Prophylaxis Among Hepatitis B Core Antibody-positive Deceased-donor Liver Transplant Recipients: Hepatitis B Immunoglobulin Plus Oral Antiviral Agents Versus Antiviral Agents Alone: A Single-center Experience.

OBJECTIVES: Hepatitis B core antibody immunoglobulin G seropositivity is evidence of past exposure to hepatitis B virus. Donor or recipient hepatitis B core antibody positivity may pose a risk of reactivation, especially early after liver transplant. Although most centers advocate using antiviral agents plus hepatitis B immunoglobulin, some have recently relied on antivirals only as prophylaxis after liver transplant. Here, we retrospectively investigated patient survival in hepatitis B core antibody-positive recipients, comparing those treated with antivirals plus hepatitis B immunoglobulin versus antivirals alone. MATERIALS AND METHODS: After Internal Review Board approval, we reviewed medical records of deceased-donor liver transplant recipients between 1995 and 2013. Demographic characteristics, transplant indication, hepatitis B core antibody status, time to death, and type of posttransplant prophylaxis were recorded. We also recorded whether donors showed hepatitis B core antibody positivity. Patients who died within 30 days of liver transplant were excluded. RESULTS: There were 148 hepatitis B core antibody-positive recipients. Prophylaxis was given to 75 recipients after transplant: 8 (5%) received hepatitis B immunoglobulin, 22 (15%) received antivirals, and 45 (30%) received the combination. There were 34 deaths: 3 (38%) in hepatitis B immunoglobulin only, 3 (14%) in antiviral only, 8 (18%) in the combination, and 20 (27%) in no prophylaxis groups. One- and 5-year survival rates were similar for binary comparisons among prophylaxis groups (P > .05). CONCLUSIONS: Preliminary results support the current practice of using hepatitis B immunoglobulin plus antivirals for prophylaxis after liver transplant. The similar survival benefit with the combination versus antiviral agents alone suggests equal effectivity for prophylaxis posttransplant. However, a clear benefit of antivirals was not evident in our analysis. Future larger prospective studies are warranted to identify potential benefits of using antivirals alone as prophylaxis after liver transplant and to further clarify their role as the sole prophylactic regimen.

The predictors of post-transplant coronary events among liver transplant recipients.

BACKGROUND/PURPOSE: Cardiac morbidities can occur during the peri- and post-liver transplant (LT) period, affecting the long-term survival. The purpose of this study was to identify the potential factors that predict a coronary event post-transplantation. METHODS: Medical records of patients who underwent liver transplantation at Johns Hopkins Hospital between 2009 and 2013 were retrospectively reviewed. We looked at pre-liver transplant cardiac risk factors and the diagnostic tests utilized for coronary artery disease screening. Patients with and without post-liver transplant coronary events were compared. RESULTS: There were a total of 146 patients with a mean age at LT of 55.3 years. The prevalence of hypertension, tobacco use and diabetes within the patient population was 61.6 % (n = 90), 39 % (n = 57) and 37.6 % (n = 55), respectively. There were 29 deaths and 30 coronary events over a median follow-up period of 1.75 years. Age at the time of liver transplant was predictive of coronary event (OR 1.11, CI 1.01-1.20). The 1-year survival in patients with a coronary event was 47 versus 94 % in patients without a coronary event. The combined use of a dobutamine stress echocardiogram and coronary artery calcium score predicted a coronary event with a sensitivity of 62.5 % and specificity of 66.7 %. CONCLUSION: In conclusion, LT recipients with cardiac events had limited survival as compared to the cohort without coronary events. Identification of such patients with noninvasive screening may provide a practical alternative to an invasive cardiac workup. Further improvement in screening strategies may minimize the liver transplant cardiac morbidity.

Late liver function test abnormalities post-adult liver transplantation: a review of the etiology, investigation, and management.

Approximately 24,000 liver transplants are performed annually worldwide, almost 7000 of which are performed in the USA. Survival is excellent and continues to improve, with 1-year survival currently exceeding 85 %, but effective management of patients after liver transplantation is critical to achieve optimal results. A plethora of diseases can affect the transplanted allograft, ranging from recurrence of the original disease to de novo liver pathology, and diagnosis can be complicated by nonclassical presentation, de novo disease, or inconclusive histology. Patients can remain asymptomatic despite significant damage to the transplanted liver, so prompt identification and treatment of liver disease after transplantation is crucial to preserve allograft function. Liver function tests are routinely taken throughout the postoperative period to monitor the graft. Although nonspecific, they are inexpensive, noninvasive, and sensitive for allograft disease and can quickly alert physicians to the presence of asymptomatic pathology. This review will outline possible causes of liver function test abnormalities in the late posttransplant period and provide guidance for investigation, diagnosis, and management.

Critical gastrointestinal bleed due to secondary aortoenteric fistula.

Secondary aortoenteric fistula (SAEF) is a rare yet lethal cause of gastrointestinal bleeding and occurs as a complication of an abdominal aortic aneurysm repair. Clinical presentation may vary from herald bleeding to overt sepsis and requires high index of suspicion and clinical judgment to establish diagnosis. Initial diagnostic tests may include computerized tomography scan and esophagogastroduodenoscopy. Each test has variable sensitivity and specificity. Maintaining the hemodynamic status, control of bleeding, removal of the infected graft, and infection control may improve clinical outcomes. This review entails the updated literature on diagnosis and management of SAEF. A literature search was conducted for articles published in English, on PubMed and Scopus using the following search terms: secondary, aortoenteric, aorto-enteric, aortoduodenal, aorto-duodenal, aortoesophageal, and aorto-esophageal. A combination of MeSH terms and Boolean operators were used to device search strategy. In addition, a bibliography of clinically relevant articles was searched to find additional articles (Appendix A). The aim of this review is to provide a comprehensive update on the diagnosis, management, and prognosis of SAEF.

Role of coronary artery calcium score in identifying occult coronary artery disease in patients evaluated for deceased-donor liver transplant - a preliminary report.

Coronary artery disease may affect cirrhotic patients regardless of age and etiology of the underlying liver disease. Early identification of coronary artery disease is important to be able to achieve the best posttransplant outcomes and survival. The coronary artery calcium score can be used as a screening tool to supplement the results of cardiac stress tests to identify a subgroup of patients who may benefit from further investigation with coronary arteriogram. Arteriogram is an invasive test and may cause renal compromise and risk of bleeding associated with coagulopathy. The present retrospective study showed that coronary artery calcium score > 250 Agatston units may help select the subgroup of patients who will benefit from further investigation with cardiac catheterization, and determining this score may limit the risks of catheterization.

Hepatitis C virus infection and its rheumatologic implications.

Extrahepatic manifestations are frequently encountered among patients with chronic hepatitis C virus (HCV) infection. Many of these manifestations are autoimmune disorders, with added mortality and morbidity due to involvement of multiple organ systems. Symptoms of HCV infection and rheumatic diseases may be similar and include arthralgia, myalgia, arthritis, and vasculitis. Also, serologic abnormalities may be found in both cases. Some treatment modalities for HCV infection, including interferon therapy, may aggravate the symptoms of rheumatic diseases, thus confounding clinical presentation. It is imperative to distinguish whether symptoms such as arthralgia, myalgia, and arthritis occur in patients with HCV infection due to primary chronic HCV infection or to a newly developed rheumatologic disease process.

Determinants of resident competence in mastoidectomy: role of interest and deliberate practice.

OBJECTIVES/HYPOTHESIS: This study explores the influence of selected factors on achievement of competency in mastoid surgery. STUDY DESIGN: A prospective study of surgical performance and a retrospective survey of learner and training factors. METHODS: The longitudinal performance of 15 residents was evaluated using the mastoidectomy task-based checklist (TBC). The influence of surgical experience, resident interest, and training factors (course attendance, voluntary use of simulation laboratory) was also examined and compared for the acquisition of distinct levels of technical skill difficulty (cortical mastoidectomy vs. facial recess). RESULTS: Ninety-six observations made during the first otology rotation were analyzed. Cortical mastoidectomy tasks showed positive associations with cumulated case numbers (OR 1.13, CI 1.04-1.23, P = .003) and interest in otology (OR 3.86, CI 1.21-12.27, P = .022). Facial recess tasks showed a larger positive association with interest in otology (OR 10.38, CI 2.25-47.94, P = .003), and negative association with extra time spent in laboratory practice (OR .05, CI 0.011-0.23, P = .000). CONCLUSIONS: Learning trajectory for cortical mastoidectomy and facial recess may be influenced by different factors. Interest in otology, in particular, may have a moderating effect on the acquisition of more complex skills in mastoid surgery. A negative association between self-directed laboratory simulation and performance may reflect the impact of assessment-guided feedback in promoting deliberate practice. Further investigations are suggested to explore the interactions between individual trainee differences, educational models, and learning outcomes.

Spectrum of immune-mediated inner ear disease and cochlear implant results.

OBJECTIVES/HYPOTHESIS: To characterize the progression of hearing loss in patients with immune-mediated inner ear disease (IMIED), and to identify disease- and patient-specific factors associated with cochlear implant (CI) performance. STUDY DESIGN: Retrospective cohort study. METHODS: Subjects consisted of CI patients suspected to have lost their hearing due to IMIED. The primary dependent variable for functional decline was time to deafness, whereas for CI benefit it was post-CI speech perception scores. Independent variables included presence or absence of systemic autoimmune disease, age at CI, and insertion depth of the cochlear electrode. RESULTS: A transient favorable response to immunosuppressive therapy was reported in 16 of 26 patients (66.67%). The time to deafness differed between an organ (ear)-specific immune-mediated group, a systemic immune-mediated group including Cogan syndrome and relapsing polychondritis (subgroup A), and a systemic immune-mediated group associated with other autoimmune diseases (subgroup B; P = .001). Disease group (-15.52; P = .04), insertion depth of the CI electrode (40.71; P = .01), and the age at CI (-0.48, P = .05) were associated with speech perception results. CONCLUSIONS: Triaging IMIED cases based on presence and type of systemic autoimmune disease may aid in selecting a management strategy. Knowledge about the predictors of CI outcome will help clinicians select appropriate patients for CIs. In the setting of significant and irreversible hearing deficit, the restoration of hearing using a cochlear prosthesis may be appropriate earlier rather than later.

Technical skills improve after practice on virtual-reality temporal bone simulator.

OBJECTIVES/HYPOTHESIS: To assess whether practice on a virtual-reality (VR) temporal bone simulator improves acquisition of technical skills in mastoid surgery. STUDY DESIGN: Prospective blinded study. METHODS: Using a previously validated objective structured assessment of technical skills (OSATS) tool, performance was assessed in 12 residents for two tasks of cortical mastoidectomy: 1) identifying and defining the tegmen and 2) defining the sigmoid sinus and sinodural angle. These surgical tasks were chosen as key steps in mastoid dissection because they were of intermediate complexity. Videos of virtual dissections were captured at baseline and again after practicing each task four to six times. RESULTS: OSATS scores for the tegmen task increased from 2.125 ± 1.25 to 3.1 ± 0.85 (P = .026), whereas for the sigmoid task scores increased from 2 ± 0.45 to 2.75 ± 1.125 (P = .0098). The time to complete the tasks decreased from 8.37 ± 4.78 minutes to 5.39 ± 3.06 minutes (P = .018) for the tegmen task and from 8.99 ± 6.7 minutes to 8.68 ± 5.98 minutes (P = .594) for the sigmoid task. There was a decline in number of injuries from 0.5 ± 1.5 to 0 ± 0.5 (P = .594) for the tegmen task and from 2.5 ± 4 to 0.5 ± 1 (P = .029) for the sigmoid task. CONCLUSIONS: Technical skills in mastoidectomy surgery can be acquired during even brief practice on the VR temporal bone simulator. It is anticipated that longer periods of practice presented within the fundamentals of comprehensive curriculum will facilitate procedural learning. Further studies are required to elucidate evidence of transference of these skills to the operating room and to procedures of greater complexity.

Comprehensive assessment of thyroidectomy skills development: a pilot project.

OBJECTIVES/HYPOTHESIS: To test the validity, reliability, and feasibility of an evaluation tool designed to measure the development of trainees' surgical skills in the operating room for thyroid surgery. STUDY DESIGN: Prospective validation study. METHODS: A modified Delphi technique was employed to develop a new Objective Structured Assessment of Technical Skills-based instrument for thyroid surgery. During a 1-year period, 16 otolaryngology-head and neck surgery residents (ranging from postgraduate year 2 to 6) and one endocrine surgery fellow were evaluated by one faculty member obtaining a total of 94 evaluations. Performance was rated using a task-based checklist (TBC) and a global rating scale (GRS). The TBC measured trainees' thyroidectomy technical skills, and the GRS assessed their overall surgical performance. RESULTS: Based on four clinical levels (junior, intermediate, senior, and surgical fellow) our tool demonstrated construct validity for both components of the assessment instrument, specifically for the TBC showing a mean difference of 0.9 (95% confidence interval: 0.5-1.3, P<.001) between the contiguous clinical levels senior versus intermediate. Cronbach α, a measure of internal consistency, was 0.96 for both components of the instrument. The correlation between the TBC and GRS was also high within trainee (r=0.62, n=94, P<.001) and across trainees (r=0.96, n=17, P<.001). CONCLUSIONS: Our tool proved to be a valid, reliable, and feasible instrument for assessing competency in thyroid surgery. It is effective in providing timely formative feedback during and upon the conclusion of the surgical procedure by identifying procedural tasks for which additional training is necessary. In addition, it enables longitudinal tracking of residents' surgical performance, thus ensuring their appropriate development.

Barriers to Implementing the ACGME Outcome Project: A Systematic Review of Program Director Surveys.

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) introduced the Outcome Project in July 2001 to improve the quality of resident education through competency-based learning. The purpose of this systematic review is to determine and explore the perceptions of program directors regarding challenges to implementing the ACGME Outcome Project. METHODS: We used the PubMed and Web of Science databases and bibliographies for English-language articles published between January 1, 2001, and February 17, 2012. Studies were included if they described program directors' opinions on (1) barriers encountered when attempting to implement ACGME competency-based education, and (2) assessment methods that each residency program was using to implement competency-based education. Articles meeting the inclusion criteria were screened by 2 researchers. The grading criterion was created by the authors and used to assess the quality of each study. RESULTS: The survey-based data reported the opinions of 1076 program directors. Barriers that were encountered include: (1) lack of time; (2) lack of faculty support; (3) resistance of residents to the Outcome Project; (4) insufficient funding; (5) perceived low priority for the Outcome Project; (6) inadequate salary incentive; and (7) inadequate knowledge of the competencies. Of the 6 competencies, those pertaining to patient care and medical knowledge received the most responses from program directors and were given highest priority. CONCLUSIONS: The reviewed literature revealed that time and financial constraints were the most important barriers encountered when implementing the ACGME Outcome Project.

Learning styles in otolaryngology fellowships.

OBJECTIVES/HYPOTHESIS: Previous studies have identified a predominant learning style in trainees from different specialties, more recently in otolaryngology residents. The purpose of our study was to determine a predominant learning style within otolaryngology fellowships and to identify any differences between otolaryngology fellows and residents. STUDY DESIGN: We conducted a survey of otolaryngology fellows at 25 otolaryngology fellowship programs accredited by the Accreditation Council for Graduate Medical Education. METHODS: We emailed Kolb's Learning Style Index version 3.1 to 16 pediatric otolaryngology (PO) and 24 otology/neurotology (ON) fellows. This index is a widely used 12-item questionnaire. The participants answered each item in the questionnaire as it applied to their preferred learning style: accommodating, converging, diverging, or assimilating. Results were then analyzed and compared between each subspecialty and the previously reported preferred styles of otolaryngology residents. RESULTS: Ten PO and 20 ON fellows completed the survey, with an overall response rate of 75%. PO and ON fellows (60% of each group) preferred a learning style that was "balanced" across all four styles. For ON fellows, 35% preferred converging and 5% preferred accommodating styles. For PO fellows, converging and accommodating styles accounted for 20% each. CONCLUSIONS: It was previously reported that 74.4% of otolaryngology residents prefer either converging or accommodating styles. We believe that the fellowship training environment calls for fellows to use more than one learning style to become proficient physicians, hence the trend toward potentially developing a balanced style when at this level.