From hepatomegaly to POEMS syndrome: A case report.

We present a case of POEMS syndrome from Turkiye, a rare, multisystemic condition resulting from plasma cell dyscrasia. POEMS is an acronym representing its cardinal features: Peripheral neuropathy; Organomegaly; Endocrinopathy; Monoclonal plasma-cell proliferative disorder; and Skin changes. The syndrome has an estimated prevalence of 0.3 per 100,000 individuals and typically manifests in the fifth or sixth decade of life. Progressive peripheral neuropathy is the syndrome's most prominent symptom. To ensure an accurate diagnosis, a thorough medical history, physical examination, and comprehensive diagnostic evaluations are essential. These evaluations should include serum immunoelectrophoresis, serum cytokines, and growth factors, a skeletal survey, and a bone marrow biopsy. Early recognition and treatment of POEMS syndrome are crucial to prevent debilitating progression and to optimize clinical outcomes.

Do different wiping techniques in phlebotomy have an effect on vessel visibility, procedural success, and phlebotomy-related complications?

BACKGROUND: This study was conducted to evaluate the effects of different wiping techniques used in phlebotomy on vein visibility, procedural success, and phlebotomy-related complications. MATERIALS AND METHODS: This single-center, comparative, randomized study was conducted with 90 patients in the internal medicine clinic of a tertiary hospital. During the phlebotomy procedure, the phlebotomy site was wiped with circular technique in the Group-I, vertical technique in the Group-II, and vertical + circular technique in the Group-III. RESULTS: There was a significant difference between the three groups in terms of vein visibility after wiping of the phlebotomy site (p < 0.05). The time spent for blood sampling was shorter in the Groups I and II (p > 0.05). In the 3-day follow-up after the blood sample was taken, the ecchymosis and hematoma rates of the groups were similar (p > 0.05). CONCLUSIONS: Vertical wiping and vertical + circular wiping techniques used in the cleaning of the phlebotomy site increased the visibility of the vein compared to only circular wiping. The time spent for blood sampling was shorter in the vertical wiping and vertical + circular wiping groups.

Healthcare-Related HCV Genotype 4d Infections in Kayseri, Turkey.

BACKGROUND: The frequency of genotype 4 hepatitis C virus infection is significantly higher in a city compared to other provinces in Turkey. In this study, we aimed to investigate the epidemiology and risk factors of hepatitis C virus genotype 4 infection in Kayseri province of Turkey. METHODS: A case-control study was conducted with 61 hepatitis C virus genotype 4-infected patients and 71 controls. A questionnaire was administered to the patients and controls, asking for information about the risk factors of hepatitis C virus transmission. Core/ E1 and NS5B regions of hepatitis C virus genome were amplified and sequenced by Sanger method. Phylogenetic analysis and molecular clock analysis were performed. The risk was determined by calculating the odds ratio and 95% CI. Logistic regression analysis was performed to determine the effect of risk factors by controlling for confounding variables. RESULTS: Kayseri isolates were closely related to type 4d sequences but formed a separate cluster. According to the molecular clock analysis, hepatitis C virus genotype 4d entered Kayseri province probably between 1941 and 1988. Blood transfusion and surgical intervention were found to be significant risk factors for the infection. CONCLUSION: Epidemiological data showed that hepatitis C virus genotype 4d infections are significantly associated with unsafe medical procedures.

Novel Anthocyanin-Based Colorimetric Assay for the Rapid, Sensitive, and Quantitative Detection of Helicobacter pylori.

Several different diagnostic tests have been reported for rapid, sensitive, and economical detection of bacterial pathogens, but most lack widespread and practical use in the clinic. In this study, we used anthocyanins from red cabbage (Brassica oleracea) as a natural pH indicator and, for the first time, incorporated this agent into a simple, rapid, and economical colorimetric strategy for the detection of Helicobacter pylori (H. pylori) (RCE@test). We prepared two sets of RCE@test solutions (test 1 is purple, and test 2 is blue) in different forms, including liquid, adsorbed filter paper, and agar, and investigated the performance of each RCE@test as a function of the test volume, H. pylori concentration, and reaction time. To elucidate the effect of the pathophysiological environment on these RCE@tests, H. pylori in an artificial gastric fluid was also detected. The 10 and 1 CFU/mL H. pylori suspensions were detected in 15 min and 3 h, respectively, and the limit of detection was determined down to 1 CFU/mL. We experimentally demonstrated the advantages of the RCE@test for detection of H. pylori by comparing it to a commercially available rapid urease test, the "CLO test (Campylobacter-like organism test)". In addition to colorimetric detection by the naked eyes, RGB (Red Green Blue) and Delta-E analysis in image-processing software was run to quantitatively monitor changes of color in the RCE@test using a smartphone application. Finally, we propose that this test provides simple, effective, rapid, and inexpensive detection and that it can be easily implemented for clinical use.

The role of endobronchial and endoscopic ultrasound guided fine needle aspiration for mediastinal nodal staging of non-small-cell lung cancer.

INTRODUCTION: Mediastinal and hilar nodal staging is one of the key points for differentiating treatment modalities in patients with non-small-cell lung cancer (NSCLC). The aim of the present study was to determinate the diagnostic yields of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and combined EBUS-TBNA and EUS-FNA modalities for nodal staging in potentially operable NSCLC patients. MATERIALS AND METHODS: Twenty consecutive patients were prospectively enrolled in the study between March 2014 and November 2015. All patients had a potentially operable NSCLC diagnosis before endosonographic procedures. RESULT: Thirty lymph nodes were sampled by EBUS-TBNA and 17 lymph nodes were sampled by EUS-FNA in all 20 patients. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of F-18 fluorodeoxyglucose positron emission tomography with computed tomography (PET-CT), EBUS-TBNA, EUS-FNA and combined EBUS-TBNA and EUS-FNA were 100%, 33.3%, 64.7%, 100% and 70.0%; 81.8%, 100%, 100%, 81.8% and 90%; 81.8%, 100%, 100%, 75% and 88.2%; 90.9%, 100%, 100%, 90.0% and 95.0%, respectively. CONCLUSIONS: The combined EBUS-TBNA and EUS-FNA technique is a successful procedure for nodal staging in potentially operable NSCLC patients.

Ipilimumab-associated cholestatic hepatitis: a case report and literature review.

Ipilimumab is a monoclonal antibody that exerts its effects by inhibiting the cytotoxic T-lymphocyte-associated protein 4 receptor on cytotoxic T lymphocytes. It is frequently used for the treatment of unresectable or metastatic melanoma. Ipilimumab may lead to several immune-related disease including colitis, thyroiditis, pneumonia, hepatitis, or pancreatitis as a side effect. Limited number of cases with hepatic damage as an ipilimumab-related adverse event has been reported in the literature. This agent has been implicated in causing acute hepatitis-like liver injury. Here, we presented a case in which cholestatic hepatitis developed during ipilimumab use for the treatment of metastatic melanoma.

Best prognostic factor of neuroendocrine tumors: Grade or Stage? A multidisciplinary single-center study.

BACKGROUND/AIMS: Currently, there is no definite consensus about the prognostic factors of neuroendocrine tumors (NETs). We evaluate epidemiology, survival and especially prognostic factors in NETs. MATERIALS AND METHODS: Patients who had a NET and were diagnosed between 2000 and 2014 at a tertiary care center were included. Demographic data, tumor characteristics and survival rates were evaluated, retrospectively. RESULTS: Two-hundred and thirty-three patients (123 male, 110 female; median age, 55 years [16-92 years]) took part in the study. Primary NET sites were the lung (n=56), stomach (n=50), pancreas (n=39), colorectal (n=21), small intestine (n=19), and appendix (n=19). According to the NET classification by the WHO in 2010, 60% (n=140) of patients were grade-1, 15% (n=35) were grade-2, and 25% (n=58) were grade-3. According to TNM staging, 88 patients (37.8%) were stage I, 30 patients (12.8%) were stage II, 22 patients (9.5%) were stage III, and 93 patients (39.9%) were stage IV. Univariate analysis revealed significant associations between gender, age, grade, lymph node metastasis, distant metastasis, stage, and the number of organs impacted by metastases and overall survival. However, with multivariate analysis only age greater than 55 years, advancing grade, and inoperable tumors were significantly associated with shortened survival. Five-year survival was 81% in grade-1, 34% in grade-2, and 9% in grade-3 NETs. CONCLUSION: This study is the most comprehensive study in Turkey that has evaluated NETs using a multidisciplinary approach. Also, we suggest that age, operability and especially grade rather than stage are the most important prognostic factors in NETs.

Serum Visfatin Levels in Ulcerative Colitis.

BACKGROUND: Previous studies have suggested that adipokines play a role in inflammatory bowel disease by inducing proinflammatory cytokines, but it is uncertain whether visfatin is causally involved in ulcerative colitis (UC). We evaluated visfatin levels in patients who presented with UC flares before and after treatment. METHODS: In this cohort study, we assessed 31 patients with UC in the activation period and remission in the same patients after treatment, and a healthy control group, consisting of 29 persons, at a single academic medical centre between 2010 and 2013. Disease severity was evaluated clinically using Trulove and Witt's criteria. RESULTS: Serum visfatin levels did not vary according to the extent of disease and were significantly higher in patients in the activation period (7.77 ± 2.41 ng/ml) than in remission (6.18 ± 2.04 ng/ml) and the healthy controls (6.54 ± 2.20 ng/ml; P < 0.01 and < 0.05, respectively). In a comparison of patients in the inactive period with the control group, there was no statistically significant difference (P > 0.05). To assess activation of the disease, a visfatin cut-off point for active UC was determined as 6.40, with sensitivity, specificity, positive predictive value (PPV) and negative predictive values (NPV) of 72%, 52%, 66.7% (43.0-85.4) and 50.0% (29.1-70.9), respectively. CONCLUSIONS: The visfatin level was higher in the active group than in post-treatment remission and the healthy control group. Sensitivity and specificity were similar to other inflammatory markers for assessing clinical activity, which did not improve clinical outcomes in patients with acute respiratory distress syndrome (ARDS). These findings did not provide a rationale for assessment of UC activation.

Red blood cell distribution width as a non-invasive marker for the assessment of inflammation in non-alcoholic steatohepatitis.

BACKGROUND/AIMS: The aim of this study was to assess the association between red cell distribution width and inflammation in biopsy proven non-alcoholic steatohepatitis. METHODOLOGY: Fifty four subjects with non-alcoholic steatohepatitis and thirty nine controls were enrolled for the study. Liver biopsy specimens were scored by using non-alcoholic fatty liver disease activity score by a single experienced liver pathologist. RESULTS: Red cell distribution width was higher in the severe inflammation group in non-alcoholic steatohepatitis (p < 0.05). The areas under the receiver operating characteristic curves for the predictive performance of aspartate aminotransferase, alanine aminotransferase, gamma glutamyl transferase and red cell distribution width in identifying inflammation in non-alcoholic steatohepatitis were 0.55 (0.41-0.68), 0.51 (0.37-0.64), 0.53 (0.39-0.67) and 0.73 (0.59-0.84) respectively and the differences of these values between red cell distribution width and other parameters were found to be statistically significant (p < 0.05). To determine the grading of inflammation, the specificity for using the red cell distribution width as an indicator in non-alcoholic steatohepatitis patients was calculated to be 73.3%, with 79.5% sen- sitivity. CONCLUSION: Red cell distribution width was a sensitive and specific method for the assessment of the inflammation in patients with non-alcoholic steatohepatitis.

Effects of ursodeoxycholic acid therapy on carotid intima media thickness, apolipoprotein A1, apolipoprotein B, and apolipoprotein B/A1 ratio in nonalcoholic steatohepatitis.

BACKGROUND: Nonalcoholic steatohepatitis (NASH) is a prevalent liver disease that is increasingly being associated with cardiovascular disease. Ursodeoxycholic acid (UDCA) may have antioxidant and anti-inflammatory activities, and may reduce liver injury in NASH. To date, no studies have assessed the efficacy of UDCA in carotid intima media thickness (CIMT), serum lipids, apolipoprotein A1 (apo A), apolipoprotein B (apo B), and apolipoprotein B/A1 (apo B/A1) ratios in patients with NASH. PATIENTS AND METHODS: In this prospective study, 30 patients with biopsy-proven NASH and 25 healthy adults as a control group were evaluated. None of the participants had diabetes, hypertension, or hyperlipidemia. Patients with NASH received UDCA 15 mg/kg/day for 6 months. BMI, waist circumference, homeostasis model assessment, lipids, apo A1, apo B, apo B/A1 ratios, and CIMT were analyzed before and after the treatment period. RESULTS: At the end of the study, there were no statistically significant changes in BMI or waist circumference. Liver enzymes decreased gradually. The homeostasis model assessment decreased from 3.4 ± 1.89 to 2.06 ± 1.68 (P < 0.001). No significant changes in the mean triglyceride, total cholesterol, low-density lipoprotein, or apo B levels were observed. The mean high-density lipoprotein (42.9 ± 7.1 vs. 45.5 ± 9.8; P = 0.037) and apo A1 (127.6 ± 17.7 vs. 135.9 ± 22.2; P = 0.02) increased significantly. Apo B/A1 ratios tended to decrease, but this decrease was not statistically significant. The mean CIMT decreased significantly (0.56 ± 0.15 vs. 0.47 ± 0.12; P = 0.001). CONCLUSION: UDCA treatment in NASH patients resulted in statistically significant reductions in the mean CIMT over a 6-month period. We believe that this benefit of UDCA may have resulted from decreased insulin resistance and increased serum high-density lipoprotein-apo A1 levels. However, larger, longer-term studies are needed to confirm this effect of UDCA in NASH.

Circulating microRNAs in patients with non-alcoholic fatty liver disease.

AIM: To identify novel non-invasive biomarkers for non-alcoholic fatty liver disease (NAFLD). METHODS: Twenty patients with histologically proven NAFLD and 20 controls were included. All NAFLD cases were scored using the NAFLD activity score. The relative expressions of miR-197, miR-146b, miR-10b, miR-181d, miR-34a, miR-122, miR-99a and miR-29a were analyzed using real-time polymerase chain reaction. RESULTS: Serum levels of miR-181d, miR-99a, miR-197 and miR-146b were significantly lower in biopsy-proven NAFLD patients than in the healthy controls. Serum levels of miR-197 and miR-10b were inversely correlated with degree of inflammation and miR-181d and miR-99a were inversely correlated with serum gamma glutamyl transferase levels in non-alcoholic steatohepatitis patients. CONCLUSION: NAFLD is associated with altered serum miRNA expression pattern. This study provides clues for defining the non-invasive diagnosis of NAFLD.

Non-alcoholic fatty liver disease in patients with migraine.

Evidence suggests that migraine is associated with metabolic syndrome, which is also implicated in non-alcoholic fatty liver disease (NAFLD). Reported for the first time, we aimed to investigate the relationship between migraine and NAFLD in patients with migraine. A total of 90 consecutive migraine patients were enrolled in this cross-sectional study. The diagnosis of migraine was determined according to the International Classification of Headache Disorders-II diagnostic criteria. The diagnosis of NAFLD was based on abdominal ultrasonography findings. Anthropometric indices and the homeostasis model assessment of insulin resistance (HOMA-IR) were calculated, and serum insulin level measurements and other biochemical analyses were performed for each subject. The measurements of body mass index and waist circumference were significantly higher in migraine patients with NAFLD than in those without NAFLD (p < 0.001). Regarding the laboratory results, insulin (p = 0.024), alanine aminotransferase (p = 0.027), and triglyceride levels (p = 0.001) and the HOMA-IR (p = 0.039) were higher in migraineurs with NAFLD than in those without NAFLD. Among the headache characteristics, the presence of aura was higher, and disease and attack durations were significantly longer in migraineurs with NAFLD than in those without NAFLD (p = 0.005, p = 0.024, and p = 0.023; respectively). However, the headache characteristics did not correlate with either the hepatosteatosis grade or HOMA-IR in migraine patients (p > 0.05). Our results show that NAFLD may present in migraine patients with higher frequency of auras and longer disease and attack durations.

Prolonged Cholestatic Jaundice Associated With Flurbiprofen.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely consumed drugs throughout the world for pain relief. Although the adverse effects of NSAIDs to the liver are well known, flurbiprofen-induced liver cholestasis is extremely rare. Herein, we present a patient with prolonged icterus that is associated with the use of flurbiprofen without causing ductopenia.

Noninvasive assessment of liver damage in chronic hepatitis B.

AIM: To evaluate the efficacy of the aspartate aminotransferase/platelet ratio index (APRI) and neutrophil-lymphocyte (N/L) ratio to predict liver damage in chronic hepatitis B (CHB). METHODS: We analyzed 89 patients diagnosed with CHB by percutaneous liver biopsy and 43 healthy subjects. Liver biopsy materials were stained with hematoxylin-eosin and Masson's trichrome. Patients' fibrosis scores and histological activity index (HAI) were calculated according to the Ishak scoring system. Fibrosis score was recognized as follows: F0-1 No /early-stage fibrosis, F2-6 significant fibrosis, F0-4 non-cirrhotic and F5-6 cirrhotic. Significant liver fibrosis was defined as an Ishak score of ≥ 2. APRI and N/L ratio calculation was made by blood test results. RESULTS: The hepatitis B and control group showed no difference in N/L ratios while there was a significant difference in terms of APRI scores (P < 0.001). Multiple logistic regression analysis revealed that the only independent predictive factor for liver fibrosis in CHB was platelet count. APRI score was significantly higher in cirrhotic patients than in non-cirrhotic patients. However, this significance was not confirmed by multiple logistic regression analysis. The optimum APRI score cut-off point to identify patients with cirrhosis was 1.01 with sensitivity, specificity, positive predictive value and negative predictive value of 62% (36%-86%), 74% (62%-83%), 29% (13%-49%) and 92% (82%-97%), respectively. In addition, correlation analyses revealed that N/L ratio has a negative and significant relationship with HAI (r = -0.218, P = 0.041). CONCLUSION: N/L ratio was negatively correlated with HAI. APRI score may be useful to exclude cirrhosis in CHB patients.

The prevalence of primary hereditary hemochromatosis in central Anatolia.

BACKGROUND/AIMS: Hereditary hemochromatosis is an autosomal recessive disorder associated with the HFE genes. Early identification and diagnosis is important as end stage organ damage may occur if treatment is delayed.. This study aimed to identify the prevalence of hereditary hemochromatosis in Kayseri and surroundings known as Central Anatolia. MATERIALS AND METHODS: 2304 participants (1220 males, 1084 females) who were older then the age of 17 were included in the study conducted between December 2005 and December 2006 in Kayseri, Turkey. Transferin saturation was measured from overnight fasting blood samples. Serum iron, total iron binding capacity, and transferin saturation were measured. Serum ferritin levels and hereditary hemochromatosis genetic analysis were also performed after an overnight fasting blood samples from participants whose transferin saturation results were more than 50% in man and more than 45% in women. RESULTS: The homozygote C282Y mutation and heterozygote C282Y mutation prevalences were found as 0.08% (1/1220) and 0.08% (1/1220) in male participants, respectively. The heterozygote H63D mutation prevalence was found in 0.09% (1/1084) of female participants. Calculated prevalences in general population are as follows; The homozygote C282Y mutation prevalence is 0.043% (1/2304), the heterozygote C282Y mutation prevalence is 0.043% (1/2304) and the heterozygote H63D mutation prevalence is 0.043% (1/2304). CONCLUSIONS: The prevalence of hereditary hemochromatosis in Central Anatolia is 0.043% (1/2304). Because of the relatively low frequency, population screening studies are not cost-effective.

Neutrophil-lymphocyte ratio as a predictor of disease severity in ulcerative colitis.

BACKGROUND: Blood neutrophil-to-lymphocyte (N/L) ratio is an indicator of the overall inflammatory status of the body, and an alteration in N/L ratio may be found in ulcerative colitis (UC) patients. The aims of this study were to investigate the utility of N/L ratio as a simple and readily available predictor for clinical disease activity in UC. METHODS: Twenty-six patients and 28 healthy controls were enrolled in the study. The neutrophil and lymphocyte counts were recorded, and the N/L ratio was calculated from these parameters. The extent of disease classified according to the Montreal classification, clinical disease activity was evaluated using a modified Truelove-Witts severity index, and endoscopic disease activities were classified according to Schroder et al. RESULTS: The serum N/L ratios of active patients were significantly higher than those of inactive UC and controls (P < 0.001). The optimum N/L ratio cut-off point for active UC was 2.47. There was no significant difference between inflammation parameters, disease extension, and disease activity. CONCLUSION: Our results demonstrate that N/L ratio is higher in patients with active UC compared with controls and UC patients in remission and a cut-off value of 2.47 can be used to identify patients with active ulcerative colitis.

Mean platelet volume in biopsy-proven non-alcoholic fatty liver disease.

Non-alcoholic fatty liver disease (NAFLD) is increasingly recognized as the most common cause of chronic liver disease worldwide. It has been shown that NAFLD has a strong association with metabolic syndrome and its component like insulin resistance (IR). Cardiovascular disease has a relation with NAFLD. Platelet volume is an indicator of platelet function and activation. Mean platelet volume (MPV) has been reported as a risk factor for atherothrombosis. In our study, we aimed to investigate the relation of MPV with NAFLD and IR in the NAFLD patients. A total of 54 patients with histologically proven NAFLD and 41 healthy age-matched control subject were enrolled in this study. The NAFLD subjects were divided into two subgroups: 42 patients in the insulin resistant group (median age 39.5, females 22 [52%]) and 12 patients in the insulin sensitive group (median age 38, females 5 [41.7%]). MPV were significantly higher in the NAFLD group in univariate analysis (p < 0.05). In the NAFLD patients, we did not find any relation between steatosis grade, lobular inflammation, hepatocellular ballooning, NAFLD activity score and fibrosis with MPV value. Among the insulin resistant and sensitive groups in the NAFLD patients MPV values were similar. The results of this study showed that MPV, an indicator of platelet activation, increased in biopsy proven NAFLD patients but MPV is not correlated with the increase of IR in NAFLD patients. MPV is not related with inflammation and steatosis degree, hepatocellular ballooning and fibrosis in NAFLD patients.