Cerrahpaşa Medical Journal is a peer-reviewed, open access, online-only journal published by İstanbul University-Cerrahpaşa. Cerrahpaşa Medical Journal is a continuously published journal in English. The journal has moved to continuous publication by volume from Volume 49.
The Impact of Perineural Invasion on Prognosis in Patients Undergoing Robot-Assisted Radical Prostatectomy
Objective: This study aimed to investigate the clinical relevance of perineural invasion (PNI) detected in prostate needle biopsy specimens (PNIb) and radical prostatectomy specimens (PNIp) and to evaluate its associations with clinical characteristics, histopathological features, biochemical recurrence, and prognostic outcomes in patients undergoing nerve-sparing robot-assisted radical prostatectomy (RARP). Methods: A retrospective analysis was conducted on 106 patients who underwent RARP for prostate cancer between September 2016 and December 2021 at the institution. Clinical data, including prostate-specific antigen (PSA) levels, multiparametric magnetic resonance imaging findings, biopsy results, and postoperative pathology reports, were reviewed. Patients were stratified based on the presence of PNI in prostatectomy specimens (PNIp), and oncological outcomes were compared accordingly. Results: The presence of PNIp was significantly associated with higher PSA density (P = .031), a greater frequency of PIRADS ≥3 lesions (P = .048), and a higher percentage of tumor involvement in biopsy cores (P = .001). Gleason scores ≥7 (P = .028) and positive surgical margins (P = .009) were also more prevalent in the PNIp group. Although biochemical recurrence occurred more frequently in PNIp-positive patients (21.1%) compared to PNIp-negative patients (6.7%), this difference did not reach statistical significance (P = .076). The mean time to biochemical recurrence was shorter in the PNIp-positive group (69.6 months) compared to the PNIp-negative group (78.6 months). Multivariate logistic regression analysis did not identify any independent predictor of recurrence (Nagelkerke R2 = 0.155, P < .001). Conclusion: While PNIp was significantly associated with adverse pathological features, it did not independently predict biochemical recurrence. Nevertheless, the earlier onset of recurrence in PNIp-positive patients—despite the lack of statistical significance—may suggest potential clinical relevance that warrants further investigation. Cite this article as: Rzayev V, Bedir S, İlki FY, Bedir S, Topçu YK, Ebiloğlu T, Coğuplugil AE. The impact of perineural invasion on prognosis in patients undergoing robot-assisted radical prostatectomy. Cerrahpaşa Med J 2025, 49, 0026, doi:10.5152/ cjm.2025.25026.
Systemic Inflammation and Early Pregnancy Loss: Evaluating Platelet-to-Albumin Ratio in First Trimester Threatened Abortion
Objective: To evaluate the clinical significance of the platelet-to-albumin ratio (PAR) as a predictive marker for early pregnancy loss (EPL) and adverse perinatal outcomes in first-trimester pregnancies complicated by threatened abortion (TA). Methods: This retrospective case-control study included 60 pregnant women hospitalized for TA and 60 matched healthy controls with term pregnancies, evaluated at Ankara Bilkent City Hospital Hospital between September 2024 and March 2025. First-trimester laboratory parameters, including PAR (calculated as platelet count divided by albumin level), were compared between groups. Demographic data, pregnancy outcomes, and perinatal complications were also analyzed. Receiver operating characteristic (ROC) analysis was performed to assess the predictive value of PAR for EPL. Results: The PAR was significantly lower in the TA group (5.15 ± 1.45) compared to controls (P < .001). Early pregnancy loss occurred in 30% of the TA cases, with a median diagnosis at 8 weeks’ gestation. The PAR cut-off value of 4.96 predicted EPL with 66.7% sensitivity and 67.7% specificity (area under the curve = 0.697, P = .008). Patients with TA also had significantly higher white blood cell counts and adverse perinatal outcomes, including lower birth weights, higher neonatal intensive care unit admissions, and increased C-section rates. Subgroup analysis based on gestational age at TA diagnosis revealed elevated inflammation markers in later first-trimester cases but no significant differences in EPL rates. Conclusion: Lower PAR values are associated with TA and may serve as a cost-effective, accessible marker to predict EPL and adverse perinatal outcomes. Although its predictive capacity is moderate, PAR could aid in early risk assessment when combined with other clinical parameters. Further large-scale, prospective studies are needed to validate these findings and establish PAR’s role in obstetric care. Cite this article as: Okutucu G, İpek G, Şahin D. Systemic inflammation and early pregnancy loss: evaluating platelet-to-albumin ratio (PAR) in first trimester threatened abortion. Cerrahpaşa Med J. 2025, 49, 0055, doi:10.5152/cjm.2025.25055.
Cure Rate of Dosimetry-based 131I Therapy in Hyperthyroidism Management
Background: This study aims to evaluate the effectiveness and cure rate of individualized radioiodine therapy in patients diagnosed with Graves’ disease and toxic adenoma. Methods: A total of 11 patients with toxic adenoma and 20 patients with Graves’ disease were enrolled in the study. Radioiodine activities were individually calculated using patient-specific data and a mathematical model to deliver target absorbed doses of 300 Gy for toxic adenoma and 200 Gy for Graves’ disease. The mean administered radioactive iodine (RAI) activity was 826 ± 124 MBq for patients with toxic adenoma and 541 ± 215 MBq for those with Graves’ disease. Results: At the 3-month follow-up, 35% of patients with Graves’ disease and 54.6% of those with toxic adenoma reached a euthyroid state. Hypothyroidism occurred in 65% of Graves’ patients and 45.4% of toxic adenoma patients; all began thyroid hormone replacement therapy and achieved euthyroid status by the 6-month follow-up. Conclusion: Dosimetry-based RAI therapy achieved complete remission within 3 months following a single administration of 131I, with no patients requiring a second course of RAI therapy. In contrast to empirical treatment protocols, individualized therapy enhances safety, minimizes risk, and improves clinical outcomes. Cite this article as: Abuqbeitah M, Yeyin N, Akyol S, Uslu-Beşli L, Demir M. Cure rate of dosimetry-based 131I therapy in hyperthyroidism management. Cerrahpaşa Med J 2025, 49, 0032, doi: 10.5152/cjm.2025.25032.
Impact of Blood Type on Treatment Response and Survival in HER2-Negative Metastatic Gastric Cancer
Objective: Metastatic gastric cancer is one of the most lethal malignancies. Recent studies indicate that the O blood group has better survival than the non-O blood group. In this study, the aim was to evaluate the impact of blood group O and non-O blood groups on survival outcomes and treatment responses in gastric cancer patients. Methods: Between January 2012 and June 2024, 187 patients with metastatic gastric cancer treated at Kartal Dr. Lütfi Kırdar City Hospital were retrospectively analyzed. Patients were divided into 2 groups: O blood group (n = 82) and non-O blood group (n = 105). The prognostic role of blood groups and their impact on survival outcomes was investigated. Results: Median overall survival was 15.7 months in the O blood group and 12.9 months in the non-O blood group (P = .04). There was no significant difference between the groups in terms of progression-free survival (7.9 months versus 7.0 months, P = .11). Disease control rates were 69.5% in the O Rh +/− group and 63.3% in the other groups. In subgroup analyses, a borderline significant interaction (P = .08) was observed between the blood group and Eastern Cooperative Oncology Group (ECOG) PS (Performance Status). In multivariate analysis, ECOG performance score was found to be an independent prognostic factor (hazard ratio = 1.6, P = .003), whereas blood group was not found to be an independent prognostic factor (P = .16). Conclusion: The study found thatpatients with bloodgroup O exhibited better survival rates inmetastatic gastric cancer; however, the blood group was not identified as an independent predictor of survival. The primary determinant of survival outcomes remained the patient’s performance status. Therefore, while bloodgroup may serveas an additionalprognostic indicator, its utility requires further validation throughlarger scale studies. Cite this article as: Yildirim S, Alan Ö, Turkoglu E, et al. Impact of blood type on treatment response and survival in HER2-negative metastatic gastric cancer. Cerrahpaşa Med J 2025, 49, 0042, doi: 10.5152/cjm.2025.25042.
Evaluating the Prognostic Role of Pan-Immune-Inflammation Value in Patients with Advanced Non-Small Cell Lung Cancer Treated with Nivolumab
Objective: Non-small cell lung cancer (NSCLC) remains a leading cause of cancer-related death. Panimmune-inflammation value (PIV), a novel biomarker that reflects systemic inflammation and immune status, has been evaluated for prognostic efficacy in various cancer types. This study aimed to investigate the efficacy of PIV on survival outcomes in patients diagnosed with advanced NSCLC who were treated with nivolumab. Methods: The single-center, retrospective, and observational study included patients with metastatic NSCLC who received nivolumab treatment. The receiver operating characteristic (ROC) curve analysis was performed to find the optimal PIV cutoff value for predicting outcomes, and patients were divided into 2 groups: low-PIV and high-PIV. Results: The median age was 63 years. The patient cohort comprised 68 male and 20 female patients. Adenocarcinoma histology was identified in the majority of patients (56.8%). Nivolumab was administered to 74% of patients as a second line of treatment and to 26% in the third line or later. In ROC analysis, the ideal cutoff value for PIV was established at 652 (AUC: 0.691, 95% CI: 0.568-0.814, P = .013). No statistically significant differences were observed in the demographic and clinicopathological features of patients between the low- and high-PIV groups. High PIV was independently associated with shorter progressionfree survival (HR: 0.47, 95% CI: 0.29-0.76; P = .002) and overall survival (HR: 0.54, 95% CI: 0.32-0.92; P = .023), independent of other factors affecting outcomes. Conclusion: The findings of the study indicate that PIV value may serve as a significant prognostic biomarker for predicting survival in metastatic NSCLC patients undergoing treatment with nivolumab. Cite this article as: Guliyev M, Alan Ö, Fidan MC, et al. Evaluating the prognostic role of pan-immune-inflammation value in patients with advanced non-small cell lung cancer treated with nivolumab. Cerrahpaşa Med J. 2025, 49, 0038, doi:10.5152/ cjm.2025.25038.
Evaluation of Physicians’ Knowledge and Anxiety Levels About Inherited Metabolic Diseases: Survey Study
Objective: Inherited metabolic disorders (IMDs) are rare genetic disorders with complex clinicalpresentations. Due to their rarity and limited presence in medical education, there is a lack of knowledge and increased anxiety among physicians in the management of these diseases. This study aims to evaluate the knowledge and anxiety levels of physicians about IMDs and to determine the factors affecting their professional competence. Method: A cross-sectional survey was conducted with the participation of 83 physicians across Türkiye. Participants completed an online questionnaire assessing demographic data, knowledge of IMDs, and anxiety about these diseases. The data were analyzed using statistical methods such as t-tests and chisquare tests. Results: The mean knowledge level of physicians was 5.6 ± 2.1 on a 10-point scale, indicating that they had basic knowledge but lacked advanced knowledge. The mean anxiety score was 5.3 ± 2.4, and the most common cause of anxiety was reported as lack of knowledge by 60.2%. It was observed that physicians who saw IMD patients less frequently perceived their level of knowledge to be higher than it was due to their inability to adequately recognize the complexity of these diseases. Although the presence of a metabolic specialist in the institution increased self-confidence, it did not have a significant effect on knowledge and anxiety levels. Conclusion: This study highlights the importance of systematic educational programs in IMD management by revealing physicians’ lack of knowledge and increased anxiety levels. Interactive case-based learning, preparation of national guidelines, and interdisciplinary collaboration are critical to increasing knowledge and improving patient outcomes. Cite this article as: Enver EÖ, Yılmaz B. Evaluation of physicians’ knowledge and anxiety levels about inherited metabolic diseases: survey study. Cerrahpaşa Med J. 2025, 49, 0006, doi:10.5152/cjm.2025.25006.
Identification of Risk Factors and Survival in Patients Undergoing Re-amputation After Extremity Amputation
Objective: This study aimed to identify the risk factors contributing to re-amputation, survival rates, and mortality determinants in patients who underwent unilateral lower extremity amputation due to diabetes mellitus (DM) or peripheral artery disease (PAD). Methods: This retrospective study included 93 patients who underwent amputation due to DM (62) or PAD (31). Data regarding the etiology and level of amputation, comorbidities, ASA scores, postoperative intensive care unit (ICU) admission, ICU length of stay, re-amputation rates, factors necessitating re-amputation, wound culture results, time to re-operation, survival status, and duration were analyzed. Results: PAD patients were older (P = .019), had fewer comorbidities than DM patients (P < .001), and predominantly underwent transfemoral amputation (TFA) (64.5%). The re-amputation rate was 32.6%, with a median interval of 6 weeks, driven by wound healing complications (64.5%). The median survival duration was 6 months (range 1–29 months). PAD-TFA patients had the highest re-amputation rates and the lowest 1-year survival. Independent mortality predictors included advanced age (P = .003), ASA-4 status (P = .018), and hypoalbuminemia (P = .032). Re-amputation did not independently affect survival (P = .213) but significantly reduced prosthetic fitting rates (P = .005). Conclusion: Patients undergoing amputation for chronic lower extremity circulatory issues should be closely monitored for wound problems, particularly during the first 6 weeks postoperatively. PAD-TFA patients represent the highest-risk subgroup. The poor prognostic factors for survival include advanced age, ASA-4 status, and hypoalbuminemia. Furthermore, the significantly older age of PAD patients highlights the importance of addressing diabetes as a critical health concern across all age groups. Cite this article as: Davulcu CD, Afacan MY. Identification of risk factors and survival in patients undergoing re-amputation after extremity amputation. Cerrahpaşa Med J. 2025, 49, 0003, doi: 10.5152/cjm.2025.25003.
Revisiting Predictors of Mortality and Analysis of the Patients with Penetrating and Iatrogenic Cardiac Injuries
Introduction: Cardiac injuries are life-threatening conditions. The aim of this study was to evaluate the incidence, outcomes, and pathophysiology of cardiac injuries, as well as concomitant pathologies, risk factors, and clinical presentations over a 19-year period. Methods: Thirty-four patients who underwent surgical intervention due to penetrating or iatrogenic cardiac injuries were retrospectively analyzed between January 2000 and April 2019. The study analyzed various factors including the duration of time before admission to the emergency service, initial vital status, preoperative resuscitation, presence of cardiac tamponade, type, extent, and localization of the injury, surgical approach, injury severity score, and duration of hospital-intensive care unit stays. Results: Significant predictors of mortality included preoperative cardiopulmonary resuscitation, cardiac tamponade, initial Glasgow Coma Scale < 9, time elapsed to reaching the hospital, and initial systolic blood pressure. The overall mortality rate was 32.4%. The right ventricle was the most frequently injured (58.8%). In 82.4% of cases, sternotomy was performed, while thoracotomy was performed in 17.6% of cases. The average injury severity score was calculated as 52.29 ± 27.69, indicating a significant level of trauma. Furthermore, a majority of the victims, specifically 76.5%, suffered from severe injuries with an ISS score greater than 25. Conclusions: The most common cause of cardiac injury was penetrating injuries, with the right ventricle being the most frequently affected site. Prompt diagnosis and intervention are crucial. Therefore, the elapsed time for transferring patients to the hospital under optimal conditions is of significant importance and could improve survival rates. Cite this article as: Arapi B, Deşer SB. Revisiting predictors of mortality and analysis of the patients with penetrating and iatrogenic cardiac injuries. Cerrahpaşa Med J 2025; 49, 0044, doi: 10.5152/cjm.2025.24044.
Perinatal and Maternal Outcomes of Pregnancies with Preterm Premature Rupture of Membranes
Objective: To evaluate the maternal and perinatal outcomes of pregnancies with preterm premature rupture of membranes (PPROM) and to explore the perinatal and obstetric outcomes according to gestational age at the time of PPROM. Methods: This retrospective study included 316 singleton pregnancies with PPROM between 16+0 and 36+6 weeks of gestation. Perinatal and maternal outcomes according to gestational age at the time of PPROM are evaluated. Results: The mean latency duration was 7.5 ± 13.8 days and the incidence of latency ≥15 days was 14.6%. There was a significant negative correlation between the gestational week at diagnosis of PPROM and the duration of the latent period (r = −0.422, P < .001). Incidences of survival were 6.2%, 80.5%, 91.8%, and 100% in pregnancies with an onset of PPROM at 16+0 to 23+6, 24+0 to 27+6, 28+0 to 32+6, and 33+0 to 36+6 weeks’ gestation, respectively. Among the 249 liveborn infants, 4.4%, 3.1% and 1.3% had vision impairment, bronchopulmonary dysplasia, and cerebral palsy respectively at 2 years’ corrected age. Incidences of survival without long-term sequelae were 6.2%, 55.6%, 73.8%, and 100% in pregnancies with an onset of PPROM at 16+0 to 23+6, 24+0 to 27+6, 28+0 to 32+6, and 33+0 to 36+6 weeks’ gestation, respectively. There was a significant negative correlation between chorioamnionitis and gestational age at diagnosis of PPROM (r = −0.173, P = .002). Conclusion: Expectant management if not otherwise contraindicated is the choice of treatment in pregnancies after 24 weeks of gestation, and perinatal survival rates reaching 95% can be achieved with proper management. Cite this article as: Alakbarlı K, Arıca G, Bayraktar E, Alıcı-Davutoğlu E, Madazlı R. Perinatal and maternal outcomes of pregnancies with preterm premature rupture of membranes. Cerrahpaşa Med J. 2025; 49, 0114, doi: 10.5152/cjm.2025.23114.
Rectal Prolapse in 12 Patients Treated by Posterior Prolene Mesh Rectopexy and Sigmoid Colon Resection
Objective: The aim of this study was to evaluate morbidity, mortality, postoperative function, and recurrence in patients treated by posterior prolene mesh rectopexy and sigmoid colon resection for complete rectal prolapse (CRP), focusing on postoperative patient satisfaction, recurrence, and functional outcomes. Methods: In this retrospective study, we evaluated the outcomes of 12 patients treated with posterior prolene mesh rectopexy and sigmoid colon resection between 2018 and 2022. Perioperative data were noted. At follow-up, functional results, patient satisfaction and recurrence were determined. Twelve patients were assessed at a median interval of 32 months. Results: None of the patients developed intraabdominal infections. One patient had postoperative pulmonary emboli, which resolved with medical therapy expressed constipation. All of the patients expressed full satisfaction with the result of the operation in the follow-up period, with a median time of 32 months. Two patients had anterior mucosal prolapsus about 1 cm in forceful straining, 1 patient had gas incontinence from time to time Conclusion: Sigmoid resection with posterior prolene mesh rectopexy appears to be a safe procedure in controlling CRP. Cite this article as: Perek A, Soylu Yalıman S, Yurdanur Kılıç H, Özcan P, Ertürk MS, Durgun AV. Rectal prolapse in 12 patients treated by posterior prolene mesh rectopexy and sigmoid colon resection. Cerrahpaşa Med J. 2025; 49, 0020, doi: 10.5152/cjm.2025.24020.
Evaluation of Pediatric Patients Admitted to the Pediatric Intensive Care Unit with Suspected Central Nervous System Infections
Objective: Central nervous system (CNS) infections, including meningitis and encephalitis, are rare but critical causes of morbidity and mortality, where rapid diagnosis is essential. This study aimed to investigate the clinical and epidemiological characteristics of patients admitted to the pediatric intensive care unit (PICU) with suspected CNS infections. Methods: This retrospective study included all children aged 1 month to 18 years who were admitted to the PICU at Bağcılar Training and Research Hospital with suspected CNS infections between July 2020 and July 2024. Results: A total of 95 patients with suspected CNS infections were included in the study, of whom 61.1% were male. Chronic comorbidities were present in 58% of the patients, with neurological disorders being the most common. CNS infections were confirmed in 37.9% (36/95) of the cases. Among those with confirmed CNS infections, ventriculoperitoneal shunt (VPS) infections accounted for 47.2%, bacterial meningitis for 41.7%, herpes simplex virus (HSV) encephalitis for 5.6%, and other viral encephalitis for 5.6%. The overall mortality rate was 23.2% (22/95). Furthermore, the initial Pediatric Glasgow Coma Score (pGCS) demonstrated a strong predictive value for mortality in the ROC analysis (AUC: 0.828, P < .001), showing better predictive ability than the Pediatric Risk of Mortality III score. Conclusions: CNS infections remain a significant cause of mortality in children. VPS infections, particularly in patients with predisposing neurological conditions, have emerged as a notable etiology of CNS infections in PICUs. Additionally, it is proposed that the initial pGCS score serves as a reliable predictor of mortality in patients with suspected CNS infections. Cite this article as: Özel A, Yüce S, Şengenç E, et al. Evaluation of pediatric patients admitted to the pediatric intensive care unit with suspected central nervous system infections. Cerrahpaşa Med J. 2025, 49, 0004, doi: 10.5152/cjm.2025.25004.
Extrapulmonary Tuberculosis Cases in an Infectious Diseases Department
Objective: Tuberculosis (TB) remains a significant public health problem in Türkiye. We aimed to document cases diagnosed as TB while being investigated for fever of unknown origin, meningitis, pleurisy, lymphadenopathy, and other clinical pictures in an infectious diseases department. Methods: We reviewed the records of the Infectious Diseases Department of a Medical Faculty retrospectively and evaluated all patients with Mycobacterium tuberculosis infection hospitalized between January 1989 and October 1998. Results: One hundred eighty-four cases diagnosed as TB were enrolled. Forty-seven percent of the patients were male. Mean age was 30 years (range: 14-76). Extrapulmonary TB was diagnosed in 157 (85%) of the patients. The distribution of the cases was as follows: miliary (27%), lymphadenitis (21%), meningitis (12%), pleural (12%), peritoneal (14%), bone (7%), and other (10%). Pulmonary TB frequency was 15%. Tuberculin skin tests were positive in 85 of 164 patients. The methods of diagnosis were acid-fast smear (60/184), culture (17/184), histology (101/184), and clinical/radiological/therapeutic test (72/184). Conclusion: Extrapulmonary TB is still a persistent problem in Türkiye. This study highlights the unique spectrum of extrapulmonary TB observed in a tertiary care center, with miliary TB being more prevalent than in national and international reports, emphasizing the need to consider departmental focus and patient demographics. Cite this article as: Keskinel İ, Güntürk A. Extrapulmonary tuberculosis cases in an infectious diseases department. Cerrahpaşa Med J 2025; 49, 0023, doi: 10.5152/cjm.2025.24023.
The Effect of Plasma Osmolality on Prognosis in Non-Massive Pulmonary Embolism
Objective: Plasma osmolality provides insight into fluid and electrolyte balance and can serve as a prognostic marker in critically ill patients. There is limited research on the relationship between plasma osmolality and mortality in pulmonary embolism (PE). The potential role of plasma osmolality in predicting mortality in PE patients is examined in this study. Methods: A retrospective analysis was conducted on patients admitted to the chest diseases ward with acute PE. Data on demographics, comorbidities, clinical and laboratory results, in-hospital mortality, and 30-day mortality were collected. Plasma osmolality was calculated using sodium, plasma glucose, and blood urea nitrogen (BUN) levels at admission. Patients were categorized into hyposmolality, normosmolality, and hyperosmolality groups. Results: The study included 226 patients (100 males, 44.2%), aged 23-90 years. In-hospital mortality occurred in 13 patients (5.8%). The mortality rate was significantly higher in patients with a simplified Pulmonary Embolism Severity Index score ≥1 (P = .031). In addition, lower albumin levels (P = .008) and higher BUN (P = .007) and urea levels (P = .005) were significantly associated with in-hospital mortality. No significant differences in D-dimer, creatinine, glucose, sodium, and osmolality levels were observed between patients who were discharged and those who experienced in-hospital mortality. Mortality rates within 30 days did not significantly differ across osmolality groups (P > .05). Conclusion: This study did not find a significant correlation between plasma osmolality and short-term mortality in patients with acute PE. Cite this article as: Eraslan BZ, Kodalak-Cengiz S, İçmeli ÖS, Kiral N, Şener-Cömert S. The effect of plasma osmolality on prognosis in non-massive pulmonary embolism. Cerrahpaşa Med J. 2025; 49, 0050, doi: 10.5152/cjm.2025.24050.
Identification and Macrolide-Lincosamide-Streptogramin B Resistance Phenotypes and Biofilm Formation of CoagulaseNegative Staphylococci Strains Isolated from Bloodstream infections in Türkiye
Objective: This study aimed to determine the species, biofilm formation ability, and macrolide-lincosamidestreptogramin B (MLSB) resistance phenotypes of coagulase-negative staphylococci (CoNS) isolated from blood cultures. Methods: Three hundred CoNS strains isolated from blood samples of patients with bacteremia hospitalized in intensive care units and other services in the hospital between 2020 and 2023 were retrospectively evaluated. Blood cultures were analyzed using the Bactec-9120 system. Strains were identified using MALDI-TOF MS (Bruker Daltonics, Germany). Antimicrobial susceptibilities were determined using the Kirby–Bauer disc diffusion method on Mueller–Hinton agar and evaluated according to EUCAST standards. Biofilm formation was assessed by the Congo Red Agar method. Results: Among isolates, Staphylococcus epidermidis was the most prevalent species (57.6%; P < .05). Methicillin-resistant CoNS isolates (MRCoNS) were determined to be more resistant to antibiotics than methicillin-susceptible CoNS isolates (MSCoNS) (P < .001). None of the isolates were resistant to vancomycin, teicoplanin, and linezolid. A total of 222 MRCoNS isolates were phenotypically categorized as the inducible MLSB, constitutive MLSB, and efflux type resistance were determined in 36%, 9%, and 36% and in 78 MSCoNS isolates 8%, 15%, and 38%, respectively. Methicillin-resistant CoNS exhibited significantly higher biofilm formation rates (77%) compared to methicillin-susceptible isolates (P < .001). Conclusion: The results showed that S. epidermidis is the most common CoNS species isolated in bloodstream infections. Multidrug resistance and increased biofilm formation ability, which come with increasing methicillin resistance, can lead to infections that are difficult to treat. It is important to routinely determine the resistance status of these bacteria for effective antibiotic therapy and prevention of nosocomial infections. Cite this article as: Özdemir S, Aydoğan O, Köksal Çakırlar F. Identification and macrolide-lincosamide-streptogramin B resistance phenotypes and biofilm formation of coagulase-negative staphylococci strains isolated from bloodstream infections in Türkiye. Cerrahpaşa Med J 2025; 49, 0047, doi: 10.5152/cjm.2025.24047.
High-Frequency versus Conventional Spinal Cord Stimulation in Patients with Failed-Back Surgery Syndrome
Objective: Failed-back surgery syndrome (FBSS) is characterized by chronic pain and disability. Spinal cord stimulation (SCS) is a viable treatment option, with conventional SCS (C-SCS) and high-frequency SCS (HF-SCS) being the most common modalities. This study aims to compare the effectiveness of HF-SCS and C-SCS in reducing pain and disability in patients with FBSS. Methods: A total of 23 patients diagnosed with FBSS who had previously undergone either HF-SCS (n = 11) or C-SCS (n = 12) previously were included in this study. Pain intensity and disability were assessed using the Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI) at baseline and at the third, sixth, and 12th months post-implantation. The changes in ODI and VAS observed in both groups were then evaluated. Results: Both HF-SCS and C-SCS were effective in reducing VAS and ODI scores over the 12-month followup period. Notably, HF-SCS demonstrated rapid improvement in VAS scores at the 3-month mark when compared to the C-SCS group (5.1 vs. 6.7, P < .05). Nevertheless, by 12 months, the difference in scores was non-significant. A similar pattern was observed in the ODI scores, which decreased significantly in both groups, with the HF-SCS group exhibiting a faster initial improvement (27 vs. 33, P < .05). At the 12-month mark, the ODI scores were comparable between the 2 groups. Conclusion: This study found that both HF-SCS and C-SCS were effective in reducing pain and disability in patients with FBSS. While HF-SCS offers quicker relief, at 12 months the outcomes are similar between the 2 modalities. These findings suggest both treatment options are feasible for managing FBSS, with the choice of modality potentially guided by patient preferences. Further research is needed to explore the long-term benefits, cost-effectiveness, and patient-reported outcomes of these therapies. Cite this article as: Dilken O, Güner D, Aşık İ. High-frequency versus conventional spinal cord stimulation in patients with failedback surgery syndrome. Cerrahpaşa Med J 2025; 49, 0064, doi: 10.5152/cjm.2025.24064
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Clinical Pathological Outcomes and Survival in Patients Undergoing Surgery for Early Stage Gastric Cancer
Objective: Gastric cancer is the fifth most common cancer worldwide and ranks fourth in cancer-related deaths. Early stage gastric cancer is usually treated with gastrectomy without requiring endoscopic methods or lymph node dissection. This study aims to evaluate the clinicopathological outcomes of early stage gastric cancer among patients undergoing surgery for gastric cancer. Methods: A retrospective analysis was conducted on 340 patients who underwent total or subtotal gastrectomy for gastric cancer at our clinic between February 2007 and September 2019. The clinicopathological features of 32 patients diagnosed with early stage gastric cancer based on histopathological evaluation were analyzed. The final follow-up date was set as December 31, 2022. Results: Early stage gastric cancer was found in 11.3% of all gastric cancer patients. Of these patients, 53.1% were male with a mean age of 61 ± 12 years. The mean tumor size was 2.5 ± 1.4 cm, with no lymph node involvement. Lymphovascular invasion (LVI) and perineural invasion (PNI) were negative in 90.6% of the patients. The mean survival time was 143.6 ± 7.9 months. Conclusion: The clinicopathological outcomes of early stage gastric cancer patients provide promising prognostic insights. The absence of LVI and PNI positively affects the prognosis. The analysis of the 3 deceased patients highlights the impact of high-risk factors. Effective management of postoperative complications can increase morbidity without affecting mortality. Early diagnosis and appropriate surgical treatment in gastric cancer play a critical role in improving long-term survival. These findings emphasize the importance of multidisciplinary approaches and early interventions. Cite this article as: Torun M, Uzun O, Gülmez S, et al. Clinical pathological outcomes and survival in patients undergoing surgery for early stage gastric cancer. Cerrahpaşa Med J 2025; 49, 0052, doi: 10.5152/cjm.2025.24052
Association Between Prognostic Nutritional Index and Clinical Outcomes in Advanced Non-Small Cell Lung Cancer Treated with Immune Checkpoint Inhibitors
Objective: The Prognostic Nutritional Index (PNI), an inflammation-based biomarker derived from serum albumin and lymphocyte count, reflects both nutritional and immunological status. Although widely studied in gastrointestinal malignancies, its prognostic value in non-small cell lung cancer (NSCLC) patients receiving immune checkpoint inhibitors (ICIs) remains insufficiently explored. Methods: A retrospective cohort of 263 patients diagnosed with stage IV non-small-cell lung cancer (NSCLC) who received ICIs (ICIs) between March 2018 and May 2024 at a single tertiary institution was evaluated. The PNI was computed using pre-treatment laboratory data obtained prior to immunotherapy initiation. Patients were categorized into high (≥45.32) and low (<45.32) PNI groups, with the cut-off value determined through receiver operating characteristic (ROC) curve analysis. Survival outcomes were assessed using Kaplan–Meier and Cox regression analyses. Radiological responses were also compared between groups. Results: Patients in the high PNI group demonstrated a markedly prolonged median overall survival (OS) compared to those in the low PNI group (14.17 vs. 6.07 months; log-rank test, P < .001). In multivariate Cox regression analysis, a high PNI was identified as an independent predictor of improved OS (hazard ratio [HR] = 0.48; 95% CI: 0.34-0.67; P < .001). While patients with elevated PNI also exhibited a trend toward longer progression-free survival (6.80 vs. 5.03 months), this finding did not reach statistical significance (P = .14). Radiologic response rates were more favorable in the high PNI group, with higher rates of partial and complete response. Conclusion: Pretreatment PNI is an independent prognostic factor for OS in patients with advanced NSCLC treated with ICIs. Its ease of calculation, low cost, and reflection of host immune-nutritional status support its potential integration into routine clinical practice to refine risk stratification and guide supportive interventions. Cite this article as: Altıntaş YE, Kınıkoğlu O, Işık D, et al. Association between prognostic nutritional index and clinical outcomes in advanced non-small-cell lung cancer treated with immune checkpoint inhibitors. Cerrahpaşa Med J 2025, 49, 0030, doi: 10.5152/ cjm.2025.25030.
Analyzing Methotrexate’s Impact on Oxidative Stress Indicators in Breast Cancer Cells
Objective: Methotrexate (MTX) is one of the most commonly used antiproliferative chemotherapeutic agents. In addition to its antiproliferative effect, MTX may also play a role in the induction of oxidative stress. This study investigates the effects of MTX on cell cytotoxicity and oxidative stress markers (superoxide dismutase [SOD] activity, malondialdehyde [MDA] levels), and total thiol content) in both human healthy breast cells (hTERT-HME1) and human breast cancer cells (MCF-7). Methods: The hTERT-HME1 and MCF-7 cell lines were divided into untreated control and MTX groups. The cell viability assay was carried out using the MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) assay. Superoxide dismutase, MDA, and total thiol levels were measured spectrophotometrically. Results: The effects of MTX on cell viability were observed after treatment of hTERT-HME1 and MCF-7 for 24, 48, and 72 hours. In comparison to MCF-7 cells, hTERT-HME1 cells exhibited increased cell survival and half-maximum inhibitory concentration 50 values after MTX treatment. Methotrexate administration also significantly decreased SOD and total thiol levels and increased MDA levels in both cell types. Conclusion: This study suggests that MTX has high anticancer activity through its effects on cell viability and oxidative stress. However, observation of similar effects in healthy cells requires the development of various combination therapies or targeted drug delivery systems to reduce the side effects of MTX. Cite this article as: Durmuş S, Ergün DD, Gelişgen R, Bakır N, Uzun H. Analyzing methotrexate’s impact on oxidative stress indicators in breast cancer cells. Cerrahpaşa Med J 2025, 49, 0007, doi: 10.5152/cjm.2025.25007.
Investigation of Apurinic/Apyrimidinic Endonuclease 1 Expression Changes in Prostate Cancer
Objective: Prostate cancer, a leading cause of cancer deaths in men, involves genetic alterations and DNA damage. Oxidative stress–induced DNA damage is crucial in its development, necessitating efficient DNA repair mechanisms. Base excision repair (BER), a key pathway, addresses oxidative DNA damage with enzymes like Apurinic/Apyrimidinic Endonuclease 1 (APE1). Recent findings show that altered APE1 expression disrupts BER balance, contributing to genomic instability and cancer progression. This study examines APE1 expression in prostate cancer tissues to clarify its role in cancer development and therapeutic implications. Assessing APE1 expression in prostate cancer may elucidate its role in tumor progression, therapeutic resistance, and genomic instability, offering deeper insights into the mechanistic relevance of the BER pathway in oncogenesis. Methods: A total of 50 male patients diagnosed with prostate cancer were included in this study. Tumor and adjacent normal tissue samples were collected from consecutive male patients who underwent Tru-cut prostate biopsies due to clinical suspicion of prostate cancer, and gene expression levels were analyzed using real-time polymerase chain reaction. Results: The results showed no significant difference in APE1 expression between tumor and normal tissues (P > .05). Clinical factors like smoking, age, diabetes, hypertension, PIRADS, and Gleason scores did not significantly correlate with APE1 expression. However, a statistically significant correlation was observed between PSA levels and APE1 expression (r: 0.287, P = .04). Conclusion: The authors’ findings suggest that while no substantial changes in APE1 expression were observed in prostate cancer tissues, the enzyme’s role in DNA repair remains crucial. Abnormalities in APE1 expression and function can contribute to genomic instability and cancer progression. Future studies with larger sample sizes and standardized methodologies are necessary to better understand the potential role of APE1 as a biomarker and therapeutic target in prostate cancer. Cite this article as: Rouhi V, Habibi S, Baykal Koca S, Köseoğlu H, Güven M. Investigation of apurinic/apyrimidinic endonuclease 1 expression changes in prostate cancer. Cerrahpaşa Med J 2025, 49, 0009, doi: 10.5152/cjm.2025.25009.
Factors Related to 6-Minute Walk Distance in Pulmonary Arterial Hypertension
Objective: The 6-minute walk test is the most commonly used tool for evaluating prognosis in patients with pulmonary arterial hypertension (PAH). This study aims to identify the parameters associated with 6-minute walk distance (6MWD) and its changes over time. Methods: Sixty-three patients diagnosed with PAH or chronic thromboembolic pulmonary hypertension between January 2005 and January 2013 were included in the study. Demographic, clinical, echocardiographic, hemodynamic data, and initial and follow-up 6MWD were recorded. The 6MWD cut-off was determined based on previous studies. Patients were then categorized into groups based on their initial 6MWD: ≥ 332 m or < 332 m. Results: Patients were followed up for 31.56 ± 15.07 months. In those with a 6MWD < 332m, diffusing capacity of the lungs for carbon monoxide (DLCO) (P = .040), estimated glomerular filtration rate (P = .018), and partial arterial oxygen pressure (PaO2) (P = .024) were significantly lower, whereas age (P = .016), right atrial pressure (P = .034), the frequency of pericardial effusion (P = .004), and mortality (P = .020) were significantly higher. Low DLCO was identified as an independent predictor of walking less than 332 meters (P = .048). In the subgroup analysis, among idiopathic PAH (IPAH) patients, DLCO (P = .024) was lower in those with 6MWD < 332 m. In patients with scleroderma-associated PAH (SSc-PAH), systolic pulmonary artery pressure (sPAP) (P = .018), and mean PAP (p = 0.034) were higher in patients with 6MWD < 332 m. When the change in 6MWD (Δ6MWD) was evaluated based on the difference between the initial 6MWD and at the end of the follow-up period, DLCO was lower in the group with a decreased 6MWD (P < .001). Conclusion: The study identified higher DLCO as an independent predictor of 6MWD ≥ 332 m and its improvement over time. In IPAH, 6MWD is more closely associated with DLCO and PaO2, whereas in SScPAH, PAPs play a more significant role. Cite this article as: Yurtseven E, Özcan S, Karadağ B, Öngen HG, Öngen Z. Factors related to 6-minute walk distance in pulmonary arterial hypertension. Cerrahpaşa Med J 2025, 49, 0015, doi: 10.5152/cjm.2025.25015.
Analysis of miR-155 Expression in Prostate Cancer Patients
Objective: Prostate cancer is a major global health issue and the second most common cancer in men. Its pathogenesis involves genetic and epigenetic changes, hormonal imbalances, and environmental factors, with deficiencies in double-strand break repair mechanisms playing a critical role. microRNAs (miRNAs) are small, non-coding RNA molecules that regulate gene expression post-transcriptionally and are implicated in cancer-related processes. Methods: microRNA-155 expression was analyzed in paired tumor and normal tissues from 50 patients with pathologically confirmed prostate cancer (PC) using quantitative reverse transcription polymerase chain reaction (qRT-PCR). In addition, clinical parameters such as age, smoking status, diabetes, hypertension, PIRADS scores, and Gleason scores were evaluated for their potential association with miR-155 expression. Results: No statistically significant difference was observed in miR-155 expression between tumor and normal tissues (P > .05). Moreover, miR-155 levels did not show significant correlation with any of the evaluated clinical factors. Conclusion: These findings suggest that miR-155 may not play a direct role in the development and progression of PC. However, this study contributes to the growing understanding of the relationship between PC, DNA repair mechanisms, and miRNA regulation. Further studies with larger cohorts and standardized methodologies are needed to clarify the potential of miR-155 as a biomarker or therapeutic target in PC. Cite this article as: Habibi S, Rouhi V, Baykal Koca S, Köseoğlu H, Güven M. Analysis of miR-155 expression in prostate cancer patients. Cerrahpaşa Med J 2025, 49, 0008, doi: 10.5152/cjm.2025.25008.
The Nutritional Parameters in Children with Delays in Speech
Objective: This study aimed to examine and compare the data on nutritional parameters in children with specific language impairments. Methods: Children under 5 years of age who presented to the outpatient clinic with isolated speech delay and were diagnosed with a specific language disorder, along with a healthy control group, were evaluated. The hemoglobin, iron, vitamin B12, and vitamin D levels of the patients were recorded after normal values and deficiency limits were determined for each age group. Results: Of the 188 children, 94 were in the control group and 94 were in the patient group. The control group was the same age and gender as the patients. Seventy-one (75.5%) of the patients were male and 23 (24.5%) were female. The mean age was 2.70 ± 0.65; the median age was 2.66 (min-max: 1.50-3.92) years. The mean serum iron levels in the patient group (67.95 ± 41.86 µg/dL) were significantly lower than in the control group (81.59 ± 37.34 µg/dL) (P = .008). B12 deficiency was significantly higher in the patient group (30%) than in the control group (16%) (P = .037). Other nutritional parameters of the patient and control groups were similar. Conclusion: Low iron levels and vitamin B12 deficiency may be effective factors in speech delay. It is important to the nutritional parameters for speech delay and to treat vitamin deficiencies if present. Cite this article as: Sürücü Kara İ, Dolğun İ, Mertoğlu C. The nutritional parameters in children with delays in speech. Cerrahpaşa Med J. 2025, 49, 0065, doi:10.5152/cjm.2025.24065.
Potential of Pramipexole in Attenuating Morphine Dependence: Insights from a Conditioned Place Preference Study in Mice
Objective: Pramipexole, a selective dopamine D2/D3 receptor agonist, has been implicated in modulating dopaminergic transmission in brain reward circuits. Morphine reward-related behaviors are associated with a reduction in dopamine levels in these regions. This study aimed to investigate the effects of pramipexole on morphine dependence in a rodent model, based on the hypothesis that enhancing dopaminergic activity may attenuate opioid dependence. Method: Swiss albino mice with established morphine dependence were assessed using the conditioned place preference (CPP) test. Morphine conditioning was performed with 10 mg/kg morphine (IP) for 8 days. On the ninth day, animals received either 1 mg/kg or 4 mg/kg pramipexole (IP), and CPP expression was evaluated 30 minutes post-administration. Results: Pramipexole (1-4 mg/kg) significantly reduced morphine-induced CPP expression by 9%-14% (P < .05 to .01). No significant dose-dependent differences were observed, indicating a potential ceiling effect. Conclusion: These findings indicate that pramipexole, a dopamine D2/D3 receptor agonist, attenuates morphine dependence-related behaviors. Pramipexole may represent a potential pharmacotherapeutic candidate for opioid dependence, warranting further investigation in preclinical and clinical settings. Cite this article as: Shahzadi A, Yunusoğlu O, Alhakim M, Gökdemir S, Ateşoğlu RR. Potential of pramipexole in attenuating morphine dependence: Insights from a conditioned place preference study in mice. Cerrahpaşa Med J 2025, 49, 0020, doi: 10.5152/ cjm.2025.25020.
Candida Spondylodiscitis: Diagnostic Dilemmas and Treatment Strategies
Spondylodiscitis is a serious and potentially life-threatening infection that affects the vertebrae and intervertebral discs. Candida spp. is a fungus that normally exists as a commensal organism in the human body but can become an opportunistic pathogen in individuals with weakened immune systems. Risk factors such as immunodeficiency, prolonged antibiotic use, intravenous drug use, diabetes, and alcohol dependency can contribute to the development of fungal spondylodiscitis. Fungal spondylodiscitis has a more insidious onset and presents with more ambiguous symptoms compared to bacterial cases, which can lead to delays in diagnosis and treatment. Patients typically present to the clinic with non-specific symptoms such as back pain, limited mobility, and sometimes fever. Because laboratory findings are generally non-specific, magnetic resonance imaging is considered an effective method for diagnosis. Definitive diagnosis typically relies on biopsy and culture results; however, cultures may be negative, and situations where biopsy is not always feasible make diagnosis more challenging. Conservative treatment is the gold standard; however, surgery can be performed when necessary. A multidisciplinary approach and individualized treatment plans are critically important in enhancing the effectiveness of therapy. In conclusion, Candida spondylodiscitis is a rare but severe infection. Mortality and morbidity rates can be reduced with early diagnosis and appropriate treatment strategies. In clinical practice, the possibility of fungal infection should not be overlooked, especially in patients with risk factors and should be actively investigated during the diagnostic process. This article aims to contribute to a better understanding of spondylodiscitis caused by Candida spp. Cite this article as: Kılınç T, Yıldız Kaya S, Mete B, Tabak F. Candida spondylodiscitis: diagnostic dilemmas and treatment strategies. Cerrahpaşa Med J 2025; 49, 0071, doi: 10.5152/cjm.2025.24071.
Surgical Management of Hepatocellular Carcinoma
Abstract Hepatocellular carcinoma (HCC) is a common primary liver tumor that often develops after chronic liver disease. Main risk factors include hepatitis B and C, alcoholic liver disease, and non-alcoholic steatohepatitis. Despite advances in technology in prevention, incidence and mortality due to HCC continue to rise. Various screening and diagnostic modalities exist, and diagnosis can be established without the need for pathological examination. In the management of HCC, a thorough evaluation of hepatic function is crucial, and various treatment options are available that can be potentially curative. A patient-tailored approach is established in the management of HCC since there are different treatment modalities. These include radiofrequency ablation, transarterial chemoembolization, cryoablation, microwave ablation, radiotherapy, and chemotherapy. Different surgical techniques such as anatomical and non-anatomical resection can also be performed. Although nonsurgical approaches can be used for certain tumors, surgery is often curative, and various classification systems can be used to stratify patients in order to choose a treatment option that is best suited for them. Cite this article as: Erginöz E, Dulundu E. Surgical management of hepatocellular carcinoma. Cerrahpaşa Med J 2025; 49, 0038, doi: 10.5152/cjm.2025.24038
Rectal Prolapse Surgery: What To Do, How To Do
Complete rectal prolapse is a full-thickness protrusion of the rectal wall through the anus. Surgery is indicated for third-degree prolapse, with a variety of surgical techniques available. This review aims to summarize the most commonly used surgical procedures for rectal prolapse and evaluate their advantages and disadvantages. A narrative review of the literature was conducted, focusing on various surgical techniques such as rectopexy, sigmoid resection, and perineal approaches. Data on surgical outcomes, recurrence rates, and complications were extracted and compared. Different surgical techniques show variable success rates. Abdominal procedures such as rectopexy generally have lower recurrence rates but may be associated with longer recovery times. Perineal approaches offer lower morbidity but higher recurrence. The choice of procedure should be individualized, considering patient factors such as age, comorbidities, and surgical risk. Abdominal approaches are favored in younger, fit patients, while perineal procedures may be appropriate for elderly or high-risk individuals. Cite this article as: Asiye P, Selen YS. Rectal prolapse surgery: what to do, how to do. Cerrahpaşa Med J. 2025; 49, 0019, doi:10.5152/cjm.2025.24019
A Case of Fever of Unknown Origin “The Clinical Case Series of Cerrahpaşa”
Cite this article as: Kaya SY, Fansa S, Asa S, Özdede A, Seyahi E, Tabak F. A case of fever of unknown origin: “the clinical case series of Cerrahpaşa”. Cerrahpaşa Med J. 2025; 49, 0026, doi: 10.5152/cjm.2025.24026.
A Patient with Arterial Thoracic Outlet Syndrome Relieved by a Calcium Channel Blocker
Cite this article as: Şenel GB. A patient with arterial thoracic outlet syndrome relieved by a calcium channel blocker. Cerrahpaşa Med J 2025, 49, 0073, doi: 10.5152/cjm.2024.24073
The Use of High-Dose Omalizumab in the Treatment of Resistant Chronic Urticaria: A Case Series
Cite this article as: Ferhatoğlu ZA, Uzunçakmak TK, Mutlu G. The use of high-dose omalizumab in the treatment of resistant chronic urticaria: a case series. Cerrahpaşa Med J. 2025, 49, 0012, doi: 10.5152/cjm.2025.25012
Case of a Rarely Encountered Membranoproliferative Glomerulonephritis:Hepatitis C Associated Cryoglobulinemic Vasculitis
Cite this article as: Tanış G, Dinçer MT, Ak T, et al. Case of a rarely encountered membranoproliferative glomerulonephritis: hepatitis C-associated cryoglobulinemic vasculitis. Cerrahpaşa Med J 2025; 49, 0033, doi:10.5152/cjm.2025.24033
A Young Man with Multiple Skin Lesions on a Positron Emission Tomography-Computed Tomography Scan
Cite this article as: Gur MB, Toker Dincer Z, Melikoglu M, Seyahi E. A young man with multiple skin lesions on a PET-CT scan. Cerrahpaşa Med J 2025, 49, 0070, doi: 10.5152/cjm.2025.24070.