Telemedically Supported Case Management of Living-Donor Renal Transplant Recipients to Optimize Routine Evidence-Based Aftercare: A Single-Center Randomized Controlled Trial.

Improving mid-term and long-term outcomes after solid organ transplantation is imperative, and requires both state-of-the-art transplant surgery and optimization of routine, evidence-based aftercare. This randomized, controlled trial assessed the effectiveness of standard aftercare versus telemedically supported case management, an innovative aftercare model, in 46 living-donor renal transplant recipients during the first posttransplant year. The model includes three components: (i) chronic care case management initiated after discharge, (ii) case management initiated in emerging acute care situations, and (iii) a telemedically equipped team comprising a transplant nurse case manager and two senior transplant physicians (nephrologist, surgeon). Analyses revealed a reduction of unplanned inpatient acute care, with considerable cost reductions, in the intervention group. The prevalence of nonadherence over the 1-year study period was 17.4% in the intervention group versus 56.5% in the standard aftercare group (p = 0.013). Only the intervention group achieved their pre-agreed levels of adherence, disease-specific quality of life, and return to employment. This comparative effectiveness study provides the basis for multicenter study testing of telemedically supported case management with the aim of optimizing posttransplant aftercare. The trial was registered with the German Clinical Trials Register (www.DRKS.de), DKRS00007634.

[Hemicentral retinal artery occlusion due to oral contraceptives]. / Hemizentralarterienverschluss bei Einnahme der "Pille"--Mitteilungen über Komplikationen von Kontrazeptiva.

BACKGROUND: Low-dose oral contraceptives can still cause thromboembolic disorders with serious neurologic or ocular disabilities. PATIENT: A 22-year-old woman having used oral contraceptives for several months noticed sudden painless visual loss in her left eye. One tablet of her contraceptive contained ethinylestradiol (0.03 mg) and chlormadinonacetate (2 mg). RESULT: Because of the lower left eye visual field defect, the patient could only read with her right eye. She presented complete left inferior hemianopia, indicating a hemicentral retinal artery obstruction. Visual acuity in both eyes was 20 / 20. The left fundus revealed a distinct retinal edema in the area superior to the optic disc and macula due to vascular disturbances of the superior temporal superior and superior nasal retinal arteries. The right eye was normal. Fluorescein angiography revealed recanalized arteries in the superior retinal area with conspiciously early dye filling as a paradoxical sign. Doppler sonography of the neck and orbital arteries and transesophageal echocardiography (TEE) findings were inconspicious. However, blood examination revealed an elevated thrombin-antithrombin complex and reduced free protein S. CONCLUSION: Coagulopathy can be a side effect of oral contraceptives. Even nowadays, women taking contraceptives risk the danger of vascular occlusions especially if the women suffers from arterial hypertension, diabetes mellitus, have a coagulation anomaly, or if she is a chronic smoker. Before treatment with oral contraceptives commences, a thorough medical examination is necessary. If the family history reveals prominent cardiovascular risk factors, testing for thrombophilia is recommended. Even nowadays, patients should be warned of the risk of visual field defects as a potential side-effect associated with oral contraceptives.

Rapidly progressive hepatic alveolar echinococcosis in an ABO-incompatible renal transplant recipient.

We report on the case of an ABO-incompatible renal re-transplant recipient maintained on an intensified immunosuppressive regimen for recurrent cellular rejection episodes and transplant glomerulopathy who presented with rapidly growing hepatic tumors, radiologically suggestive of hemangiosarcoma. Upon resection and pathological work-up, the lesions revealed alveolar echinococcosis, a rare but potentially life-threatening parasitosis. Usually infection with Echinococcus multilocularis remains asymptomatic for extended periods of time and can go unrecognized for years. In the case presented, we observed an atypically rapid growth pattern of E. multilocularis that might have been due to the extent of the immunosuppressive regimen, which included repetitive anti-CD20 treatments. Retrospectively performed serological studies with enzyme-linked immunosorbent assays known to provide high sensitivity and specificity for the detection of echinococcosis in the general population, yielded ambiguous results in our immunocompromised host, which could be, in part, explained by B-cell depletion and its effects on antibody production and indirect actions on cellular immunity. In conclusion, this is the first report to our knowledge of hepatic alveolar echinococcosis in a renal transplant recipient. This case documents an altered clinical course of the parasitosis and the challenge of serological diagnostic tools under an intensified regimen of immunosuppressive agents, including rituximab.

Medical ethics as therapy.

In this paper, the author examines a style of teaching for a medical ethics course designed for medical students in their clinical years, a style that some believe conflicts with a commitment to analytic philosophy. The author discusses (1) why some find a conflict, (2) why there really is no conflict, and (3) the approach to medical ethics through narratives. The author will also argue that basing medical ethics on the use of narratives has problems and dangers not fully discussed in the literature.

Race differences in weight concerns among women smokers: results from two independent samples.

To investigate attitudes about weight as they interact with smoking in African American women, we analyzed data from two independent samples of white and African American women smokers--one assembled via a national random-digit-dialing survey, the other consisting of candidates for enrollment in local studies. Findings for the two samples were remarkably consistent. African American women were significantly heavier and significantly more likely to have a self-reported BMI > or = 27. Although the preferred weight for African American women was significantly higher than for white women, the percentage by which they exceeded their preferred body weight did not differ significantly between groups, and the difference between actual and preferred weights was actually greater for African American women. African American women were more likely to be satisfied with their body shape and were significantly less likely to exercise to control weight. They did not differ significantly on binge-eating or dieting. African American women were more likely than white women to be unwilling to gain any weight upon quitting smoking but did not differ significantly on any other smoking-related weight concerns. Our results suggest that weight concerns, though differently conceptualized, may motivate African American women as powerfully as white women. They strongly suggest that race differences need to be considered in designing optimal smoking cessation interventions for weight-concerned women smokers. To accomplish this goal, efforts to identify a vocabulary for the expression of weight concerns in African American women will be needed, as will attention to ways to avoid exacerbating obesity and to encourage exercise.

Characterizing concerns about post-cessation weight gain: results from a national survey of women smokers.

Differences among adult women smokers with differing levels of concern about post-cessation weight gain were investigated in a national random-digit-dialing survey. To avoid defining weight concerns in terms of possible etiologies or contributory factors, respondents were stratified using a single item querying concern about post-cessation weight gain; 39% described themselves as very concerned (VC), 28% as somewhat concerned (SC), and 33% as not concerned (NC). Significant between-groups differences were detected for measures of weight and body image, eating patterns and weight control practices, and nicotine dependence, but not for depression. Differences, primarily between VC and NC, were also detected for several weight-related smoking variables, including importance of weight as a factor in initiation, smoking as a weight control strategy, increased appetite and weight gain as withdrawal symptoms, willingness to gain weight upon quitting, self-efficacy about relapse in the face of weight gain, and readiness to quit smoking. Most differences persisted even after adjusting for body mass index and nicotine dependence. Although the importance of thinness was rated higher by weight-concerned women, the difference did not reach significance. Rather, what differentiated groups was the importance of overall body image, suggesting a larger pattern of preoccupation with body image that may not be captured by queries about weight concerns alone. We conclude that weight-concerned women smokers will be especially unlikely to seek treatment or attempt self-quitting; and that redirecting attention to other aspects of body image is likely to be more helpful than attempting to divert attention away from body image.

Analysis of laboratory data in acne patients treated with isotretinoin: is there really a need to perform routine laboratory tests?

INTRODUCTION: Isotretinoin has been used to treat acne since 1982. Its current indications in the package insert are limited and many physicians still feel uncomfortable prescribing it because of its side effects. Serum levels of liver enzymes and lipids are carried out as a routine in most clinics both before and during treatment. AIMS: Our objective was to evaluate the effect of isotretinoin on serum lipids, liver function and other laboratory parameters in order to assess the necessity to perform routine laboratory tests. METHODS: Computerized medical files of 1292 patients in private practice that received isotretinoin for acne were analyzed. RESULTS: 907 patients completed a treatment course of 5 to 9 months. Serum levels of liver enzymes were not elevated to a degree necessitating discontinuation of treatment. Only 1.5% of the patients had serum triglyceride levels above 400 mg%. No laboratory abnormalities were a cause for discontinuation of treatment. During a 6-year follow up only 3.5% of patients received a second course of therapy with isotretinoin. CONCLUSIONS: Aside from its teratogenic effect, isotretinoin is a safe and excellent drug for acne therapy. It should be prescribed for any inflammatory acne and in our opinion there is no need for a routine laboratory follow-up in young, healthy patients aside from a pregnancy test in females. At present, isotretinoin should be considered as the drug of choice for moderate to severe acne.

Bribery and extortion: can restaurants help?

Examples of tipping suggest that the distinction between tipping, bribery and extortion can be questioned. Some well known ideas about bribery will not work if extended to tipping and, indeed, these analyses may founder whether or not tipping, bribery and extortion merge. I suggest that more case study analysis as well as a discussion of the relationship between character and actions are needed.

The psychological impact of reproductive difficulties on women's lives.

Little is known about the long-term impact of reproductive experiences on women's lives. This paper uses questionnaire data collected from 107 White female college graduates, when they were approximately 47 years old. More than half the sample had experienced at least one type of reproductive difficulty (abortion, miscarriage, or infertility). The stress and coping model of life difficulties (Lazarus and Folkman, 1984) was used to examine the relationship between the women's reproductive difficulties and emotional sequelae, politicization, and orientation to motherhood at midlife. As predicted, emotional responses to the reproductive difficulties varied according to the particular nature of each experience. In addition, women who had abortions and no other difficulties were more politicized at midlife than other women. Women whose reproductive experiences were especially likely to arouse feelings of not being in control of their life (those who had miscarriages or infertility) described a more agentic orientation to motherhood when compared with other women.

Death and language: some comments on Haussamen.

Brock Haussamen argues inventively that there are features of language that are the source of our belief in an afterlife, that something deep about language prevents us from talking about the dead as if they are really dead. He speaks of "language as forcing." In this response to Haussamen's article, the author attempts to show that Haussamen's arguments and examples are not strong enough to make his point. The major suggestion is that there is more to the "deep structure" of language than Haussamen has assumed. Once this is realized, it is easier to see that it is we who choose to speak of the dead as we do. It is we who choose to believe in an afterlife. Language does no forcing.

Hyperbaric oxygenation upregulates rat lung Na,K-ATPase.

Exposure of rats to hyperoxia is associated with increased active Na+ transport in rat lungs and increased Na,K-adenosine triphosphate (ATPase) expression in alveolar epithelial cells. Hyperbaric oxygenation (HBO) has been reported to act as an accelerated model of hyperoxic cell damage. Sublethal and intermittent exposure to HBO, however, has been suggested to upregulate endogenous protective mechanisms. In the present study, we tested whether short-term HBO, prior to inducing lung injury, would upregulate lung Na,K-ATPase. The results show that HBO, either intermittent or single 2.5 h exposure, increased lung Na,K-ATPase alpha-1 and beta-1 messenger ribonucleic acid (mRNA) transcript levels up to fourfold. Na,K-ATPase activity in lungs of rats exposed to HBO increased twofold during the first 2 h following removal from the hyperbaric chamber, and remained elevated for up to 6 h following HBO. Conceivably, the increase in Na,K-ATPase activity following HBO is due to an increase in activity from a basal to a higher rate, or possibly due to recruitment/translocation of Na,K-ATPases from inner membranes to the plasma membrane.

Pediatric critical care physicians' attitudes about guidelines for the use of ribavirin in critically ill children with respiratory syncytial virus pneumonia.

OBJECTIVE: To determine the attitude of pediatric critical care physicians concerning the use of ribavirin in children with respiratory syncytial virus lung disease in light of the revised American Academy of Pediatrics practice guidelines. DESIGN: A questionnaire was sent to 145 pediatric critical care doctors in the United States. MEASUREMENTS AND MAIN RESULTS: Seventy-seven percent of questionnaires were returned. The vast majority (91%) of the respondents think that the available literature does not support the Academy's recommendations for the administration of ribavirin to critically ill children with respiratory syncytial virus pneumonia. The largest single group of respondents (42%) does not usually prescribe ribavirin for these patients, but may be persuaded to use it by colleagues or consultants in individual cases. Twenty-six percent of all respondents stated that they do not use ribavirin at any time, even in severely ill patients with documented infection. Twenty-two percent of the respondents say that they will prescribe ribavirin, not because they believe it is efficacious, but because they believe the Academy guidelines compel them to do so as a standard of care. The respondents reported adverse effects of the drug, most notably exacerbations of bronchospasm (92%), far more often than the Academy document asserts. When solicited for general comments, the respondents were frequently concerned that critical care physicians were not involved in the development of the guidelines, the guidelines were based on a paucity of reliable data, and that the guidelines could put them at risk of malpractice litigation should they choose to not use ribavirin. CONCLUSIONS: Practice guidelines are increasingly being incorporated into patient care and quality improvement regimens, and it is imperative both that appropriate experts be included in their development, and that they be based on valid scientific data. The pediatric critical care community currently treats most of the severely ill patients with respiratory syncytial virus pneumonia. As a group, they remain unconvinced about the efficacy and safety of this drug, and many pediatricians are concerned about the ramifications of individualizing ribavirin therapy in their patients in light of the revised Academy recommendations.

Chapman's reflexes: medicine or metaphysics?

Clinical medicine is a pragmatic discipline. Because of its aim to alleviate pain and suffering as well as to foster well-being, its practitioners can be lulled into thinking that there are times when basic science is irrelevant to the practice of medicine. This attitude is evaluated by comparing a 19th century medical curiosity, the nasogenital reflex, to a set of reflexes, the little used and little known Chapman's reflexes. We must always attempt to substantiate the principles of clinical medicine.

Do-not-resuscitate orders in a children's hospital.

OBJECTIVES: a) To quantify the use of do-not-resuscitate orders in a tertiary care children's hospital; and b) to characterize the circumstances in which such orders are written. DESIGN: Retrospective chart review. SETTING: University teaching hospital. PATIENTS: All inpatients who died in an urban children's hospital over a 1-yr period of time. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The hospital records of 54 of 69 patients who died were reviewed. Eighty-two percent of patient deaths occurred in the ICU; 13% of patient deaths occurred in the operating room, and 5% occurred in a medical ward. Other findings included the following: 25 (46%) of 54 patients died after attempted cardiopulmonary resuscitation; 13 (24%) patients were brain dead; and 16 (30%) died with a do-not-resuscitate order in effect. Age was associated with resuscitation status: do-not-resuscitate orders were written for five (21%) of 22 infants (< 1 yr of age); seven (50%) of 14 children (1 to 11 yrs of age); and four (80%) of five adolescents who died (p < .002). Fifteen of 16 do-not-resuscitate orders were written for patients who were in the ICU, where they remained until death. Findings in patients when the do-not-resuscitate orders were written were as follows: 15 ICU patients were receiving mechanical ventilation; 14 (95%) of 15 were receiving inotropic agents; 12 (80%) of 15 patients were receiving narcotic analgesics; and one (6%) patient was being dialyzed. At least one therapeutic modality was withdrawn in 7 (44%) of 16 patients. Do-not-resuscitate orders followed documented conferences with physicians and family members in 13 (81%) of 16 cases. These discussions were initiated by physicians in 12 (92%) of 13 cases. CONCLUSIONS: Do-not-resuscitate orders in pediatric patients are written more often in older than younger hospitalized children who die. Most do-not-resuscitate orders are written for patients who are receiving aggressive medical therapy in the ICU.

Baby marrow: ethicists and privacy.

A family had a child in large part to use its marrow in the hopes of saving the life of an older child afflicted with leukaemia. Public response from medical ethicists was negative. This paper argues that what the family did was not clearly wrong and that the ethicists should not have made public pronouncements calling the morals of the family into question.

PEEP is necessary for exogenous surfactant to reduce pulmonary edema in canine aspiration pneumonitis.

Alveolar edema inactivates surfactant, and surfactant depletion causes edema by reducing lung interstitial pressure (Pis). We reasoned that surfactant repletion might reduce edema by raising Pis after acute lung injury and that positive end-expiratory pressure (PEEP) might facilitate this effect. One hour after tracheal administration of hydrochloric acid in 18 anesthetized dogs with transmural pulmonary capillary wedge pressure of 8 Torr, the animals were randomized into three groups: in the SURF + PEEP group, 50 mg/kg of calf lung surfactant extract (CLSE) was instilled into each main stem bronchus with 8 cmH2O of PEEP; in the SAL + PEEP group, PEEP was followed by an equal volume of saline (SAL); in the SURF group, CLSE was given without PEEP. After 5 h, edema in excised lungs (wet-to-dry weight ratios) was significantly less in the SURF + PEEP group (9.1 +/- 1.0) than in the other groups (11.3 +/- 1.8 and 11.3 +/- 1.8, respectively). In the SURF + PEEP group, pulmonary venous admixture fell by 6%; this change was different from the 7% increase in the SAL + PEEP group and 40% increase in the SURF group (P less than 0.05). Airway secretions obtained in the SURF + PEEP group had normal minimum surface tensions of 4 +/- 2 mN/m, a value much lower than in SAL + PEEP and SURF groups (32 +/- 4 and 22 +/- 7 mN/m, respectively). We conclude that surfactant normalizes surface tension and decreases transcapillary hydrostatic forces in this lung injury model, thereby reducing edema formation and improving gas exchange. These benefits occur only if surfactant is given with PEEP, allowing surfactant access to the alveoli and/or minimizing its inhibition by edema proteins.

Structured skin care regimen to prevent perineal dermatitis in the elderly.

A preliminary investigation was conducted to determine the efficacy of a structured skin care regimen to prevent perineal dermatitis in incontinent geriatric psychiatry patients. A 10-week, prospective, clinical trial was conducted (n = 15). Four weeks (weeks 2 to 5) were devoted to monitoring the unstructured pretreatment nursing skin care practice and to determining the incidence of perineal dermatitis in incontinent patients. Four weeks (weeks 7 to 10) were also spent implementing and observing the structured nursing skin care regimen. The study revealed that 33% (three) of the subjects in the unstructured skin care group and 33% (two) of the subjects in the structured skin care group had perineal dermatitis. In subjects with a combination of urine and stool incontinence perineal dermatitis developed within 2 days. The findings suggest that perineal dermatitis occurs quickly in the presence of urine and stool incontinence. Further research is needed to validate the efficacy of a structured skin care regimen to prevent perineal dermatitis.