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INTRODUCTION: Surgeries for chronic pancreatitis are tailored based on disease process and either include parenchymal-preserving surgeries or total pancreatectomy with or without islet cell autotransplantation. It is critical to account for vascular variants as injuries to these are associated with short- and long-term morbidity and mortality. There is a lack of contemporary data on the true incidence of aberrant arterial anatomy, and it is likely to be underreported by nonhepatobiliary radiologists. METHODS: This study is a retrospective analysis of all patients undergoing pancreatic resections for chronic pancreatitis at the single center. The presence of vascular variants was compared between standard reporting and preoperative imaging review by a hepatobiliary radiologist and surgeon. Primary outcomes were operative time and blood loss. RESULTS: Of the 72 pancreatic resections for chronic pancreatitis, 50 (69%) satisfied inclusion criteria. Three of fifty (6%) had vascular anomalies reported on standard reporting while 11 (22%) had vascular anomalies identified on preoperative imaging review and confirmed at surgery. Hence, only 27% of patients with variant vascular anatomy were reported on standard imaging. There was no significant difference in operative times or blood loss between those with and without known vascular anomalies. CONCLUSIONS: Pancreatic resection is a complex undertaking as long-standing inflammation distorts anatomic planes and increases opportunity for inadvertent vascular injury especially if there are aberrant vessels. In this study, we found that anatomic vascular variants are oftentimes not reported. Dedicated surgical planning with review of cross-sectional imaging identified all cases of anatomic variants resulting in no difference in operative time or incidence of intraoperative hemorrhage.
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In advanced Renal Cell Carcinoma (aRCC), systemic therapy is the mainstay of treatment, with no or little role for surgery in these patients. Tyrosine kinase inhibitors (TKIs) and immune-oncological (IOs) therapies, either alone or in combination, are recommended in these patients depending on patient and tumour factors. The sequencing of therapies is critical in RCC because the choice of subsequent line therapy is heavily dependent on the response and duration of the previous treatment. There are additional barriers to RCC treatment in India. Immunotherapy is the cornerstone of treatment in ccRCC, but it is prohibitively expensive and not always reimbursed, effectively putting it out of reach for the vast majority of eligible patients in India. Furthermore, in advanced RCC (particularly the clear cell variety), Indian oncologists consider the disease burden of the patients, which is particularly dependent on the quantum of the disease load, clinical symptoms, and performance status of the patient, before deciding on treatment. There are no India-specific guidelines for clear cell RCC (ccRCC) treatment or the positioning and sequencing of molecules in the management of advanced ccRCC that take these country-specific issues into account. The current consensus article provides expert recommendations and treatment algorithms based on existing clinical evidence, which will be useful to specialists managing advanced ccRCC.
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Carcinoma de Células Renais , Neoplasias Renais , Humanos , Carcinoma de Células Renais/tratamento farmacológico , Neoplasias Renais/tratamento farmacológico , Consenso , ÍndiaRESUMO
BACKGROUND: A paucity of evidence exists regarding the risks and benefits of Extracorporeal Membrane Oxygenation (ECMO) in adult kidney transplantation. METHODS: This was a systematic review conducted from Jan 1, 2000 to April 24, 2020 of adult kidney transplant recipients (pre- or post- transplant) and donors who underwent veno-arterial or veno-venous ECMO cannulation. Death and graft function were the primary outcomes, with complications as secondary outcomes. RESULTS: Twenty-three articles were identified that fit inclusion criteria. 461 donors were placed on ECMO, with an overall recipient 12-month mortality rate of 1.3% and a complication rate of 61.5%, the majority of which was delayed graft function. Fourteen recipients were placed on ECMO intraoperatively or postoperatively, with infection as the most common indication for ECMO. The 90-day mortality rate for recipients on ECMO was 42.9%, with multisystem organ failure and infection as the ubiquitous causes of death. 35.7% of patients experienced rejection within 6 months of decannulation, yet all were successfully treated. CONCLUSIONS: ECMO use in adult kidney transplantation is a useful adjunct. Recipient morbidity and mortality from donors placed on ECMO mirrors that of recipients from standard criteria donors. The morbidity and mortality of recipients placed on ECMO are also similar to other patient populations requiring ECMO.
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Oxigenação por Membrana Extracorpórea , Transplante de Rim , Humanos , Adulto , Transplante de Rim/efeitos adversos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Doadores de Tecidos , Estudos RetrospectivosRESUMO
Survivorship after liver transplantation (LT) is a novel concept providing a holistic view of the arduous recovery experienced after transplantation. We explored components of early survivorship including physical, emotional, and psychological challenges to identify intervention targets for improving the recovery process of LT recipients and caregivers. A total of 20 in-person interviews were conducted among adults 3 to 6 months after LT. Trained qualitative research experts conducted interviews, coded, and analyzed transcripts to identify relevant themes and representative quotes. Early survivorship comprises overcoming (1) physical challenges, with the most challenging experiences involving mobility, driving, dietary modifications, and medication adherence, and (2) emotional and psychological challenges, including new health concerns, financial worries, body image/identity struggles, social isolation, dependency issues, and concerns about never returning to normal. Etiology of liver disease informed survivorship experiences including some patients with hepatocellular carcinoma expressing decisional regret or uncertainty in light of their post-LT experiences. Important topics were identified that framed LT recovery including setting expectations about waitlist experiences, hospital recovery, and ongoing medication requirements. Early survivorship after LT within the first 6 months involves a wide array of physical, emotional, and psychological challenges. Patients and caregivers identified what they wish they had known prior to LT and strategies for recovery, which can inform targeted LT survivorship interventions.
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Transplante de Fígado , Sobrevivência , Adulto , Cuidadores/psicologia , Humanos , Transplante de Fígado/efeitos adversos , Transplante de Fígado/psicologia , Pesquisa Qualitativa , Qualidade de Vida/psicologiaRESUMO
Chronic pancreatitis results in permanent parenchymal destruction of the pancreas gland leading to anatomical and physiological consequences for patients. Surgical management varies, and some patients require total pancreatectomy with autologous islet cell transplantation (TPIAT). Patients undergoing TPIAT require complex and diligent management after surgery. This encompasses the management of glucose control (endocrine function of the pancreas) and supplementing loss of exocrine function of the pancreas with digestive enzymes. Other areas of management include optimizing pain relief while reducing narcotic usage, providing antimicrobial prophylaxis, and reducing loss of islet cells by improving its integrity through anticoagulation and use of anti-inflammatory agents. Each aspect of care is unique to this population. However, comprehensive reviews on its pharmacological management are scarce. This review will discuss the available literature to date surrounding all aspects of pharmacological management of patients undergoing TPIAT.
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Transplante das Ilhotas Pancreáticas , Ilhotas Pancreáticas , Pancreatite Crônica , Humanos , Transplante das Ilhotas Pancreáticas/métodos , Pancreatectomia/métodos , Pancreatite Crônica/cirurgia , Transplante Autólogo , Resultado do TratamentoRESUMO
BACKGROUND: The selection of surgery between parenchymal preserving (PPS) and total pancreatectomy (TP) with/without islet cell autotransplantation (IAT) for chronic pancreatitis (CP) patients varies based on multiple factors with a scarcity in literature addressing both at the same time. The aim of this manuscript is to present an algorithm for the surgery selection based on dominant area of disease, ductal dilatation, and glycemic control and compare outcomes. METHODS: From 2017 to 2021, CP patients offered surgery at a single institution were retrospectively evaluated. RESULTS: 51 patients underwent surgery (20 [39.2%] TPIAT, 4 [7.8%] TP, and 27 [52.9%] PPS - 9 Whipple procedures, 15 distal pancreatectomies, and 3 duct drainage procedures). No significant difference was observed in baseline characteristics or perioperative outcomes except median length of stay (8 days [IQR 6-10] vs. 13 days [IQR 9-15.5], p < 0.001), attributed to insulin requirement and education for TPIAT group. No differences in postoperative complications, such as clinically significant leak and intrabdominal fluid collection (3 [11.1%] vs 2 [10%], p = 1.0), hemorrhage (0 vs. 2 [10.0%], p = 0.2), delayed feeding (1 [3.7%] vs. 5 [25.0%], p = 0.07), or wound infection (4 [14.8%] vs. 0, p = 0.1) between PPS and TPIAT groups, respectively, were observed nor requirement of long-acting insulin at discharge (2 [15.4%] vs. 7 [43.8%], p = 0.1) for pre-operatively non-diabetic patients. No significant difference in weaning off narcotics and no mortality observed. CONCLUSION: The most appropriate selection of surgery based on the algorithm yields good and comparable outcomes.
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Transplante das Ilhotas Pancreáticas , Ilhotas Pancreáticas , Pancreatite Crônica , Humanos , Transplante das Ilhotas Pancreáticas/métodos , Pancreatectomia/métodos , Pancreatite Crônica/complicações , Estudos Retrospectivos , Transplante Autólogo , Resultado do TratamentoRESUMO
INTRODUCTION: Aim was to study the early impact of acuity circle-based allocation implementation system on liver transplantation for hepatocellular carcinoma (HCC) patients. METHODS: We assessed characteristics of HCC and non-HCC deceased donor orthotopic liver transplants (OLT) in the year before (2/2019-2/2020) and after (3/2020-2/2021) introduction of the acuity circle policy using the Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) database. RESULTS: Total OLTs reduced from 6699 in the preacuity circle era to 6660 in the postacuity circle era (-.6%); this decrease is mostly driven by a decrease in HCC transplants (1529 to 1351; -11.6%). Six out of 11 regions had a reduction in the absolute number and percentage of HCC transplants with significant reductions in regions 2 (-37.8%, p < .001) and 4 (-28.3%, p = .001). DISCUSSION: The introduction of median model for end-stage liver disease (MELD) at transplant minus 3 (MMaT-3) exception points, has created differential opportunities for HCC patients, in low-MELD as opposed to high-MELD areas, despite having the same disease. This effect has become more prominent following the implementation of acuity circle-based allocation system. Ongoing investigation of these trends is needed to ensure that HCC patients are not disparately disadvantaged due to their location.
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Carcinoma Hepatocelular , Doença Hepática Terminal , Neoplasias Hepáticas , Transplante de Fígado , Obtenção de Tecidos e Órgãos , Carcinoma Hepatocelular/patologia , Carcinoma Hepatocelular/cirurgia , Humanos , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/cirurgia , Índice de Gravidade de Doença , Listas de EsperaRESUMO
BACKGROUND: A paucity of evidence exists regarding risks and benefits of extracorporeal membrane oxygenation (ECMO) in adult liver transplantation. METHODS: This was a systematic review conducted from January 1, 2000 to April 24, 2020 of adult liver transplant recipients (pre- or post-transplant) and donors who underwent Veno-arterial or Veno-venous ECMO cannulation. Death was the primary outcome, with graft function and complications as secondary outcomes. RESULTS: Forty-one articles were identified that fit criteria. A total of 183 donors were placed on ECMO, with recipient complication profiles and mortality that mirrored rates from standard criteria donors. Sixty-one recipients were placed on ECMO intraoperatively or postoperatively. Most patients experienced at least one complication with infections as the most common cause and minimal complications specifically related to ECMO use. Multisystem organ failure (MSOF) and infections were more common among liver recipients who died compared to those who survived. Overall mortality at 90 days was 45.9%. Causes of death were most commonly MSOF and infections. CONCLUSIONS: ECMO use in adult liver transplantation is a useful adjunct. Recipient morbidity and mortality from donors placed on ECMO parallel that of recipients from standard criteria donors, and morbidity and mortality of recipients placed on ECMO are similar to other ECMO populations.
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Oxigenação por Membrana Extracorpórea , Transplante de Fígado , Adulto , Oxigenação por Membrana Extracorpórea/efeitos adversos , Humanos , Fígado , Transplante de Fígado/efeitos adversos , Estudos Retrospectivos , Doadores de Tecidos , Resultado do TratamentoRESUMO
ABSTRACT: Type 3c diabetes, also known as pancreatogenic diabetes, occurs when primary pancreatic disorders damage the pancreatic islets of Langerhans. Although often misdiagnosed as type 2 diabetes, type 3c diabetes is different in cause, clinical presentation, treatment, and prognosis. Patients with type 3c diabetes are more likely to experience complications and death related to hypoglycemic events. This article reviews the causes and management of type 3c diabetes, which is estimated to affect 5% to 10% of all patients with diabetes.
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Diabetes Mellitus Tipo 2 , Diabetes Mellitus , Pancreatite Crônica , Humanos , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/terapia , Pancreatite Crônica/complicações , Pâncreas , Hipoglicemiantes/uso terapêutico , Diabetes Mellitus/tratamento farmacológicoRESUMO
Although cellular transplantation remains a relatively small field compared to solid organ transplantation, the prospects for advancement in basic science and clinical care remain bountiful. In this review, notable historical events and the current landscape of the field of cellular transplantation are reviewed with an emphasis on islets (allo- and xeno-), hepatocytes (including bioartificial liver), adoptive regulatory immunotherapy, and stem cells (SCs, specifically endogenous organ-specific and mesenchymal). Also, the nascent but rapidly evolving field of three-dimensional bioprinting is highlighted, including its major processing steps and latest achievements. To reach its full potential where cellular transplants are a more viable alternative than solid organ transplants, fundamental change in how the field is regulated and advanced is needed. Greater public and private investment in the development of cellular transplantation is required. Furthermore, consistent with the call of multiple national transplant societies for allo-islet transplants, the oversight of cellular transplants should mirror that of solid organ transplants and not be classified under the unsustainable, outdated model that requires licensing as a drug with the Food and Drug Administration. Cellular transplantation has the potential to bring profound benefit through progress in bioengineering and regenerative medicine, limiting immunosuppression-related toxicity, and providing markedly reduced surgical morbidity.
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Diabetes Mellitus Tipo 1 , Transplante das Ilhotas Pancreáticas , Transplantes , Humanos , Tolerância Imunológica , Terapia de Imunossupressão , Células-TroncoRESUMO
Islet allotransplantation in the United States (US) is facing an imminent demise. Despite nearly three decades of progress in the field, an archaic regulatory framework has stymied US clinical practice. Current regulations do not reflect the state-of-the-art in clinical or technical practices. In the US, islets are considered biologic drugs and "more than minimally manipulated" human cell and tissue products (HCT/Ps). In contrast, across the world, human islets are appropriately defined as "minimally manipulated tissue" and not regulated as a drug, which has led to islet allotransplantation (allo-ITx) becoming a standard-of-care procedure for selected patients with type 1 diabetes mellitus. This regulatory distinction impedes patient access to islets for transplantation in the US. As a result only 11 patients underwent allo-ITx in the US between 2016 and 2019, and all as investigational procedures in the settings of a clinical trials. Herein, we describe the current regulations pertaining to islet transplantation in the United States. We explore the progress which has been made in the field and demonstrate why the regulatory framework must be updated to both better reflect our current clinical practice and to deal with upcoming challenges. We propose specific updates to current regulations which are required for the renaissance of ethical, safe, effective, and affordable allo-ITx in the United States.
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Produtos Biológicos , Diabetes Mellitus Tipo 1 , Transplante das Ilhotas Pancreáticas , Custos e Análise de Custo , Diabetes Mellitus Tipo 1/cirurgia , Humanos , Transplante Heterólogo , Estados UnidosRESUMO
Survivorship is a well-established concept in the cancer care continuum with a focus on disease recurrence, quality of life, and the minimization of competing risks for mortality; however, survivorship has not been well studied in liver transplantation (LT). We investigated what survivorship means to LT patients and identified motivations and coping strategies for overcoming challenges after LT. A total of 20 in-depth home interviews were conducted among adults 3 to 6 months after LT. Interviews were conducted by trained qualitative research experts and coded and analyzed using an inductive approach. A majority of LT recipients (75%) identified themselves as survivors. Integral to the definition of survivorship was overcoming hardship (including experiences on the waiting list) and the unique experience of being given a "second chance" at life. Motivations to survive included a new chance at life (55%), family (40%), spirituality/faith (30%), and fear of rejection (15%). LT recipients and caregivers identified multiple strategies to cope with post-LT challenges, including relying on a large network of community, spiritual, and virtual support. These findings informed a conceptual model of LT survivorship based on socioecological theory, which identified the following variables influencing survivorship: (1) pretransplant experiences, (2) individual attributes and challenges, (3) interpersonal relationships with caregivers and other social support, (4) community relationships, and (5) large-scale factors including neighborhood and financial issues. LT recipients identified themselves as survivors, and post-LT identities were greatly influenced by pre-LT experiences. These perspectives informed an in-depth conceptual model of survivorship after transplantation. We identified sources of motivation and coping strategies used in LT recovery that could be targets of survivorship interventions aimed at improving post-LT outcomes.
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Transplante de Fígado , Sobrevivência , Adaptação Psicológica , Adulto , Humanos , Pesquisa Qualitativa , Qualidade de Vida , Sobreviventes , TransplantadosRESUMO
Plasma-derived extracellular vesicles (EV) can serve as markers of cell damage/disease but can also have therapeutic utility depending on the nature of their cargo, such as miRNA. Currently, there are challenges and lack of innovations regarding early diagnosis and therapeutic options within different aspects of management of patients suffering from chronic pancreatitis (CP). Use of EV as biomarkers for pancreatic health and/or as adjuvant therapy would make a difference in management of these patients. The aim of this study was to characterize the miRNA cargo of EV purified from the plasma of CP patients and compared to those of healthy participants. EVs were isolated from plasma of 15 CP patients and 10 healthy controls. Nanoparticle tracking analysis was used to determine frequency and size, while NanoString technology was used to characterize the miRNA cargo. Relevant clinical parameters were correlated with EV miRNA cargo. ~ 30 miRNA species were identified to have significantly (p < 0.05) different expression in EV from individuals with CP compared to healthy individuals; ~ 40 miRNA were differentially expressed in EV from pre-diabetic versus non-diabetic CP patients. miR-579-3p, while exhibiting significantly lower (~ 16-fold) expression in CP compared to healthy and lower (~ 24-fold) in CP narcotic users compared to the non-users, is actually enriched (~ 32-fold) within EV in pre-diabetic CP patients compared to non-diabetic CP patients. A unique pattern was identified in female CP patients. These data support the prospect of using a plasma-derived EV cargo to assess pancreatic health and its therapeutic potential in CP patients.
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Vesículas Extracelulares/genética , MicroRNAs/genética , Pancreatite Crônica/genética , Biomarcadores/sangue , Estudos de Casos e Controles , Feminino , Humanos , Masculino , MicroRNAs/sangue , Pancreatite Crônica/sangue , Pancreatite Crônica/patologiaRESUMO
INTRODUCTION: Total pancreatectomy with autologous islet transplant (TPAIT) is indicated for patients with chronic pancreatitis to improve quality of life while reducing complications from hypoglycemia. Continuous glucose monitoring (CGM) was used to assess overall islet function and the incidence of hypoglycemia pre- and post-operatively. METHODS: Nineteen patients who underwent TPAIT at a single center from 2018 to 2020 were included. Pre-operatively, patients were defined by diabetic status. HbA1c, stimulated C-peptide, and CGM were used to characterize glycemic function. RESULTS: Pre-operatively, three patients had diabetes, and 16 patients did not have diabetes. Eight out of 16 non-diabetic patients were insulin independent (50%). Of six non-diabetic patients with > 10% hypoglycemia on pre-operative CGM, 33% were insulin-independent post-operatively (P = .3). Of non-diabetic patients with ≥ 80% time in the euglycemic range, 62% were insulin-independent post-operatively (P = .2). For patients without diabetes, the median percent time in hypoglycemic range was reduced from 8% to 1% (P = .001). Delta C-peptide had a positive correlation with islet yield (P = .03). DISCUSSION: Conventional evaluation of TPAIT patients assesses primarily beta cell function. As pancreatogenic diabetes is concerning principally for the risk of hypoglycemia, assessment of alpha cell function can improve the quality of care. CGM better captures islet function and increases the identification of hypoglycemia.
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Diabetes Mellitus Tipo 1 , Hipoglicemia , Transplante das Ilhotas Pancreáticas , Glicemia , Automonitorização da Glicemia , Humanos , Hipoglicemia/diagnóstico , Hipoglicemia/etiologia , Hipoglicemiantes , Insulina , Pancreatectomia/efeitos adversos , Qualidade de VidaRESUMO
BACKGROUND: Advances in ECMO have made it a useful adjunct in critically ill pediatric patients; however, a dearth of evidence exists regarding risks and benefits in pediatric abdominal transplantation. The purpose of this study was to perform a qualitative systematic review of outcomes in pediatric patients undergoing ECMO support pre- or post-abdominal organ transplantation. METHODS: This was a systematic review conducted from Jan 1, 1989, to April 24, 2020, via PubMed, Embase, Scopus, Web of Science, the Cochrane Library, and ClinicalTrials.gov of all pediatric solid abdominal organ transplant recipients (pre- and post-transplant) and donors who underwent V-A or V-V ECMO cannulation. Death was the primary outcome, with graft function and complications as secondary outcomes. RESULTS: Fourteen articles were identified that fit criteria, with 88% being case reports. Three patients were donors placed on ECMO, with no mortality among the 8 recipients of organs from these donors. Nineteen recipients were placed on ECMO. All were liver transplants. Most patients experienced at least one complication (84%), with bleeding as the most common cause (44%). Mortality was 26%. Causes of death included multiorgan system failure (n = 3), heart failure (n = 1), Systemic inflammatory response syndrome (n = 1), abdominal compartment syndrome (n = 3), bleeding (n = 1), septic shock from aspergillus (n = 1), and hepatic artery thrombosis (n = 2). CONCLUSIONS: The data are poor on ECMO usage in pediatric abdominal transplantation. While complications were high, mortality did not appear to be related to ECMO usage and was relatively low given the severity of patient illness.
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Oxigenação por Membrana Extracorpórea , Transplante de Fígado , Adolescente , Criança , Pré-Escolar , Humanos , Lactente , Assistência Perioperatória , Pesquisa QualitativaRESUMO
The last decade has seen the introduction of a number of important technological innovations in the management of advanced cardiovascular disease. These include transcatheter aortic valve replacement systems, a transcatheter mitral valve repair device, a left atrial appendage occluder device, coronary bioresorbable vascular scaffolds, leadless fully implantable pacemaker systems, wireless implantable pulmonary artery pressure monitors, transcatheter left ventricular assist pumping devices, drug-coated balloons, and robotic percutaneous coronary intervention devices. With the exception of drug coated balloon platforms, all have been utilized in our institution for patients from South Dakota and neighboring states. The objective of this study is to briefly describe these innovative devices, summarize the evidence for their benefit, and offer helpful pearls for the primary care providers who are key members of the care team for these patients.
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Marca-Passo Artificial , Intervenção Coronária Percutânea , Substituição da Valva Aórtica Transcateter , Valva Aórtica , Humanos , Tecnologia , Resultado do TratamentoRESUMO
Arrhythmogenic right ventricular cardiomyopathy is a predominantly inherited structural disease with a heterogeneous set of implicated genetic defects. For those patients not identified by targeted population screening programs, ventricular tachycardia can be their first presentation. We report a case of a female from the genetically isolated Hutterite colonies who presented with recurrent ventricular tachycardia. She was found to be homozygous for a truncated desmocollin-2 gene, with both severe right ventricular dysfunction and left ventricular involvement. Her medical management was complicated by the finding of concomitant pre-term pregnancy. Management options for arrhythmia suppression and treatment are reviewed taking into account her decompensated biventricular dysfunction and possible fetal effects.
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Displasia Arritmogênica Ventricular Direita , Taquicardia Ventricular , Arritmias Cardíacas , Displasia Arritmogênica Ventricular Direita/complicações , Displasia Arritmogênica Ventricular Direita/diagnóstico , Displasia Arritmogênica Ventricular Direita/genética , Feminino , Humanos , Período Periparto , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/etiologiaRESUMO
BACKGROUND: Portal vein thrombosis (PVT) is a serious complication of total pancreatectomy and autologous islet cell transplant (TPAIT); therefore, portal flow dynamics are monitored by Doppler ultrasound postoperatively. The practical value of scheduled Doppler ultrasound examinations and the relationship between portal vein velocity, liver function, and complications have not been clearly studied. METHODS: A retrospective review of 16 TPAIT was performed. Correlation analysis of portal vein velocity with indices of liver function, portal pressure, and volume of islet cells infused was conducted. RESULTS: There was no correlation between portal vein velocity and postoperative liver function tests (LFTs). Larger volume of islet cells infused and higher intraoperative portal pressure correlated with decreased postoperative portal flow. There was no significant difference in portal pressure, portal vein velocity, or LFTs between those with normal and abnormal pre-infusion liver histopathology. While no PVT occurred, there were two cases of postoperative bleeding related to anticoagulation. CONCLUSION: Segmental portal vein velocities are low in the setting of high tissue volume and portal pressure, but are not associated with variation in LFTs. Therefore, patient management in response to changes in velocities without clinical symptoms may be unnecessary.
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Transplante das Ilhotas Pancreáticas , Pancreatectomia , Humanos , Fígado , Pancreatectomia/efeitos adversos , Veia Porta/diagnóstico por imagem , Estudos Retrospectivos , Transplante AutólogoRESUMO
It is often difficult for people with cancer to make decisions for their care. The aim of this review is to understand the importance of shared decisionmaking (SDM) in Indian clinical scenario and identify the gaps when compared to practices in the Western world. A systematic search (2000-2019) was executed in Medline and Google Scholar using predefined keywords. Of the approximate 400 articles retrieved, 43 articles (Indian: 5; Western: 38) were selected for literature review. Literature review revealed the paucity of information on SDM in India compared to the Western world data. This may contribute to patientreported physical or psychological harms, life disruptions, or unnecessary financial costs. Western world data demonstrate the involvement and sharing of information by both patient and physician, collective efforts of the two to build consensus for preferred treatment. In India, involvement of patients in the planning for treatment is largely limited to tertiary care centers, academic institutes, or only when the cost of therapy is high. In addition, cultural beliefs and prejudices impact the extent of participation and engagement of a patient in disease management. Communication failures have been found to strongly correlate with the medicolegal malpractice litigations. Research is needed to explore ways to how to incorporate SDM into routine oncology practice. India has a high unmet need towards SDM in diagnosis and treatment of cancer. Physicians need to involve patients or their immediate family members in decision making, to make it a patient-centric approach as well. SDM enforces to avoid uninformed decisionmaking or a lack of trust in the treating physician's knowledge and skills. Physician and patient education, development of tools and guiding policies, widespread implementation, and periodic assessments may advance the practice of SDM.
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Marijuana is legalized for either medical or recreational use in over half of the states in the United States and in Canada, but many transplant centers will not list patients who are using marijuana. However, the effect of marijuana on transplant outcomes remains unclear. Thus, we performed a retrospective analysis of all adult (≥18 years old) liver transplant patients treated at our center between 2007 and 2017. Patients were grouped according to their marijuana use and tobacco smoking status. We also evaluated tobacco smoking status for the comparative evaluation. Posttransplant morbidity, mortality, and graft survival were evaluated. In total, 316 patients were included: 171 (54%) patients were tobacco smokers (70 current; 101 former), 81 (26%) patients were marijuana smokers (13 current; 68 former), and 64 (20#x0025;) patients were both marijuana and tobacco smokers. A total of 136 (43%) reported never smoking marijuana or tobacco. After adjustment, current tobacco users were over 3 times as likely to die within 5 years compared with never users (hazard ratio [HR], 3.25; 95% confidence interval [CI], 1.63-6.46; P < 0.001), but no difference was seen between current/former and never marijuana users (HR, 0.52; 95% CI, 0.26-1.04; P = 0.06). No significant differences in inpatient respiratory complications, reintubation, or >24-hour intubation was seen. Overall, pretransplant marijuana use, past or current, does not appear to impact liver transplant outcomes, though tobacco smoking remains detrimental.