Breast tuberculosis

Breast tuberculosis is a rare form of tuberculosis. Of all the breast diseases treated surgically, tuberculosis is seen in the range between 0.025% and 0.1%. This ratio is higher in undeveloped countries. We presented five cases with breast tuberculosis. Their ages were between 20 and 63 years. All of them had children and were breastfeeding. The cause of admission to the hospital was swelling in four of them and pain in the remainder. All of the lesions were unilateral. One case had received antituberculosis treatment for pulmonary tuberculosis 10 years ago. AAFB was not detected in sputum, breast discharge, urine and tissue culture in all the cases. Diagnosis was made histopathologically from the excisional biopsy material. Caseating granulomatosis was also found in axillary lymph nodes in three cases. Antituberculosis therapy was planned as 2HRZE/4HR for all of the cases. Three of them completed the therapy without any complaints. One case left the hospital without permission. The last one is now undergoing resistant tuberculosis treatment for pulmonary disease without any complaint of her breast. As a conclusion, although tuberculosis of breast is extremely rare, it should be kept in mind particularly in developing and undeveloped countries.

Macular Retinitis as a First Sign of Subacute Sclerosing Panencephalitis: The Importance of Early Diagnosis

PURPOSE

Subacute sclerosing panencephalitis (SSPE) is a subacute inflammatory and neurodegenerative encephalitis related to the measles (rubeola) virus and usually affecting children and young adults. The overwhelming majority of cases follow a progressive downhill course leading to death, although there have been a few case reports of patients who have apparently gone into remission. Ocular changes occur in up to 50% of SSPE cases. Visual complaints, if present, generally antedate the onset of neurological symptoms by a few weeks or months. Here, we report two cases of SSPE presenting with ocular findings and their prognoses.

METHODS

Case reports. In the first case, a 17-year-old male presenting with macular retinitis, the macular findings were mistaken for a heredodegenerative disorder and diagnosis was postponed until neurological findings took place. He died six months after the appearance of his first ophthalmic symptoms despite intravenous immune globulin and isoprinosine therapy. The second case was a 14-year-old male, who presented with only ophthalmological complaints. His diagnosis was based on both ophthalmological findings and high doses of measles IgG in the cerebrospinal fluid (CSF); isoprinosine and intramuscular beta-interferon therapy was started before the onset of neurological findings and in the follow-up time of about 18 months, neurological findings consistent with SSPE did not develop.

RESULTS

The characteristic finding of macular retinitis in SSPE patients is rapid recovery in about one month without therapy. After improvement, neurological findings take place. Once suspected, the diagnosis of SSPE is easily established by the demonstration of high levels of measles antibody in the serum and CSF. Early diagnosis can be made with typical ocular findings and high IgG titers for rubeola in CSF.

CONCLUSION

We suppose that ophthalmic manifestations, especially macular retinitis, may be useful in the diagnosis and management of SSPE cases with elevated IgG titers for rubeola in CSF. The typical clinical findings must be familiar to every ophthalmologist so that diagnostic pitfalls can be prevented and early therapy started. It may be discussed if early diagnosis and therapy will be possible before neurological signs appear, the prognosis of this relentless disease may show a more favorable course.

Effect of alendronate treatment on the clinical picture and bone turnover markers in chronic idiopathic hyperphosphatasia

Chronic idiopathic hyperphosphatasia (CIH), also known as juvenile Paget's disease, is characterized by increased bone turnover, persistently elevated serum alkaline phosphatase concentrations and progressive bone deformities. The pathogenesis of the disease is unknown. Currently, there is no specific treatment and agents that reduce bone turnover have been tried in some cases with limited success. In this report, we present our experience with alendronate treatment in a 17 year-old boy with CIH. Ten weeks of treatment with alendronate resulted in marked clinical improvement and normalization of serum alkaline phosphatase activity. Serum osteocalcin and urinary deoxypyridinoline levels were decreased approximately 50% compared to pretreatment values, indicating decreased bone turnover rate. Alendronate seems to be a promising and safe agent for treatment of CIH.

Anthrax in adults and children: a review of 132 cases in Turkey

In this retrospective study, 132 cases of anthrax observed in a Turkish hospital over a 14-year period (October 1986 to October 2000) were evaluated with respect to clinical features, therapy, and outcome. The results show that anthrax is a disease of significance in the Eastern Anatolian region of Turkey. Preventive measures such as education of the population and vaccination of animals against anthrax would reduce the incidence of the disease.

Bone Turnover Markers in Patients with Type 2 Diabetes and Their Correlation with Glycosylated Haemoglobin Levels

The aim of this prospective, longitudinal study was to investigate, over a period of 12 months, the effects of metabolic control on bone turnover markers in patients with type 2 diabetes mellitus. The study included 17 male and 18 female patients with type 2 diabetes, aged 37 − 66 years. Mean follow-up period was 12 ± 1.2 months. Mean glycosylated haemoglobin (HbA1C) levels were 10.6% ± 1.6% at the start of the study and decreased to 7.7% ± 1.0% by the end of the study. Levels of the bone resorption markers, urinary deoxypyridinoline and N-telopeptide, were 28.6 ± 11.6 nmol/mmol creatinine and 93.6 ± 13.7 nmol bone collagen equivalents [BCE]/mmol creatinine, respectively, at the start of the study, and decreased significantly to 17.9 ± 7.1 nmol/mmol creatinine and 67.8 ± 12.8 nmol BCE/mmol creatinine, respectively, by the end of the study. Bone formation parameters also significantly decreased in parallel with HbA1c levels over the study period. It is concluded that effective management of metabolic disorder in patients with type 2 diabetes plays an important contribution to bone turnover improvement.

Effect of orlistat on the total ghrelin and leptin levels in obese patients

Obesity, characterized by hyperleptinemia and hypoghrelinemia, has become a major health problem all over the world and is associated with an increased risk of complications including insulin resistance, hypertension, dyslipidemia, diabetes mellitus and atherosclerosis. The use of the pancreatic lipase inhibitor Orlistat can help seriously overweight people to achieve and maintain weight loss. The aim of our study was to compare the serum leptin and ghrelin levels in obese subjects who take orlistat with those receiving only dietary treatment. Twenty-one obese patients and 10 control subjects participated. The obese patients were divided into two groups; one group (n=11) took orlistat (120 mg, 3 times daily) and received dietary treatment and the other (n=10) only received the dietary treatment. The study lasted twelve weeks. The concentrations of serum ghrelin, leptin, insulin and C-peptide, and routine biochemical parameters, were measured in both groups. The serum ghrelin level was higher in control (183+/-62 fmol/ml) than obese (59+/-30 fmol/ml) subjects while the plasma leptin level was lower in control (8.7+/-12 microg/L) than obese (36.7+/-19 microg/L) subjects (all p<0.001). BMI and the total blood cholesterol, LDL and triglyceride levels fell significantly after both orlistat and dietary treatment in the obese subjects (all p<0.01), and the plasma ghrelin level rose (p<0.01). The leptin level demonstrated the opposite trend in both groups but only the patients taking orlistat showed a significant change (p<0.05).Taken together, these results show that orlistat has no effect on body weight in obese subjects additional to that conferred by a non-pharmacological life-style intervention. We therefore conclude that weight lost rather than type of treatment might be more valuable in obesity.

P wave signal-averaged electrocardiogram as a new marker for atrial tachyarrhythmias in postoperative Fontan patients

OBJECTIVES

This study was undertaken to determine the potential role of P wave signal-averaged electrocardiogram (PSAECG) for risk assessment of atrial tachyarrhythmias (ATs) in patients after Fontan operation.

BACKGROUND

Onset of atrial flutter/fibrillation (AFF) in patients who have undergone Fontan operation for univentricular hearts constitutes an unfavorable clinical event associated with a high risk of cardiovascular complications. There is no data available on PSAECG in postoperative Fontan patients to predict potential susceptibility to ATs.

METHODS

Twenty-four post-Fontan patients and 15 age-matched healthy subjects were prospectively studied with PSAECG, and the following measurements were made: filtered P wave duration (FPWD), P wave vector integrals (PINTs), root-mean-square voltage for the initial 30 ms (RMSi30), and duration of persistent amplitude signals <4 microV from the beginning of the P wave (Di4).

RESULTS

The FPWDs were significantly longer in the study group patients with ATs when compared with the study group patients without ATs (p<0.01) and compared with the controls (p < 0.001). An FPWD cut point of 135 ms resulted in a sensitivity of 71% and a specificity of 81% in differentiating patients with ATs from patients without ATs among the postoperative Fontan patients. The PINT was significantly greater in Fontan patients with AFF and also without AFF when compared with controls (p<0.01, p<0.05, respectively). The RMSi30 and the Di4 were not significantly different between study and control groups.

CONCLUSIONS

Signal-averaged P wave duration is significantly prolonged in postoperative Fontan patients. A prolonged signal-averaged P wave duration may be an effective noninvasive marker to predict risk of development of ATs in this patient group.

Familial pericentric inversion chromosome 3 and R448C mutation of CYP11B1 gene in Turkish kindred with 11beta-hydroxylase deficiency

11beta-hydroxylase deficiency is the second most common cause of congenital adrenal hyperplasia (CAH). This isoenzyme is coded by two highly homologous genes of cytochrome P450: CYP11B1 and CYP11B2 which were mapped to the chromosomal band 8q24. The aim of this study was to perform a series of molecular and cytogenetic analyses in two families with 11beta-hydroxylase deficiency of the Turkish kindred. Mutational analysis was carried out by directly sequencing the PCR products of CYP11B1 gene. We performed fluorescence in situ hybridisation (FISH) experiments with consecutive bacterial artificial chromosome (BAC) clones to map the breakpoints of the inversion of chromosome 3 which was detected during the karyotypic analysis of the propositus. Homozygous R448C mutations were detected in 2 individuals with 11beta-hydroxylase deficiency. Interestingly, karyotypic change of pericentric inversion [inv(3)(p13q24)] was detected in both individuals who are cousins, one transmitted paternally and the other maternally. The breakpoint at 3p included one interesting gene PPP4R2. Here we present the data of two Turkish families' members having 11beta-hydroxylase deficiency coupled with the familial chromosomal aberration of inv(3)(p13q24). Our data suggest that codon 448, which is a mutational hot spot in CYP11B1 causing 11beta-hydroxylase deficiency, is not restricted to Jews of Moroccan origin. Phenotypic variations observed in former studies in patients homozygous for R448H were stated to be due to other factors outside the CYP11B1 locus. The breakpoint in 3p might be a candidate region affecting variations in phenotypes of 11beta-hydroxylase deficiency.

Early and late advanced atrioventricular block in acute inferior myocardial infarction

BACKGROUND

Advanced atrioventricular block is a frequent complication in patients with inferior acute myocardial infarction (AMI); in patients in hospital, it often occurs concurrently with other complications and is associated with high mortality. Very little information is available about early and late advanced atrioventricular block in inferior AMI. We hypothesized that the time of appearance of advanced atrioventricular block characterized by poor response to atropine requiring temporary pacemaker therapy may affect the prognosis of patients with inferior AMI.

METHODS

We studied 51 patients with inferior AMI and advanced atrioventricular block characterized by poor response to atropine requiring temporary pacemaker therapy. According to pre-established electrocardiographic criteria and the time of appearance of the advanced atrioventricular block, patients were divided into two groups: an early block group consisting of 30 patients who developed advanced atrioventricular block during the first 24 h of inferior AMI, and a late block group consisting of 21 patients who developed advanced atrioventricular block after the first 24 h of chest pain.

RESULTS

The groups were similar regarding age, coronary risk factors, frequency of right ventricular infarction, QRS score, atrial and ventricular rates, the time of return to first-degree atrioventricular block, cardiac arrhythmias, heart failure and mortality. The early advanced atrioventricular block group included a greater number of men than did the late group (P = 0.017).

CONCLUSION

These data suggest that the time of appearance of advanced atrioventricular block does not affect the prognosis of hospital patients with inferior AMI.

Coronary vessel diameters during and after primary percutaneous coronary artery intervention

BACKGROUND

Primary percutaneous coronary intervention (P-PCI) is the gold standard treatment for acute coronary syndromes. Plasma levels of catecholamines and other vasopressors are elevated during acute myocardial infarction (AMI) and coronary vasoconstriction is frequent. We aimed to compare the reference vessel diameter (RVD) of the infarct-related artery (IRA) during primary PCI and after an average of 3 days.

METHODS

Coronary angiography (CAG) was performed on 58 patients with acute ST-segment elevation myocardial infarction (STEMI) and TIMI 3 flow after P-PCI (43 men, 15 women; mean age, 55.5 ± 10 years). TIMI 3 flow was achieved either by simple balloon dilatation and/or thrombus aspiration. Lesion length, RVD, minimal lumen diameter (MLD), mean vessel diameter (meanD), and area of stenosis were compared during P-PCI and follow-up CAG.

RESULTS

RVD, MLD, and meanD values were significantly higher during the follow-up CAG than after P-PCI (RVD 2.7 ± 0.7 mm vs. 2.9 ± 0.7 mm, p = 0.001; MLD 1.5 ± 0.5 mm vs. 1.7 ± 0.4 mm, p = 0.002; meanD 2.2 ± 0.5 mm vs. 2.4 ± 0.5 mm, p = 0.001). Area of stenosis values were significantly lower during the follow-up CAG than after primary PCI (69.5 ± 16.5 % vs. 62.1 ± 15 %, p = 0.001). Lesion lengths were not statistically significant during the follow-up CAG and primary PCI (lesion length 24.0 ± 10.8 mm vs. 22.1 ± 8.8 mm, p > 0.05).

CONCLUSION

This study showed that RVD was higher at the follow-up CAG a few days after AMI in patients who had TIMI 3 flow after P-PCI with simple balloon dilatation and/or thrombus aspiration. A delay of a few days for stent implantation in P-PCI allows for larger-diameter stent use and may help to reduce stent thrombosis and restenosis rates.

Excessive growth in a girl with Weaver syndrome

A 24 month-old female with Weaver syndrome who has the most severe overgrowth among reported cases is presented. Prenatal history was remarkable for maternal hydantoin use throughout pregnancy. In addition to all major features of the syndrome, she displayed some novel features, including patent ductus arteriosus, atrial septal defect and diffuse thinning of the corpus callosum. Initially, carpal bone age was more advanced compared to phalangeal bone age, as expected in Weaver syndrome. However, phalangeal bone age caught up with carpal bone age during the follow-up period, suggesting that dysharmonic bone age advancement is an early feature of Weaver syndrome. The apparent male predominance in Weaver syndrome is generally ascribed to milder expression of the syndrome in females. The present patient, showing the most severe expression of the syndrome, refutes the notion that females with Weaver syndrome may have a milder form of the syndrome.

A patient with extra-adrenal retroperitoneal paraganglioma and review of the literature

Paragangliomas can arise from virtually any site in the body containing embryonic neural crest tissue. We present a female patient with an extra-adrenal retroperitoneal paraganglioma, and a review of the literature.

Trauma patients and whole-body computerized tomography imaging: Location of CT-Scan and factors affecting mortality

Objective

: We aimed to study the factors affecting the mortality of trauma patients who underwent whole-body computerized tomography (CT) on Emergency department (ED) time frames in a developing emergency care system. Materials and Methods: This is a retrospective analysis of adult patients who received WBCT from August to November for two consecutive years (2014 and 2015). Non-parametric statistical methods were used to compare the patients who died and survived. The Backward logistic regression model was used to define factors significantly affecting mortality.

Results

: During 2014, 200 patients out of 827 (24.1%) received WBCT. During 2015, 263 patients out of 951 (27.6%) received WBCT. Four hundred sixteen patients were entered into the analysis. The overall mortality was 3.4% (7% in 2014 and 1% in 2015, P = 0.002). Significant factors found in backward logistic regression model defining factors affecting mortality were ISS (p < 0.0001), Glasgow Coma Scale (GCS) (p = 0.001). CT location (outside the ED in 2014, inside the ED in 2015) showed a very strong trend for affecting mortality (p = 0.054). Patients who had WBCT in the ED had lower ISS (p < 0.0001). CT imaging in the ED decreased ED to CT time 15.5 minutes (p < 0.0001), but admission time was 75.5 minutes longer.

Conclusions

ISS and GCS were the main factors predicting mortality in patients who received WBCT. Patients received more WBCT imaging and physicians showed a tendency to order WBCT for less severe patients when the CT located in the ED. CT location did not show a significant effect on mortality, but on some operational time frames.

Application of an immunoglobulin Y-alkaline phosphatase bioconjugate as a diagnostic tool for influenza A virus

The diagnosis of influenza A virus is essential since it can be confused with influenza A like illness and lead to inaccurate drug prescription. In this study, the M2e peptide, a strategic antigen that is conserved in all virus subtypes, was used as a diagnostic marker of influenza A. For the first time, M2e-specific IgY antibody was covalently conjugated to alkaline phosphatase (ALP) enzyme in the presence of glutaraldehyde. The antibody-enzyme bioconjugate was characterized by fluorescence and Fourier-transform infrared spectroscopy. Subsequently, the diagnostic value of this bioconjugate was evaluated by direct sandwich ELISA using nasopharyngeal swab samples positive/negative for H1N1 and H3N2, which were previously analyzed by rRT-PCR for influenza. In conclusion, the M2e-specific IgY-ALP bioconjugate demonstrated positive results for Influenza A in samples that were diagnosed as Influenza A via the RT-PCR method.

DICER1 Hotspot Mutations in Pleuropulmonary Blastoma: A Case Series From a Tertiary Center

Pleuropulmonary blastoma (PPB) is a potentially aggressive, rare childhood neoplasia. We investigated histopathological features, survival, and DICER1 hotspot mutations among PPB patients. Archive records at our institution were reviewed, covering a 20-year period. Thirteen children (6 males and 7 females) with a mean age of 30.5 (range 6-83) months were included. The tumor subtypes were type I in 6 (46%), type II in 4 (31%), and type III in 3 (23%). Only tumors with type II and type III histology showed anaplasia (4/7, 57%). Median follow-up was 28 (range 9-216) months. Three-year overall survival rate was 83.3% and 3-year progression-free survival rate was 25%. Progression was seen in 60% (3/5) of type I and 66.7% (4/6) of type II and type III cases. Two patients died of disseminated disease at 9 and 44 months. Hotspot missense mutations on DICER1 gene were detected in all 11 patients with available tumor tissue. We found an additional novel germline loss-of-function mutation (c.5436dupT; p.E1813*) in 1 case. To the best of our knowledge, this is the first study to investigate hotspot missense mutations on DICER1 gene among the largest series of Turkish children with PPB.

Augmented Medial Rectus Recession with Non-Absorbable Suture Loops is Effective in the Treatment of Convergence Excess Esotropia

AIM

To evaluate the surgical outcomes of augmented medial rectus recession with non-absorbable 5.0 white braided polyester suture (Alcon Laboratories, Forth Worth, Texas, USA) loops in patients diagnosed with convergence excess esotropia. Methods: Clinical records of 21 patients with convergence excess esotropia who have been operated with symmetric medial rectus recessions augmented with non-absorbable suture loops were reviewed. Initial scleral bite was planned according to the distance deviation. Non-absorbable sutures tied leaving a loose loop which was 1 mm for a near-distance disparity of 10 PD, 1.5 mm for 15PD, and 2 mm for 20 PD. Postoperative changes in near-distance disparity were evaluated.

RESULTS

The mean preoperative near-distance disparity of 17,21 ± 1,68 standard mean of error (SE) prism diopters (PD) decreased to 3,15 ± 0,88 PD SE at 12 month postoperatively. Near-distance disparity of 10 PD or less was achieved in all patients after surgery at the sixth month, 1 patient showed 12 PD of disparity at the first-year control. No overcorrection has been noted.

CONCLUSION

Bilateral medial rectus muscle recession procedure augmented with polyester suture loops effectively decreases the disparity between near and distance deviations in patients with convergence excess esotropia. Because of our good results and an easy, noninvasive approach without any additional complications, we recommend this technique to treat convergence excess esotropia.

A comparison of travoprost, latanoprost, and the fixed combination of dorzolamide and timolol in patients with pseudoexfoliation glaucoma

PURPOSE

To compare the intraocular pressure (IOP) lowering effect and safety of latanoprost, travoprost given every evening, and the fixed combination dorzolamide + timolol (DTFC) given twice daily in pseudoexfoliation glaucoma (PXG).

METHODS

This randomized, prospective, investigator-masked study has been conducted with 50 PXG patients. Patients were assigned to one of three groups: travoprost 0.004%, fixed combination of dorzolamide 2%+timolol 0.5%, or latanoprost 0.005% for 6 months. At baseline and 0.5, 1, 2, 3, 4, 5, and 6 months of therapy, IOP (8 am, 10 am, 4 pm), blood pressures, and pulse rates were measured, and ophthalmologic examination was performed. The side effects were recorded at each visit.

RESULTS

Forty-two of the 50 patients initially enrolled completed this study. Withdrawn patients included one (latanoprost) for lack of efficacy, five (three travoprost, one latanoprost, one DTFC) for adverse events, and two (one latanoprost, one DTFC) for loss of follow-up. Each of the three drugs considerably reduced the IOP in PXG cases throughout the 6 months. Mean IOP reduction at 6 months was -9.3+/-2.9 mmHg in the travoprost group, -8.2+/-1.2 mmHg in the latanoprost group, and 11.5+/-3.3 mmHg in the DTFC group. Comparing the groups, DTFC is more effective than latanoprost and travoprost in lowering IOP (p<0.05). There was no difference between travoprost and latanoprost. The most common treatment-related adverse event was conjunctival hyperemia. Intensity of ocular hyperemia was greater in the travoprost group compared with the latanoprost and DTFC groups (p<0.05). There were no significant effects on systemic safety parameters.

CONCLUSIONS

The results demonstrated that DTFC is more effective in reducing IOP than latanoprost and travoprost. Latanoprost and travoprost had similar ocular hypotensive effects in patients with PXG. All three drugs were well tolerated; there were fewer ocular side effects attributable in the latanoprost group.