Assessing the knee flexion range of motion after total knee arthroplasty: Technology versus senses.

INTRODUCTION: Following total knee arthroplasty surgery, attention should be paid to post-operative knee range of motion to achieve daily activities. Goniometer assessment is widely used to assess the range of motion in the post-operative period. This study aimed to determine the inter-rater ability of a smartphone application and visual estimation of the knee joint after total knee arthroplasty among different professions that commonly work together and compare whether any method is superior to another. METHOD: Range of motion measurements was performed by four clinicians as two physiotherapists and two orthopedic fellows. They utilized the Goniometer Reports application for smartphones, universal goniometer, and visual estimation to measure angles of knees which was operated. A two-way mixed model of intra-class correlation coefficient (ICC) with a 95% confidence level was used to assess inter-rater reliability. RESULTS: Thirteen patients (11 female) and 20 knees (10 right) were assessed. The ICCs were found excellent both for between methods and between raters. CONCLUSION: Our results show that technology seems a more accurate way to determine the knee range of motion after knee arthroplasty compared to senses. However, in lack of technological resources or time, or to avoid possible infection, visual estimation also could provide useful information.

Reliability and minimal detectable change of the 2-minute walk test and Timed Up and Go test in patients with total hip arthroplasty.

PURPOSE: Performance-based outcome measures are becoming increasingly important in health care. The 2-minute walk test (2MWT) and the Timed Up and Go test (TUG) are frequently used in clinical trials as performance-based tests in many diseases including osteoarthritis. The purposes of this study were: (1) to determine test-retest reliability of data for the 2MWT and the TUG; (2) to determine minimal detectable change (MDC) scores for the TUG and 2MWT in patients with total hip arthroplasty (THA). METHODS: 37 patients, who had undergone primary THA, were included. Patients twice performed trials for the 2MWT and TUG on the same day. In addition to demographic data of patients, the Harris Hip Score, 2MWT and TUG scores were recorded. RESULTS: The TUG and 2MWT showed excellent test-retest reliability. The Intraclass correlation coefficient ICC (2,1), Standard error of measurement (SEM) and minimal detectable chance at the 95% CI (MDC95) for TUG were 0.96, 0.59 seconds and 1.62 seconds respectively. The ICC (2,1), SEM and MDC95 for 2MWT were 0.96, 6.37 m and 17.56 m respectively. CONCLUSION: Clinicians and researchers can be confident that greater changes than 1.62 seconds for TUG and 17.56 m for the 2MWT over time represent a real clinical change in rehabilitation process in patients with THA. Both the 2MWT and TUG may assist in early identification of patients who may need additional rehabilitation to reduce the potential for poor outcomes after THA. Therefore, both of these tests can be used in a clinical setting with a small measurement error.

Evaluation of Extensor Mechanism in Revision Knee Arthroplasty.

BACKGROUND: The success of revision total knee arthroplasty depends on adequate exposure that does not produce complications. The purpose of this study was to compare the results of revision total knee arthroplasty between V-Y quadricepsplasty (QP) and quadriceps snip (QS) approaches. METHODS: In the study, 92 knees with follow-up of 12-108 months which were operated by using QP (55) and QS (37) were evaluated retrospectively. Measurements were taken by using universal transparent goniometer, also varus valgus deformities, knee flexion angles, instability, Hospital for Special Surgery and Lower Extremity Functional Scale scores, functional condition of the knee and activity levels of the patients were evaluated cross-sectionally. RESULTS: Statistically significant difference was not found regarding extensor restriction, varus or valgus deformities, knee flexion angles, flexor and extensor muscular strength, Hospital for Special Surgery and Lower Extremity Functional Scale score (P > .05). CONCLUSION: QP is a preferable method which allows a wider arthrotomy for stiff knees and revision knee surgery, and provides larger access to the joint. Choosing this incision does not bring disadvantage in terms of extensor mechanism.

Assessing Minimal Detectable Changes and Test-Retest Reliability of the Timed Up and Go Test and the 2-Minute Walk Test in Patients With Total Knee Arthroplasty.

BACKGROUND: Two-minute walk test (2MWT) and the Timed Up and Go test (TUG) are simple, quick, and can be applied in a short time as part of the routine medical examination. They were shown to be reliable and valid tests in many patient groups. The aims of the present study were: (1) to determine test-retest reliability of data for the TUG and 2MWT and (2) to determine minimal detectable change (MDC) scores for the TUG and 2MWT in patients with TKA. METHODS: Forty-eight patients with total knee arthroplasty, operated by the same surgeon, were included in this study. Patients performed trials for TUG and 2MWT twice on the same day. Between the first and second trials, patients waited for an hour on sitting position to prevent fatigue. RESULTS: The TUG and 2MWT showed an excellent test-retest reliability in this study. Intraclass correlation coefficient [ICC(2,1)] for TUG and 2MWT were 0.98 and 0.97, respectively. Standard error of measurement and MDC95 for TUG were 0.82 and 2.27, respectively. Standard error of measurement and MDC95 for 2MWT were 5.40 and 14.96, respectively. CONCLUSION: The TUG and 2MWT have an excellent test-retest reliability in patients with TKA. Clinicians and researchers can be confident that changes in TUG time above 2.27 seconds and changes in 2MWT distances above 14.96 meters, represent a "real" clinical change in an individual patient with TKA. We, therefore, recommend the use of these 2 tests as complementary outcome measures for functional evaluation in patients TKA.

Reliability of 4-meter and 10-meter walk tests after lower extremity surgery.

PURPOSE: To investigate the test-retest reliability of the 4-meter walk test (4 MWT) and 10-meter walk test (10 MWT) in patients undergoing lower extremity surgery during inpatient rehabilitation. METHOD: In all, 102 patients with total hip arthroplasty (THA), total knee arthroplasty (TKA), lower extremity fracture (LEF) and soft tissue operation were recruited. Patients performed two 4 MWT and two 10 MWT trials on the same day. The same researcher performed all the measurements to avoid inter-rater variability. RESULTS: The 4 MWT and 10 MWT were shown to have excellent test-retest reliability. The ICCs for the 4 MWT and 10 MWT were found as 0.94 and 0.95, respectively. The SEMs for the 4 MWT and 10 MWT were 2.0 and 5.5 seconds, respectively. The smallest real difference at the 95% confidence level (SRD95) was 5.5 seconds for the 4 MWT and 12.2 seconds for 10 MWT and SRD95 percentage was 31.2 for the 4 MWT and 28.5 for the 10 MWT. CONCLUSION: Both the 4 MWT and the 10 MWT have excellent reliability in patients undergoing lower extremity surgery such as TKA, THA, LEF and soft tissue operation during inpatient rehabilitation. Clinicians and researchers can be confident that changes above the SRD95s for the different patient groups, for both sexes and with regard to weight-bearing status, represent a real clinical change in rehabilitation process. Implications for Rehabilitation The 4 MWT and the 10 MWT are simple methods and were also shown to be reliable measurement methods in many patient groups. This study illustrates that the test-retest reliability of the 4 MWT and 10 MWT are excellent in patients undergoing lower extremity surgery during inpatient rehabilitation (ICC: 0.94 for 4 MWT, ICC: 0.95 for 10 MWT). Clinicians and researchers can be confident that changes above the SRD95s for the different patient groups, for both sexes and with regard to weight-bearing status represent a real clinical change in rehabilitation process.

Influence of pectoralis minor and upper trapezius lengths on observable scapular dyskinesis.

OBJECTIVES: Although a relationship between short pectoralis minor and upper trapezius and scapular dyskinesis has been postulated, no studies have investigated this theory. Understanding the effect of these muscle lengths on observable scapular dyskinesis may aid in determining risks and therefore making treatment decisions. Being aware of the magnitude of this effect would help gauge the significance of risks involved. Our aim was to evaluate the influence of pectoralis minor and upper trapezius lengths on scapular dyskinesis. DESIGN: Cross-sectional study. SETTING: University research laboratory. PARTICIPANTS: Asymptomatic participants (n = 148; 296 arms) were evaluated. MAIN OUTCOME MEASURES: Scapular Dyskinesis Test (SDT) was used to identify scapular dyskinesis, Pectoralis Minor Index (PMI) and Upper Trapezius Length Testing were used to determine muscle length. RESULTS: SDT+ arms had shorter pectoralis minor resting length (PMI: 7.49 ± 0.38) (p < 0.001) and greater incidence of short upper trapezius (ISUT) (66.7%) (p < 0.001) compared to SDT- arms (PMI:8.58 ± 0.75, ISUT:22.5%). With each decrease in PMI, the likelihood of having scapular dyskinesis increased 96% (p < 0.001). Arms with short upper trapezius were 2.049 times more likely to exhibit scapular dyskinesis than those with normal length (p = 0.042). CONCLUSIONS: Having a shorter pectoralis minor and upper trapezius length substantially increased the likelihood of having visually observable scapular dyskinesis.

Effects of Nigella sativa L. seed oil on intima-media thickness and Bax and Caspase 3 expression in diabetic rat aorta.

OBJECTIVE: Hyperglycaemia is an important risk factor for the development and progression of the macrovascular and microvascular complications that occur in diabetes. The expression of apoptotic markers in the aortic medial layer of diabetic rats and the effects of N. sativa L. seed oil on the expression of these markers were investigated in this study. METHODS: Four-month-old adult female Wistar rats (n=21) were divided into 3 groups: Group 1, control; Group 2, diabetes and Group 3, diabetes+N. sativa L. seed oil. Group 3 received 0.2 mg/kg/day N. sativa L. seed (black cumin) oil intraperitoneally 6 days per week for 30 days. At the end of the experiment, abdominal and thoracic aortas of all animals were collected and fixed in 10% formalin solution. Then, 5-µm-thick sections were stained with Verhoeff-Van Gieson stain to evaluate Bax and Caspase 3 expression. Tunica intima-media thickness was measured using the stained sections. RESULTS: There were no significant differences in abdominal or thoracic aortic intima-media thickness among the 3 groups. However, there were significant differences in Bax and Caspase 3 expression in the tunica media of the thoracic and abdominal aortas between Group 1 and Group 2 (p<0.05) and between Group 2 and Group 3 (p<0.05) evaluated with the Kruskal-Wallis and Mann-Whitney U tests. CONCLUSION: It is understood that N. sativa L. seed oil is effective against diabetes. N. sativa L. seed oil is a plant material and has value for further investigation to develop diabetes treatment strategies for preventing apoptosis in vascular structures.

Test-retest reliability of the 50-foot timed walk and 30-second chair stand test in patients with total hip arthroplasty.

The purpose was to investigate the test-retest reliability of the 50-Foot Timed Walk (50FWT), and 30-Second Chair Stand Test (30CST) in the patients with total hip arthroplasty (THA). The study was a test-retest study. Thirty-seven patients with THA performed two trials for both the 30CTS and 50FWT on the same day with one hour interval. To assess reliability, the intra-class correlation coefficient [ICC(2,1)], standard error of measurement (SEM), the smallest real difference at the 95% confidence level (SRD95) were calculated. The ICCs for the 50FWT and 30CTS were 0.98 and 0.94, respectively. The SEM and SRD95 for the 50FWT and 30CTS were 0.3 and 0.8 seconds and 0.4 and 1.2 repeats, respectively. The test-retest reliability of the tests was very high. The 50FWT and 30CST are very reliable to measure the functional performance in patients with THA in the clinical settings.

Reliability of the 50-foot walk test and 30-sec chair stand test in total knee arthroplasty.

OBJECTIVE: To investigate the reliability of the 50-Foot Walk Test (50 FWT) and 30-second Chair Stand Test (30 CST) in patients who have undergone total knee arthroplasty (TKA). METHODS: The study was designed as a test-retest research. Thirty-three patients who would undergo bilateral TKA were recruited. The tests 30 CST and 50 FWT were performed twice on the same day with 5-minute intervals, respectively. Between the first and second tests, patients waited for an hour on sitting position in order to prevent fatigue. In addition to these tests, we registered the knee pain experienced by the patients using a 100 mm VAS scale. RESULTS: The 50 FWT and 30 CST showed excellent reliability. ICC for 50 FWT and 30 CST were 0.97 and 0.92, respectively. SRD95 was 1.07 for 50 FWT and 0.96 for 30 CST. CONCLUSIONS: According to results of this study, both 50 FWT and 30 CST have excellent reliability in patients with TKA. These tests are simple, no time consuming and constitute sensitive methods to measure the functional performance in patients with TKA in the clinical settings. Clinicians and researchers may use these tests to quantify even small changes in functional performance for patients with TKA. Level of Evidence III, Diagnostic Study.

Reliability of the 50-foot walk test and 30-sec chair stand test in total knee arthroplasty

OBJECTIVE: To investigate the reliability of the 50-Foot Walk Test (50 FWT) and 30-second Chair Stand Test (30 CST) in patients who have undergone total knee arthroplasty (TKA). METHODS: The study was designed as a test-retest research. Thirty-three patients who would undergo bilateral TKA were recruited. The tests 30 CST and 50 FWT were performed twice on the same day with 5-minute intervals, respectively. Between the first and second tests, patients waited for an hour on sitting position in order to prevent fatigue. In addition to these tests, we registered the knee pain experienced by the patients using a 100 mm VAS scale. RESULTS: The 50 FWT and 30 CST showed excellent reliability. ICC for 50 FWT and 30 CST were 0.97 and 0.92, respectively. SRD95 was 1.07 for 50 FWT and 0.96 for 30 CST. CONCLUSIONS: According to results of this study, both 50 FWT and 30 CST have excellent reliability in patients with TKA. These tests are simple, no time consuming and constitute sensitive methods to measure the functional performance in patients with TKA in the clinical settings. Clinicians and researchers may use these tests to quantify even small changes in functional performance for patients with TKA. Level of Evidence III, Diagnostic Study.

Chemoprotective effect of vitamin E in cyclophosphamide-induced hepatotoxicity in rats.

Cyclophosphamide (CP) has a range of adverse effects on liver tissue in humans and animals. Administering an antioxidant with CP might reduce such side effects. Therefore, we examined the role of vitamin E in CP-induced liver toxicity in rats. Male Wistar albino rats were divided into four groups, each of seven rats: control, CP only, CP + vitamin E, and vitamin E only groups. The rats were administered treatments intraperitoneally for 7 days. Then the serum malondialdehyde (MDA), alanine aminotransferase (ALT), aspartate transaminase (AST), and lactate dehydrogenase (LDH) levels were determined while the livers were removed, tissue was prepared using routine histological procedures, sections were stained using hematoxylin and eosin, and the terminal deoxynucleotidyl transferase-mediated nick end-labeling (TUNEL) method was applied. Histopathologically, CP caused hydropic degeneration, necrosis, pleomorphism, and mitotic activity. The number of TUNEL-positive cells and the MDA and ALT levels were significantly higher in the CP group. The antioxidant effects of vitamin E significantly decreased the number of TUNEL-positive cells and the ALT and MDA levels, and normalized the liver histopathology. CP induces apoptosis, has toxic effects on liver tissue, and changes the histological structure. The administration of vitamin E prevented the liver tissue damage caused by CP.

Test-retest reliability of the stair test in patients with total hip arthroplasty.

PURPOSE: Stair climbing is one of the important functional activities of daily living to maintain mobility and independence. Walking and stair climbing have been identified by clinicians and patients as critical functional activities before and after total hip arthroplasty (THA). Testing the ability to manage steps has been commonly used in clinical and research settings because it is an inexpensive and simple way to measure functional status after THA. The frequent use of this test supports studies seeking evidence to validate stair test (ST) as a measure of physical performance in subjects with THA. The aim of this study is to determine the test-retest reliability of the 9-step ST in patients with THA. METHODS: Patients performed twice trials for the ST on the same day with one hour interval. To assess test-retest reliability, the intra-class correlation coefficient--ICC (2,1), standard error of measurement (SEM), minimal detectable change at the 90% confidence level (MDC90) were calculated. RESULTS: A total of 37 patients with THA participated in this study. The ST showed very high reliability (ICC = 0.98 (95% CI, 0.96 to 0.99)). The SEM was 0.3 seconds and the MDC90 was 0.7 seconds. CONCLUSIONS: Test-retest reliability of the ST was very high for the patients with THA, and the SEM and MDC90 were adequate for clinical use. The ST is less time consuming and has very high reliability to measure the functional level after THA in the clinical setting.

Evaluation of neuroprotection by melatonin against adverse effects of prenatal exposure to a nonsteroidal anti-inflammatory drug during peripheral nerve development.

The potential ability of melatonin to protect against impairment of the fetal peripheral nerve system due to maternal consumption of diclofenac sodium (DS) was investigated. Eighty-four pregnant rats were divided into seven groups: control (CONT), saline administered (PS), DS administered (DS), DS with low-dose melatonin administered (DS+MLT10), DS with high-dose melatonin administered (DS+MLT50), low-dose melatonin administered (MLT10), and high-dose melatonin administered (MLT50). After the pregnancy, six male newborn rats from each group were sacrificed at 4 and 20 weeks of age. Their right sciatic nerves were harvested, and nerve fibers were evaluated using stereological techniques. Mean numbers of myelinated axons, axon cross-section areas and the mean thickness of the myelin sheet were estimated. Four-week-old prenatally DS-exposed rats had significantly fewer axons, a smaller myelinated axonal area, and a thinner myelin sheath compared to CONT group (p<0.05). Although melatonin at both doses significantly increased axon numbers, only a high dose of melatonin increased the diameter of those axons (p<0.05). At 20-weeks of age, myelinated axon number in the DS group was not only significantly lower than all other groups (p<0.05) but also the cross-sectional area of these axons was smaller than all other groups (p<0.05). There were no differences between the groups regarding the mean thickness of the myelin sheet. The current study indicates that prenatal exposure to DS decreases the number and the diameter of sciatic nerve axons and that melatonin prophylaxis can prevent these effects.

Reliability of the six-minute walk test after total hip arthroplasty.

BACKGROUND: Walking ability is a crucial component of lower extremity function. Assessment of walking after total hip arthroplasty (THA) provides important information about the healing process. Walking endurance, an important functional component of walking, can be reliably measured with the 6-minute walk test (6 mWT). Even though the 6 mWT is commonly used in patients with THA, its reliability has never been reported for this patient population. The aim of this study is to assess the reliability of the test-retest 6 mWT after THA. METHODS: Thirty-four patients with THA performed two test trials on the same day, separated by a one hour seated rest. To assess reliability, intra-class correlation coefficient (ICC(2,1)), standard error of measurement (SEM), and smallest real difference (SRD) were calculated. RESULTS: The 6 mWT showed a high reliability. The patients walked 3.71 metres more at the end of the second 6 mWT in comparison with the first test. The ICC(2,1) (AS(95)), SEM (m), SEM(95) (m) and SRD(95) (m) were 0.96 (0.92), 3.67, 7.19, and 10.17 m respectively. CONCLUSIONS: Reliability of the 6 mWT was high in patients with THA. The 6 mWT is a simple and sensitive method to measure the functional performance in patients with THA in the clinical setting. Moreover, clinicians and researchers can use the 6 mWT to quantify even small changes in functional performance after THA.

Diabetes mellitus- and cooling-induced bladder contraction: an in vitro study.

The effects of diabetes mellitus during cooling on ACh- and KCl-induced responses were investigated in rat urinary bladder. Diabetes was induced in the rats by 50 mg/kg streptozotocin via an intraperitoneal injection. Rats' body and bladder weights were measured. The isometric tension to ACh (10(-9) - 3 × 10(-4) M) and KCl (5-100 mM) in strips of urinary detrusor muscle of diabetic and non-diabetic rats, in organ baths at 37 and 28ºC were recorded. The body weights were significantly decreased and the bladder weights increased in STZ-induced diabetic group compared to the non-diabetic group. ACh and KCl caused concentration-dependent contractions of urinary bladders from non-diabetic and STZ-induced diabetic rats. During cooling, the sensitivity and the maximal response were significantly higher than those during 37ºC, both in non-diabetic and diabetic preparations. Cooling of detrusor muscle preparations induces a graded contraction inversely proportional to the temperature in diabetic rats. It may be assumed that the cooling response involves the same mechanisms in the diabetic and non-diabetic animals.

p53 Expression and apoptosis in liver and spleen during CO2 pneumoperitoneum.

BACKGROUNDS AND AIMS: Laparoscopic surgery techniques have been increasingly preferred to classic laparotomy by surgeons since 1987. However, this method has some important adverse effects on intra-abdominal organs. The aim of this study is to evaluate the effects of different pressures of CO(2) on apoptosis and p53 expression in cells in liver and spleen. METHODS: In total, 30 male Sprague-Dawley rats were used in the study. CO(2) was insufflated into the intra-abdominal cavity via angiocatheter cannule by an insufflator in two different pressures of 10 and 20 mm Hg for 60 min. However, in the control group, only cannule was inserted into the intra-abdominal cavity, but no gas was insufflated. After 60 min, the rats were killed and laparotomy was applied. The liver and spleen were excised. The samples were histologically processed and immunohistochemistry was applied. RESULTS: All the data revealed that the number of apoptotic cells in liver and spleen increases in proportion to CO(2) pressure level. No p53 expression was detected in both organs. CONCLUSION: CO(2) pressure level and application time may affect on cells living in liver and spleen. High pressure and/or long application time may cause releasing of cytokines and superoxide radicals from these organs' cells, and transient or serious organ dysfunctions may occur.

The effects of CO2 pneumoperitoneum on the apoptotic index in the peritoneum.

During laparoscopic surgery, gases such as carbon dioxide (CO(2)), helium, or normal air are insufflated into the intra-abdominal cavity so the surgeon can obtain a clear surgical field; however, this insufflation technique may cause injury to the intra-abdominal organs. This study was undertaken to evaluate the effects of different pressures of CO(2) on the apoptotic index in the peritoneum during laparoscopic surgery. A total of 30 Sprague-Dawley male rats were used in the study. CO(2) was insufflated into the intra-abdominal cavity via an angiocatheter cannula by an insufflator at pressures of 10 and 20 mm Hg over 60 min. In the control group, the cannula was inserted into the intra-abdominal cavity, but no gas was insufflated. After 60 min, the rats were killed; peritoneum was harvested from the abdominal wall and was cultured in the cell culture laboratory. Apoptotic and living cells were detected immunohistochemically, and the apoptotic index was calculated and statistically analyzed. The data collected revealed that the apoptotic index increases in proportion to the level of CO(2) pressure. CO(2) pneumoperitoneum is a very useful technique. Gas pressure must be carefully set during the operation, however, or injured mesothelial cells may cause serious malfunction.

P53 expression between 13-27 weeks old human male fetus gonads.

P53 is a tumor suppressor gene and a critical component of cellular mechanisms that respond to genotoxic stresses. During normal fetal development, some of these cells lose their genomic stability because of intensive cell proliferation. They arrest cell cycle progression and repair genomic stability by p53 induction or die via apoptosis. If p53 is overexpressed, some structures may have different abnormalities. This study was conducted to investigate normal p53 expression in human male gonads during second trimester. Twenty one normal human male fetuses' testes in 2nd trimester were processed and immunohistochemistry was applied. The spermatogonia with nuclear and perinuclear staining, were accepted as p53 (+). The number of p53 (+) spermatogonia was counted in randomly 10 different seminiferous tubules. The results suggest that p53 expression in gonads of human male fetuses significantly increases in the 20th week.

Apoptosis and cerebral ischemic reperfusion injury developed after haemorrhagic shock: experimental study.

BACKGROUND: Apoptosis is a process of programmed cell death that plays a role in some normal and pathological conditions. In this study, we investigated the apoptosis during cerebral ischemic reperfusion injury in response to haemorrhagic shock in a rat model. METHODS: Thirty-six adult Sprague-Dawley rats were divided into six groups: control, haemorrhagic shock (HS), ischemic reperfusion (IR), 1st hour IR, 3rd hour IR, 6th hour IR and 24th hour IR. Rats were sacrificed by taking blood from intracardiac area after finishing the experiment. The tissues were fixed using neutral buffered 10% formaldehyde solution for histopathological examination. Tissues were stained immunohistochemically with APO 2.7 and positive expression apoptotic cells were counted using a Clemex Vision Lite 3.5 vision analysis system. RESULTS: There were 2-3 apoptotic cells in the control group (group 1) and this number increased to 8-11 in the haemorrhagic shock group (group 2) (p<0.05). Secondary or more serious injury occurs during ischemic reperfusion injury. The number of apoptotic cells increased to 11-14 at the 1st hour (group 3) and it was significant as compared to group 2 (p<0.05). The number of apoptotic cells significantly increased to 15-17 by the 3rd hour (group 4) as compared to group 3 (p<0.05). While there was no additional increase by the end of the 6th hour (group 5) as compared to group 4, the number of apoptotic cells significantly increased to 18-24 by the end of 24th hour (group 6) as compared to group 5 (p<0.05). CONCLUSION: The majority of injuries to the brain following haemorrhagic shock occur during ischemic reperfusion. We observed that apoptosis increases step by step on the 1st, 3rd and 24th hours after ischemic reperfusion injury.