Cerrahpasa Medical Faculty

We report a 44-year-old woman with intermittent left exotropia of 35 prism diopters at distance who initially exhibited alignment of both eyes after bilateral laser in situ keratomileusis (LASIK). The exophoria was not preserved due to myopic regression in the dominant eye. ...

Atypical antipsychotics commonly cause isolated asymptomatic increase in the aminotransferase levels. Olanzapine also not infrequently causes asymptomatic elevation of liver transaminase; however there have been a few case reports of olanzapine related serious hepatotoxicity. The pathogenesis of olanzapine-induced hepatotoxicity is not well known and is mostly a transient phenomenon. However substantial and lasting changes may occur and result in symptomatic hepatitis. In the following case report, we describe a 44-year-old female patient diagnosed as Bipolar Disorder Type I, whose liver enzyme levels increased ten fold of normal ranges during the third year of the olanzapine treatment and returned to the normal levels within three weeks after olanzapine discontinued. Although clinically significant liver enzyme elevations are uncommon, based on the serious case reports of hepatotoxicity, baseline and periodic monitoring of liver enzymes are advised in olanzapine-treated patients.

Our objective was to determine the effect of serum iron levels and hepatic iron overload on hepatocellular damage in nonalcoholic steatohepatitis (NASH) and to compare this with chronic viral hepatitis. Twenty-five patients who had elevated transaminase levels on at least two occasions, without any evidence of viral and autoimmune hepatitis and diabetes, without a history of significant alcohol use, and with a liver biopsy consistent with NASH were enrolled in the study. Twenty-five patients with chronic viral hepatitis (13 patients with chronic hepatitis C and 12 with chronic hepatitis B) who were not under any antiviral treatment were taken as controls. Metabolic factors were studied in the NASH and chronic hepatitis groups. Biopsy specimens were stained with hematoxylin-eosin, and the grade of steatosis and the stage of fibrosis were evaluated as I, II, or III,

Interferon-a (IFN) and ursodeoxycholic acid (UDCA) combined have a controversial role in the treatment of chronic type C hepatitis. We studied the long-term ef® cacy of both drugs alone or in combination. In a three-year period, 108 patients were randomized into three treatment arms: (1) IFN alone 3 MU three times a week (N 5 49), (2) IFN 3 MU three times a week 1 UDCA 250 mg twice a day (N 5 45), and (3) UDCA alone 250 mg twice a day (N 5 14). Response was de® ned as complete normalizati on of serum ALT. For the responders at the end of six months, the treatment was run to 12 months. Nonresponders (NRs) of the ® rst group were crossed over to combinatio n and NRs of the combination received 6 MU three times a week IFN 1 UDCA for the next six months. The enrollmen t to the UDCA alone arm was stopped early, since only 1/14 normalized serum ALT at the end of third month. However, 12/14 completed six months and 11 NRs received IFN 3 MU three times a week alone for the next six months. Twelve discontinu ed treatment due to side effects. Responders were followed-up untreated for 18 months. Sustained response (SR) was de® ned as persistence of normal serum ALT levels in this period. At the end of six months, 22/45 (48%) from the IFN-alone and 23/39 (58%) from the combination group responded. Twenty NRs from former and 15 of latter group were crossed over. While none of the 20 from the IFN-alone group responded to the combinat ion, 1/15 NRs of the combinat ion group responded to dose escalation . SR was achieved in 9/45 (20%) of the IFN alone and 7/39 (18%) of the combination group. The mean time form the end of the treatment to the relapse was not different between the groups. Five of 11 UDCA NRs responded to IFN with SR in 2. It was concluded that UDCA as a single agent is ineffective in achieving response in the treatment of chronic type C hepatitis. Combined with IFN, it increases response rate insigni® cantly although this is not sustained.

We report a case of hydatid cyst of the pelvis in a 36-year-old woman presented with right adnexal cystic mass with similar cystic lesions in the liver. Laparatomy revealed a right paraovarian cystic mass densely adhered to the uterus, to the pelvic side wall, and to the right fallopian tube. Histopathological examination of the cyst wall showed the cuticular layer of the cyst. Cystic liver lesion was later proved to be hepatic hemangioma by magnetic resonance imaging.

TO THE EDITOR: We read with interest the article by Caldwell et al. (1) about nonalcoholic steatohepatitis (NASH). We agree that hyperinsulinemia may have a role in the pathogenesis of NASH. Thus, we investigated carbohydrate metabolism in nondiabetic, both obese and nonobese patients with NASH.

A central issue in the understanding of the pathogenesis of nonalcoholic fatty liver disease is the problem of the underlying mechanisms which are not fully understood. In the setting of excessive central adiposity, insulin resistance is the major underlying cause of fat accumulation in hepatocytes. Because of the difficulties with human trials, several animal models have been developed for this purpose mainly characterized as follows: genetically disturbed or murine fatty liver, methionine-choline deficient diet fed or murine steatohepatitis, and high-fat or sucrose diet fed models. Although these animal models have provided useful information, none of them accurately reflect genetic, metabolic and biochemical characteristics of the human disease.

Objective The present study aimed to examine the effectiveness of intravenous administration of paracetamol added to morphine in the control of cancer pain and its possible contribution as reduction of opioid consumption and opioid-related side effects. Materials and methods A total of 43 patients with chronic cancer pain without neuropathic origin aged between 18 and 76 years and receiving step 2 treatment according to the World Health Organization analgesic ladder were included. Patients were randomized to receive intravenous administration of saline (control) or 1 g of paracetamol on top of morphine. Visual analog scale (VAS), patient rating index (PRI), Eastern Cooperative Oncology Group (ECOG) status, patient satisfaction, and safety were evaluated. Main results Both treatments resulted in improved VAS and PRI scores compared to baseline. However, groups did not differ in terms of VAS and PRI scores, morphine consumption, side-effect frequencies, laboratory values, ECOG status, and patient satisfaction. Conclusions Although safe and there are signals for a true analgesic efficacy, our results failed to confirm any benefits of add-on treatment with intravenous administration of paracetamol. However, the study was underpowered, and future studies in this important area need to be wary of background noise and the risk of a type II error.

Objective: The primary aim of our study is to establish the frequency and clinicopathological features of seconder primary malignant tumours (SPMTs) in cases with renal cell carcinoma (RCC). Materials and Methods: Pathology reports of 1129 RCC cases were checked retrospectively, and 70 RCC cases with SPMTs were included in the study. One patient had two and the other had three different SPMTs, so the total number of SPMTs was 73. According to occurrence times of SPMTs, the cases were classified as the antecedent, synchronous, subsequent and unknown. The first three groups were compared according to their clinicopathological features. Results: The incidence of SPMTs with RCC in our study was 6.2% and lower than that reported by many other studies. The most common SPMTs were gastrointestinal, breast, prostate, lung, thyroid carcinomas and haematolymphoid malignancies. Sixty-two per cent of SPMTs were developed as synchronous and subsequent. There was no statistically significant difference among groups regarding age, histological subtype and RCC size. Male patients had a higher percentage in the synchronous group. In all groups, the most common RCC subtype was clear cell carcinoma. The RCC subtype in cases with multiple SPMTs was papillary. The prostatic adenocarcinoma rate was remarkable in males with papillary type RCC. Conclusion: RCC can coexist with secondary malignancies. Therefore, when a new tumour appears in a patient with RCC in clinical follow-up, it is appropriate to evaluate that tumour histopathologically or cytopathologically regarding SPMT before accepting it as a metastatic spread.

A 78-year-old woman was referred to our university hospital due to dry cough, fever, and weight loss. Laboratory revealed blood eosinophilia, high ESR, CRP and LDH. Rheumatologic markers were negative. Chest X-ray showed ground glass opacities in upper lobes. Uveitis developed in the left eye 1 week after admission. Thorax CT revealed ground glass opacities, reticular appearence in the upper lobes, enlarged axillary and mediastinal lymph nodes. Bronchoalveolar lavage CD 4 /CD 8 was 2.1 and had 48% eosinophils. Histopathologic examination revealed eosinophilic infiltration and non-caseating epitheloid granulomas in the lung and mediastinal lymph nodes without vasculitis. Symptoms, blood eosinophilia and initial thorax CT findings improved after two months of methylprednisolone treatment. Chronic eosinophilic pneumonia is a rare disease characterized by systemic and pulmonary manifestations. It may be associated with other diseases.

Purpose: The clearance rather than stone disintegration of lower pole stones after shock wave lithotripsy (SWL) is significantly inferior according to the other localizations of the kidney. We retrospectively evaluated the impact of caliceal pelvic anatomy on stone clearance after SWL for pediatric lower pole stones.

Since its introduction in 1980, extracorporeal shockwave lithotripsy (SWL) has become the first therapeutic option in most cases of upper-tract urolithiasis, and the technique has been used for pediatric renal stones since the first report of success in 1986. Lithotripter effectiveness depends on the power expressed at the focal point. Closely correlated with the power is the pain produced by the shockwaves. By reducing the dimensions of the focus, it becomes possible to treat the patient without anesthesia or analgesia but at the cost of a higher re-treatment rate. Older children often tolerate SWL under intravenous sedation, and minimal anesthesia is applicable for most patients treated with second-and third-generation lithotripters. Ureteral stenting before SWL has been controversial. Current data suggest that preoperative stent placement should be reserved for a few specific cases. Stone-free rates in pediatric SWL exceed 70% at 3 months, with the rate reaching 100% in many series. Even the low-birth-weight infant can be treated with a stone-free as high as 100%. How can one explain the good results? Possible explanations include the lesser length of the child's ureter, which partially compensates for the narrower lumen. Moreover, the pediatric ureter is more elastic and distensible, which facilitates passage of stone fragments and prevents impaction. Another factor is shockwave reproduction in the body: there is a 10% to 20% damping of shockwave energy as it travels through 6 cm of body tissue, so the small body volume of the child allows the shockwaves to be transmitted with little loss of energy. There are several concerns regarding the possible detrimental effect of shockwaves on growing kidneys. Various renal injures have been documented with all type of lithotripters. On the other hand, several studies have not shown adverse effects. In general, SWL is considered to be the method of choice for managing the majority of urinary stones in children of all ages. Re-treatments improve the stone-free rate, often raising it to 100%. Among the predictors of success, stone size seems to be the most important. In the absence of guidelines, selecting the appropriate treatment modality for each child requires planning and depends on instrument availability and local expertise.

Objectives. To evaluate the efficacy of extracorporeal shock wave lithotripsy (ESWL) monotherapy for isolated lower caliceal calculi in a pediatric age group and compare it with that for isolated middle/upper caliceal and renal pelvic calculi. Methods. We retrospectively reviewed the data of 151 renal units in 126 children treated with ESWL for isolated caliceal and renal pelvic stones from March 1992 to February 2004. The stones were localized in the lower, middle/upper calices, and renal pelvis in 50, 26, and 75 renal units, respectively. The results were compared with respect to renal location and stone burden. Results. The median patient age was 8 years (range 1 to 16). The median stone burden in the lower and middle/upper caliceal groups was significantly lower than in the renal pelvis group at 0.6, 0.6, and 1 cm 2 , respectively (P ϭ 0.002). The overall stone-free rate was 62% for lower calices, 65.3% for middle/ upper calices, and 80% for renal pelvis stones. For the group with a stone size greater than 2 cm 2 , the stone-free rate decreased to 33% in both lower and middle/upper calices; however, it was almost the same in the renal pelvis (81.8%). A highly significant relation was found between the stone burden and number of sessions (P Ͻ0.001), but none between the stone burden and stone-free rate. Conclusions. In our study, ESWL was equally effective for stones in all locations. We recommend ESWL as the primary treatment of choice for stones less than 2.0 cm 2 in all caliceal locations. For the management of caliceal stones greater than 2.0 cm 2 , prospective randomized trials comparing ESWL and percutaneous nephrolithotomy are necessary. UROLOGY 67: 170-175, 2006.

Background: YKL-40, also called human cartilage glycoprotein-39 (HC gp-39) and chitotriosidase are homologs of family 18 glycosyl hydrolases secreted by human macrophages. Although high levels of YKL-40 and chitotriosidase are associated with several diseases, the physiological functions of these enzymes are still unclear. YKL-40, a growth factor for connective tissue cells, a migration factor for endothelial and vascular smooth muscle cells, is expressed by several types of solid human carcinoma, including prostate carcinoma.