Tenckhoff catheters post-renal transplantation: the 'pull' technique?

BACKGROUND: Tenckhoff catheters are used widely for the provision of continuous ambulatory peritoneal dialysis. Traditionally these catheters are removed surgically under anaesthesia. We set out to introduce and monitor prospectively a technique for removal of the Tenckhoff catheter by a 'pull' technique. The intention was to avoid the discomfort, risk and cost of traditional surgery. METHODS: Over a 1-year period all renal transplant patients having their Tenckhoff catheter removed by this technique were monitored prospectively. All patients were followed for a minimum 2-year period after removal. In the pull technique steady non-jerky traction is applied to the catheter. Complications such as catheter breakage and cuff related sepsis were recorded. RESULTS: Sepsis related to a retained cuff occurred in only one patient early in the series. There were no other complications. The procedure was well tolerated. Use of local anaesthesia used initially, was largely phased out over the course of study and the procedure moved from the theatre to the ward. CONCLUSIONS: The pull technique is safe and well tolerated. The technique has significant advantages in selected patients without a history of recent peritonitis or exit site infection, in reducing risk to the patients, the pain of abdominal wall surgery and reduced usage of costly theatre time and in-patient beds.

The CSAT methamphetamine treatment program: research design accommodations for "real world" application.

The Methamphetamine Treatment Program (MTP), funded by the Center for Substance Abuse Treatment, has the objectives of implementing the Matrix outpatient model and evaluating that model in comparison to the existing community "treatments as usual." Seven organizations in three western states (California, Montana, and Hawaii) were selected to participate in this randomized, controlled, multisite project in what constitutes the largest trial to date of treatment for methamphetamine (MA) dependence. One hundred fifty MA-dependent patients recruited at each site are randomly assigned to receive either the Matrix model, a manualized program of intensive outpatient treatment, or the site's standard treatment, "treatment as usual." Participants are evaluated at admission, weekly during treatment, at the time of scheduled discharge, and at six and 12 months after admission. Dependent measures assess changes in drug use, HIV risk behaviors, quality of life, and patient satisfaction. Cost analyses to quantify treatment costs and determine the association between costs and clinical outcomes will be conducted. A number of adjustments in the original study design have been necessitated by the realities of community sites' strengths and limitations. Experiences from this multisite project will also provide a model for other efforts to transfer research-based treatments into community settings. This article describes the main aims of the project, the background and rationale for the study design, a brief description of the research plan, and methods implemented to protect the integrity of the science.

Methamphetamine abuse: issues for special populations.

Methamphetamine (MA) abuse has been a problem in the western United States for decades. However, recently the incidence of MA abuse has risen to epidemic levels in some regions and among particular subgroups of the population. Recognizing the need to develop effective treatments for MA dependence, the Center for Substance Abuse Treatment (CSAT) established a multisite Methamphetamine Treatment Program (MTP) that compares the Matrix Model treatment program for MA to the treatments as usual at seven community-based clinics in California, Montana and Hawaii. Examination of the clients receiving services though this project provides an opportunity to explore particular issues of diverse special populations who are impacted by the problem of MA dependence. These groups include rural Americans, Native Americans, Hawaiians, gay and bisexual males and drug court participants. Specifically, this article examines cultural, geographic and situational barriers to accessing and completing treatment and presents strategies that have been used to overcome these barriers.

A descriptive analysis of participant characteristics and patterns of substance use in the CSAT methamphetamine treatment project: the first six months.

The CSAT Methamphetamine Treatment Project (MTP) is a multisite study with a two-fold purpose: to assess the feasibility and outcomes generated by a technology transfer of the Matrix treatment model for methamphetamine (MA) abuse into several community-based treatment programs, and specifically to compare outcomes of treatment as usual at each site with outcomes of the Matrix model, as implemented in each site. The study comprises seven sites, geographically situated in Hawaii, Northern and Southern California, and Montana. This article presents a demographic description of the cohort, and describes patterns of drug use, abuse, and related problems among the 169 participants recruited in the first six months of the study, from April through September 1999. Specific analyses presented include: demographic composition of the sample with respect to gender, age, ethnicity, education completed, employment status, and income; primary drug used, and mean percent of days using various drugs including MA, alcohol, and marijuana; and percent of sample reporting various routes of drug administration. Mean baseline Addiction Severity Index composite scores are presented that describe medical, employment, alcohol, drug, legal, family/social, and psychiatric status for the sample. Also presented here are comparisons of this preliminary population to other populations reported in the literature. This early subset of MTP participants is similar to other methamphetamine-abusing populations described in the literature in age, years of education, income, and mean years of use. However, because of its multisite structure and the locations of its constituent sites, the MTP population has greater variation in ethnic makeup than do populations from other studies, offering an opportunity to provide useful new information about drug use patterns and treatment responses in populations not previously studied.

Simple technique for non-operative removal of ureteric stents after renal transplantation.

Ureteric stents are employed peroperatively in renal transplantation when there is actual or suspected damage to the donor ureter. We describe a simple technique of suturing the distal end of the stent to the tip of a urinary catheter at the time of construction of the ureteric anastomosis. The stent is simply removed by gentle traction on the urinary catheter. This method obviates the need for a minor operative procedure or exposure to ionising radiation, which are the techniques commonly utilised at present. The procedure is also applicable to reconstructive urological procedures in which short-term stenting may be required.

Management of inguinal herniae in patients on continuous ambulatory peritoneal dialysis: an audit of current UK practice.

Patients receiving continuous ambulatory peritoneal dialysis are at increased risk for the development of inguinal herniae, with a reported prevalence of 14%. Elective hernia repair is indicated for these patients as strangulation is associated with a high mortality in this population. There are currently no national guidelines relating to the optimal peri-operative management of these patients, in particular the appropriate pre- and post-operative dialysis regimen. The aim of the current study was to evaluate current practice in the UK by means of a postal questionnaire sent to all centres undertaking renal transplantation. Replies were received from 34/37 centres. The principal study finding was the wide variation in surgical practice between different centres with regard to pre- and post-operative dialysis regimes. Only 44% of centres had an established protocol. Based upon the study findings we have devised a protocol that we hope to see implemented into UK practice. Following its introduction, a re-assessment will be performed and the audit cycle completed.

A double-blind, randomized, placebo-controlled study of nifedipine on early renal allograft function.

A double-blind, randomized, placebo-controlled study was conducted to determine the effect of nifedipine on early renal allograft function when added to a triple therapy immunosuppression regime comprising low-dose cyclosporin (CsA), prednisolone and azathioprine. Fifty adult cadaveric renal allograft recipients were randomized to placebo (group P n = 17), nifedipine 10 mg preoperatively and 20 mg b.d. postoperatively for 48 h, followed by matching placebo for 3 months (group NS n = 16) or nifedipine 10 mg preoperatively and 20 mg b.d. postoperatively for 3 months (group NL n = 17). Donor and recipient exclusion criteria included recent calcium antagonist treatment. At 3 months after transplantation mean GFR adjusted for graft loss was significantly higher in group NL than in NS (mean +/- SD 61 +/- 28 versus 34 +/- 25 ml/min/1.73 m2; P < 0.05), group P being intermediate (45 +/- 34 ml/min/1.73 m2). Similarly, effective renal blood flow (ERBF) at 3 months was higher in group NL than in groups P and NS (mean +/- SD 351 +/- 175 versus 216 +/- 166 and 220 +/- 162 ml/min/1.73 m2; P < 0.05). The differences were not significant by 6 months post-transplantation. This study suggests that oral nifedipine commenced preoperatively and continued for 3 months following transplantation has beneficial effects on early renal allograft function when incorporated as part of an immunotherapy regimen based on cyclosporin.

Effects of plasma exchange on sperm antibody levels in males with subfertility.

Three men with subfertility secondary to sperm antibodies with measurable serum sperm antibody levels underwent a course of 3 plasma exchanges over a period of 1 week. The levels of serum anti-sperm antibodies fell by a mean of 3.3 dilutions. This fall was maintained for approximately 4 weeks, after which there was a return to the original levels. Plasma exchange is time-consuming and relatively expensive but it offers a possible alternative to steroid treatment (with its potential side effects) in men with sperm antibodies and warrants further investigation.

Ureteroureterostomy and pyeloureterostomy without native nephrectomy in renal transplantation.

A series of 23 patients, receiving full immunosuppression following renal transplantation, underwent a uretero- or pyelo-ureterostomy with ligation of the native ureter and no nephrectomy. In 5 patients this was carried out at the time of transplantation because of a short donor ureter and in 18 patients, at a median of 47 days after transplantation, following ureteric complications. With a median follow-up of 22 months, no complications have been seen in relation to the native kidney. Ureteroureterostomy was successful in all but 3 patients. A ureteroureterostomy without native nephrectomy is a safe and effective treatment for the management of ureteric complications following renal transplantation.

Ureteric obstruction in renal transplants: the role of percutaneous balloon dilatation.

With widespread use of balloon dilatation catheters outside the vascular system, percutaneous balloon dilatation has become an accepted alternative to surgery. Seventeen patients who developed ureteric stenosis following renal transplantation underwent 21 transrenal angioplastic balloon dilatations. Fifteen patients had lower ureteric strictures (2-22 mm long), and two had multiple strictures. The time interval between transplantation and obstruction ranged from 11 to 1370 days (median 71, mean 228.9 days). Nine patients were treated successfully (53%) with no stricture recurrence during the follow-up period, which ranged from 3 to 44 months (median 16, mean 17.8 months). In eight of nine patients in this group, the stricture impression on the inflation balloon was eliminated, and this appears to correlate best with a successful outcome. The eight patients who failed balloon dilatation and restenosed, did so within 7-42 days in seven patients; one patient had late stricturing at 238 days. Serious complications occurred in only one patient, who developed an A-V fistula not amenable to correction and necessitating transplant nephrectomy.

Pain Tolerance in the Presence of Others: Implications for Youth Sports.

In brief: Forty-three second- and third-graders were compared with 40 college students to determine if youths and adults responded differently to pain alone and in the presence of others. The college students showed significantly greater pain tolerance than did the children. The youths displayed significantly greater pain tolerance when others were present; college students' tolerance, on the other hand, did not change when an audience was present. These results are relevant to youth sports situations, in which volunteer coaches must regularly assess reports of pain by those they supervise.

Synergy between subtherapeutic doses of cyclosporine and immunobiological manipulations in rat heart graft recipients.

Cyclosporine in combination with other chemical or biological immunosuppressive modalities has been useful in clinical and experimental organ transplantation. In these studies, the efficacy of adjunctive subtherapeutic doses of CsA given to immunologically enhanced heart graft recipients or to animals treated with an anti-IL-2 receptor monoclonal antibody (ART18) are described. Individually, the treatment entities are only partially effective. In rats undergoing active and passive enhancement alone, heart allograft survival was increased to 25 +/- 12 days in two-thirds, indefinitely in one-third. After ART18 treatment, grafts survive 21 +/- 1 days. Grafts are accepted permanently in animals receiving full-dose CsA (15 mg/kg X 7), but are rejected acutely (c. 7 days) when subtherapeutic doses (1.5 mg/kg X 7) are used. However, when subtherapeutic doses of CsA are given in combination with immunological enhancement or with interleukin-2-receptor-targeted therapy, graft survival increases dramatically, with permanent or markedly prolonged engraftment occurring in all instances. In the early phases of host unresponsiveness, both enhancement and IL-2R-targeted therapy, graft survival increases dramatically, with permanent or markedly prolonged engraftment occurring in all instances. In the early phases of host unresponsiveness, both enhancement and IL-2R-targeted therapy spare selectively T cells with suppressor activity in vivo; in enhanced animals, the W3/25+ subset is responsible for prolonged graft survival, the OX8+ fraction is responsible in ART18-treated animals and in CsA-treated animals. Both subpopulations show suppressor activity in the later stages of combination treatment. IL-3 production is increased significantly in these states of unresponsiveness, an observation also noted during maintenance CsA treatment; this seems to correlate with suppressor activity. Immunoperoxidase studies of the graft infiltrates emphasize the synergistic effects of combination treatments. Thus, subtherapeutic doses of CsA plus biologic host manipulations produce greatly increased graft survival by affecting selectively different host immune mechanisms.