The impact of expectant management, systemic methotrexate and surgery on subsequent pregnancy outcomes in tubal ectopic pregnancy

BACKGROUND

The most common treatment modalities of ectopic pregnancy may influence long-term subsequent fertility outcomes in women who previously treated for ectopic pregnancy.

AIMS

Our objective was to compare long-term subsequent fertility outcomes after treatment with expectant management, systemic methotrexate (MTX) and surgery in tubal ectopic pregnancy.

METHODS

We searched our database for all women diagnosed with tubal ectopic pregnancy between January 2007 and January 2011 who were managed expectantly, with systemic MTX and with surgery. Treatment success and spontaneous pregnancy rates were compared in patients who desire to conceive following a tubal pregnancy.

RESULTS

One hundred twelve of 151 women desired to conceive following tubal ectopic pregnancy. Twenty-seven of 112 (24.1 %) patients were managed expectantly. Fifty-three (47.3 %) and 32 (28.5 %) patients were managed with systemic MTX or surgery, respectively. All patients in expectant and surgery groups were managed successfully. Two (3.7 %) patients had surgery after failed treatment with systemic MTX. Spontaneous intrauterine pregnancy rates were 62.9 % in expectantly managed women, 58.4 % in women with systemic MTX and 68.7 % in women with surgery (p > 0.05).

CONCLUSIONS

Treatment of ectopic pregnancy with either expectant management or systemic MTX is equally effective as compared to surgery. Spontaneous intrauterine pregnancy rates were comparable in expectant management, systemic methotrexate and surgery.

In vitro biomechanical comparison of six different fixation methods following 5-mm sagittal split advancement osteotomies

The sagittal split ramus osteotomy (SSRO) is a surgical technique used widely to treat many congenital and acquired mandibular discrepancies. Stabilization of the osteotomy site and the potential for skeletal relapse after the procedure are still major problems. The aim of this study was to compare the mechanical stability of six methods of rigid fixation in SSRO using a biomechanical test model. Sixty polyurethane replicas of human hemimandibles were divided into six groups. In group I, the osteotomies were fixed with two four-hole titanium miniplates; in group II, with one four-hole miniplate; in group III, with one four-hole miniplate+a bicortical screw; in group IV, with a grid miniplate; in group V, with a four-hole locking miniplate; and in group VI, with a six-hole miniplate. A linear load in the premolar region was applied to the hemimandibles. The resistance forces (N) needed to displace the distal segment by 1, 3, and 5mm were recorded and the data transmitted from the load cell to a computer. One-way analysis of variance with Tukey's post hoc test was performed to compare the means between groups. For the three displacement conditions, there was a strong tendency for the 2.0-mm plate+screw and the grid plate to have higher values.

ADMA, proteinuria, and insulin resistance in non-diabetic stage I chronic kidney disease

The rationale of this study is based on the fact that, both proteinuria and elevated asymmetric dimethyl arginine (ADMA) levels have been linked to the progression of vascular disease. Currently, there is not enough knowledge about any association between the levels of proteinuria and ADMA levels. Seventy-eight non-diabetic patients (42 men, 36 women, mean age of 26.1+/-5.2 years) with proteinuria having normal glomerular filtration rate were enrolled along with 38 healthy subjects (20 men, 18 women, mean age of 26.9+/-5.9 years). Proteinuria was below 3.5 g/day in 40 patients and above 3.5 g/day in 38 patients. Both groups had similar age, gender, and body mass index distributions. Serum ADMA, symmetric dimethyl arginine (SDMA), immunoreactive insulin, and high sensitivity C reactive protein (hsCRP) levels were measured. Insulin resistance was determined by homeostasis model assessment (HOMA). Serum ADMA, SDMA, insulin, hsCRP levels, and HOMA indexes were significantly higher in patients than in healthy control subjects. The above parameters were higher in the nephrotic range proteinuria group when compared to patients having protein levels below 3.5 g/day. There were significant correlations between the levels of proteinuria and the above parameters. According to the regression analysis, levels of proteinuria and hsCRP were significant determinants of serum ADMA levels. Our results indicate that, independent of other risk factors, ADMA is directly associated with proteinuria. Further studies are recommended to find out whether elevated ADMA levels are implicated in the high cardiovascular risk of proteinuric nephropathies.

Persistent Mediastinal and Axillary Lymph Node Tuberculosis in a Renal Transplant Patient With Successful Outcome

Tuberculosis is an opportunistic infection that carries substantial morbidity and mortality in renal transplant recipients. We report here about a 21 year-old man with a living related renal transplant from his mother who developed persistent extra-pulmonary tuberculosis. The disease showed aggressive invasion to the axillary and mediastinal regions with abscess formations, despite standard antituberculosis treatment. During the course of the disease, immunosuppressive therapy was stopped, and the patient received extraordinary doses of multiple antituberculosis drugs. The patient then showed an uneventful course with good clinical and radiological responses.

Adiponectin level is reduced and inversely correlated with the degree of proteinuria in type 2 diabetic patients

AIMS

Adiponectin seems to be an important modulator for metabolic and vascular diseases. We aimed to measure plasma adiponectin levels in type 2 diabetic patients and investigate any association with the severity of proteinuria.

METHODS

80 patients (mean age, 46.9 +/- 5.1 years; body mass index (BMI), 25.8 +/- 1.98 kg/m2) and 47 healthy volunteers (mean age, 46.1 +/- 5.5 years; BMI 26.74 +/- 2.23 kg/m2) were included. Plasma adiponectin concentration, insulin levels, homeostasis model assessment (HOMA) indices, calculated glomerular filtration rate (GFR), high sensitive C reactive protein (hsCRP) and biochemistry panel were determined in all subjects. The association between adiponectin concentration and proteinuria was evaluated. Additionally, the relationship between adiponectin and hsCRP and calculated GFR were also investigated.

RESULTS

Adiponectin levels in patients were significantly lower than those of controls (n = 80; 8.76 +/- 4.50 microg/ml for patients, n = 47; 24.27 +/- 5.59 microg/ml for controls, p < 0.001). Plasma adiponectin levels in patients with proteinuria were significantly lower than those without proteinuria (n = 43; 6.81 +/- 2.82 microg/ml for proteinuria, n = 37; 11.98 +/- 3.32 microg/ml for no proteinuria, p < 0.001). There was a significant negative correlation between plasma adiponectin concentrations and the degree of proteinuria (r = -0.433, p < 0.001). There were also significant negative correlations between adiponectin concentrations and insulin levels as well as HOMA index in the patient group (r = -0.322, p = 0.004; r = -0.301, p = 0.032). Additionally there was a significant negative correlation between adiponectin and hsCRP levels in the patient group (r = -0.872, p < 0.001).

CONCLUSION

The results show that adiponectin is lower in patients with type 2 diabetes and the levels are negatively correlated with the severity of proteinuria.

The midnight-to-morning urinary cortisol increment method is not reliable for the assessment of hypothalamic-pituitary-adrenal insufficiency in patients with end-stage kidney disease

A previous study reported that the midnight-to-morning urinary cortisol increment method could be used to reliably assess the insufficiency of the hypothalamic-pituitary-adrenal (HPA) axis. The principal aim of the present study is to verify whether the midnight-to-morning urinary cortisol increment is a reliable method for the assessment of the HPA axis in patients with various degrees of impaired kidney function. Fifty-six clinically stable patients with chronic kidney disease (CKD) and 14 healthy subjects were enrolled in the present study. Patients with CKD were divided on the basis of glomerular filtration rate (GFR) into the following arbitrary groups: mild (GFR: 60-89 ml/min/1.73 m2, no.=15), moderate (GFR: 30-59 ml/min/1.73 m2, no.=12) and severe kidney insufficiency (GFR: 15-29 ml/min/1.73 m2, no.=13), and hemodialysis patients. Plasma cortisol and ACTH levels were measured. The HPA axis was assessed by short Synacthen test and overnight dexamethasone suppression test. Double voided urine samples were collected at midnight and waking in the patients and the controls. Urinary free cortisol (UFC) and creatinine levels were measured and the UFC/creatinine ratio (Cort/Cr) was calculated. Then, the Cort/Cr increment was calculated as the morning Cort/Cr minus the midnight Cort/Cr. Baseline plasma cortisol levels were not significantly different between two groups. However, we found that CKD patients had significantly greater plasma ACTH levels than controls. The patients with CKD had also significantly lower morning UFC levels than controls and there was a progressive fall in morning UFC levels with decreasing GFR. The assessment of the HPA axis in patients with GFR lower than 29 ml/min was hampered by falsely abnormal responses to the midnight-to-morning urinary cortisol increment method. Plasma cortisol responded normally to exogenously administered ACTH, while plasma cortisol was suppressed by overnight dexamethasone administration in all patients with CKD. In conclusion, this method is not a reliable test for assessment of the HPA insufficiency in patients with GFR lower than 29 ml/min.

Infectious complications in 135 Turkish renal transplant patients

Infections are the emerging causes of mortality and morbidity due to lifelong immunosuppressive therapy in renal transplant patients (1, 4). Here, we report infectious complications of 135 renal allograft recipients who were followed up in the last 20 years in Gülhane Military Medical Academy, Ankara, Turkey. Of them, 83 (61.4%) had a transplant from living related donors, 18 (13.3%) from living non-related HLA matched donors and 34 (25.1%) from cadaveric matched donors. Immunosuppression was achieved in 42 (31.1%) recipients by azathioprine plus corticosteroid (AZA + CS) and in 93 (68.8%) by AZA + CS + cyclosporin A (CsA). Encountered infections were classified according to three different periods of the transplantation procedure [early (first month), intermediate (2-6th months) and late (after the 6th month)]. Bacterial infections were the leading infections in all three periods and the most affected system was the urinary tract. Each recipient had at least one episode of urinary tract infection (UTI) and E. coli was the most common urinary pathogen. On the other hand, HCV was the leading viral pathogen (14.3%). The total mortality rate was 7.4%, and septic shock was the most common cause of death (80%).

Observations on edema formation and resolution in Gleich syndrome: essential role of the kidneys in effective arterial blood volume regulation

Gleich syndrome is clinically present with episodes of angioedema, hypereosinophilia, oliguria, and weight gain due to fluid retention which may be sudden and remarkable, sometimes increasing to 10-20% of the baseline weight. The purpose of this study was to evaluate body fluid regulation and hormonal responses during the episode of angioedema and during the recovery phase in a patient with Gleich syndrome. A 24-year-old male was referred to our hospital for further evaluation of recurrent attacks of swellings of face, upper arms, and legs, marked weight gain, and oliguria. On first admission, the patient was in a remission phase, and the initial physical examination showed no abnormalities. Underlying disorders causing edema, such as heart, kidney, and liver diseases, and the recognized causes for hypereosinophilia, such as allergy, parasites, and collagen diseases, were ruled out. After 2 months, since his course was monitored, the patient was hospitalized. During days 10-19, he developed pronounced nonpitting edema of face, upper arms, and legs. Constant leukocytosis and hypereosinophilia, oliguria, and marked weight gain were also noted. A clinical remission was observed without any medication: intensive diuresis, loss of weight, regression of edema, and decreased eosinophil and leukocyte counts within 2 weeks. Physiological mechanisms during edema and resolution are discussed. In conclusion, our patient represents a suitable model for the protection of effective arterial blood volume because of the absence of underlying disorders causing edema. The kidneys play an essential role in the effective arterial blood volume regulation.

Seroconversion rates of two different doses of hepatitis B vaccine in Turkish haemodialysis patients

Seroconversion rates of hepatitis B vaccination with increasing antigen doses, in 77 haemodialysis (HD) patients were studied in randomly divided two groups. The first group received the standard 20 microg recombinant HBsAg (rHBsAg) dose, and the second group 40 microg at the 0, 1st and 2nd months of HD. At the end of the study, there were no statistically significant differences between the two groups in the response rates of protective antibody, but the response was always higher in the second group. On the other hand, strong positive antibody response (> or = 100 mlU/ml) according to dates of each dose were as 7.4%, 13.1%, 28.9% and 42.2% in the first group and 50.0%, 50.0%, 60.0% and 52.9% in the second group respectively, and there were statistically significant differences between the two groups in the first three months. We concluded that vaccination with higher antigen doses resulted in a stronger antibody response in the early period in our HD patients. No HBV infection was observed in these two groups in the study period.

Recovery cycle of the blink reflex and exteroceptive suppression of temporalis muscle activity in migraine and tension-type headache

Brain stem interneuronal excitability can be assessed by recording the recovery cycle of the blink reflex and exteroceptive suppression of temporalis muscle activity. Abnormal endogenous pain control mechanisms due to disturbed brain stem interneuronal activity have been implicated in the pathogenesis of tension-type headaches. The blink reflex, exteroceptive suppression of temporalis muscle activity, and the recovery curve of both the R2 component of the blink reflex and the ES2 component of the exteroceptive suppression of the temporalis muscle activity were studied in 20 patients with migraine without aura, 32 patients with tension-type headache, and 20 normal controls. In our study, the blink reflex was elicited by stimulation of the supraorbital nerve; the exteroceptive suppression of the temporalis muscle activity was elicited by applying electrical shocks to the labial commissure, both on the lower and upper sides. The recovery cycle was established by delivering paired shocks at different interstimulus intervals. Comparisons were made between normal control subjects, patients with migraine without aura, and patients with tension-type headache. The latency of R1, R2, and R2', the amplitude and size of the R2 and R2' components of the blink reflex, the latency and duration of the ES1 and ES2 components, and the recovery curve of the ES2 component of the temporalis muscle activity did not differ between groups. However, the recovery curve of the R2 component of the blink reflex diminished in patients with tension-type headache compared with the other groups. Our findings indicate reduced excitability of the brain stem interneurons in patients with tension-type headache.

Detection of source of haematuria after extracorporeal shock wave lithotripsy (ESWL) by automated measurement of urinary red cell volume

Midstream urine samples taken from 35 patients with secondary haematuria due to nephrolithiasis and 31 patients with haematuria after ESWL were compared using a red cell analyser (RCA) to differentiate the source of haematuria. Urine samples obtained from both groups were examined by RCA for urinary red cell mean corpuscular volume (UMCV) and urinary red cell volume distribution curves (RCVDC). To rule out the influence of blood MCV (BMCV), BMCVs were determined separately and the ratio of UMCV/BMCV (R) was calculated. Although our findings showed no difference between haematurias after ESWL and nephrolithiasis, we cannot exclude a direct effect of shock waves on renal tissue.

Effect of chronic cadmium exposure on VEP and EEG spectral components

Pregnant swiss albino rats were divided to three groups as control (C), cadmium (Cd) and non-cadmium (NCd) groups. Control animals were received tap water while the rats of Cd group were received Cd as CdC12 in their drinking water during the experimental period. On the other hand, the NCd group was given Cd during pregnancy, but given tap water after birth. Twenty-two days after birth, fourteen rats (for each group) were taken from their mothers and continued to be treated with Cd (Cd group) or tap water (C and NCd groups) for an additional 38 days. After the experimental period, flash VEPs and EEGs of three groups were recorded and amplitude spectral analysis was computed by Transient Response-Frequency characteristics (TRFC) method. The mean amplitude (dB) of 1-3.5 and 14-20 Hz frequency bands for right response whereas 1-3.5, 4-7, 8-13 and 14-20 Hz frequency bands for left response of VEPs were decreased in Cd group compared with control group. On the other hand, significant differences were observed between Cd and control groups in all the frequency bands of EEGs except 6-8 Hz.

Cadmium induced alterations in somatosensory evoked potentials

Pregnant Swiss albino rats were divided into three groups: control (C), cadmium (Cd) and non-cadmium (NCd) groups. Control animals received tap water; the Cd rats received Cd as CdCl2 in their drinking water during the experimental period, while the NCd group was given Cd during pregnancy, and given tap water after birth. Twenty-two days after birth, 15 rats (for each group) were taken from their mothers and continued to be treated with Cd (Cd group) or tap water (C and NCd groups) for an additional 38 days. After the treatment period, somatosensory evoked potentials (SEPs) of the three groups were recorded from central (Cz) referenced to frontal (Fz) following left posterior tibial nerve (PTN) stimulation. Amplitude spectra of SEPs were computed by fast Fourier transform (FFT) algorithm. There was a significant amplitude decrease in 1-3.5 Hz in the NCd group and 1-3.5 and 14-20 Hz frequency bands of the Cd group compared with the control group.

The effect of aging on spectral parameters of event-related potentials

Forty-two healthy subjects ranging in age from 20 to 73 were divided into three groups according to age; a young group (20-33 years), a middle-aged group (34-49 years) and older group (50-73 years). Event-related potentials (ERPs) of three groups were recorded in two different experimental conditions that the infrequent stimulus was counted (Test 1) or uncounted (Test 2). ERPs were elicited using infrequent and frequent stimuli as red and green lights respectively. Spectral analysis of ERPs showed that decibel (dB) values of 1-2 and 3-4 Hz in young and middle-aged groups while dB value of 1-2 Hz in older group were significantly decreased in Test 2 compared with Test 1. When the number of subjects displaying amplitude maximum in each frequency band was considered, significant differences were found in 1-2 and 5-7 Hz frequency bands of young and middle-aged groups, but no significant differences were found for older group.

ERP spectral analysis of cholesterol rich patients

Visual event-related potentials (ERPs) were studied in twenty hypercholesterolemic (HC) patients and twenty age-matched healthy controls. ERPs were recorded in two different experimental conditions that the target stimulus (red light) was counted (Test 1) or uncounted (Test 2). Amplitude spectra of ERPs were computed by transient response-frequency characteristics (TRFC) method. Their maxima were found to occupy the frequency bands of 1-2, 3-4, 5-7, 8-12, 13-20, 20.5-32 Hz. The amplitude mean (decibel) of 1-2 and 3-4 frequency bands were decreased in Test 2 compared to Test 1 in the control group, but no significant amplitude differences were found between Test 1 and Test 2 in the HC group.

Spectral analysis of event related potentials

Event-related brain potentials (ERPs) of twenty normal subjects with no sign of neurologic diseases were measured by applying nontarget and target stimuli as green and red lights respectively. ERPs were recorded in two experimental conditions that the target stimulus was counted (Test 1) or uncounted (Test 2). The spectral analysis of ERPs recorded for Test 1 and Test 2 were computed by using the Transient Responses Frequency Characteristics (TRFC) method. Amplitude maxima were observed in the frequency bands as indicated: 1-2, 3-4, 5-6, 7-8, 8-12, 13-20, 20.5-36, 36 Hz and higher. When we compared Test 2 with the results of Test 1, we observed a significant decrease in the amplitude mean (decibel) of 1-2 Hz frequency band (p < .05). Repeated measures ANOVAs also showed that dB values of 1-2 Hz between counted and uncounted stimuli were significantly different (p < .04). When the number of subjects displaying amplitude maximum in each frequency band was considered, we have found important differences in 1-2, 3-4 Hz and 5-6 Hz bands.