Reliability, validity and sensitivity to change of neurogenic bowel dysfunction score in patients with spinal cord injury.

STUDY DESIGN: Psychometrics study. OBJECTIVES: The aim of this study is to investigate the validity, reliability and sensitivity to change of neurogenic bowel dysfunction (NBD) score. SETTING: Dokuz Eylül University Faculty of Medicine, Turkey. METHODS: The study included 42 patients with spinal cord injury (SCI). The reliability of NBD score was assessed by test-retest reliability and internal consistency. Cronbach's alpha coefficient was calculated to determine internal consistency. The construct validity was evaluated by exploring correlations between the NBD score and SF-36 scales, patient assessment of impact of NBD on quality of life (QoL) and the physician global assessment (PGA). The Global Rating of Change (GRC) scale was used to assess the change of NBD to investigate the sensitivity of the score to change. RESULTS: Cronbach's alpha coefficient was 0.547. In test-retest reliability analysis, high correlations between total test-retest NBD score and answers of each question were found (r=1.000, P<0.001). NBD score had a strong and significant correlation with PGA (r=0.98, P<0.000) and the impact on QoL (r=0.92, P<0.001). There was a significant negative correlation between NBD score and subscales of SF-36 (P<0.05) except physical functioning, physical role functioning and physical component summary score. There was a significant improvement in NBD scores after treatment (P=0.011). A significant positive correlation was found between GRC scale and change in total NBD score (r=0.821, P=0.007). CONCLUSION: The Turkish version of the NBD score is a valid and reliable instrument and also sensitive to change in patients with SCI.

Effects of intravenous N-acetylcysteine on periprocedural myocardial injury after on-pump coronary artery by-pass grafting.

AIM: Myocardial ischemia/reperfusion injury in patients undergoing coronary artery by-pass grafting (CABG) involves the reperfusion-induced conversion of reversible injured myocardial and endothelial cells. N-acetylcysteine (NAC) has a potential being the minimization of the impact of reperfusion injury. The aim of this study was to evaluate the effects of intravenous NAC on periprocedural myocardial injury after CABG. METHODS: The population of this prospective-randomized, double blind, placebo controlled study consisted of 40 patients undergoing on-pump CABG. All the patients were treated with standard medical therapy and eligible patients were randomized to NAC group (N.=19; intravenous infusion for 1 hour before the procedure at a dose of 50 mg/kg, followed by intravenous infusion for 48 hours after the operation at a dose of 50 mg/kg/day) and placebo (saline) group (N.=21). The study drug and placebo infusions were set to infuse at the same rate. RESULTS: Demographic and procedural variables were similar in the both groups (All P>0.05). Creatine kinase MB isoform (CK-MB) mass levels did not significantly differ between the groups at both preoperative and postoperative periods. Similarly, cTnT levels were similar in the groups at all periods. Eight patients in the NAC group and 7 in the placebo group had increased CK-MB >3 times normal value. However, only 3 patients in the NAC group experienced CK-MB>5 times normal value. CONCLUSION: Results of this study indicated that periprocedural use of NAC as intravenously did not attenuate myocardial damage after on-pump CABG surgery.

Repair of a ruptured posterior left ventricular pseudoaneurysm.

A 51 year old man with a large ruptured posterior left ventricular (LV) pseudoaneurysm (PsAn) was successfully surgically treated. Complete repair was performed by excision of the PsAn, leaving a cuff of fibrous tissue suitable to hold sutures and a Dacron patch reconstruction of the LV. On the 7th postoperative day, echocardiographic examination confirmed pericardial effusion (swinging heart). Media-stinal drainage tube was performed and the patient was discharged with a good recovery. The patient's preoperative LV ejection fraction (EF) increased from 42.7 to 52% after operation. We consider endoventricular circular patch plasty of ruptured posterior LV PsAn excellent because of the avoidance of thrombus and the effectiveness for improvement of LV function.

The droopy shoulder syndrome.

Droopy shoulder syndrome (DSS) is characterized by a depression of the shoulders that stretches the brachial plexus, thus causing pain without any signs of neurological impairment. We describe ten patients with DSS; all had been treated for different diagnoses before. Contrary to previous reports, three patients had unilateral involvement, and five had accompanying disease of the cervical-shoulder region. All patients responded well to conservative treatment in 2-10 weeks. DSS must be kept in mind in the differential diagnosis of pain in the cervical-shoulder region, to prevent unnecessary medication.

Multiple coronary artery aneurysms combined with abdominal aortic aneurysm.

Coronary artery aneurysm (CAA) is defined as coronary dilatation which exceeds the diameter of a normal adjacent segment or the diameter of the patients's largest coronary vessel by as much as 1.5 times. It is an uncommon pathology with a frequency of 1-4% in routine autopsies or coronary angiographies. Atherosclerosis plays an important role in the development of CAA, and it may be a predominant cause in the majority of patients. However, the timing of surgical intervention and the treatment options for CAA are still controversial. In this report, we present a patient who had multiple CAAs of all main coronary arteries and abdominal aortic aneurysm. Different treatment modalities and indications are also discussed.

Heparin-coated circuits reduce complement activation and inflammatory response to cardiopulmonary bypass.

BACKGROUND: Clinical procedures involving extracorporeal blood circulation are potentially complicated by the interaction of various blood systems with foreign surfaces. In cardiopulmonary bypass, exposure of blood to synthetic surfaces generally leads to activation of cellular and humoral blood systems with activation of complement cascade. This reaction can be associated with a variety of postoperation clinical complications such as increased pulmonary capillary permeability, anaphylactic reactions and various degrees of organ failure which contributes to mortality in routine cardiac operations. Application of biocompatible materials in an extracorporeal circuit modifies the normal pattern of blood activation, and therefore potentially may reduce clinical complications in routine cardiac surgery. METHODS: To evaluate whether the use of heparin coated extracorporeal circuits could reduce this activation process we performed a study on forty coronary artery bypass graft patients perfused randomly with heparin-coated circuits (Duraflo II, n = 20) or with non-coated circuits (De Bakey roller pump, control n = 20). Standardized heparinization was maintained for both groups of patients during cardiopulmonary bypass. RESULTS: The use of heparin-coated circuits resulted in reduction of systemic leukocyte activation of cardiopulmonary bypass reflected by reduced leukocyte and neutrophil counts 24 hours after operation (p < 0.05). Furthermore, blood samples taken from both the right and left atrium after reperfusion revealed that the differences in neutrophil counts between the right and left atrium occur less in the heparin-coated circuit in contrast to the control group (p < 0.05). The pattern of complement activation, probably initiating this inflammatory reaction, was modified by heparin coating in two different aspects. There was a significant reduction of C3 during and after cardiopulmonary bypass in patients perfused with heparin coated circuits as compared with the control group, also there was reduction of C4 after protamine administration in the same groups (p < 0.05). The reductions in blood and complement activation with heparin-coated circuit indicate a substantial improvement in biocompatibility, and consequently reducing clinical complications associated with cardiopulmonary bypass. CONCLUSIONS: In conclusions using the Duraflo II heparin-coated circuit in open heart surgery can reduce the complement activation and inflammatory response to cardiopulmonary bypass.

Increased adenoid mast cells in patients with otitis media with effusion.

OBJECTIVE: Previous studies have been suggested the possible role of adenoid mast cells in the pathogenesis of otitis media with effusion (OME). The aim of the present study was to evaluate the possible relationship of adenoid mast cells and hearing loss in patients with chronic OME. METHODS: Twenty patients with combined chronic OME and chronic adenoiditis (OME-A) and 20 patients with isolated chronic adenoiditis were studied. Hearing thresholds were determined by pure tone audiometry in both groups. All subjects underwent adenoidectomy and adenoid mast cells were counted in each specimen. Number of adenoid mast cells were determined in both groups. Possible relationship of adenoid mast cells and hearing thresholds in OME-A patients was evaluated by comparing the hearing thresholds of OME-A patients with mast cell count above the mean of OME-A group and hearing thresholds of OME-A patients with mast cell count below the mean of OME-A group. RESULTS: All isolated chronic adenoiditis patients had normal hearing thresholds. OME-A patients had hearing thresholds ranging from 12-52 dB. The number of adenoid mast cells in OME-A group (median: 80) was significantly greater than isolated chronic adenoiditis group (median: 38) (P < 0.05). OME-A patients with adenoid mast cell count above the mean of OME-A group had significantly higher hearing thresholds compared to OME-A patients with mast cell count below the mean of OME-A group (P < 0.05). CONCLUSIONS: Patients with OME-A have greater number of adenoid mast cells than patients with isolated chronic adenoiditis. OME-A patients with adenoid mast cell count above the mean of the OME-A group had higher hearing thresholds than OME-A patients with adenoid mast cell count below the mean of the OME-A group. Increased number of adenoid mast cells may contribute to the pathogenesis of higher hearing thresholds in some OME-A patients.

Immunohistochemical study on histogenesis of congenital epulis and review of the literature.

Congenital epulis is a very rare lesion found only in newborn infants. This tumor is multiple in about 10% of reported cases, rarely with the simultaneous involvement of the maxilla and mandibula, as in this article. In the presented case, light microscopy demonstrated large eosinophilic granular cells arranged in solid nests that are separated by thin fibrovascular areas. The tumors in the maxilla and mandibula were investigated with a panel of polyclonal and monoclonal antibodies, and using immunoperoxidase methods on formalin-fixed, paraffin-embedded sections. Immunohistochemical studies revealed strong and diffuse cytoplasmic staining for neuron specific enolase and vimentin. However, all other reactions were negative. These results suggest that the congenital epulis may be derived from uncommitted nerve-related mesenchymal cells.

The effect of iatrogenic vas deferens injury on fertility in an experimental rat model.

The long-term result of accidental crushing of the vas deferens during inguinal surgery is unpredictable. It is stated that even a slight disturbance in the muscular layer or mucosa may endanger fertility. This study was designed to investigate the early and late histopathologic changes of iatrogenic injury on the vas and its effect on fertility in a rat model. Both vasa deferentia of 54 male rats, divided into three groups (n = 18 each), were subjected to an operative manipulation. These manipulations consisted of digital compression for 45 seconds in group A, grasping with a mosquito clamp for 2 seconds in group B, and grasping with a mosquito clamp for 2 minutes in group C. In five rats from each group, the vasa were removed on the third and 21st postoperative day for histological evaluation. The remaining 13 rats in each group were allowed to mate for a period of 4 months. Bilateral vasa were analyzed for patency and histology. A spermatic granuloma was observed in 79% of the fertile and 80% of the infertile rats. Statistical analysis showed no significant fertility difference among the three groups. There was no statistical difference between groups B and C (P > .05) in terms of high and low flow patency rates in vitro, whereas a statistical significance was present between these two groups and group A (P< .001). It can be said that type rather than time of injury is important in this experimental model, because the results of the patency test alone are sufficient to prove the possibility of functional damage in vas deferens. The authors conclude that inguinal contents should be handled carefully and contralateral exploration in asymptomatic cases older than 1 year with inguinal pathology should be avoided.

The functional assessment of autotransplanted splenic tissue by its capacity to remove oxidatively modified erythrocytes.

Free radicals and reactive oxygen species have been implicated in the pathogenesis of a variety of hematologic diseases and erythrocyte aging. Aged erythrocytes are removed from the circulation primarily by the spleen. In this study, we aimed to determine the functional effectiveness of autotransplanted splenic tissue by its capacity to remove oxidatively modified erythrocytes from the circulation. Our experimental model in rats includes splenectomy with autotransplantation of 80% of the excised splenic tissue into the omental pouch. In this model, free radical damage was estimated by different parameters of lipid peroxidation such as carbonyl content and thiobarbituric acid reactive substances (TBARS), together with Heinz body formation. Our results have shown that splenic autotransplantation was effective in removing oxidatively modified, aged erythrocytes from the circulation.

Primary leiomyosarcoma of the breast.

Sarcomas of the breast are rare, accounting for about 1% of all malignant breast tumors. Leiomyosarcoma of the breast was an almost unknown tumor until some 20 years ago, and the few previously published cases lacked detailed information. Only 11 well-documented cases of leiomyosarcoma of the breast had been reported in the literature up to February 1992. The clinical features, diagnosis, therapy, and prognosis are discussed here in the light of the previously published literature.

The effects of diltiazem on superior mesenteric artery ligation. An experimental study.

The effects of diltiazem on an experimental study of Superior Mesenteric Artery ligation were studied on three rat groups comprising controls (N = 5), SMA ligation (N = 8), and SMA ligation and diltizem (0.25 mg/kg injection), (N = 8). Creatine phosphokinase, lactic dehydrogenase, aspartate transaminase and alanine transaminase venous blood levels were significantly decreased after diltiazem injection compared with the SMA ligation group. Histopathologic examinations revealed that diltiazem partly protected the small intestine from ischemic changes.

False aneurysm of the brachial artery in an infant following attempted venipuncture.

False aneurysms have rarely been described in the pediatric age-group. Here a case of false aneurysm of the brachial artery following accidental arterial puncture at the site of attempted venipuncture is reported. Having obtained vascular control with digital compression, the arterial repair was performed by direct suture technique. The characteristics and differential diagnosis of false aneurysms are described. The majority of false aneurysms occur as complications of percutaneous catheterization.

An atypical psoriatic spondylitis case, successfully treated with methotrexate.

We present a 45-year-old male patient who was hospitalized with lumbar disc herniation and whose control magnetic resonance imaging (MRI) findings initially suggested brucella spondylitis. Definitive diagnosis, however, indicated psoriatic spondylitis and the patient was successfully treated with methotrexate. A diagnosis of lumbar disc herniation was made in May 1991, during his psoriasis vulgaris treatment. He was hospitalized in August 1994 with a complaint of low-back pain persisting over the last six months despite treatment with analgesics. He was evaluated by clinical, radiological, laboratory and scintigraphic methods, following control MRI findings suggesting infection of vertebral bodies, particularly pointing to brucellosis in addition to disc herniation. A diagnosis of psoriatic spondylitis was finally established and 7.5 mg methotrexate weekly was administered. Significant improvement was obtained of psoriatic skin lesions, low-back pain and MRI findings through a six-month treatment period.

Pulmonary vascular sling responsible for esophageal and tracheal obstruction. A case report.

The disease of pulmonary vascular sling is a rare congenital condition. When it does occur it is often in conjunction with tracheal compression. The authors report herein a newborn with this anomaly presenting with a tracheal and esophageal compression.

Cold restraint stress-induced gastric mucosal dysfunction. Role of nitric oxide.

The objectives of this study were to determine the cold restraint stress-induced changes in gastric mucosal permeability and to assess whether nitric oxide synthesis inhibition affects gastric mucosal integrity after cold-restraint administration. Cold-restraint stress caused multiple gastric lesions in 90% of animals. The lesion index was found to be 3.87 +/- 0.97 mm. Gastric mucosal permeability to the [51CR]EDTA molecule was significantly elevated in the cold-restraint group compared to control. In order to evaluate the role of nitric oxide in cold restraint stress-induced gastropathy, L-arginine analog NG-nitro-L-arginine methyl ester (L-NAME) was given as a bolus (10 mg/kg, intravenously) and infused at a rate of 2 mg/ml/hr for 2 hr after cold-restraint administration. L-NAME greatly exacerbated gastric mucosal dysfunction associated with cold-restraint stress. D-NAME, the biologically inactive enantiomer, did not enhance mucosal dysfunction, whereas L-arginine, the substrate for nitric oxide, reversed the effect of L-NAME. In an additional group of experiments, effects of cold-restraint stress and L-NAME on net transmucosal fluid flux as well as tissue myeloperoxidase activity (MPO) were assessed. Cold-restraint stress administration significantly reduced the absorptive capacity of stomach, whereas L-NAME treatment did not affect the stress-induced alterations on net fluid absorption. Furthermore, L-NAME treatment did not affect the cold restraint stress-induced changes in tissue MPO activity. Our results suggest that gastric barrier function is altered after cold-restraint stress and nitric oxide production is important in minimizing mucosal barrier dysfunction associated with cold-restraint stress administration. Our results also indicate that L-NAME-induced alterations on mucosal permeability are not related to net transmucosal fluid flux and tissue neutrophils.

Aortic insufficiency and enterococcal endocarditis complicating systemic lupus erythematosus.

A case of aortic valve replacement for aortic insufficiency complicated with enterococcal endocarditis in a patient with systemic lupus erythematosus (SLE) is described. The cardiac complications of SLE may involve the endocardium, myocardium, pericardium, and coronary vessels. Steroids which are used for treatment probably increase the incidence of valve incompetence. Aortic insufficiency or infective endocarditis complicating Libman-Sacks endocarditis is rarely observed and may require valve replacement. Echocardiography is an important diagnostic tool. Renal function, pulmonary status, and cerebral complications require special attention in these patients.

The effects of experimental splenic autotransplantation and imipenem-cilastatin treatment in postsplenectomy Pseudomonas aeruginosa sepsis.

Male Wistar albino rats were allocated to three groups-sham operated (n: 10), splenectomized (n: 20) and splenic autotransplanted (n: 10). Twelve weeks after operation, all were challenged with 1.8 x 10(8) cfu/ml Pseudomonas aeruginosa intranasally. Half of the splenectomized rats received imipenem-cilastatin after 2 h of bacterial challenge. Mortality was then observed for the next 12 days. All animals were autopsied and liver, kidney, spleen and lung specimens were processed for microbiological culture and histopathological examination. In 80% of autotransplanted rats, splenic tissue regeneration was histopathologically verified. Hemoglobin oxidation of erythrocytes increased in splenectomized rats and remained close to control levels in the autotransplanted group. No significant difference was detected between IgM levels of splenectomized and autotransplanted groups. Mortality rates were the same for all groups, except that splenectomized animals given antimicrobial therapy had increased survival rates. In conclusion, it is likely that the spleen has no role in protection against pulmonary sepsis and that only appropriate antimicrobial therapy can protect the splenectomized host from Pseudomonas sepsis.