Effects of Early Placement of Transjugular Portosystemic Shunts in Patients With High-Risk Acute Variceal Bleeding: a Meta-analysis of Individual Patient Data

BACKGROUND & AIMS

Compared with drugs plus endoscopy, placement of transjugular portosystemic shunt within 72 hours of admission to the hospital (early or preventive transjugular intrahepatic portosystemic shunt [TIPS], also called preemptive TIPS) increases the proportion of high-risk patients with cirrhosis and acute variceal bleeding who survive for 1 year. However, the benefit of preemptive TIPS is less clear for patients with a Child-Pugh score of B and active bleeding (CP-B+AB). We performed an individual data meta-analysis to assess the efficacy of preemptive TIPS in these patients and identify factors associated with reduced survival of patients receiving preemptive TIPS.

METHODS

We searched publication databases for randomized controlled trials and observational studies comparing the effects of preemptive TIPS versus endoscopy plus nonselective beta-blockers in the specific population of high-risk patients with cirrhosis and acute variceal bleeding (CP-B+AB or Child-Pugh C, below 14 points), through December 31, 2019. We performed a meta-analysis of data from 7 studies (3 randomized controlled trials and 4 observational studies), comprising 1327 patients (310 received preemptive TIPS and 1017 received drugs plus endoscopy). We built adjusted models to evaluate risk using propensity score for baseline covariates. Multivariate Cox regression models were used to assess the factors associated with survival time. The primary endpoint was effects of preemptive TIPS versus drugs plus endoscopy on 1-year survival in the overall population as well as CP-B+AB and Child-Pugh C patients.

RESULTS

Overall, preemptive TIPS significantly increased the proportion of high-risk patients with cirrhosis and acute variceal bleeding who survived for 1 year, compared with drugs plus endoscopy (hazard ratio [HR] 0.443; 95% CI 0.323-0.607; P < .001). This effect was observed in CP-B+AB patients (HR 0.524; 95% CI 0.307-0.896; P = .018) and in patients with Child-Pugh C scores below 14 points (HR 0.374; 95% CI 0.253-0.553; P < .001). Preemptive TIPS significantly improved control of bleeding and ascites without increasing risk of hepatic encephalopathy in Child-Pugh C and CP-B+AB patients, compared with drugs plus endoscopy. Cox analysis of patients who received preemptive TIPS showed that patients could be classified into 3 categories for risk of death, based on age, serum level of creatinine, and Child-Pugh score. In each of these risk categories, preemptive TIPS increased the proportion of patients who survived for 1 year, compared with drugs plus endoscopy.

CONCLUSIONS

In a meta-analysis of data from 1327 patients with cirrhosis, acute variceal bleeding, and Child-Pugh score between 10 and 13 points or CP-B+AB, preemptive TIPS increased the proportion who survived for 1 year, in both subgroups separately, compared with drugs plus endoscopy.

Modulación en la expresión de biomarcadores (RE, RP y C-erbB2) en cáncer de mama tras tratamiento neoadyuvante

INTRODUCTION

Pre and post-operative oncological therapy in patients with breast cancer is determined, amongst other factors, by hormone receptor status and by c-erbB2 expression. The aim of this study is to determine the influence of neoadjuvant therapy on the expression of oestrogen receptor (OR), progesterone receptor (PR) and c-erbB2.

METHODS

Fifty-three patients with breast cancer diagnosed by tru-cut biopsy were studied. Patients with locally advanced carcinoma (20) had preoperative treatment. All patients underwent surgical resection. Expression of OR, PR and c-erbB2 in both the tru-cut biopsy and the gross specimen was compared.

RESULTS

We found significant differences in OR, PR expression in both biopsy and gross specimen, between the group of patients who underwent neoadjuvant treatment and the group without pre-surgical treatment. Changes in PR, OR and c-erbB2 status were found between the tru-cut biopsy and the gross specimen, in about 10 to 40% of the cases who received neoadjuvant therapy. These changes had no statistical significance.

Lipomatous melanocytic nevomatosis

Giant congenital melanocytic nevi (GCMN) are rare and occur in about one out of every 200,000-500,000 births. Their importance resides in the aesthetic alteration they produce and in the possibility of malignant transformation or in their association with nevi in the central nervous system as a distinctive syndrome: neurocutaneous melanoblastosis or nevomatosis, due to the fact that nervous system lesions are produced by infiltration of nevus cells. We present here a patient with a combination of GCMN with an outstanding lipomatosis located on the same area.

[Reproducibility of planimetric optic nerve head analysis with scanning laser ophthalmoscope]

PURPOSE

To determine the variability of disc and cup area measurements in digital images obtained with scanning laser ophthalmoscope.

METHODS

10 sets of images of 4 optic discs (normal, myopic, ocular hypertensive and glaucomatous) were obtained with the Rodenstock scanning laser ophthalmoscope. Images focused at different depths were used by 2 operators (with and without experience in planimetry) to determine the disc and cup areas by means of an image analysis program (Visilog). This study was performed in 10 images obtained from the same optic nerve (inter-image analysis) and 10 times in the same image of each optic nerve (intra-image analysis).

RESULTS

The variability of all the measurements was under 5%. Disc area measurements were lower than cup area determination. The experienced operator obtained lower variability. The myopic optic disc images were less reproducible than the other groups of images.

CONCLUSIONS

The planimetric analysis of optic nerve head digital images obtained with scanning laser ophthalmoscope is reproducible and allows quantification of optic disc areas.

Biochemical and immunological studies of protein kinase C from Trypanosoma cruzi

Phorbol ester binding was studied in protein kinase C-containing extracts obtained from Trypanosoma cruzi epimastigote forms. Specific 12-O-tetradecanoyl phorbol 13-acetate, [3H]PMA, or 12,13-O-dibutyryl phorbol, [3H]PDBu, binding activities, determined in T. cruzi epimastigote membranes, were dependent on ester concentration with a Kd of 9x10(-8) M and 11.3x10(-8) M, respectively. The soluble form of T. cruzi protein kinase C was purified through DEAE-cellulose chromatography. Both protein kinase C and phorbol ester binding activities co-eluted in a single peak. The DEAE-cellulose fraction was further purified into three subtypes by hydroxylapatite chromatography. These kinase activity peaks were dependent on Ca2+ and phospholipids and eluted at 40 mM (PKC I), 90 mM (PKC II) and 150 mM (PKC III) phosphate buffer, respectively. Western blot analysis of the DEAE-cellulose fractions, using antibodies against different isoforms of mammalian protein kinase C enzymes, revealed that the parasite expresses high levels of the alpha-PKC isoform. Immunoaffinity purified T. cruzi protein kinase C, isolated with an anti-protein kinase C antibody-sepharose column, were subjected to phosphorylation in the absence of exogenous phosphate acceptor. A phosphorylated 80 kDa band was observed in the presence of Ca2+, phosphatidylserine and diacylglycerol.

Semiconductor diode laser transscleral cyclophotocoagulation versus filtering surgery with Mitomycin-C

Both filtering surgery with Mitomycin-C and diode laser cyclophotocoagulation have proved to be effective alternatives in cases of glaucoma with poor surgical prognosis. The right eyes of 40 pigmented rabbits were randomly divided into 2 groups: Mitomycin-C group underwent filtering surgery with application of 0.4 mg/ml of Mitomycin-C whereas the diode laser (DL) group received 15 applications of 1.8 J (1800 mW. 1000 ms) distributed in 270 degrees. Mean IOP showed statistical differences in two periods between days 3-13 and 45-60-Mann-Whitney U test -with a higher IOP lowering in the DL group. The comparison of IOP survival curves (Log-Rank test) was not significant p = 0.070809. Ocular hypertension, hyphema and inflammatory signs were higher in the DL group, both in short and long term, but in terms of statistical significance only ocular hypertension showed differences p = 0.00011717-Fisher exact test. Microscopic examination revealed patent sclerostomies in 60% of the MMC group eyes with different grades of fibroblastic proliferation. In the DL group we observed necrosis of the scleral stroma and of the pigmented and unpigmented ciliary epithelium, with signs of thermal coagulation of the ciliary stroma and of the stromal vasculature. We must point out that the treatment with laser has proved to be more effective although both treatments showed very acceptable IOP lowering until 2 months after the surgery.

[The dynamic morphology of the endothelial cells of aortocoronary vessels cultured in vitro]

The morphologic and functional meaning of the endothelial cell, as the first cellular element between blood and tissues, has been investigated since the earliest histological knowledge of the vascular tree. Although there have been multiple attempts for its study, through different biological branches, very little has been comprehended in its dynamic biology, due to technical difficulties and to the apparent simplicity of this extraordinary cellular type. In this research we pretend to establish a morphodynamic pattern of the endothelial cells from the aortocoronary segment, using the particular advantages of tissue culture. Our results, have been obtained through careful observations with light microscopy under different optical systems and the help provided by spaced microcinematography. Our results showed the reality of the images in the different cellular phenomena, particularly, endocytotic pinocytosis, the dynamic of the cellular membrane, and the cell-cell linkages established in vitro.

Long term follow-up of the argon laser trabeculoplasty in eyes treated 180 degrees and 360 degrees of the trabeculum

The results obtained with the Argon Laser Trabeculoplasty (ALT) on 196 eyes with an average follow-up period of 5.24 years (maximum 9 years) have been reviewed. Of the 123 eyes treated with 75-115 burns in the 360 degrees of the trabecular meshwork, 71 eyes were successful with a follow-up of 64.3 +/- 28.3 months (mean +/- SD). This treatment reduced the previous anti-glaucomatous medical treatment in 35 eyes (28.5%). The remaining 73 eyes were treated with 40-60 burns in 180 degrees of the trabeculum, 38.4% (28 eyes) were successful therapeutically with a follow-up of 56.5 +/- 23.1 months. The treatment reduced the additional medical treatment in 9 eyes (12.3%). The comparison of these results and the survival curves of both groups showed statistically significant differences in favour of the treatment on 360 degrees of the trabeculum.

Protein kinase C in Trypanosoma cruzi epimastigote forms: partial purification and characterization

A protein kinase C activity from epimastigote forms of Trypanosoma cruzi was characterized. Cytosolic extracts were chromatographed on DEAE-cellulose columns giving two peaks of kinase activity which were eluted at 0.1 and 0.15 M NaCl. The first activity peak requires Ca2+ and phosphatidylserine for activity. Further kinase purification was performed by chromatography on phenyl Sepharose columns. In these columns the enzyme activity was adsorbed in the presence of Ca2+ and eluted with a EGTA-containing buffer. T. cruzi protein kinase C activity preferentially phosphorylated histone H1. It was stimulated by diacylglycerol and phorbol myristate acetate, and inhibited by polymyxin B and staurosporine. After subcellular fractionation and epimastigote cells, the kinase was found to be associated with microsomal and cytosolic fractions.

Long-term results of silicone tube in filtering surgery for eyes with neovascular glaucoma

We operated on 59 eyes with advanced neovascular glaucoma (37 eyes in diabetic patients and 22 eyes in patients with central retinal vein occlusion) using a trabeculectomy technique that includes a simple silicone tube as the draining element. Mean (+/- 1 S.D.) intraocular pressure preoperatively was 57 +/- 8.7 mm Hg. During follow-up periods ranging from one to five years, the mean intraocular pressure decreased to 27 +/- 16.5 mm Hg. Adequate control of intraocular pressure (24 mm Hg or less) was achieved in 37 eyes (63%). Only four eyes required enucleation. Nine silicone tubes had to be removed because of necrosis of the scleral flap and conjunctival perforation or because they were expulsed. Surgery relieved the severe ocular pain even when intraocular pressure was not satisfactorily controlled.