Indications, effectiveness and safety of percutaneous endoscopic gastrostomy: A single center experience and literature review.

BACKGROUND AND OBJECTIVES: Percutaneous endoscopic gastrostomy (PEG) has been widely used since 1980 in enteral feeding of patients that are not able to be fed orally for a long time. The aim of this study is to evaluate the PEG indications, effectiveness and PEG related complications from a single center in Istanbul, Turkey. METHODS AND STUDY DESIGN: 265 patients with PEG who were followed up by the clinical nutrition team of a university hospital between 2010-2018 were evaluated retrospectively. Nutritional Risk Screening-2002 (NRS-2002) test, anthropometric measurements, bioelectrical impedance analysis and laboratory data were used to evaluate the patients' nutritional status. RESULTS: The most common indications for PEG were dementia (35.1%), amyotrophic lateral sclerosis (22.6%), stroke (15.8%), and cancer (14%). The mean body weight of the patients was increased after PEG (63.5±12.2 vs 62.0±12.7 kg). Mid upper arm circumference and calf circumference of the patients increased after PEG (27.5±2.5 vs 25.4±3.1 cm and 32.2±7.9 vs 29.6±5.9 cm, respectively). Serum albumin of the patients was increased significantly after PEG (3.34±0.69 g/dL to 3.64±0.65 g/dL) without any significant change in serum CRP. Subgroup analyses showed a significant increase in the mean serum albumin of patients with dementia after PEG (3.23±0.67 g/dL to 3.54±0.58 g/dL). Local insertion site infection occurred in 15 patients (5.6%) and only 3 patients had systemic inflammatory symptoms after local infection (1.1%). CONCLUSIONS: The results of our study showed that long-term enteral feeding with PEG is an effective and safe method that provides improvement in nutritional status.

The Role of the Local Bone Marrow Renin-Angiotensin System in Multiple Myeloma

Objective: Angiotensin II promotes growth and angiogenesis via type 1 receptors (AGTR1) in certain tumors. In this study, we examine the bone marrow AGTR1 expression in multiple myeloma (MM) and its relationship with the regulation of angiogenesis and prognostic factors. Materials and Methods: Bone marrow AGTR1 mRNA levels of 39 MM patients and 15 healthy controls were analyzed with quantitative RT-PCR. Immunohistochemical staining of the tissue vascular endothelial growth factor (VEGF), CD34, and factor VIIIrAg (fVIIIrAg) was used to assess bone marrow angiogenesis. Results: Bone marrow samples of the patients showed increased VEGF, fVIIIrAg, and CD34 staining and higher AGTR1 expression levels when compared to controls. Patients with severe-diffuse bone marrow infiltration showed higher bone marrow VEGF, fVIIIrAg, CD34, and AGTR1 mRNA levels when compared to other patients. Conclusion: AGTR1 expression was found positively correlated with plasma ß2-microglobulin level and patients with increased AGTR1 expression showed increased bone marrow CD34 levels.

Inflammatory myofibroblastic tumor mimicking a relapse in a patient with Hodgkin's lymphoma: report of an unusual case and review of the literature.

New PET-positive lesions in previously treated patients with lymphomatous malignancies need further investigations. Relapse, sarcoidosis and secondary malignancies are the most important differential diagnosis. Inflammatory myofibroblastic tumors (IMT) is a rare complication after treatment of Hodgkin's disease and every PET-positive lesion should be biopsied to prevent unnecessary intervention.

Case report of fatal Mycobacterium tilburgii infection.

There are few reports concerning Mycobacterium tilburgii infection in humans because this bacterium is non-cultivatable. Herein, using new molecular techniques, we report the case of an immunocompromised patient with fatal disseminated lymphadenitis that was caused by M. tilburgii.26 years old Caucasian HIV negative female patient presented with abdominal pain. Her clinical assessment revealed disseminated lymphadenitis, that was acid fast bacilli positive. Further molecular evaluation showed the causative agent as M. tilburgii. Despite anti mycobacterial therapy and careful management of intervening complications patient died because of an intraabdominal sepsis. This is the first fatal M. tilburgii infection in the literature. This case points the importance of careful management of patient's immune status and intervening infections besides implementation of effective drug treatment.

Isolated renal intravascular lymphoma: a case report and review of the literature.

Intravascular large B-cell lymphoma (IVLBCL) is a very rare subtype of extranodal large B-cell lymphoma. It may involve various organ systems such as skin, liver, lung or kidney. Isolated kidney involvement of IVLBCL is also very rare. Herein we report a very rare case of isolated renal IVLBCL presented with fever of unknown origin, acute kidney injury and nephrotic syndrome. Diagnosis was suspected with isolated high renal (18)F fluorodeoxyglucose uptake in positron emission tomography and confirmed with renal biopsy. Complete remission was obtained with combined chemotherapy including rituximab. We reviewed the English literature in terms of IVLBCL with renal involvement and we could only find 16 such cases. Accordingly, fever, AKI and nephritic syndrome are the most common presenting symptoms in renal intravascular lymphoma.

Corticosteroid treatment normalizes QTc prolongation and improves heart block in an elderly patient with anti-Ro-positive systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is a multisystemic disease which potentially involves various organs including the skin, joints, kidneys, liver, hematopoetic system, and serous membranes. It is rarely seen in elderly males. The most common cardiovascular involvement type is pericarditis. Anti-Ro antibodies may be associated with neonatal lupus which causes heart blocks. Recent literature indicates that anti-Ro antibodies may be associated with various rhythm and conduction disturbances in the adulthood. The most common finding associated with anti-Ro antibodies is prolonged corrected QT (QTc) interval. Herein, we present an elderly male patient with anti-Ro-positive SLE associated with prolonged QTc interval and AV blocks that significantly improved after corticosteroid treatment.

Nutritional risk in hospitalized patients: impact of nutritional status on serum prealbumin

OBJECTIVE: Poor recognition and monitoring of nutritional status is the most important cause of malnutrition in hospitalized patients. The aim of this study was to assess the nutritional status of a group of patients and compare the results with their serum prealbumin levels. METHODS: Ninety-seven patients admitted consecutively to the hospital were enrolled in the study. The risk of malnutrition was assessed according to anthropometric data and the Subjective Global Assessment and Nutrition Risk Screening 2002 tools. The nutritional statuses of the patients were compared with their age, gender, body mass index, medical history, weight loss and routine biochemical analyses, including prealbumin and length of hospital stay. RESULTS: According to the Nutrition Risk Screening 2002, 57 percent of the patients were malnourished or at risk of malnutrition, correlating well with the Subjective Global Assessment (p<0.001, r=0.700). Multivariate analysis revealed positive correlations between malnutrition and age, weight loss, malignancy and serum C-reative protein (p=0.046, p=0.001, p=0.04 and p=0.002). Nutrition Risk Screening 2002 score ³3 was associated with prolonged length of hospital stay (p=0.001). Serum prealbumin correlated with nutritional status, regardless of the number of chronic diseases and inflammation biomarkers (p=0.01). Serum prealbumin sensitivity, specificity, positive predictive value, negative predictive value and diagnostic value in the assessment of risk of malnutrition were 94 percent, 32 percent, 0.67, 0.78 and 69 respectively. After 7 days of nutritional support, the risk of malnutrition decreased by 12 percent (p<0.001) and serum prealbumin levels increased by 20 percent (p=0.003). CONCLUSION: Instead of reflecting overall nutritional status, low serum prealbumin may be regarded as a sign of increased risk of malnutrition, requiring further nutritional assessment. It can be used for monitoring patients receiving nutritional support.

OBJETIVO: Falha no reconhecimento e acompanhamento do estado nutricional é a razão mais importante da desnutrição em pacientes hospitalizados. Este estudo objetivou avaliar o estado nutricional dos pacientes e comparar os resultados com os níveis séricos de pré-albumina. MÉTODOS: Foram incluídos 97 pacientes no estudo, internados consecutivamente. O risco de desnutrição foi avaliado de acordo com dados antropométricos e com a Avaliação Subjetiva Global e Triagem de Risco Nutricional 2002. Os estados nutricionais dos pacientes foram comparados com suas idades, sexo, índice de massa corporal, histórico médico, perda de peso e análises bioquímicas, incluindo pré-albumina e tempo de permanência hospitalar. RESULTADOS: De acordo com o Triagem de Risco Nutricional 2002, 57 por cento dos pacientes estavam desnutridos ou em risco de desnutrição, apresentando boa correlação com o Avaliação Subjetiva Global (p<0,001, r=0,700). A análise multivariada mostrou correlações positivas entre desnutrição e idade, perda de peso, malignidade e proteína reativa-C (p=0,046, p=0,001, p=0,04 e p=0,002). Um escore ³3 no Triagem de Risco Nutricional 2002 foi associado à internação prolongada (p<0,001). Houve correlação entre pré-albumina sérica e o estado nutricional, independente do número de doenças crônicas e biomarcadores de inflamação (p=0,01). CONCLUSÃO: Ao invés de refletir o estado nutricional global do paciente, níveis séricos baixos de séricos de pré-albumina podem ser vistos como um sinal de maior risco de desnutrição, exigindo uma avaliação nutricional mais extensa. A análise sérica de pré-albumina pode ser usada para o monitoramento de pacientes recebendo suporte nutricional.

A rare but significant cause of priapism in the elderly: multiple myeloma.

Priapism is a rare symptom with diverse etiological factors. Although most cases in adults are secondary to drug use and intracavernosal injections, blood dyscrasias and hypercoagulable states, vasculitis, penile metastases, neurological conditions, spider bites, carbon monoxide poisoning, and total parenteral nutrition may also result in priapism. We report a case of recurrent and refractory priapism in a 61-year-old man which was diagnosed as multiple myeloma after emergence of hypercalcemia and renal failure due to progression of the underlying pathology. The value of the initial diagnostic approach is emphasized.

Metastatic gastric melanoma: a challenging diagnosis.

BACKGROUND: The stomach is regarded as a rare site for metastasis. When a gastric mass is observed macroscopically, the presumed diagnosis is usually a primary gastric carcinoma. However, the stomach may be involved in metastatic malignant melanoma. Besides a possible macroscopical misdiagnosis, metastatic gastric melanoma may also be misdiagnosed microscopically as adenocarcinoma due to its protean histological characteristics. These features make metastatic gastric melanoma a challenging diagnosis in some cases. CASE REPORT: We report a patient with metastatic gastric melanoma referred to us with an initial macroscopic and histopathological diagnosis of primary gastric adenocarcinoma. He was diagnosed as having metastatic gastric melanoma by further examination because of the peculiar metastatic involvement and normal gastrointestinal tumor marker levels. CONCLUSIONS: The stomach may be involved in melanoma and melanoma metastasis to the stomach is a diagnosis that should be taken into account while evaluating any gastric mass lesion. It is likely to be encountered more commonly nowadays due to the significant increase in the melanoma incidence. A history of melanoma, an atypical metastatic pattern, and normal gastrointestinal tumor marker levels may contribute to its diagnosis.

Ectopic growth hormone-releasing hormone secretion by a neuroendocrine tumor causing acromegaly: long-term follow-up results.

Ectopic secretion of growth hormone-releasing-hormone (GHRH) is a rare cause of acromegaly-representing less than 1% of patients. A 25-year-old woman was admitted to the hospital with acromegaly and a 6 x 6 cm infrahepatic mass. Sellar magnetic resonance imaging indicated diffuse pituitary enlargement consistent with hyperplasia. The infrahepatic mass was resected, and the histopathological diagnosis was a well-differentiated invasive neuroendocrine carcinoma of the duodenum with metastases to local lymph nodes. The tumor cells contained cytoplasmic immunoreactivity for GHRH. Because increased IGF-1 concentrations persisted after the operation, the patient was treated with octreotide long-acting repeatable (LAR) injections of 20 mg/month. Growth hormone and IGF-1 levels normalized. After 6 years of surveillance, a left paraaortic mass was detected by uptake of indium 111 octreotide. Surgical exploration revealed metastatic neuroendocrine carcinoma in a 2.5-cm lymph node. Postoperatively, the IGF-1 concentration was mildly elevated. Octreotide LAR therapy is being continued at 10 mg/month. This case suggests that octreotide treatment may have a beneficial effect on disease course and can be maintained for as long as 7 years in a patient with acromegaly due to a GHRH-secreting neuroendocrine carcinoma.

Mucosa-associated lymphoid tissue lymphoma of the duodenum together with multiple intra-abdominal thromboses and hepatitis C virus infection: a case report.

Mucosa associated lymphoid tissue MALT lymphoma is a low grade malignancy that arises most commonly from the gastric mucosa. Small intestinal involvement is very rare. The causative relationship between Helicobacter pylori and the gastric MALT lymphoma is a well known issue, but recently there are several data suggesting the role of hepatitis C virus (HCV) infection in the pathogenesis of lymphoma including MALT lymphoma. Herein we present a rare case of duodenal MALT lymphoma with multiple intra-abdominal thromboses together with HCV infection that was confirmed by real-time polymerase chain reaction detecting HCV-RNA within the peripheral blood mononuclear cells.

Thrombotic thrombocytopenic purpura associated with multiple myeloma.

Thrombotic thrombocytopenic purpura is a thrombotic microangiopathic disease. Associations with collagen vascular diseases, pregnancy, some drugs, surgical intervention, and infections are documented (known). Malignancy is also one of the known factors associated with thrombotic thrombocytopenic purpura. These malignancies are usually the disseminated solid organ tumors. Hematological malignancies constitute a rare association. Here, we present a patient with thrombotic thrombocytopenic purpura associated with multiple myeloma and discuss the pathogenesis. To our knowledge, this is the first case report of thrombotic thrombocytopenic purpura associated with multiple myeloma.

Plasma nitrate/nitrite and endothelin-1 in patients with liver cirrhosis.

The aims of this study were to examine the plasma nitrate/nitrite (NOx; two end products of nitric oxide metabolism) and endothelin-1 (ET-1) concentrations in patients with liver cirrhosis, and to investigate whether there is a relationship between these two vasoactive parameters and the course of disease. Twenty-eight patients with liver cirrhosis (11 HBV-related, four HCV-related, four alcohol-related, and nine with idiopathic etiology) and 25 healthy subjects (controls) were included in the study. The venous plasma concentrations of NOx and ET-1 were significantly higher (P<0.01 and P<0.001) in the patients with cirrhosis than in the controls. A significant increase in ET-1 was observed in the Child B subgroup vs. Child A (P<0.05), and in the Child C subgroup vs. either subgroup A or B (P<0.05). There were no statistical differences between study subgroups (Child A-C) in the mean of NOx values. Plasma NOx and ET-1 were significantly increased in patients with ascites compared to those without ascites (P<0.05 and P<0.01). Increased nitric oxide synthesis may be a compensation mechanism against endothelial injury. The highest ET-1 levels in Child C and moderately increased ET-1 levels in Child B, and the lower increase of ET-1 levels in Child A patients suggest that plasma ET-1 increases with the progression of the disease. The fact that NOx and ET-1 levels were higher in patients with decompensated cirrhosis (patients with ascites) than in those with compensated cirrhosis (patients without ascites), and the presence of a strong correlation between ET-1, NOx, and the degree of varices, supports the suggestion that there is a relationship between NOx, ET-1, and portal hypertension. Our study demonstrates that increased ET and nitric oxide metabolism is associated with the hemodynamic alterations induced by portal hypertension.

The predictive and diagnostic values of procalcitonin and C-reactive protein for clinical outcome in febrile neutropenic patients.

BACKGROUND: Procalcitonin (PCT) represents a new marker of systemic inflammatory reactions to bacterial infections. The main aim in this study was to determine the diagnostic value of PCT in predicting the clinical severity of febril neutropenic attacks, compare it with that of C-reactive protein (CRP), and clarify its importance in culture-positive attacks. METHODS: Between February 2001 and April 2002, 36 patients who were neutropenic due to various hematologic disorders and febrile were entered into the study. Blood samples were obtained on the first day of fever for the measurement of serum PCT and CRP levels. RESULTS: In clinically severe neutropenic fever attacks, means of serum PCT and CRP levels were measured as 0.93+/-1.33 ng/mL and 67+/-24 mg/L, while they were 0.37+/-0.23 ng/mL and 32+/-19 mg/L in clinically mild ones (p = 0.033 and p < 0.001). On the other hand, no statistical significance was found between culture-positive and negative attacks when either serum PCT or CRP levels were taken into consideration (p = 0.133 and p = 0.141). The specificity and positive predictive value of the serum PCT test for severe febrile neutropenia was higher than that of the serum CRP test (0.80 vs. 0.57 and 0.50 vs. 0.39). However, sensitivity and negative predictive value for CRP were higher than the values for PCT (1.00 vs. 0.40 and 1.00 vs. 0.73). Diagnostic value and positive likelihood ratio of CRP for severe febrile neutropenia were higher than those of PCT (71 vs. 67 and 2.32 vs. 2.00). CONCLUSIONS: PCT and CRP are comparable with each other in prediction of the clinical severity of febrile neutropenic attacks. Furthermore, serum CRP levels correlate with the duration of fever.