Knowledge, attitudes, and practices related to breast cancer screening among female Jordanian university employees: A cross-sectional study.

INTRODUCTION: To improve participation in breast screening programs, the level of knowledge about BC, attitudes, and practices of women in different sections of society must be understood. This study aimed to measure the level of knowledge of BC risk factors, signs and symptoms and determine current mammography practices among female employees at Jordanian universities. METHODS: A cross-sectional descriptive study was conducted on female employees at Jordanian government universities. Data was collected using a structured questionnaire that included: sociodemographic characteristics, knowledge of BC risk factors, knowledge of BC symptoms and knowledge, attitude and practice of mammography as an early detection method. RESULTS: A total of 362 participants completed the questionnaire. Overall, 174 scored ≥50% correct answers regarding BC risk factors, while 231 scored ≥50% correct answers regarding BC signs and symptoms. Half of the participants (n = 184, 50.8%) understood mammography to be an early BC detection method. Among those participants, 95 (51.6%) were eligible for screening and 39 (21.2%) had had a previous mammogram. The main reason for not engaging in mammography was the absence of BC signs and symptoms (37.2%). Profession, educational level and family history of BC were associated with increased knowledge of BC risk factors, signs and symptoms (p = 0.01). Lecturers in medical faculties exhibited the highest level of knowledge about mammography compared to participants in other professions (p = 0.02). CONCLUSION: Only 79 participants had good to excellent knowledge about BC. Participants' profession was the major indicator for awareness of BC and mammography as an early detection method. IMPLICATIONS FOR PRACTICE: The findings of this study reinforce the importance of providing BC educational programs for university employees in Jordan to increase awareness of BC and mammography.

The Management of Intussusception: A Systematic Review.

Intussusception (ISN) is a dangerous condition where a portion of the intestine slides into an adjacent area of the intestine. This telescoping motion frequently prevents liquids or food from flowing through. Developing management guidelines for ileocolic (IC) intussusception was the aim of this systematic study. Data sources were PubMed/Medical Literature Analysis and Retrieval System Online (MEDLINE), Scopus, and Embase databases. Our review investigated English-language articles (from 2010 to 2023) according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Overall, there were 15 articles. Surveys and analyses of national databases were the most widely used methods (n=15). The search identified 561 studies; 15 were eligible for inclusion in the analysis. Further understanding of the management of intussusception may help improve evaluation and management in the future. The use of preventive antibiotics does not reduce problems following radiologic reduction. When clinically appropriate, repeated attempts at enema reduction may be made. After the enema reduction of ileocolic intussusception, patients can be safely watched in the emergency room (ER), thereby avoiding hospitalization. Success rates for laparoscopic reduction are high. When it comes to intussusception in children who are hemodynamically stable and do not have a serious illness, there is no need for pre-reduction antibiotics. Prioritizing nonoperative outpatient (OP) therapy is recommended as the primary approach, with the utilization of minimally invasive procedures to avoid the necessity for laparotomy. The management of colonic intussusception involves complete removal in one piece, while enteric intussusception can be addressed through reduction followed by resection. A targeted approach is recommended, recognizing the intermediate forms of intussusception that may exist between the colonic and enteric types. It is essential to note that the prevailing treatment for adult intussusception remains to be surgical intervention.

Australian radiographers' awareness of cardiac implantable electronic devices (CIEDs) in mammographic imaging.

INTRODUCTION: Women presenting for mammography occasionally have pacemakers or other cardiac-implantable electronic devices (CIEDs) in situ. This research investigates Australian radiographers' awareness of CIEDs in the diagnostic and screening settings. METHODS: A survey of radiographers with mammography experience in Australia was conducted using SurveyMonkey™. Respondents were asked if they could confidently identify images of devices and whether they had imaged them mammographically. A Chi-squared test of independence was used to compare the association between demographics and CIED awareness. A value of p < 0.05 was deemed statistically significant. RESULTS: There were 220 valid responses. All CIED types had been imaged. Most respondents had imaged a pacemaker (94.5%) and implantable cardioverter-defibrillator (ICD) (85.6%), compared to the three different implantable loop recorders (ILRs) (ILR-1: 63.4%; ILR-2: 14.1%; and IRL-3: 26.9% and the emerging subcutaneous ICDs (S-ICDs) (11.9%). Most respondents felt confident identifying the pacemaker (95%) and the ICD (86.1%). Only 19.4% of respondents could confidently identify the emerging S-ICD. CONCLUSION: A lack of awareness of new and emerging devices may impact approaches to imaging and present significant risk to patients. The lack of studies comprehensively describing devices and their mammographic appearance to support radiographers' knowledge and awareness highlights an urgent need to progress research in this area. IMPLICATIONS FOR PRACTICE: As a part of continuing professional development, radiographers performing mammography must ensure they remain up to date with current and emerging technology, including CIEDs. This study has identified a lack of awareness of the different types of CIEDs currently being implanted and imaged, which may translate to unsafe imaging practices. There is an urgent need for further education to bridge this knowledge gap and ensure the safety of practice in imaging women with CIEDs. FOOTLINE: Mammography: CIED Imaging.

Knowledge, attitude, understanding and implementation of evidence-based practice among Jordanian radiographers.

INTRODUCTION: Evidence-based practice (EBP) has gained attention globally from healthcare professionals and researchers. The aim of this study was to assess Jordanian diagnostic radiographers' knowledge, attitude, education/knowledge, and skills related to EBP; and identify specific terms related to EBP. METHODS: A paper-based, self-administered questionnaire with two sections was used. The first section included 11 socio-demographic questions and the second section contained 56 questions regarding EBP categorized under seven distinct subscales. The data were imported into SPSS for analysis. RESULTS: Responses were received from 203 radiographers, most of them 135 (66.5%) aged 21-30 years. The majority of radiographers agreed or strongly agreed that the application of EBP is necessary for radiography practice, and 129 (63.6%) of radiographers learned the foundations of EBP as part of their academic preparation. Less than half of the participants stated that they completely understood the research terminology listed in the survey. Most participants had access to the internet and research databases, 79.3% (n = 161). The majority of participants, 63.1% (n = 128) stated that they always used their personal experience, as a source to make a clinical decision in radiography practice. The most common barrier to the implementation of EBP was insufficient time (63.5%, n = 129). CONCLUSION: This study showed that despite the positive attitude, and beliefs of radiographers toward EBP, and access to information resources, radiographers still need a higher level of confidence in their ability to engage in and implement EBP; including increased education to support the research skills needs to search and interpret publications. IMPLICATIONS FOR PRACTICE: The findings of this study may help inform restructure of the undergraduate radiography curriculum, training programs or other interventions required to promote or facilitate the adoption of EBP in Jordan.

Assessment and correlation between job satisfaction and burnout among radiographers.

INTRODUCTION: Previous research on job satisfaction (JS) and burnout has focused on physicians and nurses. However, limited work has evaluated radiographers' JS and burnout, factors affecting them and the correlation between them. The aim of this study is to assess the level and specific factors affecting burnout and JS among radiographers and to examine the correlation between them. METHODS: A questionnaire consisting of socio-demographic information and two validated instruments (Maslach Burnout Inventory-Human Services Survey for Medical Personnel (MBI-HSS (MP)) and JS Survey (JSS)) was distributed to radiographers. The MBI included 22 questions and JSS consisted of 36 questions. Mean scores were used to compare responses between participants according to demographic characteristics. Correlation between JS and burnout was examined using Pearson correlation test, with P < 0.05 determining statistical significance. RESULTS: 308 radiographers returned a completed questionnaire, 48.4% of participants were male, 48.7% had 1-6 years of experience and 61.4% examined >25 patients per day. Total emotional exhaustion, depersonalization and personal accomplishment scores were 28.7, 11.3 and 35.8 respectively. Most participants felt dissatisfied with pay (n = 221, 71.8%), opportunities for promotion (n = 202, 65.6%), fringe benefits (n = 239, 77.6%), contingent rewards (n = 231, 75.0%), operating procedures (n = 190, 61.7%) and communication (n = 162, 52.6%). Burnout was associated with work experience and caseload and JS was associated with section of work. Most of the JS domains were significantly inversely related to emotional exhaustion and depersonalisation domains. Emotional exhaustion and depersonalization drew a significant positive correlation. Emotional exhaustion and depersonalization drew a significant positive correlation. CONCLUSION: Participating radiographers are mostly dissatisfied about their jobs and they suffer a high level of emotional exhaustion. IMPLICATIONS FOR PRACTICE: To avoid the consequences of burnout and decreased JS on individuals and organizations, efforts should be done in alleviating the main factors affecting them.

Knowledge of nosocomial infection control practices among radiographers in Jordan.

INTRODUCTION: Nosocomial infections add health-related and financial burdens on health systems. This study aims to evaluate the radiographers' knowledge of nosocomial infection control practices in Jordan. METHODS: A cross-sectional questionnaire-based assessment was conducted. The main domains of the knowledge based test were the nature of nosocomial infections, standard precautions, and infection control practices specific to the radiology department. Comparison of knowledge among radiographers was assessed using the Student t-test and ANOVA. Multiple linear regression was used to find predictors of the knowledge score. RESULTS: The final analysis included 100 radiographers from educational, private, and public hospitals. Mean knowledge score was 66.2% (SD: 20.3%, range: 25.0-100%). Questions with the lowest correctly scored were about the main source of infections (17%), recapping used needles (27%), gloves use (27%), the necessity of using overshoes (26%) and a cap (26%) when there is a risk of biological fluid splashes, the necessity of using sterile gloves (7%) and protective masks (5%) during all invasive procedures, the manoeuvrability around a sterile field (54%), and the safety of passing the imaging plate to the scrub nurse in order to place it under the radiographer's direction (37%). Predictors of knowledge score were the academic degree and training status (R2 = 0.21, P < 0.001). CONCLUSION: Knowledge of infection control practices among Jordanian radiographers was moderate. Future training should focus on handling used needles, the use of protective barriers, and the manoeuvrability around sterile fields. Improved academic curriculum and on-site training could enhance knowledge in infection control practices.

What effect does mammographic breast density have on lesion detection in digital mammography?

Effective detection of breast cancer using mammography is an important public health issue worldwide. Breasts that contain higher levels of fibroglandular compared with fatty tissue increase breast radio-opacity making it more difficult to differentiate between normal and abnormal findings. The higher prevalence of breast cancer amongst women with denser breasts demands the origination of effective solutions to manage this common radiographic appearance. This brief review considers the impact of higher levels of density on cancer detection and the importance of digital technology in possibly reducing the negative effects of increased density.

Pattern of glomerular disease in the Saudi population: a single-center, five-year retrospective study.

Glomerular diseases continue to be the leading cause of end-stage renal disease (ESRD) globally. Hence, it is important to recognize the pattern of glomerular diseases in different geographical areas in order to understand the patho-biology, incidence and progression of the disorder. Published studies from different centers in Saudi Arabia have reported contradicting results. In this retrospective study, we report our experience at the Armed Forces Hospital, Riyadh, Saudi Arabia. A total of 348 native renal biopsies performed at our center on patients with proteinuria >1 g, hematuria and/or renal impairment during a period of 5 years (between January 2005 and December 2009) were studied by a histopathologist using light microscopy, immunofluorescence and electron microscopy, and were categorized. Results showed that primary glomerular disease accounted for 55.1% of all renal biopsies. The most common histological lesion was focal and segmental glomerulosclerosis (FSGS) (27.6%), followed by minimal change disease (MCD) (17.7%) and membrano-proliferative glomerulonephritis (MPGN) (13.0%). Secondary glomerular disease accounted for 37.9% of the glomerular diseases, with lupus nephritis (LN) being the most common lesion (54.5%), followed by hypertensive nephrosclerosis (22%), post-infectious glomerulonephritis (7.5%), diabetic nephropathy (DN) (6.8%) and vasculitides (4.5%). Four percent of all biopsies turned out to be ESRD while biopsy was inadequate in 2.8% of the cases. In conclusion, our study showed that FSGS was the most common primary GN encountered, while LN was the most common secondary GN. We encountered 14 cases of crescentic glomerulonephritis. Also, the prevalence of MPGN, MCD, IgA nephropathy and membranous GN was many folds higher in males when compared with the Western data. We believe that it is mandatory to maintain a Saudi Arabian Renal Biopsy Registry to understand better the pattern of glomerular disease in the Saudi population and to follow any change in trend.

Alpha-interferon with ribavirin in the treatment of hemodialysis patients with hepatitis C.

INTRODUCTION: Hepatitis C Viral (HCV) infection is the leading cause of chronic liver disease in end-stage renal disease patients (ESRD). The impact of HCV on patient and graft survival posttransplantation is controversial. The most successful approach is to eliminate the virus while the patient is on dialysis prior to transplantation. The main aim of this pilot study was to assess the efficacy of combined alpha-interferon (alpha-IFN) and ribavirin treatment of HCV hemodialysis (HDx) patients, by comparing the sustained virological response to that obtained by local historical data on treatment with alpha-IFN alone. A secondary aim was to establish the optimal therapeutic dose of ribavirin in this regimen. METHODS: Twenty HCV-HDx patients who were histologically (liver biopsy) and virologically (HCV-PCR)-positive were selected randomly. They received combination therapy with 3 million units (MU) of alpha-IFN and 200 mg of ribavirin three times a week. Initially nine patients were treated for 24 weeks. Later, another 11 patients were randomly selected to give the combination for 48 weeks. RESULTS: Six of the nine patients who were treated for 24 weeks (66%) became HCV-PCR-negative by the end of the treatment period. They continued to have a sustain virologic response at 6 months after the cessation of therapy. Six of the 11 patients (55%) who were treated for 48 weeks became HCV-PCR-negative at the end, and at 6 months after cessation of treatment. Of the first six responders, 4 (66%) maintained a sustained virologic response at 1 year postcessation of therapy. Nine of the 11 patients had genotype 4 and 1. No side effects were reported for a ribavirin dose of 200 mg three times a week. CONCLUSION: This pilot study suggests that combination treatment for 24 weeks and 48 weeks with 3 MU alpha-IFN and 200 mg ribavirin three times a week, elicited a sustained virologic response in HDx patients with HCV infection better than IFN alone with minimal side effects. A prospective, double-blind, controlled study using pegylated INF plus ribavirin is currently underway.

Caring for hemodialysis patients in Saudi Arabia. Past, present and future.

There are currently 5706 patients receiving hemodialysis therapy in the Kingdom of Saudi Arabia - a 15 fold increase when compared to 1983. The annual increase in the number of patients on dialysis for 1999 is 696 (10 fold increase when compared to 1983). Besides the massive increase in the number of patients in the last 20 years, we have noticed a marked increase in the mean age of patients (51.3 years in 1999 as compared to 37.9 years in the early 80s). Diabetes mellitus which was an insignificant contributory etiology (4%) in the early 80s is now a major cause (16-25%). Similarly mortality has increased from 4% annually to 11-14% annually. This is largely due to increasing age and prevalence of diabetes mellitus. Within the expired cohort the mean age was 62.3 years compared to 51.3 years of the total dialysis population, and diabetes mellitus was present in 60.5% in those who expired. Moreover, ischemic heart disease was diagnosed in 50% before death. Tuberculosis and Hepatitis C virus incidences, however, have not improved over the years but the degree of rehabilitation has, largely due to better hemoglobin level and due to the technological advances in dialysis delivery. This article describes these changes, their causes and implications.

Hypercholesterolemia in renal transplantation.

OBJECTIVES: We conducted this study to evaluate the prevalence, and risk factors of hypercholesterolemia (HC) in renal transplant population. METHODS: We reviewed the records of the active renal transplant patients at two large transplant centers in Riyadh and Jeddah in Saudi Arabia transplanted between 1979 and November 1998. The patients were grouped according to the measurement of serum cholesterol level; group I (normal): below or equal 5.2 mmol/L, group II (mild HC): from 5.3-6.0 mmol/L, group III (moderate HC): from 6.1-8.0 mmol/L group IV (severe HC): above 8.0 mmol/L. RESULTS: There were 1096 patients' records included in the study. According to the level of measured serum cholesterol, there were 421 (38.4%) patients is group I, 256 (23.3%) patients in group II, 363 (33.1%) patients in group III and 57 (5.2%) patients group IV. We found no significant difference between the study groups in terms of gender (60% males, 40% females), mean duration of transplantation (66.9 months), between those transplanted before 1990 and those transplanted after 1990, donor type, prevalence of hypertension (85%), history of hypertension on dialysis, original kidney disease, frequency of rejections in the first year (28%), mean serum creatinine (220 mumol/L), cyclosporine mean dose (3.2 mg/kg/day) mean prednisone dose (0.15 mg/kg/day), number of patients on azathioprine (65%), the mean proteinuria (0.6 G/L) or number of antihypertensives. In comparison with the group with normal serum cholesterol level, the group with severe hypercholesterolemia had significantly higher mean age (40.6 versus 37.4 years), higher mean weight (72 versus 65.8 kg), rate of retransplantation (8.8% versus 3.1%), higher frequency of diabetics (35% versus 20%) and higher frequency of abnormal electrocardiogram (18.2% versus 5.2%). CONCLUSION: That hypercholesterolemia is a significant problem in the renal transplant population in Saudi Arabia. Risk factors for the development of hypercholesterolemia are mainly related to weight, age, diabetes and retransplantation.

Total plasma clearance of 51Cr-EDTA: variation with age and sex in normal adults.

Although inulin clearance measured during constant infusion is still considered the reference method, single-injection of 51Cr-EDTA with subsequent plasma sampling has become the most popular technique for the routine assessment of glomerular filtration rate. Despite the fact that the technique has been in use for 30 years, there are only a few reports of normal values calculated directly from 51Cr-EDTA data and normal ranges have generally been produced by conversions of inulin data. The aim of this study was to measure the variation in total plasma clearance, calculated directly from 51Cr-EDTA measurements, in normal males and females, of Saudi Arabian origin, over a wide range. Altogether, 201 potential kidney donors aged 16-60 years were studied. No statistically significant association of total plasma clearance with age or sex could be demonstrated; however, predictive equations suggesting a small decline in total plasma clearance with age were developed. The figures presented suggest that the reduction in total plasma clearance of 51Cr-EDTA with age is relatively shallow up to the age of at least 60 years and that normal ranges produced by conversion of inulin data may overestimate the decline with age.

Diabetes and renal transplantation: saudi experience.

We conducted this study to evaluate the prevalence and risk factors of diabetes mellitus (DM) in our renal transplant population. We retrospectively reviewed the records of the active renal transplant patients at two large transplant centers in Riyadh and Jeddah in Saudi Arabia, transplanted between 1979 and November 1998. The recipients were grouped according to the diagnosis of diabetes; group I: diabetes developed before transplantation (BTDM), group II: diabetes developed only after transplantation (ATDM) and group III: did not have diabetes (NDM). There were 1112 patients' records included in the study. The mean age was 38.2 years and the mean duration of transplantation was 66.9 months. There were 113(10.2%) patients in BTDM group, 134 (12.1%) patients in the ATDM group and 865 (77.8%) patients in the NDM group. There was no significant difference in the prevalence of hypertension among the study groups. In comparison to the other groups, the BTDM group had significantly more males (78.8%), more patients who were transplanted after 1990 (pre-cyclosporin era), more patients with grafts from living non-related donors (46%), higher incidence of acute rejection episodes (39%), higher mean serum creatinine and more patients treated with azathioprine (71%). The ATDM group had significantly higher mean age (46.4 years), higher mean duration of transplantation (91.5 months), higher rate of retransplantation (8.2%), higher mean serum cholesterol level (6.0mmol/L) and more frequently abnormal electrocardiogram (24.6%) than the other two groups. The ATDM group had comparable mean weight (70.2 kg) to the BTDM group but significantly higher than the NDM group (66.1kg). The NDM group had significantly higher mean dose of cyclosporine (3.3 mg/kg/day) and higher mean dose of prednisone (0.16 mg/kg/day) than the other groups. The only independent risk factor for developing DM after transplantation was advancing age. The currently used low-dose steroid therapy was not significantly associated with development of DM after renal transplantation. Nevertheless DM is an important co-morbid condition in the transplant population and is associated with increased risk for cardiovascular and cerebrovascular events.

A Prospective Study of Renal Biopsies Performed Over One-year at the Riyadh Armed Forces Hospital.

A prospective study of all native kidney biopsies performed over one year at the Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia was conducted. During this period, 52 kidney biopsies were performed of which, 49 had adequate tissue. All biopsies were processed for light microscopy, immunofluorescence and electron microscopy. The indications for biopsy included the nephrotic syndrome (n=28; 53.8%), asymptomatic proteinuria (n=12; 21.2%), acute nephritic presentation (n=7; 13.5%) and asymptomatic hematuria (n=7; 13.5%). Primary glomerulonephritis (GN), excluding IgA nephropathy (IgAN) was seen in 34 of the 49 patients (77.6%). Focal and segmental glomerulosclerosis and mesangial proliferative GN were the most common histological diagnoses (31% and 20.4% respectively). Surprisingly, we found a high prevalence of IgA nephropathy (IgAN) of 14.5% in comparison with other studies. The prevalence of mesangiocapillary glomerulonephritis (MCGN) was low (2%) and can only be explained as incidental. The study patients were followed-up for an average of 26.3 weeks. At the end of the observation period, 50% has unchanged course, 37.5% had improved their renal function and protein excretion, and 12.5% had deteriorated. The prognosis of different GN groups and renal survival rate cannot be assessed or calculated in this study because of the relatively short duration of follow-up. Our study further emphasizes the need for a national GN registry and long-term follow-up, in order to recognize the common patterns of GN, their natural histories, the appropriate line of management, and to try and arrest their progression to end-stage renal disease.

A new treatment forInterdialytic hyperkalemia - the use of fosinopril sodium.

Fosinopril sodium is the first of the phosphinic acid class of angiotensin-converting enzyme inhibitors (ACEI). It is used as an antihypertensive agent, but differs from other ACEI in its dual routes of excretion (liver and kidney), and less incidence of hyperkalemia and cough. We conducted a study in known chronic hemodialysis patients who developed interdialytic hyperkalemia in spite of other treatments to control hyperkalemia. We used fosinopril in this group of patients to assess the effect of fosinopril on serum potassium (K) levels. Twenty-four patients were given fosinopril 10 mg at 18:00 h daily for 8 weeks. K levels were measured before and after each dialysis treatment. Interdialytic weight gains were recorded. The average pretrial potassium level was 6.57 mmol/l (+/- 0.47), and the posttrial level was 5.34 (+/- 0.76); p

The diagnosis of segmental transplant renal artery stenosis by captopril renography.

The captopril renogram test has been shown to be a sensitive test for the diagnosis of renal artery stenosis in native and transplanted kidneys. Most reports have involved only stenosis of the main renal artery. Although segmental renal artery stenosis has been diagnosed successfully in native kidneys, it is not clear whether the captopril renogram test can diagnose segmental renal artery stenosis in a transplanted kidney. The authors report two cases of successful identification, by the captopril renogram test, of functionally significant stenosis in an intrarenal branch of a single transplant renal artery.

Hypertension in renal transplantation: saudi arabian experience.

To evaluate the prevalence, etiologic factors and therapy of hypertension in actively followed up transplant population in Saudi Arabia; we retrospectively reviewed the records of the active renal transplant patients at two large transplant centers in Riyadh and Jeddah in Saudi Arabia. These subjects were transplanted between January 1979 and November 1998. The patients were grouped according to the measurement of blood pressure; group 1 (considered normo-tensive): blood pressure below 140/90 mmHg, group2: blood pressure between 140-159/90-99, group 3: blood pressure 160-179/100-109 group 4: equal to or above 180/110. There were 1115 patients' records included in the study. The mean duration of transplantation was 66.9 +/- 50.1 months. According to the level of measured blood pressure, there were 641 (57.5%) patients in the normotensive group (group 1), 404 (36.3%) patients in the mildly hypertensive group (group 2) 64 (5.7%) patients in the moderately severe hypertension group (group 3) and only six (0.5%) patients in the severe hypertension group (group 4). The estimated prevalence of hypertension in this study was almost 85%. We found no significant difference in the prevalence of hypertension in terms of gender, year of transplantation, duration of transplantation, type of donor, number of previous transplants, diagnosis of renal artery stenosis, etiology of kidney disease, diagnosis of diabetes after transplantation, diagnosis of cerebrovascular accidents, or mean dose of prednisolone and cyclosporine. There was a statistically significant association between increased level of blood pressure and old age (above 50 years), original disease associated with hypertension, history of hypertension on dialysis, acute rejection (once or more), presence of protienuria (more than 0.3 mg/day), abnormality of ECG, or serum creatinine above 300 micromol/L. We conclude that hypertension is highly prevalent in the renal transplant population in Saudi Arabia. Risk factors for the development of hypertension or its complication should be more aggressively approached in order to protect the patients and their grafts alike.