Valproic Acid-Induced Upregulation of Multidrug Efflux Transporter ABCG2/BCRP via PPARα-Dependent Mechanism in Human Brain Endothelial Cells

Despite the progress made in the development of new antiepileptic drugs (AEDs), poor response to them is a rising concern in epilepsy treatment. Of several hypotheses explaining AED treatment failure, the most promising theory is the overexpression of multidrug transporters belonging to ATP-binding cassette (ABC) transporter family at blood-brain barrier. Previous data show that AEDs themselves can induce these transporters, in turn affecting their own brain bioavailability. Presently, this induction and the underlying regulatory mechanism involved at human blood-brain barrier is not well elucidated. Herein, we sought to explore the effect of most prescribed first- and second-line AEDs on multidrug transporters in human cerebral microvascular endothelial cells, hCMEC/D3. Our work demonstrated that exposure of these cells to valproic acid (VPA) induced mRNA, protein, and functional activity of breast cancer resistance protein (BCRP/ABCG2). On examining the substrate interaction status of AEDs with BCRP, VPA, phenytoin, and lamotrigine were found to be potential BCRP substrates. Furthermore, we observed that siRNA-mediated knockdown of peroxisome proliferator-activated receptor alpha (PPARα) or use of PPARα antagonist, resulted in attenuation of VPA-induced BCRP expression and transporter activity. VPA was found to increase PPARα expression and trigger its translocation from cytoplasm to nucleus. Findings from chromatin immunoprecipitation and luciferase assays showed that VPA enhances the binding of PPARα to its response element in the ABCG2 promoter, resulting in elevated ABCG2 transcriptional activity. Taken together, these in vitro findings highlight PPARα as the potential molecular target to prevent VPA-mediated BCRP induction, which may have important implications in VPA pharmacoresistance. SIGNIFICANCE STATEMENT: Induction of multidrug transporters at blood-brain barrier can largely affect the bioavailability of the substrate antiepileptic drugs in the brains of patients with epilepsy, thus affecting their therapeutic efficacy. The present study reports a mechanistic pathway of breast cancer resistance protein (BCRP/ABCG2) upregulation by valproic acid in human brain endothelial cells via peroxisome proliferator-activated receptor alpha involvement, thereby providing a potential strategy to prevent valproic acid pharmacoresistance in epilepsy.

Insights into Structural Modifications of Valproic Acid and Their Pharmacological Profile

Valproic acid (VPA) is a well-established anticonvulsant drug discovered serendipitously and marketed for the treatment of epilepsy, migraine, bipolar disorder and neuropathic pain. Apart from this, VPA has potential therapeutic applications in other central nervous system (CNS) disorders and in various cancer types. Since the discovery of its anticonvulsant activity, substantial efforts have been made to develop structural analogues and derivatives in an attempt to increase potency and decrease adverse side effects, the most significant being teratogenicity and hepatotoxicity. Most of these compounds have shown reduced toxicity with improved potency. The simple structure of VPA offers a great advantage to its modification. This review briefly discusses the pharmacology and molecular targets of VPA. The article then elaborates on the structural modifications in VPA including amide-derivatives, acid and cyclic analogues, urea derivatives and pro-drugs, and compares their pharmacological profile with that of the parent molecule. The current challenges for the clinical use of these derivatives are also discussed. The review is expected to provide necessary knowledgebase for the further development of VPA-derived compounds.

Correlates of depression, anxiety, self-esteem, and suicidal ideas in COVID-associated mucormycosis patients and the effects of treatment

AIM

The aim was to study the correlates of depression, anxiety, self-esteem, and suicidal ideas in patients of COVID-associated mucormycosis (CAM) and effects of treatment.

MATERIALS AND METHODS

A cross-sectional, analytical study was performed in a tertiary care center in Western Maharashtra. By purposive sampling, 34 patients of CAM were included in the study with their informed consent and after obtaining ethical clearance. A self-made questionnaire to include demographic and clinical details was filled. Hospital Anxiety and Depression Scale (HADS), Rosenberg Self-Esteem Scale (RSES), and Suicidal Ideation Attributes Scale (SIDAS) were applied after initial diagnosis. The HADS, RSES, and SIDAS were reapplied after their operative treatment.

RESULTS

A significant reduction in anxiety and depression scores postoperatively was seen. No significant difference was found in self-esteem or suicidal ideas postoperatively in the study population. However, patients who underwent orbital exenteration showed a significant reduction in level of self-esteem with anxiety and depression postoperatively. No specific correlation was found between the computed tomography score, family history, intensive care unit admission, or orbital exenteration with anxiety, depression, self-esteem, and suicidal ideas.

CONCLUSION

Levels of anxiety and depression in patients of CAM reduced significantly after treatment, but self-esteem worsened in males more than females owing to disfigurement. There is a need of psychological counseling in patients of mucormycosis undergoing a debilitating surgery both pre- and postoperatively for a better outcome and recovery.

Effect of fluid resuscitation on acute lung injury in a rat model of sepsis

AIM

Sepsis is a systemic infection reaction and intravascular volume therapy plays a crucial role in it's treatment. Acute respiratory distress syndrome (ARDS) occurs in the lungs, the most affected organ. This study aimed to investigate the different effects of fluid therapy on ARDS caused by sepsis.

METHOD

To form a sepsis model, cecal ligation and puncture (CLP) procedure were performed on 44 adult rats. Divided into six groups; normal, CLP group, those treated with 40 ml/kg 0.9 % NaCl, 3 % NaCl (hypertonic saline), Ringer Lactate and Hydroxyethyl starch. After 24 hours treatments, histopathological examination of the lungs were done, and the plasma levels of CRP, TNF-α and IL-6 and paO2 were measured.

RESULTS

The scores of all histological parameters of the group treated with hypertonic saline were significantly lower than of the other groups (p < 0.001). Likewise, according to the arterial blood gas results, paO2 was significantly higher (p < 0.01) in the hypertonic saline group compared to the other groups, and paCO2 was significantly lower (p < 0.01). CRP, TNF-α and IL-6 levels of inflammatory markers were also significantly lower in hypertonic saline groups compared to other groups (p < 0.001).

CONCLUSIONS

Our study shows that treatment with hypertonic saline reduces the progression of ARDS in sepsis (Tab. 3, Fig. 4, Ref. 49).

Clinical profile, treatment and outcome of Kawasaki disease: A single-center experience from a tertiary care referral center of Assam, north-east India

AIM

This is a retrospective study to report our experience with a cohort of 73 patients with Kawasaki disease (KD) over 2.5 years.

METHOD

The study was conducted in the Department of Pediatrics. Data were retrieved from medical records of Pediatric Rheumatology and Immunodeficiency Clinic collected from April 2017 to October 2019 and analyzed.

RESULTS

Male-to-female ratio in our cohort was 2:1. The median age at diagnosis of KD was 3 years (IQR, 4.25). Fever was present in all patients. Oral mucosal changes are the second most common symptom (N = 64, 87%) followed by extremity changes (N = 58, 79%), and rash (N = 56, 76%). Nineteen (26%) children had cardiovascular complications like coronary artery abnormalities (N = 15, 20%), cardiac tamponade (N = 2, 2%), and shock (N = 1, 1%). The effusion in the patients with cardiac tamponade contained inflammatory cells and plenty of red blood cells. Sixty-eight (93%) patients with KD had received treatment with IVIg. Patients in our cohort had completed a mean follow-up of 13.6 ± 9.4 months. No fatality or any long term adverse effects were observed on follow-up.

CONCLUSION

Kawasaki disease is a common rheumatological disorder in children at our center with diverse clinical presentations. The disease needs to be considered as a differential diagnosis in an acute febrile illness in children persisting up to 5 days.

Functional Connectivity Network Disruption Underlies Domain-Specific Impairments in Attention for Children Born Very Preterm

Attention problems are common in school-age children born very preterm (VPT; < 32 weeks gestational age), but the contribution of aberrant functional brain connectivity to these problems is not known. As part of a prospective longitudinal study, brain functional connectivity (fc) was assessed alongside behavioral measures of selective, sustained, and executive attention in 58 VPT and 65 full-term (FT) born children at corrected-age 12 years. VPT children had poorer sustained, shifting, and divided attention than FT children. Within the VPT group, poorer attention scores were associated with between-network connectivity in ventral attention, visual, and subcortical networks, whereas between-network connectivity in the frontoparietal, cingulo-opercular, dorsal attention, salience and motor networks was associated with attention functioning in FT children. Network-level differences were also evident between VPT and FT children in specific attention domains. Findings contribute to our understanding of fc networks that potentially underlie typical attention development and suggest an alternative network architecture may help support attention in VPT children.

Global Text Mining and Development of Pharmacogenomic Knowledge Resource for Precision Medicine

Understanding patients’ genomic variations and their effect in protecting or predisposing them to drug response phenotypes is important for providing personalized healthcare. Several studies have manually curated such genotype–phenotype relationships into organized databases from clinical trial data or published literature. However, there are no text mining tools available to extract high-accuracy information from such existing knowledge. In this work, we used a semiautomated text mining approach to retrieve a complete pharmacogenomic (PGx) resource integrating disease–drug–gene-polymorphism relationships to derive a global perspective for ease in therapeutic approaches. We used an R package, pubmed.mineR, to automatically retrieve PGx-related literature. We identified 1,753 disease types, and 666 drugs, associated with 4,132 genes and 33,942 polymorphisms collated from 180,088 publications. With further manual curation, we obtained a total of 2,304 PGx relationships. We evaluated our approach by performance (precision = 0.806) with benchmark datasets like Pharmacogenomic Knowledgebase (PharmGKB) (0.904), Online Mendelian Inheritance in Man (OMIM) (0.600), and The Comparative Toxicogenomics Database (CTD) (0.729). We validated our study by comparing our results with 362 commercially used the US- Food and drug administration (FDA)-approved drug labeling biomarkers. Of the 2,304 PGx relationships identified, 127 belonged to the FDA list of 362 approved pharmacogenomic markers, indicating that our semiautomated text mining approach may reveal significant PGx information with markers for drug response prediction. In addition, it is a scalable and state-of-art approach in curation for PGx clinical utility.

Pesticide usage pattern in tea ecosystem, their retrospects and alternative measures

Tea is a perennial plantation crop grown under monoculture providing favorable conditions for a variety of pests. The concept of pest control has undergone a considerable change over the past few decades. In recent years there has been a greater dependence on the use of pesticides (7.35-16.75 kgha(-1)) with little importance laid on other safe control methods for the management of tea pests. Due to this practice, the tea pests showed a higher tolerance/ resistance status due to formation of greater amount of esterases, glutathione S-transferase and acetylcholinesterase. Thus, over reliance on pesticides end up with pesticide residue in made tea (DDT - 10.4-47.1%; endosulfan - 41.1-98.0%; dicofol- 0.0-82.4%; ethion - 0.0-36.2%; cypermethrin - 6.0- 45.1%). The growing concern about the pesticide residue in made tea, its toxicity hazards to consumers, the spiraling cost of pesticides and their application have necessitated a suitable planning which will ensure a safe, economic as well as effective pest management in tea. At present it is a global concern to minimize chemical residue in tea and European union and German law imposed stringent measures for the application of chemicals in tea and fixed MRL values at < or = 0. 1 mgkg(-1) for the most commonly used pesticides which will not be met out in the real practice and has been a major constraint to tea exporting countries like India. In order to regulate the situation of the Indian market at global level, central insecticide board and prevention of food adulteration regulation committee have reviewed the MRL position for tea and has recommended 10 insecticides, 5 acaricides, 9 herbicides and 5 fungicides for use in tea and issued the tea distribution and export control order 2005 which will help the country to limit the presence of undesirable substances in tea. This review attempts to provide the readers with a comprehensive account of pesticide use in North East in tea, surveillance report of the European community regarding the residue level in Assam and Darjeeling tea, recent amendments by international and national regulatory bodies, revised MRL values of pesticides in tea, an update about the current strategies for the management of tea pests with more focus on the use of biological control agents and a possible beneficial role or judicious use of chemical pesticides in complement with other alternative measures to achieve optimum effects in terms of limiting agricultural input, lowering production costs, reducing environmental contamination and the effect on non-target organisms, delaying the development of resistant pest biotypes and above all minimizing the pesticide residues in tea to increase the exports.

A renal transplant recipient with delayed gastric emptying in amyloidosis due to familial Mediterranean fever improved with erythromycin: a case report

Patients with systemic amyloidosis often have symptoms related to impared gastrointestinal motility due to delayed gastric emptying, which results from autonomic nerve or smooth muscle infiltration with amyloid. There is no current report about gastric delaying secondary to amyloidosis due to familial Mediterranean fever. In this report, we have described a renal transplant recipient with delayed gastric emptying secondary to amyloidosis due to familial Mediterranean fever, which improved with erithromycin treatment.

Efficacy of Heatsynch protocol for induction of estrus, synchronization of ovulation and timed artificial insemination in yaks (Poephagus grunniens L.)

The objective of this study was to test the efficacy of induction of estrus, synchronization of ovulation and timed artificial insemination in anestrous yaks using the Heatsynch protocol. In Experiment 1, 10 anestrous yaks were administered an analogue of gonadotropin releasing hormone (GnRH) followed by prostaglandin (PG)F2alpha 7 days later and then estradiol cyponate (ECP) 24 h after that. Ovulation was detected by rectal palpation at 2h intervals beginning at the initial signs of estrus. Blood samples were collected at 2h intervals beginning at the time of ECP injection up to 2h after the occurrence of ovulation for the determination of LH and progesterone. All the animals responded to the Heatsynch protocol with expression of estrus and synchronization of ovulation. The mean time interval from the ECP injection to ovulation was 59.4+/-2.62 h (range 50-72 h). The interval from the LH peak to ovulation was 30.2+/-2.3 h. The high degree of synchrony in ovulation could be attributed to the synchrony in the timing of LH peaks. In Experiment 2, 10 anestrous yaks were treated with the Heatsynch protocol (as in Experiment 1) and TAI was performed at 48 and 60 h after the ECP treatment. Concurrently, 16 cycling yaks were inseminated approximately 12 h after detection of spontaneous estrus. Pregnancy rates were similar in both groups, 40% for TAI and 43.75% for yaks inseminated following spontaneous estrus (p>0.05). From this study, two conclusions can be drawn. First, the Heatsynch protocol can be successfully used to induce and synchronize estrus in anestrous yaks and, second, ovulation following the Heatsynch protocol is synchronized adequately to permit the use of fixed time AI in this species.

Validity of the in vitro fertilisation league tables: influence of patients' characteristics

We tested the hypothesis that restricting comparison of the live birth rate following in vitro fertilisation (IVF) treatment in those couples having their first IVF cycle in whom the female is under 35 years of age and has a normal follicle-stimulating hormone level would improve the validity of comparing IVF clinics' success rates. We analysed all cycles performed over a 2-year period in patients who fulfilled these criteria and divided the study population according to the referring primary care trusts: group A (n = 90) were referred from Lambeth, Southwark and Lewisham and group B (n = 134) were referred from Brent and Harrow. There was no significant difference between the two groups with regard to their IVF cycle characteristics. The two groups differed in their ethnicity, cause of infertility, prevalence of uterine fibroids and smoking and alcohol consumption habits. Group A had a significantly lower live birth rate (OR = 0.45, 95% CI 0.21-0.95, P = 0.02) compared with group B. This study confirms the impact of the non-IVF-related patient characteristics on treatment outcome and the poor validity of comparing IVF clinics' success rates based on the sparse data published by national IVF registries.

Correlation of C0 and C2 levels with lipid profiles in adolescent renal transplant recipients in the early and late posttransplant periods

Hyperlipidemia is a frequent complication after renal transplantation. Cyclosporine therapy is an important cause of hyperlipidemia. It is still controversial whether C0 or C2 is the most effective way to monitor blood cyclosporine concentrations to guide dosages. We sought to evaluate the relationship of C0 or C2 to serum lipid levels in the early and late posttransplant periods among adolescent renal transplant recipients. The posttransplantation charts of 26 adolescent renal transplant recipients were evaluated retrospectively. Serum C0 and C2 levels and serum lipid (triglyceride and total cholesterol) levels were analyzed both in the early (first 6 months) and the late (thereafter) posttransplant periods. Hypertriglyceridemia and hypercholesterolemia were defined as levels above the 95th percentile adjusted for age and gender. To evaluate the influence of C0 and C2 levels on serum lipids, we excluded one patient with familial hyperlipidemia. In addition, serum lipid levels of the remaining 25 patients were excluded in acute rejection periods and when the serum creatinine levels were above 2.5 mg/dL, representing chronic allograft nephropathy. Concurrently recorded serum C0 and C2 levels were present for only 21 patients. Overall, we evaluated the records of 245 visits for these 21 patients. The incidence of hyperlipidemia decreased in the late posttransplant period, being significant for hypercholesterolemia. C2 had strong negative correlation with serum lipids; it was significant for total cholesterol in the early posttransplant period (r=-0.542, P=.005), but weaker in the late posttransplant and whole posttransplant periods. Thus correlation of C2 with serum lipids showed differences during posttransplant follow-up. C0, on the other hand, was positively correlated with total cholesterol levels in all periods, being significant for the whole posttransplant period (r=0.293, P=.000) and for the late posttransplant period (r=0.196, P=.025). Although not statistically significant, C0 levels were higher among hypertriglyceridemic or hypercholesterolemic episodes both in the early and the late posttransplant periods. When only the C0 levels of all 25 patients were analyzed (789 visits), C0 and serum cholesterol levels were positively correlated both in the early and the late posttransplant periods (P=.013, r=0.198 and P=.000, r=0.177, respectively). We concluded that C0 has a more predictable correlation with serum cholesterol levels after renal transplantation in adolescent patients.

Effect of obesity and overweight on cyclosporine blood levels and renal functions in renal adolescent recipients

INTRODUCTION

The impact of obesity, a frequent problem after renal transplantation, which has been associated with poor graft and patient survival, was evaluated on renal function and cyclosporine (CsA) blood levels.

PATIENTS

We retrospectively evaluated the data of adolescent renal recipients between 1994 and 2004. Patients with serum creatinine > or = 2.5 mg/dL were excluded. We grouped the data with regard to the body mass index (BMI) percentiles as group I (BMI > 95th), group II (BMI < 95th), group III (BMI > 85th), group IV (BMI < 85th). We compared the clinical and laboratory findings between groups I and II and between groups III and IV.

RESULTS

We evaluated 778 visits of 27 patients (M/F: 19/8). There were 30 visits in the obesity period (group I) and 72 visits after the overweight periods were added (group III). Serum creatinine levels were significantly higher and glomerular filtration rate levels significantly lower among obese and/or overweight than lean periods (P < .05). Proteinuria levels were similar in groups I and II, but significantly higher in group III than group IV (P = .356 and .000, respectively). CsA(mg/bw), CsA(mg/bmi), and CsA(mg/bsa) levels were significantly lower in group I than group II and in group III than group IV (P < .05), while C0 and C2 levels were similar (P > .05).

CONCLUSION

Weight gain is associated with worse renal functions but not greater proteinuria in our patients. Smaller CsA doses were sufficient to maintain C0 and C2 levels similar to the lean patients, results that were parallel to those of adult renal recipients.

Outcome of Kidney Transplantation for Renal Amyloidosis:A Single-Center Experience

The aim of this retrospective study was to investigate the results of kidney transplantation in patients with renal amyloidosis. We analyzed the results of renal transplantation in 13 amyloidotic transplant recipients compared with those in a control group of 13 nonamyloidotic patients. While the etiology of amyloidosis was rheumatoid arthritis in one patient, in all of the others it was secondary to familial Mediterranean fever. Acute rejection episodes developed once in six and twice in one patient. The renal function in these patients was improved by antirejection treatment. Chronic rejection did not develop in any patient. However six patients (46%) died due to various complications despite functional grafts. The others are still being followed with well-functioning grafts. Among the control group, acute and chronic rejection were diagnosed in three and two patients, respectively: one patient returned to hemodialysis after 26 months of transplantation, while the others are still alive with functional grafts. There was no death in the control group. The 5- and 10-year actuarial patient survival rates of the amyloidosis and control groups were 52.2%, 26.6%, and 100%, 100%, respectively (P = .002). However, the graft survivals of the amyloidosis versus control groups were 100%, 100%, versus 87.5%, 87.5, respectively (P = .47). In conclusion, we observed a high rate of early mortality among recipients with amyloidosis associated with infectious complications. Moreover, patient survivals were lower among amyloidotic renal recipients.

Quantitative Digital Histochemistry With Methenamine Silver Staining in Renal Allograft Biopsies Excluding Pure Chronic Allograft Nephropathy Cases

Deterioration of renal function is correlated with irreversible damage in chronic diseases. Recently we described a digital quantitative histochemistry method, relying on periodic acid methenamine silver (PAMS) staining to determine the chronic renal lesions. This index was strongly correlated with progressive deterioration of renal function in grafts with chronic allograft nephropathy (CAN). Herein the method has been applied to a cohort of renal allografts which were biopsied for various reasons, we sought to highlight its value to quantify chronic graft damage. Forty-four renal allograft biopsies from 37 patients with elevated serum creatinine values (SCr) underwent light microscopic image analysis (Mediscope, Dokuz Eylül University, Clinical Engineering Department, Izmir, Turkey) of the PAMS-stained area percentage (SAP). SCr was recorded at four intervals to overcome acute effects: the under SCr value before (SCr1) and after a biopsy within 3 months (SCr3), SCr at the time of the biopsy (SCr2), and the latest value (SCr4). The PAMS-SAP scores were strongly associated with increased interstitial fibrosis and tubular atrophy Banff scores (Kruskal-Wallis test, P = .006 and P = .003, respectively). There was a moderate positive correlation between PAMS and SCr3 (Pearson correlation test, P = .04, r = .312), and a strong positive correlation between time from transplantation to biopsy (Pearson correlation test, P << .000, r = .532). The present results show that PAMS-SAP seems to be of value to quantify renal scarring in allograft biopsies, reflecting four compartments. The strong correlation with time is noteworthy especially as a probable reflection of aging of the renal allograft.

The factors affecting blood pressure in pediatric renal transplant recipients

To investigate the parameters affecting systemic blood pressure in pediatric renal transplant recipients, we retrospectively examined the data from 19 adolescent renal transplant recipients including 6 girls overall, mean age of 15,47 +/- 3.56 years. Serum creatinine (Scr), fractional extraction of sodium (FENa), whole blood trough cyclosporine(C0), plasma total cholesterol (TC) and triglyceride levels, and systolic and diastolic blood pressure (SBP and DBP) were monitored during a total of 677 visits. SBP and DBP, classified as <95p (groups 1s and 1d) and >95p (groups 2s and 2d), were correlated with differences between groups 1 and 2. Group 2s Scr and FENa levels were higher than group 1s (P =.002 and P =.048, respectively), whereas C0 and FENa levels were higher in Group 2d than Group 1d (P = 0.028 and P = 0.036, respectively). Among the entire group, SBP and DBP positively correlated with C0; Scr and SBP, with FENa. While there was a positive correlation between SBP and C0 in groups 1s and 2s (r = 0.188, P <.000; and r = 0.145, P =.040), DBP was only associated with C0 in group 1d (P =.03, r = 0.156). In contrast, DBP showed a positive correlation with Scr in group 2d (P =.023, r = 0.132), and SBP with Scr in Group 1s. C0 and Scr levels were correlated in Groups 1s, 1d and 2d. At high BP levels (>95p), SBP is mostly affected by C0; DBP, with Scr. However, in both groups these two parameters positively correlate with each other. Thus, in adolescent renal transplant recipients the cause of high blood pressure does not appear to be solely related to cyclosporine related to induced allograft dysfunction.

Evaluation of prosthetic mesh closure in semiopen-abdomen patients

BACKGROUND

To avoid the adverse consequences of abdominal compartment syndrome and to reduce the high mortality the celiotomy wound in patients with abdominal sepsis was closed without tension using prosthetic mesh. This produces a semiopen situation that permits staged reinterventions together with the functional reconstitution of the continuity of the abdominal wall.

MATERIAL AND METHODS

Twenty-five patients with intra-abdominal sepsis of various causes were evaluated retrospectively to assess the results of semiopen management of the septic abdomen and reoperations on demand in severe peritonitis. All of the patients were in a state of neglected peritonitis, and had at least one failing organ system. The Mannheim Peritonitis Index (MPI) scoring system was used for stratification of abdominal sepsis.

RESULTS

The mean MPI score of 25 patients was 24, ranging 10 to 33. Eight (32%) patients were reexplored (MPI=21). There were overall 9 (36%) complications in patients with mean MPI score of 23. Six (24%) mesh-related complications (infection and enterocutaneous fistulas) developed (MPI=19). The mean MPI score of patients without complications was 24. Four (16%) patients died with index MPI score of 26 due to fulminant hepatitis, myocardial infarction, and multiple organ failure. The admission period averaged 63 days.

CONCLUSIONS

In 25 critically ill patients with abdominal sepsis the mortality was lower than expected, relative to heterogeneous data from the literature; also, major complications occurred less frequently although the mean MPI score was high. The authors conclude that this approach is a reliable contribution to the complex treatment of these patients.

Malignant islet cell tumor of the pancreas associated with portal venous thrombus

In this report, CT and MR findings of a malignant islet cell tumor of the pancreas associated with tumor thrombus in the portal vein is presented. Imaging findings revealed diffuse involvement of the body and tail of the pancreas by the tumor. The most unusual finding was that this invasive tumor was an insulinoma.

Estrogens modulate experimentally induced apoptosis of granule cells in the adult hippocampus

Estrogens are known to have broad effects on neuronal plasticity, but their specific role in neuronal cell death has not been determined. In the present study, we investigated the effects of beta-estradiol on an experimental model of apoptosis of granule cells of the dentate gyrus, i.e., apoptosis induced by intraventricular injection of the microtubule polymerization inhibitor colchicine. Cell death was characterized with multiple methods, including TUNEL and DNA electrophoresis. Nonrandom digestion of DNA was observed within 8-10 hours after colchicine injection, followed by condensation and fragmentation of granule cell nuclei and extensive anterograde degeneration of mossy fibers/terminals in 2 days. We compared the outcomes of the above-described manipulation in ovariectomized or sham-operated rats and animals treated daily with beta-estradiol or vehicle. Animals were lesioned with colchicine or vehicle 2 weeks after ovariectomy or sham operation. Beta-estradiol or vehicle was administered for 1 week prior to lesion and was continued for a further 2 weeks. Total numbers and densities of granule cells in different animal groups were counted by stereology in various anteroposterior levels of the hippocampus. Our results show that ovariectomy intensifies colchicine-induced granule cell apoptosis, which is ameliorated by exogenous beta-estradiol. In doses that ameliorate the adverse effect of ovariectomy, exogenous beta-estradiol appears to have no effect of preventing granule cell death in animals with intact ovaries; i.e., an estrogen excess is not more neuroprotective than physiological levels of these hormones. Taken together, our results indicate that estrogen deprivation increases the vulnerability of hippocampal neurons to injury and may predispose to neurological diseases occurring after menopause.

Vertical banded gastroplasty in the Aegean Region of Turkey

BACKGROUND

Obesity is increasing in Turkey. The first experience with vertical banded gastroplasty (VBG) with regular intermediate-term follow-up in the Aegean Region of Turkey is presented.

METHODS

From November 1993 to August 1999, 40 morbidity obese patients underwent VBG. The patients were evaluated on the basis of excess weight loss (EWL) and satisfaction with the operation.

RESULTS

Regular follow-up was obtained in 38 patients (95%), with mean follow-up 27.2 months (14-85). Average preoperative body weight (BW) was 141.4 kg (93-238) and body mass index (BMI) was 52.3 kg/m2 (41-77.8). Average EWL was 64.1% (21.2-92.3). Average postoperative BW and BMI were 93.3 kg (70-145) and 34.4 kg/m2 (25.1-53) respectively. 35 of 38 patients (92%) lost more than 25% of EW and 28 of 38 (73.6%) lost more than 50% of EW. After weight loss, hypertension disappeared or improved in 86% of patients and diabetes resolved in 75%. Sleep apnea disappeared in 100% of patients. The early and late complication rates were 7.9% and 15.8% respectively. 33 of 38 patients (87%) were satisfied with the operation.

CONCLUSION

VBG was safe and effective, resulted in acceptable weight loss, and the vast majority of patients were satisfied.

Seroma prevention by using Corynebacterium parvum in a rat mastectomy model

Seroma formation is the most common complication after mastectomy and continues to be an important problem during the early postoperative period. Several surgical and medical methods have been developed to try to overcome this problem; however, so far none have been used successfully in the routine clinical practice. The aim of this study is to evaluate the effects of Corynebacterium parvum (CP) as a sclerosing agent in both prevention and treatment of seromas after mastectomy and axillary dissection in an animal model. Sixty female Sprague-Dawley rats underwent mastectomy and axillary dissection under general anaesthesia. Following surgery, the rats were treated in 1 of 3 ways. In the prevention group, 1 cm3 (0.35 mg) CP solution was injected beneath the skin flap just before closure of the incision after mastectomy. In the treatment group, animals in which a seroma was formed, the fluid was aspirated, and 1 cm3 CP solution was injected beneath the flap. In the control group, animals in which seromas formed, aspiration only was performed. The frequency of seroma formation decreased when CP solution was injected immediately after the operation (p < 0.01). In addition, seroma formation was effectively treated by CP injection when compared with the control group (p < 0.05). CP was effective as a prophylactic agent in the prevention group and as a therapeutic agent in the treatment group in this experimental model. CP injection may be useful for the management of this problem in a clinical setting.

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.

[Effectiveness of the Mannheim Peritonitis Index in patients with peritonitis]

Classification of patients regarding to outcome in early periods of peritonitis or intra-abdominal sepsis, has always been a primary goal of intensive care physicians. In order to predict outcome, a wide variety of scoring systems have been proposed. Mannheim Peritonitis Index (MPI) is one of the most effective scoring systems and its predictive value has been shown previously. Three hundred and twenty five patients that were admitted to Emergency Services in both Ege and Dokuz Eylül University Hospitals between 1995 and 1999, have been evaluated retrospectively by using patient records. Among them, 258 patients (79.4%) have been discharged in well condition and 67 patients died (20.6%). In the latter, MPI scores were always equal or more than 26. Mean MPI scores were 30.23 7.05 and 18.55 6.67 in exitus group and discharged group respectively. When all descriptive factors in MPI have been evaluated separately, every predictor was revealed statistically significant differences between exitus and discharged groups. It has been concluded that MPI is effective scoring system in terms of predicting final outcome in patients with peritonitis and intraabdominal sepsis.

Nerve growth factor expression and release in allergic inflammatory disease of the upper airways

It is well known that allergic airways disease is characterized by inflammation and hyperresponsiveness, but the link between these two conditions has not been elucidated. We have previously shown that in allergic rhinitis, hyperresponsiveness is attributable to increased neural reactivity. We thus hypothesized that nerve growth factor (NGF), which is expressed by inflammatory cells and effects changes that lead to increased neural responsiveness, could be a pivotal mediator in this disease. Using reverse transcription-polymerase chain reaction (RT-PCR), Western immunoblotting, and ELISA to evaluate NGF expression and release, we found that subjects with allergic rhinitis have significantly decreased NGF mRNA in superficial nasal scrapings and significantly higher baseline concentrations of NGF protein in nasal lavage fluids, compared with control subjects. Nasal provocation with allergen significantly increased NGF protein in nasal lavage fluids of subjects with allergic rhinitis, but not of control subjects. The concentrations of NGF protein in nasal lavage fluids were not affected by provocation with the vehicle for allergen or with histamine. These data provide the first evidence of a steady state of dysregulation in mucosal NGF expression and release in allergic rhinitis, and support a role of this neurotrophin in the pathophysiology of allergic inflammatory disease of the human airways.

Inflammatory fibroid polyp presenting with intestinal invagination: sonographic and correlative imaging findings

We report a case of a large inflammatory fibroid polyp of the small bowel presenting with intussusception in a 22-year-old man. Sonography demonstrated a solid, mobile, homogeneous, echogenic mass surrounded by the typical mural layers of an invaginated ileum. CT demonstrated a well-defined intraluminal solid mass with an attenuation of 17 HU. The pathologic diagnosis after segmental ileal resection was ileal inflammatory fibroid polyp.

Perforated solitary ulcer of the colon. Report of a case

PURPOSE

A patient with a solitary colonic ulcer had sudden onset of crampy abdominal pain, anorexia, fever, and vomiting, with signs of positive peritoneal irritation.

METHODS

The diagnosis was proved by histopathologic examination of right hemicolectomy material.

RESULTS

An emergency laparotomy, with right hemicolectomy and ileotransversostomy, gave complete relief from symptoms. The patient was still asymptomatic at the two-year follow-up, and control colonoscopic examinations performed at 6 and 18 months after the operation were normal.

CONCLUSION

Preoperative diagnosis of perforated solitary colonic ulcers localized at the right hemicolon may mimic acute appendicitis, and intraoperative findings may mimic colonic carcinoma. If the preoperative diagnosis is not certain, right hemicolectomy and ileotransversostomy, with regular colonoscopic controls, is a safe procedure in the treatment and follow-up of these patients.

Multiple large pyogenic liver abscesses of the tropics: a new entity

BACKGROUND

Pyogenic liver abscesses most commonly occur in males in -he sixth decade, are usually associated with biliary tract disease, malignancy and immunosuppression and the mortality rate is high. We describe another form of pyogenic abscess occurring in females which, if treated aggressively, carries a much better prognosis.

METHODS

Between 1986 and 1993 we treated 8 patients with multiple pyogenic liver abscesses. Diagnosis was established by ultrasound and CT scan followed by needle aspiration to confirm pus. Amoebic aetiology was excluded by a serology, poor response to metronidazole and biopsy of the abscess wall.

RESULTS

The mean age of our patients was 30 +/- 7 years and there were 2 males and 6 females. They presented with fever and abdominal pain for more than 2 months, tender hepatomegaly, a raised ESR and alkaline phosphatase. US and CT scans showed multiple large abscesses in the right lobe. Histology suggested chronic inflammation and with no definite organism isolated except for visceral larva migrans in one case. All patients underwent surgery--deroofing with drainage was done in four, segmental hepatic resection in three and right hepatectomy in one. One patient had a recurrence and underwent repeated resection. Only one patient died and 7 did well with no recurrence at a mean followup of 24 +/- 27 months.

CONCLUSIONS

Large multiple cryptogenic pyogenic abscesses of the liver occurring mostly in young females, which respond well to aggressive excisional surgery may constitute a distinct clinical entity.

The effects of lithotripsy on adrenocortical hormones

In order to evaluate the effects of lithotripsy (ESWL) on adrenocortical hormone levels, we prospectively compared blood ACTH, cortisol, aldosterone and DHEA-S levels of patients treated by lithotripsy and with elective operative cholecystectomy for biliary stone disease. After surgery, blood cortisol and ACTH levels were increased significantly at 16 hours (p < 0.05) and returned to normal at 40 hours while in the ESWL group the aforementioned enzyme levels were elevated significantly at 16 and 40 hours after ESWL (p < 0.05). The comparison of two groups at 16 hours showed no difference (p > 0.05). DHEA-S levels were elevated significantly at 16 hours after lithotripsy (p < 0.05) but the elevations after surgery were not significant (p > 0.05). Aldosterone levels were elevated significantly in both groups (p < 0.05) but the comparison of the two groups showed no difference (p > 0.05). In conclusion, ESWL induces trauma to the neuroendocrine system and the duration of the response is longer when compared with surgical trauma.

Management of nipple discharge

In a series of 9,312 women who consulted one of the authors with a complaint of disease of the breast between 1959 and 1991, nipple discharge was the presenting symptom in 448 (4.8 percent). Nipple discharge was spontaneous in 243 (2.6 percent) and provoked in 205 (2.2 percent) of the patients. The ages of the patients ranged from 13 to 75 years (mean of 42.5 years) in the spontaneous and 16 to 70 years (mean of 37.8 years) in the provoked discharge group. When a palpable mass was found, biopsy was undertaken, while in instances of nipple discharge only, subareolar exploration was performed. Of the 115 patients in the spontaneous and 25 patients in the provoked groups who underwent biopsy, the most frequent cause of nipple discharge was intraductal papilloma (47.8 percent). Nipple discharge was the result of carcinoma in 35 patients (14.4 percent) in the spontaneous and six patients (2.9 percent) in the provoked group, respectively. In patients with a palpable mass, the incidence of carcinoma was 61.5 percent compared with 6.1 percent in patients with nipple discharge only. Patients presenting with nipple discharge should undergo biopsy or subareolar exploration based on the presence or absence of a palpable tumor. The patients in whom no clinical findings could be detected should have follow-up evaluation at regular intervals.

Gallstone recurrence after shock wave therapy

Fifty-three patients with complete clearance of all gallstone fragments after combined extracorporeal shock wave lithotripsy (ESWL) oral litholytic therapy were included in the study. Eight patients had recurrence of gallstones within the first year at follow-up evaluation. The rate of gallstone recurrence was 15.2 percent within the first year. Four of these eight patients reported biliary pain, the other four remained asymptomatic. The incidence of gallstone recurrence was high in patients who had multiple stones before ESWL treatment (p < 0.05). Age above 60 years was also associated with a higher rate of gallstone recurrence (p < 0.05).

The effects of vitamin E on immune regulation after thermal injury

Studies were conducted on four groups of rats, each group consisting of 10 rats with burn + vitamin E, burn + saline solution, control + vitamin E and control + saline solution. Before and after burning 250 mg (2 cm3) of vitamin E was given intramuscularly. On the same days 2 cm3 of saline solution was given to the controls. The rats were burned over 30 per cent of their body surface area and then inoculated intraperitoneally with 40 units of tetanus toxoid. Complement fixation and acid phosphatase tests were carried out on the days 15 and 21 postburn. On day 21, the rats were killed and the spleens removed and weighted. In the groups that received vitamin E, the spleen weight and complement fixation test increased significantly while the acid phosphatase in serum decreased. In the clinical study, 17 burned patients with over 20 per cent deep partial or full skin thickness burns and eight healthy persons were studied. Nine of the 17 burned patients received vitamin E on 3 consecutive days, on day 4 blood was taken for analysis. The results showed that the number of T-cells decreased significantly in burn patients (P less than 0.05) whereas they increased significantly (P less than 0.05) in burn patients who received vitamin E. It is concluded from these experimental and clinical studies that vitamin E stimulates both cellular and humoral immunity. Therefore, the use of vitamin E in combination with conventional therapy in burn patients can be recommended.

A simple technique for wedge biopsy of the liver

A technique for wedge biopsy of the liver is presented. By applying pressure on the liver, biopsy is performed. Cauterization of the bleeding surfaces in small areas provides hemostasis without need for sutures and hemostatic agents.