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Introduction Canadian occupational therapists are employed as case managers on assertive community treatment (ACT) teams to support community living for individuals with severe and persistent mental illnesses. In this position, occupational therapists act primarily as generalists, typically attending appointments with clients, supervising medication adherence, supporting basic living needs, and managing client crises. Occupational therapists may also provide psychotherapy and coping skill groups, as well as profession-specific practices, such as skills training. Exploring how ACT occupational therapists describe their perceived ideal practice may support transformation in long-standing, occupational therapy practices on ACT teams. Method This qualitative, interpretive description study involved 11 Canadian ACT team occupational therapists in one individual, semi-structured in-depth interview using an interview guide containing open-ended questions. Interview transcripts were analyzed to identify themes pertaining to therapists’ descriptions of their perceived ideal occupational therapy practice on ACT teams. Results Three themes emerged: (a) Engaging in practice “with intention”; (b) Finding the space for occupational therapy practice; and (c) Supporting clients in their recovery to find their best occupational self. Conclusions The findings highlight practice possibilities for occupational therapist working on ACT teams and provide a foundation for advocating for better use of specific occupational therapy practices within community mental health settings.

Our current industrial ammonia cycle is far from being sustainable – while intense energy is required to produce ammonia – almost half of it ends up in wastewater treatment plants (WWTPs) where is finally transformed and lost. This work shows the application of flat sheet membrane distillation (MD) commercial modules for the ammonia recovery from WWTPs. First, optimized operating conditions – in terms of ammonia flux, specific thermal energy (STEC) and chemical demand – were investigated in the laboratory with a 2.3 m2 MD module. Second, optimized conditions were demonstrated in a pilot installation on site operating a 14.5 m2 MD module continuously (24/7) for three months. Results showed that MD is a robust, low-maintenance technology that can be operated at low temperature and corresponding STEC (i.e. 38 °C and 13.6 kWhth per kg1 NH3, respectively) and low pH (i.e. 8.7) for the recovery of 90% of the water-bound ammonia as an ammonium sulphate (AS) solution. The AS product reached a concentration of 5 g l-1 N–NH4, lower than conventional fertilizers, however given its high quality and volume reduction factor, it constitutes a potential fertilizer solution for local needs. The maximum AS permeate concentration was limited by the increasing water vapour flux due to a higher osmotic distillation effect and a minor ammonia flux decrease with increasing permeate concentration. Further research will focus on optimizing the module configuration to minimize water flux and overall system operation for increased heat recovery and open-loop operation.

Background Differences in mean gradients after Transcatheter valve replacement (TAVR) vary depending on the valve type and the modality used to measure the gradients. Currently there is a paucity of data on the relationship between invasive and doppler derived gradients after TAVR. Purpose We sort to assess the difference in doppler, and catheter derived aortic valve gradients after TAVR Methods This is a single center retrospective study using consecutive patients who presented for TAVR on account of native aortic valve stenosis at our institution from May 2012 till December 2020. Patients with both intraoperative invasive and postoperative doppler derived pressure gradients were included in the analysis. Student T-test were used to compare mean gradients. Pearson's correlation test was used to examine the correlation between measured gradients. Results A total of 587 patients were included in our study. Fifty one percent were male and 462 (78.7%) underwent TAVR with a balloon expandable valve. In the entire cohort the mean gradient measured invasively was significantly lower than those measured by echo doppler (4.48±3.25 vs. 5.57±3.11, P Conclusion Post TAVR gradients were all significantly lower when measured invasively as compared to those measured using doppler. Self-expanding valves overall had higher residual gradients. Further studies are needed to assess the correlations between invasively measured gradients and clinical outcomes post TAVR. Funding Acknowledgement Type of funding sources: None.

Background Despite advances in transcatheter aortic valve replacement (TAVR) technology, High grade atrioventricular block (AVB) requiring permanent pacemaker (PPM) implantation remains a frequent complication after the procedure. National inpatient sample (NIS) score and the PACeR risk cores have been developed to help identify patients at an increased risk of requiring PPM. Purpose We sort to validate both risk stratification tools developed to predict the need for PPM after TAVR. Methods This is a single center retrospective study using consecutive patients who presented for TAVR at our institution from May 2012 till December 2020. Components from the two-scoring system previously published in literature was applied. Predictive accuracy of the scores were assessed using the C-statistics for discrimination and the Hosmer-Lemeshow goodness of fit test for calibration. Results A total of 663 patients underwent TAVR over the study period. Of those, 101 were excluded. The final cohort included in the analysis were 562 patients. Fifty-seven patients (10.1%) required PPM. In both scoring, higher scores suggested increased risk of PPM implantation (Figure 1). PACeR and NIS scores showed an area under the curve of 0.750 and 0.699 respectively Figure 2. Model calibration showed a P-value of 0.799 over PACER and 0.583 for the NIS score (P>0.5 implying a good fit). Conclusion The PACer risk score and NIS models were both validated in our database with acceptable outcomes. Overall, the PACeR risk scores proved to be more accurate in our database. Further studies in larger patient cohorts are needed to further validate these models. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

We present the clinical case of a patient who, having been referred for surgery on two-stage hepatectomy, could not have a conventional portal embolization performed as an intermediate step in order to be able to resection the whole of the hepatic illness she was suffering. During right portal embolization (PE), the portography revealed minimal flow in the left portal vein, without thrombosis or stenosis. Given the risk of serious hepatic insufficiency, the embolization procedure was ruled out. Our option was to perform a portal embolization in two stages: initial PE of the right posterior branch, and subsequently, right anterior branch PE. After that, the liver resection could be completed.

Issue/problem Complex chronic patients (CCPs) present multiple chronic conditions and complex healthcare needs. Comprehensive care by multiple healthcare professionals at different settings is required to improve their outcomes. This challenge is faced by the Andalusian Public Health System (APHS), responsible for the provision of healthcare and public health services to the entire Andalusian population (8.5 million inhabitants). Description of the problem Almost 250000 CCPs have been identified within the APHS in 2018. The very complex ones (4%) utilise up to 30% of primary care and hospital resources. The Comprehensive Healthcare Plan for Patients with Chronic Diseases was launched in 2012 to ensure the comprehensive care for these patients with a multidisciplinary response. Together with the Integrated Care Process Healthcare for Multimorbidity Patients, set the scene for implementing integrated healthcare with coordination of professional services and/or centres over time, helping to decrease clinical variability and improve quality of care. Results Since 2016, Personalized Action Plans (PAPs) were introduced as key-elements to provide a holistic care coordinated at primary healthcare, including: taking patient’s individual needs, preferences and own resources as a starting point for their evaluation and the development their PAPs,involving of patient’s informal caregivers,involving all relevant care levels and health disciplines,ensuring the multidisciplinary care with a coordinating team. Lessons PAPs are a key element in the healthcare process for CCPs, and the assessment of its implementation in Andalusia is contributing to generate evidence within the Joint Action on Chronic Diseases (CHRODIS+, www.chrodis.eu). Key messages PAPs implementation and assessment are crucial to better address CCPs health needs, facilitating a patient-centred healthcare approach, and contributing to a European model of care. Involving patient, family carers together with the professional team facilitates achieving better healthcare outcomes.

Background The symposium Kuwa Tayari ("be prepared" in English): finding pathways to nutrition and food security resilience in response to climate change in East Africa was held in Eldoret, Kenya, in May, 2016. The goals of this symposium were to increase awareness, stimulate research ideas and recommendations, catalyse the development of training opportunities, and provide an evidence base for policy and decision-making in these regions in preparation for, and response to, our changing world. Here, we describe the structure, aims, and outcome of the symposium. Methods The 2-day symposium was a partnership initiative between University of Toronto Dalla Lana School of Public Health in Toronto, Canada, and Moi University, College of Health Sciences, School of Public Health in Eldoret, Kenya. Target audiences were scientists, students, and educators in public health, environmental studies, agriculture, agroecology, civil society, non-government organisations, and government stakeholders. Symposium organisers did a literature review to develop a background paper that helped inform the selection of five planetary health subthemes of the symposium: (1) agriculture, nutrition, and agro-biodiversity; (2) water security; (3) renewable and sustainable cooking fuels; (4) nutrition and food security issues affecting vulnerable populations; and (5) human rights and sustainable development. The symposium format consisted of keynote and oral abstract presentations, plenary discussions, small group work, poster viewing sessions, and networking opportunities. A final report was produced to highlight key outcomes and recommendations. Findings There were 121 attendees at the symposium from 26 institutions in Kenya, Uganda, Canada, USA, and elsewhere; most were from academic and community organisations. Participants' reasons for attending were met: personal growth and development, networking, research, course and training ideas, and potential collaborations. There was consensus on the need to invest in innovative, context-specific, climate-smart agricultural practices that support sustainable livelihoods and development, and improve food security at the household level throughout east Africa. Interpretation Multisectoral, transdisciplinary, community-based, and population health research and interventions are needed to address the complex and interconnected issues of climate change, nutrition, and food security. Within east Africa, participatory initiatives that engage vulnerable populations (such as women, pastoral populations, and the urban poor), and those that integrate indigenous food system practices are crucial. Training priorities should be in the areas of integration of climate change topics into existing public health curriculums, and novel interdisciplinary courses on planetary health. Funding Canadian Institutes of Health Research.

1. The aim of the present study was to examine the effect of chronic administration of aspirin on metabolic and cardiovascular parameters in fructose-fed rats (FFR), an experimental model of metabolic syndrome. 2. Chronic treatment of FFR with aspirin (10 mg/kg per day for 6 weeks) partially reversed the increment in systolic blood pressure. In addition, chronic aspirin treatment normalized relative heart weight and vascular remodelling of renal and carotid arteries, measured as lumen diameter : medial thickness ratio. 3. Furthermore, chronic aspirin administration completely reversed glucose intolerance and decreased the oxidative status that characterizes the FFR model, as indicated by decreased plasma levels of thiobarbituric acid-reactive substances and aortic NAD(P)H oxidase activity. 4. Prevention of oxidative stress and vascular remodelling in FFR may contribute to the protective actions attributed to aspirin in the treatment of metabolic syndrome. Fil: Renna, Nicolas Federico. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Mendoza. Instituto de Medicina y Biología Experimental de Cuyo; Argentina Fil: Vazquez, Marcela Alejandra. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Mendoza. Instituto de Medicina y Biología Experimental de Cuyo; Argentina Fil: Lama, Maria Cristina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Mendoza. Instituto de Medicina y Biología Experimental de Cuyo; Argentina Fil: Gonzalez, Elsa Susana. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Mendoza. Instituto de Medicina y Biología Experimental de Cuyo; Argentina Fil: Miatello, Roberto Miguel. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Mendoza. Instituto de Medicina y Biología Experimental de Cuyo; Argentina

El Ministerio de Sanidad y Consumo y las Comunidades Autónomas han diseñado y consensuado con los profesionales sanitarios y las organizaciones empresariales y sindicales representativas un Plan Integral de Vigilancia de la Salud de los Trabajadores que han estado expuestos a Amianto, con el objetivo de garantizar una intervención adecuada, uniforme y armonizada de estos trabajadores en todo el territorio nacional. La elaboración del Programa partió del Grupo de Trabajo de Salud Laboral del Consejo Interterritorial, se enriqueció con las aportaciones del Grupo de Trabajo Amianto de la Comisión Nacional de Seguridad y Salud en el Trabajo, fue consensuado con los profesionales de la medicina y enfermería del trabajo, y fue aprobado por las autoridades sanitarias y laborales. El Programa consta de siete grandes bloques de actividades. Dos años después de aprobado el Programa, el estado de implantación en las Comunidades Autónomas es desigual. Las principales dificultades para su puesta en marcha se encuentran en la elaboración del Registro de expuestos. Un total de 5.778 trabajadores están incluidos en el Registro. 208 trabajadores tienen EPOC, 198 alteraciones pleurales benignas, 8 cáncer de pulmón, 10 mesotelioma y 7 presentan otros cánceres con posible relación con el amianto (gástrico, de laringe y colon). El consenso y la participación alcanzados alrededor de este Programa están permitiendo lograr coberturas de las políticas de prevención de riesgos laborales muy superiores a las que se consiguen con la mera actuación institucional y elaboración de normativa, ya que en sólo los dos primeros años de implantación del Programa se ha duplicado el número de trabajadores atendidos.

ObjetivoEvaluar el impacto de dos estrategias dirigidas a mejorar la prescripción de antibióticos en el ámbito de la atención primaria.DiseñoEstudio experimental, de intervención cruzada, con grupo control y asignación aleatoria por grupos.EmplazamientoAgrupación de dos distritos sanitarios de atención primaria (Camas y Sierra Norte).ParticipantesUn total de 84 médicos generales de los que se disponía de datos de prescripción informatizados, que trabajaron más del 40% de los días hábiles del período de estudio.IntervencionesEn el grupo intervención se realizaron sesiones formativas y remisión de información escrita; en el grupo control solamente se remitió la información escrita.Mediciones principalesEl impacto de las intervenciones se evaluó mediante el test de la t de Student para datos apareados. Las variables fueron DHD de antibióticos, selección de antibióticos de primer nivel y %PVP de antibióticos frente al total del coste farmacéutico. Como mediciones secundarias, duración en el tiempo del efecto de la intervención y descripción del grupo de respondedores.ResultadosEn el grupo de intervención, disminuyó significativamente (p

Introduccion El trasplante hepatico domino consiste en la utilizacion para el trasplante del organo extirpado en el momento de realizar un trasplante hepatico en pacientes con polineuropatia amiloidotica familiar (PAF). Pacientes y metodo Entre febrero de 1999 y marzo de 2001 hemos realizado en nuestra unidad 131 trasplantes hepaticos con 121 donantes cadaver. En 10 ocasiones se realizo un trasplante hepatico domino. Resultados Los pacientes afectados de PAF eran mas jovenes (37 anos) que los receptores del segundo trasplante hepatico (64 anos). La evolucion de los pacientes trasplantados por PAF ha sido excelente y en la actualidad todos los pacientes se encuentran vivos y sin complicaciones. Entre los receptores del segundo trasplante hepatico un paciente fallecio en el postoperatorio. Otros 2 pacientes murieron por recidiva tumoral a los 18 meses y por recidiva del virus de la hepatitis C a los 9 meses. El resto de enfermos no ha presentado sintomas de aparicion de PAF durante el seguimiento. Conclusion Los resultados del trabajo permiten concluir que el trasplante hepatico domino es tecnicamente factible y permite incrementar el numero de injertos sin riesgo aparente para ninguno de los dos receptores, el afectado de PAF y el trasplantado con el higado del anterior.

Aims of this study are to analyze the influence of endothelin-1 (ET-1) on hemodynamic evolution during liver transplantation (LT) and study the role of a temporary portacaval shunt in ET-1 synthesis. Forty LTs in patients with cirrhosis were studied. Two groups were analyzed: the first group had a temporary portacaval shunt during the anhepatic phase, and the second group did not. Portal and systemic ET-1 levels were measured at several times. At the end of the anhepatic phase, systemic (16.1 [plusmn] 6.5 pg/mL) and portal (19.2 [plusmn] 7 pg/mL) ET-1 levels increased, whereas they decreased after reperfusion (systemic, 11.8 [plusmn] 7.1 pg/mL; portal, 13.2 [plusmn] 6.8 pg/mL). Portal flow at the beginning of LT correlated with systemic ET-1 levels (R2 = 0.3; P = .004). A temporary portacaval shunt reduced portal pressure during the anhepatic phase, but did not modify ET-1 levels. Patients with reperfusion syndrome had greater systemic ET-1 levels in the anhepatic phase (19.1 [plusmn] 6.9 v 15.1 [plusmn] 6.1 pg/mL; P = .07). Although there is a relationship between ET-1 levels and portal flow and reperfusion syndrome, no clear clinical effect on hemodynamics could be shown. Creation of a portacaval shunt made no change in ET-1 levels. (Liver Transpl 2002;8:27-33.)

Resumen Introduccion Uno de los metodos actualmente empleados para aumentar el pool de injertos hepaticos disponibles es el trasplante hepatico domino (THD) o secuencial. En esta modalidad de trasplante hepatico, se utiliza el organo extraido en un paciente trasplantado a causa de una polineuropatia amiloidotica familiar (PAF) (donante “domino”) para implantarlo en otro receptor. Objetivo El objetivo de este trabajo es la exposicion de los aspectos mas relevantes y caracteristicos de la tecnica quirurgica en el THD. Pacientes y metodos Se presentan los datos y resultados obtenidos en los 13 THD que nuestro grupo realizo entre febrero de 1999 y noviembre de 2001. Resultados La hepatectomia en el paciente con PAF debe incluir la vena cava retrohepatica con seccion y ligadura de las venas diafragmaticas, mientras que el implante no presenta diferencias importantes con respecto a la tecnica habitual. En tres casos los injertos obtenidos de los donantes “domino” presentaban alguna variante de la normalidad en la vascularizacion arterial, que hizo necesaria la cirugia de banco. No se produjo mortalidad, ningun paciente ha presentado complicaciones atribuibles a la tecnica y solo en un caso fue necesario transfundir sangre durante el trasplante. En los receptores del THD se empleo la tecnica de preservacion de cava en todos los casos. La anastomosis arterial se realizo con el patch formado por la arteria gastroduodenal y la hepatica comun. Para la anastomosis de la cava superior se utilizaron las tres venas suprahepaticas del receptor en 9 casos y en otros dos fue necesario realizar una anastomosis directamente con la cava inferior. La mediana de transfusion fue de 3 ± 2,5 (rango, 0-7) concentrados de hematies. La unica complicacion tecnica fue una estenosis de la anastomosis suprahepatica. Conclusiones El THD es una tecnica segura que no aumenta el riesgo operatorio de los pacientes con PAF. Los aspectos tecnicos mas relevantes son: la obtencion de una longitud suficiente de vena cava inferior y la identificacion de las variantes anatomicas arteriales en el injerto del paciente con PAF.

Background. The urgent need to increase the organ donor pool has led to the expansion of criteria for donor selection. The aim of this study was to analyze the influence of donor age on early graft function, subsequent graft loss, and mortality after liver transplantation (LT). Methods. Data on LT were evaluated retrospectively in a population-based cohort of 400 LTs in 348 patients. Of these, 21 (5%) were from donors >70 years old. Pretransplantation donor and recipient characteristics and the evolution of recipients were analyzed. The influence of donor age as a risk factor was assessed using univariate and multivariate analyses. Results. Actuarial graft survival was 89% at 1 month after LT, 81% after 6 months, and 59% after 60 months. Multivariate analysis demonstrated that only donor age (>70 years old) was associated with a higher risk of long-term graft loss (relative risk [RR] = 1.4, 95% confidence interval [CI] = 1-1.9; P=0.03) and mortality (RR=1.7, 95% CI=1.2-2.3; P=0.01). Graft survival of septuagenarian livers was 80% at 1 month after LT, 56% after 6 months, and 25% after 54 months. Actuarial survival analysis (Kaplan-Meier curves) also demonstrated worse evolution in recipients of livers from old donors (log-rank test, P

Resumen Introduccion Para obtener los mejores resultados posibles, el tratamiento de las metastasis hepaticas de carcinoma colorrectal debe ser multidisciplinario. Sin embargo, las posibilidades de curacion o supervivencia a largo plazo se basan en la reseccion completa de toda la enfermedad tumoral detectable en el estudio de extension, que debe ser lo mas preciso posible para evitar laparotomias innecesarias. Objetivos Establecer la eficacia de nuestro estudio de extension a traves del indice de resecabilidad y conocer cuales son nuestros resultados en cuanto a supervivencia a largo plazo. Pacientes y metodos. Desde enero de 1991 hasta diciembre de 2000 practicamos 273 hepatectomias por metastasis de carcinoma colorrectal en 250 pacientes. Ni el numero, ni el tamano de las metastasis, ni la invasion locorregional fueron considerados criterios de exclusion. El unico criterio utilizado para indicar la intervencion fue la presuncion preoperatoria de que la exeresis seria completa y macroscopicamente curativa. Resultados. El indice de resecabilidad fue del 91,3% (273 de 299 casos) y la mortalidad postoperatoria del 3,3%. En 37 casos se practico cirugia simultanea del tumor primario, en 23 se llevo a cabo una segunda reseccion hepatica y en 18 pacientes se realizo una reseccion pulmonar por metastasis pulmonares. En 106 pacientes (55%) se instauro quimioterapia adyuvante. La supervivencia actuarial a los 1, 3 y 5 anos fue del 87, 57 y 36%, respectivamente. En el analisis multivariante, la presencia de cuatro o mas metastasis y el margen de reseccion invadido fueron los unicos factores predictivos de mala evolucion. La quimioterapia adyuvante mejoro significativamente la supervivencia. Conclusiones. La reseccion de las metastasis hepaticas puede realizarse con una baja mortalidad operatoria y obtiene buenos resultados en cuanto a supervivencia. Con el metodo de estudio preoperatorio que aplicamos, es posible obtener un alto indice de resecabilidad. La indicacion quirurgica agresiva, el seguimiento sistematico, el rescate quirurgico con intencion curativa de recidivas y la quimioterapia adyuvante comportan una supervivencia a largo plazo del 36%.

Resumen Objetivos Describir y cuantificar las causas de muerte de nuestros pacientes e identificar su incidencia en los diversos periodos postrasplante. Pacientes y metodos Durante el periodo de estudio, se realizaron 441 trasplantes hepaticos en 381 pacientes. Definimos como causa predisponente de fallecimiento aquella que pone al paciente en situacion de riesgo de muerte, y causa inmediata la que precipita el fallecimiento. Definimos 3 periodos: mortalidad postoperatoria, temprana y tardia. Resultados La mortalidad fue de 112 pacientes (29%). Los pacientes que fallecieron en periodo de mortalidad postoperatoria, temprana y tardia fueron 32 (30%), 13 (12%) y 65 (58%), respectivamente. Los tumores de novo (15%) y la recidiva viral (14%) fueron las causas predisponentes globales mas frecuentes. Las infecciones (24%) y las complicaciones medicas (12%) fueron las causas inmediatas principales En el periodo postoperatorio y temprano las causas mas frecuentes fueron las complicaciones medicas y el rechazo ductopenico (4%), respectivamente; en cambio, en el periodo de mortalidad tardia lo fueron los tumores de novo (13%) y la recurrencia de hepatopatia por virus de la hepatitis C (13%). Conclusiones La diferenciacion entre causa predisponente e inmediata define con precision la frecuencia de cada una de ellas. Los tumores de novo y la recurrencia de hepatopatia por virus de la hepatitis C son las causas mas frecuentes de muerte global y tardia.

Resumen Introduccion La oclusion portal preoperatoria (OPP) produce una hipertrofia del higado contralateral. Gracias a ello podemos aumentar el indice de resecabilidad de algunos pacientes considerados inicialmente irresecables en funcion de un futuro remanente hepatico insuficiente. Objetivo Valorar la seguridad de la OPP y su eficacia en mejorar la resecabilidad de 8 pacientes inicialmente irresecables. Metodos Desde enero de 1997 hasta diciembre de 1999 hemos realizado resecciones hepaticas por metastasis hepaticas de carcinoma colorrectal a 136 pacientes. En 8 casos (5,8%) el futuro parenquima hepatico remanente, segun la TC helicoidal, fue considerado insuficiente ( Resultados La OPP pudo realizarse en todos los casos. No hubo complicaciones relacionadas con el procedimiento. La reseccion hepatica se practico a los 52 dias de media post-OPP. La morbilidad fue del 50% (fistula biliar, absceso subfrenico, ascitis). La mortalidad postoperatoria fue de un caso por insuficiencia hepatica. Conclusion La OPP es una tecnica segura y que aumenta el indice de resecabilidad de los pacientes con metastasis hepaticas de carcinoma colorrectal.

Resumen Introduccion Los objetivos de este estudio son establecer la incidencia y tipo de trombosis portal (TP), asi como analizar el tratamiento y evolucion de cada tipo de trombosis en 500 trasplantes hepaticos (TH) consecutivos. Material y metodos Desde 1984 hasta enero de 1999 nuestro grupo ha realizado 500 TH en 435 pacientes. Estudiamos de forma retrospectiva a todos aquellos pacientes con diagnostico de trombosis portal pre-TH. Asimismo, se estudian todos aquellos pacientes con el diagnostico de TP post-TH precoz (primeros 30 dias post-TH) y TP tardias si el diagnostico es posterior. Resultados Trombosis portal pretrasplante. Su incidencia fue del 6,2% (31 casos), siendo la mitad completas. La mayoria de TP parciales (12 de 16 casos) se solucionaron mediante anastomosis portal terminoterminal. No hubo ningun caso de TP post-TH. En la mayoria de casos con TP completa (11 de 15) el flujo portal se restablecio mediante un injerto venoso mesoportal extraanatomico. La incidencia de TP post-TH fue del 6,6% (un caso). La incidencia global de trombosis portal postrasplante precoz fue del 1,8% (9 casos). El 44% precisaron retrasplante y la mortalidad asociada fue del 22%. La incidencia de TP post-TH tardia fue del 1,4% (7 casos) con una media de diagnostico de 22,3 (rango: 2-78) meses; solo 3 casos presentaron clinica, en forma de ascitis; dos fueron tratados con exito mediante angioplastia con colocacion de protesis portal. La mortalidad asociada a esta complicacion fue nula. Conclusiones La TP pre-TH no es actualmente una contraindicacion para el trasplante. Consideramos el injerto venoso mesoportal como tecnica de eleccion cuando la TP pre-TH es completa. La trombectomia y revascularizacion urgente es el tratamiento de eleccion en los casos de TP post-TH precoz. La mortalidad del retrasplante por esta complicacion es alta. Los casos de TP post-TH tardia en adultos que cursan con hipertension portal sintomatica pueden beneficiarse de tecnicas de radiologia intervencionista como la angioplastia y la protesis portal.

El objetivo de este estudio fue analizar los factores pronosticos y las indicaciones quirUrgicas de las metastasis hepaticas de carcinoma colorrectal (CCR). Se realizaron 212 hepatectomias en 196 pacientes. No hubo un criterio fijo para la reseccion con respecto al nUmero o tamano de las metastasis o la enfermedad extrahepatica excepto que la exeresis tenia que ser macroscopicamente curativa. El indice de resecabilidad fue del 91% (196/215). La mortalidad postoperatoria fue del 4,7%. Se efectuo la exeresis de metastasis pulmonares en 14 pacientes. La supervivencia actuarial a 1, 3 y 5 anos fue del 88%, 60% y 39%, respectivamente. La supervivencia libre de enfermedad fue del 20% a los 5 anos, pero el 48% de los pacientes estaban libres de recidiva hepatica a los 5 anos. En el estudio multivariante, 4 metastasis y la invasion de margenes fueron factores independientes de peor supervivencia. La exeresis quirUrgica es un tratamiento seguro y debe considerarse la terapeutica estandar en las metastasis hepaticas de CCR. The purpose of this study was to investigate the prognostic factors and indications of surgical treatment of liver metastases from colorrectal cancer (CRC). One hundred ninety six patients were submitted to 212 liver resections. We had no predefined criteria of resectability with regard to either the number or size of the tumors or the locorregional invasion, except that resection had to be complete and macroscopically curative. Resectability rate was 91% (196/215). Postoperative mortality was 4.7%. A pulmonary resection could be performed in 14 patients with lung metastases. The actuarial survival rates at 1, 3 and 5 years were 88%, 60% and 39%, respectively. Five-year disease free survival was 20%, but the rate of survival free of hepatic recurrence was 48% at 5 years. In the multivariate analysis, four or more metastases and positive margin were independent predictors of poor outcome. Surgical resection is safe and should be considered the standard treatment in patient with liver metastases of CRC.

Fundamento Se presenta la experiencia del programa de trasplante hepatico del Hospital de Bellvitge en 500 trasplantes realizados durante 15 anos, con el objetivo de poner de manifiesto los cambios que se han producido y exponer los resultados a largo plazo de esta terapeutica. Pacientes y metodo Se consideraron y compararon 5 grupos de 100 trasplantes consecutivos (I-V). Resultados Las indicaciones mas frecuentes fueron el hepatocarcinoma (23%), la cirrosis alcoholica (22,8%) y la hepatopatia cronica por virus C (18,8%). En 59 pacientes se llevaron a cabo 65 retrasplantes (13%), cuyas indicaciones mas frecuentes fueron la trombosis arterial (13 pacientes) y el fallo primario del injerto (10 pacientes). En 19 enfermos se realizo un trasplante combinado hepatorrenal. La causa mas frecuente de muerte del donante en el grupo I fueron los traumatismos craneales (80%), mientras que en el grupo V fue la enfermedad vascular (52%). Otras diferencias significativas entre estos grupos se observan en la proporcion de pacientes en estadio 2 y 3 de la clasificacion UNOS (el 45 frente al 19%), en el consumo de hemoderivados (29,6 [26] frente a 4,6 [5,3] concentrados de hematies), en la frecuencia de reintervenciones por hemoperitoneo (el 22 frente al 5%), en la estancia en UCI (13 [13] frente a 7,4 [11] dias) y en el hospital 40 [52] frente a 23,7 [17] dias), y en la incidencia de rechazo (el 46 frente al 20%) y de fallo primario del injerto (el 9 frente al 3%). Sin embargo, la prevalencia de infeccion (el 48 frente al 54,5%) y la incidencia de complicaciones biliares (el 26 frente al 20%) no han presentado variaciones significativas. La supervivencia actuarial de los pacientes trasplantados desde 1990 es del 83 y del 70% al ano y a los 5 anos, respectivamente. Conclusiones Se observa una mejoria notable y progresiva de los resultados del trasplante hepatico. Sin embargo, los tumores de novo, la recidiva de la hepatitis por virus C y el rechazo cronico pueden limitar los resultados a largo plazo.

The aim of this study was to evaluate the tolerance of normothermic liver ischemia with different degrees of hepatic function in cirrhotic rats. Liver cirrhosis was induced by administering carbon tetrachloride (CCl4) in water solution to male Wistar rats. Hepatic function was graded using the plasma levels of antithrombin III, albumin, and bilirubin and the presence of ascites. Rats were distributed in four groups: noncirrhotic (control group), compensated cirrhosis (group A), decompensated cirrhosis (group B), and decompensated cirrhosis with ascites (group C). Groups A, B, and C were significantly different in all four parameters studied (P < .003). Subtotal liver ischemia was performed for periods of 0, 30, 45, 60, and 75 minutes. At the end of the procedure, the nonischemic lobes were resected. Postoperative evolution of alanine aminotransferase, aspartate aminotransferase, and bilirubin levels was also recorded. Survival rates after the same periods of ischemia were statistically different (P < .05): control group, 7 of 7 after 45 minutes (100%), 7 of 7 after 60 minutes (100%), and 4 of 9 after 75 minutes (44%); group A, 7 of 7 after 45 minutes (100%) and 1 of 7 after 60 minutes (14%); group B, 7 of 7 after 0 minutes (100%), 5 of 7 after 30 minutes (71%), and 1 of 7 after 45 minutes (14%); and group C, 0 of 5 after 0 minutes (0%) and 1 of 7 after 30 minutes (14%). No differences were found in the postoperative course of transaminases. However, bilirubin levels found 24 hours and 7 days after ischemia were significantly greater in cirrhotic rats, and this was directly related to the degree of hepatic insufficiency (P < .001). Histological examination of the livers exposed to CCl4 showed features of liver cirrhosis with ductal proliferation. The ischemia time tolerated by cirrhotic rat livers is shorter than the time tolerated by normal rats. Tolerance to hilar vascular occlusion depends on the degree of hepatic insufficiency. Rats with decompensated cirrhosis and ascites do not tolerate any surgical procedure.

We have developed a new method for producing infectious double subgenomic alphaviruses from plasmids transfected into mammalian cells. A double subgenomic Sindbis virus (TE3'2J) was transcribed from a cytomegalovirus PolII promoter, which results in the production of infectious virus. Transfection of as little as 125 ng of plasmid is able to produce 1 × 108 plaque forming units/ml (PFU/ml) of infectious virus 48 hours post-transfection. This system represents a more efficient method for producing recombinant Sindbis viruses.

Fundamento El trasplante hepatico domino o secuencial (DTXH) es un tipo de injerto de donante vivo propuesto en 1993 y realizado por primera vez en 1995; posteriormente se han publicadomas de 45. El higado de un paciente con polineuropatia amiloidotica familiar (PAF) se implanta a un enfermo mayor de 60 anos afectado de un proceso hepatico generalmente neoplasico, porque el higado de esos donantes es normal desde el punto de vista anatomico y funcional, salvo la sintesis de la variante sistemica de la transtirretina (TTR), que solo podria originar la PAF en el receptor al cabo de un periodo mayor de 8 anos. Pacientes y metodo Se presentan los tres primeros casos de DTXH realizados en Espana. Los donantes eran pacientes con PAF con variante TTRMet30 procedentes del foco mallorquin. El primero de los receptores presentaba un gravisimo hiperinsulismo debido a metastasis hepaticas de insulinoma maligno; los otros dos tenian hepatocarcinoma implantado sobre higado cirrotico. Resultados En el postoperatorio de los receptores, la funcion del higado fue perfecta, y desaparecio inmediatamente el hiperinsulinismo en el primero; este fallecio a los 10 dias por sepsis, mientras que los otros siguen con funcion hepatica normal, sin recidiva neoplasica ni inicio de PAF. En los donantes, la evolucion fue normal, con perfecta funcion hepatica. Conclusiones Nuestros datos, coincidentes con los publicados, permiten concluir que el DTXH es un metodo valido para un determinado grupo de pacientes. Ademas, aumenta el contingente de donantes hepaticos y, por consiguiente, disminuyen las sobrecargadas listas de espera.

Nebivolol is a vasodilator that combines beta-adrenergic blocking activity with a relaxant effect on vascular smooth muscle cells (VSMC) mediated by the endothelial nitric oxide (NO) pathway. FFR provide a model of dietary-induced insulin-resistance syndrome, which has been used to study the pathophysiological mechanisms associated with this syndrome. Our main objective was to examine the effect of long-term administration of nebivolol on metabolic and cardiovascular variables in fructose-fed rats (FFR), a model in which an altered bioavailability of NO has been already described. Male Wistar rats were randomly assigned to 4 groups (n = 8 each): I. Control (C); II. Control + nebivolol (C+N): 1 mg/kg(-1) x day(-1) in drinking water during the last 4 weeks. III. FFR: rats receiving fructose in drinking water as a 10% (w/v) solution during 8 weeks, and IV. FFR+N: idem II plus III. During the 8 weeks experimental period, variations in systolic blood pressure (SBP), glucose tolerance test (GTT) and plasma thiobarbituric acid-reactive substances (TBARS) were assessed. At the end of this experimental period, rats were killed and heart and kidneys were excised for calculation of relative heart weight (RHW) and histological evaluation of lumen to media ratio (L/M) in renal arteries. Rats from FFR group increased their SBP and RHW, showed glucose intolerance and an increment in lipid peroxidation. Moreover, FFR showed vascular remodeling in renal arteries evidenced by changes in L/M. Although the metabolic changes were not reverted by the administration of nebivolol, this drug successfully decreased SBP, TBARS levels and reverted structural changes such as cardiac hypertrophy and renal arterial remodeling. Data demonstrate that nebivolol administration could participate in the reversion of cardiovascular structural changes associated with the insulin-resistance syndrome.

OBJECTIVE: To evaluate the impact of two strategies aimed at improving the prescription of antibiotics in the primary care context. DESIGN: Experimental crossed-intervention study, with control group and randomised allocation to groups. SETTING: Two primary care helth districts (Camas and Sierra Norte). PARTICIPANTS: 84 general practitioners for whom computerised prescription data were available, and who worked for over 40% of the working days of the study period. INTERVENTIONS: In the intervention group, training sessions were conducted and written information was sent out. In the control group, only written information was sent. MAIN MEASUREMENTS: The impact of the interventions was evaluated through the student's t test for paired data. Variables were the DHD of antibiotics, selection of first-level antibiotics and %RSP of antibiotics out of total pharmaceutical cost. Secondary measurements included duration of the effect of the intervention and description of the group who responded. RESULTS: In the intervention group, the DHD dropped significantly (from 17.4 ± 1.4 to 12.2 ± 0.9) (P

The best system for organ allocation is still a controversial issue. The aim of this study was to study the accuracy of four different scores to predict mortality on the waiting list and, thus, their usefulness to determine organ allocation. We retrospectively compared two groups of patients, those who died on waiting list (group D) and those who successfully underwent transplantation (group T) during the same time period. Four scores, at the time of entering the waiting list and just before liver transplantation or death, were evaluated. The evaluated scores were as follows: (1) the Child-Pugh classification; (2) the Model for End-Stage Liver Disease (MELD) score; (3) the Freeman scale; and (4) the Guardiola et al index. The mortality rate on waiting list was 15.9%. All studied scores, except Freeman scale, were higher in group D at the time of entrance on waiting list (MELD, 17.4 +/- 8 v 12.3 +/- 6, P = .02; Child, 9.9 +/- 2 v 7.7 +/- 2, P = .002; Freeman, 9.7 +/- 4 v 7.3 +/- 3.9, P = .09; Guardiola, 2.6 +/- 0.9 v 1.7 +/- 0.7, P = .001). C-statistics of all scores were similar and in all cases lower than 0.8 (MELD, 0.75; Child, 0.78; Freeman, 0.65; Guardiola, 0.79). None of the studied scores have an excellent accuracy to predict prognosis of patients on waiting list, mainly in case of populations with high proportion of hepatocellular carcinoma. Although the MELD score is rapidly available, standardized, and objective, it does not reflect the severity of patients with cancer or metabolic disorders.

In domino liver transplantation (LT), the explanted liver of a patient with familial amyloidotic polyneuropathy (FAP) is donated to another patient.Between February 1999 and March 2001 we performed 131 LT with 121 cadaveric donors in our unit. Ten domino LTs were performed.Patients with FAP were younger (37 years) than recipients of the second LT (64 years). The evolution of patients undergoing transplantation for FAP was excellent and all are currently alive and without complications. Among recipients of the second LT, one patient died in the postoperative period. A further two patients died from tumoral recurrence and hepatitis C virus recurrence 18 months and 9 months after transplantation, respectively. The remaining patients have shown no symptoms of FAP during the follow-up.The results of this study show that domino LT is technically feasible. The technique increases the number of grafts without apparent risk either to the recipient with FAP or to the recipient of the latter's explanted liver.

PRESERVATION injury (PI) is a major contributor to primary allograft failure after liver transplantation (LT). However, few studies have analyzed the predictive value of postreperfusion liver biopsies for the development of graft dysfunction and late complications. Extended cold preservation has been associated with biliary strictures. Consequently, it has been postulated that the ischemiareperfusion injury may play a role in the pathogenesis of some biliary complications. This study was performed to assess whether the presence of histologic lesions on postreperfusion (0Post) allograft biopsy is a predictive factor of postoperative biliary complications. Other secondary objectives were to examine the possible relationship between 0Post biopsy features and donor data, and to correlate postreperfusion histologic findings with graft and patient outcome.

HE SCARCITY OF donors and the increase in the number of transplant candidates have stimulated research to minimize the loss of donated organs. Preservation solutions are available to conserve the organs for a determinate period. In liver transplant (LT) Belzer and Brettschneider solutions give satisfactory results. However, graft malfunction remains a problem and other solutions are being examined. This randomized comparative study aims to examine the hepatic function of grafts perfused with Celsior solution (CS) and Belzer solution (BS) following liver transplant in adults.

THE SHORTAGE of donor livers for transplantation means that the use of liver grafts must be optimal. To ensure efficient use of the resources available, a precise definition of the causes of mortality (CMs) in these patients is essential. In the literature on the subject there are major discrepancies regarding the incidence of the CMs. This is so because the immediate cause (IC) of death is generally considered more important than other previous circumstances that contribute to the IC. We term the circumstances involved in the lead-up to death the principal cause (PC). It should also be stressed that the incidence of different CMs changes according to the follow-up time since transplantation. The objectives of the present study are first, to present a retrospective description of the global CMs in our patients and, second, to assess the distribution of mortality in different periods of the follow-up.

Biliary complications after orthotopic liver transplantation (OLT) may occur because of preservation injury (PI). In this study, we examine findings on routine reperfusion biopsy specimens in relation to the occurrence of biliary complications and graft outcome. From 1997 to 2000, a total of 193 OLTs were performed in our center. Postreperfusion biopsy specimens were analyzed and histological lesions were graded. For analysis, grafts were grouped into 2 categories: the presence or absence of PI (severe to moderate lesions versus mild or no lesions). Histological evidence of PI was present in 17% of the biopsy specimens. The incidence of grafts with PI and ischemia time longer than 12 hours was 38% compared with 14% in PI and short ischemia time ( P = .02). Biliary complications were also more frequent in the PI group (28% v 14%; P = .03). Study of risk factors by means of logistic regression analysis confirmed that the PI group had a greater risk for biliary complications (relative risk, 2.8; 95% confidence interval, 1 to 7.4; P = .03). Moreover, moderate macrovesicular steatosis was found in 6% of the grafts, resulting in a 40% graft loss rate. We found that an increased presence of neutrophilic infiltrates in the postreperfusion biopsy specimen, indicating PI, was related to an increased incidence of biliary complications. Moreover, moderate macrovesicular steatosis was associated with increased graft loss. Therefore, postreperfusion biopsies are useful in anticipating post-OLT complications. ( Liver Transpl 2001;7:432-435 .)

We present the experience of the liver transplantation program at the Hospital of Bellvitge with 500 transplantations performed during 15 years, to describe changes in liver transplantation observed throughout the time and to analyze the long term results.Five groups each one including 100 consecutive transplantations are studied.The main indications were hepatocellular carcinoma (23%), alcoholic cirrhosis (22.8%), and post-hepatitis C cirrhosis (18.8%). Sixty-five retransplantations were performed in 59 patients (13%), being the more frequent indications arterial thrombosis (13 patients) and primary nonfunction of graft (10 patients). In 10 patients a hepatorenal transplantation was performed. In group I, the most frequent donor cause of death was cranial traumatism (80%), while in group V it was the vascular pathology (52%). There were other significative differences between these groups of patients (I vs V): patients with stage 2 or 3 from UNOS status (45 vs 19%), blood use (29.6 [26] vs 4.6 [5.3] PRBC), ICU stay (13 [13] vs 7.4 [11] days), hospital stay (40 [52] vs 23.7 [17] days), rejection rate (46 vs 20%) and primary graft nonfunction (9 vs 3%). However, the infection rates (48 vs 54.5%) and biliary tract complications (26 vs 20%) have not shown statistically significant differences. Actuarial one and 5-year survival are 83 and 70% respectively.An important and progressive improvement of liver transplantation results has been observed. However, de novo tumours, hepatitis C virus recurrence and chronic rejection can limit long term results.

AFTER A previous study that analyzed early graft function, we conclude that donor age had a direct influence on the univariate analysis, but this did not happen on an independent basis. Following the conclusions of the above-mentioned study, donor’s age was not a contraindication for liver donation in our center. The aim of this study was to assess the impact of donor age on graft and patient survival.

A retrospective analysis of our experience in the treatment of hiliary cholangiocarcinoma or Klatskin tumor was performed with the aim of evaluating the morbi-mortality and prognosis of its treatment to thereby determine the usefulness of the different therapeutic options. From 1989 to 1997, 51 patients diagnosed with hiliary cholangiocarcinoma were treated in our hospital. Surgery was indicated in 16 with curative aims (group I) while palliative treatment with percutaneous biliary drainage was indicated in 35 (group II). Biliary resection was carried out in 8 patients being associated with hepatic resection in 4 (group IA) and in 8 patients undergoing liver transplantation (group IB). Clinico-epidemiologic data and hospital stay were similar in all the groups. The frequency of complications was similar in groups I and II although the frequency of cholangitis (49%) in group II was noticeable. The percentage of readmissions was also greater in group II (12 vs 46%, respectively; p = 0.03) with prosthesis obstruction being the most frequent cause. Accumulated survival at 1, 2, and 3 years in group I was 84, 64 and 48% with a median survival of 33 months, while in group II the median survival was of 6 months with no patient surviving more than 2 years (p = 0.0001). When groups IA and IB were compared, greater frequency of complications in groups IA (100 vs 37%; p = 0.002), similar frequency of readmissions (87 vs 75%; p = NS), median survival greater in group IB (12.5 months vs 48 months) and significantly higher actuarial survival in group IB (48% in 2 years vs 83% to 2 years; p = 0.02) was observed. In conclusion, surgery is the treatment of choice in hiliary cholangiocarcinoma whenever possible, given the greater survival without a significant increase in morbimortality. Likewise, we consider that liver transplantation is a useful option in the treatment of patients with cholangiocarcinoma type IV of Bismuth.

Small size cerebral lesions, located strategically, can determine the presence of sensitive and motor signs limited to a part of an extremity, clinically suggesting peripheral nervous system affectation, determining erroneous diagnostic and therapeutic decisions. We present 5 patients initially diagnosed of peripheral nervous system pathology, which were finally diagnosed of cerebral lesions (2 lacunar infarcts, multiple sclerosis, progressive multifocal leucoencephalopaty, multicentric astrocytoma). In all, clinical examination disclosed incongruous distribution of the sensitive manifestations and myotatic reflexes were present. CT studies were normal in three patients whereas MRI showed lesions in all cases. Lesions were smaller than 1.5 cm in diameter (greater in the case of multicentric astrocytoma), and were subcortically located in the opposite cerebral hemisphere to the affected extremity. Sensitivomotor signs restricted to an extremity not concordant with a nervous or radicular distribution and with presentation of myotatic reflexes, make it necessary to look for a central nervous system lesion. Lesion will be located in the opposite cerebral hemisphere and MRI will be the elective complementary exam.

Background Arterial reconstruction is essential in liver transplantation. In some patients there may be an inadequate flow as a result of stenosis, intimal dissection, or anomalies of the hepatic artery. Methods This study analyzes our experience with 23 patients in whom arterial anastomosis was performed using the splenic artery due to the inadequacy of the hepatic artery. During the same period an aortoiliac conduit was used in 12 liver transplantations due to the same problem. Results No splenic infarction, pancreatitis, or other related complications were found. Artery thrombosis developed in only two patients in the aortoiliac conduit group. One- and three-year patient actuarial survival were 78% vs. 80% and 72% vs. 80%, respectively, for the splenic artery group and the aortoiliac conduit group. Conclusions Anastomosis with the splenic artery is an alternative in liver transplantation and is particularly suitable when splenomegaly is present.