Surgical challenges in the treatment of perimenopausal and postmenopausal endometriosis.

Endometriosis is classically defined as a chronic, recurrent and progressive disease. It is known to be estrogen-dependent, but can still be observed during the peri- and postmenopausal periods. Medical management of endometriosis is palliative symptomatic relief. Surgery when properly and timely performed for the right person may treat endometriosis. However, there is always a risk of possible major or minor surgical complications, as well as loss of some functions due to nerve damage. Management of endometriosis in the woman approaching the end of her reproductive life may require special attention both due to the potential for recurrence and transformation into various endometriosis-associated malignancies.

Native tissue repair versus mesh repair in pelvic organ prolapse surgery.

In pelvic organ prolapse, the anatomical defects develop at the anterior (anterior vaginal wall), the posterior (posterior vaginal wall) and the apical (the uterus/cervix or the apex of the vagina, vaginal vault or cuff scar after hysterectomy) compartments. These defects occur in more than one compartment. Treatment of pelvic organ prolapse is commonly surgical, aiming to restore the anatomy of structures supporting the pelvic organs. The surgical repair techniques are classified as 'native tissue repair (NTR)' when only pelvic organ support tissues are used and 'augmented repair (AR)' when some other material (prosthesis or graft) is used to reinforce the defective support system. In this review, issues related to the basic science of meshes, and NTR versus mesh or graft AR procedures for pelvic organ prolapse are discussed while considering the varying risks and benefits according to the prolapsed compartment.

Open reduction in pilon variant posterior malleolar fractures: Radiological and clinical evaluation.

BACKGROUND: Pilon variant posterior malleolar (PVPM) fractures significantly disrupt joint congruency and cause tibiotalar instability. They are often underestimated and inadequately treated. PURPOSE: This study assessed the outcomes of surgical treatment of this subtype of malleolar fracture, and examined the importance of computed tomography (CT) in diagnosis and surgical treatment. MATERIAL AND METHODS: CT images and radiographs of 67 patients with trimalleolar ankle fractures were retrospectively analyzed. Fourteen patients (6 women and 8 men) were studied. The mean age was 37.7 (range, 21-58) years, and mean follow-up period was 17.1 (range, 12-24) months. All patients underwent open reduction. Reconstruction of the joint surface was assessed with postoperative CT images. The outcomes were assessed with the American Academy of Orthopaedic Surgeons (AAOS) and Osteoarthritis (OA) scoring systems. RESULTS: The ratio of PVPM fractures to trimalleolar ankle fractures was 20.1%. Postoperative CT images demonstrated that anatomic reconstruction was achieved in 11 patients. The mean AAOS scores were 85.6 in Type 1 and 81.1 in Type 2 cases. The mean OA scores were 1 in Type 1 and 1.1 in Type 2 cases (P>0.05). The only statistically significant difference between the 2 groups was in osteochondral impaction (P<0.05). CONCLUSION: CT imaging is essential for the accurate diagnosis and management of PVPM fractures. Posteromedial and posterolateral incisions enable direct exposure, and therefore facilitate joint surface reconstruction. LEVEL OF EVIDENCE: Level IV. Retrospective study.

Unilateral sacrospinous ligament fixation (USLF) with a mesh stabilizing anchor set: clinical outcome and impact on quality of life.

UNLABELLED: Genital prolapse is one of the most significant problems which lowers the quality of life measures of middle and older aged women. A continuously growing number of women are being operated due to this indication. OBJECTIVE: This study intends to asses the clinical outcome and the impact on quality of life of uterine sacrospinous ligament fixation (USLF) conducted with a mesh stabilizing anchor set in the present clinic following vaginal hysterectomy. MATERIALS AND METHODS: Twenty-one patients, diagnosed with genital prolapse and for whom vaginal hysterectomy and (USLF) with the Surelift nesh stabilizing anchor set were performed from April 2010 to June 2013, were assesed in this study. Posterior colporrhaphy was performed in all cases, as well. The cuff level was used to asses the anatomical recovery one year following the surgery. Postoperative relaxation of the vaginal cuff line below the hymenal level was defined as failure. Quality of life (P-QOL) questionarries validated for Turkish women were used preoperatively and on their first year to asses patient satisfaction. Clinical outcome and impact on quality of life were analyzed in all these cases by using t-test for paired samples. RESULTS: The mean age of the patients was 67.4 (min-max:43-84) years; mean parity 5.4 (min-max: 2-13). The mean operation time was 56 ± 12 minutes. The mean postoperative follow-up period was 21.4 months. Preoperative mild bleeding (two), postoperative severe pain (three), and micturition problems (one) were found. Therapeutic results and patint satisfaction were evaluated in the 12th month postoperavely: In 18/21 (85%) patients, the cuff was located above the hymenal ring. P-QOL scores validated for Turkish women were 52.5 ± 12.9 preoperatively and 11.08 ± 7.9 postoperatively (t-test for paired samples revealed a significant difference; (p = 0.04). CONCLUSION: The treatment of genital prolapse through the abdominal route includes the sacrocolpopexy operation with or without hysterectomy. This method, most of the time, requires a laparotomy if not performed by a specifically trained laparoscopist. It has a longer operation time and mesh erosions are feared complications compared to vaginal route. In sacrospinous fixation cases added to vaginal hysterectomy, operation times are shorter and especially preferable in patients where medical problems coexist. Operative success and patients' satisfaction seems to be provided by this technique.

Increasing mixed chimerism and the risk of graft loss in children undergoing allogeneic hematopoietic stem cell transplantation for non-malignant disorders.

We performed quantitative PCR-based serial chimerism testing of whole blood (WB) and CD3+ cells and retrospectively correlated the results of chimerism tests and the risk of graft loss in children undergoing transplant for non-malignant disorders. Twenty-four children were included in this study. All patients initially engrafted; subsequently, 12% lost the graft, 21% achieved complete donor chimerism and 67% had mixed chimerism (MC). Patients underwent delayed taper of cyclosporine (CsA) if they had MC. Overall survival was 87+/-7% (s.d.) at 5-years post transplant, and it was not affected by chimerism status. Both WB and CD3+ chimerism showed significant fluctuations with a peak in autologous cell signal occurring at a median of 7 months for WB and 2 months for CD3+ cells. Initial post transplant chimerism percentage in either WB or CD3+ lineage was not related to graft loss. Increasing MC to >30% host cells was seen in 33% of patients, and it was related to increased risk of graft loss, as previously published. However, 63% of children with increasing MC did not lose their graft. Additional studies of post transplant chimerism are required to improve our ability to accurately identify children at risk of graft loss following transplant for non-malignant disorders.

Laparoscopic resection or sonography-guided vaginal aspiration of endometriomas prior to ICSI-ET does not worsen treatment outcomes.

OBJECTIVE: To evaluate the effect of the management modality of ovarian endometriomas on ovarian response to COH (controlled ovarian hyperstimulation) and ART (assisted reproductive technology) treatment outcome. DESIGN: Retrospective case control study. SETTING: Ege University Infertility-Family Planning Research and Treatment Center. PATIENTS: 115 cycles of 84 patients who underwent ICSI-ET (intracytoplasmic sperm injection-embryo transfer) with ejaculated sperm were enrolled in the study. The endometrioma resection group (Group I) was comprised of 36 cycles in 29 patients who were treated with laparoscopic endometrioma cyst resection prior to treatment; endometrioma aspiration (Group II) was comprised of 26 cycles in 15 patients whose endometriomas were aspirated prior to treatment; and the control group (Group III) was comprised of 53 cycles in 40 patients for whom the only infertility cause was the tubal factor. INTERVENTIONS: ICSI-ET treatment, laparascopic ovarian endometrioma cyst resection, transvaginal ultrasonography-guided endometrioma cyst aspiration. MAIN OUTCOMES MEASURES: COH results and ICSI-ET treatment outcomes. RESULTS: The groups were similar in all characteristics except for the mean age of the patients in group II being older than those in group I. Gonadotropin consumption was higher, peak estradiol level lower, and the number of oocytes less in the laparascopic resection group (Group I) with respect to the control group. The number of follicles was lower in the cyst aspiration group (Group II) with respect to the control group. The number of follicles larger than 15 mm, number of metaphase II oocytes, the fertilization, pregnancy and implantation rates were similar in all three groups. CONCLUSION: Interventions (laparascopic endometrioma resection, transvaginal ultrasound-guided endometrioma cyst aspiration) performed on endometriomas prior to ART treatment do not worsen the treatment outcome.

Complete blood count parameters for healthy, small-for-gestational-age, full-term newborns.

No previous study has investigated the full range of complete blood count (CBC) parameters in small-for-gestational-age (SGA) newborns. The main aim of this study was to compare CBC and peripheral smear parameters in term, healthy SGA neonates and appropriate-for-gestational-age (AGA) neonates, and to establish CBC reference values for full-term SGA newborns. One hundred thirty-two healthy, term newborns (73 SGA and 59 AGA) were included. On day 1, we obtained 109 samples and on day 7 we obtained 77 samples. A CBC and peripheral smear were analyzed for each sample collected and group data were compared. We observed higher mean values for normoblast count, hemoglobin, hematocrit, and red blood cell (RBC) count in the SGA babies than in the AGA babies on day 1. The mean corpuscular hemoglobin and mean corpuscular hemoglobin concentration values for the SGA babies were decreased because of the relatively high RBC count and relatively high mean corpuscular volume we observed in this group. Of the SGA newborns, 21.9% had neutropenia and 4.7% had absolute neutrophil counts lower than 1500/microl on day 1. On both day 1 and day 7, the SGA newborns had higher mean absolute metamyelocyte counts and higher mean I : T (immature : total neutrophil ratio) values than the AGA group. The SGA babies had a lower mean absolute lymphocyte count on day 7 than the AGA group. We detected thrombocytopenia in almost one-third of the 64 SGA newborns tested on day 1. In summary, our study clearly demonstrates that CBC parameters for healthy, full-term, SGA newborns are different from those of healthy, term AGA newborns. This is the first study that has documented different mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, metamyelocyte counts, lymphocyte counts, and I : T in SGA babies compared with AGA babies.

Successful use of recombinant factor VIIa (NovoSeven) during cardiac surgery in a pediatric patient with Glanzmann thrombasthenia.

Glanzmann thrombasthenia is a rare, hereditary, congenital disorder of platelet function characterized by inappropriate bleeding that is difficult to control. Recombinant activated factor VII (rFVIIa) is a new treatment that is used to stop bleeding and provide surgical support for these patients. This report describes the use of rFVIIa to prevent serious bleeding during and after open-heart surgery in a child with Glanzmann thrombasthenia.

Primary hemophagocytic lymphohistiocytosis in Turkish children.

Nineteen children with hemophagocytic lymphohistiocytosis (HLH) were studied in the Department of Pediatric Hematology, Hacettepe University. Patients were divided into two groups. Group 1: Thirteen patients were classified as having a genetic etiology (7 familial, 6 presumed familial) on the basis of an affected sibling and consanguinity. There was a history of consanguineous marriage in 13 of the families. Seven of them had a history of a sibling with HLH. Group 2: Six patients were diagnosed with sporadic HLH. The age at presentation for familial patients was 0.7-84 months (mean 21.9 +/- 24.9 months), and for sporadic cases it was 2.5-48 months (mean 22.7 +/- 19.8 months). The clinical and laboratory data of these two groups were similar at diagnosis. Thirteen cases were diagnosed premortem by bone marrow aspiration. Splenic biopsy was performed in 2 patients. Four patients were diagnosed by postmortem examination. Elevated LDH levels were found in all patients tested. No significant differences for clinical and laboratory data were found between the two groups.

Benefit of high-dose methylprednisolone in comparison with conventional-dose prednisolone during remission induction therapy in childhood acute lymphoblastic leukemia for long-term follow-up.

Eight-year event-free survival (EFS) was evaluated in 205 patients with acute lymphoblastic leukemia (ALL), to consider the efficacy of high-dose methylprednisolone (HDMP) given during remission induction chemotherapy between 1 and 29 days. The St Jude Total XI Study protocol was used after some minor modifications in this trial. Patients were randomized into two groups. Group A (n = 108) received conventional dose (60 mg/m(2)/day orally) prednisolone and group B (n = 97) received HDMP (Prednol-L, 900-600 mg/m(2) orally) during remission induction chemotherapy. Complete remission was obtained in 95% of the 205 patients who were followed-up for 11 years; median follow-up was 72 months (range 60-129) and 8-year EFS rate was 60% overall (53% in group A, 66% in group B). The EFS rate of group B was significantly higher than of group A (P = 0.05). The 8-year EFS rate of groups A and B in the high-risk groups was 39% vs 63% (P = 0.002). When we compared 8-year EFS rate in groups A and B in the high-risk subgroup for both ages together /=10 years, it was 44% vs 74%, respectively. Among patients in the high-risk subgroup with a WBC count >/=50 x 10(9)/l, the 8-year EFS was 38% in group A vs58% in group B. During the 11-year follow-up period, a total of 64 relapses occurred in 205 patients. In group A relapses were higher (39%) than in group B (23%) (P = 0.05). These results suggest that HDMP during remission-induction chemotherapy improves the EFS rate significantly for high-risk patients in terms of the chances of cure.

Thrombosis in children with cardiac pathology: frequency of factor V Leiden and prothrombin G20210A mutations.

This study analyzed 28 thrombotic children with various cardiac disorders. They comprise 17% of a total of 168 patients with thrombosis from a single center. Among the 28 patients, 21 had congenital heart disease and 7 were diagnosed with cardiomyopathy. The patients with thrombosis were evaluated for congenital and acquired thrombotic risk factors. In addition to cardiac disorders, two, three, or more risk factors were present in 61% of the children with thrombosis. Two common mutations, namely factor V Leiden and prothrombin G20210A mutations, were found in 6 patients (22%). Nine patients (32%) died of infection, congenital heart disease, cardiomyopathy, thrombosis, operation, or a combination of these; two patients required surgical intervention. Following cardiac angiography, due to necrosis, amputation of the right index finger and right lower extremity was performed on 1 patient. The second patient's index fingers had to be amputated and resection of the bowel was performed following the operation on coarctation of the aorta. This study indicates that congenital heart disease and cardiomyopathy are two common cardiac disorders that may lead to the development of thrombosis. The majority of thrombosis develops within the heart and/or its great vessels. The second predominant site for thromboembolic symptoms is in the brain, including sinovenous thrombosis.

The effects of high dose methylprednisolone on apoptosis in children with acute lymphoblastic leukemia.

Rapid leukemic cell kill at initial diagnosis of patients with acute lymphoblastic leukemia (ALL) has been shown to be associated with a favorable outcome. The aim of the present study was to investigate the effect of high dose methylprednisolone (HDMP) on in vivo blast cell apoptosis in children with ALL. Annexin V-binding and Fas (CD95), Fas ligand (FasL; CD95L), and Bcl-2 expression in PB blasts were determined in newly diagnosed children with ALL before and 4, 24, 96 h after initiation of HDMP treatment (n=20) or conventional dose steroids (CDS) (n=10) as the control group. A decrease in absolute blast count (from 40.8 x 09 to 21.4 x 109/l) associated with an increase in apoptosis (14.2 to 26.9%) (P < 0.05) was detected 4 h after initiation of HDMP. A significant increase in Fas and FasL expression was detected 96 h after HDMP. There was no significant change in apoptosis, Fas and FasL expression from baseline in the control group treated with CDS. The changes in Bcl-2 expression after treatment was not significant in both groups. The results of this preliminary study have shown that HDMP treatment was effective in inducing immediate (within 4 h) blast cell apoptosis. The contribution of Fas/FasL interaction in the rapid component of cell kill remains to be determined, as the increase in the expression of these molecules was evident later.

Behçet's disease with severe arterial involvement in a child.

Behçet's disease is a vasculitis characterised by its thrombotic tendency. In some patients, manifestations of vascular lesions may dominate the clinical picture instead of the classic triad. We describe a 13-year-old boy with a 1.5-year history of Behçet's disease presenting with complaints of acute abdominal pain, severe headache and decreased vision. His work-up revealed a saccular aneurysm of the distal abdominal aorta, thrombosis in the right common iliac, external iliac and femoral arteries, and thrombosis of the superior sagittal sinus. Aortoiliac bypass with a Dacron graft was performed with success. He also received cyclosporin A and anticoagulant therapy. Severe vasculitis may become overt at any age in patients with Behçet's disease. Early diagnosis and management is important to prevent morbidity and mortality.