Detection of early allograft dysfunction at 30 min of reperfusion in liver transplantation: An intraoperative diagnostic tool with real time assessment of graft function.

INTRODUCTION: During the anhepatic phase of liver transplantation (LT), fibrinolytic activity increases, since the liver clears tissue plasminogen activator (tPA). We hypothesize that patients who fail to reduce fibrinolytic activity following graft reperfusion will have an increased rate of early allograft dysfunction (EAD). METHODS: Assessment of fibrinolysis in liver transplant recipients was quantified with thrombelastography (TEG) LY30. Changes in LY30 were assessed after graft reperfusion. The 30-min post-reperfusion LY30 was subtracted from the anhepatic LY30 quantifying fibrinolytic changes (delta-LY30). RESULTS: Seventy-three primary LT patients were included in the analysis. Receiver operating characteristic curve (ROC) analysis identified an inflection point of delta-LY30-5.3% as a risk factor for EAD. EAD occurred in 44% of these patients compared to 5% in high delta-LY30 (p = 0.002). CONCLUSION: LT recipients that develop hyperfibrinolysis who fail to reduce fibrinolytic activity 30 min after graft reperfusion had an EAD rate 8-fold higher than patients who had a large reduction in LY30 following reperfusion.

The need for harmonisation and innovation of neuropsychological assessment in neurodegenerative dementias in Europe: consensus document of the Joint Program for Neurodegenerative Diseases Working Group.

Cognitive, behavioural, and functional assessment is crucial in longitudinal studies of neurodegenerative dementias (NDD). Central issues, such as the definition of the study population (asymptomatic, at risk, or individuals with dementia), the detection of change/decline, and the assessment of relevant outcomes depend on quantitative measures of cognitive, behavioural, and functional status.Currently, we are far from having available reliable protocols and tools for the assessment of dementias in Europe. The main problems are the heterogeneity of the tools used across different European countries, the lack of standardisation of administration and scoring methods across centres, and the limited information available about the psychometric properties of many tests currently in widespread use. This situation makes it hard to compare results across studies carried out in different centres, thus hampering research progress, in particular towards the contribution to a "big data" common data set.We present here the results of a project funded by the Joint Program for Neurodegenerative Diseases (JPND) and by the Italian Ministry of Health. The project aimed at providing a consensus framework for the harmonisation of assessment tools to be applied to research in neurodegenerative disorders affecting cognition across Europe. A panel of European experts reviewed the current methods of neuropsychological assessment, identified pending issues, and made recommendations for the harmonisation of neuropsychological assessment of neurodegenerative dementias in Europe.A consensus was achieved on the general recommendations to be followed in developing procedures and tools for neuropsychological assessment, with the aim of harmonising tools and procedures to achieve more reliable data on the cognitive-behavioural examination. The results of this study should be considered as a first step to enhancing a common view and practise on NDD assessment across European countries.

Aging in two languages: Implications for public health.

With the population aging and a dramatic increase in the number of senior citizens, public health systems will be increasingly burdened with the need to deal with the care and treatment of individuals with dementia. We review evidence demonstrating how a particular experience, bilingualism, has been shown to protect cognitive function in older age and delay onset of symptoms of dementia. This paper describes behavioral and brain studies that have compared monolingual and bilingual older adults on measures of cognitive function or brain structure and reviews evidence demonstrating a protective effect of bilingualism against symptoms of dementia. We conclude by presenting some data showing the potential savings in both human costs in terms of demented patients and economic considerations in terms of public money if symptoms of dementia could be postponed.

Pediatric liver transplantation.

PURPOSE OF REVIEW: Pediatric liver transplantation is a challenging and exciting field for all healthcare providers involved with children who have end-stage liver disease. Graft and patient survival continue to improve due to improvements in medical, surgical, and anesthetic management, organ availability, immunosuppression, and identification and treatment of postoperative complications. This review will describe recent advances in pediatric liver transplantation. RECENT FINDINGS: Although pediatric cases only represent approximately 10% of the total patients on the waiting list, the number of deaths on the waiting list increased from 196 to 1753 between 1988 and 1999. Recently, a new pediatric liver allocation policy was instituted. The utilization of cut down "reduced" livers, split liver grafts, and living-related donors has provided more organs for pediatric patients. Newer immunosuppression regimens, including induction therapy, continue to have a significant impact on graft and patient survival. Excellence in peri-operative management and identification and treatment of complications or infections also has had an impact on graft and patient survival. Finally, investigation and analysis of the postoperative quality of life, for both the patient and parents, is being conducted. SUMMARY: Pediatric liver transplantation is a challenging and rewarding field with continued improvements in patient and graft survival. A multidisciplinary team approach coupled with improvements in organ availability, immunosuppression, and peri-operative management has had a dramatic impact on survival.

Impact of pretransplant diagnosis of hepatocellular carcinoma on cadveric liver allocation in the era of MELD.

The allocation system based on the Model for End-stage Liver Disease (MELD) has led to more patients diagnosed with hepatocellular carcinoma (HCC) being transplanted. We hypothesized that more patients misdiagnosed with HCC are also being transplanted, leading to inappropriate organ allocation. Therefore, we retrospectively analyzed all liver transplants at our center from July 14, 2000, to October 22, 2002 (N = 172; 129 pre-MELD, 43 post-MELD), comparing pretransplant HCC diagnosis to explant histology. Thirty patients met the United Network for Organ Sharing (UNOS) diagnostic criteria for pretransplant HCC diagnosis. There were 25 men (median age, 52.5 yr), and 80% had hepatitis C. The proportion of patients transplanted who had an HCC diagnosis increased from 12% (15/129) pre-MELD to 35% (15/43) post-MELD implementation (P < 0.01). Three of 15 (20%) transplanted pre-MELD and 5 of 15 (33%) transplanted post-MELD lacked HCC in the explant (P = 0.10). Of the three false-positives pre-MELD, one was Status 2B already, and two received living-donor livers. Of the 5 false-positives post-MELD, three had score upgrades that led to early transplantation (13 to 29, 20 to 29, and 9 to 24) while two had MELD scores of 35 and 36 already. The percentage of organs that could have gone to patients with more advanced liver disease without HCC increased from 0% (0/129) pre-MELD to 7% (3/43) post-MELD (P < 0.01). Since the implementation of MELD, the proportion of patients transplanted who had an HCC diagnosis nearly tripled, and a small but significant proportion of organs are now going to patients misdiagnosed with HCC. More stringent HCC diagnostic criteria will be required to decrease the effect that misdiagnosis has on organ allocation.

Comprehensive cost comparison of adult-adult right hepatic lobe living-donor liver transplantation with cadaveric transplantation.

BACKGROUND: An important long-term consideration for living-donor liver transplantation (LDLT) is the expense compared with cadaveric-liver transplantation. LDLT is a more complex procedure than cadaveric transplantation and the cost of donor evaluation, donor surgery, and postoperative donor care must be included in a cost analysis for LDLT. In this study, we compare the comprehensive cost of LDLT with that of cadaveric-liver transplantation. METHODS: All costs for medical services provided at our institution were recorded for 24 LDLT and 43 cadaveric recipients with greater than 1 year follow-up transplanted between August 1997 and April 2000. The donor costs include donors evaluated and rejected, donors evaluated and accepted, donor right hepatectomy costs, and donor follow-up costs (365 days postdonation). LDLT and cadaveric recipient costs include medical care 90 days pre-LDLT, recipient transplant costs, and recipient follow-up costs (365 days posttransplant) including retransplantation. Cost is expressed as an arbitrary cost unit (CU) that is a value between $500 to $1,500. RESULTS: Total LDLT costs (evaluations of rejected donors+evaluations of accepted donors+donor hepatectomy+donor follow-up care for 1 year+pretransplant recipient care [90 days pretransplant]+recipient transplantation+recipient 1-year posttransplant care)= 162.7 CU. Total mean cadaveric transplant costs (pretransplant recipient care [90 days pretransplant]+recipient transplantation [including organ acquisition cost]+recipient 1-year posttransplant care)= 134.5 CU, (P =ns). CONCLUSIONS: The total comprehensive cost of LDLT is 21% higher than cadaveric transplantation, although this difference is not significant.