The United States Experience of Lung Transplantation in Recipients with COVID-19 Fibrosis: A UNOS/OPTN Analysis

Purpose

Coronavirus Disease 19 (COVID-19) is a novel cause of end-stage fibrotic lung disease. Data has been limited to case series and single center reports with regards to outcomes in this unique cohort of patients. We sought to investigate the largest experience to date in patients with COVID-19 fibrosis (CVF) who underwent lung transplantation.

Methods

The United Network for Organ Sharing (UNOS) database was queried for all adult patients (≥18 years old) who underwent isolated lung transplantation between 2018 and July 2021. Recipients diagnosed with CVF were identified and compared to those with idiopathic pulmonary fibrosis (IPF). The IPF cohort included recipients from 2018, in the pre-COVID era. Baseline demographics, perioperative factors, and 30-day outcomes were examined.

Results

A total of 931 recipients were included in this study, 868 (93.2%) and 63 (6.8%) were IPF and CVF, respectively. IPF recipients were on average older (65 vs. 56 years, p<0.001), white race (83% vs. 51%, p<0.001), and less likely to be male (73% vs. 86%, p=0.04). BMI was similar between the IPF and CVF, 27.6 and 27.2 kg/m², as was the mean PAP 24 and 21 mmHg. The CVF cohort had lower predicted FVC (32% vs. 47%, p=0.01), and had less tobacco use (36% vs 61%, p<0.001). Mean creatinine level was clinically similar, though statistically higher in the IPF cohort, (0.83 vs 0.64, p<0.001). CVF recipients were on the waitlist for a shorter median duration (10 vs 32 days, p<0.001) with a higher LAS (85 vs 41, p<0.001). Notably, more CVF recipient were be on ECMO at time of listing (29% vs 2%, p<0.001) and require ventilatory support (27% vs. 2%, p<0.001). CVF recipients were more likely to receive a double lung transplantation compared to IPF (83% vs 64%, p=0.002), with similar ischemia times, 5.5 vs 5.1 hrs (p=0.17). Mortality at 30 days was comparable between CVF and IPF (7.0% vs. 2.3%, p=0.09), though 20 patients in the CVF cohort had missing data.

Conclusion

Patients with end-stage lung disease secondary to CVF are higher acuity, and more likely to require ECMO and ventilatory support as a bridge to lung transplantation. Early mortality, while comparable to non-COVID related fibrotic lung disease, remains almost 3 times higher with CVF. In the era of publicly reported survival outcomes, the transplant community may need to reconsider how we approach this new and devastating diagnosis of CVF.

Perioperative Mortality Does Not Explain Racial Disparities in Gastrointestinal Cancer

BACKGROUND

Racial minorities with gastrointestinal cancer suffer disproportionately poor overall and disease-specific survival. We used a nationally representative sample to examine the relationship between race/ethnicity and mortality and determine whether these disparities were observed in the perioperative period.

MATERIALS AND METHODS

The Nationwide Inpatient Sample (NIS) was used to examine patients undergoing surgery for cancers of the esophagus, stomach, pancreas, colon and rectum ("GI cancer") between 2008 and 2012. Logistic regression was used to evaluate whether race/ethnicity was associated with perioperative mortality after adjusting for sociodemographic characteristics, perioperative factors and presentation (ER vs elective).

RESULTS

A total of 110,044 subjects were identified, including 75.8% Whites, 10.5% Black patients, 7.2% Hispanic patients, and 3.1% Asian/Pacific Islanders (API). Whites were generally older than minorities. In adjusted multivariable generalized linear mixed logistic models, no increase in perioperative mortality was seen for minorities. Worse outcomes were observed for those with higher Elixhauser comorbidity score (OR 6.90, CI 5.96-7.99), lower income region (OR 1.24, CI 1.10-1.40), males (OR 1.54, CI 1.42-1.68), and those without private insurance (Medicare OR 1.34, CI 1.16-1.55; Medicaid OR 1.27, CI 1.02-1.58; self-pay OR 1.64, CI 1.24-2.17). Differences in mortality were predominantly driven by comorbidities (pseudo %ΔR² = 38.56%) and only minimally by race (pseudo %ΔR² = 0.49%).

CONCLUSION

Minority groups do not suffer higher rates of perioperative mortality for GI cancer surgeries after controlling for clinical and demographic factors. Future work to address cancer disparities should focus on areas in the cancer care trajectory such as cancer screening, surveillance, socioeconomic factors, and access.

Very small pediatric donor kidney transplantation in pediatric recipients

Kidneys from very small pediatric donors (age <5 years, weight <21 kg) may be a means to increase the donor pool for pediatric recipients. Transplantation of small pediatric kidneys is more commonly performed in adult recipients due to the increased risks of technical complications, thrombosis, and early graft failure. While these risks are abrogated in adult recipients by limiting the donor weight to ≥10 kg and using the EB technique, it is unknown whether pediatric recipients achieve comparable results. US national data were assessed for all first-time, deceased-donor, kidney-only pediatric recipients, 1/1996-10/2013, who received very small pediatric donor grafts or grafts from ideal adult donors. We identified 57 pediatric EB, 110 pediatric SK, and 2350 adult transplants. The primary outcome was 3-year all-cause graft survival. Kaplan-Meier curves showed worse outcomes for pediatric grafts compared to adult ideal grafts (P=.042). On multivariate analysis, pediatric recipients of SK grafts had significantly higher HRs (aHR 2.01, 95% CI 1.34-3.00) and pediatric recipients of EB grafts had somewhat higher non-significant HRs (1.57; 95% CI 0.88-2.79) for graft survival. These results suggest cautionary use of very small pediatric donors as a source to expand the donor pool for pediatric candidates.

Does Lung Donation by Heart Donors Have an Impact on Survival in Heart Transplant Recipients?

Lung procurement is increasing during multiorgan recovery and substantially alters the explant process. This study evaluated whether lung donation by a heart donor affects survival in heart transplant recipients. Retrospective analysis of United Network for Organ Sharing (UNOS) adult heart transplantation data from 1998 to 2012 was performed. Lung donors (LDs) were defined as those having at least one lung procured and transplanted. Non-LDs had neither lung transplanted. Heart transplant recipients who had previous transplants, who had heterotopic transplants, who were waitlisted for other organs or who were temporarily delisted were excluded from the analysis. Kaplan-Meier survival analysis and Cox proportional hazards regression were performed. Of 23 590 heart transplant recipients meeting criteria during the study period, 8638 (36.6%) transplants were from LDs. Donors in the LD group had less history of cigarette use (15.5% vs. 29.5%, p < 0.001). On univariate analysis, LDs were associated with improved patient survival (p < 0.001). On multivariate analysis, LDs were not significantly associated with patient survival (adjusted hazard ratio 0.98, 95% confidence interval 0.94-1.03). Analysis of the UNOS registry suggested that donor pulmonary status and lung procurement had no detrimental effect on survival in heart transplant recipients, supporting the present practice of using donor lungs whenever possible.

Effect of HCV, HIV and coinfection in kidney transplant recipients: mate kidney analyses

Reports of kidney transplantation (KTX) in recipients with hepatitis C virus (HCV+), human immunodeficiency virus (HIV+) or coinfection often do not provide adequate adjustment for donor risk factors. We evaluated paired deceased-donor kidneys (derived from the same donor transplanted to different recipients) in which one kidney was transplanted into a patient with viral infection (HCV+, n = 1700; HIV+, n = 243) and the other transplanted into a recipient without infection (HCV- n = 1700; HIV- n = 243) using Scientific Registry of Transplant Recipients data between 2000 and 2013. On multivariable analysis (adjusted for recipient risk factors), HCV+ conferred increased risks of death-censored graft survival (DCGS) (adjusted hazard ratio [aHR] 1.24, 95% confidence interval [CI] 1.04-1.47) and patient survival (aHR 1.24, 95% CI 1.06-1.45) compared with HCV-. HIV+ conferred similar DCGS (aHR 0.85, 95% CI 0.48-1.51) and patient survival (aHR 0.80, 95% CI 0.39-1.64) compared with HIV-. HCV coinfection was a significant independent risk factor for DCGS (aHR 2.33; 95% CI 1.06, 5.12) and patient survival (aHR 2.88; 95% CI 1.35, 6.12). On multivariable analysis, 1-year acute rejection was not associated with HCV+, HIV+ or coinfection. Whereas KTX in HIV+ recipients were associated with similar outcomes relative to noninfected recipients, HCV monoinfection and, to a greater extent, coinfection were associated with poor patient and graft survival.

Expression and glycosylation of MUC1 in epidermolysis bullosa-associated and sporadic cutaneous squamous cell carcinomas

BACKGROUND

Cutaneous squamous cell carcinoma (SCC) is particularly problematic in certain patient groups, including patients with dystrophic or junctional epidermolysis bullosa (DEB/JEB). Theoretically, vaccination against a cell surface antigen which is expressed on this type of tumour could prevent SCC development, as well as treat primary and metastatic disease in this patient group. Preliminary studies have suggested that MUC1, a transmembrane glycoprotein, is overexpressed in sporadic cutaneous SCCs, and MUC1 has been used with some success as a target antigen for vaccine development in breast cancer, where it is expressed on > 50% of neoplastic cells in approximately 50-80% of tumours. Furthermore, aberrant glycosylation of MUC1 has been detected in this and other cancer types; however, the glycosylation status of MUC1 in cutaneous SCC is not known.

OBJECTIVES

To investigate the expression and glycosylation status of MUC1 in SCCs arising in patients with DEB and JEB, and for comparison in sporadic SCCs and sporadic Bowen's disease.

METHODS

Immunohistochemical analysis of MUC1 in 30 SCCs from subjects with DEB/JEB, 55 sporadic SCCs and 30 sporadic lesions of Bowen's disease was carried out using four separate monoclonal antibodies which recognize different isoforms of MUC1.

RESULTS

Expression of MUC1 was detected in 100% of SCCs arising in patients with DEB and JEB; > 50% of neoplastic cells stained positive for MUC1 in 57% of DEB/JEB SCCs, with over 95% of tumour cells immunopositive in 33% of cases. MUC1 expression was also observed in 95% of sporadic SCCs and 97% of Bowen's disease, with 36% of sporadic SCCs immunopositive for MUC1 in > 50% of tumour cells. Investigation of the glycosylation status showed that MUC1 was predominantly hyperglycosylated in the DEB/JEB and sporadic tumours.

CONCLUSIONS

The results demonstrate that a significant proportion of DEB/JEB and sporadic SCCs express MUC1 in > 50% of tumour cells. Therefore, MUC1 may be a suitable candidate antigen against which to develop a tumour vaccine for these patient groups.

Benefits of linking primary medical care and substance abuse services: patient, provider, and societal perspectives

Individuals with alcohol and drug use problems may receive health care from medical, mental health, and substance abuse providers, or a combination of all three. Systems of care are often distinct and separate, and substantial opportunities for benefit to patient, provider, and payer are missed. In this article, we outline (1) the possible benefits of linking primary care, mental health, and substance abuse services from the perspective of the major stakeholders-medical and mental health providers, addiction clinicians, patients, and society-and (2) reasons for suboptimal linkage and opportunities for improving linkage within the current health care system. We also review published models of linked medical and substance abuse services. Given the potential benefits of creating tangible systems in which primary care, mental health, and substance abuse services are meaningfully linked, efforts to implement, examine, and measure the real impact should be a high priority.

Continuing medical education: a new vision of the professional development of physicians

The authors describe their vision of what continuing medical education (CME) should become in the changing health care environment. They first discuss six types of literature (e.g., concerning learning and adult development principles, problem-based/practice-based learning, and other topics) that contribute to ways of thinking about and understanding CME. They then state their view that the Association of American Medical Colleges (AAMC) has made a commitment to helping CME be more effective in the professional development of physicians. In presenting their new vision of CME, the authors describe their interpretation of the nature and values of CME (e.g., optimal CME is highly self-directed; the selection and design of the most relevant CME is based on data from each physician's responsibilities and performance; etc.). They then present seven action steps, suggestions to begin them, and the institutions and organizations they believe should carry them out, and recommend that the AAMC play a major role in supporting activities to carry out these steps. (For example, one action step is the generation and application of new knowledge about how and why physicians learn, select best practices, and change their behaviors). Six core competencies for CME educators are defined. The authors conclude by stating that collaboration among the appropriate academic groups, professional associations, and health care institutions, with leadership from the AAMC, is essential to create the best learning systems for the professional development of physicians.

Angiogenic therapy for the chronically ischemic lower limb in a rabbit model

The purpose of this study was to evaluate the long-term effectiveness of basic fibroblast growth factor (bFGF) in achieving neovascularization following ischemia from arterial ligation and to determine an optimal dosage level. We used an Ameroid constrictor to produce progressive occlusion of the left femoral artery of rabbits. At 2 weeks, the rabbits were randomized to receive intravenous injection of vehicle (group A, n = 15); 3 microg/kg/day bFGF (group B, n = 12); 10 microg/kg/day bFGF (group C, n = 12); or 16 microg/kg/day bFGF (group D, n = 15) for 3 days. At 1 to 37 days after surgery, we assessed limb neovascularization by transcutaneous oximetry (TCPO(2)), angiography, heart rate, arterial pressure, peripheral vascular resistance (PRU), and muscle blood flow (MBF) during steady-state intra-arterial infusion of saline (basal), acetylcholine, papaverine, or serotonin under anesthesia and capillary density (cap/mm(2)) and capillary per muscle fiber ratio (cap/F). Groups B and C showed significantly greater change in TCPO(2) over time than groups A and D (P < 0.0001). Group D showed the lowest TCPO(2) values from days 14 to 37 and group C the highest. Groups B and C showed a higher number of vessels filled with contrast agent than groups A and D (P < 0.0001). Calf cap/mm(2) and cap/F were significantly higher in groups B and C than groups A and D (P < 0.0001). Calf basal MBF values were higher in groups B and C than in groups A and D, but were not statistically significant. Group D showed the highest level in basal PRU. There were no significant differences in heart rate or blood pressure among the groups. These results show (1) treatment with bFGF has no adverse hemodynamic effects, (2) bFGF enhances angiogenesis and circulation at moderate doses, and these effects persist at least several weeks, and (3) high doses of bFGF may inhibit angiogenesis and collateral circulation.

HIV incidence among injection drug users in New York City, 1992-1997: evidence for a declining epidemic

OBJECTIVES

We assessed recent (1992-1997) HIV incidence in the large HIV epidemic among injection drug users in New York City.

METHODS

Data were compiled from 10 separate studies (N = 4979), including 6 cohort studies, 2 "repeat service user" studies, and 2 analyses of voluntary HIV testing and counseling services within drug treatment programs.

RESULTS

In the 10 studies, 52 seroconversions were found in 6344 person-years at risk. The observed incidence rates among the 10 studies were all within a narrow range, from 0 per 100 person-years at risk to 2.96 per 100 person-years at risk. In 9 of the 10 studies, the observed incidence rate was less than 2 per 100 person-years at risk. The weighted average incidence rate was 0.7 per 100 person-years at risk.

CONCLUSIONS

The recent incidence rate in New York City is quite low for a high-seroprevalence population of injection drug users. The very large HIV epidemic among injection drug users in New York City appears to have entered a "declining phase," characterized by low incidence and declining prevalence. The data suggest that very large high-seroprevalence HIV epidemics may be "reversed."

Prevalence and risk factors for positive tuberculin skin tests among active drug users at a syringe exchange program

OBJECTIVES

To evaluate the prevalence and predictors of tuberculin skin test (TST) reactions > or =10 mm among active injection drug users (IDUs) at a syringe exchange program in New York City.

METHODS

From August 1995 to January 1996, participants were offered TB screening, an interview, and received $15.00 upon returning for skin test interpretation.

RESULTS

610/650 (94%) consented to screening. Of the 566 (93%) who returned for skin test readings, skin test data were available for 564 (99.8%); 14% (95% CI 11.6-17.4) had TSTs > or =10 mm. When the > or =5 mm threshold for interpretation of TST among HIV-infected persons was used, the prevalence of TST positivity increased by only 1%. In univariate analysis, the prevalence of TST > or =10 mm increased with age and with increasing years of IDU (both P = 0.001). Because of a strong correlation between age and duration of IDU, two logistic regression models were examined. In the model with age alone, a history of self-reported TST positivity (OR 8.88; 95% CI 4.9-16.09; P = 0.0001) and increasing age (OR per 10 years increase in age, 1.69; 95% CI 1.24-2.29; P = 0.0008) were independent predictors of TSTs > or =10 mm. In the model with duration of IDU, a history of TST positivity (OR 8.82; 95% CI 4.74-16.41; P = 0.0001) and duration of IDU (OR per 10 years of IDU, 1.46; 95% CI 1.10-1.94; P = 0.0081) were independent predictors of TST > or =10 mm.

CONCLUSIONS

Use of the reduced cutoff point for TST positivity from 10 mm to 5 mm did not significantly affect the prevalence of positive TSTs in this cohort of active drug users. Increased prevalence of TB infection with age suggests a high annual incidence of TB infection in this population, and the increased risk of TB infection with increasing duration of IDU suggests that the duration spent in IDU environments may increase infection risk.

Knowledge of tuberculosis among drug users. Relationship to return rates for tuberculosis screening at a syringe exchange

Tuberculosis is an important health issue among drug users. We sought to evaluate active drug users' (DUs) knowledge of tuberculosis (TB) and to assess the relationship between TB knowledge and attitudes and tuberculin skin test (TST) return rates at a syringe exchange program. DUs were recruited at a syringe exchange program in New York City, were interviewed and offered TSTs, and received $15.00 upon returning for TST reading. The questionnaire evaluated knowledge of TB transmission, prevention, and treatment. From March 13, 1995 to January 31, 1996, 610 of 650 (94%) of DUs approached agreed to participate. Of these, 80% had previous TSTs within the past 2 years and 20% were known to be HIV infected. Almost all knew that TB is contagious and more than two thirds knew that TB is treatable and that TB preventive therapy existed. However, fewer than half knew that HIV-related TB could be treated, 30% thought TB could be treated without a medical doctor, and the majority (70%) thought a reactive TST implied infectivity. The rate of return for TST reading was 93%. In multivariate analysis, those who knew that HIV-related TB was curable were more likely to return for TST reading (odds ratio 2.0; 95% confidence interval 1.04 to 3.95; p = .03). The high acceptance and return rates suggest that TB services can be incorporated into syringe exchange programs. However, several important gaps in TB knowledge existed in this population at high risk of TB, which may impact on adherence and which support the need for TB education for drug users.

A method to track surgical site infections

We present an approach to assessing the impact of surveillance for surgical site infections and providing feedback to surgeons on their progress, as part of continuous quality improvement. Adjusting for patient risk factors using the Standardized Mortality Ratio, there was a marked decrease over time in both SMR (1.3 to 0.27) and crude infection rates (32 to 10 per thousand operations per year). These declines cannot be explained by decreased length of hospital stay.

Papanicolaou and Kruger assessment of sperm morphology: thresholds and agreement

The current World Health Organization guidelines (1992) suggest that the presence of > or = 30% normal sperm forms (i.e. PAP criteria) is consistent with normal semen quality. Critical evaluation of sperm morphology (CE; Kruger classification) has shown an excellent correlation with human in vitro fertilization. Utilizing Kruger criteria, > 14% normal sperm forms has been proposed as indicative of normal semen quality. We have performed a retrospective analysis on 261 individuals to assess the agreement between PAP and Kruger criteria for normal sperm morphology (NSM). When the threshold for NSM by PAP was set at 30%, a significant agreement was found between the percentage normal forms of both criteria (Kappa coefficient = 0.37; p < 0.001). Sixty-seven (92%) of the 73 men found to have abnormal sperm morphology by PAP had abnormal semen by Kruger classification. When the threshold for NSM by PAP was established at 50%, the Kappa coefficient was 0.48 (p < 0.001). Sixty of the 72 samples (83%) classified as normal by PAP staining were normal by Kruger criteria. Interestingly, when NSM by PAP was between 30 and 50%, the specimen was just as likely to have normal or abnormal sperm morphology by Kruger (40 vs. 60%, respectively). These results strongly suggest that a high or low percentage of NSM by PAP is in agreement with the Kruger classification. The excellent agreement of Kruger and WHO criteria at the extremes (< 30% and > 50%) may obviate the need for Kruger assessment. However, when WHO morphology is between 30 and 50%, the addition of Kruger evaluation may provide meaningful information to help better diagnose a patient and plan his treatment.

Basic fibroblast growth factor stimulates angiogenesis in the hindlimb of hyperglycemic rats

Angiogenic growth factors including basic fibroblast growth factor (bFGF) have therapeutic value for chronic ischemia in nondiabetic animals. However, angiogenic therapy for chronic ischemia in a background of diabetes remains unexplored. In the present study, we evaluated the effects of exogenous bFGF on angiogenesis in streptozotocin-induced diabetic rats with ischemic and nonischemic limbs. We produced ischemia of the left lower limb by excising the superficial femoral artery. At 2 weeks, the rats received an intramuscular injection of vehicle (group A), 0.3 microg bFGF/day (group B), or 1 microg bFGF/day (group C), daily for 2 weeks. At 4 weeks, we assessed limb angiogenesis by skeletal muscle capillary density (cap/mm2) and capillary per muscle fiber ratio (cap/F) counts. Group C had significantly higher mean levels compared to group A for calf capillary density (P < 0.0024) and capillary per muscle fiber ratio in both thigh (P < 0.0015) and calf (P < 0.0001). There was a trend toward increased mean capillary per muscle fiber ratio with increasing dose. This trend was significant in the calf (P < 0.0015) and just missed statistical significance in the thigh. There was a similar trend in calf capillary density. We conclude that exogenous bFGF enhances angiogenesis and, possibly, collateral circulation in ischemic limbs of diabetic rats.

"Why I am not infected with HIV": implications for long-term HIV risk reduction and HIV vaccine trials

OBJECTIVE

To describe beliefs about remaining HIV-seronegative in injecting drug users in two high-seroprevalence cities, and to consider implications of these beliefs for ongoing risk reduction efforts and for HIV vaccine efficacy trials.

DESIGN

Cross-sectional survey with open- and closed-ended questions.

SUBJECTS

58 HIV-seronegative injecting drug users participating in HIV vaccine preparation cohort studies in New York City, New York, U.S.A., and Bangkok, Thailand.

MAJOR FINDINGS

Large majorities of subjects in Bangkok (90%) and in New York (89%) believed their "own efforts" to practice safer injection methods and safer sex were very important in avoiding HIV infection. More Bangkok subjects (30%) believed that they would "probably" become infected with HIV in the future than New York subjects (4%). Three percent of Bangkok subjects and 70% of New York subjects believed "having an immune system strong enough to avoid becoming infected with HIV despite exposure to the virus" was very important in avoiding HIV infection. This belief in New York subjects was associated with having previously engaged in high-risk behaviors (i.e., sharing injection equipment, unprotected sex, or both) with partners known to be HIV-seropositive.

CONCLUSIONS

Risk reduction programming for high-HIV-seroprevalence populations and within HIV vaccine trials should address not only specific HIV risk behaviors, but also the complex belief systems about avoiding HIV infection that develop within such groups. The person's "own efforts/self-efficacy" appears to be central in the psychology of risk reduction. Members of some high-risk populations may overestimate greatly the frequency of any possible natural immunity to becoming infected with HIV. Prevention programs for these populations will need to address explicitly the probabilistic nature of HIV transmission.

Response of routine semen analysis and critical assessment of sperm morphology by Kruger classification to therapeutic varicocelectomy

PURPOSE

We studied the effect of varicocelectomy on Kruger morphology and semen parameters.

MATERIALS AND METHODS

A total of 33 subfertile men diagnosed with varicoceles was evaluated 3 months before, and 3 to 4 and 6 to 8 months after varicocelectomy. Evaluation involved routine semen analysis and sperm morphology using Kruger classification.

RESULTS

Significant improvement in sperm concentration and count was found after varicocelectomy (sperm count preoperatively 117.1 +/- 29, 3 to 4 months postoperatively 162.5 +/- 41 and 6 to 8 months postoperatively 139.8 +/- 25 million sperm, p = 0.0095). Using Kruger classification, evaluation of sperm morphology revealed overall significant increase in percentage of normal A forms at 3 to 4 and 6 to 8 months after surgery (from 9.8 +/- 5.8% A forms, 13.6 +/- 7.7% A forms, and 14.5 +/- 7.5% A forms, respectively, p = 0.0002, normal greater than 14%). Twelve of the 26 patients (46%) with abnormal sperm morphology preoperatively and greater than 4% A forms reached normal levels 3 months postoperatively. Six months after surgery only 6 patients maintained normal values and 3 of the initial 14 nonresponders became normal (9 of 26, 36%). Three patients with severe teratozoospermia (less than 4% A forms) showed improvement in sperm morphology. Four patients with normal sperm morphology preoperatively were not affected by varicocelectomy.

CONCLUSIONS

Surgical correction of varicocele was associated with significant improvement in sperm morphology evaluated using Kruger classification. Concentration and count improved after varicocelectomy. Changes were observed as early as 3 months after surgery.

A prospective comparison of two expanded polytetrafluoroethylene grafts for linear forearm hemodialysis access: does the manufacturer matter?

BACKGROUND

The function and patency of standard 6-mm Goretex (W.L. Gore and Associates, Flagstaff, AZ) and Impra (Impra, Inc., Tempe, AZ) expanded polytetrafluoroethylene (e-PTFE) grafts for hemodialysis as radial-antecubital linear arteriovenous fistulae for dialysis are compared.

STUDY DESIGN

A randomized clinical trial was conducted in two community dialysis centers and in one hospital-based center serviced by one vascular surgical practice, that performed the access surgery. Selection of linear forearm access, as opposed to other hemodialysis graft configurations, was at the discretion of the surgeon. Candidates for linear grafts had palpable radial pulses with a normal Allen test and normal digital Doppler flow in the hand. Linear grafts were placed using end-to-side anastomoses to the artery and vein, and the graft type was determined by randomization. Primary patency was determined by first episode of thrombosis, first revision, or angioplasty of the graft. Secondary patency after thrombectomy, revision, or angioplasty was determined when the graft was no longer clinically usable, and a new graft needed to be placed as a parallel conduit in the forearm or in another site. Statistical analysis was by actuarial life-table methods.

RESULTS

There were 131 linear forearm grafts in 117 patients. The Impra and Goretex groups were equally matched for gender and major risk factors, except for smoking, which was more common in the Goretex group. Minimum followup was 24 months. Life table primary patencies at 1 year (Impra 43%, Goretex 47%) and at 2 years (Impra 30%, Goretex 26%) were not statistically different (p = 0.78); secondary patency was also equal at 1 year (Impra 49%, Goretex 69%) and at 2 years (Impra 33%, Goretex 41%) (p = 0.15). Discontinuance of use of a patent graft, complications, episodes of thrombosis, and the need to replace the original graft occurred in the two groups without a statistically significant difference.

CONCLUSIONS

In the linear forearm position from the radial artery to an antecubital vein, there is no difference in the performance of 6-mm standard e-PTFE grafts on the basis of manufacturer, whether Goretex or Impra. On the basis of performance, linear forearm dialysis grafts are an acceptable method for hemodialysis access.

An investigation into the effect of ischaemia and pressure on irritant inflammation

Reports of chemical burns beneath tourniquets during orthopaedic procedures led us to explore the irritant effects produced by the skin antiseptics used during such procedures. A sphygmomanometer and tourniquet, at a pressure of 200 mmHg for 30 min, was used to created pressure and ischaemia which were then examined separately for their respective effects on irritant inflammation in normal subjects and those with atopic eczema. As no inflammation could be demonstrated with the antiseptics, we subsequently used the known irritant chemical anthralin to examine the effect of ischaemia with and without pressure. Site-related variation in anthralin-induced inflammation was observed but there was no demonstrable effect of either pressure or ischaemia on the inflammatory response. Therefore, as we are unable to show a relationship between ischaemia with or without pressure and irritant inflammation, we conclude that burns under tourniquets are likely to be idiosyncratic reactions and their further investigation requires examination of the individuals affected.

Hospital utilization patterns and costs for adult sickle cell patients in Illinois

OBJECTIVES

To determine population size, demographic characteristics, hospital utilization patterns, the specialties of physicians providing care, and costs for hospitalized adult sickle cell patients in Illinois.

METHODS

A statewide, administrative dataset for the two-year period from january 1992 through December 1993 was analyzed retrospectively.

RESULTS

There were 8403 admissions among 1189 individual sickle cell patients for the two-year period. Eighty-five percent of patients resided in the Chicago metropolitan area. The median age of the 1189 patients was 29; two-thirds had Medicaid or Medicare coverage. Emergency departments were the primary source of admissions (85.7%). The most common admitting diagnosis was painful crisis (97.4%), and average length of stay was four days. The median number of admissions per patient was three; most patients (85%) used only one or two hospitals. A small group used more than four hospitals and accounted for 23% of statewide admissions. Primary care physicians cared for most patients, and total hospitalization charges were more than $59 million.

CONCLUSIONS

In Illinois the adult sickle cell population is concentrated in major urban centers, primarily the Chicago metropolitan area. These patients accounted for approximately 8400 admissions and more than $59 million in hospital charges during the two-year study period. A small group of patients used multiple hospitals and accounted for more than 23% of total hospitalization charges. This study shows the necessity of and provides a useful framework for developing targeted programs for adult sickle cell patients as well as for training physicians to efficiently provide comprehensive health care services for this population.

"Shotgunning" as an illicit drug smoking practice

There has been a rise in illicit drug smoking in the United States. "Shotgunning" drugs (or "doing a shotgun") refers to the practice of inhaling smoke and then exhaling it into another individual's mouth, a practice with the potential for the efficient transmission of respiratory pathogens. Three hundred fifty-four drug users (239 from a syringe exchange and 115 from a drug detoxification program) were interviewed about shotgunning and screened for tuberculosis (TB). Fifty-nine (17%; 95% CI 12.9%-20.9%) reported shotgunning while smoking crack cocaine (68%), marijuana (41%), or heroin (2%). In multivariate analysis, age < or = 35 years (OR 2.0, 95% CI 1.05-3.9), white race (OR 1.2, 95% CI 1.2-4.8), drinking alcohol to intoxication (OR 2.2, 95% CI 1.1-4.3), having engaged in high-risk sex (OR 2.6, 95% CI 1.04-6.7), and crack use (OR 6.0, 95% CI 3.0-12) were independently associated with shotgunning. Shotgunning is a frequent drug smoking practice with the potential to transmit respiratory pathogens, underscoring the need for education of drug users about the risks of specific drug use practices, and the ongoing need for TB control among active drug users.

The protective effect of AIDS-related behavioral change among injection drug users: a cross-national study. WHO Multi-Centre Study of AIDS and Injecting Drug Use

OBJECTIVE

This study assessed the relationship between self-reported acquired immunodeficiency syndrome (AIDS) behavioral change and human immunodeficiency virus (HIV) serostatus among injection drug users.

METHODS

The study sample involved 4419 injection drug users recruited from drug abuse treatment and nontreatment settings in 11 cities in North America, South America, Europe, Asia, and Australia. The World Health Organization multisite risk behavior questionnaire was used, and either blood or saliva samples for HIV testing were obtained. Subjects were asked, "Since you first heard about AIDS, have you done anything to avoid getting AIDS?"

RESULTS

The protective odds ratio for behavioral change against being infected with HIV was 0.50 (95% confidence interval = 0.42, 0.59). While there was important variation across sites, the relationship remained consistent across both demographic and drug use history subgroups.

CONCLUSIONS

Injection drug users are capable of modifying their HIV risk behaviors and reporting accurately on behavioral changes. These behavioral changes are associated with their avoidance of HIV infection.

Feasibility and safety of 1-day postoperative hospitalization for carotid endarterectomy

OBJECTIVE

To determine whether 1-day postoperative hospitalization after carotid endarterectomy is safe and the degree to which this can be achieved.

DESIGN

Consecutive sample series of all carotid endarterectomies performed by a single surgical group.

SETTING

A single tertiary-care hospital.

PATIENTS

All who underwent carotid endarterectomy. Patients with procedures combined with coronary revascularization and patients undergoing the first part of a staged bilateral carotid endarterectomy performed in 1 hospitalization were excluded.

INTERVENTION

In December 1993, a fast-track protocol was initiated, aiming for a 1-day stay after carotid endarterectomy without admission to an intensive care unit (ICU). Before this date, postoperative care included obligatory monitoring for at least 1 night in an ICU.

MAIN OUTCOME MEASURES

Length of stay, admission to and stay in the ICU, complications, and hospital readmission rate.

RESULTS

Over a 21-month period, 152 patients had 163 carotid endarterectomies. Of these, 124 were elective and 39 urgent (patients with a critical stenosis). Indications were stroke (n = 14 [8.6%]), transient ischemic attack (n = 50 [30.7%]), amaurosis fugax (n = 36 [22.1%]), and asymptomatic stenosis (n = 63 [38.7%]). General anesthesia was used for 159 procedures, cervical block for 4. Mean operation time was 2.6 hours. Postoperative stay was 1 day for 82 procedures (50%), 2 days for 49 procedures (30%), 3 days for 12 procedures (7%), and longer for 20 procedures (12%). In the last half of the study, 61% of patients (50/82) were discharged on postoperative day 1 and 87% (71/82) by postoperative day 2. One hundred three patients went to a surgical floor postoperatively. Overall, 60 patients went to the ICU, but only 18 (22%) of the last 82 procedures required ICU admission. The total stay averaged 3.8 days. Twenty-one patients (13%) experienced complications, including 3 deaths within 30 days and 5 neurological deficits. There were 14 early readmissions, but none was attributable to discharge on the first or second postoperative day.

CONCLUSIONS

Early discharge home after carotid endarterectomy is safe and efficacious, and obligatory admission to an ICU is not necessary. At least 60% of patients who undergo carotid endarterectomy can have a postoperative stay of 1 day, and more than 80% can be discharged by postoperative day 2. A short postoperative stay is not associated with a significant risk of readmission for complications.

[10 year results of preoperative radiotherapy in treatment of rectal carcinoma]

BACKGROUND

We have previously reported improvements in survival and disease-free survival at five years using preoperative radiation in the treatment of rectal cancer. The current update was undertaken to determine if these favorable results were durable with longer follow-up.

METHODS

Patients found to have resectable rectal cancer between 1972 and 1979 were treated with 40-45 Gy of preoperative radiation (40 patients) or resection alone (109 patients). Follow-up information beyond five years was obtained from the Tumor Registry, physician contact and a survey of the National Death Index. Of the 149 patients followed for five years, 144 were evaluable at ten years.

RESULTS

After a median follow-up of 125 months, survival of the irradiated patients was significantly better than that of controls (77 versus 57% at 5 years and 74 versus 41% at 10 years, p = 0.0044). Disease-free survival of those patients whose resection margins were free was also superior for the irradiated group (85 versus 59% at 5 years and 80 versus 45% at 10 years, p = 0.0045).

CONCLUSIONS

The results show that the survival advantage for 40 to 45 Gy preoperative radiation in the treatment of rectal cancer persist at 10 years follow-up.

Predictors and outcome of multidrug-resistant tuberculosis

We identify early predictors of multidrug-resistant tuberculosis and describe improved clinical outcomes, including survival, for patients with human immunodeficiency virus (HIV)-related multidrug-resistant tuberculosis (MDR-TB) when they are prospectively identified and receive treatment under direct observation. Analysis by means of a Cox proportional hazards model revealed that failure to defervesce while receiving a standard four-drug antituberculous regimen was independently associated with multidrug resistance (P = .004). When patients with HIV-related MDR-TB were prospectively identified and treated with at least two agents that were active in vitro, 100% bacteriologic conversion and improved survival (> or = 4 months for 88% of patients and > or = 1 year for 59% of patients) were observed. For patients with HIV-related tuberculosis, poorer survival was associated with a CD4+ lymphocyte count of < 25 mm3 (P = .03); multidrug resistance was not a predictor of poor outcome (P = .82). These data suggest that patients with prolonged fever who are receiving antituberculous therapy may be an appropriate subgroup to target for broader empirical therapy. The findings also demonstrate that improved outcomes can be achieved with HIV-related MDR-TB when patients are prospectively identified and treated with agents that are active in vitro.

Maintaining low HIV seroprevalence in populations of injecting drug users

OBJECTIVES

To describe prevention activities and risk behavior in cities where human immunodeficiency virus (HIV) was introduced into the local population of injecting drug users (IDUs), but where seroprevalence has nevertheless remained low (< 5%) during at least 5 years.

DESIGN AND SETTING

A literature search identified five such cities: Glasgow, Scotland; Lund, Sweden; Sydney, New South Wales, Australia; Tacoma, Wash; and Toronto, Ontario. Case histories were prepared for each city, including data on prevention activities and current levels of risk behavior among IDUs.

PARTICIPANTS

Injecting drug users recruited from both drug treatment and non-treatment settings in each city.

INTERVENTIONS

A variety of HIV prevention activities for IDUs had been implemented in each of the five cities.

RESULTS

There were three common prevention components present in all five cities: (1) implementation of prevention activities when HIV seroprevalence was still low, (2) provision of sterile injection equipment, and (3) community outreach to IDUs. Moderate levels of risk behavior continued with one third or more of the IDUs reporting recent unsafe injections.

CONCLUSIONS

In low-seroprevalence areas, it appears possible to severely limit transmission of HIV among populations of IDUs, despite continuing risk behavior among a substantial proportion of the population. Pending further studies, the common prevention components (beginning early, community outreach, and access to sterile injection equipment) should be implemented wherever populations of IDUs are at risk for rapid spread of HIV.

Synergistic effect of basic fibroblast growth factor and methylprednisolone on neurological function after experimental spinal cord injury

The authors evaluated the effects of exogenous basic fibroblast growth factor (bFGF) in combination with intravenous methylprednisolone on neurological function and cord angiogenesis in a model of spinal cord injury. Cord injury was produced by extradural clip compression through a T-1 laminectomy. Rats were randomized to one of six groups. Group A was given sham laminectomy without cord injury or treatment. The remaining animals were divided into five groups: untreated injury (Group B); injury treated with methylprednisolone (Group C); combined methylprednisolone and 1 microgram bFGF administered locally at the site of injury (Group D); methylprednisolone and 3 micrograms bFGF (Group E); or methylprednisolone and 3 micrograms heated bFGF (Group F). Groups C through F received treatment 1 hour after cord injury. At 1, 2, 3, and 4 weeks after surgery, neurological function of hindlimbs was assessed by blinded observers using an established multiple test method (toe spread, reflexes to extension, pain, and pressure as well as inclined plane and swim test) with tests graded and results expressed as a combined behavioral score. Animals were killed to study spinal cord angiogenesis in cord samples (2-mm sections proximal and distal to the injury site) by capillary density determination. Behavioral scores over time showed a significant difference among Groups B, C, D, E, and F (p = 0.0044), with Groups E and B maintaining highest and lowest scores, respectively. There was a linear dose effect of bFGF over time (p = 0.0187). At 4 weeks, scores showed a difference among the five groups (p = 0.006), with Group E showing higher scores than any other treatment group (for example, vs. group F: p = 0.035). There was a significant difference among the groups in gray matter capillary density counts: proximal (p = 0.0192) and distal (p = 0.024), whereas white matter capillary counts were similar across treatment groups. These results show: 1) possible synergism exists between methylprednisolone and bFGF, such that combinations of these drugs significantly enhance neurological recovery, 2) bFGF exhibits a dose-response effect in function but not in capillary density, and 3) heated, inactivated bFGF is not therapeutically effective.

HIV/AIDS-related behavior change among injecting drug users in different national settings

OBJECTIVES

To identify factors associated with effective AIDS behavior change among injecting drug users (IDU) in different national settings.

DESIGN

Cross-sectional surveys of IDU, with determination of HIV status. Trends in city HIV seroprevalence among IDU also used to validate effectiveness of behavior change.

SETTING AND PARTICIPANTS

Subjects recruited from drug-use treatment programs and outreach efforts in Bangkok, Thailand (n = 601), Glasgow, Scotland (n = 919), New York City, USA (n = 2539), and Rio de Janeiro, Brazil (n = 466).

RESULTS

Evidence for the effectiveness of self-reported risk reduction was available for all cities. Univariate followed by multiple logistic regression analyses were used to identify factors associated with self-reported AIDS behavior change. Separate analyses were conducted for each city. Talking about AIDS with drug-using friends was significantly associated with behavior change in all four cities. Talking with sex partners about AIDS, educational level, knowing that someone can be HIV-infected and still look healthy, and having been tested previously for HIV were each significantly associated with behavior change in three of the four cities.

CONCLUSIONS

Despite the substantial differences in these national settings, there were common factors associated with effective risk reduction. In particular, risk reduction appears to occur through social processes rather than through individual attitude change. HIV prevention programs need to explicitly incorporate social processes into their work.

Ureteral lymphoma: MRI demonstration

A case of ureteral lymphoma with no other areas of involvement was incidentally discovered on MRI examination. Bilateral ureteral soft tissue infiltration, asymmetrical hydronephrosis, and abnormal enhancement of lymphomatous tissue were noted. A follow-up MRI after chemotherapy demonstrated significant decrease in the size of the periureteral disease and improvement in the extent of hydronephrosis.

Risk factors for HIV-1 seroprevalence among drug injectors in the cocaine-using environment of Rio de Janeiro

To determine risk factors for HIV-1 among drug injectors in Rio de Janeiro, where cocaine is the dominant drug of injection, subjects were recruited using the criteria and interview instrument of the World Health Organization's Cross-National Study of HIV infection and risk behaviour in injecting drug users. HIV antibody test results were derived both from serum tests and from self-reports of previous tests (documented evidence of self-reported seropositivity was required). The analytical sample consists of 123 subjects, recruited both at drug abuse treatment sites and at street locations. Of 27 subjects with both serological and self-reported antibody status data, 20 reported previous negative tests; of these three had positive sera and may have seroconverted. Seven subjects reporting prior positive serostatus all tested positive. For the 123 subjects, seroprevalence was 34%. Independent significant risk factors in multivariate logistic regression with backwards elimination are: years of injection greater than 5; being a male who has had sex with men in the previous 5 years; and not having taken deliberate steps to protect oneself against AIDS. These findings indicate that homosexual/bisexual male drug injectors may be a bridge group through which HIV is entering drug-injecting networks in Rio de Janeiro. Efforts by drug injectors to reduce their risk of infection seem to have protective effects. This underscores the importance of HIV prevention efforts aimed at drug injectors.

AIDS risk reduction and reduced HIV seroconversion among injection drug users in Bangkok

Human immunodeficiency virus (HIV) seroconversion was studied in a group of 173 injection drug users in Bangkok, Thailand, who had been previously tested for HIV and were interviewed and retested in the fall of 1989. Ten percent of the group had seroconverted. Two factors protected against HIV seroconversion: having stopped sharing injection equipment in response to the acquired immunodeficiency syndrome (AIDS) and having a regular sexual partner. The association between self-reported deliberate risk reduction and reduced HIV seroconversion among persons continuing to inject illicit drugs indicates that injection drug users can change their behavior in response to AIDS and will accurately report on the behavior change, and that the changes can protect against HIV infection.

Predictors of axillary lymph node metastases in patients with T1 breast cancer. A multivariate analysis

BACKGROUND

In T1 tumors, the reported incidence of lymph node metastases ranges from 21% to 35%. The authors analyzed the pathology parameters of T1 tumors for their association with the likelihood of axillary lymph node metastases.

METHODS

Two hundred sixty-three patients with T1 unilateral invasive breast cancer were studied. All underwent axillary dissection, and the pathologic status of the nodes was known. The parameters of the primary tumor evaluated included size, histologic subtype, nuclear grade, DNA ploidy, S-phase fraction (SPF), hormone receptor status, lymphatic/vascular invasion (LVI), and host reaction.

RESULTS

Seventy-two (27%) patients had nodes that were positive for metastasis. Univariate analysis showed that lymph node metastases were associated with tumors larger than 1 cm (P = 0.001), moderate or poorly differentiated nuclear grade (P = 0.005), high SPF (P = 0.041), presence of LVI (P < 0.001) and patients younger than 60 years (P = 0.01). However, independent predictors of lymph node metastasis in the multivariate logistic regression analyses were tumor size and LVI. Twenty-five patients had tumors larger than 1.0 cm and presence of LVI; of these, 17 (68%) had lymph node metastases. Of the 79 patients who had neither of these features, only 7 (9%) had lymph node metastases.

CONCLUSIONS

The authors conclude that characteristics of the primary tumor can help assess the risk for axillary lymph node metastases. Selected patients who are assessed to be at minimal risk might be spared routine axillary dissection or radiation therapy to the axilla.