The use of toluidine blue gargles to aid the detection of impacted pharyngeal fish bones

Fishbone impaction is a common clinical problem. In most cases careful examination pinpoints the impacted bone which can then be removed. If no bone is detected a distinction must be drawn between mucosal abrasion mimicking fishbone impaction and a fine or deeply impaled fishbone eluding detection. We present a new method that may be helpful in the detection of pharyngeal fishbones.

Reciprocal inhibition between the forearm muscles in patients with paroxysmal kinesigenic dyskinesia

We measured the changes of forearm flexor H reflexes produced by conditioning radial nerve stimulation at delays of -2, 0, 2, 4, 7.5, 10, 25 and 75 ms in 10 patients with PKD and six with generalized seizure disorder. We compared the results with 12 normal volunteers. In the patients with PKD, we compared the amounts of reciprocal inhibition between the severely and the asymptomatic or mildly affected sides of arms. Follow-up studies were done in eight PKD patients after they responded to the anticonvulsant treatment. At each delay, patients with seizure disorders showed comparable amounts of changes with controls. Patients with PKD showed paradoxical facilitation at a delay of 0 ms, enhanced facilitation between 2 to 7.5 ms delays and attenuated inhibition at a delay of 75 ms. There were no significant differences in the amount of reciprocal inhibition according to the severity of clinical symptoms. Follow-up studies showed no significant changes of reciprocal inhibition compared to the baseline data. In PKD, paradoxical facilitation and enhanced first relative facilitation period may be caused by defective spinal interneurons. In addition to the defective reciprocal inhibition, abnormalities of supraspinal inputs seem to be involved in the genesis of PKD.

The modified Lapidus arthrodesis: a retrospective analysis

The authors present a review of 47 modified Lapidus arthrodesis procedures performed between 1985 and 1995. There were 29 females and 10 males. Eight patients underwent bilateral procedures. The average follow-up was 6.3 years (range, 1.5-10.6 years). The patients were evaluated preoperatively and postoperatively using standard weightbearing radiographs, clinical examination, and chart review. The average preoperative intermetatarsal angle was 13.8 degrees degrees, and the average postoperative intermetatarsal angle measured 2.1 degrees degrees, with a mean improvement of 10.8 degrees. The average effective shortening of the first metatarsal was 4.7 mm in those patients without bone graft. In patients whom bone graft was utilized, an average effective increase in first metatarsal length of 2.6 mm was identified. Complications included delayed union (n = 2), nonunion (n = 3), postoperative development of hyperkeratosis beneath the second metatarsal head (n = 4), elevation of the first ray (n = 3), and hallux varus (n = 2). There were no recurrences of hallux abducto valgus at follow-up. The average return to preoperative activity level was 13 weeks. Forty-two of the 47 procedures healed uneventfully. Of the remaining five feet, two required the use of a bone growth stimulator, and three required revisional surgery with autogenous bone graft to promote arthrodesis and restore alignment. In conclusion, the modified Lapidus arthrodesis is both a predictable and durable procedure for the correction of hallux abducto valgus.

Molecular clock calibrations and metazoan divergence dates

It has recently been argued that living metazoans diverged over 800 million years ago, based on evidence from 22 nuclear genes for such a deep divergence between vertebrates and arthropods (Gu 1998). Two "internal" calibration points were used. However, only one fossil divergence date (the mammal-bird split) was directly used to calibrate the molecular clock. The second calibration point (the primate-rodent split) was based on molecular estimates that were ultimately also calibrated by the same mammal-bird split. However, the first tetrapods that can be assigned with confidence to either the mammal (synapsid) lineage or the bird (diapsid) lineage are approximately 288 million years old, while the first mammals that can be assigned with confidence to either the primate or the rodent lineages are 65 million years old, or 85 million years old if ferungulates are part of the primate lineage and zhelestids are accepted as ferungulate relatives. Recalibration of the protein data using these fossil dates indicates that metazoans diverged between 791 and 528 million years ago, a result broadly consistent with the palaeontological documentation of the "Cambrian explosion." The third, "external" calibration point (the metazoan-fungal divergence) was similarly problematic, since it was based on a controversial molecular study (which in turn used fossil dates including the mammal-bird split); direct use of fossils for this calibration point gives the absurd dating of 455 million years for metazoan divergences. Similar calibration problems affect another recent study (Wang et al. 1999), which proposes divergences for metazoans of 1000 million years or more: recalibrations of their clock again yields much more recent dates, some consistent with a "Cambrian explosion" scenario. Molecular clock studies have persuasively argued for the imperfection of the fossil record but have rarely acknowledged that their inferences are also directly based on this same record.

Effects of ChunDoSunBup Qi-training on growth hormone, insulin-like growth factor-I, and testosterone in young and elderly subjects

We observed the response of plasma growth hormone (GH), insulin-like growth factor-I (IGF-I) and testosterone (T) to an acute period of ChunDoSunBup (CDSB) Qi-training. Although the basal level of GH was not different between the two groups, after the portion of the training in which the subjects were physically active (the mid-training point), plasma GH levels increased by 7.26 fold (p < 0.05) in the elderly trainees and by 1.66 fold (p < 0.05) in the young. In response to CDSB Qi-training, IGF-I levels in the young increased significantly at mid-training point, but there were no increase in the elderly. Significant correlations existed between GH and IGF-I levels in the young subjects, but not in the elderly. The T level at the mid-training point increased significantly in elderly subjects but not in the young. These results suggest that CDSB Qi-training is a potential method for modulating of the secretion of growth factor in the young and the elderly, but that the elderly IGF-I response does not equal that of the young. In addition, our study suggests CDSB Qi-training may be one mode of therapy applicable to growth factor related disorders such as GH deficiency in children and osteoporosis in the elderly, especially women.

Fas is expressed in murine pancreatic islet cells and an insulinoma cell line but does not mediate their apoptosis in vitro

CD4+ lymphocytes are the most important effector cells in autoimmune diabetes of NOD mice, although some role of CD8+ T cells has been demonstrated. However, it is unknown how CD4+ lymphocytes are able to destroy pancreatic beta-cells that do not express MHC (major histocompatibility complex) class II molecules. Apoptotic cell death mediated by an interaction of Fas with Fas ligand (FasL) could be a mechanism by which MHC class II-negative pancreatic beta-cells are destroyed by CD4+ T lymphocytes. We have examined the expression of Fas molecules in pancreatic islet cells, as well as in a NOD-derived mouse insulinoma cell line (MIN6N8). In addition, the role of Fas-mediated apoptosis in pancreatic islet cell death was explored in vitro. Although Fas expression was not detected by flow cytometric analysis, Fas transcripts were demonstrated in MIN6N8 cells and pancreatic islet cells by the sequencing analysis of the cloned reverse transcription polymerase chain reaction products using Fas-specific primers. IFN (interferon)-gamma, tumor necrosis factor-alpha, interleukin-1 and their combinations failed to enhance Fas expression. Unsorted activated splenocytes from diabetic NOD mice had cytotoxic T lymphocyte activity of a small degree against IFN-gamma-treated MIN6N8 cells with FasL upregulation. However, agonistic anti-Fas antibody with or without cycloheximide did not exert cytotoxicity against MIN6N8 cells or pancreatic islets. FasL transfectant cells also did not kill MIN6N8 cells. Our data indicate that pancreatic beta-islet cells express a small amount of Fas molecules but Fas molecules do not mediate apoptosis of islet cells at least in vitro.

Differential expression of O6-methylguanine-DNA methyltransferase during diethylnitrosamine-induced carcinogenesis and liver regeneration in Sprague-Dawley male rats

Differential expression of DNA-O6MeG: protein-L-cysteine S-methyltransferase (MGMT) activity and posttranslational modification of the protein during liver regeneration and carcinogenesis were compared in Sprague-Dawley male rats after partial hepatectomy and/or single i.p injection of diethylnitrosamine (DEN, 200 mg/kg). Regenerating hepatocytes after partial hepatectomy induced MGMT transiently within 3 days; however, the induction of MGMT was persistent for 2 weeks after DEN injection, and the combined treatment of DEN and partial hepatectomy maintained the elevated MGMT level for up to 4 weeks. The increased activity was transcriptionally regulated, when analyzed by Northern blot hybridization. The major active form of MGMT protein in the partially hepatectomized or DEN-treated rats was a 26-kDa or 24-kDa species respectively, which was confirmed by Western blot analysis and gel slice assay. The biological significance of the differential induction of MGMT during partial hepatectomy or DEN-induced carcinogenesis is not obvious; however, further studies on possible posttranslational modifications of MGMT protein might shed some light on the functional aspect of MGMT induction.

Vitamin A deficiency phrynoderma: due to malabsorption and inadequate diet

We describe a patient with vitamin A deficiency phrynoderma caused by a combination of inadequate dietary intake of vitamin A and beta-carotene and malabsorption secondary to primary visceral myopathy and total colectomy.

Identification of a new regulator in Streptococcus pneumoniae linking quorum sensing to competence for genetic transformation

Competence for genetic transformation in Streptococcus pneumoniae is regulated by a quorum-sensing system encoded by two genetic loci, comCDE and comAB. Additional competence-specific operons, cilA, cilB, cilC, cilD, cilE, cinA-recA, coiA, and cfl, involved in the DNA uptake process and recombination, share an unusual consensus sequence at -10 and -25 in the promoter, which is absent from the promoters of comAB and comCDE. This pattern suggests that a factor regulating transcription of these transformation machinery genes but not involved with comCDE and comAB expression might be an alternative sigma factor. A search for such a global transcriptional regulator was begun by purifying pneumococcal RNA polymerase holoenzyme. In preparations from competent pneumococcal cultures a protein which seemed to be responsible for cilA transcription in vitro was identified. The corresponding gene was identified and found to be present in two copies, designated comX1 and comX2, located adjacent to two of the repeated rRNA operons. Expression of transformation machinery operons, such as cilA, cilD, cilE, and cfl, but not that of the quorum-sensing operons comAB and comCDE, was shown to depend on comX, while comX expression depended on ComE but not on ComX itself. We conclude that the factor is a competence-specific global transcription modulator which links quorum-sensing information transduced to ComE to competence and propose that it acts as an alternate sigma factor. We also report that comAB and comCDE are not sufficient for shutoff of competence-stimulating peptide-induced gene expression nor for the subsequent refractory period, suggesting that these phenomena depend on one or more ComX-dependent genes.

Uncoupling of the hnRNP Npl3p from mRNAs during the stress-induced block in mRNA export

Npl3p, the major mRNA-binding protein of the yeast Saccharomyces cerevisiae shuttles between the nucleus and the cytoplasm. A single amino acid change in the carboxyl terminus of Npl3p (E409 --> K) renders the mutant protein largely cytoplasmic because of a delay in its import into the nucleus. This import defect can be reversed by increasing the intracellular concentration of Mtr10p, the nuclear import receptor for Npl3p. Conversely, using this mutant, we show that Npl3p and mRNA export out of the nucleus is significantly slowed in cells bearing mutations in XPO1/CRM1, which encodes the export receptor for NES-containing proteins and in RAT7, which encodes an essential nucleoporin. Interestingly, following induction of stress by heat shock, high salt, or ethanol, conditions under which most mRNA export is blocked, Npl3p is still exported from the nucleus. The stress-induced export of Npl3p is independent of both the activity of Xpo1p and the continued selective export of heat-shock mRNAs that occurs following stress. UV-cross-linking experiments show that Npl3p is bound to mRNA under normal conditions, but is no longer RNA associated in stressed cells. Taken together, we suggest that the uncoupling of Npl3p and possibly other mRNA-binding proteins from mRNAs in the nucleus provides a general switch that regulates mRNA export. By this model, under normal conditions Npl3p is a major component of an export-competent RNP complex. However, under conditions of stress, Npl3p no longer associates with the export complex, rendering it export incompetent and thus nuclear.

Diversity of core promoter mutations in immune clearance phase of chronic HBV infection

BACKGROUND/AIMS

Transcription of HBV (hepatitis B virus) pre-core and pre-genomic mRNAs is controlled by core promoter. Therefore, mutations in the core promoter region might change the activity of liver diseases through an altered transcriptional level of the mRNA. The present study was carried out to determine the diversity of HBV core promoter sequences in chronic HBV carriers.

METHODS

DNA sequences in the core promoter region were determined after cloning the PCR product. Two groups of chronic HBV carriers with HBeAg, including five cases of asymptomatic carriers (ASCs, 21 clones) and eight with chronic hepatitis (CH, 50 clones) were studied.

RESULTS

Mutations in the core promoter were found in three out of the ASCs (11 clones), and in all eight cases in the CH group (48 clones). While mutations at nucleotide 1762 (A-->T) and 1764(G-->A) were not found in ASC, mutations at the same positions were found in all the cases of CH group (40 clones) (P=0.003). Diverse patterns of mutations in the core promoter were observed in each patient in the CH group.

CONCLUSIONS

Further studies are needed to determine whether the diversity of HBV core promoter mutations has clinical significance such as the seroconversion of HBeAg to anti-HBe.

Enlistment of combinatorial techniques in drug development

Combinatorial chemistry, in its ability to generate vast arrays of non-peptide and non-oligonucleotide libraries, has had a major impact on the drug discovery effort. The design and generation of a combinatorial library, coupled with the ever important and effective feedback from high-throughput screening and data management, are critical to any drug discovery process. This review will focus on some aspects of computational chemistry, solid-phase organic chemistry and downstream analysis. The emphasis will be on computational aspects of library design and the use of cyclic scaffolds in the context of a focused library for optimization in drug discovery.

Expression of p27Kip1 and cyclin D1 proteins is inversely correlated and is associated with poor clinical outcome in human gastric cancer

BACKGROUND AND OBJECTIVES

p27Kip1 is an inhibitor of cyclin-dependent kinases and is speculated to be a potential prognostic indicator in numerous human cancers. We investigated expression of p27Kip1 along with cyclin D1 in gastric cancer to estimate the clinical utility of p27Kip1.

METHODS

Immunohistochemical assay for p27Kip1 and cyclin D1 proteins was performed in 64 patients with primary gastric cancer. Correlation between p27Kip1 expression and clinical-biological parameters including patient survival was analyzed.

RESULTS

p27Kip1 expression was suppressed in 40 (62.5%) of 64 gastric cancer patients and cyclin D1 was overexpressed in 22 (34.4%) out of 64. Expression of p27Kip1 was significantly reduced in poorly differentiated cancers (82.1%, 23/28; P = 0.015) and was also reduced in the tumors with high S-phase fraction (86.7%, 26/30) compared with tumors showing low S-phase fraction (41.2%, 14/34; P = 0.0002). Expression of p27Kip1 and cyclin D1 was inversely correlated (P = 0.021). In univariate analysis, extent of the disease (P < 0.001), expression of cyclin D1 (P = 0.0001), and reduced expression of p27Kip1 (P = 0. 0006), were statistically significant to predict patient's outcome, but depth of invasion (P = 0.008) and pathologic stage (P = 0.009) emerged as significant prognostic indicators in multivariate analysis.

CONCLUSION

Expression of p27Kip1 is closely linked with cell proliferation and differentiation of human gastric cancer. p27Kip1 seems to have potential as a prognostic marker in the management of gastric cancer patients.

Laser-induced drusen reduction improves visual function at 1 year. Choroidal Neovascularization Prevention Trial Research Group

OBJECTIVE

To describe the relationship of laser-induced drusen reduction to change in visual function at 1 year among patients enrolled in the Choroidal Neovascularization Prevention Trial (CNVPT).

DESIGN

Comparison of groups with and without drusen reduction; follow-up of a randomized controlled trial.

PARTICIPANTS

Evaluations of drusen and visual acuity at baseline and at 1 year were performed for 351 eyes of the 432 eyes enrolled in the CNVPT Bilateral Drusen Study and Fellow Eye Study (81%). One hundred eighty-four eyes were assigned to observation, and 167 eyes were assigned to laser treatment. Eyes with conditions that precluded an analysis of drusen reduction, such as those that developed choroidal neovascularization (CNV) within the first year, are excluded from this analysis.

METHODS

Change in macular drusen between initial visit and after 1 year was assessed by side-by-side grading by evaluators masked to information on visual function. Visual acuity, contrast threshold, and critical print size were measured by certified visual function examiners.

MAIN OUTCOME MEASURES

Change in visual acuity is the primary outcome. Change in contrast threshold and change in critical print size are secondary outcome measures.

RESULTS

Laser-treated eyes with 50% or more drusen reduction at 1 year had more 1- and 2-line increases in visual acuity and less losses in visual acuity compared with laser-treated eyes with less drusen reduction or with observed eyes (P = 0.001). Similar improvements were noted for contrast threshold but not critical print size at 1 year.

CONCLUSIONS

Laser-induced drusen reduction is associated with improved visual acuity and contrast sensitivity in eyes at 1 year. Longer term effects of laser-induced drusen reduction on visual function require additional observation. The overall potential value of laser treatment in eyes with high-risk drusen requires consideration of not only short-term effects on vision but also the effects of CNV and atrophy on vision.

Studies on constituents with cytotoxic activity from the stem bark of Syringa velutina

Cytotoxic compounds, oleuropein (1) and a phenylethanoid glycoside (2) were isolated from the stem bark of Syringa velutina KOM. along with coniferylaldehyde 4-O-glucoside, syringin, ligstroside, (+)-syringaresinol 4-O-glucoside, (+)-medioresinol 4"-O-glucoside and (-)-olivil 4"-O-glucoside. Phenylethanoid glycoside (2) was identified to be 3,4-dihydroxyphenylethyl alcohol 8-O-beta-D-glucopyranoside. This compound showed the most potent cytotoxic effect on several tumor cell lines (P-388, L-1210, SNU-5 and HL-60) among eight compounds isolated in the present study. We suggest that the 3,4-dihydroxyphenylethoxy moiety of this compound contributes to cytotoxicity.

Cloning of the argF gene encoding the ornithine carbamoyltransferase from Corynebacterium glutamicum

The argF gene encoding ornithine carbamoyl-transferase (OTCase; EC2.1.3.3) has been cloned from Corynebacterium glutamicum by transforming the Escherichia coli arginine auxotroph with the genomic DNA library. The cloned DNA also complements the E. coli argG mutant, suggesting a clustered organization of the genes in the genome. We have determined the DNA sequence of the minimal fragment complementing the E. coli argF mutant. The coding region of the cloned gene is 957 nucleotides long with a deduced molecular mass of about 35 kDa polypeptide. The enzyme activity and size of the expressed protein in the E. coli auxotroph carrying the argF gene revealed that the cloned gene indeed codes for OTCase. Analysis of the amino acid sequence of the predicted protein revealed a strong similarity to the corresponding protein of other bacteria.

RNA polymerase-specific nucleosome disruption by transcription in vivo

The nucleosomal chromatin structure within genes is disrupted upon transcription by RNA polymerase II. To determine whether this disruption is caused by transcription per se as opposed to the RNA polymerase source, we engineered the yeast chromosomal HSP82 gene to be exclusively transcribed by bacteriophage T7 RNA polymerase in vivo. Interestingly, we found that a fraction of the T7-generated transcripts were 3' end processed and polyadenylated at or near the 3' ends of the hsp82 and the immediately downstream CIN2 genes. Surprisingly, the nucleosomal structure of the T7-transcribed hsp82 gene remained intact, in marked contrast to the disrupted structure generated by much weaker, basal level transcription of the wild type gene by RNA polymerase II under non-heat shock conditions. Therefore, disruption of chromatin structure by transcription is dependent on the RNA polymerase source. We propose that the observed RNA polymerase dependence for transcription-induced nucleosome disruption may be related either to the differential recruitment of chromatin remodeling complexes, the rates of histone octamer translocation and nucleosome reformation during polymerase traversal, and/or the degree of transient torsional stress generated by the elongating polymerase.

Evaluation of the completeness of cancer case ascertainment in the Seoul male cohort study: application of the capture-recapture method

Since the completeness of case ascertainment is directly related to the validity of a study, the evaluation of completeness is an essential feature of a cohort study. To estimate the completeness of cancer case ascertainment during a three year period (Jan. 1, 1993, to Dec. 31, 1995) in which the Seoul Male Cohort was followed up, we applied capture-recapture method. Data were obtained from the cancer registries, medical records and death certificates, with cases identified from each source numbering 103, 105, and 38, respectively. After eliminating duplicate cases, the total number was 141, and by using a log-linear model, the number of cases not detected by any of the three data sources was estimated to be 16. For all cancers, the estimated completeness of follow-up was 89.9%.

Monitoring in vitro experiments using microdialysis sampling on-line with mass spectrometry

A method has been developed for the real-time analysis of components in in vitro reactions by the on-line combination of microdialysis sampling (MD) with tandem mass spectrometry (MS/MS) and single stage mass spectrometry (MS). Apparatus and parameters associated with the integration have been studied. Analytical figures of merit for the drug gepirone have been determined. The qualitative 'limit of identification' was found to be 100 ng/ml and 200 ng/ml for methods using thermospray and electrospray MS interfaces, respectively. Using this approach, monitoring of in vitro experiments involving drug metabolites, enzymatic reactions, and ligand-protein binding interactions were performed.

Molecular cloning and expression of a novel human cDNA related to the diazepam binding inhibitor

In order to isolate the unidentified autoantigens in autoimmune diabetes, a human pancreatic islet cDNA library was constructed and screened with the sera from the diabetic patients. From the library screening, one clone (DRS-1) that strongly reacted with the sera was isolated. Subsequent sequence analysis revealed that the clone was a novel cDNA related to the diazepam binding inhibitor. DRS-1 was expressed in most tissues including liver, lung, tonsil, and thymus, in addition to pancreatic islets. DRS-1 was in vitro translated and the recombinant DRS-1 protein was expressed in Escherichia coli and purified. The size of the in vitro translated or bacterially expressed DRS-1 protein was in agreement with the conceptually translated polypeptide of DRS-1 cDNA. Further studies are required to test whether or not DRS-1 is a new autoantigen in autoimmune diabetes.

Post mass-immunization measles outbreak in Taoyuan County, Taiwan: dynamics of transmission, vaccine effectiveness, and herd immunity

OBJECTIVES

Analysis of national surveillance data and a seroepidemiologic investigation were conducted to elucidate the causes and epidemiologic characteristics of a measles outbreak in Taoyuan, Taiwan, 1994.

METHODS

Measles cases were identified through a national surveillance system. Reported cases and their physician or school nurses were interviewed to trace additional suspect cases and were sampled for serologic diagnosis. Measles-specific IgG and IgM were assayed. A confirmed case was defined as being positive for measles IgM test but not having received measles vaccination within the previous 3 months.

RESULTS

The outbreak began in Taoyuan City in December 1993 and continued to spread in primary schools and kindergartens, but caused only sporadic cases in neighboring towns. Among 42 confirmed cases, 15 (38%) were primary school children and 16 (38%) were kindergarten children. Among 24 confirmed cases with a vaccination record, 7 had one dose of vaccination, 4 had two doses of vaccination, and 13 (54%) were unvaccinated. The overall measles susceptible proportion at a kindergarten before the outbreak was 8.1% (17/209) and the overall measles cumulative incidence among susceptibles was 0.65 (11/17).

CONCLUSIONS

A measles vaccination coverage of 82% with the first dose at 9 months of age and 63% with the second dose (measles, mumps, and rubella) at 15 months was inadequate to block measles virus circulation in Taoyuan City in 1994. The city center, with a growing population, represents a high risk as an epicenter for measles outbreaks. Measles outbreaks may occur in a school population with 92% herd immunity.

Thiotepa, busulfan and cyclophosphamide as a preparative regimen for allogeneic transplantation for advanced chronic myelogenous leukemia

Thirty-six adults with chronic myelogenous leukemia (CML) in second or greater chronic phase, accelerated phase, or blast crisis underwent marrow or blood stem cell transplantation from an HLA-matched sibling using high-dose thiotepa, busulfan and cyclophosphamide (TBC) as the preparative regimen. All evaluable patients engrafted and had complete donor chimerism. One patient failed to clear meningeal leukemia, and one patient had one of 30 metaphases positive for the Philadelphia chromosome at 2 months post transplant. The remainder of the patients studied had eradication of CML documented by cytogenetics and/or Southern blot for BCR gene rearrangement, and 13 of 15 patients studied became negative for the BCR gene rearrangement by polymerase chain reaction. Three-year relapse rate is 42% (95% CI, 19-64%). The relapse rate was significantly lower for patients transplanted without blast crisis (9% vs 100%, P < 0.001). Eight (22%, 95% CI, 10-39%) patients had severe or fatal veno-occlusive disease (VOD). Elevated liver enzymes within 1 month prior to transplantation and transplantation using marrow were significantly associated with the occurrence of VOD. Three-year survival is 28% (95% CI, 13-43%). Survival was significantly higher for patients transplanted without blast crisis (45% vs 0%, P = 0.01). TBC is an effective preparative regimen for CML in accelerated phase but not refractory blast crisis, and it should be used with caution in patients with prior hepatopathy who have an increased risk of severe VOD.