Mesenchymal hamartoma of the liver in adulthood: immunohistochemical profiles, clinical and histopathological features in two patients

Mesenchymal hamartoma is an uncommon cystic mass of the liver which occurs primarily in children. There are a few reports of its occurrence in adulthood. Here, we present two cases in female patients, 54 and 51 years old. Radiological examinations in both patients showed multiple cystic lesions in the liver. Surgically, total cystectomy was performed in the first patient, while an unroofing procedure was done in the second patient (due to misdiagnosis of the lesion as a simple cyst of the liver). On microscopic examinations of the lesion in each patient, a multilocular cyst was observed, lined by flattened epithelium and surrounded by a mesenchymal component composed of mature connective tissue, arterial and venous vascular structures, peripheral nerve bundles, and ductal structures. An immunohistochemical panel consisting of desmin, smooth-muscle actin, S-100, vimentin, CD34, carcinoembryonic antigen, pancytokeratin, cytokeratin 7, cytokeratin 8, cytokeratin 17, cytokeratin 18, cytokeratin 19, and cytokeratin 20 was applied to paraffin sections. Immunoreactivity for cytokeratin 7 and cytokeratin 19 was observed in cystic epithelium and ductal structures. Focal and patchy desmin immunoreactivity was observed in connective tissue. S-100 was positive only in peripheral nerve bundles. In conclusion, mesenchymal hamartoma of the liver in adulthood is a localized tumoral abnormality that precedes birth, and which has delayed clinical presentation. These lesions seems to be related to a maturation process. During this period of maturation, immature edematous stroma rich in mucopolysaccharides may convert to mature paucicellular hyalinized connective tissue. This maturation process may be also related to loss of premalignant potential of these tumors.     

Unilateral brachial artery antegrade selective cerebral perfusion following carotid endarterectomy for carotid, coronary, and aortic aneurysmal surgery

Abstract   In the presence of multiple concomitant occlusive and aneurysmal diseases, selection of the brain protection method is a primary concern. A case with a disease triad of stenotic lesions in internal carotid arteries, coronary artery atherosclerosis, and an ascending-arcus aorta aneurysm is presented. We simultaneously performed right carotid endarterectomy, coronary artery bypass grafting, and graft replacement of the ascending-arcus aorta. Brain protection was achieved with continuous right brachial artery antegrade selective cerebral perfusion under moderate hypothermia, following carotid endarterectomy. The operative technique is detailed and antegrade selective cerebral perfusion following the carotid endarterectomy for aneurysmal surgery is discussed.     

Ambulatory blood pressure monitoring in healthy children with parental hypertension

The aim of this study was to compare ambulatory blood pressure monitoring (ABPM) parameters in offspring with at least one hypertensive parent (HP) to offspring with normotensive parents (NP) and to determine whether gender of parent or child might influence the association between parental hypertension and blood pressure (BP). Eighty-nine healthy children (mean age 11.1 ± 3.9 years) with HP and 90 controls (mean age 10.5 ± 3.1 years) with NP were recruited. Age, gender, and height did not differ between the two groups, whereas children of HP had higher weight, body mass index (BMI), and waist circumference compared with healthy controls. No difference was found in casual BP between the two groups. In contrast, during ABPM daytime and nighttime mean systolic and diastolic BP and mean arterial pressure (MAP) standard deviation scores (SDS) were significantly elevated in children with HP. The mean percentage of nocturnal BP decline (dipping) was not significantly different between the two groups. Children with hypertensive mothers had higher daytime systolic and MAP SDS than controls; no such difference was detected for children with hypertensive fathers. Daytime systolic and MAP SDS were significantly elevated in boys with HP compared with boys with NP but failed to be significant in girls. Multiple linear regression analysis showed that parental history of hypertension (B = 0.29) and BMI (B = 0.03) were independently correlated with increase of daytime MAP SDS. Early changes in ambulatory BP parameters were present in healthy children of HP. BP in HP offspring was influenced by the gender of the affected parent and the offspring.     

A novel antioxidant agent caffeic acid phenethyl ester prevents shock wave-induced renal tubular oxidative stress

The aim of this study was to evaluate the effects of the novel free radical scavenger caffeic acid phenethyl ester (CAPE) on extracorporeal shock wave lithotripsy (ESWL) induced renal impairment. The study was performed using 30 rabbits which were divided into two groups, each exposed to 3,000 shock waves at 18 kV: (1) control group, (2) ESWL+CAPE treated group. Malodialdehyde (MDA), urine N-acetyl--glucosaminidase (NAG) activity, uric acid and white cell counts were used as markers of oxidative stress. Following shock wave exposure there was a significant rise in MDA, NAG and uric acid and white cell counts. CAPE reduced the rise in MDA, NAG, uric acid and white cell counts. Thus CAPE treatment to a great extent prevented the induction of these renal changes. Our results suggest that the antioxidant capacity of the kidney tissue was reduced after ESWL treatment and that the tissue was exposed to oxidant stress. We conclude that CAPE treatment provided significant protection against ESWL induced free radical damage.     

Preoperative multimodal administration of morphine in arthroscopic surgery

Introduction The aim of the study was to demonstrate the possible effects of preoperative intra-articular, intravenous, or intrathecal administration of morphine on postoperative pain management.Materials and methods Sixty patients undergoing arthroscopic menisectomy were included. Spinal anesthesia was performed in the lateral decubitus position with 3 ml of 0.5% hyperbaric bupivacaine, and the patients were randomized into 4 groups. The IVM (intravenous, iv, morphine) group received 3 mg of iv morphine after completion of spinal anesthesia, the ITM (intrathecal morphine) group received 0.3 mg of morphine together with bupivacaine during spinal anesthesia, the IAM (intra-articular morphine) group received 3 mg intra-articular morphine diluted in 10 ml of saline after spinal anesthesia had been induced but 15 min before surgery, while the C (control) group did not receive any drugs in addition to spinal anesthesia. The sensory block level was determined 15 min after spinal anesthesia. Pain at rest (by visual analogue scale, VAS) and pain at 30° of flexion (by verbal rating scale, VRS) were evaluated during each of the first 2 h of the postoperative period and once every 4 h thereafter until 24 h. In each group; the number of patients in need of analgesics, the timing of the first analgesic intake (duration of analgesia), and the cumulative dose of analgesics were recorded.Results The mean duration of analgesia in the IAM group was significantly longer and the mean analgesic intake was significantly lower when compared with the other groups (p<0.05). The mean VAS value of the ITM group at the 4th postoperative hour was significantly lower than that of the other groups. Mean VAS values at 8 and 12 h and mean VRS values at 4 and 8 h were significantly lower in the ITM and IAM groups (p<0.05). The ITM group had the highest rates of nausea, vomiting, pruritus, and headache (p<0.05).Conclusion It was concluded that the preoperative administration of morphine, either intrathecally or intra-articularly, provides postoperative pain relief. Of these two, the intra-articular route seems to be superior in terms of fewer side-effects (nausea, vomiting, and pruritus), longer duration of analgesia, and reduction of total need for analgesics.     

Apoptosis and proliferation in human undescended testes

OBJECTIVE: To study apoptosis and proliferation in the testes of children with undescended testes; the degree to which undescended testes contributes to a patient's ultimate fertility is debatable, but undescended testes have fewer germ cells, and some have proposed that apoptosis is an important cause. PATIENTS AND METHODS: Testis biopsies were taken at the time of orchidopexy in a consecutive series of children undergoing surgical repair for undescended testes. Immunohistological techniques were used to detect apoptosis and proliferation, and the numbers of cells undergoing apoptosis or proliferation per 50 seminiferous tubules were recorded. RESULTS: Inguinal testes had less apoptosis than abdominal testes, with a mean (sd) of 0.71 (1.31) vs 1.63 (1.95) apoptotic cells per 50 seminiferous tubules (P < 0.02). Similarly, there was less apoptosis in children aged > 1 years than in children aged < 1 years (0.68 (1.40) vs 1.35 (1.56); P < 0.03). Proliferation was very limited in all cryptorchid testes. In contrast to cryptorchid testes, five autopsy controls had many more apoptotic cells, (10.60 (1.34) per 50 seminiferous tubules), and many more proliferating cells, (8.40 (6.43) per 50 seminiferous tubules). CONCLUSION: In contrast to animal studies, neither apoptosis nor proliferation was common in undescended testes from 6 months of age onward. However, apoptosis was more common in abdominal testes and in children aged < 1 year. It is likely that, if substantial apoptosis occurs in human undescended testes, it occurs before 6 months of age.     

Anatomy, biomechanics, and pathophysiology of instability of the glenohumeral joint

The stability of the shoulder is dependent on both static and dynamic anatomic restraints. In most cases, there must be insufficiency of more than one restraint for the shoulder joint to become instable. Although the role of these restraints is largely known in maintaining shoulder stability, our information on their interactions is insufficient. This article reviews the anatomy and biomechanics of the shoulder and conditions causing instability of the glenohumeral joint.     

Delayed Reduction of Irreducible Chronic Posterolateral Dislocation of the Knee with Buttonholing of the Medial Femoral Condyle

Abstract Traumatic knee dislocations are relatively rare and almost always respond to closed reduction; however, a small percentage of knee dislocations are irreducible and in these cases open reduction is frequently required. A 65-year-old man with an unreduced posterolateral knee dislocation with laterally dislocated patella was seen 3 weeks after a motor vehicle accident. Medial femoral condyle was found buttonholed through the medial capsule together with the medial collateral ligament and lying in the medial joint space that allowed posterior rotary dislocation of the joint. Both cruciate ligaments and medial meniscus were torn. There was no evidence of any vascular or nerve injury. Reduction was accomplished by removal of the capsuloligamentous structures which were incarcerated in the trochlea and intercondylar notch and by excision of meniscal tear. Following posterior cruciate ligament reconstruction with patellar tendon autograft, lateral patellar release, vastus medialis advancement, and gracilis transfer were done.