Graft Inflow Modulation by Splenic Artery Ligation for Portal Hyper Perfusion does not Decrease Rates of Early Allograft Dysfunction in Adult Live Donor Liver Transplantation: A Randomized Control Trial.

OBJECTIVE: The primary objective was to compare the rates of early allograft dysfunction (EAD) in patients undergoing elective adult live donor liver transplantation (ALDLT) with and without graft portal inflow modulation (GIM) for portal hyper-perfusion. The secondary objectives were to compare time to normalization of bilirubin and International Normalized Ratio (INR), day 14 ascitic output more than 1liter, small-for-size syndrome (SFSS), intensive care unit / high dependency unit and total hospital stay, and 90 day morbidity and mortality. BACKGROUND: GIM can prevent EAD in ALDLT patients with portal hyper-perfusion. METHODS: A single-center randomized trial with and without GIM for portal hyper-perfusion by splenic artery ligation (SAL) in ALDLT was performed. After reperfusion, patients with portal venous pressure (PVP)>15 mm Hg with a gradient (PVP - central venous pressure) of ≥ 7 mm Hg and/or portal venous flow (PVF)>250 mL/min/100 grams of liver were randomized into two groups: GIM and No GIM. RESULTS: 75 of 209 patients satisfied the inclusion criteria, and 38 underwent GIM. Baseline PVF and PVP were comparable between the GIM and no GIM groups. SAL significantly reduced the PVF and PVP (P<0.001). There were no differences in the primary and secondary outcomes between the two groups. In the subgroup analysis, with a Graft to Recipient Weight Ratio (GRWR)≤0.8, there were no significant differences in the primary and secondary outcomes. CONCLUSION: SAL significantly decreased PVP and PVF, but did not decrease rates of EAD in adult LDLT.

Temporary Portocaval Shunt Provides Superior Intraoperative Hemodynamics and Reduces Blood Loss and Duration of Surgery in Live Donor Liver Transplantation: A Randomized Control Trial.

OBJECTIVE: To compare intraoperative hemodynamic parameters, blood loss, renal function, and duration of surgery with and without temporary portocaval shunt (TPCS) in live donor liver transplantation (LT) recipients. Secondary objectives were postoperative early graft dysfunction, morbidity, mortality, total intensive care unit, and hospital stay. BACKGROUND: Blood loss during recipient hepatectomy for LT remains a major concern. Routine use of TPCS during LT is not yet elucidated. METHODS: This study is a single-center, open-label, randomized control trial. The sample size was calculated based on intraoperative blood loss. After exclusion, a total of 60 patients, 30 in each arm (TPCS vs no TPCS) were recruited in the trial. RESULTS: The baseline recipient and donor characteristics were comparable between the groups. The median intraoperative blood loss ( P = 0.004) and blood product transfusions ( P < 0.05) were significantly less in the TPCS group. The TPCS group had significantly improved intraoperative hemodynamics in the anhepatic phase as compared with the no TPCS group ( P < 0.0001), requiring significantly less vasopressor support. This led to significantly better renal function as evidenced by higher intraoperative urine output in the TPCS group ( P = 0.002). Because of technical simplicity, the TPCS group had significantly fewer inferior vena cava injuries (3.3 vs 26.7%, P = 0.026) and substantially shorter hepatectomy time and total duration of surgery (529.4 ± 35.54 vs 606.83 ± 48.13 min, P < 0.0001). The time taken for normalization of lactate in the immediate postoperative period was significantly shorter in the TPCS group (median, 6 vs 13 h; P = 0.04). Although postoperative endotoxemia, major morbidity, 90-day mortality, total intensive care unit, and hospital stay were comparable between both groups, tolerance to enteral feed was earlier in the TPCS group. CONCLUSIONS: In live donor LT, TPCS is a simple and effective technique that provides superior intraoperative hemodynamics and reduces blood loss and duration of surgery.

e-GLR Score Predicts Early Graft Loss in Adult Live-Donor Liver Transplantation.

Objective: This study aimed to analyze risk factors and develop a predictive model for early allograft loss due to early graft dysfunction (EGD) in adult live-donor liver transplantation (LDLT). Methods: Data of patients who underwent LDLT from 2011 to 2019 were reviewed for EGD, associated factors, and outcomes. A homogeneous group of 387 patients was analyzed: random cohort A (n = 274) for primary analysis and random cohort B (n = 113) for validation. Results: Of 274 recipients, 92 (33.6%) developed EGD. The risk of graft loss within 90 days was 29.3% and 7.1% in those with and without EGD, respectively (P < 0.001). Multivariate logistic regression analysis determined donor age (P = 0.045), estimated (e) graft weight (P = 0.001), and the model for end-stage liver disease (MELD) score (0.001) as independent predictors of early graft loss due to EGD. Regression coefficients of these factors were employed to formulate the risk model: Predicted (P) early graft loss risk (e-GLR) score = 10 × [(donor age × 0.052) + (e-Graft weight × 1.681) + (MELD × 0.145)] - 8.606 (e-Graft weight = 0, if e-Graft weight ≥640 g and e-Graft weight = 1, and if e-Graft weight < 640 g). Internal cross-validation revealed a high predictive value (C-statistic = 0.858). Conclusions: Our novel risk score can efficiently predict early allograft loss following graft dysfunction, which enables donor-recipient matching, evaluation, and prognostication simply and reliably in adult LDLT.

Efficacy of rectal indomethacin in prevention of post-operative hyperamylasemia following pancreatoduodenectomy: a randomized controlled trial.

BACKGROUND: Post-operative hyperamylasemia (POH) following pancreatoduodenectomy (PD) may play a key role in pathogenesis of post-operative pancreatic fistula (POPF). Aim of the current study was to evaluate efficacy of perioperative administration of indomethacin in preventing POH. METHODS: Single-center, double-blind, randomized controlled trial (RCT) conducted on consecutive patients undergoing PD. Patients received either 100 mg of indomethacin per-rectally at induction of anesthesia or standard care. Primary endpoint was incidence of POH in the two arms. POH was defined as postoperative day (POD) 1 serum amylase (S. amylase) levels greater than the upper limit of normal. RESULTS: After exclusion 44 patients were randomized. The two arms were comparable for preoperative and intraoperative parameters. POH was noted in 20/44 (45.5%) with significantly lower incidence of POH (60.9% vs. 28.6%, p = 0.032) in intervention arm (IA). Median S. amylase, POD 1, 3, and 5 drain amylase, and incidence of clinically relevant POPF (CR-POPF) were lower in IA but failed to reach statistical significance (30.4% vs. 14.3%, p = 0.18). The severity of delayed gastric emptying (DGE) was significantly lower in the IA (grade B/C DGE 23.8% vs. 47.8%, p = 0.023). Evaluation of risk factors for POH showed IA to confer an independent protective effect and increased risk with soft pancreas. CONCLUSION: Perioperative per-rectal indomethacin administration is effective in decreasing the incidence of POH following pancreatoduodenectomy.

Early drain removal after live liver donor hepatectomy is safe - a randomized controlled pilot study.

INTRODUCTION: The current study aimed to assess the safety of early drain removal after live donor hepatectomy (LDH). METHODS: One hundred eight consecutive donors who met the inclusion criteria were randomized to early drain removal (EDR - postoperative day (POD) 3 - if serous and the drain bilirubin level was less than 3 mg/dl - "3 × 3" rule) and routine drain removal (RDR - drain output serous and less than 100 ml). The primary outcome was to compare the safety. The secondary outcome was to compare the postoperative morbidity. RESULTS: Preoperative, intraoperative, and postoperative parameters except for the timing of drain removal were comparable. EDR was feasible in 46 out of 54 donors (85.14%) and none required re-intervention after EDR. There was significantly better pain relief with EDR (p = 0.00). Overall complications, pulmonary complications, and hospital stay were comparable on intention-to-treat analysis. However, pulmonary complications (EDR - 1.9% vs RDR - 16.3% P = 0.030), overall complications (18.8% vs 36.3%, P = 0.043), and hospital stay (8 vs 9, P = 0.014) were more in the RDR group on per treatment analysis. Bile leaks were seen in three donors (3.7% in the EDR group vs 1.9% in RDR, P = 0.558), and none of them required endo-biliary interventions. Re-exploration for intestinal obstruction was required for 3 donors in RDR (0% vs 5.7%; p = 0.079). CONCLUSION: EDR by the "3 × 3" rule after LDH is safe and associated with better pain relief. On per treatment analysis, EDR was associated with significantly less hospital stay and lower pulmonary and overall complications. CLINICAL TRIAL REGISTRY: Clinical Trials.gov - NCT04504487.

Live donor liver transplantation for pediatric acute liver failure: challenges and outcomes.

OBJECTIVE: This study aimed at studying the challenges and outcomes of live-donor liver transplantation (LDLT) for pediatric acute liver failure (PALF). STUDY DESIGN: A total of 315 patients with PALF were treated over a period of 11 years. 42 underwent LT (41 LDLT and one DDLT), constituting 38% (41/110) of all pediatric transplants during this duration. The outcomes of LDLT for PALF were analyzed. RESULTS: All the 41 children who underwent LT met the Kings College criteria (KCC). The etiology was indeterminate in 46.3% (n = 19) children. 75.6% (n = 31) were on mechanical ventilation for grade 3/4 hepatic encephalopathy. There was presence of cerebral edema on a computed tomography scan of the brain in 50% of the children. One-third of our children required hemodynamic support with vasopressors. Systemic inflammatory response syndrome and sepsis were observed in 46.3% and 41.4% of patients, respectively. Post-LDLT 1- and 5-yr patient and graft survival were 75.6% and 70.9%, respectively. The survival in children satisfying KCC but did not undergo LT was 24% (38/161). Vascular and biliary complication rates were 2.4% and 4.8%, respectively. No graft loss occurred because of acute rejection. In multivariate analysis, pre-LT culture positivity and cerebral edema, persistence of brain edema after transplantation, and resultant pulmonary complications were significantly associated with post-LT death. Thirteen (32%) children who underwent plasmapheresis prior to LT had better post-LT neurological recovery, as evidenced by early extubation. CONCLUSION: LDLT for PALF is lifesaving and provides a unique opportunity to time transplantation. Good long-term survival can be achieved, despite the majority of patients presenting late for transplantation. Early referral and better selection can save more lives through timely transplantation.

Management and Outcome of Jeffrey Type 2 Fractures in Paediatric Patients: A Case Series and Review of Literature.

Introduction: Fractures of the radial neck are very uncommon in children, accounting for 5-8.5% of all fractures around the elbow in children, and are sometimes found with dislocation of the elbow joint. Jeffery carefully studied and classified these types of radial neck fractures with displaced radial head into several types. Very few cases with Jeffrey fractures are reported in the literature, and most cases were treated by surgery. Only one case of successful closed reduction and cast and two cases of closed reduction and percutaneous pinning have been reported. Case Report: We report two cases of Jeffery Type 2 fractures treated by an open reduction in an 11-year-old and a 13-year-old boy. We describe the difficulties faced in the reduction of the fracture and the complications that occurred in the patients. Conclusion: Jeffery Type 2 fracture is an uncommon and difficult-to-treat injury with the possible complication of the radial head being turned upside down if treated conservatively. Therefore, prompt recognition and careful reduction are essential in this type of injury.

Rural-Urban Disparities in Patient Care Experiences among Prostate Cancer Survivors: A SEER-CAHPS Study.

BACKGROUND: We sought to evaluate rural-urban disparities in patient care experiences (PCEs) among localized prostate cancer (PCa) survivors at intermediate-to-high risk of disease progression. METHODS: Using 2007-2015 Surveillance Epidemiology and End Results (SEER) data linked to Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, we analyzed survivors' first survey ≥6 months post-diagnosis. Covariate adjusted linear regressions were used to estimate associations of treatment status (definitive treatment vs. none) and residence (large metro vs. metro vs. rural) with PCE composite and rating measures. RESULTS: Among 3779 PCa survivors, 1798 (53.2%) and 370 (10.9%) resided in large metro and rural areas, respectively; more rural (vs. large metro) residents were untreated (21.9% vs. 16.7%; p = 0.017). Untreated (vs. treated) PCa survivors reported lower scores for doctor communication (ß = -2.0; p = 0.022), specialist rating (ß = -2.5; p = 0.008), and overall care rating (ß = -2.4; p = 0.006). While treated rural survivors gave higher (ß = 3.6; p = 0.022) scores for obtaining needed care, untreated rural survivors gave lower scores for obtaining needed care (ß = -7.0; p = 0.017) and a lower health plan rating (ß = -7.9; p = 0.003) compared to their respective counterparts in large metro areas. CONCLUSIONS: Rural PCa survivors are less likely to receive treatment. Rural-urban differences in PCEs varied by treatment status.

Incidence and predictors of alcohol relapse following living donor liver transplantation for alcohol related liver disease.

BACKGROUND: Alcohol relapse after liver transplantation has a negative impact on outcomes. There is limited data on its burden, the predictors, and impact following live donor liver transplantation (LDLT). METHODS: A single-center observational study was carried out between July 2011 and March 2021 for patients undergoing LDLT for alcohol associated liver disease (ALD). The incidence, predictors of alcohol relapse, and post-transplant outcomes were assessed. RESULTS: Altogether 720 LDLT were performed during the study period, 203 (28.19%) for ALD. The overall relapse rate was 9.85% (n = 20) with a median follow-up of 52 months (range, 12-140 months). Sustained harmful alcohol use was seen in 4 (1.97%). On multivariate analysis, pre-LT relapse (P = .001), duration of abstinence period (P = .007), daily intake of alcohol (P = .001), absence of life partner (P = .021), concurrent tobacco abuse before transplant (P = .001), the donation from second-degree relative (P = .003) and poor compliance with medications (P = .001) were identified as predictors for relapse. Alcohol relapse was associated with the risk of graft rejection (HR 4.54, 95% CI: 1.751-11.80, P = .002). CONCLUSION: Our results show that the overall incidence of relapse and rate of harmful drinking following LDLT is low. Donation from spouse and first degree relative was protective. History of daily intake, prior relapse, shorter pretransplant abstinence duration and lack of family support significantly predicted relapse.

Lifestyle Optimization Leads to Superior Liver Regeneration in Live Liver Donors and Decreases Early Allograft Dysfunction in Recipients: A Randomized Control Trial.

INTRODUCTION: The aim of the current randomized control trial was to assess the efficacy of donor lifestyle optimization on liver regeneration and outcome following live donor liver transplantation. METHODS: Live liver donors (LLDs) who were fit with no or minimal steatosis were randomized to receive either a customized low-calorie diet with calorie intake equalling their basal requirement along with exercise for 2 weeks before surgery versus to continue their normal routine lifestyle. Primary objectives were the difference in the day of normalization of serum bilirubin and PT-International normalized ratio and the percentage growth of the liver at postoperative day 7 and 14. Secondary objectives were differences in intraoperative liver biopsy, liver-regeneration markers, blood loss, hospital stay, the complication rate in LLDs, and rates of early graft dysfunction (EGD) in recipients. RESULTS: Sixty-two consecutive LLDs were randomized (28 in intervention vs. 34 in control). Baseline parameters and graft parameters were similar in both groups. LLDs in the intervention arm had significantly decreased calorie intake ( P <0.005), abdominal girth ( P <0.005), BMI ( P =0.05), and weight ( P <0.0005). The mean blood loss ( P =0.038), day of normalization of bilirubin ( P =0.005) and International normalized ratio ( P =0.061), postoperative peak aspartate transaminase ( P =0.003), Alanine transaminase ( P =0.025), and steatosis ( P <0.005) were significantly less in the intervention group. There was significantly higher volume regeneration ( P =0.03) in donors in the intervention arm. The levels of TNF-α, IL-6, and IL-10 levels were significantly higher, while the TGF-ß level was lower in donors in the intervention group. The rate of EGD was significantly higher in recipients in the control group ( P =0.043). CONCLUSION: Lifestyle optimization of LLD is simple to comply with, improves liver regeneration in LLDs, and decreases EGD in recipients, thus can enhance donor safety and outcomes in live donor liver transplantation.

Hepatic artery-related complications after live donor liver transplantation.

BACKGROUND: Hepatic artery-related complications (HARC) after live donor liver transplantation (LDLT) is associated with high morbidity and mortality rate. METHODS: Prospectively maintained data from July 2011 to September 2020 was analyzed for etiology, detection, management, and outcome of HARC. RESULTS: Six hundred fifty-seven LDLT (adult 572/pediatrics 85) were performed during the study period. Twenty-one (3.2%) patient developed HARC; 16 (2.4%) hepatic artery thrombosis (HAT) and 5 (0.76%) non-thrombotic hepatic artery complication (NTHAC). Ninety percent (19/21) HARC were asymptomatic and detected on protocol Doppler. Median time to detection was day 4 (range - 1 to 35), which included 18 early (within 7 days) vs 3 late incidents. Only one pediatric patient had HAT. Seven patients underwent surgical revascularization, 11 had endovascular intervention and 3 with attenuated flow required only systemic anticoagulation. All NTHAC survived without any sequelae. Revascularization was successful in 81% (13/16) with HAT. Biliary complications were seen in 5 (23.8%); four were managed successfully. Overall mortality was 14.8% (3/21). The 1-year and 5-year survival were similar to those who did not develop HARC (80.9% vs 84.2%, p = 0.27 and 71.4% vs 75.19%, p = 0.36 respectively) but biliary complications were significantly higher (23.8% vs 14.2%, p = 0.03). On multivariate analysis, clockwise technique of arterial reconstruction was associated with decreased risk of HAT (1.7% vs 4.1% (p value - 0.003)). CONCLUSION: Technical refinement, early detection, and revascularization can achieve good outcome in patients with HARC after LDLT.

Lessons learned from conceptualising and operationalising the National Adolescent Health Programme or Rashtriya Kishor Swasthya Karyakram's Learning Districts Initiative in six districts of India.

In 2018, WHO with the support of the Ministry of Health and Family Welfare, India and partner organisations launched a Learning Districts Initiative to strengthen the district-level application of the National Adolescent Health Programme and to draw out lessons. An assessment of this initiative from 2019 to 2023 using qualitative and quantitative programme monitoring data from interviews, discussions, observations and data from multiple secondary sources explored the evolution of the concept, the process of securing government agreement, operationalising the initiative and the feasibility, acceptability, effectiveness and the potential of sustainability and replicability within the government health system. As part of the process, WHO developed the concept with partners to address the challenges identified in a Rapid Programme Review requested by the Ministry. The Ministry concurred with the proposed participatory problem identification and problem-solving approach. A review-based process guided the implementation. Local non-government organisations supported District Health Management Units to strengthen planning, implementation and monitoring. An expert in adolescent health provided technical oversight. Three years later in 2022, adolescent health is on district agendas, staff capacity has been built, and clinic and community-based activities are carried out in a structured manner. The Initiative is feasible as it leverages local expertise. Its core interventions are acceptable to government officials. While there are improvements in inputs, processes and outputs, these need to be independently validated. Challenges such as unfilled vacancies, problems in supply procurement, inability of staff to discuss sensitive issues, weak intersectoral convergence and low engagement of adolescents in programme management remain to be addressed. Nevertheless, the overall experience augurs well for the future of the programme.

Outcomes of continent and incontinent external urinary diversion in management of patients with refractory non-malignant lower urinary tract dysfunction.

OBJECTIVE: To evaluate the early and late outcomes of continent and incontinent external urinary diversion in management of patients with refractory non-malignant lower urinary tract dysfunction (LUTD). MATERIALS AND METHODS: The charts of patients with refractory non-malignant LUTD who underwent continent or incontinent external urinary diversion at University of Cincinnati hospitals in the period between March 2012 and December 2019 were retrospectively reviewed. The demographic and baseline characteristics, surgery indications, operative data, early and late outcomes were collected, analyzed, and compared. RESULTS: A total of 78 patients including 55 patients with neurogenic bladder (NGB) and 23 patients with non-neurogenic bladder (non-NGB) refractory non-malignant LUTD were included. Fifty-three patients underwent incontinent urinary diversions (IUD), while 25 patients underwent continent urinary diversions (CUD). During the first 4 postoperative weeks, 53.85% (n=42) of patients developed complications, and the incidence was nonsignificantly higher in patients with NGB than those with non- NGB (56.36% vs 47.83%, p-value=0.490). Fever was exclusively encountered in patients with NGB earlier, while stomal retraction occurred only in patients with non-NGB later. More non- NGB patients had early wound infection. There was an overall improvement of urological symptoms in 52 patients (66.67%), and the rate was non-significantly higher in non-NGB patients than NGB patients (78.26% vs 61.82%, p-value=0.160). Late complications were reported in 47 patients and were more encountered in those with non-NGB than those with NGB (65.22% vs 58.18%). Stomal leakage and stenosis occurred more with CUD than with IUD (52% vs 0% and 28% vs 3.77%, respectively). CONCLUSIONS: External urinary diversion can achieve a reasonable level of urological symptoms control in patients with refractory non-malignant LUTD, but with associated adverse outcomes. Although non-significantly, these complications tend to be higher in patients with IUD and/or NGB during the early postoperative period and higher with CUD and/or non-NGB on the long-term.

Schema and cancer detection rates for transperineal prostate biopsy templates: a review.

Prostate cancer (PCa) is the most common noncutaneous malignancy in men and is the second leading cause of cancer mortality in men in the United States. Current practice requires histopathological confirmation of cancer achieved through biopsy for diagnosis. The transrectal approach for prostate biopsy has been the standard for several decades. However, the risks and limitations of transrectal biopsies have led to a recent resurgence of transperineal prostatic biopsies. Recent studies have demonstrated the transperineal approach for prostate biopsies to be effective, associated with minimal complications and superior in several aspects to traditional transrectal biopsies. While sextant and extended sextant templates are widely accepted templates for transrectal biopsy, there are a diverse set of transperineal biopsy templates available for use, without consensus on the optimal sampling strategy. We aim to critically appraise the salient features of established transperineal biopsy templates.

Neutrophil Lymphocyte Ratio can Preempt Development of Sepsis After Adult Living Donor Liver Transplantation.

Background: Development of sepsis is a major contributor to poor outcomes after liver transplant. The neutrophil-lymphocyte ratio (NLR) is an easily calculable inflammatory biomarker. We aim to utilize NLR to diagnose and predict the onset of sepsis in patients undergoing living donor liver transplants (LDLT). Materials and methods: Analysis of the perioperative course of 314 consecutive adult patients who underwent elective ABO compatible LDLT was done. Patients were divided into two cohorts; those who developed sepsis and a control group. Sepsis was defined by the combination of SIRS and clinical/radiological suspicion of infection. NLR was calculated by dividing the percentage of neutrophils by the percentage of lymphocytes in peripheral blood. Results: ostoperatively, 127 out of 314 patients (40.5%) having at least one episode of sepsis were included in the septic cohort and were compared to the 187 (59.5%) patients in the control group. Demographic and baseline characteristics, including NLR (13.74 ± 0.99 vs. 12.65 ± 0.57, P = 0.294) were comparable preoperatively. The NLR of the septic cohort was significantly higher than the control cohort (15.01 ± 1.67 vs. 9.98 ± 0.63, P = 0.001) 3 days prior to sepsis and remained significantly higher till the day of sepsis. The area under the cover was maximum for NLR 1 day prior to the development of sepsis (r = 0.707) with a sensitivity, specificity, positive predictive value, and negative predictive value of 62.4%, 62.2%, 51.4%, and 72.0%, respectively, at a cutoff of 8.5. Conclusion: NLR is a useful tool in diagnosing and pre-empting development of sepsis in LDLT.

Is Holmium Laser Enucleation of Prostate equally effective in management of benign prostatic hyperplasia patients with either voiding or storage lower urinary tract symptoms? A comparative study.

OBJECTIVE: To evaluate and compare the effectiveness and safety of holmium laser enucleation of prostate (HoLEP) in relieving either voiding or storage lower urinary tract symptoms (LUTS) in benign prostatic hyperplasia (BPH) patients. MATERIALS AND METHODS: The charts of patients with BPH who underwent HoLEP for either predominant voiding or predominant storage LUTS at University of Cincinnati hospitals in the period between February 2015 and December 2020 were retrospectively reviewed and analyzed for changes in voiding symptomatology, storage symptomatology, hematuria, International Prostate Symptom Score (IPSS), peak flow rates (Qmax), presence of detrusor overactivity (DO), and post-voiding residual urine (PVR) from baseline to up to 6 months postoperatively. RESULTS: A total of 132 patients were included in the analysis. Patients were divided into two groups: Group 1 included BPH patients with predominant voiding LUTS (68 Patients) while group 2 involved those with predominant storage LUTS (64 Patients). HoLEP was equally effective in management of both groups with significant improvement in urodynamics study (UDS) parameters, patient voiding and storage symptomatology, and IPSS from preoperatively to up to 6 months postoperatively with relatively low procedure complication rate and postoperative need for medication or procedure. CONCLUSIONS: HoLEP is a safe, effective, and reliable minimally invasive surgical modality that can be relied on for BPH patients with either predominant voiding or predominant storage symptoms with relatively low procedure complicat.

Impact of covid-19 pandemic on quality of life and psychosocial difficulties among liver transplant recipients.

Background: The first wave of the COVID-19 pandemic affected health in all domains i.e., physical, mental, and social aspects. Liver transplant (LT) recipients faced a multitude of challenges during the first wave of lockdown. The aim was to identify the psychosocial difficulties and quality of life during the first year of the pandemic. Methods: A cross-sectional survey was conducted on LT recipients with a predefined structured questionnaire that included clinical, COVID-19 anxiety scale, and Post-Transplant Quality of life questionnaire (pLTQ). Results: A total of 109 patients were studied; with a mean age of 50.5 ± 11.1 years, with a median post-transplant follow-up of 52.4 months and a live donor transplant in the majority (79.8%). Almost all (99.1%) could come to the hospital for regular follow-up, prior to the pandemic. But during the first wave only 57% could maintain planned hospital visits and about 88% could not pursue their regular activities, and 39% missed their routine exercise because of imposed restrictions. Similarly, financial implications were responsible for 4% defaulting from treatment; while 7.3% managed by curtailing supportive drugs (on their own) leading to deranged liver tests in 4.6%; requiring immediate attention. The psychosocial difficulties raised the stress of pandemic (median score 18), and impacted quality of life (mean total pLTQ score 4.7 ± 0.9). Conclusions: For LT recipients, the first wave of COVID-19 pandemic affected their physical, mental, financial, and social wellbeing; in addition to the disease itself. Awareness, psychosocial support, and comprehensive care are some unmet needs for this special group; especially when it is expected that subsequent waves may continue to occur.

Expanding donor pool for live donor liver transplantation: utilization of donors with non-alcoholic steatohepatitis after optimization.

INTRODUCTION: Potential live liver donors with non-alcoholic steatohepatitis (NASH) are rejected upfront for donation in live donor liver transplantation (LDLT). Herein, we share our experience of the feasibility of live liver donation in donors with NASH after successful donor optimization. MATERIALS AND METHODS: Prospectively collected data of 410 consecutive donor hepatectomies from June 2011 to January 2018 were analyzed. RESULTS: During the study period, NASH was diagnosed histopathologically in 17 donors. Four donors were rejected in view of grade 2 fibrosis on histology. Out of remaining 13 donors, six became eligible for donation following lifestyle changes, dietary modifications, and target weight reduction of ≥5%. Reversal of NASH was confirmed on repeat liver biopsy in all the 6 donors. Five out of 6 underwent right lobe (without MHV) donor hepatectomies, while one had left lobe donation. These donors had significantly higher peak bilirubin levels in the immediate post-operative period as compared to other non-NASH donors (4.00 ± 0.32 vs. 2.57 ± 1.77 mg/dL, p = 0.043). In addition, post-hepatectomy normalization of hyperbilirubinemia, if any, was slower in donors with NASH (7 ± 1.3 vs. 5 ± 1.7 days, p = 0.016). However, none of these donors had post-hepatectomy liver failure. All these donors were discharged after an average hospital stay of 8 ± 1.7 days. Their respective recipients had uneventful post-operative courses without complications. Both the recipients and donors are having satisfactory liver functions after 46.7 ± 10.2 months of follow-up. CONCLUSION: Scrupulous selection of live liver donors with NASH can open a door for expanding the organ pool in LDLT after a successful donor optimization program.

KS-DDoS: Kafka streams-based classification approach for DDoS attacks.

A distributed denial of service (DDoS) attack is the most destructive threat for internet-based systems and their resources. It stops the execution of victims by transferring large numbers of network traces. Due to this, legitimate users experience a delay while accessing internet-based systems and their resources. Even a short delay in responses leads to a massive financial loss. Numerous techniques have been proposed to protect internet-based systems from various kinds of DDoS attacks. However, the frequency and strength of attacks are increasing year-after-year. This paper proposes a novel Apache Kafka Streams-based distributed classification approach named KS-DDoS. For this classification approach, firstly, we design distributed classification models on the Hadoop cluster using highly scalable machine learning algorithms by fetching data from Hadoop distributed files system (HDFS). Secondly, we deploy an efficient distributed classification model on the Kafka Stream cluster to classify incoming network traces into nine classes in real-time. Further, this distributed classification approach stores highly discriminative features with predicted outcomes into HDFS for creating/updating models using a new set of instances. We implemented a distributed processing framework-based experimental environment to design, deploy, and validate the proposed classification approach for DDoS attacks. The results show that the proposed distributed KS-DDoS classification approach efficiently classifies incoming network traces with at least 80% classification accuracy.

Early Allograft Dysfunction After Live Donor Liver Transplantation: It's Time to Redefine?

BACKGROUND: An ideal definition of early allograft dysfunction (EAD) after live donor liver transplantation (LDLT) remains elusive. The aim of the present study was to compare the diagnostic accuracies of existing EAD definitions, identify the predictors of early graft loss due to EAD, and formulate a new definition, estimating EAD-related mortality in LDLT recipients. METHODS: Consecutive adult patients undergoing elective LDLT were analyzed. Patients with technical (vascular, biliary) complications and biopsy-proven rejections were excluded. RESULTS: There were 19 deaths due to EAD of a total of 304 patients. On applying the existing definitions of EAD, we revealed their limitations of being either too broad with low specificity or too restrictive with low sensitivity in patients with LDLT. A new definition of EAD-LDLT (total bilirubin >10 mg/dL, international normalized ratio [INR] > 1.6 and serum urea >100 mg/dL, for five consecutive days after day 7) was derived after doing a multivariate analysis. In receiver operator characteristics analysis, an AUC for EAD-LDLT was 0.86. The calibration and internal cross-validation of the new model confirmed its predictability. CONCLUSION: The new model of EAD-LDLT, based on total bilirubin >10 mg/dL, INR >1.6 and serum urea >100 mg/dL, for five consecutive days after day 7, has a better predictive value for mortality due to EAD in LDLT recipients.