedure codes for unilateral and bilateral implants, and to medical histories for new malignancies after the implant procedures. Data were cross-linked to the Connecticut Tumor Registry to confirm the clinical history of each cancer. The rates of breast and nonbreast cancers in patients with silicone breast implants were compared with those of a control population drawn from the UHDDS of 1022 women undergoing sterilization by tubal ligation between 1981 to 1985. Ages (mean +/- SD) were similar in the implant group (34 +/- 10 years) and in the sterilization group (32 +/- 6 years). The mean follow-up in the implant group (4.6 years) was also similar to that of the control group (5.4 years). Compared with the control group, the implant group demonstrated lower rates of breast cancer (0.59 versus 0.88 percent, p = 0.35) and nonbreast cancer (0.59 versus 2.7 percent, p = 0.001). Correspondingly, the implant group had a lower relative risk of breast cancer (relative risk = 0.67, 95 percent, confidence interval = 0.20 to 2.17) and nonbreast cancer (relative risk = 0.21, 95 percent, confidence interval = 0.07 to 0.60). Based on these data, it was concluded that silicone breast implants are not carcinogenic, because they are not associated with increased rates of either breast or nonbreast cancers. The validity and threats to the conclusions are discussed, and the results are placed into context with similar findings from other studies.

Mock survey. Methodology for measuring compliance and facilitating change.

Every nurse executive is responsible for maintaining compliance to current externally established standards. As standards change, the nurse executive must evaluate the organization, making sure it continues to demonstrate compliance. This article describes how one organization used the Joint Commission on Accreditation of Healthcare Organizations' Agenda for Change as an opportunity to examine its nursing practice. The process included: 1) analyzing compliance to the 1991 standards; 2) developing an action plan to address deficiencies; and 3) developing and conducting a mock survey to monitor and evaluate effectiveness of the action plan. Increased staff comfort with the survey process, monitoring tools, and data regarding compliance to standards were the primary outcomes of this process. Leadership development, team building, and networking were also outcomes.

Determination of aortic valve area by Doppler echocardiography using the continuity equation: a critical evaluation.

In 35 patients with aortic stenosis the Doppler-derived values of the aortic valve area (continuity equation) were compared with those determined at cardiac catheterization (Gorlin's formula). The comparison of three modifications of the continuity equation showed that the procedure generally proposed (calculating the area of the left ventricular outflow tract from its diameter) significantly underestimated the valve area (modification 1). Modification 2, which used direct planimetry of the left ventricular outflow tract, yielded results quite consistent with invasive measurements. The employment of peak velocities instead of velocity-time integrals (modification 3) did not significantly alter the results. However, the scatter was considerable in all three modifications. When critical aortic stenosis was defined with a valve area less than or equal to 0.70 cm2, modifications 1, 2, and 3 accurately predicted the severity of stenosis in 80, 86, and 80%, respectively.

Iodine in field milk samples and effects on mastitis organisms.

Bulk tank milk samples collected from 175 dairy herds throughout Wisconsin averaged 466 micrograms of iodine per liter with 11% of the samples containing greater than 1000 micrograms per liter. From questionnaires on feeding and management, use of iodine supplements in feed was associated with increased iodine in milk. One gram of ethylenediamine dihydriodide was fed daily for 2 wk to dairy cows with a history of mastitis. Milk iodine increased from 210 to 6225 micrograms per liter. There was no significant effect on somatic cells, mastitis organisms, or incidence of clinical mastitis.

Adenoid cystic carcinoma of the salivary glands. A study of ninety-three cases.

The present study reviews ninety-three cases of adenoid cystic carcinoma of the major (80 cases) and minor (13 cases) salivary glands occuring in ninety-one patients. This tumor is insidious in its presentation and subsequent clinical course with early perineural lymphatic invasion and late metastases. Many patients remain alive but with recurrent disease. The high incidence of recurrent disease (parotid gland 20 of 47, submaxillary gland 20 of 33, and minor salivary glands 7 of 11) suggests inadequate initial surgery at all anatomic sites. Misdiagnosis (16 cases) on frozen or permanent section has led to less than optimum primary treatment. The frequency of perineural lymphatic involvement with recurrence (11 of 19 cases) suggests that the tumor may be extending along the nerve roots in an anatomic area with extensive nerve distribution (the head and neck). Radical neck dissection, in our studies, has contributed to improved survival rates when the primary site has been the submaxillary gland. The treatment of recurrent disease has been primarily surgical (3 operations per patient), and palliation with prolonged survival has been achieved with radical excision of recurrence. The fifteen year determinate cure rate of 19 per cent in comparable to that reported in the world literature. Radiation therapy has been helpful in palliation but has not been curative. Radiation treatment was used for recurrence in twenty-seven patients, and the average time from radiation treatment to death was 3.8 years.

Primary tumors of the mandible. A study of 49 cases.

Forty-nine cases of primary tumors of the mandible have been reviewed. The anatomic location, pathologic features, sites of metastases, survival rates, and treatment methods were evaluated. Lesions studied included ameloblastoma, osteogenic sarcoma, reticulum cell sarcoma, fibrosarcoma, chondrosarcoma, myxosarcoma, epidermoid carcinoma, adenocarcinoma, and giant cell sarcoma. An in-depth discussion of primary osteogenic sarcoma of the mandible is presented. Because of upper cervical lymph node metastases in two cases of osteogenic sarcoma of the mandible, an upper neck dissection should be considered in the primary treatment. Also presented in this study are the first reported cases or primary myxosarcoma of the mandible and giant cell sarcoma of the mandible. Recent methods of treatment of ablative resection of the mandible followed by immediate or delayed repair are discussed. A revised technic for mandibular replacement which has met with success in six of seven cases is presented.

Bioavailability and pharmacokinetic analysis of chlorpromazine-induced rectal temperature depression in rabbits.

Chlorpromazine-induced depression of rectal temperatures in rabbits kept at 20 degrees was used to determine relative biophasic drug levels corresponding to observed hypothermic response intensities, which then served to establish a triexponential linear mathematical model describing drug transference and drug action in this system. Comparisons of various experimentally known, slow intravenous infusion drug inputs of chlorpromazine with drug inputs computed by deconvolution, using the derived model and observed temperature depressions, served to verify the accuracy of the model for the 0.50-4.0 mg/kg dosage range.

Pharmacokinetics of chlorpromazine-induced miotic response in rabbits.

The time variation of changes in the chlorpromazine-induced pupil diameter decrease was studied following varying bolus and slowly infused intravenous doses administered to rabbits. The observed pharmacological response data were coverted, via, the use of a dose-effect curve, to values theoretically corresponding to relative biophasic drug levels. These values were, in turn, used to construct a linear pharmacokinetic model of the drug bioavailability input equilibrium pharmacological response output dynamics of the system. The use of a time domain, MULTIFIT, computerized method of fitting the data to obtain a pharmacokinetic model was compared to the use of a frequency response, PLTEST, approach. The fidelity of the model in quantitatively relating the time course of systemic drug bioavailability to observed pupil response was verified by the satisfactory agreement obtained by directly comparing experimentally known amounts of drug intravenously infused with corresponding values computed from observed changes in pupil size. The applicability of using pharmacological data for quantitative bioavailability and pharmacokinetic analysis of chlorpromazine is demonstrated. This finding is particularly significant because no suitable chemical or radiological direct assay technique exists for determining levels of chlorpromazine, except for high doses, in body fluids.