Lattice Engineering via Transition Metal Ions for Boosting Photoluminescence Quantum Yields of Lead-Free Layered Double Perovskite Nanocrystals.

Lead-free layered double perovskite nanocrystals (NCs), i.e., Cs4M(II)M(III)2Cl12, have recently attracted increasing attention for potential optoelectronic applications due to their low toxicity, direct bandgap nature, and high structural stability. However, the low photoluminescence quantum yield (PLQY, <1%) or even no observed emissions at room temperature have severely blocked the further development of this type of lead-free halide perovskites. Herein, two new layered perovskites, Cs4CoIn2Cl12 (CCoI) and Cs4ZnIn2Cl12 (CZnI), are successfully synthesized at the nanoscale based on previously reported Cs4CuIn2Cl12 (CCuI) NCs, by tuning the M(II) site with different transition metal ions for lattice tailoring. Benefiting from the formation of more self-trapped excitons (STEs) in the distorted lattices, CCoI and CZnI NCs exhibit significantly strengthened STE emissions toward white light compared to the case of almost non-emissive CCuI NCs, by achieving PLQYs of 4.3% and 11.4% respectively. The theoretical and experimental results hint that CCoI and CZnI NCs possess much lower lattice deformation energies than that of reference CCuI NCs, which are favorable for the recombination of as-formed STEs in a radiative way. This work proposes an effective strategy of lattice engineering to boost the photoluminescent properties of lead-free layered double perovskites for their future warm white light-emitting applications.

Effect of Repeated Structured Diabetes Education on Lifestyle Knowledge and Self-Care Diabetes Management in Kidney Transplant Patients With Posttransplant Diabetes.

OBJECTIVES: Diabetes knowledge among kidney transplant recipients with posttransplant diabetes has not been clearly assessed. We evaluated whether diabetes education in kidney transplant recipients with posttransplant diabetes affected self-care, metabolic control variables, and reversibility of early diabetic microangiopathies. MATERIALS AND METHODS: In this prospective randomized controlled study, we enrolled 210 renal transplant recipients with posttransplant diabetes. Group 1 patients (n = 140) received structured diabetes education, and group 2 patients (n = 70) received conventional education. Patient data were collected through patient identification and metabolic control parameter forms and a diabetes self-care scale questionnaire (scores between 0 and 7). RESULTS: Diet knowledge improved and waist circumference was reduced with mild to moderate exercise in group 1 (P < .001), despite no differences between the 2 groups in mean body weight or body mass index. Patients in group 1 (structured diabetes education with repeated reinforcement) showed significant improvement in healthy lifestyle parameter scores versus group 2 (P < .05) and versus values before education (P < .05). At end of study, these achievements were translated into proper blood sugar monitoring, management of both hypoand hyperglycemia, improvements in logbook use and healthy sharp disposal, Ramadan fasting, sick day management, and knowledge on the importance of HbA1c (P < .05), which translated to decrease of HbA1c in group 1 by 1.35%. In group 1, proteinuria decreased significantly compared with before education and compared with group 2 values (P = .016). Diabetic retinopathy and neuropathy remained comparable between groups (P > .05). CONCLUSIONS: Structured diabetes education improved lifestyle knowledge, self-care diabetes management, and metabolic control variables among kidney transplant recipients with posttransplant diabetes. Structured diabetes education also resulted in partial reversibility of the present early diabetic nephropathy. We recommended such education to be delivered to all kidney transplant recipients with diabetes.

Distribution, composition and risk assessment of hydrocarbon residue in surficial sediments of El-Dakhla, El-Kharga and El-Farafra oases, Egypt.

This work examined the polycyclic aromatic hydrocarbons (PAHs) and n-alkanes quantities, sources, and hazards in sediments collected from the Egyptian Western Desert Oases namely: Dakhla, Kharga and Farafra oases. The n-alkane (C9-C20) residue concentrations have ranged from 0.66 to 2417.91 µg/g recorded for the three Oases. On the other hand, the total n-alkane ranged from 448.54 µg/g to 8442.60 µg/g. Higher carbon preference index (CPI) values (> 1.0) proposed that the natural sources could be the main contributor to n-alkanes in the Oases sediment. GC-MS/MS (selected reaction monitoring (SRM) method) was used for the determination of the ΣPAHs concentrations in the studied sediments. The ΣPAHs concentrations (ng/g, dry weight) in the studied three Oases varied from 10.18 to 790.14, 10.55 to 667.72, and from 38.27 to 362.77 for the Kharga, Dakhla and Farafra Oases, respectively. The higher molecular weight PAHs were the most abundant compounds in the collected samples. Assessing potential ecological and human health issues highlighted serious dangers for living things and people. All the investigated PAHs had cancer risk values between 1.43 × 10-4 and 1.64 × 10-1, this finding suggests that PAHs in the samples under study pose a moderate risk of cancer. The main sources of PAHs in this study are biomass, natural gas, and gasoline/diesel burning emissions.

Family medicine residents' perspectives on different teaching modalities used throughout their training.

Background: New teaching modalities have emerged throughout the years to help enhance residency training programs. Studies have shown that when establishing a new teaching modality, it is crucial to consider the trainee's perception and feedback as trainee-centered teaching techniques aim to enhance the students' motivations and problem-solving skills. The aim of this study is to discover residents' perceptions of different teaching modalities used through their training programs and to recognize which teaching modality is preferable to residents among the family medicine residents in Riyadh, Saudi Arabia. Methodology: A cross-sectional study was conducted between April 2021 and April 2022 that included all family medicine residents in the Saudi Board Family Medicine Training Program at Prince Sultan Military Medical City (PSMMC) in Riyadh, Kingdom of Saudi Arabia. An online questionnaire included two main parts. The first part collected demographic information. The second part concerned residents' opinions regarding different teaching modalities used throughout their training and factors leading to better learning outcomes. Results: The survey was completed by 60 family medicine residents. Half of the respondents perceived weekly academic day activities [WADA] as the most important teaching style (53.3%), followed by self-directed learning [SDL] (40%), while learning management system [LMS] was not ranked as the top choice by any of the respondents. Conclusion: These findings can be applied to the improvement of family medicine training programs. Understanding the perceptions of different teaching modalities can help enhance training programs to help future family medicine practitioners.

Chlorinated pesticides and PCB residues in the Egyptian Western Desert oases sediments.

This preliminary investigation aimed to detect concentrations of chlorinated pesticides and PCBs in 40 sediment samples from three desert oases located in Kharga, Dakhla and Farafra in western Egypt. The residues of 18 PCBs and 16 chlorinated pesticides were measured by GC-MS/MS (SRM) method. The results showed that PCBs and pesticides were present in all studied samples. The concentrations of individual PCBs ranged from undetected to 3.99 ng/g dw in all these sediment samples. The total residue of pesticides (ng/g, dry weight) in sediment samples also varied from 5.18 to 25.92, 5.41 to 29.49, and 5.93 to 24.19 ng/g dw for the Kharga, Dakhla and Farafra Oases, respectively. The concentrations of PCBs and chlorinated pesticides detected in these oasis sediments were lower than that reported for other worldwide locations. According to the recorded concentrations in this baseline study of PCBs and total DDTs, the results revealed the minimal risks to organisms and people in the studied area according to the Effects Range-Low (ERL) and Effects Range-Median (ERM) guideline values.

OOP-ESEEM Spectroscopy: Accuracies of Distances of Spin-Correlated Radical Pairs in Biomolecules.

In addition to the commonly used electron-electron double resonance (ELDOR) technique, there are several other electron paramagnetic resonance (EPR) methods by which structure information can be obtained by exploiting the dipolar coupling between two radicals based on its characteristic r -3 dependence. In this contribution, we explore the potential of out-of-phase-electron-spin echo envelope modulation (OOP-ESEEM) spectroscopy to collect accurate distance information in photo-sensitive (bio) molecules. Although the method has already been applied to spin-correlated radical pairs in several classes of light-active proteins, the accuracy of the information obtained has not yet been extensively evaluated. To do this in a system-independent fashion, OOP-ESEEM time traces simulated with different values of the dipolar and exchange couplings were generated and analyzed in a best-possible way. Excellent agreement between calculated and numerically fitted values over a wide range of distances (between 15 and 45 Å) was obtained. Furthermore, the limitations of the method and the dependence on various experimental parameters could be evaluated.

Effect of Structured Diabetes Education on Diabetic Angiopathies Among Kidney Transplant Recipients With Posttransplant Diabetes: Kuwait Experience.

OBJECTIVES: Diabetes knowledge among kidney transplant recipients with posttransplant diabetes has not been exhaustively assessed. Here, we evaluated the effects of structured diabetes education on development of diabetic micro- and macroangiopathies in kidney transplant patients with posttransplant diabetes. MATERIALS AND METHODS: This prospective randomized controlled study categorized 210 renal transplant patients with posttransplant diabetes mellitus into 2:1 groups according to type of diabetes education. Group 1 (n = 140) received structured education, and group 2 (n = 70) received conventional education. Patient data were collected through patient identification and metabolic control parameter forms. RESULTS: Most patients in groups 1 and 2, respectively, were Kuwaiti (60.7% vs 58.6%), men (57.9% vs 68.6%), and had high school-level education (43.6% vs 48.6%). Chronic glomerulonephritis was the original disease in 36.4% versus 35.4% of patients. Most patients (72.8% vs 78.6% in group 1 vs 2) received pretransplant hemodialysis. At study start, the rate of patients with diabetic neuropathy was comparable between groups (32.4% vs 27.9%). Moreover, after completion of 24 months of education, neurological evaluation by electromyograph and nerve conduction studies did not show any significant differences between the groups (P > .05). Similarly, the number of patients with fundus imaging showing retinopathy was comparable between groups at start and end of study (P > .05). Although macroangiopathic events were higher in group 1, this finding was not significant (P > .05). However, although the percentage of patients with nephropathy was comparable in both groups at start of study, the percentage decreased significantly in group 1 at 24 months after completion of education compared with group 2 and baseline value (P = .016). CONCLUSIONS: Structured diabetes education was associated with reduced diabetic nephropathy but had no significant effects on other micro- or macroangiopathies. However, we recommend education for all kidney transplant recipients with diabetes.

Comparative study between skin micrografting (Meek technique) and meshed skin grafts in paediatric burns.

BACKGROUND: Globally, burn injuries are the 3rd principal cause of death due to injury among children aged 1-9 years. Yet, the management of paediatric burns is always challenging; due to limited donor sites and the cosmetic appearance that will affect the child later in life, either at the donor or the recipient site. Skin grafts may need to be expanded to minimise donor skin size or in patients with limited donor sites. Multiple techniques were described for graft expansion, mainly the mesher and the Meek technique. PATIENTS AND METHODS: A prospective comparative randomised study was done from January 2019 to June 2020 on 40 paediatric burn patients with deep dermal and full-thickness burns. Patients were divided into two groups, Meek and meshed groups. The skin graft take, epithelialization time, total time of the surgery and the aesthetic outcomes (using the POSAS - Patient and observer scar assessment scale) in each group were evaluated at three months postoperatively. RESULTS: The percentage of take in the Meek group (84.25%) was significantly better than with the meshed group (71.5%) (P = 0.006). Epithelialization time was better for the Meek group (27.11 days) compared to the meshed group (33.5 days) (P = 0.176). In addition, infection rates were lower in the Meek group (25%) than the meshed group (40%) (P = 0.311). Subjectively POSAS scar assessment scale exhibited better results for the Meek group with a mean score of 3.17 & for the meshed group was 4.2 (P = 0.048). The observer's overall score was as well better for the Meek group with a mean overall opinion score of 2.89 & for the meshed group was 4.1 (P = 0.003). The operative time was longer with the Meek technique than the traditional mesher (P < 0.001). CONCLUSION: The Meek technique for expanding the skin grafts is useful in covering burn wounds with greater expansion rate, more accessible application, better graft take & a better scar appearance than the traditional mesher. Still, the Meek technique has a considerable learning curve, longer procedure time & is more expensive.

Selective 13C labelling reveals the electronic structure of flavocoenzyme radicals.

Flavocoenzymes are nearly ubiquitous cofactors that are involved in the catalysis and regulation of a wide range of biological processes including some light-induced ones, such as the photolyase-mediated DNA repair, magnetoreception of migratory birds, and the blue-light driven phototropism in plants. One of the factors that enable versatile flavin-coenzyme biochemistry and biophysics is the fine-tuning of the cofactor's frontier orbital by interactions with the protein environment. Probing the singly-occupied molecular orbital (SOMO) of the intermediate radical state of flavins is therefore a prerequisite for a thorough understanding of the diverse functions of the flavoprotein family. This may be ultimately achieved by unravelling the hyperfine structure of a flavin by electron paramagnetic resonance. In this contribution we present a rigorous approach to obtaining a hyperfine map of the flavin's chromophoric 7,8-dimethyl isoalloxazine unit at an as yet unprecedented level of resolution and accuracy. We combine powerful high-microwave-frequency/high-magnetic-field electron-nuclear double resonance (ENDOR) with 13C isotopologue editing as well as spectral simulations and density functional theory calculations to measure and analyse 13C hyperfine couplings of the flavin cofactor in DNA photolyase. Our data will provide the basis for electronic structure considerations for a number of flavin radical intermediates occurring in blue-light photoreceptor proteins.

The biophysical, molecular, and anatomical landscape of pigeon CRY4: A candidate light-based quantal magnetosensor.

The biophysical and molecular mechanisms that enable animals to detect magnetic fields are unknown. It has been proposed that birds have a light-dependent magnetic compass that relies on the formation of radical pairs within cryptochrome molecules. Using spectroscopic methods, we show that pigeon cryptochrome clCRY4 is photoreduced efficiently and forms long-lived spin-correlated radical pairs via a tetrad of tryptophan residues. We report that clCRY4 is broadly and stably expressed within the retina but enriched at synapses in the outer plexiform layer in a repetitive manner. A proteomic survey for retinal-specific clCRY4 interactors identified molecules that are involved in receptor signaling, including glutamate receptor-interacting protein 2, which colocalizes with clCRY4. Our data support a model whereby clCRY4 acts as an ultraviolet-blue photoreceptor and/or a light-dependent magnetosensor by modulating glutamatergic synapses between horizontal cells and cones.

Pregnancy After Renal Transplant: Single Center Experience From the Middle East in Patients Using Different Calcineurin Inhibitors.

OBJECTIVES: Pregnancy after kidney transplant has a high risk for maternal and fetal complications; however, it can be successful if patients are properly selected. Here, we studied outcomes and complications of pregnancies in kidney transplant recipients who received calcineurin inhibitor-based immunosuppression. MATERIALS AND METHODS: In this case control study, we reviewed patients who became pregnant between 2004 and 2017. For this analysis, each pregnancy was considered an event. We divided pregnancies into 2 groups according to calcineurin inhibitor-based maintenance immunosuppression: group 1 (49 pregnancies) received cyclosporine, and group 2 (33 pregnancies) received tacrolimus. Patients also received steroids and azathioprine. Patients had regular antenatal follow-up at the Hamed Alessa Organ Transplant Center (Kuwait) and in the maternity hospital (monthly until month 7 and then weekly until delivery). RESULTS: Of 750 female kidney transplant recipients within childbearing potential, there were 82 pregnancies (10.9%) in 49 recipients (6.5%). Seventy-eight pregnancies were planned, and 4 pregnancies occurred while women were using contraception. There was 1 triple pregnancy, 5 double, and 76 single pregnancies. Two women had preeclampsia as maternal complication, 2 had uncontrolled hypertension, and 7 developed graft dysfunction. Forty-seven women (57.3%) had caesarean section, and the remaining had vaginal deliveries. Of 89 babies, 86 were viable (1 intrauterine fetal death and 2 abortions). Eight babies were delivered prematurely with low birth weight, and 2 needed incubators. Mean serum creatinine levels were 97.9 ± 24, 109 ± 38, 100 ± 39, 120 ± 46, and 115 ± 57 µmol/L at baseline, first, second, and third trimesters, and postpartum, respectively. Twelve patients showed high panel reactive antibodies but without donor-specific antibodies. CONCLUSIONS: Posttransplant pregnancy can be successful in most renal allograft recipients, but the increased risk of fetal and maternal complications, including low birth weight, spontaneous abortus, and preeclampsia, should be considered.

Extended Efficacy of Low-Dose Valganciclovir for Prevention of Cytomegalovirus Disease in Intermediate-Risk Kidney Transplant Recipients: Two-Year Follow-Up.

OBJECTIVES: In a previous study, we evaluated 1-year outcomes of using low-dose valganciclovir prophylaxis for cytomegalovirus infection in intermediate-risk kidney transplant recipients. Whether this effect persists in the long term is unknown. We aimed to evaluate the 2-year follow up of such adopted prophylaxis. MATERIALS AND METHODS: We randomized 2 matched groups of kidney transplant recipients (1:1) to receive valganciclovir as 450 mg daily (group 1) or 900 mg daily (group 2) for the first 6 months after kidney transplant. The final analysis included 196 patients as intermediate-risk patients (98 in each treatment group) after exclusion of 5 high-risk patients. Serologically, all patients were at moderate risk for cytomegalovirus infection. Long-term outcomes including cytomegalovirus disease, acute rejection, new-onset diabetes after transplant, graft loss, and patient survival were assessed. RESULTS: Through year 2 of follow-up, cytomegalovirus infection was reported in only 1 patient in group 1 (at month 13) and 1 patient in group 2 (at month 19) (not significant). Biopsy-proven acute rejection episodes were not statistically different between the groups (2 episodes in group 1 and 6 in group 2; P = .431). New-onset diabetes posttransplant was reported in 8.1% in group 1 and 13.2% in group 2 (P = .535). Graft failure was equal in both groups (1 in each group) at 2 years of follow up (not significant). Patient survival was comparable in both groups (100% in group 1 versus 97.9% in group 2; P = .661). The total number of cytomegalovirus infections at 2 years was numerically less in group 1 (P = .128). CONCLUSIONS: Low-dose valganciclovir prophylaxis for 6 months was associated with sustained reduction of cytomegalovirus infection up to 2 years after kidney transplant without significant impact on the acute rejection, new-onset diabetes posttransplant, or patient and graft outcomes.

Long-Lived Hydrated FMN Radicals: EPR Characterization and Implications for Catalytic Variability in Flavoproteins.

Until now, FMN/FAD radicals could not be stabilized in aqueous solution or other protic solvents because of rapid and efficient dismutation reactions. In this contribution, a novel system for stabilizing flavin radicals in aqueous solution is reported. Subsequent to trapping FMN in an agarose matrix, light-generated FMN radicals could be produced that were stable for days even under aerobic conditions, and their concentrations were high enough for extensive EPR characterization. All large hyperfine couplings could be extracted by using a combination of continuous-wave EPR and low-temperature ENDOR spectroscopy. To map differences in the electronic structure of flavin radicals, two exemplary proton hyperfine couplings were compared with published values from various neutral and anionic flavoprotein radicals: C(6)H and C(8α)H 3. It turned out that FMN•- in an aqueous environment shows the largest hyperfine couplings, whereas for FMNH• under similar conditions, hyperfine couplings are at the lower end and the values of both vary by up to 30%. This finding demonstrates that protein-cofactor interactions in neutral and anionic flavoprotein radicals can alter their electron spin density in different directions. With this aqueous system that allows the characterization of flavin radicals without protein interactions and that can be extended by using selective isotope labeling, a powerful tool is now at hand to quantify interactions in flavin radicals that modulate the reactivity in different flavoproteins.

Annual Data for Kidney Transplant Services in Kuwait (2015).

OBJECTIVES: Renal transplant services have been provided by the Hamed Al-Essa Organ Transplant Center in Ibn Sina Hospital since 1979 for Kuwaitis and non-Kuwaiti citizens residing in Kuwait. We aimed to monitor the activity and outcome of annual renal transplants in 2015. MATERIALS AND METHODS: Data on transplant patients were collected from hospital records from January 1, 2015, through December 31, 2015, at Ibn Sina Hospital. RESULTS: Eighty-one patients underwent a renal transplant in Kuwait in 2015; 46 patients (56.8%) were male and 35 (43.2%) were female. Of these 81 patients, 24 (29.6%) received a kidney from a deceased donor, 19 (23.5%) received a kidney from a living-unrelated donor, and 38 (46.9%) received a kidney from a living-related donor. Thirty-four patients (41.98%) who were highly sensitized immunologically underwent successful desensitization before transplant according the local protocol; 13 (38.2%) of these patients were male and 21 (61.8%) were female. Two patients (2.47%) experienced acute rejection within the first week after transplant. One diabetic female patient underwent a successful simultaneous deceased-donor kidney and pancreas transplant. Seventy-nine patients who underwent a transplant outside of Kuwait in 2015 were added to the follow-up list; 62 (78%) of these patients were male and 17 (22%) were female. Of these 79 patients, 31 patients (39%) received a kidney from a living-related donor, 45 (57%) received a kidney from a living-unrelated donor, and 3 (4%) received a kidney from a deceased donor. In addition, 303 patients were assessed for fitness for kidney transplant; 204 (67.3%) of these patients were male and 99 (32.7%) were female. Eight (2.6%) patients were not placed on the waiting list for a kidney transplant for medical reasons. CONCLUSIONS: A total of 81 patients underwent a renal transplant in Kuwait in 2015, only 2 (2.47%) of whom experienced acute rejection in the first week after transplant.

Successful Cost-Effective Prevention of Cytomegalovirus Disease in Kidney Transplant Recipients Using Low-Dose Valganciclovir.

OBJECTIVES: Low-dose valganciclovir prophylaxis is still under investigation in renal transplant procedures. Our aim was to assess the cost effectiveness of 450 mg versus 900 mg valganciclovir prophylaxis in kidney transplant recipients. MATERIALS AND METHODS: In this prospective trial, 201 kidney transplant patients were randomized (1:1) to receive 450 mg/d (group 1, n = 100) or 900 mg/d (group 2, n = 101) valganciclovir prophylaxis for the first 6 months after transplant. Patients were studied for incidence of cytomegalovirus disease, leucopenia episodes, rejection episodes, and graft outcomes along with associated costs over 1 year. Costs (in US dollars) of treatment of rejection were also analyzed. RESULTS: Demographic features of the studied groups were comparable. We found that the cost of cytomegalovirus care in group 1 patients was significantly lower (by 50% at 6 months; P < .001), with less leukopenia episodes (P = .04), lower doses of granulocyte colony-stimulating factor (by 30% at 6 months; P = .03), higher doses of mycophenolate mofetil (P = .04), and less rejection episodes (P = .01) compared with group 2. In group 2, there were more episodes of cytomegalovirus infection (P = .052) and BK virus nephropathy (P = .04). Graft and patient outcomes were satisfactory in both groups. CONCLUSIONS: Low-dose valganciclovir for cytomegalovirus prophylaxis after renal transplant is safer, effective and without breakthrough infection, and less costly than using the usual dose.

Sirolimus-Induced Combined Posterior Reversible Encephalopathy Syndrome and Lymphocytic Pneumonitis in a Renal Transplant Recipient: Case Report and Review of the Literature.

The mammalian target of rapamycin inhibitor sirolimus was introduced into clinical transplant practice in 1999. Dose-related myelosuppression and hyper lipidemia are the most common adverse effects. Pulmonary toxicity has been reported since 2004 and can cause interstitial pneumonitis, organizing pneumonia, and alveolar hemorrhage. Moreover, it can occasionally induce posterior reversible encephalopathy syndrome, as documented in scarce reports. To our knowledge; this is the 1st report of combined posterior reversible encephalopathy syndrome and lymphocytic pneumonitis to be induced by sirolimus. Here, we present a renal transplant recipient with reversible sirolimus-induced brain lesions who was diagnosed after exclusion of infections (viral, bacterial, and fungal), tumors, sarcoidosis, and autoimmune disorders. Both brain lesions and pneumonitis resolved completely after sirolimus discontinuation with excellent patient and graft outcome. Early and gradual sirolimus withdrawal can reverse posterior reversible encephalopathy syndrome and lymphocytic pneumonitis with preservation of stable graft function.

Recurrent Urinary Tract Infection Among Renal Transplant Recipients: Risk Factors and Long-Term Outcome.

OBJECTIVES: Urinary tract infection is the most common type of bacterial infection in kidney transplant procedures, with adverse effects on graft and patient survival. We aimed to evaluate the risk factors of recurrent urinary tract infection in renal transplant recipients and its impact on patient and graft survival. MATERIALS AND METHODS: In a cohort of 1019 patients who were transplanted between 2000 and 2010 at Hamed Al-Essa Organ Transplant Center in Kuwait, 86% developed at least 1 episode of urinary tract infection, with only 6.2% of patients having recurrent infections. We compared patients with recurrent urinary tract infections (group 1) with those who had no recurrence (group 2) regarding their risk factors. RESULTS: Patients in group 1 were significantly younger than those in group 2 (34.9 ± 23 vs 42.8 ± 16 y; P < .001), with female preponderance (P < .001). The percentage of patients with thymoglobulin induction (21.5%) was significantly higher in group 1. Patients with pretransplant urologic problems experienced significantly more recurrent urinary tract infections (P < .001). Hepatitis C infections were significantly more prevalent among group 1 (10.8% vs 3.8%; P = .008). Long-term graft outcome (functioning and failed) were 78.5% and 21.5% in group 1 versus 85.1% and 13.9% in group 2 (P = .18). Patient outcomes (living and deceased donors) were 98.4% and 1.6% in group 1 versus 95.7% and 4.3% in group 2 (P = .187). CONCLUSIONS: Adult females, thymoglobulin induction, pretransplant urologic problems, and hepatitis C infection were the risk factors of recurrent urinary tract infection among our renal transplant patients. However, recurrence did not adversely affect graft or patient survival.

Efficacy and Safety of Low-Dose Versus Standard-Dose Valganciclovir for Prevention of Cytomegalovirus Disease in Intermediate-Risk Kidney Transplant Recipients.

OBJECTIVES: Prophylaxis for cytomegalovirus infection is highly recommended for kidney transplant recipients. The use of daily 900 mg valganciclovir is the usual prophylactic dose, whereas 450 mg daily is under investigation. We evaluated the outcome of using 2 different doses of valganciclovir prophylaxis for cytomegalovirus infection after kidney transplant. MATERIALS AND METHODS: We randomized kidney transplant recipients (1:1) to receive 450 mg daily valganciclovir (group 1) or 900 mg daily valganciclovir (group 2) for the first 6 months after kidney transplant. Serologically, all patients were at moderate risk for cytomegalovirus infection. Patients were studied for incidence of cytomegalovirus disease, leukopenia attacks, rejection episodes, and graft outcomes for 1 year. RESULTS: Demographic features of group 1 (98 patients) and group 2 (98 patients) were comparable. More than 50% of patients received thymoglobulin induction therapy without difference between the groups. There were more leukopenia attacks in group 2 (P = .03) requiring higher doses of granulocyte colony-stimulating factor (P = .03). Group 2 patients received lower doses of mycophenolate mofetil (P= .04) and required reduced doses of valganciclovir (P = .045). Compared with group 1, the high-dose group developed numerically more rejection episodes (P = .057) and more cytomegalovirus infections requiring full treatment (P = .17). Graft and patient outcomes were satisfactory in both groups. CONCLUSION: Six months of low-dose valganciclovir prophylaxis for intermediate-risk kidney transplant recipients was as effective as high-dose valganciclovir with a better safety profile.

Long-Term Follow-Up of Active Treatment Versus Minimization of Immunosuppressive Agents in Patients With BK Virus-Associated Nephropathy After Kidney Transplant.

OBJECTIVES: There is no active treatment for postrenal transplant BK virus-associated nephropathy proven to be effective so far. We assessed the effectiveness of actively treating this condition with combined leflunomide, intravenous immunoglobulin, and ciprofloxacin on long-term graft outcome compared with minimization of immunosuppressive drugs. MATERIALS AND METHODS: Kidney transplant recipients were screened for BK virus-associated nephropathy. Group 1 comprised 22 kidney trans plant recipients with twice-positive BK virus polymerase chain reaction results in urine and blood. After diagnosis was confirmed with graft biopsy, antimetabolite (mycophenolate mofetil or azathioprine) was changed to leflunomide and intravenous immunoglobulin and oral ciprofloxacin were given. Group 2 comprised 33 BK virus-associated nephropathy patients treated conventionally with reduced immunosuppressive medications. RESULTS: Fifty-five patients were treated (38 males [69%], 28 patients [50.9%] with type 2 diabetes mellitus). Mean HLA antigen mismatches were 3.65, and 28 patients (50.9%) were HLA-Cw7 negative. All patients received induction therapy, 30 patients (55.6%) received thymoglobulin, and 29 patients (52.7%) received antirejection therapy before BK virus-associated nephropathy diagnosis. Maintenance immunosuppression was prednisolone in 53 patients (96.3%), mycophenolate mofetil (2 g daily) in 52 patients (94.5%), and tacrolimus in 28 patients (50.9%). Subsequent rejection episodes occurred in 38% of patients after diagnosis. Basal mean estimated glomerular filtration rate was 52.5 ± 25.5, which was reduced significantly to 38.1 ± 27.8 mL/min/1.73 m(2) (P < .0001) at end of study but without significant differences between the groups (P = .08 and P = .17). Follow-up was 7.3 ± 4.99 years. Although no significant differences were shown in patient outcome, graft survival was significantly better in group 2 (P = .032). CONCLUSIONS: Administration of 3 different anti-BK virus agents (leflunomide, intravenous immunoglobulin, ciprofloxacin) added no benefit to longterm outcome in patients with BK virus-associated nephropathy. Reduction of immunosuppressive medications appears to be a more effective treatment.

Usefulness of full outline of unresponsiveness score to predict extubation failure in intubated critically-ill patients: A pilot study.

OBJECTIVE: To assess the usefulness of the full outline of unresponsiveness (FOUR) score in predicting extubation failure in critically ill intubated patients admitted with disturbed level of conscious in comparison with the Glasgow coma scale (GCS). PATIENTS AND METHODS: All intubated critically ill patients with a disturbed level of consciousness were assessed using both the FOUR score and the GCS. The FOUR score and the GCS were compared regarding their predictive value for successful extubation at 14 days after intubation as a primary outcome measure. The 28-day mortality and the neurological outcome at 3 months were used as secondary outcome measures. RESULTS: Eighty-six patients were included in the study. Median age was 63 (50-77) years. Sex-ratio (M/F) was 1.46. On admission, median GCS was 7 (3-10) while median FOUR score was 8.5 (2.3-11). A GCS ≤ 7 predicted the extubation failure at 14 days after intubation with a sensitivity of 88.5% and specificity of 68.3%, whereas a FOUR score <10 predicted the same outcome with a sensitivity of 80.8% and a specificity of 81.7%. The areas under the curves was significantly higher with the FOUR score than with GCS (respectively 0.867 confidence interval [CI]: 95% [0790-0.944] and 0.832 CI: 95% [0.741-0.923]; P = 0.014). When calculated before extubation, FOUR score <12 predicted extubation failure with a sensitivity of 92.3% and a specificity of 85%, whereas a GCS <12 predicted the same outcome with a sensitivity of 73% and a specificity of 61.7%. Both scores had similar accuracy for predicting 28-day mortality and neurological outcome at 3 months. CONCLUSION: The FOUR score is superior to the GCS for the prediction of successful extubation of intubated critically ill patients.