The merits of decision modelling in the earliest stages of the IDEAL framework: An innovative case in DIEP flap breast reconstructions.

BACKGROUND: The IDEAL framework aims at improving the evidence base of available surgical innovations. However, the development of such innovations and collection of evidence is costly. Surgical innovation can provide more value for money if innovations are evaluated at an early stage, where evaluations can inform the decision whether to stop or to further develop an innovation. We illustrate how decision modelling can be readily adopted at the earliest stages (0-1) of the IDEAL framework, using an innovation in bilateral DIEP flap breast reconstruction as an example. METHODS: We quantified expected costs and quality-adjusted life years (QALYs) of the current treatment and compared them with an innovation aimed at reducing complications and surgery time. The maximum effect of eliminating all complications (headroom analysis) was explored. Moreover, three scenarios with varying complications and surgery time reductions were modelled. Furthermore, the maximum price of the innovation was estimated in a threshold analysis according to its impact and societal willingness to pay. RESULTS: The headroom analysis showed that when all complications associated with the current treatment are prevented, up to €889 per patient is saved. Scenario analysis showed cost savings between €256 and €828 per patient. When surgery time is reduced by 15 min and complications by 50%, the innovation will remain cost-effective at €671 per patient. CONCLUSION: In a field struggling with cost containment, decision modelling can help to separate promising innovations from costly failures at an early stage. In this example, decision modelling showed that it seems worthwhile to further develop the innovation.

A multiplex bead array analysis to monitor donor-specific cytokine responses after withdrawal of immunosuppression in HLA-identical living related kidney transplant patients.

Immune reactivity after HLA-identical living related (LR) kidney transplantation can be caused by minor histocompatibility antigen and non-HLA antigen mismatches between donor and recipient. In our center, HLA-identical LR kidney transplant recipients receive azathioprine (AZA) or mycophenolate mofetil (MMF) in combination with corticosteroids for 1 year after transplantation. Thereafter, AZA or MMF was withdrawn, and the patients were treated with steroid monotherapy as maintenance therapy. We questioned whether withdrawal of AZA or MMF affected the donor-specific lymphocyte proliferation and cytokine production. Donor and third-party T-cell reactivities were determined by mixed lymphocyte reactions and by cytokine production using multiplex bead array technique. The donor and third-party proliferative capacities were not affected after withdrawal of AZA or MMF. Thirteen of 17 cytokines were detected by the multiplex bead array technique. No differences were observed after third-party induced cytokine production after withdrawal of AZA or MMF. However, production of donor-specific interferon-gamma and macrophage inflammatory protein-1beta increased after discontinuation of AZA or MMF, but no clinically relevant acute rejection was observed. In conclusion, after HLA-identical LR kidney transplantation, donor-specific cytokine responses can be found when AZA or MMF therapy is discontinued. The clinical relevance of this phenomenon is still not evident.

Investigating the variations in survival rates for very preterm infants in 10 European regions: the MOSAIC birth cohort.

OBJECTIVE: To investigate the variation in the survival rate and the mortality rates for very preterm infants across Europe. DESIGN: A prospective birth cohort of very preterm infants for 10 geographically defined European regions during 2003, followed to discharge home from hospital. PARTICIPANTS: All deliveries from 22 + 0 to 31 + 6 weeks' gestation. MAIN OUTCOME MEASURE: All outcomes of pregnancy by gestational age group, including termination of pregnancy for congenital anomalies and other reasons, antepartum stillbirth, intrapartum stillbirth, labour ward death, death after admission to a neonatal intensive care unit (NICU) and survival to discharge. RESULTS: Overall the proportion of this very preterm cohort who survived to discharge from neonatal care was 89.5%, varying from 93.2% to 74.8% across the regions. Less than 2% of infants <24 weeks' gestation and approximately half of the infants from 24 to 27 weeks' gestation survived to discharge home from the NICU. However large variations were seen in the timing of the deaths by region. Among all fetuses alive at onset of labour of 24-27 weeks' gestation, between 84.0% and 98.9% were born alive and between 64.6% and 97.8% were admitted to the NICU. For babies <24 weeks' gestation, between 0% and 79.6% of babies alive at onset of labour were admitted to neonatal intensive care. CONCLUSIONS: There are wide variations in the survival rates to discharge from neonatal intensive care for very preterm deliveries and in the timing of death across the MOSAIC regions. In order to directly compare international statistics for mortality in very preterm infants, data collection needs to be standardised. We believe that the standard point of comparison should be using all those infants alive at the onset of labour as the denominator for comparisons of mortality rates for very preterm infants analysing the cohort by gestational age band.

Immune monitoring after kidney transplantation.

During the last decennium, research in the field of organ transplantation changed from studying mechanisms of acute rejection shortly after transplantation to understanding why patients benefit from their grafts only for a limited time, because of irreversible chronic rejection and serious side effects of immunosuppression. To avoid side effects, tapering or even withdrawal of immunosuppression in transplant recipients is warranted, provided this is not accompanied with graft loss. Noninvasive cell mediated immune tests could be helpful to identify transplant recipients in whom the immunosuppressive load can be safely reduced, and to identify patients at risk for chronic rejection. In the present report, we describe cellular assays to determine donor-specific responses in peripheral blood mononuclear cells from transplant recipients taken before transplantation and during tapering or withdrawal of immunosuppression.

Donor-reactive cytokine production after HLA-identical living related kidney transplantation: a protein-array analysis.

In the present pilot study, we investigated which proteins are produced after donor stimulation of peripheral blood mononuclear cells from recipients of HLA-identical living related kidney transplant. We used a protein-array analysis to determine cytokines, chemokines, and growth factors in supernatant from donor-stimulated mixed lymphocyte reaction cultures. Autologous cultures were considered to be negative controls. In 38 out of 42 proteins (90%), the donor response was higher compared with the autologous response. Therefore, we concluded that even after HLA-identical living related kidney transplantation we could measure a donor-reactive response, which we assumed was directed toward minor histocompatibility or non-HLA antigens.

Granzyme B ELISPOT assay determines the cytotoxic T lymphocyte precursor frequency after HLA-identical living-related kidney transplantation.

A major goal in organ transplantation is to define the optimal immunosuppressive dose. Recently, we demonstrated that the frequency of cytotoxic T lymphocytes (CTLpf) identifies patients in whom the immunosuppressive load can be safely reduced. However, in peripheral blood mononuclear cells (PBMC) from HLA-identical living-related kidney transplant patients, no donor-specific CTLpf can be measured. The determination of the functional activity of cytotoxic T lymphocytes (CTLs) could be an alternative method for the CTLpf. Granzyme B (GrB) is present in the granules of CTLs and is involved in the direct lethal hit of donor target cells. Therefore, we wondered whether the GrB ELISPOT assay is an alternative method to determine the activity of CTLs after HLA-identical living-related kidney transplantation. We measured the number of GrB producing cells (pc) against donor PBMC and third-party PBMC in PBMC from HLA-identical patients who were reduced in their immunosuppression from 100% to 50% azathioprine with 5 to 10 mg/day prednisone. We found low numbers of GrB pc before reduction of immunosuppression, as only 20% of the patients' PBMC responded to donor cells, whereas 57% of the patients' PBMC responded to donor cells after reduction of immunosuppression. After third-party stimulation, the number of GrB pc increased after tapering the immunosuppressive load (P = .03). Our results demonstrate that the GrB ELISPOT assay might be used as an alternative for the CTLpf after HLA-identical living-related kidney transplantation.

[Three toddlers with a swelling in the neck]. / Drie peuters met een zwelling in de hals.

Three children, a girl aged 2.5 years and two boys aged 2 and 3 years respectively, presented with unilateral cervical lymphadenitis. The first patient had acute bacterial lymphadenitis due to group A Streptococcus, characterised by a painful cervical swelling of acute onset. The second patient had painless cervical lymphadenitis caused by Mycobacterium avium-intracellulare, which drained spontaneously. The third patient developed a non-tender, cervical swelling within a day. He too was systemically ill with fever and a headache. The lymphadenitis was caused by Bartonella henselae. After drainage, dissection and/or antibiotic therapy, all three recovered. A cervical mass in a young child is most frequently caused by an infectious lymphadenopathy. It rarely represents a malignant or other systemic disease. In many cases the diagnosis of infectious lymphadenitis can be made on the basis of the case history and clinical characteristics. However, when malignancy cannot be excluded tissue examination is always indicated.

Inoculation of Scytalidium thermophilum in Button Mushroom Compost and Its Effect on Yield.

Scytalidium thermophilum isolates in culture, as well as the endogenous strain(s) in mushroom compost, were inactivated at 70 degrees C. This temperature was used to pasteurize composts for experiments. Of nine thermophilic fungal species, only S. thermophilum and Myriococcum thermophilum grew well on pasteurized compost in test tubes. The effect of both species on the crop yield of Agaricus bisporus mushrooms was studied. In solid-state fermentation rooms called tunnels, compost was pasteurized and inoculated. After incubation, the inoculated organisms were reisolated and counted, showing their successful colonization. The yield of mushrooms on inoculated composts was almost twice that on the pasteurized control. This result demonstrates the effectiveness of S. thermophilum in compost preparation. Inoculation is not necessary for traditional compost preparation. Naturally occurring strains of S. thermophilum, present in ingredients, readily colonize compost during preparation. Inoculation may be vital if compost is pretreated at a high temperature in tunnels. This finding is of relevance for the environmentally controlled production of high-yielding compost.

Ecology of Thermophilic Fungi in Mushroom Compost, with Emphasis on Scytalidium thermophilum and Growth Stimulation of Agaricus bisporus Mycelium.

Twenty-two species of thermophilic fungi were isolated from mushroom compost. Scytalidium thermophilum was present in the compost ingredients, fresh straw, horse droppings, and drainage from compost and dominated the fungal biota of compost after preparation. Of 34 species of thermophilic fungi tested, 9 promoted mycelial growth of Agaricus bisporus on sterilized compost: Chaetomium thermophilum, an unidentified Chaetomium sp., Malbranchea sulfurea, Myriococcum thermophilum, S. thermophilum, Stilbella thermophila, Thielavia terrestris, and two unidentified basidiomycetes. These species will be considered for future experiments on inoculation and more controlled preparation of compost.

Optimized determination of thiochrome derivatives of thiamine and thiamine phosphates in whole blood by reversed-phase liquid chromatography with precolumn derivatization.

A liquid chromatographic method involving precolumn derivatization for determining thiamine and its phosphate esters in human blood has been optimized. Blood sample stored at - 20 degrees C were haemolysed and deproteinized by perchloric acid. The supernatants of the samples were oxidized by addition of potassium ferricyanide-sodium hydroxide, and phosphoric acid was added to obtain a neutral pH in order to extend the column life. The samples were stable after derivatization for at least 24 h, if protected from light and kept at room temperature. Gradient separation with 140 mmol phosphate buffer (pH 7.0), and methanol, tert-butylammonium hydroxide and dimethylformamide as modifiers, on a 3-microns Chromsphere octadecylsilica column gave an analysis time of 15 min. The method was found to be very suitable for the determination of thiamine components in whole blood. The minimal detectable amount is 0.5 nmol/l and the method is linear to at least 1000 nmol/l. The recovery (98 +/- 3%) and precision are very good.

Natural Occurrence of Clostridium botulinum on Fresh Mushrooms ( Agaricus bisporus ).

Clostridium botulinum was not found (

HPLC detection of choline and acetylcholine in serum and urine by an immobilized enzyme reactor followed by chemiluminescence detection.

A method using HPLC has been developed for the detection of choline (Ch) and acetylcholine (ACh) using an immobilized enzyme reactor which converts Ch and ACh into hydrogen peroxide and betaïne. The formed H(2)O(2) is quantified by means of a solid-state peroxyoxalate chemiluminescence detector based on an immobilized fluorophore and addition of oxalate from a solid bed. The conditions necessary for chemiluminescence detection are obtained by using a make-up flow of acetonitrile after the enzyme reactor. Precipitation problems due to the poor solubility of salts in the final acetonitrile-water mixture are circumvented by adding a crown ether to the make-up flow. The reproducibility of the method was calculated to be 3.4-3.7% RSD. Detection limits are in the sub-picomole range and a linear range of at least three orders of magnitude is found. Measurements in urine and serum reveal no matrix effects.