Autonomic and diastolic dysfunction association with quality of life impairment in cirrhotic patients

BACKGROUND AND STUDY AIMS

Cirrhosis is a multisystem disorder characterized by hyperdynamic circulation which can progress to multiple organ dysfunctions. Recent studies have demonstrated autonomic dysfunction and cirrhotic cardiomyopathy including diastolic dysfunction, systolic dysfunction with electrophysiologic abnormalities in patients with cirrhosis. Due to the long and complicated course of the disease, health related quality of life is affected. We aimed to evaluate the frequency of diastolic dysfunction and autonomic dysfunction in cirrhosis, and the effects on health-related quality of life.

PATIENTS AND METHODS

Hundred cirrhotic patients were enrolled in the study. According to the Child-Pugh classification 35 patients were of Child A, 36 of Child B and 29 of Child C. The proportion of autonomic dysfunction was 52%, and diastolic dysfunction 51%. Autonomic dysfunction was diagnosed using bedside maneuvers and tests; diastolic dysfunction was diagnosed using the E/A ratio in echocardiographic findings. Health-related quality of life measurements was obtained from an SF-36 questionnaire.

RESULTS

Patients with advanced Child-Pugh classifications were found to have significantly lower health-related quality of life values (p < 0.05). Likewise, health-related quality of life values were observed to be significantly lower in patients with autonomic dysfunction (p < 0.05). No significant difference was found in health related quality of life measurements between patients with and without diastolic dysfunction.

CONCLUSION

Our study showed that autonomic dysfunction and diastolic dysfunction are found in patients with cirrhosis. Further studies are needed to assess the effects of autonomic dysfunction and diastolic dysfunction on health-related quality of life.

Helicobacter pylori and mean platelet volume: a relation way before ımmune thrombocytopenia?

OBJECTIVE

Helicobacter pylori is associated with chronic immune thrombocytopenia. Eradication of H. pylori has been related with a platelet response and this treatment has been included within management strategies for a certain group of patients. However, in patients with normal platelet counts, the effects of H. pylori infection on platelet count and mean platelet volume as an important platelet index have not been investigated. In this study, we aimed to assess the relation between platelet indices and H. pylori infection in patients with dyspepsia who have otherwise normal platelet counts.

PATIENTS AND METHODS

In a retrospective manner, 4823 patients with dyspeptic complaints who have underwent an upper gastrointestinal endoscopy and a rapid urease test were included. Data of whole blood counts before the procedure were recorded from their files. Patients with normal endoscopic findings or simple gastritis were included. Patients with malignancy, GI bleeding, portal hypertension, liver or kidney disease and taking nonsteroidal anti-inflammatory drugs, proton pump inhibitors, cytotoxic medications were excluded.

RESULTS

Mean platelet count in H. pylori positive and negative patients were 246381± 92225/mm3 and 258135 ± 89912/mm3, respectively (p<0.001). Mean MPV was higher in H. pylori positive group (8.9± 1.3 vs. 8.23 ± 0.94, p<0.001). This difference was observed in both genders. MPV was observed to be higher than 10 fL in 20.5% of HP positive patients while in only 2.8% of H. pylori negative patients (p<0.0001).

CONCLUSIONS

In patients with H. pylori infection and normal platelet counts, it may be speculated that an ongoing and compensated platelet destruction-production process may be responsible for the increase in MPV. Likewise, in conditions exclusive for the host or the H. pylori strain, platelet destruction may be enhanced leading to immune thrombocytopenia. As our study is the first study to investigate the effect of H. pylori in patients with normal platelet counts, our findings may give way to further prospective researches.

An adult patient with common B-cell acute lymphoblastic leukaemia who presented with pancreatic involvement, description of the second adult case and review of paediatric cases

Pancreatic involvement in acute lymphoblastic leukaemia (ALL) may go unrecognised. There are only a few paediatric cases; nevertheless, presentation with pancreatic involvement in an adult patient with ALL has been reported rarely. Our 52-year-old male patient came to us with abdominal pain, nausea and vomiting; he had pancreatic enlargement on CT. He was diagnosed with common B-cell ALL with pancreatic involvement. The patient obtained haematological remission and the pancreatic enlargement regressed after chemotherapy, but later he had central nervous system and liver relapses. He died 6 months after diagnosis because of progressive pneumonia and chemotherapy-resistant ALL with multiple extramedullary relapses.

A new approach to gastrointestinal fistula closure: endoloop and clips technique using double endoscope

Several endoscopic techniques have been described for closure of gastrointestinal fistulas. Herein, we describe a case of iatrogenic gastric fistula successfully treated with a new approach by simultaneous insertion of two endoscopes and using the endoloop and endoclips technique.

The effects of sirolimus on target organs during mesenteric ischemia and reperfusion damage in an experimental rat model

BACKGROUND

Mesenteric ischemia and reperfusion (I/R) syndrome (MIRS) has been considered a clinicopathologic entity associated with a variety of clinically severe conditions with decreased intestinal blood flow and has been known to induce I/R damage in various organs. Sirolimus (SRL), a macrolide antibiotic isolated from a strain of Streptomyces hygroscopicus, is a potent and nonnephrotoxic immunosuppressant.

OBJECTIVE

This study was designed to investigate the potential impact of sirolimus on MIRS-induced I/R damage in renal, intestinal, pulmonary, and hepatic tissues in an experimental rat model.

METHODS

Twenty-four male Sprague-Dawley rats, aged 6 to 8 weeks and weighing 280 (±20 g), were studied. Using computer-generated random numbers, rats were assigned to 1 of the following 3 groups: group 1 (I/R group, n = 8), group 2 (I/R + sirolimus group, n = 8), and group 3 (control group, n = 8). Sirolimus, in a 1 mg/mL (60 mL) solution, was administered intraperitoneally in a dose of 1.5 mg/kg/d to the rats assigned to group 2 starting from 3 days before the surgical procedure. In surgery, a laparotomy was performed to clamp the superior mesenteric artery and, thus, induce bowel ischemia in groups 1 and 2. After 60 minutes of ischemia, the microvascular clamp on the superior mesenteric artery was removed for 3 hours of reperfusion. Soon after experimental induction of MIRS, bowel, lung, kidney, and liver specimens from each animal were harvested for both biochemical and histopathologic analysis.

RESULTS

There were statistically significant differences between groups 1 and 3 with regard to degrees of intestinal (P < 0.001), hepatic (P = 0.001), renal (P < 0.001), and pulmonary (P = 0.01) I/R damage. The lung specimens from group 2 had less inflammation and perivascular edema formation compared with specimens from group 1, but no statistical significance was observed between the groups (P < 0.33). There were statistically significant differences between groups 1 and 2 with regard to degrees of intestinal, hepatic, and renal I/R damage (P = 0.001 for all).

CONCLUSION

The findings of the present study demonstrate the attenuating effects of sirolimus on I/R damage in the intestine and remote organs, including the liver and kidney in the setting of MIRS in an experimental rat model. As a therapeutic implication, the utility of sirolimus may be of clinical value in procedures associated with a high likelihood of I/R damage, including major abdominal operations and renal transplantation. However, whether these results apply to humans is unclear. Additional experimental and clinical studies are warranted to confirm the clinical utility of sirolimus in conditions potentially associated with I/R damage.

Effects of methylene blue in reducing cholestatic oxidative stress and hepatic damage after bile-duct ligation in rats

The aim of this study was to evaluate the effects of methylene blue against cholestatic oxidative stress and liver damage after ligation of the common bile duct in male Wistar rats. Eight animals were included in each of the following five groups: untreated control, methylene blue control, sham-operated, bile-duct ligation, and bile-duct ligation plus methylene blue. Methylene blue was administered intraperitoneally for 14 days at a daily dose of 2mg/kg per day. All rats were sacrificed 2 weeks following the experimental treatment and the livers of all groups were examined biochemically and histopathologically. The severity of cholestasis and hepatic injury were determined by changes in the plasma, including enzymatic activities: aspartate aminotransferase, alanine aminotransferase, gamma glutamine transferase, and also bilirubin levels. Malondialdehyde, nitric oxide and superoxide dismutase were measured to indicate the oxidative status in the liver tissue. Myeloperoxidase activity and levels of tissue hydroxyproline were determined as measures of neutrophil activation and collagen accumulation, respectively. Liver damage was significantly prevented in the bile-duct ligated rats treated with methylene blue compared with the control bile-duct ligated rats without methylene blue. Treatment with methylene blue markedly reduced activities of serum transaminase, gamma glutamine transferase and bilirubin levels as compared to bile-duct ligated rats without methylene blue. Positive immunolabelling for alpha-smooth muscle actin (alpha-SMA) was increased, especially in vascular smooth muscle cells, fibrotic septa and also around the proliferated bile ducts, after bile-duct ligation. Only weak alpha-SMA immunolabelling was seen in livers of rats treated with methylene blue. These results indicate that methylene blue can attenuate hepatic damage in extrahepatic cholestasis by reducing oxidative stress and inflammatory processes.

Incidental pancreatic lipomas: computed tomography imaging findings with emphasis on diagnostic challenges

PURPOSE

The purpose of this study was to describe the computed tomography (CT) findings of pancreatic lipomas of 9 cases, with emphasis to diagnostic challenges.

METHODS

Between March 2006 and April 2008, 9 patients with pancreatic lipomas that were diagnosed by CT were reviewed in the present study. Clinical data and CT features of these 9 cases were retrospectively analysed. The patient population included 5 men and 4 women, aged 42-81 years (mean age, 65.8 years). The patients were followed up for at least 2 years with control CTs.

RESULTS

In all 9 cases, a well-bordered nodular fat density lesion was incidentally detected in the pancreas. Four of the lesions had a lobulated contour, and 2 of them had septations. Two of the lipomas were located in the head, 3 in the neck, 3 in the corpus, and 1 in the tail. The CT densitometric values were between -90 and -120 HU, with a mean value of -106 HU. No pancreatic or biliary dilatation or compression to the adjacent structures was seen. All the cases had control CTs, and the lipomas remained unchanged during the follow-up period. Histopathologic confirmation of the diagnosis was not planned for the cases.

CONCLUSION

Lipomas are rarely encountered in the pancreas. They often are diagnosed coincidentally as small, well-circumscribed, encapsulated, homogeneous, mature adipose masses on imaging studies. Imaging follow-up strategy or histopathologic confirmation is not necessary in asymptomatic patients.

Prevalence and MDCT characteristics of asymptomatic Bochdalek hernia in adult population

PURPOSE

To determine the frequency of asymptomatic incidental Bochdalek hernias in adults, using multidetector computed tomography (MDCT), and to ascertain any possible relationship between Bochdalek hernia and age, gender, or body mass index (BMI).

MATERIALS AND METHODS

Seven hundred and forty-eight abdominal, and 602 chest MDCT scans, which had been performed for a variety of reasons on 1350 adults, were investigated retrospectively. Location and size of Bochdalek hernias seen on these scans were correlated with age, gender, and BMI. On the basis of BMI, patients with Bochdalek hernia were classified as group A (BMI < 25) and group B (BMI > or =25).

RESULTS

A total of 171 Bochdalek hernias were identified in 142 of 1350 patients, ranging in age from 25 to 90 years (median age, 57.2), representing a prevalence of 10.5%. Sixty leftsided unilateral Bochdalek hernias (42.2%), 53 (37.4%) rightsided unilateral Bochdalek hernias, and 29 (20.4%) bilateral Bochdalek hernias were detected. Forty-five (31.6%) were categorized as small, 82 (57.8%) were medium-sized, and 15 (10.5%) were large. BMI was < 25 in 62 patients (43.7%), and > or =25 in 80 patients (56.3%). Fourteen patients (9.9%) were young adults, while 86 (60.6%) were middle aged, and 42 (29.6%) were elderly. No statistically significant relationship was found between dimensions or hernia locations and age, gender, or BMI of patients with Bochdalek hernia.

CONCLUSION

In view of the high prevalence of Bochdalek hernia in our study (10.5%), the multiplanar and reconstruction features of MDCT seem to facilitate the diagnosis of asymptomatic incidental Bochdalek hernia. No relationship was found between asymptomatic incidental Bochdalek hernia and age, gender, or BMI in adults.

Effects of sphingosylphosphorylcholine against cholestatic oxidative stress and liver damage in the common bile duct ligated rats

The goal of this study was to evaluate the possible protective effects of sphingosylphosphorylcholine (SPC) against cholestatic oxidative stress and liver damage in the common bile duct ligated rats. Fifty-six animals were included in each of the following 7 groups: control, SPC control, phosphate-buffered solution control, sham operated, bile duct ligation (BDL), BDL plus phosphate-buffered solution, and BDL plus SPC. Sphingosylphosphorylcholine was administered 14 days at a daily dose of 2 microm/mL intraperitoneally. The severity of cholestasis and hepatic injury was determined by changes in the plasma enzyme activities of aspartate aminotransferase, alanine aminotransferase, gama glutamin transferase, and levels of total bilirubin and direct bilirubin. Malondialdehyde, nitric oxide, and superoxide dismutase were determined to evaluate the oxidative status in the liver tissue. Myeloperoxidase activity and levels of tissue hydroxyproline were determined to assess neutrophil activation and collagen accumulation, respectively. Treatment with SPC markedly reduced serum transaminase activities as compared to BDL rats. Sphingosylphosphorylcholine also inhibited the increase in liver malondialdehyde; nitric oxide levels significantly and also attenuated the depletion of superoxide dismutase in the liver after BDL. Similarly, the increase in tissue myeloperoxidase activity and hydroxyproline owing to BDL was also attenuated by the SPC treatment. These data were supported by histopathologic findings. The alpha-smooth muscle actin-positive cells in the BDL were observed to be reduced with the SPC treatment. In conclusion, these findings suggested that SPC can attenuate hepatic damage in extrahepatic cholestasis by prevention of oxidative stress, and inflammatory process. All these findings suggest that SPC may be a promising new therapeutic agent for cholestatic liver injury.

A new imaging modality in detection of caustic oesophageal injury: Technetium-99m pyrophosphate scintigraphy

OBJECTIVES

Early oesophagoscopy is usually recommended in children after caustic ingestion to assess the severity of the initial digestive lesions. An oesophagoscopic procedure in children always demands to be performed under sedation and bears a certain risk of iatrogenic injury. The purpose of the study is to determine the value and sensitivity of Tc-99m pyrophosphate (99mTc-PYP) scintigraphy for the detection of caustic oesophageal injury.

METHODS

The caustic oesophageal burns were created with 25% NaOH in an experimental rat model. Seventeen rats were divided into two groups. The BURN group (n=9) included caustic oesophageal burning rats. Non-BURN group (n=8) included sham-operated rats. All animals underwent 99mTc-PYP scintigraphy 72 h after the burning experiment. Anterior static and single-photon emission computed tomography images were obtained using a low-energy all-purpose collimator, 2.55 zoom factor, 3h after intravenous injection of 10 mCi 99mTc-PYP. After the imaging, all the oesophagi were explored for external determination of the injury sites and macroautoradiographic scintigraphy as well. Rectangular region of interest were placed in the visually determined lesion of oesophagus (O) as well as non-lesion area (N), and an ON ratio was created. The severity and extension of oesophageal burn were assessed 3 days after burning by histopathologic evaluation. The injuries were graded according to the ulcer depth, ulcer width, thrombus formation, and the development of perivascular fibrinoid necrosis.

RESULTS

The oesophageal burning areas were demonstrated by visual evaluation of the Tc-99m PYP scintigraphy on all animals. The mean ON ratio of 99mTc-PYP was 21.61+/-7.01 in the BURN group and in the non-BURN group, was 2.25+/-0.24 (p<0.001). The best cut-off point of the ON ratio for caustic oesophageal injury was 5.45, with sensitivity and specificity of 100%. PYP scan findings were also confirmed by histological evidence of ulcer depth, ulcer width, thrombus formation, and perivascular fibrinoid necrosis in the same areas.

CONCLUSIONS

The caustic oesophageal injuries have been demonstrated by 99mTc-PYP scintigraphy in burning experiment. 99mTc-PYP scintigraphy is sensitive for detection of caustic oesophageal injury. This new imaging tool is found to be sensitive and specific for the detection of caustic oesophageal injury in the rats.

The relationship between virulence factors of Helicobacter pylori and severity of gastritis in infected patients

The outcome of Helicobacter pylori infection has been related to specific virulence-associated bacterial genotypes. The best known genotypic virulence factors of H. pylori are cytotoxin-associated gene A (cagA) and vacuolating cytotoxin gene A (vacA). The objective of this study was to assess the relationship between H. pylori cagA and vacA status and histopathological findings. Esophagogastrodoedonoscopy was performed in 80 dyspeptic patients. Antrum and corpus biopsies were obtained for isolation of H. pylori and for histopathological assessment. The polymerase chain reaction was used to detect cagA and vacA genes of H. pylori using specific primers. Biopsy samples were stained with hematoxylin and eosin, and histopathological findings were graded using the "updated Sydney system". H. pylori from 57 of the 80 patients was incubated. Of the 57 patients, 44 were cagA positive. In the corpus biopsy specimens there was a significant relationship between the density of H. pylori colonization (P = 0.02) and chronic inflammation (P = 0.02) and cagA-positive genotypes. In the antrum specimens there was a significant relationship between cagA positivity and neutrophil activity (P = 0.003) and glandular atrophy (P = 0.002), but not with H. pylori density, chronic inflammation, and intestinal metaplasia. The odds ratio of cagA-positive vs. cagA-negative strains for the presence of glandular atrophy, irrespective of grading and of gastric localization, was 4.62 (95% CI, 1.18-18.08, P = 0.041). No significant relationships were observed between vacA s1 and s2 genotypes and histopathological parameters. Corpus neutrophil infiltration was found to be more severe in the m1 group than in the m2 group (P = 0.004). Other histopathological features showed no difference between m1 and m2 genotypes. In conclusion H. pylori strains showing cagA positivity are associated with more severe gastritis in some histological features but virulence factors of H. pylori do not appear to determine the overall pattern of gastritis.

Patients with iron deficiency anemia have an increased prevalence of gallstones

We determined the frequency of gallstones (GS) in iron deficiency anemia (IDA) patients and evaluated factors that could affect GS formation-like lipid levels and gallbladder (GB) motilities of the patients. One hundred and eleven IDA patients (88 females, 23 males; median age, 42) and 81 healthy controls (68 females, 13 males; median age, 42) were included into our study. The clinical findings of all IDA patients were recorded down; biochemical values and body mass index (BMI) were determined; and abdominal ultrasonography was performed. In addition, GB emptying was monitored by ultrasound at 30-min intervals for 2 h after a mixed meal in randomly chosen, age-matched 25 IDA patients and 26 controls. Fasting volume (FV), residual volume (RV), and ejection fraction (EF) for all GBs were determined. The frequency of GS plus cholecystectomy was significantly higher in IDA patients (15 cases, 13.5%) than in the control group (five cases, 6.2%, p = 0.048). IDA patients with GS plus cholecystectomy were older than those without GS plus cholecystectomy (p < 0.001). FV and EF did not differ between IDA and control groups (p > 0.05). On the other hand, RV was significantly higher in IDA group than in controls (p = 0.035). The frequency of GS in IDA patients was significantly higher than in controls. The increased prevalence of GS in IDA might be explained with impaired GB motility.

Antioxidants vitamin E and C attenuate hepatic fibrosis in biliary-obstructed rats

AIM: To investigate whether antioxidants vitamin E and C can retard development of hepatic fibrosis in the biliary-obstructed rats.

METHODS: Fifty Wistar albino rats were randomly assigned to 5 groups (10 rats in each). Bile duct was ligated in 40 rats and they were treated as follows: group vitC, vitamin C 10 mg/kg sc daily; group vitE, vitamin E 15 mg/kg sc daily; group vitEC, both of the vitamins; bile duct-ligated (BDL, control) group, physiological saline sc. The fifth group was assigned to sham operation. At the end of fourth week, the rats were decapitated, and hepatic tissue biochemical collagen content and collagen surface area were measured. Hepatic tissue specimens were histopathologically evaluated according to Scheuer system. Serum hyaluronate levels were measured by ELISA method.

RESULTS: Despite being higher than sham group, hepatic collagen level was significantly decreased in each of the vitC, vitE and vitEC groups (32.7 ± 1.2, 33.8 ± 2.9, 36.7 ± 0.5 μg collagen/mg protein, respectively) compared to BDL (48.3 ± 0.6 mg collagen/g protein) (P < 0.001 for each vitamin group). Each isolated vitamin C, isolated vitamin E and combined vitamin E/C supplementation prevented the increase in hepatic collagen surface density (7.0% ± 1.1%, 6.2% ± 1.7%, 12.3% ± 2.0%, respectively) compared to BDL (17.4% ± 5.6%) (P < 0.05 for each). The same beneficial effect of vitamin C, vitamin E and combined vitamin E/C treatment was also observed on the decrease of serum hyaluronate levels compared to BDL group (P < 0.001). The relative liver and spleen weights, serum transaminases, cholestatic enzymes, bilirubins and histopathological inflammation scores were not different between the antioxidant treatment groups and the control. However, fibrosis staging scores were obviously reduced only in the vitamin E/C combination group (vit EC: 2.4 ± 0.8 vs BDL: 3.1 ± 0.7; P < 0.05).

CONCLUSION: Each antioxidant vitamin E, vitamin C and their combination retard hepatic fibrosis in biliary-obstructed rats. Oxidative stress may play a role in the pathogenesis of hepatic fibrosis in secondary biliary cirrhosis.

Increased circulating platelet-neutrophil, platelet-monocyte complexes, and platelet activation in patients with ulcerative colitis: a comparative study

It is reported that the incidence of thromboembolism is increased in ulcerative colitis (UC), and hypercoagulability persists even when patients are in remission. We evaluated the association of inflammatory response parameters with UC activity, and activation parameters of the platelets, endothelium, and the coagulation system in UC. Eighteen UC patients and 19 healthy subjects were included in the study. The patients' clinical features were recorded down; whole blood counts and acute phase parameters were evaluated. UC patients were divided into two as active (9 patients) and inactive (9 patients) according to combined clinical activity index (CAI) and endoscopic activity index (EAI) scores. In all subjects, platelet CD62P expression, platelet-monocyte complexes (PMC), platelet-neutrophil complexes (PNC), and platelet microparticles (PMP) were determined by flow cytometry. E-selectin, thrombin-antithrombin complex (TAT) levels in plasma, and sCD40L levels in serum were determined by ELISA. In both active and inactive UC patients, platelet CD62P expression, the percentages of PMC, and PNC were significantly higher than those in the control group (P< 0.01). PMP level was higher in the control group than in inactive UC patients (P = 0.001). sCD40L level was significantly higher in active UC group than in the control group (P < 0.01). EAI score correlated significantly with PMP (r = 0.5, P = 0.04) and sCD40L (r = 0.48, P = 0.044); CAI score had a negative correlation (r = -0.68, P = 0.002) with sE-selectin level. In addition to increased CD62P expression and sCD40L, increased formation of PMC and PNC suggests a role for platelet-leukocyte complex formation together with platelet activation in thromboembolic events observed in UC.

An increased frequency of gallbladder stones in rheumatoid arthritis patients. Factors related to gallbladder stone formation

OBJECTIVE

In this study, we determined the frequency of gallbladder stone (GBS) in rheumatoid arthritis (RA) patients and evaluated factors which could affect the formation of GBS--such as lipids and the GB motilities of the patients.

METHODS

One hundred and thirteen RA patients (92F, 21M, mean disease duration: 8.9 years) and 117 healthy controls (94F, 23M) were included. In all RA patients, the clinical findings were recorded down; biochemical parameters and body mass index (BMI) were determined; and, abdominal ultrasonography was performed. In addition, 16 RA patients and 20 controls who were age-matched were randomly chosen for GB emptying monitored by ultrasound at 30-minute intervals for 2 hours after a mixed meal. Fasting volume (FV), residual volume (RV) and ejection fraction (EF) for all GBs were assessed.

RESULTS

There was a tendency towards a higher frequency of GBS including cholecystectomy (11 GBS, 11 cholecystectomy, 19.5%) in RA patients when compared to controls (8 GBS, 5 cholecystectomy, 11.1%) (p = 0.08). The frequency of GBS plus cholecyctectomy in female RA patients (22.8%) was significantly higher than the control group (11.7%, p = 0.044). Logistic regression analysis showed that only older age was significantly associated with the presence of GBS in RA (OR:1.05, p = 0.048). There was no difference between the 2 groups in FV (p > 0.05). RV, PRV and EF were significantly higher in RA patients than in the control group (p < 0.05).

CONCLUSION

We diagnosed a higher frequency of GBS in female RA patients when compared to controls. Impaired GB motility in RA patients might contribute to an increased incidence of GBS development.

Successful treatment with adefovir of one patient whose cryoglobulinemic vasculitis relapsed under lamivudine therapy and who was diagnosed to have HBV virologic breakthrough with YMDD mutations

We report a patient whose cryoglobulinemic vasculitis recurred due to reactivation of lamivudine-resistant HBV. Our patient with hepatitis B-related cryoglobulinemic vasculitis was administered lamivudine. Her vasculitis regressed, ALT normalized, HBV-DNA became negative. Under lamivudine therapy, her cryoglobulinemic cutaneous vasculitis recurred. ALT increased significantly; it was found that tyrosine-methionine-aspartate-aspartate (YMDD) motif in the DNA polymerase gene had been replaced by YIDD. Adefovir was added to lamivudine. During follow-up, her purpura disappeared, ALT normalized, HBV-DNA became negative. Our patient is the first whose cryoglobulinemic vasculitis recurred under lamivudine, who had a HBV virologic breakthrough with YMDD mutation, and was successfully treated with adefovir.

Cerebral sinus thrombosis in patients with inflammatory bowel disease: A case report

Inflammatory bowel disease (IBD) is an idiopathic inflammatory disease of the gastrointestinal tract. The pathophysiology of IBD is probably the result of the complex interaction of genetic susceptibility and environmental influences. There is a well-known risk of thrombosis in patients with IBD. We present the case of a 53-year-old man with ulcerative colitis, who spontaneously developed intracranial sinus thrombosis that was treated with low molecular weight heparin. Literature was searched to assess the frequency and characteristics of cerebral sinus thrombosis in IBD and the role of certain etiopathological factors in such thrombotic patients.

Epidemiological features of ulcerative colitis in Trakya, Turkey

To determine the epidemiological features of ulcerative colitis in the Trakya region of Turkey, southeast Europe, we conducted a descriptive, cross-sectional, hospital-based study. All subjects were followed, and age, sex, place of residence, family history, educational status, tobacco consumption and use of oral contraceptives were recorded. The study included 49 cases of ulcerative colitis. The incidence of the disease was 0.59 per 100,000 in 1998, 0.89 per 100,000 in 1999, 0.89 per 100,000 in 2000 and 0.69 per 100,000 in 2001. The overall prevalence of the disease was 4.9 per 100,000; it was 2.18 per 100,000 in rural areas and 5.87 per 100,000 in urban areas. As in the Mediterranean countries, both the incidence and the prevalence of ulcerative colitis were found to be low. The incidence was significantly higher in urban areas than in rural areas.