Moyamoya disease and alternating hemiplegia. A report of two cases

Moyamoya disease is one of the cerebrovascular disorders and is characterized by bilateral stenosis or occlusion of the distal internal carotid arteries and their main branches. Repeated ischemic episodes in children and intracranial hemorrhage in adults with moyamoya disease is usually noted. In this report, we describe two children with moyamoya disease who presented with alternating hemiplegia. The final diagnosis was made by cerebral angiography and cranial computed tomography in these patients. Other neurological and radiological features of the patients were described.

Incidentally discovered solid renal masses: what are they?

In 36 of 99 consecutive patients operated on for the presumptive diagnosis of renal carcinoma the tumour was discovered accidentally during investigations for a variety of complaints. CT and ultrasound scans were responsible for discovery of the tumour in 24 of the 36 patients. Renal carcinoma accounted for 92% of incidentally discovered solid renal masses. Of 33 incidentally diagnosed renal carcinomas 27 were stage 1. An incidentally discovered solid renal mass should be regarded as a low stage renal carcinoma until proven otherwise.

Cisplatin, methotrexate and vinblastine plus surgical restaging for patients with advanced transitional cell carcinoma of the urothelium

Chemotherapy with cisplatin, methotrexate and vinblastine (CMV) is active in advanced transitional cell carcinoma of the urothelium. Aggressive surgical resection of residual disease following responses produced by CMV was incorporated into a combined modality approach. Between 1982 and 1990, 64 patients were entered into the study. Of 55 patients evaluable for response 11 (20%) had a pathological complete response, 14 (25%) achieved a complete response following resection of residual disease and 5 (9%) whose disease was not surgically restaged had a clinical complete response. The overall complete response rate was 55%. Patients with liver, lung or bone involvement had significantly decreased survival compared to patients without visceral disease (p = 0.002). With a median followup exceeding 50 months, 14 patients (22% of all patients entered into the study) were free of disease at 23 to 98+ months. There were no deaths related to treatment. CMV produced high rates of response in patients with advanced disease, including those with distant metastases. Surgical resection of residual disease following responses produced by chemotherapy proved to be feasible, without treatment related mortality, and may have prolonged survival in selected cases.

Advances in bladder cancer

Intravesical chemotherapy and immunotherapy are administered to patients with bladder cancer in the hope of decreasing the rate of recurrence and, more importantly, reducing the rate of progression. So far, bacille Calmette-Guérin is the only agent to decrease progression rate and thus increase survival. Bacille Calmette-Guérin has been shown to achieve this outcome by selectively sparing certain sequences during fibronectin degradation; these critical fragments were shown to have motility-stimulating activity, which may then enhance tumor invasion. In vivo and in vitro studies have shown that cathepsin B inhibitors prevent degradation of human basement membrane laminin, which is the first step of tumor invasion. Cathepsin B inhibitors either alone or in combination with bacille Calmette-Guérin may be valuable in preventing the progression of superficial bladder tumors in the future. Clinical studies on bacille Calmette-Guérin have repeatedly shown that a second course of bacille Calmette-Guérin to patients with local failure did not jeopardize patient survival. Adjuvant chemotherapy for patients with locally advanced disease and for those with regionally involved lymph nodes improves progression-free survival. Further controlled studies will establish the verdict for adjuvant chemotherapy. With the advancement of molecular genetic studies relevant to modern technology, our understanding of tumor behavior improves dramatically, and classic knowledge becomes more outdated every day.

Unusual neurologic complications of typhoid fever (aphasia, mononeuritis multiplex, and Guillain-Barré syndrome): a report of two cases

Although typhoid fever can frequently lead to such neurological manifestations as confusion, delirium, and encephalopathy, Guillain-Barré syndrome, aphasia and mononeuritis multiplex occur very rarely. In this report, we describe two patients with typhoid fever who developed these unusual complications.

Comparative therapeutic results of penicillin plus chloramphenicol versus ampicillin plus sulbactam in childhood meningococcemia

Fifty-seven cases of meningococcemia were evaluated retrospectively. The age of the patients ranged between 2 and 17 years. Of the 57 patients investigated for the efficacy of antibiotic treatment, 31 (54.4%) were treated with benzylpenicillin plus chloramphenicol and 26 (45.6%) with ampicillin plus sulbactam. Patients with criteria for a poor prognosis (presence of disseminated intravascular coagulation, low arterial blood pressure, and altered consciousness) were divided equally into two treatment groups. There were no statistically significant differences between the two treatment groups except for the higher incidence of convulsion in the group given penicillin plus chloramphenicol. The mortality rate was 19.3 percent for patients treated with benzylpenicillin plus chloramphenicol and 7.6 percent for patients treated with ampicillin plus sulbactam (p = 0.19; overall mortality rate 14%).

Cardiac arrest: an unusual side-effect of intravenous ornidazole

Nitroimidazoles have been used alone or in combination with other antibacterial agents in the treatment of brain abscess. They are associated with certain adverse reactions related primarily to the gastrointestinal tract and central nervous system. But, as far as we know, cardiac arrest due to ornidazole has not been reported in the literature. In this study, we presented a case in which cardiac arrest occurred as an unusual side-effect of intravenous ornidazole administered to a ten-year-old girl suffering from brain abscess.

Bladder cancer

In the search for sensitive and specific tumor markers for bladder carcinoma, expression of various oncogenes and gene products (such as c-erb B-2, p53) and epidermal growth factor receptor merits particular attention. Although the results are not yet conclusive, important predictive markers are about to emerge from ongoing studies in this field. Bacillus Calmette-Guerrin treatment in superficial bladder cancer is probably the most successful immunotherapy in humans. But there is still a large knowledge deficit in the issues of optimal dose schedule and mechanisms of action. Although promising results of neoadjuvant chemotherapy in patients with invasive bladder cancers are reported, we must be cautious about changing our conventional approach until the results of large scale, controlled, randomized studies evaluating the survival are published.

Neuroblastoma presenting as protein-losing enteropathy

Protein-losing enteropathy is often reported to be associated with malignancies such as Hodgkin's disease, non-Hodgkin's lymphoma, and mesenteric mesenchymoma, but it seldom complicates neuroblastoma. In this report, we describe a case of neuroblastoma presenting as protein-losing enteropathy in which neurohumoral mechanisms were involved.

Dynamic cavernosography in the evaluation of impotence

Dynamic cavernosography before and after papaverine injection into the corpus cavernosum of 6 sexually normal volunteers and 44 impotent patients was performed with digital subtracting angiography technique. The average infusion rates in 26 patients with venous leakage were 325.5 ml/min for induction of erection and 161 ml/min for maintenance. The results for the remaining 18 impotent patients without venous leakage were 128.8 ml/min for induction and 56.9 ml/min for induction and 58.3 ml/min for maintenance. After papaverine injection the average infusion rates decreased to 131 ml/min (induction) and 59 ml/min (maintenance) in patients with venous leakage, 38.4 ml/min and 14.6 ml/min in the impotent patients without venous leakage and 35 ml/min and 14.1 ml/min in the control group, respectively. It was also noticed that in the control group filling of the superficial and deep veins may occur during the flaccid phase which disappeared with induced erection. Therefore we suggest intracavernous papaverine injection with dynamic cavernosography. The digital subtracting technique eliminates unnecessary images, providing a more accurate diagnosis of venous incompetence.

Screening of asymptomatic siblings of patients with vesicoureteral reflux

Familial trait in vesicoureteral reflux (VUR) has been revealed in many studies. This paper reports on 36 siblings of 25 patients operated for vesicoureteral reflux at our Department. Siblings aged 2 to 21 years were evaluated by urine examination, urine culture and voiding cystourethrogram (VCU) for VUR. All of the siblings were asymptomatic and VUR was found in only 4 of them (11%), unilateral in 3 cases and bilateral in one case. It is concluded that evaluation of siblings for VUR will be suitable for revealing the presence of urinary infection, and assessing them by VCU at the time they are first seen.

Prognostic factors and therapy for superficial and invasive bladder cancer

Although most of the transitional cell carcinomas are superficial at presentation and pose little problem as far as survival is concerned, predicting the ones that will recur and, more importantly, recur as invasive tumors, is crucial. Determination of serum and urine human chorionic gonadotropin-beta levels and epidermal growth factor receptor analysis are promising in this respect. Intravesical bacillus Calmette-Guérin, which is widely used to prevent further recurrences and to treat carcinoma in situ, augments the host's immune status, probably by increasing interleukin-2 and tumor necrosis factor levels. Intravesical interferon seems to be a promising agent, especially against carcinoma in situ, and has exceptionally few side effects. Multidrug chemotherapy regimens such as methotrexate, vinblastine, doxorubicin, and cisplatin, or cisplatin, methotrexate, and vinblastine have achieved 30% to 40% objective complete remission rates in patients with metastatic bladder cancer. These regimens are also used in a neoadjuvant setting with or without irradiation in the hope that more patients will be spared cystectomy and enjoy similar if not better survival. At the same time, continent diversions and nerve-sparing cystoprostatectomy open a new era in the treatment of invasive bladder cancer by improving the quality of life after cystectomy. Although important progress has been made, there is still room for research and clinical controlled studies to achieve higher rates of response, prolonged disease-free survival, and perhaps even improved rates of cure.

Serum ferritin: a tumor marker for renal cell carcinoma

Serum ferritin levels in 32 patients with renal cell carcinoma were evaluated preoperatively and postoperatively. Serum ferritin concentration was significantly higher in renal cell carcinoma patients compared to controls (259.10 versus 61.30 ng./ml., p less than 0.001). Furthermore, there was a steady and statistically significant increase in serum ferritin levels with advancing disease stage, as well as a significant decrease in serum ferritin levels after nephrectomy for stages 1 and 2 disease. The intracellular content of ferritin as estimated by polyclonal antibody was dramatically increased in renal cancer tissue compared to normal parenchyma. Although serum ferritin regulation is complex and only partly understood, the present study suggests that serum ferritin may be a useful tumor marker for renal cell carcinoma.

Bilateral perineal ectopic testes

Perineal testicular ectopia is seen very rarely, bilaterality is even more scarce and three cases have been reported in the literature. Here we present the fourth case with bilateral perineal ectopic testes.

Treatment of testicular hydrocele with tetracycline sclerotherapy

Fifteen patients with primary hydrocele of the testis were treated by aspiration and injection of tetracycline. Only 5 patients (33.3%) were cured by a single injection of tetracycline. Furthermore, 46.6% of our patients experienced severe scrotal pain, three of whom required open surgery. We do not recommend single injection tetracycline therapy, and further injections were not performed due to severe side effects.

Histopathological changes in adult cryptorchid testes

The histological specimens of 73 patients who presented with undescended testes after puberty were re-evaluated. None of the specimens revealed carcinoma in situ but in the specimens of 5 patients severe atypia was detected. None of the patients, including 5 with severe atypia, has shown any evidence of invasive testicular tumour during follow-up.

Significance of scrotal violation in the prognosis of patients with testicular tumours

Thirty-five patients with testicular cancer who had scrotal contamination during or prior to their primary treatment were compared with 70 patients who had undergone radical inguinal orchiectomy. The survival curves, disease-free intervals and 2-year survival rates of the two groups did not differ significantly and we do not advocate additional aggressive surgical treatment to the scrotum and superficial inguinal lymph nodes in these patients.

Varicocele and antisperm antibodies

Semen analysis and immunofluorescent antisperm antibodies were tested in 65 patients with varicocele. The mean sperm count and motility values in our study were 36.8 +/- 2.9 million per ml and 38.4 +/- 2.5 per cent, respectively. Both parameters were found not to differ significantly in three grades of varicocele. Immunofluorescent antisperm antibodies were detected in 24.6 per cent of the cases. A significant correlation was demonstrated between the presence of the antibodies and genital infection.

The advantages of bilateral simultaneous stone removal from the upper urinary tract

An anterior transperitoneal approach was used to remove the stones from both kidneys and/or ureters simultaneously in 18 patients. The morbidity of this type of surgery in our study was very low and there were no surgical difficulties in exposing the intrarenal structures. Furthermore, especially in secondary cases, this approach was easier and more time-saving than the classical flank approach. We recommend its use at least in selected groups of patients in whom peritoneal gross contamination is not expected.

Surgical management of vesicoureteral reflux in children

The authors report on ten years of experience in ureteroneocystostomies on 80 ureters in 50 children suffering from vesicoureteral reflux. Complete follow-up was obtained in all cases. Postoperative radiograms revealed cure of reflux in 85 per cent of the renal units. A slightly modified Politano-Leadbetter procedure was used in all of the cases. Postoperative urinary tract infection occurred in 13 patients. This relatively low success rate is discussed briefly.

Biopsy of apparently normal bladder mucosa in patients with bladder carcinoma and its prognostic importance

A total of 100 cold cup biopsies were obtained from apparently normal vesical mucosa of 25 patients admitted to Hacettepe University Hospital between 1980 and 1981. Dysplasia was found to occur in 40.49, hyperplasia in 17.35, squamous metaplasia in 9.91 per cent. Dysplasia was shown to be increasing parallel with the increase in the grade and stage of the tumour. The frequency of dysplasia and hyperplasia in the recurrent and non-recurrent groups differed significantly (p less than 0.001). In other words, recurrence was seen more frequently in patients with positive random biopsies. Although recurrence phenomena cannot be explained on the basis of mucosal abnormalities alone, this study shows that these subendoscopic lesions do have some prognostic role in recurrences.