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Introduction Liver acceptance patterns vary significantly between transplant centers. Data pertaining to outcomes of livers declined by local and regional centers and allocated nationally remains limited. Project aim The objective was to compare post-liver transplant outcomes between liver allografts transplanted as a result of national and local-regional allocation. Design This was a retrospective evaluation of 109 nationally allocated liver allografts used for transplant by a single center. Outcomes of nationally allocated grafts were compared to standard allocation grafts (N = 505) during the same period. Results Recipients of nationally allocated grafts had lower model for end stage liver disease scores (17 vs 22, P = .001). Nationally allocated grafts were more likely to be post-cross clamp offers (29.4% vs 13.4%, P = .001) and have longer cold ischemia times (median hours 7.8 vs 5.5, P = .001). Early allograft dysfunction was common (54.1% vs 52.5%, P = .75) and did not impact hospital length of stay (median 5 vs 6 days, P = .89). There were no differences in biliary complications ( P = .11). There were no differences in patient ( P = .88) or graft survival ( P = .35). In a multivariate model, after accounting for differences in cold ischemia time and posttransplant biliary complications, nationally allocated grafts were not associated with increased risk for graft loss (HR 0.9, 95% CI 0.4-1.8). Abnormal liver biopsy findings (33.0%) followed by donor donation after circulatory death status (22.9%) were the most common reasons for decline by local-regional centers. Conclusion Despite longer cold ischemia times, patient and graft survival outcomes remain excellent and comparable to those seen from standard allocation grafts.

The 2014 Pancreas Allocation System established national qualifying criteria for simultaneous kidney pancreas (SPK) transplantation. The 2019 UNOS Pancreas Transplantation Committee Policy 11.3.B modified these guidelines to expand transplantation. Subsequent effects on recipient demographics have not been studied. We analyzed 81 SPK transplantations performed at our center from June 2014 to December 2020 to compare recipient demographics and outcomes before and after the 11.3.B policy change. National data were also investigated. Significant increases in age (38.9 v 46.4 years; p = 0.01) and c-peptide levels (1.7 v 4.9 ng/ml; p = 0.01) occurred following the removal of BMI and c-peptide requirements. No differences in BMI, outcomes, or complication rates were found. National and center trends showed increasing numbers of recipients with high c-peptide levels and decreasing numbers of recipients with undetectable c-peptide levels. Policy 11.3.B expanded transplantation access while maintaining suitable outcomes, reflecting its intended goals.

Purpose This descriptive review aims to describe the impact of controlled substance prescriptive authority (CSPA) among Drug Enforcement Administration (DEA)–registered clinical pharmacist practitioners (pharmacists) within the Veterans Health Administration (VA). The practice perspectives of pharmacists with CSPA are also reviewed. A 3-part methodology included identification and query of DEA-registered pharmacists, practice impact data analysis, and time and motion prescribing analysis. Summary Between quarter 1 of fiscal year 2018 and quarter 2 of fiscal year 2022, the number of DEA-registered pharmacists in the VA grew by 314%, from 21 to 87 pharmacists. Pharmacists in pain management and mental health reported benefits of CSPA, with the most common being practice autonomy (93%), increased efficiency (92%), and reduced burden on other prescribers (89%). Initial challenges to pharmacists obtaining DEA registration included a lack of incentive (46%) and concern about increased liability (37%). A time and motion analysis demonstrated that pharmacists with CSPA saved a median of 12 minutes for prescription writing compared to those without CSPA. Conclusion There is an opportunity for DEA-registered pharmacists to meet patient care needs to fill gaps in care from physician shortages, improve health equity, and provide quality healthcare for vulnerable, underserved populations, especially in areas where controlled substance prescribing is common. To fully optimize the role of the pharmacist, it is imperative that state practice acts be expanded to include pharmacist DEA authority as part of collaborative practice and that fair and equitable payment models be established for pharmacist comprehensive medication management.

Veterans Health Administration implemented the Opioid Safety Initiative (OSI) in 2013 to promote safe/rational opioid prescribing. West Palm Beach VA Healthcare System (WPBVAHCS) has been an outlier for the percentage of Veterans with chronic non-cancer pain receiving ≥90 mg Morphine Equivalent Daily Dosing (MEDD) in Veterans Integrated Service Networks (VISN) 8 since the 2016 fiscal year. The purpose was to determine the utility of a Pain Clinical Pharmacist Practitioner (CPP) identifying, reviewing, and approaching Veterans utilizing high-dose opioids for dose reevaluation and the impact on OSI metric post-opioid reevaluation. Pain CPP opioid education resulted in 28% (11/39) of Veterans undergoing an average 17.7 mg MEDD opioid dose reduction. For Veterans evaluated by Pain CPP, 83% (15/18) reported no change or improvement in average pain and PEG score. Pain CPP's implemented 48 interventions outside of opioid dose reduction, the most common related to naloxone. No documented opioid overdose events, hospitalizations for uncontrolled pain or mental health, suicide attempts or pain-related crisis interventions were reported. Pain CPP's are equipped to provide opioid education, address risk mitigation strategies, reassess pain regimens, and refer for non-pharmacologic modalities. Utilization of Pain CPP resources helps improve OSI metrics while providing safe comprehensive medication management (CMM) for chronic pain.

Purpose of the Review In response to the COVID-19 pandemic, vulnerable populations, such as transplant patients, were at greater risk than the regular population. In order to protect these populations, transplant centers enacted new guidelines. We approach this review by looking at how different transplant regions responded to COVID-19 and analyze the unifying themes that have proven invaluable in the subsequent waves. Recent Findings We noticed that most elective surgeries including living donor transplant operations were suspended in most countries. The response to deceased donor transplants varied between countries: in some deceased donor transplants continued with modified donor and recipient criteria, while in other countries this surgery was suspended. There was a general trend of decreasing or holding antimetabolites, treating the virus with hydroxychloroquine and/or azithromycin, and converting outpatient clinics to virtual clinics. Summary We learned how to carefully select donors and recipients, tailor immunosuppressant regiments, and implement telemedicine. The kidney recipient population can be effectively managed in times of crisis with appropriate accommodations and measures. This review can be a model for the transplant community for future pandemics.

Donation after circulatory death (DCD) liver transplantation (LT) outcomes have been attributed to multiple variables, including procurement surgeon recovery techniques. Outcomes of 196 DCD LTs at Mayo Clinic Arizona were analyzed based on graft recovery by a surgeon from our center (transplant procurement team [TPT]) versus a local procurement surgeon (non-TPT [NTPT]). A standard recovery technique was used for all TPT livers. The recovery technique used by the NTPT was left to the discretion of that surgeon. A total of 129 (65.8%) grafts were recovered by our TPT, 67 (34.2%) by the NTPT. Recipient age (p = 0.43), Model for End-Stage Liver Disease score (median 17 vs. 18; p = 0.22), and donor warm ischemia time (median 21.0 vs. 21.5; p = 0.86) were similar between the TPT and NTPT groups. NTPT livers had longer cold ischemia times (6.5 vs. 5.0 median hours; p 0.001). Early allograft dysfunction (80.6% vs. 76.1%; p = 0.42) and primary nonfunction (0.8% vs. 0.0%; p = 0.47) were similar. Ischemic cholangiopathy (IC) treated with endoscopy occurred in 18.6% and 11.9% of TPT and NTPT grafts (p = 0.23). At last follow-up, approximately half of those requiring endoscopy were undergoing a stent-free trial (58.3% TPT; 50.0% NTPT; p = 0.68). IC requiring re-LT in the first year occurred in 0.8% (n = 1) of TPT and 3.0% (n = 2) of NTPT grafts (p = 0.23). There were no differences in patient (hazard ratio [HR], 1.95; 95% confidence interval [CI], 0.76-5.03; p = 0.23) or graft (HR, 1.99; 95% CI, 0.98-4.09; p = 0.10) survival rates. Graft survival at 1 year was 91.5% for TPT grafts and 95.5% for NTPT grafts. Excellent outcomes can be achieved using NTPT for the recovery of DCD livers. There may be an opportunity to expand the use of DCD livers in the United States by increasing the use of NTPT.

Acute abdominal pain in pregnancy is common and the differential diagnosis is vast. Mature cystic teratomas are rarely the cause of adnexal torsion during pregnancy and can be difficult to diagnose. Timely surgical intervention is required to avoid ovarian infarction. We report a 22-year-old patient presenting with sudden right lower abdominal pain. Imaging including bedside Doppler ultrasonography and MRI were negative for signs of acute ovarian torsion. Despite no definitive imaging findings, due to severe pain, we made the decision for diagnostic multi-port laparoscopic examination with possible oophorectomy. The right cystic ovary was noted to be torsed three times around the utero-ovarian ligament. A right oophorectomy was performed. Grossly, cystic teratoma was confirmed with a large amount of hair and sebum, and pathological analysis also confirmed a benign mature teratoma. The patient recovered well and delivered without any complications. Bedside ultrasonography is a highly accessible tool; however, imaging can be uncertain. Despite the rarity of ovarian torsion due to mature teratomas in second- and third-trimester pregnancies, physicians should be aware of the possibility of acute ovarian torsion in a pregnant patient even with uncertain imaging results, especially those with a documented ovarian mass. Early prophylactic surgical intervention preferably with laparoscopy should be pursued for ovarian masses between 5 cm and 10 cm.

BACKGROUND/AIM Vitamin D receptor (VDR) has been shown to suppress desmoplasia in pancreatic ductal adenocarcinoma (PDAC). Our aim was to assess the clinical effects of VDR expression and its correlation with collagen content in the desmoplasia of PDAC patients. PATIENTS AND METHODS This is a retrospective analysis of 127 patients with peritumoral desmoplasia resected for PDAC. VDR expression and collagen content were assessed by immunohistochemistry and correlated with clinical outcome. RESULTS Patients were classified into those with high and those with low VDR expression. High VDR expression was associated with improved overall survival (OS) in localized disease (N0) (median= 33; 95%CI=26.4-39.6 vs. 18; 15.5-20.5 months, p=0.01). Patients with high vs. low collagen content had improved OS [34, (range=22.3-45.6 months) vs. 17, (range=14.4-19.6 months), p

For a large number of landfills, basic knowledge about extent, waste composition or environmental impact is incomplete. Considering the large number of non-sanitary landfills located in semi-urban areas subject to increased land use pressure plus the high cost for remediation, it is crucial to develop efficient characterization tools suitable in landfill contexts. Such tools are required on a broader level to enable the identification of landfills with high priority for remediation or high potential in terms of waste valorisation (landfill mining) and, on a more detailed level, to enable planning of remediation or landfill mining projects.Due to the high heterogeneity and complexity of landfills, the application of different geophysical methods in combination with targeted sampling has proven to be a highly favourable approach. In contrast to conventional ground truth methods, geophysical techniques provide the possibility to characterize large portions of the landfill volume in a non-invasive and relatively efficient way. Furthermore, the application of complementary geophysical techniques reduces the risk of misinterpretation, and by verifying/calibrating the results with targeted sampling a relatively detailed landfill model can be built. However, building a landfill model from data measured at different resolution, coverage and with different uncertainties is a challenge.We present a case study from Emersons Green (UK) where we completed multiple geophysical surveys on a former landfill site prior to its full excavation. The excavation works provided nearly continuous information on the waste and cover layer thickness as well as information on material composition from several locations. This enabled us to validate the geophysical measurements and to test different approaches for model building, as well as testing virtual sampling strategies in order to assess how the number and location of ground truth samples affects the model quality.The case study has highlighted the advantage of a multi-geophysical approach where Electromagnetics (EM) and Magnetics (Mag) were able to provide a rapid overview of the landfill structure and its lateral extent. In contrast, Induced Polarization Tomography (IPT) and Multichannel Analysis of Surface Waves (MASW) were most suitable to delineate the bottom interface of the waste layer. IPT was in addition able to delineate the cover layer thickness and Electrical Resistivity Tomography (ERT) seemed more sensitive to changes in moisture content. For the model building, a probabilistic approach has proven to be efficient. In terms of sampling strategy a minimum number of samples are required co-located with the geophysical measurements to train the probability model. Furthermore, additional sampling points at locations where geophysical methods are only sparsely available increase the model certainty.

The liver plays a key role in whole-body, glucose and lipid homeostasis. Nutritional signals in response to fasting and refeeding regulate hepatic lipid synthesis. It is established that activation of mitogen-activated protein kinase (MAPK) phosphatase-1 (MKP-1) in response to overnutrition regulates MAPK-dependent pathways that control lipid metabolism in the liver. However, the regulatory mechanisms and the impact of the actions of MKP-1 in hepatic response to fasting remains unclear. We investigated the effect of fasting on the expression of MKP-1 and the impact on hepatic response to feeding. In this study, we demonstrate that fasting stress induced upregulation of hepatic MKP-1 protein levels with a corresponding downregulation of p38 MAPK and JNK phosphorylation in mouse livers. We found that MKP-1-deficient livers are resistant to fasting-induced hepatic steatosis. Hepatic MKP-1 deficiency impaired fasting-induced changes in the levels of key transcription factors involved in the regulation of fatty acid and cholesterol metabolism including Srebf2 and Srebf1c. Mechanistically, MKP-1 negatively regulates Srebf2 expression by attenuating p38 MAPK pathway, suggesting its contribution to the metabolic effects of MKP-1 deficiency in the fasting liver. These findings support the hypothesis that upregulation of MKP-1 is a physiological relevant response and might be beneficial in hepatic lipid utilization during fasting in the liver. Collectively, these data unravel some of the complexity and tissue specific interaction of MKP-1 action in response to changes in nutritional cues, including fasting and excess nutrients

Clinical pharmacy interventions have been shown to improve medication therapy, prevent undesirable side effects, and improve patients' clinical outcomes in a number of settings; however, limited data exist to characterize clinical pharmacy specialist (CPS) providers' interventions in an inpatient hospice Veteran Affairs (VA) setting. The primary objective of this quality improvement (QI) project was to quantify the number and types of pharmacy interventions implemented from the Pharmacists Achieve Results with Medications Documentation (PhARMD) tool for inpatient hospice patient encounters in a VA medical center. A total of 453 interventions during 185 patient care encounters were documented by CPS providers between September 1, 2016, and December 31, 2016. These interventions were documented across 32 unique patients, with an average of 14.2 interventions made per patient during this period. CPS providers frequently intervened to optimize pharmacotherapy for the treatment of pain (42.38%), terminal agitation (5.08%), and nausea (3.97%). Additionally, CPS providers played a significant role in the deprescribing of medication by discontinuing drugs no longer indicated (18.3%). These results substantiate the valuable contribution to patient care that the CPS providers make in optimizing symptom management and deprescribing at end-of-life. Future studies are needed to characterize the potential cost savings of CPS provider services in the inpatient hospice setting.

An inpatient pain pharmacist consult service may help manage the complex issues associated with medications for patients with pain.

Glomerular filtration rate (GFR) is an excellent indicator of renal function; however, it is rarely evaluated as an endpoint. We investigated donor and recipient factors for associations that might be predictive of mid-term GFR after renal transplantation. We performed a retrospective review of 828 deceased donor renal transplantations performed at Montefiore Medical Center between the years 2009-2015. Donor characteristics included KDPI, [low (80%)], age, graft types [extended criteria (ECD), cardiac death (DCD), standard criteria (SCD)], CDC high risk, HCV status and cold ischemic time (CIT). Recipient factors included age at transplant, induction agent, BK status, CMV status, acute and chronic rejection, cPRA and DSA status. Primary outcome is 3-year GFR calculated via the MDRD equation. In univariate analysis, donor age, KDPI, ECD, and chronic rejection were significantly associated with changes in 3-year GFR (p0.05). We conclude that donor age, KDPI, and chronic rejection are independently associated with 3-year GFR while acute rejection, DCD, HCV status, CIT, BK and CMV viremia, PRA, existing or de novo DSA were not. Based on these findings, current scoring systems may need refinement to address the prognosis of mid-term GFR., NA

Background: The rapidly growing number of frail elderly with chronic, life-threatening comorbidities in the United States is leading to a greater need for palliative care services. The West Palm Be...

This article provides a broad overview regarding intent to initiate and consider ongoing chronic opioid therapy (COT) for treatment of chronic noncancer pain (CNCP). COT should be an individualized decision based on a comprehensive evaluation, assessment, and monitoring. It is imperative that providers discuss various risks and benefits of COT initially and at follow-up visits, and continue appropriate monitoring and follow-up at regular intervals. The decision to initiate or continue opioid therapy is based on clinical judgment; however, it is understood that opioid and other medication therapy represent one piece of the complete treatment plan for patients with CNCP.

Chronic pain management employing opioids is divided into subtopics, including: risk–benefit balance; a review of the mode of action of opioid analgesics (Chap. 8); the suitability of synthetic opioids for neuropathic pain; endocrinopathy proceeding from opioid use; the use of the morphine-equivalent daily dose as a conversion tool for managing multiple opioids; the place of extended-release and long-acting opioids; current technology in abuse deterrence; and an overview of the challenges entailed in prescribing. This last section details the complex components of a decision to prescribe opioids for chronic pain. A table is provided of the classification of common opioid analgesics and their duration of activity. A text box gives the table of contents of Appendix B, supportive tables and figures therein for this chapter; there is also a text box listing additional resources.

The narrow therapeutic index associated with most analgesic opioids creates a high degree of risk, obliging caution in patient selection; this chapter describes screening practices. More attention is due to the use of opioid therapy for chronic non-cancer pain as episodes of respiratory arrest increase. Universal precautions are recommended for all patients. Before and throughout treatment, selected tools assessing risk and misuse should be employed. Increased access to the opioid antagonist naloxone has followed the increase in opioid poisoning deaths; the Risk Index for Overdose or Serious Opioid-induced Respiratory Depression (RIOSORD) helps determine the likelihood of an opioid overdose, serving to select candidates for at-home naloxone access. Urine drug testing aids treatment plan adherence. Tables include: a comparison of screening tools for risk stratification; a comparison of tools for assessment of opioid misuse; the scoring procedure for the RIOSORD; and a list of risk classes with predicted probabilities.

BackgroundNational Institute for Health and Care Excellence have recommended faecal calprotectin (FC) testing as an option in adults with lower gastrointestinal symptoms for whom specialist investigations are being considered, if cancer is not suspected and it is used to support a diagnosis of inflammatory bowel disease (IBD) or irritable bowel syndrome. York Hospital and Vale of York Clinical Commissioning Group have developed an evidence-based care pathway to support this recommendation for use in primary care. It incorporates a higher FC cut-off value, a ‘traffic light’ system for risk and a clinical management pathway.ObjectivesTo evaluate this care pathway.MethodsThe care pathway was introduced into five primary care practices for a period of six months and the clinical outcomes of patients were evaluated. Negative and positive predictive values (NPV and PPV) were calculated. GP feedback of the care pathway was obtained by means of a web-based survey. Comparator gastroenterology activity in a neighbouring trust was obtained.ResultsThe care pathway for FC in primary care had a 97% NPV and a 40% PPV. This was better than GP clinical judgement alone and doubled the PPV compared with the standard FC cut-off (250 mcg/g and were diagnosed by ‘straight to test’ colonoscopy within three weeks. The care pathway was considered helpful by GPs and delivered a higher diagnostic yield after secondary care referral (21%) than the conventional comparator pathway (5%).ConclusionsA care pathway for the use of FC that incorporates a higher cut-off value, a ‘traffic light’ system for risk and supports clinical decision making can be achieved safely and effectively. It maintains the balance between a high NPV and an acceptable PPV. A modified care pathway for the use of FC in primary care is proposed.

This article provides a broad overview regarding intent to initiate and consider ongoing chronic opioid therapy (COT) for treatment of chronic noncancer pain (CNCP). COT should be an individualized decision based on a comprehensive evaluation, assessment, and monitoring. It is imperative that providers discuss various risks and benefits of COT initially and at follow-up visits, and continue appropriate monitoring and follow-up at regular intervals. The decision to initiate or continue opioid therapy is based on clinical judgment; however, it is understood that opioid and other medication therapy represent one piece of the complete treatment plan for patients with CNCP.