Long-term experience with everolimus in kidney transplantation in the United States.

BACKGROUND: Limited long-term data exist on US kidney transplant patients who have received everolimus at time of transplantation. METHODS: Using data from the United Network for Organ Sharing/Organ Procurement Transplant Network database, we described patient characteristics and outcomes among adult patients who received a kidney transplant between 1998 and 2007 and received everolimus maintenance immunosuppression (n = 392) at time of discharge. Outcomes included acute rejection, new-onset diabetes posttransplant, primary graft failure, and serum creatinine. We included single-organ, first-time transplants between 1998 and 2007 as a reference group. RESULTS: Primary graft survival at 3 and 5 years posttransplantation was 87.2% ± 2.1% (95% confidence interval [CI]: 82.5%-90.7%) and 77.4% ± 3.0% (95% CI: 70.8%-82.7%), respectively, in the everolimus-treated group. Improved graft survival with everolimus seemed to be more pronounced in recipients of deceased donor transplants despite the fact that everolimus-treated patients quantitatively had a higher rate of acute rejection at 3 years posttransplant versus the reference group. CONCLUSION: Although the incidence of acute rejection was slightly higher in the everolimus-treated patients, graft survival at 3 and 5 years posttransplantation favored everolimus, with the effect being particularly notable in the recipients who received deceased donor renal transplants.

Cyclosporine versus tacrolimus treated liver transplant recipients with chronic hepatitis C: outcomes analysis of the UNOS/OPTN database.

Recurrent hepatitis C virus (HCV) remains a problematic cause of morbidity and mortality for liver transplant patients. Immunosuppression including calcineurin-inhibitors has been implicated in the acceleration of recurrent HCV. Recent studies suggest that outcomes may be better with cyclosporine (CSA-ME) compared to tacrolimus (TAC), but the data are inconclusive. We retrospectively analyzed data received from the United Network for Organ Sharing on 8809 chronic HCV liver transplant recipients receiving either cyclosporine microemulsion (CSA-ME) or tacrolimus (TAC) as maintenance immunosuppression prior to discharge. We analyzed patient death, graft failure, failure due recurrent disease and acute cellular rejection (ACR) for CSA-ME versus TAC treated patients. Three-year unadjusted patient and graft survival rates were 76.8% and 71.5%, respectively, in the CSA-ME group versus 79.9% and 75.0% in the TAC group. Propensity score-adjusted results suggest CSA-ME treated patients are at increased risk of patient death and graft failure [Hazards ratio (HR) = 1.17; 95% CI = 1.01-1.36 and HR = 1.19; 95% CI = 1.04-1.35, respectively] and biopsy-confirmed AR (HR = 2.03; 95% CI = 1.54-2.67) compared to TAC treated patients. These results provide evidence to reconsider the targeted administration of CSA-ME to HCV-infected liver transplant recipients.

Can cardiac sonography and capnography be used independently and in combination to predict resuscitation outcomes?

OBJECTIVE: To measure the ability of cardiac sonography and capnography to predict survival of cardiac arrest patients in the emergency department (ED). METHODS: Nonconsecutive cardiac arrest patients prospectively underwent either cardiac ultrasonography alone or in conjunction with capnography during cardiopulmonary resuscitation at two community hospital EDs with emergency medicine residency programs. Cardiac ultrasonography was carried out using the subxiphoid view during pauses for central pulse evaluation and end-tidal carbon dioxide (ETCO(2)) levels were monitored by a mainstream capnograph. A post-resuscitation data collection form was completed by each of the participating clinicians in order to assess their impressions of the facility of performance and benefit of cardiac sonography during nontraumatic cardiac resuscitation. RESULTS: One hundred two patients were enrolled over a 12-month period. All patients underwent cardiac sonographic evaluation, ranging from one to five scans, during the cardiac resuscitation. Fifty-three patients also had capnography measurements recorded. The presence of sonographically identified cardiac activity at any point during the resuscitation was associated with survival to hospital admission, 11/41 or 27%, in contrast to those without cardiac activity, 2/61 or 3% (p < 0.001). Higher median ETCO(2) levels, 35 torr, were associated with improved chances of survival than the median ETCO(2) levels for nonsurvivors, 13.7 torr (p < 0.01). The multivariate logistic regression model, which evaluated the combination of cardiac ultrasonography and capnography, was able to correctly classify 92.4% of the subjects; however, of the two diagnostic tests, only capnography was a significant predictor of survival. The stepwise logistic regression model, summarized by the area under the receiver operator curve of 0.9, furthermore demonstrated that capnography is an outstanding predictor of survival. CONCLUSIONS: Both the sonographic detection of cardiac activity and ETCO(2) levels higher than 16 torr were significantly associated with survival from ED resuscitation; however, logistic regression analysis demonstrated that prediction of survival using capnography was not enhanced by the addition of cardiac sonography.

The role of sentinel lymph node mapping in staging of colon and rectal cancer.

PURPOSE: Nodal metastasis is the best predictor of survival for patients with colon cancer. Statistical models based on random distribution of positive lymph nodes suggest that to correctly classify nodal status with 95 percent confidence, 20 nodes are needed for T1 lesions, 17 nodes for T2, and 15 nodes for T3. The mean number of nodes identified in American patients is 8, suggesting that they might not be accurately staged. Patients in our tumor registry staged as "node-negative" had a short survival when they had < or =10 lymph nodes evaluated when compared with patients with >10 lymph nodes evaluated (p < 0.01). We hypothesized that the use of sentinel lymph node may assist in the staging of colon cancer. METHODS: Thirty-eight consecutive patients with colon lesions were prospectively enrolled into this trial between February 1998 and November 1999. Thirty-one patients met criteria for analysis. During surgery, Lymphazurin blue dye was injected subserosally into the area around the tumor. Routine nodal evaluation, with extra cuts of all sentinel nodes, was undertaken. RESULTS: At least one sentinel lymph node was found in 18 of 31 patients (58 percent). Sensitivity of 67 percent, specificity and positive predictive value of 100 percent, and negative predictive value of 94 percent were found when sentinel lymph nodes were identified. In 2 of these 18 patients, the sentinel lymph node was the only positive lymph node found. CONCLUSIONS: Application of the sentinel lymph node technique to colon cancer may make it easier to identify lymph nodes most likely to contain metastatic disease, potentially "down-staging" more patients. This may have implications in postoperative care.

A two-hour intervention using START improves prehospital triage of mass casualty incidents.

OBJECTIVE: There are few data concerning the ability of prehospital providers to triage patients in a mass casualty incident (MCI). The authors evaluated the effectiveness of a brief educational intervention on MCI triage with a written scenario and test. The START method (simple triage and rapid treatment) was used. METHODS: The authors enrolled and tested 109 prehospital providers consisting of 31 paramedics and prehospital registered nurses (PHRNs) and 78 emergency medical technicians (EMTs) and first responders. A written scenario of an MCI was used to test participants before, immediately after, and again at one month after a two-hour educational intervention consisting of a slide and video presentation utilizing START. RESULTS: The 109 participants completed the pre-intervention and post-intervention test; 72 (66%) completed the one-month post-intervention as well. Mean work experience was 9 years (ranging from 1 to 27 years). The mean immediate post-test score (75% correct) was significantly improved compared with the mean pretest score (55% correct) for the 109 providers completing both tests (p < 0.001). Among advanced life support providers (EMT-Ps and PHRNs) completing all three surveys, the mean immediate post-test score (76% correct) and mean one-month post-test score (75% correct) were not significantly different. Among the basic life support providers completing all three surveys, a modest but statistically significant decay in mean scores from immediate post-test (74% correct) to one-month post-test (68% correct) was observed (p < 0.01). Prior training in MCI had no statistically significant effect on changes in mean test scores. CONCLUSION: The ability of prehospital providers of all levels of training and experience to triage patients in an MCI is less than optimal. However, this ability improved dramatically after a single didactic session, and improvement persisted one month later.

Fast education: a comparison of teaching models for trauma sonography.

This study's objective was to evaluate the peritoneal dialysis and mannequin simulator models for the hands-on portion of a 4-h focused abdominal sonography for trauma (FAST) course. After an introductory lecture about trauma sonography and practice on normal models, trainees were assigned randomly to two groups. They practiced FAST on one of the two simulator models. After the didactic and hands-on portions of the seminar, FAST interpretation testing revealed mean scores of 82% and 78% for the peritoneal dialysis and mannequin simulator groups, respectively (p = 0.95). Post-course surveys demonstrated mean satisfaction scores for peritoneal dialysis and mannequin simulator models of 3.85 and 3.25, respectively, on a 4-point Likert scale (p = 0.317). A FAST educational seminar, which provides both didactic and hands-on instruction, can be completed in 4 h; the hands-on instruction phase can incorporate both normal models and abnormal simulation models, such as the peritoneal dialysis model and the multimedia mannequin simulator.

Tympanic membrane vs. pulmonary artery thermometry.

Studies that compare tympanic membrane thermometry with other thermometry methods conflict. Research at this facility suggests clinically significant discrepancies, which preclude expanding its tympanic thermometer use.

Comparing tympanic membrane and pulmonary artery catheter temperatures.

Studies comparing tympanic membrane thermometry with other thermometry methods have had conflicting results. Our hospital's nursing practice council sponsored this tympanic thermometry study in our cardiac surgical intensive care unit to assess the feasibility of increasing tympanic thermometer use in our hospital. Our results suggest clinically significant discrepancies between tympanic membrane and pulmonary artery catheter temperatures. These discrepancies preclude expanding tympanic thermometer use in our hospital.

Analysis of cathepsin D in human breast cancer: usefulness of the processed 31 kDa active form of the enzyme as a prognostic indicator in node-negative and node-positive patients.

The relative amounts of the precursor (52 kDa) and processed (31,27 kDa) forms of cathepsin D have been analyzed by Western blotting in biopsied breast tissue cytosols from 134 lesions from invasive breast cancer patients, 24 lesions from patients with ductal carcinoma in situ (DCIS), 227 lesions from benign breast disease patients, and 28 lesions from normal control subjects. The mean relative percentage amount of the 31 kDa form was significantly increased (p < 0.001) in the invasive breast cancer group compared to the other three groups. In addition, the mean relative percentage amount of the 31 kDa form was significantly increased (p < 0.05) in node-positive compared to node-negative breast cancer patients. In the benign breast disease group, patients with proliferative-type disease had a significantly increased (p = 0.02) mean relative percentage amount of the 31 kDa form of cathepsin D compared to patients with nonproliferative-type disease. Invasive breast cancer patients were followed for up to 75 months to determine if the relative percentage amount of the 31 kDa form of cathepsin D was predictive of disease-free and overall survival. Although the amount of the 31 kDa form was not predictive of disease-free survival, patients in the 'high' 31 kDa group (> 18%) were significantly (p < 0.05) more likely to die than patients in the 'low' 31 kDa group (< or = 18%). The 12 patients who died were all node-positive and in the high 31 kDa group. It thus appears that the relative amount of the processed, active 31 kDa form of cathepsin D is a useful prognostic indicator, at least in node-positive breast cancer patients.

What do adolescent females know about breast cancer and prevention?

Background: Many lifelong habits begin during adolescence. These habits can have profound, long-term ramifications on health. An important health habit is self-breast examination (SBE). The purpose of this study is to assess adolescent females' knowledge of breast cancer and breast cancer prevention. A survey was developed with questions that focused on female adolescents' knowledge of these topics. This information will assist health professionals in educating teens and forming public policy.Methods: Anonymous surveys consisting of ten questions were distributed to 280 females aged 13-17. These questions pertained to breast cancer with an emphasis on SBE, mammography, and risk factors. Questions were analyzed by chi square calculations. An additional section of the survey contained demographic characteristics of the respondents. Parental consent was obtained prior to completion of the surveys in accordance with the Institutional Review Board at St. Luke's Hospital. Surveys were administered during health class in a local high school.Results: One hundred and fifteen surveys were returned. Ages of participants were 13 to 17. The ethnic background of all participants were similar in that the majority were Caucasian. The overall percentage of correct answers was 65%. The majority of students knew what a mammogram is (92%) and how often screening should occur (65%), however, only 25% knew at what age screening should begin. It was encouraging that 80% of the students knew how often to perform SBE although only about half (53%) knew the time of the month this should be done. It was also encouraging that 83% knew that breast cancer is the second leading cause of cancer death, but the knowledge regarding risk factors that could possibly affect them was poor (36%). A statistically significant findings was that in the twenty percent of the students who had been taught SBE, 10 (43.5%) actually perform them. This is in relation to 2.2% of students who perform exams without any prior instruction. There was no statistically significant difference in the final score between students who had been taught how to perform exams and students who had not.Conclusions: Developing sound health habits as an adolescent should transcend to good health maintenance practices as an adult. Our study showed that adolescent females significantly lack knowledge relating to breast cancer. Adolescent females need to be better educated on the basic facts, including risk factors, screening procedures and SBE. With the incidence of breast cancer so high, knowledge of breast cancer and its prevention may result in earlier diagnosis and subsequently better long term outcomes.

Ultrasound interpretation of hydronephrosis is improved by a brief educational intervention.

Nineteen emergency medicine (EM) physicians (14 residents and 3 attendings) from an EM residency program which teaches ultrasound as part of the curriculum, were asked to rate 40 ultrasound scans showing different degrees of kidney hydronephrosis, first solely on the basis of their prior knowledge and experience. One week later, after a brief 15 minute lecture on a new objective method to read degrees of hydronephrosis, the same EM physicians were again asked to rate the 40 ultrasounds. One month later, to assess retention of the method, the same physicians were asked to read the same scans using the objective method presented 1 month prior. The three readings were compared with each other, and then each with a gold standard established for the study. Agreement of the group regarding scan interpretation improved and was maintained after the educational intervention (multirater kappa + .19, .32, and .32 for the three tests administered). When the differences between each week's readings and the gold standard were assessed, differences decreased with each successive test, and were statistically significant with the third test (P = .029). We conclude that our brief educational intervention improves agreement among physicians in readings of ultrasound scans and also significantly increases accuracy in readings when compared with a gold standard.