Randomized Trial Comparing Resection of Primary Tumor with No Surgery in Stage IV Breast Cancer at Presentation: Protocol MF07-01.

BACKGROUND: The MF07-01 trial is a multicenter, phase III, randomized, controlled study comparing locoregional treatment (LRT) followed by systemic therapy (ST) with ST alone for treatment-naïve stage IV breast cancer (BC) patients. METHODS: At initial diagnosis, patients were randomized 1:1 to either the LRT or ST group. All the patients were given ST either immediately after randomization or after surgical resection of the intact primary tumor. RESULTS: The trial enrolled 274 patients: 138 in the LRT group and 136 in the ST group. Hazard of death was 34% lower in the LRT group than in the ST group (hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.49-0.88; p = 0.005). Unplanned subgroup analyses showed that the risk of death was statistically lower in the LRT group than in the ST group with respect to estrogen receptor (ER)/progesterone receptor (PR)(+) (HR 0.64; 95% CI 0.46-0.91; p = 0.01), human epidermal growth factor 2 (HER2)/neu(-) (HR 0.64; 95% CI 0.45-0.91; p = 0.01), patients younger than 55 years (HR 0.57; 95% CI 0.38-0.86; p = 0.007), and patients with solitary bone-only metastases (HR 0.47; 95% CI 0.23-0.98; p = 0.04). CONCLUSION: In the current trial, improvement in 36-month survival was not observed with upfront surgery for stage IV breast cancer patients. However, a longer follow-up study (median, 40 months) showed statistically significant improvement in median survival. When locoregional treatment in de novo stage IV BC is discussed with the patient as an option, practitioners must consider age, performance status, comorbidities, tumor type, and metastatic disease burden.

Factors affecting mortality after hip fracture surgery: a retrospective analysis of 578 patients.

PURPOSE: To determine the effect of patient and surgical factors on mortality after hip fracture surgery. DESIGN: Retrospective study. SETTING: Level-one trauma and tertiary referral centers. METHODS: Patients were eligible if they were aged 65 years or older and had undergone surgery for a non-pathological femoral neck or intertrochanteric hip fracture between 2008 and 2011. The primary outcome was mortality: within the first year after surgery, after the first year, and survival as of the last questioning date. Of the 578 eligible patients, 399 (69%) were women; mean age was 79 years; and mean follow-up was 17 months. RESULTS: Mortality during the first year was significantly more frequent in patients aged 80 years or older (67 vs. 33%; P < 0.001). Estimated overall survival was significantly longer in women (43 vs. 37%; P = 0.01). The type of fracture had no impact on mortality (P = 0.96). Patients with high ASA class had a significant effect on mortality (P < 0.001). Surgery timing did not affect mortality in univariate analysis (P = 0.25). The mortality rate for hemiarthroplasty was higher than osteosynthesis options (P = 0.03). The effect of the type of anesthesia on mortality was not significant (P = 0.74). CONCLUSIONS: Older men had the highest risk of mortality within the first year. Patients with ASA ratings of class 3 or 4 need to be evaluated carefully because they appear to be at higher risk of early mortality. Osteosynthesis has a lower mortality than does arthroplasty for hip fracture and thus should be preferred if either treatment is possible. LEVEL OF EVIDENCE: IV.

Effects of infliximab on bacterial translocation in experimental acute necrotizing pancreatitis.

BACKGROUND & OBJECTIVES: Translocation of bacteria from the gut is an important factor in the development of septic complications and mortality in acute pancreatitis (AP). The present study was designed to assess the effects of infliximab treatment on bacterial translocation (BT) in experimental acute necrotizing pancreatitis. METHODS: Male Sprague-Dawley rats (n=45) were allocated into three groups. AP was induced in group II (positive control, n=15) and group III (Infliximab; n=15) by retrograde injection of taurocholate into the common biliopancreatic duct. Group I rats (Sham; n=15) received normal saline infusion into the common biliopancreatic duct as placebo. Groups I and II were treated by normal saline and group III was treated with infliximab intraperitoneally on 6, 30 and 54 h after induction of pancreatitis. All surviving animals were killed 60 h after the induction of pancreatitis, and specimens were collected for amylase measurement as well as histopathologic and microbiologic examinations. RESULTS: Oedema, acinar cell necrosis, inflammatory infiltration, haemorrhage, fat necrosis and perivascular inflammation in group III rats were decreased with infliximab treatment when compared with group II (P<0.001). BT to mesentery lymph node in groups I, II and III were 20, 100 and 46 per cent, respectively. BT to peritoneum and pancreas in group III was lower than group II (P<0.05). INTERPRETATION & CONCLUSIONS: Infliximab administration resulted in beneficial effects on BT and histopathologic changes in the experimental necrotizing pancreatitis. Whether anti-TNF therapy has a role in prevention of complications of ANP needs to be established.

Median nerve entrapment in an adolescent medial epicondyle fracture of humerus: A case report.

A 14-year-old boy with a displaced medial epicondyle fracture without elbow dislocation was found to have an entrapped median nerve. Entrapment of the median nerve is a potential consequence of a displaced medial epicondyle fracture, even when there are no neu-rologic deficits on presentation. This provides additional support for the open reduction of these fractures rather than percutaneous treatment or non-operative management. The early identification and release of an interposed median nerve are imperative to prevent the catastrophic consequences of the upper extremity nerve palsy in children, as well as to optimize fracture healing and development.

Outcome of Corticosteroid Injections, Extracorporeal Shock Wave Therapy, and Radiofrequency Thermal Lesioning for Chronic Plantar Fasciitis.

BACKGROUND: Chronic heel pain with plantar fasciitis is relatively common and can affect adults of all ages regardless of an active or sedentary lifestyle. The purpose of the present study was to evaluate the effectiveness of corticosteroid injection (CSI), extracorporeal shock wave therapy (ESWT), and radiofrequency thermal lesioning (RTL) treatments in chronic plantar heel pain that has been unresponsive to other conservative treatments. METHODS: We retrospectively analyzed the results of 217 patients treated with CSI (n = 73), ESWT (n = 75), and RTL (n = 69). The treatment efficacy and pain intensity, as measured using the visual analog scale, were recorded and compared at the 6-month follow-up. RESULTS: Pain intensity decreased significantly in all patients. However, it decreased significantly more in the CSI and RTL groups than in the ESWT group (P < .001). Age, sex, body mass index, calcaneal spur presence, and symptom duration were similar among 3 groups (P > .05). No complications were noted after the CSI, ESWT, or RTL sessions. CONCLUSION: CSI, ESWT, and RTL successfully treated chronic plantar heel pain that did not respond to other conservative treatments; however, CSI and RTL yielded better therapeutic outcomes. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Survey on the surgical skills of orthopedics and traumatology residents from accredited and nonaccredited institutions in Istanbul.

OBJECTIVE: To investigate whether orthopedic and traumatology residents who are undergoing training achieve competence in surgical techniques after completion of their specialization and to determine whether there are significant differences between the responses of residents from accredited and nonaccredited institutions. METHODS: A total of 131 orthopedics and traumatology residents from nine institutions in the Istanbul province answered the questionnaire during the morning training meeting. In addition to basic demographic data, level of seniority, equipment competence, and theoretical and practical training, the residents were asked about their opinion on what type of surgeries they could perform after their specialization, considering the surgery and follow-up of the case as well as the complications occurring during this period. The residents responded to questions on 46 surgeries under the main headings of trauma, arthroscopy, arthroplasty, spine, pediatric orthopedics, hand surgery, deformity, and bone and soft tissue tumors. In addition to descriptive statistical methods, one-way analysis of variance, Tukey's multiple comparison test, and chi square test were used to evaluate the data. The significance level for the results was set at p<0.05. RESULTS: In total, 131 orthopedics and traumatology residents answered the questionnaire. Furthermore, 53 (40.5%) specialization students were employed at accredited institutions and 78 (59.5%) at nonaccredited institutions. According to the responses, case presentations, article-writing sessions, and in-province meetings held regularly at accredited institutions showed a significant difference compared to non-accredited institutions (p<0.05), and the residents at the accredited institutions benefited significantly more from the availability of books and electronic media in gaining theoretical knowledge (p<0.05). When the responses of the residents from accredited and nonaccredited institutions regarding 46 different surgeries were compared, a significant difference was found in 17 of them (p<0.05). There was a significant difference between the averages of residents' responses on the surgical fields they have interest for (p<0.05). It was determined that the residents believed that they could mostly perform surgeries in the fields of trauma, followed by arthroplasty, deformity, arthroscopy, pediatric orthopedics, hand surgery, and spine and tumor surgery. According to their level of seniority, a significant difference was found between the averages of residents' opinions regarding their surgical skill levels (p=0.02). CONCLUSION: We believe that it would be beneficial for the trainers to take necessary precautions to increase the skill levels of the residents of orthopedic surgery. Accreditation significantly contributes to the standardization of education as well as quality improvement. Further action should be taken to increase the number of accredited clinics.

Effects of Graft Selection in Arthroscopic Anterior Cruciate Ligament Reconstruction: Midterm Functional Results.

OBJECTIVES: This study is a comparison of the midterm clinical results of patients who underwent anterior cruciate ligament (ACL) reconstruction using an allograft and those who had an autograft procedure. METHODS: The results of 70 patients who underwent ACL reconstruction with an anterior tibial tendon (ATT) allograft (n=18) or a hamstring (HT) autograft (n=52) were evaluated retrospectively. At the last follow-up, International Knee Documentation Committee (IKDC) and Tegner-Lysholm scores were used to assess functional status, as well as results of the Lachman test, the anterior drawer test, and the pivot-shift test. RESULTS: There was no significant difference between the 2 groups in terms of age, gender, length of time before operation, graft thickness, or femoral tunnel length (p>0.05). The results were satisfactory in both groups in the postoperative period in terms of the length of time until a return to sports, IKDC score, Tegner-Lysholm score, range of motion, quadriceps circumference, and laxity, with no significant difference between the groups (p>0.05). CONCLUSION: The results of this study suggested that midterm clinical outcomes of ACL reconstruction with an ATT allograft or an HT autograft are similar when the correct technique is used according to the appropriate indications by an experienced surgeon and a successful rehabilitation program implemented after the operation.

The protective effect of ethyl pyruvate on lung injury after burn in rats.

OBJECTIVE: To investigate the effects of administered ethyl pyruvate (EP), a novel anti-inflammatory agent, on oxidoinflammatory and apoptotic pathways in the lung tissue of rats in a full-thickness burn model. METHODS: The study took place in Ankara Research and Training Hospital Animal Laboratory, Turkey in June 2006. Thirty-two rats were randomly divided into 4 groups in equal numbers as sham, burn, sham+EP, and burn+EP. The burn model, used produced a full thickness burn of the 30-35% of the total body surface area. Ethyl pyruvate was administered as 40 mg/kg intraperitoneally. Rats were sacrificed after 24 hours, acute lung injury (ALI) was evaluated by direct light microscopy and apoptosis was evaluated by caspase-3 staining. Oxidoinflammatory events were evaluated by determining the tissue levels of myeloperoxidase (MPO), lipid peroxidation products, and nitrite. RESULTS: No significant difference was observed in lung tissue nitrite and malondialdehyde levels among the study groups. Histopathological results revealed that ALI and apoptosis were significantly higher in the burn group and EP prevented this effect. Similar results were obtained in tissue MPO levels. CONCLUSION: Ethyl pyruvate is a novel, potent anti-inflammatory agent. This agent prevented leukocyte infiltration, ALI, and apoptotic loss of the lung tissue in thermal injury.

The role of serum inflammatory markers in acute appendicitis and their success in preventing negative laparotomy.

Improving the diagnosis of acute appendicitis in order to prevent unnecessary surgery is crucial. This study was intended to identify the role of serum inflammatory markers in patients with preliminary diagnosis of acute appendicitis with a retrospective design. Eighty-five patients with the preliminary diagnosis of acute appendicitis were recruited in this study within the period of November-December 2003. The average age was 31.8 years (ranged from 15 to 85). There were 62 males (72.9%) and 23 females (27.1%). In addition to performing routine tests, preoperative serum samples were obtained from the patients to measure C-reactive protein, interleukin-6, and interleukin-10. All the patients were operated on for a clinical suspicion of acute appendicitis. Depending on the macroscopic evidence during the operation and the histopathological examination of the specimen, the patients were separated into two groups: the ones who did not have acute appendicitis as the cause for acute abdomen (group I; n = 14) and the ones who had acute appendicitis (group II; n = 71). The ones who had acute appendicitis (group II) were further grouped as noncomplicated appendicitis (group IIA; n = 44) and complicated appendicitis (group IIB; n = 27). Being a male with elevated levels of leukocytes (white blood cells, WBC); C-reactive protein (CRP), interleukin-6 (IL-6); and interleukin-10 increased the probability of having acute appendicitis in patients with evidences of acute abdomen. The risk of complication of acute appendicitis significantly increased when patients had increased levels of C-reactive protein, increased erythrocyte sedimentation rate, and increased interleukin-6 levels, had symptoms for more than 24 h, and were female. Interleukin-10 levels within normal range might be helpful in eliminating the possibility of acute appendicitis. Thus, elevated levels of WBC, IL-6 and CRP might be helpful in confirming a potential diagnosis of acute appendicitis. In addition, normal levels of IL-10 might be of additional help to possibly rule out the diagnosis of acute appendicitis.

Fournier gangrene. Approaches to diagnosis and treatment.

OBJECTIVE: To investigate the factors associated with patients with Fournier's gangrene, and to clarify the effect of diabetes mellitus (DM) as a comorbid disease on morbidity and mortality of patients with Fournier's gangrene. METHODS: Twenty-six Fournier's gangrene patients who were admitted to the Emergency Department of Ankara Numune Teaching and Research Hospital, Ankara, Turkey from 1997 to 2003 were examined retrospectively. RESULTS: The mean age of the patients was 52.8 years. There were 8 female (30.8%) and 18 male (69.2%) patients. The etiological causes were as follows: diseases of the perianal region, history of operations, trauma and injections. Major comorbid disease states were diabetes mellitus (DM) and hypertension. The lesions in Fournier's gangrene were most commonly located in the perineum and genital region. Female patients with diabetes mellitus had significantly unusual extensive involvement, especially abdominal wall involvement. The most frequently isolated pathogen was Escherichia coli, while staphylococcal infection was most commonly seen in the presence of DM. Colostomy was performed on 53.8% of the patients, and cystostomy on 7.6% of the patients. Average time of staying at the hospital was 25 days with a mortality rate of 34.6%. Patients with DM had high mortality rates and stayed longer at the hospital than the non-diabetic patients. CONCLUSION: In addition to early diagnosis, early and aggressive debridement and administration of multiple wide spectrum antibiotics chosen for the causative agent are the golden standard for decreasing the mortality and morbidity. Diabetes mellitus has been found to be an important factor to increase mortality rates of patients with Fournier's gangrene.

Effects of Zoledronate on Mortality and Morbidity after Surgical Treatment of Hip Fractures.

We aimed to evaluate the effects of intertrochanteric femoral fractures on mortality, morbidity, and cost of zoledronate treatment in elderly patients treated by osteosynthesis. Based on Evans classification, 114 patients with unstable intertrochanteric femoral fractures were treated with osteosynthesis. After the surgical treatment of intertrochanteric fractures, the treatment group (M/F, 24/32; mean age, 76.7 ± SD years) received zoledronate infusion, and the control group (M/F, 20/38; mean age, 80.2 ± SD years) received placebo. Postoperative control visits were performed at 6-week, 3-month, 6-month, and 12-month time points. Functional level of patients was evaluated by the modified Harris hip score and Merle d'Aubigné hip score. By 12 months, the mean HHS in treatment and control groups was 81.93 and 72.9, respectively. For time of death of the patients, mortality was found to be 57.1% (16/28) on the first 3 months and 92.9% (26/28) on the first six months. The mortality rate in the treatment and control groups was 14.3% (8/56) and 34.5% (20/58), respectively. The use of zoledronic acid after surgical treatment of intertrochanteric femoral fractures in osteoporotic elderly patients is a safe treatment modality which helps to reduce mortality, improves functional outcomes, and has less side effects with single dose use per year.

Ipsilateral olecranon and distal radius fracture: A case report.

INTRODUCTION: Concomitant ipsilateral olecranon and distal radius fracture are rare injuries. Their clinical presentation is unusual and investigation and management is poorly described. PRESENTATION OF CASE: We present a 55-year-old woman patient who fell off sustaining a concomitant distal radius and olecranon fracture in the same extremity. On examination, there was gross swelling of the proximal and distal forearm and no neurovascular deficit. Radiographs confirmed distal radius and olecranon fracture. Patient was treated with open reduction and anatomic locking plate for olecranon and a closed reduction percuteneous K wire fixation with penning fixator for distal radius fracture. After physical therapy program, functional results were good and DASH score was 60. DISCUSSION: Several different combinations of fracture with dislocation have been described, but, to our knowledge, concurrent ipsilateral olecranon and distal radius fracture has not been reported before. In the literature review there are two similar cases in the English literature. CONCLUSION: Ipsilateral olecranon and distal radius fracture is a very rare injury due to different trauma mechanisms. However we should keep in mind that there may be adjacent joints and structures for concomitant injuries.

Textiloma (gossypiboma) mimicking recurrent intracranial abscess.

INTRODUCTION: Cranial-retained surgical sponges (gossypiboma or textiloma) are rare incidents and mostly asymptomatic. However, they can be confused with other masses such as a hematoma abscess or tumor. During early stages, some gossypibomas can cause infection or abscess formation. CASE PRESENTATION: A 22-year-old Turkish female who had frontal lobe brain surgery to remove an abscess 2 months previously was admitted with complaints of headache and vomiting. CONCLUSION: Gossypiboma was confirmed in the patient. Following cranial surgery, gossypiboma should be considered as a differential diagnosis of recurrence of previous surgical operations.

Serum leptin levels are associated with tamoxifen-induced hepatic steatosis.

PURPOSE: Tamoxifen, used in breast cancer treatment, may induce hepatic steatosis. It has been suggested that leptin, which has a relationship with body fat stores, may be involved in the pathogenesis of hepatic steatosis. In this study, we compared serum leptin levels in tamoxifen-treated patients with and without hepatic steatosis. METHODS: Thirty-four women with breast cancer receiving tamoxifen were included in the study. Serum samples were obtained from the patients before and 3 months after tamoxifen therapy. RESULTS: Increased hepatic steatosis was detected in 15 of 34 (44%) patients after 3 months of tamoxifen therapy. Serum leptin levels were found to be significantly elevated in patients with increased hepatic steatosis (37.3 +/- 17.7 to 50.5 +/- 22.4 ng/ml, p = 0.023) compared to (48.2 +/- 20.2 to 42.6 +/- 14.9 ng/ml, p > 0.05) after tamoxifen treatment. CONCLUSION: Leptin may play a role in tamoxifen-induced hepatic steatosis. The exact mechanism involved should be investigated in further studies.

Effect of 3-aminobenzamide on perforation an experimental colitis model.

BACKGROUND/AIMS: The anti-inflammatory activity of 3-aminobenzamide (3-AB) has been shown via histopathology and immunohistochemistry in various colitis models. We aimed to study the effects of 3-AB on tissue mechanical endurance and, associatively, preventing perforation in colitis. MATERIALS AND METHODS: Thirty male Wistar albino rats were randomly divided into three groups. Rectal saline was administered to Group 1 (sham+saline). Rectal trinitrobenzensulphonic acid was applied to induce colitis in Group 2 (colitis+saline) and Group 3 (colitis+3-AB). Groups 1 and 2 were treated intraperitoneally with saline (1 ml every 12 hours) and Group 3 was treated with 3-AB (10 mg/kg every 12 hours). After seven days, rats were sacrificed and colon lipid peroxidation levels, the serum tumor necrosis factor alpha (TNF-α) level, bowel bursting pressures, and bowel wall tensions were measured. RESULTS: Bowel bursting pressure in Group 2 was significantly lower than in Groups 1 and 3 (p<0.001 for both groups). Bowel wall tension in Group 2 was significantly lower than in Groups 1 and 3 (p<0.001 for both groups). There were no significant differences between groups for serum TNF-α levels. For lipid peroxidation, malondialdehyde (MDA) levels were increased in Groups 2 and 3 compared to Group 1. CONCLUSION: 3-AB may aid prevention of perforations that develop in inflammatory bowel disease, requiring surgical treatment.

Storiform-pleomorphic type of multifocal malignant fibrous histiocytoma of the lumbar spine.

BACKGROUND: We present the extremely rare case of a 67-year-old male with malignant fibrous histiocytoma, arising in the lumbar spine, demonstrated with radiological and pathological studies. CASE REPORT: The patient and his relatives refused open surgical approach and we performed transpedicular vertebral corpus biopsy and vertebroplasty under spinal anesthesia. His pathological result was malignant fibrous histiocytoma. The spine is a very uncommon site for malignant fibrous histiocytoma. CONCLUSIONS: The management of malignant fibrous histiocytoma relies on the combination of maximum decompression surgery, chemotherapy and radiotherapy. Total removal is unrealistic and diagnosis is difficult. The prognosis in terms of continuing neurological deficit after surgery appears to be poor.

The relation between preoperative ultrasonographic thyroid volume analysis and thyroidectomy complications.

OBJECTIVE: To determine the relation between thyroid volume (ThV) and thyroidectomy complications using preoperative ultrasound and ellipsoid volumetric analysis in Turkish patients. PATIENTS AND METHODS: This prospective study included a total of 500 patients (401 females = 80.2% and 99 males = 19.8%) who were operated for benign goiter. According to their ThV estimated by ultrasound hey were classified in three groups: 1. less than 50 ml (n = 269; 53.8%), 2. between 50 and 100 ml (n = 151; 30.2%), 3. more than 100 ml (n = 80; 15.6%). By comparing the association of thyroid volume with peroperative and postoperative complications it was evaluated whether the thyroid volume could be an effective factor participating in morbidity and mortality of patients. RESULTS: Total peroperative complication rate was 2% (n = 10) with trachea injury in 2 (0.4%), bleeding in 8 (1.6%) patients. Peroperative complications were significantly more frequent in patients with large volume (p = 0.003). Temporary hypocalcemia rate in patients with less than 50 ml volume was highly significant (p < 0.001). Volume average was low in patients with hypocalcemia as compared to patients without hypocalcemia (p < 0.001). Both the temporary and permanent vocal cord paralysis (VCP) were significantly more frequent in patients with larger volumes (p = 0.002). All four patients with permanent VCP had more than 100 ml volume. CONCLUSION: Thyroid volume is an important factor affecting thyroidectomy complications. In patients with smaller ThV increased risk of hypocalcemia was found, whereas in those with larger ThV increased risk of recurrent nerve damage and peroperative bleeding was observed.

The effectiveness of early rehabilitation in patients with modified radical mastectomy.

The aim of this prospective study was to investigate the effects of early onset rehabilitation program on shoulder mobility, functional status, lymphedema, and the incidence of postoperative complications in patients who had modified radical mastectomy. Fifty-seven women were randomly assigned to either treatment group or home exercise program groups, which were consisted of 27 and 30 patients, respectively. After removal of the drains, the patients were instructed to 15 sessions of individual rehabilitation program and continued with home-based physical activity program. The home exercise program groups only received a form including the exercises, which could be performed by themselves after removal of the drains. Range of motion of the shoulder joint and upper extremity circumferential difference were measured. Functional status was assessed by functional index score. Each patient was assessed preoperatively and then postoperatively at fifth day and first, third, and sixth months. The improvement in measurements of flexion, abduction, and adduction movements of the shoulder joint and the functional questionnaire scores were significantly better in treatment group. There was no statistically significant difference in the development of lymphedema and postoperative complications in both groups. Early onset rehabilitation program after modified radical mastectomy provides improvement in shoulder mobility and functional capacity without causing adverse effect in postoperative period.