RISK FACTORS FOR POST-LIVER TRANSPLANT BILIARY COMPLICATIONS IN THE ABSENCE OF ARTERIAL COMPLICATIONS.

BACKGROUND: - Biliary complications (BC) represent the most frequent complication after liver transplantation, up to 34% of cases. AIM: To identify modifiable risk factors to biliary complications after liver transplantation, essential to decrease morbidity. METHOD: Clinical data, anatomical characteristics of recipient and donors, and transplant operation features of 306 transplants with full arterial patency were collected to identify risk factors associated with BC. RESULTS: BC occurred in 22.9% after 126 days (median) post-transplantation. In univariate analyses group 1 (without BC, n=236) and group 2 patients (with BC, n=70) did not differ on their general characteristics. BC were related to recipient age under 40y (p=0.029), CMV infection (p=0.021), biliary disease as transplant indication (p=0.018), lower pre-transplant INR (p=0.009), and bile duct diameter <3 mm (p=0.033). CMV infections occurred sooner in patients with postoperative biliary complications vs. control (p=0.07). In a multivariate analysis, only CMV infection, lower INR, and shorter bile duct diameter correlated with BC. Positive CMV antigenemia correlated with biliary complications, even when titers lied below the treatment threshold. CONCLUSIONS: Biliary complications after liver transplantation correlated with low recipient INR before operation, bile duct diameter <3 mm, and positive antigenemia for CMV or disease manifestation. As the only modifiable risk factor, routine preemptive CMV inhibition is suggested to diminish biliary morbidity after liver transplant.

Epidemiology and Treatment Barriers of Patients With Erectile Dysfunction Using an Online Prescription Platform: A Cross-Sectional Study.

INTRODUCTION: Erectile dysfunction (ED) is a highly common sexual dysfunction of men but often undertreated as patients experience high treatment barriers. AIM: The aims of this study were to characterize patients with ED using an online prescription platforms (OPPs) and determine treatment barriers that might prevent patients from seeking care in conventional health care settings. METHODS: Data from a German OPP were retrospectively analyzed with focus on patients suffering from ED with at least one online prescription of phosphodiesterase-5 (PDE5) inhibitors between May 2019 and November 2019. In addition, a voluntary questionnaire was used to assess additional social features and prior treatment barriers. MAIN OUTCOME MEASURE: The main outcome measures were the epidemiological data, prescription metadata, and follow-up questionnaires. RESULTS: A total of 11,456 male patients received prescriptions via the OPP (mean age: 49 years [95% CI 46.92-47.45]). Patients lived mainly in rural areas (69%) and frequently sought prescriptions outside the average office times of German urologists (49%). From all patients that responded to a follow-up questionnaire (n = 242), the majority were employed full-time (81%), married (50%), and native German (94%); 63.5% had not used PDE5 inhibitors before. From all repeat users, 41% had received them from unreliable sources. Reasons to seek treatment via the OPP were convenience (48%), shame (23%), and lack of discretion (13%). CONCLUSION: In this first study, to epidemiologically characterize ED patients of an OPP, it was confirmed that inconvenience is a treatment barrier, along with shame and perceived lack of discretion. This is the first evidence that OPPs reduce treatment barriers and ease access for patients to the medical system. Rodler S, von Büren J, Buchner A, et al. Epidemiology and Treatment Barriers of Patients With Erectile Dysfunction Using an Online Prescription Platform: A Cross-Sectional Study. Sex Med 2020;8:370-377.

Risk factors for post-liver transplant biliary complications in the absence of arterial complications / Fatores de risco para complicações biliares pós-transplante hepático na ausência de complicações arteriais

ABSTRACT Background - Biliary complications (BC) represent the most frequent complication after liver transplantation, up to 34% of cases. Aim: To identify modifiable risk factors to biliary complications after liver transplantation, essential to decrease morbidity. Method: Clinical data, anatomical characteristics of recipient and donors, and transplant operation features of 306 transplants with full arterial patency were collected to identify risk factors associated with BC. Results: BC occurred in 22.9% after 126 days (median) post-transplantation. In univariate analyses group 1 (without BC, n=236) and group 2 patients (with BC, n=70) did not differ on their general characteristics. BC were related to recipient age under 40y (p=0.029), CMV infection (p=0.021), biliary disease as transplant indication (p=0.018), lower pre-transplant INR (p=0.009), and bile duct diameter <3 mm (p=0.033). CMV infections occurred sooner in patients with postoperative biliary complications vs. control (p=0.07). In a multivariate analysis, only CMV infection, lower INR, and shorter bile duct diameter correlated with BC. Positive CMV antigenemia correlated with biliary complications, even when titers lied below the treatment threshold. Conclusions: Biliary complications after liver transplantation correlated with low recipient INR before operation, bile duct diameter <3 mm, and positive antigenemia for CMV or disease manifestation. As the only modifiable risk factor, routine preemptive CMV inhibition is suggested to diminish biliary morbidity after liver transplant.

RESUMO Racional: Complicações biliares (CB) são os eventos adversos mais frequentes após o transplante de fígado, ocorrendo em até 34% dos procedimentos. Objetivo: Identificar fatores de risco modificáveis para o aparecimento de complicações biliares após transplantes de fígado, essenciais para diminuir morbidade. Método: Investigação dos dados clínicos, características anatômicas de receptores e doadores e informações sobre a operação de 306 transplantes com artéria hepática pérvia, para identificar fatores de risco associados ao aparecimento de CB. Resultados: CB ocorreu em 22,9% após 126 dias (mediana) do transplante. Em análise univariada pacientes do grupo 1 (sem CB, n=236) e grupo 2 (com CB, n=70) não diferiram em suas características gerais. CB esteve relacionada à idade do receptor menor que 40 anos (p=0,029), infecção pelo citomegalovírus (CMV, p=0,021), doença biliar como indicação ao transplante (p=0,018), RNI pré-transplante mais baixo (p=0,009) e diâmetro do ducto biliar <3 mm (p=0,033). Infecções pelo CMV ocorreram mais precocemente em pacientes com CB (p=0,07). Na análise multivariada, somente infecção por ele, INR mais baixo e menor diâmetro do ducto biliar mantiveram correlação com CB. Antigenemia positiva para CMV correlacionou com CB mesmo em títulos inferiores ao cutoff para tratamento. Conclusões: CB após transplante hepático esteve relacionada com menores RNI do receptor antes da operação, diâmetro do ducto biliar <3 mm e antigenemia ou manifestação clínica positiva para CMV. Como único fator de risco evitável, tratamento preemptivo para inibição do CMV é sugerido para diminuir morbidade biliar após o transplante.

Shifting to triple value healthcare: Reflections from England.

Increasing need and demand because of growing and aging populations combined with stagnant or decreasing resources being invested into healthcare globally mean that a radical shift is needed to ensure that healthcare systems can meet current and future challenges. Quality-, safety- and efficiency-improvement approaches have been used as means to address many problems in healthcare and while they are essential and necessary, they are not sufficient to meet our current challenges. To build resilient and sustainable healthcare systems, we need a shift to focus on triple value healthcare, which will help healthcare professionals improve outcomes at the process, patient and population levels while also optimising resource utilisation. Here we present a brief history of the Quality and Evidence-based Healthcare model and then describe how value emerged as a predominant theme in England. We then highlight the four solutions that we, as part of the RightCare programme, designed and refined in the English NHS to turn theory into practice: We end with a description of how triple value is being introduced into Germany and steps that can be taken to facilitate its adoption.

Resource allocations and disparities in the Brazilian health care system: insights from organ transplantation services.

BACKGROUND: To date, few studies have assessed how Brazil's universal healthcare system's (SUS, Sistema Único de Saúde) systemic, infrastructural, and geographical challenges affect individuals' abilities to access organ transplantation services and receive quality treatment. DISCUSSION: In this article we evaluated the existing literature to examine the impact that SUS has had on an increasingly important healthcare sector: organ transplantation services. We assess how equity challenges within the transplantation system can be explained by wider problems within SUS. Findings suggest stark disparities in access to transplantation services both within and across Brazil's regions. We found that these regional differences are partially due to logistical challenges, especially in loosely populated areas but are also a consequence of disparities in resource allocations within SUS and under-capacitated health care facilities affecting transplantation services. We suggest that Brazil needs to improve its health outcome measurement system for organ transplantations and epidemiological surveillance, to gain more comprehensive and comparable data. Finally, we recommend policy strategies to reduce barriers to access to transplantation services by increasing transplantation service coverage in some areas and investing in emerging technologies.

A Patient with Non-Hodgkin Lymphoma and Nonspecific Interstitial Pneumonia during Ibrutinib Therapy.

We present a 74-year-old male with nonspecific interstitial pneumonia (NSIP) during treatment with ibrutinib for mantle cell lymphoma. Previously, the patient had received six cycles of bendamustine and rituximab and six cycles of R-CHOP, followed by rituximab maintenance therapy. Respiratory tract complications of ibrutinib other than infectious pneumonia have not been mentioned in larger trials, but individual case reports hinted to a possible association with the development of pneumonitis. In our patient, the onset of alveolitis that progressed towards NSIP together with the onset of ibrutinib treatment suggests causality. One week after ibrutinib was discontinued, nasal symptoms resolved first. A follow-up CT showed a reduction in the reticular hyperdensities and ground-glass opacities, suggestive of restitution of the lung disease. To our knowledge, this is the first case showing a strong link between ibrutinib and interstitial lung disease, strengthening a previous report on subacute pneumonitis. Our findings have clinical implications because pulmonary side effects were reversible at this early stage. We, therefore, suggest close monitoring for respiratory side effects in patients receiving ibrutinib.

From the Tattoo Studio to the Emergency Room.

BACKGROUND: While subepidermal skin inking as a fashion trend has rapidly gained popularity in Western societies, systemic anaphylaxis as a complication of tattooing has only been described once in refereed literature. Furthermore the previously reported case was from a patient who already suffered from severe allergies and no attempt to pinpoint the actual causes was made. CASE SUMMARY: We present the case of a 59-year-old man, who developed a progressive swelling and redness five hours after receiving a tattoo. Another hour later he appeared in the emergency room with a grade 3 systemic anaphylaxis. He presented with rapidly progressing swelling and redness of the tattooed left arm, left cheek and lips as well as tongue. Allergies were not previously known in this patient. He responded well to treatment with prednisolone and antihistamines. Further workup identified formaldehyde, nickel, and manganese in the inks as potential chemical triggers of the patient's symptoms. The patient refused further allergological work-up, such as prick testing. CONCLUSION: Clinicians should be alert to the potential capacity of tattoo inks to act as triggers of systemic anaphylaxis. Policymakers should attempt to better restrict the use of known allergenic compounds in commercial tattoo inks.

A pseudo-outbreak due to Acinetobacter species (GIM-1) contamination of the pneumatic transport system of a Large University Hospital.

OBJECTIVE: To establish the source and contamination routes resulting in positive clinical and surveillance microbiological cultures with carbapenem-resistant, GIM-1 metallo-ß-lactamase-positive Acinetobacter pitii and Acinetobacter radioresistens from 21 patients in 8 departments. DESIGN: Retrospective, descriptive study. SETTING: A 1,300-bed tertiary care academic medical facility consisting of 90 buildings linked by a pneumatic transport system (PTS). METHODS: Microbiological workup of the cluster strains included matrix-assisted laser desorption/ionization time-of-flight species identification, phenotypic carbapenemase tests, polymerase chain reaction-based genotyping of carbapenemase, and pulsed-field gel electrophoresis. Outbreak management procedures were employed according to institutional regulations. RESULTS: The rarity of GIM-1 Acinetobacter species in the hospital and region, the lack of epidemiological links between patients, and the fact that in some patients the apparent colonization was clearly nonnosocomial prompted the suspicion of a pseudo-outbreak. Numerous environmental cultures were positive for GIM-1-positive Acinetobacter (including archived sample requisition forms, PTS capsules, cultures from line-diverter and dispenser stations, and sterilized transport capsules following PTS delivery). Moreover, it was observed that condensation fluid from subterranean PTS tubing resulted in water entry in PTS capsules, possibly conferring specimen contamination. After extensive system disinfection, environmental surveys of the PTS were negative, and no further positive patient specimens were encountered. CONCLUSIONS: This is the first report of a PTS-associated pseudo-outbreak. The large number of falsely positive patient-related specimens in conjunction with the potential hazard of airborne and contact spread of multidrug-resistant microorganisms (in this case, GIM-1 carbapenem-resistant Acinetobacter species) underscores the need for implementation of infection control-based monitoring and operating procedures in a hospital PTS.

[Quality assessment of radiologic reports of CT examinations for tumor response evaluation]. / Évaluation de la qualité des comptes rendus radiologiques des examens tomodensitométriques d'évaluation oncologique.

PURPOSE: Our purpose was to assess the quality of radiologic reports of CT scans performed for tumor response evaluation before and after corrective procedure. MATERIALS AND METHODS: Our objective was to assess the presence of different items in radiologic reports of CT scans performed for tumor response evaluation. The present evaluation was formal, that is to say without checking the accuracy of the items identified. Ten simple items were evaluated before and after corrective procedure corresponding to an oral and written information concerning the tumor response evaluation technique with CT. RESULTS: The results were variable depending on the items measured. Most of the criteria were improved after corrective procedure. But for some items the result remained poor or very poor as the appropriate choice of comparison review (baseline or nadir). CONCLUSION: In the absence of use of the standard form, the feedback of the quality of radiologic reports of CT scans performed for tumor response evaluation shows that the quality remains largely suboptimal even after corrective procedure.