Effect of main pancreatic duct suture ligation on the prevention of clinically relevant pancreatic fistula after distal pancreatectomy: analysis of 82 consecutive patients

OBJECTIVE

This study aimed to examine the factors linked to the development of clinically significant pancreatic fistulas following distal pancreatectomy (DP) and to assess the efficacy of suture ligation of the main pancreatic duct.

PATIENTS AND METHODS

A single-center retrospective study was performed on the medical records of 82 patients who underwent DP in our institution between January 2011 and December 2019.

RESULTS

There were 28 males (34.1%) and 54 females (65.9%). The patients' age ranged from 18 to 86 years (median: 55.5 years). Indications for DP included primary pancreatic disease (n=63, 76.8%) and non-pancreatic disease (n=19, 23.2%). Postoperative mortality and morbidity rates were 3.7% and 48%, respectively. Pancreatic parenchymal closure was accomplished by a hand-sewn technique or mechanical stapling in 89 and 13 patients, respectively. Identification of the pancreatic duct and suture ligation was performed in 46 patients (56.1%). Pancreatic fistula was developed in 20 patients (24.4%); 12 fistulas were classified as Grade B, and 8 as Grade C. Biochemical leaks (Grade A) were identified in 8 patients (9.8%). Multivariate analysis indicated that failure to ligate the main pancreatic duct was the only variable associated with an increased risk for pancreatic leak (p=0.031; odds ratio=0.233; 95% confidence interval, 0.062-0.879).

CONCLUSIONS

Pancreatic leak remains a common complication after DP. The incidence of leaks is reduced significantly when the main pancreatic duct is identified and directly ligated during DP.

Concurrent application of interferon-gamma and vincristine inhibits tumor growth in an orthotopic neuroblastoma mouse model

PURPOSE

Tumor-associated macrophages are present within neuroblastoma, and interferon-gamma (IFN-γ) can polarize macrophages into cancer-inhibiting M1 type. We hypothesize that treating neuroblastoma with interferon-gamma (IFN-γ) can suppress tumor growth, and the concurrent treatment with IFN-γ and vincristine can lead to enhanced tumor killing as compared to vincristine alone.

METHODS

We loaded IFN-γ or vincristine into silk biomaterials and recorded the amount released over time. Orthotopic, syngeneic neuroblastoma xenografts were generated by injecting 9464D cells into adrenal gland of C57BL/6 mice, and IFN-γ-loaded and/or vincristine-loaded silk biomaterials were implanted into the tumor once the tumors reached 100 mm³. Drug release at different timepoints was measured and tumor growth after different treatments were compared.

RESULTS

1-2% of IFN-γ and 70% of vincristine were released from the biomaterials by the fifth day. Combining IFN-γ and vincristine significantly slowed tumor growth as compared to the controls (12.2 ± 2.7 days to reach 800 mm³ versus 5.7 ± 1.2 days, p = 0.01), and IFN-γ alone also delayed tumor growth as compared to the controls (10.9 ± 1.5 days versus 5.7 ± 1.2 days, p = 0.001). Hematoxylin and eosin staining demonstrated tumor necrosis adjacent to the drug-loaded silk biomaterials.

CONCLUSION

Local delivery of sustained release IFN-γ can inhibit neuroblastoma tumor growth by itself and in combination with vincristine.

Ileal rhabdomyosarcoma in a patient with a history of squamous cell lung cancer

Rhabdomyosarcoma is an infrequent muscular cancer seen in adults. We present a case of ileal intussusception due to pleomorphic rhabdomyosarcoma in a patient diagnosed previously with squamous cell carcinoma of the lung (SCCL). The patient was a 68-year-old man with a history of SCCL. He was admitted to the emergency department for nausea, emesis and obstipation. Surgical investigation of the abdomen revealed an intussusception caused by a tumour located 160cm distal of the ligament of Treitz. Pathological examination showed that tumour was a primary rhabdomyosarcoma of the ileum. This case contributes to the literature by defining an infrequent presentation of rhabdomyosarcoma causing ileal intussusception in an adult patient.

The harm of anticoagulation in patients with low-risk by CHADS2 and reclassified as high-risk by CHA2DS2VASc: inferences from TRAF cohort

OBJECTIVE

There is a gap in the knowledge concerning oral anticoagulation (OAC) in atrial fibrillation (AF) patients with a non-high risk of stroke. CHA2DS2VASc and CHADS2 scores generated imprecise risk estimates for low risk patients. We aimed to assess OAC in patients with low risk by CHADS2 and reclassified as high-risk by CHA2DS2VASc.

PATIENTS AND METHODS

In this study, retrospective nationwide population-based study, data were obtained from the Turkish claims and utilization management system. Patients with non-valvular AF (n=451,113) between 2007 and 2012 sub-divided into those with a CHA2DS2VASc≥1 and CHADS2=0 (n=41,273) who were off-warfarin (n=29,448) and on-warfarin (n=11,825). Stroke and systemic embolism, major bleeding, all-cause mortality, net clinical benefit (NCB) and ultimate NCB (UNCB) were assessed.

RESULTS

Of the total cohort (mean age 66.1 ± 14.1 years, 56.1% female), CHA2DS2VASc improved the net reclassification index of observed 5-year composite thromboembolic endpoint by 6.9% (p<0.05). CHA2DS2VASc reclassified 9.7% low risk patients as high risk. Among reclassified-high-risk category (patients with a CHA2DS2VASc score of ≥1 and CHADS2 score of 0), major bleeding for that prescribed warfarin was 3% and higher than the rate of thromboembolism among those off-warfarin. NCB (-0.035) and UNCB (-0.021) were negative. Death and hospitalization at 1 year were significantly higher for on-warfarin group.

CONCLUSIONS

Clinical outcomes, net clinical benefit indices are negative; rates of death and hospitalization were significantly higher for OAC in reclassified category. This emphasizes the importance of greater attention to balancing the risks and benefits of OAC in patients with low risk by CHADS2 and reclassified as high-risk by CHA2DS2VASc.

NF-κB-mediated effects on behavior and cartilage pathology in a non-invasive loading model of post-traumatic osteoarthritis

OBJECTIVE

This study aimed to examine the temporal activation of NF-κB and its relationship to the development of pain-related sensitivity and behavioral changes in a non-invasive murine knee loading model of PTOA.

METHOD

Following knee injury NF-κB activity was assessed longitudinally via in vivo imaging in FVB. Cg-Tg (HIV-EGFP,luc)8Tsb/J mice. Measures of pain-related sensitivity and behavior were also assessed longitudinally for 16 weeks. Additionally, we antagonized NF-κB signaling via intra-articular delivery of an IκB kinase two antagonist to understand how local NF-κB inhibition might alter disease progression.

RESULTS

Following joint injury NF-κB signaling within the knee joint was transiently increased and peaked on day 3 with an estimated 1.35 p/s/cm2/sr (95% CI 0.913.1.792 p/s/cm2/sr) fold increase in signaling when compared to control joints. Furthermore, injury resulted in the long-term development of hindpaw allodynia. Hyperalgesia withdrawal thresholds were reduced at injured knee joints, with the largest reduction occurring 2 days following injury (estimate of between group difference 129.1 g with 95% CI 60.9,197.4 g), static weight bearing on injured limbs was also reduced. Local delivery of an NF-κB inhibitor following joint injury reduced chondrocyte death and influenced the development of pain-related sensitivity but did not reduce long-term cartilage degeneration.

CONCLUSION

These findings underscore the development of behavioral changes in this non-invasive loading model of PTOA and their relationships to NF-κB activation and pathology. They also highlight the potential chondroprotective effects of NF-κB inhibition shortly following joint injury despite limitations in preventing the long-term development of joint degeneration in this model of PTOA.

Silk Fibroin Microneedle Patches for the Sustained Release of Levonorgestrel

The sustained release of levonorgestrel, a contraceptive, from silk-based microneedle patches was demonstrated for transdermal delivery. Modifications in the formulation of the silk protein and drug loading enabled the tuning of drug loading and release rates from the microneedle patches over time. Sustained drug release reached up to 100 days when the drug was loaded directly inside the microneedles, while release continued for more than a year when the drug was loaded inside microparticles prior to casting inside the microneedle patches. When coupled with the shelf-stable, refrigeration-less features of the silk protein matrix utilized in the microneedle fabrication, these findings suggest that long-acting contraception patches are feasible. This advance could provide practical options for women to have access to new options for protection against unwanted pregnancy.

Replicating and identifying large cell neuroblastoma using high-dose intra-tumoral chemotherapy and automated digital analysis

PURPOSE

Large cell neuroblastomas (LCN) are frequently seen in recurrent, high-risk neuroblastoma but are rare in primary tumors. LCN, characterized by large nuclei with prominent nucleoli, predict a poor prognosis. We hypothesize that LCN can be created with high-dose intra-tumoral chemotherapy and identified by a digital analysis system.

METHODS

Orthotopic mouse xenografts were created using human neuroblastoma and treated with high-dose chemotherapy delivered locally via sustained-release silk platforms, inducing tumor remission. After recurrence, LCN populations were identified on H&E sections manually. Clusters of typical LCN and non-LCN cells were divided equally into training and test sets for digital analysis. Marker-controlled watershed segmentation was used to identify nuclei and characterize their features. Logistic regression was developed to distinguish LCN from non-LCN.

RESULTS

Image analysis identified 15,000 nuclei and characterized 70 nuclear features. A 19-feature model provided AUC >0.90 and 100% accuracy when >30% nuclei/cluster were predicted as LCN. Overall accuracy was 87%.

CONCLUSIONS

We recreated LCN using high-dose chemotherapy and developed an automated method for defining LCN histologically. Features in the model provide insight into LCN nuclear phenotypic changes that may be related to increased activity. This model could be adapted to identify LCN in human tumors and correlated with clinical outcomes.

Extended release formulations using silk proteins for controlled delivery of therapeutics

INTRODUCTION

Silk is a promising biomaterial for controlled delivery of therapeutics and has a unique protein chemistry that can be tuned to form different carrier formats. The protein has been studied for sustained release depot systems for the targeted or localized delivery of drugs.

AREAS COVERED

An overview of natural silk proteins for controlled delivery of therapeutics is provided, with a focus on the features of silk proteins that allow them to be useful tools for controlled delivery. Recent applications of natural silk proteins as controlled delivery systems are also summarized.

EXPERT OPINION

The versatility of silk proteins makes them desirable biomaterials for a broad range of applications for controlled delivery of both small and large molecules. Further, the degradation profile leading to peptides and amino acids provides compatibility with pH-sensitive therapeutics. While silk sericin and spider silks are under study, silk fibroin extracted from silkworms (e.g. Bombyx mori) dominates pharmaceutical studies with silk. Silk fibroin can be formed into drug delivery tools for systemic or local injections, topical and transdermal applications, and implantation; depending on the target disease and therapeutic molecule. In vitro to in vivo correlations and scale-up needs are the next steps towards clinical applications.

Sustained release silk fibroin discs: Antibody and protein delivery for HIV prevention

With almost 2 million new HIV infections worldwide each year, the prevention of HIV infection is critical for stopping the pandemic. The only approved form of pre-exposure prophylaxis is a costly daily pill, and it is recognized that several options will be needed to provide protection to the various affected communities around the world. In particular, many at-risk people would benefit from a prevention method that is simple to use and does not require medical intervention or a strict daily regimen. We show that silk fibroin protein can be formulated into insertable discs that encapsulate either an antibody (IgG) or the potent HIV inhibitor 5P12-RANTES. Several formulations were studied, including silk layering, water vapor annealing and methanol treatment to stabilize the protein cargo and impact the release kinetics over weeks. In the case of IgG, high concentrations were released over a short time using methanol treatment, with more sustained results with the use of water vapor annealing and layering during device fabrication. For 5P12-RANTES, sustained release was obtained for 31 days using water vapor annealing. Further, we show that the released inhibitor 5P12-RANTES was functional both in vitro and in ex vivo colorectal tissue. This work shows that silk fibroin discs can be developed into formidable tools to prevent HIV infection.

Ocular Drug Delivery

Although the eye is an accessible organ for direct drug application, ocular drug delivery remains a major challenge due to multiple barriers within the eye. Key barriers include static barriers imposed by the cornea, conjunctiva, and retinal pigment epithelium and dynamic barriers including tear turnover and blood and lymphatic clearance mechanisms. Systemic administration by oral and parenteral routes is limited by static blood-tissue barriers that include epithelial and endothelial layers, in addition to rapid vascular clearance mechanisms. Together, the static and dynamic barriers limit the rate and extent of drug delivery to the eye. Thus, there is an ongoing need to identify novel delivery systems and approaches to enhance and sustain ocular drug delivery. This chapter summarizes current and recent experimental approaches for drug delivery to the anterior and posterior segments of the eye.

Silk Reservoirs for Local Delivery of Cisplatin for Neuroblastoma Treatment: In Vitro and In Vivo Evaluations

Neuroblastoma is the most common extracranial childhood tumor, and current treatment requires surgical resection and multidrug chemotherapy. Local, perioperative delivery of chemotherapeutics is a promising treatment method for solid tumors that require surgical removal. In this study, we have aimed to develop a controlled-release implant system to deliver cisplatin in tumor or tumor resection area. Silk fibroin, a biodegradable, nonimmunogenic biopolymer was used to encapsulate different doses of cisplatin in a reservoir system. The physical integrity of the reservoirs was characterized by evaluating the crystalline structure of silk secondary structure using FTIR spectroscopy. The in vitro release of cisplatin was evaluated in phosphate-buffered saline at 37°C, and the reservoirs were able to release the drug up to 30 days. The cytotoxicity of cisplatin and cisplatin reservoirs were tested on KELLY cells. Cytotoxicity data showed 3.2 μg/mL cisplatin was required to kill 50% of the cell population, and the released cisplatin from the silk reservoirs showed significant cytotoxicity up to 21 days. Intratumoral implantation of silk reservoirs into an orthotopic neuroblastoma mouse model decreased tumor growth significantly when compared with control subjects. These results suggest that silk reservoirs are promising carriers for cisplatin delivery to the tumor site.

Pharmaceutical Approaches to HIV Treatment and Prevention

Human immunodeficiency virus (HIV) infection continues to pose a major infectious disease threat worldwide. It is characterized by the depletion of CD4+ T cells, persistent immune activation, and increased susceptibility to secondary infections. Advances in the development of antiretroviral drugs and combination antiretroviral therapy have resulted in a remarkable reduction in HIV-associated morbidity and mortality. Antiretroviral therapy (ART) leads to effective suppression of HIV replication with partial recovery of host immune system and has successfully transformed HIV infection from a fatal disease to a chronic condition. Additionally, antiretroviral drugs have shown promise for prevention in HIV pre-exposure prophylaxis and treatment as prevention. However, ART is unable to cure HIV. Other limitations include drug-drug interactions, drug resistance, cytotoxic side effects, cost, and adherence. Alternative treatment options are being investigated to overcome these challenges including discovery of new molecules with increased anti-viral activity and development of easily administrable drug formulations. In light of the difficulties associated with current HIV treatment measures, and in the continuing absence of a cure, the prevention of new infections has also arisen as a prominent goal among efforts to curtail the worldwide HIV pandemic. In this review, the authors summarize currently available anti-HIV drugs and their combinations for treatment, new molecules under clinical development and prevention methods, and discuss drug delivery formats as well as associated challenges and alternative approaches for the future.

Disseminated injection of vincristine-loaded silk gel improves the suppression of neuroblastoma tumor growth

BACKGROUND

Advanced-stage neuroblastoma patients require multiagent chemotherapy. Intratumoral implantation of vincristine-loaded silk gel uses local diffusion to decrease orthotopic neuroblastoma tumor growth in mice. We hypothesize that injecting vincristine-loaded silk gel into 8 locations within the tumor, instead of only centrally, decreases the diffusion distance and improves tumor growth suppression.

METHODS

Human neuroblastoma cells, KELLY, were injected into mouse adrenal glands to create orthotopic tumors. After the tumors reached 100 mm³ by ultrasound, silk gels loaded with 50 µg vincristine were injected centrally or in 8 areas throughout the tumor. Drug-release profile was measured in vitro. Endpoints were tumor size >1,000 mm³ and histologic examination.

RESULTS

Vincristine-loaded silk gels suppressed tumor growth up to an inflection point (458.7 ± 234.4 mm³ for central, 514.3 ± 165.8 mm³ for 8-point injection) before tumor growth accelerated >200 mm³ over 3 days. The time to inflection point was 6.6 days for central, 13.3 days for 8-point injection (P < .05). Using the sphere volume equation to approximate tumor volume, splitting the volume into 1/8 decreased the diffusion radius by 1/2. Histologic examination confirmed tumor necrosis adjacent to vincristine-loaded silk gel.

CONCLUSION

Injecting vincristine-loaded sustained release silk gel at 8 separate locations halved the diffusion distance and doubled the time for the tumor to reach the growth inflexion point.

In vitro and in vivo evaluation of etoposide - silk wafers for neuroblastoma treatment

High-risk neuroblastoma requires surgical resection and multi-drug chemotherapy. This study aimed to develop an extended release, implantable and degradable delivery system for etoposide, commonly used for neuroblastoma treatment. Different concentrations of silk, a biodegradable, non-toxic, non-immunogenic material were employed to prepare etoposide-loaded wafer formulations. Secondary structure of silk in the formulations was characterized using Fourier Transform Infrared (FTIR) spectroscopy and optimized based on the crystalline structure. Accelerated in vitro degradation studies under different conditions such as acidic, alkaline, oxidizing mediums and high temperature, were performed. The integrity of the silk wafer structure was maintained unless exposed to 0.1 N NaOH for 24 h. In vitro release of etoposide was performed in PBS (phosphate buffered saline) at 37 °C. Silk coated 6% wafers released the drug up to 45 days, while uncoated wafers released the drug for 30 days. Cytotoxicity study was performed on KELLY cells to evaluate the etoposide cytotoxicity (LC50) and the long-term efficacy of the etoposide wafer formulations. The results showed that etoposide killed 50% of the cells at 1 μg/mL concentration and the wafer formulations demonstrated significant cytotoxicity up to 22 days when compared to untreated cells. Using an orthotopic neuroblastoma mouse model, intra-tumoral implantation of the coated 6%, uncoated 6%, or uncoated 3% silk wafers were all effective at decreasing tumor growth. Histological examination revealed tumor cell necrosis adjacent to the drug-loaded silk wafer.

Programmable Hydrogel Ionic Circuits for Biologically Matched Electronic Interfaces

The increased need for wearable and implantable medical devices has driven the demand for electronics that interface with living systems. Current bioelectronic systems have not fully resolved mismatches between engineered circuits and biological systems, including the resulting pain and damage to biological tissues. Here, salt/poly(ethylene glycol) (PEG) aqueous two-phase systems are utilized to generate programmable hydrogel ionic circuits. High-conductivity salt-solution patterns are stably encapsulated within PEG hydrogel matrices using salt/PEG phase separation, which route ionic current with high resolution and enable localized delivery of electrical stimulation. This strategy allows designer electronics that match biological systems, including transparency, stretchability, complete aqueous-based connective interface, distribution of ionic electrical signals between engineered and biological systems, and avoidance of tissue damage from electrical stimulation. The potential of such systems is demonstrated by generating light-emitting diode (LED)-based displays, skin-mounted electronics, and stimulators that deliver localized current to in vitro neuron cultures and muscles in vivo with reduced adverse effects. Such electronic platforms may form the basis of future biointegrated electronic systems.

Helicobacter pylori and cardiovascular disease

Helicobacter pylori (H. pylori) is one of the most common infections in human. The association between H. pylori and gastrointestinal diseases including peptic ulcer, chronic gastritis, mucosa associated tissue lymphoma (MALT) and gastric cancer is well known. However it was also suggested that H. pylori was linked to various extra-gastrointestinal disorders such as diabetes mellitus and coronary artery disease. In this review we summarized the association between H. pylori and cardiovascular disease.

Potential biomarkers for vascular damage in Alzheimer's disease: thrombomodulin and von Willebrand factor

OBJECTIVES

Evidence regarding the vascular basis of Alzheimer's disease (AD) is growing. In vascular damage thrombomodulin tears of the cell wall and its level increases in the plasma. von Willebrand factor (vWF) is also thought to be a biomarker for vascular damage. The aim of this study was to examine the levels of vWF and thrombomodulin in AD as possible markers for vascular damage and to test their utility as an early biomarker in AD.

DESIGN

Case-control study.

SETTING

Geriatric medicine outpatient clinic of a university hospital.

PARTICIPANTS

Twenty Alzheimer's disease patients free from vascular risk factors and 20 controls were enrolled in the study.

MEASUREMENTS

Thrombomodulin and VWF levels of 20 AD patients and 20 controls were analyzed by commercial kits.

RESULTS

Thrombomodulin levels were not different between Alzheimer's disease and control groups [median (range) = 4.25 (2.27-37.00) ng/ml in Alzheimer's disease and 3.55 (2.27-14.00) in control group, p=0.15]. Von Willebrand Factor antigen (%) levels were 188.5 (96-306) in Alzheimer's disease, and 181 (112- 284) in control group (p=0.74).

CONCLUSION

Although vascular damage is thought to play role in the pathogenesis of AD, vWF and thrombomodulin failed to demonstrate the vascular damage in AD. Their utility to be used as early biomarkers of AD could not be shown.

An obesity drug sibutramine reduces brain natriuretic peptide (BNP) levels in severely obese patients

OBJECTIVES

Sibutramine is a selective inhibitor of the reuptake of monoamines. Plasma levels of brain natriuretic peptide (BNP) appear to be inversely associated with body mass index (BMI) in subjects with and without heart failure for reasons that remain unexplained. The aim of this study was to investigate the possible influence of sibutramine treatment on BNP levels in severely obese patients.

METHODS

Fifty-two severely obese female patients with BMI > 40 kg/m(2) were included to this study. The women were recommended to follow a weight-reducing daily diet of 25 kcal/kg of ideal body weight. During the treatment period, all patients were to receive 15 mg of sibutramine once a day. Blood chemistry tests were performed before the onset of the medication and after 12 weeks of treatment.

RESULTS

None of the subjects was withdrawn from the study because of the adverse effects of sibutramine. Body weight (108.8 +/- 13.3 kg vs. 101.7 +/- 15.6 kg, p < 0.001), BMI (44.6 +/- 4.6 kg/m(2) vs. 41.8 +/- 5.7 kg/m(2), p < 0.001) and BNP [8.6 (0.5-49.5) ng/l vs. 3.1 (0.2-28.6) ng/l, p = 0.018] levels were significantly decreased after 12 weeks of sibutramine treatment. Total cholesterol (5.19 +/- 0.90 mmol/l vs. 4.82 +/- 1.05 mmol/l respectively; p < 0.001), low-density lipoprotein-cholesterol (3.26 +/- 0.86 mmol/l vs. 2.99 +/- 0.40 mmol/l respectively; p = 0.008), levels were significantly decreased; however, there was no significant alteration in high-density lipoprotein-cholesterol and triglyceride levels.

CONCLUSION

This study has shown a decrease in BNP levels which may lead to improvement in cardiac outcome after sibutramine treatment. Further randomised studies are needed to be conducted to clarify the relationship between sibutramine and BNP.

Determining the relationship between metabolic syndrome score and angiographic severity of coronary artery disease

BACKGROUND

Cardiovascular disease is leading cause of mortality and morbidity in developed and developing countries. Metabolic syndrome (MS) is a risk factor for coronary artery disease (CAD). The effect of MS on angiographic severity of CAD is not well defined. The aim of this study was to examine the effect of MS on angiographic severity of CAD by using Gensini score.

METHODS

The total number of 1003 patients who underwent elective coronary angiography in catheter laboratory were included in the study. MS score based on National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) criteria which ranged between zero and five were calculated for each subject. Gensini scores were determined by examining coronary angiograms of the patients.

RESULTS

The study population consisted of 634 (63%) male, and 369 (37%) female subjects. The mean age was 59 +/- 11. MS based on NCEP ATP III was present in 246 (25%) patients. CAD was present in 691 patients (69%). The median of Gensini score was five (0-192) in the total sample, 18 (1-192) in the patients with CAD and 25 (0-192) in the patients with MS. A positive correlation was found between MS score and Gensini score (r = 0.402, p < 0.001).

CONCLUSIONS

In this study, it was determined that as the severity of MS increases, the angiographic severity of CAD increases as well. Besides, the most important factor on Gensini score was diabetes mellitus in male and hypertension in female subjects.

Prevalence of MGUS in a geriatric population in Turkey

17564

Background: In this study, we aimed to investigate the prevalence of monoclonal gammopathy of unknown significance (MGUS) in the geriatric population in Turkey, with their clinical and laboratory parameters. Methods: The study group consisted of all individuals who applied to the outpatient clinic of Geriatrics Department between January-December 2005 in Hacettepe University Hospital in Ankara, Turkey. This clinic serves patients older than 65 years of age either with various acute/chronic diseases or healthy individuals for check-up purposes. All the participants had serum protein electrophoresis (SPE) -and immunofixation as needed- along with their routine laboratory tests and bone mineral density (BMD) measurements. Patients with a monoclonal protein in their SPEs were further evaluated for the presence of multiple myeloma. Clinical and laboratory parameters of patients with MGUS were compared with a control group of randomly selected 100 individuals who did not have MGUS. Results: A total of 1012 patients were enrolled in the study. Monoclonal band was detected in 22 patients (2.17%). The majority of the M proteins (63%) were of Ig G type. Of the remainder, 32% were Ig A, and 5% Ig M. Further investigations in these patients depicted one patient to have multiple myeloma and one patient to have lung carcinoma. The remaining 20 patients were diagnosed as MGUS (1.97%). BMD measurements of the patients with MGUS were significantly lower than the control group. Median lumbar BMD t score was -2.66 (Interquartile range (IQR): −.72 −3.77) in MGUS patients and -1.76 (IQR: −0.50 −2.47) in controls (p = 0.007). The two groups were found to be comparable in terms of comorbid diseases and other laboratory parameters. Conclusions: The prevalence of MGUS above the age of 25 is 1%, above 50 it is 1.7%, and above 70 it is approximately 3%. In our study, the frequency of MGUS above 65 years of age was found to be 1.97%, which is a little lower than the above quoted figures. It must be noted that our study group was not population-based and chronic diseases may be more common than the general population, resulting in a higher prevalence of MGUS. Another finding was the lower BMD measurements in patients with MGUS. BMD data is limited in patients with MGUS in the literature and further studies are needed to elucidate whether there is an association or not.

No significant financial relationships to disclose.

Serum vitamin-E levels and its relation to clinical features in nonalcoholic fatty liver disease with elevated ALT levels

BACKGROUND

Oxidative stress and free oxygen radicals play an important role in the progression from simple fatty liver to steatohepatitis. Deficiency of antioxidants like vitamin-E has been reported to trigger this progression. The main aims of our study were to measure plasma vitamin-E levels in nonalcoholic fatty liver disease (NAFLD), to explain its relationship with biochemical parameters and to examine the possible therapeutic and prophylactic role of vitamin-E.

METHODS

52 patients with NAFLD and elevated liver function tests were enrolled. After 6 months of follow-up with a standard low-fat, low-calorie diet, changes in liver enzymes were evaluated.

RESULTS

Deficiency of vitamin-E was detected in 16 patients with NAFLD. Homogenous echo pattern of the liver and attenuation was found to be significantly higher in the low vitamin-E group (p = 0.03). The low vitamin-E group had significantly higher levels of triglyceride (p = 0.02). After 6 months, patients in the low vitamin-E group did not respond to the diet and no decrease in ALT levels was detected (p = 0.04).

CONCLUSION

This is the first study measuring the serum vitamin-E levels in nonalcoholic fatty liver disease. A correlation was found between low vitamin-E levels, high triglyceride levels, as well as sonographic findings, both of which are negative prognostic factors causing progression of fatty liver to steatohepatitis. Patients with low vitamin-E levels did not respond to a classical diet for fatty liver disease. Based on the data, we suggest that diet alone is not adequate for patients with fatty liver, and vitamin-E supplementation should be added.

Intussusception in adults

This study is a review of 22 adult intussusceptions from 1983 to 1988 at Ankara Numune Hospital in Turkey. The underlying pathological processes were identified in 20 patients (81%). Of 22 patients, 12 were males (54.5%), and 10 were females (45.6%). Twenty-two patients had documented intussusception: four cases originating in colon and 18 cases originating in the small bowel (81.8%). All of the colonic intussusceptions were associated with primary carcinoma of colon. One of 18 cases of small bowel intussusceptions was malign. Because of these findings we advocate resection in colonic intussusceptions. In the patients with intussusception of small bowel, initial surgical reduction and later limited surgical resection is the preferred treatment. The sites of involvement of intussusception in our patient group were jejunojejunal (5), ileoileal (6), ileocaecal (4), ileocolic (3), colocolic (4). When an intussusception is encountered i adults, an underlying process usually can and should be determined for proper treatment.