This retrospective study suggests that in patients with HCC tumours of ≥ 3 cm, treatment with TACE + SBRT provides a survival advantage over treatment with only TACE. Confirmation of this observation requires that the concept be tested in a prospective, randomized clinical trial.

Background The number of Medicaid beneficiaries has increased under the Affordable Care Act (ACA), improving access to solid organ transplantation in this disadvantaged patient cohort. It is unclear what impact Medicaid expansion will have on transplant outcomes. We performed a retrospective cohort analysis to measure the frequency and variation in Medicaid transplantation, and post-transplant survival in Medicaid patients. Study Design Adult heart, lung, liver, and renal transplant recipients between 2002 and 2011 (n=169,194) reported to the Scientific Registry of Transplant Recipients were identified. Transplant recipients were classified based on insurance status (Private, Medicare or Medicaid). Outcome measures included five-year post-transplant survival, summarized using Kaplan-Meier curves and compared with log-rank tests. Organ-specific Cox proportional hazards models were used to adjust for donor and recipient factors. Results Medicaid patients comprised 8.6% of all organ transplant recipients. Fewer transplants were performed than expected among Medicaid beneficiaries for all organs but liver [Observed/Expected ratios (95% CI): liver=1.21 (0.68, 1.90); heart=0.89 (0.44, 1.49); lung=0.57 (0.22, 1.06); renal=0.32 (0.08, 0.72)]. Medicaid transplant recipients were listed with more severe organ failure and experienced shorter transplant wait times. Post-transplant survival was lower in Medicaid patients compared to Private insurance for all organs. Post-transplant survival in Medicaid patients was similar to Medicare patients for heart, liver and renal but lower in lung. Conclusions Medicaid organ transplant beneficiaries had significantly lower survival compared to Privately insured beneficiaries. The more severe organ failure among Medicaid beneficiaries at the time of listing suggested a pattern of late referral, which may account for worse outcomes. Implementation of the ACA affords the opportunity to develop the necessary infrastructure to ensure timely transplant referrals and improve long-term outcomes in this vulnerable population.

The production of 20-hydroxyeicosatetraenoic acid (20-HETE) in the kidney is thought to be involved in the control of renal vascular tone and tubular sodium and chloride reabsorption. 20-HETE production in the kidney has been extensively studied in rats and humans and occurs primarily via the actions of P-450 enzymes of the CYP4A and -4F families. Recent advancements in molecular genetics of the mouse have made it possible to disrupt genes in a cell-type-specific fashion. These advances could help in the creation of models that could distinguish between the vascular and tubular actions of 20-HETE. However, isoforms of the CYP4A and -4F families that may be responsible for the production of 20-HETE in the vascular and tubular segments in the kidney of the mouse are presently unknown. The goal of this study was to identify the isoforms of the CYP4A and -4F families along the nephron by RT-PCR of RNA isolated from microdissected renal blood vessels and nephron segments from 16- to 24-wk-old male and female C57BL/6J mice. CYP4A and -4F isoforms were detected in every segment analyzed, with sex differences only observed in the proximal tubule and glomeruli. In the proximal tubular segments from male mice, the 4A10 and -12 isoforms were present, whereas the 4A10 and -14 isoforms were detected in segments from female mice. In glomeruli, sex differences in the expression pattern of CYP4F isoforms were also observed, with male mice expressing the 4F13, -14, and -15 isoforms, whereas female mice expressed the 4F13, -16, and -18 isoforms. These results demonstrate that isolated nephron and renal vessel segments express multiple isoforms of the CYP4A and -4F families; therefore, elimination of a single CYP4A or -4F isoform may not decrease 20-HETE production in all nephron segments or the renal vasculature of male and female mice. However, the importance of CYP4A vs. -4F isoforms to the production of 20-HETE in each of these renal tubular and vascular segments of the mouse remains to be determined.

The purpose of this study was to evaluate the effect of sham surgery in a minimally invasive surgical model of permanent coronary artery occlusion used to generate myocardial infarction (MI) in mice. Adult male C57BL/6J mice (3-6 mo old) were divided into five groups: day (D) 0 (no surgical operation), D1 Sham, D1 MI, D7 Sham, and D7 MI. A refined MI surgery technique was used to approach the coronary artery without the ribs being cut. Both sham and MI mice had the left ventricle (LV) exposed through a small incision. To test the effects of surgery alone, the suture was passed around the coronary artery but not ligated. The MI mice were subjected to permanent coronary artery ligation. The mice were killed at D1 or D7 postsurgical procedure. Compared with D0 no surgery controls, the D1 and D7 sham groups exhibited no surgical mortality and similar necropsy and echocardiographic variables. Surgery alone did not induce an inflammatory cell response, as evidenced by the lack of leukocyte infiltration in the sham groups. Analysis of 165 inflammatory cytokines and extracellular matrix factors in sham revealed that a minor gene response was initiated but not translated to protein levels. Collagen deposition did not occur in the absence of MI. In contrast, the D1 and D7 MI groups showed the expected robust inflammatory and scar formation responses. When a minimally invasive procedure to generate MI in mice was used, the D0 (no surgical operation) control was an adequate replacement for the use of sham surgery groups.

Introduction. This study's objective was to identify risk factors associated with reoperation for bleeding following liver transplantation (LTx). Methods. A retrospective study was performed at a single institution between 2001 and 2012. Operative reports were used to identify patients who underwent reoperation for bleeding within 2 weeks following LTx (operations for nonbleeding etiologies were excluded). Results. Reoperation for bleeding was observed in 101/928 (10.8%) of LTx patients. The following characteristics were associated with reoperation on multivariable analysis: recipient MELD score (OR 1.06/MELD unit, 95% CI 1.03, 1.09), number of platelets transfused (OR 0.73/platelet unit, 95% CI 0.58, 0.91), and aminocaproic acid utilization (OR 0.46, 95% CI 0.27, 0.80). LTx patients who underwent reoperation for bleeding had a longer ICU stay (5 days ± 7 versus 2 days ± 3, P < 0.001) and hospitalization (18 days ± 9 versus 10 days ± 18, P < 0.001). The risk of death increased in patients who underwent reoperation for bleeding (HR 1.89, 95% CI 1.26, 2.85). Conclusion. Reoperation for bleeding following LTx was associated with increased resource utilization and recipient mortality. A lower threshold for intraoperative platelet transfusion and antifibrinolytics, especially in patients with high lab-MELD score, may decrease the incidence of reoperation for bleeding following LTx.

Sarcopenia is strongly associated with poor outcomes and mortality following injury among the geriatric population. Diagnosis using psoas area is most common but may be unavailable given limited radiographic evaluation following low-impact injuries. Masseter area has recently been identified as an available alternative and associated with 2-year mortality following injury. We sought to validate this measure and its association with early mortality following severe traumatic brain injury (sTBI) using a retrospective analysis of all geriatric trauma patients with sTBI admitted from 2011-2016 to our trauma center. Admission Glasgow Coma Scale (GCS) score ≤8 was used to identify sTBI. Bilateral masseter area was measured 2 cm below the zygomatic arch and the mean used for analysis. Sarcopenia was defined as mean masseter area one standard deviation or less from the sex-based mean. Multivariate models with logistic regression and Cox proportional hazards test followed univariate analysis. Kaplan-Meier survival curves were generated and evaluated by log rank. The primary outcome of interest was 30-day mortality. A total of 108 patients were identified for inclusion. Twenty-five patients, 16 male and nine female, had sarcopenia with mean masseter areas of 2.81 ± 0.45 cm and 2.24 ± 0.42 cm, respectively. Patients with sarcopenia had significantly increased rates of 30-day mortality (80.0% vs. 50.6%; p = 0.01). Sarcopenia (odds ratio [OR], 2.95; 95% confidence interval [CI] 1.03-8.49) and decreasing masseter area were significantly associated with 30-day mortality (OR, 0.66; 95% CI 0.46-0.95) in multivariate modeling. Masseter area is a readily available and objective measure to determine sarcopenia, which is significantly associated with in-creased 30-day mortality following sTBI.

Background: Despite the increasing prevalence of end-stage liver disease in older adults, there is no consensus to determine suitability for liver transplantation (LT) in the elderly. Disparities in LT access exist, with a disproportionately lower percentage of African Americans (AAs) receiving LT. Understanding waitlist outcomes in older adults, specifically AAs, will identify opportunities to improve LT access for this vulnerable population. Methods: All adult, liver-only white and AA LT waitlist candidates (1/1/2003-10/1/2015) were identified in the Scientific Registry of Transplant Recipients. Age and race categories were defined: younger (age <60) white, younger AA, older white (age ≥60), and older AA. Outcomes were delisting, transplantation, and mortality and were modeled using Fine and Gray competing risks. Results: Among 101,805 candidates, 58.4% underwent transplantation, 14.7% died while listed, and 21.4% were delisted. Among those delisted, 36.1% died, while 7.4% were subsequently relisted. Both older AAs and older whites were more likely than younger whites to be delisted and to die after delisting. Older whites had higher incidence of waitlist mortality than younger whites (sdHR 1.07; 95%CI:1.01-1.13). All AAs and older whites had decreased incidence of LT, compared with younger whites.

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