Clinical outcomes of conservative versus surgical treatment for patients with proximal humeral fracture before physiotherapy.

Fear of movement, pain, and loss of shoulder function are the most common problems irrespective of their approach to management after proximal humeral fracture (PHF). However, it has been unclear whether there could be differences between both treatments in early clinical outcomes. It can help physiotherapists to guide in choosing treatment approaches. This study aimed to compare kinesiophobia, pain, range of motion (ROM), shoulder function, and Quality of life (QoL) in patients treated with either conservative (CT) versus surgical (ST) after PHF. In addition, it aimed to determine correlations between fear of movement and seconder outcome measures. This cross-sectional study enrolled the patients having 5-6 weeks (being permitted active movement) after being treated either CT or ST and receiving no physical therapy. Pain, passive and active ROMs, shoulder function, fear of movement, and QoL were evaluated. 42 patients were recruited. Kinesiophobia scores were similar (p=0.55) and moderate in both groups. There was a significant difference in degrees of shoulder active flexion, active and passive abduction in favor of the CT group (p=0.05, p=0.02, p=0.04, respectively). However, there was no difference between groups regarding the remaining clinical outcomes. Furthermore, kinesiophobia showed a moderate negative correlation with energy/fatigue, social functioning, and general health. These findings showed that patients treated surgically did not have more kinesiophobia, less function, and QoL before starting physiotherapy, despite having soft tissue damage and different types of fractures. However, surgically treated patients had significantly less range of motion.

Comparative efficacy of medical treatment versus surgical sphincterotomy in the treatment of chronic anal fissure.

BACKGROUND: Anal fissure which is defined as a longitudinal tear in anoderm below the dentate line is one of the most common benign diseases of anorectal area. Severe pain during the defecation and emotional stress that it causes may reduce people's quality of life. AIMS: In this randomized clinical trial, we aimed to compare the efficiency of the topical ointment with medical treatment and surgical lateral internal sphincterotomy. METHOD: This is a randomized clinical trial of 550 patients who were treated for chronic anal fissure. Patients were randomly divided into 4 groups according to the treatment type they received. RESULTS: In a vast majority of the patients, the primary complaint was pain (92.3%) and bleeding during defecation (62%). Both pain relief and healing of the fissure, which are the components of response to treatment, had not been observed in 56 (37.3%) patients of topical nitroglycerin ointment group until the second month. Among the recalcitrant patients in both topical nitroglycerin (56) and topical diltiazem ointment (47) groups, 27 (48.2%), and 36 (76.5%) patients underwent surgery, respectively. The best response to treatment was also obtained in lateral internal sphincterotomy group. CONCLUSION: LIS is still the gold standard for the treatment of chronic anal fissure when the physicians would like to avoid recurrence and obtain the best pain relief.

Factors affecting recurrence and disease-free survival in granulosa cell tumors of the ovary.

PURPOSE OF INVESTIGATION: To determine risk factors for prognosis and recurrence in ovarian adult-type granulosa cell tumor (GCT). METHODS: A retrospective review of GCT cases treated at our university hospital between 1991-2006. RESULTS: Of 39 patients with GCT, 82% had Stage I disease. The median follow-up period was 71 months. There were 12 cases of recurrence (30.8%) and seven of them had died of disease. The pelvis and liver were the most common sites of recurrence (8 and 3 patients, respectively). Interestingly lymph node recurrence was encountered in two patients. Estimated disease-free survival for five years was 82%. Stage and presence of residual tumor were calculated to be the only associated risk factors for recurrence and prognosis (p < 0.05). CONCLUSION: Recurrences in GCT might be associated with stage and presence of residual tumor during primary surgery. Although rarely present during diagnosis, lymph node metastasis might be more common in recurrent disease.

Conservative treatment of an early ectopic pregnancy in a cesarean scar with systemic methotrexate--case report.

PURPOSE OF INVESTIGATION: Pregnancy implanted in a cesarean scar is rare, and is a life-threatening condition due to high risk of uterine rupture, hemorrhage, hysterectomy, and maternal mortality. CASE REPORT: We describe a 26-year-old woman who presented with five weeks of amenorrhea and a serum hCG level of 10,440 mIU/ml. Transvaginal sonography revealed a gestational sac of 15 x 11 mm containing a yolk sac located in a previous cesarean scar. She was successfully treated conservatively with multi-dose methotrexate. No side-effects were encountered. The serum hCG levels were undetectable in 58 days. The patient had normal menstrual cycles afterwards. CONCLUSIONS: In the view of increasing cesarean rates, healthcare professionals should be aware of the possibility of a scar pregnancy and the potentially life threatening sequelae. Early diagnosis by transvaginal sonography can improve outcome and minimize the need for emergent surgery. Conservative treatment with systemic methotrexate is an effective option in selected patients.

Hydatid cyst of the pancreas causing both acute pancreatitis and splenic vein thrombosis.

Hydatid cyst of the pancreas is a rarely seen entity even in endemic countries. Cyst may causes several symptoms due to external compression or fistulisation to pancreaticobiliary tract or small bowel. A 23-year-old female patient was referred with a complaint of abdominal pain. Preoperative imaging revealed an undefined cyst in the tail of pancreas. She underwent distal pancreatectomy and splenectomy, with a diagnosis of acute pancreatitis due to cystopancreatic duct fistula and also left-sided portal hypertension due to splenic vein thrombosis. Pathological examination reported a final diagnosis of hydatid cyst. To the best of our knowledge, coincidence of cystopancreatic duct fistula and splenic vein thrombosis due to pancreatic hydatid cyst has not previously been reported.

Hemorheological parameters as determinants of myocardial tissue hematocrit values.

It is well known that the hematocrit in microvessels with diameters smaller than 1000 microm is lower than either venous or arterial hematocrit, thereby resulting in significantly lower mean hematocrit values for vessels perfusing a given tissue (i.e., lower tissue hematocrit). The mechanisms that underlie this reduction of microvascular hematocrit include axial migration, plasma skimming and the Fahraeus Effect. It has been previously demonstrated in rats that a linear hematocrit gradient normally exists through the thickness of the left ventricular myocardium, and that this gradient is sensitive to alterations of the rheological properties of the circulating blood. The gradient is abolished if the RBC in the perfusate are rigid; fibrinogen infusions, and thus increases of both plasma viscosity and RBC aggregation, also affect this gradient. In a new series of studies, it has been observed that enhanced RBC aggregation affects the myocardial hematocrit gradient regardless of alterations of plasma viscosity. Although the exact mechanisms responsible for the myocardial hematocrit gradient, as well as its physiological significance, are not yet clearly known, it is possible to speculate that alterations in local hematocrit could adversely affect myocardial perfusion and function.

First report and spore ultrastructure of Vairimorpha plodiae (Opisthokonta: Microspora) from Plodia interpunctella (Lepidoptera: Pyralidae) in Turkey.

The present study describes the first isolation and characterization of Vairimorpha plodiae, a microsporidian pathogen of Plodia interpunctella (Lepidoptera: Pyralidae), from Turkey. We present characteristic light and electron microscopical features of the spores. Fresh binucleate spores are oval and measure 4.48 ± 0.23 (4.01-4.84) µm in length and 2.21 ± 0.15 (1.91-2.48) µm in width. Ultrastructural studies showed that the spore wall measures 150 to 200 nm and consists of a clear endospore (125-150 nm) and an electron-dense, uniform, thin exospore (30-50 nm). The polar filament is isofilar and with 10-12 coils. The well-developed polaroplast consists of two parts with thin lamellae anteriorly and thick, irregularly arranged lamellae posteriorly. The identity of our isolate is discussed.

The role of technetium-99m methoxyisobutyl isonitrile scintigraphy in suspected recurrent breast cancer.

The aim of this study was to determine the role of technetium-99m methoxyisobutyl isonitrile (99mTc-MIBI) scintigraphy in the evaluation of recurrence and metastases in breast cancer patients with mastectomy and/or radiotherapy. A prospective study was designed to assess the accuracy of 99mTc-MIBI scintigraphy in 36 patients (mean age 49 years) with suspected recurrent breast cancer. The scintigraphic studies were correlated with radiological findings and/or with histopathology. At 10-15 min after 740MBq 99mTc-MIBI injection, standard planar images were obtained in prone lateral and anterior supine views and then single-photon emission computed tomography (SPECT) imaging was performed. A whole body imaging was also performed to demonstrate distant metastatic lesions. Totally 52 lesions were evaluated which 19 of them in 9 patients were malignant, while 33 lesions in 27 patients were benign. The sensitivity was 33%, 88% and the specificity was 96%, 93% for planar and SPECT imaging, respectively in loco-regional lesions. Overall, the sensitivity and the specificity of MIBI imaging including whole body were 89%, 81%, in other conventional radiological imaging methods were 95%, 65%, respectively. 99mTc-MIBI scintigraphy using SPECT imaging may provide useful complementary information in patients with suspected recurrence breast cancer.

Effect of the size of regions of interest on the estimation of differential renal function in children with congenital hydronephrosis.

The estimation of differential renal function from dynamic renography affects clinical decisions. The estimation requires the kidneys to be delineated with regions of interest. However, in the presence of unilateral hydronephrosis it is not unusual for the affected kidney to be enlarged so that the regions of interest required to delineate the normal and abnormal kidneys are themselves dissimilar in size. The question, which then arises is, will this difference in the sizes of the regions of interest affect the resultant estimation of differential renal function? Eighteen children aged 1 month to 7 years, with prenatal ultrasound diagnosis of unilateral hydronephrosis where the affected kidney was larger than the normal kidney, underwent a total of 57 diuretic renograms using 99mTc-mercaptoacetyltriglycine. The renographic data were retrieved from optical disc and re-analysed. Regions of interest were generated which enclosed each kidney plus a region of interest of equal size to the abnormal large kidney was placed over the normal kidney. The consensus report from the Scientific Committee of Radionuclides in Nephrology described the Rutland-Patlak plot and integral methods for the estimation of differential renal function from dynamic renography. These two methods were used to analyse renal curves with and without background subtraction. Evaluation of the results suggest that technical factors, including the size of the region of interest, may affect differential renal function, and may, in part, explain the reports of the super-normal kidney in the literature.

The evaluation of sacroiliitis using 99mTc-nanocolloid and 99mTc-MDP scintigraphy.

The role of imaging studies in the evaluation of patients with sacroiliitis is controversial. We aimed to evaluate the role of nanocolloid and bone scintigraphy in patients with sacroiliitis and to investigate the clinical relevance of imaging findings. Thirty-two patients with clinically sacroiliac disease (nine females, 23 males, aged 22-47 years) underwent scintigraphic and radiographic examinations and all imaging studies were performed within 2 weeks. Twenty-five subjects were also included as a control group (10 females, 15 males, aged 20-51 years) for quantitative analysis of the bone scan. The quantitative analysis was done by using regions of interest drawn over the right and left sacroiliac (SI) joint and sacrum (S) and SI/S ratios were calculated. Abnormal uptake was defined as an uptake higher than the mean +/- 2 SD of the control SI/S values. Bone scintigraphy was performed using a three-phase technique and single photon emission computed tomography (SPECT). Nanocolloid scintigraphy (NS) was performed 1 h later, after administration of 370 MBq 99mTc-nanocolloid, and evaluated visually. Each of the scintigraphic examinations was performed on separate days within the same week. Sensitivity values were 25%, 47%, 69% and 97%, and specificity values were 80%, 90%, 95% and 90% in quantitative bone scanning (QBS), 99mTc-NS, planar and SPECT bone imaging, respectively, when the clinical findings were considered as the 'gold standard'. Our results showed that bone SPECT scanning was more sensitive than planar imaging, but planar imaging was the most specific method. SPECT was also the most associated technique with clinical findings. 99mTc-NS was neither specific nor sensitive enough in the detection of sacroiliitis although it could be helpful for the confirmation of inflammation.

Regional cerebral blood flow in schizophrenia before and after neuroleptic medication.

In order to investigate cerebral perfusion changes induced by neuroleptic drugs, we performed 99Tc(m) hexamethyl propyleneamine oxime (HMPAO) single-photon emission computed tomography (SPET). Fifteen patients (nine drug naive, six non-naive) diagnosed by using the DSM-III-R criteria, and 10 right-handed age and sex matched normal volunteers were included in this study. The SPET study was performed with 740 MBq 99Tc(m)-HMPAO by using a 128 x 128 matrix, 30 s/frame for a total 64 view over 360 degrees before and after 1 month of neuroleptic treatment. A semiquantitative method was used for the analysis. Patients were clinically assessed using the Brief Psychiatric Rating Scale (BPRS). There was no significant regional cerebral blood flow (rCBF) difference between the patient group and control group in whole-brain regions except in the left temporal lobe. Although clinical scores of the patients improved after neuroleptic treatment no statistically significant difference was found in the rCBF between pre- and post-treatment. Moreover, there was no statistically significant correlation between the rCBF and BPRS in any region. These results suggest that there was a discrepancy between the clinical situation and rCBF in schizophrenia and the lateralized temporal lobe blood flow, which may have important implications for the evaluation of patients with schizophrenia.

Correlation of thallium-201 uptake with proliferating cell nuclear antigen in brain tumours.

The aim of this study was to assess the correlation between thallium-201 (201Tl) uptake and proliferative activity measured using the proliferating cell nuclear antigen labelling index (PCNA-LI) in brain tumours. Twenty-nine patients with brain tumours were included in this study. Of these, seven were diagnosed with meningioma, 13 had high grade glioma (HGG) and nine had low grade glioma (LGG). A 210Tl single photon emission computed tomography study was performed on all patients before operation, and 201Tl uptake index (UI) and retention index (RI) values were calculated. Cell proliferation was determined by PCNA. While all of the HGGs and meningiomas showed intense 201Tl accumulation on visual interpretation, eight of the nine LGGs did not show accumulation of 210Tl at the tumour site. 201Tl UI values were 3.23+/-0.89 and 2.67+/-0.66 in HGG, 1.27+/-0.18 and 1.23+/-0.09 in LGG, and 4.35+/-1.60 and 2.52+/-0.78 in meningioma on early and delay images, respectively. There was a statistical difference between the 201Tl UI in HGG and LGG. PCNA-LI values were 16.72+/-6.15%, 1.63+/-0.81% and 2.00+/-1.88% in HGG, LGG and meningioma, respectively. The PCNA-LI in HGG was significantly higher than in LGG and meningioma. While the correlation coefficient between the 201Tl UI and the PCNA-LI was 0.94 in gliomas (n=22), there was no correlation in meningiomas. No statistically significant correlation was found between the RI and the PCNA-LI in gliomas. The presence of a strong positive correlation between 201Tl uptake and PCNA-LI indicates that 201Tl uptake can predict the proliferative activity of the glioma.

The value of 99mTc-DTPA renal scintigraphy in the evaluation of post-traumatic abdominal fluid collection.

A patient with a post-traumatic retroperitoneal urinoma is presented. On admission, there was a clinical suspicion of retroperitoneal hematoma and ultrasonography (US) was performed which showed a hypoechoic fluid collection suggesting retroperitoneal hematoma. In order to determine the nature of the fluid, radionuclide angiography and renal scan were performed successively with 99mTc-DTPA. Demonstration of urinary leakage into the mass in the delayed renal scintigraphic images suggested a urinoma. At laparotomy, total transection of the left ureter in the uretero-pelvic region was found and the diagnosis of urinoma was confirmed.

Scintigraphic diagnosis of intrathoracic extramedullary hematopoiesis in a patient with beta-thalassemia.

We report the scintigraphic diagnosis of intrathoracic extramedullary hematopoiesis (EMH) in a patient with beta-thalassemia. A patient had a mass in the right thoracic paravertebral region on radiography and CT. Bone marrow imaging of the thorax by means of both Tc-99m nanocolloid and phytate demonstrated uptake of the tracer in the mediastinal mass, establishing the diagnosis of EMH.

Quantitative sacroiliac joint scintigraphy in normal subjects and patients with sacroiliitis.

The aim of this study is to determine the sacroiliac index (SII) of healthy subjects and to compare these values with patients having sacroiliitis (SI). Quantitative sacroiliac scintigraphy (QSS) was performed with Tc-99m hydroxy methylene diphosphonate (HMDP) and whole sacroiliac joint-to-sacrum ratio was calculated as a SII by the region of interest (ROI) method. Forty-seven nonarthritic healthy subjects and 13 patients with SI were studied. Effects of aging, gender and laterality on SII were evaluated in 47 healthy subjects. The sacroiliac index was higher in men than women (p < 0.05). SII did not change significantly in aged men, but it decreased significantly in aged women (p < 0.05). Eleven of 13 patients with SI had a higher SII than healthy subjects (> mean + 2SD). In the other two cases by using small ROIs, SIIs were found to be higher than the normal range. Our results suggest that QSS is a sensitive method for the diagnosis of early stage SI and every institution should establish its own normal SII.

Comparison of Tc-99m HIG and Ga-67 citrate in the evaluation of bacterial abscess in a rat model.

Tc-99m labeled polyclonal human immunoglobulin (HIG) has been shown to be able to localize an inflammatory site. There are several possible explanations for HIG accumulation at focal infection sites such as increased vascular permeability, binding of the Fc part of Ig to Fc receptors of leucocytes and binding directly to bacteria. In this study, we compared Tc-99m HIG and Ga-67 citrate scintigraphy in localizing acute bacterial abscesses induced by E. coli and S. aureus. Serial scintigrams were performed at 1, 4, 24 hr after injection. Tc-99m HIG showed greater accumulation at all times with both infections agents than Ga-67 citrate (p < 0.05). While Tc-99m HIG showed greater accumulation in S. aureus than E. coli (p < 0.05), there was no statistically significant difference between E. coli and S. aureus (p > 0.05) by Ga-67 citrate. Our study suggests that Tc-99m HIG is a superior agent to Ga-67 and bacterial affinity can be a factor responsible for HIG accumulation at focal sites of inflammation.

The volume effect of the stomach on intestinal activity on same-day exercise--rest Tc-99m tetrofosmin myocardial imaging.

PURPOSE: The aim of this study was to investigate quantitatively the volume effect of the stomach on the prevention of intestinal artifacts in the rest phase on same-day exercise--rest Tc-99m tetrofosmin myocardial perfusion scintigraphy. MATERIALS AND METHODS: The study was performed in 81 consecutive patients (43 men, 38 women; mean age, 57 +/- 9 years) who were referred for routine Tc-99m tetrofosmin exercise--rest SPECT myocardial perfusion imaging with normal scintigrams or completely normal inferior wall perfusion on visual assessment of SPECT images. Group A (control group, n = 41) and group B (n = 40) were given 200 ml milk to enhance the hepatobiliary clearance of tetrofosmin 30 minutes before the exercise SPECT acquisition study and just after the injection for the rest SPECT acquisition study. For the rest SPECT acquisition study, patients in group B were given, in addition to milk, a standard solid and fluid meal to enhance the volume of the stomach after the injection of Tc-99m tetrofosmin. In all patients, both exercise and rest SPECT acquisitions were started 45 minutes after the injection of Tc-99m tetrofosmin. Myocardial and abdominal activity were assessed on three separate views in the rest phase of the study, and the mean myocardium-to-abdomen count ratios were calculated. In addition, the presence of interfering intestinal activity was assessed visually on SPECT images. Infracardiac activity was described as absent when it was equal to lung background. RESULTS: The myocardial-to-abdominal ratios were 1.38 +/- 0.05 and 1.95 +/- 0.04 in groups A and B, respectively (P < 0.0001). Interfering intestinal activity with varying degrees of intensity was seen in 20 patients in group A (49%) and in 5 patients in group B (13%; P < 0.001). CONCLUSIONS: These results suggest that filling of the stomach with some fluid and solid food before rest acquisition on the same-day stress--rest protocol, because of its volume effect, may provide a high target-to-nontarget ratio for myocardial imaging and thus may reduce the frequency of intestinal artifacts.