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Introduction: The occurrence of simultaneous liver kidney transplantation has greatly increased; however, the ideal induction and maintenance immunosuppression remains unknown. Question: This evaluation aimed to determine if corticosteroid only induction in simultaneous liver kidney transplant recipients provided adequate prophylaxis against rejection when compared to basiliximab. Design: This was a single center, retrospective, cohort study of adult simultaneous liver kidney transplant recipients from June 2010 to June 2019 receiving corticosteroid only (N = 41) or basiliximab (N = 42) induction. Results: Liver or kidney biopsy proven acute rejection at 3 months was comparable between the corticosteroid only and basiliximab groups (10% vs 7%, P = .67), which persisted through 12 months posttransplant (15% vs 21%, P = .42). The occurrence of any infection at 3 months was increased in the corticosteroid only group relative to the basiliximab group (41% vs 21%, P = .049). Graft and patient survival at 12 months were similar between groups. Maintenance immunosuppression was overall minimized with a tacrolimus goal of 6-8 ng/mL, mycophenolate mofetil dose reduction to 1000 mg/day by 3 months, and early steroid withdrawal in both groups. Conclusion: Our findings suggested that corticosteroid only induction was an effective strategy for preventing rejection in simultaneous liver kidney transplant recipients, even in combination with reduced maintenance immunosuppression.

The aim of this review was to review the ethical and multidisciplinary clinical challenges facing trauma surgeons when resuscitating patients presenting with penetrating brain injury (PBI) and multicavitary trauma.While there is a significant gap in the literature on managing PBI in patients presenting with multisystem trauma, recent data demonstrate that resuscitation and prognostic features for such patients remains poorly described, with trauma guidelines out of date in this field.We reviewed a combination of recent multidisciplinary evidence-informed guidelines for PBI and coupled this with expert opinion from trauma, neurosurgery, neurocritical care, pediatric and transplant surgery, surgical ethics and importantly our community partners.Traditional prognostic signs utilized in traumatic brain injury may not be applicable to PBI with a multidisciplinary team approach suggested on a case-by-case basis. Even with no role for neurosurgical intervention, neurocritical care, and neurointerventional support may be warranted, in parallel to multicavitary operative intervention. Special considerations should be afforded for pediatric PBI. Ethical considerations center on providing the patient with the best chance of survival. Consideration of organ donation should be considered as part of the continuum of patient, proxy and family-centric support and care. Community input is crucial in guiding decision making or protocol establishment on an institutional level.Support of the patient after multicavitary PBI can be complex and is best addressed in a multidisciplinary fashion with extensive community involvement.

Introduction: After the pilot study demonstrated safety of the Sernova Cell Pouch (SCP) , we modified islet transplantation (ITx) conditions for improved engraftment in the SCP. Methods: SCPs were implanted in the abdominal anterior rectus sheath of 7 patients with T1DM and problematic hypoglycemia. Immunosuppression was initiated 1 month after SCP implantation and a marginal dose ITx of highly purified islets 1 month later. A second ITx was scheduled 6 to 12 months later. Sentinel SCPs are explanted for histopathology 3 months after ITx. Graft function is monitored by blood glucose (BG) , C-peptide and insulin usage. Results: Seven patients underwent 27 study-related surgeries with wound infection in 2 (7.4%) patients after SCP implantation. One patient discontinued following device excision and the second patient’s infection resolved. SCPs are well tolerated with implant durations exceeding 35 months. Three patients received two ITx into SCPs, resulting in new, measurable islet function documented by detectable levels of stimulated C-peptide. A supplemental, single intraportal ITx was sufficient for the first two patients to achieve ongoing insulin independence and freedom from severe hypoglycemic events for over 22 and 4 months with HbA1c 5.4 and 5.5%, respectively. The third patient discontinued insulin support 2 months after a single supplemental intraportal ITx and presented normal blood glucose control during MMTT on post-transplant day 75 with fasting and peak values of 97 and 142mg/ml, respectively, serum C-peptide of 1. and 3.39 ng/ml and HbA1c of 5.8%. The other three patients on study are progressing as planned. All have received SCP implants and at least one ITx. Conclusion: ITx with SCP demonstrates long-term safety and efficacy in an early subset of trial patients. Ongoing results for transplanted SCPs have led to procedural adjustments to further optimize clinical outcomes. Disclosure P.J.Bachul: None. L.H.Philipson: Advisory Panel; Nevro Corp., Research Support; Dompé, Novo Nordisk, provention BIo. R.Barth: None. J.Fung: n/a. P.Witkowski: Advisory Panel; Sernova, Corp., Vertex Pharmaceuticals Incorporated. A.Perez-gutierrez: None. B.Juengel: None. K.Golab: None. L.Basto: None. L.Perea: None. L.Wang: None. M.Tibudan: None. C.Thomas: None.

Background: Since response to COVID-vaccine among transplant recipients remains diminished comparing to general population, we decided to assess effect of COVID-specifically among islet transplant patients. Methods: Response to COVID-infection and vaccine was assessed in a cohort of 20 islet transplant recipients: N=13 after islet transplant alone (ITx) , N=7 with islet after kidney (IAK) or pancreas after islet transplantation (PAI) . The median age was 48 years (25-62) . Maintenance immunosuppression included tacrolimus and an antimetabolite in addition to 5mg of Prednisone in IAK and PAI recipients. Nine patients received booster. Results: Seven patients (38%) chose not to be vaccinated and 4 (57%) of them remained COVID-free with no SARS-CV-2 Spike total antibody (Spike ab) present in their blood. The other three patients (43%) developed only mild symptoms of infection with a high level of Spike ab (>2,500 U/ml) afterwards. In contrast, all remaining 13 patients (62%) , who were vaccinated while on immunosuppression for a median of 7 years (0.5-16) , remained COVID-free (p=0.11, Fischer) . The level of Spike ab in response to vaccine varied: undetected- (N=4) , in range 1-100U/ml (N=6) , around 400U/ml (N=2) , and above 2,500U/ml (N=1) . Presence of 5mg of Prednisone did not affect the outcomes. Booster was administered in patients and increased the level of Spike ab above 100U/ml in all of them, in 7 (78%) to over 2,500 U/ml. One patient responded neither to vaccine nor to booster. There were no SAEs related to the vaccination or booster. Islet graft function remained stable in all but one patient after initial vaccination or COVID-19. Conclusion: Nearly half of unvaccinated islet transplant recipients developed Covid-19, however, all of them presented only with mild symptoms. In contrast, none of vaccinated transplant patients developed COVID-infection with 69% rate of seroconversion. Booster increased level of the Spike ab in those patients who responded to the original vaccination. Disclosure B.Juengel: None. P.Witkowski: Advisory Panel; Sernova, Corp., Vertex Pharmaceuticals Incorporated. P.J.Bachul: None. A.Perez-gutierrez: None. L.Basto: None. L.Perea: None. L.Wang: None. M.Tibudan: None. R.Barth: None. J.Fung: n/a. Funding NIDDK P30 DK020595

There is much controversy regarding enhanced recovery for recipients of liver transplants from deceased and living donors. The objectives of this Review were to summarise current knowledge on individual enhanced recovery elements on short-term outcomes, identify key components for comprehensive pathways, and create internationally accepted guidelines on enhanced recovery for liver-transplant recipients. The ERAS4OLT.org collaborative partnered by the International Liver Transplantation Society performed systematic literature reviews on the effect of 32 relevant enhanced perioperative recovery elements on short-term outcomes, and global specialists prepared expert statements on deceased and living donor liver transplantation. The Grading Recommendations, Assessment, Development and Evaluations approach was used for rating of quality of evidence and grading of recommendations. A virtual international consensus conference was held in January, 2022, in which results were presented, voted on by the audience, and discussed by an independent international jury of eight members, applying the Danish model of consensus. 273 liver transplantation specialists from 30 countries prepared expert statements on elements of enhanced recovery for liver transplantation based on the systematic literature reviews. The consensus conference yielded 80 final recommendations, covering aspects of enhanced recovery for preoperative assessment and optimisation, intraoperative surgical and anaesthetic conduct, and postoperative management for the recipients of liver transplants from both deceased and living donors, and for the living donor. The recommendations represent a comprehensive overview of the relevant elements and areas of enhanced recovery for liver transplantation. These internationally established guidelines could direct the development of enhanced recovery programmes worldwide, allowing adjustments according to local resources and practices.

This paper identifies possible pitfalls of simulation modeling and suggests ways to prevent them. First, we specify five typical pitfalls that are associated with the process of applying simulation models and characterize the "logic of failure" (D��rner 1996) behind the pitfalls. Then, we illustrate important aspects of these pitfalls using examples from applying simulation modeling to military and managerial decision making and present possible solutions to them. Finally, we discuss how our suggestions for avoiding them relate to current methodological discussions found in the social simulation community.