Endoscopic Sinus Surgery in Patients with Chronic Hepatic Failure Awaiting Liver Transplant

Background

Because of the need for posttransplant immunosuppression, patients with chronic liver failure requiring transplantation must be free of infection to maintain an active status on the transplant list. These patients present significant surgical risks due to coagulopathy. Here, we present our experience with endoscopic sinus surgery for medically refractory sinusitis in this patient population.

Methods

We created a prospective case series of seven patients undergoing 10 surgeries.

Results

All patients were given preoperative blood product infusions. Operative blood loss ranged from 150 to 1500 cc with an average of 495 cc. Two cases had to be stopped before completion because of bleeding obscuring visualization. The two cases with the greatest blood loss were in patients with the most severe liver disease (highest mathematical model for end-stage liver disease scores), lowest albumin, and most extensive sinus disease. All patients were returned to active status on the liver transplant list and four patients have undergone liver transplantation.

Conclusion

Patients with chronic hepatic disease awaiting liver transplant can be treated successfully with endoscopic sinus surgery, but significant perioperative bleeding may not be avoidable. Preoperative use of fresh frozen plasma, platelets, and sometimes albumin are necessary, and postoperative blood products may be required with more significant sinus and liver disease. NovoSeven (recombinant factor VIIa) was used on two occasions in one patient, with maximal correction of the patient's coagulopathy. Patients should be counseled on the possible need for additional procedures to adequately clear disease.

Lamivudine monoprophylaxis for liver transplant recipients with non-replicating hepatitis B virus infection

BACKGROUND

The aim of this study was to evaluate the efficacy of lamivudine (LAM) monoprophylaxis for patients with non-replicating hepatitis B virus (HBV) infection at orthotopic liver transplantation (OLT).

METHODS

Among 128 liver recipients with HBV infection between 1994 and 2004 transplanted at our institution, 60 had non-replicating HBV infection at the time of OLT. Of those, 26 patients received LAM prophylaxis (monoprophylaxis group) and 34 patients received LAM and hepatitis B immunoglobulin (HBIG) prophylaxis (combination group) after OLT.

RESULTS

Median follow-up after OLT was 67 and 54 months, for monoprophylaxis and combination groups respectively. One and five yr patient/graft survival were 96/85% and 96/80% in monoprophylaxis group, and 85/79% and 67/55% in combination group. HBV DNA was re-detected or increased >10(5) IU/mL in four patients (15%) at 20-29 month in monoprophylaxis group and six (18%) at 4-35 months in combination group. Recurrent hepatitis was seen in two patients (8%) at 27 and 45 months and monoprophylaxis group and three (9%) at 21-35 months in combination group. The rate of recurrence was not statistically different between two groups.

CONCLUSION

LAM monoprophylaxis seemed to be effective for OLT recipients with HBV infection who had non-replicating HBV at transplantation. HBIG administration may play a less valuable role in preventing HBV recurrence in this group of patients.

Very late recurrence of hepatocellular carcinoma after liver transplantation: case report and literature review

Hepatocellular carcinoma (HCC) recurs in 10% to 60% of the patients after liver transplantation (OLT) and is associated with increased mortality. The average time to recurrence ranges from 1 to 2 years following OLT, and the median survival from the time of diagnosis is about 1 year. We report a case of a 69-year-old man who underwent OLT for hepatitis C virus-related cirrhosis with HCC, and was diagnosed with recurrent HCC 6.5 years after OLT. Biopsies from the initial and recurrent tumors showed a well-differentiated HCC with foci of clear cell pattern. The patient was still alive and asymptomatic 32 months after the diagnosis despite extensive tumor burden. He expired 9 years, 9 months after OLT and 3 years, 2 months after the detection of recurrence. In conclusion, HCC may recur more than 6 years after OLT and may exhibit an indolent course. This case illustrates the highly variable rate of tumor growth and progression post-OLT. The impact of this information on the need for long-term surveillance for recurrent HCC post-OLT remains to be determined.

The Impact of Nonalcoholic Fatty Liver Disease and the Metabolic Syndrome on Progression of Fibrosis in Patients With Recurrent HCV After Liver Transplantation

Nonalcoholic fatty liver disease (NAFLD) and the metabolic syndrome (MS) have been shown to play a role in disease progression and response to therapy in patients with chronic hepatitis C virus (HCV) infection. The primary objective of this study was to evaluate the impact of coexisting NAFLD and MS on the progression of fibrosis in patients with recurrent HCV treated with interferon (IFN)/ribavirin after orthotopic liver transplantation (OLT). From 1998 to 2004, a total of 418 patients underwent OLT in our center for HCV-related cirrhosis. Thirty-five patients with recurrent HCV on IFN/ribavirin treatment, who had at least 2 posttransplant liver biopsies at least 6 months apart, were included in the study. Patients who had MS at the time of their first posttransplant biopsy were identified. The first and last posttransplant biopsies were assessed for the presence and severity of NAFLD, grade of inflammation, and stage of fibrosis. The fibrosis progression rate (FPR) was calculated and expressed in fibrosis units per month (FU/mo). Among 35 patients, 34% were diagnosed with NAFLD in the first posttransplant biopsy. The mean FPR was 0.05+/-0.16 FU/mo in the presence of NAFLD compared to 0.07+/-0.10 FU/mo in its absence (P=.68) and 0.03+/-0.06 FU/mo in the presence of MS versus 0.10+/-0.15 FU/mo in its absence (P=.06). When FPR values were divided into two categories of <0.16 FU/mo or >or=0.16 FU/mo (below/above the 25% upper quartile) or <0.08 FU/mo or >or=0.08 FU/mo (below/above the 50% upper quartile), there was no correlation between FPR categories and the presence of NAFLD with or without MS, only MS, or the absence of both in the first liver transplant biopsy (P=.13). Coexisting NAFLD or MS had no significant effect on the progression of fibrosis after OLT in patients with treated hepatitis C after OLT.

Methotrexate (MTX) plus ursodeoxycholic acid (UDCA) in the treatment of primary biliary cirrhosis

This placebo-controlled, randomized, multicenter trial compared the effects of MTX plus UDCA to UDCA alone on the course of primary biliary cirrhosis (PBC). Two hundred and sixty five AMA positive patients without ascites, variceal bleeding, or encephalopathy; a serum bilirubin less than 3 mg/dL; serum albumin 3 g/dL or greater, who had taken UDCA 15 mg/kg daily for at least 6 months, were stratified by Ludwig's histological staging and then randomized to MTX 15 mg/m2 body surface area (maximum dose 20 mg) once a week while continuing on UDCA. The median time from randomization to closure of the study was 7.6 years (range: 4.6-8.8 years). Treatment failure was defined as death without liver transplantation; transplantation; variceal bleeding; development of ascites, encephalopathy, or varices; a doubling of serum bilirubin to 2.5 mg/dL or greater; a fall in serum albumin to 2.5 g/dL or less; histological progression by at least two stages or to cirrhosis. Patients were continued on treatment despite failure of treatment, unless transplantation ensued, drug toxicity necessitated withdrawal, or the patient developed a cancer. There were no significant differences in these parameters nor to the time of development of treatment failures observed for patients taking UDCA plus MTX, or UDCA plus placebo. The trial was conducted with a stopping rule, and was stopped early by the National Institutes of Health at the advice of our Data Safety Monitoring Board for reasons of futility. In conclusion, methotrexate when added to UDCA for a median period of 7.6 years had no effect on the course of PBC treated with UDCA alone.

Endoscopic sinus surgery in patients with chronic hepatic failure awaiting liver transplant

BACKGROUND

Because of the need for posttransplant immunosuppression, patients with chronic liver failure requiring transplantation must be free of infection to maintain an active status on the transplant list. These patients present significant surgical risks due to coagulopathy. Here, we present our experience with endoscopic sinus surgery for medically refractory sinusitis in this patient population.

METHODS

We created a prospective case series of seven patients undergoing 10 surgeries.

RESULTS

All patients were given preoperative blood product infusions. Operative blood loss ranged from 150 to 1500 cc with an average of 495 cc. Two cases had to be stopped before completion because of bleeding obscuring visualization. The two cases with the greatest blood loss were in patients with the most severe liver disease (highest mathematical model for end-stage liver disease scores), lowest albumin, and most extensive sinus disease. All patients were returned to active status on the liver transplant list and four patients have undergone liver transplantation.

CONCLUSION

Patients with chronic hepatic disease awaiting liver transplant can be treated successfully with endoscopic sinus surgery, but significant perioperative bleeding may not be avoidable. Preoperative use of fresh frozen plasma, platelets, and sometimes albumin are necessary, and postoperative blood products may be required with more significant sinus and liver disease. NovoSeven (recombinant factor Vlla) was used on two occasions in one patient, with maximal correction of the patient's coagulopathy. Patients should be counseled on the possible need for additional procedures to adequately clear disease.

Comparative mapping reveals partial conservation of synteny at the apomixis locus in Paspalum spp

In plants, gametophytic apomixis is a form of asexual reproduction that leads to the formation of seed-derived offspring that are genetically identical to the mother plant. A common set of RFLP markers, including five rice anchor markers previously shown to be linked to apomixis in Paspalum simplex, were used to detect linkage with apomixis in P. notatum and P. malacophyllum. A comparative map of the region around the apomixis locus was constructed for the three Paspalum species, and compared to the rice map. The locus that controls apomixis in P. simplex was almost completely conserved in the closely related species P. malacophyllum, whereas it was only partially represented in the distantly related species P. notatum. Although strong synteny of markers was noted between this locus and a portion of rice chromosome 12 in both P. simplex and P. malacophyllum, the same locus in P. notatum was localized to a hybrid chromosome which carries markers that map to rice chromosomes 2 and 12. All three Paspalum species showed recombination suppression at the apomixis locus; in the case of P. notatum, this might be due to a heterozygosity for a translocation that most probably negatively interferes with chromosomal pairing near the locus. A common set of markers that show linkage with apomixis in all three Paspalum species define a portion of the apomixis-controlling locus that is likely to contain genes critical for apomictic reproduction.

Comparative mapping reveals partial conservation of synteny at the apomixis locus in Paspalum spp

In plants, gametophytic apomixis is a form of asexual reproduction that leads to the formation of seed-derived offspring that are genetically identical to the mother plant. A common set of RFLP markers, including five rice anchor markers previously shown to be linked to apomixis in Paspalum simplex, were used to detect linkage with apomixis in P. notatum and P. malacophyllum. A comparative map of the region around the apomixis locus was constructed for the three Paspalum species, and compared to the rice map. The locus that controls apomixis in P. simplex was almost completely conserved in the closely related species P. malacophyllum, whereas it was only partially represented in the distantly related species P. notatum. Although strong synteny of markers was noted between this locus and a portion of rice chromosome 12 in both P. simplex and P. malacophyllum, the same locus in P. notatum was localized to a hybrid chromosome which carries markers that map to rice chromosomes 2 and 12. All three Paspalum species showed recombination suppression at the apomixis locus; in the case of P. notatum, this might be due to a heterozygosity for a translocation that most probably negatively interferes with chromosomal pairing near the locus. A common set of markers that show linkage with apomixis in all three Paspalum species define a portion of the apomixis-controlling locus that is likely to contain genes critical for apomictic reproduction.

Lack of seronegative hepatitis C virus infections in patients with chronic renal failure

BACKGROUND

Recent reports have indicated that serologic testing for hepatitis C virus (HCV) in patients with chronic renal failure may be inadequate to detect infections in this patient population.

METHODS

We prospectively tested 258 patients with end-stage renal disease who were referred for evaluation for renal transplantation for anti-HCV using a second-generation enzyme immunoassay (EIA) and a second-generation qualitative reverse-transcriptase polymerase chain reaction (RT-PCR). We confirmed all positive EIAs with a third-generation recombinant immunoblot assay and genotyped RT-PCR-positive specimens.

RESULTS

We found that 22 patients (8.5%) had serological evidence of HCV infection. Nineteen (86%) of the antibody-positive patients were viremic (HCV RNA positive). All but 1 of the patients was infected with HCV genotype 1. None of the 233 HCV antibody-negative patients were shown to be viremic by RT-PCR.

CONCLUSIONS

No additional HCV cases were detected by screening all patients for HCV RNA by RT-PCR. However, RT-PCR is a valuable adjunct to serology in antibody-positive patients to distinguish resolved from active infections.

Antitumor activity- and gene expression-based profiling of ecteinascidin Et 743 and phthalascidin Pt 650

BACKGROUND

Ecteinascidin 743 (Et 743) is a potent antitumor marine alkaloid currently undergoing phase II clinical trials. The synthetic analog phthalascidin (Pt 650), a designed structural analog of Et 743 displays in vitro potency comparable to Et 743. In this study, we used a panel of 36 human cancer cell lines, flow cytometry and oligonucleotide microarrays to analyze further these two compounds in a parallel fashion with regard to both antitumor activity (phenotype) and gene expression (genotype) bases.

RESULTS

The cancer panel experiment established that activity patterns of Et 743 and Pt 650 were essentially the same with their IC(50) values ranging from pM to low nM. By means of flow cytometric cell cycle analysis using HCT116 cells, they were shown to disrupt S phase progression after a 12-h treatment at 2.0 nM, eventually resulting in the late S and G2/M accumulation at the 24-h time point. Array-based gene expression monitoring also demonstrated that the Et 743 and Pt 650 profiles were highly similar in two distinct cancer cell lines, HCT116 colon and MDA-MB-435 breast. Characteristic changes were observed in subsets of genes involved in DNA damage response, transcription and signal transduction. In HCT116 carrying the wild-type p53 tumor suppressor gene, the up-regulation of several p53-responsive genes was evident. Furthermore, a subset of genes encoding DNA-binding proteins to specific promoter regions (e.g. the CCAAT box) was down-regulated in both cell lines, suggesting one potential mode of action of this series of antitumor agents.

CONCLUSION

A combination of gene expression analysis using oligonucleotide microarrays and flow cytometry confirms an earlier finding that Et 743 and Pt 650 have remarkably similar biological activities.

A new, more efficient, and effective process for the synthesis of a key pentacyclic intermediate for production of ecteinascidin and phthalascidin antitumor agents

An efficient process is described for the synthesis of 5, a key intermediate for the synthesis of the potent antitumor agents ecteinascidin 743 (1) and phthalascidin (2) from the readily available building blocks 3b and 4.

Enantioselective synthesis of saframycin A and evaluation of antitumor activity relative to ecteinascidin/saframycin hybrids

[formula: see text] A short synthesis of saframycin A is described which begins with a readily available intermediate previously utilized for the total synthesis of ecteinascidin 743. A key step in this synthesis is the use of 1-fluoro-3,5-dichloropyridinium triflate to oxidize a phenolic ring to a 1,4-benzoquinone unit while simultaneously cleaving a methoxymethyl ether of a different phenolic ring to the corresponding phenol (4-->5). The common intermediate (2) for the synthesis of saframycin A (1) and ecteinascidin 743 also allowed the synthesis of two hybrids of these structures (6 and 7). Whole cell bioassays for antitumor activity using lung, colon, melanoma, and prostate-derived tumor cell lines allowed a clear correlation of structure with biological activity in this series.

Phthalascidin, a synthetic antitumor agent with potency and mode of action comparable to ecteinascidin 743

A series of totally synthetic molecules that are structurally related to the marine natural product ecteinascidin 743 (Et 743) has been prepared and evaluated as antitumor agents. The most active of these, phthalascidin, is very similar to Et 743 with regard to in vitro potency and mode of action across a variety of cell types. The antiproliferative activity of phthalascidin (IC50 = 0.1-1 nM) is greater than that of the agents Taxol, camptothecin, adriamycin, mitomycin C, cisplatin, bleomycin, and etoposide by 1-3 orders of magnitude, and the mechanism of action is clearly different from these currently used drugs. Phthalascidin and Et 743 induce DNA-protein cross-linking and, although they seem to interact with topoisomerase (topo) I (but not topo II), topo I may not be the primary protein target of these agents. Phthalascidin and Et 743 show undiminished potency in camptothecin- and etoposide-resistant cells. Phthalascidin is more readily synthesized and more stable than Et 743, which is currently undergoing clinical trials. The relationship of chemical structure and antitumor activity for this class of molecules has been clarified by this study.

Nonfatal gastric mucormycosis in a renal transplant recipient

Mucormycosis historically has caused substantial morbidity with high mortality in renal transplant patients with disseminated and/or rhinocerebral infection and in patients with gastrointestinal illness regardless of predisposing conditions. We report the first successful treatment of gastric mucormycosis in a renal transplant recipient and review presumed pathogenic mechanisms of mucormycosis in renal transplant recipients as well as historical data.

Deoxynivalenol and contaminant mycoflora in freshly harvested Argentinian wheat in 1993

A mycological survey was carried out on wheat heads from the main production area of Argentina. The isolation frequency and ++relative density of species from genus Fusarium and dematiaceous fungi were calculated. F graminearum was the predominant Fusarium species; similar to that observed in the USA and Canada. An analysis of deoxynivalenol (DON) natural contamination also was performed on a limited number (44) of samples. DON contamination levels in positive samples ranged from 0.2 to 30 ppm. A stepwise regression procedure showed that, among the species analysed, F. graminearum relative density was related to the DON contamination level and that other prevalent fungi did not influence or modify that relationship.

Pneumatosis cystoides intestinalis in progressive systemic sclerosis: a case report and literature review

Pneumatosis cystoides intestinalis (PCI) is an uncommon disease manifestation characterized by the presence of air in the bowel wall. It is a benign condition that often responds to conservative management; however, it may be a harbinger of end stage disease, particularly in progressive systemic sclerosis. The authors report a case of pneumatosis cystoides intestinalis in a patient with progressive systemic sclerosis in the setting of mixed connective tissue disease that responded to conservative treatment. They review the current literature on pneumatosis cystoides intestinalis, focusing on possible etiologies and potential therapies.

Significance of solitary and multiple esophageal ulcers in patients with AIDS

We endoscopically evaluated odynophagia and/or dysphagia in 23 patients with acquired immunodeficiency syndrome (AIDS). Eleven patients (48%) were found to have esophageal ulcers. Seven of them had deep, sharply demarcated, well-circumscribed ulcer craters with raised edges; in two the ulcer extended to the muscularis propria. Ulcers were single in four patients, multiple in six, and unspecified in one. Biopsies were nondiagnostic. In eight patients, mycobacterial, viral, and fungal cultures were negative. Specific infections diagnosed in three patients were treated with appropriate agents. Ulcers were treated symptomatically, and seven patients received therapy for suspected viral etiology. Symptoms remained unchanged in five patients, improved in three, and resolved in two. Fifty-five percent of patients died within 3.6 months (mean) of diagnosis. Large solitary and multiple esophageal ulcers are common in AIDS patients with odynophagia and dysphagia.

Nutritional supplementation during the preschool years and physical work capacity in adolescent and young adult Guatemalans

A follow-up study (1988-89) was carried out in 364 rural Guatemalans, 11-27 y of age, who earlier had participated in a nutritional supplementation experiment. Among its objectives was the assessment of the long-term effects of the nutrition intervention on physical work capacity. Subjects and their mothers from two villages had available a high-energy, high-protein supplement (Atole: 163 kcal/682 kJ and 6.4 g protein per serving or 180 mL), whereas in two other villages a low-energy, no-protein supplement (Fresco: 59 kcal/247 kJ per 180 mL) was provided. Consumption was ad libitum. Maximum oxygen consumption (VO2max) at follow-up was significantly greater in Atole compared with Fresco subjects of both sexes. In subjects 14-19 y, exposed to supplementation throughout gestation and the first 3 y of life, Atole males had a significantly higher VO2max (2.62 L/min) than Fresco males (2.24 L/min), the differences remaining significant even after controlling for body weight and fat-free mass; also, there was a significant positive relationship between amount of supplement consumed and VO2max. The supplementation effect in females of similar age was not statistically significant. It is concluded that early nutritional improvements can have long-lasting effects on physical performance.

Lithium-induced nephrogenic diabetes insipidus treated with indomethacin

NDI occurs in 5% to 20% of patients receiving long-term lithium therapy. The associated polyuria usually resolves within 3 weeks of lithium discontinuance but can persist beyond a year. For such patients, hydrochlorothiazide and amiloride therapy has been hampered by the delayed effect and intrinsic side effects of these agents. We have described the case of a 66-year-old man with a history of bipolar disorder treated with lithium who was transferred to the intensive care unit with coma. Indomethacin therapy, at a dose of 50 mg every 8 hours, was begun and improvement of the NDI state was observed within 3 hours of lithium administration. There was complete normalization of mental status and laboratory studies after 36 hours. A complete 3-week course of indomethacin was required to keep the patient free of symptoms of NDI. We have also discussed the role of indomethacin in reversing lithium-induced NDI and reviewed pertinent prior reports in the literature.

Predicting body composition from anthropometry and bioimpedance in marginally undernourished adolescents and young adults

Body-composition prediction equations were developed using data from a sample of 201 female and male Guatemalan ladinos (ie, people of Amerindian-European descent) aged 11-25 y. Fat-free mass (FFM) values were estimated from body density by using the two-component model and age- and sex-specific values for the density of FFM. The root-mean-square error (RMSE) of the best model predicting FFM from a set of simple anthropometric variables was 1.59 kg for females and 1.90 kg for males. The addition of more extensive anthropometry to the set of candidate predictors reduced the RMSE to 1.42 kg for females and 1.88 kg for males. The subsequent addition of a bioelectrical impedance measure (Ht2/R) further reduced the RMSE to 1.32 kg for females and 1.82 kg for males. These results suggest that for a marginally undernourished population with relatively little body fat, simple anthropometrics are as useful as more sophisticated measures for the prediction of body composition.