BackgroundHemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome that can obscure underlying malignancies, particularly aggressive B-cell lymphoma. Severe cytopenias and coagulopathy often preclude conventional biopsy, delaying diagnosis.ObjectivesTo assess the diagnostic utility of transjugular liver biopsy (TJLB) in adult patients presenting with HLH, transfusion-refractory thrombocytopenia, and predominant hepatic involvement, and to explore mechanisms of thrombocytopenia.MethodsThree adult patients with HLH, hepatic lesions, and severe thrombocytopenia unresponsive to platelet transfusions were retrospectively analyzed. Conventional biopsy was contraindicated due to bleeding risk. TJLB was performed for histopathological confirmation, followed by lymphoma-directed therapy. Laboratory, imaging, and histopathological data were reviewed.ResultsTJLB established aggressive B-cell lymphoma in all patients, enabling timely chemophagocytic therapy. Platelet counts normalized within 2–4 weeks (case 1 and 2), and HLH-related hyperinflammation resolved. Thrombocytopenia was multifactorial, reflecting hemophagocytosis, immune-mediated platelet destruction, hepatic sequestration, and cytokine-mediated suppression of megakaryopoiesis.ConclusionsHLH may be the first manifestation of occult lymphoma. TJLB is a safe, effective diagnostic strategy in patients with hepatic involvement and high bleeding risk, facilitating early curative therapy. These cases highlight the value of a multidisciplinary, risk-adapted diagnostic approach and provide mechanistic insight into cytopenia in HLH-associated lymphoma.

BACKGROUND & AIMS:Prophylactic use of antibiotics was found to decrease mortality in patients with cirrhosis and acute variceal bleeding (AVB). Patients with Child A cirrhosis have a low risk of treatment failure and mortality. The present study was designed to investigate the association between antibiotics and Child-Pugh A patients with AVB. METHODS:This retrospective analysis was conducted on Child-Pugh class A cirrhotic patients presenting with AVB at West China Hospital between January 2016 and November 2022. The outcome indicators evaluated in this study include the rate of treatment failure within five days, mortality within 6 weeks, incidence of nosocomial infections, and 1-year cumulative mortality. RESULTS:This study ultimately enrolled 237 patients. The day of patients' admission was defined as Day 0. A total of 117 patients received prophylactic use of antibiotics on Days 0-1 (Group A), and 120 patients did not receive antibiotics on Days 0-1 (Group B). Baseline characteristics were well-balanced between the two groups. The 5-day treatment failure was 8.5% in Group A and 6.7% in Group B (p = 0.63). The 6-week mortality was 1.71% in Group A and 0% in Group B (p = 0.24). The incidence of nosocomial infection (5.98% vs. 6.67%, p = 1.00) and 1-year cumulative mortality (4.81% vs. 1.89%, p = 0.40) was comparable between the two groups. CONCLUSIONS:The antibiotics' prophylactic use was not associated with 5-day treatment failure or 6-week mortality. Prophylactic use of antibiotics may not be routinely necessary in patients with Child A cirrhosis and AVB.

BACKGROUND & AIMS:In patients with variceal hemorrhage, nonselective beta-blockers plus endoscopic variceal ligation are recommended to prevent rebleeding when pre-emptive transjugular intrahepatic portosystemic shunt is not indicated or placed. The aim of this study was to determine whether decompensating events occurring before variceal hemorrhage are associated with worse outcomes in patients treated with nonselective beta-blockers plus endoscopic variceal ligation to prevent recurrent variceal hemorrhage. METHODS:This was a systematic review and individual participant data meta-analysis of studies including patients with cirrhosis and variceal hemorrhage not eligible for pre-emptive transjugular intrahepatic portosystemic shunt in patients with Child-Pugh class A-B and receiving nonselective beta-blockers plus endoscopic variceal ligation to prevent recurrent bleeding. All-cause mortality and new or worsening decompensation were analyzed using cause-specific Cox models and random-effects individual participant data meta-analysis. RESULTS:Thirteen studies (5 randomized controlled trials, 8 observational) contributed 1659 patients (Child-Pugh class A, 805; class B, 853); 606 had had prior decompensation, 121 had ascites, 154 had encephalopathy (alone or combined), 106 had ascites plus variceal hemorrhage, and 225 had variceal hemorrhage alone. The 2-year mortality was 25.1% with prior decompensation and 13.5% without (P < .0001): specific adjusted hazard ratios were 1.8 (95% confidence interval, 1.2-2.6) for prior ascites, 1.7 (95% confidence interval, 1.3-2.3) for encephalopathy, 0.83 (95% confidence interval, 0.6-1.2) for variceal hemorrhage, and 1.4 (95% confidence interval, 0.92-2.3) for variceal hemorrhage + ascites. Individual patient data meta-analysis showed a pooled adjusted hazard ratio for death of 1.4 (95% confidence interval, 1.1-1.7) with prior decompensation. New or worsening decompensation was also significantly higher with any prior decompensation: pooled adjusted hazard ratio, 1.7 (95% confidence interval, 1.15-2.44). CONCLUSIONS:Among patients with Child-Pugh class A-B cirrhosis who were not candidates for pre-emptive transjugular intrahepatic portosystemic shunt and were treated with nonselective beta-blockers plus endoscopic variceal ligation after variceal hemorrhage, prior decompensation identified a subgroup at increased risk of mortality in whom the potential benefit of transjugular intrahepatic portosystemic shunt warrants further investigation.

Purpose To determine the incidence, risk factors, and outcomes of early post-transjugular intrahepatic portosystemic shunt (TIPS) hyperbilirubinemia in cirrhotic patients. Materials and Methods In this retrospective single-center study, 1,404 cirrhotic patients who underwent TIPS were analyzed. Patients with early post-TIPS hyperbilirubinemia (total bilirubin [TB] ≥ 5 mg/dL within 1 week after TIPS; primary predictor) were classified as Group A, and those without it were classified as Group B. Threshold effect analysis was used to identify the optimal cut-off for the change in TB (ΔTB, exploratory parameter), followed by Fine-Gray modeling. Results Early post-TIPS hyperbilirubinemia occurred in 67 patients (4.8%). The cumulative incidence of mortality was higher in Group A than in Group B at 1-year (37.3% vs. 7.7%), 3-year (49.7% vs. 19.8%), and 5-year (49.7% vs. 30.3%) (p < 0.001). Multivariate analysis identified early post-TIPS hyperbilirubinemia (subdistribution hazard ratio [sHR] =3.03, p < 0.001), age (sHR = 1.05, p < 0.001), albumin level (sHR = 0.96, p < 0.001), MELD score (sHR = 1.05, p = 0.005), and Hepatocellular carcinoma (sHR = 1.77, p < 0.001) as independent predictors of mortality. ΔTB was independently associated with mortality whether analyzed as a continuous variable (sHR = 1.19, p < 0.001) or dichotomized at 2.98mg/dL (sHR = 2.64, p < 0.001). Rounding the cutoff to 3 mg/dL did not materially alter the association (sHR = 2.58, p < 0.001). Conclusion TB ≥ 5 mg/dL within the first week after TIPS, or ΔTB ≥ 2.98mg/dL (approximately 3 mg/dL), was independently associated with mortality.

BACKGROUND & AIMS:There is no consensus on the optimal modality of secondary prophylaxis for gastric variceal (GV) bleeding in patients with cirrhosis. METHODS:Observational studies and randomized controlled trials (RCTs) comparing endovascular interventions-balloon-occluded retrograde transvenous obliteration (BRTO) and transjugular intrahepatic portosystemic shunt (TIPS)-with endoscopic cyanoacrylate injection (ECI) were considered for the aggregate data meta-analysis. Individual patient data were collected from RCTs to perform an individual patient data meta-analysis in a propensity score-matched cohort. The primary outcome was comparison of the rates of all-cause rebleeding between ECI, BRTO, and TIPS. Secondary outcomes included overall survival, ascites, and hepatic encephalopathy. RESULTS:Fifteen studies (11 observational and 4 RCTs) comprising 1240 patients (ECI: 377, BRTO: 575, and TIPS: 288) were included in the aggregate data meta-analysis. In the individual patient data meta-analysis, both BRTO (subdistribution hazard ratio [sHR], 0.15; 95% confidence interval [CI], 0.05-0.43; P = .004) and TIPS (sHR, 0.49; 95% CI, 0.27-0.89; P = .019) significantly reduced all-cause rebleeding compared with ECI, without survival benefit. BRTO was associated with a higher risk of new-onset or worsening of pre-existing ascites (sHR, 3.54; 95% CI, 1.31-9.55; P = .013); TIPS increased the risk of hepatic encephalopathy (sHR, 8.84; 95% CI, 2.0-39.11; P = .004) compared with ECI. Benefit in rebleeding reduction was most pronounced among patients with Child-Pugh class B cirrhosis. The analysis revealed limited long-term outcome data, inconsistencies in reported trial outcomes, and significant heterogeneity in results, particularly regarding TIPS. CONCLUSIONS:Endovascular interventions (BRTO and TIPS) are superior to ECI for reducing all-cause rebleeding in patients with cirrhosis and gastric variceal hemorrhage. Larger studies with standardized end points and long-term outcomes are needed to clarify survival benefit and optimize treatment selection.

The VIATORR Controlled Expansion (VCX) stent-graft was developed to allow more precise control of shunt diameter during transjugular intrahepatic portosystemic shunt (TIPS) creation. However, real-world data on its actual in vivo expansion behavior and short-term clinical implications remain limited. This study aimed to provide fluoroscopic quantitative assessment of early in vivo expansion of VCX stent-grafts and to assess its association with short-term overt hepatic encephalopathy (OHE). This single-center retrospective cohort included consecutive patients with cirrhosis who underwent TIPS using either a legacy 8-mm VIATORR TIPS stent-graft (VTS) or a VCX stent-graft. In the VCX group, stents were initially dilated to 8 mm and further dilated to 10 mm only when post-procedural portal pressure gradient (PPG) remained > 12 mmHg or decreased by < 50

BACKGROUND:Many andrologists put more attention on the predictive factors of successful sperm extraction in testicular sperm aspiration (TESA) or microdissection testicular sperm extraction (micro-TESE), while the importance of laboratory processing of testicular tissue has been neglected. In fact, for non-obstructive azoospermia (NOA) patients, laboratory procedure of testicular tissue is as important as the surgery itself to find testicular sperm, yet there is no standard procedure for laboratory management of testicular tissue. OBJECTIVES:To establish a laboratory processing for testicular tissue, and to further evaluate the effectiveness of enzymatic digestion and staining for NOA patients with no spermatozoa found after mechanical mincing. MATERIALS AND METHODS:We enrolled 811 patients who underwent TESA or micro-TESE from July 2023 to December 2024, among whom 466 were diagnosed with obstructive azoospermia and 345 were diagnosed with NOA. The main outcome measure was the sperm retrieval rate (SRR) after enzymatic digestion and the sperm detection rate (SDR) after staining. RESULTS:In this study, testicular spermatozoa was found after mincing in 466 TESA patients (466/583, 79.9%) and 74 micro-TESE patients (74/228, 32.5%). Of the 237 patients for whom spermatozoa were not identified after mincing, spermatozoa were detected in 55 (23.21%) patients after enzyme digestion and staining. The additional SRR contributed by enzymatic digestion alone was 13.1%, while staining contributed an additional SDR of 10.1%. Using multivariable logistic regression analysis, the seminiferous tubule diameter was the only predictor of identifying spermatozoa in NOA patients after enzymatic digestion and staining. DISCUSSION AND CONCLUSION:In conclusion, we establish a three-step laboratory processing method for testicular tissue. This study provides strong evidence that enzymatic digestion improves SRR in NOA patients, while staining contributes additional detection value (SDR) when mechanical processing fails, the combined additional value of enzymatic digestion and staining is 23.2%, although only enzymatic digestion contributes to SRR. What is more, the current study showed that seminiferous tubule diameter is a powerful predictor for sperm retrieval, offering real-time, actionable intraoperative guidance. However, the single-center design and lack of live birth outcome data limit the external validity and generalizability of this study.

Predicting hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) is critical for guiding portal hypertension treatment strategies and enabling early intervention. This study aims to employ the Tabular Prior-data Fitted Network (TabPFN) algorithm to develop a machine learning (ML) model that predicts post-TIPS HE. This study retrospectively enrolled 218 patients who underwent TIPS across three hospitals. Preoperative contrast enhanced CT (CECT) scans were used to delineate the volumetric region of interest (VOI) for the liver, spleen, abdominal fat, and abdominal muscle. Radiomics and deep transfer learning (DTL) features were extracted from each VOI. Overt HE occurrence during follow-up was divided into two groups. 171 patients (two hospitals) were randomly split (7:3) into training and validation set, 47 patients (third hospital) formed an external test set. After feature selection, we trained and compared multiple ML models. Shapley additive explanation (SHAP) was performed for model interpretability. The overall incidence of overt HE in the study cohort was 20.6