Minimal Access Surgery

Laparoscopic repeat hepatectomy for treating recurrent liver cancer Jingwei Cai, Junhao Zheng, Yangyang Xie, Mubarak Ali Kirih, Liye Tao, Xiao Liang Journal of Minimal Access Surgery 2021 17(1):1-6 Background: Laparoscopic repeat hepatectomy (LRH) is a technically challenging procedure, so LRH for recurrent liver cancer has not been widely accepted. The aim of this study was to perform a systematic review of the current literature to identify and evaluate available data of LRH for recurrent hepatocellular carcinoma (rHCC) and metastases tumour of liver, especially of colorectal liver metastases (CRLM), focusing on the safety and feasibility. Methods: A comprehensive search of the PubMed database was performed for all studies published in English evaluating LRH for rHCC and recurrent metastases tumour of liver from 1st January, 2005 to 1st June, 2019. Results: A total of 15 studies which comprised 444 patients and reported outcomes for the efficacy and safety of LRH in the treatment of rHCC or CRLM were included in the present review. Moreover, nine studies compared the perioperative outcomes of LRH versus open repeat hepatectomy (ORH). LRH was superior to ORH with reduced blood loss, shorter operative time, shorter hospital stay and lower morbidity rates. Conclusions: LRH can safely performed in rHCC or CRLM patients with cirrhosis, previous open hepatectomy, multiple recurrent lesions and tumours located in difficult posterosuperior segments.

Hybrid approach for ventral incisional hernias of the abdominal wall: A systematic review of the literature Anil Sharma, Chaitanya Sinha, Manish Baijal, Vandana Soni, Rajesh Khullar, Pradeep Chowbey Journal of Minimal Access Surgery 2021 17(1):7-13 With increasing complexity of ventral incisional hernias being operated on, the treatment strategy has also evolved to obtain optimal results. Hybrid ventral hernia repair is a promising technique in management of complex/difficult ventral incisional hernias. The aim of this article is to review the literature and analyse the results of hybrid technique in management of ventral incisional hernia and determine its clinical status and ascertain its role. We reviewed the literature on hybrid technique for incisional ventral hernia repair on PubMed, Medline and Google Scholar database published between 2002 and 2019 and out of 218 articles screened, 10 studies were included in the review. Selection of articles was in accordance with the PRISMA guideline. Variables analysed were seroma, wound infection, chronic pain and recurrence. Qualitative analysis of the variables was carried out. In this systematic review, the incidence of complications associated within this procedure were seroma formation (5.47%), wound infections (6.53%) and chronic pain (4.49%). Recurrence was seen in 3.29% of patients. Hybrid ventral hernia repair represents a natural evolution in advancement of hernia repair. The judicious use of hybrid repair in selected patients combines the safety of open surgery with several advantages of the laparoscopic approach with favourable surgical outcomes in terms of recurrence, seroma and incidence of chronic pain. However, larger multi-centric prospective studies with long term follow up is required to standardise the technique and to establish it as a procedure of choice for this complex disease entity.

Enhanced recovery after surgery in laparoscopic distal gastrectomy: Protocol for a prospective single-arm clinical trial Xinhua Chen, Yu Zhu, Mingli Zhao, Yanfeng Hu, Jun Luo, Yuehong Chen, Tian Lin, Hao Chen, Hao Liu, Guoxin Li, Jiang Yu Journal of Minimal Access Surgery 2021 17(1):14-20 Background: The enhanced recovery after surgery (ERAS) programme is feasible and effective in reducing the length of hospital stay, overall complication rates and medical costs when applied to cases involving colonic and rectal resections. However, a recent prospective, randomised, open, parallel-controlled trial (Chinese Laparoscopic Gastrointestinal Surgery Study-01 trial), initiated by our team, indicated that under conventional peri-operative management, the reduction of the post-operative hospital stay of laparoscopic distal gastrectomy (LDG) is quite limited compared with open gastrectomy. Thus, if we could provide valuable clinical evidence for demonstrating the efficacy of the ERAS programme for gastric cancer patients undergoing LDG, it would significantly enhance the peri-operative management of gastrectomy and benefit the patients. Methods: In this prospective single-arm trial, patients who are 18–75 years of age with gastric adenocarcinoma diagnosed with cT1-4aN0-3M0 and expected to undergo curative resection through LDG, are considered eligible for this study. All participants underwent LDG with peri-operative management under the ERAS programme. The primary outcome measures included the post-operative hospital stays and rehabilitative rate of the post-operative day 4. The secondary outcome measures are morbidity and mortality (time frame: 30 days), post-operative recovery index (time frame: 30 days), post-operative pain intensity (time frame: 3 days) and the medical costs from surgery to discharge. Conclusion: With reasonable and scientific designing, the trial may be a great help to further discuss the benefit of ERAS programme and thus improving the peri-operative management of patients with gastrectomy.

Laparoscopic versus open extended cholecystectomy with bi-segmentectomy (s4b and s5) in patients with gallbladder cancer Hirdaya Hulas Nag, Ashish Sachan, Phani Kumar Nekarakanti Journal of Minimal Access Surgery 2021 17(1):21-27 Introduction: The outcome of laparoscopic extended cholecystectomy (EC) with wedge hepatic resection (LECW) in patients with gallbladder cancer (GBC) has been compared with that of open EC with wedge hepatic resection (OECW), but studies comparing laparoscopic EC with bi-segmentectomy (LECB) with open EC with bi-segmentectomy (OECB) are lacking. Patients and Methods: This retrospective study comprised of 68 patients with GBC who were offered either LECB or OECB from July 2011 to July 2018. Patients were divided into laparoscopic group (LG) and open group (OG), and appropriate statistical methods were used for comparison. Results: Out of the total 68 patients, 30 patients were in LG and 38 patients were in OG. Demographic, clinical and biochemical characteristics were similar except significantly higher number of male patients in OG (P = 0.01). In LG versus OG, the mean operation time was 286 versus 274 min (P = 0.565), mean blood loss was 158 versus 219 ml (P = 0.006) and mean hospital stay was 6.4 versus 9 days (P = 0.0001). The complication rate was 16.6% in LG and 31.5% in OG, but this difference was not statistically significant (P = 0.259). The median number of lymph nodes was 12 in both LG and OG (P = 0.62). Distribution of patients among American Joint Committee on Cancer stages I to IV was similar in both the groups (P = 0.5). Fifty percent of the patients in both the groups received adjuvant treatment (P = 1). In LG versus OG, the recurrence rate was 20% versus 28.9% (P = 0.4), mean recurrence-free survival was 48 months versus 44 months (P = 0.35) and overall survival was 51 months versus 46 months (P = 0.45). In LG versus OG, 1, 3 and 5-year survival was 96% versus 94%, 79% versus 72% and 79% versus 62% (P = 0.45). The median follow-up was statistically significantly shorter (24 vs. 36 months) in LG versus OG (P = 0.0001). Conclusions: The oncological outcome and survival after LECB in patients with resectable GBC is not inferior to that after OECB. Laparoscopic approach has a potential to improve perioperative outcome in patients with GBC.

Re-interventions and re-admissions in a 13-year series following use of laparoscopic subtotal cholecystectomy Michelle Slater, Sumit Midya, Michael Booth Journal of Minimal Access Surgery 2021 17(1):28-31 Background: Laparoscopic subtotal cholecystectomy (LSTC) without cystic duct ligation is an alternative to conversion to open surgery in a difficult cholecystectomy, thus avoiding a potentially hazardous dissection in Calot's triangle. The long-term outcomes of this procedure are not well reported. The aim of this study is to assess the rates of re-presentation, re-admissions, endoscopic interventions and completion cholecystectomy in patients who have undergone LSTC. Methods: Details of all patients undergoing cholecystectomy over a 13-year period (2003–2015) were entered on a prospective database. Further information on subsequent hospital attendances, biliary imaging, endoscopic interventions and re-operations following the index LSTC was collected retrospectively from hospital database. Results: Overall, 2313 patients underwent laparoscopic cholecystectomy. Eighty-five patients (3.7%) underwent LSTC and the rest had standard laparoscopic cholecystectomy. A controlled bile leak was observed in 16 (19%) patients post-operatively, of which 3 resolved spontaneously. The remaining 13 were managed with an early endoscopic retrograde cholangiopancreatography (ERCP) and biliary stent. Twenty-seven patients (32%), who underwent LSTC, were re-investigated for the upper abdominal symptoms. The time range for re-investigation was 21 days–124 months. Eight patients underwent ERCP post-discharge, for suspected bile duct stones on radiological imaging. Two patients required open completion cholecystectomy for symptomatic stones in the gallbladder remnant. Conclusion: LSTC is a feasible and safe alternative to open surgery with acceptable long-term consequences and re-interventions.

Robotic surgery in paediatric patients: Our initial experience and roadmap for successful implementation of robotic surgery programme Arvind Sinha, Manish Pathak, Ayushi Vig, Rahul Saxena Journal of Minimal Access Surgery 2021 17(1):32-36 Introduction: The popularity of robot-assisted surgeries has accelerated since its advent in 1990s. Recently, we procured da Vinci surgical system in our institution; and here, we present our initial experience of robot-assisted surgeries at our hospital. We also discuss the stepwise approach for successful implementation of the robotic surgical programme at our institute. Moreover, the importance of efficient use of this advanced but expensive technology has been highlighted. Materials and Methods: Retrospective analysis of the medical record of all the paediatric patients between the age ranges of 1–18 years who had undergone robotic-assisted laparoscopic surgery during April 2019–April 2019 was done. Medical record was reviewed for descriptive data, clinical presentation, investigations, operative details and follow-up. Statistical data were also obtained from medical superintendent office. Results: During April 2018–April 2019, total of 111 cases were operated across six specialities. Approximately 73% of cases (81/111) belonged to adult urology and gynaecology speciality. Less than 5% (5/111) of patients were in paediatric age group. The department of paediatric surgery performed one pyeloplasty, 3 ureteric reimplantation and 1 bladder diverticulum excision with robot assistance. The operative duration of the cases was comparable to the standard laparoscopic techniques. All patients are asymptomatic on follow-up visits. Conclusion: The robotic surgery is feasible in paediatric population and has favourable post-operative outcomes. Detailed planning and stepwise approach is key to the establishment of new robotic surgery programme in any institute.

Single-port laparoscopic appendectomy for acute appendicitis during pregnancy In Soo Cho, Sung Uk Bae, Woon Kyung Jeong, Seong Kyu Baek Journal of Minimal Access Surgery 2021 17(1):37-42 Aim of Study: Acute appendicitis is the most common non-obstetric surgical problem in pregnant patients. As minimally invasive surgery has developed, minimising surgical trauma and improving cosmetic outcomes have led to the development of single-port laparoscopic surgery (SPLS). The aim of this study was to assess the feasibility and safety of SPLS for acute appendicitis during pregnancy. Patients and Methods: Between September 2014 and May 2016, 12 pregnant patients diagnosed with acute appendicitis and having single-port laparoscopic appendectomy were included in the study. Results: The median gestational age at surgery was 16 weeks (6–30 weeks). All operations were completed safely and without vascular or visceral injury. Four patients (33.3%) required conversion to a reduced-port laparoscopic surgery with 3 patients (25%) having a 5 mm port inserted because of perforated appendicitis with drain placement, and 1 patient (8.3%) having a 2-mm needle instrument insertion. Median operation time was 60 min (32–100 min), and a drainage tube was placed in 5 patients (41.7%). Median total length of incision was 2 cm (1.2–2.5 cm). The median time to soft diet initiation and length of stay in the hospital were 1 day (0–9 days) and 5 days (2–11 days), respectively. Two patients (8.0%) developed post-operative complications: One wound site bleeding and two surgical site infections. One case of abortion (8.3%) was noted on the post-operative day 1 and one case of imperforate hymen was noted after delivery. Conclusions: SPLS appendectomy is feasible and safe for treating patients with acute appendicitis during pregnancy.

A new manoeuvre of vascular control in laparoscopic spleen-preserving distal pancreatectomy: Retrospective review for a modified Kimura's method Zhu Jie, Li Hong, Zhang Bin, Wang Haibiao Journal of Minimal Access Surgery 2021 17(1):43-48 Background: The aim of this study is to explore a new manoeuvre of vascular control technique in laparoscopic spleen-preserving distal pancreatectomy (LSPDP). Materials and Methods: A total of 63 patients were diagnosed with pancreatic tumour in our hospital from January 2013 to December 2018. In these cases, Kimura technique was utilised in 33 patients and total blood flow blocked technique was used in 30 patients. The clinical data of these 63 patients of were retrospectively analysed. Results: Four groups of patients were operated smoothly. In Kimura group, 33 patients were carried out using Kimura technique. Four patients' spleens were resected because the spleen artery was damaged. Three patients among them were converted to open surgery. In the other group, one patient was converted to open and resected the spleen. When comparing the Kimura group with the last series group, the mean surgical time decreased by 27 min, the estimated blood loss decreased by 108 ml, which had a significant statistical difference, whereas postoperative haemorrhage and postoperative pancreatic fistula had no statistical difference. Conclusion: After ten patient's practice, application of new manoeuvre of vascular control technique in LSPDP is feasible and safe, with advantages of less blood loss and shorter operation time.

Minimally invasive oesophagectomy with a total two-field lymphadenectomy after neoadjuvant chemoradiotherapy for locally advanced squamous cell carcinoma of the oesophagus: A prospective study Kuppusamy Sasikumar, Raja Kalayarasan, Senthil Gnanasekaran, Sandip Chandrasekar, Biju Pottakkat Journal of Minimal Access Surgery 2021 17(1):49-55 Introduction: In the era of neoadjuvant chemoradiotherapy (NACTRT), the safety and clinical significance of radical lymphadenectomy specifically lymphadenectomy along the recurrent laryngeal nerve (RLN) has been questioned. Furthermore, the compliance to NACTRT with the CROSS regimen has not been well studied in the Indian population. This prospective study aimed to determine the compliance with CROSS regimen, feasibility and short-term outcomes of minimally invasive oesophagectomy (MIE) with a total two-field lymphadenectomy after NACTRT. Methods: A prospective study (January 2014 to December 2018) of patients with locally advanced oesophageal squamous cell carcinoma (SCC) eligible for NACTRT (cT1-4a, N0-1, M0) with CROSS regimen followed by MIE with total two-field lymphadenectomy. The compliance rate, post-operative complications and the pathological response rate were assessed. Results: Of the 166 patients with locally advanced SCC, 76 (45.8%) were eligible for NACTRT and 34 completed NACTRT followed by MIE with a total two-field lymphadenectomy (study group). Twenty-nine (38.1%) patients did not complete NACTRT due to complications or poor compliance. Median (range) blood loss was 125 (50–450) ml and the median (range) operation time for the thoracoscopic phase was 205 (155–325) min. Total median (range) lymph node count and mediastinal lymph node counts were 20 (11–33) and 12, (8–21) respectively. Most common post-operative complications were pneumonia (n = 12, 35.3%) followed by RLN palsy (n = 10, 29.4%). Of the 22 patients who had a complete pathological response of the primary tumour, 7 (31.8%) patients had a node-positive disease. Conclusion: NACTRT followed by MIE is feasible in patients with locally advanced SCC. The nodal disease is common even in patients with the complete pathological response of the primary tumour. The dropout rate with NACTRT using the CROSS regimen is high in the present study.

Transanal total mesorectal excision for rectal cancer: Surgical outcomes and short-term oncological outcomes in a single-institution consecutive series Irit Shimoni, Moris Venturero, Ron Shapiro, Gali Westrich, Gal Schtrechman, David Hazzan, Aviram Nissan, Douglas Zippel, Lior Segev Journal of Minimal Access Surgery 2021 17(1):56-62 Introduction: Rectal cancer surgery is continuously evolving. Transanal total mesorectal excision (TaTME) is a relatively new surgical approach with possible advantages in comparison to current standard surgical techniques. Several studies in recent years have validated this approach regarding safety and effectiveness. We describe our initial experience with TaTME evaluating surgical parameters, post-operative outcomes and short-term oncological outcomes. Methods: This is a retrospective study reviewing all patients who underwent TaTME in a single institution from May 2015 to April 2018. Results: The cohort included 25 patients with an average age of 60.4 (range: 40–86), of which 13 (52%) patients were male. The average body mass index was 26.1. The overall 30-day morbidity rate was 40%, with 20% (five cases) being severe complications, defined by Clavien–Dindo Grade of 3b or above. There were three major interoperative complications. Four cases (16%) required reoperation during the first 30 post-operative days. The median length of stay was 8 days. The surgery duration was on average 296 min (range: 205–510). Negative resection margins were achieved in all patients. At a median follow-up period of 14 months, there were no local recurrences, and 4 cases (16%) had a distant recurrence. Conclusion: This study describes our initial experience with TaTME, which requires a substantial learning curve to minimise complications and morbidity. Oncological outcomes as expressed by the resection margins, number of lymph nodes harvested and local recurrence rates were all comparable to previously published data.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Anesthesia & Analgesia

Clinical Outcomes of Pregnant and Postpartum Extracorporeal Membrane Oxygenation Patients BACKGROUND: The use of extracorporeal membrane oxygenation (ECMO) as a rescue therapy for cardiopulmonary failure is expanding in critical care medicine. In this case series, we describe the clinical outcomes of 21 consecutive pregnant or postpartum patients that required venovenous (VV) or venoarterial (VA) ECMO. Our objective was to characterize maternal and fetal survival in peripartum ECMO and better understand ECMO-related complications that occur in this unique patient population. METHODS: Between January 2009 and June 2019, all pregnant and postpartum patients treated with ECMO for respiratory or circulatory failure at a single quaternary referral center were identified. For all patients, indications for ECMO, maternal and neonatal outcomes, details of ECMO support, and anticoagulation and bleeding complications were collected. RESULTS: Twenty-one obstetric patients were treated with ECMO over 10 years. Thirteen patients were treated with VV ECMO and 8 patients were treated with VA ECMO. Six patients were pregnant at the time of cannulation and 3 patients delivered while on ECMO; all 6 maternal and infant dyads survived to hospital discharge. The median gestational age at cannulation was 28 weeks (interquartile range [IQR], 24–31). In the postpartum cohort, ECMO initiation ranged from immediately after delivery up to 46 days postpartum. Fifteen women survived (72%). Major bleeding complications requiring surgical intervention were observed in 7 patients (33.3%). Two patients on VV ECMO required bilateral orthotopic lung transplantation and 1 patient on VA ECMO required orthotopic heart transplantation to wean from ECMO. CONCLUSIONS: Survival for mother and neonate are excellent with peripartum ECMO in a high-volume ECMO center. Neonatal and maternal survival was 100% when ECMO was used in the late second or early third trimester. Based on these results, ECMO remains an important treatment option for peripartum patients with cardiopulmonary failure.

Efficiency Metrics at an Academic Freestanding Ambulatory Surgery Center: Analysis of the Impact on Scheduled End-Times BACKGROUND: Understanding the impact of key metrics on operating room (OR) efficiency is important to optimize utilization and reduce costs, particularly in freestanding ambulatory surgery centers. The aim of this study was to assess the association between commonly used efficiency metrics and scheduled end-time accuracy. METHODS: Data from patients who underwent surgery from May 2018 to June 2019 at an academic freestanding ambulatory surgery center was extracted from the medical record. Unique operating room days (ORDs) were analyzed to determine (1) duration of first case delays, (2) turnover times (TOT), and (3) scheduled case duration accuracies. Spearman's correlation coefficients and mixed-effects multivariable linear regression were used to assess the association of each metric with scheduled end-time accuracy. RESULTS: There were 1378 cases performed over 300 unique ORDs. There were 86 (28.7%) ORDs with a first case delay, mean (standard deviation [SD]) 11.2 minutes (15.1 minutes), range of 2–101 minutes; the overall mean (SD) TOT was 28.1 minutes (19.9 minutes), range of 6–83 minutes; there were 640 (46.4%) TOT >20 minutes; the overall mean (SD) case duration accuracy was −6.6 minutes (30.3 minutes), range of −114 to 176; and there were 389 (28.2%) case duration accuracies ≥30 minutes. The mean (SD) scheduled end-time accuracy was 6.9 minutes (68.3 minutes), range of −173 to 229 minutes; 48 (15.9%) ORDs ended ≥1 hour before scheduled end-time and 56 (18.6%) ORDs ended ≥1 hour after scheduled end-time. The total case duration accuracy was strongly correlated with the scheduled end-time accuracy (r = 0.87, 95% confidence interval [CI], 0.84-0.89, P < .0001), while the total first case delay minutes (r = 0.12, 95% CI, 0.01-0.21, P = .04) and total turnover time (r = −0.16, 95% CI, 0.21-0.05, P = .005) were less relevant. Case duration accuracy had the highest association with the dependent variable (0.95 minutes changed in the difference between actual and schedule end time per minute increase in case duration accuracy, 95% CI, 0.90-0.99, P < .0001), compared to turnover time (estimate = 0.87, 95% CI, 0.75-0.99, P < .0001) and first case delay time (estimate = 0.83, 95% CI, 0.56-1.11, P < .0001). CONCLUSIONS: Standard efficiency metrics are similarly associated with scheduled end-time accuracy, and addressing problems in each is requisite to having an efficient ambulatory surgery center. Pursuing methods to narrow the gap between scheduled and actual case duration may result in a more productive enterprise.

Postoperative Morbidity and Mortality in Diabetic Patients After Fast-Track Hip and Knee Arthroplasty: A Prospective Follow-up Cohort of 36,762 Procedures BACKGROUND: Diabetes increases the risk of adverse outcomes in surgical procedures, including total hip and knee arthroplasty (THA/TKA), and the prevalence of diabetic patients undergoing these procedures is high, ranging from approximately 8% to 20%. However, there is still a need to clarify the role of diabetes and antihyperglycemic treatment in a fast-track THA/TKA setting, which otherwise may decrease morbidity. Consequently, we investigated the association between diabetes and antihyperglycemic treatment on length of stay (LOS) and complications following fast-track THA/TKA within a multicenter fast-track collaboration. METHODS: We used an observational study design on data from a prospective multicenter fast-track collaboration on unselected elective primary THA/TKA from 2010 to 2017. Complete follow-up (>99%) was achieved through The Danish National Patient Registry, antihyperglycemic treatment established through the Danish National Database of Reimbursed Prescriptions and types of complications leading to LOS >4 days, 90-day readmission or mortality obtained by scrutinizing health records and discharge summaries. Patients were categorized as nondiabetic and if diabetic into insulin-, orally, and dietary-treated diabetic patients. RESULTS: A total of 36,762 procedures were included, of which 837 (2.3%) had insulin-treated diabetes, 2615 (7.1%) orally treated diabetes, and 566 (1.5%) dietary-treated diabetes. Overall median LOS was 2 (interquartile range [IQR]: 1–3) days, and mean LOS was 2.4 (standard deviation [SD], 2.5) days. The proportion of patients with LOS >4 days was 6.0% for nondiabetic patients, 14.7% for insulin-treated, 9.4% for orally treated, and 9.5% for dietary-treated diabetic patients. Pharmacologically treated diabetes (versus nondiabetes) was independently associated with increased odds of LOS >4 days (insulin-treated: odds ratio [OR], 2.2 [99.6% confidence interval {CI}, 1.3–3.7], P < .001; orally treated: OR, 1.5 [99.6% CI, 1.0-2.1]; P = .002). Insulin-treated diabetes was independently associated with increased odds of "diabetes-related" morbidity (OR, 2.3 [99.6% CI, 1.2-4.2]; P < .001). Diabetic patients had increased renal complications regardless of antihyperglycemic treatment, but only insulin-treated patients suffered significantly more cardiac complications than nondiabetic patients. There was no increase in periprosthetic joint infections or mortality associated with diabetes. CONCLUSIONS: Patients with pharmacologically treated diabetes undergoing fast-track THA/TKA were at increased odds of LOS >4 days. Although complication rates were low, patients with insulin-treated diabetes were at increased odds of postoperative complications compared to nondiabetic patients and to their orally treated counterparts. Further investigation into the pathogenesis of postoperative complications differentiated by antihyperglycemic treatment is needed.

Intermittent Hypoxia and Effects on Early Learning/Memory: Exploring the Hippocampal Cellular Effects of Pediatric Obstructive Sleep Apnea This review provides an update on the neurocognitive phenotype of pediatric obstructive sleep apnea (OSA). Pediatric OSA is associated with neurocognitive deficits involving memory, learning, and executive functioning. Adenotonsillectomy (AT) is presently accepted as the first-line surgical treatment for pediatric OSA, but the executive function deficits do not resolve postsurgery, and the timeline for recovery remains unknown. This finding suggests that pediatric OSA potentially causes irreversible damage to multiple areas of the brain. The focus of this review is the hippocampus, 1 of the 2 major sites of postnatal neurogenesis, where new neurons are formed and integrated into existing circuitry and the mammalian center of learning/memory functions. Here, we review the clinical phenotype of pediatric OSA, and then discuss existing studies of OSA on different cell types in the hippocampus during critical periods of development. This will set the stage for future study using preclinical models to understand the pathogenesis of persistent neurocognitive dysfunction in pediatric OSA.

Development and Evaluation of a Risk-Adjusted Measure of Intraoperative Hypotension in Patients Having Nonemergent, Noncardiac Surgery BACKGROUND: Intraoperative hypotension is common and associated with organ injury and death, although randomized data showing a causal relationship remain sparse. A risk-adjusted measure of intraoperative hypotension may therefore contribute to quality improvement efforts. METHODS: The measure we developed defines hypotension as a mean arterial pressure <65 mm Hg sustained for at least 15 cumulative minutes. Comparisons are based on whether clinicians have more or fewer cases of hypotension than expected over 12 months, given their patient mix. The measure was developed and evaluated with data from 225,389 surgeries in 5 hospitals. We assessed discrimination and calibration of the risk adjustment model, then calculated the distribution of clinician-level measure scores, and finally estimated the signal-to-noise reliability and predictive validity of the measure. RESULTS: The risk adjustment model showed acceptable calibration and discrimination (area under the curve was 0.72 and 0.73 in different validation samples). Clinician-level, risk-adjusted scores varied widely, and 36% of clinicians had significantly more cases of intraoperative hypotension than predicted. Clinician-level score distributions differed across hospitals, indicating substantial hospital-level variation. The mean signal-to-noise reliability estimate was 0.87 among all clinicians and 0.94 among clinicians with >30 cases during the 12-month measurement period. Kidney injury and in-hospital mortality were most common in patients whose anesthesia providers had worse scores. However, a sensitivity analysis in 1 hospital showed that score distributions differed markedly between anesthesiology fellows and attending anesthesiologists or certified registered nurse anesthetists; score distributions also varied as a function of the fraction of cases that were inpatients. CONCLUSIONS: Intraoperative hypotension was common and was associated with acute kidney injury and in-hospital mortality. There were substantial variations in clinician-level scores, and the measure score distribution suggests that there may be opportunity to reduce hypotension which may improve patient safety and outcomes. However, sensitivity analyses suggest that some portion of the variation results from limitations of risk adjustment. Future versions of the measure should risk adjust for important patient and procedural factors including comorbidities and surgical complexity, although this will require more consistent structured data capture in anesthesia information management systems. Including structured data on additional risk factors may improve hypotension risk prediction which is integral to the measure's validity.

Do Elderly Patients With Diastolic Dysfunction Require Higher Doses of Norepinephrine During General Anesthesia for Noncardiac Surgeries? A Prospective Observational Study BACKGROUND: Diastolic dysfunction is a risk factor for postoperative major cardiovascular events. During anesthesia, patients with diastolic dysfunction might experience impaired hemodynamic function and worsening of diastolic function, which in turn, might be associated with a higher incidence of postoperative complications. We aimed to investigate whether patients with diastolic dysfunction require higher doses of norepinephrine during general anesthesia. Furthermore, we aimed to examine the association between the grade of diastolic dysfunction and the E/e' ratio during anesthesia. A high E/e' ratio corresponds to elevated filling pressures and is an important measure of impaired diastolic function. METHODS: We conducted a prospective observational cohort study at a German university hospital from February 2017 to September 2018. Patients aged ≥60 years and undergoing general anesthesia (ie, propofol and sevoflurane) for elective noncardiac surgery were enrolled. Exclusion: mitral valve disease, atrial fibrillation, and implanted mechanical device. The primary outcome parameter was the administered dose of norepinephrine within 30 minutes after anesthesia induction (μg·kg−1 30 min−1). The secondary outcome parameter was the change of Doppler echocardiographic E/e' from ECHO1 (baseline) to ECHO2 (anesthesia). Linear models and linear mixed models were used for statistical evaluation. RESULTS: A total of 247 patients were enrolled, and 200 patients (75 female) were included in the final analysis. Diastolic dysfunction at baseline was not associated with a higher dose of norepinephrine during anesthesia (P = .6953). The grade of diastolic dysfunction at baseline was associated with a decrease of the E/e' ratio during anesthesia (P < .001). CONCLUSIONS: We did not find evidence for an association between diastolic dysfunction and impaired hemodynamic function, as expressed by high vasopressor support during anesthesia. Additionally, our findings suggest that diastolic function, as expressed by the E/e' ratio, does not worsen during anesthesia.

Fiber-Needle Swept-Source Optical Coherence Tomography for the Real-Time Visualization of the Transversus Abdominis Plane Block Procedure in a Swine Model BACKGROUND: Fascia blocks (eg, the transversus abdominis plane [TAP] block) target the intermuscular fascia layers. Ultrasound techniques have allowed peripheral blocks to be performed with accuracy and safety, however, with limitations. Optical coherence tomography (OCT) is based on low-coherence interferometry. In this study, we examined the ability of OCT to identify the TAP. METHODS: A swept-source OCT probe was placed in a 17-gauge needle to obtain imaging. The needle was inserted within 2 different angle ranges (0°–30° and 30°–60°) on a slice of pork belly to assess imaging characteristics. A series of real-time OCT imaging of the muscle, fascia, and interfascial space was obtained. The tissue location of the needle tip was identified using near-infrared (NIR) imaging. In vivo OCT imaging was further done on 3 female 6-month-old native Chinese Landrance Duroc pigs. Real-time images of tissue layers were obtained with needle insertion. Ultrasound imaging of the OCT needle probe was also performed at the same time for needle trajectory guidance. After imaging, the OCT probe was removed, and 5 mL of normal saline was injected via the needle to confirm correct fascia plane identification. RESULTS: In and ex vivo studies showed clear visual distinction of muscle, fascia, and interfascial layer with OCT, with limitations. Independent validation of OCT criteria for the muscle/fascia differentiation by 20 OCT readers for the in vivo data demonstrated the sensitivity = 0.91, specificity = 0.90, and accuracy = 0.89. Although the angle of needle entry affected the depth of OCT penetration in the muscle, the attenuation coefficient values of the fascia and muscle tissue were statistically different (P < .001) and with high area under the receiver operating characteristics (ROC) curve (AUC) (AUC = 0.93 in 0°–30° and AUC = 1 in 30°–60°) for fascia identification. CONCLUSIONS: This study introduced a novel needle imaging probe method to identify the transversus abdominis fascia plane in real-time. Quantitative calculation of the attenuation coefficients can further aid objective identification by providing direct confirmation of the tip position, increasing the first-pass success rate, and decreasing the need for needle repositioning. Combining OCT and ultrasound may improve the accuracy of anesthetics placement.

Incidence, Mortality, and Characteristics of 18 Pediatric Perioperative Cardiac Arrests: An Observational Trial From 22,650 Pediatric Anesthesias in a German Tertiary Care Hospital BACKGROUND: Recently, a very low incidence of 3 per 10,000 and a mortality of 30% were reported for pediatric perioperative cardiac arrest (POCA). However, high-risk patients, namely children already anesthetized on the intensive care unit (ICU), were excluded. This study investigates the incidence and mortality of POCA in children in whom anesthesia was induced in the ICU or in the operating room using real-world data. In addition, different classifications of POCA were compared with respect to outcome relevance. METHODS: This is a retrospective observational study conducted at a German level 1 perinatal center and tertiary care hospital between 2008 and 2018. Children ≤15 years who underwent an anesthetic procedure and suffered from POCA (defined as any condition requiring chest compressions and/or defibrillation) from the beginning of care provided by an anesthesiologist to 60 minutes after anesthesia or sedation were included. Primary end points were incidence and mortality of POCA in children with anesthesia induced in the ICU versus in the operating room. Secondary end points included incidences and outcomes with respect to the pathophysiological cause (respiratory versus circulatory associated). RESULTS: There were 18 POCA during 22,650 anesthetic procedures (incidence 7.9 per 10,000; 95% confidence interval [CI], 4.7-12.5). Thirty-day mortality was 3.5 per 10,000 (95% CI, 1.5-6.9). Incidence and mortality were higher in children in whom anesthesia was induced in the ICU versus in the operating room (incidence: 131.6; 95% CI, 57 to 257.6 versus 4.5; 95% CI, 2.2-8.3; P < .001; and mortality: 82.2; 95% CI, 26.7-190.8 versus 1.4; 95% CI, 0.3-3.9; P < .001). Mortality in circulatory-induced POCA (n = 8; 44%) was 100%, in respiratory-induced POCA (n = 9; 50%) 0% (P < .001). CONCLUSIONS: Children with anesthesia induction in the ICU represent a high-risk population for POCA and POCA-associated mortality. POCA classification should be based on the individual cause (respiratory versus circulatory) rather than on the perioperative phase or the responsible specialty.

A Bayesian Comparison of Frailty Instruments in Noncardiac Surgery: A Cohort Study BACKGROUND: Frailty—a multidimensional syndrome related to age- and disease-related deficits—is a key risk factor for older surgical patients. However, it is unknown which frailty instrument most accurately predicts postoperative outcomes. Our objectives were to quantify the probability of association and relative predictive performance of 2 frailty instruments (ie, the risk analysis index-administrative [RAI-A] and 5-item modified frailty index [mFI-5]) with postoperative outcomes in National Surgical Quality Improvement Program (NSQIP) data. METHODS: Retrospective cohort study using Bayesian analysis of NSQIP hospitals. Adults having inpatient small or large bowel surgery 2010–2015 (derivation cohort) or intermediate to high risk mixed noncardiac surgery in 2016 (validation cohort) had preoperative frailty assigned using 2 unique approaches (RAI-A and mFI-5). Probabilities of association were calculated based on posterior distributions and relative predictive performance using posterior predictive distributions and Bayes factors for 30-day mortality (primary outcome) and serious complications (secondary outcome). RESULTS: Of 50,630 participants, 7630 (14.0%) died and 19,545 (38.6%) had a serious complication. Without adjustment, the RAI-A and mFI-5 had >99% probability being associated with mortality with a ≥2.0 odds ratio (ie, large effect size). After adjustment for NSQIP risk calculator variables, only the RAI-A had ≥95% probability of a nonzero association with mortality. Similar results arose when predicting postoperative complications. The RAI-A provided better predictive accuracy for mortality than the mFI-5 (minimum Bayes factor 3.25 × 1014), and only the RAI-A improved predictive accuracy beyond that of the NSQIP risk calculator (minimum Bayes factor = 4.27 × 1013). Results were consistent in leave-one-out cross-validation. CONCLUSIONS: Translation of frailty-related findings from research and quality improvement studies to clinical care and surgical planning will be aided by a consistent approach to measuring frailty with a multidimensional instrument like RAI-A, which appears to be superior to the mFI-5 when predicting outcomes for inpatient noncardiac surgery.

Assessment of Anesthesia Capacity in Public Surgical Hospitals in Guatemala BACKGROUND: International standards for safe anesthetic care have been developed by the World Federation of Societies of Anaesthesiologists (WFSA) and the World Health Organization (WHO). Whether these standards are met is unknown in many nations, including Guatemala, a country with universal health coverage. We aimed to establish an overview of anesthesia care capacity in public surgical hospitals in Guatemala to help guide public sector health care development. METHODS: In partnership with the Guatemalan Ministry of Public Health and Social Assistance (MSPAS), a national survey of all public hospitals providing surgical care was conducted using the WFSA anesthesia facility assessment tool (AFAT) in 2018. Each facility was assessed for infrastructure, service delivery, workforce, medications, equipment, and monitoring practices. Descriptive statistics were calculated and presented. RESULTS: Of the 46 public hospitals in Guatemala in 2018, 36 (78%) were found to provide surgical care, including 20 district, 14 regional, and 2 national referral hospitals. We identified 573 full-time physician surgeons, anesthesiologists, and obstetricians (SAO) in the public sector, with an estimated SAO density of 3.3/100,000 population. There were 300 full-time anesthesia providers working at public hospitals. Physician anesthesiologists made up 47% of these providers, with an estimated physician anesthesiologist density of 0.8/100,000 population. Only 10% of district hospitals reported having an anesthesia provider continuously present intraoperatively during general or neuraxial anesthesia cases. No hospitals reported assessing pain in the immediate postoperative period. While the availability of some medications such as benzodiazepines and local anesthetics was robust (100% availability across all hospitals), not all hospitals had essential medications such as ketamine, epinephrine, or atropine. There were deficiencies in the availability of essential equipment and basic intraoperative monitors, such as end-tidal carbon dioxide detectors (17% availability across all hospitals). Postoperative care and access to resuscitative equipment, such as defibrillators, were also lacking. CONCLUSIONS: This first countrywide, MSPAS-led assessment of anesthesia capacity at public facilities in Guatemala revealed a lack of essential materials and personnel to provide safe anesthesia and surgery. Hospitals surveyed often did not have resources regardless of hospital size or level, which may suggest multiple factors preventing availability and use. Local and national policy initiatives are needed to address these deficiencies.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

Telephone consultation 11855 int 1193,

Neonatal Care

Correlates and Trajectories of Preterm Infant Sucking Patterns and Sucking Organization at Term Age Background: Premature infants may experience increased difficulty with nutrition and growth. Successful oral feeding is an important factor associated with discharge readiness. Despite the importance of feeding as a growth-fostering process, little empiric evidence exists to guide recommendations for early interventions. Purpose: Evaluate whether specific elements of sucking, during preterm initiation of oral feeding, predict sucking organization at corrected term age. Methods: Sucking performance of 88 preterm infants born between 24 and 34 weeks of post–menstrual age was measured at baseline and term (33-35 and 40 ± 1.5 weeks). Participants were divided into 4 groups (quartiles) based on initial measures of performance including number of sucks, number of bursts, sucks per burst, and maximum pressure. Stability in sucking organization was assessed by comparing changes in infant's quartile location from baseline to term. Results: A correlation between quartile location was observed for mean maximum pressure (PMAX): infants with PMAX in the lowest quartile (poorest performance) were significantly more likely to remain in the lowest quartile at term (P < .000); infants in the highest quartile (best performance) at baseline were significantly more likely to be in the highest quartile at term (P < .000). Implication for Practice: Infants with the weakest sucking pressures at 34 weeks of post–menstrual age continue to be at risk for less than optimal feeding skills at 40 weeks of post–menstrual age. Early identification of at-risk infants may allow for effective interventions to potentially decrease long-term feeding problems. Implications for Research: Future research should focus on the development of personalized interventions to address attributes of problematic feeding such as sucking efficiency. Correspondence: Jacqueline M. McGrath, PhD, RN, FNAP, FAAN, UT Health San Antonio, School of Nursing, 7703 Floyd Curl Blvd, Room 2.202e, San Antonio, TX 78229 (mcgrathj@uthscsa.edu). There are no competing financial interests in relation to the work described. Dr McGrath, who is a coeditor for Advances in Neonatal Care and the coauthor and mentor to the primary author, was not involved in the editorial review or decision to publish this article. The entire process from submission, referee assignment, and editorial decisions was handled by other members of the editorial team for the journal. © 2020 by The National Association of Neonatal Nurses

Human Milk Expression, Storage, and Transport by Women Whose Infants Are Inpatients at a Tertiary Neonatal Unit in Melbourne, Australia: An Exploratory Study Background: Expression and storage of mothers' own milk at home and its transportation to hospital neonatal units are a common practice worldwide when newborns are inpatients. Studies assessing adherence to hospital protocols and guidelines for this are not widely published. Purpose: To explore the advice received and practices followed by mothers when expressing, storing, and transporting their milk from home to the hospital, with a substudy exploring the factors related to temperature maintenance of refrigerated milk at recommended values. Methods: Cross-sectional descriptive study at the neonatal intensive care unit of Mercy Hospital for Women, Melbourne, Australia. Mothers who were discharged home after birth of the infant, but whose infant(s) remained in the neonatal unit for 7 days or more participated. All participants completed a self-administered questionnaire. In the substudy, home refrigerator temperature and surface temperature of milk on arrival to the hospital were recorded. Results: The questionnaire was completed by 100 mothers; 38 participated in the substudy. Median travel time from home to the hospital was 32 minutes (range, 2-135 minutes). Lactation consultants were the largest group providing information, with 44 participants (45%) identifying them as the primary information source. Knowledge about recommended refrigerator storage times for expressed milk was correct in 53 mothers (54%). Coolness of milk was better maintained when transported in an insulated food container than nonuse (surface temperature: mean 9.1°C vs 12.2°C; P = .007). Distance and travel duration were not correlated with temperature. Implications for Practice: More diligent monitoring of conditions under which mothers' own milk is transported to hospital is required, and the use of an insulated food container for refrigerated/frozen milk, even for a short duration, should be strongly recommended. Staff to be trained and better equipped to provide uniform, concise information on expressed human milk management to mothers. Implications for Research: Further research to correlate factors associated with transporting human milk expressed at home and infant health outcome is needed. Correspondence: Ranmali Rodrigo, MD, DCH, MBBS, MRCPCH, Judith Lumley Centre, La Trobe University, Level 3, George Singer, Bldg, Bundoora, VIC 3086, Australia (ranmali_waduge@yahoo.com). Funding was received from the postgraduate student support grant, La Trobe University, in 2013 to purchase equipment. Conflict of Interest: None. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.advancesinneonatalcare.org). © 2020 by The National Association of Neonatal Nurses

40% Glucose Gel for the Treatment of Asymptomatic Neonatal Hypoglycemia Background: The Mother Infant Care Center at Fort Belvoir Community Hospital (FBCH) recently revised its asymptotic neonatal hypoglycemia (ANH) protocol and adopted 40% glucose gel into its treatment pathway. The previous protocol used infant formula as the primary intervention. Purpose: To evaluate the effectiveness of 40% glucose gel on exclusive human milk diet rates, time on protocol, level II Special Care Nursery (SCN) admission rates, length of stay (LOS), and total hospital costs for newborns with ANH at FBCH. Methods: Infants with ANH were treated with 40% glucose gel (n = 35) and compared with a historical group of infants with ANH (n = 29) who were treated with formula. Results: Exclusive human milk diet rates increased by 33.6%. The mean time on protocol dropped by 1.13 hours. The SCN admission rates dropped by 2.4% in the postimplementation group. The mean LOS was more than 12 hours less in the postimplementation group. The mean total cost per patient was $1190.60 lower after implementation of 40% glucose gel. Implications for Practice: The use of 40% glucose gel is a patient-focused, less-invasive, and cost-effective treatment of ANH. Implications for Research: More studies are needed to better define neonatal hypoglycemia. The use of 40% glucose gel is safe for use in infants with ANH; however, more studies are needed to examine its comprehensive benefits. Correspondence: LCDR Brandi L. Gibson, NC, USN, Duke University School of Nursing, 307 Trent Dr, Durham, NC 27710 (Gibson.brandi@rocketmail.com). All authors and coauthors of this article have read and approved the manuscript for publication and have all contributed equal substance to this work. No funding was required for this quality improvement project as it was conducted as part of the primary investigator's doctoral studies. Special acknowledgments recognize Mr Andrew Kim at Fort Belvoir Community Hospital for assisting with acquiring the cost data for the project and statistician Dr Julie Thompson at Duke for her assistance with data analysis on the project. Additional acknowledgments go to the neonatal nurse practitioners: Angela Wallace, Debbie Rosado, Christa Brown, Joan Hammond, and Tina Anderson for managing the daily data collection for our postimplementation group and championing this project. The views expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the US government. LCDR Gibson, NC, USN, and LT LeDuff, NC, USN, are military service members. This work was prepared as part of their official duties. Title 17, USC, §105 provides that "Copyright protection under this title is not available for any work of the US government." Title 17, USC, §101 defines a "US government work as a work prepared by a military service member or employees of the US government as part of that person's official duties." Written work prepared by employees of the federal government as part of their official duties is, under the US Copyright Act, a "work of the US government" for which copyright is not available. As such, copyright does not extend to the contributions of employees of the federal government. There are no conflicts of interest or financial disclosures. © 2020 by The National Association of Neonatal Nurses

What Do Neonatal Intensive Care Unit Policies Tell Us About Kangaroo Care implementation? A Realist Review Background: Kangaroo care (KC) is recommended for infants during their stay in the neonatal intensive care unit (NICU) due to the benefits to infant growth, stabilized vital signs, and parental bonding; however, literature primarily explores the physiologic benefits, barriers, and facilitators to KC practice. Little is known about the context and mechanisms of KC implementation. Purpose: This realist review is to explore what NICU policies tell us about practices to implement KC in the NICU. Methods: Policies were obtained via email, database, and search engines. Criteria were established to review each policy. Data were entered into a database then exported for frequency counts of identified characteristics. Results: Fifty-one policies were reviewed, which revealed inconsistencies in the implementation of KC practices. Inconsistencies include variability in infant postmenstrual ages and weight criteria, infant medical equipment in place during participation, duration and frequency of KC, KC documentation, and ongoing monitoring requirements. Implications for Practice: KC implementation varies widely across NICUs, even with similar infant populations. Exclusion of some infants from receiving KC may decrease the potential beneficial outcomes known to result from KC. Implications for Research: More research to understand KC best practice recommendations and implementation in the NICU is needed. Studies are needed to evaluate the duration and frequency of KC, as well as the benefits to infants and families to optimize KC in the NICU setting. Correspondence: Melissa Fluharty, BSN, RN, 4838 Buttercup Way, Summerville, SC 29485 (fluhart@musc.edu). The authors declare no conflicts of interest. © 2020 by The National Association of Neonatal Nurses

The Effect of 2 Humidifier Temperature Settings on Inspired Gas Temperatures and the Physiological Parameters of Preterm Infants Receiving Mechanical Ventilation Therapy Background: The use of heated and humidified gas during mechanical ventilation is routine care in neonatal intensive care units. Giving gas at inadequate heat and humidity levels can affect neonatal morbidity and mortality. Purpose: To compare the effects of 2 humidifier temperature settings on the temperature and humidity of the inspired gas and the physiologic parameters in preterm newborns receiving mechanical ventilation. Methods: The research was conducted in a single-group quasi-experimental design. Proximal temperature was measured using a humidity heat transmitter. The humidifier temperature was set at 38°C (temperature I) and then at 39°C (temperature II). Results: The mean proximal temperatures were significantly lower than the values set in the humidifier (33.8 ± 1.20°C at temperature I, and 34.06 ± 1.30°C at temperature II, P < .001). However, the difference between the 2 proximal temperatures was not significant (P = .162). The incubator temperature was found to be effective on the proximal gas temperature (P < .05). It was found that only preterm infants in the temperature II group had a higher mean heart rate (P < .05). Implications for Practice: Incubator temperatures may have an effect on inspired gas temperature in preterm infants who are mechanically ventilated and caregivers should be aware of these potentially negative effects. Implications for Research: Future studies should focus on how to measure the temperature and humidity of gas reaching infants in order to prevent heat and humidity losses. Correspondence: Sema Bayraktar, PhD, MSc, RN, Department of Nursing, Faculty of Health Sciences, Bezmialem Vakif University, Silahtaraga caddesi, No:189 34065 Eyupsultan, Istanbul, Turkey (sema.byrktrr@gmail.com). The project was funded by the Research Fund of Istanbul University-Cerrahpasa: project no. 24657. The authors have no conflicts of interest to disclose. © 2020 by The National Association of Neonatal Nurses

Recovering Together: Mothers' Experiences Providing Skin-to-Skin Care for Their Infants With NAS Background: Over the past 2 decades, the prevalence of neonatal abstinence syndrome (NAS) has increased almost 5-fold. Skin-to-skin care (SSC), a method of parent–infant holding, is a recommended nonpharmacologic intervention for managing NAS symptoms. SSC has the potential to reduce withdrawal symptoms while positively influencing parent–infant attachment. Yet, little is known about the SSC experiences of mothers of infants with NAS. Purpose: The purpose of this study was to explore the SSC experiences of mothers of infants with NAS, including perceived barriers to SSC in the hospital and following discharge home. Methods: A qualitative descriptive design was used to obtain new knowledge regarding the experience of SSC of mothers of infants with NAS. Purposive sampling was used to recruit participants eligible for the study. We conducted semistructured individual interviews with postpartum mothers of infants with NAS. Data were analyzed using thematic analysis. Findings/Results: Thirteen mothers participated in the study. Four themes emerged from the data analysis: "a little nerve racking"; "she needed me, and I needed her"; dealing with the "hard times"; and "a piece of my puzzle is missing." SSC was described as a conduit for healing and bonding; in addition, several barriers to SSC were reported. Implications for Practice and Research: These findings highlight the inherent benefits of SSC for infants with NAS and demonstrate the unique challenges of these mother–infant dyads. Critical changes in hospital practices are needed to create an environment supportive of SSC for this patient population. In addition, research regarding implementation of interventions to increase SSC usage in this population is warranted. Correspondence: Kelly McGlothen-Bell, PhD, RN, IBCLC, School of Nursing, UT Health San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 (mcglothen@uthscsa.edu). This work was funded by the Texas Health & Human Services Commission. The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Dr McGrath, who is a Co-Editor for Advances in Neonatal Care and the coauthor and mentor to the primary author, was not involved in the editorial review or decision to publish this article. The entire process from submission, referee assignment, and editorial decisions was handled by other members of the editorial team for the journal. © 2020 by The National Association of Neonatal Nurses

Implementing a Hospital-Based Safe Sleep Program for Newborns and Infants Background: An unsafe sleep environment remains the leading contributor to unexpected infant death. Purpose: To determine the effectiveness of a quality improvement initiative developed to create a hospital-based safe sleep environment for all newborns and infants. Methods: A multidisciplinary team from the well-baby nursery (WBN) and neonatal intensive care unit (NICU) of a 149-bed academic, quaternary care, regional referral center developed and implemented safe sleep environments within the hospital for all prior to discharge. To monitor compliance, the following were tracked monthly: documentation of parent education, caregiver surveys, and hospital crib check audits. On the inpatient general pediatric units, only hospital crib check audits were tracked. Investigators used Plan-Do-Study-Act (PDSA) cycles to evaluate the impact of the initiative from October 2015 through February 2018. Results: Safe sleep education was documented for all randomly checked records (n = 440). A survey (n = 348) revealed that almost all caregivers (95.4%) reported receiving information on safe infant sleep. Initial compliance with all criteria in WBN (n = 281), NICU (n = 285), and general pediatric inpatient units (n = 121) was 0%, 0%, and 8.3%, respectively. At 29 months, WBN and NICU compliance with all criteria was 90% and 100%, respectively. At 7 months, general pediatric inpatient units' compliance with all criteria was 20%. Implications for Practice: WBN, NICU and general pediatric inpatient unit collaboration with content experts led to unit-specific strategies that improved safe sleep practices. Implications for Research: Future studies on the impact of such an initiative at other hospitals are needed. Correspondence: Patricia A. Patrick, DrPH, Westchester Institute for Human Development, 20 Plaza West, Cedarwood Hall, Valhalla, NY 10595 (ppatrick@wihd.org). The authors declare no conflicts of interest. © 2020 by The National Association of Neonatal Nurses

Availability of Donor Human Milk Decreases the Incidence of Necrotizing Enterocolitis in VLBW Infants Background: Human milk feeding is associated with decreased risk of necrotizing enterocolitis (NEC). Purpose: To determine whether a quality improvement project in New Jersey neonatal intensive care units (NICUs) to promote human milk (HM) feedings would be associated with a decrease in NEC. Methods: Fourteen New Jersey NICUs engaged in efforts to reduce infection and promote HM feeding in very low birth-weight (VLBW) infants. Donor human milk (DHM) availability and NEC rates were assessed. Results: From 2009 to 2016, NICUs with DHM increased from 0 to 7. VLBW infants discharged on any HM increased from 35% in 2007 before the formation of the New Jersey NICU Collaborative to more than 55% in 2016. Time to first oropharyngeal colostrum decreased from 37 to 30 hours from 2014 to 2016. HM at first feeding increased from 71% in 2013 to 82% in 2016. There was an increase in the percentage of feeds that were HM over the first 7 days of feeding. Analyses of data from 9400 VLBW infants born between 2009 and 2016 showed that the incidence of NEC when DHM was not available was 5.1% (367/7182) whereas the incidence when DHM was available (64/2218) was significantly lower (2.9%; P < .0001). Implications for Practice: These findings show advantages of feeding HM and effectiveness of forming an NICU collaborative for improving care for preterm infants. Implications for Research New research projects should measure the quantity of HM consumed daily during the entire NICU stay and assess the timing and amount of HM consumption in relationship to incidence of NEC and infection in neonates. Correspondence: Morris Cohen, MBBCh, Division of Neonatal Medicine, Children's Hospital of New Jersey, Newark Beth Israel Medical Center, 201 Lyons Ave, C-10, Newark, NJ 07112 (morris.cohen@rwjbh.org). The authors have no conflicts of interest relevant to this article to disclose. The Vermont Oxford Network had no role in the concept, design, analysis, or formulation of this research. The discussion and views belong solely to the coauthors and do not represent the opinions of the Vermont Oxford Network. © 2020 by The National Association of Neonatal Nurses

Reliability and Validity of the Arabic Version of the Parental Stressor Scale and Nurse Parental Support Tool: Opening Up Research on Parental Needs in Neonatal Intensive Care Units in Egypt Background: The admission of a newborn infant to a neonatal intensive care unit (NICU) due to preterm birth or high-risk conditions, such as perinatal injury, sepsis, hypoxia, congenital malformation, or brain injury, is a stressful experience for mothers. There is currently a lack of research on maternal perceived stress and support in Egyptian NICUs and no validated Arabic tool to investigate this further. Purpose: To determine the reliability and validity of the Arabic language versions of the Parental Stressor Scale: NICU (PSS:NICU) and the Nurse Parental Support Tool (NPST). Methods: Egyptian mothers completed the PSS:NICU and the NPST at the time of their infants' discharge from the NICU. Reliability was assessed with Cronbach α and Spearman-Brown coefficient. The multifactorial structure of the PSS:NICU Arabic version was tested. Associations with sociodemographic and clinical variables were explored with bivariate correlations and t tests. Results: Sixty-eight mothers of preterm (PT) infants and 52 mothers of ill full-term (IFT) infants completed the study. Mothers of PT and IFT infants did not differ for sociodemographic variables. High internal consistency (α range between .93 and .96) emerged for both tools. Spearman-Brown coefficients ranged between 0.86 and 0.94. The multidimensional structure of the PSS:NICU was confirmed and 3 core dimensions explained up to 71.48% of the variance. Perceived nursing support did not diminish the effects of stress in mothers of infants admitted to the NICU, regardless of PT or IFT infants' status. A longer NICU stay was associated with greater stress in mothers of PT infants. The presence of comorbidities was significantly associated with stress of mothers of IFT infants. Implications for Research: Future research is needed to develop evidence-based support for mothers whose infants are admitted to a NICU in Egypt. The availability of validated and reliable PSS:NICU and NPST scales in Arabic will facilitate cross-country and cross-cultural research on maternal stress in the NICU. Implications for Practice: Neonatal care nurses in Egypt will be able to increase their understanding of the stressors experienced by mothers of infants admitted to the NICU. This will in turn enable the introduction of neonatal care policies aimed at reducing specific stressors and provide improved maternal support. Correspondence: Dina Rabie, MD, Faculty of Medicine, Ain Shams University, Abbassia Square, Ramses, Cairo, Egypt (d_essam_rabie@outlook.com). Drs Dina Rabie and Livio Provenzi are co-first authors. LP contributed to conception and design, analysis and interpretation of data, and drafting of the article. DR contributed to data acquisition and interpretation of data. NM contributed to interpretation of data. RM contributed to conception and design and interpretation of data. All the authors contributed to revising the manuscript and approved final version for submission. The authors declare no conflicts of interest. © 2020 by The National Association of Neonatal Nurses

Eat, Sleep, Console and Adjunctive Buprenorphine Improved Outcomes in Neonatal Opioid Withdrawal Syndrome Background: The worsening opioid crisis has increased the number of infants exposed to maternal opioids. Standard treatment of newborns exposed to opioids prenatally often requires prolonged hospitalization and separation of the mother–infant dyad. These practices can potentially increase severity of withdrawal symptoms, interrupt breastfeeding, and disturb mother–infant bonding. Use of the Eat, Sleep, Console (ESC) model may ameliorate symptoms, decrease mother–infant separation, and decrease hospital length of stay. Purpose: To manage opioid exposed infants in a more holistic manner to decrease neonatal intensive care unit (NICU) admissions, reduce the need for pharmacotherapy, and evaluate response and total length of treatment after a unit protocol change from morphine to buprenorphine. Methods: Implemented ESC model, optimized nonpharmacologic bundle, and prescribed buprenorphine therapy instead of morphine as needed for adjunctive therapy. Results: Admissions of opioid-exposed infants from the Mother–Baby Unit (MBU) to the NICU decreased by 22%, and the number of infants who required pharmacotherapy was reduced by 50%. The average length of pharmacotherapy fell from 14 to 6.5 days. Implications for Practice: The successful implementation of the ESC model helped keep the mother–infant dyad together, reduced admissions to the NICU, and lessened the need for pharmacotherapy. The change to buprenorphine further reduced our average length of treatment. Implications for Research: Investigation of monotherapy with buprenorphine needs to be evaluated as a valid treatment option. The buprenorphine dosing and weaning chart will need to be revised and modified if indicated. Correspondence: Sarrah Hein, PharmD, BCPPS, Pharmacy Department, Akron Children's Hospital Mahoning Valley, 6505 Market St, Boardman, OH 44512 (shein@akronchildrens.org). Conflict of Interest: None declared for the listed authors. © 2020 by The National Association of Neonatal Nurses

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

Telephone consultation 11855 int 1193,

Transplantation

Clinical Profile and Outcome of COVID-19 in 250 Kidney Transplant Recipients: a Multicenter Cohort Study From India Background: There is scarcity of data on the consequences coronavirus 19 (COVID-19) infections in kidney transplant recipients (KTR) from emerging countries. Methods: Here, we present a cohort study of 13 transplant centers in India including 250 KTR (226 living and 24 deceased donor) with PCR confirmed COVID-19 positivity from March 23, 2020 until September 15, 2020. We detailed demographics, immunosuppression regimen, clinical profile, treatment and outcomes. Results: Median age of transplant recipients was 43 years and recipients presented at a median of 3.5 years after transplant. Most common comorbidities (94%) included arterial hypertension (84%), diabetes (32%); presenting symptoms at the time of COVID-19 included fever (88%), cough (72%) and sputum production (52%). Clinical severity ranged from asymptomatic (6%), mild (60%), moderate (20%) to severe (14%). Strategies to modify immunosuppressants included discontinuation of antimetabolites without changes in calcineurin inhibitors and steroids (60%). Risk factors for mortality included older age, dyspnoea, severe disease, obesity, allograft dysfunction prior to COVID-19 infection, acute kidney injury (AKI) , higher levels of inflammatory markers including C reactive protein, IL6 level, procalcitonin, chest XR abnormality, and ICU/ventilator requirements. Overall patient mortality was 11.6%(29/250), 14.5%(29/200) in hospitalized patients, 47%(25/53) in ICU patients and 96.7%(29/30) in patients requiring ventilation. KTR with mild COVID-19 symptoms(n=50) were managed as outpatients to optimize the utilization of scarce resources during the COVID-19 pandemic. Conclusions: Mortality rates in COVID-19 positive KTR appears to be higher than those in nonimmunosuppressed patients and high mortality was noted among those requiring intensive care and those on ventilator. Disclosure: The authors of this manuscript have no conflicts of interest to disclose Financial Disclosure: The authors declare no funding was received for this study. Correspondence: Vivek Kute, MD, FCPS, DM Nephrology, FASN, FISOT, FISN, FRCP (London) Professor Nephrology and Transplantation Institute of Kidney Diseases and Research Center and Dr. H L Trivedi Institute of Transplantation Sciences,(IKDRC-ITS) Ahmedabad India, Secretary, Indian society of Organ Transplantation (ISOT). Phone: +919099927543. Email: drvivekkute@rediffmail.com. Website: www.ikdrc-its.org. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Pathways to Clinical Cardiac Xenotransplantation Heart transplantation is the only long-lasting life-saving option for patients with terminal cardiac failure. The number of available human organs is however far below the actual need, resulting in substantial mortality of patients while waiting for a human heart. Mechanical assist devices are used to support cardiac function, but are associated with a high risk of severe complications and poor quality of life for the patients. Consistent success in orthotopic transplantation of genetically modified pig hearts into baboons indicates that cardiac xenotransplantation may become a clinically applicable option for heart failure patients who cannot get a human heart transplant. In this overview, we project potential paths to clinical cardiac xenotransplantation, including the choice of genetically modified source pigs, associated requirements of microbiological, including virological, safety, optimized matching of source pig and recipient, and specific treatments of the donor heart after explantation and of the recipients. Moreover, selection of patients and the regulatory framework will be discussed. Disclosure: The authors declare no conflicts of interest. Funding: Our studies are supported by the Deutsche Forschungsgemeinschaft (TRR127 Biology of xenogeneic cell tissue and organ transplantation – from bench to bedside; to B.R., M.L., J.D., R.S., and E.W.) and by the German Center for Diabetes Research (DZD; to E.W.). P.J.C. received a fellowship of the Center for Advanced Studies (CAS) of LMU Munich. Correspondence: Bruno Reichart, MD, Walter Brendel Center for Experimental Medicine, LMU Munich, Marchioninistr. 27, 81377 Munich, Germany Phone: +49-89-4400-73727 Email: bruno.reichart@med.uni-muenchen.de Eckhard Wolf, DVM, Gene Center, LMU Munich, Feodor-Lynen-Str. 25, 81377Munich,Germany Phone: +49-89-2180-76800 Email: ewolf@genzentrum.lmu.de Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Sex-Based Disparities in Hepatocellular Carcinoma Recurrence After Liver Transplantation Background: Women with chronic liver disease have lower rates of hepatocellular carcinoma (HCC) as compared to men; it is unknown if there are sex-based differences in HCC recurrence post-liver transplant. Methods: We conducted an analysis of patients who underwent liver transplant for HCC in the United Network for Organ Sharing/Organ Procurement and Transplantation Network from January 1, 2012 through December 31, 2017. Results: A total of 12,711 patients underwent liver transplant for HCC: 2,909 (23%) women and 9,802 (73%) men. Women had significantly lower rates of post-liver transplant HCC recurrence than men (4.0 v. 5.4%, p=0.002). A cox-regression analysis for post-liver transplant HCC recurrence highlighted that even after accounting for etiology of cirrhosis, alpha-fetoprotein (AFP) at liver transplant, tumor diameter, tumor pathology, and vascular invasion, female sex was associated with a 25% lower risk of post-liver transplant HCC recurrence (95CI 0.57–0.99). There were no interactions between female sex and the following variables: age, type of locoregional therapy, AFP, donor sex, body mass index, or nonalcoholic steatohepatitis etiology (p>0.05 for each). Conclusions: This study demonstrates an independent effect of sex on risk for HCC recurrence post-liver transplant. Our data highlight an opportunity to better understand HCC tumor biology by investigating the drivers of this sex-based difference in HCC recurrence. Financial Support: This study was funded by NIA Research Project Grant (R01AG059183; Lai), K23AG048337 (Paul B. Beeson Career Development Award in Aging Research; Lai) and by grants from the National Institute of Diabetes and Digestive and Kidney Diseases (T32 DK060414; Cullaro), all of which played no role in the analysis of the data or the preparation of this manuscript Disclosures: The authors have no conflicts of interest to disclose. Correspondence: Jennifer C. Lai, MD, MBA 513 Parnassus Avenue, UCSF Box 0538 San Francisco, CA 94143 Telephone: 415-476-2777 Fax: 415-476-0659 E-mail: Jennifer.Lai@ucsf.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Fluid Management During Kidney Transplantation: A Consensus Statement of the Committee on Transplant Anesthesia of the American Society of Anesthesiologists Background: Intraoperative fluid management may affect outcome after kidney transplantation. However, the amount and type of fluid administered, and monitoring techniques vary greatly between institutions and there are limited prospective randomized trials and meta-analyses to guide fluid management in kidney transplant recipients. Methods: Members of the American Society of Anesthesiologists (ASA) committee on transplantation reviewed the current literature on the amount and type of fluids (albumin, starches, 0.9% saline and balanced crystalloid solutions) administered and the different monitors used to assess fluid status, resulting in this consensus statement with recommendations based on the best available evidence. Results: Review of the current literature suggests that starch solutions are associated with increased risk of renal injury in randomized trials and should be avoided in kidney donors and recipients. There is no evidence supporting the routine use of albumin solutions in kidney transplants. Balanced crystalloid solutions such as Lactated Ringer are associated with less acidosis and may lead to less hyperkalemia than 0.9% saline solutions. Central venous pressure is only weakly supported as tool to assess fluid status. Conclusion: These recommendations may be useful to anesthesiologists making fluid management decisions during kidney transplantation and facilitate future research on this topic. Financial Disclosure: Support was provided solely from institutional and/or departmental sources Disclaimer: NONE. Correspondence:Gebhard Wagener, MD Professor of Anesthesiology at CUMC Department of Anesthesiology, Columbia University P&S Box 46 (PH-5)630 West 168th Street New York, NY 10032-3784 Tel: (212) 305-6494 (Office) Fax: (212) 305-2182 Email: gw72@cumc.columbia.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

A Comprehensive Evaluation of Risk Factors for Pneumocystis Jirovecii Pneumonia in Adult Solid Organ Transplant Recipients: a Systematic Review and Meta-Analysis Background: There is no consensus guidance on when to reinitiate Pneumocystis jirovecii pneumonia (PJP) prophylaxis in solid organ transplant (SOT) recipients at increased risk. The 2019 American Society of Transplantation Infectious Diseases Community of Practice (AST IDCOP) guidelines suggested to continue or reinstitute PJP prophylaxis in those receiving intensified immunosuppression for graft rejection, CMV infection, higher dose of corticosteroids, or prolonged neutropenia. Methods: A literature search was conducted evaluating all literature from existence through April 22, 2020 using MEDLINE and EMBASE. (PROSPERO: CRD42019134204) Results: A total of 30 studies with 413 276 SOT recipients were included. The following factors were associated with PJP development: acute rejection (pooled odds ratio (pOR) = 2.35 (1.69, 3.26), study heterogeneity index (I2)= 23.4%), cytomegalovirus (CMV)-related illnesses (pOR = 3.14 (2.30, 4.29), I2=48%), absolute lymphocyte count < 500 cells/mm3 (pOR = 6.29[3.56, 11.13], I2 0%), BK-related diseases (pOR = 2.59[1.22, 5.49], I2 0%), HLA mismatch ≥ 3 (pOR = 1.83 [1.06, 3.17], I2= 0%), rituximab use (pOR =3.03 (1.82, 5.04); I2 =0%) and polyclonal antibodies use for rejection (pOR = 3.92 [1.87, 8.19], I2= 0%). On the other hand, sex, CMV mismatch, interleukin-2 inhibitors, corticosteroids for rejection, and plasmapheresis were not associated with developing PJP. Conclusion: PJP prophylaxis should be considered in SOT recipients with lymphopenia, BK-related infections and rituximab exposure in addition to the previously mentioned risk factors in the AST IDCOP guidelines. Correspondence: Nitipong Permpalung, MD, MPH E-mail: npermpa1@jhmi.edu Address: 601 N Wolfe Street, Carnegie Building #340, Baltimore, MD 21287; Tel: 443-287-6217; Fax: 410-955-0788 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Early Signs of Sinoatrial Reinnervation in the Transplanted Heart Background: Heart transplantation (HTx) surgically transects all connections to the heart, including the autonomic nerves. We prospectively examined signs, timing and consequences of early sympathetic and parasympathetic sinoatrial reinnervation, as well as explored indirect evidence of afferent cardiopulmonary reinnervation. Methods: Fifty HTx recipients were assessed at 2.5, 6 and 12 months after HTx. For comparison, 50 healthy controls were examined once. Continuous, noninvasive recordings of hemodynamic variables and heart rate variability indices were carried out at supine rest, 0.2 Hz controlled breathing, 60 degrees head-up-tilt, during the Valsalva maneuver and during handgrip isometric exercise. Results: In HTx recipients, supine low-frequency heart rate variability gradually increased; supine high-frequency variability did not change; heart rate variability indices during controlled breathing remained unaltered; heart rate responses during tilt and isometric exercise gradually increased; the tachycardia response during Valsalva maneuver increased while the bradycardia response remained unchanged; and indices of baroreflex sensitivity improved. Responses remained low compared to healthy controls. A negative correlation between indices of preload and heart rate response during head-up tilt emerged at 12 months. Conclusions: Results suggest that sympathetic reinnervation of the sinoatrial node starts within 6 months after HTx and strengthens during the first year. No evidence of early parasympathetic reinnervation was found. Indirect signs of afferent reinnervation of cardiopulmonary low-pressure baroreceptors emerged at 12 months. Better sympathetic sinoatrial control improved heart rate responsiveness to orthostatic challenge and isometric exercise, as well as heart rate buffering of blood pressure fluctuations. Financial Disclosure This study was founded by the Health South–East Hospital Trust, Norway. Data availability The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. Clinical trial notation: Autonomic Cardiovascular Control after Heart Transplantation (AccHEART), Clinical Trials ID: NCT01759966. Correspondence Anders Haugom Christensen, Dept. of Pediatric Cardiology, Oslo University Hospital, Rikshospitalet, N-0372, Oslo, Norway. Cell phone + 47 99 61 99 06. E-mail: a.h.christens1@gmail.com. Twitter: @AndersHaugom. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Pneumocystis jirovecii: the Changing Landscape for Prophylaxis No abstract available

Urine the Right Direction: The Consensus Statement from the Committee on Transplant Anesthesia of the American Society of Anesthesiologists on Fluid Management During Kidney Transplantation No abstract available

Uterine Transplantation; Review of Livebirths and Reproductive Implications Uterine transplantation (UTx) is a fertility restoring treatment for women with absolute uterine factor infertility. At a time when there is no question of the procedure's feasibility, and as the number of livebirths begins to increase exponentially, various important reproductive, fetal and maternal medicine implications have emerged. Detailed outcomes from 17 livebirths following UTx are now available, which are reviewed herein, along with contextualized extrapolation from pregnancy outcomes in other solid organ transplants. Differences in recipient demographics and reproductive aspirations between UTx and other transplant recipients make extrapolating management strategies and outcomes in other solid organ transplants inappropriate. Whereas preterm delivery remains prominent, small for gestational age or hypertensive disorders do not appear to be as prevalent following UTx when compared to other solid organ transplants. Given the primary objective of undertaking UTx is to achieve a livebirth, publication of reproductive outcomes is essential at this early stage, to reflect upon and optimize the management of future cases. Financial Disclosure: None Disclaimer: The authors report no conflict of interest Correspondence: Mr Benjamin P Jones MBChB BSc (Hons) MRCOG epartment of Surgery and Cancer, Imperial College London, London W12 0NN, United Kingdom. Telephone: 07740358900. E-mail: Benjamin.jones@nhs.net Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Chronic Histologic Changes Are Present Regardless of HLA Mismatches: Evidence from HLA Identical Living Donor Kidney Transplants Background: At 5 and 10 years after kidney transplantation, chronic histologic changes such as arteriolar hyalinosis and mesangial expansion are common, however, determining etiology is difficult. We compared surveillance biopsies in living donor kidney transplants (LDKTx) from HLA matched siblings (termed HLA-identical (HLA-ID)) to HLA non-ID to investigate which histologic changes were likely due to alloimmune injury and which were due to non-alloimmune injury. Methods: We performed a retrospective, cohort study comparing HLA-ID sibling LDKTx (n=175) to HLA non-ID LDKTx (n=175; matched for age, sex and year of transplant +/- 2 years) performed at a single institution from 03/1999 to 11/2018. Results: Baseline characteristics and maintenance immunosuppression were similar. Mortality rates were similar, but in the HLA-ID group, 10-year death-censored graft survival was higher (93.8% vs 80.9% HLA non-ID LDKTx, p<0.001), rejection rates were lower (after 1 year 9.6% vs 27.1%; p<0.001) and Banff inflammation scores including glomerulitis and peritubular capillaritis were lower on surveillance biopsies at 1, 5 and 10 years. In contrast, chronic Banff scores (interstitial fibrosis, arteriolar hyalinosis, mesangial expansion, etc.) were similar in prevalence and severity on surveillance biopsies at 1, 5 and 10 years. Conclusions: HLA-ID LDKTx have less inflammation and less transplant glomerulopathy, but most chronic histologic changes were similar to less-well matched LDKTx. We conclude that these types of chronic changes are not associated with HLA mismatches and may be due to non-immunologic causes (hypertension, obesity, etc.) suggesting that new management approaches to prevent these lesions may be needed. Funding Andrew Bentall would like to acknowledge internal funding awards including the 'Transplant Scholar Award' and the 'Career Development Award in Transplantation' although these funds were not directly used in this study. All other authors have no acknowledgements. Disclosure: The authors declare no conflicts of interest. Address correspondence to: Dr. Mark D. Stegall, Department of Surgery and Immunology, Division of Transplant Surgery; von Liebig Transplant Center, Mayo Clinic, Rochester, MN E-mail: stegall.mark@mayo.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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