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Archive for March, 2013

MAA – Policy Wrangle, Evidence Based Medicine

Wednesday, March 27th, 2013

March 27, 2013 at Westin Perimeter. For more information, visit the Medical Association of Atlanta.

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MAA Board Meeting

Thursday, March 21st, 2013

March 21, 2013. For more information, visit Medical Association of Atlanta

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Inaugural State of Public Health Conference

Thursday, March 21st, 2013

March 21, 2013. Hosted by the University of Georgia College of Public Health and the Georgia Public Health Training Center, Athens, Ga. For more information, visit State of Public Health Conference

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Liver Transplantation with Curative Intent for Hepatobiliary Malignancies

Thursday, March 21st, 2013

By Marty Sellers, M.D., F.A.C.S. and Harrison Pollinger D.O., F.A.C.S.

From ATLANTA Medicine, 2013, Transplantation, Vol. 84, No. 1

Liver transplantation (LT) has matured to a highly successful treatment option for patients with advanced cirrhosis. More than 50 percent of patients undergoing LT 10 years ago are alive today, and non-LT-related factors are the most common cause of death in those surviving more than one year. Because of its success and its oncologic and physiologic advantages in cirrhotics, LT has increasingly become the primary treatment option for select patients with hepatocellular carcinoma (HCC). According to the Scientific Registry of Transplant Recipients, 20.9 percent of patients undergoing LT in 2011 were treated for malignancy, primarily HCC. Proper selection of patients with certain non-HCC malignancies allows LT to be utilized with high success rates in these patients as well.

Liver transplantation for Hepatocellular carcinoma

The indications for LT are numerous, though chronic liver damage from viral hepatitis, non- alcoholic fatty liver disease and alcohol abuse collectively account for the majority of LT patients; these and other chronic liver diseases significantly increase the risk of HCC (Figure 1). Treatment of HCC is hampered by the impact of underlying cirrhosis, which is present in approximately 90 percent of patients at diagnosis in the U.S. Surgical resection (partial hepatectomy, PH) in cirrhotics is high-risk in that the liver remnant may be deficient in size and/or function, leading to fatal hepatic decompensation. PH is, thus, applicable only in non- cirrhotics or those with well-compensated (Child’s A) cirrhosis, those without portal hypertension and those with a good performance status; the lesion(s) obviously must also be resectable with an adequate margin and still have sufficient remnant liver volume. These factors eliminate PH as a feasible option in the vast majority of patients with HCC.

Other local ablative treatments (e.g., radiofrequency or microwave ablation) are also potentially curative for small (<4 cm) lesions but, for many reasons, are of limited applicability as well.

Liver transplantation is, therefore, advantageous because: 1) total hepatectomy is oncologically superior to PH in that all cells at risk of malignant transformation are removed; (2) LT replaces the diseased liver with a suitable one, allowing recovery from the physiologic insult of major surgery; and (3) portal hypertension and its complications are eliminated. Therefore, if no extrahepatic disease is present at the time of LT, a patient is cured of their HCC and cirrhosis/portal hypertension and should have an essentially normal comorbidity-adjusted life expectancy.

Many patients with HCC have underlying liver dysfunction that limits non-LT treatment options. The Model for End Stage Liver Disease (MELD) Score, which predicts risk of death from advanced liver disease, has been utilized to allocate liver organs to the sickest patients first. Those with the highest MELD scores are the sickest recipients with the highest risk of waiting-list death and are thus most likely to benefit from early access to transplantation.

Since livers are allocated according to severity of liver dysfunction, HCC patients are potentially disadvantaged, if their underlying “laboratory” MELD score is low. This disadvantage is mitigated by granting “MELD-exception” points to patients with HCC considered within “Milan criteria,” which includes those without portal and/or hepatic vein tumor invasion, those with a single lesion <5.0 cm and those with two or three lesions, the largest of which is <3.0 cm. A patient within Milan criteria is automatically granted a MELD score of 22; if not transplanted within three months and the patient remains within Milan criteria, a MELD score of 25 is granted; this score increases at three-month intervals until the patient is transplanted, has tumor progression beyond Milan criteria, develops another contraindication to LT or dies on the waiting list.

Patients remaining within Milan criteria are at low risk of having extrahepatic disease; thus, they are likely cured by LT and enjoy excellent post-transplant survival, approximately 80 percent at five years. Less restrictive size and lesion number criteria are being increasingly employed with similarly good results, but a phenomenon aptly called the European “metroticket” applies – i.e., the farther you go (in terms of size and/or lesion number), the more you pay (in terms of post-LT recurrence and death). Still, these patients have no meaningful hope without LT. The balance of using a scarce resource (donor liver) in a potentially futile LT (when it could be used with higher success in others) is weighed on a daily basis by LT physicians/surgeons.

Liver transplantation for non-Hepatocellular carcinoma malignancies

Extrahepatic cholangiocarcinoma (CCA) and unresectable metastatic neuroendocrine tumors (NETs) to the liver or primary hepatic NETs are less common malignancies where LT is used with curative intent. Currently, no other malignancy metastatic to the liver is appropriately treated with LT. Also, intrahepatic CCA is not an indication for LT; patients with intrahepatic CCA should undergo PH when technically feasible unless extrahepatic disease is known.

CCA involving the extrahepatic biliary tree, including the ductal confluence, is highly fatal, even in patients with theoretically resectable disease – a five- year survival after resection, which ideally includes PH in addition to extrahepatic bile duct resection, remains < 40 percent, even in the most experienced hepatobiliary cancer centers. Alternatively, LT, when used as an element of a multidisciplinary treatment regimen that also includes neoadjuvant chemoradiation, >80 percent five-year survival has been reported by the group with the largest experience in LT for CCA. Selection bias exists in these data, however, some patients intended to receive LT never do so because of radiographic disease progression on neoadjuvant therapy; others undergo pre-LT celiotomy (or exploration at the time of LT) and, if disease is noted in regional lymph nodes or elsewhere in the peritoneal cavity, never undergo LT. Also, many patients do not have biopsy-proven CCA, therefore raising the criticism of whether they needed treatment; that those without biopsy-proven disease have a similar CCA recurrence rate after LT, however, counters this criticism.

These issues notwithstanding, it is becoming more widely accepted that neoadjvant therapy/LT provides the best chance of cure for extrahepatic CCA, especially since many of these patients also have chronic liver disease from primary sclerosing cholangitis and are, thus, poor candidates for PH. Extrahepatic CCA patients are also granted MELD exception points to facilitate LT.

Metatastic NETs to the liver are frequently innumerable and thus not resectable for cure. Fortunately, many of these tumors grow slowly, are not life-limiting and are frequently not associated with extrahepatic disease (as long as the primary tumor has been removed); moreover, when present, systemic symtoms (e.g., “carcinoid syndrome”) are frequently palliated with sandostatin. When systemic neuroendocrine symptoms are not controlled and PH would not be curative and when there is no discernible extrahepatic disease, LT provides complete resection of all known disease and elimination of tumor-related symptoms. Additionally, some patients have biopsy-proven NET in the liver with no known primary site, even after an exhaustive search, including nuclear medicine imaging (OctreoscanTM) and chest/abdomen/pelvis contrast imaging with CT or MRI; by default, these patients are considered to have primary hepatic NET and, if not technically resectable, are candidates for LT. A thorough search for the primary site is undertaken at the time of LT; if found, it is removed in conjunction with the transplant. Routine appendectomy should also be performed as this is a common site for primary NET. Most NET series are small, though five-year recurrence-free and overall survival have been recently reported as high as 80 percent and 90 percent, respectively, in carefully selected patients. Expectedly, low mitotic indices are associated with significantly improved outcomes. Since they do not have chronic liver disease, their MELD score is low, and they also must be granted MELD exception points in order to receive a transplant.

Less common non-HCC malignant indications for LT include hepatoblastoma, which is the most common primary hepatic malignancy in children, and hepatic epitheliod hemangioendothelioma, a rare vascular malignancy. LT is indicated in patients with unresectable disease for both lesion types, and limited extrahepatic metastasis is not an absolute contraindication in either. Survival is similar to that seen with LT for HCC.

In summary, LT is potentially curative for HCC and select non-HCC malignancies. In HCC, lesion size and/or number potentially limits LT candidacy. However, LT is associated with excellent tumor-specific and overall survival with proper patient selection. Non-HCC malignant indications for LT are less common, but good post-transplant outcomes justify its consideration when no other curative options exist.

Marty Sellers, M.D., F.A.C.S., is a multi-organ transplant and hepatobiliary surgeon and Director of Hepatobiliary Service at Piedmont Hospital. He joined Piedmont from the University of Pennsylvania, where he was Associate Professor of Surgery and surgical director of renal transplantation at Children’s Hospital of Philadelphia.His training includes clinical and research fellowships in transplantation and surgical oncology. Since coming to Atlanta in 2005, he has  focused on improving outcomes of malignant and non-malignant hepatobiliary disease through transplantation, resection and non-surgical modalities.

Harrison Pollinger D.O., F.A.C.S., is a multi-organ transplant and hepatobiliary surgeon at Piedmont Hospital. He joined Piedmont from the Mayo Clinic Rochester, where he completed his fellowship in multi-organ transplantation in 2008. Clinical interests include liver transplantation and robotic and minimally invasive liver surgery.

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NFMGMA Presents Customer Service Excellence — Preventing Malpractice Claims

Wednesday, March 20th, 2013

March 20, 2013, Alpharetta. For more information, visit North Fulton Medical Group Management Association

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Living Kidney Donation, Paired Kidney Exchange Transplants, and Donor Safety

Wednesday, March 20th, 2013

By Miguel Tan, M.D., MSc, FRCSC and Joshua Wolf, M.D.

From ATLANTA Medicine, 2013, Transplantation, Vol. 84, No. 1

Despite significant advances in kidney transplantation outcomes over the last decade, the number of transplants performed remains constrained by the limited number of available kidney donors. Nationally, the number of deceased kidney donors has stagnated while the recipient waiting list continues to grow. The Scientific Registry of Transplant Recipients (SRTR) data shows that the number of donors peaked in 2006- 2007(1) and has either reached a steady state or declined in subsequent years.

In Georgia alone, the number of deceased donors declined by approximately six percent from 2009-2010 to 2010-2011. The exact reason for this is not well known, however, the increasing age and obesity of the general population has lead to more marginal donors with poor-quality organs that end up being unusable. The number of new patient registrations, on the other hand, continues to grow at two percent to three percent a year. Four percent to five percent of potential recipients die on the waiting list.(2) Nationally, 4,500 people a year die while waiting for a kidney transplant. Currently, the average waiting time for a deceased donor kidney in Georgia is four to five years.

Living kidney donation has improved outcomes and access to transplantation by decreasing waiting time, improving long-term outcomes and allowing recipients on the deceased waiting list to “move up” in the queue by decreasing the number of recipients who would otherwise be in the “pool” awaiting a deceased donor organ. The five-year graft survival of a living donor kidney is 82.9 percent compared to 70.6 percent for a deceased donor(2). The additional benefit of this improved long-term outcome is that it reduces the number of recipients that may require re-transplantation at a future date due to the almost double half-life of a live donor kidney compared to a deceased donor organ.

Paired Kidney Exchange

Although the importance of living donation is well established, it is estimated that only a third to half of potential living donors and their intended recipients are compatible. A larger number have medically suitable and willing donors, but cannot donate to their intended recipient due to either blood type mismatch or recipient antibodies to the donor.

Paired kidney exchange addresses this imbalance by entering incompatible donor/recipient pairs into a database that allows us to identify other incompatible pairs and ‘swap’ donors to achieve compatible kidney transplantation.

A variant of paired kidney exchange is the so-called domino chain transplant. This is made possible by an “altruistic” or non-directed donor who is prepared to donate a kidney to anyone in need. When this type of donor is entered in a paired exchange registry, it can result in a cascade effect or “chain” of transplants.

The main advantage of chain donation is eliminating the need to perform all the transplants simultaneously, as described in a “standard” paired exchange. This significantly eases the resource and logistic burden on the hospital, surgeons and patients. In addition, using a “bridge” donor allows for potential continuation of the chain as long as suitable pairs are subsequently found. One of the longest current chains was completed last year and involved 17 hospitals in 11 states, resulting in 30 kidney transplants as a result of the generosity of one non-directed donor(3).

For example, one nine-pair chain ended with the final donor held as a ‘bridge’ donor in order to initiate the another chain. This particular example illustrates the first reported intercontinental kidney domino exchange in the world that our center participated in. The generosity of one altruistic donor led to nine kidney transplants that otherwise would not have happened. The bridge donor at the end of this segment will allow the chain to continue.

Previous data(4) based on mathematical simulations has suggested that efficient use of these “domino” chains would result in 1.9 to 3.8 transplants per chain. However, a more recent retrospective study(5) shows that the benefit is potentially much greater. A multicenter study involving 272 kidney transplants actually yielded an average of five transplants per chain. This data illustrates the importance of altruistic/non-directed live kidney donors in increasing the number and quality of kidney transplants.

In the past, these endeavors were performed using “in-house” or regional programs limiting the potential pool. However, the importance of paired exchange has reached a point that a National Paired Kidney Donation Pilot Program was formed to maximize the opportunity for patients to receive a living donor kidney who otherwise would not have access to living kidney donation. Paired exchange essentially did not exist in 2000. By 2008, almost 300 such exchanges were performed annually.

Current projections estimate that a well- utilized national network can increase the number of kidney transplants by 10 percent to 15 percent – no small feat considering that there are more than 91,000 patients awaiting kidney transplantation in the United States. There are more than 3,200 patients waiting for kidneys in Georgia alone.

Donor Safety

Because living kidney donation is an altruistic act, donor safety is of paramount importance to the transplant community. In most programs, diabetes, obesity (BMI >30-32 kg/m2) and hypertension are contraindications to donation. Properly selected donors, however, have excellent long-term outcomes. A number of studies support the long-term safety of kidney donation, including a large study by Ibrahim et al(6). From 1963-2007, 3,698 living kidney donors were evaluated and demonstrated that carefully screened donors had the same survival and risk of end-stage renal disease as controls who were matched for age, sex and race. They also had preserved GFR, normal albumin secretion and a good quality of life.

Improving Surgical Safety and Donor Recovery

The advent of laparoscopic surgery was a boon to living kidney donation by greatly improving post-operative pain, recovery and cosmetic outcome. What used to entail an open procedure requiring a large flank incision with rib resection is now performed through two or three half-inch incisions and a three-inch incision to remove the kidney with relatively little post-operative pain. The patient typically remains in hospital for one to two days and has a rapid return to normal function.

Compared to open surgery, however, the margin of safety with laparoscopy is narrower due to the loss of 3-D visualization when observing a flat television monitor during surgery as well as instrumentation limitations. This limitation has been abrogated somewhat by robotic surgical techniques that utilize 3-D technology. The advantages of robotic technique include better visualization of fine structures in limited spaces and improved articulation of robotic instruments compared to the standard laparoscopic approach. While still a technique limited to more advanced transplant centers, its use is gaining ground as more surgeons become proficient in robotic applications.

End-stage renal disease remains a significant health issue. Kidney transplantation is the gold standard for treatment for most causes of ESRD. In order to address the shortfall in available organs, living donor and paired exchange transplantation has been developed. As an added benefit, live donor kidneys offer superior long-term outcomes compared to deceased donor organs, while paired exchange programs allow incompatible pairs to participate in and receive live donor organs.

Achieving higher kidney transplant rates not only benefits recipients through improvement mortality and quality of life, but provides significant cost savings to the healthcare system as a whole. Previous meta-analysis have demonstrated that maintaining a patient on dialysis costs more than $300,000 per Quality Adjusted Life Year (QALY). Living donor kidney transplantation reduces that cost to $120,000 per QALY(8).

In addition, advances in surgical technique has led to significant improvements in donor outcomes, thus removing most of the risk and morbidity associated with the earlier era of open-donor nephrectomy.

References
1. SRTR annual report, www.srtr.org

2. www.unos.org

3. Sack, K. 60 Kidneys, 30 Lives, All Linked. New York Times, 2012, February 19. p. A1

4. Gentry SE, et al. Am J Transplant 2009; 9: 1330-1336

5. Melcher ML, et al Am J Transplant 2012, 12:2429-2436

6. Ibrahim, H NEJM 2009; 360(5):459-69

7. Tan, M ed. A Brief Guide to Abdominal Organ Transplantation: Practical Management of the Peri-Operative Transplant Patient. 2011, P.89

8. Demartines N, Schiesser M, Clavien PA. An evidence-based analysis of simultaneous pancreas-kidney and pancreas transplantation alone Am J Transplant. 2005 Nov;5(11):2688-97

Miguel Tan, M.D., MSc, FRCSC, is a multi-organ transplant surgeon and serves as surgical director of kidney and pancreas transplantation at Piedmont Transplant Institute. Previously, he was Assistant Professor of Surgery in the Division of Transplantation at Johns Hopkins Hospital in Baltimore, Md. He received his medical degree and completed his residency at McGill University in Montreal. Dr. Tan completed a clinical fellowship in transplant surgery at the University of Minnesota.

Joshua Wolf, M.D., is a transplant nephrologist at the Piedmont Transplant Institute in Atlanta. Dr. Wolf has special interests in living donor transplantation as well as transplanting the highly sensitized
recipient. He is board certified in Internal Medicine and Nephrology by the American Board of Internal Medicine. He received his undergraduate and medical degree from Emory University School of Medicine, completed his internship and residency at New York University Medical Center, and completed his general and transplant nephrology training at the University of California, San Francisco.

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Vaccination in Solid Organ Transplant Recipients

Wednesday, March 20th, 2013

by Aneesh K. Kautilya Mehta, M.D., Rachel Jacqueline Friedman-Moraco, M.D., and George Marshall Lyon III, M.D.

Infections remain a major source of morbidity in solid organ transplant (SOT) recipients. Many of these infections may be prevented by appropriate vaccination of SOT patients, their family members and their healthcare providers.

Since vaccine responses may be significantly diminished after transplantation due to immunosuppressive medications, efforts should be made to evaluate immunity status and vaccinate patients prior to receiving immunosuppres- sion (1, 2) However, SOT recipients can benefit from vac- cination after transplantation as well, and most vaccines are safe to administer to SOT patients without increased risk of organ rejection (3, 4). This review will cover general guidelines for vaccination of SOT candidates and recipients, and their close contacts, as well as recommendations for pertinent vaccines.

General Principles

The vaccination status of potential SOT candidates should be reviewed at the time of initial consideration for transplantation, and a plan for immunizations should be formulated at that time (4). In general, live vaccines are contraindicated in immunosuppressed patients, therefore any need for these vaccines should be evaluated and given prior to transplantation. Transplantation should be delayed for at least four weeks after live viral vaccinations (4). In addition to obtaining a vaccine history, transplant candidates should be screened for immunity to vaccine-preventable diseases, including serologies for Hepatitis-A, Hepatitis-B and varicella-zoster virus (VZV), and potentially rubella in pediatric patients and those unsure of childhood immunizations. Some patients may need to proceed for transplantation before sufficient opportunity to vaccinate them. These patients generally require three to six months for their immunosuppression to stabilize in order to restart a vaccination schedule.

Specific Recommendations

Influenza vaccination
Influenza vaccination is recommended annually for all Americans greater than six months old, including transplant recipients (5, 6). While rates change yearly, influenza is estimated to infect between 1 percent and 4 percent of SOT patients annually and can cause up to 50 percent of upper and lower respiratory tract infections in SOT recipients during influenza season (1, 7, 8). Transplant patients experience more prolonged shedding and more severe disease than immunocompetent patients. Particularly susceptible are lung transplant recipients, in whom influenza may induce organ rejection and bronchiolitis obliterans syndrome (1, 7-10). The immunogenicity of influenza vaccinations in SOT has been thoroughly reviewed by Kumar et al(1), essentially demonstrating that influenza vaccines are effective, though less so than in immunocompetent individuals, and safe in SOT patients. Thus, these data indicate the importance of annual vaccination for influenza.

While data guiding the optimal time for vaccination after transplant is lacking, most transplant centers will vaccinate transplant candidates at the earliest opportunity and will begin vaccinating recipients one to six months post-transplant(11). While live-attenuated nasal vaccines may be used for transplant candidates who are unlikely to be transplanted within the following month, generally the inactivated intramuscular or intradermal immunization is used for most transplant candidates and for all recipients. While the high-dose inactivated vaccine has not been studied in SOT recipients, we believe it is reasonable to administer this vaccine in SOT patients 65 years old and older.

Pneumococcal vaccination
Most indications for transplantation are also indications for pneumococcal vaccination. Currently there are two available formulations of the pneumococcal vaccinations: the 13-valent pneumococcal conjugate vaccine (PCV- 13) and 23-valent pneumococcal polysaccharide vaccine (PPSV-23). The PPSV-23 vaccine covers more serotypes of Streptococcous pneumonia but utilizes T-cell independent mechanisms to develop immunity, and therefore is not effective in young children. PCV-13 initiates a T-cell dependent response, allowing for its utility in young children (5, 12).

Recently, the CDC’s Advisory Committee on Immunization Practices (ACIP) recommended the use of PCV-13 for adults aged 19 years and older with specified immunocompromising conditions(13). However, to date there are no studies of PCV-13 in immunocompromised patients, though there is an ongoing trial in pediatric SOT patients. This recommendation was based largely on studies of the older PCV-7 vaccine in HIV+ individuals (13). The CDC’s cost-effectiveness model demonstrated significant benefit to patients with HIV or on dialysis, with much less predicted benefit in SOT recipients (13). Thus, we recommend that transplant candidates who are HIV positive, have functional or anatomic asplenia, have CSF leaks or cochlear implants receive a PCV-13 if they have not already received one. For candidates without these conditions and not update to pneumococcal vaccinations, we recommend PPSV-23 until further data is available for PCV-13. For SOT recipients who need a pneumococcal vaccine, we recommend PPSV-23 until studies of PCV-13 in immunosuppressed patients is available. However, PCV- 13 is likely safe in SOT and therefore may be used at the discretion of the provider. Any adult who receives PCV- 13 and has not received PPSV-23 should receive a dose of PPSV-23, but not until at least eight weeks later (13).

Tetanus, diphtheria, pertussis vaccinations
The ACIP currently recommends that all Americans older than 10 years should receive a single dose of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) regardless of the interval since the last non-pertussis tetanus/diphtheria-toxoid vaccine (14). Thus, all transplant candidates should receive a Tdap. SOT patients who were not vaccinated prior to transplant should receive a Tdap vaccine once they are stable and greater than three months post-transplant. Thereafter, SOT patients should continue with tetanus toxoid/reduced diphtheria toxoid (Td) booster every 10 years.

Hepatitis A virus (HAV) vaccination
All transplant candidates should be screened for protective levels of HAV total or IgG antibodies. Non- immune candidates should receive one dose of the vaccine as soon as possible, then another dose six to twelve months later. Patients may receive a combined HAV and HBV vaccine if lacking immunity to both, dosed at zero, one and six months. SOT recipients who did not complete the series prior to transplantation may complete once stable post-transplant.

Hepatitis B virus (HBV) vaccination
All transplant candidates should be evaluated for active HBV infection with HBV surface antigen and screened for protective levels of HBV surface antibodies. Non-immune patients should receive one dose of the vaccine as soon as possible, a second dose one month later, and a third dose six to 12 months after the initial vaccine. Patients may receive a combined HAV and HBV vaccine if lacking immunity to both, dosed as above. Adult transplant candidates receiving dialysis or with significant immunocompromising conditions should receive either 40 μg/mL doses on the same three-dose schedule above or on a four-dose schedule at zero, one, two and six months. SOT recipients who did not complete the series prior to transplantation may complete once stable post-transplant with the 40 μg/mL dose.

Varicella and Zoster vaccinations
Both the varicella and zoster vaccines are live-attenuated viral vaccines and thus are contraindicated in SOT recipients. All transplant candidates should be screened for varicella-zoster virus (VZV) immunity by antibody titers. If the candidate is VZV seronegative and not in need of an urgent transplant, then he/she should receive two doses of the varicella vaccine, spaced apart by at least four weeks. If the candidate is VZV seropositive, is 50 years old or older and not in need of an urgent transplant, then he/she should receive one dose of the Zoster vaccine. We recommend checking antibody titers after the varicella vaccine series to ensure efficacy (usually > 4 weeks after second immunization), but this is not necessary for the zoster vaccine.

Human papillomavirus (HPV) vaccination
The ACIP recommends that both males and females 11 to 26 years of age should receive three doses of a HPV vaccine (5, 6). All transplant candidates in this age category should be screened for previous HPV vaccination and complete the series if not previously done. If the patient proceeds to transplant prior to completing the HPV series, then he/she may complete the series after transplant. We recommend that quadrivalent HPV vaccine (HPV4) be used for all SOT candidates and recipients.

Measles, mumps, rubella (MMR) vaccination
All persons born after 1956 should have documentation of one or more doses of MMR vaccine, documentation of previous disease or immunity, or an established medical contraindication (14). The MMR is live-attenuated vaccine and contraindicated in SOT. Thus, transplant candidates should be questioned about previous MMR vaccinations, and testing serologies should be considered in candidates raised in a foreign country, planning to live in a foreign country, planning or possible to become pregnant post-transplant, or with unknown childhood vaccine compliance. If deemed non-immune to any component of the vaccine, one dose of MMR should be administered and transplantation delayed for four weeks if possible.

Meningococcal vaccination
Transplant candidates with asplenia or significant complement deficiencies should receive two doses of quadrivalent meningococcal conjugate vaccine at least two months apart. Candidates and recipients who are likely travel to or live in countries with endemic meningococcal disease or those planning on living in dormitories should receive one dose.

Recommendations for healthcare workers and close contacts

Given that SOT recipients have a diminished response to vaccines, it is imperative that healthcare workers, household members and other close contacts be fully immunized according to the ACIP recommendations (http://www.cdc.gov/vaccines/pubs/ACIP-list.htm). There are often concerns regarding exposure of SOT recipients to contacts receiving vaccines. For inactivated vaccines (Table 1) there are no concerns; however, with live- attenuated vaccines (Table 1), there is at least a theoretical concern with some vaccines. For oral polio vaccinations (not used in the U.S.), SOT patients should avoid contact for seven days after vaccination. For recipients of the Rotavirus vaccine, SOT recipients should avoid changing diapers or contact with stool for seven to 14 days. SOT patients need to avoid contact with varicella (chickenpox or zoster) vaccinees only if vaccinee has respiratory symptoms or a rash after vaccine. For most other live viral vaccines, there are no other restrictions needed as the risk of contracting wild-type disease far outweighs any exposure from the vaccinee. Any concerns about exposure of an SOT patient to a vaccinee should be discussed with an Infectious diseases specialist.

Infectious complications continue to contribute significant morbidity in solid organ transplant patients. Most vaccines are safe and efficacious in SOT patients. Therefore, developing and implementing immunization strategies for transplant candidates and recipients, and their contacts, can significantly decrease the frequency of these infectious events in SOT recipients.

References
1. Kumar D, Blumberg EA, Danziger-Isakov L, Kotton CN, Halasa NB, Ison MG, et al. Influenza Vaccination in the Organ Transplant Recipient: Review and Summary Recommendations†. American Journal of Transplantation. 2011;11(10):2020-30.
2. Blumberg EA, Brozena SC, Stutman P, Wood D, Phan HM, Musher DM. Immunogenicity of Pneumococcal Vaccine in Heart Transplant Recipients. Clinical Infectious Diseases. 2001;32(2):307-10.
3. Avery RK, Michaels M. Update on Immunizations in Solid Organ Transplant Recipients: What Clinicians Need to Know. American Journal of Transplantation. 2008;8(1):9-14.
4. Danzinger-Isakov L, Kumar D, the ASTIDCoP. Guidelines for Vaccination of Solid Organ Transplant Candidates and Recipients. American Journal of Transplantation. 2009;9:S258-S62.
5. CDC. Recommended immunization schedules for persons aged 0 through 18 Years – United States, 2012. MMWR Morbidity and mortality weekly report. 2012;61(5):1-4.
6. CDC. Recommended Adult Immunization Schedule: United States, 2012*. Annals of Internal Medicine. 2012;156(3):211-7.
7. Gottlieb J, Schulz TF, Welte T, Fuehner T, Dierich M, Simon AR, et al. Community-acquired respiratory viral infections in lung transplant recipients: a single season cohort study. Transplantation. 2009;87(10):1530-7.
8. Vilchez RA, McCurry K, Dauber J, Iacono A, Griffith B, Fung J, et al. Influenza Virus Infection in Adult Solid Organ Transplant Recipients. American Journal of Transplantation. 2002;2(3):287-91.
9. Khalifah AP, Hachem RR, Chakinala MM, Schechtman KB, Patterson GA, Schuster DP, et al. Respiratory viral infections are a distinct risk for bronchiolitis obliterans syndrome and death. American journal of respiratory and critical care medicine. 2004;170(2):181-7.
10. Garantziotis S, Howell DN, McAdams HP, Davis RD, Henshaw NG, Palmer SM. Influenza pneumonia in lung transplant recipients: clinical features and association with bronchiolitis obliterans syndrome. Chest. 2001;119(4):1277-80.
11. Chon WJ, Kadambi PV, Harland RC, Thistlethwaite JR, West BL, Udani S, et al. Changing attitudes toward influenza vaccination in U.S. Kidney transplant programs over the past decade. Clinical journal of the American Society of Nephrology : CJASN. 2010;5(9):1637-41.
12. Nuorti JP, Whitney CG, Centers for Disease C, Prevention. Prevention of pneumococcal disease among infants and children – use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine – recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recommendations and reports : Morbidity and mortality weekly report Recommendations and reports / Centers for Disease Control. 2010;59(RR-11):1-18.
13. CDC. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morbidity and mortality weekly report. 2012;61(40):816-9.
14. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the Advisory
Committee on Immunization Practices, 2010. MMWR Morbidity and mortality weekly report. 2011;60(1):13-5.

 

Aneesh K. Mehta, M.D., is a transplant infectious diseases consultant and researcher at the Emory University School of Medicine and serves as the Assistant Director of Transplant Infectious Diseases at the Emory Transplant Center. He received his medical degree from the University of Oklahoma and trained in Internal Medicine, Infectious Diseases and Transplantation at Emory. His research interests are in exploring viral and vaccine immunology in the setting of immunosuppression.

Rachel Jacqueline Friedman-Moraco, M.D., recently joined the Division of Infectious Diseases at Emory University focused on transplant infections and HIV care and is an Assistant Professor of Medicine at Emory University School of Medicine. She completed her undergraduate education at the University of Michigan and medical school and Wayne State University in Detroit. She completed post-graduate training at Emory University.

George Lyon, III, M.D., attended Marshall University School of Medicine, followed with a fellowship at Massachusetts General Hospital and Brigham and Women’s Hospital. He started practicing at Emory University Hospital in 2003. Dr. Lyon is board certified in Infectious Disease and Internal Medicine, and his areas of clinical interest are AIDS, infectious disease and Lyme disease.

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Emory Cardiothoracic Surgeon Receives Honor from American College of Cardiology

Wednesday, March 20th, 2013

Emory cardiothoracic surgeon Vinod Thourani, MD was recently awarded the W. Proctor Harvey, MD, Young Teacher Award at the 2013 American College of Cardiology’s (ACC) annual meeting. The award recognizes and honors a promising young member of the American College of Cardiology who has distinguished him or herself by dedication and skill in teaching, and to stimulate, as far as possible, continued careers in education.

Thourani is associate director of the Structural Heart and Valve Center in the Emory Heart and Vascular Center. He is known for his research and clinical work in Transcatheter Aortic Valve Replacement (TAVR) and minimally invasive valvular surgery for patients with severe aortic stenosis.

At the ACC, Thourani presented five invited lectures, including the three-year safety and outcomes data on the PARTNER cohort, a trial comparing transcatheter aortic valve replacement with surgical aortic valve replacement in high-risk patients with severe aortic stenosis.

Thourani received his medical degree from Emory University School of Medicine, and completed his internship, residency and fellowship also at Emory.

 

Vinod Thourani, MD, Wins Harvey Young Teacher Award

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GMC Appoints Landis and Michaud to Head Oncology Services

Tuesday, March 19th, 2013

Gwinnett Medical Center (GMC) recently tapped Anthony M. Landis, DO as medical director and Katherine Michaud, MPA, as director for oncology services.

As a member of the GMC medical staff, Dr. Landis has served cancer patients for more than three decades and brings years of clinical research experience and leadership to the hospital system’s oncology services department. He has been a pharmaceutical trial investigator in more than 50 studies and has been affiliated with the Atlanta Regional Community Clinical Oncology Program, the National Cancer Institute and the Georgia Oncology Partners Research & Education Foundation. Dr. Landis has been an active member of the board of directors for the American Cancer Society, eastern chapter since 1984. He is also a member of the Translational Oncology Research International (TORI) network.

In this role, his responsibilities related to oncology include the monitoring of quality and performance improvement information; policy development, review and oversight; and development of subcommittees and their leadership appointment, among others.

Michaud’s career includes 10 years in health administration and operating specialty physician practices including oncology, pulmonology, nephrology, diabetes and nutrition center management and more. Most recently, Michaud led oncology operations for the third largest health system in Maine. Her administrative experience allows her to focus on the further expansion of GMC’s oncology program and its integration into existing services.

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Heart Health Expert and Motivational Speaker “Dr. Dave” Comes to Piedmont

Monday, March 18th, 2013

Board-certified cardiologist David E. Montgomery, M.D., Ph.D., known across the nation as “Dr. Dave,” the heart health expert and motivational speaker, has joined Piedmont Heart Institute.

With a special focus on preventive cardiology, Dr. Montgomery uses medical practice, mass media, seminars and blogging to educate the public about the ever-changing world of medical science and to help uncover tools to achieve optimal health. His community outreach work has earned a number of awards, including the 2011 Dr. Martin Luther King Jr. Humanitarian Award.

Prior to joining Piedmont Heart, Dr. Montgomery was on the hospital staff of Chicago’s Resurrection Medical Center in the medical intensive care unit. His special clinical interests include preventing and treating cardiovascular disease in young adults, athletes and those who are overweight or obese.

Dr. Montgomery is board-certified in both cardiology and internal medicine and brings more than 15 years of education and training to Piedmont Heart. He received his medical degree from Northwestern University Feinberg School of Medicine, where he continued his medical training including an internship and residency in internal medicine as well as clinical and advanced fellowships in cardiology. He also holds a Ph.D. in physiology from the University of Illinois at Chicago College of Medicine.

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