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Objective: The clinical benefit of surveillance imaging in endometrial cancer remains undefined. This retrospective study was conducted to evaluate the positive predictive value (PPV) of surveillance imaging in endometrial cancer., Methods: A total of 128 patients in first remission after treatment for endometrial cancer (uterine papillary serous, clear cell, stage III endometroid) who had surveillance imaging were retrospectively identified. The surveillance period was defined from the time of first-negative scan after treatment to the time when treatment was started for recurrent disease. Reports of surveillance scans were reviewed for the presence or absence of findings. The primary outcome was PPV of surveillance imaging. Cost and radiation exposure from surveillance imaging were also evaluated., Results: A total of 128 patients had 707 surveillance scans (computed tomography, positron emission tomography-computed tomography with 2-deoxy-2-[ 18 F]fluoro-d-glucose, magnetic resonance image, and bone scans). Median follow-up was 54 months (range: 9-173). Of all, 47 patients (37%) started therapy for recurrent endometrial cancer at the discretion of the treating physician. PPV of all surveillance imaging was 57.7%. Per patient, the mean number of surveillance scans was 5.6 (range: 2-21). The mean cost of imaging was $4200 (range: $1200-$18,700) and mean radiation exposure was 109.6mSV (range: 16-445mSv)., Conclusions: Surveillance imaging detected a significant number of recurrences in patients with high-risk endometrial cancer at a reasonable cost related to the overall risk. Well-designed prospective imaging trials are warranted to assess the clinical benefit of surveillance imaging., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose. The purpose of this study was to evaluate the feasibility of detecting pulmonary emboli utilizing noncontrast magnetic resonance imaging techniques in patients with known pulmonary embolism. Materials and Methods. Eleven patients were enrolled in a study to evaluate right ventricular function by cardiac MRI in patients diagnosed with acute pulmonary embolism on CT pulmonary angiogram. Cardiac MRI was performed as soon as possible following pulmonary embolism detection. Two independent observers reviewed the precontrast portion of each MRI, scoring right, left, and lobar arteries as positive or negative for PE. The CTs were reviewed and interpreted in the same manner. Results. MRI was obtained on average of 40 hours after the CT. Forty-eight vessels were affected by PE on CT, 69% of which were identified on MRI. All eight pulmonary emboli located in the right or left pulmonary arteries were detected on MRI. Of the 15 pulmonary emboli that were not detected on MRI, 7 were subsegmental, 6 were segmental, and 2 were located in a branch not included in the MRI field of view. Conclusions. Most pulmonary emboli detected on CT were identified on noncontrast MRI, even though our MRI protocol was not optimized for pulmonary artery visualization.

During the last 10 to 15 years, medical and surgical innovations have established pediatric liver transplantation as the optimal therapy for children suffering acute and chronic liver disease. We hypothesized that the profile of current pediatric liver transplant recipients would differ significantly from that of an earlier era. We collected and compared data regarding the characteristics of children undergoing liver transplantation alone in 2 eras separated by more than a decade from the Organ Procurement and Transplantation Network/United Network for Organ Sharing database. Transplant recipients from March 1, 2002 to December 31, 2004, compared to those from January 1, 1990, to December 31, 1992, tended to be more evenly distributed across age, race/ethnicity, and disease etiology. There was a major shift toward utilization of partial grafts from both deceased and living donors to achieve transplantation for the youngest children (<1 and 1-5 yr) in particular. However, in spite of these innovative transplant strategies and only a modest increase in demand for pediatric liver transplantation, wait list times for both pediatric candidates and recipients have still increased between eras. In conclusion, the sobering reality that mortality on the waiting list remains highest for the youngest pediatric liver candidates frames our challenge for the next decade., (Copyright 2006 AASLD)

We present brain MR images in three patients with neonatal-onset hyperammonemic encephalopathy resulting from urea-cycle disorders (two sisters with deficiency of the carbamyl phosphate synthetase I reaction step and one boy with an ornithine transcarbamylase deficiency). MR imaging revealed almost identical findings of injury to the bilateral lentiform nuclei and the deep sulci of the insular and perirolandic regions; to our knowledge, this pattern has not been previously reported. We hypothesize that these lesions presumably reflect the distribution of brain injury due to hypoperfusion secondary to hyperammonemia and hyperglutaminemia in the neonatal period.

The aim of this study was to determine whether living related liver transplantation has an immunological advantage compared with cadaveric liver transplants in children. The records of 100 pediatric primary liver transplant recipients performed between January 1992 and December 1998 at the University of California, San Francisco Medical Center, were reviewed retrospectively. Ten children who died or required a second graft within the first 14 post-operative days were excluded from this study group. Two children with combined kidney-liver transplants were also excluded. As a result, the study group included 51 children in the cadaveric liver transplantation (CLT) group and 37 children in the living-related liver transplantation (LRLT) group. Until 1995, primary immunosuppression consisted of cyclosporin A, azathioprine and steroids. Since 1995, primary immunosuppression consisted of cyclosporin A, mycophenolate mofetil and steroids. Actuarial graft survival rates at 1, 2 and 5 yrs were 90%, 80.9% and 80.9% in the CLT group vs. 94.6%, 91.6% and 78.5% in the LRLT group, respectively (NS). Rejection was diagnosed in 40 of 51 cadaveric first grafts (78.4%) and 25 of 37 living-related primary grafts (67.6%). Rejection episodes were diagnosed greater than 1 yr post-transplantation in 11 of 51 cadaveric first grafts (21.6%) and none of 37 living-related primary grafts (0%) (p < 0.05). LRLT succeeded in reducing the immunosuppressive therapy compared with CLT at 24 months after transplantation (p < 0.05). The overall incidence of rejection and graft survival rate were comparable in CLT and LRLT; however, rejection episodes in LRLT recipients diagnosed greater than 1 yr post-transplant were significantly fewer than CLT recipients. LRLT have a partial immunological advantage compared with CLT.

Objective: To elicit donor opinions on liver living donation through use of a survey that protected the anonymity of the respondent and to assay long-term (follow-up > 1 year) donor health by a widely recognized instrument for health assessment., Summary Background Data: Living-donor liver transplantation is an accepted technique for children that has recently been extended to adults. Limited donor outcomes data suggest favorable results, but no outcomes data have been reported using an instrument that elicits an anonymous response from the donor or employs a widely recognized health survey., Methods: Forty-one living-donors between June 1992 and June 1999 were identified and included in this study, regardless of specific donor or recipient outcome. Each donor received a 68-question survey and a standard McMaster Health Index., Results: Survey response was 80%. All donors were satisfied with the information provided to them before donation. Eighty-eight percent of donors initially learned of living donation only after their child had been diagnosed with liver disease: 44% through the transplant center, 40% by popular media, 12% by their pediatrician, and 4% by their primary care physician. Physical symptoms, including pain and the surgical wound, were recurrent items of concern. Perception of time to "complete" recovery were less than 3 months (74%), 3 to 6 months (16%), and more than 6 months (10%). Donors' return to physical activities was shown by above-mean McMaster physical scores; scores for social and emotional health were not different from population data. There were no reported changes in sexual function or menstruation after donation, and five of six donors procreated., Conclusions: Donors overwhelmingly endorsed living donation regardless of recipient outcome or the occurrence of a complication. Eighty-nine percent advocated "increased" application of living donation beyond "emergency situations," and no donor responded that living donation should be abandoned or that he or she felt "forced" to donate.

The aim of this retrospective analysis was to evaluate the growth of 96 pediatric liver transplant recipients from February 1988 to June 1999. Inclusion criteria were the following: age younger than 18 years, follow-up longer than 1 year, transplantation for a nontumor indication, and no retransplantation. Linear height and growth velocity SD scores were correlated to age, sex, indication for transplantation, immunosuppression, and graft type. Transplant recipients of all ages and indications and both sexes were growth retarded at transplantation. Recipients aged younger than 24 months showed growth within the first year to achieve a height distribution equal to that of an age-matched population. Posttransplantation growth inversely correlated with height standard score at transplantation. Children older than 2 years at transplantation established new growth curves, but remained growth retarded. As children approached the prepubertal growth acceleration, growth deficits frequently were erased. Transplant recipients with biliary atresia and alpha(1)-antitrypsin deficiency showed increased growth performance compared with those who underwent transplantation for chronic hepatitis or fulminant hepatic failure. Boys were less growth retarded at transplantation and showed improved posttransplantation growth performance versus girls. No correlation to immunosuppression or graft type was identified. We conclude that early transplantation of children who show growth retardation is optimal for restoration of growth potential, whereas delaying transplantation in older children impedes potential growth.

Dental practices are under scrutiny every day. The dynamics of the public, the media, the lawmakers, the regulators, and other special-interest groups create endless possibilities for influence over a practice and continue to challenge a dentist's ability to provide quality dental care to patients. This article describes examples of laws and regulations affecting dentistry and the impetus for them, whether real or perceived.

Liver transplantation is accepted as the standard management for end-stage liver disease in children. Pediatric heart and heart-lung transplant recipients have shown significantly diminished exercise capacities compared with age-matched, able-bodied, control subjects. The primary aim of this study is to compare the fitness levels of a group of pediatric liver transplant (LT) recipients (LT group, 20 boys, 9 girls; age, 8.9 +/- 4.8 years; 56 +/- 35 months posttransplantation) with a group of able-bodied control subjects (22 boys, 12 girls; age, 8.4 +/- 3.8 years). The secondary aim is to compare the performance of the LT group against the Fitnessgram criterion standards. We assessed muscular endurance by means of a partial curl-up, flexibility by means of the back-saver sit and reach, and cardiorespiratory fitness by means of the progressive aerobic cardiovascular endurance run (PACER). The only significant (P <.05) difference between the 2 groups was the number of shuttles run in the PACER (control, 16.8 +/- 9.8 v LT, 11.5 +/- 8.4 shuttles). Other differences between the 2 groups were not significant. With regard to satisfying the Fitnessgram criterion standards, only 35% of the LT group achieved the standards for the partial curl-up, 88% of the LT group achieved the criterion standards for flexibility, and 0% achieved the standards for the PACER. These results indicate that the LT group has diminished exercise capacity. The origins of exercise limitations deserve further investigation.

Objective: To compare acupuncture with sham (placebo) acupuncture for treatment of nausea of pregnancy., Methods: In a subject- and observer-masked, randomized, controlled trial in the maternity unit at Exeter Hospital, we gave 55 women between 6 and 10 weeks' gestation genuine, traditional-style acupuncture or sham treatment with a cocktail stick on three or four occasions over 3 weeks. The main outcome measure was nausea score, as determined by subject report on a visual analogue scale in a daily diary. Anxiety and depression also were assessed., Results: Nausea scores decreased from a median of 85.5 (interquartile range 71.25-89.75) to 47.5 (interquartile range 29.25-69.5) in the acupuncture group and from 87.0 (interquartile range 73.0-90.0) to 48.0 (interquartile range 14.0-80.0) in the sham treatment group. There was strong evidence of a time effect (P <.001) but no evidence of a group effect (P =.9) or a group-time interaction (P =.8). Similarly, there was evidence of time effects in scores for anxiety and depression but no group differences. The study had a power of 95% to detect significant differences in nausea scores., Conclusion: Acupuncture was as effective in treating nausea of pregnancy as a sham procedure.

Triple immunosuppressive therapy using mycophenolate mofetil (MMF), microemulsion cyclosporine (me-CsA), and prednisone offers the potential for potent immunosuppression without intravenous drug therapy or anti-T-cell antibody induction therapy. This report describes the application of an immunosuppressive protocol (CNp) using MMF, me-CsA, and prednisone as primary immunosuppression for pediatric liver transplant recipients at the University of California at San Francisco. From August 1995 through December 1996, 26 children (17 boys, 9 girls) aged 1 month to 16 years (mean +/- standard deviation, 58 +/- 62 months; median, 31 months) underwent liver transplantation at our institution, receiving CNp as primary immunosuppression. Posttransplantation renal function, incidence of leukopenia, and drug tolerance within the group receiving CNp as primary immunosuppression were compared with those of 19 children who received primary immunosuppression consisting of azathioprine, oil-based gel-encapsulated cyclosporine, and prednisone with anti-T-cell antibody induction therapy at the same institution from October 1993 through July 1995. No significant difference was observed between immunosuppressive protocols in serum creatinine level or incidence of leukopenia requiring medical therapy during the first year posttransplantation. Whereas gastrointestinal symptoms were observed in approximately 30% of CNp recipients during initial immunotherapy, tolerance of CNp primary immunotherapy was routinely achieved by the dose reduction of MMF. At 1 year posttransplantation, 20 children (77%) remained on CNp primary immunotherapy, 5 children (19%) were receiving tacrolimus-based immunotherapy secondary to rejection, and 1 patient (4%) converted to tacrolimus-based immunotherapy secondary to persistent gastrointestinal intolerance. In conclusion, CNp provides an alternative immunosuppressive protocol that eliminates the necessity of intravenous and induction immunosuppressive therapy with no increased incidence of posttransplantation renal dysfunction or leukopenia and is well tolerated in children.

Objective: To examine the role of pediatricians in posttransplantation care of pediatric liver transplant recipients., Design: Written survey of parents and pediatricians of children enrolled in a pediatric liver transplant program., Setting: Questionnaires were mailed from a liver transplant center (LTC), set in a university-affiliated, tertiary-care medical center, to the homes of families and the offices of pediatricians in a variety of urban, suburban, and rural locales worldwide., Study Population: Eighty-four percent of families and 81% of pediatricians who met study criteria participated., Results: Only 8.9% of all pediatricians reported feeling comfortable providing all care for their liver transplant patients, while 82.2% were most comfortable sharing responsibility for care with the LTC. The remaining 8.9% of pediatricians were most comfortable with the LTC providing care. The more comfort pediatricians reported in providing care, the more likely parents were to report contacting pediatricians for medical problems. The more comfort pediatricians reported, the more parents perceived that (1) pediatricians and the LTC work well together (P<.03); (2) the LTC is informed about their child (P<.001); and (3) pediatricians are similarly up-to-date (P<.001). Furthermore, the more comfort pediatricians felt, the more parents believed that the liver transplant improved their child's health (P<.03) and that their child enjoys school (P=.08). Of the pediatricians, 15.6% who reported attending a continuing medical education course were significantly more comfortable (P=.05). The 18.9% of participating pediatricians who reported receiving some training in pediatric gastroenterology were also significantly more comfortable caring for children with liver transplants (P<.05)., Conclusion: Increasing pediatrician comfort levels in providing posttransplantation care for children with liver transplants is critical to the continuing success of pediatric liver transplantation.

Objective: To determine the incidence of focal head and neck posttransplant lymphoproliferative disorder (PTLD) in children, its clinical presentation, associated risk factors, and outcome following treatment., Study Design: Retrospective., Methods: The authors conducted a 5-year retrospective study of 61 children with liver transplants at the University of California, San Francisco. Suspected head and neck lesions were evaluated and biopsies were performed by an otolaryngologist. Diagnosis was made via histologic and immunohistochemical features and in situ Epstein-Barr virus (EBV) localization., Results: Eight patients (13.1%) developed PTLD, five (8.2%) in the head and neck. Four patients had large tonsils, and one presented with airway obstruction from a supraglottic mass. Negative pretransplant EBV serology was a risk factor for PTLD. Treatment consisted of antiviral therapy and decreased immunosuppression. All patients with head and neck PTLD are disease free with excellent liver function., Conclusions: A high incidence of PTLD was found, with 63% presenting in the head and neck. While Waldeyer's ring is most commonly involved, PTLD may also present in the supraglottis. Adjunctive antiviral therapy and decreased immunosuppression are effective forms of treatment. Given the increasing number of pediatric liver transplants being performed, otolaryngologists should be familiar with PTLD and have a high index of suspicion in this at-risk population.

The transjugular intrahepatic portosystemic shunt procedure is an accepted treatment for adults with complications of portal hypertension. We performed a retrospective review of all pediatric TIPS placements performed at the University of California, San Francisco between 1990 and 1996. Twelve procedures were attempted in nine children, with a mean age (+/- SD) of 9.4 +/- 3.9 years (range, 5 to 15 years) and a mean weight of 31 +/- 18 kg (range, 16 to 70 kg). The indications for TIPS placement were portal hypertension complicated by chronic variceal hemorrhage not controlled with sclerotherapy (n = 7) and hypersplenism with thrombocytopenia (n = 2). TIPS placement was successfully completed initially in seven of nine (78%) patients. Unfavorable vascular anatomy was the cause of failure in two cases. The seven patients who underwent successful TIPS placement were followed up for an average of 136 days (range, 1 to 800 days); two still have patent shunts, three underwent liver transplantation, one had a splenorenal shunt after stenosis, and one died of underlying liver disease. Variceal bleeding was controlled in four of five patients who successfully underwent TIPS placement. Shunt occlusion occurred in four patients; patency was restored by transjugular shunt revision in three, and a splenorenal shunt was performed in one.

In December 1995 the Pew Health Professions Commission, a program of the Pew Charitable Trust, released its report titled "Reforming Health Care Workforce Regulations: Policy Considerations for the 21st Century." One of ANNA's external projects for the 1996-97 year was responding to the Commission's report. Western Region Vice President Christine Mudge was selected to serve as project director. In consultation with President Christy Price, she spearheaded ANNA's formal response. Each of the 10 recommendations was assigned to six to eight ANNA members, plus everyone was invited to comment on any portion of the report that they chose. Letters of request for participation were mailed to 66 nephrology nurses. The Board of Directors, committee chairpersons, past ANNA leaders, ANNA consultants, and members at large were involved. The response rate was 59%, or 39 thoughtful critiques of the Commission's recommendations. As project director, Christine Mudge analyzed all responses and formed a draft document. Every effort was made to include all concerns and issues raised by the ANNA participants. The draft document was reviewed at the November ANNA Board of Directors meeting and accepted with some editorial changes. ANNA's response is a 35-page document. Excerpts from ANNA's full response are included on the following two pages. Any ANNA member who desires to receive a copy of ANNA's full response to the Pew Health Professions Commission report may request a copy from the ANNA National Office by calling (609) 256-2320. The Pew Commission is now in the process of reviewing all responses and recommendations to its report. Stay informed by following the ongoing story in the ANNA Update.

The case of an adolescent transplant recipient who lost her allograft as a result of medication noncompliance serves as the focus of this multidisciplinary review. The discussion that follows includes (1) a review of current graft survival data for adolescent renal transplant recipients with particular attention to the occurrence of medication noncompliance in this patient population, (2) an overview of normal growth and development as it applies to the adolescent patient with chronic disease, and (3) proven treatment strategies with emphasis on the needs of the adolescent transplant patient. The discussion is intended to provide the reader with a greater understanding and appreciation of developmental issues that influence adolescent behavior and, in turn, impact medical care. It is also hoped that the information provided will be used by health care providers to promote adherence to a chronic medical regimen on behalf of the adolescent transplant recipient.

The purpose of this investigation was to assess the applicability of living-related liver transplantation in an established regional transplant program by determining the frequency of acceptable living donors from an unselected population of pediatric transplant candidates and identify specific factors limiting application of this technique. During the period May 1992 to May 1994, all children accepted as transplant candidates at the University of California-San Francisco were evaluated for potential living-related liver transplantation. Indications for transplantation and patient demographics represented the spectrum anticipated at a regional center. Donor evaluation was performed using a three-phase evaluation process we have previously reported. Retrospective analysis identified 75 potential donors for 38 pediatric candidates (age range, 17 days to 14.5 years; mean, 5.1 years). Twenty-three percent of potential donors declined evaluation. Of the 75 potential donors, only 10 (13%) were found to be acceptable for donation. The leading causes for donor declination were significant medical history (23%), ABO blood group incompatibility (23%), and psychosocial history (20%). Of the 38 recipient candidates, 9 (23%) were offered living-donor transplantation. Five patients have received living-donor transplantation, and 4 patients await the procedure when medical indications exist. Seventy-seven percent of recipient candidates received or are awaiting cadaveric transplantation. These results suggest that current donor criteria markedly limit the application of living-related liver transplantation.

This is the third in a series of annotated bibliographies on research topics that will appear in the ANNA Journal. The bibliographies were prepared by members of ANNA's Research Special Interest Group, which was chaired by Nancy Hoffart, PhD, RN, in 1991-1992 and is currently chaired by Donna Hathaway, PhD, RN. Each bibliography focuses on a particular topic and includes reviews of research books and articles published in nursing and allied health journals in recent years. This series is intended to assist nephrology nurse researchers in locating resources to plan and implement research studies and to communicate and implement research findings. The annotation for each item includes a full citation, a brief summary, and a categorization of the content level. The following key was used in rating the content level for each citation: (a) Basic/Introductory--For professionals who have no previous research background; (b) Intermediate--For professionals who possess some knowledge of the research process and terminology, and have participated in some research projects; and (c) Advanced--For professionals who possess broad knowledge and experience with research projects. The topics in this issue cover poster preparation, abstract writing, and collaborative research. Contributors to this bibliography were Billie J. Kostro, Christine Mudge, and Karen L. Yennie. The first installment covered grant writing (see February 1993 issue, volume 20, number 1). The second installment covered development of a research proposal, literature review, and theoretical and conceptual frameworks (see April 1993 issue, volume 20, number 2).(ABSTRACT TRUNCATED AT 250 WORDS)

The exact physiologic mechanism of the hepatorenal syndrome remains unclear; however, it always develops in the presence of liver failure. A number of theories have been postulated to explain the syndrome, which are discussed in this review. None of the proposed theories is able to explain the syndrome completely, and continued research is necessary. Management of hepatorenal syndrome is directed at supporting the patient and maintaining/restoring hepatic function to prevent further renal damage. Liver transplantation has been considered an effective method of treatment for this patient population. Nursing care is supportive and focuses on maintaining the patients' internal environment and psychologic well-being.