Biomarkers of Tolerance in Kidney Transplantation: Are We Predicting Tolerance or Response to Immunosuppressive Treatment?

We and others have previously described signatures of tolerance in kidney transplantation showing the differential expression of B cell-related genes and the relative expansions of B cell subsets. However, in all of these studies, the index group-namely, the tolerant recipients-were not receiving immunosuppression (IS) treatment, unlike the rest of the comparator groups. We aimed to assess the confounding effect of these regimens and develop a novel IS-independent signature of tolerance. Analyzing gene expression in three independent kidney transplant patient cohorts (232 recipients and 14 tolerant patients), we have established that the expression of the previously reported signature was biased by IS regimens, which also influenced transitional B cells. We have defined and validated a new gene expression signature that is independent of drug effects and also differentiates tolerant patients from healthy controls (cross-validated area under the receiver operating characteristic curve [AUC] = 0.81). In a prospective cohort, we have demonstrated that the new signature remained stable before and after steroid withdrawal. In addition, we report on a validated and highly accurate gene expression signature that can be reliably used to identify patients suitable for IS reduction (approximately 12% of stable patients), irrespective of the IS drugs they are receiving. Only a similar approach will make the conduct of pilot clinical trials for IS minimization safe and hence allow critical improvements in kidney posttransplant management.

What proportion of primary psychiatric interventions are based on evidence from randomised controlled trials?

OBJECTIVES

To estimate the proportion of psychiatric inpatients receiving primary interventions based on randomised controlled trials or systematic reviews of randomised controlled trials.

DESIGN

Retrospective survey.

SETTING

Acute adult general psychiatric ward.

SUBJECTS

All patients admitted to the ward during a 28 day period.

MAIN OUTCOME MEASURES

Primary interventions were classified according to whether or not they were supported by evidence from randomised controlled trials or systematic reviews.

RESULTS

The primary interventions received by 26/40 (65%; 95% confidence interval (95% CI) 51% to 79%) of patients admitted during the period were based on randomised trials or systematic reviews.

CONCLUSIONS

When patients were used as the denominator, most primary interventions given in acute general psychiatry were based on experimental evidence. The evidence was difficult to locate; there is an urgent need for systematic reviews of randomised controlled trials in this area.

Continuing medical education needs of rural GPs in South Australia

The very extent of the information that was sought in the questionnaire may have contributed to the relatively small (33%) response rate. However, as stated, it is considered that the information received is sufficiently representative to help planners and providers of CME to ensure that their programs are fulfilling the genuine needs of rural practitioners in South Australia. It is accepted that educational needs are not static; they are always changing due to changing circumstances, changing skill requirements and constantly changing due to changing medical knowledge. The information gained from this survey will require regular updating, and this will be undertaken.

Traffic placement policies for multi-band network

Recently protocols have been introduced that enable the integration of synchronous traffic (voice or video) and asynchronous traffic (data) and extend the size of local area networks without loss in speed or capacity. One of these is DRAMA, a multiband protocol based on broadband technology. It provides dynamic allocation of bandwidth among clusters of nodes in the total network. In this paper, we propose and evaluate a number of traffic placement policies for such networks. Metrics used for performance evaluation include average network access delay, degree of fairness of access among the nodes, and network throughput. The feasibility of the DRAMA protocol is established through simulation studies. DRAMA provides effective integration of synchronous and asynchronous traffic due to its ability to separate traffic types. Under the suggested traffic placement policies, the DRAMA protocol is shown to handle diverse loads, mixes of traffic types, and numbers of nodes, as well as modifications to the network structure and momentary traffic overloads.