Elevated intrahepatic pressures and decreased hepatic tissue blood flow prevent gas embolus during limited laparoscopic liver resections.

BACKGROUND: As new techniques are emerging for laparoscopic liver resections, concerns have been raised about the development of gas embolus related to the CO(2) pneumoperitoneum. We hypothesized that elevated intrahepatic vascular pressures and decreased hepatic tissue blood flow (LQB) would prevent gas embolus during laparoscopic liver resections under conventional pneumoperitoneum. METHODS: Intrahepatic vascular pressures and LQB were measured in nine pigs with varying CO(2) pneumoperitoneum. Gas embolus was determined after hepatic incision by monitoring pulmonary arterial pressure (PAP), hepatic venous PCO(2), systemic blood pressure (SBP), and suprahepatic vena cava ultrasound. RESULTS: As the pneumoperitoneum was increased from 0 to 15 mmHg, intrahepatic vascular pressures increased significantly (p < 0.05), while LQB decreased significantly (p < 0.05). A 2.0-cm hepatic incision at 4, 8, 15, and 20mmHg produced no ultrasound evidence of gas embolus and no changes in PAP, SBP, or hepatic venous PCO(2) (p = NS). CONCLUSION: These data suggest that the risk of significant embolus under conventional pneumoperitoneum is minimal during laparoscopic liver resections.

Protective effects of ischemic preconditioning on the cold-preserved liver are tyrosine kinase dependent.

BACKGROUND: Little data exist regarding the use of ischemic preconditioning before sustained hepatic cold storage. We hypothesized that ischemic preconditioning protects hepatic grafts via a tyrosine kinase-dependent pathway. METHODS: Six porcine livers underwent routine harvest (control). Five other livers underwent 15 min of in situ ischemia followed by 15 min of reflow before harvest (ischemic preconditioning). Another five livers were pretreated with a tyrosine kinase inhibitor (genistein) before preconditioning. Upon reperfusion and after 2 hours of cold storage, graft function, graft circulatory impairment, and markers of cellular damage were analyzed. Tissue cytoplasmic extracts were analyzed for tyrosine phosphorylation with Western blot. Significance was determined with t tests. RESULTS: Ischemic-preconditioned grafts demonstrated enhanced bile production, augmented responses to a bile acid challenge, and elevated O2 consumption (P<0.05) compared to controls. Also, preconditioned grafts demonstrated improved hepatic tissue blood flow and decreased hepatic vascular resistance (P<0.005) compared to controls. Endothelial cell preservation (factor VIII immunostain) was improved in preconditioned graft biopsies compared to controls. With genistein pretreatment, all observed improvements returned to control levels. Analysis of cytoplasmic extracts demonstrated an increase in tyrosine phosphorylation before cold ischemia in preconditioned grafts only, but not in control or genistein-pretreated grafts. CONCLUSIONS: The data indicate that ischemic preconditioning protects the liver from sustained cold ischemia and that tyrosine kinases are involved in preconditioning responses.

Protein kinase C inhibition abrogates hepatic ischemic preconditioning responses.

INTRODUCTION: A transient period of warm ischemia prior to a longer ischemic episode (ischemic preconditioning) protects the hepatic graft from cold ischemia. The mechanism for this protection is unknown, as is the role of protein kinase C in ischemic preconditioning responses. METHODS: Livers from 40 kg Yorkshire pigs were harvested and subjected to 2 h of cold ischemia (n = 6) (control). Another group of harvested livers was pretreated with a 15-min ischemic period followed by 15 min of in situ perfusion with (n = 5) or without (n = 5) a protein kinase C inhibitor, chelerythrine. Following cold ischemia, all grafts were reperfused on a perfusion circuit and the following variables evaluated: (1) hepatic graft function, (2) graft circulatory impairment, (3) hepatocellular damage, and (4) endothelial cell damage. Protein kinase C levels were also evaluated by Western blot in the cytoplasm of all grafts. RESULTS AND DISCUSSION: Ischemic preconditioned grafts demonstrate improved graft function, reduced graft circulatory impairment, and reduced endothelial cell damage as compared to cold ischemia controls. When preconditioned grafts were pretreated with chelerythrine, graft function, graft circulatory impairment, and endothelial cell damage were no different than cold ischemia controls. Ischemic preconditioned grafts demonstrated decreased levels of protein kinase C prior to cold ischemia. There was no change in protein kinase C levels in cold ischemia controls or chelerythrine-pretreated grafts prior to cold ischemia. These data indicate that modulation of protein kinase C is essential for ischemic preconditioning responses in the cold preserved hepatic graft.

Bosentan, an endothelin antagonist, augments hepatic graft function by reducing graft circulatory impairment following ischemia/reperfusion injury.

Endothelin is a potent hepatic vasoconstrictor. We evaluated the role of an endothelin antagonist in hepatic ischemia/reperfusion injury. Bosentan, a novel endothelin receptor antagonist, was infused directly into the portal vein prior to cold ischemia and immediately on reperfusion, in five porcine livers. Five other pigs underwent routine liver harvest and reperfusion without bosentan treatment. Hepatic vascular resistance and liver tissue blood flow, as measured by thermistor flow probes, were determined following reperfusion. Hepatocellular damage was assessed through hepatic venous levels of sorbitol dehydrogenase and lactate dehydrogenase. Endothelial cell damage was determined in sections immuno-stained for factor VIII. Graft function was determined through oxygen consumption, bile production, and response to bile acid challenge. Organs treated with bosentan demonstrated lower vascular resistance and enhanced tissue blood flow (P < 0.05) as compared to untreated organs. Portal vein inflow to hepatic tissue was significantly enhanced (4.4-fold) in the bosentan-treated organs (P < 0.05). No difference was observed in hepatocellular damage. Pathology scores for factor VIII immunohistochemical staining were 2.3-fold higher in the bosentan-treated livers as compared to untreated livers (P < 0.05). The bosentan-treated livers also demonstrated enhanced oxygen consumption, increased bile production, and augmented biliary response to a bile acid challenge (P < 0.05). These results indicate that administration of bosentan before and after ischemia/reperfusion reduces hepatic circulatory disturbances, diminishes endothelial cell damage, and augments hepatic graft function.

Hemodynamic and metabolic variables predict porcine ex vivo liver function.

Early recognition of hepatic function during initial graft reperfusion is important in beginning hepatic support perfusions as well as in liver transplantation. We hypothesized that both hemodynamic and metabolic perfusion variables obtained immediately after reperfusion predict eventual function during liver support or transplantation. Specific hemodynamic variables, i.e., portal vein pressure and hepatic vascular resistance, as well as metabolic variables, i.e., O(2) consumption and P(CO(2)) gradients, were compared with indices of hepatic function and damage, i.e., aqueous bile production, bile lipid outputs, lactate dehydrogenase levels, and histopathology, during an ex vivo support perfusion. O(2) consumption during early reperfusion correlated directly with unstimulated bile flows (P < 0.02) and histopathology scores (P < 0.05). Hepatic venous P(CO(2)) gradients correlated inversely with unstimulated bile flows (P < 0.05). Hemodynamic variables, i.e., portal vein pressure and hepatic vascular resistance, were inversely related with taurocholate-stimulated bile flows (P < 0.05). Hemodynamic and metabolic variables of early reperfusion are useful parameters in predicting eventual effectiveness of the harvested liver for ex vivo hepatic support perfusions.

V-PYRRO/NO: an hepato-selective nitric oxide donor improves porcine liver hemodynamics and function after ischemia reperfusion.

BACKGROUND: The role of nitric oxide (NO) in ischemia reperfusion (I/R) injury is controversial as both beneficial and harmful effects have been reported. We explored the potential role of a pharmacological agent recently shown to generate NO metabolically in the liver in an animal model of transplantation. METHODS: The effect of a selective hepatic NO donor, O2-vinyl 1-(pyrrolidin-1-yl)diazen-1-ium-1,2-diolate (V-PYRRO/NO), on hepatic hemodynamics and biliary function was evaluated in both the in situ and I/R pig liver. RESULTS: V-PYRRO/NO significantly reduced in situ hepatic vascular resistance (HVR) without altering systolic blood pressure. Portal vein flow was essentially unchanged during in situ infusions while hepatic artery flow nearly doubled (P=0.03). After I/R, V-PYRRO/NO infusions significantly reduced both portal vein pressure (PVP) and HVR (P=0.04). Also, serum bile acid clearance increased from 15% when taurocholate (TC) was infused alone to 46% (P=0.007) when infused simultaneously with V-PYRRO/NO. Aqueous bile production tripled with TC and V-PYRRO/NO as compared to TC alone (P=0.04). Analysis of bile outputs revealed a significant increase in biliary cholesterol, biliary phospholipid, and biliary bile acid (P<0.05) with V-PYRRO/NO infusion. CONCLUSIONS: The hepato-selective nitric oxide donor, V-PYRRO/NO, reduced hepatic resistance parameters of the pig liver both before and after I/R and improved the plasma clearance of bile acid and biliary outputs of bile acid-dependent compounds. The augmented function observed after I/R may be due to improvements in hepatic blood flow secondary to altered hepatic hemodynamics.

Alterations in intrahepatic hemodynamics of the harvested porcine liver.

Hemodynamic properties of a donor liver, during initial reperfusion, are associated with the degree of graft preservation injury and have been proposed to correlate with subsequent markers of liver function. In the present study, hepatic hemodynamics, that is, portal venous pressure, hepatic vascular resistance, and compliance (vascular distensibility), were characterized (1) in situ before porcine livers were manipulated, (2) after these same livers were isolated and perfused within a bypass circuit, and (3) on reperfusion after 2 hours of cold ischemia. Hepatic vascular resistance was determined in each of these three states from the portal vein pressure response to differing hepatic blood flows. In addition, the response of the same livers to norepinephrine and nitroprusside was evaluated in each condition. In the in situ and isolated perfused liver, portal venous pressure increased only modestly despite doubling of hepatic flows. After cold ischemia, the pressure response to higher flows was significantly greater and much less of a reduction in hepatic vascular resistance was noted than in studies prior to cold ischemia. Unlike livers prior to cold ischemia, the pressure response to norepinephrine was attenuated following cold ischemia. The response to nitroprusside, however, remained intact reducing the portal pressure to that of in situ livers. Therefore the portal hypertension that follows cold ischemia appears to be largely provoked by the preservation injury and not by surgical manipulation or the bypass circuit. This increment in portal pressure is responsive to a nitric oxide donor.

Stewardship or clinical freedom? variations in dialysis decision making.

BACKGROUND: It is generally agreed that acceptance criteria for dialysis have varied and changed over time and that implicit rationing, to some extent forced on clinicians by limited capacity, has been widely practised. Our objective was to study the basis and extent of variation in dialysis decision making among nephrologists in one NHS region. DESIGN AND METHODS: In a clinical judgement analysis, linear regression models were employed to reflect the impact of clinical and non-clinical cues on nephrologists' decisions to offer dialysis to 60 'paper patients' under current capacity constraints and under an assumption of no capacity limit. A short questionnaire was also completed by eight nephrologists to elicit their expressed decision drivers, which were subsequently compared with those tacitly derived from the appraisal of the 60 clinical vignettes. RESULTS: Doctors showed substantial variation in their propensity to offer dialysis and in their perceptions of the benefits of dialysis. Even for the five patients where the discordance in propensity to offer dialysis was least, the range in perceived gain in life expectancy was from 24 to 264 months (mean 91 months). The decision models had relatively good explanatory power with an average r(2) of 0.67 (0.39-0.90) and 0.70 (0.47-0.95) for decisions made under current capacity constraints and under an assumption of no limit capacity respectively. Surprisingly, for most doctors, the patient's age had very little impact on dialysis decisions but the magnitude of the beta-coefficients for the patient's mental state (mean -30.7) was of a similar order of magnitude to the coefficient for the principal 'renal' drivers (e.g. the mean coefficient for uraemic symptomatology under current capacity constraints was 47.7). The influence of other non-renal factors on the doctor's likelihood to offer dialysis was largely independent of the capacity assumption. A comparison of the doctor's stated decision drivers with those tacitly derived from their decision models showed only modest correlation. CONCLUSIONS: The extent to which doctors vary in their propensity to offer dialysis is substantial. Very few non-clinical cues appear to influence the decision to offer dialysis. The most important non-renal factor in determining dialysis decisions was the patient's mental state.

Researcher allegiance and meta-analysis: the case of cognitive therapy for depression.

K. S. Dobson (1989) conducted a meta-analysis of 28 studies of cognitive-behavioral therapy for depression that used the Beck Depression Inventory as outcome measure. He concluded that the outcome of this type of therapy was superior to that of other forms of psychotherapy and to that of pharmacotherapy. The present study reanalyzed the same studies, and a further set of 37 similar ones published from 1987 to 1994, taking into account variations in sample size and researcher allegiance. This study confirmed Dobson's conclusions for his original sample but showed that about half the difference between CT and other treatments was predictable from researcher allegiance. However, comparable analyses of the later set of studies showed no effect of researcher allegiance. Two causes for these phenomena are (a) a historical effect, whereby both effect sizes and allegiance were large in earlier years and declined over time and (b) a treatment effect whereby effect size and allegiance were correlated, but more for some treatments than others. This correlation has also weakened over time.

Use of rat and human in vitro systems to assess the effectiveness and enzymology of deoxyguanine analogs as prodrugs of an antiviral agent.

BRL 55792, BRL 55791, and BRL 55039 are prodrugs of an active antiviral agent 9-(3-hydroxypropoxy) guanine (BRL 44385). The prodrugs were 6-deoxygenated analogs of BRL 44385, with ether groups substituted at the 9-position: BRL 55792 with an (isopropoxymethyloxy)propoxy group, BRL 55791 with a (methoxymethyloxy)propoxy group, and BRL 55039 with an ethoxypropoxy group. Conversion of the prodrugs to BRL 44385 had been demonstrated in vivo in the rat and involved 6-oxidation followed by dealkylation. Metabolism was studied in rat liver in vitro systems to find a model to evaluate BRL 44385 production. Rat hepatocytes performed both reaction steps and were used to assess which of the three prodrugs demonstrated greatest production of the active drug. BRL 55792 demonstrated greatest conversion in vitro, and this was in agreement with in vivo data. The production of BRL 44385 from BRL 55792 was also demonstrated in human hepatocyte incubations, providing evidence that these reactions can occur in humans, thereby increasing confidence that BRL 55792 would be suitable prodrug for human therapy. Further experiments were performed to investigate the enzymes involved in these conversions. The 6-oxidation step occurred in the cytosol. Use of allopurinol and menadione (xanthine and aldehyde oxidase inhibitors) indicated that these conversions were catalyzed exclusively by xanthine oxidase in the rat but mainly by aldehyde oxidase in humans. The dealkylation reaction was detected in hepatocytes but not in homogenates or subcellular fractions. Inhibition of this reaction by aminobenzotriazole and ketoconazole (P-450 inhibitors) indicated that it was mediated by cytochrome P-450.

Use of rat and human in vitro systems to assess the effectiveness and enzymology of deoxy-guanine analogues as prodrugs of an antiviral agent.

BRL 55792, BRL 55791, and BRL 55039 are prodrugs of an active anti-viral agent 9-(3-hydroxypropoxy) guanine, (BRL 44385). The prodrugs were 6-deoxygenated analogues of BRL 44385 with ether groups substituted at the 9-position: BRL 55792 with an (isopropoxymethyloxy)propoxy group, BRL 55791 with a (methoxymethyloxy)propoxy group, and BRL 55039 with an ethoxypropoxy group. Conversion of the prodrugs to BRL 44385 had been demonstrated in vivo in rat and involved 6-oxidation followed by dealkylation. Metabolism was studied in rat liver in vitro systems to find a model to evaluate BRL 44385 production. Rat hepatocytes performed both reaction steps and were used to assess which of the three prodrugs demonstrated greatest production of the active drug. BRL 55792 demonstrated greatest conversion in vitro and this was in agreement with in vivo data. The production of BRL 44385 from BRL 55792 was also demonstrated in human hepatocyte incubations providing evidence that these reactions can occur in man thereby increasing confidence that BRL 55792 would be a suitable prodrug for human therapy. Further experiments were performed to investigate the enzymes involved in these conversions. The 6-oxidation step occurred in the cytosol. Use of allopurinol and menadione (xanthine and aldehyde oxidase inhibitors) indicated that these conversions were catalyzed exclusively by xanthine oxidase in the rat but mainly by aldehyde oxidase in man. The dealkylation reaction was detected in hepatocytes but not in homogenates or subcellular fractions. Inhibition of this reaction by aminobenzotriazole and ketoconazole (P-450 inhibitors) indicated that it was mediated by cytochrome P-450.

Evidence that famciclovir (BRL 42810) and its associated metabolites do not inhibit the 6 beta-hydroxylation of testosterone in human liver microsomes.

Famciclovir is the diacetyl 6-deoxy analog of the active antiviral compound penciclovir with potential use in the treatment of infections caused by the herpes family of viruses. The major pathway of metabolism of famciclovir is deacetylation to BRL 42359 followed by oxidation to penciclovir. It is possible that famciclovir may be coadministered with cyclosporin A to combat viral infections induced by immunosuppression in organ transplant and bone marrow transplant patients. As a result, information is required on possible interactions between the cytochrome P-450 3A substrate cyclosporin A and famciclovir and its metabolites in humans. In order to probe cytochrome P-450 3A activity, testosterone 6 beta-hydroxylation in two human liver microsomal preparations was measured. Nicardipine and ketoconazole, two drugs with known inhibitory interactions with cyclosporin A, were used as positive controls. Profiles of 6 beta-hydroxytestosterone production showed no inhibition effected by famciclovir, penciclovir, or BRL 42359 when marked inhibition was observed in incubations containing nicardipine, nifedipine, or ketoconazole. Further incubations of [14C]BRL 42359 with human liver cytosol and microsomes indicated that BRL 42359 is oxidized to penciclovir in cytosol but not in microsomes and that this reaction was not dependent on the presence of NADPH. Because P-450 resides mainly in the microsomal fraction and is dependent on the presence of cofactors for catalytic activity, it seems that this oxidation is not catalyzed by cytochrome P-450.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of cyclosporine on renal function in psoriasis patients.

Several prospective studies have documented the effectiveness of oral cyclosporine in the treatment of psoriasis. Despite this, the use of cyclosporine has been limited because of concern about the possibility of drug-induced renal dysfunction. We review the effects of cyclosporine on renal function.

The effects of sodium borate and sodium bicarbonate upon fluoride retention and serum calcium and phosphate in sheep.

Six sheep were each given a fluoride slow-release intra-ruminal capsule which delivered 30 +/- 1.02 mg F/d. After 20 days, fluoride balance studies were carried out for four days and serum fluoride measured daily. Each sheep was then given 23.1 mg sodium borate daily via drench gun for six days, and the balance studies continued. In a separate similar experiment, six sheep were given capsules which released 66.4 +/- 4.2 mg F/d, and 25 ml of 25 g/L sodium bicarbonate was administered half-hourly over four hours, 14 days after capsule administration. Urinary pH was also measured. Sodium borate treatment increased fluoride output, mainly in the faeces, and temporarily reduced serum fluoride concentration. Serum phosphate fell during sodium borate administration, while serum calcium was unaffected. Sodium bicarbonate reduced serum fluoride concentration over the three days, and fluoride output was increased, mainly via the urine, while urinary pH was largely unaffected. Serum calcium and phosphate were temporarily affected to a small extent.

Anxiety responses to subliminal experience of mild stress.

Two groups of undergraduates (n = 14 in each) matched for level of trait anxiety participated in the experiment. One group (E) was presented with 20 'emotional' words 10 per cent below detection threshold while the other group (N) was presented with 20 emotionally neutral words under the same conditions. Ratings of seven psychological variables were taken before and after stimulation and two psychophysiological measures, heart and respiration rate, were also taken. MANOVA and subsequent ANOVA analyses showed ratings of sweating and anxiety increased in the E group and decreased in the N group following stimulation. Ratings of shaking and muscular tension increased significantly in both groups but the increase was significantly greater in the E group. Ratings of palpitations and difficulty in breathing increased significantly in both groups as did measures of actual heart and respiration rate, but these increases appeared to be an artifact of task demands. It is concluded that manifest anxiety and some features of anxiety having somatic referents can be induced by subliminal experience of mild stress.

Effect of processing upon concentration and distribution of natural and iodophor-derived iodine in milk.

Cream removal, pasteurization, and spray-drying of milk did not affect concentration of either natural or iodophor-derived iodine, as measured by both chemical and electrode methods, although electrode results were significantly higher. The use of iodine-131 labeled iodophor showed that only .02% of iodine was lost from milk on boiling and that 3.4% of iodophor-iodine became associated with milk casein.

Dietary intake of low socioeconomic black and Hispanic teen-age girls.

Nutrient intake of black and Hispanic teen-age girls residing in the Bedford-Stuyvesant section of Brooklyn, New York, was estimated and compared with the 1974 Recommended Dietary Allowances and with the nutrient intake of the girl's mothers. The mean nutrient intake of each of the two groups of teen-age girls was similar to the other and to the intake of their mothers but was lower than or close to the 1975 Recommended Dietary Allowances for all nutrients studied except protein and ascorbic acid. There was some prevalence of overweight in black teen-agers, as indicated by the weight-for-height values and triceps skinfold measurements. Possible ways of alleviating the nutritional problems existing in the area are discussed.

Further observations concerning the effects of hypophysectomy on the gastric mucosa of the rat.

Hypophysectomy in rats markedly reduced the weight and surface area of the stomach as well as the volume (mass) of the gastric mucosa and the total parietal and total peptic cell populations. The parietal cell population was reduced by about 50%, and this effect was due entirely to the reduction that occurred in the total surface area of the stomach (50%); the average number of parietal cells per unit area, which reflects the number of parietal cells in the gastric glands, was not affected. The peptic cell population was reduced by about 90%, the factors responsible being a reduction in the average number of peptic cells per unit area (70%) as well as the reduction that occurred in the surface area of the stomach. The disproportionate effect of hypophysectomy on the cell populations was thus due to the reduction in the number of peptic cells per unit area; this effect implies that hypophysectomy had caused a reduction in the number of the peptic cells in the gastric glands.Whatever the mechanisms involved these results were due to a direct effect of pituitary deprivation on the stomach, since they could not be accounted for simply by the inhibition of somatic growth that follows hypophysectomy in rats. Thus the experiment included a group of sham hypophysectomized rats whose somatic growth was inhibited to the same extent as that of the hypophysectomized animals by deliberate underfeeding. While underfeeding reduced the surface area of the stomach (20%) and the total peptic cell population (25%), as well as exerting a marginal effect on the parietal cell population, these effects were much smaller in magnitude than those of hypophysectomy; moreover underfeeding did not affect the number of peptic cells in the gastric glands. The results confirm that the pituitary gland exerts a strong influence on the growth of the gastricmucosa.