RESUMEN
Heart failure imposes a significant burden on all health care systems and has a 5-year mortality of 50%. Heart transplantation and ventricular assist device (VAD) implantation are the definitive therapies for end stage heart disease, although transplantation appears to offer superior long-term survival and quality of life over VAD implantation. Transplantation is limited by a shortage in donor hearts, resulting in considerable waiting list mortality. Donation after circulatory determination of death (DCD) offers a significant uplift in the number of donors for heart transplantation. The outcomes both from the UK and internationally have been exciting, with outcomes at least as good as conventional donation after brain death (DBD) transplantation. Currently, DCD hearts are reperfused using ex-situ machine perfusion (ESMP). Whilst ESMP has enabled the development of DCD transplantation, it comes at significant cost, with the per run cost of approximately GBP £90,000. In-situ perfusion of the heart, otherwise known as thoraco-abdominal normothermic regional perfusion (taNRP) is cheaper, but there are ethical concerns regarding the potential to restore cerebral perfusion in the donor. We must determine whether there is any cerebral circulation during in-situ perfusion of the heart to ensure that it does not invalidate the diagnosis of death and potentially violate the dead donor rule. Besides this, there is a need for a randomised controlled trial to definitively determine whether taNRP offers any clinical advantages over ex-situ machine perfusion. This viewpoint article explores these issues in more detail.
RESUMEN
OBJECTIVE: To describe the process of planning and implementing a program of counselling and delivery of postpartum intrauterine devices (PPIUD) in 48 hospitals across six countries in Africa and Asia. METHODS: The process of planning the FIGO PPIUD initiative, selection of countries and hospitals, model of implementation, and lessons for the future are described. RESULTS: Country-level and hospital-based leadership were essential and training-the-trainer models were successful. There was a need for consistency of competency standards allowing for national variations. As the project progressed, additional steps were necessary for steady implementation of the initiative, specifically: establishment of a project steering committee and a data safety monitoring committee, audits of structure and process, and regular feedback of each center's performance to stimulate maintenance and enhancement of activities. Postnatal follow-up was challenging in many countries with fragmented maternity systems. CONCLUSION: The importance of professional leadership and commitment backed by robust data for monitoring and feedback are essential for success.