Human thrombin for the treatment of gastric and ectopic varices

AIM: To evaluate the efficacy of human thrombin in the treatment of bleeding gastric and ectopic varices. METHODS: Retrospective observational study in a Tertiary Referral Centre. Between January 1999-October 2005, we identified 37 patients who were endoscopically treated with human thrombin injection therapy for bleeding gastric and ectopic varices. Patient details including age, gender and aetiology of liver disease/segmental portal hypertension were documented. The thrombin was obtained from the Scottish National Blood Transfusion Service and prepared to give a solution of 250 IU/mL which was injected via a standard injection needle. All patient case notes were reviewed and the total dose of thrombin given along with the number of endoscopy sessions was recorded. Initial haemostasis rates, rebleeding rates and mortality were catalogued along with the incidence of any immediate complications which could be attributable to the thrombin therapy. The duration of follow up was also listed. The study was conducted according to the United Kingdom research ethics guidelines. RESULTS: Thirty-seven patients were included. 33 patients (89%) had thrombin (250 U/mL) for gastric varices, 2 (5.4%) for duodenal varices, 1 for rectal varices and 1 for gastric and rectal varices. (1) Gastric varices, an average of 15.2 mL of thrombin was used per patient. Re-bleeding occurred in 4 patients (10.8%), managed in 2 by a transjugular intrahepatic portosystemic shunt (TIPSS) (one unsuccessfully who died) and in other 2 by a distal splenorenal shunt; (2) Duodenal varices (or type 2 isolated gastric varices), an average of 12.5 mL was used per patient over 2-3 endoscopy sessions. Re-bleeding occurred in one patient, which was treated by TIPSS; and (3) Rectal varices, an average of 18.3 mL was used per patient over 3 endoscopy sessions. No re-bleeding occurred in this group. CONCLUSION: Human thrombin is a safe, easy to use and effective therapeutic option to control haemorrhage from gastric and ectopic varices

Role of inflammation and infection in the pathogenesis of human acute liver failure:Clinical implications for monitoring and therapy

Acute liver failure is a rare and devastating clinical condition. At present, emergency liver transplantation is the only life-saving therapy in advanced cases, yet the feasibility of transplantation is affected by the presence of systemic inflammation, infection and resultant multi-organ failure. The importance of immune dysregulation and acquisition of infection in the pathogenesis of acute liver failure and its associated complications is now recognised. In this review we discuss current thinking regarding the role of infection and inflammation in the pathogenesis of and outcome in human acute liver failure, the implications for the management of such patients and suggest directions for future research

Anticipated Regret and Organ Donor Registration: a randomised controlled trial

Objective: To test whether simply asking people to rate the extent to which they anticipate feeling regret for not registering as an organ donor after death increases subsequent verified organ donor registration.  Methods: 14,509 members of the general public (both registered and non-registered donors) were randomly allocated to 1 of 4 arms, each receiving different questionnaires. The no-questionnaire control (NQC) arm received a survey measuring demographics and whether or not they were registered organ donors. The questionnaire control (QC) arm completed the NQC questions plus questions regarding affective attitudes and intention to register as an organ donor. The theory of planned behaviour (TPB) questionnaire arm received the QC questionnaire, plus additional items measuring TPB variables. The anticipated regret (AR) arm received the TPB questionnaire, plus two additional items measuring anticipated regret. The main outcome measures were number of non-donor participants who subsequently registered six months later, as verified by the UK national transplant register.  Results: Intention-to-treat (ITT) analysis in non-registered donors (N = 9,139) revealed the NQC arm were more likely to register as an organ donor (6.39%) compared to the AR (4.51%) arm.  Conclusions: A brief anticipated regret intervention led to a decrease in registration. A potential reason is discussed in terms of questionnaire item content “priming” negative perceptions of organ donation. This is a methodological concern that needs to be addressed in studies that use similar interventions. Current controlled trials: www.controlled-trials.com number: ISRCTN922048897

Reasoning about goal-directed real-time teleo-reactive programs

The teleo-reactive programming model is a high-level approach to developing real-time systems that supports hierarchical composition and durative actions. The model is different from frameworks such as action systems, timed automata and TLA+, and allows programs to be more compact and descriptive of their intended behaviour. Teleo-reactive programs are particularly useful for implementing controllers for autonomous agents that must react robustly to their dynamically changing environments. In this paper, we develop a real-time logic that is based on Duration Calculus and use this logic to formalise the semantics of teleo-reactive programs. We develop rely/guarantee rules that facilitate reasoning about a program and its environment in a compositional manner. We present several theorems for simplifying proofs of teleo-reactive programs and present a partially mechanised method for proving progress properties of goal-directed agents. © 2013 British Computer Society

Update of endoscopy in liver disease:More than just treating varices

The management of complications in liver disease is often complex and challenging. Endoscopy has undergone a period of rapid expansion with numerous novel and specialized endoscopic modalities that are of increasing value in the investigation and management of the patient with liver disease. In this review, relevant literature search and expert opinions have been used to provide a brief overview and update of the current endoscopic management of patients with liver disease and portal hypertension. The main areas covered are safety of endoscopy in patients with liver disease, the use of standard endoscopy for the treatment of varices and the role of new endoscopic modalities such as endoscopic ultrasound, esophageal capsule, argon plasma coagulation, spyglass and endomicroscopy in the investigation and treatment of liver-related gastrointestinal and biliary pathology. It is clear that the role of the endoscopy in liver disease is well beyond that of just treating varices. As the technology in endoscopy expands, so does the role of the endoscopist in liver disease. (C) 2012 Baishideng. All rights reserved.</p

Application of the levitation technique for investigation of metal alloys and phase equilibria in slags

Experimental methods, based on electromagnetic levitation, have been developed for preparation and investigation of copper-rich alloys, and for the determination of oxide-metal phase equilibria. These techniques involve high-temperature equilibration, rapid quenching and chemical analysis of the phases using electron probe X-ray microanalysis. The experiments can be carried out in the temperature range 1373-1873 K (= 1100 degrees C-1600 degrees C). A developed calibration method, using phase equilibria data in known oxide systems, was applied for pyrometric temperature measurements. Described methods of the application of the electro-magnetic levitations were used for in-situ formation of Cu-based alloys and for formation of Ca-ferrite slags equilibrated with metallic copper

Thrombin is an effective and safe therapy in the management of bleeding gastric varices:A real-world experience

Variceal haemorrhage is a severe complication of liver disease with high mortality. Human recombinant thrombin has gained popularity in the management of variceal haemorrhage. We report on the use of thrombin for gastric and ectopic varices at a regional tertiary care centre. This was a retrospective observational study. Patients with portal hypertension who received endoscopic injection of recombinant thrombin were identified and data collected on haemostasis and rebleeding rates, complications and mortality. Patients were grouped by indication for thrombin injection: gastric/oesophageal/ectopic varices and endoscopic band ligation (EBL)-induced ulceration. 155 patients (96M/59F, mean age 58.3 years) received endoscopic thrombin injection. Mean volume of thrombin injected at index endoscopy was 9.5 ml/2375IU. Initial haemostasis was achieved in 144 patients (92.9%). Rebleeding occurred in a total of 53 patients (36.8%) divided as follows: early rebleeding (&lt;5 days from index endoscopy)—26 patients (18%); rebleeding within 30 days—42 patients (29.1%); delayed rebleeding (&gt; 30 days)—11 patients (7.6%). There was statistically significant difference in rate of initial haemostasis between Child-Pugh A/B patients vs Child-Pugh C (p = 0.046). There was no significant difference in rebleeding rates between different indication groups (p = 0.78), by presence of cirrhosis or by Child-Pugh Score. All-cause mortality at 6 weeks was 18.7%; 1-year mortality 37.4% (median follow-up 48 months). There was no significant difference in mortality between groups (p = 0.37). No significant adverse events or complications were reported. Thrombin is effective and safe for gastric varices and other portal-hypertension-related bleeding including oesophageal varices, ulcers secondary to EBL and ectopic varices