Use of Pulmonary Computed Tomography for Evaluating Suspected Stroke-Associated Pneumonia.

OBJECTIVES: Accurate and timely diagnosis of pneumonia complicating stroke remains challenging and the diagnostic accuracy of chest X-ray (CXR) in the setting of stroke-associated pneumonia (SAP) is uncertain. The overall objective of this study was to evaluate the use of pulmonary computed tomography (CT) in diagnosis of suspected SAP. MATERIALS AND METHODS: Patients with acute ischemic stroke (IS) or intracerebral hemorrhage (ICH) were recruited within 24h of clinically suspected SAP and underwent non-contrast pulmonary CT within 48h of antibiotic initiation. CXR and pulmonary CT were reported by two radiologists. Pulmonary CT was used as the reference standard for final diagnosis of SAP. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and diagnostic odds ratio (OR) for CXR were calculated. RESULTS: 40 patients (36 IS, 4 ICH) with a median age of 78y (range 44y-90y) and a median National Institute of Health Stroke Scale score of 13 (range 3-31) were included. All patients had at least one CXR and 35/40 patients (88%) underwent pulmonary CT. Changes consistent with pneumonia were present in 15/40 CXRs (38%) and 12/35 pulmonary CTs (34%). 9/35 pulmonary CTs (26%) were reported normal. CXR had a sensitivity of 58.3%, specificity of 73.9%, PPV of 53.8 %, NPV of 77.2 %, diagnostic OR of 3.7 (95% CI 0.7 - 22) and an accuracy of 68.5% (95% CI 50.7% -83.1%). DISCUSSION: CXR has limited diagnostic accuracy in SAP. The majority of patients started on antibiotics had no evidence of pneumonia on pulmonary CT with potential implications for antibiotic stewardship. CONCLUSIONS: Pulmonary CT could be applied as a reference standard for evaluation of clinical and biomarker diagnostic SAP algorithms in multi-center studies.

Elements of a successful hospital-based deceased donation programme in India: Zero to eighty-five in two years.

Background: Legislation has made organ donation after brain death (DBD) possible in India since 1994. However, no organs are donated in most parts of the country; the national organ donation rate is estimated at between 0.08 and 0.34 donors per million population-one of the lowest in the world. Methods: A 350-bedded private hospital in Kochi started its DBD programme in September 2013 with a structured approach based on counselling of family members of critically ill individuals. A counsellor trained to diagnose family dynamics, and recognize different stages of the grieving process, chose the right time, and the correct family member to whom the donation request could be made. Regular debriefing sessions of the core team consisting of a transplant surgeon, a transplant coordinator, an ICU counsellor and a unit administrator resulted in setting up systems that supported families of patients with catastrophic brain injury, and created an environment conducive to obtaining consent. Results: A total of 85 organ donations took place in the first 24 months (September 2013 to September 2015) of instituting the programme. Conclusion: It is possible with hospital-based teamwork and a structured approach to consistently elicit organ donation.

State-of-the-art management and monitoring of brain edema and intracranial hypertension in fulminant hepatic failure. A proposed algorithm.

AIM: Develop an evidence-based clinical algorithm integrating clinical decision making on intracranial pressure (ICP) monitoring and intracranial hypertension (ICH) management in the setting of fulminant hepatic failure (FHF). MATERIAL AND METHODS: An English-language literature review was conducted using the PubMed database in November 2007. In compiling evidence on current management trends of ICP and FHF, the paired keywords: fulminant hepatic failure and either mannitol, hypertonic saline, hyperventilation, bioartificial liver, hypothermia, indomethacin, thiopental, or propofol were used. In compiling evidence on ICP monitoring in FHF, the terms "intracranial pressure monitoring" and "liver failure" were used. Excluded references were either pertinent to animal research or irrelevant to ICP monitoring and ICH management in the setting of FHF. RESULTS: State-of-the-art management of ICH due to brain edema in FHF includes Class I therapies such as mannitol and hypertonic saline. Bioartificial liver, hypothermia and hyperventilation are supported by Class II evidence. Indomethacin and sedation remain Class III. Monitoring ICP is supported by Class II and III evidence. A clinical algorithm was created based on the existing therapeutic armamentarium and corresponding evidence support.

Alemtuzumab (Campath 1H) induction with tacrolimus monotherapy is safe for high immunological risk renal transplantation.

Immunosuppression for immunologically high-risk renal transplant patients usually involves antithymocyte globulin induction with triple drug maintenance therapy. Alemtuzumab, a humanized anti-CD52 antibody, has shown promise in tolerogenic induction protocols, requiring minimal maintenance immunosuppression. In this prospective, open-label, randomized, controlled trial, we enrolled 21 high immunological risk patients (i.e., panel reactive antibody>20% or previous transplant). Patients received either single-dose alemtuzumab given before graft reperfusion, with tacrolimus monotherapy, or four doses of Thymoglobulin with tacrolimus, mycophenolate, and steroids. Median follow-up was 377 days. One patient in the Thymoglobulin group who suffered primary graft nonfunction died. One-year cumulative graft survival was 85.7% for the alemtuzumab group and 87.5% for the Thymoglobulin group. Two alemtuzumab and three Thymoglobulin patients suffered rejection episodes. Infection rates were similar. Early results of this ongoing study indicate that a tolerogenic protocol with alemtuzumab induction and tacrolimus maintenance monotherapy is safe in immunologically high-risk renal transplant patients.

Hilar biliary cystadenocarcinoma: an uncommon hepatic neoplasm.

Biliary cystadenocarcinoma (BCAC) is a rare cystic tumour of the liver; with its benign counterpart, it accounts for <5% of non-parasitic hepatic cysts. Preoperative diagnosis of BCAC is difficult; complete surgical excision is recommended to prevent recurrence or metastasis. We present the case of a 67-year-female with centrally located BCAC involving the right hepatic duct and distorting the hepatic hilum. This report highlights the difficulties in diagnosis, surgical resection, subsequent biliary reconstruction and its outcome.

Pediatric en bloc kidney transplantation to adult recipients: more than suboptimal?

BACKGROUND: To optimize available organs, kidneys from young donors traditionally believed to be suboptimal are transplanted to adults. The purpose of this study is to compare graft survival (GS) of en bloc kidney (EBK) from young pediatric donors to other deceased donor transplants in adult recipients. METHODS: We analyzed United Network of Organ Sharing/STAR data on primary deceased donor kidney transplants to adult recipients (1988-2006). EBK (age younger than 5 years, n=1696) was compared with solitary pediatric (SP; age younger than 5 years) kidneys (n=1502), and matched standard adult donors (age 18-59 years, n=9594) and expanded criteria donor (ECD; n=6396). The adjusted GS was obtained using Cox proportional hazard model and hazard ratios were calculated. RESULTS: EBK had lowest acute rejection rates (6.0%) but similar to standard adult transplants (6.3%), and lower than SP and ECD (9.0% and 8.2%; P<0.0001). Delayed graft function rates were lowest in EBK (17.9%), highest in ECD (34.8%; P<0.0001), and similar among SP and standard adult transplants (24.4% and 24.2%). The estimated glomerular filtration rate (eGFR) was best in EBK and worst in ECD (P<0.0001). The eGFR of EBK and SP transplants continuously improved but the eGFR of standard adult and ECD declined. Graft loss was higher in EBK and SP transplants than adult donor transplants during the first 6 months. Despite the highest thrombosis rates in EBK (5.0%) (SP, 3.3%; standard adult, 1.8%; ECD, 2.0%, P<0.0001), GS of EBK became similar to standard adult donor transplants by 5 years and best at 10 years posttransplant (64.0%) and worst in ECD (39.6%; P<0.0001). CONCLUSION: EBK had the best long-term outcomes among deceased donor transplants and offer unique options for adult kidney transplant recipients.

Campath and renal transplant rejection.

No clear guidelines exist for the treatment of acute vascular rejection following renal transplantation. This report documents one patient who was treated with plasmapheresis, immunoglobulin and Campath with good initial response. However, rejection recurred resulting in graft loss and, in addition, the patient developed post-transplant lymphoma.

Domino as a bridge to definitive liver transplantation in a neonate.

An interim liver transplant was used to extend survival in a neonate. This was accomplished by the initial transplant of a left-lateral segment of a metabolically abnormal liver obtained from a 7-yr-old patient with primary oxalosis. This bridging strategy was required because our neonatal patient was dying of fulminant hepatic failure caused by hepatic vein thrombosis and a small liver or liver segment could not be found. Although problems with hyperoxaluria were encountered in the neonate post-transplant, the interim liver transplant enabled the baby to survive and grow until the age of 4 months. At that time, a definitive transplant was performed using the left-lateral segment of his mother's liver. This case represents the first reported use of a pediatric domino transplant where a metabolically abnormal liver was used to allow sufficient growth to permit a definitive liver transplantation.