Morphological and molecular characterization of Sarcocystis spp. in pigs (Sus scrofa domestica) from Argentina

Sarcocystis spp. are intracellular protozoan parasites with an obligatory heteroxenous life cycle. The objective of this study was to identify Sarcocystis spp. in pig muscles from Argentina, by light and transmission electron microscopy (TEM), and molecular studies. Muscles samples from 561 pigs (Sus scrofa domestica) were classified according to the breeding system in: intensive farming (IF, n = 295; animals kept in confinement during most of their productive cycle), or semi-extensive farming (SEF, n = 266; animals bred outdoors, generally family or backyard production). Results showed that 24.8% (139/561) were positive by light microscopy, with a significantly higher prevalence in the SEF (34.6%; 92/266) than the IF pigs (15.9%; 47/295) (p < 0.05). Of the 202 samples analyzed by PCR, 96 were positive (47.5%) for the 18S rRNA (18S ribosomal RNA) fragment. All samples analyzed by the S. suihominis specific coxI (mitochondrial cytochrome c oxidase subunit I) PCR (n = 235; 96 positives by 18S rRNA PCR and 139 positives by light microscopy) were negative. Fourteen individual cysts were positive for the 18S rRNA PCR and sequenced. Consensus sequences obtained from the 18S rRNA fragment PCR ranged from 613 to 880 bp and showed 100% of identity between them and with previously reported S. miescheriana sequences. In all the pig samples analyzed by TEM, cyst wall ultrastructure was compatible with S. miescheriana. This is the first study that provides infection rates and describes and identifies morphological and molecular features of Sarcocystis spp. cysts in pigs from Argentina.

Genetic characterization of Toxoplasma gondii from human and chicken isolates from Argentina

This study aimed to determine the nPCR-RFLP genotypes of newly obtained T. gondii isolates from human congenital toxoplasmosis cases in Argentina and to determine their allelic profiles for virulence genes ROP18/ROP5. In addition, the ROP18/ROP5 profiles were also determined for previously characterized T. gondii samples. Isolation from congenital toxoplasmosis cases was carried out in mouse bioassay from two placentas (P1 and P2). Genotyping for the new human isolates was performed by nPCR-RFLP using 10 markers. The samples analyzed for ROP18/ROP5 included the two newly obtained isolates (from the congenital toxoplasmosis cases) and nine previously genotyped T. gondii DNA samples from humans and chickens. The results for P1 and P2 named as TgHm18-02Arg and TgHm19-01Arg showed ToxoDB genotypes #14 (non-archetypal) and #2 (clonal type III), respectively. Non-archetypal #14 has been isolated from human cases before in Argentina. However, this is the first report of T. gondii clonal type III in a human case in the country. The ROP18/ROP5 combination was detected in nine samples: 3/3 (n = 1), 4/3 (n = 4), 4/4 (n = 3), and 3-4/4 (n = 1). Notably, the 4/4 profile was identified for the first time and exclusively in T. gondii samples from Misiones province (which borders southern Brazil). Further studies are required to corroborate the regionalization of the ROP18/ROP5 profiles in Argentina.

Risk factors associated with Toxoplasma gondii seroprevalence in domestic pig farms in Argentina

Toxoplasmosis is a worldwide parasitic zoonosis caused by Toxoplasma gondii. Pigs can become infected by consuming water or food contaminated with sporulated oocysts, or by carnivorism (like the consumption of infected rodents). In pigs most infections are asymptomatic. In certain countries, pig meat containing tissue cysts is a major source of infection for human beings. The aims of this study were to estimate the seroprevalence of toxoplasmosis and to identify which factors were related with the increase of the risk of infection in Argentina. The seroprevalence of T. gondii was determined in 240 pigs from 27 farms in the central-western area of Buenos Aires province, Argentina. Serum samples were analyzed using indirect fluorescent antibody test (IFAT) and enzyme-linked immunosorbent assay (ELISA) techniques. Prevalence determined was 53.33% and 32.08% by IFAT and ELISA, respectively. Results showed that 81.5% (22/27) of the farms were seropositive to T. gondii. Seropositivity for T. gondii was related with the following risk factors (p value ≤0.05): presence of felids and rodents in the farms, feeding with waste of human food and storage of food outdoors with free access to felids and to the reservoirs when applying both serological techniques. Our results strongly suggest that the risk of infection with T. gondii in pigs is related to the outdoor/extensive type of production system with low infrastructure conditions, which allows both felids and rodents to have free access to pigs and stored food. Also, the high seroprevalence detected in the present study could indicate a potential role of pork in human infections in the region.

Correlation between Cranial Nerve Microstructural Characteristics and Vestibular Schwannoma Tumor Volume

BACKGROUND AND PURPOSE

Vestibular schwannomas are common cerebellopontine angle tumors arising from the vestibulocochlear nerve and can result in cranial nerve dysfunction. Conventional MR imaging does not provide information that could correlate with cranial nerve compression symptoms of hearing loss or imbalance. We used multitensor tractography to evaluate the relationship between the WM microstructural properties of cranial nerves and tumor volume in a cohort of patients with vestibular schwannomas.

MATERIALS AND METHODS

A retrospective study was performed in 258 patients with vestibular schwannomas treated at the Gamma Knife clinic at Toronto Western Hospital between 2014 and 2018. 3T MR images were analyzed in 160 surgically naïve patients with unilateral vestibular schwannomas. Multitensor tractography was used to extract DTI-derived metrics (fractional anisotropy and radial, axial, and mean diffusivities of the bilateral facial and vestibulocochlear nerves [cranial nerves VII/VIII]). ROIs were placed in the transition between cisternal and intracanalicular segments, and images were analyzed using the eXtended Streamline Tractography reconstruction method. Diffusion metrics were correlated with 3D tumor volume derived from the Gamma Knife clinic.

RESULTS

DTI analyses revealed significantly higher fractional anisotropy values and a reduction in axial diffusivity, radial diffusivity, and mean diffusivity (all P < .001) within the affected cranial nerves VII and VIII compared with unaffected side. All specific diffusivities (axial, radial, and mean diffusivity) demonstrated an inverse correlation with tumor volume (axial, radial, and mean diffusivity, P < .01).

CONCLUSIONS

Multitensor tractography allows the quantification of cranial nerve VII and VIII WM microstructural alterations in patients with vestibular schwannomas. Our findings support the hypothesis that tumor volume may cause microstructural alterations of the affected cranial nerves VII and VIII. This type of advanced imaging may represent a possible avenue to correlate diffusivities with cranial nerve function.

Interferon-γ and IL-10 Release Assay for Patients with Ocular Toxoplasmosis

Peripheral blood mononuclear cells (PBMC) from patients with ocular toxoplasmosis were challenged with total antigens from Toxoplasma gondii lysate (TATL) in a cytokine release assay (CRA), run during the inactive period of the disease. Increased interferon gamma (IFN-γ) levels were detected after PBMC stimulation with either ME49 reference strain (P = 0.0015) or local TgCkAr-11-9 isolate (P = 0.0012), as compared with those recorded under basal conditions. TATL from TgCkAr11-9 isolate induced a higher release of IFN-γ than ME49 strain in CRA from all tested patients (P = 0.02). The median value of IFN-γ release on TgCkAr-11-9 stimulation (26.03 pg/mL) allowed the classification of patients into high- or low-/non-IFN-γ releasers. Clinical correlations were established with both groups. The results obtained in this study suggest the need to include local strains when performing CRA with TATL.

A148 EFFICIENCY IN THE ENDOSCOPY UNIT: CAN WE ‘TURN AROUND’ ROOM TURNOVER?

Background

Endoscopy units across Canada are being challenged to meet the growing demand for procedures despite limited resources, highlighting the need to optimize endoscopy unit efficiency. Earlier studies have found that non-procedural factors, such as room turnover, represent an ideal target to improve efficiency.

Aims

The objective of this research project was to identify practices that will improve efficiency for routine outpatient gastrointestinal (GI) procedures at Sunnybrook Health Sciences Centre (SHSC). There were 2 sub-aims: 1) to understand practices at Toronto hospitals that shorten room turnover time and 2) to describe the variation in room turnover time at SHSC.

Methods

Sub-aim #1: A survey of endoscopy units at five other Toronto hospitals was completed. Questions were designed to gain a better understanding of routine practices and any initiatives undertaken to improve room turnover efficiency.

Sub-aim #2: Median room turnover time from April 2018 to March 2019, defined as ‘patient out’ to ‘patient in’, was reported in an anonymized fashion for the following categories: 1) by endoscopist, 2) by nurse, and 3) by unique endoscopist-nurse pair. Only data from routine outpatient endoscopic procedures (e.g. colonoscopy, gastroscopy, flexible sigmoidoscopy) were included. In order to evaluate turnover times by endoscopist-nurse pair, consecutive cases not performed by the same pair were excluded. Procedures affected by patient- and transportation-related delays were also excluded.

Results

Of the five centers surveyed, three allocated 5 minutes for turnover and two allocated 10 minutes. All centers reported tracking turnover time and four centers reported undertaking initiatives to decrease turnover time such as involving a flow team, hiring team attendants, and sharing performance data.

Over the 12-month period, 2504 routine outpatient GI endoscopic procedures were performed at SHSC, with 803 cases meeting inclusion criteria. Median turnover time for the unit was 6 minutes, ranging from 5 to 9 minutes across endoscopists, 5 to 7 minutes across nurses, and 3 to 10 minutes across unique endoscopist-nurse pairs (Figure 1). Efficiency of endoscopist-nurse pairs did not correlate with the number of cases performed as a pair over the 12-month period.

Conclusions

Endoscopy room turnover times at SHSC are similar to those reported by other local centers, with important variation across endoscopists and nurses. The next phase of this study will involve directly observing each of the most and least efficient individuals and pairs and recording common practices. It is anticipated that these findings will enable us to identify efficient practices that should be incorporated into standard operating procedures and training for endoscopy room personnel.

Funding Agencies

None

Evaluation of biological behavior of Toxoplasma gondii atypical isolates # 14 and # 163

Toxoplasma gondii is an obligate intracellular protozoan parasite capable of infecting warm-blooded animals, including humans. A highly diverse genetic population has been reported in Central and South America, predominating mainly atypical genotypes. Different genotypes showed different biological behavior in mice. The aim of this study was to evaluate the biological behavior of T. gondii isolates obtained from Macropus rufogriseus (TgMr) and Saimiri boliviensis (TgSb) identified as atypical genotypes # 14 and # 163, respectively. Strains RH, ME49 and VEG were used as reference for clonal types I, II and III, respectively. In vitro invasion and replication capacity assays were analyzed at 6 and 18 hpi, respectively. In vivo assay was performed in Swiss mice (n = 30) using 1 × 102 and 1 × 103 parasites/mouse as infective doses (ME49, VEG, TgMr, TgSb and negative control). Morbi-mortality and tissues PCR were assessed. Lymphoproliferation assays were performed and gamma interferon was measured by ELISA. The ME49 strain showed the highest invasion, followed by TgSb and VEG, while RH and TgMr presented the lowest invasions. The RH strain and the TgSb isolate showed more endodyogeny events (fastest doubling times) than VEG and ME49 strains and the TgMr isolate. Both atypical isolates showed high virulence (100% morbi-mortality, at 8-10 dpi) and parasite DNA was detected in all tissue samples. Splenocytes from mice inoculated with TgMr and TgSb registered the highest values of gamma interferon. An in vitro invasion-replication index was established which correlates inversely with virulence in mice. In conclusion, T. gondii atypical isolates # 14 and # 163 showed a different in vitro behavior than clonal strains, with low invasion-replication indexes but being highly virulent in mouse model.

Toxoplasma gondii and Neospora caninum infections in synanthropic rodents from Argentina

Abstract Toxoplasma gondii and Neospora caninum are closely related coccidian parasites (phylum Apicomplexa). This is the first study from urban synanthropic rodent species that involved serological and molecular diagnosis of T. gondii and N. caninum infection, and genotyping of T. gondii in Argentina. A total of 127 rodent samples were trap captured: Mus musculus (n = 78), Rattus norvegicus (n = 26) and Rattus rattus (n = 23). Antibodies against T. gondii and N. caninum were detected by IFAT in 32.8% (40/122) and 0.8% (1/122) of rodent samples, respectively, demonstrating contact with these protozoans. Additionally, T. gondii DNA was detected in 3.3% (4/123) of rodent central nervous system samples and 2 samples were genotyped by multilocus nPCR-RFLP. Neospora caninum DNA was not detected by PCR. The 2 genotyped samples were type III allele for all markers except for SAG-1 (type I for Rat1Arg and type II/III for Rat2Arg) and were identified as #48 and #2 (likely) according to the allele combinations reported on Toxo DB (Toxo-DB). The results of the present study revealed a wide distribution of T. gondii and less for N. caninum, in synanthropic rats and mice in the studied area.

Congenital human toxoplasmosis caused by non-clonal Toxoplasma gondii genotypes in Argentina

Toxoplasmosis, a worldwide distributed zoonosis, can be transmitted congenitally affecting fetuses and developing variable clinical signs. Different Toxoplasma gondii genotypes and infective dose are related factors with different clinical manifestations. Several studies indicate that atypical strains could produce more severe clinical manifestations compared to typical strains. Umbilical cord blood (n = 37) and placenta (n = 19) were collected at birth from women with acute T. gondii infection and processed for isolation by mice bioassay. Six isolates were obtained and identified as TgHm14-4Arg, TgHm15-02Arg, TgHm16-01Arg, TgHm16-02Arg, TgHm17-01Arg and TgHm17-02Arg. Three genotypes described previously on Toxo-DB were identified: #138 identified in chickens from Brazil, #182 isolated from eared doves from Brazil, #14 from wallaby kangaroos and chickens from Argentina, chickens from Brazil, Colombia, Chile and Venezuela, cats and dogs from Brazil and Colombia and also coyotes from USA indicating worldwide distribution of these genotypes. Two new allele combinations were obtained showing high genotypes diversity in Argentina. Four of the isolates (TgHm14-4Arg, TgHm15-02Arg, TgHm16-01Arg, TgHm16-02Arg) and two of them (TgHm17-01Arg, TgHm17-02Arg) produced chronic and acute infections in mice, respectively. Until now, seven T. gondii isolates have been obtained from humans in Argentina, and all were atypical or non-clonal genotypes. The identification of atypical strains causing congenital toxoplasmosis and circulating in our region, make important to perform the serological screenings according Argentine Consensus of Toxoplasmosis and to apply and monitoring treatments earlier in pregnancy. To achieve this aim, it is necessary to inform general population about T. gondii infection, diagnostics and control measures. These results should serve to generate awareness about congenital toxoplasmosis in South America.

Population structure of Toxoplasma gondii in Argentina

The protozoan Toxoplasma gondii is worldwide distributed showing a particular population structure that may differ among continents and countries. The aim of this study was to analyze the T. gondii population structure in Argentina and compare it with genotyping information from other South American countries. For the analysis, 39 samples from Argentina (isolates from the provinces of Buenos Aires, Misiones, Entre Ríos and San Luis) were genotyped using 10 multilocus PCR-RFLP markers including SAG1, SAG2 (5'-3'SAG2, alt. SAG2), SAG3, BTUB, GRA6, C22-8, C29-2, L358, PK1, and Apico. The T. gondii DNA samples were obtained from domestics animals (chickens n = 20; cats n = 3; pigs n = 2; goat n = 1; rabbit n = 1), humans (n = 6), zoo animals (n = 5) and a rat (n = 1). Phylogenetic relationship of these Argentinean isolates together with representative reference genotypes was determined by phylogenetic network analysis. Thirty-seven Argentinean samples belonged to 21 genotypes and two samples were genotyped at 8 of the 10 loci and considered incomplete characterized. Among these 37 typed samples, five genotypes were not previously reported. The majority of the samples grouped with the Type III (ToxoDB PCR-RFLP genotype #2) lineage. The clonal Type II (ToxoDB genotypes #1 and #3) was also identified. Our results suggest a unique population structure with combination of unique genotypes and the common Type II and Type III lineages in Argentina. Nevertheless, different regions showed distinctive pattern of genotypes, revealing a higher variability in Northern provinces.

Mutations in osteoprotegerin account for the CCAL1 locus in calcium pyrophosphate deposition disease

OBJECTIVE

Mutations on chromosomes 5p (CCAL2) and 8q (CCAL1) have been linked to familial forms of calcium pyrophosphate deposition disease (CPDD). Mutations in the ANKH gene account for CCAL2, but the identity of CCAL1 has been elusive. Recently, a single Dutch kindred with a mutation in the Tumor Necrosis Factor Receptor Super Family member 11B (TNFRSF11B) gene coding for osteoprotegerin (OPG) was described as a gain-of-function mutation. Affected family members had premature generalized osteoarthritis (PGOA) and CPDD. As the TNFRSF11B gene is on 8q, we sought additional evidence that TNFRSF11B was CCAL1, and investigated potential disease mechanisms.

DESIGN

DNA from two novel PGOA/CPDD families was screened for sequence variants in the TNFRSF11B gene. Mutations were verified by genotype analysis of affected and unaffected family members. We also investigated effects of normal and mutant OPG on regulators of CPP crystal formation in porcine cartilage.

RESULTS

The identical TNFRSF11B mutation described in the Dutch family was present in two novel PGOA/CPDD families. ANKH was normal in affected patient fibroblasts. Exogenous OPG did not alter ANKH mRNA or protein levels, affect translocation of ANKH to the membrane, nor increase [pyrophosphate (PPi)] or other key regulators of CPDD.

CONCLUSION

We have firmly established the identity of CCAL1 as TNFRSF11B (OPG). Our findings suggest that this mutation produces disease in an ANKH-independent manner via novel mechanisms not primarily targeting cartilage. This work rationalizes further investigation of OPG pathway components as potential druggable targets for CPDD.

The views of patients with brain cancer about palliative care: a qualitative study

Background

Palliative care, a specialty aimed at providing optimal care to patients with life-limiting and chronic conditions, has several benefits. Although palliative care is appropriate for neurosurgical conditions, including brain cancer, few studies have examined the views of brain cancer patients about palliative care. We aimed to explore the thoughts of brain cancer patients about palliative care, their opinions about early palliative care, and their preferred care setting.

Methods

Semi-structured interviews and the qualitative research methodologies of grounded theory were used to explore perceptions of palliative care on the part of 39 brain cancer outpatients.

Results

Seven overarching actions emerged: ■Patients would prefer to receive palliative care in the home.■Increased time with caregivers and family are the main appeals of home care.■Patients express dissatisfaction with brief and superficial interactions with health care providers.■Patients believe that palliative care can contribute to their emotional well-being.■Patients are open to palliative care if they believe that it will not diminish optimism.■There is a preconceived idea that palliative care is directly linked to active dying, and that supposed link generates fear in some patients.■Patients prefer to be educated about palliative care as an option early in their illness, even if they are fearful of it.

Conclusions

Overall, when educated about the true meaning of palliative care, most patients express interest in accessing palliative care services. Although the level of fear concerning palliative care varies in patients, most recognize the associated benefits.

EURAMOS-1, an international randomised study for osteosarcoma: results from pre-randomisation treatment

BACKGROUND

Four international study groups undertook a large study in resectable osteosarcoma, which included two randomised controlled trials, to determine the effect on survival of changing post-operative chemotherapy based on histological response.

PATIENTS AND METHODS

Patients with resectable osteosarcoma aged ≤40 years were treated with the MAP regimen, comprising pre-operatively of two 5-week cycles of cisplatin 120 mg/m(2), doxorubicin 75 mg/m(2), methotrexate 12 g/m(2) × 2 (MAP) and post-operatively two further cycles of MAP and two cycles of just MA. Patients were randomised after surgery. Those with ≥10% viable tumour in the resected specimen received MAP or MAP with ifosfamide and etoposide. Those with <10% viable tumour were allocated to MAP or MAP followed by pegylated interferon. Longitudinal evaluation of quality of life was undertaken.

RESULTS

Recruitment was completed to the largest osteosarcoma study to date in 75 months. Commencing March 2005, 2260 patients were registered from 326 centres across 17 countries. About 1334 of 2260 registered patients (59%) were randomised. Pre-operative chemotherapy was completed according to protocol in 94%. Grade 3-4 neutropenia affected 83% of cycles and 59% were complicated by infection. There were three (0.13%) deaths related to pre-operative chemotherapy. At definitive surgery, 50% of patients had at least 90% necrosis in the resected specimen.

CONCLUSIONS

New models of collaboration are required to successfully conduct trials to improve outcomes of patients with rare cancers; EURAMOS-1 demonstrates achievability. Considerable regulatory, financial and operational challenges must be overcome to develop similar studies in the future. The trial is registered as NCT00134030 and ISRCTN 67613327.

Long-term efficacy of NASHA Dx injection therapy for treatment of fecal incontinence

BACKGROUND

Injectable bulking treatment for fecal incontinence (FI) is intended to expand tissue in the anal canal and prevent fecal leakage. Use of injectable bulking agents is increasing because it can be performed in an outpatient setting and with low risk for morbidity. This study evaluated the long-term (36-month) clinical effectiveness and safety of injection of non-animal stabilized hyaluronic acid/dextranomer (NASHA Dx) on FI symptoms.

METHODS

In a prospective multicenter trial, 136 patients with FI received the NASHA Dx bulking agent. Treatment success defined as a reduction in number of FI episodes by 50% or more compared with baseline (Responder50 ). Change from baseline in Cleveland Clinic Florida Fecal Incontinence Score (CCFIS) and Fecal Incontinence Quality of Life Scale (FIQL), and adverse events were also evaluated.

KEY RESULTS

Successful decrease in symptoms was achieved in 52% of patients at 6 months and this was sustained at 12 months (57%) and 36 months (52%). Mean CCFIS decreased from 14 at baseline to 11 at 36 months (p < 0.001). Quality-of-life scores for all four domains improved significantly between baseline and 36 months of follow-up. Severe adverse events were rare and most adverse events were transient and pertained to minor bleeding and pain or discomfort.

CONCLUSIONS & INFERENCES

Submucosal injection of NASHA Dx provided a significant improvement of FI symptoms in a majority of patients and this effect was stable during the course of the follow-up and maintained for 3 years.

Does pharmacological treatment of ADHD in adults enhance parenting performance? Results of a double-blind randomized trial

OBJECTIVE

This study examines the effects of parental lisdexamfetamine (LDX) treatment on parent-child interactions.

METHODS

Participants were 30 parents (27% were male) and their children aged 5-12 years, both diagnosed with DSM-IV attention-deficit/hyperactivity disorder (ADHD). Optimal LDX dose (30, 50, or 70 mg/day) was determined for parents during a 3-week open-label titration, followed by a within-subjects trial of the acute impact of LDX and placebo on observable parent-child interactions. Two laboratory-based, parent-child interactions simulating typical family tasks (e.g., homework, joint play) were conducted within 2 weeks, once with the adult on a blinded optimal dose of LDX and once on placebo (phase I). Parents were then randomly assigned to continue blinded treatment with LDX or placebo for another month followed by a third interaction task (phase II) to assess the ongoing effects of LDX on parent-child interactions. The primary outcome was the change in rate of parenting behaviors coded during the parent-child interaction tasks. Secondary outcomes included observed rates of children's inappropriate behaviors during the laboratory tasks and changes in parental ADHD symptom severity (ADHD-Rating Scale).

RESULTS

Twenty parents (67%) completed the trial. In phase I, medication was associated with a significant reduction in negative talk by parents (p = 0.0066, d = -0.47). There was a Medication × Task interaction (p = 0.0235) with a reduction in children's negative behaviors in the homework phase only (p = 0.0154, d = -0.58). In phase II, LDX was associated with significant increases in praise by parents (d = 0.81) and reductions in parental commands (d = -0.88) and children's inappropriate behaviors (d = -0.84) (all p-values < 0.05). While not reaching statistical significance, LDX was also associated with large reductions in parental verbalizations (d = -0.82), moderate increases in parental responsiveness (d = 0.55), and large reductions in the ratio of commands to verbalizations during the non-homework task (d = -1.05) (all p-values < 0.10). Significant reductions in parental ADHD symptoms vs. placebo were observed (p < 0.005). Loss of appetite, dry mouth, headaches, and delayed sleep onset were the most common adverse events.

CONCLUSIONS

Improvements in parent-child interactions emerged over time with LDX treatment of parental ADHD. Results suggest that pharmacological treatment of parental ADHD may improve outcomes in parents and their children.

Outcomes in patients undergoing nephrectomy for renal cancer on chronic anticoagulation therapy

AIMS

To report our experience on surgical resection of renal tumors for patients with a history of chronic anticoagulation (ACT) or aspirin use.

METHODS

We performed a retrospective analysis of 2473 patients who underwent surgery for renal tumors between 2005 and 2012. Prior to surgery, 172 were on chronic ACT and 695 on aspirin. Multivariable linear and logistic regression models were used to compare transfusion and overall complication rates between patients undergoing renal surgery who were on therapy to patients who were on aspirin and to patients with no therapy.

RESULTS

Compared to no therapy and aspirin patients those on ACT were older (57.3 (IQR 48.4-66.10) vs 63.9, (IQR 57.3-71.5) vs 68.4, (IQR 60.4-73.5); p < 0.001), with a higher percentage having an ASA score of 3 or 4 (42.4 vs 57.9 vs 82.6%; p < 0.001), respectively. ACT patients had a higher 30-day transfusion rate, 22.7% vs 7.6% vs 6.9%, and 90-day complication rate, 17.4% vs 7.2% vs 7.3%, both p < 0.001. The median length of stay differed statistically between groups (p < 0.001), with a modest longer stay in the anticoagulation group (OR 1.11 SE 0.26; p < 0.001). Transfusion and complication rates for patients on therapy undergoing minimally invasive surgery vs open surgery were not statistically different.

CONCLUSIONS

Patients on chronic ACT had higher transfusion and overall complication rates compared to patients on no treatment or on chronic aspirin. These findings did not correlate to clinical differences in length of stay or grade 3-5 complications.

Radical cystectomy and orthotopic urinary reconstruction in patients with bladder cancer after renal transplantation: clinical outcomes and description of technique

OBJECTIVES

Radical cystectomy (RC) with pelvic lymph node dissection and urinary diversion is the standard treatment for muscle-invasive bladder cancer. In the setting of prior renal transplantation, surgical treatment remains the mainstay but is technically challenging. We report our patient outcomes in this unique population with a description of the technique.

METHODS

We identified five patients with a history of renal transplantation who underwent RC and orthotopic urinary diversion. Preoperative clinical and demographic features were compiled and disease-specific and functional outcomes were assessed. Intraoperative technical challenges and maneuvers for avoiding complications are highlighted.

RESULTS

Four patients were male and one was female, with a median age of 64 years. Gross hematuria was the most common sign at presentation. Clinical staging was T2, T2 with carcinoma in situ (CIS), high-grade (HG) Ta with CIS, T2 with squamous differentiation, and HG T1, and pathologic tumor stage was pTisN1, pT3N0, pTisN0, pT3N0, and pT0N0, respectively. One patient received a Studer-type diversion and four underwent Hautmann diversion. Median follow-up after cystectomy was 12.9 months. Graft ureteral identification was aided by the use of intravenous dye in all patients. Ipsilateral pelvic lymph node dissection was not possible in any patient. All patients are alive at follow-up, with two experiencing recurrence at 7.2 months and 66.8 months. No patient experienced a significant decrease in estimated creatinine clearance postoperatively. Postoperative daytime control was reported by all patients whereas two noted complete nighttime control.

CONCLUSIONS

RC with orthotopic diversion is a technically demanding procedure in patients with a history renal transplantation. Meticulous technique and careful attention to the altered anatomy are required for successful outcomes.