Wernicke's encephalopathy: a case report and MRI findings.

Wernicke's encephalopathy (WE) is a serious, potentially fatal acute or subacute neurological disorder caused by thiamine (Vitamin B1) deficiency. Although it is most frequently observed in patients who are chronic alcoholics, WE may also be associated with hyperemesis gravidarum. We report magnetic resonance imaging (MRI) and diffusion weighted imaging (DWI) findings in this case of WE in a pregnant patient with hyperemesis gravidarum. We conclude that DWI should be included in the imaging protocols of patients suspected to suffer from Wernicke's encephalopathy.

Relation between Doppler findings and perinatal outcomes in fetuses with intrauterine growth restriction.

PURPOSE OF INVESTIGATION: To find the relationship between fetal Doppler findings and perinatal outcomes in intrauterine growth restriction. METHODS: Eighty-two cases with a prenatal diagnosis of intrauterine growth restriction between November 2008 and July 2009 were included in this prospective study at Ege University School of Medicine. Fetuses were grouped according to Doppler parameters: those with normal Doppler findings (n = 43), and those with impaired arterial (n = 27) and venous systems (n = 12). RESULTS: Out of 82 growth restricted cases, 43 (52.4%) had normal Doppler findings, while 27 (32.9%) displayed impaired arterial parameters and 12 (14.6%) had impaired venous parameters. The mean first minute Apgar scores were 7.57 +/- 1.53 for the group with normal Doppler flows, 6.8 +/- 2 for the group with an impaired arterial system, and 4 +/- 1.94 for the group with an impaired venous system. Two cases from the normal Doppler flow group (n = 42), four cases from the impaired arterial flow group (n = 27), and 11 cases from the impaired venous flow group (n = 11) had fifth minute Apgar scores under 6. Evaluation of the umbilical artery blood gas revealed acidosis in two cases from the normal Doppler flow group (n = 42), three cases from the impaired arterial system group (n = 27), and five cases from the impaired venous system group (n = 11). CONCLUSION: A Doppler spectrum from normal to venous system impairment correlated with poor fetal outcomes including fetal acidosis, fetal mortality and morbidity, decreased Apgar scores at 1 and 5 min, and neonatal morbidity.

Clinical symptoms and histopathological findings in subjects with adenomyosis uteri.

OBJECTIVE: The purpose of this study was to compare the clinical symptoms and histopathological findings in subjects with adenomyosis uteri. METHOD: Infiltration depth and spread of adenomyotic foci together with clinical symptoms and findings were compared in a total of 103 subjects who had undergone hysterectomy and were diagnosed with adenomyosis uteri through histopathological examinations. RESULTS: The spread of adenomyotic foci in myometrial tissues was observed to significantly increase as the depth of myometrial infiltration increased in subjects with adenomyosis (p < 0.05). It was observed that there was significantly higher myometrial infiltration depth in subjects with dysmenorrhea and severe anemia, and diffuse adenomyotic foci in subjects with menometrorrhagia (p < 0.05). CONCLUSION: Increased infiltration depth and spread of adenomyotic foci in myometrial tissues in subjects with adenomyosis uteri were studied. When clinical symptoms and findings in subjects with adenomyosis, such as dysmenorrhea, anemia and menometrorrhagia are compared with these histopathological findings, infiltration depth and spread of adenomyotic foci appear to determine the clinical severity of adenomyosis.

Adenomyosis: prevalence, risk factors, symptoms and clinical findings.

OBJECTIVE: This prospective study investigated the prevalence of adenomyosis in histopathological examinations of patients who had undergone hysterectomy due to various indications in our clinic. Epidemiological characteristics, predisposing risk factors, symptoms and clinical findings of adenomyosis were evaluated. METHOD: A total of 298 subjects who had undergone abdominal, vaginal or laparoscopic hysterectomy with/without salpingooophorectomy between October 2003 and April 2004 in our clinic were included. Uterine specimens obtained through hysterectomy were weighed and histopathologically examined in the Pathology Department of Ege University. The study group (n = 103), cases with adenomyosis, was compared with the control group (n=195), cases without adenomyosis, with respect to the epidemiological, clinical and histopathological characteristics. RESULTS: The prevalence of adenomyosis in 298 subjects was 36.2% (103). Duration of the reproductive period in patients with adenomyosis was found to be significantly longer than for those in the control group (p < 0.05). Prevalence of pelvic pain, dysmenorrhea and dyspareunia was also significantly higher in the study group (p < 0.05). Moreover, the number of cases requiring blood transfusion before the operation was significantly higher in the study group (p < 0.05) as were the rates of smoking, previous uterine surgery and nulliparity (p < 0.05). The most common gynecological condition accompanying adenomyosis was found to be uterine myoma in both groups, but the difference was not significant. CONCLUSION: Adenomyosis is not a rare histopathological finding. Due to diagnostic and therapeutic methods which are being developed as an alternative to hysterectomy, the clinical effects of adenomyosis and its association with other gynecological conditions, adenomyosis appears to be an issue which will be more intensively investigated in the future.

Proliferative effects of different hormone regimens on mammary glands in ovariectomized rats.

OBJECTIVE: To compare the proliferative effect of different hormone regimens and estrogen receptor modulation on mammary glands in a rat model of surgical menopause. DESIGN: Experimental animal study. SETTING: University Hospital. INTERVENTION: In a rat model of surgical menopause, 78 adult Sprague Dawley female rats were ovariectomized and treated with estrogen, estrogen combined with continuous or intermittent progesterone or the estrogen receptor modulator raloxifene and their respective vehicle controls. Following intraperitoneal drug administration for 20 days, rats were perfused, mammary glands were removed, tissues were processed for immunohistochemical (Ki-67) and hematoxylin-eosin staining, and investigated under light microscope. MAIN OUTCOME MEASURE: Histopathological examination of mammary glands and Ki-67 positive cells (proliferation index). RESULTS: Histological examination showed dilatation in the duct cysts and vacuolization in the epithelial cells in groups receiving progestin, either intermittent or continuous. Histological findings in the raloxifene group were no different from the control group, and the atrophic terminal ductal lobular unit in adipose tissue rich stroma was similar to postmenopausal breast. In animals with a proliferative response, increased proliferation started and dominated in the terminal ductal lobular unit epithelium. Comparison of Ki-67 proliferation indices between groups revealed that estrogen alone or combined with intermittent progesterone yielded significantly higher Ki-67 indices compared to controls; estrogen combined with continuous progesterone also resulted in increasing the probability of proliferation, but the effect was not as pronounced as the other two groups. Raloxifene treatment, on the other hand, did not cause proliferation. CONCLUSION: Estrogen alone or combined with progesterone may increase the risk of breast cancer by enhancing proliferation in the TDLU; raloxifen does not induce proliferation and may be a safe estrogen receptor modulator regarding its effects on mammary glands during menopause.

Effects of sequential combined transdermal and oral hormone replacement therapies on serum lipid and lipoproteins in postmenopausal women.

The aim of this study was to compare the effects of sequential combined transdermal and oral postmenopausal hormone replacement therapies on serum lipid-lipoprotein profiles risk markers for cardiovascular disease. A prospective randomize study was designed: Ninety-six healthy nonhysterectomised postmenopausal women were randomized to receive either transdermal continuous 17beta-estradiol, 0.05 mg/d (Estraderm TTS, Novartis, Basel, Switzerland), with transdermal sequential norethisterone acetate, 0.25 mg/d (Estragest TTS, Novartis, Basel, Switzerland), or oral continuous conjugated equine estrogens, 0.625 mg/d (Premarin 0.625 mg, Wyeth, Philadelphia, U.S.A.), with oral sequential medroxyprogesterone acetate, 10 mg/d (Farlutal 5 mg, Deva, Istanbul, Turkey). 84 women completed the trial, 42 in oral and 42 in the transdermal group. The serum levels of total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, apolipoproteins AI and apolipoproteins B at 6 months after starting treatment were compared with baseline values for both therapies. Both oral and transdermal therapies significantly reduced serum levels of total cholesterol (208-190 mg/dL and 216-199 mg/dL, respectively, p=0.0001) and LDL-cholesterol (128-112 mg/dL and 140-127 mg/dL, respectively, p=0.001). The serum levels of triglycerides did not show any significant change with oral therapy, whereas this lipid fell (128-101 mg/dL, p=0.0001) significantly with transdermal therapy. We found significant decrease in HDL-cholesterol with transdermal therapy while there was no significant change with oral therapy. Apolipoproteins AI, the major protein component of HDL2 subfraction, was increased by oral therapy and lowered by transdermal therapy. As a conclusion, we have found that serum total cholesterol and LDL-cholesterol were lowered by both therapies, with no significant differences between treatments, whereas there were significant differences between treatments according to effects on serum triglycerides and apolipoproteins AI.

Mammographic density changes during different postmenopausal hormone replacement therapies.

OBJECTIVE: To determine the degree of change in mammographic breast densities during different types of postmenopausal hormone replacement therapies. DESIGN: A retrospective study. SETTING: Ege University Hospital. PATIENT(S): The mammographies of 216 women on various postmenopausal hormone replacement therapies were evaluated. INTERVENTION(S): Estrogen alone (n = 76) or estrogen in cyclic (n = 44) or continuous (n = 61) combination with progestin or tibolone-only (n = 35) replacement therapies were used. Mammographic density was quantified according to the Wolfe classification in patients with different hormone replacement regimens. MAIN OUTCOME MEASURE(S): Mammographic density changes were interpreted. RESULT(S): An increase in mammographic density was much more common among women receiving continuous combination hormone replacement therapy 31.1% (19 of 61) than among those receiving estrogen-only 3.9% (3 of 76) treatment. There were no significant mammographic breast density changes among women receiving cyclic continuous combination hormone replacement therapy or tibolone-only treatment. The increase in density was apparent already at first visit after the start of hormone replacement therapy. In continuous combined postmenopausal hormone replacement therapy with norethisterone acetate, the increase in mammographic density was 34.1% (15 of 44), followed by medroxyprogesterone acetate 23.5% (4 of 17). CONCLUSION(S): Our findings show that mammographic breast density changes related to postmenopausal hormone replacement therapy are dependent on the selected hormone regimen. The continuous administration of the progestin component of the combined-hormone replacement therapy seems to effect the breast density most.

Intracranial venous thrombosis associated with severe antithrombin-III deficiency in pregnancy.

We report a patient with intracranial venous thrombosis in the third trimester of pregnancy associated with severe antithrombin-III deficiency. The evaluation of protein C, protein S and antithrombin-III levels in patients with thrombotic events during pregnancy may reveal the specific cause of the thrombotic event and thereby influence patient management

A comparison of continuous combined hormone replacement therapy, HMG-CoA reductase inhibitor and combined treatment for the management of hypercholesterolemia in postmenopausal women.

OBJECTIVE: To compare the lipid-altering effects of hormone replacement therapy alone and in combination with HMG-CoA reductase inhibitor in postmenopausal women with hypercholesterolemia. METHODS: This was a prospective randomized controlled trial with 3 parallel groups. The patients (n = 35) were randomly assigned to receive pravastatin 20 mg/day (n = 12); continuous combined hormone replacement therapy (0.625 mg conjugated estrogen/day combined with medroxyprogesterone 5 mg/day) (n = 12); continuous combined hormone replacement therapy plus pravastatin (n = 11) for 16 weeks. RESULTS: Among patients treated with continuous combined hormone replacement therapy levels of total cholesterol (10.7%) and LDL cholesterol (12.6%) decreased significantly (p < 0.05), while levels of high density lipoprotein cholesterol (5%) and triglycerides (6.2%) increased insignificantly (p > 0.05). Patients in the pravastatin group achieved significant reductions of 18.8 and 21.4% in total cholesterol and low density lipoprotein cholesterol levels, respectively (p < 0.05). Among patients treated with a combination of continuous combined hormone replacement therapy plus pravastatin, levels of total cholesterol (20.5%) and low density lipoprotein cholesterol (23.8%) decreased the most, while levels of triglycerides (2.1%) decreased lower than the pravastatin-only group. The mean percentage of the differences between the baseline and treatment levels of the lipids and lipoproteins were not significant between the 3 study groups (p > 0.05). CONCLUSION: No significant difference between hormone replacement therapy alone and in combination with HMG-CoA reductase inhibitor in the treatment of postmenopausal women with hypercholesterolemia was noted in this study. The combination of hormone replacement therapy not only does not adversely affect the lipid-lowering effect of pravastatin alone, but hormone replacement therapy also offers additional benefits in the treatment of hypoestrogenic hypercholesterolemia in postmenopausal women.

The effect of medroxyprogesterone acetate and heparin in the prevention of postsurgical adhesion formation in the rat uterine model.

OBJECTIVE: To evaluate the effects of depot medroxyprogesterone acetate and heparin in preventing postsurgical adhesion formation in the rat model. METHODS: A hundred and five female Wistar rats were divided into 7 groups. Groups 1 and 2 were injected with intramuscular 15 mg medroxyprogesterone acetate 3 weeks before surgery and at the end of laparotomy. Groups 3 and 4 were given 15 mg medroxyprogesterone acetate by intramuscular injection, 3 weeks before surgery. An equal volume of intramuscular sterile saline was injected to control groups, 3 weeks before and at the end of surgery. Before abdominal closure, 2 ml of Ringer's lactate was instilled into the peritoneal cavity of all rats, except group 7. Groups 1, 4, and 5 were given 2 ml of intraperitoneal Ringer's lactate containing 500 U heparin/ml. A standardized surgical injury was performed in all rats. Two weeks after surgery, the adhesions were scored on a scale of 0 to 3 according to their thickness-tenacity and vascularity. Kruskall-Wallis and Mann-Whitney U statistical test were used. RESULTS: The preoperative and postoperative administration of medroxyprogesterone acetate resulted in the least number of and the least severe adhesions, when compared with single dose medroxyprogesterone acetate treated rats and controls (p < 0.05). However, the combination of medroxyprogesterone acetate and intraperitoneal heparin did not enhance the adhesion reducing capacity of medroxyprogesterone acetate. CONCLUSIONS: Concurrent preoperative and postoperative administration of medroxyprogesterone acetate results in the most significant reduction of postsurgical adhesions. The combination treatment of medroxyprogesterone acetate and heparin does not show any additional effect in the reduction of adhesion formation, when compared with medroxyprogesterone acetate treatment alone.

Impaired antioxidant activity in women with pre-eclampsia.

OBJECTIVE: To investigate antioxidant activity of sera and the plasma blood levels of two potent antioxidant in women with pre-eclampsia and normotensive pregnancies. STUDY DESIGN: The antioxidant activity of sera and the blood levels of ascorbic acid and alpha-tocopherol were assayed in women with normal pregnancies (n = 33), mild pre-eclampsia (n = 8), and severe pre-eclampsia (n = 16) between 20 and 40 weeks' gestation. Ascorbic acid and alpha-tocopherol concentrations were analyzed by high-performance liquid chromatography. Antioxidant activity of sera was measured as the percent inhibition of spontaneous autoxidation of a standard brain homogenate. RESULTS: Plasma levels of ascorbic acid in women with mild and severe pre-eclampsia were significantly lower than normal pregnancies (P < 0.05). Sera alpha-tocopherol levels were significantly decreased only in severe pre-eclampsia (P < 0.05). Sera antioxidant activity were significantly decreased in mild (73%) and severe (51%) pre-eclampsia compared with normal (86%) pregnancies (P = 0.02, P = 0.000, respectively). CONCLUSIONS: In women with pre-eclampsia, sera antioxidant activity and antioxidant level of plasma are decreased when compared with normotensive pregnancies. Impaired antioxidant activity and the reduction of antioxidant levels which increase the level of lipid peroxidation products may cause peroxidative damage of vascular endothelium and result in clinical symptoms of pre-eclampsia.

Endometrial pathology of 104 postmenopausal breast cancer patients treated with tamoxifen.

OBJECTIVE: To investigate the effects of tamoxifen on the endometrium in postmenopausal breast cancer patients. METHODS: Endometrial thickness was measured by transvaginal sonography and endometrial biopsies were done in 104 postmenopausal breast cancer cases who were treated with tamoxifen. Histopathologic findings were discussed. RESULTS: Mean endometrial thickness was 11.7+/-5.9 mm and duration of tamoxifen administration was 35.3 months. Four endometrial cancers, 17 endometrial hyperplasias, 25 proliferative endometrium, 5 endometrial polyps in the endometrial biopsies. We observed atrophic endometrium in 53 of the cases. Only one case with endometrial polyps was observed as a premalignant lesion when the endometrium was less than 5 mm, 51% of the cases had thicker endometrium (more than 10 mm) and 32% of these cases had malignant and premalignant endometrium. We found a significant correlation with the duration of tamoxifen and age (p<0.05). One hundred and two of our cases were asymptomatic; only 2 out of 4 endometrial cancer cases had vaginal spotting. A significant relation was noticed between endometrial thickness and duration of tamoxifen treatment (p=0.025). CONCLUSION: It was concluded that positive endometrial findings and endometrial thickness were due to continuous unopposed tamoxifen treatment and our findings support the hypothesis that tamoxifen increases the risk of endometrial carcinoma and premalignant changes.