Methylprednisolone Concentrations in Breast Milk and Serum of Patients with Multiple Sclerosis Treated with IV Pulse Methylprednisolone.

BACKGROUND: It is commonly known that women with multiple sclerosis (MS) have an increased risk for relapses during the post-partum period. High-dose IV methylprednisolone is the first-line treatment for acute relapses. Methylprednisolone is administered to lactating women although there is insufficient data as to the levels of concentration in breast milk and serum, and the calculated steroid exposure to infants. OBJECTIVES: The study aimed to measure the transfer of methylprednisolone into breast milk and the correlation of milk and serum methylprednisolone concentrations in breastfeeding MS patients during and after infusion therapy. METHODS: IV methylprednisolone pulse therapy was given to 12 lactating MS patients. Breast milk and maternal serum samples were obtained; before infusion, 30 minutes into the infusion, at the end of infusion and at the 1st, 2nd, 4th, 8th, 12th and 24th hours subsequently. RESULTS: The highest level of methylprednisolone concentration in breast milk (2.09 µg/ml) and serum (6.09 µg/ml) was detected at the end of the infusion. According to the measurements recorded at the 1st, 2nd, 4th, 8th, 12th, and 24th hours after infusion, the concentrations showed a gradual decrease both breast milk and serum. The milk and serum methylprednisolone concentrations were below detection limits just before infusion and at the 24th hour after infusion. A highly significant correlation was found between breast milk and maternal serum levels. The absolute infant dose was calculated to be 69.50 µg/kg/day and the relative infant dose (RID) was 0.50%. CONCLUSION: Results have shown that the transfer of methylprednisolone into breast milk seems to be low. Although, concentration levels may not seem to pose a threat to the infant, mothers can choose to wait 2 to 4 hours to further limit the level of exposure.

Internal urethrotomy versus plasmakinetic energy for surgical treatment of urethral stricture.

PURPOSE: we aimed to compare the longterm outcome of surgical treatment of urethral stricture with the internal urethrotomy and plasmakinetic energy. MATERIAL AND METHODS: 60 patients, who have been operated due to urethral stricture were enrolled in our clinic. None of the patients had a medical history of urethral stricture. The urethral strictures were diagnosed by clinical history, uroflowmetry, ultrasonography and urethrography. The patients were divided two groups. Group 1 consisted of 30 patients treated with plasmakinetic urethrotomy and group 2 comprised 30 men treated with cold knife urethrotomy. RESULTS: There were no statistically significant differences between two groups in terms of patient age, maximum flow rate (Qmax) and quality of life score (Qol) value. A statistical difference between the two groups was observed when we compared the 3rd-month uroflowmetry results. Group 1 patients had a mean postoperative Qmax value of 16,1 ± 2,3 ml/s, whereas group 2 had a mean postoperative Qmax value of 15,1 ± 2,2 ml/s (p < 0.05). In the cold knife group, 3 of 11 (27,7%) recurrences appeared within the first 3 months, whereas in the plasmakinetic group zero recurrences appeared within the first 3 months in our study. The urethral stricture recurrence rate up to the 12 month period was statistically significant for group 1 (n = 7, 23%) compared with group 2 (n = 11, 37%) (p < 0.05). CONCLUSION: We believe that plasmakinetic surgery is better method than the cold knife technique for the treatment of urethral stricture.

A giant dissecting aneurysm of ascending aorta following aortic valve replacement.

Ascending aortic dissection and aneurysm are rare but life-threatening complications after aortic valve replacement. Preoperative evaluation of risk factors such as aortic diameter, structural features of aortic wall, and associated diseases may decrease complication rate. We herein present analysis of risk factors of proximal aortic events following aortic valve replacement based on patient with giant dissecting aneurysm who underwent modified Bentall procedure.

First diagonal coronary artery: left ventricular fistula presenting as unstable angina.

Coronary artery fistulae are characterized by communications between a coronary artery and a cardiac chamber or another vascular structure. They are usually congenital, but acquired forms may occur. Most patients are usually asymptomatic. However, some studies have emphasized that the incidence of symptoms and complications increases with age, particularly after the age of 20 (Liberthson et al. 1979, Hong et al. 2004). We aimed to present a very rare form of fistula originating from the first diagonal artery and connecting into the left ventricle.

[Assessment of coronary artery calcium scoring]. / Kalsiyum skorunun koroner arterlerdeki segmenter dagilimi

OBJECTIVES: Calcium accumulation in the coronary arteries is a known indicator of atherosclerosis. The purpose of this study was to demonstrate the effect of patients' demographic characteristics on calcium scoring and the topographic accumulation of calcium in the coronary arteries. STUDY DESIGN: Two-hundred ninety-nine patients were included in the study (192 male, 107 female; mean age 59.08±10.7; range 19 to 84 years). All patients with total calcium scores of 1 Hounsfield unit or more underwent 16-slice multi-detector computed tomography with calcium scoring evaluation. Their coronary trees were divided into 14 different segments, and the number of lesions in each segment was calculated separately. RESULTS: When the coronary arteries were examined for calcium accumulation by segment, the proximal segment of the LAD (left anterior descending coronary artery) had the most calcium accumulation. Total calcium scores were higher in patients with high total and LDL cholesterol values than in normolipidemic patients. Total calcium scores were higher for patients with hypertension than for patients without hypertension. Calcium scores of smokers and non-smokers were not significantly different. Diabetic patients had higher calcium scores than patients without diabetes. No significant difference was identified between patients with and without a positive family history of coronary artery disease. Total calcium scores were higher for older patients and for patients with hyperlipidemia. CONCLUSION: Segmental analysis of calcium scoring demonstrates that calcium accumulation is mostly seen in the proximal LAD. Coronary artery calcification is increased by hypertension, age and hyperlipidemia.

Clinical spectrum, presentation, and risk factors for mortality in infective endocarditis: a review of 68 cases at a tertiary care center in Turkey.

OBJECTIVES: This study was designed to evaluate clinical, laboratory, microbiological, and echocardiographic characteristics of infective endocarditis (IE) at a tertiary care center in Turkey and to identify predictors of in-hospital mortality. STUDY DESIGN: Based on a systematic retrospective review of clinical records covering 1997 to 2007, we analyzed data and outcomes of 68 patients (40 males, 28 females; mean age 51+/-20 years) with definite or possible IE according to the modified Duke criteria. RESULTS: Native valve endocarditis (NVE) was seen in 28 patients (41.2%), and prosthetic valve endocarditis (PVE) was seen in 38 patients (55.9%). Pacemaker endocarditis (PE) was observed in only two patients (2.9%). Nineteen patients (27.9%) had nosocomial IE. The most frequent predisposing factor for NVE was rheumatic heart disease (n=11; 39.3%). Echocardiography failed to show any signs of involvement in five patients (13.2%) with PVE. The most common causative microorganisms of NVE, PVE, and PE were staphylococci (n=28; 41.2%). At least one complication developed in 46 patients (67.7%), congestive heart failure being the most common (n=38; 55.9%). Forty-one patients (60.3%) underwent combined medical and surgical treatment. In-hospital mortality occurred in 17 patients (25%). Mortality rates were 37.5%, 30%, and 14.3% for early and late PVE and NVE, respectively. Mortality was significantly higher with nosocomial IE (57.9%) compared to 12.2% in the remaining patients. In multivariate analysis, septic shock (p=0.011) and nosocomial infection (p=0.032) were independently associated with in-hospital mortality. CONCLUSION: Compared to the European series, IE in our cohort occurred in a relatively younger population, with rheumatic heart disease as the most common underlying heart disease. The rates of PVE, nosocomial IE, and surgical treatment were about the same.

Common variants in the ATP-binding cassette transporter 1 gene with decreased HDL-cholesterol levels and coronary artery disease.

BACKGROUND: Our aim was to determine whether the common variants within the coding sequence of ABCA1 gene affects low plasma high-density lipoprotein cholesterol (HDL-C) levels in Turkish patients with coronary artery disease (CAD). The study group was composed of 552 CAD patients, of which 251 had HDL-C levels < or =40 mg/dL, and 301 had HDL-C levels >40 mg/dL. METHODS: PCR-RFLP was used to determine the A2589G and G3456C DNA polymorphisms of the ABCA1 gene. The study group was analyzed for potential clinical predictors of low HDL-C. RESULTS: The GG variant of the ABCA1 gene A2589G polymorphism was found in 3.6% patients within the HDL-C < or =40 mg/dL group and in 4% of HDL-C levels >40 mg/dL group. Frequency distributions of the A2589G genotypes were not found to differ significantly among groups. The CC genotype of the G3456C polymorphism was found in 6.8% of HDL-C < or =40 mg/dL group and in 11.6% individuals of the HDL-C levels >40 mg/dL group. Frequency distributions of the G3456G genotypes were not significantly different among groups. The A2589G genotypes were not found to be effective over the analyzed lipid parameters. Among G3456C genotypes, in CAD patients with HDL-C < or =40 mg/dL the low-density lipoprotein (LDL-C) levels were elevated, whereas HDL-C levels decreased in CC genotype carriers compared to GG and GC. CONCLUSIONS: No significant association was found between cardiovascular endpoints and ABCA1 gene A2589G and G3456C genotypes in this study population.

The relation between coronary flow rate, plasma endothelin-1 concentrations, and clinical characteristics in patients with normal coronary arteries.

BACKGROUND: Coronary slow flow (CSF) is characterized by delayed opacification of epicardial arteries in the absence of occlusive disease. In the present study, we aimed to investigate the relation between coronary flow rate, plasma endothelin-1 (ET-1) concentrations, and clinical characteristics in patients with normal coronary arteries. METHODS: The study population included 77 patients with angiographically normal coronary arteries who underwent coronary angiography on suspicion of ischemic heart disease due to typical chest pain or ischemic findings on treadmill exercise test or myocardial scintigraphy. Based on the Thrombolysis In Myocardial Infarction frame count (TFC), patients were grouped into those with normal coronary flow and those with slow coronary flow. RESULTS: Forty-eight (61.5%) patients were found to have CSF. Plasma ET-1 concentrations were significantly higher with the presence of CSF (P=.03). There were significant differences between plasma ET-1 concentrations, and mean TFC, TFC for left anterior descending coronary artery (LAD), TFC for left circumflex coronary artery (CX), and TFC for right coronary artery separately in patients with and without CSF (P=.033, P<.001, P<.001, P<.001, and P<.001, respectively). Mean TFC, TFC for LAD, and TFC for CX, and ET-1 concentrations were significantly higher in smokers than in nonsmokers (P<.001, P<.001, P=.004, and P=.033, respectively). However, logistic regression analysis suggested that ET-1 concentration was not an independent determinant of CSF. CONCLUSIONS: Although there is a significant relation between ET-1 concentrations and coronary flow rate, ET-1 concentrations are not sufficient to determine the presence of CSF. Smoking is strongly associated with CSF, TFC, and increased ET-1 concentrations.

Combined periprostatic and intraprostatic local anesthesia for prostate biopsy: a double-blind, placebo controlled, randomized trial.

PURPOSE: Transrectal ultrasonography guided prostate biopsy is the principle procedure in the histological diagnosis of prostate cancer. Recently a trend toward increasing the number of cores has been popularized. This practice further increases the need for a proper anesthetic application. However, there is no consensus on a standard local anesthetic strategy, while groups at most institutions currently prefer periprostatic anesthesia. We prospectively evaluated the contribution of intraprostatic anesthesia for transrectal prostate biopsies even when the sampling number was doubled to 12 cores. MATERIALS AND METHODS: A total of 200 patients who underwent prostate biopsy with transrectal ultrasound guidance were included. The 2 groups received the usual periprostatic anesthesia. Consequently patients were prospectively randomized into 2 groups. Group 1 received additional intraprostatic lidocaine injection, while group 2 received the same amount of injection of 0.9% NaCl. The efficiency of applied local anesthesia was assessed by a visual analog pain scale. RESULTS: The study groups were comparable regarding patient age, prostate size and cancer rate. Pain scores revealed that the combination of intraprostatic and periprostatic local anesthesia provided significantly better pain control than periprostatic infiltration alone. No difference was observed regarding the morbidity rate in the 2 groups. CONCLUSIONS: The current study suggested that adding intraprostatic local anesthesia provides a significantly efficient strategy during transrectal ultrasound prostate biopsy, even in cases of 12-core sampling. Subsequent trials are needed to establish a standard analgesia policy for prostate biopsy.

Impact of anemia on nonfatal coronary events after percutaneous coronary interventions.

Anemia is associated with higher rates of cardiovascular events in patients with heart failure, acute myocardial infarction, and in patients undergoing coronary artery bypass graft surgery. Although studies have focused on fatal coronary events in anemic patients following percutaneous coronary intervention (PCI), data is lacking regarding nonfatal coronary events. The aim of our study was to analyze the incidence of anemia in patients who developed nonfatal events after successful PCI, and to make a comparison with event-free patients. Forty-nine consecutive patients with and 51 without nonfatal coronary events (nonfatal myocardial infarction, coronary artery bypass grafting, or repeat PCI) during the 1-year follow-up after the index PCI procedure were included in the study. Anemia was defined using World Health Organization (WHO) criteria as a hematocrit value at initial presentation <39% for men and <36% for women. Baseline hematocrit levels were measured before the procedure. Baseline clinical, lesion, and procedural characteristics were comparable in both groups. Anemia was present in 33.8% of men and 30.4% of women. The incidence of anemia in patients with nonfatal coronary events was 46.9% and 15.7% in the event-free group, which was significantly different (P = 0.001). Anemia was found to be an independent risk factor for nonfatal coronary events in PCI patients (odds ratio: 2.24, 95% confidence interval: 1.05-4.79; P = 0.036). In conclusion, anemia is an important risk factor for predicting nonfatal coronary events after PCI. Although previous studies have shown its impact on fatal events, this study has demonstrated that anemia also has a role in nonfatal thrombotic coronary events and restenosis.