Stanley Shaldon

Portal hypertension in the myeloproliferative syndrome and the reticuloses

Abstract The association of portal hypertension in four patients with the myeloproliferative syndrome (two patients with haemorrhagic thrombocythaemia, one with chronic myeloid leukaemia, one with myelosclerosis), and in two patients with reticulosis, (one with Hodgkins disease and one with Letterer-Siwes disease), has been demonstrated. In three patients portal hypertension was due to an extrahepatic portal venous obstruction associated with an increased tendency to venous thrombosis. In the other three patients no obstruction to the main portal or splenic vein could be demonstrated. Serum alkaline phosphatase levels were raised and the portal tracts and sinusoids showed infiltrative lesions. The splenic-wedged hepatic venous pressure gradient was increased suggesting that the portal hypertension was due to presinusoidal obstruction to portal blood flow. There was no evidence of an increase in hepatic blood flow. No evidence was found to support the theory that portal hypertension in patients with gross splenomegaly is due to an increase in portal blood flow.

The Demonstration of Porta-Pulmonary Anastomoses in Portal Cirrhosis with the Use of Radioactive Krypton (Kr85)

VENOUS anastomoses connecting the portal and pulmonary veins have been shown in cirrhotic patients by post-mortem injection,1 and there has been considerable speculation concerning their possible significance in life, particularly as a cause of arterial oxygen unsaturation and finger clubbing in patients with cirrhosis.2 3 4 5 Radioactive krypton (Kr85) solution, when injected into a peripheral vein, is blown off in the expired air as it reaches the alveolar surface of the lungs (Fig. 1). This has led to its use to demonstrate intrapulmonary arteriovenous shunts, which would allow krypton to bypass the alveoli and so reach a peripheral artery. In normal .xa0.xa0.

Refrigerated Femoral Venous-Venous Haemodialysis with Coil Preservation for Rehabilitation of Terminal Uraemic Patients

The rehabilitation of patients with terminal renal failure to a useful and economic existence has been achieved by periodic haemodialysis, and patients are now in their fourth year of treatment (Hegstrom et al., 1962; Scribner, personal communication, 1963). The technique utilizes a low-flow pumpless refrigerated haemodialysis system with a permanent arteriovenous sialastic teflon shunt (Quinton et al., 1962). The major disadvantages of this system have been the difficulty in maintaining the patency of the arteriovenous fistula prosthesis (Kolff et al., 1962), inaccessibility of the prosthesis to the patients own hands, and unpredictable blood-flow rates in a pumpless haemodialysis system with consequent difficulty in predictable ultrafiltration and removal of excess body water. An alternative system of periodic haemodialysis for the rehabilitation of terminal uraemic patients has been developed at the Royal Free Hospital since September, 1961. The description and preliminary results of this technique will be reported elsewhere (Rae et al., 1963; Shaldon et al., 1963). These results demonstrated that the patient with absent renal function requires a minimum of 24 hours haemodialysis per week, with blood-flow rates of 200 ml. a minute through a twin-coil kidney. The tech-

Virus Hepatitis with Features of Prolonged Bile Retention

Previous work has shown that a gamma-globulin fraction is responsible for the L.E. cell phenomenon of Hargraves, a part of which involves alteration of the nuclear material of white cells. This suggests that the L.E. cell factor is of an antibody nature, and the present demonstration in tissue-cell nuclei of a fixed globulin derived from L.E. positive serum adds support to this hypothesis. The present work also confirms a recent finding of _____________________________, Mellors et al. Pso. 6.-Ntin-specsfic fluoreacence of (1957), w h o d e cytoplasmic granules in certain leucocytes scribed specific (? eosinophils). Unfixed blood film prelocalization of treated wvth normal serum, then stained fluorescein conjuwith conjugate. Nuclei remam nonfluorescent. ( x 480.) gated antiglobulin serum in the nuclei of the white cells in an L.E. cell preparation. It thus seems very likely that the L.E. factor active against leucocytes is also the factor reacting with the tissue-cell nuclei reported here.

The aetiology and management of ascites in patients with hepatic cirrhosis: A review

FIG. 1. The ascitic fluid is separated from the capillary lumen by the peritoneal membrane and the portal capillary wall. The forces keeping fluid in the capillaries are the colloid osmotic pressure of the serum (S.C.O.P.) and the hydrostatic pressure of the ascitic fluid (A.F.P.). The forces tending to form ascites are the portal capillary pressure (P.C.P.) and the colloid osmotic pressure of the ascitic fluid (A.C.O.P.). In a steady state these forces should balance. Plasma colloid osmotic pressure Ascitic colloid osmotic pressure = Portal capillary pressure intra-abdominal hydrostatic pressure Itis clear therefore that there are probably at least two important factors in the formation of ascites, namely, the plasma colloid osmotic pressure and the portal venous pressure.

Technique of Refrigerated Coil Preservation Haemodialysis with Femoral Venous Catheterization

The use of daily haemodialysis in the treatment of severe acute renal failure has resulted in a significant improvement in mortality rates : 75 % of patients with acute hypercatabolic renal failure survived (Teschan et al., 1960). More recently Murray et al. (1961), using continuous haemodialysis, obtained 80% survival rates in similar patients. However, these results were obtained with MacNeill-Collins (MacNeill et al., 1959), Skeggs-Leonards (Skeggs and Leonards, 1948), or modified Kiil (1960) dialyser, which require considerable technician-time in assembling and are not available in most haemodialysis units. To overcome these problems, and to provide an efficient dialyser for daily haemodialysis at an economic rate which would be available in most renal centres, we have modified the Kolff twin coil kidney (Kolff and Watschinger, 1956) and disposable circuit to permit repeated use of the disposable dialyser without extra blood requirements. In addition, the entire assembly and running of the dialyser can now be performed by trained nursing staff without any supervision by a physician.

Renal involvement in active `juvenile' cirrhosis

Twelve patients with active `juvenile cirrhosis (active chronic hepatitis, `lupoid hepatitis) and six subjects with other types of portal or postnecrotic cirrhosis were submitted to percutaneous renal biopsy. In addition, renal function was assessed in all patients by measurement of the 24-hour endogenous creatinine clearance, maximal urinary osmolality after deprivation of water, 24-hour urinary protein excretion, and routine urine analysis. Renal function was not significantly abnormal in either group of patients, but seven of the 12 patients with active `juvenile cirrhosis showed mild histological changes on renal biopsy. These changes are very similar to the lesions described in early `lupus nephritis. The significance of these findings in relation to the aetiology of active `juvenile cirrhosis is discussed.

Use of Internal Arteriovenous Fistula in Home Haemodialysis

Five patients with previous experience of home haemodialysis (lasting one to two years) had internal arteriovenous fistulae created in a previously non-cannulated limb. After training of the spouses or patients to insert the needles, the arteriovenous cannulas were removed and the patients maintained on fistula dialysis in the home, unattended, overnight, for periods of 1 to 11 months (total patient experience of 30 months). All patients expressed a preference for the arteriovenous fistula, and no significant medical complications have been noted to date. The safe use of a blood pump in the home, overnight, was achieved by the addition of an extra monitor on the outflow (arterial) blood line.

A comparison of the use of Aldactone and Aldactone A in the treatment of hepatic ascites.

In eight patients with cirrhosis and stable ascites controlled on chlorothiazide and spironolactone, a small particle preparation of spironolactone (Aldactone A) was as effective, at one quarter the dosage, as conventional spironolactone (Aldactone). Plasma spironolactone metabolite levels and urinary excretion of spironolactone metabolite were equivalent with both preparations. The variable dosage requirement of spironolactone in patients with cirrhosis and ascites is discussed in relation to these observations.

Use of a Pteridine Diuretic (Triamterene) in Treatment of Hepatic Ascites

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