Tubulovillous adenoma in the common bile duct causing obstructive jaundice.

Villous adenomas are benign epithelial lesions with a malignant potential which can occur at any site in the gastrointestinal tract, usually in the rectum and colon, less frequently in the small bowel and very rarely in the biliary tract. Villous adenomas of the extrahepatic bile ducts are exceptional and only a few cases have been reported. Common bile duct (CBD) adenomas often present in a fashion similar to their malignant counterparts, and adenocarcinoma arising from a villous adenoma of the ampullary biliary epithelium is also extremely rare. We present here a tubulovillous adenoma, arising in the common bile duct, as a cause of obstructive jaundice, and discuss the characteristics of these lesions.

The solution to organ shortage in Turkey: trained transplant coordinators.

The organ shortage is a social, psychological, ethical, moral, and probably legal and political problem of the 21st century. It must be solved as soon as possible to save lives; transplant coordinators are important cornerstones in this effort. The first transplant coordinator training course was organized in May, 2002, including 27 participants from different hospitals, but unfortunately only 13 were able to work as transplant coordinators in their hospitals after the course. After the course, the number of cadaveric donors in Turkey increased 12%, compared to 2001. Currently, only 14 hospitals have transplant coordinators and 12 of them are transplant centers. There is no transplant coordinator at 10 transplant centers. Only two nontransplant centers have a transplant coordinator. Eightyeight percent of donors are procured from hospitals with a transplant coordinator. According to data from the Transplantation Society meeting held in Rome, August 2000, there should be 1675 donors in Turkey, but we had only 100 for 2002 and 49 in 1999. Transplant coordinators are essential to organize donation, seeking to achieve the maximum for potential generating capacity (60 brain-dead pmp). So we need approximately 200 (3/pmp) trained transplant coordinators in Turkey but we presently have only 15% of this number.

Influence of inflammation on the relation between markers of iron deficiency in renal replacement therapy.

Iron deficiency is an important factor in the management of anemia in both dialysis and transplant patients. Serum ferritin and transferrin saturation (TS) may be influenced by the presence of inflammation. Recently, the soluble transferrin receptor (s-TfR) has been considered to be a marker of functional iron stores. In this study, parameters of the iron state were investigated in terms of agreement (assessed by kappa) with the diagnosis of iron deficiency and with inflammation. The study was performed in 38 hemodialysis, 31 continuous ambulatory peritoneal dialysis, and 21 anemic renal transplant patients. CRP and amyloid A protein (AAP) were studied as markers of inflammation. Iron deficiency was defined as ferritin <100 mg/L, TS <20%, or s-TfR >1.76 mg/mL. We observed that s-TfR levels were significantly related to both dialysis duration (r = 0.28 in dialysis and r = 0.60 in transplant patients, both P <.05) and PTH levels (r = 0.23 in dialysis and r = 0.55 in transplant patients, both P <.05). Among the transplant group, ferritin and TS, as well as TS and s-TfR were significantly related (r = 0.84 and r = -0.64, respectively), but not s-TfR and ferritin. Among the dialysis group, ferritin and TS, and also TS and s-TfR, were significantly related (r = 0.35 and r = -0.30, respectively), whereas s-TfR and ferritin were not. In the transplant group, the kappa value for agreement between ferritin and TS in the diagnosis of iron deficiency was 0.76 (P =.006), and 0.33 (P =.04), respectively. Among patients with CRP levels <0.3 mg/L or AAP levels <6.4 mg/L, the relation between parameters of iron state was more robust. The kappa value for agreement between ferritin and s-TfR was 0.49 (P =.006) in the dialysis group and 1 (P =.002) for that between ferritin and TS in the transplant group. Our results suggest that PTH levels may influence s-TfR levels. Discordance between ferritin, TS, and s-TfR as markers of iron deficiency might be explained by the effects of inflammation.

Evaluation of the new EMIT tacrolimus assay in kidney and liver transplant recipients.

Tacrolimus (FK506) is a potent macrolide immunosuppressant used for prevention of organ transplant rejection following transplantation. Monitoring of blood tacrolimus concentrations is essential to assess organ rejection and toxicity, because of the agent's narrow therapeutic range, wide inter- and intraindividual pharmacokinetic variability as well as drug interactions mediated by alteration in cytochrome P450. Several methods have been developed to monitor tacrolimus; immunoassays, bioassays, and HPLC/MS. The purpose of this study was to compare two analytical methods: the well-established MEIA II tacrolimus immunoassay using the IMx analyzer and the new EMIT 2000 tacrolimus immunoassay on the Cobas Integra 400 system. Tacrolimus results obtained using the two methods have been compared on 180 whole blood samples from kidney and liver transplant patients. The analytical sensitivities of both methods were defined as 1.2 ng/mL for EMIT and 1.5 ng/mL for MEIA II. The within-run CVs (n = 15) obtained with four-level controls were 9.08%, 9.41%, 5.23% and 4.4% for EMIT 2000. The comparison showed the following relationship between two methods: MEIA = 1.08.EMIT + 0.20 (r =.893). In conclusion, the EMIT 2000 tacrolimus immunoassay is a reliable alternative for the MEIA II method to monitor tacrolimus in organ transplant recipients. It provides a valid quantitative measurement of tacrolimus with comparable % CVs in quality-control as well as patient blood samples. Additionally, the EMIT 2000 method provides a rapid analysis of a large number of samples in one run with a low turnaround time and possibilities to reanalyze critical samples.

Serum cystatin C as an index of renal function in kidney transplant patients.

Management of renal transplant patients requires periodic measurement of renal function, which is usually assessed by measuring the glomerular filtration rate (GFR). The most commonly used marker for GFR is serum creatinine, although muscle wasting and tubular secretion may lead to overestimation of the actual GFR. Serum concentrations of the low-molecular-weight proteins, cystatin C and beta(2)-microglobulin (B(2)M), may afford useful markers to determine a reduced GFR. We investigated whether these molecules provide reliable indicators of renal function in 75 renal transplant patients. Cystatin C and B(2)M correlated significantly with creatinine (r =.648, P <.05 and r =.578, P <.05, respectively). Inverse serum creatinine was superior to inverse cystatin C and inverse B(2)M when renal function equations were used (r =.95, P <.05, according to MDRD; r =.87, P <.05, according to Cockroft-Gault). Receiver operating characteristic (ROC) analysis was performed to quantitate the accuracy of the different markers to detect reduced GFR using a cutoff value of 70 mL/min. No significant difference between the areas under the ROC curves comparing cystatin C and B(2)M was observed; however, serum creatinine demonstrated a significantly greater value than cystatin C (.981 vs.724, P =.001). We conclude that serum creatinine is a more efficacious marker than serum cystatin C to assess renal function.

Is there any effect of compliance on clinical parameters of renal transplant recipients?

Noncompliance with regard to diet, medications and routine physician visits is frequently observed among some patient groups. This results in late graft dysfunction and behavior loss. In the present study, we defined compliance as attendance at 80% or more outpatient visits. The study included 63 cadaveric and 158 living-related renal transplant recipients namely, 150 men and 76 women of 8 to 70 years of age (median 38 +/- 12) who were operated between 1986 and 2001. Demographic data, number of visits attended per month, cigarette smoking, and alcohol intake were probed with a questionnaire that was delivered to the patients, 8 of whom died; hemophagocytic syndrome (n = 4), cardiovascular disease (n = 2), Kaposi' sarcoma (n = 1), and cerebrovascular bleeding (n = 1). Twenty-three patients had lost their graft. Compliance among men was lower than among women, a result that trended toward statistical significance (P =.087). Compliance was not related to marital status (P =.297), but tended to increase with educational background (P =.059). Graft loss (P =.546) and aging (P =.509) were not related to compliance. There was no relationship between compliance and mortality rate (P =.526). Interestingly, living-related kidney transplant recipients showed lower compliance than cadaveric kidney recipients, a result that was statistically significant (P =.04). Noncompliance was also related to cigarette smoking during the pre- and posttransplant periods (P =.008 and P =.03, respectively), as well as alcohol intake (P =.000). In conclusion, male gender and living-related donation are related to noncompliance, but (in contrast with literature) not young age, graft loss, or mortality. Compliance increases with educational status of the patients. Smoking and alcohol intake are closely related to noncompliance.

Plasma homocysteine levels in renal transplant patients on tacrolimus therapy.

Increased plasma total homocysteine levels afford an independent risk factor to assess cardiovascular morbidity in patients with normal and impaired renal function, including stable transplant recipients. The purpose of this study was to evaluate plasma homocysteine levels and factors known to influence homocysteine metabolism (folate and Vitamin B(12)) in renal transplanted patients treated with tacrolimus. Plasma homocysteine, serum folate and serum vitamin B(12) concentrations were measured in 18 cadaveric renal transplant patients with stable function both before and 3 months after the renal transplantation. While the mean plasma homocysteine level in the renal transplant group was significantly higher than in the control group, no significant change was observed following renal transplantation under tacrolimus therapy (16.84 +/- 6.43 micromol/L vs 16.02 +/- 6.54 micromol/L). The levels of folate before and after transplantation were considerably lower than the control group; a significant effect of tacrolimus has not been observed (7.32 +/- 4.68 ng/mL and 7.55 +/- 5.20 ng/mL). Serum vitamin B(12) levels in the transplant group were significantly lower than the control group; a significant decline was seen 3 months after the renal transplantation (448.94 +/- 230.03 pg/mL vs 334.38 +/- 240.61 pg/mL). Consequently, although plasma homocysteine levels of renal transplant recipients are higher, a lowering effect of tacrolimus therapy was not observed on plasma homocysteine levels. The lower levels of folate and Vitamin B(12) in the transplant group compared to a control group supports therapy with folate and Vitamin B(12) to decrease homocysteine concentrations.

Influence of tacrolimus plus mycophenolate mofetil regimens on acute rejection rate and diabetes mellitus development in renal transplant recipients.

In this study we investigated the influence of a tacrolimus (TAC) plus mycophenolate mofetil (MMF) immunosuppressive regimen on the acute rejection rate and side effect profile in renal transplant recipients. The study included 80 living-related and 40 cadaveric donor renal transplant recipients (82 men, 38 women) of mean age 35 +/- 10 years (range, 16 to 58) who were operated between August 1999 and September 2002. The mean HLA mismatches was 3 +/- 1 (range, 0 to 5). All patients received prednisolone, MMF (2 g/d for the first 14 days posttransplant and then 1 g/d) plus TAC (0.2 mg/kg/d). They were followed for the development of rejection attacks and side effects. Diabetes mellitus developed in 13 patients (9 men, 4 women; 10.8%). Initially, patients required insulin therapy but after 6 months, 5 recipients no longer needed insulin therapy and were switched to oral hypoglycermic agents and diet control. Hypertension was diagnosed in 58 patients (48.3%). Neither gender nor donor origin (P =.14; P =.79, respectively) produced a significant difference in diabetes mellitus development. Biopsy proven acute rejection episodes were observed in 16 out of 120 patients (13.3%). Six out of 120 patients lost their grafts throughout the study period including one death because of suicide, one because of cytomegalovirus disease and hemophagocytic syndrome, one due to posttransplant lymphoproliferative disease and two to a cardiac arrhythmia. Only one patient lost his graft due to acute accelerated vascular rejection. Biopsy-proven chronic rejection appeared in one patient. In conclusion, although the incidence of insulin-dependent diabetes mellitus during posttransplant 6 months, seems high it decreased to 1.6% upon reduction of the TAC dosage. TAC plus MMF immunosuppression seems effective and safe in terms of acute rejection rates and side effect profiles.

Diagnostic value of 99mTc MIBI scintimammography in patients with breast lesions.

This study has aimed to determine the diagnostic value of the scintimammography with 99mTc-MIBI in the detection of primary breast cancer and to verify its clinical usefulness. Sixty-three female patients (age range 27-83) with breast lesions detected by physical examination, ultrasonography, and/or mammography were prospectively included in this study. An anterior and prone lateral planar 99mTc-MIBI scintimammography was performed on all patients. The final diagnosis was achieved by histopathological examination in 49 patients and clinical followup (at least one year) in 14 patients. Histopathological diagnosis confirmed that 15 lesions were malignant and 34 lesions were benign. All the malignant lesions were larger than 1 cm. The 99mTc-MIBI scintimammography showed increased focal uptake in 17 lesions (two of them were benign and the other 15 were malignant). The diffuse heterogeneous uptake pattern was considered as benign. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy values for breast carcinoma were calculated as 100%, 96%, 88%, 100%, 97%, respectively. We concluded that 99mTc-MIBI scintimammography could be a valuable method in the differentiation of malignant breast neoplasm larger than 1 cm size from benign ones, especially when the uptake pattern was considered.

The value of 99mTc-HMPAO labelled white blood cell scintigraphy in acute appendicitis patients with an equivocal clinical presentation.

Various imaging studies can be performed in the evaluation of patients with a clinical presentation equivocal for acute appendicitis. One of these studies is technetium-99m hexamethylpropylene amine oxime (HMPAO) labelled white blood cell (WBC) scintigraphy. The aim of this study was to evaluate the accuracy and clinical value of 99mTc-HMPAO WBC scintigraphy in the aforementioned group of patients. Forty-one patients who had acute right lower quadrant abdominal pain with a clinical presentation equivocal for acute appendicitis were included in the study. The anterior abdomen and pelvis were imaged up to 4 h after the injection of 125-300 MBq 99mTc-HMPAO WBCs and the results were immediately reported to the surgeon before a decision was taken on whether to perform laparotomy. Diagnostic accuracy was established by the intra-operative findings and the histopathology in operated patients. In non-operated patients, absence of abdominal symptoms 1 month after scintigraphy and/or identification of another cause of abdominal pain was used to rule out acute appendicitis. There were 16 patients with positive scintigraphy and 81% of these patients were positive within 2 h post injection. There were no false-positive or false-negative results. We operated on 17 (41.4%) patients, and only one patient (5.9%) underwent unnecessary laparotomy. We conclude that 99mTc-HMPAO WBC scintigraphy is a rapid, highly accurate method for the exclusion of acute appendicitis and that its use can lower the unnecessarily high laparotomy rate in patients with an equivocal clinical presentation.

Valor diagnóstico de la gammagrafía con 99mtc mibi en pacientes con lesiones de mama / Diagnostic value of 99mTc MIBI scintimammography in patients with breast lesions

El objetivo del estudio, fue determinar el valor de diagnóstico de la mamografía con 99mTc MIBI en la detección de cáncer del mama primario y verificar su utilidad clínica. Sesenta y tres pacientes (edad rango 27-83) con lesiones del mama descubiertas por el examen físico, la ecografía, y/o mamografía fueron incluidas en este estudio prospectivo. En todas las pacientes se realizaron proyección anterior y latera. El diagnóstico fibal se estableció por el examen del histopathológico en 49 pacientes y seguimineto clínico (por lo menos un año) en 14 pacientes. La histopatología confirmó que 15 lesiones eran malignas y 34 lesiones eran benignas. Todas las lesiones malignas eran mayores de 1 cm. La mamografía con 99mTc-MIBI mostró captación focal aumentada en 17 lesiones (dos de ellas eran benignas y las otras 15 eran malignas). La captación heterogénea difusa fue considerada como benigna. La sensibilidad, la especificidad, el valor predictivo positivo, el valor predictivo negativo y la exactitud para el carcinoma del mama fueron respectivamente 100 por ciento, 96 por ciento, 88 por ciento, 100 por ciento, 97 por ciento. Concluimos que la mamografía con 99mTc-MIBI puede ser un valioso método en la diferenciación de neoplasias de mama malignas mayores de 1 cm, de las benignas especialmente si se considera el modelo de captación. (AU)

Anxiety, depression and stressful life events among medical students: a prospective study in Antalya, Turkey.

OBJECTIVE: To assess psychological changes in medical students in Antalya, Turkey during their undergraduate education. The first-year follow-up outcomes are presented in this article. DESIGN: All first-year undergraduate students were given a detailed, self-report questionnaire and another in the second year. They were asked to complete the General Health Questionnaire (GHQ), the Spielberger State-Trait Anxiety Inventory (STAI) and the Beck Depression Inventory (BDI). SETTING: The Faculties of Medicine, Economics and Physical Education (PE) of the Akdeniz University, Antalya, Turkey. PARTICIPANTS: All first-year undergraduate students in the Faculties of Medicine, Economics and PE who were registered in 1996. RESULTS: The findings showed that psychological test scores on the GHQ, the STAI and the BDI rose significantly in medical students between the first and second years. Using the GHQ, with different cut-off scores, the percentage of students scoring above the thresholds was higher in medical students in year 2, compared with economics and PE students. In addition, the scores for some stressful life events of medical students showed a significant rise from year 1 to year 2. Multiple regression analyses indicated that some stressful life events related to social activities were associated with the psychological test scores for medical students. CONCLUSION: The results indicate that there is a decrease in the psychological health of first-year medical students. Some inadequacies in the social activities of the students might play a role in this type of disturbance.

[Legionnaires' disease following kidney transplantation]. / Böbrek transplantasyonu sonrasi gelisen Lejyoner hastaligi.

Legionella pneumonia was diagnosed in two patients receiving triple immunosuppressive drug therapy after renal transplantation. High fever was the predominant symptom of these patients. Hyponatremia, leucopenia and anemia were also observed. The disease was diagnosed by immunofluorescence antigen technique and easily controlled with erythromycin therapy.