Current indication of a modified Sugiura procedure in the management of variceal bleeding

BACKGROUND: The role of gastroesophageal devascularization (Sugiura-rype procedures) for the treatment of variceal bleeding remains controversial. Although Japanese series reported favorable longterm results, the technique has nor been widely accepted in the Western Hemisphere because of a high postoperative morbidity and mortality. The reasons for the different outcomes are unclear. In a multidisciplinary team approach we developed a therapeutic algorithm for patients with recurrent variceal bleeding. STUDY DESIGN: The Sugiura procedure was offered only to patients with well-preserved liver function (Child A or Child B cirrhosis without chronic ascites) who were not candidates for distal splenorenal shunt, transhepatic porto-systemic shunt, or liver transplantation. RESULTS: Fifteen patients with recurrent variceal bleeding underwent a modified Sugiura procedure between September 1994 and September 1997. All but one patient (operative mortality 7%) are alive after a median followup of 4 years. Recurrent variceal bleeding developed in one patient; esophageal strictures, which were successfully treated by endoscopic dilatation, developed in three patients; and one patient experienced mild encephalopathy. Major complications were noted only in patients with impaired liver function (Child B cirrhosis) or when the modified Sugiura was performed in an emergency setting. The presence of cirrhosis or the cause of portal hypertension had no significant impact on the complication rate. CONCLUSIONS: This series was performed during the last decade when all modern therapeutic options for variceal bleeding were available. Our results indicate that the modified Sugiura procedure is an effective rescue therapy in patients who are not candidates for selective shunts, transhepatic porto-systemic shunt, or transplantation. Emergency settings and decreased liver function are associated with an increased morbidity.     

Evaluation of the antimicrobial property of Polyalthia longifolia var. pendula: isolation of a lactone as the active antibacterial agent from the ethanol extract of the stem

Bioassay guided fractionation of the ethanolic extract of Polyalthia longifolia var. pendula stem, which showed promising antibacterial activity against thirteen Gram-positive and nine Gram-negative organisms, furnished (3S,4R)-3,4,5-trihydroxypentanoic acid-1,4-lactone (1) as the active principle. The structure of (1) was established by UV, IR, mass, 1H and 13C NMR as well as 2D NMR spectral studies and the formation of its acetate (1a). On acetylation activity of (1) was markedly reduced. It is synthetically well known and only recently isolated from two plants, however, its antimicrobial activity was not reported earlier. The extract, fractions and pure compounds did not show any remarkable activity against fungi and Mycobacterium fortuitum, and M. smegmatis.     

Saponins from the seeds of Achras sapota

A new pentacyclic triterpenoid saponin (2) along with one known was isolated from the cotyledons of Achras sapota. Their structures were determined with the help of (1)H NMR, (13)C NMR and MS spectral data. The isolated compounds were named as 3-O-beta-D-glucopyranosyl-(1-->6)-beta-D-glucopyranosyl-28-O-alpha-L-rhamnopyranosyl-(1-->3)-beta-D-xylopyranosyl-(1-->4)-alpha-L-rhamnopyranosyl-(1-->2)-alpha-L-arabinopyranosyl protobassic acid (1) and 3-O-beta-D-glucopyranosyl-(1-->3)-beta-D-glucopyranosyl-28-O-alpha-L-rhamnopyranosyl-(1-->3)-beta-D-xylopyranosyl-(1-->4)-alpha-L-rhamnopyranosyl-(1-->2)-alpha-L-arabinopyranosyl-16alpha-hydroxy protobassic acid (2). Compound 2 showed antibacterial activity against Gram positive and negative bacteria.     

Review of biphasic insulin aspart in the treatment of type 1 and 2 diabetes

Background

Insulin is an effective treatment for achieving glycemic control and preventing complications in patients with diabetes. In order to make insulin therapy more acceptable to patients, newer formulations of insulin have been developed, such as biphasic insulins. Biphasic insulins conveniently provide both prandial and basal insulin in a single injection. One of the most well-studied biphasic insulins is biphasic insulin aspart 70/30.

Objective

Our goal was to review the current literature on the safety and efficacy of biphasic insulin aspart in type 1 and type 2 diabetes.

Methods

A MEDLINE search was conducted using the terms “biphasic insulin aspart” to identify clinical studies and reviews.

Results

Biphasic insulin aspart more effectively reduces post-prandial glucose compared to other biphasic insulins and basal insulins. Compared to biphasic insulin aspart, fasting glucose levels are lower with NPH, similar with glargine, and similar or lower with biphasic human insulin. Treat-to-target trials have shown that a goal HbA1c below 6.5 or 7% can be achieved with biphasic insulin aspart. The risk of hypoglycemia is similar to or less than that seen with other biphasic insulins or NPH insulin.

Conclusion

Biphasic insulin aspart 70/30 is a safe and effective treatment option for patients with diabetes.     

Revised approach for identification of isolates within the Burkholderia cepacia complex and description of clinical isolates not assigned to any of the known genomovars

One hundred thirty-eight clinical isolates of the Burkholderia cepacia complex (Bcc) were identified using a modified strategy that involved PCR detection of the cblA gene for the ET12 lineage simultaneously with detection of the Bcc recA PCR product; recA sequence cluster analysis also was part of the strategy. Four strains could not be assigned to any of the known genomovars.     

Normothermic ex vivo kidney perfusion for graft quality assessment prior to transplantation

Normothermic ex vivo kidney perfusion (NEVKP) represents a novel approach for graft preservation and functional improvement in kidney transplantation. We investigated whether NEVKP also allows graft quality assessment before transplantation. Kidneys from 30‐kg pigs were recovered in a model of heart‐beating donation (group A) after 30 minutes (group B) or 60 minutes (group C) (n = 5/group) of warm ischemia. After 8 hours of NEVKP, contralateral kidneys were resected, grafts were autotransplanted, and the pigs were followed for 3 days. After transplantation, renal function measured based on peak serum creatinine differed significantly among groups (P < .05). Throughout NEVKP, intrarenal resistance was lowest in group A and highest in group C (P < .05). intrarenal resistance at the initiation of NEVKP correlated with postoperative renal function (P < .001 at NEVKP hour 1). Markers of acid‐base homeostasis (pH, HCO₃^–, base excess) differed among groups (P < .05) and correlated with posttransplantation renal function (P < .001 for pH at NEVKP hour 1). Similarly, lactate and aspartate aminotransferase were lowest in noninjured grafts versus donation after circulatory death kidneys (P < .05) and correlated with posttransplantation kidney function (P < .001 for lactate at NEVKP hour 1). In conclusion, assessment of perfusion characteristics and clinically available perfusate biomarkers during NEVKP allows the prediction of posttransplantation graft function. Thus, NEVKP might allow decision‐making regarding whether grafts are suitable for transplantation.     

Fat and liver transplantation: clinical implications

Nonalcoholic steatohepatitis (NASH), with or without hepatocellular carcinoma, is a growing indication for liver transplantation (LT) worldwide, particularly in the Western world. Patients with NASH typically combine features of metabolic syndrome with cardiovascular comorbidities, which challenge pre‐LT evaluation, surgical approaches, post‐LT management, and outcomes. Post‐LT survival in NASH patients is excellent, similar to that achieved with other indications, particularly in the absence of cardiovascular comorbidities. Although disease recurrence on the liver allograft is common, progression to advanced disease is uncommon, at least in the short term. Whether this holds true with longer follow‐up remains to be determined. Owing to the increased prevalence of nonalcoholic fatty liver disease worldwide, along with a shortened organ pool donation in many countries, utilization of donor grafts with hepatic steatosis is now more common. Understanding the limitations of these grafts as well as potential mechanisms to improve graft quality and/or transplant outcome is clue for transplant centers. In this review, we will summarize current data on evaluation of NASH patients and whether it differs from that applied to other candidates, the natural history of NASH both pre‐ and post‐transplantation, emphasizing on waiting list management and recurrence of the original disease in the new graft as well as post‐transplant outcome. Finally, we will discuss the current use of steatotic liver donors and strategies to improve outcome when using this type of grafts.     

Live donor liver transplantation with older donors: Increased long‐term graft loss due to HCV recurrence

Using our prospectively collected database all adult hepatitis C virus (HCV)‐positive patients receiving an adult‐to‐adult LDLT between October 2000 and May 2014 were identified. Outcome of LDLT with grafts from younger (<50 years=128) vs older donors (≥50 years=31) was compared. Post‐transplant graft function, postoperative complications and incidence of HCV recurrence were evaluated. Long‐term graft and patient survival was calculated. No difference in graft function was observed between younger and older grafts. Overall complications were similar between both groups. The severity of complications determined by the Dindo‐Clavien score was similar. Graft loss from HCV recurrence was significantly less frequent in younger grafts (18% vs 62%, P = 0.001). Young vs older livers had a trend toward improved 1‐, 5‐, and 10‐year graft survival (89% vs 87%, 77% vs 69%, 70% vs 55%, P = 0.096), while patient survival was comparable between both groups (91% vs 90%, 78% vs 69%, 71% vs 60%, P = 0.25). In conclusion, LDLT with older vs younger grafts are more frequently associated with long‐term graft loss due to HCV recurrence. Differences in graft survival might be more prominent with prolonged (≥5‐year) follow‐up. Living donor‐recipient matching is particularly important for younger HCV‐positive recipients.     

Mechanisms of ischemic injury are different in the steatotic and normal rat liver

Hepatic steatosis is associated with significant morbidity and mortality after liver resection and transplantation. Although apoptosis is a key mechanism of reperfusion injury in the normal liver, the pathway leading to cell death in steatotic hepatocytes is unknown. A model of hepatic ischemia and reperfusion injury in fatty and lean Zucker rats was used. Fatty animals had increased aspartate aminotransferase (AST) release and decreased survival after 60 minutes of ischemia compared with lean animals. Apoptosis was the predominant form of cell death in the lean rats (82%), whereas necrosis was minimal. In contrast, fatty animals developed only moderate amounts of apoptosis but showed massive necrosis (73%) after 24 hours of reperfusion. Intracellular mediators of apoptosis, such as caspase 8, caspase 3, and cytochrome c, were significantly lower in the steatotic than in the lean liver indicating dysfunction in activation of the apoptotic pathway. The high percentage of necrosis in the steatotic rats was associated with renal acute tubular necrosis after 24 hours of reperfusion in the fatty, but not in lean rats. Caspase inhibition significantly decreased reperfusion injury in lean animals, but was ineffective in fatty animals. The results indicate that the increased susceptibility of fatty livers to reperfusion injury is associated with a change from an apoptotic form of cell death to necrosis. We conclude that new therapeutic strategies are necessary in the fatty liver.