Screening for celiac disease in poorly controlled type 2 diabetes mellitus: worth it or not?

BACKGROUND: Recent studies have demonstrated that immune factors might have a role in the pathophysiology of insulin resistance and type 2 diabetes mellitus (T2DM). Inappropriate glycemic control in patients with T2DM is an important risk factor for the occurrence of diabetes complications. The prevalence of celiac disease (CD) is high in type 1 diabetes mellitus however, there are scarce data about its prevalence in T2DM. Our aim was to investigate the prevalence of celiac disease among insulin-using type 2 diabetes patients with inappropriate glycemic control. METHODS: IgA tissue transglutaminase antibodies (tTGA IgA) test was performed as a screening test. A total of 135 patients with T2DM whose control of glycemia is inappropriate (HbAlc value >7%) in spite of using insulin treatment for at least 3-months (only insulin or insulin with oral antidiabetic drugs) and 115 healthy controls were enrolled in the study. Upper gastrointestinal endoscopy with duodenal biopsy was performed to all patients with raised tTGA IgA or selective lgA deficiency. RESULTS: Gender, age, body mass index (BMI) and tTGA IgA, kreatinin, calcium, LDL-cholesterol (LDL-C), total cholesterol, 25-OH vitamin D3 levels were similar between groups. Systolic and diastolic blood pressure, waist circumference, fasting plasma glucose, postprandial plasma glucose, urea, sodium, HbA1c, LDL-C, triglyceride, vitamin B12 levels were significantly higher in DM group (p < 0.0001). BMI, high-sensitive CRP, microalbuminuria, and AST, ALT, potassium, phosphorus levels were significantly higher in the T2DM group (p < 0.05). HDL-cholesterol and parathormone levels were significantly lower in the T2DM group (p < 0.05). Two of the 135 patients with T2DM were diagnosed with CD (1.45%). CONCLUSIONS: The prevalence of celiac disease among patients with type 2 diabetes, with poor glycemic control despite insulin therapy, is slightly higher than the actual CD prevalence in general population. Type 2 diabetic patients with inappropriate control of glycemia in spite of insulin treatment might be additionally tested for Celiac disease especially if they have low C-peptide levels.

Significance of serum and ascitic fluid C-reactive protein in differential diagnosis of benign and malignant ascites.

BACKGROUND: The values of C-reactive protein (CRP) can prove useful in determining disease progress. Because of synthesis by the liver, production of CRP in response to inflammation may be attenuated in patients with liver dysfunction. This may result in differences interpreting CRP levels in patient with portal and non-portal hypertension ascites. AIM: The aim of the present study is to assess discriminant value of serum and ascitic fluid CRP, which is easily accessible and inexpensive laboratory marker of inflammation, concentrations for diagnosis of underlying cause of ascites. METHODS: This prospective study was conducted at Diskapi Yildirim Beyazit Educational and Research Hospital Department of Gastroenterology. Patients with ascites were further divided into two subgroups based on underlying cause of ascites: Group 1, patient with ascites due to portal hypertensive etiology (high-gradient ascites); Group 2, patient with ascites due to non-portal hypertensive etiology (low-gradient ascites). RESULTS: A total of 91 patients fulfilling the criteria for a diagnosis of ascites were enrolled in the study. Of these patients, 50 had proven (Group 1) ascites due to portal hypertensive etiology (high-gradient ascites) and 41 had clinical (Group 2) ascites due to non-portal hypertensive etiology (low-gradient ascites). Mean baseline serum and ascites levels of CRP were significantly higher in Group 2 compared to those in Group 1 (p = 0.021, p = <0.0001, respectively). CONCLUSIONS: Increased levels of serum and ascitic fluid CRP were associated with malignant ascites.

Aromatase cytochrome P450 enzyme expression in prolactinomas and its relationship to tumor behavior.

The aim of the study was to evaluate the presence of aromatase cytochrome P450 enzyme (P450AROM) expression in normal pituitary tissues and tumor tissues of patients with prolactinoma and to examine the impact of the P450AROM expression on clinical outcome. Twenty-six consecutive human pituitary tissue samples were obtained from autopsies performed at the Institute of Forensic Medicine. Sixty-four patients who had an adenomectomy between 2000 and 2009 after prolactinoma diagnosis with histologically confirmed pituitary tumor tissues were retrospectively included in this study. The slices from the pituitary tissues were subjected to immunohistochemical staining for evaluation of P450AROM and estrogen receptor beta (ER beta) subunit. Immunohistochemistry results were compared according to age, gender, remission rate, resistance and invasion status of the patients. Higher than normal P450AROM expression was found in the pituitary tissues of the patients with prolactinoma (p < 0.001). P450AROM intensity had no relation to resistance or remission in patients with prolactinoma (p = 0.44, p = 0.45, respectively). The subgroup analysis showed that compared to males without invasive adenoma, males with invasive adenoma had higher P450AROM expression (p = 0.048). ER beta was found to have an impact on resistance (p = 0.049). This study shows that P450AROM expression is present in the pituitary tissues of patients with prolactinoma and that this presence could be important in development and tumor behavior of prolactinomas.

Diagnostic accuracy of intestinal ultrasound and magnetic resonance enterography for the detection of endoscopy-based disease activity in ileocolonic Crohn's disease.

BACKGROUND: Crohn's disease (CD) is characterised by chronic gastrointestinal inflammation with relapsing-remitting behaviour and often requires endoscopic and/or radiologic assessment. OBJECTIVE: The objective of this study was to compare the diagnostic accuracy of intestinal ultrasound (IUS) and magnetic resonance enterography (MRE) for the assessment of disease activity in CD using a simple endoscopic score for CD as a reference standard. PATIENTS AND METHODS: A prospective observational study was carried out in 71 consecutive adult patients with known CD, attending our tertiary inflammatory bowel disease clinic, between November 2014 and July 2016. Ileocolonoscopy, IUS and MRE were performed within 1 month prospectively. The simple endoscopic score-CD 0-2 was accepted as remission. RESULTS: The sensitivity of IUS and MRE for detecting endoscopic activity was found similar with regard to bowel wall thickening and mesenteric fibrofatty proliferation (P>0.05). The overall accuracy for detecting mural lesions was similar between IUS and MRE. When mural lesions were analysed, the sensitivity of MRE in detecting the loss of wall stratification and stenosis was significantly higher than IUS (P<0.001 for both). IUS showed higher specificity for bowel wall thickening, loss of wall stratification and stenosis (P=0.009, P<0.001 and P<0.001, respectively). Sensitivity and accuracy of IUS were higher in detecting ascites in active disease (P=0.002). DISCUSSION: Our results showed that IUS and MRE were equally accurate in detecting endoscopic activity. IUS may be the preferred technique for the evaluation of disease activity and for the follow-up of CD.

[Aeromedical evacuation of critically ill and injured patients]. / Hava yoluyla hasta ve yarali tasinmasi.

The mission of aeromedical evacuation of patients, whether in peacetime, wartime or under unexpected conditions (earthquake, flood etc) will remain the same. Aeromedical evacuation systems have become an integral part of the practice of critical care medicine. These systems provide interhospital transport of critically ill or severely injured patients. Understanding the medical aspects of flights and the capabilities of the aeromedical environment will help to evacuate patients in a safe and a proper manner.

The efficiency of endoclips in maintaining the gastrointestinal bleeding-related Dieulafoy's lesion.

BACKGROUND: Dieulafoy's lesion (DL) is a relatively uncommon medical condition characterized by a large tortuous arteriole in the submucosa of any part of gastrointestinal (GI) tract wall that bleeds via erosion likely caused in the submucosal surface by protrusion of the pulsatile arteriole. Compared with other endoscopic hemostatic techniques, clipping alone for DL is limited. AIMS: The aim of the present case series study is to identify common clinical and endoscopic features, rates of occurrence, to review the outcome of endoscopic management of upper GI tract DL, and to illustrate the use and the efficiency of endoclips in maintaining the GI bleeding due to DL. PATIENTS AND METHODS: This case series was conducted at Department of Gastroenterology, Diskapi Yildirim Beyazit Educational and Research Hospital. The patients who were admitted to the emergency department of Diskapi Yildirim Beyazit Educational and Research Hospital underwent gastrointestinal system (GIS) endoscopy between 2008 and 2013 and were assessed retrospectively. Five cases of GI bleeding related to DL were given endoscopic treatment with hemoclip application. Clinical data, endoscopic findings, and the effects of the therapy were evaluated. RESULTS: The median number of endoscopic hemoclips application in first endoscopy was 4 (2-9). Rebleeding developed in all patients who had hemoclips applied. Re-endoscopy was performed in three of these patients, which controlled the bleeding. Two patients were transferred to surgery. CONCLUSIONS: Combination of endoscopic injection and mechanical therapies seems a suitable method for maintaining upper GIS bleeding due to DL. Also, further studies are needed to better define the best endoscopic approach for the treatment of DL.

Metastatic lung adenocarcinoma related α-Fetoprotein elevation in a patient with HBV-related cirrhosis.

HCC is the most common type of primary liver tumor. The Practice Guideline, AASLD, for HCC recommended surveillance of HBV carriers at high risk of HCC with US every 6-12 months. Laboratory surveillance option is the measurement of serum α-fetoprotein level which has long been used for the diagnosis of HCC. But, increased serum levels of α-fetoprotein are also seen in acute hepatitis, cirrhosis, and malignancies include yolk sac carcinoma, neuroblastoma, hepatoblastoma, gastric and lung carcinoma. Because of elevation α-fetoprotein in these malignancies, liver mass with an elevated α-fetoprotein does not directly indicate HCC. For these reason, clinicians evaluating patient with liver mass and HBV-related cirrhosis should be vigilant for other case of α-fetoprotein elevation.

Neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, and mean platelet volume as potential biomarkers for early detection and monitoring of colorectal adenocarcinoma.

Colorectal cancer (CRC) is the third most common cause of cancer-related death in Europe. The aim of the present study was to elucidate the efficiency of the neutrophil/lymphocyte ratio (NLR), the platelet/lymphocyte ratio (PLR), and the mean platelet volume (MPV) as tools for the preoperative diagnosis of CRC and their usefulness in the follow-up of CRC. A total of 144 CRC patients, as diagnosed by colonoscopy, and 143 age-matched and sex-matched healthy participants were included in the study. Medical records were used to compare preoperative and postoperative data including hemoglobin levels, platelet counts, MPV, NLR, and PLR. NLR, PLR, and MPV were significantly higher in CRC patients preoperatively, compared with healthy participants. Receiver-operating characteristic curve analysis suggested 2.02 as the cutoff value for NLR [area under the curve (AUC): 0.921, sensitivity: 86%, specificity: 84%], 135 as the cutoff value for PLR, (AUC: 0.853, sensitivity: 70%, specificity: 90%) and 8.25 fl as the cutoff value for MPV (AUC: 0.717, sensitivity: 54%, specificity: 76%). Subgroup analysis showed that NLR, PLR, and MPV levels were also significantly higher in nonanemic CRC patients compared with the control group, which is of great theoretical and clinical value for the early detection of CRC. Surgical tumor resection resulted in a significant decrease in NLR, PLR, and MPV. Our results suggest that NLR, PLR, and MPV may be used as easily available additional biomarkers for CRC in screening the general population, as well as in postoperative follow-up.

Tenofovir-best hope for treatment of chronic hepatitis B infection?

BACKGROUND/AIMS: To evaluate the effectiveness of tenofovir in patients with chronic hepatitis B infection in a real life setting. MATERIALS AND METHODS: We performed a retrospective analysis of data from 164 patients with chronic hepatitis B who were treated with Tenofovir. Eighty-six patients (52.4%) were naïve. Seventy-seven (46.9%) patients were previously treated with anti-viral drugs, including standard interferon (n=4), pegylated (PEG) interferon (n=14), standard interferon together with lamivudine (n=13), lamivudine alone (n=41), adefovir (n=2), lamivudine together with adefovir (n=1), and entecavir (n=2). Six patients (3.7%) had liver cirrhosis before treatment of tenofovir. RESULTS: The patients who have hepatitis B viral DNA>104 copy/mL with chronic hepatitis B infection were included in the treatment of Tenofovir. Average follow up time was 30.31±14.33 months. HBV DNA negativity and alanine aminotransferase (ALT) normalization were 86.5% and 71.3%, respectively, at the last visit. Hepatitis B e-Antigen (HBeAg) seroconversion occurred in 11 (19.6%) out of 164 patients. During the follow-up period, 4 (2.4%) patients developed liver cirrhosis and in 5 (3%) patients hepatocellular carcinoma (HCC) occurred out of 164 patients. HBsAg seroconversion occurred in one patient (0.6%). CONCLUSION: Tenofovir can be used safely and successfully in those patients that were naive, experienced with immune modulators and/or antivirals, HBeAg-positive, and HBeAg-negative patients.

[Evaluation criteria for selecting patients for surgical or nonoperative treatment in nonvariceal upper gastrointestinal bleeding]. / Varis disi üst gastrointestinal sistem kanamalarinda cerrahi ve konservatif tedavi için hasta seçiminde dikkate alinacak noktalar.

BACKGROUND: We evaluated the patients who underwent surgical or nonoperative treatment for acute nonvariceal upper gastrointestinal bleeding. METHODS: The study included 31 patients (21 males, 10 females; mean age 60 years; range 19 to 82 years) with nonvariceal upper gastrointestinal bleeding. Surgical treatment was performed in 14 patients (10 males, 4 females; mean age 64 years), while 17 patients (11 males, 6 females; mean age 55.6 years) were treated conservatively. The two groups were compared with respect to age, sex, associated diseases, arterial blood pressure, pulse rate, and hematocrit values on admission, number of blood transfusions, endoscopic findings, cause of bleeding, and mortality. RESULTS: Upon admission, all the patients underwent endoscopic examination except for five surgically-treated patients. Peptic ulcer was detected in 74.1% of the bleedings. The incidences of duodenal ulcer and stomach ulcer did not differ between the two groups. No significant differences were found with respect to the causes of bleedings. The mean number of blood transfusions was 4.36 units preoperatively, and 2.29 units in those treated conservatively (p=0.013). The mean systolic (p=0.002) and diastolic pressures (p=0.029), pulse rates (p=0.003), and hematocrit values (p=0.011) obtained on admission differed significantly. Mortality occurred in only one patient (7.1%) due to cardiac failure in the postoperative period. CONCLUSION: Our study yielded elucidative data on the referral of patients to surgical treatment for nonvariceal upper gastrointestinal bleeding.