Elevated first-trimester PAPP-A is a marker in high-risk pregnancies with an increased risk of placenta accreta in predicting adverse outcomes.

OBJECTIVE: Our work aims to determine whether there is an association between first-trimester serum pregnancy-associated plasma protein A (PAPP-A) multiples of the median (MoM) value and placenta previa with or without placenta accreta spectrum disorders (PAS) in women. PATIENTS AND METHODS: A retrospective analysis was performed on 267 patients who had first-trimester screening test results for aneuploidy, including nonadherent placenta previa (n=106), placenta previa with PAS (n=60), and control group (healthy pregnant women with previous cesarean section and normal placental location, n=101). To assess the significant difference between these groups, PAPP-A MoMs were compared. RESULTS: The median PAPP-A MoM of 1.96 in placenta previa with PAS was significant (>0.88) in nonadherent placenta previa and 0.89 in the control group (p<0.001). Serum PAPP-A was found to be significantly associated with the severity of bleeding, such that patients with severe bleeding of 1,500 mL or more (n=54) had a higher mean PAPP-A MoM (1.93±0.69; p<0.001). Furthermore, the mean PAPP-A MoM was found to be 1.96±0.74 in the hysterectomy group and 0.89±0.47 in the conservative management group, and the difference was found to be significantly higher (p<0.001). CONCLUSIONS: Elevated PAPP-A values in the first trimester of pregnancy may be a useful marker for identifying women at higher risk of PAS and adverse outcomes.

Evaluation of the bilateral cardiac afferent distribution at the spinal and vagal ganglia by retrograde labeling.

The identity of sensory neurons innervating the heart tissue and the extent of information reported to the brain via these neurons are poorly understood. In order to evaluate the multidimensional distribution and abundance of the cardiac spinal and vagal afferents, we assessed the retrograde labeling efficiency of various tracers, and mapped the cardiac afferents qualitatively and quantitatively at the bilateral nodose ganglia (NGs) and dorsal root ganglia (DRGs). From the five different retrograde tracers evaluated, Di-8-ANEPPQ yielded reproducibly the highest labeling efficiency of cardiac afferents. We demonstrated specific cardiac afferents at NGs and C4 to T11 DRG segments. Next, the 2D reconstruction of the tissue sections and 3D imaging of the whole NGs and DRGs revealed homogeneous and bilateral distribution of cardiac afferents. The quantitative analyses of the labeled cardiac afferents demonstrated approximately 5-6% of the soma in NGs that were equally distributed bilaterally. The neuronal character of Di-8-ANEPPQ labeled cells were validated by coimmunostaning with pan-neuronal marker Tuj-1. In addition, the cell diameters of labeled cardiac sensory neurons were found smaller than 20 µm, implying the nociceptor phenotype confirmed by co-labeling with TRPV1 and Di-8-ANEPPQ. Importantly, co-labeling with two distinct tracers Di-8-ANEPPQ and WGA-647 demonstrated exclusively the same cardiac afferents in DRGs and NGs, validating our findings. Collectively, our findings revealed the cardiac afferents in NGs bilaterally and DRGs with the highest labeling efficiency reported, spatial distribution and quantitation at both 2D and 3D levels, furthering our understanding of this novel neuron population.

High plasma D-dimer level is associated with decreased survival in patients with lung cancer.

AIMS: An elevated plasma D-dimer level indicates the activation of coagulation and fibrinolysis. In the present study, we investigated the association of pre-treatment haemostatic parameters (D-dimer, fibrinogen and prothrombin fragment 1+2) with clinicopathological parameters and outcome in patients with lung cancer. MATERIALS AND METHODS: Plasma levels of D-dimer and other parameters were measured in 78 evaluable patients with lung cancer (60 non-small cell lung cancers, 18 small cell lung cancers). At diagnosis, 35 patients (44.9%) were locally advanced stage (IIIA/B) and 43 patients (55.1%) had metastatic disease (IV). Multivariate statistical analysis was carried out using Cox's proportional hazards model. The receiver operating characteristic curve was used to determine the cut-off values for D-dimer, fibrinogen and prothrombin fragment 1+2. RESULTS: The median survival for all patients was 264 days (95% confidence interval 200-328 days). A significant association between the plasma levels of D-dimer and the response to chemotherapy was observed (P=0.03). With the univariate analysis, tumour stage, pre-treatment plasma levels of D-dimer, fibrinogen, platelet count, lactate dehydrogenase concentration and Karnofsky performance status were predictive for survival. With the multivariate analysis (P< or =0.1), the plasma level of D-dimer (P<0.001), tumour stage (P=0.01) and Karnofsky performance status (P=0.02) were identified as independent predictive factors. The median survival times were 405 days (95% confidence interval 165-644 days) and 207 days (95% confidence interval 146-267 days, P<0.001), respectively, for patients with a low D-dimer level (< or =0.65 microg/ml) and a high D-dimer level (>0.65 microg/ml). CONCLUSIONS: Elevated plasma levels of D-dimer in patients with lung cancer are associated with decreased survival and a poor response to treatment. Pre-treatment for the D-dimer level may be useful in the prediction of survival and the response to treatment.

Prevalence and annual risk of tuberculosis infection in Edirne, Turkey.

Tuberculosis is still an important problem in developing countries. A total of 3,774 students from primary schools in Edirne, Turkey were included in this study in order to determine the annual infection risk for the year 1994. Five tuberculin units of purified protein derivative were applied using a Mantoux test and evaluated. The mean induration diameter was 14.6 mm. A total of 51.6% of the students were found to be sensitive to tuberculin. The annual infection risk of tuberculosis was found to be 1.51%, lower than that found in 1987. Other studies from Turkey have reported lower values than ours. We did not diagnose any cases of tuberculosis. We revealed that the annual infection risk among primary schoolchildren in Edirne is close to the average for Turkey and thus tuberculosis is still a serious risk for these children. Tuberculosis remains an important public health problem in Turkey and is partially attributable to socioeconomic difficulties.

Laparoscopic versus open cholecystectomy: effect on pulmonary function tests.

BACKGROUND/AIMS: Operations often cause impairment in respiration due to pain. This study was designed to compare the changes in pulmonary function tests after open and laparoscopic cholecystectomy. METHODOLOGY: Two groups of 35 patients were randomly set up. Each patient had 3 pulmonary function tests performed and 2 postero-anterior grid chest roentgenograms taken. All of these data were evaluated by the same group of investigators. RESULTS: After taking into consideration the difference between pulmonary function tests, values were not significant (P < or = 0.05). All pulmonary function test values decreased significantly on the 1st postoperative day (P < or = 0.05). When postero-anterior chest roentgenograms were compared no clinically evident atelectasis except 3 lineary was seen in the laparoscopic cholecystectomy group, whereas 5 lineary, 7 focal, and 3 segmentary atelectasia were encountered in the open cholecystectomy group (P < or = 0.05). CONCLUSIONS: We believe that laparoscopic cholecystectomy has more advantages when speaking of postoperative pulmonary function tests and atelectasia.

Patellar metastasis from a lung epidermoid carcinoma.

Patellar metastases are very rare. There have been approximately 20 cases reported in the literature. We have also noted two other reports of patellar metastasis from lung carcinoma as the first manifestation of lung cancer in our literature review. We present a case of patellar metastasis as the first manifestation of lung epidermoid carcinoma in a patient who was a smoker for 33 years.

The prevalence of allergic diseases in primary school children in Edirne, Turkey.

BACKGROUND: Allergic diseases present a major health burden for children as shown by the rising morbidity and increased mortality from asthma. Information on the prevalences of allergic disorders and contributing factors as well will help to establish feasible measures to change this trend, and more efficient assignment of the limited health resources. OBJECTIVE: To assess the prevalences of asthma and other allergic diseases and the contribution of various risk factors in primary school children in Edirne, Turkey. METHODS: Children aged 7 to 12 in primary schools in the municipality and 24 villages of Edirne were surveyed via a questionnaire completed by the parents. The cumulative (lifetime) and current (last 12 months) prevalences of allergic diseases and the presence of passive smoking, atopic family history, animal contact and breast-feeding in infancy were determined. RESULTS: A total of 5412 children (70.1% from the metropolitan and 29.9% from the rural area) were enrolled. The cumulative and current prevalences of all allergic diseases were 24.6% and 9.9% respectively. The cumulative (lifetime) prevalences of bronchial asthma, wheezing, allergic rhinitis and atopic dermatitis were 16.4%, 18.9%, 12.3% and 2.2%, and the current (last 12 months) prevalences were 5.6%, 5.8%, 4.5% and 0.9% respectively. Three-fourths of the children were exposed to tobacco smoke at home. Atopic heredity appeared the most prominent risk factor for any allergic disorder. Neither age, breast-feeding nor place of habitation affected the occurrence of allergic disorders. Animal contact was a significant risk factor for asthma and wheezing (adjusted odd ratios (OR) and 95% confidence intervals (CI) for current prevalences are 1.38 (CI = 1.04-1.83) and 1.35 (CI = 1.02-1.78) respectively), exposure to indoor tobacco smoke for wheezing (OR = 1.52, CI = 1.10-2.09), and male gender for asthma (OR = 1.50, CI = 1.16-1.93). Current prevalences for all allergic diseases were significantly lower than those previously reported in Ankara, Turkey. CONCLUSIONS: Allergic diseases are a major health burden for primary school children in Edirne, Turkey. Although atopic heredity appears to be the foremost important risk factor, reduction of exposure to indoor tobacco smoke and animal contact, especially for those with atopic family history, are important preventive measures. The impact of environmental exposures on distinguishing prevalences of allergic diseases in Ankara and Edirne should be further investigated.

Conservative management of twin pregnancies with one dead fetus: is it safe?

BACKGROUND: Fetal death in one of the twins is unusual and the management issue of such a condition is not straightforward. METHODS: We reviewed the outcomes of nine twin pregnancies with one dead fetus in whom follow-up period exceeded 3 weeks. RESULTS: The twinning frequency was 8.9 per thousand deliveries and the frequency of subsequent antepartum death of one fetus was found to be 3.8%. The preterm birth rate was 45.5% and the survival rate was 90.1%. The perinatal mortality rate was 12%. Maternal clotting disorder was observed in one patient and treated successfully with heparin. CONCLUSIONS: We suggest that these patients are best managed conservatively unless further hazard to the fetus or mother appears.

Malignant degeneration of mature cystic teratomas.

Malignant transformation of benign cystic teratoma is rare and the most common malignancy is squamous cell carcinoma. The diagnosis is rarely made preoperatively and the prognosis is usually poor. We report 4 cases with dermoid cysts showing malignant transformation, 3 with squamous carcinoma and 1 with adenocarcinoma. The patients were within the reproductive age and underwent surgical intervention with intraoperative evaluation. Frozen section identified 2 cases with malignant transformation and staging laparotomy was performed at the initial laparotomy. One of the remaining underwent reoperation following a pregnancy termination and the other refused further surgery. None had metastases and/or capsule invasion. One had tumour rupture during excision and received combined chemotherapy following surgery. Three of the patients remain well and 1 is lost to follow-up.

Anatomic distortion of clinically normal appearing fallopian tube: to what extent does it contribute to infertility?

We analyzed whether patent but anatomically deranged tubes were more commonly encountered in infertile women than in fertile women. The fertile group consisted of 100 women who were apparently normal with respect to fertility and the infertile group consisted of 100 infertile women with no certain etiology identified. The individual tubal structure was recorded at laparoscopy and the results of the two groups were then compared. Tubal pathology was found to be significantly higher in the infertile group; however, this marked difference arose from the contribution of a significantly higher frequency of peritubal pelvic adhesions because no difference was found between the two groups regarding anatomic variations of the fallopian tube. We conclude that tubal derangement which could only be identified with laparoscopy significantly contributes to infertility.

Vaginal birth following unmonitored labor in patients with prior cesarean section.

Following a previous cesarean section, trial labour followed by spontaneous birth is currently popular but is still debatable. In an effort to assess the risks of unmonitored labor, the outcomes of 165 patients with previous cesarean section who delayed coming to hospital were reviewed. Seventy-one patients were allowed to continue labor and 62 achieved successful vaginal delivery, a success rate of 87.3%. Sixty-one of 71 patients had an unknown uterine scar type prior to birth and, of these, 57 were delivered vaginally. The scar separation rate of this group was found to be 3.5% and the overall scar separation rate in our patients was 3.6%. Other than scar separation and febrile morbidity, no maternal morbidity or mortality was observed. The vast majority (98.4%) of infants delivered vaginally had 5-min Apgar scores of 7 or greater. We suggest that increasing the use of trial labor in patients with prior cesarean section, even in the presence of an unknown scar, may reduce the number of patients laboring in an unmonitored environment who wish to give birth vaginally.

Serum CA 125 levels before, during and after treatment for endometriosis.

OBJECTIVES: The aim of this study was to assess the treatment of endometriosis with a gonadotropin-releasing hormone (GnRH) agonist in terms of changes to the extent of disease and to CA 125 levels as well as to recurrence during follow-up. METHODS: The levels of serum CA 125 were evaluated in 66 patients with endometriosis diagnosed and staged by laparoscopy according to the revised American Fertility. Society classification, who received a 6-month course of a GnRH agonist. Serum CA 125 levels were measured before, during (3 and 6 months after the initiation of therapy) and 6 months after cessation of therapy. RESULTS: Patients with minimal and mild endometriosis had significantly higher mean pretreatment values than control subjects in the luteal phase of the cycle or than postmenopausal women (P < 0.05), but the overall mean value was still below 35 U/ml. Levels of CA 125 fell during treatment to those found in normal controls, but rose again after the end of treatment. The sensitivity and specificity of CA 125 were 75% and 83.3%, respectively, and its positive predictive value as a marker of recurrence was 46.36%. CONCLUSION: These data suggest that CA 125 may be a reliable indicator for monitoring the efficacy of GnRH agonist treatment of endometriosis, but its value as a predictor of recurrence is low, probably due to the suppression of all CA 125 sources such as endometrium, ovaries and implants.

Chronic pelvic pain in adolescent women. Diagnostic laparoscopy and ultrasonography.

OBJECTIVE: To evaluate the correlation of preoperative pelvic examination and ultrasonography with the laparoscopic findings in 45 adolescent women with chronic pelvic pain. STUDY DESIGN: Between January 1, 1989, and December 31, 1992, 45 adolescent women underwent diagnostic laparoscopy following a detailed clinical workup for evaluation of chronic pelvic pain. RESULTS: Thirty-five of 45 pelvic examination findings correlated with the laparoscopic findings. The predictive values of normal and abnormal findings at pelvic examination were 42.8% and 93.5%, respectively. Ultrasonography (US) correlated with laparoscopy in 39 of 45 cases. The predictive value of normal findings at US was 60%, and that of abnormal findings was 94.2%. When both pelvic examination and US were normal, 50% of cases were abnormal at laparoscopy. However, laparoscopy revealed abnormality in 100% of patients with abnormal pelvic examinations and abnormal US findings. CONCLUSION: Clinical evaluation of chronic pelvic pain, when combined with US, is highly predictive but needs confirmation, best provided by laparoscopy.

How does negative clinical evaluation of ovarian carcinoma after full course of chemotherapy correlate with second-look laparotomy findings?

Surgical reexploration was performed in 46 patients with epithelial nonmucinous ovarian adenocarcinoma requiring adjuvant chemotherapy whose initial therapy consisted of optimum debulking and surgical staging. All patients were placed on CAP (cisplatinum, Adriamycin, cyclophosphamide) chemotherapy for at least six courses until proved to be clinically disease free (mainly CA-125 below 35 U/ml and normal ultrasonography or computerized tomography). All women underwent second-look laparotomy (SLL) after completion of adjuvant therapy. We classified SLL findings in five categories, namely, no evidence of disease, cytological evidence of disease, histological evidence of disease, macroscopic evidence of disease (< 2 cm), and bulky tumor (> 2 cm). SLL demonstrated 14 (30%) patients with disease. Of these, five cases had histological evidence of disease and nine had macroscopic disease; however, we found no patient with persistent disease larger than 1.5 cm. No patient in stage I demonstrated disease at SLL. All cases with macroscopic disease and three cases with histological disease were initially in stage III. We found that about one third of cases who were clinically free of disease had persistent disease at the completion of chemotherapy. Hence, we conclude that routine SLL is still of importance in the management of patients with epithelial ovarian adenocarcinoma except those with stage I disease.