A Case of Priapism in a Child With Autism Spectrum Disorder, Possibly Due to Risperidone Treatment With Addition of Atomoxetine.

OBJECTIVES: Risperidone is an effective drug used for the treatment of irritability in children with autism spectrum disorder (ASD). Atomoxetine (ATX) is a well-tolerated drug used in first-line therapy in children with attention-deficit/hyperactivity disorder (ADHD). However, uncommon adverse effects of risperidone and ATX are a concern among mental health professionals. To our knowledge, this is the first case report of priapism after addition of ATX upon existing treatment with risperidone. METHODS: Written informed consent for publication was obtained from the patient and his parents, and their identities were concealed for ethical reasons. RESULTS: Here, we report a case of priapism as an adverse effect of ATX and risperidone treatment in a 7-year-old boy with ASD and comorbid ADHD. In this case, priapism was not observed with risperidone until ATX was added. CONCLUSIONS: Priapism is a condition viewed as a medical emergency. Although risperidone-induced priapism is a rare phenomenon, it is advised for clinicians to consider the drug interactions in treatment of ASD and ADHD in terms of early diagnosis and intervention.

Fluoxetine Related Urinary Retention in a 15-Year-Old Girl: a Case Report.

Fluoxetine is an effective and safe agent frequently used in the treatment of childhood depression and obsessive-compulsive disorder. Urinary retention is defined as the inability to empty the bladder completely. Drug use is one of the most important factors in the etiology of urinary retention. Urinary retention is an uncommon side-effect of fluoxetine use. We report a case of chronic urinary retention during fluoxetine monotherapy in a 15-year-old girl, resolving following the discontinuation of treatment.

The effect of increasing the contact surface on tendon healing.

BACKGROUND: The most common complication after tendon repair is the development of adhesion, with subsequent rupture. METHODS: In this study, we present a new method in which the tendon healing contact surface is increased to reduce these complications. The tendons of chickens in groups 1, 3, and 5 were transversely cut and repaired with in the traditional fashion with double-modified Kessler method and 5/0 polypropylene. In the other groups, 3 mm of the tendon was removed from the proximal half of the upper end and from the distal half of the lower end of the tendon, and they were repaired with the modified Kessler method. The tendons of the chickens in groups 1 and 2 were evaluated immediatelly after surgery. Groups 3 and 4 were evaluated at 4 weeks after surgery. Groups 5 and 6 were evaluated at 6 weeks. RESULTS: Increases in transient inflammation and connective tissue formation were observed more clearly in the group treated with the new method in histopathological investigations at weeks 4 and 6. The stretching test showed statistically significant differences between groups 3 and 4 (P<0.05) and groups 5 and 6 (P<0.05). CONCLUSIONS: When repairing tendons with the new method, the healing surface increases and the direction of collagen fibers at the surface changes. Because of these effects, the strength of the tendon healing line increases; we therefore expect that this technique will enable patients to safely engage in early active exercise after the operation, with less risk of tendon rupture.

Congenital lateral cleft palate and lateral palatal synechiae.

We report a sporadic case of congenital lateral cleft palate and lateral palatal synechiae and suggest that its mechanism is embryonal. This is the first published case that we know of with cleft palate-lateral synechiae syndrome including the lateral cleft palate.

Polydactyly and hypertension.

A case diagnosed as Bardet-Biedl syndrome with polydactyly and hypertension has been presented here. Bardet-Biedl syndrome is an autosomal recessive disorder, which includes renal dystrophy, dystrophic extremities (often polydactyly), obesity, hypogenitalism, renal disease, and mental retardation. It was first described by John Z. Laurence and Robert Moon. The basic components of the syndrome were established by George Bardet in 1920 and Arthur Biedl in 1922. Although it is still referred to as Laurence-Moon-Bardet-Biedl in some reports, it has recently acquired the name Bardet-Biedl syndrome. Patients were generally lost due to renal insufficiency at young ages.

The "reading man" procedure: a new technique for the closure of circular skin defects.

BACKGROUND: As most of the skin lesions tend to grow in a circular pattern, the resultant defects after surgical removal of these lesions are often circular. Although a number of local flap procedures have been described, alternative techniques are still needed for the closure of circular defects. PURPOSE: Here, a new surgical technique for the closure of circular skin defects is presented. This technique basically uses the extra skin relaxation gained with an unequal Z-plasty maneuver in favor of the defect closure. The procedure is named as "the reading man" because its surgical design resembles the silhouette of a man who is reading a book held in his hand. MATERIAL AND METHODS: In this technique, 2 flaps designed in an unequal Z-plasty manner are used. The first flap is transposed to the defect area whereas the second flap is used for closure of the first flap's donor site. For 3 years, this technique has been used for closure of the circular skin defects in 27 patients (19 men and 8 women) aged from 2 months to 68 years. The defect size was ranging between 1.5 and 14 cm in diameter. RESULTS: A tension-free defect closure was obtained in all patients. All flaps healed with no complications. There was no patient with dog ear formation. A mean follow-up of 15 months (6 months-3 years) revealed an esthetically acceptable scar formation in all patients. CONCLUSION: The reading man procedure was found to be a useful and an easy going technique for the closure of circular skin defects located on various anatomic regions. It enables surgeon to obtain a tension-free closure of considerably large skin defects with minimal scarring and additional healthy skin excision.

Bilateral musculocutaneous unequal-Z procedure: a new technique for reconstruction of total lower-lip defects.

BACKGROUND: Although several techniques have been described for total lower-lip reconstruction, it is still a major reconstructive challenge, which often requires lengthy and risky microsurgical procedures. PURPOSE: Here, we present a new local procedure, namely, bilateral musculocutaneous unequal-Z procedure for functional reconstruction of total lower-lip defects. MATERIAL AND METHODS: In this technique, 2 musculocutaneous flaps including the depressor anguli oris and platysma muscles, respectively, are used in an unequal Z-plasty manner on each side of the defect. The lip defect is closed by the means of extra tissue relaxation provided with bilateral Z-plasty maneuver. The oral sphincter is reconstructed by suturing the depressor anguli oris muscles to each other at the midline. The mucosal coverage is provided with mucosal flaps obtained from the buccal areas bilaterally. Over 2 1/2 years, this new technique was used in 8 patients, aged between 47 and 83 years, with total lower-lip defects resulted from excision of squamous cell carcinomas. RESULTS: All patients healed uneventfully. At 6 months, physical and electromyography (EMG) examinations revealed an intact oral sphincter with a normal sensitivity. One patient died because of lung metastasis at 8 months after surgery. A mean follow-up of 2 years revealed a functionally and cosmetically acceptable lower-lip reconstruction in all surviving patients. CONCLUSIONS: As a nonmicrosurgical local procedure providing an esthetically acceptable, sensitive, and functional lower lip, this new technique seems to be a useful alternative to the microsurgical procedures in total lower-lip reconstruction.

The association between silicone implants and both antibodies and autoimmune diseases.

Silicones are widely used materials in many fields of medicine and largely are believed to be biologically inert. However, some investigators have reported that silicone implants are associated with an increased incidence of autoimmune disorders. In this study, we evaluated the capsular tissue of silicone implants and the sera of implant patients and controls for antisilicone antibodies and nonspecific immunoglobulins (IgG, IgA, IgM, and IgE). Our study group included 15 patients (eight men and seven women) undergoing reconstructive procedures for burn scars, in whom we used silicone implants, and 15 sex-matched controls undergoing reconstructive surgery for burn scars without using silicone implants. By immunofluorescence, we discovered strong capsular binding of IgG and weak capsular binding of IgM; antisilicone antibody levels were significantly higher in capsular tissue than elsewhere. Serum IgE also was higher in patient vs control subject sera. In conclusion, silicone materials do lead to an immune response consisting of antisilicone antibodies most evident immediately adjacent to the implant itself.

A new technique for closure of large meningomyelocele defects.

BACKGROUND: Although small meningomyeloceles may be amenable to direct closure by undermining of the surrounding skin, the closure of large meningomyelocele defects is a challenging reconstructive problem. PURPOSE: Here, we present a new surgical procedure for the closure of large meningomyelocele defects. MATERIAL AND METHODS: In this procedure, after neurosurgical repair and closure of the placode, the defect is surgically converted to a triangle in shape. Then, the triangular defect is closed by transposition of 2 skin flaps designed in an unequal z-plasty manner. Over 3 years, this new technique, namely Mutaf triangular closure procedure, was used for the closure of large meningomyelocele defects in 5 patients, aged between 2 days to 6 weeks. The defect size was 10.4 x 7.5 cm on average. RESULTS: In all patients, a tension-free 1-stage closure was obtained. Except one with a minimal hematoma, all patients healed with no complication. There was no patient with late breakdown of the wound during 2 years of mean follow-up. CONCLUSIONS: Besides the 2 major advantages of short operative time and minimal blood loss, our technique provides a well-vascularized soft tissue padding over the neural tissues, and no suture line overlies the cord closure. With these advantages, this new technique seems to be a useful and safe solution for closure of large meningomyelocele defects.

Versatility of the bilobed cervical skin flap for total ear reconstruction in the unfavorable temporoauriculomastoid region.

BACKGROUND: The unfavorable temporoauriculomastoid region is a serious clinical problem that makes total ear reconstruction a real challenge. In patients who have it, all local flap solutions to provide skin coverage to the cartilage frame are precluded because of loss and/or severe scarring of the regional skin in association with loss of the axial vascularity of the region. In the current literature, all available techniques for these patients are lengthy and risky free flap procedures that can provide a poor quality of skin coverage with no aesthetic harmony at best. In this article, the authors describe the use of the bilobed cervical flap as a new technique for providing skin coverage in total ear reconstruction for patients with an unfavorable temporoauriculomastoid region. METHODS: Over a period of 6 years, the technique was used in seven patients between the ages of 19 and 52 years. In all patients, the entire skin of the temporoauriculomastoid region was either lost or badly scarred. Moreover, use of the ipsilateral temporoparietal fascia was not possible because of impaired axial vascularity of the region. RESULTS: Except for mild venous congestion at the distal part of the primary flap, the flaps healed uneventfully in all patients. The patients were followed up for 1 to 4 years. The results were excellent in all patients. CONCLUSIONS: Providing a thin, pliable, hairless, and well-vascularized skin cover with a perfect color match, the bilobed cervical flap seems to be a useful solution to overcome the skin coverage dilemma in patients with an unfavorable temporoauriculomastoid region.

Expression of caspase-3, p53 and Bcl-2 in generalized aggressive periodontitis.

BACKGROUND: Apoptosis, or programmed cell death is a form of physiological cell death. It is increased or decreased in the presence of infection, inflammation or tissue remodelling. Previous studies suggest that apoptosis is involved in the pathogenesis of inflammatory periodontal disease. The aim of the present study was to investigate the clinical features and known indicators of apoptosis (p53, Bcl-2, Caspase-3) in patients with generalized aggressive periodontitis (GAP) METHODS: Eight patients with GAP, who had sites with probing depths (PD) > 5 mm, and 10 periodontally-healthy persons were included in the study. Clinical examinations and PD were performed, and the plaque index and gingival index were recorded. Gingival tissues biopsies were obtained from active site of each patient and from healthy individuals. The expression of caspase-3, Bcl-2, and p53 was evaluated by immunohistochemistry RESULTS: There were no significant differences between GAP and control group with respect to levels of caspase-3 and p53 expression (P > 0.05). Contrary, the frequency of grade 3 expression of Bcl-2 was higher in GAP group than the control group. CONCLUSION: The higher frequency of Bcl-2 expression in GAP group indicates and delayed apoptosis can lead to increasing resident inflammatory cells in periodontal tissues and resulting in progressive periodontal destruction.

A true one-stage nonmicrosurgical technique for total phallic reconstruction.

A new nonmicrosurgical technique for one-stage total phallic reconstruction is presented. In this procedure, an innervated anterolateral thigh (ALT) flap including the medial half of the fascia latae is combined with a sartorius perforator flap. Both flaps are elevated together as an island chimeric flap based on the lateral circumflex femoral vessels and tunneled to the recipient area. The neourethra is created with thin and hairless skin of the sartorius perforator flap, while the ALT flap is used to construct the shaft and glans of the neophallus. The rigidity was provided with a penile prosthesis covered with a neotunica albuginea created with vascularized fascia latae for the first time in the literature. The lateral femoral cutaneous nerve of the ALT flap is coapted to the pudendal nerve to provide erogenous sensibility. Here, a 15-year-old male in whom this new procedure was used for one-stage total phallic reconstruction is presented. Two years of follow-up revealed that an esthetically acceptable and functional neopenis with a nonhairy competent urethra, erogenous sensitivity, and a proper rigidity was achieved with no complication. This new technique, namely, the "Istanbul on the thigh" flap, is a one-stage, safe, and timesaving technique which fulfills all essential goals of phallic reconstruction but does not require microsurgical equipment and expertise. Moreover, the donor scar is located at an unexposed area, easy to conceal. Although more clinical experience is needed, this new procedure seems to be a useful alternative in phallic reconstruction.

Analysis of proliferative activity in oral gingival epithelium in immunosuppressive medication induced gingival overgrowth.

BACKGROUND: Drug-induced gingival overgrowth is a frequent adverse effect associated principally with administration of the immunosuppressive drug cyclosporin A and also certain antiepileptic and antihypertensive drugs. It is characterized by a marked increase in the thickness of the epithelial layer and accumulation of excessive amounts of connective tissue. The mechanism by which the drugs cause gingival overgrowth is not yet understood. The purpose of this study was to compare proliferative activity of normal human gingiva and in cyclosporine A-induced gingival overgrowth. METHODS: Gingival samples were collected from 12 generally healthy individuals and 22 Cyclosporin A-medicated renal transplant recipients. Expression of proliferating cell nuclear antigen was evaluated in formalin-fixed, paraffin-embedded gingival samples using an immunoperoxidase technique and a monoclonal antibody for this antigen. RESULTS: There were differences between the Cyclosporin A group and control group in regard to proliferating cell nuclear antigen and epithelial thickness. In addition, the degree of stromal inflammation was higher in the Cyclosporin A group when compared with the control group. CONCLUSION: The results suggest that the increased epithelial thickness observed in Cyclosporin A-induced gingival overgrowth is associated with increased proliferative activity in keratinocytes.

Comparison of the rate of palatal fistulation after two-flap and four-flap palatoplasty.

We studied 73 repairs of cleft palate (48 cleft lip and palate and 25 isolated cleft palate) done during a 7-year period (January 1996-October 2002) by the same plastic reconstructive surgeon. Two-flap or four-flap palatoplasty techniques were used to provide tension-free, three-layer repairs for patients with cleft palate. Their ages ranged from 10-244 months (mean 27). The postoperative follow-up period ranged from 6 to 60 months (mean 21). There was a palatal fistulation rate of 7% (5/73). There were two fistulas after two-flap palatoplasty (5%, 2/39), and three fistulas after four-flap palatoplasty (9%, 3/34). The mean diameter was 7.8 mm (range 5.1 to 13). There was no significant difference between the two techniques.

Apoptosis in cyclosporin A-induced gingival overgrowth: a histological study.

BACKGROUND: Cyclosporin A (CsA) is known to induce gingival overgrowth. Apoptosis plays a critical role in the regulation of inflammation and the host immune response. The aim of this study was to investigate apoptosis in CsA-induced gingival enlargement using electron microscopy examination of keratinocytes. METHODS: Gingiva specimens were collected from 12 CsA-treated renal transplant patients with gingival overgrowth and eight healthy controls with gingivitis. Clinical findings (probing depth, gingival index, and plaque index) were compared in the two groups. Histological and ultrastructural features of the specimens were also compared, and extent of keratinocyte apoptosis was scored on a three-tier scale: 0 = no apoptotic cells; 1 = one or two apoptotic cells; 2 = more than two cells. RESULTS: There were no significant differences between groups with respect to gingiva-related clinical findings or extent of keratinocyte apoptosis. CONCLUSIONS: The results indicate that the extent of keratinocyte apoptosis in the gingiva of kidney recipients with CsA-induced gingival overgrowth is similar to that observed in inflamed gingiva of healthy individuals. Further studies on apoptosis of different cell types in the presence of CsA should clarify this agent's role in the pathogenesis of drug-induced gingival enlargement.

Effect of cyclosporin A on apoptosis and expression of p53 and bcl-2 proteins in the gingiva of renal transplant patients.

BACKGROUND: Gingival overgrowth (GO) is a common side effect of cyclosporin A (CsA) therapy, but the exact mechanism for this is unknown. Apoptosis plays an important role in the maintenance of tissue homeostasis and mediators of this process may be involved in the pathogenesis of drug-induced GO. This study compared p53 expression, bcl-2 expression, and apoptosis in gingival samples from CsA-treated renal transplant recipients to findings in controls with gingivitis. METHODS: Twenty-two kidney recipients with CsA-induced GO and 15 systemically healthy subjects with gingivitis were included in the study. The 15 systemically and periodontally healthy volunteer control group were immunohistochemically analyzed for grades of p53 and bcl-2 expression, and were processed using terminal TdT-mediated dUTP-biotin nick-end labeling (TUNEL) technique to identify and grade levels of apoptosis. RESULTS: There were no differences between the CsA group and the control group with respect to grades of p53 and bcl-2 expression (P >0.05 for both). However, the CsA group showed a lower apoptosis grade than the control group (P <0.05). None of the clinical parameters was significantly correlated with any of the immunohistochemical findings for p53 or bcl-2 (P >0.05 for all). Similarly, grade of apoptosis was not correlated with any of the clinical parameters (P >0.05). There was a significant positive correlation between serum CsA level and level of bcl-2 expression, but serum CsA was not significantly correlated with level of apoptosis or level of p53 expression. CONCLUSION: The results indicate that the pathogenesis of CsA-induced GO might involve inhibition of apoptosis, and overexpression of bcl-2 in the setting of high serum CsA.

Immunohistochemical study of cyclosporin-induced gingival overgrowth in renal transplant recipients.

BACKGROUND: Cyclosporin A (CsA) is an immunosuppressant widely used to treat transplant patients and various systemic diseases with immunological components. Gingival overgrowth (GO) is a common side effect of CsA administration; however, the pathogenesis of drug-induced GO is poorly understood. The aim of this study was to evaluate the expression of Ki-67, activation molecules (CD71, CD98), leukocytes activation antigens (CD45, CD45RA, CD50, CD11a, CD162, CD227, CD231), neurothelin (CD147), and novel endothelial cell antigens (B-F45, SCF87, B-D46, B-C44, VJ1/6) in gingival tissue in renal transplant recipients treated with CsA. METHODS: Tissues from 15 renal transplant patients with significant GO and 10 systemically healthy control subjects with gingivitis were studied. Frozen-section biopsies were stained with monoclonal antibodies specific for the above-mentioned antigens using an indirect immunoperoxidase technique. RESULTS: Comparison of the CsA-treated and control groups revealed no significant differences with respect to expression of Ki-67; CD50; activation molecules; neurothelin; or novel endothelial cell antigens B-D46, B-C44, and VJ1/6. However, expression patterns of CD45, CD45RA, CD11a, CD162, CD227, CD231, B-F45, and SCF87 were significantly different in CsA and control groups. CONCLUSION: Leukocyte activation antigens play an important role in CsA-induced gingival overgrowth.