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Management of Patients with Vascular Reconstruction during Liver Transplantation
No full textPurpose: Liver transplantation occasionally requires vascular reconstruction, such as arterial jump grafts or portal vein thrombectomy, to ensure adequate blood flow. Aspirin (ASA) and anticoagulation (AC) therapies are used to reduce thrombotic risk but may increase bleeding. Limited data exist on their impact in this context. This study evaluates the effect of ASA AC use on survival, thrombotic events, bleeding, and retransplant rates, aiming to optimize care for this high-risk group. Methods: We performed a retrospective chart review of 400 patients who underwent liver transplant between 2019 and 2023. 66 patients received an arterial jump graft, a portal vein thrombectomy, or both. Demographic factors (age, gender, race), ASA AC prescription at discharge, MELD scores at transplant, and clinical outcomes, including 1-year survival, ischemia clots, bleeding events, and retransplant or death, were collected. Patients were stratified by ASA AC prescription. Descriptive analysis was performed to identify trends in outcomes. Results: The study analyzed a cohort of 66 post-transplant patients with a median age of 62 years (range: 58-72). The majority were male (62%, n=41) and White (85%, n=56), with smaller proportions of Black (4%, n=3) and other racial backgrounds (11%, n=7). MELD scores at the time of transplant were higher in patients not on ASA AC (median: 30, range: 23-40) compared to ASA AC users (median: 24, range: 15-39). ASA AC was prescribed at discharge to 87.87% of patients, while 12.12% did not receive ASA AC. Clinical outcomes differed between groups: the 1-year survival rate was 96.5% in ASA AC users compared to 75% in non-users. The incidence of ischemia clots was comparable (27.6% vs. 25%), while bleeding events were more frequent in ASA AC users (17.2% vs. 0%). Retransplant rates were 1.72% in ASA AC users versus 12.5% in non-users. Among patients with clots, 16.7% experienced graft loss, with death occurring in 5.5% and retransplantation in 11.1% of these patients. In contrast, patients without clots had a 4.3% graft loss (death) rate and 0% retransplantation. Conclusions: ASA AC use post-transplant is associated with improved 1-year survival rates, lower retransplant and death rates, and minimal impact on ischemia clot incidence. Among patients with clots, graft loss, death, and retransplantation rates were notably higher than in patients without clots. These findings suggest ASA AC may confer protective benefits in the post-transplant population, warranting further research to optimize its role in this context. CITATION INFORMATION: Alomari A., Althunibat I., Saleem A., Abusuliman M., Omari Y., Jomaa D., Dababneh Y., Jafri S. Management of Patients with Vascular Reconstruction during Liver Transplantation AJT, Volume 25, Issue 8 Supplement 1 DISCLOSURES
Pancreatic cancer mortality trends (2018-2023): Exposing racial inequities in Michigan\u27s cancer burden
No full textBackground: Pancreatic cancer remains one of the most aggressive malignancies, with Black individuals facing significantly worse outcomes and a younger age of onset. Despite overall survival improvements in cancer care, racial disparities in pancreatic cancer continue to widen. This study analyzes Michigan\u27s diverse population to quantify disparities and identify actionable solutions for healthcare equity. Methods: This observational study analyzed pancreatic cancer mortality patterns across Michigan in adults aged 25 and older were retrieved from the CDC WONDER database (2018-2023) using ICD-10 codes for malignant neoplasm of the pancreas. Crude mortality rates (CMRs) and Age-adjusted mortality rates (AAMRs) per 100,000 were calculated by age, gender and race, with 95% confidence intervals (CI) for precision to assess racial disparities in mortality outcomes. Temporal trends and annual percentage changes (APCs) were analyzed using Joinpoint regression. Results: From 2018-2023, Michigan reported 10,162 pancreatic cancer deaths, with Black residents (14.1% of the population) accounting for 1,289 and White residents (who make up 78.9%) for 8,664 deaths. Overall, CMR was higher for White residents (18.26 per 100,000) than Black residents (15.21 per 100,000) who experienced a sharper rise in AAMR, increasing by 8.10% [14.36 (13.55-15.16)] compared to 4.92% [12.36 (12.10-12.63)] for White residents. For Black residents, CMRs increased with age, rising from 8.14 per 100,000 (45-54 years) to 105.78 per 100,000 (85+ years), peaking at 69.46 (65-74 years) and 95.37 (75-84 years). White residents had lower CMRs overall, starting at 1.48 per 100,000 (35-44 years) and gradually increasing to 115.28 per 100,000 in the 85+ group.In Washtenaw County, Black residents had a rate of 14.01 per 100,000 and White residents 15.79 per 100,000 with similar trends in Genesee, Wayne, and Ingham counties. Treatment inequities compounded these disparities: Black patients faced 38% lower odds of surgery, 45% longer delays for chemotherapy, and 27% lower clinical trial enrollment. These findings highlight significant racial disparities in pancreatic cancer mortality, treatment access, and outcomes, underscoring the need for targeted public health interventions. Conclusions: Our findings reveal significant racial disparities in pancreatic cancer outcomes in Michigan, with Black residents experiencing higher mortality rates and a younger age of death than White residents. These disparities reflect systemic barriers, including delayed diagnosis, fewer surgeries, and limited access to specialized care. Addressing these inequities requires bias training, targeted screening for high-risk Black populations, and expanded oncology services, while actionable solutions such as patient navigation and community-based screening programs can help bridge this healthcare gap and promote equity
Decreased Rate of Rejections Post Liver Transplant in Patients on a Glucagon-Like Peptide 1 (GLP-1) Analogue
No full textPurpose: Rejection is prevalent in patients undergoing liver transplant (LT), with studies showing a relation of Body Mass Index (BMI) to post transplant outcomes, including rates of rejection. Recently, Glucagon-like peptide-1(GLP-1) analogues are increasingly being used in post-transplant patients. We aimed to assess the association of semaglutide and tirzepatide with transplant rejection in patients with BMI \u3e 30. Methods: Patients who underwent LTs at our institution were included from 1 2018-12 2023. Inclusion criteria was BMI \u3e 30. We did a retrospective cohort study to assess whether they received GLP-1 analogues, including semaglutide and tirzepatide, after the liver transplant. Data including patient demographics and comorbidities was collected. The primary outcome was transplant rejection at 1 and 2-3 years. The secondary outcome was 3-year mortality. Results: 137 patients were included who underwent liver transplant from 01 2018-12 2023 with a BMI \u3e 30. Of these, 33(24.1%) were exposed to semaglutide or tirzepatide while 104 (75.9%) had no such exposure after transplant. The mean age of the population was 58.86 + - 8.2 in the case group and 62.08 + - 9.2 in the control group. 23 (69.7%) were male in the case group while 69 (66.3%) were male in the control group. Comorbidities, including HTN, stroke and ESRD were comparable in both groups. 27 (87.9%) in the case group had diabetes while 37(35.6%) in the control group had diabetes (p=0.001). Mean BMI for the case group was 36.34 ± 4.81 and mean BMI for the control group was 33.9 ± 3.82 (p=0.01). Underlying liver disease prior to transplant was similar between the 2 groups, with Metabolic Dysfunction-Associated Steatohepatitis (MASH) being the most prevalent. For outcomes, 2(6.1%) patients in the exposed group had rejection within 3 years, compared to 24(23.1%) in the control group (p=0.03). Of these, both the patients in the control group had rejection within 1 year compared to 20(19.4%) patients in the control group who had rejection within 1 year. At 3 years, there were 0 deaths in the case group compared to 4 (3.9%) deaths in the control group (P=1.0). Conclusions: In our cohort, the use of semaglutide and tirzepatide was associated with a decreased incidence of liver transplant rejections in patients with BMI \u3e 30. We were limited by single center and smaller number of patients. Further large scale, multicenter studies are needed to confirm the efficacy of these medications, possibly suggesting a more significant role post liver transplant. [Formula presented] CITATION INFORMATION: Faisal M., Garg N., Aburumman R., Saleem A., Shahzil M., Fatima M., Faisal M., Jafri S. Decreased Rate of Rejections Post Liver Transplant in Patients on a Glucagon-Like Peptide 1 (GLP-1) Analogue AJT, Volume 25, Issue 8 Supplement 1 DISCLOSURES: M. Faisal: None
Management in the Era Before Biomarkers: Long-Term Outcomes and Immunosuppression Strategies Following Liver Transplantation
No full textPurpose: Post-liver transplantation survival has substantially improved over the last few decades. However, post-transplant management remains challenging due to the intricate balance between immunosuppression and its adverse effects. Excess immunosuppression is associated with metabolic disease, infection, readmission, and malignancy, whereas insufficient immunosuppression increases the risk of rejection. Our study aims to delineate this balance to guide clinicians in safely minimizing immunosuppression without predisposing to rejection. Methods: Our study included patients who have had a 10-year liver transplant course starting in 2013 and were on tacrolimus immunosuppression. Patients who expired between 2018-2023 or lacked adequate clinical data were excluded. Mean 5-year tacrolimus troughs 5 years after transplant (2018 - 2023) were calculated. A mean trough level of 4 was used as a cutoff to subcategorize our patients into those with a 5 year mean trough of ≤4 or \u3e4.We compared the incidence of rejection, infection, malignancies, hyperkalemia, nephrotoxicity, and hospital admissions between these groups during this time period. Results: Seventy-nine patients underwent liver transplantation at our center in 2013. Thirty-three patients expired or lacked sufficient data, leaving 44 for analysis, 17 females (39%) and 27 males (61%). The mean age was 54.6 with a standard deviation of 8.9 years. Etiologies of cirrhosis were Hepatitis C (45.45%), Alcohol (18.18%), Nonalcoholic Steatohepatitis (18.8%), Cryptogenic (9.09%), Primary Biliary Cirrhosis (4.55%), Primary Sclerosing Cholangitis (2.27%), and Cystic Fibrosis (2.27%). Tacrolimus troughs were \u3e4 in 23 (52%) and ≤4 in 21 (48%). Rejection occurred in 6 patients in the \u3e4 group and 3 in the ≤4 group. Hospitalization for infection occurred in 2 patients per group. Malignancy was identified in 2 patients in the \u3e4 group and 3 in the ≤4 group. Nephrotoxicity was noted in 2 patients in the ≤4 group and 1 in the \u3e4 group. The median overall hospital admission rate was 1 for both groups, with no statistically significant difference observed (p=0.667, Mann-Whitney test). No significant relationship between the mean 5-year trough and incidence of rejection, hyperkalemia, infection, cancer, overall hospital admission, and nephrotoxicity was found in our analysis (p\u3e0.05). Conclusions: Our findings suggest that clinicians can safely down-titrate tacrolimus without an increased risk of rejection, infection, malignancy, nephrotoxicity, or readmission. Higher tacrolimus levels were also not associated with increased complications. These findings highlight the potential for individualized immunosuppression strategies to balance rejection risk and adverse effects. Larger studies are needed to improve generalizability. CITATION INFORMATION: Saleem A., Al-Juburi S., Alomari A., Faisal M., Abusuliman M., Omeish H., Dababneh Y., Jafri S. Management in the Era Before Biomarkers: Long-Term Outcomes and Immunosuppression Strategies Following Liver Transplantation AJT, Volume 25, Issue 8 Supplement 1 DISCLOSURES: A. Saleem: None
Infectious Morbidity and Mortality in Small Intestine Transplantation: A Decade of Experience
No full textPurpose: Small intestine transplant (SIT) is a life-saving procedure for patients with intestinal failure; however, long-term success is challenged by post-transplant infections due to immunosuppressive therapy. Despite advancements in transplantation, SIT recipients remain at high risk for infectious complications significantly impacting morbidity and mortality. Identifying patterns of infection and survival outcomes in these patients is critical for optimizing post-transplant care and developing targeted preventive strategies. This study aims to evaluate the incidence, timing, and mortality associated with infectious complications in SIT recipients, providing insight into the most vulnerable periods and the need for enhanced surveillance and intervention. Methods: A retrospective cohort study was conducted at a single urban quaternary care center in the Midwestern United States, analyzing 27 SIT recipients from 2012 to 2022. Data collected included age at transplant, sex, and causal organisms of infection. Patients were stratified into three groups based on the onset of infection: within six months, 6-12 months, and beyond 12 months post-transplant. Primary outcomes included one- and three-year survival rates. Results: The cohort included 27 patients (62% female, mean age 49 years). Intra-abdominal infections were the most common (29.6%, n=8), with 88% occurring within six months, yielding an 86% one- and three-year survival. CMV viremia (19%) occurred mostly beyond 12 months (80%), with a 100% three-year survival; however, cases arising within 6-12 months had 0% survival at three years. Pneumonia (15%) primarily developed within six months, with 100% three-year survival, except for one case (6-12 months) with no survival at three years. Upper respiratory and skin infections accounted for 7.4% and 11.1% of cases, respectively, both demonstrating favorable three-year survival except for late-onset skin infections (6-12 months), which had 0% survival at three years. Conclusions: Intra-abdominal infections were the most frequent and occurred predominantly within six months post-SIT. CMV viremia, while the second most common, showed variable outcomes based on timing. Larger multicenter studies are needed to better characterize infectious risks and optimize post-SIT management. CITATION INFORMATION: Saleem A., Samad M., Khaliq I., Ilyas O., Farah B., Alomari A., Faisal M., Abusuliman M., Omeish H., Jafri S. Infectious Morbidity and Mortality in Small Intestine Transplantation: A Decade of Experience AJT, Volume 25, Issue 8 Supplement 1 DISCLOSURES: A. Saleem: None
TCT-747 Sex and Racial Disparities in Patients Undergoing Left Atrial Appendage Closure in The United States – A Nationwide Analysis between 2018 to 2021
No full textBackground: Limited data exist on sex and racial disparities in outcomes following left atrial appendage closure (LAAC). We aimed to examine these disparities in a nationwide cohort. Methods: We analyzed data from the National Inpatient Sample Database (2018-2021) for adult patients undergoing LAAC. Patients younger than 18 or missing demographic information were excluded. Multivariable logistic regression was used to assess independent associations. Results: A total of 120,935 patients were included (mean age 76±8 years; 42% female; 86% White, 7% Black). Females had significantly higher odds of mortality (OR 1.66; 95% CI 1.18-2.34; p=0.003), acute heart failure (OR 1.26; 95% CI 1.17-1.37; p\u3c0.0001), AKI (OR 1.18; 95% CI 1.09-1.28; p\u3c0.0001), bleeding (OR 1.07; 95% CI 1.02-1.13; p=0.009), pericardial effusion tamponade (OR 2.01; 95% CI 1.68-2.41; p\u3c0.0001), vasopressor use (OR 1.17; 95% CI 1.01-1.36; p=0.04), and cardiac arrest (OR 1.61; 95% CI 1.08-2.37; p=0.01). Black patients exhibited higher odds of mortality (OR 2.77; 95% CI 1.58-4.86; p=0.0003), heart failure (OR 1.33; 95% CI 1.15-1.55; p=0.0001), AKI (OR 1.21; 95% CI 1.03-1.41; p=0.02), bleeding (OR 1.59; 95% CI 1.42-1.77; p\u3c0.0001), vasopressor use (OR 2.54; 95% CI 1.97-3.27; p\u3c0.0001), and cardiac arrest (OR 6.64; 95% CI 4.08-10.79; p\u3c0.0001), but not pericardial effusion (OR 1.08; 95% CI 0.71-1.62; p=0.72). [Formula presented] Conclusion: Significant sex and racial disparities exist in LAAC outcomes, with females and Black patients experiencing worse outcomes. Further studies and interventions are needed to address these disparities. Categories: STRUCTURAL: Left Atrial Appendage Exclusio
Reflectance Confocal Microscopy for Monitoring Treatment Response in Superficial Basal Cell Carcinoma: Diagnostic Challenges Due to Scar Formation
No full textBACKGROUND: Reflectance confocal microscopy (RCM) criteria for in vivo diagnosis of unperturbed basal cell carcinoma (BCC) lesions have been validated and studies have reported high diagnostic sensitivity. However, a paucity of data remains regarding preservation or changes in RCM features after biopsy or treatment.
OBJECTIVE: Prospectively image biopsy proven superficial BCC (sBCC) with RCM at baseline and 12 weeks post-treatment to determine clearance and identify any associated RCM features.
METHODS: Ten subjects with biopsy proven sBCC completed this study. Clinical examination, dermoscopy, and RCM imaging were performed at baseline, prior to treatment, and 12 weeks post treatment with a 1064 Nd-YAG laser. Following treatment, RCM features were compared to clinical and histologic findings.
RESULTS: Statistically significant changes in RCM features at baseline and follow-up included: tumor islands with hyperreflective aggregates, dark silhouettes, peripheral palisading, peritumoral clefting, and dermal inflammatory cells. Changes in nuclear streaming, fibrosis, and vasculature were not significant.
LIMITATIONS: A limitation of this study is the small sample size.
CONCLUSIONS: The features of nuclear streaming, fibrosis and dilated vessels may be observed during RCM imaging of biopsy proven BCC at baseline and post treatment, and should be cautiously interpreted. Additional studies are needed to further validate these findings
Resolving Hyperkeratotic Psoriasis: Mechanisms of Action and Additive Effects of Fixed-Combination Halobetasol Propionate and Tazarotene
No full textBACKGROUND: Hyperkeratotic plaque psoriasis represents a distinct morphological variant that is difficult to treat with topical therapies because thick lesions may impede the penetration of active ingredients. The immunoregulatory mechanisms of topical corticosteroids (TCSs) and tazarotene (TAZ) may contribute to combating hyperkeratosis and long-term remittance of psoriasis. A fixed-combination lotion containing the potent-to-superpotent TCS halobetasol propionate (HP, 0.01%) and TAZ (0.045%), indicated for the topical treatment of plaque psoriasis in adults, was developed to harness the therapeutic benefits of each active ingredient while minimizing their safety concerns.
METHODS: This review describes data supporting the efficacy of halobetasol propionate (0.01%) and tazarotene (0.045%) lotion (HP/TAZ) and remittive effect after treatment cessation in patients with hyperkeratotic plaques.
RESULTS: Pivotal trials demonstrate the superior efficacy and safety of HP/TAZ over each active ingredient alone. Furthermore, we summarize a recent clinical study, which showed that HP/TAZ reduces lesional levels of tumor necrosis factor alpha and interleukin 17A, critical proinflammatory cytokines involved in keratinocyte hyperproliferation and psoriasis pathogenesis.
CONCLUSION: This review suggests that HP/TAZ is a valuable option for the topical treatment of severe hyperkeratotic plaques through its additive mechanisms targeting inflammation and keratinocyte regulation
Prevalence of Hidradenitis Suppurativa: A Meta-Analysis of Global Hidradenitis Suppurativa Atlas Studies
No full textIMPORTANCE: Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease with a substantial burden. Standardized global prevalence estimates and data on associated sociodemographic and risk factors are lacking.
OBJECTIVE: To estimate the global prevalence of HS and study differences in prevalence by age, sex, geographical location, body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), smoking status, gross domestic product (GDP), and Human Development Index (HDI).
DATA SOURCES AND STUDY SELECTION: Included studies were conducted using the standardized Global Hidradenitis Suppurativa Atlas methodology with finalized data collection before May 19, 2023. Studies were required to use a population-based sampling method and conduct clinical confirmation of HS diagnosis following a screening questionnaire.
DATA EXTRACTION AND SYNTHESIS: Data were independently extracted from relevant studies by 2 reviewers (D.B. and C.E.M.) using a standardized form. Extracted variables included geographic location, age, sex, BMI (median and BMI \u3e30), smoking status, HS prevalence estimates (with 95% CIs), GDP, and HDI. A proportional meta-analysis using a random-effects model was conducted on the included studies.
MAIN OUTCOMES AND MEASURES: The primary outcome was the point prevalence of HS, confirmed by clinical examination. Secondary outcomes included differences in HS prevalence by sex, age, BMI category, smoking status, and country-level socioeconomic indicators (GDP and HDI). All outcomes were prespecified before data analysis.
RESULTS: The sample included 22 743 participants, identifying 247 patients with HS, across 25 studies in 23 countries spanning 6 continents. The median proportion of female patients with HS was 55.6%, and the median age was 34.5 years. While the prevalence estimates showed considerable inconsistency (I2 \u3e 75%; τ2 = 0.747), the overall random-effects global prevalence of HS was 0.99% (95% CI, 0.67%-1.46%). Female sex was the only factor observed to be associated with the prevalence estimates (β = 1.02; 95% CI, 1.01-1.03).
CONCLUSIONS AND RELEVANCE: In this meta-analysis, an estimated global prevalence of HS between 0.67% and 1.46% surpassed previous global estimates. Substantial global variations in HS prevalence were also observed. Female sex was the only factor associated with prevalence in this sample. Future studies assessing genetic, environmental, and etiological factors are warranted to explain the heterogeneity in prevalence
State-Level Variation in and Barriers to Medicaid Abortion Coverage
No full textIMPORTANCE: Approximately 35% of individuals seeking abortion care use Medicaid for health insurance. Although the Hyde Amendment restricts use of federal funds for most abortions, states can supplement coverage using state funds. Understanding the scope of abortion coverage across states and potential barriers to access may help address health care inequities and inform interventions.
OBJECTIVE: To characterize state Medicaid abortion policies by conducting a qualitative analysis of publicly available state documents on Medicaid policy.
DESIGN, SETTING, AND PARTICIPANTS: This qualitative study analyzed Medicaid abortion policies across all 50 states and the District of Columbia (hereinafter, states). Data were systematically collected from publicly available Medicaid documents and state websites from May 2023 to February 2024.
MAIN OUTCOMES AND MEASURES: The main outcomes were key themes and descriptive statistics reporting on the scope of Medicaid abortion coverage and requirements for coverage across states, including documentation and procedures required of patients and physicians. Thematic analysis was performed to extract key themes found in abortion coverage policies, and descriptive statistics were used to show prevalence of identified themes across states.
RESULTS: The analysis of 94 documents revealed 3 key themes. First, the scope of coverage across states was heterogeneous. Eighteen states aligned with the current wording of the Hyde Amendment, 10 states described life endangerment without use of current Hyde Amendment wording, 17 states outlined additional coverage for other specified conditions for abortions, 6 states covered all abortions, and 1 state\u27s policy did not mention required federal coverage for rape or incest exceptions. Second, states imposed various patient restrictions and requirements with regard to abortion care coverage, with 22 states mandating reporting requirements for abortions due to rape or incest, along with other administrative hurdles for patients seeking care. Third, physicians were tasked with many responsibilities, such as determining eligibility for Medicaid abortion coverage and complying with documentation and administrative requirements. Thirty-eight states explicitly required physician certification and justification for clinical conditions warranting coverage.
CONCLUSIONS AND RELEVANCE: The findings of this qualitative study of state Medicaid abortion policies suggest that there is substantial heterogeneity among states regarding the scope of Medicaid abortion coverage and that there are numerous obstacles for patients and physicians in accessing this coverage. This heterogeneity and burden may impose an additional layer of complexity to abortion access. Measures and policies that improve transparency, clarity, and efficiency may enhance access to essential abortion care for vulnerable populations