Access to Grafts in a Liver Transplant Center: Does It Rely on the Severity of the Waiting List Population?

BACKGROUND: The number of transplants performed relies, partially, on recipients' variables on the waiting list. The goal of this study was to compare recipients from a high-volume liver center in Argentina with the rest of the country. METHODS: This study was a retrospective analysis of liver transplant recipients nationally between January 2013 and April 2017. It involved extracting data from the open database CRESI-SINTRA (the Argentinian database of the National Procurement Organization, an equivalent to the United Network for Organ Sharing); expressing results by percentages, medians, and interquartile ranges (IQRs); and comparing the national population with the population transplanted at Hospital El Cruce (HEC). The Mann-Whitney U test was used for analysis. RESULTS: Nationally, 1434 liver transplants were performed. A total of 177 (12.34%) were emergency status; 811 (56.6%) were by the Model for End-Stage Liver Disease (MELD) (n = 759)/PELD (Pediatric End-Stage Liver Disease) (n = 52), with a median graft assignment position of 5 (IQR, 3-10) in 57.2 days (IQR, 11-217). Median MELD access was 29 points (IQR, 24-33). A total of 446 (31.1%) had MELD exceptions; 249 (55.8%) of these were due to Milan hepatocellular carcinoma. At the HEC, 167 liver transplantations were performed; 26 (15.6%) were emergency status and 97 (58.1%) by MELD (none PELD). Their median graft assignment position was 4 (IQR, 4-16) in 19.1 days (IQR, 4-90); median MELD access was 28 points (IQR, 24-31). Forty-five patients (26.9%) had MELD exceptions; 31 (68.9%) were due to hepatocellular carcinoma. CONCLUSIONS: Our center has a larger proportion of recipients transplanted by emergency status and MELD, similar MELD access, and less waiting list time, reflecting our wide policy of liver graft acceptance.

Tenofovir-emtricitabine-efavirenz in HIV-I-infected adults in Senegal: a 96-week pilot trial in treatment-naive patients.

We report the results of a pilot open-label trial of a tenofovir (TDF)/emtricitabine (FTC)/efavirenz (EFV) combination conducted in Dakar, Senegal. Forty HIV-1-infected patients, naive of antiretroviral treatment and without active opportunistic disease, were included and followed through 96 weeks. At weeks 48 and 96, respectively, 82.5% and 85% of patients had HIV-1 RNA <400 copies/mL (72.5% and 77.5% with HIV-1 RNA <50 copies/mL). Between baseline and week 96, the mean (SD) CD4 count increased from 126 (102) to 338 (155) cells/mm(3). The mean (SD) creatinine clearance decreased from 92 (36) to 73 (19) mL/min (P = .001). Treatment adherence was at least 94% at all scheduled visits. The efficacy and tolerability of a TDF/FTC/EFV combination were high and similar to those observed in Northern countries. This drug combination can be recommended in limited-resource countries, as did the World Health Organization (WHO) and should be made readily available as a fixed-dose combination.

[Factors associated with mortality in Legionnaires' disease, France, 2002-2004]. / Les facteurs associés à la mortalité de la légionellose en France, 2002-2004.

UNLABELLED: Risk factors for Legionnaires' disease are well known (older age, smoking, or immunosuppression), however, the factors associated with mortality are less documented. A retrospective analysis based on cases notified between 2002 and 2004 was conducted in France to identify these factors. METHOD: Cases were identified through mandatory notifications sent to the Institut de veille sanitaire, France. Factors associated with mortality were identified using a logistic regression analysis. RESULTS: Three thousand two hundred sixty-seven cases of Legionnaire's disease were notified during the study period and the evolution was documented for 85% of the cases (2.791). Three hundred seventy-seven deaths (13.5%) were notified. 72.5% of the patients were men and the median age was 61. The multivariate analysis applied to patients under 60 years revealed that cancer or hemopathy (OR=6.4 CI95% 3.6-11.2), underlying renal disease (OR=3.2 CI95% 1.0-9.9), or alcohol abuse (OR=2.2 CI95% 1.1-4.4) were associated with mortality. For older patients (>60 years) factors linked to mortality were: cancer/hemopathy (OR=1.8 CI95% 1.2-2.6), underlying renal disease (OR=3 CI95% 1.4-6.4), underlying cardiac disease (OR=2.4 CI95% 1.4-4), alcohol abuse (OR=2.4 CI95% 1.2-5.2), immunosuppression (OR=1.7 CI95% 1.1-2.6), nosocomial acquisition of the disease (OR=2.0 CI95% 1.3-3), or infection acquired in nursing home residents (OR=2.4 IC 95% 1.6-3.6). CONCLUSION: These preliminary results further describe Legionnaires' disease and its mortality. However, they should be confirmed by carefully conducted prospective analysis. The description of LD patients at high risk of death will contribute to better prevention measures.

Quality of life and depression among HIV-infected patients receiving efavirenz- or protease inhibitor-based therapy in Senegal.

BACKGROUND: Efavirenz has been associated with neuropsychiatric disorders, but little is known about depression and quality of life in sub-Saharan Africa, where nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimens are still the first-line treatment recommended by the World Heath Organization (WHO) and are widely prescribed. METHODS: In a cross-sectional study, we evaluated quality of life and depression among Senegalese patients receiving efavirenz- or protease inhibitor (PI)-based regimens. Two hundred consecutive patients who had been taking highly active antiretroviral therapy (HAART) for more than 6 months were asked to complete a questionnaire. RESULTS: According to the Center for Epidemiologic Studies Depression Scale (CES-D), 18% had depression (19% for patients on a PI-based regimen and 17% for patients on efavirenz-based treatment). Fifty-nine per cent of the patients reported no health problems in the past 4 weeks. A quarter of patients had sleep disorders. Moderate or slight adverse events were reported by 28.5% of patients. CONCLUSIONS: Quality of life and depression scores remained good in both study groups. However, quality of life and depression should be monitored in follow-up of HIV-infected patients in sub-Saharan Africa.

[Prevalence and incidence of dementia among the very old. Review of the literature]. / Prévalence et incidence des démences au grand âge. Analyse de la littérature.

BACKGROUND: The increasing number of elderly and very old people observed in France for more than 20 years raises the problem of an expected increase in the prevalence and incidence of dementia in this population. Prevalence and incidence estimates for persons older than 85 years are incomplete and discordant. This information is crucial for organizing future health and social care. OBJECTIVE: Review of literature of prevalence and incidence of dementia for people older than 85 and their link to aging. METHODS: A Medline search has led to a selection of 50 articles. RESULTS: Some studies conclude that there is an exponential relationship of incidence with age; some, a decrease of dementia in the oldest old population. Prevalence estimates in these studies fluctuate between 15 and 40% and incidence between 60 and 100 person-years. CONCLUSION: The variation of prevalence and incidence estimates for 85 and over are partly due to methodological differences and limitations between studies. Further research is needed to include larger samples of persons aged 85 and over and to confirm results where clinical and public health consequences are major issues.

Survey of regional anesthetic practice among French residents at time of certification.

BACKGROUND AND OBJECTIVES: A survey of anesthesia practice was conducted among French residents in anesthesia at the end of their training. This study was performed mainly to evaluate the residents' experience in peripheral nerve blocks. METHODS: Two short clinical cases were proposed to all French residents during a telephone interview immediately before their certification. The first described the case of a young asthmatic patient admitted for an elbow fracture. The second described an elderly woman with severe aortic stenosis admitted for a supracondylar fracture of the femur. A questionnaire had been prepared and was filled in during the interview. Each resident was asked to answer according to the actual choice he or she would have made. For both cases, when general anesthesia was chosen first, the next question was to discuss which regional anesthesia would be used if general anesthesia had to be discarded. In that way, the practical knowledge about most common peripheral nerve blocks learned during residency was investigated. RESULTS: Of 77 residents registered as being at the end of their residency, 8 were on either sabbatical or maternity leave. Regional anesthesia was the first choice in 78% and 57% of cases for the first and second clinical cases, respectively. The regional anesthetic techniques chosen were axillary block (66%), interscalene block (31%), and intravenous regional anesthesia (3%) for case 1 and combined lumbar plexus and sciatic block (36%), epidural anesthesia (30%), single-shot spinal anesthesia (18%), and continuous spinal anesthesia (16%) for case 2. Throughout the residency of the group, 32 +/- 2 axillary blocks, 12 +/- 2 interscalene blocks (axillary vs interscalene, P < .0001), 21 +/- 3 femoral blocks, and 10 +/- 2 sciatic blocks (femoral vs sciatic, P < .0001) had been performed (mean +/- SEM). They had also performed 2.5 +/- 0.5 continuous spinal anesthesias and 17 +/- 3 intravenous regional anesthesias respectively. Upper extremity blocks were more often used during residency than lower extremity blocks (44 +/- 3 vs 31 +/- 4, P < .01). A peripheral nerve stimulator was routinely used by 83% of residents. CONCLUSION: French residents in anesthesiology at time of certification are better trained for peripheral nerve blocks of the upper extremity than for those of the lower extremity. Axillary plexus and femoral nerve block are the most widely used blocks, probably reflecting the techniques the most mastered among teachers. Finally, the extensive use of a peripheral nerve stimulator by residents is probably the result of the widespread use of this device by teachers in France.

[Emergency cesarean section: role of locoregional anesthesia]. / Césarienne en urgence: place de l'anesthésie locorégionale.

Emergency cesarean section is sometimes required for acute fetal distress but also for some maternal vital emergencies. In spite of its maternal (Mendelson's syndrome, difficult intubation) and fetal (neonatal depression) risks, general anaesthesia was classically used. The arguments in favor of regional anaesthesia techniques for emergency cesarean section and the respective advantages of spinal and epidural anaesthesia are developed in this text. The already functioning epidural catheter can be used to rapidly convert analgesia for labor to anaesthesia for cesarean section: this situation is probably the simplest to manage but requires that parturients at risk for cesarean section were recognized in early labor, especially all the parturients with a suspected difficult airway. In case of patchy or unilateral analgesia, it is particularly important to resite the catheter to avoid the need for emergency general anaesthesia to solve an inadequate epidural anaesthesia for cesarean section. Spinal anaesthesia is the technique of choice for its rapidity of action but its hemodynamic risks need a prior careful evaluation of maternal hemodynamics. General anaesthesia will be always indispensable in some cases; therefore, every anaesthetist should maintain sufficient experience and skills in the management of some of its complications, especially intubation difficulties.