Nerea Fernández-Ros

Partial liver volume radioembolization induces hypertrophy in the spared hemiliver and no major signs of portal hypertension

BACKGROUND Post-treatment contralateral hemiliver hypertrophy has created an interest in lobar liver radioembolization (RE) as a pre-surgery tool. METHODS Liver and spleen volumes and function were studied in 83 patients submitted to partial liver volume RE at 4-8 weeks (T1), 10-26 weeks (T2), and >26 weeks (T3) after RE. RESULTS More than half of the patients had cirrhosis with hepatocellular carcinoma. The main finding was a progressive increase in the volume of the spared hemiliver (mean absolute increase at T3: 230 ml). The percentage of patients in whom the baseline ratio of spared volume to total liver volume was <40% dropped from 56.6% at baseline to 29.4% at T2 (P < 0.001). A significant and progressive increase in spleen volume but not in portal vein diameter was also observed. A small percentage of patients developed hypersplenism, mostly those without cirrhosis (16.0% at T2). Six patients (five with portal vein thrombosis, cirrhosis or both) developed signs of portal hypertension by T2. CONCLUSIONS The present results warrant further studies to better elucidate the mechanism underlying this phenomenon of spared hemiliver hypertrophy and to investigate its role as an alternative to portal vein embolization in the management of patients with potentially resectable liver tumours.

Malignant epithelioid hemangioendothelioma of the liver successfully treated with Sorafenib

Hepatic epithelioid hemangioendothelioma (HEH) is a rare disease of unknown etiology for which a standard systemic treatment has not been established. The common expression of vascular endothelial growth factor (VEGF) and its receptor in HEH provide a rationale for the reported use of antiangiogenic drugs, including bevacizumab, lenalidomide and thalidomide. We report a case of a young male patient with HEH who was treated with sorafenib for almost 2 years. Sorafenib was used instead of other VEGF inhibitors due to its convenient oral route, its dual antiangiogenic and antiproliferative activity, and its favorable safety profile. Sorafenib therapy resulted in durable stabilization with progressive calcification of liver tumors and minor but stable response of lung lesions.

Linezolid-induced lactic acidosis in two liver transplant patients with the mitochondrial DNA A2706G polymorphism.

ABSTRACT Mitochondrial toxicity has been recently suggested to be the underlying mechanism of long-term linezolid-associated toxicity in patients with 16S rRNA genetic polymorphisms. Here, we report for the first time two cases of lactic acidosis due to long-term linezolid exposure in liver transplant recipients who presented an A2706G mitochondrial DNA polymorphism.

Radioembolization of hepatocellular carcinoma activates liver regeneration, induces inflammation and endothelial stress and activates coagulation

Radioembolization may rarely induce liver disease resulting in a syndrome that is similar to veno‐occlusive disease complicating bone marrow transplantation where inflammation, endothelial cell activation and thrombosis are likely involved. We hypothesized that similar mechanisms could be implicated in radioembolization‐induced liver disease (REILD). Moreover, lobar radioembolization may induce hypertrophy of the non‐treated hemiliver most probably by inducing liver regeneration.

Design and Performance of a New Severity Score for Intermediate Care

Background Application of illness-severity scores in Intermediate Care Units (ImCU) shows conflicting results. The aim of the study is to design a severity-of-illness score for patients admitted to an ImCU. Methods We performed a retrospective observational study in a single academic medical centre in Pamplona, Spain. Demographics, past medical history, reasons for admission, physiological parameters at admission and during the first 24 hours of ImCU stay, laboratory variables and survival to hospital discharge were recorded. Logistic regression analysis was performed to identify variables for mortality prediction. Results A total of 743 patients were included. The final multivariable model (derivation cohort = 554 patients) contained only 9 variables obtained at admission to the ImCU: previous length of stay 7 days (6 points), health-care related infection (11), metastatic cancer (9), immunosuppressive therapy (6), Glasgow comma scale 12 (10), need of non-invasive ventilation (14), platelets 50000/mcL (9), urea 0.6 g/L (10) and bilirubin 4 mg/dL (9). The ImCU severity score (ImCUSS) is generated by summing the individual point values, and the formula for determining the expected in-hospital mortality risk is: eImCUSS points*0.099 – 4,111 / (1 + eImCUSS points*0.099 – 4,111). The model showed adequate calibration and discrimination. Performance of ImCUSS (validation cohort = 189 patients) was comparable to that of SAPS II and 3. Hosmer-Lemeshow goodness-of-fit C test was χ2 8.078 (p=0.326) and the area under receiver operating curve 0.802. Conclusions ImCUSS, specially designed for intermediate care, is based on easy to obtain variables at admission to ImCU. Additionally, it shows a notable performance in terms of calibration and mortality discrimination.

Mortality Prediction in Patients Undergoing Non-Invasive Ventilation in Intermediate Care

Background Intermediate Care Units (ImCU) have become an alternative scenario to perform Non-Invasive Ventilation (NIV). The limited number of prognostic studies in this population support the need of mortality prediction evaluation in this context. Objective The objective of this study is to analyze the performance of Simplified Acute Physiology Score (SAPS) II and 3 in patients undergoing NIV in an ImCU. Additionally, we searched for new variables that could be useful to customize these scores, in order to improve mortality prediction. Design Cohort study with prospectively collected data from all patients admitted to a single center ImCU who received NIV. The SAPS II and 3 scores with their respective predicted mortality rates were calculated. Discrimination and calibration were evaluated by calculating the area under the receiver operating characteristic curve (AUC) and with the Hosmer-Lemeshow goodness of fit test for the models, respectively. Binary logistic regression was used to identify new variables to customize the scores for mortality prediction in this setting. Patients The study included 241 patients consecutively admitted to an ImCU staffed by hospitalists from April 2006 to December 2013. Key Results The observed in-hospital mortality was 32.4% resulting in a Standardized Mortality Ratio (SMR) of 1.35 for SAPS II and 0.68 for SAPS 3. Mortality discrimination based on the AUC was 0.73 for SAPS II and 0.69 for SAPS 3. Customized models including immunosuppression, chronic obstructive pulmonary disease (COPD), acute pulmonary edema (APE), lactic acid, pCO2 and haemoglobin levels showed better discrimination than old scores with similar calibration power. Conclusions These results suggest that SAPS II and 3 should be customized with additional patient-risk factors to improve mortality prediction in patients undergoing NIV in intermediate care.

Pneumatocele during sorafenib therapy: first report of an unusual complication

Sorafenib is a multi-kinase inhibitor and a vascular endothelial growth factor (VEGF) inhibitor approved to treat patients with advanced hepatocellular carcinoma, renal cell carcinoma and differentiated thyroid carcinoma. Its most common side effects are asthenia/fatigue, skin toxicity, diarrhea and arterial hypertension. Reported respiratory adverse reactions include dyspnea, cough, pleural effusion and hoarseness. The aim of this report is to describe for the first time the occurrence of pneumatocele in two patients treated with Sorafenib. Patients had no respiratory symptoms and alternative diagnoses were ruled out. Primary tumors were different (liver metastases from a pancreatic neuroendocrine tumor and hepatocellular carcinoma) but both patients had been treated with yttrium 90 radioembolization 9 and 17 months before starting on Sorafenib, respectively. No complications occurred and Sorafenib withdrawal was followed by radiologic improvement.

Lercanidipine-induced chylous ascites: Case report and literature review

Chylous ascites is a rare condition. The most frequent causes are lymphomas, solid malignancies, abdominal trauma and cirrhosis. Isolated case reports describe the relationship between calcium channel blockers (CCB) and chyloperitoneum. Lercanidipine is a third‐generation dihydropyridine with low rate of adverse events. We describe a case of lercanidipine‐induced chylous ascites.

Gastroenteritis y colecistitis alitiásica en paciente varón de 34 años

Paciente varón de 34 años de edad, homosexual y sin antecedentes de interés que ingresa en nuestro hospital por un cuadro de gastroenteritis acompañado de febrícula y síndrome constitucional con pérdida de 20 kg de peso de 5 meses de evolución. No se habían aislado bacterias enteropatógenas en coprocultivos de rutina y tampoco se habían visualizado parásitos en heces. En la TAC abdominal (fig. 1) se evidenció un engrosamiento difuso de la pared de la vesícula biliar. No se objetivó colelitiasis ni barro biliar. La vía biliar (intray extrahepática) tenía un calibre normal. En la vecindad de la vesícula se observó un engrosamiento de 15 mm que afectaba a un segmento de 3,3 cm de la pared del antro gástrico que condicionaba una disminución del 90% del calibre de la luz. Se realizó una gastroscopia y se tomaron biopsias de la mucosa antral. Se recogió muestra de aspirado duodenal, que se envió a examen parasitológico (fig. 2). En la histopatología se observó un infiltrado inflamatorio de predominio plasmocitario. Además, se observó la presencia de numerosos microorganismos redondeados