RESUMEN
BACKGROUND: Prediction of transfusion requirement is part of preoperative management in a surgical case. We aimed to develop one such tool for patients undergoing cardiac surgery. METHODS: A retrospective study for a period of 3 years was done to develop the scoring tool, Transfusion Requirement Prediction Score for Cardiac Surgery (TRPS), and internal validation was done prospectively. The primary outcome was administration of allogenic red cell units to the patients during perioperative period. The outcome is dichotomized as controls and cases based on the number of Red Blood Cell units received. Independent variables were chosen based on statistical significance and clinical judgement. Receiver operating characteristic curve was used to obtain the cut-off for each independent variable, odds ratio, and regression coefficients were used to assign the score. All patients with a cumulative score below the cut-off value were categorised as 'low risk' and above the cut off as 'high risk' group. RESULTS: During the study period, out of 602 patients, 345 met the inclusion criteria (controls: 175; cases: 170). Six variables such as age (more than 58 years), gender (female), bypass time (more than 148 min), haemoglobin (less than 12.5 g/dL), ejection fraction (less than 57%), and history of warfarin prophylaxis were chosen to develop the score. The total score value of 5 was chosen as the cut-off for the two risk groups. It predicted blood utilisation with a strength of 68% sensitivity and 79% specificity. On internal validation, the score was observed to have an accuracy of 70%. CONCLUSION: The TRPS is a simple reliable and handy tool with high accuracy.
Asunto(s)
Transfusión Sanguínea , Procedimientos Quirúrgicos Cardíacos , Femenino , Humanos , Persona de Mediana Edad , Curva ROC , Estudios Retrospectivos , Factores de Riesgo , Atención Terciaria de SaludRESUMEN
The detection and management of potential donor-derived infections is challenging, in part due to the complexity of communications between diverse labs, organ procurement organizations (OPOs), and recipient transplant centers. We sought to determine if communication delays or errors occur in the reporting and management of donor-derived infections and if these are associated with preventable adverse events in recipients. All reported potential donor-derived transmission events reviewed by the Organ Procurement and Transplantation Network Ad Hoc Disease Transmission Advisory Committee from January 2008 to June 2010 were evaluated for communication gaps between the donor center, OPO and transplant centers. The impact on recipient outcomes was then determined. Fifty-six infection events (IEs; involving 168 recipients) were evaluated. Eighteen IEs (48 recipients) were associated with communication gaps, of which 12 resulted in adverse effects in 69% of recipients (20/29), including six deaths. When IEs and test results were reported without delay, appropriate interventions were taken, subsequently minimizing or averting recipient infection (23 IEs, 72 recipients). Communication gaps in reported IEs are frequent, occur at multiple levels in the communication process, and contribute to adverse outcomes among affected transplant recipients. Conversely, effective communication minimized or averted infection in transplant recipients.
Asunto(s)
Comunicación , Transmisión de Enfermedad Infecciosa , Trasplante de Órganos/efectos adversos , Donantes de Tejidos/provisión & distribución , Obtención de Tejidos y Órganos , Humanos , Pronóstico , Receptores de TrasplantesRESUMEN
Phase III noninferiority trial examining efficacy and safety of converting stable renal transplant recipients from twice-daily tacrolimus to a novel extended-release once-daily tacrolimus formulation (LCPT) with a controlled agglomeration technology. Controls maintained tacrolimus twice daily. The primary efficacy endpoint was proportion of patients with efficacy failures (death, graft failure, locally read biopsy-proven acute rejection [BPAR], or loss to follow-up) within 12 months. Starting LCPT dose was 30% lower (15% for blacks) than preconversion tacrolimus dose; target trough levels were 4-15 ng/mL. A total of 326 patients were randomized; the mITT population (n = 162 each group) was similar demographically in the two groups. Mean daily dose of LCPT was significantly (p < 0.0001) lower than preconversion tacrolimus dose at each visit; mean trough levels between groups were similar. There were four efficacy failures in each group; safety outcomes were similar between groups. Frequency of premature study drug discontinuation was LCPT: 12% versus tacrolimus twice daily: 5% (p = 0.028). LCPT demonstrated noninferiority to tacrolimus twice daily in efficacy failure rates. LCPT may offer a safe and effective alternative for converting patients to a once-daily formulation. Compared to currently available tacrolimus formulation, LCPT requires lower doses to achieve target trough levels.
Asunto(s)
Rechazo de Injerto/tratamiento farmacológico , Inmunosupresores/administración & dosificación , Enfermedades Renales/cirugía , Trasplante de Riñón/efectos adversos , Tacrolimus/administración & dosificación , Esquema de Medicación , Femenino , Estudios de Seguimiento , Rechazo de Injerto/etiología , Supervivencia de Injerto , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Pronóstico , Estudios ProspectivosRESUMEN
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether a mechanical or bioprosthetic valve is superior for immediate and long-term survival in patients with end-stage renal disease (ESRD) undergoing a valve replacement. Altogether more than 150 papers were found using the reported search; of which, eight represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. There were no randomized controlled trials addressing the question. There was one systematic review and meta-analysis. All the other evidence was in the form of retrospective studies. The papers show that there is no significant difference in the results and survival between patients receiving a mechanical and those receiving a bioprosthetic valve. This was seen in the meta-analysis as well as the larger series of patients who underwent valve replacement. Bleeding complications were more common with mechanical valves. We conclude that the choice of valve for patients with ESRD should be determined by age, level of activity and patient choice. Due to the limited life expectancy of these patients, bioprosthetic valves should be considered, especially since there is no evidence of early degeneration of tissue valves in this subgroup of patients.
Asunto(s)
Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Fallo Renal Crónico/complicaciones , Benchmarking , Bioprótesis , Medicina Basada en la Evidencia , Femenino , Enfermedades de las Válvulas Cardíacas/complicaciones , Enfermedades de las Válvulas Cardíacas/mortalidad , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Fallo Renal Crónico/mortalidad , Masculino , Persona de Mediana Edad , Selección de Paciente , Diseño de Prótesis , Medición de Riesgo , Factores de Riesgo , Resultado del TratamientoRESUMEN
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients with hypertrophic and keloid scarring of the sternotomy wound, is surgical excision with or without adjuvant treatment of any benefit in reducing the size of the scar? Altogether, more than 15 papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. One of the studies showed no difference between surgery and adjunctive triamcinolone or colchicine. One study showed that incomplete excision resulted in higher recurrence rates. Postoperative radiation was found to be useful in two of the studies, although one study showed that it was not useful. One randomized control trial showed improvement after laser compared to no treatment. Two other trials showed no difference between laser, silicone gel, intralesional steroid or 5-fluorouracil. One trial showed that perioperative systemic steroid application gave rise to no improvement but in fact worsened scar formation. We conclude that small keloids can be treated radically by surgery with adjuvant therapy (radiation or corticosteroid injections) or by non-surgical therapy (corticosteroid injections, laser and anti-tumour/immunosuppressive agents, such as 5-fluorouracil). Large and multiple keloids are difficult to treat radically and are currently only treatable by multimodal therapies that aim to relieve symptoms.
Asunto(s)
Cicatriz Hipertrófica/terapia , Queloide/terapia , Esternotomía/efectos adversos , Benchmarking , Cicatriz Hipertrófica/tratamiento farmacológico , Cicatriz Hipertrófica/etiología , Cicatriz Hipertrófica/radioterapia , Cicatriz Hipertrófica/cirugía , Medicina Basada en la Evidencia , Humanos , Queloide/tratamiento farmacológico , Queloide/etiología , Queloide/radioterapia , Queloide/cirugía , Reoperación , Resultado del TratamientoRESUMEN
The continuing organ shortage requires evaluation of all potential donors, including those with malignant disease. In the United States, no organized approach to assessment of risk of donor tumor transmission exists, and organs from such donors are often discarded. The ad hoc Disease Transmission Advisory Committee (DTAC) of the Organ Procurement and Transplantation Network/United Network for Organ Sharing (OPTN/UNOS) formed an ad hoc Malignancy Subcommittee to advise on this subject. The Subcommittee reviewed the largely anecdotal literature and held discussions to generate a framework to approach risk evaluation in this circumstance. Six levels of risk developed by consensus. Suggested approach to donor utilization is given for each category, recognizing the primacy of individual clinical judgment and often emergent clinical circumstances. Categories are populated with specific tumors based on available data, including active or historical cancer. Benign tumors are considered in relation to risk of malignant transformation. Specific attention is paid to potential use of kidneys harboring small solitary renal cell carcinomas, and to patients with central nervous system tumors. This resource document is tailored to clinical practice in the United States and should aid clinical decision making in the difficult circumstance of an organ donor with potential or proven neoplasia.
Asunto(s)
Neoplasias/etiología , Trasplante de Órganos/efectos adversos , Humanos , Medición de RiesgoRESUMEN
Disseminated adenoviral infection is a serious problem, especially in an immunocompromised host. The disease carries a mortality rate reaching as high as 80%. It is seen most frequently in bone marrow transplant recipients, where it causes pneumonia and disseminated disease. In solid organ transplant recipients it causes graft infection. We report the case of a renal transplant recipient with disseminated adenoviral infection and acute kidney failure requiring dialysis. Reduction of immunosuppression and 1 dose of cidofovir were associated with resolution of viremia and viruria and return of kidney function to near baseline.