Results of the conversion to everolimus in renal transplant recipients with posttransplantation malignancies.

Management of posttransplantation malignancies should include control of the neoplasia and preservation of renal function. Conversion to everolimus (EVL) would potentially have both effects. Twenty-one patients were converted to EVL due to posttransplantation neoplasms. We have presented herein descriptive data and postconversion (PC) outcomes among subjects of mean age 53.6 +/- 10.1 years (range, 36-69), 57.1% were males, undergoing conversion at 108.2 +/- 74.7 (range, 5-316) months after transplantation. All patients received standard immunosuppressive therapy and 9.5% had been induced with thymoglobulin. Malignant neoplasms were as follows: skin (n = 7), gynecological (n = 3), gastrointestinal (n = 3), PTLD (n = 2), renal (n = 2), CNS (n = 1), seminoma (n = 1), Kaposi's sarcoma (n = 1), and prostate cancer (n = 1). PC to EVL, calcineurin inhibitors (CNIs) were discontinued in 18 of 19 patients, mycophenolate in 9/12, and azathioprine in 5/7; all patients continued to receive steroids. In 16 patients (79%) tumors were removed. Chemotherapy was performed in 2 patients with PTLD and radiotherapy was performed in 1 patient with prostate cancer. Mean follow-up was 505 days (range, 59-1151); baseline glomerular filtration rate (GFR) was 53.5 +/- 21.6 mL/min versus 48.5 +/- 25.7 mL/min (P = not significant [NS]) at the last control. One patient experienced graft loss at day 744 after conversion due to chronic rejection. Adverse events were observed in 57% of patients and 28% displayed infections; no patient discontinued EVL. There were 2 deaths: 1 due to an infection and the other due to postsurgical complication. No deaths due to cancer progression were observed. The results observed in this series suggested that conversion to EVL for a posttransplantation neoplasm is a valid therapeutic alternative to preserve graft function and control disease progression.

Central hemodynamic monitoring in a woman with acute respiratory insufficiency after evacuation of a complete molar pregnancy. A case report.

BACKGROUND: The incidence of hydatiform moles in the United States is approximately 1 in 1,200 pregnancies. Acute respiratory insufficiency is a known complication of molar pregnancies, occurring in 8-11%. While there have been numerous case reports and retrospective studies describing respiratory complications following evacuation of hydatiform moles, only a limited number of reports provide data from central hemodynamic monitoring in patients with this complication. CASE: A 16-year-old, Hispanic woman, gravida 1, para 0, presented to the emergency room at 13 weeks' gestational age by menstrual dating with complaints of vaginal bleeding for two days. The serum quantitative beta-hCG level was 1 x 10(6) mIU/mL, and a bedside sonogram was consistent with hydatiform mole. After informed consent was obtained, the patient underwent dilation and suction curettage. Approximately five minutes after evacuation of the uterus was begun, the patient developed pulmonary edema in the setting of oliguria. A pulmonary artery catheter was inserted to determine the etiology of the edema. The initial pulmonary capillary wedge pressure was > 18 mm Hg, consistent with hydrostatic pulmonary edema. Volume overload in association with a reduced colloid osmotic pressure to wedge pressure gradient was primarily responsible for the pulmonary edema in this patient. CONCLUSION: The majority of case reports of pulmonary complications after evacuation of a hydatidiform mole were either presumed or documented to be due to trophoblastic pulmonary embolism. Thyrotoxicosis, fluid overload with dilutional anemia, preeclampsia, sepsis, hypoalbuminemia or a combination of these factors may be more common than trophoblastic embolization.

Cervical length after multifetal pregnancy reduction in remaining twin gestations.

OBJECTIVE: Multifetal pregnancy reduction is associated with an increased risk of prematurity. Because cervical length correlates with preterm delivery risk, we sought to determine whether multifetal pregnancy reduction twin gestations are associated with shorter cervical lengths compared with non-multifetal pregnancy reduction twins. STUDY DESIGN: We compared an historic cohort of patients who underwent multifetal pregnancy reduction to twins (n = 35) to a control group of twin gestations without multifetal pregnancy reduction (n = 83) from July 1996 to January 2000. Both groups of patients were treated with identical protocols. Cervical lengths across gestation and pregnancy outcomes were compared. RESULTS: Study and control groups did not differ significantly in mean maternal age (37.8 +/- 4.9 years vs 35.5 +/- 6.2 years; P =.06), median parity (0 [range, 0-1] vs 0 [range, 0-2]; P =.56), or mean gestational age at delivery (36.2 +/- 2.6 weeks vs 35.8 +/- 3.8 weeks; P =.50). The proportion delivering before 35 weeks of gestation was not significantly different (14.3% vs 30.1%; P =.10) nor was delivery before 32 weeks of gestation (8.6% vs 8.4%; P =.98). Cervical length did not differ significantly between the 2 groups. At 14 to 19 weeks the median was 3.9 cm (range, 2.4-6.0 cm) in the multifetal pregnancy reduction group versus 3.7 cm (range, 3.1-4.7 cm) in the control subjects (P =.15); at 20 to 25 weeks, the medians were 3.2 cm (range, 2.2-5.4 cm) and 3.7 cm (range, 1.5-5.7 cm), respectively (P =.43); and at 26 to 31 weeks the medians were 3.5 cm (range, 1.2-5.9 cm) versus 3.8 cm (range, 1.2-5.3 cm), respectively (P =.56). CONCLUSION: Cervical length across gestation in twin pregnancies is not affected by multifetal pregnancy reduction, despite the likely inflammatory response expected to accompany this procedure.

Meconium staining and meconium aspiration syndrome. Is there seasonal variation?

OBJECTIVE: To determine whether the incidence of pregnancies complicated by meconium-stained amniotic fluid (MSAF) or meconium aspiration syndrome (MAS) differs with seasonal changes. METHODS: An established perinatal database was used to identify all term (> or = 37 weeks) singleton gestations resulting in a live birth from January 1, 1997 to December 31, 1999. Patients were divided into groups based on the season of delivery: winter (December-February), spring (March-May), summer (June-August), and fall (September-November). Rates of MSAF (%MSAF/total deliveries) and MAS (%MAS/total deliveries) were calculated and compared among seasons. Local climatic data (average monthly temperature and monthly precipitation) were obtained from the National Weather Service. Multiple logistic regression analysis was performed to control for the effects of confounding variables and odds ratio (OR) with 95% confidence intervals (CI) were calculated. p < 0.05 was considered significant. RESULTS: Over the 3-year study period there were a total of 14,888 deliveries meeting the criteria. MSAF occurred in 3,206 (21.5%) deliveries and MAS developed in 92 (0.6% of total, 2.9% of MSAF). There were no differences in the rate of MSAF (p = 0.2) or MAS (p = 0.6) between seasons. By logistic regression neither season, temperature, nor precipitation were associated with MSAF or MAS. CONCLUSIONS: Our findings suggest that over the period examined there were no significant seasonal variations in the incidence of MSAF or MAS.

First-trimester embryo size discordance: a predictor of premature birth following multifetal pregnancy reduction.

OBJECTIVE: We have previously reported a correlation between the starting number of embryos for multifetal pregnancy reduction (MFPR) and discordance in size during the first trimester. Here we evaluated the correlation between the degree of discordance and length of gestation in the remaining fetuses. DESIGN: Observational clinical series. SETTING: Academic medical center with a single physician who performs a large number of MFPRs. PATIENT(S): Analysis of 252 consecutive MFPRs from a 2.5-year period (1996-1998). INTERVENTION(S): MFPR for patients with multifetal pregnancies. MAIN OUTCOME MEASURE(S): We evaluated the correlation between the degree of discordance in embryo size, as measured by the greatest difference in crown-rump length (CRL) (delta max), and the length of gestation. RESULT(S): Embryo size discordance was related to length of gestation of the remaining fetuses after MFPR. Of 72 patients with a delta max >5 mm, the rate of severe premature birth (delivery at <28 weeks' gestation) was 9.7%, compared with 1.7% for patients with a delta max <5 mm (P<.01). Of patients with severe premature birth, 70% had delta max >5 mm, compared with less than 30% in patients who delivered after 28 weeks (P<.05). CONCLUSION(S): Variations in embryo growth patterns in multifetal pregnancies may be observed even in the first trimester, which may be predictive of late pregnancy outcomes. With a delta max > or =5 mm, there is a significant increase in the risk of severe premature birth (delivery at <28 weeks).

Treatment of heterotopic cervical and intrauterine pregnancy.

OBJECTIVE: To find a suitable technique to selectively terminate a cervically implanted embryo while maintaining viability of a concomitant intrauterine pregnancy. METHODS: A 34-year-old patient achieved a twin pregnancy after 4 IVF attempts. Ultrasound revealed a viable intrauterine and cervical pregnancy. Given our experience with KCl injection for fetal reduction, we offered the patient an attempt to reduce the cervical pregnancy. RESULTS: Best visualization in this case was obtained by transabdominal scanning. A 6-inch 20-gauge spinal needle was inserted transcervically and maneuvered into the thorax of the embryo. Fetal heart rate ceased even before KCl could be injected. Then 3 cm(3) of saline were injected to provide better visualization of the cervical fetus, and to confirm absence of heart beat. The patient had minor vaginal bleeding for several days. The intrauterine pregnancy progressed uneventfully through 36(1)/(2) weeks with delivery of a healthy, 2, 700-gram newborn. CONCLUSION: Cervical pregnancy is usually considered a life-threatening event. Other factors such as concomitant intrauterine pregnancy and the patient's infertility history generally would be secondary concerns. In this case, we were able to selectively terminate the cervical pregnancy, while preserving the intrauterine one, allowing this couple to have a healthy newborn. Further cases will be necessary to appropriately define risk rates for such an approach.

Repair kinetics of amnion cells after microsurgical injury.

OBJECTIVE: There is a paucity of data regarding healing of fetal membranes. We assessed the repairing ability of a microsurgically-injured monolayer of amnion-derived cells compared to an endothelial cell line. MATERIALS AND METHODS: Amnion-derived cells (FL cells) were grown to confluence in 10% fetal calf serum (FCS). A microsurgical incision was performed under an inverted microscope. The area of each incision was measured at times 0, 6, 12 and 24 h using MCID M4 image analysis software. The experiments were repeated using 1% FCS. The observations were also made replacing the media at 6 and 12 h. Umbilical-cord-derived endothelial cells were used for comparison. The rate of repair of the incision was measured using three methods: (a) absolute closure rate (ACR): (A0-A1)/T, where A0 is the original incisional area, and A1 is the new area at interval T: (b) relative percentage rate (RPR): (A0-A1)/A0/T x 100, and (c) healing rate (HR): (A0-A1)/A0 x 100. RESULTS: Amnion cells were capable of repairing the microsurgical defect. The ACR decreased over time, and was higher with larger defects. A lower concentration of FCS nor the addition of fresh media altered the repair process significantly. Endothelial cells were significantly faster than amnion cells or amnion-supplemented cells with endothelial media. The RPR remained relatively constant for all groups, suggesting Gompertzian kinetics. CONCLUSIONS: Amnion cells are capable of repairing a surgical defect at a relatively constant percent rate, but are slower than an endothelial cell line. The decreased rate of closure over time may be due to relative contact inhibition. Further studies will concentrate on the molecular and cellular mechanisms involved in this process.

A propósito de un caso de enfermedad de Ormond: fibrosis retroperitoneal idiopática / Apropos of a case of Ormond's disease: idiopathic retroperitoneal fibrosis

Este trabajo presente un caso de enfermedad de Ormond en un hombre de 56 años de edad. El cuadro se caracterizó por presentar un síndrome general, edemas en ambos miembros inferiores, insuficiencia renal y anemia. No presentó dolor abdominal o lumbar, ni hubo ingestión previa de metisergida, betabloqueantes u otras drogas. Tampoco había evidencias de enfermedad asociada alguna. Seis meses antes, el paciente no había presentado este síndrome y después de 37 días de postoperatorio, fue dado de alta hospitalaria. Por ecografía y tomografía computada se constató una masa retroperitoneal, cuya histopatología demostró que se trataba de una fibrosis retroperitoneal idiopática (IRF). La ureterolisis presentó dificuldades técnicas. El paciente comenzó a ser tratado con progesterona después de un mes de la operación. Seis meses después de su egreso, se efectuó una nueva TC que demuestra remisión total de su enfermedad hasta la fecha, encontrándose el paciente asintomático y con función renal normal

A propósito de un caso de enfermedad de Ormond: fibrosis retroperitoneal idiopática / Apropos of a case of Ormonds disease: idiopathic retroperitoneal fibrosis

Este trabajo presente un caso de enfermedad de Ormond en un hombre de 56 años de edad. El cuadro se caracterizó por presentar un síndrome general, edemas en ambos miembros inferiores, insuficiencia renal y anemia. No presentó dolor abdominal o lumbar, ni hubo ingestión previa de metisergida, betabloqueantes u otras drogas. Tampoco había evidencias de enfermedad asociada alguna. Seis meses antes, el paciente no había presentado este síndrome y después de 37 días de postoperatorio, fue dado de alta hospitalaria. Por ecografía y tomografía computada se constató una masa retroperitoneal, cuya histopatología demostró que se trataba de una fibrosis retroperitoneal idiopática (IRF). La ureterolisis presentó dificuldades técnicas. El paciente comenzó a ser tratado con progesterona después de un mes de la operación. Seis meses después de su egreso, se efectuó una nueva TC que demuestra remisión total de su enfermedad hasta la fecha, encontrándose el paciente asintomático y con función renal normal (AU)

Empleo de dosis elevadas de fosfato sódico de betametasona inyectable en el tratamiento de choque séptico y rechazo inminente de trasplante / The use of high dose of injectable betamethasone sodium phosphate in the treatment of septic shock and imminente transplantation rejection

Se administró fosfato sódico de betametasona inyectable, como bolo intravenoso, a 20 pacientes; 18 con choque séptico y dos con rechazo inminente agudo de trasplante renal. Dentro de las 4 horas siguientes al diagnóstico de choque séptico se inició la administración corticosteroide coadyuvante, a una posología de 2.88 a 3.11 mg/kg, cada cuatro horas. Los dos pacientes con rechazo inminente agudo de trasplante renal fueron tratados cada 24 horas. Cuando se consideró necesario, se emplearon tratamientos concomitantes, entre ellos: líquidos intravenosos, asistencia respiratoriaa, antimicrobianos, vasodilatadores, diuréticos, digital y medicamentos antipiréticos. Entre los valores vigilados durante el estudio, los signos vitales, gases de sangre arterial, presión venosa central, recuento sanguíneo completo, química sanguínea, electrocardiogramas y radiografías torácicas fueron indicadores de mejoría del estado de cada pacientes hacia el final del tratamiento. Hubo mejoría clínica rápida dentro de las primeras 4 a 8 horas entre los pacientes con choque séptico y a las 48 horas entre los pacientes con trasplante renal, requiriendo dos a tres dosis del medicamento. Hubo remisión completa del estado de choque en los 18 pacientes (100%) con diagnóstico de choque séptico; los dos casos con rechazo inminente de trasplante renal revirtieron el problema. La tolerancia fue buena, sin que haya habido comunicado de experiencias adversas

Celestone phosphate injection high dose: treatment of septic shock and impending transplant rejection.

Celestone Phosphate Injection was administered as an intravenous bolus to twenty patients, eighteen with septic shock and two with impending acute renal transplant rejection. Within 4 hours following the diagnosis of septic shock, adjunctive corticosteroid therapy in a dosage ranging from 2.88-3.11 mg/kg was given every 4 hours. The two patients with impending acute renal transplant rejection were dosed every 24 hours. Intravenous fluids, ventilatory assistance, antimicrobial agents, vasoactive agents, diuretics, digitalis and antipyretics were among the concomitant therapies. Among measurements monitored during the study, vital signs, arterial blood gases, central venous pressure, complete blood count, blood chemistry, electrocardiograms and chest radiographs indicated improvement in each patient's condition by the end of therapy. Rapid clinical improvement occurred within 4-8 hours for patients with septic shock and within 48 hours for patients with kidney transplants. Two to three doses of medication were required. Complete reversal of shock was achieved in eighteen (100%) patients with septic shock; both (100%) renal transplant patients experienced reversal of impending rejection. Tolerance was good and no adverse experiences were reported.