A2 to B Blood Type Incompatible Deceased Donor Kidney Transplantation in a Recipient Infected with the Human Immunodeficiency Virus: A Case Report.

BACKGROUND: With the introduction of the Kidney Allocation System in the United States in December 2014, transplant centers can list eligible B blood type recipients for A2 organ offers. There have been no prior reports of ABO incompatible A2 to B deceased donor kidney transplantation in human immunodeficiency virus-positive (HIV+) recipients to guide clinicians on enrolling or performing A2 to B transplantations in HIV+ candidates. We are the first to report a case of A2 to B deceased donor kidney transplantation in an HIV+ recipient with good intermediate-term results. METHODS AND RESULTS: We describe an HIV+ 39-year-old African American man with end-stage renal disease who underwent A2 to B blood type incompatible deceased donor kidney transplantation. Prior to transplantation, he had an undetectable HIV viral load. The patient was unsensitized, with his most recent anti-A titer data being 1:2 IgG and 1:32 IgG/IgM. Induction therapy of basiliximab and methylprednisolone was followed by a postoperative regimen of plasma exchange, intravenous immunoglobulin, and rituximab with maintenance on tacrolimus, mycophenolate mofetil, and prednisone. He had delayed graft function without rejection on allograft biopsy. Nadir serum creatinine was 2.0 mg/dL. He continued to have an undetectable viral load on the same antiretroviral therapy adjusted for renal function. CONCLUSIONS: To our knowledge, this is the first report of A2 to B deceased donor kidney transplantation in an HIV+ recipient with good intermediate-term results, suggesting that A2 donor kidneys may be considered for transplantation into HIV+ B-blood type wait list candidates.

Diagnosis and management of common tinea infections.

The estimated lifetime risk of acquiring a dermatophyte infection is between 10 and 20 percent. Recognition and appropriate treatment of these infections reduces both morbidity and discomfort and lessens the possibility of transmission. Dermatophyte infections are classified according to the affected body site, such as tinea capitis (scalp), tinea barbae (beard area), tinea corporis (skin other than bearded area, scalp, groin, hands or feet), tinea cruris (groin, perineum and perineal areas), tinea pedis (feet), tinea manuum (hands) and tinea unguium (nails). To determine the best treatment approach, the physician must consider several factors: (1) the anatomic locations of the infection, (2) the safety, efficacy and cost of treatment options and (3) the likelihood that the patient will comply with treatment. Newer medications in both oral and topical forms, including imidazoles and allylamines, have greatly increased the cure rate for tinea infections. Certain types of tinea may be treated with "pulse" regimens; these innovative therapies lower treatment costs and improve patient compliance.

Initial management of the patient with newly diagnosed diabetes.

A family physician is often the one who makes an initial diagnosis of diabetes. The physician must consider the impact of this diagnosis on both the patient and the patient's family members. Outpatient management is less costly and less traumatic for the patient than inpatient care. Initial management goals are control of hyperglycemia, correction of fluid and electrolyte imbalances, and avoidance of hypoglycemia. For patients with type I (insulin-dependent) diabetes, the initial insulin dosage ranges from 0.25 to 1.0 U per kg per day. For patients with type II (non-insulin-dependent) diabetes, standard therapy begins with dietary modifications, exercise and an oral hypoglycemic agent, if needed. Insulin is indicated in patients with type II diabetes during times of acute stress, infection, surgery and pregnancy, and if the patient is allergic to sulfonylureas. Initially, patients only need to have a basic understanding of glucose monitoring, medications, diet and symptoms of hypoglycemia. Simple instructions can help the patient achieve glycemic control without being overwhelmed with information. As the patient learns more about diabetes and the treatment regimen, therapy can become more intensive.

Allergic rhinitis.

Allergic rhinitis commonly manifests for the first time in childhood or adolescence with seasonal or perennial sneezing, rhinorrhea, nasal congestion, and pruritus of the nose, eyes and throat. The nasal mucosa are pale blue and boggy, with a clear discharge. Patients should be instructed to avoid breathing tobacco smoke, to remove bedroom carpeting, to use foam pillows, to enclose mattresses and box springs in plastic covers, to keep house windows closed and to reduce indoor humidity by using air conditioning. If these avoidance procedures, together with oral and ocular antihistamines and/or decongestants, do not provide relief of symptoms, intranasal corticosteroids and cromolyn may be prescribed. Pharmacotherapy is more effective if it is used prophylactically. Second-generation antihistamines may reduce sedative and anticholinergic side effects. Intranasal decongestants should be used for only three to four days. Immunotherapy is appropriate for patients who remain unresponsive to therapy. Intranasal cromolyn should be the first drug considered in the treatment of pregnant women.

Efficacy of sliding-scale insulin therapy: a comparison with prospective regimens.

OBJECTIVE: To compare the efficacy of retroactive sliding-scale insulin therapy, proactive therapy, and a combination of the two methods in establishing glycemic control in hospitalized diabetic patients. METHODS: Medical records of 47 diabetic ketoacidosis inpatients were reviewed retrospectively. RESULTS: The sliding-scale insulin therapy group's glucose deviation score (167.4) was significantly higher than the deviation for the proactive (112.9) and combination (121.3) groups. The sliding-scale insulin therapy group also had a significantly higher median glucose value (262.5) than the proactive (199.9) and combination (221.2) groups as well as a significantly higher number of nursing shifts (0.70) in which a glucose of 250 mg/dl or greater was recorded than in the proactive (0.37) and combination (0.40) groups. The proactive group was on their treatment regimen significantly less time than the combination group (5.5 vs 10.4 nursing shifts, respectively). The proactive group was hospitalized significantly fewer days (4.4) than the combination (6.3) and sliding-scale insulin therapy (6.3) groups. CONCLUSIONS: The present study lends support to previous concerns that sliding-scale insulin therapy is less effective than preventive therapy in the management of hospitalized diabetic patients.

Mississippi: who's staffing our emergency departments?

Emergency services in Mississippi have come under scrutiny over the past few years. As part of a summer research project, we surveyed all 88 Mississippi emergency departments available to the public to determine physician staffing characteristics. At four times during one week (10 a.m. and 10 p.m. on a Tuesday and a Saturday), we determined whether a physician was present, their specialty, board certification/resident status, and whether they were from the community. Our paper presents and discusses the findings.

Graduate follow-up in the University of Mississippi family practice residency program.

Practice profiles in 120 University Medical Center Department of Family Medicine residency graduates were assessed by questionnaire and follow-up telephone calls. Physician credentials, career satisfaction, and evaluation of residency training were also addressed. Findings include some preferences for partnership or group practice settings and practices in communities of less than 25,000. Eighty percent of graduates remain in Mississippi, and most are satisfied with their careers and the residency training they received. Changing patterns in areas such as obstetrical care provided and Medicare/Medicaid acceptance suggest new surveys may be needed to provide the department with information that will assist in meeting its goals.

Immunization of the elderly. A vital part of routine healthcare.

The vaccines recommended for routine use in healthy elderly persons (influenza vaccine, pneumococcal vaccine, tetanus-diphtheria toxoid) have benefits far outweighing any risks, yet they are under-utilized. Every patient visit to a healthcare provider presents an opportunity for assessment of the patient's immune status, but preventive care for the elderly is often neglected. Elderly patients are willing to change their habits to maintain good health. The success of any program aimed at protecting this age-group is dependent on a change in habit by the physicians and institutions that provide their healthcare.