Hepatic hydrothorax in a child and its management

Hepatic hydrothorax is a rare complication of portal hypertension. The optimal treatment for this condition is liver transplantation. Liver transplantation is significantly more manageable in children who weigh more than 8 kg. Here, an implantable pleural access device was used in a 5-month-old infant for painless iterative punctures to relieve respiratory symptoms, while waiting for liver transplantation and the patient's growth. The patient underwent successful transplantation 3 months later with a more optimal weight.

Determining the Efficacy of Liquid Sporicides Against Spores of Bacillus subtilis on a Hard Nonporous Surface Using the Quantitative Three Step Method: Collaborative Study

A collaborative study was conducted to validate the quantitative Three Step Method (TSM), a method designed to measure the performance of liquid sporicides on a hard nonporous surface. Ten laboratories agreed to participate in the collaborative study; data from 8 of 10 participating laboratories were used in the final statistical analysis. The TSM uses 5 5 1 mm glass coupons (carriers) upon which spores have been inoculated and which are introduced into liquid sporicidal agent contained in a microcentrifuge tube. Following exposure to a test chemical and a neutralization agent, spores are removed from carriers in 3 fractions: passive removal (Fraction A), sonication (Fraction B), and gentle agitation (Fraction C). Liquid from each fraction is serially diluted and plated on a recovery medium for spore enumeration. Control counts are compared to the treated counts, and the level of efficacy is determined by calculating the log10 reduction (LR) of spores. The main statistical goals were to evaluate the repeatability and reproducibility of the LR values, to estimate the components of variance for LR, and to assess method responsiveness. AOAC Method 966.04Method II was used as a reference method. The scope of the validation was limited to testing liquid formulations against spores of Bacillus subtilis, a surrogate for virulent strains of B. anthracis, on a hard nonporous surface (glass). The test chemicals used in the study were sodium hypochlorite, a combination of peracetic acid and hydrogen peroxide, and glutaraldehyde. Each test chemical was evaluated at 3 levels of presumed efficacy: high, medium, and low. Three replications were required. The TSM was validated as it successfully met the statistical parameters for quantitative test methods. Satisfactory validation parameters, such as the repeatability standard deviation (Sr) and reproducibility standard deviation (SR), were obtained for control carrier counts and LR values. Both the TSM and the reference method were responsive to the efficacy levels of the test chemicals. For the 72 total TSM tests conducted, the mean ( standard error of the mean) log density of spores per control carrier was 6.86 ( 0.08); the Sr and SR were low at 0.15 and 0.27, respectively. Across the range of test chemicals, the Sr and SR estimates associated with LR were also acceptably low. The Sr rangedfrom 0.17 to 0.72 and the SR ranged from 0.34 to 1.43. Overall, the Sr and SR estimates associated with the efficacy data were within the ranges published for other quantitative methods and meet the performance characteristics necessary for validation.

Comparative Evaluation of Two Quantitative Test Methods for Determining the Efficacy of Liquid Sporicides and Sterilants on a Hard Surface: A Precollaborative Study

Two quantitative carrier-based test methods for determining the efficacy of liquid sporicides and sterilants on a hard surface, the Standard Quantitative Carrier Test MethodASTM E 2111-00 and an adaptation of a quantitative micro-method as reported by Sagripanti and Bonifacino, were compared in this study. The methods were selected based on their desirable characteristics (e.g., well-developed protocol, previous use with spores, fully quantitative, and use of readily available equipment) for testing liquid sporicides and sterilants on a hard surface. In this paper, the Sagripanti-Bonifacino procedure is referred to as the Three Step Method (TSM). AOAC Official Method 966.04 was included in this study as a reference method. Three laboratories participated in the evaluation. Three chemical treatments were tested: (1) 3000 ppm sodium hypochlorite with pH adjusted to 7.0, (2) a hydrogen peroxide/peroxyacetic acid product, and (3) 3000 ppm sodium hypochlorite with pH unadjusted (pH of approximately 10.0). A fourth treatment, 6000 ppm sodium hypochlorite solution with pH adjusted to 7.0, was included only for Method 966.04 as a positive control (high level of efficacy). The contact time was 10 min for all chemical treatments except the 6000 ppm sodium hypochlorite treatment which was tested at 30 min. Each chemical treatment was tested 3 times using each of the methods. Only 2 of the laboratories performed the AOAC method. Method performance was assessed by the within-laboratory variance, between-laboratory variance, and total variance associated with the log reduction (LR) estimates generated by each quantitative method. The quantitative methods performed similarly, and the LR values generated by each method were not statistically different for the 3 treatments evaluated. Based on feedback from the participating laboratories, compared to the TSM, ASTM E 2111-00 was more resource demanding and required more set-up time. The logistical and resource concerns identified for ASTM E 2111-00 were largely associated with the filtration process and counting bacterial colonies on filters. Thus, the TSM was determined to be the most suitable method.

Modification to the AOAC Sporicidal Activity of Disinfectants Test (Method 966.04): Collaborative Study

In an effort to improve AOAC Method 966.04, the Sporicidal Activity of Disinfectants Test, selected modifications to the procedure were evaluated in a collaborative study. Method 966.04 is used to generate efficacy data to support the product registration of sporicides and sterilants. The method is a carrier-based test that provides a qualitative measure of product efficacy against spores of Bacillus subtilis and Clostridium sporogenes. The use of garden soil extract and the lack of standard procedures for the enumeration of spores and neutralization of the test chemicals have been considered problematic for many years. The proposed modifications were limited to the B. subtilis and hard surface carrier (porcelain penicylinder) components of the method. The study included the evaluation of a replacement for soil extract nutrient broth and an establishment of a minimum spore titer per carrier, both considered crucial for the improvement and utilization of the method. Additionally, an alternative hard surface material and a neutralization confirmation procedure were evaluated. To determine the equivalence of the proposed alternatives to the standard method, 3 medium/carrier combinations, (1) soil extract nutrient broth/porcelain carrier (current method), (2) nutrient agar amended with 5 g/mL manganese sulfate/porcelain carrier, and (3) nutrient agar amended with 5 g/mL manganese sulfate/stainless steel carrier were analyzed for carrier counts, HCl resistance, efficacy, quantitative efficacy, and spore wash-off. The test chemicals used in the study represent 3 chemical classes and are commercially available antimicrobial liquid products: sodium hypochlorite (bleach), glutaraldehyde, and a combination of peracetic acid and hydrogen peroxide. Four laboratories participated in the study. The results of the spore titer per carrier, HCl resistance, efficacy, and wash-off studies demonstrate that amended nutrient agar in conjunction with the porcelain is comparable to the current method, soil extract nutrient broth/porcelain. The nutrient agar method is simple, inexpensive, reproducible, and provides an ample supply of high quality spores. Due to the current use of porcelain carriers for testing C. sporogenes, it is advisable to retain the use of porcelain carriers until stainless steel can be evaluated as a replacement carrier material for Clostridium. The evaluation of stainless steel for Clostridium has been initiated by the Study Director. Study Director recommendations for First Action revisions are provided in a modified method.

An update on the physiopathology and therapeutic management of cholestatic pruritus in children

Pruritus is a disabling symptom accompanying chronic cholestasis. In extreme cases, the refractory nature of pruritus can result in a need for invasive therapies including liver transplantation. The pathogenesis of pruritus in cholestatic disease is poorly understood. It may involve a specific neural pathway (similar to that associated with pain) regulated by several pruritogenic substances such as bile acids, opioids, serotonin, and the more recently identified lysophosphatidic acid. While the therapeutic management of cholestatic pruritus is well established in adults, there is no consensus in children, in light of the difficulty of conducting controlled clinical studies. The currently recommended strategy to manage cholestatic pruritus in children is based on several lines of specific therapies that should be associated with skin hydration and with non-specific treatment of cholestasis including ursodeoxycholic acid. Pruritus should be assessed as objectively as possible between each line of therapy. Rifampicin, a potent CYP3A4 inducer, is the first-line treatment of cholestatic pruritus. Second-line therapies require evaluation of the child in an expert center and are discussed on a case-by-case basis depending on the underlying disease and the experience of the center. These include inhibitors of serotonin reuptake (sertraline), opioid antagonists (naloxone), or ASBT inhibitors. Invasive therapies such as biliary diversion or liver transplantation can also be proposed in the most severe cases. The aim of the current update is to review the physiopathologic mechanisms implicated in cholestatic pruritus and to propose potential therapeutic strategies in children.

Blood Coagulation, Fibrinolytic and Inhibitory Profiles in Renal Transplant Recipients: Comparison of Cyclosporine and Azathioprine

Renal transplant recipients treated with cyclosporine (CS) have been reported to be at increased risk of thrombotic complications. The present study was intended to examine the blood coagulation, fibrinolytic, and inhibitory systems in such patients. Eight transplant recipients on maintenance immunosuppression with CS and prednisone were studied. Five transplant recipients maintained on azathioprine (AZA) and prednisone and 32 normal volunteers served as controls. Plasma antigen concentrations and/or activities of various proteins in the above pathways were measured. Both the CS and AZA groups exhibited significant elevations of factor IX activity, von Willebrand factor (vWF), D-dimer, protein C and tissue type plasminogen activator (t-PA) levels when compared with the normal controls. In addition, CS group showed a significant elevation of α2-macroglobulin activity and AZA group showed a significant reduction in factor XII activity when compared with the normal controls. Comparison of data from CS and AZA groups revealed higher factor XII activity and vWF concentration in the former group. In conclusion, transplant recipients treated with long-term cyclosporine and prednisone exhibited significant elevation of plasma vWF, D-dimer and protein C concentrations. In addition, both CS and AZA-treated transplant recipients showed increased plasma concentrations of D-dimer and t-PA. The latter observations suggest in vivo thrombin generation, fibrin formation and degradation.

Significantly Improved Survival Time in Pigs with Complete Liver Ischemia Treated with a Novel Bioartificial Liver

Aim of the study was to evaluate treatment efficacy and safety of a scaled-up version of our porcine hepatocytes based BAL system in pigs with complete liver ischemia (LIS).

Thirty-one pigs underwent total devascularization of the liver (LIS) by termino-lateral porta-caval shunts and sutures around the bile duct, the common hepatic and gastroduodenal arteries and their accessory branches. The hepato-duodenal ligament was completely transected. Four experimental groups were studied: the first control group (LIS Control, n = 10) received glucose infusion only, the second control group (LIS Plasmapheresis, n = 8) was connected to a centrifugal plasma-separator with a bottle representing the bioreactor volume, the third control group (LIS Empty-BAL, n = 5) received BAL treatment without cells, and the treated group (LIS Cell-BAL, n = 8) was connected for a maximum period of 24 hours to our scaled-up BAL seeded with around 14 billion viable primary porcine hepatocytes.

BAL treatment significantly prolonged life in large animals (-35 kg) with complete LIS (Controls, mean ± SEM: 33.1 ± 3 h, Cell-BAL: 51.1 ± 3.4 h; p = 0.001; longest survivor 63 h). In addition, blood ammonia and total bilirubin levels decreased significantly, indicating metabolic activity of porcine hepatocytes in the bioreactor. No significant differences were noticed among the three control groups, indicating that there was no device effect and that the plasmapheresis procedure was well tolerated. No important adverse effectes were observed.

Association of interleukin-6 polymorphisms with obesity or metabolic traits in young Mexican-Americans

Objective

The objective of the study is to investigate the association of interleukin-6 (IL6) promoter single-nucleotide polymorphisms rs1800797 (-597 G/A) and rs1800796 (-572 G/C) with obesity or metabolic syndrome in Mexican-Americans.

Methods

The rs1800797 and rs1800796 single-nucleotide polymorphisms were genotyped in Mexican-Americans (n = 437) from South Texas, and results were correlated with measures of obesity and metabolic syndrome including body mass index, waist circumference, blood pressure, cholesterol, triglycerides, glucose, liver enzymes, plasma IL6 and high-sensitive C-reactive protein (hs-CRP).

Results

Significant associations were found for the rs1800796 variant with increased waist circumference, insulin resistance, lower IL6 levels and higher hs-CRP levels. The rs1800797 variant showed no associations with metabolic traits but was associated with higher IL6 levels and lower hs-CRP levels.

Conclusions

Findings in this study support the anti-inflammatory, anti-obesity and glucose homeostatic roles of IL6 in Mexican-American youth.

Meso-Rex bypass for extrahepatic portal vein obstruction in children

Background

Meso-Rex bypass (MRB) and portosystemic surgical shunt (PSS) are both used to treat extrahepatic portal vein obstruction (EHPVO) in children. The aim of this study was to analyse the outcome of MRB and PSS to select patients who could benefit from a prophylactic MRB.

Methods

This single-centre retrospective study of children who underwent either MRB or PSS for EHPVO was conducted between 1996 and 2010. Details of patient demographics and preoperative evaluation were collected. Success rates, defined as shunt patency after a minimum of 6 months and clearance of varices or symptoms, were compared. Determinants of outcomes were explored.

Results

Sixty-nine patients underwent a MRB or PSS. Median (interquartile range, i.q.r.) age at surgery was 6·6 (4·0–10·6) years. Twenty-four patients (35 per cent) had had a neonatal umbilical catheter (NUC) placed previously and 47 (68 per cent) had experienced an upper gastrointestinal bleed. Imaging assessment of the intrahepatic left portal vein was considered favourable in 40 patients. Of 43 MRBs attempted, 11 failed during surgery and four patients had persistent thrombosis after a median of 55 (i.q.r. 18–107) months. The success rate of MRB was 60 per cent (26 of 43) compared with 100 per cent (26 of 26) for PSS (P < 0·001). It was lower among patients in whom a NUC had been used (2 of 10 versus 24 of 33; P = 0·004), for procedures undertaken early in the series (6 of 16 versus 20 of 27; P = 0·020) and when the imaging pattern was unfavourable (0 of 5 versus 26 of 38; P = 0·006). On multivariable analysis, only a previous history of NUC predicted failure (P = 0·016).

Conclusion

Prophylactic MRB seems a good treatment option for EHPVO in children, but should be done only by an experienced team in patients with favourable imaging and without a previous history of NUC.

Presented in part to the 43rd Annual Meeting of the American Pediatric Surgical Association, San Antonio, Texas, USA, May 2012

Features of recurrence of triple-negative (TN), non-metastatic breast cancer (NMBC) patients: A single institution study

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Background: The TN BC is the most agressive subtype. Previous studies suggested that DFS of women with TN-BC is shorter than any other subtype and they demonstrated racial differences. The behaviour of these tumours are characterised by poor prognosis affecting mostly African American young obese women. Our goal is to determine the incidence of TN in non metastatic (NM) BC, the recurrence rate (RR), the patterns of recurrence by anatomic region and the DFS.

Methods: We reviewed the medical records of patients with BC diagnosed between Jan/2000 to Dec/2005 at Almenara Hospital in Lima, Peru. There were a total of 1042 patients with BC; of them 215 were identified as TN NM BC according to IHC ER, PR, and Her2/neu negatives. We collected the clinical data including age, menopausal status, staging, hormone receptor status as well as Her2/neu status. The data were analized by statistic software SPSS v. 17.0.

Results: The incidence of TN NM BC were 20.6% (215); of them 18.6% (40) patients had recurrences. The median age of recurrence were 52.5 years (31-93); the median DFS were 27 months, with a median follow-up of 64 months. According to inicial staging the recurrences were 7.5% (3); 32.5% (13); and 60% (24) respectively for patients with stages I, II and III. Almost one third (35%) of patients with recurrences were lymphatic node negative at diagnosis after mastectomy. The most frequent involved organs were visceral (lung=12, liver=3) 37.5% (15); bone 25% (10); skin 20% (8); CNS 12.5% (5) and contralateral breast 5% (2). There were four nuliparus women two of them had skin recurrence and the others two had bone metastasis.

Conclusions: TN NM BC constitutes 20.6% of all BC in our institution; the majority of relapses were stage III (60%). The median DFS for recurrence were 27 months and the most frequent sites involved were visceral (37%) and bone (25%). 12.5% of recurrences were to CNS and one third of the patients were lymph node negatives. This is to our knowledge the first study of patterns of recurrence in TN nonmetastatic BC in a Latino population. The incidence of TN-BC which is close to African-American population (25%).

Correlated electron state in Ce(1-x)Yb(x)CoIn5 stabilized by cooperative valence fluctuations

X-ray diffraction, electrical resistivity, magnetic susceptibility, and specific heat measurements on Ce(1-x)Yb(x)CoIn5 (0≤x≤1) reveal that many of the characteristic features of the x=0 correlated electron state are stable for x≤0.775 and that phase separation occurs for x>0.775. The stability of the correlated electron state is apparently due to cooperative behavior of the Ce and Yb ions, involving their unstable valences. Low-temperature non-Fermi liquid behavior is observed and varies with x, even though there is no readily identifiable quantum critical point. The superconducting critical temperature T(c) decreases linearly with x towards 0 K as x→1, in contrast with other HF superconductors where T(c) scales with T(coh).

Features of Recurrence of Triple Negative (TN) Non-Metastatic Breast Cancer (NMBC) Patients: A Single Institution Study

Background.- TN breast cancer (BC) are the most agressive type of BC, and we do not have a target therapy against this type. Our goal is to determine the rate of recurrence, the affected organs and the DFS in these patients.Materials and Methods.-We reviewed 1042 charts of all diagnosed BC patients from January/2000 to December/2005 and choose 215 who were TN-NMBC. The data was analized by analitic and descriptive statistics in SPSS v. 17.0Results.- The rate of TN-NMBC were 20.6%(215) of them 18.6%(40) patients had recurrences with an average age of 52.5(31-93) years. The median DFS were 27 months with a median follow-up of 64 months. The Stage I, II and III were 7.5%(3); 32.5%(13) and 60%(24) respectevely for patients with recurrence. The most frequent involved organs with recurrence were visceral (lung and liver) 37.5%(15), bone 25%(10), skin 20%(8), CNS 12.5%(5) and contralateral breast 5%(2). Additionally we found five patients with history of familiar BC, and four of them were stage II with negative lymph node at diagnoses.Conclusion.- TN-NMBC are 20.6% of all BC, the majority of them were stage III (60%), the median DFS for patients with recurrence were 27 months, and the most frequent sites involved were visceral (37.5%) and bone (25%). It is very interesting pay attention even in early stages to patients with history of familiar BC for risk of recurrence, BRCA positive?

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2072.