Clinical and radiological impact of liver transplantation for brain in cirrhosis patients without hepatic encephalopathy

Objective

To elucidate the effect of liver transplantation (LT) on brain dysfunctions in cirrhotic patients who had no clinical evidence of hepatic encephalopathy (HE), we performed a prospective study of voxel-based diffusion tensor imaging (DTI) and detailed cognitive examination.

Methods

We assessed 12 consecutive patients as transplant candidates by DTI, with neurological and cognitive examinations just before and at 6 months after LT.

Results

After LT, cirrhotic patients showed significant improvement in visual reproduction, digit symbol, digit span, Stroop test, and Trail-making test scores, suggesting recovery of frontal-temporal function. As for voxel-based DTI, increased mean diffusivity (MD) and reduced fractional anisotropy (FA) values were found before LT in the frontal and temporal lobes of cirrhotic patients. After LT, the unusual FA and MD values observed in the frontal and temporal lobes preoperatively were significantly reduced.

Conclusion

End-stage cirrhotic patients without clinical evidence of HE showed increased MD and decreased FA values in both frontal and temporal lobes. These parameters improved after LT, in line with cognitive function. MD and FA values might be of value as a biomarker in end-stage cirrhotic patients for investigating brain tissue dysfunctions and evaluating the efficacy of LT.     

Impaired pain processing in Parkinson's disease and its relative association with the sense of smell

Background and purposeMany non-motor symptoms are associated with Parkinson's disease (PD). Of these, pain and olfactory disturbance tend to be common premotor symptoms. PD has been shown to exhibit abnormal central pain processing, although underlying mechanisms are not yet fully understood. In order to investigate this further, we assessed PD patients by specific Aδ stimulation with intra-epidermal needle electrode and determined olfactory function.MethodsForty-two patients (18 males and 24 females) with PD and 17 healthy control subjects (8 males and 9 females) were studied. A thin needle electrode was used to stimulate epidermal Aδ fibers, and somatosensory evoked potentials (SEPs) recorded at the vertex. Olfactory function was evaluated using the Odor Stick Identification Test for Japanese (OSIT-J) and its relationship with pain-related SEPs was investigated.ResultsThere were no significant differences in N1 latencies or P1 latencies although N1/P1 peak-to-peak amplitudes were significantly lower (p < 0.01) in PD patients than in control subjects. In PD patients, there were significant correlations between N1/P1 amplitudes and disease duration (r = ?0.35, p < 0.05), Hoehn-Yahr stage (r = ?0.38, p < 0.05) and UPDRS part III (r = ?0.42, p < 0.01). Furthermore, the OSIT-J scores correlated with SEP amplitude (r = 0.41, p < 0.01).ConclusionPain processing in PD patients was impaired under specific nociceptive stimulation of Aδ fibers and significant correlation with smell dysfunction was detected. We suggest that this mechanism may involve the limbic system during PD pathology.     

Long-term results of bioprosthetic tricuspid valve replacement: an analysis of 25 years of experience

Background

Current knowledge in long-term results of tricuspid valve replacement is limited. Present study reviews our experience from a consecutive series.

Methods

We retrospectively studied the early and late results of 32 consecutive patients (7 male and 25 female; mean age 60.2 ± 18.1 years) undergoing bioprosthetic tricuspid valve replacement between 1985 and 2010. The etiology is rheumatic in 38 %, congenital in 3 %, endocarditis in 9 %, and functional in 50 %. Patients underwent isolated valve replacement. The remaining underwent combined aortic and tricuspid (n = 5, 16 %), mitral tricuspid (n = 15, 47 %), and aortic, mitral, and tricuspid (n = 1, 3 %) valve replacement. Preoperative liver dysfunction was evaluated using Model for End-stage Liver Disease (MELD) score. Mean follow-up was 5.6 ± 6.8 years (ranging from 0 to 25.0 years).

Results

Hospital mortality was 19 %. On univariate logistic regression analysis, NYHA class IV (p = 0.039, odds ratio 11.3, 95 % confidence interval 1.2–112.5), MELD score (>10) (p = 0.011, odds ratio 21.0, 95 % confidence interval 12.0–222.0) and congestive liver (p = 0.05, odds ratio 9.4, 95 % confidence interval 1.0–93.5) were incremental risk factors for hospital death. The 15- and 25-year actuarial survival were 56.5 ± 10.3 % and 45 ± 13.0 %, respectively. Multivariate analysis using Cox proportional hazard model showed MELD score (p = 0.024, hazard ratio 7.0, 95 % confidence interval 2.1–23.9) and postoperative pulmonary hypertension (p = 0.012, hazard ratio 4.4, 95 % confidence interval 1.4–14.1) were significantly associated with decreased survival. At 15 years, freedom rates from tricuspid valve reoperation, anticoagulation-related bleeding, and valve related events were 85.7 ± 13.2 %,95.7 ± 4.3 % and 81.8 ± 13.2 %, respectively. The linearized incidence of structural valve deterioration was 0.50 %/patient-year, anticoagulation-related bleeding was 0.94 %/patient-year, and valve-related events were 1.52 %/patient-year.

Conclusion

Preoperative hepatic congestion and liver dysfunction which were indicated by the MELD score >10 were associated with poor outcome for patients undergoing tricuspid valve replacement. The MELD score is useful to predict the morality among these patients.     

Liver hanging maneuver decreases blood loss and operative time in a right-side hepatectomy

Background/Aims: To clarify the clinical benefits of the maneuver in right-side hepatectomy. Methodology: Eighty-one patients with liver tumor (54 hepatocellular carcinoma, 17 metastatic liver tumor and 10 other tumors) treated with a right-side hepatectomy were prospectively analyzed. The patients were divided into the following three groups: a conventional approach (group A, n=21); liver dissection under the hanging maneuver after liver mobilization (group B, n=19) and liver dissection under the hanging maneuver prior to liver mobilization (group C, n=41). Results: The liver hanging maneuver was safely performed in all the patients in groups B and C. Tumor size had a significantly positive correlation with the amount of intraoperative blood loss (R=0.52, p<0.05) in group A only. The patients in groups B and C had a significantly lower intraoperative use of blood loss (both p<0.01), operation time (p<0.05 and p<0.01) and the frequency of blood product (both p<0.05), in comparison to group A, respectively. The postoperative morbidity and the mortality rates were similar in the three groups. Conclusions: Liver hanging maneuver is a safe procedure, which can decrease intraoperative blood loss and administration of blood product in right-side hepatectomy.     

Role of Interleukin-6 in Toll-Like Receptor 4 and 2 Expressions Induced by Lipopolysaccharide in the Lung

Our previous study demonstrated that interleukin (IL)-6 is protective against hemorrhagic lung inflammation induced by lipopolysaccharide (LPS) in mice, at least partly, by inhibition of the enhanced expressions of proinflammatory cytokines. The present study elucidated the role of IL-6 in Toll like receptor (TLR) 4 and 2 expressions in the lung during inflammation induced by intraperitoneal administration of LPS (1 mg/kg) using IL-6 null (-/-) mice and wild type (WT) mice. The expressions of mRNA for both TLR4 and 2 in the lung were evaluated 72 hrs after intraperitoneal administration. LPS enhanced both TLR4 mRNA expression as compared with vehicle. However, the enhancement was significantly stronger in IL-6 (-/-) mice than in WT mice after LPS challenge. LPS significantly increased TLR2 mRNA expression only in IL-6 (-/-) mice. As well, in the presence of LPS, the expression was significantly greater in IL-6 (-/-) mice than in WT mice. These results suggest that the protective role of IL-6 against LPS-induced hemorrhagic lung inflammation might be explained, in part, by inhibition of the enhanced lung expressions of TLR4 and 2.     

Moxibustion Promotes Formation of Granulation in Wound Healing Process through Induction of Transforming Growth Factor-β in Rats

Objective: To examine the effect of moxibustion on the wound healing process and its mechanism using a rat wound model. Methods: Sixty male Sprague-Dawley rats were randomly divided into a sham-treated group(n=30, wound surgery only) and a moxibustion group(n=30, wound treated with moxibustion). Circular fullthickness skin wounds were produced in rats. Moxibustion was applied to the edge of wound and was continued on alternating days till 14 days after surgery, followed by measurement of wound size. Expression of collagens, prolyl-4-hydroxylase(P4 H) and transforming growth factor-β(TGF-β) were evaluated by histochemical study and real-time polymerase chain reaction. Results: The size of the wound lesion was significantly reduced in rats treated with moxibustion as compared to that in sham-treated rats at 4–10 days after wounding(P0.01). Moxibustion stimulated mRNA expression of collagens at 4 days(P0.01), but not at 7 days, accompanied by enhanced proliferation of P4 H-positive fibroblasts. Of importance, expression of TGF-β in tissue from the wound lesion treated with moxibustion was significantly increased as compared to that in sham-treated rats at 4 days(P0.01 or P0.05), but not at 7 days. Conclusions: The treatment with moxibustion promoted the wound healing process in the early phase through proliferation of fibroblasts and rapid formation of granulation, possibly mediated by induction of TGF-β which is a key molecule in the physiological process of wound healing. Moxibustion can be expected to be effective as complementary treatment for intractable ulcers.