Relative hypoaldosteronism in a patient with Wolcott-Rallison syndrome

BACKGROUND

Wolcott-Rallison syndrome is an autosomal recessive, multisystem disorder with onset of diabetes in the neonatal period or early infancy.

CASE REPORT

A 9-year-old girl with diabetes and growth failure from 2 months of age presented with ketoacidosis and multiple organ failure. Evaluation for short stature revealed epiphyseal dysplasia. A homozygous mutation in the EIF2AK3 gene confirmed the clinical diagnosis of Wolcott-Rallison syndrome. She was euthyroid. Biochemical evaluation for potential adrenal dysfunction because of persistently elevated serum potassium (range 5.9-6.3 meq/l) and low serum sodium levels (range 128-130 meq/l) 2 weeks after resolution of ketoacidosis yielded normal findings with respect to basal corticotropin (31 pg/ml) and cortisol (18.7 μg/dl) levels. Estimated GFR-Schwartz (36.9 ml/min/1.73 m(2) ) was consistent with stage 3 chronic renal failure. The transtubular potassium gradient was 1.39 (normal value in hyperkalemic states: > 4.1). The plasma aldosterone (upright: 241.3 pmol/l) was within normal ranges, and plasma renin [39 pg/ml (range 5.41-34.53 pg/ml)] was slightly elevated. The patient was diagnosed as having relative hypoaldosteronism and was started on a sodium-rich diet and low potassium. Failure to respond to the dietary intervention prompted a trial of oral fludrocortisone with subsequent normalization of electrolyte levels.

CONCLUSIONS

This is the first case report of Wolcott-Rallison syndrome complicated with relative hypoaldosteronism. Further research is needed to probe the causal inference of relative hypoaldosteronism with chronic renal failure in patients with Wolcott-Rallison syndrome.

Frailty prevalence and related factors in the older adult-FrailTURK Project

Frailty is one of the geriatric syndromes and has an important relationship with mortality and morbidity. The aim of this study is to present the characteristics, prevalence, and related factors of frailty in older adults in our country. The study included 1126 individuals over 65 years of age from 13 centers. Frailty was evaluated using the Fried Frailty criteria, and patients were grouped as "frail," "pre-frail," and "non-frail." Nutritional status was assessed with "Mini Nutritional Test," psychological status with the "Center for Epidemiological Studies Depression Scale-CES-D," and additional diseases with the "Charlson Comorbidity index." Approximately 66.5 % of the participants were between 65 and 74 years of age and 65.7 % were women. Some 39.2 and 43.3 % of the participants were rated as frail and pre-frail, respectively. The multinomial logistic regression analysis was used to determine the factors associated with frailty. It was observed that age, female gender, low education level, being a housewife, living with the family, being sedentary, presence of an additional disease, using 4 or more drugs/day, avoiding to go outside, at least one visit to any emergency department within the past year, hospitalization within the past year, non-functional ambulation, and malnutrition increased the risk of frailty (p < 0.05). Establishing the factors associated with frailty is highly important for both clinical practice and national economy. This is the first study on this subject in our country and will provide guidance in determining treatment strategies.

Iloprost inhibits fracture repair in rats

BACKGROUND

Previous studies have shown that prostaglandins (PGs) dramatically stimulate healing processes in bone. However, the effect of prostaglandin I2 (PGI2) on fracture healing remains unclear. To investigate the effect of PGI2, a study on fracture healing process in closed tibia fractures was designed.

METHODS

Thirty-six Sprague-Dawley male rats were randomized into two groups. On the first day, their right tibias were fractured by three-point bending technique. The study group (n = 18) received a single injection of 10 µg/kg iloprost for 5 days, while the control group (n = 18) received saline solution in the same way. On the 7th, 14th and 28th days following the fracture, six rats were sacrificed and their right legs were harvested in each group. The progression of fracture healing was assessed for each specimen by the scores of radiography (by Lane-Sandhu) and histology (by Huo et al).

RESULTS

On the 7th day, the radiographic and histologic scores were equal. On the 14th day radiographic total score was 6 and histologic total score was 23 in the iloprost group, whereas radiographic total score was 11 and histologic total score was 33 in the control group. On the 14th day radiographic and histologic scores were significantly decreased in the iloprost group compared to the control group (P < 0.05). On the 28th day radiographic total score was 12 and histologic total score was 37 in the iloprost group, whereas radiographic total score was 15 and histologic total score was 40 in the control group. On the 28th day although there was a decrease in radiographic and histologic scores of the iloprost group acording to control group, it was not statistically significant (P > 0.05).

CONCLUSION

Iloprost delays fracture healing in early stage in rats.

What do patients really know about cardiopulmonary rehabilitation: a cross-sectional survey study

BACKGROUND

Although it is known that cardiopulmonary rehabilitation (CPR) reduces mortality and morbidity, it is not widely implemented as is in Turkey. One factor might be lack of demand since the levels of knowledge and awareness among patients who are eligible for CPR seem to be insufficient.

AIM

It is aimed to investigate the level of awareness and knowledge of CPR among patients with cardiopulmonary problems.

DESIGN

Cross-sectional survey study.

SETTING

Outpatient.

METHODS

Knowledge regarding CPR was assessed by questionnaires given to 690 patients recruited in seven university hospitals and six training and research hospitals in which either comprehensive or limited CPR services are available.

POPULATION

Patients who have cardiopulmonary problems

RESULTS

Of the patients, 34.7% were given information on CPR by healthcare staff, and 25.3% reported that their source of information was physicians. Although 49.9% of the patients knew that they needed to exercise for their cardiac/pulmonary problems, only 23.4% and 32.1% of those were aware that fast walking and climbing stairs, respectively, would not pose a risk to their cardiac/pulmonary health. The majority of the patients believed that activities of daily living, which comprise the most important component of exercise-based CPR, were harmful for their cardiopulmonary health. We found that 31.1% of the patients exercised regularly. During their stay at the hospital, certain kinds of exercises were suggested to 62.7% of the patients, and 34.7% of these patients performed various exercises. Of the patients who were given detailed information on cardiopulmonary rehabilitation, 69% stated that they would be willing to participate in a similar program.

CONCLUSION

Although nearly half of the patients stated that they needed CR, it was observed that the ratio of patients who had true knowledge of CPR was low among patients. It is imperative to furnish patients with information on CPR, both in the field of PMR and throughout Turkey, and to put more effort into running those services effectively. Furthermore, we should make an effort to increase the level of liaison between patients and physicians and other healthcare professionals who participate in the treatment of cardiac/pulmonary patients.

Salvage reirradiaton with stereotactic body radiotherapy for locally recurrent head-and-neck tumors

PURPOSE

In this study, we present our results of reirradiation of locally recurrent head-and-neck cancer with image-guided, fractionated, frameless stereotactic body radiotherapy technique.

METHODS AND MATERIALS

From July 2007 to February 2009, 46 patients were treated using the CyberKnife (Accuray, Sunnyvale, CA) at the Department of Radiation Oncology, Hacettepe University, Ankara, Turkey. All patients had recurrent, unresectable, and previously irradiated head-and-neck cancer. The most prominent site was the nasopharynx (32.6%), and the most common histopathology was epidermoid carcinoma. The planning target volume was defined as the gross tumor volume identified on magnetic resonance imaging and computed tomography. There were 22 female and 24 male patients. Median age was 53 years (range, 19-87 years). The median tumor dose with stereotactic body radiotherapy was 30 Gy (range, 18-35 Gy) in a median of five (range, one to five) fractions.

RESULTS

Of 37 patients whose response to therapy was evaluated, 10 patients (27%) had complete tumor regression, 11 (29.8%) had partial response, and 10 (27%) had stable disease. Ultimate local disease control was achieved in 31 patients (83.8%). The overall survival was 11.93 months in median (ranged, 11.4-17.4 months), and the median progression free survival was 10.5 months. One-year progression-free survival and overall survival were 41% and 46%, respectively. Grade II or greater long-term complications were observed in 6 (13.3%) patients. On follow-up, 8 (17.3%) patients had carotid blow-out syndrome, and 7 (15.2%) patients died of bleeding from carotid arteries. We discovered that this fatal syndrome occurred only in patients with tumor surrounding carotid arteries and carotid arteries receiving all prescribed dose.

CONCLUSIONS

Stereotactic body radiotherapy is an appealing treatment option for patients with recurrent head-and-neck cancer previously treated with radiation to high doses. Good local control with considerable 1-year survival is achieved with a relatively high rate of morbidity and related mortality.

[Evaluation of adult congenital heart diseases]

OBJECTIVES

Data on adult congenital heart diseases (CHD) are limited in Turkey. We evaluated the types and clinical features of CHDs in adult patients followed-up in our center.

STUDY DESIGN

This study included 200 adult patients (age >16 years) who were diagnosed as having CHD in our clinic between April 2006 and January 2009. The patients were evaluated in three groups based on the complexity of adult CHD (simple, moderate, or great) according to the most recent ACC/AHA guidelines.

RESULTS

There were 121 females (60.5%) and 79 males (39.5%). The mean age was 34.7+/-13.4 years (range 16 to 75 years) and female-to-male ratio was 1.53. The mean age was 32.8+/-14.0 years in males, and 36.0+/-12.9 in females. Nearly half of the patients were in the age groups of 20-29 years (n=46, 23%) and 30-39 years (n=49, 24.5%). According to the ACC/AHA criteria, 145 patients (72.5%) had simple CHD, 34 patients (17%) had moderate CHD, and 21 patients (10.5%) had severe-complex CHD. The mean age tended to decrease as the severity of CHD increased (35.7+/-13.7, 33.2+/-12.4, and 30.5+/-12.2 years, respectively). The most common adult CHD was atrial septal defect (n=105, 52.5%), followed by ventricular septal defect (n=34, 17%), Ebstein's anomaly (n=7, 3.5%), and Eisenmenger's syndrome (n=6, 3%). Aortic coarctation, transposition of the great vessels, patent foramen ovale, pulmonary stenosis, and aortic valve disease showed equal distribution with five patients (2.5%).

CONCLUSION

In our study, atrial and ventricular septal defects accounted for the majority of CHDs in adult patients (69.5%). Multicenter studies are required to determine the incidence of CHD among adult population in Turkey.

[A case of aortic coarctation mimicking interrupted aorta]

An asymptomatic, healthy, 19-year-old male patient was examined for aortic coarctation upon detection of a heart murmur and hypertension on routine physical examination. Transthoracic echocardiography (TTE) showed rupture of the sinus of Valsalva and bicuspid aortic valve. Findings of aortography and computed tomography (CT) angiography were compatible with an interrupted aorta. For further delineation, transesophageal echocardiography (TEE) was performed and color Doppler imaging showed passage at the site of the descending aorta, which was suggestive of interruption by other imaging methods. The patient underwent surgery for aortic coarctation. At surgery, severe aortic coarctation was noted and corrected. Although TTE is usually adequate for the diagnosis of aortic coarctation, even aortography and CT angiography were misleading in this particular case, and differentiation from interrupted aorta was only possible by TEE.

[Prosthetic mechanic valve thrombosis in pregnant women: a report of two cases]

Patients with prosthetic mechanical heart valves should always be on prophylactic anticoagulation therapy for thromboembolic events. As pregnancy represents a high-risk period for thrombosis, those with mechanical heart valves should be accorded greater importance. We presented two pregnant patients with prosthetic mechanical mitral valves, who developed mechanical valve thrombosis while on fractionated and unfractionated heparin treatment, respectively. One patient received intensive anticoagulation treatment, and the other underwent redo valve replacement. Both patients were free of symptoms.

A study of ionic composition and inorganic nutrient fluxes from rivers discharging into the Cilician Basin, Eastern Mediterranean

Present water quality of the perennial rivers; Göksu, Lamas, Efrenk, Tarsus and Seyhan discharging into the Cilician Basin have been investigated. Monthly surface samples collected from three stations downstream of the rivers during the period of October 2004-May 2005 were analyzed to determine ionic composition (Cl(-), SO(2-)(4), N(O-)(3), PO(3-)(4), N(H+)(4), Ca(2+), Mg(2+), Na(+) and K(+)), in addition to measurements of pH, electrical conductivity, alkalinity and total hardness. The results have been compared with recommended water quality standards. Excluding Göksu, Seyhan and Efrenk river mouths, values for almost all measured parameters, except N(H+)(4), were found to be lower than the desirable limits. In particular, inorganic ammonium, phosphate and nitrate concentrations for Göksu and Seyhan Deltas were 10(1) or 10(2) orders of magnitude higher than the concentrations of the rest of the samples. Temporal variation in levels, primarily observed in PO(3-)(4), suggest the impact of agricultural fertilizers intensively used around Göksu and Seyhan Rivers. According to Turkish National Water Pollution Control Regulations, all rivers were found to be unpolluted with respect to their nitrate, chloride, sulfate and sodium ion contents, while they all could be considered as slightly polluted with respect to their phosphate contents. In contrast to nitrate and phosphate, ammonium exceeded the maximum permissible limits of water quality criteria in almost all samples. Among the sampled rivers, Tarsus River was better in water quality, with the lowest electrical conductivity, alkalinity, total hardness and nutrient concentration values. Calculated values of elemental inorganic N and P fluxes suggest a substantial increase in nitrogen loads within the last decade, compared to a significant decrease in phosphorus loads of the rivers during the same period.

[Transcatheter closure of secundum atrial septal defects using the Amplatzer septal occluder in adult patients: our first clinical experiences]

OBJECTIVES

We evaluated short-term results of transcatheter closure of secundum atrial septal defects (ASD) with the Amplatzer septal occluder (ASO) in adults.

STUDY DESIGN

The study included 12 patients (6 males, 6 females; mean age 31+/-9 years; range 17 to 54 years) who underwent transcatheter ASD closure with the ASO device. Prior to the procedure, the mean pulmonary to systemic flow ratio was 1.9+/-0.3 (range 1.5 to 2.6). The mean ASD diameter measured by transesophageal echocardiography was 13.9+/-2.8 mm, the mean stretched diameter of ASD measured by balloon sizing was 15.8+/-3.4 mm, and the mean ASO device diameter was 17.3+/-4.7 mm. The patients were evaluated before and six months after the procedure by echocardiography, electrocardiography, and the New York Heart Association (NYHA) functional classification.

RESULTS

Transcatheter ASD closure was successfully performed in 11 patients (91.7%). The mean procedure time was 72 minutes. There was no residual shunt at six months after closure. No serious complications occurred during the procedure and within a mean follow-up of 11.6+/-2.3 months. Echocardiographic examination at six months showed significant decreases in right ventricular end-diastolic diameter (VEDD) (p=0.007), right/left VEDD ratio (0.003), systolic pulmonary artery pressure (p=0.017), and significant increases in left ventricular ejection fraction (p=0.014) and left VEDD (p=0.005). There were significant decreases in maximum (p=0.003) and minimum (p=0.006) P-wave durations, and P-wave dispersion (p=0.028). The NYHA functional capacity improved significantly from 1.8+/-0.8 to 1.3+/-0.5 (p=0.014).

CONCLUSION

Transcatheter closure of secundum ASD with the ASO device is a safe and effective method in adult patients, resulting in significant improvement in clinical symptoms and cardiac dimensions.

A technique for arthroscopic fasciotomy for the chronic exertional tibialis anterior compartment syndrome

Chronic exertional anterior compartment syndrome (CECS) is a condition that causes pain over the front of the shin bone that usually occurs in physically active people, especially runners. It may require sometimes an immediate fasciotomy. A longitudinal incision just over the fibula has used as surgical treatment bad cosmetic appearance. Although nowadays mini surgical incisions are preferred. The aim of this study to evaluate a simple fasciotomy technique with a minimal incision by using arthroscope. Nine legs of six patients that diagnosed as CECS has underwent fasciotomy operation with a 1 cm incision. Complaints had disappeared after operation. The mean follow-up time is 2 years. The results were good all of the patients and they never experienced exertional pain episodes. The arthroscopic assisted mini incisional fasciotomy technique has advantage such as early rehabilitation and good cosmetic appearance.