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Background Pediatric kidney transplant (KT) using larger, deceased or living donor adult kidneys can be challenging in the pediatric population due to limited space in the retroperitoneum. Liver and native kidney (L/NK) mobilization techniques can be used in smaller and younger transplant recipients to aid in retroperitoneal placement of the renal allograft. Here, we compare the clinical outcomes of pediatric retroperitoneal KT with and without L/NK mobilization. Methods We retrospectively analyzed pediatric renal transplant recipients treated between January 2015 and May 2021. Donor and recipient demographics, intraoperative data, and recipient outcomes were included. Recipients were divided into two groups according to the surgical technique utilized: with L/NK mobilization (Group 1) and without L/NK mobilization (Group 2). Baseline variables were described using frequency distributions for categorical variables and means and standard errors for continuous variables. Tests of association with the likelihood of using L/NK mobilization were performed using standard χ2 tests, t tests, and the log-rank test. Results Forty-six pediatric recipients were evaluated and categorized into Group 1 (n = 26) and Group 2 (n = 20). Recipients in Group 1 were younger (6.7 ± 0.8 years vs. 15. 3 ± 0.7, P P . 48.6 ± 3.4 kg, P P = 0.22), and there was one death with a functioning graft (in Group 2, P = 0.21). Conclusions Retroperitoneal liver/kidney mobilization is a feasible and safe technique that facilitates implantation of adult kidney allografts into pediatric transplant recipients with no increased risk of developing post-operative complications, graft loss, or mortality.

Renal cell carcinoma is no longer considered a monolithic disease, but a group of different entities exhibiting unique molecular alterations requiring a tailored systemic approach. One of the remaining challenges is the identification of the best candidate for a particular therapeutic regimen.: Current literature regarding the recent advances and treatment options in systemic therapy for metastatic RCC, and issues pertaining to the available biomarkers tested to date for a correct treatment stratification.: Underlying biology of RCC will still drive the development of new treatment agents/combinations that will be tested in earlier stages of the disease, and probably prove to have a role in the neoadjuvant/adjuvant settings. The correct characterization of the tumor microenvironment through transcriptomic analysis should help to overcome the issues related to tumor heterogeneity. Preclinical ex-vivo models will enlarge our current knowledge regarding the potential immune-escape mechanisms exhibited by RCC, and facilitate a better monitoring of the response to therapy. New tracers, image modalities, and tests aimed at detecting and analyzing tumor-circulating cells will improve our clinical performance through a better identification of the metastatic site locations and their variable histologic patterns, and ultimately their behavior in response to treatment.

Background: Multiple renal arteries (MRA) are often encountered during living-donor kidney transplantation (LDKT), requiring surgeons to pursue complex renovascular reconstructions prior to graft implantation. With improvements in reconstruction and anastomosis techniques, allografts with MRA can be successfully transplanted with similar outcomes to allografts with a single renal artery. Here, we describe in detail various surgical techniques for reconstruction of MRA grafts with the intent of creating a single arterial inflow.Methods: We retrospectively reviewed the medical records of all LDKT recipients with laparoscopically procured MRA kidneys between March 2008 and July 2021. Recipient and donor characteristics, operative data, type of reconstruction, and recipient outcomes were analyzed. The primary outcomes were the incidence of developing delayed graft function (DGF) and/or a vascular or urological complication within 12 months post-transplant.Results: Seventy-three LDKT recipients of MRA donor allografts were evaluated. Two renal arteries (RA) were encountered in 62 allografts (84.9%) and three RA in 11 allografts (15.1%). Renal artery reconstruction was performed in 95.8% (70/73) of patients. Eighteen different reconstruction techniques of MRA were utilized, the most common being side-to-side anastomosis in allografts with two RA (N = 44) and side-to-side-to-side anastomosis in allografts with three RA (N = 4). Interposition grafting was performed in seven cases (9.6%). A single ostium was created in 69 cases (94.5%), and the median warm ischemia time was 27 (range 20–42) minutes. None of the patients developed DGF or post-operative vascular or urological complications. Median creatinine at 3, 6, and 12 months post-transplant remained stable at 1.1 mg/dl. With a median follow-up of 30.4 months post-transplant, only one graft failure has been observed–death-censored graft survival was 98.6%.Conclusion: Complex reconstruction techniques to create a single renal artery ostium for graft implantation anastomosis in allografts with MRA show acceptable warm ischemic times, with no increased risk of post-operative vascular or urological complications.

Background: We previously reported that graft failure due to nonadherence (GFNA) was a major cause of graft loss in kidney transplantation. Here, among 150 prospectively-followed kidney transplant recipients at 18 years post-transplant, we provide: updated (longer-term) estimates of cause-specific graft loss probabilities, risk factors for developing GFNA, and detailed characterizations of patients’ overt nonadherent (NA) behavior, including timing, extent, and clinical consequences. Methods: Determination of the patient becoming NA in taking his/her immunosuppressive medications, and the underlying cause of graft loss, were determined prospectively by the attending physicians. For never-functioning-graft, GFNA, GF due to causes other than NA (Other GF), and death with a functioning graft (DWFG), cumulative incidence functions were used to estimate the cumulative probabilities of cause-specific graft loss. Cox stepwise regression was used to determine significant multivariable predictors for the hazard rate of developing GFNA. Results: GFNA was a major cause of graft loss (22/150 patients), particularly among African-American and Hispanic recipients

Background It has been suggested that IVC reconstruction of retroperitoneal tumors is not required when adequate collateral circulation is present, though transient rise in creatinine may occur post-operatively. There are no reports evaluating mid- and long-term effect on renal function in these patients. The purpose of this study is to assess whether resection of a right renal cell carcinoma and inferior vena cava with obstructing tumor thrombus is safe to perform without reconstructing the inferior vena cava with regard to long-term renal function. Materials and Methods A bi-institutional retrospective review was performed over an 18 year period, assessing patients with right renal cell carcinoma and obstructing level II-IV tumor thrombus. Results Twenty-two patients were included in the study. Median age was 62.5 (range 45-79) years old and 19 (86%) of the patients were male. One patient (5%) had a level II thrombus, 14 patients (64%) had a level III thrombus (IIIa n=3, IIIb n=6, IIIc n= 3, IIId n=2), and seven patients (32%) had a level IV thrombus. Intra-operatively, median estimated blood loss was 1.35 (range 0.2 – 25) L. The median length of hospital stay was 11 (range 5 – 50) days. Median preoperative creatinine was 1.20 (range 0.40 – 2.70) mg/dL and postoperatively, median creatinine was 1.3 (range 0.86 – 2.20) mg/dL. Median creatinine at 6 month and 12 months follow-up was 1.10 (range 0.5 – 1.6) and mg/dL 1.34 (range 0.6 – 2.0), respectively. Eight patients were lost to follow-up, and two died (one in the hospital, and the other three months post-operatively). Conclusions Resection of right renal cell carcinoma with inferior vena cava in the presence of an obstructing level II- IV tumor thrombus without reconstruction of the inferior vena cava appears not to have a significant adverse effect on long-term renal function.

BACKGROUND In intestinal transplantation, acute cellular rejection (ACR) remains a significant challenge to achieving long-term graft survival. It is still not clear which are the most important prognostic factors. METHODS We performed a Cox multivariable analysis of the hazard rates of developing any ACR, severe ACR, and cause-specific graft loss during the first 60 months posttransplant among 445 consecutive intestinal transplant recipients at our institution since 1994. Of particular interest was to determine the prognostic influence of induction type: rabbit antithymocyte globulin (rATG; 2 mg/kg × 5)/rituximab (150 mg/m × 1; begun in 2013), alemtuzumab (2001-2011), and less intensive forms. RESULTS First ACR and severe ACR occurred in 61.3% (273/445) and 22.2% (99/445) of cases. The following 3 multivariable predictors were associated with significantly lower hazard rates of developing ACR and severe ACR: transplant type modified multivisceral or full multivisceral (P = 0.0009 and P < 0.000001), rATG/rituximab induction (P < 0.000001 and P < 0.01), and alemtuzumab induction (P = 0.004 and P = 0.07). For both ACR and severe ACR, the protective effects of rATG/rituximab and alemtuzumab were highly significant (P ≤ 0.000005 for ACR; P ≤ 0.01 for severe ACR) but only during the first 24 days posttransplant (when the ACR hazard rate was at its peak). The prognostic effects of rATG/rituximab and alemtuzumab on ACR/severe ACR disappeared beyond 24 days posttransplant (ie, nonproportional hazards). While significant protective effects of both rATG/rituximab and alemtuzumab existed during the first 6 months posttransplant for the hazard rate of graft loss-due-to-rejection (P = 0.01 and P = 0.003), rATG/rituximab was additionally associated with a consistently lower hazard rate of graft loss-due-to-infection (P = 0.003). All significant effects remained after controlling for the propensity-to-be-transplanted since 2013. CONCLUSIONS More intensive induction was associated with a significant lowering of ACR risk, particularly during the early posttransplant period.

Background Renal cell carcinoma (RCC) with tumor thrombus extending into the inferior vena cava (IVC) occurs in 4%-10% of cases. Within this subset, pulmonary tumor embolism (PTE) appears in approximately 0.9%-2.4% of cases. We wanted to review our experience in managing patients with RCC with IVC involvement and a preoperative diagnosis of PTE. Methods A total of seven patients presented at our center between January, 2005 and January, 2015 with RCC, IVC involvement, and PTE (diagnosed either by chest computerized tomography angiography or preoperative transesophageal echocardiogram). Each patient underwent a radical nephrectomy and tumor thrombectomy using an organ transplant-based approach. Results Surgical removal of the PTE was performed in three patients (tumor embolectomy in two cases, right lower lobe resection in one case); the PTEs in four patients were considered to be too small to undergo surgical resection. PTE pathology found neoplastic cells in each patient that had surgical removal. No postoperative complications were observed in any of the seven patients. All four patients who were metastasis-free preoperatively (with 2/4 having tumor embolectomy performed) developed distant metastasis; median time-to-developing metastatic disease was 6.5 months. With a median follow-up of 19 months, three deaths because the disease have occurred. Conclusion Although RCC with IVC tumor thrombus complicated by PTE may not be catastrophic in most cases, it appears to be associated with an increased risk of developing metastatic disease. In addition, as the PTEs appear to contain neoplastic cells, pulmonary artery embolectomy at the time of nephrectomy should be performed whenever possible.

Background/Objectives: Laparoscopic living donor nephrectomy (LLDN) of the right kidney is currently considered as part of standard of care; however, dealing with the renal hilum when performing ligation/division of its renal vessels is still a main concern. Here, we describe a simple-to-perform technique, i.e., flipping the fully mobilized right kidney to the midline so that the renal artery becomes anteriorly, which offers better visualization and easier dissection of the renal vessels (achieving maximized lengths) when performing hand-assisted LLDN of the right kidney. Methods: Living donors who underwent hand-assisted LLDN of the right kidney, along with their respective renal transplant recipients, were included in this report. Donor characteristics included renal artery and vein lengths; recipient characteristics included creatinine at months 12 – 36. Graft vein and arterial anastomosis data were also reported. Results: Nineteen living donors and 19 recipients, with median donor and recipient ages being 39 (24 – 60) and 53 (3 – 81) years, respectively, were included. None of the 38 patients had intra- or postoperative complications. Donor renal vein was anastomosed to the right external iliac vein (n = 16), right common iliac vein (n = 2), and inferior vena cava (n = 1). Gonadal vein (n = 1) and deceased donor iliac vein (n = 2) were used to increase the right renal vein length in 3 cases. Four donor kidneys had 2 arteries reconstructed side by side. None of the recipients developed any vascular or urological complications. Conclusions: The laparoscopic technique described is safe and allows better visualization of the right hilum, mainly the renal artery, and helps in stapling the renal vein and renal artery.

Introduction: Renal cell carcinoma may extend into the inferior vena cava (IVC) by the tumour thrombus (TT). Renal cell carcinoma with tumour thrombus (RCC/TT) could be associated with multiple collaterals making the surgery in cases of venous involvement very complex and challenging. The pathologic findings of non-neoplastic parenchymal changes in radical nephrectomy specimens of RCC/TT have not been well described. Methods: We conducted a retrospective study of 200 nephrectomies for RCC/TT during eight years. We only included 22 patients who had a full histopathological examination of the resected nephrectomies, including the non-neoplastic parenchymal tissues. Results: Median tumour thrombus level was III (range: II-IV), and median tumour diameter was 9.3 (range: 4-17) cm. Clear cell RCC was the most common tumour diagnosis in this cohort. Non-neoplastic renal pathologies included: (1) Global Glomerulosclerosis (GGS) in 90.9% (1-9% GGS in 15, 10-30% GGS in 4, >30% GGS in 1); (2) Interstitial fibrosis in 90.9% (mild in nine, moderate in nine, severe in 2); (3) Acute tubular injury in 14 (63.6%) patients; (4) Chronic inflammation in 77.3% (5-25% in 10, 26-50% in 7); (5) Arteriolosclerosis in all patients (mild, moderate and severe in 12, 9 and 1 patients, respectively); (6) Arteriolosclerosis: as none in 12, mild in six, moderate in four patients; (7) Focal Segmental Glomerulosclerosis in one patient. Our findings suggest that non-neoplastic parenchymal changes occur in the presence of RCC/TT. Neither tumour extension (via T-stage) nor tumour thrombus level were associated with the degree of any of these non-neoplastic parenchymal changes. Conclusions: Knowledge of the existence of these non-neoplastic parenchymal changes in addition to determining the tumour margin(s) will be important in caring for and early determining whether any specific medical intervention(s) to help preserve renal function in the remaining contralateral kidney becomes warranted.

Simple Summary Renal cell carcinoma rarely invades the surrounding visceral structures. While surgical extirpation has been the mainstay of treatment for the localized disease, the role of surgery in cases of venous involvement, adjacent invasion or distant metastasis remains controversial. Furthermore, the surgical option may represent a challenge. A large series of locally advanced renal cancer with involvement of the liver, pancreas, and/or duodenum, sometimes in conjunction with tumor thrombus extending inside the inferior vena cava is herein reported. Our series establishes the technical feasibility of this complex surgical procedure with acceptable complication rates, no perioperative death, and potential for durable response. With the use of new systemic therapy schedules, these patients will probably have a better opportunity of survival extension. Abstract Background: The purpose of this study is to report the outcomes of a series of patients with locally advanced renal cell carcinoma (RCC) who underwent radical nephrectomy, tumor thrombectomy, and visceral resection. Patients and methods: 18 consecutive patients who underwent surgical treatment in the period 2003-2019 were included. Neoplastic extension was found extending into the pancreas, duodenum, and liver in 9(50%), 2(11.1%), and 7(38.8%) patients, respectively. Seven patients (38.8%) presented also inferior vena cava tumor thrombus level I (n = 3), II (n = 2), or III (n = 2). The resection was tailored according to the degree of invasiveness. Demographics, clinical presentation, disease characteristics, surgical details, 30-day postoperative complications, and overall survival (OS) were analyzed. Results: Median age was 56 years (range: 40–76). Median tumor size was 14.5 cm (range, 8.8–22), and 10 cm (range: 4–15) for those cases with pancreatico-duodenal and liver involvement, respectively. Median estimated blood loss (EBL) was 475 mL (range: 100–4000) and resulted higher for those cases requiring thrombectomy (300 mL vs. 750 mL). Nine patients (50%) required transfusions with a median requirement of 4 units (range: 2–8). No perioperative deaths were registered in the first 30 days. Overall complication rate was 44.4%. Major complications were detected in 6/18 patients (33.3%). Overall median follow-up was 24 months (range: 0–108). Five-year OS (actuarial) rate was 89.9% and 75%, for 9/11 patients with pancreatico-duodenal involvement and 6/7 patients with liver invasion, respectively. Conclusion: Our series establishes the technical feasibility of this procedure with acceptable complication rates, no deaths, and potential for durable response.

Urologic complications can still occur following kidney transplantation, sometimes requiring multiple radiological and/or surgical procedures to fully correct the problem. Previously proposed extravesical ureteral reimplantation techniques still carry non-negligible risks of the patient developing urologic complications. About 10 years ago, a new set of modifications to the Lich-Gregoir technique was developed at our center, with the goal of further minimizing the occurrence of urologic complications, and without the need for initial ureteral stent placement. It was believed that an improvement in the surgical technique to minimize the risk of developing urologic complications was possible without the need for stent placement at the time of transplant. In this report, we describe the advantages of this technique (i.e., mobilized bladder, longer spatulation of the ureter, inclusion of bladder mucosa with detrusor muscle layer in the ureteral anastomosis, and use of a right angle clamp in the ureteral orifice to ensure that it does not become stenosed). We also retrospectively report our experience in using this technique among 500 consecutive (prospectively followed) kidney transplant recipients transplanted at our center since 2014. During the first 12mo post-transplant, only 1.4%(7/500) of patients developed a urologic complication; additionally, only 1.0%(5/500) required surgical repair of their original ureteroneocystostomy. Five patients(1.0%) developed a urinary leak, with 3/5 having distal ureteral necrosis, and 1/5 subsequently developing a ureteral stricture. Two other patients developed ureteral stenosis, one due to stricture and one due to ureteral stones. These overall results are excellent when compared with other reports in the literature, especially those in which routine stenting was performed. In summary, we believe that the advantages in using this modified extravesical ureteroneocystostomy technique clearly help in lowering the early post-transplant risk of developing urologic complications. Importantly, these results were achieved without the need for ureteral stent placement at the time of transplant.

BACKGROUND/AIM: Large or bilateral multiple renal cell carcinoma (RCC) without/with tumor thrombus (TT) in the renal vein (RV) or inferior vena cava (IVC) poses a challenge to the surgeon due to the potential for massive hemorrhage, tumor thromboemboli and dialysis, and the situation is more critical due to Covid-19 pandemic. We report our experience and measures in dealing with challenging cases of large or multiple RCCs without/with TT during the ongoing Covid-19 pandemic. PATIENTS AND METHODS: Between 4/2020-10/2020, five patients underwent RCC resection with/without TT. Patients 1 and 2 had RCCs/TT in RV; Patient 3 had RCC/TT supradiaphragmatic below right atrium; Patient-4 had a 26 cm RCC; Patient-5 had multiple RCCS as part of Birt-Hogg-Dube syndrome. RESULTS: Patients were preoperatively tested negative for Covid-19. Operation times were 105, 85, 255, 200 and 247 minutes for Patients 1-5. Estimated blood loss was: 100, 50, 3,900,100 and 50 ml, respectively. Patient 3 underwent RCC resection en bloc with IVC/TT. Patients 1 and 2 underwent resections of RCC/TT in RV. Patient 4 underwent a 26 cm RCC resection. Patient 5 underwent laparoscopic bilateral radical nephrectomies. No immediate postoperative complications were reported. CONCLUSION: We successfully managed 5 challenging cases of RCCs despite the recommendations imposed by hospitals due to Covid-19 pandemic, with favorable outcomes.

While Jehovah's Witness (JW) patients refuse transfusions of blood or blood products, they are willing to accept renal allograft transplantation. We describe here a case of what we believe is the oldest (a 70-year-old) JW candidate to undergo a deceased donor kidney transplant reported in the literature. Prior to transplantation, discussions ensued amongst the multidisciplinary transplant team, weighing the potential benefits vs. risks of performing a kidney transplant on this patient due to her refusal (due to religion) to accept any blood transfusions or blood products combined with her advanced age and having longstanding insulin-dependent, type 2 diabetes mellitus with extensive peripheral vascular disease. Preoperatively, we believed that the odds were in favor of performing the kidney transplant safely without the need for any blood product usage. However, her post-operative course was complicated by severe anemia, which developed by post-transplant day 4. The anemia incapacitated the patient's physical and psychological state, creating medical, social and financial burdens on the patient, family, medical team and hospital. Both family and patient grew concerned about her overall condition. Blood transfusion was offered in order to improve her weakness and shortness of breath that developed due to the severe anemia, but the patient (along with her family) refused such treatment. During the 17 days of hospitalization, it was a continuous struggle between the transplant team, patient, and family for her to continue with the recovery process; at times we had even considered that performing the transplant had been a mistake. While organ transplantation can be performed safely in Jehovah's Witnesses, there are multiple factors seen in this particular case that warrant analyzing: (I) the potential use of stricter transplant exclusionary criteria, given the recipient's advanced age and preexisting co-morbidities, which likely increased her risk of developing severe anemia post-operatively, and (II) the recipient's emotional/psychological post-operative state of high anxiety, which developed while she was experiencing the severe anemia; in hindsight, her anxiety level may have been reduced if we had offered daily post-operative psychological counseling sessions. While the patient's allograft is currently doing well, we probably did not have strict enough criteria for proper selection of a JW candidate for kidney transplantation.

A randomized trial of 150 primary kidney transplant recipients, initiated in May 2000, compared tacrolimus (TAC)/sirolimus (SRL) vs. TAC/mycophenolate mofetil (MMF) vs. cyclosporine microemulsion (CSA)/SRL (N = 50/group). All patients received daclizumab induction and maintenance corticosteroids. With current median follow-up of 18 years post-transplant, biopsy-proven acute rejection (BPAR) occurred less often in TAC/MMF (26% (13/50)), vs. the TAC/SRL (36% (18/50)) and CSA/SRL (34% (17/50)) arms combined (p = .23), with statistical significance favoring TAC/MMF (p = .05) after controlling for the multivariable (Cox model) effects of recipient age, recipient race/ethnicity, and donor age. First BPAR rate was clearly more favorable for TAC/MMF after stratifying patients by having 0-1 (N = 72) vs. 2-3 (N = 78) unfavorable baseline characteristics (recipient age

Cyanobacterial harmful algal blooms (CHAB), caused by eutrophication, are known to threaten both wildlife and human health. Due to urbanization and land use changes, an increase of CHAB’s at a more frequent rate within Barnegat Bay has been observed. In order to detect possible CHAB causing cyanobacteria, water samples were collected from 12 different locations within Barnegat Bay. Each sample was filtered through a 30- and 0.4-μm polycarbonate filter sequentially. Flow cytometry was carried out for the filtrate collected between 0.4- and 30-μm. Chelex DNA extraction, polymerase chain reaction (PCR), and gel electrophoresis were then performed for all sites using four primer sets (27F/785R, PSF/UR, CYA359F/CYA781R and MSF/MSR) designed to detect cyanobacteria. Flow cytometric results indicated the water samples contained a wide range of cyanobacteria, including M. aeruginosa, Cylindrospermum spp., Anabaena spp., and Synechococcus sp. IU 625 ranges from 3.16 to 8.17 × 107 cells·L-1. PCR-based assays suggest that general cyanobacteria as well as phytospecific species were present for all sites, but no toxin-producing Microcystis aeruginosa was detected. Plaque assays demonstrated the presence of cyanophages for S. IU 625, Anabaena spp., and M. aeruginosa at all sites, up to 105 PFU·ml-1.

Upper urinary tract urothelial cell carcinoma (UTUC) with venous tumor thrombus (TT) that extends into the renal vein (RV) and inferior vena cava (IVC) is a rare entity and its management is a surgical challenge. We report the largest single experience of surgical management of UTUC and accompanying venous TT with radical nephroureterectomy and tumor thrombectomy (RNATT) using transplant-based (TB) surgical techniques. From September 2003 to June 2021, nine patients with UTUC and venous TT underwent RNATT. Demographics, disease characteristics, surgical details, 30-day postoperative complications, and overall survival (OS) were analyzed. All nine patients had extension of the TT into the RV. Of those, seven had additional extension of the TT into the IVC. Venous TT level was categorized as 0 (n = 2), I (n = 2), II (n = 4), and IIIa (n = 1). Median tumor size was 12 cm (range 3–20 cm). Median estimated blood loss was 300 (range 150–1000) cc. One patient was still alive at last follow-up (4 months), and in total, eight patients have died with a median time-to-death of 12 months (range 10 days–24 months). RNATT using TB maneuvers like liver mobilization and pancreas-spleen en bloc mobilization provide excellent exposure to the retroperitoneal space and enable the safe removal of UTUC with venous TT.

Surgery may set the basis for a potential cure or would provide the best achievable quality of life in locally advanced or metastatic renal cell carcinoma (mRCC). However, survival extension with this approach would be scarce and not exempt from adverse events, thus preventing its recommendation in an already frail patient. An evidence based analysis on the role of surgery in each of the possible clinical scenarios involved under this heading may provide a clear picture on this issue and would be of value in the decision making process. Areas covered: Current literature was queried in PubMed/Medline in a systematic fashion. Manuscripts included were selected according to the quality of the data provided. A narrative review strategy was adopted to summarize the evidence acquired. Expert commentary: A surgery-based multimodal treatment approach should be strongly considered after adequate counseling in locally advanced and mRCC, since it may provide for additional benefits in terms of survival. However, a critical reevaluation of its adequacy, optimal timing, and selection of ideal candidates is currently ongoing.

Gaynor, J.J.; Bologna, P.A.X.; Restaino, D.J., and Barry, C.L., 2017. qPCR detection of early life history stage Chrysaora quinquecirrha (sea nettles) in Barnegat Bay, New Jersey. In: Buchanan, G.A.; Belton, T.J., and Paudel, B. (eds.), A Comprehensive Assessment of Barnegat Bay–Little Egg Harbor, New Jersey. The sea nettle Chrysaora quinquecirrha has become abundant in the Barnegat Bay estuary and frequently blooms in warm summer months. Various factors have been attributed to the increasing localized appearance of sea nettles and other jellyfish including eutrophication, overfishing, global warming, construction, and species introduction. Despite its abundance and frequent distribution within estuarine systems, very little work has been done to detect and quantify the early life history stages of this organism. Free-swimming larval stages of C. quinquecirrha can be detected and quantified using a quantitative polymerase chain reaction assay specific for the C. quinquecirrha 16S ribosomal (r)DNA...

The objective of this study was to quantify the current and to project future patient and insurer costs for the care of patients with non-small cell lung cancer in the US.An analysis of administrative claims data among patients diagnosed with non-small cell lung cancer from 2007-2015 was conducted. Future costs were projected through 2040 based on these data using autoregressive models.Analysis of claims data found the average total cost of care during first- and second-line therapy was $1,161.70 and $561.80 for patients, and $45,175.70 and $26,201.40 for insurers, respectively. By 2040, the average total patient out-of-pocket costs are projected to reach $3,047.67 for first-line and $2,211.33 for second-line therapy, and insurance will pay an average of $131,262.39 for first-line and $75,062.23 for second-line therapy.Claims data are not collected for research purposes; therefore, there may be errors in entry and coding. Additionally, claims data do not contain important clinical factors, such as stage of disease at diagnosis, tumor histology, or data on disease progression, which may have important implications on the cost of care.The trajectory of the cost of lung cancer care is growing. This study estimates that the cost of care may double by 2040, with the greatest proportion of increase in patient out-of-pocket costs. Despite the average cost projections, these results suggest that a small sub-set of patients with very high costs could be at even greater risk in the future.

Background In intestinal transplantation, graft versus host disease (GVHD), while relatively rare, remains a major cause of morbidity and mortality posttransplant. Because of its rarity of occurrence, no multivariable analysis of risk factors for GVHD development has previously been reported. Methods We used Cox stepwise regression to determine the significant multivariable predictors of the hazard rate of developing biopsy-proven GVHD during the first 60 months posttransplant among 445 consecutive intestinal transplant cases at our center since 1994. Results GVHD was observed in 8.8% (39/445); median time-to-GVHD development (range) was 1.5 months (0.5-17.3 mo) posttransplant. Sites of GVHD included skin (N = 21), skin/gastrointestinal tract (N = 6), gastrointestinal tract/rectum (N = 4), skin/liver (N = 4), skin/lung (N = 2), skin/rectum (N = 1), and skin/bone marrow (N = 1). Three factors were selected into the Cox model offering significant protection from GVHD development (listed in order of selection): isolated intestine or liver-intestine (LI) (versus modified multivisceral [MV] or MV) allograft (P = 0.00003), alemtuzumab (versus no induction, anti-CD25, rabbit antithymocyte globulin, or rabbit antithymocyte globulin/rituximab) induction (P = 0.004), and liver inclusion (LI or MV) (P = 0.009). These results remained unchanged even after accounting for the propensity to receive alemtuzumab induction. Observed GVHD incidence was 2.4% (3/125), 0.0% (0/38), 17.9% (7/39), and 11.9% (29/243) for isolated intestine, LI, modified MV, and MV allografts, and 2.7% (3/113) versus 10.8% (36/332) for those receiving versus not receiving alemtuzumab induction, respectively. Conclusions These results may help advance the current state of knowledge about risk factors for GVHD development following intestinal transplantation.

The combination of pediatric multivisceral and kidney transplantation leads to additional recipient risks due to the number of anastomoses and to the small sizes of donor structures. The inclusion of donor kidneys, ureters, and a bladder patch en bloc with multivisceral organs decreases the number and complexity of anastomoses and has not yet been reported. Four patients were transplanted in this fashion; three underwent multivisceral-kidney and one underwent liver-kidney transplantation. The first patient was a 3-year-old male with polycystic kidney disease and congenital hepatic fibrosis. The second was a 7-year-old female with complications from necrotizing enterocolitis. The third was a 12-month-old male with megacystis microcolon intestinal hypoperistalsis syndrome and secondary hydronephrosis, and the fourth was a 3-year-old male with multiple intestinal resections secondary to incarcerated hernia. The third patient developed a right ureteral stenosis with an intact bladder patch. The fourth child expired from maintained abdominal sepsis. The first 3 patients maintained normal graft function. There were no cases of thrombosis, arterial stenosis, or urinary leakages. These reported cases demonstrate that small pediatric en bloc transplantation of the multivisceral organs and dual kidneys with a bladder patch anastomosis is a feasible and less complex alternative to the standard procedure.

Background and objectives Adrenal tumors with/out tumor thrombus (TT) in the inferior vena cava (IVC) pose a challenge to the surgeon due to the potential of massive hemorrhage and tumor thromboembolism. We report our experience in managing different types of adrenal tumors. Methods From 11/1996–5/2015, 33 patients underwent resection of adrenal tumors with/without TT/IVC in 8 and 25 patients, respectively. Transplant-based (TB) techniques were utilized to resect the tumors. Intra-operative as estimated blood loss (EBL) and cardiopulmonary bypass (CPB) use; post-operative as length of hospital stay (LOS); and actuarial survival outcomes were recorded. Results Median EBL was 200 cc (10-8,000), tumor size was 9.0 cm (4–25), and LOS was 7days (5–60). Adrenocortical carcinoma (ACC,11/33) was the commonest type. Three ACC/level IV TT/IVC underwent CPB to extract TT from the right atrium(n = 1), right atrium and right ventricle(n = 1), and right atrium and right pulmonary artery(n = 1), respectively. A complete resection of the adrenal tumors was achieved in all patients, and no deaths were observed in the immediate postoperative period. With a median follow-up of 60 (range: 18–120) months, 4/11 ACC patients have died of their disease. Actuarial survival for ACC patients at 60 months was 57.1 ± 16.4%. Conclusions An aggressive surgical approach is the only hope for curing large adrenal tumors with/without TT/IVC. TB techniques provide excellent exposure to the retroperitoneal space and safe removal of large adrenal masses.

Key points Total i.v. anaesthesia (TIVA) has been used in adult practice since 1982 with target-controlled infusion (TCI) regimes available since 1989. Conversely, the use of TIVA in paediatric practice is far less routine with a survey finding only 10% of paediatric anaesthetists using it weekly or more.1 It has previously been the subject of a special edition of the journal Pediatric Anaesthesia 2 and the use for paediatric anaesthesia care is an increasing component at international meetings: educational sessions at the European Society for Paediatric Anaesthesia (2013), ASA (2014), and the Society for Intravenous Anaesthesia meeting in November 2015. Despite a number of obstacles (including interindividual pharmacokinetic and pharmacodynamic variability and safety concerns regarding propofol infusion syndrome—PrIS), there are notable benefits to TIVA and particular areas where it is indicated for anaesthetic or surgical reasons, where it may surpass volatile anaesthesia.3 It is a mandatory technique when inhalation agents are contraindicated. ### Advantages and disadvantages For physiological and clinical3 reasons (Table 2), TIVA has increasingly established a significant role in surgery in or around the airway (e.g. ENT) by obtunding airway reflexes (Table 2). The changes in airway reactivity facilitate extubation and result in a minimal incidence of laryngospasm and stridor …

Background Recent studies suggest that the combination of tacrolimus (TAC) and everolimus (EVL) could become a viable option for use as standard maintenance immunosuppression in non−highly sensitized kidney transplant recipients. Methods We conducted a single-center, open-label, randomized pilot trial comparing two maintenance immunosuppression regimens in non−highly sensitized, adult, primary kidney transplant recipients: (TAC/EVL, Group A) vs our standard maintenance regimen of TAC plus enteric-coated mycophenolate mofetil (TAC/EC-MPS, Group B). In both treatment arms, dual induction therapy consisting of anti-thymocyte globulin (Thymoglobulin) and basiliximab was given. Early corticosteroid withdrawal (by 7–10 days posttransplantation) was also planned in both arms. There were 30 study participants, 15 per treatment arm. Results during the first 12 months posttransplantation are reported here. Results Between 1 month and 12 months posttransplantation, mean TAC trough levels ranged between 5 and 8 ng/mL in both arms. Mean trough EVL level in Group A ranged between 4 and 6 ng/mL, and mean EC-MPS dose in Group B ranged from 1440 mg at 1 month to 945 mg at 12 months. One patient in Group A vs three patients in Group B experienced a first biopsy-proven acute rejection during the first 12 months posttransplantation (P = .32). Four patients in each group experienced biopsy-proven chronic allograft injury (interstitial fibrosis/tubular atrophy) (P = .99). There was a slight trend toward more favorable renal function in Group A at months 1–3 posttransplantation (P = .06, .10, and .18 for estimated glomerular filtration rate, respectively). No graft failures or deaths were observed in either group during the first 12 months posttransplantation. Four patients in each group developed an infection during the first 12 months posttransplantation. Two patients in Group A developed new-onset diabetes after transplant during the 12-month follow-up period, vs no patients in Group B (P = .13). Conclusion TAC/EVL may be a viable alternative to TAC/EC-MPS for use as standard maintenance immunosuppression in non−highly sensitized kidney transplant recipients and should be given further consideration.

The National Heart, Lung, and Blood Institute convened a working group in January 2015 to explore issues related to an integrated data network for congenital heart disease research. The overall goal was to develop a common vision for how the rapidly increasing volumes of data captured across numerous sources can be managed, integrated, and analyzed to improve care and outcomes. This report summarizes the current landscape of congenital heart disease data, data integration methodologies used across other fields, key considerations for data integration models in congenital heart disease, and the short- and long-term vision and recommendations made by the working group.