Concerns regarding the potential for broken chains and “reneges” within kidney paired donation (KPD) and its effect on chain length have been raised previously. Although these concerns have been ...tested in simulation studies, real‐world data have yet to be evaluated. The purpose of this study was to evaluate the actual rate and causes of broken chains within a large KPD program. All patients undergoing renal transplantation through the National Kidney Registry from 2008 through May 2016 were included for analysis. Broken chains and loops were identified. A total of 344 chains and 78 loops were completed during the study period, yielding a total of 1748 transplants. Twenty broken chains and one broken loop were identified. The mean chain length (number of transplants) within broken chains was 4.8 compared with 4.6 of completed chains (p = 0.78). The most common causes of a broken chain were donor medical issues incurred while acting as a bridge donor (n = 8), donors electing not to proceed (n = 6), and kidneys being declined by the recipient surgeon (n = 4). All recipients involved in a broken chain subsequently received a transplant. Based on the results, broken chains are infrequent, are rarely due to lack of donor motivation, and have no significant impact on chain length.
A review of kidney paired donation transplants in the United States reveals that broken chains, while infrequent, are usually the result of donor medical issues incurred while acting as a bridge donor rather than donors electing not to proceed.
Study Design Clinical measurement, cross-sectional. Background Quadriceps deficits are common in individuals with knee joint impairments and impact functional and quality-of-life outcomes. Quadriceps ...strength symmetry influences clinical decisions after knee injury. Isometric electromechanical dynamometry (ISO-ED) is the gold standard for measuring symmetry, but is not available in all clinical settings. Objectives To compare concurrent validity of handheld dynamometry and 1-repetition-maximum leg press, knee extension from 90° to 0°, and knee extension from 90° to 45° to that of ISO-ED in identifying meaningful quadriceps strength deficits. Methods Fifty-six participants with knee joint impairments completed ISO-ED and 4 alternative measures of quadriceps strength symmetry in a single session. Absolute agreement of alternative measures with ISO-ED was calculated with intraclass correlation coefficients (ICCs). Clinical agreement values at thresholds of 80% and 90% symmetry were compared between the alternatives and ISO-ED. Results Knee extension from 90° to 45° (ICC = 0.67) and handheld dynamometry (ICC = 0.70) had the greatest ICCs. Clinical agreement was also best for these measures for 80% symmetry (κ = 0.56 and 0.55, respectively) and 90% symmetry (κ = 0.19 and 0.33, respectively). Conclusion Handheld dynamometry and 1-repetition-maximum testing of knee extension from 90° to 45° are fair alternatives, although symmetry is typically overestimated. Receiver operating characteristic analysis identified alternative measure thresholds that correlated with the 80% and 90% symmetry thresholds on the ISO-ED. Clinicians should use more stringent symmetry values for these alternative tests to increase the probability that individuals have a minimum ISO-ED symmetry of 80% or 90%. J Orthop Sports Phys Ther 2017;47(2):97-107. doi:10.2519/jospt.2017.6651.
•Significant association between depression, anger and perceived stress.•Reduction in state and trait anger in responders to the combination of anti-inflammatory treatment.•Trait anger remained ...unchanged in the placebo add-on arm.•Significantly higher response and remission rates in depression scores in the celecoxib add-on arm compared to the placebo add-on arm.
: Anger can worsen a person's emotions and increase the severity of an individual's mood state, notably depression. The State-Trait Anger Expression Inventory (STAXI) assessment tool is useful for assessing the experience, expression, and control of anger in normal individuals, and in evaluating anger experienced by patients with a variety of psychological and medical disorders. Since its creation, STAXI has been utilized in various studies involving substance abuse and major depressive disorder; however, anger has never been studied systematically in bipolar depression. Scientific evidence supports the hypothesis that immune system activation, reflected in its inflammatory response, contributes to the pathophysiology and phenomenology of bipolar disorder. However, there is limited research showing how the treatment of bipolar disorder is enhanced with an anti-inflammatory agent and how it affects anger, which prompted this investigation. The current clinical study tested the hypothesis that co-administration of a specific anti-inflammatory agent, Celecoxib, along with Escitalopram, a selective serotonin reuptake inhibitor, would be beneficial in patients with treatment resistant bipolar depression. In comparison to patients receiving Escitalopram monotherapy, it was hypothesized that the combination therapy would lead to an augmented response in alleviating bipolar depression. In addition, the combination therapy would result in a greater percentage of responders and remitters. It also was hypothesized that the combination therapy would reduce anger symptoms as assessed by STAXI from beginning to end of treatment.
: In this double-blind, two-arm, placebo-controlled study, 65 consenting patients diagnosed with treatment resistant bipolar depression were randomized to receive either Escitalopram (10 mg twice/day) + Celecoxib (200 mg twice/day), or Escitalopram + placebo (twice/day). There were 47 completers: 27 in the Celecoxib, and 20 in the Placebo arm. The 17-item Hamilton Depression Rating Scale was used to assess response to treatment, with a 50% reduction from baseline indicating treatment response and a score < 7 indicating remission. The Beck Depression Index also was used as a self-report measure of depression. Levels of state and trait anger were assessed using the 57-item STAXI scale. Measures of depression, anger and perceived stress were collected at baseline and at week 8 of treatment.
: A multiple regression analysis of baseline data indicated that the Hamilton depression score was significantly related to the feelings subscale of the state STAXI. However, the baseline Beck score was found to be predicted by perceived stress. To test treatment effects, an analysis of covariance revealed that the week 8 Hamilton depression score was significantly lower for patients receiving the combination therapy, controlling for baseline differences. The week 8 Beck score also was lower for those in the combination therapy group, but was not statistically significant. In comparison to the monotherapy group, those receiving the combination therapy showed a statistically higher proportion of responders and remitters. Significant differences in state or trait anger subscales were found only responders to the CBX add-on arm at week 8.
: Limitations of the study include small sample size and short period of treatment.
: An analysis of baseline data suggest that depression is associated with state feelings of anger and perceived stress. In comparison to receiving Escitalopram alone, the combination therapy was more effective in lowering Hamilton depression scores and was associated with greater proportions of responders and remitters. Anti-inflammatory combination therapy reduced state and trait anger by the end of treatment.
The continued growth of kidney paired donation (KPD) to facilitate transplantation for otherwise incompatible or suboptimal living kidney donors and recipients has depended on a balance between the ...logistics required for patients and the collaborating transplant centers. The formation of chains for KPD and the shipping of kidneys have permitted networks such as the National Kidney Registry (NKR) to offer KPD to patients over a transcontinental area. However, over the last 3 years, we have encountered patient requests for a more flexible experience in KPD to meet their individual needs often due to rigid time constraints. To accommodate these requests, we have developed an Advanced Donation Program (ADP) in which the donor desires to donate by a specific date, but their paired recipient has not yet been matched to a specific donor or scheduled for surgery. After obtaining careful informed consent from both the donor and paired recipient, 10 KPD chains were constructed using an ADP donor. These 10 ADP donors have facilitated 47 transplants, and thus far eight of their paired recipients have received a kidney within a mean of 178 (range 10–562) days. The ADP is a viable method to support time limited donors in a KPD network.
The authors review a novel program of advanced donation created for living kidney donors within the National Kidney Registry that provides the opportunity to participate in paired exchange to donors with rigid time constraints. See related articles from Gentry and Segev on page 2539, Bray et al on page 2636, and Fumo et al on page 2646.
Multi‐center kidney paired donation (KPD) is an exciting new transplant option that has not yet approached its full potential. One barrier to progress is accurate virtual crossmatching for KPD ...waitlists with many highly sensitized patients. Virtual crossmatch results from a large multi‐center consortium, the National Kidney Registry (NKR), were analyzed to determine the effectiveness of flexible center‐specific criteria for virtual crossmatching. Approximately two‐thirds of the patients on the NKR waitlist are highly sensitized (>80% CPRA). These patients have antibodies against HLA‐A (63%), HLA‐B (66%), HLA‐C (41%), HLA‐DRB1 (60%), HLA‐DRB3/4/5 (18–22%), HLA‐DQB1 (54%) and HLA‐DPB1 (26%). With donors typed for these loci before activation, 91% of virtual crossmatches accurately predicted an acceptable cell‐based donor crossmatch. Failed virtual crossmatches were attributed to equivocal virtual crossmatches (46%), changes in HLA antibodies (21%), antibodies against HLA‐DQA (6%), transcription errors (6%), suspected non‐HLA antibodies (5%), allele‐specific antibodies (1%) and unknown causes (15%). Some failed crossmatches could be prevented by modifiable factors such as more frequent assessment of HLA antibodies, DQA1 typing of donors and auditing data entry. Importantly, when transplant centers have flexibility to define crossmatch criteria, it is currently feasible to use virtual crossmatching for highly sensitized patients to reliably predict acceptable cell‐based crossmatches.
When centers have flexibility to define unacceptable antigens, virtual crossmatching can be used to reliably predict acceptable cell‐based crossmatches for highly sensitized patients.
There is an association between stress, stress-related mood disorders and inflammation. Control of inflammation in conjunction with antidepressant therapy may augment antidepressant response and ...convert treatment-resistant patients to responders. Reports with the use of celecoxib in combination with an antidepressant agent are encouraging based on the hypothesis that inhibition of cyclooxygenase-2 (COX-2) reduces inflammation and enables antidepressant action to occur. We present preliminary data from a study of treatment-resistant bipolar depression. Patients were randomized to receive escitalopram + celecoxib, or escitalopram + placebo. Subjects completed assessments at weeks 0, 1, 2, 4 and 8. Severity of depression and anxiety were quantified using the HAM-D, HAM-A, and MADRS rating scales. Perceived stress was assessed using the PSS-14 scale. There was a statistically significant reduction in HAM-D mean scores in the active group ( p = 0.0005) vs. placebo ( p = 0.145), MADRS scores in the active group ( p < 0.001) vs. placebo ( p = 0.172) and HAM-A scores in the active group ( p = 0.047) vs. placebo ( p = 0.756). The PSS and HAM-D scores were positively correlated ( r = 0.684, p = 0.02). There was a statistically significant decrease in post-treatment PSS scores in the active group ( p = 0.049) vs. placebo ( p = 0.717). The interim analysis of this ongoing study reveals that scores on scales for symptoms of depression, anxiety, and perceived stress significantly improved when subjects were treated with the combination escitalopram + celecoxib. These data suggest that controlling inflammation augments antidepressant response.
The aim of this study was to analyze clinical characteristics of rocuronium as premedication for nonemergent intubation in infants.
Preterm infants requiring nonemergent intubation were randomized to ...receive atropine and fentanyl with or without rocuronium. Outcomes, patient characteristics and intubator's experience were noted. Onset, duration and degree of clinical paralysis were recorded for rocuronium group and for older infants receiving rocuronium per unit protocol.
Forty-four intubations were randomized (20 rocuronium, 24 control). Groups were similar in chronological and corrected gestational age, weight and intubator's experience. Successful intubation on first attempt was achieved in 35% of intubations under rocuronium vs 8% of controls; rocuronium was the only significant variable by logistic regression (odds ratio=0.052, P=0.029). Complete paralysis was reported in 80% of 57 rocuronium intubations; onset ranged from 14 to 178 s (65.9±43.4), and duration from 1 to 60 min (16.3±13.5).
Rocuronium facilitated successful intubation and provided clinical paralysis quickly in most infants.
Virtual reality simulation software (VRS - FocalSim Version 4.40 with VRS prototype, Computerized Medical Systems, St. Louis, MO) is a new radiation dose planning tool that allows for 3D ...visualization of the patient and the machine couch (treatment table) in relationship to the linear accelerator. This allows the radiation treatment planner to have a “room's-eye-view” and enhances the process of virtual simulation. The aim of this study was to compare VRS to a standard planning program (XiO - Version 4.50, Computerized Medical Systems, St. Louis, MO) in regards to the time it took to use each program, the angles chosen in each, and to determine if there was a dosimetric benefit to using VRS. Ten patients who had undergone left-sided lumpectomies were chosen to have treatment plans generated. A partial breast irradiation (PBI) treatment plan by external beam radiation therapy (EBRT) was generated for each patient using two different methods. In the first method the full plan was generated using XiO software. In the second method beam angles were chosen using the VRS software, those angles were transferred to XiO, and the remaining part of the plan was completed using XiO (since VRS does not allow dose calculations). On average, using VRS to choose angles took about 10 minutes longer than XiO. None of the five gantry angles differed significantly between the two programs, but four of the five couch angles did. Dose-volume histogram (DVH) data showed a significantly better conformality index, and trends toward decreased hot spots and increased coverage of the planed treatment volume (PTV) when using VRS. However, when angels were chosen in VRS a greater volume of the ipsilateral breast received a low dose of radiation (between 3% and 50% of the prescribed dose) (VRS = 23.06%, XiO = 19.57%, p < 0.0005). A significant advantage that VRS provided over XiO was the ability to detect potential collisions prior to actual treatment of the patient in three of the ten patients studied. The potential to save time with VRS by not having to redo plans because of a collision increases clinic efficiency.
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