ObjectiveTo quantify the sequential changes in the metabolic response occurring in patients with end-stage liver disease after orthotopic liver transplantation (OLT). Summary Background DataDetailed quantification of the changes in energy expenditure, body composition, and physiologic function that occur in patients after OLT has not been performed. Understanding these changes is essential for the optimal management of these patients. MethodsFourteen patients who underwent OLT for end-stage liver disease had measurements of resting energy expenditure, body composition, and physiologic function immediately before surgery and 5, 10,15,30, 90, 180, and 360 days later. ResultsResting energy expenditure was significantly elevated after surgery (24% above predicted), peaking around day 10 after OLT, when it averaged 42% above predicted. A significant degree of hypermetabolism was still present at 6 months, but at 12 months measured resting energy expenditure was close to predicted values. Before surgery, measured total body protein was 82% of estimated preillness total body protein. During the first 10 days after OLT, a further 1.0 kg (10%) of total body protein was lost, mostly from skeletal muscle. Only 54% of this loss was restored by 12 months. Significant overhydration of the fat-free body was seen before OLT, and it was still present 12 months later. Although significant losses of body fat and bone mineral occurred during the early postoperative period, only body fat stores were restored at 12 months. Both subjective fatigue score and voluntary hand grip strength improved rapidly after OLT to exceed preoperative levels at 3 months. At 12 months grip strength was close to values predicted for these patients when well. Respiratory muscle strength improved less markedly and was significantly lower than predicted normal levels at 12 months. ConclusionsBefore surgery, these patients were significantly protein-depleted, overhydrated, and hypermetabolic. After surgery, the period of hypermetabolism was prolonged, restoration of body protein stores was gradual and incomplete, and respiratory muscle strength failed to reach expected normal values. Our measurements indicate that OLT does not normalize body composition and function and imply that a continuing metabolic stress persists for at least 12 months after surgery.Orthotopic liver transplantation (OLT) is the accepted treatment for patients with end-stage liver disease. The surgical death rate for this procedure has decreased progressively during the past decade as a result of improvements in surgical technique, anesthesia, and postoperative care. Overall 1-year graft and patient survival rates of 80% to 90% can now be expected. For elective patients with nonrecurrent disease, the 1-year survival rate exceeds 90%.

Objectives:Little is known about the impact of HIV infection on biological ageing in sub-Saharan Africa. The study aimed to assess biological ageing in South African HIV-infected adults and HIV-seronegative individuals using two validated biomarkers, telomere length and CDKN2A expression (a mediator of cellular senescence).Design:A case–control study.Methods:Two hundred and thirty-six HIV-infected adults aged at least 30 years and 250 age and sex frequency matched HIV-seronegative individuals were recruited from clinics in township communities in Cape Town. Biological ageing was evaluated by measurement of telomere length and CDKN2A expression in peripheral blood leukocytes.Results:The median ages of the HIV-infected and HIV-seronegative participants were 39 and 40 years, respectively. Among HIV-infected participants, 87.1% were receiving antiretroviral therapy (ART), their median CD4+ cell count was 468 cells/μl and 84.3% had undetectable viral load. Both biomarkers were validated against chronological age in HIV-seronegative individuals. Telomere length was significantly shorter in HIV-infected individuals than in HIV-seronegative individuals (mean relative T/S ratio ±SE:0.91 ± 0.007 vs. 1.07 ± 0.008, P < 0.0001). CD2NKA expression was higher in HIV-infected participants than in HIV-seronegative individuals (mean expression: 0.45 ± 0.02 vs. 0.36 ± 0.03, P = 0.003). Socioeconomic factors were not associated with biological ageing in HIV-infected participants. However, in participants on ART with undetectable viral load, biomarker levels indicated greater biological ageing in those with lower current CD4+ cell counts.Conclusion:Telomere length and CDKN2A expression were both consistent with increased biological ageing in HIV-infected individuals. Prospective studies of the impact of HIV on biological ageing in sub-Saharan Africa are warranted.

We have studied 22 patients to examine whether or not cricoid pressure affects ventilation of the lungs via the laryngeal mask and its correct positioning. In a randomized, crossover design, the laryngeal mask was inserted with or without cricoid pressure applied with a standardized force of 30 N using a cricoid yoke. A standardized pillow (6 cm in height) was placed under the patient's occiput, but the neck was not supported. Ventilation of the lungs via the laryngeal mask was adequate in all patients when no cricoid pressure was applied, but in only three of 22 patients when cricoid pressure was applied (P << 0.001; 95% confidence interval (CI) 0.72-1.0). The mask was positioned correctly in 18 patients when no pressure was applied, and in none after application of cricoid pressure (P << 0.001; 95% CI 0.66-0.98). We had planned to study, in an additional 20 patients, the effect of cricoid pressure without a pillow under the occiput; placement of the mask, however, was difficult even when cricoid pressure was not applied and there was a high incidence of bleeding from the oropharynx. We thus abandoned that part of the study after eight patients. In those eight patients, the success rate of ventilation via the laryngeal mask was lower when cricoid pressure was applied. We conclude that when sufficient force was applied, cricoid pressure, regardless of the method of application, did impede placement of the laryngeal mask.

This study demonstrates a significant change in management towards ERAS principles in emergency patients following the introduction of such a programme in elective patients. The lack of increased complications in the second period suggests the use of ERAS principles is not harmful. The wider application of ERAS principles could improve outcomes in emergency surgery and deserves further study.