Transporting live donor kidneys for kidney paired donation: initial national results.

Optimizing the possibilities for kidney-paired donation (KPD) requires the participation of donor-recipient pairs from wide geographic regions. Initially it was envisaged that donors would travel to the recipient center; however, to minimize barriers to participation and simplify logistics, recent trends have involved transporting the kidneys rather than the donors. The goal of this study was to review outcomes of this practice. KPD programs throughout the United States were directly queried about all transplants involving live donor kidney transport. Early graft function was assessed by urine output in the first 8 h, postoperative serum creatinine trend, and incidence of delayed graft function. Between April 27, 2007 and April 29, 2010, 56 live donor kidneys were transported among 30 transplant centers. Median CIT was 7.2 h (IQR 5.5-9.7, range 2.5-14.5). Early urine output was robust (>100 cc/h) in all but four patients. Creatinine nadir was <2.0 mg/dL in all (including the four with lower urine output) but one patient, occurring at a median of 3 days (IQR 2-5, range 1-49). No patients experienced delayed graft function as defined by the need for dialysis in the first week. Current evidence suggests that live donor kidney transport is safe and feasible.

A cholesterol-containing foreign body granuloma presenting as an inter-metatarsal bursa.

A 68-year-old man presented with progressive forefoot swelling which coincided with the onset of type 2 diabetes mellitus. Imaging revealed a cystic inter-metatarsal mass containing two foreign bodies, which had been present for many years. Following aspiration of the mass, cholesterol crystals were observed on polarised microscopy. It is postulated that the development of diabetes triggered the shedding of cholesterol crystals around a long-standing quiescent foreign body granuloma.

Early mobilisation for minimally displaced radial head fractures is desirable. A prospective randomised study of two protocols.

We compared two protocols of early mobilisation for minimally displaced radial head fractures through a single-blinded, prospective randomised trial. Sixty patients were randomly allocated to either immediate active mobilisation or 5-day delay before active mobilisation was commenced. Patients were reviewed at 7 days, 4 weeks and 3 months after injuries. A blinded observer assessed each patient. All fractures united by the third month. At the end of 7 days, the mobilisation group had less pain (visual analogue scale (VAS) 6 versus 7.6, P=0.002); greater flexion (mean 112 versus 98 degrees, P=0.0004); greater strength in supination (P<0.001) and better elbow function (Morrey Score: 54 versus 43, P=0.005). By the fourth week, both groups were comparable in all parameters and improvement continued into the third month. Mean limit of extension at the third month were 2.3 degrees in the immediate mobilisation group and 1.8 degrees in the delayed group (NS). All had excellent function on the basis of the Morrey Score. Immediate mobilisation did not adversely affect the outcome; the patients had less pain and better elbow function at 1-week post-injury. Pain, ranges of movement and function were similar by the fourth week post-injury.

Transepiphyseal fracture of the femoral neck with dislocation of the femoral head and fracture of the posterior column of the acetabulum in a child.

We describe a 15-year-old boy with a posterior dislocation of the hip, fracture of the posterior column of the acetabulum and separation of the femoral capital epiphysis. To our knowledge no previous case in a child has been reported. Such high-energy injuries are extremely rare, and a poor outcome is expected. We advocate early referral to a specialised tertiary centre, and the use of a modification of Delbet's classification to reflect the complexity and displacement which may occur with this injury.

Paediatric pelvic imaging: improvement in gonad shield placement by multidisciplinary audit.

BACKGROUND: In 1996, there were local reports of poor gonad protection for paediatric pelvic radiographs. OBJECTIVES: To investigate the nature of the problem and make necessary improvements. MATERIALS AND METHODS: A retrospective audit of 218 paediatric pelvic radiographs was undertaken in 1997. Each radiograph was assessed for the presence of a gonad shield, appropriateness of the device and its position. A multidisciplinary team was formed with representation from radiology, radiography, orthopaedics and medical physics to investigate ways of improving technique and reducing patient dose. These included radiographer training and the introduction of digital fluoroscopy as an alternative imaging technique in follow-up patients. There were further rounds of data collection in 1998 and 1999. RESULTS: In round 1, a gonad shield was present in 77.9 % of boys' films and 76 % of girls' films where one should have been, increasing to 85.2 % and 85.4 % respectively by round 3 of the audit (P < 0.05). Only 31.6 % of boys' devices and 21.9 % of girls' devices were correctly positioned in round 1, increasing to 78.3 % and 94.3 %, respectively, by round 3 of the audit (P < 0.05). After round 1, no inappropriate devices were used. CONCLUSION: Audit was an effective tool in gaining the resources needed to improve technique and reduce radiation exposure in children. The multidisciplinary approach was vital in the success of this project.

Implications of differential impacts of care-giving for future research on Alzheimer care.

As the primary caregivers for the millions afflicted with Alzheimer's disease, family members have been the focus of research for the past two decades. Differences in care patterns and deleterious effects of care provision have been clearly established. However, similar demands and hardships associated with care-giving result in different consequences for different families. A greater understanding of the care-giving context and its determinants will enhance knowledge of the differential impacts of care-giving. The most critical determinant of care-giving context is the role relationship between the caregiver and the care recipient. Future research must address role relationship as the primary determinant of what care is provided by whom, and in what manner. This will enhance the understanding of specific caregiver outcomes and lead to optimal targeting of interventions. Future research must also focus on the interface between the family and other social institutions. Evidence calls into question the equity, quality, and capacity of the current system of care, which assumes that family care is best. It will be important for future studies to explore alternate options for long-term care policy. Families and patients will also benefit from studies that assess strategies to ensure an adequate labor pool of qualified formal caregivers.

The family role in the context of long-term care.

Current long-term care policy and practices are built on the premise that family is and should be the primary party responsible for impaired older persons. This article presents evidence that this premise and the resulting policies and practices are (a) built on myth; (b) fueled by gender, income, and ethnic inequalities; and (c) largely responsible for the creation of a service system that has inadequate capacity to meet current and future needs. An alternative paradigm, which places primary responsibility for long-term care needs on the individual, is proposed here and implications for new policy direction are outlined. The projected benefits of this shift in paradigm will be the development of a more viable and more equitable long-term care system that has the capacity to provide high quality care to meet the expanding need.

Family involvement in the nursing home.

The focus of this study was the influence of preestablished family behavior patterns, family orientation of nursing home policies, and practices and caregiver and elder characteristics on the family members' expectations for involvement in the nursing home and the actual involvement 6 months later. The conceptual model was based on findings of Montgomery's nursing home study and open systems principles applicable to families. Data were collected through telephone interviews with 216 family members of residents in 24 nursing homes in southern Michigan. Regression analyses revealed that measures of preestablished patterns of family behavior accounted for 19% to 31% of variance in measures of expected family involvement. Expected family involvement, resident activities of daily learning (ADL), and caregiver relationship accounted for 11% to 23% of variance in measures of actual family involvement. Opportunity for family leadership in resident care had a mild effect of moderating the amount of family direct care and learning activities in the nursing home.

Family involvement in the nursing home: family-oriented practices and staff-family relationships.

Staff-family cooperation in caring for elders in nursing homes is recommended but poorly understood. Family involvement and staff-family interactions in nursing homes with differing family orientations were investigated. Friedemann's (1995) system-based family theory guided the study. Of all 208 licensed nursing homes in southern Michigan, 143 completed a survey about their family-oriented practices. Family orientation was ranked accordingly. Twenty-four nursing homes were randomly selected to conduct semistructured telephone interviews with 177 family members. Data were analyzed by thematic interpretation. Findings showed a wide range of involvement patterns that promoted family connectedness, maintenance of control, growth, and learning. Families desired various types of staff cooperation and were given such opportunities in homes with high family orientation.

The impact of respite use on nursing home placement.

The results of experimental studies of the effects of respite care have been difficult to interpret because researchers have lacked experimental control over who actually received the treatment. Data from one such study are reanalyzed, focusing on the linear relationship between amount of respite use and probability of nursing home placement at the end of the treatment period. The results indicate a significant negative relationship between amount of respite use and nursing home placement.

A longitudinal analysis of nursing home placement for dependent elders cared for by spouses vs adult children.

Five-wave panel data from 531 informal caregivers and frail elders were analyzed using an event history framework to identify how changes in the caregiving situation are related to nursing home placement. The results indicate that the predictors of placement differ substantially for elders cared for by spouses vs those cared for by adult children. In addition, the findings suggest dramatically different descriptions of the caregiving role over time for the two groups of caregivers. There were differences not only in the conditions under which caregiving ends, but also apparent differences in when caregiving begins and how it is perceived by the caregiver. Differences in the probability of placement of elders cared for by spouses vs adult children are interpreted within the framework of these contextual differences in the caregiving role.