Impact of untreated portal vein thrombosis on pre and post liver transplant outcomes in cirrhosis

BACKGROUND AND AIMS

Most portal vein thromboses (PVT) in cirrhotics are discovered incidentally. While case series demonstrate improved portal vein patency with anti-coagulation, there is little information on impact of PVT on morbidity and mortality. This study aimed to compare morbidity and mortality in cirrhotics with untreated PVT with those without PVT.

MATERIAL AND METHODS

Cirrhotics evaluated for orthotopic liver transplant in a single large transplant center were prospectively followed. Subjects had contrast CT or MRI at initial evaluation and serial imaging every 6 months until transplantation, removal from the list or death. Univariate and multivariate Cox regression analysis were used to assess associations between new PVT and factors of interest.

RESULTS

Of the 290 prospectively followed cirrhotics who met inclusion criteria, PVT was detected in 70 (24.1%)-47 had PVT at the time of initial evaluation and 23 developed one during the pre-transplant study period. A third of the patients with PVT had re-canalization or spontaneous resolution of thrombus while awaiting transplantation. There was no difference in the pre or posttransplant mortality between cirrhotics with and without PVT.

CONCLUSION

Cirrhotics with untreated PVT fared equally well as those without PVT before and after transplantation. Further studies with larger numbers of patients are needed to determine if anticoagulation therapy truly improves outcomes in cirrhotics with portal vein thrombosis.

Novel small molecules disrupting Hec1/Nek2 interaction ablate tumor progression by triggering Nek2 degradation through a death-trap mechanism

Hec1 (highly expressed in cancer 1) or Nek2 (NIMA-related kinase 2) is often overexpressed in cancers with poor prognosis. Both are critical mitotic regulators, and phosphorylation of Hec1 S165 by Nek2 is required for proper chromosome segregation. Therefore, inactivation of Hec1 and Nek2 by targeting their interaction with small molecules represents an ideal strategy for tackling these types of cancers. Here we showed that new derivatives of INH (inhibitor for Nek2 and Hec1 binding) bind to Hec1 at amino acids 394-408 on W395, L399 and K400 residues, effectively blocking Hec1 phosphorylation on S165 by Nek2, and killing cancer cells at the nanomolar range. Mechanistically, the D-box (destruction-box) region of Nek2 specifically binds to Hec1 at amino acids 408-422, immediately adjacent to the INH binding motif. Subsequent binding of Nek2 to INH-bound Hec1 triggered proteasome-mediated Nek2 degradation, whereas the Hec1 binding defective Nek2 mutant, Nek2 R361L, resisted INH-induced Nek2 degradation. This finding unveils a novel drug-action mechanism where the binding of INHs to Hec1 forms a virtual death-trap to trigger Nek2 degradation and eventually cell death. Furthermore, analysis of the gene expression profiles of breast cancer patient samples revealed that co-elevated expressions of Hec1 and Nek2 correlated with the shortest survival. Treatment of mice with this kind of tumor with INHs significantly suppressed tumor growth without obvious toxicity. Taken together, the new INH derivatives are suitable for translation into clinical application.

Timed barium esophagram in achalasia types

Relationships of timed barium esophagram (TBE) findings to achalasia types defined by high-resolution manometry (HRM) have not been elucidated. Therefore, we correlated preoperative TBE and HRM measurements in achalasia types and related these to patient symptoms and prior treatments. From 2006 to 2013, 248 achalasia patients underwent TBE and HRM before Heller myotomy. TBE height and width were recorded at 1 and 5 minutes; HRM measured lower esophageal sphincter mean basal pressure, integrated relaxation pressure (IRP), and mean esophageal body contraction amplitude. Achalasia was classified into types I (25%), II (65%), and III (9.7%). TBE height at 5 minutes was higher for I (median 8 cm; interquartile range 6-12) and II (8 cm; 8-11) than for III (1 cm; 0-7). TBE width at 5 minutes was widest (3 cm; 2-4), narrower in II (2 cm; 2-3), and narrowest in I (1 cm; 0-2), P < 0.001. Volume remaining at 1 and 5 minutes was lower in III (1 m(2) ; 0-16) than I (42 m(2) ; 17-106) and II (39 m(2) ; 15-60), highlighting poorer emptying of I and II. Increasing TBE width correlated with deteriorating morphology and function from III to II to I. Symptoms poorly correlated with TBE and HRM. Prior treatment was associated with less regurgitation, faster emptying, and lower IRP. Although TBE and HRM are correlated in many respects, the wide range of their measurements observed in this study reveals a spectrum of morphology and dysfunction in achalasia that is best characterized by the combination of these studies.

7 OESTRAL RESPONSE AND FERTILITY IN DAIRY COWS TREATED WITH PROGESTERONE FOR 6 DAYS PRIOR TO OESTRUS SYNCHRONIZATION WITH PROSTAGLANDIN F2α

The present study tested whether the increase in serum progesterone concentrations for 6 days before oestrus synchronization with prostaglandin F2α (PGF2) increases oestral response, pregnancy rate, and reduces the incidence of twin births in dairy cattle. Seven hundred and eighty-three first-service dairy cows were synchronized with 2 injections of PGF2 14 days apart, starting on Day 35 postpartum. Six days before the second PGF2 injection, cows were assigned to 2 groups: P4 and control. The P4 group (n = 387) received a progesterone-releasing intravaginal device and an intramuscular injection of 500 mg of progesterone. The control group (n = 396) did not receive the progesterone-releasing intravaginal device or progesterone injection. Cows were inseminated 12 h after exhibiting oestrus. Pregnancy diagnosis was performed 40 and 45 days after insemination by rectal palpation and the cumulative pregnancy rate on Day 90 postpartum was determined retrospectively through the individual records. The response to the progesterone treatment varied according to the parity of the cows (P < 0.05). Thus, progesterone administration improved the percentage of cows detected in oestrus in multiparous [192/255 (75.2%) v. 161/267 (60.2%)] but not in primiparous [93/132 (70.4%) v. 90/129 (69.7%)] cows. Progesterone treatment increased pregnancy rate in multiparous [53/192 (27.6%) v. 27/161 (16.7%)] but not in primiparous cows [25/93 (26.8%) v. 29/90 (32.2%)]. Likewise, progesterone administration increased the cumulative percentage of pregnant cows on day 90 postpartum in multiparous [149/255 (58.4%) v. 129/267 (48.3%)] but not in primiparous cows [77/132 (58.3%) v. 82/129 (63.5%)]. The incidence of twin births was lower (P = 0.07) in cows treated with progesterone [1/74 (1%)] than in the control group [4/53 (7%)]. It is concluded that progesterone administration before oestrus synchronization with PGF2 in first service dairy cows improves oestral response, increases pregnancy rate, and percentage of pregnant animals on Day 90 postpartum in multiparous cows, but not in primiparous cows, and decreases the incidence of twin births. This research was supported by PAPIIT-UNAM research grant (IN219811-3).

Links between obesity, diabetes and ethnic disparities in breast cancer among Hispanic populations

Breast cancer is the most prevalent malignancy in women worldwide and is a growing concern due to rising incidence and ongoing ethnic disparities in both incidence and mortality. A number of factors likely contribute to these trends including rising rates of obesity and diabetes across the globe and differences in genetic predisposition. Here, we emphasize Hispanic populations and summarize what is currently known about obesity, diabetes and individual genetic predisposition as they relate to ethnic disparities in breast cancer incidence and mortality. In addition, we discuss potential contributions to breast cancer aetiology from molecular mechanisms associated with obesity and diabetes including dyslipidemia, hyperglycaemia, hyperinsulinaemia, endocrine dysfunction and inflammation. We propose that unique differences in diet and lifestyle coupled with individual genetic predisposition and endocrine/immune dysfunction explain most of the ethnic disparities seen in breast cancer incidence and mortality.

[Septic pseudarthrosis of the mandible and endodontic treatment]

INTRODUCTION

Septic pseudarthrosis of the mandible is an uncommon complication with several etiologies. The presence of a tooth next to a fracture site is one of the etiological factors. Conservative management of a tooth in or near the mandibular fracture site is often the issue when treating fracture of a toothed part.

OBSERVATION

A 49 year-old male patient was hospitalized in our department for a bifocal fracture of the mandible (right parasymphysis and left sub-condylar). An open reduction internal fixation with plates and screws was performed. The immediate postoperative period was uneventful except for persistent tooth pain in the parasymphyseal fracture site. At 1 postoperative month, the fracture site was stable and signs of consolidation were documented by the panoramic view. A dentist performed root canal treatment on tooth 42, 8 weeks after surgery, because of recurrent complaint by the patient. At 6 months, clinical and radiological examinations revealed mandibular pseudarthrosis.

DISCUSSION

This type of pseudarthrosis case is relatively infrequent. It occurs after endodontic treatment of a healthy tooth close to the fracture site (performed after the physiological delay before bone healing). The bacterial colonization of the fracture site could be related to this endodontic treatment. This case raises questions on the need for endodontic treatment of a tooth near a mandibular fracture site.

[Nose surgical anatomy in six aesthetic subunits]

The nose is a complex entity, combining aesthetic and functional roles. Descriptive anatomy is a fundamental science that it can be difficult to relate directly to our daily surgical activity. Reasoning in terms of aesthetic subunits to decide on his actions appeared to us so obvious. The aim of this paper is to resume the anatomical bases relevant to our daily practice in order to fully apprehend the restorative or cosmetic procedures. We discuss the limits of the systematization of these principles in nasal oncology.

The incidence and risk factors of de novo skin cancer in the liver transplant recipients

BACKGROUND

Liver transplantation (LT) increases the risk of de novo malignancies including skin cancers. However, risk factors for this type of cancers have not been well studied.

OBJECTIVE

To determine the incidence of skin cancer in LT recipients, and to identify the risk factors of this type of cancer.

METHODS

We identified all adult patients who underwent LT and developed de novo skin cancer post-LT at our institution between 1996 and 2009. We excluded the patients with history of skin cancer prior to LT. We also studied a control group of patients who underwent LT during the same period but did not develop skin cancer; the control group was matched (1:2) for age, gender and geographical place of residence.

RESULTS

Over a median (IQR) follow-up of 41.5 (18.0, 98.6) months, 23 (2.3%) of 998 patients developed skin cancer post-LT, of whom 10 were identified with squamous cell carcinoma, 9 with basal cell carcinoma and 4 with melanoma. After adjusting the confounding variables, subjects who had combined liver/kidney transplant had 22 (95% CI: 5.1-99) times higher hazard of skin cancer compared to subjects with LT alone. Furthermore, patients who had non-skin cancer prior to LT had 23 (95% CI: 8.6-60) times higher hazard developing skin cancer after the transplant. Patients with history of alcohol consumption, as the underlying etiology of liver disease, had 4 (95% CI: 1.2-12.9) times higher hazard of developing skin cancer after transplantation. Type or duration of immunosuppression was not associated with increased risk of skin cancer post-LT. The post-LT survival outcome was not affected by the development of de novo skin cancer post-LT.

CONCLUSION

Skin cancer is relatively common in LT recipients and should be monitored, particularly in patients with a history of pretransplant malignancy, recipients of combined liver and kidney transplant or having alcoholic cirrhosis as the underlying cause of liver disease.

Moderate sedation for elective upper endoscopy with balanced propofol versus fentanyl and midazolam alone: a randomized clinical trial

BACKGROUND AND STUDY AIMS

Balanced propofol sedation (BPS) combines propofol with opiates and benzodiazepines and targets at moderate sedation. Data comparing outcomes of BPS and standard sedation with opiates and benzodiazepines during elective esophagogastroduodenoscopy (EGD) are sparse. The primary end point of this study was to compare, in the recovery area, patient satisfaction with EGD following BPS versus standard sedation.

PATIENTS AND METHODS

Prospective, single-blinded randomized trial in 110 outpatients undergoing elective EGD and randomized 1:1 to BPS or standard sedation. Upon full recovery, the primary outcome of patient satisfaction was assessed using a 100-mm visual analogue scale (VAS) (1 = not at all satisfied, 100 = completely satisfied). Sedation recovery times and recall of pain and gagging (1 = none, 100 = severe) were also evaluated using a VAS.

RESULTS

The BPS and standard sedation groups were similar regarding American Society of Anesthesiologists (ASA), Mallampati class, age, sex, and body mass index (BMI). Compared with the standard sedation arm, the BPS group exhibited higher median procedural satisfaction (99 vs. 85, P < 0.001), and lower median scores for recall of pain (P < 0.001) and gagging (P < 0.001). BPS resulted in a shorter median recovery time (min) (11 vs. 23, P < 0.001). On multivariable regression analysis, predictors of patient satisfaction included use of propofol, increased age, and higher fentanyl dosage.

CONCLUSIONS

BPS targeted to moderate sedation by adequately trained endoscopists results in superior patient satisfaction and shorter recovery times than standard sedation alone during EGD.