Understanding the factors that influence patient satisfaction with ambulance services.

The quality of ambulance services has an immense impact on patients' future well-being and quality of life. Patient satisfaction is one of the key metrics for evaluating the quality of this service. Yet, the patient satisfaction measurement may be limited in its ability to accurately reflect this service quality, and even reflect factors beyond the patient experiences. We analyze 10 years of survey data to reveal a number of factors that systematically bias ambulance satisfaction ratings. Taking into account these biases provides more robust comparison of ambulance performance over time or across different jurisdictions.

Late onset of severe graft-versus-host disease in a pediatric liver transplant recipient.

We report the management of a patient with the late onset of chronic graft-versus-host disease (GVHD) after orthotopic liver transplantation. GVHD is a rare complication of solid organ transplants that usually presents early after transplantation and is fatal in the majority of cases. Our patient differs from the typical patient with GVHD in that the onset of her disease was very late. Although most treatment to date consisted of an increase in immunosuppressive therapy, our patient showed an excellent response to a reduction. This resulted in the abatement of the symptoms of GVHD and the preservation of her allograft function.

Pediatric recipients of three or more hepatic allografts: results and technical challenges.

BACKGROUND/PURPOSE: Children who require a liver transplant at an early age risk chronic allograft rejection (CAR) and other causes of allograft loss. Multiple retransplants may be required for long-term patient survival. The authors evaluate this approach based on our results and technical difficulties. METHODS: Charts of 7 children who received 3 or more liver transplants from 1989 to the present were reviewed retrospectively. RESULTS: A total of 151 children required liver transplantation at our institution since 1989. Of these, 4 boys and 3 girls (mean age, 6.2 years; range, 3 to 14 years) have received 3 or more allografts. The etiology of liver failure for the penultimate allograft was CAR (n = 6) and hepatic artery thrombosis (HAT; n = 1). Five cases required modification of portal vein or hepatic artery anastomoses. Two patients with vena caval strictures required supradiaphragmatic vena caval reconstruction. The original Roux-en-Y limb was adequate for biliary reconstruction in all cases. Five children currently are alive (survival rate, 71%) with good graft function having had a mean follow-up of 23 months (range, 2 to 48 mos.). CONCLUSIONS: The operative procedure for the multiple hepatic transplant child is challenging. The transplant team must be prepared for intraoperative issues such as extended organ ischemia time during hepatectomy, extensive blood loss, and potential need for creative organ revascularization techniques. Overall, multiple retransplant results are good and justify the use of multiple allografts.

Infectious keratitis after photorefractive keratectomy in a comanaged setting.

A 48-year-old man had simultaneous bilateral photorefractive keratectomy (PRK). The surgeon who performed the PRK did not see the patient in follow-up, and there was confusion regarding the comanaging doctor. Therefore, the patient was not examined immediately postoperatively. Several days later, he was hospitalized for an unrelated, painful orthopedic problem and heavily sedated. Seven days after the PRK, an ophthalmologist was consulted for ocular irritation and discharge. Examination showed bilateral, purulent conjunctivitis and severe infectious keratitis in the left eye. The patient was treated with periocular and topical antibiotics. Corneal cultures yielded Staphylococcus aureus. The keratitis resolved slowly, leaving the patient with hand motion visual acuity. A corneal transplant and cataract extraction was performed 15 months later, resulting in a best corrected visual acuity of 20/400 because of glaucomatous optic nerve damage. Severe infectious keratitis may occur after PRK. Poor communication between the surgeon, comanaging doctor, and patient may result in treatment delay.

Early- versus late-onset infectious keratitis after radial and astigmatic keratotomy: clinical spectrum in a referral practice.

PURPOSE: To compare the clinical characteristics of early- versus late-onset keratitis after radial keratotomy (RK) and astigmatic keratotomy (AK). SETTING: Referral subspecialty practice. METHODS: This retrospective review comprised 19 patients with infectious keratitis after RK and AK. Early- versus late-onset groups were analyzed for predisposing conditions; infiltrate location, size, and depth; microbiologic data; and final visual outcome. RESULTS: Ten patients in the early-onset group developed keratitis within a mean of 7.4 days after surgery (range 3 to 14 days). Nine patients in the late-onset group developed keratitis a mean of 5.4 years after surgery (range 1.5 to 15.0 years). Staphylococcus aureus was the predominant organism in the early-onset group and Pseudomonas aeruginosa in the late-onset group. In the early-onset group, most infiltrates occurred in the paracentral aspect of the RK incision and extended to the middle or posterior stroma. In the late-onset group, most infiltrates occurred in the peripheral portion of the RK incision and were localized to the superficial stroma. A hypopyon was present in 7 of 10 ulcers in the early group and in 1 of 9 in the late group. Two patients in the early group developed endophthalmitis. Most patients in the late-onset group had incisional pseudocysts; 2 had other risk factors for keratitis. Final visual acuity was 20/40 or better in 7 of 10 patients in the early group and in 8 of 9 patients in the late group. CONCLUSIONS: Early-onset corneal ulcers after incisional refractive keratotomy were usually paracentral and deep, whereas late-onset ulcers were usually peripheral and superficial. Despite the predominance of Staphylococcus and Pseudomonas in the early- and late-onset groups, respectively, a variety of organisms may be responsible for infections in keratotomy incisions.

Living donor liver transplantation in critically ill children.

From December 1993, St Christopher's Hospital for Children, Philadelphia, PA, USA has provided living donors the opportunity to donate a portion of their liver to children who are critically ill. This report evaluates the results of living donor liver transplants (LDLT) in critically ill children. We retrospectively reviewed the first 22 LDLT at our institution and compared the patient and graft survival of the nine critically ill children with the 13 stable children. Twenty-two LDLT have been performed at our institution between December 1993 and October 1997. Nine of 22 transplants [United Network for Organ Sharing (UNOS) Status I] were performed in children who were critically ill. Thirteen of the LDLT (UNOS Status II and III) were performed on stable children either in the hospital or admitted electively from home. The median weight and age at the time of transplant were 7 kg (range 4.6-54.5 kg) and 16 months (range 3 months-12 yr), respectively, and there was no statistical difference between the two groups. In critically ill children the 1-yr allograft and patient survival was 66% and 89%, respectively, exceeding the published results from UNOS for patients on life support (59.5% graft and 69.7% patient survival at 1 yr). One-yr allograft and patient survival in the stable children was 92.3% and 100%, respectively. All living donors are alive and well with normal liver function. In conclusion, our results show that LDLT is a viable approach for transplantation in critically ill children with liver failure and should be offered to potential donors.

Improved cyclosporine bioavailability in black pediatric liver transplant recipients after administration of the microemulsion formulation.

Black transplant recipients are associated with low cyclosporine bioavailability, which may contribute to the poorer clinical outcomes observed with these patients. In this analysis, we compared cyclosporine exposure in black (n = 9) and nonblack (n = 18) pediatric maintenance liver transplant recipients by using steady-state pharmacokinetic profiles obtained after administration of the original and microemulsion formulations of cyclosporine. Treatment with the original cyclosporine formulation resulted in lower mean dose-normalized, area under the concentration-versus-time curve values for black compared with nonblack pediatric liver transplant recipients. On conversion to the microemulsion formulation of cyclosporine, black and nonblack patients experienced increases in cyclosporine bioavailability of 102% and 39%, respectively (P =.009 and P =.001). Because the increase in mean bioavailability was substantially greater for blacks, area under the concentration-versus-time curve values for this pediatric subpopulation became similar to those levels obtained for nonblacks receiving the microemulsion formulation for cyclosporine. When patients were further stratified by age, ethnic differences in bioavailability with the original formulation of cyclosporine were most apparent in the 1- to 5-year age group. Conversion to the microemulsion formulation resulted in a 164% increase (P =.05) in bioavailability for black patients within this age group such that, again, these levels became similar to area under the concentration-versus-time curve values obtained for young nonblacks receiving cyclosporine for microemulsion. Improvements in cyclosporine bioavailability after administration of the microemulsion formulation of cyclosporine may translate to improved long-term graft and patient outcomes for black pediatric liver transplant recipients.

Results of transplantation for acute and chronic hepatic allograft rejection.

BACKGROUND/PURPOSE: Transplantation for rejection is a requirement in liver transplant recipients when allograft failure is imminent. The authors evaluated the outcome of these children and their allografts. METHODS: The medical records of 129 children who received a liver transplant were reviewed retrospectively. Twelve children required transplantation for biopsy-proven rejection--10 chronic and two acute. Overall patient and graft survival were compared with children receiving primary liver transplants. The current allograft function of the patients undergoing transplants was also reviewed. Statistical significance was determined by Fisher's Exact test. RESULTS: Twelve children received at least one retransplant for biopsy-proven rejection. Graft survival at 1 year was 58% (v 79% for primary transplants) and patient survival was 83% (vs 89%). Two allografts were lost because of primary allograft nonfunction. Three additional allografts were lost-two to recurrent rejection and one to hepatic artery thrombosis. Two patients who lost a second transplant to rejection required a total of seven transplants to treat rejection. Two children died, one of primary nonfunction and one of adenovirus pneumonia. The 10 surviving patients all have excellent graft function (total bilirubin, 0.74 +/- 0.38, aspartate aminotransferase, 40 +/- 22). CONCLUSION: These data suggest that transplantation for rejection can be accomplished safely with a patient survival rate comparable to primary liver transplantation; however, graft loss is excessive and underscores the need for more adequate immunosuppression.

Gastrointestinal perforation after pediatric orthotopic liver transplantation.

PURPOSE: The aim of this review was to determine the incidence of gastrointestinal perforation after pediatric liver transplantation and to identify risk factors and clinical indicators that may lead to an earlier diagnosis. METHODS: A retrospective chart review of all children who presented with gastrointestinal perforation after liver transplantation at our institution between January 1, 1987 and August 1, 1996 was performed. RESULTS: One hundred fifty-seven orthotopic liver transplants were performed in 128 children. Fifty-eight reexplorations, excluding those for retransplantation, were performed in 38 children. Ten perforations occurred in six children (incidence, 6.4%). Two children required multiple reexplorations because of several episodes of perforation. The sites of perforation were duodenum (n=1), jejunum (n=8), and ileum (n=1). A single-layer closure was used to repair five perforations, two-layer closures in four, and resection with primary anastomosis in another. The type of repair did not affect the occurrence of subsequent perforations. All the children were less than 18 months old. Four children had undergone prior laparotomy. All children had choledochoenteric anastomoses, but only one had a perforation associated with it. One child sustained bowel injury during the dissection for the liver transplant, but none of the perforations occurred at this site. Bowel function had returned before perforation in five children. Five children were receiving systemic antibiotics at the time of their perforation, and none had been dosed with pulse steroids for rejection. All of the children had significant changes in their temperature. Acute leukopenia developed in one child. A leukocytosis developed in the rest of the children. Abdominal radiographs demonstrated pneumoperitoneum in only one child. All children had positive culture findings from their abdominal drains. Cytomegalovirus developed in one child. Although the diagnosis of gastrointestinal perforation after pediatric liver transplant remains difficult, positive drain culture findings and significant alterations in temperature and leukocyte counts suggest its presence. Pneumoperitoneum is rarely present. CONCLUSION: A high index of suspicion and timely laparotomy, especially in children less than 2 years of age, may be the only way to rapidly diagnose and treat this potentially devastating complication of liver transplant.

Calcineurin activity in children with renal transplants receiving cyclosporine.

BACKGROUND: The major immunosuppressive effect of cyclosporine is through the inhibition of calcineurin, an enzyme important in the activation of T lymphocytes. In children, neither calcineurin activity nor its inhibition by cyclosporine (CsA) has been investigated. METHODS: Calcineurin activity, was measured in stable pediatric renal transplant patients, with healthy children used as controls. Whole blood CsA concentrations were measured by monoclonal radioimmunoassay. Simultaneous calcineurin and CsA levels were measured before and 1, 2, 3.5, 5, and 12 hr after their routine morning CsA dose. RESULTS: Calcineurin activity was approximately 50% inhibited at trough blood concentrations (148 microg/L); moreover, inhibition increased as CsA concentrations rose and declined as concentrations fell. Maximum calcineurin inhibition was about 70% at concentrations of about 431 microg/L. Linear regression analysis revealed a significant correlation between mean CsA blood concentration and the mean degree of inhibition of calcineurin activity (P=0.005, one-tailed). CONCLUSION: We conclude that inhibition of calcineurin activity by CsA in pediatric renal transplant recipients correlates with CsA blood concentrations.

Reduced cyclosporine absorption preceded acute allograft rejection in a child with a liver transplant.

This case report correlates impaired cyclosporine absorption from the traditional oral formulation in a 9-year-old liver transplant recipient with subsequent acute allograft rejection. Although impaired absorption in this patient was documented by cyclosporine pharmacokinetic profiling (steady-state area under the cyclosporine concentration-time curve or AUC), no indication was evident from the pre-dose cyclosporine trough level, which was within the typical target range of blood concentrations. However, when the subject received the microemulsion formulation of cyclosporine the AUC value reflected an adequate absorption pattern. We recommend that if malabsorption is suspected in the de novo pediatric liver transplant patient, then single-sample pre-dose trough cyclosporine levels should not be relied on as an indicator of sufficient immunosuppression and that a limited sampling strategy be used to confirm or rule out impaired absorption.

Endophthalmitis after radial keratotomy enhancement.

A 45-year-old man developed endophthalmitis after a radial keratotomy (RK) enhancement. He developed severe intraocular inflammation, hypopyon, and dense vitreous membranes 4 days after the enhancement surgery. Cultures of the corneal wound yielded a heavy growth of Streptococcus viridans. The inflammation subsided after treatment with intraocular, intravenous, and topical antibiotics. The patient subsequently developed a cataract and retinal detachment. This case demonstrates the risk of endophthalmitis after RK enhancement.

Split liver transplantation benefits the recipient of the 'leftover liver'.

The division of a single hepatic allograft to create two reduced-size grafts has been reported with decreased graft survival (50%) resulting in decreased enthusiasm for this approach. The authors reviewed their experience with 12 recipients of this procedure to evaluate the outcome of the children electively undergoing transplant with the "leftover liver." A retrospective review of six pairs of children receiving part of one hepatic allograft included donor anatomy, recipient operation, and allograft and patient outcomes. Recipient pairs were selected according to blood type compatibility, medical priority, and size restrictions of the larger right lobe and the smaller left lateral segment. Patient and graft survival were compared with elective and urgent patients undergoing whole or reduced-size transplants. Six donors weighed 71.8 +/- 17.4 kg and were 22.6 +/- 11.0 years of age. Recipients of the right lobe were 11.8 +/- 4.2 years of age and weighed 41.9 +/- 14 kg. Recipients of the left lateral segment were 1.81 +/- 1.1 years of age and weighed 9.85 +/- 1.82 kg. Six patients were initially offered the donor allograft because of their hospitalization, critical illness or waiting time. Six additional patients electively underwent transplantation with the leftover liver. Donor organs were screened for normal arterial anatomy. Division of the allograft was performed on the back table in the falciform groove. Generally the left lateral segment graft received the major portion of the hepatic artery and the right lobe the major portion of the portal vein. Five of six (83%) elective patients, two receiving the right lobe and three receiving the left lateral segment had prompt recovery and left the hospital without surgical complication. One recipient of a right lobe transplant died from primary allograft nonfunction. These results are not different from the outcomes of all elective patients who underwent transplantation with whole or reduced-sized transplants in the same program. The authors conclude that split liver transplantation benefits the stable patient who electively receives the liver leftover after reducing the size of a large donor liver for a critically ill child.

Absorption characteristics of a microemulsion formulation of cyclosporine in de novo pediatric liver transplant recipients.

In pediatric liver transplant recipients, oral cyclosporine (CsA) therapy may be complicated by impaired or delayed absorption during the initial weeks posttransplant. Neoral (NL) is a microemulsion preconcentrate formulation of CsA expected to increase the rate and extent of absorption of CsA and have less pharmacokinetic variability. The absolute bioavailability (F) of CsA from NL was compared with that of the currently marketed Sandimmune (SM) formulation in a double-blind, crossover study conducted in 9 pediatric liver transplant recipients (age 6 months to 11 years) between 8 and 20 days posttransplant. After determination of CsA pharmacokinetics for a steady-state intravenous dose, patients were randomized to receive a single oral dose of NL or SM in period I and the alternative formulation in period II. Clearance (Clt) and volume of distribution (Vss) values (mean +/- s.d.) calculated from the i.v. dose were similar to that previously reported for pediatric patients (Clt = 12.0 +/- 1.3 ml/min/kg; Vss = 2.2 +/- 0.2 L/kg). Mean F (+/- SD) for NL was significantly higher than SM (NL = 37.6 +/- 14.6%; SM = 24.7 +/- 8.0%; P = 0.05). Although not reaching statistical significance, the observed maximum blood concentration (Cmax) was higher, and the time to Cmax (Tmax) was shorter for NL in 8 or 9 patients. There were no significant correlations between age and any pharmacokinetic parameter for the group as a whole--however, there were statistically significant correlations between age and F for NL (r = 0.87; P = 0.02), and for age and Vss (r = 0.91; P = 0.01) for the 6 patients aged 2 years or less. In this pediatric liver transplant population, Neoral demonstrated improved absorption (% increase in F) compared to Sandimmune. In liver transplant recipients aged 2 years or less, absorption of Neoral may be a function of age and/or bowel length.

Aspergillus keratitis after radial keratotomy.

PURPOSE/METHODS: A case of severe Aspergillus keratitis after radial keratotomy manifested as a discrete midstromal infiltrate along a radial incision. Despite aggressive treatment with topical amphotericin B and oral itraconazole, the patient required a therapeutic penetrating keratoplasty. RESULTS/CONCLUSIONS: Histopathologic examination disclosed a corneal ulcer with numerous septate, branching hyphae throughout the stroma, and marked stromal necrosis. Aspergillus species should be included among the microbial pathogens responsible for infectious keratitis after radial keratotomy. If infectious keratitis is suspected, comprehensive cultures for bacteria and fungi should be obtained.