Refractory Ascites After Liver Transplantation: An Analysis of 1058 Liver Transplant Patients at a Single Center

A retrospective study of 1058 liver transplant recipients was performed to determine: (i) the incidence, etiology, timing, clinical features and treatment of refractory ascites (RA), (ii) risk factors for RA development, (iii) predictors of RA disappearance, (iv) predictors of survival following RA and (v) the impact of RA on patient survival. Sixty-two patients (5.9%) developed RA and its disappearance occurred in 27/62 cases. Patients having hepatitis C virus (HCV) had a significantly higher hazard rate of developing RA (p < 0.00001). No other baseline characteristic was associated with RA. Cox stepwise regression analysis of the hazard rate of RA disappearance found two significant factors: HCV recurrence as the reason for developing RA implied a poorer outcome (p = 0.006), whereas an unknown reason implied a favorable outcome (p = 0.02). In addition, survival following RA was significantly poorer among patients having bacterial peritonitis or HCV recurrence. Finally, the mortality rate was significantly (nearly 8.6 times) higher in patients following RA development while it was ongoing (p < 0.00001); however, if the RA disappeared, then the additional risk of death also disappeared. This study illustrates the importance of developing an optimal treatment strategy to (i) effectively treat RA if it develops and (ii) prevent hepatitis C recurrence.     

Touch-Screen Computerized Education for Patients with Brain Injuries

The use of computer technology for patient education has increased in recent years. This article describes a study that measures the attitudes and perceptions of healthcare professionals and laypeople regarding the effectiveness of a multimedia computer, the Brain Injury Resource Center? (BIRC), as an educational tool. The study focused on three major themes: (a) usefulness of the information presented, (b) effectiveness of the multimedia touch-screen computer methodology, and (c) the appropriate time for making this resource available. This prospective study, conducted in an acute care medical center, obtained healthcare professionals' evaluations using a written survey and responses from patients with brain injury and their families during interviews. The findings have yielded excellent ratings as to the ease of understanding and usefulness of the BIRC. By using sight, sound, and touch, such a multimedia learning center has the potential to simplify patient and family education.     

Deprivation of parenting disrupts development of homeostatic and reward systems in marmoset monkey offspring.

BACKGROUND: Early environment is a major determinant of long-term mental health, evidenced by the relationship between early-life neglect or abuse and chronically increased vulnerability to developmental psychopathology, including major depressive disorder (MDD). Animal studies can increase understanding of environmentally mediated causal risk processes. We describe how daily deprivation of biological parenting in primate infants disrupts development of homeostatic and reward systems central to MDD. METHODS: Nine breeding pairs of marmoset monkeys provided control twins (CON) and early-deprived twins (ED); the latter were socially isolated for 30-120 min/day on days 2-28. During the first year of life, basal urinary norepinephrine (NE) titers and cardiophysiologic activity were measured. At the end of year 1 (adolescence), automated neuropsychologic tests were conducted to measure responsiveness to changes in stimulus-reward association (simple/reversed visual discrimination learning) and to reward per se (progressive ratio [PR] reinforcement schedule). RESULTS: The ED monkeys exhibited increased basal urinary NE titers and increased systolic blood pressure relative to CON siblings. The ED monkeys required more sessions to reinstate stimulus-oriented behavior following reversal, suggesting increased vulnerability to perceived loss of environmental control; ED monkeys also performed less PR operant responses, indicating that reward was less of an incentive and that they were mildly anhedonic relative to CON. CONCLUSIONS: In marmoset monkeys, neglect-like manipulation of ED leads to chronic changes in homeostatic systems, similar to those in children and adolescents exposed to early-life adversity and in MDD, and to responses to environmental stimuli similar to those that characterize MDD.     

Surgical reinterventions following the Fontan procedure.

OBJECTIVE: The Fontan procedure is utilized as a final reconstructive procedure for patients with functional single ventricle. Short- and long-term outcomes have improved significantly, however, some patients require additional cardiac procedures following the Fontan operation. The outcomes for these reinterventions are not known. METHODS: Cardiac Surgery and Cardiac Intensive Care Unit databases at The Children's Hospital of Philadelphia were reviewed to identify all patients who underwent cardiac surgery after a previous Fontan operation between January 1, 1995 and December 31, 2001. RESULTS: During the study period, 123 procedures were performed in 71 patients. The median time from Fontan to reoperation was 3.6 years (range 0.1-20 years). Indications for reintervention included arrhythmia, cyanosis, 'failing' Fontan circulation or exercise intolerance, protein losing enteropathy, atrioventricular valve (AVV) regurgitation, and other indications. Procedures included pacemaker insertion or revision (n = 59, 48%), reinclusion of previously excluded hepatic veins (n = 16, 13%), revision to either a lateral tunnel or extra-cardiac conduit Fontan (n = 13, 11%), cardiac transplantation (n = 9, 7%), enlargement or creation of a baffle fenestration (n = 6, 5%), isolated AVV repair or replacement (n = 2, 2%), and other procedures (n = 18, 14%). There were five early and five late deaths. Hospital mortality was greatest for patients undergoing cardiac transplantation (4/9, 44%), accounting for 80% of the early deaths. CONCLUSIONS: Surgical reinterventions following the Fontan procedure may be necessary for multiple indications which result in impairment of the Fontan circulation. Most reinterventions can be performed with minimal morbidity and mortality. Survival for patients requiring cardiac transplantation following the Fontan procedure remains poor.     

Control of lymphocyte migration into brain: selective interactions of lymphocyte subpopulations with brain endothelium.

The protein antigens conalbumin (CA) and ovalbumin (OVA) are known to require uptake into antigen-presenting cells (APC) for their presentation to major histocompatibility complex (MHC) class II-restricted T cells. In both cases proteolytic cleavage is thought to be a necessary step for the generation of the respective antigenic peptides. A specific inhibitor of the endosomal protease cathepsin B, Cbz-Phe-Ala-CHN2, blocks the presentation of both CA and OVA, whereas this inhibitor has no effect on the presentation of a processing-independent OVA peptide. Furthermore, the presentation of insulin, an antigen that needs processing but no proteolytic cleavage, is enhanced when cathepsin B is inhibited during antigen pulsing. When the APC were treated with an inhibitor of acid proteases, the CA response was not affected, while the presentation of OVA was diminished under these conditions. To estimate the relevance of these findings for the generation of the antigenic CA peptide, extracellular digestions of CA by cathepsin B were carried out. The fragment(s) present in these digests was recognized by T cells without further processing. Furthermore, the time-course of intra- and extracellular CA processing with respect to the capacity to stimulate T cells was similar. Taken together these data suggest that degradation by cathepsin B may be sufficient in vivo to generate the antigenic CA fragment. On the other hand, the blocking of cathepsin B does not appear to have an adverse effect on the general mechanisms of antigen presentation.     

Tissue engineering of arteries by directed remodeling of intact arterial segments

Traditional approaches to generating tissue-engineered arteries in vitro rely on expansion of cells in culture to seed appropriate scaffolds. In most envisioned applications, small autologous blood vessels would be harvested and used as a source for these cells. We propose that small autologous arteries, not the cells derived from them, may be an attractive starting point for engineered arteries. This approach capitalizes on the ability of intact arteries to grow and remodel in response to chronic changes in their mechanical environment. Carotid arteries from juvenile (approximately 30-kg) pigs were stretched longitudinally in an ex vivo perfusion system over 9 days. This resulted in a 40% increase in artery length at physiological longitudinal stress and a 20 +/- 3% increase when unstressed. Control arteries were perfused for 9 days ex vivo at their physiological loaded length. Control and elongated arteries displayed native appearance (macroscopic and histological), excellent viability (cellularity and mitochondrial activity), normal vasoactivity, and similar mechanical properties (ultimate stress and ultimate strain) as compared with freshly harvested arteries. Growth, as opposed to just redistribution of existing mass, contributed to elongation as evidenced by an increase in artery weight. Results on elongation of arteries from neonatal and adolescent pigs are also presented and discussed.     

Maternal behavior is related to prepartum urinary estradiol levels in red-bellied tamarin monkeys

This is the first study in a primate, the red-bellied tamarin (Saguinus labiatus), to demonstrate a correlation between urinary estradiol during late pregnancy and postpartum infant-directed behavior. Females were defined as good (N = 6) or poor (N = 6) mothers, and were selected so that both groups contained 3 females with and 3 without prepubertal experience with infants. Females with prepubertal experience of infants were defined as good or poor mothers if 2 or less than 2 infants survived one week, respectively; females without such experience were defined as good or poor mothers if at least 1, or 0 infants survived one week, respectively. Five of the six good mothers had 2 surviving infants; 10 of the 13 infants of poor mothers died at day 0. Prepartum urinary total estradiol concentrations were constant in good mothers (5-4 weeks prepartum: 32.29 +/- 3.65 micrograms/mg creatinine; 1 week prepartum: 33.76 +/- 5.02 micrograms/mg CR.; p greater than 0.98), but declined significantly in poor mothers (5-4 weeks prepartum: 38.34 +/- 7.07 micrograms/mg Cr.; 1 week prepartum: 18.35 +/- 4.72 micrograms/mg Cr.; p less than 0.0004). At 1 week prepartum, estradiol was significantly higher in good mothers (p less than 0.03). When analysed separately, only good and poor mothers without prepubertal experience of infants had significantly different urinary estradiol concentrations. In the 2-hour postpartum period, good mothers spent more time lick-cleaning (p less than 0.02), carrying and nursing infants; poor mothers rubbed off clinging infants more, their infants spent less time being carried (p less than 0.03), and apparently starved because they had no opportunity to suckle.     

Polymorphisms in the MAOA, MAOB, and COMT genes and aggressive behavior in schizophrenia.

Some studies have reported associations between COMT and MAO genotypes and aggression, though results have been inconsistent. We examined the relationship between Overt aggression scale (OAS) scores, and both MAOA and MAOB polymorphisms in a well-powered sample of 346 subjects with schizophrenia. We also examined COMT in a Stage II replication sample of 150 individuals, and combined these results with our previously reported (Stage I) findings for COMT. We found no evidence of any associations between OAS ratings and any of the polymorphisms investigated under different genetic models. There was no evidence of epistatic interaction between MAOA and COMT on OAS scores. These results fail to support the theory that functional polymorphisms within the MAOA, MAOB, or COMT genes, as determinants of catecholamine enzymatic activity, are risk factors for aggressive behavior.