Meticulous Management Research Articles

Arch and access vessel complications in penetrating aortic ulcer managed with thoracic endovascular aortic repair.

To analyze our experience and to describe access and arch-related challenges when performing thoracic endovascular aortic repair (TEVAR) for penetrating aortic ulcers (PAUs). This is a single-center, observational, cohort study. Between October 2003 and February 2019, 48 patients with PAU were identified; 37 (77.1%) treated with TEVAR were retrospectively analyzed. Primary major outcomes were early (<30 days) and late survival, freedom from aortic-related mortality (ARM), and a composite endpoint of arch/vascular access-related complications. On admission, 17 (45.9%) patients were symptomatic with 4 (10.8%) presenting with rupture. In-hospital mortality was 8.1% (n=3). We observed 10 (27.0%) arch/access-related complications. There were 4 (10.8%) arch issues: 2 transient ischemic attacks and 2 retrograde acute type A dissections which required emergent open conversion for definitive repair. Access issues occurred in 6 (16.2%) patients: 3 (8.1%) required common iliac artery conduit, and 1 (2.7%) patient required iliac artery angioplasty to deliver the stent-graft. In addition, 2 (5.4%) patients developed access complications which required operative repair [femoral patch angioplasty (n=2), and femoral pseudoaneurysmectomy (n=1)]. Arch/access-related mortality rate was 5.4% (n=2) and median follow-up was 24 (range, 1-156; IQR, 3-52) months. Estimated survival was 87.1% (standard error: 0.6; 95% CI: 71.2-84.9%) at 1 year, and 63.3% (SE: 0.9; 95% CI: 44.1-79%) at 4 years. Estimated freedom from reintervention was 88.9% (SE: 0.5; 95% CI: 74.8-95.6%) at 1 year, and 84.2% (SE: 0.7; 95% CI: 67.3-93.2%) at 4 years. No arch/access-related issues developed during the follow-up period. Our experience confirms that vascular access and aortic arch issues are still a challenging aspect of performing TEVAR for PAUs. Our cumulative 27% rate of access/arch issues is lower than previously reported due to both technological advancements and meticulous management of both access routes and arch anatomy.

Meticulous Management of the Whole Life Cycle of Medical Equipment in Hospital

Aiming at the different characteristics of the various stages of medical equipment life cycle in hospital, research on the targeted and meticulous management mode. Divides the whole life cycle of medical equipment in hospital into four phases, which are the selection demonstration period, purchase acceptance period, maintenance period, and retirement disposal period, and comparison with human fetal period, infant stage, adult stage and old age. With the meticulous management mode, the service quality of medical equipment in hospital has been improved, and the service benefits have been enhanced. According to the respective characteristics of different stages, the corresponding meticulous management mode is implemented to make the management more scientific and standardized, and the operation is safer and more reliable, which escorts the whole life cycle of medical equipment in hospital.

Perioperative Management of Spinal Tuberculosis in Patients with End-Stage Renal Disease: A Preliminary Report on A Patient Series

To present a preliminary experience of perioperative management for patients with spinal tuberculosis (STB) and end-stage renal disease (ESRD) and discuss strategic factors that should be considered. A retrospective study of 6 patients with STB and ESRD who underwent spine surgeries in our hospital from January 2010 to May 2017 was carried out. Medical records were reviewed for clinical manifestations, laboratory examinations, radiologic findings, perioperative management, clinical outcomes, and complications. Except for 1 patient who died of cardiac arrest 5 days after surgery, this case series was followed with a mean follow-up period of 17.0 months (range, 9-23). There were no patients reporting major side effects related to an adjusted antituberculosis chemotherapy regimen. Postoperatively, surgical incision healed primarily, whereas delirium and pneumonia were noted in 2 patients. At final follow-ups, solid bony fusion was achieved in 4 patients, whereas fusion was indefinite in the patient who underwent surgery at L3/4 level. Visual analogue scale score improved from preoperative 5.2 ± 0.37 to 2.6 ± 0.55 at the final follow-ups. Perioperative management of patients with STB and ESRD is a complicated issue, with multiple factors to be considered. Spinal surgery can achieve acceptable outcomes in these patients if meticulous management is performed.

Trust collapse caused by the Changsheng vaccine crisis in China

BackgroundThe public acceptance and implementation of vaccination programs is essential to prevent infectious diseases. However, vaccine adverse events may cause public panic and eventually lead to an increasing number of populations who were hesitant or refuse to participate in these vaccination programs. In 2018, the Changsheng vaccine crisis broke out in mainland China, and 252,600 unqualified DTP vaccines were reported to be used for child vaccination. In this study, we observed media and public reactions toward the vaccine crisis. MethodsThis study conducted Internet surveillance by four mainstream indicators from July 15th to August 7th, including social media (WeChat, Sina Weibo), online news and Baidu search index. We also analyzed the emotional perceptions of people in crisis through an online questionnaire survey. ResultsDuring the crisis, huge number of articles emerged on Internet, 125,882,894 articles (including forwarding) on WeChat friends circle, 1,877,660 Sina Weibo posts, 648,265 online news and 4,986,521 Baidu search indexes. Most of these articles were negative and expressed the public’s weak confidence to the China-made vaccines. Public confidence in vaccines was undermined by the actions of the manufacturer and the government. ConclusionsThe DTP vaccine crisis led to panic about immunization and eroded trust in the immunization program and in the government. Restoring public confidence in Chinese-made vaccines will take a long time, and meticulous management in vaccine production, and strict government regulation will help to alleviate public anxiety about vaccine safety and ultimately restore confidence.

Chronic Kidney Disease and Pregnancy

Chronic kidney disease represents a heterogeneous group of disorders characterized by alterations in the structure and function of the kidney. Chronic kidney disease significantly increases the risk of adverse maternal and perinatal outcomes, and these risks increase with the severity of the underlying renal dysfunction, degree of proteinuria, as well as the frequent coexistence of hypertension. Further, renal anatomic changes result in dilatation of the collecting system, and physiologic adaptations include alterations in the balance of vasodilatory and vasoconstrictive hormones, resulting in decreased systemic and renal vascular resistance, increased glomerular filtration rate, and modifications in tubular function. These alterations have important clinical implications and can make the diagnosis of renal compromise challenging. The effect of pregnancy on kidney disease may manifest as a loss of renal function, particularly in the context of concomitant hypertension and proteinuria, and chronic kidney disease, even when mild, contributes to the high risk of adverse pregnancy outcomes, including increased risks of preeclampsia, preterm delivery, and small-for-gestational age neonates. Strategies for optimization of pregnancy outcomes include meticulous management of hypertension and proteinuria where possible and the initiation of preeclampsia prevention strategies, including aspirin. Avoidance of nephrotoxic and teratogenic medications is necessary, and renal dosing of commonly used medications must also be considered. Mode of delivery in women with chronic kidney disease should be based on usual obstetric indications, although more frequent prenatal assessments by an expert multidisciplinary team are desirable for the care of this particularly vulnerable patient population. Obstetricians represent a critical component of this team responsible for managing each stage of pregnancy to optimize both maternal and neonatal outcomes, but collaboration with nephrology colleagues in combined clinics wherein both specialists can make joint management decisions is typically very helpful.

Container Ship Stowage Based on Monte Carlo Tree Search

ABSTRACT Zhao, N.; Guo, Y.; Xiang, T.; Xia, M.; Shen, Y., and Mi, C., 2018. Container ship stowage based on monte carlo tree search. In: Liu, Z.L. and Mi, C. (eds.), Advances in Sustainable Port and Ocean Engineering. Journal of Coastal Research, Special Issue No. 83, pp. 540–547. Coconut Creek (Florida), ISSN 0749-0208. With the development of larger ships, modernized wharves, standardized production, meticulous management, and flexible service in container transportation, port production management is becoming increasingly intelligent. How to improve the efficiency when making stowage plans, the core issue in container terminals, has become a popular topic in research. Starting with the stowage issue, this paper provides rational solutions to stowage location and loading sequence of unloaded containers on the yard, giving overall consideration on ship owners' requirement and dock authority's practical operation. Considering turnover on yard, RTG cross-container operation and RTG shifting, based on loadi...

Simultaneous pancreas-kidney transplantation: Initial experience of a center in Japan

BackgroundSimultaneous pancreas-kidney transplantation (SPK) is an established therapy for diabetes mellitus (DM) patients with associated end stage renal disease. We report the initial results of SPK in our institution after qualification as transplantation program. Patients and methodsBetween September 2017 and July 2018, we performed 3 SPK in type 1 diabetic patients with end-stage renal disease. All grafts were procured from brain-dead marginal donors according Pittsburg criteria. ResultsThe recipients were 2 men and 1 woman with a mean age of 43 ± 5.4 years. Mean time from DM diagnosis and time on dialysis were 25.7 ± 3.9 years and 19.7 ± 9.1 months. The mean age and HbA1C value of donor were 56.7 ± 0.5 years and 5.67 ± 0.05%. The pancreatic grafts were transplanted intraperitoneally in the right iliac fossa. Two patients required a relaparotomy due to arterial anastomotic hemorrhage and two patients developed acute cellular rejection. With a median follow-up of 13 (6–15) months, patient's and graft's survival rate were 100%. All patients showed HbA1C within normal range, but oral glucose tolerance test showed DM pattern in two patients at 3 months after transplantation. ConclusionsIn our initial experience with SPK, mid-term grafts and patient survival appear comparable to the results reported in literature. Despite the limited availability of donors and the use of grafts from marginal donors, a quality pancreas transplantation program can be established even in a small-volume centers. Nonetheless further improvement in surgical techniques and meticulous management appear mandatory.

Yellow nail syndrome resulting from cardiac mitral valve replacement

BackgroundYellow nail syndrome is a rare disease with unknown etiology, Attributed to functional anomalies or disturbance in lymphatic drainage. This condition is characterized by triad of nail discoloration, respiratory or intrathoracic manifestations and lymphedema.Case presentationTwenty days after mitral valve replacement for severe rheumatic mitral valve stenosis, 39 years old woman presented with face tenderness and hearing problems besides stuffy and clogged nose and underwent routin rhinosinusitis therapy. She came back to ears, nose and throat service with persistent rhinosinusitis as well as relapsing preoperative couphs and dyspnea besides lower extremities edema and toenails discoloration. After some modulations of treatment, she was introduced to pulmonary clinic on post -operative day = 30. Chest x ray showed a lot of left pleural effusion then she was returned to our service (cardiac surgery) on post- operative day = 33. The pigtail catheter was secured and we attained a significant amount of milky fluid which conformed with chylothorax. Finally Yellow nail syndrome was diagnosed with her on post–operative day = 35. Early conservative therapy such as bed rest, legs massage, low fat diet with medium chain triglycerides, diuretics, bronchodilator inhaler was not be able to satisfy us (chylous out put > 330 cc/d). Therefore the catheter replacement with chest tube was carried out followed by pleurodesis using Talc and doxycycline besides transition of oral intake to total parentral nutrition and vitamine E supplement, on post - operative day = 41. After that chylous leakage gradually subsided and patient was discharged to home on post- operative day = 47. At 4 weeks follow ups, chest x ray was clear without effusion and nails discoloration and legs lymphedema resolved.ConclusionWe reported the third post cardiac surgery Yellow nail syndrome which is an unclear entity with a set of associated signs and symptoms. Two prior reports involved with coronary artery bypass graft whereas we performed mitral valve replacement. In angiogram thoracic duct was not identified so that it seems post cardiac surgery Yellow nail the syndrome has iatrogenic origin due to the thoracic duct or its tributaries injury and requires meticulous assessment and management.

Large-bore Vascular Closure: New Devices and Techniques.

Endovascular aneurysm repair, transcatheter aortic valve implantation and percutaneous mechanical circulatory support systems have become valuable alternatives to conventional surgery and even preferred strategies for a wide array of clinical entities. Their adoption in everyday practice is growing. These procedures require large-bore access into the femoral artery. Their use is thus associated with clinically significant vascular bleeding complications. Meticulous access site management is crucial for safe implementation of large-bore technologies and includes accurate puncture technique and reliable percutaneous closure devices. This article reviews different strategies for obtaining femoral access and contemporary percutaneous closure technologies.

Complex primary total hip replacement in a patient with sickle cell disease and contralateral poliomyelitis: A case report and review of literature

Sickle cell haemoglobinopathy (SCH) and neurological sequelae of childhood poliomyelitis are still relatively common in this environment. The non-paralytic limb in polio patients is subjected to abnormal stresses due to excessive weight-bearing load, leg length discrepancy, pelvic obliquity and abnormal gait mechanics. We present this case to highlight the challenges of managing such a case and present our experience. A 47-year-old female with SCH presented with left-sided avascular necrosis (AVN) of the head of the femur and right-sided post-polio paralysis. Limb length discrepancy was 1.5 cm with a longer left lower limb. Oxford hip score (OHS) = 25 and SF12 = 16. Packed cell volume (PCV) was 20%. Radiographs revealed a destroyed left hip with secondary osteoarthritis, partial collapse, lateral subluxation and metaphyseal sclerosis. She had non-cemented left total hip arthroplasty via Hardinge approach. One-month post-operative scores were OHS = 38, SF12 = 24. Three-month follow-up scores were OHS = 46 and SF12 = 30. AVN poses a major burden. Combination with post-polio paralysis and the risk of infection with encapsulated organisms create a complex interplay of challenges. Peri-operative management requires meticulous monitoring, care and prevention of sickling crisis. Uncemented implants gave better results with fewer complications. Limb shortening at arthroplasty increases dislocation risk; so, length should be maintained. Coexisting post-polio paralysis and SCH is rare but challenging. The non-paralytic limb is subjected to excessive abnormal forces. Excellent results and low complication rates are achievable if meticulous peri-operative management, appropriate choice of cementless implants and maintenance of length are done. Ensuring adequate fixation of implants at surgery reduces risk of loosening. Rehabilitation must take the risk of falls into account. Pre-operative planning and optimisation, meticulous surgical technique and cementless implants are keys to success.

Acute corneal perforation 1 week following uncomplicated cataract surgery: the implication of undiagnosed dry eye disease and topical NSAIDs

Dry eye disease is a common ocular surface disease in patients who are undergoing cataract surgery. The significance of dry eye disease is often underestimated or overlooked during preoperative assessment of cataract. We report an 80-year-old patient, with a background of seropositive rheumatoid arthritis and diabetes, who presented with an acute corneal melt and perforation associated with undiagnosed dry eye disease and use of topical ketorolac 1 week following an uncomplicated cataract surgery. The patient underwent repeated corneal gluing for corneal perforation and was subsequently diagnosed and treated for bilateral moderate-severe dry eye disease. This case highlights the importance of meticulous preoperative assessment and management of the ocular surface, especially in patients with systemic diseases such as rheumatoid arthritis and diabetes prior to cataract surgery. The implication of the use of topical nonsteroidal anti-inflammatory drugs following cataract surgery – which might have contributed to the process of corneal melt in our case – is also discussed.

Intensive care, right ventricular support and lung transplantation in patients with pulmonary hypertension.

Intensive care of patients with pulmonary hypertension (PH) and right-sided heart failure includes treatment of factors causing or contributing to heart failure, careful fluid management, and strategies to reduce ventricular afterload and improve cardiac function. Extracorporeal membrane oxygenation (ECMO) should be considered in distinct situations, especially in candidates for lung transplantation (bridge to transplant) or, occasionally, in patients with a reversible cause of right-sided heart failure (bridge to recovery). ECMO should not be used in patients with end-stage disease without a realistic chance for recovery or for transplantation. For patients with refractory disease, lung transplantation remains an important treatment option. Patients should be referred to a transplant centre when they remain in an intermediate- or high-risk category despite receiving optimised pulmonary arterial hypertension therapy. Meticulous peri-operative management including the intra-operative and post-operative use of ECMO effectively prevents graft failure. In experienced centres, the 1-year survival rates after lung transplantation for PH now exceed 90%.

Application of BIM Technology in Nanjing Honeycomb Hotel

Based on Nanjing honeycomb hotel, the management for the whole construction process was carried out through BIM technology and the project management cloud platform. The issues of the project were analyzed by modular design method, especially honeycomb curtain wall. The project from technology level was managed based on BIM models[1]. Cooperative work could be achieved through the project management cloud platform, so as to manage the project from the level of organization. And then, project management platform was integrated with BIM, to achieve the goals of meticulous management of the construction process.

A study on evaluation of eyelid trauma in a tertiary care center

Aim: This study aims to evaluate traumatic eyelid injuries and assess functional outcome following treatment. Materials and Methods: A prospective study of 30 cases of lid injury was conducted at Orbit and Oculoplasty Department, Regional Institute of Ophthalmology and Government Ophthalmic Institute, Egmore, Chennai, Tamil Nadu, for 12 months from February 01, 2017, to February 01, 2018. Data collected were entered into Excel Spreadsheet and analyzed using STATA statistical software package release 11. Results: The incidence of lid injuries was more in males (63%) compared to females (37%). The most common mode of injury of the eyelid was accidental fall (36.7%) and assault (23.3%). Majority of the cases presented within 6 h of injury. Full-thickness involvement was seen in 20 patients (66.7%). Involvement of the eyelid margin was seen in 18 patients (60%) and was managed by three-layer margin suturing canalicular involvement in 8 cases (26.7%) underwent monocanalicular stent placement. About 40% of patients complained of epiphora and were not satisfied with cosmetic results. Conclusion: This study reveals that young adult males, most of whom were workers, were more prone to eyelid injuries. Timely meticulous management of the eyelid injury with minimal debridement of the wound and tension-free suturing gives better cosmetic outcome. Epiphora, notching of lid margin, or ectropion was the most common complication postoperatively.

Heart and liver are infected in fatal cases of dengue: three PCR based case studies

BackgroundDengue is a global problem mainly in the tropics. Meticulous clinical management of cases has reduced the death rate significantly, but large numbers of people still succumb to severe complications of the infection. Presence of myocarditis is often overlooked leading to a poor outcome. Clinical management guidelines of dengue do not stress the importance of myocarditis as a manifestation in dengue infection. Severe hepatic dysfunction also needs emphasis.Case presentationWe present three patients who had come to hospital on the 3rd day of fever. Two of them (case 1 and 3) were in shock on admission and case 2, who was stable on the3rd day, went into the critical phase and developed shock while in the hospital on the 4thday. All three had tachycardia on admission that got worse with time. The clinical course was unstable with fluctuations in urine output and deterioration of organ function. Despite frequent monitoring and life support they survived only 2–3 days in hospital. All three patients had myocarditis during the critical phase. In the first case, myocarditis was confirmed by troponin estimation and echocardiogram. In the second and third cases, histopathology confirmed myocarditis. Haemorrhagic necrosis of the liver was found in case 2 and 3 with exponential rise of transaminases. In all three cases, viral RNA was detected in both heart and liver tissues by PCR amplification.ConclusionsWe stress that detection of myocarditis and liver involvement in any dengue patient is important from the onset of the illness where treatment should be tailored to prevent development of hypotension. Our findings are novel as PCR and histology are rarely done on tissues of deceased dengue patients in the world. Studies are needed to find therapeutic interventions to reverse cardiac and hepatic dysfunction in dengue infection.

Series of 10 dengue fever cases with unusual presentations and complications in Sri Lanka: a single centre experience in 2016

BackgroundDengue has global importance as a dreaded arboviral infection. It has 4 serotypes of epidemiological imporatnce. The classification denotes two clinical spectrums- dengue fever (DF) and dengue haemorragic fever (DHF). Most cases are stereotype and amenable to fluid resuscitation. However, unusual manifestations cause fatalities and often overlooked. This study describes 10 such dengue cases to fill the knowledge gaps.Case presentationAll 10 patients presented to the Teaching Hospital, Peradeniya, Sri Lanka during mid-year epidemic of dengue in 2016. The mean age is 27 years (range 12-51 years) comprising 6 females and 4 males. The group had 7 DHF, 3 DF and 2 primary dengue infections who predominantly had severe bleeding into gut. Other potentially life threatening problems were acute severe hepatitis, severe septic shock, myocarditis, erratic rapid plasma leak, intracranial bleeding, diarrhoea and decompenstaed dengue shock due to 3rd space fluid leak. Blood transfusions and other empirical therapeutic methods were used apart from meticulous fluid management to suit issues of each patient. Bedside ultrasound scanning helped early detection of critical phase. All recovered fully.ConclusionsDengue is an extremely challenging infection to treat in the globe today. Above unusual presentation and complications could be fatal, if not detected early where therapeutic window period is very short. Clinicians need awareness of these problems which are not uncommon, but underreported and often overlooked. The clinical management of each patient was described for the purpose sharing the experiences.

TRIPLE THERAPY - WALKING ON A TIGHT ROPE!

Managing patients with atrial fibrillation (AF) requiring percutaneous interventionor those on anticoagulant therapy needing an intervention is an act of greatbalancing like walking on a tight rope. The premise revolves around three basicconsiderations - the risk of embolism and stroke due to AF, the possibility ofthrombosis due to underlying coronary obstructive disease and interventionsand more importantly the hazard of bleeding in combining different therapeuticagents. Risk of thromboembolic stroke is determined by a host of factors. CHA DS VASC score is well-validated risk score based onage, gender and comorbidities. It identifies patients at higher risk of thromboembolism who require anticoagulants to preventstroke. HASBLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile internationalnormalized ratio [INR], elderly [>65 years], drugs/alcohol concomitantly) has been recommended as a bleeding risk score forpatients with AF, with scores Ý3 considered high risk. Both scores have to be used with a grain of common sense andconsidering patient as a whole, though the HAS-BLED score has been credited to predict bleeding significantly; thediscriminating value is overall limited and similar to CHA DS VASC score. A brief period of washout from the anticoagulant effect of OAC is preferable whenever possible in elective and non-emergentprocedures. In patients on Vit K antagonists, those being subjected to radial approach, INR should be preferably U2.0 and iffemoral approach is used INR has to be U 1.5. In patients on NOAC, irrespective of vascular access site, treatment may bewithheld for 24 hours (or 48 hours for patients with impaired renal function with dabigatran). Although in stable CAD patientsbridging with parenteral anticoagulation can be omitted yet this should be considered for patients presenting with an ACS. To conclude, treating patients with triple therapy in the setting of AF and PCI is like walking on a tight rope. Three importantconsiderations for all decisions making are risk of thrombo-embolism and stroke, risk for thrombotic complications and risk ofbleeding. Meticulous management is recommended pre, intra and post procedure. This entails selecting patients usingappropriate criteria, employing radial approach, using latest generation DES, starting triple therapy and then changing over toSAPT earlier or later balancing thrombotic versus bleeding risks.

Recurrent Seizures in 2 Patients with Magnesium Sulfate-Treated Eclampsia at a Secondary Hospital.

Case seriesPatient: Female, 20 • Female, 19Final Diagnosis: Recurrent seizure eclampsiaSymptoms: Hypertension • seizureMedication: —Clinical Procedure: Magnesium sulfate therapySpecialty: Obstetrics and GynecologyObjective:Unusual clinical courseBackground:Recurrent seizure in patients with magnesium sulfate-treated eclampsia is very rare and requires meticulous management due to poor prognosis. The development of eclamptic convulsions is considered a preventable obstetric situation. Magnesium sulfate has been the drug of choice in such cases. However, some cases are persistent and need more aggressive treatment.Case Report:First case: A 20-year-old, nulliparous woman was referred from a private midwifery practice with history of convulsion, 40 weeks of gestational age (GA), and in the active phase of labor. She had been treated with magnesium sulfate and nifedipine beforehand. Her fetus was tachycardic, so an emergency caesarean section was done and placental abruption was found. The day after the surgery, the patient had recurrent seizures despite receiving a maintenance dose of magnesium sulfate. The patient then received thiopental sodium and remained stable.Second case: A 19-year-old, nulliparous woman came to the hospital with 40 weeks of GA, prolonged premature rupture of the membrane (PROM), preeclampsia, and cephalopelvic disproportion (CPD). An emergency caesarean section was performed. Eighteen hours after surgery, the patient had convulsions despite receiving magnesium sulfate maintenance therapy. We repeated the loading dose of 2 g magnesium sulfate, but the seizures persisted. Hence, midazolam was given and the seizures remained controlled. Both babies were delivered without any significant complications.Conclusions:We report 2 cases of GIP0-0 women with 40 weeks GA who had magnesium sulfate-resistant eclampsia and needed additional anticonvulsant drugs. These cases show the importance of comprehensive management and the need for alternative drugs in eclampsia.

Atypical cells in pathology of endobronchial ultrasound-guided transbronchial biopsy of peripheral pulmonary lesions: incidence and clinical significance.

Atypical cells may occasionally be the only pathologic finding in radial-probe endobronchial ultrasound (EBUS)-guided transbronchial biopsy (TBB) of peripheral pulmonary lesions (PPLs); however, it is uncertain how often we encounter such a situation and what clinical features can be used to identify these ambiguous PPLs, which are more likely to be malignant. From 2009 to 2016, consecutive patients referred for EBUS-guided TBB of PPLs and with pathology reports indicating atypical cells alone were included. Medical records were reviewed to extract patient demographics, clinical characteristics, procedural details and complications. The primary outcome was the final diagnosis of the PPLs on subsequent investigation. Multivariate logistic regression analysis was used to identify independent factors associated with a final malignant diagnosis. One hundred sixty-five (7.2%) of 2291 patients had non-diagnostic TBB showing atypical cells. Benign and malignant diagnoses were subsequently obtained in 45 (27%) and 120 (73%) patients, respectively. The leading malignancy was lung adenocarcinoma; of note, a variety of benign lesions revealed cellular atypia on pathology, in particular, chronic inflammation, tuberculosis and pneumonia. Multivariate analysis indicated lesion appearance [solid vs. others; odds ratio (OR) 7.93; 95% confidence interval (CI) 2.94-21.40; P < 0.001] and probe position (adjacent to vs. within; OR 3.36; 95% CI 1.11-10.15; P = 0.032) were two significant factors predictive of a final diagnosis of malignancy. One out of 14 EBUS-guided TBB procedures for PPLs exhibited atypical cells on pathology. Meticulous management strategies should be formulated to deal with these instances after taking into consideration lesion appearance, probe position and patient preferences.

Liver transplantation with portal vein thrombosis – The missing link in optimizing outcome: a case-control study

Background: PVT though no longer contra-indicated for Orthotopic Liver Transplantation (OLT), still associated with increased morbidity and mortality. Aims include outcomes of patients with PVT and also risk factors associated with mortality. Methods: Retrospective case control analysis of primary adult (n=629) patients who underwent OLT between August 2009 – October 2017. Outcomes of PVT were compared to matched non PVT group and analyzed for risk factors for mortality. Results: 69 (10.98%) patients had PVT. Mean age 49.09 ± 9.59 years. Males were 79.7%. 29 patients (42.02%) had Grade I, 30 patients (43.47%) had Grade II, 7 patients (10.14%) Grade III and Grade IV in 3(4.34%). Right lobe graft used in 47, Whole liver 19 and split liver graft in 3. Eversion thrombectomy was done for Grade 1, Combination of Eversion thrombectomy & Interposition Jump Grafts were used in Grade II/III. Cavo-Portal Hemi-transposition was required in 2 & Reno-Portal Transposition was done in 1, Collateral vein as inflow was used in 1. Overall mortality was 8/69 (11.5% Vs 8.69%). Blood loss, operative time, portal pressure, portal flow velocity, Hospital stay were not statistically significant. Risk factors for mortality were previous treatment for PHT like EVL, splenectomy or TIPS (p < 0.00001), CIT (p = 0.002), Sepsis (p < 0.0001), AKI (p < 0.0001) and Early Graft Dysfunction (p = 0.015). Partial PVT occurred in 3 patients (4.34%). Conclusion: Meticulous perioperative management, careful patient selection, and optimal surgical strategies are critical to improve outcomes. Risk factors for mortality are treatment for previous PHT, prolonged CIT, AKI & Sepsis.