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1. Worldwide variations in COVID-19 vaccination policies and practices in liver transplant settings: results of a multi-society global survey

Author: Tommaso Di Maira, Carmen Vinaixa, Manhal Izzy, Francesco Paolo Russo, Varvara A. Kirchner, Ashwin Rammohan, Luca Saverio Belli, Wojciech Grzegorz Polak, Thomas Berg, and Marina Berenguer
Subjects: vaccine, SARS-CoV-2, liver, transplant, survey, policy, Specialties of internal medicine, RC581-951
Abstract: BackgroundDespite the WHO's report of 24 available SARS-CoV-2 vaccines, limited data exist regarding vaccination policies for liver transplant (LT) patients. To address this, we conducted a global multi-society survey (EASL-ESOT-ELITA-ILTS) in LT centers.MethodsA digital questionnaire assessing vaccine policies, safety, efficacy, and center data was administered online to LT centers.ResultsOut of 168 responding centers, 46.4%, 28%, 13.1%, 10.7%, and 1.8% were from European, American, Western Pacific, Southeast Asian, and Eastern Mediterranean Regions. Most LT centers prioritized COVID-19 vaccine access for LT patients (76%) and healthcare workers (86%), while other categories had lower priority (30%). One-third of responders recommended mRNA vaccine exclusively, while booster doses were widely recommended (81%). One-third conducted post-vaccine liver function tests post COVID-19 vaccine. Only 16% of centers modified immunosuppression, and mycophenolate discontinuation or modification was the main approach. Side effects were seen in 1 in 1,000 vaccinated patients, with thromboembolism, acute rejection, and allergic reaction being the most severe. mRNA showed fewer side effects (−3.1, p = 0.002).ConclusionCOVID-19 vaccines and booster doses were widely used among LT recipients and healthcare workers, without a specific vaccine preference. Preventative immunosuppression adjustment post-vaccination was uncommon. mRNA vaccines demonstrated a favorable safety profile in this population.
Published: 2024
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2. Surgical outcomes of gallbladder cancer: the OMEGA retrospective, multicentre, international cohort studyResearch in context

Author: Anita Balakrishnan, Petros Barmpounakis, Nikolaos Demiris, Asif Jah, Harry V.M. Spiers, Shibojit Talukder, Jack L. Martin, Paul Gibbs, Simon J.F. Harper, Emmanuel L. Huguet, Vasilis Kosmoliaptsis, Siong S. Liau, Raaj K. Praseedom, Bristi Basu, Xavier de Aretxabala, Javier Lendoire, Shishir Maithel, Alejandro Branes, Bodil Andersson, Alejandro Serrablo, Volkan Adsay, Tomoyuki Abe, Moh'd Abu Hilal, Maria del Mar Achalandabaso Boira, Mustapha Adham, Mohamed Adam, Maryam Ahmad, Bilal Al-Sarireh, Maite Albiol, Nassir Alhaboob, Adnan Alseidi, Houssem Ammar, Akshay Anand, Pantelis Antonakis, Veronica Araya, Stanley W. Ashley, Georgi Atanasov, Fabio Ausania, Ricardo Balestri, Abhirup Banerjee, Simon Banting, Giedrius Barauskas, Fabian Bartsch, Andrea Belli, Simona Beretta, Frederik Berrevoet, Gerardo Blanco Fernandez, Louisa Bolm, Mathieu Bonal, Emre Bozkurt, Andries E. Braat, Luke Bradshaw, Lyle Burdine, Matthew Byrne, Maria Caceres, Maria Jesus Castro Santiago, Benjamin Chan, Lynn Chong, Ahmet Çoker, Maria Conde Rodriguez, Daniel Croagh, Alyn Crutchley, Carmen Cutolo, Mathieu D'Hondt, Daniel D'Souza, Freek Daams, Raffaele Dalla Valle, José Davide, Mario de Bellis, Marieke de Boer, Celine de Meyere, Philip de Reuver, Matthew Dixon, Panagiotis Dorovinis, Gabriela Echeverría Bauer, Maria Eduarda, Hasan Eker, Joris Erdmann, Mert Erkan, Evangelos Felekouras, Emanuele Felli, Eduardo Fernandes, Eduardo Figueroa Rivera, Andras Fulop, Daniel Galun, Michael Gerhards, Poya Ghorbani, Fabio Giannone, Luis Gil, Emmanouil Giorgakis, Mario Giuffrida, Felice Giuliante, Ioannis Gkekas, Miguel Gomez Bravo, Bas Groot Koerkamp, Oscar Guevara, Alfredo Guglielmi, Aiste Gulla, Rahul Gupta, Amit Gupta, Marta Gutiérrez, Abu Bakar Hafeez Bhatti, Jeroen Hagendoorn, Zain Hajee, Abdul Rahman Hakeem, Hytham Hamid, Sayed Hassen, Stefan Heinrich, Ryota Higuchi, Daniel Hoffman, David Holroyd, Daniel Hughes, Arpad Ivanecz, Satheesh Iype, Isabel Jaen Torrejimeno, Shantanu Joglekar, Robert Jones, Klaus Kaczirek, Harsh Kanhere, Ambareen Kausar, Zhanyi Kee, Jessica Keilson, Jorg Kleef, Johannes Klose, Brett Knowles, Jun Kit Koong, Nagappan Kumar, Supreeth Kunnuru, Paleswan Joshi Lakhey, Andrea Laurenzi, Yeong Sing Lee, Felipe Leon, Voon Meng Leow, Jean-Baptiste Lequeu, Mickael Lesurtel, Elisabeth Lo, Stefan Löb, Elizabeth Lockie, Peter Lodge, Dolores López Garnica, Victor Lopez Lopez, Linda Lundgren, Nikolaos Machairas, Dhiresh Maharjan, Deep Malde, Guillaume Martel, Julie Martin, Michele Mazzola, Arianeb Mehrabi, Ricardo Memeo, Flavio Milana, George Molina, Leah Monette, Haluk Morgul, Dimitrios Moris, Antonios Morsi-Yeroyannis, Nicholas Mowbray, Francesk Mulita, Edoardo Maria Muttillo, Malith Nandasena, Pueya Rashid Nashidengo, Arash Nickkholgh, Colin Byron Noel, Masayuki Ohtsuka, Arturs Ozolins, Sanjay Pandanaboyana, Nikolaos Pararas, Alessandro Parente, June Peng, Arkaitz Perfecto Valero, Julie Perinel, Konstatinos Perivoliotis, Teresa Perra, Patrick Pessaux, Natalie Petruch, Gaetano Piccolo, Laszlo Piros, Alberto Porcu, Viswakumar Prabakaran, Raj Prasad, Mikel Prieto Calvo, Florian Primavesi, Eva Maria Pueyo Periz, Alberto Quaglia, Jose M. Ramia Angel, Ashwin Rammohan, Francisco Razionale, Ricardo Robles Campos, Manas Roy, Sophie Rozwadowski, Luis Ruffolo, Natalia Ruiz, Andrea Ruzzenante, Lily Saadat, Mohamed Amine Said, Edoardo Saladino, Gabriel Saliba, Per Sandstrom, Carlo Alberto Schena, Anthony Scholer, Cristoph Schwartz, Lorenzo Serafini, Pablo Serrano, Deepak Sharma, Aali Sheen, Vishwanath Siddagangaiah, Michael Silva, Saurabh Singh, Ajith Siriwardena, Michal Skalski, Mante Smig, Faris Soliman, Donzília Sousa Silva, Ernesto Sparrelid, Parthi Srinivasan, Malin Sternby Eilard, Oliver Strobel, Urban Stupan, Miguel Angel Suarez-Munoz, Manisekar Subramaniam, Teiichi Sugiura, Robert Sutcliffe, Hilko Swank, Lillian Taylor, Prabin Bikram Thapa, Catherine The, Asara Thepbunchonchai, Caman Thieu, Navneet Tiwari, Guido Torzilli, Chutwichai Tovikkai, Blaz Trotovsek, Savvas Tsaramanidis, Georgios Tsoulfas, Katsuhiko Uesaka, Garzali Umar, Lucio Urbani, Michail Vailas, Ronald van Dam, Peter van de Boezem, Stijn van Laarhoven, Tomas Vanagas, Mike Van Dooren, Manon Viannet, Luca Vigano, Aarathi Vijayashanker, Celia Villodre, Toshifumi Wakai, Aklile Workneh, Li Xu, Masakazu Yamamoto, Zhiying Yang, Robert Young, and Marko Zivanovic
Subjects: Gallbladder cancer, Liver resection, Surgical outcomes, Cholangiocarcinoma, Medicine (General), R5-920
Abstract: Summary: Background: Gallbladder cancer (GBC) is rare but aggressive. The extent of surgical intervention for different GBC stages is non-uniform, ranging from cholecystectomy alone to extended resections including major hepatectomy, resection of adjacent organs and routine extrahepatic bile duct resection (EBDR). Robust evidence here is lacking, however, and survival benefit poorly defined. This study assesses factors associated with recurrence-free survival (RFS), overall survival (OS) and morbidity and mortality following GBC surgery in high income countries (HIC) and low and middle income countries (LMIC). Methods: The multicentre, retrospective Operative Management of Gallbladder Cancer (OMEGA) cohort study included all patients who underwent GBC resection across 133 centres between 1st January 2010 and 31st December 2020. Regression analyses assessed factors associated with OS, RFS and morbidity. Findings: On multivariable analysis of all 3676 patients, wedge resection and segment IVb/V resection failed to improve RFS (HR 1.04 [0.84–1.29], p = 0.711 and HR 1.18 [0.95–1.46], p = 0.13 respectively) or OS (HR 0.96 [0.79–1.17], p = 0.67 and HR 1.48 [1.16–1.88], p = 0.49 respectively), while major hepatectomy was associated with worse RFS (HR 1.33 [1.02–1.74], p = 0.037) and OS (HR 1.26 [1.03–1.53], p = 0.022). Furthermore, EBDR (OR 2.86 [2.3–3.52], p
Published: 2023
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3. Update on the Pathology of Pediatric Liver Tumors: A Pictorial Review

Author: Priyanka Bhagat, Mukul Vij, Lexmi Priya Raju, Gowripriya Gowrishankar, Jagadeesh Menon, Naresh Shanmugam, Ilankumaran Kaliamoorthy, Ashwin Rammohan, and Mohamed Rela
Subjects: pediatric liver tumors, pathology, hemangioma, mesenchymal hamartoma, undifferentiated embryonal sarcoma, inflammatory myofibroblastic tumor, Medicine (General), R5-920
Abstract: Liver tumors in children are uncommon and show remarkable morphologic heterogeneity. Pediatric tumors may arise from either the epithelial or mesenchymal component of the liver and rarely may also show both lines of differentiation. Both benign and malignant liver tumors have been reported in children. The most common pediatric liver tumors by age are benign hepatic infantile hemangiomas in neonates and infants, malignant hepatoblastoma in infants and toddlers, and malignant hepatocellular carcinoma in teenagers. Here, we provide an up-to-date review of pediatric liver tumors. We discuss the clinical presentation, imaging findings, pathology, and relevant molecular features that can help in the correct identification of these tumors, which is important in managing these children.
Published: 2023
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4. Liver Transplantation for Non-Resectable Colorectal Liver Metastases

Author: Ashwin Rammohan
Subjects: non-resectable colorectal liver metastases, liver transplantation, review, Medicine
Abstract: Improved results following liver transplantation (LT) over the past 20 years have led clinicians to push boundaries and expand itsindications. LT in non-resectable colorectal liver metastases (NCRLM) is being revisited with an aim to radically improve survival.By utilizing new tools for preoperative patient selection, modern operative techniques for LT and an aggressive attitude againstmetastases, long-term survival, and even cure could be expected. This paper reviews the current status of liver transplantation forNCRLM with an eye on the future.
Published: 2018

5. Gallbladder perforation presenting as a hepatic neoplasm

Author: Sangara Narayanan, Ashwin Rammohan, Jeswanth Sathyanesan, Ravichandran Palaniappan, and Manoharan Govindan
Subjects: Biliary cystadenoma, gallbladder perforation, radiology, Surgery, RD1-811
Abstract: Perforation of the gallbladder is a rare, but potentially fatal complication of acute cholecystitis. Gallbladder perforations presenting electively as a space-occupying lesion of the liver are its rarest presentation. We report one such case, which was a diagnostic conundrum. A 50-year-old female presented with upper abdominal pain of 6 months duration. On examination, she was afebrile and had minimal tenderness in the right upper quadrant. All of her blood investigations were unremarkable, and her imaging showed features suggestive of a biliary cystadenoma. Intra-operatively, she was found to have a perforated gallbladder with intrahepatic extension. Cholecystectomy with abscess drainage was done, and her post-operative period was uneventful. Gallbladder perforations can have a myriad of presentations. We report a rare case of a perforated gallbladder mimicking a biliary cystadenoma. A high index of suspicion along with prudent decision-making can help in accurate pre-operative diagnosis, thereby avoiding intraoperative surprises and unnecessary morbidity, especially in cases where a benign pathology mimics malignancy. [Arch Clin Exp Surg 2016; 5(2.000): 113-115]
Published: 2016
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6. Ultrasound Guided Fine-Needle Aspiration Cytology (FNAC) of Portal Vein Thrombus: A Novel Diagnostic and Staging Technique for Occult Hepatocellular Carcinoma

Author: Sukumar Ramaswami, Ashwin Rammohan, Jeswanth Sathyanesan, and Ravichandran Palaniappan
Subjects: Portal vein thrombus, fine-needle aspiration cytology, occult hepatocellular carcinoma, staging and diagnosis, Surgery, RD1-811
Abstract: Introduction: The diagnosis of Hepatocellular Carcinoma (HCC) is usually established using noninvasive radiological imaging and tumor markers. The stage at diagnosis is a critical factor in the treatment, course and prognosis of HCC. Patients with Tumor Portal vein thrombus (PVT) are considered to have an advanced disease and are only offered palliative therapy. Therefore, every possible attempt should be made to accurately stage HCC. Fine-needle aspiration cytology (FNAC) of PVT is an effective procedure for diagnosing and staging HCC. We present a case where we used Ultrasound (USG) guided FNAC of a PVT to successfully diagnose and stage HCC in the absence of a well-defined liver mass on imaging. Case report: A 43-year-old Hepatitis B surface antigen positive male presented with a 3-month history of fatigue, jaundice and fever. On examination he had hepatomegaly. His liver function tests were elevated, but his alpha-fetoprotein was normal. USG and Computed Tomography (CT) showed a thrombus in the portal vein but failed to show a well-defined liver lesion. FNAC was taken from the PVT, which was positive for malignancy. He was offered palliative chemotherapy and a steroid for his pyrexia. He is on follow-up. Conclusion: FNAC is a safe, quick, easy and economical technique to diagnose and stage HCC in the presence of portal vein thrombus, especially in patients where the tumor is occult on imaging. It also affords an accurate method to differentiate between malignant and nonmalignant PVT, thereby aiding appropriate therapeutic decision making. [Arch Clin Exp Surg 2014; 3(2.000): 129-132]
Published: 2014
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7. Impact of Perioperative Enteral Immunonutrition on Infectious Complications After Major Gastrointestinal Surgery

Author: Senthil Kumar Perumal, Ashwin Rammohan, J Sateesh, Jeswanth Sathyanesan, and Ravichandran Palaniappan
Subjects: Immunonutrition, enteral nutrition, perioperative nutrition, infectious complications, postoperative complications, Surgery, RD1-811
Abstract: Objective: To study the impact of perioperative, enterally administered whey protein concentrate on infectious complications after major elective gastrointestinal surgery in a tertiary care hospital. Materials and Methods: Prospective non-randomized study conducted from June 2008 and ndash;April 2010, which included 50 consecutive patients who underwent major elective gastrointestinal surgery for benign and malignant diseases. The primary outcome measured was the rate of infectious complications, and the secondary outcome was length of postoperative stay. Results: 50 patients were divided into two equal groups: Group 1 and Group 2 (n=25 each). One group received immune-enhanced enteral nutrition (IMEN) perioperatively, and the control group received standard enteral nutrition (SEN) during the same period. There were no significant differences between the two groups with regard to complications (P=0.26), either infective (P=0.76) or non-infective (P=0.65). There was no significant difference in the duration of postoperative stay (P=0.25) between the two groups. There was also no significant difference in the pre- and postoperative White Blood Cell (WBC) count, C-Reactive Protein (CRP), and albumin levels. However, a subgroup analysis carried out to identify malnourished patients in the immunonutrition group revealed significant reduction in the length of postoperative stay (P=0.03) but not the rate of infectious complications (P=0.20). Conclusion: Perioperatively administered immunonutrition did not decrease the incidence of postoperative infectious complications and the duration of postoperative stay. Malnourished patients given immunonutrition in the perioperative period showed a significant reduction in the length of postoperative hospital stay but not the incidence of infective complications. [Arch Clin Exp Surg 2014; 3(1.000): 16-25]
Published: 2014
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8. Two-port vs. three-port laparoscopic appendicectomy: A bridge to least invasive surgery

Author: Ashwin Rammohan, Paramaguru Jothishankar, A B Manimaran, and R M Naidu
Subjects: Laparoscopic appendicectomy, two-port appendicectomy, two port vs. three port, Surgery, RD1-811, Diseases of the digestive system. Gastroenterology, RC799-869
Abstract: Introduction: The conventional three-port technique for laparoscopic appendicectomy has proven its worth in the management of appendicular pathologies. From a cosmetic viewpoint, the umbilical and suprapubic port-sites are hidden by natural camouflages, the right Iliac fossa (RIF) port is the only visible external sign of surgery. The two-port technique avoids even this marker of abdominal invasion. In this study, we describe the technique of two-port laparoscopic appendicectomy (TPA) and compare it with conventional laparoscopic appendicectomy (CLA). Materials and Methods: All patients studied underwent operation for acute appendicitis during a 6-month period. Data were collected prospectively for the TPA and retrospectively for the CLA. The TPA was performed with one 10 mm umbilical working port and one 5 mm suprapubic camera port. A hypodermic needle was introduced in the RIF to retract the appendix. The appendicular artery was controlled with diathermy or ultrasonic shears. The base was ligated with a loop knotted extracorporeally. CLA was performed via the conventional 10 mm umbilical, 5 mm suprapubic and 5 mm RIF ports. The appendicular stump was ligated with an endoloop or an intracorporeal knot. Results: A total of 146 patients underwent surgery over the 6-month period for appendicitis. Out of 62 cases attempted, the TPA was successful in 51 cases, with conversion to the three-port technique in 11. The operative time, complication rates, return to work were comparable between the two groups. Patients who had TPA had a shorter postoperative stay. Conclusion: This is an initial experience with TPA. There is little difference in the operative time, postoperative stay and complications rates between this technique and the conventional three-port one. There is hence little to be lost and a likely benefit to be gained by performing the TPA although a randomised study is necessary.
Published: 2012
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9. Episodic Biliary Obstruction: Intrahepatic Biliary Cystadenoma

Author: Ashwin Rammohan, Jeswanth Sathyanesan, and Ravichandran Palaniappan
Subjects: Cystadenoma, jaundice, liver, mucinous, Surgery, RD1-811
Abstract: Biliary cystadenomas are rare, benign but potentially malignant, multilocular, cystic neoplasms of a biliary origin. They often present with non-specific symptoms. We present a rare case of an intrahepatic biliary cystadenoma causing luminal obstruction to the bile duct. Case report: A 32-year-old female with obstructive jaundice was evaluated and diagnosed as having a cystic lesion in the liver. With a preoperative differential diagnosis of a hydatid cyst, she underwent laparotomy and enucleation of the lesion. Intraoperatively, the tumor was found to be extending into the bile duct, which was occluding the lumen. This was excised and a bilioenteric anastomosis was done. Her postoperative period was uneventful and she was anicteric on follow-up. Conclusion: Biliary cystadenoma should be considered a differential diagnosis when radiologic imaging studies suggest a multilocular cystic hepatic lesion. Presence of jaundice in such patients should raise the suspicion of an intrabiliary component, the omission of which can lead to avoidable postoperative morbidity. [Arch Clin Exp Surg 2014; 3(4.000): 251-253]
Published: 2014
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10. Xanthogranulomatous Cholecystitis Masquerading as Gallbladder Cancer: Can It Be Diagnosed Preoperatively?

Author: Ashwin Rammohan, Sathya D. Cherukuri, Jeswanth Sathyanesan, Ravichandran Palaniappan, and Manoharan Govindan
Subjects: Diseases of the digestive system. Gastroenterology, RC799-869
Abstract: Background. Xanthogranulomatous cholecystitis (XGC) is often misdiagnosed as gallbladder cancer (GBC). We aimed to determine the preoperative characteristics that could potentially aid in an accurate diagnosis of XGC masquerading as GBC. Methods. An analysis of patients operated upon with a preoperative diagnosis of GBC between January 2008 and December 2012 was conducted to determine the clinical and radiological features which could assist in a preoperative diagnosis of XGC. Results. Out of 77 patients who underwent radical cholecystectomy, 16 were reported as XGC on final histopathology (Group A), while 60 were GBC (Group B). The incidences of abdominal pain, cholelithiasis, choledocholithiasis, and acute cholecystitis were significantly higher in Group A, while anorexia and weight loss were higher in Group B. On CT, diffuse gallbladder wall thickening, continuous mucosal line enhancement, and submucosal hypoattenuated nodules were significant findings in Group A. CT findings on retrospect revealed at least one of these findings in 68.7% of the cases. Conclusion. Differentiating XGC from GBC is difficult, and a definitive diagnosis still necessitates a histopathological examination. An accurate preoperative diagnosis requires an integrated review of clinical and characteristic radiological features, the presence of which may help avoid radical resection and avoidable morbidity in selected cases.
Published: 2014
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11. Diffuse Reflectance Spectroscopy for The Assessment of Steatosis in Liver Phantom and Liver Donors - A Pilot Study.

Author: Allwyn S. Rajamani, J. Kuzhandai Shamlee, Ashwin Rammohan, V. V. R. Sai, and Mohamed Rela
Published: 2022
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12. Post-COVID-19 cholangiopathy: Current understanding and management options

Author: Fadl H Veerankutty, Kushan Sengupta, Mukul Vij, Ashwin Rammohan, Dinesh Jothimani, Ananthavadivelu Murali, and Mohamed Rela
Subjects: General Earth and Planetary Sciences, General Environmental Science
Published: 2023

13. Proceedings of the 27th Annual Congress of the International Liver Transplantation Society

Author: Isabel Campos-Varela, Ashwin Rammohan, Ryan Chadha, Felipe Alconchel, Abdul R. Hakeem, Johns S. Mathew, Nicolas Goldaracena, Nicholas Syn, Sadhana Shankar, Dhupal Patel, Onur Keskin, Jiang Liu, David Nasralla, Alessandra Mazzola, Alexandra Shingina, Michael Spiro, Madhukar S. Patel, Tomohiro Tanaka, David Victor, Uzung Yoon, Young-in Yoon, Tamer Shaker, Carmen Vinaixa, Varvara A. Kirchner, and Eleonora De Martin
Subjects: Transplantation
Published: 2023

14. Pathologic and Immunophenotypic Characterization of Syncytial Giant Cell Variant of Pediatric Hepatocellular Carcinoma. A Distinct Subtype

Author: Mukul Vij, Jagadeesh Menon, Komalavalli Subbiah, Lexmi Priya Raju, Gowripriya Gowrisankar, Naresh Shanmugum, Ilankumaran Kaliamoorthy, Ashwin Rammohan, and Mohamed Rela
Subjects: Pediatrics, Perinatology and Child Health, General Medicine, Pathology and Forensic Medicine
Published: 2023

15. Significance of nucleologenesis, ribogenesis, and nucleolar proteome in the pathogenesis and recurrence of hepatocellular carcinoma

Author: Subathra Radhakrishnan, Catherine Ann Martin, Ashwin Rammohan, Mukul Vij, Mani Chandrasekar, and Mohamed Rela
Subjects: Hepatology, Gastroenterology
Published: 2023

16. Graft-Versus-Host Disease in Pediatric Living Donor Liver Transplant

Author: Joseph J. Valamparampil, G. Vimal Kumar, Naresh Shanmugam, Mukul Vij, Deenadayalan Munirathnam, Ashwin Rammohan, and Mohamed Rela
Subjects: Transplantation
Published: 2022

17. First report of auxiliary liver transplantation for severe cholangiopathy after SARS-CoV-2 respiratory infection

Author: Mohamed Rela, Muthukumarassamy Rajakannu, Fadl H. Veerankutty, Mukul Vij, and Ashwin Rammohan
Subjects: Transplantation, Immunology and Allergy, Pharmacology (medical)
Published: 2022

18. Current perspectives on the role of liver transplantation for Langerhans cell histiocytosis: A narrative review

Author: Jagadeesh, Menon, Ashwin, Rammohan, Mukul, Vij, Naresh, Shanmugam, and Mohamed, Rela
Subjects: End Stage Liver Disease, Histiocytosis, Langerhans-Cell, Cholangitis, Sclerosing, Gastroenterology, Humans, General Medicine, Liver Transplantation
Abstract: Langerhans cell histiocytosis (LCH) is a malignant disease of the histiocytes involving various organ systems. The spectrum of liver involvement in LCH ranges from mild transaminitis to end-stage liver disease. The hallmark of hepatic LCH is secondary sclerosing cholangitis, which manifests due to a progressive destruction of the biliary tree by malignant histiocytes. Chemotherapy remains the mainstay of treatment for active LCH. Early recognition, diagnosis and a systematic approach to the management of LCH can ameliorate the disease process. Nonetheless, the liver involvement in these patients may progress despite the LCH being in remission. Liver transplantation (LT) remains central in the management of such patients. Various facets of the management of LCH, especially those with liver involvement remain unclear. Furthermore, aspects of LT in LCH with regards to the indication, timing and post-LT management, including immunosuppression and adjuvant therapy, remain undefined. This review summarises the current evidence and discusses the practical aspects of the role of LT in the management of LCH.
Published: 2022

19. Liver transplantation in tight junction protein‐2 deficiency associated liver disease

Author: Jagadeesh Menon, Naresh Shanmugam, Mukul Vij, Ashwin Rammohan, and Mohamed Rela
Subjects: Transplantation, Tight Junction Proteins, Hepatology, Liver Diseases, Humans, Surgery, Zonula Occludens-2 Protein, Liver Transplantation
Published: 2022

20. Anatomical variations of left hepatic vein and outflow reconstruction techniques in pediatric living donor liver transplantation

Author: Sadhana Shankar, Ashwin Rammohan, Vasanthakumar Gunasekaran, Gomathy Narasimhan, Rajesh Rajalingam, Kumar Palaniappan, Rathnavel Kanagavelu, Akila Rajkumar, Ilankumaran Kaliamoorthy, and Mohamed Rela
Subjects: Transplantation, Immunology and Allergy, Pharmacology (medical)
Published: 2023

21. Nonalcoholic Steatohepatitis: A Rapidly Increasing Indication for Liver Transplantation in India

Author: Akila Rajakumar, Ilankumaran Kaliamoorthy, Ashwin Rammohan, Kumar Palaniappan, Mohamed Rela, Rajesh Rajalingam, Dinesh Jothimani, Silas Danielraj, Gomathy Narasimhan, Swetha Palanisamy, and Hemalatha Ramachandran
Subjects: medicine.medical_specialty, Hepatology, business.industry, medicine.medical_treatment, Fatty liver, Prevalence, Hepatitis C, Hepatitis B, Liver transplantation, medicine.disease, Gastroenterology, digestive system diseases, Internal medicine, medicine, Original Article, Steatohepatitis, business, Viral hepatitis, Survival analysis
Abstract: BACKGROUND AND AIMS: Recently, there has been a considerable increase in patients with nonalcoholic fatty liver disease. Availability of high-efficacy drugs for hepatitis B and hepatitis C virus (HCV) infection may have changed the disease prevalence. We aimed to study the impact of this changing epidemiology in patients undergoing liver transplantation (LT) over a 10-year period. METHODS: The study population was stratified into Period 1 (2009–2014) and Period 2 (2015–2019). Demographics, indications for LT and changes in the epidemiology between two periods were analysed. Aetiology-based posttransplant survival analysis was carried out. RESULTS: Indication for LT among 1017 adult patients (277 in Period 1 and 740 in Period 2) showed a significant increase in nonalcoholic steatohepatitis (NASH; 85 [30.7%] and 311 [42%]; P = 0.001), decrease in hepatitis C (49 [17.7%] and 75 [10.1%]; P = 0.002), and increase in hepatocellular carcinoma from Period 1 to Period 2 (13 [26.5%] to 38 [50.7%]; P = 0.009) among HCV patients. Patients transplanted for NASH had a lower 5-year survival compared with viral hepatitis (75.9% vs 87.4%; P = 0.03). There was a strong association between coronary artery disease and NASH (hazard ratio = 1.963, 95% confidence interval, 1.19–3.22). CONCLUSION: NASH is the leading indication for liver transplantation in India, surpassing viral hepatitis in recent years.
Published: 2022

22. Global impact of the first wave of COVID-19 on liver transplant centers: A multi-society survey (EASL-ESOT/ELITA-ILTS)

Author: Ashwin Rammohan, Manhal Izzy, Varvara A. Kirchner, Marina Berenguer, Tommaso Di Maira, Francesco Paolo Russo, Luca S. Belli, Wojciech G. Polak, Thomas Berg, and Surgery
Subjects: Tissue and Organ Procurement, Waiting Lists, Coronavirus disease 2019 (COVID-19), Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), medicine.medical_treatment, Liver transplantation, Global Health, Article, Liver disease, Pandemic, Living Donors, Humans, Medicine, survey, Prospective Studies, Organ donation, COVID, Immunosuppression Therapy, Sars-Cov-2, Hepatology, business.industry, Donor selection, COVID, Liver Transplantation, Sars-Cov-2, pandemic, survey, pandemic, COVID-19, Liver Transplantation, medicine.disease, Telemedicine, Organ procurement, Cross-Sectional Studies, business, Demography
Abstract: Background and Aims The global impact of SARS-CoV-2 on liver transplantation (LT) practices across the world is unknown. The goal of this survey was to assess the impact of the pandemic on global LT practices. Method A prospective web-based survey (available online from 7th September 2020 to 31st December 2020) was proposed to the active members of the EASL-ESOT/ELITA-ILTS in the Americas (including North, Central, and South America) (R1), Europe (R2), and the rest of the world (R3). The survey comprised four parts concerning the transplant processes, therapy, living donor, and organ procurement. Results Of the 470 transplant centers reached, 128 answered each part of the survey, 29 centers (23%), 64 centers (50%), and 35 centers (27%) from R1, R2, and R3, respectively. When we compared the practices during the first six months of the pandemic in 2020 with that a year earlier in 2019, statistically significant differences were found in the number of patients added to the waiting list (WL), the number of WL mortality, and the number of transplantations. At the regional level, we found that in R2 the number of LTs was significantly higher in 2019 (p < 0.01), while R3 had more patients listed, higher WL mortality, and more LTs performed before the pandemic. Countries severely affected by the pandemic (“hit” countries) had a lower number of WL patients (p = 0.009) and LT (p = 0.002) during the pandemic. Interestingly, WL mortality was higher in the pandemic in “non-hit” countries (p = 0.022) compared to 2019. Conclusion The first wave of the pandemic differentially impacted LT across the world, especially with detrimental effects on the “hit” countries. The modifications in the policies for recipient and donor selection, organ retrieval, and postoperative recipient management were adopted at a regional or national level. Lay summary The health emergency caused by the Coronavirus has dramatically changed clinical practice during the pandemic. The first wave of pandemic impacted Liver Transplantation across the world differently, especially with detrimental effects on the hit countries. The resilience of the entire transplant network has enabled the support of organ donations and transplants to ultimately improve the lives of patients with end-stage liver disease., Graphical abstract
Published: 2022

23. Total Internal Biliary Diversion for Post–Liver Transplant PFIC-1–Related Allograft Injury

Author: Ashwin Rammohan, Mohamed Rela, Jagadeesh Menon, Rajesh Rajalingam, Mukul Vij, and Naresh Shanmugam
Subjects: medicine.medical_specialty, Hepatology, medicine.diagnostic_test, business.industry, medicine.medical_treatment, Progressive familial intrahepatic cholestasis, Case Report, Liver transplantation, medicine.disease, Asymptomatic, Surgery, 03 medical and health sciences, 0302 clinical medicine, 030220 oncology & carcinogenesis, Liver biopsy, medicine, 030211 gastroenterology & hepatology, Liver function, medicine.symptom, Steatohepatitis, business, Emaciation, Enterohepatic circulation
Abstract: Steatohepatitis and diarrhea are well-known complications in children undergoing liver transplantation (LT) for progressive familial intrahepatic cholestasis (PFIC) type 1. Despite medical management with bile acid binders, the condition is progressive and can be associated with allograft loss. We report the case of a seven-year-old boy who underwent LT at the age of 2 years for PFIC type 1. Over the next five years, he developed refractory diarrhea, emaciation, worsening liver function, and steatohepatitis. Aiming to interrupt the enterohepatic circulation, at the age of 7 years, he underwent a total internal biliary diversion. The patient's postprocedure period was uneventful. His diarrhea settled and the transaminases normalized his follow-up liver biopsy after a year showed a complete resolution of steatohepatitis. At 18 months' follow-up, he has gained weight and remains asymptomatic. In this report, we show post-LT complications especially allograft injury related to the pathology of PFIC-1 can be safely and effectively managed by performing a total internal biliary diversion.
Published: 2022

24. ABO-Incompatible Living Donor Liver Transplant From a Blood Type A2 Donor to a Type B Recipient: A Note of Caution

Author: Yogesh Puri, Deepti Sachan, Mohamed Rela, Ashwin Rammohan, and Mukul Vij
Subjects: Blood type, Transplantation, medicine.medical_specialty, business.industry, medicine.medical_treatment, Splenectomy, Immunosuppression, Gastroenterology, Regimen, Immune system, Refractory, Internal medicine, Donation, ABO blood group system, medicine, business
Abstract: Standardization of immunomodulation protocols has enabled ABO-incompatible liver transplants with outcomes similar to those of ABO-compatible liver transplants. Patients with the A2 blood group are unique because they have a diminished expression of the A antigen. Despite rare immune complications, this phenomenon of diminished expression has led to treatment of type A2 donors according to the regimen for type O blood group donors in ABO-incompatible liver transplants. Additionally, the requirement for pretransplant recipient immunomodulation is consi dered minimal when considering these donors. The transplant of a type A2 donor kidney to a type B recipient is well recognized; however, for liver donation the A2-to-B transplant is rare. Here, we present a case of 48-year-old male patient with blood group type B who underwent ABO-incompatible liver transplant of a right lobe liver graft from a type A2 donor. Postoperatively, despite adequate immunosuppression and initiation of thera - peutic plasma exchange, the patient developed severe and refractory antibody-mediated rejection that ultimately abated with a splenectomy. This report highlights the low but tangible risk of antibody-mediated rejection in ABO-incompatible liver transp lants from type A2 donors and emphasizes the importance of serial monitoring of anti-A isohemag glutinin titers and posttransplant splenectomy to ensure that liver grafts with antibody-mediated rejection can be rescued.
Published: 2022

25. Mature Cystic Teratoma of the Gall Bladder Masquerading a 'Hepatic Space Occupying Lesion'

Author: Jagadeesh Menon, Naresh Shanmugam, Shamnad Madathil, Mukul Vij, Ashwin Rammohan, and Mohamed Rela
Subjects: Oncology, Pediatrics, Perinatology and Child Health, Hematology
Published: 2023

26. Why are there so many liver transplants from living donors in Asia and so few in Europe and the US?

Author: Ashwin Rammohan and Mohamed Rela
Subjects: 0301 basic medicine, medicine.medical_specialty, Asia, Tissue and Organ Procurement, medicine.medical_treatment, Economic shortage, Liver transplantation, Liver transplants, Extended criteria, Living donor, 03 medical and health sciences, Liver disease, 0302 clinical medicine, Living Donors, medicine, Humans, Intensive care medicine, Machine perfusion, Hepatology, business.industry, Donation after cardiac death, medicine.disease, United States, Liver Transplantation, Europe, 030104 developmental biology, 030211 gastroenterology & hepatology, business
Abstract: Summary Acceptance of liver transplantation (LT) as an established treatment modality for end-stage liver disease has led to an exponential increase in the demand for organs, resulting in an ever-increasing gap between the availability of organs and the number of sick patients waiting for them. Interestingly, influenced by cultural, socio-economic and other constraints, the West and the East have attempted to address this problem of shortage in different ways. Living donor LT (LDLT) became polarised to the East with over 90% of LT in this region being LDLT. On the other hand, the West chose to concentrate their efforts on optimising the use of cadaveric livers with techniques such as split LT, or by using extended criteria donors (including donation after cardiac death donors) and machine perfusion devices etc. Consequently, LDLT did not find the widespread acceptance it did in the East and hence over 90% of all LT are DDLT in this region. We review each regions’ perspective and attempt to provide a globally viable roadmap to bridge the widening gap between the demand and availability of livers for LT.
Published: 2021

27. Liver Transplantation for Rapidly Progressive Giant Hepatic Hemangioma With Diffuse Hemangiomatosis

Author: Sadhana Shankar, Rathnavel G Kanagavelu, Mettu Srinivas Reddy, Ashwin Rammohan, Venugopal H Kulaseharan, and Mohamed Rela
Subjects: Hepatic Hemangioma, Transplantation, Chemotherapy, Deceased donor, medicine.medical_specialty, business.industry, medicine.medical_treatment, Arterial Embolization, Usually asymptomatic, Giant Hemangioma, Liver transplantation, Consumptive Coagulopathy, medicine, Radiology, business
Abstract: Cavernous hemangiomas are the most common benign tumors of the liver and are usually asymptomatic. On the other hand, giant hemangioma and diffuse hepatic hemangiomatosis may become symptomatic by causing compression on adjacent structures, rupture, or consumptive coagulopathy. The coexistence of these 2 entities in an adult is extremely rare, and the literature, especially on their management, is sparse. We report the case of a young woman who developed a rapidly growing recurrent giant hemangioma and diffuse hepatic hemangiomatosis with significant pressure effects, raising the suspicion of a malignant tumor. She had previously undergone a liver resection and an aborted attempt at liver transplant elsewhere. As a preoperative measure, with an aim to shrink the tumor, she underwent arterial embolization and chemotherapy. After this procedure, she underwent deceased donor liver transplant. Her postoperative period was uneventful, and she was well at her 6-month follow-up. We highlight the challenges involved and the need for a multidisciplinary approach in managing these lesions. Liver transplant is an excellent option for patients who develop life-threatening complications or poor quality of life due to these benign liver tumors.
Published: 2021

28. Technique of Hepatic Artery Anastomosis in Living Donor Liver Transplantation: Review of Its Results in Over 1200 Adult and Pediatric Transplants

Author: Muthukumarassamy Rajakannu, Jasper Sandeep Rajasekar, Ramkiran Cherukuru, Ashwin Rammohan, and Mohamed Rela
Subjects: Surgery
Abstract: Failure to achieve a good arterial inflow to the graft in living donor liver transplantation (LDLT) has disastrous consequences to the graft and patient survival. Standard microvascular techniques of hepatic artery (HA) anastomosis used in deceased donor liver transplantation are not applicable in LDLT. We present the results of our unique Backwall-first technique of HA anastomosis in both adult and pediatric LDLT.Retrospective review of all consecutive patients who underwent LDLT from January 2010 to December 2020 was performed from our prospective database. Data with regard to early postoperative (90-day) hepatic arterial complications were analyzed.A total of 1276 LDLTs (876 adults, 400 children) were performed during the study period. In the 90-day postoperative period, HA anastomotic complications [thrombosis in 11 (0.9%); pseudoaneurysm in 3 (0.2%)] were observed in 14 recipients (1.1%) including 8 adults (0.9%) and 6 children (1.5%). Eight of these 14 recipients (0.6%) including 4 adults (0.5%) and 4 children (1%) had standard HA reconstruction. The remaining six (0.5%) including 4 adults and 2 children had complex arterial reconstruction with interposition graft and/or alternative arterial inflow.The Backwall-first technique of HA reconstruction described in this study achieved a very low HA complication rate in LDLT.
Published: 2022

29. Managing recurrent portal steal in auxiliary liver transplantation for non‐cirrhotic metabolic liver disease

Author: Anu K. Vasudevan, Naresh P. Shanmugam, Ashwin Rammohan, and Mohamed Rela
Subjects: Transplantation, Pediatrics, Perinatology and Child Health
Published: 2022

30. Outcomes of liver transplantation in children with Langerhans cell histiocytosis: Experience from a quaternary care center

Author: Jagadeesh Menon, Naresh Shanmugam, Joseph Valamparampil, Mukul Vij, Vimal Kumar, Deenadayalan Munirathnam, Abdul Hakeem, Ashwin Rammohan, and Mohamed Rela
Subjects: Male, Liver Cirrhosis, Histiocytosis, Langerhans-Cell, Oncology, Recurrence, Child, Preschool, Pediatrics, Perinatology and Child Health, Humans, Infant, Hematology, Child, Liver Transplantation, Retrospective Studies
Abstract: Langerhans cell histiocytosis (LCH) is a rare but important cause of end-stage liver disease in children. Conventional chemotherapeutic agents that are otherwise the standard-of-care in LCH may be counterproductive in patients with hepatic decompensation. Furthermore, the precise role of liver transplantation (LT) in the management of LCH remains unclear.Review of a prospectively collected database (January 2014 to December 2020) of children with liver disease was performed. All clinical details of patients with LCH managed at our center were collected and data analyzed. Based on the outcomes, a management algorithm was proposed.Of the eight (five male) patients referred to our unit, six (75%) underwent LT (four and two for compensated and decompensated cirrhosis, respectively). Median age at diagnosis of LCH was 25 (range: 9-48) months. Two patients, who had previously completed LCH-specific chemotherapy, underwent upfront LT for compensated cirrhosis. Other two patients with compensated cirrhosis showed evidence of active disease. They underwent LT following completion of chemotherapy. Two children with decompensated cirrhosis also had evidence of active disease and were started on modified chemotherapy Both of them had progression of liver disease while on chemotherapy. Hence, an urgent LT was performed which was followed by completion of chemotherapy in these patients. On a median follow-up of 30.5 (10.5-50) months, all post-LT patients were alive with stable graft function and showed no disease recurrence.We demonstrate that an algorithmic approach, along with newer chemotherapeutic agents, results in excellent outcomes in LCH patients with liver involvement. Larger multicentric studies on this rare disease are, however, needed to validate our findings.
Published: 2022

31. Outcomes of liver transplantation in recipients with previous coronavirus disease 2019 infection

Author: Akila Rajakumar, Susan Paulin, Premchandar Velusamy, Vidya Devarajan, Dinesh Jothimani, Rajesh Rajalingam, Ashwin Rammohan, and Mohamed Rela
Subjects: Transplantation, Hepatology, SARS-CoV-2, COVID-19, Humans, Surgery, Transplant Recipients, Liver Transplantation
Published: 2022

32. Pediatric metabolic liver diseases: Evolving role of liver transplantation

Author: Deepti Sachan, Ilankumaran Kaliamoorthy, Naresh Shanmugam, Mohamed Rela, Ashwin Rammohan, Mukul Vij, and Jagadeesh Menon
Subjects: Auxiliary liver transplant, medicine.medical_specialty, Cirrhosis, medicine.medical_treatment, 030232 urology & nephrology, Review, 030230 surgery, Liver transplantation, Gastroenterology, Urea cycle disorders, Tyrosinemia, 03 medical and health sciences, Liver disease, 0302 clinical medicine, Cholestasis, Fibrosis, Internal medicine, Pathology, medicine, Glycogen storage diseases, Contraindication, Wilson disease, Transplantation, business.industry, Metabolic liver disease, medicine.disease, Steatosis, business
Abstract: Metabolic liver diseases (MLD) are the second most common indication for liver transplantation (LT) in children. This is based on the fact that the majority of enzymes involved in various metabolic pathways are present within the liver and LT can cure or at least control the disease manifestation. LT is also performed in metabolic disorders for end-stage liver disease, its sequelae including hepatocellular cancer. It is also performed for preventing metabolic crisis’, arresting progression of neurological dysfunction with a potential to reverse symptoms in some cases and for preventing damage to end organs like kidneys as in the case of primary hyperoxalosis and methyl malonic acidemia. Pathological findings in explant liver with patients with metabolic disease include unremarkable liver to steatosis, cholestasis, inflammation, variable amount of fibrosis, and cirrhosis. The outcome of LT in metabolic disorders is excellent except for patients with mitochondrial disorders where significant extrahepatic involvement leads to poor outcomes and hence considered a contraindication for LT. A major advantage of LT is that in the post-operative period most patients can discontinue the special formula which they were having prior to the transplant and this increases their well-being and improves growth parameters. Auxiliary partial orthotopic LT has been described for patients with noncirrhotic MLD where a segmental graft is implanted in an orthotopic position after partial resection of the native liver. The retained native liver can be the potential target for future gene therapy when it becomes a clinical reality.
Published: 2021

33. Changing Indication for Liver Transplantation: 10 Year Study

Author: Srividya Manjunath, Swetha Palanichamy, Dinesh Jothimani, Silas Danielraj, Rajesh Rajalingam, Ashwin Rammohan, Akila Rajkumar, Gomathy Narasimhan, and Mohamed Rela
Subjects: Hepatology
Published: 2022

34. Neurological complications in pediatric liver transplant recipients

Author: Jagadeesh Menon, Naresh Shanmugam, Ashwin Rammohan, Abdul Hakeem, Mettu Srinivas Reddy, and Mohamed Rela
Subjects: Transplantation, Postoperative Complications, Risk Factors, Seizures, Hepatic Encephalopathy, Pediatrics, Perinatology and Child Health, Humans, Child, Tacrolimus, Liver Transplantation, Retrospective Studies
Abstract: There is paucity of data on neurological complications (NCs) and its predisposing factors, in pediatric liver transplant (PLT) recipients.Records of seventy-one children who underwent LT between October 2018 and November 2019 were reviewed. Patients were categorized into group A: with NC and group B: without NC in the post-LT period. Various risk factors contributing to NC were studied.In total, 15 (21.1%) had NC (group A) and 56 (78.9%) had no NC in the post-LT period. NC included cerebrovascular accident (n = 1), seizures (n = 5; 4 generalized, 1 focal), central pontine myelolysis (CPM) (n = 1), diaphragmatic palsy (n = 2), peripheral neuropathy (n = 1), extrapyramidal movements (n = 3), and encephalopathy beyond 96 h (n = 2). The median onset of NC was at 8.5 days post-LT (1-58 days). Ten (66.7%) patients in group A had grades 2-4 hepatic encephalopathy (HE) prior to LT. Eight (14.3%) patients in group B also had pre-LT neurological issues including HE in six, epilepsy and spastic diplegia in one each. On univariate analysis, pre-existing HE, high PELD/MELD score, pre-LT ventilation, pre-LT infection, higher day 1 post-operative bilirubin (all p .05), and higher tacrolimus were found to predict post-operative NC whereas on multivariate analysis, pre-LT HE was the only predictive factor. Median follow-up was 15.5 months. Four patients died in each group (survival log-rank p = .369). All the surviving patients in group A (n = 11) fully recovered from the NC.Pre-transplant HE was the single most significant predisposing factor for post-LT neurological complications.
Published: 2022

35. Living Liver Donation in Adults

Author: Mohamed Rela and Ashwin Rammohan
Subjects: medicine.medical_specialty, Ethical issues, business.industry, medicine.medical_treatment, Donation, Medicine, DONOR EVALUATION, Liver transplantation, business, Intensive care medicine
Published: 2021

36. Distal Gastroduodenal Arterial Inflow as a Salvage Strategy for Extensive Intraoperative Arterial Dissection in Living Donor Liver Transplantation

Author: Pradeep Krishna, Guruprasad Shetty, Mettu Srinivas Reddy, Ramkiran Cherukuru, Mohamed Rela, and Ashwin Rammohan
Subjects: Arterial inflow, Transplantation, medicine.medical_specialty, Hepatology, Arterial dissection, business.industry, Dissection, medicine.medical_treatment, Liver transplantation, Liver Transplantation, Surgery, Hepatic Artery, Living Donors, medicine, Humans, Living donor liver transplantation, business
Published: 2021

37. Enlightening Young Minds: A Small Step in the Curriculum, a Giant Leap in Organ Donation—A Survey of 996 Respondents on Organ Donation and Transplantation

Author: Mettu Srinivas Reddy, Ashwin Rammohan, Pradez Sapkota, Vasanthi Ramesh, Abdul Rahman Hakeem, Gokula Priya, Gomathy Narasimhan, and Mohamed Rela
Subjects: Transplantation, Medical education, business.industry, MEDLINE, Medicine, Organ donation, business, Curriculum
Published: 2021

38. Prognostic impact of incidentally detected hepatocellular carcinoma in explanted livers after living donor liver transplantation

Author: Taheer Mobin Ahmed Shaikh, Mettu Srinivas Reddy, Mohamed Rela, Mukul Vij, Ashwin Rammohan, and Muthukumarassamy Rajakannu
Subjects: Male, medicine.medical_specialty, Carcinoma, Hepatocellular, Cirrhosis, medicine.medical_treatment, Transplants, Liver transplantation, Milan criteria, Chronic liver disease, 03 medical and health sciences, Postoperative Complications, 0302 clinical medicine, Risk Factors, Internal medicine, Living Donors, medicine, Carcinoma, Humans, Prospective Studies, Retrospective Studies, Incidental Findings, business.industry, Liver Neoplasms, Gastroenterology, Middle Aged, Hepatology, Prognosis, medicine.disease, Liver Transplantation, Surgery, Survival Rate, Liver, 030220 oncology & carcinogenesis, Hepatocellular carcinoma, Female, 030211 gastroenterology & hepatology, Neoplasm Recurrence, Local, business, Liver cancer
Abstract: The impact of incidentally detected hepatocellular carcinoma (iHCC) in explanted liver on the prognosis of the patients undergoing orthotopic liver transplantation remains controversial with several studies reporting survival worse than true non-hepatocellular carcinoma (non-HCC) recipients. Patients undergoing living donor liver transplantation (LDLT) have the benefit of a shorter waiting time to transplant which in principle should reduce the frequency of new tumors developing while waiting for transplant. We aimed to evaluate the incidence, histopathological features, and impact of iHCC on short- and long-term outcomes in adult LDLT recipients. The present study retrospectively analyzed the patients’ demographics, tumor characteristics, and outcomes of iHCC in adult patients undergoing LDLT for non-HCC indications at our center between August 2009 and March 2018. Five hundred and forty-five adults underwent LDLT in our center during the study period. iHCC was detected in the explanted livers in 28 patients (5.1%) out of 545 LDLTs. Only one patient had iHCC beyond Milan criteria. No tumor recurrence was observed in the iHCC cohort after a median follow-up of 28 months. Five-year overall and recurrence-free survival was 96.4%. Incidence of iHCC in explanted livers after LDLT is low and most patients have very early-stage tumors with excellent recurrence-free survival. Hence, no specific post-transplant surveillance or treatment is necessary.
Published: 2021

39. The COVID-19 Pandemic and Its Effect on the Mental Health of Doctors in India

Author: Abdul Rahman Hakeem, Amritha Nair, Ashwin Rammohan, Jagadeesh Menon, Mohamed Rela, Sathya D. Cherukuri, and Mettu Srinivas Reddy
Subjects: Coronavirus disease 2019 (COVID-19), business.industry, Environmental health, Pandemic, Medicine, General Medicine, Risk factor (computing), business, Mental health
Abstract: Background and Objectives: For doctors at the forefront of the COVID-19 pandemic, failure to acknowledge and act on the warning signs of stress can adversely affect their professional, social and personal life. We conducted a nationwide survey of a large sample of Indian doctors to measure levels of perceived stress, identify risk factors for severe stress and assess their response to current issues related to the safety and well-being of the community. Methods: An online survey using Google forms was conducted between 1st May 2020 and 15th May 2020. The core component of the survey was the standardized Perceived Stress Scale answered on a Likert scale. Results: Out of 520 responders, 394 (76%) were under 45 years of age 101 (19%) were between 18-30 years and 37 (7%) were above 60 years. 312(60%) were male doctors and 203 (40%) were female doctors. 90% of respondents had a post-graduate degree, 48(9%) had undergraduate degree and 168(32%) had super specialty degree. 313 (60.2%) of the respondents were practising in the private sector, 169 (33%) worked in public sector hospitals and 32(7%) in charitable hospitals. 109 (21%) had low stress, while 371 (71%) and 40 (8%) reported moderate and severe stress respectively. Multivariate analysis revealed the female gender, being financially insecure and ICU a place of work as independent risk factors for severe stress. Conclusion: This is the first such survey done in the context of the COVID-19 pandemic from the Indian sub-continent and has identified factors that have the potential to adversely impact the mental health of doctors. These findings are applicable to many countries in Asia and Africa with similar healthcare systems and can act as a valuable guide for authorities to establish support systems at multiple levels for these “COVID Warriors”.
Published: 2020

40. ATAC-Seq Reveals an Isl1 Enhancer That Regulates Sinoatrial Node Development and Function

Author: Brian L. Black, Ravi Mandla, Hongmei Ruan, Marie B. Shi, Kevin Chang, Giselle Galang, Prasanna K.R. Allu, Brandon J. Mannion, Vasanth Vedantham, Ashwin Rammohan, Len A. Pennacchio, Catherine Jung, Tanvi Sinha, Nicole Stone, and Roland S. Wu
Subjects: Heartbeat, Physiology, Sinoatrial node, medicine.medical_treatment, ATAC-seq, Biology, Cardiac pacemaker, Chromatin, Cell biology, medicine.anatomical_structure, Heart rate, ISL1, medicine, Cardiology and Cardiovascular Medicine, Enhancer
Abstract: Rationale: Cardiac pacemaker cells (PCs) in the sinoatrial node (SAN) have a distinct gene expression program that allows them to fire automatically and initiate the heartbeat. Although critical SAN transcription factors, including Isl1 (Islet-1), Tbx3 (T-box transcription factor 3), and Shox2 (short-stature homeobox protein 2), have been identified, the cis -regulatory architecture that governs PC-specific gene expression is not understood, and discrete enhancers required for gene regulation in the SAN have not been identified. Objective: To define the epigenetic profile of PCs using comparative ATAC-seq (assay for transposase-accessible chromatin with sequencing) and to identify novel enhancers involved in SAN gene regulation, development, and function. Methods and Results: We used ATAC-seq on sorted neonatal mouse SAN to compare regions of accessible chromatin in PCs and right atrial cardiomyocytes. PC-enriched assay for transposase-accessible chromatin peaks, representing candidate SAN regulatory elements, were located near established SAN genes and were enriched for distinct sets of TF (transcription factor) binding sites. Among several novel SAN enhancers that were experimentally validated using transgenic mice, we identified a 2.9-kb regulatory element at the Isl1 locus that was active specifically in the cardiac inflow at embryonic day 8.5 and throughout later SAN development and maturation. Deletion of this enhancer from the genome of mice resulted in SAN hypoplasia and sinus arrhythmias. The mouse SAN enhancer also directed reporter activity to the inflow tract in developing zebrafish hearts, demonstrating deep conservation of its upstream regulatory network. Finally, single nucleotide polymorphisms in the human genome that occur near the region syntenic to the mouse enhancer exhibit significant associations with resting heart rate in human populations. Conclusions: (1) PCs have distinct regions of accessible chromatin that correlate with their gene expression profile and contain novel SAN enhancers, (2) cis -regulation of Isl1 specifically in the SAN depends upon a conserved SAN enhancer that regulates PC development and SAN function, and (3) a corresponding human ISL1 enhancer may regulate human SAN function.
Published: 2020

41. Negative effects of COVID-19 pandemic on adolescent health: Insights, perspectives, and recommendations

Author: Aparajita, Ashwin, Sathya D, Cherukuri, and Ashwin, Rammohan
Subjects: Adolescent, SARS-CoV-2, Health Policy, Adolescent Health, Public Health, Environmental and Occupational Health, COVID-19, Humans, Pandemics
Published: 2022

42. Enhanced recovery for liver transplantation: recommendations from the 2022 International Liver Transplantation Society consensus conference

Author: Joerg M Pollok, Pascale Tinguely, Marina Berenguer, Claus U Niemann, Dimitri A Raptis, Michael Spiro, Andreas Mayr, Beatriz Dominguez, Elmi Muller, Karina Rando, Mary Anne Enoch, Noam Tamir, Pamela Healy, Tanja Manser, Tim Briggs, Abhideep Chaudhary, Abhinav Humar, Ali Jafarian, Arvinder Singh Soin, Bijan Eghtesad, Charles Miller, Daniel Cherqui, Didier Samuel, Dieter Broering, Elizabeth Pomfret, Federico Villamil, Francois Durand, Gabriela Berlakovich, Geoffrey McCaughan, Georg Auzinger, Giuliano Testa, Goran Klintmalm, Jacques Belghiti, James Findlay, Jennifer Lai, John Fung, John Klinck, John Roberts, Linda Liu, Mark Cattral, Mark Ghobrial, Markus Selzner, Michael Ramsay, Mohamed Rela, Nancy Ascher, Nancy Kwan Man, Nazia Selzner, Patrizia Burra, Peter Friend, Ronald Busuttil, Shin Hwang, Stuart McCluskey, Valeria Mas, Vijay Vohra, Vivek Vij, William Merritt, Yaman Tokat, Yoogoo Kang, Albert Chan, Alessandra Mazzola, Amelia Hessheimer, Ashwin Rammohan, Brian Hogan, Carmen Vinaixa, David Nasralla, David Victor, Eleonora De Martin, Felipe Alconchel, Garrett Roll, Gokhan Kabacam, Gonzalo Sapisochin, Isabel Campos-Varela, Jiang Liu, Madhukar S. Patel, Manhal Izzy, Marit Kalisvaart, Megan Adams, Nicholas Goldaracena, Roberto Hernandez-Alejandro, Ryan Chadha, Tamer Mahmoud Shaker, Tarunjeet S. Klair, Terry Pan, Tomohiro Tanaka, Uzung Yoon, Varvara Kirchner, Vivienne Hannon, Yee Lee Cheah, Carlo Frola, Clare Morkane, Don Milliken, Georg Lurje, Jonathan Potts, Thomas Fernandez, Adam Badenoch, Ahmed Mukhtar, Alberto Zanetto, Aldo Montano-Loza, Alfred Kow Wei Chieh, Amol Shetty, Andre DeWolf, Andrea Olmos, Anna Mrzljak, Annabel Blasi, Annalisa Berzigotti, Ashish Malik, Akila Rajakumar, Brian Davidson, Bryan O'Farrell, Camille Kotton, Charles Imber, Choon Hyuck David Kwon, Christopher Wray, Chul-Soo Ahn, Claus Krenn, Cristiano Quintini, Daniel Maluf, Daniel Santa Mina, Daniel Sellers, Deniz Balci, Dhupal Patel, Dianne LaPointe Rudow, Diethard Monbaliu, Dmitri Bezinover, Dominik Krzanicki, Dong-Sik Kim, Elizabeth Brombosz, Emily Blumberg, Emmanuel Weiss, Emmanuel Wey, Fady Kaldas, Faouzi Saliba, Gabriella Pittau, Gebhard Wagener, Gi-Won Song, Gianni Biancofiore, Gonzalo Crespo, Gonzalo Rodríguez, Graciela Martinez Palli, Gregory McKenna, Henrik Petrowsky, Hiroto Egawa, Iman Montasser, Jacques Pirenne, James Eason, James Guarrera, James Pomposelli, Jan Lerut, Jean Emond, Jennifer Boehly, Jennifer Towey, Jens G Hillingsø, Jeroen de Jonge, Juan Caicedo, Julie Heimbach, Juliet Ann Emamaullee, Justyna Bartoszko, Ka Wing Ma, Kate Kronish, Katherine T. Forkin, Kenneth Siu Ho Chok, Kim Olthoff, Koen Reyntjens, Kwang-Woong Lee, Kyung-Suk Suh, Linda Denehy, Luc J.W. van der Laan, Lucas McCormack, Lucy Gorvin, Luis Ruffolo, Mamatha Bhat, María Amalia Matamoros Ramírez, Maria-Carlota Londoño, Marina Gitman, Mark Levstik, Martin de Santibañes, Martine Lindsay, Matteo Parotto, Matthew Armstrong, Mureo Kasahara, Nick Schofield, Nicole Rizkalla, Nobuhisa Akamatsu, Olivier Scatton, Onur Keskin, Oscar Imventarza, Oya Andacoglu, Paolo Muiesan, Patricia Giorgio, Patrick Northup, Paulo Matins, Peter Abt, Philip N Newsome, Philipp Dutkowski, Pooja Bhangui, Prashant Bhangui, Puneeta Tandon, Raffaele Brustia, Raymond Planinsic, Robert Brown, Robert Porte, Rolf Barth, Rubén Ciria, Sander Florman, Sebastien Dharancy, Sher-Lu Pai, Shintaro Yagi, Silvio Nadalin, Srinath Chinnakotla, Stuart J Forbes, Suehana Rahman, Suk Kyun Hong, Sun Liying, Susan Orloff, Susan Rubman, Susumu Eguchi, Toru Ikegami, Trevor Reichman, Utz Settmacher, Varuna Aluvihare, Victor Xia, Young-In Yoon, Yuji Soejima, Yuri Genyk, Arif Jalal, Aditya Borakati, Adrian Gustar, Ahmed Mohamed, Alejandro Ramirez, Alex Rothnie, Aneya Scott, Anika Sharma, Annalise Munro, Arun Mahay, Belle Liew, Camila Hidalgo, Cara Crouch, Cheung Tsz Yan, Christoph Tschuor, Conrad Shaw, Dimitrios Schizas, Dominic Fritche, Fabia Ferdousi Huda, Gemma Wells, Giselle Farrer, Hiu Tat Kwok, Ioannis Kostakis, Joao Mestre-Costa, Ka Hay Fan, Ka Siu Fan, Kyra Fraser, Lelia Jeilani, Li Pang, Lorenzo Lenti, Manikandan Kathirvel, Marinos Zachiotis, Michail Vailas, Michele Mazza Milan, Mohamed Elnagar, Mohammad Alradhawi, Nikolaos Dimitrokallis, Nikolaos Machairas, Nolitha Morare, Oscar Yeung, Pragalva Khanal, Pranav Satish, Shahi Abdul Ghani, Shahroo Makhdoom, Sithhipratha Arulrajan, Stephanie Bogan, Stephanos Pericleous, Timon Blakemore, Vanessa Otti, Walter Lam, Whitney Jackson, and Zakee Abdi
Subjects: Consensus, Hepatology, Gastroenterology, Living Donors, Humans, Liver Transplantation
Abstract: There is much controversy regarding enhanced recovery for recipients of liver transplants from deceased and living donors. The objectives of this Review were to summarise current knowledge on individual enhanced recovery elements on short-term outcomes, identify key components for comprehensive pathways, and create internationally accepted guidelines on enhanced recovery for liver-transplant recipients. The ERAS4OLT.org collaborative partnered by the International Liver Transplantation Society performed systematic literature reviews on the effect of 32 relevant enhanced perioperative recovery elements on short-term outcomes, and global specialists prepared expert statements on deceased and living donor liver transplantation. The Grading Recommendations, Assessment, Development and Evaluations approach was used for rating of quality of evidence and grading of recommendations. A virtual international consensus conference was held in January, 2022, in which results were presented, voted on by the audience, and discussed by an independent international jury of eight members, applying the Danish model of consensus. 273 liver transplantation specialists from 30 countries prepared expert statements on elements of enhanced recovery for liver transplantation based on the systematic literature reviews. The consensus conference yielded 80 final recommendations, covering aspects of enhanced recovery for preoperative assessment and optimisation, intraoperative surgical and anaesthetic conduct, and postoperative management for the recipients of liver transplants from both deceased and living donors, and for the living donor. The recommendations represent a comprehensive overview of the relevant elements and areas of enhanced recovery for liver transplantation. These internationally established guidelines could direct the development of enhanced recovery programmes worldwide, allowing adjustments according to local resources and practices.
Published: 2022

43. Outcomes of Liver transplantation in children with Langerhans Cell Histiocytosis: Experience from a quaternary care centre and an algorithmic approach

Author: Jagadeesh Menon, Naresh Shanmugum, Joseph Valamparampil, Mukul Vij, Vimal Kumar, DEENADAYALAN MUNIRATHNAM, Abdul Hakeem, Ashwin Rammohan, and Mohamed Rela
Abstract: Objective : Spectrum of hepatic presentation in Langerhans cell histiocytosis (LCH) varies from asymptomatic hepatomegaly to secondary sclerosing cholangitis leading to cirrhosis with or without decompensation. Conventional chemotherapy may be counterproductive in a patient with LCH and hepatic decompensation. We analysed the outcomes of our patients with hepatic presentation of LCH, including their post liver transplant (LT) follow up. Methods: A retrospective analysis was performed on patients with hepatic presentation of LCH referred to our unit. Their clinical profile, chemotherapy protocol, details of LT and survival were analysed. A management algorithm based on the outcomes was proposed. Results: Five of 8 patients were male. Median age of diagnosis was 25(9-48) months. 8(100%) patients had portal hypertension with 4(50%) having decompensated cirrhosis. 6 (75%) patients underwent LT of which 2 had acute decompensation and 4 had sclerosing cholangitis with portal hypertension. Of the two remaining patients, 1 did not tolerate chemotherapy and succumbed, whereas 1 patient after first cycle of chemotherapy was lost to follow up. As their liver disease was worsening during chemotherapy (after 8 & 20 weeks of chemotherapy), two patients underwent urgent LT followed by continuation of chemotherapy. After median follow-up of 30.5 (10.5-50) months, all patients were alive with stable graft function and no disease recurrence. Conclusion: As shown in our series, an algorithmic approach to patient and treatment selection for LCH patients with liver involvement combined with newer chemotherapeutic agents and an optimized immunosuppression can result in excellent outcomes for a hitherto unfamiliar disease.
Published: 2022

44. Effects of pre-operative isolation on postoperative pulmonary complications after elective surgery: an international prospective cohort study

Author: Dmitri Nepogodiev, Joana Ff Simoes, Elizabeth Li, Maria Picciochi, James C Glasbey, Glauco Baiocchi, Ruth Blanco-Colino, Daoud Chaudhry, Ehab AlAmeer, Kariem El-Boghdadly, Funmilola Wuraola, Dhruva Ghosh, Rohan R Gujjuri, Ewen M Harrison, Herman Lule, Haytham Kaafarani, Mohammad Khosravi, Irmgard Kronberger, Sezai Leventoğlu, Harvinder Mann, Kenneth A Mclean, Mengistu Gebreyohanes Mengesha, Maria Marta Modolo, Faustin Ntirenganya, Lisa Norman, Oumaima Outani, Riinu Pius, Peter Pockney, Ahmad Uzair Qureshi, April Camilla Roslani, Sohei Satoi, Catherine Shaw, Aneel Bhangu, Omar M Omar, Waheed-Ul-Rahman Ahmed, Leah Argus, Alasdair Ball, Edward P Bywater, Amanpreet Brar, Brett E Dawson, Irani Duran, Muhammed Elhadi, Conor S Jones, Sivesh K Kamarajah, James M Keatley, Samuel Lawday, Ella J Marson, Riinu Ots, Irène Santos, Elliott H Taylor, Isobel M Trout, Chris Varghese, Mary L Venn, William Xu, Irida Dajti, Arben Gjata, Salah Eddine Oussama Kacimi, Luis Boccalatte, Daniel Cox, Philip Townend, Felix Aigner, Irmgard Elisabeth Kronberger, Elgun Samadov, Amer Alderazi, Kamral Hossain, Greg Padmore, Gabrielle van Ramshorst, Ismaïl Lawani, Anis Cerovac, Samir Delibegovic, Gustavo Mendonça Ataíde Gomes, Igor Lima Buarque, Muhammad Gohar, Mihail Slavchev, Chukwuemeka Nwegbu, Arnav Agarwal, Janet Martin, Joshua Ng-Kamstra, Maricarmen Olivos, Wenhui Lou, Dong-Lin Ren, Jose Andres Calvache, Carlos J Perez Rivera, Ana Danic Hadzibegovic, Tomislav Kopjar, Jakov Mihanovic, Pablo Mijahil Avilés Jiménez, Nikolaos Gouvas, Jaroslav Klat, René Novysedlák, Nicolas Amisi, Peter Christensen, Alaa El-Hussuna, Sylvia Batista, Eddy Lincango-Naranjo, Sameh Emile, Danilo Alfonso Arévalo Sandoval, Hailu Dhufera, Samuel Hailu, Mengistu G Mengesha, Joonas H Kauppila, Alexis P Arnaud, Zaza Demetrashvili, Markus Albertsmeier, Hans Lederhuber, Markus W Löffler, Daniel Kwesi Acquah, Bernard Ofori, Stephen Tabiri, Symeon Metallidis, Georgios Tsoulfas, Maria-Lorena Aguilera-Arevalo, Gustavo Recinos, Tamás Mersich, Dániel Wettstein, Gabriele Kembuan, Peiman Brouki Milan, Mohammad Hossein Khosravi, Masoud Mozafari, Ahmed Hilmi, Helen Mohan, Oded Zmora, Gaetano Gallo, Francesco Pata, Gianluca Pellino, Yuki Fujimoto, Naoto Kuroda, Mohamad K Abou Chaar, Faris Ayasra, Ildar Fakhradiyev, Intisar Hisham Said Hamdun, Jang Jin-Young, Mohammad Jamal, Lina Karout, Aiste Gulla, Fanjandrainy Rasoaherinomenjanahary, Luc Hervé Samison, Iran Irani Durán Sánchez, Diana Samantha Gonzalez, Laura Martinez, María José Martínez, Alejandra Nayen, Antonio Ramos-De la Medina, Jade Nunez, Pueya Rashid Nashidengo, Rakesh Shah, Ashish Lal Shrestha, Pascal Jonker, Schelto Kruijff, Milou Noltes, Pieter Steinkamp, Deborah Wright, Lukman Abdur-Rahman, Adesoji Ademuyiwa, Adewale Adisa, Babatunde Osinaike, Justina Seyi-Olajide, Omolara Williams, Emmanuel Williams, Sofija Pejkova, Zainab Al Balushi, Raza Sayyed, Mustafa Abo Mohsen, Sadi A Abukhalaf, Moises Cukier, Hugo Gomez-Fernandez, Sebastian Shu Yip, Ximena Paola Vasquez Ojeda, Marie Dione Sacdalan, Piotr Major, José Azevedo, Miguel F Cunha, Ahmad Zarour, Eduard-Alexandru Bonci, Ionut Negoi, Sergey Efetov, Viktor Kochetkov, Andrey Litvin, Jc Allen Ingabire, Georges Bucyibaruta, Ntirenganya Faustin, Sosthene Habumuremyi, Alphonsine Imanishimwe, Haragirimana Jean de Dieu, Emmanuel Munyaneza, Isaie Ncogoza, Ehab Alameer, Abdourahmane Ndong, Dejan Radenkovic, Min Hoe Chew, Frederick Koh, James Ngu, Arpád Panyko, Uros Bele, Jurij Aleš Košir, Hassan Daoud, Ana Maria Minaya Bravo, Umesh Jayarajah, Dakshitha Wickramasinghe, Mohammed Elmujtba Adam Essa Adam, Martin Rutegård, Malin Sund, Michel Adamina, Eleftherios Gialamas, Karoline Horisberger, Muhammad Alshaar, Abel Huang, Varut Lohsiriwat, Shane Charles, Haithem Jlassi, Arda Isik, Hervé Monka Lekuya, Slava Kopetskyi, Hayder Alsaadi, Sattar Alshryda, Osaid Alser, Brittany Bankhead-Kendall, Kerry Breen, Hassan Mashbari, Fernando Bonilla Cal, Hamza Al-Naggar, Mayaba Maimbo, Dennis Mazingi, Tom Abbott, Melika Akhbari, Ruth Benson, Shivam Bhanderi, Bruce Biccard, Edward Caruana, Sohini Chakrabortee, Reema Chapatwala, Ainhoa Costas-Chavarri, Andreas K Demetriades, Anant Desai, Salomone Di Saverio, Thomas Drake, John Edwards, Jonathan Evans, Marco Fiore, Samuel Ford, Christina Fotopoulou, Alexander Fowler, Kaori Futaba, Ian Ganly, Harelimana Grace James, Ewen Griffiths, Alessandro Gronchi, Peter Hutchinson, Gabriella Yael Hyman, Joseph Incorvia, Ritu Jain, Michael Jenkinson, Tabassum Khan, Stephen Richard Knight, Angelos Kolias, Søren Kudsk-Iversen, Tsun Yu Kwan, Elaine Leung, Julio Mayol, Siobhan McKay, John G Meara, Emily Mills, Susan Moug, Akshay Patel, Roberto Perinotti, Henry E Rice, Keith Roberts, Andrew Schache, Richard Shaw, Neil Smart, Matthew Stephens, Grant D Stewart, Ella Teasdale, Peter Vaughan-Shaw, Raghavan Vidya, Naomi Wright, Natalie Zimmelman, Ervis Agastra, Dariel Thereska, Sergio Martin Lucchini, Veronica Laudani, Carina Chwat, Ivana Ines Pedraza Salazar, Diana Alejandra Pantoja Pachajoa, Agustin Duro, José Alfredo Calderón Arancibia, Giuliana D'Aulerio, Nagendra Dudi-Venkata, Natasha Egoroff, Shebani Farik, Natalie Lott, Jana-Lee Moss, Sarah Rennie, Lorwai Tan, Uyen Giao Vo, David Watson, David Watters, Tim Bright, Paul Hollington, Xuanyu Zhou, Hidde M Kroon, Anthony Farfus, John Barker, Eleanor Watson, Sean Stevens, Haider Latif, Amanda Caroline Dawson, Alwin Chuan, Vijayaragavan Muralidharan, Enoch Wong, Travis Ackermann, Maurizio Pacilli, Russell Hodgson, Alexander Heriot, Peter Choong, Wendy Brown, Surjit Lidder, Justin Yeung, Luke Traeger, Guillermo Regalo, Ralph Gourlay, Sarit Badiani, Cherry Koh, Soni Putnis, Fayza Haider, Ashrarur Rahman Mitul, Niels Komen, Bert Dhondt, Serge Cappeliez, Manon Pigeolet, Martijn Schoneveld, Jasper Stijns, Wouter Oosterlinck, Nicolas Flamey, Cyrille Kpangon, Mouhamed Agbadebo, S Mèvo Romaric Tobome, Aldo Vieira Barros, Samuel Aguiar Júnior, Heloisa Galvão do Amaral Campos, Jefferson Gross, Felipe José Fernandez Coimbra, Luiz Paulo Kowalski, Fabiana Makdissi, Suely Nakagawa, Joao Pedreira Duprat Neto, Jose Guilherme Vartanian, Guilherme Yazbek, Stenio C Zequi, Ronald Flumignan, Natalia Jaworska, Angela Dell, Harsha Shanthanna, Abdollah Behzadi, Carolyn Nessim, Michelle Mozel, Pascal St-Germain, Crispin Russell, Gary Groot, Najib Safieddine, Duminda Wijeysundera, Antoine Eskander, Sami Chadi, Shawn MacKenzie, Alana Flexman, Fernando Heredia, Julio Villanueva, Sofia Waissbluth, Roberto Macchiavello, Mario I Escudero, Tyare Fuentes, Ximena Mimica, Dinimo Bolivar Saenz, Lina Caicedo, Juan Pablo Alzate, Joaquin Luna, Nestor Fabian Pedraza Alonso, Camilo Ortiz Silva, Juliana Rodriguez, Liliana Silva-Igua, Martha Luz Torres, Lina María Trujillo, Albaro José Nieto Calvache, Julián Balanta-Melo, Rafael Figueroa-Casanova, Oscar-Julián García-Montoya, Carlos Andres Marulanda Toro, Marcela Velez Botero, Maria Clara Mendoza Arango, Eneida Diaz Martinez, Valentina Gutiérrez Perdomo, Emileth Montenegro, Julia Rodriguez-Abreu, Dolores Mejía, Galal Abouelnagah, Sameh Shehata, Ahmed Hossam Eldin Fouad Rida, Ramy A Hassan, Mahmoud M Saad, Mohamed Reda Loaloa, Badr Mostafa, Mohamed Qassem, Mohamed Fahmy, Hesham Abozied, Ahmed Y Azzam, Sherief Ghozy, Asser Sallam, Ahmed Shehta, Mohamed Abdelkhalek, Rehab Samaka, Amr Morsy, Ahmed Elshawadfy Sherif, Abraham Negussie, Tigist Fisseha, Kibruyisfaw Shumbash, Metasebia Abebe, Seid Mohammed Yasin, Yemisirach Bizuneh Akililu, Abebe Megersa, Teshome Tefera, Melatework Assefa, Bahru Atnafu, Bereket Tsegaye, Yoseph Solomon Bezabih, Silamlak Sisay, Kebebe Bekele, Moa Jira, Habtamu Derilo, Eyueal Degefa, Anteneh Tadesse, Melkamu Nidaw, Elise Sarjanoja, Sylvie Testelin, Sophie Boucher, Lionel Jouffret, Zaher Lakkis, Alban Zarzavadjian Le Bian, Luke Harper, Marc Danguy des Déserts, Benoît André, Karem Slim, Romain Verhaeghe, Andrea Police, Edouard Girard, Alexandre Chebaro, Armande Subayi Nkembi, Laurent Arnalsteen, Quentin Ballouhey, Diane Mege, Clement Jeandel, Emilie Duchalais, Pierre-Alban Bouche, Gilles Manceau, Célia Crétolle, Erik Hervieux, Noémie Girard, Agathe Seguin-Givelet, Sebastien Gaujoux, Belinda De Simone, Matthieu Boisson, Damien Bergeat, Fabien Fredon, Francesco Nappi, Radwan Kassir, Aurélien Scalabre, Federico Migliorelli, Anne-Cecile Ezanno, Barbara Seeliger, Charlotte Vaysse, Helene Charbonneau, Vincent Misrai, Olivier Abbo, Martina Aida Angeles, Laurent Brunaud, Ali Modabber, Sebastian Wolf, Carsten Kamphues, Philipp Höhn, Tim R Glowka, Alexander Christopher Rokohl, Ulrich Bork, Georg Fluegen, Raymund E Horch, Andrea Schmedding, Andreas Schnitzbauer, Helge Eberbach, Daniel Schlager, Fritz Spelsberg, Lena Keppler, Andreas Hecker, Susanne Wolfer, Ulrich Ronellenfitsch, Christine Nitschke, Christian Peiper, Ibrahim Hakami, Stefan Welter, Karine Nikolaieva, Andreas Roth, Judith Lindert, Konstantinos Gousias, Anke Rissmann, Valerie Catherine Linz, Nuh Rahbari, Marie-Claire Rassweiler-Seyfried, Anna Eleonora Gut, Jens Gempt, Daniel Reim, Arthur Wagner, Alexander M Keppler, Mircea Gabriel Stoleriu, Tim Saier, Josef Stadler, Julia Christina Kaiser, Stefan M Brunner, Karin Pfister, Jonas Herzberg, Kai Nowak, Tobias Reinhard, Gregor A Stavrou, Alfred Königsrainer, Christian Konrads, Markus Quante, Simon Laban, Silke von Pusch, Markus Hirschburger, Johannes Doerner, Armin Wiegering, Ekaterini Christina Tampaki, Alitza Gutiérrez Ruiz, Alejandra Rodas, Ana Lucía Portilla, Jacqueline Carrera, Amalia Barrios Duarte, Megan Lowey, Sabrina Barillas, Atul Suroy, Dhaivat Vaishnav, Raghunandan Gorantlu Chowdappa, Irappa Madabhavi, Dhananjaya Bhat, Sunil Kumar Venkatappa, Sumit Thakar, Kavitha Jain, Aruna Kumar, Manoj Nagar, Tushar Mishra, Arunkumar Sekar, Anand Gupta, Lileswar Kaman, Madhivanan Karthigeyan, Manjul Tripathi, Ashwin Rammohan, Sudheer Othiyil Vayoth, Anupama Rajanbabu, Anbukkani Subbian, Rahul Gupta, Monish Raut, Nissi Evelyn, R Lavanya Kannaiyan, Anil Matai, Sanjeev Misra, Vishal Bhende, Sathish Muthu, Indranil Ghosh, Abhishek Sharma, Ankur Bajaj, Shiv Rajan, Gaurav Agarwal, Pranay Pawar, Philip Alexander, M Vijayakumar Vijayakumar, Zeeshan Hameed, L Badareesh, Navneet Kumar Chaudhry, Lipika Baliarsing, Satish Dharap, Amruta Kulkarni, Yuvaraja Thyavihally, Rahul Deo Sharma, C S Pramesh, Rajesh Soni, Surya Kumar Dube, Shilpa Sharma, Harvinder Singh, Lovenish Bains, Rahul Ghodke, Ashwani Kumar, Vivek Sodhai, Suvendu Maji, Somprakas Basu, Chandrashekhar Mahakalkar, Ravi Kannan, Asif Mehraj, N Ranganath, Ashish Phadnis, I Yadev, Alfie Kavalakat, Rohin Mittal, Karthik Chandra Vallam, Hamed Akhavizadegan, Esmaeil Rezghi Maleki, Naser Yousefzadeh Kandevani, Hilary Ikele, Catherine McNestry, Christina Fleming, Stephen O'Brien, Sami Abd Elwahab, Niall Davis, Mohsen Javadpour, Brendan McDonnell, Clare O Connor, Jarlath Bolger, Cillian Clancy, Stefanie M Croghan, Noel Donlon, Carolyn Cullinane, Ben Creavin, Muheilan Muheilan, Helen Earley, Syed Mohammad Umar Kabir, Muhammad Fahadullah, Éanna Ryan, Tara Connelly, Daisuke Hashimoto, Majdi Ali Alqudah, Amer Alajalen, Rand Y Omari, Abdulrahman Qasem, Yazan Alawneh, Amer Ahmad, Omar Aladawi, Bourhan Alrayes, Hanan Haidar, Shatha Husain, Faisal Qassem, Adnan Sumadi, Ala'a Abu Salhiyeh, Balqees Mahmoud Al-Manaseer, Zaid Alsunna, Hazim Ra'ed, Faten Reyad Bani Hamad, Amro Abuleil, Elmi Ahmed Mohamed Jimaale, Marah Abu-Mehsen, Noor Olaywah, Omar Wafi, Hazim Ababneh, Luai Abu-Ismail, Almu'atasim Khamees, Ahmad Alkhatib, Raikhan Bolatbekova, Mukhtar Kulimbet, Talgat Nurgozhin, Timur Saliev, Baurzhan Zhussupov, Ydyrys Almabayev, Dilyara Kaidarova, Khalil Tamoos, Ahmed Aqeelah, Alsnosy Abdullah Khalefa Mohammed, Faraj Al Maadany, Ghadah Alkadeeki, Milad Gahwagi, Wafa Aldressi, Mohamed Amnaina, Arowa Hassan Abdulrahman Alansari, Akram Alkaseek, Ghozlan Yagoub, Anass Ben Amer, Marwa Salem, Ayman Almugaddami, Dania Burgan, Mohammed Abdelkabir, Khayriyah Alshareef, Rayet Al Islam Ben Jouira, Ayman Meelad, Ahmad Bouhuwaish, Sumayya Essayah Dwaga, Houda Khalifa, Bushray Almiqlash, Taha Suliaman, Mohammed Alawami, Fras Elhajdawe, Hajir Aboazamazem, Ibrahim Ellojli, Ahmed Msherghi, Ismail Ali Saleh, Mohammed Alayan, Marcel Didier Ndayishyigikiye, Akutu Munyika, Philipp Plarre, David W Borowski, Cameron Wells, Rebecca Teague, Brodie Elliott, David Kieser, Omar Mohyieldin, Nick McIntosh, Cheyaanthan Haran, Jasmin King, Jeong Ha, Matthew James McGuinness, Opeoluwa Adesanya, Julius Olaogun, Akinola Akinmade, Kefas Bwala, Peter Agbonrofo, Akinwale Afolabi, Usang Usang, Sebastian Ekenze, Samson Olori, Taiwo Akeem Lawal, Abiodun Okunlola, Stephen Kache, Danjuma Sale, Lofty-John Anyanwu, Chukwuma Okereke, Musliu Adetola Tolani, Venko Filipce, Lazar Todorovic, Sotir Stavridis, John George Massoud, Sareyah Alsibai, Rizwan Sultan, Humera Naz Altaf, Abu Bakar Hafeez Bhatti, Shahzad Hussain Waqar, Aliya Aziz, Asad Ali Kerawala, Lajpat Rai, Mariyah Anwer, Aiman Tariq, Bushra Ayub, Sami Ullah Niazi, Muhammad Yasir Naseem, Muhammad Zeeshan Sarwar, Muhammad Imran Khokhar, Imdad Ahmad Zahid, Haroon Javaid Majid, Nabila Talat, Muhammad Asif, Muhammad Hamid Chaudhary, Umer Farooq, Siddique Ahmad, Waleed Mabood, Syed Imran Bukhari, Muhammad Tariq, Eesha Yaqoob, Saad Javed, Muhammad Usman Malik, Hassan Nawaz Yaqoob, Glenda Marina Falcon Pacheco, Robinson Mas Melendez, Arazzelly Del Pilar Paucar Urbina, Jose Rios Chiuyari, Carlos Eduardo Otiniano Alvarado, Lorena Fuentes Rivera Lau, Giuliano Borda-Luque, Milagros Niquen-Jimenez, Claudia Arias, Sergio Zegarra, Jenner Betalleluz Pallardel, Regina Amparo Ugarte Oscco, Gian Mendiola, Yahaira Tatiana Carpio Colmenares, Carlos Shiraishi Zapata, Maria Rosa Ortiz, Filipe Castro Borges, Octavio Viveiros, Pedro Serralheiro, Paulo Santos-Costa, Filipa Mendes, Miguel Rocha Melo, Paulo Cardoso, Ana Soares, Rita Gonçalves Pereira, Nelson Silva, André Caiado, Maria Luís Sacras, Pedro Azevedo, Rui Almeida-Reis, João Oliveira, Jorge Nogueiro, Mafalda Sampaio-Alves, Luciana Cidade Costa, Catarina Baía, Ana Cláudia Deus, Rita Branquinho, André Marçal, André Tojal, Silviu Tiberiu Makkai-Popa, Aurel Mironescu, Florin Grama, Elena Adelina Toma, Daniela Filipescu, Nicolae Bacalbasa, Natalia Motas, Sebastian Ionescu, Octav Ginghina, Radu Costea, Narcis Octavian Zarnescu, Radu Drasovean, Mihail-Gabriel Dimofte, Vlad Porumb, Mikhail Kirov, Yegor Molitvin, Vadim Pykhteev, Marianna Raevskaya, Aleksandr Butyrskii, Mushabab Alshahrani, Azah Althumairi, Nasser Alzerwi, Ahmed Al Ameer, Tariq Madkhali, Abddulrahman Saleh Almulhim, Salman Ghazwani, Abdu Ayoub, Othman Iskander, Mohammed Ghunaim, Mohammed Alharthi, Turki M Alzaidi, Mohammad Alyami, Abdulrahman Al Amri, Abdullah AlFakhri, Amal Alhefdhi, Sharfuddin Chowdhury, Thamer Nouh, Ameen Alshehri, Abdulrahman Alzahrani, Yousef Alalawi, Selmy Awad, Ibrahima Konate, Jacques Tendeng, Nan Zun Teo, Sabra Aqil, Cristina Barrena López, Ana Sánchez Mozo, Antonio Rodriguez Infante, Patricia Caja Vivancos, Mikel Prieto, Igor Alberdi San Roman, Laura Gomez Fernandez, Josep Maria Muñoz Vives, Anna Carreras-Castañer, Berta Díaz-Feijoo, Ramon Sieira-Gil, Victor Turrado-Rodriguez, Anna Sánchez López, Santiago Sánchez-Cabús, Marta Jimenez Toscano, MªPilar Canals Sin, Saura García Laura, Oriol Martin Sole, Pedro Palazon Bellver, Sonia Pérez-Bertólez, Jordi Prat-Ortells, Mireia Riba Martínez, Josep Rubio-Palau, Xavier Tarrado, Jorge Nuñez, Veronica Alonso Mendoza, Coro Bescós, Eloy Espin-Basany, Martin Espinosa-Bravo, Daniel Gil-Sala, Susana González-Suárez, Nuria Montferrer Estruch, Lucia Porteiro Mariño, Ana Rodríguez-Tesouro, Fabian Rojas Portilla, M Pilar Tormos Pérez, Inmaculada Vives, Unai Garcia De Cortazar, Kiara Tudela, Aitor Landaluce-Olavarria, Mercedes Estaire Gómez, Jorge Almoguera, Bakarne Ugarte-Sierra, Virginia Jimenez, Marta Bertrand, Laura Cárdenas Puiggrós, Olga Delisau-Puig, Jorge Garcia-Adamez, David Julià Bergkvist, Eloy Maldonado-Marcos, Lucia Diego García, Marta Roldón Golet, Iván Soto-Darias, Aida Cristina Rahy-Martín, Diego Enjuto, Adolfo Ramos-Luengo, Juan Delgado Fernandez, Carolina Lugo Duarte, Cristina Ojeda Thies, Lucila Marquez, Diana Crego Vita, Jana Dziakova, Jorge Caño Velasco, Olga Mateo-Sierra, Begoña Quintana-Villamandos, Cristina Rey Valcarcel, Javier Rio, Laura Román García de León, Marcello Di Martino, Jorge Prada, Javier Serrano González, Manuel Losada, Jose Tomas Castell Gomez, Ramon Corripio-Sanchez, Alexander Forero-Torres, José Manuel Morales-Puebla, Hanna Perez-Chrzanowska, Santiago Valderrabano Gonzalez, Alvaro Yebes, Ignacio Zapardiel, Manuel Diez Alonso, Nelson Morales Palacios, Alberto Cabañero Sánchez, Fátima Sánchez Fernández, Alfredo Abad Gurumeta, Ane Abad-Motos, Fernando Corella, Javier Ripollés-Melchor, Rosa Sanz-Gonzalez, Marta Alcaraz Fuentes, Maria Teresa Fernández Martín, Pablo Calvo Espino, Milagros Carrasco Prats, Antonio-José Fernández-López, Damián García Escudero, Vanesa Garcia Soria, Jesús Aarón Martínez Alonso, Miguel Ruiz-Marín, Beatriz Gómez Pérez, Joaquin Moya-Angeler, Daniel Fernández Martínez, Heura Llaquet Bayo, Enrique Colás-Ruiz, Susana Bella Romera, M Teresa Gavaldà Pellicé, Misericòrdia Jordà Solé, Enrique Jose Ruiz Velasquez, Bernardo Núñez, Raul Jimenez, Jon Zabaleta, Maria Jose González-Gimeno, Irene Ortega Vázquez, Antonio Perez Ferrer, Rubén Martín-Láez, Marcelo Moreno Suarez, Miguel Angel Freiria Eiras, Irene Ramallo-Solís, Juan-Carlos Gomez-Rosado, Jose Ramon Oliver Guillen, Mar Achalandabaso Boira, Juan Carlos Catalá Bauset, Julio Domenech, Rafael Badenes, Juan Carlos Bernal-Sprekelsen, Jorge Sancho-Muriel, Beatriz De Andrés-Asenjo, Francisco J Tejero-Pintor, Marc Vallve-Bernal, Alba Vazquez Melero, Laura Sánchez Blasco, Jorge Escartin, Victoria Duque Mallén, Selvaratnam Srishankar, Charitha Sooriyabandara, Oshan Basnayake, Nalaka Gunawansa, Prabuth Dulanjan Weeraddana, Thanusan Vimalakanthan, Shanthamoorthy Gishanthan, Pramodh Chandrasinghe, Marc-Olivier Sauvain, Ahmad Ghazal, Yusra Al-Sabbagh, Turki Alhassoun, Sara Maa Albared, Antoine Naem, Hareth Alnahr, Ghassan Jisry, Ali Hammed, Okedi Francis Xaviour, Gaston Turinawe, Isaac Mubezi, Franck K Sikakulya, Andrew Kakeeto, Wilberforce M Kabweru, Ronald Kiweewa, Paul Matovu, Otolia Isaac, Mohamed Mashhour, Amin El Helw, Safeena Kherani, Awadelkarim Mohamed, Ferial Mohamed Ali Abbas, Diary Mohammed, Ehab Aldlyami, Rakesh Kundra, Antony Louis Rex Michael, Kareem S Khalil, Rachel Dbeis, Shafaque Shaikh, Jenny Ferry, Aiman Jamal, Haleema Siddique, Rishi Das, Nikhil Ponugoti, Pornjittra Rattanasirivilai, Asma Sultana, Frances Mosley, Matthew Chan, Antony Bateman, Gareth Davies-Jones, Fanourios Georgiades, Navid Ahmadi, Aman Coonar, Mariam Baig, Chetan Khatri, Arthika Surendran, Julian Sonksen, Robert Sinnerton, Caitlin Brennan, Gemma Faulkner, Michael Greenhalgh, Hannah Emerson, Kiran Singisetti, Joshua Totty, Michael Wilson, Terence Lo, Harriet Corbett, Ijeoma Okonkwo, Gill Arbane, Cyrus Kerawala, Chetan Parmar, Michael Bath, Funlayo Odejinmi, Jayesh Sagar, Rishi Talwar, Samuel Newman, John Hammond, John Moir, Natalie Duric, Tamas Szakmany, Ahmar Iftikhar Talib, Mina Youssef, Christopher Lewis-Lloyd, Mariam Lami, Khurram Ayub, Benjamin Dean, Supriya Balasubramanya, Sathya Lakpriya, Luke Rogers, Paul Turner, Mark Maher, Kohila Sigamoney, Jihène El Kafsi, John Hardie, David Johnson, Christin Henein, Marianne Hollyman, Ketan Agarwal, Simon Powell, Govind Singh Chauhan, Rakesh Patel, Joel Gagnier, Heather Carmichael, Aurora, Kristofor A Olson, Eric Etchill, Sameer Hirji, Matthew Naunheim, Frederick Drake, Caroline Reinke, Anna Alecci, Dennis Vaysburg, Jennifer Rodriquez, Emily Shih, Vin Shen Ban, Julia Coleman, Krista Kaups-Fresno, Emmanouil Giorgakis, Maggie DiNome, Neal Bhutiani, Omar Alnachoukati, Taylor Aiken, Thomas Diehl, Ankush Gosain, Rishi Rattan, Muhammad Owais Abdul Ghani, Nensi Melissa Ruzgar, Anna Liveris, Nina Glass, Charu Paranjape, Theresa Chin, Antonio Meola, Kristina Nicholson, John Squiers, Stephanie Lueckel, Janani Reisenauer, Rachael Callcut, Ahmed Mansour, Allison Berndtson, Lucy Kornblith, Sara Seegert, Paulo Martins, Mohammed Al-Shehari, Ibrahim Al-Raimi, Allan Ngulube, Maphios Siamuchembu, Willard Mushiwokufa, Busisiwe Mlambo, Simbarashe Chinyowa, Enton Bollano, Kostandin Gjyli, Jola Kerpaci, Enxhi Vrapi, Lorena Zijaj, Bahraoui Djahida, Belabbes Fatima Zohra, Kouidri Khadidja, Oussama Bali, Nassim Benallel, Ismahene Lalmi, Meriem Abdoun, Nesrine Aouabed, Souad Bouaoud, Kamel Bouchenak, Assia Haif, Zineddine Soualili, Joaquin Bastet, Agustín Bianco, Daniel Capitaine, Jorge Centeno Lozada, Carlos Esquivel, Rodrigo Figueroa, Manuel Garcia, Pablo Martín García, José Ignacio Gerchunoff, Fernando Martinez Iascano, Jose Mondino, María Emilia Muriel, Carmignani Pablo, Martin Passadore, Alejandra Tornini, Rogelio Traverso, Lara Vargas, Gerardo Zanoni, Norberto Berber, Estefanía Cotta, Marcela Di Vincenzo, Esteban Sebastian Gallino, 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Kache, Danjuma Sale, Lofty-John Anyanwu, Chukwuma Okereke, Musliu Adetola Tolani, Venko Filipce, Lazar Todorovic, Sofija Pejkova, Sotir Stavridis, John George Massoud, Sareyah Alsibai, Rizwan Sultan, Humera Naz Altaf, Abu Bakar Hafeez Bhatti, Shahzad Hussain Waqar, Aliya Aziz, Asad Ali Kerawala, Lajpat Rai, Mariyah Anwer, Aiman Tariq, Bushra Ayub, Sami Ullah Niazi, Muhammad Yasir Naseem, Muhammad Zeeshan Sarwar, Muhammad Imran Khokhar, Imdad Ahmad Zahid, Haroon Javaid Majid, Nabila Talat, Muhammad Asif, Muhammad Hamid Chaudhary, Umer Farooq, Siddique Ahmad, Waleed Mabood, Syed Imran Bukhari, Muhammad Tariq, Eesha Yaqoob, Saad Javed, Saad Javed, Muhammad Usman Malik, Hassan Nawaz Yaqoob, Moises Cukier, Glenda Marina Falcon Pacheco, Robinson Mas Melendez, Arazzelly Del Pilar Paucar Urbina, Jose Rios Chiuyari, Carlos Eduardo Otiniano Alvarado, Lorena Fuentes Rivera Lau, Giuliano Borda-Luque, Milagros Niquen-Jimenez, Claudia Arias, Sergio Zegarra, Jenner Betalleluz Pallardel, Regina Amparo Ugarte Oscco, Gian Mendiola, Yahaira Tatiana Carpio Colmenares, Carlos Shiraishi Zapata, Maria Rosa Ortiz, Marie Dione Sacdalan, Piotr Major, Filipe Castro Borges, Octavio Viveiros, Pedro Serralheiro, Paulo Santos-Costa, Filipa Mendes, Miguel Rocha Melo, Paulo Cardoso, Ana Soares, José Azevedo, Rita Gonçalves Pereira, Nelson Silva, André Caiado, Maria Luís Sacras, Pedro Azevedo, Rui Almeida-Reis, Miguel F Cunha, João Oliveira, Jorge Nogueiro, Mafalda Sampaio-Alves, Luciana Cidade Costa, Catarina Baía, Ana Cláudia Deus, Rita Branquinho, André Marçal, André Tojal, Ahmad Zarour, Ahmad Zarour, Silviu Tiberiu Makkai-Popa, Aurel Mironescu, Florin Grama, Elena Adelina Toma, Ionut Negoi, Daniela Filipescu, Nicolae Bacalbasa, Natalia Motas, Sebastian Ionescu, Octav Ginghina, Radu Costea, Narcis Octavian Zarnescu, Radu Drasovean, Eduard-Alexandru Bonci, Mihail-Gabriel Dimofte, Vlad Porumb, Mikhail Kirov, Yegor Molitvin, Andrey Litvin, Vadim Pykhteev, Marianna Raevskaya, Sergey Efetov, Aleksandr Butyrskii, Mushabab Alshahrani, Azah Althumairi, Nasser Alzerwi, Ahmed Al Ameer, Ahmed Al Ameer, Tariq Madkhali, Abddulrahman Saleh Almulhim, Salman Ghazwani, Abdu Ayoub, Othman Iskander, Mohammed Ghunaim, Mohammed Alharthi, Turki M Alzaidi, Azah Althumairi, Mohammad Alyami, Abdulrahman Al Amri, Azah Althumairi, Abdullah AlFakhri, Amal Alhefdhi, Sharfuddin Chowdhury, Thamer Nouh, Ameen Alshehri, Abdulrahman Alzahrani, Yousef Alalawi, Selmy Awad, Ibrahima Konate, Abdourahmane Ndong, Jacques Tendeng, Nan Zun Teo, Frederick Koh, Jurij Aleš Košir, Uros Bele, Sabra Aqil, Cristina Barrena López, Ana Sánchez Mozo, Antonio Rodriguez Infante, Patricia Caja Vivancos, Mikel Prieto, Igor Alberdi San Roman, Laura Gomez Fernandez, Josep Maria Muñoz Vives, Anna Carreras-Castañer, Berta Díaz-Feijoo, Ramon Sieira-Gil, Victor Turrado-Rodriguez, Anna Sánchez López, Santiago Sánchez-Cabús, Marta Jimenez Toscano, MªPilar Canals Sin, Saura García Laura, Oriol Martin Sole, Pedro Palazon Bellver, Sonia Pérez-Bertólez, Jordi Prat-Ortells, Mireia Riba Martínez, Josep Rubio-Palau, Xavier Tarrado, Jorge Nuñez, Veronica Alonso Mendoza, Coro Bescós, Eloy Espin-Basany, Martin Espinosa-Bravo, Daniel Gil-Sala, Susana González-Suárez, Nuria Montferrer Estruch, Jorge Nuñez, Lucia Porteiro Mariño, Ana Rodríguez-Tesouro, Fabian Rojas Portilla, M Pilar Tormos Pérez, Inmaculada Vives, Unai Garcia De Cortazar, Kiara Tudela, Aitor Landaluce-Olavarria, Mercedes Estaire Gómez, Jorge Almoguera, Bakarne Ugarte-Sierra, Virginia Jimenez, Marta Bertrand, Laura Cárdenas Puiggrós, Olga Delisau-Puig, Jorge Garcia-Adamez, David Julià Bergkvist, Eloy Maldonado-Marcos, Lucia Diego García, Marta Roldón Golet, Iván Soto-Darias, Aida Cristina Rahy-Martín, Diego Enjuto, Adolfo Ramos-Luengo, Juan Delgado Fernandez, Carolina Lugo Duarte, Cristina Ojeda Thies, Lucila Marquez, Diana Crego Vita, Jana Dziakova, Ana Maria Minaya Bravo, Jorge Caño Velasco, Olga Mateo-Sierra, Begoña Quintana-Villamandos, Cristina Rey Valcarcel, Javier Rio, Laura Román García de León, Marcello Di Martino, Jorge Prada, Javier Serrano González, Manuel Losada, Jose Tomas Castell Gomez, Ramon Corripio-Sanchez, Alexander Forero-Torres, José Manuel Morales-Puebla, Hanna Perez-Chrzanowska, Santiago Valderrabano Gonzalez, Alvaro Yebes, Ignacio Zapardiel, Manuel Diez Alonso, Nelson Morales Palacios, Alberto Cabañero Sánchez, Fátima Sánchez Fernández, Alfredo Abad Gurumeta, Ane Abad-Motos, Fernando Corella, Javier Ripollés-Melchor, Rosa Sanz-Gonzalez, Marta Alcaraz Fuentes, Maria Teresa Fernández Martín, Pablo Calvo Espino, Milagros Carrasco Prats, Antonio-José Fernández-López, Damián García Escudero, Vanesa Garcia Soria, Jesús Aarón Martínez Alonso, Miguel Ruiz-Marín, Beatriz Gómez Pérez, Joaquin Moya-Angeler, Daniel Fernández Martínez, Heura Llaquet Bayo, Enrique Colás-Ruiz, Susana Bella Romera, M Teresa Gavaldà Pellicé, Misericòrdia Jordà Solé, Enrique Jose Ruiz Velasquez, Bernardo Núñez, Raul Jimenez, Jon Zabaleta, Maria Jose González-Gimeno, Irene Ortega Vázquez, Antonio Perez Ferrer, Rubén Martín-Láez, Marcelo Moreno Suarez, Miguel Angel Freiria Eiras, Irene Ramallo-Solís, Juan-Carlos Gomez-Rosado, Jose Ramon Oliver Guillen, Mar Achalandabaso Boira, Juan Carlos Catalá Bauset, Julio Domenech, Rafael Badenes, Juan Carlos Bernal-Sprekelsen, Jorge Sancho-Muriel, Beatriz De Andrés-Asenjo, Francisco J Tejero-Pintor, Marc Vallve-Bernal, Alba Vazquez Melero, Laura Sánchez Blasco, Jorge Escartin, Victoria Duque Mallén, Selvaratnam Srishankar, Umesh Jayarajah, Charitha Sooriyabandara, Oshan Basnayake, Nalaka Gunawansa, Dakshitha Wickramasinghe, Prabuth Dulanjan Weeraddana, Thanusan Vimalakanthan, Shanthamoorthy Gishanthan, Pramodh Chandrasinghe, Eleftherios Gialamas, Marc-Olivier Sauvain, Ahmad Ghazal, Yusra Al-Sabbagh, Turki Alhassoun, Sara Maa Albared, Antoine Naem, Hareth Alnahr, Ghassan Jisry, Ali Hammed, Arda Isik, Okedi Francis Xaviour, Gaston Turinawe, Isaac Mubezi, Franck K Sikakulya, Andrew Kakeeto, Wilberforce M Kabweru, Hervé Monka Lekuya, Ronald Kiweewa, Herman Lule, Paul Matovu, Otolia Isaac, Mohamed Mashhour, Amin El Helw, Sattar Alshryda, Safeena Kherani, Awadelkarim Mohamed, Ferial Mohamed Ali Abbas, Diary Mohammed, Ehab Aldlyami, Rakesh Kundra, Mohamed Mashhour, Mohamed Mashhour, Antony Louis Rex Michael, Hayder Alsaadi, Kareem S Khalil, Rachel Dbeis, Shafaque Shaikh, Jenny Ferry, Aiman Jamal, Haleema Siddique, Rishi Das, Nikhil Ponugoti, Sivesh K Kamarajah, Pornjittra Rattanasirivilai, Asma Sultana, Frances Mosley, Matthew Chan, Antony Bateman, Gareth Davies-Jones, Fanourios Georgiades, Grant D Stewart, Navid Ahmadi, Aman Coonar, Mariam Baig, Chetan Khatri, Arthika Surendran, Julian Sonksen, Robert Sinnerton, Caitlin Brennan, Gemma Faulkner, Michael Greenhalgh, Hannah Emerson, Kiran Singisetti, Joshua Totty, Michael Wilson, Terence Lo, Harriet Corbett, Ijeoma Okonkwo, Gill Arbane, Kariem El-Boghdadly, Cyrus Kerawala, Chetan Parmar, Tom Abbott, Michael Bath, Funlayo Odejinmi, Jayesh Sagar, Rishi Talwar, Samuel Newman, John Hammond, John Moir, Natalie Duric, Tamas Szakmany, Ahmar Iftikhar Talib, Mina Youssef, Christopher Lewis-Lloyd, Christopher Lewis-Lloyd, Mariam Lami, Khurram Ayub, Benjamin Dean, Supriya Balasubramanya, Sathya Lakpriya, Luke Rogers, Paul Turner, Mark Maher, Kohila Sigamoney, John Edwards, Jihène El Kafsi, John Hardie, David Johnson, Christin Henein, Marianne Hollyman, Ketan Agarwal, Simon Powell, Govind Singh Chauhan, Rakesh Patel, Joel Gagnier, Heather Carmichael, Aurora, Kristofor A Olson, Eric Etchill, Joseph Incorvia, Sameer Hirji, Matthew Naunheim, Frederick Drake, Haytham Kaafarani, Caroline Reinke, Anna Alecci, Dennis Vaysburg, Jennifer Rodriquez, Emily Shih, Vin Shen Ban, Julia Coleman, Henry E Rice, Krista Kaups-Fresno, Emmanouil Giorgakis, Maggie DiNome, Neal Bhutiani, Omar Alnachoukati, Brittany Bankhead-Kendall, Taylor Aiken, Thomas Diehl, Ankush Gosain, Rishi Rattan, Muhammad Owais Abdul Ghani, Nensi Melissa Ruzgar, Anna Liveris, Nina Glass, Charu Paranjape, Theresa Chin, Antonio Meola, Kristina Nicholson, John Squiers, Stephanie Lueckel, Janani Reisenauer, Rachael Callcut, Ahmed Mansour, Allison Berndtson, Lucy Kornblith, Sara Seegert, Paulo Martins, Hamza Al-Naggar, Mohammed Al-Shehari, Ibrahim Al-Raimi, Allan Ngulube, Maphios Siamuchembu, Willard Mushiwokufa, Busisiwe Mlambo, Simbarashe Chinyowa, Ervis Agastra, Enton Bollano, Kostandin Gjyli, Dariel Thereska, Irida Dajti, Jola Kerpaci, Enxhi Vrapi, Lorena Zijaj, Bahraoui Djahida, Belabbes Fatima Zohra, Kouidri Khadidja, Oussama Bali, Nassim Benallel, Ismahene Lalmi, Meriem Abdoun, Nesrine Aouabed, Souad Bouaoud, Kamel Bouchenak, Assia Haif, Zineddine Soualili, Joaquin Bastet, Agustín Bianco, Daniel Capitaine, Jorge Centeno Lozada, Carlos Esquivel, Rodrigo Figueroa, Manuel Garcia, Pablo Martín García, José Ignacio Gerchunoff, Fernando Martinez Iascano, Jose Mondino, María Emilia Muriel, Carmignani Pablo, Martin Passadore, Alejandra Tornini, Rogelio Traverso, Lara Vargas, Gerardo Zanoni, Norberto Berber, Estefanía Cotta, Marcela Di Vincenzo, Esteban Sebastian Gallino, Cecilia Gigena, Bianca Grassano, Veronica Laudani, Ignacio Lugones, Constanza Madrid, Maximiliano Maricic, Antonio Alberto Martinez, Andres Rosso, Pablo Scher, Sofia Tachella, Damaris Idara Anabel Zezular, Carla Abuawad, Agustin Albani Forneris, Carola Allemand, Laura Gisela Alvarez Calzaretta, Luis Boccalatte, Jorge G Boretto, Rocio Boudou, Rodrigo Brandariz, Martin Buljubasich, Arturo Burchakchi, Martin Buttaro, Juan Pablo Campana, Virginia Cano Busnelli, Tomas Carminatti, Agustina Florencia Castro Lalín, Julian Cereghini, María Sol Crespi Amor, Roberto Sebastián Croattini, Maria Sol Fernandez, Marcelo Figari, Uriel Fraidenraij, Diego Gallegos, Agustín Maria García-Mansilla, Marcos Gonzalez, Matias Ignacio Gonzalez, Esteban Gonzalez Salazar, Jeremias Goransky, Guillermo Hernandez Gauna, Felipe Higuera, Fernando Holc, Esteban Gabriel Jauregui, Juan Larrañaga, Juan Liyo, Lionel Llano, Pablo Lobos, Emilia Luzzi, Gustavo Mastroianni, Santiago Miguel Mata-Suarez, Horacio F Mayer, Santiago Mc Loughlin, Efrain Mendoza, Ricardo Esteban Mentz, Pedro Mercado, Pablo Moyano, Florencia Noll, Diego Odetto, Agustina Rene Oliva, Rafael Perez Vidal, Catalina Poggi, Eduardo Jorge Premoli, María Lourdes Ramos, Patricio Rosas, Luciano Rossi, Gustavo Rossi, Jose Saadi, Jordán Scherñuk, Pablo Slullitel, María Verona Stang, María Victoria Taboada, Sebastian Tirapegui, Constanza Uffelmann, Carlos Vaccaro, Roberto Vagni, Ana Clara Valerio, Celeste Soledad Zarratea, Carina Chwat, Silvina Montal, Brian Morris, Pedro Valdez, Fernando Diaz-Couselo,Ricci C, Casadei R, Fruscio, R, Ornaghi, S, Felice Pecoraro, Emanuele Cammarata, Sofia Campanella, Daniela Canzonieri, Adriana Cordova, Federico De Michele, Ettore Dinoto, Mara Franza, Leo Licari, Daniele Matta, Domenico Mirabella, Roberto Pirrello, Pierfrancesco Pugliese, Fernando Rosatti, Giuseppe Salamone, Francesca Toia, Massimiliano Tripoli, Vito Chiantera, Mariano Catello Di Donna, Collaborative, Covidsurg, Collaborative, Globalsurg, Palmisano, Silvia, de Manzini, Nicolo', Simoes, J, Rosati, R, on behalf of COVIDSurg Collaborative, GlobalSurg Collaborative, Aldrighetti, L, Mortini, P, Olmi, S, Medical Oncology, Assoc Surg Training ASiT, European Soc Coloproctology ESCP, EuroSurg, G4 Alliance, GlobalPaedSurg, GICS, ItSURG, ISRC, Italian Soc Colorectal Surg SICCR, PTSurg, S-ECCO, South African Soc, and SpainSurg
Subjects: Lung Diseases, Male, Internationality, SARS-Cov-2, COVID-19, surgery, pathways, pre-operative isolation, Settore MED/18 - CHIRURGIA GENERALE, Vascular damage Radboud Institute for Health Sciences [Radboudumc 16], Lung Disease, ESTUDOS PROSPECTIVOS, Cohort Studies, Patient Isolation, Postoperative Complications, 80 and over, Prospective Studies, Prospective cohort study, 610 Medicine & health, Aged, 80 and over, Incidence (epidemiology), Treatment Outcome, Elective Surgical Procedures, Female, Elective Surgical Procedure, Cohort study, Human, medicine.medical_specialty, Isolation (health care), Preoperative care, NO, Anesthesiology, Preoperative Care, medicine, Humans, Elective surgery, LS7_4, Aged, business.industry, pathway, Surgery, Reconstructive and regenerative medicine Radboud Institute for Health Sciences [Radboudumc 10], Prospective Studie, Anesthesiology and Pain Medicine, Human medicine, Postoperative Complication, Cohort Studie, business, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology
Abstract: We aimed to determine the impact of pre-operative isolation on postoperative pulmonary complications after elective surgery during the global SARS-CoV-2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which patients did not leave their house or receive visitors from outside their household. The primary outcome was postoperative pulmonary complications, adjusted in multivariable models for measured confounders. Pre-defined sub-group analyses were performed for the primary outcome. A total of 96,454 patients from 114 countries were included and overall, 26,948 (27.9%) patients isolated before surgery. Postoperative pulmonary complications were recorded in 1947 (2.0%) patients of which 227 (11.7%) were associated with SARS-CoV-2 infection. Patients who isolated pre-operatively were older, had more respiratory comorbidities and were more commonly from areas of high SARS-CoV-2 incidence and high-income countries. Although the overall rates of postoperative pulmonary complications were similar in those that isolated and those that did not (2.1% vs 2.0%, respectively), isolation was associated with higher rates of postoperative pulmonary complications after adjustment (adjusted OR 1.20, 95%CI 1.05–1.36, p=0.005). Sensitivity analyses revealed no further differences when patients were categorised by: pre-operative testing; use of COVID-19-free pathways; or community SARS-CoV-2 prevalence. The rate of postoperative pulmonary complications increased with periods of isolation longer than 3days, with an OR (95%CI) at 4–7days or ≥8days of 1.25 (1.04–1.48), p=0.015 and 1.31 (1.11–1.55), p=0.001, respectively. Isolation before elective surgery might be associated with a small but clinically important increased risk of postoperative pulmonary complications. Longer periods of isolation showed no reduction in the risk of postoperative pulmonary complications. These findings have significant implications for global provision of elective surgical care. We aimed to determine the impact of pre-operative isolation on postoperative pulmonary complications after elective surgery during the global SARS-CoV-2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which patients did not leave their house or receive visitors from outside their household. The primary outcome was postoperative pulmonary complications, adjusted in multivariable models for measured confounders. Pre-defined sub-group analyses were performed for the primary outcome. A total of 96,454 patients from 114 countries were included and overall, 26,948 (27.9%) patients isolated before surgery. Postoperative pulmonary complications were recorded in 1947 (2.0%) patients of which 227 (11.7%) were associated with SARS-CoV-2 infection. Patients who isolated pre-operatively were older, had more respiratory comorbidities and were more commonly from areas of high SARS-CoV-2 incidence and high-income countries. Although the overall rates of postoperative pulmonary complications were similar in those that isolated and those that did not (2.1% vs 2.0%, respectively), isolation was associated with higher rates of postoperative pulmonary complications after adjustment (adjusted OR 1.20, 95%CI 1.05–1.36, p=0.005). Sensitivity analyses revealed no further differences when patients were categorised by: pre-operative testing; use of COVID-19-free pathways; or community SARS-CoV-2 prevalence. The rate of postoperative pulmonary complications increased with periods of isolation longer than 3days, with an OR (95%CI) at 4–7days or ≥8days of 1.25 (1.04–1.48), p=0.015 and 1.31 (1.11–1.55), p=0.001, respectively. Isolation before elective surgery might be associated with a small but clinically important increased risk of postoperative pulmonary complications. Longer periods of isolation showed no reduction in the risk of postoperative pulmonary complications. These findings have significant implications for global provision of elective surgical care.
Published: 2021

45. Post-transplant immunosuppression and COVID-19: From a double whammy to a mixed blessing

Author: Ashwin Rammohan
Subjects: Transplantation, medicine.medical_specialty, Coronavirus disease 2019 (COVID-19), business.industry, medicine.medical_treatment, Immunity, 030232 urology & nephrology, Clinical course, COVID-19, Minireviews, Immunosuppression, Objective data, Review, Disease, 030230 surgery, medicine.disease_cause, Post transplant, 03 medical and health sciences, 0302 clinical medicine, Post-transplant immunosuppression, Pandemic, medicine, Intensive care medicine, business, Coronavirus
Abstract: The coronavirus pandemic (COVID-19) has had an unprecedented effect on various disease processes and their management. COVID-19 is likely to have a complex pathophysiological interplay with the post-transplant patients; one affecting the clinical course and outcome of the other. In the absence of validated data from trials, there is strong dependence on experience based on previous similar epidemics (SARS/MERS), and from consensus based on expert opinions. Despite the fact that our knowledge is rapidly evolving with time, there still is relatively limited objective data on the effect of COVID-19 on the human body. Numerous questions remain unanswered, one of which involves the management of immunosuppression in the post-transplant recipient during this contagion. The core tenet of which continues to be that of establishing an equipoise between infection and rejection. This review summarises the current knowledge on immune interactions of the virus, the immunomodulatory effects that may be at play, and its relation to the art of immunosuppression.
Published: 2020

46. Proceedings of the 25th Annual Congress of the International Liver Transplantation Society

Author: Amelia J. Hessheimer, David W. Victor, Michael Spiro, Tomohiro Tanaka, Ashwin Rammohan, Marit Kalisvaart, Prashant Bhangui, Gonzalo Sapisochin, Irene Scalera, Gokhan Kabacam, Eleonora De Martin, Isabel Campos Varela, Ryan M Chadha, Varvara A. Kirchner, Carmen Vinaixa, Nicolas Goldaracena, Albert C. Y. Chan, and Young In Yoon
Subjects: Transplantation, medicine.medical_specialty, business.industry, medicine.medical_treatment, education, Treatment outcome, MEDLINE, 030230 surgery, Liver transplantation, Clinical Practice, 03 medical and health sciences, Patient safety, surgical procedures, operative, 0302 clinical medicine, Perioperative care, medicine, Vanguard, 030211 gastroenterology & hepatology, Intensive care medicine, business
Abstract: The 25th Annual Congress of the International Liver Transplantation Society was held in Toronto, Canada, from May 15 to 18, 2019. Surgeons, hepatologists, anesthesiologists, critical care intensivists, radiologists, pathologists, and research scientists from all over the world came together with the common aim of improving care and outcomes for liver transplant recipients and living donors. Some of the featured topics at this year's conference included multidisciplinary perioperative care in liver transplantation, worldwide approaches to organ allocation, donor steatosis, and updates in pediatrics, immunology, and radiology. This report presents excerpts and highlights from invited lectures and select abstracts, reviewed and compiled by the Vanguard Committee of International Liver Transplantation Society. This will hopefully contribute to further advances in clinical practice and research in liver transplantation.
Published: 2020

47. Perioperative screening and management in elective complex hepatobiliary surgery

Author: Akila Rajakumar, Ashwin Rammohan, and Mohamed Rela
Subjects: Postoperative Complications, Elective Surgical Procedures, Humans, Postoperative Period, Critical Care and Intensive Care Medicine, Risk Assessment, Perioperative Care
Abstract: Preoperative optimization and structured evidence-based perioperative care of a patient undergoing complex hepatobiliary (HPB) surgery are essential components in their management. Apart from advances in surgical technique, these perioperative measures have resulted in substantial reductions in morbidity and mortality. There hence, remains a continued need to have evidence-based updation in their management algorithm to ensure optimal outcomes.We present an evidence-based overview of the preoperative screening, optimization and perioperative management of patients undergoing complex HPB surgery.Perioperative care of these fragile patients is an evidence-based dynamic process. Optimal patient management undergoing HPB surgery requires risk assessment and stratification, and meticulous attention to the correction of underlying conditions. Despite this, postoperative morbidity remains relatively high and requires a cohesive multidisciplinary approach to minimize complications.
Published: 2022

48. Nonhepatic Cancer in the Pediatric Liver Transplant Population: Guidelines From the ILTS-SETH Consensus Conference

Author: Mohamed Rela, Jesus Quintero, Mureo Kasahara, Paolo Muiesan, Francisco Hernández-Oliveros, Rajesh Rajalingam, Sadhana Shankar, Blayne Amir Sayed, Diego di Sabato, Ashwin Rammohan, John Fung, and Itxarone Bilbao
Subjects: Adult, Immunosuppression Therapy, Transplantation, Consensus, Risk Factors, Incidence, Neoplasms, Humans, Child, Liver Transplantation
Abstract: The incidence and geographical distribution of cancers in children are dramatically different from the adult population. Consequent to improvements in postcancer survival, there is a progressive increase in the number of patients requiring liver transplantation (LT) who are in remission from pretransplant malignancy (PTM). Conventionally, however, PTM has been considered a relative contraindication to LT. Furthermore, with improving post-LT survival now extending beyond decades, the cumulative effect of immunosuppression and the increasing risk of de novo cancers need to be acknowledged. A working group was formed to evaluate, discuss, and retrieve all the evidence and provide guidelines with regards to best practices surrounding nonhepatic cancer in the pediatric LT (PLT) population. Further subsections of research included (a) extrahepatic solid tumors, leukemia, lymphoma, and other hematological disturbances before PLT and (b) malignancies following PLT (including posttransplant lymphoproliferative disorders). This guidance provides a collection of evidence-based expert opinions, consensus, and best practices on nonhepatic cancers in PLT.
Published: 2021

49. Liver Tumors in Children

Author: Mohamed Rela, Ashwin Rammohan, and Mettu Srinivas Reddy
Published: 2021

50. Multidisciplinary Management of Alagille Syndrome

Author: Jagadeesh Menon, Naresh Shanmugam, Mukul Vij, Ashwin Rammohan, and Mohamed Rela
Subjects: General Medicine, General Nursing
Abstract: Alagille syndrome (ALGS) is an autosomal dominant disorder characterized by involvement of various organ systems. It predominantly affects the liver, skeleton, heart, kidneys, eyes and major blood vessels. With myriads of presentations across different age groups, ALGS is usually suspected in infants presenting with high gamma glutamyl transpeptidase cholestasis and/or congenital heart disease. In children it may present with decompensated cirrhosis, intellectual disability or short stature, and in adults vascular events like stroke or ruptured berry aneurysm are more commonly noted. Liver transplantation (LT) is indicated in children with cholestasis progressing to cirrhosis with decompensation. Other indications for LT include intractable pruritus, recurrent fractures, hepatocellular carcinoma and disfiguring xanthomas. Due to an increased risk of renal impairment noted in ALGS, these patients would require optimized renal sparing immunosuppression in the post-transplant period. As the systemic manifestations of ALGS are protean and a wider spectrum is being increasingly elucidated, a multidisciplinary team needs to be involved in managing these patients. Moreover, many basic-science and clinical questions especially with regard to its presentation and management remain unanswered. The aim of this review is to provide updated insights into the management of the multi-system involvement of ALGS.
Published: 2021

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