Intracranial plasmacytoma as an initial presentation of multiple myeloma

Intra-cranial involvement is an uncommon complication of multiple myeloma. We report a 68-year-old woman hospitalized for acute renal failure, vertigo and headache. Magnetic Resonance Imaging (MRI) revealed two and a half and 3cm length cranial lesion, which proved to be plasmacytoma. After complete staging, we retained the diagnosis of immunoglobulin G lambda-type multiple myeloma with intracranial involvement. Cytogenetic analysis of plasma cells detected no change. Currently, she is a regular hemodialysis patient. She is planned to have both systemic therapy with 40mg dexamethasone and cranial radiotherapy. Involvement of the CNS in multiple myeloma is very rare. Diagnosis of multiple myeloma subsequent to initial intrcranial involvement is confined to exceptional cases. Despite aggressive systemic treatments, including autologous stem cell transplantation and local treatments such as cerebral radiotherapy, the prognosis for patients with CNS myeloma is extremely poor. Our unique case implies that physicians should be alert in case of vertigo or headache in cases with acute renal failure.     

Cerebral hydatid disease CT and MR findings

In this study, we reviewed the computed tomography (CT, n=9) and magnetic resonance (MR, n=5) imaging findings of 11 patients with pathologically confirmed cerebral hydatid disease. Among our patients, there were 10 cases of Echinococcus granulosus and 1 case of Echinococcus multilocularis. Common CT and MR imaging findings of E. granulosus lesions were well-defined, smooth thin-walled, spherical, homogeneous cystic lesions with no contrast enhancement, no calcification, and no surrounding edema. E. multilocularis lesions showed calcified round, solid pattern with definite margins, contrast enhancement, and surrounding edema.     

Augmented surgical amounts for intermittent exotropia to prevent recurrence

Purpose:

The purpose was to evaluate the results of bilateral lateral rectus (BLR) recession which is based on augmented surgical amounts of classical surgical table of Parks’ for basic and pseudo-divergence excess type intermittent exotropia [X(T)].

Materials and Methods:

Patients with X(T) operated by the same surgeon and followed-up for at least 6 months were included. Patients with prior surgery, neurobehavioral and musculoskeletal conditions, strabismus different from that mentioned above X(T) were excluded. All the patients received BLR only. The amount of the recession was increased by the amount needed to correct 5 prism diopters (PD) more X(T) than what was measured. After the operation, 1^st week, 2^nd and 6 months measurements were recorded. The patients were grouped according to their 1^st week (3–7 days) postoperative examination as: >10 PD esotropia (Group 1), ≤10 PD esotropia (Group 2), exotropia (Group 3), and orthotropic (Group 4), respectively. Final surgical outcomes were classified as “good” (≤10 PD exotropia and ≤5 PD esotropia), “recurrence” (>10 PD exotropia) and “overcorrected” (>5 esotropia).

Results:

Thirty-seven patients were included. The mean age was 6.78 ± 2.87 years (range: 2–12 years). Mean preoperative deviation was 29.72 ± 8.07 PD (range: 15–45 PD) at distance and 20.94 ± 11.65 PD (range: 10–45 PD) at near (P < 0.0001). There were 21 (56.8%) patients in Group 1, 9 (24.3%) patients in Group 2, 1 (2.7%) patient in Group 3 and 6 (16.2%) patients in Group 4. Initial esotropia was achieved in 30 (30/37) of the patients. Twenty-eight of them had good results at the end of the 6 months. Overall “motor surgical” success rate was found to be 89.2% (33/37 patients), with 1 (2.7%) overcorrection and 3 (8.1%) recurrences at the end of the 6 months.

Conclusion:

This study demonstrated that early overcorrection of 10–20 PD after X(T) surgery can achieve acceptable motor outcomes in the first 6 months postoperative period.     

Thymosin β(4) is a novel potential prognostic marker in gastrointestinal stromal tumors

Thymosin beta‐4 (Tβ₄) is a major actin‐sequestering molecule that contributes to cell growth, differentiation, motility, survival, mitosis and angiogenesis. It is overexpressed in certain type of carcinoma and fibrosarcoma cell lines and is associated with metastatic potential. The aim of this study was to investigate the relationship between Tβ₄ expression and clinicopathologic features and VEGF status in gastrointestinal stromal tumors (GISTs). Retrospectively, 60 GISTs were re‐examined and immunohistochemistry for Tβ₄ and VEGF was performed. Increased expression of Tβ₄ and VEGF was observed in 26 (43.3%) and in 19 (31.6%) of the tumors, respectively. Tβ₄ expression was positively correlated with VEGF expression (p < 0.01). Tβ₄ and VEGF expression were significantly associated with tumor size (p = 0.00 and p = 0.02, respectively) and high mitosis (p = 0.03 and p = 0.00, respectively). Although Tβ₄ expression was positively associated with pleomorphism (p = 0.01), VEGF expression was positively associated with necrosis (p = 0.03). Tβ₄ expression was related with local recurrence and/or metastasis (p = 0.03), but VEGF expression was not (p = 0.12). We firstly demonstrate the presence of Tβ₄ protein in GISTs. Our study reveals that increased expression of Tβ₄ could be considered as an indicator of aggressive behavior of tumor.     

Percutaneous US-guided needle biopsies of solid renal masses

Our objective was to examine the variables affecting diagnostic yield and complications in percutaneous ultrasonography-guided needle biopsies of solid renal masses. Percutaneous ultrasonography-guided needle biopsy of solid renal masses was performed in 172 patients with either large size (18G) cutting needles or small size (20G) aspiration needles. Retrospectively, 120 patients with diagnosis by percutaneous biopsy and follow-up data were included in this series. Age, gender, side, locations in kidneys, necrosis, calcification, maximum size, needle groups due to needle size and type (either 18G cutting needles or 20G aspiration needles), and needle pass were selected as variables. Their role was investigated in diagnostic yield. Two needle groups were divided and compared for diagnostic yield and safety. Also, change in treatment was evaluated. The mean maximum size of the masses was 8.8±4.9 cm. The only predictor affecting accuracy was side of kidney (p=0.002). Among patients, 15 (12.5%) and 105 (87.5%) had benign and malignant solid masses, respectively. Small and large needle groups did not differ in accuracy, 80.3% vs. 87.1% (p=1.000). Technical success was detected as 100%. No major complications neither tumor seeding was seen. Percutaneous ultrasonography-guided needle biopsy of solid renal masses is effective and safe method with large size cutting needles and small aspiration needles. Change in clinical management was significant at 63.3% rate. Diagnostic yield was low in left kidney relating to right kidney, 69.4 vs. 93.1, while upper lobe location did not lead to significant false result. Repeat biopsies can be taken under CT guidance after nondiagnostic diagnosis in solid tumors of left kidney. All the needles including large cutting type were found safe.     

Metalloproteinases and Their Inhibitors in Patients with Inguinal Hernia

Aim

The aim of this prospective study is to investigate if there is a relationship between inguinal hernia, matrix metalloproteinases (MMPs), and tissue inhibitors of metalloproteinases (TIMPs).

Materials and methods

This case control study was performed on patients admitted to the general surgery department of Erzincan University Hospital. Four groups were created: control, indirect hernia, direct hernia, and bilateral hernia. All groups were comprised of 11 patients. Serum and tissue levels of MMP-1, MMP-2, MMP-9, MMP-13, TIMP-1, TIMP-2, TIMP-3, and hydroxyproline were evaluated.

Results

MMPs values were significantly high at hernia groups, especially at bilateral hernia group (p < 0.05), whereas TIMPs values were significantly low at bilateral hernia group (p < 0.05). MMPs values were increasing at hernia groups in an order as control, indirect, direct, and bilateral. TIMPs values were decreasing at hernia groups in an order as control, indirect, direct, and bilateral.

Conclusion

Increased levels of MMP-1-2-9-13 and decreased levels of TIMP-1-2-3 may have played role in the formation of inguinal hernia. Hernia is not only a local defect, but a reflection of systemic disease. This is even more significant for bilateral hernias.

     

CD4 T cells, lymphopenia, and IL-7 in a multistep pathway to autoimmunity

There are many inhibitory mechanisms that function at the cellular and molecular levels to maintain tolerance. Despite this, self-reactive clones escape regulatory mechanisms and cause autoimmunity in certain circumstances. We hypothesized that the same mechanisms that permit T cells to expand during homeostatic proliferation may inadvertently promote autoimmunity under certain conditions. One major homeostatic cytokine is IL-7, and studies have linked it or its receptor to the development of multiple sclerosis and other autoimmune diseases. We show in a model of beta-islet cell self-reactivity that the transfer of activated autoreactive CD4 T cells can prime and expand endogenous autoreactive CD8 T cells in a CD28- and CD40-dependent manner through the licensing of dendritic cells. Despite this, mice do not develop diabetes. However, the provision of exogenous IL-7 or the physiological production of IL-7 associated with lymphopenia was able to profoundly promote the expansion of self-reactive clones even in the presence of regulatory T cells. Autoimmune diabetes rapidly ensued with CD4 help and the subsequent activation of CD8 T cells, which contributed to disease progression. With the advent of many biologicals targeting TNFalpha, IL-6, and IL-1 and their effective use in the treatment of autoimmune diseases, we propose that IL-7 and its receptor may be promising targets for biological agents in the treatment of autoimmunity.     

Infections in travellers returning to Turkey from the Arabian peninsula: a retrospective cross-sectional multicenter study

Mass gatherings pooling people from different parts of the world—the largest of which is to Mecca, Saudi Arabia, for Hajj—may impose risks for acquisition and dissemination of infectious diseases. A substantial number of pilgrims to Hajj and Umrah are Turkish citizens (456,000 in 2014) but data are lacking on scale of the problem. We did a retrospective cross-sectional multicenter study in Turkey to explore the range of infections among inpatients who had recently returned from the Arabian Peninsula. Our inclusion criteria were patients who had acquired an infection during their trip to an Arabian Peninsula country, or who became symptomatic within 1 week of their return. The data were collected retrospectively for January 1, 2013 and March 1, 2015. 185 Turkish patients were recruited to the study across 15 referral centers with travel associated infectious diseases after returning from Arabian Peninsula countries (predominantly Saudi Arabia 163 [88.1 %] for religious purposes 162 [87.5 %]). Seventy four (40.0 %) of them were?≥?65 years old with numerous comorbidities including diabetes (24.3 %) and COPD (14.1 %). The most common clinical diagnosis was respiratory tract infections (169 [91.5 %]), followed by diarrheal diseases (13 [7 %]), and there was one case of MERS-CoV. Patients spent a median of 5 (3–7) days as hospital inpatients and overall mortality was 1.1 %. Returning travellers from the Arabian Peninsula present as inpatients with a broad range of infectious diseases similar to common community acquired infections frequently seen in daily medical practices in Turkey.     

Course and prognosis of spinal epidural abscess. Report of five cases

Five patients suffering from spinal epidural abscess associated with neurologic deficit are reported. Four patients underwent a decompressive procedure for abscess drainage, and one patient was medically treated. One of the patients showed a neurologic deterioration at the early postoperative period. The long-term follow-up showed a good outcome in all patients. It is concluded that epidural abscess associated with progressive neurologic deficit requires immediate decompression and administration of antibiotic. Postoperative neurological deterioration may be seen despite proper and immediate decompression and in such a case neurologic improvement is observed in the late postoperative period.