Magnetic resonance cholangiopancreatography for the accurate diagnosis of biliary complications after liver transplantation: comparison with endoscopic retrograde cholangiography and percutaneous transhepatic cholangiography - long-term follow-up.

Biliary complications after liver transplantation remain a serious cause of morbidity and mortality. Direct invasive cholangiographic techniques, endoscopic retrograde cholangiography (ERCP) or percutaneous transhepatic cholangiography (PTC), have procedure-related complications. Magnetic resonance cholangiopancreatography (MRCP) is non-invasive, safe, and accurate. The aim of this study was to evaluate MRCP in detecting biliary complications following liver transplantation and comparing findings with ERCP and PTC. Twenty-seven consecutive liver transplant recipients who presented with clinical and biochemical, ultrasonographic, or histological evidence of biliary complications were evaluated with MRCP. Patients were followed up for a median period of 36 months. The presence of a biliary complication was confirmed in 18 patients (66.6%): anastomotic biliary stricture in 12 (66.6%); diffuse intrahepatic biliary stricture in 5 (27.7%): ischemic (n = 3), recurrence of primary sclerosing cholangitis (n = 2), and choledocholithiasis in one. In nine patients (33.3%), MRCP was normal. Six patients underwent ERCP, and eight PTC. There was a statistically significant correlation between the MRCP and both ERCP and PTC (p = 0.01) findings. The sensitivity and specificity of the MRCP were 94.4% and 88.9%, respectively, and the positive and negative predictive values, 94.4% and 89.9%, respectively. MRCP is an accurate imaging tool for the assessment of biliary complications after liver transplantation. We recommend that MRCP be the diagnostic imaging modality of choice in this setting, reserving direct cholangiography for therapeutic procedures.

Seasonal variations in pre- and post-thaw donor sperm quality.

BACKGROUND: The present study was conducted to evaluate seasonal variability in the quality of pre- and post-thaw semen parameters among sperm bank donors. METHODS: The first two consecutive ejaculates during the months March (spring, 92 males), June (summer, 97 males), September (autumn, 81 males) and December (winter, 97 males) were analysed. A comparison was made between sperm parameters from the same sperm donor at different seasons. Only males who donated semen samples during at least two seasons were enrolled in the study group (n = 103). Sperm specimens were cryopreserved in aliquots with fixed range of 8-12 x 10(6)/ml of progressive motile sperm concentration after thawing. RESULTS: Differences between months were found in sperm concentration (P = 0.030) and normal morphology (P = 0.038); highest values were found in March and December, and the lowest in September. Mean specimen volume and percent of motile sperm cells did not vary throughout the seasons. The freezability of the donors' sperm dropped dramatically from March to September, as determined by the number of straws (fixed aliquots of 0.5 ml) and total thawed progressive motile sperm that were cryopreserved for each male (P = 0.017 and P = 0.002, respectively). CONCLUSIONS: Cryopreservation of donor sperm is more effective during winter and spring than during the rest of the year.

The impact of a resident's seniority on operative time and length of hospital stay for laparoscopic appendectomy: outcomes used to measure the resident's laparoscopic skills.

BACKGROUND: Laparoscopic appendectomy (LA) frequently is performed by residents during calls. This study aimed at evaluating residents' surgical skills using parameters of operating time, length of hospital stay (LOS), and conversion rate in correlation with the operating team's level of seniority. In addition, this study compared the operating time for LA with that for open appendectomy performed by the same teams, and identified deterministic factors that have an impact on such parameters. METHODS: All records of patients undergoing appendectomy performed by residents alone during a 32-month period were reviewed retrospectively. Eight residents were assigned to two levels of seniority: juniors 3 years (S). Operating time and LOS were compared between the three surgical teams, namely, J/J, J/S, and S/J as operating and assistant surgeons, respectively. Operating time, conversion rates, and LOS were compared for the same team combinations. RESULTS: Residents alone performed 341 (151 laparoscopic and 190 open) appendectomies during on-call hours. Four of the residents had been 3 years or less in residency (J), and four had been in residency more than 3 years (S). The overall mean operating time was 1.33 +/- 0.48 h for LA and 1.2 +/- 0.5 h for open appendectomy (p = 0.016). The operating time correlated with the level of training for both LA (J/J, 1.6 +/- 0.38 h; J/S, 1.41 +/- 0.37 h; S/J, 1. 25 +/- 0.4 h; p = 0.03, ANOVA) and open appendectomy (J/J, 1.53 +/- 0.89 h; J/S, 1.4 +/- 0.63 h; S/J, 0.86 +/- 0.45 h; p = 0.023, ANOVA). The mean LOS was 2.9 +/- 3.1 days for open appendectomy and 2.1 +/- 2.8 days for LA (p = 0.065), and was not different after operation by any of the teams (J/J, J/S, S/J) for either the open or the laparoscopic procedure. CONCLUSIONS: There is a distinct difference in the surgical skills of residents according to level of seniority, as primarily reflected by operating time. Laparoscopic appendectomy requires longer time to perform in a teaching setting, but the most deterministic factor that dictates operating time is the composition of the surgical team rather than the laparoscopic approach.

Down regulation of CD45 expression on CD4 T cells during acute renal allograft rejection: evidence of a decline in T suppressor/inducer activity.

Acute rejection is associated with the activation of helper and cytotoxic cells. A shifting balance between the suppressor/inducer CD45+ CD4+ and T helper/inducer (CD4+CD45-) cells may be responsible for the transition from quiescence to overt rejection. We examined the kinetics of CD45 expression on CD4+ T cells in renal allograft recipients from pretransplant values to acute rejection and after reversal of rejection, searching for a shift in balance between helper/inducer and suppressor/inducer cell subsets. Using two color flow cytometry, the peripheral blood levels of CD4+, CD4+CD45- [T helper/inducer (Thi)], CD4+CD45+ [T suppressor/inducer (Tsi)], CD3+, and CD8+ T cells subsets and their interrelationships, were determined in 49 patients prior to transplantation, and in 10 of them, during acute rejection and after its reversal. Results were analyzed and compared to data obtained from 10 healthy blood donors. Acute rejection was associated with a significant decline in CD45+ CD4+ expression compared to quiescent phase (22% +/- 3.7% vs. 26.5% +/- 3.2%, p = 0.05) and controls (29.5% +/- 6.2%, p = 0.01). No difference was observed compared to pretransplant levels (19.9% +/- 3.2%, p = ns). CD45-/CD45+ (Thi/Tsi) ratio was lowest during quiescence (0.75) compared to rejection (0.97, p = 0.05), in controls (0.98, p = 0.05) and pretransplant values (1.4, p = 0.01). Acute rejection was characterized by higher Thi/CD8+ and lower Tsi/CD8+ ratio (103 and 88 respectively, p = 0.045), compared to clinical quiescence (104 and 116 respectively, p = 0.039). These data suggest that acute rejection is associated with down regulation of CD4+CD45+ suppressor/inducer subset. This shift may account for the transition from quiescence to overt rejection, concurring with reports on CD4+CD45 regulatory function.

Fibroadenoma of the breast: analysis of associated pathological entities--a different risk marker in different age groups for concurrent breast cancer.

BACKGROUND: Fibroadenoma, one of the most common benign breast lesions, has a characteristic age-specific incidence and is associated with other pathological entities in 50% of cases. The clinical or imaging diagnosis of fibroadenoma may be erroneous, and in some cases is found to be invasive cancer. The clustering of such entities, their correlation with age, and the risk of synchronous breast malignancy are uncertain. OBJECTIVE: To explore the possibility of any significant clustering of fibroadenoma-associated benign breast diseases and to assess the possible risk of concomitant breast cancer. METHODS: We analyzed the pathological results of 147 women undergoing excisional biopsies for fibroadenoma diagnosed pre-operatively either by clinical examination and imaging (n = 17) or by radiology alone (n = 30). The inter-relationships among all entities associated with fibroadenoma were studied by hierarchical cluster analysis. The correlation of the various pathologies with the risk of invasive breast cancer in relation to the patient's age was also evaluated. RESULTS: Fibroadenoma-associated pathologies were found in 48% of the cases: sclerosing adenosis (23%), duct ectasia (17.7%), apocrine metaplasia (15.6%), florid fibrocystic disease (12.9%), duct papillomatosis (11.6%), infiltrating duct carcinoma (5.4%), duct carcinoma in situ (3.4%), and 1 case of lobular carcinoma in situ (0.6%). An orderly internal hierarchy and three significant clusters emerged: a) epithelial apocrine metaplasia, duct ectasia and sclerosing adenosis (similarity coefficients 16.0, 11.0 and 8.0 respectively); b) papillomatosis, florid fibrocystic disease and calcifications (similarity coefficients of 6.0, 4.0 and 2.0 respectively); and c) infiltrating duct carcinoma and duct carcinoma in situ (similarity coefficients of 1.8 and 1.6 respectively). Seven of the eight patients with breast cancer were older than 40 years. CONCLUSIONS: In about half of the cases fibroadenoma was associated with other pathological entities clustered in an orderly hierarchy. The rarity of synchronous breast cancer in the younger age group and its more common association with fibroadenoma in the older age groups dictate a different approach to each. The finding of fibroadenoma in women older than 40 indicates the need for surgical excision.

The picture of inflammation: a new concept that combines the white blood cell count and erythrocyte sedimentation rate into a new hematologic diagnostic modality.

BACKGROUND: Physicians who work in small clinics, far away from medical centers, cannot obtain relevant information regarding the acute phase response at low cost and real time. METHODS: We adopted a simple slide test and image analysis to determine the number of white blood cells in the peripheral blood, their degree of adhesiveness/aggregation as well as that of the red blood cells. Three independent observers scored the images into categories of no (1), mild (2), moderate (3) or severe (4) inflammation. RESULTS: A substantial interobserver agreement was noted for all three observers. No patient classified as having no (1) inflammation was given a score of moderate (3) or severe (4) inflammation and vice versa. The one-way analysis of variance (age- and gender-adjusted) confirmed that the data obtained from the image analyzer are significantly different between the above-mentioned four categories. CONCLUSIONS: It is possible to use a simple slide test and image analysis to discriminate effectively between various degrees of inflammation intensity. Since it is possible to send the pictures via telephone, Inter- or Intranet to a physician somewhere else, it might be attractive for medical personnel who work in small clinics not equipped with sophisticated laboratory facilities. This technique is currently being evaluated for possible Telemedicine and E-Health uses.

Role of cytokine gene polymorphism in hepatitis C recurrence and allograft rejection among liver transplant recipients.

BACKGROUND: Cytokines play a key role in the regulation of immune responses. The maximal capacity of cytokine production varies between individuals and was shown to correlate with polymorphism in cytokine gene promoters. The objective of this study was to analyze the role of cytokine allelic variations in susceptibility to early graft rejection episodes and recurrence of hepatitis C infection in liver transplant (LTx) recipients. METHODS: The genetic profile of five cytokines was studied in 68 LTx recipients and 49 controls using polymerase chain reaction sequence specific primers. All individuals were genotyped as high or low producers of TNF-alpha and IL-6 and high, intermediate, or low producers of transforming growth factor beta (TGF-beta), interferon gamma (IFN-gamma), and interleukin 10 (IL-10) based on single nucleotide substitutions. RESULTS: No statistically significant differences were observed between patients with or without early rejection episodes. A significant proportion of patients more prone to rejection were genotyped as having a low production profile of IL-10 compared with the control population (P=0.04). These data are in accordance with reports regarding other solid-organ transplant recipients. Patients with no recurrence of hepatitis C had the inherent ability to produce higher TGF-beta levels than did patients with recurrent disease (P=0.042). Among nonrecurrent patients, the percentage of genetically low IL-10 producers was higher than among recurrent patients (P=0.07). Furthermore, a genetic tendency to produce higher levels of IFN-gamma was noted among LTx recipients with nonrecurrent hepatitis C than among those with recurrent hepatitis C. CONCLUSIONS: While no significant correlation was detected between particular cytokine profile and early rejection episodes, our data strongly suggest an association between cytokine gene polymorphism of TGF-beta, IL-10, and INF-gamma and recurrence of hepatitis C in LTx recipients.

The feasibility of estimating the erythrocyte sedimentation rate within a few minutes by using a simple slide test.

The acute phase response is accompanied by the appearance of aggregated red blood cells in the peripheral blood. The Westergren erythrocyte sedimentation rate (ESR) is an indirect measurement of this enhanced aggregability. We adopted a simple slide test and image analysis to reveal the adhesiveness/aggregation of red blood cells. A significant correlation was found between the erythrocyte adhesiveness/aggregation test (EAAT) and the ESR. A predictive model for ESR based on EAAT and the age of the patients was created. This new approach will enable us to obtain within a few minutes a good estimate of whether a given individual has a mild moderate or significant acute phase response. With further development, we will be able to use a bedside small cartridge that will deliver the extrapolated ESR at low costs and within a couple of minutes.

Sociodemographic and clinical factors associated with low quality of life one year after coronary bypass operations: the Israeli coronary artery bypass study (ISCAB).

OBJECTIVES: We sought to examine the effect of sociodemographic characteristics and perioperative clinical factors 1 year after coronary bypass operations on low health-related quality of life. We also sought to assess the usefulness of an additional single question on overall health for identifying patients with low health-related quality of life. METHODS: This report is part of the Israeli coronary artery bypass study of 1994, in which every patient undergoing isolated coronary bypass grafting in Israel was included. The target population for this report comprised all survivors beyond 1 year who were 45 to 65 years of age. Patients were interviewed before the operations. Self-administered questionnaires regarding health-related quality of life (SF-36) were sent to 1724 patients who were successfully located 1 year postoperatively, and 1270 questionnaires were completed. Low health-related quality of life was defined as the lowest tertile of the distribution of scores for the 2 summary components of the SF-36 and the single question on overall health. Logistic models were constructed for each of the 3 outcomes. RESULTS: Female sex and low socioeconomic background were associated with low health-related quality of life in the logistic models. Other significant factors were symptoms of angina, sleep disturbances, hypertension, high severity of illness scores, hospital readmission, no rehabilitation, and hospitals with high perioperative mortality. Of the 3 study outcomes, the model for the single question on overall health was the most discriminating (C statistic = 0.76 vs 0.70 and 0.70, respectively). CONCLUSIONS: The study identifies patients who would most benefit from posthospitalization community support after bypass operations. Under circumstances of limited resources, these disadvantaged groups should be targeted as a priority. Encouraging participation in existing rehabilitation programs or introducing telephone hotlines could improve health-related quality of life after coronary bypass grafting without large investments.

Gait festination in Parkinson's disease.

Background: Festinating gait (FSG) was first associated with parkinsonism by Sir James Parkinson, in his original essay on "The Shaking Palsy". Its frequency and relation to other parkinsonian features have never been assessed.Objective: To study the relationships between gait festination and other parkinsonian clinical features among patients with Parkinson's disease (PD).Method: During an open lecture to patients with PD who are followed at the Movement Disorders Unit (MDU) of Tel-Aviv Sourasky Medical Center one of us explained verbally and imitated festinating gait on stage. All attending patients with the help of their care-givers or family members, were asked to answer two written questions regarding their own experience with FSG as well as the degree of disability it causes. Clinical information about each patient was taken from his/her chart at the MDU and missing data was completed during the next office visit or from the family physician. Statistical analysis was performed using t-tests for comparison between groups, Chochran-Armitage test for trends and logistic regression to assess the contribution of age of onset, disease duration and disease severity to the development of FSG.Results: Eighty-one PD patients (58 males, mean age 67.5+/-10.7years) answered the FSG questionnaire. Our study population's mean disease duration was 8.5+/-6.4years, mean Hoehn and Yahr (H&Y) clinical stage of 2.6+/-0.8 and mean levodopa dose of 608+/-375mg/day (15 patients were not on levodopa). Twenty-six patients (32.1%) experienced FSG during the previous month and 56% of them reported that FSG was a significant and disabling symptom. FSG was strongly associated with higher stage of H&Y (p<0.001) with a significant trend as the disease progresses (p=0.001) but not with total score in the motor part of the Unified Parkinson's Disease Rating Scale (UPDRS). Longer disease duration was the only clinical factor, which was found to be associated with FSG in the multivariate model. Thirty seven percent (37%) of the patients with FSG reported frequent falls with association between occasional or frequent falls, as reported on the activity of daily living (ADL) part of the UPDRS, and the presence of FSG (p<0.08). There was no association between significant postural reflex abnormalities as rated on the objective part of the UPDRS and the presence of FSG. There was a significant association between the presence of freezing of gait (FOG) as reported in the ADL part of the UPDRS and the presence of FSG (p<0.001) as well as a significant trend towards more frequent FSG in patients with more severe FOG (p<0.001).Conclusion: FSG was clearly associated with longer duration of PD symptoms but not with disease severity as reflected in the motor part of the UPDRS. The relationships between FSG and postural reflexes abnormalities is unclear but it is frequently associated with falls and freezing of gait.

Activation of flexor and extensor trunk muscles in hemiparesis.

OBJECTIVE: The purpose of this work was to study the bilateral activity of trunk flexor and extensor muscles in post-stroke hemiparetic patients. DESIGN: Criterion variables were degree of temporal synchronization and level of electromyographic activity in pertinent muscle pairs during two symmetrical tasks: (1) from reclined sitting, bringing the trunk forward; (2) during upright sitting, shrugging shoulders, and extending back. The recti abdomini and external oblique muscles were tested as prime movers of the first task, and the lumbar erector spinae and latissimus dorsi muscles were tested in the second task. Electromyographic recordings from these muscles during three repetitions of each exercise were used for analysis. RESULTS: Cross-correlation analysis pointed to higher temporal synchronization between the abdominal muscles than between the back extensor muscles and in axial compared with para-axial muscles. Differences between patients and controls were found only for the erector spinae muscle pair, which indicates less synchronous activity between the two sides in the patients. The average electromyographic activity level was comparable for corresponding abdominal muscles, both in the patients and in the control subjects. Regarding the back extensor, side differences were detected for the latissimus dorsi muscles in both groups, with the paretic and right side less active in the patients and controls, respectively. CONCLUSIONS: Altogether, the findings do not support the claim of unilateral deficits in the function of trunk muscles in post-stroke hemiparetic patients. They emphasize the need for further characterization of the impairment of trunk extensor and flexor muscles in post-stroke patients.

Extension of the organ pool in kidney transplantation: first year experience of the Israel Transplant Center.

BACKGROUND: Over a 12 month period, the Israel Transplant Center doubled the number of donors by assigning a nurse coordinator to each of 22 hospitals around the country and by using kidneys from elderly donors. OBJECTIVE: To evaluate the impact of our "marginal donors" policy on the results immediately following transplantation. METHODS: Between October 1997 and September 1998, 140 cadaveric kidney transplantations from 72 donors were performed in Israel. We defined two groups of recipients: patients with immediate graft function and patients with either delayed graft function requiring > 1 week of dialysis post-transplant or with primary graft non-function. We compared the following parameters between groups: donor and recipient age and gender, cause of donor's death, length of stay in the intensive care unit, vasopressor dosage and creatinine levels before harvesting, cold ischemic time, and the number of recipient grafts. RESULTS: There were 102 recipients (72.8%) with immediate graft function and 38 with either PNF (n = 13, 9.3%) or DGF (n = 25, 17.9%). On regression analysis, donor age > 50 year and retransplantation were significant risk factors for PNF or DGF (odds ratio 4.4 and 2.8, respectively). Of the 56 kidneys from donors > 50 years old, 21 (37.5%) developed either PNF (n = 9) or DGF (n = 12). CONCLUSIONS: We conclude that kidneys from donors over age 50 are at increased risk for graft non-function or delayed function. Better assessment of functional capacity of kidneys from "aged" donors may help to choose appropriate donors from that pool.

Comparing medical centers treating hip fractures in the elderly: the importance of multi-outcome measurements.

The objective of this study was to assess the merit of multi-outcome measurements on the evaluation of quality of care, comparing different health care providers. We performed a cross-sectional study in 3 medical centers. Three hundred three patients undergoing surgical repair of traumatic femoral neck fracture were included. Trained nurses gathered data by patient and proxy interview and by chart abstraction. Multivariate analysis was performed to obtain an explanatory model for each outcome. Then, the additional contribution of each of the centers to the explanatory power of the model was examined. The outcomes were mortality, functional capacity, post-operative complications, and length of stay. Explanatory variables included were sociodemographic details, comorbidity indices, preoperative functional capacity, depression, and cognition. The results demonstrated that center A was a "good" outlier for mortality rate but, in contrast, was a "bad" outlier for complication rate and length of stay. Center B was a "bad" outlier for functional capacity but a "good" outlier for length of stay. We conclude that outcome studies for quality assurance programs should include all relevant outcomes, as the assumption that one major outcome may be representative for quality of care assessment may be misleading.