Comparison of immune activation of the COVID vaccines: ChAdOx1, BNT162b2, mRNA-1273, BBIBP-CorV, and Gam-COVID-Vac from serological human samples in Hungary showed higher protection after mRNA-based immunization

OBJECTIVE

To gain insight into the different protective mechanisms of approved vaccines, this study focuses on the comparison of humoral and cellular immune responses of five widely used vaccines including ChAdOx1 (AZD1222, AstraZeneca), BNT162b2 (Pfizer), mRNA-1273 (Moderna), BBIBP-CorV (Sinopharm), and Gam-COVID-Vac (Sputnik V).

MATERIALS AND METHODS

Isolated plasma from 95 volunteers' blood samples was used to measure anti-SARS-CoV-2 humoral and cellular immune responses. Positive controls were recovered patients from COVID-19 (unvaccinated). Specific quantification kits for anti-nucleocapsid IgG, anti-Spike protein IgG, neutralizing antibodies as well as specific SARS-CoV-2 antigens for T-cell activation were used and Spearman correlation and matrix analyses were performed to compare overall immune responses.

RESULTS

Nucleocapsid antibodies were significantly higher for the BBIBP-CorV and convalescent group when compared to other vaccines. In contrast, subjects vaccinated with BNT162b2 and mRNA-1273 presented significantly higher anti-spike IgG. In fact, 9.1% of convalescent, 4.5% of Gam-COVID-Vac, 28.6% of ChAdOx1, and 12.5% of BBIBP-CorV volunteers did not generate anti-spike IgG. Similarly, a positive correlation was observed after the neutralization assay. T-cell activation studies showed that mRNA-based vaccines induced a T-cell driven immune response in all cases, while 55% of convalescents,  8% of BNT162b1,  12,5% of mRNA-1273, 9% of Gam-COVID-Vac,  57% of ChAdOx1,  and  56% of BBIBP-CorV subjects presented no cellular response. Further correlation matrix analyses indicated that anti-spike IgG and neutralizing antibodies production, and T-cell activation follow the same trend after immunization.

CONCLUSIONS

RNA-based vaccines induced the most robust adaptive immune activation against SARS-CoV-2 by promoting a significantly higher T-cell response, anti-spike IgG and neutralization levels. Vector-based vaccines protected against the virus at a comparable level to convalescent patients.

Non-standard situation detection in smart water metering

In this paper an algorithm for detection of nonstandard situations in smart water metering based on machine learning is designed. The main categories for nonstandard situation or anomaly detection and two common methods for anomaly detection are analyzed. The proposed solution needs to fit the requirements for correct, efficient and real-time detection of non-standard situations in actual water consumption with minimal required consumer intervention to its operation. Moreover, a proposal to extend the original hardware solution is described and implemented to accommodate the needs of the detection algorithm. The final implemented and tested solution evaluates anomalies in water consumption for a given time in specific day and month using machine learning with a semi-supervised approach.

Pathologic assessment of response to chemotherapy in colorectal cancer liver metastases after hepatic resection: which method to use?

BACKGROUND

Patients with metastatic colorectal cancer receive chemotherapy prior liver resection more and more frequently. Histopathologic assessment methods of the resected specimen could evaluate the response to chemotherapy. In this study it is analyzed if these histopathologic changes are specific to preoperative chemotherapy and if these methods have correlation with survival.

METHODS

Sixty three patients with available pathology slides, resected for colorectal cancer liver metastases were enrolled in this study. 46 patients (73%) received neoadjuvant chemotherapy. Five pathological evaluation methods were compared according to the literature: [1] residual tumor cell ratio, [2] tumor regression grade (TRG) scoring system, [3] modified tumor regression grade (mTRG) scoring system with the type of necrosis, [4] pattern of tumor regression and [5] the tumor thickness at the tumor-normal interface (TNI).

RESULTS

Analyzing the pathological methods between the chemotherapy (CTX) and the non-chemotherapy group (NC), we found that that four evaluation methods showed significant and one showed strong correlation with the use of chemotherapy. (Residual tumor cell ratio: p = 0.08; TRG: p <0.01; mTRG: p = 0.03; pattern of tumor regression: p <0.01; TNI: p = 0.02). In the chemotherapy group none of the analyzed pathological methods showed significant correlation with progression free survival (PFS) or with overall survival (OS). Residual tumor cell ratio, TRG and the pattern of tumor cells showed positive but not significant correlation with OS and PFS and a slight difference in the group of patients with TNI <2 mm could be documented.

CONCLUSIONS

Tumor regression grade (TRG) and tumor thickness at the tumor-normal interface (TNI) were the most useful methods for pathological response evaluation and these methods had some correlation with survival. According to these data, authors concluded, that a reproducible and well defined scoring system, based on different histopathological evaluation methods should be developed to predict more accurately the effect of neoadjuvant chemotherapy in CRCLM patients.

Novel European lineages of bat astroviruses identified in Hungary

KEYWORDS

bat, astroviruses, coronaviruses, snRT-PCR, Hungary.

West Nile virus surveillance in mosquitoes, April to October 2013, Vojvodina province, Serbia: implications for the 2014 season

After the West Nile virus (WNV) outbreak in 2012, we collected mosquito samples from Vojvodina province, Serbia, in 2013. We found high WNV infection rate in two species, Culex pipiens and Anopheles maculipennis. Phylogenetic analysis showed that Serbian WNV strains from 2013 were most closely related to Italian and Greek strains isolated in 2012 and 2010, respectively. Public health authorities should be aware of a potentially increased risk of WNV activity during the 2014 season.

The comparison of thrombocytosis and platelet-lymphocyte ratio as potential prognostic markers in colorectal cancer

The aim of the present study was to analyse the preoperative platelet count and the platelet-lymphocyte ratio (PLR) in patients with colorectal cancer (CRC) of different stages and with hepatic metastasis of CRC (mCRC) and to compare these factors as potential prognostic markers. Clinicopathological data of 10 years were collected retrospectively from 336 patients with CRC and 118 patients with mCRC. Both in the CRC and the mCRC group overall survival (OS) was significantly worse in patients who had elevated platelet count (hazard ratio [HR] = 2.2, p < 0.001 and HR = 2.9, p = 0.018, respectively). Multivariate analysis indicated that elevated platelet count was an independent prognostic factor of CRC (HR = 1.7, p = 0.035) and mCRC (HR = 3.1, p = 0.017). Disease-free survival (DFS) was significantly worse in patients with elevated platelet count in the CRC group (HR = 2.0, p = 0.011). In the multivariate analysis the PLR was not a prognostic factor in either of the two cohorts (HR = 0.92, p < 0.001 and HR = 0.89, p = 0.789, respectively). The platelet count is a valuable prognostic marker for the survival in patients both with CRC and mCRC while the PLR is not prognostic in either group.

Genogroup I picobirnaviruses in pigs: evidence for genetic diversity and relatedness to human strains

Picobirnaviruses (PBVs) are small, non-enveloped viruses with a bisegmented double-stranded RNA genome. Their pathogenic potential, ecology, and evolutionary features are largely unexplored. Here, we describe the molecular analysis of porcine PBVs identified in the intestinal content of dead pigs. Six of 13 positive samples were cloned and then subjected to single-strand conformation polymorphism analysis and nucleotide sequencing. All clones belonged to genogroup I PBVs and almost all clones clustered on separate branches from human strains. A single strain shared a notably close genetic relationship with a Hungarian human PBV strain (89.9 nt and 96.4 % aa identity). Genetic diversity was also observed among strains identified in mixed infections. Single point mutations and deleterious mutations within highly related strains suggested that PBVs exist as quasispecies in the swine alimentary tract. Clones with complete sequence identities originating from different animals suggested effective animal-to-animal transmission of the virus. Our findings indicate that infection with genogroup I PBVs is common in pigs.

Human astroviruses in raw sewage samples in Hungary

AIMS

Routine procedures for monitoring viruses in water samples have not been drawn up for the water-microbiology screening panel. Enteric viruses, including astroviruses, are able to persist under environmental conditions and may cause public health problems by contaminating natural and drinking water resources. The aim of this study was to detect human astroviruses (HAstVs) from raw wastewater samples.

METHODS AND RESULTS

To obtain data on whether human astroviruses are shed in the environment, 35 raw sewage samples from 22 sewage plants in different regions of Baranya County, Hungary were tested for astrovirus using a polyethylene glycol method for concentration and a guanidinium thiocyanate-silica procedure for extraction of viral RNA. Reverse transcription-polymerase chain reaction (RT-PCR) with HAstV-specific primer pairs was used for amplification and the specificity of amplicons was confirmed by nucleotide sequencing and phylogenetic analysis. Among the 35 raw sewage samples, 15 (43%) contained HAstV and by sequence analysis, 10 genotype HAstV-1 and one genotype HAstV-2 were identified.

CONCLUSIONS

The high detection rate of astroviruses we encountered in this study provide convincing evidence that HAstVs circulate at a relatively high frequency in the Hungarian population. No correlation between the standard indicators of faecal pollution and the presence of HAstVs was found.

SIGNIFICANCE AND IMPACT OF THE STUDY

Our study is the first report on detection of HAstV in sewage in Hungary and suggests that HAstV might be potent indicators of viral pollution in environmental specimens.

The phylogenetic relationships among some Randia (Rubiaceae) taxa

Phylogenetic relationships among some Randia (Rubiaceae, Gardenieae) taxa were estimated based on sequence variation in the nuclear ribosomal internal transcribed spacers (ITS) and rps 16 intron (cpDNA). During the investigation of rpsl6 intron of 9 studied Central American Randia species, two well supported subclades were separated. Analysis of ITS data of 16 Randia species shows 3 major clades. A group of mainly lowland, South American Randia species is moderate supported (75%). Species from Mexico form a strongly supported (97%) clade, but the Central American and Mexican Randia species are low supported (58%). However the last two groups are well supported together (95%). The molecular delimination is well in line with the size of leaves combined with the texture of exocarp.

Prevalence and molecular characterization of human group C rotaviruses in Hungary

BACKGROUND

Group C rotaviruses are recognized enteric pathogens of humans and animals. Human group C rotaviruses have been associated with sporadic episodes and large outbreaks of gastroenteritis in children and adults but their epidemiology and ecology are still unexplored.

OBJECTIVES

To collect epidemiological data on group C rotavirus infections among children with gastroenteritis in Hungary and perform molecular characterization on the identified strains.

STUDY DESIGN

Fecal samples were collected during the 2003 surveillance in Baranya County, Hungary. The presence of group C rotavirus RNA was investigated by polyacrylamide gel electrophoresis and by reverse transcription-nested polymerase chain reaction for the VP6 gene. The identified strains were further characterized by sequencing and phylogenetic analysis of the VP7, VP6, VP4, and NSP4 genes.

RESULTS

Three of 472 samples (0.6%) tested positive for group C rotavirus. Two samples were selected for molecular analysis. Strains BaC 6104/03 and BaC 11549/03 displayed an overall identity of >99.8% and 99.3% at the nucleotide and amino acid level, respectively. The VP7 of the strain BaC 6104/03 was most closely related (99.5% aa) to the Nigerian strain Jajeri, while the VP4s of strains BaC 6104/03 and BaC 11549/03 were more similar (98.1% aa) to strains Belem and 208, detected in Brazil and China, respectively.

CONCLUSIONS

Based on this 1-year study, we conclude that group C rotaviruses are not of epidemiological relevance in the etiology of childhood acute gastroenteritis in Hungary. The low sequence divergence between the Hungarian strains suggested that a single group C rotavirus strain circulated in this period in the study area.

Genetic variation within and relationships among five subpopulations of Slovak Thoroughbred

Genetic variation at six microsatellite loci was analysed for five Thoroughbred subpopulations to determine the magnitude of genetic differentiation and the genetic relationships among the subpopulations. Significant deviations from Hardy-Weinberg equilibrium were shown for a number of locus-population combinations, with all subpopulations. The genetic diversities and relationships of five Thoroughbred subpopulations were evaluated using six microsatellites recommended by the International Society of Animal Genetics (ISAG). The allele frequencies, the effective numbers of alleles, and the observed and expected heterozygosities were calculated. POPGENE v. 1.31 (Yeh et al., 1997) was used to test for deviations from the Hardy-Weinberg (H-W) equilibrium and to assign F(IS) estimates (Weir, 1990). The utility of microsatellites for evaluating genetic diversity of horses is discussed.

Sequence heterogeneity among human picobirnaviruses detected in a gastroenteritis outbreak

Human picobirnaviruses characterised in this study were serendipitously detected in a non-bacterial gastroenteritis outbreak when specimens were examined for the presence of human rotaviruses using polyacrylamide gel electrophoresis. Of ten stool samples sent for virological examination, two, three, and one specimens were positive for human caliciviruses, picobirnaviruses, and both viruses, respectively. Partial sequences of the RNA-dependent RNA polymerase gene were determined for three picobirnavirus-positive samples. The sequence identity among these three strains was 60% to 65% for the nucleic acid and 64% to 70% for the deduced amino acid sequences. Phylogenetic analysis revealed that each of the three strains clustered with strains identified in geographically separate areas. In contrast, human calicivirus strains co-incidentally identified, showed complete nucleotide sequence identity. These findings demonstrate a lack of common exposure to or point of source for picobirnavirus infection, suggesting that the outbreak was caused by human caliciviruses. Further studies are needed to determine the etiologic role and to establish the taxonomic basis of picobirnaviruses.

A medical nutriment has supportive value in the treatment of colorectal cancer

MSC (Avemar) is a medical nutriment of which preclinical and observational clinical studies suggested an antimetastatic activity with no toxicity. This open-label cohort trial has compared anticancer treatments plus MSC (9 g once daily) vs anticancer treatments alone in colorectal patients, enrolled from three oncosurgical centres; cohort allocation was on the basis of patients' choice. Sixty-six colorectal cancer patients received MSC supplement for more than 6 months and 104 patients served as controls (anticancer therapies alone): no statistical difference was noted in the time from diagnosis to the last visit between the two groups. End-point analysis revealed that progression-related events were significantly less frequent in the MSC group (new recurrences: 3.0 vs 17.3%, P<0.01; new metastases: 7.6 vs 23.1%, P<0.01; deaths: 12.1 vs 31.7%, P<0.01). Survival analysis showed significant improvements in the MSC group regarding progression-free (P=0.0184) and overall survivals (P=0.0278) probabilities. Survival predictors in Cox's proportional hazards were UICC stage and MSC treatment. Continuous supplementation of anticancer therapies with MSC for more than 6 months is beneficial to patients with colorectal cancer in terms of overall and progression-free survival.

The first histological demonstration of pancreatic oxidative stress in human acute pancreatitis

Necrotizing acute pancreatitis is associated with an inflammatory explosion involving numerous pro-inflammatory mediator cascades and oxidative stress. Acinar oxygen free radical production aggravates pancreatic tissue damage, and promotes cellular adhesion molecule upregulation resulting in leukocyte adherence and activation. The cerium capture oxygen free radical histochemistry combined with reflectance confocal laser scanning microscopy allows the "in situ" histological demonstration of oxygen free radical formation in live tissues. Here we present a case report, where oxidative stress is demonstrated on a histological level for the first time in human acute pancreatitis. A 44-year-old male patient suffering from acute exacerbation of his chronic pancreatitis developed a pancreato-pleural fistula with amylase-rich left pleural exudate causing respiratory compromise. Subsequent to an urgent thoracic decompression a distal pancreatectomy and splenectomy was performed with the closure of abdomino-thoracic fistula. The postoperative course was uneventful, except for a transient pancreatico-cutaneous fistula, which healed after conservative treatment. To carry out cerium capture oxygen free radical histochemistry the resected pancreas specimen was readily perfused with cerium-chloride solution through the arteries on the resection surface. Frozen sections were cut, E-, P-selectin, ICAM and VCAM were labeled by immunofluorescence. The tumor-free margin of an identically treated pancreas carcinoma specimen served as a control. Intrapancreatic oxidative stress and cellular adhesion molecule expression were detected by confocal laser scanning microscopy. Numerous pancreatic acini and neighboring capillaries showed oxygen free radical-derived cerium-perhy-droxide depositions corresponding to strong local oxidative stress. Acinar cytoplasmic reflectance signals suggested xanthine-oxidase as a source of oxygen free radicals. These areas presented considerably increased endothelial P-selectin expression with adherent, oxygen free radical-producing polymorphonuclear leukocytes displaying pericellular cerium-reflectance. Modest ICAM upregulation was noted, E-selectin and VCAM expression was negligible. The control pancreas specimen showed minimal oxidative stress with weak, focal P-selectin expression. The development of deleterious pancreatic oxidative stress was based on indirect evidence in human acute pancreatitis. To the best of our knowledge this is the first report demonstrating persistent intrapancreatic oxidative stress histologically in human acute pancreatitis. We have noted P-selectin overexpression with a preponderance in the areas of acinar oxidative stress.

[Haemodialysed, hemiparetic patient operated on for aortic aneurysm followed by successful renal transplantation]

The authors present the case of a 58 years old male patient. According to his preceding record in 1991 he suffered speech disturbance and left-side hemiparesis due to multiplex vascular lesions. A fresh cerebral ictus caused a right side hemiparesis mainly in the upper limb in 1993 and sensomotororic aphasia has also been developed. In 1995 the patient was begun acute haemodialysis treatment due to his gravis uremic state, then his dialysis was continued 3 times 4 hours weekly. In 1997 the then 56 years old inveterate right-sided hemiparetic patient, treated with chronic haemodialysis requested to be put on the transplantation waiting list. The first thing that had to be done in case of this high-risk patient was the resection of the abdominal aortic aneurysm (38 mm x 67 mm x 115 mm in size) noticed at the ultrasound examination which was carried out in January 1997. The continuity of the vessel was secured by graft-interposition where the arteria mesenterica was also implanted. Following the successful operation, the patient was qualified for the transplantation list and in the February of 1998 a successful kidney-transplantation was carried out. Following the temporary, post-transplantation difficulties (post-operative 5th day acute rejection well-reacting to 3 steroid-shots; the two re-operations due to partial necrosis in the uretero-ureteralis anastomosis and successfully overcoming the Pseudomonas aeruginosa uroinfection) the patient is currently doing well and has no complaint.

First clinical data of a natural immunomodulator in colorectal cancer

BACKGROUND/AIMS

MSC (trade-name AVEMAR) is a per os applicable complex of multiple, biologically active molecules obtained from fermented wheat-germ extract. Preclinical studies suggest potent anti-metastatic activity and it has a favorable toxicity profile. It has been aimed in a pilot-scale, phase II clinical study to document whether or not MSC as a support to surgery or plus chemotherapy adds any therapeutic benefit compared to the same combination without MSC in colorectal cancer.

METHODOLOGY

From 1998 to June 1999, 18 control patients and 12 consecutive colorectal cancer patients respectively, were enrolled into this study. All patients underwent curative surgery. The control group (18 patients) received no other therapy or adjuvant chemotherapy alone. The MSC group (12 patients) received MSC alone or plus adjuvant chemotherapy. Until now, the median follow-up has been 9 months.

RESULTS

Interim data of the study document that in the MSC group no new metastases, neither hepatic nor other, have occurred, so far. On the contrary, several new metastases have developed in the control group.

CONCLUSIONS

Orally administered MSC is a potent candidate to be regarded as a supportive therapy to surgery or plus chemotherapy for colorectal cancer patients.

[Acute pancreatitis: recent advances in understanding its pathophysiology]

This article reviews the recent changes in the understanding of acute pancreatitis pathophysiology emphasizing results deriving from the more detailed comprehension of the local and systemic aspects of the inflammatory process. The authors briefly discuss those theories that have been influencing the basic philosophies of treatment efforts. The role of premature digestive enzyme activation as the principal determinant of the pathoetiology and mortality of this disease has been questioned lately, and the inflammatory explosion has been placed into the center of attention. Simultaneously with the enzyme activation, the pancreatitogenic noxious event rapidly induces the formation of oxygen derived free radicals, activation of the transcription factor NF kappa-B, with consequent citokine production, cellular adhesion molecule upregulation and leukocyte hyperstimulation. Numerous other mediator cascades are activated in parallel, the uncontrolled surge of proinflammatory stimuli, and activity of the effector cells lead to multiple organ failure in severe cases. A genetically determined catastrophe management program is set forth in the acinar cell with pancreatitis associated protein expression and activation of the apoptosis machinery. Therapeutic approaches based on these recent findings are briefly touched upon.

[Metastasized carcinoid tumor treated with interferon and octreotide]

The carcinoid tumours are rare forms of the gastrointestinal tumours (they make up 2%), though lately they have shown an upward tendency. Among different types of treatments of the carcinoid tumours in non metastatised cases, the surgical intervention stands first on the list. But when symptoms emerge, most of the tumours have metastases, for which there are various types of treatments. The authors introduce the combined therapeutical possibilities in connection with metastatised carcinoid tumours. A combination of octreotid and interferon is used in the course of the treatment. Authors introduce the therapy's indications and experiences gained during the follow up of events.

Jejunal nutrition

Contrary to the past experience of forced parenteral nutrition nowaday's the enteral [jejunal] nutrition enjoys priority. It is not questionable, that well adjusted and controlled application of fluid, ion, fat, carbon hydrate, amino acid promoted convalescence. The experiences of the Authors supports that enteral nutrition through technically proper outperformed jejunostomy does not increase complication rate and beside well controlled food administration provides the physiologic stimules of food, the method is relatively easy and cost effective. For this reason the Authors initiated jejunostomy at the end of larger interventions such as Akyama procedure, total gastrectomy, multivisceral interventions, pancreatectomy, operations for massive gastrointestinal bleeding and finally reoperations with extreme negative N-balance and with the chance of inability of oral feeding for several days.

Pancreatic pseudocyst propagating into retroperitoneum and mediastinum

The extrahepatic pseudocysts of pancreatic origin sometimes propagate into mediastinum and retroperitoneum. A large pseudocyst of pancreatic origin propagating into the mediastinum up to the aortic arch is published. The surgical intervention has been urged by the dislocation of the heart, by the danger of autodigestion of the mediastinal aorta and by the danger of rupture. Attention is directed to the external drainage operation which is suitable for emptying of the pseudocyst not independently from the ripeness of pseudocyst wall and the characteristics of the pseudocyst content. Should the time short after the exacerbation and should the amylase content high in the cyst, the immediate result of external drainage better and reliable safe.

Transverse hepatectomy in surgical treatment of gallbladder carcinoma

In the surgical treatment of gallbladder cancer not only the traditional resections (right trisegmentectomy, lobectomy), but newer, parenchyma sparing multisegmentectomies, resection of 4B, 5, 6, that is transverse resection is also justified, as it is shown by demonstrating the 2 first cases in Hungary with transverse hepatectomy. World-wide there is a tendency for more aggressive surgical treatment in case of gallbladder cancer. For this reason we introduced transverse hepatectomy in our surgical practice, and in this paper we demonstrate the technical details of the new procedure. The goal of the transverse resection is to remove the tumour with an adequate margin of resection. The remaining hepatic parenchyma allows good quality of life for the patients till recurrence develops.

The current surgical treatment of primary malignant melanoma of the skin

In our Department, between 1991 and 1996, 132 patients, there of 87 male-45 female, average age of 48.2 years underwent surgery because of stage 1 (T2) to stage 3 melanoma that was located on the skin. None of patients suffered from early or in situ melanoma. Our retrospective study was based on those 94 patients who had been followed up by Department or dermatology-oncology in our medical centre. Surgery is still the primary treatment for cutaneous malignant melanoma. Thin melanomas (up to 2 mm in thickness) can be excised with 2 cm margins. Whether this is also true for thicker melanomas is not known and the only way to obtain more knowledge is to participate in prospective randomised studies. Elective lymph node dissection is associated with significant morbidity which includes lymphedema, wound complications and paresthesias of the extremity. For this reason we use an alternative operative approach uses selective lymphadenectomy with identification of the sentinel node.

Diagnostic-staging laparoscopy

Recently instead of the old fashioned, traditional explorative laparotomy the newer up-to-date procedure, the diagnostic-staging laparoscopy has been generally used in the everyday surgical practice of the Authors. Evaluating 32 diagnostic and staging laparoscopy Authors draw the attention to the importance of this procedure which has high diagnostic value, and reduces the complication rate. Biopsy, cytology, frozen section can be done. Authors carries out diagnostic and staging laparoscopy in cases of esophageal, liver, stomach and pancreas tumours just immediately before surgery.

Experience acquired by applying gentamicin-sponge

Chronic suppuration is a reverting problem in surgical practice. The concerned region either has insufficient circulation due to basic disease, or systemic antibiotics takes no effect due to inflammatory barrier developed meanwhile. For this reason Authors initiated systematic use of gentamicin sponge (Garamycin, Schering-Plough, USA) two years ago. During this period we implanted gentamicin sponge in 40 cases. After primary intervention in 85% of treated patients we observed complete recovery, or in case of ulcus cruris we reached proper condition for skin-transplantation. Three patients needed further incision and in two cases amputation of diabetic foot could not be avoided. Our results support the effectivity of gentamicin sponge in treating local inflammatory processes supplementing and increasing efficiency of surgical procedures.

Preoperative work up and therapeutic schedule for patients with duplex tumors

Authors analyze the cases of duplex and multiplex tumors among the more than two thousand operated upon patients a year at the Surgical Department of Uzsoki Hospital, Budapest, Hungary. The study enrolls a two years period evaluating the medical history of our patients in hope of a more sophisticated and effective diagnostic and therapeutic regimen. Our experience gained by analyzing data of our patients with synchron tumors shows that the patient's life expectancy is much better if performing a radical multivisceral tumor extirpation at the same sitting even if keeping in mind the higher perioperative risk. In accordance to the above mentioned concept we would like to stress the utmost importance of the interdisciplinary cooperation.

Experiences with ethanol infiltration of the liver metastases of colorectal tumors (preliminary study)

With the aid of improvement in imaging technique and with the ability of detection of hepatic tumours, the successful treatment of primary and secondary hepatic tumours using surgical methods has gained importance. Metastasectomies were performed in 16 cases at our department in 1996. In 6 cases atypical resections and/or infiltration with 96% ethanol were performed. In 3 instances ethanol infiltration into the metastases were accomplished during the resection, in 4 cases--when metastases were discovered 1-4 year after the resection of the primary tumours--the same method was used during the relaparatomy. 96% ethanol was injected directly into the metastatic tumours during operations. The early ultrasonograph examinations proved the total destruction of the metastases in diameter of 1-3 cm, and partial necrosis of the large (d = 3-8 cm) tumours. Two patients were lost from the follow up. Five patients are still alive after 2-8 months of the ethanol infiltration. In one patient after the ethanol infiltration of metastases /d = 3-5 cm/ in 6 segments of the liver we observed the dissemination of the tumour.

Lymphadenectomy in gastrointestinal surgery for malignancy

In a randomised study 25 patients with gastrointestinal surgery combined with extended lymphadenectomy (three field lymphadenectomy in case of esophageal cancer, D2 lymphadenectomy in case of gastric cancer) has been compared to the same number of patients with limited lymphadenectomy (D1). The operation time and the need for blood transfusion has increased in the extended lymphadenectomy group. The complication rate was more than doubled in the extended lymphadenectomy group, due to fluid or lymph collection, lymphatic edema, and infection. The mapping and staging was superior in extended lymphadenectomy group, but increased morbidity and mortality has been found in this group. However the favourable effect of extended lymphadenectomy on survival needs further long-term studies and proofs.

Experiences with duodenum preserving pancreatectomy

According to the principle of surgery for chronic pancreatitis the preservation of pylorus, duodenum or distal part of common bile duct gives the benefit of more physiological intervention. 2 patients with duodenum preserving pancreatectomy are presented. The operation was carried out for chronic pancreatitis. Both patients had jaundice and needed T drainage. Both patients suffered from very severe malnutrition with cachectic condition adding severe pain. None of them proved to be malignant by the frozen section. Previous diabetes, severe chronic inflammation of the whole pancreas, destruction of the pancreatic ductal system and cysts helped the decision-making for ablation of pancreas with preservation of duodenum which seems organ saving procedure. In comparison with the Whipple operation the duodenum-preserving pancreatectomy spares the patient a gastrectomy, a duodenectomy and a resection of distal common bile duct.

Resection of giant schwannoma by combined surgical exposure

Contrary to the past experience the giant Schwannoma with symptoms of canalis vertebralis compression has been removed by combined surgical exposure in one sitting. Laminectomy, decompression of the canalis vertebralis and immediately subsequent extracanalicular resection of the tumour by retroperitoneal approach was performed in one sitting by two surgical teams. The advantages of the combined surgical exposure: 1. The affliction of the patients caused by the operation significantly decreased. 2. The expenses of the treatment, nursing and hotel decreased as well. 3. The surgical team of different specialists remove the tumour together in both approaches.

[Organizational difficulties in liver transplantation]

Author overviews the evolution of liver transplantation from the point of view of organization in North America, in Europe and in Hungary partly on the basis of his own experience. It can be stated, that in North America the liver transplantation has become the universal method for the treatment of end-stage liver diseases, only after 20 year long period since the beginning. This first 20 years could be characterized by the monopoly of few giant transplant centers. This period was different and shorter in Europe due to integration run by Eurotransplant and Council of Europe. In Hungary the need and hope for a well organized, functioning liver transplant programme has become reality after difficult long period. Individual efforts, organizations, scientific-, clinical-, experimental work are being regarded valuable experience, because due to this effort some liver patients can live with good quality of life, the results are included to the present programme, on the other hand this accumulated knowledge can serve as a basis for further transplant activity.

The relationship between portal venous and hepatic arterial blood flow. I. Experimental liver transplantation

The relationship between the changes in portal venous and hepatic arterial blood flows, in the liver is a much disputed question, it has tremendous significance in the practice of transplantation, and an explanation has been available since 1981, when Lautt published the so-called "adenosine washout theory". According to our earlier observations the decrease of portal pressure or flow consistently led to an increase in hepatic artery flow. At the same time changes in hepatic artery flow or pressure seemed to produce only inconsistent effects on the portal circulation. In the present experiments liver transplantation (OLTX) was carried out on mongrel dogs by Starzl's method. Electromagnetic flow probes were placed on the hepatic artery and the portal vein before removal of recipient's liver, and after completion of all vascular anastomoses to the newly inserted liver, during the recirculatory phase of OLTX. The flow probes were connected to a Hellige electromagnetic flowmeter, portal venous and systemic arterial pressures were also recorded. The control HAF was 241 +/- 23 ml/min, the average PVF was 517 +/- 47 ml/min before removal of the recipient's liver. In the recirculatory phase of HAF increased, by 71 +/- 12% (p < 0.001). The PVF decreased in most animals after OLTX. The decrease was in average -40.2 +/- 3.5% (p < 0.001). The THBF calculated by adding the HAF and PVF showed a small, but not significant decrease recirculation. The systemic arterial pressure decreased slightly and portal vein pressure rose in most animals after OLTX. There was a substantial increase in portal inflow resistance and prehepatic arteriolar resistance and a decrease in hepatic artery resistance. The decrease of PVF after OLTX can be explained by progressive fluid accumulation in the liver parenchyma and increased sinusoidal and portal inflow resistance. The prolonged and continuous increase in hepatic artery flow during the recirculatory phase of OLTX may be due to the decrease of portal flow. The exact mechanism, by which a change in portal flow leads to arteriolar dilatation, can be most probably explained by the "adenosine washout theory" of Lautt.

A new method to measure portal venous and hepatic arterial blood flow in patients intraoperatively

The intraoperative measurement of the afferent circulation of the liver, namely the hepatic artery flow and portal venous flow was carried out upon 14 anesthetized patients having carcinoma in the splanchnic area, mainly in the head of the pancreas by means of transit time ultrasonic volume flowmeter. The hepatic artery flow, portal venous flow and total hepatic flow were 0.377 +/- 0.10; 0.614 +/- 0.21; 0.992 +/- 0.276 l/min respectively. The ratio of hepatic arterial flow to portal venous flow was 0.66 +/- 0.259. There was a sharp, significant increase in hepatic arterial flow (29.8 +/- 6.1%, p < 0.01) after the temporary occlusion of the portal vein, while the temporary occlusion of hepatic artery did not have any significant effect on portal venous circulation. The interaction between hepatic arterial flow and portal venous flow is a much disputed question, but according to the presented data here, it is unquestionable, that the decrease of portal venous flow immediately results a significant increase in hepatic artery circulation.

Changes in hepatic hemodynamics due to primary liver tumours

Data regarding the afferent circulation of the liver in patients with primary hepatocellular carcinoma are controversial, we have carried out measurement of hepatic arterial and portal venous flow intraoperatively by transit time ultrasonic volume flowmetry. In patients with primary hepatocellular carcinoma the hepatic artery flow increased to 0.55 +/- 0.211 compared with the control value of 0.37 +/- 0.102 1/min. (p < 0.01). The portal venous flow decreased from 0.61 +/- 0.212 l/min. to 0.47 +/- l/min. P < 0.01). Due to the opposite changes in the afferent circulation the total hepatic blood flow did not change significantly, compared with controls. The ratio of hepatic arterial flow to portal vein flow increased to 1.239 +/- 0.246 in patients with hepatocellular carcinoma, which is double of the control value (0.66 +/- 0.259 l/min). After resection this ratio did not change. The resection did not alter hepatic artery or portal venous flow significantly, although the total hepatic blood flow decreased significantly (p < 0.01). On the basis of our early results it is possible that the ratio of the two circulations may be to deel measured with doppler ultrasound and provide diagnostic information.

The afferent circulation of the liver in patients with primary hepatocellular carcinoma

BACKGROUND/AIMS

The data on the afferent circulation of the liver, in patients with primary hepatocellular carcinoma, are controversial or non-existent.

MATERIALS AND METHODS

The authors measured hepatic arterial and portal venous flow intra-operatively by transit time ultrasonic volume flowmetry.

RESULTS

In patients with primary hepatocellular carcinoma, the hepatic artery flow increased to 0.55 +/- 0.21 l, as compared with the control value of 0.37 +/- 102 l/min (p < 0.01). The portal venous flow decreased from 0.61 +/- 0.212 l/min to 0.47 +/- 0.203 l/min p < 0.01). Owing to the opposite changes in the afferent circulation, the total hepatic blood flow did not change significantly. The ratio of hepatic arterial flow to portal vein flow increased to 1.239 +/- 0.246 in patients with hepatocellular carcinoma, which is twice the basic control value (0.66 +/- 0.259 l/min). After resection, this ratio showed virtually no change. The surgical intervention, that is resection of the liver, did not significantly alter hepatic artery and portal venous flow, although total hepatic blood flow decreased significantly (p < 0.01). The pronounced increase in the ratio of hepatic arterial flow may be attributed to the decrease in portal venous flow caused by the primary hepatocellular carcinoma. The decrease in venous flow can most probably be explained by compression and infiltration of the intrahepatic branches of the portal vein. As we pointed out, the decrease in portal venous circulation leads to an increase in hepatic arterial flow.

CONCLUSIONS

On the basis of our initial results, it seems probable that the ratio of the two circulations represents a diagnostic tool for the altered circulation in patients with hepatocellular carcinoma. The significance of this phenomena is not yet quite clear, but a review of the literature shows that similar observations have not been reported. In practical terms this phenomenon may be useful from the point of view of US and Doppler US diagnosis, e.g. in the case of a hypo-echoic or hyperechoir, mass in the liver, increased blood flow in the hepatic, artery, and decreased portal venous flow, a malignant liver tumor is virtually certain. The authors hypothesise that any pathology in the liver may lead to a primary decrease in PVF and a subsequent increase in HAF.

The interaction between hepatic arterial and portal venous blood flows; simultaneous measurement by transit time ultrasonic volume flowmetry

Intra-operative measurement of the afferent circulation of the liver, namely hepatic artery and portal venous flow was carried out in 14 anesthetized patients with carcinoma of the splanchnic area, mainly in the head of the pancreas, by means of transit time ultrasonic volume flowmetry. The hepatic artery flow, portal venous flow and total hepatic flow were 0.377 +/- 0.10; 0.614 +/- 0.21; 0.992 +/- 0.2761/min, respectively. The ratio of hepatic arterial flow to portal venous flow was 0.66 +/- 0.259. There was a sharp, significant increase in hepatic arterial flow (29.8 +/- 6.1%, p < 0.01) after the temporary occlusion of portal vein, while the temporary occlusion of the hepatic artery did not have any significant effect on portal venous circulation. The interaction between hepatic arterial flow and portal venous flow is much in dispute, but, as the data presented here show, there is no doubt that the decrease in portal venous flow immediately gives rise to a significant increase in hepatic artery circulation.

Blood flow measurement in patients with hepatocellular carcinomas

Since the data regarding the afferent circulation of the liver in patients having primary hepatocellular carcinoma are controversial or missing. Authors carried out the measurement of hepatic arterial and portal venous flow intraoperatively by transit time ultrasonic volume flowmetry. In patients with primary hepatocellular carcinoma the hepatic artery flow increased to 0.55 +/- 0.211 compared with the control value of 0.37 +/- 0.102 1/min (p < 0.01). The portal venous flow decreased from 0.61 +/- 0.212 1/min to 0.47 +/- 1/min (p < 0.01). Due to the opposite changes in the afferent circulation the total hepatic blood flow did not change significantly. The ratio of hepatic arterial flow to portal vein flow elevated to 1.239 +/- 0.246 in patients with hepatocellular carcinoma, which is the double of the basic control value (0.66 +/- 0.259 1/min). After resection this ratio practically did not change. The surgical intervention, that is the resection of the liver did not alter the hepatic artery and portal venous flow significantly, although the total hepatic blood flow has decreased significantly (p < 0.01). The prominent and marked increase in the ratio of hepatic arterial flow may be attributed to the decrease of portal venous flow caused by the primary hepatocellular carcinoma. The decrease of venous flow can be explained most probable by compression and infiltration of the intrahepatic branches of the portal vein. As we pointed out the decrease in portal venous circulation consequently causes increase in hepatic arterial flow.(ABSTRACT TRUNCATED AT 250 WORDS)

Complications following major abdominal surgery in cirrhotic patients

The morbidity and mortality associated with major abdominal surgical interventions in 34 histologically proven cirrhotic patients are analyzed by the authors. The surgical interventions were carried out as urgent, absolute and elective indications. Thirty-seven general and surgical complications were observed following major abdominal surgery in 34 cirrhotics. Seven out of 34 patients died, giving a mortality rate of 21%. Suture-line insufficiency, peritonitis, sepsis and other inflammatory processes turned out to be the most common complications. Statistical analysis showed that the Child criteria, prothrombin level and white blood cell count were useful prognostic factors.

[Clinical aspects and management of a retroperitoneal abscess]

14 patients with retroperitoneal abscess have been collected by the authors since June 1, 1988. The retroperitoneal abscess of multifactorial origin can be considered as a secondary disease. The physical clinical signs (e.g. psoas rigidity sign, palpable mass, costolumbal sensitivity) play central role in setting up of diagnosis, and these signs were present in more than 75% of the cases. The physical signs generally indicate advanced retroperitoneal abscess, and at the same time the contour of psoas muscle disappears and concavity of lumbal vertebras can be seen on plane abdominal X ray film. The exact diagnosis was achieved in mean 45 days after the on set of complaints, this fact urges, that the up-to-date imaging modalities (US, CT, NMR) should be applied earlier in septic conditions of unknown origin. Retroperitoneal surgical intervention was performed in their patients, in the future the percutaneous drainage procedure has to be considered as first intervention for retroperitoneal abscess. Retroperitoneal abscess secondary to malignant disease has unfavorable prognosis, 2 out of 14 patients with retroperitoneal abscess died, both of them had underlying malignancy.

Intraoperative estimation of liver blood flow in man

The intraoperative measurement of the afferent circulation of the liver, namely the hepatic artery flow and portal venous flow was carried out upon 14 anaesthetized patients having carcinoma of the splanchnic area, mainly in the head of the pancreas, by means of transit time ultrasonic volume flowmeter. The hepatic artery flow, portal venous flow and total hepatic flow were 0.377 +/- 0.10; 0.614 +/- 0.21; 0.992 +/- 0.276 l/min, respectively. The ratio of hepatic arterial flow to portal venous flow was 0.66 +/- 0.259. There was a sharp, significant increase in hepatic arterial flow (29.8 +/- 6.1%, p < 0.01) after the temporary occlusion of portal vein, while the temporary occlusion of hepatic artery did not have any significant effect on portal venous circulation. The interaction between hepatic arterial flow and portal venous flow is a much disputed question, but according to the presented data here, it is unquestionable, that the decrease of portal venous flow immediately results a significant increase in hepatic artery circulation.

[Complications of abdominal surgery in patients with liver cirrhosis]

The morbidity and mortality of major abdominal surgical interventions in 34 histologically proven cirrhotic patients are analysed by the authors. The surgical interventions were carried out by urgent, absolute and elective indications. 37 general and surgical complications could have been observed following the major abdominal surgery of 34 cirrhotics. 7 out of 34 patients died. Suture-line insufficiency, peritonitis, sepsis and other inflammatory processes turned out most frequently among the complications. The Child criteria, the prothrombin level and white blood cell count proved to be useful prognostic factors by statistical analysis.

[Gastrointestinal angiodysplasia]

8 cases of gastrointestinal angiodysplasia are reported. It can be stated on the analysis of these cases, that the angiodysplasia can be the cause of unexplained GI hemorrhages, and in the majority of cases the visceral angiography provides diagnostic evidence. The angiodysplasia can be observed frequently in association with liver cirrhosis and aortic valvular stenosis. Surgery is regarded as the best method of treatment. Subsequently the careful resection rebleeding and development of newer angiodysplasia can occur.