The Kidney Transplant Lottery: A Highly Sensitized Patient, Without Mismatches and Vein Thrombosis of the Graft; A Case Report.

A kidney transplant is the best option for patients with end-stage renal disease. The waiting list period can be long, especially for highly sensitized patients. We describe a 60-year-old woman who received a second transplant and was highly sensitized to vascular access exhaustion, anuric, and performing peritoneal dialysis. At 27 days post-transplant, the patient developed thrombosis of the allograft vein, oliguria, and elevated serum creatinine. Fibrinolysis was attempted, but the patient remained oliguric and with acute graft dysfunction. She had a suction thrombectomy using the Penumbra System, allowing the removal of all thrombi and repermeabilization of the vein graft, resolving the acute graft dysfunction.

Bet v 1-independent sensitization to major allergens in Fagales pollen: Evidence at the T-cell level.

BACKGROUND: In birch-dominated areas, allergies to pollen from trees of the order Fagales are considered to be initiated by the major birch pollen allergen Bet v 1. However, the sensitizing activity of Bet v 1-homologs in Fagales pollen might be underestimated. Allergen-specific T-cells are crucial in the sensitization process. The T-cell response to major allergens from alder, hazel, oak, hornbeam, chestnut, beech, and chestnut pollen has not yet been analyzed. Here, we characterized the cellular cross-reactivity of major allergens in Fagales pollen with Bet v 1. METHODS: T-cell-lines (TCL) were established from allergic individuals with Aln g 1, Car b 1, Ost c 1, Cor a 1, Fag s 1, Cas s 1, and Que a 1, and tested for reactivity with Bet v 1 and synthetic overlapping 12-mer peptides representing its primary sequence. Aln g 1-specific TCL was additionally tested with Aln g 1-derived peptides and all allergens. IgE-competition experiments with Aln g 1 and Bet v 1 were performed. RESULTS: T-cell-lines initiated with Fagales pollen allergens varied strongly in their reactivity with Bet v 1 and by the majority responded stronger to the original stimulus. Cross-reactivity was mostly restricted to the epitope Bet v 1142-153 . No distinct cross-reactivity of Aln g 1-specific T-cells with Bet v 1 was detected. Among 22 T-cell epitopes, Aln g 1 contained two immunodominant epitopes. Bet v 1 inhibited IgE-binding to Aln g 1 less potently than Aln g 1 itself. CONCLUSION: The cellular cross-reactivity of major Fagales pollen allergens with Bet v 1 was unincisive, particularly for Aln g 1, most akin to Bet v 1. Our results indicate that humoral and cellular responses to these allergens are not predominantly based on cross-reactivity with the major birch pollen allergen but suggest a Bet v 1-independent sensitization in individuals from birch tree-dominated areas.

Hemodialysis vascular access in elderly patients: A comprehensive review.

The number of elderly patients initiating hemodialysis (HD) increased considerably over the past decade. Arteriovenous fistulas (AVFs) are the preferred vascular access (VA) type in most HD patients. Choice of VA for older hemodialysis patients presents a challenge. The higher incidence of comorbidities, longer AVF maturation times, risk of primary failure, risk of patency loss, and shorter life expectancy are important factors to consider. In this review we provide a comprehensive analysis on maturation rates, primary failure, patency, and mortality regarding vascular access in patients older than 75 years of age.

IgE-cross-blocking antibodies to Fagales following sublingual immunotherapy with recombinant Bet v 1.

BACKGROUND: Evidence has accumulated that birch pollen immunotherapy reduces rhinoconjunctivitis to pollen of birch homologous trees. Therapeutic efficacy has been associated with IgE-blocking IgG antibodies. We have recently shown that sera collected after 16 weeks of sublingual immunotherapy with recombinant Bet v 1 (rBet v 1-SLIT) display strong IgE-blocking bioactivity for Bet v 1. Here, we assessed whether rBet v 1-SLIT-induced IgG antibodies display cross-blocking activity to related allergens in Fagales pollen. METHODS: IgE, IgG1 and IgG4 reactivity to recombinant Bet v 1, Aln g 1, Car b 1, Ost c 1, Cor a 1, Fag s 1, Cas s 1 and Que a 1 were assessed in pre- and post-SLIT samples of 17 individuals by ELISA. A basophil inhibition assay using stripped basophils re-sensitized with a serum pool containing high Bet v 1-specific IgE levels was established and used to assess CD63 expression in response to allergens after incubation with pre-SLIT or post-SLIT samples. IgG1 and IgG4 were depleted from post-SLIT samples to assess its contribution to IgE-cross-blocking. RESULTS: Sublingual immunotherapy with recombinant Bet v 1 boosted cross-reactive IgE antibodies and induced IgG1 and IgG4 antibodies with inter- and intra-individually differing reactivity to the homologs. Highly variable cross-blocking activities of post-SLIT samples to the different allergens were found. IgG1 and IgG4 antibodies displayed cross-blocking activity with individual variance. CONCLUSIONS: Our mechanistic approach suggested that immunotherapy with the reference allergen Bet v 1 induces individual repertoires of cross-reactive IgG1 and IgG4 antibodies. The cross-blocking bioactivity of these antibodies was also highly variable and neither predictable from protein homology nor IgE-cross-reactivity.

When eating makes you sick - Gastric stump obstruction caused by a phytobezoar. A case report and literature review.

INTRODUCTION AND IMPORTANCE: Bezoars result from undigested material having an incidence of 0.4-1% (Gunner et al., 2012). Impaired gastrointestinal motility is one of the risk factors. The aim of this article is to highlight the importance of this commonly disregarded entity as well as the different treatment modalities available. CASE PRESENTATION: A 68-year-old female presented to our emergency department complaining of colicky lower left abdominal pain associated with vomiting and absence of bowel movements for the past 4 days. She had a previous history of a subtotal gastrectomy due to gastric cancer. The physical examination revealed a lower left quadrant palpable mass. Abdominopelvic CT scan showed distension of the gastric remnant with anastomotic obstruction caused by a bezoar. Attempted endoscopic dissolution of the bezoar was unsuccessful. The patient then underwent surgery enterotomy proximal to the obstruction with extraction of the mass. CLINICAL DISCUSSION: Bezoars are responsible for 0.4%-4% of cases of mechanical gastrointestinal obstruction (Dikicier et al., 2015). Contrast-enhanced CT scan is the best diagnostic test with a sensitivity and specificity of 90% and 57%, respectively (Kim et al., 2003). Treatment options differ according to the type, size and location of the bezoar as well as clinical presentation. Conservative measures such as chemical dissolution and endoscopic fragmentation and extraction can be used with surgery being usually required for a bezoar-induced gastrointestinal obstruction. CONCLUSION: The clinical findings of bezoar-induced ileus do not differ from the other different causes of mechanical intestinal obstruction. Hence, a high grade of suspicion and an early radiological exam are the keys for a prompt diagnosis and treatment.

Wilkie's Syndrome: An Unexpected Finding.

Wilkie's syndrome is a rare pathology caused by extrinsic compression of the third part of the duodenum by the superior mesenteric artery (SMA) at its origin. The symptoms are variable and non-specific consisting of postprandial abdominal pain, nausea and vomiting, early satiety, anorexia, and weight loss. A contrast-enhanced CT scan is the standard imaging modality. Surgery is reserved for severe cases or those unresponsive to pharmacological treatment. We present a case of a 66-year-old woman with a history of prolonged postprandial abdominal pain, nausea, and substantial weight loss (30 kg in four months). Laboratory tests revealed acute renal failure with hypokalemia due to severe dehydration. She underwent an abdominal-pelvic CT scan that showed enlargement of the second and third parts of the duodenum, without an identifiable cause, followed by an upper gastrointestinal (GI) endoscopy that showed a dilated duodenum until D2 and inability of progression to D3, without mucosal abnormalities. Her MRI revealed considerable gastric and proximal duodenum distension with compression of D3 by the SMA. The patient underwent a laparoscopic duodenojejunostomy with intra-operative findings consistent with the diagnosis. The procedure and the postoperative period were uneventful, and the patient was discharged on the ninth postoperative day. Gastrografin study made at day six postop showed normal progression of the oral contrast. At the outpatient reevaluation one month postop, she remained asymptomatic and with progressive weight gain. Wilkie's syndrome is a rare form of intestinal obstruction, which is commonly disregarded. Its non-specific symptoms make it a challenging diagnosis and imply a high clinical suspicion. Among the different surgical options, duodenojejunostomy presents the best outcomes.

How UK-trained nurse volunteers working overseas can reduce healthcare inequalities.

Universal health coverage is an ambitious goal central to the eradication of poverty in low and middle-income countries. However, the number of qualified staff working in developing countries is not sufficient to meet the needs of the most vulnerable, and professional development opportunities for nurses are rare or non-existent. This article explores how UK-trained nurses can support the training of colleagues working in regions where resources are limited, and provides examples of current voluntary projects in old age care taking place in Sri Lanka and Nepal. It discusses the contribution that nurses can make to the reduction of healthcare inequalities worldwide and reflects on the benefits that such experiences can have on nursing practice in the UK.

Sharing skills in dementia care with staff overseas.

More than 35 million people worldwide are living with dementia. In some countries the existence of a health and social welfare state offers a level of support to those affected, but in many others resources are limited and inadequate, with responsibility for care lying primarily with relatives and friends. Significant efforts are being made by low and middle income nations to respond to the health needs of patients and carers, yet insufficient numbers of professionals and lack of specialist training opportunities are barriers that are difficult to overcome. Based on the author's volunteering experience in Sri Lanka, this article explores the role of UK trained nurses in supporting the development of dementia care services in countries where resources are limited. It discusses the contribution that nurses can make to the creation of services and reflects on the benefits that such exchanges can have on nursing practice in the UK.

Long-term release of carbon from grassland soil amended with different slurry particle size fractions: a laboratory incubation study.

Application of animal manure to agricultural soils enhances both native soil carbon (C) and overall (native soil C and added C) respiration. CO(2) effluxes were measured in a laboratory incubation study for 1465 days after the application of different slurry fractions (>2000, 425-2000, 250-425, 150-250, 45-150 and <45 µm) to a grassland soil. The slurry-derived C present in the soil was traced using the natural abundance δ(13)C method. We used two kinetic (single and two pool) models to fit the experimental data and to test the model validity with respect to long-term data sets. Mean residence times (MRTs) of the particle size based slurry-C fractions were estimated using these models and a linear (13)C natural abundance based approach. The results showed that slurry-C degradation in soil over time varied between the different particle size based slurry treatments. The two kinetic soil-C models were successful to predict medium- to long-term carbon release from soil amended with animal slurry. The estimated MRTs did vary between the linear (3.8-5.6 years) and non-linear based (0.8-3.8 years) (model) approaches. Slurry-derived C could still be (isotopically) detected in the soil 4 years after slurry application using the natural abundance δ(13)C method. This suggests that it may take a decadal timescale or longer before the entire amount of C introduced through whole slurry amendments to grassland soils is fully dissipated.

Short term N2O, CH4 and CO2 production from soil sampled at different depths and amended with a fine sized slurry fraction.

Little is known about the interaction of the soil's physicochemical environment and livestock slurry throughout the soil profile. In this study, five soil layers (2-6, 6-10, 10-14, 14-18, 18-22 cm) amended with a<45 microm slurry fraction (FS) or water (control) were incubated for 58 d at 20 degrees C to determine the effect of the slurry position in the soil profile on the production of CO(2), N(2)O, CH(4) and total greenhouse gas (GHG) expressed as CO(2) equivalent. FS application increased the CO(2) production in all soil layers by 3-8 times compared to the controls. The total CO(2) produced during the incubation in the 2-6 cm amended soil layer (>1,600 mg CO(2)-C kg(-1) dry soil) was significantly greater (P<0.05) than in other amended layers (<800 mg CO(2)-C kg(-1) dry soil). No detectable N(2)O production was observed from control treatments, and application of FS induced a slow increase in N(2)O production. N(2)O production occurred earlier and at a higher rate in deeper soil layers. Furthermore, a good correlation (r=0.899, P<0.05) was observed between N(2)O production and soil depth. The higher N(2)O production in the deeper soil layers could have been due to enhanced denitrification promoted by a lower aeration and low soil respiration in the deep soil. At the end of the incubation, >11% of the total applied N was lost as N(2)O from the two deeper soil layers against 2.5-5% in all other soil layers. Methane production was only observed from FS amended treatments within the first 7d (range 0.02-0.41 mg C kg(-1) soil d(-1)). The greatest net production of GHGs, expressed as CO(2) equivalents, was observed from the two deeper soil layers ( approximately 4.5 CO(2) eq kg(-1) soil). N(2)O and CO(2) contributed equally (50%) to the total GHG production in 2-14 cm soil layers, whereas N(2)O contributed reached 80% to the total GHG production in the deeper soil layers. The CH(4) contribution was not significant in any treatment.