Sit or Squat? Toilet Type Is a Determinant of Diverticulosis Development.

BACKGROUND/AIMS:  Diverticulosis coli is a common disorder of the colon, and a luminal pressure increase in the colon is a proposed mechanism in disease pathogenesis. Toilet types used around the world can be fundamentally categorized into 2 categories: sitting toilets and squatting toilets. Squatting toilets are shown to lead to better puborectalis muscle relaxation, wider anorectal angle, and require less straining compared to sitting toilets. Stemming from this knowledge, we hypothesized that toilet type would play a role in the complex pathogenesis of diverticulosis and that squatting toilets would lower the risk of diverticula formation. MATERIALS AND METHODS:  This study was conducted at Antalya Training and Research Hospital between January 2023 and July 2023. A 1-page questionnaire consisting of demographic data and bowel habits as well as diverticulosis-related parameters was prepared to gather the study data. Colonoscopy results were matched with corresponding questionnaires. RESULTS:  The study population consisted of 929 patients. Advanced age was found to be a risk factor for diverticulosis. Sitting toilet was also found to be a risk factor for diverticulosis in multivariate logistic regression analysis with an odds ratio of 3.36 (95% CI: 1.684-6.705) (P = .001). CONCLUSION:  The results of this study revealed that toilet type is a determining factor in diverticulosis development, as was hypothesized during the conceptualization of the study. Revealing the potential contribution of the toilet type used to the development of a relatively common and impactful disorder like diverticulosis will lay the bedrock for future studies on the topic.

Effect of serum vitamin D levels on the severity of acute pancreatitis: A prospective study.

Acute pancreatitis (AP) is a serious and complex disorder with varying disease course and severity. Early and prompt interventions are crucial in management of AP. Vitamin D, being a prominent actor in calcium metabolism, also takes part in immunity and thus in immune-system related disorders, ranging from infections to cancer. In this study, the role of vitamin D status of a patient on the severity of AP was investigated. This study was conducted between June 2021 to August 2022 with a total of 315 patients. Blood samples were obtained upon admission. A 25-(OH)D3 level less than 10 ng/ml was defined as vitamin D deficiency. 10-19 ng/ml was defined as vitamin D insufficiency whereas 20 ng/ml or above was considered to be sufficient. Scoring systems (Ranson score, CTSI, BISAP, Revised Atlanta Classification (RAC) were applied. Serum 25-(OH)D3 levels of patients with AP were found to be negatively correlated with severity of the disease according to RAC (p < 0.001). In concordance to this finding, both Ranson score and BISAP were found to be statistically significantly related to 25-(OH)D3 levels. Both scoring systems revealed higher scores in patients with insufficient or deficient levels of 25-(OH)D3. Serum 25-(OH)D3 levels were not found to be related to intensive care unit admission or mortality. This study revealed that serum 25-(OH)D3 level is related to the severity of AP. In the future, interventional studies with vitamin D therapy in otherwise serum 25-(OH)D3 deficient AP patients might reveal a new potential therapeutic agent in this mechanically complex, burdensome disorder.

Role of Pernicious Anemia in Patients Admitted to Internal Medicine with Vitamin B12 Deficiency and Oral Replacement Therapy as a Treatment Option.

BACKGROUND: To determine the role of vitamin B12 deficiency in pernicious anemia and the efficacy of oral vitamin B12 replacement therapy given regardless of the etiology, and to compare the endoscopic and pathological findings in patients diagnosed with vitamin B12 deficiency. METHODS: The study included 216 patients, aged 18 - 65 years, diagnosed with vitamin B12 level < 200 pg/mL between May 2015 and May 2016. Evaluation was made of the demographic characteristics of the patients, diseases, drugs used, dietary habits, previous use of vitamin B12 replacement therapy, family history of vitamin B12 deficiency, laboratory test values, and neurological symptoms present at the time of presentation. Endoscopy was applied to all the patients included in the study. Anti-parietal cell antibody (APCA) and anti-intrinsic factor antibody (AIFA) analyses were applied to all patients. RESULTS: Evaluation was made of a total of 216 patients diagnosed with vitamin B12 deficiency, comprising 145 (67.1%) females and 71 (32.9%) males. The mean vitamin B12 level of the patients was determined as 127 pg/mL at the time of presentation and 334 pg/mL after treatment. APCA positivity was determined in 40 (18.5%) patients, and AIFA positivity in 5 (2.3%) patients. Atrophy was determined endoscopically in 53 (24.5%) patients and pathologically in 90 (41.7%). Helicobacter pylori positivity was determined in 196 (90.7%) patients. A diagnosis of pernicious anemia (PA) was made in 4 (1.9%) patients (patients with AIFA positivity or APCA accompanied by corpus atrophy). APCA positivity was determined but not corpus atrophy in 36 (16.7%) patients and these cases were accepted as suspected pernicious anemia. In this study of 216 patients with vitamin B12 deficiency, stomach pathologies which could cause vitamin B12 deficiency (atrophic gastritis, HP, PA) and the responses to oral replacement therapy were investigated. As vitamin B12 absorption plays a role in the pathogenesis. Vitamin B12 deficiency can lead to atrophic gastritis, and this was determined with biopsy in 41.7% of the patients. APCA positivity was determined in 18.5% of the patients investigated with respect to autoimmune atrophic gastritis (pernicious anemia) and AIFA positivity in 2.3%. A diagnosis of PA was made in 4 (1.9%) patients from autoimmune marker positivity and the presence of corpus atrophic gastritis. HP was determined in 90.7% of the patients with vitamin B12 deficiency, and although no correlation was determined between HP and atrophy, HP positivity was determined in 84 (93.3%) of the patients with pathological atrophy. From the time of diagnosis, the patients in the study were prescribed 1,000 µg/day vitamin B12. At the 40-day follow-up examination, a significant increase was observed in the vitamin B12 levels of 92.5% of the patients. At the end of the study, as oral replacement therapy was seen to be effective to a great extent, even in patients with PA, it was concluded that for patients not responding to oral replacement therapy, it would be appropriate to apply parenteral vitamin B12 treatment. CONCLUSIONS: In developing countries such as Turkey, the role of HP infection in vitamin B12 deficiency must be kept in mind. The incidence of atrophic gastritis and pernicious anemia is higher than expected in vitamin B12 deficiency. Thus, it can be concluded that it is appropriate to investigate patients with vitamin B12 deficiency with respect to atrophic gastritis and PA, and oral replacement therapy should be the first stage in the treatment of vitamin B12 deficiency.

Assessment of Aortic Elasticity in Patients with Celiac Disease.

BACKGROUND AND OBJECTIVES: Celiac disease (CD) is a chronic autoimmune disorder induced by dietary gluten intake by individuals who are genetically sensitive. Many studies report an increased risk of cardiovascular diseases in such patients. The aim of this study is to assess aortic elasticity properties in patients with CD that may be associated with an increased risk of cardiovascular disease. SUBJECTS AND METHODS: Eighty-one patients diagnosed with CD by antibody test and biopsy and 63 healthy volunteers were included in this prospective study. Electrocardiographic and echocardiographic examinations were performed. RESULTS: The CD group did not have any differences in the conventional echocardiographic parameters compared to the healthy individuals. However, patients in the CD group had an increased aortic stiffness beta index (4.3±2.3 vs. 3.6±1.6, p=0.010), increased pressure strain elastic modulus (33.6±17.0 kPa vs. 28.5±16.7 kPa, p=0.037), decreased aortic distensibility (7.0±3.0×10(-6) cm(2)/dyn vs. 8.2±3.6×10(-6) cm(2)/dyn, p=0.037), and similar aortic strain (17.9±7.7 vs. 16.0±5.5, p=0.070) compared to the control group. Patients with CD were found to have an elevated neutrophil/lymphocyte ratio compared to the control group (2.54±0.63 vs. 2.24±0.63, p=0.012). However, gluten-free diet and neutrophil/lymphocyte ratio were not found to be associated with aortic elasticity. CONCLUSION: Patients with CD had increased aortic stiffness and decreased aortic distensibility. Gluten-free diet enabled the patients with CD to have a reduction in the inflammatory parameters whereas the absence of a significant difference in the elastic properties of the aorta may suggest that the risk of cardiovascular disease persists in this patient group despite a gluten-free diet.

Clinical characteristics of haematological malignancy patients diagnosed with leukaemia cutis: Experience of a single centre.

BACKGROUND/OBJECTIVES: We evaluated the clinical characteristics of patients with haematological malignancies at our centre who were diagnosed with leukaemia cutis (LC). In addition, we describe the spectrum of other skin lesions, including, secondary skin malignancies and nonspecific benign skin lesions in haematological malignancy patients. METHODS: We defined 58 skin lesions that developed in 54 inpatients hospitalised in the Department of Haematology, Trakya University Medical Faculty, Turkey. All skin lesions that developed in inpatients between 2006 and 2012 had been evaluated by a dermatologist. The patients' clinical features, skin biopsy results and therapies were obtained from hospital files. The diagnosis of LC was based on clinical features and histopathological examinations of the skin biopsy. RESULTS: There were 11 patients with LC. Six (54.5%) had acute myeloblastic leukaemia. In nine patients (82%), LC was present at the initial presentation. Secondary skin malignancy was detected in 11 patients (five basal cell carcinoma, four Kaposi's sarcoma, one squamous cell carcinoma, one malignant melanoma); and malignancy was present in two patients (18%) at the initial presentation. Nonspecific benign skin lesions, the most frequent of which were drug eruptions, were determined in 32 of our patients. LC had a significantly higher likelihood of being present at initial presentation than other skin lesions (P < 0.01). The median survival in LC patients was quite short (4.5 months). CONCLUSIONS: LC was usually diagnosed at the initial presentation of the patient or during the early course of the disease. Having LC was a poor prognostic factor.

Implementation of screening colonoscopy amongst first- degree relatives of patients with colorectal cancer in Turkey: a cross-sectional questionnaire based survey.

OBJECTIVE: To evaluate the implementation of screening colonoscopy amongst first-degree relatives (FDRs) of patients with colorectal cancer (CRC) in Turkey. MATERIALS AND METHODS: A total of 400 first-degree relatives (mean(SD)age: 42.5(12.7) years, 55.5% were male) of 136 CRC patients were included in this cross-sectional questionnaire based survey. Data on demographic characteristics, relationship to patient and family history for malignancy other than the index case were evaluated in the FDRs of patients as were the data on knowledge about and characteristics related to the implementation of screening colonoscopy using a standardized questionnaire form. RESULTS: The mean(SD) age at diagnosis of CRC in the index patients was 60.0(14.0) years, while mean(SD) age of first degree relatives was 42.5(12.7) years. Overall 36.3% of relatives were determined to have knowledge about colonoscopy. Physicians (66.9%) were the major source of information. Screening colonoscopy was recommended to 19.5% (n=78) of patient relatives, while 48.7% (n=38) of individuals participated in colonoscopy procedures, mostly (57.9%) one year after the index diagnosis. Screening colonoscopy revealed normal findings in 25 of 38 (65.8%) cases, while precancerous lesions were detected in 26.3% of screened individuals. In 19.0% of FDRs of patients, there was a detected risk for Lynch syndrome related cancer. CONCLUSIONS: In conclusion, our findings revealed that less than 20% of FDRs of patients had received a screening colonoscopy recommendation; only 48.7% participated in the procedure with detection of precancerous lesions in 26.3%. Rise of awareness about screening colonoscopy amongst patients with CRC and first degree relatives of patients and motivation of physicians for targeted screening would improve the participation rate in screening colonoscopy by FDRs of patients with CRC in Turkey.

Peripheral blood lymphocyte dynamics and viral kinetics in patients with chronic active hepatitis B virus infection treated by tenofovir.

BACKGROUND/AIMS: We investigated serum viral kinetics and peripheral blood lymphocyte dynamics in chronic hepatitis B patients during the first year of tenofovir therapy. METHODOLOGY: Fifteen patients, naive to any kind of previous antiviral therapy, were included in this study. The patients received tenofovir daily 245mg for 48 weeks. Fifteen age and gender compatible healthy subjects were enrolled as the control group. Clinical, biochemical, immunological and virological parameters were assessed at baseline, then at the first, third, sixth and twelfth months. RESULTS: CD4+CD25+FOXP3+ nTregs percentages were significantly higher in the study group than that of healthy controls, CD4+CD28+ and CD4+CD38+ T cell percentages were significantly lower in the study group than those of control group (p<0.001). Twelve cases had undetectable HBV DNA levels after the one year therapy. We determined that there was an increase of the CD28+co-stimulator molecule on both the CD4+ and CD8+ T cells while a decrease of the CD8+CD38+ T cells, CD4+CD38+ T cells and CD4+CD25+FOXP3+ nTregs, in patients with tenofovir treatment, but only CD4+CD25+FOXP3+ nTregs were statistically significant. CONCLUSIONS: We found that both viral load and CD4+CD25+FOXP3+ nTreg percentages decreased significantly in patients with chronic hepatitis B virus infection during 1 year course of tenofovir treatment.

A case of cervical spine meningioma following etanercept use in a patient with RA.

BACKGROUND: A 70-year-old female with active rheumatoid arthritis (RA) was administered etanercept to treat active disease that persisted despite therapy with conventional DMARDs. After 18 months of etanercept therapy, her RA symptoms had improved; however, she developed quadriparesis. She presented to a specialist rheumatology clinic with weakness and numbness in her arms and legs; she also had difficulty in standing up and walking. INVESTIGATIONS: Physical examination, neurological examination, nerve conduction studies, measurement of serum inflammatory markers and autoantibodies, MRI of the cranium and cervical spine, and X-rays of the chest and hands. DIAGNOSIS: The patient underwent neurosurgery to resect a 1 x 2 cm mass in the cervical spine at C6-C7. Histopathologic examination of the excised mass revealed it to be a meningioma. MANAGEMENT: Etanercept was discontinued because of a possible association between the drug and development of meningioma; however, shortly afterwards the patient experienced a flare of RA symptoms. High-dose NSAIDs and prednisolone were administered, but the patient died because of gastric perforation. To our knowledge, this is the first report in the literature of meningioma developing following use of tumor necrosis factor inhibitor therapy, and the first to suggest a cause-effect relationship.

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.

EORTC QLQ-C30 assessment in Turkish patients with hematological malignancies: association with anxiety and depression.

We aimed to evaluate the prevalences of self-reported anxiety and depression symptoms in hematological malignancy patients and to determine the association between the presence of these disorders and the results of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-30 (EORTC QLQ-C30). One hundred and forty patients with a diagnosis of a hematological malignancy completed the Hospital Anxiety and Depression Scale (HADS) and the General Health Questionnaire. Patients with higher anxiety scores were more frequently inpatients, had higher EORTC general symptom scores, and they had lower cognitive, emotional, social functioning and global quality of life (QoL) scores (all p values <0.05). Patients with higher depression scores had more frequently active disease and were inpatients; they had higher mean Eastern Cooperative Oncology Group performance scores, EORTC gastrointestinal system and general symptom scores, and significantly lower physical, role, emotional, social and cognitive functioning and global QoL scores (all p values <0.01). During follow-up, it was observed that survival curves of patients with active disease who had higher HADS depression scores tended to be shorter than those with lower scores (p = 0.1). Anxiety and depression are frequent in hematological malignancy patients and associated with poor QoL and performance status. In addition, the presence of self-reported depression might have a predictive value for poor prognosis.

Isolated bone metastasis in testicular germ cell tumors: a case report and review of the literature.

BACKGROUND: In testicular germ cell tumors (GCT), bone metastases are usually seen late in the disease progress and are almost always associated with involvement of other sites. However, isolated bone metastasis is an extremely rare finding in these patients. CASE REPORT: A 43- year-old man was admitted to the neurosurgery department of our hospital suffering from dysarthria, ataxia, headaches and a progressive swelling above the parietooccipital region of the skull. Radiological, biochemical and pathologic tests showed that the lesion of the skull was an isolated skull metastasis as an initial manifestation of nonseminomatous GCT of the testis. DISCUSSION: When a young patient presents with bone pain or painless swelling, even if it is an unusual site and isolated, testicular GCT should be considered as a differential diagnosis, as these lesions could be the first evidence of metastatic GCT.