Evaluation of a scoring system to predict treatment success with single-dose methotrexate in ectopic pregnancy.

PURPOSE: This study sought to assess the efficacy of a newly developed scoring system in predicting treatment outcomes for ectopic pregnancy among patients undergoing single-dose methotrexate therapy. The primary research question centered on the reliability and predictive accuracy of objective parameters in determining methotrexate therapy success. METHODS: Conducted as a retrospective single-center cohort study, data from 172 ectopic pregnancy patients treated with methotrexate between January 2021 and January 2023 were analyzed. Parameters including adnexal mass size, peritoneal fluid presence, yolk sac identification, endometrial thickness, ectopic pregnancy location, and initial B-hCG levels were meticulously evaluated for their association with treatment outcomes. RESULTS: Following the exclusion of 21 emergency surgery cases, the final analysis comprised 151 patients. Notable associations were observed between specific parameters (fetal cardiac activity, adnexal mass size > 3.5 cm, peritoneal fluid presence, yolk sac identification, endometrial thickness > 10 mm, and initial B-hCG levels) and treatment outcomes (p < 0.001). Additionally, the novel scoring system demonstrated promising predictive performance. At a cutoff of 2.50, it achieved a sensitivity of 91.7% and a specificity of 59.7%. Increasing the cutoff to 3.50 resulted in a sensitivity of 94.0%, with a specificity of 46.3%. CONCLUSION: Objective parameters, particularly those integrated into the developed scoring system, exhibited substantial associations with methotrexate therapy outcomes in ectopic pregnancy. These findings underscore the potential of an objective scoring model to significantly influence clinical decision-making in therapy, offering avenues for enhanced prognostication and patient care in treatment outcomes.

Management of acute metabolic crisis in TANGO2 deficiency: a case report.

OBJECTIVES: TANGO2 deficiency is a rare inborn error of metabolism, with distinct clinical features. The clinical presentations of TANGO2 deficiency are developmental delay, speech difficulties, intellectual disability, non-life-threatening paroxysmal neurologic episodes (TANGO2 spells), acute metabolic crises, cardiac crises, seizures and hypothyroidism. Patients may die in acute metabolic crises. Here we report our experience in the management of an acute metabolic crisis in TANGO2 deficiency. CASE PRESENTATION: A 9-year-old patient diagnosed with TANGO2 deficiency was admitted with fever, fatigue, unable to walk. In follow up, encephalopathy, rhabdomyolysis and arrhythmia were detected. Vitamin B-complex was started. Our patient's mental status and rhabdomyolysis improved dramatically, and cardiac crises ended without Torsades de pointes, ventricular tachycardia and/or fibrillation or myocardial dysfunction. CONCLUSIONS: With this report, we aimed to show the effectiveness of vitamin B-complex in the management of acute metabolic crises.

Diagnostic and Treatment Obstacles in Acute Myeloid Leukemia: Social, Operational, and Financial.

Acute myeloid leukemia (AML) can affect individuals of all ages, but is more common in older adults. It has been estimated that AML accounted for 1% of all newly diagnosed cancers in the USA in 2022. The diagnostic process varies depending on the presenting symptoms and the healthcare facility that patients attend at diagnosis. The treatment process is long and prone to complications, requiring experienced medical professionals and appropriate infrastructure. Treatment of the disease did not change greatly over the years until 2017 when targeted therapies were licensed. The treatment of AML is associated with significant direct economic costs. A number of obstacles originating both from individual patients and the healthcare system may be encountered during the diagnosis and treatment of the disease, which may negatively impact the optimal management of the disease process. In this article, we focus primarily on the social, operational, and financial obstacles including the corona virus disease 2019 (COVID-19) pandemic experienced during the diagnosis and treatment of AML.

QT interval alterations in epilepsy: A thorough investigation between epilepsy subtypes.

OBJECTIVES: Cardiac disturbances and rhythm abnormalities which potentially lead sudden unexpected death in epilepsy, have been extensively studied in focal epilepsies. However, studies including generalized epilepsies are scarce and it is not clear whether electrocardiogram parameters reflecting vulnerability to ventricular arrhythmias differ between these groups. METHODS: Medical records of patients who were followed in epilepsy department of a tertiary center between October 2015 and September 2016 were retrospectively reviewed. 66 generalized and 64 focal epilepsy patients with eligible electrophysiological data were analyzed. QTc interval, QTcd and other electrocardiographic indices were compared between patients with focal vs generalized epilepsy. Another analysis was performed in order to disclose any difference between patients with epilepsy (n:130) and psychogenic non-epileptic seizures. A two-tailed p value < 0.05 was considered significant. RESULTS: There was no difference in terms of QTc and QTcd between patients with focal and generalized epilepsy [median: 406 ms vs 404 ms, p = 0.119; and median: 46 ms vs 44 ms, p = 0.497, respectively]. However patients with epilepsy were found to have longer QTc and QTcd when compared to ones with psychogenic non-epileptic seizures (p = 0.035 and p < 0.001, respectively). CONCLUSION: Current findings demonstrate that patients with epilepsy have longer QTc and QTcd than patients with pure psychogenic non-epileptic seizures. Since there was no difference between patients with focal and generalized epilepsy; QTc interval, QTcd and potential susceptibility to cardiac arrhythmias as a result, could be a consequence of epilepsy itself regardless of origin.

Predictive and prognostic effect of ABO blood group on immune checkpoint inhibitors.

BACKGROUND: The relationship of the ABO blood group system with the immune response is known, but its relationship with immune checkpoint inhibitors (ICIs) has not been clearly investigated until now. OBJECTIVE: In this study, the relationship between different blood groups and nivolumab treatment response in patients with advanced malignant melanoma was investigated. METHODS: The data of patients who used nivolumab for advanced malignant melanoma between April 2018 and April 2021 were retrospectively reviewed. RESULTS: A total of 73 patients were included in the study. In the progression-free survival (PFS) analysis according to blood groups, it was 3.9 months, 16.1 months, 20.0 months and 3.0 months for A, B, AB and O, respectively (p= 0.1). Overall survival (OS) analysis according to blood groups was 5.1 months, 25.0 months, 20.0 months and 9.3 months for A, B, AB and O, respectively (p= 0.1). The B antigen group (B or AB) had significantly longer PFS and OS than the non-B antigen group (A or O) (16.1 vs. 3.5 months for PFS, respectively, p= 0.03; 20.0 vs. 7.4 months for OS, respectively, p= 0.02). CONCLUSIONS: The presence of B antigen provides a significant advantage in terms of survival in patients using ICIs for advanced melanoma.

Adjunctive lacosamide treatment for adult focal-onset epilepsy: focus on comorbid intellectual/developmental disorders and differing responses.

BACKGROUND: Data regarding lacosamide treatment as an adjunctive therapy in patients representative of a focal-onset epilepsy population including those with and without intellectual/developmental disorders (IDDs) are limited. PURPOSE: To evaluate the retention rates of lacosamide in focal-onset epilepsy patients with and without IDD. PATIENTS AND METHODS: We retrospectively reviewed all consecutive electronic and paper medical records of patients diagnosed with focal-onset epilepsy who were treated with lacosamide in two tertiary epilepsy centers. RESULTS: One hundred and thirty-six patients who met the inclusion criteria were studied. Number of patients with IDD was 46 (33.8%). Median lacosamide dose was 300 mg/day. A total of 39 patients (28.7%) experienced side effects, and 22 of them (16.2%) discontinued lacosamide. The 1-, 2-, and 3-year retention rates of lacosamide in patients with IDD were 68%, 62%, and 53%, respectively. Kaplan-Meier survival analysis showed that the retention rates were significantly lower in patients with IDD when compared to patients without IDD (P=0.04). Cox regression analysis showed that concomitant use of sodium channel blocker antiepileptic drugs (AEDs) was the only independent predictor of retention rate of lacosamide treatment (P=0.03). In the subgroup of patients with IDD, the analysis was performed again and the number of background AEDs was the only predictor for the retention rate of lacosamide (P=0.04). CONCLUSION: When compared to patients without IDD, retention rates of lacosamide adjunctive therapy were lower in patients with IDD. However, these rates were higher than the rates suggested with previously registered AEDs including lamotrigine, levetiracetam, and topiramate. Therefore, irrespective of having comorbid IDD, we might suggest that lacosamide is a well-retained drug with a high efficacy profile in patients with focal-onset epilepsy.

Efficacy, tolerability, and retention rates of zonisamide in older adult patients with focal-onset epilepsy: Experiences from two tertiary epilepsy centers.

OBJECTIVE: The objective of this study was to evaluate the efficacy, tolerability, and retention rates for zonisamide (ZNS) in older adult patients with focal-onset epilepsy. PATIENTS AND METHODS: Chart reviews of patients aged 60years and older with focal-onset epilepsy treated with ZNS in two tertiary epilepsy centers were analyzed retrospectively. RESULTS: Eighty-five patients (41 males, 44 females) aged over 60years (range: 60-81) with focal-onset epilepsy treated with ZNS were identified; 55.3% of the patients (n=47) were on monotherapy. The median and average doses of ZNS doses were 200mg/day (range: 100-400) and 212.9±84.2mg/day, respectively. With ZNS treatment, 67.1% of the patients (n=57) were seizure-free for a median of 28months (range: 10-56) whereas 20% (n=17) of the patients had seizures that were unresponsive to ZNS treatment. Best seizure control was achieved in patients with poststroke epilepsy; seizure freedom was 80% in this subgroup. Overall retention rate was found to be 83.5%. There was no significant relation between receiving poly- or monotherapy and discontinuation of ZNS (p=0.18). Thirty-two of the patients (37.6%) lost weight. Median weight loss was 8kg (range: 2-16). There was no significant correlation between weight loss and the administered doses of ZNS (r=0.34; p=0.12). CONCLUSION: Despite limitations due to the retrospective design of the study, the results show that ZNS is a well-retained drug with high efficacy in older adult patients with epilepsy.

Sleep quality, morningness-eveningness preference, mood profile, and levels of serum melatonin in migraine patients: a case-control study.

The melatonin as the pineal gland's secretory product is implicated in the pathophysiology of migraine. Melatonin has critical functions in human physiology, and research underscores the importance of melatonin in circadian rhythm, sleep, and mood regulation. Clinical observations have indicated that migraine attacks have a seasonal, menstrual, and circadian timing, suggesting that chronobiological mechanisms and their alterations may causally involve in the etiology of the disease. However, the topic has received relatively little attention in the migraine literature. Associations between melatonin, circadian preference, sleep, and mood states were investigated in the current study. Fifty-five patients (47 females and 8 males) were compared to 57 gender and age-matched control subjects (40 females and 17 males). A socio-demographical questionnaire, the Beck Depression Inventory, Beck Anxiety Inventory (BAI), Pittsburgh Sleep Quality Index (PSQI), Profile of Mood States (POMS), and Morningness-Eveningness Questionnaire were administered to volunteers. Blood samples were taken from all participants at about 1:00 AM in an unlit room not to hamper melatonin secretion, and blood melatonin levels were measured using quantitative ELISA test. In comparison with controls, melatonin levels were significantly lower among migraine patients. Migraineurs reported significantly greater scores on the BAI, confusion-bewilderment subscale of the POMS, and total and sleep latency subscale of the PSQI. Migraine patients who had nausea during the migraine attacks and who reported bouts relevant to certain food consumption, such as cheese or chocolate, had significantly lower levels of melatonin. Contrarily, groups did not reveal statistically substantial difference in circadian preferences.

Dural carotico-cavernous fistula: pre and postembolization appearances of bone-subtracted CT angiography.

Digital subtraction angiography (DSA) is the best method of evaluating carotid cavernous fistulas (CCF). DSA, however, has the disadvantage of being an invasive procedure. Computerized tomography (CT) angiography which is noninvasive, have been shown to provide more information about the size and location of fistulas. As a new method, Bone-Subtraction CT Angiography (BSCTA), than conventional CT angiography, is a method that improves the detection and interpretation of vascular lesions near to the cavernous segment of carotid artery. In this case report, we report a case of a dural carotico-cavernous fistula (CCF), appearances of pre and postembolization BSCTA images, confirmed by on DSA. As far as we know, CCF demonstrated by BSCTA has not been reported yet.

The prevalence of fibromyalgia and its relation with headache characteristics in episodic migraine.

The objective of this study was to assess the prevalence of fibromyalgia (FM) in patients with episodic migraine and to evaluate the relationship between migraine characteristics and FM. One hundred and eighteen consecutive patients (mean age = 38 years, 75% women) fulfilling the International Classification of Headache Disorders-II criteria for migraine with (n = 22) and without (n = 96) aura from an outpatient headache clinic of a university hospital were evaluated. The diagnosis of FM was made based on the 1990 American College of Rheumatology classification criteria. Participants completed some self-administered questionnaires ascertaining sociodemographics, headache severity, frequency and duration, headache-related disability (Headache Impact Test [HIT-6]) and Migraine Disability Assessment Scale, widespread musculoskeletal pain (visual analog scale), depression (Beck depression inventory), anxiety (Beck anxiety inventory), sleep quality (Pittsburgh Sleep Quality Index), fatigue (Multidimensional Assessment of Fatigue), and quality of life (Short Form-36 Health Survey [SF-36]). In patients with FM, the tender point count and the Fibromyalgia Impact Questionnaire were employed. FM was diagnosed in 37 (31.4%) of the patients. FM comorbidity was equally distributed across patients with and without aura. Severity of migraine headache, HIT-6, and anxiety were especially associated with FM comorbidity. Patients suffering from migraine plus FM reported lower scores on all items of the SF-36. This study indicates that the assessment and management of coexisting FM should be taken into account in the assessment and management of migraine, particularly when headache is severe or patients suffer from widespread musculoskeletal pain.

Lumboperitoneal shunt in a patient with Behçet's disease with medically refractory intracranial hypertension.

A 21-year-old male presented with severe throbbing headache, nausea, vomiting and progressive visual loss. Clinical examination revealed bilateral papilledema and left abducens nerve palsy. MRI showed findings consistent with dural sinus thrombosis. Combinging the clinical findings, MRI and a positive pathergy test, the patient was diagnosed with dural sinus thrombosis associated with Behçet's disease (BD). Despite acetazolamide, prednisone, azathioprine and repeated lumbar punctures, his signs and symptoms of intracranial hypertension gradually worsened. Therefore, lumboperitoneal shunting was planned after which rapid resolution of intracranial hypertension was observed. After reviewing similar reports, we suggest that lumboperitoneal shunt placement can be an effective treatment for patients with BD with medically refractory intracranial hypertension associated with dural sinus thrombosis.

Ocular changes associated with topiramate.

PURPOSE: To determine the changes in refractive error, and the cornea, anterior chamber, and retina induced by topiramate. METHODS: The study included 76 eyes of 38 patients that began to use topiramate due to migraine. Following ophthalmological examination, all of the patients underwent central corneal thickness (CCT), anterior chamber volume (ACV), anterior chamber depth (ACD), and anterior chamber angle (ACA) measurement using a Scheimpflug camera, as well as macular thickness, retinal and retinal nerve fiber layer thickness (RNFLT) measurements using optical coherence tomography (OCT). These procedures were repeated 15, 30, and 90 days after the initiation of topiramate therapy. RESULTS: The median refractive error value showed a statistically significant increase from -0.25 diopters (D) to -0.62 D at the 90th day follow-up (P < 0.001). Mean CCT was 570.56 µm before treatment and increased to 573.69 µm at the 15th day follow-up, 575.31 µm at the 30th day follow-up, and 574.56 µm at the 90th day follow-up; however, these changes were not statistically significant. Mean ACV, ACD, and ACA did not exhibit statistically significant changes. Mean retinal thickness (RT) increased during the treatment from 263.46 µm to 271.60 µm, which was not statistically significant. The initial mean RNFLT was 100.56 ± 15.36 µm and significantly increased to 110.2 ± 8.41 µm and 111.03 ± 14.59 µm at the 30th and 90th day follow-ups, respectively (P = 0.01 and P = 0.004, respectively). CONCLUSIONS: During the 3-month follow-up of patients using topiramate 50 mg d(-1) significant myopic shift and an increase in RNFLT were observed. Further studies are warranted in order to assess the effects of topiramate when used long term and at higher doses.

Anthropometric indexes, insulin resistance, and serum leptin and lipid levels in women with cryptogenic epilepsy receiving topiramate treatment.

We aimed to investigate the effects of topiramate monotherapy on anthropometric indexes, insulin resistance, and serum leptin and lipid levels in 33 premenopausal women (mean age+/-standard deviation: 26.7+/-7.1years) with cryptogenic epilepsy. Body mass index (BMI), waist circumference and serum leptin, insulin and lipid levels were measured at baseline and at 6months after initiation of topiramate. We found reductions in BMI (p<0.001), waist circumference (p<0.001) and serum high-density lipoprotein (HDL) cholesterol levels (p=0.011). We also found significant improvements in insulin resistance (p=0.023), but not in serum leptin levels (p=0.45). Our results suggest that topiramate treatment in women with epilepsy is associated with reduced BMI and waist circumference and improvement in insulin resistance; however, according to our data, topiramate treatment is also associated with lower HDL cholesterol levels, which may substantially increase vascular disease.

Evaluation of cardiac repolarization indices in well-controlled partial epilepsy: 12-Lead ECG findings.

PURPOSE: To evaluate the cardiac repolarization indices in terms of QT intervals in patients with well-controlled partial epilepsy. METHODS: Seventy-six adult patients with well-controlled partial epilepsy and 66 healthy controls were enrolled into the study. 12-Lead ECGs were obtained from all participants. Corrected QT (QTc) intervals including maximum QTc (QTmaxc), minimum QTc (QTminc) and QTc dispersion (QTcd) were calculated. RESULTS: QTmaxc and QTcd intervals were significantly longer in the epilepsy group when compared to control group (439+/-27 ms vs. 422+/-25 ms, p<0.001 and 55+/-18 ms vs. 41+/-18 ms, p<0.001). The proportion of patients with pathologically prolonged QTcd intervals (>50 ms) was significantly higher in the epilepsy group (25 of 76 vs. 7 of 66, p=0.002). QTmaxc was significantly correlated with age (beta=0.29, p=0.012) after adjusting for gender, body mass index and duration of epilepsy. No correlation was observed between the duration of epilepsy and any of the QT intervals. There were no significant differences between the subgroups regarding QT intervals according to the etiology of the seizures (symptomatic/cryptogenic), being on mono- or polytherapy and treatment regimens (carbamazepine/non-carbamazepine). CONCLUSION: The results highlight the importance of cardiac evaluation even in patients with well-controlled epilepsy. 12-lead ECG recordings might help to uncover serious cardiovascular events.

Long-term effects of valproic acid on reproductive endocrine functions in Turkish women with epilepsy.

The long-term effects of valproic acid (VPA) on reproductive endocrine functions in women with epilepsy (WWE) were studied. Serum reproductive hormone concentrations, clinical findings and ovarian morphology were analyzed in 71 WWE who had been receiving antiepileptic drugs (AED) for a minimum of 2 years. Of the 71 WWE, polycystic ovarian syndrome (PCOS) (p = 0.011) and menstrual irregularities (p = 0.009) were found to be more prevalent in women receiving VPA treatment when compared to women on non-VPA treatment. There was no statistically significant dose or duration-related rise of risk for patients who developed PCOS and menstrual irregularities and those who were not on long-term VPA therapy. The lack of a duration-related reproductive dysfunction in this patient population may support the hypothesis of early occurring VPA-associated metabolic and endocrine changes.

Neuro-Behçet's syndrome presenting with features mimicking acute tuberculous meningitis.

Behçet's disease is an inflammatory disease that can involve multiple systems. Here, we describe a case of neuro-Behçet's syndrome presenting with features mimicking acute tuberculous meningitis. Behçet's disease should be considered in the differential diagnosis of a meningeal syndrome unless a viral or bacterial agent is demonstrated.

A case with prepontine (clival) arachnoid cyst manifested as trigeminal neuralgia.

Most cases of "idiopathic" trigeminal neuralgia are thought to originate from vascular compression of the trigeminal root entry zone. In this case, we describe a young man presenting with the symptoms of trigeminal neuralgia associated with a prepontine (clival) arachnoid cyst.

Pattern-reversal visual evoked potentials in patients with newly diagnosed epilepsy.

PURPOSE: The possible occurrence of evoked potential (EP) abnormalities in patients with newly diagnosed epilepsy has been little investigated. The main purpose of the present study was to investigate possible changes in pattern-reversal visual evoked potential (P-VEP) responses in newly diagnosed epilepsy patients. METHODS: By using P-VEPs, latency values of the N75 and P100 together with amplitude values of P100 were recorded in newly diagnosed idiopathic epilepsy patients. The patients comprised two groups; nonphotosensitive (non-PS), and photosensitive (PS) patients. RESULTS: Shortened N75 and normal P100 latencies of the P-VEP with higher than normal P100 amplitudes were detected in PS patients. In non-PS patients, N75 latencies of the P-VEPs were unaffected; however, P100 latencies were prolonged, and P100 amplitudes were unchanged. CONCLUSIONS: P-VEPs are different from those of controls in previously untreated idiopathic epilepsy patients. Results also indicate different P-VEP features in patients with and without photoparoxysmal responses. The changes might be the result of a disorder of one or more neurotransmitters or subtle morphologic damage such as microdysgenesis.

Retrograde flow in the left inferior petrosal sinus and blood steal of the cavernous sinus associated with central vein stenosis: MR angiographic findings.

BACKGROUND AND PURPOSE: We attempted to identify the cause of abnormal venous flow seen during arterial MR angiography in the inferior petrosal sinus by use of in three female patients (aged 51, 48, and 70 years, respectively). METHODS: Arterial 3D time-of-flight MR angiography was performed with a tilted optimized nonsaturating excitation pulse sequence (TR/TE, 31/7; flip angle, 20 degrees; section thickness, 65 mm; effective thickness, 1 mm; number of sections, 1 to 2); no magnetization transfer pulse sequence was used. Contrast-enhanced 3D MR angiography of the neck was performed with a 3D fast low-angle shot pulse sequence (TR/TE, 4.6/1.8; flip angle, 40 to 45 degrees; section thickness, 80 mm; intersection gap, 1.5 mm; acquisition matrix, 180 x 256; acquisition time, 27 s) on a system with a whole-body coil. RESULTS: In all three patients, 3D time-of-flight MR angiography revealed abnormal vascular signal originating from the left cavernous sinus, continuing through the inferior petrosal sinus, and ending in the proximal internal jugular vein at the jugular bulb level. Abnormal vascular signal at the jugular bulb, sluggish flow and flow-related enhancement in the left internal jugular vein, and signal void in the contralateral jugular vein were noted. Contrast-enhanced delayed-phase MR angiography showed stenosis in the left brachiocephalic vein in all patients. CONCLUSION: High signal intensity noted at the inferior petrosal sinus resulted from retrograde flow. Retrograde flow was due to blood stealing from the internal jugular vein toward the cavernous sinus because of venous stenosis in the brachiocephalic vein.