In August, the American Academy of Pediatrics for the first time stated that the health benefits of circumcision outweigh the risks, but added that the decision to circumcise a child remains with parents. The U. Centers for Disease Control and Prevention is currently evaluating the potential health impact of circumcision, according to a spokeswoman, but any recommendations that come of that will also be voluntary, she said.
The estimated health benefit Morris and his colleague found was several times larger than what was projected in two previous studies, which suggested or circumcisions would be needed to prevent one case of UTI in the first year of life. Zbys Fedorowicz, director of the Bahrain branch of the UK Cochrane Centre, a non-profit organization that evaluates medical studies, said that the study analysis combined different types of studies and the researchers failed to assess their quality.
A P -value of less than 0. In the patient survival model, TX1 patients were censored from the analysis at time of second transplantation.
Available variables with suspected association with the outcome were first tested in univariable Cox models. Recipient age and gender were implemented in all multivariable models regardless of the results in the univariable model.
Except for three recipients with missing values for cold ischemic time CIT , there were no missing values in the dataset for any of the variables included in the multivariable Cox models. CIT was excluded from the final model due to very low statistical significance in the preliminary univariable models.
Accordingly, no patient was excluded from the final multivariable models because of missing values. A total of kidney transplantations were performed from to Among these, patients received a deceased donor kidney and were included in the final analyses.
Median age was One hundred and twenty-two patients Forty-six patients received their second and patients received their first deceased donor kidney transplant. Eight patients included in the TX2 group received their first graft between and and were at that time older than They were consequently included in both groups but censored from the patient survival model at time of second transplant.
Median time between first and second transplantation was 7. One patient was re-transplanted because of primary non-function.
If this patient is excluded, median time between first and second transplantation was 8. There were some differences between the groups. We found statistical significant lower median age of 1. TX2 patients were also more likely to have ESRD caused by glomerulonephritis or polycystic kidney disease and less likely to have vascular nephropathy as cause of ESRD.
The groups were comparable with respect to immunosuppressive therapy Table 3. All other causes were accounted for and because of low numbers comparisons between groups are of limited value and were not performed. Estimated mean patient survival was 7. Estimated mean uncensored graft survival was 6. Estimated mean death censored graft survival was 9. We managed to find only 42 case control pairs due to the matching variables we selected.
The remaining four TX2 patients were however included in the analysis as they were all having more comorbidities than the rest and consequently did not contribute to any further selection bias in favor of the TX2 group.
These analyses are presented in Table 4 and in Figs. Hazard ratio HR for uncensored graft loss TX2 vs. TX1 adjusted for recipient age, recipient gender, cause of ESRD, donor age, donor source, time on dialysis, dialysis modality, prevalence of diabetes mellitus, peripheral vascular disease and HLA matching was 1. The unadjusted and adjusted Cox models for uncensored graft survival are presented in Table 5.
Recipient age, donor age and time on dialysis were identified as independent risk variables for uncensored graft loss whereas IL-2 induction treatment, MMF treatment and glomerulonephritis as cause of ESRD were associated with improved uncensored graft survival.
Adjusted HR for graft loss censored for death with functioning graft TX2 vs. Donor age, female gender, pre-transplant diabetes and avoidance of CNI or induction treatment were identified as independent risk variables for death censored graft loss.
In a separate uncensored graft loss Cox model analyzing only TX2; age, gender, time on dialysis, donor age and induction treatment were included in the multivariable model based on the results of the univariable analyses. In this model, only recipient age HR 1. For induction treatment there was a trend towards an association with improved uncensored graft survival HR 0.
In patients over 65 years we find no statistical difference in uncensored or death censored graft survival between first and second deceased donor kidney transplants. To the best of our knowledge this is the first study describing the results of re-transplantation in older recipients.
With an increasing number of previous transplant recipients with failing grafts, and given the shortage of deceased donor kidneys, it is important to assess the outcome of re-transplantation in older recipients.
In spite of this, in the multivariable Cox models we did not find any statistically significant increased risk of graft loss in recipients of second grafts. The number of recipients in the TX 2 group was however small, and consequently the results must be interpreted with caution.
This increased risk is definitely of clinical significance, and it is likely that with a larger sample size, it would reach statistical significance as well. It is therefore very likely that the lower graft survival of second grafts previously described in adult recipients [ 7 ] also is present in older recipients.
In a study evaluating patients older than 60 years listed for kidney transplantation in Scotland, Oniscu et al. Our TX2 patients had an estimated mean survival of 6. Kidney re-transplantation has historically, regardless of recipient age, been associated with a poor prognosis but still provides the best chance for long-term survival and quality of life in patients facing allograft loss, as compared to maintenance dialysis therapy [ 8 , 17 — 19 ].
Coupel et al. It should be noted that the second transplant recipients were younger and had a higher level of HLA-matching than first transplant recipients. Arnol et al.
A recent large observational study with recipients including s transplant recipients the French DIVAT cohort conclude that the risk of graft failure following a second transplantation remained consistently higher than that observed in first transplantation [ 18 ].
Contrary to our study, none of these studies specifically address increasing age at re-transplantation. Both DGF and acute rejection episodes are known to be independent predictors of graft survival [ 22 — 24 ]. An interesting observation is that acute rejection episodes are less common and graft survival appears to be improved when older organs are transplanted to older recipients [ 25 , 26 ].
The association between acute rejection and poor survival has also been demonstrated for recipients of a second graft [ 21 ].
In our cohort, increased immunosuppression was clearly identified as protective variables both in the uncensored Table 4 and the death censored graft loss models. In concordance with this, our results show that with appropriate immunosuppression, graft and patient survival is good even in patients older than 65 years who receive their second transplant.
The main reason for graft loss in both groups was death with functioning graft. Graft loss due to rejection was not different between TX2 and TX1, but it must be noted that the numbers are very low in the TX2 group making it difficult to draw any firm conclusions.
We were not able to detect any statistically significant differences in ARE between the groups. The study was however clearly underpowered to investigate ARE and additional studies are needed. As always in observational studies there are several limitations. The main limitations are the small sample size, the retrospective design and the use of single centre data. Single-centre studies often end up including small numbers giving a low statistical power.
Our centre has had a liberal policy regarding transplantation of the elderly [ 27 ]. Consequently we presume that few other transplant centres can provide a similar number of older second kidney graft recipients. Single centre studies also offer homogeneity with respect to medical management.
This can be interpreted as a strength when comparing outcomes of first and second grafts. An additional strength is that no recipient was lost to follow-up and that the data collected from the Norwegian Renal Registry was complete and of superior quality.
Further single- and multicentre studies should be performed to confirm our findings. It is quite obvious that patients enlisted for re-transplantation at age above 65 belong to a selected population.
We do however use the same age-independent screening and acceptance criteria for both first and second transplants. Consequently, those patients who are accepted for listing are accepted because they are medically fit for transplantation. It is difficult to select a proper group for comparison analyses. One could argue that we should have compared our second transplant recipients with age-matched recipients with failing first grafts who were on dialysis.
The analyses of the matched dataset in which TX1 and TX2 patients had comparable comorbidities, age and time on dialysis did however not reveal any increased survival difference between the groups.
Consequently, the number of patients listed at our centre for a second transplant who are not receiving a graft, is very low and comparison using a Cox model with a time dependent variable as we have used in a previous publication [ 10 ] was evaluated as invalid.
Time on dialysis is identified as a significant risk variable for survival both in this study and in previous studies [ 28 , 29 ]. Circumcision is a surgical procedure that removes the foreskin of the penis.
In an uncircumcised penis, the foreskin remains. The main differences include appearance and hygiene practices. People may have a circumcision for many different reasons, including:.
The researchers estimated that According to the American Urological Association , the areas of the world with the highest rates of circumcision are:. An uncircumcised penis retains the foreskin, which covers the head of a nonerect penis.
When the penis is erect, the foreskin pulls back to reveal the glans. A circumcised penis has no foreskin, which exposes the glans when the penis is both erect and nonerect. For example, one study looked at the sexual sensations of 1, uncircumcised males and circumcised males.
The group of circumcised males reported lower rates of sensitivity in the glans than the uncircumcised males. A review looked at studies into the effect of male circumcision on sexual function and enjoyment.
The review found that in the most accurate studies, circumcision had no negative effects on sexual function, sensitivity, pain, or pleasure during sexual intercourse. However, one study found that there was not enough scientific evidence in some previous research to suggest that circumcision affects sexual function.
The study concluded that circumcision has no negative long-term impact on sexual function. A study compared the penis sensitivity of 30 circumcised males with that of 32 uncircumcised males ages 18— The study found that there was minimal difference between penile sensitivity in the uncircumcised and circumcised males. For teenage and adult males, pulling back and washing underneath the foreskin with mild soap and water, rinsing well, and then rolling back the foreskin can help maintain good hygiene.
Good hygiene of the foreskin can help reduce the risk of infections. Without regular cleaning, bacteria, dirt, and bodily fluids can all build up under the foreskin and form smegma, which looks yellow-white. Learn about other causes of a tight foreskin in this article.
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