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Objectives: Terlipressin improves renal function in hepatorenal syndrome (HRS) is a known fact. However the reason for lack of its long-term survival benefits despite improvement in renal function remains unclear. The aim of this study was to analyze the survival benefits of terlipressin in HRS and to address the issue of non-responder state to terlipressin. Materials and Methods: Electronic databases and relevant articles were searched for all types of studies related to HRS and use of terlipressin in HRS. Reduction in all-cause mortality rate was the primary outcome measure. Reduction in mortality rate due to HRS and other causes of death were also analyzed. Results: With total 377 patients analyzed from eight eligible studies; terlipressin reduced all-cause mortality rate by 15% (Risk Difference: -0.15%, 95% CI:-0.26 to -0.03). Reduction in the mortality rate due to HRS at three months was 9% (Risk Difference:-0.09%, 95% CI:-0.18 to 0.00). Conclusion: Terlipressin has long term survival benefits perhaps at least up to three months but only with HRS as a cause of death not for other causes of death. Benefits and role of antioxidants like N- Acetylcysteine (NAC) in non-responder patients' needs to be studied further. Long-term use of low dose terlipressin (<4mg/d) plus albumin and addition of antioxidant NAC to this regimen may help in improving both HRS reversal rate and survival rate in non-responders to terlipressin. [ABSTRACT FROM AUTHOR]

Background: Hepatorenal syndrome (HRS) is known as development of acute renal failure in a patient who usually has advanced liver disease. The aim of the present study was to determine the safety and the efficacy of noradrenalin in comparison with midodrine-octreotide in patients with HRS. Methods: This study was registered to the Iranian Registry of Clinical trials (IRCT). This study was a single-center, randomized, clinical trial that performed in Alzahra hospital, Isfahan, Iran. Since March 2011 to January 2012, twenty-three patients were enrolled in the study. Eligible patients were allocated in 2 groups. In the first group, patients received infusion of NA with the dose of 0.1-0.7 µg/kg/min, and in the other groups, patients received octreotide 100-200 µg subcutaneously 3 times daily and midodrine 5-15 mg orally 3 times daily. In both study groups, patient received albumin infusion in addition to noradrenalin or midodrine-octreotide. Results: Complete response of HRS was observed in 8 of the 11 patients (73%) treated with noradrenalin and in 9 of the 12 patients (75%) treated with midodrine-octreotide (P > 0.05). HRS recurred after treatment withdrawal in 2 of 11 in NA and 3 of 12 in MO group. That shows no significant difference between 2 groups (P > 0.05). Conclusion: We deduce that NA has the same efficacy and safety with MO and can induce a complete response in high percentage of the patients. Moreover, we observed no significant differences in the recurrence rate and outcomes after 3 months among the patients in both study groups; this result could support the use of NA in HRS management. The IRCT ID is: IRCT201107217085N1. [ABSTRACT FROM AUTHOR]

Over the last two decades the uninterrupted, high resolution observations of the Sun, from the excellent range of telescopes aboard many spacecraft complemented with observations from sophisticated ground-based telescopes have opened up a new world producing significantly more complete information on the physical conditions of the solar atmosphere than before. The interface between the lower solar atmosphere where energy is generated by subsurface convection and the corona comprises the chromosphere, which is dominated by jet-like, dynamic structures, called mottles when found in quiet regions, fibrils when found in active regions and spicules when observed at the solar limb. Recently, space observations with Hinode have led to the suggestion that there should exist two different types of spicules called Type I and Type II which have different properties. Ground-based observations in the Ca ii H and K filtergrams reveal the existence of long, thin emission features called straws in observations close to the limb, and a class of short-lived events called rapid blue-shifted excursions characterized by large Doppler shifts that appear only in the blue wing of the Ca ii infrared line. It has been suggested that the key to understanding how the solar plasma is accelerated and heated may well be found in the studies of these jet-like, dynamic events. However, while these structures are observed and studied for more than 130 years in the visible, but also in the UV and EUV emission lines and continua, there are still many questions to be answered. Thus, despite their importance and a multitude of observations performed and theoretical models proposed, questions regarding their origin, how they are formed, their physical parameters, their association with the underlying photospheric magnetic field, how they appear in the different spectral lines, and the interrelationship between structures observed in quiet and active regions on the disk and at the limb, as well as their role in global processes has not yet received definitive answers. In addition, how they affect the coronal heating and solar wind need to be further explored. In this review we present observations and physical properties of small-scale jet-like chromospheric events observed in active and quiet regions, on the disk and at the limb and discuss their interrelationship. [ABSTRACT FROM AUTHOR]

The article presents a diagnostic criteria for the hepatorenal syndrome (HRS). HRS is a unique form of kidney injury resulting from renal vasoconstriction in the setting of systemic and splanchnic arterial vasodilatation in patients with advanced cirrhosis. HRS is subdivided into two types: type-1 in which there is a rapid deterioration in kidney function and type-2 HRS occurs in patients with refractory ascites.

The interest in the liver dates back to ancient times when it was considered to be the seat of life processes. The liver is indeed essential to life, not only due to its complex functions in biosynthesis, metabolism and clearance, but also its dramatic role as the blood volume reservoir. Among parenchymal organs, blood flow to the liver is unique due to the dual supply from the portal vein and the hepatic artery. Knowledge of the mutual communication of both the hepatic artery and the portal vein is essential to understand hepatic physiology and pathophysiology. To distinguish the individual importance of each of these inflows in normal and abnormal states is still a challenging task and the subject of ongoing research. A central mechanism that controls and allows constancy of hepatic blood flow is the hepatic arterial buffer response. The current paper reviews the relevance of this intimate hepatic blood flow regulatory system in health and disease. We exclusively focus on the endogenous interrelationship between the hepatic arterial and portal venous inflow circuits in liver resection and transplantation, as well as inflammatory and chronic liver diseases. We do not consider the hepatic microvascular anatomy, as this has been the subject of another recent review. [ABSTRACT FROM AUTHOR]

AIM: To determine whether the association of β-blockers with endoscopic treatment is superior to endoscopic treatment alone for the secondary prophylaxis of oesophageal variceal bleeding. METHODS: Randomised controlled trials comparing sclerotherapy (SCL) with SCL plus β-blockers (BB) or banding ligation (BL) with BL plus BB were identified. Main outcomes were overall and 6, 12 and 24 mo rebleeding rates, as well as overall and 6, 12 and 24 mo mortality. Two statistical methods were used: Yusuf-Peto, and Der Simonian and Laird. Inter-trial heterogeneity was systematically taken into account. RESULTS: Seventeen randomised controlled trials were included, 14 with SCL and 3 with BL. Combination β-blocker and endoscopic treatment significantly reduced rebleeding rates at 6, 12 and 24 mo and overall [odds ratio (OR): 2.20, 95% confidence interval (CI): 1.69-2.85, P < 0.0001] compared to endoscopic treatment alone. Mortality at 24 mo was significantly lower for the combined treatment group (OR: 1.83, 95% CI: 1.16-2.90, P = 0.009), as well as overall mortality (OR: 1.43, 95% CI: 1.03-1.98, P = 0.03). CONCLUSION: Combination therapy should thus be recommended as the first line treatment for secondary prophylaxis of oesophageal variceal bleeding. [ABSTRACT FROM AUTHOR]

During liver resection surgery for cancer or liver transplantation, the liver is subject to ischaemia (reduction in blood flow) followed by reperfusion (restoration of blood flow), which results in liver injury [ischemiareperfusion (IR) or IR injury]. Modulation of IR injury can be achieved in various ways. These include hypothermia, ischaemic preconditioning (IPC) (brief cycles of ischaemia followed by reperfusion of the organ before the prolonged period of ischaemia i.e. a conditioning response), ischaemic postconditioning (conditioning after the prolonged period of ischaemia but before the reperfusion), pharmacological agents to decrease IR injury, genetic modulation of IR injury, and machine perfusion (pulsatile perfusion). Hypothermia decreases the metabolic functions and the oxygen consumption of organs. Static cold storage in University of Wisconsin solution reduces IR injury and has prolonged organ storage and improved the function of transplanted grafts. There is currently no evidence for any clinical advantage in the use of alternate solutions for static cold storage. Although experimental data from animal models suggest that IPC, ischaemic postconditioning, various pharmacological agents, gene therapy, and machine perfusion decrease IR injury, none of these interventions can be recommended in clinical practice. This is because of the lack of randomized controlled trials assessing the safety and efficacy of ischaemic postconditioning, gene therapy, and machine perfusion. Randomized controlled trials and systematic reviews of randomized controlled trials assessing the safety and efficacy of IPC and various pharmacological agents have demonstrated biochemical or histological improvements but this has not translated to clinical benefit. Further well designed randomized controlled trials are necessary to assess the various new protective strategies in liver resection. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the safety and efficacy of sequential transcatheter arterial chemoembolization (TACE) and portal vein embolization (PVE) prior to surgery in hepatocellular carcinoma (HCC) patients and to compare the clinical outcome of the combined procedure with that of a matched group of patients undergoing PVE alone. Patients and Methods: From 1997 to 2008, 135 patients with HCC underwent sequential TACE and PVE ( n = 71) or PVE alone ( n = 64) before right hepatectomy. PVE was performed mean 1.2 months after TACE. In both groups, computed tomography (CT) and liver volumetry were performed before and 2 weeks after PVE to assess degree of left lobe hypertrophy. Results: Baseline patient and tumor characteristics were similar in the two groups. After PVE, the chronological changes of liver enzymes were similar in the two groups. The mean increase in percentage future liver remnant (FLR) volume was higher in the TACE + PVE group (7.3%) than in the PVE-only group (5.8%) ( P = 0.035). After surgery, incidence of hepatic failure was higher in the PVE-only group (12%) than in the TACE + PVE (4%) group ( P = 0.185). Overall ( P = 0.028) and recurrence-free ( P = 0.001) survival rates were significantly higher in the TACE + PVE group than in the PVE-only group. Conclusion: Sequential TACE and PVE before surgery is a safe and effective method to increase the rate of hypertrophy of the FLR and leads to longer overall and recurrence-free survival in patients with HCC. [ABSTRACT FROM AUTHOR]

Background/Purpose: In living donor liver transplantation (LDLT), matching of liver volume between donor and recipient is critical to the success of the procedure; mismatch can result in 'small- or large-for-size syndrome'. In orthotopic liver transplantation (OLT), matching criteria are less stringent and non-uniform. We sought to determine whether a new parameter, the ratio of donor to recipient body surface area (BSAi), is predictive of size mismatch and/or post-transplant morbidity or mortality. Methods: We reviewed data on 1228 OLT recipients and stratified this data according to three categories: small-for-size (BSAi <0.6), control (BSAi = 0.6-1.4), and large-for-size (BSAi >1.4) donors. Results: We found that: (1) matching of grafts at the upper and lower extremes of BSAi had significantly reduced graft survival; (2) matches with lower BSAi sustained a less severe form of intraoperative post-reperfusion syndrome, and the incidence of hepatic artery thrombosis was high postoperatively in these grafts; (3) BSAi and donor age correlated well with the severity of intraoperative post-reperfusion hypotension; and (4) small-for-size (BSAi <0.6) and large-for-size (BSAi >1.4) grafts, as well as preoperative total bilirubin, were significant risk factors for decreased graft survival. Conclusion: We conclude that the BSAi can predict clinically significant size mismatch and adverse outcomes in cadaveric whole OLT. [ABSTRACT FROM AUTHOR]

Background: Hair transplantation surgery currently is a well-established procedure in plastic surgery. It consists of harvesting a strip of scalp from the back of the head, then obtaining grafts called follicular units (FUs) from this strip and implanting them in the bald area. The FUs undergo oxidative stress during cold ischemia and after their implantation. Methods: Surgery was performed for 18 patients between April and July 2008. Follicular units were preserved in solutions containing different growth-stimulating hormone (GSH) concentrations (5, 10, and 20 mmol). Saline solution was used as a control condition. Spectrophotometry was used to measure the thiobarbituric acid-reactive substance (TBARS) and GSH concentrations before ischemia (control group) in the FUs preserved in the four proposed solutions, then after 30 min of cold ischemia and 30 min after grafting. The data obtained were submitted to analysis of variance, t test, and linear regression analysis. Results: The TBARS (μmol of malondialdehyde [MDA]/g) and GSH (μmol/g) concentrations were not significantly different between the four solutions in either the ischemia or grafting group. The GSH concentration did not differ significantly between the control (59.801 ± 30.639 μmol/g) and ischemia (56.284 ± 28.404 μmol/g) groups. The GSH concentrations were significantly greater ( p < 0.05) in the postgrafting group (63.815 ± 28.404 μmol/g) than in the group subjected to ischemia. Conclusion: Increasing the GSH concentrations used in FU preservation solutions does not reduce the oxidative effects of cold ischemia and reperfusion injury during hair transplantation surgery. [ABSTRACT FROM AUTHOR]

Kim S-J, Kim D-G, Park J-H, Moon I-S, Lee M-D, Kim J-I, Yoon Y-C, Yoo Y-K. Clinical analysis of living donor liver transplantation in patients with portal vein thrombosis. Clin Transplant 2011: 25: 111-118. © 2010 John Wiley & Sons A/S. The aim of this study was to improve outcomes in living donor liver transplantation (LDLT) patients with portal vein thrombosis (PVT). Of 246 adult patients who underwent LDLT with a right lobe graft between January 2000 and May 2007, PVT was diagnosed in 50 patients (20.3%), who were further subdivided into partial (n = 39, 78%) and complete (n = 11, 22%) types. Patients with PVT, especially complete PVT, showed high incidences of variceal bleeding (p = 0.021), operative RBC transfusion (p < 0.046) and a post-transplantation complications related to bleeding (p = 0.058). We also classified PVT according to its location and the presence of collaterals: type I (n = 41, 82%): PVT localized above the confluence of the splenic and superior mesenteric veins (SMV); type II (n = 7, 14%): PVT extending below the confluence with a patent distal SMV; type III (n = 2, 4%): complete portal vein and SMV thrombosis except for a coronary vein. LDLT could be safely undertaken in patients with PVT without increased mortality. In our type II and III PVT, when thrombectomy fails, jump grafting using a cryopreserved vessel may serve as a reliable alternative method to restore portal flow. [ABSTRACT FROM AUTHOR]

Observations and models of solar prominences are reviewed. We focus on non-eruptive prominences, and describe recent progress in four areas of prominence research: (1) magnetic structure deduced from observations and models, (2) the dynamics of prominence plasmas (formation and flows), (3) Magneto-hydrodynamic (MHD) waves in prominences and (4) the formation and large-scale patterns of the filament channels in which prominences are located. Finally, several outstanding issues in prominence research are discussed, along with observations and models required to resolve them. [ABSTRACT FROM AUTHOR]

Currently, liver transplantation (LT) is an accepted method of treatment of end-stage liver disease, metabolic diseases with their primary defect in the liver and unresectable primary liver tumors. Surgical techniques in LT have evolved considerably over the past 40 yr. The developments have led to a safer procedure for the recipient reflected by continuously improving survival figures after LT. Also the new techniques offer the possibility of tailoring the operation to the needs and condition of the recipient as in partial grafting or in different revascularization techniques, or in techniques of biliary reconstructions. In addition, the new techniques such as split LT, domino transplantation and living donor LT have brought about an increase in the available grafts. In this review the evolution of surgical techniques in LT over the past 40 yr and their contribution to the current results are discussed. [ABSTRACT FROM AUTHOR]

Vasoconstrictors have long been used in an attempt to mitigate the effects of portal hypertension. In this review, we discuss the current understanding of portal hypertension and the use of vasoconstrictors in the management of its sequlae, including variceal hemorrhage, hepatorenal syndrome, and paracentesis-induced circulatory dysfunction. Experimental and clinical evidence for the use of vasoconstrictors is considered, and several exciting recent developments are reviewed. [ABSTRACT FROM PUBLISHER]

Orthotopic liver transplantation has been made feasible with intra-operative femoral-to-jugular veno-venous bypass (VVB) to redirect the blood from the lower extremities and the kidneys to the heart. This reduces hemodynamic instability and metabolic disturbances. However, complications such as thromboses with pulmonary thrombembolism or post-reperfusion syndrome were observed in up to 30% of the cases. The latter, recent developments of cava-sparing surgical techniques, shorter anhepatic times plus optimized anesthetic management have made the necessity for a routine use of VVB questionable. [ABSTRACT FROM AUTHOR]

The atmosphere of the Sun is characterized by a complex interplay of competing physical processes: convection, radiation, conduction, and magnetic fields. The most obvious imprint of the solar convection and its overshooting in the low atmosphere is the granulation pattern. Beside this dominating scale there is a more or less smooth distribution of spatial scales, both towards smaller and larger scales, making the Sun essentially a multi-scale object. Convection and overshooting give the photosphere its face but also act as drivers for the layers above, namely the chromosphere and corona. The magnetic field configuration effectively couples the atmospheric layers on a multitude of spatial scales, for instance in the form of loops that are anchored in the convection zone and continue through the atmosphere up into the chromosphere and corona. The magnetic field is also an important structuring agent for the small, granulation-size scales, although (hydrodynamic) shock waves also play an important role—especially in the internetwork atmosphere where mostly weak fields prevail. Based on recent results from observations and numerical simulations, we attempt to present a comprehensive picture of the atmosphere of the quiet Sun as a highly intermittent and dynamic system. [ABSTRACT FROM AUTHOR]

Ascites and hepatorenal syndrome (HRS) are the major and challenging complications of cirrhosis and portal hypertension that significantly affect the course of the disease. Liver insufficiency, portal hypertension, arterial vasodilatation, and systemic cardiovascular dysfunction are major pathophysiological hallmarks. Modern treatment of ascites is based on this recognition and includes modest salt restriction and stepwise diuretic therapy with spironolactone and loop diuretics. Tense and refractory ascites should be treated with a large volume paracentesis, followed by volume expansion or transjugular intrahepatic portosystemic shunt. New treatment strategies include the use of vasopressin V2-receptor antagonists and vasoconstrictors. The HRS denotes a functional and reversible impairment of renal function in patients with severe cirrhosis with a poor prognosis. Attempts of treatment should seek to improve liver function, ameliorate arterial hypotension and central hypovolemia, and reduce renal vasoconstriction. Ample treatment of ascites and HRS is important to improve the quality of life and prevent further complications, but since treatment of fluid retention does not significantly improve survival, these patients should always be considered for liver transplantation. [ABSTRACT FROM AUTHOR]

Type 1 hepatorenal syndrome (HRS) is prerenal failure specific to decompensated cirrhosis. In patients with HRS, there is marked splanchnic/systemic vasodilation resulting in arterial hypotension, arterial baroreceptor unloading, overstimulation of the sympathetic nervous and renin-angiotensin systems. This reflex neurohumoral hyperactivity via endogenous vasoconstrictors/vasopressors such as angiotensin II and noradrenaline induces arterial vasoconstriction in different extrasplanchnic vascular beds (including preglomerular arteries in the kidneys). Decreased arterial pressure (i.e. low renal perfusion pressure) and preglomerular vasoconstriction are thought to play a major role in the decline of the glomerular filtration rate (GFR). Nonrandomized studies in patients with HRS have shown that the administration of a splanchnic vasoconstrictor (vasopressin analogue or α1-adrenoceptor agonist), usually combined with intravenous albumin, causes increases in arterial pressure, arterial baroreceptor uploading, decreased neurohumoral activity, decreased renal vascular resistance, and increased GFR. Randomized clinical trials have shown that treatment with a combination of the vasopressin analogue terlipressin and intravenous albumin improves renal function in patients with type 1 HRS. Vasopressor therapy with terlipressin plus intravenous albumin is the medical treatment of choice for type 1 HRS. Copyright © 2008 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background  Long-term outcomes after hepatic resection for hepatocellular carcinoma are not satisfactory because of high recurrence rates. Aim  To assess whether a single session of pre-operative transarterial chemoembolization affects post-operative outcome. Methods  We analysed outcomes retrospectively in 334 consecutive patients who underwent hepatic resection for hepatocellular carcinoma, initially judged resectable. Ninety-seven of these patients had each undergone a single session of pre-operative transarterial chemoembolization (transarterial chemoembolization + hepatic resection group), whereas 237 had not (hepatic resection group). Results  Most clinicopathological characteristics were similar in the two groups. The overall survival rate was significantly higher in the hepatic resection than in the transarterial chemoembolization + hepatic resection group ( P = 0.011), whereas their disease-free survival rates were comparable ( P = 0.67). The overall and disease-free survival rates of the transarterial chemoembolization + hepatic resection group with incomplete tumour necrosis were significantly lower than those of the hepatic resection group ( P < 0.001 and P = 0.006, respectively). Multivariate analysis showed that pre-operative transarterial chemoembolization, serum alpha-fetoprotein elevation (>1000 ng/mL), tumour size (>5 cm) and vascular invasion were independent risk factors for poor overall survival after hepatic resection. Conclusions A single session of pre-operative transarterial chemoembolization for initially resectable hepatocellular carcinoma worsens overall survival rate. It may also increase the risk of tumour recurrence in patients who achieve incomplete tumour necrosis. [ABSTRACT FROM AUTHOR]

There are several indications for the use of albumin in patients with decompensated cirrhosis and its role has existed in clinical practice for many decades. While the drug enjoys immense popularity, it yet attracts intensive debate amongst clinicians and pharmacologists alike. Regardless of its pharmacological properties, its clinical use in cirrhotic patients has its fair share of proponents and opponents. At present, in the setting of cirrhosis this debate centers around the treatment of spontaneous bacterial peritonitis, in patients with ascites treated with large volume paracentesis, and in those with hepato-renal syndrome. With the evolving evidence it has become imperative to shed old dogmas and address this issue in the light of evidence-based medicine. This article gives a representative view of albumin use in the above conditions across both sides of the clinical divide. [ABSTRACT FROM AUTHOR]

Abstract  Zinc is an essential trace element, exerting important antioxidant, anti-inflammatory, and antiapoptotic effects. It affects growth and development and participates in processes such as aging and cancer induction. The liver is important for the regulation of zinc homeostasis, while zinc is necessary for proper liver function. Decreased zinc levels have been implicated in both acute and chronic liver disease states, and zinc deficiency has been implicated in the pathogenesis of liver diseases. Zinc supplementation offers protection in experimental animal models of acute and chronic liver injury, but these hepatoprotective properties have not been fully elucidated. In the present review, data on zinc homeostasis, its implication in the pathogenesis of liver diseases, and its effect on acute and chronic liver diseases are presented. It is concluded that zinc could protect against liver diseases, although up to now the underlying pathophysiology of zinc and liver interactions have not been defined. [ABSTRACT FROM AUTHOR]

Background: The role of preoperative transcatheter arterial chemoembolization (TACE) for resectable hepatocellular carcinoma (HCC) was controversial. Methods: 246 patients with large centrally located HCC underwent mesohepatectomy (MH) and were divided into two groups: group A, 89 patients with preoperative TACE; group B, 157 patients without preoperative TACE. The aim was to evaluate the influence of preoperative TACE on postoperative complications and long-term results of patients with large centrally located HCC. Results: In the 89 patients of the TACE-MH group, a total of 123 (mean 1.4 per patient) preoperative TACEs were performed. The differences in postoperative complications (34.8 vs. 24.2%;p = 0.075) and overall hospital mortality (3.4 vs. 0.6%; p = 0.103) between the two groups were not significant. The postoperative recurrence rate in the remnant liver was higher in the MH group than in the TACE-MH group (79.6 vs. 73.0%), while the extrahepatic metastasis rate in the TACE-MH group was higher than that in the MH group (11.1 vs. 7.0%). Overall 1-, 3-, and 5-year survival rates were 87.1, 62.9, and 46.2%, respectively, for the TACE-MH group, and 82.2, 54.4, and 31.7%, respectively, for the MH group (p = 0.001); 1-, 3-, and 5-year disease-free survival rates were 75.0, 46.2, and 31.8%, respectively, for the TACE-MH group, and 69.6, 38.0, and 16.5%, respectively, for the MH group (p = 0.002). Conclusions: Long-term outcomes of patients with preoperative TACE were improved and the pattern of the recurrences after surgery was altered. The patients with large centrally located HCC could benefit more from this neoadjuvant treatment, although there was some influence of preoperative TACE on postoperative complications. Copyright © 2007 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Abstract??Type 1 hepatorenal syndrome (HRS) can be a rapidly fatal consequence of liver failure. Recent studies have utilized vasoconstrictor therapies to combat splanchnic vasodilatation. We aimed to evaluate the efficacy of a promising treatment for type 1 HRS. We compared the survival of HRS patients who received octreotide and midodrine treatment at Rancho Los Amigos Medical Center with a concurrent untreated control group of HRS patients who did not receive this treatment. Of the 81 patients, 60 were treated with octreotide/midodrine and 21 were controls. Mortality was significantly lower in the treatment group (43%) than in the controls (71%;P< 0.05). Furthermore, 24 study patients (40%) had a sustained reduction of serum creatinine compared with only 2 controls (10%;P< 0.05). This large retrospective study suggests that octreotide/midodrine treatment appears to improve 30-day survival. A randomized, controlled trial is the next important step toward evaluating this treatment modality. [ABSTRACT FROM AUTHOR]

Background/Aim: Liver regeneration is a finely tuned process that is closely regulated by multiple cell cycle steps. Although the portal blood flow affects liver regeneration, the molecular mechanism by which the blood flow regulates gene expression and liver function is largely unknown. The aim of this study was to investigate the molecular effect of portal blood flow on hepatocyte proliferation and gene regulation during liver regeneration. Materials and Methods: We developed a simple surgical rat model to investigate the relation between portal blood flow and liver regeneration by partially ligating the portal trunk with 8-0 Proline sutures under microscopy to reduce the blood flow by 40%. We investigated recovery of liver volume, DNA synthesis, and gene expression associated with cell cycle regulators, comparing partially hepatectomized (PH) rats without (PH group; n = 30) and with partial portal ligation (PHPL group; n = 30) for 7 days after the operation. Results: The hepatic tissue blood flow and the recovery ratio between liver weight and body weight in the PHPL group were significantly lower than in the PH group after hepatectomy. The peak 5-bromo-2′-deoxyuridine labeling index in the PHPL group was delayed and weak compared with the PH group. The expression of CT-1 and cyclin D, E, and B mRNAs indicated that the liver regeneration in the PHPL group was delayed and weak. In addition, there was reciprocal expression of C/EBPα and C/EBPβ mRNAs, an observation supported by their nuclear protein levels. Furthermore, the cytochrome P-450 protein level in the PHPL group was higher than that in the PH group 1 day after hepatectomy. Conclusion: The portal blood flow regulates the activity of liver regeneration and the gene expression associated with cell cycle regulators, while the functions are maintained. Copyright © 2006 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

We report a case of extensive acute thrombosis of portal vein and cava in a portocaval hemitransposition liver graft that was treated successfully with percutaneous pulse spray thrombolysis through a femoral vein access. The patient subsequently developed descending and sigmoid colon ischemic necrosis because of the venous thrombosis necessitating emergency colon resection. The patient had prolonged postoperative intensive care stay, but was eventually discharged in a good condition with normal liver function. Three month follow up demonstrated persistent normalization of hepatic function and normal duplex ultrasound. [ABSTRACT FROM AUTHOR]

The article presents abstracts of medical research. They include "effect or first-trimester screening on detection of fetal aneuploidy and amniocentesis rate," "Single umbilical artery in 12,672 unselected patients, value for prediction of aneuploidies," and "Reproducibility of the fetal nasal bone length measurement."

Major complications of cirrhosis include ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, portal hypertension, variceal bleeding, and hepatorenal syndrome. Diagnostic studies on ascitic fluid should include a differential leukocyte count, total protein level, a serum-ascites albumin gradient, and fluid cultures. Therapy consists of sodium restriction, diuretics, and complete abstention from alcohol. Patients with ascitic fluid polymorphonuclear leukocyte counts of 250 cells per mm³ or greater should receive empiric prophylaxis against spontaneous bacterial peritonitis with cefotaxime and albumin. Patients who survive an episode of spontaneous bacterial peritonitis should receive long-term prophylaxis with norfloxacin or trimethoprim/sulfamethoxazole. Patients with gastrointestinal hemorrhage and cirrhosis should receive norfloxacin or trimethoprim/sulfamethoxazole twice daily for seven days. Treatment of hepatic encephalopathy is directed toward improving mental status levels with lactulose; protein restriction is no longer recommended. Patients with cirrhosis and evidence of gastrointestinal bleeding should undergo upper endoscopy to evaluate for varices. Endoscopic banding is the standard treatment, but sclerotherapy with vasoconstrictors (e.g., octreotide) also may be used. Prophylaxis with propranolol is recommended in patients with cirrhosis once varices have been identified. Transjugular intrahepatic portosystemic shunt has been effective in reducing portal hypertension and improving symptoms of hepatorenal syndrome, and can reduce gastrointestinal bleeding in patients with refractory variceal hemorrhage. When medical therapy for treatment of cirrhosis has failed, liver transplantation should be considered. Survival rates in transplant recipients have improved as a result of advances in immunosuppression and proper risk stratification using the Model for End-Stage Liver Disease and Child-Turcotte-Pugh scoring systems. [ABSTRACT FROM AUTHOR]

No consensus exists regarding the optimal reconstruction of the cavo-caval anastomosis in piggyback orthotopic liver transplantation (PB-LT). The aim of this study was to analyze our experience with end-to-side (ES) cavo-cavostomy. Outcome parameters were patient and graft survival and surgical complications. During the period 1995–2002 146 full-size PB-LT in 137 adult patients were performed with ES cavo-cavostomy without the routine use of temporary portocaval shunt (TPCS). In 12 patients (8%) this technique was used for implantation of second or third grafts. Veno-venous bypass was not used in any case and TPCS was performed only in eight patients (6%). One-, three- and five-yr patient and graft survival were 84%, 79% and 75%, and 81%, 74% and 69%, respectively. The median number of intraoperative transfusion of packed red blood cells (RBC) was 2.0 (range 0–33) and 30% of the patients (n = 43) did not require any RBC transfusion. Surgical complications of various types were observed after 49 LT (34%) and none of the complications was specifically related to the technique of ES cavo-cavostomy. Our experience indicates that PB-LT with ES cavo-cavostomy is a safe procedure, can safely be performed without the routine use of a TPCS, has a very low risk of venous outflow obstruction and can also be used effectively during retransplantations. [ABSTRACT FROM AUTHOR]

Background: Selective transarterial chemoembolization (TACE) and portal vein embolization (PVE) could improve the rate of hypertrophy of the future liver remnant (FLR) in patients with chronic liver disease. This study evaluated the feasibility and efficacy of this combined procedure. Methods: Between November 1998 and October 2004, 36 patients with cirrhosis and hepatocellular carcinoma underwent right hepatectomy after PVE. Additional TACE preceded PVE by 3-4 weeks in 18 patients (TACE + PVE group) and the remaining 18 patients had PVE alone (PVE group). Results: PVE was well tolerated in all patients. The mean increase in percentage FLR volume was significantly higher in the TACE + PVE group than in the PVE group (mean(s.d.) 12(5) versus 8(4) per cent; P = 0.022). The rate of hypertrophy was more than 10 per cent in 12 patients in the TACE + PVE group and in five who had PVE alone (P = 0.044). Duration of surgery, blood loss, incidence of liver failure and mortality (two patients in each group) were similar in the two groups. None of the 17 patients with an increase in FLR volume of more than l0 per cent died, whereas there were four deaths among 19 patients with a smaller increase. The incidence of complete tumour necrosis was significantly higher in the TACE + PVE group (15 of 18 verb-its one of 18; P < 0.001), with a higher 5-year disease-free survival rate (37 versus 19 per cent; P = 0.041). Conclusion: Sequential TACE and PVE before operation increases the rate of hypertrophy of the FLR and leads to a high rate of complete tumour necrosis associated with longer recurrence-free survival. [ABSTRACT FROM AUTHOR]

Presents a list of authors who contributed to June 2005 issue of the "European Journal of Nuclear Medicine & Molecular Imaging."

Hepatorenal syndrome (HRS) is a functional and reversible impairment of renal function in patients with severe cirrhosis. Major pathophysiological elements include liver dysfunction, a circulatory derangement with central hypovolaemia and neurohumoral activation of potent vasoactive systems leading to a pronounced renal vasoconstriction. The prognosis of patients with HRS is poor but recent research has spread new enthusiasm for treatment. Efforts at treatment should seek to improve liver function, to ameliorate arterial hypotension and central hypovolaemia, and to reduce renal vasoconstriction. Therefore a combined approach should be applied with reduction of portal pressure with e.g. ß-adrenergic blockers and transjugular intrahepatic portosystemic shunt (TIPS), with amelioration of arterial hypotension and central hypovolaemia with vasoconstrictors such as terlipressin and plasma expanders. New experimental treatments with endothelin- and adenosine antagonists and long-acting vasoconstrictors may have a future role in the management of HRS. [ABSTRACT FROM AUTHOR]

Objective: Invasive aspergillosis is associated with a poor prognosis, especially in critically ill patients with cerebral involvement. We present two cases of cerebral invasive aspergillosis successfully treated in the intensive care unit with combination antifungal therapies and without surgery.Case Presentation: The first patient was a 49-year-old man with rheumatoid arthritis who received corticosteroid and cyclophosphamide treatment and developed pulmonary and cerebral invasive aspergillosis. After failure of voriconazole the patient had a successful outcome with voriconazole and liposomal amphotericin B therapy. The patient returned home after an 8-month hospital stay. The second patient was a 54-year-old woman with pulmonary neoplasia and corticosteroid treatment who developed pulmonary and cerebral invasive aspergillosis. After failure of voriconazole and liposomal amphotericin B therapy the patient had a favorable outcome with liposomal amphotericin B and caspofungin therapy. The patient died 10 months after initial diagnosis of cardiac tamponade unrelated to fungal infection.Discussions: These cases illustrate the improving prognosis of invasive aspergillosis due to the availability of new treatments, especially in cases of cerebral involvement. It also demonstrates that the outcome of critically ill patients requiring mechanical ventilation for invasive aspergillosis can be favorable. The treatment of patients with invasive cerebral aspergillosis in the intensive care setting should be encouraged. [ABSTRACT FROM AUTHOR]

Angeli P, Fernández-Varo G, Dalla Libera V, Fasolato S, Galioto A, Arroyo V, Sticca A, Guarda S, Gatta A, Jiménez W. The role of nitric oxide in the pathogenesis of systemic and splanchnic vasodilation in cirrhotic rats before and after the onset of ascites.Liver International 2005: 25: 429–437.© Blackwell Munksgaard 2005The role of nitric oxide (NO) in the pathogenesis of splanchnic arterial vasodilation in cirrhosis has been recently debated by some experimental studies.We investigated the role of NO in the pathogenesis of the splanchnic arterial vasodilation along the course of CCl4-induced experimental cirrhosis.We analyzed the effect on mean arterial pressure (MAP), cardiac output (CO), total peripheral resistance (TPR), and resistance in the superior mesenteric artery (RSMA), before and after the administration of a unspecific NO synthase (NOS) inhibitor (Nω-nitro-l-arginine-methyl-ester,l-NAME) and a specific NOS2 inhibitor (l-N-(1-iminoethyl)-lysine,l-NIL) to cirrhotic rats with and without ascites, and to control rats. NOS2 and NOS3 protein expression was also assessed in systemic and splanchnic arteries of these animals.l-NAME in cirrhotic rats markedly improved MAP, and TPR and decreased CO regardless of whether they had ascites or not.l-NIL did not produce any significant effect on systemic haemodynamics in control and cirrhotic rats. NOS3 overexpression in the aorta of cirrhotic animals paralleled the progression of the liver disease.l-NAME increased RSMA in cirrhotic rats, but this effect was much less intense in rats with ascites.l-NIL had an effect only on RSMA in rats with ascites, which was of a similar extent to that produced byl-NAME. Western blot experiment showed a faint overexpression of NOS3 in the mesenteric artery of cirrhotic rats with and without ascites and a clear induction of NOS2 only in the mesenteric artery of rats with ascites.These results indicate that NO contributes significantly to the pathogenesis of arterial splanchnic circulation in the early stages of experimental cirrhosis but has only a minor role in its maintenance after the development of ascites. Furthermore, the expression of the different NOS isoforms varies along the course of the liver disease. [ABSTRACT FROM AUTHOR]

Hepatorenal syndrome (HRS) is a serious event during the course of decompensated cirrhosis. Although the most characteristic feature of the syndrome is a functional renal failure due to intense renal vasoconstriction, it is a more generalized process affecting the heart, brain and splanchnic organs. There are two types of HRS. Type 1 HRS is characterized by a rapidly progressive impairment of the circulatory and renal functions associated with a very poor prognosis (median survival rate lower than 2 weeks). Type 2 HRS is characterized by a steady impairment of the circulatory and renal functions with a median survival of 6 months. The pathogenesis of HRS is a deterioration of the effective arterial blood volume due to splanchnic arterial vasodilation and a reduction in venous return and cardiac output. It is therefore not surprising that the syndrome can be reversed by the simultaneous administration of intravenous albumin and arterial vasoconstrictors. Intrarenal mechanisms are important as well and require prolonged improvement of the circulatory function to be deactivated. Long-term administration of intravenous albumin and vasoconstrictors or correction of portal hypertension with a transjugular intrahepatic portacaval shunt are effective treatments of HRS, and many serve as a bridge to liver transplantation, the treatment of choice in these patients.Copyright © 2005 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

The complications of portal hypertension are totally prevented if hepatic venous pressure gradient is decreased below 12 mm Hg. Besides, if this target is not achieved, a 20% decrease in portal pressure from baseline levels offers an almost total protection from variceal bleeding. This sets the rationale for drug therapy to reduce portal pressure in portal hypertension. Pharmacological therapy to decrease portal pressure includes vasoconstrictors to decrease portal blood inflow, vasodilators to decrease hepatic resistance, and combination therapy. Oral agents, such as b-adrenergic blockers and organic nitrates, are used for long-term prevention of variceal bleeding, while parenteral agents, such as somatostatin (and analogues) and terlipressin, are used for the treatment of acute variceal bleeding.Copyright © 2005 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

The ideal method of venous outflow reconstruction with the piggyback technique (PB) in orthotopic liver transplantation (OLT) is not well-established. The complications related to PB in 431 primary OLTs were analyzed comparing the orifices used for the anastomosis (cuff of the recipient left and middle hepatic veins [LM], LM with a >1 cm cavoplasty [LM+], or also including the right hepatic vein [LMR]). Treatment strategies and outcome were also evaluated. Twenty patients (4.6%) experienced complications: 13 of 120 (10.8%) with LM, four of 225 (1.8%) with LM+, and three of 86 (3.5%) with LMR (LM versus LM+: P < 0.0001; LM versus LMR: P = NS; LM+ versus LMR = NS). Balloon dilation was successful in 10 of 13 cases in which it was attempted (77%). Eight patients required retransplantation (40%). Three patients (0.7%) died from causes linked to stenosis. Five-year survival of patients with and without complications was 75% and 79%, respectively ( P =NS); 5-year graft survival was 50% and 76%, respectively ( P = 0.001). The stump formed by the recipient left and middle hepatic veins with a transversal incision >1 cm of the caval wall constantly provides an adequate width for the caval anastomosis with the PB. [ABSTRACT FROM AUTHOR]

Sinn und Zweck der Staging-Laparoskopie ist es, die prätherapeutische Diagnostik weiter zu präzisieren, um anschließend ein stadiengerechtes Therapiekonzept für die jeweiligen Patienten zu erstellen. In dieser Arbeit soll der Stellenwert der diagnostischen Laparoskopie bei verschiedenen malignen Tumoren im Einzelnen anhand evidenzbasierter Leitlinien dargestellt werden. Zu den entsprechenden Veröffentlichungen erfolgte eine Literaturrecherche in PubMed. Lediglich beim Staging gynäkologischer Tumoren wurde eine randomisierte Studie durchgeführt. Im Rahmen dieser Studie konnte zumindest für das Zervixkarzinom keine höhere Genauigkeit durch die Laparoskopie erzielt werden. Für gastrointestinale Tumoren stehen lediglich prospektive und retrospektive Beobachtungsstudien zur Verfügung, die einen evidenzbasierten Level B erreichen. In diesen Studien wird die Staging-Laparoskopie zur Präzision der prätherapeutischen Diagnostik empfohlen. Eine Untersuchung zur Wertigkeit der diagnostischen Laparoskopie bei malignen Tumoren mit einem evidenzbasierten Level A steht derzeit nicht zur Verfügung. In den prospektiven und retrospektiven Beobachtungsstudien mit einem evidenzbasierten Level B wird die Staging-Laparoskopie vor therapeutischen Maßnahmen insbesondere für gastrointestinale Tumoren empfohlen. [ABSTRACT FROM AUTHOR]

A university child development/early childhood education professor renews her relationship with young children and with current public school teaching by spending 5 weeks in kindergarten. This article describes some highlights of her experience: the children's daily journal writing, an in-class and take-home math activity, and teaching the required kindergarten social studies unit on Antarctica. The experience provided renewal for the professor and fresh examples for the professor to share with her university students. [ABSTRACT FROM AUTHOR]

Purpose: Some patients with hepatocellular carcinoma (HCC) at an early stage cannot attain long-term survival after hepatectomy. The aim of the present study was to investigate the poor prognostic factors for hepatectomy in patients with resectable small HCC with cirrhosis. Methods: We studied 95 patients with cirrhosis with HCC, which consisted of a single tumor 5 cm or smaller or two or three tumor nodules each 3 cm or less; an absence of extrahepatic metastasis; and an absence of radiological evidence of macroscopic portal vein or hepatic vein invasion. We used Cox's proportional hazard model to identify risk factors associated with prognosis to determine the contra-indications for hepatectomy in patients with resectable small HCC. Results: Preoperative risk factors were: (1) serum AFP concentration of more than 400 ng/ml; (2) infiltrative-, massive-, or multinodular-type (multiple) HCC; and (3) the presence of intrahepatic metastasis. Patients who had had more than one of the three preoperative risk factors were poor candidates for hepatic resection, with a 4-year survival of 16.3%. Conclusion: If patients with resectable small HCC are diagnosed as having more than one of three preoperative risk factors, they should not receive hepatectomy or should be considered for primary liver transplantation as a therapeutic option for HCC. [ABSTRACT FROM AUTHOR]

ABSTRACT. The authors used gender and culture to examine the theory that touching behavior is an expression of dominance. Participants were 120 men and women from Italy, the Czech Republic, and the United States. The authors examined both hand touches and nonhand touches. For hand touches, there was a significant gender-by-culture interaction in that Czech men as a group touched more than any of the other groups. For nonhand touches, Czech and Italian women and Italian men as groups touched significantly more than any of the other groups. Taken in cultural context, these results seem to support the dominance theory for touches with the hand but not for nonhand touches. The authors discussed implications and future directions. [ABSTRACT FROM AUTHOR]