Case Report: Congenital hepatic hemangioma with arteriovenous fistula: 2-year multidisciplinary management and outcomes

Background

Congenital hepatic hemangioma with arteriovenous fistula (HHAVF) is a rare condition in newborns that may manifest as respiratory distress, pulmonary hypertension, and heart failure shortly after birth. This report describes a case of HHAVF complicated by encephalomalacia identified after transcatheter arterial embolization (TAE). However, the condition improved with multidisciplinary management and long-term follow-up.

Case presentation

A full-term female infant presented with a cardiac murmur and pulmonary hypertension at birth. Contrast-enhanced CT demonstrated multiple hepatic hemangiomas with high-flow arteriovenous shunting. Pulmonary hypertension resolved after TAE; however, the recurrence of hepatic hemangioma required oral propranolol therapy, which led to complete regression by 18 months of age. Postprocedural imaging identified encephalomalacia in the right frontotemporal and parietal lobes, as well as the basal ganglia, concurrent with left-limb motor impairment. Long-term rehabilitation improved left-limb function and the extent of encephalomalacia stabilized.

Conclusions

Current research primarily focuses on early cardiopulmonary complications in HHAVF, while multidisciplinary management strategies and long-term outcomes, particularly neurological manifestations, are rarely reported.

Optical Coherence Tomography Angiography, Elastography, and Attenuation Imaging for Evaluation of Liver Regeneration

Background/Objectives: As a result of metabolic changes and the disruption of tissue architecture and microcirculation, the regenerative potential of the liver decreases with violations at both micro and macro levels. The development of intraoperative approaches for assessing its regenerative potential is important for reducing the risk of the occurrence of post-resection liver failure. In this study, we used multimodal optical coherence tomography (MM OCT), a combination of three optical coherence tomography modalities-OCT-angiography (OCTA), attenuation coefficient mapping, and OCT-elastography (OCE) to provide real-time three-dimensional and label-free assessment of changes in microcirculation, and in the structure and stiffness of the liver during regeneration. Methods: In our study, the regeneration of a healthy liver was induced by 70% partial hepatectomy. Monitoring of changes was carried out on the 0 (normal liver), 3rd and 7th day of regeneration using modalities of MM OCT. OCT offers the benefits of higher resolution and specificity compared with other clinical imaging modalities, and can be used, even intraoperatively. Results: By the 3rd day of liver regeneration, a decreased density of all observable vessels, together with increased values of the liver tissue's attenuation coefficient and stiffness, was revealed compared to their initial state. However, by the 7th day, the studied parameters tended to return to their normal values, except that the density of large-caliber vessels continued to increase further. Histological and biochemical blood analysis methods were used to verify the MM OCT data. Conclusions: Such data are a first step towards further investigation of liver regeneration in pathology, and, taken in perspective, this should serve as a basis for predictive intraoperative assessment of the regenerative potential of the liver in a clinical setting.

Nutritional management and geno-phenotyping of clinical nutrition in patients with glycogen storage diseases type VI and IX

BACKGROUND/OBJECTIVES

Glycogen storage diseases type VI (GSD-VI) and type IX (GSD-IX) are rare inherited metabolic disorders caused by enzyme deficiencies that disrupt glycogen metabolism. The aim of this study was to analyze the clinical features, nutritional management and geno-phenotyping of clinical nutrition in a cohort of patients with GSD-VI and GSD-IX.

SUBJECTS/METHODS

A retrospective cohort study was conducted with 16 patients with GSD-VI and GSD-IX. Demographic characteristics, clinical and laboratory findings, and nutritional treatment outcomes were collected and analyzed.

RESULTS

The mean patient age was 10.57 years (±4.81). The distribution of the diagnoses was as follows: GSD-IXa (3), GSD-IXb (6), GSD-IXc (1), and GSD-VI (6). The average age at diagnosis was 36.5 months (±42.2) (13-114 months) in the GSD-VI group. Among the GSD-IX subgroups, the mean age at diagnosis varied: 23.3months (±4.16) for GSD-IXa, 35.7months (±17.5) for GSD-IXb, and 78months for GSD-IXc. Over the course of the study (4.5 ± 1.77 years), protein intake in GSD VI patients increased by 1.05 g/kg/day (91.3% increase), while in GSD IX patients, it rose by 1.09 g/kg/day (94% rise). Uncooked cornstarch (UCS) started at 1 g/kg/day for GSD-VI and 0.85 g/kg/day for GSD-IX, later reduced to 0.71 g/kg/day (29% decrease) and 0.52 g/kg/day (60% reduction), respectively.

CONCLUSION

Overall, this paper provides valuable insights into managing GSDVI and GSDIX patients, emphasizing the role of a high-protein diet aligned with the disease's pathophysiology and the potential of genotyping to enhance nutritional treatment protocols.

Digital Decision Support for Perioperative Care of Patients With Type 2 Diabetes: A Call to Action

Unlabelled

Type 2 diabetes mellitus affects over 500 million people globally, with 10%-20% requiring surgery. Patients with diabetes are at increased risk for perioperative complications, including prolonged hospital stays and higher mortality, primarily due to perioperative hyperglycemia. Managing blood glucose during the perioperative period is challenging, and conventional monitoring is often inadequate to detect rapid fluctuations. Clinical decision support systems (CDSS) are emerging tools to improve perioperative diabetes management by providing real-time glucose data and medication recommendations. This viewpoint examines the role of CDSS in perioperative diabetes care, highlighting their benefits and limitations. CDSS can help manage blood glucose more effectively, preventing both hyperglycemia and hypoglycemia. However, technical and integration challenges, along with clinician acceptance, remain significant barriers.

The 'hub' model for colorectal surgery: a viable paradigm shift?

INTRODUCTION

Nationally, in the aftermath of the first COVID-19 lockdown, the waiting list for elective surgery is approximately 7 million. To ameliorate an evolving crisis and improve system resilience, the Royal College of Surgeons of England proposed a 'New Deal for Surgery', promoting COVID-light sites and elective hubs. We evaluate the short-term outcomes, safety and sustainability of the hub model at a large National Health Service trust.

METHODS

All major elective colorectal operations performed at the hub between 8 March 2021 and 8 March 2022 were included for analysis. Pertinent data on patient demographics, operative performance and postoperative outcomes were analysed using SPSS 27.

RESULTS

In total, 401 cases were analysed. There was one same-day cancellation because of the unavailability of beds (0.2%). Median distance displacement for patients for their primary surgery was +3.2 miles. Twenty-one patients (5.2%) required postoperative blood transfusion. One patient had nosocomial COVID-19 (0.2%), severe complications of Clavien-Dindo grade ≥3 were observed in 33 patient (8.2%) and transfer-out for higher level care occurred in 34 cases (8.5%). Forty-six 30-day readmissions (11.5%) and two deaths (0.4%) were noted. Median length of stay was 6 days.

CONCLUSIONS

The volume of major colorectal surgery at the hub, with acceptable incidence of major complication, transfer-out and minimal patient displacement, attests to the efficacy and safety of the new model.

Pulmonary and functional hallmarks after SARS-CoV-2 infection across three WHO severity level-groups: an observational study

Background

The manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection range from flu-like symptoms to severe lung disease. The consequences of this inflammatory process impact overall function, which can be detected through both short- to long-term assessments. This study aimed to assess the pulmonary functional and structural characteristics of post-SARS-CoV-2 infection in patients with mild/moderate, severe, and critical clinical presentations.

Methods

An observational, analytical, and cross-sectional study was conducted between 2020 and 2022, including participants with a confirmed diagnosis of coronavirus disease (COVID)-19, with mild/moderate (G1), severe (G2), and critical (G3) clinical presentations, all evaluated at least 3 months after acute infection. Spirometry, impulse oscillometry, fractional exhaled nitric oxide (FeNO), chest computed tomography, the 6-min walk test (6MWT), hand grip strength, maximum inspiratory pressure, and maximum expiratory pressure were assessed.

Results

We enrolled 210 participants aged 18-70 years, 32.6% of whom were male, with older age observed in G3. The participants were grouped as follows: G1 (42.3%), G2 (25.7%), and G3 (31.9%). Percentage of predicted X5 differed between G1 and G2, being higher in G1. The percentage of predicted forced vital capacity (FVC) according to the Global Lung Function Initiative and its z-score were higher in G1. The FVC by Pereira was lower in G3 compared to G1. The percentage of predicted forced expiratory volume in 1 s (FEV1) by Pereira was also lower in G3. The Tiffeneau (FEV1/FVC) index was different among groups, increasing with disease severity. The percentage of predicted forced expiratory flow rate at 25-75% (FEF25-75%) of the FVC and FeNO were both higher in G2 than G1. Chest computed tomography revealed the presence of interstitial abnormalities, associated with disease severity. The respiratory muscle strength evaluation showed an association between higher maximum expiratory pressure values in G3 compared to G1, but no association with maximum inspiratory pressure was observed. The 6MWT distance covered decreased with increasing severity, with a lower percentage of predicted values in G3 compared to G1. The right-hand grip strength was also lower in G3 compared to G1.

Conclusion

Alterations in pulmonary and functional markers were observed in post-COVID-19 evaluations, increasing with disease severity, as seen in G2 and G3. These findings highlight the complexity of post-COVID-19 functional assessments, given the long-term pulmonary sequelae and the consequent impairment of functional capacity.

MiR-122-5p inhibits the epithelial mesenchymal transition of liver cancer cells by inducing hiPSCs to differentiate into hepatocyte-like cells

Epithelial-mesenchymal transition (EMT) is closely linked to liver cancer prognosis, invasiveness, and aggressiveness. One promising treatment for liver cancer is cell therapy, where stem cells are stimulated to develop into functional liver cells. This study aimed to investigate the effect of miR-122-5p on the differentiation of human induced pluripotent stem cells (hiPSCs) into hepatocyte-like cells and its impact on the EMT process in liver cancer cells. MiR-122-5p was overexpressed or silenced in hiPSCs to analyze the expression of liver-specific markers, including AFP, ALB and ASGPR, to confirm hepatocyte-like differentiation. A co-culture system with HepG2 liver cancer cells was also used to evaluate the effect of miR-122-5p-overexpressing hiPSCs or miR-122-5p-silencing hiPSCs on the expression of EMT markers. Results revealed that overexpression of miR-122-5p in hiPSCs induced hepatocyte-like characteristics, as evidenced by increased levels of AFP, ALB, and ASGPR. However, knockdown of miR-122-5p had the opposite effect. In the co-culture system, hiPSCs overexpressing miR-122-5p inhibited the EMT process of HepG2 cells, resulting in increased levels of mesenchymal markers and decreased levels of epithelial markers. Taken together, miR-122-5p promotes the differentiation of hiPSCs into hepatocyte-like cells and inhibits EMT process of liver cancer cells. Targeting miR-122-5p may be a novel approach to prevent liver cancer progression through cell therapy.

Cell therapies and liver organogenesis technologies: Promising strategies for end-stage liver disease

End-stage liver disease represents a critical hepatic condition with high mortality, for which liver transplantation remains the only effective treatment. However, the scarcity of suitable donors results in numerous patients dying while awaiting transplantation. Novel strategies, including cell therapies and technologies mimicking liver organogenesis, offer promising alternatives for treating end-stage liver disease by potentially providing new sources of liver grafts. Recently, significant progress has been made in this field, including stem cell transplantation, hepatocyte transplantation, in vitro liver tissue generation, and liver replacement technologies. Several clinical studies have demonstrated that stem cell transplantation and hepatocyte transplantation can prolong patient survival and serve as a bridge to liver transplantation. Furthermore, in vitro liver tissue generation technologies, such as liver organoids and three-dimensional bioprinting, can generate hepatic tissues with sophisticated structures and functions, making them promising transplantation materials. Notably, liver replacement technologies hold considerable potential for producing biologically functional and transplantable liver grafts. In this review, we discuss the fundamental principles and recent advancements in cell therapies and liver organogenesis technologies while also addressing the challenges and future prospects in this rapidly evolving field.

Expanding pediatric liver transplants: the role of split grafts, allocation policies, and machine perfusion

PURPOSE OF REVIEW

Pediatric liver transplant waitlist mortality remains disproportionately high, particularly among infants under one year old. Despite the success of split liver transplantation (SLT) in improving pediatric access to transplants, its utilization remains limited. This review examines barriers to SLT adoption, explores the impact of pediatric-focused allocation policies, and evaluates the potential of machine perfusion technology in expanding the pediatric donor pool.

RECENT FINDINGS

Studies have demonstrated that SLT outcomes are comparable to whole graft transplants when performed at experienced centers. However, logistical challenges, technical expertise, and policy limitations hinder its widespread adoption. Countries with pediatric-prioritized allocation and mandatory SLT policies, such as Italy and the United Kingdom, have significantly reduced pediatric waitlist mortality. Additionally, machine perfusion technology has emerged as a promising solution, allowing for ex vivo graft splitting and reducing ischemic injury, which may enhance graft utilization.

SUMMARY

A multifaceted approach is necessary to improve pediatric liver transplant outcomes, including stronger pediatric-first allocation policies, SLT training expansion, and integration of machine perfusion technologies. Implementing these strategies in the United States could significantly reduce pediatric waitlist mortality without negatively impacting adult transplant candidates.

Circulating cell-free DNA in liver transplantation: A pre- and post-transplant biomarker of graft dysfunction

BACKGROUND

Liver transplantation (LT) is still limited by organ shortage and post-transplant monitoring issues. While machine perfusion techniques allow for improving organ preservation, biomarkers like donor-derived cell-free DNA (dd-cfDNA) and mitochondrial cfDNA (mt-cfDNA) may provide insights into graft injury and viability pre- and post-LT.

METHODS

A prospective observational cohort study was conducted on LT recipients (n = 45) to evaluate dd-cfDNA as a biomarker of graft dysfunction during the first 6 months after LT. Dd-cfDNA was quantified on blood samples collected pre-LT and post-LT using droplet digital PCR. In livers undergoing dual hypothermic oxygenated machine perfusion (D-HOPE), total cfDNA and mt-cfDNA levels were measured on perfusate samples collected at 30-min intervals. Correlations with graft function and clinical outcomes were assessed.

RESULTS

Dd-cfDNA levels peaked post-LT and correlated with transaminase levels and histological injury severity. The longitudinal assessment showed that postoperative complications and rejection were associated with an increase in dd-cfDNA levels. Mt-cfDNA levels in D-HOPE perfusate correlated with graft function parameters post-LT and were higher in patients with early allograft dysfunction and severe complications.

CONCLUSIONS

This study confirms dd-cfDNA as a marker of graft injury after LT and suggests that perfusate mt-cfDNA levels during D-HOPE correlate with graft function and post-transplant clinical outcome. Integration of these tests into clinical practice may improve transplant management and viability assessment during hypothermic perfusion.

New Scenarios in Liver Transplantation for Hepatocellular Carcinoma

BACKGROUND AND AIMS

Despite liver transplantation (LT) is considered the optimal treatment for hepatocellular carcinoma (HCC), particularly in patients with impaired liver function, the shortage of donors has forced the application of very restrictive criteria for selecting ideal candidates for whom LT can offer the best outcome. With the evolving LT landscape due to the advent of direct-acting antivirals (DAAs) and the steady increase in donors, major efforts have been made to expand the transplant eligibility criteria for HCC. In addition, the emergence of immune checkpoint inhibitors (ICIs) for the treatment of HCC, with demonstrated efficacy in earlier stages, has revolutionized the therapeutic approach for these patients, and their integration in the setting of LT is challenging. Management of immunological compromise from ICIs, including the wash-out period before LT and post-LT immunosuppression adjustments, is crucial to balance the risk of graft rejection against HCC recurrence. Additionally, the effects of increased immunosuppression on non-hepatic complications must be understood to prevent them from becoming obstacles to long-term OS.

METHODS AND RESULTS

In this review, we will evaluate the emerging evidence and its implications for the future of LT in HCC. Addressing these novel challenges and opportunities, while integrating the current clinical evidence with predictive algorithms, would ensure a fair balance between individual patient needs and the overall population benefit in the LT system.

Ex-situ machine perfusion in clinical liver transplantation: Current practices and future directions

Ex-situ machine perfusion of the liver has surmounted traditional limitations associated with static cold storage in the context of organ preservation. This innovative technology has changed the landscape of liver transplantation by mitigating ischemia perfusion injury, offering a platform for continuous assessment of organ quality, and providing an avenue for optimizing the use of traditionally marginal allografts. This review summarizes the contemporary clinical applications of machine perfusion devices and discusses potential future strategies for real-time viability assessment, therapeutic interventions, and modulation of organ function after recovery.

Macrophage therapy and liver regeneration: Results and perspectives

The recent results of the study evaluating the impact of macrophage transplantation in cirrhosis with the aim of improving liver function open up a number of prospects. Although negative, fewer deaths were observed, as well as a favourable cytokine profile. This is in line with other results obtained in liver disease, notably through signalling and regeneration studies on human liver tissue. For the future, a number of questions need to be answered if we are to make progress in this fascinating field.

Implementing sustainable practices to reduce wastage and costs in adenotonsillectomy

BACKGROUND

Surgical waste presents significant environmental and economic challenges in healthcare. Adenotonsillectomy, a common otolaryngological procedure, contributes to this issue. There is limited research on sustainability measures in adenotonsillectomy, and no studies have specifically identified waste reduction strategies for this operation in a general ENT unit. This study aimed to identify sustainable practices for waste reduction in adenotonsillectomy surgeries and quantify the extent of waste reduction in terms of weight and cost.

METHODS

The items opened and waste produced during adenotonsillectomies in a single institution were documented, including weights and costs. After reviewing the actual materials used by otolaryngologists and identifying potentially avoidable waste, a low-waste setup was designed. Waste weight and costs were evaluated post-implementation and compared with baseline values.

RESULTS

Several steps to reduce wastage in adenotonsillectomy surgeries were identified, including the elimination of surgical drapes and gowns. This resulted in a waste reduction of over 60%, with an average reduction in weight per case of 1.114 kg. The estimated reduction over 1 year for 294 cases was 327.52 kg. The mean reduction in material costs per case was $41.67, with an extrapolated annual savings of $12 250.98 for 294 cases.

CONCLUSION

Implementing sustainable practices in adenotonsillectomy surgeries can significantly reduce waste and healthcare facility cost, providing both environmental and economic benefits.

Hepatocellular carcinoma: Revising the surgical approach in light of the concept of multiparametric therapeutic hierarchy

The clinical management of hepatocellular carcinoma (HCC) is strongly influenced by several prognostic factors, mainly tumor stage, patient's health, liver function and specific characteristics of each intervention. The interplay between these factors should be carefully evaluated by a multidisciplinary tumor board. To support this, the novel "multiparametric therapeutic hierarchy" (MTH) concept has been recently proposed. This review will present the main features of available surgical treatments for HCC (liver transplantation, liver resection, ablation). Strengths and weaknesses are reported in the light of clinical decision making and of treatment allocation, with a special focus on the collocation of each treatment in the MTH framework and on how MTH may be useful in supporting clinical decision. Sequential treatments and their role to allow further surgical treatments will also be analyzed.

Nomogram for prediction of severe postoperative complications in elective hepato-pancreato-biliary surgery after COVID-19 breakthrough infection: A large multicenter study

BACKGROUND

Currently, there is a deficiency in a strong risk prediction framework for precisely evaluating the likelihood of severe postoperative complications in patients undergoing elective hepato-pancreato-biliary surgery subsequent to experiencing breakthrough infection of coronavirus disease 2019 (COVID-19). This study aimed to find factors predicting postoperative complications and construct an innovative nomogram to pinpoint patients who were susceptible to developing severe complications following breakthrough infection of COVID-19 after undergoing elective hepato-pancreato-biliary surgery.

METHODS

This multicenter retrospective cohort study included consecutive patients who underwent elective hepato-pancreato-biliary surgeries between January 3 and April 1, 2023 from four hospitals in China. All of these patients had experienced breakthrough infection of COVID-19 prior to their surgeries. Additionally, two groups of patients without preoperative COVID-19 infection were included as comparative controls. Surgical complications were meticulously documented and evaluated using the comprehensive complication index (CCI), which ranged from 0 (uneventful course) to 100 (death). A CCI value of 20.9 was identified as the threshold for defining severe complications.

RESULTS

Among 2636 patients who were included in this study, 873 were included in the reference group I, 941 in the reference group II, 389 in the internal cohort, and 433 in the external validation cohort. Multivariate logistic regression analysis revealed that completing a full course of COVID-19 vaccination > 6 months before surgery, undergoing surgery within 4 weeks of diagnosis of COVID-19 breakthrough infection, operation duration of 4 h or longer, cancer-related surgery, and major surgical procedures were significantly linked to a CCI > 20.9. A nomogram model was constructed utilizing CCI > 20.9 in the training cohort [area under the curve (AUC): 0.919, 95% confidence interval (CI): 0.881-0.957], the internal validation cohort (AUC: 0.910, 95% CI: 0.847-0.973), and the external validation cohort (AUC: 0.841, 95% CI: 0.799-0.883). The calibration curve for the probability of CCI > 20.9 demonstrated good agreement between the predictions made by the nomogram and the actual observations.

CONCLUSIONS

The developed model holds significant potential in aiding clinicians with clinical decision-making and risk stratification for patients who have experienced breakthrough infection of COVID-19 prior to undergoing elective hepato-pancreato-biliary surgery.

β-sitosterol protects against ANIT-induced hepatotoxicity and cholestasis via FXR activation

Cholestasis, a condition marked by bile acid accumulation in the liver and body systems, leads to liver dysfunction and cirrhosis. Currently, ursodeoxycholic acid (UDCA) and obeticholic acid (OCA) are the only two FDA-approved drugs for Cholestasis. Thus, new therapeutic approaches need to be developed. In this study, we validated the liver-protective properties of β-sitosterol (SIT), a key bioactive element abundant in plants, against hepatic toxicity and cholestasis induced by alpha-naphthylisothiocyanate(ANIT), while elucidating its mechanisms of action both in vivo and in vitro. SIT's FXR activation was confirmed via molecular docking and dual-luciferase assays. In the mechanisms of SIT hepatoprotection, the expression levels of bile salt export pump (Bsep) and multidrug resistance protein2 (Mrp2) which are bile acid efflux transporter, and sulfate transferase 2a1 (Sult2a1) which is a bile acid metabolizing enzyme were all increased by SIT, whereas the expression of uptake transporter sodium taurocholate transporting polypeptide (Ntcp), bile acid synthesis enzyme cholesterol 7α-hydroxylase (Cyp7a1) and oxysterol 12α-hydroxylase (Cyp8b1) was decreased by SIT. In addition, SIT alleviated liver inflammation by suppressing inflammatory factor expression. However, FXR antagonist guggulsterone and FXR siRNA abolished SIT's improvements in liver histology, bile acid transporters, and enzymes. Conclusively, through activating FXR, SIT provides a protective effect against hepatotoxicity and cholestasis. SIT might serve as a new potential therapeutic strategy for the treatment of cholestatic liver diseases.

"Pathologists in Venice - Real World Cases for an Immersive Training Experience": Education, Gaming, and Show

An international meeting entitled "Pathologists in Venice: Real World Cases for an Immersive Training Experience" took place on December 12 and 13, 2024 in Venice, Italy. More than 100 pathologists from all over the world were brought together to join four opinion leaders in different pathology fields. By matching real-time whole slide imaging-based navigation exposure with a technologically cutting-edge gaming format, the meeting engaged and provided the attendees with an innovative and immersive educational approach to real-world compelling scenarios they are likely to encounter in their daily practice.

Sequential Hypothermic and Normothermic Machine Perfusion of Extended Criteria Donors in Liver Transplantation: A Single-Center Preliminary Experience

INTRODUCTION

Liver transplantation (LT) is the sole curative option for liver failure and other primary liver conditions. However, the limited number of suitable donors compared with the growing number of patients requiring LT remains a leading cause of mortality among those on the waiting list. This has resulted in the expansion of criteria for donor eligibility. The sequential combination of ex situ reperfusion, dHOPE, and NMP helps reduce the occurrence of ischemia-reperfusion injury and assess organ viability prior to transplantation.

METHODS

This is a retrospective, single-arm, single-center study including all cases of liver grafts that underwent sequential perfusion between October 2021 and July 2024. Eligibility criteria for sequential perfusion were extended criteria DBD with macrosteatosis > 35%, use of high-dose vasopressors during donor ICU stay or episodes of cardiac arrest, hemodynamic instability during procurement, prolonged ischemia time for logistic reasons, as well as DCD showing prolonged fWIT, flow alteration during normothermic regional perfusion (NRP), and DCDs in Maastricht 2 class. Viability was assessed following the Groeningen group criteria.

RESULTS

Thirty-three cases were included and 16 met the viability criteria at the end of the sequential perfusion and were transplanted. One patient developed an early allograft failure (EAF) and another a primary nonfunction (PNF). All the other patients had a regular postoperative course, with no retransplantation, 56% of the cohort showing no postoperative complication and all currently in good standing, median follow-up 19 months (range 4-39).

CONCLUSIONS

Sequential dHOPE and NMP is a strategy that can help assessing both viability and functionality of liver grafts from high-risk donors, expanding the donor pool and increasing the opportunities for patients on the waiting list to get a transplant.

The Enhanced Recovery After Surgery Pathway Is Safe, Feasible and Cost-Effective in Delayed Graft Function After Kidney Transplant

Background/Objectives: Enhanced recovery after surgery (ERAS) pathways are still underutilized in kidney transplantation (KT), and their feasibility after delayed graft function (DGF) is unknown. We aimed to evaluate safety and cost savings after ERAS implementation in KT recipients with DGF. Methods: A retrospective analysis of KT recipients enrolled in the ERAS program with DGF (≥1 dialytic treatment during the first postoperative week or creatinine≥ 2.5 mg/dL on postoperative day 10) between 2010 and 2019 was performed. Recipient, donor, and transplant data, outcomes, and 1-year post-KT costs were collected, comparing recipients within the ERAS target (≤5 days, "early discharge group") to those discharged later (>5 days, "late discharge group"). Results: Out of 170 KT recipients with DGF, 33 (19.4%) were in the "early discharge group" and 137 (80.5%) in the "late discharge group". Recipient, donor, and transplant characteristics were similar in the two groups. The length of hospital stay (LOS) of the "early discharge group" was significantly shorter, with fewer in-hospital dialysis sessions (p < 0.001) compared to the "late discharge group". One year post-KT, no significant differences were observed in postoperative complications, readmissions, or number of outpatient visits. Five-year graft and patient survival along with five-year graft function were similar between the two cohorts. First-year costs were significantly higher in the "late discharge group" (p < 0.001), with a median excess cost (Δ) of EUR 4515.76/patient. Factors influencing first-year costs post-KT were LOS for KT, recipient age, and use of expanded-criteria grafts. Conclusions: The ERAS approach is safe in KT recipients with DGF and allows for economic savings, while its implementation does not cause worse clinical outcomes in recipients.

A Greener Vascular Surgery: A Survey of Current Green Practices

BACKGROUND

Climate change is an environmental emergency. With health care systems contributing to 5% of carbon emissions globally, environmental sustainability is an important consideration when delivering surgical services. This survey aimed to understand current green practices across vascular centers.

METHODS

A survey on routine sustainable practices and the feasibility of implementing greener practices was developed between the Vascular and Endovascular Research Network and the Vascular Society of Great Britain and Ireland. The survey was delivered using the Qualtrics online survey tool and distributed through mailing lists and social media. The survey was open to completion by all vascular health care professionals internationally. Responses were collected between June 2, 2023, and September 15, 2023.

RESULTS

A total of 115 vascular health care professionals across 14 different countries responded. Disposable theater materials were used in 85% (98/115) of respondents' centers. Most centers used electronic patient records (investigation requests [76%, 85/112], observation charts [81%; 91/112], prescriptions [74%; 83/112]). Paper recycling policies were available in 52% (58/112) of respondents' centers. All the respondents agreed that vascular surgery can be greener. 80% (92/115) of respondents reported environmental sustainability was never discussed in departmental meetings and 24% (28/115) reported their department engaged with management to implement more sustainable practices. Barriers to change included finance (77%, 89/115), competing priorities (84%, 97/115), and lack of engagement (82%, 94/115).

CONCLUSION

This survey identified areas where vascular services could be more environmentally friendly, including reducing the use of disposable materials and improving recycling. Vascular health professionals are largely supportive of implementing changes to reduce the carbon footprint.

Surgical Strategy for Pediatric Liver Tumors Involving the Hepatic Venous Confluence and the Inferior Vena Cava

BACKGROUND

Pediatric liver tumors presenting as centrally located masses with contact to or even invasion of all three hepatic veins (HVs) and the inferior vena cava (IVC) present significant surgical challenges. While liver transplantation may be indicated in truly unresectable tumors, extended liver resection with vascular reconstruction can be an organ-preserving alternative.

OBJECTIVE

This study aimed to present a reference center's strategy for children with liver tumors involving the hepatic venous confluence or the retrohepatic IVC who underwent extended liver resection with vascular reconstruction.

METHODS

All pediatric patients undergoing major hepatectomy with reconstruction of an HV or the IVC over a 10-year study period were included. Preoperative imaging, surgical techniques, and short- and long-term postoperative data were analyzed.

RESULTS

From a total of 125 pediatric major hepatectomies, 17 children (15 hepatoblastoma, two undifferentiated embryonal sarcoma) underwent liver resection with vascular reconstruction of an HV or the IVC. In nine cases an HV was reconstructed, and in eight children, a partial resection of the IVC was performed. Total vascular exclusion of the liver was applied in 16/17 cases. No 90-day postoperative mortality, no major postoperative complication, and no local relapse occurred; 16/17 patients are alive without relapse at a median follow-up of 44 months (range 19-111).

CONCLUSION

This is the largest single-center series to report major hepatectomies with HV or IVC reconstruction in children. In specialized centers, these complex procedures are associated with excellent outcomes. Successful tumor resection can be achieved in selected cases even in locally advanced tumor stages.

Organ preservation: current limitations and optimization approaches

Despite the annual rise in patients with end-stage diseases necessitating organ transplantation, the scarcity of high-quality grafts constrains the further development of transplantation. The primary causes of the graft shortage are the scarcity of standard criteria donors, unsatisfactory organ preservation strategies, and mismatching issues. Organ preservation strategies are intimately related to pre-transplant graft viability and the incidence of adverse clinical outcomes. Static cold storage (SCS) is the current standard practice of organ preservation, characterized by its cost-effectiveness, ease of transport, and excellent clinical outcomes. However, cold-induced injury during static cold preservation, toxicity of organ preservation solution components, and post-transplantation reperfusion injury could further exacerbate graft damage. Long-term ex vivo dynamic machine perfusion (MP) preserves grafts in a near-physiological condition, evaluates graft viability, and cures damage to grafts, hence enhancing the usage and survival rates of marginal organs. With the increased use of extended criteria donors (ECD) and advancements in machine perfusion technology, static cold storage is being gradually replaced by machine perfusion. This review encapsulates the latest developments in cryopreservation, subzero non-freezing storage, static cold storage, and machine perfusion. The emphasis is on the injury mechanisms linked to static cold storage and optimization strategies, which may serve as references for the optimization of machine perfusion techniques.

Case Report: a giant liposarcoma of the spermatic cord

Background

Liposarcoma of the spermatic cord is an extremely rare urological malignancy, with fewer than 300 cases reported in the literature worldwide, and it is often difficult to distinguish from inguinal hernias and epididymal cysts. Typically, it presents as an asymptomatic, slow-growing paratesticular mass.

Case presentation

The case described herein involves a 59-year-old man who presented to our hospital with a painless mass in the left scrotum. Physical examination revealed a fixed, firm mass in the left scrotum. Ultrasonography of the scrotum demonstrated an inhomogeneous echogenic mass measuring approximately 113 x 83 x 62 mm on the left side. Testicular MRI showed a mass in the left scrotum measuring approximately 67 x 56 x 98 mm, exhibiting isointence T1 mixed with high T2 signals. The patient then underwent surgery and pathology confirmed a liposarcoma of the spermatic cord. Currently no signs of tumor recurrence on follow-up.

Conclusions

Liposarcoma of the spermatic cord is an exceedingly rare condition, for which surgical intervention is the preferred treatment option. While there is no definitive evidence supporting the use of adjuvant radiotherapy following surgery, it remains necessary in cases where surgical margins are uncertain.

Perioperative risk assessment for emergency general surgery in those with multimorbidity or frailty

PURPOSE OF REVIEW

This review explores advances in risk stratification tools and their applicability in identifying and managing high-risk emergency general surgery (EGS) patients.

RECENT FINDINGS

Traditional risk assessment tools have several limitations when applied to complex EGS patients as comorbidities are generally treated in a binary, linear and sequential fashion. Additionally, some tools are only usable in the postoperative period, and some require multidisciplinary involvement and are not suitable in an emergency setting. Frailty in particular - for which there are multiple calculators-maladaptively influences outcomes. Artificial intelligence tools, such as the machine-learning-based POTTER calculator, demonstrate superior performance by addressing nonlinear interactions among patient factors, offering a dynamic and more accurate approach to risk prediction.

SUMMARY

Integrating advanced, data-driven risk assessment tools into clinical practice can help identify and manage high-risk patients as well as forecast outcomes for EGS patients. Such tools are intended to trigger preoperative interventions as well as discussions that ensure goal-concordant care, align expectations with anticipated outcomes and support both facility and patient-relevant outcomes.

Lesson learnt from 60 years of liver transplantation: Advancements, challenges, and future directions

Over the past six decades, liver transplantation (LT) has evolved from an experimental procedure into a standardized and life-saving intervention, reshaping the landscape of organ transplantation. Driven by pioneering breakthroughs, technological advancements, and a deepened understanding of immunology, LT has seen remarkable progress. Some of the most notable breakthroughs in the field include advances in immunosuppression, a revised model for end-stage liver disease, and artificial intelligence (AI)-integrated imaging modalities serving diagnostic and therapeutic roles in LT, paired with ever-evolving technological advances. Additionally, the refinement of transplantation procedures, resulting in the introduction of alternative transplantation methods, such as living donor LT, split LT, and the use of marginal grafts, has addressed the challenge of organ shortage. Moreover, precision medicine, guiding personalized immunosuppressive strategies, has significantly improved patient and graft survival rates while addressing emergent issues, such as short-term complications and early allograft dysfunction, leading to a more refined strategy and enhanced post-operative recovery. Looking ahead, ongoing research explores regenerative medicine, diagnostic tools, and AI to optimize organ allocation and post-transplantation car. In summary, the past six decades have marked a transformative journey in LT with a commitment to advancing science, medicine, and patient-centered care, offering hope and extending life to individuals worldwide.

Split liver transplantation in high MELD score adult recipients: a reappraisal

BACKGROUND

Split liver transplantation (SLT) from deceased donors is a potential solution to the global organ shortage. While effective in patients with mild disease, outcomes in high MELD score recipients remain uncertain and conflicting. This study compares survival in high vs. low MELD score recipients.

METHODS

This retrospective single-centre study included all consecutive patients transplanted with a split liver graft between 2010 and 2022. Two groups of recipients with MELD<25 and ≥ 25 at LT were compared.

RESULTS

The study population included 119 patients (n = 98 with MELD<25, n = 21 with MELD≥25) with an average follow-up of 55 months. Both groups were comparable in terms of indication for transplantation and donor characteristics. The high MELD group required more blood transfusions (7 vs. 3 units; p < 0.001) during LT and had a longer stay in intensive care unit (7 vs. 5 days; p = 0.011). Biliary, arterial, and venous complications were similar between groups, as well as graft survival (5 years: 75 % vs. 61 %, p = 0.35) and long-term overall survival (5 years: 83 % vs. 75 %, p = 0.17).

DISCUSSION

Our results indicate that SLT for patients with MELD≥25 improves access to grafts, is feasible and safe, without significant increased risk of severe complications or decreased long-term overall patient or graft survivals.

Liver transplantation for hepatitis D virus/hepatitis B virus coinfection in Italy: an intention-to-treat analysis of long-term outcomes

Patients with hepatitis D virus (HDV)/hepatitis B virus (HBV)-related end-stage liver disease candidates for liver transplantation (LT) have traditionally been regarded as a special population, although their outcomes are controversial. An intention-to-treat (ITT) analysis of long-term outcomes of HDV/HBV-coinfected patients waitlisted for LT in Italy, between 2011 and 2020, was performed and compared with HBV-monoinfected LT candidates. Of 1731 HBV-infected LT candidates, 1237 (71.5%) had HBV monoinfection and 494 (28.5%) HDV/HBV coinfection. At listing, HDV/HBV-coinfected patients were significantly younger, listed mainly for decompensated cirrhosis, and with fewer hepatocellular carcinoma (HCC) cases; (26% vs 65.8%; P <.0001) compared with HBV-monoinfected patients. HDV/HBV-coinfected patients showed better 5-year ITT survival (83.2%; 95% CI: 79.4%-83.4%, vs 71.6%; 95% CI: 68.8%-74.2%; P < .0001). ITT-multivariable analysis identified the presence of HCC, advanced recipient age, and high model for end-stage liver disease-Na scores as mortality risk factors. Five years after LT, 99.1% of HDV/HBV-coinfected patients received oral nucleos(t)ide analogs, with immunoglobulins against antigen of the hepatitis B virus in 91.8% of cases. HBV and HDV viral recurrences were 1.1% and 0.2%, respectively, whereas recurrent or de novo HCC were 8.9% and 0.3%, respectively. In Italy, HDV/HBV-coinfected patients waitlisted for LT showed more favorable outcomes compared with HBV-monoinfected patients, both before and after LT. These excellent results, from the largest cohort reported so far, suggest that HDV/HBV-coinfected LT recipients do not represent a risky population and may be considered for simpler long-term antiviral prophylactic strategies.

Latin American association for the study of the liver (ALEH) guidance on postoperative care after liver transplantation

Liver transplantation (LT) is a well-established therapy for patients with decompensated cirrhosis and early-stage hepatocellular carcinoma. Liver transplantation activity varies sharply across Latin American (LATAM) countries due to differences in resources, expertise, and funding and local attitudes toward organ donation and transplantation. This current guidance of postoperative care after LT is the first position paper of the Latin American Association for the Study of the Liver (ALEH) Special Interest Group (SIG), drawing evidence-based recommendations regarding immediate and long-term postoperative care of LT recipients, taking into consideration their applicability in Latin America.

Where Are All the Clinical Trials for Chronic Rejection?

Chronic rejection is arguably the main obstacle to long-term graft survival. Yet, clinical trials focusing on this condition are disappointingly scarce. Significant advances in treating chronic rejection cannot happen if there is no conduit for testing novel therapies. Here, we identified the main hurdles holding back clinical trials for chronic rejection and outlined a series of actions to address these roadblocks. We suggest that a new strategic plan combining expertise in basic and clinical research and leveraging complementary resources be launched to specifically target chronic rejection and achieve long-awaited progress. We only need the will.

A blood-based PT-LIFE (Pediatric Liver Transplantation-LIver Fibrosis Evaluation) biomarker panel for noninvasive evaluation of pediatric liver fibrosis after liver transplantation: A prospective derivation and validation study

Allograft fibrosis is increasingly detected in graft biopsies as the postoperative period extends, potentially emerging as a pivotal determinant of long-term graft function and graft survival among pediatric recipients. Currently, there is a paucity of noninvasive diagnostic tools capable of identifying allograft fibrosis in pediatric recipients of liver transplants. This study involved 507 pediatric liver transplant patients and developed a novel blood-based diagnostic assay, Pediatric Liver Transplantation-Liver Fibrosis Evaluation (PT-LIFE), to noninvasively distinguish allograft fibrosis using blood samples, clinical data, and biopsy outcomes. The PT-LIFE assay was derived from a matrix of 23 variables and validated in 2 independent cohorts. It integrates 3 biomarkers (LECT2, YKL-40, FBLN3) with an area under the receiver operating characteristic curve of 0.91. In the pooled analysis, a PT-LIFE score lower than 0.12 identified liver allograft fibrosis semiquantitative scores 0 to 2 with a sensitivity of 91.9%, whereas scores above 0.29 indicated liver allograft fibrosis semiquantitative scores 3 to 6, with a specificity of 88.4%. The PT-LIFE assay presents as a promising noninvasive diagnostic tool for the detection of allograft fibrosis in pediatric liver transplant recipients.

Weighing up GnRH agonist therapy for endometriosis: outcomes and the treatment paradigm

INTRODUCTION

Endometriosis is a chronic inflammatory estrogen-dependent disease affecting 10% of women worldwide leading to chronic pelvic pain and infertility which may be treated clinically or surgically.

AREAS COVERED

Current literature was reviewed using the keywords 'gonadotropin releasing hormone agonists (GnRHa),' 'endometriosis,' 'infertility' and 'chronic pelvic pain.' Relevant papers prioritizing randomized controlled clinical trials (RCT), systematic reviews, meta-analyses, as well as international guidelines were evaluated.

EXPERT OPINION

Available options for relieving endometriosis-associated pain include GnRHa, progestagens, and combined oral contraceptives, all of which block menstruation to control symptoms without curing the disease. GnRHa administration decreases pain and symptom recurrence after surgical treatment, but side effects and costs limit its use. Published studies to test its effectiveness in easing endometriosis-associated pain are heterogeneous, consider different outcomes with no long-term results. Drug choice should be individualized considering the side-effect profile, tolerability, costs, risks, and benefits as one size does not fit all. As we wait for the development of an ideal pharmacological agents, GnRHa with an add-back regimen remains a second-line option to alleviate the painful symptoms in women with endometriosis. Endometriosis management should consider the systemic nature of the disease and the complexity involved in the pathogenesis of symptoms.

Scaffold implantation vs. intravenous delivery: a comparative preclinical animal study evaluating peroxisome proliferator-activated receptor gamma coactivator 1-alpha adipose-derived stem cells in liver fibrosis treatment

Purpose

Regenerative medicine is expected to offer an alternative to liver transplantation for treating liver diseases in the future, with one significant challenge being the establishment of an effective stem cell administration route. This study assessed the antifibrogenic effects of adipose-derived stem cells (ASCs) in a liver fibrosis mouse model, focusing on 2 methods of delivery: intravenous injection and scaffold implantation.

Methods

An extracellular matrix mimic scaffold was utilized for culturing peroxisome proliferator-activated receptor gamma coactivator 1-alpha-overexpressing ASCs (tASCs). These scaffolds, laden with tASCs, were then implanted subcutaneously in mice exhibiting liver fibrosis. In contrast, the Cell groups received biweekly intravenous injections of tASCs for 4 weeks. After 4 weeks, tissue samples were harvested from the euthanized mice for subsequent analysis.

Results

Real-time PCR and Western blot analyses on liver tissues, focusing on markers like alpha-smooth muscle actin (α-SMA), matrix metalloproteinase-2, and transforming growth factor-beta 1 (TGF-β1), showed that both delivery routes substantially lowered fibrotic and inflammatory markers compared to controls (P < 0.05), with no significant differences between the routes. Histological examinations, along with immunohistochemical analysis of α-SMA, collagen type I alpha, and TGF-β1, revealed that the scaffold implantation approach resulted in a greater reduction in fibrosis and lower immunoreactivity for fibrotic markers than intravenous delivery (P < 0.05).

Conclusion

These findings indicate that delivering tASCs via a scaffold could be more effective, or at least similarly effective, in treating liver fibrosis compared to intravenous delivery. Scaffold implantation could offer a beneficial alternative to frequent intravenous treatments, suggesting its potential utility in clinical applications for liver disease treatment.

Updates in the Surgical Management of Pancreatic Ductal Adenocarcinoma

Surgical management of pancreas cancer is complex, including the timing of surgery, surgical approach, intraoperative techniques, and postoperative management, which are reviewed in detail in this manuscript. Ultimately, referral to a high-volume pancreatic surgeon or pancreatic surgery center is critical to ensuring appropriate short-term and long-term outcomes.

Environmental responsibility in resource utilization during the practice of regional anesthesia: a Canadian Anesthesiologists' Society Delphi consensus study

PURPOSE

Regional anesthesia (RA) is often perceived to be more environmentally sustainable than alternative forms of anesthesia. Nevertheless, the principles of sustainable RA remain ill-defined in the presence of variability of resource utilization within RA practice. Many infection prevention practices are based on low-level evidence, and recommendations vary internationally. We sought to conduct an evidence review and Delphi consensus study to provide guidance on aspects that lack high-quality evidence in RA practice to reconcile responsible resource stewardship and infection prevention in RA.

METHODS

We conducted a three-round modified Delphi process. After distributing an initial free-text questionnaire to all collaborators, we created structured questions, followed by two rounds of anonymized voting. We defined strong consensus as ≥ 75% agreement and weak consensus as ≥ 50% but < 75% agreement.

RESULTS

Forty-six experts agreed to take part in the study and 36 (78%) completed all the voting rounds. Regional anesthesia practice parameters with strong consensus included hand hygiene using alcohol scrub rather than soap and water, sterile gowns being unnecessary for single-injection RA techniques, only minimal equipment in the premade packs, and goal-directed use of sedation and supplemental oxygen.

DISCUSSION

We obtained consensus on the safe and environmentally responsible practice of RA for both single-injection and indwelling catheter techniques and identified areas of research focus. While more robust evidence is being generated, clinicians may use these findings as a guide to infection prevention and environmental sustainability in their anesthesia practice.

Donation After Circulatory Death Liver Transplantation: Impact of Normothermic Machine Perfusion on Key Variables

BACKGROUND

During orthotopic liver transplantation, allograft reperfusion is a dynamic point in the operation and often requires vasoactive medications and blood transfusions. Normothermic machine perfusion (NMP) of liver allografts has emerged to increase the number of transplantable organs and may have utility during donation after circulatory death (DCD) liver transplantation in reducing transfusion burden and vasoactive medication requirements.

METHODS

This is a single-center retrospective study involving 226 DCD liver transplant recipients who received an allograft transported with NMP (DCD-NMP group) or with static cold storage (DCD-SCS group). Veno-venous bypass was not used in any patients. Infusion doses of norepinephrine, epinephrine, and vasopressin as well as bolus doses of vasoactive medications during reperfusion were recorded. Blood component therapy was recorded according to phase of liver transplantation and during the first 24 hours postprocedure.

RESULTS

A total of 103 recipients in the DCD-NMP group and 123 patients in the DCD-SCS group were included. Post-reperfusion syndrome (PRS) incidence was reduced in the DCD-NMP group compared to the DCD-SCS group (10.7% [95% confidence interval, CI, 5.5%-18.3%] vs 42.3% [95% CI, 33.4%-51.5%]; P < .001). During the reperfusion period, patients in the DCD-SCS group required increased bolus doses of epinephrine and vasopressin compared to the DCD-NMP group (24.6 vs 7.5 µg; P < .001) and (5.4 vs 2.4 units; P < .001), respectively. The DCD-SCS group received a higher infusion dose of epinephrine during anhepatic phase, at reperfusion, and up to 90 minutes after reperfusion. In the postreperfusion period, there were significant increases in the transfusion of red blood cells (RBCs; 5.3 vs 3.7 units; P = .006), fresh frozen plasma (FFP; 3.4 vs 1.9 units; P < .001), cryoprecipitate (2.7 vs 1.8 pooled units; P = .015) and platelets (0.9 vs 0.4 units; P = .008) in the DCD-SCS group compared to the DCD-NMP group. During the first 24 hours postprocedure, transfusion of RBCs, FFP, and cryoprecipitate in the DCD-SCS group was increased compared to the DCD-NMP group ([2.6 vs 1.7 units; P = .028], [1.6 vs 0.8 units; P < .001], [1.5 vs 0.9 pooled units; P = .031]) respectively. Administration of tranexamic acid was more frequent in the DCD-SCS group during the post-reperfusion period compared to the DCD-NMP group (13% [95% CI, 5.7%-17.4%] vs 3.9% [95% CI, 1.1%-9.6% 95%]; P = .018).

CONCLUSIONS

In DCD liver transplantation, use of NMP was associated with reduced incidence of PRS and decreased vasopressor and inotrope requirements at the time of allograft reperfusion compared to using SCS. Additionally, NMP was associated with reduced transfusion of all blood product components as well as antifibrinolytic agent administration in the post-reperfusion period. Reduced transfusion burden in the DCD-NMP group also occurred during the first 24 hours posttransplant.

Environmental Sustainability in ICUs: A Report From the Society of Critical Care Medicine Sustainability Task Force

OBJECTIVES

The charge of the newly formed Society of Critical Care Medicine Sustainability Task Force is to describe actionable items supporting environmental stewardship for ICUs, to discuss barriers associated with sustainability initiatives and outline opportunities for future impact.

DATA SOURCES

Ovid Medline, EBSCOhost CINAHL, Elsevier Embase, and Scopus databases were searched through to March 2024 for studies reporting on environmental sustainability and critical care.

STUDY SELECTION

Systematic reviews, narrative reviews, quality improvement projects, randomized clinical trials, and observational studies were prioritized for review. Bibliographies from retrieved articles were scanned for articles that may have been missed.

DATA EXTRACTION

Data regarding environmental sustainability initiatives that aimed to quantify, manage, or mitigate pollution and/or carbon emissions with a focus on ICUs, barriers to change, and opportunities for development were qualitatively assessed.

DATA SYNTHESIS

ICUs are resource-intensive and as such, methods to attenuate carbon emissions and waste can play a substantial role in mitigating the sizable burden of healthcare-related pollution and greenhouse gas emissions. Several initiatives and strategies exist for clinicians and providers to engage in environmental stewardship, with specific attention to avoiding low-value care while maintaining or improving patient safety and high-quality care. Increased focus on sustainability can be met with resistance to change, including institutional, financial, and behavioral barriers. Collaboration and innovative thinking create valuable opportunities for clinicians, patients, families, and policymakers to advocate for patient and planetary health.

CONCLUSIONS

Within the healthcare system, ICUs are well positioned to lead sustainability action, policy, and practice. Critical care teams have the capability and the moral responsibility to mitigate the negative impact of critical care medicine upon our environment and become change agents promoting sustainable healthcare for the benefit of human health.

Targeted animal models for preclinical assessment of cellular and gene therapies in pancreatic and liver diseases: regulatory and practical insights

Cellular and gene therapy (CGT) products have emerged as a popular approach in regenerative medicine, showing promise in treating various pancreatic and liver diseases in numerous clinical trials. Before these therapies can be tested in human clinical trials, it is essential to evaluate their safety and efficacy in relevant animal models. Such preclinical testing is often required to obtain regulatory approval for investigational new drugs. However, there is a lack of detailed guidance on selecting appropriate animal models for CGT therapies targeting specific pancreatic and liver conditions, such as pancreatitis and chronic liver diseases. In this review, the gastrointestinal committee for the International Society for Cell and Gene Therapy provides a summary of current recommendations for animal species and disease model selection, as outlined by the US Food and Drug Administration, with references to EU EMA and Japan PMDA. We discuss a range of small and large animal models, as well as humanized models, that are suitable for preclinical testing of CGT products aimed at treating pancreatic and liver diseases. For each model, we cover the associated pathophysiology, commonly used metrics for assessing disease status, the pros and limitations of the models, and the relevance of these models to human conditions. We also summarize the use and application of humanized mouse and other animal models in evaluating the safety and efficacy of CGT products. This review aims to provide comprehensive guidance for selecting appropriate animal species and models to help bridge the gap between the preclinical research and clinical trials using CGT therapies for specific pancreatic and liver diseases.

Side Effects of Immunosuppressant Drugs After Liver Transplant

Liver transplantation (LT) is the standard of care for both end-stage liver failure and hepatocellular carcinoma (HCC). Side effects of the main used immunosuppressive drugs have a noteworthy impact on the long-term outcome of LT recipients. Consequently, to achieve a balance between optimal immunosuppression and minimal side effects is a cornerstone of the post-LT period. Today, there are no validated markers for overimmunosuppression and underimmunosuppression, only a few drugs have therapeutic drug monitoring, and immunosuppression regimens vary from center to center and from country to country. Currently, there are many drugs with different efficacy and safety profiles. Using different agents permits a decrease in the dosage and minimizes the toxicities. A small subset of recipients achieves immunotolerance with the chance to stop immunosuppressive therapy. This article focuses on the side effects of immunosuppressive drugs, which significantly impact long-term outcomes for LT recipients. The primary aim is to highlight the balance between achieving effective immunosuppression and minimizing adverse effects, emphasizing the role of personalized therapeutic strategies. Moreover, this review evaluates the mechanisms of action and specific complications associated with immunosuppressive agents. Finally, special attention is given to strategies for reducing immunosuppressive burdens, improving patient quality of life, and identifying immunotolerant individuals.

Mechanistic link between long noncoding RNA and stability of oncogene reveals stemness and chemoresistance of hepatocellular carcinoma

This letter comments on the recently published manuscript by Yu et al, in which the authors revealed a novel mechanism by which the m6A-modified long noncoding RNA kinesin family member 9-antisense RNA 1 promotes stemness and sorafenib resistance of hepatocellular carcinoma (HCC) through ubiquitin-specific peptidase 1-mediated deubiquitination of oncogene short stature homeobox 2. Given the high mortality rate and poor prognosis of HCC, the findings by Yu et al open a new avenue for overcoming HCC burden by focusing on kinesin family member 9-antisense RNA 1 and short stature homeobox 2 as prognostic markers and therapeutic targets.

N6-methyladenosine (m6A)-forming enzyme METTL3 controls UAF1 stability to promote inflammation in a model of colitis by stimulating NLRP3

BACKGROUND

The rising incidence of ulcerative colitis (UC) in China poses a noticeable health challenge. This study aimed to assess the pivotal role of USP1-associated factor 1 (UAF1) in colitis. UC was induced in male C57BL/6 mice using 2.0% dextran sulfate sodium (DSS). In an in vitro model, RAW264.7 cells were exposed to 200 ng/ml of LPS + ATP. UAF1 expression level was evaluated in colonic tissues, macrophages, and serum samples using quantitative reverse transcription polymerase chain reaction (RT-qPCR). The study assessed weight, disease activity index (DAI) score, myeloperoxidase (MPO) activity, crypt length, inflammatory factors, and epithelial cell function in a mouse model of colitis treated with a UAF1 inhibitor. Microarray analysis identified potential UAF1 targets. Gene interference investigated NLR family pyrin domain containing 3 (NLRP3) involvement in UAF1-induced colitis inflammation. Immunoprecipitation, ubiquitination, and luciferase assays examined the effects of methyltransferase-like 3 (METTL3) methylation on the expression levels of NLRP3 and UAF1. UAF1 expression level was upregulated in colon tissues, RAW264.7 macrophages, and serum samples of colitis mice (P < 0.01). The UAF1 inhibitor (ML-323) enhanced weight and reduced DAI score in colitis mice (P < 0.01). It also decreased MPO activity and ulcer area, and restored crypt length (P < 0.01). UAF1 inhibitor improved epithelial cell function by suppressing NLRP3 activity (P < 0.01). UAF1 promoted inflammation in RAW264.7 macrophages via NLRP3 inflammasome induction (P < 0.01). UAF1 modulated NLRP3 protein expression, leading to reduced NLRP3 ubiquitination induced by LPS + ATP. The m6A-forming enzyme METTL3 enhanced UAF1 stability (P < 0.01) to facilitate UAF1 expression. The findings suggested that METTL3, as an m6A-forming enzyme, could regulate UAF1 mRNA, promoting inflammation in colitis through NLRP3 induction. Inhibiting UAF1 emerges as a potential therapeutic strategy for colitis.

Establishment of a Lactylation-Related Gene Signature for Hepatocellular Carcinoma Applying Bulk and Single-Cell RNA Sequencing Analysis

Background: Lactylation is closely involved in cancer progression, but its role in hepatocellular carcinoma (HCC) is unclear. The present work set out to develop a lactylation-related gene (LRG) signature for HCC. Methods: The lactylation score of tumor and normal groups was calculated using the gene set variation analysis (GSVA) package. The single-cell RNA sequencing (scRNA-seq) analysis of HCC was performed in the "Seurat" package. Prognostic LRGs were selected by performing univariate and least absolute shrinkage and selection operator (LASSO) Cox regression analyses to develop and validate a Riskscore model. Functional enrichment analysis was conducted by gene set enrichment analysis (GSEA) using the "clusterProfiler" package. Genomic characteristics between different risk groups were compared, and tumor mutational burden (TMB) was calculated by the "Maftools" package. Immune cell infiltration was assessed by algorithms of cell-type identification by estimating relative subsets of RNA transcript (CIBERSORT), microenvironment cell populations-counter (MCP-counter), estimating the proportions of immune and cancer cells (EPIC), tumor immune estimation resource (TIMER), and single-sample gene set enrichment analysis (ssGSEA). Immunotherapy response was predicted by the tumor immune dysfunction and exclusion (TIDE) algorithm. Drug sensitivity was analyzed using the "pRRophetic" package. A nomogram was established using the "rms" package. The expressions of the prognostic LRGs in HCC cells were verified by in vitro test, and cell counting kit-8 (CCK-8), wound healing, and transwell assays were carried out to measure the viability, migration, and invasion of HCC cells. Results: The lactylation score, which was higher in the tumor group than in the normal group, has been confirmed as an independent factor for the prognostic evaluation in HCC. Six prognostic LRGs, including two protective genes (FTCD and APCS) and four risk genes (LGALS3, C1orf43, TALDO1, and CCT5), were identified to develop a Riskscore model with a strong prognostic prediction performance in HCC. The scRNA-seq analysis revealed that LGALS3 was largely expressed in myeloid cells, while APCS, FTCD, TALDO1, CCT5, and C1orf43 were mainly expressed in hepatocytes. The high-risk group was primarily enriched in the pathways involved in tumor occurrence and development, with higher T cell infiltration. Moreover, the high-risk group was found to be less responsive to immunotherapy but was more sensitive to chemotherapeutic drugs. By integrating Riskscore and clinical features, a nomogram with a high predictive accuracy was developed. Additionally, C1orf43, CCT5, TALDO1, and LGALS3 were highly expressed in HCC cells. Silencing CCT5 inhibited the viability, migration, and invasion of HCC cells. Conclusion: The present work developed a novel LRG gene signature that could be considered a promising therapeutic target and biomarker for HCC.