The Eurasian Journal of Medicine - 2011; 43(3) - Current Issue

Fundoplication After Heller Myotomy: A Retrospective Comparison Between Nissen and Dor

2011-12-01

Objective: A retrospective comparison between Nissen and Dor fundoplication after laparoscopic Heller myotomy for achalasia. Materials and Methods: From 1998 to 2004 a first group of 48 patients underwent Heller myotomy and Nissen fundoplication for idiopathic achalasia (H+N group). From 2004 to 2010 a second group of 40 patients underwent Heller myotomy followed by Dor fundoplication (H+D group). Some patients received a previous endoscopic treatment with pneumatic dilatation or endoscopic injection of botulinum toxin that provided them only a temporary clinical benefit. Changes in clinical and instrumental examinations from before to after surgery were evaluated in all patients. Clinical evaluation was carried out using a modified DeMeester symptom score system. Results: Dor fundoplication treatment reduced both dysphagia and regurgitation severity scores significantly more than Nissen fundoplication (p<0.0001). Indeed, the incidence of dysphagia was significantly higher in patients treated with floppy-Nissen than in those treated with Dor fundoplication: by defining dysphagia as a DeMeester score equal to 3 (arbitrary cut-off), at the end of follow-up dysphagia occurred in 17.65% and 0% (p=0.037) of patients belonging to the H+N and H+D groups, respectively. Conclusion: Heller myotomy followed by Dor fundoplication is a safe and valuable treatment. The procedure showed a lower incidence of postoperative dysphagia versus Nissen fundoplication and a negligible incidence of postoperative GERD in a long-term postoperative follow-up.

Metabolic Syndrome and Neurotrophins: Effects of Metformin and Non-Steroidal Antiinflammatory Drug Treatment

Mariyana G. Hristova — 2011-12-01

Objective: Metabolic syndrome (MS) presents with central obesity, impaired glucose metabolism, dyslipidemia and hypertension. Our aim was to examine the effect of metformin treatment either alone or in combination with non-steroidal anti-inflammatory drugs (NSAID) on plasma levels of nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) in patients with early stage MS (MS-es) and generalized MS (MS-ge). Materials and Methods: The study compared 35 female patients with MS-es (mean age of 43.39�1.54 years) and 40 patients with MSge (mean age of 45.69�2.18 years) to 10 age-matched controls each. Patients with MS-es were administered 850 mg metformin twice daily. The patients with MS-ge were divided into two groups of 20 patients per group. One group received metformin alone, while the other group received metformin in combination with 500 mg aspirin and 150 mg Diclac daily. Plasma NGF and BDNF levels were measured by ELISA. Statistical data analysis was performed using ANOVA. Results: Plasma NGF and BDNF levels were significantly higher in MS-es patients and lower in MS-ge patients than in controls. NGF levels were decreased in both groups after treatment with metformin. NGF levels were significantly higher in MS-ge patients on combined therapy than in those on metformin only. Conclusion: The combination of metformin and NSAID treatment is more effective than metformin alone on NGF and BDNF production as well as on metabolism-related anthropometric and laboratory features. This represents a pathogenetic therapeutic mechanism in MS due to its strong anti-inflammatory effect and improves MS-ge symptoms.

Relationship between Meniscal Tears and Tibial Slope on the Tibial Plateau

2011-12-01

Objective: The geometry of the tibial plateau has a direct influence on the translation and the screw home biomechanics of the tibiofemoral joint. Little information on the relationship between the tibial slope and meniscal lesions is available. The objective of this retrospective study was to examine the effect of the tibial slope on the medial and lateral meniscus lesions in patients with intact ACLs. Materials and Methods: The MRIs and lat roentgenograms of 212 patients with meniscus lesions were examined to determine the possible effect of the tibial slope on meniscal tears. First, the anatomic axis of the proximal tibia was established. Then, the angle between the line drawn to show the tibial slopes (medial and lateral) and the line drawn perpendicular to the proximal tibial anatomic axis was established on MRI. The patients with previously detected meniscus lesions were classified into three categories: patients with only medial meniscal tear (Group 1, 90 patients); patients with only lateral meniscal tear (Group 2, 15 patients); and patients with both medial and lateral meniscal tear (Group 3, 19 patients). Group 4 had no meniscal tear (88 patients). The MRIs of the patients who had applied to the Orthopedic Outpatient Clinic with patellofemoral pain and no meniscal tear were included as the control group. Results: The average tibial slope of the medial tibial plateau was 3.18� in group 1, 3.64� in group 2, 3� in group 3, and 3.27� in group 4. The average tibial slope of the lateral tibial plateau was 2.88� in group 1, 3.6� in group 2, 2.68 in group 3, and 2.91 in group 4. The tibial slope on the medial tibial plateau was significantly larger than the lateral tibial plateaus in group 1 and group 4 (p<0.05). In group 2, there was no statistically significant difference between the tibial slopes of the two sides (p>0.05). In addition, the tibial slope on the lateral side of group 2 was significantly larger than that of groups 1, 3, and 4 (p<0.05). Conclusion: An increase in the tibial slopes, especially on the lateral tibial plateau, seems to increase the risk of meniscal tear.

Compared with the Conventional MR Imaging, Do the Constructive Interference Steady State Sequence and Diffusion Weighted Imaging Aid in the Diagnosis of Lumbar Disc Hernias?

Hasan Aydin, Volkan Kizilgoz, Baki Hekimoglu — 2011-12-01

Objective: Our aim was to evaluate the efficacy of Diffusion Weighted Imaging (DWI) and Constructive Interference Steady State(CISS) sequences in the depiction of lumbar disc hernias, including sequestrated and extruded discs. Materials and Methods: 100 patients; 35 males and 65 females, with 3 sequestration - 16 extruded and 81 protruded all together 100 herniated discs were involved in this study. If a patient had more than one herniated disc, then the more precise herniation was included. All the MRI procedures were handled in Siemens Symphony Power 1.5 T. magnet. DWI- Apparent diffusion coefficient (ADC mapping) and CISS sequences were obtained in axial planes. Statistical analysis of CISS and DWI results were analysed by fischer's test, chi square statistics. Results: CISS sequence had a 89% sensitivity, 100% specificity for all lumbar disc hernias, had 100% sensitivity and specificity in the evaluation of sequestrated and extruded discs. DWI had a 77% sensitivity and %100 specificity, had 100% sensitivity and 50% specificity in the evaluation of extrusion, 100% sensitivity and specificity in the evaluation of sequestration. Conclusion: CISS sequence and quantitative DWI may be alternative imaging modalities to the routine MR imaging sequences in the depiction of lumbar disc hernias, including sequestration and extruded discs.

A Study on the Complications of Surgical Treatment for Bilateral Developmental Dysplasia of the Hip and A Comparison of Two Osteotomy Techniques

Naci Ezirmik, Kadri Yildiz — 2011-12-01

Objective: This study aims to present a review about complications of surgical treatment of Developmental Dysplasia of the Hip and comparing the kinds and ratios of two osteotomy technique (Salter Innominate Osteotomy and Pemberton Pericapsular Osteotomy). Materials and Methods: Fifty-seven patients of 126 that had bilateral developmental dysplasia of the hip are the case series that had undewent to Salter Innominate Osteotomy for one hip and Pemberton Pericapsular Osteotomy for other hip by one surgeon in one stage.

Antistreptolysin O Levels in Patients with Behcet's Disease

2011-12-01

Objective: Behcet's disease is a multisystem inflammatory disorder, and its etiology has not been defined clearly yet. In this study, we aimed to investigate the antistreptolysin O (ASO) levels of patients with Behcet's disease. Materials and Methods: Thirty patients with Behcet's disease and 30 healthy controls were enrolled in this study. We measured erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP), and ASO levels in both groups. Results: There was no statistically significant difference between the two groups with respect to demographic data (p>0.05). The ASO levels of the patients and the controls were 288.4�145.7 and 170.6�142.4 ng/ml, respectively. In the patients with Behcet's disease, ASO (p<0.01) and ESR (p<0.05) values were significantly higher than in the healthy controls. There was no other significant difference in serum CRP levels between the patients and the controls. We could not find any correlation among ASO, CRP, and ESR values. Conclusion: Our results suggest that serum ASO levels may increase in patients with Behcet's disease. Further studies are needed in order to define the relationship between ASO levels and inflammation status in Behcet's disease.

Evaluation of Peripheral Blood Smear for Myelodysplasia in Breast Cancer Patients who Received Adjuvant Antracycline

Hasan Mutlu, Zeki Akca, Havva Uskudar Teke, Hediye Ugur — 2011-12-01

Objective: Therapy-related myeloid neoplasms (t-MN) account for approximately 10% to 20% of all cases of AML (acute myeloid leukemia), MDS (myelodysplastic syndrome) and MDS/MPN (myelodysplastic syndrome/myeloproliferative neoplasms), MDS, and MDS/MPN. In our study, we evaluated peripheral blood smear samples and hemogram values in breast cancer patients who were receiving adjuvant anthracycline regimens and were in remission. Materials and Methods: A total of 78 patients receiving anthracycline- based adjuvant chemotherapy treatment from Kayseri Research and Training Hospital and Mersin State Hospital were enrolled in the study. Their adjuvant treatments had been completed at least 18 months prior to the study. Results: Two patients complained of anemia (2.2%) (Hb<11 mg/dl), leukopenia was observed in seven patients (7.7%) (leukocytes<4000/ mm³ ), and thrombocytopenia was observed in four patients (4.4%) (PLT<150.000/mm³ ). In the blood smear samples, the following were observed: ovalomacrocytes (14%), macrocytes (37%), acanthocytes (1%), stomatocytes (12%), teardrops (12%), nucleated erythrocytes (1%), basophilic stippling (14%), and Howell-Jolly bodies (1%). Additionally, hypo-granulation (38%), Pelger-Huet abnormalities (26%), hypersegmentation (20%), immature granulocytes (8%), and blasts (6%) were observed. We also confirmed the presence of giant platelets (50%) and platelet hypogranulation (19%). Conclusion: According to the peripheral blood smear assessments in our study, we suggest that breast cancer patients should be evaluated for MDS in the early stages, starting from month 18, even if the automated blood counts are normal.

Incidence and Risk Factors of the Secondary Skin Infections in Patients with Radiodermatitis

Ulku Altoparlak, Ozlem Koca, Timur Koca — 2011-12-01

Objective: The aim of this prospective study was to investigate the incidence and risk factors of secondary infected radiodermatitis in patients receiving radiotherapy and to determine isolated microorganisms' resistance profiles to different antimicrobial agents. Materials and Methods: The study comprised 62 patients admitted to the Regional Training and Research Hospital from January 2009 to January 2010. Radiodermatitis was graded according to the National Cancer Institute's Common Toxicity Criteria version 3.0. Potential risk factors for secondary infection were recorded and evaluated by univariate and multivariate analyses. Results: In 62 patients, grade 1, 2, 3 and 4 radiodermatitis were observed in 33 (53.2%), 11 (17.7%), 8 (12.9%) and 10 (16.2%) patients, respectively. Skin infection secondary to radiodermatitis occurred in 14 patients (infected patients), 21.4%, 21.4% and 57.2% of whom had grade 2, 3 and 4 radiodermatitis, respectively. Forty-eight patients were found to be colonized with micoorganisms (colonized patients). In the univariate analysis, concurrent endocrine therapy and radiodermatitis grade differed significantly between infected and colonized patients (p<0.05). Multivariate analyses showed that the radiodermatitis grade was an independent risk factor for the acquisition of infection (p<0.05). The microbial pathogens isolated from patients with skin infection were seven methicillin-resistant coagulase- negative Staphylococcus (MRCNS) strains, three methicillinresistant Staphylococcus aureus (MRSA) strains, two Candida sp., one methicillin-sensitive coagulase-negative Staphylococcus (MSCNS) strain and one methicillin-sensitive S. aureus (MSSA) strain. Staphylococci strains were more resistant to beta-lactam antibiotics. No glycopeptide resistance was found. Conclusion: The results of this study indicate that high-grade radiodermatitis leads to an increased risk for secondary infection of the skin with pathogens.

Glutamate Transporter Activators as Anti-Nociceptive Agents

Robert L. Stephens Jr. — 2011-12-01

The effective management of chronic pain remains enigmatic. There is a paucity of effective mechanistically-based approaches employed. Chronic visceral pain is a particularly difficult subcategory to manage. Glutamate is the most predominant excitatory neurotransmitter and mediates many aspects of sensory function including acute and chronic pain. There is a growing literature describing the efficacy of physiologically dominant glutamate transporter GLT-1 up-regulation in attenuating chronic visceral and somatic nociception. Since glutamate is the major excitatory neurotransmitter released in the first central synapse of the pain-transmitting afferent neurons, augmentation of GLT-1 activity, which reduces extracellular levels of glutamate, may be an important target for pain management strategies. This review summarizes studies in our laboratory and others which highlight findings that GLT-1 up-regulation by transgenic, pharmacologic and viral transfection approaches attenuate a host of nociceptive responses emanating from visceral or somatic sources in animal models. The study also outlines the future work that will be required to ascertain the translational potential of this approach.

Cases of Brainstem Infarcts after Cessation of Heparin Treatment: Is It a Rebound Effect?

Caner Feyzi Demir, Fidan Surgun, Hasan Ozdemir, Oktay Kapan — 2011-12-01

The presented cases represent patients with acute coronary syndrome treated with heparin infusion who developed brainstem infarction after discontinuation of heparin treatment. The patients did not present genetic coagulopathy. Others risk factors were analyzed, and the discontinuation of heparin infusion was also considered to have a predominant role in the development of infarction.

Multimodality Treatment in the Management of Anorectal Melanoma: A Case Report and Review of the Literature

Umit Tapan, Omer Dizdar, Nilufer Bulut, Ismail Celik — 2011-12-01

Anorectal melanoma represents approximately 0.2-1% of all malignant melanomas and has a poor prognosis, with a median survival of 8 to 23 months after the time of diagnosis. The typical treatment modalities include surgery, radiotherapy and chemotherapy. The particular approach taken depends on the patient's status and disease stage. Although there are different treatment options for this rare condition, there are not enough studies on multimodality treatment. Here, we present the case of a 54-year-old female with anorectal melanoma that had metastasized to an inguinal lymph node. She underwent local excision of the rectal mass and inguinal lymph-node dissection. Temozolomide treatment was started after radiotherapy and was given for 24 months. Follow-up revealed that the patient has been doing well with no signs of recurrence three years after the completion of treatment. We aim to discuss combined treatment modalities for ARM in light of the pertinent literature.

Serious Skin Reaction Associated with Imatinib in a Patient with Chronic Myeloid Leukemia

2011-12-01

Imatinib mesylate (STI 571) is one of the fundamental chemotherapeutic agents used in the treatment of the chronic, accelerated and blastic phases of chronic myelocytic leukemia (CML), gastrointestinal stromal tumors and Philadelphia chromosome–positive acute lymphoblastic leukemia. It selectively inhibits receptor tyrosine kinases. Its effects limit the use of this drug. We present a case with a serious skin reaction requiring the discontinuation of the drug and that developed in relation to imatinib therapy. Six months prior, a 61-year-old male patient presenting to the hematology polyclinic with complaints of weight loss and sweating was hospitalized due to high leukocyte value. As a result of the hemogram, biochemistry analyses, peripheral blood smear examination, bone marrow aspiration evaluation, cytogenetic examination using FISH and PCR that were performed, CML was diagnosed. Additionally, to exclude myelofibrosis, we examined a bone marrow biopsy. Imatinib mesylate was started at 400 mg/day orally. In the fourth month of treatment, the patient complained of itching and a skin rash. Although the drug dose was reduced (300 mg/day), his complaints gradually increased. The skin biopsy result was superficial perivascular dermatitis. Imatinib was discontinued, and the patient was started on corticosteroid. The lesions disappeared completely. A month later, the patient was restarted on imatinib mesylate. However, the lesions recurred more prominently. His itching increased. The patient was considered intolerant to imatinib mesylate, and a secondgeneration tyrosine kinase inhibitor, dasatinib 100 mg/day, was started orally. The follow-up and treatment continues for the patient, who has been taking dasatinib 100 mg/day for the last two months without any skin finding or complaints. Imatinib mesylate–induced skin reactions are associated with the pharmacologic effect of the drug rather than hypersensitivity to the drug. Skin reactions are frequently observed, and this side effect is dose dependent. However, the interesting aspect of our case was that despite dose reduction, skin findings gradually increased, and eventually the drug had to be discontinued.

Nonspecific Infectious Bilateral Chylothorax and Cyhloabdomen with Symptoms of Acute Abdomen

Fuat Sayir, Ufuk Cobanoglu, Abidin Sehitogullari — 2011-12-01

Co-existence of chylothorax and chyloabdomen is a rare clinical entity. Apart from surgery and extra-surgical trauma, malignancies, liver cirrhosis, nephrotic syndrome, thrombosis in the superior vena cava and acute pancreatitis play roles in the etiology. The case presented in this article was a 35-year-old woman, and the chronic infectious pathology in the cytology, plus the other supportive nonspecific infection parameters prompted us in establishing this diagnosis. Obstruction in the abdominal lymphatics leads to chylous ascites and chylothorax develops in due course. Similar to our case, the clinical entities of chylothorax and chyloabdomen of nonspecific infectious origin may co-exist in the same patient.

Recurrent Postpartum Eosinophilic Pneumonia Presenting as Acute Respiratory Distress Syndrome

Elif Y�lmazel Ucar, Omer Araz, Nafiye Y�lmaz, Metin Akgun — 2011-12-01

Eosinophilic pneumonia (EP) is a rare disease of the lung. We aimed to present atypical course of two EP cases. They were admitted to our hospital because of acute respiratory distress syndrome (ARDS) in postpartum period. Eosinophilia was detected in bronchoscopic broncho- alveolar lavage and laboratory examination. In these cases, no spesific cause for eosinophilic pneumonia was determined and steroid treatment was started. After the treatment, the patients were in full recovery which were confirmed by clinical and radiological investigations, readmitted to our clinic with relapses of ARDS. The patients have received regular treatment for 1 year. Our cases were neither fitting the classic definitions of acute eosinophilic pneumonia nor chronic eosinophilic pneumonia. Therefore, we wanted to contribute additional data in the literature by sharing these interesting cases.

Pulmonary Arteriovenous Malformation (PAVM): Multidetector Computed Tomography Findings

Cihan Duran, Nicole Wake, Frank J Rybicki, Micheal Steigner — 2011-12-01