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SETB: 52 (4)

Volume: 52  Issue: 4 - 2018

REVIEW ARTICLE
1.Can Active Surveillance be an Alternative to Surgery in Papillary Thyroid Microcarcinoma?: The Current Situation Worldwide
Nurcihan Aygün, Adnan Işgör, Mehmet Uludağ
doi: 10.14744/SEMB.2018.15428  Pages 233 - 243
Papillary thyroid carcinoma (PTC) is the most common endocrine malignancy. Papillary thyroid microcarcinomas (PTMCs) are tumors in size of 1cm or less. The biological behaviour of these tumors differs due to the presence of their aggressive features. The prognosis of PTMCs with high-risk features such as clinical node metastasis, distant metastasis, and significant extrathyroidal extension to the tracheal or recurrent laryngeal nerve (RLN) invasion is poor, even the sufficient immediate surgery is performed at the diagnosis. However PTMCs without these aggressive features are low-risk tumors, because of their being indolent and slow growth behaviours. The increase in thyroid cancer incidence is mostly a result of overdiagnosis of small low-risk PTMCs with indolent clinical course. Despite the sudden increase in thyroid cancer incidence in the world, cancer mortality did not increase. Although the traditional treatment strategy for PTMC is immediate surgery at diagnosis, because of the rather low disease-specific mortality rate, low recurrence rate and potential risk for postoperative complications; active surveillance has been proposed as an alternative option for the PTMCs without invasion, metastasis or cytological or molecular characteristics, recently. The recent data support that active surveillance of low-risk PTMC should be the initial treatment modality, because only a small percentage of low-risk PTMCs show signs of progression and delayed surgery has not caused significant recurrence. However, recent management guidelines are shifting towards the more conservative treatments such as active surveillance. Although there is an increase in the number of studies related to active surveillance, prospective studies have been mostly from academic referral centers in Japan. The world is still in the need of class 1 evidence extended prospective studies originating from the different geographic regions. Active surveillance may be a good alternative to immediate surgery for appropriately selected patients with PTMC.
Papillary thyroid carcinoma is the most common endocrine malignancy. Papillary thyroid microcarcinomas (PTMCs) are tumors with a size of ≤1 cm. The biological behavior of these tumors differs due to the presence of their aggressive features. The prognosis of PTMCs with high-risk features, such as clinical node metastasis, distant metastasis, and significant extrathyroidal extension to the tracheal or recurrent laryngeal nerve invasion, is poor, even if a sufficient immediate surgery is performed at diagnosis. However, PTMCs without these aggressive features are low-risk tumors because of their indolent and slow growth behaviors. The increase in thyroid cancer incidence is mostly a result of overdiagnosis of small low-risk PTMCs with indolent clinical course. Despite the sudden increase in thyroid cancer incidence worldwide, cancer mortality did not increase. Although the traditional treatment strategy for PTMC is immediate surgery at diagnosis, because of the rather low disease-specific mortality rate, low recurrence rate, and potential risk for postoperative complications, active surveillance has been proposed recently as an alternative option for PTMCs without invasion, metastasis, or cytological or molecular characteristics. The recent data support that active surveillance of low-risk PTMC should be the initial treatment modality, because only a small percentage of low-risk PTMCs show signs of progression, and delayed surgery has not caused significant recurrence. However, recent management guidelines are shifting toward more conservative treatments, such as active surveillance. Although there is an increase in the number of studies related to active surveillance, prospective studies have been mostly from academic referral centers in Japan. The world still needs class 1 evidence extended prospective studies originating from different geographic regions. Active surveillance may be a good alternative to immediate surgery for appropriately selected patients with PTMC.

2.Surgical Treatment in Papillary Thyroid Microcarcinoma
Fatih Tunca, İsmail Cem Sormaz, Ahmet Yalın Işcan, Yasemin Giles Şenyürek
doi: 10.14744/SEMB.2018.45452  Pages 244 - 248
Despite the notable increasing incidence of papillary thyroid microcarcinoma (PTMC), the optimal treatment of the patients with PTMC remains controversial. Because of no consensus about its treatment, the suggested treatment varies from active surveillance alone to total thyroidectomy. Although the 2015 revised American Thyroid Association guideline recommends hemithyroidectomy as the first-line treatment, active surveillance has also been discussed and accepted as another approach for the patients with PTMC. However, the same guideline does not recommend fine needle aspiration biopsy for nodules sized <1 cm, even it is suspicious. In such situation, neither active surveillance nor hemithyroidectomy could be discussed, with a lack of objective cytologic data about the nodules sized <1 cm. In this situation, the decision to perform FNAB to the nodules <1 cm in size depends on the performer of the thyroid ultrasonography.
In this invited review, we have discussed the diagnosis and prognostic factors for PTMCs. We have also discussed surgical strategies as the accepted the first-line treatment in patients with PTMC.
Despite the notable increasing incidence of papillary thyroid microcarcinoma (PTMC), the optimal treatment of the patients with PTMC remains controversial. Because of no consensus about its treatment, the suggested treatment varies from active surveillance alone to total thyroidectomy. Although the 2015 revised American Thyroid Association guideline recommends hemithyroidectomy as the first-line treatment, active surveillance has also been discussed and accepted as another approach for the patients with PTMC. However, the same guideline does not recommend fine needle aspiration biopsy for nodules sized <1 cm, even it is suspicious. In such situation, neither active surveillance nor hemithyroidectomy could be discussed, with a lack of objective cytologic data about the nodules sized <1 cm. In this situation, the decision to perform FNAB to the nodules <1 cm in size depends on the performer of the thyroid ultrasonography.
In this invited review, we have discussed the diagnosis and prognostic factors for PTMCs. We have also discussed surgical strategies as the accepted the first-line treatment in patients with PTMC.

ORIGINAL RESEARCH
3.The Results of Core Decompression Treatment in Avascular Necrosis of the Femoral Head
Mehmet Ali Talmaç, Muharrem Kanar, Mehmet Mesut Sönmez, Hacı Musatafa Özdemir, Ferdi Dırvar, Yüksel Tenekecioğlu
doi: 10.14744/SEMB.2018.47135  Pages 249 - 253
Objective: Avascular necrosis of the femoral head (AVNFH) is a progressive disease seen in young, active patients, leaving significant disability in the joint when untreated. We retrospectively examined the results of patients with early stage AVNFH who had been operated in our clinic.
Methods: In our study, 65 hips of 46 patients were evaluated retrospectively. These patients were evaluated clinically by the Merle d'Aubigné–Postel Score and Harris Hip Score. The patients were radiologically staged according to the criteria by Ficat and Arlet with hip anterior-posterior and lateral graphs and magnetic resonance imaging.
Results: The mean follow-up period of the patient group was 73 months, and the mean age of the patients was 35 years. Of these patients, 59% were female and 41% were male; 41% had bilateral and 40% had right hip involvement. One of the patients developed AVNFH while she was pregnant, 7 were idiopathic, and 38 (81%) developed AVNFH due to steroid use. According to the Ficat and Arlet classification, 18 hips were found to be stage 1, 37 hips stage 2, and 9 hips stage 3 during admission. From the etiological point of view, 81% of the patients developed AVNFH while using steroid and 19% had idiopathic AVNFH. As for clinical improvement of the patients, the Harris Hip Score increased from 58 to 90 in idiopathic patients and 55 to 83 among steroid users. The Merle d'Aubigné–Postel classification scores increased from 6 to 15 in the idiopathic group and from 6 to 13 among steroid users. Radiologically, according to the Ficat and Arlet stage, progression was seen in all stages. Of the patients, 38.8% in stage 1, 70.2% in stage 2, and 88.8% in stage 3 showed progression, whereas 20% demonstrated rapid progression and needed total hip prosthesis. All patients who demonstrated progression were on chronic steroid therapy. The mean time to conversion to total hip replacement was 27 months.
Conclusion: Osteonecrosis is a disease associated with high morbidity. Early diagnosis can reduce morbidity and improve a patient’s quality of life. Core decompression has the effect of stopping the progression of AVNFH in the early (stage 1) stages, although it has a significant and long-term palliative effect in all stages. Most of the young and active patients with AVNFH still do not have any ideal method for treatment today, but core decompression in the early stages has been seen to reduce morbidity. It is a time-saving attempt before the final treatment, which is hip arthroplasty, is performed.
Objective: Avascular necrosis of the femoral head (AVNFH) is a progressive disease seen in young, active patients, leaving significant disability in the joint when untreated. We retrospectively examined the results of patients with early stage AVNFH who had been operated in our clinic.
Methods: In our study, 65 hips of 46 patients were evaluated retrospectively. These patients were evaluated clinically by the Merle d'Aubigné–Postel Score and Harris Hip Score. The patients were radiologically staged according to the criteria by Ficat and Arlet with hip anterior-posterior and lateral graphs and magnetic resonance imaging.
Results: The mean follow-up period of the patient group was 73 months, and the mean age of the patients was 35 years. Of these patients, 59% were female and 41% were male; 41% had bilateral and 40% had right hip involvement. One of the patients developed AVNFH while she was pregnant, 7 were idiopathic, and 38 (81%) developed AVNFH due to steroid use. According to the Ficat and Arlet classification, 18 hips were found to be stage 1, 37 hips stage 2, and 9 hips stage 3 during admission. From the etiological point of view, 81% of the patients developed AVNFH while using steroid and 19% had idiopathic AVNFH. As for clinical improvement of the patients, the Harris Hip Score increased from 58 to 90 in idiopathic patients and 55 to 83 among steroid users. The Merle d'Aubigné–Postel classification scores increased from 6 to 15 in the idiopathic group and from 6 to 13 among steroid users. Radiologically, according to the Ficat and Arlet stage, progression was seen in all stages. Of the patients, 38.8% in stage 1, 70.2% in stage 2, and 88.8% in stage 3 showed progression, whereas 20% demonstrated rapid progression and needed total hip prosthesis. All patients who demonstrated progression were on chronic steroid therapy. The mean time to conversion to total hip replacement was 27 months.
Conclusion: Osteonecrosis is a disease associated with high morbidity. Early diagnosis can reduce morbidity and improve a patient’s quality of life. Core decompression has the effect of stopping the progression of AVNFH in the early (stage 1) stages, although it has a significant and long-term palliative effect in all stages. Most of the young and active patients with AVNFH still do not have any ideal method for treatment today, but core decompression in the early stages has been seen to reduce morbidity. It is a time-saving attempt before the final treatment, which is hip arthroplasty, is performed.

4.Comparing Attention-Deficit/Hyperactivity Disorder and Oppositional Defiant Disorder Singly and Together in Terms of Behavioral Problems, Family Conflict, and Cognitive Functions
Arzu Önal Sönmez, Levent Kayaalp
doi: 10.14744/SEMB.2018.54280  Pages 254 - 261
AMAÇ: Bu çalışmada Dikkat eksikliği hiperaktivite bozukluğu (DEHB), Karşı olma karşı gelme bozukluğu (KOKGB) ve her ikisinin birlikte bulunduğu 3 grubun bilişsel yetiler, kişilik özellikleri ve aile özellikleri açısından profillerinin çıkarılması amaçlanmıştır. YÖNTEM: DEHB, KOKGB ve her ikisinin birlikte olduğu her biri 20 vakadan oluşan üç grup çalışmaya dahil edilmiştir. DSM IV kriterlerine göre seçilen vakalara Wechsler çocuklar için zeka ölçeği (WISC-R), Bender gestalt görsel motor algılama testi, 4-18 yaş çocuklar ve gençler için davranış değerlendirme ölçeği (ÇGDÖ) ve Aile içi çatışma ölçeği ile değerlendirilmiştir. BULGULAR: Bender-Gestalt Motor Görsel Algılama Testinde üç grup arasında anlamlı fark saptanmıştır. En yüksek ortalama KOKGB grubunda, en düşük ortalama ise DEHB grubunda bulunmuştur. Resim tamamlama, küplerle desen ve şifreleme gibi WISC-R testinin alt grupları arasında anlamlı ilişki saptanmamıştır. ÇGDÖ ölçeği ile değerlendirilen içe ve dışa vura davranışlar ve aile içi çatışmayı değerlendiren Aile içi çatışma ölçeğinde de üç grup arasında farklılık saptanmamıştır. SONUÇ: DEHB'deki bilişsel becerilerdeki zorluk KOKGB gibi genetik ve organik sebebe bağlı olmayan durumlarla kıyaslandığında arada fark olması DEHB'nin organik temelleri bulunabileceğini düşündürmektedir. KOKGB'da ise bilişsel bir bozulma olmaması ise çevresel ve ailesel faktörlerin önemine vurgu yapmaktadır.
Objectives: The purpose of this study is to profile three groups of children with attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and both ADHD and ODD, through analyzing their cognitive abilities, personality traits, and family characteristics.
Methods: The study included 60 patients, with 20 patients in each group. Patients were selected according to the DSM IV criteria. They completed the Wechsler Intelligence Scale for Children–Revised (WISC-R) and the Bender Visual Motor Gestalt Test, and their mothers filled out the Child Behavior Checklist (CBCL) and Marital Conflict Questionnaire.
Results: There were no significant differences in picture completion, block design, and coding, which are the WISC-R subtests, between the three groups. In addition, there was no significant difference in verbal, performance, and WISC-R scores. Finally, there was no significant difference when the subdivisions of the CBCL externalizing and internalizing behaviors were analyzed individually. The Frequency of Marital Conflict Score and Conflict Expansion Score were analyzed, and there were no significant differences found between the three groups. The highest average of the Bender Visual Motor Gestalt Test was in the ODD group, whereas the lowest average was in the ADHD group.
Conclusion: When comparing ADHD and ODD in terms of cognitive abilities, the observed differences may be because ODD has no genetic or organic component, and ADHD has an organic basis. In ODD, cognitive abilities are intact, which should underline the environmental and family factors.

5.Completion Thyroidectomy in Patients Diagnosed with Papillary Thyroid Cancer: Is There a Predictive Factor for Contralateral Lobe Tumor?
Cemal Kaya, Emre Bozkurt, Sinan Ömeroğlu, Mehmet Mihmanlı, Mehmet Uludağ
doi: 10.14744/SEMB.2018.83713  Pages 262 - 267
AMAÇ:
Tamamlayıcı tiroidektomi, genellikle başlangıçta malignite düşünülmeyen olgularda, total tiroidektomiden daha sınırlı yapılan ameliyatlardan sonra malignite saptanması durumunda kalan tiroit dokusunun çıkarılması olarak tanımlanır. Papiller tiroit kanserlerinde tümör çapı, agresif histoloji, tiroit dışı yayılım, pozitif sınır gibi faktörler tamamlayıcı tiroidektomi endikasyonlarını oluşturur. Ancak bunun dışındaki hastalarda cerrahinin genişliği tartışmalı olup, özellikle 1-4 cm arası tümör çapına sahip hastalarda halen tam bir görüş birliği yoktur. Papiller tiroit kanserlerinde prediktif faktörlerin saptanması, sık görülen ancak nispeten iyi prognoza sahip bu tiroit patolojisinde hastalar ile ilgili eksik veya aşırı tedavi konusunda yardımcı olabilir. Bununla birlikte total tiroidektominin, tek taraflı lobektomiye göre kontralateral lobda tümörü olan hastalarda lokal bölgesel nüks riskini önemli ölçüde azalttığı da bildirilmiştir.
Çalışmamızda lobektomi uygulandıktan sonra PTK saptanan ve tamamlayıcı tiroidektomi uygulanan hastalarda diğer lobda kanser saptanma oranlarını ve bunu saptamamıza yardımcı olabilecek prediktif faktörleri bulmayı amaçladık.
MATERYAL-METOD:
Kliniğimizde 2011-2016 tarihleri arasında tiroid nodüllerine lobektomi uygulandıktan sonra histopatolojik incelemede PTK saptanan 49 hastanın verileri retrospektif olarak incelendi. Hastaların demografik verileri, tümör subtipi, çapı, multicentritesi, tiroid dışı yayılım, vasküler invazyon oranları belirlendi. Hastalar, tamamlayıcı tiroidektomide karşı lobta malignite saptanmayan (Grup 1) ve malignite saptanan (Grup 2) hastalar olarak 2 gruba ayrılarak, grupların verileri karşılaştırıldı.
BULGULAR:
Hastaların 33’ü (%67.4) kadın, 16’sı erkek (% 32.6) olup yaş ortalamaları 47.59 yıl (23-77 yıl) idi. Grup 1’de 30, Grup 2’de 19 hasta yer aldı. Diğer bir anlatımla tamamlayıcı tiroidektomi ile karşı lobta tümör saptanma oranı % 38.8’ idi. İki grup arasında yaş, cinsiyet ve tümör özellikleri bakımından anlamlı fark saptanmadı. Karşı lobda tümör saptamamızı öngörebilecek prediktif faktör saptanmadı.
SONUÇ:
Çalışmamızda karşı lobta tümör varlığını öngörmede prediktif bir faktör saptanmamasına rağmen, karşı lobta tümör saptanma oranı yüksektir. Bu konuda yapılacak daha geniş çalışmalarda bu konuya katkı sağlayabilecek veriler elde edilebilir.
Objectives: Completion thyroidectomy (CT) is defined as the removal of the residual thyroid tissue in the case of detected malignancy after lobectomy for an indeterminate or non-diagnostic biopsy. Factors such as tumor diameter, aggressive histology, extrathyroidal spread, and positive surgical margin in papillary thyroid cancer (PTC) constitute CT indications. However, the type of surgery is controversial especially in patients with a tumor diameter of 1-4 cm. Determination of predictive factors for contralateral lobe tumors (CLTs) in PTC may be helpful for rough or excessive treatment of patients with this common thyroid pathology.
The aim of the present study was to determine the predictive factors and rate of detection of CLTs after CT in patients with papillary thyroid carcinoma after lobectomy.
Methods: Medical records of patients who underwent lobectomy with the final histological diagnosis of papillary thyroid carcinoma for the study period 2011 to 2016 were reviewed. Demographic data of the patients, diameter, multicentricity and subtype of tumor, extrathyroidal spread, and vascular invasion rate were obtained. Patients were divided into 2 groups as final histological examination after CT revealed benign (Group 1) and malignant (Group 2).
Results: Data of 49 patients were retrospectively analyzed during the study period. The female-to-male ratio was 33/16. The mean age of the patients was 47.59 (23–77) years. Groups 1 and 2 consisted of 30 and 19 patients, respectively. No significant difference was found between the two groups regarding demographic data and tumor characteristics.
Conclusion: Despite the fact that we have not been detecting any predictive factor in predicting the presence of tumor on the contralateral lobe in our study, the detection of a tumor on the contralateral lobe is frequent.

6.Morphometric Analysis of the Effects of Manuka Honey on Vasospastic Femoral Arteries in Rats: An Experimental Study
Osman Tanrıverdi, İlhan Yilmaz, Uzay Erdogan, Ömür Günaldi, Abuzer Güngor, Huseyin Utku Adilay, Ayca Arslanhan, Bekir Tugcu
doi: 10.14744/SEMB.2018.35761  Pages 268 - 273
Amaç: Çalışmadaki amacımız güçlü bir antienflamatuar ve antioksidan olan manuka balın deneysel olarak, sıçan femoral arterinde oluşturulan subaraknoid kanama modelinde vazospazm gelişimi üzerinde etkinliğinin olup olmadığını araştırmaktır.
Metod: Yirmi dört adet Wistar-Albino türü sıçan üç gruba ayrıldı: birinci grup (n = 8), kontrol grubu; ikinci grup (n = 8), vazospazm grubu; ve üçüncü grup (n = 8), vazospazm + bal tedavi grubu. Femoral arterlerin duvar kalınlığı (W) ve lümen çapı (L) morfometrik olarak ölçüldü. İstatistiksel analiz için SPSS kullanıldı. Alt grup analizleri Mann Whitney U testi ile yapılıp, Bonferroni düzeltmesi ile yorumlandı. İstatistiksel alfa anlamlılık seviyesi p < 0,05 olarak kabul edildi.
Sonuçlar: Grupların L ve W ortalamalarında istatistiksel olarak anlamlı fark saptandı (p < 0,001, p = 0,001). Grup 2’nin L ortalaması Grup 1 ve grup 3’e göre istatistiksel olarak anlamlı düşüktü. W ortalaması ise anlamlı olarak yüksekti (hepsi için p < 0,001). Grup 1 ve grup 3’ün L ve W ortalamaları arasında ise istatistiksel olarak anlamlı fark saptanmadı (p = 0,064 p = 0,954).
Tartışma: Manuka balı antioksidan ve antienflamatuar etkisini plazma TNFα, IL-1β, IL-6 gibi inflamatuar sitokinleri ve lipid peroksidasyon seviyesini inhibe ederek gösterir. Antienflamatuar ve antisitokin tedavinin Subaraknoid kanama sonrası iskemik komplikasyonları önlediği çeşitli çalışmalarda ortaya konulmuştur. Yapmış olduğumuz çalışmada Manuka balın antienflamatuar ve antioksidan özelliği ile, deneysel olarak sıçan femoral arterinde oluşturulan vazospasm modelinde, vazospasmı önlemede başarılı olduğu istatistiksel olarak gösterilmiştir.
Objectives: The aim of this study was to determine if Manuka honey, a potent anti-inflammatory and antioxidant agent, had any effect on the development of vasospasm in an experimental subarachnoidal hemorrhage model constructed in rat femoral arteries.
Methods: Twenty-four Wistar Albino strain rats were divided into 3 groups: Group 1 was the control group (n=8), Group 2 was the vasospasm group (n=8), and group 3 was the treatment group (n=8). The wall thickness (W) of the femoral arteries and the luminal diameter (L) were measured using morphometric methods. The data were analyzed with statistical software. The Mann-Whitney U-test was used to compare independent groups and Bonferroni post hoc analysis was used for multiple comparison tests. Significance for all of the results was established at p<0.05.
Results: A statistically significant intergroup difference was detected in the mean L and W (p<0.001, p=0.001, respectively). The mean L value in Group 2 was statistically significantly less than that of Groups 1 and 3, while the mean W value was significantly greater (p<0.001 for all). However, no statistically significant difference was detected between Groups 1 and 3 with respect to the mean L and W values (p=0.064, p=0.954, respectively).
Conclusion: Manuka honey exerts an antioxidant and anti-inflammatory effect via inhibition of inflammatory cytokines, including plasma tumor necrosis factor alpha, interleukin (IL)-1 beta, IL-6, and the lipid peroxidation level. This study statistically demonstrated that the anti-inflammatory and antioxidant properties of Manuka honey successfully inhibited the development of vasospasm in an experimentally induced vasospasm model in the femoral arteries of rats.

7.Evaluation of Laboratory Findings and Mortality in Elderly Patients with Acute Biliary Pancreatitis
Sezgin Vatansever, Remzi Doğru, Zehra Betül Pakoz, Halil Genç, Belkıs Ünsal
doi: 10.14744/SEMB.2018.37791  Pages 274 - 278
Giriş: Akut pankreatitin (AP) en sık nedeni safra taşlarıdır. AP’de laboratuvar, görüntüleme tetkikleri yanında yaş da mortaliteyi göstermede önemli bir prediktördür. Yaş artışı ile birlikte hastaneye yatış oranının da arttığı görülmektedir. Bu çalışmada akut biliyer pankreatitli 65 yaş üstü hastalarda başvuru bulguları ve toplam mortalite araştırıldı.
Materyal-metod: Çalışmaya Nisan 2006 - Ekim 2013 yılları arasında, Gastroenteroloji kliniğine başvuran ve yatarak tedavi görmüş olan toplam 852 hasta alındı. Hastaların elektronik kayıt sisteminden verileri alınarak retrospektif olarak değerlendirildi. AST değeri 3 kattan fazla yükselen, kolelitiazis olan, kolesistektomi öyküsü olan ya da koledokta taş saptanan hastalar biliyer pankreatit olarak kabul edildi. Hastalar 65 yaş üstü ve altında olmak üzere iki gruba ayrıldı.
Bulgular: Gençlerde ALT, albumin, hematokrit ve amilaz düzeyleri, yaşlılarda ise üre, lökosit ve CRP düzeyi anlamlı olarak daha yüksek saptandı. Ortalama yatış süresi iki grupta da benzer bulundu. Yaşlılarda koledokta taş saptanma oranının anlamlı olarak daha fazla olduğu görüldü (p<0.001). Mortalite oranları 65 yaş üstü hastalarda 65 yaş altı gruba göre 28. gün ve 90. günde (1.25% & 5.63%, p<0.001) anlamlı olarak daha fazla bulundu. Ayrıca lojistik regresyon çok değişkenli analizde, 90. gün mortaliteyi ön görmede yaş (OR 2.0, 95% CI 1.54-1.36; p=0.006), üre (OR 1.12, 95% CI 1.05-1.19; p=0.001), hematokrit artması (OR 1.42, 95% CI 1.13-1.77; p=0.002) ve albumin azalmasının (OR 0.05, 95% CI 0.004-0.652; p=0.022) mortalite için prediktör olduğu görüldü.
Sonuç: Yaşlı hastalarda AP’deki laboratuvar bulguları 65 yaş altındaki hastalara göre farklılık gösterebilmektedir. Kesitsel görüntüleme bulguları ise her iki grupta benzer olmasına rağmen 65 yaş üstü hastalarda mortalite daha yüksektir.
Objectives: Gallstones are the most common cause of acute biliary pancreatitis. Laboratory and imaging findings as well as age are important predictors for mortality. Hospitalization rate is also higher in elderly patients. In this study, we investigated clinical parameters and total mortality in patients with acute pancreatitis aged >65 years.
Methods: In this study, 852 patients who entered the Gastroenterology Clinic for acute biliary pancreatitis between April 2006 and October 2013 were included. Data were retrospectively collected from the electronic record system. The patients with elevated aspartate aminotransferase levels (i.e. three times higher than normal value), cholelithiasis, cholecystectomy history, or choledocholithiasis were accepted as the patients with acute biliary pancreatitis. Patients were divided into two groups based on their age, i.e., >65 and <65 years.
Results: In the group with patients aged <65 years, serum alanine aminotransferase, albumin, hematocrit, and amylase, and in the group with patients aged >65 years, urea, leukocyte, and C-reactive protein levels were significantly different. Median hospital stay was similar in both the groups. The rate of detection of choledocholithiasis was significantly higher in elderly patients (p<0.001). Mortality rate was significantly higher in elderly patients for 28 day (0.21% and 2.95%, p<0.001) and 90 day (1.25% and 5.63%, p<0.001). In logistic regression multivariate analysis, age (OR 2.0, 95% CI 1.54–1.36; p=0.006), elevated urea levels (OR 1.12, 95% CI 1.05–1.19; p=0.001), elevated hematocrit levels (OR 1.42, 95% CI 1.13–1.77; p=0.002), and decreased albumin levels (OR 0.05, 95% CI 0.004–0.652; p=0.022) were found predictors for 90-day mortality.
Conclusion: Laboratory findings in elderly patients with acute pancreatitis may differ from those in younger patients. Although radiological findings are similar in both the groups, mortality is higher in the group with patients aged >65 years.

8.Use of Single- or Two-dose Pulse Methylprednisolone in the Treatment of Acute Immune Thrombocytopenic Purpura
Ayşe Bozkurt Turhan, Zeynep Canan Özdemir, Özcan Bör
doi: 10.5350/SEMB.20171130112516  Pages 279 - 284
Amaç: Akut İmmün Trombositopenik Purpura (İTP) tedavisinde hemostazı sağlayacak trombosit düzeyini en hızlı şekilde elde etmek temel hedeftir ve bu amaçla ilk 48 saat içinde trombosit sayısında hızlı artış yapması nedeni ile intravenöz (İV) pulse steroid kullanımı yaygındır. İntravenöz pulse steroid tedavisi, genellikle sabahları tek doz şekilde, metilprednizolon olarak uygulanmaktadır. Yarılanma ömrü nedeni ile oral tedavilerde genellikle iki dozda kullanılan metilprednizolonun pulse tedavide iki dozda kullanımına dair bir etkinlik çalışması bulunmamaktadır. Bu çalışmada, medikal tedavi gereken hastalarda, en etkili ve ekonomik yönden en ucuz tedavi şekli olan pulse steroid tedavisinin, tek veya iki dozda verilmesinin trombosit sayısını yükseltme hızı açısından farklı olup olmadığını araştırmayı amaçladık.
Gereç ve Yöntem: Akut ITP tanısı uygun klinik, laboratuvar ve kemik iliği bulguları ile trombosit sayısının <100000/mm3 olması olarak belirlendi. Hastaların hepsi kemik iliği aspirasyonu ile tanı aldılar ve yatırılarak izlendiler. Trombosit sayısı 20000/mm3 altında olan, ıslak purpura veya aktif kanama şikayeti bulunan tüm hastalara tedavi verildi. Tedavi uygulanacak hastalar rastgele olarak, iki tedavi grubuna ayrıldı. Birinci gruba iv pulse metilprednizolon (30 mg/kg/gün, üç gün ve 20 mg/kg/gün, dört gün) sabah erken saatte tek doz, ikinci gruba aynı toplam doz sabah-akşam (12 saatte bir) olacak şekilde ikiye bölünerek verildi. Pulse steroid tedavisinden önce ve tedavinin 1., 2., 3., 5., 7. gününde hemoglobin, beyaz küre ve trombosit sayıları incelendi ve her iki grubun tedaviye cevap hızlarını belirlemek için trombosit sayısının 20000/mm3, 50000/mm3 ve 100000/mm3’ün üzerine çıkma süreleri, tedavinin 1., 2., 3., 5. ve 7. günlerinde karşılaştırıldı.
Bulgular: Çalışmaya iv pulse steroid tedavisi alan toplam 60 ITP’li hasta dahil edildi. İki dozda pulse steroid alan 2. gruptaki hastaların trombosit düzeylerinin 20000/mm3 ve üzerine ulaşma süresi [ortanca 2 (2-3) gün], 50000/mm3 ve üzerine ulaşma süresi [ortanca 3 (2.7-3.5) gün], 100000/mm3 ve üzerine ulaşma süresi [ortanca 5 (3-5) gün], tek doz alan 1. gruptaki hastalardan [sırasıyla ortanca 3 (2-5) gün, ortanca 5 (4-7) gün, ortanca 7 (4-7) gün] anlamlı olarak daha kısaydı (sırasıyla p<0.001, p<0.001, p=0.004).
Sonuç: Bu çalışma, akut İTP’de trombosit sayısının 20000/mm3’den düşük ve intrakranial kanama riski olan, trombosit sayısını hızla yükseltmek istediğimiz hastalarda, iv pulse steroid tedavisinin ilacın yarılanma ömrü dikkate alınarak, oral tedavide olduğu gibi iki dozda verilmesinin trombosit sayısının erken dönemde daha hızlı yükselmesinde etkili olduğunu göstermektedir.
Objectives: In immune thrombocytopenic purpura (ITP) treatment, the main goal is achieving the platelet level most rapidly for hemostasis. Pulse steroid therapy is common due to the rapid increase in the platelet count within the first 48 hours. Intravenous (IV) pulse steroid therapy is usually administered as a single methylprednisolone dose in the morning. Oral methylprednisolone is generally used as two divided doses due to its half-life, but there is no efficacy study for the use of pulse methylprednisolone therapy in two doses. In this study, we aimed to investigate whether the administration of single or double doses of pulse steroid treatment, which is the cheapest and most economical way to treat patients, differ in terms of platelet count increase rate.
Methods: The diagnosis of acute ITP was made based on the appropriate clinical, laboratory, and bone marrow findings and platelet count <100.000/mm3. All the patients were diagnosed with bone marrow aspiration, and they were admitted to the hospital. All patients with platelet counts below 20000/mm3 and those who had wet purpura or active bleeding were treated. Patients in need of treatment were randomly divided into two treatment groups with closed envelope method. The first group was given IV pulse methylprednisolone (30 mg/kg/day for three days and 20 mg/kg/day for four days) in the early morning hours. The second group received the same daily dosages in two divided doses. Hemoglobin, white blood cell, and platelet counts were evaluated before and on the first, second, third, fifth, and seventh days of treatment. To evaluate the rate of treatment response, platelet counts over 20.000/mm3, 50.000/mm3, and 100.000/mm3 obtained on the first, second, third, and seventh days of treatment were compared.
Results: Sixty patients with acute ITP diagnosis receiving pulse steroid therapy were included in the study. Platelet counts of the patients in group 2, who received pulse steroids in two doses, reached ≥20.000/mm³ on the second day [median, (2–3) days], ≥50.000/mm³ on the third day [median, (2.7–3.5) days], ≥100.000/mm³ on the fifth day [median, (3–5) days], which were significantly lower than the platelet counts of the patients in the first group on the third day [median, (2–5) days], fifth day [median, (4–7) days], and seventh day [median, (4–7) days], respectively (p<0.001, p<0.001, p=0.004).
Conclusion: This study shows that administration of IV pulse steroid therapy in two doses is more effective in increasing the platelet count in early period in patients with acute ITP, especially whose platelet count is less than 20.000/mm³, and when we prefer to increase the platelet counts rapidly due to risk of intracranial hemorrhage.

9.Long-term and Perioperative Outcomes of Laparoscopic and Open Surgery for Rectal Cancer
Huseyin Onur Aydin, Yahya Ekici, Feza Yarbug Karakayali, Tugan Tezcaner, Gonca Ozgun, Sedat Yıldırım, Gokhan Moray
doi: 10.14744/SEMB.2017.04909  Pages 285 - 288
Amaç: Rektum kanserinde minimal invaziv cerrahinin kullanımı ile onkolojik sonuçların karşılaştırılması gerekliliği ortaya çıkmıştır. Rektum kanserinde tedavi yaklaşımımızı değerlendirmek, laparoskopik ve açık cerrahi sonuçlarını karşılaştırmayı amaçladık.
Gereç ve Yöntem: Ocak 2006- Ocak 2016 yılları arasında kliniğimizde rektum karsinomu nedeniyle ameliyat edilen hastalar değerlendirildi. Sonuçlar açık ve laparoskopik cerrahi olarak iki grup arasında karşılaştırıldı. Cerrahi girişim sonrası klinik özellikler, preoperatif ve postoperatif sonuçlar; patolojik inceleme sonuçları ve hastalıksız sağkalım süreleri karşılaştırıldı.
Bulgular: Çalışmaya toplam 121 hasta dahil edildi. 50 hastaya açık, 71 hastaya laparoskopik cerrahi uygulandı. Açık cerrahi grubunda medyan takip süresi 56.75 ay; laparoskopik cerrahi grubunda hastaların medyan takip süresi 55.2 aydı. Patolojik incelemede her iki grupta benzer sayıda lenf nodu saptandı (p>0.05). Hastanede yatış süresi laparoskopik cerrahi grubunda açık cerrahi grubuna göre istatistiksel olarak anlamlı derecede düşük bulundu (p<0.05). Hastalıksız takip süresi açık cerrahi grubunda %74, laparoskopik cerrahi grubunda %82.5’idi ve istatistiksel olarak anlamlı farklılık olmadığı görüldü (p>0.05).
Sonuç: Çalışmamızda rektum karsinomu için laparoskopik ve açık cerrahi arasında komplikasyon ve rekürrens açısından anlamlı farklılık olmadığı görüldü. Laparoskopik cerrahi grubunda bulunan hastaların hastanede kalış süresi açık cerrahi grubundan istatistiksel olarak anlamlı derecede düşüktü. Laparoskopik veya açık cerrahi seçenekleri, rektal kanser tedavisinde hastanın klinik uygunluğuna, cerrahın deneyimine ve merkez kaynaklarına göre tercih edilebilir.
Objectives: The necessity of comparing oncologic results with the use of minimally invasive surgery in rectal cancer has arisen. The aim of the present study was to evaluate the treatment approach in rectal cancer and to compare the outcomes of laparoscopic and open surgery.
Methods: Patients who underwent surgery for rectal carcinoma between January 2006 and January 2016 in our institution were evaluated. The results were compared between the two groups according to open or laparoscopic surgery. Clinical characteristics, preoperative and postoperative results, pathological examination results, and disease-free survival rates were compared after the surgical procedure.
Results: A total of 121 patients were included in the study. Of the patients, 50 underwent open, and 71 underwent laparoscopic surgery. The median follow-up times were 56.75 months in the open surgery group and 55.2 months in the laparoscopic surgery group. Pathological examination revealed similar numbers of lymph nodes in both groups (p>0.05). The duration of hospital stay was statistically significantly lower in the open surgery group than in the laparoscopic group (p<0.05). The rates of disease-free survival were 74% in the open surgery group and 82.5% in the laparoscopic group, and no statistically significant difference was found (p>0.05).
Conclusion: There was no significant difference in complication and recurrence between laparoscopic and open surgery for rectal cancer in our study. The duration of hospital stay of patients was statistically significantly lower in the laparoscopic group than in the open surgery group. Laparoscopic or open surgical options could be preferred according to the clinical suitability of the patient, experience of the surgeon, and resources of the center in rectal cancer treatment.

10.The Evaluation of Upper Airway Complications Secondary to Intubation: Cuff Pressure Manometer Versus Conventional Palpation Method
Özlem Ünsal, Nurullah Seyhun, Bilge Türk, Merve Ekici, Hale Dobrucalı, Suat Turgut
doi: 10.5350/SEMB.20171214085933  Pages 289 - 295
Amaç: Kulak burun boğaz hastalıkları cerrahisinde sıklıkla tercih edilen genel anestezi sonrası entübasyona sekonder boğaz ağrısı, öksürük, ses kısıklığı gibi üst hava yolu komplikasyonlarının ve yutma güçlüğünün, entübasyon tüpü balon basıncı, entübasyon tüpü çapı ve entübasyon süresi dikkate alınarak araştırılması amaçlandı.
Gereç ve Yöntemler: Çalışmaya dahil edilen 67 hasta çalışma ve kontrol gruplarına atandıktan sonra çalışma grubunda entübasyon tüpü basıncı, manometre kullanılarak 20-30 cm H2O basınç aralığında tutuldu. Kontrol grubunda anestezi uzmanı tarafından balon basıncı palpasyonla ayarlandı. Entübasyon süresi ve tüp çapı kaydedildi. Postoperatif 4, 8 ve 24. saatlerde boğaz ağrısı, öksürük, disfoni ve disfaji açısından gruplar karşılaştırıldı.
Bulgular: Kontrol grubunda balon basıncı çalışma grubundan anlamlı yüksekti. Boğaz ağrısı kontrol 4, 8 ve 24. saatlerde, öksürük ve disfoni 4 ve 8. saatlerde, disfaji ise 4. saatte çalışma grubundan anlamlı alarak fazla gözlendi. Entübasyon süresi ile sadece öksürük arasında anlamlı ilişki saptandı.
Sonuçlar: Balon basıncının palpasyon yöntemi ile fazla şişirilmesi ve bu grup hastalarında entübasyona sekonder hava yolu komplikasyonlarının yüksek oranda görülmesi nedeniyle tüp basıncının manometre ile ayarlanması bu komplikasyonların azaltılmasında önerilmektedir.
Objectives: General anesthesia is preferred in most otorhinolaryngologic surgeries. The aim of the present study was to evaluate upper airway complications secondary to intubation including sore throat, cough, dysphonia, and dysphagia considering endotracheal tube (ET) cuff pressure, tube diameter, and duration of intubation.
Methods: After the assignment of 67 patients to the study and control groups, ET cuff pressure was adjusted to be between 20 and 30 cm H2O using a cuff pressure manometer in the study group. In the control group, the cuff pressure was decided by the anesthesiologist using the conventional palpation method. Sore throat, cough, dysphonia, and dysphagia were compared between the groups at 4, 8, and 24 h postoperatively.
Results: Cuff pressure was significantly higher in the control group than in the study group. In the control group, sore throat was more frequently observed at 4, 8, and 24 h, whereas in the study group, cough and dysphonia were more often observed at 4 and 8 h. At 4 and 8 h, cough was found to be related to the duration of intubation.
Conclusion: Arrangement of cuff pressure using a cuff manometer is suggested to decrease complications of the upper airway secondary to intubation because of the higher rate of these complaints in patients whose cuff pressure is arranged by the conventional palpation method.

11.Results of Radiofrequency Ablation of Inferior Turbinate Hypertrophy in Patients with Allergic and Non-Allergic Rhinitis
Bilge Türk, Arzu Yasemin Korkut, Kerem Sami Kaya, Egehan Salepçi, Özlem Ünsal, Berna Uslu Coşkun, Suat Turgut
doi: 10.14744/SEMB.2018.77992  Pages 296 - 301
Amaç: Medikal tedaviye cevap vermeyen alt konka hipertofisi tedavisinde radyofrekans ile konka cerrahisi yaygın olarak kullanılan bir metoddur. Bu çalışmanın amacı konka hipertrofisi tedavisinde radyofrekans ablasyonu ile konka cerrahisinin etkinliğini değerlendirmek ve alerjik ve non-alerjik rinitli hastalardaki sonuçlarını karşılaştırmaktır.
Method: Bu prospektif randomize olmayan klinik çalışmaya üçüncü basamak hastanemizde Eylül 2017 ve Ocak 2018 tarihleri arasında alt konkalarına radyofrekans işlemi uygulanan yaşları 18 ve 67 arasında değişen (ortalama 37 ± 13) 59 hasta dahil edildi. Alerjik rinitli hastalar (n=23) grup 1, non-alerjik hastalar (n=36) grup 2 olarak sınıflandırıldılar. Preoperatif ve postoperative üçüncü ve altıncı aylarda endoskopik burun muayeneleri ve akustik rinomanometri testleri uygulandı. Nazal semptomlar standart 0-10 vizüel analog skalası (VAS) ile değerlendirildi.
Bulgular: Her iki grupta da nazal tıkanıklıkta postoperative anlamlı derecede azalma olduğu ve bu azalmanın 1. grupta daha iyi olduğu görüldü. Kaşıntı, rinore ve hapşırma VAS skorlarındaki azalma grup 1 de istatiksel olarak anlamlı bulunurken, 2.grupta hapşırma VAS skorunda azalma anlamlı idi.
Sonuç: Bu çalışma radyofrekansın alt konka hipertofisi olan alerjik ve non-alerjik rinitli hastalarda etkili ve güvenli bir tedavi seçeneği olduğunu göstermiştir. Ayrıca alerjik rinitli hastalarda tüm nazal semptomların, non-alerjik rinitli hastalarda burun tıkanıklığı ve hapşırma semptomlarının daha iyi olmasını sağlamıştır.
Objectives: For the treatment of the inferior turbinate hypertrophy that is unresponsive to medical treatment, turbinate surgery with radiofrequency is a widely used method. This study aims to evaluate the efficacy of turbinate surgery with radiofrequency ablation for the treatment of turbinate hypertrophy, and compare the results of patients with allergic rhinitis and non-allergic rhinitis.
Methods: A total of 59 consecutive patients aged 18–67 years (mean 37±13) who underwent radiofrequency ablation to the inferior turbinate at our tertiary care hospital from September 2017 to January 2018 were enrolled in this prospective nonrandomized clinical study. The patients with allergic rhinitis (n=23) were classed as group 1, and the patients with non-allergic rhinitis (n=36) were classed as group 2. Endoscopic nasal examination and an acoustic rhinometer were applied, and a standard 0–10 visual analog scale (VAS) was used to assess nasal symptoms preoperatively and postoperatively at the third and sixth months.
Results: The study found a significant reduction in nasal obstruction for both groups postoperatively. This reduction was higher in group 1. The decrease in nasal VAS scores for itching, rhinorrhea, and sneezing were statistically significant in group 1, whereas the decrease in nasal VAS scores for sneezing was significant in group 2.
Conclusion: This study demonstrates that radiofrequency appears to be an effective and safe treatment option for inferior turbinate hypertrophy of patients with allergic rhinitis or non-allergic rhinitis. It also provides a better perception of all nasal symptoms in patients with allergic rhinitis, and a better perception of nasal obstruction and sneezing in patients with non-allergic rhinitis.

12.Evaluation of Comorbidities in Patients with Autoimmune Bullous Diseases: A Retrospective Study
Ezgi Aktaş Karabay, Asli Aksu Çerman, Ilknur Kıvanç Altunay
doi: 10.14744/SEMB.2018.55376  Pages 302 - 306
Amaç: Otoimmün büllöz hastalık (OBH) tanısıyla kliniğimizde yatarak tedavi almış olguların eşlik eden hastalıklar açısından retrospektif olarak değerlendirilmesi amaçlanmıştır.
Gereç ve Yöntem: Ocak 1999 - Aralık 2015 tarihleri arasında Şişli Hamidiye Etfal Eğitim ve Araştırma Hastanesi Deri ve Zührevi Hastalıklar Kliniği’nde yatarak izlenmiş 142 OBH olgusu ve 217 sağlıklı kontrol çalışmaya dahil edildi. Hastaların tanı anındaki yaşları, cinsiyetleri kaydedildi, eşlik eden hastalıkları sorgulandı ve sağlıklı kontrollerle karşılaştırıldı.
Bulgular: Çalışmamıza 80 pemfigus hastası, 62 pemfigoid hastası ve 217 sağlıklı kontrol dahil edildi. Eşlik eden hastalıklar incelendiğinde hipertansiyon, diabetes mellitus, koroner arter hastalığı, katarakt, malignite, demans, Alzheimer hastalığı, Parkinson hastalığı, serebrovasküler olay geçirme sıklığı pemfigoid grubunda pemfigus ve kontrol grubuna göre istatistiksel olarak anlamlı şekilde daha yüksekti (p<0.01, p<0.01, p= 0.001, p<0.01, p= 0.02, p= 0.008, p= 0.001, p= 0.001, p<0.01; sırasıyla). Astım, benign prostat hipertrofisi ve katarakt pemfigus grubunda kontrollerle karşılaştırıldığında daha sık izlenmekteydi (p= 0.02, p= 0.04, p= 0.02; sırasıyla).
Sonuç: Bildiğimiz kadarıyla literatürde pemfigus, pemfigoid ve sağlıklı kontrollerin komorbiditeler açısından karşılaştırıldığı çalışma bulunmamaktadır. Çalışmamızda pemfigus ve pemfigoid gruplarında daha sık izlendiği gösterilen hastalıkların gelişmesinde farklı patofizyolojik mekanizmaların mı rol oynadığı yoksa tesadüfi birliktelikler mi olduğu araştırmaya açık bir konudur. OBH olgularında eşlik eden hastalıkların da sorgulanmasının önemli olduğu kanaatindeyiz.
Objectives: The purpose of the present study was to define the accompanying diseases of patients with autoimmune bullous diseases (ABDs).
Methods: One hundred forty-two patients with ABD who were followed up in the dermatology and venereology inpatient clinic of Şişli Hamidiye Etfal Training and Research Hospital between January 1999 and December 2015 were enrolled in the study. Age, gender, and accompanying diseases of the participants were recorded and compared with the healthy subjects.
Results: Eighty patients with pemphigus, 62 patients with pemphigoid, and 217 healthy subjects were included in the study. The pemphigoid group had a statistically significant higher prevalence of hypertension, diabetes mellitus, coronary artery diseases, cataract, malignancy, dementia, Alzheimer’s disease, Parkinson’s disease, and cerebrovascular events relative to the pemphigus and control groups (p<0.01, p<0.01, p=0.001, p<0.01, p=0.02, p=0.008, p=0.001, p=0.001, and p<0.01, respectively). The prevalence of asthma, benign prostatic hyperplasia, and cataract was higher in the pemphigus group than in the controls (p=0.02, p=0.04, and p=0.02, respectively).
Conclusion: To the best of our knowledge, this is the first study comparing accompanying diseases between controls and patients with pemphigus and pemphigoid. It is disputable whether the diseases mentioned occur due to some common pathophysiological pathways or coexist just coincidentally. We believe that it is important to evaluate accompanying diseases in patients with ABD.

CASE REPORT
13.Cervical Nerve Root Compression Due to Vertebral Artery Loop Indentation: Case Report
Devrim Ulaş Urut
doi: 10.5350/SEMB.20170517045234  Pages 307 - 309
Amaç: Servikal diskopatilere ve spondiloza bağlı gelişen servikal sinir tutulumu semptomları neticesinde ağrı, uyuşma ve kas gücü kaybı gibi şikâyetler ortaya çıkabilir. Kıvrımlı vertebral arter nadir görülen bir vasküler patoloji olmakla beraber neden olduğu sinir basısı sonucu, benzer özellikte klinik semptomlara yol açar. Tedavi stratejisi, tanıyı takiben tamamen farklılık gösterebilir.
Olgu sunumu: Sağ kolda uyuşma şikayeti nedeniyle hastanemize başvuran hastanın yapılan MR (manyetik rezonans) incelemesinde, nöral foraminal alanda daralmaya ve C3 sinir kökünde basıya neden olan VA (vertebral arter) kıvrımı tespit edildi. İncelemeyi takiben VA’e yönelik yapılan RDUS (renkli doppler ultrasonografi) tetkikinde anlamlı patoloji saptanmadı.
Sonuç: Servikal disk patolojileri, servikal bölge ağrısı ile kollarda uyuşma ve güç kaybı şikayeti olan hastaların büyük bir çoğunluğunda ana patolojidir. Nadiren de olsa nöral forameni daraltan diğer patolojilerin akılda tutulması ayırıcı tanı açısından faydalıdır.
Symptoms such as pain, numbness, and loss of muscle strength may occur as a result of cervical discopathies and spondylosis-associated cervical nerve palsy symptoms. Vertebral artery loop formation is a rare vascular pathology associated with nerve root compression resulting in similar clinical symptoms. The treatment strategy may be completely different following the diagnosis. Magnetic resonance imaging of the patient who admitted to our hospital due to complaints of right-sided numbness detected vertebral artery loop causing narrowing of the neural foraminal area and C3 nerve compression. No significant pathology was found in the Doppler ultrasound (US) examination performed for the vertebral artery vasculature following the examination. Cervical disc pathologies are the main pathology in the vast majority of patients suffering from cervical region pain and numbness and loss of strength. In rare cases, keeping in mind the other pathologies that constrain neural foraminal area is useful for differential diagnosis.

14.Aldosterone Resistance Due to Tacrolimus: A Case Report
Feyza Bayraktar, Yener Koç, Taner Baştürk, Barış Hasbal, Tamer Şakacı, Elbis Ahbap, Mahmud Islam, Perin Nazif, Abdulkadir Ünsal
doi: 10.14744/SEMB.2017.75436  Pages 310 - 312
Amaç: Takrolimus ile daha sık görülmekle birlikte kalsinörün inhibitörlerinin hiporeninemik hipoaldosteronizm benzeri tablo geliştirerek hiponatremi ve hiperkalemi gibi elektrolit bozukluklarına yol açabildiği bilinmektedir.
Olgu: Yazımızda 32 yaşında renal transplantasyon yapılan ve takibinin 149. gününde hiponatremi ve hiperkalemi ile başvuran, tetkiklerinde normal anyon açıklı metabolik asidoz ve renal tübüler disfonksiyon saptanan, diğer nedenler dışlandıktan sonra takrolimusa bağlı elektrolit bozukluğu düşünülen vaka verilmektedir. Hastada takrolimusun everolimusa değişimi ile yanıt alınamamış ve aldosteron rezistansına bağlı tübüler disfonksiyon düşünülerek fludrokortizon başlanmış, elektrolit bozuklukları hızla düzelmiştir.
Sonuç: Böbrek nakli hastalarında takrolimusa bağlı hiponatremi ve/veya hiperkalemi saptandığında fludrokortizon tedavisi akla gelmelidir.
Although more common with tacrolimus, it is known that calcineurin inhibitors may induce the development of electrolyte disorders such as hyponatremia and hyperkalemia by causing a hyporeninemic hypoaldosteronism-like syndrome. We present a 32-year-old female renal transplant patient who admitted to clinic with hyponatremia and hyperkalemia. Normal anion gap metabolic acidosis and renal tubular dysfunction were detected and after other reasons were excluded, it was considered as electrolyte disorder due to tacrolimus. No response was detected after tacrolimus conversion to everolimus and considering tubular dysfunction due to aldosterone resistance, we initiated fludrocortisone therapy and electrolyte disorders rapidly improved. Fludrocortisone therapy should be considered when hyponatremia and/or hyperkalemia due to tacrolimus are detected in renal transplant patients.

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