Percutaneous mitral balloon valvuloplasty in rheumatic mitral stenosis without heparin

BACKGROUND AND AIM OF THE STUDY: Customarily, heparin is used to prevent embolic complications arising during percutaneous mitral balloon valvuloplasty (PMBV), but this may prolong hospital stay and increases the risk of bleeding, hemopericardium and cardiac tamponade. The study aim was to assess in-hospital complications of PMBV performed without heparin. METHODS: Rheumatic mitral stenosis patients undergoing PMBV between February 1997 and March 2000, either with (18 males, 91 females; mean age 37.5 +/- 8.8 years) or without (15 males, 119 females; mean age 37.5 +/- 15.1 years) heparin at conventional doses, were included in the study. Neurologic and cardiac examinations were conducted after PMBV and repeated before discharge from hospital. RESULTS: There was no statistically significant difference between groups in terms of age, gender, NYHA class, presence of atrial fibrillation, spontaneous echo contrast, left atrial appendix thrombus, left atrial diameter and mitral valve echo score. There was no difference between groups with regard to procedural success, mitral valve area and gradient attained, or rates of mitral insufficiency. Ten patients in the heparin group required transesophageal echocardiography (TEE) guidance during PMBV (p <0.001). The mean duration of PMBV was greater in the heparin group due to increased use of TEE guidance during septal puncture. During follow up, no patients in the non-heparin group had hemopericardium, cardiac tamponade, embolic event or death; by comparison, in the heparin group one patient had hemopericardium and one had a cardiac tamponade. No major bleeding episode requiring transfusion occurred in either group, but six and 10 cases of minor bleeding at access sites occurred in the non-heparin and heparin groups, respectively (p = NS). Duration of hospitalization was statistically longer in the heparin group than in the non-heparin group. CONCLUSION: Avoidance of heparin did not lead to an increase in embolic complications. The vascular access sites were withdrawn early, thereby reducing the duration of hospital stay and time to ambulation. This method did not cause any increase in numbers of vascular complications and blood transfusions.     

Outcome of nephron-sparing surgery: elective versus imperative indications

INTRODUCTION: The increase in the detection of renal tumors incidentally in earlier stages has enhanced the enthusiasm for nephron-sparing surgery (NSS). PATIENTS AND METHODS: We performed NSS in 76 patients (53 male, 23 female) with a mean age 52.3 between December 1988 and September 2001. Patients were sub-classified into 2 groups as elective or imperative indication group. They were compared regarding surgical technique, time of surgery, pathological analysis, complications, and disease free status. RESULTS: Elective indication group (group I) with a normal contralateral kidney consisted of 50 patients, whereas there were 26 patients in the imperative indication group (group II). Tumors were incidentally detected in 63%; 74% in group I and 42% in group II. Although the mean diameter of the tumor was slightly higher in group II (39.1 vs. 36.3 mm), this difference did not reach statistical significance (p > 0.05). The partial nephrectomy was performed more frequently compared to enucleation in group I (90 vs. 69%, p = 0.050). However, the mean operation time as well as the mean clamping time did not differ significantly between the two groups (p > 0.05). In the histological evaluation tumors were benign in 16 (21%) and malignant in 60 patients. All of the patients but one with renal cell carcinoma had stage T1-T2 disease. Major complications were observed in 14 (18%) and 12 were from group II. Complication rate was significantly higher in group II (p = 0.000). Of 60 patients with renal cell carcinoma, 2 died of unrelated causes. One patient died with multiple visceral metastases. One patient was lost to follow-up. In the remaining 56 patients with a mean follow-up of 37.1 months (1-152), local recurrence or distant metastases were not detected. Serum creatinine levels have remained almost the same compared to preoperative levels (1.2 +/- 0.6 vs. 1.5 +/- 0.9). Overall and cancer-specific survivals were 100 and 100% in group I, 85 and 95% in group II, and 94 and 98% for the entire patient population, respectively. CONCLUSION: NSS is an effective and reliable treatment in low stage renal tumors. It prevents unnecessary nephrectomy in benign lesions that could not be diagnosed preoperatively. However, the patients who underwent NSS with elective indication outcome with better results, compared to those with imperative indication.     

Angiotensin converting enzyme gene polymorphism and development of post-transplant erythrocytosis

BACKGROUND: An increased activation of the renin-angiotensin system probably plays a major role in the development of post-transplant erythrocytosis (PTE). It is known that deletion type polymorphism (DD) in the angiotensin converting enzyme (ACE) gene is associated with higher circulating angiotensin II (AII) levels. The aim of this study was to investigate the effect of ACE gene polymorphism on development of PTE. METHODS: 86 PTE patients (male/female: 68/18, mean age: 32 +/- 10 years) and 68 consecutively transplanted non- PTE patients (male/female: 38/30, mean age: 31 +/- 10 years) were included; 140 patients (91%) had been transplanted from living donors; 92 patients (60%) had hypertension. ACE gene polymorphism was determined by polymerase chain reaction (PCR). RESULTS: The mean time to appearance of PTE was 8.8 +/- 7.9 (range of 1-53) months. DD genotype was detected in 65 patients. PTE patients had a higher prevalence of hypertension (70% vs. 46%, p=0.003) and a lower frequency of DD genotype (34% vs. 54%, p=0.014) as compared to non-PTE patients [OR: 2.2 (1.14-4.25, 95% CI)]. PTE developed more frequently in male patients (68/106: 64%) than females (18/48: 38%) (p=0.002). Patients with DD genotype had a significantly longer leading time to PTE in Kaplan-Meier survival analysis with log-rank (136 +/- 15 vs. 92 +/- 13 months, p=0.015). In Cox regression analysis, hypertension (p=0.002) and recipient ACE genotype (p=0.013) were retained as independent variables for predicting PTE development. CONCLUSIONS: PTE develops more frequently in male, hypertensive renal transplant recipients with good allograft function. DD-type ACE gene polymorphism seems to protect against PTE development.     

Plasmacytoma of the temporal bone: management with a combination of surgery and radiotherapy

The diagnosis of solitary plasma cell neoplasm is based on clinical, radiological and laboratory findings and it can be accepted as the precursor lesion of multiple myeloma as spread of disease occurs in 30-50% of affected patients. However, solitary plasmacytoma of the temporal bone is a rare pathology. We present an interesting case of plasmacytoma of the temporal bone which was controlled by a combination of surgery and radiotherapy.     

Comparison of the effects of enalapril and losartan on posttransplantation erythrocytosis in renal transplant recipients: prospective randomized study

BACKGROUND: The aim of this prospective randomized study was to compare the safety and efficacy of enalapril (E) and losartan (L) in the treatment of posttransplantation erythrocytosis and the effect of the ACE genotype on response to therapy. METHODS: Twenty-seven (24 male and 3 female, mean age 34+/-8 years) renal transplant recipients with erythrocytosis were treated either with E (15 patients) (10 mg/day) or L (12 patients) (50 mg/day) for 8 weeks. RESULTS: The hemoglobin levels were significantly decreased in the L (17.1+/-0.7 to 15.9+/-1.3 g/dl, P=0.01) and E groups (17.4+/-1.1 to 14.9+/-2.2 g/dl, P=0.001). Among the responders who discontinued treatment, there was a trend for longer time to relapse in the L group (7.38+/-3.75 months; 95% confidence interval: 0.03-14.7) compared with the E group (2.75+/-0.70 (95% confidence interval: 1.37-4.13) (P=0.11). Decrease in hemoglobin was more prominent with E compared with L (-3.26+/-0.65 vs. -1.70+/-0.39 g/dl, P=0.05). Decrease in hemoglobin levels between DD and non-DD genotype groups was similar (-2.0+/-1.5 vs. -1.7+/-2.3 g/dl, P=0.69). CONCLUSIONS: Enalapril caused a greater decrease but faster relapse in hemoglobin levels compared with losartan in patients with posttransplantation erythrocytosis. The DD type polymorphism had no effect on response.     

A comparative analysis of the biochemical parameters used to distinguish between pleural exudates and transudates

OBJECTIVE: The aim of the present study was to compare the various parameters used to identify exudates. METHODOLOGY: The study included 255 patients with pleural effusions. According to aetiological diagnosis, 105 pleural effusions were labelled as transudates and 150 were labelled as exudates. RESULTS: Using the criteria of Light et al., 94.5% of the effusions were correctly classified, yielding a sensitivity and specificity of 99.3% and 87.6%, respectively. Use of the pleural fluid/serum bilirubin ratio produced results of 92.9%, 90.7%, and 96.2%, respectively. Using pleural fluid cholesterol level yielded results of 95.7%, 95.3%, and 96.2%, respectively. When the combination of pleural fluid cholesterol level and lactate dehydrogenase (LDH) level was used, the specificity and accuracy were found to be higher than that using the criteria of Light et al. We found that there was no significant difference among the parameters with respect to accuracy. CONCLUSION: When the accuracy and cost are considered, differentiation of pleural exudates and transudates can be achieved only by pleural fluid cholesterol level or LDH level; and when two parameters were used together, the accuracy and specificity were higher than that using the criteria of Light et al.     

17β‐hydroxysteroid dehydrogenases in normal human mammary epithelial cells and breast tissue

17hydroxysteroid dehydrogenase activity represents a group of several isoenzymes (17HSDs) that catalyze the interconversion between highly active 17hydroxy and low activity 17ketosteroids and thereby regulate the biological activity of sex steroids. The present study was carried out to characterize the expression of 17HSD isoenzymes in human mammary epithelial cells and breast tissue. In normal breast tissues 17HSD types 1 and 2 mRNAs were both evenly expressed in glandular epithelium. In two human mammary epithelial cell lines, mRNAs for 17HSD types 1, 2 and 4 were detected. In enzyme activity measurements only oxidative 17HSD activity, corresponding to either type 2 or type 4 enzyme, was present. The role of 17HSD type 4 in estrogen metabolism was further investigated, using several cell lines originating from various tissues. No correlation between the presence of 17HSD type 4mRNA and 17HSD activity in different cultured cell lines was detected. Instead, oxidative 17HSD activity appeared in cell lines where 17HSD type 2 was expressed and reductive 17HSD activity was present in cells expressing 17HSD type 1. These data strongly suggest that in mammary epithelial cell lines the oxidative activity is due to type 2 17HSD and that oxidation of 17hydroxysteroids is not the primary activity of the 17HSD type 4 enzyme.     

Frog saliva-induced toxic keratopathy: a case report

Corneal toxicity due to exposure to many chemicals and medications have been described in the literature. We present a case of toxic keratopathy by corneal exposure to salivary secretion of a frog. A 40-year-old male patient reported a sudden splash of frog saliva in his right eye while he was examining it at a close distance. Corneal punctate epitheliopathy and stromal oedema and Descemet folds were the initial clinical findings, which completely recovered on the 2nd control day of topical dexamethasone and ofloxacin treatment. We aimed to show the toxic effects of animal-derived secretions on the cornea as a rare cause of toxic keratopathy.     

QT dispersion and signal-averaged electrocardiogram in hemodialysis and CAPD patients.

OBJECTIVE: The aim of this study was to compare QT dispersion (QTd) and signal-averaged electrocardiogram (SA-ECG) parameters that may predict risk of malignant arrhythmias in patients on hemodialysis (HD), on continuous ambulatory peritoneal dialysis (CAPD), and in controls. SETTING: Controlled cross-sectional study in a tertiary-care setting. PATIENTS: 28 HD (M/F 18/10; mean age 32 +/- 9 years), 29 CAPD (M/F 17/12; mean age 34 +/- 10 years), and 29 healthy controls (M/F 17/12; mean age 32 +/- 8 years) were included. INTERVENTIONS: On ECG, minimum (QTmin) and maximum (QTmax) QT duration and their difference (QTd) were measured. In SA-ECG, duration of filtered QRS, HFLA signals less than 40 microV, and RMS voltage (40 ms) were also measured. RESULTS: Higher serum Ca2+ and lower K+ levels were found in CAPD compared to HD. All QT parameters were increased in HD and CAPD compared to controls. QT dispersion was significantly prolonged in HD compared to CAPD. In HD, QTd was correlated with left ventricular (LV) mass index (r = 0.53, p = 0.004), but not in CAPD (r = -0.09, p = 0.63). QT dispersion was significantly prolonged in patients with LV hypertrophy compared to patients without hypertrophy on HD (68 +/- 18 ms vs 49 +/- 18 ms, p = 0.008). In the analysis of SA-ECG, 3 of the 28 (11%) HD and 2 of the 29 (7%) CAPD patients had abnormal late potentials. Patients on HD and CAPD had significantly higher filtered-QRS duration compared to controls (105 +/- 15 ms and 104 +/- 12 ms vs 95 +/- 5 ms, respectively, p = 0.04). Patients with LV hypertrophy had higher filtered-QRS duration compared to patients without hypertrophy (109 +/- 12 ms vs 95 +/- 8 ms, p < 0.001). CONCLUSION: Dialysis patients had prolonged QTd and increased filtered-QRS duration in SA-ECG compared to controls. Patients on HD had longer QTd than patients on CAPD. QTd has been correlated to LV mass index in HD, but not in CAPD. This difference might be due to the effect of different dialysis modalities on electrolytes, especially the higher serum Ca2+ levels.