Patient perception of pre-pregnancy care and family planning among reproductive-age female diabetes mellitus patients in a primary care clinic in Penang, Malaysia.

INTRODUCTION: Pre-pregnancy care (PPC) is an important part of diabetic care among females in the reproductive age group, as it improves feto-maternal outcomes. OBJECTIVE: We aimed to assess female diabetic patients' perception of PPC and family planning prior to PPC care. METHODS: This was an observational, cross-sectional survey performed from June 2019 to September 2019, using universal sampling of registered female diabetic patients who fit the inclusion criteria prior to integrated PPC care. A self-administered questionnaire was used to assess patients' perception of PPC. RESULTS: A total of 67 patients were recruited for the study. Only 39.4% (n=26) of the patients had heard of PPC. In our study, Code 1 contraception included those methods with a Pearl index of ≤9. Code 2 & 3 contraception included those methods with a Pearl index of >9. Only one-third of patients, 29.9% (n=20), were using Code 1 contraception, although the majority, 79.1% (n=53), felt that they had completed their family. 45 patients (68.2%) felt that they were at risk of developing complications if they were to become pregnant, and 46 patients (69.7%) felt that their health condition was not suitable for another pregnancy. However, only 31.1% (n=14) and 34.8% (n=16) of these patients were using Code 1 contraception, respectively. There were 30 patients (65.2%) who perceived that their health was not suitable for another pregnancy but were only using Code 2 or 3 contraception. CONCLUSION: The patients' perception of PPC was poor. Patients had an inadequate knowledge of the effectiveness of their current contraceptive practice in relation to their intentions for further pregnancy and their self-perceived risk in case of future conception. We suggest that integration of PPC into routine follow-ups for other high-risk medical diseases, such as hypertension, heart disease, and epilepsy, be considered in future practice.

Biomarkers of Tolerance in Kidney Transplantation: Are We Predicting Tolerance or Response to Immunosuppressive Treatment?

We and others have previously described signatures of tolerance in kidney transplantation showing the differential expression of B cell-related genes and the relative expansions of B cell subsets. However, in all of these studies, the index group-namely, the tolerant recipients-were not receiving immunosuppression (IS) treatment, unlike the rest of the comparator groups. We aimed to assess the confounding effect of these regimens and develop a novel IS-independent signature of tolerance. Analyzing gene expression in three independent kidney transplant patient cohorts (232 recipients and 14 tolerant patients), we have established that the expression of the previously reported signature was biased by IS regimens, which also influenced transitional B cells. We have defined and validated a new gene expression signature that is independent of drug effects and also differentiates tolerant patients from healthy controls (cross-validated area under the receiver operating characteristic curve [AUC] = 0.81). In a prospective cohort, we have demonstrated that the new signature remained stable before and after steroid withdrawal. In addition, we report on a validated and highly accurate gene expression signature that can be reliably used to identify patients suitable for IS reduction (approximately 12% of stable patients), irrespective of the IS drugs they are receiving. Only a similar approach will make the conduct of pilot clinical trials for IS minimization safe and hence allow critical improvements in kidney posttransplant management.

A prospective cohort study of risk prediction in simultaneous pancreas and kidney transplantation.

INTRODUCTION: Current risk prediction scoring systems in pancreas transplantation are limited to organ factors and are specific to predicting graft outcome. They do not consider recipient factors or inform regarding recipient morbidity. The aim of this study was to assess the utility of commonly used general surgical risk prediction models (P-POSSUM [Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity], MODS [multiple organ dysfunction score], Charlson co-morbidity index, revised cardiac risk index, ASA [American Society of Anesthesiologists] grade and Waterlow score), and to correlate them with total length of hospital stay (LOS) and critical care unit (CCU) LOS, important surrogate markers of patient outcome. METHODS: All risk prediction scores were calculated prospectively for all simultaneous pancreas and kidney (SPK) transplant recipients from November 2011 to October 2013, and correlated with outcome measures. RESULTS: Overall, 57 SPK transplant recipients were analysed. The mean age was 42.0 years (standard deviation [SD]: 7.60 years), 27 (52%) were male and the mean body mass index was 25.43kg/m(2) (SD: 3.11kg/m(2)). The mean pancreas and kidney cold ischaemic times were 703 minutes (SD: 182 minutes) and 850 minutes (SD: 192 minutes) respectively. The median total LOS and mean CCU LOS was 17 days (range: 8-79 days) and 7 days (SD: 4.04 days) respectively. When correlated with risk prediction scores, Waterlow score was the only significant predictor of total LOS and CCU LOS (p<0.001 [Spearman's correlation] and p=0.001 [Pearson's correlation] respectively). CONCLUSIONS: Preoperative risk prediction plays an important part in planning perioperative care. To date, no validated risk prediction scoring system exists for SPK transplantation. This prospective study indicates that Waterlow score identifies high risk individuals and has value in the prediction of outcome following SPK transplantation.

Outcomes of methicillin-resistant Staphylococcus aureus infection after kidney and/or pancreas transplantation.

BACKGROUND: The true extent of Methicillin-Resistant Staphylococcus aureus (MRSA) colonization and incidence of infection after solid organ transplantation in adults and children is not well-known. The aim of this study was to evaluate the incidence and the outcomes of MRSA infection following kidney and/or pancreas transplantation. MATERIAL AND METHODS: We reviewed the case notes of all patients who developed MRSA colonization and infection within the first year of transplantation between September 2002 and December 2009. The primary endpoint of this study was mortality. The secondary endpoints included morbidity, graft failure, and length of hospital stay. RESULTS: During the study period 1116 transplantations were performed. MRSA colonization was detected in 14 patients (1.25%) and infection occurred in 6 cases (0.53%) post-transplantation. Graft failure was not associated with MRSA colonization/infection in any of the cases. The mortality rate attributed to MRSA was 10% (n = 2). The overall median length of stay was 16 days (range, 6-243 days). CONCLUSIONS: Our study demonstrates that the prevalence of MRSA colonization and infection in our unit is low in spite of immunosuppression. The incidence of MRSA infection was higher among patients who underwent pancreas transplantation. Patients who had MRSA colonization and then developed infection had higher morbidity and mortality rates.

Outcomes of patients who develop symptomatic Clostridium difficile infection after solid organ transplantation.

Clostridium difficile-associated diarrhea is the most common cause of hospital-associated diarrhea in the UK. Infection can produce a spectrum of manifestations from mild diarrhea to toxic megacolon, colonic perforation, and death. The aim of this study was to evaluate the outcomes of patients who developed symptomatic Clostridium difficile infection (CDI) within the first year after solid organ transplantation. Between 2004 and 2007, we performed 682 transplantation: 433 from deceased-donor kidney, 143 live-donor kidney, 18 pancreas-only, and 88 simultaneous kidney and pancreas transplants. Within the first year of transplantation, 24 patients developed symptomatic CDI. No single risk factor or antimicrobial agent was associated with acquiring infection. Among this group, 2 patients developed toxic megacolon requiring subtotal colectomy and recovered. Although 5 patients who developed CDI died within the first year, CDI was not the primary cause of death. The overall mortality of patients who developed CDI within the first year of transplantation accounted for 0.7% of all transplanted patients. Increased awareness of CDI and barrier nursing can minimize the impact of CDI on the morbidity and mortality associated with transplantation. Patients should be informed of the risk of CDI during consenting for transplantation, because the 3.5% incidence is more common than that of graft loss due to thrombosis.

The outcomes of living donor renal transplants with multiple renal arteries: a large cohort study with a mean follow-up period of 10 years.

BACKGROUND: Living donor kidney transplants with multiple arteries are presumed to be associated with an increased risk of complications. OBJECTIVES: The aim of the study was to compare the outcomes in living donor transplantation with the specific intention of comparing long-term outcomes in which the donor kidney had 1 or more renal arteries. The study was undertaken in 2 large transplant centers. METHODS: A retrospective analysis of 201 living donor kidney transplants with multiple arteries that were performed between January 1985 and December 2004 was undertaken. We recorded patient and graft survivals, urological and vascular complications. Kaplan-Meier survival estimates were calculated, and 2-tailed Student t-test was used to compare outcomes. P < .05 was considered statistically significant. RESULTS: Graft and patient survival at 1 year were 93% and 97% and at 5 years were 87% and 92%. The most common complications were vascular (8.9%), followed by urological (6%), acute tubular necrosis (5.5%), and posttransplant hypertension (4.0%). There was significantly higher incidence of acute tubular necrosis (ATN) in multiple-artery transplants. CONCLUSION: In this large cohort of patients studied, apart from a higher incidence of ATN and vascular complications, it appears that the number of renal arteries did not have any adverse impact on the outcomes. The findings from this study suggest that live donor kidneys with multiple renal arteries can be safely utilized for renal transplantation.

Staged enteric conversion after duodenal necrosis in simultaneous kidney and pancreas transplant from a donor after cardiac death: a case report.

Simultaneous pancreas and kidney transplantation (SPK) is the treatment of choice for insulin-dependent diabetics with end-stage renal failure. The shortage of suitable pancreata has led to the use of donors after cardiac death (DCD). Although more than 20,000 pancreas transplants have been performed worldwide, the experience of pancreas transplantation from DCD remains limited. Factors during recovery, storage, and reperfusion may result in injury to the duodenal segment of the pancreas allograft. Here we have reported a case of duodenal necrosis after reperfusion in a patient who underwent SPK from a DCD. The pancreas was salvaged by excising the duodenum and performing a direct pancreas duct to bladder anastomosis. After recovery of function by the transplanted kidney, the patient developed recurrent urinary sepsis. The bladder-drained pancreas was converted to a direct enteric drainage, which resolved the recurrent urinary sepsis.

Methicillin-resistant Staphylococcus aureus infection in vascular surgical patients.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) infection is emerging as a major problem in vascular surgical practice. The aim of this study was to review the management of patients with MRSA infection complicating vascular surgical operations. METHODS: Data were obtained from the vascular audit, case notes, intensive therapy unit (ITU) notes, high dependency unit (HDU) notes and microbiological records of patients who underwent either arterial reconstruction (n = 464) or limb amputation (n = 110) between April 1994 and October 1998. RESULTS: Forty-nine vascular surgical patients developed clinical MRSA infection (9%). Clinical MRSA infection in patients who had undergone aorto-iliac reconstruction (n = 18) was associated with a 56% mortality (n = 10) and the most common infections were bacteraemia (55%) and pneumonia (50%). MRSA infection occurred in 17 patients who had undergone infra-inguinal bypass and was associated with a 29% mortality (n = 5). The most common site of MRSA infection was the groin wound (76%) leading to anastomotic dehiscence and death in one patient (11%) and necessitating wound debridement in 4 patients (22%). MRSA infection of the groin wound in the presence of a prosthetic graft (n = 3) led to anastomotic dehiscence in 2 patients, and graft excision in 2 patients. Similar complications were not observed in the presence of an underlying autogeneous long saphenous vein graft (n = 16). MRSA infection following major lower limb amputation (n = 14) was associated with death in 5 patients (36%). Wound infection in 10 amputees (71%) led to revision of the amputation to a higher level in 2 (14%) and wound debridement in 2 (14%). CONCLUSIONS: MRSA infection has a high mortality in vascular surgical patients in general, and following aorto-iliac reconstruction in particular. Autogeneous vein may confer some protection against local complications following groin wound infection. Strategies aimed at reducing the incidence of infection, including strict adherence to infection control procedures, may reduce the severity of this problem.

Prevention of renal impairment following aortic cross-clamping by manipulation of the endogenous renal nitric oxide response.

OBJECTIVE: Infrarenal aortic cross-clamp-induced lower torso ischaemia-reperfusion injury is associated with impairment of glomerular filtration rate and upregulation of endogenous renal nitric oxide production. The aim of this study was to investigate whether manipulation of the endogenous renal nitric oxide response can ameliorate subsequent renal injury. METHODS: Groups of male Wistar rats (n = 6) were treated with one of the following agents before being subjected to 60 min of infrarenal aortic cross-clamping: saline (control), L-NMMA (a pan nitric oxide synthase inhibitor), 1400W (a highly selective iNOS inhibitor), hydrocortisone (an inhibitor of the systemic inflammatory response), L-arginine (the substrate for nitric oxide synthase) and NOC-18 (a nitric oxide donor). Animals were recovered after a left nephrectomy. The glomerular filtration rate (GFR) of the remaining kidney was measured on the second and seventh postoperative day using a 99Tc DPTA clearance technique as an index of renal injury. RESULTS: Animals treated with L-NMMA prior to aortic cross-clamping had a significantly impaired GFR compared to controls on the second (p<0. 01, Mann-Whitney U -test) and seventh (p<0.05, Mann-Whitney U -test) postoperative day. Hydrocortisone and 1400W had no significant effect on GFR on the second or seventh postoperative day. L-arginine and NOC-18 had no influence on GFR on the second postoperative day but significantly improved GFR on the seventh postoperative day. CONCLUSIONS: These results show that the endogenous nitric oxide response protects the kidneys from ischaemia-reperfusion injury. Manipulation of the renal nitric oxide response may have therapeutic benefits to patients undergoing aortic aneurysm repair by preventing acute renal failure.

Pulmonary nitric oxide metabolism following infrarenal aortic cross-clamp-induced ischaemia-reperfusion injury.

OBJECTIVES: to investigate endogenous pulmonary nitric oxide metabolism following infrarenal aortic cross-clamp-induced ischaemia-reperfusion injury. METHODS: groups of male Wistar rats (n=6) were subjected to 60 minutes of infrarenal aortic cross-clamping under general anaesthesia. Rats were culled after 0, 60 and 120 minutes>> reperfusion, following release of the aortic clamp. A sham-operated control group was also studied. Acute lung injury (ALI) was quantified by measuring the protein concentration in lung bronchoalveolar lavage (BAL) fluid. Pulmonary myeloperoxidase activity (MPO) was measured as an index of neutrophil infiltration and degranulation in the lung. Plasma tumour-necrosis factor-alpha (TNF-alpha) was measured as an index of the pro-inflammatory cytokine response and pulmonary nitric oxide synthase (NOS) activity was determined by measuring conversion of(3)H L-arginine to(3)H L-citrulline in tissue homogenates. RESULTS: these data show significant ALI with increased pulmonary microvascular permeability and MPO activity in animals subject to 60 minutes>> ischaemia and 60 minutes or 120 minutes of reperfusion compared to control animals (p<0.01). Plasma TNF-alpha levels were significantly increased following 60 minutes of ischaemia compared to controls (p<0.01) and remained significantly increased in animals subject to reperfusion (p<0.01). Pulmonary NOS activity was significantly increased in animals subject to reperfusion (p<0.01). CONCLUSIONS: the reperfusion phase of infrarenal aortic cross-clamping provokes a significant increase in pulmonary NOS metabolism. The increase in plasma TNF-alpha and MPO activity suggests that this response may be secondary to inducible NOS expression. Manipulation of this response may benefit patients at risk of acute injury following infrarenal aortic reconstruction.

Endogenous renal nitric oxide metabolism following experimental infrarenal aortic cross-clamp-induced ischaemia-reperfusion injury.

BACKGROUND: Abdominal aortic surgery is associated with marked changes in renal haemodynamics. The aim of this study was to investigate the influence of infrarenal cross-clamping on glomerular filtration rate and endogenous renal nitric oxide metabolism. METHODS: Groups of male Wistar rats were subjected to infrarenal aortic cross-clamping followed by reperfusion. Animals were allowed to recover after a left nephrectomy. The glomerular filtration rate of the remaining kidney was measured on the second and seventh day after the procedure before the animal was killed and the remaining kidney harvested. Total nitric oxide synthase (NOS) activity and expression of inducible NOS (iNOS) was determined in renal tissue following 1 h and 7 days of reperfusion. RESULTS: Glomerular filtration rate was impaired on the second and seventh day after operation in all animals subjected to lower torso ischaemia compared with controls (P < 0.05). Renal NOS activity was increased at 1 h and 7 days in animals subjected to infrarenal cross-clamping compared to controls (P < 0.01). iNOS was detected in renal tissue of animals subjected to infrarenal aortic cross-clamping on the seventh day after operation. CONCLUSION: Infrarenal aortic cross-clamping is associated with impairment of renal function in the early postoperative period. There is an increase in endogenous renal nitric oxide metabolism with iNOS expression. Presented in part to the Surgical Research Society, Dublin, Ireland, July 1998

Non-cardiogenic pulmonary oedema in vascular surgery.

Non-cardiogenic pulmonary oedema, an early manifestation of the adult respiratory disease syndrome, is a serious complication following major vascular surgery. Hypovolaemia, ischaemia-reperfusion injury, massive blood transfusion, transient sepsis and transient endotoxaemia are insults responsible for initiating the process in vascular surgical patients. Free radicals, cytokines and humoral factors released secondary to the above insults activate neutrophils and facilitate their interaction with the endothelium. Activated neutrophils marginate through the endothelium where they are responsible for tissue injury by the release of free-radicals and proteases. The lungs are a large reservoir of neutrophils and bear a significant part of the injury. Conventional therapy includes treating the underlying condition and providing respiratory support. A better understanding of the pathophysiology of this process has led to new experimental treatment options. Novel therapeutic interventions have included the use of compounds to scavenge free radicals, anti-cytokine antibodies, extracorporeal lung support, nitric oxide and artificial surfactant therapy. The multifactorial nature of this process makes it unlikely that a single "magic bullet" will solve this problem. It is more likely that a combination of preventative, prophylactic and therapeutic modalities may reduce the mortality of this condition.

The role of screening blood tests in patients with arterial disease attending vascular outpatients.

OBJECTIVE: To evaluate the benefits of a policy of performing screening blood tests in new patients with arterial disease referred to the vascular outpatients department. METHODS: Clinical audit over a 12-month period of all new referrals with arterial disease to the vascular outpatients department at the Leicester General Hospital. RESULTS: Two hundred and seventy-two patients had at least one blood test performed at their outpatient visit. All of these patients had a full blood count performed, of which 21 results (21%) were abnormal. Further investigation of patients with abnormal results revealed one case of bladder cancer, one case of leukaemia and one patient with polycythaemia. Urea and electrolytes were measured in 269 patients (99%). Of these, 26 (10%) were expectedly abnormal in patients with known renal impairment. A further 27 patients (10%) were identified to have some degree of unrecognised renal impairment. Serum non-fasting glucose was measured in 252 patients (93%). There were 11 unexpectedly raised results, but further investigation of these patients only diagnosed one of these patients as diabetic. Serum cholesterol was measured in 201 patients (74%). One hundred and thirty-two patients (66%) had an abnormally raised serum cholesterol level. Of these, only 12 patients (6%) were known to have hyperlipidaemia. CONCLUSIONS: Screening new patients with arterial disease in vascular outpatients does identify significant abnormalities, in particular renal impairment and hyperlipidaemia. Correction of these abnormalities may reduce the morbidity associated with contrast induced nephrotoxic acute renal failure, and also contribute to secondary prevention of vascular events associated with raised lipids.