Atrial Reservoir Strain is Associated with Decreased Cardiac Index and Adverse Outcomes Post Fontan Operation.

Fontan patients rely on atrial function for diastolic filling and to augment cardiac output. Emerging data suggests that diminished atrial function is predictive of poor outcomes in adults but studies evaluating the association between atrial mechanics in Fontan patients and outcomes are lacking. We sought to assess atrial function in Fontan patients using speckle tracking echocardiography to determine whether atrial function is associated with invasive hemodynamics and clinical outcomes. Single-center review of Fontan patients receiving both catheterization and echocardiogram from 2012-2017. Atrial reservoir, conduit and pump global longitudinal strain and strain rate were assessed by speckle tracking echocardiography. The primary outcome was a composite of all adverse clinical outcomes including cardiac hospitalizations, transplant and death. Eighty-three Fontan patients at a median age of 14.2 years (IQR 8.6, 21.7) at time of echocardiogram were included. Increased atrial reservoir strain (p = 0.04), atrial emptying fraction (p = 0.04) and atrial fractional area change (p = 0.04), were associated with higher cardiac index at baseline. There were no associations between atrial strain and systemic ventricular end diastolic pressure (EDP) at catheterization. Reservoir strain was inversely associated with the composite clinical outcome on multivariable Cox proportional hazard analysis (HR 0.96, p = 0.03). Reduced atrial function is associated with reduced cardiac index, but is not directly associated with ventricular EDP in Fontan patients. Reservoir strain is associated with an excess of adverse clinical outcomes in Fontan patients.

Assessment of National Organ Donation Rates and Organ Procurement Organization Metrics.

Importance: Organ transplant is a life-saving procedure for patients with end-stage organ failure. In the US, organ procurement organizations (OPOs) are responsible for the evaluation and procurement of organs from donors who have died; however, there is controversy regarding what measures should be used to evaluate their performance. Objective: To evaluate OPO performance metrics using combined mortality and donation data and quantify the associations of population demographics with donation metrics. Design, Setting, and Participants: This national cohort study includes data from the US organ transplantation system from January 2008 through December 2017. All individuals who died within the US, as reported by the National Death index, were included. Exposures: Death, organ donation, and donation eligibility. Main Outcomes and Measures: Evaluation of the variation in donation metrics and the use of ineligible donors by OPO and demographic subgroup. Results: This study included 17 501 742 deaths and 75 769 deceased organ donors (45 040 men [59.4%]; 51 908 White individuals [68.5%]). Of these donors, 15 857 (20.9%) were not eligible, as defined by the OPOs. The median donation metrics by OPO were 0.004 (range, 0.002-0.012) donors per death, 0.89 (range, 0.68-1.30) donors per eligible death, and 0.72 (range, 0.57-0.86) eligible donors per eligible death. The OPOs in the upper quartile of the overall eligible donors per eligible death metric were in the upper quartile of annual rankings on 90 of 140 occasions (64.3%). There was little overlap in top-performing OPOs between metrics; an OPO in the upper quartile for 1 metric was also in the upper quartile for the other metrics on 37 of 570 occasions (6.5% of the time). The median donor eligibility rate, defined as the number of eligible donors per donor, was 0.79 (range, 0.61-0.95) across OPOs. Age (eg, 65 to 84 years, coefficient, -0.55 [SE, 0.03]; P < .001; vs those aged 18 to 34 years), sex (male individuals, -0.09 [SE, 0.02]; P < .001; vs female individuals), race (eg, Black individuals, 0.35 [SE, 0.02]; P < .001; vs White individuals), cause of death (eg, central nervous system tumor, 0.48 [SE, 0.08]; P < .001; vs anoxia), year (eg, 2016-2017: -0.10 [SE, 0.03]; P < .001; vs 2008-2009), and OPO were associated with the use of ineligible donors; OPO was a significant factor associated with performance in all metrics (χ256, 500.5; P < .001; coefficient range across individual OPOs, -0.15 [SE, 0.09] to 0.75 [SE, 0.09]), even after accounting for population differences. Female and non-White individuals were significantly less likely to be used as ineligible donors. Conclusions and Relevance: We demonstrate significant variability in OPO performance rankings, depending on which donation metric is used. There were significant differences in OPO performance, even after accounting for differences in potential donor populations. Our data suggest significant variation in use of ineligible donors among OPOs, a source for increased donors. The performance of OPOs should be evaluated using a range of donation metrics.

Analysis of impact on tissue activity during COVID-19 outbreak: a survey of 8 banks in Spain.

On March 19 World Health Organization declare the pandemic situation by outbreak coronavirus disease 2019 in the world. The pressure on the health care system has been very high in several countries. Spanish National Transplant Organization (ONT) have made many efforts in maintaining transplantation activity. Although the impact of the pandemic on organ activity has been analysed, to date, less data exist regarding the impact on tissue activity. The aim of this study has been the evaluation of the possible impact on the procurement, processing and distribution of tissues during the peak period of the pandemic COVID-19 in Spain. For this study, a multicentre analysis has been made with a survey of the tissue banks in Spain, during the period March 1 to April 30, 2020. Our data suggest that the impact of coronavirus in Spain has affected dramatically tissue donation but with a moderate effect on stored tissues such as bone, valves, vessels or skin. Tissue banks should prepare if future next pandemic waves surges so that tissue provision is guaranteed both in urgent and elective surgeries.

To test or to estimate? P-values versus effect sizes.

Most research in transplant medicine includes statistical analysis of observed data. Too often authors solely rely on P-values derived by statistical tests to answer their research questions. A P-value smaller than 0.05 is typically used to declare "statistical significance" and hence, "proves" that, for example, an intervention has an effect on the outcome of interest. Especially in observational studies, such an approach is highly problematic and can lead to false conclusions. Instead, adequate estimates of the observed size of the effect, for example, expressed as the risk difference, the relative risk or the hazard ratio, should be reported. These effect size measures have to be accompanied with an estimate of their precision, like a 95% confidence interval. Such a duo of effect size measure and confidence interval can then be used to answer the important question of clinical relevance.

Most pediatric transplant centers are low volume, adult-focused, and in proximity to higher volume pediatric centers.

BACKGROUND: Independent studies provide evidence that low volume pediatric solid organ transplant centers have inferior outcomes compared to high volume pediatric centers. The study assessed whether patients treated at low volume pediatric centers have access to higher volume pediatric centers, which offer potentially better outcomes. METHODS: We analyzed center specific data on 467 pediatric solid organ transplant centers in the U.S using the Organ Procurement and Transplantation Network database from 2002 to 2014. The proximities of low volume pediatric centers to high volume pediatric centers were determined using Maptive, a tool based on Google Maps. RESULTS: Most low volume pediatric transplant centers focused on transplantation of adults (84% heart, 83% liver, and 93% kidney programs). A majority of low volume pediatric centers (77% for heart, 53% for lung, 68% for liver and 90% for kidney) were within 150 miles of high volume centers. Among all children listed for transplantation, 30.7% were listed in low volume pediatric centers. Most low volume pediatric centers are adult focused and near high volume pediatric centers. CONCLUSION: We need greater scrutiny of outcomes, particularly waitlist outcomes, of low volume pediatric solid organ transplant centers located close to high volume pediatric solid organ transplant centers. TYPE OF STUDY AND LEVEL OF EVIDENCE: Retrospective Comparative Study, Level III.

Reconstrução areolar com pele palpebral / Areolar reconstruction using eyelid skin

Introdução: Sabe-se que o câncer de mama é hoje a segunda neoplasia mais frequente entre as mulheres, as quais são submetidas desde a tratamentos clínicos até cirúrgicos mutilantes da mama. Ter mamas bonitas e harmoniosas é um direito legítimo, sendo assim o conceito de reconstrução mamária e do complexo areolo papilar se torna importante na reinserção social feminina. Este estudo visa apresentar uma técnica eficaz de reconstrução areolar, utilizando enxerto cutâneo livre palpebral bilateral, demonstrando sua eficácia através de resultados fotográficos, comparação com outras técnicas já descritas e questionários de satisfação dos pacientes. Resultados: Foram avaliados, retrospectivamente, 50 pacientes operados de reconstrução areolar com enxerto de pele palpebral e outras técnicas já descritas, operados por um único cirurgião sênior. O grupo de pacientes operados com pele palpebral não obtiveram diferenças significativas dentro da análise de resultados, comparados com outras técnicas de reconstrução. Houve boa satisfação por parte dos pacientes, quanto ao resultado das cirurgias das aréolas. Conclusão: O estudo obteve baixos índices de complicações, apresentando-se como boa opção terapêutica, dentro do arsenal cirúrgico de reconstrução areolar.

Introduction: Breast cancer is currently the second most common neoplasm among women who undergo clinical treatments and breast-mutilating surgeries. Having beautiful and harmonious breasts is a legitimate right, so the concept of reconstructing the breast and nipple-areolar complex becomes important in female social reinsertion. This study aimed to present an effective technique of areolar reconstruction using free bilateral eyelid skin grafts and demonstrate its effectiveness through photographic results, comparison with previously described techniques, and patient satisfaction questionnaires. Results: The authors retrospectively evaluated 50 patients who underwent areolar reconstruction with eyelid skin grafts and other techniques performed by a single senior surgeon. Patients who underwent eyelid skin graft surgery did not achieve significantly different results from those who underwent other reconstruction techniques. Patients who underwent areola surgeries reported good satisfaction. Conclusion: The study revealed low complication rates and demonstrated that the use of eyelid skin is a good therapeutic option for areolar reconstruction.

Transplantation crisis at the time of economic recession in Greece.

OBJECTIVES: Aim of the study was to assess the effect of economic recession on organ donation and transplantation in Greece. METHODS: Retrospective data (2002-2016) provided by the Hellenic Transplant Organization (HTO), International Registry in Organ Donation and Transplantation, Eurotransplant, Scandiatransplant, National Health Service Blood and Transplant (NHSBT), and United Network of Organ Sharing (UNOS) databases were analyzed. HTO database was divided into the precrisis (2002-2008) and crisis (2009-2016) era. Donation and transplantation rates between the two periods were compared. Trend estimation analysis was applied on the latter period. RESULTS: Since 2009, organ donation significantly declined without significant change in the reported brain deaths. Overall solid organ transplantations decreased (319.63 ± 70.4 from 460 ± 55.25 transplants/year, P = 0.001). Kidney transplantation rates declined (139.38 ± 29.7 from 209.43 ± 20.9 transplants/year, P = 0.000), with dramatic reduction in both deceased (99 ± 27.5 from 136.43 ± 131.4 transplants/year, P = 0.030) and living donor kidney transplantations (40.38 ± 6.1 from 73 ± 12.5 transplants/year, P = 0.000). Liver, heart, and lung transplant rates were not significantly affected; however, they have been low throughout both periods. Convertion to donation has not been affected by the crisis. Time series logistic regression of the crisis period demonstrated declining trends in organ donation, total solid organ transplantation, and deceased donor kidney, liver, and lung transplantation. In 2015, Greek organ donation rates were inferior to Eurotransplant, Scandiatransplant, NHSBT, UNOS, and Italy. CONCLUSIONS: There has been a temporal correlation between the economic recession and organ donation and transplantation crisis in Greece. Irrespective of the cause, measures should be taken to reverse this in order to avert the increased morbidity and mortality on the transplant waiting list.

Program-specific transplant rate ratios: Association with allocation priority at listing and posttransplant outcomes.

The Scientific Registry of Transplant Recipients (SRTR) is considering more prominent reporting of program-specific adjusted transplant rate ratios (TRRs). To enable more useful reporting of TRRs, SRTR updated the transplant rate models to adjust explicitly for components of allocation priority. We evaluated potential associations between TRRs and components of allocation priority that could indicate programs' ability to manipulate TRRs by denying or delaying access to low-priority candidates. Despite a strong association with unadjusted TRRs, we found no candidate-level association between the components of allocation priority and adjusted TRRs. We found a strong program-level association between median laboratory Model for End-stage Liver Disease (MELD) score at listing and program-specific adjusted TRRs (r = .37; P < .001). The program-level association was likely confounded by regional differences in donor supply/demand and listing practices. In kidney transplantation, higher program-specific adjusted TRRs were weakly associated with better adjusted posttransplant outcomes (r = -.14; P = .035) and lower adjusted waitlist mortality rate ratios (r = -.15; P = .022), but these associations were absent in liver, lung, and heart transplantation. Program-specific adjusted TRRs were unlikely to be improved by listing candidates with high allocation priority and can provide useful information for transplant candidates and programs.

Tuberculosis and Transplantation.

Mycobacterium tuberculosis is a major opportunistic pathogen in transplant recipients. Compared to that in the general population, the frequency of tuberculosis (TB) is 10 to 40 times higher in hematopoietic stem cell transplant (HSCT) recipients and 20 to 74 times higher in solid-organ transplant (SOT) recipients. Transplant recipients with TB are also more likely to develop disseminated disease, have longer time to definitive diagnosis, require more invasive diagnostic procedures, and experience greater anti-TB treatment-related toxicity than the general population. Specific risk factors for TB in SOT recipients include previous exposure to M. tuberculosis (positive tuberculin skin tests and/or residual TB lesions in pretransplant chest X ray) and the intensity of immunosuppression (use of antilymphocyte antibodies, type of basal immunosuppression, and intensification of immunosuppressive therapy for allograft rejection). Risk factors in HSCT recipients are allogeneic transplantation from an unrelated donor; chronic graft-versus-host disease treated with corticosteroids; unrelated or mismatched allograft; pretransplant conditioning using total body irradiation, busulfan, or cyclophosphamide; and type and stage of primary hematological disorder. Transplant recipients with evidence of prior exposure to M. tuberculosis should receive treatment appropriate for latent TB infection. Optimal management of active TB disease is particularly challenging due to significant drug interactions between the anti-TB agents and the immunosuppressive therapy. In this chapter, we address the epidemiology, clinical presentation, diagnostic considerations, and management strategies for TB in SOT and HSCT recipients.

Uso del micofenolato de mofetil (MMF) en enfermedades dermatológicas / The use of mycophenolate mofetil in dermatology diseases

Antecedentes: El ácido micofenólico (AMF) es una droga inmunosupresora que se administra como prodroga micofenolato mofetil (MMF) que ha sido usada en la prevención de rechazo en pacientes que se han realizado un trasplante de órgano. Actualmente se utiliza como opción terapéutica "off-label" en diversas patologías dermatológicas como la psoriasis, dermatitis atópica, colagenopatías, enfermedades ampollares, entre otras, debido a sus potentes efectos antinflamatorios; actuando solamente sobre la proliferación de linfocitos. Fuentes. Se revisaron artículos recientes acerca del uso del micofelonato mofetil en enfermedades dermatológicas. Desarrollo. El micofelonato mofetil es un inmunosupresor de última generación de uso muy específico, por lo que su perfil toxicológico es más bajo que el resto de inmunosupresores. Su uso en el campo de la dermatología ha sido limitado debido a la falta de estudios controlados, pero ya en la práctica consideramos que es un fármaco con un buen potencial terapéutico y nos ayuda a minimizar el uso de corticosteroides.Conclusiones. El Micofelonato de Mofetilo es una buena opción terapéutica en el tratamiento de enfermedades inflamatorias en dermatología y aunque su uso hasta los momentos sea "off-label", tiene un buen perfil de seguridad y buena tolerancia...(AU) .

Is Aesthetic Surgery Safe in the Solid Organ Transplant Patient? An International Survey and Review.

BACKGROUND: Improved immunosuppression and lifespans have afforded solid organ transplant (SOT) recipients the opportunity to seek aesthetic surgery. OBJECTIVES: To determine current trends in the provision of aesthetic in the SOT patient population, we polled the international plastic surgery community. We specifically sought to evaluate their experiences with this patient population, as well as to perform a review of the literature to provide updated guidelines for practitioners who may consider performing surgery in the SOT patient population. METHODS: A web-based survey was sent to national and international colleagues to query the experiences and complication rates of performing aesthetic surgery in this patient population. RESULTS: Thirty percent of the 1308 respondents performed surgery in SOT patients. Three hundred and forty practitioners performed 552 procedures with a 4.3% complication rate. Over 68% of all procedures were performed on kidney transplant recipients. CONCLUSIONS: SOT patients can safely undergo elective aesthetic procedures. We recommend working closely with the medical team to assure the best outcomes.

Effects of ethnicity on deceased organ donation in a minority-majority state.

OBJECTIVE: To define how ethnicity affects donation rates in New Mexico when compared with the United States. We hypothesized that deceased donation rates in New Mexico would reflect the ethnic rates of the population. DESIGN: We performed a retrospective review of the Organ Procurement Database for New Mexico from 2009 to June 2012. METHODS: Rates for donors and transplant candidates were calculated relative to 2010 census population estimates by ethnicity for non-Hispanic Whites, Hispanics, and American Indians. Poisson regression analyses were used to test whether United States and New Mexico rates differed. Rates were scaled to 100,000 patient-years for reporting. SETTING: State of New Mexico population compared to United States population. SUBJECTS: Reported deaths to New Mexico Donor Services and United Network for Organ Sharing from 2009 to 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Non-Hispanic White age-adjusted donor rates per 100,000 patient-years were 2.58 in New Mexico versus 2.60 in the United States, Hispanic donor rates were 1.98 in New Mexico versus 2.03 nationwide, and American Indian donor rates in New Mexico were 0.26 versus 1.23 nationwide (rate ratio = 0.21; 95% CI, 0.05-0.86). American Indians have significantly lower donor rates in New Mexico compared to non-Hispanic Whites (rate ratio = 0.11) and Hispanics (rate ratio = 0.13) and nationally (non-Hispanic Whites: rate ratio = 0.32 and Hispanics: rate ratio = 0.43). Hispanics and non-Hispanic Whites had similar donor rates regardless of geographic strata (Hispanics vs non-Hispanic Whites, New Mexico: 0.83; United States: 0.75). In New Mexico, Hispanic patients were 1.43 times more likely to be listed as transplant candidates than non-Hispanic Whites and American Indians were 3.32 times more likely to be listed than non-Hispanic Whites. In the United States, Hispanic patients were 1.90 times more likely to be listed as transplant candidates than non-Hispanic Whites and American Indians were 1.55 times more likely to be listed than non-Hispanic Whites. CONCLUSIONS: Donor and transplant candidate rates did not show strong differences by geographic strata. These findings suggest that further work is needed to elucidate the causes for ethnic differences in rates of consent and donation, particularly in the American Indian population.