Thromboembolic events in patients on extracorporeal membrane oxygenation without anticoagulation.

OBJECTIVE: : Heparinization is thought to be mandatory to avoid thromboembolic complications during venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, bleeding complications are common. We report our experience of VA-ECMO without systemic anticoagulation. METHODS: : A prospectively assembled database describing all ECMO cases from 2000 to 2008 was analyzed. A heparin coated circuit (Medtronic, Inc., Minneapolis, MN USA) and membrane oxygenator (Quadrox D Bioline oxygenator; MAQUET, Rastatt, Germany) were used in all cases. After the initiation of VA-ECMO support, all coagulation parameters were corrected. No further systemic maintenance anticoagulant was given, except at the time of weaning. RESULTS: : Thirty-two patients received VA-ECMO support; 20 patients (62.5%) were males with a median age of 52.5 years (interquartile range, 40.4-61.1 years). Central and peripheral cannulations were 53% and 47%, respectively. Etiologies of cardiogenic shock were postcardiotomy (75%, n = 24) and as a support to cardiopulmonary resuscitation in 25% of cases (n = 8). Thirty-day mortality was 43.8%. Median duration of ECMO support was 46.3 hours (interquartile range, 26.8-87.8 hours). The median number of packed red blood cell transfusions was 18 ± 25. Complications include five patients (16%) with limb ischemia requiring intervention, 15 patients (46.9%) had acute renal failure, two patients had deep vein thrombosis, and two patients had intracardiac clots detected on echocardiograms. No patient had a cerebrovascular event. Incidence of membrane oxygenator failure was low, requiring replacement in three patients; no adverse event occurred during replacement. Fourteen patients (43.8%) were reexplored for bleeding. Fourteen patients (44%) were discharged home and were long-term survivors. CONCLUSIONS: : VA-ECMO support without systemic anticoagulation may reduce bleeding complications and transfusion requirement, without increasing the risk of thromboembolism.

Discrepancies in households and other stakeholders viewpoints on the food security experience: a gap to address.

This paper reports results from a case study on household food insecurity needs and the interventions that address them. It aimed at comparing households' perceptions on food insecurity experience and vulnerability to those of other stakeholders: community workers, programme managers and representatives from donor agencies. Semi-structured interviews with 55 households and 59 other stakeholders were conducted. Content analysis was performed, using a framework encompassing food sufficiency, characterization of household food insecurity and vulnerability of households to food insecurity. Overall, the results draw attention to a gap between households and the other stakeholders, where the later do not seem always able to assess the realities of food-insecure households. Other areas of divergences include: characteristics of food insecurity, relative importance of various risk factors related to food insecurity and the effectiveness of the community assistance to enhance the households' ability to face food insecurity. These divergent perceptions may jeopardize the implementation of sustainable solutions to food insecurity. Training of stakeholders for a better assessment of households' experience and needs, and systematic evaluation of interventions, appear urgent and highly relevant for an adequate response to households' needs. Collaboration between all stakeholders should lead to knowledge sharing and advocacy for policies dedicated to poverty reduction.

Perception of needs and responses in food security: divergence between households and stakeholders.

OBJECTIVES: The aim of the study was (i) to describe the needs of food-insecure households and their assessment of community programmes, as expressed by households and perceived by stakeholders; and (ii) to examine the similarities and differences between households' and stakeholders' perceptions in Quebec City area. DESIGN/SETTING/SUBJECTS: A semi-structured interview and sociodemographic questionnaire with fifty-five households and fifty-nine stakeholders (community workers, managers, donor agencies). The transcriptions were subjected to content analysis and inter-coder reliability measurement. RESULTS: The respondents' perceptions converge towards three main categories of needs: needs specific to food security, conditions necessary for achieving food security and related needs. There was agreement on the necessity of better financial resources, although the impact of financial resources alone may be uncertain in the opinion of some stakeholders. Different perceptions of needs and of their fulfilment by community programmes emerge between both groups. Despite households found positive aspects, they complained that quality of food and access were major needs neglected. Their account suggests overall a partial fit between the programmes and food security needs; even a combination of programmes (e.g. collective kitchens, purchasing groups, community gardens) was insufficient to adequately meet these needs. In contrast, most stakeholders perceived that the household's primary need was a basic amount of food and that the households were satisfied with programmes. CONCLUSIONS: It is urgent to evaluate the overall effect of community programmes on specific aspects of household food insecurity. The results emphasise that community programmes alone cannot bring about social change needed to prevent food insecurity.