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INTRODUCTION: Equitable healthcare delivery is essential and requires resources to be distributed, which include assets and healthcare workers. To date, there is no gold standard for measuring the correct number of physicians to meet healthcare needs. This rapid review aims to explore measurement tools employed to optimise the distribution of hospital physicians, with a focus on ensuring fair resource allocation for equitable healthcare delivery. MATERIALS AND METHODS: A literature search was performed across PubMed, EMBASE, Emerald Insight and grey literature sources. The key terms used in the search include 'distribution', 'method', and 'physician', focusing on research articles published in English from 2002 to 2022 that described methods or tools to measure hospital-based physicians' distribution. Relevant articles were selected through a two-level screening process and critically appraised. The primary outcome is the measurement tools used to assess the distribution of hospital-based physicians. Study characteristics, tool advantages and limitations were also extracted. The extracted data were synthesised narratively. RESULTS: Out of 7,199 identified articles, 13 met the inclusion criteria. Among the selected articles, 12 were from Asia and one from Africa. The review identified eight measurement tools: Gini coefficients and Lorenz curve, Robin Hood index, Theil index, concentration index, Workload Indicator of Staffing Need method, spatial autocorrelation analysis, mixed integer linear programming model and cohortcomponent model. These tools rely on fundamental data concerning population and physician numbers to generate outputs. Additionally, five studies employed a combination of these tools to gain a comprehensive understanding of physician distribution dynamics. CONCLUSION: Measurement tools can be used to assess physician distribution according to population needs. Nevertheless, each tool has its own merits and limitations, underscoring the importance of employing a combination of tools. The choice of measuring tool should be tailored to the specific context and research objectives.
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Atenção à Saúde , Médicos , Humanos , Hospitais , Pessoal de SaúdeRESUMO
The anniversary of the publication of 'One Flew Over the Cuckoo's Nest' by Ken Kesey offers an opportunity for reflection on the use of neurosurgery in psychiatry. We used a narrative, historical and dialectical method to deliver an account of the controversial subject. A balanced representation of the negative and positive aspects, acknowledging some of the questionable ethical practices while describing well-reasoned applications is provided. It includes neurosurgeons, psychiatrists who have embraced these procedures with unwarranted enthusiasm and those who have opposed. Neurosurgical techniques for the treatment of severe mental disorders have evolved from rudimentary procedures which were used to 'correct' unwanted behaviours associated with a wide range of severe mental disorders to more refined and selective approaches used as a last resort to treat specific mental health conditions. In the absence of specific aetiological models to guide ablative surgical targets, non-ablative, stimulatory techniques have more recently been developed to allow reversibility when surgical treatment fails to obtain a sizeable improvement in quality of life. The subject is concretely illustrated by two eloquent clinical images: one on a series of brain computed tomography scans carried out on a Canadian population of subjects, who underwent leukotomy decades ago, and the other more contemporary on an implantation surgery to epidural stimulation. Alongside technical advances in psychosurgery, a regulatory framework has gradually developed to ensure vigilance in the appropriateness of patients' selection. Nevertheless, harmonisation of protocols around the world is necessary to ensure consistency in obtaining and maintaining the highest possible ethical standards for the benefit of patients. If the neurosciences promise today, in their new, better framed, and reversible applications, to provide answers to unmet therapeutic needs, we still must remain attentive to drifts linked the introduction of intrusive technologies for purposes of domination or behaviour modification that would impede our individual freedom.
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Dípteros , Transtornos Mentais , Psicocirurgia , Humanos , Animais , Psicocirurgia/história , Psicocirurgia/métodos , Qualidade de Vida , Canadá , Transtornos Mentais/cirurgiaRESUMO
Post Traumatic Stress Disorder (PTSD) is a condition which causes great sufferance to the individuals affected. The occurrence of comorbidities in PTSD is a frequent event with a negative impact on outcome. This study investigated the frequency of PTSD in relation to comorbidities by analyzing the results of the 2007 'Adult Psychiatric Morbidity Survey' in the English population, which included data on comorbidities. A population study conducted in the United Kingdom, this survey investigated the frequency of PTSD in the community and the relationship to comorbidities by adopting a random design to minimize selection bias, stratified by region and socioeconomic characteristics, and weighted according to design and non-response. The survey interviewed 7403 adults living in private households. Socio-demographic characteristics and psychiatric morbidity were systematically assessed. Results indicated that PTSD prevalence was 2.9%, with an excess in women (3.3%) compared to men (2.4%) as reported by the 2007 survey. Comorbidity was a very frequent occurrence in PTSD reaching 78.5% in affected cases. Major depression was the commonest condition and its frequency increased with symptoms severity up to 54%. Among anxiety disorders, social phobia was the most frequent, followed by generalized anxiety disorder, obsessive-compulsive disorder, agoraphobia and panic disorder. Substance use disorders were also common. The presence of psychotic symptoms was particularly significant with over 30% prevalence in PTSD. These results indicate that attention needs to be devoted to the presence of comorbidities. In view of the impact of comorbidities on PTSD severity, chronicity and functional impairment, early detection and treatment are likely to improve outcome.
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Inquéritos Epidemiológicos , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Adolescente , Adulto , Transtornos de Ansiedade/epidemiologia , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtorno Obsessivo-Compulsivo/epidemiologia , Transtorno de Pânico/epidemiologia , Prevalência , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Adulto JovemRESUMO
This study describes the registration of the first cases of lumpy skin disease in July 2016 in the Republic of Kazakhstan. In the rural district of Makash, Kurmangazinsky district of Atyrau region, 459 cattle fell ill and 34 died (morbidity 12.9% and mortality 0.96%). To determine the cause of the disease, samples were taken from sick and dead animals, as well as from insects and ticks. LSDV DNA was detected by PCR in all samples from dead animals and ticks (Dermacentor marginatus and Hyalomma asiaticum), in 14.29% of samples from horseflies (Tabanus bromius), and in one of the samples from two Stomoxys calcitrans flies. The reproductive LSD virus was isolated from organs of dead cattle and insects in the culture of LT and MDBK cells. The virus accumulated in cell cultures of LT and MDBK at the level of the third passage with titers in the range of 5.5-5.75 log 10 TCID50/cm3. Sequencing of the GPCR gene allowed us to identify this virus as a lumpy skin disease virus.
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Doenças dos Bovinos , Ixodidae , Doença Nodular Cutânea , Vírus da Doença Nodular Cutânea , Muscidae , Animais , Bovinos , Doenças dos Bovinos/epidemiologia , Cazaquistão/epidemiologia , Doença Nodular Cutânea/epidemiologiaRESUMO
Cirrhotic cardiomyopathy is a recognised complication of liver cirrhosis and predicts poor outcomes. Detection of diastolic dysfunction, an early indicator of left ventricular dysfunction can help identify those patients at risk of disease progression. In our study we showed that there was a high prevalence of diastolic dysfunction amongst patients with liver cirrhosis at our outpatient clinic, with the majority being Child-Pugh A/low MELD score. Multiple regression analysis indicated that age and sodium levels were significantly associated with the presence of diastolic dysfunction. This further reinforces the importance of dietary sodium restriction amongst patients with liver cirrhosis.
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Cardiomiopatias/etiologia , Cirrose Hepática/complicações , Disfunção Ventricular Esquerda/etiologia , Idoso , Feminino , Hospitais , Humanos , Malásia , Masculino , Pessoa de Meia-Idade , Análise de Regressão , Índice de Gravidade de Doença , Disfunção Ventricular Esquerda/fisiopatologiaRESUMO
A 63-year-old man with HIV (human immunodeficiency virus) infection and end-stage renal disease, treated with lanthanum carbonate phosphate binder for 4 years, presented with anemia and an upper gastrointestinal bleed. Upper endoscopy revealed a nodular hyperplastic epithelium, with an endoscopic ultrasound confirming hyperechoic material within the nodules. Light microscopy showed collections of histiocytes and multinucleated giant cells containing brown granular cytoplasmic material and extracellular crystalline material, a finding confirmed by electron microscopy. Similar pathologic findings associated with lanthanum exposure have been described recently. In our patient, lanthanum carbonate treatment was withdrawn and gastrointestinal bleeding has since ceased. The patient was exposed to a high amount of lanthanum over a long period, which may explain his adverse reaction. However, other contributing factors, such as competing medications or comorbid conditions, also may have increased his sensitivity to the drug.
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Reação a Corpo Estranho/induzido quimicamente , Lantânio/efeitos adversos , Diálise Renal , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de TempoRESUMO
BACKGROUND: The six-item cognitive impairment test (6CIT) is a brief cognitive screening instrument (CSI) recommended for use in primary care settings. There are very few studies of 6CIT performance in secondary care settings. METHODS: We undertook a pragmatic diagnostic accuracy study of 6CIT in consecutive patients referred over the course of one year to a neurology-led cognitive function clinic, and compared its performance for the diagnosis of dementia and mild cognitive impairment (MCI) to that of the simultaneously administered Mini-Mental State Examination (MMSE). RESULTS: In a cohort of 245 patients with dementia prevalence around 20%, 6CIT proved quick and easy to use and acceptable to patients. It had good sensitivity (0.88) and specificity (0.78) for dementia diagnosis; it was more sensitive than MMSE (0.59) but less specific (0.85). For MCI diagnosis, 6CIT was again more sensitive (0.66) than MMSE (0.51) but less specific (0.70 vs. 0.75). Weighted comparisons showed net benefit for 6CIT compared to MMSE for both dementia and MCI diagnosis. 6CIT effect sizes (Cohen's d) were large for dementia diagnosis and moderate for MCI diagnosis. CONCLUSIONS: 6CIT is an acceptable and accurate test for the assessment of cognitive problems, its performance being more sensitive than the MMSE. 6CIT use should be considered as a viable alternative to MMSE in the secondary care setting.
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Disfunção Cognitiva/diagnóstico , Demência/diagnóstico , Testes Neuropsicológicos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Disfunção Cognitiva/psicologia , Demência/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos/normas , Reprodutibilidade dos Testes , Adulto JovemRESUMO
Homestay ecotourism in Malaysia has been extensively examined in terms of its concepts, approaches, activities, and community engagement. However, a comprehensive assessment of the sustainability factors pertaining to host families remains a critical area awaiting exploration. This is paramount for ensuring the long-term viability of homestays and fostering economic benefits within rural communities. The present study seeks to establish direct subjective measurements for evaluating the interplay between local communities, tourism, and resources in safeguarding sustainable homestays. Utilizing the Delphi approach, this research conducted interviews with 51 experts who were actively involved in six homestays located on the East Coast of Peninsular Malaysia. The objective was to identify key evaluation indicators pertinent to the homestay industry. The findings underscored the pivotal roles played by community resources and tourism in the sustainability of homestays. Additionally, environmental, economic, and social factors emerged as crucial components for maintaining the industry's sustainability. This innovative assessment methodology offers a valuable instrument for enhancing the sustainability of the homestay sector, especially in the wake of the COVID-19 pandemic. By embracing this approach, homestay operators can fortify their sustainable management practices and prepare themselves for future pandemics. This study represents a significant contribution to the field of homestay ecotourism, emphasizing the imperative for continued research in this dynamic domain.
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Crimean-Congo hemorrhagic fever (CCHF) disease cases are registered annually in endemic regions of Kazakhstan. To study the prevalence of various Crimean-Congo hemorrhagic fever virus (CCHFV) genotypes, a total of 694 ticks were collected from southern regions of Kazakhstan in 2021. Hyalomma marginatum (n = 323) (46.5%), Hyalomma anatolicum (n = 138) (19.9%), Hyalomma asiaticum (n = 126) (18.2%), Hyalomma scupense (n = 80) (11.5%) and Ixodes ricinus (n = 27) (3.9%) were collected using the standardized flagging technique from the environment. All the tick samples were analyzed for the presence of CCHFV RNA by RT-PCR. The CCHF-positive samples were found within three Hyalomma asiaticum and one Ixodes ricinus tick sample. For the first time in Kazakhstan, infection of the Ixodes ricinus tick with CCHFV was detected. The results of sequencing and analysis of the S-gene fragment showed that the Asia 1 and Asia 2 CCHF genotypes circulate in the southern regions of Kazakhstan. Viruses isolated in the Zhambyl and Turkestan regions are assigned to the Asia-2 genotype, whereas the virus isolated in the Kyzylorda region to the Asia-1 genotype.
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BACKGROUND: White matter (WM) and grey matter (GM) brain damage in multiple sclerosis (MS) is widespread, but the extent of cerebellar involvement and impact on disability needs to be clarified. OBJECTIVE: This study aimed to assess cerebellar WM and GM atrophy and the degree of fibre coherence in the main cerebellar connections, and their contribution to disability in relapsing-remitting MS (RRMS) and primary progressive MS (PPMS). METHODS: Fourteen patients with RRMS, 12 patients with PPMS and 16 healthy controls were recruited. Cerebellar WM and GM volumes and tractography-derived measures from the middle and superior cerebellar peduncles, including fractional anisotropy (FA), mean diffusivity (MD), and directional diffusivities, were quantified from magnetic resonance imaging (MRI). Patients were assessed on clinical scores, including the MS Functional Composite score subtests. Linear regression models were used to compare imaging measures between 12 RRMS, 11 PPMS and 16 controls, and investigate their association with clinical scores. RESULTS: Patients with PPMS showed reduced FA and increased radial diffusivity in the middle cerebellar peduncle compared with controls and patients with RRMS. In PPMS, lower cerebellar WM volume was associated with worse performance on the upper limb test. In the same patient group, we found significant relationships between superior cerebellar peduncle FA and upper limb function, and between superior cerebellar peduncle FA, MD and radial diffusivity and speed of walking. CONCLUSION: These findings indicate reduced fibre coherence in the main cerebellar connections, and link damage in the whole cerebellar WM, and, in particular, in the superior cerebellar peduncle, to motor deficit in PPMS.
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Cerebelo/patologia , Esclerose Múltipla/patologia , Fibras Nervosas/patologia , Adulto , Idoso , Atrofia/patologia , Cerebelo/fisiopatologia , Imagem de Tensor de Difusão , Progressão da Doença , Feminino , Força da Mão/fisiologia , Humanos , Processamento de Imagem Assistida por Computador , Masculino , Pessoa de Meia-Idade , Esclerose Múltipla/fisiopatologiaRESUMO
A diarrhea-producing toxin from a blue-green alga, Microcystis aeruginosa Kützing, was obtained from standing laboratory cultures. The non-dialyzable fraction of the lysate from whole cells produced fluid accumulation in the ligated small intestinal loops in guinea pigs.
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Diarreia/etiologia , Microcystis/análise , Toxinas Biológicas/isolamento & purificação , Animais , Bioensaio , Cobaias , Técnicas In Vitro , Intestino Delgado/efeitos dos fármacos , Toxinas Biológicas/toxicidadeRESUMO
BACKGROUND AND PURPOSE: Aneurysm hemodynamics has been associated with wall histology and inflammation. We investigated associations between local hemodynamics and focal wall changes visible intraoperatively. MATERIALS AND METHODS: Computational fluid dynamics models were constructed from 3D images of 65 aneurysms treated surgically. Aneurysm regions with different visual appearances were identified in intraoperative videos: 1) "atherosclerotic" (yellow), 2) "hyperplastic" (white), 3) "thin" (red), 4) rupture site, and 5) "normal" (similar to parent artery), They were marked on 3D reconstructions. Regional hemodynamics was characterized by the following: wall shear stress, oscillatory shear index, relative residence time, wall shear stress gradient and divergence, gradient oscillatory number, and dynamic pressure; these were compared using the Mann-Whitney test. RESULTS: Hyperplastic regions had lower average wall shear stress (P = .005) and pressure (P = .009) than normal regions. Flow conditions in atherosclerotic and hyperplastic regions were similar but had higher average relative residence time (P = .03) and oscillatory shear index (P = .04) than thin regions. Hyperplastic regions also had a higher average gradient oscillatory number (P = .002) than thin regions. Thin regions had lower average relative residence time (P < .001), oscillatory shear index (P = .006), and gradient oscillatory number (P < .001) than normal regions, and higher average wall shear stress (P = .006) and pressure (P = .009) than hyperplastic regions. Thin regions tended to be aligned with the flow stream, while atherosclerotic and hyperplastic regions tended to be aligned with recirculation zones. CONCLUSIONS: Local hemodynamics is associated with visible focal wall changes. Slow swirling flow with low and oscillatory wall shear stress was associated with atherosclerotic and hyperplastic changes. High flow conditions prevalent in regions near the flow impingement site characterized by higher and less oscillatory wall shear stress were associated with local "thinning" of the wall.
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Hemodinâmica/fisiologia , Aneurisma Intracraniano/patologia , Modelos Cardiovasculares , Humanos , Hidrodinâmica , Imageamento Tridimensional , Aneurisma Intracraniano/fisiopatologia , Fatores de Risco , Estresse MecânicoRESUMO
OBJECTIVES: To study the effect of rheumatoid arthritis (RA) on the temporomandibular joints (TMJ) and related muscles using CT scan and neurophysiologic tests. METHODS: Forty-two RA patients referred from the Maxillofacial Clinic at the Special Surgeries Hospital, Medical City, Baghdad, Iraq from February 2006 to September 2006 were included in this study. Thirty-seven of them underwent CT scan of the TMJ and 25 of these patients were neurophysiologically examined. The data were compared to 30 age-matched control subjects. RESULTS: Fifteen patients showed normal TMJ, whereas, abnormal TMJ on CT scan was present in 22 patients. Of these 22 patients, 6 showed decrease in the intra-articular space, 6 exhibited erosion of the condylar head, and 3 had flattening of the condylar head. The remaining 7 patients had all the abnormalities present. Electromyography (EMG) examination showed reduced interference pattern, poor recruitment of motor unit potentials, shift of the power spectra to the lower frequencies, low mean power frequency, and root mean square values, and prolonged blink reflex component latencies. CONCLUSION: Rheumatoid arthritis patients with positive CT scan findings have poorer neurophysiologic data than those without CT scan detectable lesions. Trigeminal motor neuropathy is suggested to be the cause of the masticatory muscle weakness. Root mean square voltage as a parameter of the EMG power spectra is of great value in diagnosing such weakness.
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BACKGROUND: To our knowledge, the importance of US findings, pain (brief pain inventory (BPI)) and disability in osteoarthritic knee (OA) pain patients remain uncertain. AIM: The objectives are to evaluate the correlation of US findings, pain (brief pain inventory (BPI)) and disability in OA pain patients. MATERIALS AND METHODS: Eighty - three patients with OA knee were divided into two groups. The first group was OA as symptomatic knee group and the second group was an asymptomatic control group. The maximum sagittal height of synovial fluid in 12 scans at 0, 30, 60 and 90 degrees flexion knee in 3 major recesses were measured. RESULTS: There were a significant positive correlation between BPI Pain severity index, or BPI function interference index and a maximum height of effusion at 30-degree flexion angle in a supra-patellar recess in painful symptomatic knees. But, there was a significant negative correlation between BPI Pain severity index, and BPI function interference index and cartilage thickness in painful symptomatic knees. CONCLUSION: The increase of maximum height of synovial effusion at different angles of knee and decrease of cartilage thickness associated with pain and disability in OA pain patients and are being predictors for pain severity and disability in OA pain patients.
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Three isolates of the entomopathogen Beauveria bassiana along with one strain of Metarhizium anisopliae were cultured on seven media with different carbon/nitrogen (C/N) ratios. The effect of nutrition on virulence of the isolates was evaluated via measurement of colony growth, spore yield, germination speed, conidial C/N ratio and Pr1 (a serine protease) activity. 'Osmotic stress' medium produced the lowest colony growth with low numbers of conidia in all isolates. However, these conidia showed a high germination rate and virulence. However, conidial Pr1 activity was low in some isolates. In most but not in all cases conidia from 1% yeast extract, 2% peptone and low (10 : 1) C/N medium had higher Pr1 activity compared with conidia from other media. However, in some instances we could not conclude that there was a relationship among germination rate, conidial Pr1 activity and virulence. C/N ratio of conidia was statistically different among various media and fungal isolates. Conidia with lower C/N ratio generally produced lower LT(50) (lowest median lethal time) values (more virulent). Insect-passaged conidia from different media had lower C/N ratio compared with similar conidia from artificial cultures. Therefore, they should be more virulent than in vitro produced conidia. As germination rate, conidial Pr1 activity and C/N ratio are independent of host, it seems that host-related determinants such as insect cuticle and physiology and environmental conditions may influence host susceptibility and therefore fungal isolate virulence towards host insects.
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Beauveria/efeitos dos fármacos , Beauveria/crescimento & desenvolvimento , Besouros/microbiologia , Animais , Beauveria/patogenicidade , Carbono/farmacologia , Meios de Cultura/farmacologia , Nitrogênio/farmacologia , Virulência/efeitos dos fármacosRESUMO
In the past decade, there has been considerable interest in radiosensitization using gold nanoparticles that accumulate specifically in cancerous tissue while sparing normal tissues. Despite this interest, it remains unclear which nanoparticle morphologies, cellular uptake, or cytoplasmic distribution elicit optimal radiosensitization. We introduce gold nanotriangles (AuNTs) as a possible X-ray radiotherapy sensitizer. In this study, we first explored a large-scale synthetic method for the production of high quality monodisperse AuNTs. Second, we conducted in vitro and in vivo experiments to evaluate the effect of PEGylated AuNTs (pAuNTs) on cellular uptake, cytotoxicity, bio-distribution, and radiosensitization on radiation-resistant human Glioblastoma Multiforme (GBM) cells. Our results suggest that the new scale up synthesis methodology consistently produced high quality AuNTs and pAuNTs which had nonspecific cellular uptake without any obvious cytotoxicity and exhibited excellent radiosensitization.
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Glioblastoma/radioterapia , Ouro , Nanopartículas Metálicas , Radiossensibilizantes , Animais , Humanos , Células MCF-7 , Masculino , Camundongos , Raios X , Ensaios Antitumorais Modelo de XenoenxertoRESUMO
BACKGROUND: Gait disorders or postural instability has been done before. However, lack of reviews has addressed the relation between gait and postural stability in Parkinson's disease (PD). AIM: The aim was to evaluate the relation between gait parameters and postural stability in early and late stages of PD. MATERIALS AND METHODS: The forty-one idiopathic PD patients were divided into two groups into a group (A) considered as early PD and group (B) considered as late ambulant PD. They were evaluated for postural stability by computerised dynamic posturography (CDP) device and gait analysis using an 8 m-camera Vicon 612 data capturing system set. RESULTS: There was a statistically significant improvement of composite equilibrium score, the composite latency of motor response, walking speed and cadence after treatment as compared to before training (p < 0.05) in early PD. However, in the late PD, there was a non-significant change of previous parameters after treatment as compared to before training (p > 0.05). There was a significant correlation between UPDRS motor part score, walking speed and composite equilibrium score after training in early PD (p > 0.05). CONCLUSIONS: Both gait analysis and CDP are important quantitative assessment tools of gait and posture instability.
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BACKGROUND: To our knowledge, the correlation between ultrasonographic enthesopathy and severity in psoriatic arthritis (PsA) has been done before. However, the correlation between ultrasonography of enthesopathy and the Psoriatic Arthritis Disease Activity Score (PASDAS) have not been done. AIM: To compare the results of ultrasonographic enthesopathy of foot and PASDAS in PsA. MATERIALS AND METHODS: A total of 65 PsA patients were involved and divided into two groups. The first group of 35 active PsA and the second group of 30 ages and sex matched inactive PsA as a control group were recruited in this study. Both groups were evaluated by examination, radiological findings and ultrasonography. RESULTS: Of 70 entheses in 35 active PsA patients, the most entheseal abnormalities were tender plantar fascia (18.5%), tender Achilles tendon (37.8%). PASDAS was a direct highly significant correlated with plantar fascia and Achilles tendon thickness in in active PsA (r = 0.823 and r = 0.796, p < 0.001 respectively). CONCLUSION: Musculoskeletal US is an accurate and low-cost method for assessment of enthesopathy with significant correlation to disease activities in psoriatic arthritis.
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AIM: To review the incidence of graft loss and acute rejection among renal transplant recipients with early reduction of immunosuppression for BK viremia. METHODS: We performed a retrospective analysis of consecutive de-novo kidney-only transplants from January 2009 to December 2012 to evaluate the incidence of Polyoma-virus associated nephropathy (PyVAN). Recipient plasma was screened for BKV DNA via quantitative polymerase chain reaction (PCR) at months 1, 3, 6, 9 and 12 post-transplant and on worsening graft function. Immunosuppression was reduced at ≥ 3-log copies/mL. Those with viremia of ≥ 4-log copies/mL (presumptive PyVAN) underwent renal transplant biopsy. Presumptive PyVAN (PP) and definitive PyVAN (DP; biopsy-proven) were treated by immunosuppression reduction (IR) only. RESULTS: Among 319 kidney transplant recipients, the median age was 53 years (range 19-83), 65.8% were male, and 58.9% were white. Biopsy-proven acute rejection was found in 18.5% within 0-168 wk. Death-censored graft loss occurred in 5.3% (n = 17) and graft loss attributable to PyVAN was 0.6% (n = 2). Forty-seven patients were diagnosed with PP (14.7%) and 18 (5.6%) with DP. Graft loss among participants with PyVAN (8.5%) and those without (4.8%) was not significantly different. Deceased donor kidney transplantation (OR = 2.3, 95%CI = 1.1-4.6) and AR (OR = 2.3, 95%CI = 1.2-4.7) were associated with PyVAN in the multivariate analysis. BK viremia between 3 and 4-log copies/mL occurred in 27 patients, all of whom underwent IR. Of these, 16 (59%) never developed PyVAN while 11 (41%) developed PyVAN (4 DP, 7 PP) within a range of 11-39 wk. CONCLUSION: Instituting an early reduction of immunosuppression, in the absence of adjunctive antivirals, is effective at preventing PyVAN and may be associated with a lower incidence of graft-loss without a reciprocal increase in the incidence of acute rejection.
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OBJECTIVE: International resuscitation guidelines recommend clinical assessment and exhaled CO2 to confirm tube placement immediately after intubation. However, exhaled CO2 devices can display false negative results. In comparison, any respiratory function monitor can be used to measure and display gas flow in and out of an endotracheal tube. However, neither method has been examined in detail. We hypothesized that a flow sensor would improve the assessment of tracheal vs esophageal tube placement in neonates with a higher success rate and a shorter time to tube placement confirmation when compared with the use of a quantitative end-tidal CO2 (ETCO2) detector. STUDY DESIGN: Between December 2013 and September 2014, preterm and term infants requiring endotracheal intubation were eligible for inclusion and randomly allocated to either ETCO2 ('ETCO2 group') or flow sensor ('flow sensor group'). All infants were analyzed according to their group at randomization (that is, analysis was by intention-to-treat). RESULT: During the study period, a total of 110 infants (n=55 for each group) were randomized. Successful endotracheal tube placements were correctly identified in 100% of cases by the flow sensor compared with 72% of cases with the ETCO2 detector within 10 inflations (P<0.05). The median (interquartile range) number of inflations needed to identify successful tube placement was significantly lower in the flow sensor group with 2 (1 to 3) inflations vs 8 (6 to 10) inflations with the ETCO2 detector (P<0.001). CONCLUSION: A flow sensor would improve the assessment of successful endotracheal tube placement with a higher success rate and a shorter time compared with an ETCO2 detector.