The Bad Bug is Back: Acinetobacter Baumannii Bacteremia Outbreak during the COVID-19 Pandemic in an Intensive Care Unit

Background

Epidemiology of nosocomial infections may show variability because of under-estimation of infection control measures (ICMs) in coronavirus disease 19 (COVID-19) outbreak.

Aim

To investigate the Acinetobacter bacteremia outbreak developed in an intensive care unit (ICU) between March 20 to May 15, 2020, examine the risk factors, and re-evaluate ICM retrospectively.

Material and Methods

A retrospective cohort analysis was conducted to determine the risk factors, pulsed field gel electrophoresis (PFGE) was performed for analysis of the outbreak, ICM practices were observed by a team, and infection control interventions were undertaken.

Results

Acinetobacter bacteremia developed in 17 patients (21.5%) within 79 COVID-19 patients included in the study. The mean age of the bacteremic patients was 67.3 (SD = 14.82) years, and 82.4% of them were male; of these, 15 died, leading to 88.2% mortality. The bacteremia rate was higher compared with a 14-month period preceding the COVID-19 pandemic (17/79 versus 12/580 patients, respectively). PFGE revealed that the outbreak was polyclonal. On multi-variate analysis, the bacteremia development rate was 13.7 and 5.06 times higher with central venous catheter (CVC) use and in patients with chronic obstructive pulmonary disease (COPD), respectively. The mortality rate was higher in bacteremic patients (p = 0.0016). It was observed that ICMs were not followed completely, especially change of gloves and hand hygiene. Contamination of A. baumannii was observed in 38% of the gloves.

Conclusion

COPD and CVC use were determined as risk factors for Acinetobacter bacteremia development, and failures in ICM may have led to cross-contamination of endemic A. baumannii. The outbreak could be controlled within 3 weeks of interventions.

The retrospective analysis of patients with uterine sarcomas: A single-center experience

BACKGROUND

Uterine sarcomas are rare, malignant, gynecological tumors and show diverse histopathological features. Therefore, there is no consensus on risk factors for poor outcome and optimal treatment. The aim of this retrospective analysis is to report the clinical outcome of patients with uterine sarcoma treated at a single center.

MATERIALS AND METHODS

The data was obtained regarding the patient's demographic characteristics, pathological results, treatments given, survival, and complications of all uterine sarcoma patients treated in a single center between the years 2000 and 2012. The 80.month overall survival. (OS) was determined with respect to prognostic factors including age, stage of disease, histopathological type, and adjuvant treatment.

RESULTS

A total of 57 case records are retrieved for this retrospective analysis. The mean age of the patients is 62.5 ± 11.2 years. International Federation of Gynecology and Obstetrics (FIGO) stage distribution is stage I: 29; stage II: 13; stage III: 9; stage IV: 6. Fifty-seven patients underwent surgery, 33 received postoperative radiotherapy (PORT), and 32 received chemotherapy. Median follow-up period was 25 months (range 2-85 months). The 80-month OS for the entire group of patients was 36.7%. The significant prognostic factors for survival are age under 50 years, stage of disease, and adjuvant chemotherapy.

CONCLUSION

Although limited by small sample size and retrospective nature, age under 50 years, stage of disease, and adjuvant chemotherapy are significant prognostic factors for survival for uterine sarcomas.

The prediction of myometrial infiltration by three-dimensional ultrasonography in patients with endometrial carcinoma: a validation study from Ege University Hospital

AIM

To predict the myometrial invasion with three-dimensional (3D) ultrasonography in a cohort of patients with endometrial carcinoma by a previously described technique.

MATERIAL AND METHODS

The moyometrial infiltration was evaluated by 3D ultrasonography before surgery in 54 patients with endometrial carcinoma. After scanning the whole uterus by ultrasonography, three perpendicular planes were identified to find the shortest myometrial tumor-free distance to serosa (TDS) by examining the lateral, anterior, posterior, and fundal parts of the myometrium. Myometrial infiltration was also estimated by the subjective impression of the examiner. The reference standards consist of myometrial infiltration and TDS which are measured by an experienced pathologist.

RESULTS

Forty-five patients (age range 45-86 years) were included for the final analysis. Myometrial invasion was ˂50% in 36 and ≥50% in 9 cases at histologic sections. The TDS which is measured with 3D ultrasonography was positively correlated with histologically measured TDS (r=0.474, p=0.001). The best cut-off value for ultrasonographically measured TDS was 9 mm with a sensitivity of 89%, specificity of 61%, positive predictive value of 36%, and negative predictive value of 96%. Subjective impression has a sensitivity of 100%, specificity of 88%, positive predictive value of 69%, and negative predictive value of 100%. Cervical involvement was correctly identified in all 6 cases by subjective impression.

CONCLUSION

This validation study confirms the 3D ultrasonography as a valuable tool for the evaluation of myometrial infiltration in patients with endometrial carcinoma.

Do preoperative serum vascular endothelial growth factor and migration-inhibitory factor predict the nature of the adnexal masses? A prospective-controlled trial

The aim of this study was to identify the role of preoperative serum vascular endothelial growth factor (VEGF) and migration inhibitor factor (MIF) in differentiation of benign and malignant adnexal masses, as well as the relationship between prognostic factors and VEGF and MIF in ovarian cancer patients. This prospective study included 41 patients who were admitted between November 2010 and March 2012. In the malignant group, there were 21 patients, and remaining 20 had benign adnexal masses. Age, CA125 levels, grade, stage, presence of ascites and the degree of cytoreduction performed were noted. There was no significant difference between two groups in preoperative serum VEGF and MIF levels (p = 0.118 and p = 0.297, respectively). CA125 levels were significantly higher in the malignant group (p < 0.0001). There was no significant difference for VEGF and MIF between the groups evaluated for tumour grade, stage, presence of ascites and degree of cytoreduction performed in the malignant group. Preoperative serum, VEGF and MIF levels are not suitable for the differentiation of malignant and benign adnexal masses, and they do not correlate with the prognostic factors of ovarian cancer in this cohort of patients.

Can preoperative neutrophil:lymphocyte and platelet:lymphocyte ratios be used as predictive markers for lymph node metastasis in squamous cell carcinoma of the vulva?

OBJECTIVE

To determine whether the neutrophil:lymphocyte ratio (NLR) and platelet:lymphocyte ratio (PLR) before complete surgical staging provide information on lymph node metastasis in vulvar squamous cell carcinoma (SCC).

STUDY DESIGN

All patients with vulvar SCC who underwent complete surgical staging at two institutions between 1 January 2005 and 31 December 2011 were identified retrospectively from patient databases. Receiver operating characteristic (ROC) curve analysis was used to evaluate cut-off, sensitivity, and specificity values for preoperative NLR and PLR to predict lymph node metastasis.

RESULTS

Data from 64 women with adequate information were analyzed. Lymph node involvement was detected in 19 (29.7%) patients. NLR and PLR were higher in the lymph node--positive group than in the--negative group (p < 0.001). The best cut-off values for predicting lymph node metastasis were 2.81 for the NLR, with 84.5% sensitivity and 89.5% specificity, and 139.5 for the PLR, with 68.9% sensitivity and 89.5% specificity. Forty of the 64 (62.5%) patients had NLRs ≤ 2.81 and 24 (37.5%) had NLRs >2.81. Lymph node involvement was more common in the NLR >2.81 group [60.7% vs. 5.6%; relative risk RR = 10.9, 95% confidence interval CI = 2.7-43.4; p < 0.001]. Mean tumor sizes were 4.2 ± 2.3 cm in the NLR >2.81 group and 2.1 ± 1.2 cm in the NLR ≤ 2.81 group (p = 0.001). The rate of lymph node involvement was higher in the PLR >139.5 group than in the PLR ≤ 139.5 group (54.8% vs. 6.1%; RR = 9.0, 95% CI = 2.2-35.9; p<0.001).

CONCLUSION

Preoperative NLR and PLR are directly associated with nodal involvement status of vulvar SCC. These markers are simple, readily obtained and calculated, and easy to integrate into the surgical work-up of patients with vulvar SCC, at no extra cost.

Evaluation of treatment results and prognostic factors in early-stage cervical carcinoma patients treated with postoperative radiotherapy or radiochemotherapy

PURPOSE

To investigate the clinical features, prognostic factors, and treatment outcome in early-stage cervical carcinoma patients treated with postoperative radiotherapy (RT)/radiochemotherapy (RCT).

METHODS

The records of 256 Stage IB and II cervical cancer patients treated with postoperative RT/RCT from 1992-2007 were retrospectively reviewed. Median age of the patients was 47 (range: 25-78). Two hundred one (78.6%) patients had squamous cell carcinoma and 29 (11.3%) had adenocarcinoma. One hundred and eighty-seven (73.0%) had FIGO Stage IB and 69 (27%) had Stage II disease. Concomitant cisplatin-based chemotherapy was administered to 47 (18.4%) patients. Metastatic lymph node ratio (MLNR), defined as number of metastatic lymph nodes divided by the number of dissected lymph nodes, was 0 in 142 (55.5%) patients, from 1% to 10% in 27 (10.5%) and > 10% in 31 (12.1%) patients.

RESULTS

Median follow-up duration was 60.5 months (range: 6-202 months). Five-year locoregional control (LRC), disease-free survival (DFS), disease specific survival (DSS) and overall survival (OS) rates were 90.8%, 83.4%, 91.2%, and 85%, respectively. In multivariate analysis; bulky tumor (> 4 cm) was shown as an important prognostic factor for LRC, DFS and DSS. Pretreatment hemoglobin level (< 10 g/dl) was associated with lower OS rate. Endometrial involvement was associated with lower LRC and DFS. Treatment break > 14 days showed significance for DFS and DSS. MLNR was found as a valuable prognostic factor for all endpoints (LRC, DFS, DSS and OS). The rate of grade 3-4 late toxicity was 3.6% and 2%, respectively.

CONCLUSION

Postoperative RT/RCT is an effective treatment modality for early-stage cervical cancer patients with unfavorable features and provides satisfactory local control and survival rates with low morbidity.

Congenital vulvar lymphangioma circumscriptum

Lymphangioma circumscriptum (LC) is a defect of lymphatic channels in the deep dermis and subcutaneous layers, characterized by grouped vesicles. This disorder rarely occurs in vulvar sites. We present a rare case of LC in a 72-year-old patient who presented with a vulvar mass and ipsilateral leg edema.

Pegylated liposomal doxorubicin in heavily pretreated epithelial ovarian cancer patients

PURPOSE

While most patients with ovarian cancer respond to first-line treatment, 50-75% of these patients will eventually relapse. Pegylated liposomal doxorubicin (PLD) is an active agent indicated for the treatment of patients with disease that is refractory to both paclitaxel- and platinum-based regimens, but skin toxicity remains the dose-limiting toxicity of the drug. The primary objective of this retrospective study was to evaluate the activity and safety of this agent in patients with heavily pretreated ovarian cancer.

PATIENTS AND METHODS

Patients with platinum-refractory/ resistant, paclitaxel-pretreated epithelial ovarian carcinoma were treated with PLD 50 mg/m2 in 4-week courses until disease progression or unacceptable toxicity. All patients had progressive disease (PD) before starting PLD. Primary endpoints were response rate, progression free survival (PFS) and toxicity and secondary endpoints duration of response (DOS) and overall survival (OS).

RESULTS

Seventeen heavily pretreated patients (median number of previous chemotherapy regimens 3, range 1-5) with taxane- and platinum-refractory disease were analysed. No complete response (CR) was achieved, while 3 (17%) partial responses (PR) and 2 (11%) cases with stable disease (SD) were observed. The median PFS was 15 weeks (range 10-21) and median OS 32 weeks (range 16-47). Palmar plantar erythrodysesthesia (PPE) occurred in 4 (23%) patients and was of grade 4 in 1 (6%) patient. Stomatitis occurred in 3 (17%) patients and was grade 3 in 1 (6%) patient. Grade 3-4 neutropenia occurred in only 2 (12%) patients. No febrile neutropenia was encountered.

CONCLUSION

Pegylated liposomal doxorubicin is an active and tolerable agent in heavily pretreated epithelial ovarian cancer patients.

The effects of raloxifen on depression and cognition in ovariectomized rats

This study investigates the effects of raloxifen on cognition and depression in an animal model.

Postoperative radiotherapy in intermediate and high-risk Stage I endometrial cancer: analysis of prognostic factors and survival

PURPOSE

Patients with Stage IA Grade (G) III, Stage IB GII-III and Stage IC GI-II-III endometrial cancer who received postoperative adjuvant radiotherapy were evaluated in terms of local control, disease-free and overall survival rates and prognostic factors.

MATERIALS AND METHODS

Four hundred and three patients with Stage I endometrial cancer treated with radiotherapy from January 1990 to December 2003 at Ege University Faculty of Medicine Department of Radiation Oncology were reviewed retrospectively. According to our radiotherapy protocol patients with Stage IB G2 disease (149 patients) received only external radiotherapy and the remaining (254 patients) received both external radiotherapy and intracavitary brachytherapy.

RESULTS

Median age of the patients was 58 (range: 37-83). Nine patients (2.2%) had Stage IA, 196 (48.6%) had Stage IB and 198 (49.1%) had Stage IC disease. Histologic grade was 1 in 52 (12.9%) patients, 2 in 268 (66.5%) patients and 3 in 83 (20.6%) patients. Seventy-one (17.7%) patients had lymphovascular space invasion. Five-year locoregional relapse-free, distant-free, disease-free survival (DFS) and overall survival (OS) were 98.2%, 92.8%, 91.8% and 87.7%, respectively. In multivariate analysis, myometrial invasion and lymphovascular invasion were predictive factors for DFS and for OS prognostic factors were histologic type, myometrial invasion, and histologic grade. During radiotherapy 47.9% of the patients developed acute morbidity and 26.3% developed late morbidity, vaginal stenosis being the most frequent late morbidity.

CONCLUSION

Postoperative adjuvant radiotherapy provides high locoregional control rates with acceptable toxicity in selected patients with Stage I endometrial carcinoma.

MMAC tumor supressor gene expression in ovarian endometriosis and ovarian adenocarcinoma

OBJECTIVE

The aim of this study was to investigate the role of MMAC1 protein in the relationship between ovarian endometriosis and clear cell and endometrioid-type ovarian adenocarcinomas.

METHODS

A total of 63 subjects who underwent surgery for a pelvic tumoral mass, 30 of whom were diagnosed with grade 1 to 3 ovarian adenocarcinoma and 33 of whom were diagnosed with grade 1 to 4 endometriosis during histopathological examination were included in this study. The mean age for subjects with ovarian endometrioid type adenocarcinoma was 51.8 +/- 12.4, whereas the mean age for subjects with ovarian clear cell type adenocarcinoma was 59.5 +/- 13.7. Ovarian carcinomas were graded in accordance with the FIGO 1989 grading system. The mean age for subjects with endometriosis was 37 +/- 11.9. New sections were obtained from paraffin blocks in the archives of Ege University, School of Medicine, Department of Pathology onto lysinated slides and immunohistochemical staining by using mouse monoclonal antibody (MMAC1, 28H6 clone, Novocastra, UK) as MMAC antibody was applied in order to determine MMAC1 protein. Brown staining on the nucleus was considered as positive immunoreactivity. Immunoreactive staining was evaluated as percentage staining over the whole preparative.

RESULTS

Of the 63 subjects included in the immunohistochemical study, ovarian endometrioid adenocarcinoma was identified in 18 subjects, while 12 subjects were diagnosed with ovarian clear cell adenocarcinoma and 33 subjects with ovarian endometriosis. No significant relationships were observed between age and MMAC immune staining in the ovarian endometrioid adenocarcinoma (r = -0.41, p = 0.08) and ovarian endometriosis (r = 0.12, p = 0.50) groups, whereas a significant relationship was observed in the ovarian clear cell adenocarcinoma group (r = 0.631, p = 0.02). No significant relationships were observed between CA125 levels and MMAC immune staining in the ovarian endometrioide adenocarcinoma (r = 0.056, p = 0.82), ovarian endometriosis (r = 0.21, p = 0.36) and ovarian clear cell adenocarcinoma (r = 0.363, p = 0.24) groups. No correlations were observed between endometriosis stages and the MMAC immune staining (r = -0.17, p = 0.92). There was no correlation between mean diameter of endometrioma and MMAC immune staining (r = -0.230, p = 198). Mean endometrioma diameter was 5.7 +/- 3.5 (1-15.5). No correlations were detected between MMAC immune staining and ovarian endometrioide adenocarcinoma or ovarian clear cell adenocarcinoma stage (r = -0.22, p = 0.37; r = 0.44, p = 0.14, respectively). No significant relationships with respect to MMAC immune staining were detected between the endometriosis and ovarian clear cell adenocarcinoma groups (p = 0.05) and between the ovarian clear cell adenocarcinoma and ovarian endometrioid adenocarcinoma groups (p = 0.27). A significant relationship with respect to MMAC immune staining was observed between ovarian endometrioide adenocarcinoma and endometriosis groups (p = 0.001).

CONCLUSION

Immunohistochemical determination of MMAC defective protein expressions could be considered for utilization as a new, simple and useful technique in determination of endometriosis patients with increased risk of malignant transformation, patients where early surgical treatment would be necessary and patients that should be subjected to follow-up controls with a higher frequency.

Topotecan in Platinum-Resistant Epithelial Ovarian Cancer

BACKGROUND

Topotecan has been emerged as a new promising anticancer drug for patients with ovarian cancer.

METHODS

In this study, patients who were treated with topotecan were reviewed retrospectively. A total of 26 patients was included the study. All patients had received platinum-based regimens previously. Topotecan was administered a dose of 1.5 mg/m(2) intravenously 30 min daily for 5 days and repeated every 21 days.

RESULTS

The response rates were 30% by CA-125 level and 29% in clinic evaluation. Median duration of response was 8 (3-15) months, median progression-free interval was 12 (4-30) months and median overall survival was 15 (4-36) months. Grade 3-4 neutropenia occurred in 58% of the patients (38% of the courses) and trombocytopenia in 29% of the patients (12% of the courses). Nonhematological toxicities were mild. There was no drug-related death.

CONCLUSION

Topotecan is considered as a reasonable option for treatment of patients with platinum refractory recurrent ovarian cancer.

Predictive value of serum interleukin-8 levels in ovarian cancer patients treated with paclitaxel-containing regimens

Previous findings showed that paclitaxel induces interleukin-8 (IL-8) transcription and secretion in ovarian cancer cells in vitro. We hypothesized that paclitaxel treatment, which is a standard care for ovarian cancer patients, may increase the secretion of IL-8, resulting in the elevated serum IL-8 levels. In this study, we investigated the relationship between paclitaxel exposure and IL-8 levels of an ovarian and a breast carcinoma cell line in vitro and serums of patients with ovarian carcinoma. Both MDAH 2774 ovarian and MCF-7 breast carcinoma cell lines were sensitive to paclitaxel-mediated cytotoxicity. However, supernatant levels of IL-8 assessed by enzyme-linked immunosorbent assay before and after treatment with different concentrations of paclitaxel were significantly lower in MCF-7 than in MDAH 2774. Serum IL-8 levels were measured in serum samples from patients with ovarian carcinoma before and after paclitaxel-containing treatment regimens. Forty-eight patients were included in the study. The basal level of IL-8 after paclitaxel-containing treatment was found to be significantly higher in the serums of patients who had high tumor burden than in patients who had optimal debulking surgery and low tumor burden. These data strongly suggest that IL-8 may be an important predictive marker for tumor volume as well as sensitivity to paclitaxel.

Predictive value of serum interleukin-8 levels in ovarian cancer patients treated with paclitaxel-containing regimens

Previous findings showed that paclitaxel induces interleukin-8 (IL-8) transcription and secretion in ovarian cancer cells in vitro. We hypothesized that paclitaxel treatment, which is a standard care for ovarian cancer patients, may increase the secretion of IL-8, resulting in the elevated serum IL-8 levels. In this study, we investigated the relationship between paclitaxel exposure and IL-8 levels of an ovarian and a breast carcinoma cell line in vitro and serums of patients with ovarian carcinoma. Both MDAH 2774 ovarian and MCF-7 breast carcinoma cell lines were sensitive to paclitaxel-mediated cytotoxicity. However, supernatant levels of IL-8 assessed by enzyme-linked immunosorbent assay before and after treatment with different concentrations of paclitaxel were significantly lower in MCF-7 than in MDAH 2774. Serum IL-8 levels were measured in serum samples from patients with ovarian carcinoma before and after paclitaxel-containing treatment regimens. Forty-eight patients were included in the study. The basal level of IL-8 after paclitaxel-containing treatment was found to be significantly higher in the serums of patients who had high tumor burden than in patients who had optimal debulking surgery and low tumor burden. These data strongly suggest that IL-8 may be an important predictive marker for tumor volume as well as sensitivity to paclitaxel.

Large cell neuroendocrine carcinoma of the uterine cervix: a report of a case and review of the literature

INTRODUCTION

Large cell neuroendocrine carcinoma is a rare aggressive cervical neoplasm, considerably rarer than the well-recognized small cell neuroendocrine carcinoma of the cervix. Cervical large cell neuroendocrine carcinomas are distinctive cervical carcinomas that are frequently misdiagnosed and have an unfavorable outcome, similar to that of small cell carcinoma.

CASE REPORT

We report a 45-year-old woman with large cell neuroendocrine uterine cervical carcinoma.

Large cell neuroendocrine carcinoma of the uterine corpus metastatic to brain and lung: case report and review of the literature

Neuroendocrine carcinoma of the uterine corpus is a rare aggressive tumor with a similar unfavorable outcome to that of the cervix. The large cell type is considerably rarer than the small cell neuroendocrine carcinoma of the uterine corpus. We report a case of a 52-year-old woman who presented with a large cell neuroendocrine tumor of the uterine corpus with very aggressive clinical behavior, cerebral and pulmonary metastases six and four months after initial diagnosis and adjuvant radiotherapy, respectively. Despite successful surgical extirpation of the cerebral metastatic lesion she did not respond to chemotherapy and died four months after disease recurrence.

Cellular angiofibroma of the vulva: report of a case

A case of vulvar cellular angiofibroma in a 50-year-old woman was immunohistochemically examined. She presented with a right labial mass which was noticed four years before. Surgical excision of the mass was performed. Histopathological examination revealed typical characteristics of cellular angiofibroma. Immunohistochemically, the lesion was CD34 positive but non-reactive for desmin, smooth muscle actin and S-100 protein. In this article, we present a case of vulvar cellular angiofibroma, a lesion that should be considered in the differential diagnosis of vulvar soft tissue tumors.

Subcutaneous metastasis of endometrial adenocarcinoma: case report of an incidental diagnosis during abdominal sonography

A rare case of subcutaneous metastasis from endometrial adenocarcinoma detected incidentally on the anterior abdominal wall during routine abdominal sonography is reported. A 62-year-old woman with clinical FIGO Stage IA, grade 2 endometrial mixed type (endometrioid and mucinous) adenocarcinoma was found with a subcutaneous mass located in the abdomen 18 months after initial surgery.

Critically ill obstetric patients in the intensive care unit

We aimed to determine the morbidity and mortality among obstetric patients admitted to the intensive care unit. In this study, we analyzed retrospectively all obstetric admissions to a multi-disciplinary intensive care unit over a five-year period. Obstetric patients were identified from 4733 consecutive intensive care unit admissions. Maternal age, gestation of newborns, mode of delivery, presence of coexisting medical problems, duration of stay, admission diagnosis, specific intensive care interventions (mechanical ventilation, continuous veno-venous hemofiltration, central venous catheterization, and arterial cannulation), outcome, maternal mortality, and acute physiology and chronic health evaluation (APACHE) II score were recorded. Obstetric patients (n=125) represented 2.64% of all intensive care unit admissions and 0.89% of all deliveries during the five-year period. The overall mortality of those admitted to the intensive care unit was 10.4%. Maternal age and gestation of newborns were similar in survivors and non-survivors. There were significant differences in length of stay and APACHE II score between survivors and non-survivors P < 0.05. The commonest cause of intensive care unit admission was preeclampsia/eclampsia (73.6%) followed by post-partum hemorrhage (11.2%). Intensive care specialists should be familiar with these complications of pregnancy and should work closely with obstetricians.

Respiratory mechanics in morbid obese patients with chronic obstructive pulmonary disease and hypertension during pneumoperitoneum

BACKGROUND AND OBJECTIVE

To evaluate the effects of pneumoperitoneum and the reverse Trendelenburg position on respiratory mechanics and blood-gases in morbid obese patients with chronic obstructive pulmonary disease and hypertension.

METHODS

Sixteen morbid obese patients with chronic obstructive pulmonary disease and hypertension were studied. Mean arterial pressure, heart rate, respiratory resistance, dynamic respiratory compliance and peak inspiratory pressures were measured at four time points: 5 min after induction of anaesthesia (T1), 5 min after insufflation of the peritoneum (T2), 5 min after adoption of a 20 degrees reverse Trendelenburg position (T3), and 5 min after deflation of the peritoneum (T4). Arterial blood-gas status was measured at the same measuring points.

RESULTS

Respiratory compliance was 40 +/- 12, 28 +/- 8, 32 +/- 8 and 37 +/- 11 mL cm H2O(-1) in T1, T2, T3 and T4, respectively. The changes were significant at T2, T3 and T4. Airway resistance and peak inspiratory pressures showed comparable changes throughout the study with that of respiratory compliance. Haemodynamic measurements showed no clinically significant changes in this study.

CONCLUSIONS

In morbid obese patients with chronic obstructive pulmonary disease and hypertension, a 20 degrees reverse Trendelenburg position improved respiratory mechanics and oxygenation without any apparent adverse effects on haemodynamics during laparoscopic gastric banding surgery.

Pulmonary mechanics during isoflurane, sevoflurane and desflurane anaesthesia

This study was designed to investigate the effects of desflurane on bronchial smooth muscle tone, following intubation and to compare these effects with isoflurane and sevoflurane. Patients were randomly divided into three groups to receive, isoflurane (n = 22), sevoflurane (n = 23), or desflurane (n = 22). Peak inspiratory pressure (PIP), respiratory resistance (Rr) and dynamic compliance (Cdyn) measurements were recorded at three time points; After the beginning of ventilation and before inhalation agent was started, following 5 min of ventilation with 1 MAC (minimum alveolar concentration) inhalation agent and following 5 min of 2 MAC inhalation agent. We found that all inhalation agents caused a significant decrease in Peak Inspiratory Pressure (PIP) and respiratory resistance (Rr), and an increase in dynamic compliance (Cdyn) at 1 MAC concentrations. When the agent concentration was increased to 2 MAC, desflurane caused a significant increase in Rr and PIP and a decrease in Cdyn. We concluded that desflurane, like isoflurane and sevoflurane, exhibits a bronchodilator effect at 1 MAC concentration. However, increasing the concentration to 2 MAC caused an increase in airway resistance with desflurane, whilst sevoflurane and isoflurane continued to have a bronchodilator effect.

Crush syndrome patients after the Marmara earthquake

BACKGROUND

To assess the treatment and outcome of patients with crush injury sustained in the Marmara earthquake.

METHODS

Seven hundred eighty three patients were transferred to a university hospital and 25 of them were admitted to the intensive care unit. The medical records of 18 crush injury patients were retrospectively reviewed.

RESULTS

The major associated injuries were in the lower extremities, upper extremities, and chest. Seven patients underwent fasciotomy and six patients had amputations. Twelve patients required mechanical ventilation. Adult respiratory distress syndrome developed in four patients. Oliguria occurred in eight patients. Hyperkalaemia was seen in six patients and four of them underwent emergency haemodialysis. One patient died because of hyperkalaemia on arrival to the intensive care unit. Renal failure was treated with haemodialysis or haemoperfusion in 13 patients. Five patients died because of multiple organ failure and two patients because of sepsis.

CONCLUSION

Crush syndrome is a life threatening event. The authors believe that early transportation and immediate intensive care therapy would have improved the survival rate.

The triage of squamous cell abnormalities of cervical cytology by human papilloma virus screening

OBJECTIVE

The aim of the study was to determine the presence of human papilloma virus (HPV) infection in cervical swabs by the use of the Digene Hybrid Capture assay in a cohort of patients with squamous cell abnormalities found in cervical cytologic screening.

MATERIALS AND METHODS

Thirty-four (0.3%) of 1,100 patients who came for their routine cervical cytologic screening and diagnosed as having squamous cell abnormalities were enrolled in the study. Colposcopy-directed biopsy was obtained from all study patients. HPV DNA was sought in cervical swab specimens placed in Digene transport medium by the use of the Digene Hybrid Capture assay. The findings of cervical cytology, colposcopy-directed biopsy and HPV screening were compared.

RESULTS

In a total of 34 women who were diagnosed as having squamous cell abnormalities in their routine cervical cytologic screening, 15 women had atypical squamous cell lesions of undetermined significancy (ASCUS), 16 women had low-grade cervical intraepithelial lesions (LGSIL), and three women had high-grade cervical intraepithelial lesions (HGSIL). Five (15%) of these women tested positive for HPV screening in cervical swabs where four women had infection with high-risk and one woman had infection with low-risk subtypes. None of the patients with koilocytotic changes of the squamous cells in the class of LGSIL histopathologically tested positive for HPV screening. In addition, one patient diagnosed as having invasive cervical carcinoma histopathologically tested negative for HPV screening. Atypical vascularization was seen colposcopically in this 37-year-old woman who had ASCUS cytologically.

CONCLUSION

HPV screening seems to have value in the triage of patients with ASCUS with no clear advantage to colposcopy-directed biopsy. The routine performance of HPV screening for the triage of patients with squamous cell abnormalities has no advantage over colposcopy-directed biopsy.

Abdominal skin metastasis of endometrial adenocarcinoma: case report

Skin metastasis from endometrial adenocarcinoma in the radiotherapy field is reported. A 60-year-old woman with FIGO stage IB, grade 2 endometrial adenocarcinoma presented 24 months after initial surgery with skin metastasis located on the abdomen.

Ovarian cysts in postmenopausal tamoxifen-treated breast cancer patients with endometrial thickening detected by transvaginal sonography

OBJECTIVE

To investigate the frequency of ovarian cysts in tamoxifen-treated postmenopausal breast cancer patients with endometrial thickening detected by transvaginal sonography.

METHODS

Medical records and transvaginal sonographies of 38 postmenopausal women treated for breast cancer with adjuvant tamoxifen therapy who had undergone endometrial sampling due to abnormal endometrial thickness were reviewed retrospectively.

RESULTS

During the study period five of 38 tamoxifen-treated postmenopausal patients (13.2%) had ovarian cysts. The mean tamoxifen treatment interval of the patients with an ovarian cyst was 22.4 +/- 18.4 months (p = 0.17). The mean endometrial thickness of the patients with an ovarian cyst was 12.6 +/- 5.9 mm (p = 0.17). Endometrial biopsy detected six cases of abnormal endometria, including endometrial carcinoma (n = 1), endometrial polyp (n = 1) and simple endometrial hyperplasia without atypia (n = 4). Three patients with ovarian cysts underwent laparatomy revealing simple cysts on histopathological examination. Two patients with ovarian cysts declined laparatomy and are currently under follow-up.

CONCLUSION

Ovarian cysts a common side-effect of tamoxifen treatment in postmenopausal tamoxifen-treated breast cancer patients. Transvaginal sonography should be performed to detect any concomitant endometrial pathology.

Environmental contamination during a carbapenem-resistant Acinetobacter baumannii outbreak in an intensive care unit

During a three-month period in 1999, 25 strains of carbapenem resistant Acinetobacter baumannii were isolated from 12 of 170 hospitalized intensive care unit (ICU) patients, of which 16 were considered to be clinically significant. These strains were indistinguishable by biotyping and antibiograms, but genotyping was not performed. Appropriate antibiotic treatment, isolation precautions, and infection control education of the staff failed to halt the outbreak. Environmental contamination was therefore investigated, and A. baumannii was found out in 22 (39.3%) of 56 environmental samples obtained by swabbing. Different antibiotic sensitivity patterns were obtained in the majority of these isolates, but four (7.1%) of the strains were found to have the same sensitivity pattern as the strain causing the outbreak. As a result the ICU was closed, equipment and the environment cleaned, with hypochlorite and terminal disinfection carried out. No bacteria were grown on repeat environmental cultures. Environmental contamination has an important reservoir role in outbreaks of A. baumannii in ICUs and must be eradicated in order to overcome such outbreaks.

Metabolic effects associated with high-dose continuous megestrol acetate administration in the treatment of endometrial pathology

OBJECTIVES

To determine the metabolic effects and efficacy of high-dose continuous megestrol acetate administration in the treatment of endometrial pathology.

MATERIAL AND METHODS

27 women with histologically proven endometrial pathology (endometrial hyperplasia and irregularly proliferative endometrium) were treated with megestrol acetate orally 160 mg/d given once-a-day for 3 months. In 5 of 27 patients the dose of megestrol acetate was increased to 320 mg/d to alleviate irregular uterine bleeding. Serum lipid profiles and fasting and 2-h postprandial serum glucose levels were studied at baseline and one week after the therapy was completed.

RESULTS

HDL-cholesterol level significantly lowered from a mean of 50.4+/-11.1 mg/dL to 44.4+/-8.5 mg/dL after 3 months of megestrol acetate therapy (p<0.05). Serum total cholesterol level significantly lowered from a mean of 222.8+/-50.0 mg/dL to 192.7+/-36.5 mg/dL (p<0.05) and apolipoprotein A-I level from a median of 134 mg/dL to 116 mg/dL (p<0.05) after the therapy. Serum LDL-cholesterol, triglyceride, apolipoprotein B, fasting and 2-h postprandial glucose levels did not significantly change after the therapy (p>0.05). The median weight of patients was found to be 70 (53-110) kg before the therapy and 74 (56-111) kg after the therapy (p=0.001).

CONCLUSIONS

The use of megestrol acetate, 160-320 mg/d, in the treatment of endometrial pathology is an effective method without marked harmful effects on serum lipid profiles or glucose levels but is associated with weight gain.

Uterine adenosarcoma with rhabdomyosarcomatous overgrowth. Brief communication

A case of a rhabdomyosarcomatous uterine adenosarcoma with sarcomatous overgrowth is presented. The rhabdomyosarcoma component constituted about 90% of the tumor. The patient died 5 years and 5 months after the operation. Rhabdomyosarcomatous uterine adenosarcoma even with a sarcomatous overgrowth does not seem to be more malignant than other adenosarcomas.

Bilateral metastatic carcinoma of the breast from primary ovarian cancer

We report a case of ovarian cancer with metastasis to both breasts and axillary lymph nodes and the vaginal cuff. A 41-year-old previously hysterectomized women presented with pelvic mass and malignant pleural effusion. During the courses of chemotherapy; bilateral breast nodules, and bilateral axillary lymphadenopathies and a nodule in the vaginal cuff were identified. The biopsy of both breasts, axillary lymph nodes and the nodule in the vaginal cuff revealed papillary serous cystadenocarcinoma. Immunohistochemical staining of breast specimens were positive for ovarian tumor marker CA-125.

Giant myoma and erythrocytosis syndrome

The objective of this study is to discuss the myomatous erythrocytosis syndrome in a patient with a giant subserous uterine myoma. She presented with plethora and an abdominal mass. After venesection of 4 units of blood, the preoperative haematocrit value of 53.3% and haemoglobin value of 17.5 g/dL had decreased to 48.6% and 16.8 g/dL levels, respectively. After the operative extraction of the giant subserous myoma with attached uterus weighing 14.2 kg, the haematocrit and the haemoglobin values had regressed to 40.3% and 14.3 g/dL levels, respectively. The findings indicated that the giant subserous myoma was the cause of the myomatous erythrocytosis syndrome in this patient.

p53 staining as a prognostic indicator in endometrial carcinoma

OBJECTIVE

To investigate p53 expression in endometrial cancer and its significance as a prognostic indicator.

METHODS

Thirty-five consecutively surgically treated patients with endometrial cancer had their p53 expression studied by immunoperoxidase staining and quantified by lighted microscopic evaluation of the staining pattern. The determination of mean percentage of p53 expression was compared to prognostic indicators of endometrial cancer.

RESULTS

p53 staining was detected in 20 of the 35 cases of endometrial carcinoma. Eleven of the 21 endometrioid tumors stained positive, while 9 out of 14 tumors with more aggressive histology stained positive for p53. If the grade I and II patients were taken into account as a whole, there was a statistically significant correlation (p<0.001) between the grade I and II patients and the grade III patients. The difference was statistically significant between stage I and III (p<0.05). The difference between lymphovascular space invasion and no lymphovascular invasion and p53 positivity was statistically significant (p<0.05).

CONCLUSION

p53 expression is more common in more aggressive histologic subtypes than in endometrioid adenocarcinomas. Strong expression of p53 correlates with advanced stage and high grade and is detected more frequently in endometrial cancers with lymphovascular invasion.

Evaluation of the risk of cervical intraepithelial neoplasia and human papilloma virus infection in renal transplant patients receiving immunosuppressive therapy

OBJECTIVE

To investigate the risk of cervical intraepithelial neoplasia and the coexistence of human papilloma virus (HPV) infection in renal transplant patients receiving immunosuppressive therapy.

MATERIALS AND METHODS

Cervical Papanicolaou (Pap) smear and colposcopic examinations were performed in 48 renal transplant patients receiving immunosuppressive therapy. Microbiological and histopathologic findings were discussed.

RESULTS

The patients were evaluated as to cervical neoplasia risk factors and the results were found to be statistically insignificant (p>0.05). Genital neoplasia was encountered in 20 of the 48 renal transplant patients. Koilocytosis developed in 6 out of 8 (75%) patients who were receiving high dose immunosuppressive therapy due to transplant rejection. HPV was found in 2 out of 48 patients; these 2 patients had koilocytosis in their cervical biopsies. The difference between the positive predictive value of colposcopic evaluation and the Pap smear was found to be insignificant (p>0.05). However, if colposcopy had not been performed in two cases of cervical intraepithelial neoplasia class I (CIN-I) and in one case of cervical microinvasive carcinoma, the cases would have been incorrectly diagnosed as normal by the false-negative results of the Pap smear.

CONCLUSION

Renal transplant patients who were undergoing immunosuppressive therapy were found to be at increased risk of developing cervical intraepithelial neoplasia. All the patients using immunosuppressive agents should be followed-up by Pap smears every six months and by colposcopic evaluation every year. Avoiding high-risk sexual acts will decrease the risk of HPV transmission and the risk of genital neoplasia as well.

Endometrial pathology of 104 postmenopausal breast cancer patients treated with tamoxifen

OBJECTIVE

To investigate the effects of tamoxifen on the endometrium in postmenopausal breast cancer patients.

METHODS

Endometrial thickness was measured by transvaginal sonography and endometrial biopsies were done in 104 postmenopausal breast cancer cases who were treated with tamoxifen. Histopathologic findings were discussed.

RESULTS

Mean endometrial thickness was 11.7+/-5.9 mm and duration of tamoxifen administration was 35.3 months. Four endometrial cancers, 17 endometrial hyperplasias, 25 proliferative endometrium, 5 endometrial polyps in the endometrial biopsies. We observed atrophic endometrium in 53 of the cases. Only one case with endometrial polyps was observed as a premalignant lesion when the endometrium was less than 5 mm, 51% of the cases had thicker endometrium (more than 10 mm) and 32% of these cases had malignant and premalignant endometrium. We found a significant correlation with the duration of tamoxifen and age (p<0.05). One hundred and two of our cases were asymptomatic; only 2 out of 4 endometrial cancer cases had vaginal spotting. A significant relation was noticed between endometrial thickness and duration of tamoxifen treatment (p=0.025).

CONCLUSION

It was concluded that positive endometrial findings and endometrial thickness were due to continuous unopposed tamoxifen treatment and our findings support the hypothesis that tamoxifen increases the risk of endometrial carcinoma and premalignant changes.

Unilateral high frequency jet ventilation during one-lung ventilation

Fifteen patients undergoing elective thoracic surgery were studied in order to investigate the efficacy of high frequency jet ventilation of the non-dependent lung with respect to arterial oxygenation. During the study PaO2, PaCO2, arterial pressures and heart rate were recorded during ventilation of both lungs in the lateral decubitus position during one-lung ventilation and during high frequency jet ventilation of the non-dependent lung. Mean PaO2 was 28 +/- 8.75 kPa and mean PaCO2 was 5.4 +/- 0.7 kPa during control. During one-lung ventilation, PaO2 dropped to 10.8 +/- 2.57 kPa and PaCO2 rose to 6.3 +/- 0.9 kPa. With high frequency jet ventilation to the non-dependent lung, mean PaO2 increased to 25 +/- 6.75 kPa and PaCO2 decreased to 5.16 +/- 0.9 kPa respectively. Arterial pressures and heart rate remained stable during the study period. In conclusion high frequency jet ventilation of the non-dependent lung was effective in providing arterial normoxaemia and normocapnia during one-lung ventilation.

Comparison of intrapleural versus intravenous morphine for postthoracotomy pain management

OBJECTIVE

To compare the analgesic effects of intrapleural and intravenous morphine administration for postthoracotomy pain management.

DESIGN

Randomized, prospective trial.

SETTING

University teaching hospital.

PARTICIPANTS

Twenty-eight consenting patients scheduled for elective thoracotomy operations.

INTERVENTIONS

Patients were randomly allocated into two groups to receive either 20 mg of intrapleural morphine (IPM group) or 20 mg of intravenous morphine (IVM group) at the end of the operation. Plasma morphine levels, arterial pressures, heart rate, verbal analog scale (VAS), respiratory rate, and PaCO2 levels were compared in two groups.

MEASUREMENTS AND MAIN RESULTS

Plasma morphine levels were significantly higher in the IVM group at the 5th minute until the 2nd postoperative hour. VAS was significantly higher in the IVM group. Respiratory rates were significantly higher in the IPM group, whereas PaCO2 remained significantly lower than in the IVM group.

CONCLUSIONS

IPM achieved better analgesia than IVM and this effect is probably attributable to peripheral effects of morphine.