A liver transplant center experience with liver dialysis in the management of patients with fulminant hepatic failure: a preliminary report

Among extracorporeal liver support devices, liver dialysis is cleared by the U.S. Food and Drug Administration to be used for the management of fulminant hepatic failure (FHF). The outcomes of patients following liver dialysis need to be clearly evaluated. Among the 25 patients with FHF admitted to the Liver ICU between May 2000 and November 2002, 12 underwent liver dialysis, including 6 men and 6 women, of mean age 32 years. The causes of FHF were identified as acetaminophen (n = 10), herbal medications (n = 1) and autoimmune disease (n = 1). At presentation, the mean total bilirubin was 9.35 mg/dL (range, 0 to 1.3), mean ALT 3015 U/L (range, 0 to 48), mean AST 3457 (range, 0 to 42), mean ammonia 98 micromol/L (range, 10 to 60) and mean INR 1.88. A control group including 13 patients (2 men and 11 women), of mean age 27.8 years mean total bilirubin 5.66, mean ALT 3494, mean AST 3528, mean ammonia 113 and mean INR 3, were not treated with liver dialysis, due to the lack of machine availability or physician's choice. The causes of FHF were acute hepatitis B (n = 1), acetaminophen (n = 10) or unknown (n = 2). There was no statistically significant difference in the baseline characteristics of the two groups (P >.05). Among the liver dialysis group, 1 patient died, 2 underwent OLTx, and 9 were discharged home. Among the control group; 4 patients died, 2 underwent OLTx, and 7 were discharged home. Preliminary results seem to support survival benefit among patients who underwent liver dialysis compared to non-liver dialysis; however, further randomized control trials are warranted to verify this observation.     

Sleeve gastrectomy prior to liver transplantation is superior to medical weight loss in reducing posttransplant metabolic complications

Strategies to optimize the management of obesity-related metabolic complications after liver transplantation (LT) are needed. We examined the effect of pre-LT sleeve gastrectomy (SG), as compared to medical weight loss (MWL), on post-LT outcomes. This is a cohort study of adults (≥18 years) with medically complicated obesity who were eligible for pre-LT SG and underwent LT from January 1, 2006 to June 1, 2016. Logistic regression models evaluated the association of SG on post-LT diabetes and hypertension, defined as new-onset or progressive disease post-LT. Cox regression models evaluated the association of SG on recurrent and de novo nonalcoholic fatty liver disease (NAFLD). Among 70 LT recipients who were eligible for pre-LT SG, 14 (20%) underwent SG and 56 (80%) underwent MWL only. Mean follow-up was 5.2 years post-LT. The SG cohort sustained higher % total body weight loss at 3 years post-LT (28.9% vs. 5.4%, p < .001). In multivariable analyses, SG was associated with significantly lower risk of post-LT diabetes (OR 0.04, 95% CI 0.00–0.41, p = .01), hypertension (OR 0.15, 95% CI 0.04–0.67, p = .01), and recurrent and de novo NAFLD (HR 0.19, 95% CI 0.04–0.91, p = .04). When compared to MWL, SG resulted in sustained weight loss and significantly lower risk of diabetes, hypertension, and recurrent and de novo NAFLD post-LT.     

The turmoil around the drug-eluting stents

Of 141 hospital survivors after intracardiac repair of tetralogy of Fallot, eight died suddenly 6–23 years later. Compared with the other 133 patients, these eight were older at operation, with higher post-repair systolic right ventricular pressure and more often complete atrioventricular block; ventricular arrhythmia was diagnosed before death in three cases. In follow-up totalling 2255 patient years, the linearized rate of sudden death was 0.35%/year. The instantaneous risk of sudden death showed continuous increase with the length of follow-up. Of 80 survivors electrocardiographically evaluated 13–26 (median 20) years postoperatively, none had complete block, but 79 had complete right bundle branch block, including seven with left anterior hemiblock. Ventricular extrasystoles were recorded in 1% at rest, in 34% during exercise and in 83% during 24-hour ambulatory monitoring, with Lown Grade ≥II in 27%. Old age and possibly presence of fibrosis and/or fibroelastosis in right ventricular outflow tract muscle correlated independently with high Lown Grade. A patient with Lown grade III died suddenly 2 years after our follow-up. Old age at repair thus was associated with increased risk of late sudden death and with frequent ventricular arrhythmia in long-term survivors.     

Excisional biopsy of borderline lesions after large bore vacuum-assisted core needle biopsy- is it necessary?

The current recommendation for borderline breast lesions after core needle biopsy is for surgical excision due to a high rate of pathologic underestimation. With the use of vacuum-assisted core needle (VACN) biopsy devices, upgrade rates have improved, but still average 20 per cent. We routinely use larger bore VACNs (7- and 8-gauge) than previously reported (9 to 11-gauge). The aim of this study is to evaluate the upgrade rate to malignancy in patients undergoing VACN using larger bore needles. VACN biopsies were performed in 902 patients. Of those, 87 were recommended excisional biopsy for borderline or noncorrelating lesions and 66 underwent the procedure. Two patients were upgraded to cancer, for an overall upstage rate of 3 per cent. Both of these underestimations were in patients that initially had atypical ductal hyperplasia. In the patients not excised, no patient developed further cancer. A 7- or 8-gauge needle was used in 57 per cent of patients, greater than 90 per cent removal of the initial lesion was accomplished in 53 per cent of cases, and there were no bleeding complications. This study suggests that upgrade rates decline with larger bore biopsy needles with near complete excision of the initial lesion, and that some borderline lesions may potentially be managed nonoperatively.     

亚洲少年眼和肾结节病1例

结节病通常导致年轻人患双侧肺门淋巴腺病,肺实质疾病和/或皮肤损伤等。儿童结节病是一种相对罕见的疾病,尤其是眼和肾脏同时受累的儿童患者。我们这里呈现了一个双侧复发性前葡萄膜炎伴发肾功能衰竭的结节病的少年亚裔病情。口服类固醇与甲氨喋呤后临床症状得到明显改善。因顽固性青光眼行小梁切除术后双眼视力令人满意。因此,给予及时的诊断及迅速适当的处理能避免这类罕见疾病的眼部发病率。     

The effect of natural adjuvants on tracheal responsiveness and cell count in lung lavage of sensitized guinea pigs

Background and objective:   Airway inflammation is a well-characterized pathological feature of asthma. The effects of two natural adjuvants on lungs of sensitized guinea pigs were examined.
Methods:   The responses of guinea pig tracheal chains, WBC, differential WBC in lung lavage and IL-4 and interferon (IFN)-γ levels in serum were examined in control guinea pigs and four treatment groups, including sensitized animals (S) and sensitized animals treated with the adjuvants PC (S + PC), G2 (S + G2) or both adjuvants (S + PCG2) ( n  = 6). Animals were sensitized by injection and inhalation of ovalbumin.
Results:   Tracheal responsiveness to methacholine (concentration of methacholine causing 50% of maximum contraction), WBC, eosinophil, neutrophil and basophil numbers were increased and lymphocyte numbers were decreased in lung lavage of sensitized animals compared with the control group ( P  < 0.01 to P  < 0.001). However, G2 adjuvant and the combination of G2 and PC adjuvants caused a significant reduction in tracheal responsiveness ( P  < 0.01 and P  < 0.001, respectively). In addition both adjuvants prevented changes in WBC ( P  < 0.001 for both). Both adjuvants and the combination prevented changes in eosinophil, neutrophil and basophil numbers in lung lavage of sensitized animals ( P  < 0.05 to P  < 0.001). The adjuvants also prevented changes in IL-4 but increased IFN-γ levels in all treatment groups compared with group S ( P  < 0.001 for all cases).
Conclusions:   These results indicate that the two natural adjuvants (especially G2 adjuvant) and their combination have therapeutic effects, with reduction in tracheal responsiveness and WBC in lung lavage of sensitized guinea pigs.     

Poliovirus antibody titres, relative affinity, and neutralising capacity in maternal milk.

Varying titres of secretory IgA antibodies to poliovirus type 1 were found previously in the milk of unvaccinated, lactating Pakistani mothers during two different years, reflecting the antigenic exposure on mucosal membranes. To study further the changes in the extent and the form of antigenic exposure reflected in the human milk, human milk samples from Pakistani, Indian, Japanese, and Swedish mothers were collected. The quality and the neutralising capacity of the antibodies was also studied. Secretory IgA, IgG, and IgM antibodies to poliovirus type 1 were determined using enzyme linked immunosorbent assay (ELISA) and relative affinity was measured in ELISA by elution with potassium thiocyanide. Microneutralisation tests were also performed. The higher secretory IgA antibody titres to poliovirus type 1 in the unvaccinated, naturally exposed Pakistani and Indian mothers' milk, compared with the Swedish and Japanese mothers, presumably reflect the epidemiological situation in these countries. Neutralising capacity and the relative antibody affinity seemed to be higher both in the Pakistani mothers and the group without natural exposure but only given inactivated poliovirus vaccine, that is the Swedish mothers, than the group meeting only live vaccine strains, that is the Japanese mothers.     

Excitable gap composition in the presence of antiarrhythmic drugs in common human atrial flutter

BACKGROUND AND OBJECTIVE: Recurrence of atrial flutter (AFl) on antiarrhythmic drugs is frequently observed. To determine the reasons for drug inefficacy, the electrophysiological parameters of AFl were studied in eight patients without drug, six patients on sotalol (Sot), eight patients on amiodarone (Amio) and four patients on propafenone (PPF) who presented to the electrophysiology laboratory for conversion of AFl by rapid atrial pacing. METHODS: A quadripolar electrode catheter was positioned in the right atrium in the pathway of the AFl circuit. The duration and composition of the excitable gap (EG) were determined by premature stimuli during AFl. RESULTS: The EG in AFl recurring on Sot (80 +/- 25 ms), Amio (78 +/- 13 ms) and PPF (83 +/- 26 ms) was not significantly different from that without drug (88 +/- 14 ms). Furthermore, a fully excitable portion of the EG was present whether with or without drug. CONCLUSIONS: AFl recurrence on Amio, PPF or Sot is associated with the continued presence of an EG and fully excitable portion. These findings explain the persistent viability of the AFl circuit despite drug therapy in these patients.     

Breast angiosarcomas: three case reports

Angiosarcoma is a rare type of breast cancer, it has the worst prognosis of all breast malignancies. We report three cases of breast angiosarcoma observed at the National Oncology Institute and the Maternity of Orangers. A preoperative diagnosis was evoked in one case only, after a local recurrence in the second one and histological in the last one. Mastectomy is the reference treatment. The development is distinguished by general metastasis. Based on review of literature, we analysed the different aspects of this disease.