Cost burden following esophagectomy:A single centre observational study

BACKGROUND Cost analyses of patients undergoing esophagectomy is valuable for identifying modifiable expenditure drivers to target and curtail costs while improving the quality of care.We aimed to define the cost-complication relationship after esophagectomy and delineate the incremental contributions to costs.AIM To assess the relationship between the hospital costs and potential cost drivers post esophagectomy and investigate the relationship between the cost-driving variables(predicting variables)and hospital costs(dependent variable).METHODS In this retrospective single center study,the severity of complications was graded using the Clavien-Dindo(CD)classification system.Key esophagectomy complications were categorized and defined according to consensus guidelines.Raw costing data included the in-hospital costs of the index admission and any unplanned admission within 30 postoperative days.We used correlation analysis to assess the relationship between key clinical variables and hospital costs(in United States dollars)to identify cost drivers.A mediation model was used to investigate the relationship between these variables and hospital costs.RESULTS A total of 110 patients underwent primary esophageal resection.The median admission cost was $47822.7(interquartile range:35670.2-68214.0).The total effects on costs were $13593.9(95%CI:10187.1-17000.8,P<0.001)for each increase in CD severity grade,$4781(95%CI:3772.7-5789.3,P<0.001)for each increase in the number of complications,and $42552.2(95%CI:8309-76795.4,P=0.015)if a key esophagectomy complication developed.Key esophagectomy complications drove the costs directly by $11415.7(95%CI:992.5-21838.9,P=0.032).CONCLUSION The severity and number of complications,and the development of key esophagectomy complications significantly contributed to total hospital costs.Continuous institutional initiatives and strategies are needed to enhance patient outcomes and minimize costs.

Association of age at diagnosis of diabetes with subsequent risk of age-related ocular diseases and vision acuity

BACKGROUND The importance of age on the development of ocular conditions has been reported by numerous studies.Diabetes may have different associations with different stages of ocular conditions,and the duration of diabetes may affect the development of diabetic eye disease.While there is a dose-response relationship between the age at diagnosis of diabetes and the risk of cardiovascular disease and mortality,whether the age at diagnosis of diabetes is associated with incident ocular conditions remains to be explored.It is unclear which types of diabetes are more predictive of ocular conditions.AIM To examine associations between the age of diabetes diagnosis and the incidence of cataract,glaucoma,age-related macular degeneration(AMD),and vision acuity.METHODS Our analysis was using the UK Biobank.The cohort included 8709 diabetic participants and 17418 controls for ocular condition analysis,and 6689 diabetic participants and 13378 controls for vision analysis.Ocular diseases were identified using inpatient records until January 2021.Vision acuity was assessed using a chart.RESULTS During a median follow-up of 11.0 years,3874,665,and 616 new cases of cataract,glaucoma,and AMD,respectively,were identified.A stronger association between diabetes and incident ocular conditions was observed where diabetes was diagnosed at a younger age.Individuals with type 2 diabetes(T2D)diagnosed at<45 years[HR(95%CI):2.71(1.49-4.93)],45-49 years[2.57(1.17-5.65)],50-54 years[1.85(1.13-3.04)],or 50-59 years of age[1.53(1.00-2.34)]had a higher risk of AMD independent of glycated haemoglobin.T2D diagnosed<45 years[HR(95%CI):2.18(1.71-2.79)],45-49 years[1.54(1.19-2.01)],50-54 years[1.60(1.31-1.96)],or 55-59 years of age[1.21(1.02-1.43)]was associated with an increased cataract risk.T2D diagnosed<45 years of age only was associated with an increased risk of glaucoma[HR(95%CI):1.76(1.00-3.12)].HRs(95%CIs)for AMD,cataract,and glaucoma associated with type 1 diabetes(T1D)were 4.12(1.99-8.53),2.95(2.17-4.02),and 2.40(1.09-5.31),respectively.In multivariable-adjusted analysis,individuals with T2D diagnosed<45 years of age[β95%CI:0.025(0.009,0.040)]had a larger increase in LogMAR.Theβ(95%CI)for LogMAR associated with T1D was 0.044(0.014,0.073).CONCLUSION The younger age at the diagnosis of diabetes is associated with a larger relative risk of incident ocular diseases and greater vision loss.

One fifth of hospitalizations for peptic ulcer-related bleeding are potentially preventable

AIM: To calculate the proportion of potentially preventable hospitalizations due to peptic ulcer disease (PUD), erosive gastritis (EG) or duodenitis (ED).

DNA末端定量及其应用的研究

为定量DNA断裂末端评价DNA的降解程度 ,以饱和标记 (TdT)法定量DNA末端最大标记量 (Lmax) ;并用流式细胞分析 (FCA)、原位DNA末端标记 (TUNEL)和琼脂糖电泳检测或标记DNA降解片段 .结果发现 :a TdT法最低检测限 5ngDNA ,线性范围为 5～ 5 0 0 0ng ,较检测DNA降解片段的琼脂糖电泳敏感 2 0 0倍以上 ;b 地塞米松 (DEX)诱导淋巴瘤 (Raji)细胞凋亡产生的Lmax呈DEX剂量与诱导时间依赖性增加 ;c 自发性高血压大鼠 (SHR)心肌的Lmax呈年龄依赖性增加并与正常对照鼠 (WKY)相比差异非常显著 (P <0 0 1) ;d TdT法定量Lmax与FCA、TUNEL或电泳分析的相关性良好 (r >0 98) .TdT法定量Lmax敏感、特异、准确 ,可应用于分子生物学、细胞生物学 。

慢性脑、脊髓静脉功能不全——一种新近认识的血管疾病

慢性脑、脊髓静脉功能不全(CCSVI)是指中枢神经系统静脉回流功能异常或障碍的一种状态,是一种新近被认识的中枢神经系统血管性疾病,类似于下肢静脉功能不全的病理生理变化。CCSVI异常的脑部静脉血流触发炎症反应,导致静脉屏障受损、铁沉积、免疫炎症反应增强等,造成白质脱髓鞘的病理变化,可能是多发性硬化的病因之一。最新的研究表明,应用血管腔内技术干预CCSVI,有望成为治疗多发性硬化的一种新方法。

甘氨酸延伸型胃泌素受体在结肠和结直肠肿瘤中的研究

目的：建立甘氨酸延伸型胃泌素胞浆膜受体结合试验，并应用该方法检测甘氨酸延伸型胃泌素受体的部分特 性及其在正常结肠和人结直肠肿瘤中的表达。方法：用人结直肠肿瘤细胞株ＤＬＤ－１建立胞浆膜制备方法，１２５Ｉ标记 的甘氨酸延伸型胃泌素进行受体结合试验。结果：胞浆膜受体结合试验的条件为： ５～１０ ｍｇ胞浆膜（离心２５ ０００ ｒ／ ｍｉｎ ４５ ｍｉｎ制备），３７ ℃温育６０ ｍｉｎ。正常Ｓｐｒａｇｕｅ－Ｄａｗｌｅｙ大鼠结肠粘膜和从结肠粘膜制备的胞浆膜有特异结合， 而从完整结肠制备的胞浆膜无特异结合。胞浆膜甘氨酸延伸型胃泌素受体抑制５０％结合的非标记配体浓度（ＩＣ５０）为 ３．６４ μｍｏｌ／Ｌ±１．９３μｍｏｌ／Ｌ；特异性胆囊收缩素（ＣＣＫ）－Ａ受体拮抗剂Ｌ３６４和特异性ＣＣＫＢ受体拮抗剂Ｌ３６５不能 拮抗该受体；非特异性受体拮抗剂氯苯酰色氨酸则能拮抗。结论：甘氨酸延伸型胃泌素受体位于正常大鼠结肠粘 膜、结肠粘膜和结直肠肿瘤细胞膜上，属单结合位点、低亲和力受体，不能被特异性ＣＣＫ－Ａ或ＣＣＫ－Ｂ受体拮抗剂拮 抗，是一种新受体。

DLD-1细胞上甘氨酸延伸型胃泌素受体的结合特性

目的考察人结直肠肿瘤细胞株DLD - 1上甘氨酸延伸型胃泌素受体的结合特性 ;与CCK -A和CCK -B比较 ,找出不同之处。 方法 12 5Ⅰ标记甘氨酸延伸型胃泌素 ,反相高压液相纯化。用DLD - 1细胞进行受体结合试验 ,检测甘氨酸延伸型胃泌素受体结合试验受金属离子K+、Mg2 +、Al3+及温育温度、时间的影响 ;拮抗剂竞争抑制试验比较各种拮抗剂的作用。 结果金属离子K+、Mg2 +能提高甘氨酸延伸型胃泌素受体的特异结合 ,以10 0mmol/LTrisHCl缓冲液中含 10 0mmol/LK+,2mmol/LMg2 +为最佳 ;缓冲液含二个蛋白酶抑制剂时的最大结合发生在 37℃温育 90min ;没有蛋白酶抑制剂的最大结合发生在 37℃温育 6 0min。甘氨酸延伸型胃泌素受体的结合不被特异性CCK -A受体拮抗剂或特异性CCK -B受体拮抗剂拮抗 ,能被非特异性胃泌素受体拮抗剂benzotript拮抗。结论甘氨酸延伸型胃泌素受体的结合特性不同于CCK -A或CCK -B受体。DLD - 1细胞上的甘氨酸延伸型胃泌素受体既能与甘氨酸延伸型胃泌素结合 ,也能与酰胺化胃泌素结合 ,是一个不同于CCK -A和CCK

AIMS65: A promising upper gastrointestinal bleeding risk score but further validation required

A novel upper gastrointestinal bleeding risk stratification score(AIMS65) has recently been developed and validated. It has advantages over existing risk scores including being easy to remember and lack of subjectivity in calculation. We comment on a recent study that has cast doubt on the applicability of AIMS65 in the peptic ulcer disease population. Although promising, further studies are required to evaluate the validity of AIMS65 in various populations.

Characteristics of hepatocellular carcinoma in cirrhotic and non-cirrhotic non-alcoholic fatty liver disease

AIM: To determine characteristics and prognosticpredictors of patients with hepatocellular carcinoma(HCC) in association with non-alcoholic fatty liver disease(NAFLD).METHODS: We reviewed the records of all patients with NAFLD associated HCC between 2000 and 2012. Data collected included demographics; histology; presence or absence of cirrhosis, size and number of HCC, alpha-fetoprotein, body mass index(BMI), and the presence of diabetes, hypertension, or dyslipidaemia.RESULTS: Fifty-four patients with NAFLD associated HCC were identified. Mean age was 64 years with 87% male. Fifteen percent(8/54) were not cirrhotic. 11%, 24% and 50% had a BMI of < 25 kg/m2, 25-29 kg/m2 and ≥ 30 kg/m2 respectively. Fifty-nine percent were diabetic, 44% hypertensive and 26% hyperlipidaemic. Thirty-four percent of the patients had ≤ 1 of these risk factors. Non-cirrhotics had a significantly larger mean tumour diameter at diagnosis than cirrhotics(P = 0.041). Multivariate analysis did not identify any other patient characteristics that predicted the size or number of HCC.CONCLUSION: HCC can develop in NAFLD without cirrhosis. At diagnosis such tumours are larger than those in cirrhotics, conferring a poorer prognosis.

Intrahepatic cholestasis of pregnancy:When should you look further?

Pruritis with abnormal liver function tests is the classical presentation of intrahepatic cholestasis of pregnancy(ICP),a condition associated with significant fetal complications.Although the etiology of ICP is unclear in many cases,certain features of the clinical presentation should alert the practitioner to the possibility of an underlying metabolic defect, which may not only affect subsequent pregnancies, but may be an indicator of more serious subsequent liver disease.We report a kindred of Anglo-Celtic descent,among whom many members present with ICP,gallstones or cholestasis related to use of oral contraception.Genetic studies revealed a novel mutation in the ABCB4 gene,which codes for a phospholipid transport protein.The clinical significance of this mutation and the importance of identifying such patients are discussed.

Perioperative fluid management in major hepatic resection: an integrative review

BACKGROUND: Fluid intervention and vasoactive pharmacological support during hepatic resection depend on the preference of the attending clinician, institutional resources, and practice culture. Evidence-based recommendations to guide perioperative fluid management are currently limited. Therefore, we provide a contemporary clinical integrative overview of the fundamental principles underpinning fluid intervention and hemodynamic optimization for adult patients undergoing major hepatic resection. DATA SOURCES: A literature review was performed of MEDLINE, EMBASE and the Cochrane Central Registry of Controlled Trials using the terms 'surgery', 'anesthesia', 'starch', 'hydroxyethyl starch derivatives', 'albumin', 'gelatin', 'liver resection', 'hepatic resection', 'fluids', 'fluid therapy', 'crystalloid', 'colloid', 'saline', 'plasma-Lyte', 'plasmalyte', 'hartmann's', 'acetate', and 'lactate'. Search results for MEDLINE and EMBASE were additionally limited to studies on human populations that included adult age groups and publications in English. RESULTS: A total of 113 articles were included after appropriate inclusion criteria screening. Perioperative fluid management as it relates to various anesthetic and surgical techniques is discussed.CONCLUSIONS: Clinicians should have a fundamental understanding of the surgical phases of the resection, hemodynamic goals, and anesthesia challenges in attempts to individualize therapy to the patient's underlying pathophysiological condition. Therefore, an ideal approach for perioperative fluid therapy is always individualized. Planning and designing large-scale clinical trials are imperative to define the optimal type and amount of fluid for patients undergoing major hepatic resection. Further clinical trials evaluating different intraoperative goal-directed strategies are also eagerly awaited.

Plasma-Lyte 148: A clinical review

AIM To outline the physiochemical properties and specific clinical uses of Plasma-Lyte 148 as choice of solution for fluid intervention in critical illness, surgery and perioperative medicine.METHODS We performed an electronic literature search from Medline and Pub Med(via Ovid), anesthesia and pharmacology textbooks, and online sources including studies that compared Plasma-Lyte 148 to other crystalloid solutions. The following keywords were used: "surgery", "anaesthesia", "anesthesia", "anesthesiology", "anaesthesiology", "fluids", "fluid therapy", "crystalloid", "saline", "plasma-Lyte", "plasmalyte", "hartmann's", "ringers" "acetate", "gluconate", "malate", "lactate". All relevant articles were accessed in full. We summarized the data and reported the data in tables and text. RESULTS We retrieved 104 articles relevant to the choice of Plasma-Lyte 148 for fluid intervention in critical illness, surgery and perioperative medicine. We analyzed the data and reported the results in tables and text.CONCLUSION Plasma-Lyte 148 is an isotonic, buffered intravenous crystalloid solution with a physiochemical composition that closely reflects human plasma. Emerging data supports the use of buffered crystalloid solutions in preference to saline in improving physicochemical outcomes. Further large randomized controlled trials assessing the comparative effectiveness of PlasmaLyte 148 and other crystalloid solutions in measuring clinically important outcomes such as morbidity and mortality are needed.

Dietary advanced glycation end-products aggravate non-alcoholic fatty liver disease

AIM To determine if manipulation of dietary advanced glycation end product(AGE), intake affects nonalcoholic fatty liver disease(NAFLD) progression and whether these effects are mediated via RAGE. METHODS Male C57Bl6 mice were fed a high fat, high fructose, high cholesterol(HFHC) diet for 33 wk and compared with animals on normal chow. A third group were given a HFHC diet that was high in AGEs. Another group was given a HFHC diet that was marinated in vinegar to prevent the formation of AGEs. In a second experiment, RAGE KO animals were fed a HFHC diet or a high AGE HFHC diet and compared with wildtype controls. Hepatic biochemistry, histology, picrosirius red morphometry and hepatic mR NA were determined. RESULTS Long-term consumption of the HFHC diet generated significant steatohepatitis and fibrosis after 33 wk. In this model, hepatic 4-hydroxynonenal content(a marker of chronic oxidative stress), hepatocyte ballooning, picrosirius red staining, α-smooth muscle actin and collagen type 1A gene expression were all significantly increased. Increasing the AGE content of the HFHC diet by baking further increased these markers of liver damage, but this was abrogated by pre-marination in acetic acid. In response to the HFHC diet, RAGE-/-animals developed NASH of similar severity to RAGE+/+ animals but were protected from the additional harmful effects of the high AGE containing diet. Studies in isolated Kupffer cells showed that AGEs increase cell proliferation and oxidative stress, providing a likely mechanism through which these compounds contribute to liver injury. CONCLUSION In the HFHC model of NAFLD, manipulation of dietary AGEs modulates liver injury, inflammation, and liver fibrosis via a RAGE dependent pathway. This suggests that pharmacological and dietary strategies targeting the AGE/RAGE pathway could slow the progression of NAFLD.

Pharmacokinetics and pharmacodynamics of lignocaine: A review

Lignocaine is an essential drug on World Health Organisation essential drug list, considered efficacious, safe and cost-effective for any health-care system. Despite its ubiquitous use in medicine and surgery, there are few detailed reviews of its pharmacokinetics and pharmacodynamics. Being an amide-type local anesthetic and Class 1b antiarrhythmic, lignocaine is most frequently used clinically for its anesthetic and antiarrhythmic benefits. However, lignocaine has important antinociceptive, immuno-modulating, and antiinflammatory properties. Information pertaining to the pharmacokinetics and pharmacodynamics of lignocaine was examined by performing a literature search of Pub Med, Embase and MEDLINE(via Ovid), pharmacology textbooks and online sources. We present a focused synopsis of lignocaine's pharmacological composition, indications for use and mechanisms of action, focusing on its anti-inflammatory, immuno-modulating and analgesia effects. In addition we review the dosing regimes and infusion kinetics of lignocaine in the clinical setting. Finally, we review the evidence for ligocaine's modulation of the inflammatory response during major surgery and its specific effects on cancer recurrence. These indirect effects of local anesthetics in tumor development may stem from the reduction of neuroendocrine responses to the stress response elicited by major surgery and tissue damage, enhanced preservation of immune-competence, in addition to opioid-sparing effects of modulating tumor growth.

Compliance in patients with dietary hyperoxaluria: A cohort study and systematic review

Objective:Hyperoxaluria leads to calcium oxalate crystal formation and subsequent urolithiasis.This study aims to analyse the effect of treatment compliance in hyperoxaluria,firstly by analysis of patients with non-primary hyperoxaluria and secondly via systematic review in patients with any hyperoxaluria.Methods:In a retrospective cohort study,adults with non-primary hyperoxaluria managed with dietary counselling in 2013 were enrolled.Twenty-four-hour(24 h)urine collections initially and at 6 months were obtained.Compliance was assessed by self-reported dietary compliance and 24 h urinary volume>2 L.Patients were followed for 24 months.Primary outcomes were urinary oxalate and calcium 24 h load at 6 months,and urolithiasis-related procedural rates at 24 months.A Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA)-compatible systematic review of compliance among hyperoxaluric patients was performed.Results:In the cohort study,of 19 eligible patients(4 female)with median age 52 years,10(53%)were considered compliant.Compared with the non-compliant group,these patients had significantly increased subsequent 24 h urinary volume(2250 mL vs.1600 mL;p=0.008)and lower procedural rates(10%vs.56%;p=0.033).Subsequent 24 h urinary oxalate load was nonsignificantly lower in compliant patients.Systematic review regarding compliance in hyperoxaluric patients revealed five studies.Only one utilised dietary counselling or analysed compliant vs.non-compliant patients,finding no difference.None examined the effect of compliance on procedural rates.

Thromboelastography in elective total hip arthroplasty

BACKGROUND Hypercoagulability plays an important role in predisposing patients to venous thromboembolism(VTE)after total hip arthroplasty(THA).We used thromboelastography(TEG)to examine the coagulation status of patients undergoing THA.AIM To examine coagulation as measured by TEG in patients undergoing THA who received standard VTE chemoprophylaxis with enoxaparin.METHODS After ethical approval,we performed a retrospective analysis of data collected in patients undergoing primary elective THA.We analyzed TEG data on samples performed before skin incision,intraoperatively and for 5 d postoperatively.Conventional coagulation tests were performed preoperatively and on postoperative day 5.RESULTS Twenty patients undergoing general anesthesia and 32 patients undergoing spinal anesthesia(SA)were included.TEG demonstrated a progressively hypercoagulable state postoperatively,characterized by elevated maximum amplitude.TEG also demonstrated transient intraoperative hypercoagulability in patients receiving SA.In contrast,conventional coagulation tests were normal in all patients,pre-and postoperatively,except for an increase in plasma fibrinogen day 5 postoperatively.CONCLUSION Despite VTE prophylaxis,patients following total hip replacement remain in a hypercoagulable state as measured by both TEG and conventional tests.This group may benefit from more optimal anticoagulation and/or additional perioperative hemostatic monitoring,via TEG or otherwise.

Comprehensive neurocognitive assessment of patients with anorexia nervosa

AIM:To utilise a comprehensive cognitive battery to gain a better understanding of cognitive performance in anorexia nervosa(AN).METHODS:Twenty-six individuals with AN and 27 healthy control participants matched for age,gender and premorbid intelligence,participated in the study.A standard cognitive battery,the Measurement and Treatment Research to Improve Cognition in Schizophrenia Consensus Cognitive Battery,was used to investigate performance on seven cognitive domains with the use of 10 different tasks:speed of processing[Brief Assessment Of Cognition In Schizophrenia:Symbol Coding,Category Fluency:Animal Naming(Fluency)and Trail Making Test:Part A],attention/vigilance[Continuous Performance Test-Identical Pairs(CPT-IP)],working memory[Wechsler Memory Scale(WMS?-Ⅲ):Spatial Span,and Letter-Number Span(LNS)],verbal learning[Hopkins Verbal Learning Test-Revised],visual learning[Brief Visuospatial Memory Test-Revised],reasoning and problem solving[Neuropsychological Assessment Battery:Mazes],and social cognition[Mayer-Salovey-Caruso Emotional Intelligence Test:Managing Emotions].Statistical analyses involved the use of multivariate and univariate analyses of variance.RESULTS:Analyses conducted on the cognitive domain scores revealed no overall significant difference between groups nor any interaction between group and domain score[F(1,45)=0.73,P=0.649].Analyses conducted on each of the specific tasks within the cognitive domains revealed significantly slower reaction times for false alarm responses on the CPT-IP task in AN[F(1,51)=12.80,P<0.01,Cohen’s d=0.982]and a trend towards poorer performance in AN on the backward component of the WMS?-ⅢSpatial Span task[F(1,51)=5.88,P=0.02,Cohen’s d=-0.665].The finding of slower reaction times of false alarm responses is,however,limited due to the small number of false alarm responses for either group.CONCLUSION:The findings are discussed in terms of poorer capacity to manipulate and process visuospatial material in AN.

Alcohol intake is associated with a decreased risk of developing primary biliary cholangitis

BACKGROUND Primary biliary cholangitis(PBC)is a chronic progressive liver disease of unknown aetiology characterised by immune-mediated destruction of small and medium-sized intrahepatic bile ducts.There are few well-established risk factors and epidemiological studies are needed to further evaluate the pathogenesis of the disease.AIM To evaluate the relationship between alcohol intake,smoking and marijuana use with PBC development.METHODS We conducted a prevalent case control study of 200 cases and 200 age(within a five year age band)and sex-matched controls,identified from the Victorian PBC prevalence study.We assessed lifetime alcohol intake and smoking behaviour(both tobacco and marijuana)prior to PBC onset and used conditional logistic regression for analyses.RESULTS Alcohol intake consistently showed a dose-dependent inverse association with case status,and this was most substantial for 21-30 years and 31-40 years(Ptrend<0.001).Smoking was associated with PBC,with a stronger association with a longer duration of smoking[e.g.,adjusted OR 2.27(95%CI:1.12-4.62)for those who had smoked for 20-35 years].There was no association between marijuana use and PBC.CONCLUSION Alcohol appears to have an inverse relationship with PBC.Smoking has been confirmed as an environmental risk factor for PBC.There was no association between marijuana use and PBC.

Enhanced apoptosis in post-liver transplant hepatitis C:Effects of virus and immunosuppressants

Hepatitis C(HCV)-infected patients have a poorer survival post-liver transplantation compared to patients transplanted for other indications,since HCV recurrence post-transplant is universal and commonly follows an aggressive course.There is increasing evidence that in the non-transplant setting,induction of hepatocyte apoptosis is one of the main mechanisms by which HCV drives liver inflammation and fibrosis,and that HCV proteins directly promote apoptosis.Recent studies have shown that post-liver transplant,there is a link between high levels of HCV replication,enhanced hepatocyte apoptosis and the subsequent development of rapidly progressive liver fibrosis.Although the responsible mechanisms remain unclear,it is likely that immunosuppressive drugs play an important role.It is well known that immunosuppressants impair immune control of HCV,thereby allowing increased viral replication.However there is also evidence that immunosuppressants may directly induce apoptosis and this may be facilitated by the presence of high levels of HCV replication.Thus HCV and immunosuppressants may synergistically interact to further enhance apoptosis and drive more rapid fibrosis.These findings suggest that modulation of apoptosis within the liver either by changing immunosuppressive therapy or the use of apoptosis inhibitors may help prevent fibrosis progression in patients with post-transplant HCV disease.

Haemostatic management for aortic valve replacement in a patient with advanced liver disease

Redo-sternotomy and aortic valve replacement in patients with advanced liver disease is rare and associated with a prohibitive morbidity and mortality. Refractory coagulopathy is common and a consequence of intense activation of the coagulation system that can be triggered by contact of blood with the cardiopulmonary bypass circuitry, bypass-induced fibrinolysis, plate-let activation and dysfunction, haemodilution, surgical trauma, hepatic decompensation and hypothermia. Management can be further complicated by right heart dysfunction, porto-pulmonary hypertension, poor myocardial protection, and hepato-renal syndrome. Complex interactions between coagulation/fibrinolysis and systemic inflammatory response syndrome reactions like "post-perfusion-syndrome" also compound haemostatic failure. Given the limited information available for the specific management and prevention of cardiopulmonary bypass-induced haemostatic failure, this report serves to guide the anaesthesia and medical management of future cases of a similar kind. We discuss our multimodal management of haemostatic failure using pharmacological strategies, thromboelastography, continuous cerebral and liver oximetry, and continuous cardiac output monitoring.