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Cuvelier S, Van Caeseele P, Kadatz M, Peterson K, Sun S, Dodd N, Werestiuk K, Koulack J, Nickerson P, Ho J. Expanding the Deceased Donor Pool in Manitoba Using Hepatitis C-Viremic Donors: Program Report. Can J Kidney Health Dis 2021; 8:20543581211033496. [PMID: 34367648 PMCID: PMC8317248 DOI: 10.1177/20543581211033496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 06/07/2021] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Susan Cuvelier
- Section of Hepatology, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | | | - Matthew Kadatz
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Kathryn Peterson
- Transplant Manitoba Adult Kidney Program, Winnipeg, Manitoba, Canada
| | - Siyao Sun
- Transplant Manitoba Adult Kidney Program, Winnipeg, Manitoba, Canada
| | - Nancy Dodd
- Transplant Manitoba Adult Kidney Program, Winnipeg, Manitoba, Canada
| | - Kim Werestiuk
- Transplant Manitoba Adult Kidney Program, Winnipeg, Manitoba, Canada
| | - Joshua Koulack
- Section of Vascular Surgery, Department of Surgery, University of Manitoba, Winnipeg, Canada
| | - Peter Nickerson
- Transplant Manitoba Adult Kidney Program, Winnipeg, Manitoba, Canada.,Section of Nephrology, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada.,Department of Immunology, University of Manitoba, Winnipeg, Canada
| | - Julie Ho
- Transplant Manitoba Adult Kidney Program, Winnipeg, Manitoba, Canada.,Section of Nephrology, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada.,Department of Immunology, University of Manitoba, Winnipeg, Canada
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Affiliation(s)
- Andrew Walkty
- Department of Internal Medicine, Section of Infectious Diseases, Winnipeg.,Department of Medical Microbiology & Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg.,Shared Health, Winnipeg
| | - Joshua Koulack
- Department of Surgery, Section of Vascular Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg
| | | | - Miao Lu
- Department of Pathology, Winnipeg, Canada
| | - Jeffrey Mottola
- Department of Radiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - John Embil
- Department of Internal Medicine, Section of Infectious Diseases, Winnipeg.,Department of Medical Microbiology & Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg
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Houston BL, Fergusson DA, Falk J, Krupka E, Perelman I, Breau RH, McIsaac DI, Rimmer E, Houston DS, Garland A, Ariano RE, Tinmouth A, Balshaw R, Turgeon AF, Jacobsohn E, Park J, Buduhan G, Johnson M, Koulack J, Zarychanski R. Evaluation of Transfusion Practices in Noncardiac Surgeries at High Risk for Red Blood Cell Transfusion: A Retrospective Cohort Study. Transfus Med Rev 2020; 35:16-21. [PMID: 32994103 DOI: 10.1016/j.tmrv.2020.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/17/2020] [Accepted: 08/21/2020] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
- Brett L Houston
- Department of Medical Oncology and Haematology, CancerCare Manitoba and Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jamie Falk
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Emily Krupka
- Faculty of Science, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Iris Perelman
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Rodney H Breau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada; Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada; Department of Anesthesiology & Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Emily Rimmer
- Department of Medical Oncology and Haematology, CancerCare Manitoba and Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Donald S Houston
- Department of Medical Oncology and Haematology, CancerCare Manitoba and Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Allan Garland
- Departments of Medicine and Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Robert E Ariano
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alan Tinmouth
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Robert Balshaw
- George & Fay Yee Center for Healthcare Innovation, University of Manitoba/Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada; CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Eric Jacobsohn
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jason Park
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gordon Buduhan
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Research Institute in Oncology and Hematology, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Michael Johnson
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Joshua Koulack
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ryan Zarychanski
- Department of Medical Oncology and Haematology, CancerCare Manitoba and Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Research Institute in Oncology and Hematology, CancerCare Manitoba, Winnipeg, Manitoba, Canada
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Parekh R, Koulack J, Boyd A. Radiographic and Functional Outcomes of Vascular Thoracic Outlet Decompressive Surgery: Is There a Benefit? J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Shaw J, Gibson IW, Wiebe C, Houston DS, Koulack J, Rush D, Nickerson P, Ho J. Hyperacute Antibody-mediated Rejection Associated With Red Blood Cell Antibodies. Transplant Direct 2019; 5:e477. [PMID: 31576373 PMCID: PMC6708630 DOI: 10.1097/txd.0000000000000925] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 06/26/2019] [Accepted: 06/27/2019] [Indexed: 12/04/2022] Open
Affiliation(s)
- James Shaw
- Section of Nephrology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Ian W. Gibson
- Department of Pathology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Chris Wiebe
- Section of Nephrology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Donald S. Houston
- Section of Hematology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Joshua Koulack
- Section of Vascular Surgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - David Rush
- Section of Nephrology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Nickerson
- Section of Nephrology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Immunology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Julie Ho
- Section of Nephrology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Immunology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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Rampersad C, Patel P, Koulack J, McGregor T. Back-to-back comparison of mini-open vs. laparoscopic technique for living kidney donation. Can Urol Assoc J 2016; 10:253-257. [PMID: 27878046 DOI: 10.5489/cuaj.3725] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
| | - Premal Patel
- Section of Urology, University of Manitoba, Winnipeg, MB, Canada
| | - Joshua Koulack
- Section of Vascular Surgery, University of Manitoba, Winnipeg, MB, Canada
| | - Thomas McGregor
- Section of Urology, University of Manitoba, Winnipeg, MB, Canada
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McGregor T, Kroczak T, Huang C, Koulack J. Ureteric re-implant for the strictured renal allograft: How I do it. Can J Urol 2016; 23:8296-8300. [PMID: 27347624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
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.
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Affiliation(s)
- Thomas McGregor
- Division of Urology, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
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McGregor T, Bjazevic J, Patel P, Koulack J. Changing of the guard? A glance at the surgical representation in the Canadian renal transplantation community. Can Urol Assoc J 2016; 10:E7-E11. [PMID: 26858788 PMCID: PMC4729576 DOI: 10.5489/cuaj.3256] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Tom McGregor
- University of Manitoba, Section of Urology, Winnipeg, MB, Canada
| | | | - Premal Patel
- University of Manitoba, Section of Urology, Winnipeg, MB, Canada
| | - Joshua Koulack
- University of Manitoba, Section of Vascular Surgery, Winnipeg, MB, Canada
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Funk DJ, HayGlass KT, Koulack J, Harding G, Boyd A, Brinkman R. A randomized controlled trial on the effects of goal-directed therapy on the inflammatory response open abdominal aortic aneurysm repair. Crit Care 2015; 19:247. [PMID: 26062689 PMCID: PMC4479246 DOI: 10.1186/s13054-015-0974-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 06/04/2015] [Indexed: 12/15/2022]
Abstract
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 m2, p < 0.01) and stroke volume index (50.1 ± 7.4 vs. 38.1 ± 9.8 ml/m2, 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.
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Affiliation(s)
- Duane J Funk
- Department of Anesthesia, University of Manitoba, 2nd Floor Harry Medovy House, 671 William Avenue, R3E 0Z2, Winnipeg, MB, Canada.
| | - Kent T HayGlass
- Department of Anesthesia, University of Manitoba, 2nd Floor Harry Medovy House, 671 William Avenue, R3E 0Z2, Winnipeg, MB, Canada.
| | - Joshua Koulack
- Department of Anesthesia, University of Manitoba, 2nd Floor Harry Medovy House, 671 William Avenue, R3E 0Z2, Winnipeg, MB, Canada.
| | - Greg Harding
- Department of Anesthesia, University of Manitoba, 2nd Floor Harry Medovy House, 671 William Avenue, R3E 0Z2, Winnipeg, MB, Canada.
| | - April Boyd
- Department of Anesthesia, University of Manitoba, 2nd Floor Harry Medovy House, 671 William Avenue, R3E 0Z2, Winnipeg, MB, Canada.
| | - Ryan Brinkman
- Department of Anesthesia, University of Manitoba, 2nd Floor Harry Medovy House, 671 William Avenue, R3E 0Z2, Winnipeg, MB, Canada.
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Hrymak C, Liu S, Koulack J, Funk DJ, Schaffer SA, Tam JW. Embolus from probable Takotsubo cardiomyopathy: a bedside diagnosis. Can J Cardiol 2014; 30:1732.e9-11. [PMID: 25442462 DOI: 10.1016/j.cjca.2014.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 08/14/2014] [Accepted: 08/18/2014] [Indexed: 10/24/2022] Open
Abstract
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.
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Affiliation(s)
| | - Shuangbo Liu
- University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Duane J Funk
- University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - James W Tam
- University of Manitoba, Winnipeg, Manitoba, Canada
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Reda A, Hurton S, Embil JM, Smallwood S, Thomson L, Zacharias J, Dascal M, Cheang M, Trepman E, Koulack J. Effect of a preventive foot care program on lower extremity complications in diabetic patients with end-stage renal disease. Foot Ankle Surg 2012; 18:283-6. [PMID: 23093125 DOI: 10.1016/j.fas.2012.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Revised: 04/18/2012] [Accepted: 05/13/2012] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Andrew Reda
- Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Hurton S, Embil JM, Reda A, Smallwood S, Wall C, Thomson L, Zacharias J, Dascal M, Trepman E, Koulack J. UPPER EXTREMITY COMPLICATIONS IN PATIENTS WITH CHRONIC RENAL FAILURE RECEIVING HAEMODIALYSIS. J Ren Care 2010; 36:203-11. [DOI: 10.1111/j.1755-6686.2010.00197.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Rose G, Duerksen F, Trepman E, Cheang M, Simonsen JN, Koulack J, Fong H, Nicolle LE, Embil JM. Multidisciplinary treatment of diabetic foot ulcers in Canadian Aboriginal and non-Aboriginal people. Foot Ankle Surg 2010; 14:74-81. [PMID: 19083619 DOI: 10.1016/j.fas.2007.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2006] [Revised: 10/15/2007] [Accepted: 10/29/2007] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Greg Rose
- Department of Medicine, Section of Infectious Diseases, University of Ottawa, Ottawa, Ontario, Canada
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Goulet S, Trepman E, Mmath MC, Koulack J, Fong H, Duerksen F, Martin B, Simonsen JN, Nicolle L, Embil J. Revascularization for peripheral vascular disease in Aboriginal and non-Aboriginal patients. J Vasc Surg 2006; 43:735-41. [PMID: 16616229 DOI: 10.1016/j.jvs.2005.11.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2005] [Accepted: 11/29/2005] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Stephen Goulet
- Department of Medicine, University of Manitoba, Winnipeg, Canada
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Meatherall BL, Garrett MR, Kaufert J, Martin BD, Fricke MW, Arneja AS, Duerksen F, Koulack J, Fong HM, Simonsen JN, Nicolle LE, Trepman E, Embil JM. Disability and Quality of Life in Canadian Aboriginal and Non-Aboriginal Diabetic Lower-Extremity Amputees. Arch Phys Med Rehabil 2005; 86:1594-602. [PMID: 16084813 DOI: 10.1016/j.apmr.2004.11.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2004] [Revised: 10/20/2004] [Accepted: 11/12/2004] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- J M Embil
- Department of Medicine, Section of Infectious Disease, University of Manitoba, Infection Control Unit, 820 Sherbrook St., R3A 1R9, Winnipeg, Manitoba, Canada.
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Koulack J, McAlister VC, MacAulay MA, Bitter-Suermann H, MacDonald AS, Lee TD. Importance of minor histocompatibility antigens in the development of allograft arteriosclerosis. Clin Immunol Immunopathol 1996; 80:273-7. [PMID: 8811047 DOI: 10.1006/clin.1996.0123] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Although acute rejection has been mostly ameliorated with the use of powerful immunosuppressive drugs, kidney and heart transplants continue to succumb to a more chronic response characterized by intimal lesions in the graft vasculature. This late-stage response is referred to as allograft arteriosclerosis. Allorecognition is clearly involved in the initiation of this response but the relative importance of major histocompatibility (MHC) and minor histocompatibility (mH) antigens remains unclear. By taking advantage of the B10 congenic set of mice and our newly described mouse aortic interposition graft model we have been able to assess the contribution of these antigens to the development of the concentric intimal lesions characteristic of allograft arteriosclerosis. We performed transplants between syngeneic animals, animals which were disparate at both MHC and multiple mH, animals which were disparate at MHC only, and animals which were disparate at multiple mH antigens only. H-Y antigen variation was controlled for by performing all transplants between female mice. In all cases the recipients were C57BL/10 (H-2b) mice. Both cellular infiltration into the intima and resulting intimal thickness were measured at 2, 4, 8, and 13 weeks posttransplant. At all time points, the grafts from MHC disparate only donors showed less severe intimal lesions than the grafts from fully disparate or mH disparate donors. This difference reached statistical significance at 4 and 13 weeks. This suggests that mH antigens are as immunogenic as MHC antigens with respect to the generation of allograft arteriosclerosis. These findings are not unique to vascular grafts and may relate to the importance of indirect antigen presentation in the development of chronic rejection.
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Affiliation(s)
- J Koulack
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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Koulack J, McAlister VC, Giacomantonio CA, Bitter-Suermann H, MacDonald AS, Lee TD. Development of a mouse aortic transplant model of chronic rejection. Microsurgery 1995; 16:110-3. [PMID: 7783601 DOI: 10.1002/micr.1920160213] [Citation(s) in RCA: 92] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Chronic rejection is the most common cause of late graft failure after solid organ transplantation. A model of chronic rejection, the rat aortic allograft, has histologic features that parallel those in the vessels of human transplanted organs. However, the molecular tools required to dissect the immunology of chronic rejection are unavailable in the rat. We developed aortic transplantation in the mouse as a new model of chronic rejection. This will allow the use of the diversity of recombinant cytokines and monoclonal antibodies available for the mouse and its well-defined genetics to investigate chronic rejection in greater detail. We describe the perioperative care and surgical technique for the model in which a 1 cm segment of donor thoracic aorta was used to replace a section of recipient abdominal aorta below the renal arteries and above the aortic bifurcation. Mortality rates were initially high (70%) due to thrombosis and shock. Changes in technique and operator facility resulted in a high rate of success (75%). After 192 operations, the current success rate is > 80%. Mice free from complications at 12 hrs postop had indefinite survival, and after 2 months the typical vascular lesion of chronic rejection was present. This new model of chronic rejection will be a valuable tool to study the molecular immunology and genetics of chronic rejection.
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Affiliation(s)
- J Koulack
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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Abstract
Routine inguinal hernia repair in the pediatric population has a low complication rate. Very few complications are identified at follow-up, which brings into question the necessity of the traditional postoperative visit. A retrospective review of patients who had undergone a routine inguinal hernia repair in 1991 at our institution was done in order to determine our current follow-up practices and complication rate. To determine the perceived necessity for the follow-up visit, parents were given a short telephone questionnaire. Of 175 eligible patients, questionnaires were completed on 145. Of these 145 patients, 77 were seen in follow-up by the pediatric surgeon only, 43 by the family doctor only, 12 were seen by both, and 13 patients had no physician follow-up. The sole complication was a stitch abscess (complication rate 0.7%). Results of the questionnaire showed that 90% of parents felt the follow-up visit was "helpful," 80% felt it was "necessary," and 35% would have been satisfied with telephone follow-up. The main purpose of the postoperative visit appears to be parental reassurance. Careful preoperative and postoperative instruction and reassurance may be sufficient in a significant number of cases.
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Affiliation(s)
- J Koulack
- Department of Surgery, Izaak Walton Killam Children's Hospital, Halifax, Nova Scotia, Canada
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