Decompression sickness of the inner ear and relationship with a patent oval foramen: a study of 61 cases.

OBJECTIVE: To discuss the link between inner ear decompression sickness and patent foramen ovale. MATERIALS AND METHODS: Monocentric and retrospective study on decompression sickness of the inner ear requiring hyperbaric chamber treatment, from 2014 to 2021. RESULTS: Sixty-one patients of inner ear decompression sickness were included in this study. Twenty-four patients had vestibular injuries, 28 cochlear injuries and 9 cochleo-vestibular injuries. Compression chamber treatment was given, using an oxygen-helium mixture with oxygen partial pressure (PIO2) limited to 2.8 atmosphere absolute (ATA). All vestibular accidents completely recovered without clinical sequelae. For cochlear accident only 10 out of 37 patients (27%) recovered completely. A right-left shunt (patent foramen oval or intra-pulmonary shunt) was found in 31.1% of patients with inner ear decompression sickness (p > 0.05). CONCLUSION: The presence of patent foramen oval in patients with inner ear decompression was not statistically significant in our study. Understanding of the pathophysiology of decompression illness and the physiology and anatomy of the labyrinth would suggest a mechanism of supersaturation with degassing in intra-labyrinthine liquids.

Albumin dialysis with a noncell artificial liver support device in patients with acute liver failure: a randomized, controlled trial.

BACKGROUND: Albumin dialysis with the Molecular Adsorbent Recirculating System (MARS) (Gambro, Lund, Sweden), a noncell artificial liver support device, may be beneficial in acute liver failure (ALF). OBJECTIVE: To determine whether MARS improves survival in ALF. DESIGN: Randomized, controlled trial. (ClinicalTrials.gov: NCT00224705). SETTING: 16 French liver transplantation centers. PATIENTS: 102 patients with ALF. INTERVENTION: Conventional treatment (n = 49) or MARS with conventional treatment (n = 53), stratified according to whether paracetamol caused ALF. MEASUREMENTS: 6-month survival and secondary end points, including adverse events. RESULTS: 102 patients (mean age, 40.4 years [SD, 13]) were in the modified intention-to-treat (mITT) population. The per-protocol analysis (49 conventional, 39 MARS) included patients with at least 1 session of MARS of 5 hours or more. Six-month survival was 75.5% (95% CI, 60.8% to 86.2%) with conventional treatment and 84.9% (CI, 71.9% to 92.8%) with MARS (P = 0.28) in the mITT population and 75.5% (CI, 60.8% to 86.2%) with conventional treatment and 82.9% (CI, 65.9% to 91.9%) with MARS (P = 0.50) in the per-protocol population. In patients with paracetamol-related ALF, the 6-month survival rate was 68.4% (CI, 43.5% to 86.4%) with conventional treatment and 85.0% (CI, 61.1% to 96.0%) with MARS (P = 0.46) in the mITT population. Sixty-six of 102 patients had transplantation (41.0% among paracetamol-induced ALF; 79.4% among non-paracetamol-induced ALF) (P < 0.001). Adverse events did not significantly differ between groups. LIMITATION: The short delay from randomization to liver transplantation (median, 16.2 hours) precludes definitive efficacy or safety evaluations. CONCLUSION: This randomized trial of MARS in patients with ALF was unable to provide definitive efficacy or safety conclusions because many patients had transplantation before administration of the intervention. Acute liver failure not caused by paracetamol was associated with greater 6-month patient survival. PRIMARY FUNDING SOURCE: Assistance Publique-Hôpitaux de Paris.

Outcome of patients treated with molecular adsorbent recirculating system albumin dialysis: A national multicenter study.

BACKGROUND AND AIM: The molecular adsorbent recirculating system (MARS) is the most widely used device to treat liver failure. Nevertheless, data from widespread real-life use are lacking. METHODS: This was a retrospective multicenter study conducted in all French adult care centers that used MARS between 2004 and 2009. The primary objective was to evaluate patient survival according to the liver disease and listing status. Factors associated with mortality were the secondary objectives. RESULTS: A total of 383 patients underwent 393 MARS treatments. The main indications were acute liver failure (ALF, 32.6%), and severe cholestasis (total bilirubin >340 µmol/L) (37.2%), hepatic encephalopathy (23.7%), and/or acute kidney injury-hepatorenal syndrome (22.9%) most often among patients with chronic liver disease. At the time of treatment, 34.4% of the patients were listed. Overall, the hospital survival rate was 49% (95% CI: 44-54%) and ranged from 25% to 81% depending on the diagnosis of the liver disease. In listed patients versus those not listed, the 1-year survival rate was markedly better in the setting of nonbiliary cirrhosis (59% vs 15%), early graft nonfunction (80% vs 0%), and late graft dysfunction (72% vs 0%) (all P < 0.001). Among nonbiliary cirrhotic patients, hospital mortality was associated with the severity of liver disease (HE and severe cholestasis) and not being listed for transplant. In ALF, paracetamol etiology and ≥3 MARS sessions were associated with better transplant-free survival. CONCLUSION: Our study suggests that MARS should be mainly used as a bridge to liver transplantation. Survival was correlated with being listed for most etiologies and with the intensity of treatment in ALF.

[EBV-induced fulminant hepatic failure: favorable outcome after liver transplantation]. / Hépatite fulminante à virus Epstein-Barr: évolution favorable après transplantation hépatique.

Viral hepatitis are the leading cause of fulminant hepatitis. Epstein Barr virus is the viral agent involved in infectious mononucleosis, associated with a frequent and usually benign hepatitis, except in case of immunodeficiency, congenital or acquired. We report the case of an immunocompetent young woman who presented an EBV induced fulminant hepatic failure, requiring liver transplantation that was successful. This observation emphasizes that EBV must be known as a possible cause of fulminant hepatitis and that liver transplantation is probably the unique therapeutic option to avoid a usually fatal course.

Uncoupling the systemic circulation and the Ex Vivo circuit during experimental isolated liver perfusion.

Performing an ex vivo liver perfusion as a transient liver support requires perfusing the liver with a flow of 1 ml/min per kg of liver, which could reach 25% of the cardiac output when a human liver is used. This high flow could be detrimental in patients with acute liver failure. Therefore, in an ischemic-induced liver failure pig model, we developed a circuit allowing low flows going out of and into the systemic circulation, whereas the flow going through the ex vivo liver is maintained at a high value. This was obtained by uncoupling the ex vivo circuit from the systemic circulation. Ex vivo liver perfusion was performed in a closed circuit with a flow averaging 1 ml/min per kg of ex vivo liver (700 to 800 ml/min, according to the weight of the livers we used). It was linked to the systemic circulation with input and output flows equal to that used during hemodialysis (200 ml/min). Compared with previously reported direct circuits, this perfusion system was well tolerated from a circulatory point of view. After the induction of ischemic liver failure, the ex vivo liver perfusion led to an increase in urea, branched amino acids to aromatic amino acid ratio, and fractional clearance of indocyanine green and galactose and to a decrease in ammonia and lactic acid. This system allowed the ex vivo liver to keep its clearing properties despite a low extracorporeal flow. It represents an extracorporeal circuit that could be used in place of the direct extracorporeal high-flow liver perfusion.

Liver function during extracorporeal whole liver perfusion in a pig model of acute ischemic liver failure.

The shortage of livers for transplant has renewed interest in the potential of temporary liver support such as extra corporeal whole liver perfusion. In an ischemic induced liver failure model we perfused an extra corporeal liver through only a portal vein and assessed the function of this ex vivo liver by using hepatic tests to estimate elimination as well as synthesis capacities. Acute liver failure was performed in five control pigs by a hepatic devascularization associated to an end to side portocaval shunt. In a treated group, 5 to 6 h after this hepatic devascularization, animals were connected to an extra corporeal liver perfused via the portal vein with blood withdrawn from the ischemic liver animal from its portal vein. Devascularization of the liver induced an increase in liver enzymes and ammonia, a drop in the ratio of branched chain amino acids to aromatic amino acids, and a decrease in blood urea and indocyanine green and galactose clearances. In treated animals, urea, amino acid ratio, and clearances increased after the ex vivo liver perfusion. In this group, mean bile production and mean liver oxygen consumption were 13.7 +/- 3.6 ml/h and 16.1 +/- 7.7 ml/min, respectively. In an acute ischemic liver failure pig model, an extra corporeal whole liver perfusion demonstrated detoxification properties as well as synthesis capacities.

[Induced interstitial pneumonitis: role of pegylated interferon alpha 2b]. / Forme pegylée de l'interféron alpha 2b et pneumopathies interstitielles diffuses.

Pulmonary complications of alpha interferon are rare. We report two cases of lung complications in liver transplantation patients for HCV related cirrhosis. After switching from interferon alpha to pegylated interferon alpha 2b, one patient developed a BOOP (Bronchiolitis Obliterans Organizing Pneumonia) and the other severe interstitial pneumonitis. We discuss the causes of these rare pulmonary alpha-interferon induced complications and the different way to suggest that the pegylated interferon alpha 2b could be related to the risk of pulmonary toxicity of this treatment.

Paradoxical symptomatic air embolism after saline contrast transesophageal echocardiography.

We describe one case of paradoxical air embolism after contrast transesophageal echocardiography realized to detect a patent foramen ovale. At the end of this procedure, the patient presented a left lateral homonymous hemianopsia attributed to air embolism. Total recovery was obtained after one therapeutic recompression.

Negative impact of de novo malignancies rather than alcohol relapse on survival after liver transplantation for alcoholic cirrhosis: a retrospective analysis of 305 patients in a single center.

OBJECTIVES: Alcoholic liver disease is a leading indication for liver transplantation (LT). The aim of this study was to evaluate long-term results and survival prognostic factors of LT in this indication from a large cohort of patients. METHODS: From October 1990 to October 2005, 305 consecutive patients with alcoholic cirrhosis (from 594 patients presenting with cirrhosis, i.e., 51.3%) underwent LT in our center. There were 229 men and 76 women, with a median age of 50 yr (range 30-68). Clinical and biological variables with possible prognostic value were analyzed. RESULTS: Global survival rate was 92.6% at 1 yr, 88.5% at 3 yr, 84.3% at 5 yr, and 73.4% at 10 yr, and was similar (P=0.78, log-rank test) to that of patients transplanted for other cirrhosis (88.8% at 1 yr, 84.1% at 3 yr, 80.6% at 5 yr, and 74.7% at 10 yr). Recurrence of alcohol consumption was observed in 37 patients (12.1%). De novo cancer occurred in 35 patients after LT (11.5%). Univariate analysis disclosed that male gender, history of smoking, and de novo carcinoma were significant survival prognostic factors (P<0.05, log-rank test). CONCLUSIONS: Our results strongly confirm that alcoholic liver disease is an excellent indication for LT, but long-term survival is reduced because of other target-organ damage of both alcohol and tobacco, especially aero-digestive malignancies, which are greater causes of morbidity and mortality than is recurrent alcohol liver disease.

Impact of adult-to-adult living donor liver transplantation on access to transplantation and patients' survival: an 8-year single-center experience.

While the number of candidates for liver transplantation has increased in the recent years, the pool of cadaveric donor organs has remained constant and the waiting time progressively increases. These facts led us to start a program of adult-to-adult living-donor liver transplantation in 1998. The aim of this study was to compare the outcome of all patients put on the waiting list since 1998. Between January 1, 1998, and January 1, 2005, 505 patients were put on the waiting list in our center, and living donor liver transplantation was considered in 57 cases (11.3%). At the time of evaluation (April 1, 2006), liver transplantation was performed in 377 patients (46 living donor liver transplantations), and 89 patients died on waiting list. On an intention-to-treat basis, the 1-year survival rate from the time of listing was 87.5% in the "living donor" group vs. 76.2% in the "cadaveric donor" group (P < 0.05), whereas the 1-year survival after liver transplantation was similar (92.3% vs. 86.9%). Our living donor liver transplantation program was able to improve the access to liver transplantation by reducing waiting time and the number of deaths on waiting list, despite the fact that these patients were more critically ill (liver failure and/or liver cancer).

Peritoneovenous shunt as a bridge to liver transplantation.

Intractable ascites carries great morbidity. The aim of this study was to determine the efficacy of peritoneovenous shunt (PVS) in patients listed for liver transplantation (LT). Between January 1999 and January 2004, PVS was inserted in 36 (30 males and 6 females) cirrhotic patients, 50.3 years of median age (range: 30-66), who failed multiple large-volume paracenteses and diuretic therapy, when listed for LT. Data were collected until LT or the present time, and were compared to an historical cohort (1997-1998) as control. No operative death occurred. Four patients died before LT in a median delay of 9 months after PVS insertion. PVS provided palliation for intractable ascites in 30 patients (83%). Renal function significantly improved (glomerular filtration rate (GFR) improved from 0.642 to 0.987 mL/s, p<0.05). Eighteen patients were transplanted in a median delay of 6 months (range: 3-12 months) after PVS insertion. When compared to the historical cohort of 18 patients, the occurrence of post-LT acute renal failure was significantly lower in the PVS group (3/18 vs. 13/18, p<0.05). Our results suggest that PVS might be beneficial in patients with refractory ascites waiting for LT and could prevent postoperative acute renal failure.

Small-for-size partial liver graft in an adult recipient; a new transplant technique.

We report a new technique of adult liver transplantation using a small-for-size graft. In order to avoid graft congestion and failure by overperfusion, we completely diverted the superior mesenteric venous flow by a mesocaval shunt with downstream ligation of the superior mesenteric vein. The recipient recovered well, and the graft had normal histology and function at 5 months follow-up. Given the current scarcity of cadaveric donors, this technique may increase the numbers of adult recipients by using left lobes from cadaveric split liver grafts.

Hepatic ischemia is associated with an increase in liver parenchyma nitric oxide that is in part enzyme-independent.

BACKGROUND: Nitric oxide (NO) might be involved in liver response to local ischemia-reperfusion injury. METHODS: A specific NO-sensitive electrode was inserted into liver parenchyma of anesthetized rabbits. After a 45-min period of stable NO signal, the vascular pedicle of the caudal lobe of the liver was clamped for 45 min, then the clamp was removed. Perfusion of the right upper lobe was left unchanged. The same procedure was applied in other animals after administration of a long-acting nonspecific NO synthase inhibitor NAPNA. RESULTS: Occlusion of the caudal pedicle was associated with a mean threefold increase in NO signal measured in the caudal lobe. After unclamping, this signal returned within 8 min to baseline value and remained stable for the next 6 h. In the right upper lobe, NO signal was unaffected by caudal lobe ischemia. By the end of the 6-h reperfusion period, administration of the NO inhibitor l-NAME led to a suppression of the NO signal, thus demonstrating the specificity of the measurement. Plasma nitrate and nitrite concentrations remained almost unchanged during the study period in all groups. In animals whose NO synthases had been previously inhibited by NAPNA, clamping the caudal pedicle for 45 min was still associated with a significant increase in caudal lobe NO signal. CONCLUSION: Nitric oxide is present in liver parenchyma, and its generation is dramatically affected by an ischemia injury. The increased NO generation during local ischemia is, at least in part, independent of NO synthases.