The impact of expectant management, systemic methotrexate and surgery on subsequent pregnancy outcomes in tubal ectopic pregnancy.

BACKGROUND: The most common treatment modalities of ectopic pregnancy may influence long-term subsequent fertility outcomes in women who previously treated for ectopic pregnancy. AIMS: Our objective was to compare long-term subsequent fertility outcomes after treatment with expectant management, systemic methotrexate (MTX) and surgery in tubal ectopic pregnancy. METHODS: We searched our database for all women diagnosed with tubal ectopic pregnancy between January 2007 and January 2011 who were managed expectantly, with systemic MTX and with surgery. Treatment success and spontaneous pregnancy rates were compared in patients who desire to conceive following a tubal pregnancy. RESULTS: One hundred twelve of 151 women desired to conceive following tubal ectopic pregnancy. Twenty-seven of 112 (24.1 %) patients were managed expectantly. Fifty-three (47.3 %) and 32 (28.5 %) patients were managed with systemic MTX or surgery, respectively. All patients in expectant and surgery groups were managed successfully. Two (3.7 %) patients had surgery after failed treatment with systemic MTX. Spontaneous intrauterine pregnancy rates were 62.9 % in expectantly managed women, 58.4 % in women with systemic MTX and 68.7 % in women with surgery (p > 0.05). CONCLUSIONS: Treatment of ectopic pregnancy with either expectant management or systemic MTX is equally effective as compared to surgery. Spontaneous intrauterine pregnancy rates were comparable in expectant management, systemic methotrexate and surgery.

Occurrence of microcystins in water, bloom, sediment and fish from a public water supply.

Microcystin (MC) accumulation was determined in the liver and muscle of two omnivorous fish species which are consumed and are economically important, and in a planktivorous-carnivorous fish from Lake Egirdir, Turkey. Free extractable MCs in fish tissue samples were detected by enzyme-linked immunosorbent assay (ELISA) with confirmation by high performance liquid chromatography with photodiode array detection (HPLC-PDA). MC-LA and -YR, were detected in both liver and muscle, followed by MCs -LY, -LF, -RR and -LR respectively. The MC concentrations varied between 0.043 and 1.72µg/g dry weight in liver and muscle tissues. MCs were also determined in samples of water, sediment and a bloom sample of Microcystis aeruginosa from the lake by HPLC-PDA. MC-LY and -YR were most commonly identified in water samples, with total MC concentrations ranging from 2.9±0.05 to 13.5±2.3µg/L. Sediment analyses, showed that MC-YR was present in samples between 7.0 and 17.6µg/g dw, especially in October, November and December when no MC-YR was recorded in water, followed by MC-LW. The findings indicate that water and sediment contained MCs, and more importantly that fish were contaminated with MCs that may pose an MC-associated human health risk.

In vitro biomechanical comparison of six different fixation methods following 5-mm sagittal split advancement osteotomies.

The sagittal split ramus osteotomy (SSRO) is a surgical technique used widely to treat many congenital and acquired mandibular discrepancies. Stabilization of the osteotomy site and the potential for skeletal relapse after the procedure are still major problems. The aim of this study was to compare the mechanical stability of six methods of rigid fixation in SSRO using a biomechanical test model. Sixty polyurethane replicas of human hemimandibles were divided into six groups. In group I, the osteotomies were fixed with two four-hole titanium miniplates; in group II, with one four-hole miniplate; in group III, with one four-hole miniplate+a bicortical screw; in group IV, with a grid miniplate; in group V, with a four-hole locking miniplate; and in group VI, with a six-hole miniplate. A linear load in the premolar region was applied to the hemimandibles. The resistance forces (N) needed to displace the distal segment by 1, 3, and 5mm were recorded and the data transmitted from the load cell to a computer. One-way analysis of variance with Tukey's post hoc test was performed to compare the means between groups. For the three displacement conditions, there was a strong tendency for the 2.0-mm plate+screw and the grid plate to have higher values.

Are success and survival rates of early implant placement higher than immediate implant placement?

Immediate placement refers to the placement of an implant into a tooth socket at the time of extraction; early placement refers to the placement of an implant after substantial gingival healing, but before any clinically significant bone fill occurs within the socket. This study evaluated the success and survival rates of implants following immediate and early placement. 50 implants were placed in 36 patients. 26 immediate (group I) and 24 early placements (group II) were performed. Pain or tenderness with function, mobility, radiographic bone loss from initial surgery and exudate history were evaluated. Mean vertical bone loss in the immediate placement group was 0.55 mm and 0.80 mm in the early placement group. The survival rate for the immediate placement group was 96.16% with 51.6 months follow-up and in the early placement group was 100% with 61.9 months follow-up. The results of this study suggest that although the success and survival rates of early placed implants were a little higher and the follow up period was longer than immediately placed implants, the difference was not remarkable. In conclusion, both implant insertion techniques are safe and reliable procedures with considerably high survival rates.

ADMA, proteinuria, and insulin resistance in non-diabetic stage I chronic kidney disease.

The rationale of this study is based on the fact that, both proteinuria and elevated asymmetric dimethyl arginine (ADMA) levels have been linked to the progression of vascular disease. Currently, there is not enough knowledge about any association between the levels of proteinuria and ADMA levels. Seventy-eight non-diabetic patients (42 men, 36 women, mean age of 26.1+/-5.2 years) with proteinuria having normal glomerular filtration rate were enrolled along with 38 healthy subjects (20 men, 18 women, mean age of 26.9+/-5.9 years). Proteinuria was below 3.5 g/day in 40 patients and above 3.5 g/day in 38 patients. Both groups had similar age, gender, and body mass index distributions. Serum ADMA, symmetric dimethyl arginine (SDMA), immunoreactive insulin, and high sensitivity C reactive protein (hsCRP) levels were measured. Insulin resistance was determined by homeostasis model assessment (HOMA). Serum ADMA, SDMA, insulin, hsCRP levels, and HOMA indexes were significantly higher in patients than in healthy control subjects. The above parameters were higher in the nephrotic range proteinuria group when compared to patients having protein levels below 3.5 g/day. There were significant correlations between the levels of proteinuria and the above parameters. According to the regression analysis, levels of proteinuria and hsCRP were significant determinants of serum ADMA levels. Our results indicate that, independent of other risk factors, ADMA is directly associated with proteinuria. Further studies are recommended to find out whether elevated ADMA levels are implicated in the high cardiovascular risk of proteinuric nephropathies.

Persistent mediastinal and axillary lymph node tuberculosis in a renal transplant patient with successful outcome.

Tuberculosis is an opportunistic infection that carries substantial morbidity and mortality in renal transplant recipients. We report here about a 21 year-old man with a living related renal transplant from his mother who developed persistent extra-pulmonary tuberculosis. The disease showed aggressive invasion to the axillary and mediastinal regions with abscess formations, despite standard antituberculosis treatment. During the course of the disease, immunosuppressive therapy was stopped, and the patient received extraordinary doses of multiple antituberculosis drugs. The patient then showed an uneventful course with good clinical and radiological responses.

Adiponectin level is reduced and inversely correlated with the degree of proteinuria in type 2 diabetic patients.

AIMS: Adiponectin seems to be an important modulator for metabolic and vascular diseases. We aimed to measure plasma adiponectin levels in type 2 diabetic patients and investigate any association with the severity of proteinuria. METHODS: 80 patients (mean age, 46.9 +/- 5.1 years; body mass index (BMI), 25.8 +/- 1.98 kg/m2) and 47 healthy volunteers (mean age, 46.1 +/- 5.5 years; BMI 26.74 +/- 2.23 kg/m2) were included. Plasma adiponectin concentration, insulin levels, homeostasis model assessment (HOMA) indices, calculated glomerular filtration rate (GFR), high sensitive C reactive protein (hsCRP) and biochemistry panel were determined in all subjects. The association between adiponectin concentration and proteinuria was evaluated. Additionally, the relationship between adiponectin and hsCRP and calculated GFR were also investigated. RESULTS: Adiponectin levels in patients were significantly lower than those of controls (n = 80; 8.76 +/- 4.50 microg/ml for patients, n = 47; 24.27 +/- 5.59 microg/ml for controls, p < 0.001). Plasma adiponectin levels in patients with proteinuria were significantly lower than those without proteinuria (n = 43; 6.81 +/- 2.82 microg/ml for proteinuria, n = 37; 11.98 +/- 3.32 microg/ml for no proteinuria, p < 0.001). There was a significant negative correlation between plasma adiponectin concentrations and the degree of proteinuria (r = -0.433, p < 0.001). There were also significant negative correlations between adiponectin concentrations and insulin levels as well as HOMA index in the patient group (r = -0.322, p = 0.004; r = -0.301, p = 0.032). Additionally there was a significant negative correlation between adiponectin and hsCRP levels in the patient group (r = -0.872, p < 0.001). CONCLUSION: The results show that adiponectin is lower in patients with type 2 diabetes and the levels are negatively correlated with the severity of proteinuria.

The midnight-to-morning urinary cortisol increment method is not reliable for the assessment of hypothalamic-pituitary-adrenal insufficiency in patients with end-stage kidney disease.

A previous study reported that the midnight-to-morning urinary cortisol increment method could be used to reliably assess the insufficiency of the hypothalamic-pituitary-adrenal (HPA) axis. The principal aim of the present study is to verify whether the midnight-to-morning urinary cortisol increment is a reliable method for the assessment of the HPA axis in patients with various degrees of impaired kidney function. Fifty-six clinically stable patients with chronic kidney disease (CKD) and 14 healthy subjects were enrolled in the present study. Patients with CKD were divided on the basis of glomerular filtration rate (GFR) into the following arbitrary groups: mild (GFR: 60-89 ml/min/1.73 m2, no.=15), moderate (GFR: 30-59 ml/min/1.73 m2, no.=12) and severe kidney insufficiency (GFR: 15-29 ml/min/1.73 m2, no.=13), and hemodialysis patients. Plasma cortisol and ACTH levels were measured. The HPA axis was assessed by short Synacthen test and overnight dexamethasone suppression test. Double voided urine samples were collected at midnight and waking in the patients and the controls. Urinary free cortisol (UFC) and creatinine levels were measured and the UFC/creatinine ratio (Cort/Cr) was calculated. Then, the Cort/Cr increment was calculated as the morning Cort/Cr minus the midnight Cort/Cr. Baseline plasma cortisol levels were not significantly different between two groups. However, we found that CKD patients had significantly greater plasma ACTH levels than controls. The patients with CKD had also significantly lower morning UFC levels than controls and there was a progressive fall in morning UFC levels with decreasing GFR. The assessment of the HPA axis in patients with GFR lower than 29 ml/min was hampered by falsely abnormal responses to the midnight-to-morning urinary cortisol increment method. Plasma cortisol responded normally to exogenously administered ACTH, while plasma cortisol was suppressed by overnight dexamethasone administration in all patients with CKD. In conclusion, this method is not a reliable test for assessment of the HPA insufficiency in patients with GFR lower than 29 ml/min.

Infectious complications in 135 Turkish renal transplant patients.

Infections are the emerging causes of mortality and morbidity due to lifelong immunosuppressive therapy in renal transplant patients (1, 4). Here, we report infectious complications of 135 renal allograft recipients who were followed up in the last 20 years in Gülhane Military Medical Academy, Ankara, Turkey. Of them, 83 (61.4%) had a transplant from living related donors, 18 (13.3%) from living non-related HLA matched donors and 34 (25.1%) from cadaveric matched donors. Immunosuppression was achieved in 42 (31.1%) recipients by azathioprine plus corticosteroid (AZA + CS) and in 93 (68.8%) by AZA + CS + cyclosporin A (CsA). Encountered infections were classified according to three different periods of the transplantation procedure [early (first month), intermediate (2-6th months) and late (after the 6th month)]. Bacterial infections were the leading infections in all three periods and the most affected system was the urinary tract. Each recipient had at least one episode of urinary tract infection (UTI) and E. coli was the most common urinary pathogen. On the other hand, HCV was the leading viral pathogen (14.3%). The total mortality rate was 7.4%, and septic shock was the most common cause of death (80%).

Oral and parenteral essential amino acid therapy in malnourished hemodialysis patients.

BACKGROUND/AIMS: Malnutrition has been encountered more frequently than expected and is associated with increased morbidity and mortality in hemodialysis (HD) patients. Until the last few years, only oral and enteral nutritional supplies have been used in the treatment of malnutrition in HD patients. However, intradialytic parenteral essential amino acid (EAA) nutrition has recently been introduced to treat these patients. The present study was conducted to compare both methods of EAA nutrition, oral and parenteral, in malnourished HD patients. METHODS: Half of the 20 malnourished HD patients in this study received 0.9 g/kg/week of oral EAA (oral group), while the other half of the patients were treated with the same dose of parenteral EAA (parenteral group) for 4 months. However, at the very beginning of the study, 4 patients from the oral group were transferred to the parenteral group because of complaints such as nausea and vomiting. Therefore, this study was completed with 6 patients in the oral group and 14 patients in the parenteral group. Some biochemical parameters, including blood lymphocyte counts and anthropometric measurements as indicators of the nutritional status, were obtained from both of the groups in the pre- and posttreatment periods. RESULTS: Following the treatment, there were no statistically significant differences between the groups with respect to anthropometric measurements. However, statistically significant increases were observed in serum albumin (p = 0.048) and creatinine (p = 0.006) levels and blood lymphocyte counts (p = 0.006) in the parenteral group, while there were statistically significant increases only in serum calcium (p = 0.028) levels and blood lymphocyte counts (p = 0.038) in the oral group following the treatment when compared to pretreatment values. CONCLUSION: These results show that parenteral EAA therapy is more comfortable and effective than oral EAA therapy in the treatment of malnourished HD patients.

Observations on edema formation and resolution in Gleich syndrome: essential role of the kidneys in effective arterial blood volume regulation.

Gleich syndrome is clinically present with episodes of angioedema, hypereosinophilia, oliguria, and weight gain due to fluid retention which may be sudden and remarkable, sometimes increasing to 10-20% of the baseline weight. The purpose of this study was to evaluate body fluid regulation and hormonal responses during the episode of angioedema and during the recovery phase in a patient with Gleich syndrome. A 24-year-old male was referred to our hospital for further evaluation of recurrent attacks of swellings of face, upper arms, and legs, marked weight gain, and oliguria. On first admission, the patient was in a remission phase, and the initial physical examination showed no abnormalities. Underlying disorders causing edema, such as heart, kidney, and liver diseases, and the recognized causes for hypereosinophilia, such as allergy, parasites, and collagen diseases, were ruled out. After 2 months, since his course was monitored, the patient was hospitalized. During days 10-19, he developed pronounced nonpitting edema of face, upper arms, and legs. Constant leukocytosis and hypereosinophilia, oliguria, and marked weight gain were also noted. A clinical remission was observed without any medication: intensive diuresis, loss of weight, regression of edema, and decreased eosinophil and leukocyte counts within 2 weeks. Physiological mechanisms during edema and resolution are discussed. In conclusion, our patient represents a suitable model for the protection of effective arterial blood volume because of the absence of underlying disorders causing edema. The kidneys play an essential role in the effective arterial blood volume regulation.

Recovery cycle of the blink reflex and exteroceptive suppression of temporalis muscle activity in migraine and tension-type headache.

Brain stem interneuronal excitability can be assessed by recording the recovery cycle of the blink reflex and exteroceptive suppression of temporalis muscle activity. Abnormal endogenous pain control mechanisms due to disturbed brain stem interneuronal activity have been implicated in the pathogenesis of tension-type headaches. The blink reflex, exteroceptive suppression of temporalis muscle activity, and the recovery curve of both the R2 component of the blink reflex and the ES2 component of the exteroceptive suppression of the temporalis muscle activity were studied in 20 patients with migraine without aura, 32 patients with tension-type headache, and 20 normal controls. In our study, the blink reflex was elicited by stimulation of the supraorbital nerve; the exteroceptive suppression of the temporalis muscle activity was elicited by applying electrical shocks to the labial commissure, both on the lower and upper sides. The recovery cycle was established by delivering paired shocks at different interstimulus intervals. Comparisons were made between normal control subjects, patients with migraine without aura, and patients with tension-type headache. The latency of R1, R2, and R2', the amplitude and size of the R2 and R2' components of the blink reflex, the latency and duration of the ES1 and ES2 components, and the recovery curve of the ES2 component of the temporalis muscle activity did not differ between groups. However, the recovery curve of the R2 component of the blink reflex diminished in patients with tension-type headache compared with the other groups. Our findings indicate reduced excitability of the brain stem interneurons in patients with tension-type headache.

Seroconversion rates of two different doses of hepatitis B vaccine in Turkish haemodialysis patients.

Seroconversion rates of hepatitis B vaccination with increasing antigen doses, in 77 haemodialysis (HD) patients were studied in randomly divided two groups. The first group received the standard 20 microg recombinant HBsAg (rHBsAg) dose, and the second group 40 microg at the 0, 1st and 2nd months of HD. At the end of the study, there were no statistically significant differences between the two groups in the response rates of protective antibody, but the response was always higher in the second group. On the other hand, strong positive antibody response (> or = 100 mlU/ml) according to dates of each dose were as 7.4%, 13.1%, 28.9% and 42.2% in the first group and 50.0%, 50.0%, 60.0% and 52.9% in the second group respectively, and there were statistically significant differences between the two groups in the first three months. We concluded that vaccination with higher antigen doses resulted in a stronger antibody response in the early period in our HD patients. No HBV infection was observed in these two groups in the study period.

Age-related alterations in antioxidant enzymes, lipid peroxide levels, and somatosensory-evoked potentials: effect of sulfur dioxide.

The effect of sulfur dioxide (SO(2)) on somatosensory-evoked potentials (SEPs), thiobarbituric acid reactive substances (TBARS), and the activities of Cu,Zn-superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), and catalase (CAT) were investigated in young (3 months), middle-age (12 months), and old (24 months) Swiss male albino rats. Ten ppm SO(2) was administrated to the animals of SO(2) groups in an exposure chamber for 1 h/day x 7 days/week x 6 while control groups were exposed to filtered air in the same condition. SO(2) exposure caused increased levels of brain Cu,Zn-SOD activity and decreased levels of brain GSH-Px activity in all experimental groups with respect to their corresponding control groups. Brain CAT activities were unaltered. Brain TBARS levels of all SO(2)-exposed groups were significantly increased in comparison with their respective control groups. The mean latencies of P(1), P(2), and N(2) components in the older group were either significantly different from the young or from the middle-age groups. The mean latency of the N(1) component in the older group and that of P(1) and N(1) in the middle-age group were significantly increased compared with the young group. SO(2) exposure caused the prolongation of all components in the young group, whereas it affected only the P(2) component in the middle-age group, but it did not result in any latency change in the older group in comparison with their corresponding control groups.http://link.springer-ny. com/link/service/journals/00244/bibs/37n4p554.html

The effect of cadmium (Cd) treatment on somatosensory evoked potentials (SEPs) and conduction velocity in alloxane-induced diabetic rats: relation to lipid peroxidation.

Fifty-two healthy Swiss male albino rats, aged three months, were divided into four groups: Control (C), diabetic (D), cadmium (Cd), and diabetic + Cd (D+Cd). Diabetes was induced in D and D+Cd groups by administration of alloxane (5 mg/100 g). Cd and D+Cd groups were injected with CdCl2 i.p. (2 mg/kg/week) for 2 months. Somatosensory evoked potentials (SEPs) of the four groups were recorded following left posterior tibial nerve (PTN) stimulation. The mean latencies of P1, N1, P2 and N2 components were prolonged in all experimental groups compared with the control group. P1N1 and N1P2 amplitudes were significantly decreased in Cd and D+Cd groups in comparison with the control group. P2N2 amplitude was significantly decreased in the Cd group compared with the control group. In addition, conduction velocities and action potential amplitudes were determined from the sciatic nerves. The means of peripheral conduction velocities and action potential amplitudes were decreased significantly in all the experimental groups in comparison with the control group. Thiobarbituric acid reactive substances (TBARS), an indicator of lipid peroxidation, were increased in the kidneys and sciatic nerves of all experimental groups compared with the control group. A significant increase in the TBARS level of the brain was found in the Cd and D+Cd groups.

The effect of cadmium on visual evoked potentials in alloxane-induced diabetic rats: relation to lipid peroxidation.

Fifty-two healthy male Swiss albino rats, aged three months, were used in this study. They were divided into four groups: control (c), diabetic (D), cadmium (Cd), and diabetic + Cd (D+Cd). A diabetic condition was induced in D and D + Cd groups by administration of alloxane (5 mg/100 g). After this treatment, Cd and D + Cd groups were injected intraperitoneally with CdCl(2) (2 mg/kg week). At the end of the 2-month experimental period, flash visual evoked potentials (FVEPs) of the four groups were recorded with disk electrodes attached with electrode paste 0.5 cm in front of and behind the bregma. The mean latencies off the P(1), N(1), P(2), N(2) and P(3) components were significantly prolonged in the diabetic group compared with the control group. The mean latencies of P(3) in the D + Cd group and of P(1) and P(3) in the Cd group were longer than those of the control group. P(2)N(2) amplitude of Cd and D + Cd groups were significantly increased compared with the control group. On the other hand, thiobarbituric acid-reactive substances (TBARS) were determined as an indicator of lipid peroxidation. Our data showed that Cd treatment and diabetic condition caused a significant increase of lipid peroxidation in kidney, brain, retina and lens.

Detection of source of haematuria after extracorporeal shock wave lithotripsy (ESWL) by automated measurement of urinary red cell volume.

Midstream urine samples taken from 35 patients with secondary haematuria due to nephrolithiasis and 31 patients with haematuria after ESWL were compared using a red cell analyser (RCA) to differentiate the source of haematuria. Urine samples obtained from both groups were examined by RCA for urinary red cell mean corpuscular volume (UMCV) and urinary red cell volume distribution curves (RCVDC). To rule out the influence of blood MCV (BMCV), BMCVs were determined separately and the ratio of UMCV/BMCV (R) was calculated. Although our findings showed no difference between haematurias after ESWL and nephrolithiasis, we cannot exclude a direct effect of shock waves on renal tissue.

The effect of developmental exposure to cadmium (Cd) on visual evoked potentials (VEPs) and lipid peroxidation.

Pregnant Swiss albino rats were divided into three groups: control (C), gestational exposure of Cd (G-Cd), and gestational/postnatal exposure of Cd (GP-Cd) groups. Control animals received tap water, and the rats of GP-Cd group received Cd as CdC12 in their drinking water during the experimental period. The G-Cd group was given Cd during pregnancy, but given tap water after birth. Twenty-two days after birth, 15 rats (for each group) were taken from their mothers and continued to be treated with Cd (GP-Cd group) or tap water (C and G-Cd groups) for an additional 38 days. On postnatal day (PND) 60, flash visual evoked potentials (FVEPs) were recorded with disc electrodes attached with collodion 0.5 cm in front of and behind bregma. The mean latencies on N1, P2, and P3 were prolonged in the GP-Cd group compared with controls. The mean latency of P3 was also significantly different between G-Cd and GP-Cd groups. P1-N1 and N1-P2 amplitudes of VEPs were significantly decreased in the GP-Cd group compared with control group. N1-P2 amplitude of the G-Cd group was significantly lower than that of the control group. Thiobarbituric acid reactive substances (TBARS) were determined as an indicator of lipid peroxidation. Our data showed that pre- and postnatal Cd treatment caused a significant increase of lipid peroxidation in the brain.

Effect of chronic cadmium exposure on VEP and EEG spectral components.

Pregnant swiss albino rats were divided to three groups as control (C), cadmium (Cd) and non-cadmium (NCd) groups. Control animals were received tap water while the rats of Cd group were received Cd as CdC12 in their drinking water during the experimental period. On the other hand, the NCd group was given Cd during pregnancy, but given tap water after birth. Twenty-two days after birth, fourteen rats (for each group) were taken from their mothers and continued to be treated with Cd (Cd group) or tap water (C and NCd groups) for an additional 38 days. After the experimental period, flash VEPs and EEGs of three groups were recorded and amplitude spectral analysis was computed by Transient Response-Frequency characteristics (TRFC) method. The mean amplitude (dB) of 1-3.5 and 14-20 Hz frequency bands for right response whereas 1-3.5, 4-7, 8-13 and 14-20 Hz frequency bands for left response of VEPs were decreased in Cd group compared with control group. On the other hand, significant differences were observed between Cd and control groups in all the frequency bands of EEGs except 6-8 Hz.