The significance of initial lactate levels in emergency department presentations of abdominal wall hernia.

INTRODUCTION: Abdominal wall hernias are a frequent cause of abdominal pain-related emergency department visits. Our study aimed to establish the connection between lactate levels and patient outcomes in those with abdominal pain due to abdominal wall hernias. MATERIALS AND METHODS: Our research followed a retrospective, observational, and descriptive approach and two center. We included patients who visited the emergency department for abdominal pain and were confirmed to have abdominal wall hernias through ultrasound. RESULTS: We enrolled 493 patients meeting the criteria. Median age was 65 years, with 54% (n = 266) being male. Regarding outcomes, 40.5% (n = 200) were hospitalized, 27.7% (n = 137) underwent surgery, and 7.9% (n = 39) underwent bowel resection. Mortality rate during hernia-related hospital admission was 0.6% (n = 3). For hospitalized patients, there were significant differences in white blood cell count, neutrophil count and percentage, platelet count, lymphocyte count, and percentage (p < 0.05). Patients undergoing resection showed significant differences in neutrophil count, neutrophil percentage, lymphocyte count, and lymphocyte percentage (p < 0.05). Lactate levels were statistically significant in all patient groups requiring hospitalization, surgery, and resection (p < 0.05). Sensitivity and specificity of lactate test results indicated in patients undergoing bowel resection, lactate values ≥1.96 mmol/L had a specificity of 64%, sensitivity of 71%, and a negative predictive value of 96% (p < 0.05). CONCLUSION: Low lactate levels in patients presenting to the emergency department with abdominal pain caused by abdominal wall hernias have a high negative predictive value for excluding strangulation and the need for bowel resection. Therefore, we recommend the use of lactate as an additional diagnostic tool in emergency department presentations related to abdominal wall hernias.

Neonatal morbidity mortality outcomes in pre-term premature rupture of membranes.

We present a retrospective review of 228 pre-term premature rupture of membranes (PPROM) singleton pregnancies followed-up in our clinic between 1996 and 2005. The most common neonatal morbidities in PPROM cases are respiratory distress syndrome (RDS), sepsis and intraventricular haemorrhage (IVH). The route of delivery does not affect newborn intensive care unit (NICU) requirements, perinatal asphyxia, sepsis and IVH rates in PPROM cases. NICU and PPV requirements, RDS, sepsis and IVH rates increase if the Apgar score is < 5. Neonatal morbidity and mortality rates increase as the latent period lengthens. C reactive protein (CRP) on admission, last CRP, birth weight and the 5 min Apgar score was found to be associated with NICU requirements; only the 5 min Apgar score was found to be associated with RDS; and last leukocyte count and maternal haemotocrit was found to be associated with sepsis and pneumonia, independently. In PPROM cases, CRP on admission, last CRP, birth weight, the 5 min Apgar score, last leukocyte count and maternal haemotocrit, should be considered to predict neonatal outcomes.

Characteristics and outcome of 102 fetuses with fetal cerebral ventriculomegaly: experience of a university hospital in Turkey.

The aim of this study was to evaluate the incidence of associated structural anomalies and the outcome of fetuses with ventriculomegaly. We retrospectively collected 102 cases of antenatally diagnosed ventriculomegaly examined between 2000 and 2008. Ventricular width measurements were 10-12 mm, 12.1-14.9 mm and ≥ 15 mm in 24.5%, 20.6% and 54.9% of the cases, respectively. Associated structural malformations were detected in 77.4% of the fetuses. Mortality rate of fetuses with associated malformations and isolated ventriculomegaly was 86.1% and 55.7%, respectively (p < 0.001). The mortality rate was significantly lower in mild (10-12 mm) than in moderate (12.1-14.9 mm) and severe (≥ 15 mm) cases (p < 0.05). All of the fetuses with mild isolated ventriculomegaly were alive at >12 months of age, without morbidity. Our results suggest that the prognosis of fetuses with ventriculomegaly mainly depends on the aetiology and on the presence of associated abnormalities. Fetuses with mild isolated ventriculomegaly have a favourable outcome.

Systemic lupus erythematosus and pregnancy.

We present a retrospective study of 42 consecutive cases of systemic lupus erythematosus (SLE) and pregnancy followed and delivered during the period 2002-2007 in our department. The mean patient age was 28.6 years and the nulliparity rate was 45.2%. Disease flare up occurred in 9.5% of patients. Lupus anticoagulants, anticardiolipin IgG and IgM antibodies were positive in 33%, 16.6% and 19% of patients, respectively. Mean gestational age at delivery was 36.9 +/- 4.2 and mean birth weight was 2,750 +/- 844 g. Stillbirth, fetal growth restriction, pre-eclampsia and pre-term delivery rates were 7.1%, 14.3%, 2.4% and 23.1%, respectively. Cases with uterine artery Doppler abnormalities had significantly poorer obstetric outcomes. Antiphospholipid antibodies, renal involvement and lupus activation did not have any significant influence on poor obstetric outcome. Multidisciplinary approach to the care of pregnant women with SLE is mandatory for good maternal and fetal outcomes. Uterine artery Doppler seems to be a good prognostic factor for adverse obstetric outcomes.

A new syndrome, congenital extraocular muscle fibrosis with ulnar hand anomalies, maps to chromosome 21qter.

BACKGROUND: Congenital fibrosis of the extraocular muscles (CFEOM) is a heterogeneous group of disorders that may be associated with other anomalies. The association of a CFEOM syndrome with ulnar hand abnormalities (CFEOM/U) has not been reported to date. OBJECTIVE: To describe a new autosomal recessive syndrome of CFEOM and ulnar hand abnormalities, and localise the disease causing gene. METHODS: Clinical evaluation of the affected members and positional mapping. RESULTS: Six affected patients with CFEOM/U (aged 2 to 29 years) from a large consanguineous Turkish family were studied. Ophthalmological involvement was characterised by non-progressive restrictive ophthalmoplegia with blepharoptosis of the right eye. The postaxial oligodactyly/oligosyndactyly of the hands was more severe on the right side. A genome-wide scan established linkage of this new autosomal recessive syndrome to a locus on chromosome 21qter. The multipoint LOD score was 4.53 at microsatellite marker D21S1259, and fine mapping defined a approximately 1.5 Mb critical region between microsatellite marker D21S1897 and the telomere of the long arm. CONCLUSIONS: CFEOM/U maps to a 1.5 Mb region at chromosome 21qter. Future identification of the disease causing gene may provide insights into the development of the extraocular muscles and brain stem alpha motor neurones, as well as anteroposterior limb development.

Radical versus conservative surgery for vulvar carcinoma.

OBJECTIVE: The comparison of the radical and conservative surgical approaches for vulvar carcinoma in relation to the rate of recurrence and complications. METHODS: The records of invasive vulvar carcinoma cases were retrospectively reviewed in Istanbul University, Cerrahpasa School of Medicine, Gynecologic Oncology Division and Social Insurance Institution, Ankara Maternity Hospital, Gynecologic Oncology Department. Surgically treated cases with squamous histology were divided into radical vulvectomy and conservative procedures groups and were compared with respect to recurrence, complications, and disease-free survival. RESULTS: One hundred thirteen cases of invasive vulvar carcinoma cases were of squamous histopathology and 92 of these were surgically treated. The rate of local recurrence was lower in the radical vulvectomy group (25%) compared to conservative procedures groups (42.5%; p>0.05). The complication rates were comparable between the radical vulvectomy and conservative procedures groups (32.7% versus 35%, respectively; p>0.05). At the end of five years of the follow-up, the disease-free survival rates were 51.5% in radical vulvectomy group versus 35.7% in conservative procedures group (p>0.05). CONCLUSION: The rate of recurrence, complication, and disease-free survival are similar for the radical vulvectomy and the conservative procedures. Deciding the surgical strategy for vulvar carcinoma should depend on the experience of the surgeon for the short-term adequate results.

Perinatal and maternal outcomes of fetal macrosomia.

OBJECTIVE: To determine the perinatal and maternal outcome of the macrosomic infants. STUDY DESIGN: A case-control, retrospective study is performed in the Department of Gynecology and Obstetrics, Istanbul University Cerrahpasa Medical Faculty, between 1988-1992. The maternal and neonatal records of infants with birthweight of at least 4000g (n=1000) were reviewed. Another 1000 cases amongst the newborns delivered in the same period between 2500 and 3999g formed the control group. The obstetrical outcome variables of the groups including mode of delivery and the incidence of maternal and perinatal complications were compared. RESULTS: A total of 16,112 deliveries occurred during the study period. The rate of macrosomic deliveries was 6.21% and the rate of the deliveries (4500g or heavier) was 1.04%. The mean birthweight of the study group was 4272+/-239 and 3277+/-316g of the control group (P<0.001). While the cesarean section rate was 28.8% for the study group and it was 16.6% for the control group (P<0.001). In the study group, 17 cases of brachial plexus palsy (2.4%), 16 cases of clavicular fracture (2.3%) and one case of humeral fracture were observed (P<0.001). The rate of perinatal mortality was 0.8% in the study group. No perinatal mortality was recorded in the control group. There were 14 cases (1.4%)of asphyxia related to delivery in the study group (P<0.01). The rate of maternal complications, were significantly higher in the study group (P<0.01). CONCLUSION: The macrosomic infants are in increased risk for birth trauma and asphyxia. The risk of birth trauma for the infants weighing 4500g or more is even greater.

Appendectomy in the surgical staging of ovarian carcinoma.

OBJECTIVES: Extensive debulking is accepted as the primary method of operative management for carcinoma of the ovary. However, there is no consensus regarding the role of appendectomy in primary surgical treatment. The aim of this study was to assess the role of appendectomy in the surgical staging and cytoreduction of ovarian carcinoma. METHODS: The study was a retrospective review of 90 primary malignant ovarian carcinoma patients who had an appendectomy in addition to primary cytoreductive surgery. RESULTS: Out of 90 patients, 10 (11.1%) had metastasis to the appendix. The rate of metastasis to the appendix was 11.5% (9/78) in malignant epithelial ovarian carcinomas and 8.3% (1/12) in non-epithelial ovarian tumors. Of the patients with metastasis in the appendix, malignant epithelial ovarian tumors were identified in 90% (serous: 70%; clear cell: 20%), and non-epithelial malignant ovarian tumor were disclosed in 10% (granulosa cell carcinoma). There were no metastases to the appendix in the other histological types. Although metastasis to the appendix was not observed in early stage ovarian carcinomas, it was detected in 21.4% (9/42) of stage III and 50% (1/2) of stage IV. Macroscopic tumor metastasis in the abdomen was noted in all patients with metastasis to the appendix. CONCLUSION: Appendectomy for stage I and II patients was not beneficial and did not affect final staging. As a result, for the proper staging of ovarian carcinoma there is no advantage to the addition of routine appendectomy to primary cytoreductive surgery in early stage (stage I and II) malignant epithelial ovarian tumors. Appendectomy would contribute to the cytoreduction of advanced stage disease if it is macroscopically involved.

Vascular cell adhesion molecule-1 (VCAM-1) and leukocyte activation in pre-eclampsia and eclampsia.

OBJECTIVE: To evaluate the levels of VCAM-1 in pre-eclampsia/eclampsia as a possible marker of leukocyte activation and endothelial damage. METHODS: We performed a case-control study on 25 healthy pregnant women and 35 patients diagnosed as pre-eclampsia or eclampsia which were randomly selected. Peripheral venous blood samples were obtained and serum levels of VCAM-1 were measured by enzyme-linked immunoassay (ELISA). RESULTS: In pre-eclampsia/eclampsia, VCAM-1 levels were higher than in normal pregnancy. Serum concentrations of VCAM-1 were significantly higher in severe pre-eclampsia and eclampsia compared to mild pre-eclampsia or healthy controls. ROC analysis detected that VCAM-1 > or = 450 ng/ml had a sensitivity of 0.79 and a specificity of 0.90 in detecting severe pre-eclampsia and eclampsia. CONCLUSION: This is the first study to correlate VCAM-1 levels with severity of disease in pre-eclampsia. Our findings indicate that increasing levels of soluble VCAM-1 are present in the circulation of patients with severe pre-eclampsia/eclampsia compared to mild pre-eclampsia or healthy pregnant women. Elevated VCAM-1 levels may represent a possible mechanism by which endothelial cells attract leukocytes and cause endothelial cell damage.

The role of patient's age in regression of holmium:YAG thermokeratoplasty-induced correction of hyperopia.

PURPOSE: Hyperopic correction can be induced with holmium:YAG laser thermokeratoplasty, which changes corneal curvature by shrinking stromal collagen. The thermal effectiveness of pulsed Ho:YAG laser depends on the water content of the corneal stroma, which should be related to age. This study investigated the presumed effect of age on the stability of the results of Ho:YAG laser thermokeratoplasty. METHODS: Ho:YAG laser thermokeratoplasty was done in 63 eyes of 45 patients for low to moderate hyperopic correction (up to 5 diopters). Patients were treated with one or two rings of 8 spots each, with an optical zone of 6 or 7 mm diameters respectively. RESULTS: Regression of the therapeutic effect was evaluated on the basis of the difference between the attempted to achieved correction ratio on the first postoperative day and at the last visit. The regression ratio was 18% in the patients older than 20 years. Patients younger than 20 years showed a ratio of 48%. Achieved correction was +2.40 D in older patients and +2.05 in younger patients. These values are respectively 43% and 35% of the attempted corrections. CONCLUSIONS: It appears that age-dependent corneal factors do influence the effectiveness of thermal energy on stromal collagen.

Management of retinopathy of prematurity with cryotherapy.

PURPOSE: Newborns at risk for retinopathy of prematurity (ROP) should be examined 4 to 8 weeks postpartum. Various treatment modalities including cryotherapy, are proposed to ablate the retinal proliferation, when serious and progressive ROP is detected. This study stresses as main risk factors low birth weight and short gestational age as pre-disposing to ROP and the efficiency of cryotherapy as a treatment modality. METHODS: One hundred and twenty five newborns were examined before hospital discharge and after oxygen administration was terminated. Patients with suspected ROP returned for frequent follow-up visits. In patients with stage III ROP (ridge with extraretinal fibrovascular proliferation) ablation by cryotherapy was performed. RESULTS: Retinal ridge and extraretinal proliferation characteristic of stage III ROP were detected in ten newborns. All surviving stage III patients were treated with cryoablation and two of them progressed to stage IV. Regression of ROP was observed in eight of the ten treated cases. CONCLUSIONS: With properly planned screening of newborns at risk for ROP, early diagnosis and treatment are possible. Cryotherapy seems to be effective for ablation of the proliferation.

Hematological abnormalities in adolescent menorrhagia.

BACKGROUND: The purpose of this study is to determine the frequency of underlying hematological disorders as the cause of acute adolescent menorrhagia. METHODS: The records of 25 patients that were hospitalized with acute adolescent menorrhagia in the Obstetrics and Gynecology Department of Cerrahpasa Medical School of Istanbul University between 1988 and 1995 were analyzed. RESULTS: The mean age of the patients was 13.9 +/- 1.6 (SD) years. A hematological abnormality that caused bleeding diathesis and acute menorrhagia was diagnosed in 7 of the 25 patients (28%). There were four cases of immune thrombocytopenic purpura, two cases of Van Willebrand disease and one case of acute promyelocytic leukemia. All seven patients with a coagulation disorder required blood transfusions and the mean hemoglobin level at presentation was 6.2 g/dl.

Is serum leptin level regulated by thyroid functions, lipid metabolism and insulin resistance in polycystic ovary syndrome?

Our aim was to determine whether serum leptin level is regulated by thyroid hormones, lipid metabolic products and insulin resistance status in women with polycystic ovary syndrome (PCOS). A prospective case-controlled study was carried out in Istanbul University, Cerrahpasa School of Medicine in 25 lean PCOS (L-PCOS) women, 19 obese PCOS (O-PCOS) women and 28 normal women. The diagnosis of PCOS was established according to the clinical, hormonal (elevated luteinizing hormone and serum androgens) and ultrasonographic findings. Fasting serum levels of thyroid stimulating hormone (TSH), free triiodothyronine (FT3), free thyroxine (FT4), fasting glucose, insulin, total cholesterol (TC), triglyceride (TG), high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), very low-density lipoprotein-cholesterol (VLDL-C) and leptin were measured and compared in the three groups and the correlations between serum levels of leptin and other parameters were evaluated. Serum leptin levels were higher in the O-PCOS group, while its level was comparable between the L-PCOS and control groups. Serum levels of FT4 were significantly lower in both L-PCOS and O-PCOS groups than the control group. Women in both L-PCOS and O-PCOS groups were found to be significantly hyperinsulinemic and insulin resistant. Serum levels of TC, VLDL-C and TG were significantly higher in the O-PCOS group, while serum HDL-C level was lower. There was a poor correlation between serum leptin, and FT4, TC, TG, HDL-C and VLDL-C levels. A significant correlation was observed between serum leptin levels and both BMI and insulin resistance status in PCOS. We believe that, although thyroid hormones and lipid metabolic products do not seem to participate in the regulation of serum leptin levels, BMI and insulin resistance status may have a key role in women with PCOS.

Primary psoas muscle abscess diagnosed and treated during pregnancy: case report and literature review.

BACKGROUND: Primary psoas muscle abscess is rare and can be difficult to diagnose, particularly during pregnancy. CASE: To our knowledge, this is the first case of primary psoas muscle abscess diagnosed during pregnancy. Clinical investigation did not reveal any infection spreading from adjacent structures. Surgical drainage and simultaneous Cesarean delivery of the infant, combined with appropriate antibiotics, enabled a cure. CONCLUSION: The possibility of psoas muscle abscess should be taken into account when investigating lower back pain during pregnancy if conventional approaches are unsatisfactory.

Changes in bone mineral density with age, menopausal status and body mass index in Turkish women.

OBJECTIVE: The aim was to evaluate changes in bone mineral density (BMD) with age and body mass index (BMI) in healthy pre- and postmenopausal women living in the urban areas of Turkey. DESIGN: The study was prospective, carried out from 1993 to 1997. SETTING: The study carried out at a university hospital, the Istanbul University Cerrahpasa School of Medicine, Turkey. PATIENTS: The study group consisted of 849 healthy women of ages 20-84 years, admitted to the Istanbul University Cerrahpasa School of Medicine. The cases were divided into age groups, starting with 20-29 years and ending with 70 years and over. For regression analysis, the cases were further regrouped as 20-39, 40-59 and 60 years and over. Dual energy X-ray absorptiometry (DEXA) was used to measure BMD in the lumbar vertebrae (L2-L4) and in the classical locations of the proximal femur such as the femoral neck, the Ward's triangle and the trochanter. Multiple regression analysis was performed for the evaluation of annual changes in BMD with respect to age and/or BMI. RESULTS: A significant decrease in BMD started especially in the 40-49 age group, matching the average age of menopause in the study population. In contrast to the non-significant changes in the 20-39 age group, a significant decrease in BMD in the 40-59 age group, which included the average age of menopause, was detected in all locations (p < 0.0001). In addition to the significant effect of the menopause on BMD, an association between BMD and BMI was found in every location and age group (p = 0.02 to p < 0.0001). The total bone loss in the 70 and over age group, in comparison with the 30-39 age group, was 18.78% in L2-L4, 21.69% in the femoral neck, 32.68% in the Ward's triangle and 14.11% in the trochanter. Corresponding values between age groups 70 and over and 60-69 were 0.25%, 7.62%, 11.94% and 8.29%, respectively. Women in the older age groups had a slower decline in BMD in the lumbar vertebrae, in comparison with the proximal femur. Moreover, the maximum postmenopausal total bone mineral loss was in the Ward's triangle. CONCLUSIONS: The present results, confirming the results of other studies, have revealed a significant association between BMD and the menopausal status of women in the Turkish population. Additionally, a significant correlation has been detected between BMI and BMD, regardless of location and age.

Prognosis of patients with positive screening but negative diagnostic test for gestational diabetes.

OBJECTIVE: This is a retrospective study that is designed to investigate the prognosis of the patients with abnormal diabetes screening test and a negative 100 g oral glucose tolerance test that is accepted as the diagnostic test for gestational diabetes mellitus (GDM). MATERIALS AND METHOD: The records of 281 pregnant patients were reviewed. The data of the patients divided into groups with normal diabetes screening (1 h/50 g oral glucose tolerance test) and abnormal diabetes screening. The patients with abnormal diabetes screening were further divided into all values normal in 100 g Oral glucose tolerance test (OGTT), one value abnormal in 100 g OGTT and GDM subgroups. The prognosis of these patients was reanalyzed concerning the complications that may be attributed to glucose intolerance. RESULTS: Abnormal diabetes screening test was detected in 89 patients (31.6%) and 14 cases were diagnosed as GDM (4.9%). The data of 9 patients were not suitable to analyze. In 31 cases out of 80 (38.75%), an obstetric complication was detected. The rate of similar complications was 27.0% (52/192) in the control group. The difference in the rate of complications was not statistically significant (p>0.05). When the patients with one value abnormal in 100 g OGTT, were further evaluated, the complication rates were 3/9 (33.3%) for the 1st hour abnormal patients, 1/1 for the 2nd hour abnormal patients and 1/1 for the 3rd hour abnormal patients. When the values of 100 g OGTT were compared in complicated and uncomplicated cases, the difference between the groups was not statistically significant (p>0.05). CONCLUSION: 100 g OGTT is the universal diagnostic test for GDM. There is a major subgroup of patients whose screening positive but diagnostic test (100 g OGTT) negative. These patients seem to be prone to develop obstetric complications related to glucose intolerance but there is not a proper means to detect these patients in clinical practice.

Early first trimester ultrasound examination. Is it really efficient in the clinical management of the pregnancy?

OBJECTIVE: This is a retrospective study accomplished to determine the efficiency of the first trimester ultrasound examination especially when performed on elective conditions. MATERIALS AND METHOD: The records of patients who had undergone early first trimester transvaginal ultrasound in Obstetrics and Gynecology Department of Cerrahpasa School of Medicine, Istanbul University between from January 1999 to December 2000 were reviewed. The records of 426 patients were eligible for the analysis. The age, parity, gestational week that the ultrasound performed, the complaint on appliance, the features visible on the ultrasound were noted. The patients were divided into two groups: patients without any complaint (Group 1) and patients applied with any complaint (Group 2). The prognosis of the pregnancy was determined through the follow-up. On the statistical analysis, chi-square test, student-t test, Pearson correlation analysis and multiple linear regression analysis were utilized. RESULTS: In group 1, 79% of examinations were normal whereas the rate of normal ultrasound was 50% in group 2. The difference between the groups was statistically significant (p=0.000). On group 1, 7 subsequent abortions, 7 missed abortions and one case of mole hydatiform were identified (7.6%). When the patient applied with a complaint, ultrasound examination revealed abnormal findings that enabled to reach an accurate diagnosis in 29.9% of these patients. 50 abortions (inevitable or incomplete), 13 missed abortions, 3 ectopic pregnancies and 2 mole hydatiform were diagnosed. The difference between the two groups according to ability to reach a diagnosis on the initial ultrasound was statistically significant (p=0.000). CONCLUSION: The value of ultrasound examination before the 10th weeks of pregnancy is not validated when the patient has no complaint even if it appears as the most powerful mean to assess the accurate gestational age and observing fetal cardiac activity is the best prognostic variable for the outcome of the fetus.