Acute liver failure following hemodialysis arteriovenous graft placement: a case report

<p>Abstract</p> <p>Introduction</p> <p>Severe high-output cardiac failure is a serious complication of high-flow vascular access requiring immediate intervention. Ischemic hepatitis is defined as a massive increase in serum transaminase levels due to an imbalance between hepatic oxygen supply and demand in the absence of other acute causes of liver damage. It is typically preceded by hypotension, hypoxemia, or both, and occurs mostly in elderly patients with right-sided congestive heart failure.</p> <p>Case presentation</p> <p>We report a fatal case of acute liver failure in an 84-year-old Caucasian man with high-output cardiac failure due to arteriovenous hemodialysis access. The chronological sequence of acute liver failure in the context of vascular access created two days before suggests that ischemic hepatitis was the result of high-output cardiac failure due to vascular access.</p> <p>Conclusions</p> <p>A thorough cardiac assessment should be performed in patients with severe cardiac disease prior to placing an arteriovenous access, and arteriovenous fistula should be the preferred vascular access.</p

The VITAH Trial-Vitamin D Supplementation and Cardiac Autonomic Tone in Patients with End-Stage Kidney Disease on Hemodialysis: A Blinded, Randomized Controlled Trial

End-stage kidney disease (ESKD) patients are at increased cardiovascular risk. Vitamin D deficiency is associated with depressed heart rate variability (HRV), a risk factor depicting poor cardiac autonomic tone and risk of cardiovascular death. Vitamin D deficiency and depressed HRV are highly prevalent in the ESKD population. We aimed to determine the effects of oral vitamin D supplementation on HRV ((low frequency (LF) to high frequency (HF) spectral ratio (LF:HF)) in ESKD patients on hemodialysis. Fifty-six subjects with ESKD requiring hemodialysis were recruited from January 2013-March 2015 and randomized 1:1 to either conventional (0.25 mcg alfacalcidol plus placebo 3×/week) or intensive (0.25 mcg alfacalcidol 3×/week plus 50,000 international units (IU) ergocalciferol 1×/week) vitamin D for six weeks. The primary outcome was the change in LF:HF. There was no difference in LF:HF from baseline to six weeks for either vitamin D treatment (conventional: p = 0.9 vs. baseline; intensive: p = 0.07 vs. baseline). However, participants who remained vitamin D-deficient (25-hydroxyvitamin D < 20 ng/mL) after treatment demonstrated an increase in LF:HF (conventional: n = 13, ∆LF:HF: 0.20 ± 0.06, p < 0.001 vs. insufficient and sufficient vitamin D groups; intensive: n = 8: ∆LF:HF: 0.15 ± 0.06, p < 0.001 vs. sufficient vitamin D group). Overall, six weeks of conventional or intensive vitamin D only augmented LF:HF in ESKD subjects who remained vitamin D-deficient after treatment. Our findings potentially suggest that while activated vitamin D, with or without additional nutritional vitamin D, does not appear to improve cardiac autonomic tone in hemodialysis patients with insufficient or sufficient baseline vitamin D levels, supplementation in patients with severe vitamin D deficiency may improve cardiac autonomic tone in this higher risk sub-population of ESKD. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01774812

Towards the “ultimate earthquake-proof” building: Development of an integrated low-damage system

The 2010–2011 Canterbury earthquake sequence has highlighted the severe mismatch between societal expectations over the reality of seismic performance of modern buildings. A paradigm shift in performance-based design criteria and objectives towards damage-control or low-damage design philosophy and technologies is urgently required. The increased awareness by the general public, tenants, building owners, territorial authorities as well as (re)insurers, of the severe socio-economic impacts of moderate-strong earthquakes in terms of damage/dollars/ downtime, has indeed stimulated and facilitated the wider acceptance and implementation of cost-efficient damage-control (or low-damage) technologies. The ‘bar’ has been raised significantly with the request to fast-track the development of what the wider general public would hope, and somehow expect, to live in, i.e. an “earthquake-proof” building system, capable of sustaining the shaking of a severe earthquake basically unscathed. The paper provides an overview of recent advances through extensive research, carried out at the University of Canterbury in the past decade towards the development of a low-damage building system as a whole, within an integrated performance-based framework, including the skeleton of the superstructure, the non-structural components and the interaction with the soil/foundation system. Examples of real on site-applications of such technology in New Zealand, using concrete, timber (engineered wood), steel or a combination of these materials, and featuring some of the latest innovative technical solutions developed in the laboratory are presented as examples of successful transfer of performance-based seismic design approach and advanced technology from theory to practice

Decreased cerebral blood flow in the limbic and prefrontal cortex using SPECT imaging in a cohort of completed suicides

Suicide has a high comorbidity with impulsivity and depression, and finding imaging biomarkers indicative of patients at high risk for suicidal behavior is invaluable to the clinician. Using single-photon emission computed tomography (SPECT) imaging, we have previously reported regional cerebral blood flow (rCBF) decreases in the medial prefrontal cortex, ventral tegmental area and subgenual cingulate cortex (Brodmann area 25 (BA 25)), a region found to be hypoperfused with treatment-resistant depression. From 2007 to 2010, we have extended our analysis to include nine additional completed suicides. In all, 27 healthy, age- and gender-matched subjects from a previously acquired healthy brain study served as controls to our 21 completed suicides. All 21 suicides had been previously diagnosed with depression according to Diagnostic and Statistical Manual of Mental Disorder-IV criterion. Voxel-by-voxel analyses were performed using statistical parametric mapping to compare the differences in technetium-99m hexamethylpropylene amine oxime brain uptake between the groups. Factor analysis of the data identified the top 10 regions of hypoperfusion in the suicidal group, including the bilateral superior frontal lobes, the right precuneus, the rolandic operculum, postcentral gyrus, left caudate and insular cortex. We also demonstrate more focal decreases in rCBF in the subgenual cingulate cortex (BA 25) in 18 subjects, supporting our previous hypothesis that hypoperfusion of BA 25 may be a risk factor for suicide in depressed patients. This work suggests that SPECT might be useful in predicting risk for suicide completion in subjects with depression or treatment-resistant depression. Further investigation of this work is necessary to better understand the predictive value of this finding

Internet-based medical education: a realist review of what works, for whom and in what circumstances

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The Role of Dicer Protein Partners in the Processing of MicroRNA Precursors

One of the cellular functions of the ribonuclease Dicer is to process microRNA precursors (pre-miRNAs) into mature microRNAs (miRNAs). Human Dicer performs this function in cooperation with its protein partners, AGO2, PACT and TRBP. The exact role of these accessory proteins in Dicer activity is still poorly understood. In this study, we used the northern blotting technique to investigate pre-miRNA cleavage efficiency and specificity after depletion of AGO2, PACT and TRBP by RNAi. The results showed that the inhibition of either Dicer protein partner substantially affected not only miRNA levels but also pre-miRNA levels, and it had a rather minor effect on the specificity of Dicer cleavage. The analysis of the Dicer cleavage products generated in vitro revealed the presence of a cleavage intermediate when pre-miRNA was processed by recombinant Dicer alone. This intermediate was not observed during pre-miRNA cleavage by endogenous Dicer. We demonstrate that AGO2, PACT and TRBP were required for the efficient functioning of Dicer in cells, and we suggest that one of the roles of these proteins is to assure better synchronization of cleavages triggered by two RNase III domains of Dicer

Compression garments and fabric orthoses for rehabilitation and function: a systematic mapping review.

Background/aims: Compression garments, joint supports and dynamic movement orthoses all use elastic fibres and close-fitting designs and have been researched for their effects on movement. There is little cross-referencing between research into these interventions. This review aimed to improve inter-disciplinary understanding by analysing key characteristics of the published evidence. Methods: Systematic mapping reviews identify gaps in an evidence base and identify questions for more in-depth reviews. This review was conducted in-line with current guidance. MEDLINE, CINAHL and Sports Discuss were searched for primary research investigating compression garments and orthoses for movement and function. The following search terms were used: "elastane", "spandex", "Lycra", "elastomer*", "Theratog*", "compression", "Neoprene", "orthotic", "orthosis", "shorts", "garment*", "splint", "brace", "sock*" and "stockings". Studies were screened against predetermined criteria and key study characteristics extracted. Findings: Three hundred and fifty-one studies were selected and analysed. Compression garment research was most common (236 studies), followed by research into joint supports (64 studies) and dynamic movement orthoses (42 studies). Research largely reflects the purpose for which each intervention was originally designed. Common topics investigated include posture and movement control, proprioception and muscle activity. Pressure beneath compression garments was measured in 30% of studies. Conclusions: The review highlights a need for more robust study designs in patient populations and accurate description of interventions. There is a need for a review on the possible effects of compression and support on movement control which should be used to inform future primary research

Single- versus two- layer intestinal anastomosis: a meta-analysis of randomized controlled trials

BACKGROUND: To compare single- with two- layer intestinal anastomosis after intestinal resection: a meta-analysis of randomized controlled trials. METHODS: Randomized controlled trials comparing single- with two-layer intestinal anastomosis were identified using a systematic search of Medline, Embase and the Cochrane Library Databases covering articles published from 1966 to 2004. Outcome of primary interest was postoperative leak. A risk ratio for trial outcomes and weighted pooled estimates for data were calculated. A fixed-effect model weighted using Mantel-Haenszel methods and a random-effect model using DerSimonian-Laird methods were employed. RESULTS: Six trials were analyzed, comprising 670 participants (single-layer group, n = 299; two-layer group, n = 371). Data on leaks were available from all included studies. Combined risk ratio using DerSimonian-Laird methods was 0.91 (95% CI = 0.49 to 1.69), and indicated no significant difference. Inter-study heterogeneity was significant (χ(2 )= 10.5, d.f. = 5, p = 0.06). CONCLUSION: No evidence was found that two-layer intestinal anastomosis leads to fewer post-operative leaks than single layer. Considering duration of the anastomosis procedure and medical expenses, single-layer intestinal anastomosis appears to represent the optimal choice for most surgical situations

Screen-detected colorectal cancers are associated with an improved outcome compared with stage-matched interval cancers

Background: Colorectal cancers (CRCs) detected through the NHS Bowel Cancer Screening Programme (BCSP) have been shown to have a more favourable outcome compared to non-screen-detected cancers. The aim was to identify whether this was solely due to the earlier stage shift of these cancers, or whether other factors were involved. Methods: A combination of a regional CRC registry (Northern Colorectal Cancer Audit Group) and the BCSP database were used to identify screen-detected and interval cancers (diagnosed after a negative faecal occult blood test, before the next screening round), diagnosed between April 2007 and March 2010, within the North East of England. For each Dukes' stage, patient demographics, tumour characteristics, and survival rates were compared between these two groups. Results: Overall, 322 screen-detected cancers were compared against 192 interval cancers. Screen-detected Dukes' C and D CRCs had a superior survival rate compared with interval cancers (P=0.014 and P=0.04, respectively). Cox proportional hazards regression showed that Dukes' stage, tumour location, and diagnostic group (HR 0.45, 95% CI 0.29-0.69, P<0.001 for screen-detected CRCs) were all found to have a significant impact on the survival of patients. Conclusions: The improved survival of screen-detected over interval cancers for stages C and D suggest that there may be a biological difference in the cancers in each group. Although lead-time bias may have a role, this may be related to a tumour's propensity to bleed and therefore may reflect detection through current screening tests

Tourism and water inequity in Bali: A social-ecological systems analysis

This paper is a social-ecological systems (SES) analysis of tourism and water inequity in Bali. It uses Elinor Ostrom’s SES model to look at the particular niche of Bali’s tourism and water nexus. Re-analysis of previous qualitative research revealed that the vulnerability of the SES was due to numerous characteristics. In particular, user groups are highly diverse, transient and stratified, thereby inhibiting communication and knowledge sharing. This, in combination with weak governance systems and the economic power of the tourism industry, interact to affect declining water resources and the iniquitous impact of this. Whilst there are obvious indications that Bali’s water resources are over stretched, there is no feedback loop to the institutional structures that would help enable appropriate responses from the user groups or governance system