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The ideal management for end stage liver disease, acute liver failure, and hepatocellular carcinoma (HCC), within specific criteria, is liver transplantation (LT). Over the years, there has been a steady increase in the candidates listed for LT, without a corresponding increase in the donor pool. Therefore, due to organ shortage, it has been substantially difficult to reduce waitlist mortality among patients awaiting LT. Thus, marginal donors such as elderly donors, steatotic donors, split liver, and donors after cardiac death (DCD), which were once not commonly used, are now considered. Furthermore, it is encouraging to see the passing of Acts, such as the HIV Organ Policy Equity (HOPE) Act, enabling further research and development in utilizing HIV grafts. Subsequently, the newer antivirals have aided in successful post-transplant period, especially for hepatitis C positive grafts. However, currently, there is no standardization, and protocols are center specific in the usage of marginal donors. Therefore, studies with longer follow ups are required to standardize its use.

Hepatitis D virus (HDV) is a dependent virus that relies on hepatitis B virus for its replication and transmission. Chronic hepatitis D is a severe form of viral hepatitis that can result in end stage liver disease. Currently, pegylated interferon alpha is the only approved therapy for chronic HDV infection and is associated with significant side effects. Liver transplantation (LT) is the only treatment option for patients with end-stage liver disease, hepatocellular carcinoma, or fulminant hepatitis due to coinfection with HDV. As LT for HDV and hepatitis B virus coinfection is uncommon in the United States, most data on the long-term impact of LT on HDV are from international centers. In this review, we discuss the indications and results of LT with treatment options in HDV patients.

Thyroid nodules are commonly diagnosed in the general population. Though the majority of them are benign and followed clinically once detected, if compressive symptoms arise or malignancy is diagnosed, then surgical excision is considered the standard treatment. As surgery is associated with various post-operative complications, newer less invasive techniques have gained popularity. This article presents the various percutaneous ablation techniques that are currently being used for thyroid nodules. In recent years, several studies largely from Asian and Europe institutions have shown promising results with the use of radiofrequency ablation (RFA), ethanol ablation (EA), and laser ablation (LA) for thyroid nodules. These techniques are gaining more acceptance worldwide as an alternative to surgery. Comparatively newer techniques such as microwave ablation (MWA) and high-intensity focus ultrasound (HIFU) are also available but there is little evidence about their efficacy. Percutaneous ablation techniques with a promising safety profile can be an effective alternative to traditional surgical methods for the management of carefully selected thyroid nodules. However, large-scale randomized control trials are needed to establish the efficacy and safety of these techniques in the North American population.

OBJECTIVE Autonomously functioning thyroid nodules (AFTNs) have long been treated with either surgery or radioactive iodine (RAI). Being an invasive procedure, even thyroid lobectomy for this condition is associated with complications such as anesthesia side effects, scarring, iatrogenic hypothyroidism, and injury to other structures. Similarly, RAI is associated with hypothyroidism and may require multiple courses. Therefore, minimally invasive techniques such as radiofrequency ablation (RFA) are being advocated as an alternative treatment for AFTNs. To date, only few studies have been published on this topic and are largely on European and Asian populations. The aim of this review is to assess the efficacy and safety of RFA as a potential alternative for treatment of AFTNs compared to conventional surgery and radioiodine. METHODS/STUDY DESIGN Comprehensive PubMed and Embase searches were performed using the following terms such as (autonomously functioning thyroid nodules and radiofrequency ablation), (radiofrequency ablation and hyperthyroidism), and (radiofrequency ablation and toxic thyroid nodule). Both prospective and retrospective studies were included based on the inclusion and exclusion criteria specified in the text. RESULTS Initially, 57 studies were identified and after excluding 47 studies, finally 10 studies were included in the review. CONCLUSION Although surgery remains the first line treatment for AFTN. However, RFA is a safe option compared to RAI or surgery, especially in patients who are high-risk surgical candidates or have absolute contraindications to RAI. Currently, trials with follow-up greater than or equal to 5 years are warranted. It will aid in formulating a standardized surveillance protocol and also generalize RFA's use for AFTN. Laryngoscope, 2021.

Background Thyroid nodules are commonly being diagnosed in general population and have a potential for malignant transformation. Historically, surgery has been considered as the first line treatment for these tumors. However, with passage of time newer minimally invasive techniques such as RFA (radiofrequency ablation) has been adapted. Though, RFA for thyroid tumors has been performed more commonly in Asian and European countries, it is a fairly new technique in North America. The aim of the review is to assess the current data and conclude that whether RFA is likely a valuable option when compared to surgery for treatment of thyroid tumors. Materials and methods A Comprehensive PubMed/MEDLINE, Embase and Web of Science search was performed. To expand our search, references of the retrieved articles were also screened for additional data. After selecting the studies that fulfilled the initial screening, authors independently reviewed the selected studies and screened the full texts to identify those that met the inclusion criteria. Results The comprehensive literature search from PubMed/MEDLINE, Web of Science, and EMBASE databases revealed 1094 studies (Embase 870, PubMed 200, and Web of Science 24). References were imported for screening. Amongst 1094 studies, 138 duplicates removed, and 956 studies were screened against title and abstract. After these 777 studies were excluded the remaining 179 studies were assessed for full-text eligibility. Amongst them 127 studies excluded due to wrong design or setting. Finally, 18 studies were included in the review. Conclusion RFA appears to be a safe alternative to surgery in selected cases. However, it is not widely used and there are few randomized controlled trials. Furthermore, it is associated with a low risk profile and has shown promising results in patients who are difficult surgery candidates. Currently large-scale prospective studies are needed in North America to establish the efficacy of RFA and its use as an alternative to surgery for thyroid tumors.

Patient: Female, 80 Final Diagnosis: Diffuse alveolar hemorrhage in influenza A viral pneumonia Symptoms: Generalized fatigue • shortness of breath Medication: — Clinical Procedure: — Specialty: Critical Care Medicine Objective: Rare co-existance of disease or pathology Background: Diffuse alveolar hemorrhage (DAH) represents a life-threatening complication for many respiratory infections. We present a case of a patient with influenza A pneumonia associated with DAH. Case Report: An 80-year-old female patient was admitted with lethargy, dyspnea, and chest pain. On examination, she was afebrile with bilateral basal inspiratory crackles. Her chest x-ray revealed retro-cardiac infiltrate. Her hospital course was complicated by respiratory failure and septic shock requiring intubation. Nasopharyngeal swabs, rapid testing was positive for influenza A. Bronchoscopy showed diffuse bleeding and bronchoalveolar lavage (BAL) of the left lower lobe showed progressively bloody returns, consistent with DAH. Methylprednisolone 250 mg daily was started, with improvement in oxygenation. Repeat bronchoscopy 2 days later revealed normal mucosa and no further bleeding. The patient’s respiratory status and infiltrates improved, but her overall status continued to deteriorate, and she died 2 weeks after admission. Conclusions: High fatality rates have been reported in patients with influenza A viral pneumonia complicated by DAH. Advanced age and the presence of significant co-morbidities might predispose a patient to the development of a more aggressive clinical manifestation of influenza A and also increases the risk of developing DAH. Therefore, clinicians managing patients with influenza A viral pneumonia with this predisposing history should also maintain a high suspicion for DAH. We suggest early BAL for diagnosis and for the evaluation of other infections etiologies. Aggressive supportive care and the use of antiviral agents is recommended. The role of steroids is unclear and can be considered in patients with fulminant disease but might have no outcome benefit.

Chronic hepatitis B is a worldwide health problem. Hepatitis D virus (HDV) is a dependent virus that relies on hepatitis B virus (HBV) to synthesize the pathogenic genomes. This may lead to HDV and HBV coinfection or superinfection that results in rapid liver damage that may lead to various serious complications, such as acute liver failure, cirrhosis, and hepatocellular cancer requiring liver transplantation. However, post-transplant HBV reactivation is always a concern as it can be detrimental to allograft function, leading to poor survival. The mainstay strategy to prevent this has been prophylaxis with hepatitis B immunoglobulin (HBIG) and potent anti-viral drugs. This treatment option has been investigated over the years in terms of appropriate dosing, duration and combination. Furthermore, with the advent of more potent antivirals there have been suggestions to use them as a monotherapy. Although, currently there is no effective therapy available for HDV, but the success of the liver transplantation in these patients is dependent on preventing HBV recurrence. Therefore, there has been a continuous effort to come up with an effective treatment plan that is effective and economical. In this review, we discuss the available treatment options for HBV/HDV after liver transplantation.

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer deaths worldwide and liver transplantation (LT) is the only potentially curative treatment. Over the years, Milan criteria has been used for patient selection. There is ongoing research in this field with introduction of new biomarkers for HCC that can help guide future treatment. Furthermore, newer therapies for downstaging of the tumor are being implemented to prevent dropout from the transplant list. In addition, combination therapies for better outcome are under investigation. Interestingly, the concept of living-donor LT and possible use of hepatitis C virus-positive donors has been implemented as an attempt to expand the organ pool. However, there is a conflict of opinion between different centers regarding its efficacy and data is scarce. The aim of this review article is to outline the various selection criteria for LT, discuss the outcomes of LT in HCC patients, and explore future directions of LT for HCC. Therefore, a comprehensive PubMed/MEDLINE review was conducted. To expand our search, references of the retrieved articles were also screened for additional data. After selecting the studies, the authors independently reviewed them to identify the relevant studies. After careful evaluation 120 studies relevant to out topic are cited in the manuscript. Three tables and two figures are also included. In conclusion LT for HCC has evolved over the years. With the introduction of several expanded criteria beyond Milan, the introduction of bridging therapies, such as transcatheter arterial chemoembolization and radiofrequency ablation, and the approval of newer systemic therapies, it is evident that there will be more LT recipients in the future. It is promising to see ongoing trials and the continuous evolution of protocols. Prospective studies are needed to guide the development of a pre-LT criteria that can ensure low HCC recurrence risk and is not overly stringent, clarify the role of LDLT, and determine the optimal bridging therapies to LT.