Objective: To determine the outcomes in solid organ transplant recipients following inpatient rehabilitation, as a result of a unique partnership between the rehabilitation hospital and the multi-organ transplant prog...Objective: To determine the outcomes in solid organ transplant recipients following inpatient rehabilitation, as a result of a unique partnership between the rehabilitation hospital and the multi-organ transplant program in an acute hospital. Design: Retrospective observational study. Setting: Community rehabilitation hospital affiliated with a university. Participants: A cohort of 173 organ transplant patients admitted consecutively over a four-year period (2004-2008) was compared to a cohort of all rehabilitation patients (n = 9762) admitted to the same inpatient rehab facility during the same period. Interventions: Inpatient rehab program to all participants. Main Outcome Measures: Length of hospital stay, Functional Independence Measure (FIMTM) change (admission-discharge), and rate of discharges to home. Results: Outcomes were measured using components of the FIMTM instrument, admission and discharge data. Chi-square and independent two-sample t-tests were used for statistical analysis. Compared to a general rehabilitation inpatient population, transplant rehabilitation inpatients had: more immediate (TM change (8.9 vs. 20.9, p TM efficiency (1.1 vs. 1.4, p < 0.001);and a higher rate of discharges to home in patients not readmitted to acute care (98.5% vs. 94.5% p < 0.001). Conclusion: Outcomes of rehabilitation in solid organ transplant patients are comparable but not identical to those in other patient groups. Inpatient rehabilitation for transplant patients is therefore fully justifiable and necessary. The ten times higher rate of transplant patient readmission to acute hospital must be communicated, facilitated, accepted and managed within a partnership strategy.展开更多
BACKGROUND Early hospital readmissions(EHRs)after kidney transplantation range in incidence from 18%-47%and are important and substantial healthcare quality indicators.EHR can adversely impact clinical outcomes such a...BACKGROUND Early hospital readmissions(EHRs)after kidney transplantation range in incidence from 18%-47%and are important and substantial healthcare quality indicators.EHR can adversely impact clinical outcomes such as graft function and patient mortality as well as healthcare costs.EHRs have been extensively studied in American healthcare systems,but these associations have not been explored within a Canadian setting.Due to significant differences in the delivery of healthcare and patient outcomes,results from American studies cannot be readily applicable to Canadian populations.A better understanding of EHR can facilitate improved discharge planning and long-term outpatient management post kidney transplant.AIM To explore the burden of EHR on kidney transplant recipients(KTRs)and the Canadian healthcare system in a large transplant centre.METHODS This single centre cohort study included 1564 KTRs recruited from January 1,2009 to December 31,2017,with a 1-year follow-up.We defined EHR as hospitalizations within 30 d or 90 d of transplant discharge,excluding elective procedures.Multivariable Cox and linear regression models were used to examine EHR,late hospital readmissions(defined as hospitalizations within 31-365 d for 30-d EHR and within 91-365 d for 90-d EHR),and outcomes including graft function and patient mortality.RESULTS In this study,307(22.4%)and 394(29.6%)KTRs had 30-d and 90-d EHRs,respectively.Factors such as having previous cases of rejection,being transplanted in more recent years,having a longer duration of dialysis pretransplant,and having an expanded criteria donor were associated with EHR post-transplant.The cumulative probability of death censored graft failure,as well as total graft failure,was higher among the 90-d EHR group as compared to patients with no EHR.While multivariable models found no significant association between EHR and patient mortality,patients with EHR were at an increased risk of late hospital readmissions,poorer kidney function throughout the 1st year post-transplant,and higher hospital-based care costs within the 1st year of follow-up.CONCLUSION EHRs are associated with suboptimal outcomes after kidney transplant and increased financial burden on the healthcare system.The results warrant the need for effective strategies to reduce post-transplant EHR.展开更多
Metabolic dysfunction-associated steatotic liver disease is the most prevalent chronic liver condition,affecting over one-third of the global population,with cirrhosis present in up to 3.3%of cases.Early detection of ...Metabolic dysfunction-associated steatotic liver disease is the most prevalent chronic liver condition,affecting over one-third of the global population,with cirrhosis present in up to 3.3%of cases.Early detection of advanced liver disease in at-risk populations can enable timely intervention,prevent progression,and reduce complications.This review focuses on the current recommendations for early detection of advanced liver disease,evaluates the evidence for the performance of non-invasive tests in the target population for screening,and examines the multifaceted burden of screening,including economic implications and psychological impacts.Additionally,we discuss future directions,such as integrating liver health into a multidisciplinary care framework.Current guidelines recommend case-finding,targeting individuals with type 2 diabetes,metabolically complicated obesity,or persistent elevated liver enzymes.The Fibrosis-4 index is widely endorsed as a first-line non-invasive test,yet the diagnostic performance in primary care settings seems suboptimal,particularly for pre-cirrhotic disease.Sequential strategies incorporating novel non-invasive tests may improve accuracy and cost-effectiveness.Confirmation typically involves vibration-controlled transient elastography.Key challenges include a large eligible population,uncertainties in optimal screening intervals,patient adherence to follow-up,and limited real-world cost-effectiveness data.Integrating liver health assessment into cardiometabolic care pathways,reflex testing,telehealth,and patient education may enhance uptake.While challenges remain,early detection of advanced liver disease is already likely cost-effective.Ongoing advances in screening pathways and treatment options are expected to further strengthen the case for widespread implementation.展开更多
BACKGROUND Old donor allografts in liver transplantation(LT)account for 25%of all allografts,and their utilization is projected to increase with the aging general population.Older allografts are associated with higher...BACKGROUND Old donor allografts in liver transplantation(LT)account for 25%of all allografts,and their utilization is projected to increase with the aging general population.Older allografts are associated with higher rates of all-cause mortality and graft failure;however,there is limited literature exploring the specific phenotypic changes(e.g.,functional status,cause-specific mortality)observed in different donor:recipient age pairs.AIM To investigate differences in functional impairment and cause-specific mortality between different donor:recipient age pairs.METHODS This was a retrospective analysis of LT patients from the Scientific Registry of Transplant Recipients from 2002 to 2022.Donors were categorized into younger age donors,≤45-years(YAD),middle-aged donors,46-69-years(MAD),and older age donors,≥70-years(OAD).Recipients were categorized into younger age recipients,≤55-years(YAR)and older age recipients,>55-years(OAR)age recipients.Multivariate Fine-Gray competing risk and logistic regression analyses identified independent risk factors for cause-specific mortality and improvements in functional status,respectively.RESULTS Overall,126185 patients were included in the analysis:YAD:YAR(32.7%), YAD:OAR (25.2%), MAD:YAR (17.5%), MAD:OAR (20.7%), OAD:YAR (1.3%), and OAD:OAR (2.7%). Compared toYAD:YAR, OAD pairs had the lowest likelihoods of improved functional status 5 years post-LT (OAD:YAR oddsratio 0.53, 95% confidence interval 0.42-0.67, P < 0.001;OAD:OAR odds ratio 0.67, 95% confidence interval 0.51-0.89, P = 0.006). Donor:recipient age pairs with older donors had higher rates of graft- and infection-relatedmortality compared to those with younger donors (P < 0.001). Meanwhile, donor:recipient age pairs with olderrecipients had higher cardioneurovascular- or malignancy-related deaths compared to those with youngerrecipients (P < 0.001).CONCLUSIONDonor:recipient age mismatch was associated with differences in cause-specific mortality and functional status.These insights could potentially inform age-matched organ allocation strategies, though future work is warranted.展开更多
Contrast-enhanced ultrasound(CEUS)using microbubble contrast agents are useful for the diagnosis of the nodules in liver cirrhosis.CEUS can be used as a problem-solving method for indeterminate nodules on computed tom...Contrast-enhanced ultrasound(CEUS)using microbubble contrast agents are useful for the diagnosis of the nodules in liver cirrhosis.CEUS can be used as a problem-solving method for indeterminate nodules on computed tomography(CT)or magnetic resonance imaging(MRI)or as an initial diagnostic test for small newly detected liver nodules.CEUS has unique advantages over CT and MRI including no renal excretion of contrast,real-time imaging capability,and purely intravascular contrast.Hepatocellular carcinoma(HCC)is characterized by arterial-phase hypervascularity and later washout(negative enhancement).Benign nodules such as regenerative nodules or dysplastic nodules are usually isoechoic or slightly hypoechoic in the arterial phase and isoechoic in the late phase.However,there are occasional HCC lesions with atypical enhancement including hypovascular HCC and hypervascular HCC without washout.Cholangiocarcinomas are infrequently detected during HCC surveillance and mostly show rimlike or diffuse hypervascularity followed by rapid washout.Hemangiomas are often found at HCC surveillance and are easily diagnosed by CEUS.CEUS can be effectively used in the diagnostic work-up of small nodules detected at HCC surveillance.CEUS is also useful to differentiate malignant and benign venous thrombosis and to guide and monitor the local ablation therapy for HCC.展开更多
Non-alcoholic fatty liver disease(NAFLD) is an important health problem worldwide. NAFLD encompasses a histological spectrum ranging from bland liver steatosis to severe steatohepatitis(nonalcoholic steatohepatitis, N...Non-alcoholic fatty liver disease(NAFLD) is an important health problem worldwide. NAFLD encompasses a histological spectrum ranging from bland liver steatosis to severe steatohepatitis(nonalcoholic steatohepatitis, NASH) with the potential of progressing to cirrhosis and its associated morbidity and mortality. NAFLD is thought to be the hepatic manifestation of insulin resistance(or the metabolic syndrome); its prevalence is increasing worldwide in parallel with the obesity epidemic. In many developed countries, NAFLD is the most common cause of liver disease and NASH related cirrhosis is currently the third most common indication for liver transplantation. NASH related cirrhosis is anticipated to become the leading indication for liver transplantation within the next one or two decades. In this review, we discuss how liver transplantation is affected by NAFLD, specifically the following:(1) the increasing need for liver transplantation due to NASH;(2) the impact of the increasing prevalence of NAFLD in the general population on the quality of deceased and live donor livers available for transplantation;(3) the long term graft and patient outcomes after liver transplantation forNASH,and finally;and(4)the de novo occurrence of NAFLD/NASH after liver transplantation and its impact on graft and patient outcomes.展开更多
Non-alcoholic fatty liver disease(NAFLD)ranges from simple steatosis to nonalcoholic steatohepatitis(NASH),leading to fibrosis and potentially cirrhosis,and it is one of the most common causes of liver disease worldwi...Non-alcoholic fatty liver disease(NAFLD)ranges from simple steatosis to nonalcoholic steatohepatitis(NASH),leading to fibrosis and potentially cirrhosis,and it is one of the most common causes of liver disease worldwide.NAFLD is associated with other medical conditions such as metabolic syndrome,obesity,cardiovascular disease and diabetes.NASH can only be diagnosed through liver biopsy,but noninvasive techniques have been developed to identify patients who are most likely to have NASH or fibrosis,reducing the need for liver biopsy and risk to patients.Disease progression varies between individuals and is linked to a number of risk factors.Mechanisms involved in the pathogenesis are associated with diet and lifestyle,influx of free fatty acids to the liver from adipose tissue due to insulin resistance,hepatic oxidative stress,cytokines production,reduced very low-density lipoprotein secretion and intestinal microbiome.Weight loss through improved diet and increased physical activity has been the cornerstone therapy of NAFLD.Recent therapies such as pioglitazone and vitamin E have been shown to be beneficial.Omega 3 polyunsaturated fatty acids and statins may offer additional benefits.Bariatric surgery should be considered in morbidly obese patients.More research is needed to assess the impact of these treatments on a long-term basis.The objective of this article is to briefly review the diagnosis,management and treatment of this disease in order to aid clinicians in managing these patients.展开更多
AIM： To evaluate the expression of fibrinogenlike protein 2 （fgl2） and its correlation with disease progression in both mice and patients with severe viral hepatitis. METHODS： Balb/cJ or A/J mice were infected int...AIM： To evaluate the expression of fibrinogenlike protein 2 （fgl2） and its correlation with disease progression in both mice and patients with severe viral hepatitis. METHODS： Balb/cJ or A/J mice were infected intraperitoneally （ip） with 100 PFU of murine hepatitis virus type 3 （MHV-3）, liver and serum were harvested at 24, 48, and 72 h post infection for further use. Liver tissues were obtained from 23 patients with severe acute chronic （AOC） hepatitis B and 13 patients with mild chronic hepatitis B. Fourteen patients with mild chronic hepatitis B with cirrhosis and 4 liver donors served as normal controls. In addition, peripheral blood mononuciear cells （PBMC） were isolated from 30 patients （unpaired） with severe AOC hepatitis B and 10 healthy volunteers as controls. Procoagulant activity representing functional prothrombinase activity in PBMC and white blood cells was also assayed. A polyclonal antibody against fgl2 was used to detect the expression of both mouse and human fgl2 protein in liver samples as well as in PBMC by immunohistochemistry staining in a separate set of studies. Alanine aminotransferase （ALT） and total bilirubin （TBil） in serum were measured to assess the severity of liver injury.RESULTS： Histological changes were found in liver sections 12-24 h post MHV-3 infection in Balb/cJ mice. In association with changes in liver histology, marked elevations in serum ALT and TBil were observed. House fgl2 （mfgl2） protein was detected in the endothelium of intrahepatic veins and hepatic sinusoids within the liver 24 h after MHV-3 infection. Liver tissues from the patients with severe AOC hepatitis B had classical pathological features of acute necroinflammation. Human fgl2 （hfgl2） was detected in 21 of 23 patients （91.30%） with severe AOC hepatitis B, while only 1 of 13 patients （7.69%） with mild chronic hepatitis B and cirrhosis had hfgl2 mRNA or protein expression. Twenty-eight of thirty patients （93.33%） with severe AOC hepatitis B and 1 of 10 with mild chronic hepatitis B had detectable hfgl2 expression in PBMC. No hfgl2 expression was found either in the liver tissue or in the PBMC from normal donors. There was a positive correlation between hfgl2 expression and the severity of the liver disease as indicated by the levels of TBil. PCA significantly increased in PBMC in patients with severe AOC hepatitis B. CONCLUSION： The molecular and cellular results reported here in both mice and patients with severe viral hepatitis suggest that virus-induced hfgl2 prothrombinase/fibroleukin expression and the coagulation activity associated with the encoded fgl2 protein play a pivotal role in initiating severe hepatitis. The measurement of hfgl2/fibroleukin expression in PBMC may serve as a useful marker to monitor the severity of AOC hepatitis B and a target for therapeutic intervention.展开更多
Liver transplantation(LT) is the most effective treatment modality for end stage liver disease caused by many etiologies including autoimmune processes. That said, the need for transplantation for autoimmune hepatitis...Liver transplantation(LT) is the most effective treatment modality for end stage liver disease caused by many etiologies including autoimmune processes. That said, the need for transplantation for autoimmune hepatitis(AIH) and primary biliary cirrhosis(PBC), but not for primary sclerosing cholangitis(PSC), has decreased over the years due to the availability of effective medical treatment. Autoimmune liver diseases have superior transplant outcomes than those of other etiologies. While AIH and PBC can recur after LT, recurrence is of limited clinical significance in most, but not all cases. Recurrent PSC, however, often progresses over years to a stage requiring re-transplantation. The exact incidence and the predisposing factors of disease recurrence remain debated. Better understanding of the pathogenesis and the risk factors of recurrent autoimmune liver diseases is required to develop preventive measures. In this review, we discuss the current knowledge of incidence, diagnosis, risk factors, clinical course, and treatment of recurrent autoimmune liver disease(AIH, PBC, PSC) following LT.展开更多
From its inception the success of liver transplantation has been associated with massive blood loss. Massive transfusion is classically defined as > 10 units of red blood cells within 24 h, but describing transfusi...From its inception the success of liver transplantation has been associated with massive blood loss. Massive transfusion is classically defined as > 10 units of red blood cells within 24 h, but describing transfusion rates over a shorter period of time may reduce the potential for survival bias. Both massive haemorrhage and transfusion are associated with increased risk of mortality and morbidity(need for dialysis/surgical site infection) following liver transplantation although causality is difficult to prove due to the observational design of most trials. The blood loss associated with liver transplantation is multifactorial. Portal hypertension secondary to cirrhosis results in extensive collateral circulation, which can bleed during hepatectomy particular if portal pressures are increased. Avoiding volume loading and maintenance of a low central venous pressure together with the use of vasopressors have been shown to reduce blood loss and transfusion during liver transplantation, but may increase the risk of renal impairment post-operatively. Coagulation defects may be present pre-transplant, but haemostasis is often re-balanced due to a deficit in both proand anti-coagulation factors. Further derangement of haemostasis may develop in the anhepatic and neohepatic phases due to absent hepatic metabolic function, hyperfibrinolysis and platelet sequestration in the donor liver. Point-of-care tests of coagulation such as the viscoelastic tests rotation thromboelastometry/thromboelastometry allow and more accurate and rapid assessment of these derangements in coagulation and guide the use of factor replacement and antifibrinolytics. Transfusion protocols guided by these tests have been shown to reduce transfusion rates compared with conventional coagulation tests, but have not shownimprovements in mortality or morbidity. Pre-operative factors associated with massive transfusion include previous surgery, re-do transplantation, the aetiology and severity of liver disease. Intra-operatively the use of piggy-back technique and avoiding veno-veno bypass has been shown to reduced blood loss.展开更多
Thoracic endovascular aortic repair for thoracic aortic aneurysms is an accepted alternative to open surgery, especially in patients with significant comorbidities. The procedure itself has a low risk of complications...Thoracic endovascular aortic repair for thoracic aortic aneurysms is an accepted alternative to open surgery, especially in patients with significant comorbidities. The procedure itself has a low risk of complications and fistulas to surrounding organs are rarely reported. An 86-year-old patient was admitted to our hospital with gastro intestinal(GI) bleeding and a suspected aortoesophageal fistula. Eight months prior, the patient had undergone a stent graft repair of a mycotic thoracic aneurysm. Computerized tomography angiography and upper GI endoscopy confirmed an aortoesophageal fistula, which was treated by esophageal stenting. With early recognition, esophageal stenting may have a role in the initial emergency control of bleeding from and palliation of aortoesophageal fistula.展开更多
In patients with diabetes mellitus, cardiovascular disease is the principal cause of mortality and chest pain is the most frequent symptom in patients with stable and acute coronary artery disease. However, there is l...In patients with diabetes mellitus, cardiovascular disease is the principal cause of mortality and chest pain is the most frequent symptom in patients with stable and acute coronary artery disease. However, there is little knowledge concerning the pervasiveness of uncommon presentations in diabetics. The symptomatology of acute coronary syndrome, which comprises both pain and non-pain symptoms, may be affected by traditional risk factors such as age, gender, smoking, hypertension, diabetes, and dyslipidemia. Such atypical symptoms may range from silent myocardial ischemia to a wide spectrum of non-chest pain symptoms. Worldwide, few studies have highlighted this under-investigated subject, and this aspect of ischemic heart disease has also been under-evaluated in the major clinical trials. The results of these studies are highly diverse which makes definitive conclusions regarding the spectrum of atypical presentation of acute and even stable chronic coronay artery disease difficult to confirm. This may have a significant impact on the morbidity and mortality of coronary artery disease in diabetics. In this up-to-date review we will try to analyze the most recent studies on the atypical presentations in both acute and chronic ischemic heart disease which may give some emphasis to this under-investigated topic.展开更多
The adult congenital heart disease (ACHD) population continues to grow and most cardiologists, emergency room physicians and family doctors will intermittently come into contact with these patients. Oftentimes this ma...The adult congenital heart disease (ACHD) population continues to grow and most cardiologists, emergency room physicians and family doctors will intermittently come into contact with these patients. Oftentimes this may be in the setting of a presentation with atrial tachyarrhythmia; one of the commonest late complications of ACHD and problem with potentially serious implications. Providing appropriate initial care and ongoing management of atrial tachyarrhythmia in ACHD patients requires a degree of specialist knowledge and an awareness of certain key issues. In ACHD, atrial tachyarrhythmia is usually related to the abnormal anatomy of the underlying heart defect and often occurs as a result of surgical scar or a consequence of residual hemodynamic or electrical disturbances. Arrhythmias significantly increase mortality and morbidity in ACHD and are the most frequent reason for ACHD hospitalization. Intra-atrial reentrant tachycardia and atrial fibrillation are the most prevalent type of arrhythmia in this patient group. In hemodynamically unstable patients, urgent cardioversion is required. Acute management of the stable patient includes anticoagulation, rate control, and electrical or pharmacological cardioversion. In ACHD, rhythm control is the preferred management strategy and can often be achieved. However, in the long-term, medication side-effects can prove problematic. Electrophysiology studies and catheter ablation are important treatments modalities and in certain cases, surgical or percutaneous treatment of the underlying cardiac defect has a role. ACHD patients, especially those with complex CHD, are at increased risk of thromboembolic events and anticoagulation is usually required. Female ACHD patients of child bearing age may wish to pursue pregnancies. The risk of atrial arrhythmias is increased during pregnancy and management of atrial tachyarrhythmia during pregnancy needs specific consideration.展开更多
We report the first case of acute renal failure secondary to prucalopride, a novel agent for the treatment of chronic constipation. The 75 years old male patient was initiated on prucalopride after many failed treatme...We report the first case of acute renal failure secondary to prucalopride, a novel agent for the treatment of chronic constipation. The 75 years old male patient was initiated on prucalopride after many failed treatments for constipation following a Whipple's procedure for pancreatic cancer. Within four months of treatment his creatinine rose from 103 to 285 μmol/L(e GFR 61 decrease to 19 m L/min per 1.73 m2). He was initially treated with prednisone for presumed acute interstitial nephritis as white blood casts were seen on urine microscopy. When no improvement was detected, a core biopsy was performed and revealed interstitial fibrosis and tubular atrophy. The presence of oxalate and calcium phosphate crystals were also noted. These findings suggest acute tubular necrosis which may have been secondary to acute interstitial nephritis or hemodynamic insult. The use of prednisone may have suppressed signs of inflammation and therefore the clinical diagnosis was deemed acute interstitial nephritis causing acute tubular necrosis. There are no previous reports ofprucalopride associated with acute renal failure from the literature, including previous Phase Ⅱ and Ⅲ trials.展开更多
A metabolic profile of plasma samples from patients undergoing heart surgery with the use of cardiopulmonary bypass （CPB） and concurrent administration of tranexamic acid was determined. Direct immersion solid phase...A metabolic profile of plasma samples from patients undergoing heart surgery with the use of cardiopulmonary bypass （CPB） and concurrent administration of tranexamic acid was determined. Direct immersion solid phase microextraction （DI-SPME）, a new sampling and sample preparation tool for metabolomics, was used in this study for the first time to investigate clinical samples. The results showed alteration of diverse compounds involved in different biochemical pathways. The most significant contribution in changes induced by surgery and applied pharmacotherapy was noticed in metabolic profile of lysophospholipids, triacylglycerols, mediators of platelet aggregation, and linoleic acid metabolites. Two cases of individual response to treatment were also reported.展开更多
AIM To develop a prediction model aimed at identifying patients that may require higher than usual sedation doses during colonoscopy.METHODS A retrospective chart review on 5000 patients who underwent an outpatient co...AIM To develop a prediction model aimed at identifying patients that may require higher than usual sedation doses during colonoscopy.METHODS A retrospective chart review on 5000 patients who underwent an outpatient colonoscopy at St.Paul's Hospital from 2009 to 2010 was conducted in order to develop a model for identifying patients who will require increased doses of sedatives.Potential predictor variables including age,gender,endoscopy indication,high sedation requirements during previous endoscopies,difficulty of the procedure,bowel preparation quality,interventions,findings as well as current use of benzodiazepines,opioids and alcohol were analyzed.The outcome of study was the use ofhigh dose of sedation agents for the procedure.In particular,the high dose of sedation was defined as fentanyl greater than 50 mcg and midazolam greater than 3 mg.RESULTS Analysis of 5282 patients(mean age 57 ± 12,49% female) was performed.Most common indication for the procedure was screening colonoscopy(57%).Almost half of our patients received doses exceeding Fentanyl 50 mcg and Midazolam 3 mg.Logistic regression models identified the following variables associated with high sedation:Younger age(OR=0.95 95%CI:0.94-0.95;P < 0.0001);abdominal pain(OR=1.45,95%CI:1.08-1.96);P=0.01) and Inflammatory Bowel Disease(OR=1.45,95%CI:1.04-2.03;P=0.02) as indications for the procedure;difficult procedure as defined by gastroenterologist(OR=1.73,95%CI:1.48-2.03;P < 0.0001);past history of abdominal surgery(OR=1.33,95%CI:1.17-1.52;P <0.0001) and previous colonoscopy(OR=1.39,95%CI:1.21-1.60;P=0.0001) and alcohol use(OR=1.26,95%CI:1.03-1.54;P=0.02).Age and gender adjusted analysis yielded inflammatory bowel disease as an indication(OR=3.17,95%CI:1.58-6.37;P=0.002);difficult procedure as defined by an endoscopist(OR=5.13 95%CI:2.97-8.85;P=0.0001) and current use of opioids,benzodiazepines or antidepressants(OR=2.88,95%CI:1.74-4.77;P=0.001) having the highest predictive value of high sedation requirements.Our prediction model using the following pre-procedural variables including age,indication for the procedure,medication/substance use,previous surgeries yielded an area under the curve of 0.76 for Fentanyl ≥ 100 mcg and Midazolam ≥ 3 mg.CONCLUSION Pre-procedural planning is the key in conducting successful,efficient colonoscopy.Logistic regression analysis of 5000 patients who underwent out-patient colonoscopy revealed the following factors associated with increased sedation requirement:Younger age,female gender,difficult endoscopy,specific indications as well as cardiopulmonary complications and current use of opioids/benzodiazepines.Age and gender adjusted analysis yielded similar results.These patients are more likely to need a longer recovery periods post-endoscopy,which could result in additional time and personnel requirements.The final predictive model has good predictive ability for Fentanyl ≥ 100 mcg and Midazolam ≥ 3 mg and fair predictive ability for Fentanyl ≥ 50 mcg and Midazolam ≥ 2 mg.The external validity of this model is planned to be tested in another center.展开更多
BACKGROUND Solid organ transplantation is a life-saving intervention for end-stage organ disease.Post-transplant diabetes mellitus(PTDM)is a common complication in solid organ transplant recipients,and significantly c...BACKGROUND Solid organ transplantation is a life-saving intervention for end-stage organ disease.Post-transplant diabetes mellitus(PTDM)is a common complication in solid organ transplant recipients,and significantly compromises long-term survival beyond a year.AIM To perform a systematic review and meta-analysis to estimate incidence of PTDM and compare the effects of the 3 major immunosuppressants on incidence of PTDM.METHODS Two hundred and six eligible studies identified 75595 patients on Tacrolimus,51242 on Cyclosporine and 3020 on Sirolimus.Random effects meta-analyses was used to calculate incidence.RESULTS Network meta-analysis estimated the overall risk of developing PTDM was higher with tacrolimus(OR=1.495%CI:1.0–2.0)and sirolimus(OR=1.8;95%CI:1.5–2.2)than with Cyclosporine.The overall incidence of PTDM at years 2-3 was 17%for kidney,19%for liver and 22%for heart.The risk factors for PTDM most frequently identified in the primary studies were age,body mass index,hepatitis C,and African American descent.CONCLUSION Tacrolimus tends to exhibit higher diabetogenicity in the short-term(2-3 years post-transplant),whereas sirolimus exhibits higher diabetogenicity in the longterm(5-10 years post-transplant).This study will aid clinicians in recognition of risk factors for PTDM and encourage careful evaluation of the risk/benefit of different immunosuppressant regimens in transplant recipients.展开更多
文摘Objective: To determine the outcomes in solid organ transplant recipients following inpatient rehabilitation, as a result of a unique partnership between the rehabilitation hospital and the multi-organ transplant program in an acute hospital. Design: Retrospective observational study. Setting: Community rehabilitation hospital affiliated with a university. Participants: A cohort of 173 organ transplant patients admitted consecutively over a four-year period (2004-2008) was compared to a cohort of all rehabilitation patients (n = 9762) admitted to the same inpatient rehab facility during the same period. Interventions: Inpatient rehab program to all participants. Main Outcome Measures: Length of hospital stay, Functional Independence Measure (FIMTM) change (admission-discharge), and rate of discharges to home. Results: Outcomes were measured using components of the FIMTM instrument, admission and discharge data. Chi-square and independent two-sample t-tests were used for statistical analysis. Compared to a general rehabilitation inpatient population, transplant rehabilitation inpatients had: more immediate (TM change (8.9 vs. 20.9, p TM efficiency (1.1 vs. 1.4, p < 0.001);and a higher rate of discharges to home in patients not readmitted to acute care (98.5% vs. 94.5% p < 0.001). Conclusion: Outcomes of rehabilitation in solid organ transplant patients are comparable but not identical to those in other patient groups. Inpatient rehabilitation for transplant patients is therefore fully justifiable and necessary. The ten times higher rate of transplant patient readmission to acute hospital must be communicated, facilitated, accepted and managed within a partnership strategy.
基金The study was reviewed and approved by the University Health Network Institutional Review Board.
文摘BACKGROUND Early hospital readmissions(EHRs)after kidney transplantation range in incidence from 18%-47%and are important and substantial healthcare quality indicators.EHR can adversely impact clinical outcomes such as graft function and patient mortality as well as healthcare costs.EHRs have been extensively studied in American healthcare systems,but these associations have not been explored within a Canadian setting.Due to significant differences in the delivery of healthcare and patient outcomes,results from American studies cannot be readily applicable to Canadian populations.A better understanding of EHR can facilitate improved discharge planning and long-term outpatient management post kidney transplant.AIM To explore the burden of EHR on kidney transplant recipients(KTRs)and the Canadian healthcare system in a large transplant centre.METHODS This single centre cohort study included 1564 KTRs recruited from January 1,2009 to December 31,2017,with a 1-year follow-up.We defined EHR as hospitalizations within 30 d or 90 d of transplant discharge,excluding elective procedures.Multivariable Cox and linear regression models were used to examine EHR,late hospital readmissions(defined as hospitalizations within 31-365 d for 30-d EHR and within 91-365 d for 90-d EHR),and outcomes including graft function and patient mortality.RESULTS In this study,307(22.4%)and 394(29.6%)KTRs had 30-d and 90-d EHRs,respectively.Factors such as having previous cases of rejection,being transplanted in more recent years,having a longer duration of dialysis pretransplant,and having an expanded criteria donor were associated with EHR post-transplant.The cumulative probability of death censored graft failure,as well as total graft failure,was higher among the 90-d EHR group as compared to patients with no EHR.While multivariable models found no significant association between EHR and patient mortality,patients with EHR were at an increased risk of late hospital readmissions,poorer kidney function throughout the 1st year post-transplant,and higher hospital-based care costs within the 1st year of follow-up.CONCLUSION EHRs are associated with suboptimal outcomes after kidney transplant and increased financial burden on the healthcare system.The results warrant the need for effective strategies to reduce post-transplant EHR.
文摘Metabolic dysfunction-associated steatotic liver disease is the most prevalent chronic liver condition,affecting over one-third of the global population,with cirrhosis present in up to 3.3%of cases.Early detection of advanced liver disease in at-risk populations can enable timely intervention,prevent progression,and reduce complications.This review focuses on the current recommendations for early detection of advanced liver disease,evaluates the evidence for the performance of non-invasive tests in the target population for screening,and examines the multifaceted burden of screening,including economic implications and psychological impacts.Additionally,we discuss future directions,such as integrating liver health into a multidisciplinary care framework.Current guidelines recommend case-finding,targeting individuals with type 2 diabetes,metabolically complicated obesity,or persistent elevated liver enzymes.The Fibrosis-4 index is widely endorsed as a first-line non-invasive test,yet the diagnostic performance in primary care settings seems suboptimal,particularly for pre-cirrhotic disease.Sequential strategies incorporating novel non-invasive tests may improve accuracy and cost-effectiveness.Confirmation typically involves vibration-controlled transient elastography.Key challenges include a large eligible population,uncertainties in optimal screening intervals,patient adherence to follow-up,and limited real-world cost-effectiveness data.Integrating liver health assessment into cardiometabolic care pathways,reflex testing,telehealth,and patient education may enhance uptake.While challenges remain,early detection of advanced liver disease is already likely cost-effective.Ongoing advances in screening pathways and treatment options are expected to further strengthen the case for widespread implementation.
文摘BACKGROUND Old donor allografts in liver transplantation(LT)account for 25%of all allografts,and their utilization is projected to increase with the aging general population.Older allografts are associated with higher rates of all-cause mortality and graft failure;however,there is limited literature exploring the specific phenotypic changes(e.g.,functional status,cause-specific mortality)observed in different donor:recipient age pairs.AIM To investigate differences in functional impairment and cause-specific mortality between different donor:recipient age pairs.METHODS This was a retrospective analysis of LT patients from the Scientific Registry of Transplant Recipients from 2002 to 2022.Donors were categorized into younger age donors,≤45-years(YAD),middle-aged donors,46-69-years(MAD),and older age donors,≥70-years(OAD).Recipients were categorized into younger age recipients,≤55-years(YAR)and older age recipients,>55-years(OAR)age recipients.Multivariate Fine-Gray competing risk and logistic regression analyses identified independent risk factors for cause-specific mortality and improvements in functional status,respectively.RESULTS Overall,126185 patients were included in the analysis:YAD:YAR(32.7%), YAD:OAR (25.2%), MAD:YAR (17.5%), MAD:OAR (20.7%), OAD:YAR (1.3%), and OAD:OAR (2.7%). Compared toYAD:YAR, OAD pairs had the lowest likelihoods of improved functional status 5 years post-LT (OAD:YAR oddsratio 0.53, 95% confidence interval 0.42-0.67, P < 0.001;OAD:OAR odds ratio 0.67, 95% confidence interval 0.51-0.89, P = 0.006). Donor:recipient age pairs with older donors had higher rates of graft- and infection-relatedmortality compared to those with younger donors (P < 0.001). Meanwhile, donor:recipient age pairs with olderrecipients had higher cardioneurovascular- or malignancy-related deaths compared to those with youngerrecipients (P < 0.001).CONCLUSIONDonor:recipient age mismatch was associated with differences in cause-specific mortality and functional status.These insights could potentially inform age-matched organ allocation strategies, though future work is warranted.
文摘Contrast-enhanced ultrasound(CEUS)using microbubble contrast agents are useful for the diagnosis of the nodules in liver cirrhosis.CEUS can be used as a problem-solving method for indeterminate nodules on computed tomography(CT)or magnetic resonance imaging(MRI)or as an initial diagnostic test for small newly detected liver nodules.CEUS has unique advantages over CT and MRI including no renal excretion of contrast,real-time imaging capability,and purely intravascular contrast.Hepatocellular carcinoma(HCC)is characterized by arterial-phase hypervascularity and later washout(negative enhancement).Benign nodules such as regenerative nodules or dysplastic nodules are usually isoechoic or slightly hypoechoic in the arterial phase and isoechoic in the late phase.However,there are occasional HCC lesions with atypical enhancement including hypovascular HCC and hypervascular HCC without washout.Cholangiocarcinomas are infrequently detected during HCC surveillance and mostly show rimlike or diffuse hypervascularity followed by rapid washout.Hemangiomas are often found at HCC surveillance and are easily diagnosed by CEUS.CEUS can be effectively used in the diagnostic work-up of small nodules detected at HCC surveillance.CEUS is also useful to differentiate malignant and benign venous thrombosis and to guide and monitor the local ablation therapy for HCC.
文摘Non-alcoholic fatty liver disease(NAFLD) is an important health problem worldwide. NAFLD encompasses a histological spectrum ranging from bland liver steatosis to severe steatohepatitis(nonalcoholic steatohepatitis, NASH) with the potential of progressing to cirrhosis and its associated morbidity and mortality. NAFLD is thought to be the hepatic manifestation of insulin resistance(or the metabolic syndrome); its prevalence is increasing worldwide in parallel with the obesity epidemic. In many developed countries, NAFLD is the most common cause of liver disease and NASH related cirrhosis is currently the third most common indication for liver transplantation. NASH related cirrhosis is anticipated to become the leading indication for liver transplantation within the next one or two decades. In this review, we discuss how liver transplantation is affected by NAFLD, specifically the following:(1) the increasing need for liver transplantation due to NASH;(2) the impact of the increasing prevalence of NAFLD in the general population on the quality of deceased and live donor livers available for transplantation;(3) the long term graft and patient outcomes after liver transplantation forNASH,and finally;and(4)the de novo occurrence of NAFLD/NASH after liver transplantation and its impact on graft and patient outcomes.
文摘Non-alcoholic fatty liver disease(NAFLD)ranges from simple steatosis to nonalcoholic steatohepatitis(NASH),leading to fibrosis and potentially cirrhosis,and it is one of the most common causes of liver disease worldwide.NAFLD is associated with other medical conditions such as metabolic syndrome,obesity,cardiovascular disease and diabetes.NASH can only be diagnosed through liver biopsy,but noninvasive techniques have been developed to identify patients who are most likely to have NASH or fibrosis,reducing the need for liver biopsy and risk to patients.Disease progression varies between individuals and is linked to a number of risk factors.Mechanisms involved in the pathogenesis are associated with diet and lifestyle,influx of free fatty acids to the liver from adipose tissue due to insulin resistance,hepatic oxidative stress,cytokines production,reduced very low-density lipoprotein secretion and intestinal microbiome.Weight loss through improved diet and increased physical activity has been the cornerstone therapy of NAFLD.Recent therapies such as pioglitazone and vitamin E have been shown to be beneficial.Omega 3 polyunsaturated fatty acids and statins may offer additional benefits.Bariatric surgery should be considered in morbidly obese patients.More research is needed to assess the impact of these treatments on a long-term basis.The objective of this article is to briefly review the diagnosis,management and treatment of this disease in order to aid clinicians in managing these patients.
基金Supported by the National Natural Science Foundation of China for Distinguished Young Scholars, No. 30225040 for Dr Ning Q,No. 30123019 for Dr Luo XP
文摘AIM： To evaluate the expression of fibrinogenlike protein 2 （fgl2） and its correlation with disease progression in both mice and patients with severe viral hepatitis. METHODS： Balb/cJ or A/J mice were infected intraperitoneally （ip） with 100 PFU of murine hepatitis virus type 3 （MHV-3）, liver and serum were harvested at 24, 48, and 72 h post infection for further use. Liver tissues were obtained from 23 patients with severe acute chronic （AOC） hepatitis B and 13 patients with mild chronic hepatitis B. Fourteen patients with mild chronic hepatitis B with cirrhosis and 4 liver donors served as normal controls. In addition, peripheral blood mononuciear cells （PBMC） were isolated from 30 patients （unpaired） with severe AOC hepatitis B and 10 healthy volunteers as controls. Procoagulant activity representing functional prothrombinase activity in PBMC and white blood cells was also assayed. A polyclonal antibody against fgl2 was used to detect the expression of both mouse and human fgl2 protein in liver samples as well as in PBMC by immunohistochemistry staining in a separate set of studies. Alanine aminotransferase （ALT） and total bilirubin （TBil） in serum were measured to assess the severity of liver injury.RESULTS： Histological changes were found in liver sections 12-24 h post MHV-3 infection in Balb/cJ mice. In association with changes in liver histology, marked elevations in serum ALT and TBil were observed. House fgl2 （mfgl2） protein was detected in the endothelium of intrahepatic veins and hepatic sinusoids within the liver 24 h after MHV-3 infection. Liver tissues from the patients with severe AOC hepatitis B had classical pathological features of acute necroinflammation. Human fgl2 （hfgl2） was detected in 21 of 23 patients （91.30%） with severe AOC hepatitis B, while only 1 of 13 patients （7.69%） with mild chronic hepatitis B and cirrhosis had hfgl2 mRNA or protein expression. Twenty-eight of thirty patients （93.33%） with severe AOC hepatitis B and 1 of 10 with mild chronic hepatitis B had detectable hfgl2 expression in PBMC. No hfgl2 expression was found either in the liver tissue or in the PBMC from normal donors. There was a positive correlation between hfgl2 expression and the severity of the liver disease as indicated by the levels of TBil. PCA significantly increased in PBMC in patients with severe AOC hepatitis B. CONCLUSION： The molecular and cellular results reported here in both mice and patients with severe viral hepatitis suggest that virus-induced hfgl2 prothrombinase/fibroleukin expression and the coagulation activity associated with the encoded fgl2 protein play a pivotal role in initiating severe hepatitis. The measurement of hfgl2/fibroleukin expression in PBMC may serve as a useful marker to monitor the severity of AOC hepatitis B and a target for therapeutic intervention.
文摘Liver transplantation(LT) is the most effective treatment modality for end stage liver disease caused by many etiologies including autoimmune processes. That said, the need for transplantation for autoimmune hepatitis(AIH) and primary biliary cirrhosis(PBC), but not for primary sclerosing cholangitis(PSC), has decreased over the years due to the availability of effective medical treatment. Autoimmune liver diseases have superior transplant outcomes than those of other etiologies. While AIH and PBC can recur after LT, recurrence is of limited clinical significance in most, but not all cases. Recurrent PSC, however, often progresses over years to a stage requiring re-transplantation. The exact incidence and the predisposing factors of disease recurrence remain debated. Better understanding of the pathogenesis and the risk factors of recurrent autoimmune liver diseases is required to develop preventive measures. In this review, we discuss the current knowledge of incidence, diagnosis, risk factors, clinical course, and treatment of recurrent autoimmune liver disease(AIH, PBC, PSC) following LT.
基金Supported by Department of AnesthesiaPain Management academic program support
文摘From its inception the success of liver transplantation has been associated with massive blood loss. Massive transfusion is classically defined as > 10 units of red blood cells within 24 h, but describing transfusion rates over a shorter period of time may reduce the potential for survival bias. Both massive haemorrhage and transfusion are associated with increased risk of mortality and morbidity(need for dialysis/surgical site infection) following liver transplantation although causality is difficult to prove due to the observational design of most trials. The blood loss associated with liver transplantation is multifactorial. Portal hypertension secondary to cirrhosis results in extensive collateral circulation, which can bleed during hepatectomy particular if portal pressures are increased. Avoiding volume loading and maintenance of a low central venous pressure together with the use of vasopressors have been shown to reduce blood loss and transfusion during liver transplantation, but may increase the risk of renal impairment post-operatively. Coagulation defects may be present pre-transplant, but haemostasis is often re-balanced due to a deficit in both proand anti-coagulation factors. Further derangement of haemostasis may develop in the anhepatic and neohepatic phases due to absent hepatic metabolic function, hyperfibrinolysis and platelet sequestration in the donor liver. Point-of-care tests of coagulation such as the viscoelastic tests rotation thromboelastometry/thromboelastometry allow and more accurate and rapid assessment of these derangements in coagulation and guide the use of factor replacement and antifibrinolytics. Transfusion protocols guided by these tests have been shown to reduce transfusion rates compared with conventional coagulation tests, but have not shownimprovements in mortality or morbidity. Pre-operative factors associated with massive transfusion include previous surgery, re-do transplantation, the aetiology and severity of liver disease. Intra-operatively the use of piggy-back technique and avoiding veno-veno bypass has been shown to reduced blood loss.
文摘Thoracic endovascular aortic repair for thoracic aortic aneurysms is an accepted alternative to open surgery, especially in patients with significant comorbidities. The procedure itself has a low risk of complications and fistulas to surrounding organs are rarely reported. An 86-year-old patient was admitted to our hospital with gastro intestinal(GI) bleeding and a suspected aortoesophageal fistula. Eight months prior, the patient had undergone a stent graft repair of a mycotic thoracic aneurysm. Computerized tomography angiography and upper GI endoscopy confirmed an aortoesophageal fistula, which was treated by esophageal stenting. With early recognition, esophageal stenting may have a role in the initial emergency control of bleeding from and palliation of aortoesophageal fistula.
文摘In patients with diabetes mellitus, cardiovascular disease is the principal cause of mortality and chest pain is the most frequent symptom in patients with stable and acute coronary artery disease. However, there is little knowledge concerning the pervasiveness of uncommon presentations in diabetics. The symptomatology of acute coronary syndrome, which comprises both pain and non-pain symptoms, may be affected by traditional risk factors such as age, gender, smoking, hypertension, diabetes, and dyslipidemia. Such atypical symptoms may range from silent myocardial ischemia to a wide spectrum of non-chest pain symptoms. Worldwide, few studies have highlighted this under-investigated subject, and this aspect of ischemic heart disease has also been under-evaluated in the major clinical trials. The results of these studies are highly diverse which makes definitive conclusions regarding the spectrum of atypical presentation of acute and even stable chronic coronay artery disease difficult to confirm. This may have a significant impact on the morbidity and mortality of coronary artery disease in diabetics. In this up-to-date review we will try to analyze the most recent studies on the atypical presentations in both acute and chronic ischemic heart disease which may give some emphasis to this under-investigated topic.
文摘The adult congenital heart disease (ACHD) population continues to grow and most cardiologists, emergency room physicians and family doctors will intermittently come into contact with these patients. Oftentimes this may be in the setting of a presentation with atrial tachyarrhythmia; one of the commonest late complications of ACHD and problem with potentially serious implications. Providing appropriate initial care and ongoing management of atrial tachyarrhythmia in ACHD patients requires a degree of specialist knowledge and an awareness of certain key issues. In ACHD, atrial tachyarrhythmia is usually related to the abnormal anatomy of the underlying heart defect and often occurs as a result of surgical scar or a consequence of residual hemodynamic or electrical disturbances. Arrhythmias significantly increase mortality and morbidity in ACHD and are the most frequent reason for ACHD hospitalization. Intra-atrial reentrant tachycardia and atrial fibrillation are the most prevalent type of arrhythmia in this patient group. In hemodynamically unstable patients, urgent cardioversion is required. Acute management of the stable patient includes anticoagulation, rate control, and electrical or pharmacological cardioversion. In ACHD, rhythm control is the preferred management strategy and can often be achieved. However, in the long-term, medication side-effects can prove problematic. Electrophysiology studies and catheter ablation are important treatments modalities and in certain cases, surgical or percutaneous treatment of the underlying cardiac defect has a role. ACHD patients, especially those with complex CHD, are at increased risk of thromboembolic events and anticoagulation is usually required. Female ACHD patients of child bearing age may wish to pursue pregnancies. The risk of atrial arrhythmias is increased during pregnancy and management of atrial tachyarrhythmia during pregnancy needs specific consideration.
基金Supported by A Kidney Foundation of Canada Scholarship and a Canadian Diabetes Association-KRESCENT Program Joint New Investigator Award and receives operating support from the Canadian Institutes of Health Research and the Heart and Stroke Foundation of Canada to Cherney D
文摘We report the first case of acute renal failure secondary to prucalopride, a novel agent for the treatment of chronic constipation. The 75 years old male patient was initiated on prucalopride after many failed treatments for constipation following a Whipple's procedure for pancreatic cancer. Within four months of treatment his creatinine rose from 103 to 285 μmol/L(e GFR 61 decrease to 19 m L/min per 1.73 m2). He was initially treated with prednisone for presumed acute interstitial nephritis as white blood casts were seen on urine microscopy. When no improvement was detected, a core biopsy was performed and revealed interstitial fibrosis and tubular atrophy. The presence of oxalate and calcium phosphate crystals were also noted. These findings suggest acute tubular necrosis which may have been secondary to acute interstitial nephritis or hemodynamic insult. The use of prednisone may have suppressed signs of inflammation and therefore the clinical diagnosis was deemed acute interstitial nephritis causing acute tubular necrosis. There are no previous reports ofprucalopride associated with acute renal failure from the literature, including previous Phase Ⅱ and Ⅲ trials.
基金the Natural Sciences and Engineering Research Council of Canada Industrial Research Chairs (NSERC IRC) and the Canada Research Chairs (CRC) for financial support of the project
文摘A metabolic profile of plasma samples from patients undergoing heart surgery with the use of cardiopulmonary bypass （CPB） and concurrent administration of tranexamic acid was determined. Direct immersion solid phase microextraction （DI-SPME）, a new sampling and sample preparation tool for metabolomics, was used in this study for the first time to investigate clinical samples. The results showed alteration of diverse compounds involved in different biochemical pathways. The most significant contribution in changes induced by surgery and applied pharmacotherapy was noticed in metabolic profile of lysophospholipids, triacylglycerols, mediators of platelet aggregation, and linoleic acid metabolites. Two cases of individual response to treatment were also reported.
基金the Department of Gastroenterology of the Saint Paul Hospital for the support with this project
文摘AIM To develop a prediction model aimed at identifying patients that may require higher than usual sedation doses during colonoscopy.METHODS A retrospective chart review on 5000 patients who underwent an outpatient colonoscopy at St.Paul's Hospital from 2009 to 2010 was conducted in order to develop a model for identifying patients who will require increased doses of sedatives.Potential predictor variables including age,gender,endoscopy indication,high sedation requirements during previous endoscopies,difficulty of the procedure,bowel preparation quality,interventions,findings as well as current use of benzodiazepines,opioids and alcohol were analyzed.The outcome of study was the use ofhigh dose of sedation agents for the procedure.In particular,the high dose of sedation was defined as fentanyl greater than 50 mcg and midazolam greater than 3 mg.RESULTS Analysis of 5282 patients(mean age 57 ± 12,49% female) was performed.Most common indication for the procedure was screening colonoscopy(57%).Almost half of our patients received doses exceeding Fentanyl 50 mcg and Midazolam 3 mg.Logistic regression models identified the following variables associated with high sedation:Younger age(OR=0.95 95%CI:0.94-0.95;P < 0.0001);abdominal pain(OR=1.45,95%CI:1.08-1.96);P=0.01) and Inflammatory Bowel Disease(OR=1.45,95%CI:1.04-2.03;P=0.02) as indications for the procedure;difficult procedure as defined by gastroenterologist(OR=1.73,95%CI:1.48-2.03;P < 0.0001);past history of abdominal surgery(OR=1.33,95%CI:1.17-1.52;P <0.0001) and previous colonoscopy(OR=1.39,95%CI:1.21-1.60;P=0.0001) and alcohol use(OR=1.26,95%CI:1.03-1.54;P=0.02).Age and gender adjusted analysis yielded inflammatory bowel disease as an indication(OR=3.17,95%CI:1.58-6.37;P=0.002);difficult procedure as defined by an endoscopist(OR=5.13 95%CI:2.97-8.85;P=0.0001) and current use of opioids,benzodiazepines or antidepressants(OR=2.88,95%CI:1.74-4.77;P=0.001) having the highest predictive value of high sedation requirements.Our prediction model using the following pre-procedural variables including age,indication for the procedure,medication/substance use,previous surgeries yielded an area under the curve of 0.76 for Fentanyl ≥ 100 mcg and Midazolam ≥ 3 mg.CONCLUSION Pre-procedural planning is the key in conducting successful,efficient colonoscopy.Logistic regression analysis of 5000 patients who underwent out-patient colonoscopy revealed the following factors associated with increased sedation requirement:Younger age,female gender,difficult endoscopy,specific indications as well as cardiopulmonary complications and current use of opioids/benzodiazepines.Age and gender adjusted analysis yielded similar results.These patients are more likely to need a longer recovery periods post-endoscopy,which could result in additional time and personnel requirements.The final predictive model has good predictive ability for Fentanyl ≥ 100 mcg and Midazolam ≥ 3 mg and fair predictive ability for Fentanyl ≥ 50 mcg and Midazolam ≥ 2 mg.The external validity of this model is planned to be tested in another center.
文摘BACKGROUND Solid organ transplantation is a life-saving intervention for end-stage organ disease.Post-transplant diabetes mellitus(PTDM)is a common complication in solid organ transplant recipients,and significantly compromises long-term survival beyond a year.AIM To perform a systematic review and meta-analysis to estimate incidence of PTDM and compare the effects of the 3 major immunosuppressants on incidence of PTDM.METHODS Two hundred and six eligible studies identified 75595 patients on Tacrolimus,51242 on Cyclosporine and 3020 on Sirolimus.Random effects meta-analyses was used to calculate incidence.RESULTS Network meta-analysis estimated the overall risk of developing PTDM was higher with tacrolimus(OR=1.495%CI:1.0–2.0)and sirolimus(OR=1.8;95%CI:1.5–2.2)than with Cyclosporine.The overall incidence of PTDM at years 2-3 was 17%for kidney,19%for liver and 22%for heart.The risk factors for PTDM most frequently identified in the primary studies were age,body mass index,hepatitis C,and African American descent.CONCLUSION Tacrolimus tends to exhibit higher diabetogenicity in the short-term(2-3 years post-transplant),whereas sirolimus exhibits higher diabetogenicity in the longterm(5-10 years post-transplant).This study will aid clinicians in recognition of risk factors for PTDM and encourage careful evaluation of the risk/benefit of different immunosuppressant regimens in transplant recipients.
