Search

Background and aims: Cardiac dysfunction may be present in patients with cirrhosis. This study was undertaken to relate plasma concentrations of cardiac peptides reflecting early ventricular dysfunction (pro-brain natriuretic peptide [...]

This case report investigate a 61-year-old healthy man who, during a Christmas goose-shooting, got repeated punches on the right breast region, owing to a defective shotgun stock. The initial suggilations and haematomas disappeared in three weeks, but after three months a tender enlargement of the periareolar area developed. Mammography and sonography showed typical right gynaecomastia. History, andrologial examination and biochemistry disclosed no explanation. It was concluded that a traumatic aetiology of the gynaecomastia was most likely. During the next year, the clinical signs regressed somewhat, but control sonography showed leftovers of ductal tissue, and the bird shooter has become reconciled with his "goose breast".

Background and Aim: The study was undertaken in order to compare single injection indocyanine green (ICG)-clearances with the steady-state ICG-clearance (ICG Cl ) in patients with cirrhosis in order to assess the most accurate estimate for ICG-clearance and to relate the ICG-clearances to established indicators of liver dysfunction., Methods: Thirty-eight patients (male 29) with cirrhosis (Child-Turcotte class A 8, class B 21, and class C 9) were studied during a hemodynamic investigation. A single injection of ICG was followed by blood samples for 5, 10, 15, and 20 min. The dose/plasma area clearance (Cl A ) and plasma volume · initial slope clearance (Cl PV ) were determined and compared with the steady-state infusion/plasma concentration ratio clearance (ICG Cl )., Results: The Cl A (310; 214; 502 mL/min) and Cl PV (294; 164; 481 mL/min) correlated closely with ICG Cl (243; 120; 383 mL/min [median; interquartile range], R = 0.95-0.98, P < 0.000), but were significantly higher than ICG Cl (P < 0.001). All three clearance measures correlated significantly with biochemical and hemodynamic variables of liver dysfunction (P < 0.05-0.000). All three ICG-clearances showed significantly lower values in patients with ascites compared to those without, and lower ICG-clearance values were present in patients with esophageal varices compared to those without (P < 0.05-0.002)., Conclusion: Single injection markers (Cl A and Cl PV ) of the steady-state ICG-clearance as derived from the ICG-retention curve and the plasma volume correlate with ICG Cl and established variables of portal hypertension and liver cell bile excretory dysfunction. Therefore, these markers can safely replace the more costly ICG Cl ., (© 2022 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

This review describes the development of single-photon emission tomography (SPECT) in the Copenhagen area under the leadership of the internationally renown scientist, Niels A. Lassen, and the history leading up to construction of the tomograph. Measurements of global cerebral blood flow (CBF) in the 1940s and 1950s were performed by Kety & Schmidt and Lassen & Munck. Determination of regional cerebral blood flow (rCBF) by intra-arterial injection of 133 Xe and measurement with a 254-multicrystal scintillation detector and a computer system was a major step forward in the study of physiology and pathophysiology of cortical cerebral blood flow. Tomography with radioisotope ligands, including non-invasive administration, was advanced in different centres during the 1970s. An emission tomograph, the Tomomatic 64, was developed as a result of a multidisciplinary Danish and international collaboration. It was the first emission tomograph to provide dynamic data that could produce cross-sectional rCBF images. The present description of the construction and function of the Tomomatic 64 includes comparison with other contemporary and later brain-dedicated SPECT systems. Basic and clinical application of the Tomomatic 64 in Copenhagen resulted in several hundred important scientific publications and improved diagnostics for patients with a variety of neurological disorders. It is concluded that the development of the Tomomatic 64 was a major step forward in the study and examination of rCBF and brain function related to several brain disorders, in addition to vascular diseases., (© 2020 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd.)

Background: In human immunodeficiency virus (HIV)-infected patients on combination antiretroviral therapy (cART), lipodystrophy shares many similarities with metabolic syndrome, but only metabolic syndrome has objective classification criteria. We examined adipose tissue changes related to lipodystrophy and metabolic syndrome to clarify whether it may be acceptable to focus diagnosis on metabolic syndrome rather than lipodystrophy., Methods: This is a cross-sectional study of 60 HIV-infected men on cART and 15 healthy men. We evaluated lipodystrophy (clinical assessment) and metabolic syndrome (JIS-2009). We compared adipocyte size, leukocyte infiltration, and gene expression in abdominal subcutaneous adipose tissue biopsies of patients with and without lipodystrophy and with and without metabolic syndrome., Results: Lipodystrophy was only associated with increased macrophage infiltration (P = .04) and adiponectin messenger ribonucleic acid ([mRNA] P = .008), whereas metabolic syndrome was associated with larger adipocytes (P < .0001), decreased expression of genes related to adipogenesis and adipocyte function (P values between <.0001 and .08), increased leptin mRNA (P = .04), and a trend towards increased expression of inflammatory genes (P values between .08 and .6)., Conclusions: Metabolic syndrome rather than lipodystrophy was associated with major unfavorable abdominal subcutaneous adipose tissue changes. In a clinical setting, it may be more relevant to focus on metabolic syndrome diagnosis in HIV-infected patients on cART with regards to adipose tissue dysfunction and risk of cardiometabolic complications.

Background: Cirrhosis is accompanied by portal hypertension with splanchnic and systemic arterial vasodilation, and central hypovolaemia. A transjugular intrahepatic portosystemic shunt (TIPS) alleviates portal hypertension, but also causes major haemodynamic changes., Aims: To investigate effects of TIPS on regional blood volume distribution, and systemic haemodynamics., Methods: Thirteen cirrhotic patients had their regional blood volume distribution determined with gamma-camera technique before and after TIPS. Additionally, we measured systemic haemodynamics during liver vein and right heart catheterization. Central and arterial blood volume (CBV) and cardiac output (CO) were determined with indicator dilution technique., Results: After TIPS, the thoracic blood volume increased (+10.4% of total blood volume (TBV), p<0.01), whereas the splanchnic blood volume decreased (-11.9% of TBV, p<0.001). CO increased (+22%, p<0.0001), and systemic vascular resistance decreased (-26%, p<0.001), whereas CBV did not change. Finally, right atrial pressure and mean pulmonary artery pressure increased after TIPS (+50%, p<0.005; +40%, p<0.05, respectively)., Conclusions: TIPS restores central hypovolaemia by an increase in thoracic blood volume and alleviates splanchnic vascular congestion. In contrast, CBV seems unaltered. The improvement in central hypovolaemia is therefore based on an increase in thoracic blood volume that includes both the central venous and arterial blood volume. This is supported by an increase in preload, combined with a decrease in afterload., (Copyright © 2017 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

In patients with fluid retention, the plasma clearance of 51 Cr-EDTA (Cl exp obtained by multiexponential fit) may overestimate the glomerular filtration rate (GFR). The present study was undertaken to compare a gamma-variate plasma clearance (Cl gv) with the urinary plasma clearance of 51 Cr-EDTA (Cl u ) in patients with cirrhosis with and without fluid retention. A total of 81 patients with cirrhosis (22 without fluid retention, 59 with ascites) received a quantitative intravenous injection of 51 Cr-EDTA followed by plasma and quantitative urinary samples for 5 h. Cl gv was determined from the injected dose relative to the plasma concentration-time area, obtained by a gamma-variate iterative fit. Cl exp and Cl u were determined by standard technique. In patients without fluid retention, Cl gv , Cl exp and Cl u were closely similar. The difference between Cl gv and Cl u (Cl gv - Cl u  = ΔCl) was mean -0·6 ml min -1  1·73 m -2 . In patients with ascites, ΔCl was significantly higher (11·8 ml min -1  1·73 m -2 , P<0·0001), but this value was lower than Cl exp - Cl u (17·5 mL min -1  1·73 m -2 , P<0·01). ΔCl increased with lower values of GFR (P<0·001). In conclusion, in patients with fluid retention and ascites Cl gv and Cl exp overestimates GFR substantially, but the overestimation is smaller with Cl gv . Although Cl u may underestimate GFR slightly, patients with ascites should collect urine quantitatively to obtain a reliable measurement of GFR., (© 2016 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd.)

Patients with advanced cirrhosis have abnormal sodium homoeostasis. The study was undertaken to quantify the sodium transport across the plasma membrane of red blood cells (RBC) in patients with cirrhosis. RBC efflux and influx of sodium were studied in vitro with tracer (22) Na(+) according to linear kinetics in 24 patients with cirrhosis and 14 healthy controls. The sodium efflux was modified by ouabain (O), furosemide (F) and a combination of O and F (O + F). RBC sodium was significantly decreased (4·6 versus control 6·3 mmol l(-1) , P<0·001) and directly related to serum sodium (r = 0·57, P<0·05). The RBC fractional sodium efflux was higher in patients with cirrhosis (+46%, P<0·01) compared to controls. Inhibition in both high (145 mmol l(-1) )- and low (120 mmol l(-1) )-sodium buffers showed that the F-insensitive sodium efflux was twice as high in cirrhosis as in controls (P = 0·03-0·007), especially the O-sensitive, F-insensitive efflux was increased (+ 225%, P = 0·01-0·006). Fractional F-sensitive transport was normal in cirrhosis. RBC sodium influx was largely normal in cirrhosis. In conclusion, RBC sodium content is reduced in patients with cirrhosis with a direct relation to serum sodium. Increased RBC sodium efflux is especially related to ouabain-sensitive, furosemide-insensitive transport and thus most likely due to upregulated activity of the sodium-potassium pump. The study gives no evidence to an altered intracellular/extracellular sodium ratio or to a reduced fractional furosemide-sensitive sodium transport in cirrhosis., (© 2015 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd.)

Background: Despite effective antiretroviral therapy (ART), HIV-infected patients exhibit systemic inflammation, early onset of age-related diseases, and features of immunosenescence. The role of inflammation in the development of age-related diseases is widely recognized. However, the role of immunosenescence is not well established. Studying immunosenescence in HIV-infection could give insight into its role in ageing processes. In this cross-sectional study, we aimed to investigate whether ART-treated HIV-infected patients exhibit immunosenescence; and whether immunosenescence is associated with age-related processes of inflammation, metabolism, adipose tissue, and muscle. T cell immunosenescence and exhaustion were assessed by flow cytometry analysis of CD8 (+) cells from 43 ART-treated HIV-infected patients (HIV(+)) and ten Controls using markers of differentiation: CD27/CD28; maturation: CD27/CD45RA; senescence: killer cell lectin-like receptor G1 (KLRG1); and exhaustion: programmed death-1 (PD-1). Relationships between CD8 (+) T cell immunosenescence, exhaustion, and age-related processes were assessed using linear regressions., Results: HIV-infection was strongly associated with more highly differentiated and mature CD8 (+) T cell phenotypes. PD-1 and KLRG1 expression did not differ between HIV(+) and Controls, but depended on differentiation and maturation stages of the cells. CD8 (+) T cell maturation was associated with age. KLRG1 expression was associated with age, metabolic syndrome, visceral adipose tissue, and high muscle mass. PD-1 expression was not associated with age-related parameters., Conclusions: HIV-infection strongly affected CD8 (+) T cell differentiation and maturation, whereas age-related processes were only weakly associated with immune parameters. Our findings suggest that, in contrast to inflammation, immunosenescence appears to be highly dependent on HIV-infection and is only to a small extent associated with age-related parameters in well-treated HIV-infection.

Background: HIV-infected patients could exhibit accelerated ageing, since age-associated complications like sarcopenia; increased inflammation; lipodystrophy with loss of subcutaneous adipose tissue and/or gain of visceral adipose tissue (VAT); and cardiovascular disease occur at an earlier age. Inflammation is involved in age-associated complications. However, it is not understood whether it is the same inflammatory changes that are involved in the various ageing-associated complications. Our objective was to study whether leptin, interleukin 6 (IL-6), and soluble urokinase plasminogen activator receptor (suPAR) were associated distinctively with adiposity, lipodystrophy and sarcopenia, in HIV-infected patients and healthy Controls., Results: Systemic leptin levels were significantly higher in patients with lipodystrophy than without, whereas there was no difference in IL-6 or suPAR levels. Leptin was significantly positively associated with fat mass index (FMI) and abdominal VAT, but not with lean mass index (LMI). IL-6 was significantly associated with both FMI and VAT, and low LMI. High suPAR was associated with low LMI, and weakly with high FMI and VAT., Conclusions: Leptin reflected adiposity- and lipodystrophy-related inflammation, but not sarcopenia. IL-6 reflected both adiposity-, but also sarcopenia-related inflammation; and suPAR was a marker of sarcopenia-related inflammation. Our results indicate that different inflammatory processes can be active simultaneously contributing to the systemic low grade inflammatory state. Identifying major contributors to circulating leptin, IL-6, and suPAR levels could levels could therefore improve our understanding of which inflammatory processes are involved in the various age-related complications.

Purpose: Acid-base disturbances were investigated in patients with cirrhosis in relation to hemodynamic derangement to analyze the hyperventilatory effects and the metabolic compensation., Methods: A total of 66 patients with cirrhosis and 44 controls were investigated during a hemodynamic study., Results: Hyperventilatory hypocapnia was present in all patients with cirrhosis and progressed from Child class A to C (P<0.01). Arterial pH increased significantly from class A to C (P<0.001) and was correlated inversely to the mean arterial blood pressure (r=-0.30, P<0.02), systemic vascular resistance (r=-0.25, P<0.05), indocyanine green clearance (r=-0.37, P<0.005), and serum sodium (r=-0.38, P<0.002). Metabolic compensation was shown by a reduced standard base excess in all patients (P<0.001). Standard base excess contained elements related to changes in serum albumin, water dilution, and effects of unidentified ions (all P<0.001). A significant hepatic component in the acid-base disturbances could not be identified., Conclusion: Hypocapnic alkalosis is related to disease severity and hyperdynamic systemic circulation in patients with cirrhosis. The metabolic compensation includes alterations in serum albumin and water retention that may result in a delicate acid-base balance in these patients.

Background: Ethical conflicts, often leading to poor teamwork and moral distress, are very challenging to patients, patients' families, and health care providers. A proactive approach to ethical conflicts may improve patient care outcomes., Objectives: To examine acceptability and feasibility of an ethics screening and early intervention tool for use by nurses caring for critically ill patients., Methods: Twenty-eight nurses in 2 medical centers applied the ethics screening tool to 55 patient situations. Nurses assessed situations for risk factors and early indicators of ethical conflicts and analyzed level of risk. At study completion, nurses participated in focus group discussions about the tool's benefits and challenges. Frequency counts were performed on risk factors and early indicators of ethical conflicts. Content analysis was used on written explanations regarding high-, medium-, and low-risk situations and on focus group data., Results: Older patients with multiple comorbid conditions and aggressive treatments were frequently assessed to be at risk for ethical conflicts. Nurses who witnessed patients' suffering and deterioration were likely to initiate the screening process. The most prominent family risk factors included unrealistic expectations and adamancy about treatment. The most prominent early indicators were signs of patients' suffering, unrealistic expectations, and providers' own moral distress. High-risk situations averaged a greater number of risk factors and early indicators than did medium- and low-risk situations. Certain risk factors featured prominently in high-risk situations., Conclusions: A phenomenon of shared suffering emerged from the study and signifies the importance of relational strategies such as routine family conferences and ethics consultation., (©2015 American Association of Critical-Care Nurses.)

Background: Inflammation, and specifically adipose tissue (AT) inflammation, is part of the pathophysiology of obesity and HIV-associated lipodystrophy. Local AT protein assessment methods are limited, and AT inflammation studies have therefore primarily examined inflammatory gene expression. We therefore investigated the utility of microdialysis to study in situ AT interstitial inflammatory protein levels., Material and Methods: Abdominal subcutaneous AT microdialysis was performed in six healthy men, six HIV-infected men with lipodystrophy and six without lipodystrophy using the internal references (51) Cr-EDTA and (125) I-human serum albumin. We measured 41 inflammatory proteins in microdialysis samples by Luminex technology, as well as systemic levels in 14 subjects. Furthermore, in vitro studies of the internal reference technique for microdialysis recovery of inflammatory proteins were made., Results: We detected in situ AT interstitial levels of 14 inflammatory proteins by microdialysis, while the 27 other inflammatory proteins assessed were only detected sporadically. Initial levels of IL-6 and IL-8 were undetectable. Insertion trauma affected IL-1α, IL-6, IL-8, monocyte chemotactic factor (MCP)-1, IP-10, G-CSF, growth-related oncogene (GRO), macrophage-derived chemokine (MDC) and macrophage inflammatory protein (MIP)-1β levels, while fibroblast growth factor (FGF)-2 was not affected. Systemic and AT interstitial levels were poorly correlated. The microdialysis recovery of smaller proteins was higher than for larger, and the internal references improved microdialysis by accounting for variation in perfusion across the membrane., Conclusion: Interstitial inflammatory proteins can be sampled in situ using microdialysis. Use of internal references improves the microdialysis technique. However, insertion trauma hampers the use of microdialysis to study AT inflammatory levels, except for FGF-2. Still, microdialysis gives unique insight to in situ AT interstitial concentrations., (© 2014 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd.)

Background and Aim: In patients with fluid retention, the total plasma clearance of (51)Cr-EDTA (ClP) may overestimate the glomerular filtration rate (GFR). The present study was therefore undertaken in order to compare ClP with the urinary plasma clearance of (51)Cr-EDTA (ClU) in patients with cirrhosis with and without fluid retention., Material and Methods: A total of 136 patients with cirrhosis (24 without fluid retention, 112 with ascites) received a quantitative intravenous injection of (51)Cr-EDTA followed by plasma and quantitative urinary samples for 5 hours. ClP was determined from the injected dose relative to the plasma concentration-time area, extrapolated to infinity. ClU was determined as urinary excretion relative to the plasma concentration-time area up to voiding., Results: In patients without fluid retention, the difference between ClP and ClU (ClP - ClU = ClΔ) was mean 4.5 mL/min/1.73 m(2). In patients with ascites, ClΔ was significantly higher (17.6 mL/min/1.73 m(2), p < 0.0001). ClΔ increased with lower values of GFR (r = - 0.458, p < 0.001). Repeated measurements of ClU in a subgroup of patients with fluid retention (n = 25) gave almost identical values. Different types of corrections of one-pool clearance were almost identical with ClP, except for higher clearance values, which were somewhat underestimated by the former., Conclusion: In patients with fluid retention and ascites ClP and corrected one-pool clearance overestimates GFR substantially. Although ClU may underestimate GFR slightly, patients with ascites should collect urine quantitatively in order to obtain a reliable measurement of GFR.

In subjects without fluid retention, the total plasma clearance of a renal filtration indicator (inulin, (99m) Tc-DTPA, (51) Cr-EDTA) is close to the urinary plasma clearance. Conversely, in patients with fluid retention (oedema, pleural effusions, ascites), there is a substantial discrepancy between the total plasma clearance and the urinary plasma clearance. This is owing to delayed indicator distribution to smaller or larger parts of the interstitial space, which in patients with ascites may simulate a peritoneal dialysator. In patients with fluid retention, urinary plasma clearance should be assessed to obtain a correct measurement of the glomerular filtration rate (GFR). In theory, total plasma clearance with late samples (24-h, 48-h) may be applied in patients with fluid retention, but validation hereof has not been performed. Until such studies are completed, it is recommended that patients with fluid retention have their GFR measured by a urinary plasma clearance technique with controlled quantitative urinary sampling within a few hours after indicator injection., (© 2014 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd.)

In addition to complications relating to the liver, patients with cirrhosis and portal hypertension develop extrahepatic functional disturbances of multiple organ systems. This can be considered a multiple organ failure that involves the heart, lungs, kidneys, the immune systems, and other organ systems. Progressive fibrosis of the liver and subsequent metabolic impairment leads to a systemic and splanchnic arteriolar vasodilatation. This affects both the haemodynamic and functional homeostasis of many organs and largely determines the course of the disease. With the progression of the disease, the circulation becomes hyperdynamic with cardiac, pulmonary as well as renal consequences for dysfunction and reduced survival. Infections and a changed cardiac function known as cirrhotic cardiomyopathy may be involved in further aggravation of other complications such as renal failure precipitating the hepatorenal syndrome. Patients with end-stage liver disease and related complications as for example the hepatopulmonary syndrome can only radically be treated by liver transplantation. As a bridge to this treatment, knowledge on the mechanisms of the pathophysiology of complications is essential for the choice of vasoactive drugs, antibiotics, drugs with specific effects on fibrogenesis and inflammation, and drugs that target specific receptors.

Background: To better define potential challenges in dental professional ethics, the authors gathered data regarding patients' characterizations of an ideal dentist and compared them with their impressions of dentists in general., Methods: The authors invited 500 consecutively seen primary care patients at an academic medical center to participate in the study. Participants completed a 32-item survey assessing key domains of ethical characteristics of health care professionals: trustworthiness, honesty, beneficence, nonmaleficence, respect for autonomy, empathy, compassion, patience, courage, humility and dedication. The authors used the McNemar paired t test to compare respondents' ratings of ideal dentists with their ratings of dentists in general., Results: Two hundred eight-five patients returned completed surveys, for a response rate of 57 percent. The authors found statistically significant differences between ideal and perceived characteristics in all but one domain. The area of greatest difference related to the domain of trustworthiness (that is, dentists should not "propose unnecessary treatments just so they can make money"). For this survey item, 98 percent of patients reported that it was very or extremely important, but only 57 percent of respondents moderately or strongly agreed that dentists in general were engaging in this practice (P < .0001)., Conclusions and Practical Implications: These data reveal gaps between patients' expectations of the dental profession and their actual impressions of dentists in general. Addressing these discrepancies may be crucial if dentistry is to continue to enjoy the public's trust.

This review imparts the history and the present status of the indicator dilution technique with quantitative bolus injection. The first report on flow measurement with this technique appeared 100 years ago. In 1928, the use of intravascular dyes made possible a widespread application in animals and human during the next decades. Multiple indicators, radioactive tracers, inlet-outlet detection and residue detection were introduced in the 1950s and 1960s, and refined along with the development of indicator kinetics. From the 1970s, a wide clinical use in the study of heart, brain, lungs, liver and kidneys developed, and powerful computers in the 1980s and 1990s accorded the technique a new dimension. Today, the indicator dilution technique, on one hand, is applied in the same way as 100 years ago, on the other hand it forms the basis of quantitative SPECT, positron emission tomography, and dynamic MR scans. The technique still undergoes refinement and elaboration as a lasting concept with a high potential for further development., (© 2013 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd.)

Gray geese of the bar-headed type (Anser indicus synonym: Eulabeia indica) perform trans-Himalayan migratory flight at extreme altitude. The physiological mechanisms include hyperventilation of cold air, increased lung diffusion capacity, proton gradients, high muscular temperature, amino acid mutation in haemoglobin and cytochrome oxidase, re-location of mitochondria, and extreme shifts in the oxy-haemoglobin dissociation curve due to Bohr- and temperature effects. The second annual migration takes place in late autumn, and the bar-headed geese come home in due time before Christmas.

We developed and assessed feasibility of an Ethics Screening and Early Intervention Tool that identifies at-risk clinical situations and prompts early actions to mitigate conflict and moral distress. Despite intensive care unit and oncology nurses' reports of tool benefits, they noted some risk to themselves when initiating follow-up actions. The riskiest actions were discussing ethical concerns with physicians, calling for ethics consultation, and initiating patient conversations. When discussing why initiating action was risky, participants revealed themes such as "being the troublemaker" and "questioning myself." To improve patient care and teamwork, all members of the health care team need to feel safe in raising ethics-related questions.

Background and Aim: From a clinical point of view determination of glomerular filtration rate (clearance) is important. The aim of the present study was to compare the one-sample clearance to reference multiple-sample (51)Cr-EDTA clearance in consecutively referred children suspected of or with established nephro-urological disorders., Material and Methods: A total of 75 children, age ½-13 years, received a quantitative intravenous injection of (51)Cr-EDTA followed by six plasma samples 10-120 min after injection. The multiple-sample clearance was measured as injected dose relative to the area under the plasma radioactivity curve. The one-sample clearance was determined from a single plasma sample collected at 60, 90 or 120 min after injection according to the one-pool method., Results: The overall accuracy of one-sample clearance was excellent with mean numeric difference to the reference value of 0.7-1.7 mL/min. In 64 children, the one-sample clearance was within ± 4 mL/min of the multiple-sample value. However, in 11 children the numeric difference exceeded 4 mL/min (4.4-19.5). Analysis of age, body size, distribution volume, indicator retention time, clearance level, curve fitting, and sampling time could not explain the observed large difference between one-sample and multiple-sample clearance in these 15% of the children., Conclusion: In the majority of children there is an excellent agreement between one-sample clearance and multiple-sample clearance. However, unexpectedly in a small fraction (15%) larger discrepancies are found. If an accurate clearance value is essential a multiple-sample determination should be performed.

Background and Aims: Determination of plasma volume (PV) is important in several clinical situations. Thus, patients with liver disease often have augmented PV as part of their sodium-water retention. This study was undertaken to compare PV determination by two indicators: technetium-labelled human serum albumin ((99m) Tc-HSA) and iodine-labelled human serum albumin ((125) I-HSA), as the former may have advantages at repeated measurements and the latter is the classical gold standard., Study Population and Methods: In 88 patients, (64 with liver disease, mainly cirrhosis, and 24 patients without liver disease), simultaneous measurements of PV were taken with (99m) Tc-HSA and (125) I-HSA after 1 h in the supine position. Blood samples were obtained before and 10 min after quantitative injection of the two indicators. In a subset of patients (n = 32), the measurements were repeated within 1 h., Results: In all patients, a close correlation was present between PV determined by the two indicators (r = 0·89, P<0·0001). In all, but twelve patients, a higher PV was obtained with (99m) Tc-HSA compared with (125) I-HSA (P<0·0001). PV determined with (99m) Tc-HSA exceeded PV determined with (125) I-HSA by 367 ml (5·2 ml kg(-1) ) in liver patients as compared to 260 ml (3·5 ml kg(-1) ) in patients without liver disease (P<0·05). The precision of repeated PV determination was 1·75% (coefficient of variation) with (99m) Tc-HSA and 1·71% with (125) I-HSA (ns), and similar values were found in patients with and without liver disease., Conclusion: The study demonstrates that (99m) Tc-HSA has the same precision as that of (125) I-HSA. However, especially in patients with liver disease, (99m) Tc-HSA consistently overestimates the PV, most likely owing to indicator heterogeneity with subsequent fast removal from the circulating medium with a higher volume of distribution as the outcome., (© 2012 The Authors Clinical Physiology and Functional Imaging © 2012 Scandinavian Society of Clinical Physiology and Nuclear Medicine.)

Aim: To determine the splanchnic blood flow and oxygen uptake in healthy-subjects and patients and to relate the findings to body-composition., Methods: The total splanchnic blood flow (SBF) and oxygen uptake (SO₂U) were measured in 20 healthy volunteers (10 women) and 29 patients with suspected chronic intestinal ischemia (15 women), age 40-85 years, prior to and after a standard meal. The method is based on the Fick principle using the continuous infusion of an indicator (99mTechnetium-labelled mebrofenin) and catheterization of an artery and the hepatic vein. An angiography of the intestinal arteries was performed during the same investigation. A whole-body dual-energy x-ray absorptiometry scan was performed in healthy volunteers to determine body composition., Results: Angiography revealed no atherosclerotic lesions in the intestinal arteries. The mean baseline SBF was 1087 mL/min (731-1390), and this value increased significantly to 1787 mL/min after the meal in healthy volunteers (P < 0.001). The baseline SBF in patients was 1080 mL/min, which increased to 1718 mL/min postprandially (P < 0.001). The baseline SBF was independent of age, sex, lean body mass and percentage of body fat. The mean meal-induced increase in SBF was equal to 282 mL/min + 5.4 mL/min × bodyweight, (P = 0.025). The SO₂U in healthy volunteers and patients was 50.7 mL/min and 48.0 mL/min, respectively, and these values increased to 77.5 mL/min and 75 mL/min postprandially, respectively. Both baseline and postprandial SO₂U were directly related to lean body mass. Age and sex exerted no impact on SO₂U., Conclusion: A direct correlation between body weight and the postprandial increase in SBF was observed. The effect of body weight should be considered in the diagnosis of chronic intestinal ischemia.

Objective: Patients with cirrhosis often present with an abnormal distribution of blood volume with a reduced central blood volume (CBV) and central circulation time (CCT). In this group of patients it is important to determine the central haemodynamics as accurately as possible. The purpose of the present study was to compare an alternative injection technique by injecting technetium-labelled human serum albumin ((99m)Tc-HSA) from a deposit within the catheter lumen with the conventional injection technique by injecting iodine-labelled human serum albumin ((125)I-HSA) directly from a syringe., Materials and Methods: In 192 patients with cirrhosis, CCT, CBV, and cardiac output (CO) were determined according to kinetic principles. Injection of the two radiolabelled HSA were performed simultaneously and followed by arterial blood sampling every second for the first minute., Results: CCT was significantly shorter, and CO and CBV were significantly lower when determined by the alternative catheter deposit injection technique compared to determination by the traditional syringe deposit injection technique. The mean difference (bias) between CCT measured with the two methods was 0.38 s with limits of agreement ranging from - 0.83 s to 1.59 s., Conclusion: This study demonstrates that different injection techniques result in a minor but significant difference of the measured haemodynamics. When highly accurate measurements of the central haemodynamics are needed, we recommend using the alternative injection technique by injection of the indicator from a deposit within the catheter in order to reduce overestimation of CCT.

Objective: Atrial fibrillation diminishes cardiac function, exercise tolerance and quality of life. The objective of this study was to determine whether exercise training in atrial fibrillation affects muscle strength, body composition, maximal exercise capacity and walking capacity positively, thus improving quality of life., Design: Randomized clinical trial. Twelve weeks of physical exercise training or control., Patients: Forty-nine patients in permanent atrial fibrillation were randomized to training or control., Methods: Intervention consisted of aerobic training for 1 h 3 times per week at 70% of maximal exercise capacity vs control. Muscle strength, exercise capacity, 6-minute walk test, lean body mass, fat percentage, and quality of life were assessed., Results: Muscle strength increased in the training group (p = 0.01), but no change was observed in controls. Lean body mass was unchanged in both groups. Fat percentage decreased in both groups, but there was no significant difference between the groups. Exercise capacity improved in the training group (p < 0.001), with no change in the control group. There was a significant difference after the training period between the training and control groups in terms of exercise capacity. (p = 0.001). Six-min walk test improved in the training group compared with controls (p < 0.01). Overall quality of life score, as measured by the Minnesota Living with Heart Failure Questionnaire, improved in the training group (p = 0.03). Quality of life, measured by Short Form-36, improved in the training group in 3 out of 8 subscales: physical functioning (p = 0.02), general health perceptions (p = 0.001) and vitality (p = 0.02)., Conclusion: Muscle strength, exercise capacity and quality of life increased with exercise training in subjects with atrial fibrillation. Lean body mass was unchanged.

Objective: Patients with cirrhosis have cardiovascular dysfunction and altered mechanical properties of large and small arteries. This study was undertaken in order to analyze the arterial pressure curve in relation to mean arterial pressure level, stroke volume, and severity of liver disease., Materials and Methods: Forty-one patients with cirrhosis (Child-Turcotte classes A/B/C = 13/15/13) were studied during a hemodynamic investigation of portal hypertension. Fifteen patients without liver disease served as controls. We applied fast Fourier analysis to quantify the pressure components of the arterial curve, the harmonic Fourier coefficients (HFC)., Results: Mean arterial pressure was significantly reduced (91 vs. 98 mmHg, p < 0.001) and stroke volume was significantly increased (94 vs. 78 ml, p < 0.001) in patients with cirrhosis versus controls. The HFC were significantly lower in patients with cirrhosis than in controls (-15 to -24%, p < 0.002), except for the fourth HFC, which was significantly increased (+28%, p < 0.02). In contrast to controls, which showed a highly significant effect of the level of arterial pressure on their HFC (p < 0.001), patients with cirrhosis did not show pressure or stroke volume dependence on their HFC, indicating an overall compliant and slow reflective arterial vascular bed. The initial rise in pulse pressure (dP/dt) was inversely related to the Child-Turcotte score (p < 0.05), and the HFC were borderline significantly related to this score (p = 0.07)., Conclusions: The arterial pulsation in cirrhosis is qualitatively changed with reduced pulse reflections, which may protect against manifest cardiac failure in patients with advanced cirrhosis.

The aim of this study was to evaluate the measurement of the total splanchnic blood flow (SBF) using a clinical diagnostic method based on Fick's principle and hepatic extraction of 99mTc-mebrofenin (99mTc-MBF) compared with a paraaminohippuric acid (pAH) dilution method in a porcine model. Another aim was to investigate whether enterohepatic cycling of 99mTc-MBF affected the SBF measurement. Five indwelling catheters were placed in each pig (n = 15) in the portal, mesenteric, and hepatic veins, as well as in the aorta and the vena cava. The SBF was measured using both methods. The portal blood flow; the intestinal and hepatic oxygen uptake; the net fluxes of oxygen, lactate, and glucose; and the extraction fraction (EF) of 99mTc-MBF were measured before and for 70 min after feeding. The mean baseline SBF was 2,961 ml/min vs. 2,762 ml/min measured by pAH and 99mTc-MBF, respectively, and increased significantly to 3,977 ml/min and 3,981 ml/min postprandially. The hepatic EF of 99mTc-MBF decreased from 40% at the start of the investigation to 16% 70 min after feeding. The arterial-portal difference in 99mTc-MBF concentration was 0.21% (P = 0.48), indicating no intestinal extraction or metabolism. The clinical method for measuring the SBF based on hepatic 99mTc-MBF extraction is robust compared with the indicator dilution method, despite the decrease seen in hepatic extraction of 99mTc-MBF. Because there was no difference in the content of 99mTc-MBF between the arterial and portal vein plasma, the SBF can be calculated from an arterial and a hepatic vein sample.

Objectives: To examine mechanisms underlying the increased inflammatory state of HIV-infected patients, by investigating the association of HIV-related factors, demography, lifestyle, and body composition with the inflammatory marker soluble urokinase plasminogen activator receptor (suPAR)., Methods: suPAR was measured in EDTA-plasma and associated with HIV-related factors (HIV-duration, combination antiretroviral treatment (cART), nadir CD4+ cell count, CD4+ cell count, and HIV RNA); demography; lifestyle; and body composition determined by Dual energy X-ray Absorptiometry (DXA) scan, in multiple linear regression analyses adjusted for biological relevant covariates, in a cross-sectional study of 1142 HIV-infected patients., Results: Increased suPAR levels were significantly associated with age, female sex, daily smoking, metabolic syndrome and waist circumference. cART was associated with 17% lower suPAR levels. In cART-treated patients 10-fold higher HIV RNA was associated with 15% higher suPAR, whereas there was no association in untreated patients. Patients with CD4+ cell count <350 cells/µL had higher suPAR levels than patients with CD4+ cell count ≥350 cells/µL , though not significantly. We found no association with nadir CD4+ cell count or with duration of HIV-infection [corrected]. Finally, suPAR was not associated with adipose tissue distribution, but strongly associated with low leg muscle mass [corrected].In patients infected through intravenous drug use (IDU), CD4+ cell counts ≥350 cells/µL were associated with 27% lower suPAR (p = 0.03), andsuPAR was 4% lower pr. year during treatment (p = 0.05); however, there was no association with HIV RNA, duration of HIV-infection, nor cART [corrected]., Conclusion: We found elevated suPAR levels in untreated patients compared to patients on cART. Moreover, we observed a significant positive association between suPAR and HIV RNA levels in cART-treated patients. Age, HIV-transmission through IDU, metabolic syndrome, smoking, and low leg muscle mass were also significantly associated with suPAR levels. Our study therefore indicates, that also other aspects of living with HIV than virologic and immunologic markers add to the increased inflammation in HIV-infected patients.

Background: Atrial fibrillation (AF) is associated with significant morbidity and mortality. To test the effect of interventions, knowledge of cardiac output (CO) is important. However, the irregular heart rate might cause some methods for determination of CO to have inherent weaknesses. Objective. To assess the validity of these methods in AF, a new inert gas rebreathing device and impedance cardiography was tested with echocardiography as reference., Methods: Using a cross-sectional design, 127 patients with AF and 24 in SR were consecutively recruited. Resting CO was measured using inert gas rebreathing (n = 62) or impedance measurement of intrathoracic blood flow (n = 89) in separate studies with echocardiographic measurement as reference., Results: CO determined with impedance cardiography was mean 4.77 L/min ± 2.24(SD) compared to 4.93 L/min ± 1.17 by echocardiography (n = 89, n.s.) in patients with AF. CO by inert gas rebreathing was 4.98 L/min ± 2.49(SD) compared to 5.70 L/min ± 2.49 by echocardiography (n = 62, n.s.) in patients with AF and SR (AF 5.42 ± 2.9 vs. 6.27, n.s. and SR 4.09 ± 1.08 vs. 4.35 ± 0.86, n.s.). Mean bias between impedance cardiography and echocardiography was 0.14 ± 0.95 L/min and -0.13 ± 0.98 L/min between inert gas rebreathing and echocardiography. Inert gas rebreathing showed larger intra-patient variation than impedance cardiography (0.11 vs. 0.054). Correlation between inert gas rebreathing and echocardiography was r = -0.060 and between impedance cardiography and echocardiography was r = 0.128. Impedance cardiography and inert gas rebreathing both underestimated CO compared to echocardiography., Conclusion: Variation between the inert gas rebreathing and the reference method for AF patients was less than desired. Impedance cardiography was superior to inert gas rebreathing and showed acceptable agreement with echocardiography and variability similar to echocardiography.

Background: Water retention in advanced cirrhosis and ascites may involve disturbances in renal distal tubular function and in the vasopressin system., Methods: Twelve patients with Child B cirrhosis and ascites were compared with 11 patients with Child C cirrhosis and ascites. The subjects were studied during a 400 ml/h oral water load., Results: Child C patients had a lower baseline glomerular filtration rate (32 vs 63 ml/min, P<0.001) and a lower urinary flow rate (V(u)) (0.86 vs 1.95 ml/min, P<0.001) than the Child B patients. However, the free water clearance (C(H2O)) did not differ (-0.60 vs -0.21 ml/min, P=0.20). After the water loading, plasma vasopressin (AVP) decreased significantly in both the groups (P<0.05). The Child B patients had increased V(u) (1.95-3.24 ml/min, P<0.001) and C(H2O) (-0.21-1.21 ml/min, P<0.01) and distal fractional water excretion (10.5 vs 0% in Child C, P=0.01) and aquaporin-2 (AQP2) (P<0.058) after water loading. In contrast, the Child C patients did not have increased V(u) and C(H2O) in response to the water and the decrease in AVP. Furthermore, the markers of distal tubular water regulation, AQP2 excretion and distal fractional water excretion, were unaltered., Conclusion: In Child C cirrhosis, ascites and mild hyponatraemia, there is an impaired ability to excrete solute-free water. The patients are characterised by a low glomerular filtration rate, a low distal tubular flow and an inability to increase free water clearance during water loading. This may be related to a vasopressin-independent production of AQP2., (© 2010 John Wiley & Sons A/S.)

Aim: Comprilan bandage may be an attractive treatment of leg oedema, but theoretically bandage could compromise peripheral circulation. The present study was undertaken to investigate circulation in the first toe before, during, and after treatment with comprilan bandage., Methods and Study Population: Blood flow rate was measured by the heat-washout method in the pulp of the first toe of 10 patients (eight women, two men, aged 75-94) with leg oedemas, and systolic toe blood pressure was determined by the strain gauge method. Oedema was scored according to a visual scale, and the patients were treated with comprilan (short stretch) bandage for 1 week. Toe blood flow rate was measured before, during and after the use of the bandages, and toe blood pressure was measured before and after the use of bandages., Results: According to the visual scale, all subject benefited from the treatment by reduction of oedema, and they reported increased well-being after. Blood flow rate was not significantly altered during and after the treatment. Systolic toe pressure was normal in all patients (R/L = 94/83 mmHg), and no significant change took place during and after the use of the bandages (92/90 mmHg)., Conclusion: Comprilan bandage has a positive effect on legs oedemas, visually as well as according to the patients well-being. The treatment does not have any significant influence on toe blood pressure. It cannot, however, be excluded that the use of comprilan bandage may compromise toe blood flow rate slightly (<5%). A larger study with more subjects has to be made to come this closer, and additional capillary blood flow rate should be measured in an area without arteriovenous anastomoses.

Objective: Terlipressin (TP) is a potent vasoconstrictor, which is widely used in the treatment of bleeding esophageal varices and the hepatorenal syndrome. Side effects to TP are often related to skin hypoxaemia. The aim of the study was to investigate the transcutaneous oxygen pressures (TcPO(2) mmHg) after administration of 2 mg of TP., Patients and Methods: Nineteen patients with cirrhosis and ascites were included. TcPO(2) mmHg were measured continuously measured at the chest, abdominal wall and at the lower extremity at baseline and after 2 mg TP in 15 patients and placebo in 4 patients., Results: The mean whole body TcPO(2) decreased after TP by 34% (p < 0.005). The decrease was even more pronounced in the lower extremity: above knee -33% (50 vs. 33 mmHg, p = 0.01) and below knee -52% (52 vs. 26 mmHg, p = 0.001). Levels below 30 mmHg, were found in 60% of the patients after TP compared to 0% in the placebo group, p = 0.005. There were no significant changes in TcPO(2) after placebo. The baseline leg TcPO(2) correlated inversely with the MELD score (r = -0.64 and p < 0.003) and the increase in MAP after TP correlated inversely with TcPO(2) at the thorax (r = -0.60, p = 0.009)., Conclusions: Sixty percent of patients with decompensated cirrhosis develop hypoxaemia in the lower limb after one dose of TP.

Increased cardiac output was first described in patients with cirrhosis more than fifty years ago. Later, various observations have indicated the presence of a latent cardiac dysfunction, which includes a combination of reduced cardiac contractility with systolic and diastolic dysfunction and electrophysiological abnormalities. This syndrome is termed cirrhotic cardiomyopathy. Results of experimental studies indicate the involvement of several mechanisms in the pathophysiology, such as reduced beta-adrenergic receptor signal transduction, altered transmembrane currents and electromechanical coupling, nitric oxide overproduction, and cannabinoid receptor activation. Systolic incompetence in patients can be revealed by pharmacological or physical strain and during stressful procedures, such as transjugular intrahepatic portosystemic shunt insertion and liver transplantation. Systolic dysfunction has recently been implicated in development of renal failure in advanced disease. Diastolic dysfunction reflects delayed left ventricular filling and is partly attributed to ventricular hypertrophy, subendocardial oedema, and altered collagen structure. The QT interval is prolonged in about half of the cirrhotic patients and it may be normalised by beta-blockers. No specific therapy for cirrhotic cardiomyopathy can be recommended, but treatment should be supportive and directed against the cardiac dysfunction. Future research should better describe the prevalence, impact on morbidity and survival, and look for potential treatments., (Copyright 2010 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Objectives: Recent studies suggest that cardiac dysfunction precedes development of the hepatorenal syndrome. In this follow-up study, we aimed to investigate the relation between cardiac and renal function in patients with cirrhosis and ascites and the impact of cardiac systolic function on survival., Patients and Design: Twenty-four patients with cirrhosis and ascites were included. Cardiac function was investigated by gated myocardial perfusion imaging (MPI) for assessment of cardiac index (CI) and cardiac volumes. The renal function was assessed by determination of glomerular filtration rate (GFR) and renal blood flow (RBF) and the patients were followed up for 12 months., Results: In patients with a CI below 1.5 l/min/m(2) on MPI, GFR was lower (39 (SD 24) vs 63 (SD 23) ml/min, p = 0.03), RBF was lower (352 (SD 232) vs 561 (SD 229) ml/min, p = 0.06), and serum creatinine was higher (130 (SD 46) vs 78 (SD 29) mumol/l, p<0.01). The number of patients who developed hepatorenal syndrome type 1 within 3 months was higher in the group with low CI than in the high CI group (43% vs 5%, p = 0.04). Patients with the lowest CI (N = 8) had significantly poorer survival at 3, 9, and 12 months compared to those with a higher CI (N = 16), p<0.05. In contrast, the Model for End-stage Liver Disease (MELD) score failed to predict mortality in these patients., Conclusions: The development of renal failure and poor outcome in patients with advanced cirrhosis and ascites seem to be related to a cardiac systolic dysfunction. Other parameters may be more important than MELD score to predict prognosis.

Rifle contra shotgun shots are considered in relation to an X-mas goose and shooting accident. Depending on the size of shots, material and velocity, the effect in the body may vary considerably. Myocardial infarction, secondary to accidental shotgun shot, may be caused by 1) thrombosis secondary to intima lesion, 2) stenosis, oedema and haematoma in relation to myocardial lesion; and, in addition, 3) the cumulative energy of many shots may give myocardial contusion with infarction. Pathotechnical and pathophysiological analyses are required to reveal complicated causes and effects and unusual disease events.

Background: Pulmonary dysfunction including the hepatopulmonary syndrome (HPS) is an important complication to cirrhosis and portal hypertension. However, the precise relation to liver dysfunction and the prevalence of HPS are unclear., Aims: We therefore aimed to assess (i) the prevalence of HPS in consecutive alcoholic cirrhotic patients, (ii) the degree of pulmonary dysfunction in relation to liver function and (iii) the response of a 100% oxygen test on cardiopulmonary and peripheral oxygenation., Methods: Fifty patients with cirrhosis and 12 matched healthy controls were entered in this study. All underwent haemodynamic and pulmonary investigations [lung diffusing capacity for carbon monoxide (DLCO), contrast-enhanced echocardiography and detection of extrapulmonary shunt fraction]. A 100% oxygen test was performed with the assessment of arterial oxygen tension (PaO(2)), the alveolar-arterial oxygen gradient (AaPO(2)) and peripheral transcutaneous oxygen tension (tcPO(2))., Results: The prevalence of HPS was 10%. PaO(2) and DLCO were reduced in 32 and 72% and AaPO(2), was increased in 60% of the patients respectively. DLCO correlated with indicators of liver dysfunction (galactose elimination capacity, P<0.01, indocyanine green clearance, P<0.001), portal hypertension (post-sinusoidal resistance, P<0.01) and central hypovolaemia (central and arterial blood volume, P<0.01). After 100% oxygen inhalation, the changes in PaO(2), AaPO(2), tcPO(2) and heart rate were abnormal in the patients compared with controls (P<0.02)., Conclusions: Pulmonary dysfunction in alcoholic cirrhosis is common and relates to different aspects of liver dysfunction, whereas the prevalence of HPS is low. The haemodynamic response to oxygen inhalation is clearly impaired and HPS and pulmonary dysfunction seem to be caused by different pathophysiological mechanisms.

Cardiovascular complications of liver cirrhosis include cardiac dysfunction and abnormalities in the central-, splanchnic,- and peripheral circulation. Vasodilatation prevails, but vascular beds with various degrees of reduced and increased haemodynamic resistance are the results of massive activation of powerful homeostatic, regulatory systems. Cirrhotic cardiomyopathy implies systolic and diastolic dysfunction and electrophysiological abnormalities, an entity that is different from alcoholic heart muscle disease. Being often clinical latent, cirrhotic cardiomyopathy can be unmasked by physical and pharmacological strain. Cardiac failure is an important cause of mortality after liver transplantation and stressful procedures as insertions of transjugular intrahepatic portal systemic shunt (TIPS), peritoneal venous shunting, and other types of surgery. Improvement of liver function has been shown to reverse the cardiovascular complications. The clinical significance is an important topic for future research. At present, no specific treatment can be recommended, and the cardiac failure in cirrhosis should be treated as in non-cirrhotic patients with sodium restriction, diuretics, and beta-adrenergic blocking agents. Special care should be taken with the use of ACE-inhibitors and angiotensin antagonist in these patients.

Ascites is a classic complication of advanced cirrhosis and it often marks the first sign of hepatic decompensation. Ascites occurs in more than 50% of patients with cirrhosis, worsens the course of the disease, and reduces survival substantially. Portal hypertension, splanchnic vasodilatation, liver insufficiency, and 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 large volume paracentesis followed by plasma volume expansion or transjugular intrahepatic portosystemic shunt. Ascites complicated by spontaneous bacterial peritonitis requires adequate treatment with antibiotics. New potential treatment strategies include the use of vasopressin V(2)-receptor antagonists and vasoconstrictors. Since formation of ascites is associated with a poor prognosis, and treatment of fluid retention does not substantially improve survival, such patients should always be considered for liver transplantation.

Cardiovascular complications of cirrhosis include cardiac dysfunction and abnormalities in the central, splanchnic and peripheral circulation, and haemodynamic changes caused by humoral and nervous dysregulation. Cirrhotic cardiomyopathy implies systolic and diastolic dysfunction and electrophysiological abnormalities, an entity that is different from alcoholic heart muscle disease. Being clinically latent, cirrhotic cardiomyopathy can be unmasked by physical or pharmacological strain. Consequently, caution should be exercised in the case of stressful procedures, such as large volume paracentesis without adequate plasma volume expansion, transjugular intrahepatic portosystemic shunt (TIPS) insertion, peritoneovenous shunting and surgery. Cardiac failure is an important cause of mortality after liver transplantation, but improved liver function has also been shown to reverse the cardiac abnormalities. No specific treatment can be recommended, and cardiac failure should be treated as in non-cirrhotic patients with sodium restriction, diuretics, and oxygen therapy when necessary. Special care should be taken with the use of ACE inhibitors and angiotensin antagonists in these patients. The clinical significance of cardiovascular complications and cirrhotic cardiomyopathy is an important topic for future research, and the initiation of new randomised studies of potential treatments for these complications is needed.

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 V(2)-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.

Purpose: We present an unusual case of extra cardiac activity of 99mTc-MIBI in the left part of thorax and left upper extremity in a patient admitted for myocardial perfusion scintigraphy., Methods: A standard 2-day protocol of 99mTc-MIBI perfusion scintigraphies starting day 1 with stress (dipyridamol) imaging and followed by rest imaging day 2 was performed., Results: On day 2, when rest perfusion scintigraphy was carried out, extra cardiac activity was present in the left part of thorax and in the left upper extremity resulting in reduced accumulation of 99mTc-MIBI in cardiac tissue, prolongation of the study and interference of the extra cardiac activity with the cardiac image reconstructions. Whole-body scintigraphy disclosed an arterial flow distribution of activity to skeletal muscles in left shoulder and upper limb., Conclusion: Accidentally injected radiotracer retrogradely into the arterial system resulted in an unusual extra cardiac activity interfering with later image processing.