Performance of pre-transplant criteria in prediction of hepatocellular carcinoma progression and waitlist dropout.

BACKGROUND & AIM: Liver transplantation (LT) selection models for hepatocellular carcinoma (HCC) have not been proposed to predict waitlist dropout because of tumour progression. The aim of this study was to compare the alpha-foetoprotein (AFP) model and other pre-LT models in their prediction of HCC dropout. METHODS: A multicentre cohort study was conducted in 20 Latin American transplant centres, including 994 listed patients for LT with HCC from 2012 to 2018. Longitudinal tumour characteristics, and patterns of progression were recorded at time of listing, after treatments and at last follow-up over the waitlist period. Competing risk regression models were performed, and model's discrimination was compared estimating Harrell's adapted c-statistics. RESULTS: HCC dropout rate was significantly higher in patients beyond (24% [95% CI 16-28]) compared to those within Milan criteria (8% [95% IC 5%-12%]; p < .0001), with a SHR of 3.01 [95% CI 2.03-4.47]), adjusted for waiting list time and bridging therapies (c-index 0.63 [95% CI 0.57; 0.69). HCC dropout rates were higher in patients with AFP scores >2 (adjusted SHR of 3.17 [CI 2.13-4.71]), c-index of 0.71 (95% CI 0.65-0.77; p = .09 vs Milan). Similar discrimination power for HCC dropout was observed between the AFP score and the Metroticket 2.0 model. In patients within Milan, an AFP score >2 points discriminated two populations with a higher risk of HCC dropout (SHR 1.68 [95% CI 1.08-2.61]). CONCLUSIONS: Pre-transplant selection models similarly predicted HCC dropout. However, the AFP model can discriminate a higher risk of dropout among patients within Milan criteria.

Liver transplantation for hepatocellular carcinoma: impact of expansion criteria in a multicenter cohort study from a high waitlist mortality region.

This study aimed to compare liver transplantation (LT) outcomes and evaluate the potential rise in numbers of LT candidates with hepatocellular carcinoma (HCC) of different allocation policies in a high waitlist mortality region. Three policies were applied in two Latin American cohorts (1085 HCC transplanted patients and 917 listed patients for HCC): (i) Milan criteria with expansion according to UCSF downstaging (UCSF-DS), (ii) the AFP score, and (iii) restrictive policy or Double Eligibility Criteria (DEC; within Milan + AFP score ≤2). Increase in HCC patient numbers was evaluated in an Argentinian prospective validation set (INCUCAI; NCT03775863). Expansion criteria in policy A showed that UCSF-DS [28.4% (CI 12.8-56.2)] or "all-comers" [32.9% (CI 11.9-71.3)] had higher 5-year recurrence rates compared to Milan, with 10.9% increase in HCC patients for LT. The policy B showed lower recurrence rates for AFP scores ≤2 points, even expanding beyond Milan criteria, with a 3.3% increase. Patients within DEC had lower 5-year recurrence rates compared with those beyond DEC [13.3% (CI 10.1-17.3) vs 24.2% (CI 17.4-33.1; P = 0.0006], without significant HCC expansion. In conclusion, although the application of a stricter policy may optimize the selection process, this restrictive policy may lead to ethical concerns in organ allocation (NCT03775863).

Latin American Association for the study of the liver (ALEH) practice guidance for the diagnosis and treatment of non-alcoholic fatty liver disease.

Non-alcoholic fatty liver disease (NAFLD) currently represents an epidemic worldwide. NAFLD is the most frequently diagnosed chronic liver disease, affecting 20-30% of the general population. Furthermore, its prevalence is predicted to increase exponentially in the next decades, concomitantly with the global epidemic of obesity, type 2 diabetes mellitus (T2DM), and sedentary lifestyle. NAFLD is a clinical syndrome that encompasses a wide spectrum of associated diseases and hepatic complications such as hepatocellular carcinoma (HCC). Moreover, this disease is believed to become the main indication for liver transplantation in the near future. Since NAFLD management represents a growing challenge for primary care physicians, the Asociación Latinoamericana para el Estudio del Hígado (ALEH) has decided to organize this Practice Guidance for the Diagnosis and Treatment of Non-Alcoholic Fatty Liver Disease, written by Latin-American specialists in different clinical areas, and destined to general practitioners, internal medicine specialists, endocrinologists, diabetologists, gastroenterologists, and hepatologists. The main purpose of this document is to improve patient care and awareness of NAFLD. The information provided in this guidance may also be useful in assisting stakeholders in the decision-making process related to NAFLD. Since new evidence is constantly emerging on different aspects of the disease, updates to this guideline will be required in future.

Direct-Acting Antivirals and Hepatocellular Carcinoma: No Evidence of Higher Wait-List Progression or Posttransplant Recurrence.

The association between direct-acting antivirals (DAAs) and hepatocellular carcinoma (HCC) wait-list progression or its recurrence following liver transplantation (LT) remains uncertain. We evaluated the impact of DAAs on HCC wait-list progression and post-LT recurrence. This Latin American multicenter retrospective cohort study included HCC patients listed for LT between 2012 and 2018. Patients were grouped according to etiology of liver disease: hepatitis C virus (HCV) negative, HCV+ never treated with DAAs, and HCV+ treated with DAAs either before or after transplantation. Multivariate competing risks models were conducted for both HCC wait-list progression adjusted by a propensity score matching (pre-LT DAA effect) and for post-LT HCC recurrence (pre- or post-LT DAA effect). From 994 included patients, 50.6% were HCV-, 32.9% were HCV+ never treated with DAAs, and 16.5% were HCV+ treated with DAAs either before (n = 66) or after LT (n = 98). Patients treated with DAAs before LT presented similar cumulative incidence of wait-list tumor progression when compared with those patients who were HCV+ without DAAs (26.2% versus 26.9%; P = 0.47) and a similar HCC-related dropout rate (12.1% [95% CI, 0.4%-8.1%] versus 12.9% [95% CI, 3.8%-27.2%]), adjusted for baseline tumor burden, alpha-fetoprotein values, HCC diagnosis after listing, bridging therapies, and by the probability of having received or not received DAAs through propensity score matching (subhazard ratio [SHR], 0.9; 95% CI, 0.6-1.6; P = 0.95). A lower incidence of posttransplant HCC recurrence among HCV+ patients who were treated with pre- or post-LT DAAs was observed (SHR, 0.7%; 95% CI, 0.2%-4.0%). However, this effect was confounded by the time to DAA initiation after LT. In conclusion, in this multicenter cohort, HCV treatment with DAAs did not appear to be associated with an increased wait-list tumor progression and HCC recurrence after LT.

Partial traumatic amputation of an upper limb with excellent functional recovery: A 13-year follow-up clinical case.

Introducción: Se han publicados pocos informes sobre el seguimiento a largo plazo de la reparación quirúrgica de una amputación parcial. Algunos estudios de largo plazo han registrado tasas similares de discapacidad entre los pacientes con amputaciones y los sometidos a operación reconstructiva. Objetivo: Informar un caso clínico de una amputación traumática parcial de una extremidad superior con recuperación funcional después de 13 años de seguimiento. Caso clínico: Paciente masculino de ocho años con traumatismo grave en la extremidad superior izquierda, desprendimiento de los músculos bíceps y tríceps y una fractura diafisaria oblicua del húmero distal. La fractura se fijó de manera transitoria con alambres de Kirschner de 2.0 mm, seguido de inmovilización con aparato de Sarmiento y al final se realizó reducción abierta y fijación interna con placa de compresión dinámica de 3.5 mm. La integridad muscular y neurovascular permitió la reparación microquirúrgica del nervio radial y la rehabilitación neuromuscular. Conclusiones: Este informe clínico representa un caso de una recuperación funcional excelente atestiguada a través de un periodo de seguimiento de 13 años.

Introduction: There are just a few reports that deal with long-term outcomes of a partial amputation surgical repair. Long-term studies have reported similar rates of disability among patients with amputations and those that have been undergoing reconstructive surgery. Objective: The purpose of this report is describing a clinical case of a patient with partial traumatic amputation of an upper limb with an excellent functional recovery after 13 years of follow-up. Clinical case: The case of an 8 year old male patient with severe trauma to the upper left limb is described. The lesions included an oblique diaphyseal open fracture of the distal region of the humerus, along with detachment of the biceps and triceps muscles. The fracture was fixed transiently with 2.0 mm Kirschner's wire followed by immobilization with Sarmiento's brace, and finally, open reduction and internal fixation with a 3.5 mm dynamic compression plate were performed. The muscular and neurovascular integrity allowed microsurgical repair of the radial nerve and neuromuscular rehabilitation. Conclusion: This clinical report represents a case with an excellent functional recovery witnessed through a 13-year follow-up period.

Índice de calidad de vida: Validación en una muestra peruana / Quality of Life Index: Validation in a sample Peruvian

La publicación describe la metodología del cálculo del Índice de Calidad de Vida (ICV) versión española de Mezzich y colaboradores, estimar su confiabilidad y validez, obtención de normas para la población de Lima y análisis de variación de las puntuaciones según las variables demográficas

Trasplante simultáneo de páncreas y riñón: reporte del primer caso realizado en el Perú / Simultaneous pancreas and kidney transplant: report of the first case performed in Peru

El trasplante simultáneo de páncreas y riñón es la opción terapéutica ideal para pacientes con diabetes mellitus tipo 1 con insuficiencia renal crónica. Permite recuperar la insulino-independencia y evita la necesidad de diálisis, mejorando notablemente la calidad de vida. Así mismo, la restitución de la euglicemia logra que las complicaciones tardías de la diabetes no progresen e incluso regresionen, prolongando la supervivencia global de estos pacientes. Estos beneficios superan a los riesgos de la cirugía y de la inmunosupresión inherentes al trasplante. A nivel mundial, desde 1966, en que se llevó a cabo el primer trasplante de páncreas en Minnesota (Estados Unidos), se han registrado más de 20 000 trasplantes de páncreas, con resultados cada vez mejores gracias al refinamiento en las técnicas quirúrgicas y a los nuevos esquemas de inmunosupresión. En el presente caso clínico, se reporta y describe la realización del primer trasplante simultáneo de páncreas y riñón en el Perú.

Simultaneous pancreas and kidney transplantation is the ideal treatment option for patients with type 1 diabetes mellitus with chronic renal failure. Restoring insulin independence and avoiding the need for dialysis dramatically improves the quality of life. Also, the return of euglycemia accomplishes progression and even regression of late diabetes complications, extending overall survival in these patients. These benefits outweigh surgery and immune suppression risks inherent to transplantation. Globally, since 1966 when the first pancreas transplant in Minnesota (United States) was conducted there have been more than 20 000 pancreas transplants with increasing success thanks to the refinement in surgical techniques and new immune suppression schemes. In the present clinical case we report and describe the completion of the first simultaneous pancreas and kidney transplant in Peru.

Effects of glycine on electrical and histological properties of a rat peripheral nerve injury model.

BACKGROUND: Treatment of peripheral nerve injuries focuses on lesion type, from expectant to interfascicular repair. Many experiments have been undertaken using different factors to facilitate better or faster nerve stump growth: nerve growth factor (NGF), plaque growth factor (PGF), hyaluronic acid, leukemic inhibiting factor, and GABA, etc. Glycine is an inhibitory neurotransmitter in the brain stem and spinal cord, and it also plays a critical role as a modulator of NMDA receptors. We studied the potential regenerative effect of glycine administered for different periods of time and compared results with a control group. METHODS: The sciatic nerve of Wistar rats was exposed and the electrophysiology procedure was performed: the nerve was cut transversally and stitched back in place with four isolated cardinal 9/0 nylon stitches on each end. Study group rats were administered glycine 40 mM/kg daily for 15, 30, and 60 days, while control group rats were medicated with isotonic saline solution 0.9% for the same time periods. At the end of each study time period, the electrophysiological study was repeated. Animals were sacrificed on the 15th, 30th and 60th postoperative day and the sciatic nerve was exposed and prepared for histological studies. RESULTS: According to our results, glycine was effective in the morphologic regeneration and functional recovery of the sciatic nerve post-injury in Wistar rats with one month administration. CONCLUSION: We observed that nerve histology with glycine administration was more similar to that of normal nerves.

Enfermedad de Menière: tratamiento con corticoide intratimpánico: evolución clínica / Intratympanic steroid perfusion in Menière's disease: clinical progression

Objetivo: describir la experiencia con el uso de corticoide intratimpánico para el tratamiento de la enfermedad de Menière, en el Hospital de San José. Estudio: observacional descriptivo tipo serie de casos. Métodos: pacientes con enfermedad de Menière de acuerdo con los criterios establecidos por la Academia Americana de Otorrinolaringología (AA OHNS) en 1995, a quienes se estudiaron los cambios audiométricos y mejoría de sintomatología posterior a la aplicación de CIT. Resultados: dos pacientes mejoraron la audiometría, uno de ellos de hipoacusia profunda recuperó a moderada y otro mejoró según los criterios de la AA OHNS. Conclusión: la terapia intratimpánica con dexametasona puede ser útil en el tratamiento de la enfermedad de Menière para controlar la sintomatología y el deterioro auditivo. En nuestro estudio no se hallaron complicaciones relacionadas con el procedimiento.

Objective: to describe the experience at the San José Hospital with the use of intratympanic steroid perfusion (ITSP) to treat Meniére's disease. Type of Study: case series observational descriptive study. Met' evaluation of audiometric changes and symptom relief in patients who underwent ITSP and met the diagnostic criteria established by the American Academy of Otolaryngology (AA OHNS) in 1995 for Meniere's disease. Results: audiogram results improved in two patients. Hearing impairment down-regulated from profound to moderate in one patient and the other improved according to the AA OHNS criteria. Conclusion: intra-tympanic perfusion with dexametasone to treat Meniére's disease may be useful for symptom and hearing impairment control. No procedure-related complications were found in our study.