Neoadjuvant intermediate-course versus long-course chemoradiotherapy in T3-4/N0+rectal cancer:Istanbul R-02 phase II randomized study

Radiation therapy(RT)is typically applied using one of two standard approaches for preoperative treatment of resectable locally advanced rectal cancer(LARC):short-course RT(SC-RT)alone or long-course RT(LC-RT)with concurrent fluorouracil(5-FU)chemotherapy.The Phase II single-arm KROG 11-02 study using intermediate-course(IC)(33 Gy(Gray)/10 fr(fraction)with concurrent capecitabine)preoperative chemoradiotherapy(CRT)demonstrated a pathologically complete response rate and a sphincter-sparing rate that were close to those of LC-CRT.The current trial aim to compare the pathological/oncological outcomes,toxicity,and quality of life results of LC-CRT and IC-CRT in cases of LARC.The prescribed dose was 33 Gy/10 fr for the IC-CRT group and 50.4 Gy/28 fr for the LC-CRT group.Concurrent chronomodulated capecitabine(Brunch regimen)1650 mg/m2/daily chemotherapy treatment was applied in both groups.The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Colorectal Cancer Module(EORTC QLQ-CR29)was administered at baseline and at three and six months after CRT.A total of 60 patients with LARC randomized to receive IC-CRT(n=30)or LC-CRT(n=30)were included in this phase II randomized trial.No significant difference was noted between groups in terms of pathological outcomes,including pathological response rates(ypT0N0-complete response:23.3%vs.16.7%,respectively,and ypT0-2N0-downstaging:50%for each;p=0.809)and Dworak score-based pathological tumor regression grade(Grade 4-complete response:23.3 vs.16.7%,p=0.839).The 5-year overall survival(73.3 vs.86.7%,p=0.173)rate was also similar.The acute radiation dermatitis(p<0.001)and any hematological toxicity(p=0.004)rates were significantly higher in the LC-CRT group,while no significant difference was noted between treatment groups in terms of baseline,third month,and sixth month EORTC QLQ-CR29 scores.

Intrahepatic biliary cystic neoplasms:Surgical results of 9 patients and literature review

AIM: To investigate the eligible management of the cystic neplasms of the liver. METHODS: The charts of 9 patients who underwent surgery for intrahepatic biliary cystic liver neoplasms between 2003 and 2008 were reviewed retrospectively. Informed consent was obtained from the patients and approval was obtained from the designated review board of the institution. RESULTS: All patients were female with a median (range) age of 49 (27-60 years). The most frequent symptom was abdominal pain in 6 of the patients. Four patients had undergone previous laparotomy (with other diagnoses) which resulted in incomplete surgery or recurrences. Liver resection (n = 6) or enucleation (n = 3) was performed. The final diagnosis was intrahepaticbiliary cystadenoma in 8 patients and cystadenocarcinoma in 1 patient. All symptoms resolved after surgery. There has been no recurrence during a median (range) 31 (7-72) mo of follow up. CONCLUSION: In spite of the improvement in imaging modalities and increasing recognition of biliary cystadenoma and cystadenocarcinoma, accurate preoperative diagnosis may be difficult. Complete surgical removal (liver resection or enucleation) of these lesions yields satisfying long-term results.

Planned second-look laparoscopy in the management of acute mesenteric ischemia

AIM: To investigate the role of second-look laparoscopy in patients with acute mesenteric ischemia (AMI).METHODS: Between January 2000 and November 2005, 71 patients were operated for the treatment of AMI. The indications for a second-look were low flow state, bowel resection and anastomosis or mesenteric thromboembolectomy performed during the first operation. Regardless of the clinical course of patients, the second-look laparoscopic examination was performed 72 h post-operatively at the bed side in the ICU or operating room.RESULTS: The average time of admission to the hospital after the initiation of symptoms was 3 d (range, 5 h-9 d). In 14 patients, laparotomy was performed. In 11 patients, small and/or large bowel necrosis was detected and initial resection and anastomosis were conducted. A low flow state was observed in two patients and superior mesenteric artery thromboembolectomy with small bowel resection was performed in one patient. In 13 patients, a second-look laparoscopic examination revealed normal bowel viability, but in one patient, intestinal necrosis was detected. In two of the patients, a third operation was necessary to correct anastomotic leakage. The overall complication rate was 42.8%, and in-hospital mortality rate was 57.1% (n = 6).CONCLUSION: Second-look laparoscopy is a minimally invasive, technically simple procedure that is performed for diagnostic as well as therapeutic purposes. The simplicity and ease of this method may encourage wider application to benefit more patients. However, the timing of a second-look procedure is unclear particularly in a patient with anastomosis.

Histopathological comparison of topical therapy modalities for acute radiation proctitis in an experimental rat model

瞄准：与福尔马林相比评估为尖锐放射直肠炎的治疗可得到的流行热门治疗学的形式。方法：120 只老鼠的一个总数被使用。四个组(n = 30 ) 为每下列应用治疗形式与一个组一起被分析：控制， mesalazine，福尔马林， betamethasone，和 misoprostol。17.5 Gy 的单个部分被送到每只老鼠。在组老鼠被给 saline 的控制的老鼠，和在另外的三个组的老鼠在照耀以后开始第一天直到无痛苦的死亡的日子的一天收到了适当灌肠剂两次。在 d 上 5， 10，和 15，从每个组的十只老鼠是 euthanized，不知道处理赋值的一个病理学家用一个得分系统检验了直肠。结果：为表面上皮，腺(地窟) 和直肠的薄板 propria 基质的组织病理学说的分数在 d 上到达了他们的最大的水平 10。控制和福尔马林组有最高并且有的 mesalazine 最低，分别地在 d 上 10。在第 15 d 上， mesalazine， betamethasone，和 misoprostol 有 betamethasone 的最低分数。结论：Mesalazine， betamethasone，和 misoprostol 是最好的热门代理人因为放射直肠炎和福尔马林有煽动性的效果并且不应该被使用。

Effects of glutamine and curcumin on bacterial translocation in jaundiced rats

AIM: To investigate the effect of curcumin on bacterial translocation and oxidative damage in an obstructive jaundice model and compare the results to glutamine, an agent known to be effective and clinically used. METHODS: Twenty-four female Wistar-Albino rats, weighing 200-250 g, were randomly divided into three groups (8 in each group). After ligation of the common bile duct in all animals, GroupⅠ received oral normal saline, Group Ⅱ received oral glutamine and Group Ⅲ received oral curcumin for seven days. Blood samples via cardiac puncture, tissue samples (terminal ileum, liver and mesenteric lymph node) and peritoneal fluid were obtained from the animals at the time of death to investigate bacterial translocation and oxidative damage. RESULTS: We observed that both glutamine and curcumin reduced bacterial translocation in blood, hepatocellular damage, plasma cytokine levels, oxidative tissue damage and apoptosis significantly compared to the control group. Additionally, glutamine showed protective effects on ileal epithelium and reduced villus atrophy. CONCLUSION: On the basis of these findings, both curcumin and glutamine are thought to be effective in preventing or reducing bacterial translocation and oxidative damage in obstructive jaundice.

Effect of growth hormone,hyperbaric oxygen and combined therapy on the gastric serosa

AIM:To investigate the role of growth hormone(GH),hyperbaric oxygen therapy(HBOT) and combined therapy on the intestinal neomucosa formation of the gastric serosa.METHODS:Forty-eight male Wistar-albino rats,weighing 250-280 g,were used in this study.The rats were divided into four groups(n = 12):Group 1,control,gastric serosal patch;Group 2,gastric serosal patch + GH;Group 3,gastric serosal patch + HBOT;and Group 4,gastric serosal patch + GH + HBOT.Abdominal access was achieved through a midline incision,and after the 1-cm-long defect was created in the jejunum,a 1 cm × 1 cm patch of the gastric corpus was anastomosed to the jejunal defect.Venous blood samples were taken to determine the insulin-like growth factor 1(IGF-1) and insulin-like growth factor binding protein 3(IGFBP-3) basal levels.HBOT was performed in Groups 3 and 4.In Groups 2 and 4,human GH was given subcutaneously at a dose of 2 mg per kg/d for 28 d,beginning on the operation day.All animals were sacrificed 60 d after surgery.The jejunal segment and the gastric anastomotic area were excised for histological examination.The inflammatory process,granulation,collagen deposition and fibroblast activity at the neomucosa formation were studied and scored.Additionally,the villus density,villus height,and crypt depth were counted and recorded.The measurements of villus height and crypt depth were calculated with an ocular micrometer.New vessel growth was determined by calculatingeach new vessel in a 1 mm 2 area.RESULTS:In the histological comparison of groups,no significant differences were observed between the control group and Groups 2 and 3 with respect to epithelialization,granulation,fibroblastic activity and the inflammatory process,but significant differences were present between the control group and all others groups(Groups 2-4) with respect to angiogenesis(P < 0.01) and collagen deposition(P < 0.05,P < 0.01).Significant differences between the control group and Group 4 were also observed with respect to epithelialization and fibroblastic activity(P < 0.01 and P < 0.05,respectively).There were significant differences in villus density in all of groups compared with the control group(P < 0.05).Crypt depth was significantly greater in Group 4 than in the control group(P < 0.05),but no other groups had deeper crypts.However,villus height was significantly longer in Groups 2 and 4 than in the control group(P < 0.05).The comparison of groups revealed,significant difference between control group and Groups 2 and 4) with respect to the levels of IGF-1 and IGFBP-3(P < 0.01) 3 wk after the operation.CONCLUSION:HBOT or GH and combined therapy augmented on neomucosal formation.The use of combined therapy produced a synergistic effect on the histological,morphological and functional parameters.

Effects of hyperbaric oxygen and Pgg-glucan on ischemic colon anastomosis

瞄准：在颜色表面的外科，吻合失败仍然是在局部缺血的一个问题。这里，我们在冒号上分析了高比重的氧和 beta-glucan 的效果吻合在是化学家状况。方法：在书籍的右页 sigmoid 区域的结肠的切除术和吻合在四组相等的数字的四十只 Wistar 白化体老鼠被做。冒号肠系膜被绑扎导致局部缺血。第一个组是控制组。第二个组的题目与高比重的氧被对待；有 glucan 的第三个组并且向前，组与两个被对待。在向前白天，老鼠被牺牲的、吻合的片断是吻合的层次衬里的 resected 和爆炸压力和羟脯氨酸被测量。结果：从控制组的第二和第三个组的爆炸压力差别是有意义的(P【0.01 ) ；向前，组与控制(P【0.001 ) 显著地不同。爆炸压力水平(P】0.05 ) 上的对待的组之间没有差别。在所有对待的组的羟脯氨酸层次显著地与控制组不同(P【0.001 ) 。羟脯氨酸层次在向前组是比第二和第三个组(P【0.001 ) 的那些高级的。在在爆炸压力和羟脯氨酸层次(P】0.05 ) 的第二和第四个组之间没有有效差量。结论：高比重的氧和 glucan 改善愈合在化学家冒号由 anti-microbic 吻合，有免疫力的刺激性质并且当一起联合了时，似乎 synergistically 行动。

Real-life experience of ranibizumab therapy for neovascular age-related macular degeneration from Turkey

AIM： To report the real-life experience and clinical results of intravitreal ranibizumab injections to neovascular agerelated macular degeneration（nAMD） in a single institution in Turkey.METHODS： A total of 101 eyes of 89 patients with nAMD treated with intravitreal ranibizumab injection, followed up for at least 24 mo between 2009 and June 2014, which were evaluated retrospectively. A pro re nata（PRN） treatment protocol was performed after the patients had received three, monthly loading injections. Best corrected visual acuity（BCVA） and central macular thickness measurements were evaluated at baseline and 3, 6, 12, 18, and 24 mo. Number of injections and visits were also recorded.RESULTS： Of the 89 patients, 34（38.2%） were male and 55（61.8%） were female and the mean age was 74.0±9.5（52-91）y. The mean follow-up period was 24.82±4.4（24-29）mo. Mean number of visits was 8.4±1.12（7-12） in the first year and 6.6±1.33（4-12） in the second year. The mean number of injections was 5.8±1.6（3-10） and 4.2±2.2（0-9） in the first and second year, respectively. The mean BCVA was 59±15.8 letters at baseline by the Early Treatment Diabetic Retinopathy Study（ETDRS） chart. The mean BCVA at 3, 12, and 24 mo was 70.3±15.9, 67.9±14.3 and 67.3±16.9 letters, respectively. Improvement in visual acuity for each of the visits from baseline was found to be statistically significant（P〈0.01）. Visual acuity in 9 eyes at month 3, 7 eyes at month 12, and 13 eyes at month 24 did not change. The mean central macular thickness（CMT） was 437.99±164.78 μm at baseline. The mean CMT was 348.05±138.47 μm, 349.27±139.79 μm, and 344.13±146.30 μm at months 3, 12, and 24, respectively. The decrease in CMT for each of the visits from baseline was found to be statistically significant（P〈0.01）.CONCLUSION： Anatomical and functional achievement are obtained in our study, but the mean number of injections and visits are found to be lower than the findings reported in randomized controlled clinical trials in the literature. However, the mean number of injections and visits in our study are compatible with the findings reported in real-life experience studies in the literature.

Rupture of abdominal aortic aneurysm into sigmoid colon:A case report

Primary aorto-colic fistula is rarely reported in the literature. Although infrequently encountered, it is an important complication since it is usually fatal unless detected. Primary aorto-colic fistula is a spontaneous rupture of abdominal aortic aneurysm into the lumen of the adjacent colon loop. Here we report a case of primary aorto-colic fistula in a 54-year old male. The fistulated sigmoid colon was repaired by end-to-end anastomosis. Despite inotropic support, the patient died of sepsis and multiorgan failure on the first postoperative day.

Is There a Link between Circadian Clock Protein PERIOD 3 (PER3) (rs57875989) Variant and the Severity of COVID-19 Infection?

Objective:Corona Virus Disease-2019(COVID-19)has been among the major infectious events of the century.In today’s literature where COVID-19 and host factor effects are frequently examined,we aimed to examine another factor:Circadian Clock Protein PERIOD 3(PER3).There is a significant correlation between PER3 gene polymorphism and circadian rhythm disturbances and immune system dysregulation.Methods:In our study,we recruited 200 patients diagnosed with COVID-19 in our hospital between April-June 2020,and 100 volunteers without known comorbidities to create a healthy control group.After comparing the initial gene polymorphisms of the patients with healthy controls,three separate clinical subgroups were formed.Gene polymorphism distribution and statistical significance were examined in the formed patient groups.Results:No significant difference was found between the patient group and the healthy controls(P>0.05,for all).When patients were divided into two separate clinical subgroups as exitus/alive according to their last condition during their 28-day follow-up,the 4R/5R genotype was significantly more common in patients with a mortal course(P=0.007).The PER34R75R genotype was found at a significantly higher rate in the group of patients with the need for intensive care(P=0.034).Conclusion:The 4R/5R genotype may be associated with the need for intensive care and mortality in COVID-19 patients.These important results will be a guide for future studies.

What is the impact of capsule endoscopy in the long term period?

AIM: To assess the clinical impact of capsule endoscopy(CE) in the long-term follow-up period in patients with obscure gastrointestinal bleeding(OGIB). METHODS: One hundred and forty-one patients who applied CE for OGIB between 2009 and 2012 were retrospectively analyzed, and this cohort was then questioned prospectively. Demographic data of the patients were determined via the presence of comorbid diseases, use of non-steroidal anti-inflammatory drugs anticoagulant-antiaggregant agents, previous diagnostic tests for bleeding episodes, CE findings, laboratory tests and outcomes.RESULTS: CE was performed on 141 patients becauseof OGIB. The capsule was retained in the upper gastrointestinal(GI) system in two of the patients, thus video monitoring was not achieved. There were 139 patients [62% male, median age: 72 years(range: 13-93 years) and a median follow-up duration: 32 mo(range: 6-82 mo)]. The overall diagnostic yield of CE was 84.9%. Rebleeding was determined in 40.3%(56/139) of the patients. The rebleeding rates of patients with positive and negative capsule results at the end of the follow-up were 46.6%(55/118) and 4.8%(1/21), respectively. In the multivariate analysis, usage of NSAIDs, anticoagulant-antiaggregant therapies(OR = 5.8; 95%CI: 1.86-18.27) and vascular ectasia(OR = 6.02; 95%CI: 2.568-14.146) in CE were detected as independent predictors of rebleeding. In the univariate analysis, advanced age, comorbidity, and overt bleeding were detected as predictors of rebleeding.CONCLUSION: CE is a reliable method in the diagnosis of obscure GI bleeding. Negative CE correlated with a significantly lower rebleeding risk in the long-term follow-up period.

Comparison via Digital Radiography of Radiopacity Levels of Composite Materials with Various Shades and Viscosities

Aim of the present in vitro study is to evaluate the radiopacity levels of composite resins with various shades and viscosity.10 mm×2 mm discs were prepared from 7 condensable and 4 flowable composites(n=10).An aluminum step wedge ranging from 2.0 to 10.0 mm in thickness was placed on the occlusal film.Digital radiographs were taken using a dental X-ray device and radiographic densities of each step of the aluminum wedge and the samples were recorded to the computer.Five readings were taken and means were calculated.One-Way Anova and Tamhane post hoc tests were performed.While G-eanial Posterior has the highest radiopacity value followed by Filtek Z550,Aelite Flo has the lowest radiopacity value.Posterior composites show higher radiopacity and flowable composites with higher filler loadings have superior radiopacity levels to condensable composites.Enamel and body shades of the composite brands have also statistically significant differences in radiopacity scores.Eventually,radiopacity level of a composite resin material is not affected by the size of fillers;however,the composition,shape and loading of the fillers can specify the radiodensity.

Reactive oxygen species and chemokines: Are they elevated in the esophageal mucosa of children with gastroesophageal reflux disease?

AIM: To determine the role of inflammatory cytokines and reactive oxygen species (ROS) in childhood reflux esophagitis. METHODS: A total of 59 subjects who had complaints suggesting GERD underwent esophagogastroduoden oscopy. Endoscopic and histopathologic diagnosis of reflux esophagitis was established by Savary-Miller and Vandenplas grading systems, respectively. Esophageal biopsy specimens were taken from the esophagus 20% proximal above the esophagogastric junction for conventional histopathological examination and the measurements of ROS and cytokine levels. ROS were measured by chemiluminescence, whereas IL-8 and MCP-1 levels were determined with quantitative immunometric ELISA on esophageal tissue. Esophagealtissue ROS, IL-8 and MCP-1 levels were compared among groups with and without endoscopic/histo- pathologic esophagitis. RESULTS: Of 59 patients 28 (47.5%) had normal esophagus whereas 31 (52.5%) had endoscopic esophagitis. In histopathological evaluation, almost 73% of the cases had mild and 6.8% had moderate degree of esophagitis. When ROS and chemokine levels were compared among groups with and without endoscopic esophagitis, statistical difference could not be found between patients with and without esophagitis. Although the levels of ROS, IL-8 and MCP-1 were found to be higher in the group with histopathological reflux esophagitis, this difference was not statistically significant. CONCLUSION: These results suggest that the grade of esophagitis is usually mild or moderate during childhood and factors apart from ROS, IL-8 and MCP-1 may be involved in the pathogenesis of reflux esophagitis in children.

Effect of trabeculated myocardial mass on left ventricle global and regional functions in noncompaction cardiomyopathy

BACKGROUND Left ventricular(LV)noncompaction cardiomyopathy is a rare cardiomyopathic subtype that has been recognized in recent years and is being diagnosed at an increased rate.There is no consensus regarding the diagnosis of the disease,and increased trabeculation rates that meet the existing diagnostic criteria may even be present in healthy asymptomatic people.This indicates that differentiating criteria for diagnosis are needed.AIM To examine the increase in myocardial trabeculation and the change in left ventricular global and regional functions.METHODS This retrospective study included 65 patients(28 females,37 males)diagnosed with LV noncompaction cardiomyopathy who underwent cardiac magnetic resonance imaging between January 2011 and August 2016 and had a noncompacted/compacted myocardial thickness ratio of over 2.3 in more than one segment in the left ventricle.The distribution and ratios of trabeculations in apical,midventricular,and basal regions were examined in short-axis images obtained from cardiac magnetic resonance.In addition,by using short-axis cine images,regional ejection fraction(EF)and global EF were calculated using the Simpson method in the left ventricle at apical,basal,and midventricular levels.RESULTS While the number of trabeculated segments were similar at the apical(3.2±1.0)and midventricular levels,a statistically significant level of involvement was not observed at the basal level(0.4±0.9)(P>0.05).The highest noncompacted/compacted(trabeculation)ratio was observed at the apical level(3.9±1.4),while this ratio was higher at the anterior(59%-89.4%)and lateral(62%-84.8%)segments(P>0.05).Global EF was positively correlated with apical,midventricular,and basal regional EF(P<0.05).However,there was no significant correlation between regional EF and the number of trabeculated segments or trabeculation ratio in all three regions;nor was there a significant correlation between regional EF and the number of trabeculated segments or trabeculation ratio in the entire LV(P>0.05).CONCLUSION No global or regional relationship was observed between LV dysfunction and trabeculation rate or the number of trabeculated segments.This limits the usefulness of change in LV functions in the differentiation between normal and pathological trabeculation.

Cervical adenocarcinoma and adenomatoid tumor of the uterus;A rare coexisting finding and review of the literature

Genital origin adenocarcinomas with coexisting uterine adenomatoid tumors are very rare with only four published cases in the literature. We report a case of adenomatoid tumor of the uterus that was found incidentally during treatment of cervical adenocarcinoma. Although adenomatoid tumors may cause a differential diagnostic problem, in our case the hematoxylin-eosin histological and immunhistochemical studies confirmed mesothelial phenotype of tumor and these also helped in differentiating an adenomatoid tumor from the carcinomatous myometrial invasion. Adenomatoid tumors are easily recognizable benign pathologies. An incidental finding of adenomatoid tumors accompanied by adenocarcinoma of the endometrium or cervix should always be considered.

Marked elevation of troponin I without wall motion abnormality in a patient with myocarditis: Cardiac enzymes may not predict the outcome in myocarditis

A seventeen-year-old male presented with severe substernal chest pain after an episode of upper respiratory tract infection. On clinical grounds, a diagnosis of myocarditis was established. He had a peak troponin I level as high as 40.4 ng/dl but interestingly with no abnormal wall motion and normal ejection fraction in echocardiography. Coronary artery disease was excluded with normal coronary angiography. Diagnosis of myocarditis was confirmed with cardiac MRI. After one month, patient had no complaint and ejection fraction were still normal. Our case emphasizes that the troponin levels predict neither the early nor the late outcome of the left ventricular functions in myocarditis, therefore serum troponin I may not be helpful in determining the prognosis of patients with myocarditis.

Ultrasound guided percutaneous cholecystostomy in high-risk patients for surgical intervention

AIM: To assess the efficacy and safety of ultrasound guided percutaneous cholecystostomy (PC) in the treatment of acute cholecystitis in a well-defined high risk patients under general anesthesia. METHODS: The data of 27 consecutive patients who underwent percutaneous transhepatic cholecystostomy for the management of acute cholecystitis from January 1999 to June 2003 was retrospectively evaluated. All of the patients had both clinical and sonographic signs of acute cholecystitis and had comorbid diseases. RESULTS: Ultrasound revealed gallbladder stones in 25 patients and acalculous cholecystitis in two patients. Cholecystostomy catheters were removed 14-32 d (mean 23 d) after the procedure in cases where complete regression of all symptoms was achieved. There were statistically significant reductions in leukocytosis, (13.7 × 103 ± 1.3 × 103 μg/L vs 13 × 103 ± 1 × 103 μg/L, P < 0.05 for 24 h after PC; 13.7 × 103 ± 1.3 × 103 μg/L vs 8.3 × 103 ± 1.2 × 103 μg/L, P < 0.0001 for 72 h after PC), C -reactive protein (51.2 ± 18.5 mg/L vs 27.3 ± 10.4 mg/L, P < 0.05 for 24 h after PC; 51.2 ± 18.5 mg/L vs 5.4 ± 1.5 mg/L, P < 0.0001 for 72 h after PC), and fever (38 ± 0.35℃ vs 37.3 ± 0.32℃, P < 0.05 for 24 h after PC; 38 ± 0.35℃ vs 36.9 ± 0.15℃, P < 0.0001 for 72 h after PC). Sphincterotomy and stone extraction was performed successfully with endoscopic retrograde cholangio-pancreatography (ERCP) in three patients. After cholecystostomy, 5 (18%) patients underwent delayed cholecystectomy without any complications. Three out of 22 patients were admitted with recurrent acute cholecystitis during the follow-up and recoveredwith medical treatment. Catheter dislodgement occurred in three patients spontaneously, and two of them were managed by reinsertion of the catheter. CONCLUSION: As an alternative to surgery, percutan- eous cholecystostomy seems to be a safe method in critically ill patients with acute cholecystitis and can be performed with low mortality and morbidity. Delayed cholecystectomy and ERCP, if needed, can be performed after the acute period has been resolved by percutaneous cholecystostomy.

Non-alcoholic fatty liver disease: What has changed in the treatment since the beginning?

Non-alcoholic fatty liver disease(NAFLD) is an umbrella term to describe the entire spectrum of this common liver disease. In patients with NAFLD, especially those with non-alcoholic steatohepatitis(NASH), most often have one or more components of the metabolic syndrome, but this is not universal. Although most patients with NAFLD share many clinical features, only a subset of patients develops significant liver inflammation and progressive fibrosis. On the other hand, not all patients with NASH exhibit insulin resistance. NASH can be seen in patients who are lean and have no identifiable risk factors. Many clinical studies have tried numerous drugs and alternative medicine, however, investigators have failed to identify a safe and effective therapy for patients with NASH. As summarized, the heterogeneity of pathogenic pathways in individual patients with NASH may warrant the development of an individualized treatment according to the underlying pathogenic pathway. The differentiation of pathogenetic targets may require the development of diagnostic and prognostic biomarkers, and the identification of genetic susceptibilities. At present, evidence-based medicine provides only a few options including life-style modifications targeting weight loss, pioglitazone and vitamin E in non-diabetic patients with biopsy-proven NASH.

Rare pancreas tumor mimicking adenocarcinoma: Extramedullary plasmacytoma

Neoplastic proliferation of plasma cells is called plasma cell dyscrasias, and these neoplasms can present as a solitary neoplasm or multiple myeloma. Extramedullary plasmacytoma, in particular pancreatic plasmacytoma, is a rare manifestation of multiple myeloma. Although computerized tomography is useful for the diagnosis of extramedullary plasmacytoma, there are no specific radiologic markers that distinguish it from adenocarcinoma. Histological confirmation by biopsy is necessary for accurate diagnosis and management of the tumor. Endosonography is the most sensitive method for the diagnosis of pancreatic tumors, and the use of fine needle aspiration by endosonography is associated with a lower risk for malignant seeding and complications. Here, we report a case of pancreatic plasmacytoma in newly identified multiple myeloma as diagnosed by endosonography. Endosonography is a reliable and rapid method for the diagnosis of extramedullary plasmacytoma. Therefore, endosonographic fine needle aspiration should be the first choice for histological evaluation when pancreatic plasmacytoma is suspected. Ideally, the pathology would be performed at the same site as endosonographic biopsy.

Gastroesophageal reflux in asymptomatic obese subjects:An esophageal impedance-pH study

AIM:To investigate the relationship between reflux and body mass index(BMI) in the asymptomatic obese population using the impedance-p H technique.METHODS:Gastroesophageal reflux is frequent in the obese population.However,the relationship between acid reflux and BMI in asymptomatic obese people is unclear.Forty-six obese(BMI > 25 kg/m2) people were enrolled in this prospective study.We evaluated the demographic findings and 24-h impedance p H values of the whole group.Gas,acid(p H < 4),weak acid(p H = 4-7) and weak alkaline(p H ≥ 7) reflux parameters were analyzed.RESULTS:The mean age of patients was 49.47±12.24 years,and half of them were men.The mean BMI was 30.64±3.95 kg/m2(25.14-45.58 kg/m2).BMI of 23 was over 30 kg/m2.Seventeen patients had a comorbidity(hypertension,diabetes mellitus,or ischemic heart disease).Endoscopic examination revealed esophagitis in 13 of the 28 subjects(10Grade A,3 Grade B).The subjects were divided into two groups according to BMI(<30 and>30 kg/m2).Demographic and endoscopic findings,and impedance results were similar in these two groups.However,there was a positive correlation between BMI and total and supine p H<4 episodes(P=0.002,r=0.414;P=0.000,r=0.542),p H<4 reflux time(P=0.015,r=0.319;P=0.003,r=0.403),and De Meester score(P=0.012,r=0.333).CONCLUSION:Acid reflux is correlated with BMI in asymptomatic obese individuals.