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Introdução: A deficiência de glicose-6-fosfato desidrogenase (G6PD) afeta cerca de 400 milhões de pessoas no mundo, na Amazônia brasileira foi descrita uma prevalência de 5,6%. É uma desordem enzimática, e torna a hemácia suscetível à injúria oxidativa após contato com antimaláricos, como a primaquina e tafenoquina. Sendo de fundamental importância na região amazônica, que corresponde a 99% dos casos de malária do Brasil. Objetivo: Avaliar a atividade de G6PD e suas características epidemiológicas em indivíduos com diagnóstico de malária. Método: Foram avaliadas as características epidemiológicas e exame de G6PD dos indivíduos com diagnóstico de malária por P. vivax (incluindo mista PV+PF) atendidos no ambulatório de síndromes febris do Centro de Pesquisa em Medicina Tropical de Rondônia (CEPEM), em Porto Velho, em 2022. Aprovado pelo CEP/CEPEM. Resultados: Avaliamos 2.066 casos de P. vivax, com média de idade de 38 anos (0,6-85 anos; DP 15,8), 1.385 (67%) do sexo masculino. Do sexo feminino, 13 (1,9%) eram gestantes e 30 (4,4%) lactantes. Todos realizaram o teste de G6PD, sendo 206 (10%) com baixa atividade (≤ 4,0), 656 (31,7%) com atividade intermediária (≥ 4,1 e ≤ 6,0) e 1.204 (58,3%) atividade normal (≥ 6,1), (p > 0,013). Dentre os homens (n = 1.385) a atividade de G6PD foi: 125 (9%) baixa, 465 (33,6%) intermediária e 795 (57,4%) normal, já as mulheres (n = 681), 81 (11,9%) apresentaram baixa atividade, 191 (28%) intermediária e 409 (60,1%) normal. Os pacientes foram tratados com os seguintes esquemas: 980 (47,4%) com primaquina 7 dias; 570 (27,6%) tafenoquina, 295 (14,3%) com primaquina 14 dias; e 205 (9,9%) primaquina semanal. A proporção de recaída foi de 255 (12,3%), sendo 7,3% com primaquina semanal e 12,9% com outros esquemas, além disso, não houve diferença estatística na média de peso de quem apresentou recaída quando comparada a quem não apresentou (p = 0,352). Conclusão: A prevalência de deficiência de G6PD foi maior (10% versus 5,6%) quando comparado a estudos anteriores na Amazônia brasileira. O Ministério da Saúde prevê a implementação da tafenoquina, mostramos que mais de 40% dos indivíduos analisados teriam contraindicação à tafenoquina. Dessa forma, reforçamos a importância da testagem de G6PD prévia à administração de antimaláricos, a fim de evitar complicações. Nos casos de deficiência vimos que o esquema semanal não aumentou as recaídas. Demonstramos que, apesar de relacionada ao cromossomo X, não houve diferença estatística de deficiência ao comparar os sexos.

Introdução: Visando diminuir recaídas, o tratamento da malária foi modificado aumentando a dose diária da primaquina e reduzindo o tempo de tratamento. Essa estratégia parece ter aumentado episódios de metahemoglobinemia, ações oxidantes nas hemoglobinas, transformando as em metemoglobina (metaHb), que não possuem capacidade de transporte de oxigênio aos tecidos. Objetivo: Analisar a prevalência de metemoglobina, seus níveis e manifestações clínicas. Método: Os participantes foram atendidos no ambulatório de malária do Centro de Pesquisa em Medicina Tropical de Rondônia, em Porto Velho, no período de 2022 a 2023, com diagnóstico de metahemoglobinemia (MetaHB > 3,0%) em seus retornos. Foram avaliados níveis de metemoglobina e aspectos clínicos. Aprovado pelo CEP/CEPEM. Resultados: Foram atendidos 5330 indivíduos e analisados 556 participantes com metahemoglobinemia (10,4%), com média de idade de 39 anos (DP 16), 68,2% eram do sexo masculino. Eram primoinfecção 135 indivíduos, destes 80,7% apresentavam valor de metaHb 5 (p < 0,001). 496 indivíduos retornaram em menos de 15 dias do diagnóstico de malária e 66,5% apresentavam metaHb > 5 (p < 0,001). Conclusão: As manifestações clínicas estão diretamente relacionadas aos níveis de MetaHb. Entretanto, os sintomas estão presentes quando MetaHB < 10%, divergindo de estudos que sugerem o início dos sintomas com valor superior a 12%. É fundamental que os profissionais de saúde tenham conhecimento sobre a metaHb como complicação do tratamento de malária (10,4%), principalmente nas regiões endêmicas. O diagnóstico pode ser um desafio sem o auxílio do co-oximetro, mas características clínicas podem ser fundamentais.

Introdução: A malária é uma das doenças infecto-parasitárias de maior importância no mundo. A metahemoglobinemia é uma das principais complicações relacionada a terapêutica medicamentosa para o P. vivax com derivados 8-aminoquinolinas, como primaquina e tafenoquina. O acesso a métodos diagnósticos nem sempre estão disponíveis, o que se faz necessário suspeita clínica. Objetivo: Descrever as características clínicas em pacientes internados com metaemoglobinemia. Método: Foram atendidas 4.541 pessoas com malária no hospital Cemetron, em Porto Velho, entre os anos de 2019 e 2023, e apenas 60 destes pacientes apresentaram diagnóstico clínico e/ou laboratorial de metahemoglobinemia. Foram avaliados dados clínicos e laboratoriais durante toda a internação. Aprovação CEP/CEPEM (CAAE 68890523.4.0000.0011). Resultados: Dos 4.541 indivíduos internados, 60 tiveram diagnóstico de metahemoglobinemia (1,3%). Dos 60 com diagnóstico de metahemoglobinemia, a média de idade foi de 33 anos, sendo 36 (60%) do sexo masculino. Todos foram internados já com complicações da terapeutica, sendo os seguintes esquemas: 43 (71,6%) primaquina 7 dias, 10 (16,6%) primaquina 14 dias, 1 (1,6%) tafenoquina, 1 (1,6%) primaquina semanal e 5 (8,3%) sem informação. Em 58,4% dos casos, houve necessidade de interromper teraperutica e 3,3% teve esquema modificado. Dos indivíduos que tiveram avaliação da metemoglobina (metaHb), 65,2% apresentaram valor > 10. Dos sintomas apresentados, 42 (70%) tinham dispneia, 28 (46,6%) cefaleia, 27 (45%) fraqueza, 21 (35%) cianose, 19 (31,6%) vômito. Com relação a oximetria, os valores variaram de 65-93%, sendo que 39 (65%) indivíduos receberam suplementação de O², sendo 19 (49%) por máscara de alto fluxo, 11 (28%) por cateter nasal, 8 (20,5%) por máscara de Venturi e 1 (2,5%) por ventilação mecânica. O tempo médio de internação foi de 6,1 dias, e não foi registrado nenhum óbito. Conclusão: Encontramos uma baixa prevalência de metahemoglobinemia com necessidade de internação, porém 65% dos que internaram tiveram necessidade de suplementação de O2, inclusive com ventilação mecânica. É uma complicação que diagnosticada precocemente e com a interrupção ou modificação do esquema para semanal, pode modificar desfecho, como vimos em outro estudo do nosso grupo com acompanhamento ambulatorial.

(1) Background: Femicide is an increasing phenomenon consisting of the murder of a woman for gender-related reasons. Despite the enactment of new laws aimed at controlling the phenomenon by toughening the penalties and introducing aggravating circumstances, there is an increasing trend that testifies to the persistence of a flaw in the actual measures. (2) Case Presentation. We report the case of the murder of a 32-year-old woman-perpetrated by an ex-husband who refused to accept the end of the marriage-the analysis of which allowed us to frame the case as femicide. (3) Discussion. Despite global awareness of this phenomenon, the identification of risk factors to predict and prevent femicide is of utmost importance. This can be achieved by a multidisciplinary approach involving police officers, legal professionals, hospitals, governmental and nongovernmental organizations, and medico-legal departments aimed at promoting standardized methodologies. (4) Conclusions. We evaluate the contribution of forensic investigations to the identification of key elements that can help frame the murder of a woman as a femicide. Considering the devastating consequences for children who witness this kind of violence within the domestic setting, the planning of more impactful preventive actions is, thus, mandatory to minimize effects on public health.

Background: Tumor consistency recently emerged as a key factor in surgical planning for pituitary adenomas, but its impact on postoperative endocrine function is still unclear. Our study aimed to evaluate the impact of tumor consistency on the development of postoperative pituitary deficiencies., Methods: Single-center, retrospective analysis of consecutive pituitary surgeries performed between January 2017 and January 2021 at Policlinico Umberto I in Rome. All patients underwent radiological and biochemical evaluations at baseline, and hormone assessments 3 and 6 months after pituitary surgery. Postoperative MRI studies were used to determine resection rates following surgery. Data on tumor consistency, macroscopic appearance, neurosurgical approach, and intraoperative complications were collected., Results: Fifty patients [24 women, mean age 57 ± 13 years, median tumor volume 4800 mm 3 [95% CI 620-8828], were included. Greater tumor volume (χ 2  = 14.621, p = 0.006) and male sex (χ 2  = 12.178, p < 0.001) were associated with worse preoperative endocrine function. All patients underwent transsphenoidal adenomectomy. Fibrous consistency was observed in 10% of patients and was associated with a Ki-67 greater than 3% (χ 2  = 8.154, p = 0.04), greater risk of developing postoperative hormone deficiencies (χ 2  = 4.485, p = 0.05, OR = 8.571; 95% CI: 0.876-83.908), and lower resection rates (χ2 = 8.148, p = 0.004; OR 1.385, 95% CI; 1.040-1.844). Similarly, worse resection rates were observed in tumors with suprasellar extension (χ2 = 5.048, p = 0.02; OR = 6.000, 95% CI; 1.129-31.880) and CSI (χ2 = 4.000, p = 0.04; OR = 3.857, 95% CI; 0.997-14.916)., Conclusions: Tumor consistency might provide useful information about postoperative pituitary function, likely due to its impact on surgical procedures. Further prospective studies with larger cohorts are needed to confirm our preliminary findings., (© 2023. The Author(s).)

Neuromyelitis Optica spectrum disorder is an inflammatory demyelinating disease affecting the central nervous system (CNS), characterized by triad optic neuritis, transverse myelitis, and area postrema syndrome. Antibodies directed against aquaporin-4 (AQP-4), a water channel expressed on the astrocytic membrane, are supposed to play a pathogenic role and are detected in ~80% of cases. Clinical signs of Neuromyelitis Optica spectrum disorder (NMOSD) in elderly patients should arouse the suspicion of paraneoplastic etiology. In this article, we discussed a case of a 76-year-old woman with a 2-month history of confusion, dysarthria, and progressive bilateral leg weakness. A whole-body CT scan showed a neoformation of 5 cm in diameter in the median lobe infiltrating the mediastinal pleura. The tumor had already spread to both the upper and lower right lobes, parietal pleura, and multiple lymph nodes. Pleural cytology revealed adenocarcinoma cells. The brain MRI documented hyperintense alteration in fluid-attenuated inversion recovery (FLAIR) images, involving the anterior portion of the corpus callosum and the periependymal white matter surrounding the lateral ventricles, with mild contrast enhancement on the same areas and meningeal tissue. T2-weighted spinal cord MRI sequences showed extended signal hyperintensity from bulbo-cervical junction to D7 metamer, mainly interesting the central component and the gray matter. Cerebrospinal fluid analysis revealed no neoplastic cells. Serum AQP-4 immunoglobulin (IgG) antibodies were found. Meanwhile, the patient rapidly developed progressive paraparesis and decreased level of consciousness. High-dose intravenous methylprednisolone therapy was started but her conditions rapidly deteriorated. No other treatment was possible., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The handling editor declared a shared affiliation with the authors at the time of the review., (Copyright © 2022 Maiorca, Moret, Martines, Tramontano, Papassifachis, Bini, Caramazza, Fontana, Lucia and Inghilleri.)

Introduction and Importance: Spinal epidural cavernous hemangiomas are a rare occurrence. This particular case is made even more distinctive by the fact that the lesion mimicked a dumbbell-shaped neuroma. Moreover, it had a very unique localization (wholly epidural, at cervical-thoracic -C7-D1- level). The importance of this case is linked not only to its remarkable rarity, but also to the diagnostic avenues explored. The surgery was carried out by Prof. Riccardo Caruso, Head of the Neurosurgical Department of the Military Hospital of Rome and Professor of Neurosurgery of Sapienza University of Rome, assisted by Dr. Luigi Marrocco, Senior Neurosurgeon of the Military Hospital of Rome. Postsurgical recovery was managed by Dr. Venceslao Wierzbicki, Senior Neurosurgeon of the Military Hospital of Rome., Case Presentation: In 2020, a 71 year-old man, suffering from intense pain in the left scapular region and in the ulnar area of the left forearm, underwent surgery for the removal of a spinal epidural cavernous hemangioma involving the left C7-D1 foramen. Prior to surgery, the lesion had been misdiagnosed as a neuroma by a radiologist., Clinical Discussion: In the Literature there are other, rare cases of hemangiomas partly located in the spinal canal, and partly located intra and extra foramen. In the case here presented, differential diagnosis as well as a potential Schwannoma, suggested by the dumbbell shape of the lesion, should have considered also the possibility of a meningioma. Two teams of radiologists examined the images, the radiologists of our team, Dr. Valentina Martines and Dr. Emanuele Piccione, thanks to a close inspection of the features of the lesion, postulated the extra-dural position. Other aspects of the scans were then analyzed to help guide future diagnosis of similar lesions., Conclusion: With a spinal tumor affecting the foramen, a close examination of the images allows for accurate presurgical differential diagnosis, differentiating between the more frequent neuroma and other rarer tumors, such as a hemangioma., (Copyright © 2021. Published by Elsevier Ltd.)

Background: The degenerative lumbar spinal stenosis is one of the most commonly treated spinal disorders in older adults; despite its increasing frequency, it is not yet clear what the most effective therapy might be. The aim of this study is to investigate the very long term results of a homogenized cohort of patients suffering from lumbar spinal stenosis: the first subset of patients operated on with laminectomy and the second subset of patients was also advised to undergo laminectomy but never operated on., Methods: Patients from both subgroups were advised to undergo surgery, according to the same criteria, in the period between 2000 and 2010 and were re-evaluated in the period between January and December 2016., Results: Comparing the two subsets of patients, both suffering from clinically relevant LSS, the first subset returns a statistically significant clinical improvement at follow-up. The rate of excellent results decreases over years. Iatrogenic spinal instability incidence was found to be 3.8% in the present cohort., Conclusions: Although the improvement of the first postoperative years decreases over time and despite the lack of general consensus, the lack of established shared guidelines and the limitations of this research, the results support the utilisation of surgery for the management of this condition., Level of Evidence: 3.

The patient is a 79-year-old male, suffering from advanced metastatic prostate cancer, who developed a progressively worsening ideomotor slowing and was therefore referred to the emergency department of our institution. A plain axial computed tomography (CT) scan revealed a vast hemispheric subdural fluid collection, apparently a subdural hematoma. On closer inspection, and most of all, in hindsight, a tenuously isohyperdense signal irregularity at the frontal aspect of the fluid collection appears. Because of the declined general medical conditions and the paucity of the neurologic impairment, a high-dose, corticosteroid-based conservative strategy was performed. The total body CT scan for the routine oncologic follow-up of the prostate cancer scan fell at 20 days from the first CT of the emergency department. A second contrast-enhanced axial CT scan demonstrated the presence of 2 subdural metastases, presumably the initial pathogenesis of the subdural fluid collection., (Copyright © 2017 Elsevier Inc. All rights reserved.)

There is no universally approved method in the scientific literature to identify subjects exposed to asbestos and divide them in classes according to intensity of exposure. The aim of our work is to study and develope an algorithm based on the findings of occupational anamnestical information provided by a large group of workers. The algorithm allows to discriminate, in a probabilistic way, the risk of exposure by the attribution of a code for each worker (ELSA Code--work estimated exposure to asbestos). The ELSA code has been obtained through a synthesis of information that the international scientific literature identifies as the most predictive for the onset of asbestos-related abnormalities. Four dimensions are analyzed and described: 1) present and/or past occupation; 2) type of materials and equipment used in performing working activity; 3) environment where these activities are carried out; 4) period of time when activities are performed. Although it is possible to have informations in a subjective manner, the decisional procedure is objective and is based on the systematic evaluation of asbestos exposure. From the combination of the four identified dimensions it is possible to have 108 ELSA codes divided in three typological profiles of estimated risk of exposure. The application of the algorithm offers some advantages compared to other methods used for identifying individuals exposed to asbestos: 1) it can be computed both in case of present and past exposure to asbestos; 2) the classification of workers exposed to asbestos using ELSA code is more detailed than the one we have obtained with Job Exposure Matrix (JEM) because the ELSA Code takes in account other indicators of risk besides those considered in the JEM. This algorithm was developed for a project sponsored by the Italian Armed Forces and is also adaptable to other work conditions for in which it could be necessary to assess risk for asbestos exposure.

A 75-year-old women was admitted to our hospital due to anal bleeding from 5 days. At clinical examination abdomen was soft but tenderness in the lower quadrants, where a soft, mobile, round mass measuring 10 cm in diameter was palpable. CT scan demonstrated the presence of sigmoido-rectal intussusception. The patient underwent emergency anterior resection of rectum with stapled termino-terminal colo-rectal anastomosis. Postoperative course was uneventful and the patient was discharged 7 days after the operation. Histopathological examination demonstrated a tubular adenoma with low grade dysplasia, 1,2 cm in diameter, located in the distal sigmoid colon. Intussusception is a rather common pediatric condition that rarely presents in adults. Adults intussusception represents 5% of all cases of intussusception. In children it is usually primary and benign, and pneumatic or hydrostatic reduction of the intussusception is sufficient to treat the condition in 80% of patients. In contrast a demonstrable etiology is found in 70% to 90% of cases in adults, and approximately 40%-50% of them are caused by malignant neoplasms. Surgical intervention is necessary in all cases of intussusception in adults. Due to the low incidence and the rare consideration given to this condition among adults the preoperative diagnosis can be difficult, especially in emergency cases. Abdominal CT provides the most accurate diagnostic rate for intestinal intussusception.

The monitoring of health conditions in workers exposed to asbestos for prolonged periods is a problematic issue. The Occupational Health physician being required to carry out his activity of prevention of the medical consequences and protection of the workers can use various instruments among which there is the evaluation of lung function. We have performed a meta-analysis on the scientific evidence on this matter in order to identify significant alterations of the lung function parameters in subjects professionally exposed to asbestos compared with controls. By the means of a bibliographic search and the application of selected inclusion and exclusion criteria, we identified 21 articles presenting data from controlled studies. Our results show that the number of controlled trials is very small compared to the totality of studies performed on this matter (1 to 70 ratio) and that the number of the subjects included in the majority of the analyzed studies is oddly divided in the experimental and control group. For this and other reasons the analyzed studies are very heterogeneous. Despite these difficulties, the meta-analysis evidences that some parameters of respiratory functioning are more likely to be influenced by asbestos exposure taking into account the smoking habit and that other parameters are sinergically influenced by both asbestos exposure and smoking. Our meta-analysis points out the necessity to define a common methodology about the technical and operatives procedures in the evaluation of the effects on lung function measures determined by an occupational exposure to asbestos and a thorough examination of the intensity of abnormality levels that could allow using the values obtained from the above mentioned measures in a discriminating diagnostic way.

Gastric cancer is currently an important clinical and social problem. TRIMprob is a portable system for the non-invasive diagnosis of gastric cancer, designed to differentiate between normal and pathological tissues on the basis of their electromagnetic characteristics. The aim of our study was to evaluate the accuracy and feasibility of use of the TRIMprob system in diagnosing gastric neoplasms. From January to September 2006 we screened 28 symptomatic patients with TRIMprob; afterwards they underwent an endoscopic and bioptic examination. On the basis of the histological diagnosis these patients were divided into 2 groups: group A (patients with a diagnosis of gastric malignancies) and group B (patients with inflammatory disease). There also was a group C, which was a control group of 15 asymptomatic volunteers. The TRIMprob system located all cases of gastric cancer (group A) with 100% sensitivity, specificity and accuracy. The TRIMprob examination seems to be extremely accurate in diagnosing gastric malignancies. If these results are confirmed, TRIMprob could be used for the early diagnosis of gastric cancer and for selecting symptomatic subjects for gastroscopy.

Objects: The authors report their experience of gamma knife radiosurgery (GKR) in a large series of pediatric cerebral arteriovenous malformations (cAVMs). The advantages, risks and failures of this approach are presented and discussed., Methods: Gamma knife radiosurgery was performed on 63 children aged < or =16 years. Haemorrhage was the clinical onset in 50 out of 63 cases. The mean pre-GK cAVM volume was 3.8 cm(3). Fifty-eight out of 63 cAVMs were Spetzler-Martin grades I-III. Most lesions (47 out of 63) were in eloquent or deep-seated brain regions., Conclusion: Gamma knife radiosurgery-related complications occurred in 2 out of 47 cases with an available follow-up (1 had transient and 1 permanent morbidity). No bleeding occurred during the latency period. In 39 children with >36-month follow-up, complete cAVM occlusion was angiographically documented in 31, with a 3- and 4-year actuarial obliteration rate of 72 and 77% respectively. High rates of complete obliteration and very low frequency of permanent morbidity with no bleeding during the latency period encourage widespread application of GKR in the treatment of pediatric cAVMs.

Purpose: To evaluate the sensitivity of selective sampling from the inferior petrosal sinuses in the differential diagnosis of ACTH-dependent hypercortisolism with non-diagnostic pituitary imaging., Materials and Methods: Between 1987 and 2001, 17 patients (14 women and 3 men, aged 18-63 years) with ACTH-dependent hypercortisolism and negative X-ray of the sellar region, underwent simultaneous bilateral sampling from the inferior petrosal sinuses with ACTH measurement, at baseline and after stimulation with CRH (100 micro i.v.). Baseline samplings were also carried out at the level of the infrarenal and suprarenal inferior vena cava, of the adrenal and suprahepatic veins, of the superior vena cava, of the jugular veins, and of a peripheral vein. A central/peripheral gradient >2 at baseline and/or one >3 after stimulation with CRH was considered indicative of the pituitary origin of ACTH. Bilateral femoral venous catheterization was performed in an angiographic room using 5-French introducers after local anaesthesia. Selective catheterization of the inferior petrosal sinuses was achieved with 100 cm-long, steam-bent (45 degrees) 5-French catheters, without lateral holes., Results: Twelve patients exhibited ACTH central/ peripheral gradients indicating the pituitary origin of the hormonal hyperincretion; this was confirmed by surgical exploration of the hypophysis in 10 patients, whereas 2 refused surgery and were therefore "lost". Of the five patients without ACTH central/peripheral gradients, one had an adrenal metastasis from ACTH-secreting lung neoplasia (with ACTH gradient in the blood flowing back from the adrenal gland), one had a hepatic CRHoma (with high levels of CRH in the suprahepatic veins), whereas the origin of the hyperincretion remained indeterminate in three., Conclusions: Bilateral simultaneous selective sampling from the inferior petrosal sinuses for ACTH measurements proved to be highly sensitive and free of complications in the differential diagnosis of ACTH-dependent forms of hypercortisolism.

Reduced thermic response after a glucose load has been reported in liver cirrhosis. To determine the mechanism and the site of this phenomenon, the effects of glucose and fructose on energy expenditure (EE) were measured in seven well-nourished cirrhotic patients and in six healthy control subjects. EE and fuel utilization were measured via indirect calorimetry for 3 h after oral glucose or fructose administration (1 g/kg body wt). After a glucose load, plasma glucose and insulin concentrations were higher in cirrhotic patients than in control subjects (p < 0.05). During the glucose trial, the cumulative incremental changes in EE over the 3-h measurement period were lower (p < 0.01) in patients than in the control subjects (0.98 +/- 0.13 vs. 1.70 +/- 0.23 kJ.kg-1.3 h-1). After fructose ingestion, the cumulative changes in the EE of control subjects (1.76 +/- 0.24 kJ.kg-1.3 h-1) and cirrhotic patients (1.59 +/- 0.15 kJ.kg-1.3 h-1) were similar. In cirrhotic patients, the EE increase after fructose was higher than after glucose (p < 0.05). After glucose and fructose ingestion, no difference was observed between the carbohydrate oxidation in cirrhotic patients and that in control subjects, and lipid oxidation was suppressed to the same extent in both groups. We conclude that glucose-induced thermogenesis is impaired in liver cirrhosis, whereas fructose can normalize the thermic response. Because fructose is chiefly metabolized in the liver, these findings suggest that extrahepatic tissues are the site of defective thermogenesis in liver cirrhosis.