A randomized trial of normothermic preservation in liver transplantation.

Liver transplantation is a highly successful treatment, but is severely limited by the shortage in donor organs. However, many potential donor organs cannot be used; this is because sub-optimal livers do not tolerate conventional cold storage and there is no reliable way to assess organ viability preoperatively. Normothermic machine perfusion maintains the liver in a physiological state, avoids cooling and allows recovery and functional testing. Here we show that, in a randomized trial with 220 liver transplantations, compared to conventional static cold storage, normothermic preservation is associated with a 50% lower level of graft injury, measured by hepatocellular enzyme release, despite a 50% lower rate of organ discard and a 54% longer mean preservation time. There was no significant difference in bile duct complications, graft survival or survival of the patient. If translated to clinical practice, these results would have a major impact on liver transplant outcomes and waiting list mortality.

Promoting Opioid Awareness Through a Union-Based Peer Training Model.

Work factors, including physical job demands, appear to be risk factors for opioid overdoses. We collaborated with unions representing workers in high-risk occupations and offered resources to develop tailored educational interventions for their members. An ironworkers' local, a statewide nurses' union, and a Teamsters local union participated, at levels higher than we had anticipated. The three unions trained 285 workers, including apprentices, stewards, and those nearing retirement. Short surveys assessed pre- and post-training knowledge, attitudes, confidence in helping others, and related domains. Seventy percent of respondents reported heavy or very heavy physical demands at work, and one-half had experienced work-related pain. After training, participants reported more knowledge about opioids, less concern about stigma related to help-seeking, and more ability to provide help to a co-worker struggling with opioids. Peers with recovery experience provided a unique contribution to training. Tailored job-specific and peer-delivered educational interventions may be able to reduce the potential impact of opioids on working people.

A case of intracranial hemorrhage causing stress-induced cardiomyopathy.

The classic finding of Takotsubo's cardiomyopathy is left ventricular systolic dysfunction with echocardiographic evidence of apical ballooning in the absence of significant coronary disease. Intracranial hemorrhage is a known cause for stress-induced cardiomyopathy with a similar echocardiographic presentation. This diagnostic finding suggests a similar pathophysiologic mechanism between neurogenic cardiac damage and the wide array of medical and psychosocial disorders that are known to cause stress-induced cardiomyopathy (Takotsubo's syndrome). The neurogenic-cardiac variant of stress-induced cardiomyopathy is associated with good cardiovascular prog- nosis; the hallmark feature of the disorder is complete echocardiographic resolution of systolic dysfunction within a short period of time. While malignant presentations are rare, the disorder can present as severe heart failure or ventricular tachyarrhythmias. We report a case of a near life-threatening episode of polymorphic ventricular tachycardia due to a subarachnoid hemorrhage (SAH)-induced stress-cardiomyopathy.

Methadone-induced Torsades de pointes.

Torsades de pointes is a polymorphic ventricular tachycardia that can quickly evolve into ventricular fibrillation and sudden death. This arrhythmia often occurs secondary to medication- induced cardiac repolarization dysfunction with resultant prolonged QTc interval on ECG. Numerous medications can predispose patients to this deadly tachycardia. We report a case of methadone-induced Torsades de pointes complicated by ventricular fibrillation and cardiac arrest. Through rapid taper of methadone, the patient's ECG normalized, allowing for safe discharge. This clinical vignette highlights the importance of close monitoring of patient medications. Performing periodic ECGs with prompt removal of offending agent when repolarization abnormalities are appreciated is ideal. Most importantly, as the vast array of medications continues to grow, it is imperative that clinicians are cognizant of side effects and tailor treatment accordingly.