GDF11 level and its effect on prognosis in patients with acute myeloid leukemia

Acute myeloid leukemia (AML) is a hematologic malignancy characterized by the proliferation of CD34 positive self-renewing malignant hematopoietic stem cells. Previous studies have shown that the transforming growth factor beta (TGFβ) pathway plays a role in AML pathogenesis, especially by affecting the microenvironment. Growth differentiation factor 11 (GDF11) is a member of the TGFβ superfamily, involved in embryological development and known as rejuvenating factor. In this study, our aim was to determine the serum GDF11 level in patients with AML, to compare it with the control group, to determine its relationship with follistatin, vimentin, and E-cadherin levels, and to determine whether GDF11 influences AML prognosis. Serum GDF11, vimentin, follistatin, and E-cadherin levels of newly diagnosed or relapsed/refractory AML patients and age- and gender-matched control group were measured by enzyme-linked immunosorbent assay. Serum GDF11 level was higher in the patient group (263.87 ± 126.54 ng/L) compared to the control group (211.54 ± 61.47 ng/L; p = 0.035). GDF11 level did not change according to age, gender, hemoglobin level, and bone marrow blast rate. No correlation was found between GDF11 level, response rates, and survival status of the patients. A positive correlation was detected between GDF11, E-cadherin, and vimentin levels. As a conclusion, increased serum GDF11 levels in AML patients may be linked to the regeneration ability of leukemic stem cells. There is a need for studies investigating GDF11 expression in myeloblasts.

Bosutinib-induced massive pleural effusion: Cross-intolerance with all tyrosine kinase inhibitors

BACKGROUND

The discovery of tyrosine kinase inhibitors provided a breakthrough in the treatment of chronic myeloid leukemia. Nowadays, the management of tyrosine kinase inhibitor-related side effects is one of the important problems in chronic myeloid leukemia treatment. Grades 3-4 pulmonary toxicity; especially pleural effusion is mostly seen with dasatinib treatment but rarely seen with nilotinib and bosutinib. Development of cross-intolerance due to pleural effusion is not an expected situation. Pleural effusion related to tyrosine kinase inhibitors is mostly exudative in nature with abundant lymphocytes.

CASE REPORT

Massive pleural effusion developed in a 59-year-old male patient with chronic myeloid leukemia, who was being treated with bosutinib. In the past, the patient had experienced massive pleural effusion also with dasatinib and nilotinib. The evaluation for differential diagnosis of pleural effusion did not reveal any additional malignancy.

MANAGEMENT AND OUTCOME

After discontinuation of bosutinib and initiation of prednisolone, pleural effusion was totally resolved. Prednisolone was gradually discontinued and third-generation tyrosine kinase inhibitor ponatinib was started. After 12 months of follow-up, massive pleural effusion occurred again, leading to discontinuation of ponatinib.

DISCUSSION

Cross-intolerance is an important problem in the tyrosine kinase inhibitor era. The significance of this case is the development of cross-intolerance to all second-generation tyrosine kinase inhibitors and furthermore to a third-generation tyrosine kinase inhibitor. Management strategies for pleural effusion and close follow-up are important.

Clinical Characteristics and Outcome of COVID-19 in Turkish Hematological Malignancy Patients

Objective:

Patients with solid malignancies are more vulnerable to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection than the healthy population. The outcome of SARS-CoV-2 infection in highly immunosuppressed populations, such as in patients with hematological malignancies, is a point of interest. We aimed to analyze the symptoms, complications, intensive care unit admissions, and mortality rates of patients with hematological malignancies infected with SARS-CoV-2 in Turkey.

Materials and Methods:

In this multicenter study, we included 340 adult and pediatric patients diagnosed with SARS-CoV-2 from March to November 2020. Diagnosis and status of primary disease, treatment schedules for hematological malignancies, time from last treatment, life expectancy related to the hematological disease, and comorbidities were recorded, together with data regarding symptoms, treatment, and outcome of SARS-CoV-2 infection.

Results:

Forty four patients were asymptomatic at diagnosis of SARS-CoV- 2 infection. Among symptomatic patients, fever, cough, and dyspnea were observed in 62.6%, 48.8%, and 41.8%, respectively. Sixty-nine (20%) patients had mild SARS-CoV-2 disease, whereas moderate, severe, and critical disease was reported in 101 (29%), 71 (20%), and 55 (16%) patients, respectively. Of the entire cohort, 251 (73.8%) patients were hospitalized for SARS-CoV-2. Mortality related to SARS-CoV-2 infection was 26.5% in the entire cohort; this comprised 4.4% of those patients with mild disease, 12.4% of those with moderate disease, and 83% of those with severe or critical disease. Active hematological disease, lower life expectancy related to primary hematological disease, neutropenia at diagnosis of SARS-CoV-2, ICU admission, and first-line therapy used for coronavirus disease-2019 treatment were found to be related to higher mortality rates. Treatments with hydroxychloroquine alone or in combination with azithromycin were associated with a higher rate of mortality in comparison to favipiravir use.

Conclusion:

Patients with hematological malignancy infected with SARS-CoV-2 have an increased risk of severe disease and mortality.

Is CONUT score a prognostic index in patients with diffuse large cell lymphoma?

Background/aim

The aim of the study was to evaluate the effect of Controlling Nutritional Status (CONUT) score on the prognosis in patients with diffuse large B-cell lymphoma (DLBCL).

Materials and methods

The present study was a retrospective study. The CONUT score was calculated based on serum albumin, total cholesterol and lymphocyte levels. This study included a total of 266 patients, 131 (49.2%) were female and 135 (50.8%) were male. The median follow-up period was 51 months (range: 1–190).

Results

The median age was 64 years. The cut off CONUT was 1.5. There was a significant difference between patients with high (≥ 2) or low (< 2) CONUT scores in terms of overall survival (OS) and progression-free survival (PFS). The 5-year OS and PFS in patients with high CONUT score was 52.1% and 49.7%. The 5-year OS and PFS in patients with low CONUT score was 79.8% and 75.6% (p < 0.001). In the multivariate analysis for OS, age ≥ 65 years (HR = 1.80, p = 0.028), Eastern Cooperative Oncology Group (ECOG) > 1 (HR = 2.04, p = 0.006), stage IIIA–IVB disease (HR = 2.75, p = 0.001) and the CONUT score (HR = 1.15, p = 0.003) were found statistically significant. In the multivariate analysis for PFS, age ≥ 65 years (HR = 2.02, p = 0.007), stage IIIA–IVB disease (HR = 2.42, p = 0.002) and the CONUT score (HR = 1.19, p = 0.001) were found to be significant parameters.

Conclusion

High CONUT score reduces OS and PFS in DLBCL. CONUT score is an independent, strong prognostic index in patients with DLBCL.

Non-Hodgkin's Lymphomas of the Tonsil: A Retrospective Analysis of Twenty-Eight Patients with Primary Tonsillary Lymphoma

Aims

To analyze the clinical and therapeutic aspects of patients with primary tonsillary non-Hodgkin's lymphoma.

Methods

Twenty-eight patients with primary tonsillary non-Hodgkin's lymphoma who had been followed in the Hacettepe Oncology Institute between 1974 and 1992 were retrospectively analyzed. Fifteen patients were male, 13 were female. Median age was 55 years.

Results

Constitutional symptoms were present in 10 patients (35.7%). Stages according to the Ann Arbor classification were I and II in 12 and 16 patients, respectively. According to the Rappaport classification, poorly differentiated lymphocytic was the most common pathologic subgroup (42.9%). Grades according to the Working Formulation were low, intermediate and high in 3, 22 and 3 patients, respectively. Twenty-two patients had received chemotherapy. Cyclophosphamide, vincristine and prednisone (CVP), and cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) were the regimens most commonly employed. Eighteen patients received radiotherapy to Waldeyer's ring and neck. Eight patients achieved remission with chemotherapy plus radiotherapy, 7 patients with chemotherapy alone, and 5 patients with radiotherapy alone. In addition to the 20 patients who achieved complete remission, 3 patients achieved partial remission; the overall response rate was 82.1%. The response rates and survival attained with the combined modality, chemotherapy, or radiotherapy alone were not statistically different (P > 0.05). The median follow-up was 14 months. Overall and disease-free survival at 5 years were 62.6% and 77.6%, respectively. Pathologic grade was the most important prognostic factor influencing overall survival in the Cox multivariate model.

Conclusions

Poorly differentiated lymphocytic lymphomas were the most common pathologic subtype, and pathologic grade was the most important prognostic factor to influence survival in the present study. Although combined modality treatment did not appear to be superior to chemotherapy or radiotherapy alone, a larger number of patients is needed to draw definite conclusions.

Ifosfamide and Etoposide in Previously Treated Patients with Advanced Breast Cancer

Aims and background

Ifosfamide is an active alkylating agent in the treatment of breast cancer, as a first-line therapy and in advanced disease. Since the combination of etoposide with an alkylating agent produces a synergistic and tolerable activity in various malignancies, in the present study, ifosfamide and etoposide were administered to patients with advanced breast cancer to evaluate the response characteristics and the toxicity profile.

Study design

The combination of ifosfamide, mesna and etoposide was prospectively administered to 41 previously treated patients with stage IV breast carcinoma. The treatment schedule consisted of ifosfamide, 1500 mg/m2, infused over 24 hrs with 1500 mg/m2 mesna on days 1 to 5 and 120 mg/m2 etoposide, infused over 1 hr on days 1 to 3, to be repeated every 4th week.

Results

After a median follow-up of 10 months, an objective response rate of 23% (overall 2.5% complete remission and 20.5% partial remission) and a median response duration of 5.3 months were obtained in 39 assessable patients. The non-responder group consisted of 28.3% stable disease and 48.7% progressive disease. The prior status of chemotherapy was the only significant prognostic factor with an impact on the response rate. The overall toxicity was generally mild, with grade 3 myelotoxicity encountered in 25.7% of patients.

Conclusions

The tolerable side effect profile of the ifosfamide and etoposide combination might be advantageous as regards the quality of life. To improve the rate and/or the duration of response and to clarify the precise role of the ifosfamide-etoposide combination in previously treated advanced breast cancer, further trials are warranted.

Combination of Docetaxel and Doxorubicin as First-Line Chemotherapy in Metastatic Breast Cancer

Docetaxel (Taxotere®) and doxorubicin have previously demonstrated a significant antitumor activity in patients with metastatic breast cancer. Furthermore, a lack of cross resistance and overlapping toxicities between the two agents have been reported. In a prospective study, docetaxel (80 mg/m2, 1-hr iv infusion) and doxorubicin (60 mg/m2, 1-hr iv infusion) were administered as first-line chemotherapy in metastatic breast cancer patients to evaluate the clinical efficacy and toxicity of the combination. Forty-three patients were enrolled in the study. The median age was 47 years (range, 30-69). The docetaxel-doxorubicin combination was applied with 3-week intervals until progression. Complete response was achieved in 9 (21.4%) of 42 assessable patients and partial response in 24 (57.2%) patients, for an overall response rate of 78.6%. Median response duration was 8 months (3-18 months). Nausea and vomiting (76%), alopecia (64%), neutropenia (35.7%) and mucositis (33%) were the major side effects of the combination. There was one case of cardiac toxicity. In conclusion, the docetaxel-doxorubicin protocol can be considered as an active regimen for the treatment of patients with metastatic breast cancer with acceptable toxicity and a fairly high response rate.

Comparison of Rai and Binet Classifications in Chronic Lymphocytic Leukemia

Staging systems are essential for understanding disease, in predicting the outcome, and therapeutic decision making in any tumor as well as chronic lymphocytic leukemia (CLL). In this study, we compared the clinical correlation of the Rai and Binet classification systems in 133 CLL patients. The distribution of 133 patients according to the Rai system was as follows, stage 0:17, I:13, II:45, III:30, IV:28, and in the Binet system stage A:35, B:40, C:58 patients. Median survival of patients according to the Rai staging system was >67.0, >91.0, 63.8, 20.9 and 9.8 months, and >91.0, 63.4, 16.0 months according to Binet, respectively. Although no difference was found between Rai stages 0, I, II (p > 0.05) in terms of median survival, the difference between these stages and stages III and IV was statistically significant (p < 0.05). In the Binet staging system statistically significant survival difference was found between all stages (p < 0.05). We concluded that although both systems are comparable in terms of staging and predicting the outcome of patients with CLL, the Rai staging system appears to have an advantage over the Binet system by defining a subset of patients with excellent prognosis (stage 0) which is included within stage A of the latter.

The relationship of T helper-2 pathway components interleukin-4, interleukin-10, immunoglobulin e, and eosinophils with prognostic markers in non-hodgkin lymphoma: a case-control study

Objective: Increased risk for non-Hodgkin lymphoma (NHL) is associated with infections and environmental agents. We hypothesized that these factors chronically trigger the T helper-2 (Th2) pathway and result in lymphoma. We investigated the role of the Th2 pathway by exploring the relationships between components of the Th2 pathway, interleukin (IL)-10, IL-4, immunoglobulin E (IgE), and eosinophils, and prognostic markers of NHL.

Materials and Methods: Thirty-one NHL patients and 27 healthy controls were enrolled. IL-10, IL-4, IgE, and eosinophils were measured. IL-4 and IL-10 were analyzed with the enzyme amplified sensitivity immunoassay method.

Results: High IL-10 levels were correlated with several poor prognostic features, short early survival, and lymphopenia. There was a positive correlation between albumin and IL-4 levels and a negative correlation between IL-10 and albumin. There was no relationship related with eosinophils and IgE. We found remnant increased IL-4, which could be a clue for the triggering of the Th2 pathway in the background.

Conclusion: There is a need for differently designed studies to detect the place of the Th2 pathway in NHL.

Predicting survival for multiple myeloma patients using baseline neutrophil/lymphocyte ratio

The neutrophil/lymphocyte ratio (NLR) at diagnosis has been shown to be a prognostic factor for survival in solid tumors. The NLR at diagnosis as a prognostic factor for multiple myeloma (MM) has not been studied. Therefore, the focus of the study was the correlation of NLR with the proven prognostic parameters in patients with MM. A total of 151 MM patients who fulfilled the International Myeloma Working Group (IMWG) criteria were enrolled in the study by a retrospective review of the patients' records. One hundred fifty-one age- and gender-matched healthy controls were also included in the study. NLR was calculated using data obtained from the complete blood count (CBC). NLR was significantly higher in MM patients than the control group (2.79 ± 1.82 vs. 1.9 ± 0.61, respectively; p < 0.0001). The median follow-up on living patients in this study was 41 months. NLR at the diagnosis was found to be an independent predictor for overall survival (OS) and event-free survival (EFS) by univariate and multivariate analysis. Patients with a NLR <2 at diagnosis experienced superior OS compared with patients with a NLR ≥2 (5-year OS rates were 87.5 and 42.4 %, respectively; p < 0.0001). In a similar fashion, superior EFS was observed in patients with a NLR <2 at the diagnosis compared with patients with a NLR ≥2 (5-year EFS rates were 88.4 and 41.8 %, respectively, p < 0.0001). This study suggests that NLR at the diagnosis is a simple, inexpensive, possible prognostic factor to assess clinical outcomes in MM patients.

The effects of high molecular weight hyaluronic acid (Hylan G-F 20) on experimentally induced temporomandibular joint osteoartrosis: part II

The aim of this study was to determine the efficacy of Hylan G-F 20 on experimentally induced osteoarthritic changes in rabbit temporomandibular joint (TMJ). A 3mg/ml concentration of sodium mono iodoacetate (MIA) had been injected into both joints of 24 rabbits to create osteoartrosis. The study group was injected with Hylan G-F 20 in one joint and saline in the contralateral joint as a control (once a week for 3 weeks). Histological changes in articular cartilage, osteochondral junction, chondrocyte appearance and subchondral bone were determined at 4, 6, and 8 weeks. Regarding cartilage, there was a statistically significant difference between the two groups at 4 weeks. Degenerative bony changes to subchondral bone were significantly higher in the controls. No statistical difference was found in the study group at 6 weeks. A positive correlation was found between osteochondral junction and subchondral bone in the study group at 8 weeks. The changes in chondrocyte appearance were significantly decreased in the study group at all follow-up times. Intra-articular injection of Hylan G-F 20 decreased cartilage changes in early stage TMJ osteoartrosis and clustering of chondrocytes showed the chondroprotective effects of Hylan G-F 20 caused by hypertrophic responses.

Sodium iodoacetate induced osteoarthrosis model in rabbit temporomandibular joint: CT and histological study (part I)

Studies to elucidate the pathophysiology of osteoarthrosis have been hampered by the lack of a rapid, reproducible animal model that mimics the histopathology and symptoms associated with the disease. The aim of this study is to evaluate the radiological, histological and histomorphometrical findings of four different concentrations of sodium iodoacetate (MIA) to create osteoarthrosis by using an arthrocentesis technique on rabbit temporomandibular joint (TMJ). 12 New Zealand white male rabbits received an injection of MIA (50 μl dose of 1.5, 2, 2.5, 3mg/ml concentrations) to a single joint of each group by arthrocentesis. Computed tomography (CT) images were obtained pre- and post-injections at 2, 4 and 6 weeks. Early osteoarthritic changes in the rabbit TMJ were found histologically at 4 weeks and with a 3mg/ml concentration of MIA. The mean subchondral bone volume depended on the concentration of MIA and was 62±2.6%, 63±4.1%, 42±3.6% and 38±3.8%, respectively. A minor abnormality was found on CT in six joints at the 4-week follow up. MIA injection and arthrocentesis offer a rapid and minimally invasive method of reproducing histologically osteoarthrotic lesions in the rabbit TMJ.

Levels of depression, anxiety and behavioural problems and frequency of psychiatric disorders in children with chronic idiopathic urticaria

BACKGROUND

Several studies reported that adults with chronic idiopathic urticaria (CIU) frequently exhibit psychiatric comorbidity, most commonly depression and anxiety disorders. However the literature about children is limited.

OBJECTIVES

To investigate the frequency of psychiatric disorders and to determine the levels of depression, anxiety and behavioural problems in a group of children with CIU.

METHODS

The study included 27 children with CIU and 27 age- and sex-matched healthy subjects. Psychiatric assessment was done by using the Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version (K-SADS-PL). The State-Trait Anxiety Inventory for Children (STAI-C), Children's Depression Inventory (CDI) and Child Behavior Checklist (CBCL) were used to examine the levels of depression, anxiety and behavioural behaviours, respectively.

RESULTS

The study group had more frequent psychiatric diagnoses than the control group (70% vs. 30%) and the most common psychiatric disorders were social anxiety disorder, separation anxiety disorder and specific phobia. Depression, trait anxiety, internalizing problems, somatic complaints and anxiety/depressed scores were significantly higher in children with CIU. No correlation was found between the severity and duration of illness and psychological functioning.

CONCLUSION

This study showed that children with CIU had high psychiatric morbidity. The results suggest that the psychological status of children with CIU should be screened by clinicians and that an interdisciplinary approach combining dermatological and psychiatric evaluations is necessary for the management of CIU.

Evaluation of the Standardized MDI-Spacer Checklist on Pediatric Asthma Management

A metered-dose inhaler (MDI) with spacer allows for the delivery of maintenance therapy for childhood asthma. In this study, the authors aimed to assess the possible effects of inhalation skills in the use of an MDI with a small-volume spacer on asthma outcome in asthmatic children. The study group consisted of 66 asthmatic children between 7 and 11 years of age (mean ± SD, 8.2 ± 1.7 years) and a control group that consisted of 54 asthmatic children between 7 and 12 years of age (mean ± SD, 7.7 ± 0.9 years). All subjects were prescribed fluticasone propionate 125 µg 1 puff by an MDI with a small-volume Aerochamber spacer twice daily for 12 weeks. Inhalation skill scoring was made using the standardized MDI spacer checklist. Spirometric measurements and Health-related qualify-of-life measures were performed before and at the end of the 12-week treatment. There was no significant correlation between asthma outcome measures and MDI spacer checklist scores in children with asthma ( r = 1.76, P > .05). Moreover, the MDI spacer checklist scores were not statistically different between the study and control groups ( P > .05). This finding suggests that the standardized MDI spacer checklist scale scores have no significant impact on asthma outcome in children with asthma.

Delayed type allergic reaction following the use of nonlatex rubber dam during endodontic treatment

AIM

To describe the development of a delayed type allergic reaction 24 h following the use of nonlatex rubber dam during endodontic treatment. The symptoms were alleviated with adequate medication; however, the patient rejected any further analysis.

SUMMARY

In recent years, allergic reactions because of latex rubber dam and gloves have received more attention. Nonlatex products are advocated in clinical use in cases where the patient presents an allergic background. Although rare, adverse reactions may be encountered even with these products. In this article, a very rare case is presented in which a patient developed signs of allergy 24 h after the utilization of nonlatex rubber dam and gloves during endodontic treatment. Signs including visible redness on the mucosa, submucosal oedema and desquamation in the vestibular mucosa were observed. With proper medication, the signs and symptoms were alleviated. Although the patient was referred to an allergy specialist for patch testing, she did not accept any further analysis.

KEY LEARNING POINTS

This case emphasizes the necessity of precautions during the management of latex-allergic patients in clinical practice. The unusual response encountered in this patient does not undermine the usefulness of nonlatex rubber dam and gloves in sensitive individuals.

The plateled-derived growth factor level (PDGF) in Hodgkin's disease and non-Hodgkin's lymphoma and its relationship disease activation

The research reported in this paper was designed to study the role of plateled-derived growth factor (PDGF) in Hodgkin's disease (HD) and non-Hodgkin's lymphomas (NHL). The PDGF levels in 9 patients with HD and 12 NHL and in a control group consisting of 20 people, was measured by ELISA method. The PDGF values in the disease group of 19 patients were raised. The values of PDGF in the control group were 28.977+/-9 pg/ml, but were measured at 147.083+/-54 pg/ml in HD group and 131.487+/-56 pg/ml in NHL group (p < 0.01). The observation of a 5-fold increase in PDGF values in the disease group when compared to the control group suggests that PDGF could itself be considered as a possible factor in the pathogenesis of HD and NHL. In order to support this, there is a need to design additional studies monitoring PDGF in larger number of patients at various stages of the disease.

Temporomandibular joint internal derangement: relationship between joint pain and MR grading of effusion and total protein concentration in the joint fluid

OBJECTIVES

The objective of this study was to determine whether there is any association between the protein concentration in the synovial fluid and (i) the amount of articular hydrops, as graded in magnetic resonance (MR) images, and (ii) joint pain in temporomandibular joints (TMJs) with and without displacement of the disc.

PATIENTS AND METHODS

This study involved 16 joints in 16 patients referred to our clinic with the complaint of pain and limited mouth opening. The control group consisted of 15 joints in 15 patients with unilaterally normal disc and condyle relationship and no pain while the opposite side had a non-painful joint with disc displacement without reduction (DDwoR). The subjects and controls were different individuals and only a single joint was used for each. Pain and dysfunction were evaluated by visual analogue scale. Bilateral proton density and T2 weighted images of the TMJs of the 31 subjects were analysed for fluid and condyle bony changes as well as disc position. The amount of fluid, identified as an area of high signal intensity in the region of the upper and lower joint spaces, was characterized as none, minimal, moderate or marked. Arthrocentesis was performed both for synovial fluid analysis of total protein concentration and the treatment of the joints with DDwoR. Total protein concentration was measured by using protein dye binding on spectrophotometry.

RESULTS

All patients experienced a significant (P<0.01) increase in maximal mouth opening immediately post-arthrocentesis. In the study group, the disc was displaced most frequently in an anteriormedial direction (75%) and deformation of disc form was seen in 13 joints. Condylar bony changes were seen in 27% of joints in the control group and in 81% of joints in the study group. A statistically significant association was found between joints with disc displacement, disc form and condylar bony changes (P<0.05). In the control group, only one joint, which had an osteophyte, showed joint effusion (JE) with moderate fluid. In the study group, only four joints had no fluid (25%). JE was found in 10 (63%) joints with disc displacement on anteromedial direction, in 10 (63%) joints with disc deformation and in 10 (63%) joints with osteophytes and erosion. Mean total protein concentration was 16.87+/-7.9 (range 7.4-34.1 mg dl-1) in control joints, 55.08+/-35.16 (range 21.5-153.9 mg dl-1) in study joints. There were significant differences in the mean total protein concentration between the control and study groups (P<0.01). Significant positive correlation was found between the total protein concentration and JE (r=0.65, P<0.01). No significant correlation was found between the level of pain and dysfunction and JE and total protein concentration in either control or study groups (P>0.05).

CONCLUSION

Pain in the TMJ was not related to MR findings of effusion in internal derangement and synovial fluid aspirate findings of total protein concentration. However, total protein concentration was related to the amount of JE in DDwoR joints and painful joints were more likely to demonstrate the JE.

Incidence of the type and calcification patterns in patients with elongated styloid process

We investigated the incidence of elongated styloid process (Eagle's syndrome) using panoramic radiographs taken of 860 patients referred to our clinic. Any styloid process identified was classified according to its length, type and the pattern of calcification. Fifty-nine elongated styloid processes were identified in 32 patients (3.7%), most being bilateral; 24 patients were female and eight were male (female/male ratio: 3:1). The mean age of these patients was 43 +/- 14 years (range: 18 - 78 years). Type I (elongated) was the most frequent type on both sides (42/59); and the most frequent patterns of calcification were partially calcified on the left side (18/59) and completely calcified on the right side (16/59). Only two patients were symptomatic. A corrected differential diagnosis is important to distinguish elongated styloid process from other pathologies with partially overlapping symptoms. We would recommend that clinicians consider the possibility of Eagle's syndrome when both the clinical and radiographic evidence support this diagnosis.

Temporomandibular internal derangement: correlation of MRI findings with clinical symptoms of pain and joint sounds in patients with bruxing behaviour

OBJECTIVES

The aim of this study was to correlate magnetic resonance imaging (MRI) findings of effusion, disc displacement, condylar bony changes and disc form with clinical findings of pain and sounds in patients with bruxing and non-bruxing behaviour.

METHODS

Disc displacement was confirmed by MRI in 102 joints from 64 patients (total of 128 joints) with bruxing behaviour who were referred for clinically diagnosed internal derangements of the temporomandibular joint (TMJ). Sixty joints with internal derangement from 30 patients without bruxing behaviour served as a control group. The clinical inclusion criteria were pain in the pre-auricular area and muscles of mastication, limitation or deviation in mandibular range of motion, and TMJ sounds. Signs of bruxism were diagnosed clinically and were obtained from the patient's history given on their first visit. Pain was evaluated using a visual analogue scale.

RESULTS

Of the 102 joints in the study group with disc displacement, 53 (52%) showed disc displacement with reduction and 49 (48%) showed disc displacement without reduction. In the control group, 16 joints were classified as normal. Of the remaining 44 joints, 27 (61%) had disc displacement with reduction and 17 (39%) had unilateral disc displacement without reduction. Condylar bony changes were seen in 55% of the reducing joints in the study group and in 38% of the reducing joints in the control group, compared with 86% of the non-reducing joints in the study group and 24% of the non-reducing joints in the control group. There was a strong correlation between age and degenerative change in the study group. In the reducing joints, there was a significant difference in the prevalence of condylar bony changes between the study and control groups (P<0.01). In non-reducing joints, 30% of painful joints in the study group and 59% of those in the control group showed a strong signal in the joint space on T(2) weighted imaging. Statistically significant differences between the study and control groups were also found for disc form and the prevalence of effusion and disc displacement. Joint sounds were important in unilaterally affected joints in the study group. A statistically significant correlation was found between joint sounds and reducing joints (P<0.05).

CONCLUSION

It was demonstrated that a higher prevalence of condylar bony changes occurred in reducing joints in patients with bruxing behaviour.

Lamivudine therapy in acute leukemia patients who are hepatitis B surface antigen carriers

BACKGROUND

Reactivation of hepatitis B in patients receiving chemotherapy for acute leukemia may give rise to a variety of clinical patterns including hepatitis, asymtomatic hepatic dysfunction, massive hepatic necrosis and fatal hepatic failure. Lamivudine is a nucleoside analogue which can directly suppress Hepatitis B virus (HBV) replication. We reviewed our combined experience to evaluate the role of lamivudine as prophylaxis in acute leukemia patients who were HBsAg carriers treated with chemotherapy between July 2000 and October 2002 at the Numune Education and Research Hospitals (Ankara, Turkey) retrospectively.

METHODS

We investigated 75 acute leukemia patients who received chemotherapy. Thirteen (17.3%) of 75 acute leukemia patients were HbsAg positive and of 7 (53.3%) were HBV DNA positive. Two patients (patients 5 and 6) had a chemotherapy regimen that included corticosteroids and were HBsAg and HBV DNA negative but anti HBc total positive. HBsAg positive patients with or without HBV DNA positivity were treated with a dose of 100 mg/day lamivudine commencing when chemotherapy was initiated. Lamivudine started at the beginning of chemotherapy and was maintained for 6 months following the cessation of chemotherapy. During lamivudine treatment, Aspartate aminotransferase (AST), Alanine aminotransferase (ALT), Gama glutamile transpeptidase (GGT), Alkaline phosphatase (ALP) were followed.

RESULTS

Of the 8 patients who presented with hepatic dysfunction during the first chemotherapy cycle, 4 improved during the second course. After completing chemotherapy, the levels of hepatic enzymes were in the normal range in all but one patient. With lamivudune prophylaxis, HBV DNA positivity did not develop in any of the HBV DNA negative patients. The two patients who received corticosteroids with their first chemotherapy cycle became positive for HBsAg and HBV DNA and were given Lamivudine when the seroconversion was established. Median follow up from the diagnosis of leukemia was 14.5 months. Survival rate at the end of follow up was 5 (38%) for the 13 patients.

CONCLUSIONS

As this infection is endemic in our country and the exposure to blood products is high in these patients, HBV infection is more common. Prophylaxis with daily administration of lamivudine to HBsAg carriers who are candidates for chemotherapy seems to be effective and may prevent chemotherapy induced HBV reactivation and hepatic failure.

Non-small-cell lung cancer with nonfamilial diffuse palmoplantar keratoderma

Palmoplantar keratoderma (PPK) is a congenital or acquired disorder characterized by the abnormal thickening of the skin of the palms and soles. The thickening can present as a diffuse, focal or punctate pattern. It has been reported to be associated with internal malignancies such as lung and esophageal carcinomas. When PPK is associated with malignancy the prognosis is poor. Patients with these conditions should undergo frequent medical examinations, which should include chest radiography and cytologic examination of the sputum. The present patient is a 47-year-old-man with PPK who suffered from metastatic non-small-cell carcinoma of the lung.

Inflammatory breast metastases of ovarian cancer: a case report

BACKGROUND

Metastasis to the breast from extramammary malignancies is rare.

CASE

A 35-year-old woman presented with bilaterally inflammatory breast involvement, 2 years after the diagnosis of stage IIIC epithelial ovarian cancer. Neoplastic tissue was immunohistochemically positive using antibodies against OC125 and negative for gross cystic disease fluid protein-15 (BRST-2) and estrogen receptor in biopsy material in the breast. Combination chemotherapy consisting of paclitaxel, cisplatin, and anthracycline was started. She died 18 months after the breast metastasis.

CONCLUSION

Ovarian carcinoma usually presents with signs and symptoms related to the tumor burden within the abdominal cavity. The finding of isolated, distant metastases such as breast involvement without intraabdominal disease is extremely rare. Determining the origin of the primary tumor is important in directing the actual therapy.

Infantile lobar emphysema and tracheal bronchus in a patient with congenital heart disease

A 7-month-old girl was admitted with severe respiratory distress. Chest roentgenogram showed hyperinflation of the right middle lobe and mediastinal shift. Bronchogram showed tracheal lobe displaced superiorly by the hyperinflated right middle lobe. Echocardiography showed left-to-right shunt at the ventricular level. The patient responded well after surgical correction of cardiac defect. Four years after the operation, computed tomography examinations showed no evidence of emphysema.

Effect of blood pressure reduction on abnormal left atrial appendage function in untreated systemic hypertensive patients with sinus rhythm

To investigate whether reduction in blood pressure has a beneficial effect on left atrial appendage (LAA) function, the authors evaluated 24 untreated systemic hypertensive patients with normal left ventricular systolic function in sinus rhythm at baseline and at 3 months after initiation of antihypertensive therapy. They performed transthoracic and transesophageal echocardiographic examinations in hypertensive patients before and after treatment of hypertension. Three of the 24 patients had blood pressure that failed to respond to the regimen of antihypertensive therapy and were removed from the analysis. Of the remaining 21 patients, mean systolic and diastolic blood pressures at baseline were 170 +/- 18 and 104 +/- 6 mm Hg, respectively, and fell significantly at 3 months to 141 +/- 10 and 90 +/- 5 mm Hg, respectively, (p<0.001) after initiation of antihypertensive therapy. There was no significant change in heart rate with treatment (baseline 81 +/- 8 and at 3 months 84 +/- 9 beats/min). There was no significant change in left ventricular end-diastolic diameter, left ventricular ejection fraction, left ventricular wall thickness, or left atrial diameter from baseline (49 +/- 4 mm, 58 +/- 5%, 12 +/- 1 mm, and 41 +/- 4 mm, respectively) at 3 months (48 +/- 5 mm, 59 +/- 4%, 12 +/- 1 mm, and 40 +/- 3 mm). The treatment caused a significant reduction in maximal LAA areas (6.3 +/- 1.3 cm2 at baseline, 4.6 +/- 0.7 cm2 at 3 months, p<0.001), with a concomitant increase in LAA emptying velocity (44 +/- 7 cm/sec at baseline, 60 +/- 9 cm/sec at 3 months, p<0.001). In conclusion, these findings suggest that reduction in blood pressure with antihypertensive therapy could improve LAA function in hypertensive patients with normal left ventricular systolic function in sinus rhythm.

Late systolic wave on brachial artery blood flow velocity pattern in patients with coronary artery disease and its relation to vascular stiffness

Duplex-Doppler study typically exhibits triphasic brachial artery blood flow velocity pattern in subjects classified as normal without clinically evident atherosclerotic complications, heart disease, hypertension, or diabetes mellitus. In this study, the authors described the late systolic wave on the brachial artery blood flow velocity pattern in patients with coronary artery disease and investigated the relation between late systolic wave and vascular stiffness. Blood flow profile and velocity of the brachial artery were determined noninvasively by ultrasound pulsed-Doppler technique under the guidance of a B-mode ultrasound image in 96 patients with coronary artery disease (CAD). The control group consisted of 23 healthy subjects with no or maximally 2 risk factors (only among age, cigarette smoking, obesity, and gender) for vascular disease. None of the patients and controls had clinical evidence of arterial disorders at upper extremities. In 32 patients (33%) with CAD, a late systolic wave was observed in the brachial artery Doppler study. On the other hand, no late systolic wave was observed in the healthy subjects. In addition, multivessel disease, hypertension, advanced age, diabetes, and smoking were significantly more frequent in patients with the late systolic wave. In conclusion, peripheral arterial abnormalities induced by vascular stiffness may produce alterations in regional wave reflections, and the normal triphasic pattern of the brachial artery blood flow may change by the appearance of the late systolic wave.

Myasthenia gravis and lymphoblastic lymphoma involving the thymus: a rare association

Myasthenia gravis (MG) is an autoimmune neuromuscular junction disease. An association between thymic epithelial neoplasms and MG is well known. However, it is rarely associated with hematologic malignancies. In particular, very few cases of lymphoblastic lymphoma involving the thymus and MG have been reported. Here we report a case T-cell lymphoblastic lymphoma involving the thymus who developed MG after the initial diagnosis. The patient initially presented with a mediastinal mass which was diagnosed as lymphoblastic lymphoma. MG was diagnosed during leukemic relapse in this patient and was based on clinical presentation and neurophysiologic studies including single fiber electromyography (EMG) and repetitive nerve stimulation tests. In contrast to the other cases with such an association, the myasthenic symptoms presented nine months after the diagnosis of lymphoma by thymectomy. The patient had a highly aggressive clinical course and was resistant to various chemotherapy regimens.

Cardiac troponin I levels in patients with left heart failure and cor pulmonale

Cardiac troponin levels are regarded as the most specific of currently available biochemical markers of myocardial damage. Elevated levels of troponin have been previously reported in patients with left heart failure, reflecting small areas of undetected myocardial cell death. The aim of this study was to compare the levels of the cardiac troponin I (cTnI) in patients with left- and right-sided heart failure. Cardiac troponin I levels were studied with immunochemical methods in patients with right heart failure (n = 17) resulting from chronic obstructive pulmonary disease, ischemic left heart failure (n = 23), and nonischemic left heart failure (n = 18) who were admitted to departments of cardiology and chest diseases. Also, cTnI levels were measured in 32 healthy subjects as control group. Protein markers of myocardial injury (cTnI and myoglobin) in patients with left and right heart failure were collected approximately 12 to 36 hours after onset of obvious symptoms. Serum creatine kinase MB band was determined on admission and thereafter twice a day during the first 3 days. Elevated levels of serum cTnI were found in patients with nonischemic (0.83 +/- 0.6 ng/mL, p<0.01) and ischemic left heart failure (0.9 +/- 0.5 ng/mL, p<0.01) when compared to healthy subjects, whereas serum cTnI levels in patients with right heart failure due to chronic obstructive pulmonary disease were not significantly different from those of control subjects (0.22 +/- 0.1 vs 0.16 +/- 0.1 ng/mL, p>0.05). In addition, creatine kinase MB band and myoglobin levels were not significantly different between patient and healthy groups. The mean of cTnI levels in ischemic and even nonischemic left heart failure were increased compared to the mean of values in healthy individuals but without significant creatine kinase MB band and myoglobin elevations. But cTnI levels were not increased in patients with right heart failure due to chronic obstructive pulmonary disease. These data indicate that the cTnI levels are abnormal in left heart failure but not in cor pulmonale.

Comparison of the acute effects of salbutamol and terbutaline on heart rate variability in adult asthmatic patients

This study investigated the effects of beta2-adrenergic agonist therapy on heart rate variability (HRV) in adult asthmatic patients by using frequency domain measures of HRV. A randomized crossover design was used. Twenty adult patients with asthma were studied. All patients showed a mild-to-moderate decrease in baseline forced expiratory volume in one second. Any diseases that might have influenced the autonomic function were excluded. All patients had a complete physical examination and medical history that revealed no cardiovascular disease or medication. The study used 200 microg inhaled salbutamol and 500 microg inhaled terbutaline. HRV analysis was performed for each 5-min segment, 5 min before inhalation of the study drug and 5, 10, 15, 20, 25 and 30 min after inhalation. Total power (TP: <0.40 Hz), high-frequency power (HF: 0.15-0.40 Hz), low-frequency power (LF: 0.04-0.15 Hz) and LF/HF ratio were calculated. The LF and LF/HF ratio increased and TP decreased at 5, 10, 15 and 20 min after the salbutamol and the terbutaline inhalation, HF did not change significantly after the salbutamol and terbutaline inhalation. Acute salbutamol and terbutaline inhalation produce similar effects on heart rate variability and increase sympathetic modulation in the cardiac autonomic activity.

Polyserositis as a rare component of polyglandular autoimmune syndrome type II

Polyglandular autoimmune (PGA) syndromes (types I and II) may affect various endocrine and non-endocrine organs in the body. In the commoner PGA type II, primary adrenal insufficiency, autoimmune thyroid disease and type I diabetes mellitus are the most frequent manifestations. Serositis with pericardial or pleural involvement is not a well known component of the disease. Here, we report a 21-year-old man who first presented with a pleuropericardial effusion and Graves' disease, and who then developed type I diabetes mellitus.

The effects of volatile anesthetics on the Q-Tc interval

OBJECTIVE

To examine the effects of halothane, isoflurane, and sevoflurane on Q-Tc interval (corrected for heart rate) during inhalation induction of anesthesia.

DESIGN

Prospective, double-blind, randomized study.

SETTING

Departments of Cardiology and Anesthesiology in a university hospital.

PARTICIPANTS

Patients undergoing noncardiac surgery.

INTERVENTIONS

A total of 65 American Society of Anesthesiologists physical status I-II patients, aged 16 to 50 years, undergoing general anesthesia, were randomly allocated to receive halothane, isoflurane, or sevoflurane.

MEASUREMENTS AND MAIN RESULTS

The time to reach the predetermined end-tidal concentrations of 3 minimum alveolar concentration was 6 to 10 minutes. When compared with preinduction values, heart rate decreased after halothane (p < 0.01) and sevoflurane (p < 0.05) administration; in contrast, heart rate increased after induction of anesthesia with isoflurane (p < 0.05). The mean QRS intervals were not significantly changed after halothane, isoflurane, or sevoflurane. The Q-Tc interval was increased with isoflurane compared with baseline (465 +/- 23 v 441 +/- 18 msec, p < 0.01), not changed with sevoflurane (441 +/- 17 v 434 +/- 19 ms, p > 0.05), and shortened with halothane (426 +/- 23 v 445 +/- 21 msec, p < 0.01).

CONCLUSION

Sevoflurane or halothane may be preferred to isoflurane in patients with conditions that are known to induce a prolonged Q-Tc interval. The effects of Q-Tc interval changes resulting from different anesthetic agents on morbidity and the incidence of arrhythmias during anesthesia warrant further investigation.

Wolff-Parkinson-White syndrome mimicking acute anterior myocardial infarction in a young male patient--a case report

A young male with Wolff-Parkinson-White syndrome whose electrocardiographic pattern was suggestive of acute anterior myocardial infarction is described. A 21-year-old male with a history of ventricular fibrillation after being successfully resuscitated was admitted to the coronary care unit. His electrocardiogram showed ST elevation in the precordial leads (V1-V6). This condition was erroneously interpreted as an acute myocardial infarction. At the fourth day, while ST elevations returned to baseline, short PR interval and delta waves were observed on the ECG. Myocardial infarction was excluded by biochemical tests, echocardiography, and coronary angiography. Electrophysiologic study confirmed Wolff-Parkinson-White syndrome with two accessory pathways.

[The effects of sildenafil citrate on the isolated rat aorta: comparative in vitro study]

OBJECTIVE

Sildenafil, an inhibitor of cGMP-specific phosphodiesterase 5 (PDE5), is currently being used as oral therapy for penile erectile dysfunction. The aim of this study was to investigate the relaxing effect of sildenafil on vascular tissue and compare it with the known vasodilatator agents, sodium nitroprusside and acetylcholine.

METHOD

Rat thoracic aorta samples were cut into rings, mounted on steel hooks, and immersed in aerated Krebs solution maintained at 37 degree C. Isometric responses were recorded by strain gauge transducers connected to a polygraph. Graded relaxations were induced using increasing concentrations of acetylcholine sodium nitroprusside and sildenafil.

RESULTS

The agents all does-dependently relaxed rat aorta strips. The relaxing potential of sildenafil was found to be similar to sodium nitroprusside, but higher than acetylcholine.

CONCLUSIONS

In the absence of regulatory mechanisms, sildenafil citrate has noticeable vasodilatatory effect in vitro.

Does acute-phase beta blockade reduce left atrial appendage function in patients with chronic nonvalvular atrial fibrillation?

To investigate whether acute-phase beta-blocker therapy has a harmful effect on left atrial appendage (LAA) function in patients with chronic nonvalvular atrial fibrillation by transesophageal echocardiography (TEE), we evaluated 21 patients with normal left ventricular systolic function and a poorly controlled ventricular rate, despite the use of digoxin. Baseline parameters that were obtained included heart rate, blood pressure, LAA emptying velocities, and left atrial spontaneous echo contrast intensity. Then, each patient was given a bolus dose of 5 mg metoprolol. Ten minutes later, a second set of assessments was performed. After the first TEE studies, each patient began treatment with metoprolol (50 mg orally twice daily for 1 week). A second TEE study was performed after 1 week of continuous oral metoprolol therapy at maintenance dose, and values were again determined. The average resting apical heart rate was 91 +/- 7 bpm. As expected, beta-blocker therapy showed a marked decrease in heart rate at 10 minutes (79 +/- 6 bpm, P <.001) and at 1 week (71 +/- 4 bpm, P <.001). Beta-blocker therapy caused a significant reduction in systolic and diastolic blood pressures (144 +/- 16 / 93 +/- 6 mm Hg at baseline, 137 +/- 16 / 87 +/- 9 mm Hg at 10 minutes, and 135 +/- 12 / 86 +/- 8 mm Hg at 1 week, P <.001). With the beta-blocker therapy, the baseline transesophageal Doppler parameter of LAA emptying velocities (at baseline 24 +/- 7 cm/s) fell significantly at 10 minutes (19 +/- 7 cm/s, P <.001) and at 1 week (17 +/- 6 cm/s, P <.001) after initiation of beta-blocker therapy. After a bolus of metoprolol, spontaneous echo contrast intensity did not change in any patients, but 1 week later, it increased in 1 patient. In 2 patients who had not been found to have an LAA thrombus at baseline TEE study, the second TEE examination demonstrated new thrombi in the LAA. In conclusion, our findings suggest that in patients with chronic nonvalvular atrial fibrillation who have normal left ventricular systolic function and a poorly controlled ventricular rate despite the use of digoxin, acute-phase beta blockade may have a harmful effect on LAA function.

A case of left atrial appendage thrombus with embolic stroke in association with aortic stenosis in sinus rhythm

Although left atrial appendage (LAA) thrombus formation in the presence of sinus rhythm may potentially be the source for embolic events in various types of heart disease, no cases of LAA thrombus with embolic stroke in association with aortic stenosis in sinus rhythm have been reported. We present a case of valvular aortic stenosis with cerebral embolism in a person who was in sinus rhythm and had an LAA thrombus diagnosed by transesophageal echocardiography.

Biatrial thrombosis after acute inferior wall myocardial infarction--a case report

The authors describe a case of biatrial thrombosis after acute inferior wall myocardial infarction (MI) with sinus rhythm. The presence of atrial thrombosis in patients with acute MI has recently been recognized with the aid of echocardiography. However, to the author's knowledge, a case of biatrial thrombosis after acute MI has not been reported previously. In this case, blood stasis, resulting from both left ventricular and right ventricular systolic dysfunction, was the most likely cause of the biatrial thrombi formation. In summary, this case suggests that biatrial thrombosis may occur in acute MI, even in the presence of sinus rhythm.

Acute ECG changes and chest pain induced by neck motion in patients with cervical hernia--a case report

We report two cases of acute cervical angina and ECG changes induced by anteflexion of the head. Cervical angina is defined as chest pain that resembles true cardiac angina but originates from cervical discopathy with nerve root compression. In these patients, Prinzmetal's angina, valvular heart disease, congenital heart disease, left ventricular aneurysm, and cardiomyopathy were excluded. After all, the patient's chest pain was reproduced by anteflexion of head, at this time, their ECGs showed nonspecific ST-T changes in the inferior and anterior leads different from the basal ECG. ECG changes returned to normal when the patient's neck moved to the neutral position. To our knowledge, these are the first cases of cervical angina associated with acute ECG changes by neck motion.

Effects of cigarette smoking on the circadian rhythm of heart rate variability

BACKGROUND

The effects of cigarette smoking on the circadian rhythm of heart rate variability (HRV) are not known.

METHODS

We studied the effects of cigarette smoking on the circadian rhythm of HRV in 24 smoking and 21 non-smoking healthy subjects. Twenty-four hour ambulatory electrocardiograms were recorded and time domain parameters of HRV (SDNN [standard deviation of all R-R intervals], SDANN [standard deviation of the averages of R-R intervals in all 5-minute segments of the entire recording], RMSSD [the square root of the mean of the sum of the squares of differences between adjacent R-R intervals]) were determined for the entire 24-hour period and for each 3-hour period.

RESULTS

In total, SDNN and SDANN were significantly lower in smokers than non-smokers (116 +/- 26 vs 136 +/- 27, p < 0.05 for SDNN, 109 +/- 25 vs 121 +/- 24, p < 0.05 for SDANN). However, there were no statistical differences between smokers and non-smokers in heart rate (81 +/- 9 vs 76 +/- 10, p > 0.05) and RMSSD (32 +/- 12 vs 37 +/- 18, p > 0.05). These HRV parameters showed a circadian variation: they increased at night and decreased during the day in both groups. The parameters were lower in smokers than non-smokers during daytime (especially, between 8-14 hours). However, no differences were detected during night-time.

CONCLUSIONS

Time domain parameters of HRV (SDNN, SDANN and RMSSD) in both smoking and non-smoking healthy subjects have a circadian rhythm. SDNN and SDANN were lower in smokers than non-smokers during daytime.

Primary breast lymphomas--a retrospective analysis of twelve cases

This study was undertaken to define the natural history and treatment results of patients with primary breast non-Hodgkin's lymphoma (NHL). Twelve female patients who had been followed at Hacettepe University Hospital between 1973 and 1997 were retrospectively evaluated. All patients presented with breast masses (6 in the right breast and 6 in the left) that had recently enlarged. The most common histologic subtype was diffuse, small cleaved-cell lymphoma. Chemotherapy regimens were employed in 9 patients. Radiotherapy was delivered to the breast and its lymphatics in 8 patients. Lumpectomy, simple or modified radical mastectomy was performed in 5 cases. An objective response was attained with surgery, chemotherapy, or radiotherapy alone in 2, 1, and 1 cases, respectively. Combined modality treatment including either two or three modalities was successful in 7 cases. The median progression-free and overall survival times were 49 and 56 months, respectively. Although primary NHL of the breast is a rare disease compared to carcinoma, it should be considered in the differential diagnosis of breast masses.

Right atrial appendage function in patients with chronic nonvalvular atrial fibrillation

To assess right atrial appendage (RAA) flow and its possible relationship to left atrial appendage (LAA) flow in chronic nonvalvular atrial fibrillation (AF), transesophageal echocardiography (TEE) was performed in 26 patients with chronic nonvalvular AF (group I). For the purpose of comparison, an additional group of 27 patients with chronic valvular AF due to mitral stenosis (group II) was analyzed. The clinically estimated duration of AF in group I was significantly longer than that of group II (8.7+/-3.4 versus 2.7+/-1.1 years). Although right atrial size and RAA maximal area were larger in group I than those in group II, left atrial size was larger in group II than that in group I. Group II had larger LAA maximal areas than group I, but this difference did not reach statistical significance. The two groups were not different with respect to the RAA or LAA emptying velocities. Significant correlations were observed between echocardiographic parameters of the two atria in patients with nonvalvular AF (r range, 0.4 to 0.7). In contrast, in patients with valvular AF, no correlation was observed between the echocardiographic parameters of the two atria (appendage emptying velocity, r = 0.38, p = 0.051; atrial size, r = -0.03, p = 0.89; maximal appendage area, r = 0.07, p = 0.75, respectively). There were no significant differences in the presence of right and left atrial spontaneous echo contrast and thrombus between the groups. All of the right and left atrial thrombi were confined to their respective appendages and were found in the atria with spontaneous echo contrast. Both RAA and LAA thrombi were present in one patient. In conclusion, our findings suggest that AF could affect both atria equally in nonvalvular AF, in contrast to valvular AF. Therefore, the assessment of RAA function as well as LAA may be important in patients with chronic nonvalvular AF.

The effect of autonomic nervous system activity on exaggerated blood pressure response to exercise: evaluation by heart rate variability

OBJECTIVE

We investigated the effect of autonomic nervous system activity on exaggerated systolic blood pressure (SBP) response to exercise in healthy subjects using heart rate variability (HRV) analysis.

METHOD AND RESULTS

We studied 53 healthy volunteer subjects with exercise treadmill test according to the Bruce protocol. Time domain and frequency domain of HRV were measured for each 5-minute segment before (rest) and after exercise (recovery) and during the total exercise period. The mean change in SBP (delta SBP) was 39 +/- 18 mm Hg. The delta SBP above the value of mean (> or = 40 mm Hg) was defined as an exaggerated delta SBP. According to the delta SBP, subjects were classified into two groups. Group I consisted of 32 patients who showed a normal delta SBP, group II consisted of 21 patients who showed exaggerated delta SBP. There were no significant differences in baseline clinical characteristics and exercise duration between the two groups. There were no significant differences in the mean RR intervals, SDNN (standard deviation of all RR intervals), RMSSD (the square root of the mean of the sum of the squares of differences between adjacent RR intervals), and HF (high-frequency power, 0.15 to 0.40 Hz) at rest between the two groups. However, LF (low-frequency power, 0.04 to 0.15 Hz) and LF/HF ratio at rest were significantly higher at rest in group II than in group I. There were no significant differences in the mean RR intervals and HF at exercise between the groups. However, SDNN and RMSSD were significantly lower, LF and the LF/HF ratio were significantly higher at exercise in group II than in group I. No differences in these parameters were observed at recovery between the two groups.

CONCLUSIONS

The sympathetic activity was higher at rest and during the total exercise period, parasympathetic activity was lower during the total exercise period in healthy subjects with exaggerated SBP response to exercise than in those with normal SBP response.

Sonographic assessment of ceftriaxone-associated biliary pseudolithiasis in children

PURPOSE

Ceftriaxone is a widely used third-generation cephalosporin. In this prospective study, we used sonography to investigate the incidence and outcome of biliary complications in children receiving ceftriaxone therapy.

METHODS

Ceftriaxone was administered intravenously at a dosage of 100 mg/kg/day for 1-3 weeks to 118 children hospitalized for severe infection. Serial gallbladder sonograms were obtained on days 1, 5-7, and 10-14 of therapy and the day after therapy ended if it had lasted more than 2 weeks. When sonographic abnormalities were found, additional sonograms were obtained every 3 days until the abnormalities had completely resolved.

RESULTS

Twenty patients (17%), all asymptomatic, demonstrated sonographic abnormalities: 8 had gallbladder sludge, defined as echogenic material without associated acoustic shadowing, and 12 had pseudolithiasis, defined as echogenic material with acoustic shadowing. These abnormalities spontaneously resolved within 2 weeks of stopping the ceftriaxone (mean time to disappearance, 8.2 +/- 3.4 days). No significant differences were found between patients with normal versus abnormal sonographic findings in sex, age, duration of treatment, or other risk factors for drug precipitation.

CONCLUSIONS

Ceftriaxone-associated biliary pseudolithiasis is usually asymptomatic and was rapidly reversible after cessation of therapy in this group of Turkish children.