Klebsiella necrotizing soft tissue infections in liver transplant recipients: a case series.

Necrotizing soft tissue infections (NSTI) are rare but carry high mortality rates. NSTI with Klebsiella species have been previously described as associated with Klebsiella liver abscesses and endophthalmitis. Here, we describe 6 cases of NSTI in liver transplant recipients associated with Klebsiella pneumoniae, 4 of which were K. pneumoniae carbapenemase (KPC)-producing K. pneumoniae (CRKP). Increased awareness of this emerging pathogen and its association with necrotizing skin and soft tissue infection is critical, as early recognition and debridement may improve survival. Antimicrobial treatment of CRKP infections remains an ongoing challenge and implementation of enhanced infection control measures is essential.

A national survey of independent living donor advocates: the need for practice guidelines.

In 2000, representatives of the transplant community convened for a meeting on living donation in an effort to provide recommendations to promote the welfare of living donors. One key recommendation included in the consensus statement was that all transplant centers which have performed living donor surgeries have an independent living donor advocate (ILDA) "whose only focus is on the best interest of the donor." The aims of this study were to begin to understand the sociodemographic characteristics, selection and training, and clinical practices of ILDAs. All US transplant centers performing living donor surgeries were contacted to identify the ILDA at their center. One hundred and twenty ILDAs completed an anonymous survey. Results indicated considerable variability with regard to the sociodemographic characteristics of ILDAs, how the ILDA was selected and trained, and the ILDAs' clinical practices, particularly ethical challenges encountered by ILDAs. The variability observed may result in differential selection of donors and could have a potential negative impact on the lives of both donors and transplant candidates. The variability in the background, training, and practice of ILDAs suggests the need for strategies, such as practice guidelines, to standardize the interaction between ILDAs and living donors.

Anti-lymphocyte therapy successfully controls late "cholestatic" rejection in pediatric liver transplant recipients.

Rejection is independently associated with liver graft loss in children. We report the successful rescue of grafts using ATG+/-OKT3 in late rejection associated with cholestasis. Retrospective chart review was performed after IRB approval. Between 2003 and 2010, 14 pediatric liver transplant recipients received anti-lymphocyte treatment for "cholestatic" rejection. Median age at transplantation was 12.7 yr (range 0.9-23.4), eight were boys, and immunosuppression was tacrolimus based. Median time from transplantation to rejection was five yr (range 1.1-10.5). Median peak total bilirubin was 11.1 mg/dL (range 1.4-18). All showed moderate to severe acute rejection and hepatocellular cholestasis on histology. ATG/OKT3 was started as first-line therapy in six and in the remaining eight as second-line therapy after failure of pulse steroids. Thirteen responded with normalization of aminotransferases and bilirubin, median time 16 wk (range 7-112); one non-adherent recipient has still not achieved normal graft function at last follow-up. Patient survival is 100%, with no re-transplantation and no post-transplant lymphoproliferative disease, median follow-up 2.9 yr (range 1.1-7.2). Cholestasis associated with acute rejection occurring late after liver transplantation may herald steroid resistance. First-line therapy with anti-lymphocyte preparations, prophylactic anti-microbial therapy, and close monitoring allow excellent rates of patient and graft survival.

Nevirapine-induced stevens johnson-syndrome and fulminant hepatic failure requiring liver transplantation.

We describe a case of nevirapine-induced Stevens-Johnson Syndrome (SJS) and fulminant hepatic failure (FHF) requiring liver transplantation. Five weeks prior to admission, a 57-year-old female with HIV infection had been switched to a nevirapine-based regimen of highly active antiretroviral therapy (HAART) with a CD4 cell count of 695/mm(3). Examination of the explanted native liver at initial transplantation revealed massive hepatic necrosis consistent with drug-induced liver injury. Primary graft nonfunction complicated the early postoperative course and liver retransplantation was required. On follow-up 2 years later, she remains in good health with an undetectable viral load on an efavirenz-based regimen of HAART. To our knowledge, this is the first report of successful liver transplantation following SJS and FHF.

Orthotopic placement of a segmental pancreas graft for transplant: a case report.

Pancreas retransplantation has become more frequent and represents a technical challenge for surgeons. Knowledge of alternative surgical options could be useful in difficult cases. We present a case of brutal diabetes mellitus in a patient with severe vascular disease that underwent a third pancreas transplant. Difficulties in obtaining arterial inflow were solved utilizing the native splenic vessels, placing the graft in orthotopic position, and a combination of historical surgical techniques in pancreas transplantation; that is, segmental grafts and duct injection for exocrine management made transplantation successful.

Outcome of combined liver and kidney transplantation in hepatitis C: a single-center long-term follow-up experience.

INTRODUCTION: Hepatitis C (HCV) cirrhosis is the prevalent liver disease requiring liver transplantation in the United States. Candidates who also have end-stage renal disease, chronic renal disease stage 4, or prolonged hepatorenal syndrome are considered for combined liver and kidney transplantation (CLKT). MATERIALS AND METHODS: We performed a retrospective study of HCV(+) and HCV(-) CLKT patients with more than 12 months of follow-up and HCV(+) patients with isolated liver transplant (OLT) to compare the outcomes of various groups. RESULTS: Since 1988, 2983 OLTs were performed at our institution including 58 CLKTs. Of these, 23 were HCV(+) subjects who were significantly older than HCV(-) CLKT patients. Race, pretransplant dialysis time, renal indication for CLKT, Model for End-stage Liver Disease score, donor age, liver and kidney rejection as well as occurrence of posttransplant hypertension were similar among HCV(+) and HCV(-) CLKT patients. Posttransplant diabetes was observed in 80% of the HCV(+) group and 30% of the HCV(-) group (P = .01). Renal function seemed to be better in HCV(-) when compared with HCV(+) subjects at 5 years (P = .09). Overall patient survival for HCV(+) CLKT, HCV(-) CLKT, and HCV(+) OLT groups at 1, 2, and 5 years were not significantly different (P = .6). CONCLUSION: HCV positivity should not exclude appropriate candidates for CLKT.

Alcohol abstinence and orthotopic liver transplantation in alcoholic liver cirrhosis.

Patients diagnosed with acute alcoholic hepatitis (AAH) are routinely managed medically and not considered suitable for orthotopic liver transplantation (OLT). The eligibility for OLT in these patients has been questioned due to the social stigma associated with alcohol abuse, based on the fact that AAH is "self-induced" with an unacceptably high recidivism rate. Many centers in Europe and the United States require abstinence periods between 6 and 12 months before OLT listing. AAH outcomes in the literature are poor, in particular due to patient noncompliance during the immediate 3 months preceeding OLT. Between January 1997 and December 2007, 246 patients were evaluated in our center for alcoholic liver disease: 133 (54%) were listed for OLT (I-OLT), including 110 (83%) who underwent transplantation and 8 (6%) still listed as well as 15 (11%) removed from consideration. One hundred thirteen (46%) patients had no indication for OLT (NO I-OLT), including 18 (16%) who died, 81 (71%) still monitored, and 14 (12%) lost to follow-up. Patient survival rates post-OLT were 79%, 74%, 68%, and 64% at 1, 3, 5, and 10 years, respectively. Explant (native liver) pathologic examination revealed AAH in 8 (7.2%) patients who underwent OLT. In this group, patient survival and the post-OLT recidivism rate were statistically identical to the overall group of transplant recipients.

Death on the kidney waiting list--good candidates or not?

The waiting list for a kidney or simultaneous pancreas-kidney transplant is growing, and waiting times are getting longer. As a consequence, transplant candidates are dying while waiting for a transplant. In a retrospective analysis, we studied whether patients on our list who died while waiting were good candidates. From January 1, 2002, through September 30, 2004, 85 candidates on our list died. Of these, 71% were waiting for a first transplant; 62% had a current panel-reactive antibody (PRA) level of 0%. Of the 85 candidates who died, the mean (+/-SD) age was 53 +/- 11 years; mean waiting time from listing to death, 979 +/- 749 days. The most common cause of death was cardiovascular disease. Many of those candidates who died while waiting were young, first-transplant candidates with a low PRA level. But only limited information was available; prospective studies are necessary to determine whether or not they were, in fact, good candidates.

Blunt traumatic rupture of the thoracic aorta: a report of an unusual mechanism of injury.

Classic teaching suggests that blunt thoracic aortic rupture (BTAR) results from high-speed deceleration injury mechanisms. Our recent experience with a patient who sustained fatal aortic rupture resulting from a low-speed crushing injury emphasizes the importance of maintaining a high index of suspicion for BTAR, even in patients with "low-risk" injury mechanisms. Several potential pathophysiologic mechanisms of BTAR are discussed.

The relationship of unsafe sexual behavior and the characteristics of sexual partners of HIV infected and HIV uninfected adolescent females.

PURPOSE: To compare characteristics of sexual relationships in HIV infected and HIV uninfected female adolescents and their association with condom use. METHODS: HIV infected and uninfected subjects, aged 13-19 years, were enrolled in a prospective HIV study from 15 sites in 13 U.S. cities. Baseline data on demographic information, substance use, sexual behavior, partner information, and condom use were collected through direct and computer-assisted interviews from currently sexually active females. Univariate, multiple logistic regression, and repeated measures analyses were employed. RESULTS: Data from 153 HIV infected and 90 HIV uninfected female subjects showed, on average, that current partners were 4-6 years older. In multivariate analysis, HIV infected subjects were older (OR = 1.37; 95% CI: 1.04-1.81), had more lifetime partners (OR = 2.23; 95% CI: 1.03-4.82), initiated consensual vaginal sex earlier (OR = .74; 95% CI:.58-.95), perceived partner to also be HIV infected (OR = 7.46; 95% CI: 3.2-17.4), and had less unprotected sex (OR = .27; 95% CI:.16-.45). Length of relationship was associated with more unprotected sex for both HIV infected and uninfected subjects (OR = 2.59, 95% CI: 1.27-5.27, OR = 4.13; 95% CI: 1.31-13.05, respectively). Mean partner age difference was greater among HIV infected than for HIV uninfected (OR = 1.06; 95%CI: 1.01-1.12); this greater age difference for HIV infected females was associated with less protection (OR = 1.09; 95% CI: 1.03-1.15). HIV disclosure influenced condom use: without disclosure, less condom use was reported (OR = 6.8; 95% CI: 2.29-20.24) controlling for perception that partner was also HIV infected (OR = 1.1; 95% CI: 1.02-1.21). CONCLUSIONS: Because age differential influenced reported condom use, more research, particularly qualitative, is needed into the dynamics of these relationships. Prevention efforts must address partners, particularly older ones.

Service use patterns of youth with, and at high risk for, HIV: a care typology.

This paper uses confirmatory structural equation models to develop and test a theoretical model for understanding the service utilization history of 4679 youth who received services from 10 national HIV/AIDS demonstration models of youth-appropriate and youth-attractive services funded by the Special Projects of National Significance (SPNS) Program, HIV/AIDS Bureau, Health Resources and Services Administration. Although the projects differ from one another in the areas of emphasis in their service models, each is targeted to youth at high risk for HIV, or those youth who have already contracted HIV. Collectively, the projects represent a comprehensive adolescent HIV service model. This paper examines the characteristics of the services provided to young people ranging from outreach to intensive participation in medical treatment. Major typologies of service utilization are derived empirically through exploratory factor and cluster analysis methods. Confirmatory structural equation modeling methods are used to refine the exploratory results using a derivation and replication strategy and methods of statistical estimation appropriate for non-normally distributed service utilization indicators. The model hypothesizes that youth enter the service system through a general construct of connectedness to a comprehensive service model and through service-specific methods, primarily of outreach or emergency services. Estimates are made of the degree to which a comprehensive service model drives the services as opposed to specific service entry points.

Predicting substance abuse among youth with, or at high risk for, HIV.

This article describes data from 4,111 males and 4,085 females participating in 10 HIV/AIDS service demonstration projects. The sample was diverse in age, gender, ethnicity, HIV status, and risk for HIV transmission. Logistic regression was used to determine the attributes that best predict substance abuse. Males who were younger; HIV positive; homeless; involved in the criminal justice system; had a sexually transmitted disease (STD); engaged in survival sex; and participated in risky sex with men, women, and drug injectors were most likely to have a substance abuse history. For females, the same predictors were significant, with the exception of having an STD. Odds ratios as high as 6 to 1 were associated with the predictors. Information about sexual and other risk factors also was highly predictive of substance abuse issues among youth.

Risk factors and characteristics of youth living with, or at high risk for, HIV.

Over 8,000 adolescents and young adults (4,111 males; 4,085 females) reported on several HIV-related risk behaviors during enrollment into 10 service demonstration projects targeted to youth living with, or at risk for, HIV. Distinct risk patterns emerged by gender when predicting HIV serostatus (versus unknown serostatus/negative serostatus). Males who had injection drug risk histories, had sex with an HIV positive partner, had sexually transmitted diseases, had sex with males, and/or were homeless had an inflated risk of being HIV positive. Females who engaged in sex with an HIV partner, had sex with an injection drug user, and/or had sexually transmitted diseases, were at the highest HIV risk. For both samples, engaging in sex with women reduced the likelihood of HIV positive status. Very basic information about risk factors obtained at service intake offers important information about HIV status of "high risk" youth presenting for care in community programs, as well as suggests clear risk factors for targeted preventive efforts.

The University of Alabama Teenage Access Project: a model for prevention, referrals, and linkages to testing for high-risk young women.

The Teenage Access Project (TAP) was supported by the Special Projects of National Significance Program to expand and ensure access to health and support services for disadvantaged, human immunodeficiency virus (HIV)-positive, and at-risk adolescent and young adult women aged 10-21 years by: (a) preventing further HIV transmission through empowerment and reduction of risk behavior, (b) providing HIV counseling and testing to increase screening of young women, and (c) facilitating referrals to medical and psychosocial services through the TAP activities. TAP served 403 young people (82% African-American and 83% young women). The basic elements of the TAP service model components were: (a) outreach to community agencies serving high-risk, disadvantaged young women; (b) My Individual Responsibility Reduces Our Risk (MIRROR), a six-module risk-reduction and empowerment activity specifically designed for young women in Jefferson County, using a small group format; and (c) the Adolescent Testing Center (ATC), a center for age and culturally appropriate HIV testing, pre- and posttest counseling, risk assessment, and referrals. HIV testing and pre- and posttest counseling were provided confidentially in both clinical and community settings. More than 200 participated in the MIRROR activity. A total of 101 young women received HIV counseling and testing services.

Risk for gonococcal and chlamydial cervicitis in adolescent females: incidence and recurrence in a prospective cohort study.

PURPOSE: This study attempted to determine the incidence and risk for gonococcal and chlamydial cervicitis among sexually active urban adolescent females. METHODS: The study design is a prospective cohort study. A cohort of 216 sexually active females were followed with repeat sexually transmitted diseases screening for 12-24 months. Subjects positive on any retest (FU) were compared with those who remained negative on all FU. Subjects were interviewed for history and screened for endocervical gonococcal and chlamydial infection. RESULTS: The number of visits per patient ranged from 2 to 9 (median, 3). The initial Chlamydia trachomatis and Neisseria gonorrhoeae rates were 23.2 and 11.6%, respectively. The cumulative FU positive rates were 20.8% for C. trachomatis and 17.1% for N. gonorrhoeae. Although the initial gonococcal infection was a significant risk for a subsequent infection by C. trachomatis (p = .05) and N. gonorrhoeae (p = .001), the initial C. trachomatis status was not predictive of subsequent infections. The number of partners was not predictive of subsequent infections with either. In the entire study period, 86 patients had at least one episode of C. trachomatis and N. gonorrhoeae infection was confirmed in 52; 20 patients had recurrent cervicitis. During the study, 101 episodes of C. trachomatis and 68 episodes of N. gonorrhoeae infections were identified. Those with recurrent cervicitis (9.3%) were responsible for 33% of all cervicitis episodes identified during the study. CONCLUSIONS: Adolescents in our study were at high risk for cervicitis, particularly as a result of C. trachomatis. Risk for subsequent C. trachomatis cervicitis was the same among initially positive and negative groups. Our data underscore the importance of repeat screening for sexually transmitted infections and treatment of contacts of adolescent females.

Sexual behavior and sexually transmitted diseases among male adolescents in detention.

BACKGROUND: Youth in detention represent a medically underserved population at risk for a variety of medical and emotional disorders. GOAL OF THE STUDY: To determine prevalence of STDs and high-risk sexual behaviors for HIV/STD among adolescent males admitted to a juvenile detention facility. STUDY DESIGN: Cross-sectional study of behavioral risk factors and STD prevalence among detained males, 11 to 18 years of age. Study subjects were interviewed for behavioral history and screened for STD. RESULTS: The median number of lifetime partners of the population was 8 (range 1-100), the number of partners in the preceding 4 months was 2 in median (range 0-30), 59% used a condom with their last sex, and consistent condom use in the past 4 months was reported by 37%. A history of sexual intercourse within the last one week was reported by 43%. Chlamydia trachomatis infection rate was 6.9% (66/957), Neisseria gonorrhoeae 4.5% (42/940) and syphilis 0.9% (8/930) including one who seroconverted while in detention. Overall, 12% (109/908) of subjects tested for all three infections were positive for at least one STD. Stepwise logistic regression analysis showed that greater than one partner in the previous 4 months (OR 1.53, 95% confidence interval [95% CI] 1.18-1.98), inconsistent or no condom use in the preceding 4 months (OR 1.77, 95%CI 1.37-2.28), a history of recent STD (OR 1.80, 95%CI 1.33-2.42) and greater than five lifetime partners (OR 2.03, 95% CI 1.41-2.92) were independent predictors of these STDs in this population. CONCLUSION: Detained juvenile males in our study were at a high-risk for STD/HIV infections and probably form a core group of STD transmitters. Vigorous attempt to reduce STD reservoir and change behavior of juveniles in detention, such as our study subjects, is urgently needed for the control of the STD/HIV infections.

Single dose of azithromycin for the treatment of genital chlamydial infections in adolescents.

We compared a single 1 gm dose of azithromycin with the standard 7-day course of doxycycline for the treatment of uncomplicated chlamydial genital infection in sexually active adolescents. Seventy-three adolescents (65 female) with a cervical or urethral culture positive for Chlamydia trachomatis were enrolled in the study; 46 received azithromycin and 27 received doxycycline. Follow-up evaluations were done 1, 2, and 4 weeks after treatment with azithromycin or initiation of treatment with doxycycline. There were four treatment failures (8.7%) among the patients who received azithromycin and four in the doxycycline-treated group (14.8%); all were female. Six of these girls (three treated with azithromycin and three with doxycycline) gave histories of unprotected intercourse with an untreated partner and were probably reinfected. Almost half the patients were clinically symptom free. The clinical response rate for the remaining patients with symptoms was 97.4% at 4 weeks. Nineteen percent of the azithromycin-treated patients and 33.3% of those treated with doxycycline had mild to moderate drug-related side effects, which were predominantly gastrointestinal. We conclude that treatment with a single oral dose of azithromycin appears to be as safe and efficacious as a 7-day course of doxycycline for the treatment of uncomplicated genital chlamydial infection in adolescents.