Healthcare systems worldwide were challenged during the COVID‐19 pandemic. In Mexico, the public hospitals that perform most transplants were adapted to provide care for COVID‐19 patients. Using a ...nationwide database, we describe the first report of the impact of COVID‐19 and related transplantation healthcare policies in a middle‐income country by comparing statistics before and during the pandemic (pre‐COVID: March 2019–February 2020 vs. COVID era: March 2020–February 2021) and by type of institution (public vs. private). The global reduction in transplantation was higher in public institutions compared with private institutions, 89% versus 62%, respectively, p < .001. When analyzing by organ, kidney transplantation decreased by 89% at public versus 57% at private, p < .001; cornea by 88% at public versus 64% at private, p < .001; liver by 88% at public versus 35% at private, p < .001; and heart by 88% in public versus 67% at private institutions, p = .4. The COVID‐19 pandemic along with the implemented health policies were associated with a decrease in donations, waiting list additions, and a decrease in transplantation, particularly at public institutions, which care for the most vulnerable.
Analysis of a nationwide database demonstrates that healthcare policy changes during the COVID‐19 pandemic is associated with a decrease in solid organ transplantation with greater impact in public hospitals.
Many safe and effective severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) vaccinations dramatically reduce risks of coronavirus disease 2019 (COVID‐19) complications and deaths. We aimed ...to describe cases of SARS‐CoV‐2 infection among patients with chronic liver disease (CLD) and liver transplant (LT) recipients with at least one prior COVID‐19 vaccine dose. The SECURE‐Liver and COVID‐Hep international reporting registries were used to identify laboratory‐confirmed COVID‐19 in CLD and LT patients who received a COVID‐19 vaccination. Of the 342 cases of lab‐confirmed SARS‐CoV‐2 infections in the era after vaccine licensing, 40 patients (21 with CLD and 19 with LT) had at least one prior COVID‐19 vaccination, including 12 who were fully vaccinated (≥2 weeks after second dose). Of the 21 patients with CLD (90% with cirrhosis), 7 (33%) were hospitalized, 1 (5%) was admitted to the intensive care unit (ICU), and 0 died. In the LT cohort (n = 19), there were 6 hospitalizations (32%), including 3 (16%) resulting in mechanical ventilation and 2 (11%) resulting in death. All three cases of severe COVID‐19 occurred in patients who had a single vaccine dose within the last 1‐2 weeks. In contemporary patients with CLD, rates of symptomatic infection, hospitalization, ICU admission, invasive ventilation, and death were numerically higher in unvaccinated individuals. Conclusion: This case series demonstrates the potential for COVID‐19 infections among patients with CLD and LT recipients who had received the COVID‐19 vaccination. Vaccination against SARS‐CoV‐2 appears to result in favorable outcomes as attested by the absence of mechanical ventilation, ICU, or death among fully vaccinated patients.
COVID-19 vaccination has proved to be effective to prevent symptomatic infection and severe disease even in immunocompromised patients including liver transplant patients. We aim to assess the impact ...of COVID-19 vaccination on the mortality and development of severe and critical disease in our center.
A retrospective cohort study of LT patients in a reference center between March 2020 and February 2022. Demographic data, cirrhosis etiology, time on liver transplantation, immunosuppressive therapies, and vaccination status were recorded at the time of diagnosis. Primary outcome was death due to COVID-19, and secondary outcomes included the development of severe COVID-19 and intensive care unit (ICU) requirement.
153 of 324 LT recipients developed COVID-19, in whom the main causes of cirrhosis were HCV infection and metabolic-associated fatty liver disease. The vaccines used were BNT162b2 (48.6%), ChAdOx1 nCoV-19 (21.6%), mRNA-1273 vaccine (1.4%), Sputnik V (14.9%), Ad5-nCoV-S (4.1%) and CoronaVac (9.5%). Case fatality and ICU requirement risk were similar among vaccinated and unvaccinated LT patients (adjusted relative case fatality for vaccinated versus unvaccinated of 0.68, 95% CI 0.14-3.24, p = 0.62; adjusted relative risk aRR for ICU requirement of 0.45, 95% CI 0.11-1.88, p = 0.27). Nonetheless, vaccination was associated with a lower risk of severe disease (aRR for severe disease of 0.32, 95% CI 0.14-0.71, p = 0.005).
Vaccination reduces the risk of severe COVID-19 in LT patients, regardless of the scheme used. Vaccination should be encouraged for all.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Objective
This study aimed to evaluate outcomes in cirrhotic patients diagnosed with spontaneous bacterial empyema (SBE) compared with those without this complication.
Methods
We performed a ...retrospective cohort study of cirrhotic patients from a tertiary care center. The primary outcome was time to death or liver transplantation (LT) within one year after diagnosis of infection. We integrated three groups: patients with SBE (group A), patients with spontaneous bacterial peritonitis (SBP; group B), and cirrhotic patients without SBP or SBE (group C), matched by age, model for end‐stage liver disease‐sodium (MELD‐Na) score and year of infection. Outcomes were analyzed using a Cox regression model adjusted for cardiovascular risk factors and MELD‐Na score.
Results
Between January 1999 and February 2019, 4829 cirrhotic patients were identified. Among them, 73 (1.5%) had hepatic hydrotorax, of whom 22 (30.1%) were diagnosed with SBE. Median age in group A was 58 years, 50% were men, and median MELD‐Na was 21.5. Compared with group C, the hazard ratio of death or LT during the first year after infection was 2.98 (95% confidence interval CI 1.43‐6.22, P = 0.004) for group A and 1.23 (95% CI 0.65‐2.32, P = 0.522) for group B.
Conclusions
Our results suggest that patients with SBE have a worse outcome during the first year after infection is diagnosed. Patients who develop SBE should be promptly referred for transplant evaluation. SBE may emerge as new indication that could benefit from MELD exception points.
Spontaneous bacterial empyema (SBE) is a rare complication of portal hypertension. After the first episode of SBE the natural history of patients with cirrhosis changes abruptly with a poor one‐year survival. Patients who develop SBE should be referred for a liver transplantation evaluation.
Electrolyte and acid–base disturbances are frequent in patients with end-stage liver disease; the underlying physiopathological mechanisms are often complex and represent a diagnostic and therapeutic ...challenge to the physician. Usually, these disorders do not develop in compensated cirrhotic patients, but with the onset of the classic complications of cirrhosis such as ascites, renal failure, spontaneous bacterial peritonitis and variceal bleeding, multiple electrolyte, and acid–base disturbances emerge. Hyponatremia parallels ascites formation and is a well-known trigger of hepatic encephalopathy; its management in this particular population poses a risky challenge due to the high susceptibility of cirrhotic patients to osmotic demyelination. Hypokalemia is common in the setting of cirrhosis: multiple potassium wasting mechanisms both inherent to the disease and resulting from its management make these patients particularly susceptible to potassium depletion even in the setting of normokalemia. Acid–base disturbances range from classical respiratory alkalosis to high anion gap metabolic acidosis, almost comprising the full acid–base spectrum. Because most electrolyte and acid–base disturbances are managed in terms of their underlying trigger factors, a systematic physiopathological approach to their diagnosis and treatment is required.
Antibiotic prophylaxis in patients with cirrhosis and acute variceal bleeding is part of the standard of care according to most clinical guidelines. However, with recent evidence arguing against ...antibiotic prophylaxis, the role of this intervention has become less clear.
The COVID-19 pandemic has brought unprecedented changes to medical education. However, no data are available regarding the impact the pandemic may have on medical training in Mexico. The aim of our ...study was to evaluate and identify the medical school students' perceptions of the changes in their clinical training due to the pandemic in Mexico.
This was a cross-sectional study where a previous validated online survey was translated and adapted by medical education experts and applied to senior medical students from March to April of 2021. The 16-item questionnaire was distributed online combining dichotomous, multiple-choice, and 5-point Likert response scale questions. Descriptive and multivariate analyses were performed to compare the student's perceptions between public and private schools.
A total of 671 responses were included in the study period. Most participants were from public schools (81%) and female (61%). Almost every respondent (94%) indicated it was necessary to obtain COVID-19 education, yet only half (54%) received such training. Students in private schools were less likely to have their clinical instruction canceled (53% vs. 77%, p = 0.001) and more likely to have access to virtual instruction (46% vs. 22%, p = 0.001) when compared to students from public schools. Four out of every five students considered their training inferior to that of previous generations, and most students (82%) would consider repeating their final year of clinical training.
The impact of the COVID-19 on medical education in Mexico has been significant. Most final-year medical students have been affected by the cancellation of their in-person clinical instruction, for which the majority would consider repeating their final year of training. Efforts to counterbalance this lack of clinical experience with virtual or simulation instruction are needed.
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