Assessment of Educational Needs and Design of a Preceptor Development Program for Health Professional Education Programs in Qatar

INTRODUCTION

Experiential learning is the backbone of many health care professional education programs; however, the quality of learning is profoundly dependent on the skills and experiences of clinical preceptors. This study was conducted at Qatar University Health Cluster (Colleges of Pharmacy, Medicine, and Health Sciences) with the primary objective of identifying the educational needs of preceptors to design and review an educational professional development program.

METHODS

This study adopted a mixed-methods approach and was conducted in three stages: (1) assessment of preceptor educational needs, (2) designing of the Practice Educators' Academy program, and (3) revision and refinement of the designed program. The needs' assessment was conducted at all the three colleges through a validated survey and focus groups comprising of preceptors, students, and clinical faculty members. The sample included 209 survey respondents and 11 focus group sessions.

RESULTS

The results yielded five key themes and a variety of individual preferences, which were used to design a five-module face-to-face two-day interactive workshop. For the revision of the designed program, the syllabus was shared purposively with selected scholars and experts in the area of health professions education, and their feedback was collected and critically examined. Furthermore, the refinement of the program was performed on the basis of this feedback, resulting in the revised and representative program being ready for piloting.

DISCUSSION

A preceptor development program on experiential teaching and learning skills was successfully designed and revised with the needs of the clinical preceptors at its core. Preceptors' skills development can advance health care outcomes by preparing competent health professional graduates.

KCNJ11 and KCNQ1 Gene Polymorphisms Are Not Associated with Post-Transplant Diabetes Mellitus in Kidney Allograft Recipients Treated with Tacrolimus

Post-transplant diabetes mellitus (PTDM) is a metabolic disorder occurring after solid organ transplantation during the therapy with calcineurin inhibitors. ATP-sensitive potassium channels KCNJ11 and KCNQ1 play an important role in the regulation of insulin secretion by β cells and development of diabetes mellitus. Numerous studies have confirmed the association between KCNJ11 and KCNQ1 gene polymorphisms and type 2 diabetes. The aim of this study was to examine the association between KCNJ11 and KCNQ1 gene polymorphisms and posttransplant diabetes mellitus in kidney allograft recipients treated with tacrolimus. The study included 201 patients who received kidney transplants. The patients were subdivided into two subgroups: patients with PTDM (N = 35) and patients without PTDM (N = 166). The association between KCNJ11 and KCNQ1 gene polymorphisms and post-transplant diabetes was studied in three models of univariate Cox regression analysis, i.e., additive, dominant and recessive. In these three models there were no statistically significant associations between KCNJ11 and KCNQ1 gene polymorphisms and PTDM. The results of this study suggest lack of association between KCNJ11 and KCNQ1 gene polymorphisms and post-transplant diabetes mellitus in kidney allograft recipients treated with tacrolimus in the Polish population.

The impact of interleukin 12B (1188A>C), interleukin 16 (-295T>C), and interleukin 18 (607C>A, 137G>C) gene polymorphisms on long-term renal transplant function and recipient outcomes

BACKGROUND

Inflammatory mediators play an important role in kidney graft outcome. The cytokine and chemokine gene polymorphisms are associated with variable production, activity, expression, or ligand-receptor affinity. Genetic variation in the DNA sequence of the interleukin 12B (IL12B), interleukin 16 (IL16), and interleukin 18 (IL18) genes may lead to altered cytokine production and activity. These variations can lead to changes in individual patient outcomes after kidney transplantation. It is known that polymorphisms of interleukins have an influence on inflammatory diseases, eg, Crohn's disease, diabetes, and asthma.

AIM

The aim of this study was to evaluate the correlation between IL12B, IL16, and IL18 gene polymorphisms with delayed graft function (DGF), acute rejection episodes (AR), and chronic rejection episodes (CR).

MATERIALS AND METHODS

A total of 267 (38.6% women, 61.4% men) recipients were included in the study. Cadaveric kidney transplantations were performed at the Department of General Surgery and Transplantation. Polymerase chain reaction was used to determine gene polymorphisms of IL12B (rs3212227), IL16 (4778889), and IL18 (rs1946518, rs187238) in 2 mL of serum. Statistical significance (P < .05) was analyzed by logit regression, ANOVA and odds ratio (OR) of χ(2) with Yates correction (95% confidence interval).

RESULTS

Regression analysis revealed no significance between AR/DGF/CR and IL-2B, IL16, IL18rs1946518, and IL18-rs187238 (P > .05). The CR group, AA vs CC genotype of IL18 (rs1946518), had an OR = 2.35 (P = .04). AR and DGF groups had no significance in OR.

CONCLUSIONS

There was no statistical significance between IL12B, IL16, and IL18 (rs187238) gene polymorphisms and kidney graft outcome after transplantation. Presence of AA genotype (IL18-rs1946518) is connected with a 2.35 times higher risk of CR occurrence.

Interleukin-17 gene polymorphisms in patients with post-transplant diabetes mellitus

OBJECTIVE

Post-transplant diabetes mellitus (PTDM) is a common complication after organ transplantation which leads to impaired graft function. Various factors may increase the risk of the development of PTDM. It has been reported that cytokines and genetic variations of inflammatory cytokines were associated with glucose homeostasis or diabetes. The pro-inflammatory cytokine IL-17, which is produced by T-helper 17 (Th17) cells, has been reported to be involved in the glucose metabolism and pathogenesis of diabetes via the induction of low-grade inflammation. The aim of this study was to examine the association between polymorphisms in the IL17A (rs2275913) and IL17F (rs11465553, rs2397084, rs763780) genes with post-transplant diabetes mellitus.

PATIENTS AND METHODS

The study included 169 patients of Caucasian origin who received kidney transplants. For the purpose of the study, the patients were subdivided into two subgroups: patients with PTDM (n = 23) and patients without PTDM (n = 146). Standard immunosuppression consisted of tacrolimus, mycophenolate mofetil, and steroids.

RESULTS

Post-transplant diabetes was diagnosed in 10.97% of the carriers of the IL17F rs763780 TT genotype and 42.86% of those with the TC genotype (TC vs TT: OR = 6.09, 95% CI 1.89-19.66, p = 0.0048). In multivariate analysis, older recipient age and the presence of the TC genotype were independent significant predictors of higher risk of post-transplant diabetes.

CONCLUSIONS

The results of this study suggest an association between the IL17F rs763780 polymorphism and post-transplant diabetes.

Methylene blue usage in horseshoe kidney graft separation: case report

Definitive diagnostics and strict procedures during kidney donor qualification are required. Nowadays, precise and accurate imaging techniques are at hand for every diagnostician. However, many studies have described intraoperative occurrence of horseshoe kidney. Although the harvesting procedure in the case of horseshoe kidney is not technically difficult, graft separation for successful renal transplantation is a challenge. The complex anatomy of malformed organs causes issues during kidney separation. This procedure may lead to damage of the collecting urinary system as well as vascularization damage. Separate graft transplantation is probable when a thin isthmus in a horseshoe kidney is present. Otherwise, poor graft function may occur. We present a technique for horseshoe kidney separation with the use of methylene blue for vascularization determination. The above-mentioned procedure was performed with the methylene blue solution dose injected into a single renal graft artery. Even with the malformed organ's thick isthmus, the exact incision line was identified, exposing vascular perfusion asymmetry and allowing precise renal graft separation.

Influence of tianeptine on melatonin homeostasis and psychosomatic symptoms in patients with irritable bowel syndrome

Selective serotonin reuptake inhibitors (SSRIs) exert beneficial effect on gastrointestinal tract (GIT), but its mechanism has not been recognized. One of the hypothesis assumes, that fluoxetine increases indirectly melatonin production. For this reason it can be hypothesized, that administration of drugs of opposite effect, for example tianepine (selective serotonin reuptake enhancer (SSRE), can reduce melatonin production resulting in harmful effects as regards GIT. The aim of the study was to confirm or reject this hypothesis. The study included 100 patients, aged 21-58 years, with irritable bowel syndrome (IBS). Basing on the Rome III Criteria patients with constipation-predominant (IBS-C, n=50) and with diarrhoea-predominant (IBS-D, n=50) and 25 health volunteers (control group C) were distinguished. Visual Analog Scale (VAS) and Hamilton Depression Rating Scale (HDRS) were used to determine the severity of somatic and psychic symptoms. The concentration of 6-sultatoxymelatonin (6-HMS) in the urine was measured by ELISA method. In both groups the patients were administrated tianeptine 12.5 mg three times daily or placebo for 8 weeks. After 8 weeks of tianeptine therapy no significant changes were found in urinary 6-HMS excretion both in IBS-C group (9.9±3.2 versus 11.5±3.5 μg/24 h) and in IBS-D group (11.8±3.3 versus 12.2±3.5 μg/24 h). Eight-week tianeptine therapy resulted in significant decrease of somatic and psychic symptoms in both investigated groups. The improvement in the quality of life indices was obtained in 76.5% of IBS-C and in 63.3% of IBS-D patients.

CONCLUSIONS

tianeptine does not impair melatonin homeostasis in patients with IB, diminishes IBS symptoms and improves the patients' quality of life.

Experience with autosomal dominant polycystic kidney disease in patients before and after renal transplantation: a 7-year observation

OBJECTIVE

Autosomal dominant polycystic kidney disease (ADPKD) is characterized by the presence of multiple cysts in both kidneys. Symptoms of the disease may arise either from the presence of cysts or from increasing loss of kidney function. First symptoms usually appear in the third decade of life: lumbar pain, urinary tract infections, arterial hypertension, or renal colic due to cyst rupture or coexistent nephrolithiasis. An early diagnosis, male gender, large kidneys by sonography, arterial hypertension, hematuria, and urinary tract infections are predictive factors of a faster progression of the disease. Our aim was to establish the indications for nephrectomy among symptomatic ADPKD patients before kidney transplantation and to assess the risks of posttransplantation complications among ADPKD patients without nephrectomy.

PATIENTS AND METHODS

The observed group consisted of 183 patients with ADPKD among whom 50 (27.3%) underwent kidney transplantation during a 7-year observation period (2000-2007). Among those subjects were 3 groups: (I) nephrectomy preceding transplantation; (II) nephrectomy during kidney transplantation; and (III) without nephrectomy.

RESULTS

Among group I before transplantation we observed: arterial hemorrhage, wound infections, and splenectomy 4 weeks after ADPKD nephrectomy; afterward we observed: urinary tract infections and contralateral cyst infection. Among group II we only observed 1 case of wound infection. Among group III we observed: ascending urinary tract infections, cyst infections, and cyst hemorrhage. Cyst hemorrhage and cyst infections led mainly to ADPKD kidney nephrectomy. During the observation time, 80.95% of grafts were functioning.

CONCLUSIONS

Unilateral nephrectomy is a well-founded preliminary surgical treatment before kidney transplantation. Bilateral nephrectomy before or during transplantation eliminates ADPKD complications and does not significantly increase general complications. The greatest numbers of complications and of graft losses were observed among the group without pretransplantation nephrectomy.

Purine and Cytokine Concentrations in the Renal Vein of the Allograft During Reperfusion

The impairment of organ function derived from ischemia-reperfusion injury is still an important problem in solid organ transplantation. Cell alterations induced by ischemia prime the tissue for subsequent damage during the reperfusion phase. The aim of present study was to examine the association between changes in cytokine and purine metabolite concentrations in graft renal vein during reperfusion. The study included 17 recipients of cadaveric renal grafts: 10 men and seven women of overall mean age of 49 +/- 7 years and cold ischemia time 25 +/- 3 hour. The levels of interleukin (IL)-1beta, IL-2, IL-4, IL-6, IL-10, interferon (INF)-gamma, tumor necrosis factor (TNF)-beta, and TNF-alpha in renal graft vein plasma during 5 first minutes of reperfusion were quantified by flow cytometry. Increased concentrations of IL-6, TNF-alpha, and IL-1beta were observed during reperfusion. The IFN-gamma concentrations correlated negatively with xanthine (Xan) concentrations in renal vein blood during reperfusion, whereas there was a positive correlation between IL-2 and Xan concentrations. Moreover, the concentrations of IL-6 and IL-10 correlated negatively with hypoxanthine concentrations, and the concentrations of IL-4 also correlated negatively with Xan concentrations. The results of this study indicated the enhanced release of some cytokines during kidney graft reperfusion. It occurred in association with release of purine metabolites-the markers of energy status of renal tissue. Therefore, the enhanced cytokine production during reperfusion might influence ischemia-reperfusion injury and the early graft function.

Influence of Perioperational Acid-Base Balance Disorders on Early Graft Function in Kidney Transplantation

INTRODUCTION

Reperfusion is a crucial moment in kidney transplantation, connected with many metabolic changes that are the result of preservation and intraoperative course including ion movements, free radical generation, ATP and other adenylate depletion. During reperfusion we observed increased metabolic acidosis, which may be the result of accumulation of lactic acid due to anaerobic metabolism, with a simultaneous expiratory pCO(2) growth as respiratory compensation. The study's purpose was to examine acid-base balance dynamics during 30 minutes of reperfusion of the transplanted kidney and its influence on renal function based on observations of the 1-year creatinine values.

MATERIALS AND METHODS

The examined group consisted of 76 recipients: 44 men, 32 women. Measurements by gasometric analysis and expiratory pCO(2) in each patient were performed nine times during reperfusion. In the postoperative period we analyzed donor-related factors including: gender, age, number of HLA matches weight and height, as well as recipient-related factors including: gender, age, basic immunosuppression, creatinine level at hospital discharge and at 5 to 24 months of follow-up. Statistical significance was analyzed using repeated-measures analysis of variance followed by Tukey post hoc test as well as Mann-Whitney U and Spearman's correlation tests.

RESULTS

The analysis showed correlations between reperfusion, acidosis, respiratory pCO(2) compensation, early graft loss, patient death, donor and recipient gender, renal function, donor age, and histocompatibility.

CONCLUSIONS

At the beginning of reperfusion there is increasing metabolic acidosis with simultaneous expiratory pCO(2) as compensation. A greater relative increase in expiratory air pCO(2) was correlated with a higher incidence of early graft loss. The higher intensity of metabolic acidosis correlated with worse renal function at 6 months after transplantation. Elderly donor age and fewer HLA-matched antigens correlated with greater intensity of metabolic acidosis during 30 minutes of kidney reperfusion.

Histopathologic Evaluation of Pretransplant Biopsy as a Factor Influencing Graft Function After Kidney Transplantation: A 1-Year Observation

INTRODUCTION

Many factors affect long-term results in kidney transplantation including histologic damage as a independent predictor, such as chronic allograft/nephropathy in protocol biopsies and age-dependent lesions. Histopathologic findings correlate with the incidence of delayed graft function, renal function, and allograft survival, allowing a rather precise prediction of graft outcome.

MATERIALS AND METHODS

We analyzed 92 renal thick needle preimplantation and 29 postexplantation biopsies. Biopsies were preserved in 4% formalin and immersed in paraffin. Optimal biopsies contained at least 10 glomeruli and at least 2 cross-sections of arteries. We analyzed tubulitis, intensity of acute tubular necrosis, inflammatory infiltration, glomerulonephritis, arterial hyalinization, arteritis, fibrosis, tubular atrophy, arterial intimal fibrosis, increase of mesangial matrix, and percentage of glomerulosclerosis. During the postoperative course we analyzed patients condition, exigency of postoperative dialysis, urine output, as well as serum concentrations of creatinine, urea, uric acid, and ions. During a 1-year observation period, we analyzed living recipients, graft loss, death with a functioning graft, incidence of nephropathy (CAN), and acute rejection episodes (ARE).

RESULTS

We observed a significant correlation between immediate graft function (IGF) and lack of ATN in the pre-0 biopsy. We observed no correlation between renal function and arterial hyalinization and fibrosis, inflammatory infiltration, tubular atrophy. In the postoperative period, we observed a significant correlation between IGF and lack of interstitial fibrosis with significantly lower levels of creatinine, urea, and potassium and higher urine output early after transplantation. IGF and better function of the right kidney was correlated with shorter time to reach a creatinine level of 2 mg%. In the postoperative periods, we also observed a difference between renal function depending on gender. The presence of acute tubular necrosis, arterial fibrosis, lack of inflammatory infiltration in the pre-0 biopsy correlated with worse late renal function. Among explantation biopsies 65.5% showed signs of CAN, and 37.93%, histologic marks of ARE.

Circulating adhesion molecules during kidney allograft reperfusion

Adhesion molecule expression is an important event during early transplant failure. The aim of the present study was to examine the release of adhesion molecules during the first minutes of kidney allograft reperfusion in relation to delayed graft function and acute graft rejection. We enrolled 49 renal transplant recipients, including 13 cases of delayed graft function (DGF) and 11 cases of acute graft rejection (AR). Plasma concentrations of E-selectin, VCAM-1 and ICAM-1 after 3 min of reperfusion were significantly higher than in the iliac vein before reperfusion. There was no statistically significant difference between patients with and without DGF as regards E-selectin, VCAM-1 and ICAM-1 concentrations in the iliac vein before and in the renal vein after 3 min of reperfusion. Concentrations of adhesion molecules in the iliac vein before reperfusion and in the renal vein after 3 min of reperfusion did not differ significantly between patients with and without AR except for ICAM-1 iliac vein concentration which was significantly increased in AR patients. Plasma levels of E-selectin, ICAM-1 and VCAM-1 were increased after kidney allograft reperfusion. Moreover, elevated serum levels of ICAM-1 before transplantation correlated with subsequent acute kidney allograft rejection. The results suggest that elevated ICAM-1 levels may be implicated in acute graft rejection.

Hypoxanthine as a graft ischemia marker stimulates catalase activity in the renal vein during reperfusion in humans

BACKGROUND

The impairment of organ function derived from ischemia-reperfusion injury is still an important problem in solid organ transplantation. Cell alterations induced by ischemia prime the tissue for subsequent damage occurring during the reperfusion phase. Purine nucleotides and oxypurines are products of adenine nucleotide degradation. Reperfusion and reoxygenation are characterized by great production of reactive oxygen species and free radicals. On the contrary, superoxide dismutase, catalase, glutathione, and glutathione peroxidase are involved in protecting against free radicals. The aim of the study was to examine the correlation between concentrations of ischemia markers (hypoxanthine or inosine) and the activity of erythrocyte superoxide dismutase, catalase, or glutathione peroxidase.

PATIENTS AND METHODS

The study included 40 renal transplant recipients. Before anastomosis of the kidney vessels with the recipient's iliac vessels, a "0" blood sample was taken from the iliac vein. Then, after anastomosis, the renal vein of the graft was cannulated and blood samples I, II, and III were obtained. The reperfusion of the transplanted kidney was measured with a thermovision camera ThermaCAM SC500.

RESULTS

The plasma concentrations of hypoxanthine and inosine increased in statistically significant fashion immediately after total tissue reperfusion (P < .0001). Catalase activity at 4 minutes after total tissue reperfusion correlated positively with hypoxanthine concentrations immediately after total tissue reperfusion (Rs = +0.49), 2 minutes after total tissue reperfusion (Rs = +0.47), and 4 minutes after total tissue reperfusion (Rs = +0.46). There were no statistically significant correlations between hypoxanthine or inosine concentrations or superoxide dismutase or glutathione peroxidase activities.

CONCLUSIONS

The results of the present study suggest that catalase activity may correlate with the concentration of hypoxanthine in the graft renal vein and other mediators of oxidative stress.

Laparoscopic Removal of Renal Cysts in Patients With ADPKD as an Alternative Method of Treatment and Patient Preparation for Kidney Transplantation: Preliminary Results

BACKGROUND

The most frequent genetic disease of the kidneys occurring in 1 of 1000 inhabitants is autosomal-dominant polycystic kidney disease (ADPKD). Growing renal cysts compress the kidney resulting in damage to parenchyma and functional disorders. Around 10% of these patients are dialyzed due to terminal renal insufficiency. With the advent of laparoscopic techniques, the idea of laparoscopic excision of cysts seemed a tempting alternative to nephrectomy. We assessed the preliminary results of laparoscopic treatment of polycystic kidneys compared with open nephrectomy for patients with ADPKD.

MATERIALS AND METHODS

Thirty ADPKD patients were treated between 2000 and 2004. Eleven procedures in five men and six women of mean age 51 years included laparoscopic cyst excisions. In the remaining 19 patients (six men and 13 women) of mean age 54 years, nephrectomy was done. Indications for surgery included pain due to compression by large cysts and cyst contamination. Patients after nephrectomy were prepared for renal transplantation when necessary.

RESULTS

Laparoscopic polycyst removal produced better effects than nephrectomy. Mean operative time was significantly shorter (86 minutes for cyst removal vs 108 minutes for nephrectomy; P < .05). Postoperative pain measured with the VAS scale was reduced in patients after laparoscopy. Hospital stay was shorter (5 vs 9 days), as well as time to recovery. Other benefits of laparoscopic cyst removal included maintained urination in the patient and no need for erythropoietin substitution, as well as reduced risk of cyst contamination. When eligible for renal transplantation, patients after laparoscopic polycyst removal have smaller kidneys that do not interfere with the graft and the risk of infection during immunosuppression seems lower.

CONCLUSION

Although larger series of patients are required in patients with ADPKD, laparoscopic polycyst removal seemed superior to early nephrectomy.

Activity of CuZn-superoxide dismutase, catalase and glutathione peroxidase in erythrocytes in kidney allografts during reperfusion in patients with and without delayed graft function

BACKGROUND

Generation of reactive oxygen species (ROS) is the main mechanism involved in the ischemic/reperfusion damage of the transplanted organ. Oxygen burst is a trigger for complex biochemical events leading to generation of oxygenated lipids and changes in microcirculation. Many markers have been researched to prove the presence of ROS in the transplanted tissue. Some of them, like superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GPx) are considered to play a major role in graft protection against oxygen stress during reperfusion.

METHODS

The aim of this study was to examine the changes of SOD1, CAT and GPx activity in erythrocytes during the first minutes after total graft reperfusion. Forty patients undergoing kidney transplantation at our center were assigned to two groups: with or without delayed graft function (DGF). Before anastomosing kidney vessels with recipient's iliac vessels, the '0' blood sample was taken from the iliac vein. Next blood samples I, II and III were taken from the graft's renal vein. The reperfusion of the transplanted kidney was evaluated precisely with the thermovision camera. Erythrocyte SOD1, CAT and GPx activity was measured with a spectrophotometric method.

RESULTS

We did not observe statistically significant changes in SOD1, CAT and GPx activity in erythrocytes during the early phase of reperfusion in patients with and without DGF.

CONCLUSIONS

Erythrocyte-antioxidative system in graft's vein remain stable during the early phase of reperfusion. The results of the study suggest that further studies on extracellular enzymes are required for the assessment of antioxidant system in the conditions of ischemia/reperfusion.

Impact of Presence of HBs Antigen and Anti-Hepatitis C Virus and Anti-Cytomegalovirus Antibodies on Transplanted Kidney Survival

INTRODUCTION

Infections are one of the most common complications after organ transplantation. Viral infections such as hepatitis type B (HBV) and C (HCV) or cytomegalovirus (CMV) infections are among the most serious ones. A high frequency of HBV and HCV infections has been recognized in kidney recipients. Viral infections play a special role in graft recipients because of clinical symptoms influencing graft function and recipient survival. Immunosuppressive treatment to decrease immunological reactions after organ transplantation may increase the risk of viral infections. The aim of this study was to evaluate the impact of the presence of HBs antigen and HCV and CMV antibodies on patient and graft survivals.

MATERIAL AND METHODS

Two hundred one enrolled kidney transplantation patients (96 women and 105 men) were treated with the same immunosuppressive regimen. Age, sex, and viral state (HBs antigen, anti-HCV and anti-CMV antibodies) were evaluated in every patient. Statistical analysis was performed with the Gompertz model, Kaplan-Meier curves and Cox proportional hazard tests.

RESULTS

The presence of HBs antigen was detected in 161 patients (20.4%), HCV antibodies in 61 recipients (30.3%); and CMV antibodies in 12 patients (5.9%). Eighty-seven recipients (43.4%) were seronegative. Average recipient age was 38.5 years.

CONCLUSION

Time of graft function was independent of the presence of HBs antigen or HCV or CMV antibodies.

Early Acid–Base Balance Disorders During Kidney Transplantation

INTRODUCTION

Reperfusion is a crucial moment in kidney transplantation. Resumption of blood flow is associated with many metabolic changes, which result from the kidney's initial condition and preservation. These biochemical alterations including the acid-base balance are the part of ischemia-reperfusion injury. The study's purpose was to examine acid-base balance during the first 30 minutes after reperfusion of the transplanted kidney.

MATERIALS AND METHODS

The 30 recipients (13 men, 17 women) averaged ages of 46 +/- 14 years. Measurements performed nine times (at 0, 1, 3, 5, 10, 15, 20, 25, and 30 minutes after unclamping renal vessels) included: gas analysis, expiratory Pco(2), tidal volume, and respiratory rate. The evaluation of the temporary acid-base balance was performed on the basis of common parameters: pH, Pco(2), [HCO(3)(-)], and base excess (BE). The patients were under general anesthesia with stable external conditions of O(2) saturation, heart rate, blood pressure, and temperature. Blood samples were analyzed using Corning 278 and 248 blood gas analyzer; vital parameters were recorded using Ohmeda 5250 RGM and Dräger Sulla 909V/Julian apparatus.

RESULTS

The analysis showed increasing metabolic acidosis with coexisting increase in blood Pco(2), changes that were most intense in the first minute of reperfusion. Decreasing mean pH index did not exceed physiologic limits, but the final mean values of [HCO(3)(-)] and BE were in most of cases below the limit. Increased expiratory air Pco(2) was most intense in the first 3 minutes reaching a maximum at about 15 minutes.

CONCLUSIONS

The beginning of reperfusion was the cause of increasing metabolic acidosis, which was partially compensated by blood buffers. Simultaneous increase in expiratory Pco(2), corresponding to the dynamics of acidosis, indicated the existence of respiratory compensation. Sudden increase in acidosis parameters may be the result of lactate accumulation during kidney ischemia. The decreased [HCO(3)(-)] may indicate postreperfusion kidney injury, which must be the subject of further research.

Experiences in Kidney Transplantation With Duplicated Ureters

INTRODUCTION

The purpose of this study was to evaluate the complications of duplicated ureters in renal transplant recipients.

METHODS

Between 1983 and 2004, 12 patients (median age 34 years) received renal transplants from donors with duplicated ureters. In four patients the ureter to bladder anastomoses were performed separately according to the method described by MacKinnon, including two cases transplanted with ureteral catheters because of narrow widths. In the following cases of eight duplicated ureters an anastomosis was performed between the distal part of each ureter to form a common ureteral ostium, which was connected to the urinary bladder. A ureteral catheter was used to the splint ureterovesical anastomosis.

RESULTS

No graft loss to ureteral complications was observed. There was no ureteral necrosis in the postoperative period. No clinical symptoms of ureteral junction obstruction were revealed after removing the ureteral catheter. By ultrasound examination four patients showed a slight temporary pyelocaliectasis was observed and four patients developed temporary urinary fistulas.

CONCLUSION

Our ureterocystoneostomy procedures with duplicated ureters were safe and useful in kidney transplantation.

Factors that impact on immediate graft function in patients after renal transplantation

Kidney transplantation has become therapy of choice for patients with end-stage renal failure. However, many factors may cause graft rejection or delayed graft function, both of which decrease the prognosis for graft survival. For transplantologists the most important endeavor is to eliminate factors responsible for shortening graft function and to find those predictive of immediate graft function. The aim of the study was to investigate which factors influence early graft function. We retrospectively reviewed 442 renal transplant patients performed between 1990 and 1995 in two Szezecin units. All patients received an identical immunosuppressive drug schedule. Three hundred twelve patients who displayed immediate graft function were included in the study group to analyze donor and recipient age and sex, etiology of ESRD, HLA compatibility AB0 and Rh compatibility cold ischemia time, warm ischemia time, antileukocytes antibodies (PRA), and period of dialysis therapy before transplantation. We observed statistical significance for HLA and AB0 compatibility, younger donor age, and shorter cold ischemia time as the most important factors predictive of early graft function and an improved prognosis for graft survival.

Postoperative adaptation of urinary bladder to variable volume of urine in the initial period following kidney transplantation

OBJECTIVES

Postoperative adaptation of urinary bladder is a process involving all patients after kidney transplantation that is facilitated by improve surgical techniques and new perioperative protocols.

METHODS

The study enrolled 102 kidney transplant recipients whose transplantations were performed between 2000 and 2002. The function of urinary bladder was examined: on the day of operation and 2, 4, 8, 12, 16, and 24 weeks following operation. Patients were assessed with respect to bladder adaptation in relation to the period of dialysis.

RESULTS

In patients undergoing dialysis up to 24 months, the maximum speed of flow increased from the 2nd week postoperation and regained normal values after 12 weeks. Volume of micturition, cystometric volume, and compliance regained proper values after 24 weeks of observation.

CONCLUSION

The findings confirm that adaptation of the bladder is faster among patients who have had dialysis for longer than 12 months. The most useful, economical, and noninvasive assessment of bladder function was obtained with uroflowmetry in combination with daily bladder diary.

Impact of selected factors on early graft function in patients after renal transplantation

Transplantation is the best treatment for end-stage renal diseases. For transplantologists, it is most important to know the factors that worsen graft survival prognosis. The aim of the study was to investigate factors predictive of graft loss and shortened graft survival. We retrospectively reviewed 442 renal transplant patients between 1990 and 1995 in two Szczecin units, all of whom received a triple-drug immunosuppressive regimen. One hundred thirty patients showed graft disorders such as delayed graft function or primary nonfunction. The occurrence of these disorders was examined as a function of donor and recipient age and sex, cause of ESRD, HLA compatibility, ABO and Rh compatibility, cold ischemia time, warm ischemia time, antileukocyte antibody level (PRA), and period of dialysis therapy before transplantation. The study showed that a high maximal PRA level, incompatibility for ABO group, and a longer warm ischemia time increase the probability of early graft function disorders.

Variations in temperature of the donor kidney during cold ischemia time and subsequent assessment of reperfusion using the application of thermovision camera

Cold ischemia time (CIT) and graft reperfusion events are important nonimmunological factors that influence kidney graft function. The optimal temperature for the organs during CIT ranges from 4 degrees C to 8 degrees C. However, preservation of the designated temperature is usually not controlled during standard storage procedures. Aspects of initial graft reperfusion are usually assessed indirectly. Better evaluation of the effectiveness of the early blood supply may improve the surgical outcome. The aim of the study was to monitor the temperature during CIT in the kidney and surrounding area and subsequently to assess graft reperfusion using thermography. Temperature values of the area surrounding the kidney were registered during 8 organ procurements. We observed that the area surrounding the kidney displayed the optimal temperature range only during the first 5 minutes of CIT; later the temperature oscillated between 1 degrees C and 3.5 degrees C. The study proved that the temperature of the preservation fluid is frequently below prescribed. Analysis of the thermograms of 40 transplanted kidneys with the use of a thermovision camera ThermaCAM SC500 showed usefulness of this method to assess reperfusion and blood distribution in the transplanted kidney.

[Laryngeal mask of gastroesophageal reflux disease]

Gastroesophageal reflux disease has become a serious problem not only for general practitioners but for other specialists as well. It is caused by the fact that its clinical picture and symptomatology are very rich. Beside characteristic symptoms such as: heartburn, eructation, gastric contents reflux, epigastric burning or dysphagia, there may appear extroesophageal symptoms (frequently as single or leading ones). It is generally though that the above symptoms result from the direct effect of gastric contents on throat and larynx and/or through vagus nerve. Direct effect of hydrochloric acid and other gastric juice components on larynx may be the cause of subglottic laryngostenosis, neoplastic transformation and development of squamous cell carcinoma. This, it may be concluded that gastroesophageal reflux disease should be in the sphere of interest of laryngologists as well as gastroenterologists. Cooperation of these specialists is particularly useful as it quickens the choice of proper diagnostic procedure and an introduction of an appropriate therapeutic treatment.

Antitumor effect of electrochemical therapy on transplantable mouse cancers

The aim of our study was to assess the antitumor effect of electrochemical therapy (ECT) in the mice bearing advanced transplantable tumours. Mouse mammary cancer 16/C (group 1) and fibrosarcoma F69-3 (group 2) were transplanted subcutaneously (s.c.) into the C3H or BALB/c mice, respectively. Twenty animals in each group bearing measurable s.c. tumours were randomly divided into two subgroups (experimental and control). Two electrodes were inserted into tumours and low level direct current (6-7 V, 5-21 mA) was passed. The animals were observed and tumors were measured twice a week. The animals were sacrificed and autopsied when the tumor diameter reached 2.0 cm. Two animals of each group (experimental and control) were sacrificed for histopathological tumor examination on the 1st and 6th day after ECT. A significant inhibition of tumor growth in mice subjected to ECT was observed, both in those with s.c. growing mammary cancer and with fibrosarcoma. This inhibition was associated with marked prolongation of survival time of ECT-treated mice. It appeared that the mice with mammary cancers were more susceptible to ECT therapy than those with growing s.c. fibrosarcoma. The histopathological studies of tumor specimens from ECT-treated mice showed extensive foci of necrosis with shrinkage of cell nuclei deprived of chromatin. In conclusion, the treatment which inhibits the growth of experimental mammary and fibrosarcoma tumors was demonstrated. However, in no mice complete regression of tumours was observed.

Aedes (Finlaya) japonicus japonicus (Theobald), a new introduction into the United States

Aedes (Finlaya) japonicus japonicus is recorded for the 1st time in the United States. Four adult females were collected in light traps at 2 sites in New York and one site in New Jersey during the months of August and September 1998. Notes on bionomics are provided. Illustrations of the adult female, male, and larva are included.

Electrochemical therapy in palliative treatment of malignant dysphagia: a pilot study

BACKGROUND/AIMS

Electrochemical therapy (ECT), a method based on the application of a low-level direct current, was employed in this study to relieve severe dysphagia. In addition, we aimed to assess the efficacy, safety and requirements for follow-up re-interventions.

METHODOLOGY

Sixteen patients with inoperable and circumferential malignant stenosis of the esophagus were palliated by ECT at presentation and then repeatedly whenever tumor growth and dysphagia recurred. The electrode was inserted and placed at the level of stenosis under fluoroscopic guidance, and an electric quantity of 300-560 coulombs (5-6.5 V; 60-90 mA) was given. When total luminal occlusion was found, prior balloon dilatation enabled insertion of the electrode. Patients with squamous cell carcinoma also received external beam radiotherapy of 20-30 Gy in 10 daily fractions. Dysphagia was graded on a scale of O to 4 (O = normal; 4 = complete dysphagia), and follow-up esophagograms were obtained for response evaluation.

RESULTS

The severity of dysphagia decreased by 1-4 (median: 2) grades with an improvement in 6 patients with totally obstructing lesions. Dysphagia recurred in all but 1 patient after a median interval of 10 weeks, but was easily treated with repeat ECT sessions. However, 2 patients became unresponsive to ECT after 7 and 3 months of therapy, respectively. There were no ECT-related complications.

CONCLUSIONS

In conclusion, this pilot study suggests that electrochemical therapy may provide safe and effective palliation of narrowing and circumferential esophageal carcinoma. It requires repeat interventions and dilatation expertise is necessary for insertion of the electrode through the totally obstructing lesion.

Modifications of the 4,4'-residues and SAR studies of Biphalin, a highly potent opioid receptor active peptide

Modifications of 4,4' residues of Biphalin have resulted in greater binding selectivity and biological potency for the mu opioid receptor. A higher partition coefficient across the phospholipid bilayer membrane has been achieved by using a beta-branched unusual amino acids.

Interaction of a highly potent dimeric enkephalin analog, biphalin, with model membranes

Biphalin, (Tyr-D-Ala-Gly-Phe-NH)2, is a highly potent dimeric analog of enkephalin. Its analgesic efficacy is due in part to its ability to permeate the blood-brain barrier. To aid in understanding the mechanism of the transmembrane movement we determined and analyzed the permeability and partition coefficients of biphalin and a series of analogues where F, Cl, I, NO2, or NH2 were placed in the para position of the aromatic rings of Phe4,4'. Liposomes composed of neutral phospholipids and cholesterol were used as the model membrane. The overall good correlation between permeability and water-membrane partition coefficients suggests that the movement of biphalins across the model membrane is controlled by diffusion and depends on the water-membrane partition coefficient. To explain the observed correlation between permeability and the electron withdrawing/donating character of the substituents in the phenylalanine ring, we examined various folding patterns of Leu-enkephalin, an endogenous pentapeptide that exhibits affinities toward the same classes of opioid receptors (delta and mu). The observed permeabilities and partition coefficients of biphalin and analogues, as well as the tyrosine side chain accessibility, are consistent with the presence of the type of folding where the tyrosine and phenylalanine side chains are in a close contact. We propose that the aromatic ring interaction can promote the peptide permeability by stabilizing a more compact structure of biphalin that would minimize the number of hydrogen bonds with water and therefore enhances partitioning into the model membrane.

Lipid membrane permeability of modified c[D-Pen2, D-Pen5]enkephalin peptides

Permeability coefficients of a series of analogues of a potent opioid peptide, c[D-Pen2, D-Pen5]enkephalin, were measured in a model membrane system. The analogues included hydrophobic amino acid substitutions on position 3. Liposomes of a mixed composition consisting of zwitterionic lipids and cholesterol served as the model membranes. The obtained permeability coefficients range between 0.38 x 10(-12) and 2.9 x 10(-12) cm/s. These data were correlated with the hydrophobicity scale of Nozaki and Tanford (J. Biol. Chem. 246, 1971, 2211-2217) (correlation coefficient = 0.9933) and with determinations of lipid order perturbation by differential scanning calorimetry (correlation coefficient = -0.9779). The reasonably good correlation obtained within the family of analogues substituted on position 3 (Gly, Ala, Leu, Phe) indicates that changes in permeabilities are primarily related to increases in the partition coefficient of the peptide. However, Phe residue added on the N-terminal end of the peptide (position 0) does not appear to follow the observed trend, showing stronger lipid perturbation and lower permeability compared to the Phe3 analog. This observation demonstrates that each class of peptide modifications requires a new basis of permeability analysis and predictions.

Structural domains of phytochrome deduced from homologies in amino acid sequences

A method of semiempirical identification of structural domains is proposed. The procedure is based on the comparison of amino acid sequences in groups of homologous proteins. This approach was tested using 32 known protein sequences from different cytochrome b5, cytochrome c, lysozyme, hemoglobin, and myoglobin proteins. The method presented was able to identify all structural domains of these reference proteins. A consensus secondary structure provided information on structural content of these domains predicting correctly 21 of 23 (91%) of alpha-helices. We applied this method to six homologous phytochrome sequences from Avena, Arabadopsis, Cucurbita, Maize, Oryza, and Pisum. Some of the identified domains can be assigned to the known tertiary structure categories. For example, an alpha/beta domain is localized in the region known to stabilize the phytochrome chromophore in the red light absorbing form (Pr). One alpha-helical and one alpha/beta domains are localized in regions important for the chromophore stabilization in the far-red absorbing form (Pfr). From an analysis of noncovalent interaction patterns in another domain it is proposed that a phytochrome dimer contact involves two segments localized between residues 730 and 821 (using numbering of aligned sequences). Also, a possible antiparallel beta-sheet structure of this region has been suggested. According to this model, the long axis of the interacting structures is perpendicular to a twofold symmetry axis of the phytochrome dimer.

Use of a filter disc micro-sampling atomic absorption method for blood lead level screening

The filter-paper disc method using capillary blood was compared with the Delves techniques using venous blood. For routine screening, the filter-paper disc method was found to yield rapid and reasonable results and, in addition, to be relatively inexpensive. The method was used to screen the blood lead level of over 1000 children in pediatric hospitals of four major cities in Canada. Results of the survey are discussed with regard to sampling technique, analytical technique, and the statistical analysis.