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Transplantation immunology
Published in Gabriel Virella, Medical Immunology, 2019
Satish N. Nadig, Jane C. Kilkenny
Although blood transfusions were generally avoided in potential transplant recipients due to the fear of sensitization to HLA, blood groups, and other antigens, in the early 1980s it was reported that kidney graft survival was longer in patients who had received blood prior to transplantation. This led to attempts to precondition transplant recipients with multiple pretransplant transfusions. Some investigators suggested that the tolerizing effect of blood transfusions was due to the transfer of donor-derived hematopoietic stem cell precursors. This could lead to the establishment of a low level of donor-derived cells within the recipient bone marrow and peripheral blood and result in a state of microchimerism. The microchimeric state could then induce tolerance to the donor tissues and, consequently, result in improved graft survival. While pretransplant transfusions have been very much abandoned—with improvements in matching and immunosuppression protocols the transfusion effect became less and less evident—there is considerable interest in developing protocols to induce a more complete tolerance state that could allow suspension or significant dose reduction of immunosuppressive drugs. It has long been known that chimerism induces tolerance to organ and tissue transplants. Hematopoietic cell chimerism is defined by the presence of donor hematopoietic cells in the circulation of the recipient. Complete chimerism is when all the hematopoietic cells in the recipient are of donor origin. Mixed chimerism is a variable number of donor cells in the recipient. And microchimerism is when the donor cells in the recipient are below the level of detection from flow cytometry and can only be identified by polymerase chain reaction. Mixed chimerism is the goal of the current tolerance induction trials. The Stanford protocol has been used to induce tolerance in HLA-matched kidneys, allowing cessation of immunosuppressive therapy in a majority of their study participants (80% of participants). Work continues on these approaches to determine if early observations are reproducible in larger groups of patients.
Surgeon volume and body mass index influence positive surgical margin risk after robot-assisted radical prostatectomy: Results in 732 cases
Published in Arab Journal of Urology, 2019
Antonio B. Porcaro, Alessandro Tafuri, Marco Sebben, Paolo Corsi, Tania Processali, Marco Pirozzi, Nelia Amigoni, Riccardo Rizzetto, Aliasger Shakir, Giovanni Cacciamani, Arianna Mariotto, Matteo Brunelli, Riccardo Bernasconi, Giovanni Novella, Vincenzo De Marco, Walter Artibani
Specimens were processed according to the Stanford protocol by dedicated pathologists [20]. Prostate weight (g) was calculated and tumours were classified according to the ISUP pathological grade group system [14,15]. Nodal packets were grouped according to a standard template and submitted in separate packages. Lymph nodes were histopathologically assessed after haematoxylin and eosin (H&E) staining. Immunohistochemical staining was performed if appropriate. In every case, the numbers of removed and metastatic nodes were evaluated. Specimens were staged using the 2010 AJCC staging system for prostate cancer (pathological tumour stage [pT] and pathology nodal stage [pN] status).
Obstructive sleep apnea: personalizing CPAP alternative therapies to individual physiology
Published in Expert Review of Respiratory Medicine, 2022
Brandon Nokes, Jessica Cooper, Michelle Cao
Broadly speaking, the surgical management of OSA includes skeletal surgery, tongue base surgery, palatopharyngeal surgery, as well as implantable neurostimulators [87]. Prior to proceeding with surgery, attempts are made at improving either CPAP or MAD adherence, weight loss optimization, and positional therapy, if relevant. The Revised Stanford Protocol for sleep surgery provides a useful decision tree for strategizing upper airway surgery decisions (Figure 2) [88]. If patients are CPAP or MAD intolerant, a nasopharyngoscopy and drug-induced sleep endoscopy (DISE) is performed to assess for intervenable anatomic components either to CPAP intolerance or as a primary OSA treatment. The elements of upper airway surgery are discussed individually below but are typically part of a multi-level surgery (nasopharynx to hypopharynx) based on individual anatomic contributions to velopharyngeal collapse [89]. The impact of multi-level surgery for OSA is still being determined. A recent JAMA article attempted to compare multi-level surgery to CPAP therapy (medical therapy) [89]. The mean AHI was reduced from 47.9 to 20.8 at 6 months in the surgery cohort and decreased from 45.3 to 34.5 for the medical management group. However, only 7 of 51 medical management patients attempted CPAP during the trial, indicating the 44 patients in the control arm were not receiving treatment. Certainly, this may skew the differences in AHI noted between surgical and non-surgical groups. However, surgery does appear to play an important role in OSA management for carefully selected patients, as detailed below. Historically, tracheostomy was the surgical treatment for OSA, but is now avoided due to advancement of other therapeutic options as well as for prevention of unnecessary patient harm [90].
Role of dental sleep medicine in management of patients with obstructive sleep apnea disorders using a team approach
Published in Acta Odontologica Scandinavica, 2018
Takayuki Nakai, Akira Matsuo, Yoshifumi Takata, Yasuhiro Usui, Koichi Kitamura, Daichi Chikazu
The Stanford protocol was the only method followed for sleep surgery when we started our team corroboration in 2004. Recently, another treatment protocol [33] and results of the meta-analysis [32] has been reported. These new ideas may change the discrepancy of the sleep surgery between the first choice therapeutic strategy and the actual treatments. Moreover, two different teams (sleep and orthognathic) managed the patients during the long treatment period.