A multidisciplinary approach to improving transition readiness in pediatric liver transplant recipients

The Six Core Elements of Transition have been advocated to guide transition, but little is published about their use with liver transplant patients. We started a liver transplant transition program in August 2015 using quality improvement (QI) methods and by linking the Six Core Elements of Transition to process measures. Eligible patients completed baseline transition readiness assessments (Readiness for Transition Questionnaire, RTQ), interviews with a psychologist, received focused education, and completed follow-up RTQs before transfer to adult care. Our QI goal was to improve RTQ scores by 20% prior to transfer to adult care. We also assessed continuity of care, tacrolimus levels, rejection, and retransplantation as balancing measures. Of the 24 patients who completed the transition program and were transferred to adult care, RTQ scores were available for 11 patients. Overall RTQ scores improved from 23.7 to 30.5 (+28.7%, P = .009) prior to transfer. Nearly two-thirds (63%) of patients were seen by adult transplant hepatology within 6 months, and one patient was lost to follow-up after the first adult visit. Tacrolimus-level standard deviations were <2.0 in 45% of patients in pediatric care and 72% of patients in adult care. Three patients had undergone immunosuppression withdrawal in pediatric care, with one restarted on immunosuppression prior to transfer to adult care due to late acute rejection. The Six Core Elements of Transition can be translated into patient- and system-level transition milestones to serve as potential quality metrics in the implementation of transition programs.

Society of pediatric liver transplantation: Current registry status 2011-2018

BACKGROUND

SPLIT was founded in 1995 in order to collect comprehensive prospective data on pediatric liver transplantation, including waiting list data, transplant, and early and late outcomes. Since 2011, data collection of the current registry has been refined to focus on prospective data and outcomes only after transplant to serve as a foundation for the future development of targeted clinical studies.

OBJECTIVE

To report the outcomes of the SPLIT registry from 2011 to 2018.

METHODS

This is a multicenter, cross-sectional analysis characterizing patients transplanted and enrolled in the SPLIT registry between 2011 and 2018. All patients, <18 years of age, received a first liver-only, a combined liver-kidney, or a combined liver-pancreas transplant during this study period.

RESULTS

A total of 1911 recipients from 39 participating centers in North America were registered. Indications included biliary atresia (38.5%), metabolic disease (19.1%), tumors (11.7%), and fulminant liver failure (11.5%). Greater than 50% of recipients were transplanted as either Status 1A/1B or with a MELD/PELD exception score. Incompatible transplants were performed in 4.1%. Kaplan-Meier estimates of 1-year patient and graft survival were 97.3% and 96.6%. First 30 days of surgical complications included reoperation (31.7%), hepatic artery thrombosis (6.3%), and portal vein thrombosis (3.2%). In the first 90 days, biliary tract complications were reported in 13.6%. Acute cellular rejection during first year was 34.7%. At 1 and 2 years of follow-up, 39.2% and 50.6% had normal liver tests on monotherapy (tacrolimus or sirolimus). Further surgical, survival, allograft function, and complications are detailed.

Outpatient cold knife tonsillectomy in toddlers with sleep disordered breathing

PROBLEM

Tonsillectomy performed as day surgery has become popular over the last fifteen years. However, there are conflicting opinions regarding the safety of this practice, especially in children of very young age. We sought to determine the safety of outpatient tonsillectomy in children aged three years old and younger.

METHODOLOGY

A retrospective study of all tonsillectomies performed in a major pediatric hospital during a two-year period was conducted. Age, gender, indication for tonsillectomy, other procedures performed simultaneously, seniority of operating surgeon, and reasons for hospital admissions during the first post-operative week were recorded. Patients with inappropriate records for the analysis were excluded. A total of 1058 patients were studied. Tonsillectomized children were divided into two age groups: greater than 3 years old (n = 951) and 3 years old or younger (n = 107).

RESULTS

Male gender, obstructed sleep disordered breathing as indication for surgery, seniority of the operating surgeon, and age of 3 years old or younger were not associated with post-operative complications.

CONCLUSIONS

Outpatient tonsillectomy can be managed safely regardless of age, as long as specific factors, such as good recovery room supervision, exist.

Prelingual nonsyndromic hearing loss in Greece. Molecular and clinical findings

Mutations in the gene encoding the gap-junction protein connexin 26 (GJB2) on chromosome 13q11 have been shown as a major contributor to prelingual, sensorineural, nonsyndromic deafness. One specific mutation, 35delG, has accounted for the majority of the mutations detected in the GJB2 gene in Caucasian populations and is one of the most frequent disease mutations identified so far with highest carrier frequency of 3,5% in the Greek population. In a collaboration with the major referral centers for childhood deafness in Greece, patients were examined by an extensive questionnaire to exclude syndromic forms and environmental causes of deafness and by allele-specific PCR for the detection of the 35delG mutation. The 35delG mutation was found in 32.1% of the alleles in 173 unrelated cases of prelingual deafness: 50 homozygotes and 11 heterozygotes. Individuals heterozygous for the 35delG mutation were further analyzed by direct genomic sequencing of the coding region of the GJB2 gene, which revealed R184P and 486insT mutations in single alleles. We conclude that the 35delG GJB2 mutation is responsible for one third of prelingual, sensorineural deafness in Greece, which is higher than the usually quoted 20% for Caucasian populations.

A study on the otoscopical and audiological findings in patients with Down's syndrome in Greece

One hundred and twenty patients (children) with Down's Syndrome were examined by the Audiological Dept. at 'Aghia Sophia' Children's Hospital during the period 1988-1990. Of these 73 (60.8%) were boys and 47 (37.2%) were girls. Their ages varied from 7-18 years of age with an average age of 14.8 years. Physical examination included otoscopy, tympanometry, and in some cases auditory brainstem audiometry. It is worth noting that a high percentage of these patients were unable to cooperate in this study, therefore making it obligatory to utilize objective measures for hearing evaluation.