Kidney transplant in pediatric gut transplant recipients - Technical challenges and outcomes

BACKGROUND

There is limited data in the literature about pediatric kidney transplant (KT) following gut transplant (GT). The purpose of this study is to highlight the technical challenges and outcomes of KT in pediatric gut recipients who developed kidney failure (KF).

METHODS

A retrospective single-center study of pediatric GT recipients from January 2000 to December 2019 was performed. In total, 14 (7%) out of 206 pediatric GT recipients developed KF and were listed for KT. Ten patients underwent kidney after gut transplant (KAGT), three patients underwent simultaneous kidney and re-do gut transplant (SKAGT), and one patient died on the KT waitlist.

RESULTS

1-, 5-, and 10-year kidney graft survival was 100%, 91%, and 78%, respectively. 1-, 5-, and 10-year GT graft survival was 100%, 77%, and 77%, respectively. 1-, 5-, and 10-year patient survival was 100%, 91%, and 91%, respectively.

CONCLUSION

Despite the technical complexity, KAGT and SKAGT for pediatric GT recipients that develop KF can be performed with favorable outcomes.

Enhanced Donor Antigen Presentation by B Cells Predicts Acute Cellular Rejection and Late Outcomes After Transplantation

Background

Enhanced B-cell presentation of donor alloantigen relative to presentation of HLA-mismatched reference alloantigen is associated with acute cellular rejection (ACR), when expressed as a ratio called the antigen presenting index (API) in an exploratory cohort of liver and intestine transplant (LT and IT) recipients.

Methods

To test clinical performance, we measured the API using the previously described 6-h assay in 84 LT and 54 IT recipients with median age 3.3 y (0.05-23.96). Recipients experiencing ACR within 60 d after testing were termed rejectors.

Results

We first confirmed that B-cell uptake and presentation of alloantigen induced and thus reflected the alloresponse of T-helper cells, which were incubated without and with cytochalasin and primaquine to inhibit antigen uptake and presentation, respectively. Transplant recipients included 76 males and 62 females. Rejectors were tested at median 3.6 d before diagnosis. The API was higher among rejectors compared with nonrejectors (2.2 ± 0.2 versus 0.6 ± 0.04, P value = 1.7E-09). In logistic regression and receiver-operating-characteristic analysis, API ≥1.1 achieved sensitivity, specificity, and positive and negative predictive values for predicting ACR in 99 training set samples. Corresponding metrics ranged from 80% to 88% in 32 independent posttransplant samples, and 73% to 100% in 20 independent pretransplant samples. In time-to-event analysis, API ≥1.1 predicted higher incidence of late donor-specific anti-HLA antibodies after API measurements in LT recipients (P = 0.011) and graft loss in IT recipients (P = 0.008), compared with recipients with API <1.1, respectively.

Conclusions

Enhanced donor antigen presentation by circulating B cells predicts rejection after liver or intestine transplantation as well as higher incidence of DSA and graft loss late after transplantation.

Mental health and academic outcomes over the first year at university in international compared to domestic Canadian students

OBJECTIVE

To compare risk factors and associated mental health and academic outcomes between international and domestic students.

PARTICIPANTS

Canadian university undergraduate students.

METHODS

Electronic surveys were completed at university entry and the end of first year. Surveys assessed demographics, risk factors, symptoms of mental disorders, and access to support. Academic outcomes were obtained from university databases.

RESULTS

International students had comparable or lower rates of clinically significant anxiety, depression, and insomnia. Domestic female students reported the highest screening rates for common mental disorders. However, international students were more likely to report having attempted suicide. International students felt less connected to the university community and had lower academic performance. Psychosocial risk factor profiles and proportions accessing mental health services were similar.

CONCLUSIONS

The scope of mental health need appears more similar than different between international and domestic students; however, international students may benefit from targeted academic and social support initiatives.

Work-related musculoskeletal pain and discomfort in laparoscopic surgeons: an international multispecialty survey

INTRODUCTION

As laparoscopic surgery is used more widely across the globe and within multiple surgical specialties the potential impact on surgeons is yet to be fully quantified. Maintenance of uncomfortable body positions may lead to work-related musculoskeletal disorders (WMSD) in surgeons, with potential knock-on effects.

METHODS

An international open online survey of multispecialty laparoscopic surgeons was carried out, designed and reported in accordance with the CHERRIES checklist for internet e-survey research. There was no paid advertising and no incentives offered.

RESULTS

A total of 259 surgeons from 9 specialties and 32 countries answered the survey, with 90% reporting pain attributable to performing laparoscopic surgery. All training grades were represented. Longer average operative duration and a greater number of years in practice were both associated with a significantly higher prevalence of pain. Surgeons with a pre-existing injury were significantly more likely to report pain than those without. Twenty per cent of surgeons would consider early retirement owing to pain.

CONCLUSIONS

The impact on surgeons of performing laparoscopic surgery is significant, even given the limitations of an open survey. Innovations such as robotic surgery and improved ergonomic education may reduce the incidence of WMSD in surgeons, to mitigate both the personal effects on surgeons and the wider effect on the future surgical workforce.

Impaired Cellular and Antibody immunity after COVID-19 in Chronically Immunosuppressed Transplant Recipients

Assessment of cellular immunity to the SARS-CoV-2 coronavirus is of great interest in chronically immunosuppressed transplant recipients (Tr), who are predisposed to infections and vaccination failures. We evaluated CD154-expressing T-cells induced by spike (S) antigenic peptides in 204 subjects-103 COVID-19 patients and 101 healthy unexposed subjects. S-reactive CD154+T-cell frequencies were a) higher in 42 healthy unexposed Tr who were sampled pre-pandemic, compared with healthy NT (p=0.02), b) lower in Tr COVID-19 patients compared with healthy Tr (p<0.0001) and were accompanied by lower S-reactive B-cell frequencies (p<0.05), c) lower in Tr with severe COVID-19 (p<0.0001), or COVID-19 requiring hospitalization (p<0.05), compared with healthy Tr. Among Tr with COVID-19, cytomegalovirus co-infection occurred in 34%; further, incidence of anti-receptor-binding-domain IgG (p=0.011) was lower compared with NT COVID-19 patients. Healthy unexposed Tr exhibit pre-existing T-cell immunity to SARS-CoV-2. COVID-19 impairs anti-S T-cell and antibody and predisposes to CMV co-infection in transplant recipients.

A systematic review of point-of-care abdominal ultrasound scans performed by general surgeons in paediatric patients

BACKGROUND/PURPOSE

Bedside point-of-care ultrasound scans are a cheap, quick and safe diagnostic tool. There is increasing evidence for the use of point-of-care surgeon-performed ultrasound scans in adults, however there are fewer studies of its use in children. This systematic review aims to provide an up-to-date summary of the evidence behind surgeon-performed ultrasound scans in paediatric surgery.

METHODS

The PubMed database was used to conduct this systematic review between the dates 1 Jan 1980 to 1 June 2020 (last search: 1 June 2020). Seven primary research studies were included in this review.

RESULTS

There is good evidence for the use of ultrasound scans in appendicitis and hypertrophic pyloric stenosis. Training times are easily achievable and transferable within a surgical department.

CONCLUSIONS

Although the use of surgeon-performed bedside ultrasound scans has been described in appendicitis and hypertrophic pyloric stenosis, more research is required to embed this into clinical practice, particularly in low volume centres such as district general hospitals. A robust training programme is also recommended to incorporate ultrasound scans into clinical practice.

The First Collective Examination of Immunosuppressive Practices Among American Intestinal Transplant Centers

Background

Unlike other solid organs, no standardized treatment algorithms exist for intestinal transplantation (ITx). We established a consortium of American ITx centers to evaluate current practices.

Methods

All American centers performing ITx during the past 3 y were invited to participate. As a consortium, we generated questions to evaluate and collect data from each institution. The data were compiled and analyzed.

Results

Ten centers participated, performing 211 ITx during the past 3 y (range, 3-46; mean 21.1). Induction regimens varied widely. Thymoglobulin was the most common, used in the plurality of patients (85/211; 40.3%), but there was no consensus regimen. Similarly, regimens for the treatment of acute cellular rejection, antibody-mediated rejection, and graft-versus-host disease varied significantly between centers. We also evaluated differences in maintenance immunosuppression protocols, desensitization regimens, mammalian target of rapamycin use, antimetabolite use, and posttransplantation surveillance practices. Maintenance tacrolimus levels, stoma presence, and scoping frequency were not associated with differences in rejection events. Definitive association between treatments and outcomes, including graft and patient survival, was not the intention of this initial collaboration and is prevented by the lack of patient-level data and the presence of confounders. However, we identified trends regarding rejection episodes after various induction strategies that require further investigation in our subsequent collaborations.

Conclusions

This initial collaboration reveals the extreme heterogeneity of practices among American ITx centers. Future collaboration will explore patient-level data, stratified by age and transplant type (isolated intestine versus multivisceral), to explore the association between treatment regimens and outcomes.

Operational tolerance after intestine re-transplantation in childhood and immunological correlates. Case report and review

BACKGROUND

Operational tolerance after retransplantation of the intestine has never been reported.

PURPOSE

To two recently described intestine transplant recipients with operational tolerance, we now add a third.

METHODS

Review of case record and immunological testing to confirm donor-specific hyporesponsiveness in multiple immune cell compartments.

RESULTS

Re-transplanted with a multivisceral liver- and kidney-inclusive intestine allograft at age 12 years, this recipient self-discontinued immunosuppression 14 years after the retransplant and has been rejection free for 2 years thereafter. As in the two previous reports, immunological testing demonstrated decreased donor-specific inflammatory response of T-cytotoxic memory cells and B-cells, decreased presentation of donor antigen by B-cells and monocytes, absence of donor-specific anti-HLA antibodies, circulating FOXP3 + T-helper cells, and intact cellular and humoral immunity to cytomegalovirus and Epstein-Barr virus. Additionally, our recipient demonstrated enhanced donor-activation-induced apoptosis of alloreactive T-cytotoxic memory cells.

CONCLUSIONS

Despite variable paths to tolerance which include graft versus host disease in two previous cases, and rejection-related loss of the primary isolated intestinal allograft in our recipient, the three cases with operational tolerance are bound by common themes: a relatively large donor antigenic load transmitted during intestine transplantation, and donor-specific hyporesponsiveness. Cell-based assays suggest enhanced donor-induced apoptosis of recipient T-cells and circulating T-regulatory cells as mechanistic links between antigenic load and donor-specific hyporesponsiveness.

464 Local Extension of a Solitary Extra Medullary Nasal Plasmacytoma into the Orbit

Aim

Method

Results

Conclusions

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Long-term outcomes of intestinal transplantation from donors aged under 1 year

BACKGROUND

The aim of the study was to analyze the long-term outcomes of transplants utilizing ITx donors <1 year and to compare these results with older donors.

METHODS

Between January 2007 and December 2019, the primary ITx donors in the Children's Hospital of Pittsburgh of UPMC were retrospectively reviewed. Short- and long-term outcomes of recipients receiving a deceased donor organ from donors <1 year were compared with those found in all other recipients.

RESULTS

During the study period, there were 89 primary ITx donors, using 30 donors (33.7%) aged <1 year. The mean age of their recipients was 1.6 ± 0.7 (0.7-3.2) years. The 30 graft types were isolated intestine (n = 3, 10.0%), liver bowel (n = 20, 66.7%), and multivisceral (n = 7, 23.3%). Technical complications occurred in 12 (40.0%) recipients. Candidates transplanted with intestine allografts from donors <1 year of age had shorter wait times (p < .001), more liver-inclusive grafts (p < .001), and less donor-specific antibodies (DSA) (p = .014). During follow-up, the recipients had less graft loss (p = .018), and more remained alive with graft in place (p = .011). Among children transplanted with such donors, 3-year and graft survival rates were 86.7% and 82.9% compared to 62.8% and 49.9% in the cohort of donors >1 year (p = .032 and .011).

CONCLUSIONS

Donor age <1 year was associated with improved graft survival. Optimal utilization of this population for toddler candidates would increase intestine availability, reduce time to transplantation, and potentially improve long-term outcome.

301 Blood Grouping and Save in Day Case Laparoscopic Surgery – Potential for Resource Savings?

Introduction

Currently, patients listed for Laparoscopic cholecystectomy and Laparoscopic Appendicectomy undergo routine Blood Grouping and Saving (G&S) pre-operatively. Blood transfusion administration in this context is a rare occurrence. Processing of G&S samples takes approximately 45 minutes and costs £31 per sample. This excludes the phlebotomy and junior doctor resources for sample collection, which incurs additional costs.

We retrospectively assessed the blood transfusion requirements in those patients who underwent either a laparoscopic appendicectomy or cholecystectomy in the last 18 months at a busy District General Hospital (Milton Keynes Hospital) to determine if there were any potential costs and resource savings that could have been made.

Method

Retrospective case notes analysis of patients who had laparoscopic cholecystectomy and laparoscopic appendicectomy from January 2019 to June 2020 focusing on timing of G&S, preoperative and postoperative haemoglobin, the timing of blood transfusion and the number of units transfused.

Results

Of a total of 613 patients, 323 patients had laparoscopic cholecystectomy. 256 (78.8%) of these had 1 G&S sample and 96 (29.7%) had 2 samples.

290 patients had laparoscopic appendicectomy. 190 (65.5%) of these laparoscopic appendicectomy patients had 1 G&S sample and 89 (30.6%) had two G&S samples.

None of the 613 patients was transfused. The total cost of G&S was £22,196.

Conclusions

Our study illustrates that in this group there was no requirement for blood transfusion. Routine group and save samples result in a significant waste of resources and finances. Targeted groups and save samples should be reserved for high-risk groups only.

Effectiveness of two tobacco cessation methods among TB patients

BACKGROUND: Tobacco and TB are the world´s two greatest public health problems. Exposure to tobacco has been shown to be associated with higher risk of acquiring TB and adverse outcomes such as relapse and TB mortality.OBJECTIVE: To assess and compare self-reported tobacco quit status and biochemically verified cotinine levels among TB patients at different time intervals among two study groups.METHODS: A cluster, randomised controlled trial was conducted on TB patients attending DOTS centres in Delhi, India, who reported using tobacco in any form. Participants were assigned into one of two treatment groups. Centres were randomly assigned to two intervention groups: 1) integrated intervention using behavioural counselling with nicotine replacement therapy (NRT) gum, and 2) intervention using behavioural counselling alone (50 each in intervention and control group). The subjects were followed at Week 1, Month 1, Month 3 and Month 6 for tobacco cessation.RESULTS: At the end of 6 months, patients who received the integrated intervention had significantly higher rate of success in quitting tobacco than those who received the conventional TB treatment alone (78.7% vs. 57.8%; P < 0.03).CONCLUSION: DOTS with tobacco use dependence treatment was successful in our study in helping TB patients to quit tobacco dependence and should therefore be offered to every tobacco user.

773 The Impact of Introducing an Enhanced Recovery Nurse Practitioner on Colorectal ERP Protocol Compliance and Surgical Outcome: A Single-Unit Experience

Introduction

The enhanced recovery programme (ERP) is a validated perioperative care plan that has consistently shown to reduce morbidity and improve patient outcomes. Our trust introduced ERP for major elective colorectal procedures in 2007. However, it had been noted that compliance to protocol was variable. This audit was conducted to see if introduction of an enhanced recovery nurse (ERN) improved compliance.

Method

This was a single-centre, retrospective, closed-loop audit; each cycle consists of resectional cases over a 1-year period. Perioperative data were collected from preoperative assessment documents, anaesthetic charts, operation notes and post-operative patient records. Compliance to 20elements of the agreed ERP protocol and length of stay (LOS) were assessed. First-cycle results were presented locally, leading to protocol revision and introduction of a dedicated ERN. Two years following ERN introduction, data were re-audited and compliance assessed. Statistical analyses were performed using Chi-squared test or independent t-test as appropriate.

Results

Among 101 procedures analysed in the first-cycle, compliance to ERP elements ranged between 30-95%. Following intervention, among 113 cases, compliance improved to 46-99%. Statistically significant improvements were observed in post-operative ERP elements. Compliance to early cessation of intravenous fluids increased from 44% to 61% (p = 0.02), and early urinary catheter removal increased two-fold, from 30% to 62% (p &lt; 0.01). Patients resumed light diet earlier and mobilised out of bed sooner. LOS improved from median of 7(1-48) to 6(2-50) days (p = 0.03).

Conclusions

This study demonstrates that the introduction of a dedicated ERN is associated with significantly improved protocol compliance and reduced LOS following major colorectal resection.

Five Hundred Patients With Gut Malrotation: Thirty Years of Experience With the Introduction of a New Surgical Procedure

OBJECTIVES

Define clinical spectrum and long-term outcomes of gut malrotation. With new insights, an innovative procedure was introduced and predictive models were established.

METHODS

Over 30-years, 500 patients were managed at 2 institutions. Of these, 274 (55%) were children at time of diagnosis. At referral, 204 (41%) patients suffered midgut-loss and the remaining 296 (59%) had intact gut with a wide range of digestive symptoms. With midgut-loss, 189 (93%) patients underwent surgery with gut transplantation in 174 (92%) including 16 of 31 (16%) who had autologous gut reconstruction. Ladd's procedure was documented in 192 (38%) patients with recurrent or de novo volvulus in 41 (21%). For 80 patients with disabling gastrointestinal symptoms, gut malrotation correction (GMC) surgery "Kareem's procedure" was offered with completion of the 270° embryonic counterclockwise-rotation, reversal of vascular-inversion, and fixation of mesenteric-attachments. Concomitant colonic dysmotility was observed in 25 (31%) patients.

RESULTS

The cumulative risk of midgut-loss increased with volvulus, prematurity, gastroschisis, and intestinal atresia whereas reduced with Ladd's and increasing age. Transplant cumulative survival was 63% at 10-years and 54% at 20-years with best outcome among infants and liver-containing allografts. Autologous gut reconstruction achieved 78% and GMC had 100% 10-year survival. Ladd's was associated with 21% recurrent/de novo volvulus and worsening (P > 0.05) of the preoperative National Institute of Health patient-reported outcomes measurement information system gastrointestinal symptom scales. GMC significantly (P ≤ 0.001) improved all of the symptomatology domains with no technical complications or development of volvulus. GMC improved quality of life with restored nutritional autonomy (P < 0.0001) and daily activities (P < 0.0001).

CONCLUSIONS

Gut malrotation is a clinicopathologic syndrome affecting all ages. The introduced herein definitive correction procedure is safe, effective, and easy to perform. Accordingly, the current standard of care practice should be redefined in this orphan population.

Metabolic Control and "Ideal" Outcomes in Liver Transplantation for Maple Syrup Urine Disease

OBJECTIVES

To assess outcomes following liver transplantation for maple syrup urine disease by determining attainment and sustainability of metabolic control and apply an "ideal" outcome composite in long-term survivors.

STUDY DESIGN

A single center, retrospective review collected clinical data including branched-chain amino acid (leucine, isoleucine, and valine) levels following liver transplant and determined achievement of an ideal long-term outcome profile of a first allograft stable on immunosuppression monotherapy, normal growth, and absence of common transplant-related sequelae.

RESULTS

Of 77 patients meeting inclusion criteria identified, 23 were long-term (≥10-year) survivors and were additionally assessed for ideal outcome attainment. Patient and graft survival were 100% and 99%, respectively, and all patients were on an unrestricted protein intake diet. Although significant variation was noted in mean isoleucine (P < .01) and leucine (P < .05) levels postliver transplantation, no difference was seen in valine (P = .29) and overall clinical impact was likely negligible as metabolic stability was achieved and sustained beyond 3 years postliver transplantation and no metabolic crises were identified. Of 23 long-term survivors with available data, 9 (39%) achieved all composite metrics determined to define "ideal" outcomes in pediatric postliver transplantation populations.

CONCLUSIONS

Liver transplant enables long-term metabolic stability for patients with maple syrup urine disease. A combination of experience and improvement in both pre- and postliver transplantation care has enabled excellent survival and minimal comorbidities following transplant.

352 A Retrospective Audit to Determine the Appropriateness of Antibiotic Use in Surgical Patients in MKUH

Introduction

This audit’s aim is to determine the appropriateness of antibiotics dispensed in Emergency Surgery Clinic (ESC) for a two-month period in 2020. Antibiotic stewardship promotes appropriate antibiotic use in clinical settings whilst limiting unnecessary use. Appropriate antibiotic use is important in reducing the risk of antibiotic resistance.

Method

We extracted the following details from 801 patients’ electronic notes who attended MKUH ESC: diagnosis, prescription of antibiotics, hospital admission, and re-attendance at the ESC. Prescriptions were analysed as to whether they were in accordance with our microbiology guidelines. Patients were analysed as a collective and within diagnosis sub-specialities (appendicitis, wound infection, gallstones/cholecystitis, testicular pathology, UTI, diverticulitis, renal stones and abscesses).

Results

218 (27%) patients were given antibiotics, 180 (22%) patients re-attended ESC and 111 (14%) were admitted. Only 77 patients (35%) receiving antibiotics were prescribed appropriately. Outcomes also varied by diagnosis. All patients presenting with UTI (n = 15) were treated correctly. In contrast, only 71% of patients with renal stones (n = 68) were incorrectly treated with antibiotics.

Conclusions

Two-thirds of patients receiving antibiotics were inappropriately prescribed. This together with the variation by diagnosis would suggest further measures be introduced to support antibiotic stewardship and mitigate the risk of antibiotic resistance.

59 Should The ‘Normal’ And ‘Ideal’ Nipple Position in A Male Influence the Surgeon When Planning Severe Gynaecomastia Correction?

Background

The ideal nipple position of the male chest following gynecomastia surgery is well documented however with increased development of the chest muscles, the NAC placement can change, leading to the medial displacement of the nipple giving a poor aesthetic outcome. Therefore, we feel these measurements need to be applied to the patients build and take into consideration the patient's future fitness goals.

Method

We have analysed photographs of 3 groups of men: super- athletes, athletes and severe gynaecomastia. We assessed the proportions of the chest in relation to the NAC and the degree of ptosis.

Results

There is wide variation in the position of the nipple to the chest wall between each group with minor variation within each group. Based on this research we believe that surgeons should be circumspect when considering breast reduction with a Wise pattern in patients with severe gynaecomastia.

In patient with increased development of the pectoralis major muscles, the NAC placement can change, leading to medial displacement of the nipple and ptosis and poor aesthetic result.

Conclusions

We suggest a two-stage procedure, carried out on two separate occasions wound be more ideal than a single stage as this allows better long-term better positioning of the nipple.

Impaired T-cell and antibody immunity after COVID-19 infection in chronically immunosuppressed transplant recipients

Assessment of T-cell immunity to the COVID-19 coronavirus requires reliable assays and is of great interest, given the uncertain longevity of the antibody response. Some recent reports have used immunodominant spike (S) antigenic peptides and anti-CD28 co-stimulation in varying combinations to assess T-cell immunity to SARS-CoV-2. These assays may cause T-cell hyperstimulation and could overestimate antiviral immunity in chronically immunosuppressed transplant recipients, who are predisposed to infections and vaccination failures. Here, we evaluate CD154-expressing T-cells induced by unselected S antigenic peptides in 204 subjects-103 COVID-19 patients and 101 healthy unexposed subjects. Subjects included 72 transplanted and 130 non-transplanted subjects. S-reactive CD154+T-cells co-express and can thus substitute for IFNγ (n=3). Assay reproducibility in a variety of conditions was acceptable with coefficient of variation of 2-10.6%. S-reactive CD154+T-cell frequencies were a) higher in 42 healthy unexposed transplant recipients who were sampled pre-pandemic, compared with 59 healthy non-transplanted subjects (p=0.02), b) lower in Tr COVID-19 patients compared with healthy transplant patients (p<0.0001), c) lower in Tr patients with severe COVID-19 (p<0.0001), or COVID-19 requiring hospitalization (p<0.05), compared with healthy Tr recipients. S-reactive T-cells were not significantly different between the various COVID-19 disease categories in NT recipients. Among transplant recipients with COVID-19, cytomegalovirus co-infection occurred in 34%; further, CMV-specific T-cells (p<0.001) and incidence of anti-receptor-binding-domain IgG (p=0.011) were lower compared with non-transplanted COVID-19 patients. Healthy unexposed transplant recipients exhibit pre-existing T-cell immunity to SARS-CoV-2. COVID-19 infection leads to impaired T-cell and antibody responses to SARS-CoV-2 and increased risk of CMV co-infection in transplant recipients.

Strengthened capacity of India´s bedaquiline Conditional Access Programme for introducing new drugs and regimens

BACKGROUND: Addressing TB in India is critical to meeting global targets. With the scale-up of diagnostic networks and the availability of new TB drugs, India had the opportunity to improve the detection and treatment outcomes in drug-resistant TB (DR-TB).OBJECTIVE: To document how the introduction of new drugs and regimens is helping India improve the care of DR-TB patients.DESIGN: In 2016, India´s National TB Programme (NTP) introduced bedaquiline (BDQ) under a Conditional Access Programme (BDQ-CAP) at six sites after providing extensive training and strengthening laboratory testing, pre-treatment evaluation, active drug safety monitoring and management (aDSM) and follow-up systems.RESULTS: An interim analysis reflected earlier and better culture conversion rates: 83% of the 620 patients converted within a median time of 60 days. However, 248 serious adverse events were reported, including 73 deaths (12%) and 100 cardiotoxicity events (16.3%). Encouraged by the evidence of safety and efficacy of BDQ, the NTP took steps to systematically expand its access to cover the entire population by 2018.CONCLUSION: The cautious yet focused approach used to introduce BDQ under BDQ-CAP paved the way for the rapid introduction of delamanid, as well as the shorter treatment regimen and the all-oral regimen for DR-TB.

A case of Infective Native (Abdominal) Aortic Aneurysm Caused by Streptococcus Agalactiae: An Updated Literature Review Based on New Nomenclature

The management of abdominal aortic aneurysms (AAA) has evolved significantly with the advent of endovascular strategies. Thus, there has been a decline in the number of open AAA repairs once an endovascular option is available. There have also been reports of successful endovascular management of infective native aortic aneurysms (INAA)¹, previously called mycotic aneurysms². The rarity of this condition makes its management a challenging one as there are no standard guidelines. The European Society of Vascular Surgery has suggested that the nomenclature be changed from mycotic aneurysms as this can be misleading to standardise reporting¹. The authors' present a case of a 67-year old male who presented during the peak of the Corona Virus pandemic with constitutional gastrointestinal symptoms. He was subsequently diagnosed with an INAA and successfully managed with open Neo-Aorto Iliac System reconstruction with a homograft³. The report highlights various strategies used in the surgical approach and their benefits in the management of INAA. Furthermore, a literature review of Streptococcus (Streptococcus agalactiae) species as a rare cause of INAA and how these cases were managed are also highlighted.

A systematic review of point-of-care abdominal ultrasound scans performed by general surgeons

BACKGROUND

Ultrasound is an established imaging modality in general surgery. With the increasing use of bedside point-of-care ultrasounds, general surgeons have been incorporating this skill into their clinical practice. This systematic review provides an up-to-date summary of the evidence for abdominal ultrasound scans performed by general surgeons to diagnose intra-abdominal pathology.

METHODS

Two independent reviewers searched the PubMed database between 1 January 1980 and 1 June 2020. Articles about surgeon-performed abdominal ultrasound in adult patients were included. Studies on trauma and vascular surgery were excluded.

RESULTS

26 articles met the inclusion criteria, presented as a narrative analysis. There was good evidence for the use of surgeon-performed ultrasound, particularly in gallstone-related diseases and moderate evidence for the use of ultrasound in appendicitis. Further evidence is required for point-of-care ultrasounds for other pathologies such as diverticulitis and groin hernias. Ultrasound training for general surgeons is variable with notable heterogeneity across studies.

CONCLUSION

A standardised training programme for general surgeons will greatly improve confidence and skill. There is good evidence for the use of bedside ultrasound by general surgeons in the acute and elective setting with reduced time to definitive treatment and fewer unnecessary hospital admissions.

Major colorectal resection is feasible using a new robotic surgical platform: the first report of a case series

Background

The number of abdominal procedures performed via a robotic-assisted approach is increasing as potential advantages of the modality are recognised. We report the first in human case series of major colorectal resection performed using a new system, Versius^®, and assess the feasibility of its use.

Methods

The initial cases performed using Versius^® at a single centre in the UK were included in the study. Anonymised data were prospectively collected including patient demographics, operative details and postoperative outcomes.

Results

Twenty-three operations were performed, including left (n = 14) and right (n = 9)-sided colonic resections. Rectal mobilisation was performed in 13. Fifty-seven percent of the patients were male, with a malignant indication for surgery in 70% of cases. Overall mean age was 59.1 ± 15.3 (range 23–89) years. Overall mean body mass index was 28.9 ± 5.2 with a mean of 31.3 ± 4.5 for left-sided resections. The median console operating time was 166 min (range 75–320 min). All malignant cases had negative resection margins and the mean lymph node yield was 18 (SD 9.4). Only one operation (4%) was converted from robotic to open approach. Postoperative length of stay was a median of 5 days (range 3–34 days) and there were no readmissions within 30 days.

Conclusions

These results compare favourably with the literature on existing robotic systems and also conventional laparoscopic surgery; hence, we believe that this series indicates the Versius^® system is feasible for use in major colorectal resection. These early results from a robot-naïve centre show exciting promise for an expanding robotic market and highlight the need for further evaluation.

Liver transplant for inherited metabolic disease among siblings

Liver transplantation is a successful option for inherited metabolic disease yet little is published on the outcome among siblings. We report outcomes of siblings who have undergone liver transplantation for metabolic disease in a single program. Seventy-one siblings (35 males) from 33 individual families underwent liver transplantation since 1982. Outcomes were compared over three consecutive eras. Twenty-eight families had two siblings, four had three siblings, and one had four siblings. In half of families where dates of listing were known, siblings were listed simultaneously. Mean (SD) age at listing for the oldest and second sibling was 13.2 (7.1) and 9.8 (5.7) years, respectively (p < .01). In 18/33 families, the oldest sibling underwent transplantation first. Mean (SD) age at transplant fell from the oldest to second sibling from 12.9 (7.2) to 9.5 (6.3) years, respectively (p < .001). Ten-year patient survival was 83.5% which improved over the eras: era 1 (1982-1994) 65.0%, era 2 (1995-2007) 87.5%, and era 3 (2008-2019) 93.8%: p < .03. Sex, age at transplant, order of transplant, and presence of structural liver disease did not significantly impact survival. When siblings undergo liver transplant for inherited metabolic disease, later siblings are listed and transplanted at a significantly younger age.

ENT training amongst general practitioners: results from a questionnaire

OBJECTIVES

To evaluate the level of undergraduate and post-graduate ENT exposure amongst general practitioners and their perceived quality of this training. A secondary aim was to examine whether general practitioners believe ENT department based rotations should remain in the undergraduate curriculum.

METHOD

An online questionnaire-based survey was sent to general practices in England.

RESULTS

A total of 417 general practitioners completed the questionnaire. Sixty-seven per cent had completed an ENT rotation at medical school whereas 27 per cent had undertaken a postgraduate placement in ENT. Fifty-one per cent had received post-graduate teaching in ENT, mainly in the form of lectures. The majority of general practitioners were not satisfied with their training in ENT at undergraduate and post-graduate levels. Eighty-five per cent of general practitioners believed formal hospital-based ENT training should remain in the undergraduate curriculum.

CONCLUSION

General practitioners reported insufficient exposure to ENT during both post-graduate and undergraduate training. Proposals to outsource undergraduate ENT teaching to affiliated departments such as general practice are of concern.

CD154-expressing CMV-specific T cells associate with freedom from DNAemia and may be protective in seronegative recipients after liver or intestine transplantation

Cell-mediated immunity to CMV, if known, could improve antiviral drug therapy in at-risk children and young adults with LT and IT. Host immunity has been measured with CMV-specific T cells, which express IFNγ, but not those which express CD154, a possible substitute for IFNγ. CMV-specific CD154+ T cells and their subsets were measured with flow cytometry after stimulating PBL from recipient blood samples with an overlapping peptide mix of CMV-pp65 antigen for up to 6 hours. CMV-specific CD154+ T cells co-expressed IFNγ in PBL from three healthy adults and averaged 3.8% (95% CI 3.2%-4.4%) in 40 healthy adults. CMV-specific T cells were significantly lower in 19 CMV DNAemic LT or IT recipients, compared with 126 non-DNAemic recipients, 1.3% (95% CI 0.8-1.7) vs 4.1 (95% CI 3.6-4.6, P < .001). All T-cell subsets demonstrated similar between-group differences. In logistic regression analysis of 46 training set samples, 12 with DNAemia, all obtained between days 0 and 60 from transplant, CMV-specific T-cell frequencies ≥1.7% predicted freedom from DNAemia with NPV of 93%. Sensitivity, specificity, and PPV were 83%, 74%, and 53%, respectively. Test performance was replicated in 99 validation samples. In 32 of 46 training set samples, all from seronegative recipients, one of 19 recipients with CMV-specific T-cell frequencies ≥1.7% experienced DNAemia, compared with 8 of 13 recipients with frequencies <1.7% (P = .001). CMV-specific CD154+ T cells are associated with freedom from DNAemia after LT and IT. Among seronegative recipients, CMV-specific T cells may protect against the development of CMV DNAemia.

Technique and outcome of domino liver transplantation from patients with maple syrup urine disease: Expanding the donor pool for live donor liver transplantation

AIM/BACKGROUND

Domino liver transplantation (DLT) using liver allografts from patients with metabolic disorders enhances organ utilization. Short- and long-term course and outcome of these patients can impact the decision to offer this procedure to patients, especially those with diseases that can potentially be cured with liver transplant. We reviewed the outcomes of DLT from maple syrup urine disease (MSUD) patients in our large academic pediatric and adult transplant program.

METHODS

All patients receiving DLT were analyzed retrospectively with a minimum of one-year follow-up period for patient and donor characteristics, early and late postoperative complications and patient and graft survival with their MSUD donors in terms of age, weight, MELD/PELD scores, cold ischemia time, postoperative leucine levels, and peak ALT (alanine aminotransferase) levels during the first 48 postoperative hours.

RESULTS

Between 2006 and May 2019, 21 patients underwent domino liver transplantation with live donor allografts from MSUD patients. Four patients transplanted for different metabolic diseases are focus of a separate report. Seventeen patients with minimum one-year follow-up period are reported herein. The indications were primary sclerosing cholangitis (PSC, n = 4), congenital hepatic fibrosis (CHF, n = 2), alpha-1 antitrypsin deficiency (A-1 ATD, n = 2), progressive familial intrahepatic cholestasis (PFIC, n = 2), cystic fibrosis (n = 1), primary biliary cirrhosis (PBC, n = 1), neonatal hepatitis (n = 1), embryonal sarcoma (n = 1), Caroli disease (n = 1), hepatocellular carcinoma (HCC, n = 1), and chronic rejection after liver transplantations for PSC (n = 1). All patients and grafts survived at median follow-up of 6.4 years (range 1.2-12.9 years). Median domino recipient age was 16.2 years (range 0.6-64.6 years) and median MSUD recipient age was 17.6 years (range 4.8-32.1 years). There were no vascular complications during the early postoperative period, one patient had portal vein thrombosis 3 years after DLT and a meso-Rex bypass was successfully performed. Small for size syndrome (SFSS) occurred in reduced left lobe DLT recipient and was managed successfully with conservative management. Biliary stricture developed in 2 patients and was resolved by stenting. Comparison between DLT and MSUD recipients' peak postoperative ALT results and PELD/MELD scores showed lower levels in DLT group (P-value <.05).

CONCLUSIONS

Patient and graft survival in DLT from MSUD donors was excellent at short- and long-term follow-up. Metabolic functions have been normal in all recipients on a normal unrestricted protein diet. Ischemia preservation injury based on peak ALT was significantly decreased in DLT recipients. Domino transplantation from pediatric and adult recipients with selected metabolic diseases should be increasingly considered as an excellent option and alternative to deceased donor transplantation, thereby expanding the living donor pool. This, to date, is the largest world experience in DLT utilizing livers from patients with MSUD.

Domino liver transplantation for select metabolic disorders: Expanding the living donor pool

Domino liver transplantation (DLT) involves transplanting liver from a patient with metabolic disease into a patient with end-stage liver disease with the expectation that the recipient will not develop the metabolic syndrome or the recurrent syndrome will have minimal affect. The domino donor gets a deceased donor or a segment of live-donor liver through the deceased donor organ allocation system. Waitlist mortality for the domino recipient exceeds morbidity associated with getting the donor disease. Between 2015 and 2017, four patients with three metabolic disorders at UPMC Children's Hospital of Pittsburgh underwent DLT with domino allografts from maple syrup urine disease (MSUD) patients. These included patients with propionic acidemia (PA) (n = 1), Crigler-Najjar (CN) syndrome type-1 (n = 2), and carbamoyl phosphate synthetase deficiency (CPSD) (n = 1). Mean follow-up was 1.6 years (range 1.1-2.1 years). Total bilirubin levels normalized postoperatively in both CN patients and they maintain normal allograft function. The PA patient had normal to minimal elevations of isoleucine and leucine, and no other abnormalities on low protein diet supplemented with a low methionine and valine free formula. No metabolic crises have occurred. The patient with CPSD takes normal baby food. No elevation in ammonia levels have been observed in any of the patients. DLT for a select group of metabolic diseases alleviated the recipients of their metabolic defect with minimal evidence of transferrable-branched chain amino acid elevations or clinical MSUD despite increased protein intake. DLT using allografts with MSUD expands the live donor liver pool and should be considered for select metabolic diseases that may have a different enzymatic deficiency.

Patient experiences and health system responsiveness among internal migrants: A nationwide study in 13 Indian cities

OBJECTIVE

To report various components of health system responsiveness among poor internal migrants who availed the government health facilities in 13 Indian cities.

MATERIALS AND METHODS

Cluster random sampling was used to select 50,806 migrant households, of which 14,263 households avail the government health facility in last six months. In addition, 5072 women, who sought antenatal care and 3946 women who had delivery in government health facility during last six months were also included. Data on different domains of health system responsiveness were collected using an interviewer-administered questionnaire, developed based on the World Health Survey of WHO.

RESULTS

Of the eight domains of responsiveness, namely, autonomy, communication, confidentiality, dignity, choice, quality of basic facilities, prompt attention and access to family and community, seven domains, except the 'choice', are assessed, and they are moderate. Only about 30% of participants said that doctor discussed on treatment options (autonomy). And 50-60% of participants said positively for questions of clarity of communication. About 59% of participants acknowledged the confidentiality. Not more than 40% of participants said they were treated with dignity, and privacy is respected (dignity). The responses to quality basic amenities, prompt attention and access to family and community domains are fairly satisfactory.

CONCLUSIONS

This study has implications as many urban poor, including migrants do not utilize the services of public healthcare facilities. Hence, a responsive health system is required. There should be a policy in place to train and orient healthcare workers on some of the domains of health system responsiveness.

Myeloid-derived suppressor cells increase and inhibit donor-reactive T cell responses to graft intestinal epithelium in intestinal transplant patients

Recent advances in immunosuppressive regimens have decreased acute cellular rejection (ACR) rates and improved intestinal and multivisceral transplant (ITx) recipient survival. We investigated the role of myeloid-derived suppressor cells (MDSCs) in ITx. We identified MDSCs as CD33⁺ CD11b⁺ lineage(CD3/CD56/CD19)^- HLA-DR^-/low cells with 3 subsets, CD14^- CD15^- (e-MDSCs), CD14⁺ CD15^- (M-MDSCs), and CD14^- CD15⁺ (PMN-MDSCs), in peripheral blood mononuclear cells (PBMCs) and mononuclear cells in the grafted intestinal mucosa. Total MDSC numbers increased in PBMCs after ITx; among MDSC subsets, M-MDSC numbers were maintained at a high level after 2 months post ITx. The MDSC numbers decreased in ITx recipients with ACR. MDSC numbers were positively correlated with serum interleukin (IL)-6 levels and the glucocorticoid administration index. IL-6 and methylprednisolone enhanced the differentiation of bone marrow cells to MDSCs in vitro. M-MDSCs and e-MDSCs expressed CCR1, -2, and -3; e-MDSCs and PMN-MDSCs expressed CXCR2; and intestinal grafts expressed the corresponding chemokine ligands after ITx. Of note, the percentage of MDSCs among intestinal mucosal CD45⁺ cells increased after ITx. A novel in vitro assay demonstrated that MDSCs suppressed donor-reactive T cell-mediated destruction of donor intestinal epithelial organoids. Taken together, our results suggest that MDSCs accumulate in the recipient PBMCs and the grafted intestinal mucosa in ITx, and may regulate ACR.

Treatment seeking pathways in pediatric tuberculosis patients attending DOTS centers in urban areas of Delhi

BACKGROUND

The treatment seeking pathways prior to initiation of Direct Observed Treatment Short-course Therapy (DOTS), provides the extent of patient and health system delays among pediatric tuberculosis (TB) patients.

OBJECTIVES

The study attempted to understand the treatment seeking pathways of pediatric TB patients under revised national tuberculosis control program (RNTCP).

STUDY DESIGN AND SETTING

It was a prospective observational study carried out from January 2015 to December 2015. A predesigned, pretested and semi-structured questionnaire was used to interview 141 caregivers of pediatric patients (0-14 years) at two chest clinics selected purposively.

RESULTS

Thirteen different treatment seeking pathways were identified and fever was the commonest symptom (41.8%) for seeking care from 1st health facility. Median time taken from onset of symptoms to first consultation varied from 1 to 144 weeks. More than half of the study subjects were first taken to a private practitioner (64.5%) followed by a pharmacist (19.1%) and trust in provider was the commonest reason for choosing the first care-provider in 52 (41.1%), followed by easy access or convenience in 49 (34.8%).

CONCLUSION

A significant delay was found in treatment initiation of patients with extra pulmonary tuberculosis (EPTB), those belonging to lower socio-economic class families, low literacy level of parents, who went to private facility first and availed more than three health facilities before diagnosis.

Improvements in intestine transplantation

Transplantation of the intestine in children has presented significant challenges even as it has become a standard to treat nutritional failure due to short gut syndrome. These challenges have been addressed in part by significant improvements in short and long-term care. Noteworthy enhancements include reduced need for intestine transplantation, drug-sparing immunosuppressive regimens, immune monitoring, and improved surveillance and management of PTLD and non-adherence.

Epigenetic Mechanisms and Events in Gastric Cancer-Emerging Novel Biomarkers

Gastric cancer is one of the most common malignancy worldwide. The various genetic and epigenetic events have been found to be associated with its carcinogenesis. The epigenetic is a heritable and transient/reversible change in the gene expression that is not accompanied by modification in the DNA sequence. This event is characterized by the alteration in the promoter CpG island of the gene or histone modification. These events are associated with silencing of critical tumor suppressor gene and activation of oncogenes leading to carcinogenesis. The DNA methylation is a chemical change in the DNA sequence that most commonly occurs at cytosine moiety of CpG dinucleotide and histone, primarily on N- terminal tail that ultimately effect the interaction of DNA with chromatin modifying protein.Hypermethylation of tumor suppressor genes and global hypomethylation of oncogenes are widely studied epigenetic modifications. There are large number of publish reports regarding epigenetic events involving gastric cancer. These changes are potentially useful in identifying markers for early diagnosis and management of this lethal malignancy. Also, role of specific miRNAs and long non coding RNAs in regulation of gene expression is gaining interest and is a matter of further investigation. In this review, we aimed to summarize major epigenetic events (DNA methylation) in gastric cancer along with alteration in miRNAs and long non coding RNAs which plays an important role in pathology of this poorly understood malignancy.

Thermal Hydraulic Safety Assessment of LLCB Test Blanket System in ITER Using Modified relap/scdapsim/mod4.0 Code

This work attempts to investigate the thermal hydraulic safety of lithium lead ceramic breeder (LLCB) test blanket system (TBS) in International Thermonuclear Experimental Reactor (ITER) with the help of modified thermal hydraulic code relap/scdapsim/mod4.0. The design basis accidents, in-vessel and ex-vessel loss of coolant of first wall (FW) of test blanket module (TBM) are analyzed for this safety assessment. The sequence of accidents analyzed was started with postulated initiating events (PIEs). A detailed modeling of first wall helium cooling system (FWHCS) loop and lithium lead cooling system (LLCS) is presented. The analysis of steady-state normal operation along with 10 s power excursion before the accident is also discussed in order to better understanding of initial condition of accidents. The analysis discusses a number of safety concerns and issues that may result from the TBM component failure, such as vacuum vessel (VV) pressurization, TBM FW temperature profile, passive decay heat removal capability of TBM structure, pressurization of port cell and Tokomak cooling water system vault annex (TCWS-VA) and to check the capability of passive safety system (vacuum vessel pressure suppression system (VVPSS)). The analysis shows that in these accident scenarios, the critical parameters have reasonable safety margins.

Factors associated with sputum culture conversion in multidrug-resistant pulmonary tuberculosis

INTRODUCTION

Sputum culture conversion in pulmonary multidrug-resistant tuberculosis (MDR-TB) is important to make treatment-related decisions and prevent transmission of disease.

OBJECTIVE

To identify factors associated with sputum culture conversion, and to determine time to culture conversion and the impact of culture conversion on successful treatment outcomes in MDR-/rifampicin (RMP) resistant TB.

METHOD

Retrospective analysis of data from treatment cards and registers of MDR-/RMP-resistant patients initiated on treatment under India's Revised National TB Control Programme in Delhi, West Bengal and Kerala from January 2009 to December 2011. Proportions were calculated and logistic regression analysis was performed.

RESULTS

Of 836 patients, 787 were analysed, 651 (83%) of whom experienced culture conversion: respectively 57%, 73% and 79% culture converted by month 3, 4 and 6 of treatment. The median time to culture conversion was 91.3 days. Patients with body mass index (BMI) 16 kg/m2 (OR 0.403, P = 0.001) and 1618 kg/m2 (OR 0.519, P = 0.039) were less likely to have culture conversion. High rates of culture conversion were observed in patients with successful treatment outcomes compared to those without treatment success (462/469, 99% vs. 183/311, 59%; P 0.0001).

CONCLUSION

Low BMI is associated with poor sputum culture conversion in MDR-/RMP-resistant TB patients. Lack of culture conversion can impact successful treatment outcomes.

Pediatric intestinal transplantation

The field of intestinal transplantation has experienced dramatic growth since the first reported cases 3 decades ago. Improvements in operative technique, donor assessment and immunosuppressive protocols have afforded children who suffer from life-threatening complications of intestinal failure a chance at long-term survival. As experience has grown, newer diseases, with more systemic manifestations have arisen as potential indications for transplant. After discussing the historical developments of intestinal transplant as a backdrop, this review focuses on the specific pre-operative indications for transplant as well as the great success that intestinal rehabilitation has witnessed over the past decade. A detailed discussion of evolution of immunosuppressive strategies is followed a general review of the common infectious complications experienced by children after intestinal transplant as well as the current long- and short-term results, including a section on new research on the quality of life in this challenging population of patients.

Ex-Vessel Loss of Coolant Accident Analysis of ITER Divertor Cooling System Using Modified RELAP/SCADAPSIM/Mod 4.0

The initial design of ITER incorporated the use of carbon fiber composites in high heat flux regions and tungsten was used for low heat flux regions. The current design includes tungsten for both these regions. The present work includes thermal hydraulic modeling and analysis of ex-vessel loss of coolant accident (LOCA) for the divertor (DIV) cooling system. The purpose of this study is to show that the new concept of full tungsten divertor is able to withstand in the accident scenarios. The code used in this study is RELAP/SCADAPSIM/MOD 4.0. A parametric study is also carried out with different in-vessel break sizes and ex-vessel break locations. The analysis discusses a number of safety concerns that may result from the accident scenarios. These concerns include vacuum vessel (VV) pressurization, divertor temperature profile, passive decay heat removal capability of structure, and pressurization of tokamak cooling water system. The results show that the pressures and temperatures are kept below design limits prescribed by ITER organization.