Gemcitabine plus vinorelbine chemotherapy in patients with advanced bladder carcinoma who are medically unsuitable for or who have failed cisplatin-based chemotherapy

Objective: To evaluate the efficacy and toxicity of gemcitabine plus vinorelbine chemotherapy in patients with advanced bladder carcinoma who are unsuitable for or who have failed cisplatin-containing chemotherapy.Patients and Methods: Thirty-one patients with advanced transitional cell carcinoma (TCC) of the bladder were scheduled to receive gemcitabine and vinorelbine chemotherapy. Twenty-one patients had received no prior chemotherapy and their creatinine clearance was below 50 ml/min (group 1), and the remaining 10 patients did not respond to previous cisplatin-containing chemotherapy (group 2).Results: In group 1, objective response rate was 47.6%, including 2 (9.5%) complete and 8 (38.9%) partial responses. In group 2, partial response was observed in 2 (20%) patients. The median survival time for patients in group 1 and 2 were 15 months (range 3–23) and 7 months (range 3–21), respectively. Grades 3 or 4 leukopenia developed in 16.1% of patients. Overall, 12.9% of the patients suffered from grade 3 nonhematologic toxicity.Conclusion: Our preliminary data indicate that the combination of gemcitabine and vinorelbine is active and well tolerated especially in patients with advanced TCC who are unsuitable for cisplatin-based chemotherapy.     

Timing of cholecystectomy for acute biliary pancreatitis: outcomes of cholecystectomy on first admission and after recurrent biliary pancreatitis

Abstract Biliary stones are the leading cause of acute pancreatitis. Although cholecystectomy and selective endoscopic retrograde cholangiography (ERC) comprise the current treatment in patients with acute biliary pancreatitis (ABP), the time of intervention is still controversial. In this study we evaluated the outcomes of cholecystectomy on first admission for ABP and in patients with recurrent biliary pancreatitis. A series of 43 patients with ABP between January 1997 and November 2000 were evaluated retrospectively. Patients were classified into two groups. Group I included 27 patients who underwent cholecystectomy on first admission before discharge from the hospital. Group II comprised 16 patients who had recurrent biliary pancreatitis and then underwent cholecystectomy. The severity of the pancreatitis was determined by Ranson’s criteria. Age, gender, length of hospital stay, severity of pancreatitis, amylase level, and complications of cholecystectomy were evaluated in both groups. Patients in group I underwent cholecystectomy during the original hospital admission and patients in group II during an admission for a recurrence. There were 24 patients with a Ranson’s score ≤ 3 in group I and 12 in group II. The mean hospital stays were 15.29 days (range 4–48 days) and 36.66 days (range 15–123 days) in groups I and II, respectively (p = 0.006). Morbidity was 11% without mortality in group I and 43% with one mortality in group II (p = 0.023). Definitive treatment of ABP can be accomplished effectively and safely by cholecystectomy following clinical improvement, with selective ERC performed during the first admission (delayed cholecystectomy). Waiting to perform cholecystectomy (interval cholecystectomy) may result in recurrent biliary pancreatitis, which may increase morbidity and the length of the hospital stay. Electronic Publication     

Risk and Outcome of Bowel Resection in Patients with Incarcerated Groin Hernias: Retrospective Study

The goal of this retrospective study was to evaluate factors that increase the risk of bowel necrosis and document the outcome of bowel resection in patients with strangulated hernias. We identified 102 patients (60 men, 42 women) who underwent surgical treatment for an incarcerated hernia at the Kartal Education and Research Hospital Emergency Unit between April 1997 and April 2001. Patients in group 1 required intestinal resection (n = 16), and patients in group 2 did not (n = 86). The median age of the patients was 53 years (range 3–96). Demographic and surgical data were obtained from the patients charts and compared between the two groups. Women required bowel resections more often than men (p < 0.05). Patients older than 65 years and those with femoral or epigastric hernias required resection more often than patients younger than 65 years and those with inguinal, umbilical, or incisional hernias (p < 0.05 for all). Group 1 patients had a longer hospitalization and experienced more overall complications and wound infections than group 2 (p < 0.05 for all). In conclusion, incarcerated hernias are more common in men, but intestinal resection is required more often in women. The risk of intestinal resection is higher for patients with femoral hernias and those older than 65 years. Patients who undergo intestinal resection have a higher overall complication rate related to wound infections but not an increased risk of other complications or mortality.This study was presented at the 5th European Congress of Trauma and Emergency Surgery, Istanbul, Turkey, October 2002.     

Subperiosteal tissue expansion: an experimental study

Periosteal flaps have been used to cover bone defects. There are no sufficient data on whether expanded periosteum can be used to repair bone defects after subperiosteal tissue expansion. In this experimental study, 14 male dogs, which were 2 years-old and weighed 14.5–16.0 kg, were used to investigate the repair of bony defects with expanded periosteum. Rectangular tissue expanders, measuring 50 mm in width, 70 mm in length, and 20 mm in height (volume: 20 ml) were used. The dogs were divided into two groups each of seven dogs: one control group and one experimental group. In each dog, a pocket, 50×70 mm in size, was prepared in parietal area, and a periosteal area, 30×40 mm in size, was marked out. A rectangular tissue expander was inserted into the pocket. In the control group, the tissue expanders were not inflated. On the seventh postoperative day, the tissue expander inflation with normal saline (5 ml per 2 days) was started in the experimental group. After 15 days, the previously marked out periosteal area was measured. A specimen was taken from this periosteal tissue for histopathological evaluation. A bone defect, 20×20 mm in size, was created beneath expanded periosteal tissue, and this defect was covered with the expanded periosteal tissue. After 15 days, a histopathological evaluation was carried out. Statistical analysis was carried out using the Mann–Whitney U-test. The area of periosteum expanded was more in the experimental group than that of the control group (p>0.05). After removal of the tissue expander, both in the control and subperiosteal tissue expansion group, osteoblastic lining of the expanded periosteum, increased vascularity, and granulation tissue was noted. Following 15 days, woven and lamellated bone tissue was formed both in the control and subperiosteal expansion group. In the subperiosteal expansion group, there was greater bone formation, the expanded periosteum was thickened, and thickened lamellated bone was covered by active osteoblasts. It is concluded that subperiosteal tissue expansion may be worthwhile to provide large periosteal flaps for the repair of large bone defects, by increasing osteogenic capacity.     

Adrenomedullin and nitric oxide in children with detrusor instability

Detrusor instability (DI) and detrusor-external sphincter dyssynergia lead to poor bladder emptying and high bladder pressure. Recent results indicate that nitric oxide (NO) is an important transmitter or messenger molecule in autonomic neurotransmission. Adrenomedullin (AM) is a potent vasodilator and natriuretic peptide, originally purified from human pheochromocytoma. Since NO and AM have vasodilatory effects on smooth muscles, we considered them to be of interest in children with DI. We determined the tissue levels of NO and AM in 14 children with DI, and compared these with 6 children with normal bladder activity. Bladder biopsy total nitrite levels (nmol/g tissue) were decreased in children with DI (10.69+/-0.91 vs. 12.83+/-0.98, P<0.01). However, AM levels (pmol/g tissue) were increased in the same patients (48.84+/-3.52 vs. 28.79+/-1.53, P<0.001). According to our results, decreased NO production probably has a role in the pathophysiology of DI, although increased AM appears to be compensatory. NO may provide a therapeutic target in clinical situations related to DI. However, the functional significance of AM and NO in bladder smooth muscle remains to be determined by further detailed studies.     

Adrenomedullin and total nitrite levels in children with Henoch-Schönlein purpura

Nitric oxide (NO) is synthesized from endothelium and has an important role in the control of vascular tonus. Adrenomedullin (AM) is a potent vasodilator, and cytoprotective peptide is produced not only in adrenal medulla, but also in the vascular smooth muscle and endothelial cells. To investigate the endothelial synthesis of AM and NO, and endothelial injury in Henoch-Schönlein purpura (HSP), we measured their levels in 16 children with HSP, who were evaluated during the acute and remission phases, and compared with 12 healthy controls. Plasma AM levels (pmol/ml) were significantly higher in acute phase children (46.87±11.49) than in those in remission (35.59±12.39, p<0.01) and controls (30.70±9.12, p<0.001). Similarly, plasma total nitrite levels (mol/l) were higher in acute phase patients (47.50±12.30) than in those in remission (35.94±10.08, p<0.005) and controls (34.56±11.51, p<0.05). Urinary excretion of AM (pmol/mg creatinine) was higher in acute phase patients (53.85±23.22) than in remission patients (29.97±9.33, p<0.01) and controls (37.43±15.78, p<0.05). Patients had increased urinary nitrite excretion (mol/mg creatinine) in acute phase (2.39±1.18) compared to those in remission (1.53±0.90, p<0.05) and controls (1.05±0.61, p<0.005). There was no significant difference between remission phase and controls in AM and nitrite levels (p>0.05). This study concluded that AM and NO may have a role in the immunoinflammatory process of HSP, especially in the active stage, although whether this perpetuates, or protects against, further vascular injury is not clear. Further studies are needed to clearly establish the roles of AM and NO in the pathogenesis of HSP.     

The role of cholesterol on the pressure sensing ability of kidneys in rats

We studied the effect of hypercholesterolemia on the pressure-sensing and regulating ability of the kidneys, using an acute hemorrhage model to provide 40% and 60% reduction in the blood pressure of hypercholesterolemic and control rats. The control group (n = 22) was fed a normal rat pellet diet and tap water; the experimental group (n = 22) received a diet containing 2% cholesterol/0.2% thaurocholate. Half the animals were subjected to 6 mL/kg bw and the others to 12 mL/kg bw of bleeding for 1 min. Blood pressure recording and proper samplings were done before bleeding and during the 20 min post-hemorrhagic period for analysis. Despite a finding of hypercholesterolemia in the experimental group, kidney cholesterol content as well as its function remained unchanged. Following an initial 40% decrease in rats bled 6 mL/kg bw, 20 min later the mean blood pressure returned to 90% of its initial value in control rats and to 70% of its basal level in hypercholesterolemic rats. A similar delay in pressure normalization occurred in rats subjected to 12 mL/kg of bleeding. Plasma renin activity remained unaffected. We conclude that dietary hypercholesterolemia delays the normalization of blood pressure after hemorrhage without affecting the sensing ability of kidneys, and that the kidneys are less sensitive than other organs to plasma cholesterol levels.     

Surveillance of Haemophilus influenzae among respiratory tract samples of Turkish children

We conducted three prospective studies of Haemophilus influenzae in different groups of children. Pharyngeal swab samples were taken (i). from 1382 healthy infants and children between 0 and 10 years of age (group 1), attending well child clinics (n=438), day care centres (n=440) and elementary schools (n=504), and (ii). from 322 children aged 2-10 years (group 2), clinically diagnosed as having upper respiratory tract infection. Pharyngeal swab samples and sinus aspirates were obtained from 49 children between 2 and 9 years of age (group 3), clinically diagnosed as having sinusitis. H. influenzae was isolated in similar rates from 315 (22.7%) of children in group 1, 72 (22.3%) of children in group 2 and 12 (24.4%) of children in group 3. Serotype b comprised 7, 5.2 and 2% of all H. influenzae isolates for group 1, 2 and 3, respectively. Production of beta-lactamase was detected in 1.0% of H. influenzae type b isolates in group 1, 1.2 and 6.1% of all isolates in group 2 and 3, respectively. There were no beta-lactamase negative ampicillin-resistant strains.