Kenan Köse

Quantitative Assessment of Normal Soft-Tissue Elasticity Using Shear-Wave Ultrasound Elastography

OBJECTIVE The aim of this study was to measure the elasticity of various tissues and report it in kilopascals. SUBJECTS AND METHODS The thyroid, submandibular, and parotid glands, masseter and gastrocnemius muscles, supraspinatus and Achilles tendons, renal cortex and pelvis, pancreas, and spleen of 127 healthy volunteers (89 women, 38 men; mean age, 37.72 ± 9.11 years; range, 17-63 years) were evaluated with shear-wave ultrasound elastography. RESULTS The mean elasticity values were determined to be 10.97 ± 3.1 kPa for the thyroid, 10.92 ± 3.1 kPa for the submandibular glands, 10.38 ± 3.5 kPa for the parotid glands, 10.4 ± 3.7 kPa for the masseter muscle, 11.1 ± 4.1 kPa for the gastrocnemius muscle, 31.2 ± 13 kPa for the supraspinatus muscle, 51.5 ± 25.1 kPa for the Achilles tendons, 5.0 ± 2.9 kPa for the renal cortex, 23.6 ± 5.4 kPa for the renal pelvis, 4.8 ± 3 kPa for the pancreas, and 2.9 ± 1.8 kPa for the spleen. CONCLUSION Elasticity values were determined for different tissues with shear-wave ultrasound elastography. Further studies comparing the elasticity values of normal and pathologic tissues are necessary to determine the diagnostic role of this technique.

Health-Related Quality of Life in Patients with Sleep-Related Breathing Disorders: Relationship with Nocturnal Parameters, Daytime Symptoms and Comorbid Diseases

Background: Sleep-related breathing disorders (SRBD) are frequently encountered health problems in the general population. Habitual snoring and obstructive sleep apnea/hypopnea syndrome (OSAHS) constitute most SRBD diagnoses. Although the decrease in quality of life is a well-known entity in SRBD patients, there is not enough data regarding the underlying pathophysiological mechanisms to explain this deterioration. Objectives: The aim of this study was to investigate which parameters were affecting the quality of life in patients with SRBD. Methods: Medical Outcome Survey – Short Form 36 (SF-36) and Epworth Sleepiness Scale were used in 135 patients with SRBD (69 patients with OSAHS and 66 patients with habitual snoring), and Charlson comorbidity index was calculated. Acquired data were compared with leading symptoms and polysomnographic findings in these patients. Results: All SF-36 scores were significantly decreased in SRBD patients. However, there were no significant differences in the SF-36 scores of these patients. Also, no significant correlation was found between the severity of OSAHS and the SF-36 scores. Similarly, none of the polysomnographic parameters was found significantly correlated with SF-36 scores. In contrast, all SF-36 scores were influenced by body mass index, Epworth Sleepiness Scale score, mean nocturnal saturation and the presence of coexisting diseases. Conclusions: According to the results of multiple variance analysis, we concluded that the quality of life depends on a number of collaborative factors such as obesity, mean nocturnal saturation, symptoms related to SRBD and the presence of comorbid diseases, rather than only on one independent parameter in the patients with SRBD.

Is There Any Difference in the Use of Complementary and Alternative Therapies in Patients Asthma and COPD? A Cross-Sectional Survey

Background. Data on the use and efficacy of complementary and alternative medicine (CAM) in patients with asthma are limited, and there is a lack of studies documenting the use of CAM in patients with chronic obstructive pulmonary disease (COPD) in Turkey. Aim. To determine the prevalence of CAM usage in patients with asthma and COPD and to assess the clinical and demographic factors associated with the use of CAM. Materials and methods. A total of 521 patients (313 with asthma and 208 with COPD) were randomly enrolled into this cross-sectional survey. A face-to-face interview was conducted using a structured questionnaire. Results. One hundred sixty-three patients (52%) with asthma and 70 patients (33%) with COPD were reported to be using some form of CAM (p < 0.001). The most popular modalities were herbal remedies (46% and 28% in the two groups, respectively) and animal products (28% and 5% in the two groups, respectively). CAM-practicing asthma patients were typically younger with longer duration of disease and higher income than the CAM-practicing COPD patients. For the patients, the main source of information on CAM practices was their relatives and friends. Only a small number of the patients consulted with their physicians about CAM. The main reasons to use CAM for patients with asthma and COPD were harmlessness and symptomatic relief, respectively. CAM-related adverse effects and difficulties to obtain CAM were significantly higher in patients with asthma than in patients with COPD. Conclusion. There is a high prevalence of CAM usage in patients with asthma and COPD in Turkey. Hence, becoming familiar with CAM therapy and inquiring about patient practice of CAM as part of the routine medical history will allow the physicians to provide reliable information to their patients on these medical practices.

Retinoblastoma in Turkey: Results From a Tertiary Care Center in Ankara

PURPOSE To evaluate the presentation patterns and results of management of retinoblastoma at a tertiary care center in Ankara, Turkey, with special emphasis on globe conservation rate in unilateral and bilateral intraocular retinoblastoma. METHODS Patients were grouped according to the International Classification of Retinoblastoma. For intraocular retinoblastoma, group E and some group D eyes underwent primary enucleation. Secondary enucleation was performed after failure of chemoreduction, focal treatments, external beam radiotherapy (EBRT), and intra-arterial chemotherapy used in various combinations. For extraocular retinoblastoma cases, treatment consisted of enucleation/exenteration or orbital biopsy, high-dose chemotherapy, and EBRT to the orbit and metastatic sites. RESULTS During the study period from October 1998 to May 2010, 165 of 192 (85.9%) patients had intraocular disease and 27 (14.1%) patients had extraocular disease. In total, primary or secondary enucleation was performed in 70 of 94 eyes with unilateral retinoblastoma (74.5%) and in 34 of 142 eyes with bilateral retinoblastoma (23.9%). The overall globe conservation rate was 69.6%. Only one patient in the intraocular retinoblastoma group died of metastatic retinoblastoma to the central nervous system. Twenty of 27 patients (74.1%) with extraocular retinoblastoma were found to have metastasis to the central nervous system, bone, bone marrow, and/or lymph nodes. At a mean follow-up of 28.0 months (median: 12 months; range: 1 to 120 months), survival was 33.3% despite intensive treatment. CONCLUSIONS The overall risk of enucleation was 75% in eyes with unilateral retinoblastoma and 24% in eyes with bilateral retinoblastoma. Extraocular retinoblastoma carries a 75% risk of systemic metastasis and 67% risk of death.

Relationship Between Angiotensin-Converting Enzyme Gene Polymorphism and Severity of Aortic Valve Calcification

OBJECTIVE To investigate the role of angiotensin-converting enzyme (ACE) gene polymorphism in patients with degenerative aortic valve calcification (AVC). PATIENTS AND METHODS Our study consisted of 305 Turkish patients of European descent (139 male, 166 female; mean plus or minus age, 68 plus or minus 9 years) referred to our echocardiography laboratory for aortic valve evaluation between June 2, 2003, and April 29, 2005. The severity of AVC was graded from 1 to 6 by echocardiography. We used polymerase chain reaction to determine ACE gene polymorphism. RESULTS The ACE insertion/deletion genotype distributions for the study population were in Hardy-Weinberg equilibrium (chi square equals 3.5, P equals .18). The study population was divided into 3 groups based on the severity of AVC: those with grade 1 calcification were in group 1, those with grades 2 to 4 in group 2, and those with grades 5 to 6 in group 3. Group 1 patients were significantly younger, less likely to have hypertension and diabetes, and had higher high-density lipoprotein cholesterol levels. The genotype frequencies were significantly different among groups, with the insertion/insertion genotype being less prevalent in group 3 patients. In multivariate analysis, independent predictors of severe AVC were hypertension (odds ratio [OR], 5.6; 95% confidence interval [CI], 2.8 to 11.0; P less than .001), low high-density lipoprotein cholesterol (OR, 2.7; 95 percent CI, 1.5 to 4.9; P equals .001), and the deletion/deletion and insertion/deletion vs insertion/insertion genotype (OR, 3.2; 95 percent CI, 1.5 to 7.2; P equals .004). CONCLUSION These results suggest that ACE gene polymorphism may be associated with severe AVC.

Effects of postoperative parenteral nutrition with different lipid emulsions in patients undergoing major abdominal surgery.

Purpose This study was designed to investigate the effects of total parenteral nutrition (PN) using different lipid emulsions in patients undergoing major abdominal surgery. Methods Fifty-two patients were randomized to receive soybean oil + medium chain triglycerides (MCT) (group I), soybean oil + olive oil (group II), soybean oil + olive oil + fish oil (group III) as a lipid source. PN was started on postoperative day 1 and patients were maintained on PN for a minimum period of 4 days. Laboratory variables (CRP, prealbumin, transferrin) were measured before surgery and on postoperative days. Results Three treatment groups were included in the study. Patients in group I received long chain triglycerides (LCT) + LCT/MCT emulsion (%75 LCT + %25 LCT/MCT); Patients in group II received olive oil based emulsion (80% olive oil + 20% soybean oil, ClinOleic); Patients in group III received fish oil in addition to olive oil based emulsion (%85 ClinOleic + %15 Omegaven; Fresenius Kabi). The following 14 parameters were assessed: body weight, CRP, prealbumin, transferrin, tumor necrosis factor-α, interleukin-6, total antioxidant status, thiobarbituric acid reactive substances, oxidized low density lipoprotein-2, complete blood cell, international normalized ratio, D-dimer, activated partially thromboplastin time, prothrombin time. All other parameters showed no differences among the groups. Conclusion The results of our trial demonstrate a potential beneficial effect of soybean oil/olive oil based lipid emulsions for use in PN regarding inflammatory response and oxidant capacity in the treatment of patients.

Ruthenium-106 plaque radiotherapy alone or in combination with transpupillary thermotherapy in the management of choroidal melanoma

PurposeTo evaluate the results of ruthenium-106 (Ru-106) plaque radiotherapy alone (group A) or in combination with transpupillary thermotherapy (TTT) (group B) in the management of choroidal melanoma with tumor thickness (height) <8 mm. The tumors in each group were subclassified as those with thickness ≤5 mm versus those with thickness of >5 and <8 mm.MethodsIn this retrospective review, the main outcome measures were globe conservation rate, the rate of a reduction of at least 50% in tumor thickness, treatment complications, visual acuity (VA) change, and metastasis. Kaplan-Meier curves for prediction of decrease in tumor thickness of at least 50% over time were constructed.ResultsA total of 54 patients (24 in group A and 30 in group B) were included in this study. The groups were matched with respect to patient age, tumor base diameter, tumor thickness, tumor distance to optic disc, tumor distance to foveola, and baseline visual acuity (VA). The mean follow-up was 24.6 months in group A and 44.9 months in group B. Globe conservation was achieved in 21 (87.5%) eyes in group A and in 26 (86.7%) eyes in group B. The globe conservation rates did not differ significantly between groups A and B or between tumors ≤5 mm in thickness and those >5 to <8 mm in thickness in each group (P > 0.05). There was no statistical difference between groups A and B in the rate of tumor thickness reduction of at least 50% (P> 0.05). There was a significant decrease in final VA compared to baseline VA in group B (P = 0.007) but not in group A. Radiation complications were similar in groups A and B. Liver metastasis occurred in two patients in group A and in one patient in group B. Statistical analysis could not be carried out for the latter two variables because of the small number of affected patients.ConclusionsCompared to Ru-106 plaque radiotherapy alone, Ru-106 plaque radiotherapy combined with TTT did not result in a significant change in the globe conservation rate or the rate of at least 50% reduction in tumor thickness in choroidal melanomas <8 mm in thickness. Although Ru-106 plaque radiotherapy is mainly used for choroidal melanomas ≥5 mm thick, it can also be considered in selected tumors with thickness between 5 and 8 mm with comparable tumor control.

Investigating the role of IL-33 in the pathogenesis of Behçet’s Disease

Objectives: Behçet’s disease (BD) is an inflammatory disease, characterized by oral aphthous lesions, recurrent uveitis, skin lesions, and genital ulcerations. Increased release of several cytokines may play a role in the inflammatory stages of BD. IL-33, a member of the IL-1 cytokine superfamily, plays an important role in inflammation. We analyzed serum IL-33 concentration in BD patients to assess its possible role in the pathophysiology of this disease. Methods: The study included 54 BD patients, 31 with active BD and 23 with inactive BD as well as 18 matched healthy controls. Serum IL-33 levels were measured using an enzyme-linked immunosorbent assay (ELISA). Results: The mean serum IL-33 levels were 4.84 ± 2.81 pg/ml in the BD patients (6.16 ± 2.94 pg/ml in the active stage and 2.86 ± 0.54 pg/ml in the inactive stage) and 2.88 ± 0.42 pg/ml in the healthy controls. Serum IL-33 levels were significantly higher in patients with BD compared with the healthy controls (p < 0.01). In active Behçet patients with arthritis the mean serum IL-33 level was higher but this finding was not statistically significant (p = 0.122). Conclusion: IL-33 may play a significant role of in the pathogenesis of BD.

Primary transpupillary thermotherapy of choroidal melanocytic lesions.

Purpose: To evaluate the role of primary transpupillary thermotherapy (TTT) in the treatment of choroidal melanocytic lesions. Materials and Methods: Retrospective chart review of 24 patients (24 eyes) with choroidal melanocytic lesions, including 20 choroidal melanoma and four choroidal nevus treated with primary TTT. Choroidal nevus cases treated with primary TTT either demonstrated risk factors for growth into an early melanoma or had overlying choroidal neovascularization. Results: The mean initial tumor basal diameter was 6.6 (3.0-10.0) mm and the mean initial tumor thickness was 3.0 (1.0-5.0) mm. The mean number of TTT sessions was 2.5 (1-6). The mean decrease in tumor thickness was 1.2 mm (from 3.0 to 1.8 mm) at a mean follow-up of 22.7 (range 3-90) months. On the LogMar scale, visual acuity was stable at 1.0. Complications occurred in 50% of eyes. The most frequent complications were vitreous hemorrhage [5 patients (20.8%)], focal cataract [5 patients (20.8%)], iris atrophy [4 patients (16.6%)] and posterior synechia [4 patients (16.6%)]. There was no significant difference in the complication rate with respect to tumor thickness >3 mm versus tumor thickness ≤3 mm and juxtapapillary versus nonjuxtapapillary location (Fisher’s exact test, P>0.05). Kaplan-Meier curves showed that 9% of eyes develop recurrence by 1 year and 27% develop recurrence by 5 years after primary TTT. Two eyes (8.3%) were enucleated because of neovascular glaucoma and one eye (4.1%) was exenterated because of extraocular tumor recurrence. Globe salvage was achieved in 21 patients (87.5%). One patient (4.1%) with extraocular tumor recurrence developed liver metastasis and expired. Conclusions: Although TTT may be useful in the treatment of small choroidal melanocytic lesions, the high complication and recurrence rates warrant close monitoring of patients after primary TTT even when a flat chorioretinal scar has been achieved.

HLA-DR alleles in patients with post-streptococcal reactive arthritis

Sir Reactive arthritis is a term used to describe a sterile inXammatory arthritis occurring after a documented infection elsewhere in the body. Infections of the gastrointestinal, genitourinary and respiratory tract appear to provoke reactive arthritis. Acute rheumatic fever (ARF) and post-streptococcal reactive arthritis (PSReA) are the known complications of streptococcal throat infections. Not all patients infected with streptococcus causing pharyngitis result in with ARF as well as PSReA. ARF develops in 2–3% of children/adolescents infected with group A -haemolytic streptococci causing pharyngitis. Main manifestations of ARF include carditis, migratory polyarthritis, cutaneous signs, chorea and subsequent acquired valvular disease. PSReA appeared diVerent from that of acute rheumatic fever (ARF) and from that of HLA B27-associated reactive arthritis [1–3]. However, PSReA shares some features with ARF and with HLA B27-related spondyloarthropathies. Clinical features of the patients with PSReA include additive than migratory arthritis involving large and small joints that responds relatively poorly to salicylates and nonsteroidal anti-inXammatory drugs. Joint involvement lasts 8–12 weeks. PSReA patients can develop mitral valve disease [1] and does not fulWll two of Jones major criteria [4] for diagnosis of ARF. However, the appropriate guidelines for patient selection have not been determined. Laboratory Wndings reveal elevated acute phase reactants; and evidence of recent group A streptococcal infection [5]. However, the assumed causal role of streptococcal infection for PSReA has been discussed [6]. Genetic susceptibility for ARF has been supported by several data of certain HLA-class I and II antigens in the various geographical regions and racial groups, although there has been found heterogeneity. The strongest associations were found with the HLA-DR2, HLA-DR4 and HLA-DR-7 phenotypes [7–9]. The literature concerning associations between HLA-DR antigens and PSReA were very limited. A few reported data seem to support a link between PSReA and HLA antigens [10–11] and PSReA was not found an associated with HLA-B27 but rather with HLA-DRB1*01 [10]. To our knowledge, HLA typing has never been reported in Turkish PSReA patients. We analysed HLA-DRB1 alleles to examine the association between HLA Class II genes and PSReA. The study consisted of 31 adult patients with PSReA (19 females, 12 males, mean § SD age: 35.2 § 12.2 years) identiWed with clinical and laboratory Wndings (Table 1), according to the previously published reports [1–3, 5]. None of the PSReA patients fulWlled the Jones criteria for the diagnosis of ARF, who had mainly non-migratory arthritis of large and small joints (>4 joints) that responded relatively poorly to salicylates and lasted approximately 10 weeks; laboratory Wndings revealed F. E. Haydardedeoflu · H. Tutkak · N. Düzgün (&) Department of Clinical Immunology and Rheumatology, Ankara University School of Medicine, SÂhhiye, 06100 Ankara, Turkey e-mail: duzgun@medicine.ankara.edu.tr