Use of machine learning models for the prognostication of liver transplantation: A systematic review

BACKGROUND Liver transplantation(LT)is a life-saving intervention for patients with end-stage liver disease.However,the equitable allocation of scarce donor organs remains a formidable challenge.Prognostic tools are pivotal in identifying the most suitable transplant candidates.Traditionally,scoring systems like the model for end-stage liver disease have been instrumental in this process.Nevertheless,the landscape of prognostication is undergoing a transformation with the integration of machine learning(ML)and artificial intelligence models.AIM To assess the utility of ML models in prognostication for LT,comparing their performance and reliability to established traditional scoring systems.METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines,we conducted a thorough and standardized literature search using the PubMed/MEDLINE database.Our search imposed no restrictions on publication year,age,or gender.Exclusion criteria encompassed non-English studies,review articles,case reports,conference papers,studies with missing data,or those exhibiting evident methodological flaws.RESULTS Our search yielded a total of 64 articles,with 23 meeting the inclusion criteria.Among the selected studies,60.8%originated from the United States and China combined.Only one pediatric study met the criteria.Notably,91%of the studies were published within the past five years.ML models consistently demonstrated satisfactory to excellent area under the receiver operating characteristic curve values(ranging from 0.6 to 1)across all studies,surpassing the performance of traditional scoring systems.Random forest exhibited superior predictive capabilities for 90-d mortality following LT,sepsis,and acute kidney injury(AKI).In contrast,gradient boosting excelled in predicting the risk of graft-versus-host disease,pneumonia,and AKI.CONCLUSION This study underscores the potential of ML models in guiding decisions related to allograft allocation and LT,marking a significant evolution in the field of prognostication.

Predicting major adverse cardiovascular events after orthotopic liver transplantation using a supervised machine learning model:A cohort study

BACKGROUND Liver transplant(LT)patients have become older and sicker.The rate of post-LT major adverse cardiovascular events(MACE)has increased,and this in turn raises 30-d post-LT mortality.Noninvasive cardiac stress testing loses accuracy when applied to pre-LT cirrhotic patients.AIM To assess the feasibility and accuracy of a machine learning model used to predict post-LT MACE in a regional cohort.METHODS This retrospective cohort study involved 575 LT patients from a Southern Brazilian academic center.We developed a predictive model for post-LT MACE(defined as a composite outcome of stroke,new-onset heart failure,severe arrhythmia,and myocardial infarction)using the extreme gradient boosting(XGBoost)machine learning model.We addressed missing data(below 20%)for relevant variables using the k-nearest neighbor imputation method,calculating the mean from the ten nearest neighbors for each case.The modeling dataset included 83 features,encompassing patient and laboratory data,cirrhosis complications,and pre-LT cardiac assessments.Model performance was assessed using the area under the receiver operating characteristic curve(AUROC).We also employed Shapley additive explanations(SHAP)to interpret feature impacts.The dataset was split into training(75%)and testing(25%)sets.Calibration was evaluated using the Brier score.We followed Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis guidelines for reporting.Scikit-learn and SHAP in Python 3 were used for all analyses.The supplementary material includes code for model development and a user-friendly online MACE prediction calculator.RESULTS Of the 537 included patients,23(4.46%)developed in-hospital MACE,with a mean age at transplantation of 52.9 years.The majority,66.1%,were male.The XGBoost model achieved an impressive AUROC of 0.89 during the training stage.This model exhibited accuracy,precision,recall,and F1-score values of 0.84,0.85,0.80,and 0.79,respectively.Calibration,as assessed by the Brier score,indicated excellent model calibration with a score of 0.07.Furthermore,SHAP values highlighted the significance of certain variables in predicting postoperative MACE,with negative noninvasive cardiac stress testing,use of nonselective beta-blockers,direct bilirubin levels,blood type O,and dynamic alterations on myocardial perfusion scintigraphy being the most influential factors at the cohort-wide level.These results highlight the predictive capability of our XGBoost model in assessing the risk of post-LT MACE,making it a valuable tool for clinical practice.CONCLUSION Our study successfully assessed the feasibility and accuracy of the XGBoost machine learning model in predicting post-LT MACE,using both cardiovascular and hepatic variables.The model demonstrated impressive performance,aligning with literature findings,and exhibited excellent calibration.Notably,our cautious approach to prevent overfitting and data leakage suggests the stability of results when applied to prospective data,reinforcing the model’s value as a reliable tool for predicting post-LT MACE in clinical practice.

Duodenal Crohn’s disease:Case report and systematic review

BACKGROUND Inflammatory bowel disease,including ulcerative colitis,microscopic colitis,and Crohn’s disease(CD),has a global impact.This review focuses on duodenal CD(DCD),a rare subtype affecting the duodenum.DCD’s rarity and asymptomatic nature create diagnostic challenges,impacting prognosis and patient well-being.Delayed diagnosis can worsen DCD outcomes.AIM To report a rare case of DCD and to discuss the diagnostic challenges and its implications on prognosis.METHODS A systematic literature search,following the PRISMA statement,was conducted.Relevant studies were identified and analysed using specific Medical Subject Terms(MeSH)from PubMed/MEDLINE,American Journal of Gastroenterology,and the University of South Wales database.Data collection included information from radiology scans,endoscopy procedures,biopsies,and histopathology results.RESULTS The review considered 8 case reports and 1 observational study,involving 44 participants diagnosed with DCD,some of whom developed complications due to delayed diagnosis.Various diagnostic methods were employed,as there is no gold standard workup for DCD.Radiology scans[magnetic resonance imaging(MRI),computed tomography(CT),and upper gastrointestinal X-ray],endoscopy procedures(colonoscopy and esophagogastroduodenoscopy),biopsies,and clinical suspicions were utilized.CONCLUSION This review discusses DCD diagnosis challenges and the roles of CT,MRI,and fluoroscopy.It notes their limitations and compares findings with endoscopy and histopathology studies.Further research is needed to improve diagnosis,emphasizing scan interpretation,endoscopy procedures,and biopsies,especially in high-risk patients during routine endoscopy.

Treatment of Helicobacter pylori with potassium competitive acid blockers:A systematic review and meta-analysis

BACKGROUND Helicobacter pylori(H.pylori)infects over half the global population,causing gastrointestinal diseases like dyspepsia,gastritis,duodenitis,peptic ulcers,GMALT lymphoma,and gastric adenocarcinoma.Eradicating H.pylori is crucial for treating and preventing these conditions.While conventional proton pump inhibitor(PPI)-based triple therapy is effective,there’s growing interest in longer acid suppression therapies.Potassium competitive acid blocker(P-CAB)triple and dual therapy are new regimens for H.pylori eradication.Initially used in Asian populations,vonoprazan(VPZ)has been recently Food and Drug Administration-approved for H.pylori eradication.AIM To assess the efficacy of regimens containing P-CABs in eradicating H.pylori infection.METHODS This study,following PRISMA 2020 guidelines,conducted a systematic review and meta-analysis by searching MEDLINE and Scopus libraries for randomized clinical trials(RCTs)or observational studies with the following command:[("Helicobacter pylori"OR"H pylori")AND("Treatment"OR"Therapy"OR"Eradication")AND("Vonaprazan"OR"Potassium-Competitive Acid Blocker"OR"P-CAB"OR"PCAB"OR"Revaprazan"OR"Linaprazan"OR"Soraprazan"OR"Tegoprazan")].Studies comparing the efficacy of P-CABs-based treatment to classical PPIs in eradicating H.pylori were included.Exclusion criteria included case reports,case series,unpublished trials,or conference abstracts.Data variables encompassed age,diagnosis method,sample sizes,study duration,intervention and control,and H.pylori eradication method were gathered by two independent reviewers.Meta-analysis was performed in R software,and forest plots were generated.RESULTS A total of 256 references were initially retrieved through the search command.Ultimately,fifteen studies(7 RCTs,7 retrospective observational studies,and 1 comparative unique study)were included,comparing P-CAB triple therapy to PPI triple therapy.The intention-to-treat analysis involved 8049 patients,with 4471 in the P-CAB intervention group and 3578 in the PPI control group across these studies.The analysis revealed a significant difference in H.pylori eradication between VPZ triple therapy and PPI triple therapy in both RCTs and observational studies[risk ratio(RR)=1.17,95%confidence interval(CI):1.11-1.22,P<0.0001]and(RR=1.13,95%CI:1.09-1.17,P<0.0001],respectively.However,no significant difference was found between tegoprazan(TPZ)triple therapy and PPI triple therapy in both RCTs and observational studies(RR=1.04,95%CI:0.93-1.16,P=0.5)and(RR=1.03,95%CI:0.97-1.10,P=0.3),respectively.CONCLUSION VPZ-based triple therapy outperformed conventional PPI-based triple therapy in eradicating H.pylori,positioning it as a highly effective first-line regimen.Additionally,TPZ-based triple therapy was non-inferior to classical PPI triple therapy.

Navigating treatment resistance:Janus kinase inhibitors for ulcerative colitis

The management of refractory ulcerative colitis(UC)and acute severe UC(ASUC)is challenging due to the lack of standardized approaches in cases resistant to multiple treatments.In this editorial,I investigate the efficacy and safety of Janus kinase inhibitors,particularly upadacitinib and tofacitinib,in controlling severe and refractory disease.I highlight a notable case report by Xu et al,which explores the case of a patient with primary nonresponse to two classes of biologics and two fecal microbiota transplants who exhibited a remarkable response to upadacitinib.Furthermore,I discuss the use of tofacitinib in refractory UC and ASUC,either as monotherapy or in combination with biologics,which has shown promising response rates.Additionally,emerging evidence of upadacitinib efficacy in ASUC is presented.Overall,these cases emphasize the complex nature of managing refractory ASUC and the potential of small-molecule therapies to achieve remission.Further research is needed to refine treatment strategies for patients with treatment-resistant UC.

Insights into skullcap herb-induced liver injury

This editorial addresses the growing concern of herb-induced liver injury(HILI),focusing on a unique case of Skullcap-induced HILI report.This editorial underscore the significant mortality rate linked to Skullcap-induced HILI,emphasizing the importance of vigilant monitoring and intervention.As herbal supplement usage rises,collaboration among clinicians and researchers is crucial to comprehend and address the complexities of HILI,particularly those involving Skullcap.

Immunological crossroads:The intriguing dance between hepatitis C and autoimmune hepatitis

Delving into the immunological crossroads of liver diseases,this editorial explores the dynamic interplay between hepatitis C virus(HCV)and autoimmune hepatitis(AIH).While HCV primarily manifests as a viral infection impacting the liver,previous studies unveil a captivating connection between HCV and the emergence of AIH.The dance of the immune system in response to HCV appears to set the stage for an intriguing phenomenon-an aberrant autoimmune response leading to the onset of AIH.Evidence suggests a heightened presence of autoimmune markers in individuals with chronic HCV infection,hinting at a potential overlap between viral and autoimmune liver diseases.Navigating the intricate terrain of viral replication,immune response dynamics,and genetic predisposition,this editorial adds a layer of complexity to our understanding of the relationship between HCV and AIH.In this immunological crossroads,we aim to unearth insights into the complex interplay,using a compelling case where AIH and primary sclerosing cholangitis overlapped following HCV treatment with direct-acting antivirals as background.

Cardiac stress testing and coronary artery disease in liver transplantation candidates： Meta-analysis

dAIMTo evaluate the diagnostic value of dobutamine stress echocardiography （DSE） and myocardial perfusion sci-ntigraphy （MPS） in predicting coronary artery disease （CAD） in cirrhotic patients listed for liver transplanta-tion （LT）, using invasive coronary angiography （ICA） as gold-standard.METHODSRetrieval of studies was based on Medical Subject Headings and Health Sciences Descriptors, which were combined using Boolean operators. Searches were run on the electronic databases Scopus, Web of Science, EMBASE, MEDLINE （PubMed）, BIREME （Biblioteca Regional de Medicina）, LILACS （Latin American and Cari-bbean Health Sciences Literature）, Cochrane Library for Systematic Reviews and Opengray.eu. There was reference lists of the studies retrieved were searched manually.RESULTSThe search strategy retrieved 322 references for DSE and 90 for MPS. In the fnal analysis, 10 references for DSE and 10 for MPS were included. Pooled sensitivity was 28% and 61% for DSE and MPS and specificity was 82% and 74%, for diagnosis of CAD using ICA as gold-standard, respectively.CONCLUSIONDSE and MPS do not have adequate sensitivity for determination of whether CAD is present, despite having signifcant specifcity.

Blastocystis hominis as a cause of chronic diarrhea in low-resource settings:A systematic review

BACKGROUND Blastocystis hominis(B.hominis),an anaerobic unicellular protist parasite,is known for its diverse clinical manifestations upon infecting the human gastrointestinal tract.Although globally distributed,it is particularly prevalent in developing nations.Examining the symptoms and treatment outcomes of B.hominis infection in low-resource settings holds immense significance,providing healthcare practi-tioners with valuable insights to enhance patient care.AIM To synthesize existing evidence on the symptomatology and treatment outcomes of B.hominis infection in low-resource settings.METHODS Following the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines,a systematic review was conducted.The search spanned electronic databases including PubMed,Scopus,and Google Scholar.After a comprehensive screening process,a thorough examination of the papers,adhering to inclusion and exclusion criteria,and data extraction from eligible studies was conducted.The findings underwent summarization through simple descriptive analysis.RESULTS The search yielded 1200 papers,with 17 meeting inclusion criteria.Chronic diarrhea due to B.hominis infection was reported in only two studies,while abdominal pain,diarrhea,flatulence,constipation,and nausea/vomiting emerged as the most commonly documented symptoms.Recovery rates after one week of treatment ranged from 71.8%to 100%,and after two weeks,from 60%to 100%.CONCLUSION In low-resource settings,chronic diarrhea resulting from B.hominis infection is infrequent.Common symptoms include abdominal pain,diarrhea,flatulence,constipation,and nausea/vomiting.Post-treatment,clinical outcomes are notably favorable,supporting the recommendation for treatment.Metronidazole is advocated as the first-line agent,with consideration for switching to a second-line option in cases of treatment failure or poor response.

Palliative care for end-stage liver disease and acute on chronic liver failure:A systematic review

BACKGROUND End stage liver disease(ESLD)represents a growing health concern characterized by elevated morbidity and mortality,particularly among individual ineligible for liver transplantation.The demand for palliative care(PC)is pronounced in patients grappling with ESLD and acute on chronic liver failure(ACLF).Unfortunately,the historical underutilization of PC in ESLD patients,despite their substantial needs and those of their family caregivers,underscores the imperative of seamlessly integrating PC principles into routine healthcare practices across the entire disease spectrum.AIM To comprehensively investigate the evidence surrounding the benefits of incorporating PC into the comprehensive care plan for individuals confronting ESLD and/or ACLF.METHODS A systematic search in the Medline(PubMed)database was performed using a predetermined search command,encompassing studies published in English without any restrictions on the publication date.Subsequently,the retrieved studies were manually examined.Simple descriptive analyses were employed to summarize the results.RESULTS The search strategies yielded 721 references.Following the final analysis,32 fulllength references met the inclusion criteria and were consequently incorporated into the study.Meticulous data extraction from these 32 studies was undertaken,leading to the execution of a comprehensive narrative systematic review.The review found that PC provides significant benefits,reducing symptom burden,depressive symptoms,readmission rates,and hospital stays.Yet,barriers like the appeal of transplants and misconceptions about PC hinder optimal utilization.Integrating PC early,upon the diagnosis of ESLD and ACLF,regardless of transplant eligibility and availability,improves the quality of life for these patients.CONCLUSION Despite the substantial suffering and poor prognosis associated with ESLD and ACLF,where liver transplantation stands as the only curative treatment,albeit largely inaccessible,PC services have been overtly provided too late in the course of the illness.A comprehensive understanding of PC's pivotal role in treating ESLD and ACLF is crucial for overcoming these barriers,involving healthcare providers,patients,and caregivers.

Virtual reality tools for training in gastrointestinal endoscopy:A systematic review

BACKGROUND Virtual reality(VR)has emerged as an innovative technology in endoscopy training,providing a simulated environment that closely resembles real-life scenarios and offering trainees a valuable platform to acquire and enhance their endoscopic skills.This systematic review will critically evaluate the effectiveness and feasibility of VR-based training compared to traditional methods.AIM To evaluate the effectiveness and feasibility of VR-based training compared to traditional methods.By examining the current state of the field,this review seeks to identify gaps,challenges,and opportunities for further research and implementation of VR in endoscopic training.METHODS The study is a systematic review,following the guidelines for reporting systematic reviews set out by the PRISMA statement.A comprehensive search command was designed and implemented and run in September 2023 to identify relevant studies available,from electronic databases such as PubMed,Scopus,Cochrane,and Google Scholar.The results were systematically reviewed.RESULTS Sixteen articles were included in the final analysis.The total number of participants was 523.Five studies focused on both upper endoscopy and colonoscopy training,two on upper endoscopy training only,eight on colonoscopy training only,and one on sigmoidoscopy training only.Gastrointestinal Mentor virtual endoscopy simulator was commonly used.Fifteen reported positive results,indicating that VR-based training was feasible and acceptable for endoscopy learners.VR technology helped the trainees enhance their skills in manipulating the endoscope,reducing the procedure time or increasing the technical accuracy,in VR scenarios and real patients.Some studies show that the patient discomfort level decreased significantly.However,some studies show there were no significant differences in patient discomfort and pain scores between VR group and other groups.CONCLUSION VR training is effective for endoscopy training.There are several well-designed randomized controlled trials with large sample sizes,proving the potential of this innovative tool.Thus,VR should be more widely adopted in endoscopy training.Furthermore,combining VR training with conventional methods could be a promising approach that should be implemented in training.

Herb-induced liver injury: Systematic review and meta-analysis

BACKGROUND The use of herbal supplements and alternative medicines has been increasing in the last decades.Despite popular belief that the consumption of natural products is harmless,herbs might cause injury to various organs,particularly to the liver,which is responsible for their metabolism in the form of herb-induced liver injury(HILI).AIM To identify herbal products associated with HILI and describe the type of lesion associated with each product.METHODS Studies were retrieved using Medical Subject Headings Descriptors combined with Boolean operators.Searches were run on the electronic databases Scopus,Web of Science,MEDLINE,BIREME,LILACS,Cochrane Library for Systematic Reviews,SciELO,Embase,and Opengray.eu.Languages were restricted to English,Spanish,and Portuguese.There was no date of publication restrictions.The reference lists of the studies retrieved were searched manually.To access causality,the Maria and Victorino System of Causality Assessment in Drug Induced Liver Injury was used.Simple descriptive analysis were used to summarize the results.RESULTS The search strategy retrieved 5918 references.In the final analysis,446 references were included,with a total of 936 cases reported.We found 79 types of herbs or herbal compounds related to HILI.He-Shou-Wu,Green tea extract,Herbalife,kava kava,Greater celandine,multiple herbs,germander,hydroxycut,skullcap,kratom,Gynura segetum,garcinia cambogia,ma huang,chaparral,senna,and aloe vera were the most common supplements with HILI reported.Most of these patients had complete clinical recovery(82.8%).However,liver transplantation was necessary for 6.6%of these cases.Also,chronic liver disease and death were observed in 1.5%and 10.4%of the cases,respectively.CONCLUSION HILI is normally associated with a good prognosis,once the implied product is withdrawn.Nevertheless,it is paramount to raise awareness in the medical and non-medical community of the risks of the indiscriminate use of herbal products.

Primary sclerosing cholangitis and autoimmune hepatitis overlap syndrome associated with inflammatory bowel disease:A case report and systematic review

BACKGROUND A previously healthy 22-year-old woman presented with abdominal pain and jaundice.She had a reagent antinuclear factor(1:640,with a homogeneous nuclear pattern)and hypergammaglobulinemia(2.16 g/dL).Anti-smooth muscle,antimitochondrial and anti-liver-kidney microsomal antibody type 1 antibodies were negative.Magnetic resonance cholangiography showed a cirrhotic liver with multiple focal areas of strictures of the intrahepatic bile ducts,with associated dilations.Liver biopsy demonstrated periportal necroinflammatory activity,plasmocyte infiltration and advanced fibrosis.Colonoscopy showed ulcerative pancolitis and mild activity(Mayo score 1),with a spared rectum.Treatment with corticosteroids,azathioprine,ursodeoxycholic acid and mesalamine was initiated,with improvement in laboratory tests.The patient was referred for a liver transplantation evaluation.AIM To report the case of a female patient with autoimmune hepatitis and primary sclerosing cholangitis(PSC)overlap syndrome associated with ulcerative colitis and to systematically review the available cases of autoimmune hepatitis and PSC overlap syndrome.METHODS In accordance with preferred reporting items for systematic reviews and metaanalysis protocols guidelines,retrieval of studies was based on medical subject headings and health sciences descriptors,which were combined using Boolean operators.Searches were run on the electronic databases Scopus,Web of Science,MEDLINE(PubMed),Biblioteca Regional de Medicina,Latin American and Caribbean Health Sciences Literature,Cochrane Library for Systematic Reviews and Opengray.eu.Languages were restricted to English,Spanish and Portuguese.There was no date of publication restrictions.The reference lists of the studies retrieved were searched manually.RESULTS The search strategy retrieved 3349 references.In the final analysis,44 references were included,with a total of 109 cases reported.The most common clinical finding was jaundice and 43.5%of cases were associated with inflammatory bowel disease.Of these,27.6%were cases of Crohn’s disease,68%of ulcerative colitis,and 6.4%of indeterminate colitis.Most patients were treated with steroids.All-cause mortality was 3.7%.CONCLUSION PSC and autoimmune hepatitis overlap syndrome is generally associated with inflammatory bowel disease and has low mortality and good response to treatment.

CLIF-SOFA and CLIF-C scores for the prognostication of acute-onchronic liver failure and acute decompensation of cirrhosis:A systematic review

BACKGROUND Acute-on-chronic liver failure(ACLF)is a syndrome characterized by decompensation in individuals with chronic liver disease,generally secondary to one or more extra-hepatic organ failures,implying an elevated mortality rate.Acute decompensation(AD)is the term used for one or more significant consequences of liver disease in a short time and is the most common reason for hospital admission in cirrhotic patients.The European Association for the Study of Liver-Chronic-Liver Failure(EASL-CLIF)Group modified the intensive care Sequential Organ Failure Assessment score into CLIF-SOFA,which detects the presence of ACLF in patients with or without AD,classifying it into three grades.AIM To investigate the role of the EASL-CLIF definition for ACLF and the ability of CLIF-SOFA,CLIF-C ACLF,and CLIF-C AD scores for prognosticating ACLF or AD.METHODS This study is a literature review using a standardized search method,conducted using the steps following the guidelines for reporting systematic reviews set out by the PRISMA statement.For specific keywords,relevant articles were found by searching PubMed,ScienceDirect,and BioMed Central-BMC.The databases were searched using the search terms by one reviewer,and a list of potentially eligible studies was generated based on the titles and abstracts screened.The data were then extracted and assessed on the basis of the Reference Citation Analysis(https://www.referencecitationanalysis.com/).RESULTS Most of the included studies used the EASL-CLIF definition for ACLF to identify cirrhotic patients with a significant risk of short-term mortality.The primary outcome in all reviewed studies was mortality.Most of the study findings were based on an area under the receiver operating characteristic curve(AUROC)analysis,which revealed that CLIFSOFA,CLIF-C ACLF,and CLIF-C AD scores were preferable to other models predicting 28-d mortality.Their AUROC scores were higher and able to predict all-cause mortality at 90,180,and 365 d.A total of 50 articles were included in this study,which found that the CLIF-SOFA,CLIF-C ACLF and CLIF-C AD scores in more than half of the articles were able to predict short-term and long-term mortality in patients with either ACLF or AD.CONCLUSION CLIF-SOFA score surpasses other models in predicting mortality in ACLF patients,especially in the short-term.CLIF-SOFA,CLIF-C ACLF,and CLIF-C AD are accurate short-term and long-term mortality prognosticating scores.

Risk and management of post-operative infectious complications in inflammatory bowel disease: A systematic review

BACKGROUND Indications for surgery in inflammatory bowel disease(IBD)include treatment-refractory disease or severe complications such as obstruction,severe colitis,dysplasia,or neoplasia.Infectious complications following colorectal surgery in IBD are significant,particularly in high-risk patients.AIM To gather evidence on risk factors associated with increased post-operative infectious complications in IBD and explore management strategies to reduce morbidity and mortality.METHODS A systematic review adhering to PRISMA-P guidelines was conducted.MEDLINE(PubMed)and Cochrane Library databases were searched using specific key-words.Inclusion criteria encompassed studies involving patients with IBD under-going abdominal surgery with infectious complications within 30 d postoper-atively.Exclusion criteria included patients under 18 years and non-infectious complications.Selected papers were analyzed to identify factors contributing to post-operative infections.A narrative analysis was performed to provide eviden-ce-based recommendations for management.The data were then extracted and assessed based on the Reference Citation Analysis(https://www.referencecitation-analysis.com/).RESULTS The initial database search yielded 1800 articles,with 330 articles undergoing full-text review.After excluding duplicates and irrelevant papers,35 articles were included for analysis.Risk factors for post-operative complications in patients with IBD included hypoalbuminemia,malnutrition,preoperative abscess,and obesity.Perioperative blood transfusion was associated with increased infectious complications.Medications such as 5-aminosalicylates and immunomodulators did not increase post-operative complications.Corticosteroids were associated with an increased risk of complications.Ustekinumab and vedolizumab showed similar rates of infectious complic-ations compared to other treatments.The impact of minimally invasive surgery on post-operative complications varied across studies.CONCLUSION In order to reduce post-operative infectious complications in patients with IBD,a comprehensive approach involving multiple disciplines is necessary.

Management of sepsis in a cirrhotic patient admitted to the intensive care unit:A systematic literature review

BACKGROUND Sepsis is a severe medical condition that occurs when the body's immune system overreacts to an infection,leading to life-threatening organ dysfunction.The"Third international consensus definitions for sepsis and septic shock(Sepsis-3)"defines sepsis as an increase in sequential organ failure assessment score of 2 points or more,with a mortality rate above 10%.Sepsis is a leading cause of intensive care unit(ICU)admissions,and patients with underlying conditions such as cirrhosis have a higher risk of poor outcomes.Therefore,it is critical to recognize and manage sepsis promptly by administering fluids,vasopressors,steroids,and antibiotics,and identifying and treating the source of infection.AIM To conduct a systematic review and meta-analysis of existing literature on the management of sepsis in cirrhotic patients admitted to the ICU and compare the management of sepsis between cirrhotic and non-cirrhotic patients in the ICU.METHODS This study is a systematic literature review that followed the PRISMA statement's standardized search method.The search for relevant studies was conducted across multiple databases,including PubMed,Embase,Base,and Cochrane,using predefined search terms.One reviewer conducted the initial search,and the eligibility criteria were applied to the titles and abstracts of the retrieved articles.The selected articles were then evaluated based on the research objectives to ensure relevance to the study's aims.RESULTS The study findings indicate that cirrhotic patients are more susceptible to infections,resulting in higher mortality rates ranging from 18%to 60%.Early identification of the infection source followed by timely administration of antibiotics,vasopressors,and corticosteroids has been shown to improve patient outcomes.Procalcitonin is a useful biomarker for diagnosing infections in cirrhotic patients.Moreover,presepsin and resistin have been found to be reliable markers of bacterial infection in patients with decompensated liver cirrhosis,with similar diagnostic performance compared to procalcitonin.CONCLUSION This review highlights the importance of early detection and management of infections in cirrhosis patients to reduce mortality.Therefore,early detection of infection using procalcitonin test and other biomarker as presepsin and resistin,associated with early management with antibiotics,fluids,vasopressors and low dose corticosteroids might reduce the mortality associated with sepsis in cirrhotic patients.

Hepatobiliary tuberculosis in the developing world

BACKGROUND Hepatobiliary tuberculosis is a challenging disease that poses diagnostic difficulties due to its resemblance to other etiologies.Delayed diagnosis may lead to inadequate treatment,thus necessitating an urgent need for accurate diagnosis and appropriate management.AIM To systematically review case reports on hepatobiliary tuberculosis,focusing on symptomatology,diagnostic procedures,management,and outcomes to provide patient safety and ensure an uneventful recovery.METHODS A systematic search was conducted on PubMed from 1992 to 2022,using keywords such as hepatobiliary,liver,tuberculosis cholangitis,cholangiopathy,and mycobacterium.Only case reports or case series in English were included in the study,and research papers published as abstracts were excluded.The search yielded a total of 132 cases,which were further narrowed down to 17 case studies,consisting of 24 cases of hepatobiliary tuberculosis.RESULTS The 10 most common symptoms observed in these cases were fever,abdominal pain,weight loss,jaundice,anorexia,generalized weakness,pruritus,chills,fatigue,and chest pains.Objective findings in these cases included hepatomegaly,hepatic nodules,elevated liver enzymes,and elevated bilirubin.Computed tomography scan and ultrasound of the abdomen were the most useful diagnostic tools reported.Histologic demonstration of Mycobacterium tuberculosis confirmed the cases of hepatobiliary tuberculosis.Treatment regimens commonly used included Rifampicin,Isoniazid,Pyrazinamide,and Ethambutol.Out of the 24 cases,18 presented improvements while 4 had completely recovered.CONCLUSION Hepatobiliary tuberculosis is a disease that requires accurate diagnosis and appropriate management to avoid complications.

Acute-on-chronic liver failure is independently associated with higher mortality for cirrhotic patients with acute esophageal variceal hemorrhage:Retrospective cohort study

BACKGROUND Acute esophageal variceal hemorrhage(AEVH)is a common complication of cirrhosis and might precipitate multi-organ failure,causing acute-on-chronic liver failure(ACLF).AIM To analyze if the presence and grading of ACLF as defined by European Society for the Study of the Liver-Chronic Liver Failure(EASL-CLIF)is able to predict mortality in cirrhotic patients presenting AEVH.METHODS Retrospective cohort study executed in Hospital Geral de Caxias do Sul.Data from medical records from 2010 to 2016 were obtained by searching the hospital electronic database for patients who received terlipressin.Medical records were reviewed in order to determine the diagnosis of cirrhosis and AEVH,including 97 patients.Kaplan-Meier survival analysis was used for univariate analysis and a stepwise approach to the Cox regression for multivariate analysis.RESULTS All-cause mortality for AEVH patients was 36%,40.2%and 49.4%for 30-,90-and 365-day,respectively.The prevalence of ACLF was 41.3%.Of these,35%grade 1,50%grade 2 and 15%grade 3.In multivariate analysis,the non-use of non-selective beta-blockers,presence and higher grading of ACLF and higher Model for End-Stage Liver Disease scores were independently associated with higher mortality for 30-day with the addition of higher Child-Pugh scores for 90-day period.CONCLUSION Presence and grading of ACLF according to the EASL-CLIF criteria was independently associated with higher 30-and 90-day mortality in cirrhotic patients admitted due to AEVH.

Pulmonary cytomegalovirus infection:A case report and systematic review

BACKGROUND Cytomegalovirus(CMV)is a common virus that can cause the first infection in childhood or adolescence and reactivate later in life due to immunosuppression.CMV pneumonia is a rare illness in immunocompetent patients but is one of the most significant opportunistic infections in immunocompromised patients.AIM To report a case and review published cases of pulmonary CMV infection in both immunocompromised and immunocompetent patients.METHODS We conducted a systematic search on the MEDLINE(PubMed)database,without date or language restrictions,to identify relevant studies using Medical Subject Headings and Health Science Descriptors.We manually searched the reference lists of the included studies.Simple descriptive analysis was used to summarize the results.RESULTS Our search identified 445 references,and after screening,43 studies reporting 45 cases were included in the final analysis,with 29(64%)patients being immunocompromised and 16(36%)being immunocompetent.Fever(82%)and dyspnea(75%)were the most common clinical findings.Thoracic computed tomography showed bilateral ground-glass opacities,a relevant differential diagnosis for severe acute respiratory syndrome coronavirus 2 infection.The majority of patients(85%)received antiviral therapy,and 89%of patients recovered,while 9%of patients died.CONCLUSION CMV pneumonia should be considered as a differential diagnosis for coronavirus disease 2019 pneumonia,especially in immunocompromised patients.Clinicians should be aware of the clinical presentation,management,and outcomes of CMV pneumonia to guide appropriate treatment decisions.

Comprehensive analysis of sodium polystyrene sulfonate-induced colitis:A systematic review

BACKGROUND Sodium polystyrene sulfonate(SPS)is commonly prescribed for the management of hyperkalemia,a critical electrolyte imbalance contributing to over 800000 annual visits to emergency departments.AIM To conduct a systematic review of documented cases of SPS-induced colitis and assess its associated prognosis.METHODS Following the PRISMA-P guidelines,our study employed Medical Subject Headings and Health Sciences Descriptors,skillfully combined using Boolean operators,to conduct comprehensive searches across various electronic databases,including Scopus,Web of Science,MEDLINE(PubMed),BIREME(Biblioteca Regional de Medicina),LILACS(Latin American and Caribbean Health Sciences Literature),SciELO(Scientific Electronic Library Online),Embase,and Opengray.eu.Language criteria were confined to English,Spanish,and Portuguese,with no limitations on the publication date.Additionally,we manually scrutinized the reference lists of retrieved studies.To present our findings,we utilized simple descriptive analysis.RESULTS Our search strategy yielded a total of 442 references.After rigorous evaluation,we included 51 references,encompassing 59 documented cases of colitis.Predominant clinical presentations included abdominal pain,observed in 35(60.3%)cases,and bloating,reported in 18(31%)cases.The most frequently affected sites of inflammation were the cecum,rectum,and small intestine,accounting for 31%,25.8%,and 22.4%of cases,respectively.Colonoscopy findings were described in 28(48.2%)cases,and 29(50%)of patients required surgical intervention.Among the subset of patients for whom outcome data was available,39(67.2%)experienced favorable outcomes,while 12(20.6%)unfortunately succumbed to the condition.The mean time required for resolution was 36.7 d,with a range spanning from 1 to 120 d.CONCLUSION SPS demonstrates the capacity to effectively lower serum potassium levels within 24 h.However,this benefit is not without the risk of bowel injury.Our study highlights the absence of high-quality data pertaining to the incidence of adverse events associated with SPS usage,making it challenging to determine whether the potential risks outweigh the benefits.However,a significant mortality rate related to SPS-induced colitis was noted.Future investigations should prioritize randomized controlled trials with a sufficiently large patient cohort to ascertain the true utility and safety profile of this medication.