Surgical management of biliary complications following living donor liver transplantation

Khalaf H, Alawi K, Alsuhaibani H, Hegab B, Kamel Y, Azzam A, Albahili H, Alsofayan M, Al Sebayel M. Surgical management of biliary complications following living donor liver transplantation.
Clin Transplant 2011: 25: 504–510. © 2010 John Wiley & Sons A/S. Abstract: Background: Biliary complications (BC) account for much of the morbidities seen after living donor liver transplantation (LDLT). Surgical reconstruction might be necessary after the failure of endoscopic or percutaneous procedures. Methods: Between November 2002 and December 2009, a total of 76 LDLTs were performed. Six patients were excluded from statistical analysis because of early graft or patient loss. Results: Of 70, 26 (37.1%) developed BC; 12 (46.2%) were successfully managed by non‐surgical procedures, three (11.5%) died from BC‐related sepsis, one (3.8%) died from BC‐unrelated causes, and 10 (38.5%) underwent surgical reconstruction. Of those 10, four patients had single duct reconstruction, five patients had double ducts reconstruction, and reconstruction was abandoned in one patient because of hepatic artery thrombosis. After a median follow‐up period of 4.5 yr (0.1–6), seven (70%) remained well with no recurrent biliary problems, and three (30%) had recurrent BCs that were managed either conservatively or by retransplantation. Patients who underwent surgical reconstruction had significantly fewer hospital admissions, less need for invasive procedures, and shorter cumulative hospital stay (p < 0.05). Conclusions: In our experience, BCs after LDLT were frequently resistant to non‐surgical procedures. Surgical reconstruction is associated with fewer hospital admissions and less need for invasive procedures leading to reduced resources utilization.     

Consultation on interactions between National Regulatory Authorities and National Immunization Technical Advisory Groups

A consultation during the Developing Country Vaccine Regulators' Network meeting of May 2010 considered the interactions between the National Immunization Technical Advisory Group (NITAG) and the National Regulatory Authority (NRA) in various countries. This meeting was co-hosted by the WHO and the Supporting Independent Immunization and Vaccine Advisory Committees Initiative implemented by the Agence de Médecine Préventive in partnership with the International Vaccine Institute. Representatives from Developing Country Vaccine Regulators' Network and representatives from several additional countries' regulatory authorities met representatives from NITAGs and/or the National Immunization Program from these countries (Brazil, Canada, China, Cuba, France, Indonesia, Iran, South Africa, Thailand, Vietnam and the USA). The objectives of the workshop included a discussion on the issues of NRA-NITAG interaction, the assessment of the advantages of different models of interaction and proposals for an optimal coordination process for market authorization and recommendations for use of vaccines. It was concluded that there is need for increased and more formal interactions between NRAs and NITAGs, a clear framework establishing a formal interaction and early interactions before market authorization. NRA experts being at the same time NITAG ex officio members and vice versa are solutions which can be adopted by countries. The NRA issues the license based on the evidence submitted by the manufacturer. The NITAG makes recommendations based on scientific evidence, public health needs and policy, and consideration of the license conditions. If there is a need to make recommendations that are not covered by the license evidence then there should be interactions between NITAG, NRA and the license holder to encourage the license-holder to submit appropriate evidence, or to ensure that the justification for the off-label recommendation is communicated to the users of the medicine.     

Heterogeneity in the processing of CLCN5 mutants related to Dent disease

Mutations in the electrogenic Cl(-)/H(+) exchanger ClC-5 gene CLCN5 are frequently associated with Dent disease, an X-linked recessive disorder affecting the proximal tubules. Here, we investigate the consequences in Xenopus laevis oocytes and in HEK293 cells of nine previously reported, pathogenic, missense mutations of ClC-5, most of them which are located in regions forming the subunit interface. Two mutants trafficked normally to the cell surface and to early endosomes, and displayed complex glycosylation at the cell surface like wild-type ClC-5, but exhibited reduced currents. Three mutants displayed improper N-glycosylation, and were nonfunctional due to being retained and degraded at the endoplasmic reticulum. Functional characterization of four mutants allowed us to identify a novel mechanism leading to ClC-5 dysfunction in Dent disease. We report that these mutant proteins were delayed in their processing, and that the stability of their complex glycosylated form was reduced, causing lower cell surface expression. The early endosome distribution of these mutants was normal. Half of these mutants displayed reduced currents, whereas the other half showed abolished currents. Our study revealed distinct cellular mechanisms accounting for ClC-5 loss of function in Dent disease.     

Prophylactic preoperative balloon occlusion of hypogastric arteries in abnormal placentation; 5 years experience

Purpose

The purpose is to describe and evaluate the technique of prophylactic balloon occlusion of the anterior division of the internal iliac arteries (hypogastric arteries) in abnormal placentation.

Materials and methods

It is a retrospective study; the records of 44 patients with a diagnosis of placenta previa/accreta/percreta were retrospectively reviewed. Patients were divided into two groups. Thirty-two patients underwent prophylactic temporary balloon occlusion, followed by cesarean section. A review of cases was done over a period of 5 years. All cases after previous arrangement with the interventional radiologist and after admission, patient in the balloon occlusion group underwent the procedure of hypogastric artery balloon occlusion under fluoroscopy using minimal radiation exposure. Intra-operatively, the balloon was inflated as needed. Twelve patients underwent cesarean section without endovascular intervention. The following parameters were compared in the two groups: patient age, gravidity, parity, gestational age at delivery, pregnancy outcome, and days in the intensive care unit after delivery, total hospital days, volume of transfused blood products, operating room time, estimated blood loss, and postoperative morbidity and mortality.

Results

Patients in the balloon occlusion group had significantly less in estimated blood loss than the non balloon occlusion group. There was no statistical difference in mean volume of replaced blood products, operating room time or postoperative recovery time.

Conclusion

Our results support that in patients with placenta accreta/percreta, pre-operative prophylactic temporary balloon occlusion diminishes intra-operative blood loss. We conclude that balloon occlusion of the hypogastric arteries is safe and effective in an attempt to minimize blood loss in patients with abnormal placentation.     

Depression and caregiver burden experienced by caregivers of Jordanian patients with stroke

Many stroke survivors will be cared for at home, primarily by their relatives. Providing care to a family member with a chronic disabling disease can be both emotionally and physically distressing for the caregivers. The purpose of this study was to investigate the relationship between patients' characteristics, duration of caregiving, daily caregiving time, caregiver's characteristics, caregiver depression and burden in caregivers of patients with stroke. A cross-sectional design was used with a convenience sample of 116 subjects. The Center of Epidemiologic Studies of Depression and the Caregiver Strain Index were used to identify caregiver depression and burden, respectively. Logistic regression analysis identified the influence of independent variables on caregiver depression and caregiver burden. Caregivers had high scores for depression and burden indices. Caregivers' health, receiving professional home health care and caregivers' burden were related to caregiver depression. Functional disabilities of patients with stroke and depression of caregivers were related to caregiver burden. To decrease caregiver depression and burden, nurses must provide caregivers with instructions for home management of patients with stroke. Development of specialized stroke home health services in Jordan that targets patients with stroke and their caregivers are recommended.