Endoscopic Removal of Duodenal Perforating Fishbone - A Case Report.

BACKGROUND: Accidental ingestion of foreign bodies is common in clinical practice. While perforation of the ileum and jejunum due to the ingested foreign body is common, duodenal perforation is rare. In this report, our experience with this rare entity is shared. CASE REPORT: Here we present a 31-year-old patient with gastrointestinal tract perforation at the second part of the duodenum due to an ingested fishbone. The patient was admitted to the emergency room with abdominal pain. Right upper quadrant tenderness was detected at physical examination, and leukocytosis on the laboratory test results. Ultra-sonography was not diagnostic, however, computerized tomo-graphy showed an ingested foreign body in the second part of the duodenum. A fishbone perforating the duodenum was retrieved by endoscopy. The patient was managed non-operatively, and discharged without any problems on the third day after endoscopy. CONCLUSION: Endoscopic removal and non-operative management may be feasible in carefully selected patients with duodenal perforated fishbone ingestion.

Evaluation of tularaemia courses: a multicentre study from Turkey.

In this multicentre study, which is the largest case series ever reported, we aimed to describe the features of tularaemia to provide detailed information. We retrospectively included 1034 patients from 41 medical centres. Before the definite diagnosis of tularaemia, tonsillitis (n = 653, 63%) and/or pharyngitis (n = 146, 14%) were the most frequent preliminary diagnoses. The most frequent clinical presentations were oropharyngeal (n = 832, 85.3%), glandular (n = 136, 13.1%) and oculoglandular (n = 105, 10.1%) forms. In 987 patients (95.5%), the lymph nodes were reported to be enlarged, most frequently at the cervical chain jugular (n = 599, 58%), submandibular (n = 401, 39%), and periauricular (n = 55, 5%). Ultrasound imaging showed hyperechoic and hypoechoic patterns (59% and 25%, respectively). Granulomatous inflammation was the most frequent histological finding (56%). The patients were previously given antibiotics for 1176 episodes, mostly with ß-lactam/ß-lactamase inhibitors (n = 793, 76%). Antituberculosis medications were provided in seven (2%) cases. The patients were given rational antibiotics for tularaemia after the start of symptoms, with a mean of 26.8 ± 37.5 days. Treatment failure was considered to have occurred in 495 patients (48%). The most frequent reasons for failure were the production of suppuration in the lymph nodes after the start of treatment (n = 426, 86.1%), the formation of new lymphadenomegalies under treatment (n = 146, 29.5%), and persisting complaints despite 2 weeks of treatment (n = 77, 15.6%). Fine-needle aspiration was performed in 521 patients (50%) as the most frequent drainage method. In conclusion, tularaemia is a long-lasting but curable disease in this part of the world. However, the treatment strategy still needs optimization.

Psychodrama: an innovative way of improving self-awareness of nurses.

The aim of this educational session was to form a group interaction model for improving the self-awareness of nurses via psychodrama. The structured group interaction session was conducted three times, with three separate groups, during the 'Intensive Care Nursing' training programme at a teaching hospital in Ankara. An assessment was made using the written records and observations of the group director and co-directors and feedback from nurses regarding the session. The nurses were highly motivated, adapting readily to the learning environment and following the instructions without difficulty. They were able to describe their personal experience with a specific patient and also to identify the fundamental emotion engendered by that interaction. Their feedback regarding the session was favourable. The psychodrama technique helped the nurses to understand themselves, to explore the perspective of others and to make the connection between their own thoughts/feelings and those of their patients. Psychodrama can be an effective teaching tool in addressing the communication issues that arise in nursing.

Tularaemia outbreaks in Sakarya, Turkey: case-control and environmental studies.

INTRODUCTION: Tularaemia is an important zoonotic disease that leads to outbreaks. This study aimed to compare the epidemiological characteristics of two tularaemia outbreaks that occurred in the Sakarya region of Turkey, analyse the risk factors for the development of outbreaks and identify Francisella (F.) tularensis in the water samples. METHODS: Two tularaemia outbreaks occurred in the Kocadongel village in 2005 and 2006. A field investigation and a case-control study with 47 cases and 47 healthy households were performed during the second outbreak. Clinical samples from the patients and filtrated water samples were analysed for F. tularensis via real-time polymerase chain reaction. RESULTS: From the two outbreaks, a total of 58 patients were diagnosed with oropharyngeal tularaemia based on their clinical and serological results. Both outbreaks occurred between the months of January and April, and the number of patients peaked in February. Logistic regression analysis revealed that the consumption of natural spring water was the only significant risk factor for tularaemia infection (odds ratio 3.5, confidence interval 1.23-10.07). F. tularensis was detected in eight clinical samples and in the filtrated natural spring water. CONCLUSION: This study is the first report of tularaemia from this region. The results show that both tularaemia outbreaks were related to the consumption of untreated natural spring water. To prevent waterborne tularaemia, community water supplies should be treated and checked periodically.

Naturally occurring amino-acid substitutions to nucleos(t)ide analogues in treatment naive Turkish patients with chronic hepatitis B.

Naturally occurring amino-acid substitutions in the hepatitis B virus (HBV) polymerase gene may be responsible for resistance to nucleoside/nucleotide (NUCs) analogues. To date, only pre-existing lamivudine resistance has been extensively studied. The aim of the present study was to determine the naturally occurring or pre-existing amino-acid substitutions related to NUCs in treatment naive Turkish patients with chronic hepatitis B (CHB). The investigation involved a total of 88 patients (65 males and 23 females; mean age, 34 years; range, 15-61 years) who were diagnosed with CHB between April 2008 and January 2009. According to HBeAg status, 66 patients were HBeAg-negative and 22 patients were HBeAg positive. Naturally occurring substitutions in the HBV polymerase region were detected by DNA sequencing in 17 (19%) and 30 (34%) patients, based on manual and geno2pheno tool database interpretation, respectively. Each amino-acid substitution appeared alone and included rtA194T, rtV214A, rtQ215S, rtI233V and rtN236T. The median values for viral load, ALT and AST were 3.3 log(10) (2.0-6.0) IU/mL, 36 (12-515) U/L and 27 (13-284) U/L, respectively, but these did not correlate with the observed amino-acid substitutions in the polymerase region. By direct sequencing, genotype D of HBV was found to still be dominant among Turkish patients. In conclusion, every patient who is diagnosed with CHB should be monitored before the start of treatment for more effective management of patient treatment options.

Investigation of early atherosclerotic changes in acromegalic patients.

BACKGROUND: Functional and morphological changes of endothelium were risk factors for mortality attributed to atherosclerosis. Studies investigating early atherosclerotic alterations and the effect of the treatment of acromegaly on these alterations gave conflicting results. OBJECTIVE: Surrogate markers of early atherosclerotic changes, i.e. brachial artery flow-mediated dilation (FMD) and carotid artery intima-media-thickness (IMT) in active and inactive acromegalic patients were compared with control subjects matched to patients for age, sex and cardiovascular risk factors to find out the direct effects of growth hormone (GH)/insulin-like growth factor-1 excess. METHODS: In 14 active acromegalics and their 14 matched controls, 14 inactive acromegalics and their 14 matched controls, carotid artery IMT and FMD of brachial artery were measured. Inactive acromegalics were in remission for at least 1 year. RESULTS: Active acromegalics had higher IMT than matched controls and inactive acromegalics (0.85 +/- 0.20 mm, 0.64 +/- 1.77 mm, 0.66 +/- 0.20 mm respectively; p < 0.005, p < 0.05) and IMT of inactive acromegalics was not different from their matched controls (0.61 +/- 0.12 mm). FMD was significantly lower in active acromegalics than in matched controls and inactive acromegalics (2.910 +/- 2.00 mm, 6.5 +/- 2.81 mm, 5.68 +/- 2.9 mm respectively; p < 0.005, p < 0.05). FMD of inactive acromegalics was not significantly different from their matched controls (7.96 +/- 3.12 mm). A significant inverse relationship was found between GH and FMD in active acromegalics (r = -0.659, p = 0.010). CONCLUSION: In active acromegalics, early atherosclerotic changes are not only attributed to the high prevalence of risk factors, but also to the abnormal GH secretion itself.

An outbreak of oropharyngeal tularaemia linked to natural spring water.

A tularaemia outbreak was investigated involving 188 suspected cases in the Kocaeli region of Turkey between December 2004 and April 2005. A case-control study comprising 135 laboratory-confirmed cases and 55 controls was undertaken to identify risk factors for the development of the outbreak and to evaluate laboratory diagnostic methods. Tularaemia was confirmed by a microagglutination test (MAT) titre of >or=1 : 160 in 90 of the patients. In MAT-negative sera, 23/44 (52 %) were positive by ELISA with Francisella tularensis LPS and 1/9 (11 %) by Western blotting with this antigen. A species-specific PCR was positive in 16/25 (64 %) throat swabs and 8/13 (62 %) lymph node aspirates. Multivariate analysis showed that drinking natural spring water was the leading risk factor for the development of tularaemia (P=0.0001, odds ratio 0.165, 95 % CI 0.790-0.346). The outbreak ceased after abandonment of the suspected natural water springs.

Diffusion weighted MRI of primary pituitary abscess. Case report.

Pituitary abscess is a rarely seen entity that can lead to serious neuroendocrine disorders or even be fatal if not diagnosed or treated correctly. Preoperative diagnosis plays an important role in planning the operation and treatment strategies. This report describes the diagnostic value of diffusion-weighted imaging (DWI) in addition to conventional magnetic resonance imaging (MRI) of primary pituitary abscess formation caused by Klebsiella ozaenea in a 33-year-old man.

Effects of amlodipine and fosinopril on heart rate variability and left ventricular mass in mild-to-moderate essential hypertension.

The differences between long-acting dihydropyridines and angiotensin-converting enzyme inhibitors with regard to their long-term effects on 24-h heart rate variability (HRV) and left ventricular (LV) mass are less clear in mild-to-moderate essential hypertension. We studied the long-term effects of amlodipine and fosinopril on 24-h HRV and LV mass in mild-to-moderate essential hypertension. In this study, 27 patients with never treated mild-to-moderate essential hypertension were randomised to receive either amlodipine or fosinopril once daily as monotherapy. At baseline and at the end of the third and sixth months, each of the patients underwent 24-h HRV and ambulatory systolic (SBP) and diastolic (DBP) blood pressure analysis. LV mass index was calculated from echocardiographic examination at baseline and at the end of the sixth month. In amlodipine group (n = 14), 24-h SBP/DBP (mmHg) decreased from 144 +/- 8/94 +/- 4 to 128 +/- 6/83 +/- 3 at the end of the third month and to 125 +/- 5/81 +/- 2 at the end of the sixth month (p < 0.0001). In fosinopril group (n = 13), the respective changes were 143 +/- 9/97 +/- 7, 132 +/- 6/87 +/- 5 and 127 +/- 6/82 +/- 3 (p < 0.0001). At the end of the sixth month, LV mass index (g/m(2)) decreased from 122 +/- 26 to 105 +/- 21 in amlodipine group (p < 0.0001) and from 118 +/- 23 to 101 +/- 14 in fosinopril group (p < 0.0001). There were no significant changes in HRV parameters in both the groups. It was concluded that both drugs caused significant decrease in SBP and DBP, and LV mass in patients with mild-to-moderate essential hypertension did not have significant long-term effects of either amlodipine or fosinopril on 24-h HRV parameters reflecting sympathetic or parasympathetic activity in these patients.

Does the endothelial function change in renal transplant patients with longer duration of exposure and with higher cumulative doses of cyclosporine?

OBJECTIVE: Administration of cyclosporine (CsA) is one potential cause of endothelial dysfunction in renal transplant patients. We sought to investigate endothelial functional changes with respect to the cumulative dose and duration of exposure to CsA. METHODS: Sixty-six renal recipients and 25 healthy controls were included in the study. The recipients were classified according to their time of CsA exposure: group 1 (0 to 36 months); group 2 (36 to 72 months); and group 3 (over 72 months). Endothelial function of the brachial artery was evaluated using high-resolution vascular ultrasound. Endothelium-dependent and -independent vasodilatation (EDD and EID, respectively) were assessed by assessing the responses to reactive hyperemia and using sublingual isosorbide dinitrate (ISDN), respectively. RESULTS: There were no statistically significant differences between the groups with regard to their demographic, clinical, and most biochemical characteristics. Baseline measurements of the diameter of the brachial artery were similar in all groups. The values of mean brachial artery EDD and EID responses in groups 1, 2, and 3 were less than those in the control group (P < .05, P < .05, and P < .05, respectively). Mean brachial artery EDD and EID in group 1 were significantly impaired compared to groups 2 and 3 (for EDD: P < .05 and P < .05, respectively; for EID: P < .05 and P < .05, respectively). In contrast there was no difference between groups 2 and 3 with respect to these parameters. There were mild to moderate positive correlations between the cumulative doses of CsA and EDD and EID (r = .26 and r = .52, P < .05, respectively). CONCLUSION: Endothelial dysfunction was more prominent in the first 36-month period than later despite the longer exposure to and higher cumulative doses of CsA. This finding may reflect an extended effect of the uremic state on endothelial function or more intense doses of CsA in early posttransplant period.

Is there a relation between duration of cyclosporine usage and right and left ventricular function in renal transplant patients? Tissue Doppler Echocardiography study.

BACKGROUND: Our aim was to investigate the effect of cyclosporine (CsA), which is commonly used in renal transplant patients and causes myocardial fibrosis and elevated arterial tension, on cardiac function. METHODS: Sixty-six renal transplant patients (RTPs) and 25 healthy controls were included in the study. Renal transplantation patients were divided according to time of CsA exposure: group 1 (0 to 36 months); group 2 (36 to 72 months) and group 3 (> 72 months). Systolic peak velocity (Sm, mitral; St, tricuspid) and mitral early (e)/late (a) (Me/a) and tricuspid e/a (Te/a) waves of the right and the left ventricles were measured by pulse-wave (PW) Doppler used for tissue Doppler imaging of both ventricles as well as the ventricle free wall near to the lateral tricuspid and the posterior mitral leaflets. The measurements included conventional diastolic early (E) and late (A) waves and deceleration time (DT) of the E wave, isovolumetric relaxation time (IVRT) of both ventricles, as well as left ventricular systolic ejection fraction (EF). RESULTS: There were no statistically significant differences between the groups with regard to demographic, clinical, and most biochemical characteristics. Left ventricular EF was normal in all groups; there were no statistically significant differences. IVRT and DT of left ventricle and right ventricle DT values were similar among RTPs. On the other hand, values were found to be increased in RTP groups compared with the control group. E/A ratio, Me/a Te/a of both ventricles were similar among RTPs. However, these values were found to be decreased in RTP groups compared with the control group. CONCLUSIONS: Although left ventricular systolic functions were normal in all groups, there were statistically significant impairments of biventricular diastolic function parameters among renal transplant recipients compared with the control group.

[Disorders of diastolic function in patients on hemodialysis]. / Poremecaji dijastolne funkcije u pacijenata na hemodijalizi.

INTRODUCTION: Impaired cardiac function is frequently present in patients on maintenance haemodialysis. AIM: To assess the left ventricular diastolic function in patients on haemodialysis. MATERIAL AND METHODS: We used 2D and pulsed wave Doppler echocardiography to evaluate the left ventricular diastolic function in 40 patients on haemodialysis and compared those to healthy controls. RESULTS: Majority of Doppler parameters were changed in patients on haemodialysis. Diastolic dysfunction was present in 77.5% patients. In comparison to the healthy controls haemodialysis patients showed significant increase in peak velocity of late diastolic filling, (A wave, 76.82 +/- 23.76 cm/s vs. 58.46 +/- 9.65 cm/s p < 0.001) and reduction in the E/A ratio (1.00 +/- 0.26 vs. 1.26 +/- 0.31 p < 0.001). CONCLUSION: There was significant impairment in left ventricular diastolic function in patients on haemodialysis.

[Morphologic changes in the interventricular septum and the posterior wall of the left ventricle in patients on hemodialysis]. / Morfoloske promjene interventrikularnog septuma i straznjeg zida lijevog ventrikula u pacijenata na hemodijalizi.

Left ventricular hypertrophy is dominant finding in patients with chronic renal failure. In our work we have analysed the interventricular septum and left ventricular posterior wall in thirty patients on chronic hemodialysis, using an echocardiography. Increased thickness of interventricular septum and left ventricular posterior wall were found in 70% patients. We have also confirmed correlation between these parameters and value of systolic arterial blood pressure. Echocardiography is very useful and powerful method for the assessment of morphological cardiac disorders in patients on hemodialysis.

[Effect of hemodialysis on functional parameters of the left ventricle]. / Uticaj hemodijalize na funkcionalne parametre lijevog ventrikula.

Many cardiac functional disorders are developed in chronic renal failure. The aim of our work was the echocardiographic assessment of left ventricular functional parameters in patients on haemodialysis. We observed that left ventricular end-diastolic volume, left ventricular end-systolic volume and stroke volume significantly decreased after haemodialysis. Left ventricular ejection fraction increased after haemodialysis, but not significantly. Systolic and diastolic blood pressure decreased significantly after haemodialysis while heart rate increased significantly. During the haemodialysis, many haemodynamic changes are observed. Analysis of cardiac functional status is essential before the haemodialysis starts.

Left ventricular geometric patterns and QT dispersion in untreated essential hypertension.

The spectrum of left ventricular adaptation to hypertension, different types of hypertrophy patterns, and QT dispersion in different types of hypertrophy was investigated in 107 patients with untreated essential hypertension and 30 age- and gender-matched normal adults studied by 12-derivation electrocardiogram (ECG), two-dimensional, and M-mode echocardiography. Left ventricular mass (LVM), body mass index, total peripheral resistance (TPR), relative wall thickness (RWT), and QT dispersion were found to be statistically significantly higher in the hypertension group (P < .001 for all). Among hypertensive patients, 41.1% had both normal LVM and RWT, here called normal left ventricle in hypertension; 10.3% had concentric hypertrophy with increased LVM and RWT; 14.95% had eccentric hypertrophy with increased LVM and normal RWT; and 32.7% had concentric remodeling with normal LVM and increased RWT. Echocardiographically derived cardiac index was higher in the concentric hypertrophy and eccentric hypertrophy patterns (P = .002 and P < .0001, respectively), whereas TPR was higher in the concentric hypertrophy and concentric remodeling patterns (P = .017 and .02, respectively). QT dispersion values were found to be increased in the hypertensive group (P = .001), whereas similar values were calculated for different types of hypertrophy patterns. We conclude that the more common types of ventricular adaptation to essential hypertension are eccentric hypertrophy and concentric remodeling. Concentric hypertrophy is found to be associated with both volume and pressure overload, whereas eccentric hypertrophy is associated with volume overload only and concentric remodeling is associated with pressure overload. But different left ventricular geometric patterns seem to have similar effects on QT dispersion.

Acute myocardial infarction in man treated with epirubicin for non-Hodgkin lymphoma.

This article presents a young patient affected with non-Hodgkin lymphoma who developed acute myocardial infarction 7 days after treatment with epirubicin (90 mg/m2, day 1), cyclophosphamide (600 mg/m2, day 1), vincristine (2 mg, day 1), prednisolone (100 mg, days 1-5), and ondansetron (3 x 4 mg/day, days 1-2). Six months after the myocardial infarction the patient had no further cardiac complications after treatment with cylcophosphamide, vincristine, and ondansetron chemotherapy regimen. Epirubicin was considered to play an important role in the production of infarction, and the probable mechanisms of epirubicin-induced myocardial infarction are discussed.

Comparison of renal perfusion indices in captopril scintigraphy.

Perfusion indices used in renal scintigraphy were adapted to captopril-enhanced renal scintigraphy in order to determine if these parameters have any value in differentiating patients with renovascular hypertension (RVH) from normal subjects. Regions of interest (ROIs) were chosen over the aorta and kidneys, and time-activity curves generated. The ratio of integrated aortic counts to renal counts, from the time of injection to arterial peak, was calculated. The difference in the value of this index between captopril and basal scintigraphies was -17 +/- 12 and -16 +/- 13 for the right and left kidneys, respectively, in the group of patients with essential hypertension, whereas in the patients with renovascular hypertension, these values were 24 in the stenotic and 14 in the non-stenotic kidney. This parameter is useful for separating patients with RVH from normal subjects.

The value of captopril renal scintigraphy in assessing the results of percutaneous transluminal renal angioplasty and in following up renovascular hypertension--a case report.

Percutaneous transluminal renal angioplasty (PTRA) was performed in a patient with bilateral renal artery stenoses diagnosed noninvasively by captopril renal scintigraphy and confirmed by renal arteriography. The captopril renal scintigraphy parameters returned to normal in correlation with improved blood pressure response fifteen days after PTRA. Five months later hypertension reappeared and the repeated captopril renal scintigraphy suggested left renal artery stenosis. PTRA was repeated and a stent was implanted with reversal of blood pressure, and captopril renal scintigraphy findings returned to normal levels. Six months after second PTRA, the blood pressure increased to hypertensive levels, and captopril renal scintigraphy indicated left renal artery stenosis. The renal arteriography, however, revealed a new stenosis at the left renal artery ostium. The PTRA with a second stent implantation was performed successfully. The captopril renal scintigraphic parameters and the blood pressure were again normalized after the last intervention and remained normal for thirteen months of follow-up.