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Non-alcoholic steatohepatitis (NASH) is the most common chronic liver disease worldwide, and the fastest growing indication for liver transplantation in the United States. NASH is now the leading etiology for liver transplantation in women, the second leading indication for men, and the most common cause amongst recipients aged 65 years and older. Patients with end-stage liver disease related to NASH represent a unique and challenging patient population due the high incidence of associated comorbid diseases, including obesity, type 2 diabetes (T2D), and hypertension. These challenges manifest in the pre-liver transplantation period with increased waitlist times and waitlist mortality. Furthermore, these patients carry considerable risk of morbidity and mortality both before after liver transplantation, with high rates of T2D, cardiovascular disease, chronic kidney disease, poor nutrition, and disease recurrence. Successful transplantation for these patients requires identification and management of their comorbidities in the face of liver failure. Multidisciplinary evaluations include a thorough pre-transplant workup with a complete cardiac evaluation, control of diabetes, nutritional support, and even, potentially, consultation with a bariatric surgeon. This article provides a comprehensive review of the conditions and challenges facing patients with NASH cirrhosis undergoing liver transplantation and provides recommendations for evaluation and management to optimize them before liver transplantation to produce successful outcomes.

Introduction: The COVID-19 pandemic demands an urgent response from the transplant community in order to protect our vulnerable patient population We present the rare case of COVID-19 in a combined liver-kidney transplant recipient from the United States Case Report: The patient is a 77 year-old diabetic woman who presented to our transplant center with decompensated cryptogenic cirrhosis She underwent combined liver-kidney transplant Postoperatively, her liver enzymes normalized, and she no longer required dialysis She was discharged to a rehabilitation facility 12 days after transplant (POD #12) On POD #13, the patient had rehabilitation sessions with an occupational therapist who later tested positive for COVID-19 This day is presumed to be her first exposure, and subsequent days will be referred to as 'post-exposure days' (PEXD) On PEXD #9 (POD #22), the patient developed a fever of 103 degrees, accompanied by chills and nausea However, no dyspnea, cough, or respiratory complaints were present at presentation Other than an elevation in alkaline phosphatase of 168 U/L, her liver enzymes and creatinine were normal (Table 1) Chest CT only showed trace right pleural effusion with no pulmonary infiltrates, no ground-glass opacification, and no consolidation (Figure 1) Abdominal CT revealed a 20 x 15 cm fluid collection surrounding the left kidney graft Mycophenolate mofetil was discontinued, but prednisone and tacrolimus were continued Tacrolimus dosing was adjusted to achieve a target daily through level range of 6 - 10 ng/mL The following morning (PEXD #10), the patient underwent percutaneous drainage of her perinephric abscess Her fever and pain subsided following intervention On PEXD #11, the patient's COVID-19 test resulted as positive Isolation precautions were maintained Chest X ray was clear She had no dyspnea or cough, and she maintained oxygen saturation of 96-100% on room air A five-day course of treatment with oral hydroxychloroquine at 400 mg was planned, and started on PEXD #11 However, the patient had a significant elevation in liver enzymes immediately following treatment initiation The drug was discontinued on PEXD #13 The patient's liver enzymes improved following drug cessation We decided to initiate treatment with azithromycin on PEXD #15, completing a five-day treatment course The patient remained asymptomatic and did not require oxygen therapy at any point On PEXD #23 (hospital day 14, POD# 36), the patient was discharged home MMF was not restarted Tacrolimus and steroid taper were continued as scheduled Allograft function and chest imaging prior to discharge were normal Conclusions: Calcineurin inhibitors interfere with the cyclophilins and FKBP required by various coronaviridae for replication Along with steroids, they also dampen the cytokine storm The antiviral potential of calcineurin inhibitors and steroids warrants further investigation into their role as viable therapy for COVID-19

Ronald S Chamberlain,1–5 Jaswinder Sond,1 Krishnaraj Mahendraraj,1 Christine SM Lau,1,3 Brianna L Siracuse1 1Department of Surgery, Saint Barnabas Medical Center, Livingston, 2Department of Surgery, Rutgers New Jersey Medical School, Rutgers University, Newark, NJ, USA; 3St. George’s University School of Medicine, Grenada, West Indies; 4Department of Surgery, Banner MD Anderson Cancer Center, Gilbert, AZ, USA; 5Department of Surgery, Valley Cancer Surgical Specialists, Phoenix, AZ, USA Background: Chronic heart failure (CHF), which affects >5 million Americans, accounts for >1 million hospitalizations annually. As a part of the Hospital Readmission Reduction Program, the Affordable Care Act requires that the Centers for Medicare and Medicaid Services reduce payments to hospitals with excess readmissions. This study sought to develop a scale that reliably predicts readmission rates among patients with CHF. Methods: The State Inpatient Database (2006–2011) was utilized, and discharge data including demographic and clinical characteristics on 642,448 patients with CHF from California and New York (derivation cohort) and 365,359 patients with CHF from Florida and Washington (validation cohort) were extracted. The Readmission After Heart Failure (RAHF) scale was developed to predict readmission risk.Results: The 30-day readmission rates were 9.42 and 9.17% (derivation and validation cohorts, respectively). Age 15; 12.04% readmission rate). The relative risk of readmission was 1.67 for the high-risk group compared with the low-risk group. Conclusion: The RAHF scale reliably predicts a patient’s 30-day CHF readmission risk based on demographic and clinical factors present upon initial admission. By risk-stratifying patients, using models such as the RAHF scale, strategies tailored to each patient can be implemented to improve patient outcomes and reduce health care costs. Keywords: heart failure, readmission, risk factors, risk assessment, RAHF scale, hospital readmission reduction program, HRRP, SID database

Christine SM Lau,1,2 Krishnaraj Mahendraraj,1 Ronald S Chamberlain1–4 1Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA; 2Saint George’s University School of Medicine, Grenada, West Indies; 3Department of Surgery, New Jersey Medical School, Rutgers University, Newark, NJ, 4Department of Surgery, Banner MD Anderson Cancer Center, Gilbert, AZ, USA Introduction: Oligodendrogliomas (OGs) account for 4cm in size. Children typically present with tumors in the temporal lobe, while adults present with tumors in the frontal lobe. Surgical resection confers a survival advantage among all patients, especially pediatric patients. Overall survival (OS) and cancer-specific survival are higher in the pediatric population. Further studies on novel treatment techniques, including bevacizumab and immunotherapy approaches, are required. Keywords: oligodendroglioma, brain cancer, SEER database

Introduction: Mortality following cardiac arrest (CA) is extremely high, with rates as high as 91.5% after out-of-hospital cardiac arrest (OHCA) and 76.1% after in-hospital cardiac arrest (IHCA). This study assessed the clinical profile and outcomes of a large cohort of patients undergoing primary percutaneous coronary intervention (PCI) for OHCA to determine its effect on clinical outcomes and mortality. Methods: 247,456 patients with OHCA due to acute coronary syndrome (ACS) were abstracted from the Nationwide Inpatient Sample database (2001-2011). Results: Among 247,456 OHCA patients, 11,111 (4.5%) had PCI while 236,345 (95.5%) did not. Patients who underwent PCI were younger than those who did not receive PCI (64 vs. 66 years), p p p p 65 years, female gender, AA or Hispanic race, advanced cancer, and liver dysfunction as independent factors associated with increased mortality, while PCI conferred a survival advantage in OHCA, p 50 years old, and those with Medicare. PCI significantly reduces mortality in OHCA patients and should be considered in all OHCA patients. Further investigation and development of methods to overcome the apparent socioeconomic barriers to PCI is required.

Introduction: Aortic dissection is a rare complication of Percutaneous Coronary Intervention (PCI) for Acute Coronary Syndrome (ACS), but is associated with mortality rates of up to 20%. This study assessed the demographic and clinical profile of a large cohort of patients undergoing PCI for ACS to assess patient and clinical risk factors that may predispose to the development of aortic dissection. Methods: The Nationwide Inpatient Sample (NIS) database (2001-2011) was used to abstract admission data on patients undergoing PCI for ACS. Results: 777,595 patients underwent PCI and 380 (0.05%) developed aortic dissection. Patients who developed aortic dissection were more often older (68 vs. 64 years), female (47.4% vs. 33.8%), insured through Medicare (56.2% vs. 50.7%), Medicaid (7.9% vs. 5.3%) or uninsured/self-pay (6.3% vs. 4.7%), p < 0.05. Patients with aortic dissection had a higher rate of ventricular fibrillation (6.3% vs. 1.8%), cerebrovascular accident (2.4% vs. 0.4%), longer lengths of hospitalization (9 days vs. 3 days), as well as higher mortality (13.2% vs. 1.4%), p < 0.001. Multivariate analysis identified female gender, Hispanic race, uninsured/self-pay, fluid and electrolyte disorders, and peripheral vascular disease (PVD) as independent risk factors for aortic dissection after PCI. Conclusion: Aortic dissection is a rare complication of PCI, which occurs more often in older patients with Medicare insurance status. Hispanics, females, uninsured patients and those with PVD are at the highest risk of aortic dissection. Clinicians should be more cognizant of patients at increased risk of developing PCI in order to institute earlier screening in high-risk patients.

Background Although burn patients with preexisting mood disorders have been shown to have diminished clinical recovery, acute mental disorders (AMD) are often unrecognized despite a link with post-traumatic stress disorder and social maladjustment later on. This study assessed the clinical profile of a large cohort of burn patients who developed AMD compared to those with chronic mental illness (CMI) and those without mental health problems to assess the impact of AMI on burn outcomes. Methods Admission data on 96,451 patients with third degree flame burns was abstracted from the Nationwide Inpatient Sample (NIS) Database from 2001 to 2011. AMD was defined as adjustment disorder (ICD-10 codes F43.2–F43.29) and acute stress disorder (F43.0), while CMI was defined as major depressive disorder (F33.0–F33.9) and bipolar disorder (F31.0–F31.9). Data was compared across three subgroups: AMD, CMI, and patients without any mood disorders. Categorical variables were compared using the Chi-square test, and continuous variables were compared using Student t-test and analysis of variance (ANOVA). Multivariate analysis using the “backward Wald” method was performed to calculate odds ratios (OR) and determine independent factors which increased the risk of developing AMD after burn. Results 979 (1%) burn patients were diagnosed with AMD, compared to 5971 (6.2%) with CMI and 89,501 (92.8%) without mood disorders at the time of the burn. Patients with AMD were significantly younger, predominantly male and Caucasian. Patients with AMD had a higher frequency of multiple third-degree burn sites. AMD patients had a significantly longer length of hospitalization and shorter actuarial survival. More AMD patients lacked social or family support, suffered from alcoholism or illicit drug abuse, and had a history of psychological trauma or self-inflicted injuries compared to other groups. After burn, 4.9% of AMD patients developed burn wound infections, 5.0% had nutritional deficiencies, 1.7% had skin graft failure, 0.7% had acute psychosis, and 3.7% had suicidal ideation, p

Background/Aims: Primary chordomas, rare cancers arising from the notochord remnants, are extremely rare in the pediatric population. This study examined a large cohort of primary chordoma patients to determine factors impacting prognosis and survival. Methods: Demographic and clinical data on 1,358 primary chordoma patients (86 pediatric patients ≤19 years of age and 1,272 adult patients ≥20 years of age) were abstracted from the Surveillance, Epidemiology, and End Result (SEER) database (1973-2011). Results: Pediatric primary chordomas present most often as small tumors Conclusions: Pediatric primary chordomas present most often as small tumors

Irreversible electroporation (IRE) for treatment of locally advanced pancreatic tumors is garnering increasing attention. This study was conducted to determine perioperative morbidity and mortality for locally advanced pancreatic cancer. Prospective data of 50 consecutive patients receiving IRE for T4 lesions at a single tertiary center were analyzed. The primary end point was Clavien–Dindo complications at 90 days, and the secondary outcomes were survival and recurrence. A total of 50 patients underwent 53 IRE procedures for primary treatment (n = 29) or margin extension (n = 24), and 47 patients had adenocarcinoma. Six patients died within 90 days after the procedure (5 in the primary control group). Mortality occurred a median of 26 days (range, 8–42 days) after the procedure. Five patients in both the margin-extension and primary control groups experienced grade 3 or 4 morbidity (p = 0.739). The incidences of grades 3 to 5 complications did not differ significantly based on the adjustable parameters of IRE, tumor size, or primary treatment versus margin extension. After a median follow-up period of 8.69 months [interquartile range (IQR), 0.26–16.26 months], the median overall survival period for the primary control group was 7.71 months [95 % confidence interval (CI), 6.03–12.0 months) and was not reached in the margin-extension group (p = 0.01, log-rank). At the authors’ center, the mortality rate after IRE was higher than reported in other series, with the majority occurring in the primary control group. Major morbidity trended around upper gastrointestinal bleeding, visceral ulcerations/perforations, and portal vein thromboses. This favors further investigation of the safety and efficacy of IRE.

Malignant melanoma accounts for 75% of all skin cancer deaths and is potentially curable if identified early. Although melanoma is rare in African–Americans (AA), it is associated with a worse prognosis than in Caucasians. This study examines the demographic, pathologic, and clinical factors impacting AA melanoma outcomes. Data for 1106 AA and 212,721 Caucasian cutaneous melanoma patients were abstracted from the Surveillance, Epidemiology, and End Result (SEER) database (1988–2011). Data were grouped on the basis of histological subtypes: “Superficial Spreading” (SS), “Nodular” (NM), “Lentigo Maligna” (LM), “Acral Lentiginous” (AL), and “Not otherwise specified” (NOS). Cutaneous malignant melanoma occurs most commonly in the sixth and seventh decade of life. Caucasian patients presented most commonly with trunk melanomas (34.5%), while lower extremity melanomas were more common in AAs (56.1%), P

Introduction. Gallbladder carcinoma (GBC) is the most common malignancy of the biliary tract and the third most common gastrointestinal tract malignancy. This study examines a large cohort of GBC patients in the United States in an effort to define demographics, clinical, and pathologic features impacting clinical outcomes. Methods. Demographic and clinical data on 22,343 GBC patients was abstracted from the SEER database (1973–2013). Results. GBC was presented most often among Caucasian (63.9%) females (70.7%) as poorly or moderately differentiated (42.5% and 38.2%) tumors, with lymph node involvement (88.2%). Surgery alone was the most common treatment modality for GBC patients (55.0%). Combination surgery and radiation (10.6%) achieved significantly longer survival rates compared to surgery alone (4.0±0.2 versus 3.7±0.1 years, p=0.004). Overall mortality was 87.0% and cancer-specific mortality was 75.4%. Conclusions. GBC is an uncommon malignancy that presents most often among females in their 8th decade of life, with over a third of cases presenting with distant metastasis. The incidence of GBC has doubled in the last decade concurrent with increases in cholecystectomy rates attributable in part to improved histopathological detection, as well as laparoscopic advances and enhanced endoscopic techniques. Surgical resection confers significant survival benefit in GBC patients.

Krishnaraj Mahendraraj,1 Christine SM Lau,1,2 Injoon Lee,2 Ronald S Chamberlain1–3 1Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA; 2St George’s University School of Medicine, Grenada, West Indies; 3Department of Surgery, New Jersey Medical School, Rutgers University, Newark, NJ, USA Introduction: Uveal melanoma (UM) is the most common primary intraocular malignancy, despite comprising 50years (OR 4.0, CI =3.4–4.6), distant metastases (OR 8.6, CI =4.7–15), and primary surgical treatment (OR 2.6, CI =2.0–3.3) as independently associated with increased mortality, P

Unintentional burn injury is the third most common cause of death in the U.S. for children age 5 to 9, and accounts for major morbidity in the pediatric population. Pediatric burn admission data from U.S. institutions has not been reported recently. This study assesses all pediatric burn admissions to a State wide Certified Burn Treatment Center to evaluate trends in demographics, burn incidence, and cause across different age groups. Demographic and clinical data were collected on 2273 pediatric burn patients during an 18-year period (1995-2013). Pediatric patients were stratified by age into "age 0 to 6," "age 7 to 12," and "age 13 to 18." Data were obtained from National Trauma Registry of the American College of Surgeons and analyzed using standard statistical methodology. A total of 2273 burn patients under age 18 were treated between 1995 and 2013. A total of 1663 (73.2%) patients were ages 0 to 6, 294 (12.9%) were 7 to 12, and 316 (13.9%) were age 13 to 18. A total of 1400 (61.6%) were male and 873 (38.4%) were female (male:female ratio of 1.6:1). Caucasians had the highest burn incidence across all age groups (40.9%), followed by African-Americans (33.6%), P < .001. Caucasian teenagers formed 62.1% of patients age 13-18, P < .001. A total of 66.3% of all pediatric burns occurred at home, P < .001. Mean TBSA burned was 8.9%, with lower extremity being the most common site (38.5%). Scald burns constituted the majority of cases (71.1%, n = 1617), with 53% attributable to hot liquids related to cooking, including coffee or tea, P < .001. In the teenage group, flame burns were the dominant cause (53.8%). Overall mean length of stay was 10.5 ± 10.8 days for all patients, and15.5 ± 12 for those admitted to the intensive care unit, P < .005. One hundred (4.4%) patients required ventilator support (P = .02), and average duration of mechanical ventilation was 11.9 ± 14.5 days. Skin grafting was performed for 520 (22.9%) patients, P < .001. Overall mortality was 0.9% (n = 20), with mean TBSA involved of 61.5%. The majority of pediatric burn injuries are scald burns that occur at home and primarily affect the lower extremities in Caucasian and African-American males. Among Caucasian teenagers flame burns predominate. Mean length of stay was 10 days, 23% of patients required skin grafting surgery, and mortality was 0.9%. The results of this study highlight the need for primary prevention programs focusing on avoiding home scald injuries in the very young, as well as fire safety training for teenagers.

Background Completion pancreatectomy (CP) is a reoperative procedure to excise remnant pancreatic tissue after a prior pancreatic resection. In this study, we document our institution’s experience with CP for recurrent malignant disease of the pancreas, describing indications for surgery, procedures performed, and patient outcomes. Methods We performed a retrospective review of 861 patients from the pancreatic surgery database in the Department of Surgery of Thomas Jefferson University from October 2005 to December 2010 to identify all cases of CP performed for suspected malignant disease. Results Eleven patients underwent reoperative CP at our institution from 2005 to 2010. The median time interval between the initial operation and CP was 32 mo. A combination of clinical symptoms, elevated tumor markers, and imaging studies were used for diagnosis of recurrent disease. Pancreatic ductal adenocarcinoma was the most common pathology, found in six patients. The postoperative complication rate was 18% and the median postoperative hospital length of stay was 6 d. There were no 30-d readmissions and no perioperative deaths. The 1-y survival rate following CP was 71% with an overall median survival of 17.5 mo. Conclusions CP is a safe and effective option for a highly selected group of patients with suspected recurrent malignant disease of the remnant pancreas. Morbidity and mortality rates are within acceptable limits and similar to initial pancreatic resection. Eligibility depends heavily upon the absence of distant metastatic disease, technical factors for resection, and patient performance status.

Christine SM Lau,1,2 Krishnaraj Mahendraraj,1 Ronald S Chamberlain1–31Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA; 2Saint George's University School of Medicine, Grenada, West Indies; 3Department of Surgery, New Jersey Medical School, Rutgers University, Newark, NJ, USA Introduction: Atypical teratoid rhabdoid tumors (ATRTs) are rare, highly malignant embryonal tumors of the central nervous system (CNS) accounting for 20% of CNS tumors in children under the age of 3. This study examines a large cohort of ATRT patients to determine demographic, clinical, and pathologic factors which impact prognosis and survival. Methods: Demographic and clinical data were abstracted on 174 ATRT patients (171 pediatric patients age 4 cm in male Caucasian children of age

Introduction. Hepatocellular carcinoma (HCC) is a rare pediatric cancer accounting for 0.5% of all pediatric malignancies. This study examines a large cohort of HCC patients in an effort to define the factors impacting clinical outcomes in pediatric HCC patients compared to adults. Methods. Demographic and clinical data on 63,771 HCC patients (257 pediatric patients ≤ 19 and 63,514 adult patients age ≥ 20) were abstracted from the SEER database (1973–2011). Results. HCC was more common among males (59.5% pediatric and 75.1% adults) and Caucasians (50.4% and 50.5%), p<0.05. Children more often presented with fibrolamellar variant HCC (24.1% versus 0.3%, p=0.71) and advanced HCC, including distant disease (33.1% versus 20.8%, p<0.001), and tumors > 4 cm in size (79.6% versus 62.0%, p=0.02). Pediatric HCC patients undergoing surgery (13.107 versus 8.324 years, p<0.001) had longer survival than adult HCC patients. Overall mortality was lower (65.8% versus 82.0%, p<0.001) in the pediatric HCC group. Conclusion. HCC is a rare pediatric malignancy that presents most often as an advanced tumor, >4 cm in Caucasian males. Children with HCC achieve significantly longer mean overall survival compared to adults with HCC, primarily attributable to the more favorable fibrolamellar histologic variant, and more aggressive surgical intervention, which significantly improves survival.

RESULTS: The 349 cases of MM were evenly distributed between age groups 65. A majority of MM occurred in Caucasians (86.8%) and in the bone marrow (73.4%). 55.6% of patients 65 were male. 55.6% of MM had lymph node invasion. 28.6% of patients >65 had a history of a prior malignancy compared to only 4.8% of patients 50. Multivariate analysis identified age 50-65 (OR 4.9) and age >65 (OR 17.3) as associated with increased mortality.