Portopulmonary hypertension in liver transplant candidates

Pulmonary vascular disorders including portopulmonary hypertension(PoPHT) are among the common complications of liver disease and are prognostically significant. Survival is very low without medical treatment and liver transplantation. With advances in medical therapy for elevated pulmonary artery pressure(PAP) and liver transplant surgery, survival of patients with Po PHT and advanced liver disease is significantly improved. Because of the prognostic significance of Po PHT and the limited donor pool, a comprehensive preoperative cardio-pulmonary assessment is of great importance in cirrhotic patients prior to transplant surgery. Therefore, a detailed transthoracic Doppler echocardiographic examination must be an essential component of this evaluation. Patients with mild Po PHT can safely undergo liver transplant surgery. In cases of moderate to severe Po PHT, right heart catheterization(RHC) should be performed. In patients with moderate to severe Po PHT on RHC(mean PAP 35-45 mm Hg), vasodilator therapy should be attempted. Liver transplantation should be encouraged in cases that demonstrate a positive response. Bridging therapy with specific pulmonary arterial hypertension treatment agents should be considered until the transplant surgery and should be continued during the peri- and post-operative periods as needed.

Combination of allopurinol and hyperbaric oxygen therapy:A new treatment in experimental acute necrotizing pancreatitis?

AIM： To investigate the individual and combined effects of allopurinol and hyperbaric oxygen （HBO） therapy on biochemical and histopathological changes, oxidative stress, and bacterial translocation （BT） in the experimental rat acute pancreatitis （AP）. METHODS： Eighty-five Sprague-Dawley rats were included in the study. Fifteen of the eighty-five rats were used as controls （sham, Group I ）. AP was induced via intraductal taurocholate infusion in the remaining seventy rats. Rats that survived to induction of acute necrotizing pancreatitis were randomized into four groups. Group H received saline, Group m allopurinol, Group IV allopurinol plus HBO and Group v HBO alone. Serum amylase levels, oxidative stress parameters, BT and histopathologic scores were determined. RESULTS： Serum amylase levels were lower in Groups Ⅲ, Ⅳ and v compared to Group H （974 ± 110, 384 ± 40, 851 ＋ 56, and 1664 Ⅳ 234 U/L, respectively, P 〈 0.05, for all）. Combining the two treatment optionsrevealed significantly lower median [25-75 percentiles] histopathological scores when compared to individual administrations （13 [12.5-15] in allopurinol group, 9.5 [7-11.75] in HBO group, and 6 [4.5-7.5] in combined group, P 〈 0.01）. Oxidative stress markers were significantly better in all treatment groups compared to the controls. Bacterial translocation into the pancreas and mesenteric lymph nodes was lower in Groups m, iV and v compared to Group H （54%, 23%, 50% vs 100% for translocation to pancreas, and 62%, 46%, 58% vs 100% for translocation to mesenteric lymph nodes, respectively, P 〈 0.05 for all）. CONCLUSION： The present study confirms the benefit of HBO and allopurinol treatment when administered separately in experimental rat AP. Combination of these treatment options appears to prevent progression of pancreatic injury parameters more effectively.

Evaluation of ischemic lesions after carotid artery stenting with diffusion-weighted imaging

BACKGROUND Almost 90%of cerebral thromboembolism cases are caused by atherosclerosis.Craniocervical atherosclerosis is often observed at the carotid bifurcation and is responsible for 20%-30%of all stroke cases.The course of atherosclerotic carotid artery stenosis varies depending on the grade of stenosis and characteristics of the plaque.Carotid artery stenting(CAS)can be used as a less invasive method in patients with symptomatic and asymptomatic high-grade carotid artery stenosis.Diffusion-weighted imaging(DWI)is an effective method for detection of silent or symptomatic acute ischemic lesions that may arise due to CAS or carotid endarterectomy.The number and volume of new ischemic lesions are determined using DWI.AIM To evaluate the number and volume of ischemic lesions and their cerebral parenchymal and vascular distribution after CAS using DWI.METHODS Forty-seven male(73.4%)and seventeen female(26.6%)patients(total,n=64)aged 42-84 years(mean 67.96±8.03 years)diagnosed with carotid stenosis between October 2006 and July 2012 were included in this retrospective study.Twelve of the cases(18.8%)were asymptomatic,while fifty-two(81.2%)were symptomatic.The area where the stenosis was highest was measured,and the stenosis rate was determined using the North American Symptomatic Carotid Endarterectomy Trial method.DWI of the cases was evaluated by two radiologists experienced in neuroradiology(B.A.with more than 15 years of experience,E.G.with more than 10 years of experience).Routine DWI examinations were carried out by a 1.5 T MR device 1 h before and after the operation.Since the ischemic lesions that developed in the first hour and in the follow-up period of 5-24 h were assumed to be due to CAS,all lesions within the first 24 h were considered as new ischemias.RESULTS In the present study,39 new ischemic lesions were detected in 20 cases.The average number of new lesions after all CAS operations was 0.62.They were mostly located in the occipital lobes,followed by the frontal and parietal lobes.These new ischemic lesions were most common in the middle cerebral artery territory,followed by the posterior cerebral artery territory and middle cerebral artery-posterior cerebral artery watershed areas.New lesions were found in 31.2%(20/64)of patients,including 17(26.5%)in ipsilateral and three(4.6%)in contralateral hemispheres.New bilateral lesions were detected in one case(1.5%).The average volume of the new ischemic lesions detected by the two observers was 1.10 cm³.The numbers of newly appearing ischemic lesions in DWI after CAS were significantly higher in cases where stenting was applied on the left side of the carotid artery and in cases where longer plaques(>1 cm)were responsible for the narrowing in symptomatic patients.The stenosis rate was low in the group with ulcerated plaques.CONCLUSION New ischemic lesions due to CAS appear mostly in the main arterial territory but they may also occur in watershed areas.

The Number of Lymph Nodes and Relationship with Presence of Thyroiditis and Thymic Tissue in the Central Neck Dissection Materials for Thyroid Papillary Carcinoma: Pathologic Analysis

Background: Central lymph node dissection (CLND) for papillary thyroid carcinoma (PTC) allows correct pathologic staging of lymph nodes and planning of postoperative management. The purpose of this study was to determine the number of the lymph nodes in the CLND and the relationship to presence of chronic lymphocytic thyroiditis (CLT) and thymic tissue (TT). Methods: Total thyroidectomy and CLND materials from 153 patients with PTC were included in this study. Two histopathologic features (presence of CLT and TT) were evaluated for their value in adequacy of CLND. Results: Histopathologic examination revealed CLT and TT in CLND materials in 70 (46%) and 63 (41%) patients, respectively. Total number of lymph nodes in CLND materials was significantly higher in CLT (+) and TT (+) groups (p Conclusions: Our study demonstrates that presence of CLT in thyroid gland has been associated with higher number of central lymph nodes mainly due to increased number of benign hyperplastic lymph nodes. It may be possible to conclude that upper limit of lymph nodes for satisfactory CLND would be higher to correctly evaluate central lymph node status in existing staging systems if specimens have CLT. Results of this study also show that the presence of TT in surgical materials may represent the adequacy of CLND.

Epstein Barr Virus Infection Induced Suspected Acute Myocarditis in COVID-19 Pandemic

Background: Epstein Barr Virus infection (EBV) could be associated with cardiovascular disease, including myocarditis. We informed a case of EBV infection presenting initially as myocarditis, followed 5 days later by the typical symptoms of infectious mononucleosis. Case Presentation: A 19-year-old man with persistent retrosternal chest pain was admitted to the emergency department. On physical examination, the patient had sub-febrile fever (37.2°C) and palpable cervical lymphadenopathy, with no hepatosplenomegaly. Initial ECG has repolarization abnormalities in leads II, aVF and III. Laboratory testing revealed elevated cardiac enzymes and liver enzymes (high sensitive troponin I levels 3000 ng/mL, aspartate transaminase 158 U/L, alanine transaminase 100 U/L). Blood white cells were 10,500 μL, platelet level were low 98,000 (thrombocytopenia), and lenfo-monocytosis in complete blood count. We hospitalized the patients the intensive coronary unit (ICU) because of high troponin levels. We recognized hypokinesia of the posterolateral wall of the left ventricle with mild impaired systolic function and increased perimyocardial brightness by echocardiography. Antibody serology tests showed that the anti-EBV capsid antigen IgM (EBV-VCA) was positive, EBV-VCA) IgG was negative. Other etiologies were excluded. Therefore, the patient was referred to cardiac positron emission tomography due to technic problems of magnetic resonance imaging device. We documented in positron emission tomography imaging that increased 18F-FDG uptake on posterior and posterolateral walls of left ventricle (indicating a large jeopardized area). We diagnosed suspected diagnosis of myocarditis without associated pericarditis. We monitored the patient and gave beta blocker, and aldosterone antagonists. Complications in the intensive care unit not occurred. We discharged patients after one week. After three weeks, we re-evaluated the patient. We not observed wall segment motion abnormality on echocardiography and liver tests were near normal. Conclusion: In suspected EBV myocarditis, 18F-FDG PET-CT cardiac positron emission tomography imaging represents an interesting noninvasive imaging technique to identify inflammatory processes in acute myocarditis and can be considered in patients with contraindications/unavailable to cardiac magnetic resonance.

Staging of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the third leading cause of cancer deaths in the world. In contrast to other cancers, survival of patients with HCC is determined by the extent of the tumor in addition to underlying liver disease and its functional reserve. From risk factors to management, HCC reveals a considerable geographic and institutional variation throughout the world. Although many staging and/or scoring systems have been proposed, each prognostic system has several benefits and limitations on its own. Therefore, there is currently no globally accepted system for HCC due to the extreme heterogeneity of the disease. In this review, currently available staging systems for assessing the prognosis of HCC, their uses, limitations, and future prospects are revisited.