Band 6, Heft 3

Budd–Chiari syndrome (BCS) is a rare but fatal disease caused by the obstruction in hepatic venous outflow tract (usually by thrombosis) and is further classified into two subtypes depending on the level of obstruction. Patients with BCS often have a combination of prothrombotic risk factors. Clinical presentation is diverse. Stepwise management strategy has been suggested with excellent 5-year survival rate. It includes anticoagulation, treatment of identified prothrombotic risk factor, percutaneous recanalization, and transjugular intrahepatic portosystemic shunt (TIPS) to reestablish hepatic venous outflow and liver transplantation in unresponsive patients. Owing to the rarity of BCS, there are no randomized controlled trials (RCTs) precisely identifying the timing for TIPS. TIPS should be considered in patients with refractory ascites, variceal bleed, and fulminant liver failure. Liver replacement is indicated in patients with progressive liver failure and in those in whom TIPS is not technically possible. The long-term outcome is usually influenced by the underlying hematologic condition and the development of hepatocellular carcinoma. This review focuses on the timing and the long-term efficacy of TIPS in patients with BCS.

There have been recent advances in stroke prevention in nutrition, blood pressure control, antiplatelet therapy, anticoagulation, identification of high-risk asymptomatic carotid stenosis, and percutaneous closure of patent foramen ovale. There is evidence that the Mediterranean diet significantly reduces the risk of stroke and that B vitamins lower homocysteine, thus preventing stroke. The benefit of B vitamins to lower homocysteine was masked by harm from cyanocobalamin among study participants with impaired renal function; we should be using methylcobalamin instead of cyanocobalamin. Blood pressure control can be markedly improved by individualized therapy based on phenotyping by plasma renin and aldosterone. Loss of function mutations of CYP2D19 impair activation of clopidogrel and limits its efficacy; ticagrelor can avoid this problem. New oral anticoagulants that are not significantly more likely than aspirin to cause severe bleeding, and prolonged monitoring for atrial fibrillation (AF), have revolutionized the prevention of cardioembolic stroke. Most patients (~90%) with asymptomatic carotid stenosis are better treated with intensive medical therapy; the few that could benefit from stenting or endarterectomy can be identified by a number of approaches, the best validated of which is transcranial Doppler (TCD) embolus detection. Percutaneous closure of patent foramen ovale has been shown to be efficacious but should only be implemented in selected patients; they can be identified by clinical clues to paradoxical embolism and by TCD estimation of shunt grade. “Treating arteries instead of treating risk factors,” and recent findings related to the intestinal microbiome and atherosclerosis point the way to promising advances in future.

In most of the case, regional citrate anticoagulation is using diluted citrate around 1% depending on the types used in clinical practice. Diluted citrate is much more safer when compared to highly concentrated citrate around 4% or even more. In clinical practice, trisodium citrate is used in high concentration (around 30%) as a bactericidal agent with anticoagulant properties for locking deep venous catheters used in hemodialysis (HD; close to 25–30% of citrate). In this review article, buffer and anticoagulant potential of citrate are discussed during renal replacement therapy in critically ill patients with particular focus on the practical approach at the bedside.

Glioblastoma multiforme (GBM), a grade IV astrocytoma as defined by the World Health Organization (WHO) criteria, is the most common primary central nervous system tumor in adults. After treatment with the current standard of care consisting of surgical resection, concurrent temozolomide (TMZ), and radiation, the median survival is only 15 months. The limited and less-effective treatment options for these highly aggressive GBMs call for the development of new techniques and the improvement of existing technologies. Nanotechnology has shown promise in treating this disease, and some nanomaterials have demonstrated the ability to cross the blood–brain barrier (BBB) and remain in GBM tissues. Although the retention of nanoparticles (NPs) in GBM tissue is necessary to elicit an antitumor response, the delivery of the NP needs to be enhanced. Current research in nanotechnology is directed at increasing the active targeting of GBM tissue not only for the aid of chemotherapeutic drug delivery but also for imaging studies. This review is aimed at describing advancements in increasing nanotechnology specificity to GBM tissue.

Aplastic anemia (AA) is a hematologic disease characterized by pancytopenia. Up to now, severe aplastic anemia (SAA) has been recognized by international and domestic scholars as an autoimmune disease with bone marrow (BM) failure mediated by the hyperfunctional T lymphocytes. The incidence of AA is more in China compared with other countries. In the recent years, both the pathogenesis and treatment of AA have made a great progress in our country. Thus, the therapeutic effect of AA was much better than before. Here, we conclude the researches of AA in China.

Objectives To non-invasively evaluate by computational fluid dynamic (CFD) analysis the physiology and rheology of aortoiliac bifurcation disease at different angles and different stent configurations. Material and methods For the analysis, we considered a physiologic model of abdominal aorta with an iliac bifurcation set at 30°, 45° and 70° without stenosis. Subsequently, a bilateral ostial common iliac stenosis of 80% was considered for each type of bifurcation. For the stent simulation, we reconstructed Zilver vascular self-expanding (Zilver; Cook, Bloomington, MN) and Palmaz Genesis Peripheral (Cordis, Miami, FL) stents. Results The physiologic model, across the different angles, static pressure, Reynolds number and stream function, were lower for the 30° bifurcation angle with a gradient from 70° to 30° angles, whereas all the other parameters were inversely higher. After stenting, all the fluid parameters decreased homogenously independent of the stent type, maintaining a gradient in favour of 30° compared to 45° and 70° angles. The absolute greater deviation from physiology was observed for low kissing when self-expandable stents were used across all angles; in particular, the wall shear stress was high at at 45° angle. Conclusion Bifurcation angle deeply impacts the physiology of aortoiliac bifurcations, which are used to predict the fluid dynamic profile after stenting. CFD, having the potential to be derived both from computed tomography scan or invasive angiography, appears to be an ideal tool to predict fluid dynamic profile before and after stenting in aortoiliac bifurcation.

Background and Objectives Hepatic encephalopathy (HE) research has long been impeded by the vague definition of this disabling complication of liver failure. This article provides an overview of the etiology and impact of HE on neuromuscular functions as well as its role in the development of infections and anemia. Materials and Methods This was a descriptive study conducted in 36 patients with HE. Close monitoring of these patients was done by checking on several parameters. Results The etiological distribution: alcohol (67%), hepatitis C virus (HCV; 17%), HCV and alcohol (8%), hepatitis B virus (HBV; 3%), HBV and alcohol (3%), HBV and HCV (6%), and cryptogenic (3%). The laboratory results indicated an elevation of De Ritis level in 69% of cases and in 92% of total bilirubin values. The Halstead-Reitan (H-R) test score with regards to gender indicated that more than half of the patients had a score of 2, while only few cases received the scores 3 and 4. The frequency of H-R score with regards to Child-Pugh score showed the significant preponderance of Child-Pugh score of 7–9 (B): 58.3% compared to others groups of results, and these results indicated patients’ poor prognosis. Conclusion Findings showed the preponderance of female patients towards developing HE and the poor survival rate of patients older than 65 years. Alcohol and hepatitis C were the main causes associated with the development of HE. The neurological assessment marked the preponderance of Child-Pugh grades B and C and also the prevalence in female patients with neuropsychological disabilities through the assessment of H-R test.

We present a case of a 21-year-old Caucasian woman at 27 weeks of pregnancy who was admitted to the obstetric department for pre-term labor. She received 10 mg of nifedipine 4 times in 1 h, according to the internal protocol. Shortly after, she brutally deteriorated with pulmonary edema and hypoxemia requiring transfer to the intensive care unit (ICU) for mechanical ventilation. She finally improved and was successfully extubated after undergoing a percutaneous valvuloplasty of the mitral valve. This case illustrates a severe cardiogenic shock after administration of nifedipine for premature labor in a context of unknown rheumatic mitral stenosis. Nifedipine induces a reflex tachycardia that reduces the diastolic period and thereby precipitates pulmonary edema in case of mitral stenosis. This case emphasizes the fact that this drug may be severely harmful and should never be used before a careful physical examination and echocardiography if valvular heart disease is suspected.