Expanding the Deceased Donor Pool in Manitoba Using Hepatitis C-Viremic Donors: Program Report.

PURPOSE OF PROGRAM: The ongoing shortage of organs for transplant combined with Manitoba having the highest prevalence of end-stage renal disease (ESRD) in Canada has resulted in long wait times on the deceased donor waitlist. Therefore, the Transplant Manitoba Adult Kidney Program has ongoing quality improvement initiatives to expand the deceased donor pool. This clinical transplant protocol describes the use of prophylactic pan-genotypic direct-acting anti-viral agents (DAA) for transplanting hepatitis C (HCV)-viremic kidneys (HCV antibody positive/nucleic acid [nucleic acid amplification testing, NAT] positive) to HCV-naïve recipients as routine standard of care. We will evaluate the provincial implementation of this protocol as a prospective observational cohort study. SOURCES OF INFORMATION: Scoping literature review and key stakeholder engagement with interdisciplinary health care providers and health system leaders/decision markers. METHODS: Patients will be screened pre-transplant for eligibility and undergo a multilevel education and consent process to participate in this expanded donor program. Incident adult HCV-naïve recipients of an HCV-viremic kidney transplant will be treated prophylactically with glecaprevir-pibrentasvir with the first dose administered on call to the operation. Glecaprevir-pibrentasvir will be used for 8 weeks with viral monitoring and hepatology follow-up. Primary outcomes are sustained virologic response (SVR) at 12 weeks and the tolerability of DAA therapy. Secondary outcomes within the first year post-transplant are patient and graft survival, graft function, biopsy-proven rejection, HCV transmission to recipient (HCV NAT positive), and HCV nonstructural protein 5A (NS5A) resistance. Safety outcomes within the first year post-transplant include fibrosing cholestatic hepatitis, acute liver failure, primary and secondary DAA treatment failure, HCV transmission to a recipient's partner, elevated liver enzymes ≥2-fold, abnormal international normalized ratio (INR), angioedema, anaphylaxis, cirrhosis, and hepatocellular carcinoma. KEY FINDINGS: This program successfully advocated for and obtained hospital formulary, provincial Exceptional Drug Status (EDS), and Non-Insured Health Benefits (NIHB) to provide prophylactic DAA therapy for this indication, and this information may be useful to other provincial transplant organizations seeking to establish an HCV-viremic kidney transplant program with prophylactic DAA drug coverage. LIMITATIONS: (1) Patient engagement was not undertaken during the program design phase, but patient-reported experience measures will be obtained for continuous quality improvement. (2) Only standard criteria donors (optimal kidney donor profile index [KDPI] ≤60) will be used. If this approach is safe and feasible, then higher KDPI donors may be included. IMPLICATIONS: The goal of this quality improvement project is to improve access to kidney transplantation for Manitobans. This program will provide prophylactic DAA therapy for HCV-viremic kidney transplant to HCV-naïve recipients as routine standard of care outside a clinical trial protocol. We anticipate this program will be a safe and effective way to expand kidney transplantation from a previously unutilized donor pool.

OBJECTIF DU PROGRAMME: La pénurie actuelle d'organes à transplanter, combinée au fait que le Manitoba est la province qui présente la plus forte prévalence d'insuffisance rénale terminale au Canada, entraîne de longs délais sur la liste d'attente d'un organe provenant d'un donneur décédé. Le programme de transplantation rénale pour les adultes du Manitoba (Transplant Manitoba Adult Kidney Program) a mis en place des initiatives d'amélioration continue de la qualité afin d'élargir le bassin de donneurs décédés. Ce protocole clinique de transplantation décrit l'emploi, comme traitement habituel, d'agents antiviraux directs (AAD) pan-génotypiques prophylactiques pour la transplantation de reins provenant de donneurs infectés par le virus de l'hépatite C (VHC) (individus positifs pour les anticorps VHC et acides nucléiques [NAT]) à des receveurs naïfs pour VHC. La mise en œuvre provinciale de ce protocole sera évaluée en tant qu'étude de cohorte prospective et observationnelle. SOURCES: Examen de la documentation et évaluation de l'engagement des principaux intervenants avec les fournisseurs de soins de santé interdisciplinaires et les dirigeants/décideurs du système de santé. MÉTHODOLOGIE: L'admissibilité au programme sera évaluée avant la greffe. Pour participer à ce programme élargi de donneurs, les patients devront se soumettre à un processus d'information et de consentement à plusieurs niveaux. Les adultes incidents naïfs pour VHC devant recevoir un rein virémique-VHC seront traités de façon prophylactique par glécaprévir+pibrentasvir; la première dose administrée au moment de l'appel pour l'opération. Le traitement par glécaprévir+pibrentasvir sera administré pendant 8 semaines avec surveillance virale et suivi hépatologique. Les principaux résultats évalués seront une réponse virologique prolongée (RVP) à 12 semaines et la tolérance au traitement par AAD. Les résultats secondaires mesurés dans la première année suivant la greffe seront la survie du patient et du greffon; la fonction du greffon; le rejet avéré par biopsie; la transmission du VHC au receveur (positif pour VHC et NAT) et la résistance aux protéines non structurelles 5A (NS5A) du VHC. Les résultats relatifs à l'innocuité dans la première année suivant la greffe comprennent la cholestase hépatique fibrosante; l'insuffisance hépatique aiguë; l'échec primaire et secondaire du traitement par AAD; la transmission du VHC au partenaire d'un receveur; une élévation supérieure à 2 fois du taux d'enzymes hépatiques; un INR anormal; un angio-œdème; l'anaphylaxie; une cirrhose ou un carcinome hépatocellulaire. PRINCIPAUX RÉSULTATS: Le programme a recommandé et obtenu l'inscription du traitement prophylactique par AAD sur la liste de médicaments des hôpitaux pour cette indication, en plus du statut de médicament d'exception provincial et de son ajout au Programme des services de santé non assurés (SSNA). Ces renseignements pourraient être utiles à d'autres organismes provinciaux de transplantation qui cherchent à mettre en œuvre un programme de transplantation rénale virémique-VHC avec un traitement prophylactique par AAD. LIMITES: (1) La participation des patients n'a pas été entreprise pendant la phase de conception du programme, mais des mesures de l'expérience des patients seront obtenues pour l'amélioration continue de la qualité. (2) Seuls les donneurs satisfaisant aux critères standards (Kidney Donor Profile Index [KDPI] ≤ 60) seront inclus. Si cette approche est sécuritaire et faisable, des donneurs de KDPI plus élevés pourront être inclus. CONCLUSION: L'objectif de ce projet d'amélioration de la qualité est d'améliorer l'accès aux transplantations rénales pour les Manitobains. Ce programme offrira un traitement prophylactique aux AAD pour les greffes de reins virémiques-VHC à des receveurs naïfs pour VHC comme traitement de référence habituel en dehors d'un protocole d'essai clinique. Nous pensons que ce programme sera un moyen sûr et efficace d'étendre la transplantation rénale à partir d'un bassin de donneurs auparavant non utilisés.

Evaluation of Transfusion Practices in Noncardiac Surgeries at High Risk for Red Blood Cell Transfusion: A Retrospective Cohort Study.

Perioperative bleeding is a major indication for red blood cell (RBC) transfusion, yet transfusion data in many major noncardiac surgeries are lacking and do not reflect recent blood conservation efforts. We aim to describe transfusion practices in noncardiac surgeries at high risk for RBC transfusion. We completed a retrospective cohort study to evaluate adult patients undergoing major noncardiac surgery at 5 Canadian hospitals between January 2014 and December 2016. We used Canadian Classification of Health Interventions procedure codes within the Discharge Abstract Database, which we linked to transfusion and laboratory databases. We studied all patients undergoing a major noncardiac surgery at ≥5% risk of perioperative RBC transfusion. For each surgery, we characterized the percentage of patients exposed to an RBC transfusion, the mean/median number of RBC units transfused, and platelet and plasma exposure. We identified 85 noncardiac surgeries with an RBC transfusion rate ≥5%, representing 25,607 patient admissions. The baseline RBC transfusion rate was 16%, ranging from 5% to 49% among individual surgeries. Of those transfused, the median (Q1, Q3) number of RBCs transfused was 2 U (1, 3 U); 39% received 1 U RBC, 36% received 2 U RBC, and 8% were transfused ≥5 U RBC. Platelet and plasma transfusions were overall low. In the era of blood conservation, we described transfusion practices in major noncardiac surgeries at high risk for RBC transfusion, which has implications for patient consent, preoperative surgical planning, and blood bank inventory management.

Back-to-back comparison of mini-open vs. laparoscopic technique for living kidney donation.

INTRODUCTION: Laparoscopic living donor nephrectomy is the standard of care at high-volume renal transplant centres, with benefits over the open approach well-documented in the literature. Herein, we present a retrospective analysis of our single-institution donor nephrectomy series comparing the mini-open donor nephrectomy (mini-ODN) to the laparoscopic donor nephrectomy (LDN) with regards to operative, donor, and recipient outcomes. METHODS: From 2007-2011, there were 89 cases of mini-ODN, at which point our centre transitioned to LDN; 94 cases were performed from 2011-2014. In total, 366 patients were reviewed, including donor and recipient pairs. Donor and recipient demographics, intraoperative data, postoperative donor recovery, recipient graft outcomes, and financial cost were assessed comparing the surgical approaches. RESULTS: We demonstrate a reduced estimated blood loss (347.83 vs. 90.3 cc), lower intraoperative complication rate (4 vs. 11) and shorter length of hospital stay (2.4 vs. 3.3 days) for patients in the LDN group. Operative time was significantly longer for the LDN group (108.4 vs. 165.9 minutes), although this did not translate to a longer warm ischemia time (mean 2.0 minutes for each group). The rate of delayed graft function and recipient 12-month creatinine were comparable for ODN and LND. Overall cost of LDN was $684 higher for an uncomplicated admission. CONCLUSIONS: Despite a longer surgical time and higher upfront cost, our study supports that LDN yields several advantages over the mini-ODN, with a lower estimated blood loss, fewer intraoperative complications, and shorter length of hospital stay, all while maintaining excellent renal allograft outcomes.

Ureteric re-implant for the strictured renal allograft: How I do it.

Ureteric stricture is the most common urologic complication following renal transplantation. Initial treatment should consist of endoscopic management, however patients that fail endoscopic management or strictures that are not amendable to endoscopic management are appropriate candidates for open surgical repair. In this manuscript we describe the steps and surgical technique we use to manage complicated ureteric strictures refractory to endoscopic management at our center. Ureteric re-implant with the use of a Boari flap is a safe, effective and definitive option for repair of ureteric strictures following renal transplantation. This approach provides excellent long term outcomes in terms of renal function preservation and negligible recurrence rates.

Changing of the guard? A glance at the surgical representation in the Canadian renal transplantation community.

INTRODUCTION: Renal transplant is the gold standard treatment for end-stage renal disease (ESRD), and the prevalence of both ESRD and renal transplant has been steadily increasing over the past decade. However, involvement of urology in renal transplant has been declining. We examine the current state of urology involvement in renal transplant programs across Canada. METHODS: A telephone survey of all surgical transplant centres in Canada was performed. Information regarding the number of transplant surgeons, their individual training background, and their involvement in specific procedures, including open and laparoscopic living donor nephrectomy, deceased donor nephrectomy, and recipient renal transplant were collected. RESULTS: There are 59 Canadian transplant surgeons, including 27 (46%) who completed a urology residency and 32 (54%) with a general surgery background. With regards to procedures performed, 58 (98%) perform recipient renal transplant surgery, 36 (61%) perform laparoscopic donor nephrectomy, and 17 (29%) perform open donor nephrectomy. There was no significant difference in the number of surgeons that perform renal recipient surgery, laparoscopic or open donor nephrectomies, and deceased donor nephrectomies between surgeons of the two different training backgrounds. CONCLUSIONS: The role of urology in Canadian renal transplant has declined significantly over the past decade. Given the medical and surgical complexity of renal transplant, along with the growing need for renal transplants, a multidisciplinary team approach is imperative. Strong urology involvement with the transplant team is crucial for optimal care of these complex patients.

A randomized controlled trial on the effects of goal-directed therapy on the inflammatory response open abdominal aortic aneurysm repair.

INTRODUCTION: Goal-directed therapy (GDT) has been shown in numerous studies to decrease perioperative morbidity and mortality. The mechanism of benefit of GDT, however, has not been clearly elucidated. Targeted resuscitation of the vascular endothelium with GDT might alter the postoperative inflammatory response and be responsible for the decreased complications with this therapy. METHODS: This trial was registered at ClinicalTrials.gov as NCT01681251. Forty patients undergoing elective open repair of their abdominal aortic aneurysm, 18 years of age and older, were randomized to an interventional arm with GDT targeting stroke volume variation with an arterial pulse contour cardiac output monitor, or control, where fluid therapy was administered at the discretion of the attending anesthesiologist. We measured levels of several inflammatory cytokines (C-reactive protein, Pentraxin 3, suppressor of tumorgenicity--2, interleukin-1 receptor antagonist, and tumor necrosis factor receptor-III) preoperatively and at several postoperative time points to determine if there was a difference in inflammatory response. We also assessed each group for a composite of postoperative complications. RESULTS: Twenty patients were randomized to GDT and twenty were randomized to control. Length of stay was not different between groups. Intervention patients received less crystalloid and more colloid. At the end of the study, intervention patients had a higher cardiac index (3.4 ± 0.5 vs. 2.5 ± 0.7 l/minute per m(2), p < 0.01) and stroke volume index (50.1 ± 7.4 vs. 38.1 ± 9.8 ml/m(2), p < 0.01) than controls. There were significantly fewer complications in the intervention than control group (28 vs. 12, p = 0.02). The length of hospital and ICU stay did not differ between groups. There was no difference in the levels of inflammatory cytokines between groups. CONCLUSIONS: Despite being associated with fewer complications and improved hemodynamics, there was no difference in the inflammatory response of patients treated with GDT. This suggests that the clinical benefit of GDT occurs in spite of a similar inflammatory burden. Further work needs to be performed to delineate the mechanism of benefit of GDT. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01681251 . Registered 18 May 2011.

Embolus from probable Takotsubo cardiomyopathy: a bedside diagnosis.

A 59-year-old woman with stroke and thromboembolic aortoiliac disease in the setting of profound stress was found to have severe left ventricular (LV) systolic dysfunction and large mobile clot on focused cardiac ultrasonography (FCU). Marked recovery of LV function and thrombus resolution within 4 days suggested resolving Takotsubo cardiomyopathy. The role of FCU in early diagnosis and treatment is outlined here.

Laparoscopic nephrectomy, ex vivo partial nephrectomy, and autotransplantation for the treatment of complex renal masses.

In the contemporary era of minimally invasive surgery, very few T1/T2 renal lesions are not amenable to nephron-sparing surgery. However, centrally located lesions continue to pose a clinical dilemma. We sought to describe our local experience with three cases of laparoscopic nephrectomy, ex vivo partial nephrectomy, and autotransplantation. Laparoscopic donor nephrectomy was performed followed by immediate renal cooling and perfusion with isotonic solution. Back-table partial nephrectomy, renorrhaphy, and autotransplantation were then performed. Mean warm ischemia (WIT) and cold ischemic times (CIT) were 2 and 39 minutes, respectively. Average blood loss was 267 mL. All patients preserved their renal function postoperatively. Final pathology confirmed pT1, clear cell renal cell carcinoma with negative margins in all. All are disease free at up to 39 months follow-up with stable renal function. In conclusion, the described approach remains a viable option for the treatment of complex renal masses preserving oncological control and renal function.

Effect of a preventive foot care program on lower extremity complications in diabetic patients with end-stage renal disease.

BACKGROUND: Lower extremity complications are a major cause of morbidity and mortality in patients with end-stage renal disease (ESRD) and diabetes mellitus. Patient education programs may decrease the risk of diabetic foot complications. METHODS: A preventive program was instituted, consisting of regular assessments by a foot care nurse with expertise in foot care and wound management and patient education about foot care practices and footwear selection. Medical records were reviewed and patients were examined. A comparison was made with data about patients from a previous study done from this institution prior to development of the foot care program. RESULTS: Diabetic subjects more frequently had weakness of the left tibialis anterior, left tibialis posterior, and left peroneal muscles than non-diabetic subjects. A smaller percentage of diabetic subjects had sensory neuropathy compared with the previous study from 5years earlier, but a greater percentage of diabetic subjects had absent pedal pulses in the current study. The frequency of inadequate or poor quality footwear was less in the current study compared with the previous study. CONCLUSIONS: The current data suggest that a foot care program consisting of nursing assessments and patient education may be associated with a decrease in frequency of neuropathy and improved footwear adequacy in diabetic patients with ESRD.

Upper extremity complications in patients with chronic renal failure receiving haemodialysis.

Limited data are available about disability associated with upper extremity complications in patients who receive haemodialysis for end-stage renal disease. In this study of 123 patients receiving haemodialysis, the mean Disabilities of the Arm, Shoulder and Hand (DASH) score was 31 ± 22 points, indicating markedly greater disability than in a normal population. Dupuytren's contracture was the most frequent deformity. Brachial, radial and ulnar pulses were present in most upper limbs, but 14 (14%) of 102 patients had poor arterial perfusion pressures. Diabetic patients had residual or complete loss of protective sensation more frequently than nondiabetic patients. Motor testing with the index finger abduction and fifth finger flexion tests showed a significantly greater frequency of weakness in diabetic than nondiabetic patients. In summary, upper extremity disability was noted in haemodialysis patients, including loss of protective sensation and motor strength, both in diabetic and nondiabetic subjects.

Lactate flux during carotid endarterectomy under general anesthesia: correlation with various point-of-care monitors.

PURPOSE: The ability to assess the brain-at-risk during carotid endarterectomy (CEA) under general anesthesia remains a major clinical problem. Point-of-care monitoring can potentially dictate changes to management intraoperatively. In this observational study, we examined the correlation between a series of point-of-care monitors and lactate flux during CEA. METHODS: Both neurosurgeons and vascular surgeons participated in the study. The patients underwent arterial-jugular venous blood sampling for oxygen, carbon dioxide, glucose, and lactate, n = 26; bispectral index (BIS) monitoring ipsilateral to side of surgery, n = 26; raw and processed electroencephalogram (EEG), n = 22; and bi-frontal cerebral oximetry using the Fore-Sight monitor, n = 20. RESULTS: One patient experienced a new neurological deficit when assessed at 24 hr following surgery. Lactate flux into the brain was correlated with the greatest decrease in cerebral oximetry with carotid cross-clamping; lactate efflux was correlated with the least. The most noticeable changes in processed EEG (density spectral analysis) were also seen with lactate influx, but at a slower time resolution than cerebral oximetry. Loss of autoregulatory behaviour was demonstrated with lactate influx; however, no correlation was seen between lactate flux and BIS monitoring. CONCLUSION: There was a correlation between cerebral oximetry and lactate flux during carotid cross-clamping. The Fore-Sight monitor may be of value as a point-of-care monitor during CEA under general anesthesia. A novel finding of this study is lactate flux into the brain in the presence of a large difference in cerebral oxygenation during cross-clamping of the carotid artery. Registered at clinicaltrials.gov: NCT000737334.

Multidisciplinary treatment of diabetic foot ulcers in Canadian Aboriginal and non-Aboriginal people.

BACKGROUND: Diabetic foot ulcers are a major cause of morbidity and mortality. This study evaluated the clinical outcomes in Canadian non-Aboriginal and Aboriginal diabetic patients with foot ulcers managed at a multidisciplinary, tertiary care diabetic foot clinic. METHODS: A retrospective review of medical records was done for 325 patients receiving care during a 2-year period. All patients were followed at least 1 year after the initial visit. RESULTS: There were 224 (69%) non-Aboriginal and 101 (31%) Aboriginal patients with 697 foot ulcers. At the initial office visit, 204 (63%) patients had lesions in Wagner grades 2-4. At the most recent evaluation (average, 79+/-73 weeks after initial clinic visit), 190 (58%) patients were rated as having a good outcome (either healed or healing), but a poor outcome (static, progression, amputation, or death) was noted in 135 (42%) patients. At the most recent evaluation, the majority of the 697 ulcers that were noted at the initial or subsequent clinic visits were healed. Aboriginal patients had a shorter average time from initial clinic visit to major lower extremity amputation (Aboriginal, 50+/-64 weeks; non-Aboriginal, 62+/-56 weeks; P<0.01). Residence in a rural or reserve community also correlated with shorter average time from initial clinic visit to major lower extremity amputation (rural or reserve, 45+/-56 weeks; urban, 66+/-61 weeks; P<0.002). When controlled for non-urban residence, Aboriginal ethnicity was not associated with poorer clinical outcome. Earlier major lower extremity amputation was significantly associated with non-urban residence, Aboriginal ethnicity, and arterial insufficiency. Poor clinical outcome was significantly associated with being referred with a lesion present, age greater than 60 years, prior lower extremity amputation or revascularization, arterial insufficiency, more than one lesion on initial presentation, longer duration of type 2 diabetes, and a higher initial Wagner grade for the most advanced lesion. CONCLUSIONS: A multidisciplinary diabetic foot clinic may be successful in treating diabetic foot ulcers in Aboriginal and non-Aboriginal people. However, the frequency of poor outcome is high, consistent with the high prevalence of associated significant risk factors in this population.

Revascularization for peripheral vascular disease in Aboriginal and non-Aboriginal patients.

BACKGROUND: Canadian Aboriginal subjects have a higher prevalence of diabetes, renal disease, and lower extremity amputation than non-Aboriginal subjects. However, limited information is available about patient outcomes for arterial bypass surgery in Canadian Aboriginal compared with non-Aboriginal subjects. METHODS: A retrospective study of all patients undergoing revascularization for peripheral vascular disease at a tertiary care referral center was performed. RESULTS: A total of 828 procedures were performed on 678 patients between 1995 and 2002: 108 (13%) procedures on 84 (12%) Aboriginal patients and 720 (87%) procedures on 594 (88%) non-Aboriginal patients. Aboriginal patients had a higher prevalence of diabetes, chronic renal failure, and end-stage renal disease than non-Aboriginal patients. Aboriginal patients presented with more serious complications (gangrene [Aboriginal, 63 [58%] of 108 patients; non-Aboriginal, 112 [16%] of 720 patients; P < .0001] and nonhealing ulcer [Aboriginal, 29 [27%] of 108 patients; non-Aboriginal, 131 [18%] of 720 patients; P < .05]) and required urgent or emergency revascularization (Aboriginal, 47 [49%] of 95 patients; non-Aboriginal, 228 [36%] of 634 patients; P < .02) more frequently than non-Aboriginal patients. The 60-month patient mortality was similar for both groups (Aboriginal, 20 [24%] of 84 patients; non-Aboriginal, 160 [27%] of 594 patients; not significant), but Aboriginal patients had loss of limb more frequently (Aboriginal, 19 [18%] of 108 patients; non-Aboriginal, 62 [9%] of 720 patients; P < .0001) and had loss of primary graft patency more frequently (Aboriginal, 39 [36%] of 108 patients; non-Aboriginal, 155 [22%] of 720 patients; P < .0001) than non-Aboriginal patients. CONCLUSIONS: Canadian Aboriginal subjects had worse outcomes with revascularization than non-Aboriginal subjects, but ethnicity and diabetes were not independent risk factors for poor outcome. Multivariate analysis showed that the poor outcomes in mortality, limb salvage, and primary graft patency among Aboriginal patients undergoing revascularization may be attributed to renal disease and a more advanced mode of presentation of peripheral vascular disease complications at the time of intervention.

Disability and quality of life in Canadian aboriginal and non-aboriginal diabetic lower-extremity amputees.

OBJECTIVE: To compare and contrast disability and quality of life (QOL) in Aboriginal and non-Aboriginal subjects with diabetes who had lower-extremity amputation (LEA) and were living in urban and rural communities in Canada. DESIGN: Descriptive study using an interviewer-administered questionnaire and hospital medical record review. SETTING: Tertiary care center. PARTICIPANTS: Forty-four diabetic subjects (minimum age, 18 y) not receiving dialysis, including 21 Aboriginal (8 urban, 13 rural) and 23 non-Aboriginal (16 urban, 7 rural) subjects. Subjects were living in their current residence and had undergone LEA above the level of the ankle 6 months or more before interview. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Qualitative and quantitative data about symptoms, impairment, and QOL. RESULTS: Aboriginal subjects were younger than non-Aboriginal subjects at the time of diabetes diagnosis (Aboriginal, 42+/-10 y; non-Aboriginal, 52+/-14 y; P<.005) and first major LEA (Aboriginal, 57+/-7 y; non-Aboriginal, 64+/-11 y; P<.015). All subjects received rehabilitation after amputation. More rural non-Aboriginal subjects (83%) used their prosthesis both in and outside the home for all movements than other subjects (P<.048). Rural non-Aboriginal subjects had the lowest and urban non-Aboriginal subjects had the highest frequency of walking-aid use outside the home. Assistance with personal care was required by a minority of subjects, but assistance with daily housework was required by the majority of subjects. Qualitative analysis revealed that participants were, in most cases, comfortable with their postamputation life. CONCLUSIONS: Although the majority of participants in this study generally felt satisfied with their current status, major functional changes were noted after LEA that had a large negative impact on QOL.