Pretransplant survival is shorter in HIV-positive than HIV-negative subjects with end-stage liver disease.

Despite improved survival after liver transplantation (OLTX) in HIV-positive individuals treated with highly active antiretroviral therapy (HAART), some transplant candidates do not survive to OLTX. To determine if pretransplant outcome is related to severity of liver disease and/or HIV infection, we prospectively evaluated 58 consecutive HIV-positive candidates seen at a single center from 1997-2002. Of the 58, 15 (25.9%) were transplanted, whereas 21 (36.2%) died before OLTX, a median one month of evaluation, with more than half of those (12 of 21, 57.1%) dying from infection. By contrast, of 1,359 HIV-negative candidates, 860 (63.3%) were transplanted, whereas 211 (15.5%) died before OLTX (P < 0.001). The cumulative survival following initial evaluation was significantly shorter among HIV-positive than HIV-negative candidates (880 vs. 1,427 days, P = 0.035, Breslow) but was not related to the initial pretransplant MELD score (16 vs. 15), INR (1.5 vs. 1.5), creatinine (1.3 vs. 1.3 mg/dL), or total bilirubin (6.6 vs. 5.7 mg/dL), respectively, all P > 0.05. Among untransplanted HIV-positive candidates, the 21 who died did not differ from the 22 surviving in initial MELD (15 vs. 13), CD4 (230 vs. 327/microL), HIV load (both < 400 copies/mL), HAART intolerance (10/21, 47.6% vs. 10/22, 45.4%), or HCV infection (16/21, 76.2% vs. 16/22, 72.3%), all P > 0.05. Further, the 21 did not differ from the 15 transplanted in pre-OLTX CD4, HIV load, or MELD score, all P > 0.05. In conclusion, pretransplant survival appears shorter in HIV-positive OLTX candidates and is unrelated to severity of liver or HIV disease. Further study is warranted to determine risk factors for poorer pretransplant outcomes.     

Gastroesophageal Reflux,Motility Disorders,and Psychological Profiles in the Etiology of Globus Pharyngis

The aim of this study was to investigate the origin of globus pharyngis with particular reference to esophageal disorders such as gastroesophageal reflux disease (GERD), motility disorders, structural abnormalities, other gastrointestinal tract diseases, and psychological profile. Previous studies on this subject using 24-hour pH monitoring give conflicting results and are hampered by the high background prevalence of asymptomatic GERD in the normal Western population. The local Chinese population is known to have a very low background level of GERD and therefore is an ideal study population. Twenty-six patients with globus pharyngis underwent 24-hour ambulatory pH monitoring, esophageal manometry, and esophagogas-troduodenoscopy with lower esophageal biopsy. A control group of 20 patients presenting with non-ulcer dyspepsia was similarly investigated. Personality profiles of the globus pharyngis subjects and an appropriate control group were assessed. Eight of the globus pharyngis group (30.7%) had evidence of GERD, whereas only one of the controls (5%) demonstrated GERD on 24-hour esophageal pH monitoring (P < 0.05). The manometric and personality profile studies did not show significant differences between study and control groups. We concluded that the finding of GERD in patients with globus pharyngis is not a coincidental finding but that there is a true association between GERD and globus pharyngis.     

Effects of 1-week head-down tilt bed rest on bone formation and the calcium endocrine system.

To understand the potential early responses of human bone and the calcium endocrine system to spaceflight, we studied 8 healthy men, aged 35-44 years before, during, and after bed rest in a -6 degrees head-down tilt model for microgravity. Based on a novel single-dose labeling schedule, average rates of bone formation in the iliac crest were reduced in 6, unchanged in 1, and increased in 1 following the bed rest period. The decrease was greatest for subjects whose daily walking miles were highest (r = -0.762, p less than 0.05, n = 7). Before a measurable increase in ionized serum calcium the sixth bed rest day, there was increased excretion of urinary calcium and sodium, evident the first 2 bed-rest days and parallel for the entire week (r = 0.92, p less than 0.001). Reduced excretion of phosphorus and 3', 5' cyclic adenosine monophosphate on the first and second bed rest days was followed by an increase in serum phosphorus by the sixth bed rest day. Depressed serum concentrations of parathyroid hormone and 1,25-dihydroxyvitamin D were manifest by the sixth and seventh bed rest days. The similarity of the response of bone and the calcium endocrine system of healthy men after only 7 days to results of longer term bed rest studies emphasizes the responsiveness of the adult human skeleton to biomechanical stimuli induced by changes in activity and/or position.     

The incidence, timing, and management of biliary tract complications after orthotopic liver transplantation.

OBJECTIVE: This study analyzed the incidence and timing of biliary tract complications after orthotopic liver transplantation (OLTx) in 1792 consecutive patients. These results were then compared with those of previously reported series. Finally, recommendations were made on appropriate management strategies. SUMMARY BACKGROUND DATA: Technical complications after OLTx have a significant impact on patient and graft survival. One of the principal technical advances has been the standardization of techniques for biliary reconstruction. Nonetheless, biliary complications still occur. A 1983 report from the University of Pittsburgh reported biliary complications in 19% of all transplants, and an update in 1987 reported biliary complications in 13.2% of transplants. METHODS: The medical records of all patients who underwent liver transplantation and were hospitalized between January 1, 1988 and July 31, 1991 were reviewed. The case material consisted of the medical records of 217 patients treated for 245 biliary complications. RESULTS: Primary biliary continuity was established by either choledochocholedochostomy over a T-tube (C-C, n = 129) or a Roux-en-Y choledochojejunostomy with an internal stent (C-RY, n = 85). The overall incidence for biliary complication in this large series was 11.5%. Strictures (n = 93) and bile leak (n = 58) were the most common complications (69.6%). Most biliary complications (n = 143, 66%) occurred within the first 3 months after surgery. In general, leaks occurred early, and strictures developed later. Bile leaks were equally frequent in both C-C and C-RY (27.1% and 25.9%, respectively); strictures were more common after a C-RY type of reconstruction (36.4% and 52.9%, respectively). Twenty-one patients died, an incidence of 9.6%. Fifteen of the 21 biliary-related deaths were among patients treated for rejection before the recognition of biliary tract pathologic findings. CONCLUSIONS: Progress has been made on improving the results of biliary reconstruction after OLTx. Nonetheless, patients continue to experience biliary complications after OLTx, and these complications cause considerable loss of grafts and life. If significant additional improvement in patient and graft survival are to be obtained, the technical performance of OLTx must continue to improve.     

In vivo production of tumor necrosis factor for the treatment of mice bearing Ehrlich ascites tumor.

Tumor necrosis factor (TNF) was produced in mice bearing Ehrlich ascites tumor (EAT) by priming with zymosan and subsequently challenging with lipopolysaccharide. The optimal conditions for the in vivo production of TNF in treating EAT bearing mice were established. The endotoxin shock induced in mice during TNF production could be minimized by the combined administration of sulindac and mannoheptulose. The endogenous TNF produced could suppress proliferation of EAT cells as well as prolong the survival time of mice bearing small tumors.     

Neurofibromatosis and insulinoma.

A 45-year-old man with neurofibromatosis presented with recurrent seizures due to hypoglycaemia caused by an insulinoma. The attacks were abolished after the successful removal of the insulinoma. This probably represents another example of the association between neurofibromatosis and a tumour consisting of cells with amine-precursor-uptake and decarboxylation.     

The epidemiology of urinary dysfunction in Chinese women

The epidemiology of urinary dysfunction in a Chinese population living in Hong Kong was investigated. Fifteen hundred ethnic Chinese women answered a telephone questionnaire including symptoms of urinary dysfunction, anthropometric measurements, obstetric history and place of birth. The relative predictive value of these factors was analyzed using logistic regression. The prevalence of urinary dysfunction was 13%. Ten percent reported stress incontinence, and 4% had urgency or urge incontinence. The strongest predictor was place of birth, with women born in mainland China having the highest prevalence of pure stress incontinence (OR 1.33, CI 1.1–1.6). For the symptoms of detrusor instability age was the strongest predictor, with women over 50 years being at greater risk (OR 2.8, CI 1.6–5.0). Contrary to earlier beliefs, urinary dysfunction in Chinese women is as common as in Caucasian women. Place of birth is the strongest predictor for pure stress incontinence, with women born in mainland China being at greater risk. This suggests that environmental factors in early life have a differential effect on the development of urinary incontinence. EDITORIAL COMMENT: Taiwan Chinese women have a comparable prevalence of urinary dysfunction with Hong Kong Chinese women. A survey representing a multistage sample of 82 678 women aged 18 years or older was conducted in the Taipei area from January to June 1993. A total of 818 cases were interviewed by trained students. One hundred and eighty-nine (23.1%) of the respondents reported having had some degree of incontinence in the preceding 12 months, 28 (3.4%) reporting regular incontinence. Most presented with stress urinary incontinence, whereas urge incontinence and mixed incontinence were more commonly seen in the elderly group (aged 60 years or older). The risk factors for urinary incontinence included age, number of vaginal deliveries (>3), number of abortions (>2) and maternal history of incontinence. Voiding symptoms (irritative or obstructive) and constipation were significantly more prevalent among respondents with incontinence than those without (P<0.001). This evidence also indicates that the long-held belief that Chinese women have a much lower prevalence of urinary dysfunction than western women has all but ended.     

Isolated sphenoiditis: a diagnostic problem

A case of primary isolated sphenoiditis that developed cavernous sinus thrombosis is presented. It is difficult to diagnose and patients are often not seen initially by an ENT surgeon, making it more important for other branches of medicine to be aware of this condition. We discuss isolated sphenoiditis with particular reference to the diagnosis, management and complications of this condition.