Using Animated Videos to Increase Patient Knowledge: A Meta-Analytic Review.

This article meta-analyzed 21 studies that tested the effectiveness of animated videos in improving learning in clinical and nonclinical settings compared with standard education. Animation was defined as the use of moving objects that are typically drawn or simulated. Videos ranged from just over 2 min in duration to 16 min in duration in articles published from 2009 through 2020. Mayer's Cognitive Theory of Multimedia Learning provided the theoretical model to frame the current analyses. Findings indicated an overall positive effect (d = 0.35) for use of animation in improving viewers' learning across a variety of health and clinical contexts, including surgery and diabetes. Moderator analyses indicated learning effects were greater in patient samples and samples with a higher proportion of male participants. Study findings were discussed in terms of the theoretical and practical implications for health communication scholars and practitioners.

A prospective multicenter observational study of cell-mediated immunity as a predictor for cytomegalovirus infection in kidney transplant recipients.

T cell immunity is essential for the control of cytomegalovirus (CMV) infection after transplantation. We evaluated a CMV-specific peptide-based enzyme-linked immunosorbent spot (ELISPOT) assay to determine whether assay results could predict subsequent CMV events. Adult kidney transplant recipients at 43 centers underwent ELISPOT testing to enumerate interferon gamma (IFN-γ) binding spot-forming units (sfu) after stimulation of cells with an overlapping peptide pool of CMV phosphoprotein 65 (pp65) and immediate early-1 (IE-1) protein at the end of antiviral prophylaxis (EOP) and various time points thereafter. The primary outcome was a CMV event in the first posttransplant year. In 583 kidney transplant recipients (260 seropositive donor [D+]/seronegative recipient [R-] and 277 R+), CMV events occurred in 44 of 368 eligible patients (11.8%) at a median of 227 days (range 92-360) posttransplant. A cutoff value of >40 sfu/2.5 × 105  cells for either IE-1 or pp65 was derived as a threshold for positivity, with a negative predictive value of >97% for CMV events. CMV events were significantly lower in assay positive vs assay negative patients (3.0% vs 19.5%, P < .0001 for pp65). Time to CMV event post-EOP was significantly greater in those with sfu >40 at EOP (P < .0001). In this large, multicenter trial of kidney transplant recipients, we show that an assessment of CMV-specific immunity using a novel ELISPOT assay is able to predict protection from CMV infection.

Hard-to-place kidney offers: Donor- and system-level predictors of discard.

Understanding risk factors for deceased-donor kidney nontransplantation is important since discard rates remain high. We analyzed DonorNet® data of consecutive deceased-donor nonmandatory share primary kidney-only offers to adult candidates at our center and beyond between July 1, 2015 and March 31, 2016 for donor- and system-level risk factors of discard, defined as nontransplantation at our or subsequent transplant centers. Exclusions were hepatitis C virus/hepatitis B virus core antibody status, blood type AB, and donor <1 year based on low candidate waitlist size. Of 456 individual kidney offers, from 296 donors, 73% were discarded. Most were national (93%) offers from Kidney Donor Profile Index 35-85% (n = 233) or >85% (n = 208) donors late in the allocation sequence with prior refusals logged for numerous candidates. On multivariate regression, factors significantly associated with discard were donor cerebrovascular accident (adjusted odds ratio [aOR]: 3.32), cancer transmission concern (aOR: 6.5), renal artery luminal compromise (aOR: 3.97), biopsy score ≥3 (aOR: 5.09), 2-hour pump resistive index >0.4 (aOR: 3.27), absence of pump (aOR: 2.58), nonspecific kidney abnormality (aOR: 2.76), increasing offer cold ischemia time category 11-15, 16-20, and >21 hours (aOR: 2.07, 2.33, 2.82), nighttime notification (aOR: 2.19), and neither kidney placed at time of offer (aOR: 2.74). Many traditional determinants of discard lack discriminatory value when granular factors are assessed. System-level factors also influence discard and warrant further study.

Benefits of multimodal enhanced recovery pathway in patients undergoing kidney transplantation.

BACKGROUND: Use of enhanced recovery after surgery (ERAS) pathways to accelerate functional recovery and reduce length of stay (LOS) has rarely been investigated in kidney transplantation (KTX). MATERIALS AND METHODS: Consecutive adult isolated KTXs between July 2015 and July 2016 (ERAS, n = 139) were compared with a historical cohort between January 2014 and July 2015 (HISTORIC, n = 95). RESULTS: Enhanced recovery after surgery recipients were significantly more likely to receive kidneys that were non-local (56.1% vs 4.2%), higher Kidney Donor Profile Index (36-85, 58.4% vs 45.2%; >85, 15.2% vs 10.7%), cold ischemia time ≥30 h (62.4% vs 4.7%), induced with antithymocyte globulin (97.1% vs 87.4%), and to develop delayed graft function (46.4% vs 25.0%). LOS was shorter by 1 day among ERAS (mean 4.59) compared to HISTORIC patients (mean 5.65) predominantly due to a shift in discharges within 3 days (32.4% vs 4.2%); 30-day readmission to the hospital (27.3% vs 27.4%) or emergency room visit (9.4% vs 7.4%) was similar. There was one 30-day death in the ERAS group and none in the HISTORIC group. Return to bowel function and early meal consumption were significantly associated with ERAS, however, with somewhat higher diarrhea and emesis rates. CONCLUSION: ERAS following KTX correlated with lower LOS without change in readmissions or ER visits despite higher delayed graft function rates.

Early Readmission After Kidney Transplantation: Examination of Discharge-Level Factors.

BACKGROUND: Early rehospitalization after kidney transplantation (KTx) is common and is considered a quality metric. Recipient and donor risk factors for early readmission after KTx are well studied. Little data exist on discharge-level factors associated with readmission. METHODS: We performed a single-center, retrospective cohort study between 2011 and 2015 of adult KTx recipients to examine readmission indication, risk factors, and opportunities for reduction. RESULTS: Of 462 KTxs, 145 (31.4%) were readmitted within 30 days of discharge. The primary reason for readmission was surgery-site specific in 30 cases (20.7%). Of 115 recipients with nonsurgical indications for readmission 25 (21.7%) were related to infection, 24 (20.9%) graft dysfunction, 25 (21.7%) gastrointestinal, 25 (21.7%) metabolic, and 16 (13.9%) other reasons. On multivariate analysis significant independent predictors of early readmission were electrolyte abnormalities on the day of discharge (odds ratio [OR], 1.77; 95% confidence interval [95% CI], 1.17-2.69), 3 or more comorbidities (OR, 2.01; 95% CI, 1.04-3.86), delayed graft function at the time of discharge (OR, 1.65; 95% CI, 1.00-2.70), and post-KTx hospitalization complication (OR, 1.70; 95% CI, 1.10-2.61). Among 11.7% of patients, readmission may have been attenuated by addressing the medical issue before discharge from index hospitalization. In 28.3% of patients, readmission rates may have been reduced with continued management as an outpatient or provision of observational or same-day diagnostic resources. CONCLUSIONS: Specific discharge level factors correlate with readmission irrespective of comorbidities and transplant complications. These findings may have important implications on discharge practice by aiding to identify which KTx recipients could be targeted for enhanced care transitions. Overall, potential opportunities for readmission reduction exist on multiple process levels.

Kidney transplant complications from undiagnosed benign prostatic hypertrophy.

BACKGROUND: It is estimated that approximately 50% of males over 50 have benign prostatic hypertrophy (BPH). BPH is underappreciated in anuric patients with end stage renal disease, and failure of diagnosis in this population can lead to complications after kidney transplantation. METHODS: A single-center retrospective review of male patients over 50 yr of age transplanted from January 1, 2010, until September 30, 2013, was performed. Outcomes assessed were as follows: graft survival, urinary retention, discharge with Foley catheter, and urinary tract infection (UTI). RESULTS: Of 147 patients, 17.0% were diagnosed with BPH before transplant, 19.0% received a BPH diagnosis after transplant, and 64% did not have BPH. Compared to those without BPH, a post-transplant BPH diagnosis was associated with urinary retention during the transplant admission (0% vs. 46.4%, p < 0.01), discharge with Foley catheter (0% vs. 21.4%, p < 0.01), readmission related to urinary retention (0% vs. 46.4%, p < 0.01), and UTI (18.0% vs. 64.3%, p < 0.01). Patients with prior diagnosis of BPH and on therapy had similar outcomes to those without BPH. CONCLUSIONS: Following kidney transplant, urinary tract complications are more common in patients with BPH; however, being on medical therapy prior to transplantation diminishes the incidence of these complications significantly.

Clinical outcomes associated with induction regimens among retransplant kidney recipients in the United States.

BACKGROUND: Numerous studies have evaluated outcomes and risk factors associated with induction protocols among kidney transplant recipients. However, few studies have evaluated outcomes in the subset of retransplant recipients who often have unique immunologic condition and risk profile and represent an increasing proportion of transplant patients in the United States. METHODS: We evaluated the association of common induction treatments (alemtuzumab, thymoglobulin, interleukin-2 receptor blockers, and no induction) given at transplantation with clinical outcomes among adult recipients retransplant between 2003 and 2011 using national Scientific Registry of Transplant Recipients data (n = 14,336). We used a propensity score analysis to minimize potential selection biases for allocation of treatment. RESULTS: In adjusted models, there were no significant differences between induction groups for outcomes of delayed graft function, 1-year acute rejection, 1-year BK virus or patient death. Acute rejection before hospital discharge was lowest among patients treated with thymoglobulin and alemtuzumab. The no induction group had the highest average 1-year estimated glomerular filtration rate (62 mL/min/1.73 kg/m(2)) and lowest incidence of any malignancies within 1 year (1.0%). Hospitalizations after transplantation were highest among patients treated with thymoglobulin (42% at 1 year). Recipients with alemtuzumab had the highest relative risk for graft loss (adjusted hazard ratio, 1.19; 95% confidence interval, 1.01-1.40, relative to patients treated with thymoglobulin). CONCLUSION: There is moderate variation in clinical outcomes associated with induction treatment among retransplant kidney recipients in the United States, including higher graft loss rates among recipients treated with alemtuzumab but similar patient survival between all regimens.

Alemtuzumab induction in simultaneous pancreas and kidney transplantation.

BACKGROUND: Alemtuzumab (AZ) is a monoclonal anti-CD52 antibody used as an induction agent in organ transplantation. Few studies have analyzed this agent in the context of simultaneous kidney-pancreas transplantation (SPKT). METHODS: We examined US registry data of SPKT recipient outcomes from January 2002 to October 2009 stratified by induction agent including AZ, other T-cell-depleting agents combined (T cell), IL2 receptor blockade (IL-2RAb), and no induction (none). RESULTS: Of 6860 SPKT recipients, induction therapy was AZ in 10%, T cell in 49%, IL-2RAb in 18%, and none in 22%. On multivariate analysis, there were no significant differences in overall patient survival, pancreas or renal allograft survival, or delayed renal graft function for the three induction groups compared with no induction. Rehospitalization within six months of transplantation occurred more often with AZ (51%) T cell (52%), and IL-2RAB (45%) compared with none (41%; p < 0.0001). On multivariate analysis, there was a significant higher odds of six-month rehospitalization with AZ (aOR 1.40, 95%CI 1.14-1.71), IL-2RAb (aOR 1.20, 95%CI 1.01-1.42-1.20), and other T-cell-depleting agents (aOR 1.50, 95%CI 1.31-1.73) compared with none. Median length of stay was significantly shorter in the AZ (8 d) compared with the IL-2RAb (9 d), T cell (10 d), and none (10 d) groups (p < 0.0001). CONCLUSIONS: There are no differences in patient, pancreas or renal allograft survival using AZ induction. AZ may confer an advantage in the perioperative period as evidenced by a decreased hospital length of stay. However, this benefit may be lost due to more frequent rehospitalizations.

Campath induction in HCV and HCV/HIV-seropositive kidney transplant recipients.

Alemtuzumab (AZ) induction in hepatitis C-seropositive (HCV+) kidney transplant (KTX) recipients may negatively affect patient survival; however, available information is scant. Using US registry data from 2003 to 2010 of adult HCV+ deceased-donor KTXs (n = 4910), we examined outcomes by induction agent - AZ (n = 294), other T cell-depleting agents, (n = 2033; T cell), IL-2 receptor blockade (n = 1135; IL-2RAb), and no induction (n = 1448). On multivariate analysis, induction therapy was associated with significantly better overall patient survival with AZ [adjusted hazards ratio (aHR) 0.64, 95% confidence interval (CI) 0.45, 0.92], T cell (aHR 0.52, 95% CI 0.41, 0.65) or IL-2RAb (aHR 0.67, 95% CI 0.53, 0.87), compared to no induction. A significant protective effect was also seen with AZ (aHR 0.63, 95% CI 0.40, 0.99), T cell (aHR 0.62, 95% CI 0.49, 0.78), and IL2R-Ab (aHR 0.62, 95% CI 0.47, 0.82) in terms of death-censored graft survival relative to no induction. There were 88 HIV+/HCV+ coinfected recipients. Compared to noninduction, any induction (i.e. three induction groups combined) was associated with similar overall patient survival (P = 0.2255) on univariate analysis. Induction therapy with AZ, other T cell-depleting agents, or IL-2RAb in HCV+ KTX is associated with better patient and death-censored graft survival compared to noninduction. In HCV/HIV coinfected patients, induction is not contraindicated.

Kidney transplant ureteroneocystostomy: comparison of full-thickness vs. Lich-Gregoir techniques.

Despite a variety of urinary tract reconstructive techniques, urinary complications are the most frequent technical adverse event following kidney transplantation. We examined outcomes of two ureteroneocystostomy techniques, the full-thickness (FT) technique and the Lich-Gregoir (LG) technique in 634 consecutive kidney-alone transplants (327 FT and 307 LG) between December 2006 and December 2010. Urological complications at one yr post-transplantation occurred in 27 cases (4.3%) including 16 ureteral strictures (2.5%), four ureteral obstructions (0.6%) owing to donor-derived stones or intrinsic hematoma, and seven urine leaks (1.1%). Compared with LG, the FT technique was associated with similar proportions of ureteral complications overall (3.9% vs. 4.6%, p = 0.70), ureteral strictures (3.7% vs. 1.3%, p = 0.08), urinary stones/hematoma (1.0% vs. 0.3%, p = 0.36), and overall urinary leaks (1.6% vs. 0.6%, p = 0.22); however, the FT technique was associated with somewhat fewer urine leaks at the ureterovesical junction (0% vs. 1.3%, p = 0.05). There were no differences between the two groups in terms of length of stay, delayed graft function, urinary tract infection with the first post-transplant year, estimated glomerular filtration rate, and overall graft and patient survival. The FT technique of ureteroneocystostomy is technically simple to perform and has a similar incidence of urinary complications compared with the LG technique.

The association of community health indicators with outcomes for kidney transplant recipients in the United States.

OBJECTIVE: To evaluate the association of community health indicators with outcomes for kidney transplant recipients. DESIGN: Retrospective observational cohort study using multivariable Cox proportional hazards models. SETTING: Transplant recipients in the United States from the Scientific Registry of Transplant Recipients merged with health indicators compiled from several national databases and the Centers for Disease Control and Prevention, including the National Center for Health Statistics, the Behavioral Risk Factor Surveillance System, and the National Center for Chronic Disease Prevention and Health Promotion. PATIENTS: A total of 100 164 living and deceased donor adult (aged 18 years) kidney transplant recipients who underwent a transplant between January 1, 2004, and December 31, 2010. MAIN OUTCOME MEASURES: Risk-adjusted time to posttransplant mortality and graft loss. RESULTS: Multiple health indicators from recipients' residence were independently associated with outcomes, including low birth weight, preventable hospitalizations, inactivity rate, and smoking and obesity prevalence. Recipients in the highest-risk counties were more likely to be African American (adjusted odds ratio, 1.59, 95% CI, 1.51-1.68), to be younger (aged 18-39 years; 1.46; 1.32-1.60), to have lower educational attainment (

Combined resection of the liver and pancreas for malignancy.

BACKGROUND: Combined resection of both the liver and pancreas for malignancy remains a controversial procedure. To many, the need for such an extended procedure implies an extent of disease that is usually not amenable to surgical control, and the extent of the procedure exposes the patients to substantial operative risks. The purpose of this study was to assess our results with combined resection of the liver and pancreas. STUDY DESIGN: Forty patients underwent combined liver and pancreas resection from 1996 to 2009. Patient ages ranged from 39 to 69 years (mean 53 years). Underlying diagnoses were neuroendocrine tumor (13), cholangiocarcinoma (13), gallbladder carcinoma (9), gastrointestinal stromal tumor (3), colorectal cancer (1), and metastatic ocular melanoma (1). Pancreatic resections included 26 pancreaticoduodenectomies (PD) and 14 distal pancreatic resections. Liver resections included 18 trisectionectomies (13 right, 5 left), 10 lobectomies (8 right, 2 left), and 12 segmental resections. RESULTS: There was no perioperative mortality. One patient who underwent PD with right trisegmentectomy for gallbladder cancer developed postoperative liver failure that improved with supportive management. Two patients developed bile leaks that resolved with conservative management. One patient developed a pancreatic leak/hemorrhage and required a completion pancreatectomy. Mean hospital stay was 14 days (range 7 to 42 days). Median follow-up was 30 months (range 3 to 76 months). Patients undergoing resection for neuroendocrine tumors had a better 5-year survival than those with hepatobiliary malignancies (100% vs 37% p = 0.01). CONCLUSIONS: Combined resection of the liver and pancreas can be performed safely. The need for combined partial hepatectomy and pancreatectomy to remove malignancy should not be considered a contraindication to resection in selected patients.

Single versus dual renal transplantation from donors with significant arteriosclerosis on pre-implant biopsy.

BACKGROUND: Transplantation of kidneys from donor with arteriosclerosis seen on pre-implantation biopsy has not been well studied. METHODS: We retrospectively evaluated 20 dual kidney transplant (DKT) and 28 single (SKT) kidney transplant recipients with >or=12 months follow-up from donors with moderate arteriosclerosis (>or=25% luminal diameter narrowing). RESULTS: Death censored graft survival was 100% and 79%, respectively (p = 0.0339). DKT recipients had significantly lower mean creatinine levels at one, three, six, and nine months and spent somewhat less time on the waiting list (181 +/- 160 vs. 318 +/- 306 d, p = 0.1429). DKT patients received kidneys from significantly older donors (64 +/- 7 vs. 54 +/- 11 yr; p = 0.0012), proportionately more expanded criteria donors (95% vs. 54%; p = 0.0029), and more donors with hypertension (81% vs. 48%, p = 0.0344) and death related to cerebrovascular accident (100% vs. 71%, p = 0.0143); however, more DKT kidneys underwent machine perfusion (95% vs. 57%, p = 0.0068). Baseline recipient variables were comparable between the two groups including age, race, gender, retransplantation, and HLA mismatch. Pre-implant biopsy was notable for similar frequencies of moderate interstitial fibrosis (10% vs. 14%, respectively) and glomerulosclerosis. CONCLUSION: Among recipients of deceased-donor kidneys with >25% arteriosclerosis, short-term outcomes after DKT were superior to that of SKT grafts. This approach may help to expand the donor-organ pool while optimizing outcomes.

Duplicate gallbladder arising from the left hepatic duct: report of a case.

Gallbladder duplication is a rare congenital biliary anomaly with different morphologies depending on events at embryogenesis. This case report describes a symptomatic duplicate gallbladder arising from the left intrahepatic duct 10 years after an open cholecystectomy: this is the rarest form of gallbladder duplication. The symptoms resolved following a second open cholecystectomy. This case illustrates the importance of preoperative imaging, intraoperative cholangiography, and a high index of suspicion of anomalous gallbladder anatomy in the diagnosis and management of this rare condition. We discuss the classification of anomalous gallbladder anatomy and review previous cases, to propose a modification of the common classification scheme.

Clinicopathologic analysis of patients with BK viruria and rejection-like graft dysfunction.

BK virus infection can be associated with interstitial inflammation, tubulitis without viral cytopathic effect, and negative in situ hybridization for viral DNA. We evaluated the consequences of increased immunosuppression in 32 viruric patients, with such acute cellular rejection-like changes in allograft biopsies (n = 50). When follow-up information was available, complete creatinine response, decrease in urine viral load (VL), and improvement in overall Banff grade for acute rejection were only seen in 13 (27%) of 49, 7 (21%) of 33, and 10 (39%) of 26 episodes of graft dysfunction, respectively. Histologic response was not always accompanied by clinical response. This low rate of response to antirejection therapy suggests that interstitial nephritis in a subset of these patients was secondary to viral infection. The presence of high VL (>1.0 E+05 copies/mL) was associated with low immune cell function values (129 +/- 99 ng of adenosine triphosphate per milliliter, P = .08) and with significant development of viremia after antirejection treatment (5/9 [56%] versus 0/24 [0%] in patients with low VL, P < .001).

Treatment for BK virus: incidence, risk factors and outcomes for kidney transplant recipients in the United States.

There has been a notable rise of BK virus among kidney transplant recipients. Single-center reports have identified risk factors for development of BK virus. However, there has not been an assessment of risk factors and incidence of this complication at a national level. This study utilized newly collected follow-up information from the national SRTR database to investigate incidence, risk factors and outcomes for solitary kidney transplant recipients associated with treatment for BK virus (TBKV) from 2004 to 2006. Logistic and Cox models were utilized to assess risk factors and evaluate graft survival associated with TBKV. Incidence of TBKV was 1.6% at 6 months and 2.6% at 1 year following transplantation. Patients with and without TBKV at 6 months had 79% and 90% 3-year overall graft survival respectively. Risk factors included advanced donor age, pediatric, African American and male recipients, human leukocyte antigen-mismatching and tacrolimus and thymoglobulin induction as baseline immunosuppression. Acute rejection episodes were more frequent prior to and following TBKV. TBKV is a common and rising incidence, varies based on transplant characteristics and should be included as a safety endpoint in studies investigating immunosuppressive protocols. Careful monitoring and further understanding of disease etiology and treatment strategies are needed.

Hepatocellular carcinoma in a 10-month-old biliary atresia child.

We present a case of a 10-month-old boy with BA who developed HCC and was treated with liver transplantation. A four-month-old boy was referred to our institution because of persistent jaundice, hepatomegaly, and coagulopathy. He had been treated for the diagnosis of neonatal hepatitis at an outside hospital. He was evaluated and was accepted as a liver transplant candidate, and was subsequently transplanted with a deceased donor liver allograft at the age of 10 months. His native liver showed established cirrhosis because of BA with one focus of moderately differentiated HCC, measuring 0.7 cm in a diameter with microscopic vascular invasion in pathological study. The postoperative course was uneventful, and he is well without recurrence four months after liver transplantation. The occurrence of HCC in a child under one yr old is extremely rare, and only three cases are reported so far including our case.

Antirejection treatment in kidney transplant patients with BK viruria.

BACKGROUND: Kidney transplant recipients with BK virus nephropathy or viremia are generally treated with reduction of immunosuppression to facilitate virus eradication. METHODS: Prompted by biopsy findings interpreted as acute rejection, we administered intravenous bolus steroids to five patients with BK virus in the plasma (BKP) (group 1) and also tried other antirejection therapies in 13 patients with BK virus in the urine (BKU) but no BKP (group 2). RESULTS: All group 1 patients had continued viremia, whereas two viruric patients in group 2 developed viremia after therapy. Ultimately, after reduced immunosuppression both groups cleared BKP over 53+/-29 days and 50+/-6 days. BKU clearance was not consistently observed. One year postbiopsy, there were no graft failures (0%) in group 1 and 2 (15%) in group 2; however, suboptimal renal function was observed in 40% and 62%, respectively (P=0.6). CONCLUSION: Cautious antirejection treatment to patients with active BKP or BKU can lead to two possible outcomes: (a) reduction in serum creatinine that is seemingly consistent with a diagnosis of acute rejection and (b) lack of clinical response, which in the absence of overt BK nephropathy, makes it difficult to distinguish between refractory rejection and virus-induced tissue inflammation.