Biomedical subjects
Publications and source records attributed to A Nocera.
A case of fatal aluminium phosphide poisoning that forced the evacuation of the emergency department of a Sydney teaching hospital highlights the importance of hospitals being able to safely manage hazardous materials incidents.
Disasters and mass casualty incidents are traumatic events that are followed by a predictable media response. Managing the media response appropriately can avoid problems in a hospital's security, command, control and communications structures and mitigate the stress of hospital staff attempting to deal with the incident.
The purpose of this study was to determine the frequency and the outcome of de novo malignancies in a cohort of renal transplant paediatric patients. The records of 493 kidney transplants, carried out in 454 paediatric recipients at the three paediatric transplant centres of the North Italy Transplant programme (NITp, Italy) were reviewed. 10 cases of malignancies (2.2%) comprising both PTLD (post-transplant lymphoproliferative disorders) (6 cases, 1.3%) and non-PTLD malignancies (4 cases, 0.88%) were reported. Non-PTLD included one urothelial carcinoma and one Wilms' tumour of the recipient's left native kidney, one abdominal dysgerminoma and one optic nerve glioma of the left eye. The PTLD consisted of localised or disseminated Epstein-Barr virus (EBV)--associated B-lymphocyte monoclonal (5 cases) and polyclonal (1 case) proliferations. All patients suffering from PTLD had been EBV-negative at the time of transplantation, but developed EBV primary infection after transplantation. All PTLD patient donors were EBV-positive. In addition, all but 1 patient received, before and/or after transplantation, a range of immunosuppressive drugs in addition to the baseline prophylactic immunosuppressive regimen. Moreover, 3 patients suffered from syndromes associated with a genetic predisposition to cancer. Finally, the malignancies reported here were associated with 20% graft failure and 20% mortality rates.
BACKGROUND AND OBJECTIVE: gd T-cell lymphomas are only exceptionally observed in transplanted patients. Aim of this study was the detailed characterization of one such case. DESIGN AND METHODS: The patient developed spontaneous splenic rupture six years after kidney transplantation. The splenic red pulp was infiltrated by medium-sized and large lymphoid cells with two or more nucleoli. At autopsy, similar lymphoid cells infiltrated the hepatic sinusoids. Histologic, immunologic and molecular studies were carried out. RESULTS: By immunohistochemistry, the atypical lymphoid cells were found to express CD3, CD45 and CD43, indicating their T-lineage origin. Approximately 99% of spleen mononuclear cells (MNC) were CD3(+), gammadelta TcR+, CD4-, CD8-, alphabeta TcR-. A clonal gammadelta TcR rearrangement (Vgamma1-Jgamma1.3/2.3-Cgamma2; Vdelta1-Ddelta2-Jdelta1) was detected. The final diagnosis was peripheral T-cell lymphoma, hepato-splenic gammadelta-type. EBV infection of spleen MNC was documented by molecular studies. However, in situ hybridization for EBER-1 (EBV-RNA) showed that only a minority of malignant lymphoid cells (5-7%) were EBV-infected. INTERPRETATION AND CONCLUSIONS: It is concluded that EBV infection was as a late event involving an already transformed gd T-cell clone.
Bone marrow transplantation (BMT) from an HLA-identical donor is an established therapy to cure homozygous beta-thalassemia. Approximately 10% of thalassemic patients developed a persistent mixed chimerism (PMC) after BMT characterized by stable coexistence of host and donor cells in all hematopoietic compartments. Interestingly, in the erythrocytic lineage, close to normal levels of hemoglobin can be observed in the absence of complete donor engraftment. In the lymphocytic lineage, the striking feature is the coexistence of immune cells. This implies a state of tolerance or anergy, raising the issue of immunocompetence of the host. To understand the state of the T cells in PMC, repertoire analysis and functional studies were performed on cells from 3 ex-thalassemics. Repertoire analysis showed a profound skewing. This was due to an expansion of some T cells and not to a collapse of the repertoire, because phytohemagglutinin stimulation showed the presence of a complex repertoire. The immunocompetence of the chimeric immune systems was further established by showing responses to alloantigens and recall antigens in vitro. Both host and donor lymphocytes were observed in the cultures. These data suggest that the expanded T cells play a role in specific tolerance while allowing a normal immune status in these patients.
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BACKGROUND: Despite numerous advances in the areas of organ preservation, histocompatibility, and immunosuppression, chronic deterioration of organ allograft function, referred to as "chronic rejection," still remains the main obstacle to long-term graft survival. The common feature of chronic rejection is a concentric generalized graft arteriosclerosis associated with interstitial fibrosis that reflects an allogeneic injury to graft arteries, possibly worsened by other alloantigen-independent risk factors. The presence of the angiotensin I-converting enzyme (ACE) gene-deleted (D) allele has been associated, when in homozygosity, with increased risk of cardiovascular diseases and with an accelerated progression of organ damage in a variety of kidney diseases. In this study, we analyzed whether the insertion/deletion polymorphism of the ACE gene, because of its negative prognostic impact on cardiovascular and renal pathology, could have any influence on kidney graft survival in pediatric recipients. METHODS: DNA was isolated from peripheral blood mononuclear cells from 146 pediatric dialysis patients (mean age: 12.9 years) who received a first kidney graft at our center between December 1985 and July 1997. To rule out any bias due to acute graft losses, only 119 patients who reached a minimum of 12 months of graft survival were considered for statistical analysis. The insertion/deletion polymorphism of the ACE gene was detected using a polymerase chain reaction technique with two flanking primers. RESULTS: The results demonstrated that (i) the distribution of DD and non-DD (ID + II) genotypes was 36.1% (43 patients) and 63.8% (76 patients), respectively; (ii) actuarial graft survival at 7, 8, 9, and 10 years in patients with non-DD genotype was significantly higher than that in patients with DD genotype (7 years: 94.6% vs. 72.4%, P<0.05; 8 years: 94.6% vs. 62%, P<0.025; 9 years: 87.3% vs. 51.4%, P<0.025; 10 years: 76.3% vs. 25.7%, P<0.01). CONCLUSIONS: In conclusion, the above data indicate that DD genotype is associated in pediatric kidney graft recipients with a shorter long-term kidney graft survival and suggest a possible role of this genotype as a cofactor in the progression of nonimmunological injuries leading to chronic kidney graft failure.
Antigenic peptides with substituted side chains inhibit immune responses to a number of recall Ags from infectious agents in vitro. Here we show that the same strategy can be applied to peptides derived from a pollen protein, the major allergen of Parietaria judaica(Par j1), a plant responsible for most allergenic sensitization in the southern Mediterranean area. Three T cell lines responding to Par j1 protein were used to identify a stimulatory peptide. Two different monosubstituted altered peptide ligands (APL) were identified that bound to the HLA-DR of the responders, did not stimulate the T cell lines on their own, and decreased the response to subsaturating amounts of the unmodified stimulatory peptide. Most important, these APL were able to inhibit the response of these cell lines to intact Par j1 protein. A third monosubstituted peptide bound to the HLA-DR but did not show inhibitory activity. The two APL had a lower affinity than the unsubstituted peptide for the HLA-DR. The last two observations make MHC blockade an unlikely explanation for the observed effect. These results indicate the action of a specific peptide-mediated antagonism that may be useful in controlling the T cell component of an allergic response.
From June 1985 to December 1998, 173 pediatric renal transplants were carried out in 170 patients at our center. From this pool, 73 patients (34 males and 39 females) with a follow-up of 48 months were examined. In all patients, ureteroneocystostomy was performed according to the Lich-Grégoire procedure. All patients were treated with cyclosporin A (CsA)-based immunosuppression, including prednisone and sometimes azathioprine (AZA). Six months after transplantation, voiding cystography (VCU) was performed in all patients and reflux was classified from Grade I to Grade IV. The patients were divided into two groups: those with reflux (Group A: 25 patients) and those without (Group B: 48 patients). Grade I reflux was found in four patients, Grade II in seven patients, Grade III in seven patients, and Grade IV in seven patients. All the patients with severe reflux (Grade IV) underwent a corrective surgical procedure. Both groups were examined for immunologic and non-immunologic risk factors and no significant differences were found. Analysis of patient and graft survival rates revealed no statistical differences (NS) between Groups A and B. Mean serum creatinine (mg/dL) was 1.06 +/- 0.28 and 1.12 +/- 0.41 at 4 yr in Groups A and B, respectively (NS). Mean calculated creatinine clearance (cCrC; ml/min) was 76.74 +/- 15.92 and 77.96 +/- 15.66 in Groups A and B, respectively (NS). The analysis was further extended by considering the grade of reflux (I to IV). Again, no significant differences in the above parameters emerged between the reflux sub-groups; only in the Grade IV sub-group was a slight decrease in cCrC detected, although this difference was not statistically significant when compared with the other sub-groups. In conclusion, vesico-ureteral reflux (VUR) does not seem to negatively affect graft function. However, as all severe reflux patients (Grade IV) were surgically corrected, no conclusions can be drawn with regard to the influence of Grade IV reflux on long-term graft function.
BACKGROUND: The objective of this study was to review the systems of disaster triage used by Australian State and Territory ambulance services and compare their triage taxonomy, methodology and documentation with the Australian Council on Health Care Standard's (ACHCS) National Triage Scale, which is used in all Australian hospital emergency departments. METHODS: A postal survey of the State and Territory ambulance services during October 1996 was conducted. Details of the mass casualty incident (MCI) triage systems were then compared with the ACHCS National Triage Scale. Colours specified or used on a triage tag were checked for compliance with Standards Australia AS-2700 1996 Colour Standards for General Purposes. Participants consisted of those State and Territory ambulance services which would be the initial emergency medical service responders in the event of an MCI in an Australian capital city, and the ACHCS. The main outcome measure was the homology between the respective triage taxonomies, methodologies and documentation systems. RESULTS: All eight State and Territory ambulance services used a numerical and colour coded system to indicate triage priority during an MCI. There were five different triage tag designs for triage documentation, six different triage taxonomies and five different triage methodologies with minimal homology between the different triage systems and the National Triage Scale used in hospitals. Only two ambulance triage systems specifically triaged emotional disturbance. Several triage tags and their patient attachments were made from perishable materials and are thus likely to fail under field conditions. CONCLUSION: The multiplicity of triage systems used within Australia will result in avoidable confusion, thus hindering the medical response to an MCI, especially for incidents near State or Territory borders. There is little evidence to support the continued use of triage tags. Australia needs to develop a uniform system of patient triage as a national priority.
BACKGROUND: The purpose of this study was to create a system of mass casualty incident triage that provides a common language platform for both ambulance and hospital personnel based upon standard daily operating procedures for both groups. METHODS: An annotated literature review was conducted. RESULTS: The Homebush Triage Standard taxonomy consists of five categories: immediate, urgent, not urgent, dying and dead, which are given the phonetic alphabet designations of Alpha, Bravo, Charlie, Delta and Echo, respectively, to facilitate radio voice communications. Colours are assigned to each category: red (Homebush Red), yellow (Homebush Gold), green (Homebush Green), white and black comply with Standards Australia AS-2700 1996 Colour Standard for General Purposes, to ensure triage materials have consistent production standards. Numbers are reserved to either quantify or stratify individuals within a particular triage category. The Homebush Triage Standard methodology is based on START (Simple Triage Assessment and Rapid Transport) and SAVE (Secondary Assessment of Victim Endpoint) and documents triage priority using geographic triage with triage flags, instead of triage tags. CONCLUSION: The Homebush Triage Standard provides a basis for both seamless patient reassessment at all points along the casualty evacuation chain and the audit of the medical response to mass casualty incidents. It allows hospital and ambulance staff to keep working using familiar routines and removes fundamental barriers to good communication during a time of crisis.
BACKGROUND: The aim of the present review was to assess the suitability of hospital disaster medical teams' training, personal safety and medical equipment for site casualty work at multiple casualty incidents (MCI), and to compare this with retrieval teams who routinely provide pre-hospital trauma care. The options for the provision of a site medical response based upon international and Australian disaster planning guidelines are also reviewed. METHODS: A questionnaire was mailed to all doctors dispatched to the 1997 Thredbo disaster as part of trauma service (TS) hospital medical teams, medical commanders or Helicopter Emergency Medical Service (HEMS) crew. Doctors with Sydney retrieval services (SRS) experience were compared with those without SRS experience in regard to the reported level of relevant training and experience as defined by current Australian guidelines and the Education and Training in Disaster Medicine Curriculum, Scientific Committee of the International Society of Disaster Medicine. Familiarity with medical equipment was assessed, as was level of compliance with Australian guidelines for personal protective clothing and equipment. RESULTS: Responses were obtained from all 25 doctors. Nine had SRS experience. None of the 16 doctors without SRS experience met the criteria of the Education and Training Curriculum, compared with four of nine doctors with SRS experience (44%). All six SRS doctors using SRS equipment had personally used or checked their equipment within 2 weeks prior to dispatch to Thredbo, compared with none of the 19 doctors using hospital equipment. Of the 11 areas of personal safety equipment and clothing assessed, all SRS doctors using SRS equipment complied with the guidelines in five areas (45%). There was no area assessed in which all the doctors using hospital equipment complied. CONCLUSION: Hospital medical teams suffer from the same problems of inadequate training, experience and personal safety equipment that are identified in previous reports from disasters overseas. The continued focus on hospital medical teams in counter-disaster planning as the primary source of on-site medical services is inappropriate because, with the exception of retrieval doctors who routinely provide pre-hospital trauma care, appropriately trained and experienced doctors are unlikely to be available from within the hospital system.
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A 44-year old bushwalker was envenomed in an isolated area late in the afternoon, and a succession of difficulties with his rescue resulted in his not reaching hospital until nearly 24 hours later. This case highlights the problems of prolonged delays before treatment for envenomation, and points to the advantages of physician-staffed emergency helicopter services carrying snake antivenoms into the field.
Cytomegalovirus (CMV) infection is still a major cause of morbidity in high-risk renal transplant recipients. In the present report, we have reviewed our records of renal transplant pediatric recipients (RTPR; mean age 14.1 +/- 4.9 years) since 1991, when we started a policy of CMV prophylaxis constituting high-dose oral acyclovir plus CMV hyperimmune immunoglobulins (HIg) followed by early i.v. ganciclovir therapy in high-risk patients (i.e., CMV donor+/recipient-). Four patients received a kidney from a living relative (LR), 2 patients had one previous transplant, and 1 had a combined liver-kidney transplant. Thirty-three patients who were negative for CMV antibodies (ab) before transplantation received a kidney from CMV ab positive donors. The immunosuppressive regimen included cyclosporine A and steroids, with the addition of azathioprine in the 4 patients who received an LR kidney. Serial assessments for CMV antigenemia (pp 65) were routinely performed for 6 months after transplantation to define CMV infection. Among the 33 CMV seronegative recipients (R-) who received the graft from a CMV seropositive donor (D+), 18 (54.5%) experienced CMV infection, whereas among the 28 CMV R+, who received a graft from a CMV D+, 11 (39.3%) experienced CMV infection. With regard to CMV- related symptoms, only 2 patients suffered from a CMV syndrome (fever and leukopenia in 1 patient, fever and arthralgia in the other). In no case did the spectrum of CMV disease occur; only minor symptoms were present in 7 of the remaining CMV-infected patients (fever in 6 and leukopenia in 1). Rejection episodes and renal function did not differ between CMV-infected and non-CMV-infected patients. Our experiences support the use of prophylactic acyclovir plus CMV HIg followed by early therapy with i.v. ganciclovir to combat the risk of increased morbidity in high risk RTPR.
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