Indications, effectiveness and safety of percutaneous endoscopic gastrostomy: A single center experience and literature review.

BACKGROUND AND OBJECTIVES: Percutaneous endoscopic gastrostomy (PEG) has been widely used since 1980 in enteral feeding of patients that are not able to be fed orally for a long time. The aim of this study is to evaluate the PEG indications, effectiveness and PEG related complications from a single center in Istanbul, Turkey. METHODS AND STUDY DESIGN: 265 patients with PEG who were followed up by the clinical nutrition team of a university hospital between 2010-2018 were evaluated retrospectively. Nutritional Risk Screening-2002 (NRS-2002) test, anthropometric measurements, bioelectrical impedance analysis and laboratory data were used to evaluate the patients' nutritional status. RESULTS: The most common indications for PEG were dementia (35.1%), amyotrophic lateral sclerosis (22.6%), stroke (15.8%), and cancer (14%). The mean body weight of the patients was increased after PEG (63.5±12.2 vs 62.0±12.7 kg). Mid upper arm circumference and calf circumference of the patients increased after PEG (27.5±2.5 vs 25.4±3.1 cm and 32.2±7.9 vs 29.6±5.9 cm, respectively). Serum albumin of the patients was increased significantly after PEG (3.34±0.69 g/dL to 3.64±0.65 g/dL) without any significant change in serum CRP. Subgroup analyses showed a significant increase in the mean serum albumin of patients with dementia after PEG (3.23±0.67 g/dL to 3.54±0.58 g/dL). Local insertion site infection occurred in 15 patients (5.6%) and only 3 patients had systemic inflammatory symptoms after local infection (1.1%). CONCLUSIONS: The results of our study showed that long-term enteral feeding with PEG is an effective and safe method that provides improvement in nutritional status.

The Role of the Local Bone Marrow Renin-Angiotensin System in Multiple Myeloma

Objective: Angiotensin II promotes growth and angiogenesis via type 1 receptors (AGTR1) in certain tumors. In this study, we examine the bone marrow AGTR1 expression in multiple myeloma (MM) and its relationship with the regulation of angiogenesis and prognostic factors. Materials and Methods: Bone marrow AGTR1 mRNA levels of 39 MM patients and 15 healthy controls were analyzed with quantitative RT-PCR. Immunohistochemical staining of the tissue vascular endothelial growth factor (VEGF), CD34, and factor VIIIrAg (fVIIIrAg) was used to assess bone marrow angiogenesis. Results: Bone marrow samples of the patients showed increased VEGF, fVIIIrAg, and CD34 staining and higher AGTR1 expression levels when compared to controls. Patients with severe-diffuse bone marrow infiltration showed higher bone marrow VEGF, fVIIIrAg, CD34, and AGTR1 mRNA levels when compared to other patients. Conclusion: AGTR1 expression was found positively correlated with plasma ß2-microglobulin level and patients with increased AGTR1 expression showed increased bone marrow CD34 levels.

Inflammatory myofibroblastic tumor mimicking a relapse in a patient with Hodgkin's lymphoma: report of an unusual case and review of the literature.

New PET-positive lesions in previously treated patients with lymphomatous malignancies need further investigations. Relapse, sarcoidosis and secondary malignancies are the most important differential diagnosis. Inflammatory myofibroblastic tumors (IMT) is a rare complication after treatment of Hodgkin's disease and every PET-positive lesion should be biopsied to prevent unnecessary intervention.

Isolated renal intravascular lymphoma: a case report and review of the literature.

Intravascular large B-cell lymphoma (IVLBCL) is a very rare subtype of extranodal large B-cell lymphoma. It may involve various organ systems such as skin, liver, lung or kidney. Isolated kidney involvement of IVLBCL is also very rare. Herein we report a very rare case of isolated renal IVLBCL presented with fever of unknown origin, acute kidney injury and nephrotic syndrome. Diagnosis was suspected with isolated high renal (18)F fluorodeoxyglucose uptake in positron emission tomography and confirmed with renal biopsy. Complete remission was obtained with combined chemotherapy including rituximab. We reviewed the English literature in terms of IVLBCL with renal involvement and we could only find 16 such cases. Accordingly, fever, AKI and nephritic syndrome are the most common presenting symptoms in renal intravascular lymphoma.

Nutritional risk in hospitalized patients: impact of nutritional status on serum prealbumin

OBJECTIVE: Poor recognition and monitoring of nutritional status is the most important cause of malnutrition in hospitalized patients. The aim of this study was to assess the nutritional status of a group of patients and compare the results with their serum prealbumin levels. METHODS: Ninety-seven patients admitted consecutively to the hospital were enrolled in the study. The risk of malnutrition was assessed according to anthropometric data and the Subjective Global Assessment and Nutrition Risk Screening 2002 tools. The nutritional statuses of the patients were compared with their age, gender, body mass index, medical history, weight loss and routine biochemical analyses, including prealbumin and length of hospital stay. RESULTS: According to the Nutrition Risk Screening 2002, 57 percent of the patients were malnourished or at risk of malnutrition, correlating well with the Subjective Global Assessment (p<0.001, r=0.700). Multivariate analysis revealed positive correlations between malnutrition and age, weight loss, malignancy and serum C-reative protein (p=0.046, p=0.001, p=0.04 and p=0.002). Nutrition Risk Screening 2002 score ³3 was associated with prolonged length of hospital stay (p=0.001). Serum prealbumin correlated with nutritional status, regardless of the number of chronic diseases and inflammation biomarkers (p=0.01). Serum prealbumin sensitivity, specificity, positive predictive value, negative predictive value and diagnostic value in the assessment of risk of malnutrition were 94 percent, 32 percent, 0.67, 0.78 and 69 respectively. After 7 days of nutritional support, the risk of malnutrition decreased by 12 percent (p<0.001) and serum prealbumin levels increased by 20 percent (p=0.003). CONCLUSION: Instead of reflecting overall nutritional status, low serum prealbumin may be regarded as a sign of increased risk of malnutrition, requiring further nutritional assessment. It can be used for monitoring patients receiving nutritional support.

OBJETIVO: Falha no reconhecimento e acompanhamento do estado nutricional é a razão mais importante da desnutrição em pacientes hospitalizados. Este estudo objetivou avaliar o estado nutricional dos pacientes e comparar os resultados com os níveis séricos de pré-albumina. MÉTODOS: Foram incluídos 97 pacientes no estudo, internados consecutivamente. O risco de desnutrição foi avaliado de acordo com dados antropométricos e com a Avaliação Subjetiva Global e Triagem de Risco Nutricional 2002. Os estados nutricionais dos pacientes foram comparados com suas idades, sexo, índice de massa corporal, histórico médico, perda de peso e análises bioquímicas, incluindo pré-albumina e tempo de permanência hospitalar. RESULTADOS: De acordo com o Triagem de Risco Nutricional 2002, 57 por cento dos pacientes estavam desnutridos ou em risco de desnutrição, apresentando boa correlação com o Avaliação Subjetiva Global (p<0,001, r=0,700). A análise multivariada mostrou correlações positivas entre desnutrição e idade, perda de peso, malignidade e proteína reativa-C (p=0,046, p=0,001, p=0,04 e p=0,002). Um escore ³3 no Triagem de Risco Nutricional 2002 foi associado à internação prolongada (p<0,001). Houve correlação entre pré-albumina sérica e o estado nutricional, independente do número de doenças crônicas e biomarcadores de inflamação (p=0,01). CONCLUSÃO: Ao invés de refletir o estado nutricional global do paciente, níveis séricos baixos de séricos de pré-albumina podem ser vistos como um sinal de maior risco de desnutrição, exigindo uma avaliação nutricional mais extensa. A análise sérica de pré-albumina pode ser usada para o monitoramento de pacientes recebendo suporte nutricional.

A rare but significant cause of priapism in the elderly: multiple myeloma.

Priapism is a rare symptom with diverse etiological factors. Although most cases in adults are secondary to drug use and intracavernosal injections, blood dyscrasias and hypercoagulable states, vasculitis, penile metastases, neurological conditions, spider bites, carbon monoxide poisoning, and total parenteral nutrition may also result in priapism. We report a case of recurrent and refractory priapism in a 61-year-old man which was diagnosed as multiple myeloma after emergence of hypercalcemia and renal failure due to progression of the underlying pathology. The value of the initial diagnostic approach is emphasized.

Metastatic gastric melanoma: a challenging diagnosis.

BACKGROUND: The stomach is regarded as a rare site for metastasis. When a gastric mass is observed macroscopically, the presumed diagnosis is usually a primary gastric carcinoma. However, the stomach may be involved in metastatic malignant melanoma. Besides a possible macroscopical misdiagnosis, metastatic gastric melanoma may also be misdiagnosed microscopically as adenocarcinoma due to its protean histological characteristics. These features make metastatic gastric melanoma a challenging diagnosis in some cases. CASE REPORT: We report a patient with metastatic gastric melanoma referred to us with an initial macroscopic and histopathological diagnosis of primary gastric adenocarcinoma. He was diagnosed as having metastatic gastric melanoma by further examination because of the peculiar metastatic involvement and normal gastrointestinal tumor marker levels. CONCLUSIONS: The stomach may be involved in melanoma and melanoma metastasis to the stomach is a diagnosis that should be taken into account while evaluating any gastric mass lesion. It is likely to be encountered more commonly nowadays due to the significant increase in the melanoma incidence. A history of melanoma, an atypical metastatic pattern, and normal gastrointestinal tumor marker levels may contribute to its diagnosis.

Ectopic growth hormone-releasing hormone secretion by a neuroendocrine tumor causing acromegaly: long-term follow-up results.

Ectopic secretion of growth hormone-releasing-hormone (GHRH) is a rare cause of acromegaly-representing less than 1% of patients. A 25-year-old woman was admitted to the hospital with acromegaly and a 6 x 6 cm infrahepatic mass. Sellar magnetic resonance imaging indicated diffuse pituitary enlargement consistent with hyperplasia. The infrahepatic mass was resected, and the histopathological diagnosis was a well-differentiated invasive neuroendocrine carcinoma of the duodenum with metastases to local lymph nodes. The tumor cells contained cytoplasmic immunoreactivity for GHRH. Because increased IGF-1 concentrations persisted after the operation, the patient was treated with octreotide long-acting repeatable (LAR) injections of 20 mg/month. Growth hormone and IGF-1 levels normalized. After 6 years of surveillance, a left paraaortic mass was detected by uptake of indium 111 octreotide. Surgical exploration revealed metastatic neuroendocrine carcinoma in a 2.5-cm lymph node. Postoperatively, the IGF-1 concentration was mildly elevated. Octreotide LAR therapy is being continued at 10 mg/month. This case suggests that octreotide treatment may have a beneficial effect on disease course and can be maintained for as long as 7 years in a patient with acromegaly due to a GHRH-secreting neuroendocrine carcinoma.

Mucosa-associated lymphoid tissue lymphoma of the duodenum together with multiple intra-abdominal thromboses and hepatitis C virus infection: a case report.

Mucosa associated lymphoid tissue MALT lymphoma is a low grade malignancy that arises most commonly from the gastric mucosa. Small intestinal involvement is very rare. The causative relationship between Helicobacter pylori and the gastric MALT lymphoma is a well known issue, but recently there are several data suggesting the role of hepatitis C virus (HCV) infection in the pathogenesis of lymphoma including MALT lymphoma. Herein we present a rare case of duodenal MALT lymphoma with multiple intra-abdominal thromboses together with HCV infection that was confirmed by real-time polymerase chain reaction detecting HCV-RNA within the peripheral blood mononuclear cells.

Thrombotic thrombocytopenic purpura associated with multiple myeloma.

Thrombotic thrombocytopenic purpura is a thrombotic microangiopathic disease. Associations with collagen vascular diseases, pregnancy, some drugs, surgical intervention, and infections are documented (known). Malignancy is also one of the known factors associated with thrombotic thrombocytopenic purpura. These malignancies are usually the disseminated solid organ tumors. Hematological malignancies constitute a rare association. Here, we present a patient with thrombotic thrombocytopenic purpura associated with multiple myeloma and discuss the pathogenesis. To our knowledge, this is the first case report of thrombotic thrombocytopenic purpura associated with multiple myeloma.

The predictive and diagnostic values of procalcitonin and C-reactive protein for clinical outcome in febrile neutropenic patients.

BACKGROUND: Procalcitonin (PCT) represents a new marker of systemic inflammatory reactions to bacterial infections. The main aim in this study was to determine the diagnostic value of PCT in predicting the clinical severity of febril neutropenic attacks, compare it with that of C-reactive protein (CRP), and clarify its importance in culture-positive attacks. METHODS: Between February 2001 and April 2002, 36 patients who were neutropenic due to various hematologic disorders and febrile were entered into the study. Blood samples were obtained on the first day of fever for the measurement of serum PCT and CRP levels. RESULTS: In clinically severe neutropenic fever attacks, means of serum PCT and CRP levels were measured as 0.93+/-1.33 ng/mL and 67+/-24 mg/L, while they were 0.37+/-0.23 ng/mL and 32+/-19 mg/L in clinically mild ones (p = 0.033 and p < 0.001). On the other hand, no statistical significance was found between culture-positive and negative attacks when either serum PCT or CRP levels were taken into consideration (p = 0.133 and p = 0.141). The specificity and positive predictive value of the serum PCT test for severe febrile neutropenia was higher than that of the serum CRP test (0.80 vs. 0.57 and 0.50 vs. 0.39). However, sensitivity and negative predictive value for CRP were higher than the values for PCT (1.00 vs. 0.40 and 1.00 vs. 0.73). Diagnostic value and positive likelihood ratio of CRP for severe febrile neutropenia were higher than those of PCT (71 vs. 67 and 2.32 vs. 2.00). CONCLUSIONS: PCT and CRP are comparable with each other in prediction of the clinical severity of febrile neutropenic attacks. Furthermore, serum CRP levels correlate with the duration of fever.

Catastrophic secondary antiphospholipid syndrome with peripheral nervous system involvement: a case report.

A 34-year-old woman was admitted to our emergency room with a high fever, abdominal pain, dyspnea and confusion. High fever and abdominal pain had first occured after a cystocele operation 5 months earlier. Later, congestive heart failure with mural thrombus formation, peripheral polyneuropathy and ischemic cerebrovascular accident were identified in clinical follow-ups, and multiple arterial and venous thromboses were seen on cranial and abdominal magnetic resonance imaging angiography. The patient's symptoms improved with anticoagulant treatment. Antiphospholipid syndrome with elevated serum anticardiolipin IgG levels was diagnosed, and ischemic peripheral polyneuropathy with axonal degeneration was determined by sural nerve biopsy. In antiphospholipid syndrome, elevated anticardiolipin antibodies appear to be the most common acquired blood protein defect causing thrombosis. Disseminated vascular thrombosis in catastrophic antiphospholipid syndrome can result in multiorgan failure with increased morbidity and mortality. It rarely occurs secondary to various infections as in the case of our patient, who suffered postoperative intraabdominal infection. It is important to note that peripheral nervous system involvement is rare in antiphospholipid syndrome.

Soluble transferrin receptor and soluble transferrin receptor-ferritin index for evaluation of the iron status in elderly patients.

We aimed to evaluate the diagnostic values of soluble transferrin receptor (sTfR) concentration, transferrin-ferritin index (soluble transferrin receptor concentration/log ferritin), ferritin levels and other related parameters in geriatric patients with anemia of chronic disease (ACD) and iron deficiency (IDA). Forty-four elderly subjects (median age 73 [63-94]) and twenty healthy subjects (median age 49 [44-56]) were enrolled into this study, divided into four groups: twenty middle aged healthy subjects (group A), fifteen elderly patients with IDA (group B), fourteen elderly patients with ACD (group C) and fifteen nonanemic geriatric subjects (group D). Hemoglobin, mean corpuscular volume, serum iron concentration and transferrin saturation levels of the patients in IDA group were found significantly lower than those in both non-anemic group and healthy subjects. Serum sTfR concentrations of the patients in IDA group were significantly higher than those in non-anemic geriatric group, ACD group and healthy subjects. Transferrin-ferritin index of the patients with IDA was significantly higher than that in non-anemic geriatric and ACD group. Serum ferritin levels of the patients in IDA group did not show any differences when compared with the other groups. Serum ferritin was highly specific for IDA (95%) when compared with ACD, although its sensitivity was low (38%). STfR values were negatively correlated with both transferrin and ferritin levels (p = 0.042 r = -0.40; and p = 0.034 r = -0.41, respectively). In conclusion, serum soluble transferrin receptor and transferrin-ferritin index may be used together with serum ferritin to distinguish the iron deficiency state in the elderly.

Sister chromatid exchange and mitotic index in patients with cirrhosis related to hepatitis B and C viruses and in chronic carriers.

BACKGROUND/AIMS: It is controversial whether hepatitis B or C viruses induce liver cancer through non-specific mechanisms (inflammation and cell renewal) or direct genotoxicity. Considering that both viruses infect peripheral lymphocytes, studying sister chromatid exchange frequency and mitotic index in peripheral lymphocytes is a reasonable experimental approach to investigate their genotoxic potential separately. In the present study we investigated sister chromatid exchange frequency and mitotic index in the peripheral lymphocytes of patients with cirrhosis and chronic carriers with positive serology for HBV or HCV infections. METHODOLOGY: The study population consisted of 3 groups: group I involved 23 HBsAg positive chronic carriers; group II involved 30 HBsAg positive patients with cirrhosis and group III involved 9 HCV-positive patients with cirrhosis. The control group involved 30 healthy individuals. RESULTS: Sister chromatid exchange frequency was significantly higher in all the study groups than the control group (p < 0.05). The mitotic index was significantly lower in all the study groups than the control group (p < 0.05). CONCLUSIONS: The increased sister chromatid exchange frequency and low mitotic index may be reflecting a direct genotoxic effect of HBV and HCV in peripheral lymphocytes. We suggest that the same genotoxicity may also operate in the liver and contribute to hepatocarcinogenesis.

The in vitro effect of interferon-alpha 2a on CD95 expression of T cells in hepatitis B.

BACKGROUND/AIMS: In chronic hepatitis B, apoptotic rate of peripheral cytotoxic T cells may be related with hepatocyte injury. We aimed to investigate Fas (CD95) expression of peripheral cytotoxic T cells and to show the in vitro effect of interferon-alpha 2a on Fas expression and apoptosis. METHODOLOGY: The study group consisted of 17 patients with chronic hepatitis B and control group consisted of 10 healthy subjects. Apoptotic cells were identified by flow-cytometric assay using Annexin V and propidium iodide. We used monoclonal antibodies stained by direct immunofluorescent method to show surface molecules. CH-11 monoclonal antibodies were used as anti-Fas antibodies. RESULTS: Basal expressions of CD95 and CD8+ CD95+ in the peripheral mononuclear cells were higher in chronic hepatitis B patients than controls. In vitro treatment with interferon-alpha 2a increased the percentage of CD8+ 95+ peripheral mononuclear blood cells in controls; this effect was less remarkable in patients with chronic B hepatitis, and the difference was not statistically significant. The number of apoptotic cytotoxic T cells also increased in 5 subjects of the study group and 3 subjects of controls; the percentage of CD95+ cells increased in 7 of 17 patients and 8 of 10 controls. The percentage of CD8+ 95+ cells and the apoptotic rate of CD8+ cells were not different between study group and controls after combined treatment with interferon-alpha 2a and monoclonal stimulating anti-Fas antibodies. CONCLUSIONS: We suggest that interferon-alpha 2a does not induce Fas-dependent apoptosis in CD8+ peripheral T cells of the patients with chronic hepatitis B, and CD95 molecules on peripheral cytotoxic T cells might be defective.

Extrapulmonary sarcoidosis with chronic renal failure.

We present a young woman with extrapulmonary sarcoidosis who had been treated for tuberculosis 15 years earlier. The initial diagnosis had been made on the basis of liver biopsy. The patient later developed bilateral visual loss secondary to uveitis. We identified noncaseating granulomatous lesions in the kidney, intra-abdominal lymph node, and previous liver biopsy specimens. Although rare, renal sarcoidosis can manifest itself as hypercalcemic nephropathy, granulomatous interstitial nephritis, renal tubular dysfunction, or glomerulonephritis. Corticosteroids are the treatment of choice.