Unilateral Multiple Evanescent White Dot Syndrome-Like Reaction Following the CyberKnife Stereotactic Radiotherapy for Choroidal Malignant Melanoma.

A 58-year-old otherwise healthy man received a diagnosis of choroidal malignant melanoma (CMM) in June 2021 and underwent a single session of (21 Gy) CyberKnife stereotactic radiotherapy (SRT). Eleven months later, we noticed 3+ anterior chamber cells with occasional vitreous cells in the left eye. Though the tumor looked regressed, there were mild optic disc leakage, early hypofluorescent and late hyperfluorescent punctate lesions scattered 360 degrees, and late staining of the mass on fluorescein angiogram. The findings were compatible with a unilateral multiple evanescent white dot syndrome (MEWDS)-like reaction that was most likely related to CyberKnife SRT-induced tumor necrosis, and a dexamethasone implant was administered intravitreally into the left eye together with topical steroids. A second intravitreal injection of dexamethasone was given three months later due to remittance of the angiographic features. As there are only a few reports on CyberKnife SRT for the treatment of CMM, we wanted to share our interesting observation of a post-treatment MEWDS-like reaction likely related to tumor necrosis syndrome with the ophthalmic community.

CyberKnife Stereotactic Radiotherapy in Secondary Vasoproliferative Tumor of the Retina.

A 16-year-old boy with X-linked retinoschisis was examined for the visual decline on his left eye. Upon examination, a vasopermeable elevated mass lesion was determined at the lower temporal retinal periphery associated with surrounding arc-like hard exudates which is consistent with a vasoactive proliferative tumor of the retina. After discussing the therapeutic options with the patient and his parents, 3 successive dexamethasone implants 6 months apart were administered. As no satisfactory regression was noticed, CyberKnife stereotactic radiosurgery (SRS) was performed. Regression of the exudative tumor was obtained in follow-up examinations at 12 and 24 months after the SRS session and the thickness of the lesion was markedly reduced.

Quantification of tributyltin in seawater using triple isotope dilution gas chromatography-inductively coupled plasma mass spectrometry achieving high accuracy and complying with European Water Framework Directive limits.

A triple isotope dilution GC-ICPMS method for the determination of tributyltin (TBT) was developed and validated to meet the European Water Framework Directive (WFD) requirements. The validation procedure involved the evaluation of trueness, precision (repeatability, intermediate precision), limit of detection (LOD) and limit of quantification (LOQ), stability, measurement uncertainty and traceability studies. The method is one of the most sensitive methods published to date with good accuracy, 103% average recovery in the range with %RSDs of 2.8-6.7%. A LOD value of 0.015 ng L-1 for the TBT cation was achieved with a sample volume of 12 mL seawater. TBT was derivatized using 20 µL sodium tetraethylborate solution (0.05% NaBEt4) to make volatile for GC-ICPMS. Measurement uncertainty was in the range of 4.8-13% which was achieved through dissolution of tributyltinchloride (TBTCl) in 1-propanol, a low-volatility solvent combined with the use of a triple isotope dilution (ID) calibration technique. Isotope dilution calibration was performed by adding 117Sn isotopically enriched TBT to the seawater samples. The stability test results showed that TBT concentration was stable for three months in seawater samples after passing through a 0.2 µm filter and stored in amber glass bottles at 4°C. The response surface methodology (RSM) approach was successfully implemented to provide optimal conditions for large volume injection (LVI) to obtain the maximum analytical signal. The key variables selected in the experimental design were evaporation time, evaporation temperature, carrier flow, and injection speed. This method was applied to seawater samples collected from the Bay of Izmit, Kocaeli, Turkey, where TBT pollution has not been measured yet.

Practical and theoretical considerations for the determination of δ13 CVPDB values of methylmercury in the environment.

RATIONALE: Analytical methods that can identify the source and fate of mercury and organomercury compounds are likely to be useful tools to investigate mercury in the environment. Carbon isotope ratio analysis of methylmercury (MeHg) together with mercury isotope ratios may offer a robust tool to study environmental cycling of organomercury compounds within fish tissues and other matrices. METHODS: MeHg carbon isotope ratios were determined by gas chromatography/combustion-isotope ratio mass spectrometry (GC/C-IRMS) either directly or following derivatization using sodium tetraethylborate. The effects of a normalization protocol and of derivatization on the measurement uncertainty of the methylmercury δ13 CVPDB values were investigated. RESULTS: GC/C-IRMS analysis resulted in a δ13 CVPDB value for an in-house MeHg reference material of δ13 CVPDB = -68.3 ± 7.7‰ (combined standard uncertainty, k = 1). This agreed very well with the value obtained by offline flow-injection analysis/chemical oxidation/isotope ratio mass spectrometry of δ13 CVPDB = -68.85 ± 0.17‰ (combined standard uncertainty, k = 1) although the uncertainty was substantially larger. The minimum amount of MeHg required for analysis was determined to be 20 µg. CONCLUSIONS: While the δ13 CVPDB values of MeHg can be obtained by GC/C-IRMS methods with or without derivatization, the low abundance of MeHg precludes such analyses in fish tissues unless there is substantial MeHg contamination. Environmental samples with sufficient MeHg pollution can be studied using these methods provided that the MeHg can be quantitatively extracted. The more general findings from this study regarding derivatization protocol implementation within an autosampler vial as well as measurement uncertainty associated with derivatization, normalization to reporting scales and integration are applicable to other GC/C-IRMS-based measurements.

The association between variant urothelial histologies, pathological stage and disease specific survival in patients with bladder cancer.

OBJECTIVE: We aimed to compare the oncological outcomes of patients with variant urothelial histologies (VH) with pure urothelial histology (PUH) in bladder cancer (BC) patients. MATERIAL AND METHODS: This study includes 223 patients who underwent radical cystectomies (RCs) between September 2006 and July 2016 with complete follow-up data A retrospective screening was performed to identify the patients with PUH and VH. The primary outcomes of interest were pathological stage of disease at RC and disease-specific survival (DSS). For comparison of categorical variables, Fisher's exact test and Pearson chi- square and for continuous variables Wilcoxon rank-sum and Mann-Whitney U tests were used. Kaplan-Meier (KM) method was used for survival analysis and log-rank test was used for comparison of survival rates. Predictors of survival were detected with mulitivariable Cox-proportional hazards model including the variables such as gender, age, existence of VH, lymph node dissection (LND) type and pathological stage of the disease. RESULTS: A moderate-degree correlation was detected between VH and pathological stages of RC (r=0.45, p<0.001). In PUH group, 39 (25.8%) of 151 patients died after a median follow-up of 20 (0-107) months; whereas 37 (51.4%) of 72 patients with VH died after a median follow-up of 16.5 (0-104) months (p<0.001). In terms of pathological stage, the number of patients with PUH and VH were at stages pT0-2 (n=100; 66.2% vs. n=19; 26.4%), pT3-4 (n=35; 23.2% vs. 38; 52.8%, and in 16 (10.6%) and 15 (20.8%) patients with LN positivity, respectively (p<0.001). KM survival analysis revealed a significantly decreased DSS in patients with VH compared to PUH (p<0.001). Meanwhile, pathological disease stage and existence of VH were found to be associated with decreased DSS in the multivariate model. CONCLUSION: The present study revealed that VH is associated with advanced pathological tumor stage at RC and decreased DSS compared to patients with PUH in patients with BC.

Towards tributyltin quantification in natural water at the Environmental Quality Standard level required by the Water Framework Directive.

The European Union (EU) has included tributyltin (TBT) and its compounds in the list of priority water pollutants. Quality standards demanded by the EU Water Framework Directive (WFD) require determination of TBT at so low concentration level that chemical analysis is still difficult and further research is needed to improve the sensitivity, the accuracy and the precision of existing methodologies. Within the frame of a joint research project "Traceable measurements for monitoring critical pollutants under the European Water Framework Directive" in the European Metrology Research Programme (EMRP), four metrological and designated institutes have developed a primary method to quantify TBT in natural water using liquid-liquid extraction (LLE) and species-specific isotope dilution mass spectrometry (SSIDMS). The procedure has been validated at the Environmental Quality Standard (EQS) level (0.2ngL(-1) as cation) and at the WFD-required limit of quantification (LOQ) (0.06ngL(-1) as cation). The LOQ of the methodology was 0.06ngL(-1) and the average measurement uncertainty at the LOQ was 36%, which agreed with WFD requirements. The analytical difficulties of the method, namely the presence of TBT in blanks and the sources of measurement uncertainties, as well as the interlaboratory comparison results are discussed in detail.

Prospective evaluation of complications in laparoscopic urology at a mid-volume institution using standardized criteria: Experience of 1023 cases including learning curve in 9 years.

AIM: To evaluate the laparoscopic operations performed in our department according to the modified Clavien classification system of complications. MATERIALS AND METHODS: Between September, 2005 and February, 2014, a total of 1023 laparoscopic cases were performed. This period was divided into three terms (Terms 1, 2 and 3 consisting of 38, 32 and 32 months, respectively). According to the European Scoring System (ESS), easy (E), slightly difficult (SD), fairly difficult (FD), difficult (D), very difficult (VD) and extremely difficult (ED) cases were 35, 88, 170, 390, 203 and 137, respectively. The perioperative complications were evaluated based on the 3 time periods, with a specific emphasis on determining the learning curve according to the modified Clavien classification system of complications. RESULTS: A total of 236 (23.1%) complications were observed according to the modified Clavien classification. The minor (Clavien I-II) and major (Clavien III, IV and V) complication rates were 20.5% (n = 210) and 2.4% (n = 26), respectively. Clavien I was the most frequently encountered type of complication (n = 120, %11.7). No significant difference was observed among all 3 time periods regarding total complication rates. The D cases had the highest complication rate compared to E, SD, FD, VD and ED cases among all three terms. The total number of complications increased significantly with increasing grade of technical difficulty according to the ESS. CONCLUSION: Complications encountered in our laparoscopic surgery experience were predominantly minor, and the rate of complications was not significantly increased during the learning curve. The present data can provide guidance and manage expectations for surgeons introducing laparoscopy into their practice.

Serous retinal detachment and cystoid macular edema in a patient with Wyburn-Mason syndrome.

Wyburn-Mason syndrome is a rare phacomatosis characterized by unilateral arteriovenous malformations (AVMs) involving the brain, retina, and (rarely) the skin. The diagnosis is concluded with dilated fundus examination and markedly dilated tortuous vascular loops with arteriovenous communications on fluorescent angiography. We present a 14-year-old male patient with Wyburn-Mason syndrome who developed serous macular neuroretinal detachment, cystoid macular edema (CME), and consequent visual deterioration in the left eye. To the best of our knowledge, this is the first report of a patient with Wyburn-Mason syndrome who developed serous retinal detachment and CME.

International system of units traceable results of Hg mass concentration at saturation in air from a newly developed measurement procedure.

Data most commonly used at present to calibrate measurements of mercury vapor concentrations in air come from a relationship known as the "Dumarey equation". It uses a fitting relationship to experimental results obtained nearly 30 years ago. The way these results relate to the international system of units (SI) is not known. This has caused difficulties for the specification and enforcement of limit values for mercury concentrations in air and in emissions to air as part of national or international legislation. Furthermore, there is a significant discrepancy (around 7% at room temperature) between the Dumarey data and data calculated from results of mercury vapor pressure measurements in the presence of only liquid mercury. As an attempt to solve some of these problems, a new measurement procedure is described for SI traceable results of gaseous Hg concentrations at saturation in milliliter samples of air. The aim was to propose a scheme as immune as possible to analytical biases. It was based on isotope dilution (ID) in the liquid phase with the (202)Hg enriched certified reference material ERM-AE640 and measurements of the mercury isotope ratios in ID blends, subsequent to a cold vapor generation step, by inductively coupled plasma mass spectrometry. The process developed involved a combination of interconnected valves and syringes operated by computer controlled pumps and ensured continuity under closed circuit conditions from the air sampling stage onward. Quantitative trapping of the gaseous mercury in the liquid phase was achieved with 11.5 µM KMnO4 in 2% HNO3. Mass concentrations at saturation found from five measurements under room temperature conditions were significantly higher (5.8% on average) than data calculated from the Dumarey equation, but in agreement (-1.2% lower on average) with data based on mercury vapor pressure measurement results. Relative expanded combined uncertainties were estimated following a model based approach. They ranged from 2.2% to 2.8% (k = 2). The volume of air samples was traceable to the kilogram via weighing of water for the calibration of the sampling syringe. Procedural blanks represented on average less than 0.1% of the mass of Hg present in 7.4 cm(3) of air, and correcting for these blanks was not an important source of uncertainty.

Obstructive sleep apnoea syndrome in patients with primary open-angle glaucoma.

OBJECTIVE: To investigate the prevalence of obstructive sleep apnoea syndrome in patients with primary open-angle glaucoma. DESIGN: Case series. SETTING: School of Medicine, Düzce University, Turkey. PATIENTS: Twenty-one consecutive primary open-angle glaucoma patients (12 females and 9 males) who attended the out-patient clinic of the Department of Ophthalmology between July 2007 and February 2008 were included in this study. All patients underwent polysomnographic examination. RESULTS: The prevalence of obstructive sleep apnoea syndrome was 33.3% in patients with primary open-angle glaucoma; the severity of the condition was mild in 14.3% and moderate in 19.0% of the subjects. The age (P=0.047) and neck circumference (P=0.024) in patients with obstructive sleep apnoea syndrome were significantly greater than those without the syndrome. Triceps skinfold thickness in glaucomatous obstructive sleep apnoea syndrome patients reached near significance versus those without the syndrome (P=0.078). Snoring was observed in all glaucoma cases with obstructive sleep apnoea syndrome. The intra-ocular pressure of patients with primary open-angle glaucoma with obstructive sleep apnoea syndrome was significantly lower than those without obstructive sleep apnoea syndrome (P=0.006 and P=0.035 for the right and left eyes, respectively). There was no significant difference in the cup/disc ratio and visual acuity, except visual field defect, between primary open-angle glaucoma patients with and without obstructive sleep apnoea syndrome. CONCLUSIONS: Although it does not provide evidence for a cause-effect relationship, high prevalence of obstructive sleep apnoea syndrome in patients with primary open-angle glaucoma in this study suggests the need to explore the long-term results of coincidence, relationship, and cross-interaction of these two common disorders.

Use of a combined retroperitoneoscopic and transperitoneal laparoscopic technique for the management of renal cell carcinoma with level I tumor thrombi.

BACKGROUND: To report our initial experiences using a combined retroperitoneoscopic and transperitoneal laparoscopic technique for the management of renal cell carcinoma with level I tumor thrombi. MATERIALS AND METHODS: Two patients underwent this technique for tumors 11- and 13-cm in diameter. After transection of the renal artery with limited mobilization of the kidney using a retroperitoneoscopic approach, additional ports were placed, and the management of the tumor thrombus was performed in the large working space provided by the transperitoneoscopic approach. RESULTS: The technique was feasible in the present 2 cases. The total operative times were 170 and 200 min, respectively. The estimated blood loss was 450 cc in the first case and 200 cc in the second case. No complications were observed in either of the patients. CONCLUSIONS: Based on the initial clinical experience, we have presented a feasible surgical option for the laparoscopic management of renal cell carcinoma with level I thrombi.

Future prospects in the diagnosis and management of localized prostate cancer.

Prostate cancer (PCa) is the commonest visceral cancer in men worldwide. Introduction of serum PSA as a highly specific biomarker for prostatic diseases has led to a dramatic increase in the diagnosis of early stage PCa in last decades. Guidelines underline that benefits as well as risks and squeals of early diagnosis and treatment should be discussed with patients. There are several new biomarkers (Pro-PSA, PCA-3 test, and TMPRSS2-ERG) available on the market but new ones are awaited in order to improve specificity and sensitivity. Investigators have also focused on identifying and isolating the gene, or genes, responsible for PCa. Current definitive treatment options for clinically localized PCa with functional and oncological success rates up to 95% include surgery (radical prostatectomy), external-beam radiation therapy, and interstitial radiation therapy (brachytherapy). Potential complications of overdiagnosis and overtreatment have resulted in arguments about screening and introduced a new management approach called "active surveillance." Improvements in diagnostic techniques, especially multiparametric magnetic resonance imaging, significantly ameliorated the accuracy of tumor localization and local staging. These advances will further support focal therapies as emerging treatment alternatives for localized PCa. As a conclusion, revolutionary changes in the diagnosis and management of PCa are awaited in the near future.

Relation between platelet indices and branch retinal vein occlusion in hypertensive patients.

BACKGROUND: Branch retinal vein occlusion (BRVO) is the second most common retinal vascular disease after diabetic retinopathy. To date, the studies were unable to elucidate the mechanism of the thrombosis leading to the entity; particularly the relation between thrombocyte aggregation and retinal vein occlusion is still unclear. Mean platelet volume (MPV) is a determinant of rate of platelet production and activation, both of which are indices of function of platelets. The relation between MPV and BRVO has not been studied before. The aim was to evaluate MPV in BRVO. MATERIALS AND METHODS: Forty patients were included in the study. Forty six age and sex matched hypertensive volunteers were recruited as the control group. RESULTS: MPV values were significantly higher in BRVO patients compared with the control subjects (8.01 ± 0.79 vs 7.52 ± 0.32 fL, respectively; P < 0.001). CONCLUSION: MPV is significantly higher in patients hypertensive BRVO patients and further investigations regarding its potentially use as a prognostic biomarker in patients with BRVO are needed.

Branch retinal vein occlusion associated with tamoxifen use.

Tamoxifen is a selective estrogen receptor modulator widely used in the treatment of hormone-responsive breast cancer. Tamoxifen-induced ocular complications are very rare. A post-menopausal woman with carcinoma of the left breast had presented with sudden loss of vision. The patient had been on tamoxifen therapy 20 mg daily for the last three years. Fundus examination showed left branch retinal vein occlusion. Fluorescein angiography and optical coherence tomography confirmed the diagnosis. Tamoxifen therapy was discontinued. Although branch retinal vein occlusion is rare, careful evaluation of patients on tamoxifen therapy with visual symptoms is required.

Susac's syndrome: a case of simultaneous development of all three components of the triad.

Susac's syndrome is characterized by the clinical triad of encephalopathy, branch retinal artery occlusions and sensorineural hearing loss. We here report a case of 46 year old woman with a sudden diminution in visual acuity at the left eye, headache and decreased hearing at the right ear with mild confusion considered as Susac's syndrome with complete triad. Although it's a relatively rare entity, it should be kept in mind in differential diagnosis of the neurological disorders, especially in women in 20- to 40-year of age presenting with acute hearing loss.

Premacular hemorrhage due to isotretinoin use.

Isotretinoin is a vitamin A derivative used for serious acne that is refractory to other modes of treatment. The most common side effects include dryness of the skin and mucous membranes. Itching as a result of neurological, hematological and ocular side effects has also been reported. Here, we present a 19-year-old female patient who developed premacular hemorrhage and consequent loss of vision in the left eye after oral use of isotretinoin. To the best of our knowledge, this is the first report of the development of premacular hemorrhage as a result of isotretinoin use.

LKB1 mutations and their correlation with LKB1 and Rheb expression in bladder cancer.

Although there are extensive studies on the genetics of bladder cancer, several questions remain unanswered. One of the pathways which are altered in bladder cancer is the mTOR signaling pathway. In the present study, we analyzed the expression of Rheb gene and genetic alterations in the LKB1 gene which are the key components of mTOR pathway. Nine exons of the LKB1 gene were analyzed by direct sequencing in 51 bladder cancer patients. To investigate the expression of Rheb and LKB1, real-time quantitative RT-PCR was performed in bladder tumor and normal bladder tissue samples. We did not observed a statistically significant difference in Rheb or LKB1 expression between the tumor and normal tissue samples. We detected a novel missense mutation creating stop codon in a high percent of the tumor samples. Five different single nucleotide substitutions were also observed in the introns. Our results indicate that LKB1 gene may play a role in the progression of bladder cancer.

Neuroprotective effects of olanzapine in N-methyl-D-aspartate-induced retinal injury.

PURPOSE: The aim of this study was to investigate the neuroprotective effect of olanzapine (OLA), an atypical antipsychotic drug, on N-methyl-d-aspartate (NMDA)-induced retinal injury. METHODS: Retinal neuronal ischemia was induced by NMDA in Wistar rats. OLA was administered intraperitoneally in 2 different dosages: 2 and 12 mg/kg. At the end of 2 weeks of OLA treatment, 1 eye of each animal was enucleated for histopathologic examination. We also measured malondialdehyde (MDA) levels in retinal homogenates as a marker of ischemic injury. RESULTS: The retinal ganglion cell (RGC) count was significantly higher in cases where we used OLA 2 mg/kg or OLA 12 mg/kg compared to the control group (P=0.0032 and P=0.0005, respectively). We also found that MDA was significantly reduced by OLA 2 mg/kg or OLA 12 mg/kg compared to the control group (P=0.0001 and P=0.0001, respectively). There was no statistically significant difference between OLA 2 mg/kg or OLA 12 mg/kg groups in terms of RGC count and MDA levels (P>0.05 for all). CONCLUSION: Our data showed that OLA preserved RGCs from NMDA-induced retinal injury; thus, it may have potential neuroprotective effects.

What is the role of enlarged lymph node resection alone in patients with nonseminomatous germ cell tumor who had stage II or III disease?

BACKGROUND: Retroperitoneal lymph node dissection is an important treatment modality in nonseminomatous germ cell tumors of the testis. However, the role of more limited surgical approaches such as resection of enlarged lymph nodes only is still controversial. PATIENTS AND METHODS: Between January 1991 and December 2010, charts of 94 patients who underwent resection of enlarged retroperitoneal lymph nodes alone were reviewed. Pathologic findings, local recurrence, and adverse effects were noted after this surgical approach. RESULTS: The median age was 25.5 years. Twenty-one (22.6%) patients had lung metastasis, and 5 (5.4%) patients had nonregional lymph node metastasis at the initial visit. Eighty-seven (91.6%) patients received chemotherapy after inguinal orchiectomy, and the other patients had mass resection only for enlarged lymph nodes without prior chemotherapy. In patients who had chemotherapy before surgery, the median retroperitoneal lymph node size before and after chemotherapy cycles was 55 mm and 32.5 mm, respectively. The pathologic assessment of retroperitoneal masses revealed mature teratoma in 51.6% (n = 47) of patients, viable carcinoma in 20.9% (n = 19) of patients, and necrosis or fibrosis in 27.5% (n = 25) of patients. The median follow-up time was 60.2 months (range, 2.7-334.8 months). During follow-up, 5 (5.4%) patients had radiologic relapse at the retroperitoneal area, and 3 patients developed systemic metastases. Six (6.4%) patients died of their disease, 2 (2.1%) patients were alive with disease, 86 (91.5%) patients were healthy at the last follow-up. Ejaculation status was recorded in 56 patients. Antegrade ejaculation had preserved in 53 (94.6%) of these patients. CONCLUSIONS: Resection of enlarged lymph node metastases alone is a reasonable treatment option for patients with nonseminomatous germ cell tumors.