Undesirable repigmentation in vitiligo patient receiving methotrexate therapy for the treatment of psoriasis: treatment or side effect?

Vitiligo is an acquired skin depigmentation disorder related to the destruction of melanocytes. There are a limited number of case reports and studies in current literature that show methotrexate (MTX) is effective in the treatment. A 44-year-old man presented to our clinic with a one-year history of psoriasis. On dermatological examination, there were erythematous, scaly papules and plaques on knees, elbows, gluteal area, and scalp compatible with psoriasis. In addition there was total depigmentation over the body. He had a 30-year history of vitiligo, beginning localized but progressed gradually and covered the entire body surface. Subcutaneous methotrexate 10mg weekly was started for psoriasis. On the 6th week of methotrexate treatment, he presented to our clinic with newly developed brown macules on his face. The result of the punch biopsy taken from a macule was reported as normal skin findings. Because his body was fully depigmented, his brown melanocytic macules on his face were considered as repigmentation associated with MTX treatment. His MTX treatment was stopped by patient request. On his 6-month follow-up, hypopigmentation was observed at prior repigmented macules. Methotrexate can be considered an alternative treatment for vitiligo patients when topical therapy and phototherapy are ineffective or not applicable.

Coexistence of restless legs syndrome and multiple sclerosis aggravates anxiety and depression.

BACKGROUND: Among the comorbidities that accompany multiple sclerosis (MS), restless legs syndrome (RLS) is one of the most common. Anxiety and depression are common psychological comorbidities that impact the quality of life of patients with MS (PwMS), as well as patients with RLS. OBJECTIVE: To investigate the psychiatric burden of MS and RLS coexistence, we conducted a nationwide, multicenter and cross-sectional survey. METHODS: Participants were assessed by using demographic and clinical parameters along with the Hamilton Anxiety and Hamilton Depression Scales (HAM-A and HAM-D). RESULTS: Out of the 1,068 participants, 173 (16.2%) were found to have RLS [RLS(+)] and 895 (83.8%) did not [RLS(-)]. The mean scores for HAM-A and HAM-D were significantly higher among RLS(+) subjects than among RLS(-) subjects (p<0.001 for all variables). CONCLUSIONS: According to our data, the presence of RLS in PwMS may increase the occurrence of both anxiety and depression symptoms. Awareness and treatment of RLS in PwMS could possibly reduce the symptoms of psychiatric comorbidities originating from RLS.

Coexistence of restless legs syndrome and multiple sclerosis aggravates anxiety and depression / A coexistência da síndrome das pernas inquietas e esclerose múltipla agrava ansiedade e depressão

ABSTRACT Background: Among the comorbidities that accompany multiple sclerosis (MS), restless legs syndrome (RLS) is one of the most common. Anxiety and depression are common psychological comorbidities that impact the quality of life of patients with MS (PwMS), as well as patients with RLS. Objective: To investigate the psychiatric burden of MS and RLS coexistence, we conducted a nationwide, multicenter and cross-sectional survey. Methods: Participants were assessed by using demographic and clinical parameters along with the Hamilton Anxiety and Hamilton Depression Scales (HAM-A and HAM-D). Results: Out of the 1,068 participants, 173 (16.2%) were found to have RLS [RLS(+)] and 895 (83.8%) did not [RLS(-)]. The mean scores for HAM-A and HAM-D were significantly higher among RLS(+) subjects than among RLS(-) subjects (p<0.001 for all variables). Conclusions: According to our data, the presence of RLS in PwMS may increase the occurrence of both anxiety and depression symptoms. Awareness and treatment of RLS in PwMS could possibly reduce the symptoms of psychiatric comorbidities originating from RLS.

RESUMO Antecedentes: Considerando-se as comorbidades que acompanham a esclerose múltipla (EM), a síndrome das pernas inquietas (SPI) é uma das mais comuns, e ansiedade e depressão são comorbidades psicológicas comuns que afetam a qualidade de vida de pacientes com EM, bem como de pacientes com SPI. Objetivo: Investigar a carga psiquiátrica da coexistência de EM e SPI por meio de uma pesquisa nacional, multicêntrica e transversal. Métodos: Os participantes foram avaliados por parâmetros demográficos e clínicos, além da versão turca das escalas de ansiedade e depressão de Hamilton (HAM-A e HAM-D). Resultados: Dos 1.068 participantes, 173 (16,2%) apresentaram SPI [SPI (+)] e 895 (83,8%) não [SPI (-)]. As pontuações médias no HAM-A e no HAM-D foram significativamente maiores em indivíduos com SPI (+) do que naqueles com SPI (-) (p <0,001 para todas as variáveis). Conclusões: De acordo com nossos dados, a presença de SPI na EM pode aumentar a ocorrência de sintomas de ansiedade e depressão. A conscientização e o tratamento da SPI na EM podem reduzir os sintomas de comorbidades psiquiátricas originadas da SPI.

Restless legs syndrome and headache cause sleepiness and consequent poor school performance: a community based study from Turkey.

BACKGROUND: Disturbance of sleep habits leads to excessive daytime sleepiness (EDS), which may affect learning abilities and consequently academic performance. Therefore the main purpose of current paper was to determine the prevalence of headache and Restless legs syndrome (RLS) in school-aged adolescents and to evaluate the type of headache in adolescents, with a secondary aim to determine the effect of daytime sleepiness on academic success. METHODS: This cross-sectional study was conducted on adolescents aged between 15 and 19 years of age, who were in high school education in the 2016-2017 academic years in Kahramanmaras province. A comprehensive interview form including questions on demographic data, RLS diagnostic criteria, headache and Epworth Sleepiness Scale (ESS) was applied to a total of 4151 students. RESULTS: RLS was found in 3.2% of the participants in all age groups. The mean ESS scores in adolescents with RLS were significantly higher than in those without RLS. Headache was reported by 46.9% of the adolescents in the study, with a frequency of TTH type headache of 17.7% and migraine frequency of 5.2%. RLS frequency was determined to be significantly higher in adolescents with headache and migraine. The academic success rate was significantly lower in those with higher ESS scores. CONCLUSIONS: Migraine and RLS often coexist as comorbid conditions. EDS is an important factor affecting academic success in children. Headache and RLS should not be forgotten, among other reasons for increased daytime sleepiness and its etiology.

Oncocytic Lesions of Salivary Glands with Morphological and Immunohistochemical Findings.

OBJECTIVES: Salivary gland neoplasms are less than 5% of all head and neck neoplasms (1). Although there are morphological similarities between different neoplasms, there may be catchy morphological differences in a single tumour. According to the World Health Organization (WHO), 4th Head and Neck Tumours Classification oncocytic salivary gland lesions are classified as nodular oncocytic hyperplasia, oncocytoma and oncocytic carcinoma. Oncocytic cells may be a component of other salivary gland neoplasms and metastatic malignities. METHODS: In this study, salivary gland oncocytic lesions diagnosed in 2016-2017 were evaluated with Haematoxylin and Eosin (H&E) sections and PAS, diastase resistance PAS, p63, DOG1, cytokeratin7 (CK7), androgen receptor (AR) and PAX8 stains. RESULTS: Nineteen cases were benign, two cases were malignant. Eighteen of the benign lesions were Warthin tumour (WT), one case was oncocytoma with nodular oncocytic hyperplasia. Acinic cell carcinoma (AciCCA) with oncocytic cells predominant was one of the malignant cases. The other case was high-grade salivary duct carcinoma (SDCA). CONCLUSION: The rarity and heterogeneity of this group of lesions may cause difficulties in diagnosis. We present histochemical and immunohistochemical findings of these lesions in light of the literature.

The Contribution of Additional Sampling in Cholecystectomy Materials: A Multicenter Prospective Study.

OBJECTIVE: Cholecystectomy materials are frequently encountered in routine practice. The aim of this study was to determine the true frequency of gallbladder lesions, the diagnostic consistency, and standardization of reports after macroscopic sampling and microscopic evaluation based on previously defined criteria. MATERIAL AND METHOD: 14 institutions participated in the study within the Hepato-Pancreato-Biliary Pathology Study Group. Routinely examined cholecystectomies within the last year were included in the study in these institutions. Additional sampling was performed according to the indications and criteria. The number of blocks and samples taken in the first macroscopic examination and the number of blocks and samples taken in the additional sampling were determined and the rate of diagnostic contribution of the additional examination was determined. RESULTS: A total of 5,244 cholecystectomy materials from 14 institutions were included in the study. Additional sampling was found to be necessary in 576 cases (10.98%) from all institutions. In the first macroscopic sampling, the mean of the numbers of samples was approximately 4 and the number of blocks was 2. The mean of the numbers of additional samples and blocks was approximately 8 and 4, respectively. The diagnosis was changed in 144 of the 576 new sampled cases while the remaining 432 stayed unaltered. CONCLUSION: In this study, it was observed that new sampling after the first microscopic examination of cholecystectomy materials contributed to the diagnosis. It was also shown that the necessity of having standard criteria for macroscopic and microscopic examination plays an important role in making the correct diagnosis.

'Is RLS a harbinger and consequence of MS?: Striking results of the 'RELOMS-T' study'.

BACKGROUND: Although studies report a high prevalence rate of restless legs syndrome (RLS) among patients with multiple sclerosis (PwMS) ranging from 13.3 to 65.1%, little is known about the causes of this relationship. METHODS: To ascertain the prevalence, features and impact of RLS among PwMS a nation-wide, multicenter, prospective and a cross-sectional survey, designed to reflect all of the PwMS throughout Turkey, was conducted in 13 centers. Exploring the relationship of the two conditions could possibly contribute to the understanding of the causes of the high and wide-ranging prevalence rates and the pathophysiology of both diseases. RESULTS: Of the 1068 participants 173 (16,2%) found to have RLS [RLS(+)] and 895 (83,8%) did not [RLS(-)]. Among the RLS(+) 173, all but 8 patients (4,6%) were underdiagnosed in terms of RLS. More than half of the patients with RLS had 'severe' or 'very severe' RLS. The onset of RLS was before or synchronous with the onset of MS in about a half of our patients. CONCLUSION: We conclude that RLS should be meticulously investigated in PwMS and MS can be a direct cause of RLS at least in part of PwMS. Our data about the timing of the onset of MS and RLS, along with the high prevalence of RLS in PwMS suggest that the pathologic changes in the initial phases of MS can possibly trigger RLS symptoms.

Poorly Cohesive (Signet Ring Cell) Carcinoma of the Ampulla of Vater.

In the ampulla of Vater, carcinomas with "diffuse-infiltrative"/"signet ring cell" morphology, designated as "poorly cohesive carcinoma" (PCC) in the WHO classification, are very rare and poorly characterized. Nine cases with a classical PCC morphology constituting >50% of the tumor were identified. Mean age was 64.8 years (vs 64.6 in ampullary carcinomas [ACs]) and 6 were males, 3 females. The mean invasive tumor size was 2.5 cm (vs 1.9 in ACs). Other morphologic patterns displayed included cord-like infiltration (n=2), plasmacytoid cells (n=2), and microglandular component (n=4), including goblet cell adenocarcinoma-like foci. None of the cases were associated with dysplasia. By immunohistochemistry, the carcinomas did not show intestinal differentiation (CDX2 0/9, CK20 1/9, MUC2 3/9), MUC1 was positive in 4/9, MUC5AC was positive in 7/8. E-cadherin loss was noted in 4/9. All cases were advanced stage (6/9-pT3, 3/9-pT4) (vs 43% in ACs). Lymph node metastases were identified in 44% (vs 45% in AC). Six patients (67%) died of disease at a median of 25 months, 3 were alive at 13, 15, and 60 months. Overall median survival was significantly worse than that of intestinal-type ACs (26 vs 122 months, P = .006) and trended toward worse than pancreatobiliary type (26 vs 42 months, P = .1). In conclusion, PCCs constitute 2.45% of all ACs. These present as advanced tumors and express upper-gastrointestinal immunoprofile with frequent MUC5AC labeling, which may be helpful in identifying subtle infiltration in the surface mucosa since MUC5AC is not expressed in the ampullary mucosa. Patients have poor prognosis.

A new immunohistochemical marker, insulinoma-associated protein 1 (INSM1), for Merkel cell carcinoma: Evaluation of 24 cases.

Merkel cell carcinoma (MCC) is an uncommon primary neuroendocrine carcinoma of the skin. Nowadays, pathologists are required to perform immunohistochemistry to demonstrate neuroendocrine and epithelial differentiation for diagnosis of MCC. Insulinoma-associated protein 1 (INSM1) is a zinc-finger transcription factor expressed in tissues undergoing terminal neuroendocrine differentiation, and INSM1 immunohistochemistry is a well-validated nuclear marker of neuroendocrine differentiation. We evaluated 24 cases of MCC for the expression of INSM1 and compared it with frequently used neuroendocrine markers, Chromogranin A, Synaptophysin, and CD56. INSM1 was positive in all cases, and its expression was stronger, more extensive, clean and homogeneous compared to other markers. As a consequence, INSM1 can be used to serve as a solitary marker for neuroendocrine differentiation due to high sensitivity and specificity in MCC cases.

Impaired cognition in hemodialysis patients: The Montreal Cognitive Assessment (MoCA) and important clues for testing
.

BACKGROUND: Cognitive impairment is common among hemodialysis (HD) patients and is associated with poor treatment compliance and mortality. The aim of this study is to evaluate relatively young HD patients with less comorbidities using the Montreal Cognitive Assessment (MoCA) and identify clues for earlier detection of cognitive impairment with the help of cognitive subscale scores. MATERIALS AND METHODS: A total of 103 chronic HD patients (mean age 48.3 years) and 37 stage-3 to 5 chronic kidney disease (CKD) patients with similar demographics were included. Patients with cerebrovascular disease, dementia, depression, malignancy, and infections were excluded. All participants were tested with MoCA. Patients with an MoCA global score < 24/30 were considered cognitively impaired. Groups were compared for MoCA subscales and clinical features. RESULTS: 75 patients (72.8%) in the HD group and 19 in the CKD group (51.3%) had impaired cognition. The number of patients with cognitive impairment was significantly higher in the HD group compared with the CKD group (p = 0.024). The mean total MoCA score was lower in the HD group (p = 0.043). MoCA subscale analysis revealed that the mean score for visuospatial/executive domain was significantly lower in the HD group (p = 0.001). CONCLUSION: In this study, we showed that cognitive impairment was more common in HD patients compared with predialytic CKD patients. This difference was predominantly related to the difference in executive scores. We may think that young HD patients with less comorbidities are also at risk for cognitive impairment. Noticing progressive declines in MoCA cognitive domains, before the development of global cognitive impairment, could be beneficial for HD patients.
.

Approach to Patients with Malignant Melanoma of Unknown Primary Origin.

OBJECTIVES: Although malignant melanoma accounts for 3% of skin cancers, it is responsible for 75% of deaths associated with skin cancer. In our study, all melanoma cases diagnosed and treated at our clinic were retrospectively reviewed, and the cases of unknown primary origin among them were examined in detail in terms of diagnosis and treatment. METHODS: The patients with malignant melanoma treated at the inpatient services of our clinic between January 1991 and April 2017 were retrospectively screened in the records. These patients were evaluated for age, sex, tumor type, Breslow depth, metastasis, and treatment. Among these patients, four cases of unknown primary origin were examined in detail. RESULTS: During January 1991 and April 2017, 173 patients received inpatient care for malignant melanoma at our clinic. As regards to the melanoma subtypes, nodular type in 45 patients, acral lentiginous type in 43 patients, superficial spreading type in 63 patients, lentigo maligna melanoma in 15 patients, subungual type in 7 patients, and either unidentified melanoma or other subtypes in 10 patients were identified. CONCLUSION: The ideal treatment of a patient with melanoma is multidisciplinary, with plastic surgery having a central role.

A Retrospective Evaluation of the Epithelial Changes/Lesions and Neoplasms of the Gallbladder in Turkey and a Review of the Existing Sampling Methods: A Multicentre Study.

OBJECTIVE: As there is continuing disagreement among the observers on the differential diagnosis between the epithelial changes/lesions and neoplasms of the gallbladder, this multicentre study was planned in order to assess the rate of the epithelial gallbladder lesions in Turkey and to propose microscopy and macroscopy protocols. MATERIAL AND METHOD: With the participation of 22 institutions around Turkey that were included in the Hepato-Pancreato-Biliary Study Group, 89,324 cholecystectomy specimens sampled from 2003 to 2016 were retrospectively evaluated. The numbers of adenocarcinomas, dysplasias, intracholecystic neoplasms/adenomas, intestinal metaplasias and reactive atypia were identified with the review of pathology reports and the regional and countrywide incidence rates were presented in percentages. RESULTS: Epithelial changes/lesions were reported in 6% of cholecystectomy materials. Of these epithelial lesions, 7% were reported as adenocarcinoma, 0.9% as high-grade dysplasia, 4% as low-grade dysplasia, 7.8% as reactive/regenerative atypia, 1.7% as neoplastic polyp, and 15.6% as intestinal metaplasia. The remaining lesions (63%) primarily included non-neoplastic polypoids/hyperplastic lesions and antral/pyloric metaplasia. There were also differences between pathology laboratories. CONCLUSION: The major causes of the difference in reporting these epithelial changes/lesions and neoplasms include the differences related to the institute's oncological surgery frequency, sampling protocols, geographical dissimilarities, and differences in the diagnoses/interpretations of the pathologists. It seems that the diagnosis may change if new sections are taken from the specimen when any epithelial abnormality is seen during microscopic examination of the cholecystectomy materials.

Nonneoplastic Lesions of the Pancreas: A Retrospective Analysis of 20 Cases.

OBJECTIVES: In the pancreatic lesion cases, surgery is often planned based only on imaging results and without a preoperative histological diagnosis, due to the high risk of malignancy in combination with the difficulty of invasive interventions and limited cytopathological evaluation. In this study, the records of 20 patients who had undergone a pancreatectomy procedure and who were diagnosed with nonneoplastic pancreatic lesions were retrospectively evaluated according to the clinical and histopathological findings. METHODS: A total of 122 cases of patients who underwent a pancreatectomy with suspicious lesions between 2004 and 2016 were retrospectively assessed in detail using the clinical and histopathological findings. RESULTS: Nonneoplastic lesions were observed in 20 (16%) of 122 patients who underwent a pancreatectomy. Histopathological examination revealed 11 cases of chronic pancreatitis, 1 hematoma, 1 instance of hemorrhagic necrosis secondary to trauma, 1 pseudocyst, 1 granulation tissue, 1 retention cyst, 1 bile duct cyst, 1 patient with Castleman disease, and 1 instance of fat necrosis were seen. In 1 patient, no evidence of disease was found. In addition, among the patients with chronic pancreatitis, autoimmune pancreatitis was observed in 1, adenomyoma of the ampulla of Vater was present in 1, and a pseudocyst was found in 1 patient. CONCLUSION: A clinical and histopathological analysis of nonneoplastic lesions found in pancreatectomy patients was performed.

Sarcoidosis with Hepatic Involvement: A Case Report.

Sarcoidosis is a systemic, noncaseating granulomatous disease with an unknown etiology. The liver is one of the most frequently affected organs. This case is presented to emphasize that hepatic granulomatous foci can lead to a determination of etiology in a diagnosis of sarcoidosis. A 53-year-old-female patient with complaints of fatigue and abdominal pain was admitted to the clinic of gastroenterology. The blood levels of alanine transaminase, aspartate transaminase, alkaline phosphatase and gamma-glutamyl transferase were markedly increased. The autoimmune parameters were negative. A Tru-Cut biopsy (Becton, Dickinson and Co., Franklin Lakes, NJ, USA) of the liver was performed based on the initial diagnoses of tuberculosis, lymphoma, and sarcoidosis. Histopathological evaluation revealed noncaseating granulomatous inflammation with Grade 3 macrovesicular steatosis. An investigation for hepatic sarcoidosis was recommended. The angiotensin-converting enzyme levels were 5 times higher than normal. Based on this result, the diagnosis was sarcoidosis with hepatic involvement. The treatment and follow-up of the patient continues.

Primary Pure Uterine Lipoma: A Report of two Cases and Review of the Literature.

Pure uterine lipomas are rare diagnoses despite lipoma being a common entity. The histogenesis of these lesions remains unknown, and its clinical symptoms are similar to those of uterine leiomyomas. In this report, two cases of uterine lipomas were presented with their histopathological and clinical aspects.

Inflammatory myofibroblastic pancreas tumor: a case report.

Inflammatory myofibroblastic tumor (IMT) histologically characterized by fibroblastic and myofibroblastic proliferation with inflammatory infiltrate. The therapy adopted was Whipple's pancreaticoduodenectomy with a histological diagnosis of the inflammatory myofibroblastic tumor. The disease that should be considered as the differential diagnosis is pancreatic cancer. The diagnosis and treatment of IMT is surgical resection.

Impact of aggression, depression, and anxiety levels on quality of life in epilepsy patients.

The aim of this study was to investigate the impact of aggression levels on the quality of life (QoL) of epilepsy patients. This study was conducted on 66 volunteer control subjects, who were matched by age and sex to the patient group, which consisted of 66 patients who applied to the Psychiatry and Neurology clinics for outpatient treatment, were aged between 18 years and 65 years, and were diagnosed with epilepsy. A sociodemographic and clinical data form designed by us was distributed among the study participants, along with Buss-Perry Aggression Scale, Beck Anxiety Scale, Beck Depression Scale, and the Quality of Life Scale Short Form (SF-36). Compared with the control group, the patient group displayed higher scores in all subgroups of Buss-Perry Aggression Scale subscales at a statistically significant level (P<0.05). As per the SF-36 questionnaire, physical functioning, physical role disability, general health perception, social functioning, mental health perception, and pain subscales were statistically lower in the patient group (P<0.05). Significant links between Beck Depression Scale and Beck Anxiety Scale levels, as well as some subscales of QoL and aggression levels, were also determined. In conclusion, epilepsy patients experienced impaired QoL compared with the healthy control group and their QoL was further impaired due to increased levels of anxiety, depression, and aggression.

Automatic Diagnosis of Obstructive Sleep Apnea/Hypopnea Events Using Respiratory Signals.

Obstructive sleep apnea is a sleep disorder which may lead to various results. While some studies used real-time systems, there are also numerous studies which focus on diagnosing Obstructive Sleep Apnea via signals obtained by polysomnography from apnea patients who spend the night in sleep laboratory. The mean, frequency and power of signals obtained from patients are frequently used. Obstructive Sleep Apnea of 74 patients were scored in this study. A visual-scoring based algorithm and a morphological filter via Artificial Neural Networks were used in order to diagnose Obstructive Sleep Apnea. After total accuracy of scoring was calculated via both methods, it was compared with visual scoring performed by the doctor. The algorithm used in the diagnosis of obstructive sleep apnea reached an average accuracy of 88.33 %, while Artificial Neural Networks and morphological filter method reached a success of 87.28 %. Scoring success was analyzed after it was grouped based on apnea/hypopnea. It is considered that both methods enable doctors to reduce time and costs in the diagnosis of Obstructive Sleep Apnea as well as ease of use.