Evaluation of panoramic radiographs taken from 1,056 Turkish children

OBJECTIVE

Panoramic radiographs (PRs) play an important role in the diagnosis and treatment planning of a wide range of dental and maxillofacial diseases and conditions. To examine and to determine the status of oral lesions, dental anomalies and pathologies in panoramic radiographs, which were taken at the department of pediatric dentistry, Dental School, Marmara University, Istanbul, Turkey.

MATERIALS AND METHODS

This retrospective study consists of 1,056 randomly selected PRs of children aged from 4 to 12 years old, conducted at the department of pediatric dentistry at Dental School, Marmara University, between 5 th December 2011 and 17 th January 2012. The following information was obtained from the patients' records and PRs: Gender, age, presence or absence of oral lesions, dental anomalies and pathologies such as mesiodentes, supernumerary teeth, odontoma, radicular cyst, impacted tooth, and fusion.

RESULTS

One thousand and fifty-six PRs from 520 girls and 536 boys were observed. The mean and standard deviation age of the patients was 8.43 ± 2.17. Among 1,056 patients, 457 (43.28%) of them had oral lesions, discovered by the PRs. The age of these 457 patients was ranged from 4 to 12 years. There were 37 (3.50%) mesiodentes, 9 (0.85%) supernumerary teeth, 4 (0.38%) odontoma, 12 (1.14%) radicular cyst, 16 (1.52%) impacted tooth, and 20 (1.89%) fusion.

CONCLUSIONS

Oral lesions with a rate of 43.28% could be detected relatively at early age, as presented in the present study. Early treatment of these lesions, dental anomalies, and pathologies could avoid maxillofacial deformity and other complications.

Evaluation of vitamin D receptor (VDR) gene polymorphisms (FokI, TaqI and ApaI) in a family with dentinogenesis imperfecta

Dentinogenesis imperfecta Type II (DGI-II) is a condition inherited as an autosomal dominant trait and characterized by abnormal dentine structure affecting both the primary and secondary dentitions. The genetic etiology of the disease still remains unclear, suggesting a genetically heterogeneous background. The aim of this study is to manifest briefly DGI-II and to investigate the association between BsmI, TaqI and FokI polymorphisms of Vitamin D receptor (VDR) gene and dentinogenesis imperfecta type II in a Turkish family by PCR-RFLP methodology. The affected mother and her two affected daughters were bb for BsmI polymorphism, whereas her unaffected son and her husband were Bb for the same polymorphism. One of the affected children was tt, the rest of the family were Tt for TaqI polymorphism, and all of the enrolled subjects were FF for FokI polymorphism. As a conclusion, BsmI polymorphism bb seems to be associated with (DGI-II), but should be examined in larger numbers in order to be considered as a risk factor.

Incidence and prevention of traumatic injuries in paediatric handball players in Istanbul, Turkey

AIM

To investigate the frequency of dental injuries in paediatric handball players. In addition, the players' habits with regard to mouthguard usage, as well as their general knowledge of the prevention of traumatic dental injuries (TDIs) were investigated. Data were collected by structured one-to-one interviews with children of 14 randomly selected handball teams in the amateur national league.

METHODS

The questionnaire consisted of 15 questions. The age, gender, trauma experience and league status of each interviewee was recorded. The interviews took place mainly at national championships or tournaments.

RESULTS

A total of 212 individuals, 74 girls and 138 boys, were interviewed. Forty-one of the 212 participants (19.3 %) had sustained a dental injury. The mean age of participants was 12 ± 1.6 years. Concussion was the most frequent finding and the cause of injury was a blow from another player. The number of individuals that were aware of mouthguards was only 15.6 % and surprisingly no players used mouthguards.

CONCLUSIONS

The results show that handball players need more knowledge and education considering the prevention of TDIs from their sports clubs and dentists. The importance of adequate facial protection in contact sports should be endorsed by all sports clubs, and parents advised accordingly.

Mixed hepatocellular carcinoma and hepatoblastoma: cytohistopathologic findings and differential diagnosis

BACKGROUND

Hepatocellular carcinoma (HCC) accounts for approximately 80% of all the primary malignant tumors of the liver. Hepatoblastoma (HBL) is the most common primary malignant neoplasm of the liver in childhood, and extremely rare in adults. To the best of our knowledge, this is the first report of an adult case with cytopathologic description of a combined HCC and HBL, occurring in a noncirrhotic liver.

CASE

A 24-year-old male was admitted to the hospital with right-sided abdominal pain. Masses in the liver were detected radiologically. Fine-needle aspiration biopsy and core-needle biopsy revealed a malignant hepatocellular tumor with features of both HCC and HBL.

CONCLUSION

In the present case among the distinct HCC cell groups, areas of smaller and more primitive cells consistent with embryonal type HBL and some other groups of cells with intermediate morphology were observed. These findings suggested the probable single stem cell origin of the tumor with differentiation to both cell groups rather than a combination of two different tumors. Therefore, the term 'malignant hepatocellular tumor' could also be considered to define this particular tumor. This case provides support to the previous reports in which HBL areas are described in HCC.

Validation of biochemical markers for the prediction of liver fibrosis and necroinflammatory activity in hemodialysis patients with chronic hepatitis C

BACKGROUND

Liver biopsy is an imperfect gold standard for assessing the disease severity in hemodialysis patients with chronic hepatitis C. Our purpose was to compare the accuracy of the FibroTest (FT) and ActiTest (AT) with liver biopsy and the AST-to-platelet ratio index (APRI) in determining hepatic fibrosis and necroinflammatory activity in hemodialysis patients with hepatitis C virus (HCV).

METHODS

The FT-AT index combining 6 biochemical markers was assessed in 33 hemodialysis patients with HCV. Liver fibrosis and necroinflammatory activity was staged and graded according to the METAVIR scoring system.

RESULTS

The accuracy of FT-AT versus biopsy was 0.46 for significant fibrosis and 0.36 for severe necroinflammatory activity. The FT index had a positive predictive value of 20% for scores greater than 0.6 and a negative predictive value of 45% for scores less than 0.2. Eleven of the 33 patients had scores ≤0.2, 6 had significant fibrosis on biopsy. Four out of 5 patients with FT scores >0.6 had mild fibrosis. APRI correlated well with the biopsy.

CONCLUSION

The FT-AT test does not seem to be a reliable noninvasive marker for the prediction of necroinflammatory activity and fibrosis in hemodialysis patients with HCV and cannot be used as an alternative to either liver biopsy or APRI.

Is alanine aminotransferase level a surrogate biomarker of hepatic apoptosis in nonalcoholic fatty liver disease?

Aim: To evaluate the serum alanine aminotransferase (ALT) variabilities in nonalcoholic fatty liver disease (NAFLD) and correlate it with hepatocyte apoptosis and oxidative stress parameters. Methods: 24 patients with NAFLD and normal ALT were compared with 26 subjects with NAFLD and elevated ALT. Liver oxidative stress was estimated on the basis of malondialdehyde, superoxide dismutase and glutathione. Immunohistochemistry was performed for activated caspase 3 and 8, nuclear factor-κB, antiapoptotic Bcl-2 protein and serum TNF receptor levels were measured. Results: The mean caspase 3 and 8 activity scores, oxidative stress parameters, necroinflammatory grade and prevalence of severe fibrosis were comparable across the groups with normal versus elevated ALT. Patients with nonalcoholic steatohepatitis had significantly higher caspase 3 and 8 activity (percentage of cells with positive staining per high power field), and serum malondialdehyde (mmol/l) levels than those with simple steatosis. ALT elevation was not a risk factor for advanced necroinflammatory grade and fibrosis. A receiver operating characteristic curve did not demonstrate sensitivity and specificity for discriminative power of ALT. Conclusion: Apoptosis and oxidative stress are the main processes contributing to disease progression in NAFLD. ALT values do not correlate with the parameters of apoptosis and oxidative stress. The disease severity can only be determined by liver biopsy.

Antianginal and anti-ischemic effects of nisoldipine and ramipril in patients with syndrome X

BACKGROUND

Syndrome X is defined as typical angina pectoris, positive treadmill exercise test, negative intravenous ergonovine test, and angiographically normal coronary arteries.

HYPOTHESIS

In the present study, we investigated the anti-ischemic and antianginal effects of nisoldipine and ramipril in patients with syndrome X.

METHODS

After 2 weeks of the first wash-out period, 18 patients (7 men, 11 women, age 46 +/- 10 years) were given nisoldipine (NIS) 5 mg twice daily for 4 weeks, and after 2 weeks of the second wash-out period, the same patients were given ramipril (RAM) 2.5 mg once daily for 4 weeks. A treadmill exercise test with modified Bruce protocol was performed at the end of each period.

RESULTS

The time to angina in exercise (607 +/- 115 s-650 +/- 117 s, p = 0.006, vs. 630 +/- 114 s-660 +/- 123 s, p = 0.02), total exercise time (612 +/- 110 s-656 +/- 114 s, p = 0.0008, vs. 630 +/- 114 s-660 +/- 123 s, p = 0.02), and maximum MET value (11.09 +/- 2.08-11.86 +/- 2.04, p = 0.0016, vs. 11.42 +/- 2.09-12.2 +/- 2.26, p = 0.01) were increased significantly with both therapy modalities. The time to 1 mm ST-segment depression (123 +/- 93 s-220 +/- 172 s, p = 0.002) was increased significantly with NIS therapy. The time to ST-segment recovery (434 +/- 268 s-330 +/- 233 s, p = 0.016 vs. 443 +/- 289 s-370 +/- 278 s, p = 0.012), the frequency of anginal attacks per week (1.27 +/- 1.4-0 +/- 0.38, p = 0.005, vs. 1 +/- 1.32-0.33 +/- 0.59, p = 0.028), and the need for sublingual nitroglycerin (1.16 +/- 1.29-0.11 +/- 0.32, p = 0.005, vs. 0.94 +/- 1.16-0.27 +/- 0.57, p = 0.012) were decreased significantly with both drugs.

CONCLUSION

We observed that 10 mg daily NIS and 2.5 mg daily RAM have similar anti-ischemic and antianginal effects in patients with syndrome X.

Serum neopterin levels in children with hepatitis-B-related chronic liver disease and its relationship to disease severity

AIM: To evaluate serum neopterin levels and their correlations with liver function tests and histological grade in children with hepatitis-B-related chronic liver disease.

METHODS: The study population comprised 48 patients with chronic active hepatitis B, 32 patients with hepatitis-B-related active liver cirrhosis and 40 normal controls. Serum neopterin was measured using an enzyme-linked immunosorbent assay.

RESULTS: The mean ± SD serum neopterin levels were 14.2 ± 5.6 nmol/L in patients with chronic hepatitis, 20.3 ± 7.9 nmol/L in patients with liver cirrhosis and 5.2 ± 1.4 nmol/L in control group. Serum neopterin levels were significantly higher in patients with chronic hepatitis (P = 0.005) and cirrhosis patients (P = 0.008), than in control subjects. Cirrhotic patients had significantly higher serum neopterin levels than patients with chronic hepatitis (P = 0.004). There was a positive correlation between serum neopterin levels and alanine aminotransferase levels in patients with chronic hepatitis (r = 0.41, P = 0.004) and cirrhotic patients (r = 0.39, P = 0.005). Positive correlations were detected between serum neopterin levels and inflammatory score in patients with chronic hepatitis (r = 0.51, P = 0.003) and cirrhotic patients (r = 0.49, P = 0.001).

CONCLUSION: Our results suggest that serum neopterin levels can be considered as a marker of inflammatory activity and severity of disease in children with hepatitis-B-related chronic liver disease.

Serum gamma-glutamyltranspeptidase distinguishes non-alcoholic fatty liver disease at high risk

BACKGROUND/AIMS

Hepatocyte apoptosis is an important and invasive predictor of liver injury and fibrosis in non-alcoholic fatty liver disease (NAFLD). Increased gamma-glutamyltranspeptidase (GGT) level is frequently observed in NAFLD. Hepatocyte growth factor (HGF) stimulates fibrogenesis and is correlated with GGT. The study aimed to determine whether GGT can distinguish NAFLD patients at high risk.

METHODOLOGY

Fifty biopsy-proven NAFLD patients (M/F: 24/26) were divided as the normal GGT group (n = 25) and the high GGT group (n = 25) (each patients' GGT > two fold of upper-limit of normal). Liver histology was graded according to Brunt et al. TNF-sRp55, caspase-3 and 8, NFkappaB and Bcl-2 were measured by immunohistochemical methods. For statistical analysis, Student's t test, chi-square test, multivariate regression analysis and the area under receiver operating characteristic (ROC) curve were used.

RESULTS

The high GGT group had significantly higher NFkappaB, caspase-3 and 8, and Bcl-2 levels (54.52 +/- 26.02, p = 0.002; 55.95 +/- 27.18, p = 0.002; 47.85 +/- 28.04, p = 0.001; 11.19 +/- 12.33, p = 0.016, respectively). Serum TNF-sRp55 levels of both groups were similar (2922.93 +/- 307.26, and 2885 +/- 194.47; p = 0.78). Differences in reference to histological steatosis grade and inflammation were not significant. However, fibrosis stage was higher in the high GGT group (p = 0.048).

CONCLUSION

Multinominal logistic regression analysis showed that increased GGT level was a risk factor for advanced fibrosis in NAFLD (OR: 1.0, CI: 0.98-1.01; p =0.032). Using serum GGT levels the area under the ROC curve for the prediction of advanced fibrosis was 0.74 (95% CI: 0.54-0.94). The serum GGT cut-off value for the prediction of advanced fibrosis was 96.5 U/L; with 83% sensitivity and 69% specificity.

Chronic hepatitis C responds poorly to combination therapy in chronic hepatis B carriers

BACKGROUND

The effect of conventional interferon-based therapy of hepatitis B virus (HBV) and hepatitis C virus (HCV) dual infection is controversial. Yet, no studies have been carried out into pegylated interferon treatment for chronic HBV/HCV coinfection. We aimed to evaluate the response rate and side effects of conventional or pegylated interferon combined with ribavirin on chronic HBV/HCV coinfection therapy.

METHODS

The study included 36 chronic hepatitis patients (M/F: 28/8, mean age 47+/-12 years) who were positive for HBsAg and anti-HCV. They were tested for the presence of HBV-DNA by hybridisation assay, and the samples giving negative results were retested by polymerase chain reaction (PCR). All patients were tested for HCV-RNA using PCR, and the HCV genotype was determined.

RESULTS

Nineteen patients were given standard interferon either alone or in combination with ribavirin, whereas 17 were given pegylated interferon and ribavirin combination therapy. None of the patients had HBV-DNA positivity; however, all had HCV-RNA detectable by PCR. All the patients had HCV genotype 1b. The mean alanine aminotransferase and aspartate aminotransferase levels were 118+/-65 U/l and 90+/-95 U/l respectively. Five patients in each group discontinued the treatment due to side effects. Only two patients (one from each group) reached sustained virological response.

CONCLUSION

Neither pegylated nor conventional interferon based regimes were effective for HBV/HCV coinfection, in which the dominant virus was HCV. Pegylated interferon and ribavirin therapy was not superior to conventional interferon based regimes in the treatment of HBV/HCV coinfection.

Clinical, biochemical and histological correlations in a group of non-drinker subjects with non-alcoholic fatty liver disease

The correlation between biochemistry, imaging-studies and histology is a matter of controversy in non-alcoholic fatty liver disease (NAFLD) and the major pathophysiology of non-alcoholic steatohepatitis (NASH) is still unknown. We aimed to perform a comparative analysis between clinical, biochemical and histological variables of NAFLD. One-hundred and five NAFLD patients (F/M: 51/54), were studied, all with no-alcohol intake. The groups were followed-up for six months. Necroinflammation and fibrosis were more severe in patients with diabetes (p = 0.002, and p = 0.0001, respectively). In comparing NAFL to NASH, plasma nitric-oxide and malondialdehyde levels were significantly higher (p = 0.05, for-both), and vitamin-E and-C levels were significantly lower in NASH (p = 0.002, and 0.001, respectively). The serum ferritin levels were higher in NASH patients (p = 0.016). While the ultrasonographic grade was significantly higher, the liver-spleen density gradient was significantly lower in NASH group (p = 0.017, and 0.005, respectively). Within a six month period, serum ALT levels dropped into the normal range in 23/76 (30.3%) patients and serum ALT in the 6th month correlated significantly with the severity of steatosis, inflammation and fibrosis in initial biopsy (p = 0.023, 0.035, 0.011, respectively). In conclusion, the probability of severe liver disease is higher in patients with elevated-ALT in NAFLD. Serum ferritin levels have some prognostic significance in liver damage and fibrosis. Overt diabetes is predictive of advanced fibrosis and inflammation. However impaired glucose-tolerance is not. The advice on diet and exercise for six months after diagnosis may be a good strategy in NAFLD. The patients with normal-ALT without hepatomegaly, morbid-obesity and diabetes seem to have a good prognosis, however some of these patients may still require liver biopsy.

Acute renal failure in a patient with severe hemolysis

Paroxysmal nocturnal hemoglobinuria (PNH) is a clonal disorder of bone marrow. It is characterized by blood cells lacking membrane proteins that are normally attached by the glycosylphosphatidylinositol (GPI) anchor. The cellular defect arises in a hematopoetic stem cell and is due to somatic mutation of the Phosphatidylinositol-glycan protein-A gene (PIG-A gene), encoding a protein needed for the biosynthesis of the anchor GPI. Paroxysmal nocturnal hemoglobinuria is presented by intravascular hemolysis, cytopenias, frequent infections, bone marrow hypoplasia, and a high incidence of life threatening venous thrombosis. Kidney involvement is usually benign and secondary to chronic tubular deposition of hemosiderin. Acute renal failure may occur in association with a hemolytic crisis. Here we report a case of 40-year-old woman with hematuria, pancytopenia, and acute renal failure due to PNH.

Liver steatosis in hepatitis C positive hemodialysis patients and factors affecting IFN-2a treatment

OBJECTIVE

Hepatitis C virus (HCV) infection is endemic among hemodialysis (HD) patients. It is well known that HCV causes approximately 50% of hepatosteatosis in patients with normal renal function and that this rate is higher in patients infected with genotype 3. The aim of this study was to investigate the rate of steatosis, the regression in steatosis with interferon (IFN) treatment and factors affecting IFN treatment in hemodialysis patients with chronic hepatitis C (CHC).

MATERIAL AND METHODS

Thirty-seven HD patients with CHC were included in the study. All patients received hemodialysis treatment three times a week during the follow-up period. Patients were treated with 3 million units (MU) of IFN-alpha 2a monotherapy for at least 6 months. All patients were evaluated by liver biopsy before therapy and 16 were evaluated at 12-month follow-up.

RESULTS

Mean age of the 37 patients (23 M, 14 F) was 44+/-11.6 years and body mass index was 21.8+/-1.8 kg/m2. Twenty-eight of the patients included in the study (75.7%) were of genotype 1b. RNA response after treatment was 78.4% and sustained response after the follow-up period of 14.9+/-8 months was 54%. Total cholesterol values were directly proportional to RNA response (p<0.003) and inversely correlated with resistance to treatment (p<0.008). Triglyceride values were inversely correlated with resistance to treatment (p<0.041). At evaluation of steatosis scores in baseline liver biopsy, severe and mild to moderate steatosis was found in 3 (8.1%) and 16 (43.2%) patients, respectively. In 18 patients (48.7%) there was no steatosis. The rate of steatosis was found to be 44% in control biopsies. While there was no regression in the rates of steatosis (p=0.499), it was found that steatosis regressed after IFN treatment in two patients infected with genotype 3. No correlations were observed between HCV genotype, sustained response and liver steatosis.

CONCLUSIONS

Response and sustained response rates of HD patients with HCV in a Turkish population were found to be high after IFN monotherapy. With the exception of two patients infected with genotype 3a, the rate of liver steatosis was found to be high and did not change after IFN treatment in HD patients with CHC.

Efficacy of interferon alpha-2b and lamivudine combination treatment in comparison to interferon alpha-2b alone in chronic delta hepatitis: a randomized trial

BACKGROUND AND AIM

Delta hepatitis is characterized by rapidly progressive liver disease with adverse prognosis in most patients. Patients benefit from high doses and prolonged courses of interferon (IFN) therapy; however, lamivudine as a single agent has been disappointing. Data relating to the efficacy of IFN and lamivudine in combination is limited. The aim of this study was to test the efficacy of IFN-alpha 2b and lamivudine combination treatment in comparison to IFN-alpha 2b alone in patients with chronic delta hepatitis.

METHODS

Twenty-six patients with chronic delta hepatitis were randomized into two groups. Twelve patients received IFN-alpha 2b alone (eight men, four women; mean +/- SD age: 43.83 +/- 8.57 years), and 14 patients received IFN-alpha 2b plus lamivudine combination (seven men, seven women; mean +/- SD age: 42.5 +/- 11.02 years). The dose of IFN-alpha 2b was 10 MU t.i.w. and of lamivudine was 100 mg/day. The groups were comparable in reference to serum alanine aminotransferase (ALT), aspartate aminotransferase, bilirubin, albumin levels, histological activity and stage. Four patients (33.3%) in the IFN group and two (14.3%) in the combination group had cirrhosis (P = 0.2). The duration of treatment was 48 weeks with an untreated follow-up period of at least 96 weeks (mean +/- SD, 3.1 +/- 1.9 years). A liver biopsy was performed at the end of treatment.

RESULTS

Eight patients from the IFN group and 11 from the combination group completed treatment. Serum ALT values became normal in 8/14 patients (57.1%) treated with IFN plus lamivudine and in 5/12 patients (41.7%) treated with IFN alone (P = 0.43). Serum hepatitis delta virus RNA was no longer detectable in nine of 14 (64.3%) patients treated with IFN plus lamivudine as compared to five of 12 (41.6%) patients treated with IFN alone (P = 0.024). In both groups female patients had significantly better virological response rate (P = 0.007). There was a significant improvement in histological activity in the combination group (mean decrease 5.27 +/- 1.08 score, P = 0.001), but not in the IFN group (mean decrease 1.44 +/- 1.59 score, P = 0.39). No significant improvement was observed in regards to fibrosis. Four of the 14 patients (28.6%) treated with combination therapy as compared to two of 12 patients treated with IFN (16.7%) were sustained virological responders (P = 0.47). The 5-year survival rate was 65% in the IFN group and 85% in the combination group (P > 0.05).

CONCLUSION

Interferon and lamivudine in combination is an encouraging treatment method and may be superior to IFN alone in chronic delta hepatitis.

Serum iron levels and hepatic iron overload in nonalcoholic steatohepatitis and chronic viral hepatitis

Our objective was to determine the effect of serum iron levels and hepatic iron overload on hepatocellular damage in nonalcoholic steatohepatitis (NASH) and to compare this with chronic viral hepatitis. Twenty-five patients who had elevated transaminase levels on at least two occasions, without any evidence of viral and autoimmune hepatitis and diabetes, without a history of significant alcohol use, and with a liver biopsy consistent with NASH were enrolled in the study. Twenty-five patients with chronic viral hepatitis (13 patients with chronic hepatitis C and 12 with chronic hepatitis B) who were not under any antiviral treatment were taken as controls. Metabolic factors were studied in the NASH and chronic hepatitis groups. Biopsy specimens were stained with hematoxylin-eosin, and the grade of steatosis and the stage of fibrosis were evaluated as I, II, or III, I being mild and III being severe. Iron overload in the hepatic tissue was studied by Prussian blue staining. Serum ALT, AST, ALP, GGT, globulin, and ferritin levels were comparable in both steatohepatitis and chronic viral hepatitis groups. However, patients with chronic hepatitis had a lower albumin level and a higher serum iron level, with higher transferrin saturation. Among patients with NASH, mild, moderate, and severe steatosis was found in 7, 10, and 8 patients, respectively. Inflammatory infiltration was grade I in 24 patients and grade III in 1 patient. Fibrosis was mild in 12 patients and 13 patients had no fibrosis. Among patients with chronic viral hepatitis, inflammatory infiltration of grade I was seen in 11 patients, grade II in 11 patients, and grade III in 3 patients. Fibrosis was mild in 9 patients, moderate in 13 patients, and severe in 2 patients; 1 patient had no fibrosis. Compared to patients with NASH, those with chronic viral hepatitis cases had more severe inflammatory infiltration and fibrosis (P < 0.01). While five patients with chronic viral hepatitis had mild iron overload, patients with NASH had no hepatic paranchymal iron overload. Neither NASH nor chronic viral hepatitis revealed a relationship between hepatic iron overload and disease activity. This suggests that the iron overload actually may be a result of hemachromatosis gene mutation. The absence of hepatic parenchymal iron overload in the NASH group and only mild iron accumulation in the chronic hepatitis group may be explained by a lower frequency of the gene mutation in our country.

Prevalence of hepatic granulomas in chronic hepatitis B

An increasing frequency of hepatic granulomas, up to 10%, in chronic hepatitis C patients is reported, and their presence is considered to be a predictor of treatment success. However, there is only one prevalence study on granuloma in chronic hepatitis B, and its significance for treatment outcome is unknown. We aimed to determine the prevalence of hepatic granulomas in a larger group of chronic hepatitis B patients and to compare their presence with the response to interferon therapy. Biopsy specimens of chronic hepatitis B patients were reevaluated for the presence of hepatic granulomas. All patients with hepatic granuloma were screened for other granulomatous diseases by tuberculin skin test, chest X-ray and computed tomography, venereal disease research laboratory, Brucella agglutination tests, and exposure to hepatotoxic agents. We screened 663 cases of chronic hepatitis B. Hepatic granulomas were found in 10 cases (1.5%). The granulomas could not be ascribed to any other reason. Of the 10 patients with hepatic granulomas, 4 responded to interferon therapy, 2 dropped out, and 4 were nonresponders. We conclude that hepatic granuloma is a rare finding in chronic hepatitis B and its presence does not seem to predict the response to interferon therapy.

Management of marked liver enzyme increase during clozapine treatment: a case report and review of the literature

OBJECTIVE

Clozapine-induced hepatotoxicity is not infrequent and usually transient. It mostly causes asymptomatic elevation of liver transaminases. "Elevation in liver enzymes to what extent should preclude further treatment?" or "Is only a dose-reduction sufficient?" are questions yet to be answered. The present article uses a case report to discuss the treatment alternatives when liver enzymes reach three times the upper normal limits during the clozapine therapy.

METHODS

In the following case report, the authors describe a 27-year-old male patient diagnosed with schizophrenia, resistant to different atypical and typical antipsychotics. Based on the pathological findings of our patient and a review of the literature, the author summarizes the reasons for the liver enzymes increase and treatment alternatives during clozapine treatment.

RESULTS

Substantial improvement was achieved with clozapine therapy. Increase in liver enzymes at the beginning of the clozapine treatment was successfully managed with a multidisciplinary approach: the treatment was initially withdrawn, afterwards restarted, and carefully continued.

CONCLUSION

The authors demonstrate that clozapine may be cautiously continued in selected patients who showed marked psychiatric improvement with clozapine in the face of liver enzyme elevation.

Melatonin reduces dimethylnitrosamine-induced liver fibrosis in rats

Increased deposition of the extracellular matrix components, particularly collagen, is a central phenomenon in liver fibrosis. Stellate cells, the central mediators in the pathogenesis of fibrosis are activated by free radicals, and synthesize collagen. Melatonin is a potent physiological scavenger of hydroxyl radicals. Melatonin has also been shown to be involved in the inhibitory regulation of collagen content in tissues. At present, no effective treatment of liver fibrosis is available for clinical use. We aimed to test the effects of melatonin on dimethylnitrosamine (DMN)-induced liver damage in rats. Wistar albino rats were injected with DMN intraperitoneally. Following a single dose of 40 mg/kg DMN, either saline (DMN) or 100 mg/kg daily melatonin was administered for 14 days. In other rats, physiologic saline or melatonin were injected for 14 days, following a single injection of saline as control. Hepatic fibrotic changes were evaluated biochemically by measuring tissue hydroxyproline levels and histopathogical examination. Malondialdehyde (MDA), an end product of lipid peroxidation, and glutathione (GSH) and superoxide dismutase (SOD) levels were evaluated in blood and tissue homogenates. DMN caused hepatic fibrotic changes, whereas melatonin suppressed these changes in five of 14 rats (P < 0.05). DMN administration resulted in increased hydroxyproline and MDA levels, and decreased GSH and SOD levels, whereas melatonin reversed these effects. When melatonin was administered alone, no significant changes in biochemical parameters were noted. In conclusion, the present study suggests that melatonin functions as a potent fibrosuppressant and antioxidant, and may be a therapeutic choice.

The prevalence of hepatic granulomas in chronic hepatitis C

OBJECTIVES

Hepatic granulomas are not usual findings in chronic hepatitis C. A few studies addressing the frequency of hepatic granulomas in chronic hepatitis C reported it as less than 10%. The presence of it has been suggested to predict a favorable response to interferon treatment. Also, case reports described the development of hepatic granulomas after interferon treatment. In this study, we aimed to detect the prevalence of hepatic granulomas in chronic hepatitis C and to identify the causes other than chronic hepatitis C, if present, to search whether there is an association between the presence of granuloma and response to interferon treatment and also to see whether interferon leads to the formation of hepatic granulomas.

METHODS

Patients from 3 university clinics were included. All patients with chronic hepatitis C were determined. All patients with hepatic granulomas were screened for the other causes of hepatic granuloma with tuberculin skin test, chest X-ray and computed tomography, Venereal Disease Research Laboratory, and Brucella agglutination tests. The histologic assessment of liver biopsies was done by the same pathologist in each center.

RESULTS

A total of 725 liver biopsies of 605 patients with chronic hepatitis C were screened. In 8 patients, hepatic granulomas were detected in the initial liver biopsies. Four patients had repeat biopsies, and all had hepatic granulomas again. The prevalence of hepatic granulomas in patients with chronic hepatitis C was calculated as 1.3% (8 of 605) in reference to patient population. Presence or absence of hepatic granulomas was seemingly stable. All patients with hepatic granulomas had negative results of tuberculin skin test, Venereal Disease Research Laboratory, chest X-ray and computed tomography, and Brucella agglutination tests. All repeat biopsies were obtained after interferon (+/- ribavirin) in varying doses and duration. Four of 8 patients with hepatic granulomas were found to respond interferon therapy. No patient was found to develop hepatic granulomas after interferon therapy.

CONCLUSION

Hepatic granulomas are a rare finding in HCV infection. The presence of it does not seem to predict the response to interferon therapy. The development of hepatic granulomas during interferon therapy is not usual.

Ornidazole-induced liver damage: report of three cases and review of the literature

Metronidazole and ornidazole, synthetic nitroimidazole derivatives, are used in the treatment of infections caused by anaerobic bacteria and protozoa. The drugs are well tolerated and serious side effects are very rarely encountered. Hepatotoxicity is a rare side effect and hitherto only six cases have been reported. We describe three patients who developed hepatitis after ornidazole use and review the previously reported cases. All three cases used ornidazole in conventional doses and developed hepatitis and associated cholestasis. They improved 1-2 months after discontinuation. We concluded that nitroimidazole derivatives may cause hepatotoxic damage resembling acute cholestatic hepatitis. Early recognition and withdrawal of the drug may prevent further damage.

Acute exacerbation during interferon alfa treatment of chronic hepatitis B: frequency and relation to serum beta-2 microglobulin levels

BACKGROUND

We aimed to determine the frequency of alanine aminotransferase (ALT) elevation during interferon-alpha treatment, the so-called "flare", its relation to serum beta-2 microglobulin levels, and its impact on the outcome of treatment in chronic hepatitis B.

METHODS

The files of 53 treatment-naive patients with chronic hepatitis B (17 hepatitis B e antigen (HBeAg) +ve, 36 HBeAg -ve) who had been treated with 10 MU interferon-alpha 2b three times per week for 24 weeks were reviewed. We analyzed the fluctuations in serum ALT, beta(2)-microglobulin, and HBV-DNA levels before, during, and after flare.

RESULTS

We detected flare in 4/17 (24%) of the HBeAg +ve and 7/34 (21%) of the HBeAg -ve patients. ALT level peaked between weeks 2 and 16 (mean, week 8). After flare, HBV-DNA disappeared in 5/7 (71%) HBeAg -ve vs 3/4 (75%) HBeAg +ve patients (all seroconverted to anti-HBe). The overall sustained response rate was 41%: 55% in the patients with flare, and 38% in those without ( P > 0.05). Basal serum beta(2)-microglobulin levels were significantly higher in responders vs nonresponders (2.19 +/- 0.32 vs 1.78 +/- 0.34 mg/l, mean +/- SD; P < 0.005). In addition, during treatment, serum beta(2)-microglobulin levels increased significantly only in responders, and the degree of increase was significantly higher in responders with flare vs responders without flare (3 +/- 0.33 vs 2.34 +/- 0.35 mg/l; P < 0.001).

CONCLUSIONS

This study, with a limited sample size, showed that, in chronic hepatitis B, there is a trend for a higher response in patients with exacerbation of hepatitis B with interferon-alpha treatment. However, the difference does not reach statistical significance to be of predictive value. On the other hand, serum beta(2)-microglobulin levels before and during treatment may be useful in predicting the outcome.

Interferon-alpha2b induction treatment with or without ribavirin in chronic hepatitis C: a multicenter, randomized, controlled trial

We aimed to compare the efficacy of interferon-alpha2b (IFN) induction treatment in combination with ribavirin to IFN induction alone in chronic hepatitis C. In total, 125 patients (66 male, 59 female, mean age: 48 +/- 9, range: 21-70) were enrolled and randomized into two arms: In the first, patients received 5 MU/day of IFN for 4 weeks followed by 3 MU/day for the next 4 weeks. Treatment was continued with 3 MU three times a week IFN for an additional 40 weeks. Ribavirin was administered 1000-1200 mg/day according to the body weight for the entire 48-week period. In the second arm, patients received placebo in addition to IFN. Fifty-nine patients were placed in the ribavirin arm and 66 in placebo arm. All patients were genotype 1. At week 48, 24/66 (36%) from the placebo and 31/59 (52%) from the ribavirin group responded (P > 0.05). However, during the 24-week untreated follow-up period, 13/24 (54%) from the placebo, and 8/31 (26%) from the ribavirin group relapsed (P = 0.002.), resulting in a sustained virologic response (SVR) rate of 17% in the placebo and 39% in the ribavirin group (P = 0.005.) In conclusion, IFN induction treatment in combination with ribavirin is superior to IFN induction treatment alone in genotype 1 patients, and the SVR rate of 39% is encouraging.

Diffuse diabetic glomerulosclerosis in a patient with impaired glucose tolerance: report on a patient who later develops diabetes mellitus

Diabetic glomerulosclerosis might be seen in diabetics but its presence in patients with impaired glucose tolerance is quite rare. A 31-year-old woman who was admitted to our department was diagnosed with hypertension, nephrotic syndrome and impaired glucose tolerance. Her renal biopsy was compatible with diabetic glomerulosclerosis. She developed overt diabetes mellitus (DM) after one year of impaired glucose tolerance. Hypertension might have accelerated the progression of diabetic nephropathy.

Chylous ascites after liver transplantation with mesentero-portal jump graft

Chylous effusions and lymphatic leaks occur after trauma, malignant disease, primary lymphatic disorders, and parasitosis, and rarely after abdominal surgery. Chylous ascites after orthotopic liver transplantation is a rare complication. We report a case of chylous ascites occurring after hepatic transplantation with a mesentero-portal venous jump graft, successfully treated with conservative management.

Losartan-induced hepatic injury

Losartan, an angiotensin II receptor antagonist, is widely used for the treatment of hypertension. Clinical experience with this drug has demonstrated that it is safe. Losartan-induced hepatic toxicity is extremely rare. We report a case of severe hepatic toxicity and fibrosis caused by losartan use, and we review four previously reported cases. Drug-induced hepatic injury may be seen during the treatment of hypertension by losartan and the clinician should be aware of this toxicity, especially during the initial phase of treatment.

Therapeutic vaccination in chronic hepatitis B

AIMS

The aim was to test the efficacy of a pre-S2-containing vaccine (Genhevac-B) in chronic hepatitis B (CHB). Twenty-five naive patients (22 male, three female; median age 35; range: 6-69 years) with CHB were recruited. The inclusion criteria were: hepatitis B e antigen (HBeAg) positive or HBV-DNA detectable with liquid hybridization; alanine aminotransferase (ALT) is at least 1.5-fold the upper normal limit and histological evidence of chronic hepatitis.

METHODS

In the first period, all patients received monthly injections of 20, 40 and 60 microg of the vaccine. One month after the last injection, patients who still had HBV-DNA were divided into two randomly assigned groups. While the patients in the first group and the patients who lost HBV-DNA in the first period continued to receive monthly injections of 20 microg vaccine for a further 6 months, the patients in the second group received 9 MU interferon alpha-2b (Roferon-A), three times per week using the same method as for the first group. Patients were followed up after 12 months without treatment. Response was defined as the loss of HBV-DNA and normalization of ALT.

RESULTS

Six of the 25 patients lost HBV-DNA after 3 months. Nine of the remainder were randomly placed in the first group (vaccine-only) and 10 were placed in the second group (vaccine + interferon). End-of-treatment response was achieved, overall, 8/15 from the vaccine group and 6/10 from the combination. One patient from each group relapsed during the follow up. Overall, the sustained response (SR) rate was 46% (7/15) in the vaccine group, and 50% (5/10) in the combination group. Histological improvement was achieved in 6/7 SR with vaccine-only and all five with combination treatment, while 1/8 of failures of vaccine and 2/5 of failures of combination improved.

CONCLUSIONS

It was concluded that Genhevac-B decreases serum HBV-DNA levels in the majority of patients with CHB and sustained clearance was achieved in some patients. Combination of interferon-alpha with Genhevac-B is effective for the vaccine failures and may increase sustained response compared to interferon-alpha alone. However, the mechanism of action is yet to be explained.

Intermittent mode reversion to VOO of a dual chamber pacemaker model

This report describes an asymptomatic patient with a DDDR pacemaker system (Inos Cls, Biotronik) that showed intermittent mode reversion to VOO and sometimes to VVI without a detectable source of electromagnetic interference and oversensing. Patients with this Biotronik model should be carefully assessed along with a surface ECG before placing the programming head.

Follow-up of a patient with chronic hepatitis C-associated cryoglobulinemia during four and a half years of maintenance interferon treatment

In this report, we present a patient with chronic hepatitis C-associated cryoglobulinemia who was kept on maintenance interferon treatment because of flare-ups in cryoglobulinemia-associated signs and hepatitis after withdrawal, dose reduction, and increase in dose intervals of interferon. This type of interferon use for treatment of cryoglobulinemia gave us a chance to observe the long-term effects of interferon on cryoglobulinemia and chronic hepatitis C remission for biochemical, virologic, and histologic aspects.

Right ventricular aneurysm complicating right ventricular infarction

Right ventricular (RV) involvement commonly occurs in patients with acute inferior myocardial infarction and is associated with high mortality and morbidity. RV dysfunction and dilatation commonly recover in survivors; chronic RV dyskinesia and failure are rare complications. This case report presents a patient in whom an isolated RV aneurysm complicates a RV involvement of acute inferior-posterior myocardial infarction.

Amantadine monotherapy of chronic hepatitis C patients infected with genotype lb

We aimed to test the efficacy of amantadine in chronic hepatitis C (CHC) patients infected with genotype b. Twenty patients completed treatment with amantadine HCl, 100 mg b.i.d., for 6 months. Non-sustained biochemical improvement was observed without loss of HCV-RNA. We conclude that amantadine monotherapy is not effective in CHC.

[Quantitative ultrasonic myocardial texture analysis of the diabetic heart]

OBJECTIVE

Contraction and relaxation of the heart cause decrease and increase in myocardial video intensity (MVI) recorded from echocardiographic images, respectively. The present study was planned to compare this physiological cyclic variations of MVI in patients with type 1 diabetes mellitus and healthy subjects.

METHODS

For this purpose, standard echocardiographic examination was performed to 18 young patients (age 23.2+6.4; range: 15-37 years) with insulin dependent type 1 diabetes mellitus (diabetes duration: 7.8+5.6; range: 1-17 years) and 14 age and sex matched controls. In all subjects, end-diastolic and end-systolic 2D echocardiographic images of 3 consecutive beats that had been recorded on videotapes were digitized. The quantitative analysis of digitized imaging was performed with the help of a calibrated digitization system in order to calculate the septum and the posterior wall textural parameters. The cyclic variation index (CVI) of the mean gray level (MGL) was calculated according the formula: (MGL dias- MGL diast x 100.

RESULTS

Among the groups, left ventricular diastolic dimension-index, fractional shortening, E/A ratio, and isovolumic relaxation time showed no statistically significant differences, while septum and (8.3+1.1 vs. 7.3+0.9 mm; p=0.016) and posterior wall thickness (8+0.6 vs. 6.8+1.1mm; p=0.004) and E-deceleration time (167+23 vs. 140=19 msec.; p=0.003) were significantly higher in diabetics. The diabetic patients showed significantly lower CVI both for septum (18.2+11.5% vs. 39.3+11.5%; p=0.0001) and posterior wall (16.4+16% vs. 40.5+9.2%; p=0.0001), respectively.

CONCLUSIONS

Altered videoensitometric parameters possibly represent a preclinical alteration, conceivably related to the myocardial collagen content increase, which does not necessarily indicate an actual disease but may be considered an early marker of the histopathologic findings of diabetic cardiomyopathy.

The prevalence of hereditary thrombophilia in the Trakya region of Turkey

The prevalences of deficiencies in antithrombin III (AT III), protein C (PC), protein S (PS) and in the activated protein C (APC) resistance in the thrombotic population of the Trakya region, Turkey were investigated. 37 patients with venous thrombosis (VT) and 17 patients with arterial thrombosis (ArT) were included in this study. The mean ages of the patients with VT and ArT were 46 years (range 20-70) and 38 years (range 32-40), respectively. The activity of AT III was measured by commercially available immuno-turbidimetric assay. The activities of PC and PS were determined by coagulometric assay. The APC resistance was measured using a modified APTT-based clotting assay. Among the VT patients, there were 2 cases (5.4%) with AT III, 5 (13.51%) with PC deficiency, 5 (13.51%) with PS deficiency and 2 (5.4%) with APC resistance. In the ArT patient group, there was 1 patient (5.88%) with AT III, 3 (17.64%) with PC deficiency, 1 (5.88%) with PS deficiency and no APC resistant patients, while there was one (2.08%) with PC deficiency and one (2.08%) with APC resistance in the control group (49 persons, mean age 41 years). The relative risk of thrombosis (odds ratio) was 1.7 in the deficiency of PC and 5.6 in the deficiency of PS. The data presented suggests that the prevalences of AT III, PC and PS deficiencies causing thrombophilia in the Trakya region of Turkey are higher than in other reported studies while the APC resistance is lower than in others. Further studies including more patients would be required to clarify these discrepancies.

Heart failure during first inferior acute myocardial infarction

BACKGROUND

Inferior acute myocardial infarctions (AMI) have better in-hospital prognosis than do anterior AMI. Authors of several studies reported that patients with inferior AMI complicated by atrioventricular block, concomitant precordial ST-segment depression and involvement of right ventricle have larger infarctions and a worse prognoses than do patients without these features.

OBJECTIVE

To analyse the incidence, clinical course and in-hospital prognosis of patients with heart failure and first inferior AMI.

METHODS

We analysed in 257 consecutive patients with first inferior AMI who had been admitted to the coronary care unit during January 1991 and March 1995. The clinical and electrocardiographic characteristics, as well as the morbidities and in-hospital mortalities, of groups of patients with and without heart failure during inferior AMI were compared.

RESULTS

Symptoms and signs of heart failure were noted for 49 patients (19%). We found that patients who had suffered heart failure during inferior AMI were older (62.1 +/- 9.86 versus 58.78 +/- 10.58 years, P < 0.05) than those who had not suffered heart failure. There was no significant difference between patients' sex, history of diabetes mellitus, hypertension, smoking status, thrombolytic therapy, involvement of right ventricle and QRS score for these two groups. We found a greater prevalence of ST-segment depression (ST-segment depression > or = 1 mV in more than one precordial lead with maximal ST-segment depression in leads V4-V6) of V4-V6 precordial leads (57 versus 26%, P = 0.00002) and a lesser prevalence of no ST-segment depression (ST-segment depression < 0.1 mV in each precordial lead; 14 versus 38%, P = 0.001) among patients who had suffered heart failure. We found greater incidences of serious ventricular arrhythmias (53 versus 26, P = 0.0002) and ventricular tachycardiafibrillation (16 versus 7%, P = 0.03) among patients who had suffered heart failure than we did among those who had not. Third-degree atrioventricular block was more often found in patients who had suffered heart failure (23 versus 12%, P = 0.07) but this difference was not statistically significant. We found that the in-hospital mortality among patients who had suffered heart failure was much higher than that among those who had not (24.5 versus 3.8%, P = 0.000001).

CONCLUSION

We found that heart failure occurs primarily in old patients, and in those with precordial ST-segment depression, especially in leads V4-V6. The patients who suffer heart failure have worse in-hospital prognosis due to serious ventricular arrhythmias and cardiogenic shock.

Multilocular cystic nephroma: an unusual localization

We present a case of multilocular cystic nephroma with an unusual localization treated by a nephron-sparing procedure. A 21-year-old white woman presented with a history of hematuria and right lumbar pain. Imaging techniques revealed a multilocular cystic mass originating from the renal parenchyma but mainly involving the renal pelvis. The lesion was localized almost entirely within the renal pelvis at surgery and was treated by excision. Pathologic analysis was consistent with multilocular cystic nephroma. The patient remains free of recurrence with 10 years of follow-up. We conclude that multilocular cystic nephroma may present as a cystic lesion localized within the renal pelvis, and we advocate simple excision of these lesions.

Effect of aminophylline in patients with atropine-resistant late advanced atrioventricular block during acute inferior myocardial infarction

BACKGROUND

Advanced atrioventricular (AV) block is a frequent complication in patients with acute inferior myocardial infarction (AIMI). This conduction abnormality is associated with narrow QRS complex in conducted or junctional escape beats, suggesting that the site of block is the AV node; however, its pathophysiology has not been properly established.

HYPOTHESIS

This study investigated the effect of aminophylline in eight patients (5 men, 3 women, age range 51 to 78 years, mean 67.5 +/- 8.8 years) with atropine-resistant late advanced AV block during AIMI.

METHODS

Advanced AV block was late in appearance in all patients, starting 2 to 5 days after AIMI, and consisted of second-degree Mobitz II type in two patients and of complete AV block in six patients; all patients had narrow QRS complexes. Before aminophylline administration, all patients had a temporary pacemaker installed which was switched off throughout the study. They were given intravenous atropine (1 mg) that was found to be ineffective. One-half h after atropine, the first aminophylline injection (240 mg) was given intravenously over 10 min. One h following the first injection, a second aminophylline dose (240 mg) was administered. Electrocardiographic rhythm strips were obtained before and after drug administration, and the type of AV block and atrial and ventricular rate were noted.

RESULTS

Aminophylline restored 1:1 conduction with first-degree AV block in six patients, Mobitz I AV block in one patient, and normal sinus rhythm in one patient. Mean atrial and ventricular rates before aminophylline were 104 +/- 16 beats/min and 57 +/- 9 beats/min, respectively, and after drug administration 95 +/- 25 beats/min and 89 +/- 17 beats/min, respectively, (p = 0.012).

CONCLUSION

These results indicate that aminophylline improves AV conduction in atropine-resistant late advanced AV block complicating AIMI.