The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set up in 2004 on acute-on-chronic liver failure (ACLF) was published in 2009. Due to the rapid advancements in the knowledge and available information, a consortium of members from countries across Asia Pacific, "APASL ACLF Research Consortium (AARC)," was formed in 2012. A large cohort of retrospective and prospective data of ACLF patients was collated and followed up in this data base. The current ACLF definition was reassessed based on the new AARC data base. These initiatives were concluded on a 2-day meeting in February 2014 at New Delhi and led to the development of the final AARC consensus. Only those statements which were based on the evidence and were unanimously recommended were accepted. These statements were circulated again to all the experts and subsequently presented at the annual conference of the APASL at Brisbane, on March 14, 2014. The suggestions from the delegates were analyzed by the expert panel, and the modifications in the consensus were made. The final consensus and guidelines document was prepared. After detailed deliberations and data analysis, the original proposed definition was found to withstand the test of time and identify a homogenous group of patients presenting with liver failure. Based on the AARC data, liver failure grading, and its impact on the "Golden therapeutic Window," extra-hepatic organ failure and development of sepsis were analyzed. New management options including the algorithms for the management of coagulation disorders, renal replacement therapy, sepsis, variceal bleed, antivirals, and criteria for liver transplantation for ACLF patients were proposed. The final consensus statements along with the relevant background information are presented here.
The effect of griseofulvin treatment on signal grass (Brachlaria decumbens) toxicity was studied in 27 male Wiltshire Indigenous Malaysian crossbred sheep. Grazing on signal grass generally decreased the activity of the drug metabolizing enzymes in livers and kidneys. Griseofulvin oral administration of 5 mg/kg body weight for 5 consecutive days every other week for 10 w increased the hepatic concentration of cytochrome P-450 and the activity of phase II drug metabolizing enzymes (UDP-glucuronyltransferase and glutathione-S-transferase) while it decreased the hepatic and increased the renal activity of phase I enzymes aminopyrine-N-demethylase and aniline-4-hydroxylase. Griseofulvin did not protect sheep against B decumbens toxicity as 5/7 animals treated with griseofulvin and grazed on B decumbens showed signs of the plant toxicity.
Biological therapies are new additions to breast cancer treatment. Among biological compounds, beta-carotene has been reported to have immune modulatory effects, in particular, enhancement of natural killer cell activity and tumor necrosis factor-alpha production by macrophages. The objective of this study was to investigate the effect of palm carotene supplementation on the tumorigenicity of MCF-7 human breast cancer cells injected into athymic nude mice and to explore the mechanism by which palm carotenes suppress tumorigenesis. Forty-eight 4-wk-old mice were injected with 1 x 10(6) MCF-7 cells into their mammary fat pad. The experimental group was supplemented with palm carotene whereas the control group was not. Significant differences were observed in tumor incidence (P< 0.001) and tumor surface area and metastasis to lung (P< 0.005) between the two groups. Natural killer (NK) cells and B-lymphocytes in the peripheral blood of carotene-supplemented mice were significantly increased (P < 0.05 and P < 0.001, respectively) compared with controls. These results suggest that palm oil carotene is able to modulate the immune system by increasing peripheral blood NK cells and B-lymphocytes and suppress the growth of MCF-7 human breast cancer cells.
The effect of Brachiaria decumbens (signal grass) on drug-metabolizing enzymes was studied in sheep. After 14 d of grazing a pure signal grass pasture, significant declines were observed in hepatic aminopyrine N-demethylase and aniline 4-hydroxylase (phase I biotransformation) and in conjugative enzymes UDP-glucuronyltransferase and glutathione S-transferase. Kidney enzymes were significantly decreased except for UDP-glucuronyltransferase. Enzyme activities were also compared for normal sheep and cattle livers and kidneys. Lower activities were found in cattle, indicating that factors other than biotransformation are responsible for the clincial tolerance of cattle to B. decumbens toxicity.
Trace elements, such as As, Co, Cr, Hg, Sb, and Zn, were determined by neutron activation analysis (NAA), whereas Cd, Cu, and Pb were determined by graphite furnace atomic absorption spectroscopy (GFAAS) in clam, crab, prawn, swamp cerith, and mussel samples after digestion by microwave heating under controlled conditions before eluting the solutions through a column of a chelating resin, Chelex-100. The standard used in the determination of percentage volatile elements retained by microwave digestion and also in the activation process was Lobster Hepatopancreas TORT-1, whereas known mixed standards were prepared from nitrate salts to determine the efficiency of the separation procedure at a controlled pH. Mercury and lead detected in crabs exceeded the maximum permissible level. Some species also showed a high affinity toward certain elements, and their levels of accumulation in the tissues of these species corresponded with the concentration of these elements in sediments, especially at sites in the vicinity of an industrial zone.
A retrospective study was carried out on 42 patients (38 males, 4 females, mean age 25.9) with liver injury at the University Hospital, Kuala Lumpur from 1994 through to 1991. Prognostic factors that might help to identify those patient survival was related to pulse rate on arrival ( < or = 120 beats per minute, p = 0.027), systolic blood pressure at induction of anaesthesia ( > or = to 80 mmHg, p = 0.003) and intraoperative blood transfusion of < or = to 4 units (p = 0.05). This data were supported by the 95% confidence interval suggesting that these factors may be strong prognostic indicators individually. Increased mortality was also associated with increased total blood transfused (p = 0.002) and grade of liver injury (p = 0.02). Although the factors we have identified reflect both the severity of injury and resuscitative and surgical efforts, further studies using a prospective design are required to confirm these findings.
A review of 82 (68 male) Kelantanese patients with non-alcoholic cirrhosis who underwent gastroduodenal endoscopy revealed duodenal and gastric ulcers in 4.9% and 7.3% of patients respectively. Comparing with prevalence rates of peptic ulcer disease reported in the literature, there was no evidence to suggest that duodenal ulcers occur more frequently in patients with non-alcoholic cirrhosis. There is a suggestion, albeit a tenuous one, that non-alcoholic cirrhosis may be associated with gastric ulceration.
This study was undertaken to investigate whether serum CA 125 could complement alpha-fetoprotein (AFP) to improve the diagnosis of hepatocellular carcinoma (HCC). CA 125 showed a sensitivity of 92% for HCC against the 58.8% sensitivity of AFP at the cutoff value of 200 ng/ml. However, the former was less specific (48.5% versus 97.4%) in relation to benign liver diseases (BLD). CA 125 had a higher negative predictive value (NPV) of 84.6% compared to 69.2% for AFP; when both markers were combined, however, the NPV rose to 91.7%. Overall, AFP was more efficient than CA 125 for the diagnosis of HCC. While a positive AFP result was highly indicative of HCC, a negative result did not rule out the disease; however, negative AFP and CA 125 meant that the likelihood of the disease was low. In situations of low HCC prevalence, CA 125 could serve as a first-line screening test followed by confirmation of positives by AFP.
Biopsy and necropsy tissue from 31 unselected patients with systemic amyloidosis, in which there was histologic evidence of liver involvement, were reviewed with reference to the location and pattern of amyloid deposition in the liver. Amyloidosis was classified into AA and AL types on the basis of immunohistochemistry and permanganate reaction of the amyloid deposits. Nineteen were categorized as AA (secondary) and 12 as AL (primary) amyloidosis. Deposition of AA amyloid was limited to the walls of vessels in the portal tract, constituting a "vascular" pattern. In AL amyloidosis, the deposits exhibited a "sinusoidal" pattern in that they were seen along hepatic sinusoids as well as in vessel walls. This difference was statistically significant (P less than .001). The histologic pattern of liver infiltration offers a valuable clue in the classification of systemic amyloidosis and provides information that may be useful in the selection of patients for therapy.
A three and a half year old boy with shigellosis developed fulminant hepatic failure. The hepatic derangements rapidly improved over a period of two weeks after treatment of the shigellosis with parenteral gentamicin. We believe this is the first documented report of fulminant hepatic failure due to shigella sepsis.
There is evidence to show that paraquat poisoning is alarmingly common in Malaysia. This paper reviews 30 cases of paraquat poisoning seen at the General Hospital, Kuala Lumpur from 1978 to 1979 inclusive. Preventive measures and management are discussed. It is felt that tighter legislation to control its use in agriculture should be implemented now.
1. Glutathione transferases from the liver, lung and kidney tissues of the buffalo (Bubalus bubalis) and the Kedah-Kelantan cattle (Bos indicus) were partially purified by ammonium sulphate precipitation and Sephadex G-75 gel filtration. 2. Liver tissue contains the highest enzyme activity when compared to the lung and kidney tissues. 3. The activity in cattle is higher than that in the buffalo. 4. Isoelectric focusing separates the activities into the acidic, near neutral and basic fractions. 5. The focused patterns are different for each of the tissues and in each of the species investigated.
Drug eruptions from indeginous medicine is often difficult to diagnosis and confirm. It is known that a number of these now supplied by bomohs and Chinese sinsehs contain known drugs and are dispensed as tablets and capsules. We report 3 cases of adverse drug eruption to "Jamu", a Malay herb. A particular brand, "Jamu Indonesia, Toko Air Pancur", from Johor Bahru, Malaysia, is especially recommended for "sakit pinggang" or backache. The cases occurred between January and February 1985, and all had taken brown kidney shaped tablets. The adverse reactions were moderately severe. Two had erythroderma with hepatitis, and one, Steven Johnson Syndrome. Analysis of this jamu for analgesics led to the discovery of adulteration with phenylbutazone and diazepam. Records from local cases from 1974-1984 showed that 8 other patients, all Chinese had adverse cutaneous eruptions from phenylbutazone, oxybutazone and propyphenazone. The skin manifestations were erythroderma (2 cases), vasculitis (2 cases) and toxic epidermal necrolysis (4 cases). Those with toxic epidermal necrolysis had 100% mortality.
An abnormal, fast-moving 5'-nucleotide phosphodiesterase isozyme was found in 90.0% of 20 Malaysian patients with primary hepatoma and in 23.5% of 391 Malaysian patients with various malignant diseases; it was also discovered in 42.9% of 14 Malaysian and American patients with clinically active hepatitis B infection; in 16.7% of 18 healthy American blood bank donors who were positive for hepatitis B surface antigen (HBsAg); in 13.9% of 287 healthy Malaysian blood bank donors, some positive for HBsAg; and in none of 160 healthy American donors who were negative for HBsAg. A correlation of this abnormal isozyme with hepatoma and with infectious hepatitis B is clearly evident.
A pilot epidemiologic study of all cases of Reye and Reye-like syndromes was undertaken at 8 representative major hospitals in Peninsular Malaya from January 1st to December 31st 1986. The cases were classified as definitive Reye's syndrome, clinical Reye's syndrome and encephalo-hepatopathies. Less than 50% of cases reviewed fulfilled the National Center for Disease Control criteria for clinical Reye's syndrome. Causes of Reye-like syndromes/encephalo-hepatopathies included fulminant hepatitis, Japanese B encephalitis, dengue, septicaemia, and complex febrile fits. It was not possible to differentiate clinical Reye's syndrome from the other encephalo-hepatopathies by either the clinical features (except for jaundice) or biochemical parameters. Liver biopsy is necessary for a definitive diagnosis of Reye's syndrome in Malaysia, because of the high prevalence of Reye-like diseases. The mortality rate in the 2 groups of patients is similar. Ingestion of salicylates was not found to be significantly associated with Reye and Reye-like syndromes in this study.