Erkan Caglar

Vascular involvement in Behçet’s syndrome: a retrospective analysis of associations and the time course

OBJECTIVE Some features of Behçets syndrome (BS) tend to go together. We aimed to explore the association and timing of various vascular events in both the venous and the arterial vascular tree. METHODS We conducted a chart survey on the type and time of vascular involvement of BS. The cross-relationships of involvement were assessed by phi correlation coefficients. Multiple correspondence analysis was used to identify patterns of vascular involvement. The risk of vascular recurrence was also estimated. RESULTS We identified 882 patients with vascular involvement among 5970 BS patients (14.7%). Deep vein thrombosis (DVT), almost always in the legs, was the most frequent single vascular event (592/882; 67.1%). The cumulative risk of a recurrent vascular event was 38.4% at 5 years. Patients with extrapulmonary artery involvement (EPAI) were significantly older than those with venous and pulmonary artery involvement (PAI). There were significant correlations between dural sinus thrombosis (DST) and PAI, Budd-Chiari syndrome (BCS) and inferior vena cava syndrome (IVCS) and between IVCS and superior vena cava syndrome (SVCS). Multiple correspondence analysis further indicated clustering of PAI, DST, BCS, IVCS and SVCS. However, EPAI and DVT clustered separately from forms of vascular disease, the separate clustering of the DVT being attributed to its propensity to occur solo. CONCLUSION The most common type of vascular involvement in BS is solo DVT, almost always occurring in the legs. Various forms of venous disease in BS segregate together and PAI is included in this group. EPAI segregates separately.

Screening for Cushing's syndrome in obese patients.

OBJECTIVES: The aim of this study was to examine the frequency of Cushing’s syndrome (CS) in obese patients devoid of specific clinical symptoms of Cushing’s syndrome. METHODS: A total of 150 obese patients (129 female, 21 male; mean age 44.41 ± 13.34 yr; mean BMI 35.76 ± 7.13) were included in the study. As a first screening step, we measured 24-h urinary free cortisol (UFC). An overnight 1-mg dexamethasone suppression test was also performed on all patients. Urinary free cortisol levels above 100 μg/24 h were considered to be abnormal. Suppression of serum cortisol <1.8 μg/dL after administration of 1 mg dexamethasone was the cut-off point for normal suppression. The suppression of the serum cortisol levels failed in all of the patients. RESULTS: Measured laboratory values were as follows: ACTH, median level 28 pg/ml, interquartile range (IQR) 14–59 pg/ml; fasting glucose, 100 (91–113) mg/dL; insulin, 15.7 (7.57–24.45) mU/ml; fT4, 1.17 (1.05–1.4) ng/dL; TSH, 1.70 (0.91–2.90) mIU/L; total cholesterol, 209 (170.5–250) mg/dL; LDL-c, 136 (97.7–163) mg/dL; HDL-c, 44 (37.25–50.75) mg/dL; VLDL-c, 24 (17–36) mg/dL; triglycerides, 120.5 (86–165) mg/dL. The median UFC level of the patients was 30 μg/24 h (IQR 16–103). High levels of UFC (>100 μg/24 h) were recorded in 37 patients (24%). Cushing’s syndrome was diagnosed in 14 of the 150 patients (9.33%). Etiologic reasons for Cushing’s syndrome were pituitary microadenoma (9 patients), adrenocortical adenoma (3 patients), and adrenocortical carcinoma (1 patient). CONCLUSION: A significant proportion (9.33%) of patients with simple obesity were found to have Cushing’s syndrome. These findings argue that obese patients should be routinely screened for Cushing’s syndrome.

An outcome survey of 43 patients with Budd–Chiari syndrome due to Behçet’s syndrome followed up at a single, dedicated center

BACKGROUND Behçets syndrome (BS) is a well-recognized cause of Budd-Chiari syndrome (BCS); however, information about its clinical characteristics and outcome is limited. METHODS We reviewed the records of about 9000 patients with BS registered at the multidisciplinary Behçets syndrome outpatient clinic at Cerrahpasa Medical Faculty between July 1977 and October 2013. We identified 43 (40 M/3 F) patients who were diagnosed as having BCS. Their outcome was evaluated between September 2012 and October 2013. RESULTS In total, 33 patients (77%) had presented with liver-related symptoms (Group I), while 10 (23%) were asymptomatic for liver disease (Group II). This latter group had presented with symptoms related to the presence of major vessel disease such as fever, leg swelling, or dyspnea. The site of venous obstruction determined in 41 patients was inferior vena cava (IVC) and hepatic veins combined in 25 (61%), IVC alone in 12 (29%), and only hepatic veins in 4 patients (10%). The number of patients with concurrent obstruction in the hepatic veins and the IVC was less in Group II than in Group I (3/10 vs 22/31, p = 0.06). A total of 20 (19 M/1 F) patients (47%) had died at a median of 10 months after diagnosis. Mortality was significantly lower in Group II (10%) than in Group I (58%), (p = 0.011). By the end of the survey, 23 patients were alive, of whom 21 could be re-evaluated at the clinic. CONCLUSIONS BCS associated with BS is usually due to IVC thrombosis with or without hepatic vein thrombosis. Silent cases exist and have a better prognosis. The mortality rate among the patients symptomatic for liver disease remains high.

Gastric balloon to treat obesity: Filled with air or fluid?

Our aim was to study the efficacy and safety of different types of intragastric balloon in morbidly obese patients.

Autoantibody Frequency in Celiac Disease

AIM: In our study, we investigated the levels of glutamic acid decarboxylase antibody (anti-GAD), islet cell antibody (ICA), thyroperoxidase antibody (anti-TPO), thyroglobulin antibody (anti-TG), antinuclear antibodies (FANA), antibodies to double-stranded DNA (anti-ds DNA), antibody to Sjögren syndrome A antigen (anti-SSA), antibody to Sjögren syndrome B antigen (anti-SSB), Smith antibody (anti-Sm), smooth muscle antibodies (ASMA), and antimitochondrial antibody liver-kidney microsome (AMA-LKM) in patients with celiac disease as compared to healthy controls and autoimmune hypothyroid patients. MATERIALS AND METHODS: A total of 31 patients with celiac disease, 34 patients with autoimmune hypothyroidism and 29 healthy subjects were included in this study. Anti-SSA, anti-SSB, anti-Sm, anti-ds DNA, anti-GAD, anti-TPO and anti-TG were studied by Enzyme-Linked Immunosorbent Assay (ELISA), and AMA-LKM, ASMA, ANA and ICA were studied by immunofluorescence. Clinical data and the results of free thyroxine-thyroid stimulating hormone (FT4-TSH) were collected from the patients’ files by retrospective analysis. SPSS ver 13.0 was used for data analysis, and the χ2 method was used for comparisons within groups. RESULTS: The frequency of anti-SSA, anti-SSB, anti-GAD, anti-Sm, anti-ds DNA, AMA-LKM, ASMA, ANA and ICA were not significantly different between the groups. Levels of anti-TPO and anti-TG antibodies were found to be significantly higher (<0.001) in autoimmune hypothyroid patients when compared with other groups. CONCLUSION: In previous studies, an increased frequency of autoimmune diseases of other systems has been reported in patients with celiac disease. We found that the frequency of autoimmune antibodies specific for other autoimmune diseases was not higher in celiac disease.

The relationships of leptin, adiponectin levels and paraoxonase activity with metabolic and cardiovascular risk factors in females treated with psychiatric drugs.

OBJECTIVES The aim of this study was to investigate serum leptin, adiponectin and paraoxonase1 levels in adult females receiving pharmacotherapy for various psychiatric disorders. METHODS The study group consisted of 32 obese females (mean age 40.53 ± 11.00 years, mean body mass index 35.44 ± 5.33 kg/m2) who were receiving treatment for psychiatric disorders, and the control group included 22 obese females (mean age 35.95 ± 9.16 years, mean body mass index 30.78 ± 3.33 kg/m2) who were free of psychiatric disorders. Analyses were performed using a bioelectrical impedance device. Fasting blood samples were obtained for complete blood count and various biochemical tests, including determination of leptin, adiponectin and paraoxonase1 activity. RESULTS Body mass index, waist and hip circumference, body fat percentage, fasting blood glucose, insulin, glycosylated hemoglobin, homeostasis model assesment of insulin resistance, alanine transaminase, aspartate tarnsaminase, and leptin levels were significantly higher in the study group than in controls. Although body weight was positively correlated with leptin levels in both groups, body weight was negatively correlated with adiponectin levels in the control group and positively correlated with adiponectin levels in the study group. In the study group, body mass index and hip circumference correlated positively with leptin levels, hip circumference correlated positively with adiponectin levels, and waist to hip ratio correlated positively with paraoxonase levels. In the control group, body mass index as well as waist and hip circumferences were positively correlated with leptin levels. Weight, body mass index, and hip circumference were also negatively correlated with the adiponectin/leptin ratio in the control group. CONCLUSION This study indicates a higher risk for obesity-related disorders, particularly metabolic syndrome, diabetes and cardiovascular disease, in patients treated with psychiatric drugs.

Self-Expandable Metallic Stent Placement in the Palliative Treatment of Malignant Obstruction of Gastric Outlet and Duodenum

Background/Aims To asses the usefulness of flexible metallic stents in the palliation of malignant obstruction of gastric outlet and duodenum. Methods Retrospective review was performed between January 2006 and December 2011 in 30 patients. Thirty consecutive patients with obstruction of the gastric outlet underwent palliative treatment with self-expandable flexible metallic stents. Complications and clinical outcomes were assessed. Results Twenty-four patients had advanced gastric carcinoma at the antrum and/or pylorus, four patients had obstruction at the pylorus due to pancreas tumours and one patient had duodedum and one patient had gall bladder tumour. Symptoms improved in 82.7% of the patients after the procedure. The improvement in ability to eat using the score system was statistically significant (p<0.001). Tumor ingrowth and/or overgrowth were seen in four patients (13.3%), and a second stent was inserted in these patients. The mean stent patency was 100 days (range, 5 to 410). The mean survival was 120.76±38.96 days. Conclusions Endoscopic placement of self-expendable metallic stents under fluoroscopy is a safe and effective treatment for the palliation of patients with inoperable malignant gastric outlet obstruction caused by stomach or pancreas cancer.

Concordance of Endoscopic Ultrasonography-Guided Fine Needle Aspiration Diagnosis with the Final Diagnosis in Subepithelial Lesions

Background/Aims In this study we aimed to determine the rate of concordance of endoscopic ultrasonography (EUS)-guided fine needle aspiration (FNA) diagnosis with the final diagnosis obtained by surgery or endoscopic resection and follow-up in upper gastrointestinal subepithelial lesions. Methods We retrospectively studied patients with subepithelial lesions who underwent EUS at our center from 2007 to 2011. Results We had a final diagnosis in 67 patients (mean age±SD, 51.23±12.48 years; 23 [34.3%] female, 44 [65.6%] male). EUS-FNA was performed in all of the patients. On-site pathology was not performed. In nine of the patients, the obtained material which was obtained was insufficient. The cytologic examination was benign in 31 and malignant in 27 of the patients. Based on the final diagnosis, the EUS-FNA had a sensitivity of 96%, a specificity of 100%, and a diagnostic yield of 85%. Conclusions The diagnostic yield of EUS-FNA, in the absence of the on-site cytopathologist, is feasible for the diagnosis of subepithelial lesions of the upper gastrointestinal system.

Familial chylomicronemia syndrome related chronic pancreatitis: A single-center study

BACKGROUND Hypertriglyceridemia induces acute recurrent pancreatitis, but its role in the etiology of chronic pancreatitis (CP) is controversial. This study aimed to evaluate the clinical, laboratory and radiological findings of 7 patients with CP due to type 1 hyperlipidemia compared to CP patients with other or undefined etiological factors. METHODS We retrospectively analyzed the clinical, laboratory and radiological findings of 7 CP patients with type 1 hyperlipidemia compared to CP patients without hypertriglyceridemia. These 7 patients had multiple episodes of acute pancreatitis and had features of CP on abdominal CT, endoscopic retrograde cholangiopancreatography and/or endoscopic ultrasonography. RESULTS All CP patients were classified into two groups: a group with type 1 hyperlipidemia (n=7) and a group with other etiologies (n=58). The mean triglyceride level was 2323+/-894 mg/dL in the first group. Age at the diagnosis of CP in the first group was significantly younger than that in the second group (16.5+/-5.9 vs 48.3+/-13.5, P<0.001). The number of episodes of acute pancreatitis in the first group was significantly higher than that in the second group (15.0+/-6.8 vs 4.0+/-4.6, P=0.011). The number of splenic vein thrombosis in the first group was significantly higher than that in the second group (4/7 vs 9/58, P=0.025). Logistic regression analysis found that younger age was an independent predictor of CP due to hypertriglyceridemia (r=0.418, P=0.000). CONCLUSIONS Type 1 hyperlipidemia appears to be an etiological factor even for a minority of patients with CP. It manifests at a younger age, and the course of the disease might be severe.

Serum Levels of Mannan-Binding Lectin in Patients with Crimean-Congo Hemorrhagic Fever

OBJECTIVE Mannan-binding lectin (MBL) is a central component of the innate immune response. Genetic variations in the MBL gene that reduce circulating levels and alter functional properties of the MBL are associated with susceptibility for many infectious diseases. Crimean-Congo hemorrhagic fever (CCHF) is a tick-borne disease caused by an arbovirus in the family Bunyaviridae. We have investigated serum MBL levels in CCHF patients and a possible association between circulating MBL concentrations and the severity of CCHF. MATERIALS AND METHODS Forty-seven patients found to have CCHF in Cumhuriyet University Hospital and 29 healthy controls were recruited for this study. There were no differences in terms of age and sex between the patients and the healthy controls (p = 0.64 and p = 0.484, respectively). This study was conducted between July 1 and August 31, 2007, in Cumhuriyet University Hospital in Sivas, a city located in the central Anatolian region of Turkey. Patients with CCHF were matched with healthy controls, and serum MBL levels were measured. RESULTS The median serum MBL level was significantly lower in the patient group than in the healthy control group (48.0 ng/mL [inter-quartile range (QR) 30.4-128.0] and 212.0 ng/mL [IQR: 115.8-524.0], respectively; p < 0.001). No significant difference was found between serum MBL levels in CCHF patients with severe and nonsevere form of the disease (p = 0.167). CONCLUSION MBL levels were significantly lower in patients with CCHF than in healthy controls. There was no meaningful correlation between the serum MBL level and severity of CCHF disease. Low serum MBL level may be associated with the high consumption of MBL in CCHF infection and/or MBL gene polymorphism.