Refractory Hepatic Hydrothorax Is an Independent Predictor of Mortality When Compared to Refractory Ascites.

BACKGROUND: Hepatic hydrothorax (HHT) is an uncommon but significant complication of cirrhosis and portal hypertension, associated with a worse prognosis and mortality. Nearly 25% of patients with HHT will have refractory pleural effusion. It is unclear if refractory HHT has a different prognosis compared to refractory ascites. AIMS: We aim to evaluate the prognostic significance of refractory HHT when compared to refractory ascites. METHODS: Forty-seven patients who had refractory HHT in a tertiary care center were identified, and matched, retrospectively, one-to-one by age, gender and MELD-Na with 47 patients with refractory ascites. One-year mortality rate was compared between both groups. Cox proportional hazard regression was used to identify the association between different covariates and primary endpoint. RESULTS: The 1-year mortality was 51.06% in the HHT group compared to 19.15% in the refractory ascites group. The median survival for patients with refractory hepatic hydrothorax was 4.87 months while the median survival for patients with refractory ascites exceeded 1 year. The presence of HHT was statistically significant in predicting the development of 1-year mortality [Hazard Ratio (HR) 4.45, 95% Confidence Interval (CI) 2.25-8.82; P value < 0.001]. Furthermore, refractory HHT remained associated with one-year mortality after adjusting for all other covariates. In a subgroup of patients with MELD-Na ≤ 20, HHT continued to be a significant predictor of one-year mortality (HR 3.30, 95% CI 1.47-7.40; P value 0.004). CONCLUSIONS: Refractory HHT is a significant independent predictor of mortality and offers additional prognostic value.

Endoscopic Management of Giant Walled-Off Pancreatic Necrosis With a High Risk of Bleeding.

Walled-off pancreatic necrosis (WOPN) is one of the late complications of acute pancreatitis. We present a 37-year-old man who developed a large WOPN 6 weeks after treatment of severe complicated pancreatitis. Imaging studies revealed a necrotic retroperitoneal fluid collection measuring 27 × 12 × 27 cm with large crossing blood vessels. Cystogastrostomy was performed using a lumen-apposing metal stent. He underwent multiple necrosectomies with significant improvement in the cyst size. Bleeding is a major complication of direct endoscopic necrosectomy; hence, specific imaging and a careful approach should be taken into consideration, especially in WOPN with a high risk of bleeding.

Review of Haploidentical Hematopoietic Cell Transplantation.

Use of haploidentical (haplo) donors for hematopoietic cell transplantation (HCT) has significantly increased in the last decade. The major advantage with this strategy is universal availability and faster acquisition of the donor, along with affordability and provision of immunotherapy in post-transplantation period. Historically, haplo-HCT was associated with compromised outcomes because of high rates of graft-versus-host disease and graft failure, but after the development of a post-transplantation high-dose cyclophosphamide strategy, which results in selective T-cell depletion, these issues have been addressed to a large extent. Nevertheless, graft failure, high treatment-related mortality due to graft-versus-host disease, infections, delayed immune reconstitution, and disease relapse remain significant concerns. As the experience with haplo-HCTs grows, the clinical outcomes are becoming more at par with those seen with fully matched unrelated donor allogeneic HCTs.

Variations in perioperative warfarin management: outcomes and practice patterns at nine hospitals.

BACKGROUND: Before surgery, most patients receiving oral anticoagulation require temporary cessation of treatment. Physicians sometimes substitute heparin or low-molecular-weight heparin for oral anticoagulation in the perioperative setting ("bridging therapy"). We sought to characterize rates of bridging therapy use at 9 clinical centers to determine the extent to which the use of bridging is explained by clinical characteristics of patients (vs physician style) and to determine the 30-day incidence of thrombotic and bleeding complications. METHODS: This was a prospective, multicenter, observational study. Periprocedural bridging anticoagulation was classified as none, prophylactic-dose heparin/low-molecular-weight heparin, or full-dose heparin/low-molecular-weight heparin. We collected data on patient and surgery characteristics, anticoagulation management, and thromboembolic and bleeding events. RESULTS: A total of 492 of 497 consecutive patients completed the study; 54%, 14%, and 33% of patients had no, prophylactic, and full (therapeutic) doses, respectively, of heparin/low-molecular-weight heparin postprocedure. Two hospitals treated more than 80% of their patients with full-dose heparin, whereas the remaining 7 hospitals used full-dose heparin in an average of 22% of cases (P<.001); this variation persisted after adjustment for patient characteristics. There were 4 thromboembolic events (0.8%) and 16 major bleeding events (3.2%). Full-dose heparin/low-molecular-weight heparin postprocedure was associated with a higher likelihood of major bleeding: adjusted odds ratio 4.4 (95% confidence interval, 1.5-14.7). CONCLUSION: Management of anticoagulation after an invasive procedure varies widely and is not explained by clinical characteristics of patients alone. The risk of major bleeding is strongly associated with the use of postoperative therapeutic doses of heparin/low-molecular-weight heparin.