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A Burroughs

Publications and source records attributed to A Burroughs.

At least 37 records · Page 2Linked to original sources
PubMed1998

Factors related to early mortality after transjugular intrahepatic portosystemic shunt for failed endoscopic therapy in acute variceal bleeding.

BACKGROUND: Uncontrolled variceal haemorrhage is the main indication for transjugular intrahepatic portosystemic shunt. However, mortality is 50% for this high-risk group. We have evaluated clinical and laboratory variables prior to transjugular intrahepatic portosystemic shunt in order to establish predictors of mortality, validated prospectively. METHOD: Over a 4-year period, 367 patients were admitted with variceal bleeding. In 54 patients endoscopic therapy for acute variceal bleeding failed and they had emergency transjugular intrahepatic portosystemic shunt. Failure of therapy was defined as continued bleeding after 2 endoscopy sessions (n=39) or vasoconstrictor-resistant bleeding from gastric/ectopic varices (n=15). Thirty-three variables were analysed from data available immediately prior to transjugular intrahepatic portosystemic shunt. RESULTS: Twenty-six patients died within 6 weeks. In a multivariate analysis, 6 factors had independent prognostic value: moderate/severe ascites, requirement for ventilation, white cell blood count (WBC), platelet count (PLT), partial thromboplastin time with kaolin (PTTK) and creatinine. A prognostic index (PI) score was derived, in which presence of moderate/severe ascites, or need for ventilation, scored 1: PI=1.54 (Ascites)+1.27 (Ventilation)+1.38 Ln (WBC)+2.48 ln (PTTK)+1.55 Ln (Creat)-1.05 Ln (PLT). Using this equation, 42% (n=10) of deaths occurred in the fifth quintile (PI > or = 18.52), where the mortality was 100%. The score was prospectively validated in a further 31 patients, giving 100% positive predictive value. Eleven further patients died, including all seven with a PI >18.5. No survivors had a PI >18.3. CONCLUSION: Despite immediate control of bleeding by transjugular intrahepatic portosystemic shunt, patients with uncontrolled variceal haemorrhage have a high mortality, particularly when associated with markers of advanced liver disease, sepsis and multi-organ failure. The use of transjugular intrahepatic portosystemic shunt is probably not justified in this subgroup. Our prognostic index can help identify such patients, and, if validated elsewhere, will help in deciding when to use transjugular intrahepatic portosystemic shunt.

Acute Disease↗
PubMed1998

Maximizing participation by black Americans in population-based diabetes research: the Project DIRECT pilot experience.

Diabetes and its associated complications and risk factors have a higher prevalence among blacks than whites. To reduce the burden of diabetes within the black community, research is needed to assess the behavioral, social, and environmental correlates associated with this disproportionate burden. Because of some well known instances of historical exploitation and abuse from medical and public health research conducted in black communities, this population has little enthusiasm for additional research, despite pressing health needs. This paper describes the process used to eliminate barriers and enhance trust between the target community and the researchers conducting a population survey of diabetes in Wake County, North Carolina. A community advisory board was organized to (1) review the survey instruments and methodologies, (2) identify persons from the community to serve as interviewers, and (3) promote the survey using the major local communication channels. The response rate to both the household survey and the comprehensive medical exam was 77%. Eighty-one percent of eligible black respondents completed the household exam and 80% completed the comprehensive medical exam. Advantages of building collaborative relationships between the community and research team are discussed.

Adult↗
PubMed1997

Small hepatocellular carcinomas in cirrhotic explant livers: identification by macroscopic examination and lipiodol localization.

Small hepatocellular carcinomas (HCCs) in cirrhotic livers are difficult to detect. This study aimed to assess if small HCCs can be better identified using specific macroscopic sampling criteria and Lipiodol (iodized oil) localization on radiographs, and to evaluate thereby their incidence and morphology. Prospective cirrhotic recipients of orthotopic liver transplantation (OLT) were administered hepatic arterial Lipiodol at angiography. Posttransplantation, the explant livers were sliced and inspected as per routine for unusual nodules. If unusual nodules were found or HCC clinically suspected, the slices underwent soft-tissue radiography. Tissue samples were then taken as per protocol from all nodules with diameter > or =1 cm/unusual appearance/exophytic bulge, and from foci of radiographic Lipiodol uptake or high soft-tissue density. One hundred three lesions were assessed and classified histologically as HCC (n = 55) or regenerative nodule (n = 39) or borderline (n = 9). Sampling according to predetermined macroscopic criteria proved an effective method for identifying small HCCs: 44 cancers were detected, most <5 mm in diameter, additional to those picked up on routine assessment. Green nodules were more likely to be HCC (P < .0001). The cancers were all multifocal, and had characteristic histological features of HCC except for 12 unusual fibrotic cancers in livers with alcoholic cirrhosis. Lipiodolization alone identified one additional HCC. Lipiodol retention on x-ray is fairly specific for HCC (83%), and can even identify lesions 2 mm in diameter. But its sensitivity is poor (45%), and its routine use to identify HCCs in explant livers is not recommended.

Carcinoma, Hepatocellular↗
PubMed1997

Hypercoagulability in patients with primary biliary cirrhosis and primary sclerosing cholangitis evaluated by thrombelastography.

BACKGROUND/AIMS: Patients with primary biliary cirrhosis and primary sclerosing cholangitis survive variceal bleeding better than patients with alcoholic cirrhosis and have less bleeding at liver transplantation. Recently, patients with primary biliary cirrhosis have been found to have a higher incidence of thrombosis in the portal venous tree. We hypothesized that primary biliary cirrhosis and primary sclerosing cholangitis patients may be hypercoagulable. METHODS: We used thrombelastography, which is a simple technique for evaluating whole blood clotting and fibrinolysis, to establish if hypercoagulability was present, defined by thrombelastography values greater than 2SD over controls: r<19 mm (this reflects plasma clotting factors), maximum amplitude (ma) >60 mm, and alpha angle >43 degrees (these reflect platelets and fibrinogen levels). We evaluated 47 primary biliary cirrhosis and 21 primary sclerosing cholangitis patients, 40 with non-cholestatic cirrhosis and 40 healthy subjects as control groups with thrombelastography, full blood count, prothrombin time, partial thromboplastin time and, fibrinogen concentrations. In those with hypercoagulability we evaluated protein S, C, anti-thrombin III levels and activated protein C phenotype. RESULTS: All three thrombelastography abnormalities present together defined hypercoagulability: these were found in 13 of 47 (28%) primary biliary cirrhosis and in nine of 21 (43%) primary sclerosing cholangitis patients independent of cirrhosis, and bilirubin concentration, but in only 2 of 40 (5%) patients with noncholestatic cirrhosis and in none of the healthy controls (p<0.03 and p<0.0002, respectively). There was no correlation between the fibrinogen concentration (which was normal in all patients) or platelet count and the thrombelastography parameters. Only six of the 22 hypercoagulable patients had lower than normal values of protein S, C or antithrombin III. Activated protein C phenotype was normal in all. CONCLUSIONS: This diffference between biliary and parenchymal liver disease may have clinical implications, which need to be defined.

Adolescent↗
PubMed1997

Interrelationships among quantity of human cytomegalovirus (HCMV) DNA in blood, donor-recipient serostatus, and administration of methylprednisolone as risk factors for HCMV disease following liver transplantation.

Longitudinal analysis of 162 liver transplant recipients identified 51 patients who were viremic. Virus load was determined in 47 of these patients using quantitative-competitive polymerase chain reaction. Peak virus load was significantly higher in 20 symptomatic patients than 27 asymptomatic patients (P < .0001). Elevated virus load, donor seropositivity, and total methylprednisolone dosage were risk factors for human cytomegalovirus (HCMV) disease (odds ratio [OR], 2.22/0.25 log10 increase in virus load, P = .001; OR, 4.11, P = .05; OR, 1.30/1-g increment in methylprednisolone, P = .01). Methylprednisolone and virus load were independent risk factors in a multivariate analysis (OR, 2.70/1-g increase, P = .003; OR, 1.61/0.25 log10 increase, P = .03, respectively). Virus loads of 10(4.75)-10(5.25) genomes/mL of blood were associated with an increased disease probability; the latter was shifted to lower virus loads with increasing quantities of methylprednisolone. These data illustrate the central role of virus load in HCMV pathogenesis.

Adolescent↗
PubMed1997

Prospective study of hepatobiliary scintigraphy and endoscopic cholangiography for the detection of early biliary complications after orthotopic liver transplantation.

BACKGROUND: Biliary complications are a significant cause of morbidity and death after orthotopic liver transplantation (OLT). This study was a prospective evaluation of endoscopic retrograde cholangiography (ERC) and hepatobiliary scintigraphy (HBS), using 99mTc Mebrofenin, to detect early biliary complications following OLT. METHODS: One hundred consecutive patients who had OLT with a biliary duct-to-duct anastomosis were studied. Of these, 67 had both ERC and HBS performed within 30 days of OLT. Sensitivity, specificity and diagnostic accuracy of HBS in identifying biliary leak or stricture was calculated. RESULTS: Of the 67 cholangiographies performed 45 were normal. In 22 patients there was radiological evidence of a leak (n = 14) or stricture (n = 8) which required further intervention in nine and four patients respectively. The sensitivity and specificity of scintigraphy for the detection of biliary leak after transplantation was 50 and 79 per cent and for biliary stricture 62 and 64 per cent respectively. No patient with normal scintigraphy required biliary intervention. Only six of 14 patients with biliary leaks and two of 20 with strictures suggested by scintigraphy required intervention. If both ERC and HBS reported leak or stricture, the intervention rate was considerably higher at five of seven leaks and two of five strictures. CONCLUSION: This study suggests that scintigraphy is a useful screening test for biliary complications after OLT, ERC is only necessary if HBS is abnormal.

Adolescent↗
PubMed1996

Chronic ecstasy (3,4-methylenedioxymetamphetamine) abuse: a recurrent and unpredictable cause of severe acute hepatitis.

Fifteen reports of hepatitis induced by ecstasy (MDMA, 3,4-methylenedioxymetamphetamine) have been published over the last 3 years. With the increasing enthusiasm for "Rave" parties, the incidence appears to be increasing, and is an important and often concealed cause of acute hepatitis in young people. We report two cases of recurrent ecstasy-associated hepatitis where the interval between drug consumption and jaundice was variable and the link therefore initially obscured. Liver biopsies of both patients showed acute hepatitis. One was of relatively mild degree, and the other was severe, with features suggesting auto-immune hepatitis. Both cases resolved spontaneously. A high index of suspicion and careful specific enquiry are necessary to make the diagnosis and warn the patient to abstain in future, since subsequent attacks may be fatal and insidious chronic damage may occur.

3,4-Methylenedioxyamphetamine↗
PubMed1996

Variceal and portal pressure measurement: techniques and applications.

Variceal and portal pressure measurements are currently the most widely used invasive techniques for the haemodynamic evaluation of portal hypertension in cirrhotic patients. Variceal pressure can be measured during endoscopy either directly by variceal puncture or indirectly by using a pressure sensitive gauge. More recently, an indirect technique which uses a plastic balloon attached to the end of the endoscope has been described. Variceal pressure appears to be an important risk factor for the occurrence of variceal haemorrhage as most studies concluded that variceal pressure tends to be higher in patients with previous bleeding than those without. Hepatic venous catheterization with measurements of the wedged and free hepatic pressures has become the method of choice in the estimation of portal pressure as it is a simple, fast and safe procedure, less invasive and more reproducible than the other techniques. Information obtained from hepatic vein catheterization gives a significant prognostic value in predicting survival. Despite the lack of a linear relationship between portal pressure and risk of variceal bleeding most prospective studies have concluded that the height of portal pressure is an important and independent predictive factor for bleeding. Hepatic venous catheterization is currently the best method of assessing the haemodynamic response to drug treatment and prediction of therapeutic response for the prevention of bleeding.

Blood Pressure Determination↗
PubMed1996

Acute Budd-Chiari syndrome treated by liver transplantation in a woman homozygous for factor V Leiden.

We describe the first case of Budd-Chiari syndrome due to homozygosity for factor V Leiden resulting in resistance to activated protein C. This is now recognized as the most common procoagulant disorder, and may account for many cases of Budd-Chiari syndrome previously though to be idiopathic or due to a latent myeloproliferative disorder. A further unique feature of this case is that the patient required orthotopic liver transplantation following failure of portacaval shunting and progressive hepatic necrosis. We demonstrated that liver transplantation resulted in correction of the serum coagulation abnormality; however, it is unlikely to have cured the disorder as platelet factor V would still be of the Leiden phenotype.

Acute Disease↗
PubMed1995

Indications, methods, and outcomes of percutaneous liver biopsy in England and Wales: an audit by the British Society of Gastroenterology and the Royal College of Physicians of London.

The liver section of the British Society of Gastroenterology and the research unit of the Royal College of Physicians collaborated to set up a nationwide audit to investigate the practice of percutaneous liver biopsy in England and Wales. Each of 189 health districts in England and Wales was approached to provide a list of 10 consecutive percutaneous biopsies performed during 1991, and details of demographic data, indications, suspected diagnosis, investigations, biopsy technique, outcome, and influence on patient management were collected. Data were retrieved on 1500 (79%). The age distribution showed 6% of biopsies were done in those over 80 years of age and as many over 90 as under 10 years of age. Suspected malignancy and chronic liver disease each contributed one third of the indications. In 34% the procedure was carried out by radiologists under ultrasound image control. The remainder were done by general physicians and gastroenterologists, with the operator in the second group being more senior and experienced. The Trucut biopsy needle accounted for two thirds of biopsies, the remainder being the Menghini type. For both needles the samples were recorded as excellent or satisfactory in 83% and inadequate in only 5%. Bleeding complicated 26 procedures (1.7%), requiring transfusion in 11, and was commoner when clotting was impaired or serum bilirubin raised. There were two definite and three possible procedure related, given an overall mortality of 0.13-0.33%. The diagnosis made before biopsy was confirmed in 63% of patients, and the clinician found the biopsy helpful in treatment in 75%. Day case biopsy and techniques to reduce the risk of bleeding were surprisingly rare in this series, which has given a unique opportunity to examine everyday practice across a wide range of hospitals.

Adolescent↗
PubMed1995

Psychiatric and social outcome of liver transplantation.

BACKGROUND: This study measures psychiatric morbidity, quality of life, and cognitive function after liver transplantation. METHOD: We undertook a cross-sectional study, with a longitudinal subgroup. The setting was a tertiary referral centre for liver transplantation. The subjects were 30 post-liver-transplantation patients, including 11 also interviewed before the operation. The main outcome measures were the Clinical Interview Schedule (CIS), the General Health Questionnaire (GHQ), the Nottingham Health Profile (NHP), and the Mini-Mental State Examination (MMSE). RESULTS: Of the patients, 8/30 were CIS cases, and 7/30 were GHQ cases. NHP scores were higher than a previous postal study indicated, with less impairment after than before transplant. MMSE scores were 24-30. Median GHQ was 7.0 before operation and 1.0 after operation (P = 0.03), with no significant change in CIS score. CONCLUSION: Liver transplantation improves quality of life, but not to the level of the general population; post-transplantation patients have a prevalence of psychiatric morbidity comparable with that of general medical patients.

Adolescent↗
PubMed1995

Longterm follow-up of biliary stents for retained common bile duct stones in elderly patients.

Common bile duct (CBD) stones in elderly patients are best treated by endoscopic sphincterotomy (ES). If CBD clearance cannot be achieved endoscopically a biliary stent may be inserted. Although satisfactory short-term results have been reported, few reports on their longterm outcome are available. Over a 3-year period, January 1987 to December 1989, 100 patients with CBD stones were referred for endoscopic stone removal. In 14 of these patients (3 men, 11 women; median age 83 years, range 79-97 years) the CBD could not be cleared endoscopically and a stent was inserted. Twelve of the 14 patients were jaundiced and 5 had acute cholangitis (AC). The maximum diameter of the retained stones ranged from 10-42 mm with a median of 17 mm. Stent insertion resolved jaundice and sepsis in all cases and all patients were discharged from hospital. In-patient stay ranged from 1-82 days (median 12 days) and was significantly increased by the presence of acute cholangitis (P = 0.03, Mann-Whitney U-test). Longterm follow-up was obtained in 13 of the 14 patients (93%) by referral to their general practitioner and out-patient notes. Seven patients are alive and well (median follow-up 43 months, range 34-60 months). One of these 7 developed further jaundice owing to stent migration and had further ES and stone removal. Six patients died at 1, 3, 12, 32, 36 and 42 months following stent insertion from unrelated causes. One patient developed further AC requiring antibiotic treatment and another patient required stent replacement.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
PubMed1994

Incidence, risk factors, management, and outcome of portal vein abnormalities at orthotopic liver transplantation.

Portal vein thrombosis is often considered a contraindication to orthotopic liver transplantation. We have analyzed the incidence, risk factors, management and outcome of patients with portal vein thrombosis undergoing orthotopic liver transplantation. During the period from October 1988 to October 1992 140 grafts were performed on 132 patients. Fourteen had portal vein thrombosis with either partial (n = 7) or complete (n = 7) occlusion of the portal vein at surgery. Portal vein thrombosis was more common in patients with autoimmune chronic active hepatitis (3/5 vs. 11/127, chi 2 = 13.3, P < 0.001), cryptogenic cirrhosis (4/12 vs. 10/120, chi 2 = 7.2, P < 0.01), or those with tumors (6/22 vs. 10/110, chi 2 = 5.7, P < 0.05). In 13 of the 14 portal inflow was reestablished by flushing, balloon thrombectomy, or passage of a graduated dilator. In one patient complete fibrous obliteration necessitated a portal vein to right gastroepiploic vein anastomosis. On follow-up there have been 6 deaths in this group (6/14 = 43%) from recurrent cancer (n = 1), sepsis (n = 4), and cardiac and renal failure (n = 1). Four of these 6 patients had confirmation of PV patency on imaging. The remaining 8 patients are alive and well (median follow-up 37 months, range 6-53 months). Post-transplant portal vein thrombosis occurred in 3 of the 14 patients (21%) with a portal vein abnormality at surgery and in two of the 118 patients with a normal portal vein (3/14 vs. 2/118, chi 2 = 8.5, P < 0.01). Four of the 5 cases were successfully treated by surgical thrombectomy.

Adolescent↗
PubMed1994

Biliary anastomosis after liver transplantation does not benefit from T tube splintage.

T tubes are commonly used to splint biliary anastomoses after liver transplantation. Although several advantages are claimed for this approach, there is undoubtedly some iatrogenic morbidity associated with the use of T tubes in this situation. We have evaluated 120 consecutive biliary reconstructions after liver transplant, the majority of which were unsplinted end to end bile duct anastomoses. We have shown that biliary leakage and stricture rates are not significantly affected by T tubes. We have also shown that endoscopic retrograde cholangiopancreatography and percutaneous cholangiography are reliable posttransplant methods for cholangiography and stricture dilatation. Routine T tube splintage of post-liver transplant biliary anastomoses is unjustified.

Anastomosis, Surgical↗
PubMed1994

Outcome of surgery for failed endoscopic extraction of common bile duct stones in elderly patients.

Endoscopic sphincterotomy (ES) is the treatment of choice for common bile duct stones in elderly patients. For those in whom endoscopic clearance of the common bile duct fails the treatment options include stenting, dissolution therapy and lithotripsy. Surgery is often avoided because of the reported high morbidity and mortality in elderly patients. We have reviewed the outcome of patients referred for surgery after failed endoscopic clearance of common bile duct stones. Over a 3-year period, 100 patients with common bile duct stones were referred specifically for endoscopic clearance of the common bile duct (median age 69 years, range 19-97 years). In seven patients duct clearance was possible without ES and in five patients ES was considered inappropriate. ES was attempted in 88 patients and was successful in 75 (85%). Of the 13 patients failing ES or stone removal, surgery was performed in nine and four were stented. Of patients having successful ES (n = 75), ten were referred for surgery because of incomplete duct clearance. Surgery was performed to obtain duct clearance in 19 patients (eight male, 11 female, median age 77 years, range 47-90 years). Of the 19, eight had previously undergone a cholecystectomy (42%) and 17 of the 19 had biliary tract drainage preoperatively (90%). The procedures performed consisted of choledocholithotomy in all plus cholecystectomy (11), choledochoduodenostomy (7) and choledochojejunostomy (7). There were no deaths and only one major complication. The median total inpatient stay was 26 days (range 14-75 days) and the median postoperative stay was 12 days (range 7-50 days). We would conclude that open surgery can be performed safely and effectively in elderly patients with retained bile duct stones.

Aged↗