Transjugular intrahepatic portosystemic shunt treatment of variceal bleeding in an unselected patient population

OBJECTIVE

To evaluate transjugular intrahepatic portosystemic shunt (TIPS) in variceal bleeding in a clinical setting.

MATERIALS AND METHODS

Retrospective review of 131 patients (116 with liver cirrhosis) treated with TIPS with covered stent grafts in a single centre from 2002 to 2016.

RESULTS

Survival at 1 and 2 years was 70% and 57% in patents with, and 100% at 2 years in patients without liver cirrhosis, respectively. A high Child-Pugh score and severe hepatic encephalopathy (HE) within 12 months post-TIPS were related to increased mortality. Re-bleeding occurred in 8% within 12 months and was related to TIPS dysfunction and a post-TIPS portosystemic gradient (PSG) of ≥5 mmHg. The main cause of TIPS dysfunction was that the stent did not fully reach the inferior vena cava. There was no correlation between the PSG and the occurrence of HE.

CONCLUSIONS

TIPS was safe and prevented re-bleeding in patients with variceal bleeding, with or without liver cirrhosis, regardless of Child-Pugh class and of how soon after bleeding onset, the TIPS procedure was performed. A post-TIPS PSG of ≥5 mmHg was associated with an increased risk for re-bleeding and there was no correlation between the post-TIPS PSG and the occurrence of HE.

Oral clodronate and reduction in loss of bone mineral density in women with operable primary breast cancer

BACKGROUND

Women with primary breast cancer who receive systemic therapy may experience ovarian failure or early menopause, leading to a loss of bone mineral density (BMD). Loss of BMD may be reduced by use of bisphosphonates, compounds that inhibit the action of osteoclasts (cells that absorb or remove bone tissue). We have conducted a double-blind, randomized, two-center trial to evaluate BMD in women with primary breast cancer who were given the bisphosphonate clodronate (1600 mg/day orally) or placebo for 2 years.

METHODS

From August 31, 1990, through March 31, 1996, more than 300 eligible patients had been accrued, randomly assigned to study treatment, given the appropriate primary surgical care and systemic (chemotherapy and/or tamoxifen) therapy, and had completed follow-up for at least 1 year. BMD in the lumbar spine and in the hip, including the trochanteric area, was measured by use of dual-energy x-ray absorptiometry at the beginning of treatment and after 1 and 2 years of treatment. Changes in BMD were calculated as percent changes from the initial readings. Treatment effects for clodronate versus placebo (i.e., mean percent changes in BMD with clodronate minus mean percent changes in BMD with placebo) at 1 and 2 years for individual sites were calculated.

RESULTS

After 1 year, the treatment effects for clodronate versus placebo in the lumbar spine, the total hip, and the trochanter, respectively, were as follows: +2.38% (95% confidence interval [CI] = 1.36-3.41), +0.74% (95% CI = -0.13 - 1.60), and +1.29% (95% CI = 0.24-2.34). After 2 years, the corresponding treatment effects were +1.72% (95% CI = 0.12-3.34), +1.85% (95% CI = 0.51-3.20), and +2.30% (95% CI = 0.66-3.94), respectively.

CONCLUSIONS

Oral clodronate appears to reduce the loss of BMD in patients who receive treatment for primary breast cancer.

Increased resistance among Staphylococcus epidermidis isolates in a large teaching hospital over a 12-year period

The prevalence of drug resistance among clinically significant blood isolates of Staphylococcus epidermidis (n = 464) and consumption of antibiotics at a tertiary care teaching hospital (Meilahti Hospital, Helsinki) were analysed for the period 1983-1994. Resistance to methicillin increased from 28 to 77%. Simultaneously, usage of third-generation cephalosporins increased nearly sevenfold (from 8.6 kg/ to 56.4 kg/year). A significant correlation was found between percentages of methicillin resistance and usage of penicillinase-stable beta-lactam agents, including cloxacillin, imipenem, and first-, second-, and third-generation cephalosporins (r = 0.737, p < 0.0062). The increase in ciprofloxacin resistance occurred soon after the introduction of ciprofloxacin. Moreover, there was a remarkable increase in resistance to fusidic acid (from 10 to 40%) and rifampin (from 0 to 23%) despite the low usage of these agents. Overall, the rate of multiply resistant isolates roughly tripled (from 20 to 71%) and, by 1994, the frequency of isolates susceptible to vancomycin only was as high as 11%, which remarkably limits options for therapy.

Intravenous lipid emulsions: removal mechanisms as compared to chylomicrons

We have compared the metabolism of chylomicrons and a labeled emulsion, similar to those used for parenteral nutrition. Both were labeled in their triglyceride moieties and by a core label. It is known that chylomicron triglycerides are cleared by two processes: removal of triglycerides from the particles through lipolysis and removal of whole or partly lipolyzed particles. It has been proposed that emulsion droplets are cleared by the same pathways. After intravenous injection to postprandial rats, triglycerides were cleared less rapidly from the emulsion than from the chylomicrons (half-lives of 6.4 and 4.0 min), whereas the core labels were cleared at the same rate (half-lives around 7.5 min). This suggests that there was less lipolysis of the emulsion droplets which was further supported by the finding that less label appeared in the plasma free fatty acids (FFA). In adipose tissue of fed rats given chylomicrons, the ratio between fatty acid and core label was above 6, showing that fatty acids had been taken up after lipoprotein lipase-mediated hydrolysis. In contrast, for rats given emulsion, that ratio was only 1.2 showing that nearly as much emulsion droplets as emulsion-derived fatty acids were present in the tissue. In the liver the ratio was 0.55 after chylomicrons but 0.93 after emulsion. In further support of more lipolysis, fatty acids were oxidized more rapidly from chylomicrons than from emulsion. These data suggest that a large fraction of the emulsion droplets was removed from plasma with little or no preceding lipolysis. A substantial proportion, more than 50%, of this uptake occurred in extrahepatic tissues.

Effects of intraventricular taurine, homotaurine and GABA on serum prolactin and thyrotropin levels in female and in male rats

Serum prolactin and thyrotropin levels of conscious, unrestrained male and female rats were compared after intracerebroventricular (i.c.v.) administration of taurine, gamma-aminobutyric acid (GABA) and homotaurine. The amino acids studied had no clear effect on serum basal thyrotropin levels in male or female rats. All amino acids elevated serum prolactin levels in female rats at the dose of 5 mumol/rat; homotaurine by about 18-fold, taurine and GABA by 3-fold. Only homotaurine elevated serum prolactin of male rats at this dose, but its effect was less pronounced (p < 0.01) in male than in female rats. Although homotaurine was clearly more potent than the two other amino acids, at the dose of 10 mumol/rat taurine and GABA also elevated serum prolactin in male rats. These findings show that there are gender-related differences in the responses of serum prolactin levels to homotaurine, taurine and GABA in rats. The tuberoinfundibular dopaminergic pathway, which exerts tonic inhibitory influence on prolactin secretion, is sexually differentiated. Hence the gender-related differences in the effects of the amino acids on prolactin secretion suggest that they might inhibit dopamine release from the median eminence. In case of homotaurine, the gender effect was most pronounced. The less clear dependence of GABA's effect on the gender is in accordance with the suggestions that GABA influences the secretion of serum prolactin by more than one mechanism.