Understanding the holistic experiences of living with a kidney transplant: an interpretative phenomenological study (protocol).

BACKGROUND: Currently very little is known about the perceptions and experiences of kidney transplant recipients from a qualitative perspective. As highlighted by the European Kidney Health Alliance recommendations, providing holistic care to kidney patients is important however this is currently an unmet care need in renal disease. It is imperative to understand patient experiences to ensure that they are included in key strategies and future renal service planning. Ignoring these important patient views means that there is a significant risk of inappropriate renal service provision and lack of adequate support impacting on overall health. METHOD: A purposive sampling strategy will recruit individuals currently living with a kidney transplant, 6 months to 5 years post-transplant. A maximum of 30 patients will be recruited between two Regional Nephrology units within the United Kingdom via clinical gatekeepers. In-depth interviews will be undertaken with participants living with a kidney transplant across the two sites. Interviews will be digitally-recorded, transcribed verbatim and subjected to interpretative phenomenological analysis. DISCUSSION: Renal healthcare professionals need to understand more than the biological impact of receiving a kidney transplant. Understanding the holistic and multi-domain experiences that these patients experience will help healthcare professionals to recognize the needs of this group and ensure more responsive care.

[Is extracorporeal membrane oxygenation necessary?]. / Est-ce que l'oxygénation membranaire extracorporelle est nécessaire?

In order to evaluate our hospital center needs for extracorporeal membrane oxygenation (ECMO), a retrospective study was carried out over a two-year-period to determine the mortality rates of infants < or = 35 weeks of gestation and > or = 2000 grams with severe respiratory failure. The data was obtained from a perinatal center that serves a population that has 50,000 newborn deliveries per year. During the period of the study there were 75 infants meeting the above criteria admitted to the NICU with severe respiratory failure (defined as need for mechanical ventilation and 100% O2). Forty-four patients were excluded because of improvement of their respiratory status on conventional therapy, and 16 were ineligible for ECMO because of their primary diagnosis. Of the 15 infants considered ECMO candidates, there were 2 deaths as a result of streptococcal beta hemolytic septicemia. The result of this study showed that few infants in the population served by this perinatal center would have benefited from ECMO.

Morphological changes in the placentas of smoking mothers: a histomorphometric study.

The morphological changes in the functional structure of placentas from women who smoke cigarettes during pregnancy have been investigated by quantitative, light-microscopic techniques. It has been demonstrated that the placentas of the smoking mothers were morphologically very similar to the placentas of the nonsmokers. The results only showed a tendency for the placentas in the study group to contain proportionally more nonparenchymal and less parenchymal tissue than the control group, mainly in terms of a relative reduction in the intervillous space volume and peripheral villous mass and surface area. The findings of this study support the hypothesis that the perinatal morbidity associated with cigarette smoking during pregnancy is probably more related to the ischemic and/or toxic effects of several compounds in tobacco smoke, partly on placental function and also directly on the fetus, than to significant alterations in the functional structure of the placenta.

Intrauterine growth retardation: morphometry of the microvillous membrane of the human placenta.

The syncytiotrophoblast microvillous membrane of the human placenta has been investigated with quantitative analyses in cases of severe fetal growth retardation associated with a marked reduction in the surface area of exchange at the peripheral villous level. This study has shown that, in placentae of intrauterine growth-retarded infants of unknown origin, there were morphological changes in the microvillous membrane characterized by an increase in the microvillous surface density and surface enlargement factor, associated with a reduction of the intermicrovillous space. It is not possible to state whether these morphological changes represent a delayed maturation of the placental tissue, or compensatory mechanisms to improve the functional efficiency of the placenta. In pre-eclampsia, these placental changes were much less pronounced, possibly due to severe uteroplacental ischaemia in this complication of pregnancy. Despite these morphological changes, both groups of placentae showed significant reductions in absolute values for the microvillous and total trophoblastic surface areas, which can have major implications on the functional efficiency of the placenta.

Histomorphometry of the human placenta in pre-eclampsia associated with severe intrauterine growth retardation.

The morphological changes in the functional structure of the placenta in cases of pre-eclampsia associated with severe intrauterine growth retardation have been investigated with quantitative analyses. It has been demonstrated that in pregnancies complicated by severe pre-eclampsia, the placenta can suffer significant morphological alterations characterized by an abnormal maturation or arborization of the terminal villi. The findings of this study suggest that, among the pathogenic mechanisms responsible for the observed placental changes, uteroplacental ischaemia is probably a dominant factor, and that any ill effects on fetal growth and viability are very likely to be related not only to the inadequate maternal supply of oxygen and nutrients but also to placental ischaemic damage.

Morphometry of the microvillous membrane of the human placenta in maternal diabetes mellitus.

The syncytiotrophoblast microvillous membrane of the human placenta has been investigated with quantitative analyses in a group of placentae from diabetic mothers, these placentae being compared to a group of normal placentae. This study has shown that, in the placentae of the diabetic mothers, there was a significant increase in the surface density of the microvilli and in the microvillous surface enlargement factor as compared to those of the controls. Consequently, it has demonstrated that the already large villous surface area found in the placentae of diabetic mothers can be enlarged very significantly by the microvilli, in terms of the total trophoblastic surface area which is in contact with the maternal blood. On a functional basis, these findings support the theory that placental function is probably not adversely affected in these placentae, and that these placentae can efficiently support the growth of large fetuses.

Morphometric evaluation of the microvillous surface enlargement factor in the human placenta from mid-gestation to term.

The factor by which the villous surface area is enlarged owing to the presence of microvilli has been evaluated with quantitative analyses in human placental tissues from mid-gestation to term. It has shown that, between 25 and 36 weeks of gestation, the peripheral villous surface area is enlarged by a constant factor of approximately 9.47 +/- 0.28 (mean +/- s.d.). Then, from 36 weeks to term, it has shown a significant decrease in the microvillous surface enlargement factor (9.44 to 7.67; P less than 0.01). Consequently, the actual surface area of exchange between mother and fetus was shown to be significantly decreased during that same period (93.91 to 67.02 m2; P less than 0.01). On a functional basis, these findings support the theory that, during that last four weeks of pregnancy, the increasing physiological needs of the fetus are probably met by profound functional changes in the permeability and transfer functions of the cells that constitute the placental barrier.

Histomorphometry of the human placenta in maternal preeclampsia.

The placentas of five mothers with severe preeclampsia who gave birth to moderately growth-retarded term infants were compared to a group of placentas collected from mothers who had uncomplicated pregnancies and normal term infants who were appropriate for gestational age. This study demonstrated that, on a quantitative histologic basis, the placentas of the preeclamptic mothers were morphologically very similar to the control placentas in terms of weight, parenchymal and cellular content, and surface areas of exchange between mother and fetus. The findings of this study support the hypothesis that, in preeclampsia not associated with severe intrauterine growth retardation, the perinatal morbidity associated with this condition is probably related more to some alterations in uteroplacental and, possibly, umbilical blood flows than to significant changes in placental structure and function. This may be due to compensatory repair mechanisms and extensive functional reserve capacities in these placentas.

Steroid metabolism by human chorion laeve from dichorionic twin pregnancies.

Certain steroid metabolic properties of chorion laeve from dichorionic twin pregnancies were examined to determine whether they were present in chorion not contaminated by decidua or serum. In the chorion situated between the two amniotic sacs and not in contact with decidua, aryl sulfatase, 3 beta-hydroxysteroid dehydrogenase, and aromatase activities were found. This indicates that these reactions are present in chorion laeve and were not previously ascribed to this tissue because of decidual contamination. Specific cortisol binding was also present in this area of chorion laeve, which excludes serum contamination. It is suggested that the specific steroid-binding protein in the membranes may be derived from the transcortin-like protein present in amniotic fluid.

Histomorphometry of the human placenta in Class C diabetes mellitus.

Placentae from Class C diabetic mothers were compared by histomorphometric analyses with a group of normal placentae. The placentae of the diabetics were divided in two groups based on the growth characteristics and neonatal outcome of the infants at birth. This study has demonstrated that the placentae of both groups were somewhat heavier than the controls due to a parallel increase in parenchymal and non-parenchymal tissues. The placentae were also shown to be characterized by a relative increase in the surface areas of exchange between mother and fetus, in terms of peripheral villous and capillary surface areas and intervillous space volume. Consequently, the results of this study suggest that, in Class C diabetics, placental morphology and placental function are probably not more adversely affected than in other less severe forms of the disease during pregnancy. Furthermore, the findings in this investigation support the hypothesis that the placental changes, and the perinatal morbidity associated with this condition, are probably the results of hormonal and metabolic abnormalities present in the mother and the fetus.

Value of systolic time intervals in the diagnosis of large patent ductus arteriosus in fluid-restricted and mechanically ventilated preterm infants.

M-mode echocardiographic features suggesting a patent ductus arteriosus are based on two groups of indirect criteria: dilation of the left cardiac cavities and changes of systolic time intervals. The reliability of the first group of criteria has been questioned in fluid-limited, mechanically ventilated preterm infants. The sensitivity of the systolic time intervals in the same circumstances is investigated. Twenty-three patients with a large patent ductus arteriosus were selected. Review of their echocardiograms shows that the sensitivity of the various criteria (expressed as percentage of positivity) was as follows: inversion of the ratio of left ventricular preejection period to right ventricular preejection period, 91.3%; left ventricular preejection period to left ventricular ejection time over right ventricular preejection period to right ventricular ejection time less than 1,83%; left atrium dilation, 74%; shortening of left ventricular preejection period, 70%; dilation of left ventricular internal dimensions in diastole, 65%; increase in left atrium/aorta, 52%; and decrease of left ventricular preejection period to left ventricular ejection time, 48%. Three criteria involving time intervals (left ventricular preejection period to right ventricular preejection period, left ventricular preejection period, and left ventricular preejection period to left ventricular ejection time) had 100% specificity. The lowest specificity was found with criteria involving the left atrium (left atrial to aortic root ratio 75% and left atrium 63%). It is concluded that study of systolic time intervals is a reliable means of detecting preterm infants with hemodynamically significant left-to-right shunt through a patent ductus arteriosus even if the infants are mechanically ventilated and fluid restricted.

[Thoracic opacity in a newborn infant disclosing an adenomatoid cyst of the lung. Radio-echographic case]. / Opacité thoracique chez un nouveau-né révélant un kyste adénomatoïde du poumon. Observation radio-échographique.

In a preterm infant (28 week gestation), the chest film performed at 1 hour of life because of mild respiratory insufficiency showed a massive opacity of the right hemithorax. Congenital cystic adenomatoid malformation was suspected on the basis of ultrasonographic findings of multiple cysts. It was confirmed by further X ray examination and pathologic findings. This unusual case shows the ultrasonographic pattern and X ray evolution of this rare malformation.

Idiopathic intrauterine growth retardation: histomorphometry of the human placenta.

The morphological changes in the functional structure of the placenta in cases of idiopathic intrauterine growth retardation (IUGR) have been investigated with quantitative analyses. It has shown that the placentae of the small-for-gestational-age (SGA) infants were 45 per cent smaller than the controls, due to an almost equal reduction in parenchymal (48 per cent) and non-parenchymal (42 per cent) tissues. Consequently, in relative values the placentae of the SGA infants were shown to be otherwise very similar to the controls. In contrast, in absolute values, the placentae of the growth-retarded infants were shown to differ from the controls by having significantly less surface area of exchange between mother and fetus, mainly in terms of peripheral capillary (3.85 vs 7.21 m2; P less than 0.02) and villous (4.31 vs 8.74 m2; P less than 0.005) surface areas, and intervillous space volume (53.71 vs 103.26 cm3; P less than 0.001). The total number of cells (53 418 x 10(6) vs 104 820 x 10(6); P less than 0.005) was also shown to be markedly decreased in the placentae of the SGA infants, compared with the controls, and the placental membrane showed a 51 per cent decrease in trophoblast mass or cellular content. On a functional basis, these findings suggest that, in these cases of idiopathic IUGR, the placental morphological changes are bound to produce placental insufficiency and fetal growth retardation.

The importance of an antenatal ultrasonographic diagnosis of correctable fetal malformations.

This study describes the importance of an early echographic examination during pregnancy for the antenatal diagnosis of fetal anomalies potentially correctable after birth. During a period of 18 months there were 28 cases. In seven fetuses a gastrointestinal malformation was diagnosed between 20 and 36 weeks of gestation; there were 16 cases of urogenital anomalies detected between 19 and 38 weeks of gestation, and five other various malformations were detected between 17 and 33 weeks of gestation (two diaphragmatic hernias, one congenital heart malformation, and two cases of benign tumors). This study suggests that ultrasonic antenatal diagnosis could result in a decrease in the morbidity of congenital malformations that are correctable if the delivery is carried out in a high-risk perinatal center.

Histomorphometry of the human placenta in Class B diabetes mellitus.

Different morphometric parameters have been applied to the study of the morphological differences between a group of normal placentae and a group of placentae collected from Class B diabetic mothers. The placentae of the diabetics were divided in two groups based on the growth characteristics and neonatal outcome of the infants at birth. It has been shown that the placentae of the appropriate for gestational age infants were morphologically very similar to the control group except for a well-developed villous vascularization. In contrast, the placentae of the large for gestational age infants were shown to differ from the controls by having heavier placentae due mainly to a significant accumulation of non-parenchyma and a moderate increase in parenchymal tissue. Consequently, although there was significantly more villous tissue in these placentae, the surface areas of exchange between mother and fetus in terms of capillary and villous surface areas were only moderately enlarged due to a relatively lower number of villi containing non-parenchymal tissue. However, on a functional basis, despite these morphological differences, the results of this study suggest that placental function is not adversely affected in Class B diabetics, and the perinatal morbidity associated with this condition is probably the result of metabolic abnormalities present in the mother and the fetus.

Morphometric evaluation.

Placental dysfunction can be evaluated through the quantitative analysis of the morphological changes in the placental structures that are intimately related to the transfer function of the placenta. This is illustrated in the results collected from the placenta of an SGA infant, which show that this placenta differs from a control group by having significantly less functional tissues and surface areas of exchange between mother and fetus. These structural changes can undoubtedly impair placental function and fetal growth in utero. In this context, morphometry is presented as an indirect and noninvasive approach to the study of the physiology and physiopathology of gestation in the human.

Histomorphometry of the placenta of the diabetic women: class A diabetes mellitus.

Different morphometric parameters have been applied to the study of the morphological differences between a group of normal placentae and a group of placentae collected from Class A diabetic women. It has shown that although fetal weights were significantly higher in the infants of the diabetic mothers, placental weights showed only a tendency to be heavier than the gestationally matched controls, though the difference was not statistically significant. However, the placentae of the Class A diabetic mothers were shown to differ from the control group by having significantly more parenchymal and villous tissues and a higher cellular content. There were also more surface areas of exchange between mother and fetus, in terms of peripheral and villous capillary surface areas and intervillous space volume. On a functional basis, these morphological changes suggest that, in diabetes mellitus Class A, the placenta can efficiently support the growth of a large fetus, and the perinatal associated with this condition is not likely to be related to decreased or insufficient function of the placenta.