Cardiovascular dysfunction in patients with liver cirrhosis

Abstract Hyperdynamic syndrome is a well-known clinical condition found in patients with cirrhosis and portal hypertension, characterized by increased heart rate and cardiac output, and reduced systemic vascular resistance and arterial blood pressure. Th e leading cause of hyperdynamic circulation in cirrhotic patients is peripheral and splanchnic vasodilatation, due to an increased production/activity of vasodilator factors and decreased vascular reactivity to vasoconstrictors. Th e term "cirrhotic cardiomyopathy" describes impaired contractile responsiveness to stress, diastolic dysfunction and electrophysiological abnormalities in patients with cirrhosis without known cardiac disease. Underlying circulatory and cardiac dysfunctions are the main determinant in the development of hepatorenal syndrome in advanced cirrhosis. Moreover, the clinical consequences of cirrhosis-related cardiovascular dysfunction are evident during and aft er liver transplantation, and aft er transjugular intrahepatic portosystemic shunt insertion. Cardiovascular complications following these procedures are common, with pulmonary edema being the most common complication. Other complications include overt heart failure, arrhythmia, pulmonary hypertension, pericardial eff usion, and cardiac thrombus formation. Th is review discusses the circulatory and cardiovascular dysfunctions in cirrhosis, examining the pathophysiologic and clinical implications in light of the most recent published literature

Seismological constraints for the dyke emplacement of the July-August 2001 lateral eruption at Mt. Etna volcano, Italy

In this paper we report seismological evidence regarding the emplacement of the dike that fed the July 18 - August 9, 2001 lateral eruption at Mt. Etna volcano. The shallow intrusion and the opening of the eruptive fracture system, which mostly occurred during July 12, and July 18, were accompanied by one of the most intense seismic swarms of the last 20 years. A total of 2694 earthquakes (1 £ Md £ 3.9) were recorded from the beginning of the swarm (July 12) to the end of the eruption (August 9). Seismicity shows the upward migration of the dike from the basement to the relatively thin volcanic pile. A clear hypocentral migration was observed, well constraining the upwards propagation of a near-vertical dike, oriented roughly N-S, and located a few kilometers south of the summit region. Earthquake distribution and orientation of the P-axes from focal mechanisms indicate that the swarm was caused by the local stress source related to the dike intrusion

Serum Albumin Is Inversely Associated With Portal Vein Thrombosis in Cirrhosis

We analyzed whether serum albumin is independently associated with portal vein thrombosis (PVT) in liver cirrhosis (LC) and if a biologic plausibility exists. This study was divided into three parts. In part 1 (retrospective analysis), 753 consecutive patients with LC with ultrasound-detected PVT were retrospectively analyzed. In part 2, 112 patients with LC and 56 matched controls were entered in the cross-sectional study. In part 3, 5 patients with cirrhosis were entered in the in vivo study and 4 healthy subjects (HSs) were entered in the in vitro study to explore if albumin may affect platelet activation by modulating oxidative stress. In the 753 patients with LC, the prevalence of PVT was 16.7%; logistic analysis showed that only age (odds ratio [OR], 1.024; P = 0.012) and serum albumin (OR, -0.422; P = 0.0001) significantly predicted patients with PVT. Analyzing the 112 patients with LC and controls, soluble clusters of differentiation (CD)40-ligand (P = 0.0238), soluble Nox2-derived peptide (sNox2-dp; P < 0.0001), and urinary excretion of isoprostanes (P = 0.0078) were higher in patients with LC. In LC, albumin was correlated with sCD4OL (Spearman's rank correlation coefficient [r(s)], -0.33; P < 0.001), sNox2-dp (r(s), -0.57; P < 0.0001), and urinary excretion of isoprostanes (r(s), -0.48; P < 0.0001) levels. The in vivo study showed a progressive decrease in platelet aggregation, sNox2-dp, and urinary 8-iso prostaglandin F2 alpha-III formation 2 hours and 3 days after albumin infusion. Finally, platelet aggregation, sNox2-dp, and isoprostane formation significantly decreased in platelets from HSs incubated with scalar concentrations of albumin. Conclusion: Low serum albumin in LC is associated with PVT, suggesting that albumin could be a modulator of the hemostatic system through interference with mechanisms regulating platelet activation

Acute Liver Failure: Pathophysiologic Basis, and The Current and Emerging Therapies

Acute liver failure (ALF) is a devastating condition that occurs in patients who previously had a normal liver. Although the outcome of patients with ALF has improved, without liver transplantation (LT) mortality rates remain in the range of 35-50% in different geographical areas and therefore, its treatment remains an unmet need. In the Western world toxic liver injury from acetaminophen remains one of the common causes but, in the East, hepatitis of unknown aetiology remains the most common cause. Treatment options are limited to meticulous attention to multi-organ support, use of N-acetyl cysteine, judicious use of antibiotics, and timely LT. This review describes the state-of-the-art techniques in the issues related to prognosis, outcome, and treatment of this devastating syndrome

Comparison of total cortisol, free cortisol, and surrogate markers of free cortisol in diagnosis of adrenal insufficiency in patients with stable cirrhosis

BACKGROUND & AIMS: Measurements of serum levels of total cortisol can overestimate the prevalence of adrenal dysfunction in patients with cirrhosis because they have low concentrations of corticosteroidbinding globulin and albumin. We used measurements of serum total cortisol and serum free cortisol after the low-dose short Synacthen test (LDSST) to assess adrenal dysfunction.METHODS: We studied 79 patients with stable cirrhosis; adrenal dysfunction was defined by peak concentrations of total cortiso

Guidelines on the management of atrial fibrillation in the emergency department: a critical appraisal

Several guidelines often exist on the same topic, sometimes offering divergent recommendations. For the clinician, it can be difficult to understand the reasons for this divergence and how to select the right recommendations. The aim of this study is to compare different guidelines on the management of atrial fibrillation (AF), and provide practical and affordable advice on its management in the acute setting. A PubMed search was performed in May 2014 to identify the three most recent and cited published guidelines on AF. During the 1-week school of the European School of Internal Medicine, the attending residents were divided in five working groups. The three selected guidelines were compared with five specific questions. The guidelines identified were: the European Society of Cardiology guidelines on AF, the Canadian guidelines on emergency department management of AF, and the American Heart Association guidelines on AF. Twenty-one relevant sub-questions were identified. For five of these, there was no agreement between guidelines; for three, there was partial agreement; for three data were not available (issue not covered by one of the guidelines), while for ten, there was complete agreement. Evidence on the management of AF in the acute setting is largely based on expert opinion rather than clinical trials. While there is broad agreement on the management of the haemodynamically unstable patient and the use of drugs for rate-control strategy, there is less agreement on drug therapy for rhythm control and no agreement on several other topics

Seismological constraints for the dyke emplacement of the July-August 2001 lateral eruption at Mt. Etna volcano, Italy

In this paper we report seismological evidence regarding the emplacement of the dike that fed the July 18 - August 9, 2001 lateral eruption at Mt. Etna volcano. The shallow intrusion and the opening of the eruptive fracture system, which mostly occurred during July 12, and July 18, were accompanied by one of the most intense seismic swarms of the last 20 years. A total of 2694 earthquakes (1 £ Md £ 3.9) were recorded from the beginning of the swarm (July 12) to the end of the eruption (August 9). Seismicity shows the upward migration of the dike from the basement to the relatively thin volcanic pile. A clear hypocentral migration was observed, well constraining the upwards propagation of a near-vertical dike, oriented roughly N-S, and located a few kilometers south of the summit region. Earthquake distribution and orientation of the P-axes from focal mechanisms indicate that the swarm was caused by the local stress source related to the dike intrusion