Laparoscopic removal of a swallowed sewing needle that migrated into the greater omentum without clinical evidence

We report a case of a sewing needle, presumably originating from the transverse colon or the ligament of Treitz, that migrated to the greater omentum. A 24-year-old woman was referred to our clinic with a complaint of abdominal pain which was exacerbated by breathing or any physical activity. Abdominal plain x-ray showed a needle in the left upper abdominal area. Abdominal computed tomography (CT) and contrast enhanced x-ray studies was unable to reveal whether the needle was in the colonic lumen. Virtual colonoscopy examination demonstrated that the foreign body was not in the lumen. The foreign body was removed from the patient's greater omentum in a fluoroscopy- guided laparoscopic surgery. An accurate and rapid diagnosis of a perforation in the gastrointestinal tract as the result of an ingested foreign body is difficult in the absence of peritonitis or abscess formation. In such cases, the virtual colonoscopy is useful if there is uncertainty whether the foreign body is in the lumen. Perioperative fluoroscopy can be useful to overcome the lack of tactile discrimination in laparoscopy, in patients who have been scheduled for surgery who have no signs of the localization of the foreign body (such as abscess or solid organ migration).     

Circumferential negative-pressure dressing (VAC) to bolster skin grafts in the reconstruction of the penile shaft and scrotum

This paper presents 4 consecutive cases using negative-pressure dressings (VAC) to bolster skin grafts in male genital reconstruction. In this series reconstruction followed 1 case of tumor ablation and 3 cases of debridement of abscesses or Fornier's gangrene. The VAC was applied circumferentially to the penis to secure skin grafts either directly to the penile shaft or to facilitate skin grafting to the scrotum. Graft areas ranged from 75 to 250 cm. All cases resulted in successful genital wound coverage; minor complications are described. Three practical points are brought forth. First, the VAC facilitates skin grafting to the complex contour of male genitalia. Second, the VAC can be applied circumferentially to the penis without the need for perfusion monitoring or fears of avascular necrosis. Third, with the use of the VAC, bolster use can likely be discontinued as early as 72 hours with good graft adherence and survival.     

Lumbosacral neurenteric cyst with associated tethered cord in an adult

Spinal neurenteric cysts are rare congenital lesions of endodermal origin that lead to spinal cord compression or tethering. These cysts are usually lined by mucus-secreting epithelium resembling that of the gastrointestinal tract. A 31-year-old man presented with low back and bilateral limb pain of three-year duration. Magnetic resonance imaging (MRI) revealed an intradural extramedullary heterogeneous mass lesion at L4 - L5 disc level causing severe compression and displacement of terminal portion of conus medullaris to the left side. Additionally, tethered cord, syringohydromyelia and spina bifida were present. He had also polysyndactyly on the left foot. The patient underwent laminoplasty and partial excision of the lesion through a posterior approach. Neurosurgical exploration revealed a large intradural, extramedullary solid lesion with cystic component, compressing the spinal cord. Histopathology confirmed a neurenteric cyst with mucin-producing cuboidal or columnar epithelium lining the cystic cavity. Clinical suspicion is important for an early diagnosis, and their early preplanned surgical removal should be the goal of treatment, which leads to a better outcome. This case is reported in view of rare congenital abnormality in an adult with peculiar presentation.     

The results of cytogenetic analysis with regard to intracytoplasmic sperm injection in males, females and fetuses

OBJECTIVES: To determine the incidence of chromosome abnormalities among couples for whom intracytoplasmic sperm injection (ICSI) treatment was indicated and fetuses conceived through the ICSI procedure. METHODS: All cytogenetic results were evaluated retrospectively. Patients undergoing ICSI (n = 508) were classified according to the referring indications as: (1) males with severe infertility (87 azoospermia and 34 oligoasthenoteratozoospermia, OAT), (2) prior to ICSI (56 males and 61 females), and (3) following an unsuccessful ICSI procedure (132 males and 138 females). Fetuses conceived through ICSI (n = 475) were also classified into 4 groups according to the additional risk factors for chromosome abnormalities: ICSI (n = 185), ICSI + advanced maternal age (AMA, n = 215), ICSI + positive triple test result (TT, n = 50), and ICSI + abnormal ultrasound findings (USG, n = 25). RESULTS: An abnormal karyotype was found in 31.03% of males with azoospermia and 14.71% of males with OAT, in 3.57% of males and 1.64% of females in the group prior to ICSI, and in 5.30 and 5.07%, respectively, in the group following unsuccessful ICSI treatment. Gonosomal aneuploidies were predominant in males with azoospermia and autosomal rearrangements in males with OAT, while low-level sex chromosome mosaicism was found in females. The overall frequency of chromosome abnormalities in fetuses was 4.42% and varied in the different groups from 1.62% in ICSI, 2.79% in ICSI + AMA, 10.0% in ICSI + TT to 28.0% in ICSI + USG. The frequencies of the different types of chromosome abnormalities were as follows: balanced 1.05%, unbalanced 3.37%, familial 0.84%, de novo 3.37%, autosomal 3.58%, gonosomal 0.84%, numerical 1.89%, structural abnormalities 2.53%, and mosaicism 1.26%. CONCLUSION: Our results indicate that cytogenetic investigations of the ICSI parents and fetuses are essential for the families, genetic counselors and also reproductive centers. In fetal karyotyping, de novo structural chromosome abnormalities and mosaicism should be taken into consideration.     

Reduced bone mineral density in childhood chronic idiopathic thrombocytopenic purpura treated with high-dose methylprednisolone

PURPOSE: To evaluate whether repeated courses of high-dose methylprednisolone (HDMP) affect the lumbar spine bone mineral density (BMD) in children with chronic idiopathic thrombocytopenic purpura (ITP). MATERIALS AND METHODS: This study included 24 patients with chronic ITP and 149 healthy controls. The patients were allocated into three groups according to the number of HDMP courses (30 mg/kg per day as a single dose for 7 days); group 1 (10 patients), group 2 (9 patients), and group 3 (5 patients) had received less than 5, 6-10, and more than 10 courses, respectively. Lumbar spine BMD and body composition were measured using dual energy X-ray absorptiometry of lumbar spine (L2-L4), and volumetric bone mineral density (vBMD) values were calculated and compared with the controls. The z score of the vBMD was also calculated and compared in the patients of each other groups. Serum markers of the bone turnover were measured to exclude other factors that could effect BMD. RESULTS: The vBMD values of the patients, corrected BMDs for age, were significantly lower than the values of controls (P = 0.018). It was significantly lower in group 3 than groups 1 and 2 (P = 0.005 and P = 0.006, respectively), but there was no statistically significant difference between groups 1 and 2 (P = 0.87). The vBMD z scores were significantly lower in group 3 than in groups 1 and 2 (P = 0.003 and P = 0.004, respectively), and also in group 2 than in group 1 (P = 0.034). There were a weak negative correlation between the cumulative dose of HDMP and vBMD (r = -0.39, P = 0.054), and strong negative correlation between the cumulative dose of HDMP and vBMD z score (r = -0.63, P = 0.001). CONCLUSION: Children with chronic ITP are at risk for decreased BMD because of the repeated courses of HDMP; especially more than 2100 mg of cumulative dose. We therefore recommend that BMD should be monitored in patients with chronic ITP who received repeated courses of HDMP.     

Comparison of various simple insulin sensitivity and beta-cell function indices in lean hyperandrogenemic and normoandrogenemic young hirsute women

OBJECTIVE: To assess and compare various simple insulin sensitivity and beta-cell function indices in lean, hirsute, young women. DESIGN: Prospective study. SETTING: Departments of endocrinology and metabolism at a university and a state hospital. PATIENT(S): Seventy-one hirsute young women were classified as hyperandrogenemic or normoandrogenemic. MAIN OUTCOME MEASURE(S): Insulin sensitivity and beta-cell function indices derived from a single sample and an oral glucose tolerance test (OGTT). RESULT(S): Lean hyperandrogenemic hirsute women have insulin resistance and increased beta-cell function. The most sensitive indices of insulin resistance were total and 1-hour and 2-hour post-challenge insulin levels during OGTT. When a cut-off value of 3.2 or greater for homeostasis model assessment of insulin resistance (HOMA-IR) was accepted, 46% of hyperandrogenemic women and 30% of normoandrogenemic women were insulin resistant. Fasting insulin level was best correlated with the fasting insulin resistance index, HOMA-IR, and Quicky index. The HOMA-IR was best correlated with fasting insulin level and the hepatic insulin sensitivity index (ISI(HOMA)). CONCLUSION(S): Insulin levels based on OGTT are the most useful index of insulin resistance and beta-cell function index in hirsute women. The HOMA-IR may be a proposed global test for insulin resistance; it correlated well with both OGTT-derived insulin resistance and beta-cell function indices and with global insulin resistance indices derived from a single sample (such as ISI (HOMA), Quicky index, FIRI(-1), fasting Belfiore index, and glucose/insulin ratio).     

The relation between tooth loss and bone mass in postmenopausal osteoporotic women in Turkey: a multicenter study

 The purpose of this study was to investigate the associations of tooth loss with skeletal bone mass, years since menopause, educational level, current smoking status, dietary calcium intake, and number of pregnancies in postmenopausal osteoporotic women in Turkey. The study population consisted of 1171 postmenopausal women aged 40–86 years (mean age, 61.19 ± 7.28 years). A detailed history was obtained from all women, including relevant lifestyle parameters, risk factors, and measurements of weight and height. Women were separated into three groups according to the number of teeth remaining as group 1 (edentulous, 457 women), group 2 (10 or fewer teeth, 232 women), and group 3 (more than 10 teeth remaining, 482 women). There was no significant difference among the three groups in mean age and menopausal age (P < 0.05). Body mass index of group 1 was significantly higher than that of group 2 (P < 0.01). Educational level was significantly different between three groups: groups 1 and 2 (P < 0.001), groups 1 and 3 (P < 0.0001), and groups 2 and 3 (P < 0.001). Educational level was lowest in group 1 and highest in group 3. Despite a low ratio of cigarette smoking in general, a smoking habit was most prevalent in group 3 and least in group 2. The ratio of women receiving adequate calcium was significantly lower in group 1 than in other groups (P < 0.001); mean calcium intake was similar in all groups. The number of pregnancies was significantly higher in group 1 than in other groups (P < 0.001). Lumbar bone mineral density (BMD) of group 1 was significantly lower than that of groups 2 and 3 (P < 0.001). Although no significant difference was found between groups 1 and 3, femoral neck BMD of group 2 was less than in others, and differences between groups 1 and 2 and between groups 2 and 3 (P < 0.001) were significant. Lumbar bone mineral content (BMC) of group 1 was significantly lower than that of groups 2 and 3 (P < 0.001), and lumbar BMC in group 2 was significantly higher than in group 3 (P < 0.05). Femoral neck BMC in group 1 was significantly higher than in groups 2 and 3 (P < 0.001). In conclusion, lumbar BMD and BMC in the edentulous group were significantly lower, whereas femoral neck BMD and BMC were significantly higher in edentulous group compared with the others. Our findings indicated that improvement in lifestyle factors and nutritional strategies for the treatment and prevention of osteoporosis may have additional benefit in reducing tooth loss. Received: February 18, 2002 / Accepted: June 21, 2002 Offprint requests to: A. Gur     

Bone Mineral Changes in Acute Metabolic Acidosis due to Acute Gastroenteritis

We studied bone mineral metabolism changes complicated by acute gastroenteritis in a clinical acute metabolic acidosis milieu where we observed hypercalcemia, hypercalciuria, and elevated urinary hydroxyproline excretion. Serum magnesium and plasma osteocalcin, alkaline phosphatase, and IGF-1 levels were decreased. No significant changes in serum inorganic phosphate and plasma PTH, calcitonin, or 25-hydroxy vitamin D3 levels were detected. All abnormalities disappeared with the correction of acidosis. Observed hypercalcemia seems to be the result of increased calcium efflux from bone due to metabolic acidosis-induced catabolism of type 1 collagen and decreased osteoblastic activity. This study provides data regarding acute metabolic acidosis-induced changes in noninvasive parameters of bone modeling, assessed for the first time in humans.