The accuracy of pre-operative (P)-POSSUM scoring and cardiopulmonary exercise testing in predicting morbidity and mortality after pancreatic and liver surgery: A systematic review.

BACKGROUND: Cardiopulmonary exercise-testing (CPET) and the (Portsmouth) Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity ((P)-POSSUM) are used as pre-operative risk stratification and audit tools in general surgery, however, both have been demonstrated to have limitations in major hepatopancreatobiliary (HPB) surgery. MATERIALS AND METHODS: The aim of this review is to determine if CPET and (P)-POSSUM scoring systems accurately predict morbidity and mortality. Eligible articles were identified with an electronic database search. Analysis according to surgery type and tool used was performed. RESULTS: Twenty-five studies were included in the final review. POSSUM predicted morbidity demonstrated weighted O/E ratios of 0.75(95%CI0.57-0.97) in hepatic surgery and 0.85(95%CI0.8-0.9) in pancreatic surgery. P-POSSUM predicted mortality in pancreatic surgery demonstrated an O/E ratio of 0.75(95%CI0.27-2.13) and 0.94(95%CI0.57-1.55) in hepatic surgery. In both pancreatic and hepatic surgery an anaerobic threshold(AT) of between 9 0.5-11.5 ml/kg/min was predictive of post-operative complications, and in pancreatic surgery ventilatory equivalence of carbon dioxide(˙VE/˙VCO2) was predictive of 30-day mortality. CONCLUSION: POSSUM demonstrates an overall lack of predictive fit for morbidity, whilst CPET variables provide some predictive power for post-operative outcomes. Development of a new HPB specific risk prediction tool would be beneficial; the combination of parameters from POSSUM and CPET, alongside HPB specific markers could overcome current limitations.

Impact of portal vein infiltration and type of venous reconstruction in surgery for borderline resectable pancreatic cancer.

BACKGROUND: The International Study Group of Pancreatic Surgery (ISGPS) recommends operative exploration and resection of pancreatic cancers in the presence of reconstructable mesentericoportal axis involvement. However, there is no consensus on the ideal method of vascular reconstruction. The effect of depth of tumour invasion of the vessel wall on outcome is also unknown. METHODS: This was a retrospective cohort study of pancreaticoduodenectomy with vein resection for T3 adenocarcinoma of the head of the pancreas across nine centres. Outcome measures were overall survival based on the impact of the depth of tumour infiltration of the vessel wall, and morbidity, in-hospital mortality and overall survival between types of venous reconstruction: primary closure, end-to-end anastomosis and interposition graft. RESULTS: A total of 229 patients underwent portal vein resection; 129 (56·3 per cent) underwent primary closure, 64 (27·9 per cent) had an end-to-end anastomosis and 36 (15·7 per cent) an interposition graft. There was no difference in overall morbidity (26 (20·2 per cent), 14 (22 per cent) and 9 (25 per cent) respectively; P = 0·817) or in-hospital mortality (6 (4·7 per cent), 2 (3 per cent) and 2 (6 per cent); P = 0·826) between the three groups. One hundred and six patients (47·5 per cent) had histological evidence of vein involvement; 59 (26·5 per cent) had superficial invasion (tunica adventitia) and 47 (21·1 per cent) had deep invasion (tunica media or intima). Median survival was 18·8 months for patients who had primary closure, 27·6 months for those with an end-to-end anastomosis and 13·0 months among patients with an interposition graft. There was no significant difference in median survival between patients with superficial, deep or no histological vein involvement (20·8, 21·3 and 13·3 months respectively; P = 0·111). Venous tumour infiltration was not associated with decreased overall survival on multivariable analysis. CONCLUSION: In this study, there was no difference in morbidity between the three modes of venous reconstruction, and overall survival was similar regardless of tumour infiltration of the vein.

Complications of biliary-enteric anastomoses.

INTRODUCTION Biliary-enteric anastomoses are performed for a range of indications and may result in early and late complications. The aim of this study was to assess the risk factors and management of anastomotic leak and stricture following biliary-enteric anastomosis. METHODS A retrospective analysis of the medical records of patients who underwent biliary-enteric anastomoses in a tertiary referral centre between 2000 and 2010 was performed. RESULTS Four hundred and sixty-two biliary-enteric anastomoses were performed. Of these, 347 (75%) were performed for malignant disease. Roux-en-Y hepaticojejunostomy or choledocho-jejunostomy were performed in 440 (95%) patients. Perioperative 30-day mortality was 6.5% (n=30). Seventeen patients had early bile leaks (3.7%) and 17 had late strictures (3.7%) at a median of 12 months. On univariable logistic regression analysis, younger age was a significant risk factor for biliary anastomotic leak. However, on multivariable analysis only biliary reconstruction following biliary injury (odds ratio [OR]=6.84; p=0.002) and anastomosis above the biliary confluence (OR=4.62; p=0.03) were significant. Younger age and biliary reconstruction following injury appeared to be significant risk factors for biliary strictures but multivariable analysis showed that only younger age was significant. CONCLUSIONS Biliary-enteric anastomoses have a low incidence of early and late complications. Biliary reconstruction following injury and a high anastomosis (above the confluence) are significant risk factors for anastomotic leak. Younger patients are significantly more likely to develop an anastomotic stricture over the longer term.

Outcome after pancreaticoduodenectomy for T3 adenocarcinoma: A multivariable analysis from the UK Vascular Resection for Pancreatic Cancer Study Group.

BACKGROUND: Most resectable pancreatic cancers are classified as T3, including those involving the porto-mesenteric vein. Survival and perioperative morbidity for venous resection have been found to be comparable to standard resection. We investigate factors associated with short and long term outcomes in pancreaticoduodenectomy with (PDVR) and without (PD) venous resection exclusively for T3 adenocarcinoma of the head of the pancreas. METHODS: This is a UK multicenter retrospective cohort study assessing outcomes in patients undergoing PD and PDVR. All consecutive patients with T3 only adenocarcinoma of the head of the pancreas undergoing surgery between December 1998 and June 2011 were included. Multivariable logistic and proportional hazards regression analyses were performed to determine the association between the surgical groups and in-hospital mortality (IHM) and overall survival (OS). RESULTS: 1070 patients were included of whom 840 (78.5%) had PD and 230 (21.5%) had PDVR. Factors independently associated with IHM were a high creatinine (aHR 1.14, p = 0.02), post-operative bleeding (aHR 2.86, p = 0.04) and a re-laparotomy (aHR 8.42, p = 0.0001). For OS, multivariable analyses identified R1 resection margin status (aHR 1.22, p = 0.01), N1 nodal status (aHR 1.92, p = 0.0001), perineural invasion (aHR 1.37, p = 0.002), tumour size >20mm (aHR 0.63, p = 0.0001) and a relaparotomy (aHR 1.84, p = 0.0001) to be independently associated with overall mortality. CONCLUSION: This study on T3 adenocarcinoma of the head of the pancreas suggests that IHM is strongly associated with perioperative complications whilst OS is affected by histological parameters. Detailed pre-operative disease evaluation and advances in oncological treatment have the potential to improve OS.

Vaginal microbiota of spayed dogs with or without recurrent urinary tract infections.

BACKGROUND: Limited information is available regarding the vaginal microbiota of normal spayed dogs and spayed dogs with recurrent UTIs. Vaginal lactic acid-producing bacteria (LAB) have been associated with decreased frequency of recurrent urinary tract infection in women and may have a protective role within the urinary tract of female dogs. HYPOTHESIS/OBJECTIVES: Spayed dogs with historical recurrent UTI will have decreased prevalence of LAB and increased prevalence of uropathogenic bacterial populations in the vaginal microbiota when compared with the vaginal microbiota of healthy, spayed dogs. ANIMALS: Twenty-one client-owned adult spayed female dogs with historical recurrent UTI and 23 healthy, spayed female dogs without a history of recurrent UTI. METHODS: Dogs were placed into a recurrent UTI group or control group in this prospective study. Bacterial populations were isolated and characterized from vaginal swabs obtained from each dog. RESULTS: The most common bacterial isolates obtained from the vaginal tract of all dogs were Escherichia coli (11/44) and S. pseudintermedius (13/44). E. coli was isolated from the vaginal tract of 8 of 21 (38%) dogs in the rUTI group and 3 of 23 (13%) dogs in the control group (P = .08). LAB were isolated from 7 of the 44 dogs. Two of these 7 dogs were in the rUTI group and 5 of the 7 dogs were in the control group. CONCLUSIONS AND CLINICAL IMPORTANCE: The vaginal microbiota of spayed female dogs with recurrent UTI was similar to the control population of normal, spayed female dogs.

The effect of an oral probiotic containing lactobacillus, bifidobacterium, and bacillus species on the vaginal microbiota of spayed female dogs.

BACKGROUND: Recurrent urinary tract infections (UTIs) are often difficult to treat. Vaginal colonization with lactic acid-producing bacteria (LAB) is associated with reduced frequency of recurrent UTIs in women. Oral probiotics might help increase the prevalence of vaginal LAB and decrease the frequency of recurrent UTIs in dogs. HYPOTHESIS: Administration of an oral probiotic supplement containing Lactobacillus, Bifidobacterium, and Bacillus species will increase the prevalence of LAB in the vagina of dogs. ANIMALS: Thirty-five healthy, spayed female dogs without history of recurrent UTIs. METHODS: Prospective, controlled study. Enrolled dogs received an oral probiotic supplement for 14 or 28 days. A vaginal tract culture was obtained from each dog before and after oral probiotic administration. Twenty-three dogs received the oral probiotic supplement daily for a period of 14 days and 12 dogs received the oral probiotic supplement daily for a period of 28 days. RESULTS: Lactic acid-producing bacteria were isolated from 7 of 35 dogs prior to probiotic administration. After the treatment course, 6 of 35 dogs had LAB isolated. Only one of these dogs had LAB (Enterococcus canintestini) isolated for the first time. Enterococcus canintestini was the most common LAB isolated from all dogs in this study, although it was not included in the probiotic supplement. CONCLUSIONS AND CLINICAL IMPORTANCE: Lactic acid-producing bacteria are not a common isolate from the vaginal vault of dogs. Administration of this oral probiotic supplement for a 2- or 4-week period did not increase the prevalence of vaginal LAB in dogs.

Methodology for the MASCC/ISOO Mucositis Clinical Practice Guidelines Update.

Members of the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) recently completed the process of updating the MASCC/ISOO Clinical Practice Guidelines for the prevention and treatment of mucositis. These guidelines, originally published in 2004, and last updated in 2007, provide clinicians with objective, evidence-based recommendations for the management of mucositis secondary to cancer therapy. This brief paper describes the methodology used to conduct the most recent systematic review in 2011, and develop new guidelines, providing the basis for the update. The overriding aims of the process were to assess evidence of effectiveness of interventions for the prevention and treatment of mucositis and to produce clinical practice guidelines for the management of mucositis using best available evidence.

Retinal tears after posterior vitreous detachment and vitreous hemorrhage in patients on systemic anticoagulants.

UNLABELLED: AIMS OR PURPOSE: To determine the rate of retinal tears (RTs) after posterior vitreous detachment (PVD) and vitreous hemorrhage (VH) in patients on systemic anticoagulants. METHODS: In all, 260 eyes of 260 patients with an acute PVD and VH were followed for evidence of an RT or detachment. Patients were divided into those taking systemic anticoagulants and those not taking anticoagulants. RESULTS: A total of 137 patients (53%) were taking anticoagulants, 123 (47%) were not. Overall, 72% of patients not taking any anticoagulant had evidence of an RT, whereas 46% of patients taking an anticoagulant had an RT (P-value 0.0002). Also, 37% of patients not taking an anticoagulant had a retinal detachment (RD), whereas 23% of patients taking any anticoagulant had an RD (P-value 0.01). CONCLUSIONS: In patients with an acute PVD and VH using anticoagulants, RTs and RDs were common. Anticoagulation status may be an important contributing factor in predicting the incidence of an RT or detachment.

Larger hepatic metastases are more frequent with N0 colorectal tumours and are associated with poor prognosis: implications for surveillance.

BACKGROUND: Surgery is the treatment of choice for colorectal cancer liver metastases (CLM). The aim of our study was to analyze which clinical and pathological risk factors can predict recurrence after liver resection. METHODS: Consecutive patients who underwent hepatic resection for CLM were studied retrospectively to identify risk factors influencing cancer recurrence, by univariate and multivariable analyses. RESULTS: 97 patients (2004-2008) with a median age of 64.6 years (inter-quartile range 57.6-72.6) had a median disease free survival of 16.4 months. On univariate analysis the largest metastasis >5 cm (hazard ratio, HR 2.04, 95% CI 1.10-3.80, p = 0.03), presence of extra-hepatic disease (HR 2.39, 95% CI 1.14-5.02, p = 0.02) and a resection margin ≤5 mm (HR 1.91, 95% CI 1.06-3.47, p = 0.03) were significantly associated with a higher risk of recurrence after curative resection for CLM. These were confirmed as independent predictors for recurrence on multivariable analysis. There were significantly more patients with lymph node negative (N0) primary in the group with liver secondary > 5 cm (n = 18, 39%), than in the group with liver secondary £5 cm (n = 7, 14.6%) (p = 0.01). CONCLUSION: We demonstrated a positive correlation between N0 primary tumour and large liver metastases, which have a higher risk of disease recurrence. If validated in larger, independent studies, this study would suggest routine imaging surveillance follow up of even N0 colorectal tumours, until the biology of these tumours is fully understood.

Impact of hospital volume on outcomes for pancreaticoduodenectomy: a single UK HPB centre experience.

BACKGROUND: High hospital volume has a favorable impact on outcomes for complex procedures including pancreaticoduodenectomy (PD); however, the temporal relationship has not been evaluated in a single centre. AIM: To evaluate the impact of UK cancer outcome guidelines (COG) on outcomes for PD in a single UK HPB specialist centre. PATIENTS AND METHODS: All patients with pancreatic pathologies undergoing surgery at our institution from 1999 to 2006 were identified, of which 140 underwent PD. The annual caseload for PD and corresponding outcomes for length of hospital stay, morbidity, mortality and survival were analysed during the period around the implementation of UK COG with an increase in the surgical workload correlating with catchment's population increase from 1.6 to 3.1 million. RESULTS: Between January 1999 and December 2006, 140 patients underwent a PD (M:F 1.06:1; median age 64 (range 34-84) years). Median hospital stay was 16 days (range 7-318). The 30-day mortality was 2.8%, in-hospital mortality was 6.4% and morbidity was 37.1%. Pancreatic leak/fistula rate was 8.6%. Over the 7-year period, PDs per year increased 5.3 fold from 6 procedures in 1999 to 32 in 2006. Analysis of the data for 1999-2002-(pre-COG) and 2003-2006-(post-COG) showed a trend towards decrease in mortality (from 9.7% to 5.0%, p = 0.448: OR = 2.74 (95% CI, 0.58-12.88); Fisher's exact test) and morbidity (from 41.6% to 35.3%; OR = 1.29 (95% CI, 0.74-3.56); p = 0.565). CONCLUSION: With COG implementation within a single UK pancreatic unit, the PD volume and staffing levels increased with a trend towards decreased morbidity and mortality.

Preoperative chemotherapy and the outcome of liver resection for colorectal metastases.

BACKGROUND: Neoadjuvant systemic chemotherapy is being increasingly used prior to liver resection for colorectal metastases. Oxaliplatin has been implicated in causing structural changes to the liver parenchyma, and such changes may increase the morbidity and mortality of surgery. PATIENTS AND METHODS: A retrospective study was undertaken of 101 consecutive patients who had undergone liver resection for colorectal metastases in two HPB centers. Preoperative demographic and premorbid data were gathered along with liver function tests and tumor markers. A subjective assessment of the surgical procedure was noted, and in-hospital morbidity and mortality were calculated. The effect of preoperative chemotherapy on short-term and long-term outcome was analyzed, and actuarial 1 and 3 year survival was determined. RESULTS: Patients who received neoadjuvant chemotherapy had a higher number of metastases (median 2, range 1-8 versus median 1, range 1-5; P = 0.019) and more had synchronous tumors (24 patients versus 8; P < 0.001). Overall morbidity was 37% and hospital mortality was 3.9%. Operative and in-hospital outcome was not influenced by chemotherapy. Long-term survival was worse in patients who had received preoperative chemotherapy (actuarial 3-year survival 62% versus 80%; P = 0.04). CONCLUSIONS: This study shows no evidence that neoadjuvant chemotherapy, and in particular oxaliplatin, increases the risk associated with liver resection for colorectal metastases. Long-term outcome is reduced in patients receiving preoperative chemotherapy, although they have more advanced disease.

Portal vein embolisation prior to hepatic resection for colorectal liver metastases and the effects of periprocedure chemotherapy.

Portal vein embolisation (PVE) is an effective method of increasing future liver remnant (FLR) but may stimulate tumour growth. The effect of periprocedure chemotherapy has not been established. 15 consecutive patients underwent PVE prior to hepatic resection for colorectal liver metastases with a FLR <30% of tumour-free liver (TFL). Liver and tumour volumes pre-PVE and 6 weeks post-PVE were calculated by CT or MRI volumetry and correlated with the periprocedure chemotherapy regimen. PVE increased the FLR from 18+/-5% of TFL to 27+/-8% post-PVE (p<0.01). Post-PVE chemotherapy did not prevent hypertrophy of the FLR but the volume increase with chemotherapy (median 89 ml, range 7-149 ml) was significantly reduced (median 135 ml, range 110-254 ml without chemotherapy) (p = 0.016). Tumour volume (TV) decreased in those receiving post-PVE chemotherapy (median TV decrease 8 ml, range -77 ml to +450 ml) and increased without chemotherapy (median TV increase 39 ml, range -58 ml to +239 ml). Of the 15 patients, eight underwent resection; four were not resected due to disease progression and three due to insufficient hypertrophy of the FLR. PVE increased the FLR by an average of 9% allowing resection in 50% of patients. Periprocedure chemotherapy did not prevent but did reduce hypertrophy. A trend towards tumour regression was observed.

Prognostic significance of intratumoural microvessel density (IMD) in resected pancreatic and ampullary cancers to standard histopathological variables and survival.

AIM: Angiogenesis is required for tumour growth. Its evaluation, by intratumoural microvessel density (IMD), has prognostic significance in many solid tumours. There is controversy regarding its use in pancreatic cancer and little is known about its role in ampullary tumours. The aim is to study IMD as a prognostic marker in resected ductal adenocarcinomas of head of pancreas and cancers of the ampullary region. METHODS: Forty-seven patients (23 pancreatic and 24 ampullary, mean age 62.0 years) surviving a potentially curative (R0/R1) resection were analysed. Paraffin-embedded sections of these tumours were immunohistochemically stained for CD-34 and IMD was determined (magnification x200). This was correlated with histopathological data and survival using Cox's multivariate analysis. RESULTS: Mean survival for the pancreatic cancer group was 18.4 months (SE=2.7) and 81.2 months (SE=9.9) for the ampullary cancer group. In the pancreatic cancer group, IMD was found to have independent prognostic significance to survival on multivariate analysis (P=0.002, Hazard Ratio (HR) 13.60) along with microscopic resection margin involvement (P=0.003, HR 15.18). For ampullary cancers, IMD was higher in those with lymph node metastasis (P=0.02, Mann-Whitney U -test). CONCLUSION: IMD in resected pancreatic cancers correlates with survival.

Short and long-term outcome of pancreatic surgery in a district general hospital.

Pancreatic surgery is a formidable undertaking with historically high mortality and poor prognosis for periampullary lesions. This has led to recommendations that all pancreatic surgery should be performed in specialist centres. There is no doubt from large series that a low mortality can be achieved in these centres, but there has been no direct comparison between results from these specialist centres and district general hospitals with an interest in pancreatic disease. We present a retrospective, seven-year experience with a 3% 30 day mortality, 39% morbidity and 14 month median survival for malignant disease. Comparison with the UK survey of specialist pancreatic units shows that pancreatic surgery can be safely performed in the setting of a district general hospital with low morbidity and mortality, and good long-term outcome.

The expression of antiapoptotic proteins Bcl-2, Bcl-X(L), and Mcl-1 in benign, dysplastic, and malignant biliary epithelium.

AIM: Cholangiocarcinoma can be cured by surgery, but only in a minority of cases. The activation of apoptosis is a major mode of action of chemotherapy and radiotherapy, which have limited benefit in the treatment of cholangiocarcinoma. The antiapoptotic members of the Bcl-2 protein family (Bcl-2, Bcl-X(L), and Mcl-1) are important inhibitors of apoptosis, but have not been investigated extensively in cholangiocarcinoma. METHODS: The expression of Bcl-2, Bcl-X(L), and Mcl-1 was investigated in normal biliary epithelium (17), biliary dysplasia (three), and invasive cholangiocarcinoma (51), in addition to three human cholangiocarcinoma cell lines, by immunohistochemistry and immunofluorescence. RESULTS: The expression of Bcl-2 was not detected in normal or malignant biliary tissue. In contrast, granular cytoplasmic Bcl-X(L) and Mcl-1 staining was found in 60-100% of cells in all normal, dysplastic, and malignant specimens, including the human cell lines examined in this study. CONCLUSION: These findings indicate that Mcl-1 and Bcl-X(L), but not Bcl-2, are involved in the survival of normal and neoplastic cells in the biliary tree. By prolonging survival through blocking apoptosis, these proteins might be reducing the efficacy of cytotoxic anticancer treatments in cholangiocarcinoma.

Adenocarcinoma of the small bowel.

Cancer of the small bowel is a rare entity but its incidence is rising. Historically, outcome is poor despite apparent curative resection. At present surgery remains the only treatment modality of proven benefit in the management of this disease. Recent data would suggest 5-year survival rates in the order of 40-50% at all sites of small bowel cancer. To improve upon this, earlier diagnosis with a high index of suspicion and multicentre adjuvant therapy trials are required.

Loss of cytomegalovirus-specific CD4+ T cell responses in human immunodeficiency virus type 1-infected patients with high CD4+ T cell counts and recurrent retinitis.

Clinical histories are reported for 2 patients treated with highly active antiretroviral therapy (HAART) who experienced multiple relapses of cytomegalovirus (CMV) retinitis, despite suppression of human immunodeficiency virus type 1 (HIV-1) viremia and improvement in CD4+ T cell counts (to >400 cells/microL). CMV-specific CD4+ T cell immune reconstitution was measured directly, using cytokine flow cytometry, which revealed persistent deficits in CMV-specific CD4+ T cell responses in both patients. CMV-specific T cells constituted 0.14% and 0.05% of the total CD4+ T cell count in these patients, which is significantly lower than the percentages for 34 control subjects (0.6%-46%; CD4+ T cell count range, 7-1039 cells/microL; P=.019). Deficits in pathogen-specific immune responses may persist in some individuals, despite suppression of HIV-1 replication and substantial increases in circulating CD4+ T cells after HAART, and such deficits may be associated with significant morbidity from opportunistic infections.

Spontaneous perforation of the bile duct.

BACKGROUND: Spontaneous perforation of the bile ducts is a rare condition in adults. It is commonly secondary to gallstones, and the site of the perforation is nearly always extrahepatic. Intrahepatic perforation has only once been described in the literature to date. CASE OUTLINE: We report an unusual presentation of this condition with perforation occurring at an intrahepatic site. The management of perforation and the possible predisposing factors are described. DISCUSSION: Adequate management of this problem requires an awareness of its existence and prompt, appropriate investigation to discover the cause and site of perforation.

Reciprocal coactivation patterns of the medial and lateral quadriceps and hamstrings during slow, medium and high speed isokinetic movements.

The effect of movement velocity and fatigue on the reciprocal coactivation of the quadriceps and hamstrings was investigated through analysis of the root mean square (RMS) and the median frequency (MDF) of surface electromyography for the vastus medialis (VM), vastus lateralis (VL), medial hamstrings (MH) and biceps femoris (BF). Fourteen subjects performed six continuous isokinetic knee extension and flexion movements at 60 degrees, 180 degrees and 300 degrees s(-1), and 30 continuous movements at 300 degrees s(-1) to examine muscular fatigue patterns. Statistical analyses revealed that the RMS activity of the VM displayed greater coactivation than the VL (P<0.01) and the BF displayed greater coactivation than the MH (P<0.0001). There was no effect of velocity on the coactivation levels of the VM, the VL, or the MH; however, there was an effect of velocity on the coactivation levels of the BF (P<0.0001). Relative to MDF activity, the MH shifted upward as velocity increased (P<0. 01) while the BF decreased between 180 and 300 degrees s(-1) (P<0. 01). Results of the muscular fatigue test indicated that the RMS activity of the VM showed a higher degree of coactivation than the VL (P<0.01) and the BF showed approximately three times the coactivation level of the MH (P<0.001). The MDF of the VL and MH shifted downward as the repetitions progressed (P<0.01) with no changes for the VM or for the BF. Results of this study suggest that during isokinetic testing, both the VM and BF have significantly greater reciprocal coactivation levels when compared to the VL and MH, respectively. In addition, these results suggest that motor unit recruitment patterns of the VM and VL and the MH and BF differ with regard to the effects of velocity and fatigue.

Liver transplantation complicated by embedded transjugular intrahepatic portosystemic shunt: a new method for portal anastomosis- a surgical salvage procedure.

A transjugular intrahepatic portosystemic shunt (TIPS) is an increasingly used method of treating variceal bleeding from portal hypertension. Many patients are subsequently listed for transplantation, which may be complicated by malposition of the inferior end of the TIPS stent. This report details such a case and offers a surgical technique to salvage this situation.