The Evolution of Redo Liver Transplantation Over 35 Years: Analysis of 654 Consecutive Adult Liver Retransplants at a Single Center.

OBJECTIVE: To examine liver retransplantation (ReLT) over 35 years at a single center. BACKGROUND: Despite the durability of liver transplantation (LT), graft failure affects up to 40% of LT recipients. METHODS: All adult ReLTs from 1984 to 2021 were analyzed. Comparisons were made between ReLTs in the pre versus post-model for end-stage liver disease (MELD) eras and between ReLTs and primary-LTs in the modern era. Multivariate analysis was used for prognostic modeling. RESULTS: Six hundred fifty-four ReLTs were performed in 590 recipients. There were 372 pre-MELD ReLTs and 282 post-MELD ReLTs. Of the ReLT recipients, 89% had one previous LT, whereas 11% had ≥2. Primary nonfunction was the most common indication in the pre-MELD era (33%) versus recurrent disease (24%) in the post-MELD era. Post-MELD ReLT recipients were older (53 vs 48, P = 0.001), had higher MELD scores (35 vs 31, P = 0.01), and had more comorbidities. However, post-MELD ReLT patients had superior 1, 5, and 10-year survival compared with pre-MELD ReLT (75%, 60%, and 43% vs 53%, 43%, and 35%, respectively, P < 0.001) and lower in-hospital mortality and rejection rates. Notably, in the post-MELD era, the MELD score did not affect survival. We identified the following risk factors for early mortality (≤12 months after ReLT): coronary artery disease, obesity, ventilatory support, older recipient age, and longer pre-ReLT hospital stay. CONCLUSIONS: This represents the largest single-center ReLT report to date. Despite the increased acuity and complexity of ReLT patients, post-MELD era outcomes have improved. With careful patient selection, these results support the efficacy and survival benefit of ReLT in an acuity-based allocation environment.

Management of Patients After Treatment of Severe Alcohol-associated Hepatitis.

Alcohol-associated liver disease is the leading indication for hospitalization among patients with chronic liver disease. Rates of hospitalization for alcohol-associated hepatitis have been rising over the last 2 decades. Patients with alcohol-associated hepatitis carry significant morbidity and mortality, but there is a lack of standardized postdischarge management strategies to care for this challenging group of patients. Patients warrant management of not only their liver disease but also their alcohol use disorder. In this review, we will discuss outpatient management strategies for patients who were recently hospitalized and discharged for alcohol-associated hepatitis. We will discuss short management of their liver disease, long-term follow-up, and review-available treatment options for alcohol use disorder and challenges associated with pursuing treatment for alcohol use disorder.

Role of Biomarkers to Assess the Use of Alcohol.

Alcohol-associated liver disease has seen a significant rise in the last 2 decades, with an associated rise in the need for accurate alcohol use assessment. Alcohol use has been associated with poor outcomes in both the pre-liver transplant and post-liver transplant patients. Patients with alcohol use disorder often under-report their alcohol consumption because of varying factors, highlighting the need for objective assessment of alcohol use. Aside from the available self-report questionnaires, multiple serologic biomarkers are currently available to assist clinicians to assess recent alcohol consumption among patients with chronic liver disease, liver transplant candidates, and recipients. In this review, we will assess some of these alcohol biomarkers, discuss their strengths and weakness, and review-available data to discuss their role in pre-liver transplant and post-liver transplant population.

Survival following liver transplantation for locally advanced, unresectable intrahepatic cholangiocarcinoma.

Intrahepatic cholangiocarcinoma (iCCA) has previously been considered a contraindication to liver transplantation (LT). However, recent series showed favorable outcomes for LT after neoadjuvant therapy. Our center developed a protocol for neoadjuvant therapy and LT for patients with locally advanced, unresectable iCCA in 2010. Patients undergoing LT were required to demonstrate disease stability for 6 months on neoadjuvant therapy with no extrahepatic disease. During the study period, 32 patients were listed for LT and 18 patients underwent LT. For transplanted patients, the median number of iCCA tumors was 2, and the median cumulative tumor diameter was 10.4 cm. Patients receiving LT had an overall survival at 1-, 3-, and 5-years of 100%, 71%, and 57%. Recurrences occurred in seven patients and were treated with systemic therapy and resection. The study population had a higher than expected proportion of patients with genetic alterations in fibroblast growth factor receptor (FGFR) and DNA damage repair pathways. These data support LT as a treatment for highly selected patients with locally advanced, unresectable iCCA. Further studies to identify criteria for LT in iCCA and factors predicting survival are warranted.

Early Liver Transplantation for Severe Alcohol-Associated Hepatitis and a History of Prior Liver Decompensation.

INTRODUCTION: In the published studies of early liver transplantation (LT) for alcohol-associated hepatitis (AH), patients with a prior liver decompensation are excluded. The appropriateness of this criteria is unknown. METHODS: Among 6 American Consortium of Early Liver Transplantation for Alcohol-Associated Hepatitis sites, we included consecutive early LT for clinically diagnosed AH between 2007 and 2020. Patients were stratified as first vs prior history of liver decompensation, with the latter defined as a diagnosis of ascites, hepatic encephalopathy, variceal bleeding, or jaundice, and evidence of alcohol use after this event. Adjusted Cox regression assessed the association of first (vs prior) decompensation with post-LT mortality and harmful (i.e., any binge and/or frequent) alcohol use. RESULTS: A total of 241 LT recipients (210 first vs 31 prior decompensation) were included: median age 43 vs 38 years ( P = 0.23), Model for End-Stage Liver Disease Sodium score of 39 vs 39 ( P = 0.98), and follow-up after LT 2.3 vs 1.7 years ( P = 0.08). Unadjusted 1- and 3-year survival among first vs prior decompensation was 93% (95% confidence interval [CI] 89%-96%) vs 86% (95% CI 66%-94%) and 85% (95% CI 79%-90%) vs 78% (95% CI 57%-89%). Prior (vs first) decompensation was associated with higher adjusted post-LT mortality (adjusted hazard ratio 2.72, 95% CI 1.61-4.59) and harmful alcohol use (adjusted hazard ratio 1.77, 95% CI 1.07-2.94). DISCUSSION: Prior liver decompensation was associated with higher risk of post-LT mortality and harmful alcohol use. These results are a preliminary safety signal and validate first decompensation as a criterion for consideration in early LT for AH patients. However, the high 3-year survival suggests a survival benefit for early LT and the need for larger studies to refine this criterion. These results suggest that prior liver decompensation is a risk factor, but not an absolute contraindication to early LT.

Current treatment options for nonalcoholic fatty liver disease.

PURPOSE OF REVIEW: Nonalcoholic fatty liver disease (NAFLD) is the leading cause of liver disease in the United States and is strongly associated to the metabolic syndrome. In this review, we will discuss the evidence behind the current recommendations on lifestyle modifications and available treatment options for NAFLD. RECENT FINDINGS: The unrelenting rise in obesity and diabetes epidemic has led to a large healthcare burden from NAFLD and it is projected to continue to grow over the next two decades. Lifestyle modification that leads to weight loss is effective at treating NAFLD, but these modifications require a multidisciplinary approach for success in the real world. Multiple pharmacologic treatment options have been studied with promising results, but none have been approved for treatment in the United States. Clinical trials are on-going to study further pharmacologic treatment alternatives. SUMMARY: NAFLD is the most common chronic liver disease in United States, and an independent risk factor for mortality. Implementation of lifestyle modifications through a multidisciplinary approach and careful selection of patients for pharmacologic interventions will be essential for successful management of NAFLD.

Use of Hepatitis C-Positive Liver Grafts in Hepatitis C-Negative Recipients.

As the demand for liver transplantation continues to rise, the scarcity of liver donor grafts has led to the use of extended criteria grafts for liver transplantation in select group of patients. Hepatitis C-seropositive liver grafts have been used primarily in hepatitis C-positive recipients, with studies showing non-inferior outcomes when compared to hepatitis C-negative grafts. Studies suggest that hepatitis C serology status of the donor liver does not influence the patient or graft outcomes in the recipient. These results advocate for offering hepatitis C-positive grafts to all patients awaiting liver transplantation regardless of their hepatitis C status. However, some concerns persist regarding the ethics of potentially introducing a new infection into a patient that could progress to chronic liver disease following liver transplantation. The recent approval of direct-acting antiviral therapy offers a solution to this dilemma, as it has changed the landscape of hepatitis C management by making it a curable disease. In this review, we shall discuss the current evidence regarding the use of hepatitis C-seropositive donor grafts in hepatitis C-positive and hepatitis C-negative patients.

Efficacy of PRF vs PRF + Biodegradable Collagen Plug in Post-extraction Preservation of Socket.

AIM: To compare the clinical sequelae of the efficacy of PRF vs PRF + collagen plug in soft tissue healing and preservation of the socket width, height, and bone density in patients reporting for extractions of maxillary or mandibular anterior or posterior teeth and patients who desired replacement of teeth with dental implants in future. MATERIALS AND METHODS: The study included 54 patients who were divided randomly into 3 groups consisting of 18 patients in each group: in group I, no preservation of extraction socket; in group II, PRF was used; and in group III, PRF + collagen plug was used for preservation of extraction socket. Assessment of the soft tissue healing, bone density, bone height, and width was done on 1st, 8th, 12th, and 16th weeks, postoperatively. RESULT: Both PRF and PRF + Collaplug are comparable to each other in preserving the bone height, bone density, and also similar soft tissue healing; however PRF + Collaplug is better than PRF alone in preserving the bone width 4th month postoperatively, indicating that the resorbable Collaplug® does play an additional role in preserving the socket width. CONCLUSION: PRF + Collaplug® has better clinical outcome in socket preservation in comparison to PRF alone. However, as results were not statistically significant, subjecting a larger sample size with PRF + Collaplug® for socket preservation may result in statistical critical values to substantiate our observations. CLINICAL SIGNIFICANCE: PRF and Collaplug® can help in ridge preservation after extraction and also avoid additional bone grafting procedures in future implant placement for the patients. How to cite this article: Ahmed N, Gopalakrishna V, Shetty A, et al. Efficacy of PRF vs PRF + Biodegradable Collagen Plug in Post-extraction Preservation of Socket. J Contemp Dent Pract 2019;20(11):1323-1328.

Clinical, endoscopic, and histologic characteristics of lymphocytic esophagitis: a systematic review.

OBJECTIVE: Lymphocytic esophagitis (LyE) is a novel, yet poorly described, clinicopathologic entity. The aim of this systematic review was to characterize the demographic, clinical, endoscopic, and histologic features of LyE in observational studies of adult and pediatric patients. DESIGN: We searched the Embase, MEDLINE, and SCOPUS databases for relevant studies in 2018. Two authors reviewed and extracted data from studies that met the inclusion and exclusion criteria. RESULTS: We identified 20 studies for analysis of demographic, clinical, and endoscopic features of LyE. The mean age ranged from 9 to 67 years. When pooled, there were 231 (52.7%) patients with LyE that were female. The most common presenting symptom was dysphagia reported in 191 (48.8%) patients. On endoscopy, most patients with LyE tended to have abnormal findings (69.0%), which included erosive esophagitis, multiple esophageal rings, linear furrows, and narrow-caliber esophagus. In the 31 studies used to assess the histologic definition, the cut-off number of intraepithelial lymphocytes (IELs) was reported in 16 (51.6%) studies, peripapillary IEL specification in 18 (58.1%) studies, and presence of spongiosis in 6 (19.4%) studies. CONCLUSION: We identified a spectrum of demographic, clinical, and endoscopic findings characteristic of patients with LyE. A consensus on the diagnostic criteria of LyE is required.

Role of the Circadian Clock in the Metabolic Syndrome and Nonalcoholic Fatty Liver Disease.

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in industrialized nations and is strongly associated with the metabolic syndrome. The prevalence of NAFLD continues to rise along with the epidemic of the metabolic syndrome. Metabolic homeostasis is linked to the circadian clock (rhythm), with multiple signaling pathways in organs regulated by circadian clock genes, and recent studies of circadian clock gene functions suggest that disruption of the circadian rhythm is associated with significant morbidity and mortality, including the metabolic syndrome. In the industrialized world, various human behaviors and activities such as work and eating patterns, jet lag, and sleep deprivation interfere with the circadian rhythm, leading to perturbations in metabolism and development of the metabolic syndrome. In this review, we discuss how disruption of the circadian rhythm is associated with various metabolic conditions that comprise the metabolic syndrome and NAFLD.

Social Impact of Hepatic Encephalopathy.

Hepatic encephalopathy is a medical condition that stems from liver dysfunction, leading to the accumulation of toxins in the bloodstream. This can result in cognitive impairments, mood changes, and motor dysfunction. Its social impact includes challenges in employment, relationships, and daily functioning for affected individuals. Stigma and misunderstanding around the condition can further exacerbate the difficulties faced by both patients and their caregivers. Efforts to raise awareness, improve medical management, and provide support systems can help mitigate the social impact of hepatic encephalopathy.

Cost effectiveness of hepatitis C direct acting agents.

INTRODUCTION: Introduction of direct acting antivirals (DAA) has transformed treatment of chronic hepatitis C (HCV) and made the elimination of HCV an achievable goal set forward by World Health Organization by 2030. Multiple barriers need to be overcome for successful eradication of HCV. Availability of pan-genotypic HCV regimens has decreased the need for genotype testing but maintained high efficacy associated with DAAs. AREAS COVERED: In this review, we will assess the cost-effectiveness of DAA treatment in patients with chronic HCV disease, with emphasis on general, cirrhosis, and vulnerable populations. EXPERT OPINION: Multiple barriers exist limiting eradication of HCV, including cost to treatment, access, simplified testing, and implementing policy to foster treatment for all groups of HCV patients. Clinically, DAAs have drastically changed the landscape of HCV, but focused targeting of vulnerable groups is needed. Public policy will continue to play a strong role in eliminating HCV. While we will focus on the cost-effectiveness of DAA, several other factors regarding HCV require on going attention, such as increasing public awareness and decreasing social stigma associated with HCV, offering universal screening followed by linkage to treatment and improving preventive interventions to decrease spread of HCV.

Versatility of Titanium Mesh in Comminuted Maxillofacial Fractures. A Retrospective Study.

Background: Titanium mesh provides three-dimensional stability, it is easier and quick in placement, highly malleable and adaptable hence, proved to be worth in restoring the function and form in cases of comminuted maxillofacial fractures. Materials and Methods: A total of 12 patients were included in this retrospective study at Department of Oral and maxillofacial surgery, Sri Rajiv Gandhi College of Dental Science and Hospital, from December 2015 to June 2020. Out of 12 patients, 7 reported with frontal bone fracture and 5 reported with mandibular fracture. Patients were followed up for upto 18 months to evaluate efficacy of titanium mesh on postoperative long-term healing, aesthetic outcomes and return to normal function were evaluated. Results: The results have shown that titanium mesh has low complication rates and the ability to maintain occlusion and chewing postoperatively. Union occurred without complication in 90% of fractures, and patients treated for frontal bone fracture had excellent cosmetic results. Conclusion: The semi rigid nature of the titanium mesh fixation allows micro movement at the healing bone ends, reduces stress shielding effect which may improve functional bone healing. Bony continuity of the mandible can be restored providing three-dimensional morphology and stability. The versatile placement of screws is the principal advantage.

Impact of phosphatidylethanol in the surveillance for alcohol use in post-liver transplant population: A retrospective study.

BACKGROUND: Alcohol-related liver disease (ALD) is the leading indication for liver transplantation in the United States. The aim of this study was to describe the impact of phosphatidylethanol (PEth) in the surveillance for alcohol use after liver transplantation. METHODS: We conducted a single-center retrospective study to assess the impact of phosphatidylethanol (PEth) for the surveillance of alcohol use and its correlation to health outcomes. We compared orthotopic liver transplant (OLT) recipients for ALD transplanted between 2016 and 2018, before the introduction of PEth, to those transplanted between 2019 and 2022, after the introduction of PEth. Alcohol relapse versus nonrelapse cohorts were also compared. Follow-up time for all cohorts was limited to 3 years post-OLT. Continuous variables were analyzed with an independent t-test and categorical variables with Fischer's exact test and chi-square test. The Kaplan-Meier method and log-rank test were used to assess alcohol-free survival. RESULTS: We reviewed 263 patients who were transplanted for ALD; 46 (17.5%) patients were noted to have at least one episode of alcohol relapse after their transplant. Patients with alcohol relapse had more frequent episodes of elevated liver enzymes compared with nonrelapsed patients (4.35 episodes vs. 2.46 episodes respectively, p < 0.001). The number of hospitalizations was also noted to be elevated among relapsed versus nonrelapsed patients; however, this was not statistically significant (2.85 vs. 2.50 respectively, p = 0.307). When comparing relapse rates before and after the introduction of PEth, relapses were notably detected more frequently after the introduction of PEth (17% vs. 7%, p = 0.012). No difference was noted in rates of mortality between patients who did or did not relapse. CONCLUSIONS: Overall, PEth is an effective surveillance tool in the postliver transplant population to monitor for alcohol relapse. Early detection of relapse can lead to opportunities for early intervention to avoid alcohol-related complications.

Complications of Conventional Sinus Augmentation Techniques Versus Modified Osteotome Techniques in Dental Implant Surgery: A 3-Year Retrospective Clinical Study.

Introduction: Sinus Augmentation has proven to be a predictable and popular approach to overcome bone volume deficiency in the posterior maxilla for patients seeking dental implants. The most common surgical methods utilized for maxillary sinus augmentations are the lateral window approach and crestal osteotome technique, which may cause many complications like sinus membrane tear, bleeding, sinusitis, etc. the purpose of this study is to compare complications rates of different sinus lift techniques in dental implant surgery. Aims and Objective: To assess the intraoperative and postoperative complications between the conventional direct or indirect method with alternative sinus lift techniques using Modified Crestal and Lateral (CAS & LAS KIT) ®method (Osstem/Hiossen). Materials and Methods: This is a retrospective study where in all the sinus lift cases done during 3year duration in the center data was collected and analyzed a total of 61 sinus lift procedure was done and all the data is tabulated and analyzed. Results: Results show of the total 61 cases 25 (40%) male patients and 36(59%)female patients traditional techniques like summers osteotome and conventional direct or indirect method had 7 cases (33.3%-37.5%) complication rates compared to Modified Lateral osteotome had 2 complications (14.2%) & Modified Crestal osteotome had only 3 case(3.7%) infections, wound dehiscence, membrane tear etc. Conclusion: Modified Crestal & Lateral Osteotome (CAS KIT & LAS KIT) ® technique does reduce the incidence of complications like sinus membrane tear compared to conventional Direct and Indirect techniques, because of stopper system used in hydraulic lift and the special design of drill head of these instruments.

Comparative Evaluation of Efficacy of EMLA Versus Ice as Topical Anesthetic in Prior to Needle Prick in Palatine Nerve Blocks-A Randomized Split Mouth Study EMLA Versus Ice as Topical Anesthetic in Dental Nerve Blocks.

Background and Objectives: The study aims to evaluate the pain efficacy of EMLA versus ice in palatine nerve blocks undergoing extraction. Materials and Methods: A prospective randomized study, single-blind, split-mouth study carried out on a total of 20 healthy individuals needing extraction of bilateral maxillary teeth under local anesthesia referred to our department in the university from March 2021 to April 2022. Patients were randomly categorized into two groups: Group E (5% EMLA) and Group I (ice application), with 20 operative sites, respectively. In the study, the VAS-pain and satisfaction score and SEM score were analyzed. Statistical analysis was done using SPSS version 20.0 software using the Mann-Whitney U test. Results: Study results showed that 13 patients were men and 7 were women whose ages ranged from 46 ± 18 years. Statistical analysis of pain on the VAS scale showed that the mean score for Group E and Group I were 2.3 ± 0.47 and 3.2 ± 0.41(mean ± SD), respectively, which was statistically significant (P < 0.001). On the statistical analysis of the SEM scale for Group E and Group I, the mean score was 1.00 ± 0.00 and 1.25 ± 0.44426 (mean ± SD), respectively, which was statistically significant (P < 0.018). Conclusion: EMLA and ice were both good topical anesthetics each with advantages and disadvantages in clinical use. Each clinician needs to weigh the pros and cons of the different available methods and expenses to determine what type of anesthetic to use for each particular case during treatment.

Evaluation and Comparison of Impact Strength and Transverse Strength of Heat Polymerized Polymethylmethacrylate (PMMA) Denture Base Resin Repaired Using Heat Polymerizied PMMA Denture Base Resin, Auto-Polymerized PMMA Resin and A New Light Polymerizied Denture Resin: An In Vitro Study.

Context: Repaired denture prosthesisdemands adequate transverse and impact strength. A new repairdenture base resin- "Lukafix" require to fulfil these criteria. Aims: This study evaluates and compares the transverse and impact strength of heat polymerizing, auto polymerizing and LUKAfix denture resin. Methods and Material: 20 specimens were control(without repair), and other were test specimens which were fractured and repaired with heat polymerized PMMA resin, chemically polymerized PMMA resin and LUKAfix light polymerizing denture resin. Each group wasdivided in two subgroups. Subgroup A was subjected to transverse strength test and subgroup B to impact strength test. Statistical Analysis Used: One way ANOVA was used to identify the mean difference among the four groups. Post-Hoc-Bonferroni was done to observe the difference between the groups. Results: Maximum transverse strength was observed in specimens repaired with heat polymerized (48.33 ± 9.19) and least in LUKAfix denture resin (6.56 ± 1.15). Also, impact strength was maximum for heat polymerized (3.64 ± 0.41) followed by LUKAfix denture resin (2.34 ± 0.44). Conclusions: Repair with LUKAfix denture resin resulted inferior transverse and impact strength as compared to heat polymerized PMMA resin.