Dyspnea and respiratory muscle strength in end-stage liver disease.

AIM: To investigate the prevalence of chronic dyspnea and its relationship to respiratory muscle function in end-stage liver disease. METHODS: Sixty-eight consecutive, ambulatory, Caucasian patients with end-stage liver disease, candidates for liver transplantation, were referred for preoperative respiratory function assessment. Forty of these (29 men) were included in this preliminary study after applying strict inclusion and exclusion criteria. Seventeen of 40 patients (42%) had ascites, but none of them was cachectic. Fifteen of 40 patients (38%) had a history of hepatic encephalopathy, though none of them was symptomatic at study time. All patients with a known history and/or presence of co-morbidities were excluded. Chronic dyspnea was rated according to the modified medical research council (mMRC) 6-point scale. Liver disease severity was assessed according to the Model for end-stage liver disease (MELD). Routine lung function tests, maximum static expiratory (Pemax) and inspiratory (Pimax) mouth pressures were measured. Respiratory muscle strength (RMS) was calculated from Pimax and Pemax values. In addition, arterial blood gases and pattern of breathing (VE: minute ventilation; VT: tidal volume; VT/TI: mean inspiratory flow; TI: duration of inspiration) were measured. RESULTS: Thirty-five (88%) of 40 patients aged (mean ± SD) 52 ± 10 years reported various degrees of chronic dyspnea (mMRC), ranging from 0 to 4, with a mean value of 2.0 ± 1.2. MELD score was 14 ± 6. Pemax, percent of predicted (%pred) was 105 ± 35, Pimax, %pred was 90 ± 29, and RMS, %pred was 97 ± 30. These pressures were below the normal limits in 12 (30%), 15 (38%), and 14 (35%) patients, respectively. Furthermore, comparing the subgroups of ascites to non-ascites patients, all respiratory muscle indices measured were found significantly decreased in ascites patients. Patients with ascites also had a significantly worse MELD score compared to non-ascites ones (P = 0.006). Significant correlations were found between chronic dyspnea and respiratory muscle function indices in all patients. Specifically, mMRC score was significantly correlated with Pemax, Pimax, and RMS (r = -0.53, P < 0.001; r = -0.42, P < 0.01; r = -0.51, P < 0.001, respectively). These correlations were substantially closer in the non-ascites subgroup (r = -0.82, P < 0.0001; r = -0.61, P < 0.01; r = -0.79, P < 0.0001, respectively) compared to all patients. Similar results were found for the relationship between mMRC vs MELD score, and MELD score vs respiratory muscle strength indices. In all patients the sole predictor of mMRC score was RMS (r = -0.51, P < 0.001). In the subgroup of patients without ascites this relationship becomes closer (r = -0.79, P < 0.001), whilst this relationship breaks down in the subgroup of patients with ascites. The disappearance of such a correlation may be due to the fact that ascites acts as a "confounding" factor. PaCO2 (4.4 ± 0.5 kPa) was increased, whereas pH (7.49 ± 0.04) was decreased in 26 (65%) and 34 (85%) patients, respectively. PaO2 (12.3 ± 0.04 kPa) was within normal limits. VE (11.5 ± 3.5 L/min), VT (0.735 ± 0.287 L), and VT/TI (0.449±0.129 L/s) were increased signifying hyperventilation in both subgroups of patients. VT/TI was significantly higher in patients with ascites than without ascites. Significant correlations, albeit weak, were found for PaCO2 with VE and VT/TI (r = -0.44, P < 0.01; r = -0.41, P < 0.01, respectively). CONCLUSION: The prevalence of chronic dyspnea is 88% in end-stage liver disease. The mMRC score closely correlates with respiratory muscle strength.

Alopecia: a common paraneoplastic manifestation of cholangiocarcinoma in humans and animals.

The coincidence of alopecia and a tumour may indicate the paraneoplastic nature of alopecia. Paraneoplastic alopecia is not uncommon in animals, feline paraneoplastic alopecia being the best example known. We present a case of alopecia coinciding with the presentation of a cholangiocarcinoma in a woman. Following surgical resection of the tumour, alopecia resolved spontaneously and it reappeared on local recurrence, 2 years later. As far as pathogenesis is concerned, the coincidence of alopecia and cholangiocarcinoma may indicate the paraneoplastic nature of alopecia as a rare complication of this rare tumour in humans. This also implies that common interspecies mechanism(s) must exist as far as this paraneoplastic complication is concerned.

Mirizzi Syndrome: an unexpected problem of cholelithiasis. Our experience with 27 cases.

PURPOSE: Mirizzi syndrome is a rare complication of long standing cholelithiasis. The purpose of this study is to retrospectively estimate the diagnostic and treatment methods applied in patients with Mirizzi syndrome. MATERIALS AND METHODS: Our experience with 27 cases with Mirizzi syndrome is presented. They were diagnosed either by imaging techniques, or during surgical operation. All of the patients were managed surgically. RESULTS: 8 patients were diagnosed preoperatively and the rest intraoperatively. Morbidity rate after surgery was 18,5%, and mortality rate was zero. The patients presented free of symptoms three months after surgery during the follow-up. CONCLUSION: Mirizzi syndrome is rarely diagnosed preoperatively and US proved inadequate for this purpose. Surgery is the only therapy and usually provides additionally definitive diagnosis.

Anastomosis between the median and ulnar nerve in the forearm. An anatomic study and literature review.

Anastomosis between the median and ulnar nerve in the forearm has been shown to be of clinical significance. We aimed to determine the presence of median to ulnar nerve communications in the forearm of the Greek population by anatomical studies. At the same time we defined the types and patterns of the anastomoses found and compared them to those reported in similar studies that were retrieved after a wide review of the literature. One hundred and sixty three forearms from 100 cadavers (53 males, 47 females, 25-91 years old) were carefully dissected to observe median and ulnar nerve communication. The anastomosis was found in 10 cadavers; it was bilateral in 4 and unilateral in 6, on the right side in four and on the left side in two. It occurred in 7 of the 53 male cadavers (14%) and in 3 of the 47 females (6.5%). Overall, the anastomosis was found in 14 of the 163 forearms (8.6%). No case of ulnar to median nerve anastomosis in the forearm was found in anatomical examination.