Outcomes of living liver donors are worse than those of matched healthy controls.

BACKGROUND & AIMS: Donor death is the most serious complication of living liver donation but is reported rarely. We investigated the actual mortality of living liver donors (LLDs) compared with matched control groups based on analysis of the Korean National Health Insurance Services (NHIS) database. METHODS: This cohort study included 12,372 LLDs who donated a liver graft between 2002 and 2018, and were registered in the Korean Network for Organ Sharing. They were compared to 3 matched control groups selected from the Korean NHIS and comprising a total of 123,710 individuals: healthy population (Group I); general population without comorbidities (Group II); and general population with comorbidities (Group III). RESULTS: In this population, 78.5% of living liver donors were 20-39 years old, and 64.7% of all donors were male. Eighty-nine donors (0.7%) in the LLD group died (68 males and 21 females), a mortality rate (/1,000 person-years) of 0.91 (0.74-1.12). Mortality rate ratio and the adjusted hazard ratio of the LLD group was 2.03 (1.61-2.55) and 1.71 (1.31-2.25) compared to Control Group I, 0.75 (0.60-0.93) and 0.63 (0.49-0.82) compared to Control Group II, and 0.58 (0.46-0.71) and 0.49 (0.39-0.60) compared to Control Group III. LLD group, depression, and lower income were risk factors for adjusted mortality. The incidence of liver failure, depression, cancer, diabetes, hypertension, brain infarction, brain hemorrhage, and end-stage renal disease in the LLD group was significantly higher than in Control Group I. CONCLUSIONS: Outcomes of the LLD group were worse than those of the matched healthy control group despite the small number of deaths and medical morbidities in this group. LLDs should receive careful medical attention for an extended period after donation. LAY SUMMARY: The incidence of mortality, liver failure, depression, cancer, diabetes, hypertension, brain infarction, brain hemorrhage, and end-stage renal disease in the living liver donor group was significantly higher than in the matched healthy group. Careful donor evaluation and selection processes can improve donor safety and enable safe living donor liver transplantation.

Effect of CaCO3(S) Nucleation Modes on Algae Removal from Alkaline Water.

The role of calcite heterogeneous nucleation was studied in a particle-coagulation treatment process for removing microalgae from water. Batch experiments were conducted with Scenedesmus sp. and Chlorella sp. in the presence and absence of carbonate and in the presence and absence of magnesium to delineate the role of CaCO3(S) nucleation on microalgae removal. The results indicate that effective algae coagulation (e.g., up to 81% algae removal efficiency) can be achieved via heterogeneous nucleation with CaCO3(S); however, supersaturation ratios between 120 and 200 are required to achieve at least 50% algae removal, depending on ion concentrations. Algae removal was attributed to the adsorption of Ca2+ onto the cell surface, which provides nucleation sites for CaCO3(S) precipitation. Bridging of calcite particles between the algal cells led to rapid aggregation and formation of larger flocs. However, at higher supersaturation conditions, algae removal was diminished due to the dominance of homogeneous nucleation of CaCO3(S). The removal of algae in the presence of Ca2+ and Mg2+ required higher supersaturation values; however, the shift from heteronucleation to homonucleation with increasing supersaturation was still evident. The results suggest that water chemistry, pH, ionic strength, alkalinity, and Ca2+ concentration can be optimized for algae removal via coagulation and sedimentation.

On the feasibility of small communities wellhead RO treatment for nitrate removal and salinity reduction.

The feasibility of wellhead water treatment in small communities for nitrate removal and salinity reduction via a flexible high recovery RO system was evaluated through analysis of treatment options, laboratory and onsite field tests. In small remote communities that rely on septic systems for residential wastewater treatment, discharge of the RO residual stream (containing nitrate) to the community septic tank is shown to be a feasible option. It is demonstrated that RO treatment with a system that employs partial concentrate recycle, integrated with a pressure intensifier, enabled the use of a relatively low-pressure feed pump while allowing high recovery operation. The approach of integrating RO treatment into existing community small water systems is demonstrated to be suitable for providing effective nitrate removal and salinity reduction over wide range of nitrate and salinity levels, while meeting community water demand and regulatory water quality requirements.

Recurrent Guillain-Barré Syndrome Following Urinary Tract Infection by Escherichia coli.

Recurrent Guillain-Barré syndrome (GBS) is a rare, immune-mediated disease of the peripheral nervous system. It has been reported to occur at intervals ranging from four months to 10 years; published case studies suggest that 1%-6% of patients who have had GBS will experience recurrent attacks. The most commonly identified infections coinciding with GBS are Campylobacter jejuni, Haemophilus influenzae, Mycoplasma pneumonia, and cytomegalovirus, while an antecedent infection with Escherichia coli is very uncommon. In this case report, we present a rare episode of recurrent GBS, which followed a urinary tract infection (UTI) by E. coli, and an accompanying literature review. A 75-year-old woman with a prior history of acute motor axonal neuropathy (AMAN), a subtype of GBS, presented with subsequent weakness of limbs and areflexia following 10 days of fever, frequency, and dysuria. Base on nerve conduction studies, cerebrospinal fluid analysis and other clinical investigation, we diagnosed the patient with recurrent GBS caused by E. coli. The patient recovered with mild subjective weakness following treatment of intravenous immunoglobulin with ceftriaxone. We suggest that E. coli causes UTI could be one of the diverse trigger factors involved in recurrent GBS.

Outcome of partial reconstruction of multiple hepatic arteries in pediatric living donor liver transplantation using left liver grafts.

Partial liver grafts used in living donor liver transplantation (LDLT) may have multiple hepatic artery (HA) stumps. This study was designed to validate the safety of partial reconstruction of multiple HAs in pediatric LDLT cases. From January 2000 to June 2014, 136 pediatric LDLT recipients were categorized into three groups: single HA group (Group 1, n = 74), multiple HAs with total reconstruction group (Group 2, n = 23), and multiple HAs with partial reconstruction group (Group 3, n = 39). Partial reconstruction was performed only when there was pulsatile back-bleeding after larger HA reconstruction and sufficient intrahepatic arterial flow was confirmed by Doppler ultrasound (DUS). There was no significant difference in biliary complication rate, artery complication rate, patient survival, and graft survival among these groups. Risk factor analysis revealed that the presence of multiple HAs and partial reconstruction of multiple HAs were not risk factors of biliary anastomosis stricture. In conclusion, partial reconstruction of HAs during pediatric LDLT using a left liver graft with multiple HA stumps does not increase the risk of biliary anastomosis stricture or affect graft survival when intrahepatic arterial communication is confirmed by pulsatile back-bleeding and DUS.

The effects of care management on depression treatment in a psychiatric clinic: a randomized controlled trial.

OBJECTIVE: This study aims to examine whether care management has an effect on adherence to depression treatment in a psychiatric clinic in Korea. METHODS: Fifty-seven patients with depression aged 60 years or over participated in the study. They were all low-income patients screened in the community and treated in a psychiatric clinic. The study design was a double-blind randomized controlled trial. The patients were randomly assigned to intervention (n = 29) or usual care (n = 28) groups. Intervention patients received depression care management for 6 months. Primary endpoint was an increase in remission rate as assessed using the 17-item Hamilton Depression Rating Scale score at 6 months. Secondary endpoints included improvement in treatment adherence, improvement in health-related quality of life, and a reduction in feelings of hopelessness. RESULTS: Patients in the care management intervention group showed a higher remission rate than those in the usual care group (55% vs. 29%, p = 0.0421). Intervention patients were significantly more likely to adhere to the treatment (59% vs. 18%, p = 0.0016). The hopelessness score at the 6-month assessment was significantly lower in the intervention group than the usual care group (23.5 vs. 25.7, p = 0.0443). However, there was not a significant group difference in the quality of life. CONCLUSIONS: We found that care management not only contributed to reducing depressive symptoms in geriatric patients suffering from depression but also increased the treatment adherence rate, which in turn increased the remission rate. Care management intervention is both feasible and effective in psychiatric clinics in Korea.

A case of acute motor and sensory axonal neuropathy following hepatitis a infection.

Acute motor and sensory axonal neuropathy (AMSAN) are recently described subtypes of Guillain-Barre syndrome characterized by acute onset of distal weakness, loss of deep tendon reflexes, and sensory symptoms. A 21-yr-old male was transferred to our hospital due to respiration difficulties and progressive weakness. In laboratory findings, immunoglobulin M antibodies against hepatitis A were detected in blood and cerebrospinal fluid. The findings of motor nerve conduction studies showed markedly reduced amplitudes of compound muscle action potentials in bilateral peroneal, and posterior tibial nerves, without evidence of demyelination. Based on clinical features, laboratory findings, and electrophysiologic investigation, the patient was diagnosed the AMSAN following acute hepatitis A viral infection. The patient was treated with intravenous immunoglobulin and recovered slowly. Clinicians should consider this rare but a serious case of AMSAN following acute hepatitis A infection.

Korean Red Ginseng Induced Cardioprotection against Myocardial Ischemia in Guinea Pig.

This study was designed to evaluate the protective effect of Korean red ginseng (KRG) against ischemia/reperfusion (I/R) injury in isolated guinea pig heart. KRG has been shown to possess various ginsenosides, which are the major components of Panax ginseng. These components are known naturally occurring compounds with beneficial effects and free radical scavenging activity. The heart was induced to ischemia for 60 min, followed by 120 min reperfusion. The hearts were randomly allocated into five groups (n=8 for each group): normal control (N/C), KRG control, I/R control, 250 mg/kg KRG group and 500 mg/kg KRG group. KRG significantly increased hemodynamics parameters such as aortic flow, coronary flow and cardiac output. Moreover, KRG significantly increased left ventricular systolic pressure (LVSP), the maximal rate of contraction (+dP/dtmax) and maximal rate of relaxation (-dP/dtmax). Also, treatment of KRG ameliorated electrocardiographic index such as the QRS, QT and RR intervals. Moreover, KRG significantly suppressed the lactate dehydrogenase, creatine kinase-MB fraction and cardiac troponin I and ameliorated the oxidative stress markers such as malondialdehyde and glutathione. KRG was standardized through ultra performance liquid chromatograph analysis for its major ginsenosides. Taken together, KRG has been shown to prevent cardiac injury by normalizing the biochemical and oxidative stress.

A case of cerebellar infarction presenting as thunderclap headache.

Thunderclap headache (TCH) refers to a sudden-onset, severe headache that features in subarachnoid hemorrhage, unruptured intracranial aneurysm, cerebral venous thrombosis, pituitary apoplexy, cervical artery dissection, and hypertensive reversible posterior leukoencephalopathy. TCH is a rare manifestation in cerebral or cerebellar infarctions. Herein, we report on a 60-year-old woman with a thunderclap headache as the first symptom of cerebellar infarction, in the absence of abnormal findings in the brain computed tomography (CT), CT angiography, and lumbar puncture. An urgent brain MRI showed an acute infarction of the right cerebellar hemisphere. The next day, the patient presented with right side ataxia. In emergency cases presenting with thunderclap headache, one should consider an expanded evaluation and/or close observation, with frequent neurological examinations, even though the findings are normal on the initial neurological examination, cerebrospinal fluid analysis, and brain CT.

Promising therapeutics with natural bioactive compounds for improving learning and memory--a review of randomized trials.

Cognitive disorders can be associated with brain trauma, neurodegenerative disease or as a part of physiological aging. Aging in humans is generally associated with deterioration of cognitive performance and, in particular, learning and memory. Different therapeutic approaches are available to treat cognitive impairment during physiological aging and neurodegenerative or psychiatric disorders. Traditional herbal medicine and numerous plants, either directly as supplements or indirectly in the form of food, improve brain functions including memory and attention. More than a hundred herbal medicinal plants have been traditionally used for learning and memory improvement, but only a few have been tested in randomized clinical trials. Here, we will enumerate those medicinal plants that show positive effects on various cognitive functions in learning and memory clinical trials. Moreover, besides natural products that show promising effects in clinical trials, we briefly discuss medicinal plants that have promising experimental data or initial clinical data and might have potential to reach a clinical trial in the near future.

Desupersaturation of RO concentrate and gypsum removal via seeded precipitation in a fluidized bed crystallizer.

The feasibility of a continuous chemically-enhanced seeded precipitation (CCESP) process was evaluated for desupersaturation of primary reverse osmosis (PRO) concentrate generated from RO desalting of inland agricultural drainage (AD) water with high gypsum scaling potential. The CCESP approach, comprised of partial lime treatment (PLT) followed by gypsum seeded precipitation (GSP), was assessed via laboratory and field tests, along with model simulations. PLT effectiveness was confirmed for residual antiscalant removal from the PRO concentrate, which otherwise would suppress gypsum crystallization. GSP was carried out in a fluidized bed crystallizer (FBC) demonstrating the feasibility of continuous PRO concentrate desupersaturation with suitable solids management. FBC operation was stable, with respect to desupersaturation performance, when operating over a sequence of periodic solids purge-only mode with intermittent seeds replenishment. The study suggests that CCESP integration with primary and secondary RO desalting (i.e., PRO-CCESP-SRO) can provide for significant enhancement of product water recovery for inland water of high gypsum scaling propensity. For example, source water of high salinity (14,347 mg/L total dissolved solid) AD water, nearly saturated with respect to gypsum, could be desalted up to a recovery of 88-96% (relative to merely 66% recovery feasible via PRO desalting. Moreover, net salt harvesting of 2.6-3.6 kg per m3 RO concentrate (with concentrate recycle) can be obtained from high recovery desalting of the above PRO concentrate.

Long-term mortality of living kidney donors: a systematic review and meta-analysis.

BACKGROUND: To date, several studies have reported inconsistent findings regarding the mortality risk faced by living kidney donors and controls. Our study assessed the methodological quality of previous studies and performed an updated meta-analysis of the mortality risk. METHODS: Comprehensive literature searches were conducted involving the PubMed, Embase, and Cochrane databases through September 2020. The search terms used included 'living donor' and 'kidney transplantation' and 'kidney donor' and 'mortality' or 'death' or 'survival'. We evaluated the risk of bias in such studies using ROBINS-I tool. Mortality risk was analyzed using OR and HR. RESULTS: The qualitative review involved 18 studies and the meta-analysis included nine studies. We identified 3 studies with an overall risk of bias rated as "Low", 2 studies rated as "Moderate", 8 studies rated as "Serious", and 5 studies rated as "Critical". The pooled overall mortality risk in the meta-analysis was 0.984 (95% CI: 0.743, 1.302). In the subgroup analysis of HR and OR, the summary effect estimates did not reach statistical significance. The meta-regression analysis revealed that the donor group of more than 60,000 (1.836, 95% CI: 0.371, 6.410) carried a significantly high mortality risk compared with the donor group of less than 60,000 (0.810, 95% CI: 0.604, 1.086) (P = 0.007). The number of total patients was associated with slightly elevated mortality risks (0.796 for < 10,000, 0.809 for 10,000-60,000, and 1.852 for > 60,000; P < .054). CONCLUSIONS: Current evidence based on this systematic review suggests that the methodology of previous studies was inconsistent and also carried a high risk in several aspects. Updated meta-analysis showed that the mortality risk was not significantly different. Future studies with well-designed methodology are necessary.

What surgeons should know about emergency operation for COVID-19 confirmed patients: A case report.

INTRODUCTION: This case is shared to reiterate and confirm the principles of ensuring the safety of the surgical team caring for COVID-19-confirmed patients, thus, preventing the spread of infection within the hospital. CASE PRESENTATION: A 54-year-old male, COVID-19-confirmed patient complaining of abdominal pain since two days prior was transferred to our hospital. Perforated appendicitis with a periappendiceal abscess was diagnosed by computed tomography. Laparoscopic appendectomy was performed in a negative-pressure operating room. The surgical team wore enhanced personal protective equipment. Electrocautery was not used during surgery and no other special instruments were applied to reduce aerosol generation. No special instruments or filters were used for the removal of intra-abdominal gas. The operation was completed successfully and no immediate surgical complications occurred. The patient advanced to a normal diet on the 4th postoperative day. The patient was treated with antibiotics for bacteremia and antiviral therapy for underlying pneumonia in the setting of COVID-19 with most symptoms dissipating by the 7th postoperative day. The patient was discharged on the 30th postoperative day without any complications. DISCUSSION: A well-designed manual, a well-trained surgical team, and a negative-pressure operating room are essential for safe laparoscopic appendectomies in COVID-19 patients. CONCLUSION: When surgery is performed in a negative-pressure operating room by a well-trained surgical team, a laparoscopic appendectomy can be successfully performed under the principles of obtaining optimum clinical outcomes while faithfully ensuring the safety of healthcare providers and the hospital environment.

Impact of technical innovation on surgical outcome of laparoscopic major liver resection: 10 years' experience at a large-volume center.

PURPOSE: Laparoscopic major liver resection (major LLR) remains a challenging procedure because of the technical difficulty. Several significant technical innovations have been applied in our center since 2012. They include routine application of bipolar electrocautery, initiation of temporary increase of intra-abdominal pressure during bleeding events from veins to balance the central venous pressure, and use of temporary inflow control of the Glissonean pedicle. This study evaluated the impact of these technique modifications in patients with major LLR. METHODS: Between January 2004 and February 2015, a total of 606 patients underwent LLR at Samsung Medical Center in Seoul, Korea. Major LLR was employed in 233 cases. All major LLR procedures were anatomical resections performed with a totally laparoscopic approach. We compared surgical parameters of right hepatectomy (RH), left hepatectomy (LH), and right posterior sectionectomy (RPS) before and after 2012. RESULTS: Open conversion rates of RH and LH and estimated blood loss in RPS significantly decreased after 2012. The postoperative complication rate of major LLR was 12.7% and was similar before and after 2012. Bile leakage was the most common complication (3.2%). CONCLUSION: The modifications of surgical techniques resulted in good outcomes for laparoscopic major LLR. We recommend routine application of these techniques to improve outcomes, especially in patients requiring major liver resection.

Treatment of patients with clinically lymph node-negative squamous cell carcinoma of the oral cavity.

OBJECTIVE: To evaluate treatment outcome and to determine optimal treatment strategy for patients with clinically lymph node-negative (N0) oral cavity squamous cell carcinoma (SCC). METHODS: Two hundred and twenty-seven patients with oral cavity SCC received radiotherapy with curative intent. We retrospectively analyzed 69 patients with clinically N0 disease. Forty-three patients were treated with surgery followed by radiotherapy (S+EBRT) and 26 with radiotherapy alone (EBRT). The median doses administered were 63.0 Gy for S+EBRT and 70.2 Gy for EBRT. RESULTS: The rates of occult metastasis were 60% for T1, 69% for T2, 100% for T3 and 39% for T4, respectively, among patients who underwent neck dissection. A contralateral occult metastasis occurred only in two patients. The median follow-up was 39 months (range, 6-170 months). The 5-year overall survival (OS), disease-free survival (DFS), local control (LC) and regional control (RC) rates for all patients were 56, 50, 66 and 79%, respectively. The 5-year OS, DFS, LC and RC rates were 67/39% (P < 0.01), 66/24% (P < 0.01), 87/30% (P < 0.01) and 73/89% (P = 0.11) for S+EBRT/EBRT, respectively. CONCLUSIONS: The risk for occult neck metastasis is high in patients with oral cavity SCC; therefore, elective neck treatment should be considered. Excellent RC for subclinical disease can be achieved with radiotherapy alone. However, external beam radiotherapy alone to primary tumor resulted in poor LC and combined treatment with surgery and radiotherapy appeared to be a better treatment strategy.

Observational Study of Clinical and Functional Progression Based on Initial Brain MRI Characteristics in Patients with Alzheimer's Disease.

BACKGROUND: Magnetic resonance imaging (MRI) is a useful tool to predict the diagnosis and progression of Alzheimer's disease (AD), especially for primary physicians. However, the correlation between baseline MRI findings and AD progression has not been fully established. OBJECTIVE: To investigate the correlation between hippocampal atrophy (HA) and white matter hyperintensities (WMH) on initial brain MRI images and the degree of cognitive decline and functional changes over 1 year. METHODS: In this prospective, 12-month observational study, dementia outpatients were recruited from 29 centers across South Korea. Baseline assessments of HA and WMH on baseline brain MRI were derived as well as cognitive function, dementia severity, activities of daily living, and acetylcholinesterase inhibitor (AChEI) use. Follow-up assessments were conducted at 6 and 12 months. RESULTS: Among 899 enrolled dementia patients, 748 were diagnosed with AD of whom 654 (87%) were taking AChEIs. Baseline WMH showed significant correlations with age, current alcohol consumption, and Clinical Dementia Rating score; baseline HA was correlated with age, family history, physical exercise, and the results of cognitive assessments. Among the AChEI group, changes in the Korean version of the Instrumental Activities of Daily Living (K-IADL) were correlated with the severity of HA on baseline brain MRI, but not with the baseline severity of WMH. In the no AChEI group, changes in K-IADL were correlated with the severity of WMH and HA at baseline. CONCLUSION: Baseline MRI findings could be a useful tool for predicting future clinical outcomes by primary physicians, especially in relation to patients' functional status.

HMCO5, herbal extract, inhibits NF-kappaB expression in lipopolysaccharide treated macrophages and reduces atherosclerotic lesions in cholesterol fed mice.

HMCO5 is a herbal extract which comprises of eight different herbs. We studied whether this extract has anti-atherosclerotic effects. In lipopolysaccharide (LPS) stimulated RAW264.7 cells, HMCO5 inhibited NF-kappaB activation as well as iNOS promoter activity, inhibited the secretion of TNF-alpha and IL-1beta, and directly inhibited the intracellular accumulation of reactive oxygen species. ApoE knock-out mice fed a high-fat high-cholesterol diet with HMCO5 for 10 weeks showed a significant reduction in atherosclerotic lesions. A notable finding was the preservation of the smooth muscle cell layer in the media of aorta in the HMCO5 co-treated mice. HMCO5 treated mice did not show significant decrease in serum level of cholesterol. These results suggest that HMCO5 has anti-atherosclerotic effects which in part may be attributable to the inhibition of production of NF-kappaB dependent pro-inflammatory cytokines.

The correlation between preoperative volumetry and real graft weight: comparison of two volumetry programs.

PURPOSE: Liver volumetry is a vital component in living donor liver transplantation to determine an adequate graft volume that meets the metabolic demands of the recipient and at the same time ensures donor safety. Most institutions use preoperative contrast-enhanced CT image-based software programs to estimate graft volume. The objective of this study was to evaluate the accuracy of 2 liver volumetry programs (Rapidia vs. Dr. Liver) in preoperative right liver graft estimation compared with real graft weight. METHODS: Data from 215 consecutive right lobe living donors between October 2013 and August 2015 were retrospectively reviewed. One hundred seven patients were enrolled in Rapidia group and 108 patients were included in the Dr. Liver group. Estimated graft volumes generated by both software programs were compared with real graft weight measured during surgery, and further classified into minimal difference (≤15%) and big difference (>15%). Correlation coefficients and degree of difference were determined. Linear regressions were calculated and results depicted as scatterplots. RESULTS: Minimal difference was observed in 69.4% of cases from Dr. Liver group and big difference was seen in 44.9% of cases from Rapidia group (P = 0.035). Linear regression analysis showed positive correlation in both groups (P < 0.01). However, the correlation coefficient was better for the Dr. Liver group (R2 = 0.719), than for the Rapidia group (R2 = 0.688). CONCLUSION: Dr. Liver can accurately predict right liver graft size better and faster than Rapidia, and can facilitate preoperative planning in living donor liver transplantation.