Patterns of injuries and motor-vehicle traffic accidents in Athens.

The extremely high cost of motor-vehicle accidents in public health leads to the necessity of a better injury data collection in the Accident and Emergency Hospital Departments. The 'Asclepeion' of Voula Hospital covers the southeastern suburban areas of the greater Athens area (1,000,000 population). The aim of this study is to present information on the pattern of injuries in Athens, in order to understand the magnitude of the problem and develop rational prevention programmes. Specially trained health visitors of the Emergency Department Injury Surveillance System (EDISS) interviewed in person every injured victim who was brought into the Emergency Service of the 'Asclepeion' of Voula Hospital. The study was performed during a 3-year period, from 1996 to 1998; 4564 persons were interviewed. Traffic accidents were more frequent on weekdays with a seasonal peak in July and among young Greeks (aged 25 - 34 years). The usual type of injuries seen in vehicle-accident victims were cerebral contusion and concussion, while in motorcycle-accident victims, head contusion and fractures. The most common reasons for the accident were excessive speed, poor condition of road, inattention, abstraction or drowsiness and drug effects. A total of 29.8% of motorcycle drivers and 5.7% of motorcycle passengers wore a helmet and 26.3% of car drivers and 14.1% of car passengers were using seatbelts. The identification of road traffic injury patterns can contribute to the development of injury prevention measures and guide rational preventive interventions that can reduce the incidence of these injuries. The EDISS system established at 'Asclepeion' of Voula Emergency Service can provide useful and accurate information about this serious and multidimensional problem of Greek Public Health.

The treatment of chronic anal fissure with botulinum toxin.

BACKGROUND/AIMS: The aim of this study was to evaluate the effectiveness of botulinum toxin for the treatment of uncomplicated dorsal chronic idiopathic anal fissure. MATERIAL AND METHODS: Forty-five patients who reported post defecatory anal pain since two months or more were given a total of 20U botulinum toxin in the anal sphincter apparatus on both sides as well as below the anal fissure. RESULTS: Thirty-seven patients received a second session of 25U botulinum toxin injection. Thirty-five patients (78%) presented completely healed anal fissure, while ten needed lateral internal sphincterotomy. All patients were followed up for 8-36 months. Two patients relapsed. CONCLUSION: Local injection of botulinum toxin is a new and safe treatment; however, two sessions of injections are necessary to be effective and long-term follow-up to assess the recurrence rate of fissure is needed to evaluate further this method of treatment. Partial internal lateral sphincterotomy is no more the treatment of choice for chronic anal fissure.

Anemia following renal transplantation: erythropoietin response and iron deficiency.

To define the etiology of anemia post-renal transplantation, we assessed hematologic parameters and EPO levels in 38 anemic and 16 non-anemic control renal transplant recipients (RTRs) with varying degrees of allograft function at periods > 3 months post-transplantation. Significant differences between the two groups were found for serum creatinine (Cr) 291.7 +/- 26.5 vs. 203.3 +/- 26.5 mumol/l, p < 0.01; iron 9.3 +/- 0.92 vs. 13.6 +/- 1.7 mumol/l, p < 0.05; and ferritin 345.5 +/- 90.8 vs. 91.1 +/- 18.5 micrograms/l, p < 0.01. Serum EPO levels were inappropriately low in anemic patients with no significant correlation between EPO and Cr or hematocrit (Hct) levels. Serum iron was the only predictive factor for anemia on regression analysis (p < 0.05). Ferritin levels did not correlate with serum iron or Hct, and may be falsely elevated in iron deficient RTRs. Iron deficiency, poor renal function and inappropriately low EPO levels are major contributors to the 12% of our outpatient renal transplant population who are anemic.

The influence of donor age on function of renal allografts from live related donors.

To assess the influence of donor age on renal allograft outcome, we retrospectively analyzed all 169 consecutive cyclosporine-treated live related donor kidney transplants, of whom 40 were HLA identical siblings. All recipients were similar with respect to demographic and immunologic characteristics. Incidence of rejection episodes and graft survival rates at 1 and 5-year posttransplant were independent of donor age. Best renal function, as assessed by the mean of the lowest 3 serum creatinine concentration levels in the first 2 months posttransplant correlated positively with donor age, particularly among HLA mismatched male recipients (r = 0.4, P < 0.002). Short and intermediate term renal function was inferior, but stable in the older donor recipient group when compared to the younger cohort. Mean serum creatinine levels at 5 years in recipients of kidneys from older donors (age > 55 years) was 2.6 mg/dl compared to 1.7 and 1.9 mg/dl in recipients of kidneys from donors between the ages of 18-39 and 40-54 years, respectively (P < 0.001). In view of the universal shortage of organs and the negligible morbidity to the donors, our results should not discourage the use of kidneys from elderly (age > 55 years) donors.

Intermediate-term outcome of renal retransplants in the cyclosporine era.

To determine the influence of selected parameters on intermediate-term outcome of renal retransplants, univariate and multiple regression analyses were performed on all 100 consecutive cyclosporine treated retransplants performed between 1984 and 1990 (mean follow up, 4.6 +/- 2.3 years). Actual 1 year and actuarial 5 year graft survivals were higher in living compared with cadaver donor transplants (84% and 79% vs 69% and 56%, respectively; p < 0.05). Among cadaver donor transplant recipients, allografts with immediate early function had better 1 and 5 year graft survivals when compared with those with delayed function (81% and 62% vs 59% and 38%, respectively; p < 0.05). Recipients with acute rejection had inferior 1 year and 5 year graft survivals when compared with rejection free patients (65% and 35% vs 80% and 57%, respectively; p < 0.05). Graft survival time of primary transplants was also a significant predictor of retransplant outcome with 1 and 5 year graft survivals of 50% and 36%, respectively, in patients in whom primary grafts survived less than 3 months, compared with 75% and 58% in those in whom grafts survived longer than 3 months (p < 0.05). Recipient age, race, renal disease, and levels of panel reactive antibodies had no effect on intermediate-term outcome. In a multiple regression analysis, delayed graft function, acute rejection, and primary graft survival time less than 3 months correlated inversely with long-term survival of retransplants (multiple r = 0.65). A total of 39 grafts were lost due to rejection (22), sepsis (6), graft nonfunction (5), death with a functioning graft (4), noncompliance (1), and recurrent renal disease (1).(ABSTRACT TRUNCATED AT 250 WORDS)

Erythrocytosis after renal transplantation. A prospective analysis.

A prospective analysis of all cyclosporine treated renal transplants performed between 1987 and 1990 was performed to determine the incidence and etiologic factors of post transplant erythrocytosis (PTE) and its effect on short-term outcome. PTE developed in 25 (8.1%) recipients (mean age, 41 +/- 10 years). PTE occurred more frequently in men (12.8%) than women (1.6%) (p < 0.001), diabetic patients (22.9%) than nondiabetic patients (6.2%) (p < 0.001), and rejection-free recipients (11%) compared with those with early rejection (4%) (p < 0.05) but was independent of recipient race and donor source. Sixteen patients in whom PTE subsequently developed had pretransplant hematocrits above 30%. PTE occurred most frequently in the first year posttransplant (range, 2-29 months). Serum erythropoietin levels were inappropriately elevated in all patients (mean, 24 +/- 2.2 mU/ml), but serum iron, folate, and B12 levels were all normal. Mean serum creatinine and creatinine clearance were 1.7 +/- 0.5 mg/dl and 58 +/- 20 ml/min, respectively. Twenty-three patients underwent phlebotomy (mean, 3.5 +/- 0.5 units) and six had PTE-related complications. In 14 patients, PTE persisted with hematocrit of 53 +/- 1.5% (range, 51-56) compared with 57 +/- 2.6% (range, 54-64) at the time of PTE onset. In conclusion, PTE occurs primarily in the first year posttransplant and is characterized by inappropriate elevation of erythropoietin. Predictors for PTE include male gender, diabetes mellitus, pretransplant hematocrit above 30%, absence of rejection, and excellent renal allograft function.

The influence of nephrectomy of the primary allograft on retransplant graft outcome in the cyclosporine era.

The present analysis was undertaken to evaluate the influence of primary allograft nephrectomies on the early function, incidence of rejection, and short-term graft survival of subsequent renal retransplants. Among 95 consecutive cyclosporine treated retransplant recipients, 52 were retransplanted without primary allograft nephrectomy; 35 had removal of their primary grafts prior to retransplantation for fever and graft tenderness (30 patients) and persistent hematuria (5 patients); and 8 patients had an elective primary graft nephrectomy at the time of retransplantation. Demographic characteristics and immunosuppressive regimens were otherwise similar in all three groups. Nephrectomy of the primary allograft prior to retransplantation was associated with a significant subsequent rise in preformed cytotoxic antibody levels (57% having PRA greater than 30% compared with 33% in those with retention of primary grafts), a significantly higher incidence of delayed graft function among retransplants (63% compared with 30% in those who did not undergo primary allograft nephrectomy) and a trend toward decreased allograft survival in the subgroup who lost their primary allografts in the first year posttransplant. The incidence of acute rejection and 3-year posttransplant renal function in retransplants were not, however, influenced by nephrectomy of the primary allograft.

Renal allograft outcome in the cyclosporine era: comparison between intermediate-term failure and long-term survival.

A single center experience of 160 cyclosporine-treated renal allografts that survived longer than 1 year was reviewed in an attempt to analyze the contribution of selected parameters to long-term survival. Sixty-one grafts were lost between 1 and 5 years, with the remaining functioning for longer than 5 years. Parameters with a significant influence on long-term survival included both quality of early graft function, with 13% of long-term survivors having delayed function, compared to 52% among the short-term survival group, and the incidence of acute rejection in the first year posttransplant (31% in long-term survivors compared to 63% in the short-term survival group). A marker for long-term survival (greater than 5 years) was a lower serum creatinine at 1 year (1.9 +/- 0.1 mg/dl, compared with 2.6 +/- 0.2 mg/dl in the short-term survival group). Recipient race, original renal disease, number of transplants and/or transfusions, panel reactive antibodies, and human leukocyte antigens matching did not appear to influence long-term outcome.

Retrospective analysis of posttransplantation diabetes mellitus in black renal allograft recipients.

OBJECTIVE: To study the incidence, outcome, and possible etiopathogenic factors involved in posttransplantation diabetes mellitus in cyclosporine-treated black renal allograft recipients. RESEARCH DESIGN AND METHODS: One hundred thirty-eight nondiabetic black renal transplant recipients whose grafts survived greater than 1 yr were studied retrospectively. RESULTS: Twenty-eight (20.3%) patients developed posttransplantation diabetes mellitus, 46 and 75% were diagnosed by 6- and 12-mo posttransplantation, respectively, and 46% were insulin dependent. Diabetes was more frequently encountered in older recipients and recipients of cadaveric kidneys but was independent of sex, number of transplants, incidence of acute rejection, percentage of body weight gain, steroid or cyclosporine dose, and use of beta-blockers and/or diuretics. Renal function was similar in the diabetic group compared with the control group. Actuarial 5-yr graft survival was 82% in the diabetic cohort compared with 78% in the control group, with chronic rejection accounting for all graft losses within the diabetic group. CONCLUSIONS: Twenty percent of black cyclosporine-treated renal allograft recipients developed diabetes mellitus in the posttransplantation period. However, its presence did not appear to influence intermediate-term graft or patient survival.

Racial differences in renal transplant outcome of insulin-dependent diabetic recipients in the cyclosporine era.

In an attempt to analyze the influence of race on renal allograft outcome among insulin-dependent diabetic uremics, all 109 cyclosporine treated transplants were studied. Black recipients were noted to have inferior 1 year survival for both living related and cadaver donor grafts when compared with both whites and Hispanics (67% and 43% vs. 92% and 84%, 100% and 80%, respectively, p less than 0.01). Nonimmunologic causes accounted for 69% of graft losses among blacks, compared with 39% and 33% in whites and Hispanics, respectively. Among long-term survivors, however, renal function remained relatively stable among all racial groups. This differing trend among black diabetic recipients suggests the need for aggressive cardiac workups before transplantation, and judicious immunosuppression in the posttransplant period.

Renal transplantation from elderly living donors.

A worldwide shortage of cadaveric donors has led to the increased utilization of elderly living donors, with controversial results. In an attempt to assess the effect of donor age on graft survival and subsequent renal function, we analyzed our clinical results in 276 consecutive recipients of living related renal transplants spanning both the cyclosporine and the azathioprine eras, of whom a total of 44 recipients received kidneys from donors over 55 years old. All recipients were otherwise similar in age, race, haplotype mismatch, number of retransplants, and number of pretransplant transfusions, apart from an increased number of diabetics among the CsA-treated recipients of elderly kidneys (38% vs. 14%). The cumulative patient and graft survival rates at 1 and 5 years were independent of donor age whether CsA or AZA was utilized. Nor was the incidence of rejection or infection significantly different in the older donor group when compared with the younger cohort. Short-term and intermediate-term renal function, as assessed by serum creatinine, was however poorer but stable in the older donor group when compared with the younger one. The mean serum creatinine levels at 1 year in the CsA- and AZA-treated recipients of kidneys from older donors were 2.4 and 2.0 mg/dl, respectively, compared with 1.6 and 1.4 mg/dl, respectively, when the donor age was less than 55 years (P less than 0.001). Since renal function at the end of the first posttransplant year is considered a determinant of long-term graft survival, this is a cause for concern, but in view of the universal shortage of organs and the negligible morbidity to donors, renal transplantation from elderly living donors remains an acceptable practice.

Diabetes mellitus after renal transplantation in the cyclosporine era--an analysis of risk factors.

Despite mounting experimental evidence that cyclosporine inhibits pancreatic islet cell function, clinical data on posttransplant diabetes mellitus (PTDM) in renal allograft recipients in the cyclosporine era are scarce. Between June 1983 and December 1988, 39 of 337 (11.6%) cyclosporine-treated adult renal transplant recipient whose grafts survived longer than 1 year developed PTDM. Of these, 43.6% and 74.4% were diagnosed by 3 and 12 months posttransplant, respectively, and 51.3% were insulin-dependent. Incidence of PTDM was highest in blacks (19.8%) and Hispanics (21.3%) and in those with HLA-A 30 and Bw 42 antigens. Older recipients and those that received cadaveric kidneys were more likely to develop diabetes than those who received living related allografts (14% vs. 5.3%, P less than 0.05). The rate of PTDM appeared to be independent of the type of induction, immunosuppressant therapy, incidence of rejection, total steroid and cyclosporine dose, percentage of body weight gain in the first posttransplant year, and serum creatinine concentration. Actuarial 5-year, decaying from 100% at 1 year, patient and graft survival rates were 87% and 70%, respectively, in the PTDM group compared with 93% and 90%, respectively, in controls. Causes of graft failure among the diabetics included chronic rejection (6), patient death (3), noncompliance with immunosuppressants (2), and sepsis (1). The incidence of infectious complications was significantly higher in the PTDM group compared with the control group (53% vs. 16%, P less than 0.05), with all 5 deaths among the diabetics being sepsis-related.