Marc L. Melcher

All Publications

• Pathologic Response to Pretransplant Locoregional Therapy is Predictive of Patient Outcome After Liver Transplantation for Hepatocellular Carcinoma Analysis From the US Multicenter HCC Transplant Consortium ANNALS OF SURGERY DiNorcia, J., Florman, S. S., Haydel, B., Tabrizian, P., Ruiz, R. M., Klintmalm, G. B., Senguttuvan, S., Lee, D. D., Taner, C., Verna, E. C., Halazun, K. J., Hoteit, M., Levine, M. H., Chapman, W. C., Vachharajani, N., Aucejo, F., Nguyen, M. H., Melcher, M. L., Tevar, A. D., Humar, A., Mobley, C., Ghobrial, M., Nydam, T. L., Amundsen, B., Markmann, J. F., Berumen, J., Hemming, A. W., Langnas, A. N., Carney, C. A., Sudan, D. L., Hong, J. C., Kim, J., Zimmerman, M. A., Rana, A., Kueht, M. L., Jones, C. M., Fishbein, T. M., Markovic, D., Busuttil, R. W., Agopian, V. G. 2020; 271 (4): 616–24

  View details for DOI 10.1097/SLA.0000000000003253

  View details for Web of Science ID 000544920700005

• Artificial Intelligence May Detect Donor Liver Steatosis and Predict Early Post-Transplantation Graft Failure Narayan, R. R., Yang, L., Abadilla, N., Chen, S. B., Higgins, J. P., Melcher, M. L. WILEY. 2020: 257

  View details for Web of Science ID 000546629501003

• Improving Liver Transplant (LT) Waitlist Attrition Concepcion, W., Ahmed, A., Tulu, Z., Hogan, L., Bonham, A., Gallo, A., Melcher, M., Kwo, P., Esquivel, C. WILEY. 2020: 284–85

  View details for Web of Science ID 000546629501065

• Center-level Variation in HLA-incompatible Living Donor Kidney Transplantation Outcomes. Transplantation Jackson, K. R., Long, J., Motter, J., Bowring, M. G., Chen, J., Waldram, M. M., Orandi, B. J., Montgomery, R. A., Stegall, M. D., Jordan, S. C., Benedetti, E., Dunn, T. B., Ratner, L. E., Kapur, S., Pelletier, R. P., Roberts, J. P., Melcher, M. L., Singh, P., Sudan, D. L., Posner, M. P., El-Amm, J. M., Shapiro, R., Cooper, M., Verbesey, J. E., Lipkowitz, G. S., Rees, M. A., Marsh, C. L., Sankari, B. R., Gerber, D. A., Wellen, J., Bozorgzadeh, A., Gaber, A. O., Heher, E., Weng, F. L., Djamali, A., Helderman, J. H., Concepcion, B. P., Brayman, K. L., Oberholzer, J., Kozlowski, T., Covarrubias, K., Desai, N., Massie, A. B., Segev, D. L., Garonzik-Wang, J. 2020

  Abstract

  BACKGROUND: Desensitization protocols for HLA-incompatible living donor kidney transplantation (ILDKT) vary across centers. The impact of these, as well as other practice variations, on ILDKT outcomes remain unknown.METHODS: We sought to quantify center-level variation in mortality and graft loss following ILDKT using a 25-center cohort of 1358 ILDKT recipients with linkage to SRTR for accurate outcome ascertainment. We used multilevel Cox regression with shared frailty to determine the variation in post-ILDKT outcomes attributable to between-center differences, and to identify any center-level characteristics associated with improved post-ILDKT outcomes.RESULTS: After adjusting for patient-level characteristics, only 6 centers (24%) had lower mortality and 1 (4%) had higher mortality than average. Similarly, only 5 centers (20%) had higher graft loss and 2 had lower graft loss than average. Only 4.7% of the differences in mortality (p<0.01) and 4.4% of the differences in graft loss (p<0.01) were attributable to between-center variation. These translated to a median hazard ratio of 1.36 for mortality and 1.34 of graft loss for similar candidates at different centers. Post-ILDKT outcomes were not associated with the following center-level characteristics: ILDKT volume and transplanting a higher proportion of highly sensitized, prior transplant, preemptive, or minority candidates.CONCLUSION: Unlike most aspects of transplantation where center-level variation and volume impact outcomes, we did not find substantial evidence for this in ILDKT. Our findings support the continued practice of ILDKT across these diverse centers.

  View details for DOI 10.1097/TP.0000000000003254

  View details for PubMedID 32235255

• Influence of Student Loan Debt on General Surgery Resident Career and Lifestyle Decision-Making Gray, K., Kaji, A. H., Wolfe, M., Calhoun, K., Amersi, F., Donahue, T., Smith, B. R., Salcedo, E. S., Murayama, K., de Virgilio, C., Neville, A., Arnell, T., Jarman, B., Inaba, K., Melcher, M., Morris, J. B., Reeves, M., Gauvin, J., Sidwell, R., Damewood, R., Poola, V., Dent, D., Surg Educators Workgrp ELSEVIER SCIENCE INC. 2020: 173–81

  Abstract

  The average medical school debt in 2011 was $170,000 and by 2017 it increased to $190,000. High debt burden has been shown to affect career choices for residents in primary care specialties; however, it has not been well studied among surgical residents. The purpose of this multi-institutional study is to assess the amount of debt among general surgery residents and its effects on their career and lifestyle decisions.Surveys were distributed to 607 categorical general surgery residents at 19 different residency programs. Degree of debt was assessed and responses compared.Overall, 427(70.3%) residents completed the survey, of which 317(74.2%) reported having student loan debt. Of those with debt, 262(82.6%) felt that repaying debt was a significant financial burden in residency, 248 (78.3%) felt it would remain a burden after residency, 210(66.2%) felt their debt would influence their future job choice, and 225(71%) felt their debt will delay their ability to buy a home. Debt did not affect decisions to get married or have children. There were 109(25.6%) residents with no debt, 131(30.8%) with <$200,000, 103(24.2%) with $200,000-300,000, and 83(19.5%) with >$300,000. Residents with high debt were less likely to feel financially secure now (p<0.0001) and when thinking about their future (p-0.0001). They also had higher minimum starting salary goals (p=0.002) and were less likely to have had assistance paying for their education (p=0.0001).Surgical residents feel their debt is a significant financial burden. Furthermore, high debt significantly influences their financial security, practice location, and salary goals.

  View details for DOI 10.1016/j.jamcollsurg.2019.10.016

  View details for Web of Science ID 000508903700002

  View details for PubMedID 31783093

• Liver Transplantation Outcomes in a U.S. Multicenter Cohort of 789 Patients with Hepatocellular Carcinoma Presenting Beyond Milan Criteria. Hepatology (Baltimore, Md.) Kardashian, A., Florman, S. S., Haydel, B., Ruiz, R. M., Klintmalm, G. B., Lee, D. D., Taner, C. B., Aucejo, F., Tevar, A. D., Humar, A., Verna, E. C., Halazun, K. J., Chapman, W. C., Vachharajani, N., Hoteit, M., Levine, M. H., Nguyen, M. H., Melcher, M. L., Langnas, A. N., Carney, C. A., Mobley, C., Ghobrial, M., Amundsen, B., Markmann, J. F., Sudan, D. L., Jones, C. M., Berumen, J., Hemming, A. W., Hong, J. C., Kim, J., Zimmerman, M. A., Nydam, T. L., Rana, A., Kueht, M. L., Fishbein, T. M., Markovic, D., Busuttil, R. W., Agopian, V. G. 2020

  Abstract

  The Organ Procurement and Transplantation Network recently approved liver transplant (LT) prioritization for patients with hepatocellular carcinoma (HCC) beyond Milan Criteria (MC) who are downstaged (DS) with locoregional therapy (LRT). We evaluated post-LT outcomes, predictors of downstaging, and the impact of LRT in beyond-MC HCC patients from the US Multicenter HCC Transplant Consortium (20 centers, 2002-2013). Clinicopathologic characteristics, overall survival (OS), recurrence-free survival (RFS), and HCC recurrence (HCC-R) were compared between patients within MC (n=3,570) and beyond MC (n=789) who were downstaged (DS, n=465), treated with LRT and not downstaged (LRT-NoDS, n=242), or untreated (NoLRT-NoDS, n=82). Five-year post-LT OS and RFS was higher in MC (71.3% and 68.2%) compared to DS (64.3% and 59.5%), and lowest in NoDS (n=324; 60.2% and 53.8%; overall P<0.001). DS patients had superior RFS (60% vs 54%,P=0.043) and lower 5-year HCC-R (18% vs 32%,P<0.001) compared to NoDS, with further stratification by maximum radiologic tumor diameter (5-year HCC-R of 15.5% in DS/< 5cm and 39.1% in NoDS/>5cm,P<0.001). Multivariate predictors of downstaging included alpha-fetoprotein response to LRT, pathologic tumor number and size, and wait time >12 months. LRT-NoDS had greater HCC-R compared to NoLRT-NoDS (34.1% vs 26.1%,P<0.001), even after controlling for clinicopathologic variables (HR=2.33,P<0.001) and inverse probability of treatment weighted propensity matching (HR=1.82,P<0.001). Conclusion In LT recipients with HCC presenting beyond MC, successful downstaging is predicted by wait time, alpha-fetoprotein response to LRT, and tumor burden, and results in excellent post-LT outcomes, justifying expansion of LT criteria. In LRT-NoDS patients, higher HCC-R compared to NoLRT-NoDS cannot be explained by clinicopathologic differences, suggesting a potentially aggravating role of LRT in patients with poor tumor biology that warrants further investigation.

  View details for DOI 10.1002/hep.31210

  View details for PubMedID 32124453

• What Solid Organ Transplant Healthcare Providers should know about Renin-Angiotensin-Aldosterone System Inhibitors and COVID-19. Clinical transplantation Wong, S. Y., Brubaker, A. L., Wang, A. X., Taiwo, A. A., Melcher, M. L. 2020: e13991

  Abstract

  The data on the outcomes of solid organ transplant recipients who have contracted coronavirus disease 2019 (COVID-19) are still emerging. Kidney transplant recipients are commonly prescribed renin-angiotensin-aldosterone system (AAS) inhibitors given the prevalence of hypertension, diabetes, and cardiovascular disease. As the angiotensin-converting enzyme 2 (ACE2) facilitates the entry of coronaviruses into target cells, there have been hypotheses that preexisting use of Renin-Angiotensin-Aldosterone System (RAAS) inhibitors may increase the risk of developing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Given the common use of RAAS inhibitors among solid organ transplant recipients, we sought to review the RAAS cascade, the mechanism of SARS-CoV-2 entry, and pertinent data related to the effect of RAAS inhibitors on ACE2 to guide management of solid organ transplant recipients during the COVID-19 pandemic. At present there is no clear evidence to support the discontinuation of RAAS inhibitors in solid organ transplant recipients during the COVID-19 pandemic.

  View details for DOI 10.1111/ctr.13991

  View details for PubMedID 32446267

• Understanding Health Care Utilization and Mortality After Emergency General Surgery in Patients With Underlying Liver Disease. The American surgeon Tennakoon, L., Baiu, I., Concepcion, W., Melcher, M. L., Spain, D. A., Knowlton, L. M. 2020; 86 (6): 665–74

  Abstract

  Mortality and complications are not well defined nationally for emergency general surgery (EGS) patients presenting with underlying all-cause liver disease (LD).We analyzed the 2012-2014 National Inpatient Sample for adults (aged ≥ 18 years) with a primary EGS diagnosis. Underlying LD included International Classification of Diseases, Ninth Revision, Clinical Modification codes for alcoholic and viral hepatitis, malignancy, congenital etiologies, and cirrhosis. The primary outcome was mortality; secondary outcomes included complications, operative intervention, and costs.Of the 6.8 million EGS patients, 358 766 (5.3%) had underlying LD. 59.1% had cirrhosis, 6.7% had portal hypertension, and 13.7% had ascites. Compared with other EGS patients, EGS-LD patients had higher mean costs ($12 847 vs $10 234, P < .001). EGS-LD patients were less likely to have surgery (26.1% vs 37.0%, P < .001) but for those who did, mortality was higher (4.8% vs 1.8%, P < .001). Risk factors for mortality included ascites (adjusted odds ratio [aOR] = 2.68, P < .001), dialysis (aOR = 3.44, P < .001), sepsis (aOR = 8.97, P < .001), and respiratory failure requiring intubation (aOR = 10.40, P < .001). Odds of death increased in both surgical (aOR = 4.93, P < .001) and non-surgical EGS-LD patients (aOR = 2.56, P < .001).Underlying all-cause LD among EGS patients is associated with increased in-hospital mortality, even in the absence of surgical intervention.

  View details for DOI 10.1177/0003134820923304

  View details for PubMedID 32683972

• NuSeT: A deep learning tool for reliably separating and analyzing crowded cells PLoS Computational Biology Yang, L., et al 2020

  View details for DOI 10.1371/journal.pcbi.1008193

• Underrepresented Minorities in General Surgery Residency: Analysis of Interviewed Applicants, Residents, and Core Teaching Faculty. Journal of the American College of Surgeons Jarman, B. T., Borgert, A. J., Kallies, K. J., Joshi, A. R., Smink, D. S., Sarosi, G. A., Chang, L., Green, J. M., Greenberg, J. A., Melcher, M. L., Nfonsam, V., Whiting, J. 2020

  Abstract

  The ACGME requires diversity in residency. The self-identified race/ethnicity of general surgery applicants, residents, and core teaching faculty were assessed to evaluate underrepresented minority (URM) representation in surgery residency programs and to determine the impact of URM faculty and resident on URM applicants' selection for interview or match.Data from the 2018 application cycle was collated for 10 general surgery programs. Applicants without a self-identified race/ethnicity were excluded. URMs were defined as those identifying as Black/African American, Hispanic/Latino/of Spanish origin, American Indian/Alaskan Native/Native Hawaiian/Pacific Islander-Samoan. Statistical analyses included chi-square tests, and a multivariate model.Ten surgery residency programs received 9,143 applications from 3,067 unique applicants. Applications from White, Asian, Hispanic/Latino, Black/African American and American Indian applicants constituted 66%, 19%, 8%, 7% and 1% of those applications selected to interview and 66%, 13%, 11%, 8% and 2% of applications resulting in a match. Among programs' 272 core faculty and 318 current residents, 10% and 21%, respectively, were identified as URMs. As faculty diversity increased, there was no difference in selection to interview for URM (OR=0.83; 95%CI:0.54-1.28, per 10% increase in faculty diversity) or non-URM applicants (OR=0.68; 95%CI:0.57-0.81). Similarly, greater URM representation among current residents did not impact likelihood of being selected for an interview for URM (OR=1.20; 95%CI:0.90-1.61) vs. non-URM applicants (OR=1.28; 95%CI:1.13-1.45). Current resident and faculty URM representation was correlated (r=0.8; P=0.005).Programs with a greater proportion of URM core faculty or residents did not select a greater proportion of URM applicants for interview. However, core faculty and resident racial diversity were correlated. Recruitment of racially/ethnically diverse trainees and faculty will require ongoing analysis to develop effective recruitment strategies.

  View details for DOI 10.1016/j.jamcollsurg.2020.02.042

  View details for PubMedID 32156654

• THE ROLE OF LOCOREGIONAL THERAPY (LRT), POST LRT IMAGING, AND EXPLANT PATHOLOGY AS PREDICTORS OF HEPATOCELLULAR CARCINOMA (HCC) RECURRENCE POST ORTHOTOPIC LIVER TRANSPLANT (OLT) Prabhakar, V., Dhanasekaran, R., Arjunan, V., Tulu, Z., Ahmed, A., Daugherty, T., Kumari, R., Patel, B., Kim, W., Goel, A., Esquivel, C. O., Concepcion, W., Melcher, M., Bonham, C., Gallo, A., Kwo, P. WILEY. 2019: 691A–692A

  View details for Web of Science ID 000488653502295

• Quantification of Donor Liver Steatosis Using an Unsupervised Artificial Intelligence Platform Narayan, R., Abadilla, N., Yang, L., Hsu, C., Jensen, C., Chen, S. B., Higgins, J. P., Melcher, M. L. ELSEVIER SCIENCE INC. 2019: E151

  View details for Web of Science ID 000492749600360

• Health Care Utilization and Mortality after Emergency General Surgery in Patients with Underlying Liver Disease: A National Perspective Tennakoon, L., Concepcion, W., Melcher, M. L., Spain, D. A., Knowlton, L. M. ELSEVIER SCIENCE INC. 2019: E139

  View details for Web of Science ID 000492749600329

• Matching Kidneys with Priority in Kidney Exchange Programs. Medical decision making : an international journal of the Society for Medical Decision Making Liu, W., Melcher, M. L. 2019: 272989X19849457

  Abstract

  Kidney exchanges were developed to match kidney failure patients with willing but incompatible donors to other donor-patient pairs. Finding a match in a large candidate pool can be modeled as an integer program. However, these exchanges accumulate participants with characteristics that increase the difficulty of finding a match and, therefore, increase patients' waiting time. Therefore, we sought to fine-tune the formulation of the integer program by more accurately assigning priorities to patients based on their difficulty of matching. We provide a detailed formulation of prioritized kidney exchange and propose a novel prioritization algorithm. Our approach takes advantage of the global knowledge of the donor-patient compatibility within a pool of pairs and calculates an iterative, paired match power (iPMP) to represent the donor-patient pairs' abilities to match. Monte Carlo simulation shows that an algorithm using the iPMP reduces the waiting time more than using paired match power (PMP) for the difficult-to-match pairs with hazard ratios of 1.3480 and 1.1100, respectively. Thus, the iPMP may be a more accurate assessment of the difficulty of matching a pair in a pool than PMP is, and its use may improve matching algorithms being used to match donors and recipients.

  View details for DOI 10.1177/0272989X19849457

  View details for PubMedID 31142192

• Liver transplantation for hepatitis C virus (HCV) non-viremic recipients with HCV viremic donors AMERICAN JOURNAL OF TRANSPLANTATION Kwong, A. J., Wall, A., Melcher, M., Wang, U., Ahmed, A., Subramanian, A., Kwo, P. Y. 2019; 19 (5): 1380–87

  View details for DOI 10.1111/ajt.15162

  View details for Web of Science ID 000471342300016

• Benefits of an interview match for breast fellowship positions Wapnir, I., Lo, I., Roth, A., Ashlagi, I., Melcher, M. SPRINGER. 2019: 279–80

  View details for Web of Science ID 000467382700224

• Using Liver Transplant (LT) Data And Analytics to Improve Program Clinical and Financial Performance. Bonham, A., Tulu, Z., Concepcion, W., Gallo, A., Melcher, M., Kwo, P., Ahmed, A., Esquivel, C. WILEY. 2019: 583–84

  View details for Web of Science ID 000474897601616

• Increasing the Number of Liver Ttransplants through Active Review of Offers Turned Down. Melcher, M. L., Bonham, C. A., Gallo, A., Concepcion, W., Jacobson, I., Esquivel, C. O. WILEY. 2019: 995–96

  View details for Web of Science ID 000474897603230

• Reducing the Burden of Fellowship Interviews Reply JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Melcher, M. L., Ashlagi, I., Wapnir, I. 2019; 321 (11): 1107

  View details for DOI 10.1001/jama.2018.21596

  View details for Web of Science ID 000461683500026

• Living Kidney Donation: Strategies to Increase the Donor Pool. The Surgical clinics of North America Lee, L., Pham, T. A., Melcher, M. L. 2019; 99 (1): 37–47

  Abstract

  End-stage renal disease (ESRD) is a significant health care burden. Although kidney transplantation is the optimal treatment modality, less than 25% of waiting list patients are transplanted because of organ shortage. Living kidney donation can lead to better recipient and graft survival and increase the number of donors. Not all ESRD patients have potential living donors, and not all living donors are a compatible match to recipients. Kidney paired exchanges allow incompatible pairs to identify compatible living donors for living donor kidney transplants for multiple recipients. Innovative modifications of kidney paired donation can increase the number of kidney transplants, with excellent outcomes.

  View details for PubMedID 30471740

• Underrepresented Minorities are Underrepresented Among General Surgery Applicants Selected to Interview. Journal of surgical education Jarman, B. T., Kallies, K. J., Joshi, A. R., Smink, D. S., Sarosi, G. A., Chang, L., Green, J. M., Greenberg, J. A., Melcher, M. L., Nfonsam, V., Ramirez, L. D., Borgert, A. J., Whiting, J. 2019

  Abstract

  Diversity is an ill-defined entity in general surgery training. The Accreditation Council for Graduate Medical Education recently proposed new common program requirements including verbiage requiring diversity in residency. "Recruiting" for diversity can be challenging within the constraints of geographic preference, type of program, and applicant qualifications. In addition, the Match process adds further uncertainty. We sought to study the self-identified racial/ethnic distribution of general surgery applicants to better ascertain the characteristics of underrepresented minorities (URM) within the general surgery applicant pool.Program-specific data from the Electronic Residency Application Service was collated for the 2018 medical student application cycle. Data were abstracted for all participating programs' applicants and those selected to interview. Applicants who did not enter a self-identified race/ethnicity were excluded from analysis. URM were defined as those identifying as Black/African American, Hispanic/Latino/of Spanish origin, American Indian/Alaskan Native, or Native Hawaiian/Pacific Islander-Samoan. Appropriate statistical analyses were accomplished.Ten general surgery residency programs-5 independent programs and 5 university programs.Residency applicants to the participating general surgery residency programs.Ten surgery residency programs received 10,312 applications from 3192 unique applicants. Seven hundred and seventy-eight applications did not include a self-identified race/ethnicity and were excluded from analysis. The racial/ethnic makeup of applicants in this study cohort was similar to that from 2017 to 2018 Electronic Residency Application Service data of 4262 total applicants to categorical general surgery. Programs received a median of 1085 (range: 485-1264) applications each and altogether selected 617 unique applicants for interviews. Overall, 2148 applicants graduated from US medical schools, and of those, 595 (28%) were offered interviews. The mean age of applicants was 28.8 ± 3.8 years and 1316 (41%) were female. Hispanic/Latino/of Spanish origin, Black, and American Indian/Alaskan Native/Hawaiian/Pacific Islander-Samoan applicants constituted 12%, 8%, and 1% of total applicants, but only 8%, 6%, and 1% of those selected for interview. Overall, 29% of applicants had United States Medical Licensing Examination (USMLE) Step 1 scores ≤220; 37 (6%) of those selected for interviews had a USMLE Step 1 score of ≤220. A higher proportion of URM applicants had USMLE scores ≤220 compared to White and Asian applicants. Non-white self-identification was a significant independent predictor of a lower likelihood of interview selection. Female gender, USMLE Step 1 score >220, and graduating from a US medical school were associated with an increased likelihood of being selected to interview.URM applicants represented a disproportionately smaller percentage of applicants selected for interview. USMLE Step 1 scores were lower among the URM applicants. Training programs that use discreet USMLE cutoffs are likely excluding URM at a higher rate than their non-URM applicants. Attempts to recruit racially/ethnically diverse trainees should include program-level analysis to determine disparities and a focused strategy to interview applicants who might be overlooked by conventional screening tools.

  View details for DOI 10.1016/j.jsurg.2019.05.018

  View details for PubMedID 31175064

• Career Goals, Salary Expectations, and Salary Negotiation Among Male and Female General Surgery Residents. JAMA surgery Gray, K., Neville, A., Kaji, A. H., Wolfe, M., Calhoun, K., Amersi, F., Donahue, T., Arnell, T., Jarman, B., Inaba, K., Melcher, M., Morris, J. B., Smith, B., Reeves, M., Gauvin, J., Salcedo, E. S., Sidwell, R., Murayama, K., Damewood, R., Poola, V. P., Dent, D., de Virgilio, C. 2019

  Abstract

  In general surgery, women earn less money and hold fewer leadership positions compared with their male counterparts.To assess whether differences exist between the perspectives of male and female general surgery residents on future career goals, salary expectations, and salary negotiation that may contribute to disparity later in their careers.This study was based on an anonymous and voluntary survey sent to 19 US general surgery programs. A total of 606 categorical residents at general surgery programs across the United States received the survey. Data were collected from August through September 2017 and analyzed from September through December 2017.Comparison of responses between men and women to detect any differences in career goals, salary expectation, and perspectives toward salary negotiation at a resident level.A total of 427 residents (70.3%) responded, and 407 responses (230 male [58.5%]; mean age, 30.0 years [95% CI, 29.8-30.4 years]) were complete. When asked about salary expectation, female residents had lower expectations compared with men in minimum starting salary ($249 502 [95% CI, $236 815-$262 190] vs $267 700 [95% CI, $258 964-$276 437]; P = .003) and in ideal starting salary ($334 709 [95% CI, $318 431-$350 987] vs $364 663 [95% CI, $351 612-$377 715]; P < .001). Women also had less favorable opinions about salary negotiation. They were less likely to believe they had the tools to negotiate (33 of 177 [18.6%] vs 73 of 230 [31.7%]; P = .03) and were less likely to pursue other job offers as an aid in negotiating a higher salary (124 of 177 [70.1%] vs 190 of 230 [82.6%]; P = .01). Female residents were also less likely to be married (61 of 177 [34.5%] vs 116 of 230 [50.4%]; P = .001), were less likely to have children (25 of 177 [14.1%] vs 57 of 230 [24.8%]; P = .008), and believed they would have more responsibility at home than their significant other (77 of 177 [43.5%] vs 35 of 230 [15.2%]; P < .001). Men and women anticipated working the same number of hours, expected to retire at the same age, and had similar interest in holding leadership positions, having academic careers, and pursuing research.This study found no difference in overall career goals between male and female residents; however, female residents' salary expectations were lower, and they viewed salary negotiation less favorably. Given the current gender disparities in salary and leadership within surgery, strategies are needed to help remedy this inequity.

  View details for DOI 10.1001/jamasurg.2019.2879

  View details for PubMedID 31461140

• Factors associated with general surgery residents' decisions regarding fellowship and subspecialty stratified by burnout and quality of life. American journal of surgery McClintock, N. C., Gray, K. E., Neville, A. L., Kaji, A. H., Wolfe, M. M., Calhoun, K. E., Amersi, F. F., Donahue, T. R., Arnell, T. D., Jarman, B. T., Inaba, K., Melcher, M. L., Morris, J. B., Smith, B. R., Reeves, M. E., Gauvin, J. M., Salcedo, E. S., Sidwell, R. A., Dent, D. L., Murayama, K. M., Damewood, R. B., Poola, V. P., de Virgilio, C. M. 2019

  Abstract

  Although most surgery residents pursue fellowships, data regarding those decisions are limited. This study describes associations with interest in fellowship and specific subspecialties.Anonymous surveys were distributed to 607 surgery residents at 19 US programs. Subspecialties were stratified by levels of burnout and quality of life using data from recent studies.407 (67%) residents responded. 372 (91.4%) planned to pursue fellowship. Fellowship interest was lower among residents who attended independent or small programs, were married, or had children. Residents who received AOA honors or were married were less likely to choose high burnout subspecialties (trauma/vascular). Residents with children were less likely to choose low quality of life subspecialties (trauma/transplant/cardiothoracic).Surgery residents' interest in fellowship and specific subspecialties are associated with program type and size, AOA status, marital status, and having children. Variability in burnout and quality of life between subspecialties may affect residents' decisions.

  View details for DOI 10.1016/j.amjsurg.2019.08.003

  View details for PubMedID 31421896

• Predicting skin cancer in organ transplant recipients: Development of the SUNTRAC screening tool using data from a multi-center cohort study. Transplant international : official journal of the European Society for Organ Transplantation Jambusaria-Pahlajani, A., Crow, L. D., Lowenstein, S., Garrett, G. L., Melcher, M. L., Chan, A. W., Boscardin, J., Arron, S. T. 2019

  Abstract

  Skin cancer is a common post-transplant complication. In this study, the Skin and Ultraviolet Neoplasia Trasnplant Risk Assessment Calculator (SUNTRAC) was developed to stratify patients into risk groups for post-transplant skin cancer.Data for this study were obtained from the Transplant Skin Cancer Network (TSCN), which conducted a multicenter study across 26 transplant centers in the United States. In total, 6340 patients, transplanted from 2003 to 2008, were included. Weighted point values were assigned for each risk factor based on beta coefficients from multivariable modeling: white race (9 points), pre-transplant history of skin cancer (6 points), age ≥ 50 years (4 points), male sex (2 points), and thoracic transplant (1 point).Good prognostic discrimination (optimism-corrected c statistic of 0.74) occurred with a 4-tier system: 0-6 points indicating Low Risk, 7-13 points indicating Medium Risk,14-17 points indicating High Risk,and 18-22 points indicating Very High Risk. The 5 year cumulative incidence of development of skin cancer was 1.01%, 6.15%, 15.14%, and 44.75%, for Low, Medium, High, and Very High SUNTRAC categories, respectively.Based on the skin cancer risk in different groups, the authors propose skin cancer screening guidelines based on this risk model. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1111/tri.13493

  View details for PubMedID 31423648

• Microvascular Free Flaps as the Vascularized Foundation for Hepatic Tissue Engineering Than, P., Davis, C., Rustad, K., Mittermiller, P., Findlay, M., Liu, W., Whittam, A., Le, T., Khong, S., Ma, K., Melcher, M., Melcher, M., Gurtner, G. WILEY. 2019: 21

  View details for Web of Science ID 000457809000016

• Pathologic Response to Pretransplant Locoregional Therapy is Predictive of Patient Outcome After Liver Transplantation for Hepatocellular Carcinoma: Analysis From the US Multicenter HCC Transplant Consortium. Annals of surgery DiNorcia, J., Florman, S. S., Haydel, B., Tabrizian, P., Ruiz, R. M., Klintmalm, G. B., Senguttuvan, S., Lee, D. D., Taner, C. B., Verna, E. C., Halazun, K. J., Hoteit, M., Levine, M. H., Chapman, W. C., Vachharajani, N., Aucejo, F., Nguyen, M. H., Melcher, M. L., Tevar, A. D., Humar, A., Mobley, C., Ghobrial, M., Nydam, T. L., Amundsen, B., Markmann, J. F., Berumen, J., Hemming, A. W., Langnas, A. N., Carney, C. A., Sudan, D. L., Hong, J. C., Kim, J., Zimmerman, M. A., Rana, A., Kueht, M. L., Jones, C. M., Fishbein, T. M., Markovic, D., Busuttil, R. W., Agopian, V. G. 2019

  Abstract

  MINI: In a large, multicenter study of patients undergoing liver transplantation for hepatocellular carcinoma, complete pathologic response (cPR) to pretransplant locoregional therapy (LRT) portended significantly superior overall and recurrence-free survival. Multivariable predictors of cPR included age, sex, liver disease diagnosis, MELD, AFP, NLR, radiographic Milan status, and number of LRT treatments.The aim of the study was to determine the rate, predictors, and impact of complete pathologic response (cPR) to pretransplant locoregional therapy (LRT) in a large, multicenter cohort of hepatocellular carcinoma (HCC) patients undergoing liver transplantation (LT).LRT is used to mitigate waitlist dropout for patients with HCC awaiting LT. Degree of tumor necrosis found on explant has been associated with recurrence and overall survival, but has not been evaluated in a large, multicenter study.Comparisons were made among patients receiving pre-LT LRT with (n = 802) and without (n = 2637) cPR from the United States Multicenter HCC Transplant Consortium (UMHTC), and multivariable predictors of cPR were identified using logistic regression.Of 3439 patients, 802 (23%) had cPR on explant. Compared with patients without cPR, cPR patients were younger; had lower Model for End-stage Liver Disease (MELD) scores, AFP levels, and neutrophil-lymphocyte ratios (NLR); were more likely to have tumors within Milan criteria and fewer LRT treatments; and had significantly lower 1-, 3-, and 5-year incidence of post-LT recurrence (1.3%, 3.5%, and 5.2% vs 6.2%, 13.5%, and 16.4%; P < 0.001) and superior overall survival (92%, 84%, and 75% vs 90%, 78%, and 68%; P < 0.001). Multivariable predictors of cPR included age, sex, liver disease diagnosis, MELD, AFP, NLR, radiographic Milan status, and number of LRT treatments (C-statistic 0.67).For LT recipients with HCC receiving pretransplant LRT, achieving cPR portends significantly lower posttransplant recurrence and superior survival. Factors predicting cPR are identified, which may help prioritize patients and guide LRT strategies to optimize posttransplant cancer outcomes.

  View details for PubMedID 30870180

• Preparation for the Diversity of 21st Century Surgical Leadership Opportunities Demands Diverse Opportunities for "Professional Development'' ANNALS OF SURGERY Melcher, M. L., Greco, R. S., Krummel, T. M., Morris, A. M., Hawn, M. T. 2018; 268 (6): E52–E53

  View details for DOI 10.1097/SLA.0000000000002470

  View details for Web of Science ID 000452668900017

• Liver Transplantation for HCV Non-Viremic Recipients with HCV Viremic Donors. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons Kwong, A. J., Wall, A., Melcher, M., Wang, U., Ahmed, A., Subramanian, A., Kwo, P. Y. 2018

  Abstract

  In the context of organ shortage, the opioid epidemic, and effective direct-acting antiviral (DAA) therapy for hepatitis C (HCV), more HCV-infected donor organs may be used for liver transplantation. Current data regarding outcomes after donor-derived HCV in previously non-viremic liver transplant recipients are limited. Clinical data for adult liver transplant recipients with donor-derived HCV infection from March 2017 to January 2018 at our institution were extracted from the medical record. Ten patients received livers from donors known to be infected with HCV based on positive nucleic acid testing (NAT). Seven had a prior diagnosis of HCV and were treated before liver transplantation. All recipients were non-viremic at the time of transplantation. All 10 recipients derived hepatitis C infection from their donor and achieved sustained virologic response at 12 weeks post-treatment (SVR-12) with DAA-based regimens, with a median time from transplant to treatment initiation of 43 days (IQR 20-59). There have been no instances of graft loss or death, with median follow-up of 380 days (IQR 263-434) post-transplant. Transplantation of HCV-viremic livers into non-viremic recipients results in acceptable short-term outcomes. Such strategies may be used to expand the donor pool and increase access to liver transplantation. This article is protected by copyright. All rights reserved.

  View details for PubMedID 30378723

• Matching for Fellowship Interviews JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Melcher, M. L., Ashlagi, I., Wapnir, I. 2018; 320 (16): 1639–40

  View details for DOI 10.1001/jama.2018.13080

  View details for Web of Science ID 000448069100009

• Pragmatic Surgical Risk Assessment Criteria in Critically Ill Patients Prior to Liver Transplantation. Bonham, C., Tulu, Z., Melcher, M., Kwo, P., Concepcion, W., Ahmed, A., Esquivel, C. WILEY. 2018: 849–50

  View details for Web of Science ID 000431965404018

• Antiviral Therapy for Donor-Derived Hepatitis C Virus Infection after Solid Organ Transplantation. Kwong, A., Wall, A., Melcher, M., Wang, U., Ahmed, A., Khush, K., Subramanian, A., Tan, J., Kwo, P. WILEY. 2018: 464

  View details for Web of Science ID 000431965401570

• Structured Reporting of Multiphasic CT for Hepatocellular Carcinoma: Effect on Staging and Suitability for Transplant. AJR. American journal of roentgenology Poullos, P. D., Tseng, J. J., Melcher, M. L., Concepcion, W., Loening, A. M., Rosenberg, J., Willmann, J. K. 2018: 1–9

  Abstract

  The purpose of this study is to evaluate whether use of a standardized radiology report template would improve the ability of liver transplant surgeons to diagnose stage T2 hepatocellular carcinoma (HCC) and determine patient suitability to undergo orthotopic liver transplant (OLT).In this retrospective study, a standardized template was devised, and its use was mandated for reporting of liver CT findings for patients with cirrhosis and HCC. Two surgeons analyzed 200 reports (100 before and 100 after template implementation) for descriptions of cirrhosis, portal hypertension, lesion enhancement characteristics, tumor thrombus, portal and superior mesenteric vein patency, and Organ Procurement Transplantation Network (OPTN) class. Ability to determine Milan criteria and surgeon satisfaction were also assessed. Data obtained before and after template implementation were statistically analyzed using the Cochran-Mantel-Haenszel test.Template implementation increased the percentage of reports documenting the presence or absence of portal hypertension (74% to 88% for surgeon 1 and 86% to 87% for surgeon 2; p = 0.042); lesion number (76% to 88% for surgeon 2 [no change for surgeon 1]; p = 0.038), size (95% to 96% for surgeon 1 and 82% to 93% for surgeon 2; p = 0.03), and enhancement (93% to 94% for surgeon 1 and 80% to 91% for surgeon 2; p = 0.049); presence of tumor thrombus (10% to 57% for surgeon 1 and 31% to 63% for surgeon 2; p < 0.001); and OPTN class (8% to 82% for surgeon 1 and 2% to 81% for surgeon 2; p < 0.001). The surgeons were significantly more able to determine the presence of T2 disease and qualification for exception points after implementation of the template (increasing from 80% to 94%; p = 0.025). Satisfaction with reports also improved (p < 0.0001).The reporting template improved determination of patient suitability to undergo transplant according to the Milan criteria.

  View details for PubMedID 29470153

• Socioeconomic Status in Non-directed and Voucher-based Living Kidney Donation. European urology focus Nassiri, N., Baskin, A. S., Herbert, L. K., Connor, S., Pham, T., Melcher, M. L., Sinacore, J., Veale, J. L. 2018; 4 (2): 185–89

  Abstract

  BACKGROUND: Little has been reported about the socioeconomic status (SES) and demographics of non-directed (altruistic) and voucher-based donation.OBJECTIVE: To analyze common characteristics amongst altruistic donors in order to promote non-directed and voucher-based donation.DESIGN, SETTING, AND PARTICIPANTS: Information regarding altruistic donations from 2008 to 2015 and voucher-based donors was obtained from the National Kidney Registry.OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: An SES index, created and validated by the Agency for Healthcare Research and Quality (AHRQ), was created by geocoding the donor's zip code and linking it to seven publicly available SES variables found in the 2010 United States Census data.RESULTS AND LIMITATIONS: In total, 267 non-directed and 3 voucher-based donations were identified. Non-directed donors were predominantly female (58%), with an average age of 45.6 yr (range, 21-72). The mean SES index score was 55.6 (SD=3.2), which corresponds to the 77th percentile of 1.5 million MediCare beneficiaries as reported by the AHRQ in 2008. Voucher-based donors were Caucasian males of high SES. The study was limited by the number of voucher-based donations.CONCLUSIONS: Non-directed and voucher-based donors are in the upper end of the economic spectrum. The voucher-based program has built within it the inherent capacity to remove disincentives to donation, which currently limit altruistic donation.PATIENT SUMMARY: We wanted to determine what types of people donated their kidneys altruistically, so that we could understand how to motivate more people to donate their kidneys. The voucher-based program was recently started and is a promising tool to motivate many people to donate kidneys by removing major disincentives to donation.

  View details for PubMedID 30122635

• Matching for Fellowship Interviews. JAMA Melcher, M. L., Ashlagi, I., Wapnir, I. 2018; 320 (16): 1639–40

  View details for PubMedID 30422279

• A Multicenter Prospective Comparison of the Accreditation Council for Graduate Medical Education Milestones: Clinical Competency Committee vs. Resident Self-Assessment. Journal of surgical education Watson, R. S., Borgert, A. J., O Heron, C. T., Kallies, K. J., Sidwell, R. A., Mellinger, J. D., Joshi, A. R., Galante, J. M., Chambers, L. W., Morris, J. B., Josloff, R. K., Melcher, M. L., Fuhrman, G. M., Terhune, K. P., Chang, L., Ferguson, E. M., Auyang, E. D., Patel, K. R., Jarman, B. T. 2017; 74 (6): e8–e14

  Abstract

  OBJECTIVE: The Accreditation Council for Graduate Medical Education requires accredited residency programs to implement competency-based assessments of medical trainees based upon nationally established Milestones. Clinical competency committees (CCC) are required to prepare biannual reports using the Milestones and ensure reporting to the Accreditation Council for Graduate Medical Education. Previous research demonstrated a strong correlation between CCC and resident scores on the Milestones at 1 institution. We sought to evaluate a national sampling of general surgery residency programs and hypothesized that CCC and resident assessments are similar.DESIGN: Details regarding the makeup and process of each CCC were obtained. Major disparities were defined as an absolute mean difference of ≥0.5 on the 4-point scale. A negative assessment disparity indicated that the residents evaluated themselves at a lower level than did the CCC. Statistical analysis included Wilcoxon rank sum and Sign tests.SETTING: CCCs and categorical general surgery residents from 15 residency programs completed the Milestones document independently during the spring of 2016.RESULTS: Overall, 334 residents were included; 44 (13%) and 43 (13%) residents scored themselves ≥0.5 points higher and lower than the CCC, respectively. Female residents scored themselves a mean of 0.08 points lower, and male residents scored themselves a mean of 0.03 points higher than the CCC. Median assessment differences for postgraduate year (PGY) 1-5 were 0.03 (range: -0.94 to 1.28), -0.11 (range: -1.22 to 1.22), -0.08 (range: -1.28 to 0.81), 0.02 (range: -0.91 to 1.00), and -0.19 (range: -1.16 to 0.50), respectively. Residents in university vs. independent programs had higher rates of negative assessment differences in medical knowledge (15% vs. 6%; P = 0.015), patient care (17% vs. 5%; P = 0.002), professionalism (23% vs. 14%; P = 0.013), and system-based practice (18% vs. 9%; P = 0.031) competencies. Major assessment disparities by sex or PGY were similar among individual competencies.CONCLUSIONS: Surgery residents in this national cohort demonstrated self-awareness when compared to assessments by their respective CCCs. This was independent of program type, sex, or level of training. PGY 5 residents, female residents, and those from university programs consistently rated themselves lower than the CCC, but these were not major disparities and the significance of this is unclear.

  View details for PubMedID 28666959

• Preparation for the Diversity of 21st Century Surgical Leadership Opportunities Demands Diverse Opportunities for "Professional Development". Annals of surgery Melcher, M. L., Greco, R. S., Krummel, T. M., Morris, A. M., Hawn, M. T. 2017

  View details for PubMedID 29064907

• Recurrence-Free Survival in Liver Transplant Recipients with Non-Alcoholic Fatty Liver Disease-Related Hepatocellular Carcinoma: Results from the US Multicenter HCC Transplant Consortium Verna, E. C., Abdelmessih, R. M., Florman, S. S., Haydel, B. M., Ruiz, R., Klintmalm, G., Lee, D. D., Taner, B., Hoteit, M. A., Halazun, K. J., Tevar, A. D., Humar, A., Chapman, W. C., Vachharajani, N., Aucejo, F. N., Melcher, M. L., Nguyen, M. H., Nydam, T. L., Amundsen, B., Markmann, J. F., Mobley, C., Ghobrial, R. M., Langnas, A. N., Carney, C., Berumen, J., Hemming, A. W., Sudan, D., Hong, J. C., Kim, J., Zimmerman, M. A., Rana, A., Kueht, M. L., Jones, C., Fishbein, T., Busuttil, R. W., Agopian, V. WILEY. 2017: 900A–901A

  View details for Web of Science ID 000412089802045

• Evaluating the Impact of Blinded vs Non-Blinded Interviews on the General Surgery Resident Selection Process Shipper, E. S., Forrester, J., Lau, J. N., Melcher, M. L. ELSEVIER SCIENCE INC. 2017: S174–S175

  View details for DOI 10.1016/j.jamcollsurg.2017.07.396

  View details for Web of Science ID 000413315300374

• Advanced Donation Programs and Deceased Donor Initiated Chains - 2 Innovations in Kidney Paired Donation. Transplantation Wall, A. E., Veale, J. L., Melcher, M. L. 2017

  Abstract

  Kidney paired donation strategies have facilitated compatible living-donor kidney transplants for end stage renal disease patients with willing but incompatible living donors. Success has inspired further innovations that expand opportunities for kidney-paired donation. Two such innovations are the advanced donation strategy in which a donor provides a kidney before their recipient is matched, or even in need of, a kidney transplant, and deceased donor initiated chains in which chains are started with deceased donors rather than altruistic living donors. While these innovations may expand kidney paired donation, they raise several ethical issues. Specific concerns raised by advanced donation include the management of uncertainty, the extent of donor and recipient consent, the scope of the obligation that the organization has to the kidney exchange paired recipient, the naming of alternative recipients, and the potential to unfairly advantage the recipient. Use of deceased donors for chain initiating kidneys raises ethical issues concerning the consent process for each involved party, the prioritization of deceased donor kidneys, the allocation of chain ending kidneys, and the value of a living donor kidney versus a deceased donor kidney. We outline each ethical issue and discuss how it can be conceptualized and managed so that these kidney paired donation innovations programs are ultimately successful.

  View details for DOI 10.1097/TP.0000000000001838

  View details for PubMedID 28574902

• A multi-institution analysis of general surgery resident peer-reviewed publication trends JOURNAL OF SURGICAL RESEARCH Forrester, J. D., Ansari, P., Are, C., Auyang, E., Galante, J. M., Jarman, B. T., Smith, B. R., Watkins, A. C., Melcher, M. L. 2017; 210: 92-98

  Abstract

  The process of taking a research project from conception to publication is one way to encourage surgeons to communicate hypothesis, critically assess literature and data, and defend research conclusions to a broad audience. The goal of this study was to define surgery resident publishing epidemiology and identify characteristics of residents and residency programs that might predict increased publication productivity.A survey was administered to eight general surgery residency programs to collect residency and resident variables from 1993-2013. The primary endpoint was the number of first-author publications produced per resident. Secondary endpoints included clinical setting at which the former resident was practicing, fellowship pursued, and manuscript quality.Between 1993 and 2013, 676 residents graduated, median age was 33 years (range: 29-43 years) and 182 (27%) were female. Three hundred and sixty-six (54%) residents produced 1229 first-author publications. Of these, 112 (31%) residents produced one manuscript, 125 (34%) produced two-three manuscripts, 107 (29%) produced four-nine manuscripts, and 22 (6%) produced 10 or more manuscripts. Publishing ≥1 manuscript in residency was associated with a 1.5 (P = 0.01) increased odds of having attended a top-tier research institution for medical school and a 2.3 (P < 0.001) increased odds of having dedicated research years incorporated into residency. Surgeons practicing at academic centers had 1.7 (P = 0.003) greater odds of having attended top-tier medical schools, and 1.5 (P = 0.02) greater odds of publishing during residency.Additional research directed at identifying interventions promoting resident publishing and scholastic achievement should benefit all surgery training programs looking to cultivate the next generation of critically thinking surgeons.

  View details for DOI 10.1016/j.jss.2016.11.015

  View details for PubMedID 28457346

• The incremental cost of Incompatible Living Donor Kidney Transplant: A National Cohort Analysis. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons Axelrod, D., Lentine, K. L., Schnitzler, M. A., Luo, X., Xiao, H., Orandi, B. J., Massie, A., Garonzik-Wang, J., Stegall, M. D., Jordan, S. C., Oberholzer, J., Dunn, T. B., Ratner, L. E., Kapur, S., Pelletier, R. P., Roberts, J. P., Melcher, M. L., Singh, P., Sudan, D. L., Posner, M. P., El-Amm, J. M., Shapiro, R., Cooper, M., Lipkowitz, G. S., Rees, M. A., Marsh, C. L., Sankari, B. R., Gerber, D. A., Nelson, P. W., Wellen, J., Bozorgzadeh, A., Gaber, A. O., Montgomery, R. A., Segev, D. L. 2017

  Abstract

  Incompatible living donor kidney transplant (ILDKT) has been established as an effective option for end stage renal disease (ESRD) patients with willing but HLA incompatible live donors, reducing mortality and improving quality of life. Depending upon antibody titer, ILDKT can require highly resource intensive procedure including intravenous immunoglobulin, plasma exchange and/or cell depleting antibody treatment as well as protocol biopsies and DSA testing. This study sought to compare the cost and Medicare reimbursement, exclusive of organ acquisition payment, for ILDKT recipients (N=926) with varying antibody titers to matched compatible transplants (N=2762) performed between 2002-2011. Data were assembled from a national cohort study of ILDKT and a unique dataset linking hospital cost accounting data, and Medicare claims. Overall, ILDKT transplants were 41% more expensive than their compatible counterparts ($151,024 vs. $106,636, p<.0001). The incremental cost varied by antibody titers: positive on Luminex assay but negative flow cytometric crossmatch 20% increase, positive flow cytometric crossmatch but negative cytotoxic crossmatch 26% increase, and positive cytotoxic crossmatch 39% increase (p<.0001 for all). ILDKT was associated with higher Medicare payments ($91,330 vs. $63,782 p<.0001), longer median length of stay (12.9 vs. 7.8 days), and greater outlier payments. In conclusion, ILDKT increases the cost of and payments for kidney transplant. This article is protected by copyright. All rights reserved.

  View details for PubMedID 28613436

• Pilot evaluation of the Computer-Based Assessment for Sampling Personal Characteristics test. The Journal of surgical research Shipper, E. S., Mazer, L. M., Merrell, S. B., Lin, D. T., Lau, J. N., Melcher, M. L. 2017; 215: 211–18

  Abstract

  High attrition rates hint at deficiencies in the resident selection process. The evaluation of personal characteristics representative of success is difficult. Here, we evaluate a novel tool for assessing personal characteristics.To evaluate feasibility, we used an anonymous voluntary survey questionnaire offered to study participants before and after contact with the CASPer test. To evaluate the CASPer test as a predictor of success, we compared CASPer test assessments of personal characteristics versus traditional faculty assessment of personal characteristics with applicant rank list position.All applicants (n = 77) attending an in-person interview for general surgery residency, and all faculty interviewers (n = 34) who reviewed these applications were invited to participate. Among applicants, 84.4% of respondents (65 of 77) reported that a requirement to complete the CASPer test would have no bearing or would make them more likely to apply to the program (mean = 3.30, standard deviation = 0.96). Among the faculty, 62.5% respondents (10 of 16) reported that the same condition would have no bearing or would make applicants more likely to apply to the program (mean = 3.19, standard deviation = 1.33). The Spearman's rank-order correlation coefficients for the relationships between traditional faculty assessment of personal characteristics and applicant rank list position, and novel CASPer assessment of personal characteristics and applicant rank list position, were -0.45 (P = 0.033) and -0.41 (P = 0.055), respectively.The CASPer test may be feasibly implemented as component of the resident selection process, with the potential to predict applicant rank list position and improve the general surgery resident selection process.

  View details for PubMedID 28688650

• Association of General Surgery Resident Remediation and Program Director Attitudes With Resident Attrition. JAMA surgery Schwed, A. C., Lee, S. L., Salcedo, E. S., Reeves, M. E., Inaba, K., Sidwell, R. A., Amersi, F., Are, C., Arnell, T. D., Damewood, R. B., Dent, D. L., Donahue, T., Gauvin, J., Hartranft, T., Jacobsen, G. R., Jarman, B. T., Melcher, M. L., Mellinger, J. D., Morris, J. B., Nehler, M., Smith, B. R., Wolfe, M., Kaji, A. H., de Virgilio, C. 2017

  Abstract

  Previous studies of resident attrition have variably included preliminary residents and likely overestimated categorical resident attrition. Whether program director attitudes affect attrition has been unclear.To determine whether program director attitudes are associated with resident attrition and to measure the categorical resident attrition rate.This multicenter study surveyed 21 US program directors in general surgery about their opinions regarding resident education and attrition. Data on total resident complement, demographic information, and annual attrition were collected from the program directors for the study period of July 1, 2010, to June 30, 2015. The general surgery programs were chosen on the basis of their geographic location, previous collaboration with some coauthors, prior work in surgical education and research, or a program director willing to participate. Only categorical surgical residents were included in the study; thus, program directors were specifically instructed to exclude any preliminary residents in their responses.Five-year attrition rates (2010-2011 to 2014-2015 academic years) as well as first-time pass rates on the General Surgery Qualifying Examination and General Surgery Certifying Examination of the American Board of Surgery (ABS) were collected. High- and low-attrition programs were compared.The 21 programs represented different geographic locations and 12 university-based, 3 university-affiliated, and 6 independent program types. Programs had a median (interquartile range [IQR]) number of 30 (20-48) categorical residents, and few of those residents were women (median [IQR], 12 [5-17]). Overall, 85 of 966 residents (8.8%) left training during the study period: 15 (17.6%) left after postgraduate year 1, 34 (40.0%) after postgraduate year 2, and 36 (42.4%) after postgraduate year 3 or later. Forty-four residents (51.8%) left general surgery for another surgical discipline, 21 (24.7%) transferred to a different surgery program, and 18 (21.2%) exited graduate medical education altogether. Each program had an annual attrition rate ranging from 0.73% to 6.0% (median [IQR], 2.5% [1.5%-3.4%]). Low-attrition programs were more likely than high-attrition programs to use resident remediation (21.0% vs 6.8%; P < .001). Median (IQR) Qualifying Examination pass rates (93% [90%-98%] vs 92% [86%-100%]; P = .92) and Certifying Examination pass rates (83% [68%-84%] vs 81% [71%-86%]; P = .47) were similar. Program directors at high-attrition programs were more likely than their counterparts at low-attrition programs to agree with this statement: "I feel that it is my responsibility as a program director to redirect residents who should not be surgeons."The overall 5-year attrition rate of 8.8% was significantly lower than previously reported. Program directors at low-attrition programs were more likely to use resident remediation. Variations in attrition may be explained by program director attitudes, although larger studies are needed to further define program factors affecting attrition.

  View details for PubMedID 28813585

• Impact of Pretransplant Bridging Locoregional Therapy for Patients With Hepatocellular Carcinoma Within Milan Criteria Undergoing Liver Transplantation: Analysis of 3601 Patients from the US Multicenter HCC Transplant Consortium. Annals of surgery Agopian, V. G., Harlander-Locke, M. P., Ruiz, R. M., Klintmalm, G. B., Senguttuvan, S., Florman, S. S., Haydel, B., Hoteit, M., Levine, M. H., Lee, D. D., Taner, C. B., Verna, E. C., Halazun, K. J., Abdelmessih, R., Tevar, A. D., Humar, A., Aucejo, F., Chapman, W. C., Vachharajani, N., Nguyen, M. H., Melcher, M. L., Nydam, T. L., Mobley, C., Ghobrial, R. M., Amundsen, B., Markmann, J. F., Langnas, A. N., Carney, C. A., Berumen, J., Hemming, A. W., Sudan, D. L., Hong, J. C., Kim, J., Zimmerman, M. A., Rana, A., Kueht, M. L., Jones, C. M., Fishbein, T. M., Busuttil, R. W. 2017

  Abstract

  To evaluate the effect of pretransplant bridging locoregional therapy (LRT) on hepatocellular carcinoma (HCC) recurrence and survival after liver transplantation (LT) in patients meeting Milan criteria (MC).Pre-LT LRT mitigates tumor progression and waitlist dropout in HCC patients within MC, but data on its impact on post-LT recurrence and survival remain limited.Recurrence-free survival and post-LT recurrence were compared among 3601 MC patients with and without bridging LRT utilizing competing risk Cox regression in consecutive patients from 20 US centers (2002-2013).Compared with 747 LT recipients not receiving LRT, 2854 receiving LRT had similar 1, 3, and 5-year recurrence-free survival (89%, 77%, 68% vs 85%, 75%, 68%; P = 0.490) and 5-year post-LT recurrence (11.2% vs 10.1%; P = 0.474). Increasing LRT number [3 LRTs: hazard ratio (HR) 2.1, P < 0.001; 4+ LRTs: HR 2.5, P < 0.001), and unfavorable waitlist alphafetorotein trend significantly predicted post-LT recurrence, whereas LRT modality did not. Treated patients achieving complete pathologic response (cPR) had superior 5-year RFS (72%) and lower post-LT recurrence (HR 0.52, P < 0.001) compared with both untreated patients (69%; P = 0.010; HR 1.0) and treated patients not achieving cPR (67%; P = 0.010; HR 1.31, P = 0.039), who demonstrated increased recurrence compared with untreated patients in multivariate analysis controlling for pretransplant and pathologic factors (HR 1.32, P = 0.044).Bridging LRT in HCC patients within MC does not improve post-LT survival or HCC recurrence in the majority of patients who fail to achieve cPR. The need for increasing LRT treatments and lack of alphafetoprotein response to LRT independently predict post-LT recurrence, serving as a surrogate for underlying tumor biology which can be utilized for prioritization of HCC LT candidates.

  View details for PubMedID 28654545

• Hospital readmissions following HLA-incompatible live donor kidney transplantation: A multi-center study. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons Orandi, B. J., Luo, X., King, E. A., Garonzik-Wang, J. M., Bae, S., Montgomery, R. A., Stegall, M. D., Jordan, S. C., Oberholzer, J., Dunn, T. B., Ratner, L. E., Kapur, S., Pelletier, R. P., Roberts, J. P., Melcher, M. L., Singh, P., Sudan, D. L., Posner, M. P., El-Amm, J. M., Shapiro, R., Cooper, M., Lipkowitz, G. S., Rees, M. A., Marsh, C. L., Sankari, B. R., Gerber, D. A., Nelson, P. W., Wellen, J., Bozorgzadeh, A., Osama Gaber, A., Segev, D. L. 2017

  Abstract

  Thirty percent of kidney transplant recipients are readmitted in the first month posttransplantation. Those with donor-specific antibody requiring desensitization and incompatible live donor kidney transplantation (ILDKT) constitute a unique subpopulation that might be at higher readmission risk. Drawing on a 22-center cohort, 379 ILDKTs with Medicare primary insurance were matched to compatible transplant-matched controls and to waitlist-only matched controls on panel reactive antibody, age, blood group, renal replacement time, prior kidney transplantation, race, gender, diabetes, and transplant date/waitlisting date. Readmission risk was determined using multilevel, mixed-effects Poisson regression. In the first month, ILDKTs had a 1.28-fold higher readmission risk than compatible controls (95% confidence interval [CI] 1.13-1.46; P < .001). Risk peaked at 6-12 months (relative risk [RR] 1.67, 95% CI 1.49-1.87; P < .001), attenuating by 24-36 months (RR 1.24, 95% CI 1.10-1.40; P < .001). ILDKTs had a 5.86-fold higher readmission risk (95% CI 4.96-6.92; P < .001) in the first month compared to waitlist-only controls. At 12-24 (RR 0.85, 95% CI 0.77-0.95; P = .002) and 24-36 months (RR 0.74, 95% CI 0.66-0.84; P < .001), ILDKTs had a lower risk than waitlist-only controls. These findings of ILDKTs having a higher readmission risk than compatible controls, but a lower readmission risk after the first year than waitlist-only controls should be considered in regulatory/payment schemas and planning clinical care.

  View details for PubMedID 28834181

• Effect of match-run frequencies on the number of transplants and waiting times in kidney exchange. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons Ashlagi, I., Bingaman, A., Burq, M., Manshadi, V., Gamarnik, D., Murphey, C., Roth, A. E., Melcher, M. L., Rees, M. A. 2017

  Abstract

  Numerous kidney exchange (kidney paired donation [KPD]) registries in the United States have gradually shifted to high-frequency match-runs, raising the question of whether this harms the number of transplants. We conducted simulations using clinical data from 2 KPD registries-the Alliance for Paired Donation, which runs multihospital exchanges, and Methodist San Antonio, which runs single-center exchanges-to study how the frequency of match-runs impacts the number of transplants and the average waiting times. We simulate the options facing each of the 2 registries by repeated resampling from their historical pools of patient-donor pairs and nondirected donors, with arrival and departure rates corresponding to the historical data. We find that longer intervals between match-runs do not increase the total number of transplants, and that prioritizing highly sensitized patients is more effective than waiting longer between match-runs for transplanting highly sensitized patients. While we do not find that frequent match-runs result in fewer transplanted pairs, we do find that increasing arrival rates of new pairs improves both the fraction of transplanted pairs and waiting times.

  View details for PubMedID 29087017

• Shipping Living Donor Kidneys and Transplant Recipient Outcomes. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons Treat, E., Chow, E. K., Peipert, J. D., Waterman, A., Kwan, L., Massie, A. B., Thomas, A. G., Bowring, M. G., Leeser, D., Flechner, S., Melcher, M. L., Kapur, S., Segev, D. L., Veale, J. 2017

  Abstract

  Kidney paired donation (KPD) is an important tool to facilitate living donor kidney transplantation (LDKT). Concerns remain over prolonged cold ischemia times (CIT) associated with shipping kidneys long distances through KPD. We examined the association between CIT and delayed graft function (DGF), allograft survival, and patient survival for 1,267 shipped and 205 non-shipped/internal KPD LDKTs facilitated by the National Kidney Registry in the United States from 2008-2015, compared to 4,800 unrelated, non-shipped, non-KPD LDKTs. Shipped KPD recipients had a median CIT of 9.3 hours (range = 0.25 to 23.9 hours), compared to 1.0 hour for internal KPD transplants and 0.93 hours for non-KPD LDKTs. Each hour of CIT was associated with a 5% increased odds of DGF (adjusted odds ratio: 1.05, 95% CI: 1.02-1.09, p<0.01). However, there was not a significant association between CIT and all-cause graft failure (aHR: 1.01, 95% CI: 0.98-1.04, p=0.4), death-censored graft failure (aHR: 1.02, 95% CI: 0.98-1.06, p=0.4), or mortality (aHR 1.00, 95% CI: 0.96-1.04, p>0.9). This study of KPD-facilitated LDKTs found no evidence that long CIT is a concern for reduced graft or patient survival. Studies with longer follow-up are needed to refine our understanding of the safety of shipping donor kidneys through KPD. This article is protected by copyright. All rights reserved.

  View details for PubMedID 29165871

• Kidney paired exchange and desensitization: Strategies to transplant the difficult to match kidney patients with living donors TRANSPLANTATION REVIEWS Pham, T. A., Lee, J. I., Melcher, M. L. 2017; 31 (1): 29-34

  Abstract

  With organs in short supply, only a limited number of kidney transplants can be performed a year. Live donor donation accounts for 1/3rd of all kidney transplants performed in the United States. Unfortunately, not every donor recipient pair is feasible because of Human leukocyte antigen (HLA) sensitization and ABO incompatibility. To overcome these barriers to transplant, strategies such as kidney paired donation (KPD) and desensitization have been developed. KPD is the exchange of donors between at least two incompatible donor-recipient pairs such that they are now compatible. Desensitization is the removal of circulating donor specific antibodies to prevent graft rejection. Regardless of the treatment strategy, highly sensitized patients whose calculated panel reactive antibody (cPRA) is ≥95% remain difficult to transplant with match rates as low as 15% in KPD pools. Desensitization has proved to be difficult in those with high antibody titers. A novel approach is the combination of both KPD and desensitization to facilitate compatible and successful transplantation. A highly sensitized patient can be paired with a better immunological match in the KPD pool and subsequently desensitized to a lesser degree. This article reviews the current progress in KPD and desensitization and their use as a combined therapy.

  View details for DOI 10.1016/j.trre.2017.01.003

  View details for PubMedID 28284304

• HLA Matching Trumps Donor Age: Donor-Recipient Pairing Characteristics That Impact Long-Term Success in Living Donor Kidney Transplantation in the Era of Paired Kidney Exchange. Transplantation direct Milner, J., Melcher, M. L., Lee, B., Veale, J., Ronin, M., D'Alessandro, T., Hil, G., Fry, P. C., Shannon, P. W. 2016; 2 (7)

  Abstract

  We sought to identify donor characteristics influencing long-term graft survival, expressed by a novel measure, kidney life years (KLYs), in living donor kidney transplantation (LDKT).Cox and multiple regression analyses were applied to data from the Scientific Registry for Transplant Research from 1987 to 2015. Dependent variable was KLYs.Living donor kidney transplantation (129 273) were performed from 1987 to 2013 in the United States. To allow sufficient time to assess long-term results, outcomes of LDKTs between 1987 and 2001 were analyzed. After excluding cases where a patient died with a functioning graft (8301) or those missing HLA data (9), 40 371 cases were analyzed. Of 18 independent variables, the focus became the 4 variables that were the most statistically and clinically significant in that they are potentially modifiable in donor selection (P <0.0001; ie, HLA match points, donor sex, donor biological sibling and donor age). HLA match points had the strongest relationship with KLYs, was associated with the greatest tendency toward graft longevity on Cox regression, and had the largest increase in KLYs (2.0 year increase per 50 antigen Match Points) based on multiple regression.In cases when a patient has multiple potential donors, such as through paired exchange, graft life might be extended when a donor with favorable matching characteristics is selected.

  View details for PubMedID 27830179

• NEAD Chains Do Not Disadvantage Blood Type O, Black, or Highly Sensitized Patients Rees, M., Roberts, J., Lentine, K., Roth, A., Leichtman, A., Xiao, H., Rafizadeh, S., Neidich, E., Melcher, M. WILEY-BLACKWELL. 2016: 440

  View details for Web of Science ID 000383373903115

• Utilization of Deceased Donor Kidneys to Initiate Living Donor Chains AMERICAN JOURNAL OF TRANSPLANTATION Melcher, M. L., Roberts, J. P., Leichtman, A. B., Roth, A. E., Rees, M. A. 2016; 16 (5): 1367-1370

  Abstract

  We propose that some deceased donor (DD) kidneys be allocated to initiate nonsimultaneous extended altruistic donor chains of living donor (LD) kidney transplants to address, in part, the huge disparity between patients on the DD kidney waitlist and available donors. The use of DD kidneys for this purpose would benefit waitlisted candidates in that most patients enrolled in kidney paired donation (KPD) systems are also waitlisted for a DD kidney transplant, and receiving a kidney through the mechanism of KPD will decrease pressure on the DD pool. In addition, a LD kidney usually provides survival potential equal or superior to that of DD kidneys. If KPD chains that are initiated by a DD can end in a donation of an LD kidney to a candidate on the DD waitlist, the quality of the kidney allocated to a waitlisted patient is likely to be improved. We hypothesize that a pilot program would show a positive impact on patients of all ethnicities and blood types.

  View details for DOI 10.1111/ajt.13740

  View details for PubMedID 26833680

• Prehabilitation in our most frail surgical patients: are wearable fitness devices the next frontier? Current opinion in organ transplantation Rumer, K. K., Saraswathula, A., Melcher, M. L. 2016; 21 (2): 188-193

  Abstract

  Frailty is the concept of accumulating physiologic declines that make people less able to deal with stressors, including surgery. Prehabilitation is intervention to enhance functional capacity before surgery. Frailty and prehabilitation among transplant populations and the role of wearable fitness tracking devices (WFTs) in delivering fitness-based interventions will be discussed.Frailty is associated with increased complications, longer length of hospital stay and increased mortality after surgery. Frail kidney transplant patients have increased delayed graft function, mortality and early hospital readmission. Frail lung or liver transplant patients are more likely to delist or die on the waitlist. Prehabilitation can mitigate frailty and has resulted in decreased length of hospital stay and fewer postsurgical complications among a variety of surgical populations. Increasingly, WFTs are used to monitor patient activity and improve patient health. Interventions using WFTs have resulted in improved activity, weight loss and blood pressure.Frailty is a measurable parameter that identifies patients at risk for worse health outcomes and can be mitigated through intervention. Prehabilitation to reduce frailty has been shown to improve postsurgical outcomes in a variety of populations. WFTs are being integrated in healthcare delivery for monitoring and changing health behavior with promising results.

  View details for DOI 10.1097/MOT.0000000000000295

  View details for PubMedID 26859220

• Survival Benefit with Kidney Transplants from HLA-Incompatible Live Donors NEW ENGLAND JOURNAL OF MEDICINE Orandi, B. J., Luo, X., Massie, A. B., Garonzik-Wang, J. M., Lonze, B. E., Ahmed, R., Van Arendonk, K. J., Stegall, M. D., Jordan, S. C., Oberholzer, J., Dunn, T. B., Ratner, L. E., Kapur, S., Pelletier, R. P., Roberts, J. P., Melcher, M. L., Singh, P., Sudan, D. L., Posner, M. P., El-Amm, J. M., Shapiro, R., Cooper, M., Lipkowitz, G. S., Rees, M. A., Marsh, C. L., Sankari, B. R., Gerber, D. A., Nelson, P. W., Wellen, J., Bozorgzadeh, A., Gaber, A. O., Montgomery, R. A., Segev, D. L. 2016; 374 (10): 940-950

  Abstract

  A report from a high-volume single center indicated a survival benefit of receiving a kidney transplant from an HLA-incompatible live donor as compared with remaining on the waiting list, whether or not a kidney from a deceased donor was received. The generalizability of that finding is unclear.In a 22-center study, we estimated the survival benefit for 1025 recipients of kidney transplants from HLA-incompatible live donors who were matched with controls who remained on the waiting list or received a transplant from a deceased donor (waiting-list-or-transplant control group) and controls who remained on the waiting list but did not receive a transplant (waiting-list-only control group). We analyzed the data with and without patients from the highest-volume center in the study.Recipients of kidney transplants from incompatible live donors had a higher survival rate than either control group at 1 year (95.0%, vs. 94.0% for the waiting-list-or-transplant control group and 89.6% for the waiting-list-only control group), 3 years (91.7% vs. 83.6% and 72.7%, respectively), 5 years (86.0% vs. 74.4% and 59.2%), and 8 years (76.5% vs. 62.9% and 43.9%) (P<0.001 for all comparisons with the two control groups). The survival benefit was significant at 8 years across all levels of donor-specific antibody: 89.2% for recipients of kidney transplants from incompatible live donors who had a positive Luminex assay for anti-HLA antibody but a negative flow-cytometric cross-match versus 65.0% for the waiting-list-or-transplant control group and 47.1% for the waiting-list-only control group; 76.3% for recipients with a positive flow-cytometric cross-match but a negative cytotoxic cross-match versus 63.3% and 43.0% in the two control groups, respectively; and 71.0% for recipients with a positive cytotoxic cross-match versus 61.5% and 43.7%, respectively. The findings did not change when patients from the highest-volume center were excluded.This multicenter study validated single-center evidence that patients who received kidney transplants from HLA-incompatible live donors had a substantial survival benefit as compared with patients who did not undergo transplantation and those who waited for transplants from deceased donors. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases.).

  View details for DOI 10.1056/NEJMoa1508380

  View details for PubMedID 26962729

• We Need to Take the Next Step. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons Melcher, M. L., Roberts, J. P., Leichtman, A. B., Roth, A. E., Rees, M. A. 2016

  View details for PubMedID 27515865

• Saving Supersick Patients Undergoing Liver Transplant. JAMA surgery Melcher, M. L. 2015; 150 (11): 1073-?

  View details for DOI 10.1001/jamasurg.2015.1881

  View details for PubMedID 26309213

• Program Factors That Influence American Board of Surgery In-Training Examination Performance: A Multi-Institutional Study. Journal of surgical education Kim, J. J., Gifford, E. D., Moazzez, A., Sidwell, R. A., Reeves, M. E., Hartranft, T. H., Inaba, K., Jarman, B. T., Are, C., Galante, J. M., Amersi, F., Smith, B. R., Melcher, M. L., Nelson, M. T., Donahue, T., Jacobsen, G., Arnell, T. D., Lee, S., Neville, A., De Virgilio, C. 2015; 72 (6): e236-42

  Abstract

  To determine the influence of program strategies, such as program directors' (PD) attitudes about the American Board of Surgery In-Training Examination (ABSITE) and approach to ABSITE preparation, on residents' ABSITE performance.A 17-item questionnaire was sent to PDs at surgical residency programs. The questions were designed to elicit information regarding the educational curriculum, remediation protocols, and opinions relating to the ABSITE. Main outcome measure was categorical resident ABSITE percentile scores from the January 2014 examination. Statistical analysis was performed using the Student t-test, analysis of variance, and linear regression as appropriate.The study was carried out at general surgery residency programs across the country.In total, 15 general surgery residency PDs participated in the study.The PD response rate was 100%. All 460 resident ABSITE scores from the 15 programs were obtained. In total, 10 programs (67%) identified as university affiliated, 4 programs (27%) as independent academic, and 1 program (7%) as hybrid. The mean number of residents per program was 30.7 (range: 15-57). In total, 14 PDs (93%) indicated that an ABSITE review curriculum was in place and 13 PDs (87%) indicated they had a remediation protocol for residents with low ABSITE scores (with differing thresholds of <30th, <35th, and <40th percentile). The median overall ABSITE score for all residents was 61st percentile (interquartile range = 39.5). The mean ABSITE score for each program ranged from 39th to 75th percentile. Program factors associated with higher ABSITE scores included tracking resident reading throughout the year (median 63rd percentile with tracking vs 59th percentile without, p = 0.040) and the type of remediation (by PD: 77th percentile, by PD and faculty: 57th percentile, faculty only: 64th percentile, with Surgical Education and Self-Assessment Program (SESAP): 63rd percentile, outside review course: 43rd percentile; p < 0.001). Programs with a remediation protocol trended toward higher ABSITE scores compared with programs without remediation protocols (median 61st percentile vs 53rd percentile, p = 0.098). Factors not significantly associated with ABSITE performance included number of structured educational hours per week and frequency of ABSITE review sessions.Program factors appear to significantly influence ABSITE performance. Programs where the PD was actively involved in remediation mentorship and the tracking of resident reading achieved higher ABSITE percentile scores on the January 2014 examination. Counterintuitively, residents from programs with a lower ABSITE threshold for remediation performed better on the examination.

  View details for DOI 10.1016/j.jsurg.2015.06.014

  View details for PubMedID 26319103

• Reading Habits of General Surgery Residents and Association With American Board of Surgery In-Training Examination Performance JAMA SURGERY Kim, J. J., Kim, D. Y., Kaji, A. H., Gifford, E. D., Reid, C., Sidwell, R. A., Reeves, M. E., Hartranft, T. H., Inaba, K., Jarman, B. T., Are, C., Galante, J. M., Amersi, F., Smith, B. R., Melcher, M. L., Nelson, T., Donahue, T., Jacobsen, G., Arnell, T. D., de Virgilio, C. 2015; 150 (9): 882-889

  Abstract

  Few large-scale studies have quantified and characterized the study habits of surgery residents. However, studies have shown an association between American Board of Surgery In-Training Examination (ABSITE) scores and subsequent success on the American Board of Surgery Qualifying and Certifying examinations.To identify the quantity of studying, the approach taken when studying, the role that ABSITE preparation plays in resident reading, and factors associated with ABSITE performance.An anonymous 39-item questionnaire including demographic information, past performance on standardized examinations, reading habits, and study sources during the time leading up to the 2014 ABSITE and opinions pertaining to the importance of the ABSITE was administered August 1, 2014, to August 25, 2014, to 371 surgery residents in 15 residency programs nationwide.Scores from the 2014 ABSITE.A total of 273 residents (73.6%) responded to the survey. Seven respondents did not provide their January 2014 ABSITE score, leaving 266 for statistical analysis. Most respondents were male (162 of 266 [60.9%]), with a mean (SD) age of 29.8 (2.6) years. The median number of minutes spent studying per month was 240 (interquartile range, 120-600 minutes) for patient care or clinical duties and 120 for the ABSITE (interquartile range, 30-360 minutes). One hundred sixty-four of 266 respondents (61.7%) reported reading consistently throughout the year for patient care or clinical duties. With respect to ABSITE preparation, 72 of 266 residents (27.1%) reported reading consistently throughout the year, while 247 of 266 residents (92.9%) reported preparing between 1 and 8 weeks prior to the examination. Univariate analysis (with results reported as effect on median ABSITE percentile scores [95% CIs]) identified the following factors as positively correlated with ABSITE scores: prior United States Medical Licensing Examination (USMLE) 1 and 2 scores (per 1-point increase: USMLE 1, 0.1 [0.02-0.14], P = .03; USMLE 2, 0.3 [0.19-0.44], P < .001), prior Medical College Admission Test (MCAT) scores (per 1-point increase, 1.2 [1.3-2.0]; P = .002), high opinion of ABSITE significance (P < .001), surgical textbook use (11 [6-16]; P = .02), daily studying (13 [4-23]; P = .02), and high satisfaction with study materials (P < .001). On multivariable analysis, USMLE 2 score (per 1-point increase, 0.4 [0.2-0.6]; P < .001), MCAT score (0.6 [0.2-1.0]; P = .003), opinion of ABSITE significance (9.2 [6.9-11.6]; P < .001), and having an equal focus on patient care and ABSITE preparation during study (6.1 [0.6-11.5]; P = .03) were identified as positive predictors of ABSITE performance.Most residents reported reading consistently for patient care throughout the year. Daily studying and textbook use were associated with higher ABSITE scores on univariate analysis. Scores on the USMLE 2 and MCAT, as well as resident attitude regarding the importance of the ABSITE results, were independent predictors of ABSITE performance.

  View details for DOI 10.1001/jamasurg.2015.1698

  View details for Web of Science ID 000367584100013

• Identifying Opportunities to Increase the Throughput of Kidney Paired Donation. Transplantation Liu, W., Treat, E., Veale, J. L., Milner, J., Melcher, M. L. 2015; 99 (7): 1410-1415

  Abstract

  Although kidney paired donation (KPD) has led to thousands of transplants, the 2012 KPD Consensus Conference concluded that more could be done. Perceptions are that a large number of match offers never resulted in transplantations, and unfruitful matches have both financial and emotional costs.To describe, quantify, and analyze the unrealized match offers, we studied the matching process from registration to transplantation in the National Kidney Registry, a large KPD registry, over a 25-month period.Of the 3,180 match offers, 454 were turned down. The most common reasons were the donor was not acceptable (50%) and their recipient had unacceptably high donor-specific antibodies (28%). Of the 2,228 accepted offers, 1,335 advanced to the cell-based cross-match stage because 893 of these were part of chains that fell through. Fifty-five of 887 recorded cell-based cross-matches were positive, 20 donors were unacceptable, and 22 recipients had unacceptably high donor-specific antibodies. Six hundred ninety transplantations were performed.Despite the success of KPD, by analyzing the matching process, we identify several strategies to increase the number of KPD transplantations, including recruiting more participants, processing the match offers more quickly at the transplant center level, enhancing the donor preselection tools, improving communication between centers and the registries, and combining desensitization with KPD.

  View details for DOI 10.1097/TP.0000000000000527

  View details for PubMedID 25606799

• Inside Out Autologous Neo-Liver Fabrication Than, P., Davis, C., Findlay, M., Liu, W., Le, T., Khong, S., Melcher, M., Gurtner, G. WILEY-BLACKWELL. 2015

  View details for Web of Science ID 000370124201434

• Paired Match Power and Challenges for O-Patients in Kidney Paired Donation Liu, W., Melcher, M. WILEY-BLACKWELL. 2015

  View details for Web of Science ID 000370124201323

• Recurrent Hepatocellular Carcinoma and Poorer Overall Survival in Patients Undergoing Left-sided Compared With Right-sided Partial Hepatectomy. Journal of clinical gastroenterology Valenzuela, A., Ha, N. B., Gallo, A., Bonham, C., Ahmed, A., Melcher, M., Kim, L. H., Esquivel, C., Concepcion, W., Ayoub, W. S., Lutchman, G. A., Daugherty, T., Nguyen, M. H. 2015; 49 (2): 158-164

  Abstract

  We aimed to determine the incidence and predictors of recurrent hepatocellular carcinoma (HCC) after partial hepatectomy.Liver transplantation is the preferred treatment for selected patients with HCC, but access to donor organs is limited. Partial hepatectomy is another accepted treatment option; however, postoperative recurrence is frequently observed.This is a retrospective cohort study of 107 consecutive patients who underwent partial hepatectomy for HCC between January 1993 and February 2011 at a US University Medical Center. Study endpoints were recurrent HCC, death, loss to follow-up, or last visit without HCC.The study cohort was 78% male with a median age of 61 years and 59% Asians. A total of 50 patients developed recurrent HCC (46.7%) after a median follow-up of 12 (1 to 69) months postresection. Recurrent HCC was significantly higher in patients with left-sided resection (41% at year 1, 54% at year 2, 62% at year 3, 81% at year 4, and 90% at year 5) compared with right-sided resection (18% at year 1, 34% at year 2, 36% at year 3, 44% at year 4, and 72% at year 5). In multivariate Cox proportional hazards model also inclusive of anatomic resection and TNM stage 3/4, left-sided resection was significantly associated with increased HCC recurrence (hazard ratio, 2.13; P=0.02; 95% confidence interval, 1.08-4.2) compared with right-sided resection.HCC recurrence rate is higher among those undergoing left-sided resection: 54% at year 2 and 81% at year 4. Liver transplantation should be considered in patients who are at high risk for recurrence.

  View details for DOI 10.1097/MCG.0000000000000144

  View details for PubMedID 24804988

• Is Informed Consent Enough? American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons Liu, W., Krawiec, K. D., Melcher, M. L. 2015

  Abstract

  As illustrated by Flechner et al (1), patients with renal failure continue to benefit from rapid innovations within multiple Kidney Paired Donation (KPD) registries. The development of the Advanced Donation Program (ADP) facilitates transplants by enabling the donors to donate even when their intended recipients (IR) are not matched yet. However, as with any innovation, ADP introduces new challenges including risks to the IRs and registries, vagueness in the definition of priority granted to the IR, and concerns about fairness to the donor should the IR become untransplantable. This article is protected by copyright. All rights reserved.

  View details for PubMedID 26603607

• Reading Habits of General Surgery Residents and Association With American Board of Surgery In-Training Examination Performance. JAMA surgery Kim, J. J., Kim, D. Y., Kaji, A. H., Gifford, E. D., Reid, C., Sidwell, R. A., Reeves, M. E., Hartranft, T. H., Inaba, K., Jarman, B. T., Are, C., Galante, J. M., Amersi, F., Smith, B. R., Melcher, M. L., Nelson, M. T., Donahue, T., Jacobsen, G., Arnell, T. D., de Virgilio, C. 2015; 150 (9): 882–89

  Abstract

  Few large-scale studies have quantified and characterized the study habits of surgery residents. However, studies have shown an association between American Board of Surgery In-Training Examination (ABSITE) scores and subsequent success on the American Board of Surgery Qualifying and Certifying examinations.To identify the quantity of studying, the approach taken when studying, the role that ABSITE preparation plays in resident reading, and factors associated with ABSITE performance.An anonymous 39-item questionnaire including demographic information, past performance on standardized examinations, reading habits, and study sources during the time leading up to the 2014 ABSITE and opinions pertaining to the importance of the ABSITE was administered August 1, 2014, to August 25, 2014, to 371 surgery residents in 15 residency programs nationwide.Scores from the 2014 ABSITE.A total of 273 residents (73.6%) responded to the survey. Seven respondents did not provide their January 2014 ABSITE score, leaving 266 for statistical analysis. Most respondents were male (162 of 266 [60.9%]), with a mean (SD) age of 29.8 (2.6) years. The median number of minutes spent studying per month was 240 (interquartile range, 120-600 minutes) for patient care or clinical duties and 120 for the ABSITE (interquartile range, 30-360 minutes). One hundred sixty-four of 266 respondents (61.7%) reported reading consistently throughout the year for patient care or clinical duties. With respect to ABSITE preparation, 72 of 266 residents (27.1%) reported reading consistently throughout the year, while 247 of 266 residents (92.9%) reported preparing between 1 and 8 weeks prior to the examination. Univariate analysis (with results reported as effect on median ABSITE percentile scores [95% CIs]) identified the following factors as positively correlated with ABSITE scores: prior United States Medical Licensing Examination (USMLE) 1 and 2 scores (per 1-point increase: USMLE 1, 0.1 [0.02-0.14], P = .03; USMLE 2, 0.3 [0.19-0.44], P < .001), prior Medical College Admission Test (MCAT) scores (per 1-point increase, 1.2 [1.3-2.0]; P = .002), high opinion of ABSITE significance (P < .001), surgical textbook use (11 [6-16]; P = .02), daily studying (13 [4-23]; P = .02), and high satisfaction with study materials (P < .001). On multivariable analysis, USMLE 2 score (per 1-point increase, 0.4 [0.2-0.6]; P < .001), MCAT score (0.6 [0.2-1.0]; P = .003), opinion of ABSITE significance (9.2 [6.9-11.6]; P < .001), and having an equal focus on patient care and ABSITE preparation during study (6.1 [0.6-11.5]; P = .03) were identified as positive predictors of ABSITE performance.Most residents reported reading consistently for patient care throughout the year. Daily studying and textbook use were associated with higher ABSITE scores on univariate analysis. Scores on the USMLE 2 and MCAT, as well as resident attitude regarding the importance of the ABSITE results, were independent predictors of ABSITE performance.

  View details for PubMedID 26176352

• Demographic and Clinical Characteristics of 207 Non-Directed Donors Participating in Paired Exchange Through the National Kidney Registry Pham, T., Waterman, A., Veale, J., Melcher, M. WILEY-BLACKWELL. 2015: 79

  View details for Web of Science ID 000348030600090

• Factors Associated With General Surgery Residents' Desire to Leave Residency Programs A Multi-institutional Study JAMA SURGERY Gifford, E., Galante, J., Kaji, A. H., Nguyen, V., Nelson, M. T., Sidwell, R. A., Hartranft, T., Jarman, B., Melcher, M., Reeves, M., Reid, C., Jacobsen, G. R., Thompson, J., Are, C., Smith, B., Arnell, T., Hines, O. J., de Virgilio, C. 2014; 149 (9): 948-953

  Abstract

  General surgical residency continues to experience attrition. To date, work hour amendments have not changed the annual rate of attrition.To determine how often categorical general surgery residents seriously consider leaving residency.At 13 residency programs, an anonymous survey of 371 categorical general surgery residents and 10-year attrition rates for each program. Responses from those who seriously considered leaving surgical residency were compared with those who did not.Factors associated with the desire to leave residency.The survey response rate was 77.6%. Overall, 58.0% seriously considered leaving training. The most frequent reasons for wanting to leave were sleep deprivation on a specific rotation (50.0%), an undesirable future lifestyle (47.0%), and excessive work hours on a specific rotation (41.4%). Factors most often cited that kept residents from leaving were support from family or significant others (65.0%), support from other residents (63.5%), and perception of being better rested (58.9%). On univariate analysis, older age, female sex, postgraduate year, training in a university program, the absence of a faculty mentor, and lack of Alpha Omega Alpha status were associated with serious thoughts of leaving surgical residency. On multivariate analysis, only female sex was significantly associated with serious thoughts of leaving residency (odds ratio, 1.2; 95% CI, 1.1-1.3; P = .003). Eighty-six respondents were from historically high-attrition programs, and 202 respondents were from historically low-attrition programs (27.8% vs 8.4% 10-year attrition rate, P = .04). Residents from high-attrition programs were more likely to seriously consider leaving residency (odds ratio, 1.8; 95% CI, 1.0-3.0; P = .03).A majority of categorical general surgery residents seriously consider leaving residency. Female residents are more likely to consider leaving. Thoughts of leaving seem to be associated with work conditions on specific rotations rather than with overall work hours and are more prevalent among programs with historically high attrition rates.

  View details for DOI 10.1001/jamasurg.2014.935

  View details for Web of Science ID 000342389000020

• Resolution of Acute Kidney Injury After Liver Transplantation: A Single Center Experience. Todo, T., Gallo, A., Berumen, J., Feinberg, E., Melcher, M., Bonham, C., Busque, S., Concepcion, W., Esquivel, C. LIPPINCOTT WILLIAMS & WILKINS. 2014: 759

  View details for Web of Science ID 000339104605025

• Utility, Equality, and the Tradeoff Between Quality of Graft and Waiting Time in KPD Liu, W., Melcher, M. LIPPINCOTT WILLIAMS & WILKINS. 2014: 125

  View details for Web of Science ID 000339104600385

• Early Excellent Outcomes of Flow Cross-Match Negative Kidney Transplant Recipients With Pre-Formed IgG DSA, C1q Negative With or Without Peri-Operative IVIg Infusion. Busque, S., Yabu, J., Melcher, M., Gallo, A., Kong, S., Makki, T., Burke-Barber, K., Scandling, J., Tyan, D. LIPPINCOTT WILLIAMS & WILKINS. 2014: 512

  View details for Web of Science ID 000339104603107

• Center-Defined Unacceptable HLA Antigens Facilitate Transplants for Sensitized Patients in a Multi-Center Kidney Exchange Program AMERICAN JOURNAL OF TRANSPLANTATION Baxter-Lowe, L. A., Cecka, M., Kamoun, M., Sinacore, J., Melcher, M. L. 2014; 14 (7): 1592-1598

  Abstract

  Multi-center kidney paired donation (KPD) is an exciting new transplant option that has not yet approached its full potential. One barrier to progress is accurate virtual crossmatching for KPD waitlists with many highly sensitized patients. Virtual crossmatch results from a large multi-center consortium, the National Kidney Registry (NKR), were analyzed to determine the effectiveness of flexible center-specific criteria for virtual crossmatching. Approximately two-thirds of the patients on the NKR waitlist are highly sensitized (>80% CPRA). These patients have antibodies against HLA-A (63%), HLA-B (66%), HLA-C (41%), HLA-DRB1 (60%), HLA-DRB3/4/5 (18-22%), HLA-DQB1 (54%) and HLA-DPB1 (26%). With donors typed for these loci before activation, 91% of virtual crossmatches accurately predicted an acceptable cell-based donor crossmatch. Failed virtual crossmatches were attributed to equivocal virtual crossmatches (46%), changes in HLA antibodies (21%), antibodies against HLA-DQA (6%), transcription errors (6%), suspected non-HLA antibodies (5%), allele-specific antibodies (1%) and unknown causes (15%). Some failed crossmatches could be prevented by modifiable factors such as more frequent assessment of HLA antibodies, DQA1 typing of donors and auditing data entry. Importantly, when transplant centers have flexibility to define crossmatch criteria, it is currently feasible to use virtual crossmatching for highly sensitized patients to reliably predict acceptable cell-based crossmatches.

  View details for DOI 10.1111/ajt.12734

  View details for Web of Science ID 000338024700019

• Quantifying the Risk of Incompatible Kidney Transplantation: A Multicenter Study AMERICAN JOURNAL OF TRANSPLANTATION Orandi, B. J., Garonzik-Wang, J. M., Massie, A. B., Zachary, A. A., Montgomery, J. R., Van Arendonk, K. J., Stegall, M. D., Jordan, S. C., Oberholzer, J., Dunn, T. B., Ratner, L. E., Kapur, S., Pelletier, R. P., Roberts, J. P., Melcher, M. L., Singh, P., Sudan, D. L., Posner, M. P., El-Amm, J. M., Shapiro, R., Cooper, M., Lipkowitz, G. S., Rees, M. A., Marsh, C. L., Sankari, B. R., Gerber, D. A., Nelson, P. W., Wellen, J., Bozorgzadeh, A., Gaber, A. O., Montgomery, R. A., Segev, D. L. 2014; 14 (7): 1573-1580

  Abstract

  Incompatible live donor kidney transplantation (ILDKT) offers a survival advantage over dialysis to patients with anti-HLA donor-specific antibody (DSA). Program-specific reports (PSRs) fail to account for ILDKT, placing this practice at regulatory risk. We collected DSA data, categorized as positive Luminex, negative flow crossmatch (PLNF) (n = 185), positive flow, negative cytotoxic crossmatch (PFNC) (n = 536) or positive cytotoxic crossmatch (PCC) (n = 304), from 22 centers. We tested associations between DSA, graft loss and mortality after adjusting for PSR model factors, using 9669 compatible patients as a comparison. PLNF patients had similar graft loss; however, PFNC (adjusted hazard ratio [aHR] = 1.64, 95% confidence interval [CI]: 1.15-2.23, p = 0.007) and PCC (aHR = 5.01, 95% CI: 3.71-6.77, p < 0.001) were associated with increased graft loss in the first year. PLNF patients had similar mortality; however, PFNC (aHR = 2.04; 95% CI: 1.28-3.26; p = 0.003) and PCC (aHR = 4.59; 95% CI: 2.98-7.07; p < 0.001) were associated with increased mortality. We simulated Centers for Medicare & Medicaid Services flagging to examine ILDKT's effect on the risk of being flagged. Compared to equal-quality centers performing no ILDKT, centers performing 5%, 10% or 20% PFNC had a 1.19-, 1.33- and 1.73-fold higher odds of being flagged. Centers performing 5%, 10% or 20% PCC had a 2.22-, 4.09- and 10.72-fold higher odds. Failure to account for ILDKT's increased risk places centers providing this life-saving treatment in jeopardy of regulatory intervention.

  View details for DOI 10.1111/ajt.12786

  View details for Web of Science ID 000338024700017

• PREDICT: Instituting an Educational Time Out in the Operating Room. Journal of graduate medical education Yang, R. L., Esquivel, M., Erdrich, J., Lau, J., Melcher, M. L., Wapnir, I. L. 2014; 6 (2): 382-383

  View details for DOI 10.4300/JGME-D-14-00086.1

  View details for PubMedID 24949168

• Resolution of Acute Kidney Injury After Liver Transplantation: A Single Center Experience. Todo, T., Gallo, A., Berumen, J., Feinberg, E., Melcher, M., Bonham, C., Busque, S., Concepcion, W., Esquivel, C. WILEY-BLACKWELL. 2014: 759

  View details for Web of Science ID 000338033303356

• Primary surgical resection versus liver transplantation for transplant-eligible hepatocellular carcinoma patients. Digestive diseases and sciences Wong, R. J., Wantuck, J., Valenzuela, A., Ahmed, A., Bonham, C., Gallo, A., Melcher, M. L., Lutchman, G., Concepcion, W., Esquivel, C., Garcia, G., Daugherty, T., Nguyen, M. H. 2014; 59 (1): 183-191

  Abstract

  Hepatocellular carcinoma (HCC) is a leading cause of mortality worldwide. Existing studies comparing outcomes after liver transplantation (LT) versus surgical resection among transplant-eligible patients are conflicting.The purpose of this study was to compare long-term survival between consecutive transplant-eligible HCC patients treated with resection versus LT.The present retrospective matched case cohort study compares long-term survival outcomes between consecutive transplant-eligible HCC patients treated with resection versus LT using intention-to-treat (ITT) and as-treated models. Resection patients were matched to LT patients by age, sex, and etiology of HCC in a 1:2 ratio.The study included 171 patients (57 resection and 114 LT). Resection patients had greater post-treatment tumor recurrence (43.9 vs. 12.9 %, p < 0.001) compared to LT patients. In the as-treated model of the pre-model for end stage liver disease (MELD) era, LT patients had significantly better 5-year survival compared to resection patients (100 vs. 69.5 %, p = 0.04), but no difference was seen in the ITT model. In the multivariate Cox proportional hazards model, inclusive of age, sex, ethnicity, tumor stage, and MELD era (pre-MELD vs. post-MELD), treatment with resection was an independent predictor of poorer survival (HR 2.72; 95 % CI, 1.08-6.86).Transplant-eligible HCC patients who received LT had significantly better survival than those treated with resection, suggesting that patients who can successfully remain on LT listing and actually undergo LT have better outcomes.

  View details for DOI 10.1007/s10620-013-2947-8

  View details for PubMedID 24282054

• Quantifying the Risk of Incompatible Kidney Transplantation: A Multi-Center Study Orandi, B., Garonzik-Wang, J., Montgomery, J., Massie, A., Van Arendonk, K., Stegall, M., Jordan, S., Oberholzer, J., Dunn, T., Ratner, L., Kapur, S., Pelletier, R., Roberts, J., Melcher, M., Singh, P., Sudan, D., Posner, M., El-Amm, J., Shapiro, R., Cooper, M., Lipkowitz, G., Rees, M., Marsh, C., Mongtomery, R., Segev, D. WILEY-BLACKWELL. 2014: 67

  View details for Web of Science ID 000328999400035

• Measuring Utility and Fairness in Kidney Paired Donation (KPD) Liu, W., Milner, J., Veale, J., Melcher, M. WILEY-BLACKWELL. 2014: 79

  View details for Web of Science ID 000328999400073

• Resolution of Acute Kidney Injury after Liver Transplantation: Single Center Experience Todo, T., Gallo, A., Beruman, J., Feinberg, E., Melcher, M., Bonham, C., Busque, S., Concepcion, W., Esquivel, C. WILEY-BLACKWELL. 2014: 101

  View details for Web of Science ID 000328999400137

• HIGH MELD VERSUS HIGH DONOR AGE: LESSONS LEARNED COMPARING THE AMERICAN AND THE ITALIAN LIVER TRANSPLANT EXPERIENCES Avolio, A. W., Cillo, U., Agnes, S., Lirosi, M. C., Perkins, J., Romagnoli, R., Cucchetti, A., Humar, A., Spada, M., Melcher, M. L., Caccamo, L., Santaniello, W., Baccarani, U., Ponziani, F. R., Burra, P., Halldorson, J. B. WILEY-BLACKWELL. 2013: 31

  View details for Web of Science ID 000328232000104

• Effect of the 16-Hour Work Limit on General Surgery Intern Operative Case Volume A Multi-institutional Study JAMA SURGERY Schwartz, S. I., Galante, J., Kaji, A., Dolich, M., Easter, D., Melcher, M. L., Patel, K., Reeves, M. E., Salim, A., Senagore, A. J., Takanishi, D. M., de Virgilio, C. 2013; 148 (9): 829-833

  Abstract

  The 80-hour work-week limit for all residents was instituted in 2003 and studies looking at its effect have been mixed. Since the advent of the 16-hour mandate for postgraduate year 1 residents in July 2011, no data have been published regarding the effect of this additional work-hour restriction.To determine whether the 16-hour intern work limit, implemented in July 2011, has adversely affected operative experience.A retrospective review of categorical postgraduate year 1 Accreditation Council for Graduate Medical Education case logs from the intern class (N = 52) (with 16-hour work limit) compared with the 4 preceding years (2007-2010; N = 197) (without 16-hour work limit). A total of 249 categorical general surgery interns from 10 general surgery residency programs in the western United States were included.Total, major, first-assistant, and defined-category case totals.As compared with the preceding 4 years, the 2011-2012 interns recorded a 25.8% decrease in total operative cases (65.9 vs 88.8, P = .005), a 31.8% decrease in major cases (54.9 vs 80.5, P < .001), and a 46.3% decrease in first-assistant cases (11.1 vs 20.7, P = .008). There were statistically significant decreases in cases within the defined categories of abdomen, endocrine, head and neck, basic laparoscopy, complex laparoscopy, pediatrics, thoracic, and soft tissue/breast surgery in the 16-hour shift intern era, whereas there was no decrease in trauma, vascular, alimentary, endoscopy, liver, and pancreas cases.The 16-hour work limit for interns, implemented in July 2011, is associated with a significant decrease in categorical intern operative experience. If the 16-hour shift were to be extended to all postgraduate year levels, one can anticipate that additional years of training will be needed to maintain the same operative volume.

  View details for DOI 10.1001/jamasurg.2013.2677

  View details for Web of Science ID 000325212300009

  View details for PubMedID 23843028

• Kidney failure in a transplant from an identical twin. American journal of kidney diseases Lum, E. L., Morton, J. M., Melcher, M. L. 2013; 62 (2): xxi-xxiii

  View details for DOI 10.1053/j.ajkd.2013.03.046

  View details for PubMedID 23883662

• Dynamic Challenges Inhibiting Optimal Adoption of Kidney Paired Donation: Findings of a Consensus Conference AMERICAN JOURNAL OF TRANSPLANTATION Melcher, M. L., Blosser, C. D., Baxter-Lowe, L. A., Delmonico, F. L., Gentry, S. E., Leishman, R., Knoll, G. A., Leffell, M. S., Leichtman, A. B., Mast, D. A., Nickerson, P. W., Reed, E. F., Rees, M. A., Rodrigue, J. R., Segev, D. L., Serur, D., Tullius, S. G., Zavala, E. Y., Feng, S. 2013; 13 (4): 851-860

  Abstract

  While kidney paired donation (KPD) enables the utilization of living donor kidneys from healthy and willing donors incompatible with their intended recipients, the strategy poses complex challenges that have limited its adoption in United States and Canada. A consensus conference was convened March 29-30, 2012 to address the dynamic challenges and complexities of KPD that inhibit optimal implementation. Stakeholders considered donor evaluation and care, histocompatibility testing, allocation algorithms, financing, geographic challenges and implementation strategies with the goal to safely maximize KPD at every transplant center. Best practices, knowledge gaps and research goals were identified and summarized in this document.

  View details for DOI 10.1111/ajt.12140

  View details for PubMedID 23398969

• Impact of Matching Frequency in Kidney Paired Donation. Ashlagi, I., Anderson, R., Gamarnik, D., Hil, G., Melcher, M., Roth, A. WILEY-BLACKWELL. 2013: 136

  View details for Web of Science ID 000318240300340

• A COMPARISON OF PRIMARY SURGICAL RESECTION TO LIVER TRANSPLANTATION (LT) AMONG TRANSPLANT-ELIGIBLE HEPATOCELLULAR CARCINOMA (HCC) PATIENTS USING AN INTENTION-TO-TREAT MODEL Wong, R. J., Wantuck, J., Valenzuela, A., Ahmed, A., Bonham, C., Gallo, A., Melcher, M., Lutchman, G., Concepcion, W., Esquivel, C., Garcia, G., Daugherty, T., Nguyen, M. H. ELSEVIER SCIENCE BV. 2013: S117

  View details for DOI 10.1016/S0168-8278(13)60277-9

  View details for Web of Science ID 000322983000276

• The influence of intern home call on objectively measured perioperative outcomes. JAMA surgery Kastenberg, Z. J., Rhoads, K. F., Melcher, M. L., Wren, S. M. 2013; 148 (4): 347-351

  Abstract

  HYPOTHESIS In July 2011, surgical interns were prohibited from being on call from home by the new residency review committee guidelines on work hours. In support of the new Accreditation Council for Graduate Medical Education work-hour restrictions, we expected that a period of intern home call would correlate with increased rates of postoperative morbidity and mortality. DESIGN Prospective cohort. SETTING University-affiliated tertiary Veterans Affairs Medical Center. PATIENTS All patients identified in the Veterans Affairs National Surgical Quality Improvement Program database who underwent an operation performed by general, vascular, urologic, or cardiac surgery services between fiscal years (FYs) 1999 and 2010 were included. MAIN OUTCOME MEASURES During FYs 1999-2003, the first call for all patients went to an in-hospital intern. In the subsequent period (FYs 2004-2010), the first call went to an intern on home call. Thirty-day unadjusted morbidity and mortality rates and risk-adjusted observed to expected ratios were analyzed by univariate analysis and joinpoint regression, respectively. RESULTS Unadjusted overall morbidity rates decreased between 1999-2003 and 2004-2010 (12.14% to 10.19%, P =  .003). The risk-adjusted morbidity observed to expected ratios decreased at a uniform annual percentage change of -6.03% (P < .001). Unadjusted overall mortality rates also decreased between the 2 periods (1.76% to 1.26%; P =  .05). There was no significant change in the risk-adjusted mortality observed to expected ratios during the study. CONCLUSIONS The institution of an intern home call schedule was not associated with increased rates of postoperative morbidity or mortality.

  View details for DOI 10.1001/jamasurg.2013.1063

  View details for PubMedID 23715944

• Evaluating Deceased Donor Registries: Identifying Predictive Factors of Donor Designation AMERICAN SURGEON Hajhosseini, B., Stewart, B., Tan, J. C., Busque, S., Melcher, M. L. 2013; 79 (3): 235-241

  Abstract

  The objectives of this study were to evaluate and compare the performance of the deceased donor registries of the 50 states and the District of Columbia and to identify possible predictive factors of donor designation. Data were collected retrospectively by Donate Life America using a questionnaire sent to Donor Designation Collaborative state teams between 2007 and 2010. By the end of 2010, there were 94,669,081 designated donors nationwide. This accounted for 39.8 per cent of the U.S. population aged 18 years and over. The number of designated organ donors and registry-authorized recovered donors increased each year; however, the total number of recovered donors in 2010 was the lowest since 2004. Donor designation rate was significantly higher when license applicants were verbally questioned at the Department of Motor Vehicles (DMV) regarding their willingness to register as a donor and when DMV applicants were not given an option on DMV application forms to contribute money to support organ donation, compared with not being questioned verbally, and being offered an option to contribute money. State registries continue to increase the total number of designated organ donors; however, the current availability of organs remains insufficient to meet the demand. These data suggest that DMV applicants who are approached verbally regarding their willingness to register as a donor and not given an option on DMV application forms to contribute money to support organ donation might be more likely to designate themselves to be a donor.

  View details for Web of Science ID 000315606500003

  View details for PubMedID 23461946

• Kidney Transplant Chains Amplify Benefit of Nondirected Donors JAMA SURGERY Melcher, M. L., Veale, J. L., Javaid, B., Leeser, D. B., Davis, C. L., Hil, G., Milner, J. E. 2013; 148 (2): 165-169

  Abstract

  Despite the potential for altruistic nondirected donors (NDDs) to trigger multiple transplants through nonsimultaneous transplant chains, concerns exist that these chains siphon NDDs from the deceased donor wait list and that donors within chains might not donate after their partner receives a transplant.To determine the number of transplantations NDDs trigger through chains.Retrospective review of large, multicenter living donor-recipient database.Fifty-seven US transplant centers contributing donor-recipient pairs to the database.The NDDs initiating chain transplantation.Number of transplants per NDD.Seventy-seven NDDs enabled 373 transplantations during 46 months starting February 2008. Mean chain length initiated by NDDs was 4.8 transplants (median, 3; range, 1-30). The 40 blood type O NDDs triggered a mean chain length of 6.0 (median, 4; range, 2-30). During the interval, 66 of 77 chains were closed to the wait list, 4 of 77 were ongoing, and 7 of 77 were broken because bridge donors became unavailable. No chains were broken in the last 15 months, and every recipient whose incompatible donor donated received a kidney. One hundred thirty-three blood type O recipients were transplanted. CONCLUSION AND RELEVANCE: This large series demonstrates that NDDs trigger almost 5 transplants on average, more if the NDD is blood type O. There were more blood type O recipients than blood type O NDDs participating. The benefits of transplanting 373 patients and enabling others without living donors to advance outweigh the risk of broken chains that is decreasing with experience. Even 66 patients on the wait list without living donors underwent transplantation with living-donor grafts at the end of these chains.

  View details for PubMedID 23426593

• Desensitization Combined With Paired Exchange Leads to Successful Transplantation in Highly Sensitized Kidney Transplant Recipients: Strategy and Report of Five Cases TRANSPLANTATION PROCEEDINGS Yabu, J. M., Pando, M. J., Busque, S., Melcher, M. L. 2013; 45 (1): 82-87

  Abstract

  Sensitization remains a major barrier to kidney transplantation. Sensitized patients comprise 30% of the kidney transplant waiting list but fewer than 15% of highly sensitized patients are transplanted each year. Options for highly sensitized patients with an immunologically incompatible living donor include desensitization or kidney paired donation (KPD). However, these options when used alone may still not be sufficient to allow a compatible transplant for recipients who are broadly sensitized with cumulative calculated panel-reactive antibody (cPRA) > 95%. We describe in this report the combined use of both desensitization and KPD to maximize the likelihood of finding a compatible match with a more immunologically favorable donor through a kidney exchange program. This combined approach was used in five very highly sensitized patients, all with cPRA 100%, who ultimately received compatible living and deceased donor kidney transplants. We conclude that early enrollment in paired kidney donor exchange and tailored desensitization protocols are key strategies to improve care and rates of kidney transplantation in highly sensitized patients.

  View details for DOI 10.1016/j.transproceed.2012.08.007

  View details for PubMedID 23375278

• Reoperation in Pediatric Liver Transplantation: A Five Year Review 13th Annual State of the Art Winter Symposium of the American-Society-of-Transplant-Surgeons (ASTS) Held in Conjunction with the NATCO Symposium for Advanced Transplant Professionals Feinberg, E. J., Beruman, J. A., Campos, B. D., Lodhia, N., Gallo, A. E., Melcher, M., Bonham, C. A., Concepcion, W., Esquivel, C. O. WILEY-BLACKWELL. 2013: 84–84

  View details for Web of Science ID 000312540200091

• Symbiotic or Parasitic? A Review of the Literature on the Impact of Fellowships on Surgical Residents ANNALS OF SURGERY Plerhoples, T. A., Greco, R. S., Krummel, T. M., Melcher, M. L. 2012; 256 (6): 904-908

  Abstract

  We conducted a systematic review of published literature to gain a better understanding of the impact of advanced fellowships on surgical resident training and education.As fellowship opportunities rise, resident training may be adversely impacted.PubMed, MEDLINE, Scopus, BIOSIS, Web of Science, and a manual search of article bibliographies. Of the 139 citations identified through the initial electronic search and screened for possible inclusion, 23 articles were retained and accepted for this review. Data were extracted regarding surgical specialty, methodology, sample population, outcomes measured, and results.Eight studies retrospectively compared the eras before and after the introduction of a fellowship or trended data over time. Approximately half used data from a single institution, whereas the other half used some form of national data or survey. Only 3 studies used national case data. Fourteen studies looked at general surgery, 6 at obstetrics-gynecology, 2 at urology, and 1 at otolaryngology. Only one study concluded that fellowships have a generally positive impact on resident education, whereas 9 others found a negative impact. The remaining 13 studies found mixed results (n = 6) or minimal to no impact (n = 7).The overall impact of advanced surgical fellowships on surgical resident education and training remains unclear, as most studies rely on limited data of questionable generalizability. A careful study of the national database of surgery resident case logs is essential to better understand how early surgical specialization and fellowships will impact the future of general surgery education.

  View details for DOI 10.1097/SLA.0b013e318262edd5

  View details for Web of Science ID 000312261000012

  View details for PubMedID 22968071

• Chain Transplantation: Initial Experience of a Large Multicenter Program AMERICAN JOURNAL OF TRANSPLANTATION Melcher, M. L., Leeser, D. B., Gritsch, H. A., Milner, J., Kapur, S., Busque, S., Roberts, J. P., Katznelson, S., Bry, W., Yang, H., Lu, A., Mulgaonkar, S., Danovitch, G. M., Hil, G., VEALE, J. L. 2012; 12 (9): 2429-2436

  Abstract

  We report the results of a large series of chain transplantations that were facilitated by a multicenter US database in which 57 centers pooled incompatible donor/recipient pairs. Chains, initiated by nondirected donors, were identified using a computer algorithm incorporating virtual cross-matches and potential to extend chains. The first 54 chains facilitated 272 kidney transplants (mean chain length = 5.0). Seven chains ended because potential donors became unavailable to donate after their recipient received a kidney; however, every recipient whose intended donor donated was transplanted. The remaining 47 chains were eventually closed by having the last donor donate to the waiting list. Of the 272 chain recipients 46% were ethnic minorities and 63% of grafts were shipped from other centers. The number of blood type O-patients receiving a transplant (n = 90) was greater than the number of blood type O-non-directed donors (n = 32) initiating chains. We have 1-year follow up on the first 100 transplants. The mean 1-year creatinine of the first 100 transplants from this series was 1.3 mg/dL. Chain transplantation enables many recipients with immunologically incompatible donors to be transplanted with high quality grafts.

  View details for DOI 10.1111/j.1600-6143.2012.04156.x

  View details for PubMedID 22812922

• General Surgery Resident Remediation and Attrition A Multi-institutional Study ARCHIVES OF SURGERY Yaghoubian, A., Galante, J., Kaji, A., Reeves, M., Melcher, M., Salim, A., Dolich, M., de Virgilio, C. 2012; 147 (9): 829-833

  Abstract

  To determine the rates and predictors of remediation and attrition among general surgery residents.Eleven-year retrospective analysis of 348 categorical general surgery residents at 6 West Coast programs.Rates and predictors of remediation and attrition.Three hundred forty-eight categorical general surgery residents were included. One hundred seven residents (31%) required remediation, of which 27 were remediated more than once. Fifty-five residents (15.8%) left their programs, although only 2 were owing to failed remediation. Remediation was not a predictor of attrition (20% attrition for those remediated vs 15% who were not [P = .40]). Remediation was most frequently initiated owing to a deficiency in medical knowledge (74%). Remediation consisted of monthly meetings with faculty (79%), reading assignments (72%), required conferences (27%), therapy (12%), and repeating a clinical year (6.5%). On univariate analysis, predictors of remediation included receiving honors in the third-year surgery clerkship, United States Medical Licensing Examination (USMLE) step 1 and/or step 2, and American Board of Surgery In-Training Examination scores at postgraduate years 1 through 4. On multivariable regression analysis, remediation was associated with receiving honors in surgery (odds ratio, 1.9; P = .01) and USMLE step 1 score (odds ratio, 0.9; P = .02). On univariate analysis, the only predictor of attrition was the American Board of Surgery In-Training Examination score at the postgraduate year 3 level (P = .04).Almost one third of categorical general surgery residents required remediation during residency, which was most often owing to medical knowledge deficits. Lower USMLE step 1 scores were predictors of the need for remediation. Most remediated residents successfully completed the program. Given the high rates of remediation and the increased educational burden on clinical faculty, medical schools need to focus on better preparing students to enter surgical residency.

  View details for Web of Science ID 000308883700013

  View details for PubMedID 22987173

• Incidental kidney stones: a single center experience with kidney donor selection CLINICAL TRANSPLANTATION Kim, I. K., Tan, J. C., Lapasia, J., Elihu, A., Busque, S., Melcher, M. L. 2012; 26 (4): 558-563

  Abstract

  The presence of kidney stones has been a relative contraindication for living donation. With the widespread use of more sensitive imaging techniques as part of the routine living donor workup, kidney stones are more frequently detected, and their clinical significance in this setting is largely unknown. Records from 325 potential kidney donors who underwent MRA or CT-angiography were reviewed; 294 proceeded to donation. The prevalence of kidney stones found incidentally during donor evaluation was 7.4% (24 of 325). Sixteen donors with stones proceeded with kidney donation. All incidental calculi were nonobstructing and small (median 2 mm; range 1-9 mm). Eleven recipients were transplanted with allografts containing stones. One recipient developed symptomatic nephrolithasis after transplantation. This recipient was found to have newly formed stones secondary to hyperoxaluria, suggesting a recipient-driven propensity for stone formation. The remaining ten recipients have stable graft function, postoperative ultrasound negative for nephrolithiasis, and no sequelae from stones. No donor developed symptomatic nephrolithiasis following donation. Judicious use of allografts with small stones in donors with normal metabolic studies may be acceptable, and careful follow-up in recipients of such allografts is warranted.

  View details for DOI 10.1111/j.1399-0012.2011.01567.x

  View details for PubMedID 22168332

• Multiple renal arteries and non-contrast magnetic resonance angiography in transplant renal artery stenosis. Clinical kidney journal Munoz Mendoza, J., Melcher, M. L., Daniel, B., Tan, J. C. 2012; 5 (3): 272-275

  View details for DOI 10.1093/ckj/sfs027

  View details for PubMedID 26069784

• EFFICIENT USE OF ONLINE PRE-SELECTED PAIRS FOLLOWED BY VIRTUAL CROSSMATCHING ENABLES TRANSPLANTS THROUGH MULTICENTER KIDNEY PAIRED DONATION (KPD) Kamoun, M., Cecka, M., Baxter-Lowe, L., Sinacore, J., Melcher, M. L. ELSEVIER SCIENCE INC. 2012: 68

  View details for DOI 10.1016/j.humimm.2012.07.154

  View details for Web of Science ID 000311189400089

• Potential Nutritional Conflicts in Bariatric and Renal Transplant Patients OBESITY SURGERY Lightner, A. L., Lau, J., Obayashi, P., Birge, K., Melcher, M. L. 2011; 21 (12): 1965-1970

  Abstract

  An increasing number of morbidly obese patients with end stage renal disease (ESRD) are sequentially undergoing bariatric surgery followed by renal transplantation. Discrepancies between the nutritional recommendations for obesity and chronic kidney disease (CKD) are often confusing for the obese patient in renal failure. However, when recommendations are structured according to stage and treatment of disease, a consistent plan can be clearly communicated to the patient. Therefore, to optimize patient and graft outcomes we present nutritional recommendations tailored to three patient populations: obese patients with ESRD, patients post Roux-en-Y gastric bypass (RYGBP) with ESRD, and patients post RYGBP and post renal transplantation.

  View details for DOI 10.1007/s11695-011-0423-0

  View details for PubMedID 21526378

• Cytomegalovirus in the transplanted kidney: a report of two cases and review of prophylaxis. NDT plus Anand, S., Yabu, J. M., Melcher, M. L., Kambham, N., Laszik, Z., Tan, J. C. 2011; 4 (5): 342-345

  View details for DOI 10.1093/ndtplus/sfr074

  View details for PubMedID 25984184

• Incidence and Predictors of Recurrent Hepatocellular Carcinoma (HCC) Following Partial Hepatectomy 76th Annual Scientific Meeting of the American-College-of-Gastroenterology Vergara, A. M., Gallo, A., Nghiem Ha, N., Bonham, C., Esquivel, C., Concepcion, W., Melcher, M., Daugherty, T., Ayoub, W., Lutchman, G., Ahmed, A., Mindie Nguyen, M. NATURE PUBLISHING GROUP. 2011: S103–S104

  View details for Web of Science ID 000299772000262

• Managing Finances of Shipping Living Donor Kidneys for Donor Exchanges AMERICAN JOURNAL OF TRANSPLANTATION Mast, D. A., Vaughan, W., Busque, S., VEALE, J. L., Roberts, J. P., Straube, B. M., Flores, N., Canari, C., Levy, E., Tietjen, A., Hil, G., Melcher, M. L. 2011; 11 (9): 1810-1814

  Abstract

  Kidney donor exchanges enable recipients with immunologically incompatible donors to receive compatible living donor grafts; however, the financial management of these exchanges, especially when an organ is shipped, is complex and thus has the potential to impede the broader implementation of donor exchange programs. Representatives from transplant centers that utilize the National Kidney Registry database to facilitate donor exchange transplants developed a financial model applicable to paired donor exchanges and donor chain transplants. The first tenet of the model is to eliminate financial liability to the donor. Thereafter, it accounts for the donor evaluation, donor nephrectomy hospital costs, donor nephrectomy physician fees, organ transport, donor complications and recipient inpatient services. Billing between hospitals is based on Medicare cost report defined costs rather than charges. We believe that this model complies with current federal regulations and effectively captures costs of the donor and recipient services. It could be considered as a financial paradigm for the United Network for Organ Sharing managed donor exchange program.

  View details for DOI 10.1111/j.1600-6143.2011.03690.x

  View details for PubMedID 21831153

• Successful Avoidance of Post-Transplant Antibody Mediated Rejection When Desensitizing Patients with IVIG: In Vitro C1q Test Predicts and Monitors In Vivo Efficacy and Time to Transplant Tyan, D., Yabu, J., Chen, G., Lou, C., Melcher, M., Scandling, J., Busque, S. WILEY-BLACKWELL. 2011: 91

  View details for Web of Science ID 000289318400200

• Renal Transplants Can Be Performed in High CPRA Patients without a Prospective Crossmatch Tyan, D., Lou, C., Melcher, M., Scandling, J., Busque, S. WILEY-BLACKWELL. 2011: 58

  View details for Web of Science ID 000289318400094

• Transporting Live Donor Kidneys for Kidney Paired Donation: Initial National Results AMERICAN JOURNAL OF TRANSPLANTATION Segev, D. L., VEALE, J. L., Berger, J. C., Hiller, J. M., Hanto, R. L., Leeser, D. B., GEFFNER, S. R., Shenoy, S., BRY, W. I., Katznelson, S., Melcher, M. L., Rees, M. A., Samara, E. N., Israni, A. K., Cooper, M., Montgomery, R. J., Malinzak, L., Whiting, J., Baran, D., Tchervenkov, J. I., Roberts, J. P., Rogers, J., Axelrod, D. A., Simpkins, C. E., Montgomery, R. A. 2011; 11 (2): 356-360

  Abstract

  Optimizing the possibilities for kidney-paired donation (KPD) requires the participation of donor-recipient pairs from wide geographic regions. Initially it was envisaged that donors would travel to the recipient center; however, to minimize barriers to participation and simplify logistics, recent trends have involved transporting the kidneys rather than the donors. The goal of this study was to review outcomes of this practice. KPD programs throughout the United States were directly queried about all transplants involving live donor kidney transport. Early graft function was assessed by urine output in the first 8 h, postoperative serum creatinine trend, and incidence of delayed graft function. Between April 27, 2007 and April 29, 2010, 56 live donor kidneys were transported among 30 transplant centers. Median CIT was 7.2 h (IQR 5.5-9.7, range 2.5-14.5). Early urine output was robust (>100 cc/h) in all but four patients. Creatinine nadir was <2.0 mg/dL in all (including the four with lower urine output) but one patient, occurring at a median of 3 days (IQR 2-5, range 1-49). No patients experienced delayed graft function as defined by the need for dialysis in the first week. Current evidence suggests that live donor kidney transport is safe and feasible.

  View details for DOI 10.1111/j.1600-6143.2010.03386.x

  View details for Web of Science ID 000286626700023

  View details for PubMedID 21272238

• Sclerosing Peritonitis After Kidney Transplantation: A Not-So-Silky Cocoon DIGESTIVE DISEASES AND SCIENCES Morrow, E. H., Gallo, A. E., Melcher, M. L. 2011; 56 (2): 307-310

  View details for DOI 10.1007/s10620-010-1471-3

  View details for PubMedID 21063775

• Cytomegalovirus in the transplanted kidney: a report of two cases and review of prophylaxis Nephrology Dialysis Transplantation Anand S, Yabu JM, Melcher ML, Kambham N, Laszik Z, Tan JC. 2011; 4 (5): 342-345
• Donors with Kidney Stones: Should We Pass? Congress of the American-Society-of-Transplant-Surgeons Kim, I. K., Lapasia, J., Elihu, A., Tan, J., Scandling, J., Busque, S., Melcher, M. WILEY-BLACKWELL PUBLISHING, INC. 2011: 66–66

  View details for Web of Science ID 000286406500042

• Population Pharmacokinetic Analysis of Mycophenolic Acid Coadministered With Either Tasocitinib (CP-690,550) or Tacrolimus in Adult Renal Allograft Recipients THERAPEUTIC DRUG MONITORING Lamba, M., Tafti, B., Melcher, M., Chan, G., Krishnaswami, S., Busque, S. 2010; 32 (6): 778-781

  Abstract

  Tasocitinib (CP-690,550) is an orally active Janus kinase inhibitor that is in development for prophylaxis of acute rejection after kidney transplantation and for the treatment of select autoimmune diseases. The current study was conducted to evaluate the systemic exposure of mycophenolic acid (MPA) in de novo kidney transplant patients when coadministered with tasocitinib compared with exposure in patients receiving tacrolimus, which has no effect on MPA pharmacokinetics. Plasma MPA concentrations were obtained from 17 adult patients who received either 15 mg or 30 mg tasocitinib twice daily (eight patients) or tacrolimus (nine patients) after kidney transplantation. All patients also received concomitant mycophenolate mofetil, prednisone, and basiliximab induction. The median mycophenolate mofetil dose was 1000 mg twice daily. A two-compartment population pharmacokinetic model estimating oral clearance, between-patient variability in oral clearance, central volume of distribution, and residual variability in combination with historical estimates of first-order absorption rate constant, intercompartmental clearance, and peripheral volume of distribution adequately described the sparse MPA data. Based on individual estimates oral clearance from the population pharmacokinetic model, mean steady-state area under the concentration-time curve values for a mycophenolate mofetil dose of 1000 mg twice daily were 63 mg·hr/L (22%) and 59 mg·hr/L (36%) for the tasocitinib and tacrolimus groups, respectively. These results indicate that tasocitinib does not influence systemic MPA exposure.

  View details for DOI 10.1097/FTD.0b013e3181f361c9

  View details for Web of Science ID 000284103400017

  View details for PubMedID 20926996

• Outcomes of surgical repair of bile leaks and strictures after adult-to-adult living donor liver transplant CLINICAL TRANSPLANTATION Melcher, M. L., Freise, C. E., Ascher, N. L., Roberts, J. P. 2010; 24 (6): E230-E235

  Abstract

  We sought to determine factors that predict the successful surgical repair of biliary complications after adult living donor liver transplantation (ALDLT).Records of 82 consecutive ALDLT right lobe recipients were reviewed. Operations were performed on 19 recipients for biliary complications. Post-operative biliary complications were analyzed. Fisher's exact test was used to identify variables that correlated with successful surgical repair.A total of 29 recipients had biliary complications, of which 19 had a surgical repair. The five recipients, operated on for a stricture without history of leaks, did not develop further complications. However, nine of 14 with a history of a leak developed further complications after surgical repair (p-value = 0.044). All five who presented with a biliary complication more than 100 d after transplant had successful surgical repair; however, nine out of 13 who presented within 57 d had additional complications after repair.Operations for strictures after ALDLT are more successful than operations for leaks. Recipients with isolated biliary strictures after ALDLT can be managed surgically; however, recipients with history of a leak often require additional interventions after surgical repair.

  View details for DOI 10.1111/j.1399-0012.2010.01289.x

  View details for PubMedID 20529098

• Comparison of biliary complications in adult living-donor liver transplants performed at two busy transplant centers CLINICAL TRANSPLANTATION Melcher, M. L., Pomposelli, J. J., Verbesey, J. E., McTaggart, R. A., Freise, C. E., Ascher, N. L., Roberts, J. P., Pomfret, E. A. 2010; 24 (5): E137-E144

  Abstract

  Adult living-donor liver transplantation (ALDLT) has a high rate of biliary complications. We identified risk factors that correlate with biliary leaks and strictures by combining data from two centers. Records of ALDLT right lobe recipients (n = 156) at two centers between December 1998 and February 2005 were reviewed. Leak rate was analyzed in 144 recipients after we excluded those with hepatic artery thrombosis or death within 30 d of transplant. Stricture rate was also analyzed in 132 recipients after we excluded those with graft survival or follow-up <180 d. Biliary reconstructions were performed using either duct-to-duct (DD) or Roux-en-Y hepaticojejunostomy and were subclassified by anatomic type, number of anastomoses performed, and stent use. Prevalence of a leak and/or a stricture was 39%; 11% of recipients developed both. Single DD anastomoses between the graft right hepatic duct to the recipient common duct had significantly lower incidence of leaks compared to all other anastomotic types. Early leak was predictive of late stricture development (p = 0.006), but recipient demographics, diagnosis, warm ischemia time, anastomosis type, duct number, year of transplant, stent use, and transplant center were not. The results suggest donors with a single right hepatic duct reconstructed to the recipient common bile duct are the most likely to avoid biliary problems after ALDLT.

  View details for DOI 10.1111/j.1399-0012.2009.01189.x

  View details for PubMedID 20047615

• Predicting Performance on the American Board of Surgery Qualifying and Certifying Examinations A Multi-institutional Study ARCHIVES OF SURGERY de Virgilio, C., Yaghoubian, A., Kaji, A., Collins, J. C., Deveney, K., Dolich, M., Easter, D., Hines, O. J., Katz, S., Liu, T., Mahmoud, A., Melcher, M. L., Parks, S., Reeves, M., Salim, A., Scherer, L., Takanishi, D., Waxman, K. 2010; 145 (9): 852-856

  Abstract

  We sought to determine whether US Medical Licensing Examination (USMLE) Step 1 score, American Board of Surgery (ABS) In-Training Examination (ABSITE) score, and other variables are associated with failing the ABS qualifying and certifying examinations. Identifying such factors may assist in the early implementation of an academic intervention for at-risk residents.Retrospective review.Seventeen general surgery training programs in the western United States.Six hundred seven residents who graduated in 2000-2007.First-time pass rates on the qualifying and certifying examinations, US vs non-US medical school graduation, USMLE Steps 1 and 2 scores, ABSITE scores, operative case volume, fellowship training, residency program type, and mandatory research.The first-time qualifying and certifying examination pass rates for the 607 graduating residents were 78% and 74%, respectively. On multivariable analysis, scoring below the 35th percentile on the ABSITE at any time during residency was associated with an increased risk of failing both examinations (odds ratio, 0.23 [95% confidence interval, 0.08-0.68] for the qualifying examination and 0.35 [0.20-0.61] for the certifying examination), as was scoring less than 200 on the USMLE Step 1 (0.36 [0.21-0.62] for the qualifying examination and 0.62 [0.42-0.93] for the certifying examination). A mandatory research year was associated with an increased likelihood of passing the certifying examination (odds ratio, 3.3 [95% confidence interval, 1.6-6.8]).Residents who are more likely to fail the ABS qualifying and certifying examinations can be identified by a low USMLE Step 1 score and by poor performance on the ABSITE at any time during residency. These findings support the use of the USMLE Step 1 score in the surgical residency selection process and a formal academic intervention for residents who perform poorly on the ABSITE.

  View details for Web of Science ID 000281764400010

  View details for PubMedID 20855755

• Wealthy Patients Are More Likely To Be Listed at Multiple Transplant Centers and Be Transplanted. Melcher, M. L., Javaid, B., Esquivel, C. O. WILEY-BLACKWELL PUBLISHING, INC. 2010: 288

  View details for Web of Science ID 000275921702270

• NEAD Chain Transplantation Does Not Favor Less Sensitized Patients. Melcher, M. L., Leeser, D. B., Katznelson, S., Busque, S., Mulgaonkar, S., Bry, W., Gritsch, H., Yang, H., Hil, G., Roberts, J., Kapur, S., Veale, J. L. WILEY-BLACKWELL. 2010: 277

  View details for Web of Science ID 000275921702232

• Risk of Graft Failure Due to Disease Recurrence in Patients with FSGS 10th American Transplant Congress Kim, J., Yabu, J., Tan, J., Scandling, J., Melcher, M., Busque, S., Javaid, B. WILEY-BLACKWELL. 2010: 196–197

  View details for Web of Science ID 000275921701535

• Impact of Short Term Pre-Transplant Dialysis on Kidney Transplant Outcomes 10th American Transplant Congress Javaid, B., Kim, J., Yabu, J., Tan, J., Melcher, M., Busque, S., Scandling, J. WILEY-BLACKWELL. 2010: 525–525

  View details for Web of Science ID 000275921703406

• Asynchronous, Out-of-Sequence, Transcontinental Chain Kidney Transplantation: A Novel Concept AMERICAN JOURNAL OF TRANSPLANTATION Butt, F. K., Gritsch, H. A., Schulam, P., Danovitch, G. M., Wilkinson, A., Del Pizzo, J., Kapur, S., Serur, D., Katznelson, S., Busque, S., Melcher, M. L., McGuire, S., Charlton, M., Hil, G., Veale, J. L. 2009; 9 (9): 2180-2185

  Abstract

  The organ donor shortage has been the most important hindrance in getting listed patients transplanted. Living kidney donors who are incompatible with their intended recipients are an untapped resource for expanding the donor pool through participation in transplant exchanges. Chain transplantation takes this concept further, with the potential to benefit even more recipients. We describe the first asynchronous, out of sequence transplant chain that was initiated by transcontinental shipment of an altruistic donor kidney 1 week after that recipient's incompatible donor had already donated his kidney to the next recipient in the chain. The altruistic donor kidney was transported from New York to Los Angeles and functioned immediately after transplantation. Our modified-sequence asynchronous transplant chain (MATCH) enabled eight recipients, at four different institutions, to benefit from the generosity of one altruistic donor and warrants further exploration as a promising step toward addressing the organ donor shortage.

  View details for DOI 10.1111/j.1600-6143.2009.02730.x

  View details for Web of Science ID 000269180500027

  View details for PubMedID 19563335

• Recovery of Renal Function in a Dialysis-Dependent Patient Following Gastric Bypass Surgery OBESITY SURGERY Tafti, B. A., Haghdoost, M., ALVAREZ, L., Curet, M., Melcher, M. L. 2009; 19 (9): 1335-1339

  Abstract

  There is increasing evidence that obesity, independently from other comorbidities such as diabetes and hypertension, can cause renal dysfunction. While this indolent dysfunction may be asymptomatic, it can render patients more susceptible to renal insufficiency when the kidneys are further injured by other pathological processes. Here, we present a morbidly obese patient whose type-A aortic dissection was complicated by acute renal failure that subsequently progressed into end-stage renal disease. However, his renal function improved dramatically following substantial weight reduction after gastric bypass surgery obviating the need for dialysis and transplantation. The potential mechanisms by which a patient's obesity may lead to renal dysfunction are discussed. This case and other similar reports suggest that obese patients with renal failure can safely undergo bariatric surgery and that bariatric surgery may have a role in treating chronic kidney disease in select morbidly obese patients.

  View details for DOI 10.1007/s11695-009-9907-6

  View details for PubMedID 19693639

• TARGETED QUANTITATIVE METABOLOMICS IN RATS DURING EARLY REPERFUSION. Dang, K., Melcher, M. L., Park, Y., Serkova, N. J., Niemann, C. U. JOHN WILEY & SONS INC. 2009: S176

  View details for Web of Science ID 000267792300346

• Postoperative infectious complications of abdominal solid organ transplantation. Journal of intensive care medicine Hlava, N., Niemann, C. U., Gropper, M. A., Melcher, M. L. 2009; 24 (1): 3-17

  Abstract

  There is a rapidly growing population of immunocompromised organ transplant recipients. These patients are at risk of a large variety of infections that have significant consequences on mortality, graft dysfunction, and graft loss. The diagnosis and treatment of these infections are facilitated by an understanding of the preoperative, perioperative, and postoperative risk factors; the typical pathogens; and their characteristic time of presentation. On the basis of these factors, we put forth an algorithm for diagnosing and treating suspected infections in solid organ transplant recipients.

  View details for DOI 10.1177/0885066608327127

  View details for PubMedID 19017663

• Accounting for Donor Charges in Kidney Donor Chains. 9th Joint Meeting of the American-Society-of-Transplant-Surgeon/American-Society-of-Transplantation Melcher, M. L., Veale, J., Mast, D., Standridge, K., Goldberg, S., MOYLE, C., Flores, N., Busque, S. WILEY-BLACKWELL. 2009: 435–436

  View details for Web of Science ID 000265068800857

• "Something Special in the Air": Transcontinental Shipments of Living Donor Kidneys for Transplantation. 9th Joint Meeting of the American-Society-of-Transplant-Surgeon/American-Society-of-Transplantation Veale, J. L., Butt, F. K., Gritsch, H. A., Danovitch, G., Wilkinson, A., Schulam, P., Del Pizzo, J., Kapur, S., Leeser, D., Serur, D., Katznelson, S., Busque, S., Melcher, M. L., McGuire, S., Charlton, M., Hil, G., Cecka, J. M. WILEY-BLACKWELL. 2009: 435–435

  View details for Web of Science ID 000265068800855

• Overcoming Immunological Barriers to Living Donor Kidney Transplantation At Stanford University Medical Center SGH Proceedings Ladner DP, Busque S, Melcher ML 2008; 17 (1): 5-19
• Thymoglobulin-associated Cd4+ T-cell depletion and infection risk in HIV-infected renal transplant recipients AMERICAN JOURNAL OF TRANSPLANTATION Carter, J. T., Melcher, M. L., Carlson, L. L., Roland, M. E., Stock, P. G. 2006; 6 (4): 753-760

  Abstract

  HIV-infected patients are increasingly referred for kidney transplantation, and may be at an increased risk for rejection. Treatment for rejection frequently includes thymoglobulin. We studied thymoglobulin's effect on CD4+ T-cell count, risk of infection and rejection reversal in 20 consecutive HIV-infected kidney recipients. All patients used antiretroviral therapy and opportunistic infection prophylaxis. Maintenance immunosuppression consisted of prednisone, mycophenolate mofetil and cyclosporine. Eleven patients received thymoglobulin (7 for rejection and 4 for delayed/slow graft function) while 9 did not. These two groups were similar in age, gender, race, donor characteristics and immunosuppression. Mean CD4+ T-cell counts remained stable in patients who did not receive thymoglobulin, but became profoundly suppressed in those who did, decreasing from 475 +/- 192 to 9 +/- 10 cells/microL (p < 0.001). Recovery time ranged from 3 weeks to 2 years despite effective HIV suppression. Although opportunistic infections were successfully suppressed, low CD4+ T-cell count was associated with increased risk of serious infections requiring hospitalization. Rejection reversed in 6 of 7 patients receiving thymoglobulin. We conclude that thymoglobulin reverses acute rejection in HIV-infected kidney recipients, but produces profound and long-lasting suppression of the CD4+ T-cell count associated with increased risk of infections requiring hospitalization.

  View details for DOI 10.1111/j.1600-6143.2006.01238.x

  View details for Web of Science ID 000235839900015

  View details for PubMedID 16539632

• Antibody-mediated rejection of a pancreas allograft AMERICAN JOURNAL OF TRANSPLANTATION Melcher, M. L., Olson, J. L., Baxter-Lowe, L. A., Stock, P. G., Posselt, A. M. 2006; 6 (2): 423-428

  Abstract

  The role of antibody-mediated rejection (AMR) in pancreas transplantation is poorly understood. Here, we report on a patient who developed AMR of his pancreas allograft after receiving a simultaneous pancreas-kidney transplant. Pre-operative enhanced cytotoxicity and flow cytometry T-cell crossmatches were negative; B-cell crossmatches were not performed as per institutional protocol. The patient's post-operative course was significant for elevated serum amylase levels and development of hyperglycemia approximately 1 month after transplantation. A pancreatic biopsy at this time showed no cellular infiltrate but strong immunofluorescent staining for C4d in the interacinar capillaries. Analysis of the patient's serum identified donor-specific HLA-DR alloantibodies. He received intravenous immunoglobulin (IVIg), rituximab and plasmapheresis, and his pancreatic function normalized. We conclude that clinically significant AMR can develop in a pancreas allograft and recommend that pancreatic biopsies be assessed for C4d deposition if the patient has risk factors for AMR and/or the pathologic evidence for cell-mediated rejection is underwhelming.

  View details for DOI 10.1111/j.1600-6143.2005.01185.x

  View details for Web of Science ID 000234735200025

  View details for PubMedID 16426331

• Spontaneous splenic rupture: The masquerade of minor trauma 35th Annual Meeting of the Western-Trauma-Association Tataria, M., Dicker, R. A., Melcher, M., Spain, D. A., Brundage, S. I. LIPPINCOTT WILLIAMS & WILKINS. 2005: 1228–30

  View details for DOI 10.1097/01.ta.0000196439.77828.9d

  View details for PubMedID 16385305

• More than 500 consecutive laparoscopic donor nephrectomies without conversion or repeated surgery 76th Annual Meeting of the Pacific-Coast-Surgical-Association Melcher, M. L., Carter, J. T., Posselt, A., Duh, Q. Y., Stoller, M., Freise, C. E., Kang, S. M. AMER MEDICAL ASSOC. 2005: 835–39

  Abstract

  Concern exists as to the safety of laparoscopic donor nephrectomy (LDN) compared with open donor nephrectomy. Reported complications of LDN include emergent conversion to an open procedure, repeated surgery for postoperative bleeding, and even death. We hypothesize that LDNs can be performed safely, with a complication rate comparable with that of open donor nephrectomies.Case series and review of the literature.Tertiary care university hospital.Five hundred thirty kidney donors.An LDN performed without hand assistance, with the kidney extracted through a low transverse incision.Mean operative time, requirement for transfusion, intraoperative complications, and postoperative complications.This series includes 84 right-sided donor nephrectomies, 86 donors with a body mass index greater than 30 (calculated as weight in kilograms divided by the square of height in meters), and 91 donors with complex vascular anatomy. Mean donor age was 40 years (range, 18-73 years), and mean +/- SD operative time was 196 +/- 43 minutes. The only conversion occurred early in the series, and there have been 525 subsequent cases without the need for conversion or repeated surgery. There were no donor deaths. Five donors (0.9%) required perioperative blood transfusions. Overall complication rate was 6.4%, including 14 minor wound infections, 2 bowel injuries, 1 case of prolonged ileus, 3 splenic injuries, 2 bladder infections, 1 bladder injury, 1 case of rhabdomyolysis, 1 case of pneumonia, and 2 thromboembolic events.This series demonstrates that LDN can be performed at least as safely as open donor nephrectomy, with minimal bleeding and few postoperative complications.

  View details for Web of Science ID 000231641400004

  View details for PubMedID 16172291

• Gastric carcinoid tumors in multiple endocrine neoplasia-1 patients with Zollinger-Ellison syndrome can be symptomatic, demonstrate aggressive growth, and require surgical treatment 25th Annua Meeting of the American-Association-of-Endocrine-Surgeons NORTON, J. A., Melcher, M. L., Gibril, F., Jensen, R. T. MOSBY-ELSEVIER. 2004: 1267–73

  Abstract

  Gastric carcinoid tumors occur in 15% to 50% of patients with multiple endocrine neoplasia-1/Zollinger-Ellison syndrome (MEN-1/ZES) but are thought to be benign. We report 5 patients with MEN-1/ZES with symptomatic, aggressive gastric carcinoid tumors that required surgical procedures.This was a retrospective chart review.Each patient had MEN-1/ZES. Each patient had innumerable gastric carcinoid tumors with symptoms. The fasting gastrin level was 47,000 pg/mL (normal, <200 pg/mL); the basal acid output was 79 mEq/hr (n = 3), and the age at surgical exploration was 47 +/- 6 years, with a duration of MEN-1 of 21 +/- 3 years and of ZES of 15 +/- 2 years. All patients had elevated 5-HIAA or serotonin levels. Somatostatin receptor scintigraphy showed increased stomach uptake in 4 patients (80%). Four patients had a total gastrectomy; 4 patients had lymph node metastases removed, and 3 patients had liver metastases resected. One patient who did not have a total gastrectomy had liver carcinoid metastases.These results demonstrate that gastric carcinoid tumors in patients with longstanding MEN-1/ZES may be symptomatic, aggressive, and metastasize to the liver. With increased long-term medical treatment and life expectancy, these tumors will become an important determinant of survival.

  View details for DOI 10.1016/j.surg.2004.06.057

  View details for PubMedID 15657586

• A novel technique to treat ruptured umbilical hernias in patients with liver cirrhosis and severe ascites JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES-PART A Melcher, M. L., Lobato, R. L., Wren, S. M. 2003; 13 (5): 331-332

  Abstract

  The full-thickness skin erosion (rupture) of an umbilical hernia in a patient with end-stage liver disease can lead to significant morbidity and mortality. Here, we present a case report of the use of a novel technique to treat a patient with this condition. The use of a fibrin-based tissue adhesive provides a means of managing such patients medically.

  View details for PubMedID 14617394

• Ileocolic intussusception in an adult JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Melcher, M. L., Safadi, B. 2003; 197 (3): 518-518

  View details for DOI 10.1016/S1072-7515(03)00589-1

  View details for PubMedID 12946809

• Identification and characterization of the CLK1 gene product, a novel CaM kinase-like protein kinase from the yeast Saccharomyces cerevisiae JOURNAL OF BIOLOGICAL CHEMISTRY Melcher, M. L., Thorner, J. 1996; 271 (47): 29958-29968

  Abstract

  The CLK1 gene of Saccharomyces cerevisiae encodes a 610-residue protein kinase that resembles known type II Ca2+/calmodulin-dependent protein kinases (CaM kinases), including the CMK1 and CMK2 gene products from the same yeast. The Clk1 kinase domain is preceded by a 162-residue N-terminal extension, followed by a 132-residue C-terminal extension (which contains a basic segment resembling known calmodulin-binding sites) and is as similar to mammalian CaM kinase (38% identity to rat CaM kinase alpha) as it is to yeast CaM kinase (37% identity to Cmk2). However, Clk1 shares 52% identity with Rck1, another putative protein kinase encoded in the S. cerevisiae genome. Clk1 tagged with a c-myc epitope (expressed in yeast) and a GST-Clk1 fusion (expressed in bacteria) underwent autophosphorylation and phosphorylated an exogenous substrate (yeast protein synthesis elongation factor 2), primarily on Ser. Neither Clk1 activity was stimulated by purified yeast calmodulin (CMD1 gene product), with or without Ca2+; no association of Clk1 with Cmd1 was detectable by other methods. C-terminally truncated Clk1(Delta487-610) was growth-inhibitory when overexpressed, whereas catalytically inactive Clk1(K201R Delta487-610) was not, suggesting that the C terminus is a negative regulatory domain. Using immunofluorescence, Clk1 was localized to the cytosol and excluded from the nucleus. A clk1Delta mutant, a clk1Delta rck1Delta double mutant, a clk1Delta cmk1Delta cmk2Delta triple mutant, and a clk1Delta rck1Delta cmk1Delta cmk2Delta quadruple mutant were all viable and manifested no other overt growth phenotype.

  View details for Web of Science ID A1996VU52500069

  View details for PubMedID 8939941