Are there geographical disparities in access to liver transplantation in Atlantic Canada?

OBJECTIVE:

To characterize the patient population served by Atlantic Canada’s Multi-Organ Transplant Program liver transplant service over the first five years of activity in its current iteration.

METHODS:

Data from a prospective institutional database, supplemented by retrospective medical record review, were used to identify and characterize the cohort of patients assessed for consideration of first liver transplant between December 1, 2004 and December 1, 2009.

RESULTS:

In the five-year period after reactivation, the program assessed 337 patients for first liver transplant. The median age at referral for this group of 199 men (59.0%) and 138 women (41.0%) was 56.1 years (range 16.3 to 72.3 years). The leading three liver diseases indicating liver replacement were alcohol-related end-stage liver disease (20.5%), hepatocellular cancer (16.6%) and hepatitis C-related end-stage liver disease (14.0%). When evaluated according to provincial population-standardized incidence, significant differences in the incidence of liver transplant assessment among the four Atlantic Canadian provinces were found (per 100,000 inhabitants: Nova Scotia 19.8, New Brunswick 13.0, Newfoundland and Labrador 9.1 and Prince Edward Island 11.0; Fisher’s exact P<0.001). Of the 337 individuals who began the assessment process, 153 (45.4%) were assigned to the wait list. The probability of an individual being assigned to the wait list was not found to differ according to province of residence (Nova Scotia 45.3%, New Brunswick 40.0%, Newfoundland and Labrador 58.7% and Prince Edward Island 40.0%; Fisher’s exact P=0.206).

CONCLUSIONS:

The analysis suggests that there are geographical disparities in access to liver transplantation in Atlantic Canada. These disparities appear to be related to factors that precede the transplant assessment process.     

Desmopressin for haemostasis in cardiac surgery: when to use?

Bleeding after cardiac surgery increases morbidity and exposes patients to the risks associated with blood transfusion. Desmopressin acetate, a synthetic vasopressin analogue, has been used in patients undergoing cardiac operations to reduce postoperative blood loss and transfusion requirements, although a benefit has not been demonstrated in large randomized controlled trials. Therefore, the routine use of desmopressin in uncomplicated cardiac operations is not recommended. This review article discusses the pharmacology of desmopressin as a haemostatic agent and evaluates available clinical evidence to determine current indications for desmopressin as a haemostatic agent in cardiac surgery.     

Post-operative nausea and vomiting in the cardiac surgery population: Who is at risk?

ObjectivesPost-operative nausea and vomiting (PONV) is a common and distressing complication following cardiac surgery. Therefore, our primary objective was to explore the predictors of severe PONV in the cardiac surgery population.MethodsA retrospective study was completed on cardiac surgery patients (N = 150). A modified preoperative PONV risk assessment tool was utilized to identify patients at high and low risk for PONV.Results54% of the high-risk group versus 13% of the low-risk group experienced ≥2 nausea events in the early post-operative period (p < 0.0001). The high-risk group had a uniquely elevated and sustained number of PONV events post-operatively. History of PONV (p = 0.03) and female gender (p = 0.01) emerged as significant predictors of any nausea event.ConclusionsA specific PONV risk assessment tool may be useful for predicting those at highest risk following cardiac surgery. Further research is required to identify strategies to reduce PONV.     

Who is the right patient for TAVI?

Transcatheter aortic valve implantation (TAVI) has rapidly emerged as a valid therapeutic option for patients with severe symptomatic aortic stenosis who are high risk or ineligible for conventional surgical aortic valve replacement. Despite its minimally invasive nature, TAVI is invariably associated with complications in these old patients that may affect outcomes. Although the success of TAVI is determined by multiple factors, good screening and appropriate patient selection is crucial. Selection of the right patient includes the determination of risk levels and feasibility of a safe procedure in each individual case. Here, we describe below our critical appraisal of patient selection for TAVI.