Comparison of refugee patients with cystic fibrosis and their counterpart children from Turkey during the war

Since the outbreak of the Syrian civil war in 2011, the population of Arab refugees in Turkey has rapidly increased. While cystic fibrosis (CF) is believed to be rare among Arabs, recent studies suggest it is underdiagnosed. This study aims to present the demographic, clinical, and genetic characteristics of CF patients among Arab refugees in Turkey. Additionally, a comparison is made between the findings in the National CF Registry 2021 in Turkey (NCFRT) and the refugee CF patient group. The study included refugee patients between the ages of 0 and 18 years who were diagnosed with CF and received ongoing care at pediatric pulmonology centers from March 2011 to March 2021. The study examined demographic information, age at diagnosis, age of diagnosis of patients through CF newborn screening (NBS), presenting symptoms, CF transmembrane conductance regulator (CFTR) mutation test results, sputum culture results, weight, height, and body mass index (BMI) z score. Their results were compared with the NCFRT results. The study included 14 pediatric pulmonology centers and 87 patients, consisting of 46 (52.9%) boys and 41 (47.1%) girls. All of the patients were Arab refugees, with 80 (92%) being Syrian. All the patients were diagnosed in Turkey. The median age at diagnosis of patients was 22.33 (interquartile range, 1-258) months. The median age of diagnosis of patients through NBS was 4.2 (interquartile range, 1-12) months. The median age of older patients, who were unable to be included in the NBS program, was 32.3 (interquartile range, 3-258) months. Parental consanguinity was observed in 52 (59.7%) patients. The mutation that was most frequently found was F508del, which accounted for 22.2% of the cases. It was present in 20 patients, constituting 32 out of the total 144 alleles. There was a large number of genetic variations. CFTR genotyping could not be conducted for 12 patients. These patients had high sweat tests, and their genetic mutations could not be determined due to a lack of data. Compared to NCFRT, refugee patients were diagnosed later, and long-term follow-up of refugee CF patients had significantly worse nutritional status and pseudomonas colonization.  Conclusion: Although refugee CF patients have equal access to NBS programs and CF medications as well as Turkish patients, the median age at diagnosis of patients, the median age of diagnosis of patients through NBS, their nutritional status, and Pseudomonas colonization were significantly worse than Turkish patients, which may be related to the difficulties of living in another country and poor living conditions. The high genetic heterogeneity and rare mutations detected in the refugee patient group compared to Turkish patients. Well-programmed NBS programs, thorough genetic studies, and the enhancement of living conditions for refugee patients in the countries they relocate to can have several advantages such as early detection and improved prognosis. What is Known: • Children who have chronic diseases are the group that is most affected by wars. • The outcome gets better with early diagnosis and treatment in patients with Cystic Fibrosis (CF). What is New: • Through the implementation of a newborn screening program, which has never been done in Syria previously, refugee patients, the majority of whom are Syrians were diagnosed with cystic fibrosis within a duration of 4 months. • Despite equal access to the newborn screening program and CF medications for both Turkish patients and refugee patients, the challenges of living in a foreign country have an impact on refugees.

Neutrophil lymphocyte ratio, mean platelet volume, and immunoreactive trypsinogen as early inflammatory biomarkers for cystic fibrosis in infancy: A retrospective cohort study

BACKGROUND

Airway inflammation starts in early life in cystic fibrosis (CF) and limited, objective markers are available to help identify infants with increased inflammation. We aimed to investigate neutrophil, lymphocyte ratio (NLR), mean platelet volume (MPV) and immunoreactive trypsinogen (IRT) to be a possible inflammatory biomarker for CF in infancy.

METHODS

This was a retrospective cohort study in three centers. Between January 2015 and December 2022, children with CF newborn screening (NBS) positivity and diagnosed as CF were included in the study. Correlation analysis were performed with NLR, MPV, IRT and follow-up parameters such as z-scores, modified Shwachman-Kulczycki score (mSKS) at the first, second, third and sixth ages and pulmonary function test (PFT) at the sixth age.

RESULTS

A total of 92 children with CF included in the study and 47.8% of them were female. There were no correlations between NLR, MPV and weight and height z-scores for all ages (p > 0.05), a negative correlation was found between MPV and body mass indexes (BMI) z-score at the age of 6 (r = -0.443, p = 0.038). No correlation was found between NLR, MPV and PFT parameters and mSKS at all ages (p > 0.05). There was a negative correlation between first IRT and BMI z-score at 6 years of age (r = -0.381, p = 0.046) and negative correlations between second IRT and weight and BMI z-score at the age of 6 (r = -0.462, p = 0.010; r = -0.437, p = 0.016, respectively).

CONCLUSION

Higher MPV and IRT levels during NBS period are associated with worse nutritional outcome which may reflect chronic inflammation. Children with higher MPV and IRT should be followed up closely in terms of chronic inflammation and nutritional status.

Childhood sarcoidosis in the middle Anatolia of Turkey

OBJECTIVE

This retrospective study aimed to describe the clinical and radiological features, diagnostic methods, laboratory findings, organ involvement, and treatment strategies of 22 patients who followed up with late-onset childhood sarcoidosis and compare them with the literature.

MATERIAL AND METHOD

This retrospective multicenter study reviewed the medical records of 22 children with sarcoidosis who applied to the Pediatric pulmonology department of Erciyes University Faculty of Medicine and Necmettin Erbakan Faculty of Medicine in 2012 and 2022.

RESULTS

The mean age of the patients at the time of diagnosis was 13.1/year (interquartile range [IQR]1:6.3-[IQR]3:15.7). The most common first presenting symptom was cough 40.9% (n = 9), weight loss 31.8% (n = 7), and dyspnea 22.7% (n = 5). There were elevated levels of C-reactive protein (CRP; 59%), angiotensin-converting enzyme (ACE; 54.5%), erythrocyte sedimentation rate (ESR; 54.5%), and immunoglobulin G (IgG; 54.5%). Twenty patients (90%) received systemic steroid treatment. Eighteen (81.8%) of these patients responded positively to treatment. Two patients had a recurrence.

CONCLUSION

The incidence of sarcoidosis in children in Turkey is currently unknown. However, a regional average of 2.2 cases per year has been documented for the first time. Contrary to previous studies, a significant prevalence of consanguineous marriage was observed in our study. While constitutional symptoms were most common in other studies, the cough was the most common symptom in our study. To our knowledge, this is one of the Turkish studies with the highest number of sarcoidosis in children and one of the few European studies on sarcoidosis in children.

Effects of smoking on controlled hypotension with nitroglycerin during ear-nose-throat surgery

Background and Aim

In this study, the aim was to research the effects of smoking habits on controlled hypotension administered with nitroglycerin during ear-nose-throat surgery.

Materials and Methods

This study administered controlled hypotension with nitroglycerin and total intravenous anesthesia to a total of 80 patients undergoing septoplasty operations. The patients were divided into two groups of 40 non-smokers (Group 1) and 40 smokers (Group 2). Intravenous propofol infusion was used for anesthesia maintenance. Nitroglycerin with 0.25-1 μg/kg/min dose was titrated to provide controlled hypotension. During this process, the hemodynamic parameters of patients, total propofol and nitroglycerin amounts used, operation duration, and duration of controlled hypotension were recorded at the end of the operation. At the end of the operation, the surgeon assessed the lack of blood in the surgical field with Fromme Scale.

Results

Fromme scale values were significantly higher in Group 2 compared to Group 1. The MAP values at 10, 20, 30 min, and end of operation were lower, while 10- and 20-min heart rate values were higher in Group 2 compared to Group 1.

Conclusion

Nitroglycerin, chosen for controlled hypotension to reduce hemorrhage in the surgical field during nasal surgery, was shown to cause more pronounced hypotension and reflex tachycardia due to endothelial dysfunction linked to nicotine in patients who smoke. Despite lower pressure values in the smoking group, the negative effects of nicotine on platelet functions combined with similar effects of nitroglycerin to increase bleeding amounts.

Effects of age and comorbidities on prognosis and mortality in geriatric patient groups in ıntensive Care

Backround

Treatment of geriatric intensive care patients is tiring and difficult for intensive care physicians due to comorbidities, accompanying acute illnesses and vulnerabilities.

Aim

The aim of our study was to determine other factors affecting mortality and morbidity with age in geriatric intensive care patients.

Patients and Methods

A total of 937 geriatric intensive care patients were divided into three groups as young-old (65-74 years), middle-old (75-84 years), and oldest-old (85 years and more). Demographic characteristics such as age, gender, and comorbid diseases (oncological malignancy, chronic renal failure, sepsis, chronic anemia, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, pulmonary embolism) were recorded. The number of patients who needed a mechanical ventilator, developed decubit ulcers, underwent percutaneous tracheostomy, and renal replacement therapy were recorded. In addition, the number of central venous catheter insertions for patients, Acute Physiology and Chronic Health Evaluation II scores (APACHE II), hospitalization days, and mortality rates were recorded and compared.

Results

In the comparison between the groups in terms of gender, in the 65-74 years' age group, male gender was higher, while in the age group of 85 years and more, the female gender was found to be statistically higher. Among comorbid diseases, the rate of oncological malignancy was found to be statistically significantly lower in patients aged 85 years and more. Comparing the APACHE II scores of the patients as per the groups, scores were found to be statistically significantly higher in the oldest-old group. APACHE II Score, central venous catheter application, chronic obstructive pulmonary disease, chronic renal failure, sepsis, oncological malignancy, and renal replacement therapy were shown to be statistically significant as factors affecting death. The factors affecting the survival or hospitalization time of the patients of decubit ulcer, mechanical ventilator, percutaneous tracheostomy, chronic obstructive pulmonary disease, Sepsis, APACHE II Score, and age were shown to be statistically significant.

Conclusion

Our study showed that not only age has an effect on mortality and morbidity in geriatric intensive care patients but also comorbidities and intensive care treatments of the patients are also effective in this process.

Pulmonary Embolism in Childhood: A Multicenter Experience from Turkey

Background:

Pulmonary embolism is a clinical condition caused by the obstruction of the pulmonary artery and its branches with endogenous, exogenous embolism, or local thrombus formation. It is a rare but potentially life-threatening event in the pediatric population. Pediatric pulmonary embolism has many unknown characteristics.

Aims:

To evaluate clinical features, genetic and acquired risk factors, diagnostic imaging, and treatment strategies with long-term results in children with pulmonary embolism.

Study Design:

A retrospective multicenter clinical trial.

Methods:

Patients aged 0-18 years who were diagnosed with pulmonary embolism with computed tomography pulmonary angiography (CTPA) findings (intraluminal filling defect in the lobar or main pulmonary artery) in 3 university hospitals between 2006 and 2021 were included in the study. A form was created for data standardization, and variables were collected retrospectively through medical record review. In addition to the features given above, we also evaluated in situ pulmonary artery thrombosis (ISPAT) and patients’ Wells scores. Follow-up CTPA results were evaluated for patient response to treatment. Complete recovery means that there were no lesions, incomplete recovery if there was still embolism, and no response if there was no change.

Results:

Twenty-four patients (female:13, male:11) were included in the study. The mean age was 13.5 years. All patients but one had at least one or more genetic or acquired risk factors. Factor V Leiden mutation (16.6%) was the most common genetic risk factor. Six of 16 patients with Doppler ultrasonography were diagnosed with ISPAT because there was no sign of thromboembolic thrombosis. Nine (41.6%) patients had a Wells score of >4 (pulmonary embolism clinically strong), and 15 (58.4%) patients scored <4 (pulmonary embolism clinically likely weak), indicating that an alternative diagnosis was more likely than pulmonary embolism (sensitivity %37.5). The mean follow-up period was 23 (±17) months. Complete and incomplete recovery was observed in 15 (62.5%) and 7 (29.1%) patients, respectively, among the patients who underwent follow-up evaluation. No response was obtained in 2 patients (8.3%) who died.

Conclusion:

The Wells scoring system seems insufficient to diagnose pulmonary embolism in children and should be improved by adding new parameters. ISPAT may be more common in children with congenital heart disease and systemic disease.

Assessment of quality attributes of hybrids developed from pure lines of cherry and cocktail-type tomatoes

Tomato is worldwide the most grown vegetable. The primary target of breeding programs is to develop new tomato cultivars that are resistant to pests and diseases, in combination with high quality and yield, well-adaptation and good firmness. Among the different tomato types, cherry and cocktail tomatoes are widely preferred by consumers due to their better taste and appearance. In this study, two female tester lines were crossed with four male lines to obtain new tomato hybrids. The eight F1 hybrids and two commercial hybrids were planted in a randomised complete block design with two replications in a greenhouse in Antalya. The tomatoes of the hybrids and lines were harvested at fully ripened stage to evaluate yield, total soluble solids (TSS), fruit firmness, lycopene content and fruit colour parameters. TSS values of the cultivars and lines ranged from 4.5 to 9.5 °Bx, fruit firmness from 7.94 to 11.85 kg cm−2, lycopene from 52.10 to 55.88 mg kg−1, yield from 554.3 to 1336.7 g/plant. Hybrid AK0020 was found the best for both yield and quality.

SAT0200 RISK FACTORS FOR ADVERSE PREGNANCY OUTCOMES IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS

Background:

Pregnancies of patients with systemic lupus erythematosus (SLE) can be risky both for the mother and the fetus because of disease activity and pregnancy complications.1

Objectives:

In this study, we evaluated the risk factors related to adverse pregnancy outcomes (APO) in our pregnant SLE cohort who were followed up by both Rheumatology and Obstetrics and Gynecology departments at our university.

Methods:

168 pregnancy data were analyzed from 136 patients who fulfilled ACR classification criteria for SLE. The course of pregnancies were monitored and fetal/neonatal outcomes were recorded. Unexplained fetal death after 12 weeks of gestation, neonatal death, preterm birth due to preeclampsia, eclampsia or HELLP and birth of small for gestational age (SGA) infant were defined as APO. Cumulative clinical, laboratory and serological findings, disease activity (SLEDAI-2K) and damage (SLICC/ACR), and conventional risk factors were compared between APO(+) and APO(-) groups.

Results:

The comparison of demographics, conventional risk factors and disease characteristics in APO(+) and APO(-) groups are summarized in Table-1. In APO(+) pregnancies, the duration of disease was longer (p <0.05) and the frequency of chronic hypertension was higher (p <0.05) compared to APO(-) pregnancies. Renal and neuropsychiatric (NP) involvement, thrombocytopenia, antiphospholipid syndrome (APS), lupus anticoagulant and anti-cardiolipin IgM positivity were significantly higher in APO(+) group. Mean SLEDAI-2K scores of three trimesters and postpartum 6 months were higher in APO(+) patients compared to APO(-) patients (2.2 ± 3.6 vs 1.2 ± 2.04, p <0.05; 4.9 ± 6.03 vs 2.7 ± 5.01, p = 0.02, respectively). Percentage of patients with damage at the beginning of pregnancy and the mean SLICC damage score were significantly higher in APO(+) group compared to APO(-) group (1.8 ± 2.1 vs 0.8 ± 1.3, p <0.05). In APO(+) group, damage was significantly higher in neuropsychiatric, renal and cardiovascular and locomotor systems (p <0.05).

Conclusion:

Although an important proportion of SLE pregnancies result in live birth, active disease, especially renal and NP involvement, and presence of damage at the beginning of pregnancy increase the risk of maternal and fetal complications. Furthermore, the presence of APS or antiphospholipid antibody positivity are important risk factors for obstetric complications. In conclusion, pregnancy should be allowed after controlling the disease activity and patients should be closely monitored in coordination with Obstetrics and Gynecology clinics. In case of presence of damage, both the patient and the physician should be aware of a possible adverse pregnancy outcome.

References:

[1]Ann Intern Med. 2015 August 4; 163(3): 153–163. doi:10.7326/M14-2235.

Table 1.

Demographic data of APO (+) and APO (-) groups, comparison of conventional risk factors, cumulative clinical, serological and laboratory features

APO(-)(n=111)APO (+)(n=57)pAge35.1±6.734.9±5.9NSAge at conception30.6±5.628.9±4.2NSDisease duration (months)141.6±70166.9±87.9<0.05Chronic hypertension, n (%)6 (7)11 (19.6)<0.05Photosensitivity, n (%)86 (77.5)43 (75.4)NSMalar rash, n (%)66 (59.5)38 (66.7)NSOral ulcer, n (%)11 (9,9)6 (10.5)NSArthritis, n (%)77 (59.4)42 (73.7)NSSerositis, n (%)17 (15.3)13 (22.8)NSRenal, n (%)39 (35.1)30 (52.6)<0.05Hematologic, n (%)78 (70.3)40 (70.2)NSThrombocytopenia, n (%)37 (33.3)30 (52.6)<0.05AIHA, n (%)16 (14.4)14 (24.6)NSNeurologic, n (%)7 (6.3)9 (15.8)<0.05Anti-cardiolipin IgG, n(%)28 (25.2)18 (32.1)NSAnti-cardiolipin IgM, n (%)18 (16.2)18 (32.1)<0.05Lupus anticoagulant, n (%)26 (23.4)28 (49.1)<0.001Antiphospholipid syndrome, n (%)28 (25.2)30 (52.6)<0.001

(NS=not significant, APO=adverse pregnancy outcome, AIHA=autoimmune hemolytic anemia)

Disclosure of Interests: :

None declared

Association Between Resistance to Cinacalcet and Parathyroid Gland Hyperplasia in Kidney Transplant Recipients with Persistent Hypercalcemia

BACKGROUND

Persistent hypercalcemia and hyperparathyroidism after successful kidney transplantation can be detrimental in some recipients and should be ameliorated.

OBJECTIVE

To point out the concerns regarding resistance to cinacalcet in kidney transplant recipients with persistent hypercalcemia.

METHODS

14 renal transplant recipients who received cinacalcet treatment because of persistent hypercalcemia were included in the study. Serum creatinine, estimated glomerular filtration rate (eGFR), calcium, phosphorus, and intact parathyroid hormone (PTH) levels at the baseline and throughout the treatment, and ultrasonography and parathyroid scintigraphy findings were recorded.

RESULTS

Cinacalcet treatment was initiated after a mean±SD of 20.7±19.7 months of transplantation and maintained for 16.9±7.9 months. Serum calcium levels were significantly decreased with the cinacalcet treatment. There were no significant changes in serum creatinine, eGFR, phosphorus, and PTH levels. In all participants, serum calcium levels were increased from 9.8±0.6 to 11.1±0.6 mg/dL (p<0.001) within 1 month of cessation of cinacalcet. 7 recipients with adenoma-like hyperplastic glands underwent parathyroidectomy (PTx) due to failure with cinacalcet.

CONCLUSION

Cinacalcet may be an appropriate treatment for a group of recipients with hypercalcemia without adenoma-like hyperplastic glands or who had a contraindication for surgery. Recipients with enlarged parathyroid gland may resist to cinacalcet-induced decrease in serum PTH, although the concomitant hypercalcemia may be corrected.

Transplantation Opportunities of Hepatitis C Virus-Seropositive Patients on the Kidney Waiting List

OBJECTIVE

Besides severe organ shortage, hepatitis C virus (HCV) infection is an important obstacle for kidney transplantation because of long waiting times on deceased kidney donor waiting lists. We aimed to evaluate calling number of candidates according to HCV serology.

METHOD

A total of 404 adults on the deceased donor waiting list invited for cadaveric transplantation was evaluated. Demographic data, waiting time, calling number for transplantation, and viral serology were obtained during the 6-year period.

RESULTS

Mean waiting duration and calling number of all patients were 42.7 ± 34 months and 1.56 ± 4.37 times, respectively. Twenty-six candidates had chronic HCV infection and 12 of 26 were HCV RNA-positive. Mean waiting duration and calling number in anti-HCV-positive candidates were significantly higher compared with anti-HCV-negative candidates (85.3 ± 38.8 vs 39.8 ± 31.6 months, and 10.8 ± 10.3 vs 0.92 ± 2.6 times, respectively; P < .001). Mean waiting duration and total calling number in HCV-RNA-positive candidates were significantly higher than in HCV-RNA-negative ones (107.5 ± 7.5 vs 66.2 ± 44.8 months; P = .018; 15 ± 9.7 vs 7.3 ± 9.8 times, respectively; P = .026).

CONCLUSIONS

Chronic HCV infection is an important issue leading to longer waiting time on the list. Our observation showed that waiting durations of anti-HCV-positive candidates were longer than that of negative patients, although they had more frequent opportunity for transplantation.

Gabapentin pretreatment for propofol and rocuronium injection pain: A randomized, double-blind, placebo-controlled study

AIM

This prospectively-planned, randomized, double-blind and placebo-controlled study aims to evaluate the effect of 1200 mg gabapentin premedication on the incidence and severity of propofol and rocuronium injection pain.

METHOD

One hundred patients, between 18-60 years of age and ASA I-II for elective surgery planned under general anaesthetic, were randomized and divided into two groups. Two hours before the operation, the patients were given either a placebo tablet (Group P, n = 50) or 1200 mg gabapentin tablet (Group G, n = 50). On the back of the non-dominant hand, a vein was opened using a 20 G cannula , 0.9% NaCl was begun and preoxygenation was provided. For anaesthesia induction, 1% propofol at 800 ml/hr infusion rate was administered for 20 s. Propofol injection pain was evaluated up to the 20th second and recorded using a scale between 0 and 3 developed by McCrirrick and HunteR The remaining propofol dose (2.5 mg/kg), 5 ml saline and 0.6 mg/kg rocuronium were injected in that order over 10 seconds and rocuronium injection pain response was evaluated with a four point scale.

RESULTS

Pain after propofol infusion average score (degree ≥ 1) (Group G = 0.5; Group P = 1.0) and incidence (Group G = 46%; Group P = 68%); and average withdrawal movements response score linked to rocuronium injection pain (≥ 1 response) (Group G = 0.3; Group P = 1.2) and incidence (Group G = 20%; Group P = 80%) were detected to be significantly lower in the gabapentin group compared to the placebo group (p < 0.001).

CONCLUSION

Premedication with 1200 mg gabapentin 2 hours before propofol and rocuronium injection reduced the incidence and severity of injection pain.

Aspergillosis osteomyelitis and joint infection in a renal transplant recipient

Invasive Aspergillosis occurs in almost every human organ, most commonly in the lungs. Bone involvement classically has been considered exceedingly rare for both immunocompromised and immunocompetent hosts, however, there are limited data in transplant recipients. We report an unusual case of osteomyelitis and joint infection of the ankle caused by Aspergillus fumigatus in a renal transplant recipient.

Arterial elasticity measurement in renal transplant recipients

Arterial distensibility is reduced in chronic kidney disease (CKD) and after kidney transplantation. Pulse counter analysis provides an assessment of compliance or elasticity of the large conduit arteries (C1) and small arteries (C2). Decreased compliance has been shown to be predictive of primary coronary events in CKD patients. The aim of the present study was to compare elasticity measurements in hemodialysis (HD) patients, renal transplant recipients (RTR), and healthy subjects whose coronary angiographies were without lesion. Twenty-three RTRs, 18 HD patients, and 20 healthy subjects were included in the study. Pulse wave analysis was used to determine large and small vessel compliances. The C1 and C2 levels were significantly lower in HD patients compared with recipients and healthy subjects. Recipients showed lower C2 level compared with healthy subjects. There was no difference in C1 and C2 measurements between recipients receiving tacrolimus versus cyclosporine. Transplantation improves large and to some extend small artery elasticities in CKD patients.

Primary central nervous system lymphoma in a renal transplant recipient with Bardet-Biedl syndrome

Bardet-Biedl syndrome (BBS) is a rare autosomal recessive disorder. End-stage renal failure has been reported as the most frequent cause of death in this disorder. There are few reports of kidney transplantation in these patients. Renal transplant patients are known to be at increased risk for the development of malignancies. Although a few patients with BBS have been described to develop malignant disease, there was no previous association with lymphoma. We report a 20-year-old patient in whom primary central nervous system lymphoma was diagnosed 20 months after renal transplantation.

Efficacy of sildenafil in male dialysis patients with erectile dysfunction unresponsive to erythropoietin and/or testosterone treatments

The aim of this study was to evaluate the effects of recombinant human erythropoietin (Epo), testosterone (T) or a combination of them in the treatment of erectile dysfunction (ED) in hemodialysis patients, as well as the efficacy of sildenafil in patients unresponsive to combination treatment. A total of 23 patients with ED were divided into two groups. The international index of erectile function (IIEF) was used to evaluate ED and treatment response. Patients received Epo or T treatments for 12 weeks. Later on both groups received combination treatment for another 12 weeks. Although IIEF scores increased significantly in both groups after the combination treatment, the score changes were similar. After combination treatment, 16 patients still having IIEF score <26 were given sildenafil treatment in combination with Epo while T was discontinued. Although the IIEF scores increased significantly in all patients (17.4%), only eight of them attained an IIEF score of > or =26. The baseline IIEF scores of the patients with satisfactory response to the sildenafil treatment were higher than those with unsatisfactory response. The patients with a score of > or =22 responded better to the treatment. Although Epo and/or T therapies could partially improve ED in male dialysis patients besides correcting renal anemia and hypogonadism, sildenafil treatment could improve ED in unresponsive patients. Especially, those with higher baseline IIEF scores benefited more.

Effects of pentylenetetrazole-induced status epilepticus on behavior, emotional memory and learning in immature rats

Status epilepticus (SE) can be harmful to the developing brain. Our knowledge of the emotional and behavioral consequences of generalized SE in developing animals remains limited. Therefore, we investigated the short- and long-term effects of pentylenetetrazole (PTZ)-induced SE on emotional memory and learning and behavioral parameters in immature rats. SE was induced in 16- to 20-day-old rats (P16-P20) using intraperitoneal injections of PTZ (n=21); control rats received saline (n=10). All animals were tested using an elevated T-maze and open-field test 2, 14, 30, and 180 days after SE, to evaluate emotional memory and learning and behavior. Anxiety levels decreased 2 and 14 days after SE, and conditioned learning of PTZ-treated immature rats was better than that of the control rats. These results indicate that a decreased anxiety level facilitates conditioned learning. Behavioral changes are transient, and no emotional memory or learning deficits occur following PTZ-induced SE in immature rats.

An Unusual Cause of Ureteral Obstruction in a Renal Transplant Recipient: Ureteric Aspergilloma

Mycotic infections in various organ transplant recipients represent severe and often fatal complications. Aspergillosis isolated from the urinary tract occurs quite infrequently in renal transplant recipients. Besides, fungus balls are rare causes of ureteral obstruction. We report a 51-year-old patient with the diagnosis of ureteral obstruction caused by aspergillosis in the early post-renal transplant period, who unfortunately died with the clinical picture of disseminated infection and its complications.

Anemia Due to Losartan in Hypertensive Renal Transplant Recipients Without Posttransplant Erythrocytosis

Losartan is a safe, effective long-term treatment for hypertension or posttransplant erythrocytosis (PTE) in renal transplant recipients. There were only a few studies in patients without PTE and their results were different. Starting from week 6 and continuing to the week 12 we observed a decrease in hemoglobin (Hb) and hematocrit (Hct) levels in patients without PTE. Anemia developed in 42.8% of the patients, and Hb levels increased after the withdrawal of losartan treatment. There was a significant decrease in Hct levels beginning from week 3 when compared with the control group. Our study suggests that losartan therapy can decrease Hb beyond its antihypertensive efficacy. Based on the capacity of losartan to decrease Hb and Hct, this drug should be carefully used in patients with preexistent anemia or low Hb levels.

Aspergillus pneumonia in renal transplant recipients at a medical center in Turkey

Pulmonary aspergillosis is a devastating disease. Early diagnosis allowing early treatment may improve the prognosis. However, this goal remains difficult to achieve. When the diagnosis is confirmed, it is often already too late. Despite antifungal treatment, the mortality rate is high. Patients with immunosuppression show a high mortality rate. We present five patients of ages ranging between 34 and 43 years who displayed aspergillus pneumonia between 1991 and 2000. All patients received cyclosporine, azathioprine, and prednisone for maintenance immunosuppressive therapy. Their ages ranged from 34 to 43 years with the onset of infection between 1 to 25 months posttransplant. In all cases, the infection was localized to the lungs. Standard methods of fungal culture and identification were used. No coinfections with tuberculosis or other fungi or bacteria were identified. Three cases were successfully treated but two patients showed deterioration despite appropriate therapy and died. Among patients with solid organ transplantation, lung, liver, and renal transplant patients are at the highest risk of developing aspergillus lung infections. A high degree of awareness and efforts for early diagnosis and therapy may improve the poor prognosis.

Diabetic ketoacidosis following development of de novo diabetes in renal transplant recipient associated with tacrolimus

Although drugs used in renal transplant recipients such as steroids, cyclosporine, and particularly, tacrolimus have diabetogenic potential, diabetic ketoacidosis is uncommon. There are few data concerning the long-term follow-up of these patients. Diabetic ketoacidosis occurred in a renal transplant recipient following de novo development associated with tacrolimus.

Characterization of land contaminated by past heavy metal mining using geostatistical methods

Aspects of mining operations, including production, processing, transportation, and, finally, abandoned mine workings, can undoubtedly cause varying degrees of environmental pollution and contamination. Characterization of the spatial distribution of pollutants in contaminated soil is important for risk assessment and soil remediation. This study has been carried out using both conventional statistics and geostatistical methods which are useful for site assessment, characterization, and monitoring situations where data are collected spatially. These methods are particularly suited to cases where spatial dependence structure and contour maps of contaminant concentration or other variables are needed. The aims of this paper were to determine the extent and severity of the pollution levels on land contaminated by past mining activity through using geostatistical techniques, assess sampling strategy, and interpret data for potentially contaminated land. In the study, a total of 329 soil samples was collected at 1-, 5-, and 10-m regular grid intervals of 100 x 1 00-m area of Carsington Pasture in the UK and analyzed using an automatic X-ray fluorescence machine for a large number of elements. Only a few elements (Cu, Pb, Zn, and Ba) were subsequently studied in detail because of their association with the mining operation. Directional and omnidirectional experimental semivariograms of elements Cu, Pb, Zn, and Ba for 10-m grid intervals, pooled data of 10- and 5-m grid intervals (S10+5), and pooled data of 10-, 5-, and 1-m grid interval (S10+5+1) showed that neither geometric nor zonal anisotropy exits in the data. The most evident spatial dependence structure of the continuity for omnidirectional experimental semivariogram, characterized by a spherical model, of each element was obtained for the pooled data set of S10+5. Pooling 1-m grid data to S10+5 shaded the spatial dependence structure. The spherical model adopted for each element embodied no nugget effect, indicating that mineralization did not occur as nuggets in the study area, but it did show different ranges of influence and sill values. Spherical semivariogram model of each element for the pooled data set of S10+5 passed the cross validation tests. Graphs of cross validation test results proved that the isotropic spherical model, with its parameters and kriging search parameters, is representative for the area under study. The values of 10,000 grid nodes established regularly over the study area were estimated by kriging interpolation technique to smooth out the contours. Kriged maps for the Cu, Pb, Zn, and Ba elements were plotted. Anomalies such as bull's-eyes and drift did not observed in the maps generated. Contour maps of estimated element concentrations revealed the extent and severity of contamination. Spatial distribution maps of the elements might be used in the remediation studies and help decision-makers and others involved in the abandoned heavy metal mining site in the UK.

A renal transplant recipient with pulmonary tuberculosis and visceral leishmaniasis: review of superimposed infections and therapy approaches

Visceral leishmaniasis (VL) is an acute or subacute disease that is almost invariably fatal if untreated. It is a rare disease in renal transplant recipients and frequently reported together with other infectious agents. A 39-year-old renal transplant patient was admitted to hospital for elective coronary surgery. In the post-operative period, he developed spiking fever and non-productive cough and his general condition deteriorated. While he was taking medication for non-specific pneumonia, a cavitary lesion occurred in his lung, and he had the diagnosis of pulmonary tuberculosis and antituberculous treatment was started. Despite treatment, his fever continued. As the patient developed pancytopenia and splenomegaly, a bone marrow aspiration was done. Evaluation of bone marrow aspirate indicated Leishmania parasites. He was successfully treated with a more intensive liposomal amphotericin (L-AmB). Complete cure was achieved during follow-up period of 10 months without clinical relapse. In the existence of fever and long-standing pancytopenia, VL should be suspected although the patient had another proved infection and did not live or visit an endemic area. L-AmB usage can be safely preferred for treatment of selected renal transplant recipients with VL as first-line therapy.

Survival analysis of the factors affecting in mortality in injured patients requiring dialysis due to acute renal failure during the Marmara earthquake: survivors vs non-survivors

BACKGROUND

We reviewed medical records of dialyzed patients admitted to our hospital after the Marmara earthquake and evaluated the factors affecting mortality in survivors and non-survivors according to the survival times.

PATIENTS AND METHODS

Crush syndrome (CS) was diagnosed in 110 patients. Dialysis treatment was initiated in 60 patients; 21 of all died. The patients were divided into 2 groups which consisted of 39 survivors (Group A, 25 male, 14 female, mean age: 31 +/- 2.2 years) and 21 non-survivors (Group B, 9 male, 12 female, mean age: 27 +/- 3.0 years). Victims treated by any form of renal replacement therapy, including daily or intermittant hemodialysis and/or continuous venovenous hemodiafiltration. Clinical and laboratory findings were recorded regularly. Statistical analysis was performed with Kaplan-Meier method, log rank test and Cox regression analysis for the survival functions.

RESULTS

APACHE II scores were 13.5 +/- 0.5 for Group A and 13 +/- 0.9 for Group B. Dialysis support was started to patients in Group A in a mean period of 2.8 +/- 0.2 days and in Group B in a mean period of 3.7 +/- 0.6 days after the earthquake (p > 0.05). The most frequent site of trauma was lower extremity (61.5%) and upper + lower extremities (23%) in Group A, and lower extremity (38.1%) and trunk + lower extremity (23.8%) in Group B. The frequencies of abdominal trauma, pelvic fracture and thoracic trauma in Group B were 23.8%, 19% and 14.2%, respectively. Multiple trauma was more frequent in Group B than in Group A (42.8% vs 2.5%). The rates of fasciotomy, amputation and surgery were similar in both groups. The frequency of sepsis was higher in non-survivors. In our center, the overall mortality rate was 8%, mortality rate in CS was 21% and in dialyzed patients it was 35%. Mortality was mainly associated with sepsis. Survival periods (52.3 +/- 4.0 days) in Group A were longer than in Group B (17.3 +/- 2.5 days). With Cox regression analysis, the parameters such as systolic hypotension on admission, female gender, high serum peak creatine kinase (> 20,000 U/l) and multiple trauma including thoracic and abdominal regions, were factors increasing risk of mortality.

CONCLUSION

As a result, sepsis, multiple trauma and severe crush injury were the main factors increasing mortality risk in dialyzed injuries after the earthquake.

Efficacy of losartan in patients with primary focal segmental glomerulosclerosis resistant to immunosuppressive treatment

OBJECTIVES

Angiotensin II may play an important role in the progression of renal disease. Currently, angiotensin converting enzyme (ACE) inhibitors and angiotensin II receptor antagonists are commonly used for renoprotection. To our knowledge, there is no study investigating this effect of angiotensin II receptor antagonists in patients with primary focal segmental glomerulosclerosis (FSGS) in the literature. The aim of this study was to evaluate the effects of losartan on proteinuria and renal function in patients with FSGS refractory to immunosuppressive treatment.

DESIGN

Twenty-three normotensive patients with FSGS proven through renal biopsy were included in the study. Thirteen of them, five men and eight women, were given losartan in a dose of 50 mg day(-1) during 12 months, and 10, four men and six women, were in the control group. Mean arterial blood pressure (MAP), 24-h urine protein excretion, serum total protein and albumin levels were determined just before the start of treatment as well as after 1, 6 and 12 months of the study. In addition, serum creatinine, creatinine clearance (CrCl), cholesterol and triglyceride levels were determined at the beginning and end of the study.

RESULTS

Age, gender and baseline levels of proteinuria, serum albumin, total protein, creatinine, CrCl and MAPs were similar in the two groups. Nephrotic range of proteinuria was present in five of 13 patients (38.4%) in the losartan group and in four of 10 patients (40%) in the control group. In the losartan group, 24-h proteinuria had decreased from 3.6 +/- 0.5 g to 2.3 +/- 0.5 g after 1 month, to 2.4 +/- 0.7 g after 6 months and to 1.9 +/- 0.7 g after 12 months. In the control group, a significant increase in proteinuria compared with the baseline value was noticed after 12 months. Proteinuria levels were significantly higher in the control group than in the losartan group after 6 and 12 months. Whilst total protein and albumin levels increased in the losartan group, they did not change significantly in the control group. The total protein levels after 6 and 12 months, and albumin levels after 6 months were significantly higher in the losartan group than in the control group. No significant change was observed between the baseline and the 12-month creatinine and CrCl levels of the groups when intra- and inter-group comparisons were made. Furthermore, serum cholesterol levels of the losartan group were reduced significantly. The changes in MAP values did not reach significant levels in either of the groups. There was no correlation between the percentage changes in MAP and in proteinuria of the losartan group after 12 months.

CONCLUSIONS

Angiotensin II receptor antagonists may be an alternative therapy in FSGS patients who are resistant to immunosuppressive therapy.

A family with IgA nephropathy and hereditary lymphoedema praecox

Immunoglobulin A (IgA) nephropathy is the most common primary glomerulonephritis worldwide. The pathogenesis is still unknown and treatment has not yet been established. Rarely it can be associated with other disorders. Its association with hereditary lymphoedema is not reported before. We report four patients, a 60-year-old father, his two sons and his daughter, with hereditary lymphoedema. The family had nine members and in four of them lymphoedema was evident. The other members had neither lymphoedema nor IgA nephropathy. This is the first report of IgA nephropathy in association with hereditary lymphoedema.

Treatment of patients with acute renal failure during Marmara earthquake

Crush syndrome or traumatic rhabdomyolysis is a serious and epidemic clinical case that develops among casualties of earthquakes or other catastrophic events. Hypocalcaemia is one of the main symptoms that accompanies crush syndrome. It is essential that immediate IV volume replacement treatment be initiated for such patients, which is known to positively affect prognosis and help prevent the development of acute renal failure. Following the earthquake of 17th August 1999 in the north-west of Turkey, 333 casualties were hospitalised in the Medical Faculty of Uludag University. 60 (18%) of these patients [34 males (56.6%) and 26 females (43.4%)] received haemodialysis treatment. The average number of HD sessions received bythe patients was 48. Intermittent HD applied to 44 patients (73.3%) was the preferred method of treatment. Fluid overload and azotemia were the leading indications (76.6%) for dialysis. The lower extremities were mainly injured in these patients [33 (55%)]. Therefore, subclavian catheterisation was preferred in those patients with trauma at this site. 594 (67.1%) HD sessions were applied with limited heparin due to the risk of bleeding. Hypotension in 94 patients (61%) and thrombosis in 60 (45.7%) were the main complications. Of the complications not due to HD, infection in 23 patients (38.3%) was the most significant. 21 patients (35%) were lost during the treatment. It was thanks to the sacrifices and co-operation among national and international medical teams that the mortality rate was low.