Evaluation of neuraxial analgesia on outcomes for patients undergoing robot assisted abdominal surgery

STUDY OBJECTIVE

Following robot assisted abdominal surgery, the pain can be moderate in severity. Neuraxial analgesia may decrease the activity of the detrusor muscle, reduce the incidence of bladder spasm and provide effective somatic and visceral analgesia. In this systematic review, we assessed the role of neuraxial analgesia in robot assisted abdominal surgery.

DESIGN

Systematic review.

SETTINGS

Robot assisted abdominal surgery.

PATIENTS

Adults.

INTERVENTIONS

Subsequent to a search of the electronic databases, observational studies and randomized controlled trials that assessed the effect of neuraxial analgesia instituted at induction of anesthesia or intraoperatively in adult and robot assisted abdominal surgery were considered for inclusion. The outcomes of observational studies as well as randomized controlled trials which were not subjected to meta-analysis were presented in descriptive terms. Meta-analysis was conducted if an outcome of interest was reported by two or more randomized controlled trials.

MAIN RESULTS

We included 19 and 11 studies that investigated spinal and epidural analgesia in adults, respectively. The coprimary outcomes were the pain score at rest at 24 h and the cumulative intravenous morphine consumption at 24 h. Spinal analgesia with long acting neuraxial opioid did not decrease the pain score at rest at 24 h although it reduced the cumulative intravenous morphine consumption at 24 h by a mean difference (95%CI) of 14.88 mg (-22.13--7.63; p < 0.0001, I2 = 50%) with a low and moderate quality of evidence, respectively, on meta-analysis of randomized controlled trials. Spinal analgesia with long acting neuraxial opioid had a beneficial effect on analgesic indices till the second postoperative day and a positive influence on opioid consumption up to and including the 72 h time point. The majority of studies demonstrated the use of spinal analgesia with long acting neuraxial opioid to lead to no difference in the incidence of postoperative nausea and vomiting, and the occurrence of pruritus was found to be increased with spinal analgesia with long acting neuraxial opioid in recovery but not at later time points. No difference was revealed in the incidence of urinary retention. The evidence in regard to the quality of recovery-15 score at 24 h and hospital length of stay was not fully consistent, although most studies indicated no difference between spinal analgesia and control for these outcomes. Epidural analgesia in robot assisted abdominal surgery was shown to decrease the pain on movement at 12 h but it had not been studied with respect to its influence on the pain score at rest at 24 h or the cumulative intravenous morphine consumption at 24 h. It did not reduce the pain on movement at later time points and the evidence related to the hospital length of stay was inconsistent.

CONCLUSIONS

Spinal analgesia with long acting neuraxial opioid had a favourable effect on analgesic indices and opioid consumption, and is recommended by the authors, but the evidence for spinal analgesia with short acting neuraxial opioid and epidural analgesia was limited.

A study of validity and usability evidence for non-technical skills assessment tools in simulated adult resuscitation scenarios

BACKGROUND

Non-technical skills (NTS) assessment tools are widely used to provide formative and summative assessment for healthcare professionals and there are now many of them. This study has examined three different tools designed for similar settings and gathered evidence to test their validity and usability.

METHODS

Three NTS assessment tools designed for use in the UK were used by three experienced faculty to review standardized videos of simulated cardiac arrest scenarios: ANTS (Anesthetists' Non-Technical Skills), Oxford NOTECHS (Oxford NOn-TECHnical Skills) and OSCAR (Observational Skill based Clinical Assessment tool for Resuscitation). Internal consistency, interrater reliability and quantitative and qualitative analysis of usability were analyzed for each tool.

RESULTS

Internal consistency and interrater reliability (IRR) varied considerably for the three tools across NTS categories and elements. Intraclass correlation scores of three expert raters ranged from poor (task management in ANTS [0.26] and situation awareness (SA) in Oxford NOTECHS [0.34]) to very good (problem solving in Oxford NOTECHS [0.81] and cooperation [0.84] and SA [0.87] in OSCAR). Furthermore, different statistical tests of IRR produced different results for each tool. Quantitative and qualitative examination of usability also revealed challenges in using each tool.

CONCLUSIONS

The lack of standardization of NTS assessment tools and training in their use is unhelpful for healthcare educators and students. Educators require ongoing support in the use of NTS assessment tools for the evaluation of individual healthcare professionals or healthcare teams. Summative or high-stakes examinations using NTS assessment tools should be undertaken with at least two assessors to provide consensus scoring. In light of the renewed focus on simulation as an educational tool to support and enhance training recovery in the aftermath of COVID-19, it is even more important that assessment of these vital skills is standardized, simplified and supported with adequate training.

Central line training models: limitations and modifications

Training in simulated environments allows clinicians to practise procedures and make mistakes without risk to patients. It is important training models offer sufficient fidelity, allowing the trainee to face the same difficulties and hazards that they would in clinical practice. This is particularly true of technical skills training using part-task trainers. Current designs of central-venous cannulation simulators may not fully meet this need. Not all training models allow for the guidewire in the Seldinger technique to be over-inserted. This means guidewire loss cannot be demonstrated in many simulators, which undermines recognition of this important complication, one of the preventable and significant hazards of the procedure [1]. Our simulation centre uses Blue Phantom’s Gen II Central Line Ultrasound Training Model. This simulator replicates the upper torso and neck, with a right internal jugular vein and carotid artery that can be cannulated. The simulated vessels terminate in clear tubes that run outside of the manikin’s torso and contain a reservoir of fluid. Full insertion of the line is blocked due to the diameter of the reservoir tubing being too small to accommodate the J-tip of the guidewire.

In order to permit over-insertion of the guidewire, the tubing connected to the internal jugular vein has to be replaced with one of a larger diameter, sufficient to allow passage of the guidewire’s J-tip. We developed a 3D printed adaptor which allows smooth passage of the wire into the larger-diameter tubing. The connection between the tube and adaptor is then made water-tight with silicone sealant. The modifications were designed using SolidWorks, Dassault Systèmes, and printed using VeroWhitePlus™ on a Object500 Connex1™ by Stratasys. Since the reservoir tubing can now accommodate guidewire retention, a further modification was required to allow for retrieval of the wire at the end of the simulation. We have achieved this by including access to the tubing secured by a screw cap.

With the modifications made (

Modified central line insertion model with over-inserted guidewire.

The trainee cannot now rely on the manikin preventing them from making this potentially serious mistake, so training now more accurately replicates the real-life experience. This allows for a richer training experience and a more valuable post-simulation learning conversation.

1- Cheung ME, Mellert LT, Firstenberg MS. Bedside Procedure: Retained Central Venous Catheter. In: Firstenberg MS & Stawicki SP, editors. Vignettes in Patient Safety – Volume 2. London: IntechOpen; 2017.

Influence of respiratory protective equipment on simulated advanced airway skills by specialist tracheal intubation teams during the COVID-19 pandemic

Background

The COVID-19 pandemic has highlighted the importance of respiratory protective equipment for clinicians performing airway management.

Aim

To evaluate the impact of powered air-purifying respirators, full-face air-purifying respirators and filtering facepieces on specially trained anaesthesiologists performing difficult airway procedures.

Methods

All our COVID-19 intubation team members carried out various difficult intubation drills: unprotected, wearing a full-face respirator, a filtering facepiece or a powered respirator. Airway management times and wearer comfort were evaluated and analysed.

Results

Total mean (SD) intubation times did not show significant differences between the control, the powered, the full-face respirator and the filtering facepiece groups: Airtraq 6.1 (4.4) vs. 5.4 (3.1) vs. 6.1 (5.6) vs. 7.7 (7.6) s; videolaryngoscopy 11.4 (9.0) vs. 7.7 (4.3) vs. 9.8 (8.4) vs. 12.7 (9.8) s; fibreoptic intubation 16.6 (7.8) vs.13.8 (6.7) vs. 13.6 (8.1) vs. 16.9 (9.2) s; and standard endotracheal intubation by direct laryngoscopy 8.1 (3.5) vs. 6.5 (5.6) vs. 6.2 (4.2) vs. 8.0 (4.4) s, respectively. Use of the Airtraq achieved the shortest intubation times. Anaesthesiologists rated temperature and vision significantly better in the powered respirator group.

Conclusions

Advanced airway management remains unaffected by the respiratory protective equipment used if performed by a specially trained, designated team. We conclude that when advanced airway skills are performed by a designated, specially trained team, airway management times remain unaffected by the respiratory protective equipment used.

Validating peer-led assessments of CPR performance

BACKGROUND

A patient's survival from cardiac arrest is improved if they receive good quality chest compressions as soon as possible. During cardiopulmonary resuscitation (CPR) training subjective assessments of chest compression quality is still common. Recently manikins allowing objective assessment have demonstrated a degree of variance with Instructor assessment. The aim of this study was to compare peer-led subjective assessment of chest compressions in three groups of participants with objective data from a manikin.

METHOD

This was a quantitative multi-center study using data from simulated CPR scenarios. Seventy-eight Instructors were recruited, from different backgrounds; lay persons, hospital staff and emergency services personnel. Each group consisted of 13 pairs and all performed 2 ​min of chest compressions contemporaneously by peers and manikin (Brayden PRO®). The primary hypothesis was subjective and objective assessment methods would produce different test outcomes.

RESULTS

13,227 chest compressions were assessed. The overall median score given by the manikin was 88.5% (interquartile range 71.75-95), versus 92% (interquartile range 86.75-98) by observers. There was poor correlation in scores between assessment methods (Kappa -0.051 - +0.07). Individual assessment of components within the manikin scores demonstrated good internal consistency (alpha ​= ​0.789) compared to observer scores (alpha ​= ​0.011).

CONCLUSION

Observers from all backgrounds were consistently more generous in their assessment when compared to the manikin. Chest compressions quality influences outcome following cardiac arrest, the findings of this study support increased use of objective assessment at the earliest opportunity, irrespective of background.

Effects of a single interprofessional simulation session on medical and nursing students' attitudes toward interprofessional learning and professional identity: a questionnaire study

BACKGROUND

Participation in simulation-based interprofessional education (sim-IPE) may affect students' attitudes towards interprofessional learning (through gaining experience with others) and their professional identity (by increasing the 'fit' of group membership). We examined this in two questionnaire studies involving students from four universities in two areas of the UK.

METHOD

Questionnaire data were collected before and after students took part in a sim-IPE session consisting of three acute scenarios. Questionnaires included the Readiness for Interprofessional Learning Scale (RIPLS) and measures of professional identity derived from the social identity theory literature. In Study 1, only identification with Professional Group (doctor or nurse) was measured, while in Study 2 identification with Student Group (medical or nursing student) and the immediate interprofessional Team worked with in the simulation were also measured. Linear mixed effects regression analysis examined the effect of the simulation session, and differences between medical and nursing students, sites and identity measures.

RESULTS

A total of 194 medical and 266 nursing students completed questionnaires. A five-item subset of RIPLS (RIPLSCore) was used in analysis. In both studies RIPLSCore increased for all groups following participation in sim-IPE, although this was larger for nursing students in Study 1. Nursing students had consistently higher RIPLSCore scores than medical students at one site. Effects of the session on identity varied between sites, and dimensions of identity. Notably, while positive emotions associated with group membership (Ingroup Affect) increased for Student Group, Professional Group and Team, the sense of belonging (Ingroup Ties) and importance (Centrality) of the group increased only for Team. Nursing students had consistently higher identification scores than medical students.

CONCLUSIONS

Participation in a sim-IPE session can improve attitudes towards interprofessional learning. It can also enhance professional identity, particularly as related to emotional aspects of group membership, with possible benefits for wellbeing. Changes in identification with the immediate Team suggest positive psychological consequences of ad hoc Team formation in the workplace. Differences between medical and nursing students suggest their differing opportunities to work with other professions during training may change baseline attitudes and identity. However, a single sim-IPE session can still have an additive effect.

Donor outcomes in anonymous live liver donation

BACKGROUND & AIMS

Death rates on liver transplant waiting lists range from 5%-25%. Herein, we report a unique experience with 50 anonymous individuals who volunteered to address this gap by offering to donate part of their liver to a recipient with whom they had no biological connection or prior relationship, so called anonymous live liver donation (A-LLD).

METHODS

Candidates were screened to confirm excellent physical, mental, social, and financial health. Demographics and surgical outcomes were analyzed. Qualitative interviews after donation examined motivation and experiences. Validated self-reported questionnaires assessed personality traits and psychological impact.

RESULTS

A total of 50 A-LLD liver transplants were performed between 2005 and 2017. Most donors had a university education, a middle-class income, and a history of prior altruism. Half were women. Median age was 38.5 years (range 20-59). Thirty-three (70%) learned about this opportunity through public or social media. Saving a life, helping others, generativity, and reciprocity for past generosity were motivators. Social, financial, healthcare, and legal support in Canada were identified as facilitators. A-LLD identified most with the personality traits of agreeableness and conscientiousness. The median hospital stay was 6 days. One donor experienced a Dindo-Clavien Grade 3 complication that completely resolved. One-year recipient survival was 91% in 22 adults and 97% in 28 children. No A-LLD reported regretting their decision.

CONCLUSIONS

This is the first and only report of the characteristics, motivations and facilitators of A-LLD in a large cohort. With rigorous protocols, outcomes are excellent. A-LLD has significant potential to reduce the gap between transplant organ demand and availability.

LAY SUMMARY

We report a unique experience with 50 living donors who volunteered to donate to a recipient with whom they had no biological connection or prior relationship (anonymous living donors). This report is the first to discuss motivations, strategies and facilitators that may mitigate physical, social and ethical risk factors in this patient population. With rigorous protocols, anonymous liver donation and recipient outcomes are excellent; with appropriate clinical expertise and system facilitators in place, our experience suggests that other centers may consider the procedure for its significant potential to reduce the gap between transplant organ demand and availability.

Predictors of Post-operative Pain and Opioid Consumption in Patients Undergoing Liver Surgery

BACKGROUND

Post-operative pain management is a critical component of perioperative care. Patients at risk of poorly controlled post-operative pain may benefit from early measures to optimize pain management. We sought to identify risk factors for post-operative pain and opioid consumption in patients undergoing liver resection.

METHODS

This is a multi-institutional prospective nested cohort study of patients undergoing open liver resection. Opioid consumption and pain scores were collected following surgery. To estimate the effects of patient factors on opioid consumption (oral morphine equivalents-OME) and on pain scores (NRS-11), we used generalized linear models and multivariable linear regression model, respectively.

RESULTS

One hundred and fifty-three patients who underwent open liver resection between 2013 and 2016 were included in the study. The mean patient age was 62.2 years, and 43.3% were female. Younger patients were significantly more likely to use more opioids in the early post-operative period (16.7 OME/10 years, p < 0.001). Patient factors that were significantly associated with increased NRS-11 pain scores also included younger patient age (difference in pain score of 0.3/10 years with cough and 0.2/10 years at rest, p < 0.01 for both) as well as a history of analgesic use (difference in pain score of 0.9 with cough and 0.6 at rest, p < 0.01 and p = 0.07, respectively).

CONCLUSION

Younger patients and those with a history of analgesic use are more likely to report higher post-operative pain and require higher doses of opioids. Early identification of these patients, and measures to better manage their pain, may contribute to optimal perioperative care.

Burnout Syndrome in UK Intensive Care Unit staff: Data from all three Burnout Syndrome domains and across professional groups, genders and ages

Introduction

This is the first comprehensive evaluation of Burnout Syndrome across the UK Intensive Care Unit workforce and in all three Burnout Syndrome domains: Emotional Exhaustion, Depersonalisation and lack of Personal Accomplishment.

Methods

A questionnaire was emailed to UK Intensive Care Society members, incorporating the 22-item Maslach Burnout Inventory Human Services Survey for medical personnel. Burnout Syndrome domain scores were stratified by 'risk'. Associations with gender, profession and age-group were explored.

Results

In total, 996 multi-disciplinary responses were analysed. For Emotional Exhaustion, females scored higher and nurses scored higher than doctors. For Depersonalisation, males and younger respondents scored higher.

Conclusion

Approximately one-third of Intensive Care Unit team-members are at 'high-risk' for Burnout Syndrome, though there are important differences according to domain, gender, age-group and profession. This data may encourage a more nuanced understanding of Burnout Syndrome and more personalised strategies for our heterogeneous workforce.

Neoadjuvant therapy and major arterial resection for potentially reconstructable arterial involvement by stage 3 adenocarcinoma of the pancreas

BACKGROUND

Stage 3 pancreatic ductal adenocarcinoma (PDAC) is defined by arterial involvement. This study objective was to evaluate outcomes for patients with stage 3 PDAC with potentially reconstructable arterial involvement, considered for neoadjuvant therapy (NAT) and pancreatic resection, and to compare outcomes following arterial (AR) and non-arterial resection (NAR).

METHODS

This study included patients from 2009 to 2016 with biopsy-proven stage 3 PDAC who were offered NAT before surgical exploration. AR was performed if required to achieve R0 resection. Time to event outcomes were analysed from diagnosis date.

RESULTS

87/89 patients (97.8%) received NAT (chemotherapy 41.6%, chemotherapy/radiotherapy 56.2%). 46/89 (51.7%) underwent exploration; 31 underwent resection (AR n = 20, NAR n = 11). AR patients had longer operative time (681 vs. 563 min, p = 0.006) and more blood loss (1600 vs. 575 mL, p = 0.0004), with no difference for blood transfusion, pancreatic fistula, length of stay, reoperation, or mortality. R0 rate was 30/31. Post-resection 90-day mortality was 3.2%. Median overall survival was statistically comparable between the AR and NAR groups (19.7 vs. 28.4 months, p = 0.41).

CONCLUSIONS

AR had comparable clinical and oncologic outcomes to NAR. Following careful selection and non-progression after NAT, major AR may cautiously be considered if required to obtain a negative resection margin.

Predictors of De Novo Nonalcoholic Fatty Liver Disease After Liver Transplantation and Associated Fibrosis

Nonalcoholic fatty liver disease (NAFLD) can occur de novo in patients undergoing liver transplantation (LT) for indications other than NAFLD, and it has been increasingly recognized as a complication in the post-LT setting. This study aims to better characterize de novo NAFLD after LT by identifying risk factors for its development, describing incidence and extent of fibrosis, assessing the diagnostic utility of noninvasive serum fibrosis algorithms, and comparing survival to those without NAFLD. This was a retrospective single-center analysis of de novo NAFLD in a post-LT cohort. Those whose primary indication for LT was nonalcoholic steatohepatitis (NASH) were excluded. Risk factors were analyzed by univariate and multivariate analyses. De novo NAFLD and fibrosis were assessed on posttransplant liver biopsies, and noninvasive fibrosis scores were calculated from concomitant blood tests. After applying the exclusion criteria, 430 for-cause post-LT biopsies were evaluated; 33.3% (n = 143) had evidence of de novo steatosis and/or NASH at a median of 3.0 years after transplant. On multivariate analysis, body mass index (BMI; odds ratio [OR], 1.12; P < 0.001), diabetes mellitus (OR, 3.01; P = 0.002), hepatitis C virus (OR, 4.61; P < 0.001), weight gain (OR, 1.03; P = 0.007), and sirolimus use (OR, 3.11; P = 0.02) were predictive of de novo NAFLD after LT. Significant fibrosis (≥F2) was present in almost 40% of the cohort. Noninvasive serum fibrosis scores were not useful diagnostic tests. There was no significant difference in the short-term or longterm survival of patients who developed de novo NAFLD. In conclusion, diabetes, BMI, weight gain after LT, and sirolimus-based immunosuppression, in keeping with insulin resistance, were the only modifiable factors associated with development of de novo NAFLD. A significant proportion of patients with de novo NAFLD had fibrosis and given the limited utility of noninvasive serum fibrosis algorithms, alternative noninvasive tools are required to screen for fibrosis in this population. There was no significant difference in the short-term or longterm survival of patients who developed de novo NAFLD.

In-hospital opioid consumption, but not pain intensity scores, predicts 6-month levels of pain catastrophizing following hepatic resection: A trajectory analysis

BACKGROUND

The study aims were to model acute pain intensity and opioid consumption trajectories up to 72 hr after open hepatic resection, identify predictors of trajectory membership and examine the association between trajectory memberships and 6-month pain and psychological outcomes. This is a long-term analysis of a published randomized controlled trial on the impact of medial open transversus abdominis plane catheters on post-operative outcomes.

METHODS

A total of 152 patients (89 males; mean age 63.0 [range: 54-72]) completed questionnaires on pain and related characteristics pre-operatively and 6 months post-operatively. Total opioid use was recorded several times over a 72-hr period while self-reported pain intensity scores were collected multiple times until hospital discharge. Analyses were carried out using growth mixture modelling, logistic regression and general linear models.

RESULTS

Both pain intensity and opioid consumption showed that a four-trajectory model best fits the data. Patients in the lowest opioid consumption trajectory were more likely to be classified in the constant mild pain intensity trajectory. Age and baseline levels of anxiety significantly predicted opioid trajectory membership while baseline depressive symptoms significantly predicted pain intensity trajectory membership. Patients in the two highest opioid consumption trajectories reported significantly higher levels of pain catastrophizing at 6 months compared to patients in the other 3 trajectories (all p < 0.05).

CONCLUSION

High consumption of opioids after surgery is associated with higher levels of pain catastrophizing 6 months later. Identification of patients within these trajectories may lead to the development of early interventions targeted to high risk individuals.

SIGNIFICANCE

Differences in initial levels of opioid consumption and rates of change in opioid consumption shortly after surgery can help predict long-term psychological responses to pain. Identifying key characteristics associated with initial opioid consumption can lead to the development of cost-effective early interventions targeted to high risk individuals.

Single cell RNA sequencing of human liver reveals distinct intrahepatic macrophage populations

The liver is the largest solid organ in the body and is critical for metabolic and immune functions. However, little is known about the cells that make up the human liver and its immune microenvironment. Here we report a map of the cellular landscape of the human liver using single-cell RNA sequencing. We provide the transcriptional profiles of 8444 parenchymal and non-parenchymal cells obtained from the fractionation of fresh hepatic tissue from five human livers. Using gene expression patterns, flow cytometry, and immunohistochemical examinations, we identify 20 discrete cell populations of hepatocytes, endothelial cells, cholangiocytes, hepatic stellate cells, B cells, conventional and non-conventional T cells, NK-like cells, and distinct intrahepatic monocyte/macrophage populations. Together, our study presents a comprehensive view of the human liver at single-cell resolution that outlines the characteristics of resident cells in the liver, and in particular provides a map of the human hepatic immune microenvironment.

The development of single cell RNA sequencing technologies has been instrumental in advancing our understanding of tissue biology. Here, MacParland et al. performed single cell RNA sequencing of human liver samples, and identify distinct populations of intrahepatic macrophages that may play specific roles in liver disease.

Splenectomy as Flow Modulation Strategy and Risk Factors of De Novo Portal Vein Thrombosis in Adult-to-Adult Living Donor Liver Transplantation

Portal vein thrombosis (PVT) is a severe complication after liver transplantation that can result in increased morbidity and mortality. Few data are available regarding risk factors, classification, and treatment of PVT after living donor liver transplantation (LDLT). Between January 2004 and November 2014, 421 adult-to-adult LDLTs were performed at our institution, and they were included in the analysis. Perioperative characteristics and outcomes from patients with no-PVT (n = 393) were compared with those with de novo PVT (total portal vein thrombosis [t-PVT]; n = 28). Ten patients had early portal vein thrombosis (e-PVT) occurring within 1 month, and 18 patients had late portal vein thrombosis (l-PVT) appearing later than 1 month after LDLT. Analysis of perioperative variables determined that splenectomy was associated with t-PVT (hazard ratio [HR], 3.55; P = 0.01), e-PVT (HR, 4.96; P = 0.04), and l-PVT (HR, 3.84; P = 0.03). In contrast, donor age was only found as a risk factor for l-PVT (HR, 1.05; P = 0.01). Salvage rate for treatment in e-PVT and l-PVT was 100% and 50%, respectively, without having an early event of rethrombosis. Mortality within 30 days did not show a significant difference between groups (no-PVT, 2% versus e-PVT, 10%; P = 0.15). No significant differences were found regarding 1-year (89% versus 92%), 5-year (79% versus 82%), and 10-year (69% versus 79%) graft survival between the t-PVT and no-PVT groups, respectively (P = 0.24). The 1-year (89% versus 96%), 5-year (82% versus 86%), and 10-year (79% versus 83%) patient survival was similar for the patients in the no-PVT and t-PVT groups, respectively (P = 0.70). No cases of graft loss occurred as a direct consequence of PVT. In conclusion, the early diagnosis and management of PVT after LDLT can lead to acceptable early and longterm results without affecting patient and graft survival.

Surgical Complications after Right Hepatectomy for Live Liver Donation: Largest Single-Center Western World Experience

The authors assessed the incidence, management, and risk factors for postoperative complications after right lobe (RL) live donor hepatectomy in a high-volume center in North America. All donors undergoing an RL live donor hepatectomy between 2000 and 2017 at our institution were included. The primary outcome was the development of complications (both medical and surgical). Predictors of postoperative complications were determined by logistic regression. A total of 587 patients underwent RL live donor hepatectomy. Among those, 187 postoperative complications were diagnosed in 141 (24%) patients. One patient had >90-day morbidity, and there were no donor deaths. Overall complications were significantly higher in the first era, 2000 to 2008 (81 [57.4%]) versus the second era, 2009 to 2017 (60 [42.6%]) (p = 0.01). On multivariate analysis, the only predictor of postoperative complications was the center volume of RL live donor hepatectomy in the previous 12 months with an odds ratio of 0.97 (95% confidence interval: 0.95-0.99). In conclusion, increasing center volume is associated with lower rates of postoperative complications after RL living liver donation.

Depicting surgical anatomy of the porta hepatis in living donor liver transplantation

Visualizing the complex anatomy of vascular and biliary structures of the liver on a case-by-case basis has been challenging. A living donor liver transplant (LDLT) right hepatectomy case, with focus on the porta hepatis, was used to demonstrate an innovative method to visualize anatomy with the purpose of refining preoperative planning and teaching of complex surgical procedures. The production of an animation-enhanced video consisted of many stages including the integration of pre-surgical planning; case-specific footage and 3D models of the liver and associated vasculature, reconstructed from contrast-enhanced CTs. Reconstructions of the biliary system were modeled from intraoperative cholangiograms. The distribution of the donor portal veins, hepatic arteries and bile ducts was defined from the porta hepatis intrahepatically to the point of surgical division. Each step of the surgery was enhanced with 3D animation to provide sequential and seamless visualization from pre-surgical planning to outcome. Use of visualization techniques such as transparency and overlays allows viewers not only to see the operative field, but also the origin and course of segmental branches and their spatial relationships. This novel educational approach enables integrating case-based operative footage with advanced editing techniques for visualizing not only the surgical procedure, but also complex anatomy such as vascular and biliary structures. The surgical team has found this approach to be beneficial for preoperative planning and clinical teaching, especially for complex cases. Each animation-enhanced video case is posted to the open-access Toronto Video Atlas of Surgery (TVASurg), an education resource with a global clinical and patient user base. The novel educational system described in this paper enables integrating operative footage with 3D animation and cinematic editing techniques for seamless sequential organization from pre-surgical planning to outcome.

Euglycaemic ketoacidosis in a postoperative Whipple patient using canaglifozin

SGLT2 inhibitors are a new class of oral antihyperglycaemic agents that have garnered much attention for their attractive efficacy profile in glycaemic control along with the added benefit of weight loss. There has been increasing concern for the risk of euglycaemic (serum glucose 4-8 mmol/L) ketoacidosis with these agents. In the setting of a postoperative patient, the use of these drugs may exacerbate the normal physiological stresses of the body and increase the risk of developing euglycaemic ketoacidosis (euKDA). This case highlights a postoperative patient who was using an SGLT2 inhibitor and developed severe euKDA after a pancreaticoduodenectomy. The goal of this case report was to bring awareness to the possibility of this rare adverse event. In doing so, it may aid in preoperative planning of the diabetic patient and trigger appropriate management for those who develop euKDA.

Recipient factors associated with having a potential living donor for liver transplantation

Because of a persistent discrepancy between the demand for liver transplantation (LT) and the supply of deceased donor organs, there is an interest in increasing living donation rates at centers trained in this method of transplantation. We examined a large socioeconomically heterogeneous cohort of patients listed for LT to identify recipient factors associated with living donation. We retrospectively reviewed 491 consecutive patients who were listed for LT at our center over a 24-month period. Demographic, medical, and socioeconomic data were extracted from electronic records and compared between those who had a potential living donor (LD) volunteer for assessment and those who did not; 245 patients (50%) had at least 1 potential LD volunteer for assessment. Multivariate logistic regression analysis identified that patients with a LD were more likely to have Child-Pugh C disease (odds ratio [OR], 2.44; P = 0.02), and less likely to be older (OR, 0.96; P = 0.002), single (OR, 0.34; P = 0.006), divorced (OR, 0.53; P = 0.03), immigrants (OR, 0.38; P = 0.049), or from the lowest income quintile (OR, 0.44; P = 0.02). In conclusion, this analysis has identified several factors associated with access to living donation. More research is warranted to define and overcome barriers to living donor liver transplantation through targeted interventions in underrepresented populations.

Liver transplantation in patients with end-stage liver disease requiring intensive care unit admission and intubation

Data regarding transplantation outcomes in ventilated intensive care unit (ICU)-dependent patients with end-stage liver disease (ESLD) are conflicting. This single-center cohort study investigated the outcomes of patients with ESLD who were intubated with mechanical support before liver transplantation (LT). The ICU plus intubation group consisted of 42 patients with decompensated cirrhosis and mechanical ventilation before transplantation. LT was considered for intubated ICU patients if the fraction of inspired oxygen was ≤40% with a positive end-expiratory pressure ≤ 10, low pressor requirements, and the absence of an active infection. Intubated ICU patients were compared to 80 patients requiring ICU admission before transplantation without intubation and to 126 matched non-ICU-bound patients. Patients requiring ICU care with intubation and ICU care alone had more severe postoperative complications than non-ICU-bound patients. Intubation before transplantation was associated with more postoperative pneumonias (15% in intubated ICU transplant candidates, 5% in ICU-bound but not intubated patients, and 3% in control group patients; P = 0.02). Parameters of reperfusion injury and renal function on postoperative day (POD) 2 and POD 7 were similar in all groups. Bilirubin levels were higher in the ICU plus intubation group at POD 2 and POD 7 after transplantation but were normalized in all groups within 3 months. The ICU plus intubation group versus the ICU-only group and the non-ICU group had decreased 1-, 3-, and 5-year graft survival (81% versus 84% versus 92%, 76% versus 78% versus 87%, and 71% versus 77% versus 84%, respectively; P = 0.19), but statistical significance was not reached. A Glasgow coma scale score of <7 versus >7 before transplantation was associated with high postoperative mortality in ICU-bound patients requiring intubation (38% versus 23%; P = 0.01). In conclusion, ICU admission and mechanical ventilation should not be considered contraindications for LT. With careful patient selection, acceptable long-term outcomes can be achieved despite increased postoperative complications.

Thrombolytic protocol minimizes ischemic-type biliary complications in liver transplantation from donation after circulatory death donors

Liver transplantation (LT) with donation after circulatory death (DCD) donors has been associated with a high rate of ischemic-type biliary strictures (ITBSs) and inferior graft survival. To investigate the impact of an intraoperative tissue plasminogen activator (tPA) on outcomes following DCD LT, we conducted a retrospective analysis of DCD LT at the Toronto General Hospital (TGH) and the Ochsner Medical Center (OMC). Between 2009 and 2013, 85 DCD LTs were performed with an intraoperative tPA injection (n = 30 at TGH, n = 55 at OMC), and they were compared with 33 DCD LTs without a tPA. Donor and recipient characteristics were similar in the 2 groups. There was no significant difference in the intraoperative packed red blood cell transfusion requirement (3.2 ± 3.4 versus 3.1 ± 2.3 U, P = 0.74). Overall, biliary strictures occurred less commonly in the tPA-treated group (16.5% versus 33.3%, P = 0.07) with a much lower rate of diffuse intrahepatic strictures (3.5% versus 21.2%, P = 0.005). After 1 and 3 years, the tPA group versus the non-tPA group had superior patient survival (97.6% versus 87.0% and 92.7% versus 79.7%, P = 0.016) and graft survival (96.4% versus 69.7% and 90.2% versus 63.6%, P < 0.001). In conclusion, a tPA injection into the hepatic artery during DCD LT reduces ITBSs and improves graft and patient survival without increasing the risk for bleeding.

Routine induction therapy in living donor liver transplantation prevents rejection but may promote recurrence of hepatitis C

BACKGROUND

Routine induction therapy in living donor liver transplantation (LDLT) has not been well described.

METHODS

We reviewed outcomes of induction therapy with rabbit antithymocyte globulin (rATG) or basiliximab within 1 year of LDLT.

RESULTS

Between 2002 and 2007, 184 adults underwent LDLT and received induction therapy in addition to standard immunosuppression. Acute cellular rejection (ACR) developed in 17 of 130 patients (13.1%) who received rATG and 13 of 54 patients (24.1%) who received basiliximab (P = .066). The interval between transplantation and rejection as well as rejection severity was similar in patients who received rATG and those who received basiliximab. Hepatitis C (HCV) recurrence requiring initiation of antiviral therapy was more common in patients who received rATG compared with basiliximab (34.5% vs 8.7%; P = .021), and in those who received induction combined with tacrolimus as opposed to cyclosporine (38.5% vs 3.9%; P = .001). rATG and basiliximab were associated with excellent patient and graft survivals well as low rates of opportunistic infections and malignancies.

CONCLUSION

Induction with rATG or basiliximab was well tolerated and highly effective at preventing ACR within 1 year of LDLT, but may be associated with a higher risk of clinically significant HCV recurrence in some patients.

Post-hepatectomy haemorrhage: a definition and grading by the International Study Group of Liver Surgery (ISGLS)

BACKGROUND

A standardized definition of post-hepatectomy haemorrhage (PHH) has not yet been established.

METHODS

An international study group of hepatobiliary surgeons from high-volume centres was convened and a definition of PHH was developed together with a grading of severity considering the impact on patients' clinical management.

RESULTS

The definition of PHH varies strongly within the hepatic surgery literature. PHH is defined as a drop in haemoglobin level > 3 g/dl post-operatively compared with the post-operative baseline level and/or any post-operative transfusion of packed red blood cells (PRBC) for a falling haemoglobin and/or the need for radiological intervention (such as embolization) and/or re-laparotomy to stop bleeding. Evidence of intra-abdominal bleeding should be obtained by imaging or blood loss via the abdominal drains if present. Transfusion of up to two units of PRBC is considered as being Grade A PHH. Grade B PHH requires transfusion of more than two units of PRBC, whereas the need for invasive re-intervention such as embolization and/ or re-laparotomy defines Grade C PHH.

CONCLUSION

The proposed definition and grading of severity of PHH enables valid comparisons of results from different studies. It is easily applicable in clinical routine and should be applied in future trials to standardize reporting of complications.

Posthepatectomy liver failure: a definition and grading by the International Study Group of Liver Surgery (ISGLS)

BACKGROUND

Posthepatectomy liver failure is a feared complication after hepatic resection and a major cause of perioperative mortality. There is currently no standardized definition of posthepatectomy liver failure that allows valid comparison of results from different studies and institutions. The aim of the current article was to propose a definition and grading of severity of posthepatectomy liver failure.

METHODS

A literature search on posthepatectomy liver failure after hepatic resection was conducted. Based on the normal course of biochemical liver function tests after hepatic resection, a simple and easily applicable definition of posthepatectomy liver failure was developed by the International Study Group of Liver Surgery. Furthermore, a grading of severity is proposed based on the impact on patients' clinical management.

RESULTS

No uniform definition of posthepatectomy liver failure has been established in the literature addressing hepatic surgery. Considering the normal postoperative course of serum bilirubin concentration and International Normalized Ratio, we propose defining posthepatectomy liver failure as the impaired ability of the liver to maintain its synthetic, excretory, and detoxifying functions, which are characterized by an increased international normalized ratio and concomitant hyperbilirubinemia (according to the normal limits of the local laboratory) on or after postoperative day 5. The severity of posthepatectomy liver failure should be graded based on its impact on clinical management. Grade A posthepatectomy liver failure requires no change of the patient's clinical management. The clinical management of patients with grade B posthepatectomy liver failure deviates from the regular course but does not require invasive therapy. The need for invasive treatment defines grade C posthepatectomy liver failure.

CONCLUSION

The current definition of posthepatectomy liver failure is simple and easily applicable in clinical routine. This definition can be used in future studies to allow objective and accurate comparisons of operative interventions in the field of hepatic surgery.

Intraoperative 'no go' donor hepatectomies in living donor liver transplantation

Donor safety is the paramount concern of living donor liver transplantation (LDLT). Although LDLT is employed worldwide, there is little data on rates and causes of 'no go' hepatectomies-patients brought to the operating room for possible donor hepatectomy whose procedure was aborted. We performed a single-center, retrospective review of all patients brought to the operating room for donor hepatectomy between October 2000 and November 2008. Of 257 right lobe donors, the donor operation was aborted in 12 cases (4.7%). The main reasons for stopping the operation were aberrant ductal or vascular anatomy (seven cases), unsuitable liver quality (three cases) or unexpected intraoperative events (two cases). Over the median period of follow-up of 23 months, there were no long-term complications of patients with aborted donor procedures. This report focuses exclusively on an important issue: the frequency and causes of no go decisions at a single large volume North American LDLT center. The rate of no go donor hepatectomies should be as low as possible without compromising donor safety--however, even with rigorous preoperative evaluation the rate of donor abortions will be significant. The default surgical position should always be to abort the donor operation if there is an unexpected finding that places the donor at increased risk.

Percutaneous Ethanol Injection of Unresectable Medium-to-Large-Sized Hepatomas Using a Multipronged Needle: Efficacy and Safety

Fine needles with an end hole or multiple side holes have traditionally been used for percutaneous ethanol injection (PEI) of hepatomas. This study retrospectively evaluates the safety and efficacy of PEI of unresectable medium-to-large (3.5-9 cm) hepatomas using a multipronged needle and with conscious sedation. Twelve patients, eight men and four women (age 51-77 years; mean: 69) received PEI for hepatomas, mostly subcapsular or exophytic in location with average tumor size of 5.6 cm (range: 3.5-9.0 cm). Patients were consciously sedated and an 18G retractable multipronged needle (Quadrafuse needle; Rex Medical, Philadelphia, PA) was used for injection under real-time ultrasound guidance. By varying the length of the prongs and rotating the needle, the alcohol was widely distributed within the tumor. The progress of ablation was monitored by contrast-enhanced ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI) after each weekly injection and within a month after the final (third) injection and 3 months thereafter. An average total of 63 mL (range: 20-154 ml) of alcohol was injected per patient in an average of 2.3 sessions. Contrast-enhanced CT, ultrasound, or MRI was used to determine the degree of necrosis. Complete necrosis was noted in eight patients (67%), near-complete necrosis (90-99%) in two (16.7%), and partial success (50-89%) in two (16.7%). Follow-up in the first 9 months showed local recurrence in two patients and new lesions in another. There was no mortality. One patient developed renal failure, liver failure, and localized perforation of the stomach. He responded to medical treatment and surgery was not required for the perforation. One patient had severe postprocedural abdominal pain and fever, and another had transient hyperbilirubinemia; both recovered with conservative treatment. PEI with a multipronged needle is a new, safe, and efficacious method in treating medium-to-large-sized hepatocellular carcinoma under conscious sedation. Its survival benefits require further investigations.

Natural History and Chemotherapy Effectiveness for Advanced Adenocarcinoma of the Small Bowel: A Retrospective Review of 113 Cases

BACKGROUND

Small bowel adenocarcinoma is a rare cancer that has generally been considered resistant to chemotherapy, although little has been published on the role of chemotherapy. A retrospective analysis was conducted of patients with advanced small bowel adenocarcinoma to explore chemotherapy use, and gain knowledge for ongoing management and future clinical trials.

PATIENTS AND METHODS

All patients with advanced adenocarcinoma of the small bowel treated at Princess Margaret Hospital (PMH) between 1986 and 2004 were identified through the cancer registry. The medical records were reviewed for patient characteristics, treatment and outcome data. Survival statistics were estimated using the Kaplan Meier survival curves and Cox proportional regression model.

RESULTS

Data on 113 patients was reviewed. Forty-four patients received palliative chemotherapy with an overall response rate (ORR) of 36% during a first or second line regimen (9% complete responses and 27% partial responses). Newer chemotherapy regimens including gemcitabine and irinotecan combinations appeared to have higher ORR, than older fluorouracil-based regimens. Some patients responded to more than one line of chemotherapy. Palliative chemotherapy predicted for overall survival (OS) in a multivariate analysis (HR 0.47, P = 0.035).

CONCLUSION

Chemotherapy appears to have activity in adenocarcinoma of the small bowel. Prospective trials evaluating patient benefit are required to confirm this activity using newer systemic therapies, until such time retrospective reviews such as this will continue to guide treatment decisions.

An aggressive surgical approach leads to improved survival in patients with gallbladder cancer: a 12-year study at a North American Center

OBJECTIVE

To determine if an aggressive surgical approach, with an increase in R0 resections, has resulted in improved survival for patients with gallbladder cancer.

SUMMARY BACKGROUND DATA

Many physicians express a relatively nihilistic approach to the treatment of gallbladder cancer; consensus among surgeons regarding the indications for a radical surgical approach has not been reached.

METHODS

A retrospective review of all patients with gallbladder cancer admitted during the past 12 years was conducted. Ninety-nine patients were identified. Cases treated during the 12-year period 1990 to 2002 were divided into 2 time-period (TP) cohorts, those treated in the first 6 years (TP1, N = 35) and those treated in the last 6 years (TP2, N = 64).

RESULTS

Disease stratification by stage and other demographic features were similar in the 2 time periods. An operation with curative intent was performed on 38 patients. Nine (26%) R0 resections were performed in TP1 and 24 (38%) in TP2. The number of liver resections, as well as the frequency of extrahepatic biliary resections, was greater in TP2 (P < 0.04). In both time periods, an R0 resection was associated with improved survival (P < 0.02 TP1, P < 0.0001 TP2). Overall survival of all patients in TP2 was significantly greater than in TP1 (P < 0.03), with a median survival of 9 months in TP1 and 17 months in TP2. The median 5-year survival in TP1 was 7%, and 35% in TP2. The surgical mortality rate for the entire cohort was 2%, with a 49% morbidity rate.

CONCLUSIONS

A margin-negative, R0 resection leads to improved survival in patients with gallbladder cancer.

[Attachment and detachment]

Drawn as a conclusion to the colloquium of Bordeaux (June 2003), on mother-child attachment, these reflections open up to new venues. Indeed, the author makes the assumption that attachment and detachment make up a fundamental couple with attachment and detachment, which leads to getting one's autonomy, discovering the world and expressing one's pulsions. The very tension inside this antagonistic and fundamental couple--between attachment and pulsions--would be the origin of all forms of language.

Prognostic factors in resected pancreatic adenocarcinoma: analysis of actual 5-year survivors

BACKGROUND

Pancreatic cancer is a rapidly fatal disease with very few 5-year survivors even after aggressive surgical treatment. Our objective was to determine the actual 5-year survival rate of patients with pancreatic adenocarcinoma who underwent a resection with curative intent in 5 teaching hospitals within the University of Toronto system. We then sought to determine clinical and histopathologic features of 5-year survivors to determine factors associated with a favorable prognosis.

STUDY DESIGN

A retrospective chart review was performed using surgeon and hospital databases to identify patients who had a surgical resection for pancreatic adenocarcinoma between January 1, 1988, and December 31, 1996.

RESULTS

One hundred twenty-three patients who had a resection and a pathologic diagnosis of pancreatic adenocarcinoma with complete followup were identified from seven surgical practices. Mean survival (+/- standard error) in this series was 31.7 +/- 3.5 months (median 13.6 months). There were 18 5-year survivors (14.6%), including 5 patients (4.1%) who survived longer than 10 years. The survivors included 13 patients who had undergone a Whipple resection, 4 who had undergone a distal pancreatectomy, and 1 who had undergone a total pancreatectomy. Tumor size, lack of jaundice at presentation, negative nodal disease, low tumor grade, and a low tumor stage were all significant predictors of survival in univariate analysis (all p < 0.05). Only tumor stage (hazard ratio [95% confidence interval]: stage IIA 1.5 [0.8 to 2.8], stage IIB 2.6 [1.4 to 4.7], stage III 1.8 [0.8 to 4.3]) and tumor grade (hazard ratio [95% confidence interval]: moderately differentiated 1.6 [0.9 to 2.9], and poorly differentiated 3.1 [1.6 to 6.2]) were independently associated with survival differences in a multivariate Cox proportional hazards model.

CONCLUSIONS

We conclude that longterm survival from pancreatic adenocarcinoma is possible if the disease is identified in its early stages. These and other similar data should provide further stimulus for the development and evaluation of novel screening strategies to improve early detection of this disease.

Early steroid withdrawal after liver transplantation: the Canadian tacrolimus versus microemulsion cyclosporin A trial: 1-year follow-up

Corticosteroid therapy contributes significant toxicity to liver transplantation. The safety and efficacy of early steroid withdrawal were determined in patients treated with either tacrolimus or microemulsion cyclosporin A (micro-CsA). The primary outcome was the proportion of patients who were steroid-free 1 year posttransplantation. From the seven Canadian adult liver transplant centers, 143 patients were randomly allocated oral treatment with either tacrolimus (n = 71) or micro-CsA (n = 72), together with corticosteroids and azathioprine. Eligibility criteria for steroid withdrawal included freedom from acute rejection for a minimum of 3 months, and prednisone </=0.15 mg/kg/d. In eligible patients, the daily steroid dose was reduced by 2.5 mg each month until complete discontinuation was achieved. At 1 year after transplantation, 75% of the tacrolimus patients and 63% of the micro-CsA patients were steroid-free (P =.20). Of all of the patients who became eligible for steroid withdrawal, steroid discontinuation was achieved in over 80%. One-year patient survival was 97% with tacrolimus and 89% with micro-CsA (P =.052). Graft survival was 97% and 86%, respectively (P =.017). The overall incidence of acute rejection during the first year was 35% with tacrolimus and 43% with micro-CsA (P =.26). There was no difference in survival, acute rejection, or rate of steroid withdrawal when adjusting for hepatitis C. All acute rejection episodes experienced during steroid withdrawal were steroid-responsive. Steroid-resistant rejection occurred in 5.6% of the tacrolimus and 9.7% of the micro-CsA patients. One patient, in the micro-CsA group, experienced refractory rejection. Chronic rejection was not observed in either group. The toxicity profiles were similar. Postoperative serum creatinine levels were similar, and dialysis was required in less than 10% of patients in each group. Infectious complications were similar in both groups. Neurotoxicity was a serious adverse event in 13% and 10% of patients receiving tacrolimus and micro-CsA, respectively. Early steroid withdrawal is safe and effective after liver transplantation using either tacrolimus plus azathioprine or micro-CsA plus azathioprine immunoprophylaxis.

Radiofrequency ablation of malignant hepatic neoplasms

OBJECTIVE

To assess the safety and efficacy of radiofrequency ablation (RFA) in the treatment of malignant neoplasms of the liver.

METHODS

Sixty-seven patients received RFA for primary or secondary hepatic malignancies. Patients were followed prospectively with computed tomography (CT) scanning to assess for therapeutic response, disease progression and complications.

RESULTS

Eighty-eight lesions were treated, including 57 hepatocellular carcinomas, 28 metastases, 2 cholangiocarcinomas and 1 hepatic plasmacytoma. Mean tumour size was 2.7 cm (range 0.5-6.9 cm). A total of 101 ablations were performed (66 percutaneously, 35 intraoperatively). Over a mean follow-up period of 142 days, results were available for 85 lesions. Local tumour control was achieved for 61 (72%) lesions, but new distant lesions developed in 6 of these cases. Residual disease was present in 20 (23%) lesions, and 4 (5%) lesions developed local recurrence. There were 10 complications, including 1 death in a patient who developed a liver abscess and subsequently died from hepatic failure.

CONCLUSIONS

RFA is safe and effective in the treatment of hepatic malignancies. Local tumour control can be achieved in most cases; however, careful surveillance is important for detecting recurrent disease, as well as new lesions distant from the treated site.

Identification and characterization of teicoplanin-intermediate Staphylococcus aureus blood culture isolates in NE Scotland

The study objective was to screen both methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive S. aureus (MSSA) isolates from blood cultures for reduced susceptibility to vancomycin and teicoplanin. A total of 72 MRSA and 143 MSSA isolates were screened on brain-heart infusion agar containing either 4 mg/L vancomycin or 8 mg/L teicoplanin, using an inoculum of approximately 10(6) organisms. MICs were determined by Etest, broth microdilution and agar incorporation. Isolates were characterized by PFGE, mecA and nuc PCR, transmission electron microscopy (TEM) and analysis of cell proteins (proteomics). Based on British Society for Antimicrobial Chemotherapy (BSAC) breakpoints, seven MRSAs and seven MSSAs were teicoplanin resistant, with MICs of up to 16 and 24 mg/L respectively, but were vancomycin sensitive. Based on higher NCCLS breakpoints, five MRSAs and six MSSAs were teicoplanin intermediate, vancomycin sensitive. All the MRSAs belonged to the EMRSA-16 clone and subdivided into two groups. The MSSAs belonged to five different clones. TEM showed the resistant variants to have slightly thicker cell walls than sensitive variants. Most notably, the resistant variants possessed characteristic dark, granular material concentrated in the middle of the cells, believed to be chromosome. Proteomics showed the resistant variants to overexpress phosphoglycerate kinase. Both MRSA and MSSA with reduced teicoplanin susceptibility may remain vancomycin sensitive by NCCLS and BSAC criteria and it is important to screen clinical isolates of MRSA and MSSA for reduced susceptibility to both agents.

Human herpesvirus-6 is associated with cytomegalovirus reactivation in liver transplant recipients

Human herpesvirus-6 (HHV-6) may be a risk factor for cytomegalovirus (CMV) disease in posttransplant patients, possibly through a direct interaction or through a general immunomodulatory effect. To examine this possibility, 88 liver transplant recipients were monitored with serial HHV-6 polymerase chain reaction (PCR), CMV antigenemia, and CMV plasma viral load. HHV-6 infection was defined by a positive PCR of peripheral blood lymphocytes. Forty-eight (54.4%) of 88 patients had at least 1 positive HHV-6 PCR. CMV recurrence was significantly more common in patients with HHV-6 infection (38/48 patients [79. 2%]), compared with recurrence in those without HHV-6 infection (18/40 patients [45%]; P=.001). Peak CMV viral load was 24, 147+/-6799 copies/mL in patients with HHV-6 infection versus 8391+/-4598 copies/mL in patients without HHV-6 infection (P=.001). Symptomatic CMV disease was more common in patients with HHV-6 infection than it was in those without infection (15/48 patients [31. 3%] vs. 4/10 patients [10.0%]; P=.013). In a multivariate analysis including other risk factors for CMV, HHV-6 infection remained an independent risk factor for CMV disease (P=.013; odds ratio, 7.26; 95% confidence interval, 1.52-34.72). HHV-6 is associated with CMV infection and disease, thus supporting an interaction between these viruses.

Clinical utility of quantitative cytomegalovirus viral load determination for predicting cytomegalovirus disease in liver transplant recipients

BACKGROUND

The early detection of cytomegalovirus (CMV) after liver transplantation may form the basis of a preemptive strategy for prevention of active CMV disease.

METHODS

We prospectively analyzed the clinical use of weekly quantitative polymerase chain reaction-(PCR) based plasma viral load determinations and the antigenemia assay for predicting the development of active CMV disease in 97 consecutive liver transplant recipients.

RESULTS

CMV disease occurred in 21/97 patients. Using a positive cut-off of >400 copies/ml plasma, PCR had a sensitivity of 100%, specificity 47.4%, positive predictive value 34.4% and negative predictive value 100% for prediction of CMV disease. Respective values for a positive antigenemia (>0 positive cells/slide) were 95.2, 55.3, 37.0, and 97.7%. Different cut-off points for a positive test were analyzed using receiver-operating characteristic (ROC) curves. The optimal cut-off for viral load was in the range of 2000-5000 copies/ml (sensitivity 85.7%, specificity 86.8%, PPV 64.3%, NPV 95.7% for >5000 copies/ml). The optimal cut-off for antigenemia was in the range of four to six positive cells/slide. Mean peak viral load in symptomatic patients was 73,715 copies per/ml versus 3615 copies/ml in patients with asymptomatic CMV reactivation (P<0.001). In a multivariate logistic regression analysis of risk factors for CMV disease (CMV serostatus, acute rejection, and induction immunosuppression), peak viral load and peak antigenemia emerged as the only significant independent predictors of CMV disease (for PCR, odds ratio=1.40/1000 copy/ml increase in viral load, P=0.0001; for antigenemia odds ratio=1.17/1 positive cell/slide).

CONCLUSIONS

Plasma viral load by quantitative PCR is useful for predicting CMV disease and could be used in a preemptive strategy.