Treatment Of Choice For People Research Articles

Survival of patients with kidney failure awaiting transplantation stratified by age and ethnicity: population-based cohort analysis.

Kidney transplantation is the treatment of choice for people living with kidney failure who are suitable for surgery, but survival benefits for older and/or ethnic minority candidates are unclear. To inform decision-making, the survival of patients on a waiting list for kidney transplantation was assessed. A retrospective study was undertaken of registry data for patients with kidney failure listed for transplantation in the UK. From 1 January 2000 until 30 September 2019, all patients listed for a first kidney-alone transplant were included. The primary outcome was all-cause mortality. After testing for violations of the proportional hazards assumption, an extended Cox regression model factoring in transplantation as a time-dependent variable according to the intention-to-treat principle was developed. The study cohort included 47 917 patients on a waiting list for kidney transplantation, of whom 34 558 (72.1%) subsequently received a transplant. Transplantation compared with remaining on dialysis was associated with an overall survival benefit (HR 0.17, 95% c.i. 0.16 to 0.18; P < 0.001), occurring immediately within 30 days, and observed regardless of ethnicity. For White kidney transplant candidates aged at least 65 or at least 70 years, a significant survival benefit was observed within 6 months (HR 0.49, 0.29 to 0.82) and 1 year (HR 0.45, 0.25 to 0.79) after transplantation respectively, which contrasted with 3 years after kidney transplantation for candidates from ethnic minorities aged at least 65 years (HR 0.53, 0.36 to 0.78) or at least 70 years (HR 0.53, 0.36 to 0.78). Although time-to-survival benefits are stratified by age and ethnicity, all kidney transplant candidates on the waiting list are better off with transplantation compared with remaining on dialysis. The absence of any early postoperative mortality suggests that some high-risk patients with kidney failure may not be receiving transplantation opportunities.

Cochlear implants – An Overview. Are CIs world’s most successful sensory prostheses?

Cochlear implants (CIs) have greatly improved over the last 2 decades and now are the world’s most successful sensory prostheses, that restored hearing to more than 800,000 deaf people. CIs are small electronic devices that consists of an external portion that is located behind the ear and a second portion that is surgically fixed under the skin, they replace the function of the inner hair cells in the cochlea by direct electrical stimulation of the auditory nerve. Although cochlear implantation has been used for almost 50 years, the indications for this procedure are subject to constant modifications but the main indication is the inability to achieve sufficient speech understanding. Properly implanted, fitted, and rehabilitated hearing prostheses allow to achieve open speech understanding in 70-80% of post-lingual deafness patients and very good speech development results in children. These days cochlear implantation has become the treatment of choice for people with significant hearing loss and are constantly being developed intensively.

Prolonged grief disorder treatment: An approach to COVID-19 grief

Background. It has been estimated that COVID-19 grief will affect approximately sixteen million people worldwide, while the prevalence of prolonged grief disorder (PGD) could rise to 40%. Objective. To review treatments that can be administered to patients with PGD due to COVID-19. Method. PUBMED and Google Scholar were searched with the following keywords: prolonged grief disorder, complicated grief, grief and psychotherapy, and treatment of prolonged grief, complicated grief or persistent complex grief. Results. Fifty articles were reviewed on the efficacy of interpersonal therapy, rational emotional-behavioral therapy, supportive therapy, humanistic therapy, systemic family therapy, group therapy, writing therapy, Internet-based intervention, and a modality of cognitive behavioral therapy used with prolonged grief, metacognitive therapy, and acceptance and commitment therapy. Discussion and conclusion. There is no consensus on the psychotherapeutic treatment of choice for people with PGD due to the loss of a family member to COVID-19. Group therapy is effective in reducing the intensity of uncomplicated grief, cognitive-behavioral therapy is highly efficacious in reducing the severity of grief, metacognitive therapy specifically designed for PGD has a positive impact on depression, anxiety, stress, rumination, and quality of life while Acceptance and Commitment Therapy is helpful for restoring spirituality. Psychotherapy is most effective when combined with drug therapy. It is suggested that comparative studies be undertaken of psychotherapeutic techniques for managing patients with PGD associated with COVID-19 and the adaptation of these techniques to virtual settings.

MO995: Survival Benefits of Kidney Transplantation for Waitlisted Patients in the Contemporary Era

Abstract BACKGROUND AND AIMS BACKGROUND. Kidney transplantation is recognised as the treatment of choice for people living with kidney failure who are suitable for surgery. However, with evolving donor-recipient characteristics, survival benefits attributed to kidney transplantation warrants validation in the contemporary era. Therefore, this national cohort study aimed to examine survival of waitlisted hemodialysis-maintained kidney failure patients from the last two decades, comparing those who proceed with transplantation versus those who did not. METHOD A retrospective cohort study was undertaken of prospectively collected registry data of all waitlisted kidney failure patients receiving hemodialysis in the United Kingdom. From 1 January 2000 until 30 September 2019 inclusive, all patients listed for their first single kidney transplant were included. The primary outcome was mortality, with survival analysis conducted according to the intention-to-treat principle. Time-to-death from listing was modelled using weighted estimation of Cox regression to account for non-proportional hazards. RESULTS A total of 40 887 waitlisted kidney failure patients formed the study cohort, of whom 31 037 (75.9%) underwent transplantation. Transplant recipients were younger with lower proportion of females, minority ethnics, and diabetes. In a weighted Cox regression model, mortality risk was higher within 30 days of surgery, risk equivalent between 31 and 180 days with survival benefit thereafter. Hazard ratios for mortality within 1 year (HR: 0.575, 95% CI: 0.531–0.623, P&amp;lt; 0.001) and 1–5 years (HR: 0.129, 95% CI: 0.116–0.143, P &amp;lt; 0.001) of surgery favor transplantation. Survival benefit was retained for every donor type in sub-group analysis, but no survival benefit was observed for patients aged ≥70 within 5 years of transplant surgery. CONCLUSION In the contemporary era, kidney transplantation remains the superior treatment modality for waitlisted kidney failure patients from a survival perspective but not among older recipients.

The EKiTE network (epidemiology in kidney transplantation - a European validated database): an initiative epidemiological and translational European collaborative research

BackgroundKidney transplantation is considered to be the treatment of choice for people with end-stage renal disease (ESRD). However, due to the shortage of available organs and the increase in the ESRD prevalence in Europe, it is essential to improve transplantation outcomes by studying the related prognostic factors. Today, there is no European registry collecting data to perform such clinical epidemiology studies.Main bodyEntitled EKiTE, for European cohort for Kidney Transplantation Epidemiology, this prospective and multicentric cohort includes patients from Spanish (Barcelona), Belgian (Leuven), Norwegian (Oslo) and French (Paris Necker, Lyon, Nantes, Nancy, Montpellier, Nice and Paris Saint Louis) transplantation centers and currently contains 13,394 adult recipients of kidney (only) transplantation from 2005 and updated annually. A large set of parameters collected from transplantation until graft failure or death with numbers of post-transplantation outcomes. The long-term follow-up and the collected data enable a wide range of possible survival and longitudinal analyses.ConclusionEKiTE is a multicentric cohort aiming to better assess the natural history of the ESRD in European kidney transplant recipients and perform benchmarking of clinical practices. The data are available for clinical epidemiology studies and open for external investigators upon request to the scientific council. Short-term perspectives are to extend EKITE network to other European countries and collect additional parameters in respect of the common thesaurus.

Potential impact of the antirheumatic agent auranofin on proviral HIV-1 DNA in individuals under intensified antiretroviral therapy: Results from a randomised clinical trial

Antiretroviral therapy (ART) is typically composed of a combination of three antiretroviral drugs and is the treatment of choice for people with human immunodeficiency virus type 1/acquired immune deficiency syndrome (HIV-1/AIDS). However, it is unable to impact on viral reservoirs, which harbour latent HIV-1 genomes that are able to reignite the infection upon treatment suspension. The aim of this study was to provide an estimate of the safety of the disease-modifying antirheumatic agent auranofin and its impact on the HIV-1 reservoir in humans under intensified ART. For this purpose, an interim analysis was conducted of three of the six arms of the NCT02961829 clinical trial (five patients each) with: no intervention, i.e. continuation of first-line ART; intensified ART (ART + dolutegravir and maraviroc); and intensified ART plus auranofin. Auranofin treatment was found to be well tolerated. No major adverse events were detected apart from a transient decrease in CD4+ T-cell counts at Weeks 8 and 12. Auranofin decreased total viral DNA in peripheral blood mononuclear cells compared with ART-only regimens at Week 20 (P = 0.036) and induced a decrease in integrated viral DNA as quantified by Alu PCR. Despite the limited number of patient-derived sequences available in this study, phylogenetic analyses of nef sequences support the idea that auranofin may impact on the viral reservoir. [ClinicalTrials.gov ID: NCT02961829].

Well-Being, Self-Efficacy and Independence in older adults: A Randomized Trial of Occupational Therapy

ObjectiveThe main objective of the research was to analyze whether there were differences in the effects of individual and group occupational therapy (OT) treatment on psychological well-being, self-efficacy and personal independence. MethodA randomized clinical trial (N = 70; age = 85 years, SD = 4) comparing individual versus group occupational therapy treatment for 6 months was conducted. The evaluation was performed with the Barthel Index (Personal Independence), the Ryff Wellness Index (Well-being), the Global Self-Efficacy Scale (Self-efficacy) and the Geriatric Depression Scale (Affective state Scale). ResultsResults showed a decrease in individual treatment scores in the variables autonomy, environmental mastery, personal growth and purpose in life, reflecting worse self-acceptance and negative well-being as well as a lower ability to maintain stable relationships. By contrast, group treatment users maintained more stable social relationships and exhibited a greater ability to resist social pressure, to develop their potential skills and to define their goals in life. There were statistically significant differences in overall self-efficacy (p < 0.001), emotional well-being (p < 0.001) and personal independence (p = 0.013), with better scores in group versus individual treatment. ConclusionsGroup occupational therapy interventions in older adults could be the treatment of choice in people with depressed state, improving their emotional well-being, sense of self-efficacy and level of personal independence in basic activities of daily living.

Diabetic macular oedema and diode subthreshold micropulse laser (DIAMONDS): study protocol for a randomised controlled trial

BackgroundIn the UK, macular laser is the treatment of choice for people with diabetic macular oedema with central retinal subfield thickness (CST) < 400 μm, as per National Institute for Health and Care Excellence guidelines. It remains unclear whether subthreshold micropulse laser is superior and should replace standard threshold laser for the treatment of eligible patients.MethodsDIAMONDS is a pragmatic, multicentre, allocation-concealed, randomised, equivalence, double-masked clinical trial that aims to determine the clinical effectiveness and cost-effectiveness of subthreshold micropulse laser compared with standard threshold laser, for the treatment of diabetic macular oedema with CST < 400 μm. The primary outcome is the mean change in best-corrected visual acuity in the study eye from baseline to month 24 post treatment. Secondary outcomes (at 24 months) include change in binocular best corrected visual acuity; CST; mean deviation of the Humphrey 10–2 visual field; change in percentage of people meeting driving standards; European Quality of Life-5 Dimensions, National Eye Institute Visual Functioning Questionnaire-25 and VisQoL scores; incremental cost per quality-adjusted life year gained; side effects; number of laser treatments and use of additional therapies.The primary statistical analysis will be per protocol rather than intention-to-treat analysis because the latter increases type I error in non-inferiority or equivalence trials. The difference between lasers for change in best-corrected visual acuity (using 95% CI) will be compared to the permitted maximum difference of five Early Treatment Diabetic Retinopathy Study (ETDRS) letters. Linear and logistic regression models will be used to compare outcomes between treatment groups. A Markov-model-based cost-utility analysis will extend beyond the trial period to estimate longer-term cost-effectiveness.DiscussionThis trial will determine the clinical effectiveness and cost-effectiveness of subthreshold micropulse laser, when compared with standard threshold laser, for the treatment of diabetic macular oedema, the main cause of sight loss in people with diabetes mellitus.Trial registrationInternational Standard Randomised Controlled Trials, ISRCTN17742985. Registered on 19 May 2017 (retrospectively registered).

Thrombolysis with tissue plasminogen activator (TPA) in feline acute aortic thromboembolism: a retrospective study of 16 cases

Thrombolytic therapy is a treatment of choice for people with acute ischemic events, but is uncommonly administered for feline aortic thromboembolism (FATE). This study reports selected clinical data and outcomes of acute FATE treated with tissue plasminogen activator (TPA). A reference group treated with current standard of care (SOC) was analyzed for comparison. This was a retrospective study of FATE in two academic hospitals. TPA-treated cats with two or more limbs (n = 16) affected were compared with a SOC-treated group with two or more limbs affected (n = 38). A limb score based on motor function and pulse quality was calculated for each group. Limb score and proportion of congestive heart failure at admission was similar in both groups. Time from FATE to admission was shorter in the TPA group, with a median of 3 h (range 0-6 h) vs 6 h (range 0-48 h; P = 0.0004). The most common regimen received for TPA was 1 mg/kg over 1 h. Other treatments were similar to those of the SOC group and included analgesia, thromboprophylaxis and furosemide. Documented complications for TPA-treated cats included reperfusion injury (5/10) and acute kidney injury (AKI; 3/10). Discharge proportion rate was 44% (TPA) vs 29% (SOC; P = 0.351). There were no differences in short-term survival rate (56.2% vs 39.5%; P = 0.369), clinical improvement (56.2% vs 31%; P = 0.122), rates of reperfusion injury (50% vs 50%; P = 1.00) or AKI (30% vs 27%; P = 1.00) between the TPA-treated and SOC groups, respectively. Survival and complication rates of TPA-treated cats and SOC-treated cats for acute FATE were similar.

Bisphosphonates for Paget's disease of bone in adults.

Bisphosphonates for Paget's disease of bone in adults.

Leaving the experts: Experiences of liver transplant recipients in New Zealand

IntroductionOrthoptic liver transplantation surgery commenced in New Zealand in 1998 (Gane et al., 2002), and is now the treatment of choice for people with end-stage liver failure, with a total of 36 liver transplantations performed in 2015 (Organ Donation New Zealand, 2015). However, there is a scarcity of studies investigating the experiences of liver transplant recipients' recovery - a concept which has only recently started to mean something different from survival. An early Australian study, exploring the experiential issues of one woman, a liver transplant recipient, concluded that although survival had many dimensions, going home did not appear to be one of them (Lumby, 1997). Rather, the subject of this study, Maree, explored the paradox of confronting both life and death at the same time and doing so as a nurse, a mother, a wife and a daughter (Lumby, 1997, p. 232),noting that her family appeared to expect that she would resume her previous roles as though there had been no changes. In a study exploring the first five years of the Australian National Liver Transplant Unit, established in 1985, survival was defined as going home, but absent from this study were the perceptions patients held of their experiences from diagnosis to survival and (Lumby, 1997, p. 232).Leaving the hospital, and thereby leaving the experts, following a liver transplantation has many unique facets that up to this point in time have not been widely investigated from a patient's perspective. This article reports on the findings of a doctoral research project that sought to understand the experiences of liver transplant patients and the specific aspects that ensue following discharge from a clinical facility. Nurses are pivotal in assisting patients to broaden their view and understanding of liver transplantation recovery, beyond mere survival, to surviving and thriving. They provide essential preparatory information and patient education to assist transplant recipients as they transition from admission through to discharge and on to returning home.Research by Blanch and colleagues (2004) noted that studies have consistently found that a patient's psychosocial or emotional adjustment following a major illness is as important as physical health status. In their study of liver transplant recipients in Spain, they found that gender was the only factor that predicted a poor adjustment. An earlier study in relation to bone marrow transplant had found that women reported higher psychiatric morbidity, more medical problems and were less active (Prieto et al., 1996). In their study, Blanch et al. (2004) found that women demonstrate more dysfunction in their attitude to health care, sexual relationships, extended family relationships and psychological distress. Women seemed to be more impacted by their illness status. The authors hypothesised that this might be because men more readily assume support from their partner, while women are expected to not only care for themselves, but also care for their families. This inequality was reflected in the Spanish benefit and pension arrangements. Men were considered disabled and received state support, but women were expected to resume their family duties (Blanch et al., 2004). While men expected to be cared for by their partners, women might not receive the same care unless they had daughters.Kim and Suh (2003) described the structure of five liver transplant recipients' lives in Korea. Although they identified nine themes, going home did not appear to be a focus of the research. In Jones's (2005) longitudinal study of 20 liver transplant recipients, she too made no specific comments on going home. In contrast to these studies, Forsberg, Backman, and Moller (2000) found that going home, or leaving the experts, was one of seven themes emerging from their analysis of interviews conducted with 12 liver transplant recipients, a year after their transplantation. This theme was evident for both men and women, irrespective of whether they were discharged to a local hospital or returned directly to their own homes. …

Lispro insulin in people with non-alcoholic liver cirrhosis and type 2 diabetes mellitus

AimsTo compare metabolic control under lispro and recombinant regular human insulin (RHI) in people with diet-unresponsive type 2 diabetes mellitus (T2DM) and compensated non-alcoholic liver disease (CLD). Methods108 people with T2DM and CLD were randomly allocated to RHI or lispro according to a 12+12 week cross-over protocol. A 1-week continuous glucose monitoring (CGM) session was performed at the end of each treatment period followed by a standard meal test with a 12IU lispro or RHI shot ahead. ResultsCGM showed higher glycemic excursions under RHI than under lispro (p<0.01) with lower glucose levels in the late post-absorption phase (p<0.05) and even more during the night (p<0.01). Post-challenge incremental areas under the curve (ΔAUC) were undistinguishable for insulin but lower for glucose, while insulin peaked higher and earlier and glycemic excursions were lower with lispro than with RHI (0.05<p<0.001). ConclusionsLispro granted lower early postprandial glucose levels and late postprandial hypoglycemic rates and therefore might represent the treatment of choice for people with T2DM and compensated CLD. This might depend on its faster/shorter–living effects, as well as, on the lower liver glucose output expected from its earlier hepatic distribution.

A randomized controlled trial for the use of Thymus Honey in decreasing Salivary Gland Damage following Radioiodine Therapy for Thyroid cancer: research protocol

To test the effectiveness of thymus honey as a complementary intervention for decreasing the salivary gland damage due to Radioiodine ((131) I) therapy. Radioiodine is the treatment of choice in people diagnosed with thyroid cancer following total thyroidectomy. Although its value has been acknowledged in eradicating remnant thyroid tissue and treating residual disease in patients with visible, inoperable, iodine-avid metastases, it has been associated with various salivary gland side effects. This is a randomized controlled trial with a 2 × 3 mixed between-within subjects design. In total, 120 participants of postsurgical differentiated thyroid cancer, who will be referred to this centre for (131) I therapy to ablate the remnant thyroid tissue or to treat metastatic tumour, will be prospectively studied under varying regimens of lemon candy (standard treatment) and thymus honey mouthwashes (experimental intervention). Patients will be randomized in four equally numbered groups based on the assumptions and hypothesis of the study. The recruiting process will be informed by predefined inclusion and exclusion criteria. Mixed statistical modelling will be adopted taking into consideration between and within subjects' effects and repeated measures. The recommended intervention protocol is expected to improve the comprehensive management of salivary gland-related side effects induced by the radioiodine treatment in people diagnosed with thyroid cancer. Through the methodological approach chosen, the ideal intervention protocol in terms of the time to initiate the intervention and the frequency of the intervention to acquire optimal results in minimizing salivary glands damage will be tested.

Tailored versus Standard Dose Prophylaxis in Children with Hemophilia A

Prophylaxis is universally recognized as the treatment of choice in people with hemophilia, and tailored prophylaxis is the consistent modification of the standard weight-based dosing regimen. A large number of factors guide the choice of a specific tailored regimen, and different regimens are under evaluation. Tailored low-dose frequent regimens are likely to be cost-effective, but they are less accepted by patients. Escalating dose regimens seem to be quite effective in preventing bleedings and, consequently, arthropathy, although data on long-term outcomes are still not available. Pharmacokinetic-driven approaches have been also proposed. Sensitive and validated tools able to reliably measure the different outcomes are necessary in this setting. With regard to the evaluation of arthropathy, magnetic resonance imaging and ultrasound are promising imaging techniques in detecting early joint damage. Factor VIII trough levels can be considered a measure of the efficacy of FVIII infused, although other factors influence the bleeding pattern. Global assays of coagulation could provide more complete information on the hemostatic potential of a sample and predict bleeding phenotype. These techniques are also promising for the individualization of prophylaxis regimens, potentially resulting in less frequent dosing, more comfortable and less expensive approaches.

Community Preferences for the Allocation &amp; Donation of Organs - The PAraDOx Study

BackgroundTransplantation is the treatment of choice for people with severe organ failure. However, demand substantially exceeds supply of suitable organs; consequently many people wait months, or years to receive an organ. Reasons for the chronic shortage of deceased organ donations are unclear; there appears to be no lack of 'in principle' public support for organ donation.Methods/DesignThe PAraDOx Study examines community preferences for organ donation policy in Australia. The aims are to 1) determine which factors influence decisions by individuals to offer their organs for donation and 2) determine the criteria by which the community deems the allocation of donor organs to be fair and equitable. Qualitative and quantitative methods will be used to assess community preferences for organ donation and allocation.Focus group participants from the general community, aged between 18-80, will be purposively sampled to ensure a variety of cultural backgrounds and views on organ donation. Each focus group will include a ranking exercise using a modified nominal group technique. Focus groups of organ recipients, their families, and individuals on a transplant waiting list will also be conducted.Using the qualitative work, a discrete choice study will be designed to quantitatively assess community preferences. Discrete choice methods are based on the premise that goods and services can be described in terms of a number of separate attributes. Respondents are presented with a series of choices where levels of attributes are varied, and a mathematical function is estimated to describe numerically the value respondents attach to different options. Two community surveys will be conducted in approximately 1000 respondents each to assess community preferences for organ donation and allocation. A mixed logit model will be used; model results will be expressed as parameter estimates (β) and the odds of choosing one option over an alternative. Trade-offs between attributes will also be calculated.DiscussionBy providing a better understanding of current community preferences in relation to organ donation and allocation, the PAraDOx study will highlight options for firstly, increasing the rate of organ donation and secondly, allow for more transparent and equitable policies in relation to organ allocation.

Clozapine combined with different antipsychotic drugs for treatment resistant schizophrenia.

Although clozapine has been shown to be the treatment of choice in people with schizophrenia that are resistant to treatment, one third to two thirds of people still have persistent positive symptoms despite clozapine monotherapy of adequate dosage and duration. The need to provide effective therapeutic interventions to patients who do not have an optimal response to clozapine is the most common reason for simultaneously prescribing a second antipsychotic drug in combination with clozapine. To determine the efficacy and tolerability of various clozapine combination strategies with antipsychotics in people with treatment resistant schizophrenia. We searched the Cochrane Schizophrenia Group Trials Register (March 2008) and MEDLINE (up to November 2008). We checked reference lists of all identified randomised controlled trials and requested pharmaceutical companies marketing investigational products to provide relevant published and unpublished data. We included only randomised controlled trials recruiting people of both sexes, aged 18 years or more, with a diagnosis of treatment-resistant schizophrenia (or related disorders) and comparing clozapine plus another antipsychotic drug with clozapine plus a different antipsychotic drug. Two review authors independently extracted data and resolved disagreement by discussion with third member of the team. When insufficient data were provided, we contacted the study authors. Three small (range of number of participants 28 to 60) randomised controlled trials were included in the review. Even though results from individual studies did not find that one combination strategy is better than the others, the methodological quality of included studies was too low to allow authors to use the collected data to answer the research question correctly. In this review we considered the risk of bias too high because of the poor quality of the retrieved information (small sample size, heterogeneity of comparisons, flaws in the design, conduct and analysis). Although clinical guidelines recommend a second antipsychotic in addition to clozapine in partially responsive patients with schizophrenia, the present systematic review was not able to show if any particular combination strategy was superior to the others. New, properly conducted, randomised controlled trials independent from the pharmaceutical industry need to recruit many more patients to give a reliable estimate of effect or of no effect of antipsychotics as combination treatment with clozapine in patients who do not have an optimal response to clozapine monotherapy.

Setting research priorities to improve cost‐effectiveness estimations of primary prophylaxis with clotting factor for people with severe haemophilia

Primary prophylaxis with clotting factor is the clinical treatment of choice for people with severe haemophilia, as evidence suggests it can prevent the onset and progression of joint- and muscle-related problems caused by bleeding episodes. However, the major limitation of this approach is that it requires considerably more clotting factor compared with treating on-demand. Thus, there is a need to establish its cost-effectiveness. The aim of this paper is to review the published evidence on the cost-effectiveness of prophylaxis and to highlight areas for future research that would decrease the uncertainty around these findings.

Psychoanalysis and infertility. Myths and realities.

Psychoanalysis, long interested in infertility, and a valuable treatment for men and women suffering with this affliction, has also helped to create and support a myth of psychogenic infertility. Multiple causes of infertility exist across the physiological-psychological spectrum. There is no simple psychodynamic causality. Advances in assisted reproductive technologies provide treatments that create emotional stress and outpace psychological preparedness of patients and analysts. This paper is based on the experience of a unique study group in Boston. An analytic case illustrates some of the ways analysis can be a treatment of choice for people using assisted reproduction. In fact, analysis offers a unique opportunity to elaborate fully the complex realities and dilemmas faced by people and their therapists throughout the infertility experience. More generally, this study of the concept of psychogenic infertility explores a valuable role for psychoanalysis in the treatment of medical conditions.

Psychoanalysis and infertility myths and realities

Psychoanalysis, long interested in infertility, and a valuable treatment for men and women suffering with this affliction, has also helped to create and support a myth of psychogenic infertility. Multiple causes of infertility exist across the physiological ‐ psychological spectrum. There is no simple psychodynamic causality. Advances in assisted reproductive technologies provide treatments that create emotional stress and outpace psychological preparedness of patients and analysts. This paper is based on the experience of a unique study group in Boston. An analytic case illustrates some of the ways analysis can be a treatment of choice for people using assisted reproduction. In fact, analysis offers a unique opportunity to elaborate fully the complex realities and dilemmas faced by people and their therapists throughout the infertility experience. More generally, this study of the concept of psychogenic infertility explores a valuable role for psychoanalysis in the treatment of medical conditions.

The potential contribution of rejection to survival of transplanted human islets

Clinical islet transplantation is potentially the treatment of choice for people with type I diabetes. Rates of insulin independence in islet transplant recipients are disappointingly low, and the relative contribution of the rejection response compared with the loss of islet function is still unclear. We have compared the mixed lymphocyte islet coculture (MLIC) with the mixed lymphocyte acinar cell coculture (MLAC) and the mixed lymphocyte response (MLR) as in vitro models of allograft rejection to MHC and tissue-specific antigens expressed by human islets and acinar cells. The reduced number of MHC class II antigen-positive cells in islets and acinar tissue compared to those in the stimulator lymphocyte population of the MLR, correlated with a reduced proliferative response in the MLIC and MLAC. Enhancement of MHC class II antigen expression by islets using TNFα and IFNγ did not increase their stimulatory capacity in the islet cocultures, which may have been due to a corresponding absence of B7 expression. The lack of T cell proliferation to acinar cells despite cytokine-induced enhancement of MHC class II expression and detectable B7 expression appeared to be due to the inhibitory effect of exocrine enzymes on lymphocyte proliferation. In conclusion, we suggest that a rejection response to islets and acinar tissue is possible due to the accompanying MHC class II-positive cells and that, in this model, islet and acinar-specific antigens do not significantly contribute to that response. Acinar cells may have the potential to stimulate lymphocytes directly, but this was not evident by proliferation in the MLAC. Rejection appears to contribute to the low survival rate of human islet allografts, but it is unlikely that this is the sole explanation, and other factors should be considered.