Tuberculosis in renal transplant patients

Tuberculosis (TB) was diagnosed in 25 of 466 patients who underwent renal transplant over a period of 15 years. TB developed from 1 month to 9 years post-transplant. In 56% of the cases the onset was within the first post-transplant year. TB affected several isolated or combined organs. Pulmonary involvement was present in 76% of cases, either as isolated pleuro-pulmonary (56%) or associated with other sites (20%). The non-pulmonary sites were: skin, joints, tests, urinary tract, central nervous system and lymphonodules. The diagnosis was confirmed by biopsy in 64% of the cases, by identification of tubercle bacilli in 24% and only at necropsy in 12% Biopsy specimens could be classified in three histological forms: exudative, that occurred in early onset and more severe cases granulomatous in late onset and benign cases; and mixed in intermediate cases. Azathioprine dosages were similar along post-transplant time periods in TB patients and in the control groups; and in TB patients who were cured and who died. The number of steroid treated rejection crises was greater in TB than in the control group. Prednisone doses were higher and the number of rejection crises was greater in TB patients who died than in those who were cured. Fifteen patients were cured and ten died, two of them of causes unrelated to TB. Six of the eight TB-related deaths occurred in the first 6 post-transplant months. The outcome was poor in patients in whom TB arose early in post-transplant period and where the exudative or mixed forms were present; whereas the prognosis was good in patients with late onset and granulomatous form of TB. In one patient TB was transmitted by the allograft

Water Governance in Times of Uncertainty: Complexity, Fragmentation, Innovation

One of the major uncertainties of our era is to what extent and how anthropogenic climate change will affect ecosystems and livelihoods. Given the vast concentration of urban poor in low elevation coastal zones and hillsides susceptible to landslides, many cities in the South are considered particularly at risk. In some cities natural hazards such as droughts will reduce the amount of water available, while in other cities an increase in the number of storms or flood events, where intense flows of water enter the city system very rapidly, and an increase in annual rainfall will intensify the need to capture and manage water in a sustainable and safe manner. Various cities will probably have to face both prolonged periods of droughts in one season and more intense rainfall in another. In some cases different scenarios even predict very different trends. What is evident is that many of the plausible effects of climate change impact water availability, which in turn impacts energy provision in some cities whereas in others it does not. Water is thus one of the primary media through which climate change will impact daily existence and ecosystems (Heath, Parker et al. 2012:619). Yet, as Pelling has recently argued: because of the scalar and temporal nature of climate change and its effects, it is still invisible in and dissociated from everyday life, yet increasingly formative of it. This is a challenge of alienation and separation. There is an existential gap between what can be done to confront the climate change challenges, and what culture and society determine as reasonable and proper to do (Pelling, Manuel-Navarrete et al. 2012:13)

Regional Variation in Medication Adherence

An extensive literature has demonstrated geographic variation in medical services and this variation has been largely attributed to the health care system and not to regional differences in patient behavior. We use empirical Bayes shrinkage models, conditional on patient, firm, and market covariates, to investigate geographic variation in adherence to prescription medications across hospital referral regions (HRRs). Models are estimated for commercially insured patients in 11 combinations of chronic diseases and drug classes. We use factor analysis to create a market-level composite measure of adherence that we relate to adjusted market-level spending on non-drug services. We find that there is a very small amount of variation in adherence to prescription drugs across HRRs supporting the widely held assumption that geographic variation is attributable to the health system. Markets with high adherence have systematically lower medical spending, and this inverse correlation is more likely due to unobserved market traits.

Seminoma arising in corrected and uncorrected inguinal cryptorchidism: treatment and prognosis in 66 patients

Purpose: The purpose of this study was to analyze prognosis and treatment results for seminoma arising in corrected and uncorrected inguinal cryptorchidism (SCIC and SUIC). Methods and Materials: We reviewed 66 patients with inguinal seminomas between June 1958 and December 1991 at the Cancer Hospital and Institute of Chinese Academy of Medical Sciences. Of these patients, 23 had prior orchiopexy and 43 presented with an inguinal form of cryptorchidism. At presentation, 17 of 66 (26%) patients had nodal metastases. This nodal involvement was 30% (7 of 23) for SCIC and 23% (10 of 43) for SUIC, respectively. These numbers are comparable with those in a series of patients treated for scrotal seminoma at our institution (26% vs. 20%). However, 3 of 23 (13%) patients who had prior orchiopexy presented with inguinal nodal metastasis as compared with 0 of 43 patients with SUIC or 4 of 237 patients with scrotal seminoma (p < .05). There were 49 stage I, 5 stage IIA, 8 stage IIB, 3 stage III, and 1 stage IV patients. All patients underwent radical orchiectomy and received further radiotherapy, chemotherapy, or both. Patients with stage I and stage II disease were treated primarily with radiotherapy, whereas patients with stage III and IV disease were treated with chemotherapy. Results: The overall and disease-free survival at 5 and 10 years was 94% and 92%, 89% and 87%, respectively. The overall 5- and lo-year survival by stage was 100% and 100% for stage I, and 77% and 68% for stage II, respectively @ < .05). There was no significant difference in survival between SUIC and SCIC (93% vs. 96% at 5 years). Four patients developed relapse. Two of these four patients experienced relapse at the inguinal area, due to a marginal miss. Three of four patients with relapse were successfully salvaged, and one died of disease. Conclusion: Our results indicate that prognosis for inguinal seminoma is excellent and similar to that of scrotal seminoma. Postorchiectomy radiotherapy can be considered as the standard treatment for stage I and IIA inguinal seminoma. We recommend routinely including the para-aortic and ipsilateral pelvic nodes. 0 1997 Elsevier Science Inc