Clinical characteristics of thrombotic microangiopathy following ABO incompatible living donor liver transplantation.

Thrombotic microangiopathy (TMA) may develop after living donor liver transplantation (LDLT), but the mechanism is not fully understood. We retrospectively analyzed all patients undergoing LDLT at our center, including TMA patients, to elucidate the clinical characteristics and presentation and to determine which patients have a higher risk of occurrence of TMA. In all, 57 adult patients were reviewed after LDLT at our institution. TMA was diagnosed by sudden and severe thrombocytopenia, followed by hemolytic anemia with fractionated erythrocytes in the blood smear. Clinical features were compared between the TMA group and the non-TMA group. Of the 57 patients, 4 were diagnosed with posttransplantation TMA. ABO blood group (ABO)-incompatibility, cyclophosphamide (CPA), and recipient blood group (type O) were closely correlated with the occurrence of TMA. Thrombocytopenia appeared 1 to 5 days before hemolytic anemia. Coagulative function markers stayed at the same level after TMA, while marked elevation was shown in fibrinolytic function markers such as plasminogen activator inhibitor type 1 (PAI-1). TMA occurred at a higher prevalence in ABO-incompatible graft recipients. Additional factors associated with ABO-incompatible transplantation, such as an overdose of immunosuppressants, may affect the likelihood of TMA. Sudden and severe thrombocytopenia presented before hemolytic anemia and the serum levels of PAI-1 correlated well with the clinical course of TMA. In conclusion, early recognition of thrombocytopenia and elevation of PAI-1 is crucial to diagnose TMA especially in ABO-incompatible LDLT.     

Skeletonization of internal thoracic artery affects its innervation and reactivity.

OBJECTIVE: The studies showing the superior characteristics of ITA graft and its impact on the clinical results of coronary artery surgery were performed with ITA harvested almost exclusively as a pedicle. This study assesses the impact of ITA skeletonization on its innervation and reactivity. METHODS: Segments of skeletonized and non-skeletonized ITA were stained with antibodies against protein S-100 to look for the presence of sympathetic nerve fibers. The functional studies were performed on segments of discarded human pedicled ITA that were divided into two 3mm rings, one skeletonized and another non-skeletonized. We compared concentration-effect relationships for the contraction to norepinephrine and endothelium-dependent relaxation to acetylcholine and bradykinin, as well as endothelium-independent relaxation to sodium nitroprusside in skeletonized and non-skeletonized segments of the same ITA. RESULTS: Skeletonized ITA was devoid of protein S-100 positive nerve fibers. It contracted stronger (maximal response 37.0+/-2.04 vs. 25.4+/-1.83mN (P<0.001)) and was twice as sensitive to norepinephrine: pD(2) 6.03+/-0.10 vs. 5.70+/-0.12 (P=0.035). The endothelium-dependent relaxation responses did not differ between skeletonized and non-skeletonized ITA rings. The skeletonized ITA rings appeared over 10 times more sensitive to sodium nitroprusside: pD(2) 6.66+/-0.20 vs. 5.59+/-0.37 (P=0.012)-potency ratio 11.61. The maximal responses did not differ significantly: 112.0+/-6.71 vs. 129.4+/-16.4% (P=0.33). CONCLUSIONS: Skeletonization results in sympathectomy of ITA. It has no effect on endothelium-dependent relaxation but increases reactivity of ITA to norepinephrine. This augmented response to alpha-agonist is small, in comparison with over a ten-fold increase in sensitivity to sodium nitroprusside. Pedicled and skeletonized ITA are functionally significantly different vessels when studied in vitro.     

A Case of Postsurgical Pancreatic Pseudocyst Treated by Endoscopic Cystogastrostomy

Pancreatic pseudocyst after pancreatic surgery is a relatively rare condition and conservative therapy is the common treatment of choice. When symptoms persist or complications follow, however, surgical treatment is considered. There have been reports on endoscopic cystoenterostomy since the early 1980s. We herein describe a case of postsurgical pancreatic pseudocyst treated successfully by endoscopic cystogastrostomy. A nineteen-year-old female showing left hypochondralgia and back pain with elevation of her serum amylase level, who had undergone enucleation of a solid cystic tumor in the body of the pancreas, was referred to our department. She was diagnosed as having a pseudocyst of the pancreas 5.8×4.5 cm in size at the site of enucleation by US and CT. Endoscopic retrograde pancreatography and endoscopic ultrasonography performed simultaneously revealed obstruction of the main pancreatic duct and a cystic change in the body-tail of the pancreas just behind the gastric wall of the upper body. An extrinsic compression was seen in the posterior wall of the upper body of the stomach endoscopically. An incision was made using a sphincterotome. A pigtail stent, 7.2 Fr in size, was placed to keep the patency of the fistula, which was removed one and a half months later. Her symptoms showed great improvement immediately after the procedure. Follow-up CT demonstrated no recurrence of the pseudocyst.     

Post-streptococcal glomerulonephritis in Hong Kong.

Of 74 paediatric inpatients with acute glomerulonephritis, 58 (78%) had a raised (greater than 1/200) antistreptolysin O titre. Serum C3 concentration was low in 73, but returned to normal within six weeks. Streptococcal infection remains the commonest cause of acute nephritis in children in Hong Kong, possibly due to overcrowded living conditions.     

Long-term results of treatment for articular calcaneus fractures with Westhues method]

In this paper the authors evaluate the long-term results of treatment for articular calcaneus fractures with Westhues method. This evaluation is performed with regard to triple measurement of B?hler's angle value and to subjective criteria. The clinical material from years 1985-2002 consists of 47 patients aged between 24 and 56 years (mean age 32 years) with articular calcaneus fractures--namely, 41 male patients (87.2%) and 6 female patients (12.8%). The follow-up examination was performed in 24 patients (51% of all patients), namely, in 23 male patients (48.8%) and in one female patient (2.2%). Minimum follow-up time was 12 months and maximum was 9 years. Acquired results suggest that Westhues method restores normal B?hler's angle value only in tongue-type calcaneous fractures.     

Scintigraphic diagnosis of bile leakage after laparoscopic cholecystectomy. A prospective study.

To assess the role of Tc-99m IDA cholescintigraphy in diagnosing bile leakage and bile obstruction after laparoscopic cholecystectomy, 51 studies were performed in 51 patients on the first postoperative day. Two different radioactive bile acid analogs were used, Tc-99m HIDA and Tc-99m trimethylbromo IDA. Scintigraphic findings were correlated with the clinical conditions. Results of seven out of 51 cholescintigrams were abnormal, showing accumulations of activity in the right paracolic gutter. Of these seven patients, only three had clinical symptoms consisting of more than normal postoperative abdominal pain and peritoneal irritation. The other four patients had minimal abnormal accumulation in the right paracolic gutter and showed no clinical signs postoperatively. Complete common bile duct obstruction or other bile duct-related complications, except for bile leakage, were not observed. Cholescintigraphy is feasible for the early detection of bile leakage and bile flow obstruction after laparoscopic cholecystectomy in patients with increased postoperative abdominal discomfort.     

Cleaved variant of plasmacytoma with myelomonocytic differentiation--immunohistochemical and ultrastructural studies.

Although plasma cells are terminally differentiated B cells, neoplastic plasma cells frequently express not only pre-B cell antigen, but also megakaryocytic, myelomonocytic, or erythroid markers. Since morphologic diagnosis of plasmacytoma is based on the recognition of neoplastic cells closely resembling normal plasma cells, unusual morphologic variants of neoplastic cells associated with these aberrant immunohistochemical features frequently cause diagnostic difficulty. The authors report a case of plasmacytoma with cleaved nuclei and myelomonocytic features occurring in the clavicle. The tumor was composed of immature plasma cells showing irregular, cleaved, and multilobated nuclei and abundant cytoplasm with prominent eosinophilic granules. A few tumor cells showing recognizable plasmacytic differentiation were admixed within the tumor. Immunohistochemically, the tumor cells expressed CD45RB, CD68, lysozyme, myeloperoxidase and kappa light chain with focal positivity for lambda chain. Ultrastructurally, the tumor cells contained numerous membrane bound electron dense lysosomal granules, some of them resembling Auer rods, as well as rough endoplasmic reticula arranged in lamellated stacks. Small biopsied nasal mucosal tissue in same patient revealed well differentiated plasmacytoma composed of tumor cells showing round, eccentric nuclei devoid of marked nuclear cleavage and cytoplasmic granularity. Immunohistochemically, these cells were kappa(+), lambda(-), myeloperoxidase(-), lysozyme(-) and CD68(-).     

Surfactant-induced cell toxicity and cell lysis. A study using B16 melanoma cells

The effects of a variety of detergents (non-ionic, ionic and bile derivatives) on B16 melanoma cells have been examined. Two main effects can be clearly differentiated: loss of cell viability and cell lysis. Under our conditions, cell-surfactant interaction is highly dependent on the nature of the amphiphile (more specifically, on its critical micellar concentration). Loss of cell viability occurs at surfactant concentrations below the critical micellar concentration, i.e. the incorporation of detergent monomers into the cell membranes is enough to impair their barrier function, so that Trypan Blue is no longer actively secreted outside the cell. On the other hand, cell lysis only occurs at or near the critical micellar concentration of the detergent, i.e. when the bilayer-micelle transition may take place. Comparative studies using B16 cells and phospholipid vesicles indicate that the amount of detergent required to induce cell lysis is the same that produces disruption of the lipid bilayer. Thus, our results suggest that membranes are the primary target for the toxicologic effects of surfactants on cells. Moreover, they provide a rationale for the interpretation of other studies in this field: previous results from different laboratories are shown to fit very well our data.     

A rare case of nasopharyngeal angiofibroma in an elderly female

Nasopharyngeal angiofibromas occur predominantly in males in their puberty and adolescence; the incidence in other age groups and in women is exceptional. This report describes a case of a 57-year-old woman with nasopharyngeal angiofibroma presenting typical radiological findings in computed tomography, MR imaging and angiography. The tumour was successfully removed and histopathological examination confirmed the diagnosis. In 6 years follow-up the patient is free of symptoms.