Assessing the value of ureteral stent placement in pediatric kidney transplant recipients.

BACKGROUND: Ureteral stent placement at kidney transplantation may reduce stenosis or leakage (S/L) complication rates. However, stent placement may also increase risk for early urinary tract infection (early UTI; <3 months after transplant) and BK virus allograft nephropathy (BKVAN). In children, the usefulness of stent placement is not well defined. METHODS: We analyzed retrospective data from children transplanted at our center for the three above outcomes in relation to stents. At our center, stent placement decision is driven by surgeon preference. RESULTS: Among 129 transplants from 1996 to 2006, early UTI was seen in 9.3% and S/L in 4.6%. By univariate analyses, stent placement was a significant risk factor for early UTI (P=0.0399) but not protective for S/L (P=0.23). In multivariate analyses, stent placement, human leukocyte antigen match, and bladder augmentation increased the odds ratio for early UTI. Only deceased donor source increased the odds ratio for S/L. In a truncated data set from 1999 to 2006, BKVAN occurred in 9 of 93 (9.6%). Per minute increase in warm ischemia time was the only significant risk factor for BKVAN by both univariate and Cox regression analyses. Stent placement did not improve graft survival (P=0.5726) but required general anesthesia for removal in the operating room, leading to additional cost and potential risk. CONCLUSION: Routine stent placement in children in this era of low urological complication rates and BKVAN needs reevaluation.

Ferguson v. Florida: rationally understanding competence to be executed?

The U.S. Supreme Court addressed competency to be executed in Ford v. Wainwright, holding that execution of the insane violates the Eighth Amendment. More than 20 years later, the Court defined this standard in its landmark decision in Panetti v. Quarterman. The Panetti ruling held that an inmate's factual awareness of the reasons for his execution was not sufficient to determine his competence. The Court advised that a prisoner must have a rational understanding of the reasons for his death sentence. The Panetti Court declined to establish specific competency criteria and acknowledged that rational understanding is difficult to define. Following Ford and Panetti, lower courts have struggled to apply the standards articulated in these two landmark cases. This struggle was recently highlighted in Ferguson v. Florida (2013), a case that received substantial attention and was decided by the Florida Supreme Court and the Eleventh Circuit Court. Ferguson featured majority and concurring opinions that, although consistent in their ultimate conclusions, expressed differing interpretations of their application of the Panetti standard. Although the Panetti Court declined to set a national standard for competency to be executed, Ferguson v. Florida is a cautionary reminder that more tangible guidelines are necessary for consistent application of a conclusion that cannot be revised.