Fulminant endocarditis and disseminated infection caused by carbapenem-resistant Acinetobacter baumannii in a renal-pancreas transplant recipient.

Acinetobacter baumannii is an important cause of healthcare-associated infections, and is particularly problematic among patients who undergo organ transplantation. We describe a case of fulminant sepsis caused by carbapenem-resistant A. baumannii harboring the blaOXA-23 carbapenemase gene and belonging to international clone II. This isolate led to the death of a patient 6 days after simultaneous kidney-pancreas transplantation. Autopsy findings revealed acute mitral valve endocarditis, myocarditis, splenic and renal emboli, peritonitis, and pneumonia. This case highlights the severe nature of certain A. baumannii infections and the vulnerability of transplanted patients to the increasingly intractable "high-risk" clones of multidrug-resistant organisms.

Cutaneous histoplasmosis in renal transplant recipients.

Cutaneous histoplasmosis is a rare entity, although it can be seen in a substantial portion of renal transplant recipients with disseminated disease. The prognosis of disseminated disease is worse than isolated cutaneous involvement, and significant delays in diagnosis are reported. We reviewed reports of cutaneous histoplasmosis with and without dissemination in the setting of renal transplantation to examine incidence, timing of diagnosis, clinical features, and prognosis. Remarkable morphologic variability and the non-specific appearance of skin findings suggest that tissue culture is required for definitive diagnosis. Cutaneous lesions represent an easily accessible source for early diagnosis.

Clinical predictors of proteinuria after conversion to sirolimus in kidney transplant recipients.

Proteinuria is an increasingly recognized effect of sirolimus (SRL) therapy in kidney transplant recipients. Predictors of proteinuria after conversion to SRL are not well described, and in particular the risk in African-American (AA) kidney recipients is unknown. We sought to analyze risk factors for proteinuria with SRL therapy in a cohort of 39 patients (44% AA) converted from tacrolimus to SRL at a mean time of 4 months posttransplantation. Patients were maintained on therapy with mycophenolate mofetil while most patients underwent early steroid withdrawal. Urinary protein to creatinine ratio (Up/cr) at a mean of 14 months postconversion increased to > or =500 mg/g in 65% of AAs versus 14% of non-AAs (p = 0.001). Mean arterial blood pressure at the time of conversion and pretransplant proteinuric kidney disease were also predictors of proteinuria after SRL conversion. In conclusion, AAs appear to be at high risk for proteinuria and should be monitored closely after conversion to SRL in calcineurin inhibitor sparing protocols.

Abdominal Organ Transplant Center Tobacco Use Policies Vary by Organ Program Type.

BACKGROUND: Smoking is a modifiable risk factor for cardiovascular disease, malignancy, and surgical complications. Transplant center practices toward smokers vary widely and evoke the classic tension between the ethical principles of justice and utility. We sought to assess current smoking policy variation in U.S. kidney, liver, and pancreas transplant centers. METHODS: An online survey was sent to program directors of all United Network for Organ Sharing-approved solid abdominal organ transplant programs regarding their policies toward prior and current tobacco use. RESULTS: Responses were received from 26% of kidney, 31% of liver, and 37% of pancreas transplant centers. Across organ programs, virtually all centers (97% to 100%) reported transplantations for former smokers, whereas 59% of kidney, 62% of liver, and 33% of pancreas programs reported transplantations for current smokers. Organ programs reported similar rates of having smoking cessation programs (74% to 77%) and performing serum cotinine testing (31% to 38%). Smoking was an absolute contraindication to transplantation at 38% of kidney, 15% of liver, and 50% of pancreas programs. Programs with absolute contraindication policies were less likely to perform transplantations in current smokers and more likely to check serum cotinine levels, but no more likely to have smoking cessation programs. CONCLUSIONS: There is variation in tobacco use policies among abdominal organ transplant programs and centers. Balancing equity and justice when deciding which patients to waitlist requires an individualized approach to the tobacco-using patient, consideration of organ-specific factors, tobacco-related disease burden, and overall patient health. Such multifaceted assessments might be favorable to inflexible tobacco use policies.

Experience with everolimus.

Everolimus is a novel macrolide immunosuppressant that acts as a T-lymphocyte proliferation signal inhibitor. Its actions are complementary to and synergistic with those of the calcineurin inhibitors. Compared with sirolimus, everolimus has unique pharmacokinetic characteristics including greater bioavailability and a shorter half-life, allowing more rapid achievement of a steady state. Clinical experience to date, largely limited to use in kidney transplant patients receiving cyclosporine-based immunosuppression, indicates that administration of everolimus is associated with low rates of acute rejection and a tolerable safety profile. Recent observations in heart transplant patients suggest that the antiproliferative effects of everolimus may prevent allograft vasculopathy.

Lessons in emergency evacuation from the Miamisburg train derailment.

Hazardous materials incidents result from the release of materials considered to be harmful or potentially harmful to human beings or the environment. This article describes a train derailment and subsequent hazardous materials release with the evacuation of approximately 50,000 citizens. The hazardous materials release took five days to control and resulted in 561 patient visits to local emergency departments for symptoms related to chemical exposure. The evacuation and emergency medical operations are described and serve as a model for developing community emergency preparedness plans and managing victims involved in hazardous materials incidents.

Optimum Initial Inoculum Levels for Evaluation of Resistance in Tomato to Meloidogyne spp. at Two Different Soil Temperatures.

The effects of Meloidogyne incognita or M. javanica at five initial inoculum levels of 20, 100, 200, 1,000, and 2,000 eggs and infective juveniles per seedling on 'Floradade,' 'Nemarex,' 'Patriot,' and 'PI 129149-2(sib)-5' tomatoes maintained at 25 or 32.5 C were studied. The number of egg masses on roots of the susceptible cultivar Floradade was similar for both species of root-knot nematodes at either 2.5 or 32.5 C soil temperatures. At 25 C, very low numbers of egg masses were produced by both species of root-knot nematodes on Nematex, Patriot, and Lycopersicon peruvianum PI 129149-2(sib)-5. At 32.5 C, the best inoculum level for assessing resistance in these tomato genotypes was 200 eggs and infective juveniles per seedling. With 28 days of incubation, this temperature and inoculum level produced quantitative differences in resistance for both species of Meloidogyne.

Medical direction and EMS.

Excellent training and operating protocols will improve patient care, and that is the ultimate goal of the EMS system. Online communication is a valuable enhancement to written protocols and requires excellent reporting skills on both ends of the conversation.

Influence of African-American ethnicity on acute rejection after early steroid withdrawal in primary kidney transplant recipients.

BACKGROUND AND PURPOSE: The influence of African-American ethnicity on outcomes of kidney transplant recipients subjected to early steroid withdrawal remains controversial. Recent studies that suggest no higher risk among African Americans may be biased by recruitment of relatively small number of African Americans or by patient selection. We compared outcomes of African Americans to non-African Americans in a center in which early steroid withdrawal has become the standard of practice. METHODS: This was a single-center prospective study of 133 consecutive patients receiving primary kidney transplants between January 2006 and December 2008, followed for >or=3 months, and managed with a similar immunosuppression regimen that included induction antibody therapy, tacrolimus, mycophenolate mofetil, and withdrawal of steroids on postoperative day 5. Acute rejection and other outcomes were compared in African-American patients (n = 55) and compared with those of non-African-American patients (n = 78). RESULTS: During the first 12 months after early steroid withdrawal, African-American patients experienced a significantly higher cumulative incidence of acute rejection than non-African Americans (23.6% vs 7.7%; P = .020). Using multivariate logistic regression, ethnicity (odds ratio 3.33; P = .047) and HLA mismatch (odds ratio 1.44; P = .041) were significantly correlated with acute rejection independent of recipient age, gender, historical peak panel reactive antibody level (PRA) or PRA at time of transplant, time on dialysis, or donor source. CONCLUSIONS: African Americans are at increased risk of acute rejection after early steroid withdrawal, particularly when they receive kidneys from poorly matched donors.

Genotypic variation in carboxylation of tomatoes.

The gas exchange characteristics of 24 genotypes of Lycopersicon esculentum Mill. and one of L. minutum were measured with an infrared gas analyzer and dew point hygrometer in an open system. Net carbon exchange (NCE) and transpiration rate were measured at 50, 100, 150, and 300 mu1 1(-1) CO(2), and a regression of NCE versus internal lead [CO(2)] estimates was calculated. The slope of the regression curve at the CO(2) compensation point was used as the measure of carboxylation efficiency (CE). Significant genotypic differences for CE were obtained. Differences in CE did not appear to be due to differences in diffusive resistance defined as the sum of the boundary layer resistance (r(a)) and the stomatal plus cuticular resistance (r(1)). There was no correlation (r = -0.07) between (r(a) + r(1)) and CE. Within groups with nonsignificantly different means for (r(a) + r(1)) there were genotypes with extremes for CE.The zero CO(2) intercept has been used as an indication of photorespiration. Application of this method revealed a strong inverse relationship between CE and the intercept value, indicating either that photorespiration is related directly to CE or that this method is unreliable for estimating photorespiration. The fact that the variation in CE occurs at light saturation suggests that the observed differences in CE and rates of NCE are determined either by: (a) the concentration and/or kinetic properties of the photochemical reaction centers and associated electron transfer components as they affect the supply of NADPH and ATP and consequently the levels of Calvin cycle intermediates; or (b) the concentration and/or kinetic properties of ribulose 1,5-diphosphate carboxylase.

Physician at the scene of an emergency.

Growth and maturation in the delivery of prehospital emergency medical care has been dramatic in the past 15 years. The increased availability and use of emergency medical services (EMS) has led to more frequent interactions between providers of prehospital care and the medical practitioner. This paper reviews the training and capabilities of emergency medical personnel and introduces the issue of medical control at the scene of an emergency. Also presented are the basics of emergency scene and victim stabilization. Physicians can help improve prehospital care by becoming familiar with local EMS capabilities and personnel.