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Association of Mean Arterial Pressure (MAP) with Mortality in Patients with Liver Cirrhosis Awaiting Transplantation
No full textPurpose: Patients with liver cirrhosis listed for liver transplantation often experience hemodynamic changes, including changes in mean arterial pressure (MAP). Identifying the prognostic impact of MAP on mortality in this population may guide clinical decision-making. This study evaluates the association between MAP and mortality in patients listed for liver transplant. Methods: We conducted a retrospective cohort study of adult patients with liver cirrhosis listed for liver transplantation at a quaternary care center. To ensure comparability, only patients with a Model for End-Stage Liver Disease (MELD) score of 20-24 at the time of listing were included, while those with hepatocellular carcinoma (HCC) were excluded. Data collected included demographic information, mean arterial pressure (MAP) at listing, and clinical factors such as the use of antihypertensive medications, beta-blockers, and midodrine, as well as complications like hepatorenal syndrome (HRS), hepatic encephalopathy (HE), ascites, and variceal bleeding. We used logistic regression models to analyze the relationship between MAP and mortality on the waiting list, adjusting for medications and complications to isolate the independent effect of MAP. Additionally, a two-sample t-test was performed to compare the mean MAP between patients who died and those who survived Results: A total of 103 patients were analyzed. Higher MAP was significantly associated with lower odds of mortality on the waiting list (OR = 0.94, 95% CI: 0.89-0.99, p = 0.041). Each unit increase in MAP was associated with a 6% reduction in mortality risk. The mean MAP was significantly lower in patients who died (76.9 mmHg) compared to those who survived (83.2 mmHg) (p = 0.043). Additionally, higher MAP was associated with a decreased risk of HRS (OR = 0.94, 95% CI: 0.89-0.98, p = 0.011), but no significant associations were found between MAP and HE (OR = 0.97, 95% CI: 0.93-1.02, p = 0.247), ascites (OR = 1.00, 95% CI: 0.95-1.05, p = 0.847), or variceal bleeding (OR = 1.02, 95% CI: 0.95-1.09, p = 0.567). Conclusions: Lower MAP at the time of listing is an independent predictor of mortality in cirrhotic patients awaiting liver transplantation. The association remains robust after controlling for disease severity (MELD score), medications, and common complications. Additionally, low MAP was associated with a higher risk of developing HRS but not with HE, ascites, or variceal bleeding. These findings highlight the potential importance of hemodynamic optimization in this population. CITATION INFORMATION: Alomari A., Saleem A., Althunibat I., Abusuliman M., Dababneh Y., Jomaa D., Abdulraheem A., Mo J., Chen K., Jafri S. Association of Mean Arterial Pressure (MAP) with Mortality in Patients with Liver Cirrhosis Awaiting Transplantation AJT, Volume 25, Issue 8 Supplement 1 DISCLOSURES
Strategies for Success in Endoscopic Retrograde Cholangiopancreatography (ERCP) Intervention in Liver Transplant Patients with Biliary Complications and Altered Intestinal Anatomy
No full textPurpose: Surgically altered anatomy in patients who undergo Liver Transplant (LT) offers a unique challenge to endoscopists. There is limited data regarding the optimal endoscopic approach for the management of biliary complications in this population. We aim to assess the safety, efficacy and outcomes of various endoscopic approaches to managing patients with altered anatomy following LT. Methods: Retrospective data was collected after study approval from our IRB. Individuals who had a history of LT and surgically altered anatomy who subsequently underwent an ERCP from 2017-2024 were selected. Individual charts were reviewed to collect demographic and procedural data. Outcomes included post-procedure complications and technical success. Results: 61 patients were identified who had surgically altered anatomy with a history of LT. Of these, 13 underwent ERCP, for a total of 29 procedures. 24 ERCPs were done in patients with hepaticojejunostomy (HJ), and 5 in Roux-en-Y gastric bypass (RYGB). For patients with HJ, 6(25%) ERCPs were done within 6 months of LT, whereas 2(40%) were done in this timeframe for RYGB. Indications for both groups included jaundice(N=11, 38%), stent management(N=9, 31%), sepsis(N=6, 21%), and others. For the two patients who had RYGB, one had EDGE procedure with same day ERCP and three subsequent ERCPs through the gastrogastric fistula via the lumen apposing metal stent. The other patient had laparoscopy assisted ERCP. For patients with HJ anatomy, adult colonoscope was used in 15(26%) procedures, pediatric colonoscope for 4(17%) procedures, single balloon enteroscope for 4(17%) procedures and 1(4%) was done with a duodenoscope. Rigidizing overtube was used in 9(37.5%) of these procedures. Of these, 6(25%) were unsuccessful, with inability to reach HJ with colonoscope (N=3), excessive looping with single balloon enteroscope (N=1), and inability to locate HJ (N=2). Percutaneous Transhepatic Cholangiogram (PTC) drain placement was required in 3 of the unsuccessful procedures. Adverse events included esophageal mucosal breaks (N=2). Conclusions: We highlight the favorable success rate of endoscopic interventions in this population, with minimal adverse events. This suggest that ERCP can be a first step in managing biliary disease in post-LT patients with altered anatomy. Furthermore, successful interventions through ERCP can reduce the rate of PTC drain placement and the risk of infection related to PTC. Endoscopists should be aware of the various techniques and equipment available for technical success. Larger studies need to be done to establish guidelines for this indication. [Formula presented] CITATION INFORMATION: Faisal M., Faisal M., Saleem A., Karmo B., Hasso M., Chaudhary A., Shahzil M., Jafri S., Zuchelli T. Strategies for Success in Endoscopic Retrograde Cholangiopancreatography (ERCP) Intervention in Liver Transplant Patients with Biliary Complications and Altered Intestinal Anatomy AJT, Volume 25, Issue 8 Supplement 1 DISCLOSURES: M. Faisal: None
From liver to life: The overlooked impact of MASLD on digestive cancer outcomes
No full textBackground: Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) is an increasing public health concern with the potential to increase the development of malignancy of the digestive tract and beyond. We aim to explore mortality trends of digestive cancer (DC) among MASLD patients. Methods: The CDC WONDER database was examined to extract age-adjusted mortality rates (AAMR) regarding DC among MASLD patients aged 25 years and older between 1999 and 2020. Data was stratified by age, gender, race, and U.S geographic regions. Results: 67616 deaths were documented from 1999 to 2020, with an overall AAPC of 2.8 (95% CI 1.99 to 3.62) and total AAMR of 13.6 (95%CI 13.5 to 13.7). Males showed higher mortality rates than females with an overall AAMR of 22.1 (95%CI 21.9 to 22.3). However, female gender showed higher AAPC with value of 3.6 (95%CI 2.88 to 4.32). Slight difference of AAPC between patients aged 55-64 and over 85 years as they showed the highest AAPC with value of 4.23 (95%CI 3.23 to 5.24) and 4.21 (95%CI 2.31 to 6.14) receptively. White race accounted for the highest AAPC followed by African American with 3.11 (95%CI 2.18 to 4.06) and 1.73 (95%CI 0.33 to 3.15) respectively. Conclusions: The highest AAPC was observed among Whites, older males, large central metropolitan residents and West residents. The observed disparities suggest the importance of improving outcomes for DC patients, particularly with MASLD. Keywords: Digestive cancer, MASLD, CDC WONDER, AAPC
Extensive lymph node dissection and overall survival in colon cancer: A systematic review and meta-analysis
No full textBackground: Colon cancer remains a leading cause of cancer-related mortality, with surgical resection and lymph node dissection (LND) being key to recovery treatment. Extensive lymph node dissection (ELND) in enhancing overall survival (OS) remains a subject of ongoing debate, as the evidence regarding its benefits versus associated risks is mixed or inconclusive. This meta-analysis aims to evaluate whether ELND improves OS compared to standard lymph node dissection (SLND) in patients with colon cancer while assessing its impact on perioperative outcomes and lymph node retrieval. Methods: This Systematic Review and Meta-Analysis followed the PRISMA guidelines for evaluating the effectiveness of ELND, which analyzed seven articles containing 3,843 patients diagnosed with primarily local-stage (I-III) colon cancer, which met the inclusion criteria after screening 2797 articles, procured from a rigorous search strategy across bibliographic databases of PubMed, Medline, Pubmed Central, Scopus, Web of Science, and Embase until November 2024. Data analysis was performed using RevMan 5.4 software, which facilitated the computation of risk ratios, mean differences, and 95% confidence intervals (CIs). The assessment of heterogeneity was conducted using I2 statistics, while the evaluation of publication bias was carried out through the application of funnel plots. Results: ELND showcased significantly better overall survival rates than SLND with an RR of 0.34; 95% CI: 0.17-0.68; p = 0.002 with no observed heterogeneity (I2 = 0%). However, intraoperative complications between ELND and SLND were similar (RR: 0.90; 95% CI: 0.68-1.19; p = 0.45), although with substantial heterogeneity (I2 = 61%). As expected, given the nature of extensive dissection involved in ELND, it is expected to retrieve more lymph nodes, and statistically, there is an average difference of 10 nodes between the approaches (MD: 10.0; 95% CI: 0.10-10.0; p\u3c 0.0001). However, this outcome exhibited significant heterogeneity (I2 = 100%), likely due to the variations in surgical technique and the definitions of \u27extensive\u27 dissection in each study included in the analysis. The survival benefit could be attributed to a more thorough removal of Lymph nodes, leading to improved disease staging and subsequent risk assessment and treatment planning. Conclusions: ELND provides promising oncological advantages through improved OS and enhanced staging accuracy without any difference in intraoperative complications. These findings suggest ELNDis a valuable technique in colon cancer surgery, specifically for local-stage disease. Further research can focus on having a standardized definition of \u27extensive dissection\u27 and further validate the study results
Managing pregnancy with long-term parenteral nutrition: A case report and review of the literature
No full textParenteral nutrition (PN) is essential for patients with chronic intestinal failure but poses significant challenges during pregnancy because of increased nutrition needs and associated risks such as central line-associated bloodstream infections. We report a case of a 29-year-old primigravid woman with Crohn\u27s disease who required chronic PN. Despite these complexities, her pregnancy was managed successfully with tailored PN adjustments. She developed intrahepatic cholestasis of pregnancy at 38 weeks and delivered a healthy, full-term newborn. Meticulous planning and individualized nutrition management are crucial in navigating the complexities of PN during pregnancy, demonstrating the potential for successful outcomes with strategic and personalized interventions
Hypertensive disorders of pregnancy trends in the United States post aspirin recommendation guidelines
No full textOBJECTIVE: To evaluate changes in the rates of hypertensive disorders of pregnancy (HDP) in the US after the publication of aspirin (ASA) recommendation guidelines by the USPSTF and ACOG.
METHODS: A population-based retrospective cohort study was performed using the US Natality database. The pre-ASA group included births between 2010-2014. The post-ASA group were births between 2016-2021. Births in 2015 were excluded. Outcomes were rates of HDP. Univariate and multivariate analyses were performed. Using the 2010-2014 HDP trend, a projected trend was calculated and compared to the actual trend across the entire cohort.
RESULTS: There were 12,127,659 births in the pre-ASA group and 17,665,217 births in the post-ASA group. The post-ASA group had a significantly higher rate of overall HDP than the pre-ASA group (7.7 % vs 4.9 %; aOR 1.58, 95 % CI [1.57-1.59]). When stratified by gestational age at delivery, the post-ASA group had a significantly lower rate of preterm HDP prior to 37 weeks (21.6 % vs 23.7 %; aOR 0.90, 95 % CI [0.89-0.91]) and preterm HDP prior to 34 weeks (6.0 % vs 7.5 %; aOR 0.79, 95 % CI [0.78-0.81]). The actual HDP trend post-ASA recommendation was higher than projected for overall HDP and preterm HDP \u3c 37 weeks but was not different for preterm HPD \u3c 34 weeks.
CONCLUSION: While overall HDP is increasing, the rate of preterm births complicated by HDP has been decreasing. The actual trend for the overall HDP category and the two preterm HDP categories, however, remains either higher or no different compared to the projected trend post aspirin recommendation guidelines
Challenges in Meeting Centers for Medicare and Medicaid Services Patient-Reported Outcome Measures Collection Requirements and Patient Predictors of Substantial Clinical Benefit Achievement in Total Joint Arthroplasty
No full textBACKGROUND: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are highly effective procedures, with the Centers for Medicare & Medicaid Services (CMS) mandating patient-reported outcome measures (PROMs) for Medicare patients starting July 1, 2024. This study evaluated PROM collection rates and identified predictors of substantial clinical benefit (SCB), defined by CMS as a 22-point improvement in Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement for THA and a 20-point improvement in Knee Injury and Osteoarthritis Outcome Score for Joint Replacement for TKA at four surgical sites across an academic tertiary referral center.
METHODS: This retrospective cohort study analyzed PROM data for all patients who underwent THA or TKA from January 2021 to December 2022. Collection rates for PROMs were assessed by meeting the CMS requirement of matched pairs of preoperative and 1-year postoperative PROM and meeting SCB. Logistic regression was used to identify predictors of SCB.
RESULTS: Collection rates of PROMs improved from 2021 to 2022, but matched pair rates remained below 33%. The SCB was achieved by 70.9% of THA patients and 62.1% of TKA patients. Significant predictors of SCB included younger age, lower preoperative PROM scores, and absence of comorbidities such as diabetes or preoperative opioid use. Non-White race patients had significantly lower odds of achieving SCB for TKA (P = 0.003), while preoperative education did not significantly impact SCB rates for either procedure.
CONCLUSIONS: The collection of PROMs remains a major challenge, particularly for postoperative intervals, but patients who had greater initial limitations showed substantial improvement. Targeted interventions to optimize preoperative risk factors and enhance long-term follow-up may improve SCB rates and CMS compliance
Cemented and Cementless Robotic-Assisted versus Manual Total Knee Arthroplasty Outcomes: A Single Center Michigan Arthroplasty Registry Collaborative Quality Initiative-Based Study
No full textBACKGROUND: The purpose of our study was to determine whether a difference existed between cemented and cementless robotic-assisted total knee arthroplasty (RA-TKA) and manual TKA with regard to revision rates and 90-day outcomes. We hypothesized these techniques would have similar results.
METHODS: A single center\u27s data from the Michigan Arthroplasty Registry Collaborative Quality Initiative were queried for all primary TKAs from January 2012 to July 2023. The RA-TKA and manual cohorts were compared for revisions and 90-day complications, including emergency department (ED) visits, readmissions, and returns to the operating room Chi-square and Fisher\u27s exact tests were used for categorical data, and t-tests for continuous data. Of the 7,417 cemented TKAs (mean age 67 ± 9.6 years, 70% women), 273 were RA-TKA and 7,144 were manual. Of the 2,407 cementless TKAs (mean age 65 ± 8.6 years, 53% women), 730 were RA-TKA and 1,677 were manual.
RESULTS: Cemented RA-TKA had more periprosthetic joint infection revisions, more 90-day ED visits, and readmissions for wound complications compared to cemented manual TKA. Cementless RA-TKA had more 90-day readmissions for wound complications, while manual TKA had more 90-day ED visits for postoperative pain. Cemented and cementless RA-TKA had longer surgical time, shorter length of stay, and shorter time to revision. There were 283 revisions performed on cemented manual TKA (nine RA-TKAs, 3.2%, 274 manual, 3.8%, (P = 0.87)). There were 56 revisions performed on cementless knees (13 RA-TKAs, 1.7%, 43 manual 2.5% (P = 0.303)). Cumulative percent revision at 5 years was 3.9% for cemented RA-TKA, 3.5% for cemented manual TKA, 1.8% for cementless RA-TKA, and 2.8% for cementless manual TKA.
CONCLUSIONS: Both RA-TKA and manual TKA have similar revision rates, while RA-TKA had more wound complications. Cementless RA-TKA may be beneficial in reducing postoperative pain
Suspected late graft failure and graft versus host disease 34 years after hematopoietic stem cell transplantation clinically and pathologically presenting as host versus graft disease with liver injury
No full textA 36-year-old man who underwent hematopoietic stem cell transplantation (HSCT) at the age of 2 years for severe combined immunodeficiency, presented with jaundice, skin rash, and elevated liver function tests 34 years after HSCT. Liver biopsy showed bile duct injury and cholestasis. Viral studies, autoimmune panel, review of medications, and imaging did not establish a cause of liver injury. However, graft-versus-host disease (GVHD) was unlikely because of the remote history of HSCT. Short tandem repeat-polymerase chain reaction (STR-PCR) chimerism analysis showed that the percentage of donor DNA in the liver biopsy specimen was very low (11 %); hence, host-versus-graft disease (HVGD) was implicated. Because STR analysis of patient\u27s blood showed a mixed chimera with 11 % donor DNA, graft failure was suspected; however, fractionated STR analysis ruled out complete graft failure. Overall, this case outlines liver injury caused by HVGD in the absence of complete graft failure 34 years after HSCT, which has never been reported in the literature. STR-PCR analysis was essential for mitigating the diagnostic dilemma
A Case Report on an Uncommon Presentation of Giant Cell Tumor of the Tendon Sheath in the Infrapatellar Region
No full textGiant cell tumor of the tendon sheath (GCT-TS) is a benign yet locally aggressive soft tissue neoplasm that typically arises in synovium-lined structures, including tendon sheaths, bursae, and joints. Also known as localized nodular tenosynovitis, this tumor primarily affects the hands and fingers but can occur in other anatomical locations. GCT-TS is histologically characterized by multinucleated giant cells within a background of mononuclear stromal cells. While it is generally nonmetastatic, the tumor carries a risk of local recurrence following surgical removal. Recognizing the clinical presentation, histopathological features, and appropriate management strategies is essential for effective treatment and recurrence prevention. Here, we present the case of a 34-year-old woman with a one-year history of pain in the infrapatellar region. Imaging revealed a well-defined soft tissue mass posterior to the patellar tendon, which was surgically excised. Histopathological examination confirmed the diagnosis of nodular-type GCT-TS. The patient\u27s symptoms resolved completely postoperatively, and no recurrence was observed during a five-year follow-up period, highlighting the effectiveness of surgical excision in managing this rare tumor location