Incidence and risk factors of hepatocellular carcinoma after orthotopic liver transplantation.

BACKGROUND: The incidence of hepatocellular carcinoma has doubled over the past 2 decades, becoming the fifth most common cancer worldwide. Orthotopic liver transplant is the gold standard treatment for those with hepatocellular carcinoma meeting eligibility criteria, although recurrence rates of hepatocellular carcinoma after orthotopic liver transplant still remain an understudied obstacle. METHODS: We performed a single-center, retrospective, longitudinal study with the aim of determining the predominant baseline and follow-up variables associated with hepatocellular carcinoma recurrence. We gathered pre- and post-transplant data and conducted univariate and multivariate analysis to assess variables predicting hepatocellular carcinoma recurrence after orthotopic liver transplant. RESULTS: Between 2003 and 2015, 141 patients underwent orthotopic liver transplant for hepatocellular carcinoma. We identified 9 (6.4%) cases of documented hepatocellular carcinoma recurrence. Univariate analysis indicated that the difference in serum alpha-fetoprotein levels (most recent prior to transplant subtracted from maximum level) was lower in the hepatocellular carcinoma recurrence group (median 3 ng/mL vs 0 ng/mL, P = .052) as well as the pretransplant serum cholesterol level (median 158 mg/dL vs 113 mg/dL, P = .019) and days between hepatocellular carcinoma neoadjuvant treatment initiation and transplantation (median 122 vs 0, P = .045). Multivariate analysis revealed that a low pretransplant serum cholesterol level (<100 mg/dL) was independently associated with hepatocellular carcinoma recurrence (hazard ratio 11.0, P = .004). CONCLUSION: The risk of hepatocellular carcinoma recurrence after orthotopic liver transplant was low, at 6.4%, in this cohort. Low pretransplant serum cholesterol was the strongest predictor of recurrence and may help clinicians risk stratify patients for appropriate post-transplant monitoring and follow-up.

Prolapsed bilateral ureteroceles leading to intermittent outflow obstruction.

A ureterocele refers to a cystic dilatation of the distal ureter. It may be unilateral or bilateral and may be associated with a duplex system in some cases. We present an unusual case where a young patient was found to have large bilateral ureteroceles which prolapsed into the urethra, causing intermittent incontinence and obstruction. We discuss the case and review the literature concerning this rare anomaly.

Pneumatosis intestinalis and portal-venous gas: an unusual presentation of acute appendicitis.

Pneumatosis Intestinalis in association with portal venous gas is a very rare finding in children and young adults. When present, it is typically associated with bowel infarction and carries a poor prognosis. We present an extremely unusual case where imaging revealed extensive pneumatosis intestinalis and portal venous gas in a patient with acute appendicitis.

Calvarial tuberculosis: an unusual presentation (2007: 8b).

We describe a case of calvarial tuberculosis with an associated extra-dural collection. This presentation has rarely been reported in the literature and the magnetic resonance imaging features are not well documented.

The usefulness of CT guided drainage of abscesses caused by retained appendicoliths.

OBJECTIVES: To determine the utility of percutaneous computed tomography (CT) guided drainage of abscesses formed secondary to retained appendicoliths. MATERIALS AND METHODS: A retrospective review was conducted over a 5-year period to identify patients who underwent CT guided drainage of abscesses related to retained appendicoliths. Inclusion criteria were a history of prior proven appendicitis treated by laparoscopic appendicectomy, identification of a post-operative abscess related to a visualised retained appendicolith and initial treatment by CT guided drainage. Data regarding initial technical success as well as long-term outcome was recorded in each case. RESULTS: In total, five patients were identified who underwent CT guided abscess drainage related to retained appendicoliths. There were three males and two females (age range 12-54 years). Initial drainage under CT guidance was technically successful in all cases with successful catheter placement and resolution of the abscess cavity. In all five cases however, there was recurrence of abscess formation following catheter removal. In one case, a second attempt with CT guided drainage was performed. Again this was initially successful with abscess recurrence following catheter removal. In all five cases, formal surgical drainage with removal of retained appendicolith resulted in a successful outcome. CONCLUSION: CT guided percutaneous drainage of intra abdominal abscess secondary to retained appendicoliths is only successful in the short term. Formal surgical drainage and removal of the appendicolith is required for long-term success.

The imaging of intussusception.

Intussusception is defined as the telescoping of one segment of the gastrointestinal tract into an adjacent one. It is relatively common in children and is the second most common cause of an acute abdomen in this age group. It is much less common in adults and accounts for less than 5% of cases of mechanical small bowel obstruction. Whereas the diagnosis is usually already suspected in children before imaging, it is often made unexpectedly in adults. In addition, although in children there is usually no specific underlying cause, an underlying lead point is often present in adults. Plain film radiography, barium studies and ultrasound imaging play major roles in both the diagnosis and management of this condition, and it is increasingly common for the diagnosis to be made by CT and MRI, particularly in adults. This pictorial essay reviews the imaging features that may be found in patients with bowel intussusception. As well as describing the imaging features of the more commonly used tests, we also stress the role of emerging technologies such as MRI using ultrafast half-fourier sequences with single shot turbo spin echo.

Renal parenchymal damage in sibling vesicoureteric reflux.

AIM: To compare the incidence of renal damage in siblings of patients with vesicoureteric reflux (VUR) who presented with a documented history of urinary tract infection (UTI) with asymptomatic siblings who were diagnosed with reflux during a screening programme for hereditary VUR. METHODS: Medical and radiological records of the VUR patients (1990-2000) were examined for age, gender, mode of presentation, reflux grade and renal damage. RESULTS: VUR was noted in 226 siblings (352 ureters) in 107 families. Of the 119 siblings of index patients, 64 were investigated for a documented UTI and 55 with no history of UTI were detected during screening for sibling reflux. Dimercaptosuccinic acid scan revealed reflux nephropathy in 25 (26%) of the 97 renal refluxing units (RRU) of siblings who presented with a UTI and in 6 (7%) of the 89 RRU of asymptomatic siblings who underwent screening voiding cystourethrography (p=0.0006). Mild renal damage was present in 20 (21%) RRU of siblings with UTI and in 2 (2%) RRU of the screened siblings (p < 0.001). Moderate to severe renal damage was present in 5 (5%) RRU of siblings with UTI and in 4 (4%) RRU of the screened siblings (p > 0.05). CONCLUSION: This study demonstrated that the incidence of mild renal scarring was much higher in siblings who presented with UTI than in asymptomatic siblings. However, the incidence of moderate and severe renal scarring among asymptomatic siblings was comparable to that in siblings with VUR and UTI.

Renal parenchymal damage in male infants with high grade vesicoureteral reflux diagnosed after the first urinary tract infection.

PURPOSE: Vesicoureteral reflux during infancy is found mainly in males, and it is of high grade and often bilateral. The higher predominance of male infants is reported in series when the reflux is diagnosed prenatally and when it is detected after urinary tract infection. Renal parenchymal damage may already be present at birth before any episode of urinary tract infection or acquired after a febrile urinary tract infection. We evaluate the incidence of renal damage in a large series of male infants with high grade vesicoureteral reflux diagnosed after the first urinary tract infection. MATERIALS AND METHODS: We reviewed the medical and radiological records of 141 consecutive male infants 3 weeks to 1 year old (mean age 5.8 months) who were diagnosed with high grade (III to V) vesicoureteral reflux on voiding cystourethrography during 1984 to 2000 following hospitalization for the first febrile urinary tract infection. A total of 127 (90%) patients underwent technetium dimercapto-succinic acid scan to evaluate renal damage 3 to 6 months after the initial infection. RESULTS: Vesicoureteral reflux was unilateral in 46 infants and bilateral in the remaining 95, comprising 236 ureters. Reflux was grade III in 79 ureters, IV in 114 and V in 43. Renal parenchymal damage was detected in 56 (44%) of the 127 infants on dimercapto-succinic acid scan, and was bilateral in 18 and unilateral in the 38, representing 74 renal refluxing units. Renal damage was mild (greater than 40% uptake) in 47 units, moderate (less than 40% and greater than 20% uptake) in 22 U and severe (less than 20% uptake) in 5 U. CONCLUSIONS: This study shows that nearly half of the male infants with high grade reflux who present with the first febrile urinary tract infection have renal parenchymal damage. This high incidence of renal damage may be explained by the coexistence of the 3 risk factors of gender, urinary tract infection and high grade vesicoureteral reflux.

Bacterial colonization of the prepuce in boys with vesicoureteral reflux who receive antibiotic prophylaxis.

Culture swabs were taken from the periurethral area of 59 consecutive uncircumcised boys with vesicoureteral reflux (VUR) and 36 boys undergoing circumcision. A pure growth of a uropathogen was isolated in 22 (37%) boys with VUR who were receiving antibiotic prophylaxis and in 10 (28%) boys who underwent circumcision. Antibiotic prophylaxis in patients with VUR was not effective in reducing the bacterial colonization of the prepuce. We recommend circumcision in boys, particularly infants with VUR, to reduce the risk of urinary tract infections.

Megaprepuce associated with vesicoureteric reflux.

OBJECTIVE: To describe 4 patients in whom megaprepuce was associated with vesicoureteric reflux (VUR). PATIENTS AND METHODS: Four boys aged 6, 4, 5 and 7 months, respectively, presented with dribbling of urine, gross penile swelling and inability to void spontaneously. The first 3 patients had a history of documented urinary tract infection. Micturating cystourethrogram (MCUG) revealed grade III VUR on the right in the first patient, grade V on the left in the second patient, grade III on the right and grade IV in both moieties of left duplex system in the third patient and bilateral grade III in the fourth patient. All patients underwent circumcision. RESULTS: Follow-up MCUG demonstrated complete resolution of VUR in 2 patients after circumcision. One patient with bilateral VUR showed resolution of VUR on right side but persistence of VUR into the lower moiety of left duplex system after circumcision. Vesicoureteric reflux was downgraded from grade 5 to grade 3 after circumcision in one patient. CONCLUSION: These cases demonstrate for the first time the association of megaprepuce with VUR. VUR associated with megaprepuce is usually resolved after circumcision.

Urinary tract infection and renal damage in sibling vesicoureteral reflux.

PURPOSE: Siblings of index patients with vesicoureteral reflux are known to have an increased incidence of reflux. Previously reported studies have evaluated vesicoureteral reflux in asymptomatic siblings of children who were previously proved to have reflux. We determine the incidence and nature of vesicoureteral reflux in symptomatic siblings of children with documented vesicoureteral reflux. MATERIALS AND METHODS: Between January 1990 and December 1996, 624 patients were diagnosed with vesicoureteral reflux during the investigation of documented urinary tract infections. All patients were evaluated for reflux by contrast voiding cystourethrography and reflux was graded according to the international reflux study. 99mTechnetium dimercapto-succinic acid nuclear renal scans were performed to detect renal scarring. The medical records and voiding cystourethrograms of the 624 consecutive patients with vesicoureteral reflux were retrospectively reviewed to identify siblings with vesicoureteral reflux. RESULTS: Vesicoureteral reflux was noted in 85 siblings (134 refluxing ureters) of the 624 index patients (13.6%), including 1 and 2 siblings of 38 and 3 patients, respectively. Mean age at presentation of the 37 boys and 48 girls was 2.5 years. Reflux was unilateral in 36 siblings and bilateral in 49. Reflux was grades I to V in 8, 9, 51, 55 and 11 ureters, respectively. Nuclear scan revealed reflux nephropathy in 22 of the 77 tested siblings (28.5%). CONCLUSIONS: When vesicoureteral reflux is discovered in symptomatic siblings, it is usually high grade and associated with a higher incidence of reflux nephropathy. Of further interest are the findings that refluxing symptomatic siblings of index patients are usually younger and boys are as commonly affected as girls. Screening for vesicoureteral reflux in asymptomatic siblings is recommended to decrease the incidence of reflux nephropathy.

Hemodynamic alterations in the paravertebral venous plexus after spinal injury.

PURPOSE: To assess the prevalence of altered venous hemodynamics after spinal cord injury. MATERIALS AND METHODS: The authors performed venography in 200 ambulant patients and 107 patients with spinal injury. The hemodynamic characteristics of the paravertebral venous plexus were documented after pedal injection of contrast material. The hemodynamic and clinical data were correlated in patients with spinal cord injury. RESULTS: Abnormal venous return via the paravertebral venous plexus in the absence of iliac or inferior vena caval occlusion was shown in 73 (68%) of the 107 patients with spinal injury. This paravertebral venous flow route is not related to the time between injury and examination. It was demonstrable in the early as well as late post-traumatic period and was reproducible at subsequent examinations. The paravertebral venous flow route was more commonly seen in cervical than thoracolumbar injuries and was closely related to the severity of neurologic deficit (P = .0012). CONCLUSION: Abnormal vertebral venous hemodynamics occur in most patients with spinal cord injury and are more likely to occur in patients with complete neurologic deficit and cervical injury.

Cholinergic but not GABAergic neuronal markers are decreased in primary neuronal cultures treated with choline mustard.

Nitrogen mustard analogues of choline are potent irreversible inhibitors of high-affinity choline transport at the cholinergic presynaptic nerve terminal in vitro. Ethylcholine mustard aziridinium ion, and to a lesser extent choline mustard aziridinium ion, have been used as tools to chemically lesion cholinergic neurons in the central nervous system. The selectivity of these compounds as neurotoxins for cholinergic neurons in vivo has been questioned and the mechanism by which they mediate neuronal death has not been elucidated. The objective of the present study was to investigate the selectivity of choline mustard aziridinium ion on embryonic rat brain neurons maintained in primary culture. The effect of choline mustard aziridinium ion on levels of cholinergic neuronal markers was compared with markers for GABAergic neurons as a measure of neuronal specificity. Choline mustard aziridinium ion at 10 and 30 microM irreversibly inhibited hemicholinium-sensitive, high-affinity choline transport into the cultured neurons without altering sodium-dependent, high-affinity GABA transport. Similarly, incubation of the neurons for 30 min in the presence of 10 microM choline mustard aziridinium ion led to a decrease in choline acetyltransferase activity of the cultures which was maintained for 72 h; glutamic acid decarboxylase activity was not altered under the same experimental conditions. Protein and DNA content and DNA-to-protein ratios of the choline mustard aziridinium ion-treated cultures were monitored as indicators of generalized cellular damage.(ABSTRACT TRUNCATED AT 250 WORDS)

Holocene to Middle Last Glaciation vegetation history at Newall Creek, western Tasmania.

Pollen analysis and 14 C dating of 5.5m of organic-rich soil and fluviatile deposits from Newall Creek (altitude 140 m) indicate that temperate rainforest (0-11 K yr B.P.) was preceded by grassland-herbland (11 to 21 K yr B.P.), and then by open grassy Eucalyptus woodland. Comparison with a lake-swamp site at Tullabardine Dam showed that the main vegetation changes were comparable making allowance for some spatial variations in the taxa represented and the lower quantity of pollen in the fluviatile deposits. The inferred sequence of climatic change was from a cool moist interstadial through a cold last glacial maximum to a warm moist Holocene environment, a sequence also indicated at Tullabardine.

Changes at ureteroenteric anastomoses masquerading as a neoplastic polyp. Report of two cases.

Two cases are presented where changes at ureteoenteric anastomoses masqueraded as neoplastic polyps that resulted in excision of the tip of the implanted ureter in one patient. The colonoscopist should be aware of this possibility and endeavor to identify the exact location of the ureteric orifices before excision of any polypoid lesion in this situation.

Provocation discography as a guide to planning operations on the spine.

In a prospective study we attempted to define the role of lumbar discography in the investigation of patients with low back pain with or without non-dermatomal pain in the lower limb. The records of 195 patients were studied at least two years after a technically successful operation. Of 137 patients in whom discography had revealed disc disease and provoked symptoms, 89% derived significant and sustained clinical benefit from operation. Of 25 patients whose discs showed morphological abnormality but had no provocation of symptoms on discography only 52% had clinical success. These findings support the continued use of lumbar discography for the investigation of this particular group of patients.

A comparison between area and volume measurements of the mastoid air spaces in normal temporal bones.

In a study of 26 normal cadaveric temporal bones, a significant correlation was found between the area of the mastoid air spaces assessed from a conventional lateral radiograph and the mastoid volume as determined using high resolution computed tomography. The relationship, which was found to be linear, is of the form V = 0.82 A + 0.13. The correlation coefficient is 0.95 with a residual standard deviation about the regression of 1.14 cm3. It is apparent, therefore, that an accurate assessment of the mastoid air space volume can be obtained by means of a simple and routinely requested investigation, i.e. the 35 degree lateral oblique radiograph.