A Less Restrictive Policy for Liver Transplantation in Coronavirus Disease 2019 Positive Patients, Based Upon Cycle Threshold Values.

Coronavirus disease 2019 drastically impacted solid organ transplantation. Lacking scientific evidence, a very stringent but safer policy was imposed on liver transplantation (LT) early in the pandemic. Restrictive transplant guidelines must be reevaluated and adjusted as data become available. Before LT, the prevailing policy requires a negative severe acute respiratory syndrome coronavirus 2 real-time polymerase chain reaction (RT-PCR) of donors and recipients. Unfortunately, prolonged viral RNA shedding frequently hinders transplantation. Recent data reveal that positive test results for viral genome are frequently due to noninfectious and prolonged convalescent shedding of viral genome. Moreover, studies demonstrated that the cycle threshold of quantitative RT-PCR could be leveraged to inform clinical transplant decision-making. We present an evidence-adjusted and significantly less restrictive policy for LT, where risk tolerance is tiered to recipient acuity. In addition, we delineate the pretransplant clinical decision-making, intra- and postoperative management, and early outcome of 2 recipients of a liver graft performed while their RT-PCR of airway swabs remained positive. Convalescent positive RT-PCR results are common in the transplant arena, and the proposed policy permits reasonably safe LT in many circumstances.

[Best conditions to perform TAVI procedures]. / Les bonnes conditions pour réaliser des TAVI.

Well conditions to perform TAVI procedures are guided by ministry regulation and dedicated to centers with both on-site a cath-lab and cardiac surgery. Heart Team decision is mandatory to select patient for TAVI and local anesthesia is recommended. Conditions changes would be discuss according to increased procedures number related to indications evolution.

Medicolegal structure, consequences, and recommendations for daily practice: The example of surgical infection.

Surgical infections are the leading cause of complications and have major economic consequences and medico-legal fallout. In this article, the author revisits the foundations of medical law in France and reviews the mechanisms of medical liability, the place of recommendations in the definition of "secundum Artem", or the "state-of-the-art", and the necessity to provide high quality information. The author then proposes an approach to improve safety in daily practice.

A review of illicit psychoactive drug use in elective surgery patients: Detection, effects, and policy.

Limited information is present in literature regarding detection of illicit drug users visiting physicians when planning elective surgery; also, there is no update manuscript that is illustrating the effects of illicit drugs use that require reconstructive surgery interventions. Aims of this manuscript are: 1) to summarize existing knowledge, and give surgeons information how to detect patients who might possible use illicit drugs; 2) to review the effects of illicit drug use that specifically require reconstructive surgery interventions; 3) to assess on existing policies on asymptomatic illicit drug users when planning elective surgery. Studies were identified by searching systematically in the electronic databases PubMed, Medline, The Cochrane Library and SveMed+. Because of the nature of research questions to be investigated (drug policy and surgery), a "systematic review" was not possible. In spite of some existing policies to detect illicit drug use in specific situations such as workplaces or acute trauma patients, there is a lack of data and lack of information, and subsequently no policy has ever been made, for detection and management of illicit drug use asymptomatic patients requesting or referred for plastic surgery interventions. This manuscript poses questions for further ethical evaluations and future policy.

A Preoperative Medical History and Physical Should Not Be a Requirement for All Cataract Patients.

Cataract surgery poses minimal systemic medical risk, yet a preoperative general medical history and physical is required by the Centers for Medicare and Medicaid Services and other regulatory bodies within 1 month of cataract surgery. Based on prior research and practice guidelines, there is professional consensus that preoperative laboratory testing confers no benefit when routinely performed on cataract surgical patients. Such testing remains commonplace. Although not yet tested in a large-scale trial, there is also no evidence that the required history and physical yields a benefit for most cataract surgical patients above and beyond the screening performed by anesthesia staff on the day of surgery. We propose that the minority of patients who might benefit from a preoperative medical history and physical can be identified prospectively. Regulatory agencies should not constrain medical practice in a way that adds enormous cost and patient burden in the absence of value.

[Preoperative tests recommendations in adult patients for ambulatory surgery]. / Recomendaciones de pruebas preoperatorias en el paciente adulto para procedimientos en régimen de cirugía ambulatoria.

Anesthetic assessment traditionally included a series of laboratory tests intended to detect undiagnosed diseases, and to ensure that the patient undergoes surgery following safety criteria. These tests, without a specific clinical indication, are expensive, of questionable diagnostic value and often useless. In the context of outpatient surgery, recent evidence suggests that patients of any age without significant comorbidity, ASA physical status gradei and grade ii, do not need additional preoperative tests routinely. The aim of the present recommendations is to determine the general indications in which these tests should be performed in ASA gradei and grade ii patients undergoing ambulatory surgery.

Patient viewing of the ultrasound image prior to abortion.

BACKGROUND: Little research has investigated women's interest in and factors associated with viewing their ultrasound image in abortion care. STUDY DESIGN: Using medical records for all abortion care visits in 2011 (n = 15,575) at an urban abortion provider, we determined the proportion of women who chose to view by sociodemographic and pregnancy-related characteristics. We used bivariate and multivariable mixed-effects logistic regression models to examine associations between individual-level factors and the decision to view. RESULTS: A total of 42.6% of women chose to view. Identifying as nonwhite, being under age 25, being at or below the federal poverty level, and having medium or low decision certainty about the abortion were associated with increased odds of viewing. Being age 30 and over, having previously been pregnant and being more than 9 weeks gestation were associated with decreased odds of viewing. CONCLUSIONS: Many women seeking abortion care want to view their ultrasound image when offered the opportunity.

[Surgical errors and risks--the head and neck cancer patient]. / Fehler und Gefahren: Onkochirurgie im Kopf-Hals-Bereich.

Head and neck surgery is one of the basic principles of head and neck cancer therapy. Surgical errors and malpractice can have fatal consequences for the treated patients. This can lead into functional impairment and even have impact in future chances for disease related survival. There are many risks for head and neck surgeons which can cause errors and malpractice. To avoid surgical errors, thorough preoperative management of patients is demanded for. Such is ensuring operability, cautious evaluation of preoperative diagnostics and operative planning. Moreover knowledge of anatomical structures of the head and neck, of medical studies and data as well as qualifications in modern surgical techniques and the surgeons ability for critical self assessment are basic but important prerequisites for head and neck surgeons in order to prevent from mistakes. Moreover it is important to have profound knowledge in nutrition management of cancer patients, wound healing and to realize and be capable of dealing with complications, when they occur.Despite all preventive precaution and surgical care, mistakes cannot always be avoided. For that it is important to be able to deal with errors and to establish an appropriate and clear communication and management for such events. The manuscript comments on recognition and prevention of risks and mistakes in the preoperative, operative and postoperative phase of head and neck cancer surgery.

[Preoperative risk evaluation from the perspective of anaesthesiology]. / Präoperative Risikoevaluation aus anästhesiologischer Sicht.

Medical and technical progress together with demographic changes has led to a more complex perioperative care for patients. Accordingly, an optimal preoperative assessment in particular an adequate risk evaluation is more important than ever. A recently published joint recommendation of the German Society of Anaesthesiology and Intensive Care Medicine, the German Society of Surgery and the German Society of Internal Medicine aims to reduce considerable uncertainties in the preoperative risk evaluation especially with regard to"technical tests" by providing transparent and comprehensive arrangements. Consequently, routine screening will be abandoned in favour of targeted patient and operation-oriented individual risk assessment. This approach will change the preoperative risk evaluation in a scientific, organisational and economic way. The following article on preoperative risk evaluation is based on the valuable and helpful recommendation and aims to provide additional important aspects from the perspective of anaesthesiologists.

[Refusal of allogeneic blood transfusion by Jehovah's Witnesses. Perioperative management from a legal viewpoint]. / Ablehnung von Fremdblut durch Zeugen Jehovas. Perioperatives Management aus rechtlicher Sicht.

The perioperative management of patients belonging to the faith of Jehovah's Witnesses poses two equally difficult problems for physicians due their strict refusal of allogeneic blood transfusions: From a medical point of view everything must be done to avoid fatal anemia and coagulopathy. On the other hand, the physician is confronted with the legal problem even in extreme cases, whether the wishes of the patient, i.e. the religiously motivated right to self-determination, should or even must be followed when despite all preventative measures as described in this case, the risk of fatality is only avoidable by a blood transfusion and therefore represents the only life-saving option. In order to be able to answer this question this article supplies information on the unanimously recognized conditions in the jurisdiction and prevailing legal opinion and derives the consequences for the physician that this does not necessarily signify an unconditional legal obligation in association with a patient directive.

Blood transfusion: implications of treating a Jehovah's Witness patient.

Jehovah's Witnesses believe that an individual's life is contained within blood, and that accepting transfusion of blood and blood products is sinful. The administration of blood to a Jehovah's Witness who has refused to accept transfusion may lead to criminal or civil proceedings. From an ethical viewpoint, if a rational adult who has been fully apprised of the consequences of not receiving this treatment persists in a refusal, the decision should be respected. Medical and nursing staff faced with such a problem should explore fully with the patient any transfusion alternatives that the patient might find acceptable, such as cell salvage, volume expanders, antifibrinolytics and pharmaceutical options, such as erythropoietin. This article examines the legal and consent issues around blood transfusion in Jehovah's Witness patients and their implications for medical and surgical management.

Preoperative consent: how to make sure your practice is legal--Part one.

Perioperative practitioners encounter consent issues constantly in their practice, both in terms of the main procedure listed and procedures they will undertake personally to enable the main procedure to be carried out safely. The law on consent has previously been governed by case (common) law but is now also partly governed by the Mental Capacity Act 2005 (MCA) (HMSO 2005). The onus is on practitioners to ensure that their practice is legal. This article and the subsequent companion article aim to emphasise the key legal points.