Assessment of serum glucose/potassium ratio as a predictor for delayed neuropsychiatric syndrome of carbon monoxide poisoning.

INTRODUCTION: Carbon monoxide (CO) poisoning is a crucial cause of delayed neuropsychiatric syndrome (DNS). However, most biomarkers are not satisfactory for the prediction of DNS caused by CO poisoning. Thus, we evaluated the adequacy of the serum glucose/potassium (GLU/K) ratio, which may be an easy, quick, and readily available parameter that can be used in the emergency department for predicting DNS. METHODS: We evaluated 281 patients who were admitted to our emergency department between January 2012 and December 2018. The patients were divided into two groups: DNS (+) and DNS (-). The GLU/K was compared for the groups. RESULTS: Glucose, blood urea nitrogen, carboxyhemoglobin, and GLU/K ratios of patients in the DNS (+) group were statistically significantly higher than those patients in DNS (-) group (140 ± 34 vs. 110 ± 24, p < 0.001; 17.58 ± 6.14 vs. 14.27 ± 5.08, p = 0.003; 29 ± 5.1 vs. 18.9 ± 7.6, p < 0.001; and 38.35 ± 10.11 vs. 28.65 ± 6.53, p < 0.001, respectively). The area under the curve for GLU/K to predict DNS was measured as 0.791, and 35.9 as a cut-off value had 63.6% sensitivity and 89.6% specificity. CONCLUSIONS: DNS development in CO poisoning is a serious and feared complication. We suggest that the GLU/K ratio has a high potential as a rapid, easy preliminary marker for the exclusion of patients who will not subsequently develop DNS.

A unique biological in-vivo model to evaluate follicular development during in-vitro maturation treatment.

The aim of this study was to identify the size in which the dominant follicle acquires the ability to produce a functional corpus luteum. This observational study includes 15 women with ovulatory cycles who underwent human chorionic gonadotrophin (HCG)-primed in-vitro maturation (IVM) treatments without embryo transfer. All patients received subcutaneous injection of HCG 10,000 IU 38 h prior to oocyte retrieval. Five to seven days following retrieval, serum concentrations of progesterone and oestradiol were measured along with ultrasound scan measuring the antral follicle count. Using receiver operating characteristic curves and the Youden index (J), this study clearly shows that the diameter of the dominant follicle at the time of the LH surge is a good predictor for its ability to form a progesterone-producing corpus luteum (area under the curve 0.94). These findings revealed that the dominant follicle develops the competence to form a corpus luteum, signified by the production of more than 10 nmol/l serum progesterone at 5-7 days from oocyte retrieval, as soon as it acquires a diameter of 10.5-12.0mm. In addition, a new cohort of viable antral follicles can be identified as early as 5-7 days following IVM oocyte retrieval.

Fertility preservation treatment for young women with autoimmune diseases facing treatment with gonadotoxic agents.

OBJECTIVE: To describe a case series of seven women with SLE and other systemic autoimmune rheumatic diseases (SARDs) who required cyclophosphamide therapy and underwent fertility preservation treatments. METHODS: Of the seven patients reported here, five women had SLE with nephritis, the sixth had immune thrombocytopenia purpura (ITP) and the seventh had microscopic polyangiitis (MPA) with renal involvement. All women were nulliparous and younger than 35 yrs. RESULTS: Patients with SLE underwent in vitro maturation (IVM) of immature oocytes aspirated during a natural menstrual cycle followed by vitrification of the matured oocytes if a male partner was not available, or vitrification of embryos if one was available. The patient with ITP and the patient with MPA underwent gonadotropin ovarian stimulation followed by oocyte or embryo vitrification. All women completed fertility preservation treatment successfully and mature oocytes or embryos (36 and 13, respectively) were vitrified. No complications were associated with this treatment and cytotoxic therapy was initiated as scheduled in all cases. CONCLUSIONS: Oocyte or embryo cryopreservation should be considered for fertility preservation in young women with SARDs who face imminent gonadotoxic treatment. In patients, where gonadotropin ovarian stimulation is deemed unsafe, IVM of immature oocytes, aspirated during a natural menstrual cycle, followed by vitrification or fertilization of the mature oocytes, seems to be safe and feasible. For patients in whom hormonal ovarian stimulation is not contraindicated, this method may be considered depending on the urgency to start cytotoxic therapy.

Redo valve surgery with on-pump beating heart technique.

AIM: Reoperations have become of increasing frequency in the last four decades. Redo surgery is more complex than primary surgery and is associated with higher mortality and morbidity. We present our immediate and mid-term results of mitral and aortic prosthetic valve replacement undertaken with beating heart technique. METHODS: The prospective study included 26 consecutive redo valve surgery patients who underwent valve re-replacement. The operation was carried out on a beating heart using normothermic bypass without cross-clamping the aorta for mitral valve surgery and retrograde coronary sinus normothermic noncardioplegic blood perfusion during cross-clamping the aorta for aortic valve procedures. RESULTS: Twenty-six patients (mean age 50+/-15 years) underwent reoperation with beating heart technique. Twenty (76.9%) mitral prosthetic replacements, 4 (15.4%) aortic prosthetic replacements, and 2 (7.7%) double valve replacements were achieved. Fourteen patients (53.8%) were operated for prosthetic valve dysfunction. Eighteen patients (69.2%) were in NYHA class III or IV preoperatively. Mean bypass time was 85+/-30 min. Mean duration of ventilation was 13.6+/-6 h, mean intensive unit stay was 2.8+/-6.4 days, and mean hospital stay was 8.3+/-7.2 days. Two (7.7%) patients required high dose inotropic support and in one patient (3.8%) intra-aortic balloon support was required. Pulmonary complication occurred in 1 patient (3.8%), low cardiac output in 1 patient (3.8%), and re-exploration for bleeding in 2 patients (7.7%). Operative mortality was not observed. CONCLUSION: Normothermic on-pump beating heart valve replacement offers a safe alternative to cardioplegic arrest in high-risk group. Complication rates are low and perioperative mortality is lower than with conventional surgery. Beating heart technique has the advantage of maintaining physiologic condition of the heart throughout the procedure.

Repair of postinfarction ventricular septal defect through the right atrium.

Repair of post infarction posterior ventricular septal defect has generally been performed with a ventriculotomy through the infarcted zone. This approach has a significant mortality and morbidity due to haemorrhage, extension of infarction or further compromise of ventricular function secondary to suture placement. We present a case with delayed repair of a post infarction posterior septal defect using a right atrial approach, where no discrete infarct or other abnormality of the free ventricular wall was found.

High frequency of thrombophilic disorders in women with recurrent fetal miscarriage.

OBJECTIVES: Our purpose was to examine whether genetic thrombophilias are etiological factors for recurrent fetal miscarriage or not. STUDY DESIGN: We compared the rate of thrombophilic anomalies in women with unexplained recurrent fetal miscarriages to the rate of age-matched women with successful pregnancies as a case-control study. RESULTS: A total of 101 consecutive patients with 102 age-matched controls were included in the study. The rate of Factor V (FV) Leiden mutation, Factor (F) II mutation, protein S, protein C, antithrombin III deficiencies and overall thrombophilia in patients with recurrent fetal loss was significantly higher than the frequencies in control patients. CONCLUSION: Women with recurrent fetal miscarriages have an increased incidence of thrombophilia. Genetic thrombophilias may be one of the major etiological factors for recurrent abortion and fetal demise.

Langerhans' cell histiocytosis of the temporal lobe and pons.

Intracerebral Langerhans' cell histiocytosis (LCH) is rare and tends to involve the hypothalamus. The authors report a rare case of LCH in the temporal lobe that subsequently was followed by a brainstem lesion. This appears to be the first case of temporal lobe and brainstem LCH that has been treated successfully and published. A 24-year-old man complained of cacosmia and nausea with a slight headache. He had a left temporal LCH, which was removed completely, but developed a brainstem lesion a year later. The pontine LCH was treated with radiosurgery. The follow-up period was 4 years without any neurological or radiological symptoms or signs. The 12 cases of solitary intracranial non-hypothalamic LCH reported previously are reviewed. Gamma knife radiosurgery effectively controlled the local growth of the pontine LCH without adverse effect.

A comparison of prognoses of FIGO stage IB adenocarcinoma and squamous cell carcinoma.

OBJECTIVES: The objective of this study was to compare clinical and pathologic variables and prognosis of FIGO stage IB adenocarcinoma and squamous cell carcinoma of uterine cervix. METHODS: A retrospective review was performed of 521 patients with stage IB squamous cell carcinoma and adenocarcinoma of cervix who treated primarily by type 3 hysterectomy and pelvic and/or para-aortic lymphadenectomy at Hacettepe University Hospitals between 1980 and 1997. RESULTS: Age, tumor size, grade, depth of invasion, lymph node metastasis, parametrial, vaginal, and lymphvascular space involvement (LVSI) were not different between two cell types except number of the lymph nodes involved. Metastasis to three or more lymph nodes was significantly higher in adenocarcinoma. Overall and disease-free survival were 87.7%, 84.0% versus 86.4%, 83.1% for squamous cell carcinoma and adenocarcinoma, respectively (P > 0.05). The rate and site of recurrence were not different between two cell types. Multivariate analysis of disease-free and overall survival revealed independent prognostic factors as tumor size, LVSI, number of involved lymph node, and vaginal involvement. CONCLUSION: Prognosis of FIGO stage IB cervical cancer patients who were treated by primarily radical surgery was found to be same for those with adenocarcinoma and squamous cell carcinoma.

Prognostic factors in FIGO stage IB cervical cancer without lymph node metastasis and the role of adjuvant radiotherapy after radical hysterectomy.

OBJECTIVES: The aim of this study was to evaluate the clinical and pathologic prognostic variables for disease free survival, overall survival and the role of adjuvant radiotherapy in FIGO stage IB cervical carcinoma without lymph node metastasis. METHODS: A retrospective review was performed of 393 patients with lymph node negative stage IB cervical cancer treated by type 3 hysterectomy and pelvic lymphadenectomy at the Hacettepe University Hospitals between 1980 and 1997. RESULTS: The disease free survival and overall survival were 87.6 and 91.0%, respectively. In univariate analysis, tumor size, depth of invasion, vaginal involvement, lympho-vascular space involvement (LVSI) and adjuvant radiotherapy were found significant in disease free survival. Overall survival was affected by tumor size, LVSI, vaginal involvement and adjuvant radiotherapy. Tumor size, LVSI and vaginal involvement were found as independent prognostic factors for overall and disease free survival in multivariate analysis. Disease free survival, recurrence rate and site did not differ between patients underwent radical surgery and radical surgery plus radiotherapy. CONCLUSION: Tumor size, LVSI and vaginal involvement were independent prognostic factors in lymph node negative FIGO stage IB cervical cancer. Adjuvant radiotherapy in stage IB cervical cancer patients with negative nodes provides no survival advantage or better local tumoral control.

The influence of splenic metastases on survival in FIGO stage IIIC epithelial ovarian cancer.

The purposes of this study were to compare the survival of ovarian cancer patients with splenic metastasis to patients without it and to evaluate the complications of the procedure. A retrospective study was performed on 34 patients with ovarian cancer who underwent splenectomy for initial cytoreduction at gynecologic oncology unit of Hacettepe University Hospitals between 1989 and 2001. All patients had FIGO stage IIIC disease and were left with <1 cm residual tumor after surgery. Eighteen patients (52.9%) had splenic metastasis. Patients with splenic metastasis tended poorer survival. Median survivals were 28.9 and 41.3 months for patients with splenic disease and for patients without it, respectively (P > 0.05). Univariate analysis revealed that performance status and histologic type influenced survival. Histologic type and performance status were identified as independent risk factors by multivariate analysis. Postoperative complications were developed in ten (29.4%) patients and three of these (8.8%) died in 1 month after operation. None of the complications was attributed directly to the splenectomy procedure. Complete surgical cytoreduction confers a survival benefit whether the parenchyma was involved or not. The splenectomy should be considered with its acceptable morbidity in selected patients who have a chance to achieve optimal debulking.

Comparison of hepatocyte growth factor levels of epithelial ovarian cancer cyst fluids with benign ovarian cysts.

Hepatocyte growth factor (HGF) is known to take role in oncogenesis and tumoral behavior of the tumors of the organs that contain mesenchymal and epithelial cells together. This study aims to compare HGF levels in cyst fluids of epithelial ovarian cancer and benign ovarian cysts and look for the role of HGF in ovarian carcinogenesis. Twenty-four consecutive patients with ovarian cancer and 34 with benign cysts of ovary were recruited prospectively at Gynecologic Oncology Departments of SSK Ankara Maternity Hospital and Hacettepe University School of Medicine between 2001 and 2002. Cyst fluids were collected during primary staging in cancer patients and during laparatomy for benign patients. HGF levels were measured by enzyme-linked immunosorbent assay method. Median HGF levels of the benign ovarian cysts and epithelial ovarian tumoral fluids were found as 3822 pg/ml (85-15,253 pgr/ml) and 12,962 pgr/ml (4136-16,025 pgr/ml), respectively. Malign cyst fluids have higher HGF levels when compared with benign ovarian cysts (P < 0.01). This finding suggests that HGF may take a paracrine role in oncogenic differentiation and tumoral development of epithelial ovarian cancers. Mechanisms that take role in HGF secretion and the answers of the neighboring epithelial cells to HGF during tumoral development need to be investigated.

Comparison of HGF (hepatocyte growth factor) levels of epithelial ovarian cancer cyst fluids with benign ovarian cysts.

Hepatocyte growth factor (HGF) is known to take a role in oncogenesis and tumoral behavior of the tumors of the organs that contain both mesenchymal and epithelial cells. This study compares HGF levels in cyst fluids of epithelial ovarian cancer and benign ovarian cysts to look for the role of HGF in ovarian carcinogenesis. Twenty-four consecutive patients with ovarian cancer and 34 with benign ovarian cysts were recruited prospectively at the Gynecologic Oncology Departments of SSK Ankara Maternity Hospital and Hacettepe University School of Medicine between 2001 and 2002. Cyst fluids were collected during primary staging in cancer patients and during laparatomy for benign patients. HGF levels were measured by ELISA method. Median HGF levels of the benign ovarian cysts and epithelial ovarian tumoral fluids were found to be 3822 pg/ml (85-15253 pg/ml) and 12962 pg/ml (4136-16025 pg/ml), respectively. Malignant cyst fluids have higher HGF levels when compared with benign ovarian cysts (P < 0.01). This finding suggests that HGF may take a paracrine role in oncogenic differentiation and tumoral development of epithelial ovarian cancers. Mechanisms that take a role in HGF secretion and the responses of neighboring epithelial cells to HGF during tumoral development need to be investigated.

Neuroendoscopic biopsy for intraventricular tumors.

Neuroendoscopy has been shown to be an effective and minimally invasive method in the management of intraventricular tumors. Endoscopic tumor biopsy with or without additional endoscopic procedures such as third ventriculostomy and septostomy can be performed at the same session. Neuroendoscopic tumor biopsy was performed in 18 patients in our department. Their ages ranged from 2 to 65 years (median 12 years); only two of them were adult. Location of the tumors were as follows: pineal region in 7, hypothalamus and 3rd ventricle in 4, lateral ventricle in 4, thalamus in 2, and tectal in 1 patient. All procedures were performed under general anesthesia using rigid neuroendoscopes. Cerebrospinal fluid (CSF) was collected at the beginning of the procedure for cytological analysis and for pineal tumor markers. Biopsy forceps were used to obtain tissue from the lesion. The third ventriculostomy was performed in all patients with a pineal tumor, in addition to the tumor biopsy. The pathological examinations revealed a low-grade astrocytoma in 6 patients, anaplastic astrocytoma in 3, germinoma in 3, pineocytoma in 1, pineoblastoma in 2, glioblastoma multiforme in 1 and granulomatous lesion in 1. Subsequent mode of treatment such as radiation therapy, chemotherapy or radical surgery was determined on the basis of pathological diagnosis. Neuroendoscopic tumor biopsy is a less invasive method than open surgery and has some advantages such as treating the hydrocephalus at the same surgical session and the availability of CSF cytology. Neuroendoscopic techniques should be considered in selected patients.

Pregnancy complicated by Evan's syndrome.

Evan's syndrome was initially diagnosed in a 26-year-old pregnant patient. Following the introduction of high dose steroid therapy, the patient developed possible disseminated gonococcal infection which was followed by preterm labor and abruptio placentae. A cesarean delivery was performed at the 34th week of pregnancy following platelet infusion. While the infant survived, the mother had delayed postpartum hemorrhage.

Molybdenum cofactor deficiency associated with Dandy-Walker complex.

Molybdenum cofactor deficiency is a rare and devastating disease leading to intractable seizures in the neonatal period. Severe loss of neocortical neurons, gliosis, and cystic necrosis of cerebral white matter resulting in significant cerebral volume loss are the neuropathological findings. The mechanism of cerebral injury is unknown, but sulphite excess, and sulphate or uric acid deficiencies are possible factors. We present here a new case of Molybdenum cofactor deficiency associated with Dandy-Walker complex with a history of three dead siblings, the latter also having Dandy-Walker malformation. We speculate that severe cerebral volume loss due to the above mentioned mechanisms may lead to an appearance resembling Dandy-Walker malformation.

Comparison of enoxaparin and standard heparin in gynaecologic oncologic surgery: a randomised prospective double-blind clinical study.

OBJECTIVE: This study aimed to compare the haemorrhagic complications and efficacy of enoxaparin, a low molecular weight heparin (LMWH), and conventional standard heparin (SH) in gynaecological oncologic surgery. MATERIALS METHODS: A double blind, randomised trial was performed on 102 consecutive women undergoing gynaecologic cancer surgery with pelvic and paraaortic lymphadenectomy. The women were separated into those who were given 2,500 IU enoxaparin once daily and SH in a dose of 5,000 IU three times daily. The groups were analysed for intraoperative blood loss, drainage, transfusion requirements, perioperative haemoglobin decrease, wound haematoma, and clinical deep venous thrombosis. RESULTS: The two groups were well matched for age, weight, and other factors, which could predispose to the development of deep venous thrombosis (DVT) and haemorrhage. No patient developed clinical significant DVT, wound haematoma or intra-abdominal bleeding. There was no significant difference in bleeding complications between the two regimens. The antiFXa level in the plasma was correlated strongly with patient weight. CONCLUSIONS: A dose of 2,500 IU enoxaparin/day does not cause more bleeding complications than SH 5,000 IU three times daily when used to prevent thrombosis. However, the dose of enoxaparin must be adjusted to the patient's weight.

Hemangioblastoma causing cervical neural foraminal widening.

We present the MRI findings in a case of a 24-year-old woman with spinal hemangioblastoma, causing neural foraminal widening by producing a dumbbell mass in the lower cervical region. Hemangioblastomas can very rarely present as an intradural extramedullary lesions and this case is another exceptional pathology which should be considered among the differential diagnosis of enlarged intervertebral foramen due to neoplastic processes.

The role of palliative radiotherapy in locally advanced non-small cell lung cancer.

The aim of this study was to evaluate retrospectively the treatment results of non-small cell lung cancer (NSCLC) patients treated with palliative intent in Dokuz Eylul University Hospital, Radiation Oncology Department. One hundred and fifteen inoperable, non-metastatic and symptomatic NSCLC patients were treated with palliative radiotherapy (PRT) between July 1991 and May 2000. PRT was used in patients with low performance status, weight loss more than 10% within last 6 months, secondary malignancies, co-morbid diseases and socio-economic problems. Parallelly opposed isocentric antero-posterior fields including both the parenchymal and mediastinal masses were used. 10-55 Gy total doses were delivered in 1-23 fractions with a median of 30 Gy. Nineteen patients received systemic chemotherapy before PRT. Survival analysis was made from the treatment beginning date, and subjective palliation rates were assessed according to clinical improvements in symptomatology evaluated 1-6 weeks after PRT. The median follow-up time was 28 weeks (1-234 weeks). Totally, 245 disease-related symptoms were detected in 115 patients. Overall "improvement" in symptomatology was found to be 90% (221/245) with a "near-total response" rate of 46% (113/245). Hemoptysis was the best palliated symptom. Median survival time was 30 weeks. Karnofsky performance status (KPS) (p=0.015), weight loss (p=0.0015), histologic tumor type (p=0.0024) and tumor size (p=0.02) were found to effect overall survival rates significantly in uni-variant analysis. Multi-variant analysis revealed statistically significant effect with histological tumor type and weight loss status. Only 16% of patients (3/19) showed partial and 5% (1/19) complete response to systemic treatment. Median survival time was 46 weeks in this group. In conclusion, this retrospective study of patients with poor prognostic factors confirms that PRT is an effective treatment modality in symptomatic locally advanced NSCLC patients resulting in 90% symptomatic improvement rate and a median survival of 30 weeks.