Changing trends in the etiology of liver transplantation in Turkiye: A multicenter study

Background and Aim

This study aimed to identify the indications for liver transplantation (LT) based on underlying etiology and to characterize the patients who underwent LT.

Materials and Methods

We conducted a multicenter cross-sectional observational study across 11 tertiary centers in Turkiye from 2010 to 2020. The study included 5,080 adult patients.

Results

The mean age of patients was 50.3±15.2 years, with a predominance of female patients (70%). Chronic viral hepatitis (46%) was the leading etiological factor, with Hepatitis B virus infection at 35%, followed by cryptogenic cirrhosis (24%), Hepatitis C virus infection (8%), and alcohol-related liver disease (ALD) (6%). Post-2015, there was a significant increase in both the number of liver transplants and the proportion of living donor liver transplants (p<0.001). A comparative analysis of patient characteristics before and after 2015 showed a significant decline in viral hepatitis-related LT (p<0.001), whereas fatty liver disease-related LT significantly increased (p<0.001).

Conclusion

Chronic viral hepatitis continues to be the primary indication for LT in Turkiye. However, the proportions of non-alcoholic fatty liver disease (NAFLD) and ALD-related LT have seen an upward trend over the years.

The efficacy and tolerability of glecaprevir/pibrentasvir treatment in a real-world chronic hepatitis C patients cohort

Background and Aim

The aims of the present study were to evaluate the real-life efficacy and tolerability of glecaprevir (GLE)/pibrentasvir (PIB) in the treatment of patients with chronic hepatitis C (CHC).

Materials and Methods

Between May 2019 and May 2022, 686 patients with CHC, treated with GLE/PIB combination from 21 participating centers in Turkiye, were enrolled in the study.

Results

All patients were Caucasian, and their median age was 56 years. At the start of GLE/PIB treatment, the median serum Hepatitis C virus RNA and serum alanine amino transaminase (ALT) levels were 6.74 log10 IU/mL and 47 U/L, respectively. Fifty-three percent of the patients were infected with genotype 1b, followed by genotype 3 (17%). Diabetes was the more common concomitant disease. The sustained virological response (SVR12) was 91.4% with intent-to-treat analysis and 98.5% with per protocol analysis. The SVR12 rates were statistically significant differences between the patients who were i.v. drug users and non-user (88.0% vs. 98.8%, p=0.025). From the baseline to SVR12, the serum ALT levels and Model for End-Stage Liver Disease score were significantly improved (p<0.001 and p=0.014, respectively). No severe adverse effect was observed.

Conclusion

GLE/PIB is an effective and tolerable treatment in patients with CHC.

TASL Practice Guidance on the Clinical Assessment and Management of Patients with Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is a multisystem disease and is significantly associated with obesity, insulin resistance, type 2 diabetes mellitus, metabolic syndrome, and cardiovascular disease. NAFLD has become the most prevalent chronic liver disease in Western countries, and the proportion of NAFLD-related cirrhosis among patients on liver transplantation waiting lists has increased. In light of the accumulated data about NAFLD, and to provide a common approach with multi-disciplines dealing with the subject, it has become necessary to create new guidance for diagnosing and treating NAFLD. This guidance was prepared following an interdisciplinary study under the leadership of the Turkish Association for the Study of the Liver (TASL), Fatty Liver Special Interest Group. This new TASL Guidance is a practical application guide on NAFLD and was prepared to standardize the clinical approach to diagnosing and treating NAFLD patients. This guidance reflects many advances in the field of NAFLD. The proposals in this guidance are meant to aid decision-making in clinical practice. The guidance is primarily intended for gastroenterology, endocrinology, metabolism diseases, cardiology, internal medicine, pediatric specialists, and family medicine specialists.

The evaluation of thiol-disulfide homeostasis in children with Triple-A syndrome

OBJECTIVE

Triple-A syndrome occurs due to the dysfunction of the ALADIN protein as a result of a mutation in the AAAS gene. ALADIN is involved in redox homeostasis in human adrenal cells and steroidogenesis. It has also been shown to have important roles in DNA repair and the protection of cells against oxidative stress. We planned to investigate serum thiol/disulfide homeostasis, which is a part of redox hemostasis in patients with Triple-A syndrome.

PATIENTS AND METHODS

The study included patients with the Triple-A syndrome (26 patients) and healthy children (26 patients). Thiol and disulfide levels of patients and healthy groups were compared. In addition, patients with the Triple-A syndrome were divided into 2 subgroups according to the mutation type, and their thiol and disulfide levels were compared.

RESULTS

Triple-A syndrome patients had increased native thiol (SH), total thiol (SH+SS) concentrations, and native thiol/total thiol (SH/SH+SS) ratios than healthy controls. However, Triple-A syndrome patients had lowered disulfide (SS), disulfide/native thiol (SS/SH), and disulfide/total thiol (SS/SH+SS) ratios than the controls. When the group with the p.R478* mutation and the group with other mutation were compared, disulfide level, disulfide/native thiol ratio, and disulfide/total thiol ratio were statistically higher in the group with the p.R478* mutation, while native thiol/total thiol ratio was found to be lower. However, no statistical difference was found between native thiol and total thiol levels.

CONCLUSIONS

This is the first study in the literature to evaluate thiol-disulfide homeostasis in patients with the Triple-A syndrome. Patients with Triple-A syndrome had an increased level of thiol compared with healthy controls. Comprehensive studies are needed to clarify these thiol levels, which are thought to be compensatory. Also, mutation type affects thiol-disulfide levels.

Recommendations for Hepatitis B Immunoglobulin and Antiviral Prophylaxis Against Hepatitis B Recurrence After Liver Transplantation

The combination of hepatitis B immunoglobulin and potent nucleos(t)ide analogs after liver transplantation is considered as the standard of care for prophylaxis against hepatitis B virus recurrence. However, the recommended doses, route of administration, and duration of HBIG administration remain unclear. Moreover, hepatitis B immunoglobulin-free prophylaxis with potent nucleos(t)ide analogs has shown promising disease outcomes in preventing hepatitis B virus recurrence. The current recommendations, produced by the Turkish Association for the Study of the Liver, Acute Liver Failure and Liver Transplantation Special Interest Group, suggest a reduced need for hepatitis B immunoglobulin administration with effective long-term suppression of hepatitis B virus replication using potent nucleos(t) ide analogs after liver transplantation.

Hepatitis E virus IgG seroprevalence in liver transplant patients: A retrospective single-center experience

BACKGROUND AND AIM

Hepatitis E virus (HEV) may cause chronic liver disease in solid organ transplant recipients. We determined HEV seroprevalence and associated factors in liver transplant recipients.

MATERIALS AND METHODS

Patients followed at the outpatient clinic of liver transplantation between January 2019 and January 2020 were screened retrospectively for HEV serology (HEV immunoglobulin M [IgM] and HEV immunoglobulin G [IgG]).

RESULTS

Of the 150 patients (male/female, 104/46; age, 55.4±13.2 years), anti-HEV IgG was positive in 31 (20.7%), and anti-HEV IgM was negative in all. The mean time after liver transplantation (72 [48%] deceased and 78 [52%] living donors) was 81±78.5 months. Drinking water consisted of carboy and tap water in 88 (58.7%) and 62 patients (41.3%), respectively. Of the patients, 120 (80%) and 30 (20%) lived in urban and rural areas, respectively. On comparison, the difference between positive and negative anti-HEV IgG groups in terms of age, place of birth, water supply, and donor type was statistically significant (p=0.007, p=0.000, p=0.034, and p=0.049, respectively).

CONCLUSION

HEV seroprevalence was more frequent in liver transplant recipients compared with the normal population. Older age, water supply, and place of birth were risk factors for HEV seroprevalence.

Ethyl pyruvate prevents from chronic cerebral hypoperfusion via preserving cognitive function and decreasing oxidative stress, caspase 3 activation and IL-1β level

BACKGROUND

One of the important risk factors for dementia is chronic cerebral hypoperfusion (CCH) especially in patients with cerebrovascular disease.

OBJECTIVES

In the present study, using rat model of bilateral common carotid artery occlusion, the possible protective effects of ethyl pyruvate (EP) have been explored in terms of memory impairment, oxidative stress, and levels of caspase-3, Na-K ATPase, and IL- 1β.

METHODS

Rats were treated with EP (50 mg/kg, i.p) for 4 weeks. Cognitive function was evaluated by Morris Water Maze (MWM). Both levels of caspase-3 and Na-K ATPase in tissue, IL-1β in plasma were measured by ELISA method. Status of oxidative stress in brain was assessed by the measurements of the tissue malondialdehyde (MDA) and reduced glutathione (GSH) contents.  RESULTS: Results showed that CCH caused a striking impairment of spatial working memory, accompanied with increased levels of MDA and IL-1β as well as caspase 3 level. The treatment with EP, however, significantly improved the memory impairment. Moreover, the treatment also provided beneficial effects on the disturbances of caspase 3, IL-1β and MDA.

CONCLUSION

This study strongly imply that the EP administration can alleviate the memory impairment observed due to CCH. The protection provided by EP may result from inhibition of inflammatory response, apoptotic processes and oxidative stress (Fig. 3, Ref. 58).

Magnetic compression anastomosis for patients with a disconnected bile duct after living-donor related liver transplantation: a pilot study

BACKGROUND AND STUDY AIM

We present the use of the magnetic compression anastomosis (MCA) technique for treatment of disconnected bile duct after living-donor related liver transplantation (LDLT) using the recently introduced through-the-scope magnet.

PATIENTS AND METHODS

The MCA technique was used in patients with disconnected bile duct who could not be treated with either percutaneous or endoscopic procedures. All patients already had a percutaneous external biliary drainage catheter before the procedure. The magnet was placed percutaneously into the proximal side of the obstruction by pushing a 5-Fr catheter over a guidewire. Concurrently, endoscopic retrograde cholangiopancreatography (ERCP) including endoscopic papillary sphincterotomy was performed. The sister magnet was then carefully advanced to the opposite side of the obstruction with a 5-Fr catheter over a guidewire. After the confirmation of biliary recanalization, a guidewire was passed through the stricture and a percutaneous dilation of the stricture was performed with a balloon-tipped catheter. Endoscopic balloon dilation of the stricture, insertion of two plastic stents and the removal of the internal drainage catheter were performed during the first ERCP session. Stent exchange and multiple side-by-side stent placements were planned at regular intervals (3 monthly) for all patients.

RESULTS

A total of six LDLT patients with disconnected bile duct (aged 37 - 68, four men) underwent the MCA technique between September 2014 and July 2015. Biliary recanalization was achieved 13 - 42 days after the magnet placement procedure. The success rate of the procedure was 100 %.

CONCLUSIONS

The MCA technique using a small magnet (diameter 2.4 mm) is effective and useful in LDLT patients with disconnected bile duct.

In vitro fertilization-induced pregnancies predispose to gastroesophageal reflux disease

BACKGROUND

Women conceiving following in vitro fertilization (IVF) likely have a variety of risk factors that predispose them to gastroesophageal reflux disease (GERD) in the future.

OBJECTIVE

We aimed to investigate whether pregnancy through IVF may predispose to subsequent GERD compared with pregnancies without IVF. We also evaluate whether twin IVF pregnancies lead to additional risk for having GERD compared with singleton IVF pregnancies.

METHODS

A validated reflux questionnaire was administered to 156 women with singleton (n = 102) or twin (n = 54) IVF birth (IVF group) and 111 women with a naturally conceived singleton birth (control group). All women included in the study were primiparas who had given birth at least 1 year prior to data collection. The diagnosis of GERD was based on the occurrence of typical symptoms (heartburn, regurgitation, or both) at least once a week.

RESULTS

The prevalence of GERD was 13.5% and 4.5% in IVF and control groups (p = 0.015); in the IVF group, this was slightly higher, but not statistically significant, in women with twin compared with singleton pregnancies (14.8% vs. 12.7%, p = 0.749). Logistic regression analysis showed that IVF was strongly associated with subsequent GERD (OR, 3.30; 95% CI 1.20-9.04; p = 0.02).

CONCLUSION

The risk of developing GERD at least 1 year after delivery increased following IVF. Long-term follow-up studies are required to determine whether therapy during pregnancy can prevent this risk.

Telbivudine in liver transplant recipients: Renal protection does not overcome the risk of polyneuropathy and myopathy

The recently reported benefit of telbivudine for renal function has not been systematically studied in long-term liver transplantation (LT) recipients who are at high risk for renal impairment. We aimed to examine whether switching lamivudine therapy to telbivudine could improve renal function in LT recipients who have impaired renal function. This single-center, prospective cohort study enrolled LT recipients who were on lamivudine for hepatitis B virus (HBV) prophylaxis and who had renal impairment for at least 1 year. Lamivudine was switched to telbivudine. The primary outcome was to evaluate the change in renal function at weeks 12, 24, 36, and 48. The secondary outcomes were to assess the efficacy of telbivudine for HBV prophylaxis and the safety profile of telbivudine in the posttransplant setting. After 45 patients were enrolled, the study was terminated early because of increased rates of polyneuropathy/myopathy. During telbivudine treatment (median, 64 weeks), estimated glomerular filtration rate (eGFR) increased in 34 patients (76%). The improvement in renal function was prominent after 24 weeks of telbivudine treatment. Telbivudine was effective as prophylaxis against HBV recurrence. Twenty-six patients (58%) developed polyneuropathy and/or myopathy. The 1-year estimated incidence of polyneuropathy/myopathy was 28%. Diabetes was the strongest predictor of polyneuropathy/myopathy (hazard ratio, 4.13; 95% confidence interval, 1.49-11.50; P = 0.007). In conclusion, although it seems to have a favorable effect in the improvement of renal function and seems to be effective in the prevention of HBV recurrence, the high risk of polyneuropathy and myopathy hampers the use of telbivudine in LT recipients.

The effects of nitrous oxide on vitamin B12 and homocysteine levels in methyltetrahydrofolate reductase gene mutation

BACKGROUND

We aimed to investigate the effects of nitrous oxide on plasma total homocysteine and vitamin B12 levels in patients with or without methyltetrahydrofolate reductase (MTHRF) gene mutation.

METHODS

After obtaining the ethics committee approval and written informed consents of patients, 93 patients between 18-70 years of age scheduled for surgery anticipated to last 1-4 hours were enrolled in the study. Patients with contraindications for nitrous oxide use were excluded. Preoperatively, blood samples were obtained from all patients for the determination of MTHFR gene mutation. Anesthesia induction was achieved with 3 mg.kg-1 of propofol and 1 µg.kg-1 of fentanyl. Anesthesia maintenance was performed with sevoflurane and with a carrier gas composed of 40 % O2 and 60 % N2O. Venous blood samples were obtained after venous canulation, and 24 hours after extubation for the analysis of plasma total homocysteine, vitamin B12 levels.

RESULTS

Eighty-one patients were included in the study. Postoperative vitamin B12 levels were found to be significantly lower when compared with their preoperative levels (p<0.05). It was found that MTHRF gene polymorphism had no significant effect on postoperative plasma total homocysteine and serum vitamin B12 levels (p>0.05). Postoperative plasma total homocysteine levels were found to be significantly different between patients with operation times under and over 3 hours (p=0.028).

CONCLUSIONS

We conclude that MTHRF gene polymorphism had no significant effects on postoperative plasma total homocysteine levels. However, we found that homocysteine levels might rise in patients who received general anesthesia with nitrous oxide for longer than 3 hours (Tab. 7, Ref. 26).

Preventive and protective effects of Turkish propolis on H₂O₂-induced DNA damage in foreskin fibroblast cell lines

The aim of the present study was to evaluate the potential of Turkish propolis extracts if they prevent or protect foreskin fibroblast cells against hydrogen peroxide (H₂O₂)-induced oxidative DNA damage. Hydrogen peroxide (40 μM) was used as an inducer of oxidative DNA damage. The damage of DNA was evaluated by using the alkaline single cell gel electrophoresis (comet) assay. Turkish propolis extracts at concentrations of 25, 50, 75 and 100 μg/ml were prepared by ethanol. Anti-genotoxicity was assessed before, simultaneously, and after treatment of propolis extract (50 μg/ml) with H₂O₂. The results showed a significant decrease in H₂O₂-induced DNA damage in cultures treated with propolis extract. The antioxidant activity of phenolic components found in propolis may contribute to reduce the DNA damage induced by H₂O₂. Our findings confirmed the chemopreventive activity of propolis and showed that this effect may occur under different mechanisms.

Evaluation for Helicobacter pylori in Meckel's diverticulum by using real-time PCR

BACKGROUND

Although Helicobacter pylori (H. pylori) has been identified in heterotopic gastric mucosa of Meckel's diverticulum, controversial results are reported in the pertinent literature.

AIMS

The aim of this study was to evaluate for the presence of H. pylori histologically using hematoxylin-eosin and Toluidine Blue in Meckel's diverticulum and by real-time TaqMan polymerase chain reaction (PCR) in those with heterotopic gastric mucosa.

METHODS

The study included 21 consecutive patients who had undergone resection of Meckel's diverticulum at our hospital between 1995 and 2007. The paraffin-embedded tissues were retrieved and reviewed for the presence of histological abnormalities and H. pylori-like organisms and for the presence or absence of heterotopic mucosa. H. pylori was sought in those cases that contained heterotopic gastric mucosa using real-time TaqMan PCR to amplify a fragment of the 23S ribosomal RNA (rRNA) gene of H. pylori.

RESULTS

Upon histological examination, heterotopic gastric mucosa was found to be present in 12 cases. H. pylori was not identified in any of the sections examined. A genomic PCR product was also not obtained in real-time PCR study.

CONCLUSIONS

We have confirmed that colonization of H. pylori, if it occurs at all, is exceedingly rare in heterotopic gastric mucosa of Meckel's diverticulum.

The modified sequential treatment regimen containing levofloxacin for Helicobacter pylori eradication in Turkey

BACKGROUND

Eradication rates of Helicobacter pylori have declined to unacceptable levels in recent years. New and effective treatment options are warranted both as a first and second line treatment.

AIM

To test an effectiveness of modified sequential therapy with levofloxacin for H. pylori eradication in Turkey.

MATERIAL AND METHODS

Helicobacter pylori infected dyspeptic patients were included to the study. Subjects were treated with modified sequential therapy consisting of rabeprazole 20 mg b.i.d. and amoxicillin 1 g b.i.d., for 7 days followed by rabeprazole 20 mg b.i.d, levofloxacin 500 mg q.d. and metronidazole 500 mg b.i.d for the remaining 7 days.

RESULTS

Sixty-three treatment naive patients and 37 previous treatment failures were enrolled to the study (59 F, 41 M, age: 21-80 years). There was five drop out. Helicobacter pylori eradication was achieved in 80 patients, intention-to-treat (ITT): 80% (95% CI: 71-87%) and per-protocol (PP): 84.2% (95% CI: 75-91%), totally. In treatment naive patients ITT and PP eradication rates were 82.5% (95% CI: 71-91%), and 86.7% (95% CI: 75-94%), respectively. As a second line treatment eradication was successful in ITT 75.7%.(95% CI: 59-88%), and PP 80% (95% CI: 63-92%).Mild side effects were reported by 8 patients (8.4%).

CONCLUSIONS

Sequential therapy using "rabeprazole and amoxicillin 7 days followed by rabeprazole, metronidazole and levofloxacin for 7 days" is a new regimen with acceptable eradication rates in naïve patients in Turkey. Further modifications in the dose or duration of this new sequential therapy might increase its effectiveness as both first and second line treatment.

The acquisition time of infection: a determinant of the severity of hepatitis C virus-related liver disease in renal transplant patients

BACKGROUND

The aim of this study was to compare the clinical and histopathological course of HCV infection acquired before and during or after renal transplantation.

METHODS

According to HCV status, 197 RT patients were divided into three groups. At the time of RT, anti-HCV antibody was positive in 47 patients (pre-RT HCV group). In 27 patients, in whom anti-HCV negative at the time of RT, anti-HCV and/or HCV RNA was found to be positive following an ALT elevation episode after RT (post-RT HCV group). Both anti-HCV and HCV RNA were negative at all times in remaining 123 patients (control group).

RESULTS

Liver biopsy was performed in 31 of 47 patients in pre-RT and 24 of 27 in post-RT HCV group after RT. Duration of follow-up was similar in all groups with a mean of 7.1 +/- 4.0 yr. Ascites and encephalopathy were seen in only post-RT HCV group (22%). Histological grade (6.5 +/- 2.7 vs. 4.1 +/- 1.4) and stage (2.0 +/- 1.5 vs. 0.8 +/- 0.8) was significantly severe in post-RT HCV group (p < 0.01). Three patients died due to liver failure in post-RT HCV group.

CONCLUSIONS

HCV infection acquired during or after RT shows a severe and rapidly progressive clinicopathological course, which is significantly different from pre-transplant anti-HCV positive patients.

Antimicrobial effects of two anaesthetic agents: dexmedetomidine and midazolam

Some anaesthetic agents are known to inhibit microbial growth. The aim of this in vitro study was to investigate possible antimicrobial effects of two frequently used agents in intensive care units, dexmedetomidine and midazolam. Antimicrobial effect was tested on Staphylococcus aureus, Enterococcus faecalis, Escherichia coli and Pseudomonas aeruginosa by broth microdilution method. Midazolam showed inhibitor and bactericidal effect on S. aureus at concentrations 256 mmicrog x ml(-1) and 512/microg x ml(-1) respectively and on E. faecalis at concentrations 128 microg x ml(-1) and 256 microg x ml(-1). Dexmedetomidine demonstrated inhibitor effect on S. aureus, E. coli and P aeruginosa at concentrations 32 microg x ml(-1), 16 microg x ml(-1) and 16 microg x ml(-1) respectively. Midazolam had inhibitor and bactericidal effects on S. aureus and E. faecalis. Dexmedetomidine had only inhibitor effects on S. aureus, E. coli and P aeruginosa. Further studies are needed to determine the antimicrobial mechanisms and clinical applications.

Serum ischaemia-modified albumin increases in critical lower limb ischaemia

BACKGROUND

Ischaemia is a common phenomenon in the pathogenesis of a wide range of medical and surgical conditions, including myocardial infarction, mesenteric vascular occlusion and compartment syndrome. Ischaemia modified albumin has been suggested as an aid to clinical decision making in various clinical settings. This study examines the usefulness of IMA in the diagnosis of limb ischaemia (LI).

METHODS

This case-controlled study was performed in the emergency department of Karadeniz Technical University Hospital, Turkey. 22 patients presenting to the emergency departments and definitively diagnosed with LI were enrolled in the study. A control group of 22 healthy volunteers served as a reference for biochemical parameters.

RESULTS

The mean serum IMA level for LI patients was 0.295 (SD 0.062) ABSU. The mean serum IMA level for control patients was 0.174 (SD 0.061) ABSU. There was a statistically significant difference between the mean LI patient and mean control patient IMA levels (p<0.0005). A ROC curve analysis reveals the relationship between sensitivity and specificity for IMA in limb ischaemia.

CONCLUSION

There is a significant increase in serum IMA in limb ischaemia. Furthermore, using a cutoff of 0.22 ABSU, ROC curve analysis shows that IMA is 81.8% sensitive and 81.8% specific 81.8% in patients with clinically severe lower limb ischaemia. Future studies would be needed to determine if IMA would be clinically useful in the diagnosis of subtle limb ischaemia.

Normative values of the balloon expulsion test in healthy adults

BACKGROUND/AIMS

Constipation is the most frequent complaint of the digestive tract. It has been reported that approximately half of the patients with constipation have functional defecation disorders (dyssynergic defecation). An important diagnostic tool for the diagnosis of functional defecation disorders is the balloon expulsion test. Normative values have not been widely determined in different populations. We aimed to determine the data which could be indicative of normative values of the balloon expulsion test for healthy individuals in our society.

METHODS

A total of 116 healthy volunteers were evaluated in the study (55 men). Subjects were classified into three subgroups according to age (20-39 yrs, 40-59 yrs, > or = 60 yrs). Catheters with balloon and application room were standardized, and then a balloon expulsion test was performed in all groups. The results of the balloon expulsion test were statistically compared between groups.

RESULTS

The distribution of males/females according to age groups was: 20-39 yrs: 20/22, 40-59 yrs: 20/23, > or = 60 yrs: 15/16. The balloon expulsion time was determined as 44.1+/-19.0 seconds in male subjects and 56.4+/-21.4 seconds in females (p=0.001). An increase in the balloon expulsion time was observed to be related with age in males (p=0.00001); however, no statistically significant difference was shown by age in female subjects (p=0.80). If the entire study group was considered, there was a significant correlation between age and balloon expulsion time (p=0.0001).

CONCLUSIONS

The balloon expulsion test is a simple procedure to identify impaired evacuation in constipated patients. This study represents the first assessment of the balloon expulsion test in a healthy Turkish population. It has been demonstrated that expulsion should take less than 30 seconds for men younger than 40 years of age and less than 1 minute above 40 years. For women, expulsion should occur in 1 minute regardless of age. Our results could serve as a valuable resource of normative data.

A cerebrovascular event after single-dose administration of recombinant factor VIIa in a patient with esophageal variceal bleeding

Upper gastrointestinal bleeding (UGIB) is a life-threatening complication of cirrhosis that develops from esophageal varices in almost 70% of patients. The mortality rate from the bleeding episodes is reported to be 30% [1-4]. Standard management of UGIB of cirrhotic patients is vasoactive therapy combined with endoscopic procedures such as endoscopic sclerotherapy and band ligation [5]. Currently, it is reported that recombinant activated fVIIa (Novoseven, NovoNordisc) can correct the prothrombin time in decompensated cirrhotic patients and also can be used safely in Child's B and C cirrhotic patients with UGIB [6-8]. Herein, we describe the first case report in the literature of a cerebrovascular event after the administration of a single dose of fVIIa in a cirrhotic patient with esophageal variceal bleeding.

Swallow-Induced Syncope in a Patient with Achalasia

A 48-year-old man was referred for the evaluation of dysphagia and syncope. He suffered from both dysphagia and transient loss of consciousness when eating solid food, especially bread. An upper gastrointestinal barium examination and esophageal manometry suggested achalasia. Ambulatory ECG revealed marked sinus bradycardia when experiencing a syncopal episode following the ingestion of a solid meal. A permanent pacemaker was implanted and the patient's syncopal attacks were relieved following this procedure. However, the dysphagia and cardiac arrhythmia completely disappeared only following a successful pneumatic balloon dilatation for achalasia. This observation suggests that swallowing-induced sinus bradycardia and syncope might occur in the course of achalasia and these rhythm abnormalities could be relieved by successful treatment of the achalasia.

Neuropeptide- and tyrosine hydroxylase-immunoreactive nerve fibers in painful Morton's neuromas

We examined the expression of three neuropeptides that have been implicated in nociceptive transmission, and the sympathetic nerve fiber marker tyrosine hydroxylase, in 11 painful human Morton's neuromas, using immunohistochemistry. Antibodies against the neural markers RT97 and PGP 9.5 were used to map the general nerve fiber organization of the neuromas. Four specimens of normal human peripheral nerves were used as controls. Substance P, calcitonin gene-related peptide, and neuropeptide Y immunoreactivities were more pronounced in neuroma tissue than in control nerves. Neuropeptide immunofluorescence was seen both in larger nerve fiber trunks and in masses of disorganized axon profiles dispersed in loose connective tissue. Tyrosine hydroxylase immunoreactivity was present at varying levels of expression in neuroma nerve fiber trunks, in connective tissue nerve fiber bundles, and around some blood vessels. Our findings suggest that neuropeptides are involved in the response to injury in Morton's neuromas and that they could play a role in initiation or modulation of pain. In addition, pain from Morton's neuromas could be influenced by sympathetic nerve fibers.

Complications with infection and foreign body reaction after silicon implant arthroplasty in the second metatarsophalangeal joint in an adolescent: a case report

A 21-year-old otherwise healthy male was referred to our clinic due to severe pain, deformation, development of fistules, and swelling of the second metatarsophalangeal joint of the right foot. He presented a history of two previous operations. At the age of 13, a 2-cm. resection of the distal part of the proximal phalanx was performed due to severe hammertoe deformity. At the age of 19, a partial phalanx resection and implantation of a silicon elastomer ball-shaped joint spacer was performed due to second metatarsophalangeal joint instability. After this operation, the patient suffered from fistules that appeared in the second metatarsophalangeal region. Following referral to our clinic, the patient was operated on. The proximal phalanx was removed along with the prosthesis which had slipped from the metatarsophalangeal joint into the proximal phalanx with the ends of the prosthesis perforating the skin. Debridement of infected tissue and implantation of gentamicin containing beads were performed. Bacterial specimens revealed growth of coagulase-negative staphylococci. Microscopic examination of the debrided tissue showed signs of acute and chronic inflammation. Postoperatively, the patient was treated with antibiotics and healing was uneventful. This case advocates the need for proper selection criteria and strict indications in patients with joint disease needing an arthroplasty.

Tarsal tunnel syndrome. Outcome of surgery in longstanding cases

Cases of longstanding (median, 60 months) tarsal tunnel syndrome were decompressed surgically in 14 female and four male patients. Patients reported intermittent dysesthesia, paresthesia, or anesthesia at the medial plantar aspect of the foot. Symptoms were aggravated by physical activities. Previous trauma was noted in four patients. Tinel's sign was positive in 16 patients. Magnetic resonance imaging was performed in 10 patients but was conclusive in only two. At surgery, the posterior tibial nerve or one of its branches was found to be entrapped in 15 patients. Entrapments were observed isolated or in combination within the fascial septa (n = 5), varicose veins (n = 6), scar tissues (n = 4), tenosynovitis and edema (n = 1), or within the abductor hallucis muscle (n = 1). Two neuromas were excised. In three patients no obvious entrapments were found. Clinical followup was performed a median 18 months after surgery. Relief of symptoms was reported as long as 1 year after surgery. All symptoms were relieved in 11 (61%) patients. Three (17%) patients with previous trauma had relatively severe pain after surgery and were considered to have failed results. Surgical decompression was beneficial in most patients with longstanding tarsal tunnel syndrome.

Plantar fascia rupture: diagnosis and treatment

Two patients with spontaneous medial plantar fascia rupture due to a definite injury with no prior symptoms, were referred to our institution. Clinically, there was a tender lump in the sole, and magnetic resonance imaging confirmed the diagnosis. Nonoperative treatment was sufficient in curing the acute total rupture. Endoscopic release was used on the partially ruptured plantar fascia, but it is probably more optimal in the acute phase. The literature provides no comparative data on operative or nonoperative treatment efficacy for this rare condition.

Dislocation of the tibialis posterior tendon: diagnosis and treatment

Traumatic dislocation of the tibialis tendon occurred from minor ankle sprains in a 37-year-old male and a 53-year-old female. Both complained of local pain at the medial malleolus, and both walked with a limp. The diagnosis was suspected by clinical examination, in one case with 2 months' delay, and verified by ultrasound, computed tomography, and magnetic resonance imaging. The male patient was initially treated for an "uncomplicated ankle sprain." For various reasons surgery was delayed 4 months. During this interval the male patient complained of pain and severe dysfunction, requiring analgesic treatment. A medial Achilles tendon flap was used to support the repositioned tendon. The female patient was operated on within 1 week from injury, by resuturing of the retinaculum over the tendon. Postoperatively, both patients were immobilized with below-knee casts for 6 weeks, allowing full weightbearing, followed by strength and stretching exercises. They were free of symptoms 2 and 3 months, respectively, after surgery. At follow-up 1 year postoperatively, both were asymptomatic and participated in activities like those before their injuries.

A study of intrinsic factors in patients with stress fractures of the tibia

We aimed to study intrinsic factors in 29 consecutive patients with well-documented unilateral stress fractures of the tibia. Anthropometry, range of motion, isokinetic plantar flexor muscle performance, and gait pattern were analyzed. The uninjured leg served as the control. A reference group of 30 uninjured subjects was compared regarding gait pattern. Anterior stress fractures of the tibia (N = 10) were localized in the push-off/ landing leg in 9/10 athletes, but were similarly distributed between legs in posteromedial injuries (N = 19). Ten (30%) of the stress fracture subjects had bilateral high foot arches, similar to those found in the reference group. There were no other systematic differences in anthropometry, range of motion, gait pattern, or isokinetic plantar flexor muscle peak torque and endurance between injured and uninjured legs. No other differences were found between anterior and posteromedial stress fractures. We conclude that anterior stress fractures of the tibia occur mainly in the push-off/landing leg in athletes. Within the limitations of our protocol, no registered intrinsic factor was found to be directly associated with the occurrence of a stress fracture of the tibia.

The effect of weight-bearing pressure on the plantar circulation in diabetes mellitus

Patients with diabetic neuropathy are prone to ulceration on the sole of the foot, especially in areas with high weight-bearing pressure. The relationship between weight-bearing pressure and nutritive skin circulation in the plantar region was studied. Gait analysis was performed with the EMED Gait Analysis System and the skin circulation was measured by fluorescein flowmetry in ten neuropathic diabetic patients and in eight healthy controls. The critical plantar foot pressure above which nutritional blood flow in the skin was arrested was 3 N cm-2 or more in both diabetic and control subjects. Below 3 N cm-2 the blood flow was independent of weight-bearing pressure both in diabetic and control subjects (correlation coefficient r = -0.01 and -0.19, respectively). Thus, our results indicate that the nutritional blood flow in the plantar region is not decreased in patients with diabetic neuropathy.

Postoperative evaluation of Keller's arthroplasty and arthrodesis of the first metatarsophalangeal joint using the EMED gait analysis system

The authors examined 10 patients who had arthrodesis at the first metatarsophalangeal joint and 10 patients who had Keller's arthroplasty operation. The EMED gait analysis was used to measure the pressure distribution over the sole of the foot during walking. Arthrodesis group had significantly increased maximum pressure in the first and third metatarsal regions. The Keller arthroplasty group had the lowest maximum pressure in the big toe but it was not significant.

Surgical treatment of forefoot deformity with special reference to polyarthritis

Among 523 patients consecutively treated for forefoot pain and deformity, 64 had inflammatory arthritis. Most patients no longer had difficulties finding shoes that fit after the deformities were surgically corrected. Although about one half of the patients had some residual symptoms after treatment, 57 (89%) were satisfied with the operation. If the deformities are corrected early, joint resections can be avoided and toe function preserved.

Computed tomography for diagnosis of Morton's neuroma

Fifteen patients suspected to have Morton's neuroma were examined by computed tomography, which revealed the neuroma in seven cases. All seven underwent surgery and had the diagnosis confirmed. If there is doubt about the diagnosis, it is possible to use computed tomography as shown here.

Ankle arthrodesis by the Heiple technique in rheumatoid arthritis

The authors report on seven rheumatoid arthritic patients that successfully sustained ankle joint arthrodesis. They incorporated a chevron fusion technique previously described. Patients were followed an average of 44 +/- 11 months. They report a satisfactory result.