How Do Hepatologists Gain Access to Liver Transplant Units?

Liver transplantation has evolved from an experimental treatment to be considered as the most effective therapy for end-stage liver disease and selected cases of hepatocellular carcinoma. Transplant hepatologists must have specific knowledge and abilities to treat those patients who receive a liver transplant. In Spain, approximately 1100 liver transplants are performed each year, and most centers assume both postoperative care and long-term follow-up, which has led to a significant work load in liver transplant units. Despite previous attempts to establish an official training program in hepatology, the Spanish health system does not presently have a specific liver transplant training program to guarantee that future needs of physicians are covered. Collaboration between health authorities and scientific societies is required to guarantee adequate assistance to liver transplant recipients in the future.

High doses of systemic corticosteroids in patients hospitalised for exacerbation of chronic obstructive pulmonary disease. A cohort study. / Dosis altas de corticoides sistémicos en pacientes ingresados por exacerbación de enfermedad pulmonar obstructiva crónica. Un estudio de cohortes.

OBJECTIVES: To assess the effect of high doses of corticosteroids in patients hospitalised for exacerbation of chronic obstructive pulmonary disease (COPD). PATIENTS AND METHODS: A prospective cohort study was conducted on patients hospitalized with COPD between January and March 2015, grouped according to the glucocorticoid dosage administered (cutoff, 40mg of prednisone/day). We compared the results of hospital stay, readmission and mortality at 3 months of discharge. RESULTS: We analysed 87 patients. The median daily dose was 60mg of prednisone (interquartile range, 46.67-82.33mg/day), and the administration route was intravenous in 96.6% of the cases. We established a relative risk (RR) for hospital stays longer than 8 days of 1.095 (95% CI 0.597-2.007; P=.765) when steroid dosages greater than 40mg/day were employed. In these patients, the hazard ratio (HR) for readmission in the 3 months after discharge was 0.903 (95% CI 0.392-2.082; P=.811), and the mortality was 1.832 (95% CI 0.229-16.645; P=.568). Neither the RR nor the HR varied in a statistically significant manner after adjusting for confounding factors. CONCLUSIONS: A daily dose greater than 40mg of prednisone in patients hospitalised for COPD exacerbation was not associated with a shorter hospital stay or a reduction in readmissions or mortality at 3 months.

Everolimus-based immunosuppression in patients with hepatocellular carcinoma at high risk of recurrence after liver transplantation: a case series.

BACKGROUND: Liver transplantation offers the most effective treatment in patients with hepatocellular carcinoma (HCC). However, transplant patients outside the Milan criteria have a high risk of tumor recurrence, which has been linked to standard immunosuppression regimens. Everolimus is a mammalian target of rapamycin inhibitor that has been used for immunosuppression, but its effect on recurrence and survival in HCC patients with a high risk of tumor recurrence has not been examined. We compared long-term survival and cumulative recurrence in high-risk patients receiving everolimus-based immunosuppression after liver transplantation for HCC with an historic control group. METHODS: The everolimus group comprised 21 patients receiving a liver transplant at our center from February 2005 to December 2010. The control group comprised 31 patients receiving a liver transplant from May 1994 to January 2005. All patients received cyclosporine or tacrolimus as initial post-transplant immunosuppression. Patients in the everolimus group switched to everolimus 2 weeks later. RESULTS: There were no differences between the two groups in number of rejection episodes or of infectious or surgical complications. Five-year survival was 60.2% in the everolimus group and 32.3% in the control group (P = .05). Five-year cumulative recurrence rate was 61.3% in the control group and 41.3% in the everolimus group. Treatment with everolimus was identified as an independent predictor of longer survival (hazard ratio = 0.34; P = .02). CONCLUSIONS: Patients receiving liver transplantation for HCC with a high risk of tumor recurrence may well benefit from everolimus-based immunosuppression, with no added risks of rejection or other post-transplant complications.

Relevance of MICA antibodies in acute humoral rejection in renal transplant patients.

The presence of MICA antibodies was examined in eleven patients diagnosed with AHR. MICA typing was performed in both recipients and donors. Sera were collected sequentially: pre-transplant, at the AHR episode and at follow-up. Sera from 30 patients with functioning graft were also analysed. A stable MICA()008 transfected cell line was used as target to identify MICA antibodies. MICA antibodies were not detected pre-transplant nor post-transplant in patients receiving a compatible graft. MICA antibodies were detected post-transplant AHR in patients receiving an incompatible graft. The persistence of MICA antibodies was associated with chronic graft dysfunction in 3 of 4 patients in this series; although it was not always associated with the graft loss in treated AHR. None of the 30 patients in the control group with long-term functioning grafts showed antibodies to MICA()008. This report provides some insights of the relevance of MICA antibodies in AHR.

Carcinoma papilar de tiroides sobre conducto tirogloso persistente / Papillary thyroid carcinoma arising in a thyroglossal duct cyst

La malignización de los quistes del conducto tirogloso es infrecuente y corresponde fundamentalmente, a carcinomas papilares del tejido tiroideo que los constituye. En este trabajo se describe un carcinoma papilar que se asienta sobre el conducto tirogloso en una mujer de 40 años intervenida previamente de bocio multinodular que tenía una biopsia con aguja fina preoperatoria de carcinoma papilar de tiroides (AU)

Malignant transformation of thyroglossal duct cysts is uncommon and usually corresponds to papillary carcinoma of the thyroid tissue constituting the cyst. We report a case of papillary thyroid carcinoma originating in a thyroglossal duct cyst in a 40-year-old woman who had previously undergone surgery for goitre with a prior diagnosis of papillary carcinoma by fine needle punch biopsy (AU)

Obscure gastrointestinal bleeding: a complication of radiation enteritis diagnosed by wireless capsule endoscopy.

Obscure gastrointestinal bleeding is a common disorder and may account for as many as 5% of all gastrointestinal hemorrhages. It is often caused by lesions in the small intestine, which were very complicated to examine prior to the advent of wireless capsule endoscopy. Here we present the case of a 31-year-old woman with obscure gastrointestinal bleeding as a complication of radiation enteritis, which was diagnosed only after she underwent an examination with wireless capsule endoscopy. This technique has proven to be far superior to other radiographic and endoscopic methods in diagnosing obscure gastrointestinal bleeding and pathologies of the small intestine in general.

Indication and results of endoscopic management of sigmoid volvulus.

INTRODUCTIONS: sigmoid volvulus is a relatively common cause of intestinal obstruction, particularly in the elderly and in patients with debilitating conditions. As the risks associated with surgical treatment of the sigmoid volvulus are in many cases too high, conservative (endoscopic) management is an option to be considered. MATERIAL AND METHODS: all emergency lower gastrointestinal endoscopies performed between January 1, 1996 and December 31, 2001 were review and, among these, the cases of diagnosis of sigmoid volvulus were selected. The results of the endoscopic management, percentage of recurrence, mortality rate, complications, surgical procedures etc were evaluated in the select cases. RESULTS: lower gastrointestinal endoscopy was diagnostic in all cases. Endoscopic management showed and overall efficacy of 87.5%. recurrence appeared in approximately 57% of the cases. Successful treatment was accomplished for the first episode in 25% of the cases. In case of recurrence, endoscopic management could be performed again with similar efficacy and safety. CONCLUSIONS: endoscopic reduction is a safe and successful technique for the management of emergency sigmoid volvulus, provided vascular compromise in the intestinal wall is ruled out. As recurrence is frequent, elective definitive surgery could be a treatment to consider. Endoscopic management could be the only choice treatment in the case of patients not it for surgery due to the very important risks associated with it their cases.

[Intraoral non-Hodgkin's lymphoma. Presentation of 4 clinical cases]. / Linfoma no-Hodgkin intraoral. Presentación de 4 casos clínicos.

The non-Hodgkin lymphomas (NHL) represent an heterogeneous group of malignancies of lymphoreticular histogenesis. In most cases, they initially arise within lymph nodes but so-called extranodal lymphomas are also found. The NHL has low incidence in the oral cavity. It may involve bone and/or soft tissues as a primary or secondary manifestation. We present a review of the literature and four clinical cases of intraoral NHL. The first couple of cases are primary forms, the third one is associated to HIV infection and the last one is an oral presentation as a component of more widely disseminated disease.

Computed tomography, angiography, and endoscopic retrograde cholangiopancreatography in the nonoperative management of hepatic and splenic trauma.

There is a marked trend toward nonoperative management of abdominal trauma. This has been possible thanks to the advances in imaging and interventional techniques. In this work we review in which way computed tomography (CT) abdominal scans, angiography, and endoscopic retrograde cholangiopancreatography (ERCP) can guide the nonoperative management of hepatic and splenic trauma. The CT abdominal scan with intravenous contrast is the "departure imaging" of choice for the nonoperative management of hepatic and splenic trauma in the hemodynamically stable patient. It is the most accurate test for detecting, defining, and characterizing these injuries, the associated hemoperitoneum, and other abdominal abnormalities (the hollow viscus injuries missed on the CT scan were detected by clinical parameters and had no negative consequences in the outcome). It has an accuracy of more than 95% for these injuries, but CT grading alone cannot decide which patient can be treated conservatively and which patient requires surgery. Its usefulness for follow-up seems challenging. Angiography can be therapeutic, thereby avoiding surgery (some report that angiography can be performed even in patients with active bleeding as damage control); if vessel injury, active bleeding or hemobilia are suspected on the basis of a CT scan in a stable patient, angiography should be carried out. ERCP should be performed in patients with suspected injury to the biliary tree, even with normal iminodiacetic acid radionuclide scanning (HIDA) if symptoms persist. A biliary stent can be placed. Indications for angiography and ERCP remain unclear.

Thoracoscopic clipping and ligation of a patent ductus arteriosus.

Several techniques of patent ductus arteriosus occlusion primarily by thoracotomy have been practiced. They have shown to be more reliable than nonsurgical procedures. Videothoracoscopy has been useful in several intrathoracic surgical procedures with faster recovery and minimal mortality and morbidity. We report 2 patients with clipping and ligation of a patent ductus arteriosus by a thoracoscopic approach. This technique may be useful in children with a noncomplicated patent ductus arteriosus. It allows an easier recovery and causes less pain.

Angiotensin II binding sites in the rat fetus: characterization of receptor subtypes and interaction with guanyl nucleotides.

Angiotensin II (AII) receptor subtypes were studied in the 18-day gestation fetal rat, using two non-peptide AII antagonists: (2-n-butyl-4-chloro-5-hydroxymethyl-1-(2'-(1H-tetrazol-5-yl) biphenyl-4-yl)methyl)imidazol (DuP 753; type 1 (AT1) specific), and 1-(4-amino-3-methylphenyl)methyl-5-diphenacetyl -4,5,6,7-tetrahydro-1-H-imidazo[4,5-c]pyridine-6-carboxylic acid (PD 123177; type 2 (AT2) specific). Autoradiography using 125I(-)[Sar1,Ile8]AII showed that 10 microM PD 123177 decreased binding to near-nonspecific levels in skin, skeletal muscle and adrenal medulla, whereas 10 microM DuP 753 blocked binding in the liver and lung. Studies in skin and liver membranes confirmed the autoradiographic data: AT1 receptors were predominant in the liver (95%), and AT2 in the skin (97%). There was no cross-reactivity between receptor subtype and the heterologous antagonist up to a concentration of 10 microM. In both skin and liver, 2 mM dithiothreitol enhanced the binding of AT2 receptors by increasing receptor affinity, but inhibited binding of AT1 by decreasing the receptor number. In the absence of antagonists, guanyl nucleotides, added at equilibrium, caused marked dissociation of 125I-AII binding in liver membranes, but had minimal effect in skin. However, dissociation occurred in the skin when AT2 sites were blocked with 10 microM PD 123177, and in liver, dissociation was not observed when AT1 sites were blocked with DuP 753. Hence, in contrast to classical AII target tissues, which contain predominantly AT1, most of the sites in fetal skin and skeletal muscle are AT2. The demonstration that the effects of guanyl nucleotides are selective for receptor subtype suggests that the AT1 receptor, but not the AT2, is coupled to cell function via guanyl nucleotide binding proteins. The functional importance of the AT2 receptors and their role in fetal physiology is under current investigation.

Differential distribution of AT1 and AT2 angiotensin II receptor subtypes in the rat brain during development.

Angiotensin II (AII) receptor subtypes were analyzed in the brains of adult and 2-week-old rats by in vitro autoradiography with 125I-labeled [Sar1,Ile8]AII and competition studies with three AII antagonists: the nonpeptide antagonist, DuP 753, which is specific for AT1 receptors that mediate the calcium-inositol phospholipid signaling actions of AII; and nonpeptide (PD 123177) and peptide (CGP 42112A) antagonists that are selective for AT2 receptors of yet unknown function. In the adult rat brain, DuP 753 inhibited radioligand binding to the circumventricular organs and paraventricular nucleus but not to the lateral septum, subthalamic nucleus, and inferior olive. However, binding of 125I-labeled [Sar1,Ile8]AII in the latter regions was inhibited by the AT2 receptor antagonists PD 123177 and CGP 42112A. These areas showed similar displacement by the AT2 receptor subtype-specific antagonists in 2-week-old rats. In addition, radioligand binding at multiple sites of transient expression of AII receptors in 2-week-old rats, including several thalamic nuclei, the nuclei of the 3rd and 12th cranial nerves, geniculate bodies, cerebellum, and cingulate cortex, was displaced by the AT2 antagonists but not by DuP 753. These studies have demonstrated the presence of two AII receptor subtypes in the brain, one (AT1) in areas related to regulation of blood pressure, water intake, and pituitary hormone secretion, and one (AT2) whose function is not yet defined. The abundance and location of brain AT2 receptors in young animals, and the age-related changes in relative expression of the receptor subtypes, suggest that AII exerts specific actions according to the developmental stage of the central nervous system.