Liver Hemorrhage Research Articles

First report of Duck Hepatitis A virus genotype 2 in India.

Sudden death of ducklings was reported in a duck farm located at Tiruvallur district in Tamil Nadu, India. Disease investigation began with post mortem findings of dead birds revealing enlarged pale-pink / pale-yellow liver with multifocal petechiae and ecchymosis. A positive amplification with duck hepatitis A virus specific primers by reverse transcription-polymerase chain reaction (RT-PCR) on the tissue samples collected from dead birds indicated infection by duck hepatitis A virus (DHAV), an avian picornavirus, known to cause acute and high-mortality in ducklings. The virus isolation was successful in 9-days old embryonated chicken eggs, in primary chicken embryo fibroblast (CEF) cells and from experimentally infected ducklings. The embryonic death on day 5 to 7 post inoculation in chicken embryos with signs of cutaneous hemorrhage, edema and greenish yellow liver together with histopathology of embryonic liver and kidney further confirmed DHAV infection. TEM analysis of the infected allantoic fluid and infected CEF cell culture supernatant showed the presence of spherical shaped, non-enveloped virion particles of ~ 20-38nm diameter, typical for DHAV. Experimental infection of ducklings with RT-PCR positive tissue supernatant caused 40% to 50% mortality with typical petechial hemorrhages on the surface of liver. Further, histopathological analysis and RT-PCR of the inoculated duckling's tissues confirmed the presence of DHAV. Nucleotide sequencing of the 5'UTR region and VP1 region confirmed duck hepatitis A virus genotype 2 (DHAV-2). To the best of our knowledge, this is the first report of laboratory confirmation of DHAV-2 in India. This study warrants the need for the extensive epidemiological surveillance to understand the prevalence of DHAV-2 in India and to take appropriate control measures to curtail the disease spread.

Biomimetic, self-coacervating adhesive with tough underwater adhesion for ultrafast hemostasis and infected wound healing.

Massive bleeding and wound infection due to severe traumas pose a huge threat to the life and health of sufferers; therefore, it is of clinical importance to fabricate adhesives with rapid hemostatic and superior antibacterial capabilities. However, the weak wet adhesion and insufficient function of existing bioadhesives limits their practical application. In this study, a sandcastle worm protein inspired polyelectrolyte self-coacervate adhesive of poly-γ-glutamic acid (PGA) and lysozyme (LZM) was developed. The adhesive exhibited strong underwater adhesion to various surfaces (>250 kPa for solid plates and >50 kPa for soft tissues) and maintained a 80 kPa even when soaked in water for 7 days. Rat liver and tail defect bleeding models revealed that the hemostatic efficiency was superior to that of commercial samples. The in vitro antimicrobial tests showed that the bacterial inhibition to Staphylococcus aureus and Escherichia coli reached almost 100%. Additionally, the infected wound regeneration model demonstrated that the healing rate of the adhesive group was about 100% within 15 days, which was greater than that of the control group. In vitro and in vivo experiments proved that this facilely prepared adhesive will be a promising material to fulfil the integration functions for rapid wound closure and facilitating wound healing.

An interesting presentation of leptospirosis

Leptospirosis is a zoonotic infection more common in south India. Most of the cases are asymptomatic but rarely patient can develop complications like renal failure, acute liver failure, pancreatitis, ARDS and bleeding diathesis. Haemorrhage has been reported in multiple sites, of which the most common is pulmonary haemorrhage. Here we report a case of 53-year-old male presenting with acute febrile illness and seizures. CT brain revealed subdural hemorrhage (SDH). He also had thrombocytopenia with elevated liver and renal parameters and elevated Lipase levels. CT abdomen revealed features of acute pancreatitis. Here we encounter a rare case of leptospirosis presenting with subdural haemorrhage and pancreatitis.

Characteristics of injuries in cyclists injured when other vehicles collide with the side of the body of moving bicycles

BACKGROUND: Bicycle injuries, as a separate type of traffic accidents, require forensic medical examinations to establish the mechanism, duration, and severity of injuries. Forensic medical aspects of cycling injuries are insufficiently covered in the literature.
 AIM: To study the nature and features of the injury formation in cyclists who sustained injured when other vehicles hit the side of the moving bicycle.
 MATERIALS AND METHODS: The results of forensic medical examinations of 51 cyclists who died when the moving bicycles collided with the side of vehicles.
 RESULTS: The most frequently observed injuries in cyclists are traumatic brain injury (21.56%) and combined injuries, namely, head and chest (15.68%), lower extremities with trauma to the head, and chest (11.76%). Nearly all deceased cyclists sustained damage to the head (96.0%), which was characterized by the formation of a severe contusion of the brain with fractures of the parietotemporal and occipital bones. Damage to the chest and chest cavity organ was also observed frequently (50.69%). Rib fractures were noted in 74.2% of cases. Injuries to the abdominal organs were detected in 20.15% of the cases, such as liver rupture and hemorrhage in the ligaments of organs. Diaphyseal comminuted fractures of the bones of the lower leg and femur were also observed.
 CONCLUSION: The most common types of injuries in deceased cyclists in a side collision of other vehicles with a moving bicycle are traumatic brain injury and combined injuries of the head, chest, and fractures of the bones of the lower extremities in combination with a head and chest injury. Damage to the head was characterized by the formation of linear, depressed, and comminuted fractures of the parietaltemporal and occipital bones. Damage to the chest was characterized by fractures of the upper ribs and bruises of the lungs. Damage to the skin, resembling a picture of a road rash, was noted on the anterolateral body parts.

A novel monoclonal antibody efficiently blocks the infection of duck adenovirus 3 by targeting Fiber-2

Duck adenovirus 3 (DAdV-3), identified as the causative agent of a disease characterized by swelling and hemorrhage of liver and kidney, has caused substantial economic losses to duck industry in China. However, the neutralizing epitopes and the infection mechanism of DAdV-3 have not been extensively elucidated. In this study, a novel monoclonal antibody (mAb) targeting Fiber-2 protein of DAdV-3 was generated and designated as mAb 3E7. Indirect immunofluorescence assay showed that mAb 3E7 specifically reacted with the Fiber-2 in LMH cells transfected with pcDNA3.1-Fiber-2 or infected with DAdV-3. Moreover, mAb 3E7 could immunoprecipitate the Fiber-2 and efficiently inhibit the infection of DAdV-3 in vitro. Further epitope mapping revealed mAb 3E7 recognized the epitope 108LALGDGLE115 in Fiber-2, which was highly conserved among DAdV-3 strains. These findings not only identified a novel neutralizing epitope in Fiber-2, but also paved the way for further elucidating the vital roles of Fiber-2 in the infection and pathogenesis of DAdV-3.

Preparation of Nile tilapia skin collagen powder by low-temperature and comprehensive evaluation of hemostasis and wound healing.

Nile tilapia (hereinafter referred to as tilapia) is a species with high economic value and extensive cultivation. In this study, the low-temperature Nile tilapia skin collagen powder (TSCP) was prepared by liquid nitrogen freeze pulverization. After physical and chemical analysis of its properties, it was found that its characteristics were similar to those of type I collagen. The three-dimensional helix structure of protein peptide is good and non denatured. It shows that cryogenic temperature guarantees the activity of TSCP. In addition, TSCP has good biocompatibility. Specifically, it has good blood compatibility, lacks cytotoxicity, will not cause intradermal stimulation and acute systemic toxicity, and has no obvious rejection after implantation. In the rat liver hemorrhage model and wound repair model, compared with the commercially available bovine collagen powder (BSCP), TSCP has better blood coagulation ability: the shortest hemostatic time (135 s) and wound healing efficiency: the wound healing is obvious on the 14th day. The results of this study indicate that the TSCP is an ideal candidate for hemostatic agents and wound healing dressings.

Succinic Ester-Based Shape Memory Gelatin Sponge for Noncompressible Hemorrhage without Hindering Tissue Regeneration.

Shape memory sponges are very promising in stopping the bleeding from noncompressible and narrow entrance wounds. However, few shape memory sponges have fast degradable properties in order to not hinder tissue healing. In this work, based on cryopolymerization, a succinic ester-based sponge (Ssponge) is fabricated using gelatin and bi-polyethylene glycol-succinimidyl succinate (Bi-PEG-SS). Compared with the commercially available gelatin sponge (Csponge), Ssponge possesses better water/blood absorption ability and higher mechanical pressure over the surrounding tissues. Moreover, in the models of massive liver hemorrhage after transection and noncompressive liver wounds by penetration, Ssponge exhibits a better hemostasis performance than Csponge. Furthermore, in a liver regeneration model, Ssponge-treated livers shows higher regeneration speed compared with Csponge, including a lower injury score, more cavity-like tissues, less fibrosis and enhanced tissue regeneration. Overall, it is shown that Ssponge, with a fast degradation behavior, is not only highly efficient in stopping bleeding but also not detrimental for tissue healing, possessing promising clinical translational potential.

Allopurinol Induction on Histopathological Structure of the Liver in Male Mice (Mus musculus)

Allopurinol is used to reduce total uric acid levels in the body into oxypurinol which can inhibit xanthine oxidase. Allopurinol inhibits the precursors of uric acid formation, xanthine, and hypoxanthine. However, consumption of the drugs can cause side effects on the liver. The aim of the research was to determine the effect of allopurinol induction on the liver histopathology of male mice (Mus musculus) DDY strain. The method used in this research was an experimental design used post-test only that was divided into 4 groups of 4 mice per group. The control group (P0) was given 0.5% Na-CMC, and groups I, II, and III (P1, P2, and P3) were induced by allopurinol at 10 mg/kg BW, 20 mg/kg BW, and 30 mg/kg BW for 14 days. Allopurinol induction was performed by oral gavage. The results of the research showed that treatment with allopurinol caused changes in the mice’s body weight, liver index, liver morphology, and histological structure of the liver tissue, including necrosis, steatosis, leukocyte infiltration, binuclear hepatocytes, hepatocyte swelling, congestion, sinusoid dilatation, and hemorrhage. The level of liver damage increased in line with the dose used. This research indicated that the higher the allopurinol level, the higher the level of alteration in the liver section structure. Long-term use of allopurinol can cause damage to the structure of mice liver (liver toxicity).

Decellularized liver extracellular matrix and thrombin loaded biodegradable TOCN/Chitosan nanocomposite for hemostasis and wound healing in rat liver hemorrhage model

During deep noncompressible wound management, surgery, transplantation or post-surgical hemorrhage, rapid blood absorption and hemostasis are the key factors to be taken into consideration to reduce unexpected deaths from severe trauma. In this study, a novel hemostatic biodegradable nanocomposite was fabricated where decellularized liver extracellular matrix (L-ECM) was loaded with two natural polymers (oxidized cellulose and chitosan) in association with thrombin. Plant-derived oxidized cellulose nanofiber (TOCN) and Chitosan (CS) from deacylated chitin were self-assembled with each other by electrostatic interactions. ECM was prepared by the whole tissue decellularization process and incorporated into the composite as a source of collagen and other integrated growth factors to promote wound healing. Thrombin was also anchored with the polymers by freeze drying for enhanced hemostatic efficiency of the composite. This study is the first of its kind to report non-solubilized L-ECM and thrombin loaded TOCN and CS composite, CN/CS/EM-Th for faster hemostasis effect in a rat tail amputation (~71 s) and liver avulsion model (~41 s). Furthermore, excellent liver wound regeneration efficacy was observed in-vivo in comparison to the commercially available oxidized regenerated cellulose product SURGICEL gauge.

Immediately activating hemostatic cellulose sealants for uncontrolled hemorrhage

The control of bleeding is one of the most important processes in surgical treatments and wound healing, and the development of effective hemostatic agents is urgently required. An ideal hemostatic agent should be immediately activated when exposed to bleeding to reduce blood loss as soon as possible and should be user-friendly for urgent situations. To meet these demands, we functionalized carboxymethyl cellulose (CMC) with two different phenolic moieties, catechol (CA) and pyrogallol (PG), and then formulated each CMC derivative into adhesive hydrogels with high hemostatic ability. These hemostatic platforms exhibited sturdy modulus (CMC-CA: 0.55 ± 0.08 kPa, CMC-PG: 1.37 ± 0.24 kPa), wet-tissue adhesiveness (CMC-CA: 2.19 ± 0.53 kPa, CMC-PG: 3.13 ± 0.25 kPa), and rapid crosslinking within seconds for wound closure. We transformed the CMC hydrogels into a patch design, resulting in 16∼19-fold increase in elastic modulus and 3∼4-fold increase in adhesiveness, which can completely seal the wound for more efficient hemostatic action. The adhesive CMC patches exhibited superior hemostatic capability to fibrin glue as a wound sealant by rapidly stopping bleeding in mouse liver hemorrhage. This study demonstrated that bio-inspired polyphenolic CMC hydrogels produce a highly effective, instantly working hemostatic agent.

Pathological changes in an Alsatian dog following Amitraz and Sniper (dichlorvos) exposure

Amitraz and Sniper (dichlorvos) are known ectoparasiticides of dogs in Nigeria. Although reports of their toxicosis exist, information on the pathological presentations of their combined toxicosis is scanty hence the present case report. Two dogs both had Amitraz bath with simultaneous fumigation of their immediate environment with Sniper (diclorvos). Excessive salivation, staggering gait, and respiratory distress were observed shortly thereafter with the prompt administration of atropine sulphate which ameliorated it, but a particular dog progressively became weak, inactive and off feed. A vomitus, dark watery stool and blood spots were observed within its kennel before death. The post-mortem examination revealed emaciated, dehydrated and tick infested carcass with pale ocular and oral mucous membranes. There was also ileocolic intestinal intussusception characterized by anal intussusceptum protrusion, congested liver and pulmonary peribronchial haemorrhage with inter-alveoli cellular infiltration including haemorrhagic enteritis. Death might have been due to hypovolemic shock following the observed dehydration, pallor, haematochezia, peritoneal fluid exudation, hepatic congestion, pneumonia characterized by peribronchial haemorrhages, and haemorrhagic enteritis. The observed intussusception was a rare occurrence in a dog following Amitraz and Sniper poisoning in Abuja, Nigeria, which highlighted the need for their cautious and professional use.

Molecular characterization of recombinant premembrane protein of dengue virus serotype-2 for development of diagnostic assay.

Dengue is an acute arboviral infection common in tropical and subtropical countries. Dengue has been highlighted as a public health concern in the last five decades, affecting almost 50% of the population in developing nations. Dengue infection results in a complex symptomatic disease that ranges from headache, fever, and skin rash to extreme hemorrhage fever and liver dysfunction. The diagnosis of the disease is essential for effective treatment. The early onset of the infection can be detected through viral structural peptides that act as markers for detection, including Pre-Membrane (Pre-M) protein. In the currently proposed research, the structural gene obtained from local isolates was targeted for studies. For this purpose, recombinant structural protein Pre-M was amplified, cloned, and expressed in the bacterial expression system. The expression of the structural protein (Pre-M) was scrutinized by Sodium Dodecyl Sulphate-Polyacrylamide Gel Electrophoresis (SDS-PAGE) and validated by western blot and dot blot, and afterwards, the antigen was purified. The purified Pre-M protein carries the potential for the development of in-house diagnostic assay as well as for vaccine production. This study aimed to develop a highly specific, sensitive, and cost-effective in-house enzyme-linked immunoassay (ELISA) for the detection of antibodies of Pakistani most prevalent dengue virus serotype 2 (DENV-2). The success of this research would also pave the way toward developing novel vaccines for the future prevention of dengue infection.

Novel monoclonal antibodies against Fiber-1 of duck adenovirus 3 and their B cell epitopes.

Recently, the outbreak of the infection of Duck adenovirus 3 (DAdV-3) characterized by swelling and hemorrhagic liver and kidney has caused huge economic losses to duck industry since 2014 in China. To date, the B cell epitopes in the Fiber-1 protein and the underlying infection mechanism of DAdV-3 have not been investigated. In this study, the recombinant Fiber-1 protein was first expressed in E. coli and six novel monoclonal antibodies (mAbs) against Fiber-1 were generated, designated as 1D8, 1E6, 3G6, 4G1, 4G2, and 6F10, respectively. Moreover, mAbs 3G6 and 6F10 could efficiently immunoprecipitate the Fiber-1 in LMH cells infected with DAdV-3 or transfected with pcDNA3.1-Fiber-1. Notably, mAbs 3G6 and 4G2 also showed certain neutralizing activity against DAdV-3 infection in vitro. Epitopes mapping revealed that the B cell epitope recognized by 6F10, 3G6, 4G1, 1D8, 4G2, and 1E6 was located in 34-66aa, 67-99aa, 64-296aa, 297-329aa, 330-362aa, and 363-395aa, respectively. Sequence alignments further found that the six epitopes recognized by these mAbs were highly conserved among different DAdV-3 isolates. The generated mAbs specific to Fiber-1 and their defined epitopes provide powerful tools for establishing rapid and efficient diagnostics for the detection of DAdV-3 and pave the way for further studying on the critical role of Fiber-1 in mediating the infection of DAdV-3.

S2800 Endoscopic Ultrasound Guided Drainage of a Massive Right Sided Hemorrhagic Liver Cyst: The Rapidly Evolving Field of Endo-Hepatology

Introduction: Hepatic cysts are the most common benign lesions in the liver. Overall incidence among the population is about 5%, being more common in women. Therapeutic interventions are reserved for acutely symptomatic patients with life threatening complications. Herein, we highlight a unique case of a patient with a massive right hepatic cyst, drained under the guidance of an endoscopic ultrasound (EUS), along with a literature review of its applications in Endo-Hepatology. Case Description/Methods: A 76-year-old male with a history of benign liver cyst, presented with severe right upper quadrant abdominal pain associated with nausea and vomiting. On physical examination, he had a markedly distended, diffusely tender abdomen, with palpable hepatomegaly. Initial blood work revealed a Hb of 6.7 g/dL (known baseline Hb was 9 g/dL). Compared to previous imaging from 2014 (Figure A), CT abdomen revealed significant enlargement of a known right hepatic cyst (largest dimension: 24.2 X 16 X 25.6 cm) (Figure B). Volume resuscitation with blood transfusions was done. An EUS guided drainage of the cyst using a Lumen-Apposing Metal Stent (LAMS) was performed. After locating an appropriate avascular window, the cyst was successfully traversed, sterile contrast was used to delineate the lesion, followed by deployment of the LAMS. A total of 2.8 liters of dark, reddish-brown fluid was drained, with an additional 1.1 liter suctioned out through a nasogastric (NG) tube over the next 24 hours. Following the procedure, the patient remained hemodynamically stable with significant improvement symptomatically. Discussion: Diagnostic imaging is essential in delineating the characteristics of liver cysts to determine the appropriate intervention. Decision regarding the choice of intervention should be individualized for each patient. Therapeutic interventions for liver cysts are predominantly performed through a percutaneous (PC) route, with EUS being deemed as a safe alternative when PC intervention is not favorable. The efficacy and recurrence rates of liver cysts after drainage with EUS versus PC drainage with sclerotherapy have been compared previously, with EUS guided drainage being recognized traditionally as a safe approach in drainage of left/caudate lobe hepatic cysts, and PC drainage being preferred for right lobe/hepatic dome cysts. EUS also aids in detection of smaller, focal liver lesions not apparent on gross imaging, elastography, biopsies, portosystemic pressure gradient monitoring and thermal ablative therapy.Figure 1.: Figure A : 2014, demonstrates the right hepatic cyst. Figure B : 2022, demonstrates the significantly enlarged right hepatic cyst (largest dimension : 24.2 X 16 X 25.6 cm).

MKK4 Knockdown Plays a Protective Role in Hemorrhagic Shock-Induced Liver Injury through the JNK Pathway.

Hemorrhagic shock (HS) triggers tissue hypoxia and organ failure during severe blood loss, and the liver is sensitive to HS. Mitogen-activated protein kinase kinase 4 (MKK4) activates the c-Jun NH2-terminal kinase (JNK) pathway, and its expression is upregulated in the serum of HS patients and mouse livers at 1 h post-HS. However, the function of MKK4 in HS-induced liver injury is unclear. The role of MKK4 was investigated in vivo using rat models of HS. Before HS, lentivirus harboring shRNA against MKK4 was injected into rats via the tail vein to knock down MKK4 expression. HS was induced by bloodletting via intubation of the femoral artery followed by resuscitation. The results showed that MKK4 knockdown reduced HS-induced apoptosis in the liver by decreasing Bax expression and the cleavage of caspase 3 and promoting Bcl-2 expression. Moreover, the generation of intracellular reactive oxygen species (ROS) and malondialdehyde (MDA) in the liver was promoted, while superoxide dismutase (SOD) activity was inhibited by HS. However, the effect of HS on oxidative stress was abrogated by MKK4 knockdown. Furthermore, MKK4 knockdown restored MMP and complex I and complex III activities and promoted ATP production, suggesting that HS-induced mitochondrial dysfunction in the liver was ameliorated by MKK4 knockdown. The inhibitory effect of MKK4 knockdown on the phosphorylation and activation of the JNK/c-Jun pathway was confirmed. Overall, MKK4 knockdown may suppress oxidative stress and subsequent apoptosis and improve mitochondrial function in the liver upon HS by inhibiting the JNK pathway. The MKK4/JNK axis was shown to be a therapeutic target for HS-induced liver injury in this study.

Microwave assisted preparation of a hemostatic gauze with mesoporous silica through in-situ synthesis.

The medical disinfection cotton gauze is the most frequently used medical consumables for wound care. Here this ordinary commercial gauze was upgraded to a hemostatic gauze, which was loaded with mesoporous silica through in-situ synthesis and further microwave treatment. The original cotton gauze was pretreated with NaOH solutions for surface activation, soaked in double-silica source precursor solution for moderate in-situ synthesis, treated with microwave for quick template removement and dehydration. The final obtained hemostatic gauze (MS-G1) showed superior physical, biocompatible and hemostatic advantages. The newborn mesoporous silica was firmly anchored onto the cotton fiber surface with <20% leaching after 10 min of sonication. The microwave treatment not only shortened the time for template removal but also promotes the formation of mesoporous structure. The clotting blood time (CBT) of MS-G1 were only (62.00 ± 5.56s), which was 23.14% shorter than that of original medical gauze, and even 3.6% shorter than Combat Gauze (CG). MS-G1 also showed excellent biocompatibility in cytotoxicity tests of L-929 cells, with a 116% proliferation rate at the concentration of 5mg/mL. Furthermore, the hemostatic performance was explored on a rabbit wound model of hemorrhagic liver injury, and MS-G1 showed both shorter hemostasis time (113.75s) and less blood loss (1.69g) than that of CG (180.00 s, 5.13g). The hemostatic gauze anchored with mesoporous silica was expected to be an excellent prehospital hemostatic dressing for field first aid.

Amino Acid Surfactant‐Induced Superfast Gelation of Silk Fibroin for Treating Noncompressible Hemorrhage

AbstractThe gelation of silk fibroin (SF) aqueous solution cross‐linked by externally induced β‐sheets generally takes longer times, and requires relatively strict conditions, limiting their biomedical application possibilities. Here, a simplified and straightforward strategy is proposed to induce superfast gelation of SF by a biocompatible Food and Drug Administration‐approved amino acid surfactant, ethyl lauroyl arginine hydrochloride (LAE). The gelation time is as short as 15 s at 60 °C and falls within 1 min around body temperature. The distinct pathway and thermodynamics of superfast gelation of SF is deciphered, and three important factors including superfast and complete unfolding, heterogeneous nucleation seeds, and faster formation of more β‐sheets that are crucial for superfast SF assembly are revealed. The LAE‐induced in situ superfast gelation mechanism is first harnessed to fabricate an injectable antibacterial biodegradable hemostatic hydrogel for treatment of noncompressible liver bleeding. The amphiphilicity of LAE and superfast gelation is exploited to quickly entrap different sizes of air bubbles in the upper and lower part of the hydrogel, which is then lyophilized to form an asymmetric hierarchical porous SF‐LAE sponge, where the large pores serve to drain blood, and dense pores prevent the outflow of blood to seal the wound.

Incidence and risk factors for anastomotic bile leakage in hepatic resection with bilioenteric reconstruction – A international multicenter study

BackgroundAnastomotic leak (AL) after bilioenteric reconstruction (BR) is a feared complication after bile duct resection, especially in combination with liver resection. Literature on surgical outcome is sparse. This study aimed to determine the incidence and risk factors for AL after combined liver and bile duct resection with a focus on operative or endoscopic reinterventions. MethodsData from consecutive patients who underwent liver resection and BR between 2004 and 2018 in 11 academic institutions in Europe were collected from prospectively maintained databases. ResultsWithin 921 patients, AL rate was 5.4% with a 30d mortality of 9.6%. Pringle maneuver (p<0.001),postoperative external biliary (p=0.007) and abdominal drainage (p<0.001) were risk factors for clinically relevant AL. Preoperative biliary drainage (p<0.001) was not associated with a higher rate of AL. AL was more frequent in stented patients (76.5%) compared to PTCD (17.6%) or PTCD+stent (5.9%,p=0.017). AL correlated with increased incidence of postoperative liver failure (p=0.036), cholangitis, hemorrhage and sepsis (all p<0.001). ConclusionThis multicenter data provides the largest series to date of LR with BR and could help in the management of these patients which are often challenging and hampering the patients’ postoperative course negatively.

Effectiveness and Safety of the Traditional Chinese Medicine Treatment (HuoxueHuayu Therapy) for Malignant Tumors: A Systematic Review and Meta-Analysis

Background. A malignant tumor is one of the refractory diseases that threaten human life and health. HuoxueHuayu therapy (one of the Traditional Chinese Medicine therapies to promote blood circulation and remove blood stasis) is widely used as an antitumor supplementary method. However, its efficacy and safety are still controversial. Therefore, the objective of this study was to provide evidence-based evidence for HuoxueHuayu therapy in the treatment of malignant tumors and confirm its safety and effectiveness. Methods. A systematic search in 8 electronic databases targeted randomized clinical studies evaluating HuoxueHuayu therapy for response evaluation, tumor progression rate, quality of life (QoL), peripheral hemogram, performance status, immunologic function, tumor marker, and blood coagulation function in cancer patients, published from the establishment of the database to December 31, 2020. Risk ratio (RR) was used for counting data, mean difference (MD) or standardized mean difference (SMD) was used for measurement data, and 95% confidence interval (CI) was used as efficacy analysis statistics. Results. Our search identified 69 studies, evaluating 4402 patients in total. Randomized controlled trials (RCTs) evaluated gastric (n = 14), lung (n = 18), pancreatic (n = 2), colorectal (n = 10), liver (n = 14), breast (n = 2), ovarian (n = 2), gallbladder (n = 1), esophagus (n = 1), and combined (n = 14) cancers and hematological malignancies (n = 2). The duration of HuoxueHuayu therapy ranged from 3 to 48 weeks. Methodological bias was low in 64 studies and high in 5 studies. HuoxueHuayu therapy was associated with significant improvement in response evaluation (Response Evaluation Criteria in Solid Tumor (RECIST): RR: 1.44, 95% CI: 1.27 to 1.63, I2 = 0%, n = 33 studies; World Health Organization Criteria in Solid Tumors (WHOCIST): RR: 1.40, 95% CI: 1.23 to 1.59, I2 = 0%, n = 26 studies), recurrence rate (RR: 0.85, 95% CI: 0.72 to 0.99, I2 = 0%, n = 2 studies), quality of life, performance status (MD: 5.60, 95% CI: 5.04 to 6.15, p &lt; 0.001 ), immunologic function (CD3: SMD: 1.23, 95% CI: 0.79 to 1.66, p &lt; 0.001 ; CD4: SMD: 1.25, 95% CI: 0.77 to 1.74, p &lt; 0.001 ; CD4/CD8: SMD: 1.05, 95% CI: 0.69 to 1.42, p &lt; 0.001 ; natural killer cell (NK): SMD: 0.74, 95% CI: 0.32 to 1.15, p &lt; 0.001 ), tumor marker, and blood coagulation function (D-dimer (D-D); fibrinogen (FIB)). In addition, HuoxueHuayu therapy could reduce toxicity caused by chemotherapy and radiotherapy without risks of liver and kidney injury or bleeding, although the effect on tumor metastasis was uncertain. Conclusions. The present update of our systematic review and meta-analyses provided essential evidence for the beneficial effect of HuoxueHuayu therapy to show promise in cancer treatment, improving quality of life, addressing cancer-related symptoms, and reducing toxicity in a secure way.

Liver Cirrhosis Due to Fetal CMV Infection: A Case Report

Introduction: CMV is the most common cause of congenital viral infection. We observed a cirrhotic liver and intracerebral hemorrhage due to fetal CMV infection. Case presentation: Fetal CMV infection was diagnosed at 20 weeks of gestation, leading to termination of pregnancy. At fetopsy, the liver was macronodularly cirrhotic with necrosis and CMV inclusions. Intracerebral hemorrhage, seen on the prenatal ultrasound, was confirmed. Discussion/Conclusion: Congenital CMV infection can cause cirrhosis and intracerebral hemorrhage as early as 20 weeks gestation.