Molecular Adsorbent Recirculating System Treatment Can Reduce Blood Levels of N-Acetylcysteine in Patients With Acetaminophen Overdose: Case Reports.

BACKGROUND: Acetaminophen poisoning continues to be a major cause of liver failure that can lead to liver transplantation. N-acetylcysteine (NAC) is the cornerstone of treatment. Some authors use a Molecular Adsorbent Recirculating System (MARS) system in acetaminophen poisoning. It is reported that the MARS system eliminates acetaminophen more efficiently than conventional dialysis. It is theoretically possible that treatment with MARS administered after NAC will increase the effectiveness of treatment. CASE REPORTS: The first patient, a woman of 14 years old, presented blood levels of 112 mg/dL 12 hours after ingestion of 15 g of acetaminophen. Treatment with NAC was initiated. At 17 and 23 hours after ingestion, blood levels were 23.5 µg/mL and 5.9 µg/mL, respectively. The second patient, a woman of 28 years old, presented blood levels of 115 mg/dL 4 hours after ingestion of 40 g of acetaminophen. Treatment with NAC was initiated. At 14 and 23 hours after ingestion, blood levels were 15.8 µg/mL and <2 µg/mL, respectively. In both patients, we performed MARS after completing treatment with NAC, and after the first session, blood levels were below the lower limit of detection (≤2 µg/mL). DISCUSSION: The correct timing of MARS to avoid interactions with the administered dose of NAC in acetaminophen overdose is essential so as to not impair the effectiveness of this treatment. These considerations in the management of this entity help in the resolution of liver failure, thus avoiding the need for a liver transplant.

Laparoscopic treatment of biliary peritonitis after removal of T-tube in liver transplant patients.

INTRODUCTION: T-tube removal in liver transplant patients can occasionally cause a massive biliary leak and may require surgical treatment for its resolution. We present our experience with a laparoscopic approach to biliary peritonitis in liver transplant patients after the removal of a T-tube. PATIENTS AND METHODS: From January 2003 until February 2010, we performed 351 liver transplantations in 313 recipients, including 135 with a T-tube. After its removal 31 biliary leaks developed (23%); 12 were massive and required surgery, which utilized a laparoscopic approach. RESULTS: The mean length of the intervention was 72.9 ± 12.87 minutes (range = 55-95), without any complications during the procedure, and no need to convert to a laparotomy. Mean hospital stay after the intervention was 6.75 ± 3.88 days (range 4-18). There was no mortality from the procedure. CONCLUSION: The laparoscopic approach for biliary leakage after T-tube removal is indicated when large diffuse acute peritonitis is established a few hours postremoval of the T-tube. This safe procedure treats the complication without the need for another laparotomy.

FTY720 inhibits TH1-mediated allogeneic humoral immune response.

Phosphorylated FTY720 is an analog of Sphingosine 1 Phosphate (S1P) with immunosuppressive activity that negatively regulates the expression of S1P-Receptor 1. It also inhibits the migration of CD4 and CD8 single-positive T cells from the thymus to the periphery, sequesters peripheral blood lymphocytes in lymph nodes and Peyer's patches, and delays the exit of effector T cells toward the graft. The aim of our work was to study the effect of FTY720 on the kinetics of skin allograft rejection in a fully mismatched model; euthymic (Euthy) versus thymectomized (ATX) C57BL/6 mice (haplotype H-2(b)) recipients of BALB/c mice (haplotype H-2(d)) donor cells. The animals were injected daily with FTY720 (1 mg/kg) intraperitoneally for 2 weeks. To monitor the humoral immune response, serum samples collected at day 0 (pre-immune) and at day 23 after skin graft rejection were examined using BALB/c thymocytes as antigens in flow cytometry. To confirm the effect of FTY720 on peripheral lymphocytes, peripheral blood was analyzed by flow cytometry. Euthy and ATX FTY720-treated mice showed prolongation of skin allograft survival when compared with nontreated Euthy and ATX controls (P < .005). Unexpectedly, FTY720-treated Euthy mice showed significantly delayed graft rejection when compared to similarly treated ATX mice (P < .005). The delayed graft rejection in FTY720-treated Euthy mice correlated with a reduced content of Th1-mediated IgG(2a) and IgG(2b) antibodies when compared with FTY720-treated ATX mice (P < .05). In conclusion, FTY720 delays the kinetics of allograft rejection in a fully mismatched model by inhibiting Th1-mediated humoral immune responses. The presence of the host thymus appears to be required for this phenomenon.

[Importance of primary health-care professionals in the sanitary education about organ donation]. / Importancia de los profesionales de atención primaria en la educación sanitaria de la donación de órganos.

AIM: To determine the influence of the information on donation generated from primary health-care on the attitude towards organ donation. DESIGN: Descriptive transversal study. SETTING: 45 municipalities of Murcia Region, Spain. PARTICIPANTS: The population in this study was randomly selected and stratified according to age, sex, and geographic localization among people over > or =15 years of age (n=1887). INTERVENTIONS AND MEASURES: The attitude was evaluated according to a questionnaire psychosocial aspects of donation. There is valued the information transmitted on donation to the population from primary care (group A) or other informative sources (group B), and if this information was to favour or in opposition to the same one. STATISTICS: chi2 test, t Student, and logistic regression analysis. RESULTS: Of 1887 surveys, 129 cases (group A) (7%) had received information from primary care. In this group, the 89% is in favour of the donation. In 120 cases the received information was favourable, presenting an attitude in favour of the donation of 93%, whereas in all 9 remaining cases the information was in against, decreasing the attitude to favour up to 44% (P<.05). In the group B (n=1758) the attitude in favour of the donation was of 65% (P<.05, with regard to the group A). The 62% (n=1083) received favourable information, improving in them the favourable attitude towards the donation up to 74%. The rest (38%; n=675) had received also unfavourable information, decreasing his attitude to favour up to 51% (P<.05). CONCLUSIONS: Little information about organ donation is transmitted from primary care, but when it is realized a very positive impact has if it is favourable and very negative if it is unfavourable.

[Fulminant hepatic failure and liver transplantation. Experience of the Hospital Virgen de la Arrixaca]. / Fracaso hepático fulminante y trasplante hepático. Experiencia del Hospital Virgen de la Arrixaca.

INTRODUCTION: Medical treatment for fulminat hepatic failure seeks spontaneous recovery of the liver function, but the results are very discouraging (50-80% mortality). Liver transplantation is an option in patients with a poor evolution despite medical treatment, with survival rates of > 50%. The ideal moment for performing the transplant is controversial, as it should not be done too soon, when the liver disease is still reversible, or tool late, when the patient is in an irreversible clinical situation. PATIENTS AND METHOD: A retrospective review was made of the clinical histories of 34 patients admitted to our hospital with a diagnosis of fulminant hepatic failure, of whom 26 underwent transplantation. The most frequent cause was viral, with 10 cases (38%); no aetiology at all could be established in 11 cases (42%). Thirteen patients had preoperative complications, the most frequent being renal insufficiency. As for degree of ABO/DR compatibility, 13 cases were identical (40%), 17 compatible (51%) and the other 3 incompatible (9%). RESULTS: Thirty-three transplants were performed in 26 patients: 4 were retransplants due to chronic rejection, 2 for primary graft failure and 1 for hyperacute rejection. The overall mortality rate was 46% (12 patients), the most frequent cause of death being infection (50%). The overall actuarial survival rate was 68% at 1 year, 63% at 3 years and 59% at 5 years. The factors of poor prognosis were renal and respiratory insufficiency, a grade D electroencephalogram, and encephalopathy grades III and IV, the latter being the only prognostic factor identified in the multivariate analysis. The prognostic factors for mortality were a grade D electroencephalogram, encephalopathy grades III and IV and respiratory insufficiency, the latter being the only prognostic factor identified in the multivariate analysis. CONCLUSIONS: The achievement of good results with the use of transplantation in the management of fulminant hepatic failure depends on an optimum selection of transplant candidates, which means identifying them early, i.e. early indication for transplant, reduction in mean waiting time and exclusion of factors of poor prognosis.

Ischemia and reperfusion injury of the rat liver: the role of nimodipine.

The protective effect of the calcium channel blocker nimodipine on liver ischemia and reperfusion was studied in the rat. The homeostasis of intracellular calcium ions seems to be a determinant factor in the cell injury that appears after ischemia and reperfusion. Nimodipine was used to downregulate the calcium levels in the cytosol of the ischemic cell, the hypothetical role of Ca2+ in the pathogenesis of ischemia and reperfusion injury. The experimental procedure consisted of the temporary interruption of blood flow to the left lateral and medial lobes of the rat liver and subsequent reperfusion after a period of 45 min of ischemia. Nimodipine (10 micrograms/kg body wt) was administered either before or after the onset of ischemia. The postischemic liver blood flow and liver oxyhemoglobin saturation were recorded using a He-Ne laser Doppler flowmeter and photometer, which showed, in the pretreated group, a recovery of reperfusion blood flow (58.1%) and liver reflectance (85.5%) significantly better (P < 0.01 and P < 0.001) than those in the respective untreated controls of flow (32.8%) and reflectance (70.5%). In the group that received nimodipine after ischemia, the recovery of the blood flow and the postreperfusion liver reflectance were not significantly better than those in the untreated control group. ALT levels (P < 0.05), galactose elimination capacity (P < 0.001), and histological studies also showed a protective effect of calcium antagonist nimodipine when administered before ischemia.

Quantification of duodenogastric reflux in patients with choledochoduodenostomy.

BACKGROUND: Frequently, patients present with symptoms after cholecystectomy (pain or discomfort in the upper part of the abdomen, postprandial fullness, bile vomiting, among others). Duodenogastric reflux has been associated with these symptoms in some patients. Therefore, this study was done to investigate this relationship. STUDY DESIGN: We evaluated duodenogastric reflux (DGR) in ten healthy patients, in ten patients who had asymptomatic simple cholecystectomy, in ten patients who had asymptomatic cholecystectomy with supraduodenal choledochoduodenostomy (CD), and in ten patients who had cholecystectomy plus CD followed by discomfort in the upper abdomen, postprandial fullness and bile vomiting, but no colicky pain or acute cholangitis. Duodenogastric reflux was quantified using continuous intravenous infusion of technetium-99m labeled hepatoiminodiacetic acid (99mTc-HIDA) and subsequently determining its concentration in gastric juice. RESULTS: All of the patients who underwent operation, whatever the technique used, had higher reflux rates than those in the control group (p < 0.001). Moreover, reflux rates were comparable in the patients who underwent simple cholecystectomy compared with patients in the asymptomatic cholecystectomy plus CD group. Conversely, when patients with cholecystectomy plus CD presented with discomfort in the upper part of the abdomen as well as bile vomiting, they had higher reflux rates than patients who underwent simple cholecystectomy (p < 0.001) and asymptomatic patients with associated CD (p < 0.001). CONCLUSIONS: Our results suggest that DGR must be involved in the genesis of these dyspeptic symptoms.

Laser-Doppler flowmetry in the study of in vivo liver ischemia and reperfusion in the rat.

Estimation of blood flow in the microcirculation is essential in the analysis of the events that occur during organ ischemia and subsequent reperfusion. In this study the use of laser-Doppler flowmetry is evaluated as a method for studying liver blood flow in the rat using an in vivo ischemia-reperfusion model. The experimental procedure consists of the temporary interruption of blood flow to the left lateral and medial lobes of the liver and subsequent recording of the postischemic liver blood flow using a laser-Doppler flowmeter. Flow was recorded for 60 min after periods of ischemia of 30 sec (control), 30, 45, and 60 min. The reperfusion records showed a biphasic curve with a mean flow of 59.6% of the baseline after 30 min of ischemia and of 38.3 and 41.1% after 45 and 60 min of ischemia, respectively. There were statistically significant differences between all the groups and the controls, and between 45 and 30 min of ischemia but not between 45 and 60 min. This is a useful model for studying ischemic liver injury in the rat.

Rat liver blood flow after ischemia and reperfusion. The effects of the platelet-activating factor antagonist WEB-2170 and of removing circulating leukocytes.

The inflammatory response to trauma induces release of platelet activating factor (PAF), which promotes leukocyte adherence to the vascular endothelium. Ischemia and reperfusion induces inflammatory reactions that play a role in reperfusion injury, and here we investigate the role of both PAF and of leukocytes in damage to reperfused rat liver. The experimental procedure consisted of the temporary interruption of blood flow to the left lateral and medial lobes of the rat liver in vivo, and subsequent reperfusion after defined periods. Rats were pretreated either with the PAF-antagonist WEB-2170 or with vinblastine to induce leukopenia, and compared with controls. The postischemic liver blood flow and liver oxyhemoglobin saturation were recorded using an He-Ne Laser doppler flowmeter and photometer. Reperfusion after 30 and 45 min of ischemia was associated with partial recovery to normal values and was inversely proportional to the duration of ischemia. In the WEB-2170-treated group, liver flow and hemoglobin saturation upon reperfusion did not show significant differences when compared with the untreated control groups, suggesting that inhibition of PAF activity did not protect against the microcirculatory disturbance induced by ischemia and reperfusion in the liver. In contrast, rats made leukopenic by treatment with vinblastine showed significantly better recovery of blood flow and hemoglobin saturation than the control group after 45 min of ischemia. Thus, we found that although PAF alone did not appear to have a pivotal role in the cascade of reperfusion injury, the effect of leukocytes is critical.

[Quantification of duodenogastric reflux in symptomatic patients with choledochoduodenostomy using intravenous continuous perfusion of 99mTc-HIDA as duodenal marker]. / Cuantificación del reflujo duodenogástrico en pacientes con coledocoduodenostomía sintomáticos utilizando la perfusión continua intravenosa de 99mTc-HIDA como marcador duodenal.

The purpose of the present study was to determine whether the measurement of intravenously administered 99mTc-HIDA in samples of gastric juice can be used as a reliable marker of duodenogastric reflux. Ten normal volunteers and 10 patients with a laterolateral choledocho-duodenostomy complaining of dyspepsia but no biliary pain, were given a continuous i.v. infusión of 99mTc-HIDA. The isotope concentration was then measured in samples of gastric juice. We found that duodeno-gastric reflux was significantly higher (p less than 0.001) in patients with choledochoduodenostomy and dyspepsia than in normal volunteers.

[Surgical treatment of gastric cancer. Evaluation of results in 313 consecutive cases]. / Tratamiento quirúrgico del cáncer gástrico. Valoración de resultados en 313 casos consecutivos.

The results of 313 gastric adenocarcinomas, treated by the same surgical team during 10 years have been evaluated retrospectively. The pathological characteristics, operability (88.8%) and resectability (69.8%) rates, surgical technique and morbility and mortality rates are analyzed. The causes of late mortality, total five-year survival, depending on the stage of the tumors, and survival in relation to treatment are reported.

[Clinical and epidemiological features of hepatic cirrhosis. Analysis of 200 patients]. / Aspectos clinicoepidemiológicos de la cirrosis hepática. Análisis en 200 pacientes.

We have evaluated the clinical and epidemiological features of hepatic cirrhosis in a retrospective study of 200 patients admitted to our Area Hospital from 1984 to 1987. 77% of patients were 40-69 years old and 74% were males, with a M/F ratio of 2.84. 56% were caused by high alcohol intake, 25% were cryptogenic and 13% post-hepatitis. 29.2% were diagnosed in a compensated stage of the disease. 52.2% presented with ascites, and 30.5% with upper gastrointestinal hemorrhage. We found superimposed hepatocellular carcinoma in 4.5% of patients, all of them males, with a mean age of 63.5 years. 18% died during their hospital admission, 50% from hepatic coma, 19.4% from hypovolemic shock and 16.6% from hepatorenal syndrome. Survival from the time of diagnosis in the patients who died was shorter than one year in 41.5%.