Emotional regulation strategies (ER) used by trainees to overcome negative emotions.

OBJECTIVE: To identify the use of different emotion regulation strategies by medical trainees, and to determine the frequency and the predominant pattern of emotional response in emotion-triggering situations. METHODS: The descriptive cross-sectional study was conducted at 2 public and 1 private medical college in Lahore, Pakistan, from March to September 2019, and comprised postgraduate medical trainees of either gender from all clinical disciplines from years 1-4. Data was collected using a questionnaire based on the Gross theory of emotional regulation and the Situational model of emotion. Emotion regulation strategies included situation selection, situation modification, cognitive change, attention deployment, and response modulation. Data was analysed using SPSS 25.. RESULTS: Of the 377 trainees approached, 308(81.69%) participated; 206(67%) females and 102(33%) males. The overall mean age was 27.8 ± 2.91 years. The majority of the trainees were from the Obstetrics and Gynaecology department 133(43.2%) and were in the first year of their training 116(37.7%). The most frequent emotiontriggering situation identified was prolonged working hours 292(95%), and the major emotional response was quietness in 5 out of ten situations (50%). The trainees used greater emotion regulation strategies in sad situations 3.49±1.79 (p<0.01). Trainees managed sad emotions by keeping themselves involved in other activities 152 (49%); in anger, they blamed others 124(40.3%); in fear, they opted for suppression of emotions 71(22.7%); in disgust, they preferred avoidance 90(29.2%); and in shock, acceptance was a common strategy 21(12.7%). CONCLUSIONS: Postgraduate medical trainees struggled to manage emotions and used maladaptive strategies.

Placenta Accreta Spectrum Disorders: A. Chohan Continuous Squeezing Suture (ACCSS) for Controlling Haemorrhage from the Lower Uterine Segment at Caesarean Section.

Objectives: To describe the simplicity, efficacy and safety of A. Chohan Continuous Squeezing Suture (ACCSS) for controlling haemorrhage from the lower uterine segment at caesarean section for placenta praevia and accreta spectrum disorders. Methods: This prospective study was conducted on 47 patients with placenta praevia and accreta spectrum disorders from February 2019 to May 2022 in two teaching hospitals of Lahore and ACCSS was applied. The outcome measures were peripartum hysterectomy procedure time, estimated blood loss, number of blood transfusions, duration of stay in the hospital, bladder trauma, uterine necrosis, pelvic abscess formation, secondary postpartum haemorrhage and maternal mortality. Descriptive statistics were calculated by using SPSS version 21. Results: Out of 47 patients, 7 (15%) had placenta creta, 29 (61.7%) increta, 11 (23.3%) percreta (grade 3a), and 36 (76.6%) central anterior dominant placenta. Peripartum hysterectomy was prevented in 97.8% of patients. ACCSS procedure time was 5-10 minutes (87.2%), with mean blood loss 2500±485 ml, mean blood transfusion 1.85±1.02 units and mean hospital stay of 3.3±0.84 days. One patient had bladder trauma. There was no case of uterine necrosis, pelvic abscess formation, secondary postpartum haemorrhage or maternal mortality. Conclusion: ACCSS appears to be a simple, effective and safe treatment option for placenta praevia and accreta spectrum disorders, as an alternative to hysterectomy.

Steroid-free maintenance immunosuppression using alemtuzumab in pediatric kidney transplantation: Long-term longitudinal follow-up.

BACKGROUND: There is a scarcity of long-term data on steroid-free immunosuppression using alemtuzumab in pediatric kidney transplantation (KTx). This study examines long-term outcomes with alemtuzumab without steroid maintenance therapy in pediatric KTx. METHODS: From July 2005 to June 2015, 71 pediatric KTx recipients received alemtuzumab without steroid maintenance. They were followed from 4.1 to 14.1 years post KTx. RESULTS: Patient survival: One child expired with a functioning graft from post-transplant lymphoproliferative disorder (PTLD). Patient survival was 98.6%. Graft survival: Eighteen grafts were lost (16 from chronic rejection). Graft survival at 5 and 10 years was 92.3% and 61.3%, respectively. Rejection: Twenty-three (32.4%) patients were free from T-cell-mediated rejection (TCMR), 16 (22.5%) had >3 episodes. Sixteen (22.5%) were treated for antibody-mediated rejection (AMR). Infection: Twenty-three children developed Epstein-Barr virus (EBV), 5 developed cytomegalovirus (CMV), and 20 developed BK virus infection. Four (5.6%) developed PTLD. Twenty-two (31.0%) required treatment for neutropenia. Growth parameters: Mean height and weight increased by 0.56 and 0.69 SDS (standard deviation score), respectively. Body mass index increased by 5.1 kg/m2 at 10 years. Less than 40% required antihypertensive medications at all-time points. CONCLUSION: Alemtuzumab, without corticosteroid maintenance, offers 98.6% patient survival at 14 years with five and 10-year graft survival of 92.3% and 61.3%, respectively. TCMR and AMR requiring treatment were 67.4% and 22.5%, respectively. CMV, EBV, and BK viremia rates were 7.0%, 32.4%, and 28.2%, respectively. Thirty-one percent were treated for neutropenia; 5.6% developed PTLD. There were improvements in growth parameters and blood pressure.

Transmission of Balamuthia mandrillaris by Organ Transplantation.

BACKGROUND: During 2009 and 2010, 2 clusters of organ transplant-transmitted Balamuthia mandrillaris, a free-living ameba, were detected by recognition of severe unexpected illness in multiple recipients from the same donor. METHODS: We investigated all recipients and the 2 donors through interview, medical record review, and testing of available specimens retrospectively. Surviving recipients were tested and treated prospectively. RESULTS: In the 2009 cluster of illness, 2 kidney recipients were infected and 1 died. The donor had Balamuthia encephalitis confirmed on autopsy. In the 2010 cluster, the liver and kidney-pancreas recipients developed Balamuthia encephalitis and died. The donor had a clinical syndrome consistent with Balamuthia infection and serologic evidence of infection. In both clusters, the 2 asymptomatic recipients were treated expectantly and survived; 1 asymptomatic recipient in each cluster had serologic evidence of exposure that decreased over time. Both donors had been presumptively diagnosed with other neurologic diseases prior to organ procurement. CONCLUSIONS: Balamuthia can be transmitted through organ transplantation with an observed incubation time of 17-24 days. Clinicians should be aware of Balamuthia as a cause of encephalitis with high rate of fatality, and should notify public health departments and evaluate transplant recipients from donors with signs of possible encephalitis to facilitate early diagnosis and targeted treatment. Organ procurement organizations and transplant centers should be aware of the potential for Balamuthia infection in donors with possible encephalitis and also assess donors carefully for signs of neurologic infection that may have been misdiagnosed as stroke or as noninfectious forms of encephalitis.

Comparative efficacy of density gradient and swim-up methods of semen preparation in intrauterine insemination cycles.

OBJECTIVE: To see the efficacy of different methods of intrauterine insemination preparation for sperm recovery and conception rate. METHODS: This prospective observational study was carried out at Chohan Reproduction and Assisted Fertility Treatment Centre, Lahore, Pakistan, from January 2014 to July 2014, and comprised infertile couples undergoing intrauterine insemination cycles. Method of sperm preparation for intrauterine insemination during super-ovulation was randomly assigned for swim-up and density gradient techniques. Total sperm count, percentage recovery of motile sperm count, conception rate and cycle fecundity (live births, miscarriages, ectopic pregnancy) were measured.Mean percentages of sperm recovery and motility were compared. SPSS 21 was used for data analysis. RESULTS: Of the 220 couples who underwent 440 cycles, 138(62.7%) suffered from primary infertility and 82(37.27%) from secondary infertility. The mean age of women was 31.75±5.47 years, while that of men was 35.78±5.27 years. Mean duration of infertility in these couples was 5.50±3.51 years. Intrauterine insemination was performed at the first attempt in 180(81.8%) couples, at the second attempt in 37(16.8%) and at the third attempt in 3(1.3%) couples. Mean percentage of sperm motility in post-preparation of density gradient procedure was 83.88±15.02 (day 1) and 84.02±18.51 (day 2) while in swim-up procedure it was 91.02±11.85 (day 1) and 92.28±9.89 (day 2). Mean percentage of sperm concentration after processing in density gradient procedure was higher than swim-up (p=0.368 day 1; p=0.225 day 2) but mean percentage of sperm motility in post-preparation of density gradient procedure was less than swim-up procedure (p=0.000 day 1; p=0.000 day 2). Recovery rates in density gradient were 50.89% on day 1 and 5 13% on day 2compared to 36.69% on day 1 and 37.5%on day 2in swim-up technique (p=0.02). Conception rate was 15%. CONCLUSIONS: Despite the difference in percentage recovery of motile sperms in different techniques, cycle fecundity remained the same.

Semen analysis parameters: experiences and insight into male infertility at a tertiary care hospital in Punjab.

OBJECTIVE: To determine the prevalence of low sperm count including oligospermia and azoospermia in male infertile population, and to assess the pattern and distribution of abnormal semen parameters in infertile men. METHODS: The descriptive cross-sectional survey was carried out at the Department of Gynaecology and Obstetrics, Sharif Medical City Hospital, Lahore, from June 2009 to June 2010. A total of 500 consecutively consenting male partners of women fulfilling the inclusion criteria between 20 and 40 years of age were approached. Semen analysis was performed according to methods and standards defined by the World Health Organisation (WHO). Samples were categorised into normospermia, oligospermia and azoospermia on the basis of sperm count. After exclusion of azoospermic samples, normospermic and oligospermic samples were compared for ejaculated volume, pus cells, motility and morphology. SPSS 10 was used for statistical analysis. RESULTS: Out of the 500 males approached, 104 (20.8%) had to be left out either because of their unwillingness or inability to pass semen. The study sample comprised of 396 (response rate 79.2%); normospermia was observed in 293 (73.99%) males, azoospermia in 59 (14.89%), and oligospermia in 44 (11.11%). The oligospermic samples had low ejaculated volume, but significantly higher percentage of non-motile sperms 62% +/- 23.9% and abnormal morphology 55% +/- 15.6% in comparison to normospermic samples (p 0.0001). Asthenospermia was observed in 37 (25.81%), teratospermia in 11 (3.26%) and oligoasthenoteratospermia in 4 (9.09%) of samples. CONCLUSION: Semen analysis is the cornerstone for the evaluation of infertility in men. Sperm concentration, motility and morphology are related to each other, factors that cause deterioration of one of them usually also have negative impact on the other two as well.

Review of Sarcopenia and Testosterone Deficiency With Chronic Liver Disease and Postoperative Liver Transplant Utility of Short-Term Testosterone Replacement Therapy.

OBJECTIVES: Chronic liver disease is often associated with testosterone deficiency. However, testosterone replacement does not improve hepatic function or survival with diseased liver. So far, to our knowledge, testosterone replacement therapy after successful livertransplantforfunctional sarcopenia has not been studied. We had 3 goals: (1) define postoperative functional sarcopenia afterlivertransplant with serum testosterone level; (2) examine the role of short-term testosterone replacement therapy with active in-bed exercise of upper and lower extremity joints; and (3) correlate functional sarcopenia with skeletal muscle index and skeletal muscle density in relation to ascites, pleural effusion subtracted body mass index. MATERIALS AND METHODS: We evaluated 16 liver transplant recipients who had been receiving posttransplanttestosterone replacementtherapy with functional sarcopenia. Preoperative and postoperative demographics and laboratory and radiological data were retrieved; body mass index, skeletal muscle index, and skeletal muscle density were calculated. For this retrospective study, institutional review board approval was obtained before the electronic database was reviewed and analyzed. RESULTS: Mean testosterone level was 28.3 ng/dL (<5% of expected). Twelve patients received 1 dose, and the remaining 4 patients received >1 dose oftestosterone cypionate, 200 mg. Mean hospital stay was 26 days. Seven patients were discharged home, with the remaining patients to a rehabilitation facility or nursing home. One patient died from a cardiac event, and another patient died from recurrent metastatic malignancy. The 1-year and 5-year actuarial patient and graft survival rates were 93.8% and 87.5%, respectively. Overall, 5 patients were sarcopenic by skeletal muscle index, and 6 patients had poor muscle quality by skeletal muscle density. CONCLUSIONS: Testosterone deficiency after liver transplant exists with functional sarcopenia. Two- thirds of such recipients have low skeletal muscle index and/or have low skeletal muscle density. Short- term testosterone replacement therapy with in-bed active exercise provides 5-year patient and graft survival of 87.5%.

Navigating Kidney Transplantation in the Early Phase of Coronavirus Disease 2019: Screening Patients With Reverse Transcriptase Polymerase Chain Reaction and Low-Radiation-Dose Chest Computed Tomography.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic of 2020 changed organ transplantation. All elective cases at our institution were postponed for approximately 3 months. Centers for Medicare and Medicaid Services considers organ transplant surgery a Tier 3b case, along with other high acuity procedures, recommending no postponement. Our transplant program collaborated with our transplant infectious disease colleagues to create a protocol that would ensure both patient and staff safety during these unprecedented times. METHODS: The living donor program was electively placed on hold until we had the proper protocols in place. Preoperative COVID-19 testing was required for all recipients and living donors. All patients underwent a rapid nasopharyngeal swab test. After testing negative by nasopharyngeal swab, recipients also underwent a low-radiation-dose computed tomography scan to rule out any radiographic changes suggestive of a COVID-19 infection. RESULTS: We performed 8 living donor and 9 deceased donor kidney transplants. In comparison, we performed 10 living donor and 4 deceased donor transplants during the same time period in the previous year. Our testing protocol enabled efficient use of all suitable organs offered during the viral pandemic. No recipients or living donors tested positive or developed COVID-19. CONCLUSIONS: Creation of a viral testing protocol, developed in conjunction with our infectious disease team, permitted kidney transplantation to be performed safely, and the number of deceased donor transplants increased considerably without adversely affecting our outcomes.

Renal Protective Effect of Everolimus in Liver Transplantation: A Prospective Randomized Open-Label Trial.

Renal dysfunction is associated with poor long-term outcomes after liver transplantation. We examined the renal sparing effect of everolimus (EVR) compared to standard calcineurin inhibitor (CNI) immunosuppression with direct measurements of renal function over 24 months. METHODS: This was a prospective, randomized, open-label trial comparing EVR and mycophenolic acid (MPA) with CNI and MPA immunosuppression. An Investigational New Drug Application (IND # 113882) was obtained with the Food and Drug Administration as EVR is only approved for use with low-dose tacrolimus. Serum creatinine, 24-hour urine creatinine clearance, iothalamate clearance, Cockcroft-Gault creatinine clearance (CrCl), and Modification of Diet in Renal Disease estimated glomerular filtration rate were prospectively measured at 4 study visits. Nonparametric statistical tests were used for analyses, including the Mann-Whitney U test for continuous outcomes and Pearson's chi-square test for binary outcomes. Effect size was measured using Cohen's d. Patients also completed quality of life surveys using the FACT-Hep instrument at each study visit. Comparison between the 2 groups was performed using the Student t test. RESULTS: Each arm had 12 subjects; 4 patients dropped out in the EVR arm and 1 in the CNI arm by 24 months. Serum creatinine (P = 0.015), Modification of Diet in Renal Disease estimated glomerular filtration rate (P = 0.013), and 24-hour urine CrCL (P = 0.032) were significantly better at 24 months with EVR. Iothalamate clearance showed significant improvement at 12 months (P = 0.049) and a trend toward better renal function (P = 0.099) at 24 months. There was no statistical significance with Cockcroft-Gault CrCl. Adverse events were not significantly different between the 2 arms. The EVR group also showed significantly better physical, functional, and overall self-reported quality of life (P = 0.01) at 24 months. CONCLUSIONS: EVR with MPA resulted in significant long-term improvement in renal function and quality of life at 24 months after liver transplantation compared with standard CNI with MPA immunosuppression.

Improved freedom from rejection after a loading dose of sirolimus.

BACKGROUND: Sirolimus (SIR) in combination with cyclosporine reduces the incidence of acute rejection in renal transplant recipients. Limited data are available regarding SIR in combination with tacrolimus (TAC). METHODS: A single-center, retrospective review of renal transplant recipients receiving SIR, TAC, and corticosteroids postoperatively was conducted. A total of 118 consecutive renal transplant recipients were included on the basis of availability of day 1 SIR dose information. Seventy-seven patients received an SIR loading dose (SIR-LD) immediately posttransplantation, and 41 patients did not (SIR no loading dose [SIR-NLD]). RESULTS: The two groups showed similar demographic and transplant characteristics. SIR doses and trough levels were significantly higher in the SIR-LD patients at 1 and 7 days posttransplantation; however, no differences occurred beyond day 7. Patients receiving an SIR-LD experienced significantly better freedom from rejection at 1, 3, and 6 months posttransplantation (P<0.05). This rejection benefit in the SIR-LD group was independent of donor source and use of antibody induction. SIR-LD patients experienced fewer serious infections (12% SIR-LD vs. 27% SIR-NLD, P=0.04) and a lower incidence of delayed graft function (21% SIR-LD vs. 39% SIR-NLD, P<0.05). No significant differences in serum creatinine, hemoglobin, and platelet counts occurred in the first 180 days posttransplantation, but the patients in the SIR-NLD group experienced lower hemoglobin levels at day 30 than those in the SIR-LD group (10.8 g/dL SIR-LD vs. 9.7 g/dL SIR-NLD, P=0.03). CONCLUSION: SIR-LD significantly improves early posttransplantation freedom from rejection in renal transplant recipients without increasing other complications.