Risk factors and outcomes of early infection in liver transplant recipients with acute-on-chronic liver failure.

OBJECTIVES: Patients with acute-on-chronic liver failure (ACLF) have a high risk of infection after liver transplantation (LT). In this study, we aimed to evaluate the prevalence of early post-LT infection (within one month after LT) in recipients with ACLF, and to compare the survival rate between patients with or without post-LT infection. METHODS: Patients with ACLF who underwent LT between January 2015 and December 2017 were retrospectively included. Characteristics of the patients, prevalence, site and pathogen of post-LT infection, and its risk factors were evaluated. RESULTS: A total of 62 patients with ACLF developed bacterial or fungal infection after LT. The 30-day, 90-day, and 1-year survival rates in the infected group were found to be significantly lower than those in the non-infected group (67.7% vs 98.5%, 64.5% vs 97.7%, and 48.4% vs 95.4%; all P < 0.001). The most common pathogens involved were carbapenem-resistant gram-negative organisms, including Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter lwoffi. Multivariate analysis demonstrated that reoperation and length of intensive care unit stay were independently associated with post-LT infection. In addition, living donor LT and early allograft dysfunction were independently associated with 30-day all-cause mortality, whereas red blood cell transfusion and post-LT infection were independently associated with all-cause 30-day and 90-day mortality after LT. CONCLUSIONS: Early infection after LT is a major prognostic factor in patients with ACLF. Constant vigilance for the risk factors of early infection after LT is needed for timely diagnosis and prompt intervention.

High mortality associated with gram-negative bacterial bloodstream infection in liver transplant recipients undergoing immunosuppression reduction.

BACKGROUND: Immunosuppression is an important factor in the incidence of infections in transplant recipient. Few studies are available on the management of immunosuppression (IS) treatment in the liver transplant (LT) recipients complicated with infection. The aim of this study is to describe our experience in the management of IS treatment during bacterial bloodstream infection (BSI) in LT recipients and assess the effect of temporary IS withdrawal on 30 d mortality of recipients presenting with severe infection. AIM: To assess the effect of temporary IS withdrawal on 30 d mortality of LT recipients presenting with severe infection. METHODS: A retrospective study was conducted with patients diagnosed with BSI after LT in the Department of Liver Surgery, Renji Hospital from January 1, 2016 through December 31, 2017. All recipients diagnosed with BSI after LT were included. Univariate and multivariate Cox regression analysis of risk factors for 30 d mortality was conducted in the LT recipients with Gram-negative bacterial (GNB) infection. RESULTS: Seventy-four episodes of BSI were identified in 70 LT recipients, including 45 episodes of Gram-positive bacterial (GPB) infections in 42 patients and 29 episodes of GNB infections in 28 patients. Overall, IS reduction (at least 50% dose reduction or cessation of one or more immunosuppressive agent) was made in 28 (41.2%) cases, specifically, in 5 (11.9%) cases with GPB infections and 23 (82.1%) cases with GNB infections. The 180 d all-cause mortality rate was 18.5% (13/70). The mortality rate in GNB group (39.3%, 11/28) was significantly higher than that in GPB group (4.8%, 2/42) (P = 0.001). All the deaths in GNB group were attributed to worsening infection secondary to IS withdrawal, but the deaths in GPB group were all due to graft-versus-host disease. GNB group was associated with significantly higher incidence of intra-abdominal infection, IS reduction, and complete IS withdrawal than GPB group (P < 0.05). Cox regression showed that rejection (adjusted hazard ratio 7.021, P = 0.001) and complete IS withdrawal (adjusted hazard ratio 12.65, P = 0.019) were independent risk factors for 30 d mortality in patients with GNB infections after LT. CONCLUSION: IS reduction is more frequently associated with GNB infection than GPB infection in LT recipients. Complete IS withdrawal should be cautious due to increased risk of mortality in LT recipients complicated with BSI.

The efficacy of extracorporeal membrane oxygenation in liver transplantation from non-heart-beating donors: A systemic review and meta-analysis.

BACKGROUND: A systematic review and meta-analysis was made to see whether extracorporeal membrane oxygenation (ECMO) in liver transplantation could improve non-heart-beating donors (NHBDs) recipients' outcomes compared with donors after brain death (DBDs) recipients. METHODS: We searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials for eligible studies. The study eligible criteria are cohort or case-control studies using ECMO in all NHBDs; studies involved a comparison group of DBDs; and studies evaluated 1-year graft and patient survival rate in NHBDs and DBDs groups. RESULTS: Four studies with 704 patients fulfilled the inclusion criteria. The pooled odds ratio (OR) of 1-year patient survival rate in NHBDs recipients compared with DBDs recipients was 0.8 (95% confidence interval [CI], 0.41-1.55). The pooled OR of 1-year graft survival rate in NHBDs recipients compared with DBDs recipients was 0.46 (95% CI, 0.26-0.81). NHBDs recipients were at greater risks to the occurrence of primary nonfunction (PNF) (OR = 7.12, 95% CI, 1.84-27.52) and ischemic cholangiopathy (IC) (OR = 9.46, 95% CI, 2.76-32.4) than DBDs recipients. CONCLUSIONS: ECMO makes 1-year patient survival acceptable in NHBDs recipients. One-year graft survival rate was lower in NHBDs recipients than in DBDs recipients. Compared with DBDs recipients, the risks to develop PNF and IC were increased among NHBDs recipients.

[Modified incision to prevent the postoperative spinal lateral angulation in surgery via anterior approach for lumbar fracture].

OBJECTIVE: To explore a method of modified incision to prevent the postoperative spinal lateral angulation via anterior approach for lumbar fracture. METHODS: A total 40 patients with lumbar fracture from January 2016 to Jun 2017 were internalized in the study. Including 28 males and 12 females, aged from 27 to 68 years with an average of (39.5±14.9) years. Among them, 28 cases caused by high fall, 9 cases by heavy injury, 3 cases by traffic accidents; and 35 fractures were located at L1,4 at L2,1 at L3. All the fractures were type A based on AO classification. According to Frankel classify of spinal cord injury, 5 cases were grade A, 1 case was B, 10 cases were C, 15 cases were D, 9 cases were E. The patients were divided randomly into modified incision groups and routine incision groups. All patients were treated with decompression, internal fixation and titanium mesh supported bone graft fusion via anterior approach. All the internal fixation materials were ANTERIOR (Medtronic Inc). Incision direction and incision plane were improved in modified incision groups. The coronal Cobb angle and the angle between the vertebral screw and the corresponding endplate were analyzed before and after operation. RESULTS: Pre-and post-operative coronal Cobb angles were (1.20±3.26) °, ( 2.16±3.55)° in modified incision groups and(1.22±4.42)°, (3.91±3.78)° in routine incision groups respectively. And there was no statistical difference before operation, and there was statistical difference after operation between two groups(P=0.017). There was no lateral angulation of more than 5 degrees in modified incision group, but there was lateral angulation of 5 to 10 degrees in routine incision group in 6 cases. The incidence of lateral angulation about 5 degrees after operation was significantly different between two groups (P=0.010). There was significant difference in the angle between the proximal two vertebral screws and the corresponding endplate between two groups (P<0.05), but there was no significant difference in the angle between the distal two vertebral screws and the corresponding endplate (P>0.05). CONCLUSIONS: The improvement of incision direction and plane can effectively prevent the postoperative spinal lateral angulation via anterior approach for lumbar fracture.

Anterior release and nonstructural bone grafting and posterior fixation for old lower cervical dislocations with locked facets.

Lower cervical dislocations are often missed at the time of initial injury for several reasons. The treatment of old facet dislocations of the lower cervical spine is difficult, and the optimal method has not been established. The objective of the present study was to evaluate the clinical outcomes of a surgical technique, anterior release, and nonstructural bone grafting combined with posterior fixation, for the treatment of old lower cervical dislocations with locked facets.This was a retrospective study of 17 patients (13 men and 4 women) with old facet dislocations, who underwent the same surgical treatment at our hospital between April 2010 and January 2016. The anterior procedure was conducted to remove the fusion mass and to achieve discectomy and morselized bone grafting. Subsequent posterior procedure included release, reduction, and posterior fusion. The neurologic status, clinical data (Japanese Orthopedic Association [JOA], Neck Disability Index [NDI], and Visual Analog Scale [VAS] scores), and radiographic information (local sagittal alignment and bone graft fusion) were recorded and evaluated pre and postoperatively.All patients achieved a nearly complete reduction intraoperatively. The mean operative time was 178 ±â€Š49 minutes. The mean blood loss was 174 ±â€Š73 mL. Each patient completed at least 12 months of follow-up. The mean follow-up duration was 32.6 ±â€Š18.5 months. The neurologic status according to the Frankel grade was significantly improved at the last follow-up. The JOA, NDI, and VAS scores all demonstrated significant improvements compared with the preoperative values (P < .05). The kyphosis angle of the dislocated segments was 10.5 ±â€Š5.9° at preoperation, and was corrected to 5.9 ±â€Š4.3° lordosis postoperatively. Anterior and posterior solid fusion was observed in all patients within 12 months of follow-up. Fat liquefaction and delayed healing of the posterior wound occurred in 1 patient. Cerebrospinal fluid leakage occurred in another patient. There was no neurologic deterioration and no procedure-related complications.Anterior release and nonstructural bone grafting combined with posterior fixation provides a safe and effective option for treating old lower cervical dislocations with locked facets.

Biomechanical Analysis of Bilateral Facet Joint Stabilization Using Bioderived Tendon for Posterior Cervical Spine Motion Reservation in Goats.

OBJECTIVES: To investigate the biomechanical properties of a novel stabilization method for posterior cervical motion preservation using bioderived freeze-dried tendon. METHODS: Experiments were conducted both in vitro and in vivo. For the in vitro group, 15 fresh-frozen goat spines (C1-C7) were randomly divided into 3 subgroups: intact (INT-vitro, n = 5), injury model (IM-vitro, n = 5), and bilateral facet joint stabilization (BFJS-vitro, n = 5) subgroups. For the in vivo group, 15 adult goats were randomly divided into 3 experimental subgroups: INT-vivo subgroup (n = 5), IM-vivo subgroup (n = 5), and BFJS-vivo subgroup (n = 5). Goats in the in vivo group were euthanized 12 weeks after surgery. Biomechanical tests were performed to evaluate range of motion. Histologic analysis was conducted to evaluate survival and reactions associated with the bioderived tendon. RESULTS: Compared with the INT-vitro and INT-vivo subgroups, the flexion of IM-vitro and IM-vivo subgroups increased significantly, respectively (P < 0.05). The flexion of the BFJS-vitro and BFJS-vivo subgroups was significantly smaller than in the IM-vitro and IM-vivo subgroups, respectively (P < 0.05). Significant differences between the BFJS-vitro and BFJS-vivo subgroups were observed in flexion, lateral bending, and rotation (P < 0.05). Histologic evaluation demonstrated that fibers arranged regularly and stained homogeneously. New vessels in growth indicated that the bioderived tendon was survival and processed good regeneration. CONCLUSIONS: Bilateral facet joint stabilization can significantly limit excessive flexion motion and maintain adequate stability. Furthermore, the preservation of extension motions without limiting lateral bending and rotation ideally simulates the features of the posterior ligamentous complex. This preserves the dynamic stability of the lower cervical spine.

Intraoperative conversion of artificial cervical disc replacement to anterior cervical discectomy and fusion for iatrogenic fracture: A rare case report.

RATIONALE: Artificial cervical disc replacement (ACDR) has been reported to be an effective and safe surgical treatment for cervical spondylosis. However, iatrogenic fracture during ACDR surgery has rarely been reported. Considering its infrequency, we report a rare clinical case, with the aim of sharing our experience and exploring when to convert ACDR to fusion intraoperatively. PATIENTS CONCERNS: A 47-year-old woman felt neck pain with weakness and numbness in both upper limbs for 5 months. DIAGNOSES: The patient had received discectomy and fusion procedure on C3/4 and C5/6 to relieve her radicular pain nearly 4 years prior. Neurologic examination revealed a diminished sensation at the C6-C8 skin areas and level Grade-4 power in the left wrist extensor and grip muscle strength. Magnetic resonance imaging (MRI) showed disc herniation compressing the spinal cord at C6/7. Computed tomography (CT) scans showed intervertebral fusion in both the C3/4 and C5/6 segments. INTERVENTIONS: Surgery was performed to remove the plate and replace C6/7 with an artificial disc, but a transverse cleavage endplate cortical fracture was detected after cutting the blades. Thus, we terminated artificial cervical disc replacement intraoperatively and changed to discectomy and fusion in C6/7. OUTCOMES: The patient's symptoms were remarkably relieved. Postoperative CT scans showed a transverse cleavage fracture in the backside of the C6 caudal endplate. Good fusion was achieved after 6 months. LESSONS: Iatrogenic fracture during ACDR is rare but does occur in clinic practice. Complete examination and an alternative approach determined before surgery are important for operative safety. Anterior cervical discectomy and fusion (ACDF) is recommended as a feasible remedial surgical strategy if ACDR fails intraoperatively.

[Effects of transforming growth factor-beta1 on rat cardiocyte hypertrophy].

AIM: To investigate the effects of transforming growth factor-beta1 (TGF-beta1) and signal protein Smad3 on rat myocardial hypertrophy. METHODS: The total protein was analysed by flow cytometer assay to judge the hypertrophy of myocardial cell incubated with different level of TGF-beta1 in cultured myocardial cells of neonatal rats. The models of rat cardiac hypertrophy were produced with constriction of the abdominal aorta. At the different time after the operation, the rats were killed, and the left ventricular mass indexes (LVMl) were investigated. The mRNA expressions of TGF-beta1 and Smad3 of cultured cells and hypertrophic left ventricles were assessed by RT-PCR, the protein expressions of Smad3 were assessed by Western blot. RESULTS: In cultured neonatal myocardial cells, different level TGF-beta1 could significantly increase the total protein, and TGF-beta1 (3 ng/ml) could increase the expression of mRNA and protein of Smad3 and continued for 8 h of cultured cardiomyocytes. The LVMI and the expression of TGF-beta1 mRNA and Smad3 mRNA/protein of hypertrophic left ventricle were increased at the 3rd day after the operation and continued for 4 weeks. The peak expression of them was in 2 weeks after operation. CONCLUSION: TGF-beta1 has the effects on rat myocardial hypertrophy, signal protein Smad3 is included in the pathologic progress of rat myocardial hypertrophy.