Ali Harlak

Breast Cancer-Related Lymphedema – What Are the Significant Predictors and How They Affect the Severity of Lymphedema?

Abstract:  According to the American Cancer Society, there are currently 2 million breast cancer (BC) survivors in the USA and 20% of them cope with lymphedema (LE). The primary aim of this study was to determine the predictive factors of BC‐related LE. The secondary aim was to investigate the impact of predictors on the severity of LE. The study design was intended to be a 1:2 matched case–control study. Instead, we stratified on age (±10 years), radiation therapy (y/n), and type of operation (SM/MRM/MRM with tram). Patients who underwent BC surgery between 1990 and 2000 at UPMC Magee‐Womens Hospital were reviewed for LE. Data were collected on 52 women with LE and 104 female controls. Logistic regression was utilized to assess the relationship between risk factors and LE. Ordinal logistic regression was performed to determine the association between risk factors and severity of LE. Severity was defined according to the volume difference between affected and unaffected limbs. Risk factors considered were occupation/hobby (hand use), TNM stage, number of dissected nodes, number of positive nodes, tumor size, infection, allergy, diabetes mellitus, hypertension, hypothyroidism, chronic obstructive pulmonary disease, and body mass index (BMI). LE was mild in 43 patients and was moderate/severe in nine patients. The level of hand use in the control group was categorized as low in 56 (54%), medium in 15 (14%), and high in 33 (32%) patients. The corresponding frequencies were 14 (33%), 6 (14%) and 23 (53%) for patients with mild LE and 3 (33%), 1 (11%), 5 (56%) for patients with moderate/severe LE (p < 0.05). Infection of the operated side arm was reported by two (2%) patients in the control group, 14 (33%) patients with mild LE and five (56%) patients with moderate/severe LE (p < 0.05). The mean BMI was 26.1 kg/m2 (SD 4.9) for the control group, 29.0 kg/m2 (SD 5.9) for the mild LE group and 30.9 kg/m2 (SD 7.5) for patients with moderate/severe LE (p < 0.05). The results of this stratified case–control study demonstrated that the risk and severity of LE was statistically related to infection, BMI, and level of hand use.

Ultrasonography accurately evaluates the dimension and shape of the pilonidal sinus.

PURPOSE To study the benefits of ultrasonography for detecting the borders of pilonidal sinus tissue. The correlation between physical and ultrasonographic examination was used for surgical planning. METHOD Between April and December 2004, 73 patients were recruited for this study. All patients were examined, and the borders of the sinus tissue were marked on the skin according to palpation before surgery. The surgeon also made a treatment plan considering the diseased tissue and marked a possible incision line. Patients were subsequently examined with ultrasonography. According to the ultrasonographic evaluation, the margins, extensions, and openings of pilonidal sinus tissue were determined and marked on the patient in a different color by a radiologist prior to surgery. The most suitable surgical treatment was decided according to the information obtained by ultrasonography. RESULTS The average age was 23.03 ± 3.05 (range 18–39) years. We found 81 lesions in 73 patients. Ultrasonographic borders of sinus tissue were similar to the borders marked by the surgeon in 56 patients (76.7%). In the remaining 17 patients (23.3%), ultrasonography detected branches or borders that distinctly exceeded the planned incision line. After ultrasonographic examination, the surgeon changed his incision line in 14 patients and the surgical intervention in 3 patients. CONCLUSION Palpation and methylene blue injection do not provide appropriate information in many patients. Our study revealed that pre-operative ultrasonography can improve the identification of the sinus tract and its branches when compared to palpation and methylene blue injection.

The importance of urine 5-hydroxyindoleacetic acid levels in the early diagnosis of acute appendicitis

PURPOSE Acute appendicitis is one of the most common surgical emergencies. Diagnosis is usually made depending on the presenting history, clinical evaluation, and laboratory tests. The aim of this study was to investigate the role of urinary 5-hydroxyindoleacetic acid (U-5-HIAA) in the early diagnosis of acute appendicitis. METHODS Thirty-five pigmented male rabbits were divided into 5 groups. Group 1 is the control (n = 7); group 2 is the sham (n = 10). The appendix was ligated from its base, and an appendectomy was performed after 12, 24, 36 hours in group 3 (n = 7), group 4 (n = 7), and group 5 (n = 7), respectively. Spot urine samples were obtained for U-5-HIAA determination, and appendectomy tissues were examined histopathologically. RESULTS Acute appendicitis was diagnosed in all animals in group 3, group 4, and group 5, and the mean levels of U-5-HIAA in group 3 were higher than in the other groups. The mean of U-5-HIAA levels between animals with appendicitis and those without showed a significant difference (P = .003). The U-5-HIAA cutoff point of 4.15 mg/g creatinine had a sensitivity of 85%, a specificity of 64.29%, and an accuracy of 76% (area under curve = 0.805) for acute appendicitis. The probability of acute appendicitis is found to be 10, 2 times more when the U-5-HIAA level is greater than 4.15 mg/g creatinine. CONCLUSION We have concluded that spot U-5-HIAA level increases significantly in the early stages of acute appendicitis.

Placement technique and the early complications of balloon breast brachytherapy: Magee-Womens Hospital experience.

Backgrounds and Objectives:Open (OT) and percutaneous closed (PCT) techniques have been described for placement of the MammoSite catheter to deliver accelerated partial breast brachytherapy. We report early complications of both techniques. Methods:A total of 125 patients underwent catheter placement for MammoSite high-dose rate brachytherapy, with 108 patients successfully completing treatment. The OT was used in 85 patients and PCT in 40 patients. The mean distance between the balloon surface and breast skin was 1.44 cm and 1.31 cm, respectively. Average skin dose was 278 cGy in the OT group and 295 cGy in the PCT group (P > 0.05). Average gross specimen size was 43.16 cm3 in the OT group and 62.19 cm3 in the PCT group. Median follow-up was 11 months for the OT group and 5 months for the PCT group. Results:In 17 cases, the catheter was subsequently removed without the patient completing treatment. Two of the patients in the OT group (3%) developed a delayed abscess. The overall incidence of persistent seroma (>6 months) was 20% with all occurring in the OT group, 30% of those patients. There were no acute skin toxicities higher than grade 2. The overall cosmesis is excellent or good in 95% of patients. Conclusion:Despite short follow-up and a small sample size in this study, it seems that the MammoSite brachytherapy was well tolerated by patients with early stage breast cancer when using either the OT or PCT.

The value of serum fibrinogen level in the diagnosis of acute appendicitis

BACKGROUND The aim of this study was to investigate the importance of serum fibrinogen level in the diagnosis of acute appendicitis. METHODS This study was performed on 201 patients who admitted to our clinic. Symptoms, signs, duration of symptoms, and laboratory indicators of appendicitis were recorded, in keeping with the Alvarado score for acute appendicitis. The ultimate diagnosis was based on histopathological results. Serum fibrinogen levels were detected before surgery. The sensitivity, specificity, and predictive values of single test and test combinations were calculated at different cut-off levels. RESULTS During the study period, 201 patients underwent surgery for suspected acute appendicitis. Appendicitis was confirmed in 179 (89%) patients. The mean age was 24.8±7.7 (range, 20-57) years, and 154 (76.6%) patients were male and 47 (23.4%) female. The best diagnostic cut-off point for fibrinogen was found at 245.5 mg/dl, for white blood cells (WBC) at 11,900x109/L and for Alvarado score at 7. CONCLUSION The use of fibrinogen blood level may be a new diagnostic acute-phase reactant in the diagnosis of acute appendicitis. The formulation of a triple test is recommended as criteria in deciding emergency surgery or observation.

Can D-dimer become a new diagnostic parameter for acute appendicitis?

INTRODUCTION In this study, we investigated D-dimer serum level as a diagnostic parameter for acute appendicitis. MATERIALS AND METHODS Forty-nine patients were enrolled in the study. Patients were classified according to age; sex; duration between the beginning of pain and referral to a hospital or clinic; Alvarado scores; and in physical examination, presence of muscular defense, the number of leukocytes, preoperative ultrasonography, and D-dimer levels of histopathologic study groups were analyzed. RESULTS Of the patients enrolled in the study, 26.5% were females and 73.5% males. The average age was 21 years (range, 16-38 years) and 81.7% acute appendicitis (AA). According the duration of pain, 63.2% of the patients were referred to the hospital within the first 24 hours, 26.5% of the patients were referred to the hospital within 24 to 48 hours, and 10.3% were referred to the hospital within a period of more than 48 hours. No statistically significant difference was determined regarding D-dimer levels between the histopathologic study groups (P > .05). Alvarado scores lower than 7 were found in 36.7% and 7 or higher in 63.3% of the patients. There was no statistically significant difference related with D-dimer levels between histopathologic study groups (P > .05). The ratio of cases with a number of leukocytes below the upper limit were determined respectively as 32.7% and 67.3%, and no statistically significant difference was found regarding d-dimer levels between histopathologic study groups (P > .05). CONCLUSION Increased D-dimer levels should not be considered as a diagnostic parameter in diagnosis of acute appendicitis.

Predisposition and risk factor rates for pilonidal sinus disease

We read with great interest the recently published paper by Sabuncuoglu et al entitled “Eyedrop-shaped, modified Limberg transposition flap in the treatment of pilonidal sinus disease.” We would like to congratulate the authors and thank them for sharing their experiences with us. We think that the procedure of eyedrop technique will reduce wound tension and increase postoperative patient comfort. It is a very good initiative. Different surgical treatment procedures for pilonidal disease have been described and tried, with numerous reports comparing these procedures being available in the literature. The results of these studies are on the same line as Sabuncuoglu et al. However, information on the comparison of the most common surgical procedures, including flap technique and others, with respect to quality of health and patient satisfaction criteria, is scarce. A wide intergluteal depth, bathing habituation, sitting time, hairy rate, body mass index, and genetic predisposition have been shown as the predisposition factors of sacrococcygeal pilonidal sinus disease by some authors. In the light of all the facts mentioned above, we think that the predisposition and risk factor rates of the patients, reported in the study by Sabuncuoglu et al, can help us explain the results more explicitly. This study recommends us to make a comparison between eyedrop technique and other surgical procedures. We think that a comparison of the results of these two techniques, with respect to the criteria of quality of life and patient satisfaction, would lead us to the next step in the treatment of this disease.

Comment on: Clinical outcomes after unplanned extubation in a surgical intensive care population.

Dear Editor We read with interest the article Clinical Outcomes after Unplanned Extubation in a Surgical Intensive Care Population by Lee et al. [1] published online in the World Journal of Surgery. The authors evaluated clinical outcomes in patients with unplanned extubation (UE) in a surgical intensive care unit, and found increased in-hospital mortality associated with reintubation, chronic neurologic disease, emergency operation, and higher APACHE II score. They also reported that low Richmond Agitation– Sedation Scale (RASS) score, low PaO2/FiO2 ratio, and long duration of mechanical ventilation before UE were associated with reintubation after UE. We consider that clarification regarding some details of the patient population would be useful. Some conditions are known to be associated with an increased risk of UE, such as prolonged intubation, high level of the endotracheal tube relative to the carina, instability of the endotracheal tube, morbid obesity, persistent chewing of the tube, excessive oral secretions, forceful coughing or exhalation, uncontrolled movement of the patient, high airway pressure or positive end-expiratory pressure, and patient agitation. The authors reported and analyzed the RASS score, PaO2/ FiO2 ratio before UE, and duration of mechanical ventilation before UE. However, some of the conditions known to be associated with UE were not described. As the authors mention in the discussion, the study did not focus on identification of risk factors for UE. However, we think that knowledge of these risk factors in the patient population would be interesting to the readers. We wonder especially about body mass index, which was not included in the analysis. Obesity is associated with difficult intubation and increased risk of complications. Anatomic features such as a short neck, large tongue, excessive palatal and pharyngeal soft tissue, high and anterior larynx, and fat face have been reported to cause problems with tracheal intubation in 14.6 % of obese patients [2]. Prolonged mechanical ventilation and high O2 needs are inevitable in obese patients because of abnormal chest elasticity, increased airway resistance, and inefficiency of the respiratory muscles [3], resulting in an increased risk of complications. Analysis of the cut-off value for body mass index associated with increased risk would therefore be valuable in determining the probability of UE. The authors used the APACHE II score in their analyses. As the APACHE II score is usually assessed on the first day of hospitalization, it may not accurately reflect the condition of the patient at the time of the study. Brinkman et al. [4] reported that APACHE IV scores were useful for prediction of in-hospital mortality and mortality after a prolonged intensive care unit admission, and the APACHE IVa score was reported to be a good method of assessing patients with prolonged intensive care unit admission [5]. We consider that analysis of the APACHE IV score would be better than analysis of the APACHE II score for these patients.

Complicated solitary intraductal papilloma of the breast

Solitary intraductal papillomas are benign breast neoplasms that clinically present with bloody nipple discharge. Most intraductal papillomas are less than 0.5 cm in diameter; however, papillomas as large as 10 cm have been reported (1). Although intraductal papillomas can present at any age, solitary intraductal papillomas occur most commonly in premenopausal women 35–55 years of age (2). Fortunately, the life expectancy of women is increasing, and ageing women will become the predominant patients seeking health care. This may allow us to diagnose more benign neoplasms of the breast, and it also may make treatment more difficult because of the patient’s comorbidities. Lesions of the breast in elderly females are most often malignant, but one should keep in mind the possibility of other neoplasms, such as intraductal papillomas.

Are endothelial damage and inflammation level demonstrated clearly in liver transplant patients

We read with great interest the recently published article by Hayashi et al in which the authors aimed to evaluate the relationship between neutrophil-to-lymphocyte ratio (NLR) and adult small-for-size grafts, along with an analysis of other clinical factors. As a result, although the neutrophil and lymphocyte absolute counts in groups did not differ significantly, the NLR showed significant differences between the two groups from Postoperative Day 3 to Postoperative Day 10. In conclusion, the elevation of postoperative NLR has been claimed to reflect suggestive pathophysiology of endothelial injuries that related to small-for-size graft syndrome in living donor liver transplantation. However, there are some points that we would like to address about this study. Firstly, as is known, NLR combines the antagonistic effects of neutrophilia (an indicator of inflammation) and lymphopenia (an indicator of physiologic stress). There are several clinical conditions and comorbidities that possibly affect the distribution of white blood cell (WBC) counts, which should be excluded to avoid possible confounders for the NLR results. Also, the WBC cut-off values may vary depending on many factors such as the population studied, the individual laboratory, and the instruments or measurement methods used. Studies evaluating inflammation underlying endothelial injuries, initially, in the patients included inflammation in this study or at least the WBC levels should be assessed, it should be exclude those over a certain cut-off. Moreover, as done before in similar studies, adding C-reactive protein (CRP), which is a very common marker of inflammation, it can be excluded in high level NLR patients caused by comorbidities.