Challenges to Research and Innovation to Optimize Deceased Donor Organ Quality and Quantity

Solid organ transplantation is encumbered by an increasing number of waitlisted patients unrequited by the current organ supply. Preclinical models suggest that advances in deceased donor management and treatment can increase the quantity and quality of organs available for transplantation. However, the science of donor intervention and the execution of high quality, prospective, multi‐center, randomized‐controlled trials are restricted by a myriad of logistical challenges mired in regulatory and ethical ambiguity. By highlighting the obstacles to conducting research in deceased donors, this report endeavors to stimulate the creation of a multi‐disciplinary framework to facilitate the design, implementation and supervision of innovative trials that increase the quantity and/or quality of deceased donor organs.     

Split‐liver transplantation in the high‐MELD adult patient: are we being too cautious?

The fear that patients with high-mathematical model for end stage liver disease (MELD) score may not be suitable candidates for segmental grafts because of their need for greater liver mass has continued to push the transplant community toward the use of whole LT (WLT) in preference to split LT (SLT). In order to define the outcome of segmental liver transplantation in a better manner in high-MELD patients (score ≥26), we queried the UNOS registry for graft and patient survival results according to MELD score in adult patients receiving WLT and SLT in the United States from the inception of MELD allocation (February 27, 2002) through March 9, 2007. A total of 316 adult patients received a SLT as compared with 20 778 WLTs. Patient and graft survival rates at 6 and 12 months were comparable for all MELD ranges, including the 'high-MELD' recipients (e.g. at MELD score 31–35, patients' and grafts' survival rates at 12 months was 87.5% in SLT group vs. 84.4% and 76.7% in WLT group respectively). The results even at higher MELD scores (i.e. >35) were more than acceptable. In conclusion, patient and graft survival rates for SLT in high-MELD adult patients are comparable to the same for WLT.     

Prevention of atrial fibrillation after cardiac surgery using low-dose landiolol: A systematic review and meta-analysis

Study objectiveAtrial fibrillation (AF) is associated with mortality after cardiac surgery. Several studies have reported that landiolol might help to prevent postoperative AF. The objective of this study was to investigate whether low-dose landiolol is useful in terms of balance of benefit and risk.DesignWe conducted a meta-analysis after systematically searching the PubMed, the Cochrane library and the ICHUSHI to identify randomized, controlled trials investigating the preventive effect of landiolol on incidence of AF after cardiac surgery.PatientsSix randomized trial with 571 patients were included.MeasurementsThe primary outcome was incidence of AF after surgery, while secondary outcomes were mortality and complications.Main resultsIncidence of AF within 1 week after surgery was significantly lower in the landiolol group than in the control group (odds ratio, 0.27; 95% confidence interval, 0.18–0.42; p < 0.001). Three of the 6 studies reported data regarding in-hospital mortality and complications, showing no significant differences between groups (0.7 vs 3.0%; OR, 0.45; 95% CI, 0.07–2.74; p = 0.39; and 4.5 vs 9.7%; OR, 0.45; 95% CI, 0.16–1.23; p = 0.12, respectively).ConclusionsOur systematic review revealed that low-dose landiolol might help to prevent AF after cardiac surgery and further large trials are needed to evaluate safety because mortality and morbidity rate were very low in included studies.     

Breast cancer detection using high-resolution breast PET compared to whole-body PET or PET/CT

Purpose

To compare the performance characteristics of positron emission mammography (PEM) with those of whole-body PET (WBPET) and PET/CT in women with newly diagnosed breast cancer.

Methods

A total of 178 women consented to PEM for presurgical planning in an IRB-approved protocol and also underwent either WBPET (n?=?69) or PET/CT (n?=?109) imaging, as per usual care at three centers. Tumor detection sensitivity, positive predictive values, and ¹⁸F-fluorodeoxyglucose (FDG) uptake were compared between the modalities. The effects of tumor size, type, and grade on detection were examined. The chi-squared or Fisher’s exact tests were used to compare distributions between groups, and McNemar’s test was used to compare distributions for paired data within subject groups, i.e. PEM versus WBPET or PEM versus PET/CT.

Results

The mean age of the women was 59?±?12 years (median 60 years, range 26–89 years), with a mean invasive index tumor size of 1.6?±?0.8 cm (median 1.5 cm, range 0.5–4.0 cm). PEM detected more index tumors (61/66, 92 %) than WBPET (37/66, 56 %; p?<?0.001) or PET/CT (95/109, 87 % vs. 104/109, 95 % for PEM; p?<?0.029). Sensitivity for the detection of additional ipsilateral malignancies was also greater with PEM (7/15, 47 %) than with WBPET (1/15, 6.7 %; p?=?0.014) or PET/CT (3/23, 13 % vs. 13/23, 57 % for PEM; p?=?0.003). Index tumor detection decreased with decreasing invasive tumor size for both WBPET (p?=?0.002) and PET/CT (p?<?0.001); PEM was not significantly affected (p?=?0.20). FDG uptake, quantified in terms of maximum PEM uptake value, was lowest in ductal carcinoma in situ (median 1.5, range 0.7–3.0) and invasive lobular carcinoma (median 1.5, range 0.7–3.4), and highest in grade III invasive ductal carcinoma (median 3.1, range 1.4–12.9).

Conclusion

PEM was more sensitive than either WBPET or PET/CT in showing index and additional ipsilateral breast tumors and remained highly sensitive for tumors smaller than 1 cm.     

Methicillin-resistant Staphylococcus aureus pelvic abscesses in a female after gynecologic pelvic surgery

Pelvic abscesses occurring after gynecologic pelvic surgery are uncommon. We describe the case of a woman who, after undergoing such a procedure, was found to have pelvic abscesses infected with methicillin-resistant Staphyloccocus aureus. The purpose of this report is to raise awareness of a life-threatening complication of gynecologic pelvic surgery.     

The Incremental Cost of Incompatible Living Donor Kidney Transplantation: A National Cohort Analysis

Incompatible living donor kidney transplantation (ILDKT) has been established as an effective option for end‐stage renal disease patients with willing but HLA‐incompatible living donors, reducing mortality and improving quality of life. Depending on antibody titer, ILDKT can require highly resource‐intensive procedures, including intravenous immunoglobulin, plasma exchange, and/or cell‐depleting antibody treatment, as well as protocol biopsies and donor‐specific antibody testing. This study sought to compare the cost and Medicare reimbursement, exclusive of organ acquisition payment, for ILDKT (n = 926) with varying antibody titers to matched compatible transplants (n = 2762) performed between 2002 and 2011. Data were assembled from a national cohort study of ILDKT and a unique data set linking hospital cost accounting data and Medicare claims. ILDKT was more expensive than matched compatible transplantation, ranging from 20% higher adjusted costs for positive on Luminex assay but negative flow cytometric crossmatch, 26% higher for positive flow cytometric crossmatch but negative cytotoxic crossmatch, and 39% higher for positive cytotoxic crossmatch (p < 0.0001 for all). ILDKT was associated with longer median length of stay (12.9 vs. 7.8 days), higher Medicare payments ($91 330 vs. $63 782 p < 0.0001), and greater outlier payments. In conclusion, ILDKT increases the cost of and payments for kidney transplantation.     

Real-world experience with neuromuscular blockade reversal

Neuromuscular blocking agents are used in many surgical procedures and have enabled new surgical advances. The expanded landscape of neuromuscular blockade (NMB) reversal drugs allows for fast and complete NMB reversal and the reduction of postoperative complications from residual block. In the United States, neostigmine/glycopyrrolate and sugammadex are the primary agents for pharmacologic antagonism of neuromuscular blocking agents. Whereas neostigmine and an anticholinergic have been

Acknowledgment

This educational activity is jointly provided by The Elsevier Office of Continuing Medical Education and Miller Medical Communications, LLC.It is the policy of The Elsevier Office of Continuing Medical Education that all faculty, instructors, and planners disclose any real or apparent conflict of interest relating to the topics of this educational activity.The faculty reported the following financial relationships or relationships to products or devices they or their spouse/life partner have

Funding

This CME activity is supported by an independent educational grant from Merck & Co, Inc.