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1.
Can J Kidney Health Dis ; 10: 20543581231209185, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-38020483

RESUMO

Purpose of the Conference: The 2022 Banff-Canadian Society of Transplantation Meeting in Banff, Alberta, brought together transplant professionals to review new developments across various aspects of solid organ transplantation (SOT) in Canada. Sources of Information: Presentations included consensus recommendations from expert-led forums; experiences with new procedures and legislation; reports from public health data repositories; original clinical and laboratory research; and industry updates regarding novel technologies. Speakers referenced articles and reports published in peer-reviewed journals and online, and unpublished data and preliminary findings. Methods: All authors attended presentations in-person or virtually. Recordings of select presentations were available for later review. Summaries emphasize concepts indicated by speakers as new and clinically relevant. Key Findings: The COVID-19 pandemic disproportionately affected solid organ transplant recipients (SOTRs), who experience worse outcomes of COVID-19 infection than the general population. Vaccinations demonstrate an attenuated immunological response in SOTRs yet provide meaningful protection. Monoclonal antibodies are effective for both passive immunization and treatment of COVID-19 in SOTRs. Infection control protocols have driven the development of virtual methods for clinical research, such as using home blood draws and virtual follow-up to evaluate vaccine efficacy in SOTRs; and patient care delivery, such as employing telerehabilitation post transplant. Access to living kidney donation is limited by various disincentives experienced by potential donors, which may be overcome by more efficient evaluations including a One-Day Living Kidney Donor Assessment Clinic. The International Donation and Transplantation Legislative and Policy Forum provided a means of establishing consensus guidance for organ donation and transplantation (ODT) program policy to standardize delivery across jurisdictions. The implementation of a deemed consent model for organ and tissue donation in Nova Scotia may provide insight as to whether this model indeed improves access to organs. Canada's Indigenous population experiences unique barriers to transplantation, prompting efforts for more inclusive ODT policy-making. The Pan-Canadian ODT Data and Performance Reporting System Project has defined performance quality indicators, of which iTransplant and other point-of-care software solutions may facilitate collection; however, these endeavors ultimately require information technology infrastructure that exceeds the capabilities of the existing Canadian Organ Replacement Register and Canadian Transplant Registry. Pig-to-human xenotransplantation requires genetic modification of pigs and xenoantibody testing in recipients but may yet prove viable. Serum cell-free DNA, urine biomarkers, and genetic markers offer an alternative to routine biopsy for identifying subclinical rejection. Modified perfusion temperatures and perfusion solutions with hydrogen sulfide donor compounds may improve organ preservation. Molecular compatibility tools provide another means of improving SOTR outcomes, and the Genome Canada Transplant Consortium has been examining important considerations of their implementation. Limitations: We were unable to capture all presentations and topics at the meeting due to the sizable quantity and variety. Topics ultimately excluded from this summary include those in pathology including Banff Classification updates; those unique to extra-renal SOT; as well as numerous abstract and poster presentations, allied health provider forums, and business meetings. A portion of the material was presented by speakers prior to peer-review or publication. Implications: The various conference presentations summarized in this report identify methods by which individual clinicians and provincial ODT programs may improve access, delivery, and quality of SOT care in Canada, while additionally identifying gaps in the literature that investigators are encouraged to pursue.


Objectifs de la conférence: En 2022, le congrès annuel de la Société canadienne de transplantation qui s'est tenu à Banff (Alberta) a réuni des professionnels de la transplantation qui se sont penchés sur les nouveaux développements dans divers aspects de la transplantation d'organes solides (TOS) au Canada. Sources: Les présentations portaient notamment sur : les recommandations consensuelles issues de forums dirigés par des experts; l'expérience avec les nouvelles procédures et lois; des rapports provenant de dépôts de données de santé publique; des recherches cliniques et des recherches de laboratoire originales; et les mises à jour du secteur sur les nouvelles technologies. Les intervenants ont fait référence à des articles et rapports publiés en ligne et dans des revues évaluées par les pairs, ainsi qu'à des données non publiées et des conclusions préliminaires. Méthodologie: Tous les auteurs ont assisté aux présentations en personne ou virtuellement. Les enregistrements de certaines présentations étaient disponibles pour visionnement ultérieur. Les résumés mettent l'accent sur les concepts jugés comme nouveaux et cliniquement pertinents par les intervenants. Principaux résultats: La pandémie de COVID-19 a affecté les receveurs d'une transplantation d'organe solide (RTOS) de manière disproportionnée; ces derniers ayant suivi une évolution plus défavorable que la population générale à la suite d'une infection à la COVID-19. La vaccination, bien qu'elle offre une protection significative, montre une réponse immunologique plus faible chez les RTOS. Les anticorps monoclonaux sont efficaces à la fois pour l'immunization passive et le traitement de la COVID-19 chez les RTOS. Les protocoles de contrôle des infections ont mené au développement de méthodes virtuelles pour la recherche clinique (p. ex. prélèvements sanguins à domicile, suivi virtuel pour évaluer l'efficacité du vaccin chez les RTOS) et la prestation de soins aux patients (p. ex. rééducation à distance) après la transplantation. L'accès au don de rein vivant est limité par divers facteurs dissuasifs pour les donneurs potentiels, mais ces obstacles peuvent être surmontés par des évaluations plus efficaces, notamment par une clinique d'un jour pour évaluer la candidature des donneurs vivants de rein. Le Forum législatif et politique international sur le don et la transplantation a fourni un moyen d'établir des lignes directrices consensuelles pour la politique du program de dons d'organes et de transplantation (DOT), dans l'objectif de normaliser la prestation d'une juridiction à l'autre. La mise en œuvre en Nouvelle-Écosse du consentement présumé pour le don d'organes et de tissus pourrait aider à déterminer si un tel modèle améliore effectivement l'accès aux organes. Les populations autochtones du Canada sont confrontées à des obstacles uniques en matière de transplantation, ce qui encourage les efforts visant l'élaboration de politiques plus inclusives en matière de DOT. Le Projet de système pancanadien de données et de mesure de la performance pour les DOT a défini des indicateurs de performance, dont iTransplant et d'autres solutions logicielles pour les points de soins, qui peuvent faciliter la collecte des données; ces derniers nécessitent toutefois une infrastructure informatique qui dépasse les capacités du Registre canadien des insuffisances et des transplantations d'organes et du Registre canadien de transplantation. La xénogreffe de porc à humain requiert une modification génétique des porcs et le dépistage de xénoanticorps chez les receveurs, mais elle peut encore s'avérer viable. L'ADN acellulaire sérique, les biomarqueurs urinaires et les marqueurs génétiques offrent une alternative à la biopsie de routine pour identifier les rejets subcliniques. Des températures de perfusion modifiées et des solutions de perfusion contenant des composés générateurs de sulfure d'hydrogène peuvent améliorer la conservation des organes. Les outils de compatibilité moléculaire offrent un autre moyen d'améliorer les résultats des RTOS, et le Genome Canada Transplant Consortium a examiné les aspects importants à prendre en considération pour leur mise en œuvre. Limites: Nous n'avons pas été en mesure d'assister à toutes les présentations en raison du grand nombre et de la grande diversité des sujets abordés. Les sujets exclus de ce résumé incluent la pathologie, notamment les mises à jour de la classification Banff; les sujets propres à la TOS extrarénale; ainsi que de nombreux résumés et présentations d'affiches, forums de prestataires de soins de santé alliés et réunions d'affaires. Une partie du matériel présenté l'a été avant l'examen par les pairs ou la publication. Conclusion: Les présentations du congrès qui sont résumées dans le présent rapport identifient les méthodes que les programs provinciaux de DOT et les cliniciens pourraient employer pour améliorer l'accès, la prestation et la qualité des soins en TOS au Canada, et soulignent des lacunes dans la littérature que les chercheurs sont encouragés à creuser.

3.
J Can Assoc Gastroenterol ; 3(3): 127-134, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32395687

RESUMO

BACKGROUND: Whether certain clinical or laboratory characteristics are able to differentiate cirrhotic patients with upper gastrointestinal bleeds (UGIB) at high-risk inpatient mortality is unknown. The objective of this study is to elucidate patient factors at presentation that are associated with in-hospital mortality. METHODS: A retrospective analysis of cirrhotic patients presenting with UGIB was performed. Baseline characteristics at admission including demographics, clinical and laboratory characteristics were collected. Factors associated with in-hospital mortality were evaluated with logistic regression analyses. The discriminative power of MELD score was evaluated with the use of area under the receiver operating characteristic (ROC) curve. RESULTS: One hundred and sixteen patients were included in this study. MELD score at presentation was higher in the death cohort (24.0 versus 14.8, P < 0.001) and remained significantly associated with mortality after multivariable adjustment (P < 0.001). ROC analysis of MELD score for death yielded an area under the curve of 0.88. At admission, the death group had lower systolic blood pressure (103 mmHg versus 123 mmHg, P=0.008 and more frequently presented with bright red blood per rectum (46.7% versus 11.9%, P = 0.003). Bilirubin and international normalized ratio were also higher, and albumin was lower in patients who died. CONCLUSIONS: Among cirrhotic patients presenting with UGIB, the severity of symptoms and impairment in hepatic synthetic function is associated with in-hospital mortality. Admission MELD score may be useful in predicting in-hospital mortality.

4.
Can Liver J ; 3(4): 348-357, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-35990511

RESUMO

Background: Quality indicators (QIs) exist for the care of patients with cirrhosis. We retrospectively examined the records of patients admitted to a large academic tertiary care centre for adherence to QIs and examined for an association between QI adherence and hospital outcomes. Methods: We conducted a cross-sectional study of all patients with decompensated liver cirrhosis admitted to a large academic tertiary care centre over a 2-year period (2014-2016). Medical records of 522 patients were examined for 17 QIs related to inpatient cirrhosis care and adherence-judged using three different standards: 100% adherence, 70% adherence, or the QI score as a continuous variable. Linear and logistic regression was used to evaluate the association between QI score and length of stay (LOS), 30-day readmissions, and inpatient mortality, respectively. Results: Adherence to QIs was variable (range 20%-95%). Overall, adherence to QIs relating to variceal bleeding was higher than adherence to indicators related to hepatic encephalopathy and spontaneous bacterial peritonitis. There was weak evidence for a decreased odds of 30-day readmission when more QIs were met, regardless of the method used to quantify adherence (100% standard OR 0.53 [95% CI 0.26-1.09, p = .09], 70% standard OR 0.58 [95% CI 0.32-1.06, p = .08], continuous method OR 0.90 [95% CI 0.81-1.01, p = .07]). There was no observed relationship between mortality and QI adherence and equivocal evidence for an association between QI adherence and LOS. Conclusions: Adherence to QIs related to inpatient care of decompensated cirrhosis may be associated with decreased 30-day readmissions.

5.
Syst Rev ; 7(1): 218, 2018 11 30.
Artigo em Inglês | MEDLINE | ID: mdl-30497505

RESUMO

BACKGROUND: With over 230 million surgical procedures performed annually worldwide, better application of evidence in anesthesia and perioperative medicine may reduce widespread variation in clinical practice and improve patient care. However, a comprehensive summary of the complete available evidence has yet to be conducted. This scoping review aims to map the existing literature investigating perioperative anesthesia interventions and their potential impact on patient mortality, to inform future knowledge translation and ultimately improve perioperative clinical practice. METHODS: Searches were conducted in MEDLINE, EMBASE, CINAHL, and the Cochrane Library databases from inception to March 2015. Study inclusion criteria were adult patients, surgical procedures requiring anesthesia, perioperative intervention conducted/organized by a professional with training in anesthesia, randomized controlled trials (RCTs), and patient mortality as an outcome. Studies were screened for inclusion, and data was extracted in duplicate by pairs of independent reviewers. Data were extracted, tabulated, and reported thematically. RESULTS: Among the 10,505 publications identified, 369 RCTs (n = 147,326 patients) met the eligibility criteria. While 15 intervention themes were identified, only 7 themes (39 studies) had a significant impact on mortality: pharmacotherapy (n = 23), nutritional (n = 3), transfusion (n = 4), ventilation (n = 5), glucose control (n = 1), medical device (n = 2), and dialysis (n = 1). CONCLUSIONS: By mapping intervention themes, this scoping review has identified areas requiring further systematic investigation given their potential value for reducing patient mortality as well as areas where continued investment may not be cost-effective given limited evidence for improving survival. This is a key starting point for future knowledge translation to optimize anesthesia practice.


Assuntos
Anestesia/métodos , Mortalidade Hospitalar , Período Perioperatório/mortalidade , Anestesia/efeitos adversos , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto
6.
J Gastroenterol Hepatol ; 33(10): 1773-1779, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29601652

RESUMO

BACKGROUND AND AIM: Acute upper gastrointestinal bleeding (UGIB) in cirrhosis is associated with significant morbidity and mortality and can be classified as acute variceal bleeding (AVB) or non-variceal bleeding (NVB). Differences in mortality, hospital length of stay (LOS), and 30-day readmission have yet to be determined. As such, the study aimed to evaluate differences in these clinical outcomes in cirrhotic patients admitted with UGIB. METHODS: This retrospective study included all cirrhotic patients hospitalized for UGIB who underwent upper endoscopy from July 2014 to July 2016. AVB was defined as the presence of varices on endoscopy with high-risk stigmata such as cherry-red spots. Mortality, intensive care unit admission, hospital LOS, and 30-day hospital readmission were recorded and compared among patients with AVB and NVB. RESULTS: A total of 116 patients with cirrhosis were included, 73 with AVB and 43 with NVB. Patients with NVB were older than those with AVB (60.4 ± 11.1 vs 55.0 ± 9.5, P = 0.006) whereas patients with AVB were more likely to have known esophageal varices (64.4% vs 37.2%, P = 0.007). Patients with AVB and NVB had similar mortality (15.1% vs 9.3%, P = 0.57), hospital LOS (4.9, interquartile range: 3.6-6.9 days vs 5.0, interquartile range: 2.7-8.3 days), and 30-day readmission rates (19.2% vs 30.2%, P = 0.18). Severity of clinical presentation was associated with increased LOS and overall mortality, including the need for intensive care unit admission, but these were not associated with 30-day readmission rates. CONCLUSION: There were no differences in clinical outcomes, including mortality, in cirrhotic patients admitted with AVB and NVB.


Assuntos
Varizes Esofágicas e Gástricas/complicações , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/mortalidade , Cirrose Hepática/complicações , Doença Aguda , Adulto , Idoso , Humanos , Tempo de Internação , Pessoa de Meia-Idade , Readmissão do Paciente , Prognóstico , Estudos Retrospectivos , Fatores de Tempo
7.
J Comp Neurol ; 523(16): 2409-25, 2015 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-25921857

RESUMO

The siphon of Aplysia californica has several functions, including involvement in respiration, excretion, and defensive inking. It also provides sensory input for defensive withdrawals that have been studied extensively to examine mechanisms that underlie learning. To better understand the neuronal bases of these functions, we used immunohistochemistry to catalogue peripheral cell types and innervation of the siphon in stage 12 juveniles (chosen to allow observation of tissues in whole-mounts). We found that the siphon nerve splits into three major branches, leading ultimately to a two-part FMRFamide-immunoreactive plexus and an apparently separate tyrosine hydroxylase-immunoreactive plexus. Putative sensory neurons included four distinct types of tubulin-immunoreactive bipolar cells (one likely also tyrosine hydroxylase immunoreactive) that bore ciliated dendrites penetrating the epithelium. A fifth bipolar neuron type (tubulin- and FMRFamide-immunoreactive) occurred deeper in the tissue, associated with part of the FMRFamide-immunoreactive plexus. Our observations emphasize the structural complexity of the peripheral nervous system of the siphon, and the importance of direct tests of the various components to better understand the functioning of the entire organ, including its role in defensive withdrawal responses.


Assuntos
Aplysia/anatomia & histologia , Células Receptoras Sensoriais/citologia , Animais , Aplysia/metabolismo , FMRFamida/metabolismo , Imuno-Histoquímica , Microscopia Confocal , Células Receptoras Sensoriais/metabolismo , Tubulina (Proteína)/metabolismo , Tirosina 3-Mono-Oxigenase/metabolismo
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