Extrahepatic portal hypertension following liver transplantation: a rare but challenging problem

This study reports our experience of 8 cases of extrahepatic portal hypertension after 273 orthotopic liver transplantations in 244 adult patients over a 10-year period. The main clinical feature was ascites, and the life-threatening complication was variceal bleeding. Extrahepatic portal hypertension was caused by portal vein stenosis in 6 patients, and left-sided portal hypertension in 2 patients after inadventent ligation of portal venous tributaries or portasystemic shunts. All patients with portal vein stenosis had complete relief of portal hypertension after percutaneous transhepatic venoplasty (n = 4) or surgical reconstruction (n = 2), after a median follow-up of 33 (range: 6-62) months. Of the 2 patients with left-sided portal hypertension, one died after splenectomy and one rebled 6 months after left colectomy. This study suggests that extrahepatic portal hypertension is a series complication after liver transplantation that could be prevented by meticulous portal anastomosis and closure of portal tributaries or portasystemic shunts to improve the portal venous flow. However, any ligation has to be performed under ultrasound guidance to avoid inadventent venous ligations.     

Pseudotumor cerebri: a pediatric case report

We describe a case of pseudotumor cerebri (PTC) in a five years old child. Pseudotumor cerebri is a not very common syndrome in the pediatric age. The incidence rate in about 1:100.000. The prognosis of PTC is usually good. Sometimes however, PTC could be complicated by eye diseases such as reduction of visual field. Our case is a child with diplopia and with a bilateral oedema of the papilla. The diagnosis of PTC was possible after the physical examination and the instrumental exams (EEG, brain NMR and others). During the staying in the hospital the child performed a therapy with betamethasone and acetazolamide; the diplopia improved and the bilateral oedema of the papilla started to be less evident. The child was discharged in good health and with a planned ocular follow-up. We think that the Pediatrician must considered the possibility of the presence of a PTC; that is an important syndrome not only for the Neurologist.     

Solitary necrotic nodule of the liver: diagnosis and treatment

In 1983, Shepherd and Lee described the solitary necrotic nodule of the liver, an uncommon non-malignant lesion with a characteristic histological appearance. This nodule can often be misinterpreted as a necrotic secondary tumour. Limited liver resection can make differential diagnosis and cure the lesion.     

Hepatocarcinogenesis in liver cirrhosis: imaging diagnosis

Point mutations in the ras proto-oncogenes, notably at codon 12, are found in high frequency of human malignancies and, thus, may be appropriate targets for the induction of tumor-specific T cell responses in cancer immunotherapy. In this study, we examined the mutant ras protein sequence reflecting the substitution of Gly to Val at position 12 as a putative point-mutated determinant for potential induction of an HLA-A2-reactive, CD8+ cytotoxic T lymphocyte (CTL) response. We identified the ras 4-12(Val12) sequence as a minimal 9-mer peptide, which displayed specific binding to HLA-A2 by T2 bioassays. Peptide binding to HLA-A2 on T2 cells was weak and required coincubation with exogenous beta(2)-microglobulin to facilitate and enhance complex formation. In contrast, the wild-type ras 4-12(Gly12) peptide failed to bind to HLA-A2 even in the presence of beta(2)-microglobulin, consistent with the hypothesis that the point mutation creates a C-terminus anchor residue. A CD8+ CTL line against the ras 4-12(Val12) peptide was derived in vitro from a normal HLA-A2+ donor using a model culture system consisting of T2 cells as antigen presenting cells pulsed with exogenous mutant ras peptide and beta(2)-microglobulin plus cytokines (interleukin-2 and 12). Functional characterization of CD8+ CTL line revealed (1) peptide-specific and HLA-A2-restricted cytotoxicity against a panel of peptide-pulsed targets; (2) no specific lysis using the normal ras peptide sequence; (3) half-maximal lysis with exogenous peptide of approximately 0.3 microM; (4) lysis of HLA-A2+ B cell lines infected with a recombinant vaccinia virus construct encoding the point-mutated human K-ras gene; and (5) specific lysis of the HLA-A2+ SW480 colon carcinoma cell line expressing the naturally occurring K-ras Val12 mutation. Maximal lysis of SW480 cells occurred following interferon (IFN)-gamma pretreatment, which correlated with enhanced HLA-A2 and ICAM-1 (CD54) expression. Specificity of lysis was revealed by the absence of lysis against a HLA-A2+ melanoma cell line (+/- IFN-gamma), which lacked the mutant Val12 mutation, and the inability of an irrelevant CD8+ CTL line to lyse SW480 (+/- IFN-gamma) unless the appropriate exogenous peptide was added. These findings demonstrated that tumor cells may endogenously process and express mutant ras epitopes, such as the 4-12(Val12) sequence, albeit in limiting amounts that may be potentiated by IFN-gamma treatment. These data support the biological relevance of this sequence and, thus, may have important implications for the generation of ras oncogene-specific CTL responses in clinical situations.     

Hypnotic sex change: Creating and challenging a delusion in the laboratory.

The authors suggested a change of sex to virtuoso, high-hypnotizable, and low-hypnotizable simulating participants in an application of the real-simulating paradigm of hypnosis. The experiences of sex change that participants reported during hypnosis were challenged through procedures of contradiction and confrontation. Behavioral and self-report data indicated that virtuosos experienced a transient delusion about their sex that was compelling and resistant to challenge. Implications are discussed for investigations of delusion through the use of hypnosis in the laboratory and for understanding delusion in the clinical setting. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Management of deep vein thrombosis of the lower extremity in pregnancy: a challenging dilemma

This study reviews our experience in the management of deep vein thrombosis (DVT) of the lower extremity during pregnancy and analyzes the outcome of various treatment alternatives, including conventional full-dose heparin therapy and Greenfield filter insertion. Twenty-four patients treated over an 8-year period were reviewed. Fifteen patients were treated with conventional full-dose intravenous heparin therapy for 5 to 10 days, followed by subcutaneous low-dose heparin until labor, and continued for 6 weeks postpartum (Group A); Eleven patients had Greenfield filters inserted, followed by the same low-dose subcutaneous heparin regimen (Group B). There were 18 femoral or iliofemoral, 5 femoropopliteal, and 1 popliteal and below-knee DVT. The indications for Greenfield filter insertion included two patients in Group A (one with pulmonary embolism, despite adequate heparin therapy, and one with significant bleeding). Nine other patients had prophylactic indications: two for free-floating iliofemoral DVT, three with iliofemoral DVT (occurring just 1-2 weeks before labor), and four with femoropopliteal DVT. There were three immediate major complications (pulmonary embolism, bleeding, or death) in Group A; two with pulmonary embolism, one of which was fatal, and one with significant bleeding (3 of 15 patients; 20%). No major complications occurred in Group B. On long-term follow-up (mean, 61 months), 4 of 12 patients (33%) in Group A had significant leg swelling, with partial resolution of DVT in 2 patients and venous occlusion in 2 patients by duplex ultrasound. This is in contrast to 3 of 11 patients (27%) in Group B with significant leg swelling. There was no fetal morbidity or mortality in either group. Conventional full-dose heparin therapy for DVT of the lower extremity in pregnancy can carry significant morbidity and mortality. Greenfield filters may be used safely in some of these patients.     

Pseudotumor form of hepatic distomatosis: successful treatment with praziquantel

Human Fasciola hepatica infection is usually discovered either early, during the acute (invasive) phase, or in the advanced phase, which is characterized by biliary complications. We report a case of liver distomatosis with nodular intra-hepatic lesions in a 58-year-old woman. Radiological investigations showed 3 nodular lesions in the VII segment, which were difficult to distinguish from liver metastases or liver abscesses. Distomatosis serology was positive with passive hemagglutination. After a 5-day treatment with praziquantel, clinical symptoms resolved quickly while serological tests became negative. Radiological images slowly decreased to a calcified scar at 13 months. No side-effects were noted. Praziquantel, whose efficacy in the common presentations of liver distomatosis has recently been demonstrated, also seems effective and well tolerated in case of nodular intra-hepatic lesions.     

Pseudotumor aspect of ovarian vein thrombosis

Peritoneal lavage is one of the interventional approaches that have gained some attention in the early, toxaemic phase of acute pancreatitis. Additionally some kind of drainage is necessary for suppurative collections that characterize the late phase of the disease. In both the above situations tube plugging is a common problem and it is usually associated with a relapse of the patient's septic state and newly formed collection(s) on abdominal CT. Two cases are presented, in early and in late phases respectively, in which drainage tube adoscopy (DTE) re-established tube patency and ensured drainage. DTE may represent an alternative to surgery or to CT-guided paracentesis and evacuation of newly formed intra-abdominal collections secondary to tube obstruction.     

Comprehensive Soldier Fitness: Building resilience in a challenging institutional context.

The Comprehensive Soldier Fitness (CSF) program is designed to increase psychological strength and positive performance and to reduce the incidence of maladaptive responses of the entire U.S. Army. Based on the principles of positive psychology, CSF is a historically unique approach to behavioral health in a large (1.1 million members) organization. There are four program elements: (a) the assessment of emotional, social, family, and spiritual fitness; (b) individualized learning modules to improve fitness in these domains; (c) formal resilience training; and (d) training of Army master resilience trainers (MRTs) to instill better thinking skills and resilience in their subordinates. In contrast to traditional approaches, CSF is proactive; rather than waiting to see who has a negative outcome following stress, it provides ways of improving resilience for all members of the Army. CSF aims to move the full spectrum of responses to trauma and adversity—ranging from stress-related disorders to ordinary resilience—toward personal growth. This program may provide a model for implementing similar interventions in other very large institutions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Translumbar placement of inferior vena caval catheters: a solution for challenging hemodialysis access

Access to the central venous circulation for hemodialysis has traditionally been achieved via the subclavian or jugular venous routes. With ongoing improvements in medical management, many hemodialysis recipients develop exhaustion of these routes and require alternative means of central venous access. Inferior vena caval (IVC) catheters have been placed with a percutaneous translumbar approach to allow central venous access for chemotherapy, harvesting of stem cells, and total parenteral nutrition. Translumbar placement of IVC catheters has become accepted by some as a useful and reliable alternative in patients who require long-term hemodialysis but have exhausted traditional access sites. IVC catheters have been placed in patients with IVC filters, and IVC filters have been placed in patients with IVC catheters. Complications include those associated with central venous catheters, for example, sepsis, fibrin sheaths, and thrombosis. A complication specific to placement of IVC hemodialysis catheters is migration of the catheter into the subcutaneous soft tissues, retroperitoneum, or iliac veins. Translumbar placement of IVC catheters is performed only in patients considered to have few or no other medical options and is not intended as a primary means of central venous access.     

Beauty as an emotion: The exhilarating prospect of mastering a challenging world.

Beauty has received sparse attention from emotion theorists, some of whom have argued that aesthetic pleasure is cognitive in nature and too disinterested to be emotional. This view is supported by research suggesting that aesthetic pleasure is based on processing fluency. The authors review recent findings in the psychology of aesthetics and present two arguments. First, processing fluency explains the mild pleasure associated with simple or familiar objects, but it cannot account for the more intense pleasure associated with complex or novel objects. Immediately recognizing an object tends to be mildly pleasant, whereas sensing the prospect of successfully representing a complex object can be exhilarating. Second, to explain how these forms of aesthetic pleasures differ, a theory must go beyond cognitive dynamics. The authors' affect-based model of emotion differentiates aesthetic pleasures in terms of epistemic goals. Pretty, fluently processed stimuli implicate prevention goals that maintain and protect knowledge. Beautiful, novel stimuli implicate promotion goals that reshape and expand knowledge. The emotional nature of interest and awe are also discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The diagnosis and treatment of liver abscesses

An analysis of results of treatment of 15 patients with abscesses of the liver of different genesis is given in the article. The ultrasonic method of examination was shown to be highly efficient for diagnosis of liver abscesses. The authors stress the necessity of differential approach to treatment of such patients based on etiopathogenesis of the disease. In most cases the method of choice for treatment of liver abscesses was found to be the percutaneous puncture and drainage under control of echography.     

Hemangioma of the rib: a rare diagnosis

Hemangioma of the rib is an exceedingly rare tumor with less than ten cases reported in the literature. Wide local resection without preoperative needle biopsy is the preferred treatment. The case of a 76-year-old man with a right chest mass that was discovered on chest X-ray obtained for asbestos exposure is reported to demonstrate the presentation, diagnosis, and treatment of this distinctly uncommon tumor.     

Importance of duplex velocity histograms in the diagnosis of liver cirrhosis

Urea transporters are membrane proteins that mediate rapid, passive movement of urea across cell membranes. Physiological studies have revealed their significant roles in urea accumulation in the kidney inner medulla, and consequently in the urinary concentrating mechanism. Three mammalian urea transporters have been identified and their expression in the kidney was found to occur in a tissue-specific manner. This review discusses our current knowledge with emphasis on the localization and regulation of expression of urea transporters in different physiological conditions.