Primary Sepsis Presenting as Fulminant Hepatic Failure

Four patients who were referred to the Liver Failure Unit withan initial diagnosis of fulminant hepatic failure were foundto have severe bacterial infeclion from a primary septic focusas the cause of their illness. Clinical and biochemical characteristicswere not helpful in differentiating these patients from thosewith hepatic failure from other causes, and only a high degreeof suspicion will prevent delay in the diagnosis of underlyingsepsis and initiation of appropriate treatment. The possiblemechanisms respomible for this uncommon association are discussed.     

Plasma and Brain Amino Acids in Fulminant Hepatic Failure and their Relationship to Hepatic Encephalopathy

Amino acid concentrations were determined in plasma, whole blood, cerebrospinal fluid and brain tissue of 45 patients with grade 3 or 4 coma due to fulminant hepatic failure. The concentration of 15 of the 19 amino acids determined were significantly increased in blood and the, increases were greatest for the amino acids concerned with neurotransmitter metabolism. There was no correlation, however, between the plasma concentration of these amino acids and changes in the grade of hepatic coma. The plasma concentrations of the branched chain amino acids were normal except in those patients who subsequently recovered in whom levels were slightly decreased. Phenylalanine, tyrosine and methionine were among the 15 out of 18 amino acids which were significantly increased in cerebrospinal fluid and among the 15 out of 21 amino acids which were significantly increased in the brain. The increase in tryptophan was associated with a significant elevation in brain 5-hyroxyindoleacetic acid concentration suggesting an increase in 5-hydroxytryptamine turnover in hepatic coma. Brain to plasma ratios of most amino acids in hepatic coma patients were similar to control subjects suggesting that plasma concentration is the main factor controlling the cerebral concentration. However, for the branched chain amino acids, cerebrospinal fluid and brain concentrations were increased when plasma concentrations were normal suggesting an increase in brain uptake.     

Fulminant Hepatic Failure Due to Acetaminophen Poisoning May Be Less Common in Hong Kong

Case Report: Peritoneal exposure to mercury has been rarely reported and long-term consequences of this type of exposure have not been documented. We report the clinical course of a patient who has survived almost eight years with a massive intraperitoneal load of mercury. She has suffered formication, pruritis, fatigue, irritiability, insomnia, alopecia, dizziness, a gait disturbance, loss of balance and multiple falls, abdominal pain, choking, and headaches. Two courses of chelation with dimercaptosuccinic acid using the standard protocol were undertaken, resulting in increased daily excretion, but without demonstrable objective or subjective benefit or lasting effect. She had multiple medical problems before the mercury intoxication, which complicates the attribution of all her problems to mercury intoxication. It is of particular interest that the patient survived and did not suffer any marked cognitive deterioration. She died in 2002 shortly after being diagnosed with lung cancer and declaring that she would fight it. Phasing out of mercury-weighted tubes is recommended.     

Causes of Death in Fulminant Hepatic Failure and Relationship to Quantitative Histological Assessment of Parenchymal Damage

The clinical course and causes of death in 132 consecutive patientswith fulminant hepatic failure and grade III or IV encephalopathyhave been reviewed. 105 patients died and in 96 of these anautopsy examination was performed. In 36 patients there wascerebral oedema and the mean age of this group was significantlyyounger than the other fatal cases. In 28 patients death wasattributed to major haemorrhage which originated in the gastrointestinaltract in 25. The prothrombin time ratio was not significantlygreater in patients with major bleeding than in those withoutbut they did have a significantly lower platelet count. Sepsiscontributed to death in 12 patients. In 25 patients massivehepatic necrosis only was found at autopsy and death was consideredto be due solely to hepatic failure. The degree of hepatocyte loss was assessed in 80 fatal casesby a histological morphometric technique on a needle specimenof liver taken immediately postmortem. The proportion of theliver volume occupied by hepatocytes (hepatocyte volume fraction,HVF) was greatly reduced in all patients (normal 85 ±SD 5 per cent) but the mean value was significantly higher inthe patients dying with sepsis, cerebral oedema or haemorrhagethan in the group in whom death was attributed solely to hepaticfailure. There were ten patients in whom liver function wasimproving at the time of death which was due to cerebral oedema(9) or haemorrhage (1). These observations suggest that manypatients presently dying from fulminant hepatic failure maybe expected to survive, once more effective therapy is availablefor the complications of the illness. ¹Present address: Charing Cross Hospital, London W.C.2     

Intracranial and Cerebral Perfusion Pressure Changes Before, During and Immediately After Orthotopic Liver Transplantation for Fulminant Hepatic Failure

Several centres that perform liver transplantation for fulminanthepatic failure have experience of patients who have not regainedconsciousness despite adequate graft function. In some of these,decerebration because of elevation in intracranial pressurewas thought to have occurred intraoperatively or in the earlypost-operative period. In the present study six patients withfulminant hepatic failure who were transplanted had extraduralmonitors inserted before operation. Intracranial pressure had been controlled prior to transplanatationand rose during the preclamp phase of the operation. Levelsfell during the anhepatic phase but rose again during the reperfusionphase (p=0.033). Overall, from the induction of anaesthesiato the reperfusion phase there was a significant increase inmean intracranial pressure (p<0.01). The cerebral perfusionpressure fell after induction of anaesthesia from a median 54mmHg (range 46–62) to a median 35 mmHg (range 19–49,p<0.001) in the pre-clamp phase and remained low throughoutthe operation. During the first 10 hours after transplantation,three patients had further episodes of intracranial hypertensionrequiring treatment and it is important that monitoring shouldbe continued through this period.     

N‐Acetylcysteine for the Treatment of Clove Oil Induced Fulminant Hepatic Failure: Case Report and Review of the Literature

We present a 3‐month‐old female who developed fulminant hepatic failure after ingesting less than 8 mL of clove oil. Initial treatment involved gastrointestinal decontamination, supportive measures, and admission to hospital. She subsequently developed fulminant hepatic failure and was treated with intravenous N‐acetylcysteine (N‐AC) according to a protocol used for acetaminophen poisoning. Over the next 72h her liver synthetic function and clinical status improved, and she made a complete recovery. Previous reported cases of clove oil toxicity and the potential role of N‐AC therapy are reviewed.     

多次机采血小板对献血者血小板功能的影响

目的 观察连续多次机采血小板对献血者血常规和血栓弹力图(TEG)的影响,以保证血小板的采集质量和献血者的自身健康.方法 分别检测观察组(连续固定采集血小板时间大于1年,每次间隔15～20 d)与对照组(首次采集血小板或距上次采集时间超过1年)采血前后的血常规、TEG常规指标(R值、K值、α角、MA值)及纤维蛋白原(FIB).结果 采血前后观察组较对照组MPV、PDW均增大(P＜0.05),而PLT及TEG各参数(R值、K值、α角、MA值)两组间差异均无统计学意义;观察组采血后较采血前K值、MPV、PDW增大(P＜0.05),α角、MA值、PLT减小(P＜0.05);对照组采血后较采血前K值、MPV增大(P＜0.05),α角、MA值、PLT减小(P＜0.05).结论 频采献血者MPV、PDW均增大,但其血小板的数量及功能仍在正常范围,即频采不会损害献血者的健康及血小板的采集质量,可以保证血小板输注疗效,满足临床用血的需要.     

治疗性血小板单采术在临床上的应用及其对血小板功能的影响

目的探讨治疗性血小板单采术临床应用及其对血小板功能的影响。方法应用血细胞分离机去除血小板,并进行血小板黏附率、聚集率和血小板α颗粒膜蛋白(GMP-140)的检测。结果通过治疗性血小板单采术去除了患者体内增多的血小板,同时单采前、后血小板黏附率、聚集率及血小板α颗粒膜蛋白(GMP-140)表达没有显著变化。结论治疗性血小板单采术可以有效地去除血小板,并且对血小板无异常活化作用。     

成人急性白血病血小板活化和活化功能的研究

为了用流式细胞术(FCM)微量全血法检测血小板活化状态和血小板活化功能,探讨其与成人急性白血病出血、浸润的关系,利用FCM检测成人急性白血病(AL)患者初诊期、缓解期(CR1)和持续长期缓解期(CCR)外周血血小板活化标志物CD62P、PAC-1的表达变化,并以健康体检者作对照组。结果表明:与健康组比较ADP激活前,AL组CD62P、PAC1表达高于对照组(P<0.001)。ADP激活后,AL组CD62P表达高于对照组(P<0.05),PAC1表达低于对照组(P<0.001);CR1组PAC1表达仍低于对照组(P<0.001),CD62P无差异;CCR组PAC1、CD62P无差异。无巨核细胞恶性病变组AL与伴有巨核细胞恶性病变组AL比较,血小板ADP激活前两组CD62P和PAC1无显著性差异;激活后伴有巨核细胞恶性病变组PAC1表达低于无巨核细胞恶性病变组(P<0.001)。结论:①AL患者外周血血小板存在较高水平的活化,提示血小板活化与肿瘤细胞相互作用可能是急性白血病患者存在广泛的浸润、出血的原因之一。②AL初发时血小板减少,同时伴有血小板活化功能异常,这种异常可能是骨髓白血病细胞恶性增生,导致骨髓巨核细胞生成减少或功能异常所致。     

慢性肾功衰竭患者的糖代谢紊乱

本文测定了27例慢性肾功衰竭(CRF)患者口服葡萄糖耐量试验(OGTT)时的血清胰岛素,并以性别年龄匹配的27例正常人作为对照。结果显示CRF患者耐糖曲线及胰岛素释放曲线均高于正常对照组;耐糖异常(IGT)及耐糖正常(NGT)的CRF患者胰岛素释放曲线有明显差异。     

Kidney Function in Heart Failure

Objective. The purpose of this investigation was to improve a rankit ordinal model for evaluating and validating dichotomized tests in a prospective Nordic project. Material and methods. The model is based on the assumption that the S‐shaped curve of fractions of positive for increasing concentrations can be de‐convoluted to a histogram and thereby used to calculate the parameters for a ln‐Gaussian distribution. In a Nordic survey, four urine samples with known concentrations of hCG (human chorionic gonadotrophin) and nitrites were distributed to more than 2500 practitioners' offices. Results. The results are presented as parameters (geometric mean and CV) for the components urine‐hCG and urine‐nitrites, together with fractions of positive for clinical critical values (5 and 40?IU/L for hCG), for which fractions should be below 0.01 and above 0.99, respectively, and 7?µmol/L for nitrites. Furthermore, the concentration intervals of varying fractions of positive from 0.01 to 0.99 are estimated as grey zones. The parameters and grey zones for different kits are compared. No urine‐hCG kit fulfilled the low clinical criterion, whereas all fulfilled the high criterion. Seven of the eight nitrites kits had fractions of positive above 0.9 for the company confirmation limit, but varying fractions for the clinically important limit of 7?µmol/L (fractions from 0.06 to 0.83). Conclusions. The present model makes it easy to estimate parameters for the kits, and also to estimate the fractions of measured positives for specified concentrations. It is thus suited for external quality assessment as well as for manufacturers' method validation.     

Dietary Fats and Platelet Function among Finnish Men

The aim of this study was to elucidate the role of platelet aggregation as a risk factor for ischemic heart disease (IHD) and the relationship between fatty acids and platelet function. Platelet aggregation upon adenosine diphosphate (ADP), adrenaline and thrombin were measured in middle aged men in east and west, two regions of Finland with a nearly twofold difference in IHD mortality. Platelet aggregation results were correlated with the fatty acid compositions of plasma lipid fractions, adipose tissue triglycerides and platelet phospholipids.

There was no significant east-west difference in platelet reactivity to ADP, adrenaline and thrombin. ADP-induced platelet aggregation showed significant negative correlations with all the platelet C20-C22 n-3 polyunsaturated fatty acids (PL)FA), but significant positive correlations with the percentage of 18:2n-6 in adipose tissue and plasma cholesterol esters (CE) and triglycerides (TG). Adrenaline-induced aggregation correlated negatively with the percentage of 20:5n-3 in plasma CE and TG, and positively with the total percentage of saturated fatty acids in platelets. Aggregation upon thrombin had a negative correlation with the 20:3n-6/20:4n-6 ratio in plasma CE and a positive correlation with 18: 2n-6 in adipose tissue.

The percentages of the major PUFA in platelets correlated sgnificantly with the same fatty acids in plasma CE and phospholipids PL. Platelet 20: 5n-3 had a highly significant negative correlation with the percentage of 18:2n-6 in plasma and adipose tissue lipids. Platelet 20: 4n-6 was unrelated to its precursors in plasma. The percentage of 18: 2n-6 in plasma and adipose tissue lipids was consistently lower in men from eastern than western Finland, whereas the percentage of platelet 20: 5n-3 was higher in the eastern men.

The results indicate, that (1) platelet function may not play a role in the regional gradient in IHD rate in Finland, (2) in a free-living population, relatively small changes in plasma and platelet fatty acids may have significant influence on platelet aggregation and on thrombosis tendency and (3) an increase in dietary PUFA content may not affect platelet function favourably, unless attention is paid to the maintaining of the n-3/n-6 ratio in the diet.     

捐献机采血小板者血液初筛不合格原因分析及对策

目的分析捐献机采血小板者血液初筛不合格原因,以提出针对性的对策,提高再次献血率。方法统计2006—2008年捐献机采血小板者共26862例次血液初筛检测情况,将血液初筛检测不合格者按照转氨酶、血小板计数、红细胞计数、白细胞计数、红细胞压积和血红蛋白含量6项指标进行统计,并对初筛不合格原因进行分析。结果2006—2008年,捐献血小板者血液初筛不合格率分别为9.56%、9.41%、8.87%。不合格原因以转氨酶异常居首,分别为4.47%、3.73%、3.91%,主要集中在40～100U范围内;其次是血小板计数不合格,分别为2.02%、2.11%、1.73%,主要集中在〈150&#215;109/L范围;男性以转氨酶不合格为主,占男性初筛检测总例次的5.03%,而女性以血细胞压积不合格为主,占女性初筛检测总例次的3.32%。结论转氨酶和血小板计数不合格是捐献机采血小板者血液初筛不合格的主要原因,而红细胞压积不合格是导致女性捐献者暂缓捐血的主要原因,提示对捐献者进行有针对性的干预具有重要意义。     

慢性心力衰竭患者B型钠尿肽与血小板参数的相关性观察

【目的】探讨慢性心力衰竭（CHF）患者B型钠尿）tk（BNP）与血小板参数的相关性。【方法】分别检测116倒CHF患者（CHF组）和60例非心衰心脏病患者（对照组）的BNP、血小板计数（PLT）、平均血小板体积（MPV）、血小板体积分布宽度（PDW）和大血小板比率（P-LCR）,并进行对比性分析。【结果ICHF组的BNP水平明显高于对照组,差异有统计学意义（P〈0．01,z=7．276）;CHF组的MPV、PDW和P—LCR明显高于对照组,差异有统计学意义（均P〈0．01,t=4．203,8．484,5．760）;而两组间的PLT差异无显著性（P〉0．05,t=0．210）。CHF组患者BNP水平与MPV（r=0．246,P〈O．05）、PDW（r=0．299,P〈0．05）和P—LCR（r=0．329,P〈0．05）呈正相关。【结论】CHF患者血小板参数与BNP密切相关,检测这些指标有助于CHF患者的病情评估、疗效监测和预后判断。     

枯否细胞在急性实验性肝功能衰竭发生中的作用

实验表明,单纯大剂量四氮化碳可严重损伤肝实质细胞,由于对枯否细胞的功能无明显影响,故未形成严重的内毒素血症。在四氯化碳损伤肝脏的同时,用二氧化硅抑制枯否细胞的功能则形成严重的内毒素血症,动物发生急性肝功能衰竭(肝昏迷与功能性肾衰竭)。从而进一步证实了我们提出的肝功能衰竭发病机制一肠源性内毒素血症这一假说。     

血小板膜微粒的制备及止血功能的研究

目的探讨血小板膜微粒(IPMs)的制备工艺,并对研制的IPMs的止血功能及对凝血系统的影响进行动物实验研究。方法用街头采集的全血制备浓缩血小板悬液,用血小板型去白细胞滤器去除白细胞,轻离心去除红细胞后,用生理盐水洗涤血小板并调血小板浓度为2×109/ml,置-80℃反复冻溶3次,再用生理盐水洗涤,然后置60℃、20h灭活病毒,用高压匀质机进行匀质化破碎血小板膜,即为IPMs。用粒度测定仪检测IPMs的粒度;应用活化血浆凝固时间(APCT)检测IPMs的体外促凝血活性;将IPMs输入血小板减少症兔出血动物模型体内,观察IPMs止血效果及对凝血系统的影响。结果制备的IPMs颗粒均匀,大小为200～300nm;50μg/mlIPMs相当于250×109/L新鲜血小板的体外促凝血活性;将IPMs按2mg/Kg输入兔血小板减少症的出血动物模型体内,在输注2～12h内,兔耳出血时间和APCT均明显缩短,而其他凝血指标(PT、APTT、Fg、TT)均无明显变化。结论血小板膜微粒止血效果好,输注IPMs并不影响凝血系统,是一个很有前途的生物止血剂。     

血小板冰冻后功能变化及临床应用研究

目的 探讨血小板冰冻后功能变化及临床应用,并试图探讨血细胞冰冻的个体化依据.方法 将不同浓度的二甲基亚砜(DMSO)作为保护剂加入血小板中,在--80℃条件下冰冻,观察冰冻前后凝血及收缩块形成过程,检测冰冻前后及不同离心条件下血小板计数、血浆中血小板第3因子(PF3)、第4因子(PF4)、血小板体积分布宽度(PDW)及P-选择素(CD62P)对血小板的聚集、黏附、血块收缩功能的影响.对质控条件合格的冰冻血小板单独或合并新鲜血小板的临床应用进行回顾性分析.结果 血小板阻断后血液不凝集;5 ％DMSO与2％DMSO做保护剂冰冻血小板的血浆凝固时间、血块收缩时间及血块收缩功能(血浆析出率)的差异均无统计学意义(P＞0.05),但1％DMSO做保护剂的冰冻血小板的上述各项指标与5％DMSO做保护剂的血小板的差异均有统计学意义(P＜0.05);各样本随着离心次数的增多,所取上清血浆中血小板计数越低,但血浆凝固时间也越短,血块凝固效果越差,离心1次和离心2次后上清血浆的凝固时间、凝固效果的差异均有统计学意义(P＜0.05),1％ DMSO做保护剂的冰冻血小板的上述各项指标与5％DMSO做保护剂的血小板的差异也有统计学意义(P＜0.05);1％DMSO做保护剂的冰冻血小板无凝块形成,将其离心并用新鲜血浆代替上清液后,血块收缩现象又重新出现.2％ DMSO做保护剂与5％DMSO做保护剂的样本中血小板计数、PDW、血浆中PF3、PF4及CD62P等各项指标的差异有统计学意义(P＜0.05).冰冻血小板和新鲜血小板搭配应用与单独新鲜血小板临床效果的差异有统计学意义(P＜0.05).结论 血小板冰冻后血浆凝固时间明显缩短,且与血小板破坏程度有关,血小板破坏越严重,血浆凝固时间越短;但血块收缩时间明显延长,血小板破坏程度越严重,血块收缩时间越长;血块的凝固质量随着血小板的破坏增加而变差;血小板破坏后释放出的PF3、PF4、CD62P对血小板功能有促进凝集和抑制收缩两方面的影响.冰冻血小板和新鲜血小板搭配应用效果较好;可用低浓度2％ DMSO进行冻存.