Reduction of immunosuppression for transplant-associated skin cancer: expert consensus survey

BACKGROUND: Reduction of immunosuppression is considered a reasonable adjuvant therapeutic strategy in solid-organ transplant recipients experiencing multiple or high-risk skin cancers. However, the literature provides no guidance about what threshold of cancer development would warrant initiation of reduction of immunosuppression. OBJECTIVES: To develop expert consensus guidelines for initiation of reduction of transplant-associated immunosuppression for solid-organ transplant recipients with severe skin cancer. METHODS: An expert consensus panel was convened by the International Transplant Skin Cancer Collaborative and Skin Care for Organ Transplant Patients Europe Reduction of Immunosuppression Task Force. Thirteen hypothetical patient scenarios with graduated morbidity and mortality risks were presented and mean and mode expert opinions about appropriate level of reduction of systemic immunosuppression (mild, moderate, severe) were generated. RESULTS: Mild reduction of transplant-associated immunosuppression was considered warranted once multiple skin cancers per year developed or with individual high-risk skin cancers. Moderate reduction was considered appropriate when patients experienced > 25 skin cancers per year or for skin cancers with a 10% 3-year risk of mortality. Severe reduction was considered warranted only for life-threatening skin cancers. CONCLUSIONS: Reduction of immunosuppression is considered a reasonable adjuvant management strategy for transplant recipients with numerous or life-threatening skin cancers. Proposed guidelines are presented for the graduated reduction of immunosuppression coincident with the increasing skin cancer risks.     

Home-Delivered Meal Programs for Homebound People with HIV/Aids

In major cities within the past decade, 17 community-based, home-delivered meal programs have emerged to meet the specialized nutrition needs of homebound people living with the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (HIV/AIDS). This review includes specifics about these meal programs: funding, eligibility criteria, establishing and following nutrition and food safety standards, creating a network of volunteers for delivery of meals, providing nutrition counseling, and conducting periodic program evaluation. People living with HIV/AIDS may need the services of home-delivered meal programs throughout the course of HIV disease. Clinical dietitians and public health nutritionists should become familiar with existing programs and refer clients to services as needed. J Am Diet Assoc. 1995; 95:476–481.     

The future of ethnic minority nurses in the NHS

The subject of discrimination especially with regard to the ethnic minority workforce in the NHS was the focus of a specially commissioned Task Force funded by the Department of Health and the King's Fund in 1991 followed by the PSI Report published last year to help health authorities to address racial discrimination. The first of these reports, for example, states quite clearly that 'racial inequalities between managers and staff in the service are glaring … black and ethnic minority staff will not join or remain in a service which they do not see to be providing good and fair employment prospects'. This perhaps influenced the Secretary of State for Health, in 1993, to set up a programme of action which included a number of targets to be achieved. Goal seven, for example, specifically addresses nursing by stating that NHS authorities and trusts are to set local objectives to achieve representation of ethnic minority nurses at ward manager level within 5 years.
This programme seems to focus on the issue of equal opportunities but although it does make reference to 'racial harassment' it does not include 'racism'. Hence the purpose of this paper is to address the issues of equal opportunities and anti-racism from a theoretical and practice base. It also intends to offer alternatives for the way forward by focusing on local initiatives.     

Immunogenicity and safety of the 13-valent pneumococcal conjugate vaccine in 23-valent pneumococcal polysaccharide vaccine-naïve and previously immunized adult patients with severe chronic kidney disease

Individuals with chronic kidney disease (CKD) are at high risk of pneumococcal infections and recommended to receive the 23-valent pneumococcal polysaccharide vaccine (PPV23). Although the 13-valent pneumococcal conjugate vaccine (PCV13) has been found to have higher immunogenicity compared to PPV23 in adults with some immunocompromising conditions, previous PPV23 immunization may decrease the immunogenicity of PCV13. We assessed immunogenicity and safety of PCV13 in 74 PPV23-naïve and 58 previously PPV23-immunized (>1 year ago) patients with severe (stage 4–5) CKD. Serum IgG, IgM, and IgA specific to seven serotypes, i.e. 3, 6B, 9V, 14, 19A, 19F, 23F were quantified pre- and 4 weeks and one year post-immunization.Baseline concentrations for most serotype-specific IgG and IgM, and serotype 3-specific IgA were higher in previously PPV23-immunized compared to PPV23-naïve patients. Immunization with PCV13 significantly increased almost all serotype-specific IgG, all IgA and some IgM; an increase in some serotype-specific IgG and IgM lasted for one year. Fold increases in antibody concentrations and the proportion of individuals with >2-fold increase post-immunization were generally larger in PPV23-naïve than previously immunized patients for most serotype-specific IgG and some IgA. The data show that in patients with CKD who received previous PPV23 immunization over one year ago, the antibody response to PCV13 was inferior compared to pneumococcal vaccine naïve study participants. In both groups, the lowest response to PCV13 was found for serotype 3. Patients of Indigenous ethnic background demonstrated a superior immune response to PCV13 compared to the non-Indigenous counterpart that could partially be related to Indigenous study participants' younger age. Although we found that previous PPV23 immunization could contribute to the more frequent occurrence of systemic adverse events post PCV13 immunization, those did not exceed the mild to moderate range.     

Effect of carnitine supplementation on cardiac function in hemodialyzed children

Thirteen carnitine-deficient children (mean age, 16.1 ±2.56 years) on a three-times-weekly hemodialysis program for at least 1 year, and 11 healthy age matched children were involved in the study. All the patients had stable blood pressure and hemoglobin (Hb) levels with a maintenance dose of erythropoetin and none were digitalized. The total carnitine (TC) and free carnitine (FC) plasma levels were sampled prior to hemodialysis (HD) before and after 3 months of carnitine supplementation. A free carnitine (FC) to acylcarnitine (AC) ratio less than 4 was defined as carnitine deficiency. Intravenous L-carnitine was injected at a dose of 20–4.0 mg/kg three times weekly at the end of each dialysis session for a 3-month period. Echocardiographic examination was performed the day following HD, before and after carnitine treatment. Systolic and diastolic functions of the left ventricle, including the ejection fraction, were measured. Almost all the parameters were significantly different in controls and hemodiaiyzed patients. In carnitine-deficient hemodiaiyzed patients. 3 months of L-carnitine supplementation resulted in a significant increase in blood carnitine levels and the FC/AC ratio, but this was not associated with any significant improvement of cardiac function. Furthermore no significant changes were observed in plasma triglycerides, total cholesterol or other lipoprotein parameters before or after carnitine supplementation. Although there was a moderate increase in mean hematocrit (Hct) and Hb levels, these also did not reach statistically significant levels. These results suggest that the 3 months of carnitine supplementation is not sufficient to ameliorate cardiac function or increase Hb levels in children.     

杀虫剂诱导人外周血淋巴细胞DNA损伤

目的:用人外周血淋巴细胞彗星试验检测乐果、甲基对硫磷、氯氰菊酯、扑灭司林等杀虫剂的遗传毒性。方法:分别用10,50,100,200μg/ml浓度的乐果、甲基对硫磷、氯氰菊酯、扑灭司林在37℃下染毒人外周血淋巴细胞0.5 h,同时用100μg/ml的过氧化氢(H2O2)作阳性对照,用磷酸盐缓冲液(PBS)作阴性对照。用彗星试验检测以上4种农药对人外周血淋巴细胞DNA损伤作用。结果:与阴性对照相比,乐果和对硫磷在100μg/ml浓度,扑灭司林和氯氰菊酯在200μg/ml浓度对人外周血淋巴细胞DNA损伤作用明显增强(P<0.01)。结论:受试的4种农药可引起DNA损伤。