Acute-on-Chronic Liver Failure (ACLF): The ‘Kyoto Consensus’-Steps From Asia

Acute-on-chronic liver failure (ACLF) is a condition associated with high mortality in the absence of liver transplantation. There have been various definitions proposed worldwide. The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set in 2004 on ACLF was published in 2009, and the APASL ACLF Research Consortium (AARC) was formed in 2012. The AARC database has prospectively collected nearly 10,500 cases of ACLF from various countries in the Asia-Pacific region. This database has been instrumental in developing the AARC score and grade of ACLF, the concept of the \u27Golden Therapeutic Window\u27, the \u27transplant window\u27, and plasmapheresis as a treatment modality. Also, the data has been key to identifying pediatric ACLF. The European Association for the Study of Liver-Chronic Liver Failure (EASL CLIF) and the North American Association for the Study of the End Stage Liver Disease (NACSELD) from the West added the concepts of organ failure and infection as precipitants for the development of ACLF and CLIF-Sequential Organ Failure Assessment (SOFA) and NACSELD scores for prognostication. The Chinese Group on the Study of Severe Hepatitis B (COSSH) added COSSH-ACLF criteria to manage hepatitis b virus-ACLF with and without cirrhosis. The literature supports these definitions to be equally effective in their respective cohorts in identifying patients with high mortality. To overcome the differences and to develop a global consensus, APASL took the initiative and invited the global stakeholders, including opinion leaders from Asia, EASL and AASLD, and other researchers in the field of ACLF to identify the key issues and develop an evidence-based consensus document. The consensus document was presented in a hybrid format at the APASL annual meeting in Kyoto in March 2024. The \u27Kyoto APASL Consensus\u27 presented below carries the final recommendations along with the relevant background information and areas requiring future studies

Temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures: a staged protocol

Introduction: This study determined outcomes after temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures. Materials and methods: A retrospective case analysis was done of all patients who were treated between 2000 and 2008 in 3 level I trauma centers with temporary joint-spanning external fixation before internal fixation of an open intra-articular distal humeral fracture. Healing rates, complications, Disabilities of Arm, Shoulder and Hand ( DASH), and Smith and Cooney outcome scores were documented. Results: The study included 16 patients. Mean follow-up was 35.2 months. Fractures united after an average of 5.2 months. No complications specifically related to the external fixation occurred. The DASH outcome score averaged 15.1. Although complications occurred in 12 patients ( 9 patients requiring surgery), 10 of 16 had an excellent/good outcome score. Conclusions: Temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures is a safe adjunc

Osteochondral Lesions of Talus Associated with Ankle Fractures

Background: Residual ankle pain and stiffness is not uncommon after ankle fractures. Proposed etiologies include ligamentous instability, joint arthrosis and osteochondral injuries. We studied the incidence of osteochondral lesions of the talus (OCLT) with various ankle fracture patterns and assessed their impact on functional outcome. Materials and Methods: Preoperative MRI of 153 patients with ankle fractures who underwent operative fixation was studied. Ligamentous structures around the ankle and OCLT were assessed by MRI. The OCLT was graded as follows: 0, normal; 1, hyperintense but morphologically intact cartilage; 2, fibrillations or fissures not extending into the bone; 3, cartilage flap or bone exposed; 4, loose undisplaced fragment; 5, displaced fragments. Functional outcome was assessed using Foot and Ankle Outcome Scoring (FAOS) at a minimum of 6 months. Outcome between the OCLT and non OCLT group with similar fracture pattern was compared using Fischer's exact test. Results: There were 26 (17%) associated OCLT; four grade I, five grade II, one grade III, eight grade IV, and eight grade V lesions. Three were associated with supination adduction, 21 with supination external rotation injuries and two with pronation external rotation injuries. In the OCLT and the non OCLT group, the average symptom score, pain score, activities of daily living score, sports/recreation score and quality of life score was 80, 72, 79, 45, 50 and 73, 73, 79, 60, 45, respectively. There was no statistically significant difference between the two groups ( p &gt; 0.1). Conclusion: Osteochondral lesions were frequently associated with ankle fractures; however they had no significant impact on the functional outcome when associated with ankle fractures. </jats:p