Primary liver transplantation vs transplant after Kasai portoenterostomy in children with biliary atresia: A retrospective Brazilian single-center cohort

BACKGROUND Biliary atresia(BA)is the most common indication for pediatric liver transplantation,although portoenterostomy is usually performed first.However,due to the high failure rate of portoenterostomy,liver transplantation has been advocated as the primary procedure for patients with BA.It is still unclear if a previous portoenterostomy has a negative impact on liver transplantation outcomes.AIM To investigate the effect of prior portoenterostomy in infants un-dergoing liver transplantation for BA.METHODS This was a retrospective cohort study of 42 pediatric patients with BA who underwent primary liver transplantation from 2013 to 2023 at a single tertiary center in Brazil.Patients with BA were divided into two groups:Those undergoing primary liver transplantation without portoenterostomy and those undergoing liver transplantation with prior portoenterostomy.Continuous variables were compared using the Student’s t-test or the Kruskal-Wallis test,and categorical variables were compared using theχ2 or Fisher’s exact test,as appropriate.Multivariable Cox regression analysis was performed to determine risk factors for portal vein thrombosis.Patient and graft survival analyses were conducted with the Kaplan–Meier product-limit estimator,and patient subgroups were compared using the two-sided log-rank test.RESULTS Forty-two patients were included in the study(25[60%]girls),23 undergoing liver transplantation without prior portoenterostomy,and 19 undergoing liver transplantation with prior portoenterostomy.Patients with prior portoenterostomy were older(12 vs 8 months;P=0.02)at the time of liver transplantation and had lower Pediatric End-Stage Liver Disease scores(13.2 vs 21.4;P=0.01).The majority of the patients(35/42,83%)underwent livingdonor liver transplantation.The group of patients without prior portoenterostomy appeared to have a higher incidence of portal vein thrombosis(39 vs 11%),but this result did not reach statistical significance.Prior portoenterostomy was not a protective factor against portal vein thrombosis in the multivariable analysis after adjusting for age at liver transplantation,graft-to-recipient weight ratio,and use of vascular grafts.Finally,the groups did not significantly differ in terms of post-transplant survival.CONCLUSION In our study,prior portoenterostomy did not significantly affect the outcomes of liver transplantation.

Impact of multidrug resistance on the management of bacterial infections in cirrhosis

Patients with cirrhosis have an increased risk of infection and differently from other complications,that over the years are improving in their outcomes,infections in cirrhotic patients are still a major cause of hospitalization and death(up to 50%in-hospital mortality).Infections by multidrug-resistant organisms(MDRO)have become a major challenge in the management of cirrhotic patients with significant prognostic and cost-related impact.About one third of cirrhotic patients with bacterial infections is infected with MDR bacteria and their prevalence has increased in recent years.MDR infections have a worse prognosis compared to infections by non-resistant bacteria because they are associated with lower rate of infection resolution.An adequate management of cirrhotic patients with infections caused by MDR bacteria depends on the knowledge of some epidemiological aspects,such as the type of infection(spontaneous bacterial peritonitis,pneumonia,urinary tract infection and spontaneous bacteremia),bacteriological profile of antibiotic resistance at each health care unit and site of infection acquisition(community acquired,healthcare associated or nosocomial).Furthermore,regional variations in the prevalence of MDR infections determine that the choice of empirical antibiotic therapy must be adapted to the local microbiological epidemiology.Antibiotic treatment is the most effective measure to treat infections caused by MDRO.Therefore,optimizing antibiotic prescribing is critical to effectively treat these infections.Identification of risk factors for multidrug resistance is essential to define the best antibiotic treatment strategy in each case and the choice of an effective empirical antibiotic therapy and its early administration is cardinal to reduce mortality.On the other hand,the supply of new agents to treat these infections is very limited.Thus,specific protocols that include preventive measures must be implemented in order to limit the negative impact of this severe complication in cirrhotic patients.

Liver volumetric and anatomic assessment in living donor liver transplantation: The role of modern imaging and artificial intelligence

The shortage of deceased donor organs has prompted the development of alternative liver grafts for transplantation.Living-donor liver transplantation(LDLT)has emerged as a viable option,expanding the donor pool and enabling timely transplantation with favorable graft function and improved long-term outcomes.An accurate evaluation of the donor liver’s volumetry(LV)and anatomical study is crucial to ensure adequate future liver remnant,graft volume and precise liver resection.Thus,ensuring donor safety and an appropriate graftto-recipient weight ratio.Manual LV(MLV)using computed tomography has traditionally been considered the gold standard for assessing liver volume.However,the method has been limited by cost,subjectivity,and variability.Automated LV techniques employing advanced segmentation algorithms offer improved reproducibility,reduced variability,and enhanced efficiency compared to manual measurements.However,the accuracy of automated LV requires further investigation.The study provides a comprehensive review of traditional and emerging LV methods,including semi-automated image processing,automated LV techniques,and machine learning-based approaches.Additionally,the study discusses the respective strengths and weaknesses of each of the aforementioned techniques.The use of artificial intelligence(AI)technologies,including machine learning and deep learning,is expected to become a routine part of surgical planning in the near future.The implementation of AI is expected to enable faster and more accurate image study interpretations,improve workflow efficiency,and enhance the safety,speed,and cost-effectiveness of the procedures.Accurate preoperative assessment of the liver plays a crucial role in ensuring safe donor selection and improved outcomes in LDLT.MLV has inherent limitations that have led to the adoption of semi-automated and automated software solutions.Moreover,AI has tremendous potential for LV and segmentation;however,its widespread use is hindered by cost and availability.Therefore,the integration of multiple specialties is necessary to embrace technology and explore its possibilities,ranging from patient counseling to intraoperative decision-making through automation and AI.

Liver transplantation and alcoholic liver disease:History,controversies,and considerations

Alcohol consumption accounts for 3.8% of annual global mortality worldwide, and the majority of these deaths are due to alcoholic liver disease(ALD), mainly alcoholic cirrhosis. ALD is one of the most common indications for liver transplantation(LT). However, it remains a complicated topic on both medical and ethical grounds, as it is seen by many as a "self-inflicted disease". One of the strongest ethical arguments against LT for ALD is the probability of relapse. However, ALD remains a common indication for LT worldwide. For a patient to be placed on an LT waiting list, 6 mo of abstinence must have been achieved for most LT centers. However, this "6-mo rule" is an arbitrary threshold and has never been shown to affect survival, sobriety, or other outcomes. Recent studies have shown similar survival rates among individuals who undergo LT for ALD and those who undergo LT for other chronic causes of end-stage liver disease. There are specific factors that should be addressed when evaluating LT patients with ALD because these patients commonly have a high prevalence of multisystem alcohol-related changes. Risk factors for relapse include the presence of anxiety or depressive disorders, short pre-LT duration of sobriety, and lack of social support. Identification of risk factors and strengthening of the social support system may decrease relapse among these patients. Family counseling for LT candidates is highly encouraged to prevent alcohol consumption relapse. Relapse has been associated with unique histopathological changes, graft damage, graft loss, and even decreased survival in some studies. Research has demonstrated the importance of a multidisciplinary evaluation of LT candidates. Complete abstinence should be attempted to overcome addiction issues and to allow spontaneous liver recovery. Abstinence is the cornerstone of ALD therapy. Psychotherapies, including 12-step facilitation therapy, cognitive-behavioral therapy, and motivational enhancement therapy, help support abstinence. Nutritional therapy helps to reverse muscle wasting, weight loss, vitamin deficiencies, and trace element deficiencies associated with ALD. For muscular recovery, supervised physical activity has been shown to lead to a gain in muscle mass and improvement of functional activity. Early LT for acute alcoholic hepatitis has been the subject of recent clinical studies, with encouraging results in highly selected patients. The survival rates after LT for ALD are comparable to those of patients who underwent LT for other indications. Patients that undergo LT for ALD and survive over 5 years have a higher risk of cardiorespiratory disease, cerebrovascular events, and de novo malignancy.

Immune aspects of hepatocellular carcinoma:From immune markers for early detection to immunotherapy

Hepatocellular carcinoma(HCC)is one of the most prevalent cancers and one of the main causes of cancer-related deaths worldwide.Most HCCs develop in an inflammatory microenvironment,and mounting evidence emphasizes the importance of immune aspects in hepatocarcinogenesis.In normal physiology,both innate and adaptive immune responses are responsible for eliminating malignantly transformed cells,thus preventing the development of liver cancer.However,in the setting of impaired natural killer cells and exhaustion of T cells,HCC can develop.The immunogenic features of HCC have relevant clinical implications.There is a large number of immune markers currently being studied for the early detection of liver cancer,which would be critical in order to improve surveillance programs.Moreover,novel immunotherapies have recently been proven to be effective,and the combination of atezolizumab and bevacizumab is currently the most effective treatment for advanced HCC.It is expected that in the near future different subgroups of patients will benefit from specific immunotherapy.The better we understand the immune aspects of HCC,the greater the benefit to patients through surveillance aiming for early detection of liver cancer,which allows for curative treatments,and,in cases of advanced disease,through the selection of the best possible therapy for each individual.

Albumin administration in patients with cirrhosis: Current role and novel perspectives

Mortality in cirrhosis is mostly associated with the development of clinical decompensation,characterized by ascites,hepatic encephalopathy,variceal bleeding,or jaundice.Therefore,it is important to prevent and manage such complications.Traditionally,the pathophysiology of decompensated cirrhosis was explained by the peripheral arterial vasodilation hypothesis,but it is currently understood that decompensation might also be driven by a systemic inflammatory state(the systemic inflammation hypothesis).Considering its oncotic and nononcotic properties,albumin has been thoroughly evaluated in the prevention and management of several of these decompensating events.There are formal evidence-based recommendations from international medical societies proposing that albumin be administered in individuals with cirrhosis undergoing large-volume paracentesis,patients with spontaneous bacterial peritonitis,those with acute kidney injury(even before the etiological diagnosis),and those with hepatorenal syndrome.Moreover,there are a few randomized controlled trials and meta-analyses suggesting a possible role for albumin infusion in patients with cirrhosis and ascites(long-term albumin administration),individuals with hepatic encephalopathy,and those with acute-on-chronic liver failure undergoing modest-volume paracentesis.Further studies are necessary to elucidate whether albumin administration also benefits patients with cirrhosis and other complications,such as individuals with extraperitoneal infections,those hospitalized with decompensated cirrhosis and hypoalbuminemia,and patients with hyponatremia.

Current impact of viral hepatitis on liver cancer development: The challenge remains

Chronic infections due to hepatitis B and hepatitis C viruses are responsible for most cases of hepatocellular carcinoma(HCC)worldwide,and this association is likely to remain during the next decade.Moreover,viral hepatitis-related HCC imposes an important burden on public health in terms of disability-adjusted life years.In order to reduce such a burden,some major challenges must be faced.Universal vaccination against hepatitis B virus,especially in the neonatal period,is probably the most relevant primary preventive measure against the development of HCC.Moreover,considering the large adult population already infected with hepatitis B and C viruses,it is also imperative to identify these individuals to ensure their access to treatment.Both hepatitis B and C currently have highly effective therapies,which are able to diminish the risk of development of liver cancer.Finally,it is essential for individuals at high-risk of HCC to be included in surveillance programs,so that tumors are detected at an early stage.Patients with hepatitis B or C and advanced liver fibrosis or cirrhosis benefit from being followed in a surveillance program.As hepatitis B virus is oncogenic and capable of leading to liver cancer even in individuals with early stages of liver fibrosis,other high-risk groups of patients with hepatitis B are also candidates for surveillance.Considerable effort is required concerning these strategies in order to decrease the incidence and the mortality of viral hepatitis-related HCC.

Cumulative sum analysis score and phacoemulsification competency learning curve

AIM： To use the cumulative sum analysis score（CUSUM） to construct objectively the learning curve of phacoemulsification competency.METHODS： Three second-year residents and an experienced consultant were monitored for a series of 70 phacoemulsification cases each and had their series analysed by CUSUM regarding posterior capsule rupture（PCR） and best-corrected visual acuity. The acceptable rate for PCR was 〈5%（lower limit h） and the unacceptable rate was 〉10%（upper limit h）. The acceptable rate for bestcorrected visual acuity worse than 20/40 was 〈10%（lower limit h） and the unacceptable rate was 〉20%（upper limit h）. The area between lower limit h and upper limit h is called the decision interval. RESULTS： There was no statistically significant difference in the mean age, sex or cataract grades between groups. The first trainee achieved PCR CUSUM competency at his 22 nd case. His best-corrected visual acuity CUSUM was in the decision interval from his third case and stayed there until the end, never reaching competency. The second trainee achieved PCR CUSUM competency at his 39^ th case. He could reach best-corrected visual acuity CUSUM competency at his 22 ^nd case. The third trainee achieved PCR CUSUM competency at his 41 st case. He reached bestcorrected visual acuity CUSUM competency at his 14 ^th case.CONCLUSION： The learning curve of competency in phacoemulsification is constructed by CUSUM and in average took 38 cases for each trainee to achieve it.

Acute pancreatitis complicated with splenic rupture: A case report

Atraumatic splenic rupture is an uncommon complication of acute pancreatitis. This report describes the case of a 30-year-old man with acute pancreatitis and splenic vein thrombosis complicated by splenic rupture. The patient was admitted to the emergency department with pain in the upper abdomen that had been present for six hours and was associated with vomiting and sweating. He was diagnosed with acute pancreatitis of alcoholic etiology. Upon computed tomography(CT) of the abdomen, the pancreatitis was scored as Balthazar C grade, and a suspicious area of necrosis affecting 30% of the pancreas with splenic vein thrombosis was revealed. Seventytwo hours after admission, the patient had significant improvement in symptoms. However, he showed clinical worsening on the sixth day of hospitalization, with increasing abdominal distension and reduced hemoglobin levels. A CT angiography showed a large amount of free fluid in the abdominal cavity, along with a large splenic hematoma and contrast extravasation along the spleen artery. The patient subsequently underwent laparotomy, which showed hemoperitoneum due to rupture of the splenic parenchyma. A splenectomy was then performed, followed by ultrasound-guided percutaneous drainage.

Hepatocellular carcinoma in nonalcoholic fatty liver disease:A growing challenge

Nonalcoholic fatty liver disease(NAFLD)is the most common cause of liver disease worldwide,and its prevalence increases continuously.As it predisposes to hepatocellular carcinoma both in the presence and in the absence of cirrhosis,it is not surprising that the incidence of NAFLD-related hepatocellular carcinoma would also rise.Some of the mechanisms involved in hepatocarcinogenesis are particular to individuals with fatty liver,and they help explain why liver cancer develops even in patients without cirrhosis.Genetic and immune-mediated mechanisms seem to play an important role in the development of hepatocellular carcinoma in this population.Currently,it is consensual that patients with NAFLD-related cirrhosis should be surveilled with ultrasonography every 6 mo(with or without alpha-fetoprotein),but it is known that they are less likely to follow this recommendation than individuals with other kinds of liver disease.Moreover,the performance of the methods of surveillance are lower in NAFLD than they are in other liver diseases.Furthermore,it is not clear which subgroups of patients without cirrhosis should undergo surveillance.Understanding the mechanisms of hepatocarcinogenesis in NAFLD could hopefully lead to the identification of biomarkers to be used in the surveillance for liver cancer in these individuals.By improving surveillance,tumors could be detected in earlier stages,amenable to curative treatments.

Testosterone replacement maintains smooth muscle content in the corpus cavernosum of orchiectomized rats

Objective:To evaluate the effects of testosterone(T)on the maintenance of corpus cavernosum(CC)structure and apoptosis.Methods:Animals were divided into three groups:sham operation group(n Z 8)underwent sham operation;Orchiectomized(Orchiec)t oily vehicle group(n Z 8)underwent bilateral orchiectomy and received a single dose of oily vehicle by intramuscular injection(i.m.)30 days after orchiectomy;and Orchiec t T group(n Z 8)underwent bilateral orchiectomy and received a single dose of T undecanoate 100 mg/kg i.m.30 days after the surgery.Animals were euthanized 60 days after the beginning of the experiment with an anesthetic overdose of ketamine and xylazine.Blood samples and penile tissue were collected on euthanasia.

Risk factors associated with inflammatory bowel disease: A multicenter case-control study in Brazil

BACKGROUND The etiology of inflammatory bowel disease(IBD)is unknown,but it is believed to be multifactorial.The hygiene hypothesis proposes that better hygiene conditions would lead to less infectious disease during childhood and favor the development of immune-mediated diseases.AIM To test the hygiene hypothesis in IBD by assessing the environmental risk factors associated with IBD development in different regions of Brazil with diverse socioeconomic development indices.METHODS A multicenter case-control study was carried out with 548 Crohn’s disease(CD)and 492 ulcerative colitis(UC)outpatients and 416 healthy controls,from six IBD centers within different Brazilian states at diverse socioeconomic development stages.A semi-structured questionnaire with 87 socioeconomic and environmental questions was applied.Logistic regression model was created to assess the odds ratio(OR)with P value and 95%confidence intervals(CI).RESULTS Predictive variables for both diseases(CD and UC)were women[odd ratios(OR)=1.31;OR=1.69],low monthly family income(OR=1.78;OR=1.57),lower number of cohabitants(OR=1.70;OR=1.60),absence of vaccination(OR=3.11;OR=2.51),previous history of bowel infections(OR=1.78;OR=1.49),and family history of IBD(OR=5.26;OR=3.33).Associated risk factors for CD were age(18-39 years)(OR=1.73),higher educational level(OR=2.22),absence of infectious childhood diseases(OR=1.99).The UC predictive variables were living in an urban area(OR=1.62),inadequate living conditions(OR=1.48)and former smokers(OR=3.36).Appendectomy was a risk factor for CD(OR=1.58)with inverse association with UC(OR=4.79).Consumption of treated and untreated water was associated with risk of CD(OR=1.38)and UC(OR=1.53),respectively.CONCLUSION This is the first examining environmental exposures as risk factors for inflammatory bowel disease in Brazil.Most of the variables associated with disease risk support the role of the hygiene hypothesis in IBD development.

Non-alcoholic fatty liver disease-related hepatocellular carcinoma:Is there a role for immunotherapy?

Hepatocellular carcinoma(HCC)is among the most common cancers and it is a major cause of cancer-related deaths.Non-alcoholic fatty liver disease(NAFLD)affects approximately one fourth of individuals worldwide and it is becoming one of the most important causes of HCC.The pathogenic mechanisms leading to NAFLD-related HCC are complex and not completely understood.However,metabolic,fibrogenic,oncogenic,inflammatory and immunological pathways seem to be involved.First-line therapy of advanced HCC has recently undergone major changes,since the combination of atezolizumab and bevacizumab was proven to increase survival when compared to sorafenib.Other immune-oncology drugs are also demonstrating promising results in patients with advanced HCC when compared to traditional systemic therapy.However,initial studies raised concerns that the advantages of immunotherapy might depend on the underlying liver disease,which seems to be particularly important in NAFLD-related HCC,as these tumors might not benefit from it.This article will review the mechanisms of NAFLD-related hepatocarcinogenesis,with an emphasis on its immune aspects,the efficacy of traditional systemic therapy for advanced NAFLD-related HCC,and the most recent data on the role of immunotherapy for this specific group of patients,showing that the management of this condition should be individualized and that a general recommendation cannot be made at this time.

Vitamin D deficiency,functional status,and balance in older adults with osteoarthritis

BACKGROUND Low vitamin D levels are associated with a more severe case of knee osteoarthritis(OA).However,there are few published reports concerning an association between vitamin D deficiency and functional status of individuals with OA and no reports about postural balance in this population.AIM To analyze the relationship between vitamin D deficiency and severity,functional status,and balance in elderly patients with OA.METHODS In this cross-sectional study,105 elderly patients with hip and knee OA were included.The severity was assessed by the Kellgren-Lawrence criteria.The functional status was assessed with the Lequesne index.Postural balance was assessed using a force platform,and center-of-pressure parameters(velocity at anteroposterior and mediolateral axis)were used as the balance outcomes.Serum 25(OH)vitamin D levels were measured using a chemiluminescence method.RESULTS Most of the patients(mean age:70.6±6.5 years)were female(n=78,74.3%).In the group with vitamin D deficiency,43 patients(56.6%)had severe OA,while 33 patients(43.4%)had mild or moderate OA(χ^(2) test,P=0.04).Patients with vitamin D deficiency showed a higher Lequesne index score(Mann-Whitney test,P=0.04),indicating a worse functional impairment when compared to individuals with normal vitamin D levels.Additionally,patients with vitamin D deficiency had worse postural balance according to the Mann-Whitney test(P=0.03).CONCLUSION Vitamin D deficiency is associated with worse severity,functional status,and postural balance in patients with OA.

Interleukin 28B-related polymorphisms: A pathway for understanding hepatitis C virus infection?

AIM:To analyze the role of rs12979860 and rs8099917polymorphisms in hepatitis C virus(HCV)genotype 1infection of Brazilians.METHODS:A total of 145 adult patients diagnosed with genotype 1 chronic hepatitis C(CHC)who had completed a 48-wk regimen of pegylated-interferonα-2a or-2b plus ribavirin combination therapy were recruited from six large urban healthcare centers and199 healthy blood donors(controls)from a single site between January 2010 and January 2012.Data on the patients’response to treatment was collected.Polymerase chain reaction-restriction fragment length polymorphism genotyping of the interleukin(IL)28B gene fragment encompassing the single nucleotide polymorphisms(SNPs)rs12979860(C/T)and rs8099917(T/G)was carried out for 79 of the CHC patients and 199 of the controls.Bi-directional amplicon sequencing of the two SNPs was carried out for the remaining 66 CHC patients.RESULTS:SNP rs12979860 genotyping was successful in 99.5%of the controls and 97.2%of the CHC patients,whereas the SNP rs8099917 genotyping was successful in 95.5%of the controls and 100%of the CHC patients.The genotype and allele distributions for both rs12979860 and rs8099917 were significantly different between the control and CHC patient groups,with significantly higher genotype frequencies of CC and TT in the controls(P=0.037 and 0.046,respectively)and of TT and GG in the CHC patients(P=0.0009and 0.0001,respectively).Analysis of the CHC patients who achieved sustained virological response(SVR)to treatment(n=55)indicated that the rs12979860 C allele and CC genotype were predictors of SVR(P=0.02).No significant correlation was found between rs8099917 genotypes and treatment response,but carriers of the T allele showed significantly higher rates of SVR(P=0.02).Linkage disequilibrium analysis of the group that achieved SVR showed a significant association between rs12979860 and rs8099917(P=0.07).CONCLUSION:The higher allele frequency of rs12979860 C and rs8099917 T observed in non-HCVinfected individuals may indicate a potential protective role for these IL28B-related polymorphisms.

Ultrasound-Guided Central Venous Catheterization: A Protocol to Be Followed in Pediatrics?

Objective: To investigate the effectiveness of ultrasound-guided central venous catheterization when compared to the conventional procedure. Method: A prospective cohort study was carried out over a 9-month period from February to October 2016 involving 144 inpatients at PICU of Irmandade da Santa Casa de Sao Paulo Hospital, undergoing central venous catheterization. The patients were matched in pairs of identical patients according to the levels of potentially intervening variables (age, nutritional status, puncture site, professional experience), differing only as to the CVC technique: ultrasound-guided (USG-CVC) or conventional (C-CVC). Discarding data from non-paired patients, the remaining did forming 47 pairs, matched as two related samples: USG-CVC and C-CVC groups. Success parameters: number of puncture attempts;time spent at CVC;success rate and complications. Results: In the USG-CVC group, the number of attempts (mean = 2.04) and the time spent at catheterization (mean = 11.89 minutes) were lower (t = 2.34, df = 46, t 0.95 = 2.02, p t = 3.07, df = 46, t 0.95 = 2.02, p < 0.05), respectively, when compared to the results obtained for the control group (C-GVC), (mean = 3.21) and (mean = 28.26 minutes), respectively. As to success, there was observed a significant difference (F (1, 46) = 16.6;Q (1) = 12.5, p < 005) when considering only one trial (USG -CVC = 27/47;C-CVC = 9/47), but no significant difference (F (1, 46) = 3.76;Q (1) = 3.56, p > 0.05) when considering several attempts. Complications were found less frequently in the USG-CVC group (3/47) than in the CVC-C (13/47), (F (1, 46) = 8.24;Q (1) = 7.14, p < 0.05). Conclusion: USG-CVC was found to be more effective than the conventional technique, especially regarding success at the first puncture attempt.

Total Knee Arthroplasty:Patellar Replacement’s Influence in Patient Quality of Life Postoperatively

Objective: To study the influence of patellar resurfacing on quality of life under a standardised score. The chosen score was the Knee Society Score (KSS), which considers range of motion, pain, contractors, alignment and stability. Methods: Retrospective review of 60 patients submitted to total knee arthroplasty (TKA) was divided into two groups: with patellar resurfacing (PR) and without patellar resurfacing (NPR). We reviewed data from these patients containing the KSS, which are routinely used in our service. Data were analysed from 2013 to 2014, with a minimal patient follow-up of 18 months. Results: There were no unsatisfactory scores in our study. Total scores (KSS) were similar between the groups (mean KSS: PR = 88.36 ± 9.64;NPR = 84.26 ± 9.44 [p = 0.1]). While stratifying into groups (poor, fair, good, excellent), we found excellent results in 84.8% of PR versus 59.3% NPR (p = 0.056). These data did not reach statistical significance and can therefore be considered a coincidental result. Conclusion: Although these results did not show statistical significance (p = 0.056), patellar resurfacing patients tend to get more “excellent” results after 18 months of follow-up in quality of life when evaluated by KSS. Perhaps a larger amount of patients would suffice to acquire statistical significance in a future study.

单剂量放线菌素D对青春期高危葡萄胎患者葡萄胎后妊娠滋养细胞肿瘤预防性治疗的功效

Objective.:To evaluate the efficacy of a single prophylactic dose of actinomycin D (Act-D) in the reduction of postmolar gestational trophoblastic neoplasia (GTN) in adolescents with high-risk hydatidiform mole (Hr-HM). Methods.:In a retrospective study,60 adolescents with Hr-HM were selected from a cohort of patients with gestational trophoblastic disease (GTD)-followed at Santa Casa,Porto Alegre,Brasil. Twenty-nine received a single dose of Act-D at the time of uterine evacuation as prophylactic chemotherapy (P-chem) (study group) and 31 patients with the same risk factors did not received P-chem (control group). Patient follow-up was the same in both groups. Each group was analyzed for number of adolescents with postmolar GTN,morbidity associated with postmolar GTN,and reproductive outcomes. Results.:Postmolar GTN was diagnosed in two (6.9%) adolescents (95%CI,0.0-16.1) in the study group and in 9 (29.0%) patients (95%CI,13-45) in the control group. The reduction of postmolar GTN with a single dose of Act-D used as P-chem was 76%(relative risk = 0.24; 95%CI,0.06-0.99). Adverse effects of P-chem were minor. In the follow-up,when postmolar GTN were diagnosed,severity of disease was not increased,compliance with follow-up was not reduced,and reproductive outcomes after discharge were similar. Conclusions.:P-chem with a single dose of Act-D reduced postmolar GTN in 76%during follow-up of adolescents with Hr-HM. Since this regimen may reduce treatment costs,without affecting compliance with follow-up,it can be adopted by any Trophoblastic Disease Center.

A Case Report of Calcifying Epithelioma of Malherbe(Pilomatrixoma)Mimicking Breast Carcinoma in Male Patient

Pilomatricoma or calcifying epithelioma of Malherbe is a rare benign tumor of the skin and/or the subcutaneous tissue originating from the hair matrix. It is usually seen in children and adolescents, however a smaller second peak of onset is seen in the elderly. The head, neck, or upper extremities are the most common anatomical sites of pilomatricomas, being less frequently seen on the trunk and lower extremities, and very rarely have they been diagnosed in the breast. Its malignant counterpart, pilomatrix carcinoma, is rare and found more often in men. Due to its incapacity of regression, treatment consists of surgical excision. We present the case of a man with a pilomatrixoma of the breast, presenting as ACR BI-RADS 4, and we review the literature regarding pilomatrixomas.

Artificial intelligence and human liver allocation:Potential benefits and ethical implications

Since its implementation almost two decades ago,the urgency allocation policy has improved the survival of patients on the waiting list for liver transplantation worldwide.The Model for End-Stage Liver Disease score is widely used to predict waiting list mortality.Due to some limitations related to its use,there is an active investigation to develop other prognostic scores.Liver allocation(LA)entails complex decision-making,and grafts are occasionally not directed to the recipients who are more likely to survive.Prognostic scores have,thus far,failed to predict post-operatory survival.Furthermore,the increasing use of marginal donors is associated with worse outcomes.Adequate donor-recipient pairing could help avoid retransplantation or futile procedures and reduce postoperative complications,mortality,hospitalization time,and costs.Artificial intelligence has applications in several medical fields.Machine learning algorithms(MLAs)use large amounts of data to detect unforeseen patterns and complex interactions between variables.Artificial neural networks and decision trees were the most common forms of MLA tested on LA.Some researchers have shown them to be superior for predicting waiting list mortality and graft failure than conventional statistical methods.These promising techniques are increasingly being considered for implementation.