Spine

"The Night View of Bund in Shanghai, China" No abstract available

It is Time to Change Our Mindset and Perform More High-quality Research in Low Back Pain No abstract available

The Impact of Anterior Spondylolisthesis and Kyphotic Alignment on Dynamic Changes in Spinal Cord Compression and Neurological Status in Cervical Spondylotic Myelopathy: A Radiological Analysis Involving Kinematic CT Myelography and Multimodal Spinal Cord Evoked Potentials Study Design. A retrospective study of prospectively collected data. Objective. This study aimed to examine how radiological parameters affect dynamic changes in the cross-sectional area of the spinal cord (CSA) in cervical spondylotic myelopathy (CSM) patients and how they correlate with the severity of myelopathy, by evaluating multi-modal spinal cord evoked potentials (SCEPs). Summary of Background Data. Appropriate assessments of dynamic factors should reveal hidden spinal cord compression and provide useful information for choosing surgical procedures. Methods. Seventy-nine CSM patients were enrolled. They were examined with kinematic CT myelography (CTM), and the spinal levels responsible for their CSM were determined via SCEP examinations. The C2–7 angle, C2–7 range of motion, and percentage of slip were measured on the midsagittal view during flexion and extension, and the CSA was measured on the axial view in each neck position using kinematic CTM. The patients who exhibited the smallest CSA values during extension and flexion were classified into Groups E and F, respectively. Results. Fifty-two (65.8%) and 27 (34.2%) cases were included in Groups E and F, respectively. The preoperative JOA score did not differ significantly between the groups; however, the preoperative lower-limb JOA score of Group F was significantly lower than that of Group E (2.24 ± 0.82 vs. 2.83 ± 1.09, P = 0.016). In the multiple logistic regression analysis, a small C2–7 angle during extension (β = 5°, odds ratio: 0.69, 95% confidence interval [CI]: 0.54–0.90) and the slip percentage during flexion (β = 5%, odds ratio: 1.42, 95% CI: 1.09–1.85) were identified as significant predictors of belonging to Group F. Conclusion. Exhibiting more severe spinal cord compression during neck flexion was associated with a small C2–7 angle and anterior spondylolisthesis. The neurological status of the patients in Group F was characterized by severe lower limb dysfunction because of a disturbed blood supply to the anterior column. Level of Evidence: 4

Cervical Extensor Muscles Play the Role on Malalignment of Cervical Spine: A Case Control Study With Surface Electromyography Assessment Study Design. A case control study. Objective. The aim of this study was to identify the potential impact of cervical spine malalignment on muscle parameters. Summary of Background Data. Muscular factors are associated with cervical alignment. Nevertheless, only muscle dimensions or imaging changes have been evaluated, function of cervical muscles has scarcely been investigated. Methods. Thirty-four patients diagnosed as cervical spine degeneration associated with cervical malalignment and 32 control subjects were included in this case control study. Visual analogue scale (VAS) and the neck disability index (NDI) were used. The sagittal alignment parameters and cervical range of motion (ROM) were measured on cervical spine lateral radiographs, included C2-C7 lordosis, C2-C7 sagittal vertical axis (C2-C7 SVA), cervical gravity-sagittal vertical axis (CG-SVA), T1-Slope, and spinal canal angle (SCA). Surface electromyography (SEMG)-based flexion-relaxation ratio (FRR) was measured. Results. The result showed VAS score of the neck significantly lower in controls (P<0.05), C2-C7 lordosis, C2-C7 SVA, CG-SVA, T1-Slope and ROM showed significantly different (P<0.001) between malalignment group and control group, FRR of splenius capitis (FRRSpl) and upper trapezius (FRRUTr) of the malalignment group were lower than in the control group, which correlated well with NDI (rSpl = −0.181 rUTr = −0.275), FRRSpl correlated well with VAS (rSpl = −0.177). FRRSpl correlated strongly with C2-C7 SVA (r = 0.30), CG-SVA (r = 0.32), T1-Slope (r = 0.17), ROM (r = 0.19), FRRUTr correlated with C2-C7 lordosis (r = −0.23), CG-SVA (r = 0.19), T1-Slope (r = 0.28), ROM (r = 0.23). Conclusion. Cervical malalignment patients had more tensional posterior cervical muscle and poor muscle functions. CG-SVA showed advantages in evaluating cervical malalignment. Level of Evidence: 3

Preoperative Opioid Weaning Before Major Spinal Fusion: Simulated Data, Real-World Insights Study Design. Retrospective cohort. Objective. To identify gaps in opioid prescription immediately prior to spinal fusion and to study the effect of such simulated "opioid weaning/elimination" on risk of long-term postoperative opioid use. Summary of Background Data. Numerous studies have described preoperative opioid duration and dose thresholds associated with sustained postoperative opioid use. However, the benefit and duration of preoperative opioid weaning before spinal fusion has not been elaborated. Methods. Humana commercial insurance data (2007-Q1 2017) was used to study primary cervical and lumbar/thoracolumbar fusions. More than 5000 total morphine equivalents in the year before spinal fusion were classified as chronic preoperative opioid use. Based on time between last opioid prescription (<14-days' supply) and spinal fusion, chronic opioid users were divided as; no gap, >2-months gap (2G) and >3-months gap (3G). Primary outcome measure was long-term postoperative opioid use (>5000 total morphine equivalents between 3 and 12-mo postoperatively). The effect of "opioid gap" on risk of long-term postoperative opioid use was studied using multiple-variable logistic regression analyses. Results. 17,643 patients were included, of whom 3590 (20.3%) had chronic preoperative opioid use. Of these patients, 41 (1.1%) were in the 3G group and 106 (3.0%) were in the 2G group. In the 2G group, 53.8% patients ceased to have long-term postoperative use as compared with 27.8% in NG group. This association was significant on logistic regression analysis (OR 0.30, 95% CI: 0.20–0.46, P < 0.001). Conclusions. Chronic opioid users whose last opioid prescription was >2-months prior to spinal fusion and less than 14-days' supply had significantly lower risk of long-term postoperative opioid use. We have simulated "opioid weaning" in chronic opioid users undergoing major spinal fusion and our analysis provides an initial reference point for current clinical practice and future clinical studies. Level of Evidence: 3

Relationship Between Pulmonary Function and Thoracic Morphology in Adolescent Idiopathic Scoliosis: A New Index, the "Apical Vertebra Deviation Ratio", as a Predictive Factor for Pulmonary Function Impairment Study Design. A retrospective study. Objective. The aim of this study was to investigate the relationship between thoracic morphology (TM) and pulmonary function (PF) in patients with adolescent idiopathic scoliosis (AIS) and the feasibility of the "apical vertebra deviation ratio (AVDR)" as a predictor of PF impairment. Summary of Background. The PF of AIS is one of the key focuses of clinicians' attention. Early identification of AIS patients who are at risk of developing impaired PF is important for improving patient management. Methods. Preoperative PF and radiographic examination data of 108 patients with thoracic AIS were collected. The following TM data were collected: the costophrenic angle distance (CAD), distance between T1 and mean diaphragm height (T1-diaphragm), T1-T12 height, and AVDR. The correlation coefficient between PF and TM measurements was analyzed, and univariable and multivariable linear regressions were used to determine whether the TM measurements could predict PF. Results. The CAD, T1-diaphragm, and T1-T12 height were significantly positively correlated with forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), vital capacity, and total lung capacity (r = 0.54–0.74, P < 0.01). A linear equation between CAD and pulmonary volume could be established: FVC (L) = −3.46 + CAD (cm) × 0.27 (R2 = 0.54). If T1-T12 height is included, the correlation is further enhanced (R2 = 0.68). There was a significant negative correlation between the AVDR and predicted values of forced vital capacity (FVC%), FEV1%, predicted values of vital capacity, and predicted values of total lung capacity (r = −0.46 to −0.52, P < 0.01). The AVDR could predict the value of each of these variables. One of the linear equations is as follows: FVC% = 110.70–99.73 × AVDR (R2 = 0.272). Conclusion. The two novel, two-dimensional TM measurements, CAD and AVDR, can be used as moderate to strong predictors of PF outcome in statistical terms. An AVDR >0.2 suggests that the patient may suffer from moderate or severe PF damage. Level of Evidence: 4

Predictive Probability of the Global Alignment and Proportion Score for the Development of Mechanical Failure Following Adult Spinal Deformity Surgery in Asian Patients Study Design. This is a multicenter retrospective review of 257 surgically treated consecutive ASD patients who had a minimum of five fused segments, completed a 2-year follow-up (53 ± 19 yrs, females: 236 [92%]). Objective. This study aimed to validate the predictive probability of the GAP score in an Asian ASD patient cohort. Summary of Background Data. The GAP score is a recently established risk stratification model for MF following ASD surgery. However, the predictive ability of the GAP score is not well studied. This study aimed to validate the predictive probability of the GAP score in an Asian ASD patient cohort. Methods. Comparisons of the immediate postoperative GAP scores between MF the and MF-free groups were performed. We evaluated the discriminative ability of the GAP score based on the area under the receiver operating characteristic curve (AUROC). The Cuzick test was performed to determine whether there is a trend between the GAP score and the incidence of MF or revision surgery. Univariate logistic regression analyses were performed to explore the associations between the GAP score and the incidence of MF or revision surgery. Results. No difference was observed in the GAP score between the MF and MF-free groups (MF vs. MF-free; GAP: 5.9 ± 3.3 vs. 5.2 ± 2.7, P = 0.07). The Cuzick analysis showed no trend between the GAP score and the risk for MF or revision surgery. Likewise, the MF rate was not correlated with the GAP score, as shown by the ROC curve (AUC of 0.56 [95% CI 0.48–0.63], P = 0.124). Univariate logistic regression confirmed no associations between the GAP score and the incidence of MF or revision surgery (MF; moderately disproportioned [MD]: OR: 0.6 [95% CI: 0.3–1.2], P = 0.17, severely disproportioned [SD]: OR: 1.2 [95% CI: 0.6–2.3], P = 0.69, revision surgery; MD: OR: 0.8 [95% CI: 0.2–2.8], P = 0.71, SD: OR: 1.2 [95% CI: 0.9–8.7], P = 0.08). Conclusion. In this multicenter study, in an Asian ASD patient cohort, the GAP score was not associated with the incidence of MF or revision surgery. Additional studies on the predictive ability of the GAP score in different patient cohorts are warranted. Level of Evidence: 3

Accuracy of EOS Imaging Technology in Comparison to Computed Tomography in the Assessment of Vertebral Rotational Orientation in Instrumented Spines in Adolescent Idiopathic Scoliosis Study Design. Retrospective radiographic reliability study. Objective. The aim of this study was to assess the validity of EOS 3D imaging technology in the determination of vertebral rotations in the spine of patients with previous instrumentation. Summary of Background Data. There is a lack of evidence on the accuracy of vertebral rotational measurement using EOS 3D morphological analysis in the instrumented spine. Methods. A retrospective review of 31 patients with adolescent idiopathic scoliosis (AIS) who underwent instrumented fusion and postoperative computed tomography (CT) scans of the spine was performed. Vertebral rotations of the apex vertebra, the uppermost (UIV) and lowermost (LIV) instrumented vertebra, the noninstrumented vertebra one level cranial to the UIV (UIV + 1) and one level caudal to LIV (LIV + 1) were determined using EOS 3D reconstruction. The vertebral rotation was also measured using reformatted CT axial images. Relative vertebral rotational difference (VRD) were calculated for UIV to apex, UIV + 1 to apex, LIV to apex, LIV + 1 to apex, UIV to LIV and UIV + 1 to LIV + 1. Paired t tests were used to compare the VRD measured using the two different imagining modalities. For values where P > 0.05, the Bland-Altman plot was used to assess the agreement between the measures. Interclass correlation (ICC) was used to determine interobserver and intraobserver reliabilities of EOS and CT measurements. Results. EOS analysis of relative VRD was found to be significantly different from that of CT for UIV to apex (P = 0.006) and UIV + 1 to apex (P = 0.003). No significant differences were found for LIV to apex (P = 0.06), LIV + 1 to apex (P = 0.06), UIV to LIV (P = 0.59) and UIV + 1 to LIV + 1 (P = 0.64). However, Bland-Altman plots showed that agreement was poor, and variance was beyond acceptable. ICC showed good interobserver and good to very good intraobserver reliability for EOS. Conclusion. EOS 3D morphological analysis of VRD in the instrumented levels of the spine demonstrated significant difference and unacceptable variance in comparison to CT measurement. Level of Evidence: 4

Presurgical Short-Term Halo-Pelvic Traction for Severe Rigid Scoliosis (Cobb Angle >120°): A 2-Year Follow-up Review of 62 Patients Study Design. A 2-year follow-up review of 62 patients with severe rigid scoliosis (>120°). Objective. To evaluate the effectiveness and safety of halo-pelvic traction (HPT) for treating severe rigid scoliosis (>120°). Summary of Background Data. Severe rigid scoliosis (>120°) is still a challenge for spine surgeons. A combination of presurgical HPT traction, osteotomy, and internal fixation could be a safe and effective solution for these cases. Methods. We reviewed the records of all the patients with severe rigid scoliosis (>120°) treated with presurgical HPT from 2013 through 2017. Radiographic measurements were performed. The period of traction, estimated blood loss, operation time, complications, and bed rest period were recorded. Results. A total of 62 patients who had 2-year radiological follow-up were included in the study. In 30 patients, vertebral column resection (VCR) was performed aiming to achieve a better correction rate. In patients who received a VCR, the average preoperative Cobb angle was 133.6°, and the average correction rate at 2 years after surgery was 65.4%. Compared with the average height before treatment, at 2 years after surgery the average height was 12.5 cm greater. In patients who did NOT received VCR, the average preoperative Cobb angle was 131.5°, and the average correction rate at 2 years after surgery was 64.1%. Compared with the average height before treatment, at 2 years after surgery the average height was 14.0 cm greater. Common complications during HPT included infected pelvic pins, brachial plexus palsy, and weakness of the lower extremities. No patients experienced permanent neurological deficits or death. Conclusion. For severe rigid scoliosis with a Cobb angle greater than 120°, a combination of short-term presurgical HPT and posterior surgery is an effective and safe solution. After 4 to 6 weeks of presurgical HPT the Cobb angle can be decreased by approximately 50%, providing a favorable condition for spine corrective surgery. Level of Evidence: 3

Three-Dimensional Analysis of Preoperative and Postoperative Rib Cage Parameters by Simultaneous Biplanar Radiographic Scanning Technique in Adolescent Idiopathic Scoliosis: Minimum 2-Year Follow-Up Study Design. Prospective study. Objective. This study aimed to investigate the changes in rib cage deformity in adolescent idiopathic scoliosis (AIS) by comparing the preoperative and postoperative three-dimensional (3D) reconstruction images using simultaneous biplanar radiographic scanning technique (EOS) (EOS Imaging, Paris, France). Summary of Background Data. EOS data are limited for the analyses of preoperative and postoperative rib cage deformity. Methods. A total of 67 Lenke type 1 or 2 AIS patients who underwent surgery (59 females and 8 males) were enrolled in this study. The mean patient age was 14.4 years (range: 11–17 yr). In all patients, posterior corrective fusion was performed with a rod rotation maneuver based on segmental pedicle fixation. Spinal parameters (scoliosis and kyphosis) and rib cage parameters (max thickness, thoracic index (TI), rib hump (RH), surface spinal penetration index (sSPI), end thoracic hump ratio, vertebra-sternum angle, rib vertebral angle difference at the apex, and vertebral lateral decentering), were measured. 3D images were assessed preoperatively and postoperatively at 2-year follow-up. Results. Both main thoracic (MT) and proximal thoracic scoliosis were significantly corrected (51° to 15°, 30° to 17°, P < 0.0001). The rotation of MT apical vertebrae was also significantly corrected (12° to 5°, P < 0.0001). Thoracic kyphosis (T4-T12) significantly increased (13° to 18°, P < 0.0001). Besides, max thickness, TI, and RH demonstrated significant differences between preoperative and postoperative images (P < 0.01). T8–10 sSPI and end thoracic hump ratio decreased significantly postoperatively (P < 0.05). Although surgery significantly decreased vertebra-sternum angle (P < 0.0001), no significant difference was observed between the preoperative and postoperative rib vertebral angle difference (P = 0.32). Following the surgery, vertebral lateral decentering and rib cage volume were significantly increased (P < 0.0001). Conclusions. 3D reconstruction of the rib cage using biplanar standing stereoradiography is useful to evaluate preoperative and postoperative rib cage deformity in patients with AIS. Level of Evidence: 2

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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,

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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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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