Quality of comprehensive assessment among severely ill TB patients referred after triaging in southern India.

To reduce TB deaths, Tamil Nadu, a southern Indian state, implemented the first state-wide differentiated TB care strategy starting April 2022. Triage-positive severely ill patients are prioritised for comprehensive assessment and inpatient care. Routine program data during October-December 2022 revealed that documentation of total score after comprehensive assessment was available in only 39%, possibly indicating poor quality of comprehensive assessment. We confirmed this using operational research. The case record form to record comprehensive assessment was used only in 26% and among these, the completeness and correctness in filling out the form were sub-optimal. There is a clear need to enhance the quality of comprehensive assessments.

Depuis avril 2022, le Tamil Nadu, un État du sud de l'Inde, a mis en œuvre la première stratégie de soins différenciés pour la TB à l'échelle de l'État afin de réduire le nombre de décès dus à la TB. Les personnes gravement malades ayant obtenu un résultat positif au triage sont prioritaires pour une évaluation complète et des soins hospitaliers. Les données du programme de routine entre octobre et décembre 2022 ont révélé que la documentation du score total après l'évaluation complète n'était disponible que dans 39% des cas, ce qui pourrait indiquer une mauvaise qualité de l'évaluation complète. Nous l'avons confirmé par le biais d'une recherche opérationnelle. Le formulaire de dossier pour enregistrer l'évaluation complète n'a été utilisé que dans 26% des cas et, parmi ceux-ci, l'exhaustivité et l'exactitude du remplissage du formulaire n'étaient pas optimales. Il est manifestement nécessaire d'améliorer la qualité de l'évaluation complète.

Effect of calcined clay on the improvement of compaction, swell and microstructural characteristics of expansive soil.

Expansive soil is problematic soil because its alternate swell shrink behaviour depends on the presence of water. Soil stabilization technique was widely adopted to alter the characteristics of the expansive soil which is suitable for construction. Among the various soil stabilization techniques, chemical stabilization was found to be more suitable method of sustainable stabilizing the soil due to its effective and timely reaction with the chemical compound. Calcined form of clay material is used as an admixture to study the effects on the improvement of soil properties. Calcined Clay (CC) is added into the virgin soil with different percentages of 2%,4%,6%,8% and 10% under varying 1,3,7,14,28 and 60 days of curing by conducting experiments such as standard proctor test, Free Swell test to analyse the compaction characteristics and swelling behaviour of the soil. In addition to that the X-Ray Diffraction (XRD) and Scanning Electron Microscope (SEM) on virgin and treated soil were studied by varying 2% incremental of CC up to 10% at 28 days of curing. From the test results it shows the variation in the compaction characteristics by rising in Maximum Dry Density (MDD) and reduction in Optimum Moisture Content (OMC) that merges at 8% as an optimum to develop the soil behaviour and from the free swell test, it was found that the Free Swell Index (FSI) of the soil decrease from 210 to 80 at 10% calcined clay added soil and the Mineralogical studies also show the variation in the compounds. Thus, this naturally available calcined clay was used to improve the soil Compaction and swell characteristics that influences the reduction in deformation and increase in shear strength of soil which helped to minimize the environmental problem as well as one of the effective admixtures to improve the expansive soil characteristics.

Experimental safety testing shows that the NSAID tolfenamic acid is not toxic to Gyps vultures in India at concentrations likely to be encountered in cattle carcasses.

Population declines of Gyps vultures across the Indian subcontinent were caused by unintentional poisoning by the non-steroidal anti-inflammatory drug (NSAID) diclofenac. Subsequently, a number of other NSAIDs have been identified as toxic to vultures, while one, meloxicam, is safe at concentrations likely to be encountered by vultures in the wild. Other vulture-safe drugs need to be identified to reduce the use of those toxic to vultures. We report on safety-testing experiments on the NSAID tolfenamic acid on captive vultures of three Gyps species, all of which are susceptible to diclofenac poisoning. Firstly, we estimated the maximum level of exposure (MLE) of wild vultures and gave this dose to 40 Near Threatened Himalayan Griffons G. himalayensis by oral gavage, with 15 control birds dosed with benzyl alcohol (the carrier solution for tolfenamic acid). Two birds given tolfenamic acid died with elevated uric acid levels and severe visceral gout, while the remainder showed no adverse clinical or biochemical signs. Secondly, four G. himalayensis were fed tissues from water buffaloes which had been treated with double the recommended veterinary dose of tolfenamic acid prior to death and compared to two birds fed uncontaminated tissue; none suffered any clinical effects. Finally, two captive Critically Endangered vultures, one G. bengalensis and one G. indicus, were given the MLE dose by gavage and compared to two control birds; again, none suffered any clinical effects. The death of two G. himalayensis may have been an anomaly due to i) the high dose level used and ii) the high ambient temperatures at the time of the experiment. Tolfenamic acid is likely to be safe to Gyps vultures at concentrations encountered by wild birds and could therefore be promoted as a safe alternative to toxic NSAIDs. It is manufactured in the region, and is increasingly being used to treat livestock.

A Modified Laparoscopic Technique for the Removal of Nonfragmentable Giant Gastric Trichobezoar.

Bezoars are usually defined as collections of nondigestible matter that most commonly accumulates in the stomach and can sometimes extend to the small bowel. Trichobezoars are a rare entity which is most commonly observed in young psychiatric females with trichotillomania and trichophagia. Here, we report a case of giant gastric trichobezoar and a novel technique of laparoscopic removal in a 16 year old female with trichophagia. The giant gastric trichobezoar weighing about half a kilogram was removed en masse laparoscopically by a novel technique. She had an uneventful postoperative recovery and was discharged after psychiatric counseling.

Optimizing the route for production of activated carbon from Casuarina equisetifolia fruit waste.

This work deals with optimizing the conditions of pyrolysis and type of activator to upgrade the use of Casuarina equisetifolia fruit waste (CFW) as available and a potential precursor, in production of activated carbon (AC). In this respect, the route of activation was carried out through one- and two-step pyrolysis processes, using different chemical activating agents, such as H3PO4, KOH and ZnCl2. The performance of the CFW-based ACs is assessed by estimating the physico-chemical characteristics (pH, electrical conductivity, bulk density and hardness), surface morphology and scanning electron microscopy, together with carbon yield, surface area and adsorption performance of pollutants in aqueous medium (methylene blue, iodine and molasses colour removal efficiencies). The results show that the two-step activation process was more effective than one-step activation for providing high adsorption performance CFW-based ACs. The maximum Brunauer-Emmett-Teller surface area 547.89 m2 g-1 was produced by using H3PO4 activating agents, and applied two-step pyrolysis. According to the American Water Work Association and based on bulk density of the investigated ACs, we recommend that most of produced ACs are suitable for treating waste water.

DNA sequence information resolves taxonomic ambiguity of the common mud crab species (Genus Scylla) in Indian waters.

For several years, mud crabs of genus Scylla have been misidentified owing to their high morphological plasticity and the absence of distinct morphological diagnostic characters. The taxonomic confusion of genus Scylla de Haan is considered to be a primary constraint to the development of aquaculture. Although genus Scylla was revised using morphological and genetic characteristics, taxonomy of Scylla species occurring in India is still not clear. In this study, partial sequences of two mitochondrial genes, 16S rRNA and CO1 (Cytochrome C oxidase subunit I) in populations of Scylla spp. obtained from eleven locations along the Indian coast were used to differentiate and resolve taxonomical ambiguity of the mud crab species in India. The sequences were compared with previously published sequences of Scylla spp. Both trees generated based on 16S rRNA and CO1 indicated that all S. tranquebarica morphotypes obtained during this study and S. tranquebarica sequences submitted previously from Indian waters reciprocally monophyletic with reference sequence of S. serrata. Both sequence data and morphological characters revealed that the species S. serrata (Forskal) is the most abundant followed by S. olivacea. Further, the 16S rRNA and COI haplotypes of Indian S. tranquebarica obtained in the study significantly differed with the known S. tranquebarica by 6.7% and 10.6% respectively whereas it differed with known S. serrata by 0.0-0.7% only, a difference that was not statistically significant. From these studies it is clear that "S. tranquebarica" commonly reported from India should be S. serrata (Forskal).

Vivipary in Ophiorrhiza mungos L. - a rare phenomenon in angiosperms.

Vivipary, the precocious germination of seeds within the parent plant, is a specialised feature of evolutionary and biological importance that ensures survival of a plant. Reports on vivipary in angiosperms are rare, accounting for <0.1% of flowering plants. Here, we report a remarkable case of occurrence of vivipary in Ophiorrhiza mungos. A study was conducted to collect information on the morphology of the capsules that support vivipary, environmental factors that induce vivipary, survival mode and the survival of viviparous seedlings. The hydroscopic movement of the cup-shaped capsules of O. mungos was found to help in viviparous germination during the rainy season. Of the total seeds in a capsule, 70% showed viviparous germination. The seedlings remaining inside the capsule attain a height of 0.98 ± 0.4 cm and reach the ground when the capsule falls. On the ground, seedlings obtain easy anchorage to the substratum since they have already germinated. Vivipary appears to be an adaptation of O. mungos to the rainy season for ensuring viable offspring. This suggests that vivipary in this species might be artificially induced by continuous spraying with water to rescue seeds in all seasons for use in large-scale propagation to meet increasing market demand and conservation of this valuable anticancer medicinal herb.

Association of dual viral infection with mortality of Pacific white shrimp (Litopenaeus vannamei) in culture ponds in India.

Pacific white shrimp, Litopenaeus vannamei has been introduced recently for culture practice in India. Though SPF stocks are imported for larval production and thereafter culture practice, these are prone to infection with the existing viruses in the environment. Here we report mortality of L.vannamei in several farms in India with minimum biosecurity. The shrimp were harvested early within 50-72 days of culture due to the onset of disease and consequent mortality. As per the analysis carried out, the shrimp were infected with two virus, white spot syndrome virus (WSSV) and infectious hypodermal and hematopoietic necrosis virus (IHHNV). About 80 % of the samples collected had either or both of the viruses. A majority of these samples (60 %) had dual infection with WSSV and IHHNV. Infection of shrimp with WSSV and IHHNV could be detected both by PCR and histopathology. Some of the samples had either exclusively WSSV infection or IHHNV infection and were also harvested before the completion of the required culture period. All the samples analyzed were negative for taura syndrome virus, yellow head virus and infectious myonecrosis virus. While it is difficult to point out the exact etiological agent as the cause of mortality, strict biosecurity measures are advisable for the continuity of L. vannamei culture in India.

Percutaneous ultrasound-guided fine-needle aspiration of portal vein thrombi as a diagnostic and staging technique for hepatocellular carcinoma.

BACKGROUND: Detection of portal vein tumor invasion in hepatocellular carcinoma (HCC) is important in determining therapy and prognosis. Patients with portal vein thrombus (PVT) due to tumor are considered to have advanced disease and are only offered palliative therapy. Therefore, every possible attempt should be made to accurately differentiate benign from malignant PVT. METHODS: In this study, 20 patients presenting to the out-patient department with a PVT and a diagnosis/diagnostic suspicion of HCC were subjected to FNAC of PVT. Clinical, cytological, and histopathological data for these patients were analyzed. RESULTS: The patients had a median age of 58 years, with majority being cirrhotic (80%) and males (80%). Thirteen patients had a prior radiological diagnosis of HCC at the time of FNAC. In three patients without any mass on imaging, FNAC made the initial diagnosis and staged the disease simultaneously. 50% of the thrombi were limited to 1st-order portal vein branches (vp3). Sixteen of the aspirates were positive for malignancy with 50% of the tumors being moderately differentiated. On histologic follow-up, three of the patients with negative aspirates had bland thrombi in their portal veins. No complications resulted from the procedure. CONCLUSIONS: FNAC of PVT is a simple, safe, effective, well-tolerated, and economical method for staging of patients with HCC. When used as the initial diagnostic procedure, in selected patients, it can provide the diagnosis and staging information simultaneously.

Bleeding complication after pancreatic surgery: role of harmonic scalpel.

In this modern era of technological advancements, though many centers are contemplating complex surgical procedures on the pancreas, morbidity is still high and around 30-35 %. Post-operative bleeding complications are the most worrisome of all, which need vigilance by the operating team. Early recognition and prompt management using endoscopy, intervention radiology or urgent surgery, with a low threshold for relaparotomy is needed to avoid mortality. After successfully completing more than 500 Whipple's operations and over 300 Frey's procedures in the last 10 years, our bleeding complication, which is around 2 %, has substantially increased. This increase over the last couple of years is seen with usage of harmonic scalpel in pancreatic surgery. Here we report our recent encounter with bleeding in the post-operative period after Whipple's pancreaticoduodenectomy and Frey's procedure, where harmonic scalpel was used. We have recommended our suggestion to avoid this complication, by adopting a simple technique. We have achieved optimal results by applying this technique in our subsequent cases.

Case matched comparison study of the necrosectomy by retroperitoneal approach with transperitoneal approach for necrotizing pancreatitis in patients with CT severity score of 7 and above.

BACKGROUND: Minimally invasive necrosectomy through a retroperitoneal approach has shown promising results for the treatment of necrotizing pancreatitis. There is however, little evidence from comparative studies in favor of these techniques over laparotomy. AIM: To perform a case matched comparison of patients with necrotizing pancreatitis who underwent necrosectomy by the retroperitoneal approach with transperitoneal approach, thus minimizing the risk of confounding and selection bias. METHODS: Between August 2008 and March 2011, 85 patients were admitted with pancreatic necrosis. Each of the 15 patients who underwent necrosectomy by retroperitoneal approach using a small flank incision (RP group) were compared with 15 of those treated with necrosectomy by transperitoneal approach (TP group). These patients were matched for the age (±10 years), status of infection, CT severity score (±2 points), preoperative organ failure and timing for surgery (±7 days). RESULTS: Postoperative complications occurred in 4 patients (26.6%) in the RP group and 8 (53.3%) in the TP group (p = 0.248). Reintervention, was required in 4 patients (26.6%) in the RP group and 7 (46.6%) in the TP group (p = 0.366). The median post operative ICU stay was 10 days in the RP group compared to 15 days in the TP group (p = 0.317). Median post operative hospital stay was 26 days in the RP group and 32 days in the TP group (p = 0.431). The total hospital stay among the survivors was 31 days in the RP group and 40 days in the TP group (p = 0.285). CONCLUSIONS: The RP approach for pancreatic necrosectomy through a small flank incision was associated with less post operative morbidity compared to TP approach. The surgical outcomes in terms of post operative new onset organ failure and in hospital mortality were similar in both the groups, but the post op ICU/hospital stay and the total hospital stay was lower in the RP approach group. These results still requires to be confirmed by further randomized studies.

Hematological changes following early ligation of splenic artery during splenectomy in shunt surgery for portal hypertension.

OBJECTIVE AND BACKGROUND DATA: Reduction in cellular elements of blood, secondary to hypersplenism is an established component of non-cirrhotic portal hypertension. Prior transfusion of blood or blood components is frequently required for safe surgical intervention. Due to thrombocytopenia, epidural catheter insertion for effective and durable analgesia is not possible. The aim of the present study was to objectively demonstrate the gain in blood components following early ligation of splenic artery for splenectomy in shunt surgery. METHODS: From Jan 2008 to July 2010, 30 patients underwent elective proximal spleno renal shunt for portal hypertension, for various indications and were analyzed prospectively. We followed the standard protocol of ligating the splenic artery in situ, first in the lesser sac. Proximal spleno shunt was done. After the surgical procedure and before extubation, an epidural catheter was placed for effective and durable analgesia. 5ml of venous blood was drawn in the following order of sequence: prior to induction of anesthesia, immediately after the ligation of splenic artery, 30 minutes after ligation of splenic artery and 30 minutes after splenectomy. Samples were sent for complete hemogram and values were analyzed in respective order. Patients requiring transfusion of blood or blood components during surgery were excluded from the study. RESULTS: 30 patients (M - 9, F- 21) with mean age of 29.4 years (11-60 years) were analyzed (NCPF- 20, EHPVO- 9, cirrhosis- 1). We objectively demonstrated a significant gain in RBCs (p = 0.016) and platelets (p = 0.000) using this standard protocol. As there were no intrinsic abnormalities in RBCs, red blood cell indices (MCV, MCH, MCHC) showed no changes as expected (p-0.9). CONCLUSION: By following this standard protocol, in addition to reduction in blood loss there was a significant gain in RBCs and platelets. This gain allows the surgeon to perform the surgical procedure safely and the anesthetist to secure an epidural catheter immediately after surgery for effective and durable analgesia without prior transfusion.

Inflammatory pseudotumour secondary to spilled intra-abdominal gallstones.

INTRODUCTION: Spillage of calculi in the abdomen is frequent during Laparoscopic Cholecystectomy (LC). Though uncommon, these stones may lead to early or late complications. We describe a rare case of spilled gallstone presenting four years after the index procedure, with a mass in the parietal wall mimicking a neoplastic lesion. PRESENTATION OF CASE: A 50 year old male presented with a mass in the right upper quadrant for the past 2 years. His past surgical history included a LC done four years ago. Intraoperative procedural details of the surgery were not available. A Computed Tomography (CT) scan showed an extrahepatic mass in the subdiaphragmatic space extending onto the soft tissues of the parietal wall. He underwent laparoscopic piecemeal excision of this organized mass. His post operative period was uneventful and he was pain-free on follow up. DISCUSSION: Gallbladder perforation can occur due to excessive traction during retraction or during dissection from the liver bed. It can also occur during extraction from the abdomen. Infected bile, pigment gallstones, male gender, advanced age, perihepatic location of spilled gallstones, more than 15 gallstones and an average size greater than 1.5cm have been identified as risk factors for complications. Definitive treatment is surgery with excision of the organized inflammatory mass and extraction of gallstones to avoid future recurrence. CONCLUSION: Spilled gallstones can be a diagnostic challenge and can cause significant morbidity to the patient. Clear documentation of spillage and explanation to the patient is of utmost importance, as this will enable prompt recognition and treatment of any complications. Prevention of spillage is the best policy.

Post pancreaticoduodenectomy haemorrhage: outcome prediction based on new ISGPS Clinical severity grading.

UNLABELLED: OBJECTIVE & BACKGROUND DATA: Mortality following pancreatoduodenectomy (PD) has fallen below 5%, yet morbidity remains between 30 and 50%. Major haemorrhage following PD makes a significant contribution to this ongoing morbidity and mortality. The aim of the present study was to validate the new International Study Group of Pancreatic Surgery (ISGPS) Clinical grading system in predicting the outcome of post pancreaticoduodenectomy haemorrhage (PPH). MATERIAL AND METHODS: Between January 1998 and December 2007 a total of 458 patients who underwent Whipple's pancreaticoduodenectomy in our department were analysed with regard to haemorrhagic complications. The onset, location and severity of haemorrhage were classified according to the new criteria developed by an ISGPS. Risk factors for haemorrhage, management and outcome were analysed. RESULTS: Severe PPH occurred in 14 patients (3.1%). Early haemorrhage (<24 hours) was recorded in five (36%) patients, and late haemorrhage (>24 hours) in nine (64%) patients. As per Clinical grading of ISGPS 7 (50%) belongs to Grade C and 7 (50%) belongs to Grade B. Haemostasis was attempted by surgery in 10 (71%) patients; angioembolisation was successful in two (14%) and endotherapy in one (7%) patient. The overall mortality is 29%(n=4). Age >60 years (p=0.02), sentinel bleeding (p=0.04), pancreatic leak (p=0.04) and ISGPS Clinical grade C (p=0.02) were associated with increased mortality. CONCLUSION: Early haemorrhage was mostly managed surgically with better outcome when endoscopy is not feasible. Late haemorrhage is associated with high mortality due to pancreatic leak and sepsis. ISGPS Clinical grading of PPH is useful in predicting the outcome.

Role of retrograde dilatation in the management of pharyngo-esophageal corrosive strictures.

Pharyngo-esophageal corrosive stricture is a complex clinical scenario. If an esophageal opening cannot be found orally through endoscopy, a retrograde approach with a mini-laparotomy and gastrostomy should be attempted. This study primarily aimed at defining the role of preoperative retrograde dilatation of pharyngo-esophageal corrosive strictures. A retrospective analysis of 51 cases of pharyngo-esophageal corrosive strictures identified between 1997-2005 was performed. The demographic details were analyzed. The details of the injury to the pharynx either in isolation or in combination were noted and the management details were recorded. In 21 patients preoperative retrograde dilatation was considered and the technique was successful in 14 (Group I). In seven the technique failed (Group II) and these patients underwent transhiatal resection and gastric pull-through and/or retrosternal pharyngocoloplasty. In Group I patients the postoperative stay was significantly less than in Group II (12 +/- 2.03 days vs. 18 +/- 4.32 days; p = 0.001) Recurrent aspiration, respiratory tract infections, choking sensation and the need for tracheostomy were less frequent in Group I. The overall functional assessment was good in Group I. For treatment of pharyngo-esophageal obstruction, if antegrade dilatation is not possible due to technical reasons, retrograde dilatation is a viable option before opting for organ replacement/bypass procedures. There is no best replacement of the native organ to maintain quality of life.

Solitary extra-hepatic hilar peribiliary cyst presenting with obstructive jaundice: a case report.

Peribiliary cyst is a poorly recognized and under-reported clinico-pathologic entity around the biliary tree. Peribiliary cysts are cystic dilatations of obstructed peribiliary glands, which are normal elements of the biliary tract. They are generally asymptomatic and rarely cause biliary obstruction. They are usually discovered incidentally at autopsy or in explants following liver transplantation. A 59-year-old male patient presenting with obstructive jaundice due to a large extra-hepatic hilar peribiliary cyst is reported here. We briefly discuss its differential diagnoses such as bile duct cyst, liver cyst or lymph cyst, and its management. Radiological imaging demonstrated a solitary large (5 cm) well-defined, smooth, thin walled cystic lesion at the porta hepatis paralleling but not communicating with the bile duct. A wide cyst de-roofing was performed and histological examination of the cystic wall revealed an inflammatory cyst. The patient made an uneventful recovery and remained asymptomatic with normal liver function tests 36 months postoperatively.

Transabdominal modified devascularization procedure with or without esophageal stapler transection--an operation adequate for effective control of a variceal bleed. Is esophageal stapler transection necessary?

BACKGROUND: In Japan, the original Sugiura procedure reported favorable results in non-cirrhotic patients but in the West, the modified Sugiura procedure is not widely accepted because of high rebleeding, morbidity, and mortality in cirrhotics. We retrospectively analyzed the efficacy of our modified Sugiura procedure i.e., devascularization with/without esophageal transection combined with salvage endotherapy and pharmacotherapy for control of a variceal bleed. MATERIALS AND METHODS: Between January 1999 and December 2004, 912 patients with variceal bleeding were treated. Of these, 66 (7.2%) patients were subjected to surgery after failed endotherapy/propranolol. Among these 66 patients, 52 had transabdominal devascularization (16 emergency, 36 elective); 14 patients underwent devascularization with esophageal stapler transection (group I), and 38 patients had devascularization without esophageal stapler transection (group II). Another 14 patients underwent elective end-to-side proximal splenorenal shunt surgery. RESULTS: Postoperative mortality was 7.1% in group I, 10.5% in group II (P>0.05). Mortality for emergency surgery was 31.2% (5/16) but there were no deaths in the elective surgery group. Overall morbidity was 57.1% in group I and 21.0% in group II (P<0.05). The rates of variceal rebleeding were 7.1% and 7.8%; residual varices were 30.7% and 32.3%; recurrent varices were 7.6% and 5.8% following the group I and group II procedures, respectively, over a mean follow-up period of 39.9 (7-2) months. Esophageal transection-related morbidity (leak, stricture, and bleeding) was 21.4% (3/14) in group I. CONCLUSIONS: Devascularization without esophageal stapler transection is a safe and effective procedure for adequate (urgent and long-term) control of variceal bleeding with similar results and less morbidity when compared to devascularization with esophageal transection in cirrhotic patients, as well as non-cirrhotic patients.

Endobronchial pseudo-tumour caused by herpes simplex.

Herpes simplex virus (HSV) causes tracheobronchitis and pneumonitis; however, to date, there has only been one report of an endobronchial mass caused by HSV type II. This case study describes a 68-yr-old female with severe kyphoscoliosis who was intubated for acute on chronic hypercapnic respiratory failure and developed blood-tinged endotracheal secretions. Fibreoptic bronchoscopy demonstrated an endobronchial mass in the right middle lobe. Cultures grew HSV type I and biopsy specimens demonstrated cytopathological changes consistent with HSV infection. This is the first reported case of HSV type I presenting as an endobronchial tumour.

Splenic radiation and double-filtration plasmapheresis in crossmatch-positive live renal transplantation.

Double-filtration plasmapheresis (DFPP) and splenectomy prior to transplant is used in a few centers for high-risk transplantations. We undertook a prospective study to examine the outcome of 16 kidney transplantations in crossmatch-positive patients using splenic radiation and DFPP as pretransplant immunomodification procedures. All patients received a single dose of Zenapax (50 mg intravenously [IV] 8 hours before transplant), before treatment with cyclosporine, mycophenolate mofetil, and steroids immediately posttransplant. Follow-up ranged from 3 months to 1 year. Hyperacute rejection requiring graft nephrectomy was necessary in one patient; acute rejection, which was seen in three patients, was reversed with five doses of Iort3 at 1-month posttransplant the mean creatinine was 1.3 +/- 0.6 mg/dL in patients who did not have rejection and 1.9 +/- 0.3 mg/dL in the three patients who had acute rejection. Six patients were switched from cyclosporine to sirolimus. At the end of 3 months the mean creatinine levels was 1.4 +/- 0.3 mg%. The infections included oral candida (n = 2), urinary tract infection (UTI) (n = 1), bacterial pneumonia (n = 1), and herpes zoster (n = 1). With the advent of modern immunosuppressants, pretransplant immunomodification with DFPP and splenic radiation is safe and effective. Splenic radiation is devoid of surgical risk and more acceptable to patients.