The right person? the right place? the right time? a pilot study of the appropriateness of nursing home placements

The appropriate use of health services is a key challenge for the NHS. Older people have been consistently identified as being disproportionately represented amongst those defined as 'inappropriately' located within the acute health sector. Prior to the introduction of community care it was hypothesised that older people were entering nursing home care inappropriately. With the requirement for assessment prior to entry into nursing homes now a feature of the system such 'inappropriate' admissions should not occur. This pilot study investigates the feasibility of determining inappropriate admissions and the extent of this phenomenon in nursing homes used by three inner London Boroughs. To determine the number of 'inappropriate' placements in nursing homes in three London Boroughs (Lambeth, Southwark & Lewisham). Retrospective audit of nursing home case notes using standardised data collection method. New local authority funded admissions to nursing homes from LSL during the period 1 April 1993-31 March 1995. One hundred and fifty seven people entered the 25 nursing homes identified. For 65% nursing home placement was appropriate, 14% were apparently more suited to residential care and 17% for community care. Documentation concerning clients held by the nursing homes was generally poor. Despite the introduction of the Community Care Act and the clear requirement for assessment before entry into nursing home care, approximately one-third of the placements reviewed were inappropriate and did not meet the individual's care needs. Further research is underway to determine if these findings apply nationally.     

Solitary fibrous tumor of the liver

BACKGROUND: Solitary fibrous tumor of the liver is a rare neoplasm. So far, 23 cases have been described in the English literature. We reported an additional case. METHODS: A 46-year-old woman presented with abdominal mass for 2 weeks. Both abdominal sonography and CT scan showed a solid mass occupying the right lobe of the liver. Right lobectomy was performed and the tumor was resected. RESULTS: Pathological examination showed spindle cell and fibroblast-like cells within the collagenous troma. On immunohistochemical staining, these spindle tumor cells showed diffusely CD34 positive reactivity. The post-operative course was uneventful. The patient recovered smoothly, and was alive half a year without evidence of disease recurrence. CONCLUSIONS: The proper diagnosis was depended on CD34 immunohistochemical study. The number of solitary fibrous tumor of the liver reported to date is too limited to confirm the definite prognosis of the tumor.     

Problems in adult living donor liver transplantation using the right hepatic lobe

BACKGROUND: Adult living donor liver transplantation (LDLT) is now widely applied to patients, children or adults, and the graft extends from the left hepatic lobe to the right hepatic lobe. Harvesting the right hepatic lobe would mean putting the donor at high risk. The congestion of a graft may cause small-for-size syndrome. The safety of the donor and its evaluation, which are related to the outcome for the recipient,play an important role in LDLT. How to decrease the congestion of the graft is another challenge to transplant experts. DATA SOURCES: A literature search from MEDLINE about adult LDLT in recent years was made to analyze the safety of the living donor and the innovation of surgical techniques for preventing small-for-size syndrome. RESULTS: The top priority for adult LDLT is donor safety. Preoperative donor evaluation consists of three stages: phase 1 for general evaluation, phase 2 for laboratory tests, and phase 3 for radiological evaluation of graft volume and vessel anatomy. The potential pathogenic mechanisms of small-for-size syndrome seem to be related to persistent portal hypertension and portal overperfusion. Improved surgical techniques for decreasing portal hypertension and preventing congestion of a graft may reduce the incidence of small-for-size syndrome. The improved techniques include reconstruction of the tributaries of the middle hepatic vein, end-to-side portocaval shunting, ligation of the splenic artery, dual-graft transplantation, and modified reconstruction of hepatic veins. CONCLUSION: With the careful preoperative assessment and the safety of the living donor, as well as improved surgical techniques, adult LDLT using the right lobe is safe.     

Is right lobe liver graft without main right hepatic vein suitable for living donor liver transplantation?

BACKGROUND Since the first living donor liver transplantation(LDLT) was performed by Raia and colleagues in December 1988, LDLT has become the gold standard treatment in countries where cadaveric organ donation is not sufficient. Adequate hepatic venous outflow reconstruction in LDLT is essential to prevent graft congestion and its complications including graft loss. However, this can be complex and technically demanding especially in the presence of complex variations and congenital anomalies in the graft hepatic veins.CASE SUMMARY Herein, we aimed to present two cases who underwent successful right lobe LDLT using a right lobe liver graft with rudimentary or congenital absence of the right hepatic vein and describe the utility of a common large opening drainage model in such complex cases.CONCLUSION Thanks to this venous reconstruction model, none of the patients developed postoperative complications related to venous drainage. Our experience with venous drainage reconstruction models shows that congenital variations in the hepatic venous structure of living liver donors are not absolute contraindications for LDLT.     

Omega 3 – Omega 6: What is right for the liver?

Linoleic and alpha-linolenic acids are the fatty acids designated as "essential" since they are not synthesized by mammalian cells and must be provided in the diet. The recent dietary shift towards the consumption of n-6 (omega-6) at the expense of n-3 (omega-3) polyunsaturated fatty acids (PUFAs) is thought to be a primary cause of many diseases related to the Western diet. The body converts linoleic acid to arachidonic acid and derives eicosapentaenoic acid from alpha-linolenic acid. Ideally the effects of these fatty acids and their eicosanoid derivatives are tailored to the specific biological needs of the body. The balance between n-3 and n-6 PUFAs is essential for metabolism and maintenance of the functions of both classes. The availability of n-3 long chain PUFAs plays a major role in regulating both fat accumulation and its elimination by the liver. Derangement of hepatic n-6:n-3 PUFA ratio impacts on the histological pattern of fatty liver through modulation of the amount of intrahepatic lipids. Moreover, the influence of PUFAs and their eicosanoid products on hepatic microcirculation and ischemia/reperfusion injury has been demonstrated in many studies. This concise review article will focus on the role of PUFAs and eicosanoids in hepatic steatosis, microcirculation and ischemia/reperfusion injury.     

Percutaneous support of the failing left and right ventricle—recommendations for the use of mechanical device therapy

Patients in cardiogenic shock and acute heart failure show high mortality and morbidity despite aggressive and invasive methods such as percutaneous coronary intervention and the use of mechanical support devices. Percutaneous implantation of active hemodynamic support is often the only option for hemodynamic stabilization of patients in cardiogenic shock. Therefore, current guidelines support the use of these devices. Standardized protocols and clinical algorithms for the use of these support devices decrease mortality in these patients. The aim of this review is an overview of current therapies of cardiogenic shock with special focus on mechanical support devices and the suggestion of a clinical algorithm for the differential use of current devices as well as the hemodynamic monitoring of such patients in order to reduce mortality in cardiogenic shock.     

A new approach to the surgical treatment of parasitic cysts of the liver： Hepatectomy using the liver hanging maneuver

AIM： To review 11 patients with parasitic cysts of the liver, who were treated by hepatic Iobectomy using the liver hanging maneuver （LHM）.
METHODS： Between January 2003 and June 2006, we retrospectively analyzed patients who underwent surgical treatment due to parasitic cysts of the liver, at the Ege University School of Medicine, Department of General Surgery. Of these, the patients who underwent hepatic lobectomy using the LHM were reviewed and evaluated for surgical treatment outcome.
RESULTS： Over a three-year period, there were 102 patients who underwent surgical treatment for parasitic cysts of the liver. Of these, 11 （10%） patients with parasitic cysts of the liver underwent hepatic Iobectomy using the LHM. Presenting symptoms were abdominal pain, dyspepsia, and cholangitis. Cyst locations were as follows： right lobe filled with cyst, 7 （63%）; segmental location, 2 （18%）; and multiple locations, 2 patients （18%）. All patients underwent hepatic Iobectomy with an anterior approach using the LHM. The intraoperative blood transfusion requirement was one unit for 3 patients and two units for one patient. Postoperative complications included pulmonary atelectasy （2, 18%） and pleural effusion （2, 18%）. No significant morbidity or mortality was observed.
CONCLUSION： We concluded that hepatic Iobectomy using the LHM should be considered, not only for hepatic tumors or donor hepatectomy, but also to treat parasitic cysts of the liver.     

What is the long-term outcome of the liver allograft?

With improved long-term survival following liver transplantation (LT), issues relating to the assessment of the liver allograft in long-term survivors are becoming increasingly relevant. Histological abnormalities are commonly present in late post-transplant biopsies, including protocol biopsies from patients who appear to be well with good graft function. Recurrent disease is the commonest recognised cause of abnormal graft histology, but may be modified by the effects of immunosuppression or interactions with other graft complications, resulting in complex or atypical changes. Other abnormalities seen in late post-transplant biopsies include rejection (which often has different appearances to those seen in the post-transplant period), de novo disease, "idiopathic" post-transplant hepatitis (IPTH) and nodular regenerative hyperplasia. In many cases graft dysfunction has more than one cause and liver biopsy may help to identify the predominant cause of graft damage. Problems exist with the terminology used to describe less well understood patterns of graft injury, but there is emerging evidence to suggest that late rejection, de novo autoimmune hepatitis and IPTH may all be part of an overlapping spectrum of immune-mediated injury occurring in the late post-transplant liver allograft. Careful clinico-pathological correlation is very important and the wording of the biopsy report should take into account therapeutic implications, particularly whether changes in immunosuppression may be indicated. This article will provide an overview of the main histological changes occurring in long-term survivors post-LT, focusing on areas where the assessment of late post-transplant biopsies is most relevant clinically.     

Long-Term Results of the Anterior Delorme’s Operation in the Management of Symptomatic Rectocele

PURPOSE Although the results of surgery for symptomatic rectocele seem satisfactory initially, there is a trend toward deterioration with time. This study was designed to assess the long-term outcome of Anterior Delormes operation for rectocele.METHODS Questionnaires were sent to all females who had Anterior Delormes operation performed in Auckland between 1990 and 2000. The questionnaires included obstructed defecation symptoms and a validated fecal incontinence severity index questionnaire and fecal incontinence quality of life questionnaire. Preoperative and postoperative obstructed defecation symptoms and incontinence score were compared.RESULTS A total of 150 females (mean age, 56 (range, 30–83) years) who had an Anterior Delormes operation for a rectocele were identified. One hundred seven patients (71.5 percent; mean age, 56 years) completed the questionnaire. Median follow-up was four (range, 2–11) years. The number of patients with obstructed defecation reduced from 87 preoperatively to 23 postoperatively using Rome II criteria (P < 0.0001). Postoperatively there was a reduction in the number of patients with each of the symptoms of obstructed defecation from 83 to 27 for straining, 87 to 33 for incomplete emptying, 64 to 14 for feeling of blockage, 41 to 10 for digitation (P < 0.0001 for all). The median incontinence score reduced from 20 of 61 preoperatively to 12 of 61 postoperatively (P = 0.0001).CONCLUSIONS In patients with symptomatic rectocele, Anterior Delormes operation provides long-term benefit for patients with obstructed defecation and leads to a significant improvement of incontinence scores.Presented at the scientific meeting of the Surgical Society of New Zealand, Wellington, New Zealand, September 17, 2003.     

Arterial chemotherapy of 5—fluorouracil and mitomycin Cin the treatment of liver metastases of colorectal cancer

AIM：Regional chemotherapy using hepatic artery catheters is a good method of treating patients with colorectal cancer liver metastases.We investigated the survival of patients with liver metastases from colorectal cancer using 5-fluorouracil(5-FU)and mitomycin C Cthrough implantable hepatic arterial infusion port.METHODS:Seventy-five patents with inoperable liver metastases forom colorectal cancer were included between March,1992 and November,2001,We placed implantable hepatic arterial cathter(HAC)port by laparotomy,5-FU,1000mg/m^2/d continuors infusion for five days every four weeks,was delivered in the hepatic arterial catheter through the port.Mitomycin C,30mg/m^2/d infusion in the first day every cycel through the port.Response to the treatment was evaluated by serial determinations of plasma CEAand imaping techniques consisting of computerized tomography and sonography of liver.RESULTS:Sixty-eight were performed hepatic artery chemotherapy and fifty-six were followed up among seventy-five HAC patients.Twenty-six patients(46.4%)have responded and4complete remission were achieved.Eight patients(14.3%)had stable liver metastases.Twenty-two patients(39.3%)were progressed with increased tumor size and number.Twenty-nine patients(51.8%)had a decreased serum CEAlevel.while10patients(17.9%) were stable and 17patients(30.4%)had an increased serum CEAlevel.There were no operative death in this serise.Complications,which occurred in 18patients(32.1%),were as followed:hepatic artery thrombosis in11,Upper gastric and intestinal bleeding in3,liver abscess in1,pocket infection in1,cholangitis in1,and hepatic artery pseudo-aneurysm in one patient.CONCLUSION:Combined infusion of 5-FU and mitomycin C by hepatic artery catheter port is an effective treatment for liver metastases from colorectal cancer.The high response and lower complication rater prove the adjuvant treatment of colorectal cancer with this treatment.     

What determines ageing of the transplanted liver?

Background

Liver transplantation is used to treat patients with irreversible liver failure from a variety of causes. Long-term survival has been reported, particularly in the paediatric population, with graft survival longer than 20 years now possible. The goal for paediatric liver transplantation is to increase the longevity of grafts to match the normal life expectancy of the child. This paper reviews the literature on the current understanding of ageing of the liver and biomarkers that may predict long-term survival or aid in utilization of organs.

Methods

Scientific papers published from 1950 to 2013 were sought and extracted from the MEDLINE, PubMed and University of Melbourne databases.

Results

Hepatocytes appear resistant to the ageing process, but are affected by both replicative senescence and stress-related senescence. These processes may be exacerbated by the act of transplantation. The most studied biomarkers are telomeres and SMP-30.

Conclusion

There are many factors that play a role in the ageing of the liver. Further studies into biomarkers of ageing and their relationship to the chronological age of the liver are required to aid in predicting long-term graft survival and utilization of organs.