Molecular Adsorbent Recirculating System Treatment Can Reduce Blood Levels of N-Acetylcysteine in Patients With Acetaminophen Overdose: Case Reports.

BACKGROUND: Acetaminophen poisoning continues to be a major cause of liver failure that can lead to liver transplantation. N-acetylcysteine (NAC) is the cornerstone of treatment. Some authors use a Molecular Adsorbent Recirculating System (MARS) system in acetaminophen poisoning. It is reported that the MARS system eliminates acetaminophen more efficiently than conventional dialysis. It is theoretically possible that treatment with MARS administered after NAC will increase the effectiveness of treatment. CASE REPORTS: The first patient, a woman of 14 years old, presented blood levels of 112 mg/dL 12 hours after ingestion of 15 g of acetaminophen. Treatment with NAC was initiated. At 17 and 23 hours after ingestion, blood levels were 23.5 µg/mL and 5.9 µg/mL, respectively. The second patient, a woman of 28 years old, presented blood levels of 115 mg/dL 4 hours after ingestion of 40 g of acetaminophen. Treatment with NAC was initiated. At 14 and 23 hours after ingestion, blood levels were 15.8 µg/mL and <2 µg/mL, respectively. In both patients, we performed MARS after completing treatment with NAC, and after the first session, blood levels were below the lower limit of detection (≤2 µg/mL). DISCUSSION: The correct timing of MARS to avoid interactions with the administered dose of NAC in acetaminophen overdose is essential so as to not impair the effectiveness of this treatment. These considerations in the management of this entity help in the resolution of liver failure, thus avoiding the need for a liver transplant.

Laparoscopic treatment of biliary peritonitis after removal of T-tube in liver transplant patients.

INTRODUCTION: T-tube removal in liver transplant patients can occasionally cause a massive biliary leak and may require surgical treatment for its resolution. We present our experience with a laparoscopic approach to biliary peritonitis in liver transplant patients after the removal of a T-tube. PATIENTS AND METHODS: From January 2003 until February 2010, we performed 351 liver transplantations in 313 recipients, including 135 with a T-tube. After its removal 31 biliary leaks developed (23%); 12 were massive and required surgery, which utilized a laparoscopic approach. RESULTS: The mean length of the intervention was 72.9 ± 12.87 minutes (range = 55-95), without any complications during the procedure, and no need to convert to a laparotomy. Mean hospital stay after the intervention was 6.75 ± 3.88 days (range 4-18). There was no mortality from the procedure. CONCLUSION: The laparoscopic approach for biliary leakage after T-tube removal is indicated when large diffuse acute peritonitis is established a few hours postremoval of the T-tube. This safe procedure treats the complication without the need for another laparotomy.

Tolerancia y quimerismo en el trasplante hepático / Tolerance and chimerism in liver transplantation

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FTY720 inhibits TH1-mediated allogeneic humoral immune response.

Phosphorylated FTY720 is an analog of Sphingosine 1 Phosphate (S1P) with immunosuppressive activity that negatively regulates the expression of S1P-Receptor 1. It also inhibits the migration of CD4 and CD8 single-positive T cells from the thymus to the periphery, sequesters peripheral blood lymphocytes in lymph nodes and Peyer's patches, and delays the exit of effector T cells toward the graft. The aim of our work was to study the effect of FTY720 on the kinetics of skin allograft rejection in a fully mismatched model; euthymic (Euthy) versus thymectomized (ATX) C57BL/6 mice (haplotype H-2(b)) recipients of BALB/c mice (haplotype H-2(d)) donor cells. The animals were injected daily with FTY720 (1 mg/kg) intraperitoneally for 2 weeks. To monitor the humoral immune response, serum samples collected at day 0 (pre-immune) and at day 23 after skin graft rejection were examined using BALB/c thymocytes as antigens in flow cytometry. To confirm the effect of FTY720 on peripheral lymphocytes, peripheral blood was analyzed by flow cytometry. Euthy and ATX FTY720-treated mice showed prolongation of skin allograft survival when compared with nontreated Euthy and ATX controls (P < .005). Unexpectedly, FTY720-treated Euthy mice showed significantly delayed graft rejection when compared to similarly treated ATX mice (P < .005). The delayed graft rejection in FTY720-treated Euthy mice correlated with a reduced content of Th1-mediated IgG(2a) and IgG(2b) antibodies when compared with FTY720-treated ATX mice (P < .05). In conclusion, FTY720 delays the kinetics of allograft rejection in a fully mismatched model by inhibiting Th1-mediated humoral immune responses. The presence of the host thymus appears to be required for this phenomenon.

[Importance of primary health-care professionals in the sanitary education about organ donation]. / Importancia de los profesionales de atención primaria en la educación sanitaria de la donación de órganos.

AIM: To determine the influence of the information on donation generated from primary health-care on the attitude towards organ donation. DESIGN: Descriptive transversal study. SETTING: 45 municipalities of Murcia Region, Spain. PARTICIPANTS: The population in this study was randomly selected and stratified according to age, sex, and geographic localization among people over > or =15 years of age (n=1887). INTERVENTIONS AND MEASURES: The attitude was evaluated according to a questionnaire psychosocial aspects of donation. There is valued the information transmitted on donation to the population from primary care (group A) or other informative sources (group B), and if this information was to favour or in opposition to the same one. STATISTICS: chi2 test, t Student, and logistic regression analysis. RESULTS: Of 1887 surveys, 129 cases (group A) (7%) had received information from primary care. In this group, the 89% is in favour of the donation. In 120 cases the received information was favourable, presenting an attitude in favour of the donation of 93%, whereas in all 9 remaining cases the information was in against, decreasing the attitude to favour up to 44% (P<.05). In the group B (n=1758) the attitude in favour of the donation was of 65% (P<.05, with regard to the group A). The 62% (n=1083) received favourable information, improving in them the favourable attitude towards the donation up to 74%. The rest (38%; n=675) had received also unfavourable information, decreasing his attitude to favour up to 51% (P<.05). CONCLUSIONS: Little information about organ donation is transmitted from primary care, but when it is realized a very positive impact has if it is favourable and very negative if it is unfavourable.

Importancia de los profesionales de atención primaria en la educación sanitaria de la donación de órganos / Importance of Primary Health-Care Professionals in the Sanitary Education About Organ Donation

Objetivo. Determinar la influencia de la información sobre donación generada desde atención primaria (AP) en la actitud poblacional. Diseño. Estudio descriptivo, transversal. Emplazamiento. Un total de 45 municipios de la Comunidad Autónoma de Murcia. Participantes. Muestra aleatoria y estratificada por edad, sexo y localización geográfica entre la población >= 15 años (n = 1.887). Mediciones principales. Encuesta psicosocial sobre donación y trasplante de órganos. Se valora la información transmitida desde AP (grupo A) u otras fuentes informativas (grupo B), y su impacto en la actitud hacia la donación. Se analizan diversas variables psicosociales. Se aplicaron los tests de la * 2 y de la t de Student y un análisis de regresión logística. Resultados. De los 1.887 encuestados, 129 del grupo A (7%) habían recibido información desde AP. En este grupo, el 89% está a favor de la donación. En 120 casos la información recibida fue favorable, con una actitud a favor del tema del 93%, mientras que en los 9 casos restantes la información fue en contra, con lo que dicha actitud favorable descendió al 44% (p < 0,05). En el grupo B (n = 1.758), la actitud a favor de la donación fue del 65% (p < 0,05, respecto al grupo A). El 62% (n = 1.083) recibió una información favorable, con una actitud a favor del 74%. El resto (38%; n = 675) había recibido también información desfavorable, por lo que su actitud favorable disminuyó hasta el 51% (p < 0,05). Conclusiones. Se transmite poca información sobre donación desde AP. Sin embargo, cuando se realiza, tiene un impacto muy positivo si es favorable y muy negativo si es desfavorable (AU)

Aim. To determine the influence of the information on donation generated from primary health-care on the attitude towards organ donation. Design. Descriptive transversal study. Setting. 45 municipalities of Murcia Region, Spain. Participants. The population in this study was randomly selected and stratified according to age, sex, and geographic localization among people over >=15 years of age (n=1887). Interventions and measures. The attitude was evaluated according to a questionnaire psychosocial aspects of donation. There is valued the information transmitted on donation to the population from primary care (group A) or other informative sources (group B), and if this information was to favour or in opposition to the same one. Statistics: * 2 test, t Student, and logistic regression analysis. Results. Of 1887 surveys, 129 cases (group A) (7%) had received information from primary care. In this group, the 89% is in favour of the donation. In 120 cases the received information was favourable, presenting an attitude in favour of the donation of 93%, whereas in all 9 remaining cases the information was in against, decreasing the attitude to favour up to 44% (P<.05). In the group B (n=1758) the attitude in favour of the donation was of 65% (P<.05, with regard to the group A). The 62% (n=1083) received favourable information, improving in them the favourable attitude towards the donation up to 74%. The rest (38%; n=675) had received also unfavourable information, decreasing his attitude to favour up to 51% (P<.05). Conclusions. Little information about organ donation is transmitted from primary care, but when it is realized a very positive impact has if it is favourable and very negative if it is unfavourable (AU)

Efectividad a medio y largo plazo de las campañas escolares a favor de la donación de órganos / Effectiveness in the medium and long term of school campaigns in favour of organ donation

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[Fulminant hepatic failure and liver transplantation. Experience of the Hospital Virgen de la Arrixaca]. / Fracaso hepático fulminante y trasplante hepático. Experiencia del Hospital Virgen de la Arrixaca.

INTRODUCTION: Medical treatment for fulminat hepatic failure seeks spontaneous recovery of the liver function, but the results are very discouraging (50-80% mortality). Liver transplantation is an option in patients with a poor evolution despite medical treatment, with survival rates of > 50%. The ideal moment for performing the transplant is controversial, as it should not be done too soon, when the liver disease is still reversible, or tool late, when the patient is in an irreversible clinical situation. PATIENTS AND METHOD: A retrospective review was made of the clinical histories of 34 patients admitted to our hospital with a diagnosis of fulminant hepatic failure, of whom 26 underwent transplantation. The most frequent cause was viral, with 10 cases (38%); no aetiology at all could be established in 11 cases (42%). Thirteen patients had preoperative complications, the most frequent being renal insufficiency. As for degree of ABO/DR compatibility, 13 cases were identical (40%), 17 compatible (51%) and the other 3 incompatible (9%). RESULTS: Thirty-three transplants were performed in 26 patients: 4 were retransplants due to chronic rejection, 2 for primary graft failure and 1 for hyperacute rejection. The overall mortality rate was 46% (12 patients), the most frequent cause of death being infection (50%). The overall actuarial survival rate was 68% at 1 year, 63% at 3 years and 59% at 5 years. The factors of poor prognosis were renal and respiratory insufficiency, a grade D electroencephalogram, and encephalopathy grades III and IV, the latter being the only prognostic factor identified in the multivariate analysis. The prognostic factors for mortality were a grade D electroencephalogram, encephalopathy grades III and IV and respiratory insufficiency, the latter being the only prognostic factor identified in the multivariate analysis. CONCLUSIONS: The achievement of good results with the use of transplantation in the management of fulminant hepatic failure depends on an optimum selection of transplant candidates, which means identifying them early, i.e. early indication for transplant, reduction in mean waiting time and exclusion of factors of poor prognosis.

Sobre la donación de órganos para trasplantes y la Atención Primaria / About organ donation for trasplantation and Primary Health Care

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Influencia del tipo de material (látex frente a silicona) y de los corticoides en la producción de fibrosis peritoneal por el tubo de kehr. estudio experimental en ratas / Influence of the type of material employed (latex versus silicone) and of corticosteroids on the production of peritoneal fibrosis due to the presence of a "T"-tube: experimental study in rats

Introducción. La producción de fístulas biliares tras la retirada del tubo de Kehr es un problema de la cirugía de la vía biliar que presenta una importancia aún mayor en el trasplante hepático. En su etiología se han barajado diversos factores, entre los que destacan la interferencia que puedan llegar a ocasionar, en el desarrollo del trayecto fibroso en torno al tubo, tanto el tipo de material utilizado (generalmente látex o silicona) como el tratamiento con corticoides que suele ser administrado a estos pacientes. Objetivos. Comparar el grado de adherencias peritoneales producidas por dos tipos de materiales de tubos en "T" (látex y silicona), y analizar la influencia que sobre aquéllas pueda tener la administración de corticoides. Material y métodos. Se han utilizado 50 ratas hembra distribuidas en cinco grupos (control, látex, silicona, látex más corticoides y silicona más corticoides) y se ha estudiado, mediante un sistema de puntuación, el grado de adherencias peritoneales producidas por un fragmento de tubo de Kehr colocado en el espacio subhepático de la cavidad peritoneal. Se calculó un índice de producción de adherencias, que se utilizó para comparar a los grupos entre sí. Resultados. El índice de producción de adherencias media ñ desviación estándar fue: grupo de látex: 6,7 ñ 1,4; grupo de silicona: 2,1 ñ 1,7; grupos de látex tratados con corticoides: 3,5 ñ 1,4, y grupo de silicona más corticoides: 1,2 ñ 1,3. Se encontraron diferencias al comparar los dos materiales (p < 0,001). La administración de corticoides redujo la producción de adherencias tanto en el grupo de látex (p < 0,001) como en el de silicona (p < 0,05). Conclusiones. Los tubos de silicona condicionan una menor formación de adherencias peritoneales postoperatorias que los de látex, y la administración de corticoides reduce dicha formación en ambos casos (AU)

Las revistas nacionales y extranjeras como fuente de información científica de los cirujanos españoles / National and foreign journals as a source of scientific information for Spanish surgeons

Objetivo. Identificar las revistas científicas que ejercen mayor influencia sobre los autores españoles en cirugía general y digestiva; nuestra hipótesis principal fue que la máxima influencia proviene de la bibliografía americana y británica, pero que también la española tiene una alta visibilidad y repercusión. Material y método. Se comparan los resultados obtenidos en el análisis de Cirugía Española con el de las referencias contenidas en los 483 artículos de cirugía publicados en Revista Española de Enfermedades Digestivas entre 1991 y 1995, así como con otras revistas médicas españolas. La relación de revistas citadas fue obtenida directamente de la sección de bibliografía de cada uno de los artículos. De cada referencia se identificaron la revista citada y su nacionalidad, y de cada artículo citador, el área temática de la que se ocupa. Resultados. Más del 90 por ciento de las citas contenidas en artículos de tema quirúrgico corresponden a revistas. Las publicaciones citadas por la Revista Española de Enfermedades Digestivas fueron en orden decreciente de repercusión, además de ella misma, Annals of Surgery, American Journal of Surgery y Surgery, Gynecology and Obstetrics. En Cirugía Española, fueron Annals of Surgery, la propia Cirugía Española, American Journal of Surgery, y Surgery, Ginecology and Obstetrics. Conclusiones. Se confirma la elevada influencia de las publicaciones americanas, británicas y españolas, pero estas últimas limitadas a Revista Española de Enfermedades Digestivas y Cirugía Española. La repercusión de las revistas sobre los autores españoles difiere de la estimada en Science Citation Index (impact factor), lo que demuestra que las fuentes de información utilizadas por éstos son diferentes a las de los americanos (AU)

Ischemia and reperfusion injury of the rat liver: the role of nimodipine.

The protective effect of the calcium channel blocker nimodipine on liver ischemia and reperfusion was studied in the rat. The homeostasis of intracellular calcium ions seems to be a determinant factor in the cell injury that appears after ischemia and reperfusion. Nimodipine was used to downregulate the calcium levels in the cytosol of the ischemic cell, the hypothetical role of Ca2+ in the pathogenesis of ischemia and reperfusion injury. The experimental procedure consisted of the temporary interruption of blood flow to the left lateral and medial lobes of the rat liver and subsequent reperfusion after a period of 45 min of ischemia. Nimodipine (10 micrograms/kg body wt) was administered either before or after the onset of ischemia. The postischemic liver blood flow and liver oxyhemoglobin saturation were recorded using a He-Ne laser Doppler flowmeter and photometer, which showed, in the pretreated group, a recovery of reperfusion blood flow (58.1%) and liver reflectance (85.5%) significantly better (P < 0.01 and P < 0.001) than those in the respective untreated controls of flow (32.8%) and reflectance (70.5%). In the group that received nimodipine after ischemia, the recovery of the blood flow and the postreperfusion liver reflectance were not significantly better than those in the untreated control group. ALT levels (P < 0.05), galactose elimination capacity (P < 0.001), and histological studies also showed a protective effect of calcium antagonist nimodipine when administered before ischemia.

Quantification of duodenogastric reflux in patients with choledochoduodenostomy.

BACKGROUND: Frequently, patients present with symptoms after cholecystectomy (pain or discomfort in the upper part of the abdomen, postprandial fullness, bile vomiting, among others). Duodenogastric reflux has been associated with these symptoms in some patients. Therefore, this study was done to investigate this relationship. STUDY DESIGN: We evaluated duodenogastric reflux (DGR) in ten healthy patients, in ten patients who had asymptomatic simple cholecystectomy, in ten patients who had asymptomatic cholecystectomy with supraduodenal choledochoduodenostomy (CD), and in ten patients who had cholecystectomy plus CD followed by discomfort in the upper abdomen, postprandial fullness and bile vomiting, but no colicky pain or acute cholangitis. Duodenogastric reflux was quantified using continuous intravenous infusion of technetium-99m labeled hepatoiminodiacetic acid (99mTc-HIDA) and subsequently determining its concentration in gastric juice. RESULTS: All of the patients who underwent operation, whatever the technique used, had higher reflux rates than those in the control group (p < 0.001). Moreover, reflux rates were comparable in the patients who underwent simple cholecystectomy compared with patients in the asymptomatic cholecystectomy plus CD group. Conversely, when patients with cholecystectomy plus CD presented with discomfort in the upper part of the abdomen as well as bile vomiting, they had higher reflux rates than patients who underwent simple cholecystectomy (p < 0.001) and asymptomatic patients with associated CD (p < 0.001). CONCLUSIONS: Our results suggest that DGR must be involved in the genesis of these dyspeptic symptoms.

Rat liver blood flow after ischemia and reperfusion. The effects of the platelet-activating factor antagonist WEB-2170 and of removing circulating leukocytes.

The inflammatory response to trauma induces release of platelet activating factor (PAF), which promotes leukocyte adherence to the vascular endothelium. Ischemia and reperfusion induces inflammatory reactions that play a role in reperfusion injury, and here we investigate the role of both PAF and of leukocytes in damage to reperfused rat liver. The experimental procedure consisted of the temporary interruption of blood flow to the left lateral and medial lobes of the rat liver in vivo, and subsequent reperfusion after defined periods. Rats were pretreated either with the PAF-antagonist WEB-2170 or with vinblastine to induce leukopenia, and compared with controls. The postischemic liver blood flow and liver oxyhemoglobin saturation were recorded using an He-Ne Laser doppler flowmeter and photometer. Reperfusion after 30 and 45 min of ischemia was associated with partial recovery to normal values and was inversely proportional to the duration of ischemia. In the WEB-2170-treated group, liver flow and hemoglobin saturation upon reperfusion did not show significant differences when compared with the untreated control groups, suggesting that inhibition of PAF activity did not protect against the microcirculatory disturbance induced by ischemia and reperfusion in the liver. In contrast, rats made leukopenic by treatment with vinblastine showed significantly better recovery of blood flow and hemoglobin saturation than the control group after 45 min of ischemia. Thus, we found that although PAF alone did not appear to have a pivotal role in the cascade of reperfusion injury, the effect of leukocytes is critical.

Laser-Doppler flowmetry in the study of in vivo liver ischemia and reperfusion in the rat.

Estimation of blood flow in the microcirculation is essential in the analysis of the events that occur during organ ischemia and subsequent reperfusion. In this study the use of laser-Doppler flowmetry is evaluated as a method for studying liver blood flow in the rat using an in vivo ischemia-reperfusion model. The experimental procedure consists of the temporary interruption of blood flow to the left lateral and medial lobes of the liver and subsequent recording of the postischemic liver blood flow using a laser-Doppler flowmeter. Flow was recorded for 60 min after periods of ischemia of 30 sec (control), 30, 45, and 60 min. The reperfusion records showed a biphasic curve with a mean flow of 59.6% of the baseline after 30 min of ischemia and of 38.3 and 41.1% after 45 and 60 min of ischemia, respectively. There were statistically significant differences between all the groups and the controls, and between 45 and 30 min of ischemia but not between 45 and 60 min. This is a useful model for studying ischemic liver injury in the rat.