Effectiveness of Power Exercises Compared to Traditional Strength Exercises on Motor Skills, Muscle Performance and Functional Muscle Strength of Children with Attention Deficit Hyperactivity Disorder: A Single-Blind Randomized Controlled Trial

The aim of this study was to compare the impact of 8-weeks of power exercises compared to traditional strength exercises on motor abilities, muscle performance, and functional strength in children with ADHD. A total of 34 children with ADHD were randomized into two groups to receive functional power training (n = 17, M age: 121.2 ± 16.6 months) and traditional strength training (n = 17, M age: 116.1 ± 13.4 months). After the 8-week intervention, two-way ANOVA results with 95% confidence intervals showed no differences between the groups in motor skills, muscle power, or functional muscle strength. However, the functional power training group had larger effect sizes and greater increases in total motor composite score (10% vs 7%), body coordination (13.8% vs 4.9%) and bilateral coordination (38.8% vs 27.9%) than the traditional strength training group. The power training group also exhibited catch-up growth with typically developing peers. These findings suggest that power exercises may be more effective than strength exercises for rapid force generation in daily life, particularly for children with ADHD.

Evaluation of the effects of Ankaferd hemostat application on bone regeneration in rats with calvarial defects: histochemical, immunohistochemical and scintigraphic study

BACKGROUND

Bone wax, a hemostatic agent, is widely used in craniospinal surgical procedures for a long time, inspite of controversial results regarding its negative influence upon bone regeneration. In this experimental study, the effects of Ankaferd Blood Stopper (ABS), as an alternative hemostatic agent, were evaluated through histochemical, immunohistochemical and scintigraphic studies.

MATERIALS AND METHODS

The total of 30 adult female Wistar-Albino rats was randomly divided into three groups: intact control group (n=10), bone wax group (n=10), and ABS group (n=10). Surgically, a 3.0 mm hole in diameter was drilled on the right side of calvarium of the rats using a Class Mini Grinder set in all three groups, as described previously. At the end of 8 weeks, bone healing and connective tissue alterations surrounding drilled calvarial defect areas of the rats were determined via Hematoxylin and Eosin (H&E) and the Mallory's trichrome staining and anti-bone sialoprotein (BSP) immunohistochemistry. Image Pro Express 4.5 program was used for histomorphometric calculation of new bone and fibrotic tissue areas. All statistical analyzes were made with SPSS 25.0 and analysis of variance (one-way ANOVA) followed by Bonferroni post hoc test was performed, p<0.001 was considered as significance level.

RESULTS

Histomorphometrically, it was found that he had the largest hole diameter and the least fibrotic scar area in the bone-wax group. In the bone wax group, it was observed that the material closed the hole and there was only a fibrotic scar tissue in the area between the bone tissue at the edge of the hole and bone wax, and a fibrotic tissue was formed in the bone wax area. During the histological procedure, this bone-wax material was poured and the sections were seen as a gap in this area. In the ABS hemostat group, the smallest hole diameter and the least fibrotic scar tissue were observed. Fibrotic scar tissue close to each other was found in the ABS hemostat and bone wax groups. Histological analysis of samples also showed a statistical significance for fibrotic connective tissue area between groups (p <0.05). Scintigraphically, osteoblastic activity related to blood flow in the animal taken from the group with application of ABS hemostat was more pronounced compared to the other two groups.

CONCLUSIONS

In our study, it has been concluded that the ABS yields affirmative effects on the bone healing, while bone wax leads to negative impact on the bone regeneration. Scintigraphic, histochemical and immunohistochemical data support the affirmative impact of the ABS hemostat application upon the bone regeneration apart from the quick stop of hemorrhage.

Laboratory in complicated appendicitis prediction and predictive value of monitoring

OBJECTIVES

The purpose of the study was that monitoring, which is used in diagnosis of acute appendicitis, and laboratory values, were evaluated for verifying diagnosis of complicated appendicitis and these parameters revealed cut-off values in complicated acute/non-complicated appendicitis.

METHODS

195 patients, who had had an operation for acute appendicitis between January 2012 and March 2015 and who were proved to have acute complicated/non-complicated appendicitis from the results of histopathology consideration, were included in this study. Patients' age, preoperative serum, WBC, CRP, NLR and BT with USG results were evaluated.    RESULTS: Among the groups, there were no meaningful differences in the sense of age. Meaningful difference was obtained in between (p > 0.05), WBC, NLR, CRP and appendix diameter values.Serum in WBC >13800 (AUC = 0.614, p = 0.006, %95 GA: 0.541-0.682), in NLR > 4.87 (AUC = 0.641, p = 0.001, %95 GA: 0.569-0.708), in CRP > 5.98 (AUC = 0.651, p 11 mm (AUC = 0.630, p = 0.002, %95 GA: 0.558-0.698) values were obtained. The values that were obtained, were confirmed to be descriptive in analysis of complicated appendicitis and non-complicated appendicitis.According to the obtained cut-off values, serum WBC, diameter of appendicitis, NLR and CRP values', (OR) ratios were calculated for complicated appendicitis by being classified (odds ratio respectively; 3.103 (1.713-5.621), 2.765 (1.496-5.109), 3.025 (1.665-5.494), 2.313 (1.295-4.130)).

CONCLUSION

It is important that treatment options are evaluated to be able to discriminate complicated appendicitis fast and with a high accuracy. In the case that serum WBC is higher than 13800. CRP is higher than 5.98, NLR is higher than 4.87 and appendicitis diameter is longer than 11mm, inflammation of appendicitis is complex with gangrene, perforation and abscess and it emphasizes the suggestion of surgical treatment option to patients (Tab. 4, Fig. 1, Ref. 28).

Anesthesia-related complications in living liver donors: the experience from one center and the reporting of one death

Living donor liver transplantation has become an alternative therapy for patients with end-stage liver disease. Donors are healthy individuals and donor safety is the primary concern. The objective of this study was to evaluate the anesthetic complications and outcomes for our donor cases; we report one death. The charts of the patients who underwent donor hepatectomy from February 1997 to June 2007 were retrospectively reviewed. Right hepatectomy (resection of segments 5-8) was done in 101 donors, left lobectomy (resection of segments 2-3) in 11 donors, and left hepatectomy (resection of segments 2-4) in one donor. Minor anesthetic complications were shoulder pain, pruritus and urinary retention related to epidural morphine, and major morbidity included central venous catheter-induced thrombosis of the brachial and subclavian vein, neuropraxia, foot drop and prolonged postdural puncture headache. One of 113 donors died from pulmonary embolism on the 11th postoperative day. This procedure has some major risks related to anesthesia and surgery. Although careful attention will lower complication rate, we have to keep in mind that the risks of donor surgery will not be completely eliminated.

Efficacy of right anterior sector drainage reconstruction in right-lobe live-donor transplantation

BACKGROUND

Without including the middle hepatic vein (MHV) into right-lobe grafts, venous drainage of the anterior segment (AS) has always been a concern. The efficacy and the necessity of additional venous reconstruction in the AS for graft viability and function are still controversial.

METHODS

Since February 2002, 57 right-lobe grafts were implanted into adult recipients. The mean graft to ideal recipient weight ratio (GRWR) was 1.3% (minimum: 0.8%, maximum 2.1%). All minor venous tributaries to the MHV less than 5 mm in diameter were ligated. The management of MHV tributaries was categorized into three groups: (A) no major tributaries (n = 33); (B) major tributaries ligated (n = 11); and (C) major tributaries reconstructed (n = 13). Reconstructions were established using vascular grafts (PTF, n = 8; cadaveric, n = 2) or joining with right hepatic vein orifice (n = 6). The groups were homogenous in age, gender, MELD (17 +/- 6, 16 +/- 4, 18 +/- 7), graft weight (817 +/- 181, 838 +/- 152, and 855 +/- 159 g), and graft/ideal liver weight ratio (0.54 +/- 0.12, 0.57 +/- 0.13, and 0.57 +/- 0.1, respectively). We investigated the volume of ascites, serum bilirubin, albumin, and liver enzyme levels and INR on postoperative day 4 (POD4) and POD21.

RESULTS

Two patients died of MRSA sepsis on POD18 and POD23 (MELD: 24 and 28) after initial graft function. Their graft weights were 800 g and 980 g, and their volumes were 47% (group B) and 62% (group A) of the ideal liver mass of the recipients, respectively. One PTF and another cadaveric vascular graft were found occluded 4 and 7 days after implantation without any negative consequence. At 6-month follow-up, the remaining 55 patients were alive with primary liver grafts. Vascular reconstructions were patent except for 2 early occlusions. Among the 3 groups, no significant difference was found on POD4. Three weeks after transplantation, the mean AST level in the major ligation group (46.7 +/- 8.14) was significantly higher than in the minor ligatation group (29.6 +/- 8.6) but not in the major reconstruction group (33.7 +/- 3.7; P = .03 and P = .29). The mean albumin level was highest after minor ligation (3.2 +/- 0.18), which was significantly better than the major reconstruction (2.7 +/- 0.1) but not the major ligation (3.1 +/- 0.14) cohorts (P = .02 and P = .13).

CONCLUSIONS

In this study of a limited number of cases, right-lobe liver grafts with GRWR of > or =1.1% displayed optimal graft function without additional venous reconstruction to the AS.

Prophylactic use of low-dose, on-demand, intramuscular hepatitis B immunoglobulin and lamivudine after liver transplantation

The combination of hepatitis B immunoglobulin (HBIG) and antivirals (nucleos[t]ide analogs) has extended the applicability of orthotopic liver transplantation (OLT) for patients with hepatitis B virus (HBV)-related liver disease. However, HBIG administrations have an extremely high cost. Herein, we evaluated our results with low-dose, on-demand, intramuscular HBIG plus lamivudine (LAM) prophylaxis after OLT. The HBV DNA status in 40 patients at the time of OLT determined the treatment: group A (n = 22), HBV DNA (-), no antiviral pretreatment; group B (n = 11), HBV DNA (-), after LAM; group C (n = 3), HBV DNA (+) after LAM (LAM resistance/Adefovir [ADV] unavailable); group D (n = 2), HBV DNA (+), no antiviral pretreatment; and group E (n = 2), HBV DNA (-) after LAM + ADV (LAM resistance/ADV available). Five patients died within 12 months after OLT unrelated to HBV infection. The remaining 35 patients were followed for a median duration of 16 months (range, 6-93 months). Only two recipients from group C, who were transplanted despite LAM resistance + no ADV pretreatment, revealed recurrent HBV infections at 14 and 16 months posttransplantation; they were then treated successfully with ADV as it became available. The third group C recipient had undetectable HBV DNA at 18 months after OLT. The mean cumulative doses of HBIG administered within the first, second, and third years were 34,014, 5258, and 5090 IU, respectively. In conclusion, low-dose, on-demand, intramuscular HBIG plus (LAM +/- ADV) prophylaxis is a safe, efficient, and cost-effective regimen to prevent recurrent HBV infection following OLT. OLT despite untreated LAM resistance may require sustained higher serum HBsAb levels after surgery.

First graduates' perceptions on a problem-based and task-based learning curriculum

INTRODUCTION

Determination of graduates' perceptions and suggestions is essential in the evaluation of educational programmes. Dokuz Eylul University School of Medicine (DEUSM), the country's first medical school implementing a Problem-Based Learning (PBL) and Task-Based Learning (TBL) programme, graduated the first students of its new educational programme starting from the 2002-2003 academic year. The aim of the present study is to determine first graduates' perceptions on their self-efficacy and school's educational programme's efficacy.

METHODS

In June 2003, 51 graduating students were asked to use five-point scales to evaluate: the content of the educational programme, the educational methods, communication with educators, assessment methods and instruments, the efficacy of each year of their undergraduate programme and the overall program, their satisfaction levels about educational programme regarding the acquisition of knowledge and skills, their self-efficacy and contentment level of being a physician.

RESULTS

In the content of educational programme, the highest score was attributed to "acquisition of behavioural objectives" and the lowest score to "acquisition of basic science knowledge". Regarding the efficacy of educational programme, the highest score was attributed to "communication with educators". The highest scores regarding the satisfaction levels on the acquisition of knowledge and skills provided by the School were attributed to "implementing basic professional procedures" and "history taking" and the lowest score to "selecting appropriate treatment".

CONCLUSION

The graduating students' mainly positive evaluations regarding the efficacy of DEUSM's new educational programme were considered as supportive reflections on the new educational programme. Further studies to monitor our graduates' future professional performances are being envisaged.

Incarcerated inferior lumbar (Petit's) hernia

Petit's hernia is an uncommon abdominal wall defect in the inferior lumbar triangle. Colonic incarceration through the inferior lumbar triangle, which causes mechanical obstructive symptoms, necessitates particular diagnostic and management strategy. We present a rare case of inferior lumbar hernia, leading to mechanical bowel obstruction, successfully treated with prosthetic mesh reinforcement repair.

Myocardial performance index combining systolic and diastolic myocardial performance in doxorubicin-treated patients and its correlation to conventional echo/Doppler indices

This study was designed to evaluate the utility of myocardial performance index (MPI) in anthracycline cardiotoxicity. The MPI measures the ratio of total time spent in isovolumic activity (isovolumetric contraction time and isovolumetric relaxation time) to the ejection time, thus giving a global index combining systolic and diastolic myocardial performance. In this study, MPI was measured in 35 doxorubicin-treated children (aged 108.5+/-55.31 months, 23 males and 12 females) in sinus rhythm and 32 age-matched controls, and it was compared with conventional Doppler echocardiographic parameters. The isovolumetric contraction time was prolonged (38.37+/-24.43 vs 26.37+/-15.53, p <0.02) and ejection time was shortened (231.91 +/- 28.87 vs 256.21+/-19.55, p<0.001) in doxorubicin-treated patients compared to that in normal children. The isovolumetric relaxation time did not show significant difference between patients and control group (60.11+/-10.92 vs 61.06+/-12.12, p>0.05). MPI was significantly increased in doxorubicin-treated patients compared with that in control groups (0.42+/-0.07 vs 0.34+/-0.06, p<0.001), and significant correlation was observed between MPI and fractional shortening, ejection fraction, and left ventricular end diastolic and end systolic diameters (respectively, r = -0.508, p <0.002; r = -0.532, p<0.001; r = 0.467 p<0.005; r=0.606, p<0.001). Also, a weak correlation was found between MPI and duration of the disease and patient ages (r = 0.393, p < 0.02; r = 0.379; p < 0.02). However, there was no correlation between MPI and cumulative doxorubicin dose (r = 0.311, p > 0.05) and diastolic Doppler parameters in doxorubicin-treated patients. We think that MPI may be a useful parameter in monitoring left ventricular dysfunction in anthracyline-treated patients.

Protective effects of carnitine in an experimental ischemia-reperfusion injury

BACKGROUND/AIMS

We aimed to determine the role of exogenous carnitine to prevent ischemia-reperfusion damage in liver tissue in experimental model.

METHODS

Rats were divided into four groups as Sham (SG), 30% Hepatectomy (HG), ischemia-reperfusion +30% hepatectomy (IRHG) and ischemia-reperfusion+30% hepatectomy+carnitine (IRHCG). Serum AST, ALT and GGT levels have been determined in systemic blood samples (post-hepatic vena cava) and liver tissue and serum carnitine levels in blood samples from portal vein (pre-hepatic blood samples).

RESULTS

Serum carnitine levels were significantly higher in IRHCG compared to SG (P < 0.01). Each of the serum AST, ALT and GGT levels were statistically higher in HG, IRHG and IRHCG than SG (P < 0.001). While these values in IRHG were also higher than those in HG (P < 0.001), in IRHCG enzyme levels were significantly lower than IRHG (P < 0.001). Liver tissue damage was less in IRHCG than IRHG statistically (P < 0.001).

CONCLUSIONS

This animal model implies that exogenous carnitine supplementation may be helpful in preventing free oxygen radical damage and inflammatory reactions in liver tissue.

Pseudoachondroplasia in a child with prolapse of the mitral valve

Pseudoachondroplasia is an autosomal dominant variant of osteochondroplasia that results in mild to severe short-limb dwarfism and early-onset of osteoarthrosis. It has been linked to results from mutations in the gene for cartilage oligomeric matrix protein. We describe a 4-year-old boy with pseudoachondroplasia who also had prolapse of the mitral valve. To the best of our knowledge, this association has not previously been reported.

Cholangiocytic apoptosis in chronic ductopenic rejection

The significance of cholangiocytic apoptosis as a mechanism of ductopenia in liver rejection remains controversial. In a previous study, the presence but not the extent of ductal apoptosis was assessed by electron microscopy. Other previously published studies using an in situ hybridization method (in situ end labeling) produced conflicting results (no apoptosis v massive apoptosis). We studied 47 liver needle biopsies from 8 patients with chronic ductopenic rejection confirmed by pathologic examination of the failed grafts. These biopsies were performed because of graft dysfunction, during a period of several months before retransplantation, and they showed cholangiocytic injury with progressive ductal paucity. Terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick-end labeling (TUNEL) was used to detect apoptosis (tissue digestion with proteinase K 20 microg/mL for 20 minutes). The interlobular bile ducts did not show labeling, even in lymphocytic cholangitis with obvious epithelial injury. However, there was minimal staining of ductular nuclei. Lymphocytic nuclei were also labeled. Apoptosis was not detectable in the vanishing interlobular bile ducts, even when more representative samples were studied and a more sensitive method was used. Unless apoptosis of cholangiocytes is an exceptionally rapid process escaping detection by conventional methods, ductopenia results mainly from ordinary, nonprogrammed cholangiocytic death. Apoptosis could still be involved in the pathogenesis of ductopenia by depleting cholangiocytic precursors, generally presumed to reside in ductules. This is a possible mechanism suggested by the following: (1) the established role of apoptosis in the homeostatic control of immature/progenitor cells, (2) the paucity of ductular proliferation in chronic rejection, (3) the previously reported decrease of ductular bcl-2 expression in rejection, and (4) the sporadic ductular TUNEL labeling seen in this study.

Is mannitol effective against platelet-activating factor (PAF)-induced liver damage in obstructive jaundice?

BACKGROUND/AIMS

Platelet-activating factor, is a unique phospholipid with a broad range of biological activities that may be relevant in the development of inflammatory reactions. Platelet-activating factor has been suspected to play an important role in liver pathophysiology. The cultured Kupffer and endothelial cells produce and release platelet-activating factor in order to facilitate communication between hepatic sinusoidal and parenchymal cells. In this study, in the experimental jaundice model, platelet-activating factor levels were measured in liver tissue and plasma and the possible effects of mannitol on this mediator were assessed.

METHODOLOGY

The experimental model consisted of 7 rats in the control group (CG), 7 rats in the sham operation group (ShG), and 7 rats in the obstructive jaundice group (JG) created by ligating the common bile duct. The last group was the mannitol-treated jaundiced group (MJG) and all animals in this group received 20% mannitol in doses of 2 mL/day, intraperitoneally, following common bile duct ligation. A week later all animals were sacrificed and plasma and liver tissue samples were collected. Platelet-activating factor levels were measured by radioimmunoassay technique.

RESULTS

Liver tissue platelet activating factor levels (pg/mg tissue protein) were 72 +/- 18 in the CG, 183 +/- 51 in the JG, 84 +/- 17 in ShG, and 124 +/- 36 in MJG. Plasma levels were 460 +/- 13, 1600 +/- 40, 560 +/- 19, and 1200 +/- 23, respectively. In both sample types, MJG and JG values were significantly different from CG and ShG as well. MJG levels were also different from JG.

CONCLUSIONS

These results showed that plasma and liver tissue platelet-activating factor levels are increased in experimental obstructive jaundice; and activation of this mediator contributes to the ongoing liver injury. Mannitol may improve or lessen this damage.

Pancreatic adenocarcinoma: detection and staging with dynamic MR imaging

OBJECTIVE

To compare the efficacy of dynamic contrast-enhanced MR imaging and spin-echo T1-weighted with and without fat-saturated MR imaging in the detection and staging of pancreatic adenocarcinoma.

METHODS AND MATERIAL

Spin-echo T1-weighted, fat-saturated T1-weighted and dynamic breath-hold 2D-FLASH MR imaging were performed in 25 patients with pancreatic adenocarcinoma. MR images were analysed by calculating the CNR between tumor and normal portion of the pancreas. The CNRs calculated at each sequences were compared. A total of 16 out of 25 patients underwent surgery. Preoperative staging according to TNM classification was also done in patients undergoing surgery.

RESULTS

The CNR was significantly different (P<0.05) in the arterial phase of dynamic MR images. The accuracy of 'T' staging was 75% for SE T1-W, fat-saturated T1-W and arterial phase of dynamic MR images.

CONCLUSION

The CNRs between pancreatic carcinoma and normal pancreas is significantly higher in dynamic MR sequences than the SE T1-W, fat-saturated T1-W sequences. However, the accuracy of tumor staging according to TNM is equivocal to SE T1-W and fat-saturated T1-W images.

Tumor angiogenesis as a prognostic predictor in pancreatic cancer

The purpose of this study was to evaluate the role of angiogenesis, proliferative activity (assessed by Ki-67 expression), p53 and ras-oncogene (H-ras) expression, and conventional clinicopathologic factors in predicting overall survival rates in patients with pancreatic ductal adenocarcinoma. We followed-up 22 patients with ductal adenocarcinoma of the pancreas for a median of 19 months (range, 2 to 44 months). Angiogenesis was quantitated as vascular surface density (VSD) and the number of vessels per mm2 stroma (NVES) after microvessels were immunostained, using factor VIII-related antigen. p53, H-ras, and Ki-67 proteins were also determined immunohistochemically. VSD and NVES showed significant correlations with increased proliferative activity, poor tumor differentiation, and tumor size of 3 cm or more (P = 0.001, P = 0.013, and P = 0.047, respectively). The overall 2-year survival rate of 33.3% in patients with high VSD and NVES values was significantly worse than that of 66.6% estimated in patients with low microvessel count (log rank, 3.97; P = 0.046). In multivariate analysis using the Cox model, VSD was found to be an independent prognostic factor of survival (P = 0.039). H-ras and p53 expressions were not correlated with angiogenesis parameters. We conclude that, in pancreatic ductal adenocarcinoma, angiogenesis is closely related to tumor growth and patient survival.

Comparison of different surgical repairs in the treatment of experimental duodenal injuries

BACKGROUND

In this experimental study, we aimed to investigate the results of different surgical repair methods for delayed reconstruction of severe experimental duodenal defects.

METHODS

A large duodenal defect with irregular and tagged margins covering about 50% of the circumference was created in the second part of duodenum of male Wistar rats. The effectiveness of primary repair, jejunal serosal patch, Roux-en-Y duodenojejunostomy, or expanded polytetrafluoroethylene patch repair techniques were investigated on the basis of survival and histologic assessment.

RESULTS

No significant survival benefit was observed between jejunal serosal patch, Roux-en-Y duodenojejunostomy, or expanded polytetrafluoroethylene patch repair techniques. But these repair modalities were associated with better survival rates than no-treatment or primary repair techniques. Complete coverage of the expanded polytetrafluoroethylene grafts by neomucosa consisting of columnar epithelium with villus formation was observed in surviving rats about 16 weeks after surgery.

CONCLUSIONS

Expanded polytetrafluoroethylene patch can be used in the repair of experimental large duodenal defects, which can not be repaired primarily.

Seventh Day Syndrome--acute hepatocyte apoptosis associated with a unique syndrome of graft loss following liver transplantation

AIM

The aim of this study is to describe a unique 7th day syndrome (7DS), quite different from other causes of post-transplantation allograft dysfunction in a group of orthotopic liver transplant (OLT) patients who needed retransplantation.

METHODS

A retrospective analysis of 594 consecutive OLT over an 8-year period revealed that 10 patients developed allograft dysfunction approximately 7 days following an initially normal graft function.

RESULTS

The features included: (a) severe liver failure; (b) sudden peak of extremely high liver enzymes at approximately day 7; (c) serial liver biopsy findings of central lobular hemorrhage with minimal inflammatory cell infiltrate and (d) an explant with no evidence of vascular thrombosis. The biochemical and morphometric pathological data of these patients were compared with data of patitents who had early acute rejection (AR), hepatic artery thrombosis (HAT), primary nonfunction (PNF), severe sepsis and no dysfunction. Lastly, serial liver core biopsies and explants were tested for evidence of apoptosis, which revealed a significantly higher number of apoptotic hepatocytes in 7DS compared to all control groups.

CONCLUSIONS

Seventh Day Syndrome is a distinct entity associated with early graft dysfunction characterized by a marked apoptosis of hepatocytes. Fas receptor activation or other pathways of program cell death may be implicated in occurrence of 7DS.

Mirizzi's syndrome: diagnostic and surgical considerations in 25 patients

Mirizzi's syndrome is a rare complication of long-standing cholelithiasis. Many surgical approaches of varying complexity have been advocated for treatment. However, the distorted extrahepatic biliary anatomy continues to be threatening, with a high risk of biliary complications. Presented here is a series of 25 patients with Mirizzi's syndrome who were treated at the Dokuz Eylul University Hospital since 1985. Type I lesion (without cholecystocholedochal fistula) was encountered in 11 patients, while the remaining 14 had type II lesions (with cholecystocholedochal fistula). Preoperative diagnoses were made in 14 of the 25 patients (56%). Follow-up in 17 patients ranged from 1 to 96 months (mean, 40 months). Unfortunately, the remaining 8 patients were lost to follow-up after discharge. The morbidity rate in our series was 32%, while no mortality was encountered. During long-term follow-up, no biliary stricture was diagnosed. Following an uneventful postoperative course, all of our patients are symptom-free and doing well, with normal liver function. We conclude that partial cholecystectomy alone is a safe and sound surgical approach for the treatment of type I lesions. For type II lesions, depending on the size of the fistula, either primary closure over a T-tube, or bilio-digestive anastomosis, preferably Roux-en-Y, can be an appropriate treatment modality, with a low morbidity rate.

Left ventricular diastolic functions in juvenile rheumatoid arthritis

Cardiac involvement as pericarditis, myocarditis, and endocarditis is common in juvenile rheumatoid arthritis (JRA). Though there are many reports concerning systolic and diastolic functions of adults with rheumatoid arthritis, there are no studies on children with JRA. Thirty patients with JRA without any cardiac symptoms and 30 sex- and age-matched controls were included in the study. M-mode and pulsed-wave Doppler echocardiography were performed on each participant to assess the systolic and diastolic functions of the left ventricle. Left ventricular end-systolic diameter and volume were larger and ejection fraction and fractional shortening were decreased in the JRA group. Among the diastolic parameters, increased late flow velocity, decreased early flow velocity, and prolonged isovolumic relaxation time reflected an abnormal relaxation form of diastolic dysfunction. Mortality rate is increased in adults with rheumatoid arthritis, and ischemic heart disease is the leading cause of cardiovascular mortality. The abnormal relaxation form of diastolic dysfunction found in children with JRA is seen in ischemic heart disease. These children can therefore be candidates for ischemic heart disease in the future even though they are fully asymptomatic at present. In conclusion, children with JRA should be assessed for systolic and diastolic functions with serial echocardiography. In this way it may be possible to reduce the mortality and morbidity of the disease from cardiac causes.

Beneficial effects of pentoxifylline pretreatment in non-heart-beating donors in rats

BACKGROUND

Pentoxifylline (PTX) pretreatment of recipients was shown to protect against liver graft failure from ischemia-reperfusion injury after orthotopic rat liver transplantation. It has also been shown that PTX protects against normothermic ischemia-reperfusion injury to the liver in lobar ischemia model in the rat. Whether PTX can benefit the liver procured from non-heart-beating donors (NHBDs) with up to 9 hr of cold ischemia is unknown.

METHODS

Donor and recipient rats were pretreated with intraperitoneal PTX (50 mg/kg) 1 hr before cardiac arrest and transplantation, respectively. Grafts were transplanted 0, 30, and 60 min after cardiac arrest with additional 1 and 9 hr of cold ischemia in both PTX-pretreated or untreated (control) groups (10 rats per group). PTX (25 mg/kg/day) was continuously given to the surviving rats for 5 days postoperatively. Recipient survival rates, serum enzyme levels, and histopathological examination of postreperfusion liver biopsies were all analyzed.

RESULTS

The survival rates, serum enzyme levels, and postreperfusion histology were significantly improved in groups pretreated with PTX compared to the controls.

CONCLUSION

Donor and recipient PTX pretreatment significantly improves the viability of the liver grafts procured from NHBDs.

Angiogenesis and p53 and H-ras mutations in pancreatic ductal adenocarcinoma

OBJECTIVE

To evaluate the correlation of angiogenesis and p53 and H-ras mutations with prognostic factors and proliferative activity assessed with Ki-67 protein expression by studying archival tissues from 24 patients with primary pancreatic ductal adenocarcinoma.

STUDY DESIGN

Vascular structures were labeled immunohistochemically using factor VIII-related antigen. Vascular surface density (VSD) and microvessel number (NVES) were assessed by stereology. The tissues were also analyzed with the immunohistochemical method for the expression of proteins, including p53, H-ras and Ki-67.

RESULTS

Statistical analysis revealed that tumors with greater NVES and VSD values significantly correlated with occurrence of metastases, higher proliferative activity, poorer histologic differentiation and greater tumor size. p53 Mutations were found in 11 cases (45.8%). However, only three cases (12.5%), all negative for p53 mutations, showed H-ras mutations. p53 Mutation-positive tumors exhibited a statistically significant correlation with occurrence of metastases and higher proliferative activity, whereas H-ras mutations did not show such a correlation.

CONCLUSION

Angiogenesis might have a role in predicting prognosis in pancreatic carcinomas, and p53 mutations might be acquired in later stages associated with metastatic progression and higher proliferative activity. Although H-ras mutations were rare in the present study, they might play a role in a different carcinogenic pathway excluding p53 mutations.

Scurvy. A case report

An 18-month-old girl presented with irritability, epistaxis, spongy appearance of the gums perifollicular papules with follicular hyperkeratosis, ecchymosis, painful swollen knees and scorbutic rosary. Her diet consisted mainly of wheat flour. X-ray of the knees showed findings compatible with scurvy. Ascorbic acid level was below 0.003 g/L. Ascorbic acid therapy resulted in a dramatic clinical improvement. Scurvy is an uncommon disease in our society today. It is important to recognize the signs and symptoms of scurvy because it is easily treated with vitamin C replacement.

Quantitation of the changes in splenic architecture during the rejection of cardiac allografts or xenografts

BACKGROUND

The spleen plays a central role in the generation of both cellular and antibody responses during graft rejection. Although changes in lymphocyte function have been extensively analyzed in vitro, there have been limited attempts at quantitating the structural changes in the lymphoid compartments within the spleen during graft rejection.

METHODS

We describe here a means of quantitating the histological changes in the spleen using immunohistochemical techniques and computerized image analysis.

RESULTS

Allograft rejection at 6 days after transplant is characterized by a threefold increase in the T cell-rich areas of the periarteriolar lymphoid sheaths (PALs). The follicular areas are enlarged and germinal centers appear in 55% of the white pulp regions. Acute xenograft rejection, 4 days after transplant, is specifically accompanied by a 2.3-fold increase in the marginal zone (MZ) and an increase in the numbers of B cells in the red pulp of the spleen. The expansion of both PALs and follicular/germinal centers during xenograft rejection is comparable to that observed during allograft rejection. We also investigated the effect of two immunosuppressants, leflunomide and cyclosporine, on the spleen of rats with hamster hearts. Leflunomide, which prevents acute xenograft rejection, prevented the increase in PALs and significantly reduced the areas comprising the MZ and follicles. Cyclosporine, which does not alter the tempo of xenograft rejection and only partially inhibited xenospecific antibody production, inhibited the increase in PALs and the appearance of germinal centers, while permitting a modest increase in the area of MZ and follicles.

CONCLUSIONS

These observations collectively suggest that both T cell-dependent and T cell-independent responses are stimulated by the transplanted xenograft. However, the T cell-independent responses that initiate xenograft rejection are characterized by very modest increases in the area of MZ and follicles within the white pulp of the spleen.

Prediction of abstinence from ethanol in alcoholic recipients following liver transplantation

The prediction of abstinence from ethanol may be crucial to the optimal selection of liver transplantation candidates with alcoholism. Of 84 consecutive end-stage alcoholic patients who underwent transplantation (1986-1994) at our institution, we analyzed 63 long-surviving recipients for pretransplantation variables to predict posttransplantation abstinence (follow-up: 49.3 +/- 21 mo). Thirty-three pretransplantation variables were reviewed from our transplantation data base and supplemented and confirmed with interviews with recipients. The psycho-social inclusion criteria included the following: patient recognition of alcoholism, a domicile, an occupation, and at least one close personal relationship. The incidence of abstinence from ethanol was (50/63) 79%. A logistic regression of the 33 variables in conjunction with our above inclusion criteria accurately predicted abstinence (90% accuracy, chi2 model, P < .00001) based on the absence of previous history of any illicit drug use (Drug Use: yes = 1/no = 0), the presence of an active, personal life insurance policy (Life Ins: yes = 1/no = 0), number of alcoholic sisters (ETOH-SIS), and the length of pretransplantation abstinence (PRE-TRANS-ABS, mos): Prob. of abstinence = 1/1 + e(-F), F = -0.33 +/- 0.89 (DRUG USE) -1.02 (LIFE INS) -1.68 (ETOH-SIS) +0.24 (PRE-TRANS-ABS). In contrast, receiver-operating characteristic curve analysis found that 7 and 9 months of pretransplantation abstinence were the best cut-off points in predicting subsequent abstinence, but poor utility was noted at these points with this specific value alone (sensitivity 61-84%, specificity 64-68%). A separate analysis of high-risk patients with poly-drug use (n = 15, alcohol recidivism 8/15, 53%) and the remaining low-risk group of purely alcohol dependent patients (n = 48, alcohol recidivism 5/48, 10%) found no combination of variables was predictive of abstinence in either group. The length of pretransplantation abstinence is a relatively poor predictor of posttransplantation abstinence. Variables of comorbid substance use, social function, and possibly family history are more predictive in conjunction with our standard criteria and might be useful as tools in evaluating liver transplantation candidates whose primary diagnosis is alcohol-induced cirrhosis.

Hepatic artery aneurysm in a 10-year-old boy as a complication of infective endocarditis

Mycotic aneurysms occur from septic emboli in patients with infective endocarditis and may involve any artery, but frequently they are not detected before autopsy. The most common sites are the brain, abdominal aorta, sinus of Valsalva, ligated ductus arteriosus, and superior mesenteric, splenic, coronary, and pulmonary arteries. The authors report on a 10-year-old boy who had a mycotic aneurysm of the common hepatic artery, which developed during the course of infective endocarditis of the mitral valve and was cured successively using a platinum coil embolization technique.