RESUMO
Post-traumatic epilepsy is a complicated disease that remains challenging to treat even for patients who are able to access care regularly. People experiencing homelessness (PEH) represent a vulnerable demographic for neurologic disorders, especially due to gaps in care, limited resources, and low health literacy. This is a case of a 53-year-old male experiencing homelessness who was encountered by low-resource medical providers in an extra-clinical setting. His medical history was pertinent for a traumatic brain injury at a construction site a few years prior. He was diagnosed with post-traumatic epilepsy but was lost to follow-up due to being homeless and lacking health insurance. He also had a history of multiple hospitalizations secondary to seizures and did not consistently take his anti-epileptic medications. He was noted to have multiple facial wounds of unclear etiology. Upon further investigation, he complained of episodes of waking up on the sidewalk with facial injuries. The high-risk characteristics of his seizures prompted street medicine providers to quickly arrange an appointment with a primary care doctor. The process was further expedited by petitioning other local charitable organizations. He was later connected to a physician and re-prescribed levetiracetam 1000 mg twice daily for his post-traumatic epilepsy. After taking his medication regularly, his facial wounds were noted to have dramatic improvement. In this way, his medication adherence was measured as a function of his healing wounds since a lack of fresh wounds implied a lack of spontaneous seizures and subsequent reinjury. Low-resource medical providers caring for PEH in extra-clinical settings may necessitate using unconventional indicators to assess disease status.
RESUMO
OBJECTIVES: The primary aim of this study was to determine whether specific preoperative clinical characteristics were associated with low-volume transfusion in liver transplant recipients. Low-volume transfusion was defined as transfusion of < 2100 mL of packed red blood cells intraoperatively during liver transplant. The ability to accurately predict low-volume transfusion could increase patient safety, decrease complications associated with transfusion, improve blood management, and decrease transplant case cost. MATERIALS AND METHODS: Data were retrieved by retrospective chart review of 266 patients who received a liver transplant at the Mayo Clinic (Jacksonville, FL, USA). The primary outcome was low-volume transfusion. Associations of preoperative information with low-volume transfusion were explored using single-variable and multivariable logistic regression models; missing data were imputed with the sample median for continuous data and the most frequent category for categorical variables. RESULTS: Low-volume transfusion occurred in 23% of first-time liver transplant recipients (62/266 patients; 95% confidence interval, 18%-29%). History of hepatitis C virus infection (P = .048), history of hepatocellular carcinoma (P = .050), short cold ischemia time (P = .006), and low international normalized ratio (P = .002) were independently associated with low-volume transfusion during liver transplant in a multivariable logistic regression model. CONCLUSIONS: Multiple studies have shown increased morbidity and mortality after orthotopic liver transplant when more than 6 U of packed red blood cells are administered within 24 hours of surgical incision. A method to identify low-volume transfusion candidates could help predict patient outcomes, decrease blood handling, and reduce costs. If patients with low-volume transfusion could be identified, fewer blood products would need to be prepared in advance. Although elevated preoperative coagulation parameters decrease the probability of low-volume transfusion, a definitive profile of a low-volume transfusion liver transplant recipient was not established.
