Fulminant hepatic failure from primary hepatic lymphoma: successful treatment with orthotopic liver transplantation and chemotherapy

Systemic lymphomas may involve the liver but rarely cause fulminant hepatic failure (FHF). Acute liver failure from primary hepatic lymphoma (PHL) is even less common with most patients succumbing to the sequelae of FHF before the correct diagnosis is made. We report a patient who underwent successful orthotopic liver transplant (OLT) and chemotherapy for FHF secondary to PHL. This previously-well male developed profound coagulopathy and encephalopathy 6 weeks after the onset of jaundice and fatigue. Workup failed to reveal the underlying cause of his liver failure and the patient soon required urgent OLT. Pathologic evaluation of his explanted liver revealed a malignant T-cell rich, large B-cell non-Hodgkin's lymphoma with widespread hepatocellular necrosis. The patient made an excellent clinical recovery and is undergoing CHOP-Rituxan chemotherapy. This scenario demonstrates that lymphoma should be considered in the differential diagnosis of FHF without clear etiology because of the potential for intervention with transplant and chemotherapy.     

Differing effects of N(G)-monomethyl L-arginine and 7-nitroindazole on detrusor activity

AIMS: Previous studies reported that nitric oxide (NO) synthase (NOS) inhibition decreases micturition volume threshold (MVT), the volume required to produce a centrally mediated micturition contraction, and that NO can be released from urothelium by means of certain stimuli. With elucidation of multiple isoforms of NOS, studies were performed to determine whether inhibition of specific isoforms of NOS altered MVT in different ways. METHODS: In naive, anesthetized cats, the urinary bladder was exposed by means of a midline abdominal incision and cannulated through a slit in the internal urethra approximately 4-5 cm distal to the neck of the bladder. The left renal artery and left radial vein were cannulated for the intra-arterial and intravenous administration of drugs, respectively. All nerves were left intact. A control MVT was determined by slowly infusing saline into the bladder at a rate of 0.018 mL/kg per minute. Varying doses of L-NMMA (N(G)-monomethyl-L-arginine) or 7-NI (7-nitro indazole) were administered and the MVT was again determined. RESULTS: Inhibition of endothelial NOS (eNOS), by L-NMMA, or neuronal NOS (nNOS), by 7-NI, produces varying effects on certain detrusor activities and that inhibition of different isoforms of NOS produces qualitatively different effects. L-NMMA significantly decreases MVT (up to 60% decrease), whereas 7-NI significantly increases MVT (over 300% increase). L-NMMA increases frequency and onset of small bladder contractions, whereas 7-NI produces opposite effects. CONCLUSIONS: The results suggest that detrusor relaxation and contractility may be modulated by NO levels and that NO released from the urothelium may be a mediator of detrusor relaxation during the storage phase of micturition.     

Effects of maximal static apnea on antioxidant defenses in trained free divers

PURPOSE: To investigate the effects of maximal static apnea on plasma antioxidant status, oxidative stress, and antioxidant enzyme activities in trained free divers. METHODS: Blood was taken from apnea-trained (Tr) and control (Con) subjects at baseline (B) and after one (A1), three (A3), and five (A5) apneas. Trolox equivalent antioxidant capacity (TEAC), ferric reducing ability of plasma (FRAP), uric acid, and bilirubin assays assessed plasma antioxidant status and malondialdehyde (MDA) quantified the oxidative stress response. The activities of erythrocyte antioxidant enzymes superoxide dismutase (SOD), glutathione peroxidase (GPx), and catalase (CAT) were determined at baseline and after the fifth apnea. RESULTS: TEAC was significantly higher in divers versus controls after A1 (P < 0.05). A group effect of SOD activity indicated higher activity throughout the protocol in Tr (mean +/- SD; Con, 43.2 +/- 10.1 U.g Hb; Tr, 50.1 +/- 7.3 U.g Hb; P = 0.04). With no other group differences, the groups' data were combined. Apnea significantly increased SOD (B, 44.1 +/- 11.1 U.g Hb; A5, 48.1 +/- 7.5 U.g Hb; P < 0.05) and GPx activity (B, 60.5 +/- 14.9 U.g Hb; A5, 70.1 +/- 16.0 U.g Hb; P = 0.02); however, CAT activity decreased (B, 5.25 +/- 0.59 U.mg Hb; A5, 5.00 +/- 0.53 U.mg Hb; P = 0.03). MDA was unaffected by apnea (P = 0.32). CONCLUSIONS: Trained free divers have increased SOD activity during apnea; however, there is little difference in their antioxidant and oxidative stress responses compared with controls. In both groups, acute changes in antioxidant enzyme activities suggest that they may protect from excessive antioxidant depletion and oxidative stress during apnea.     

Young patients with shoulder chondrolysis following arthroscopic shoulder surgery treated with total shoulder arthroplasty

Chondrolysis following shoulder arthroscopy is a devastating complication, often seen in young patients. After nonoperative measures have been exhausted, there are few treatment options available that reliably improve pain and function. The purpose of this study is to examine the intra-operative findings, radiographic features, and clinical outcomes of a series of patients with chondrolysis following arthroscopic surgery managed with a total shoulder arthroplasty. A retrospective review was performed on 11 patients (average age 39) with shoulder chondrolysis following arthroscopy. Attention was focused on review of the index arthroscopy, radiographs, and functional outcome scores prior to total shoulder arthroplasty, as well as intra-operative cultures, histology, radiographs, and functional outcomes from most recent follow-up. All patients were treated with total shoulder arthroplasty at an average of 26 months after the index arthroscopy. Preoperative and postoperative radiographs were reviewed, and outcomes were compared using validated measurements. Statistically significant improvements in shoulder abduction (89 degrees -123 degrees , P = .027), external rotation (26 degrees -48 degrees , P = .037), total ASES scores (30-77.5, P = .0039), and SST scores (3-8, P = .0078) were noted. Ten patients subjectively rated their outcomes as good or excellent, with 1 as satisfactory. Chondrolysis after shoulder arthroscopy has a rapid clinical progression and is likely multifactorial in etiology. Early results of total shoulder arthroplasty show an opportunity for improvements in pain and function; however, progressive glenoid radiolucencies may develop in these patients.     

Down-regulation of urea transporters in the renal inner medulla of lithium-fed rats

BACKGROUND: Lithium is commonly used to treat bipolar psychiatric disorders but can cause reduced urine concentrating ability. METHODS: To test whether lithium alters UT-A1 or UT-B urea transporter protein abundance or UT-A1 phosphorylation, rats were fed a standard diet supplemented with LiCl for 10 or 25 days, and then compared to pair-fed control rats. To investigate another potential mechanism for decreased urea transport, inner medullary collecting duct (IMCD) suspensions from lithium-fed or control rats were incubated with 32P-orthophosphate to measure the phosphorylation of UT-A1. RESULTS: In lithium-fed rats (25 days), UT-A1 abundance was reduced to 50% of control rats in IM tip and to 25% in IM base, and UT-B abundance was reduced to 40% in IM base. Aquaporin-2 (AQP2) protein abundance was reduced in both IM regions. Vasopressin (100 pmol/L) increased UT-A1 phosphorylation in IMCD suspensions from control but not from lithium-fed rats; a higher vasopressin concentration (100 nmol/L) increased UT-A1 phosphorylation in control and lithium-fed rats. CONCLUSIONS: Decreases in UT-A1, UT-B, and AQP2 protein abundance, and/or vasopressin-stimulated phosphorylation of UT-A1, can contribute to the reduced urine concentrating ability that occurs in lithium-treated rats.     

Periacetabular osteotomy through a modified ollier transtrochanteric approach for treatment of painful dysplastic hips

BACKGROUND: Elimination of abnormally high joint-loading resulting in excessive contact stresses may prevent or reduce the onset of osteoarthrosis in a dysplastic hip. A number of periacetabular osteotomies have been shown to be effective in restoring normal hip-joint mechanics. We treat acetabular dysplasia with a periacetabular osteotomy performed through a modified Ollier transtrochanteric approach. In this report, we describe the operative technique and the clinical and radiographic results. METHODS: Thirty-six patients (thirty-eight hips) in whom a painful dysplastic hip had been treated with a periacetabular osteotomy between March 1991 and June 1999 were included in the study. There were thirty-five female patients and one male patient with a mean age (and standard deviation) at the operation of 29.42 +/- 9.1 years. The technique utilizes a u-shaped skin incision, and a routine osteotomy of the greater trochanter with distal transfer if needed, and allows excellent visualization enabling the surgeon to perform the periacetabular osteotomy without penetrating the joint. RESULTS: At a mean of five years and six months postoperatively, the mean modified Harris hip score had improved from 59.1 +/- 15.8 points preoperatively to 87.97 +/- 14.3 points. Radiographically, the degree of osteoarthrosis had decreased in eleven hips, remained unchanged in twenty-four, and worsened in three. The mean anterior center-edge angle had increased from 22.0 degrees +/- 12.9 degrees to 36.1 degrees +/- 12.3 degrees, the mean lateral center-edge angle had increased from -2.7 degrees +/- 14.4 degrees to 26.6 degrees +/- 14.1 degrees, the mean acetabular index angle had improved from 23.4 degrees +/- 6.6 degrees to 12.7 degrees +/- 4.6 degrees, and the mean acetabular head index had increased from 48.2% +/- 12.7% to 73.1% +/- 16.0%. The Shenton line was restored in eleven hips. Thirty patients (thirty-two hips; 84%) had a satisfactory result. A poor preoperative functional score was associated with an unsatisfactory outcome (p = 0.00191). Complications included prolonged limping (eleven hips); numbness in the distribution of the lateral femoral cutaneous nerve (four); osteonecrosis of the rotated acetabular fragment (two); and acetabulofemoral impingement, heterotopic ossification, and a defect on the rotated ilium (one hip each). CONCLUSIONS: Painful dysplastic hips should be treated before function becomes seriously impaired. We believe that periacetabular osteotomy through a modified Ollier approach, which allows osseous cuts to be made under direct vision, can be learned readily. It provides improved femoral head coverage and relief of symptoms in most painful dysplastic hips in adolescents and young adults.     

Transverse plane pelvic rotation in adolescent idiopathic scoliosis: primary or compensatory?

Several studies have suggested that the pelvis is involved in the etiology or pathogenesis of adolescent idiopathic scoliosis (AIS). The purpose of this retrospective, cross-sectional radiographic study is to identify any correlation between the transverse plane rotational position of the pelvis in stance and operative-size idiopathic or congenital scoliosis deformities, using Scheuermann’s kyphosis and isthmic spondylolisthesis patients for comparison. The hypothesis tested was that the direction of transverse pelvic rotation is the same as that for a thoracic scoliosis. As a group, AIS patients had a significant transverse plane pelvic rotation in the same direction as the thoracic curve. When subdivided into the six Lenke curve patterns, this was true for the groups with a major thoracic curve: thoracic (1), double thoracic (2) and double curve patterns (3). It was not true for patterns with a major thoracolumbar/lumbar curve: single thoracolumbar/lumbar (5) and double thoracic-thoracolumbar/lumbar (6). Nor was it true for triple (4) curves. The Lenke 1 and 2 major thoracic curves without compensatory thoracolumbar/lumbar curves did not have the predicted pelvic rotation. All congenital scoliosis patients studied had main thoracic curves and significant transverse plane pelvic rotation in the same direction as the thoracic curve. There was no transverse plane pelvic rotation in the Scheuermann’s kyphosis or isthmic spondylolisthesis patients. We interpret these findings as consistent with a compensatory rotation of the pelvis in the same direction as the main thoracic curve in most patients with a compensatory thoracolumbar/lumbar curve as well as in patients with main thoracic congenital scoliosis.     

Hematoma-Directed Ultrasound-Guided (HUG) Breast Lumpectomy

Background Needle localization breast biopsy (NLBB) is presently the primary means of localizing non-palpable lesions. Disadvantages of NLBB include vasovagal episodes, patient discomfort, and miss rates. Because hematomas naturally fill the cavity after vacuum-assisted breast biopsies (VABB), we hypothesized that ultrasound (US) could be used to find and accurately excise the actual biopsy site of non-palpable breast lesions without a needle. Methods This is a retrospective study from January 2000 to July 2005. Electronic chart review identified patients with non-palpable breast lesions detected by means of mammogram who then underwent lumpectomy via NLBB or the hematoma-directed ultrasound-guided technique (HUG). HUG involved localizing the hematoma with a 7.5-MHz US probe and using the “line of sight” technique straight down toward the chest wall. A block of tissue encompassing the hematoma was then excised. Results Localization procedures were performed in 186 patients—63 (34%) via needle localization and 123 (66%) via HUG. The previous VABB site in 100% of patients was successfully excised using HUG, 65 of 123 (53%) were benign and 58 of 123 (47%) were malignant; margins were positive in 13 of these 58 (22%). NLBB was successful in 100% of patients, 44 of 63 (70%) were benign and 19 of 63 (30%) were malignant; margins were positive in 14 of these 19 (73%). Margin positivity was significantly higher for NLBB than HUG (P = 0.0001, Fisher Exact). Conclusions This study suggests that HUG is more accurate in localizing non-palpable lesions than NLBB. By eliminating the additional procedure needed for NLBB, HUG may also be more time- and cost efficient. HUG makes VABB not only a less invasive diagnostic procedure, but also a localization procedure. Margaret Thompson: Supported by the Virginia Clinton Kelley/Fashion Footwear Association of New York Breast Cancer Research Fellowship Aaron Margulies: Supported by the Susan G. Komen Breast Cancer Clinical Fellowship     

Molecular approaches to urea transporters

Urea plays a critical role in the urine-concentrating mechanism in the inner medulla. Physiologic data provided evidence that urea transport in red blood cells and kidney inner medulla was mediated by specific urea transporter proteins. Molecular approaches during the past decade resulted in the cloning of two gene families for facilitated urea transporters, UT-A and UT-B, encoding several urea transporter cDNA isoforms in humans, rodents, and several nonmammalian species. Polyclonal antibodies have been generated to the cloned urea transporter proteins, and the use of these antibodies in integrative animal studies has resulted in several novel findings, including: (1) the surprising finding that UT-A1 protein abundance and urea transport are increased in the inner medulla during conditions in which urine concentrating ability is reduced; (2) vasopressin increases UT-A1 phosphorylation in rat inner medullary collecting duct; (3) UT-A protein abundance is upregulated in uremia in both liver and heart; and (4) UT-B is expressed in many nonrenal tissues and endothelial cells. This review will summarize the knowledge gained from using molecular approaches to perform integrative studies into urea transporter protein regulation, both in normal animals and in animal models of human diseases, including studies of uremic rats in which urea transporter protein is upregulated in liver and heart.