Daniel P. Milgrom

Comparison of pulsatile perfusion and cold storage for paired kidney allografts.

Use of pulsatile perfusion to optimize outcomes in deceased donor kidney transplantation remains controversial. This study is a retrospective analysis of all cadaveric renal allografts procured locally by our center over a 3-year period. Kidney pairs were identified in which one kidney underwent pulsatile perfusion and transplantation at our center, whereas the contra-lateral kidney underwent cold storage and transplantation at another center. Eighty-eight percent of the exported kidneys were six-antigen matches. Study outcomes included 1-year graft and patient survival, delayed graft function, and need for posttransplant dialysis. Recipients had similar demographic and disease characteristics. Survival for pulsatile perfusion and cold storage were 95% and 88% (graft, P=0.43) and 98% and 90% (patient, P=0.36), respectively. The incidence of delayed graft function was 5% and 35% (P<0.01), whereas posttransplant dialysis was 5% and 30% (P<0.01), for pulsatile perfusion and cold storage, respectively. These data support routine use of pulsatile perfusion.

The Role of R.E.N.A.L. Nephrometry Score in the Era of Robot-Assisted Partial Nephrectomy

PURPOSE We studied the role of the R.E.N.A.L. nephrometry score (NS) in predicting surgical outcomes in a series of robot-assisted partial nephrectomy (RAPN). PATIENTS AND METHODS Of 99 cases of minimally invasive partial nephrectomy performed by a single surgeon from 2003 to 2011, 83 were performed with robotic assistance. A trained physician investigator applied the NS to these 83 cases using the preoperative CT scans. Forty-two of these were reviewed by a urology resident to eliminate interobserver variation. Tumors were categorized into noncomplex (NS 4-6) or complex (NS 7-12) tumors, and perioperative outcomes were compared. Outcomes were also compared by each component of the NS. Perioperative outcomes were analyzed using chi-square tests and Mann-Whitney/Kruskal-Wallis tests. Univariate regression was used to analyze trends between nephrometry and outcomes. RESULTS Strong correlation was found between the two sets of NS (Spearman correlational coefficient 0.814, P<0.001). Comparing between noncomplex and complex tumors, statistical differences were found in operative time (181 min vs 215 min, P=0.028) and ischemia time (21 min vs 24 min, P=0.006). Complication rates, blood loss, conversion rate, and decrease in glomerular filtration rate were similar in both groups. On univariate regression analysis, only warm ischemia time showed a significant trend with the overall NS (P=0.007) and the location score (P=0.031). CONCLUSIONS A high NS was not associated with clinically worse outcomes during RAPN. Such renal tumors can still be excised safely with robotic assistance without adverse long-term effects.

Bone Pain and Muscle Weakness in Cancer Patients

Purpose of ReviewIn this article, we will discuss the current understanding of bone pain and muscle weakness in cancer patients. We will describe the underlying physiology and mechanisms of cancer-induced bone pain (CIBP) and cancer-induced muscle wasting (CIMW), as well as current methods of diagnosis and treatment. We will discuss future therapies and research directions to help patients with these problems.Recent FindingsThere are several pharmacologic therapies that are currently in preclinical and clinical testing that appear to be promising adjuncts to current CIBP and CIMW therapies. Such therapies include resiniferitoxin, which is a targeted inhibitor of noceciptive nerve fibers, and selective androgen receptor modulators, which show promise in increasing lean mass.SummaryCIBP and CIMW are significant causes of morbidity in affected patients. Current management is mostly palliative; however, targeted therapies are poised to revolutionize how these problems are treated.

Management of Hepatocellular Carcinoma (HCC)

Hepatocellular carcinoma (HCC) is the fifth most common malignancy worldwide and the third leading cause of cancer-related death. Historically, HCC has been a problem mostly faced by patients from Asian countries due to the high prevalence of hepatitis B (HBV). Increasing global rates of HBV, hepatitis C, and obesity-related non-alcoholic steatohepatitis has caused a global increased incidence in HCC. Potentially curative therapies for HCC include liver resection, liver transplant, and radiofrequency ablation. More advanced HCC may be palliated with transarterial chemoembolization, transcatheter radioembolization, and sorafenib. Appropriate surveillance for those at risk and accurate clinical staging allows for earlier diagnosis and improved chance for cure. Hepatic resection remains the preferred primary therapy for HCC in the setting of relatively preserved liver function, while liver transplantation is the preferred curative therapy in the setting of small tumor burden with underlying liver disease. The application of locoregional therapies can also cure small lesions and maximize the utility of the limited donor pool by temporizing HCC and reserving livers for those who succumb to their underlying chronic liver disease.

Meloxicam increases epidermal growth factor receptor expression improving survival after hepatic resection in diet-induced obese mice

Background: Patients with fatty liver have delayed regenerative responses, increased hepatocellular injury, and increased risk for perioperative mortality. Currently, no clinical therapy exists to prevent liver failure or improve regeneration in patients with fatty liver. Previously we demonstrated that obese mice have markedly reduced levels of epidermal growth factor receptor in liver. We sought to identify pharmacologic agents to increase epidermal growth factor receptor expression to improve hepatic regeneration in the setting of fatty liver resection. Methods: Lean (20% calories from fat) and diet‐induced obese mice (60% calories from fat) were subjected to 70% or 80% hepatectomy. Results: Using the BaseSpace Correlation Engine of deposited gene arrays we identified agents that increased hepatic epidermal growth factor receptor. Meloxicam was identified as inducing epidermal growth factor receptor expression across species. Meloxicam improved hepatic steatosis in diet‐induced obese mice both grossly and histologically. Immunohistochemistry and Western blot analysis demonstrated that meloxicam pretreatment of diet‐induced obese mice dramatically increased epidermal growth factor receptor protein expression in hepatocytes. After 70% hepatectomy, meloxicam pretreatment ameliorated liver injury and significantly accelerated mitotic rates of hepatocytes in obese mice. Recovery of liver mass was accelerated in obese mice pretreated with meloxicam (by 26% at 24 hours and 38% at 48 hours, respectively). After 80% hepatectomy, survival was dramatically increased with meloxicam treatment. Conclusion: Low epidermal growth factor receptor expression is a common feature of fatty liver disease. Meloxicam restores epidermal growth factor receptor expression in steatotic hepatocytes. Meloxicam pretreatment may be applied to improve outcome after fatty liver resection or transplantation with steatotic graft.

Sarcopenia is a Significant Predictor of Mortality After Abdominal Aortic Aneurysm Repair

Repair of abdominal aortic aneurysms (AAA) decreases the incidence of rupture and death. In cancer patients, sarcopenia has been associated with increased surgical complications and mortality. The impact of sarcopenia on survival after AAA repair has yet to be described.

An Assessment of the Academic Impact of Shock Society Members

ABSTRACT Professional society membership enhances career development and productivity by offering opportunities for networking and learning about recent advances in the field. The quality and contribution of such societies can be measured in part through the academic productivity, career status, and funding success rates of their members. Here, using Scopus, NIH RePORTER, and departmental websites, we compare characteristics of the Shock Society membership to those of the top 55 NIH-funded American university and hospital-based departments of surgery. Shock Society members’ mean number of publications, citations and H-indices were all significantly higher than those of non-members in surgery departments (P < 0.001). A higher percentage of members also have received funding from the NIH (42.5% vs. 18.5%, P < 0.001). Regression analysis indicated that members were more likely to have NIH funding compared with non-members (OR 1.46, 95% CI 1.12–1.916). Trauma surgeons belonging to the Shock Society had a higher number of publications and greater NIH funding than those who did not (130.4 vs. 42.7, P < 0.001; 40.4% vs. 8.5%, P < 0.001). Aggregate academic metrics from the Shock Society were superior to those of the Association for Academic Surgery and generally for the Society of University Surgeons as well. These data indicate that the Shock Society represents a highly academic and productive group of investigators. For surgery faculty, membership is associated with greater academic productivity and career advancement. While it is difficult to ascribe causation, certainly the Shock Society might positively influence careers for its members.

Resection or transplantation for hepatocellular carcinoma: is the decision clear for patients beyond Milan criteria?

Hepatocellular carcinoma (HCC) is the second leading cause of cancer related mortality worldwide, and in western countries, its incidence is on the rise (1,2).