Outcomes of Technical Variant Liver Transplantation versus Whole Liver Transplantation for Pediatric Patients: A Meta-Analysis

Objective

To overcome the shortage of appropriate-sized whole liver grafts for children, technical variant liver transplantation has been practiced for decades. We perform a meta-analysis to compare the survival rates and incidence of surgical complications between pediatric whole liver transplantation and technical variant liver transplantation.

Methods

To identify relevant studies up to January 2014, we searched PubMed/Medline, Embase, and Cochrane library databases. The primary outcomes measured were patient and graft survival rates, and the secondary outcomes were the incidence of surgical complications. The outcomes were pooled using a fixed-effects model or random-effects model.

Results

The one-year, three-year, five-year patient survival rates and one-year, three-year graft survival rates were significantly higher in whole liver transplantation than technical variant liver transplantation (OR = 1.62, 1.90, 1.65, 1.78, and 1.62, respectively, p<0.05). There was no significant difference in five-year graft survival rate between the two groups (OR = 1.47, p = 0.10). The incidence of portal vein thrombosis and biliary complications were significantly lower in the whole liver transplantation group (OR = 0.45 and 0.42, both p<0.05). The incidence of hepatic artery thrombosis was comparable between the two groups (OR = 1.21, p = 0.61).

Conclusions

Pediatric whole liver transplantation is associated with better outcomes than technical variant liver transplantation. Continuing efforts should be made to minimize surgical complications to improve the outcomes of technical variant liver transplantation.     

Outcomes of Renal Transplantation in HIV-1 Associated Nephropathy

Introduction

Several studies have demonstrated that renal transplantation in HIV positive patients is both safe and effective. However, none of these studies have specifically examined outcomes in patients with HIV-associated nephropathy (HIVAN).

Methods

Medical records of all HIV-infected patients who underwent kidney transplantation at Johns Hopkins Hospital between September 2006 and January 2014 were reviewed. Data was collected to examine baseline characteristics and outcomes of transplant recipients with HIVAN defined pathologically as collapsing focal segmental glomerulosclerosis (FSGS) with tubulo-interstitial disease.

Results and Discussion

During the study period, a total of 16 patients with HIV infection underwent renal transplantation. Of those, 11 patients were identified to have biopsy-proven HIVAN as the primary cause of their end stage renal disease (ESRD) and were included in this study. They were predominantly African American males with a mean age of 47.6 years. Seven (64%) patients developed delayed graft function (DGF), and 6 (54%) patients required post-operative dialysis within one week of transplant. Graft survival rates at 1 and 3 years were 100% and 81%, respectively. Acute rejection rates at 1 and 3 years were 18% and 27%, respectively. During a mean follow up of 3.4 years, one patient died.

Conclusions

Acute rejection rates in HIVAN patients in this study are higher than reported in the general ESRD population, which is similar to findings from prior studies of patients with HIV infection and ESRD of various causes. The high rejection rates appear to have no impact on short or intermediate term graft survival.     

Current Trainee and Workforce Patterns for Thyroid and Parathyroid Surgery in the United States

ObjectiveThyroid and parathyroid surgery is performed by both general surgeons and otolaryngologists. We describe the proportion of surgeries performed by specialty, providing data to support decisions about when and to whom to direct research, education, and quality improvement interventions.MethodsWe tabulated case numbers for privately insured patients undergoing thyroid and parathyroid surgery in Marketscan: 2010–2016 and trainee case logs for residents and fellows in general surgery and otolaryngology. Summary statistics and tests for trends and differences were calculated.ResultsMarketscan data captured 114 500 thyroid surgeries. The proportion performed by each specialty was not significantly different. Otolaryngologists performed 58 098 and general surgeons performed 56 402. Otolaryngologists more commonly performed hemithyroidectomy (n = 25 148, 43.29% of all thyroid surgeries performed by otolaryngologists) compared to general surgeons (n = 20 353, 36.09% of all thyroid surgeries performed by general surgeons). Marketscan data captured 21 062 parathyroid surgeries: 6582 (31.25%) were performed by otolaryngologists, and 14 480 (68.75%) were performed by general surgeons. The case numbers of otolaryngology and general surgery trainees completing residency and fellowship varied 6- to 9-fold across different sites. The wide variation may reflect both the level of exposure a particular training program offers and trainee level of interest.ConclusionThyroid surgical care is equally provided by general surgeons and otolaryngologists. Both specialties contribute significantly to parathyroid surgical care. Both specialties should provide input into and be targets of research, quality, and education interventions.     

Immunologic Predictors of Liver Transplantation Outcomes in HIV-HCV Co-Infected Persons

Liver disease is a leading cause of mortality among HIV-infected persons in the highly active anti-retroviral therapy (HAART) era. Hepatitis C Virus (HCV) co-infection is prevalent in, and worsened by HIV; consequently many co-infected persons require liver transplantation (LT). Despite the need, post-LT outcomes are poor in co-infection. We examined predictors of outcomes post-LT. Immunologic biomarkers of immune activation, microbial translocation, and Th1/Th2 skewing were measured pre-LT in participants enrolled in a cohort of HIV infected persons requiring solid organ transplant (HIVTR). Predictive biomarkers were analyzed in Cox-proportional hazards models; multivariate models included known predictors of outcome and biomarkers from univariate analyses. Sixty-nine HIV-HCV co-infected persons with available pre-LT samples were tested: median (IQR) CD4+ T-cell count was 286 (210–429) cells mm^-3; 6 (9%) had detectable HIV RNA. Median (IQR) follow-up was 2.1 (0.7–4.0) years, 29 (42%) people died, 35 (51%) had graft loss, 22 (32%) were treated for acute rejection, and 14 (20%) had severe recurrent HCV. In multivariate models, sCD14 levels were significantly lower in persons with graft loss post-LT (HR 0.10 [95%CI 0.02–0.68]). IL-10 levels were higher in persons with rejection (HR 2.10 [95%CI 1.01–4.34]). No markers predicted severe recurrent HCV. Monocyte activation pre-LT may be mechanistically linked to graft health in HIV-HCV co-infection.     

Patterns and drivers for wetland connections in the Prairie Pothole Region,United States

Ecosystem function in rivers, lakes and coastal waters depends on the functioning of upstream aquatic ecosystems, necessitating an improved understanding of watershed-scale interactions including variable surface-water flows between wetlands and streams. As surface water in the Prairie Pothole Region expands in wet years, surface-water connections occur between many depressional wetlands and streams. Minimal research has explored the spatial patterns and drivers for the abundance of these connections, despite their potential to inform resource management and regulatory programs including the U.S. Clean Water Act. In this study, wetlands were identified that did not intersect the stream network, but were shown with Landsat images (1990–2011) to become merged with the stream network as surface water expanded. Wetlands were found to spill into or consolidate with other wetlands within both small (2–10 wetlands) and large (>100 wetlands) wetland clusters, eventually intersecting a stream channel, most often via a riparian wetland. These surface-water connections occurred over a wide range of wetland distances from streams (averaging 90–1400 m in different ecoregions). Differences in the spatial abundance of wetlands that show a variable surface-water connection to a stream were best explained by smaller wetland-to-wetland distances, greater wetland abundance, and maximum surface-water extent. This analysis demonstrated that wetland arrangement and surface water expansion are important mechanisms for depressional wetlands to connect to streams and provides a first step to understanding the frequency and abundance of these surface-water connections across the Prairie Pothole Region.     

Patterns of success in game bird introductions in the United States

Better predictions of the success of species’ introductions require careful evaluation of the relative importance of at least three kinds of factors: species characteristics, characteristics of the site of introduction, and event-level factors such as the numbers of individuals released. (Henceforth, we call this propagule pressure.) The 1644 introductions of 17 Phasianid species released in various US states during the Foreign Game Investigation Program provides a particularly rich source of data to test these ideas. An examination of these records indicates that 13 of these 17 species always failed, despite generally numerous individual releases and large numbers of individuals in each release. Moreover, ten of these species have been successfully introduced elsewhere. Only four of the 17 species were successful in at least one state. Some 20 sets of releases of three of these four species always failed in some states, again given generally numerous individual releases of large numbers of individuals in each release. Simply, the combination of site and species factors explain the lack of successes. This leaves a combination of 18 states where one or more of the four species succeeded. For these, there are significant differences in the numbers of birds introduced from state to state. But only for two species Alectoris chukar and; Tetraogallus himalayensis are there significant differences that show a greater chance of success when more individuals are introduced. These results support the conclusion that the number of individuals released, meaning propagule pressure, is not as important as characteristics of the species and the location to where its introduction occurred.     

Monitoring Sub-Saharan African Physician Migration and Recruitment Post-Adoption of the WHO Code of Practice: Temporal and Geographic Patterns in the United States

Data monitoring is a key recommendation of the WHO Global Code of Practice on the International Recruitment of Health Personnel, a global framework adopted in May 2010 to address health workforce retention in resource-limited countries and the ethics of international migration. Using data on African-born and African-educated physicians in the 2013 American Medical Association Physician Masterfile (AMA Masterfile), we monitored Sub-Saharan African (SSA) physician recruitment into the physician workforce of the United States (US) post-adoption of the WHO Code of Practice. From the observed data, we projected to 2015 with linear regression, and we mapped migrant physicians’ locations using GPS Visualizer and ArcGIS. The 2013 AMA Masterfile identified 11,787 active SSA-origin physicians, representing barely 1.3% (11,787/940,456) of the 2013 US physician workforce, but exceeding the total number of physicians reported by WHO in 34 SSA countries (N = 11,519). We estimated that 15.7% (1,849/11,787) entered the US physician workforce after the Code of Practice was adopted. Compared to pre-Code estimates from 2002 (N = 7,830) and 2010 (N = 9,938), the annual admission rate of SSA émigrés into the US physician workforce is increasing. This increase is due in large part to the growing number of SSA-born physicians attending medical schools outside SSA, representing a trend towards younger migrants. Projection estimates suggest that there will be 12,846 SSA migrant physicians in the US physician workforce in 2015, and over 2,900 of them will be post-Code recruits. Most SSA migrant physicians are locating to large urban US areas where physician densities are already the highest. The Code of Practice has not slowed the SSA-to-US physician migration. To stem the physician “brain drain”, it is essential to incentivize professional practice in SSA and diminish the appeal of US migration with bolder interventions targeting primarily early-career (age ≤ 35) SSA physicians.     

Fall Migration and Habitat Use of American Woodcock in the Central United States

Abstract: Little is known about the migration ecology of the American woodcock (Scolopax minor). From 2001 to 2003, we began a 3-year study to document woodcock fall migration routes, rates, and habitat use from Minnesota, Wisconsin, and Michigan, USA. Some 586 radiomarked woodcock initiated migration. During 224 hours of aerial telemetry, we located 42 radiomarked woodcock in 6 states. Using locations of radiomarked birds, we speculated woodcock migration routes in the central United States. Stopover duration often exceeded 4 days, with some birds stopping longer than a week. Radiomarked birds were located in upland habitats more frequently than bottomland habitats, and used a higher proportion of mature forest than expected. A Geographic Information System was used to map potential woodcock habitat in the Central Region. Based on our results, we identified possible fall migration routes and priority areas for woodcock management in the Central Region. Our results should be used by land managers to prioritize future land acquisition and management of woodcock habitat.     

Focus: Bioethics: Cannabis Use Patterns and Related Health Outcomes Among Spanish Speakers in the United States and Internationally

Cannabis and health research continue to largely ignore the usage patterns, perceptions, and medically related use in Spanish-speaking communities. The primary aim of this study was to collect data among Spanish-speaking communities on cannabis use that specifically characterizes granular demographic information, medically motivated and recreational use patterns including potency of products, medical motivations for use, and what perceptions are held as to risks and benefits. Secondarily, exploratory analyses were made to investigate potential effects of location or acculturation status. Five hundred forty-nine individuals completed the survey, including 294 residing in the United States (US) (M_age=31.8, SD=9.72; 154 women, 137 men, 3 non-binary and self-described individuals), 174 residing outside of the US (International) (M_age=26.6, SD=8.75; 77 women, 96 men, 1 non-binary and self-described individuals), and 81 who did not report country of residence (Unknown location) (M_age=26.7, SD=7.37; 17 women, 61 men, 3 non-binary and self-described individuals). Overall use was mostly recreational, while the US group was significantly more motivated by medical or combined medical and recreational reasons than the other two groups (p=0.02). The most common reason for medical use was anxiety or depression (14% of sample). The US group also smoked or vaporized significantly more often than the other two groups and was more likely to include daily users (p<0.001). The sample generally viewed the effects of cannabis use more favorably than negatively, but there were significant differences in these views between users and non-users. The rich heterogeneity suggested by these data belies the importance of taking an equity focused approach to cannabis research and will help to improve representation in the field.     

原位肝移植术后急性肺损伤的相关因素的临床分析

目的：探讨肝移植后急性肺损伤（ALI）的相关因素,为肝移植术后ALI的预防和治疗提供参考。方法：回顾性分析了2005年1月-2010年10月在我院行肝移植术的98例患者的临床资料,对术后并发ALI的相关因素进行分析。结果：98例行肝移植术后发生ALI12例,发生率为12．24％。单因素分析显示年龄、术前血清TBIL、术中失血量、术中尿量和术后血BUN对ALI的发生有显著影响（P〈0．05）。多因素Logistic回归法分析表明,术中失血量、术前TBIL、年龄为术后并发ALI的危险因素。结论：术中失血量、术前TBIL、年龄为术后并发ALI的危险因素,对上述因素加以重点评估和合理控制,可以控制肝移植术后ALI的发生。     

肝移植术后急性肾功能衰竭的相关因素的临床分析

目的：探讨肝移植术后并发急性肾功能衰竭（ARF）的相关因素,为肝移植术后ARF的预防和治疗提供参考。方法：回顾性分析了2005年1月-2010年10月在我院行肝移植术的98例患者的临床资料,对术后并发ARF的相关因素进行分析。结果：98例行肝移植术后发生ARF13例,发生率为13．27％。单因素分析显示术前血尿素氮CBUN）、术前血清肌酐（Scr）、术前血清白蛋白（Alb）、手术时间、失血量与ARF的发生有关（P〈0．05）。多因素Logistic回归法分析表明,术前Ser和BUN是肝移植术后并发ARF的危险因素。结论：术前血BUN、血清Scr、血清Alb、手术时间和失血量是肝移植术后并发ARF主要因素,而术前Scr和BUN水平升高是肝移植术后并发ARF的危险因素。对上述因素加以重点评估和合理控制,可以控制肝移植术后ARF的发生。     

原位肝移植术后急性肺损伤的相关因素的临床分析

目的:探讨肝移植后急性肺损伤(ALI)的相关因素,为肝移植术后ALI的预防和治疗提供参考。方法:回顾性分析了2005年1月~2010年10月在我院行肝移植术的98例患者的临床资料,对术后并发ALI的相关因素进行分析。结果:98例行肝移植术后发生ALI12例,发生率为12.24%。单因素分析显示年龄、术前血清TBIL、术中失血量、术中尿量和术后血BUN对ALI的发生有显著影响(P<0.05)。多因素Logistic回归法分析表明,术中失血量、术前TBIL、年龄为术后并发ALI的危险因素。结论:术中失血量、术前TBIL、年龄为术后并发ALI的危险因素,对上述因素加以重点评估和合理控制,可以控制肝移植术后ALI的发生。     

肝移植术后急性肾功能衰竭的相关因素的临床分析

目的:探讨肝移植术后并发急性肾功能衰竭(ARF)的相关因素,为肝移植术后ARF的预防和治疗提供参考。方法:回顾性分析了2005年1月~2010年10月在我院行肝移植术的98例患者的临床资料,对术后并发ARF的相关因素进行分析。结果:98例行肝移植术后发生ARF 13例,发生率为13.27%。单因素分析显示术前血尿素氮(BUN)、术前血清肌酐(Scr)、术前血清白蛋白(Alb)、手术时间、失血量与ARF的发生有关(P<0.05)。多因素Logistic回归法分析表明,术前Scr和BUN是肝移植术后并发ARF的危险因素。结论:术前血BUN、血清Scr、血清Alb、手术时间和失血量是肝移植术后并发ARF主要因素,而术前Scr和BUN水平升高是肝移植术后并发ARF的危险因素。对上述因素加以重点评估和合理控制,可以控制肝移植术后ARF的发生。     

Effectiveness and Outcomes of Current Practice in Treating Vitamin D Deficiency in Patients Listed for Liver Transplantation

Objective: Vitamin D deficiency is prevalent in cirrhotic patients awaiting liver transplantation (LT). Optimal vitamin D management for these patients remains undefined. We sought to determine the effectiveness of our practice in addressing vitamin D deficiency in LT patients.Methods: This retrospective study included 127 patients who received a first LT between July 2010 and July 2011. Outcomes measured included readmission rates, fractures, and functional status post-LT. 25-Hydroxyvitamin D (25-OH D) deficiency was stratified as: mild (20–30 ng/mL), moderate (15–19.9 ng/mL), and severe (<15 ng/mL). We estimated the amount of vitamin D supplementation required for each patient.Results: At LT evaluation, 107 patients (84%) had vitamin D deficiency, and 74% remained vitamin D deficient at LT. Only 62% received vitamin D supplementation pre-LT. Moderate and severe deficiencies were less common at LT and rare 4 months post-LT. There was an association between improvement in vitamin D deficiency category at LT and increased vitamin D (>400,000 IU total) supplementation (P = .004). We found no association between vitamin D deficiency at LT and functional status, fractures, or readmissions post-LT. Patients receiving induction immunosuppressant therapy with basiliximab had a significantly greater degree of worsening in bone mineral density (BMD) post-LT.Conclusion: Moderate-to-severe vitamin D deficiency was very prevalent in a cohort of patients undergoing evaluation for LT. Deficiency was improved with increased vitamin D replacement therapy. Vitamin D deficiency at LT was not associated with worse bone or functional outcomes post-LT. The influence of basiliximab on bone health post-LT requires further evaluation.Abbreviations: 25-OH D = 25-hydroxyvitamin D BMD = bone mineral density BMI = body mass index CI = confidence interval LT = liver transplantation MELD = Model for End-Stage Liver Disease PTH = parathyroid hormone     

Patterns of Early Cretaceous molluscan diversity gradients in south-central United States

During the maximum trangression of the Early Cretaceous sea into the Western Interior of the central United States, species diversity decreased from south to north. Maximum bivalve, gastropod. and cephalopod diversities occurred where lagoonal. basinal, and near-shore deposits intertongue. Mollusk diversities are low in the southern reefal deposits. Infaunal suspension-feeding and detritus-feeding gastropods and bivalves are most diverse in the northern nearshore areas, while epifaunal bivalves and carnivorous gastropods characterize the southern reefal areas. Noded-ribbed ammonoids are most diverse in the transitional area between the reefs, while nearshore substrates and smooth-flanked forms characterize the nearshore area. In the reefal area. the variety of ammonoid types is much reduced. This Early Cretaceous (Washitian Stage, mainly upper Albian) gradient is the result of a northward reduction in both habitat variability and predictability of limiting factors such as salinity and resources. This diversity gradient indicates that marine benthic communities in the Gulf Coast were structurally complex, whcreas those of the Western Interior were relatively simple.