A new technique for the diagnosis of acute appendicitis: abdominal CT with compression to the right lower quadrant.

OBJECTIVE: To determine the diagnostic accuracy of abdominal CT with compression to the right lower quadrant (RLQ) in adults with acute appendicitis. METHODS: 168 patients (age range, 18-78 years) were included who underwent contrast-enhanced CT for suspected appendicitis performed either using compression to the RLQ (n = 71) or a standard protocol (n = 97). Outer diameter of the appendix, appendiceal wall thickening, luminal content and associated findings were evaluated in each patient. Kruskal-Wallis, Fisher's and Pearson's chi-squared tests were used for statistical analysis. RESULTS: There was no significant difference in the mean outer diameter (MOD) between compression CT scans (10.6 ± 1.9 mm) and standard protocol (11.2 ± 2.3 mm) in patients with acute appendicitis (P = 1). MOD was significantly lower in the compression group (5.2 ± 0.8 mm) compared to the standard protocol (6.5 ± 1.1 mm) (P < 0.01) in patients without appendicitis. A cut-off value of 6.75 mm for the outer diameter of the appendix was found to be 100% sensitive in the diagnosis of acute appendicitis for both groups. The specificity was higher for compression CT technique (67.7 vs. 94.9%). CONCLUSION: Normal appendix diameter was significantly smaller in the compression-CT group compared to standard-CT group, increasing diagnostic accuracy of abdominal compression CT. KEY POINTS: • Normal appendix diameter is significantly smaller in compression CT. • Compression could force contrast material to flow through the appendiceal lumen. • Compression CT may be a CT counterpart of graded compression US.

Unusual presentations of Carney Complex in patient with a novel PRKAR1A mutation.

Carney Complex (CNC) is a multiple neoplasia syndrome characterized by skin tumors and pigmented lesions, myxomas, and various endocrine tumors. The aim of this case report was to describe a case of CNC with a novel PRKAR1A mutation. A man aged 46 years with a medical history of surgery for cardiac myxomas at the age of 39 was admitted to our hospital because of four newly-developed heart masses. The histologic examination confirmed cardiac myxomas. He had many presentations of CNC such as growth hormone (GH) and prolactin (PRL)-secreting mixed pituitary adenoma, benign thyroid nodule, large-cell calcifying Sertoli cell tumor (LCCST), and superficial angiomyxoma. A bilateral adrenalectomy was performed because the laboratory findings suggested primary pigmented nodular adrenocortical disease (PPNAD). The pathologic examination revealed a focal unilateral PPNAD, unilateral nonpigmented adrenocortical nodule, and bilateral adrenal medullary hyperplasia. Two years after the second cardiac operation, an interatrial septum-derived tumor was detected. An atrial myxoma was confirmed with histologic studies. Based on these findings, the patient was confirmed to have CNC. A novel insertion mutation in the type 1A regulatory subunit of the cAMP-dependent protein kinase A gene (PRKAR1A) in exon 2 was detected in our patient through genetic analysis. The presence of multiple myxomas and endocrine abnormalities should be an indication to physicians to further investigate for CNC. Herein, we described a case of CNC with a novel mutation in exon 2 of the PRKAR1A gene with typical and atypical clinical features.

Methylation status of TSHr in well-differentiated thyroid cancer by using cytologic material.

BACKGROUND: The role of methylation status of the thyroid stimulating hormone receptor gene (TSHr) in the discrimination of benign and malignant thyroid nodules has already been studied using paraffin blocks and cell lines. As cytological sampling plays an important role in assessment of thyroidal nodules, we have investigated the potential clinical use of TSHr methylation status of fine needle aspiration specimens reported according to Bethesda System. METHOD: Sixty nine patients who had both cytological and pathological diagnosis of the same nodule were selected. Four groups were composed according to cytological and pathological diagnoses: Benign (B), papillary thyroid carcinoma (PTC), atypia of unknown significance (AUS) and follicular neoplasia (FN). The latter 2 groups were further sub-classified into 2 as benign (AUS-B and FN-B) and malignant (AUS-M and FN-M) according to final pathological diagnosis. DNAs were isolated from the fine needle aspiration cytology specimens and the methylation status of TSHr promotor region was investigated by using methylation specific polymerase chain reaction. RESULTS: Overall, TSHr methylation was present in 58% of cases; 71% of malignant and 46% of benign nodules. PTC group showed the highest TSHr methylation rate (87%), followed by 61% in AUS, 44% in B, and 30% in FN (p = 0.016). TSHr methylation rate was significantly higher in PTC group when compared to B (p = 0.013) and FN-B (p = 0.004) groups; but not in FN-M (p = 0.115) or AUS (p = 0.096) groups. All 9 cases of papillary thyroid carcinoma with lymph node metastasis showed TSHr methylation. Positive predictive value, negative predictive value, sensitivity and specificity of TSHr methylation in determination of malignancy were calculated as 60, 66, 71 and 54%, respectively. CONCLUSION: The eminent ratio of TSHr methylation in well-differentiated thyroid carcinoma against benign thyroidal nodules adduced that TSHr methylation status can be utilized as a tumor marker for well-differentiated thyroid cancer; however, it has a limited value. The determination of methylation status of TSHr gene had no efficiency on decision of the malignant potential for the nodules which are cytologically classified as atypia of undetermined significance.

GC-MS Based Metabolomics Analysis to Evaluate Short-Term Effect of Tumor Removal on Patients with Early-Stage Breast Cancer.

In this study, it was aimed to demonstrate the short-term effect of breast cancer surgery and tumor removal on the metabolomic profiles of patients with early-stage breast cancer. This cohort consisted of 18 early-stage breast carcinoma patients who had breast cancer surgery to remove tumor and surrounding tissues. The blood samples obtained preoperatively and 24 h after surgery were used in this investigation. Gas chromatography-mass spectrometry (GC-MS) based metabolomic analysis was performed to determine the metabolites. The GC-MS-based metabolomics profile enabled the identification of 162 metabolites in the plasma samples. Postoperatively, glyceric acid, phosphoric acid, O-phosphocolamine, 2-hydroxyethyliminodiacetic acid, N-acetyl-D-mannosamine, N-acetyl-5-hydroxytryptamine, methyl stearate, methyl oleate, iminodiacetic acid, glycerol 1-phosphate, ß-glycerol phosphate and aspartic acid were found to be significantly increased (P < 0.05 for all), whereas saccharic acid, leucrose, gluconic acid, citramalic acid and acetol were significantly decreased (P < 0.05 for all). Breast cancer surgery and tumor removal has an impact on the metabolomic profiles of patients with early-stage breast cancer. These findings can be used for understanding the pathogenesis of breast cancer biology and screening the success of the surgery.

Adnexal masses in women with breast cancer.

BACKGROUND: Adnexal masses detected in breast cancer survivors are of particular concern because of the increased risk of ovarian malignancy. AIMS: This study was performed to analyse adnexal masses among women with breast cancer with regard to variables predictive of malignancy. METHODS: The study included women with breast cancer who had undergone surgery for an adnexal mass between 2002 and 2010 at Hacettepe University Hospital. A total of 45 consecutive women with a mean age of 47.3 years (range 25-76) were analysed retrospectively. RESULTS: Of 45 cases reviewed, benign ovarian pathology was found in 35 cases (77.8%) and malignant ovarian neoplasms were found in 10 cases (22.2%). A simple ovarian cyst was observed in 25 cases (71.4%) as the most common type of benign pathology. Of the 10 cases with malignancy, 5 (50%) had primary ovarian carcinoma, while the remaining five women had breast carcinoma metastases to the ovary. Complex mass at ultrasonography, increased CA 125 level and oestrogen receptor-negative tumour were found to be the significant predictors of ovarian malignancy. CONCLUSIONS: Although an adnexal mass in a woman with breast cancer is most commonly a benign ovarian cyst, the overall risk of ovarian malignancy is increased with breast cancer. An adnexal mass with complex architecture detected by ultrasonography and high CA 125 level were the strongest risk factors associated with increased risk of malignancy.

Scoring systems in the diagnosis of acute appendicitis in the elderly.

BACKGROUND: Although special features of acute appendicitis in the elderly have been described in some studies, no studies evaluating the applicability of appendicitis scores exist in the literature. The aim of this study was to compare Alvarado and Lintula scores in patients older than 65 years of age. METHODS: Patients older than 65 years with appendicitis confirmed by pathology report were matched by year of admission with a group of patients admitted to the emergency department with non-specific abdominal pain. Alvarado and Lintula scores were calculated retrospectively from patient charts. RESULTS: Both scores were observed to operate well in distinguishing between abdominal pain due to appendicitis and non-specific abdominal pain. The Alvarado score was a better predictor compared to the Lintula score. Two parameters (absent, tingling or high-pitched bowel sounds and nausea) had similar prevalence in the control and appendicitis groups. We selected to recalculate the two scores with the exclusion of these two parameters. The two scores performed better but were more similar to each other after the modification. CONCLUSION: Both Alvarado and Lintula scores have a high sensitivity and specificity in the diagnosis of acute appendicitis in the geriatric age group. Their performance improves with exclusion of the two parameters "nausea" and "absent, tingling or high-pitched bowel sounds".

The use of gamma probe for the intraoperative localization of an ectopic parathyroid adenoma.

The most common etiologic factor of primary hyperparathyroidism is a solitary parathyroid adenoma that might be located in the mediastinum. The mediastinally located ectopic parathyroid adenomas are often out of reach with a cervical incision and require a thoracic approach. We present a case of 55 year-old female patient with a parathyroid adenoma located anterior to the ascending aorta within the thymus resulting in primary hyperparathyroidism. The patient underwent an extended thymectomy with intraoperative use of a gamma probe as an adjunct to surgical resection which provided the accurate localization of the parathyroid adenoma. Histologic diagnosis confirmed the tumor to be an ectopic parathyroid adenoma. The patient showed an uneventful postoperative period with decreased levels of both calcium and parathyroid hormone. We emphasize that the gamma probe serves as a very useful device to differentiate the ectopic parathyroid adenoma from surrounding tissues for complete surgical excision.

Undifferentiated Embryonal Sarcoma of the Liver in an Adult Patient.

An undifferentiated embryonal sarcoma of the liver (UESL) is a rare and highly malignant mesenchymal neoplasm that is uncommonly observed in adults. We report a case of UESL found in a 26-year-old female. Our case was initially regarded as a type II hydatid cyst and then a malignant mass in radiological studies. The patient underwent nonanatomic liver resection. There were postoperative complications, but they were handled successfully. The patient received taxol-cisplatin-ifosfamide chemotherapy protocol and is disease-free after six years. Although UESL is exceedingly rare in adults, it must be considered while evaluating large hepatic masses since curative resection has an excellent prognosis.

Double Incomplete Internal Biliary Fistula: Coexisting Cholecystogastric and Cholecystoduodenal Fistula.

Internal biliary fistula is a rare complication of a common surgical disease, cholelithiasis. It is seen in 0.74% of all biliary tract surgeries and is thought to be a result of repeated inflammatory periods of the gallbladder. In this report we present a case of incomplete cholecystogastric and cholecystoduodenal fistulae in a single patient missed by ultrasonography and endoscopic retrograde cholangiopancreatography and diagnosed intraoperatively. In the literature there is only one report of an incomplete cholecystogastric fistula. To our knowledge this is the first case of double incomplete internal biliary fistulae.

Resuscitation and monitoring in gastrointestinal bleeding.

INTRODUCTION: Gastrointestinal bleeding is a common life-threatening problem, causing significant mortality, costs and resource allocation. Its management requires a dynamic multidisciplinary approach that directs diagnostic and therapeutic priorities appropriately. MATERIALS AND METHODS: Articles published within the past 15 years, related to gastrointestinal bleeding, were reviewed through MEDLINE search, in addition to current guidelines and standards. RESULTS: Decisions of ICU admission and blood transfusion must be individualized based on the extent of bleeding, hemodynamic profile and comorbidities of the patient and the risk of rebleeding. A secure airway may be required to optimize oxygenation and to prevent aspiration. Doses of induction agents must be reduced due to the changes in volume of distribution. Volume replacement is the cornerstone of resuscitation in profuse bleeding, but nontargeted aggressive fluid resuscitation must be avoided to allow clot formation and to prevent increased bleeding. Decision to give blood transfusion must be based on physiologic triggers rather than a fixed level of hemoglobin. Coagulopathy must be corrected and hypothermia avoided. Need for massive transfusion must be recognized as early as possible, and a 1:1:1 ratio of packed red blood cells, fresh frozen plasma and platelets is recommended to prevent dilutional coagulopathy. Tromboelastography can be used to direct hemostatic resuscitation. Transfusion related lung injury (TRALI) is a significant problem with a mortality rate approaching 40%. Prevention of TRALI is important in patients with gastrointestinal bleeding, especially among patients having end-stage liver disease. Preventive strategies include prestorage leukoreduction, use of male-only or never-pregnant donors and avoidance of long storage times. Management of gastrointestinal bleeding requires delicately tailoring resuscitation to patient needs to avoid nonspecific aggressive resuscitation. "Functional hemodynamic monitoring" requires recognition of indications and limitations of hemodynamic measurements. Dynamic indices like systolic pressure variation are more reliable predictors of volume responsiveness. Noninvasive methods of hemodynamic monitoring and cardiac output measurement need further verification in patients with gastrointestinal bleeding. CONCLUSIONS: Management of gastrointestinal bleeding requires a dynamic multidisciplinary approach. The mentioned advances in management of hemorrhagic shock must be considered in resuscitation and monitoring of patients with GI bleeding.

Chronic anemia due to watermelon stomach.

Antral gastric vascular ectasia is a rare cause of chronic anemia. When encountered, the diagnosis is usually delayed. Endoscopic findings are well established, although radiologic findings are not. Patients respond well to surgery. Our case was of a 62-year-old female with chronic anemia who required multiple blood transfusions and iron replacement therapy, without significant response. Computed tomography revealed a focal thickening of the gastric antrum. Endoscopy showed vascular ectasia between the antrum and corpus. The patient underwent gastrectomy. We reviewed the literature on gastric angiodysplasia and have presented our unique tomography findings in this first report on a novel association between ectopic pancreas and gastric angiodysplasia.

Renal cell carcinoma with inferior vena cava thrombus: the Hacettepe experience.

OBJECTIVES: We evaluated the clinical outcome and factors affecting survival in patients with renal cell carcinoma (RCC) and tumor thrombus involving inferior vena cava (IVC). METHODS: Between 1990 and 2007, 28 patients with RCC and tumor thrombus extending into IVC underwent radical nephrectomy and thrombectomy. Patient data were reviewed retrospectively to evaluate the demographics, clinical presentation, surgical approach, pathological features, clinical outcomes, and survival. RESULTS: Twenty-eight patients with a mean age of 52.7 years were operated. Thrombus level was infrahepatic in 15 patients (54%), intrahepatic in 3 patients (10%), suprahepatic in 3 patients (10%), supradiaphragmatic in 2 patients (8%), and intracardiac in 5 patients (18%). All patients with intracardiac thrombi underwent cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA). The mean tumor size was 98.21 mm. Four patients had distant metastases and 3 patients had lymph node involvement. Pathological examination revealed RCC of clear cell type in 26 patients, papillary in 1 and chromophobe in 1 patient. At a mean follow-up of 36.4 months, 16 patients were still alive while 8 patients died due to disease progression and 2 patients died of other causes. Two patients died of pulmonary emboli in the early postoperative period. Lymph node involvement, distant metastases, hypercalcemia, and sarcomatoid component were found to be factors affecting overall survival significantly. Level of tumor thrombus and Fuhrman grade did not affect survival. CONCLUSIONS: Radical nephrectomy and tumor thrombectomy is currently known to be the most effective method in patients with RCC and tumor thrombus extending into IVC. Factors affecting survival are the ones related to tumor biology. Tumor thrombus level does not affect the prognosis.

Normal parathyroid hormone levels in a diabetic patient with parathyroid adenoma.

OBJECTIVE: The incidence of diabetes mellitus in patients with primary hyperparathyroidism and, conversely, primary hyperparathyroidism in diabetic patients are approximately threefold higher than the respective expected prevalence in the general populace. The diagnosis is straightforward when the patient presents hypercalcemia and inappropriately elevated serum parathyroid hormone (PTH) levels. We report a case of parathyroid adenoma in a diabetic patient with persistent hypercalcemia and normal PTH levels. PATIENT: A 50-year-old female patient who was referred to our outpatient clinic presented with persistent hypercalcemia (serum Ca levels between 10.5 and 11 mg/dl) with a normal serum intact PTH level of 46.1 pg/ml. Her blood pressure was 120/80 mmHg, and she was being treated with antihypertensive therapy. Her HbA1c was 7.2%, and her triglycerides were in the normal range. A bone densitometry exam revealed osteopenia of radius -1.39, femoral neck -1.39, and the total hip -1.04. A neck ultrasound revealed a mass of 13 mm next to the inferior and posterior of the right thyroid lobe. A dual phase Tc-99m-sestamibi scan revealed an area of increased uptake in the same region, which is indicative of a parathyroid adenoma. The parathyroid adenoma was removed, which resulted in the achievement of normocalcemia. CONCLUSION: Diabetic patients should be evaluated for hyperparathyroidism as associated hypertension can complicate the course of the disease. These patients should be evaluated for primary hyperparathyroidism when they exhibit persistent hypercalcemia and when clinical suspicion is aroused even if the serum PTH levels are within the normal range.

Antibacterial activity of triclosan chitosan coated graft on hernia graft infection model.

The use of mesh in hernia repair has become common, because of lower recurrence rate and simple application. Data from the meta-analysis and the multi-central studies support the use of meshes in hernia repair. One of the complications due to the hernia repair with mesh is the infection. The incidence range is between 1 and 10%. Triclosan embedded commercial absorbable suture materials are used to reduce surgical site infection rate. This study was planned on mesh infection model, because of the low incidence rate. The agent isolated from mesh infections was mostly Staphylococcus aureus and thus it was used as the infecting agent in this research. To achieve a better therapeutic efficacy, triclosan was formulated in chitosan gels. Chitosan is an attractive biopolymer because of its biocompatible, biodegradable, bioadhesive properties. Gel formulations using chitosans (low, medium and high molecular weight) were prepared in 1% (v/v) acetic acid solution and in vitro release profiles were evaluated. Gel formulations showed release profile extended up to 7 days and high molecular weight chitosan gel formulation was released higher quantity drug than other formulations. Meshes coated with triclosan loaded chitosan gel were used to reduce bacterial count and to prevent mesh infection in the study. 24h and simultaneous bacteria inoculation was used to model mesh infection. The rats were observed for 8 days by means of surgical site infection. On the eighth day, the animals were sacrificed and the grafts were removed. Tissue squeezers were used to liberate bacterias from removed grafts. The isolated suspensions were cultured on blood agar plates and colony-forming units were counted overnight. Grafts coated with triclosan loaded chitosan gel presented satisfactory preventive effect against graft infection.