The psychology, legality, ethics and medical aspects of organ donation by minors.

Any individual who has not attained the chronological age of legal majority as per national law is termed a minor. The concept of living donation (LD) has always been a subject of ethical debate and further compounding the controversy is the question of LD by minors. The decision for a minor to donate poses a special challenge as it involves a close family unit of parent-child relationship. Such an emotionally loaded situation wherein questions of attachment, perceived duties, moral obligation are likely to cloud a truly informed consent on the part of the minor to donation, who may find themselves in a vulnerable position. Furthermore, a minor's cognitive ability to comprehend the gravity of LD and when required defy parental coercion need to be elucidates before a minor is accepted for LD. Experts have set out stringent conditions which need to be met prior to the exceptional circumstance that a minor is considered for organ donation. Such donations should require parental permission, child's assent and the involvement of a paediatric-trained donor advocacy team. This article debates the question of minors acting as live donors from ethical, medical, psychosocial and legal viewpoints with an aim to present internationally defined circumstances when a minor may morally participate as a LD, thereby laying the foundation for future deliberations in this regard using traditional metrics to juxtapose divergent courses of action.

Propensity score matched analysis and risk stratification of donors with G6PD deficiency in living donor liver transplantation.

INTRODUCTION: Glucose 6 phosphate dehydrogenase (G6PD) deficiency (G6PDd) can trigger hemolysis following surgical stress. Differentiating G6PDd-related post-operative hemolytic episodes (PHE) and post-hepatectomy liver failure may be challenging especially in living donors where donor safety is paramount. We analysed outcomes of our cohort of G6PDd liver donors. METHODS: G6PDd individuals with no evidence of hemolysis were considered as living donors if there was no alternative family donor. Outcomes of G6PDd donors undergoing left lateral/left lobe donation (Group LL) and right lobe donation (Group RL) were compared with non-G6PDd donors matched in a 1:3 ratio using propensity score matching. RESULTS: 59 G6PDd donors (5.8% of 1011) underwent living donor hepatectomy (LiDH) during the study period. LL-G6PDd donors (22.37%) had higher post-operative peak bilirubin level compared to matched controls, but no difference in morbidity or need for post-operative blood transfusion.RL-G6PDd donors (37.63%) had higher peak bilirubin level, morbidity (16.2% vs. 3.6%, p = 0.017) and more post-operative blood transfusion (21.6% vs. 6.4%, p = 0.023) as compared to matched non-G6PDd cohort. Four RL-G6PDd donors (10.8%) developed PHE. Low G6PD activity (15% vs. 40%, p = 0.034) and lower future liver remnant (FLR) (34.3% vs. 37.8%, p = 0.05) were identified as risk factors for PHE. CONCLUSION: We report the largest to-date series of G6PDd individuals undergoing LiDH and confirm the safety of LL donation in G6PDd. Our analysis identifies specific risk factors for PHE and suggests that right lobe LiDH be avoided in individuals with less than 25% G6PD activity when the FLR is less than 36%.

Living Donor Liver Transplantation for Budd-Chiari Syndrome: A Propensity Score-Matched Analysis.

INTRODUCTION: There are unique technical and management challenges associated with living donor liver transplantation (LDLT) for Budd-Chiari Syndrome (BCS). The outcomes of LDLT for BCS in comparison to other indications remain unclear and warrant elucidation. METHODS: Data of 24 BCS patients who underwent LDLT between January 2012 and June 2019 were analyzed. There were 20 adults and 4 children. The early and long-term outcomes of adult LDLT BCS patients were compared to a control group of LDLT patients for other indications and matched using propensity scoring methodology. RESULTS: Primary BCS was observed in 18 (90%) patients. Caval replacement was performed in 7 (35%) patients. Early and late hepatic venous outflow tract (HVOT) complications were seen in 1 (5%) and 3 (15%) patients. Preoperative acute kidney injury was identified as a risk factor for mortality in the BCS cohort (p = 0.013). On comparison, BCS recipients were younger with fewer comorbidities, more large volume ascites and higher rates of PVT. They also had longer cold ischemia time, increased blood loss and transfusion requirements, increased hospital stay, and higher late outflow complications. The 1-year and 3-year survivals were similar to non-BCS cohort (84.2% vs. 94% and 71.3% vs. 91.9%, respectively, log rank test p = 0.09). CONCLUSION: LDLT is a good option for symptomatic BCS who have failed non-transplant interventions. The clinical and risk factor profile of BCS recipients is distinct from non-BCS recipients. By following an algorithmic management protocol, we show on propensity-score matched analysis that outcomes of LDLT for BCS are similar to non-BCS indications.

Ranking list for scientists: From heightening the rat-race to fraying the scientific temper.

Citations and validation of work play a crucial and integral role in a researcher's career. Ranking systems of scientists, on the other hand, potentially scratch and expose the fallible egoistic human face of science, leading to an unhealthy milieu of competition rather than the uplifting one of motivation. We have attempted to highlight and bring to fore these factors in our brief viewpoint. We critically analyze the reasons why ranking systems of scientists, especially in the field of medicine, will shift the focus from advancement of science to advancement of "self."

Outcomes for high-risk hepatoblastoma in a resource-challenged setting.

BACKGROUND: Outcomes of high-risk hepatoblastoma have been dismal, especially in resource-challenged countries where access to chemotherapy and paediatric liver transplantation is limited for the underprivileged. This study aimed to assess the results of treatment of high-risk hepatoblastoma in a tertiary centre, including patients who had non-transplant surgical procedures in the form of extended resection. METHODS: A review of patients with high-risk hepatoblastoma treated between January 2012 and May 2018 was carried out. Perioperative data and long-term outcomes were analysed. RESULTS: Of 52 children with hepatoblastoma, 22 were considered to have high-risk hepatoblastoma (8 girls and 14 boys). The mean(s.d.) age at diagnosis was 35(20) months. Of these 22 children, five died without surgery. Of the remaining 17 who underwent surgery, six had a resection (4 right and 2 left trisectionectomies) and 11 underwent living-donor liver transplantation. Median follow-up was 48 (range 12-90) months. Thirteen of the 17 children were alive at last follow-up and four developed disseminated disease (3 had undergone liver transplantation and 1 liver resection). The overall survival rate at 1, 3 and 5 years was 77, 64 and 62 per cent for the whole cohort with high-risk hepatoblastoma. In children who had surgery, 1-, 3- and 5-year survival rates were 91, 82 and 73 per cent for transplantation and 100, 83 and 83 per cent for resection. There was no difference in survival between the two surgical groups. CONCLUSION: Excellent results in the treatment of high-risk hepatoblastoma are possible, even in resource-challenged countries.

ANTECEDENTES: Los resultados del hepatoblastoma de alto riesgo (high risk hepatoblastoma, HRH) han sido pésimos, especialmente en países con recursos limitados, donde el acceso a la quimioterapia y al trasplante hepático pediátrico es limitado para los menos privilegiados. Este estudio tuvo como objetivo evaluar los resultados del HRH en un centro de tercer nivel, incluyendo a los pacientes que se sometieron a procedimientos quirúrgicos diferentes del trasplante en forma de resecciones extendidas. MÉTODOS: Se realizó una revisión de los pacientes con HRH tratados entre enero del 2012 y mayo de 2018. Se analizaron los datos perioperatorios y los resultados a largo plazo. RESULTADOS: De 52 niños con hepatoblastomas, 22 fueron considerados HRH (8 pacientes del sexo femenino/14 del sexo masculino). La edad media al diagnóstico fue de 35 ± 20 meses. De estos 22 pacientes, cinco fallecieron sin haber sido intervenidos quirúrgicamente. De los 17 restantes que se sometieron a cirugía, en seis se realizaron resecciones (4 trisectorectomías derechas, 2 trisectorectomías izquierdas) y 11 se sometieron a un trasplante de hígado de donante vivo. La mediana de seguimiento fue de 48 meses (12-90 meses). Trece de 17 niños estaban vivos en el último seguimiento, y cuatro habían desarrollado enfermedad diseminada (3 habían sido sometidos a trasplante hepático y 1 a resección hepática). La supervivencia global a 1, 3 y 5 años fue del 77,3%, 63,6% y 62% para toda la cohorte de HRH. Entre los que se sometieron a cirugía, las supervivencias a 1, 3 y 5 años fueron del 90,9%, 81,8% y 72,7% para el trasplante y del 100%, 83,3% y 83,3% para la resección. No hubo diferencia en la supervivencia entre los dos grupos sometidos a cirugía. CONCLUSIÓN: En países con recursos limitados es posible obtener excelentes resultados en el tratamiento de HRH.

Auxiliary partial orthotopic liver transplantation for acute liver failure.

INTRODUCTION: Auxiliary partial orthotopic liver transplantation (APOLT) in acute liver failure acts as a bridge to native liver regeneration with potential for immunosuppression free survival. While technical concerns limit its universal acceptance, the indications in acute liver failure also need to be examined for this procedure to ultimately succeed. CASE HISTORY: We present the case of an eight-month-old girl with cryptogenic acute liver failure who underwent APOLT. She developed postoperative liver dysfunction, most likely owing to the persistence of the diseased native liver, ultimately leading to an orthotopic retransplantation. She remains well on follow-up review. CONCLUSIONS: A tempered approach to selecting patients for APOLT (especially with regard to aetiology of acute liver failure) makes it a safe and effective alternative to orthotopic liver transplantation.

Religious coping and psychological wellbeing in carers of relatives with schizophrenia.

OBJECTIVE: To examine the use of religious coping and its relation to psychological wellbeing in carers of relatives with schizophrenia. METHOD: Sixty carers of patients with an ICD-10 diagnosis of schizophrenia, were assessed on strength of religious belief, perceived burden, religious and other coping strategies and psychological wellbeing. RESULTS: Coping strategies of denial and problem solving, strength of religious belief and perceived burden were significant predictors of wellbeing. CONCLUSION: Strength of religious belief plays an important role in helping family members to cope with the stress of caring for a mentally ill relative. In addition to psychoeducation and problem solving coping, the role of religious coping in enhancing wellbeing of carers needs to be considered in family intervention programmes.