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Background Liver transplantation (LT) can significantly improve mortality for severe alcoholic hepatitis (AH). However, this practice remains controversial. Our aim is to report the findings from our institution regarding outcomes for LT in severe AH and to discuss the results of a pilot program for discharging selected patients with close follow-up, in order to demonstrate sustained outpatient sobriety before listing. Methods Patient records were reviewed retrospectively from January 1, 2015 to January 17, 2018. The primary outcomes were patient and graft survival after LT. Secondary outcomes included relapse rates after LT, survival for those not transplanted, and reasons for denial among those not approved for transplant listing. Results A total of 18 patients with severe AH were considered for LT, of which 10 were transplanted and 8 were either denied transplantation or died before completing the evaluation. Patient and graft survival rates were 100% among those transplanted, and only 1 of the 10 patients (10%) returned to harmful drinking. In comparison, 6 of 8 (75%) of patients not transplanted died. Among the 10 patients transplanted, 4 were initially not approved for listing and were discharged with close follow-up, to demonstrate outpatient sobriety. All 4 of those patients demonstrated short-term abstinence and ultimately underwent transplantation, with no instances of relapse post-LT. Conclusions Liver transplantation for AH can achieve excellent outcomes with low rates of relapse. Carefully selected patients can be discharged with close monitoring to demonstrate commitment to outpatient sobriety prior to transplant listing.

This front-end engineering and design (FEED) study is for a carbon dioxide (CO2) capture system for Unit #2 (816 MW) at the Prairie State Generating Company’s (PSGC) Energy Campus in Marissa, IL. The capture technology used is the Advanced KM CDR Process™ from Mitsubishi Heavy Industries (MHI). The project will be the largest post-combustion capture plant in the world. In addition, it will incorporate advancements in the technology including lessons learned from past projects and a new proprietary solvent. The overall business model being developed by PSGC focuses on the generation of 45Q tax credits as a result of sequestering the captured CO2. Because the Prairie Research Institute (PRI) within the University of Illinois at Urbana-Champaign (UIUC) leads both this capture effort and the storage effort, there is close coordination and integration between the capture and storage efforts. This integration is vital to achieving the desired business targets for the project.

Alcoholic hepatitis (AH) is a condition of acute liver inflammation in the setting of heavy alcohol use that is often managed with corticosteroids in severe cases. Among non-responders to steroids, however, prognosis is poor with up to 75% mortality within 6 months after treatment failure. Early liver transplantation (LT) can achieve an acceptable short-term survival, and initial studies have demonstrated 3-year survival rates of up to 84%. However, the practice of early LT in severe AH remains controversial with concerns over the 6-month rule of sobriety and risk of alcohol relapse post-transplant. Proponents of LT advocate for better understanding of alcohol use as a disorder rather than self-inflicted cause of illness, aim to redefine the misguided application of the 6-month rule, and point out similar relapse rates among patients with early LT and those with greater than 6 months abstinence before transplant. Opponents of LT emphasize the correlation between alcohol relapse and graft failure and mortality, public resistance and potential for distrust among donors, and arguments that transplant centers need to establish improved models to predict relapse and standardize candidate selection criteria across centers. Here we review recent literature on this controversy and provide recommendations for moving forward to consensus.

Introduction Heart failure guidelines recommend that patients with acute decompensated heart failure (ADHF) be transitioned to oral (PO) loop diuretics prior to discharge but little evidence supports this recommendation. Objectives We sought to identify the frequency that patients admitted for ADHF are transitioned to PO loop diuretics prior to discharge, identify predictors for transitioning to PO loop diuretics, and compare outcomes between patients converted to PO loop diuretics (PO group) to those who were not (IV group). Methods We conducted a retrospective chart review of unique adult patients hospitalized for ADHF at our facility between 9/1/2017 and 8/31/2019. Patients hospitalized for ADHF (ICD-10 I50.xx) with evidence of fluid overload, treated with IV loop diuretics during the first 24 hours of admission, and discharged home with a prescription for PO loop diuretic were included. Patients were excluded if they were on dialysis, left against medical advice, received palliative care referral while inpatient, or had a history of cirrhosis or received > 50mg of aldosterone antagonist a day. Patient demographics, clinical features, and practice patterns were characterized to identify predictors of PO transition. Thirty-day readmission rates were compared between the PO and IV groups. Results Among 240 patients included, 155 (65%) patients were transitioned to PO loop diuretics prior to discharge (PO group). Mean age was 63 years, most were men (55%) of African American (66%) descent. Compared to the IV group, the PO group had higher baseline potassium (4.3 vs 4.1 mEq/L, p=0.010), lower eGFR (52 vs 60 mL/min/1.73m2, p=0.016), were less likely to be on hydralazine (12.9% vs 24.7%, p=0.020), and more likely to be on a thiazide-type diuretic (9.7% vs 2.4%, p=0.034) on admission. Neither age, gender, blood pressure, renal function, nor electrolytes were significant predictors of transitioning to PO loop diuretics prior to hospital discharge. Within 30 days, 36 (23.2%) patients in the PO group were rehospitalized compared to 19 (22.4%) patients in the IV group (p=0.88). Conclusions Most patients admitted for ADHF were transitioned to PO loop diuretics prior to discharge. Although differences were noted in baseline characteristics, we did not identify any significant predictors for patients transitioned to PO diuretics. Thirty-day readmission rates were similar between patients who were and were not transitioned. Further study is warranted to identify the best approach for transitioning ADHF patients to PO diuretics prior to discharge.

Background Carotid endarterectomy (CEA) as treatment in patients with asymptomatic carotid stenosis is the subject of much debate. Methods The National Surgical Quality Improvement Program database from 2005 to 2012 was queried. Patients undergoing CEA for asymptomatic carotid stenosis were identified. Preoperative risk factors and patient demographics were compared using chi-square analysis and logistic regression to determine their relation with stroke and death. Results During an 8-year period, 24,211 CEAs performed for asymptomatic carotid stenosis were identified. Patients with dependent functional status (12.5%), recent myocardial infarction (6.3%), chronic heart failure (5.0%), hypoalbuminemia (4.8%), angina (4.1%), dialysis dependence (3.4%), steroid dependence (3.4%), chronic obstructive pulmonary disease (3.3%), and American Society of Anesthesiologists > 3 (3.2%) had a clinically significant increase in risk of stroke and death. Patients with none of the above risk factors had a stroke and death rate of 1.08%, which was significantly less than the overall stroke and death rate ( P Conclusions A high-risk subset of patients undergoing CEA for asymptomatic carotid stenosis can be identified. If patient selection is optimized and perioperative morbidity and mortality are minimized, CEA will continue to play an important role in stroke prevention for those with significant asymptomatic carotid stenosis.

Background & Aims Liver transplantation for patients with acute-on-chronic liver failure (ACLF) with 3 or more failing organs (ACLF-3) is controversial. We compared liver waitlist mortality or removal according to model for end-stage liver disease (MELD) score vs ACLF category. We also studied factors associated with reduced odds of survival for 1 year after liver transplantation in patients with ACLF-3. Methods We analyzed data from the United Network for Organ Sharing (UNOS) from 2005 through 2016. We identified patients who were on the waitlist (100,594) and those who received liver transplants (50,552). Patients with ACLF were identified based on the European Association for the Study of the Liver-chronic liver failure criteria. Outcomes were evaluated with competing risks regression, Kaplan-Meier analysis, and Cox proportional hazards regression. Results Patients with ACLF-3 were more likely to die or be removed from the waitlist, regardless of MELD-sodium (MELD-Na) score, compared with the other ACLF groups; the proportion was greatest for patients with an ACLF-3 score and MELD-Na score below 25 (43.8% at 28 days). Mechanical ventilation at liver transplantation (hazard ratio [HR] 1.49; 95% confidence interval [CI] 1.22–1.84), donor risk index above 1.7 (HR 1.22; 95% CI 1.09–1.35), and liver transplantation within 30 days of listing (HR 0.89; 95% CI 0.81–0.98) were independently associated with survival for 1 year after liver transplantation Conclusions In an analysis of data from the UNOS registry, we found high mortality among patients with ACLF-3 on the liver transplant waitlist, even among those with lower MELD-Na scores. So, certain patients with ACLF-3 have poor outcomes regardless of MELD-Na score. Liver transplantation increases odds of survival for these patients, particularly if performed within 30 days of placement on the waitlist. Mechanical ventilation at liver transplantation and use of marginal organs were associated with increased risk of death.

ObjectiveProductive communication among clinical practitioners is essential if recommendations regarding practice are to exist. The durability of vascular procedures is often influenced by factors such as lesion classification and runoff quality. It is the purpose of this article to determine how reproducible these measures are in the hands of various specialists who deal extensively with peripheral arterial disease.MethodsThe peripheral arteriograms of 100 patients undergoing percutaneous intervention were distributed to six specialists (three vascular surgeons, two interventional radiologists, and one interventional cardiologist). Each was provided with the reference document describing TASC II classification, Society for Vascular Surgery (SVS) runoff score, and simplified runoff score. With no further instruction, each individual was asked to assign each angiogram a TASC II class, SVS runoff score, and a simplified runoff score. Comparisons between the scores assigned were made using kappa statistic.ResultsWhen using the simplified runoff score for grading peripheral arterial disease, there was excellent correlation among readers (k = 0.81; P = .001), even across different specialties. When using TASC II class to grade lesions, there was a greater degree of variation when compared with the simplified runoff score (k = 0.44; P < .05). Finally, there was poor correlation between readers when using the SVS runoff score (k = 0.10; P < .05) and the modified SVS runoff score (k = 0.26; P = .001).ConclusionsDescriptors of clinical disease severity are not universally reproducible. The simplified runoff score is reproducible when interpreted by multiple readers across different specialties and can be used without further modification. The TASC II classification may need minor alterations in description to obtain good correlation among readers. Before the SVS runoff score can be universally adapted, it will need to be described in much better detail or significantly modified.

SummaryMetabolites in the kynurenine pathway, generated by tryptophan degradation, are thought to play an important role in neurodegenerative disorders, including Alzheimer's and Huntington's diseases. In these disorders, glutamate receptor-mediated excitotoxicity and free radical formation have been correlated with decreased levels of the neuroprotective metabolite kynurenic acid. Here, we describe the synthesis and characterization of JM6, a small-molecule prodrug inhibitor of kynurenine 3-monooxygenase (KMO). Chronic oral administration of JM6 inhibits KMO in the blood, increasing kynurenic acid levels and reducing extracellular glutamate in the brain. In a transgenic mouse model of Alzheimer's disease, JM6 prevents spatial memory deficits, anxiety-related behavior, and synaptic loss. JM6 also extends life span, prevents synaptic loss, and decreases microglial activation in a mouse model of Huntington's disease. These findings support a critical link between tryptophan metabolism in the blood and neurodegeneration, and they provide a foundation for treatment of neurodegenerative diseases.