Peyronie's disease:a silent consequence of diabetes mellitus

Aim:To investigate the clinical characteristics of patients with Peyronie's disease(PD)and diabetes mellitus(DM).Methods:During an 8-year period,a total of 307 men seen at our outpatient clinic were diagnosed with PD.Clinicalcharacteristics,penile deformities and the erectile status of patients with PD and DM together(n=102)were retro-spectively analyzed and compared to patients with PD alone with no risk factors for systemic vascular diseases(n=97).Results:The prevalence of PD among men with DM and sexual dysfunction was 10.7%.The mean ageof diabetic patients with PD was(55.9±8.9)years;in the no risk factor group it was(48.5±9.0)years(P<0.05).The median duration of DM was 5 years.The majority of diabetic patients with PD(56.0%)presented in the chronicphase(P<0.05),and they were more likely to have a severe penile deformity(>60°)than the no risk factor group(P<0.05).In the diabetic group,the most common presenting symptom was penile curvature(81.4 %),followedby a palpable nodule on the shaft of the penis(22.5%)and penile pain with erection(14.7 %).A total of 19.6 % ofpatients were not aware of their penile deformities in the diabetic group.Erectile function,provided by history and inresponse to intracavernosal injection and a stimulation test,was significantly diminished in patients with PD and DM(P<0.05).Conclusion:DM probably exaggerates the fibrotic process in PD.Diabetic patients with PD have ahigher risk of severe deformity and erectile dysfunction(ED).PD seems to be a silent consequence of DM andshould be actively sought in diabetic men.(Asian J Androl 2006 Jan;8:75-79)     

Heart Rate Variability Predicts Severe Hypotension after Spinal Anesthesia

Background: Hypotension due to vasodilatation after spinal anesthesia (SA) may be harmful. Heart rate variability, an indirect measure of autonomic control, may predict hypotension.

Methods: One hundred patients were studied. Retrospectively, heart rate variability was analyzed in 30 patients, classified depending on the lowest systolic blood pressure (SBP) after SA. Seventy patients were studied prospectively, assigned to one of two groups by their low to high frequency ratio (LF/HF) before SA. Sensitivity and specificity of LF/HF for prediction of decrease of SBP greater 20% of baseline were tested.

Results: Retrospective analysis showed differences of LF/HF depending on the degree of hypotension after SA. Prospective analysis demonstrated significant differences of SBP after SA depending on baseline LF/HF (mean +/- SD): low LF/HF (1.3 +/- 0.7) = > SBP: 91 +/- 8% of baseline versus high LF/HF (5.5 +/- 2.4) = > SBP: 66 +/- 10% of baseline (P < 0.05). Baseline LF/HF as well as high frequency and proportional decrease of SBP after SA correlated significantly, in contrast to baseline hemodynamic parameters heart rate and SBP. A receiver operator curve characteristic analysis showed a sensitivity and specificity of LF/HF > 2.5 of 85% to predict SBP decrease of greater than 20% of baseline after SA.     

Reconstruction of the wrist pseudoarthrosis due to radioulnar fractures with vascularized fibular graft in a child with neurofibromatosis

Nonunion in the forearm following a radioulnar fracture is one of the nightmares of the orthopedic surgeon. Fortunately, it is rare. We treated a large bone defect of the forearm, using a vascularized fibular graft after excision of the unhealed bone segment in a 10-year-old boy with neurofibromatosis. This situation followed a double fracture that had been operated on several times using conventional methods. Following the debridement of the unhealthy tissues in the pseudoarthrotic region, the vascularized fibula was placed on the dorsal surface of the proximal radius fragment. The distal fragment of the radius was inserted into the fibular cavity and fixation was established with a Kirschner wire distally and with a plate proximally. Only two screws were used to fix the plate. The peroneal artery was anastomosed with the radial artery; one of its venae comitantes was anastomosed with the cephalic vein in an end-to-end fashion. After surgery, the elbow was immobilized at 90 degrees of flexion with a splint for 6 weeks. One year after surgery, forearm stabilization and elbow and hand functions were very satisfactory. However, because the distal epiphyses of the bones were destroyed following the repeated surgery and the original trauma itself, a very prominent difference between the two forearms occurred, suggesting the need for bone lengthening in the future. By presenting this case we would like to conclude that one can expect good bone healing with a vascularized bone transfer in these cases when there is not enough space to place screws, but support can be provided by an external splint and K wire.     

Pre-clinical Cushing's syndrome: an unexpected frequent cause of poor glycaemic control in obese diabetic patients

OBJECTIVE Autonomous cortisol secretion without clinical stigmata of Cushing's syndrome (CS) has been recently recognized and termed pre-clinical or sub-clinical CS. The common assumption is that CS is an extremely rare cause of uncontrolled diabetes; however, the prevalence of this entity has not been studied. We assessed the prevalence of pre-clinical CS among obese patients with uncontrolled diabetes. PATIENTS AND DESIGN (1) In a retrospective analysis, the medical records of 63 patients with endogenous CS were reviewed. (2) In a cross-sectional study, 90 obese patients (BMI >25 kg/m²) followed in a University Hospital and the local Health Fund endocrine and diabetes clinics, with poorly controlled diabetes (glycosylated haemoglobin >9%), underwent an overnight 1 mg dexamethasone suppression. In patients with non-suppressible cortisol levels (>140 nmol/l), Liddle's 2 and 8 mg dexamethasone suppression tests and imaging studies were performed. MEASUREMENTS The prevalence of poorly controlled diabetes, the major presenting symptom of CS, was assessed in the retrospective analysis. The prevalence of ‘true’ CS and the false positive rate in the overnight dexamethasone suppression test were calculated. The endocrine evaluation of the patients with pre-clinical CS and the effects of surgical cure on glycaemic control are described. RESULTS In the retrospective analysis, 11 (17.5%) had diabetes and 2 (3.2%) lacked the classic physical characteristics of the syndrome. In the cross-sectional study, 4 patients failed to suppress plasma cortisol (<140 nmol/l). In one patient the diagnosis of CS was not confirmed by a standard Liddle’s test and was therefore considered false positive. In the other 3, the diagnosis of CS was confirmed (prevalence of 3.3%, 95% confidence interval 1–9%). In all other patients the overnight cortisol suppression test was normal (cortisol level 47.3 ± 2.5 nmol/l (mean ± SEM)). After surgical treatment of CS, glycaemic control was markedly improved in all 5 patients (2 from retrospective and 3 from cross-sectional studies). CONCLUSIONS The prevalence of pre-clinical Cushing's syndrome in obese patients with poorly controlled diabetes appears to be considerably higher than previously believed. The overnight dexamethasone suppression test proved to be a simple, sensitive and highly specific screening test for Cushing's syndrome despite the presence of obesity and hyperglycaemia.     

Bilateral perineal ectopic testes

Perineal testicular ectopia is seen very rarely, bilaterality is even more scarce and three cases have been reported in the literature. Here we present the fourth case with bilateral perineal ectopic testes.     

Meloxicam-associated anaphylactic reaction.

Anaphylactic reaction to meloxicam has never been reported to date. We report 2 cases of meloxicam-induced anaphylactic reaction with no sensitivity to another selective cyclooxygenase 2 inhibitor. A thorough drug allergy work-up should be done before other cyclooxygenase inhibitors are prescribed.     

Incisional healing in rats treated with diethyl maleate

Diethyl maleate (DEM) which binds and thus depletes tissue glutathione levels was used to aggravate the injury and to determine its effect on incisional healing. A 5 cm dorsal midline skin incision was performed on 40 albino Wistar rats in two groups and then closed by interrupted sutures. Groups received 0.9% NaCl and DEM at a dosage of 1 mg/kg/day intraperitoneally for seven days, respectively. On postoperative days 7 and 14, histopathological assessment and tensile strengths were measured. The DEM treated group had a marked inflammation with poorly defined collagen formation and the tensile strength measurements revealed a significant decrease (p <0.001) on the 7t day. On the other hand, the first group showed better collagenization and a lesser degree of inflammation. However, on the 14th day, there was no noticeable histopathological difference between the two groups; but, tensile strength values of the second group were still lower (p <0.05). In this animal model, DEM postponed the healing process and reduced the tensile strength.     

Preliminary findings for preemptive analgesia with inhaled morphine: efficacy in septoplasty and septorhinoplasty cases.

OBJECTIVE: The aim of this study was to assess the efficacy of inhaled morphine for preemptive analgesia in patients who undergo septoplasty or septorhinoplasty. STUDY PLAN AND METHODS: Eighty ASA I-II patients scheduled for septoplasty or septorhinoplasty were recruited and randomly divided into 2 groups that received different treatments 10 minutes prior to induction. The preemptive analgesia group (Group P, n = 40) received 65 mug kg(-1) morphine sulphate (a 3-mL volume) via an oral nebulizer, and the control group (Group C, n = 40) received 3 mL 0.9% sodium chloride (physiological saline) via the same type of nebulizer. Blood pressure, oxygen saturation, heart rate, time to first requirement for analgesia, and occurrence of nausea/vomiting were recorded. RESULTS: There were no significant differences between Groups P and C with respect to age, body weight, sex distribution, or duration of surgery. There was also no significant difference between the group frequencies of postoperative nausea/vomiting. The time to first requirement for analgesia was significantly longer in Group P than Group C. CONCLUSION: The results of this preliminary study suggest that a single dose of inhaled morphine administered preemptively prior to septoplasty or septorhinoplasty provides effective postoperative analgesia. EBM rating: B-3b.     

Spiral-shaped Metallic Implant in the Treatment of Achilles Tendon Ruptures: An Experimental Study on the Achilles Tendon of Sheep

There are 2 main factors contributing to the strength of tendon repair: the tensile strength of the material used in repair and the tendon-holding capacity of the suture configuration. In the current study, we aimed to find a technique with high repair strength by increasing both the tensile strength of the material and the tendon-holding capacity of the configuration. We developed metal implants (models 1 and 2) made from stainless-steel wire with 2 different spiral-shaped configurations. We measured tendon-holding capacities of these alternative implants biomechanically and compared them with frequently used suture techniques, the Bunnell and locking loop, which were achieved with 5 Ticron sutures. Sixty-four sheep Achilles' tendons were used in the study as 16 tendons in each group. Model 2 was more resistant to deformation under loading when compared with model 1. The results demonstrated that model 2 was superior to model 1 and both suture techniques. This study could be accepted as a step for reaching a strong tendon repair technique. It should be emphasized that the technique needs to be improved technically to make it convenient for clinical use.     

One-year follow-up results of combined use of CO<Subscript>2</Subscript> laser and cold instrumentation for Reinke’s edema surgery in professional voice users

The purpose of this study was to present our experience with combined use of CO₂ laser and cold instrumentation for Reinke’s edema surgery and to evaluate 1-year follow-up results of the technique in a series of professional voice users. Fifteen patients with Reinke’s edema who underwent microlaryngoscopic surgery were included. Videolaryngostroboscopy, perceptual and acoustic voice analyses were performed before and after surgery. During the 1-year follow-up, no recurrence of Reinke’s edema was encountered. Significant postoperative improvement was obtained in the quality of voice, in terms of GRBAS scores, Fo, jitter, shimmer and NHR. No evidence of laryngeal cancer was found on the histological examinations. Combined use of CO₂ laser and cold instrumentation provides a reliable and safe method for Reinke’s edema surgery, and cessation of smoking, voice rest and control of the laryngopharyngeal reflux contribute to the success of surgery. We consider that the removal of redundant mucosa of the vocal fold reduces the risk of the recurrence of Reinke’s edema and provides better quality of voice. However, it does not imply that our method is superior to others’, but this procedure constitutes an effective treatment of choice for Reinke’s edema patients, including professional voice users.