Formation of Biologic Plug and Patch Mesh for Use in Perforated Femoral Hernia.

Incarcerated inguinal hernias with contamination frequently lead to an open inguinal hernia primary repair. If no contamination is present, a tension-free repair with mesh is a good option. In this case, we encountered an incarcerated femoral hernia with perforation of the small bowel.

Adequate early cyclosporin exposure is critical to prevent renal allograft rejection: patients monitored by absorption profiling.

This study used receiver operating characteristic analysis to investigate the properties of area under the concentration-time curve during the first 4h after cyclosporin-microemulsion dosing (AUC0-4) and cyclosporin (CyA) levels immediately before and at 2 and 3h after dosing (C0, C2 and C3) to predict the risk of biopsy-proven acute rejection (AR) at 6 months. Ninety-eight kidney transplant recipients treated with CyA-microemulsion-based triple therapy immunosuppression were studied on post-transplant days 3, 5, and 7, and at increasing intervals thereafter. The most sensitive and specific predictor of AR was AUC0-4.

A clinical pharmacokinetic study of tacrolimus and sirolimus combination immunosuppression comparing simultaneous to separated administration.

The pharmacokinetic (PK) interaction between tacrolimus (TAC) and sirolimus (SRL), similarly structured immunosuppressive compounds that share binding proteins, is unknown. The combination of SRL with cyclosporin (CsA) has been studied, and a 4-hour interval between dosing of the two drugs is recommended even though it is inconvenient for patients and may affect compliance. Twenty-five liver and kidney-pancreas transplant recipients treated with a combination of SRL and low-dose TAC completed full PK studies while being treated with 4-hour interval dosing (ID) and then with simultaneous dosing.

Clinical pharmacokinetics of sirolimus.

Sirolimus (previously known as rapamycin), a macrocyclic lactone, is a potent immunosuppressive agent. Sirolimus was recently approved by the US Food and Drug Administration, on the basis of 2 large, double-blind, prospective clinical trials, for use in kidney transplant recipients at a fixed dosage of 2 or 5 mg/day in addition to full dosages of cyclosporin and prednisone. However, despite the fixed dosage regimens used in these pivotal trials, pharmacokinetic and clinical data show that sirolimus is a critical-dose drug requiring therapeutic drug monitoring to minimise drug-related toxicities and maximise efficacy.

Approaching the therapeutic window for cyclosporine in kidney transplantation: a prospective study.

Neoral dosing is traditionally based on cyclosporine (CyA) trough levels (C(0)). Four-h area under the curve (AUC(0-4)) for Neoral in the early posttransplantation period was shown previously to have a better correlation to acute rejection (AR) and CyA nephrotoxicity (CyANT), compared with C(0). An AUC(0-4) range of 4400 to 5500 microg/h per L during the first week was associated with the lowest AR and CyANT.

Pharmacological surrogates of allograft outcome.

Because virtually all of the currently available oral immunosuppressive agents show significant inter- and/or intrapatient variability, drug doses do not predict patient exposure, which is the critical parameter of efficacy versus toxicity. Therefore, at least for the critical-dose baseline immunosuppressive agents CsA and tacrolimus, all transplant centers use some sort of therapeutic drug monitoring. However, for CsA, Cminss values show a poor correlation with exposure and therefore are of limited use.

Conversion to rapamycin immunosuppression in renal transplant recipients: report of an initial experience.

Background: The aim of this study is to evaluate the effects of RAPA conversion in patients undergoing cyclosporine (CsA) or tacrolimus (Tac) toxicity.

Methods: Twenty renal transplant recipients were switched to fixed dose rapamycin (RAPA) (5 mg/day) 0 to 204 months posttransplant. Drug monitoring was not initially used to adjust doses.

Is routine ureteric stenting needed in kidney transplantation? A randomized trial.

Background: Whether routine ureteric stenting in low-urological-risk patients reduces the risk of urological complications in kidney transplantation is not established.

Methods: Eligible patients were recipients of single-organ renal transplants with normal lower urinary tracts. Patients were randomized intraoperatively to receive either routine stenting or stenting only in the event of technical difficulties with the anastomosis.

Multicentricity in renal cell carcinoma.

Objective: To find the incidence of multicentric renal cell carcinoma and its possible relationship to the other clinical and pathologic findings.

Methods: A total of 40 patients with renal cell carcinoma underwent radical nephrectomy between March 1994 and January 1996 at Hacettepe University, School of Medicine, Department of Urology. All of the materials were examined grossly and histologically by the same pathologist.

Sirolimus-tacrolimus combination immunosuppression.

A series of 32 recipients of liver, kidney, or pancreas transplants who were treated with sirolimus and low-dose tacrolimus experienced a low rate of rejection and excellent graft function without drug-related toxic effects.

Is 3-hour cyclosporine blood level superior to trough level in early post-renal transplantation period?

Purpose: Cyclosporine dose is traditionally based on trough blood levels. Cyclosporine trough blood level correlates poorly with acute rejection and cyclosporine nephrotoxicity after renal transplantation. We determined whether cyclosporine blood level at any other time point is superior to cyclosporine trough blood level as a predictor of acute rejection and cyclosporine nephrotoxicity.

Persistant pre-eclampsia post partum with elevated liver enzymes and hemolytic uremic syndrome.

The spectrum of complications with pre-eclampsia, which may include AFLP (acute fatty liver of pregnancy) as well as the HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets), is resolved by early delivery. However, the ravages of HUS/TTP (hemolytic uremic syndrome/thrombotic thrombocytopenic purpura) require therapy usually by plasma exchange. Overlap between these two groups of syndromes has occurred on rare occasions and usually requires the therapy of the predominant or more dangerous or threatening form.

Neoral monitoring by simplified sparse sampling area under the concentration-time curve: its relationship to acute rejection and cyclosporine nephrotoxicity early after kidney transplantation.

Background: Cyclosporine (CsA) dosing is traditionally based on trough blood levels (C0) rather than area under the concentration-time curve (AUC), although AUC correlates better with posttransplantation clinical events. For Neoral, AUC based on limited sampling correlates closely with full 12-hr AUC. The purpose of our study was to correlate C0 with AUC based on CsA levels at 0, 1, 2, 3, and 4 hr after dose (PK0-4) and to compare this AUC with C0 in predicting acute rejection (AR) and acute cyclosporine nephrotoxicity (CsANT) in de novo first kidney transplant patients.

Predictable recovery from myasthenia gravis crisis with plasma exchange: thirty-six cases and review of current management.

Adult, acquired, idiopathic, autoimmune myasthenia gravis has a well-characterized IgG anti-acetylcholine striated-muscle receptor antibody. Removal by plasma exchange is effective, established therapy to augment anti-cholinesterase and immunosuppressive therapy and is the treatment of choice for myasthenia gravis crisis. We report 36 consecutive patients referred and accepted for plasma exchange, 32 of whom were in or entering myasthenia crisis, over a 10 year period.

The management of brain metastasis in nonseminomatous germ cell tumours.

Objective: To review our experience of patients with brain metastases from nonseminomatous germ cell tumours (NSGCTs) and to indicate important clinical observations.

Patients And Methods: Between 1990 and 1996, 167 patients with metastatic NSGCT were treated in our department; 11 had brain metastases (eight with solitary metastases and three with multiple lesions, mean age 27 years, range 18-41). These patients were treated initially with either; cisplatin, bleomycin, etoposide and/or cisplatin, vincristin, methotrexate, bleomycin, actinomycin-D, cyclophosphamide, etoposide and intrathecal methotrexate chemotherapy protocols.

Methotrexate tolerance in patients with ileal conduits and continent diversions.

Background: Methotrexate is readily absorbed from the intestinal tract. When given to patients with urinary diversion to the intestinal tract, methotrexate may be reabsorbed into the circulation, thus increasing its serum concentration and potentially increasing its toxicity.

Methods: Forty-eight patients with transitional cell carcinoma of the urinary tract who had undergone cystectomy and either an ileal conduit or a continent diversion were evaluated for their tolerance of chemotherapy.

Characteristics of 73 patients, 1984-1993, treated by plasma exchange for Guillain-Barre syndrome.

Acute Guillain-Barre syndrome (GBS) is a demyelinating polyneuropathy which responds readily to plasma exchange (PEX). According to the North American Acute GBS PEX study there is a 50% or more reduction in the recovery time if PEX is initiated early in the course of the disease. Demyelinating antibodies are usually IgM.

Ureteroscopic management of lower ureteral stones: two years' experience.

A total of 140 ureteroscopies in 119 patients done between January 1992 and December 1994 at the Department of Urology, Hacettepe University Hospital, were reviewed. Factors such as previous ESWL therapy, previous surgery and use of in situ lithotripsy were noted. Success was defined as complete removal or disintegration and partial removal of the lower ureteral stones.

A modified BEP protocol: reduction of hospitalization without reducing the efficacy.

Objective: We have aimed at assessing whether a condensed bleomycin/etoposide/cisplatinum (BEP) regimen would be as effective as the conventional protocol in the treatment of patients with metastatic testicular tumors.

Methods: Sixty-four consecutive patients with metastatic germ cell testicular tumors were included into this modified BEP protocol between April 1991 and January 1995. The condensed regimen consisted of a single daily dose of cisplatin (100 mg/m2) and bleomycin (30 mg) plus 3 consecutive days of etoposide (150 mg/m2).