Topical haemostatic agents in liver surgery: do we need them?

AbstractBackgroundWorldwide, partial liver resections are increasingly being performed for primary or secondary hepatic malignancies. There are various techniques to reduce blood loss druing liver surgery. Several topical haemostatic agents have been developed to improve haemostasis of the resection surface and these agents are used more and more, even although the true effects remain unclear.MethodsThe present literature about the use of topical haemostatic agents in liver surgery was reviewed. Furthermore we conducted a Dutch national survey to explore the use of and belief in these agents in liver surgery.ResultsThe Dutch national survey among surgeons showed that topical haemostatic agents are frequently used not only to lower intra-operative blood loss or shorten time to haemostasis, but even more importantly, to reduce resection surface related complications such as bile leakage, postoperative haemorrhage and abscess formation. Although various topical haemostatic agents have been shown to reduce intra-operative time to haemostasis at the resection surface after liver resections, there is no scientific proof that these topical haemostatic agents really reduce resection surface related complications.ConclusionThis review highlights the need for more randomized clinical trials to investigate the efficacy of topical haemostatic agents in reducing resection surface related complications

Torsion of the Gallbladder

A 77-year-old woman was seen with progressive abdominal pain. A CT scan was made and showed a large gallbladder extending into the right lower abdomen. Ultrasound was performed but demonstrated no gallstones. Laparoscopy showed a tordated, necrotic gallbladder that was attached to the liver only by the cystic artery and cystic duct. Cholecystectomy was performed. Torsion of the gallbladder is a rare but clinically important condition in which the diagnosis seldom is made preoperatively. In radiological and clinical signs of cholecystitis without gallstones, this condition should be considered

Locomotor adaptability in persons with unilateral transtibial amputation

Background Locomotor adaptation enables walkers to modify strategies when faced with challenging walking conditions. While a variety of neurological injuries can impair locomotor adaptability, the effect of a lower extremity amputation on adaptability is poorly understood. Objective Determine if locomotor adaptability is impaired in persons with unilateral transtibial amputation (TTA). Methods The locomotor adaptability of 10 persons with a TTA and 8 persons without an amputation was tested while walking on a split-belt treadmill with the parallel belts running at the same (tied) or different (split) speeds. In the split condition, participants walked for 15 minutes with the respective belts moving at 0.5 m/s and 1.5 m/s. Temporal spatial symmetry measures were used to evaluate reactive accommodations to the perturbation, and the adaptive/de-adaptive response. Results Persons with TTA and the reference group of persons without amputation both demonstrated highly symmetric walking at baseline. During the split adaptation and tied post-adaptation walking both groups responded with the expected reactive accommodations. Likewise, adaptive and de-adaptive responses were observed. The magnitude and rate of change in the adaptive and de-adaptive responses were similar for persons with TTA and those without an amputation. Furthermore, adaptability was no different based on belt assignment for the prosthetic limb during split adaptation walking. Conclusions Reactive changes and locomotor adaptation in response to a challenging and novel walking condition were similar in persons with TTA to those without an amputation. Results suggest persons with TTA have the capacity to modify locomotor strategies to meet the demands of most walking conditions despite challenges imposed by an amputation and use of a prosthetic limb

Design and baseline characteristics of the finerenone in reducing cardiovascular mortality and morbidity in diabetic kidney disease trial

Background: Among people with diabetes, those with kidney disease have exceptionally high rates of cardiovascular (CV) morbidity and mortality and progression of their underlying kidney disease. Finerenone is a novel, nonsteroidal, selective mineralocorticoid receptor antagonist that has shown to reduce albuminuria in type 2 diabetes (T2D) patients with chronic kidney disease (CKD) while revealing only a low risk of hyperkalemia. However, the effect of finerenone on CV and renal outcomes has not yet been investigated in long-term trials. Patients and Methods: The Finerenone in Reducing CV Mortality and Morbidity in Diabetic Kidney Disease (FIGARO-DKD) trial aims to assess the efficacy and safety of finerenone compared to placebo at reducing clinically important CV and renal outcomes in T2D patients with CKD. FIGARO-DKD is a randomized, double-blind, placebo-controlled, parallel-group, event-driven trial running in 47 countries with an expected duration of approximately 6 years. FIGARO-DKD randomized 7,437 patients with an estimated glomerular filtration rate >= 25 mL/min/1.73 m(2) and albuminuria (urinary albumin-to-creatinine ratio >= 30 to <= 5,000 mg/g). The study has at least 90% power to detect a 20% reduction in the risk of the primary outcome (overall two-sided significance level alpha = 0.05), the composite of time to first occurrence of CV death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure. Conclusions: FIGARO-DKD will determine whether an optimally treated cohort of T2D patients with CKD at high risk of CV and renal events will experience cardiorenal benefits with the addition of finerenone to their treatment regimen. Trial Registration: EudraCT number: 2015-000950-39; ClinicalTrials.gov identifier: NCT02545049

Genome-wide association study of primary sclerosing cholangitis identifies new risk loci and quantifies the genetic relationship with inflammatory bowel disease.

Primary sclerosing cholangitis (PSC) is a rare progressive disorder leading to bile duct destruction; ∼75% of patients have comorbid inflammatory bowel disease (IBD). We undertook the largest genome-wide association study of PSC (4,796 cases and 19,955 population controls) and identified four new genome-wide significant loci. The most associated SNP at one locus affects splicing and expression of UBASH3A, with the protective allele (C) predicted to cause nonstop-mediated mRNA decay and lower expression of UBASH3A. Further analyses based on common variants suggested that the genome-wide genetic correlation (rG) between PSC and ulcerative colitis (UC) (rG = 0.29) was significantly greater than that between PSC and Crohn's disease (CD) (rG = 0.04) (P = 2.55 × 10-15). UC and CD were genetically more similar to each other (rG = 0.56) than either was to PSC (P < 1.0 × 10-15). Our study represents a substantial advance in understanding of the genetics of PSC

The Quest for Luschka's Duct: An Eponym Leading a Life of Its Own?

Background: The German anatomist Hubert von Luschka gave name to several structures in the human body. One of great discussion is the duct of Luschka, part of the biliary system. There are different descriptions of the duct of Luschka. This might lead to confusion in the debate and as to what therapy should best be provided in case of an injured duct of Luschka. Methods: We reviewed the literature on descriptions of Luschka's duct and studied the original German descriptions by Hubert von Luschka. Results: While reading the original work by von Luschka on the hepatobiliary system, we were not able to find a description of either one of the two structures that are nowadays referred to as 'the duct of Luschka'. Conclusions: von Luschka maybe never described the so-called duct of Luschka. He did, however, describe the peribiliary glands in the intra- and extrahepatic bile ducts and gallbladder wall. These might have been misinterpreted as a duct running along the gallbladder fossa. The lack of a clear definition is the reason for the development of rather confusing and sometimes misleading eponyms as the duct of Luschka. The eponym 'duct of Luschka' should, therefore, better not be used. (C) 2014 S. Karger AG, Base

You can hide but you can't run:Apparent competition, predator responses and the decline of Arctic ground squirrels in boreal forests of the southwest Yukon

Throughout much of North America’s boreal forest, the cyclical fluctuations of snowshoe hare populations (Lepus americanus) may cause other herbivores to become entrained in similar cycles. Alternating apparent competition via prey switching followed by positive indirect effects are the mechanisms behind this interaction. Our purpose is to document a change in the role of indirect interactions between sympatric populations of hares and arctic ground squirrels (Urocitellus parryii plesius), and to emphasize the influence of predation for controlling ground squirrel numbers. We used mark-recapture to estimate the population densities of both species over a 25-year period that covered two snowshoe hare cycles. We analysed the strength of association between snowshoe hare and ground squirrel numbers, and the changes to the seasonal and annual population growth rates of ground squirrels over time. A hyperbolic curve best describes the per capita rate of increase of ground squirrels relative to their population size, with a single stable equilibrium and a lower critical threshold below which populations drift to extinction. The crossing of this unstable boundary resulted in the subsequent uncoupling of ground squirrel and hare populations following the decline phase of their cycles in 1998. The implications are that this sustained Type II predator response led to the local extinction of ground squirrels. When few individuals are left in a colony, arctic ground squirrels may also have exhibited an Allee effect caused by the disruption of social signalling of approaching predators

Role of Fibrin Sealants in Liver Surgery

Background: Fibrin sealants are widely used in liver surgery. The aim of this article is to review the literature on evidence of hemostatic and biliostatic capacities of different fibrin sealants in liver surgery. Methods: In PubMed, a literature search was done with the search terms 'fibrin sealant' or 'fibrin glue' combined with 'liver resection' or 'bile leakage'. Thirteen comparative fibrin sealant studies were selected. Results:In general, these studies have shown a reduced time to hemostasis when fibrin sealants were used. So far, only a few studies have been published that have focused on postoperative resection surface-related complications. There is no strong evidence that fibrin sealants reduce the incidence of bile leakage after liver resection. Important new evidence shows that bile contains profibrinolytic activity that causes lysis of the clot formed by the fibrin sealant at least in vitro. Conclusions: Fibrin sealants can be effective as an adjunct to achieve hemostasis during liver resections. However, considering lack of evidence on the efficacy of fibrin sealants in reducing postoperative resection surface-related complications, routine use of fibrin sealants in liver surgery cannot be recommended. Copyright (C) 2012 S. Karger AG, Base