Acute Budd-Chiari syndrome due to a simple liver cyst.

Simple liver cysts are common, rarely causing significant morbidity or mortality. Budd-Chiari syndrome (BCS) is caused by obstruction of hepatic venous outflow and is the leading cause of postsinusoidal liver failure. We present a rare case of BCS caused by a simple hepatic cyst. A 16 cm × 16 cm liver cyst was found on computed tomography of a 66-year-old woman presenting with abdominal pain. The cyst had become infected, thus enlarged, exerting mass effect with almost complete compression of the inferior vena cava. Shortly after admission, the patient developed acute liver failure, with deranged clotting and hepatic encephalopathy requiring full organ support on the intensive care unit. Cardiac output studies showed a low cardiac index of 1.4 l/min/m(2). An emergency laparotomy with fenestration of the cyst and drainage of 2l of purulent material led to a full recovery. Intraoperative cystic fluid aspirates later confirmed no evidence of Echinococcus. Histology confirmed a simple cyst. Liver biopsies showed severe, confluent, bridging necrosis, without background parenchymal liver disease. Acute BCS due to rapid compression of all major hepatic veins leading to fulminant hepatic failure is rare. Our case highlights a clinically significant complication of a simple liver cyst of which clinicians should be aware when managing these 'innocent' lesions.

Role of an improvement in acid-base status and nutrition in CAPD patients.

Short-term correction of metabolic acidosis in normal and uremic subjects has been shown to decrease protein degradation, but the long-term effects of better correction of acidosis on nutrition in ESRF are unknown. The aim of this study was to assess the possible benefits, in the nutritional state and morbidity, of improved correction of acidosis in the first year of treatment with continuous ambulatory peritoneal dialysis (CAPD). Two hundred consecutive new CAPD patients were randomized, in a single-blind fashion, to receive a high (HA; lactate 40 mmol/liter) or low (LA; lactate 35 mmol/liter) alkali dialysate for one year. Calcium carbonate and sodium bicarbonate were also used to correct acidosis in the HA group. At one year, the venous serum bicarbonate and arterial pH were 7.44 +/- 0.004 and 27.2 +/- 0.3 mmol/liter in the HA group, and 23.0 +/- 0.3 mmol/liter and 7.4 +/- 0.004 in the LA group (P < 0.001). Dialysis dose, at one year or at the point of leaving the study (HA 8.0 +/- 0.1 liters/day vs. LA 8.5 +/- 0.3 liters/day) was not significantly different (P = 0.18). At one year, the increase in body weight in the HA group (6.1 +/- 0.66 kg) was higher than in the LA group (3.71 +/- 0.56 kg, P < 0.05). The increase in midarm circumference in the HA patients (1.26 +/- 0.16 cm) was significantly higher than the increase in the LA patients (0.61 +/- 0.16 cm, P < 0.05). The increase in triceps skinfold thickness were not significantly different (HA 2.5 +/- 0.41 mm vs. LA 1.24 +/- 0.38 mm, P = 0.1). Serum albumin was 37.8 +/- 0.4 g/dl at one year in the HA group, and 38.2 +/- 0.5 g/dl in the LA group (NS). Dietary protein intake at one year (HA 0.9 +/- 0.2 g/kg/day vs. LA 1.0 +/- 0.1 g/kg/day) was not significantly different. There were fewer hospital admissions in the HA group (1.13 +/- 0.16 per patient per year) compared to the LA group (1.71 +/- 0.22 per patient per year, P < 0.05). The HA patients spent less days in hospital per year than the LA patients (16.4 +/- 1.4 days/year vs. 21.2 +/- 1.9 days/year; P < 0.05). It is concluded that better correction of metabolic acidosis leads to greater increases in body weight and midarm circumference, but not triceps skinfold thickness, in the first year of CAPD. The improvement in morbidity, in terms of number of admissions and days in hospital per year, may be associated with the improvement in nutritional state.

The beneficial effects of oral nifedipine on cyclosporin-treated renal transplant recipients--a randomised prospective study.

The aim of this study was to test the hypothesis that nifedipine will improve graft survival in cyclosporin A (CyA)-treated renal transplant recipients. One hundred and forty-seven patients were randomised to one of three regimens. Group A received CyA, 7 mg/kg per day, and prednisolone; group B followed the same regimen as group A plus oral nifedipine and group C received CyA, 4 mg/kg per day, prednisolone and azathioprine. Calcium channel blockers were avoided in groups A and C. The crude 2-year (P = 0.0223) and 4-year (P = 0.0181) graft survival was significantly better in group B (86% and 81%, respectively) than in group A (75% and 63%, respectively). Delayed initial function was seen least frequently in group B (10.2%) compared to groups A (31%) and C (28%; P < 0.01). Group B also experienced fewer rejection episodes than groups A and C (P < 0.05). We conclude that the combination of oral nifedipine and CyA significantly improves initial graft function, rejection frequency and long term graft survival.

Peritonitis rate: traditional versus low calcium dialysate.

The results of nonrandomized retrospective studies have suggested that low calcium dialysate (LCD; ionized calcium concentration 1.25 mmol/L) is associated with a higher peritonitis rate than traditional dialysate (TD; ionized calcium concentration 1.75 mmol/L). For this reason, 86 consecutive new continuous ambulatory peritoneal dialysis patients were randomized, in a single-blind fashion, to TD or LCD for 1 year. The results were analyzed on an intention-to-treat basis, no matter what fluid or what modality of treatment was being used at the end of the year. The two groups were well matched at baseline. At 1 year, 28 of 43 TD patients were still on continuous ambulatory peritoneal dialysis (one had a catheter changed due to peritonitis), four had a working transplant, one had recovered renal function, nine had died, and one had been transferred to hemodialysis because of peritonitis. Twenty-seven of 43 LCD patients were on continuous ambulatory peritoneal dialysis (one catheter change), nine had a working transplant, six had died, and one was on hemodialysis. There were 17 proven (33 possible) peritonitis episodes in 417 patient-months in the TD group. In the LCD group, there were 17 (35 possible) episodes in 432 patient-months. The proven peritonitis rate was 0.49 episodes/patient/yr in the TD group versus 0.48 episodes/patient/yr in the LCD group (P = NS). In conclusion, there is no controlled evidence that LCD is associated with a higher incidence of peritonitis than TD.

Influence of nifedipine on interstitial fibrosis in renal transplant allografts treated with cyclosporin A.

AIMS: To compare the degree of interstitial fibrosis in renal transplant biopsy specimens from immunosuppressed patients using conventional doses of cyclosporin with and without calcium channel blockade with a combination of low dose cyclosporin and azathioprine; to correlate the degree of interstitial fibrosis with the glomerular filtration rate. METHODS: A single blind histomorphometric assessment was done of cortical interstitial volume fraction from biopsy specimens taken intraoperatively and at one, six, and 12 months after transplantation from three prospectively randomised groups of patients: (A) conventional dose cyclosporin; (B) conventional dose cyclosporin plus nifedipine; (C) low dose cyclosporin plus azathioprine. RESULTS: Interstitial volume increased with time in all groups. No differences in interstitial volume were present at operation or at one month, but at six months interstitial volume was significantly less in group B than group A (p < 0.001) or group C (p < 0.05). More grafts failed in group A than group B leaving only small numbers for comparison at 12 months. At 12 months the differences persisted but did not reach significance. These results strongly reflected the clinical findings, where glomerular filtration rate was significantly lower in group A than groups B or C at six and 12 months; no differences in glomerular filtration rate were found at one month. In a direct comparison glomerular filtration rate showed a significant negative correlation with interstitial volume fraction. CONCLUSIONS: These findings suggest that calcium channel blockade with nifedipine slows the development of interstitial fibrosis in renal transplant recipients treated with cyclosporin. When clinical data are considered, it is suggested that calcium channel blockade may have a mitigating effect on the long term nephrotoxic effects of cyclosporin and should be considered as adjunctive treatment in patients requiring this immunosuppressant following renal transplantation.

Evidence for a multi-allelic heterokaryon incompatibility (het) locus detected by hybridization among three heterokaryon-compatibility (h-c) groups of Aspergillus nidulans.

A strain of heterokaryon-compatibility (h-c) group A was crossed sexually to strains of h-cB and h-cGL of Aspergillus nidulans. A back-crossing programme established that there were seven hetero-allelic heterokaryon compatibility (het) genes controlling somatic incompatibility between strains of h-cA and h-cB. A similar back-crossing programme between strains of h-cA and h-cGL confirmed that these two groups differ at six het loci. Previous work has shown that h-cB differs from h-cGL at two het loci, hetA on linkage group V and hetB on linkage group VI. As an allelic difference at a single het locus is enough to cause two strains to be heterokaryon incompatible, 15 alleles spread over seven het loci are necessary to explain the h-cA, h-cB, h-cGL triangular compatibility relationship. One het locus is multi-allelic and this locus must be either hetA or hetB.

Nifedipine improves immediate, and 6- and 12-month graft function in cyclosporin A (CyA) treated renal allograft recipients.

To investigate the effect of oral nifedipine, a calcium channel blocker known not to modify cyclosporin A (CyA) pharmacokinetics, on immediate transplant function and CyA nephrotoxicity, 68 adult renal transplant recipients were pre-operatively randomized to one of three regimes: A (high-dose CyA, initial dose 17 mg/kg per day, maintenance dose 7 mg/kg per day); B (regime A plus oral nifedipine); C low-dose CyA, initial dose 10 mg/kg per day, maintenance 4 mg/kg per day plus azathioprine 1 mg/kg per day). All three groups received identical steroid regimes. Calcium channel blockers of all types were avoided in groups A and C. Delayed graft function (dialysis dependence by day 4) was seen least frequently in group B (P < 0.02). Group B had improved graft function at 6 months compared with group A, identified by differences in serum creatinine (P < 0.05), GFR (P < 0.01) and ERPF (P < 0.05). Similar differences in serum creatinine (P < 0.05) and GFR (P < 0.05) were also identified at 12 months. Group C also had better 6- and 12-month GFR values than group A (P < 0.05 each). The three groups did not differ in donor or recipient age, HLA matching, ischaemic or anastomosis times, frequency of early rejection or whole-blood CyA levels. These results indicate that nifedipine significantly improves immediate and medium-term graft function.

Oral Health Status in Southern Malawian School Children : Part 1

This survey is set to determine the oral health status inselected schools in the southern region of Malawi

Oral Health Status in Southern Malawian School Children: Part II

A knowledge; attitude and practice survey (KAP) of 12 year old primary school children and their teachers was carried out in the southern region of Malawi. Two schools; within easy access from a district hospital; were chosen from each district in the southern region. 160 randomly selected questions were examined during June and July 1990 (male:female ratio of appropriately 1:1)

Stopping a walking locust with sound: an analysis of variation in behavioural threshold.

Pulses of 3 kHz sound, varying in intensity from 46 dB SPL to 113 dB SPL (reference value = 20 microPa), were presented to fifth instar larvae of the locust Locusta migratoria migratorioides (R. and F.) walking on a recording treadmill. Walking locusts either responded to the sound by stopping within 2.1 s of its presentation or they continued walking apparently unaffected by it. The latency of the stopping response was correlated with stimulus intensity: the higher the stimulus intensity, the sooner the locust stopped walking. Pauses induced by sounds were longer than those that occurred 'spontaneously' and increased in duration with increasing stimulus intensity. This relationship, however, was modulated by walking speed: the faster the locust was walking, the shorter the following pause for a given stimulus intensity. The intensity of sound needed to elicit a response depended on the length of time the locust had spent in uninterrupted walking before the stimulus was presented. The stopping threshold for sound stimuli presented 3 s into the walking bout was 84 dB SPL (SE +/- 1.56), and at 20 s it was significantly less, at 76 dB SPL (SE +/- 1.56). This effect of time was significant even when other factors, such as differences between individual locusts, were allowed for in the regression analysis. This shift in the behavioural threshold could not be explained simply by on-going changes in walking behaviour, for although the speed of walking was correlated with stopping threshold its effect was not statistically significant when differences between individuals and time of stimulus presentation were allowed for in the regression analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

The location and analysis of two heterokaryon incompatibility (het) loci in strains of Aspergillus nidulans.

The heterokaryon incompatibility system in Aspergillus nidulans has been investigated by parasexual methods. The use of complementary auxotrophs with a repeated serial transfer method or with a protoplast fusion technique has enabled heterokaryons and diploid strains to be recovered from heterokaryon incompatible combinations of strains. The effects of allelic interaction at heterokaryon incompatibility (het) loci on the morphologies of the heterokaryon and diploid colonies isolated are described. Parasexual analyses conducted among strains belonging to the heterokaryon compatibility groups, h-cGl and h-cB, and the two recombinant compatibility classes, have located the hetA and hetB genes to linkage groups V and VI respectively.

Circulating alanine disposal in diabetes mellitus.

Alanine was selected for study as a representative circulating glucose precursor in relation to the question of the source of the excess circulating glucose in diabetes mellitus. U-14C alanine and U-14C glucose infusions were given to healthy subjects and to subjects with untreated mild maturity, severe maturity, and juvenile diabetes. Comparative studies after a 24-hour fast were made in healthy and in mildly diabetic subjects. The alanine production rate was unaltered by fasting or diabetes. The glucose production rate was unaltered by fasting but increased in diabetes in relation to the severity of the disease. The fractions of alanine-to-glucose and of glucose-from-alanine were increased by fasting. The effect of diabetes was different. The fraction of alanine-to-glucose was much less in mild maturity diabetes than in health, and it was increased only in juvenile diabetes. In all the diabetic groups the glucose-from-alanine fraction was much less than in health. In every group the change in the alanine oxidation rate was reciprocal to that in the alanine-derived glucogenesis rate. The results are consistent with the possibility that the principal source of the excess circulating glucose in diabetes is glycogen.

Circulating alanine production and disposal in healthy subjects.

UNLABELLED: Circulating-alanine production and disposal rates were estimated in eight healthy postabsorptive subjects by means of U-14C alanine and U-14C glucose infusions. The mean circulating-alanine production rate was 368 +/- S.E.M. 28 mumol/min. -1.8(2). Approximately 50 percent of circulating-alanine carbon exchanged rapidly with that of circulating lactate. Approximately 30 per cent of circulating alanine exchanged with protein stores. Other disposal was 29 +/- 2 per cent to circulating glucose and 40 +/- 4 per cent to oxidation. CONCLUSIONS: (1) The carbon moieties of circulating alanine and lactate are freely exchangeable. (2) Assessment of the contribution of alanine to gluconeogenesis will depend on establishing the extent to which the precursor pyruvate carbon is derived from glycolysis or from proteolysis. (3) If the principal pyruvate precursor is glycolysis, then the principal specific function of the glucose-alanine cycle appears to be ammonia transport.

Glucose turnover and disposal in maturity-onset diabetes.

The glucose turnover rate in maturity-onset diabetes in man has been variously reported as increased, normal, and decreased. The present experiments suggest that these discrepancies may have been due to methodology, and to nonrecognition of a circadian cycle in the glucose turnover rate that is present in health, and marked in diabetes. During the early morning hours the glucose turnover rate in maturity-onset diabetes is increased in proportion to the fasting blood glucose level. It may reach three to four times the rate found in health. During the evening hours the increments are about one-half as great. The glucose outflow rate constant, k, lower in diabetes than in health, is also lower in both groups in the evening than in the morning. An analysis of the relative contributions of glucose overproduction and underutilization to the development of hyperglycemia in maturity-onset diabetes indicates that overproduction is the greater factor. The relative role of underutilization appears to increase as the fasting blood glucose level increases. The circulating glucose oxidation rate in maturity-onset diabetes is only slightly lower than in health, but the fraction oxidized is markedly lower, and only a small fraction is excreted. The principal conclusion is that in maturity-onset diabetes there is a hypertrophied flux of endogenous glucose, most of which is neither oxidized nor excreted. The precursors and the qualitative and quantitative metabolic fates of this excess glucose are unknown.