Incidence rates and trends of hip/femur fractures in five European countries: comparison using e-healthcare records databases.

Hip fractures represent a major public health challenge worldwide. Multinational studies using a common methodology are scarce. We aimed to estimate the incidence rates (IRs) and trends of hip/femur fractures over the period 2003-2009 in five European countries. The study was performed using seven electronic health-care records databases (DBs) from Denmark, The Netherlands, Germany, Spain, and the United Kingdom, based on the same protocol. Yearly IRs of hip/femur fractures were calculated for the general population and for those aged ≥50 years. Trends over time were evaluated using linear regression analysis for both crude and standardized IRs. Sex- and age-standardized IRs for the UK, Netherlands, and Spanish DBs varied from 9 to 11 per 10,000 person-years for the general population and from 22 to 26 for those ≥50 years old; the German DB showed slightly higher IRs (about 13 and 30, respectively), whereas the Danish DB yielded IRs twofold higher (19 and 52, respectively). IRs increased exponentially with age in both sexes. The ratio of females to males was ≥2 for patients aged ≥70-79 years in most DBs. Statistically significant trends over time were only shown for the UK DB (CPRD) (+0.7% per year, P < 0.01) and the Danish DB (-1.4% per year, P < 0.01). IRs of hip/femur fractures varied greatly across European countries. With the exception of Denmark, no decreasing trend was observed over the study period.

Antidepressant prescribing in five European countries: application of common definitions to assess the prevalence, clinical observations, and methodological implications.

PURPOSE: Drug utilization studies have applied different methods to various data types to describe medication use, which hampers comparisons across populations. The aim of this study was to describe the time trends in antidepressant prescribing in the last decade and the variation in the prevalence, calculated in a uniform manner, in seven European electronic healthcare databases. METHODS: Annual prevalence per 10,000 person-years (PYs) was calculated for 2001-2009 in databases from Spain, Germany, Denmark, the United Kingdom (UK), and the Netherlands. Prevalence data were stratified according to age, sex, antidepressant type (selective serotonin re-uptake inhibitors [SSRIs] or tricyclic antidepressants [TCAs]) and major indications. RESULTS: The age- and sex-standardized prevalence was lowest in the two Dutch (391 and 429 users per 10,000 PYs) and highest in the two UK (913 and 936 users per 10,000 PYs) populations in 2008. The prevalence in the Danish, German, and Spanish populations was 637, 618, and 644 users per 10,000 PY respectively. Antidepressants were prescribed most often in 20- to 60-year-olds in the two UK populations compared with the others. SSRIs were prescribed more often than TCAs in all except the German population. In the majority of countries we observed an increasing trend of antidepressant prescribing over time. Two different methods identifying recorded indications yielded different ranges of proportions of patients recorded with the specific indication (15-57% and 39-69% for depression respectively). CONCLUSION: Despite applying uniform methods, variations in the prevalence of antidepressant prescribing were obvious in the different populations. Database characteristics and clinical factors may both explain these variations.

[Impact of transtympanic miniature endoscopy of the middle ear--a conceptual cadaver study]. / Wertigkeit der transmyringealen Mini-Endoskopie des Mittelohres--Eine konzeptionelle Kadaver-Studie.

OBJECTIVE: Endoscopic inspections of the middle ear have already been described. So far, the low optical quality due to the small diameter is limiting this type of procedure. In this study the use of a miniature endoscope for visualization of the middle ear structures has been evaluated. MATERIAL AND METHODS: 8 human cadaveric head specimens have been inspected. Following myringotomy, 2 miniature endoscopes were placed into the middle ear and the promontory, the incudostapedial joint, the round und oval window niche with stapes footplate were visualized and fotodocumentated. After endaural approach all middle ear structures were visualized microscopically and the quality of pictures was compared. Technical picture quality and anatomical visualization were evaluated by 5 ear surgeons. In addition, 2 interventional procedures were performed (control of ossicular chain mobility and intratympanic substance application). RESULTS: Still, the technical picture quality was significantly better for the microscope. The anatomical visualization of the middle ear structures with the miniature endoscope was not inferior compared to the microscope. The feasibility of additional interventions, e.g. control of ossicular chain mobility or intratympanic substance application could be shown. An inspection of the correct prosthesis position after tympanoplasty could be evaluated, too. CONCLUSION: This study showed that middle ear structures can be visualized by trans-tympanic miniature endoscopy equal or even better compared to conventional microscopy in spite of reduced technical quality.

[Laparoscopic recovery continuity after the Hartmann procedure]. / Die laparoskopische Wiederanschlussoperation nach Hartmann-Resektion.

In the period from January 2003 to June 2009 923 complex laparoscopic colorectal procedures were performed by one surgeon. Data was as­sessed prospectively in a database including 152 variables. In 15 patients (10 f, 5 m), with a median age of 61 years (range: 35-83 years), discontinuity resection of the colon was performed including 3 patients with open discontinuity resection of the sigma and 12 patients with laparoscopic Hartmann procedures. In all cases continuity of the ­colon was recovered laparoscopically. Median op­er­ation time was 100 min, conversion to an open procedure was not necessary. No intra-operative complications occurred and only one wound infection (6.6 %) was recorded postoperatively with a median postoperative stay of 8 days. Although the laparoscopic approach to recover continuity of the colon is technically challenging, we con­clude that the experienced bowel surgeon is able to perform the laparoscopic approach with a low morbidity and mortality by retaining the well known advantages of laparoscopic colonic sur­gery.

One-day or two-day procedure for sentinel node biopsy in melanoma?

PURPOSE: We compared the outcome of a 1-day and a 2-day sentinel node (SN) biopsy procedure, evaluated in terms of lymphoscintigraphic, surgical and pathological findings. METHODS: We studied 476 patients with melanoma from two melanoma centres using static scintigraphy and blue dye. A proportional odds model was used for statistical analysis. RESULTS: The number of SNs visualized at scintigraphy increased significantly with time from injection to scintigraphy and activity left in the patient at scintigraphy, and depended on the melanoma location. The number of SNs removed at surgery increased with the number of SNs visualized at scintigraphy and time from injection to surgery. The frequency of nodal metastasis increased with increasing thickness and Clark level of the melanoma, and was highest for two SNs visualized at scintigraphy. CONCLUSION: This study showed that early vs. late imaging and surgery do make a difference on the outcome of the SN procedure and confirmed the importance of the scintigraphic visualization of all true SNs.

[Ultrasonic scissors. New vs resterilized instruments]. / Ultraschallscheren. Neue vs. resterilisierte Einmalinstrumente.

BACKGROUND: The aim of this study was to compare reliability in handling and function of resterilized and single-use disposable ultrasonic scissors. METHODS: In a prospective randomized study, the surgeon blindly tested new and resterilized ultrasonographic scissors. The parameters were force of activation, cutting effect, coagulation effect, error messages, and disturbing generator noise. RESULTS: Fifty-one new and 49 resterilized instruments in 94 operations were evaluated. The differences in force of activation, cutting effect, and coagulation were not significant. Error messages and disturbing noises were rare in both groups. Six new instruments and two resterilized instruments had to be exchanged because of problems during surgery. CONCLUSION: This study demonstrates comparable reliability in function and handling of resterilized and new ultrasonic scissors. The use of resterilized instruments leads to distinctly reduced costs and could contribute to efficiency in laparoscopic surgery.

[Twenty years of experience with bariatric surgery in a general hospital]. / Entwicklung der Adipositaschirurgie am Krankenhaus der Maximalversorgung: Uber 20 Jahre Behandlungserfahrung.

BACKGROUND: Bariatric surgery has been performed since 1983 at the Bad Cannstatt Hospital near Stuttgart, Germany. The aim of this study was to investigate the development of bariatric surgery during the past 25 years. METHODS: Data were collected retrospectively. The parameters were number of surgical procedures, hospital stay, and postoperative complications. RESULTS: In the 25-year period 1,041 primary bariatric operations were performed. Open horizontal bypass and open vertical banded gastroplasty were performed initially. Starting in 2003 there was a change to laparoscopic procedures (gastric banding and Roux-en-Y bypass). The mean hospital stays were 14.7+/-5.1 days for open procedures and 6.7+/-4.2 days for laparoscopic methods, with 30-day mortalities of 0.8% and 0.0% and short-term complications at 16.9% and 7.8%, respectively. CONCLUSIONS: Perioperative complications and hospital stay were reduced by performing laparoscopic bariatric surgery. Our study emphasizes the advantages of the laparoscopic procedures which are standard at our hospital and fit in with the remaining operations in a department of visceral surgery.

[Minimally invasive robot-assisted gastric bypass after open Mason reduction gastroplasty]. / Minimal-invasive, roboterassistierte Magenbypassanlage nach offener Mason-Gastroreduktionsplastik.

BACKGROUND: The introduction of robot-assisted surgery in the treatment of morbidly obese patients has enlarged the armamentarium for surgeons involved in bariatric surgery. This article describes the experiences with a conversion surgery from a complicated open Mason gastroplasty to a Roux en Y gastric bypass using the da Vinci Xi robotic system. CASE: A 29-year-old female patient underwent a Mason reduction gastroplasty by laparotomy in 1995 (body mass index BMI 53.2 kg/m2). The course was complicated with a revision due to abscess formation and subsequent secondary healing. In 1996 an open revision of the gastroplasty due to persisting gastroesophageal reflux disease and outlet stenosis with dilatation of the outlet and an open cholecystectomy for cholecystolithiasis were performed . Abdominoplasty was performed for skin flaps in 2001 after the patient had lost 68 kg in weight. The patient presented at our hospital because of insufficient weight reduction even with weight gain since 2001 and treatment-refractive gastroesophageal reflux with adhesion problems. Clinical examination revealed normal scar tissue formation with no indications for an incisional hernia. The BMI was 48.2 kg/m2 with a body weight of 124 kg. The surgery was performed using a da Vinci Xi robotic system after access via a blunt dissection with the introduction of two trocars and adhesiolysis. The gastric pouch was created using Echelon 60 mm cartridges via an additional trocar. The gastroenterostomy was constructed with a 150 cm alimentary loop and a 60 cm biliodigestive loop resulting in a Roux en Y bypass. The operating time was 224 min. RESULTS: The postoperative course was uneventful. Enteral nutrition was resumed on day 2 and the patient was discharged from the hospital 4 days postoperation. CONCLUSION: This preliminary experience suggests that robotic revisional surgery can be performed safely even after complicated bariatric operations.

Neurotrophin-3, but not nerve growth factor, promotes survival of human intestinal mast cells.

Neurotrophins are potent regulators of neuronal cell survival and function. Nerve growth factor (NGF) was shown to reduce apoptosis in cord blood-derived mast cells. Here, we examined the effect of the neurotrophins NGF and neurotrophin (NT)-3 on survival and mediator release of human intestinal mast cells. Mast cells isolated from normal intestinal tissue were cultured in the presence of NGF, NT-3, or stem cell factor (SCF) alone or in the presence of SCF together with each neurotrophin. NGF or NT-3 alone did not promote mast cell survival. In contrast, mast cell recovery was increased twofold when mast cells were cultured with NT-3 in addition to SCF for 14 days compared with control. Mast cell recovery was further increased following a combined addition of NT-3, SCF and IL-4. NT-3 mediated mast cell growth was dependent on the primary receptor for NT-3 TrkC. NGF in combination with SCF or with SCF and IL-4 showed no effect on mast cell survival. Histamine release and histamine content per mast cell remained unchanged, whereas leukotriene C4 release decreased if mast cells were cultured with NGF or NT-3 in addition to SCF. In summary, NT-3 affects mature human mast cells by promoting mast cell survival, whereas NGF does not.

Influence of serum amylase and plasma glucose levels in pancreas cadaver donors on graft function in recipients.

In a series of 101 pancreas transplants from brain cadaver donors, serum amylase levels were determined preoperatively in 47 donors, and plasma glucose levels were monitored in 94 donors. Eighty-six percent of the donors died from head injury and 14% from asphyxia. No donors had a history of diabetes or pancreatitis, and the pancreas was grossly normal in all donors. Of the 47 cadaver pancreas donors in whom serum amylase levels were measured, the values of 20 donors were elevated (110-994 IU/L), and the values of 11 donors were greater than 300 IU/L. In 51 of 94 braindead cadaver pancreas donors in whom plasma glucose determinations were made, hyperglycemia was present (200-980 mg/dl). Early posttransplant pancreas-graft function was excellent in all recipients except for 5 patients in whom the grafts had to be removed for reasons not related to donor serum amylase and plasma glucose levels. Hyperamylasemia and hyperglycemia are probably not contraindications for cadaver pancreas organ donation unless overt pancreatic trauma, pancreatitis, or a history of diabetes is present.

Comparison of two methods of islet preparation and transplantation in dogs.

Seventy-nine mongrel dogs underwent total pancreatectomy. Fifteen dogs served as apancreatic controls and died 7.0 +/- 4.2 days later (mean +/- SD). The pancreases of 44 dogs (group 1) were intraductally distended by manual injection of Hanks' balanced salt solution (HBSS). Thereafter each organ was mechanically disrupted and subjected to collagenase digestion as described by Mirkovitch et al. The pancreases of 20 dogs (group 2) were intraductally distended and subsequently perfused with collagenase by a roller pump. The organs were then mechanically disrupted and filtered through screens as described by Horaguchi et al. The resulting tissue suspensions were injected into the spleens of the dogs as autotransplants in both groups, by direct punction of the splenic capsule in group 1 and by retrograde infusion via a splenic vein tributary in group 2. The functional outcome was better in group 2 than in group 1, as assessed by the number of animals that became normoglycemic after transplantation [15/20 (75%) vs. 13/44 (30%); P = .0025]. The degree of islet purification, as measured by an increase in the tissue insulin/amylase ratio, was higher in group 2, and in both groups it was higher in normoglycemic than in hyperglycemic animals. The percent engraftment [i.e., amount of insulin recovered from spleen as percent of tissue transplanted (mean, 15.4% in group 1 and 14.5% in group 2) or as percent of original pancreas (mean, 4.9% in group 1 and 4.4% in group 2)] was low in both groups but again was higher in normoglycemic than in hyperglycemic animals within each group. In conclusion, both the degree of engraftment and purification and the route of implantation influenced the functional outcome after dispersed pancreatic islet autotransplantation to the spleen of totally pancreatectomized dogs, with purified tissue injected retrogradely functioning better than unpurified tissue injected directly.

Life saving abdominal decompression in a patient with severe acute pancreatitis.

Severe acute pancreatitis can be complicated early in its course by life threatening conditions such as abdominal compartment syndrome. We report a patient who needed abdominal decompression three days after admission to the intensive care unit because of intra-abdominal hypertension and end stage organ dysfunction. The clinical course was protracted, but the patient survived and was discharged from the hospital.

Prospectively randomized trial using perioperative low dose octreotide to prevent organ related and general complications following pancreatic surgery and pancreatico-jejunostomy.

BACKGROUND: The aim of the study was to evaluate the influence of low dose perioperative Octreotide on the prevention of complications (pancreatic fistula and general complications) in patients undergoing pancreatic surgery followed by pancreatico-jejunostomy. MATERIAL AND METHODS: 105 patients were randomized to receive either Octreotide 0.1 mg subcutaneously 3 times/day for a total of 7 days or no Octreotide. The primary endpoints were the occurrence of a pancreatic fistula and/or general complications including the length of hospital stay. There were 25 surgical draining procedures performed and 80 duodeno-pancreatectomies with or without preservation of the pylorus. Twenty-six (24.8%) of the patients were treated for chronic pancreatitis, 8 (7.6%) for benign tumoral disease and 71 (67.6%) for carcinoma. All patients underwent pancreatico-jejunostomy. RESULTS: 56 patients received Octreotide and 49 did not. The incidence of fistula formation in the Octreotide group was 8.9% (n=5) and in the control group 8.2% (n=4) for a total incidence of 8.5%. The difference between the two groups was not statistically significant. There was one death in the Octreotide group and none in the control group for an overall mortality of 0.9%. The morbidity, except fistulas, was 10.7% in the Octreotide group and 12.2% in the control group. The length of hospital stay was 23.1 +/- 15.1 days in the group receiving Octreotide vs 20.4 +/- 8.1 days in the control group (p = 0.808). Stratifying the data for duodenopancreatectomy and for draining procedures there was no difference between the groups either. CONCLUSION: In patients undergoing pancreatic surgery and pancreatico-jejunostomy, the perioperative use of 3 x 0.1 mg Octreotide for 7 days does not reduce general complications nor fistula formation.

Cold preservation of the porcine pancreas with histidine-tryptophan-ketoglutarate solution.

BACKGROUND: Histidine-tryptophan-ketoglutarate (HTK) has been used for experimental and clinical cardiac, renal, and liver transplantation. No experience exists in either experimental or clinical pancreas transplantation. METHODS: In the present study, the solution was employed to flush segmental pancreatic grafts and to autotransplant the grafts after 24, 48, and 72 hr of cold storage in a porcine model. The results were compared to those obtained from animals receiving pancreatic grafts flushed and preserved with UW (University of Wisconsin) solution. RESULTS: A total of 10 landrace pigs received a graft stored with HTK solution for 24 hr, and 6 animals received a graft stored with UW solution for 24 hr. Daily blood glucose levels were normoglycemic (i.e., blood glucose < 150 mg/dl), and glucosuria was absent in all transplant animals. Intravenous glucose tolerance tests were comparable to two unoperated controls. Seven totally pancreatectomized, nontransplant diabetic controls exhibited daily hyperglycemia, glucosuria (i.e., > 1,000 mg/dl) and highly impaired intravenous glucose tolerance tests (mean K-values of -0.52+/-0.19 vs. -1.25+/-0.46 for HTK, -1.30+/-0.81 for UW, and -1.53+/-0.81 for controls, P-value vs. diabetic <0.01). The changes in wet weight between flushing and reperfusion were +2.22+/-2.84 g for HTK and -1.40+/-2.70 g for UW stored grafts (P=0.034). After 48 hr of storage with HTK, 4/17 grafts were functioning and 1/11 recipients of grafts stored with UW were normoglycemic. All grafts stored for 72 hr in either HTK (n=3) or UW (n=3) uniformly failed to render the recipients normoglycemic. CONCLUSIONS: It is concluded that preservation of segmental pancreatic autografts for 24 hr with HTK solution provides reliable graft function, as does preservation with UW solution associated with an increase in wet weight after HTK preservation. Cold preservation with HTK and UW is feasible for 48 hr; however, the success rate is equally reduced with HTK and UW solution. Cold storage for 72 hr in either HTK or UW solution results in uniform graft failure in this model.

Reduced incidence of acute renal graft failure in patients treated with peritoneal dialysis compared with hemodialysis.

In a case-control study performed in two centers, the incidence of delayed graft function (DGF), defined as the necessity to perform dialysis after transplantation, was analyzed according to prior treatment with continuous ambulatory peritoneal dialysis (CAPD; n = 117) or hemodialysis (HD; n = 117). The patients were matched for age, sex, HLA compatibility, and cold ischemia time. The patients were followed up for 6 months to monitor renal graft function (serum creatinine [Screa] level immediately after transplantation, at 6 weeks, at 6 months) and postoperative complications. No significant differences were found in the warm ischemia time of the graft or previous time on dialysis. DGF occurred in 27 CAPD patients (23.1%) and 59 HD patients (50.4%; P < 0.0001). The decline in Screa level after transplantation was faster in CAPD patients: the time for Screa level to decrease 50% after transplantation (T1/2Screa) was reached after 5.0 +/- 6.6 days in the CAPD group compared with 9.8 +/- 11.5 days in the HD group (P < 0.0001). A greater number of patients developed acute rejection episodes in the CAPD group (P < 0. 05), but Screa level was not different in the two groups 6 weeks and 6 months after transplantation. No differences were observed in infectious or surgical complications. This study shows that immediate renal function after transplantation is better in CAPD patients and that peritoneal dialysis should be considered as a first choice for pretransplantation therapeutic modality.

Alternative technique for creation of a proximal gastric pouch in laparoscopic adjustable silicone gastric banding.

BACKGROUND: Laparoscopic adjustable silicone gastric banding (LASGB) has become a widely used procedure for the treatment of morbid obesity. The original operation, as described by Kuzmak, has been subjected to modifications. Construction of a proximal gastric pouch is an important part of the operation. Until now, we used the technique of Niville. Since this was often complicated by gastric bleeding and/or serosal tears, we developed a new technique to construct a pouch. SURGICAL TECHNIQUE: A new technique, using a thread previously fixed to that portion of the fundus that will be used to construct the pouch, is described. CONCLUSION: A safe and easy adaptation of the LASGB technique is proposed to create the gastric pouch.

Retrospective analysis of laparoscopic gastric banding technique: short-term and mid-term follow-up.

BACKGROUND: Although adjustable gastric banding shows good results concerning weight loss, several complications such as excessive vomiting, total dysphagia, and slipping of the stomach through the band with pouch dilatation may occur rather frequently. Different types of adjustable bands are available to prevent these short- and mid-term complications. METHODS: In this retrospective study, 120 consecutive laparoscopic adjustable gastric bandings were performed. In group I, 50 patients were treated with adjustable silicone gastric banding (ASGB) by an intragastric balloon calibration technique. Group II (n = 29) received the same band by a surgical technique with tunneling behind the esophagus toward the angle of His. Group III (n = 41) received Swedish adjustable gastric banding (SAGB) by the same technique as in Group II. RESULTS: Weight loss was approximately 15% of the excess weight after 3 months, 30% after 6 months, and 45% after 12 months in all groups. Total dysphagia was significantly more frequent in Groups I and II. The incidence of slipping of the band and pouch dilatation was more frequent in Group II. CONCLUSION: The diameter of the ASGB band is rather small and can cause total dysphagia independently of surgical technique. The SAGB is easy to perform and seems less vulnerable to complications like dysphagia and slipping of the band, probably because of the individual adjustment of the stoma diameter during surgery and good fixation of both band and ventral pouch with separate posterolateral sutures.

Canine islet autografts with and without administration of cyclosporine.

Cyclosporine administration prolongs the survival of immediately vascularized allografts. However, its role in the prevention of rejection of dispersed pancreatic islet allografts is uncertain, and some studies have suggested that it may be harmful. We performed total pancreatectomies in 21 mongrel dogs, followed by intrasplenic autotransplantation of islet-enriched, dispersed pancreatic tissue prepared by means of ductal perfusion and collagenase digestion. Ten dogs received no other therapy (controls) and 11 received orally administered cyclosporine from the day before to 30 days after transplantation. Therapeutic blood levels of cyclosporine were documented by means of high-pressure liquid chromatography. There was no difference in engraftment in six of 10 controls, and eight of 11 cyclosporine-treated dogs remained normoglycemic for more than 30 days. Intravenous glucose tolerance test results (K values), fasting serum insulin levels, and insulin secretion in response to a glucose challenge were similar in the two groups. There were two late treatment failures in the control group and one in the cyclosporine-treated group. We were unable to detect an adverse effect of cyclosporine on the engraftment or function of canine islet autografts. We conclude that cyclosporine remains a promising drug for use in studies of islet transplantation in human beings.

Experience with 3, 6, and 24 hours' hypothermic storage of the canine pancreas before islet cell preparation and transplantation.

Canine pancreases underwent cold storage in Collins' solution (CS) or in silica gel-filtered plasma (SGF) for 3, 6, and 24 hours before collagenase digestion and autotransplantation of dispersed pancreatic tissue that contained islet cells to the spleens of totally pancreatectomized dogs. The functional outcome in these animals was compared with animals that received intrasplenically autotransplanted pancreatic islet cell preparations from unstored pancreases. Normoglycemia was restored in 15 of 20 (75%) dogs that received freshly prepared islets. Two of five dogs (40%) whose pancreases were stored in CS for 3 hours became normoglycemic, as did 2 of 5 dogs (40%) whose pancreases were stored for 3 hours in SGF. When 6-hour storage was used only 1 of 5 dogs (20%) whose pancreases were stored in CS and 1 of 5 dogs (20%) in whom SGF was used for storage became normoglycemic. Normoglycemia occurred in only 2 of 16 dogs (12.5%) whose pancreases were stored for 24 hours (one in SGF and one in CS). The results indicate that islet cell preparation should be performed immediately after pancreatectomy. The failure thus far of clinical islet allotransplantation may be due, at least in part, to functional deterioration during preservation of the donor pancrease before isolation of islet cells.

Pulmonary infections. The Minnesota randomized prospective trial of cyclosporine vs azathioprine-antilymphocyte globulin for immunosuppression in renal allograft recipients.

Nineteen of 224 renal allograft recipients who were prospectively randomized to receive either cyclosporine (n = 117) or azathioprine sodium-antilymphocyte globulin (n = 107) for immunosuppression suffered from one period of pneumonia (14 azathioprine and five cyclosporine recipients); two recipients of azathioprine had two episodes. Four patients in the azathioprine group and one in the cyclosporine group died, for mortalities of 3.7% and 0.85%, respectively. The percentage of pneumonia-free patients at one year was 96.3% in the cyclosporine group while it was 90.8% in the azathioprine group. Nondiabetics, women, and recipients of grafts from living related donors were at a statistically lower risk of developing pneumonia when treated with cyclosporine. Viral (cytomegalovirus), fungal (Candida, Aspergillus), and multibacterial causes of pneumonia each occurred with a similar incidence.