Enhanced Recovery After Surgery (ERAS) Reduces Hospital Costs and Length of Hospital Stay in Radical Cystectomy: A Prospective Randomized Controlled Study.

Enhanced recovery after surgery (ERAS) protocols challenge the conventional and rigid methods of surgery and anesthesia and bring about novel changes that are quite drastic. The core principle of the protocol is to minimize the metabolic disturbance caused by surgical injury, facilitate the restoration of functions in a brief period, and promote the resumption of normal activity at the earliest. To compare the outcomes of ERAS and standard protocol for patients who have undergone radical cystectomy (RC) with ileal conduit urinary diversion. This prospective randomized controlled study was performed between 2015 and 2023. The 77 patients were divided into two groups ERAS (n=39) and Standard (n=38) by sequential randomization. These two groups are divided according to protocols of bowel preparation, anesthesia, and postoperative nutrition. The clinical and demographic characteristics of the patients, and the American Society of Anesthesiologists (ASA) and Eastern Cooperative Oncology Group (ECOG) scores were recorded. Perioperative findings, the degree of complications according to the Clavien-Dindo classification, and the total cost of treatment were recorded and analyzed. Length of hospital stay (18.82±9.25 day vs 27.34±15.05 day), and cost of treatment (2168,2±933$ 2879±1806$) were higher in the standard group. The rate of nausea and vomiting and the use of antiemetics were higher in the ERAS group compared to the standard group. In patients undergoing RC, the ERAS protocol was found to shorten the duration of hospitalization and reduce the total cost of hospital stay.

Predictive value of Prognostic Nutritional Index (PNI) for the severity of vasculogenic erectile dysfunction.

PURPOSE: Our aim was to investigate the association of prognostic nutritional index (PNI) score with erectile dysfunction (ED), therefore, we prospectively evaluated the relationship between penile doppler ultrasonography (PDU) findings, PNI and Sexual Health Inventory for Men (SHIM) scores in patients with ED. METHODS: A total of 414 patients' characteristics, laboratory findings, SHIM and PNI scores were recorded. The PNI is calculated using the formula: 10 × serum albumin + 0.005 × total lymphocyte count. PDU was performed in patients with a SHIM score of 17 and below, while patients with a SHIM score ≥ 18 were recruited for the control group. Correlation analysis was performed to evaluate the relationship between PNI, SHIM scores and PDU parameters. The predictive value of variables for severe ED was assessed with regression analysis. RESULTS: A significant difference was demonstrated between the ED subgroups and control group for total cholesterol (p = 0.04), serum albumin (p = 0.03), total lymphocyte count (p = 0.02), BDI score (p < 0.001), and PNI score (p = 0.03). A strong positive correlation between PNI score and PSV (rho = 0.73; p = 0.001), a moderate negative correlation between PNI score and EDV (rho = - 0.54; p = 0.02), and a moderate positive correlation between PNI and SHIM scores (rho = 0.61; p = 0.02) were demonstrated. PNI score ≤ 40 (OR: 3.49; p = 0.01), age (OR: 2.15; p = 0.03) and total cholesterol (OR: 2.03; p = 0.04) were determined as significant predictors of severe ED in multivariate analysis. CONCLUSION: Our results demonstrated that PNI score is significantly lower in patients with severe and moderate ED. It has been also revealed that the PNI score is an independent predictive factor for severe ED.

Predictive value of Controlling Nutritional Status score and Prognostic Nutritional Index for systemic inflammatory response syndrome/sepsis after percutaneous nephrolithotomy.

PURPOSE: Our aim was to investigate the predictive value of Controlling Nutritional Status (CONUT) score and Prognostic Nutritional Index (PNI) for systemic inflammatory response syndrome (SIRS)/sepsis after percutaneous nephrolithotomy (PNL). METHODS: Demographic and clinical data of 422 patients who underwent PNL were evaluated. The CONUT score was calculated from lymphocyte count, serum albumin, and cholesterol, while the PNI was calculated using lymphocyte count and serum albumin. Spearman's correlation coefficient was used to evaluate the relationship between nutritional scores and systemic inflammation markers. Logistic regression analysis was performed to determine the risk factors for SIRS/sepsis development after PNL. RESULTS: Patients with SIRS/sepsis had a significantly higher preoperative CONUT score and lower PNI compared with the SIRS/sepsis (-) group. A positive significant correlation between CONUT score and CRP (rho = 0.75), CONUT score and procalcitonin (rho = 0.36), and CONUT score and WBC (rho = 0.23) were determined. Additionally, a negative significant correlation was shown between PNI and procalcitonin (rho = - 0.30) and PNI and CRP (rho = - 0.64). The ROC curve analysis showed that the cut-off values for the CONUT score and PNI were 4 (AUC = 0.827) and 42 (AUC = 0.734), respectively. Age, stone size, history of pyelonephritis, residual stone, presence of infection stone, CONUT score ≥ 4, and PNI ≤ 42 were found to be independent predictors for postoperative SIRS/sepsis in multivariate analysis. CONCLUSION: Our results demonstrated that preoperative CONUT score and PNI are potential predictive factors for SIRS/sepsis development after PNL. Therefore, patients with CONUT score ≥ 4 and PNI ≤ 42 are suggested to be closely monitoring due to the risk of post-PNL SIRS/sepsis.

The use of natural killer cell activity and PPD test in the prediction of results in intravesical BCG treatment of patients with nonmuscle-invasive bladder cancer.

PURPOSE: To predict the efficacy of intravesical BCG therapy in patients with nonmuscle-invasive bladder tumors (NIBC) by using components of the cellular immune response such as the tuberculin skin test (PPD) and natural killer (NK) activity measurement. METHODS: Ninety-nine patients who were started on intravesical BCG therapy for NIBC were evaluated prospectively. Patients who were included in the intermediate, high, and very high-risk groups according to the EAU NMIBC Scoring System and who had never received intravesical BCG therapy previously were included. The clinical and demographic characteristics of the patients (age, gender, EAU NMBIC risk group, EORTC progression and recurrence scores, CUETO progression and recurrence scores, presence and types of comorbidity) were recorded. NK activity was measured and the PPD test was applied 3 days before the start of intravesical BCG therapy. The results of PPD were measured in millimeters 72 h after the test. RESULTS: PPD values measured before BCG treatment, as an independent variable, were found to be significantly lower in patients with recurrence. A significant correlation was detected between NK activity results obtained before BCG treatment and recurrence after treatment, when the cutoff was 200-500 pg/dl. There was no significant relationship between the time to recurrence and PPD and NKA measurements. CONCLUSION: We conclude that the results of PPD test and NK activity measurement performed before starting intravesical BCG therapy in NIBC may be a marker that can be used to predict the risk of recurrence under treatment.

Double-Edged Sword: A Case with Withdrawal-Emergent Dyskinesia. / Iki Ucu Keskin Biçak: Nöroleptik Kesilmesiyle Gelisen Diskinezi Olgusu.

Tardive dyskinesia is defined as involuntary athetoid or choreiform movements that develop due to the use of neuroleptic drugs for at least a few months. Tongue, lower face, jaw, upper and lower extremities are the most affected parts of the body in tardive dyskinesia. Quality of life is negatively affected because of the low remission rates. Besides tardive dyskinesia, involuntary movements may appear after discontinuation, change or a reduction in the dose of antipsychotic medications, which is called withdrawal-emergent dyskinesia (WED). Unlike tardive dyskinesia, the involuntary movements involve mainly the neck, trunk, and limbs and regress in shorter period of time in WED. A consensus has not yet been reached for the treatment of WED. Restarting the previous antipsychotic agent with slow titration or switching to an atypical antipsychotic with low affinity for dopamine D2 receptors are among the primary options for treatment. As WED is one of the predictors of tardive dyskinesia development, early detection and treatment is believed to have positive effect on the quality of life. In this report, the case of a patient followed up for bipolar disorder type I (BD-I) and started on clozapine for WED after discontinuation of haloperidol on account of adverse effects is discussed. It is necessary for clinicians to consider these types of complications when discontinuing or changing treatment. Further research is needed in order to reach a common approach for the treatment of WED.

Comparison of sleep structure in patients with fibromyalgia and healthy controls.

BACKGROUND: Sleep disturbances such as nonrestorative sleep and nighttime awakenings play a crucial role in fibromyalgia (FMS). Pain and sleep disturbances show a bidirectional relationship which affect outcomes in FMS. This study aims to compare sleep structures between patients with fibromyalgia and healthy controls. METHODS: We evaluated subjective and objective sleep structures of 33 patients with fibromyalgia and 34 healthy controls using the Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, and polysomnography. Student's T test, chi-square, discriminant analysis, the Kruskal-Wallis, and Mann-Whitney U test were used for statistical analysis. RESULTS: Patients with FMS reported poorer sleep quality than controls (p = 0.003). Polysomnography data showed patients with FMS exhibited a greater number of awakenings (p = 0.01), more arousals (p = 0.00), higher arousal index (p = 0.00), greater apnea hypopnea index (p = 0.03), and less N1 sleep (p = 0.02) than healthy controls. The discriminant analysis revealed that number of arousals, arousal index, and N1 sleep were able to distinguish patients with FMS from healthy controls with 78.5% accuracy. Twelve of the 33 patients with FMS were diagnosed with obstructive sleep apnea syndrome (OSAS). When we excluded patients with OSAS, a statistically significant difference was maintained. CONCLUSIONS: Our findings may explain the deterioration of subjective sleep, symptoms as unrefreshing sleep, fatigue, and pain in patients with FMS. Despite similar clinical manifestations, patients with FMS should be evaluated for OSAS due to treatment differences. The role of sleep alterations in the clinical manifestation and severity of FMS suggest that effective treatments to improve sleep quality may lead to more effective management of FMS.

Is obstructive sleep apnea syndrome related to nocturia?

OBJECTIVE: The aim of this study was to investigate the relationship between obstructive sleep apnea syndrome (OSAS) and lower urinary tract symptoms (LUTS) in patients with benign prostatic hyperplasia (BPH). METHODS: This multicenter study was performed on 122 male patients with dyspnea and/or sleep disorder. Patient characteristics were recorded. All patients underwent full-night polysomnography, and the apnea-hypopnea index (AHI) was calculated. LUTS were evaluated using the International Prostate Symptom Score (IPSS) and prostate volume was calculated by transabdominal ultrasonography. Based on the AHI, patients were classified as normal or as having mild, moderate, or severe OSAS. Regression analyses were performed to identify independent predictive factors associated with nocturia. RESULTS: Severe, moderate, and mild OSAS was present in 53, nine, and 46 patients, respectively, where 14 patients with dyspnea and sleep disorder were classified as normal. There were no significant differences between the severe and mild OSAS groups with regard to age, body mass index, systolic and diastolic blood pressure, smoking history, fluid intake, and serum creatinine and glucose concentrations. However, there was a significant difference between two groups in AHI (P < 0.001), nocturia (P < 0.001), and nocturnal voided volume (P = 0.011). Univariate and multivariate analyses revealed that age, smoking history, and an AHI >15 were independent predictors of nocturia. CONCLUSIONS: Sleep disorders are thought to be one reason for nocturia and nocturnal polyuria. Thus, OSAS must be considered in BPH patients who predominantly have storage symptoms.

Evaluation of ABO blood groups and blood-based biomarkers as a predictor of growth kinetics of renal angiomyolipoma.

PURPOSE: The aim of our study was to investigate the impact of the ABO blood groups and blood-based biomarkers on the growth kinetics of renal angiomyolipoma (AML). METHODS: A total of 124 patients with AML who were followed-up between 2010 and 2018 were retrospectively reviewed. The patients' characteristics were recorded, including age, body mass index (BMI), blood pressure, smoking history, and ABO blood group. Baseline laboratory test results, including serum creatinine, AST, ALT, platelet, neutrophil and lymphocyte count, were used to calculate the estimated glomerular filtration rate (eGFR), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and De Ritis ratio. The Cox regression analysis was used to evaluate the relationship between variables and tumor growth. RESULTS: The study population comprised 71 women and 44 men with a median age of 47.3 (28-65) years. Among patients classified according to the blood groups, no significant differences were observed regarding age, BMI, smoking history, co-morbidities, NLR, PLR, De Ritis ratio, eGFR, or tumor size and localisation. The mean growth rate from baseline to the last scan was 0.36 ± 0.27 cm, 0.21 ± 0.21 cm, 0.14 ± 0.11 cm, and 0.19 ± 0.17 cm for blood type O, A, B, and AB, respectively. In multivariate analysis, eGFR < 60 (p = 0.044), central tumor localisation (p = 0.030), presence of blood group-0 (p = 0.038), and De Ritis ratio ≥ 1.24 (p = 0.047) were statistically associated with tumor growth. CONCLUSION: Our study demonstrates that both the ABO blood groups and the De Ritis ratio might represent independent predictors of tumor growth rate in patients with renal AML.

Is the plasma endocan level a reliable predictor for the severity of erectile dysfunction?

PURPOSE: The aim of our study was to assess the correlation between serum endocan level and erectile dysfunction (ED). METHODS: A total of 92 patients were reviewed in this study after institutional review board approval. The patients' characteristics were recorded, including age, body mass index, blood pressure, smoking history, serum creatinine, glucose, lipid profile, total testosterone, and Beck Depression Inventory scores. ED was evaluated with the Sexual Health Inventory for Men (SHIM) questionnaire and classified as severe, moderate, or mild. Scores of > 18 indicate normal erectile function and were recruited for the control group. RESULTS: Sixty-three patients with a median age of 56 years in the ED group and 29 patients with a median age of 55 years in the control group were compared. ED was classified as severe in 20, moderate in 25, and mild in 18 patients. A significant difference was determined between the severe ED group and the control group for serum endocan levels (p < 0.001). A significant negative correlation between the SHIM score and endocan levels (rho - 0.65; p < 0.01), age and SHIM score (rho - 0.32; p = 0.04), BMI and SHIM score (rho - 0.25; p = 0.03), and BMI and total testosterone (rho - 0.16; p = 0.04) was determined upon Spearman's correlation analysis. A positive correlation was also determined between total testosterone and SHIM score (rho 0.50; p = 0.04). Patients' age (p = 0.037) and serum endocan level (p = 0.029) were determined as significant in the multivariate analysis. CONCLUSION: This study demonstrated the presence of an association between plasma endocan levels and ED. Endocan may be used as a new diagnostic marker for the severity of ED.

Association between apolipoprotein E genotypes and panic disorder in Turkish population.

AIM: In this study, we aimed to investigate possible interactions among the apolipoprotein E (ApoE) and panic disorder (PD), taking into account serum cholesterol levels and subfractions. METHODS: ApoE genotyping was performed by real-time polymerase chain reaction in DNA samples of PD patient group (n = 45) and healthy control group (n = 50). The serum lipid levels, low-density lipoprotein (LDL), and high-density lipoprotein (HDL) subfraction analysis were examined. RESULTS: There was a significant difference of ApoE genotypes in patient and control groups. The E3/E3 genotypes lower whereas E4 allele carriers were significantly higher in PD group ApoE4allele carriers had 3.2-fold higher risk of PD. PD group had significantly lower LDL and HDL levels. In spite of the decreased levels of total LDL, antiatherogenic large LDL subgroup was significantly lower in a patient with PD. Antiatherogenic large HDL and Intermediate HDL levels were lower, while atherogenic small HDL subfraction was significantly higher in PD group. Furthermore, Apo E3/E3 genotype carriers had significantly higher large LDL, HDL, large HDL, intermediate HDL level, and also had highest HDL between all the groups. ApoE4 allele carriers while they had highest atherogenic small HDL level. CONCLUSION: E4 allele can be associated with PD as an eligible risk factor, the E3/E3 could be a risk-reducing factor for PD. Patients with PD not only had lower LDL and HDL levels but also they have higher atherogenic LDL and HDL subfractions. Also, E3/E3 genotype carriers had convenient but ApoE4 carriers had atherogenic plasma cholesterol levels and subfractions.

Objective measures of sleep in fibromyalgia syndrome: Relationship to clinical, psychiatric, and immunological variables.

We aimed to investigate the changes in the objective and subjective sleep variables during painful episodes of fibromyalgia and post-episode period, and to evaluate the impact of the sleep variables on the current clinical, psychological, and immunologic parameters. Thirty-one consecutive patients who were referred to the Erenköy Physical Therapy and Rehabilitation Polyclinic with a diagnosis of fibromyalgia were evaluated before and in the sixth week of the acute pain treatment. The sleep variables were measured by polysomnography, Pittsburgh Sleep Quality Index, and Epworth Sleepiness Scale. The clinical and psychiatric assessment of patients was performed by using Fibromyalgia Impact Questionnaire; Patient Health Questionnaire-Somatic, Anxiety, and Depressive Symptoms; and Visual Analog Scale. Serum pro-inflammatory molecules were measured to evaluate the immunological status. The pain treatment significantly affected subjective sleep variables, psychiatric variables, clinical variables, and IL-6 levels. The subjective sleep parameters, clinical and psychiatric variables, and IL-6 levels were improved with pain treatment in fibromyalgia. The objective sleep variables, IL-1 and TNF-alpha levels were not significantly improved with the pain treatment, and they were not related to clinical presentation of patients with fibromyalgia. Subjective variability of sleep contributes to the clinical presentation, suggesting that the objective structure is trait-specific with IL-1 and TNF-alpha.

Paraoxonase1 192 (PON1 192) gene polymorphism and serum paraoxonase activity in panic disorder patients.

BACKGROUND/AIM: Reactive oxygen species (ROS) are involved in the development of certain neuropsychiatric disorders. Paraoxonase 1 (PON1) activity has been suggested to be adversely related to oxidative stress in plasma. The purpose of the present study was to demonstrate the relationship between serum PON1 activity and PON1 192 polymorphism in panic disorder (PD). MATERIALS AND METHODS: Fourty-two patients with PD and 46 healthy controls were included in this study. PON1 192 genotypes were determined by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis. PON1 activity was measured by spectrophotometric assay of p-nitrophenol production following the addition of paraoxon. RESULTS: PON1 192 AA genotype and A allele in PD were significantly higher than in the control group, whereas the B allele was found to be significantly higher in the control group. Patients with panic disorder have lower PON1 activity than the control group. CONCLUSION: The PON1 192 AA genotype may increase the risk of PD depending on lipid peroxidation.

Parkinsonism secondary to duloxetine use: a case report.

In literature, there are more than hundred cases of extrapyramidal symptoms (EPS) associated with selective serotonin reuptake intibitors (SSRI) whereas EPS case reports associated with serotonin noradrenaline reuptake inhibitors (SNRI) are in a relatively small number. A SNRI group drug duloxetine that is used for indication of major depression since 2004 is a double acting antidepressant that acts by blocking serotonin and noradrenaline reuptake. Side effects of duloxetine on extrapyramidal system are not expected due to low affinity to D2 receptors. In this case, report manifestations of parkinsonism developed in a patient who used duloxetine for major depression are presented. Since any duloxetine induced EPS case has not reported so far, we have thought that this case can contribute to the literature.

The relationship between ACE polymorphism and panic disorder.

BACKGROUND: The angiotensin converting enzyme (ACE) gene, which has been found to have an insertion and deletion polymorphism (I/D), is of increasing interest in etiology and treatment of various psychiatric disorders such as panic disorder. The present study aimed to investigate the relationship between ACE polymorphism and panic disorder. MATERIALS AND METHODS: In this study, 43 patients diagnosed with panic disorder at the Erenköy Mental and Neurological Diseases Training and Research Hospital, Istanbul and 41 healthy controls were enrolled. The ACE gene insertion/deletion polymorphism of exon 16 was evaluated using the polymerase chain reaction method. RESULTS: There was a significant association between I/D genotype and panic disorder (p=0.003). However, the frequency of the I allele was found to be significantly higher in patients compared to controls (p=0.002). In addition, we recognized a significant association between I/D polymorphism and respiratory-type panic disorder in patients. Carriers of the D allele also had an increased risk of respiratory type panic disorder patients (p=0.034). Moreover, the result of Spearman correlation analysis showed an association with ACE D allele and severity of panic disorder (p<0.001). CONCLUSION: We suggest that the I/D polymorphism of the ACE gene is associated with panic disorder and particularly respiratory-type panic disorder in patients. The I/D polymorphism of the ACE gene seems to influence therapeutic outcome in patients suffering from panic disorder. Our results indicate that ACE D allele is associated with the severity of panic disorder.