Relationships between the severity of cirrhosis and haemodynamic values in patients with cirrhosis

Abstract The relationship between the severity of cirrhosis and systemic and hepatic haemodynamic values was evaluated in 193 patients with cirrhosis, most of whom were diagnosed with post-necrotic cirrhosis. It was found that the hepatic venous pressure gradient and cardiac output in Pugh's A patients (13.6 ± 4.8 mmHg and 6.2 ± 1.6 L/min, mean ± s.d.) were significantly lower than in both Pugh's B (16.8 ± 4.3 mmHg and 7.3 ± 2.1 L/min) and Pugh's C (18.8 ± 5.5 mmHg and 7.4 ± 2.3 L/min) patients ( P < 0.01), respectively. In contrast, the systemic vascular resistance in Pugh's A patients (1232 ± 369 dyn/s per cm⁵) was significantly higher than in both Pugh's B (1016 ± 345 dyn/s per cm⁵) and Pugh's C (935 ± 234 dyn/s per cm⁵) patients ( P < 0.01), respectively. Additionally, not only was there a positive correlation found between Pugh's score and cardiac output and hepatic venous pressure gradient, but a negative correlation was found between Pugh's score and systemic vascular resistance. It was also confirmed that the degree of portal hypertension and the hyperdynamic circulation were more severe in patients with ascites than in those without ascites. However, there were no statistically significant differences in hepatic venous pressure gradient among patients with F1, F2 and F3 esophageal varices (15.7 ± 4.0, 17.0 ± 4.8 and 18.0 ± 4.8 mmHg, respectively). It is concluded that in those patients with cirrhosis, the severity of cirrhosis is closely related to the degree of the hyperkinetic circulatory state and portal hypertension.     

Microcystic meningiomas—an unusual morphological variant of meningiomas

Evidence for tumour suppressor genes (anti-oncogenes, hemerogenes, flatogenes) has been obtained from the behaviour of familial childhood tumours in man, tumours in Drosophila caused by recessive mutations, experiments on fusing tumour cells to normal cells in tissue culture and revertants of oncogene-transformed cells. They may comprise more than one class of genes, one of which is likely to consist of genes responsible for normal differentiation. In large long-lived animals like man, which have a large potential somatic mutational load, mutant genes are associated with autosomal dominant behaviour in families. The susceptible individuals inherit heterozygosity of the tumour gene but the emergence of a tumour appears to follow a second somatic mutational event which results in homozygosity or hemizygosity. Hence, in tumour cells the mutations behave in a recessive manner. Success in isolating the normal genes may provide new tools for antenatal diagnosis of carriers and open up the possibility of developing new gene therapy.     

Emergency Cardiac Pacing for Severe Bradycardia

ALTAMURA, G., ET AL.: Emergency Cardiac Pacing for Severe Bradycardia. Our study included the treatment of transcutaneous cardiac pacing (TCP) in 32 patients: (A) 19 patients were treated in the emergency area for complete symptomatic AV block before endocavitary pacing; (B) five patients were in asystole following DC shock or out-of-hospital cardiac arrest; and (C) eight patients were affected by bifascicular block undergoing emergency surgery and were treated in order to prevent complete AV block. Two transcutaneous stimulators were used. PaceAid-CRC model 50/52 with 20-msec pulse width; the electrodes were positioned on the V, ECG position and on the back. Results: in all but two patients, it was possible to obtain stable cardiac capture; in one patient arrived in hospital in asystole after prolonged cardiac arrest and in the other one was affected by complete AV block, TCP was ineffective. In groups A and B, TCP was maintained for a mean time of 15 minutes; in group C, TCP was tested in all patients, but performed in only one patient during surgery. Mean threshold was 81 mA. Stimulation was well tolerated in all but five patients. TCP is a reliable, noninvasive method that offers the possibility to initiate pacing within seconds and can be used by medical staff. In our opinion, it should be considered as the first choice emergency treatment of severe symptomatic bradycardia. In asystole, beneficial effects can be obtained only if TCP is performed early enough after the onset of arrhythmia.     

Life charts on a palmtop computer: first results of a feasibility study with an electronic diary for bipolar patients

Schärer LO, Hartweg V, Valerius G, Graf M, Hoern M, Biedermann C,Walser S, Boensch A, Dittmann S, Forsthoff A, Hummel B, Grunze H, Walden J. Life charts on a palmtop computer: first results of a feasibility study with an electronic diary for bipolar patients. Bipolar Disord 2002: 4(Suppl. 1): 107–108. © Blackwell Munksgaard, 2002     

Nursing ethics and its relation with power and work organization

Difficulties faced in the nursing routine, mainly in hospitals, have been reported without the resulting ethical implications to workers and especially to clients, been sufficiently questioned. The work organization can be the main source of suffering to nursing workers, related to the exercise of power of different actors involved in the health institutions, which can potentially cause multiple problems and distress of ethical order. This study aims to make a critical reflection about some relations between the nursing work organization, power relations and its ethical dimension. Strategies for an ethical performance of nurses and other nursing professionals in the organization of work in the healthcare institutions point to the need of these professionals exercise power in an ethical way.     

Risk of domiciliation of Triatoma williami Galvão,Souza e Lima, 1965 in a municipality of Brazilian Legal Amazon region

ObjectiveTo notify the positivity and presence of vectors in natural and artificial ecotopes and analyze the basic knowledge of the Chagas disease vectors among population of amazon legal municipality.MethodsThe molecular confirmation of the parasite species was by PCR using species-specific markers. Data collection was conducted using semi-structured interviews.ResultsAll of 34 specimens collected were classified to be a single species, Triatoma williami. The natural infection rate of vectors in the specimens by T. cruzi was 30%. Most interviewees recognized adult triatomines. For 24.43% of respondents who had found the vector inside the house the main practice reported was killing the insects by crushing.ConclusionsDespite the knowledge shown by the residents, educational measures are needed to improve entomological surveillance of Chagas disease into enzootic amazon area.     

Inter-subjectivity in the context of people with cystic fibrosis' family

This is a qualitative investigation with a phenomenological approach, which aimed to reveal the inter-subjective processes in the context of the family in which there is a person who suffers from Cystic Fibrosis (CF). Fourteen families of CF carriers were interviewed. They were registered at the Paranaense Association of Cystic Fibrosis Care, and lived in the north and northwest regions of Paraná estate (PR), Brazil. Significant units were taken from their speech and grouped into three categories: Family, Carrier of CF and the other; Religious aspects about the life of the CF carrier in the family; Carrier of CF in the scholar, professional and affective life. The results confirmed that families' experience shared with the other was crucial to face the disease. Knowing the inter-subjective processes that underlie the core of the family of people affected by CF provides a new way of working in nursing.     

Posterior reversible encephalopathy syndrome in the Intensive Care Unit after liver transplant: a comparison of our experience with the existing literature

Posterior reversible encephalopathy syndrome (PRES) is a rare disease characterized by altered mental status, seizures, headache, vomiting and visual disturbances, most often described after transplantation and immunosuppressive therapy. PRES is commonly first diagnosed by the neuroradiologist, rather than the clinician, as it is characterized by very typical magnetic resonance imaging (MRI) features, i.e., hyperintense lesions in the territories of the posterior cerebral artery. Here we report our experience in the Intensive Care Unit (ICU) with a case of tacrolimus-related PRES after liver transplant, presenting with sudden neurological deterioration and diffuse and massive hyperintensities upon brain MRI. Discontinuation of tacrolimus, as prompted by the established literature, permitted the patient to eliminate tacrolimus-associated toxicity, whereas its substitution with everolimus and mycofenolic acid allowed the maintenance of immunosuppression while avoiding acute organ rejection and reducing the dosage of corticosteroids. The lowering of blood pressure with drugs reported in the literature for use in PRES proved to be effective but challenging, requiring the use of multiple drugs and only slowly leading to proper control of hypertensive peaks. Nonetheless, hypertension management and supportive therapy allowed for a complete neurological restitutio ad integrum of the patient. In conclusion, tacrolimus-related brain adverse events need to be promptly recognized, especially during the first months after transplantation. When tacrolimus-related PRES occurs, immunosuppressive therapy may be safely and efficiently switched to everolimus and mycofenolic acid. This strategy may help not only to avoid acute organ rejection but also to reduce the dosage of corticosteroids, which might interfere with proper control of hypertension.     

Prolonged Atrium Electromechanical Interval Is Associated with Stroke in Patients with Atrial Fibrillation After Catheter Ablation

Electromechanical Interval and Strokes After Ablations of AF . Introduction: Atrial fibrillation (AF) is associated with increased risk of embolic stroke. Catheter ablation of AF provides an effective therapy for patients with symptomatic and drug‐refractory AF. The aim of this study was to evaluate whether the atrial electromechanical interval is useful in identifying patients at risk of stroke after successful catheter ablation. Methods and Results: A total of 279 AF patients who received catheter ablation and showed no evidence of recurrences were enrolled. Electromechanical interval (PA–PDI) was determined as the time interval from the initiation of P wave deflection to the peak of mitral inflow A wave on pulse wave Doppler imaging. The PA–PDI interval was measured for each patient after the 3‐month blanking period of catheter ablation. The clinical endpoint was the occurrence of ischemic stroke. During the follow‐up of 46.5 ± 17.2 months, 6 patients suffered from ischemic strokes. Patients with strokes had higher CHA₂DS₂–VASc scores and longer PA–PDI intervals (138.7 ± 12.4 ms vs 161.2 ± 7.7 ms, P value < 0.001) compared to those without strokes. At a cutoff point of 150 ms identified by ROC curve, the positive and negative predictive values of the PA–PDI interval to predict stroke were 86.7% and 100%, respectively. The PA–PDI interval improved the predictive performance of the CHA₂DS₂–VASc score, and the area under the ROC curve increased from 0.75 to 0.85. Conclusions: Our results suggest that the PA–PDI interval is a useful tool to identify patients with high risk of stroke after successful catheter ablation of AF. (J Cardiovasc Electrophysiol, Vol. 24, pp. 375‐380, April 2013)