Type A intramural hematoma in a patient with acute coronary syndrome mimicking acute Type A aortic dissection.

Intramural hematoma (IMH) of ascending aorta is a rare but potentially lethal form of acute aortic syndrome (AAS). It is characterized by a hematoma within the media layer of the aorta secondary to rupture of the vasa vasorum in the absence of an intimal tear. However, the theory of "micro-tear" which cannot be easily detected has been raised. It may stabilize, regress, or progress to rupture or dissection. Similar to Type A aortic dissection (AD), patients with IMH of ascending aorta, as well as patients with persistent pain, are treated urgent surgery. We report a case of an ascending aorta IMH in a patient admitted to hospital with epigastric and chest pain with ST-elevation myocardial infarction in inferior leads. Coronary angiography (CAG) was performed and contrast injection from the right coronary artery (RCA) ostium showed marked contrast enhancement of the aortic wall. The CAG was terminated with a suspicion of Type A AD. The diagnosis of IMH starting just above RCA ostium with a thickness of 18 mm was made with computed tomographic angiography. An emergent surgical repair of the aorta and one-vessel coronary artery bypass graft surgery was performed successfully in our patient.

Prognostic value of the PAI-1 4G/5G polymorphism in invasive ductal carcinoma of the breast.

The study group was derived from the archive materials of 55 invasive ductal breast cancer (IDC) patients who had undergone breast-preserving surgery (partial mastectomy/ axillary dissection). All patients included in the study had clinically T(1)-2, N0-M0 invasive ductal carcinoma. Genomic DNA species were extracted from paraffin-embedded blocks, and plasminogen activator inhibitor type-1 (PAI-1) gene 4G/5G genotyping was done by polymerase chain reaction (PCR)-restriction fragment length polymorphism (RFLP). Patient demographics, axillary metastasis status, metastatic lymph nodi/total dissected lymph nodes from axilla, histopathologic characteristics of tumors, local recurrences, and survival ratio were assessed. PAI-1 4G/5G genotype frequencies were 4G/4G (64%), 4G/5G (31%), and 5G/5G (5%) in the patient group. According to the results based on frequencies, the demographics were not different. Five-year local recurrence rate of 4G/5G patients was the lowest (2/17, 12%) (P = 0.02). Also five-year distant metastases ratio of 4G/5G patients was the highest (18%) (P = 0.01). Five- and 10-year disease-free survival rates for the 4G/4G, 4G/5G, and 5G/5G groups were 97% and 94%, 82% and 77%, and 100% and 94%, respectively (P = 0.004). The results of this study indicate that the 4G allele in the PAI 1 gene had a negative impact on local recurrence and disease-free survival of patients with clinical T(1)-2N0M0 IDC.

Renal scintigraphy findings in allograft recipients with increased resistance index on Doppler sonography.

AIM: The measurement of intrarenal resistance indices (RIs) by doppler ultrasound plays an important role in the evaluation of renal transplant recipients. Although an elevated RI was initially considered to be specific for rejection, later studies revealed this parameter as a nonspecific marker of transplant dysfunction. In this study, we analysed Tc-99m DTPA renal scintigraphy findings in patients with increased RI during the early posttransplantation period. METHODS: This study included 22 patients with increased RI on doppler sonography during the first week after transplantation. Twenty-two recipients with uncomplicated early postoperative courses were used as a control group. An RI value >0.7 was considered pathologic. All patients underwent Tc-99m DTPA renal scintigraphy just after doppler sonography. In addition to visual interpretation of images, renogram curves were evaluated for patterns suggestive of acute tubular necrosis and acute rejection. Glomerular filtration rate (GFR) was calculated using computer software. Perfusion time-activity curves were assessed for the presence of peak and plateau patterns to calculate this ratio (P:PL). RESULTS: The mean value for P:PL in patients with increased RI and in the control group were 1.37 +/- 0.33 and 1.53 +/- 0.47, respectively (P < .05). The mean value for GFR was significantly lower in the patient group compared with control subjects. Six patients had normal perfusion and function (27%). Perfusion pattern and renogram changes were suggestive of acute tubular necrosis in 5 patients and acute rejection in 6 patients. These diagnoses were confirmed later with serial scintigraphic changes or biopsy results. Three patients had an accumulation pattern on the renogram suggesting partial obstruction. CONCLUSION: During the early posttransplantation period an increased RI on doppler sonography was seen in both normal functioning grafts and those with allograft dysfunction. Renal scintigraphy with perfusion and renogram patterns highly suggestive of specific allograft pathologies seemed to provide useful information to distinguish early postoperative renal allograft pathologies.

Spleen size changes in pediatric liver transplant recipients with functioning grafts.

OBJECTIVE: Hypersplenism and splenomegaly are common pathologic conditions in patients with chronic liver failure. Herein we discuss the prognosis of these conditions after orthotopic liver transplantation (OLT) in pediatric patients with functional grafts. MATERIALS AND METHODS: Forty-eight pediatric patients with cirrhosis underwent OLT. Seven patients were excluded from the study because of death within 1 month. Patients were divided into 2 groups: group A consisted of patients with nonfunctioning grafts (n=9), and group B, patients with functioning grafts (n=32). We measured preoperative leukocytes, platelet counts, and spleen sizes. Postoperative measurements were performed at 1 week as well as at 1, 3, 6, and 12 months after grafting. Statistical analyses were performed to evaluate reversal of hypersplenism and splenomegaly after OLT. RESULTS: No change in hypersplenism and splenomegaly was seen in group A, whereas in group B, a statistically significant change was seen in spleen sizes with improvement in hypersplenism after OLT, although persistent splenomegaly was observed in 17 patients. CONCLUSIONS: Reversal of hypersplenism and improvement of splenomegaly can be expected after OLT in pediatric patients with functioning grafts. Although the literature points to the duration of chronic liver disease as a causative factor for persistent splenomegaly in adults, there must be other causes, as the condition is seen in pediatric patients as well.

Venous complications after orthotopic liver transplantation.

We report venous complications, including portal vein and hepatic vein stenoses, that required interventional radiological treatment in three pediatric and two adult living related liver transplant recipients. Between April 2001 and April 2005, 81 liver transplantations were performed at our hospital. Sixty-two grafts were from living donors. During follow-up, three portal vein stenoses were identified in three pediatric recipients, and two hepatic vein stenoses in two adult patients. In the children, two had received left lateral segment grafts, and one had received a right lobe graft from two mothers and one father, respectively. The etiologies of liver failure were Alagille syndrome, biliary atresia, and fulminant Wilson's disease. Portal vein stenoses were identified at 8, 11, and 12 months after transplantation; all three patients underwent percutaneous transhepatic portal venous angioplasty with a success rate of 100%. The mean follow-up was 102 days; no recurrence has occurred. In contrast, hepatic venous stenoses were diagnosed in two adult recipients. One of them was a 24-year-old woman with autoimmune hepatitis and the other a 43-year-old man with cryptogenic cirrhosis. Hepatic vein stenoses were diagnosed at 3 and 4 months after transplantation. Both hepatic vein stenoses were dilated with balloon angioplasties via the transjugular route. Venous complications identified by Doppler ultrasonography were confirmed by computerized tomographic angiography. Angioplasty represents an effective and safe alternative to reconstructive surgery in the treatment of venous complications after liver transplantation.

Localized fluid collections after liver transplantation.

BACKGROUND: Liver transplantation is an accepted effective therapy for patients with diseases that lead to hepatic failure. In addition to vascular, rejection-related, biliary, and lymphoproliferative complications, posttransplantation fluid collections, such as hematomas, seromas, bilomas, localized ascites, and abscesses can affect graft survival. In this study, we have presented, ultrasonography and computed tomography images as well as reviewed the literature. METHODS: Between December 1988 and March 2005, 138 patients (94 men [68.11%], 44 women [31.89%] of mean age, 26.77 years (range, 1 to 64) underwent liver transplantation in our institution from living-related donors in 85 and deceased donors in 53 recipients. This retrospective study analyzed the fluid collections diagnosed after liver transplantation. RESULTS: Among 138 liver transplants we identified 56 localized intra-abdominal fluid collections, including 46 hematomas, 4 bilomas, and 6 abscesses. Fluid collections were noticed between 0 and 1095 days (mean = 13.50 +/- 152.82 days). Thirty-three collections were identified in living-related, and 23 in deceased donor recipients. The collections showed an average volume of 375 cm3, with a range of 1 to 4368 cm3. Two cases of bilomas were related to hepatic arterial insufficiency, one from a hepatic artery occlusion and the other from a significant stenosis. CONCLUSIONS: Localized intra-abdominal fluid collections were commonly seen after liver transplantations, diminished in size without treatment, but required aspiration or drainage in some patients.

Relationship between leptin and bone mineral density in renal transplant recipients.

INTRODUCTION: Leptin plays an important role in regulating appetite and energy expenditure and also functions in the neuroendocrine, hematopoietic, and immune systems, among others. Leptin may be involved in modulating bone mineralization. The relationship between leptin and bone mineral density (BMD) is not clear. This study examined the relationship between BMD and serum leptin levels in renal transplant recipients. MATERIALS AND METHODS: Forty-one patients (28 men and 13 women; age 16 to 55 years) were grouped according to percentile of serum leptin level hypoleptinemic (<5th percentile, n = 14), normoleptinemic (between the 5th and 95th percentiles, n = 19), or hyperleptinemic (>95th percentile, n = 8). The patients also were grouped according to lumbar z score) and total femur z scores (>-2 vs <-2 for both). RESULTS: The groups with different leptin statuses were compared with respect to age, sex distribution, and body mass index. Mean lumbar z score and mean lumbar BMD were higher in the hyperleptinemic group than in the normo- and hypoleptinemic groups (P < .05 for all). Considering the 42 patients overall, those with lumbar z scores >-2 had higher mean serum leptin/BMI than those with lumbar z scores <-2 (0.55 +/- 0.65 vs 0.18 +/- 0.23, respectively, P < .05). Serum leptin/BMI ratio was correlated with lumbar z score (r = .38, P < .05) and lumbar BMD (r = .32, P < .05). CONCLUSION: In conclusion, the data indicate that elevated leptin level is associated with increased bone mass at lumbar sites in renal transplant recipients. This suggest that increased leptin has a bone-sparing effect, especially in the lumbar region, in this patient group.

Osteoarthritis in hemodialysis patients: relationships with bone mineral density and other clinical and laboratory parameters.

OBJECTIVE: The aim of this study was to determine the role that hemodialysis (HD) plays in radiologically assessed osteoarthritis (OA) of the hand, knee, and hip. MATERIALS AND METHODS: Eighty patients who had been on regular HD for at least 2 years were included. Anterior-posterior radiographs of the pelvis, weight-bearing knees, and hands and wrists of each patient were examined. Bone mineral density (BMD) of spine, femur, and forearm was measured. RESULTS: Radiologic assessment of the 80 patients' hands showed that 41 individuals had osteopenia, 12 had midphalangeal subperiosteal resorption, 11 had cystic bone lesions, eight had bone erosion, four had osteophytic lesions, and three had subchondral sclerosis. Bone erosion in the hands was significantly associated with HD duration, forearm T score, and serum parathyroid hormone level. Radiologically, OA was demonstrated in eight knee and ten hip joints. Minimum joint space in the tibiofemoral compartment correlated with body mass index, and minimum joint space in the hip correlated with age. The mean BMD measurements at all three sites studied in the HD patients were low. Only the duration of HD significantly correlated with forearm BMD. CONCLUSION: Osteoarticular complications are common in HD patients.

Bone mineral density in patients on maintenance hemodialysis and effect of chronic hepatitis C virus infection.

OBJECTIVE: To determine the prevalence of osteopenia and osteoporosis in HD patients at our center; to investigate whether HCV infection affects BMD in hemodialysis patients; to test for correlations between bone mineral density (BMD) and clinical and laboratory parameters in this population. SUBJECTS AND METHODS: The study involved 76 end-stage renal disease patients. Forty-three (56.6%) patients were tested negative for anti-HCV antibodies and HCV-RNA. Thirty-three (43.4%) of them had positivity of anti-HCV antibodies and permanent or intermittent HCV-RNA positivity at least for two years. Mean HD duration was 86.4 months. Patients completed a standard questionnaire that listed age, sex, occupation, education level; cause of renal failure, smoking history, dialysis duration, and sports activities engaged in during life, and pathologic bone fractures. The women answered additional items about age at menarche, number of pregnancies and menopausal status. Each subject underwent a baseline physical examination, including measurement of body weight and height for calculation of body mass index. The results of laboratory tests that had been done at monthly visits in the previous year were retrospectively evaluated, and mean levels for the year were used for correlation testing. Bone mineral density was measured in the spine, femoral neck and forearm. Relationships between BMD values and chronic HCV infection, laboratory results and clinical parameters were analyzed. RESULTS: In the 43 patients who were negative for anti-HCV antibodies and HCV-RNA, spine BMD testing showed osteopenia in 16 (37.2%) cases and osteoporosis in 7 (16.3%) cases. The corresponding values for the neck of the femur were 14 (32.6%) and 6 (14.0%), and for the forearm were 19 (44.2%) and 15 (34.9%). In the 33 anti-HCV antibodies and HCV-RNA positive patients; spine BMD testing showed osteopenia in 10 (30.3%) cases and osteoporosis in 7 (21.2%) cases. The corresponding values for the neck of the femur were 17 (51.5%) and 4 (12.1%), and for the forearm were 4 (12.1%) and 25 (75.8%). Bone mineral density decreased as dialysis duration increased (p<0.05). There was no statistical difference between BMD measurements of chronic HCV infection positive and negative group. CONCLUSION: However the mean BMD values for all three sites in the 76 HD patients were low HCV infection may not be a risk factor for low BMD in this population.

Joint pain and arthritis in renal transplant recipients and correlation with cyclosporine therapy.

OBJECTIVE: The aim of this study was to determine the prevalence of joint pain and arthritis in renal transplant recipients and to investigate relationships with various laboratory and clinical parameters. METHODS: Eighty-two patients who underwent renal transplantation (RT) had joint examinations and reported by questionnaire on levels of joint pain and arthritis. Each individual was then followed by the rheumatology department for 1 year, with joint examination and laboratory tests every 3 months. RESULTS: Thirty-one of 82 patients (37.8%) complained of joint pain before RT, of whom seven reported pain continuing after the operation. Seventeen of the 82 (20.7%) began to suffer joint pain after RT. Six (7.3%) and three (3.7%) of the 82 patients, respectively, developed arthritis before and after transplantation. CONCLUSION: The study showed that joint pain is common before and after RT. In renal transplant recipients, joint pain significantly correlated with serum cyclosporine levels higher than 200 ng/ml.

The effect of cisapride on gallbladder contractility in type II diabetic patients.

BACKGROUND/AIMS: To investigate whether diabetics have altered gallbladder motility, and whether cisapride has any effect on gallbladder motility in these patients. The factors associated with abnormal gallbladder contractility, and with the effects of cisapride on gallbladder contractility in diabetics were also evaluated. METHODOLOGY: The gallbladder contractility parameters of 20 diabetics and 20 controls were assessed by real time ultrasonography. The same measurements were made after cisapride treatment in diabetics. RESULTS: Fasting gallbladder volume and residual gallbladder volume were statistically higher in the diabetic group than in the controls (P = 0.018 and P = 0.022, respectively). Multivariate analysis also showed a significant association between fasting gallbladder volume and existing diabetes (P = 0.0002). There was a significant positive correlation between level of hemoglobin A1c and fasting gallbladder volume (r = 0.48, P = 0.031). Responders to cisapride treatment had significantly higher hemoglobin A1c levels than nonresponders (6.6 +/- 1.3 vs. 9.1 +/- 1.8, respectively; P = 0.004). Logistic multiple regression analysis revealed that hemoglobin A1c level was the only independent factor that was predictive for efficacy of cisapride treatment. CONCLUSIONS: This study demonstrates that diabetics have impaired gallbladder contractility, and that control of diabetes is predictive for gallbladder contractility and response to cisapride therapy in these patients.

Osteoporosis after renal transplantation: single center experience.

BACKGROUND: Osteoporosis is a major source of morbidity after renal transplantation. The aim of this retrospective study was to determine the independent influences of different parameters on bone mineral density (BMD) in various parts of the body after renal transplantation. METHODS: BMD was measured in 130 of 954 renal allograft recipients who underwent surgery between 1985 and 1999. RESULTS: Time since transplantation and cumulative prednisolone doses were significantly higher in patients who had osteoporosis of the lumbar vertebrae (P=0.06 and 0.034, respectively). Logistic regression analysis revealed that cumulative prednisolone dose was the only significant predictor of low vertebral BMD (P=0.02, r=0.33). For the neck of the femur, high blood urea nitrogen and low Mg levels were found to be the predictors of low bone density (P=0.002 and 0.04, respectively). Although parathyroid hormone levels were higher in femoral osteoporosis patients than in those not affected at this site, the difference was not statistically significant (P=0.294). Time since transplantation, cumulative prednisolone dose, and cyclosporine A dose were all found to have a major negative impact on BMD in the radius region (P=0.001, 0.000, 0.001, respectively). Regression analysis showed that cumulative prednisolone dose (P=0.0008, r=0.34), time since transplantation (P=0.005, r=0.27), body mass index (P=0.01, r=-0.21), male gender (P=0.02, r=-0.21), and age (P=0.04, r=0.16) all had major effects on radius BMD. In conclusion, the radius seems to be one of the major parts of the skeleton affected by factors introduced after renal transplantation.

Effect of apolipoprotein E polymorphism on serum lipid, lipoproteins, and atherosclerosis in hemodialysis patients.

Atherosclerosis and cardiovascular disease are the main causes of death in hemodialysis patients. Possession of the apolipoprotein E4 (ApoE4) allele has been associated with increased levels of serum lipids and with coronary and carotid artery atherosclerosis. We investigated the possible relationship between ApoE polymorphism and atherosclerosis risk factors in hemodialysis patients. Two hundred sixty-nine hemodialysis patients (115 women, 154 men) were included in our study. The mean patient age and mean hemodialysis duration were 45.8 +/- 15.3 years and 52.6 +/- 40.6 months, respectively. Testing was done on all patients to determine ApoE genotype and serum levels of total cholesterol (T-Cho), low-density lipoprotein (LDL-C), high-density cholesterol (HDL-C), triglyceride (TG), lipoprotein (a) (Lp[a]), intact parathormone (iPTH), and fibrinogen. ApoE genotype was identified with the polymerase chain reaction. Ultrasonographic measurement of carotid artery intima media thickness (IMT) was used to diagnose atherosclerosis. We also analyzed ApoE polymorphism and risk factors such as age, gender, duration of hemodialysis, smoking, and hypertension in relation to the presence of atherosclerosis. Serum T-Cho and LDL-C levels were higher in patients with the ApoE4/3 phenotype than in those with ApoE3/3 and ApoE3/2 phenotypes (P < 0.05). However, there was no statistically significant link between ApoE polymorphism and serum levels of TG, HDL-C, or Lp(a) (P > 0.05). Apart from a relationship with age and duration of hemodialysis (P < 0.05), we found no significant association between atherosclerosis and ApoE polymorphism or the other risk factors analyzed (P > 0.05). In conclusion, although ApoE polymorphism significantly affects serum levels of T-Cho and LDL-C in hemodialysis patients, this study indicates that ApoE polymorphism is not associated with the presence of atherosclerosis in these individuals. The high incidence of atherosclerosis in these patients underlines the need for further research on other possible causative factors.

From donor to recipient. Doppler US, power US and scintigraphy of kidney perfusion before and after transplantation.

PURPOSE: To follow kidneys from the donor to the recipient by assessing whether perfusion changes occur by using duplex Doppler US, power Doppler US and scintigraphy. MATERIAL AND METHODS: The prospective study included 12 donors and their corresponding 12 recipients. For each donor, both donor kidneys were evaluated by duplex Doppler US, power Doppler US and scintigraphy 1 day before surgery. The same procedure was carried out on the renal allografts at days 1, 3, 5 and months 1 and 3 post-transplantation. Power Doppler findings were classified according to a grading system of 1 to 4. Resistive indices (RIs) were determined based on interlobar and segmental arterial flow. Peak systolic velocity and RIs of the main renal artery were also measured. A perfusion parameter named the peak-to-plateau ratio was calculated. Statistical analysis was performed using the paired-samples t-test. RESULTS: Intrarenal RI elevation and decreased renal artery peak systolic velocity was observed in normally functioning recipient kidneys. CONCLUSION: Duplex Doppler sonography demonstrated that transplanted kidneys had an increase in intrarenal vascular resistance at 1 month and a decrease in renal artery peak systolic velocity at 3 months post-transplantation. Scintigraphy and power Doppler US did not reveal any statistically significant perfusion change in normally functioning kidneys from donor to recipient.

Hepatic alveolar echinococcosis. A case report.

Alveolar echinococcosis is a rare parasitic disease caused by Echinococcus multilocularis and most commonly involves the liver. Early diagnosis and precise evaluation of the localisation and the extent of the lesions are essential for treatment. In this report, we present US and CT findings in a patient with hepatic alveolar echinococcosis.