Selective decontamination of the digestive tract helps prevent bacterial infections in the early postoperative period after liver transplant

In liver transplant (LTx) recipients, gut-associated bacterial and fungal organisms produce significant postoperative morbidity and mortality. We sought to assess the role of selective digestive decontamination (SDD) in preventing postoperative infections in a large single-center cohort of liver recipients transplanted under two non-simultaneous protocols. In 212 consecutive patients transplanted between 1/1/91 and 7/31/92, SDD (gentamicin 80 mg, polymyxin B 100 mg, nystatin suspension 10 mL) was employed, starting after induction of anesthesia and continued until POD 21 (SDD Group). In 157 consecutive patients transplanted between 1/1/93 and 12/31/93, SDD was not used (non-SDD Group). Both groups received IV vancomycin and cefotaxime prophylaxis. All culture-positive infections within the first 30 days post-LTx were recorded and classified as bacterial or fungal. Infection-related mortality (patients who died of infectious complications without any technical complication) was recorded. Groups did not differ in patient demographics, United Network for Organ Sharing (UNOS) status, use of veno-venous bypass, total/warm ischemia, or length of ICU stay. Infections developed in fewer SDD patients (56/212; 26%) than non-SDD patients (69/157; 44%) (p<0.001). The incidence of gram-negative infection was less in the SDD group (11% vs. 26%, p<0. 001) as was gram-positive infection (16% vs. 26%, p<0.001). Among patients who developed infection, there was no difference between groups in infections per patient. Primary graft non-function (PNF) developed in 20 SDD patients (7/20 had infections) and 8 non-SDD patients (6/8 had infections) (p=0.06). There were no differences in incidence of fungal infections or of infection-related mortality between groups. In the SDD group, there were fewer abdominal (p<0. 001), lung (p<0.001), wound (p<0.01), and urinary tract infections (p<0.05). CONCLUSION: Use of SDD in liver recipients early after transplant was associated with significantly fewer infections in the early postoperative period.     

Tacrolimus-associated mutism after orthotopic liver transplantation

BACKGROUND: Mutism/speech apraxia has been well documented as a toxic effect of cyclosporine after liver transplantation but has been reported only rarely with tacrolimus. Brain imaging with magnetic resonance or computed tomography has failed to demonstrate abnormalities in affected patients. METHODS: We present the first example of an acute onset of loss of speech associated with a sudden elevation of serum tacrolimus level after successful orthotopic liver transplantation. We also describe the positron emission tomography (PET) scan of this patient's brain. RESULTS: PET scan imaging of the brain was abnormal, demonstrating decreased metabolism in the posterior temporo-parieto-occipital regions. Statistical probability mapping revealed additional areas of hypometabolism in the cingulate gyrus. CONCLUSIONS: PET scan revealed abnormalities of the brain in a patient with tacrolimus-induced mutism. The cingulate gyrus may play a role in the mutism/speech apraxia syndrome seen with cyclosporine/tacrolimus neurotoxicity.     

Mesoatrial shunt in Budd-Chiari syndrome

BACKGROUND: The operations with proven effects on survival in Budd-Chiari syndrome are shunt operations and liver transplantation. PATIENTS AND METHODS: Between 1993 and 1999 (June), 13 cases of Budd-Chiari syndrome have been treated surgically. Four cases had concomitant thrombosis of the inferior vena cava; the others had marked narrowing of the lumen due to the enlarged caudate lobe. Mesoatrial (n = 12) or mesosuperior vena caval (n = 1) shunts were constructed with ringed polytetrafluoroethylene grafts. RESULTS: The median portal pressure fell from 45 (range 32 to 55) to 20 (range 11 to 27) cm H(2)O (P <0.001). Two patients died in the early postoperative period. One patient who did not comply with anticoagulant treatment had a shunt thrombosis in the second postoperative year. The other 10 patients are alive without problems during a median 42 (range 1 to 76) months of follow-up. CONCLUSION: Mesoatrial shunt with a ringed polytetrafluoroethylene graft is effective in Budd-Chiari syndrome cases with thrombosis or significant stenosis in the inferior vena cava.     

Ginkgo biloba extract ameliorates ischemia reperfusion-induced renal injury in rats.

There is increasing evidence to suggest that reactive oxygen metabolites (ROMs) play a role in the pathogenesis of ischemia/reperfusion injury (I/R) in the kidney. This study was designed to determine the possible protective effect of Ginkgo biloba extract (EGb) on renal ischemia/reperfusion (I/R) injury. Wistar albino rats were unilaterally nephrectomized, and 15 days later they were subjected to 45 min of renal pedicle occlusion followed by 6 h of reperfusion. Ginkgo biloba extract (EGb) (50 mg kg(-1) day(-1)) or saline was administered twice, 15 min prior to ischemia and immediately before the reperfusion period. At the end of the treatment period, all rats were decapitated. Kidney samples were taken for histological examination or determination of the renal malondialdehyde (MDA) and glutathione (GSH) levels, myeloperoxidase (MPO) activity and collagen content. Production of reactive oxidants was monitored by chemiluminescence (CL) assay. Creatinine and urea concentrations in blood were measured for the evaluation of renal function. Tumor necrosis factor-alpha (TNF-alpha) and lactate dehydrogenase (LDH) were also assayed in serum samples. Ischemia/reperfusion caused a significant decrease in GSH level, which was accompanied with significant increases in MDA level, MPO activity and collagen content of kidney tissues. Similarly, serum BUN and creatinine levels, as well as LDH and TNF-alpha, were elevated in the I/R group as compared to control group. On the other hand, EGb treatment reversed all these biochemical indices, as well as histopathological alterations, which were induced by I/R. The findings imply that ROMs play a causal role in I/R-induced renal injury and EGb exerts renoprotective effects probably by the radical scavenging and antioxidant activities.     

A reliable option for wrist soft tissue defects: adipofascial flaps for immediate and late reconstruction

Extensive volar injuries are common and devastating because of the long‐term adhesion potency. The gliding effect of the adipose tissue is essential in preventing tendon adhesions after injury. In this study, we present the results of performing adipofascial flaps for the reconstruction of soft tissue defects following wrist trauma. The study included 15 patients. Adipofascial flaps were performed for immediate coverage of the tissue defect in 2 patients and for late adhesion‐related problems in 13 patients. Flap dimensions varied from 8 × 14 to 8 × 20 cm. All but one of the flaps and skin grafts survived uneventfully. None of the patients, whether immediate or late, required another operation to address further adhesion problems. Since adipofascial flaps provide a gliding surface, they are a good choice for immediate coverage of soft tissue defects in the wrist that are not suitable for skin grafting alone as well as for late adhesion‐related problems.     

Expansion of Patient Education Programming Regarding Live Donor Liver Transplantation via Virtual Group Encounters During the COVID-19 Pandemic

During the coronavirus 2019 pandemic we converted our liver transplant waitlist candidate education and support program to a virtual format and expanded it to include ongoing engagement sessions aimed to educate and empower patients to maximize opportunity for live donor liver transplantation. Over a period of 6 months from April 2020 to Sept 2020 we included 21 patients in this pilot quality improvement program. We collected data regarding patient response and potential donor referral activity. Overall, patient response was positive, and some patients saw progress toward live donor liver transplantation by fostering inquiry of potential live liver donors. Optimization of logistical aspects of the program including program flow, technology access, and utilization is required to enhance patient experience. Long-term follow-up is needed to assess impact on the outcome of transplantation rates. Future data collection and analysis should focus on assessment of any potential disparity that may result from utilization of virtual programming. Herein we provide a framework for this type of virtual program and describe our experience.     

Comparison of patient satisfaction,quality of life,and bite force between elderly edentulous patients wearing mandibular two implant‐supported overdentures and conventional complete dentures after 4 years

This study compared two groups of patients who were elderly and edentulous, one group included subjects who had mandibular overdentures supported by two implants (Group I); the other groups wore conventional complete dentures (Group II). This retrospective study included 100 edentulous patients (50 from each group) with an average age of 67.86 years, who had been followed for 4 years. The groups were compared in terms of patient satisfaction, quality of life (QOL), and bite force. The bite force and patient satisfaction scores of Group I were found to be statistically significantly higher than Group II (p < .05). However, no statistically significant difference was found between the two groups’ QOL scores (p > .05) except on the physical pain subscale (p = .013). Based on these results, it can be concluded that after 4 years of function, subjects wearing mandibular overdentures supported by two implants had higher values for bite force and patient satisfaction scores, but similar QOL scores when compared to conventional complete denture‐wearers.