Continuous renal replacement therapy and therapeutic plasma exchange in pediatric liver failure.

Patients with acute liver failure (ALF) and acute on chronic liver failure (ACLF) have significant morbidity and mortality. They require extracorporeal blood purification modalities like continuous renal replacement therapy (CRRT) and therapeutic plasma exchange (TPE) as a bridge to recovery or liver transplantation. Limited data are available on the outcomes of patients treated with these therapies. This is a retrospective single-center study of 23 patients from 2015 to 2022 with ALF/ACLF who underwent CRRT and TPE. We aimed to describe the clinical characteristics and outcomes of these patients. Median (IQR) age was 0.93 years (0.57, 9.88), range 16 days to 20 years. Ten (43%) had ALF and 13 (57%) ACLF. Most (n = 19, 82%) started CRRT for hyperammonemia and/or hepatic encephalopathy and all received TPE for refractory coagulopathy. CRRT was started at a median of 2 days from ICU admission, and TPE started on the same day in most. The liver transplant was done in 17 (74%), and 2 recovered native liver function. Four patients, all with ACLF, died prior to ICU discharge without a liver transplant. The median peak ammonia pre-CRRT was 131 µmol/L for the whole cohort. The mean (SD) drop in ammonia after 48 h of CRRT was 95.45 (43.72) µmol/L in those who survived and 69.50 (21.70) µmol/L in those who did not (p 0.26). Those who survived had 0 median co-morbidities compared to 2.5 in non-survivors (aOR (95% CI) for mortality risk of 2.5 (1.1-5.7), p 0.028). Conclusion: In this cohort of 23 pediatric patients with ALF or ACLF who received CRRT and TPE, 83% survived with a liver transplant or recovered with their native liver. Survival was worse in those who had ACLF and those with co-morbid conditions. What is Known: •  Pediatric acute liver failure is associated with high mortality. •  Patients may require extracorporeal liver assist therapies (like CRRT, TPE, MARS, SPAD) to bridge them over to a transplant or recovery of native liver function. What is New: • Standard volume plasma exhange has not been evaluated against high volume plasma exchange for ALF. • The role, dose, and duration of therapeutic plasma exchange in patients with acute on chronic liver failure is not well described.

Optimizing pediatric liver transplantation: Evaluating the impact of donor age and graft type on patient survival outcome.

BACKGROUND: We examined the combined effects of donor age and graft type on pediatric liver transplantation outcomes with an aim to offer insights into the strategic utilization of these donor and graft options. METHODS: A retrospective analysis was conducted using a national database on 0-2-year-old (N = 2714) and 3-17-year-old (N = 2263) pediatric recipients. These recipients were categorized based on donor age (≥40 vs <40 years) and graft type. Survival outcomes were analyzed using the Kaplan-Meier and Cox proportional hazards models, followed by an intention-to-treat (ITT) analysis to examine overall patient survival. RESULTS: Living and younger donors generally resulted in better outcomes compared to deceased and older donors, respectively. This difference was more significant among younger recipients (0-2 years compared to 3-17 years). Despite this finding, ITT survival analysis showed that donor age and graft type did not impact survival with the exception of 0-2-year-old recipients who had an improved survival with a younger living donor graft. CONCLUSIONS: Timely transplantation has the largest impact on survival in pediatric recipients. Improving waitlist mortality requires uniform surgical expertise at many transplant centers to provide technical variant graft (TVG) options and shed the conservative mindset of seeking only the "best" graft for pediatric recipients.

Eliciting perspectives on remote healthcare delivery from service users with psychosis in the community: a cross-sectional survey study.

Introduction: The transition towards remote healthcare has been rapidly accelerated in recent years due to a number of factors, including the COVID-19 pandemic, however, few studies have explored service users' views of remote mental healthcare, particularly in community mental health settings. Methods: As part of a larger study concerned with the development of a remotely delivered psychosocial intervention, a survey was conducted with service users with psychosis (N = 200) from six NHS trusts across England to gain cross-sectional data about service users' opinions and attitudes towards remote interventions and explore how digital access varies across different demographic groups and geographical localities. Results: The majority of service users had access to technological devices and a quiet space to receive care. Age was a key factor in motivation to engage with remote care as older participants had less access to technological devices and the internet, and reported less confidence to learn how to use new technologies compared to younger participants. Differences in access and attitudes towards remote care were found across the different geographical localities. Over half of the participants (53.1%) preferred a hybrid model (i.e., mixture of face-to-face and remotely delivered treatment), with only 4.5% preferring remote treatment exclusively. Factors that both encourage and deter service users from engaging with remote care were identified. Conclusions: The findings of this study provide important information about the environmental and clinical barriers that prevent, or limit, the uptake of remotely delivered care for people with psychotic disorders. Although service users often have the ability and capacity to receive remote care, providers need to be cognisant of factors which may exacerbate digital exclusion and negatively impact the therapeutic alliance.

Small-for-size syndrome in a 9.7 kg pediatric recipient with a whole liver graft.

BACKGROUND: Small-for-size syndrome (SFSS) in pediatric liver transplant recipients, particularly those weighing less than 10 kg, is rare. This report describes a case of a 15-month-old whole liver transplant recipient who suffered SFSS, and systematic literature review was performed to identify outcomes of such cases and potential risk factors for SFSS. CASE PRESENTATION: A 15-month-old toddler with a history of biliary atresia underwent a deceased donor whole liver transplant. The graft weighed 160 g, resulting in a graft-to-recipient weight ratio (GRWR) of 1.6%. The post-operative course was complicated by SFSS, characterized by massive ascites causing hemodynamic instability and compromised hepatic artery flow. Pharmacological intervention with octreotide was initiated, and the patient eventually recovered. CONCLUSION: In small pediatric recipients, especially those weighing less than 10 kg, the native liver body weight ratio (LBWR) is significantly higher. When selecting an appropriately sized graft for these recipients, this higher ratio should be taken into consideration. The literature review suggests that a GRWR of less than 2% is associated with a higher incidence of small-for-size syndrome in small pediatric recipients weighing less than 10 kg.

Working with roubles and failures in conversation between humans and robots: workshop report.

This paper summarizes the structure and findings from the first Workshop on Troubles and Failures in Conversations between Humans and Robots. The workshop was organized to bring together a small, interdisciplinary group of researchers working on miscommunication from two complementary perspectives. One group of technology-oriented researchers was made up of roboticists, Human-Robot Interaction (HRI) researchers and dialogue system experts. The second group involved experts from conversation analysis, cognitive science, and linguistics. Uniting both groups of researchers is the belief that communication failures between humans and machines need to be taken seriously and that a systematic analysis of such failures may open fruitful avenues in research beyond current practices to improve such systems, including both speech-centric and multimodal interfaces. This workshop represents a starting point for this endeavour. The aim of the workshop was threefold: Firstly, to establish an interdisciplinary network of researchers that share a common interest in investigating communicative failures with a particular view towards robotic speech interfaces; secondly, to gain a partial overview of the "failure landscape" as experienced by roboticists and HRI researchers; and thirdly, to determine the potential for creating a robotic benchmark scenario for testing future speech interfaces with respect to the identified failures. The present article summarizes both the "failure landscape" surveyed during the workshop as well as the outcomes of the attempt to define a benchmark scenario.

Critical elements of pediatric liver cancer surgery.

The appropriate management of pediatric liver malignancies, primarily hepatoblastoma and hepatocellular carcinoma, requires an in depth understanding of contemporary preoperative risk stratification, experience with advanced hepatobiliary surgery, and a good relationship with one's local or regional liver transplant center. While chemotherapy regimens have become more effective, operative indications more well-defined, and overall survival improved, the complexity of liver surgery in small children provides ample opportunity for protocol violation, inadequate resection, and iatrogenic morbidity. These guidelines represent the distillation of contemporary literature and expert opinion as a means to provide a framework for preoperative planning and intraoperative decision-making for the pediatric surgeon.

Interactive deformable electroluminescent devices enabled by an adaptable hydrogel system with optical/photothermal/mechanical tunability.

Deformable electroluminescent devices (DELDs) with mechanical adaptability are promising for new applications in smart soft electronics. However, current DELDs still present some limitations, including having stimuli-insensitive electroluminescence (EL), untunable mechanical properties, and a lack of versatile stimuli response properties. Herein, a facile approach for fabricating in situ interactive and multi-stimuli responsive DELDs with optical/photothermal/mechanical tunability was proposed. A polyvinyl alcohol (PVA)/polydopamine (PDA)/graphene oxide (GO) adaptable hydrogel exhibiting optical/photothermal/mechanical tunability was used as the top ionic conductor (TIC). The TIC can transform from a viscoelastic state to an elastic state via a special freezing-salting out-rehydration (FSR) process. Meanwhile, it endows the DELDs with a photothermal response and thickness-dependent light shielding properties, allowing them to dynamically demonstrate "on" or "off" or "gradually change" EL response to various mechanical/photothermal stimuli. Thereafter, the DELDs with a viscoelastic TIC can be utilized as pressure-responsive EL devices and laser-engravable EL devices. The DELDs with an elastic TIC can withstand both linear and out-of-plane deformation, enabling the designs of various interactive EL devices/sensors to monitor linear sliders, human finger bending, and pneumatically controllable bulging. This work offers new opportunities for developing next-generation EL-responsive devices with widespread application based on adaptable hydrogel systems.

Transplant renal vein stent placement complicated by obstructive hematuria: A case report.

BACKGROUND: Renal vein stenosis is uncommon following transplantation. We report acute renal vein stenosis post-transplant treated with an endovascular stent and complicated by urinary obstruction from clot formation. METHODS: Retrospective case report. RESULTS: A 16-year-old female 3 years post-transplant suffered anuria post-stenting with renal ultrasound demonstrating obstructive clot in the collecting system, a previously unreported complication. Subsequent nephroureteral JJ stent placement resulted in high-volume urine output. CONCLUSION: This article underscores the high index of suspicion required for renal vein stenosis following transplantation and the need to monitor urine output closely following stent placement.

Maximizing utility of nondirected living liver donor grafts using machine learning.

Objective: There is an unmet need for optimizing hepatic allograft allocation from nondirected living liver donors (ND-LLD). Materials and method: Using OPTN living donor liver transplant (LDLT) data (1/1/2000-12/31/2019), we identified 6328 LDLTs (4621 right, 644 left, 1063 left-lateral grafts). Random forest survival models were constructed to predict 10-year graft survival for each of the 3 graft types. Results: Donor-to-recipient body surface area ratio was an important predictor in all 3 models. Other predictors in all 3 models were: malignant diagnosis, medical location at LDLT (inpatient/ICU), and moderate ascites. Biliary atresia was important in left and left-lateral graft models. Re-transplant was important in right graft models. C-index for 10-year graft survival predictions for the 3 models were: 0.70 (left-lateral); 0.63 (left); 0.61 (right). Similar C-indices were found for 1-, 3-, and 5-year graft survivals. Comparison of model predictions to actual 10-year graft survivals demonstrated that the predicted upper quartile survival group in each model had significantly better actual 10-year graft survival compared to the lower quartiles (p<0.005). Conclusion: When applied in clinical context, our models assist with the identification and stratification of potential recipients for hepatic grafts from ND-LLD based on predicted graft survivals, while accounting for complex donor-recipient interactions. These analyses highlight the unmet need for granular data collection and machine learning modeling to identify potential recipients who have the best predicted transplant outcomes with ND-LLD grafts.

"Who's there?": Depicting identity in interaction.

Social robots have limited social competences. This leads us to view them as depictions of social agents rather than actual social agents. However, people also have limited social competences. We argue that all social interaction involves the depiction of social roles and that they originate in, and are defined by, their function in accounting for failures of social competence.

Power and vulnerability: managing sensitive language in organizational communication.

Organizational responsibilities can give people power but also expose them to scrutiny. This tension leads to divergent predictions about the use of potentially sensitive language: power might license it, while exposure might inhibit it. Analysis of peoples' language use in a large corpus of organizational emails using standardized Linguistic Inquiry and Word Count (LIWC) measures shows a systematic difference in the use of words with potentially sensitive (ethnic, religious, or political) connotations. People in positions of relative power are ~3 times less likely to use sensitive words than people more junior to them. The tendency to avoid potentially sensitive language appears to be independent of whether other people are using sensitive language in the same email exchanges, and also independent of whether these words are used in a sensitive context. These results challenge a stereotype about language use and the exercise of power. They suggest that, in at least some circumstances, the exposure and accountability associated with organizational responsibilities are a more significant influence on how people communicate than social power.

"It's cleaner, definitely": Collaborative Process in Audio Production.

Working from vague client instructions, how do audio producers collaborate to diagnose what specifically is wrong with a piece of music, where the problem is and what to do about it? This paper presents a design ethnography that uncovers some of the ways in which two music producers co-ordinate their understanding of complex representations of pieces of music while working together in a studio. Our analysis shows that audio producers constantly make judgements based on audio and visual evidence while working with complex digital tools, which can lead to ambiguity in assessments of issues. We show how multimodal conduct guides the process of work and that complex media objects are integrated as elements of interaction by the music producers. The findings provide an understanding how people currently collaborate when producing audio, to support the design of better tools and systems for collaborative audio production in the future.

Employment search, initial employment experience, and career preferences of recent pediatric surgical fellowship graduates: An APSA survey, part of the right child/right surgeon initiative.

BACKGROUND: APSA's Right Child/Right Surgeon Initiative addresses issues concerning patient access to appropriate pediatric surgical care and workforce distribution. The APSA Workforce Committee sought to understand the experiences and motivations of recent graduates of Pediatric Surgery Training Programs entering the workforce. METHODS: Using APSA membership databases, we identified members who completed fellowship training from 2010 to 2019. An online survey was created using Survey Monkey, and invitations to participate were sent via email. RESULTS: 144 of 447 invited participants responded (32% response rate). 91% of respondents participated in dedicated research prior to fellowship, but only 64% perform research during their employment. 23% completed an additional clinical fellowship, but only 54% currently practice within the second field. When asked to identify the top three factors used to choose a position, the most common responses were "location or geography" (71%), "available mentorship" (53%), and "compensation and benefits" (37%). Describing their first position, 77% reported working in an academic institution, 78% reported working in a metropolitan/urban area, and 55% reported working in a free-standing children's hospital. 94% participate in General Surgery resident education, and 49% are faculty within a Pediatric Surgery fellowship. Overall, 92% of respondents were able to find the type of employment position that they had wanted. CONCLUSION: In our survey the overwhelming majority of young pediatric surgeons found the type of job they desired. Most report beginning their practice in more populated, urban areas within academic institutions. Geographic location and work environment played heavily into their employment decisions. These preferences could contribute to continued disparity in access to pediatric surgeons between urban and rural America and to dilution of experience for urban surgeons. Possible solutions include alternative incentive programs for employment in less populated areas or new training models for general surgeons in rural areas to train in fundamentals of Pediatric Surgery.

Do funding sources influence long-term patient survival in pediatric liver transplantation?

BACKGROUND: Socioeconomic status has been associated with inferior outcomes after multiple surgical procedures, but has not been well studied with respect to pediatric liver transplantation. This study evaluated the impact of insurance status (as a proxy for socioeconomic status) on patient and allograft survival in pediatric first-time liver transplant recipients. METHODS: Our retrospective analysis of the UNOS data base from January 2002 through September 2017 revealed 6997 pediatric patients undergoing first-time isolated liver transplantation. A mixed Cox proportional hazards model adjusted for donor, recipient, and program characteristics determined the RR of insurance status on allograft and patient survival. All results were considered significant at P < .05. All statistical results were obtained using R version 3.5.1 and coxme version 2.2-10. RESULTS: Medicaid status had a significant negative impact on long-term survival after controlling for multiple covariates. Pediatric patients undergoing first-time isolated liver transplantation with Medicaid insurance had a RR of 1.42 [confidence interval: 1.18-1.60] of post-transplant death. CONCLUSION: Pediatric patients undergoing first-time isolated liver transplantation have multiple risk factors that may impact long-term survival. Having Medicaid insurance almost doubles the chances of dying post-liver transplant. This patient population may require more global support post-transplant to improve long-term survival.

The impact of public health service increased risk donors in pediatric liver transplantation.

Many transplant programs are reluctant to use organs from deceased donors designated as "PHS increased risk" due to misconceptions regarding the quality of those organs. This study evaluated the impact of PHS increased risk donors on patient and allograft survival in pediatric patients undergoing liver transplantation. Retrospective analysis of the UNOS database from January 2005 through September 2017 revealed 5615 pediatric patients who underwent isolated liver transplantation; of these, 5057 patients received primary isolated liver transplants and 558 patients received isolated liver retransplants. PHS increased risk organs were used in 6.7% and 5.4% of the children receiving primary isolated and retransplant livers, respectively. Cox proportional hazards models adjusted for donor and recipient characteristics determined the relative risk of PHS status on allograft and patient survival. Sicker children (those in ICU [P < .001] and on life support [P = .04]) were more likely to receive PHS increased risk donor organs. There were no differences in overall patient (P = .61) or allograft (P = .68) survival between pediatric patients receiving PHS positive vs PHS negative deceased donor organs; adjusted models also demonstrated no statistically significant differences in patient or allograft survival. Excellent patient and allograft survival can be accomplished with PHS increased risk organs.

New Evidence Supporting Increased Use of Split Liver Transplantation.

BACKGROUND: Young children and small-statured candidates are dying on liver candidate waitlists. The Organ Procurement and Transplantation Network and United Network for Organ Sharing have proposed a split liver (SL) variance encouraging transplant programs to split more livers to aid these smaller statured candidates. METHODS: We evaluated the US experience of splitting donor livers during 2002-2016. The results of our analysis provide new evidence to support this variance. RESULTS: During 2002-2016, SL grafts from 935 donors were transplanted into 1870 recipients. Controlling for recipient factors and using time period and program identification as random variables, a multivariable mixed Cox proportional hazards model for graft failure revealed that donor aged 3-10 years had a relative risk (RR) of 3.94 (2.86-5.44), and donor aged >30 years had a RR of 1.94 (1.59-2.35) for graft failure. Donor-to-recipient body surface area ratio <0.90 had a RR of 1.40 (1.13-1.75). Programs with experience transplanting <23 SLs had a RR of 1.43 (1.21-1.75). The same program transplanting both split segments had a RR of 1.38 (1.20-1.59). CONCLUSIONS: Splitting protocols based on these findings could improve graft survival after SL transplantation, which would encourage programs to opt into splitting more livers. The new protocols may consider donor age restrictions, necessary program experience, donor with body surface area appropriate for recipient, and improved logistical factors to share segments between transplant programs. The result would likely be a drastic reduction in liver waitlist deaths for young children and small-statured candidates.

Endovascular treatment of surgical mesoportal and portosystemic shunt dysfunction in pediatric patients.

BACKGROUND: Published data describing the endovascular treatment of dysfunctional mesoportal and portosystemic shunts in the pediatric population are limited. OBJECTIVE: We sought to describe the treatment and follow-up of such shunts managed by interventional radiology at a single pediatric hospital. We hypothesized that stenotic and occluded pediatric portosystemic and mesoportal shunts can be maintained patent by interventional radiology in the moderate term. MATERIALS AND METHODS: We conducted a single-center retrospective study at a tertiary pediatric hospital. We included children with surgical mesoportal (meso-Rex) or portosystemic (mesocaval, splenorenal or splenocaval) shunts treated with attempted angioplasty or stenting from 2010 to 2018. Technical success was defined as catheterization and intervention upon the shunt with venographic evidence of flow improvement. The primary outcome variables were shunt patency at 1 month, 6 months, 12 months and 24 months post-procedure and freedom from reintervention. RESULTS: Twenty pediatric patients (11 boys, 9 girls; mean age 8.25 years, range 1.3-17 years) met inclusion criteria. Fifty-two interventions (primary and reintervention) on 13 splenorenal, 3 meso-Rex, 2 mesocaval and 2 splenocaval shunts were performed because of evidence of shunt failure, including gastrointestinal bleeding, hypersplenism, or radiographic evidence of a flow defect. The 11 stenotic shunts were treated with 100% technical success, while the remaining 9 occluded shunts were treated with 66.7% technical success. The mean number of reinterventions was 1.9 (standard deviation [SD] = 3.1) per child, which did not differ between stenotic and occluded shunts (P=0.24). Primary patency at 1-month, 6-month, 12-month and 24-months follow-up visits was 17/17 (100%), 10/16 (62.5%), 7/15 (46.7%) and 4/10 (40%), respectively. However, 100% of shunts were either primary patent or primary-assisted patent by endovascular reintervention. There were no cases of shunt occlusion following initial technical success. Finally, the median freedom from reintervention duration was 387 days (SD=821 days). CONCLUSION: Dysfunctional portosystemic surgical shunts are effectively managed by endovascular methods. While many shunts require reintervention, combined primary patency and assisted primary patency rates are excellent.

Engaging With Contemporary Dance: What Can Body Movements Tell us About Audience Responses?

In live performances seated audiences have restricted opportunities for response. Some responses are obvious, such as applause and cheering, but there are also many apparently incidental movements including posture shifts, fixing hair, scratching and adjusting glasses. Do these movements provide clues to people's level of engagement with a performance? Our basic hypothesis is that audience responses are part of a bi-directional system of audience-performer communication. This communication is part of what distinguishes live from recorded performance and underpins live performers' moment-to-moment sense of how well a performance is going. Here we investigate the range of visible real-time movements of audiences in four live contemporary dance performances. Video recordings of performers and audiences were analyzed using computer vision techniques for extracting face, hand and body movement data. The meaning of audience movements were analyzed by comparing clips of the audience at moments of maximum and minimum movement to expert and novice judges. The results show that audience clips with the lowest overall movement are judged as displaying the highest engagement. In addition, we found that while there is no systematic relationship between audience and dancers movement, hands seem to play an especially significant role since they move significantly more compared to the rest of the body. We draw on these findings to argue that collective stillness is an especially salient signal of audience engagement.

Living liver donation improves patient and graft survival in the pediatric population.

BACKGROUND: The utilization of living donor grafts resulted in an increased availability of liver for pediatric recipients, and accordingly, this was associated with a significantly decreased waiting time before liver transplantation as well as reduced pre-transplant mortality. We hypothesized that the use of living donors in pediatric LT may lead to improved graft and patient survival, when compared to LT using deceased donors. METHODS: Retrospective cohort analysis of pediatric recipients (aged <18 years) registered in the UNOS database who received a primary liver transplant between February 2002 and December 2016. Covariates predictive of survival by multivariable analyses were included in the Cox proportional hazards regression models to determine predictors of patient and graft survival. RESULTS: A total of 6312 children received a primary LT from a LD (n = 800) or a deceased donor (n = 5517; partial graft n = 1784 and whole graft n = 3733). Vascular and biliary complications were similar. Kaplan-Meier graft and patient survival rates were superior in LD recipients compared with recipients of deceased whole and reduced graft (Figures 1 and 2). In the multivariable analysis, LD were an independent predictor of improved patient and graft survival. CONCLUSION: The use of LD in children is associated with improved patient and graft survival. The option of LD should be introduced early on in the evaluation of every pediatric patient being evaluated for liver transplant.

Editors' Introduction: Miscommunication.

Miscommunication is a neglected issue in the cognitive sciences, where it has often been discounted as noise in the system. This special issue argues for the opposite view: Miscommunication is a highly structured and ubiquitous feature of human interaction that systematically underpins people's ability to create and maintain shared languages. Contributions from conversation analysis, computational linguistics, experimental psychology, and formal semantics provide evidence for these claims. They highlight the multi-modal, multi-person character of miscommunication. They demonstrate the incremental, contingent, and locally adaptive nature of the processes people use to detect and deal with miscommunication. They show how these processes can drive language change. In doing so, these contributions introduce an alternative perspective on what successful communication is, new methods for studying it, and application areas where these ideas have a particular impact. We conclude that miscommunication is not noise but essential to the productive flexibility of human communication, especially our ability to respond constructively to new people and new situations.