Failure to convert computer‐identified possible kidney paired donation (KPD) exchanges into transplants has prohibited KPD from reaching its full potential. This study analyzes the progress of ...exchanges in moving from “offers” to completed transplants. Offers were divided into individual segments called 1‐way transplants in order to calculate success rates. From 2007 to 2014, the Alliance for Paired Donation performed 243 transplants, 31 in collaboration with other KPD registries and 194 independently. Sixty‐one of 194 independent transplants (31.4%) occurred via cycles, while the remaining 133 (68.6%) resulted from nonsimultaneous extended altruistic donor (NEAD) chains. Thirteen of 35 (37.1%) NEAD chains with at least three NEAD segments accounted for 68% of chain transplants (8.6 tx/chain). The “offer” and 1‐way success rates were 21.9 and 15.5%, respectively. Three reasons for failure were found that could be prospectively prevented by changes in protocol or software: positive laboratory crossmatch (28%), transplant center declined donor (17%) and pair transplanted outside APD (14%). Performing a root cause analysis on failures in moving from offer to transplant has allowed the APD to improve protocols and software. These changes have improved the success rate and the number of transplants performed per year.
This analysis of the reasons for failure to progress from computer‐generated kidney exchanges to actual transplants in a multi‐center kidney paired donation program identifies obstacles in matching incompatible donor/recipient pairs and discusses implications for a national kidney paired donation program. See related articles from Gentry and Segev on page 2539, Bray et al on page 2636, and Flechner et al on page 2712.
The decline of fisheries over recent decades and a growing human population has coincided with an increase in aquaculture production. As farmed fish densities increase, so have their rates of ...infectious diseases, as predicted by the theory of density-dependent disease transmission. One of the pathogen that has increased with the growth of salmon farming is sea lice. Effective management of this pathogen requires an understanding of the spatial scale of transmission. We used a two-part multi-scale model to account for the zero-inflated data observed in weekly sea lice abundance levels on rainbow trout and Atlantic salmon farms in Chile, and to assess internal (farm) and external (regional) sources of sea lice infection. We observed that the level of juvenile sea lice was higher on farms that were closer to processing plants with fish holding facilities. Further, evidence for sea lice exposure from the surrounding area was supported by a strong positive correlation between the level of juvenile sea lice on a farm and the number of gravid females on neighboring farms within 30km two weeks prior. The relationship between external sources of sea lice from neighboring farms and juvenile sea lice on a farm was one of the strongest detected in our multivariable model. Our findings suggest that the management of sea lice should be coordinated between farms and should include all farms and processing plants with holding facilities within a relatively large geographic area. Understanding the contribution of pathogens on a farm from different sources is an important step in developing effective control strategies.
Previous studies of task-specific skills have suggested that a loss of technical performance occurs if the skill is not practiced for a six-month period. The aims of this study were to objectively ...demonstrate the learning curve for a complex arthroscopic task (meniscal repair) by means of motion analysis and to determine the impact of task repetition on the retention of this skill.
Nineteen orthopaedic residents with experience in routine knee arthroscopy but not in arthroscopic meniscal repair were recruited into a randomized study. During the initial learning phase, all subjects performed twelve meniscal repairs on a knee simulator over a three-week period. A validated motion analysis tracking system was used to objectively record the performance and learning of each subject; the outcomes were the time taken, distance traveled, and number of hand movements. The subjects were then randomized into three groups. Group A performed one meniscal repair each month, Group B performed one meniscal repair at three months, and Group C performed no repairs during this interim phase. All three groups then returned at the six-month point for the final assessment phase, during which they carried out an additional twelve meniscal repairs over three weeks.
All subjects demonstrated a clear learning curve during the initial learning phase, with significant objective improvement in all motion analysis parameters over the initial twelve episodes (p < 0.0001). Although some residents had reached a learning plateau by twelve episodes, others continued to make further improvements for up to another nine episodes. Importantly, Group C did not display any loss of skill between the initial learning phase and final evaluation phase despite a six-month break in task repetition (p > 0.05).
In contrast to previous studies, residents did not lose any skill over a six-month interruption in task performance, and other residents took longer to produce a more consistent performance.
Colonoscopy in the very elderly Neilson, L J; Thirugnanasothy, S; Rees, C J
British medical bulletin,
09/2018, Letnik:
127, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Abstract
Introduction
Colonoscopy is the gold standard test for investigating lower gastrointestinal symptoms and is an important therapeutic tool for colonic polypectomy. This paper is aimed at the ...general physician and examines the role of colonoscopy in very elderly patients by exploring the particular risks in this population, the yield of colonoscopy and potential alternative investigations.
Sources of data
Original research and review articles were identified through selective PubMed searches. Guidelines were identified through interrogation of national and international society websites in addition to PubMed searches.
Areas of agreement
Advanced age alone is not a reason to avoid investigation. The decision to perform colonoscopy in this population must take into account indication and yield, risks of the procedure and bowel preparation, physical fitness of the patient, potential alternative and the ability to consent. As a general rule, the principle of ‘first doing no harm’ should be applied and requires balancing of the risks of the procedure and preparation with the benefits of doing the test.
Areas of controversy
There is no defined upper age limit at which colonoscopy is contraindicated, however; the National Health Service Bowel Cancer Screening Programme stops inviting patients for screening and surveillance colonoscopy at age 75.
Growing points and areas timely for developing research
The concepts of ‘first do no harm’ and shared decision-making are not new but are increasingly important, particularly in this patient group. It is crucial to provide patients with information about risks, benefits and alternative investigations to empower their decision-making.
Summary
Emergency front‐of‐neck access to achieve a percutaneous airway can be a life‐saving intervention, but there is debate about the preferred technique. This prospective, observational study was ...designed to compare the two most common emergency surgical airway techniques in a wet lab simulation using an ovine model. Forty‐three doctors participated. After providing standardised reading, a lecture and dry lab benchtop training, participants progressed to a high‐fidelity wet lab simulation. Participants entered an operating theatre where a ‘cannot intubate, cannot oxygenate’ situation had been declared and were directed to perform emergency front‐of‐neck access: first with a cannula technique (14‐gauge cannula insertion with ventilation using a Rapid‐O2® cricothyroidotomy insufflation device); and subsequently, a scalpel‐bougie technique (surgical incision, bougie insertion into trachea and then tracheal tube passed over bougie, with ventilation using a self‐inflating bag). The primary end‐point was time from declaration of ‘cannot intubate, cannot oxygenate’ to delivery of oxygen via a correctly placed percutaneous device. If a cannula or tracheal tube was not placed within 240 s, the attempt was marked as a failure. There was one failure for the cannula approach and 15 for the scalpel‐bougie technique (OR 0.07 (95%CI 0.00–0.43); p <0.001). Median (IQR range) time to oxygenation, if successful, was 65 (57–78 28–160) s for the cannula approach and 90 (74–115 40–265) s for the scalpel‐bougie technique (p=0.005). In this ovine model, emergency front‐of‐neck access using a cannula had a lower chance of failure and (when successful) shorter time to first oxygen delivery compared with a scalpel‐bougie technique.
Optimizing the possibilities for kidney‐paired donation (KPD) requires the participation of donor–recipient pairs from wide geographic regions. Initially it was envisaged that donors would travel to ...the recipient center; however, to minimize barriers to participation and simplify logistics, recent trends have involved transporting the kidneys rather than the donors. The goal of this study was to review outcomes of this practice. KPD programs throughout the United States were directly queried about all transplants involving live donor kidney transport. Early graft function was assessed by urine output in the first 8 h, postoperative serum creatinine trend, and incidence of delayed graft function. Between April 27, 2007 and April 29, 2010, 56 live donor kidneys were transported among 30 transplant centers. Median CIT was 7.2 h (IQR 5.5–9.7, range 2.5–14.5). Early urine output was robust (>100 cc/h) in all but four patients. Creatinine nadir was <2.0 mg/dL in all (including the four with lower urine output) but one patient, occurring at a median of 3 days (IQR 2–5, range 1–49). No patients experienced delayed graft function as defined by the need for dialysis in the first week. Current evidence suggests that live donor kidney transport is safe and feasible.
In this study of live donor kidney transplants that required transportation of the organ and resultant cold ischemia, the authors report that excellent early function was seen, supporting the safety and feasibility of this practice.
ObjectiveTo appraise studies reporting on clinical effectiveness and safety of surgical meshes used to augment rotator cuff repairs (RCRs).DesignSystematic review and meta-analysis.Data ...sourcesMEDLINE, Embase and Cochrane databases were searched between April 2006 and April 2020.Eligibility criteriaAll studies evaluating adults (≥18 years) undergoing RCR were considered. There were no language restrictions.Data extraction and synthesisScreening, data extraction and quality appraisal were conducted by two independent reviewers. Meta-analysis was conducted using a random-effects models if ≥2 comparative studies reported the same outcome measure. Risk of bias assessment was undertaken for randomised (RoB2, Cochrane) and comparative studies (ROBINS-I, Cochrane).ResultsWe included 60 studies, consisting of 7 randomised controlled trials, 13 observational comparative studies and 40 observational case series. All comparative studies reported on shoulder-specific functional outcome scores, 18 on the radiographic occurrence of re-tear and 14 on pain score metrics. All studies contained some risk of bias.Compared with non-augmented repair, a small improvement in shoulder-specific function or pain scores was observed for synthetic patches with a mean improvement of 6.7 points on the University of California Los Angles (UCLA) shoulder score (95% CI 0.1 to 13.4) and 0.46 point reduction on the Visual Analogue Scale (95% CI −0.74 to −0.17), respectively. A reduced likelihood of radiologically observed re-tear was observed for synthetic (risk ratio (RR) 0.41, 95% CI 0.27 to 0.61) and allograft (RR 0.34, 95% CI 0.18 to 0.65) patches. A total of 49 studies reported on the occurrence of complications. Slightly higher crude complication rates were observed following patch-augmented repair (2.1%) than standard repair (1.6%).ConclusionsWhile several studies suggest a decreased failure rate and small improvements in shoulder function and pain following augmented RCR, a paucity of rigorous clinical evaluation, for both effectiveness and safety, prevents firm recommendations.Prospero registration numberCRD42017057908.
Lead poisoning, through the ingestion of spent lead gunshot, is an established cause of morbidity and mortality in waterbirds globally, but the thresholds at which blood levels begin to affect the ...physiology of birds in the wild are less well known. Here we determine the prevalence of lead exposure in whooper swans and, for the first time, identify the level of blood lead associated with initial reductions in body condition. Blood lead elevated above background levels (i.e. >20 μg dL−1) was found in 41.7% (125/300) of swans tested. Blood lead was significantly negatively associated with winter body condition when levels were ≥44 μg dL−1 (27/260 = 10%). Our findings indicating that sub-lethal impacts of lead on body condition occur at the lower end of previously established clinical thresholds and that a relatively high proportion of individuals in this population may be affected, reaffirm the importance of reducing contamination of the environment with lead shot.
Display omitted
•Elevated blood lead levels of >20 μg dL−1 were found in 41.7% of whooper swans.•Blood lead levels of ≥44 μg dL−1 were negatively associated with body condition.•Clinical effects were at lower levels than previously described for Anseriformes.•Reduction of lead shot in the environment would reduce the risk of lead exposure.
Blood lead was significantly negatively associated with the body condition of free-living whooper swans in winter when levels were ≥44 μg dL−1 (27/260 = 10% of birds were above this threshold).
Despite being one of the most common orthopaedic operations, it is still not known how many arthroscopies of the knee must be performed during training in order to develop the skills required to ...become a Consultant. A total of 54 subjects were divided into five groups according to clinical experience: Novices (n = 10), Junior trainees (n = 10), Registrars (n = 18), Fellows (n = 10) and Consultants (n = 6). After viewing an instructional presentation, each subject performed a simple diagnostic arthroscopy of the knee on a simulator with visualisation and probing of ten anatomical landmarks. Performance was assessed using a validated global rating scale (GRS). Comparisons were made against clinical experience measured by the number of arthroscopies which had been undertaken, and ROC curve analysis was used to determine the number of procedures needed to perform at the level of the Consultants. There were marked differences between the groups. There was significant improvement in performance with increasing experience (p < 0.05). ROC curve analysis identified that approximately 170 procedures were required to achieve the level of skills of a Consultant. We suggest that this approach to identify what represents the level of surgical skills of a Consultant should be used more widely so that standards of training are maintained through the development of an evidenced-based curriculum.
The role of histamine H
1
, H
2
, H
3
and H
4
receptors in acute itch induced by histamine was investigated in female BalbC mice. Scratching was induced by intradermal injections of pruritogen into ...the back of the neck and ‘itch’ assessed by quantifying the scratching evoked.
Histamine (0.03–80
μ
mol), histamine‐trifluoromethyl‐toluidine (HTMT, H
1
agonist, 0.002–2
μ
mol), clobenpropit (H
4
agonist, H
3
antagonist, 0.002–0.6
μ
mol) and to a lesser extent imetit (H
3
/H
4
agonist, 0.03–3
μ
mol) all induced dose‐dependent scratching. Dimaprit (H
2
agonist, 0.04–40
μ
mol) did not cause scratching.
Mepyramine (H
1
antagonist, 20 mg kg
−1
, i.p.) reduced scratching evoked by histamine and HTMT, but not that caused by H
3
or H
4
agonists. Thioperamide (H
3
/H
4
antagonist, 20 mg kg
−1
, i.p.) reduced scratching induced by histamine, H
3
and H
4
agonists, but not that caused by HTMT. The non‐sedating H
1
antagonist, terfenadine, also significantly reduced the scratching induced by the H
1
agonist, HTMT. Cimetidine (H
2
antagonist, 20 mg kg
−1
, i.p.) did not affect histamine‐induced scratching.
These results indicate that activation of histamine H
4
receptors causes itch in mice, in addition to the previously recognised role for H
1
receptors in evoking itch. Histamine H
4
receptor antagonists therefore merit investigation as antipruritic agents.
British Journal of Pharmacology
(2004)
142
, 374–380. doi:
10.1038/sj.bjp.0705754
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