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Nine of 10 patients with hemophilia B who received a liver-directed adeno-associated viral vector containing a hyperactive variant of factor IX maintained factor IX activity for up to 42 months. Thrombosis developed in 1 patient.

These guidelines on transjugular intrahepatic portosystemic stent-shunt (TIPSS) in the management of portal hypertension have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the Liver Section of the BSG. The guidelines are new and have been produced in collaboration with the British Society of Interventional Radiology (BSIR) and British Association of the Study of the Liver (BASL). The guidelines development group comprises elected members of the BSG Liver Section, representation from BASL, a nursing representative and two patient representatives. The quality of evidence and grading of recommendations was appraised using the GRADE system. These guidelines are aimed at healthcare professionals considering referring a patient for a TIPSS. They comprise the following subheadings: indications; patient selection; procedural details; complications; and research agenda. They are not designed to address: the management of the underlying liver disease; the role of TIPSS in children; or complex technical and procedural aspects of TIPSS.

In this randomized trial in patients hospitalized with alcoholic hepatitis, pentoxifylline did not improve survival. The 28-day survival advantage in patients treated with prednisolone did not reach significance and was not sustained at 90 days or 1 year. Alcoholic hepatitis is a distinct manifestation of alcoholic liver disease that is characterized by jaundice and liver failure. This condition develops in persons with a history of prolonged and heavy alcohol use. 1 The severity of alcoholic hepatitis is conventionally defined by Maddrey’s discriminant function, which is calculated as 4.6×(patient’s prothrombin time in seconds−control’s prothrombin time in seconds)+patient’s serum bilirubin level in milligrams per deciliter; a value of 32 or higher indicates severe alcoholic hepatitis that carries an adverse prognosis, with mortality of 20 to 30% within 1 month after presentation and 30 to 40% within 6 months after presentation. 2 A . . .

Background Although malnutrition and sarcopenia are prevalent in cirrhosis, their impact on outcomes following liver transplantation is not well documented. Methods The associations of nutritional status and sarcopenia with post‐transplant infections, requirement for mechanical ventilation, intensive care (ICU) and hospital stay, and 1 year mortality were assessed in 232 consecutive transplant recipients. Nutritional status and sarcopenia were assessed using the Royal Free Hospital‐Global Assessment (RFH‐GA) tool and the L3‐psoas muscle index (L3‐PMI) on CT, respectively. Results A wide range of RFH‐SGA and L3‐PMI were observed within similar Model for End‐stage Liver Disease (MELD) sub‐categories. Malnutrition and sarcopenia were independent predictors of all outcomes. Post‐transplant infections were associated with MELD (OR = 1.055, 95%CI = 1.002–1.11) and severe malnutrition (OR = 6.55, 95%CI = 1.99–21.5); ventilation > 24 h with MELD (OR = 1.1, 95%CI = 1.036–1.168), severe malnutrition (OR = 8.5, 95%CI = 1.48–48.87) and suboptimal donor liver (OR = 2.326, 95%CI = 1.056–5.12); ICU stay > 5 days, with age (OR = 1.054, 95%CI = 1.004–1.106), MELD (OR = 1.137, 95%CI = 1.057–1.223) and severe malnutrition (OR = 7.46, 95%CI = 1.57–35.43); hospital stay > 20 days with male sex (OR = 2.107, 95%CI = 1.004–4.419) and L3‐PMI (OR = 0.996, 95%CI = 0.994–0.999); 1 year mortality with L3‐PMI (OR = 0.996, 95%CI = 0.992–0.999). Patients at the lowest L3‐PMI receiving suboptimal grafts had longer ICU/hospital stay and higher incidence of infections. Conclusions Malnutrition and sarcopenia are associated with early post‐liver transplant morbidity/mortality. Allocation indices do not include nutritional status and may jeopardize outcomes in nutritionally compromised individuals.

Chemoembolization (TACE) improves survival in cirrhotic patients with hepatocellular carcinoma (HCC). The optimal schedule, or whether embolization (TAE) alone gives the same survival advantage, is not known. To evaluate whether specific patient characteristics and/or radiological transarterial techniques result in better outcomes. A PubMed search was carried out for cohort and randomized trials (n = 175) testing transarterial therapies; meta-analysis was performed where appropriate. Anticancer drugs were used as sole agent in 75% of cases (double 15% and triple 6%): doxorubicin (36%), cisplatin (31%), epirubicin (12%), mitoxantrone (8%), mitomycin (8%), and SMANCS (5%). Embolizing agents used were: gelatin sponge particles (71%), polyvinyl alcohol (PVA) particles (8%), degradable starch microspheres (DSM) (4%), and embospheres (4%). Sessions per patient were 2.5 +/- 1.5 (interval: 2 months). Objective response was 40 +/- 20%; survival rates at 1, 2, 3, and 5 years were: 62 +/- 20%, 42 +/- 17%, 30 +/- 15%, and 19 +/- 16%, respectively, and survival time was 18 +/- 9.5 months. The post-TACE complications were: acute liver failure, 7.5% (range 0-49%); acute renal failure, 1.8% (0-13%); encephalopathy, 1.8% (0-16%); ascites, 8.3% (0-52%); upper gastrointestinal bleeding; 3% (0-22%); and hepatic or splenic abscess, 1.3% (0-2.5%). Treatment-related mortality was 2.4% (0-9.5%), mainly due to acute liver failure. Our meta-analysis of nine randomized controlled trials (RCTs) confirmed that TACE improves survival; but a meta-analysis of TACE versus TAE alone (3 RCTs, 412 patients) demonstrated no survival difference. No chemotherapeutic agent appears better than any other. There is no evidence for benefit with lipiodol. Gelatin sponge is the most used embolic agent, but PVA particles may be better. TAE appears as effective as TACE. New strategies to reduce the risk of post-TACE complications are required.

The purpose of this study was to investigate the association between pre-operative anemia and prolonged hospital stay among geriatric patients with operative femoral neck fractures. This retrospective cohort study was performed at a level I trauma center and included geriatric patients with femoral neck fractures (OTA/AO 31) and operative treatment with Current Procedural Terminology code 27236. Exclusion criteria were admission to the intensive care unit, evacuation of subdural hematoma, and conditions requiring exploratory laparotomy. A total of 207 individuals, with data collected between January 2015 and August 2019 and age 65 years and older, were included in the analysis. Linear regression was used to evaluate the association between anemia and length of stay adjusting for potential confounders. Anemia was defined using preoperative hematocrit. The primary outcome was prolonged length of stay, defined as 5 or more days. The group was 65% women. The mean age was 80.2 years (range, 64–98 years). The majority (61%) of patients had anemia. American Society of Anesthesiologists classification was associated with preoperative anemia (P=.02). Patients with anemia had a 16% higher risk of prolonged length of stay compared with patients without anemia (81% vs 65%, P=.009). In the linear regression model, preoperative hematocrit was associated with length of stay (P=.032) when adjusted for sex, age, preoperative tranexamic acid, preoperative hemoglobin, postoperative hemoglobin, and postoperative hematocrit. Length of stay was approximately 1 week in this study, with anemia being a statistically significant risk factor for prolonged length of stay. Health care providers and administrators can consider anemia on admission when predicting length of stay. [Orthopedics. 2023;46(4):211–217.]

Gastrointestinal motility is impaired in a substantial proportion of patients with cirrhosis. Cirrhosis-related autonomic neuropathy, increased nitric oxide production, and gut hormonal changes have been implicated. Oesophageal dysmotility has been associated with increased frequency of abnormal gastro-oesophageal reflux. Impaired gastric emptying and accommodation may result in early satiety and may have an impact on the nutritional status of these patients. Small intestinal dysmotility might be implicated in small intestinal bacterial overgrowth and increased bacterial translocation. The latter has been implicated in the pathophysiology of hepatic encephalopathy and spontaneous bacterial peritonitis. Enhanced colonic motility is usually associated with the use of lactulose. Pharmacological interventions aiming to alter gastrointestinal motility in cirrhosis could potentially have a beneficial effect reducing the risk of hepatic decompensation and improving prognosis.

Background Collagen proportionate area (CPA) has a better correlation with hepatic venous pressure gradient (HVPG) than with Ishak stage. Liver stiffness measurement (LSM) is proposed as non invasive marker of portal hypertension/disease progression. Our aim was to compare LSM and CPA with Ishak staging in chronic viral hepatitis, and HVPG in HCV hepatitis after transplantation. Methods One hundred and sixty-nine consecutive patients with chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infections pre/post liver transplantation (LT), had a liver biopsy combined with LSM (transient elastography), CPA (biopsies stained with Sirius Red and evaluated by digital image analysis and expressed as CPA) and HVPG (measured contemporaneously with transjugular biopsies in LT HCV patients). Results LSM was dependent on CPA in HBV ( r 2  = 0.61, p  < 0.0001), HCV ( r 2  = 0.59, p  < 0.0001) and LT groups ( r 2  = 0.64, p  < 0.0001). In all three groups, CPA and Ishak were predictors of LSM, but multivariately CPA was better related to LSM (HBV: r 2  = 0.61, p  < 0.0001; HCV: r 2  = 0.59, p  < 0.0001; post-LT: r 2  = 0.68, p  < 0.0001) than Ishak stage. In the LT group, multiple regression analysis including HVPG, LSM, aspartate aminotransferase to platelet ratio index (APRI) and Ishak stage/grade, showed that only CPA was related to HVPG ( r 2  = 0.41, p  = 0.01), both for HVPG ≥6 mmHg (OR 1.34, 95 % CI 1.14–1.58; p  < 0.0001) or ≥10 mmHg (OR 1.25, 95 % CI 1.06–1.47; p  = 0.007). Conclusion CPA was related to LSM in HBV or HCV hepatitis pre/post-LT. CPA was better related to LSM than Ishak stage. In the LT HCV group, CPA was better related to HVPG than Ishak stage/grade, LSM or APRI. CPA may represent a better comparative histological index for LSM, rather than histological stages.

Abstract Pediatric hallux valgus (PHV), while relatively rare, is still often encountered by general pediatricians. Herein, we concisely summarize the existing literature regarding the pathogenesis, associated conditions, clinical diagnosis, radiographic characteristics, conservative management, and surgical management of PVH. Though PHV is generally considered benign, the progression of hallux valgus can result in complications. The presence of an open physis in the pediatric age group delineates first line treatment choices, whenever possible, as nonoperative. The general exception to this recommendation is for children with neuromuscular and connective tissues disease who may benefit from earlier surgical management. If conservative approaches fail prior to skeletal maturity, the risk of recurrence and need for revision surgery should be discussed with patients and their families before surgical referral is made. The current review was conducted to aid primary care providers in better understanding the pathogenesis, associated conditions, and intervention options available to manage PHV. Graphical Abstract Graphical Abstract

Category: Midfoot/Forefoot Introduction/Purpose: The Modified Lapidus arthrodesis is a historically established surgical technique for treatment of hallux valgus, providing quality patient outcomes and reproducible results. Addition of a transverse first to second intermetatarsal screw spanning the base of the metatarsals in this procedure can increase stability. However, no study evaluates the radiographical parameters following application of this intermetatarsal screw fixation to procedures without first to second intermetatarsal screw fixation. The purpose of this study was to assess the quality of radiographic parameters between individuals receiving a first to second intertarsal screw fixation to those that did not receive intermetatarsal screw fixation following a non-saw cut Modified Lapidus procedure. Methods: A retrospective review was performed on 74 patients that underwent a Modified Lapidus arthrodesis between 2016- 2020 at a single institution. Preoperative indications for the procedure included first ray instability, first ray hypermobility, hallux abductovalgus, and metatarsal primus elevatus. Inclusion criteria consisted of skeletally mature patients undergoing non sawcut Modified Lapidus procedure. Patients that received the procedure due to a traumatic event or patients with concomitant second metatarsal arthrodesis were excluded. Review of patient's charts was performed. Basic demographics data, implant type, and radiographic parameters including intermetatarsal angle (IMA) and first metatarsal length were obtained from preoperative as well as postoperative films. Results: A total of 74 patients who underwent a Modified Lapidus arthrodesis were included in the study. A group of 43 patients received the Modified Lapidus arthrodesis with the addition of a first to second intermetatarsal screw fixation compared to a group of 31 patients who only received the Modified Lapidus arthrodesis procedure. The average IMA in all patients prior to surgery was 13°. The patients who received intermetatarsal screw fixation had significantly higher IMA reductions between preoperative and postoperative films than those who did not receive the intermetatarsal screw (-8.41° vs. -5.78°, p=.005). The difference in first metatarsal length on preoperative and postoperative films was less in patients who received the screw fixation but this was not statistically significant. Conclusion: The Modified Lapidus procedure is a commonly used procedure to treat hallux valgus. The results of this study found that the addition of a first to second intermetatarsal significantly reduced the IMA when compared to individuals who did not receive the screw construct. These findings will help surgeons further delineate if an intermetatarsal screw is required and how it will contribute to the radiographic parameters of interest.