Women Are Also Disadvantaged in Accessing Transplant Outside the United States: Analysis of the Spanish Liver Transplantation Registry.

Sex inequities in liver transplantation (LT) have been documented in several, mostly US-based, studies. Our aim was to describe sex-related differences in access to LT in a system with short waiting times. All adult patients registered in the RETH-Spanish Liver Transplant Registry (2000-2022) for LT were included. Baseline demographics, presence of hepatocellular carcinoma, cause and severity of liver disease, time on the waiting list (WL), access to transplantation, and reasons for removal from the WL were assessed. 14,385 patients were analysed (77% men, 56.2 ± 8.7 years). Model for end-stage liver disease (MELD) score was reported for 5,475 patients (mean value: 16.6 ± 5.7). Women were less likely to receive a transplant than men (OR 0.78, 95% CI 0.63, 0.97) with a trend to a higher risk of exclusion for deterioration (HR 1.17, 95% CI 0.99, 1.38), despite similar disease severity. Women waited longer on the WL (198.6 ± 338.9 vs. 173.3 ± 285.5 days, p < 0.001). Recently, women's risk of dropout has reduced, concomitantly with shorter WL times. Even in countries with short waiting times, women are disadvantaged in LT. Policies directed at optimizing the whole LT network should be encouraged to guarantee a fair and equal access of all patients to this life saving resource.

Can artificial intelligence increase the efficiency of referrals from primary to specialized care?

The overload of the current healthcare model makes the search for strategies to improve process efficiency essential. An artificial intelligence (AI) program based on Natural Language Processing pipelines (1-5) was used. It analyzed the referrals from primary care to Gastroenterology in the health area corresponding to our hospital in order to identify the most frequent reasons for consultation and to assign them a protocol for the performance of complementary tests before being seen for the first time in specialized care. We compared all referrals received in the first half of 2018, prior to the implementation of the AI pathway July 2018, with those received in the first half of 2019. Our aim was to evaluate the efficiency of this program in terms of discharges, need for additional tests and the number of follow-up visits required (number of follow-up visits/number of first visits in a given time period, FU/F index). In 2018, 1799 referrals were received, 1309 within our health area and 490 from outside the area. In 2019, 2261 referrals were received, 1392 from our area and 869 out-of-area. The AI pathway was applied to 31.4% of the area-referred patients. Overall, in 2019, the number of blood tests and CT scans requested at the first visit decreased (55.3 vs 61.4% and 4.4 vs 7.4% respectively, p<0.05 for both comparisons). The FU/F index in 2019 was 1.9 ± 0.04 vs 2.26 ± 0.07 in 2018 (p<0.05). When analysing patients from our health area, a higher number of discharges at the first consultation was observed during 2019 The number of requested supplementary exams among patients referred using the AI pathway was reduced compared to 2018. The FU/F index in patients referred using the AI pathway was 1.72 ± 0.08 vs 2.25 ± 0.08 in 2018 (p<0.05) and 1.93 ± 0.07 in those referred through the standard pathway in 2019 (p=0.07). Among patients referred from outside our health area, the number of endoscopies requested in 2019 was higher. The FU/F index improved in 2019 (1.95 ± 0.06 vs 2.29 ± 0.13, p<0.05). The number of patients referred using the AI pathway remains low, which could explain the lack of differences observed in the number of discharges or tests requested compared to patients referred via the standard pathway. However, the number of endoscopies and follow up visits requested for these patients did decrease.

Tolvaptan in portal hypertension: real life experience.

Tolvaptan (TVP) is a selective antagonist of vasopressin receptors, approved for the treatment of hyponatremia in SIADH, congestive heart failure (CHF) and cirrhosis. We retrospectively reviewed all cases where TVP was used in a tertiary hospital (January 2012- January 2017). Our aim was to study the use of TVP in real life practice in patients with portal hypertension (PHT) (past history of non-malignant ascites or variceal bleed).

Are MELD and MELDNa Still Reliable Tools to Predict Mortality on the Liver Transplant Waiting List?

Liver transplantation is the only curative treatment for end-stage liver disease. Unfortunately, the scarcity of donor organs and the increasing pool of potential recipients limit access to this life-saving procedure. Allocation should account for medical and ethical factors, ensuring equal access to transplantation regardless of recipient's gender, race, religion, or income. Based on their short-term prognosis prediction, model for end-stage liver disease (MELD) and MELD sodium (MELDNa) have been widely used to prioritize patients on the waiting list for liver transplantation resulting in a significant decrease in waiting list mortality/removal. Recent concern has been raised regarding the prognostic accuracy of MELD and MELDNa due, in part, to changes in recipients' profile such as body mass index, comorbidities, and general condition, including nutritional status and cause of liver disease, among others. This review aims to provide a comprehensive view of the current state of MELD and MELDNa advantages and limitations and promising alternatives. Finally, it will explore future options to increase the donor pool and improve donor-recipient matching.

Retrieval and treatment of patients with primary biliary cholangitis who are lost in the health system.

INTRODUCTION: hepatitis C patients loss to follow-up in the health care system has been shown to have negative consequences. This study aimed to investigate this issue as regards primary biliary cholangitis. METHODS: the databases (immunology, biochemistry, clinical reports, drug dispensation, appointments) of 4 reference hospitals in Spain (serving a population of 1,450,000 inhabitants) were analyzed. The diagnosis of primary biliary cholangitis was based on an antimitochondrial antibody titer ≥ 1:80, chronically elevated alkaline phosphatase, and the absence of other liver disease. Patients were classified as lost in the absence of reports indicating a diagnosis, specific medical follow-up, and/or treatment with bile salts. RESULTS: a total of 1372 patients with antimitochondrial antibody titers ≥ 1:80 were included between January 2010 and June 2019. A total of 697 (50.8 %) were classified as having primary biliary cholangitis, and 100 patients (14.3 %; 95 % CI: 11.8-17.2) were identified as lost. Of these, 30 were contacted and retrieved. The median age was 70 years, 93 % were female, median alkaline phosphatase was 185 IU/L, 10 % had pruritus, and 27 % had a transient elastography value > 9.5 kPa. The disease was confirmed and ursodeoxycholic acid was started in all 30 patients. Death was liver-related in 6 of the 100 patients classified as lost. CONCLUSION: up to 14.3 % of patients (1 out of 7) with a definitive diagnosis of primary biliary cholangitis remain undiagnosed, thus preventing monitoring and treatment. More than a quarter are at risk of advanced liver disease and its complications. Patients lost in the system must be identified and retrieved, and searching hospital databases is a suitable approach to meet this goal.

Functional gastrointestinal disorders: real-life results of a multidisciplinary non-pharmacological approach based on group-consultations.

INTRODUCTION: functional gastrointestinal disorders are prevalent and resource consuming. The use of group-consultations in these diseases is limited and no specific multidisciplinary programs have been developed. METHODS: a multidisciplinary approach was used in patients with diverse functional gastrointestinal disorders attending group-consultations (group A). Five two-hour sessions were scheduled over a four-month period. Sessions consisted of a theoretical introduction (Pathophysiology, Low fodmap diet, Over the counter medications, Mediterranean diet, and Laughter therapy workshop) followed by relaxation techniques. This group was compared to a similar group of patients who received written information covering the topics discussed during the group-consultations (group B). Severity of digestive and psychological symptoms, use of drugs and adherence to the diet were the main outcomes measured. RESULTS: the mean age of participants was 43 (± 1.38) years, 78 % were female and 73 % had at least two functional gastrointestinal disorders. Sixty-two patients were included in group A and 17 in group B. The severity of gastrointestinal and psychological symptoms at baseline was similar in both groups. Globally, there was an improvement in all symptoms in both groups. The proportion of participants with severe baseline gastrointestinal symptoms or pathologic anxiety scores that showed improvement was significantly higher in group A (74 % vs 23 %, p = 0.005; 47 % vs 8 %, p = 0.02, respectively). Symptoms were reassessed at six and 12 months after the intervention in participants from group A who attended ≥ 80 % sessions and a sustained response was observed. CONCLUSIONS: group-consultations are useful and efficient to alleviate gastrointestinal and psychological symptoms in patients with functional gastrointestinal disorders.

Management of hyponatremia associated with acute porphyria-proposal for the use of tolvaptan.

Hyponatremia is a common feature during the neurovisceral acute attacks which characterize hepatic porphyrias, as well as a sign of its severity. Therapeutic options for first-line acute attacks are intravenous administration of glucose and/or exogenous heme. The former treatment can aggravate hyponatremia by dilution and cause seizures; thus, the correction of hyponatremia must be carried out with extreme caution. This review summarizes recommendations for the management of hyponatremia during acute episodes of porphyria. Hyponatremia should be corrected slowly and seizures treated with medications in order to not exacerbate motor and sensory axonal neuropathy. The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is considered a frequent cause of hyponatremia in acute porphyrias and must be identified as a symptom of an acute porphyria attack. Tolvaptan produces aquaresis and is considered a safe drug in porphyria. However, its use has only been reported in isolated cases during a porphyria attack. The convenience and usefulness of this drug in acute porphyria are discussed.

Secondary prophylaxis for esophageal variceal bleeding.

Combination therapy with beta-blockers and endoscopic band ligation (EBL) is the standard prophylaxis of esophageal variceal rebleeding in cirrhosis. Beta-blockers are the backbone of combination therapy, since their benefit extend to other complications of portal hypertension. EBL carries the risk of post-banding ulcer bleeding, which explains why overall rebleeding is reduced when beta-blockers are added to EBL, and not when EBL is added to beta-blockers. TIPS is the rescue treatment, but it could be considered as first choice in patients that first bleed while on beta-blockers, those with contraindications to beta-blockers or with refractory ascites, and those with fundal varices.

Rebleeding prophylaxis improves outcomes in patients with hepatocellular carcinoma. A multicenter case-control study.

UNLABELLED: Outcome of variceal bleeding (VB) in patients with hepatocellular carcinoma (HCC) is unknown. We compared outcomes after VB in patients with and without HCC. All patients with HCC and esophageal VB admitted between 2007 and 2010 were included. Follow-up was prolonged until death, transplantation, or June 2011. For each patient with HCC, a patient without HCC matched by age and Child-Pugh class was selected. A total of 292 patients were included, 146 with HCC (Barcelona Classification of Liver Cancer class 0-3 patients, A [in 25], B [in 29], C [in 45], and D [in 41]) and 146 without HCC. No differences were observed regarding previous use of prophylaxis, clinical presentation, endoscopic findings, and initial endoscopic treatment. Five-day failure was similar (25% in HCC versus 18% in non-HCC; P = 0.257). HCC patients had greater 6-week rebleeding rate (16 versus 7%, respectively; P = 0.025) and 6-week mortality (30% versus 15%; P = 0.003). Fewer patients with HCC received secondary prophylaxis after bleeding (77% versus 89%; P = 0.009), and standard combination therapy was used less frequently (58% versus 70%; P = 0.079). Secondary prophylaxis failure was more frequent (50% versus 31%; P = 0.001) and survival significantly shorter in patients with HCC (median survival: 5 months versus greater than 38 months in patients without HCC; P < 0.001). Lack of prophylaxis increased rebleeding and mortality. On multivariate analysis Child-Pugh score, presence of HCC, portal vein thrombosis, and lack of secondary prophylaxis were predictors of death. CONCLUSIONS: Patients with HCC and VB have worse prognosis than patients with VB without HCC. Secondary prophylaxis offers survival benefit in HCC patients.

Prognostic value of hepatic venous pressure gradient in patients with compensated chronic hepatitis C-related cirrhosis.

BACKGROUND AND AIM: Hepatic venous pressure gradient (HVPG) is the main predictor of clinical decompensation in cirrhotic patients with compensated disease of any etiology without varices. However, the predictive factors of decompensation are not so well known in patients with hepatitis C-related compensated cirrhosis, in whom etiology-based therapy is difficult. The aim of this study was to identify predictors of decompensation in patients with compensated chronic hepatitis C (CHC)-related cirrhosis with and without esophageal varices (Baveno stages 1 and 2). METHODS: The study population was a cohort of 145 of such consecutive patients who received hepatic hemodynamic study. All patients were similarly followed every 6 months. Through multivariate Cox regression and bootstrap analyses, a prognostic index (PI) was developed and tested in an external cohort (n = 38). RESULTS: Forty-two patients (29%) suffered a first decompensation episode after a median follow-up of 27 months (2-110). Cox regression analysis identified HVPG (hazard ratio (HR) 1.11; 95% confidence interval (CI): 1.05-1.17) and albumin (HR 0.42; 95% CI: 0.22-0.82) as independent predictors of decompensation. Bootstrapping confirmed that HVPG (95% CI: 1.05-1.18) and albumin (95% CI: 0.12-0.74) were the most robust predictive variables. Using a cut-off level of 2.5, the PI [4 + (0.11 × HVPG - 0.8 × albumin)] was able to distinguish two populations of patients with very different risks of decompensation in both the exploratory and validation cohorts. A time-dependent ROC curve identified HVPG as the best predictive variable. CONCLUSION: HVPG and albumin are independent predictors of clinical decompensation in patients with compensated CHC-related cirrhosis irrespective of the existence of varices.

Infección de prótesis articular por Listeria monocytogenes: caso clínico y revisión de la literatura médica / Listeria monocytogenes prosthetic joint infection: Case report and review of the literature

Introducción Listeria monocytogenes es una causa poco común de enfermedad en la población general. Es una causa importante de bacteriemia y meningoencefalitis en recién nacidos, embarazadas, ancianos e inmunodeprimidos. Además, se ha descrito de forma excepcional como agente patógeno en infecciones de prótesis articular. Métodos Descripción de un caso de infección sobre prótesis de rodilla en un adulto de 74 años. Se realizó revisión sistemática de la literatura médica (Medline, hasta noviembre de 2007) y síntesis de los casos previamente comunicados. Resultados Se han comunicado 16 casos de infección de prótesis articular por L. monocytogenes, que afectaron preferentemente a ancianos (media de 67,4 años; moda de 70 años) e inmunodeprimidos. En la mayoría de los casos la infección fue tardía. Conclusión La L. monocytogenes se debe tener en consideración como agente causal en las infecciones de prótesis articular, especialmente en el caso de pacientes ancianos o con enfermedades o tratamientos que conlleven inmunodepresión. De la revisión realizada se puede concluir que el tratamiento antibiótico de elección es la ampicilina parenteral durante al menos 6 semanas. Siempre que sea posible, se debe asociar la retirada de la prótesis infectada (AU)

Introduction Listeria monocytogenes is an unusual pathogenic agent in the general population, but is an important cause of bacteriemia and meningoencephalitis among newborns, pregnant women, the elderly population, and immunosuppressed patients. In rare cases, it has been described in joint prosthesis infections. Methods A case description of prosthetic joint infection caused by Listeria in a 74-year-old man is presented. A systematic review of the literature (MEDLINE up to November 2007) was performed, and the reported cases are summarized. Results Sixteen cases of prosthetic joint infection by L. monocytogenes have been reported, mainly in patients of advanced age (mean, 67.4 years; mode, 70 years) and immunosuppressed patients. Most cases were late infections. ConclusionL. monocytogenes should be kept in mind as a pathogen involved in joint prosthesis infection, particularly among the elderly and immunosuppressed populations. Based on the literature review, parenteral ampicillin for at least 6 weeks is the treatment of choice. If possible, prosthesis removal should also be performed(AU)

[Listeria monocytogenes prosthetic joint infection: Case report and review of the literature]. / Infección de prótesis articular por Listeria monocytogenes: caso clínico y revisión de la literatura médica.

INTRODUCTION: Listeria monocytogenes is an unusual pathogenic agent in the general population, but is an important cause of bacteriemia and meningoencephalitis among newborns, pregnant women, the elderly population, and immunosuppressed patients. In rare cases, it has been described in joint prosthesis infections. METHODS: A case description of prosthetic joint infection caused by Listeria in a 74-year-old man is presented. A systematic review of the literature (MEDLINE up to November 2007) was performed, and the reported cases are summarized. RESULTS: Sixteen cases of prosthetic joint infection by L. monocytogenes have been reported, mainly in patients of advanced age (mean, 67.4 years; mode, 70 years) and immunosuppressed patients. Most cases were late infections. CONCLUSION: L. monocytogenes should be kept in mind as a pathogen involved in joint prosthesis infection, particularly among the elderly and immunosuppressed populations. Based on the literature review, parenteral ampicillin for at least 6 weeks is the treatment of choice. If possible, prosthesis removal should also be performed.