Sarcopenia in hepatocellular carcinoma: Current knowledge and future directions

Liver cancer is the second most occurring cancer worldwide and is one of the leading causes of cancer-related deaths.Hepatocellular carcinoma(HCC)is the most common(80%-90%)type among malignant liver cancers.Sarcopenia occurs very early in HCC and can predict and provide an opportunity to improve muscle health before engaging in the treatment options such as loco-regional,systemic,and transplant management.Multiple prognostic stating systems have been developed in HCC,such as Barcelona Clinic Liver Cancer,Child-Pugh score and Albumin-Bilirubin grade.However,the evaluation of patients’performance status is a major limitation of these scoring systems.In this review,we aim to summarize the current knowledge and recent advances about the role of sarcopenia in cirrhosis in general,while focusing specifically on HCC.Additionally,the role of sarcopenia in predicting clinical outcomes and prognostication in HCC patients undergoing loco-regional therapies,liver resection,liver transplantation and systematic therapy has been discussed.A literature review was performed using databases PubMed/MEDLINE,EMBASE,Cochrane,Web of Science,and CINAHL on April 1,2021,to identify published reports on sarcopenia in HCC.Sarcopenia can independently predict HCC-related mortality especially in patients undergoing treatments such as loco-regional,surgical liver transplantation and systemic therapies.Basic research is focused on evaluating a balance of anabolic and catabolic pathways responsible for muscle health.Early clinical studies have shown promising results in methods to improve sarcopenia in HCC which can potentially increase prognosis in these patients.As sarcopenia occurs very early in HCC,it can predict and provide an opportunity to improve muscle health before engaging in the treatment options such as loco-regional,systemic,and transplant management.Further,sarcopenia measurement can obviate the confounding caused by the abdominal ascites in these patients.The use of sarcopenia can add to the existing scoring systems to better prognosticate the HCC.     

Increasing thirty-day readmissions of Crohn’s disease and ulcerative colitis in the United States: A national dilemma

BACKGROUNDThe prevalence of Crohn’s disease (CD) and ulcerative colitis (UC) is on the rise worldwide. This rising prevalence is concerning as patients with CD and UC may frequently relapse leading to recurrent hospitalizations and increased healthcare utilization.AIMTo identify trends and adverse outcomes for 30 d readmissions for CD and UC. METHODSThis was a retrospective, interrupted trends study involving all adult (≥ 18 years) 30 d readmissions of CD and UC from the National Readmission Database (NRD) between 2008 and 2018. Patients < 18 years, elective, and traumatic hospitalizations were excluded from this study. We identified hospitalization characteristics and readmission rates for each calendar year. Trends of inpatient mortality, mean length of hospital stay (LOS) and mean total hospital cost (THC) were calculated using a multivariate logistic trend analysis adjusting for age, gender, insurance status, comorbidity burden and hospital factors. Furthermore, trends between CD and UC readmissions were compared using regression of the interaction coefficient after adjusting for age and gender to determine relative trends between the two populations. Stata^® Version 16 software (StataCorp, TX, United States) was used for statistical analysis and P value ≤ 0.05 were considered statistically significant. RESULTSTotal number of 30 d readmissions increased from 6202 in 2010 to 7672 in 2018 for CD and from 3272 in 2010 to 4234 in 2018 for UC. We noted increasing trends for 30-day all-cause readmission rate of CD from 14.9% in 2010 to 17.6% in 2018 (P-trend < 0.001), CD specific readmission rate from 7.1% in 2010 to 8.2% in 2018 (P-trend < 0.001), 30-day all-cause readmission rate of UC from 14.1% in 2010 to 15.7% in 2018 (P-trend = 0.003), and UC specific readmission rate from 5.2% in 2010 to 5.6% in 2018 (P-trend = 0.029). There was no change in the risk adjusted trends of inpatient mortality and mean LOS for CD and UC readmissions. However, we found an increasing trend of mean THC for UC readmissions. After comparison, there was no statistical difference in the trends for 30 d all-cause readmission rate, inpatient mortality, and mean LOS between CD and UC readmissions.CONCLUSIONThere was an increase in total number of 30 d readmissions for CD and UC with a trend towards increasing 30 d all-cause readmission rates.     

Etiology of Failed Anterior Cruciate Ligament Reconstruction: a Scoping Review

Purpose of ReviewRecent literature was reviewed to identify and summarize the etiology of primary anterior cruciate ligament (ACL) reconstruction (ACLR) failure reported.MethodsThe databases Embase, PubMed, and Medline were searched on March 10, 2022, for English-language, clinical studies that reported on the etiology of failure of primary ACLR. The studies were systematically screened in duplicate and data abstracted.Recent FindingsForty-three studies were identified that reported mode of failure in primary ACLR. Trauma (43 studies), technical error (11 studies), and biology (9 studies) remain the most reported etiologies of ACLR failure. A combination of causes was listed in three studies. No reported cause or “other” was listed in 22 studies.SummaryMany clinical studies fail to report etiology of ACLR failure. Level of detail provided regarding mode of failure varies widely. Trauma, technical error, and biological failure remain the leading etiologies of ACLR failure reported in recent literature. Technical error is likely underreported and a contributing factor in traumatic failures.     

Endoscopic ultrasound guided liver biopsy: Recent evidence

Liver biopsy(LB) is an essential tool in diagnosing, evaluating and managing various diseases of the liver.As such, histopathological results are critical as they establish or aid in diagnosis, provide information on prognosis, and guide the appropriate selection of medical therapy for patients.Indications for LB include evaluation of persistent elevation of liver chemistries of unclear etiology,diagnosis of chronic liver diseases such as Wilson's disease, autoimmune hepatitis, small duct primary sclerosing cholangitis, work up of fever of unknown origin, amyloidosis and more.Traditionally, methods of acquiring liver tissue have included percutaneous LB(PCLB), transjugular LB(TJLB) or biopsy taken surgically via laparotomy or laparoscopy.However, traditional methods of LB may be inferior to newer methods.Additionally, PCLB and TJLB carry higher risks of adverse events and complications.More recently, endoscopic ultrasound guided LB(EUS-LB) has evolved as an alternative method of tissue sampling that has proven to be safe and effective, with limited adverse events.Compared to PC and TJ routes, EUS-LB may also have a greater diagnostic yield of tissue, be superior for a targeted approach of focal lesions, provide higher quality images and allow for greater patient comfort.These advantages have contributed to the increased use of EUS-LB as a technique for obtaining liver tissue.Herein, we provide a review of the recent evidence of EUS-LB for liver disease.     

Doppler ultrasonography reveals adult-worm nests in the lymph vessels of children with brugian filariasis

Although ultrasonography has allowed 'nests' of live adult worms and dilated lymphatics to be detected in the early stages of infection with Wuchereria bancrofti, previous attempts to locate such adult-worm nests in brugian filariasis have been unsuccessful. In this study, the successful location of live adult Brugia malayi parasites, in the lymphatics of the axilla, thigh, epitrochlear region and/or popliteal fossa of children aged 3-15 years, is described for the first time. The 'filarial dance sign' (FDS), which indicates the presence of live adult worms, was observed in six children with microfilaraemia and in eight children who, though amicrofilaraemic, either had experienced an episode of lymphoedema (one) or were only positive for antifilarial IgG4 antibodies (seven). In bancroftian infection, the adult-worm nests have mostly been seen in asymptomatic but microfilaraemic subjects. The suspected worm nests, 18 in the 14 children, were all confirmed using colour-power and pulse-wave Doppler examinations. The worm nests were distinctly smaller and the wriggling movements were less rapid and less conspicuous than those seen in bancroftian filariasis. The importance of these findings in the management and control of lymphatic filariasis is discussed.     

Laparoscopic cholecystectomy in the pediatric population

BACKGROUND: The experience with laparoscopic cholecystectomy in children trails the adult numbers and remains underreported. Therefore, we reviewed our experience with this approach. METHODS: A retrospective review of our most recent 6-year experience with laparoscopic cholecystectomy at Children's Mercy Hospital (Kansas City, MO) between September 5, 2000, and June 1, 2006, was performed. Data points reviewed included patient demographics, indication for operation, operative time, complications, and recovery. RESULTS: During the study period, 224 patients underwent a laparoscopic cholecystectomy. The mean age was 12.9 years (range, 0-21) with a mean weight of 58.3 kg (range, 3-121). Indications for laparoscopic cholecystectomy were symptomatic gallstones in 166 children, biliary dyskinesia in 35, gallstone pancreatitis in 7, gallstones and an indication for splenectomy in 6, calculous cholecystitis in 5, choledocholithiasis in 1, gallbladder polyps in 1, acalculous cholecystitis in 1, and congenital cystic duct obstruction in 1. The mean operative time (excluding patients with concomitant operations) was 77 minutes (range, 30-285). An intraoperative cholangiogram was performed in 38 patients. Common bile duct (CBD) stones were cleared intraoperatively in 5 patients. Two patients required a postoperative endoscopy to retrieve CBD stones. One sickle-cell patient developed a postoperative hemorrhage, requiring a laparotomy. There were no conversions, ductal injuries, bile leaks, or mortality. Biliary dyskinesia was diagnosed in 10% of the first 30 patients in this series and 40% of the most recent 30 patients. The mean ejection fraction in these patients was 21%. All experienced an improvement in their symptoms after the cholecystectomy. CONCLUSIONS: Laparoscopic cholecystectomy is safe and effective in children. Biliary dyskinesia is becoming more frequently diagnosed in children, and these patients respond favorably to cholecystectomy. As opposed to the adult population, the incidence of complicated gallstone disease appears less common in children, as most present with symptomatic cholelithiasis without active inflammation, accounting for the very low rate of ductal complications.     

Current application of thoracoscopy in children

BACKGROUND: The safety and efficacy of thoracoscopy for thoracic lesions and conditions in children is evolving. Our experience with thoracoscopy has expanded in recent years. Therefore, we reviewed our most recent 7-year experience to examine the current applications for thoracoscopy in children. METHODS: A retrospective review of all patients undergoing a thoracoscopic operation at Children's Mercy Hospital (Kansas City, MO) between January 1, 2000, and June 18, 2007, was performed. Data points reviewed included patient demographics, type of operation, final diagnosis, complications, and recovery. RESULTS: During the study period, 230 children underwent 231 thoracoscopic procedures. The mean age was 9.6 +/- 6.1 years with a mean weight of 36.6 +/- 24.1 kg. Fifty percent of the patients were male. The thoracoscopic approach was used for decortication and debridement for empyema in 79 patients, wedge resection for lung lesions in 37, exposure for correction of scoliosis in 26, excision or biopsy of an extrapulmonary mass in 26, operation for spontaneous pneumothorax in 25, lung biopsy for a diffuse parenchymal process in 15, lobectomy in 9, repair of esophageal atresia with a tracheoesophageal fistula (EA-TEF) in 8, clearance of the pleural space for hemothorax or effusion in 3, diagnosis for trauma in 1, and repair of bronchopleural fistula in 1. Conversion was required in 3 patients, all of whom were undergoing a lobectomy. Two of these were right upper lobectomies and the other was a left lower lobectomy with severe infection and inflammation. The mean time of chest tube drainage (excluding scoliosis and EA-TEF patients) was 2.9 +/- 2.0 days. There were no major intraoperative thoracoscopic complications. A correct diagnosis was rendered in all patients undergoing a biopsy. One patient required a second thoracoscopic biopsy to better define a mediastinal mass. Two patients developed postoperative atelectasis after scoliosis procedures. One patient had a small persistent pneumothorax after a bleb resection for a spontaneous pneumothorax. This subsequently resolved. CONCLUSIONS: In pediatric patients with thoracic pathology, thoracoscopy is highly effective for attaining the goal of the operation, with a low rate of conversion and complications.