Is Cytomegalovirus Surveillance Necessary for Patients With Low Reactivation Risk in an Autologous Hematopoietic Cell Transplantation Setting?

BACKGROUND

In an autologous hematopoietic cell transplantation (AHCT) setting, routine cytomegalovirus (CMV) surveillance is not indicated except in high-risk situations. On the other hand, some studies reported increased CMV reactivation in AHCT setting as a result of incorporation of novel agents into treatment algorithms, such as bortezomib and rituximab. We retrospectively analyzed CMV reactivation and infection rates in patients with no high-risk features, who were treated with AHCT.

METHODS

During January 2010 to November 2015, all consecutive, CMV-seropositive patients were included. The viral copy numbers were measured twice a week from the start of the conditioning regimen until engraftment, once a week for the remaining time period until day 30 after AHCT and once weekly only for patients who had been diagnosed with CMV reactivation before and who developed primary/secondary engraftment failure during 31 to 60 days after AHCT.

RESULTS

One hundred one (61.6%) men and 63 (38.4%) women were included in the study. The median age of study cohort was 51 years (range, 16-71 years). The indications for AHCT were Hodgkin lymphoma, non-Hodgkin lymphoma, and multiple myeloma in 44 (26.8%), 41 (25%), and 79 (48.2%) patients, respectively. CMV reactivation occurred in 60 (37%) patients, and 13 patients (8%) received pre-emptive ganciclovir treatment.

CONCLUSIONS

On the basis of our results, it might be stated that CMV surveillance may be recommended during 40 days after AHCT in countries with a high CMV prevalence, even in patients without high-risk features regarding reactivation. Additionally, the risky conditions necessitating CMV screening after AHCT must be re-defined in the era of novel agents.

Resection of endobronchial hamartoma causing recurrent hemoptysis by electrocautery and cryotherapy

BACKGROUND

Pulmonary hamartomas are rare benign tumors of the lung with an incidence of 0.025%-0.32%. Endobronchial benign lesions can cause bronchial obstruction and recurrent respiratory infections or obstructive pneumonia and recurrent hemopthysis.

CASE REPORT

A 66-year-old male with recurrent hemoptysis and pneumonias for a year, was referred to our department for an endoscopic resection of an endobronchial hamartoma. Initially he refused any intervention but, as he suffered additional episodes of hemoptysis and chest infections during a year on follow up, he finally underwent interventional bronchoscopy and the lesion was cauterized using snare electrocautery probe and removed with cryoextraction. The patient has been followed for two years in our outpatient clinic, with no further problems.

CONCLUSION

Endoscopic treatment with flexible bronchoscope, electrocautery and cryotherapy provides an excellent outcome. Surgical therapy, should be reserved for the hamartomas that cannot be approached through endoscopy. Hippokratia 2014; 18 (4): 355-356.

Concomitant Gerbode-like defect and anterior mitral leaflet perforation after aortic valve replacement for endocarditis

We present a case of concomitant left ventricle (LV) to right atrial shunt (Gerbode-like defect) and anterior mitral leaflet perforation in a 32-year-old male after aortic valve replacement for infective endocarditis of bicuspid aortic valve. This case emphasises that intra-operative transesophageal echocardiography is a sine qua non for valvular surgical procedures.

Effectiveness of preoperative plasmapheresis in a pregnancy complicated by hyperthyroidism and anti-thyroid drug-associated angioedema

Hyperthyroidism is not a rare entity in pregnancy and 85% of these cases attributed to Graves' disease (GD). There is no therapeutic modality for GD considered as totally safe in pregnancy. Fetal and neonatal risks of maternal hyperthyroid disease are related to the hyperthyroidism itself and/or to the medical treatment of the disease. There are no data supporting an association between congenital anomalies in the fetus and propylthiouracil (PTU). Hepatotoxicity, cytopenias--especially agranulocytosis and quite rarely, angioedema, may be seen as side effects of PTU. In this case report, we examine an instance of Graves' hyperthyroidism diagnosed during pregnancy. In this case, a serious side effect during anti-thyroid drug usage was encountered, eventually resulting in surgery in the second trimester. This intervention was assisted by the use of plasmapheresis to obtain rapid normalization of serum thyroid hormone levels.

Sensorimotor performance asymmetries predict hand selection

Handedness is most often measured by questionnaires that assess an individual's preference for using a particular hand to perform a variety of tasks. While such assessments have proved reliable, they do not address the underlying neurobehavioral processes that give rise to the choice of which hand to use. Recent research has indicated that handedness is associated with hemispheric specializations for different aspects of sensorimotor performance. We now hypothesize that an individual's choice of which hand to use for a given task should result from an interaction between these underlying neurobehavioral asymmetries with task conditions. We test this hypothesis by manipulating two factors in targeted reaching movements: (1) region of workspace and (2) visual feedback conditions. The first manipulation modified the geometric and dynamic requirements of the task for each arm, whereas the second modified the sensorimotor performance asymmetries, an effect predicted by previous literature. We expected that arm choice would be reflected by an interaction between these factors. Our results indicated that removing visual feedback both improved the relative performance of the non-dominant arm and increased the choice to use this arm for targets near midline, an effect that was enhanced for targets requiring larger movement amplitudes. We explain these findings in the context of the dynamic dominance hypothesis of handedness and discuss their implications for the link between hemispheric asymmetries in neural control and hand preference.

Evaluation of relationship between meteorological parameters and air pollutant concentrations during winter season in Elaziğ, Turkey

In recent years, due to the rapid increase in population density, building density and energy consumption, the outdoor air quality has deteriorated in the crowded urban areas of Turkey. Elaziğ city, which is located in the east Anatolia region of Turkey, is also influenced by air pollutants. In the present study, relationship between monitored air pollutant concentrations such as SO2 and the total suspended particles (TSP) data and meteorological factors such as wind speed, temperature, relative humidity, solar radiation and atmospheric pressure was investigated in months of October, November, December, January, February, and March during the period of 3 years (2003, 2004 and 2005) for Elaziğ city. According to the results of linear and non-linear regression analysis, it was found that there is a moderate and weak level of relation between the air pollutant concentrations and the meteorological factors in Elaziğ city. The correlation between the previous day's SO2, TSP concentrations and actual concentrations of these pollutants on that day was investigated and the coefficient of determination R2 was found to be 0.64 and 0.54, respectively. The statistical models of SO2 and TSP including all of meteorological parameters gave R2 of 0.20 and 0.12, respectively. Further, in order to develop this model, previous day's SO2 and TSP concentrations were added to the equations. The new model for SO2 and TSP was improved considerably with R2 = 0.74 and 0.61, respectively.

The prevalence of overweight and obese children aged 6-17 years in the West Black Sea region of Turkey

OBJECTIVE

To assess the prevalence of overweight and obese Turkish children.

DESIGN

Cross-sectional study in school children.

SUBJECTS

A total of 6924 children (3281 boys and 3643 girls) aged 6-17 years from the West Black Sea region of Turkey.

MEASUREMENTS

Overweight and obese were defined using international age- and sex-specific cutoff points for body mass index. The data were analysed by age, sex, residence and socioeconomic level.

RESULTS

The overall prevalence of overweight and obesity was 10.3% and 6.1% respectively. The overall prevalence of obesity in boys and girls was 7.0% and 5.4%, respectively, and the difference was significant (chi(2) = 8, p = 0.004). The prevalence of obesity in urban and rural areas was 7.7% and 3.9%, respectively, and the difference was significant (chi(2) = 40, p < 0.001). The prevalence of overweight boys and girls in urban areas was 11.6% and 13.2%, respectively, but the difference was not significant (chi(2) = 2, p > 0.05). However, the prevalence of overweight boys and girls in rural areas was 4.8% and 9.4%, respectively, and the difference was significant (chi(2) = 25, p < 0.001). Although the prevalence of obesity differed significantly between boys and girls in urban children (chi(2) = 13, p < 0.001), no significant difference was detected in the prevalence between boys and girls from rural areas (chi(2) = 0.4, p > 0.5). The prevalence of obesity was significantly higher in private schools than in public schools (chi(2) = 48, p < 0.0001). The prevalence of overweight and obese Turkish children aged 6-17 years is considerably lower than in most European countries. The children in urban settings and higher socioeconomic groups had a higher prevalence of overweight and obesity. The Westernisation of the behaviour patterns of children and living in an urban setting in a developing country are risk factors for obesity.

An intraoperative unexpected respiratory problem in a patient with Apert syndrome

We present a case of a 5-year-old child who underwent four operations (three for syndactyly of the hands and one for craniofacial corrections). At the third hour of his craniofacial operation, his EtCO2 started to increase and airway resistance was encountered during manual ventilation. The position of the head and neck was checked. An increase in secretion with oral and endotracheal aspiration and a decrease in saturation were observed. When breath sounds disappeared, the patient was reintubated orally. The nasal tube was obstructed with a mucolytic plug. There was no problem during the other operations. This case is presented since anaesthesiologists should be aware of the high incidence of respiratory complications in Apert syndrome.

Effect of bispectral index monitoring on sevoflurane consumption

BACKGROUND AND OBJECTIVE

The bispectral index, a parameter derived from the electroencephalograph, has been shown to correlate with the loss of consciousness and sedation. This study was designed to assess the effects of bispectral index monitoring on sevoflurane and its recovery profiles.

METHODS

Sixty ASA I and II patients undergoing open abdominal surgery were randomized into two groups: one monitored using the bispectral index (Group BIS) and the other without its use (controls). After a standardized induction, anaesthesia was maintained with sevoflurane in both groups. In Group BIS, sevoflurane was titrated to maintain the bispectral index in the range 40-60. In the control group, the administered sevoflurane concentration was adjusted according to the signs of anaesthesia. The end-tidal sevoflurane concentration, bispectral index and routine haemodynamic variables were noted every 5 min during surgery. The consumption of sevoflurane was computed. At the conclusion of surgery operations, the time to 'open eyes on verbal command', 'motor response to verbal command' and Aldrete's score were recorded by a blinded anaesthesiologist.

RESULTS

The difference in the consumption of sevoflurane was not significant between the groups. Bispectral index monitoring was associated with a reduction of 4.73% in sevoflurane usage and 2.19 mL h(-1) was saved.

CONCLUSIONS

Bispectral index monitoring during anaesthesia provides only a small advantage related to the need to monitor the depth of anaesthesia.

The primary restless legs syndrome pathogenesis depends on the dysfunction of EEG alpha activity

A dopaminergic drug - lisuride exhibited increase in alpha, decrease in beta and slow activities on brain function measured by computerized EEG. It was postulated that reverse EEG changes might play role in the pathogenesis of RLS. During transition from wakefulness to sleep stage 1 changes in alpha activity initiate long-lasting alpha arousal responses and they continue increasingly at sleep stage 2. This dysfunction is probably due to a genetic vulnerability of EEG alpha rhythm and disinhibits the diencephalospinal dopamine system, mostly during sleep but also during wakefulness. The disinhibition produces background for activation of PLMs, disturbing sensations in brainstem and urge to move, motor restlessness at cerebral cortex, generally for legs. All lead to severe insomnia. In RLS patients, forced deviations from alpha to theta or beta activity are unsuitable and resting EEGs reflect a dopamine receptor-specific 'individual sensitivity.' This vulnerability is alleviated after lisuride with suitable CEEG changes.

Osteoid osteoma in the base of the coracoid process of the scapula. Excision by anterior approach: a case report

Osteoid osteoma in the base of the coracoid process of the scapula is very rare and diagnosis and treatment often is delayed. A lesion in this atypical location may seem surgically unreachable. This report is of a case of osteoid osteoma in the base of coracoid process in a 14-year-old female. The lesion had been diagnosed as a nontumorous condition and overlooked for four years. Computed tomography and magnetic resonance imaging revealed a nidus in the base of the coracoid process. The en bloc excision of the osteoid osteoma was managed by an anterior approach using an osteotomy of the coracoid process. A 12-month follow-up examination revealed no symptoms and computed tomography showed bone healing with no recurrence of the tumor.

Modification of Bankart reconstruction with lateral capsulotomy and selective anatomic repair using suture anchors

Twenty consecutive patients (17 male, 3 female) with a diagnosis of traumatic recurrent anterior instability of the shoulder were treated by a modified Bankart procedure using suture anchors. The technique consists of vertical incision of the capsule, just medial to the lateral insertion on the humerus and anatomic repair of the Bankart lesion. Humeral-based capsular shifting was performed in patients with anterior-inferior instability. The average age was 24 years (range: 14 to 39 years), and average follow-up period 68 months (range: 2 to 8 years). The average Bankart rating score was 92.5 (range: 70 to 100); with 16 (80%) excellent (score 90 to 100), 2 (10%) good (score 75 to 89), and 2 (10%) fair results. Failure in terms of recurrent dislocation was not reported. Eleven patients (55%) had a loss of 5 degrees to 10 degrees of external rotation either with the extremity at the side or at 90 degrees of abduction. Nine (45%) patients had external rotation equal to the contralateral side. We believe selective anatomic Bankart reconstruction by lateral capsulotomy and humeral-based capsular shifting in cases with marked inferior laxity is a more anatomic and physiologic technique.

[Hip fracture-dislocation (Pipkin type IV) associated with an apparent traumatic aortic valve rupture. Case history]

Traumatic aortic valve rupture with resultant aortic insufficiency is a rare complication of blunt trauma. Here reported is a case with a posterior fracture-dislocation of the hip (Pipkin type-IV) and an undisplaced sternum fracture who developed hemodynamic instability in the clinical follow-up and was diagnosed having a traumatic aortic valve rupture using echocardiography. He first was treated with a biological valve replacement. Two weeks later a total hip arthroplasty combined with the osteosynthesis of the posterior wall of the acetabulum was performed. Sternum fracture healed conservatively. In multiply injured patients especially with a blunt thorax trauma hemodynamic instability despite appropriate fluid replacement should rise the suspicion of cardiac injuries, especially traumatic aortic valve rupture. Echocardiography is a simple but reliable method for the diagnosis.

Time-dependent reduction in load to failure of wedge-type polyglyconate suture anchors

SUMMARY

Thirty-two absorbable (polyglyconate) and 24 nonabsorbable (polyacetal) wedge-type suture anchors (TAG; Acufex, Mansfield, MA) were implanted into sheep tibiae. Load to failure tests were performed on the day of insertion and at weeks 3, 6, and 12, followed by macroscopic examination. Failure type was suture breakage for nonabsorbable anchors in all groups, with average forces of 142.5 +/- 4.8 N on the first day, 138.0 +/- 6.6 N in week 6, and 135.6 +/- 2.9 N in week 12. In the absorbable group, suture breakage occurred on the first day with a mean force of 133.5 +/- 4. 2 N. In weeks 3, 6, and 12, suture cutout occurred with average forces of 33.75 +/- 5.0 N, 23.25 +/- 2.2 N, and 23.25 +/- 5.9 N, respectively. For absorbable anchors, results at weeks 3, 6, and 12 were significantly lower compared with initial results (P <.001). These results show that wedge-type polyglyconate anchors lose 75% of their initial pullout strength within the first 3 weeks and 84% in 6 weeks.

Two-stage treatment of chronic staphylococcal orthopaedic implant-related infections using vancomycin impregnated PMMA spacer and rifampin containing antibiotic protocol

To determine the clinical role of rifampin containing antibiotic combination and modified two-stage exchange arthroplasty with a vancomycin loaded polymethylmethacrylate (PMMA) spacer for the treatment of orthopaedic implant related Staphylococcus epidermidis infections, a prospective study was initiated. A total of 10 patients, with a mean age of 59 years (range: 32 to 78 years) were included in the study. The mean follow up was 23.4 months (range: 16 to 36 months). Six patients had an infected hemiarthroplasty of the hip, three had infected total hip arthroplasty, and one had an infected femoral neck fracture with implant failure and pseudoarthrosis. All had culture-proven Staphylococcus epidermidis infections, six of the isolates were methicillin resistant. Following debridement and implantation of a PMMA spacer, a rifampin-vancomycin antibiotic protocol was initiated until the erythrocyte sedimentation rate and C-reactive protein levels were within normal limits. After reimplantation and discharge from the hospital, oral antibiotics with rifampin-ciprofloxacin were continued for three to six months. At the final follow-up none of the patients had any clinical or laboratory signs of infection. Although this study includes a limited number of patients and relatively short-term follow-up the results indicate that in the presence of orthopaedic implant infection with Staphylococcus epidermidis, modified two-stage exchange arthroplasty using a vancomycin-loaded PMMA spacer and a rifampin-containing antibiotic protocol may be beneficial.

Primary replacement of the humeral head in iatrogenically displaced fracture-dislocations of the shoulder: a report about six cases

Dislocation of the shoulder is a common injury and may be associated with a variety of complications. We report six cases of primary replacement of the humeral head where closed reduction of a shoulder dislocation associated with an undisplaced fracture of the humeral neck led to displacement of the neck fracture. All dislocations examined were anterior with a displaced greater tubercle fracture. The patients had undergone closed reduction at other medical centres and were referred to us because of iatrogenically displaced fracture-dislocations of the shoulder. Three were women and three were men with a mean age of 52.8 years (range 38-72). Primary replacement of the humeral head was done in an average of 9.3 days (range 2-30 days) following the injury. The average follow-up period was 30.2 months (range 12-55 months). Postoperative pain, active range of motion and function were evaluated with the American Shoulder and Elbow Surgeons Criteria. The forward flexion averaged 124 degrees, active external rotation averaged 29 degrees and internal rotation (achieved movement) to the second lumbar vertebra. Because of the high risk of avascular necrosis and severe collapse of the humeral head, we conclude that the primary replacement of the humeral head is the superior treatment option in iatrogenically displaced fracture dislocations of the shoulder.

Strength of different meniscus suturing techniques

We measured and compared the primary stabilities of five different meniscal suturing techniques. The techniques tested were horizontal mattress, vertical mattress, knot-end, vertical, and vertical loop. Twenty bovine medial menisci were cut to simulate peripheral longitudinal tears and repaired with one of the five suture techniques. Then the two parts of the meniscus were pulled using the Instron Tensometer until failure occurred. Knot-end techniques gave inferior results (mean ultimate failure strength 64 +/- 5 N) compared with the other techniques. Vertical mattress failed at 130 +/- 3 N, vertical loop at 128 +/- 4.5 N, horizontal mattress at 98 +/- 5 N and vertical suturing at 136 +/- 2.7 N. This study shows the superior mechanical characteristic of the vertical suturing technique.

Palliation of malignant esophageal strictures with self-expanding nitinol stents: drawbacks and complications

PURPOSE

To evaluate the usefulness of self-expanding nitinol stents in the palliative treatment of malignant dysphagia.

MATERIALS AND METHODS

Eighty self-expanding nitinol stents were placed in 59 patients (43 men, 16 women; mean age, 55 years; age range, 23-75 years) with inoperable malignant stenosis due to squamous cell carcinoma of the esophagus (n = 36), adenocarcinoma (n = 19), invasion of the esophagus due to carcinoma of the lung (n = 2), and recurrent anastomotic carcinoma (n = 2). Dysphagia was graded on a scale of 0 to 3. Follow-up esophagograms were obtained to evaluate stent patency.

RESULTS

Stent placement was successful in all patients. The severity of dysphagia decreased at least one grade in all but one patient. Tumor ingrowth and overgrowth were seen in 21 (36%) patients 2 days to 7 months after stent placement and caused recurrent dysphagia. These 21 patients underwent balloon dilation and additional stent placement. A mediastinal fistula was seen in three patients (5%), ulceration in four (7%), stent torsion in three (5%), and incomplete expansion of the stent in two (2%). Repeat intervention was necessary in 51% of the patients.

CONCLUSION

There is a substantial range of drawbacks and complications associated with the use of self-expanding nitinol stents for palliation of malignant esophageal strictures. A covering would be necessary to prevent tumor ingrowth.

Paraneoplastic cerebellar degeneration associated with multiple myeloma--3.4 years follow up

A 57 year old female patient demonstrated subacute generalized cerebellar symptoms and the investigations which were done exhibited that the clinical picture was due to the remote effect of multiple myeloma. In this case of paraneoplastic cerebellar degeneration, MRI showed cerebellar vermian atrophy when the brain CT scan was negative. Diagnosis of multiple myeloma was possible only on about the 17th month of the illness when monoclonal gammapathy-IgG in serum of the patient and abnormal plasma cells of 13% in her bone marrow biopsy were exhibited. Bence-Jones proteinuria with kappa light chain was found in the 3.4th year of the illness. Paraneoplastic cerebellar degeneration disabled the patient in 3-4 months and remained as an irreversible process during the 3.4 years in which she was followed until her death. Chemotherapy for multiple myeloma did not affect the cerebellar syndrome.

Restless legs syndrome treatment with dopaminergic drugs

Sixteen patients with symptoms of restless legs syndrome and resulting insomnia are included in this study. They were nine women and seven men with a mean age of 50.8 years and with a mean duration of symptoms of 6.3 years. The purpose of the study is to determine the drugs that are useful for the treatment of restless legs syndrome. In 13 patients L-Dopa plus benserazide, in two patients bromocriptine, and in the remaining one patient piribedil were used orally at night approximately 1 h before bedtime. Compared with placebo these dopaminergic drugs decreased the times of waking up and staying awake periods at a statistically significant level (p changed between 0.025 and 0.01, t test). In this susceptibility of CNS there is dysfunction of the dopamine system triggered by sleep, and resting and dopaminergic potentiation by drugs affect the symptoms.

Prediction of psychotropic properties of lisuride hydrogen maleate by quantitative pharmaco-electroencephalogram

Based on "quantitative pharmaco-EEG" using computer-analyzed EEG (CEEG) measurements, unknown CNS effects of lisuride hydrogen maleate (LHM) were established. CEEG profiles of LHM in low dosages (less than or equal to 10 mcg) are similar to CNS "inhibitory" compounds, while in higher dosages (25 mcg to 100 mcg) they resemble "psychostimulant" compounds. By measuring the brain function using computer period analysis of cerebral biopotentials, dose-efficacy relations were found (in the range of 25-75 mcg) which suggest the bioavailability of LHM at the CNS level. By comparing the CEEG profiles of LHM with the previously studied compounds, five different clinical uses of LHM were predicted. The pilot trials suggest that LHM may have therapeutic potentials in patients with "aging" and/or organic brain syndromes, and in children with behavioral disturbances.

Different effects of trifluoperazine when administered daytime or night

The neuroleptics which are very effective in chronic schizophrenia, such as fluphenazine, thiothixene and haloperidol, have both central ‘inhibitory’ and 'stimulatory’ properties (Itil et al., 1969, 1970). When chronically administered in low dosages, these compounds decrease Stage 4 of the sleep process and produce insomnia, while in high dosages they produce deeper sleep stages. Based on these observations and the fact that extrapyramidal symptoms usually do not occur during deep sleep, we hypothesized that high oral doses of trifluoperazine given at night would produce fewer sleep disturbances and extrapyramidal symptoms than the same dosages of this compound administered during the morning.