Independent risk factors for COVID-19-associated coagulopathy

OBJECTIVE

Past three years since the beginning of the outbreak, we have obtained satisfactory data on COVID-19. However, data on risk factors of COVID-19-associated coagulopathy (CAC) are extremely limited. Prediction of CAC might be a game changer since it is related to poor prognosis. Seeking independent risk factors for CAC was the main aim of the study.

PATIENTS AND METHODS

510 hospitalized COVID-19 patients were retrospectively screened. Forty-eight of them were excluded due to irrelevant D-dimer or ferritin elevation. The remaining patients were stratified into three groups as overt coagulopathy, significant pulmonary microthrombosis, and patients without coagulopathy. The overt coagulopathy group included cases with macrothrombosis or disseminated intravascular coagulation (DIC). The significant pulmonary microthrombosis group covered the cases that had clinical deterioration with simultaneous marked D-dimer elevation. The group of patients without coagulopathy included the asymptomatic patients with normal or elevated D-dimer levels.

RESULTS

Overt coagulopathy developed in 3.2% and significant pulmonary microthrombosis in 10.1% of the patients. In the multivariate analysis, not receiving low molecular weight heparin (LMWH) (p=0.002), a level of D-dimer >15,000 U/ml (p=0.013) were associated with overt coagulopathy. In addition, levels of initial LDH >480 IU/L (p=0.022) and initial ferritin >1,000 ng/ml (p=0.036) were associated with significant pulmonary microthrombosis. Not receiving LMWH (p=0.001) was also associated with significant pulmonary microthrombosis, when multivariate analysis was performed by the parameters with a p-value <0.1 in the univariate analysis. Furthermore, all cases with DIC had Gram-negative bacterial sepsis.

CONCLUSIONS

Not receiving LMWH, high levels of D-dimer, initial LDH, and initial ferritin are independent risk factors for CAC. DIC does not appear to develop based on COVID-19.

The effect of hereditary thrombotic factors and comorbidities on the severity of COVID-19 disease

OBJECTIVE

Coronavirus disease 2019 (COVID-19) has rapidly spread worldwide and presents critical challenges for public health. Due to its chronic and systemic course, COVID-19 is currently accepted as a multi-systemic infectious disease. Here we explore the possible association between disease course and hereditary thrombotic factors and comorbidities.

PATIENTS AND METHODS

The patients admitted to the COVID-19 center in the Istanbul Faculty of Medicine were recruited for the study. The patients were classified according to the clinical course, severe vs. mild. Five polymorphic loci were analyzed by multiplex PCR: Factor V Leiden (FVL), FII G20210A, Beta-fibrinogen G-455A, and methylenetetrahydrofolate reductase (MTHFR) C677T and A1298C.

RESULTS

FII G20210A and Beta-fibrinogen G-455A genotypes were significantly higher in the study group compared to the literature. Wildtype genotype (GG) in Factor V Leiden locus was significantly associated with low D-Dimer levels (p =0.013). The GA genotype increased the D-Dimer levels 2.55-times compared to the GG genotype (p =0.003). Moreover, the Beta-fibrinogen G-455G genotype was significantly higher in the LDH>250 group (p =0.046).

CONCLUSIONS

The presence of solid tumors in patients with COVID-19 was related to the severity of the disease course. No evidence of a correlation between the severity of the disease and all five thrombotic mutations was found, whereas the FII G20210A and Beta-fibrinogen G-455A mutations were significantly high compared to previously reported Turkish population data and global carrier rates. This finding will need to be verified by further studies with larger samples since it may reflect a likelihood of having the COVID-19 disease. The high carrier frequency of FVL mutation was more likely present in the D-dimer high group generating an increase in the D-dimer levels 2.55-times compared to the wildtype.

Severe vitamin D deficiency is associated with endothelial inflammation in healthy individuals even in the absence of subclinical atherosclerosis

OBJECTIVE

Vitamin D has beneficial effects, some of which involve the cardiovascular system. No study to date has investigated the association between serum endocan levels, as a biomarker of endothelial inflammation, and vitamin D levels in the absence of subclinical atherosclerosis detected by carotid intima-media thickness (CIMT) in healthy individuals.

PATIENTS AND METHODS

Subjects were categorized into three groups based on vitamin D levels according to Endocrine Society guidelines. Mean CIMT was calculated from six measurements on two scans. Statistical significance was set at p < 0.05, and all testing was two-sided.

RESULTS

The concentration of serum endocan was 802.8 ± 411.4 ng/L in the group with the lowest serum vitamin D level, 454.8 ± 334.3 ng/L in the mild/moderately low serum vitamin D level group, and 269.4 ± 180.2 ng/L in the group with normal serum vitamin D levels (p < 0.01). Receiver operating characteristics curve analysis revealed that a serum vitamin D concentration of 7.5 ng/mL had a 97% sensitivity and 81% specificity for the prediction of serum endocan level greater than 270 ng/L, which could be an indicator for endothelial inflammation.

CONCLUSIONS

Demonstrating that vitamin D deficiency can cause endothelial damage in the early period of atherosclerosis without the development of clinical cardiovascular disease will have a pivotal role in the prevention of cardiovascular mortality and morbidity.

POS1216 POTENTIAL PREDICTORS OF OUTCOME FOR ANAKINRA TREATMENT IN COVID-19 PATIENTS WITH MACROPHAGE ACTIVATION SYNDROME

Background

A hyperinflammatory response compatible with features of macrophage activation syndrome (MAS) contributes to this worse outcome in patients with Coronavirus Disease 2019 (COVID-19). Glucocorticoids have become the standard of care for those requiring oxygen support or mechanical ventilation. More targeted anti-inflammatory treatments with tocilizumab and anakinra have also been shown to be effective.

Objectives

More studies are being awaited to clarify the features of patients who would benefit more, and we investigated the characteristics of the surviving and dead patients who received anakinra.

Methods

The records of hospitalized adult patients between March 2020 and May 2021 in a tertiary referral center were evaluated. Diagnosis of COVID-19-related MAS was based on the expert opinion and preliminary criteria developed by our group that patients with a score of ≥45 were accepted COVID-19-related MAS.1 Patients who received anakinra constituted the study group. Anakinra dose was determined according to the clinical and inflammatory parameters; and doses varied between daily 100-300 mg SC to 400-800 mg IV.

Laboratory data of surviving and died patients were comparatively analyzed by using the ANCOVA method on the relevant days (baseline, anakinra-onset day, first response to anakinra treatment, and discharge or death). The temporal variation (drug onset day-first response day, drug onset day-discharge, or death day) was evaluated using the ANOVA method. A 50% reduction of CRP compared to the anakinra start day was accepted as the first response to the treatment.

Results

Out of 1080 hospitalized patients, 218 (151 male, 67 female, mean age 60.0±14.1) who received anakinra were identified. Among them, 125 (57.3%) patients were followed in the ward, 21 (9.6%) did not need oxygen treatment during the hospitalization; 69 (31.6%) patients were followed at ICU, 40 of them were intubated, 30 (13.7%) died in ICU. Anakinra had been started in a mean of 4.8 days of hospitalization. Twenty had tocilizumab initially and then received anakinra because of ongoing inflammatory parameters. The majority (83.5%) received steroid treatment (79.5% methylprednisolone, 5% of dexamethasone), and 6 received one IV pulse 250 mg of methylprednisolone; 36 (16.5%) were followed before September 2020 and received anakinra without steroids because of the standard of care at that period. Only CRP was different between the alive and dead patients for the baseline parameters (p=0.05). On the first day of drug treatment, CRP and procalcitonin values were significantly higher in dead patients (Table 1). A 50% decrease in CRP level was achieved in 3.1 days in survivors and 4.7 days in dead patients. D-dimer (p=0.018), CRP (p=0.006), LDH (p=0.003), procalcitonin (p=0.005), creatinine kinase (p=0.001), and fibrinogen levels (p=0.05) were significantly different between the surviving and dead patients when the measurements between the first drug administration day and response day were compared. Neutrophil, lymphocyte count, ferritin, D-dimer, CRP, LDH, AST, procalcitonin, creatinine kinase, and fibrinogen levels were significantly different between the patients when the parameters between the first drug administration day and discharge/death day were compared. Dead patients had higher CRP values and they did not show a continuing CRP decrease with the steroids and anakinra (Figure 1).

Conclusion

Retrospective analysis of 218 patients suggests that starting anakinra earlier in hospitalized patients may provide better results, and a decrease in CRP, ferritin, D-dimer values, as well as an increase in lymphocyte count, are associated with favorable outcomes. Increasing values of D-dimer and troponin during treatment are associated with worse outcomes, possibly indicating cardiovascular and thrombotic pathologies not responding to anakinra. Changes in the CRP values are found to help monitor the response to anakinra. Other inflammatory pathways could be targeted in those who are not responding to appropriate doses of anakinra within 5 days.

Disclosure of Interests

None declared

OP0313 PRELIMINARY CRITERIA FOR MACROPHAGE ACTIVATION SYNDROME ASSOCIATED WITH CORONAVIRUS DISEASE-19

Background:

COVID-19 runs a severe disease associated with acute respiratory distress syndrome in a subset of patients, and a hyperinflammatory response developing in the second week contributes to the worse outcome. Inflammatory features are mostly compatible with macrophage activation syndrome (MAS) observed in other viral infections despite resulting in milder changes. Early detection and treatment of MAS may be associated with a better outcome. However, available criteria for MAS associated with other causes have not been helpful.

Objectives:

To identify distinct features of MAS associated with COVID-19 using a large database enabling to assess of dynamic changes.

Methods:

PCR-confirmed hospitalized COVID-19 patients followed between March and September 2020 constituted the discovery set. Patients considered to have findings of MAS by experienced physicians and given anakinra or tocilizumab were classified as the MAS group and the remaining patients as the non-MAS group. The MAS group was then re-grouped as the cases with exact-MAS and borderline-MAS cases by the study group. Clinical and laboratory data including the Ct values of the PCR test were obtained from the database, and dynamic changes were evaluated especially for the first 14 days of the hospitalization. The second set of 162 patients followed between September-December 2020 were used as the replication group to test the preliminary criteria. In the second set, hospitalization rules were changed, and all patients required oxygen support and received dexamethasone 6mg/day or equivalent glucocorticoids. Daily changes were calculated for the laboratory items in MAS, borderline, and non-MAS groups to see the days differentiating the groups, and ROC curves and lower and upper limits (10-90%) of the selected parameters were calculated to determine the cutoff values.

Results:

A total of 769 PCR-confirmed hospitalized patients were analysed, and 77 of them were classified as MAS and 83 as borderline MAS patients. There was no statistically significant difference in the baseline viral loads of MAS patients compared to the non-MAS group according to the Ct values. Daily dynamic changes in the MAS group differed from the non-MAS group especially around the 6th day of hospitalization, and more than a twofold increase in ferritin and a 1.5-fold increase in D-dimer levels compared to the baseline values help to define the MAS group. Twelve items selected for the criteria are given in Table 1 below. The total score of 45 provided 79.6% sensitivity for the MAS (including borderline cases) and 81.3% specificity around days 5 and 6 in the discovery set, and a score of 60 increased the specificity to 94.9% despite a decrease in sensitivity to 40.8%. The same set provided a similar sensitivity (80.3%) in the replication, but a lower specificity (47.4-66% on days 6 to 9) due to a group of control patients with findings of MAS possibly masked by glucocorticoids.

Table 1.

Preliminary Criteria for Macrophage Activation Syndrome Associated with Coronavirus Disease-19

1.Fever (>37.0 °C)2.Ferritin concentration > 550 ng/mL3.More than 2 times increase of ferritin concentration within 7 days of disease onset4.Neutrophil count > 6000 cell/mm35.Lymphopenia < 1000 cell/mm36.Neutrophil/lymphocyte ratio > 67.D-dimer concentration > 1000 ng/ml8.More than 50% increase of D-dimer concentration within 7 days of disease onset9.CRP concetration > 50 mg/L10.LDH concentration > 300 U/L11.ALT or AST concentration > 50 U/L12.Procalcitonin concentration < 1.2

1 point for each positive item assessed on Days 5-7

Score calculation: Total points / 12 x 100

Possible MAS ≥45 and Definite MAS ≥60

Conclusion:

This study defined a set of preliminary criteria using the most relevant items of MAS according to the dynamic changes in the parameters in a group of COVID-19 patients. A score of 45 would be helpful to define a possible MAS group with reasonable sensitivity and specificity to start necessary treatments as early as possible.

Disclosure of Interests:

None declared.

Clinical and genetic features of 13 patients with mucopolysaccarhidosis type IIIB: Description of two novel NAGLU gene mutations

Aim

Mucopolysaccharidosis type III B (MPS IIIB) is an autosomal recessive lysosomal storage disease caused by mutations in the NAGLU gene which codes the lysosomal enzyme alpha-N-acetylglucosaminidase. The major symptoms of the disease are cognitive and neurological defects. In this study, the molecular spectrums of 13 MPS IIIB patients were evaluated.

Material and methods

Thirteen MPS IIIB patients from 11 families were included in this study. All patients were both clinically and molecularly diagnosed. NAGLU gene sequencing was performed using a next generation sequencing platform (Illumina MiSeq). Demographic, clinical and laboratory findings of the patients were obtained via the hospital records.

Results

Ten different mutations from the 13 MPS IIIB patients were identified. Eight of the 10 mutations were missense, one was splice site, and one large deletion was also observed. Two mutations c.509G>T (p.Gly170Val) and c.700C>G (p.Arg234Gly) have been defined for the first time in this study.

Conclusion

Our study expanded the mutation spectrum of the NAGLU gene thereby contributing to the improved genetic counselling of MPS IIIB patients. Confirming the literature, missense mutations were also found to be the most common NAGLU mutations in our study.

Older Adults Hospitalized with Covid-19: Clinical Characteristics and Early Outcomes from a Single Center in Istanbul, Turkey

OBJECTIVE

Older adults have been continuously reported to be at higher risk for adverse outcomes of Covid-19. We aimed to describe clinical characteristics and early outcomes of the older Covid-19 patients hospitalized in our center comparatively with the younger patients, and also to analyze the triage factors that were related to the in-hospital mortality of older adults.

DESIGN

Retrospective; observational study.

SETTING

Istanbul Faculty of Medicine hospital, Turkey.

PARTICIPANTS

362 hospitalized patients with laboratory-confirmed Covid-19 from March 11 to May 11, 2020.

MEASUREMENTS

The demographic information; associated comorbidities; presenting clinical, laboratory, radiological characteristics on admission and outcomes from the electronic medical records were analyzed comparatively between the younger (<65 years) and older (≥65 years) adults. Factors associated with in-hospital mortality of the older adults were analyzed by multivariate regression analyses.

RESULTS

The median age was 56 years (interquartile range [IQR], 46-67), and 224 (61.9%) were male. There were 104 (28.7%) patients ≥65 years of age. More than half of the patients (58%) had one or more chronic comorbidity. The three most common presenting symptoms in the older patients were fatigue/myalgia (89.4%), dry cough (72.1%), and fever (63.5%). Cough and fever were significantly less prevalent in older adults compared to younger patients (p=0.001 and 0.008, respectively). Clinically severe pneumonia was present in 31.5% of the study population being more common in older adults (49% vs. 24.4%) (p<0.001). The laboratory parameters that were significantly different between the older and younger adults were as follows: the older patients had significantly higher CRP, D-dimer, TnT, pro-BNP, procalcitonin levels, higher prevalence of lymphopenia, neutrophilia, increased creatinine, and lower hemoglobin, ALT, albumin level (p<0.05). In the radiological evaluation, more than half of the patients (54.6%) had moderate-severe pneumonia, which was more prevalent in older patients (66% vs. 50%) (p=0.006). The adverse outcomes were significantly more prevalent in older adults compared to the younger patients (ICU admission, 28.8% vs. 8.9%; mortality, 23.1% vs. 4.3%, p<0.001). Among the triage evaluation parameters, the only factor associated with higher mortality was the presence of clinically severe pneumonia on admission (Odds Ratio=12.3, 95% confidence interval=2.7-55.5, p=0.001).

CONCLUSION

Older patients presented with more prevalent chronic comorbidities, less prevalent symptomatology but more severe respiratory signs and laboratory abnormalities than the younger patients. Among the triage assessment factors, the clinical evaluation of pulmonary involvement came in front to help clinicians to stratify the patients for mortality risk.

Type I cardiorenal syndrome in patients with acutely decompensated heart failure: the importance of new renal biomarkers

OBJECTIVE

Type 1 cardiorenal syndrome (CRS) is an acute renal failure in patients with acute decompensated heart failure with an incidence of 24% to 45%. The aim of our study was to investigate the significance of new renal biomarkers to predict type 1 CRS.

PATIENTS AND METHODS

The study included 111 patients with acute decompensated heart failure diagnosed at the Istanbul Medical Faculty Emergency Department between 2014 and 2016, and 24 healthy volunteers. All urine samples were stored at -80°C after centrifugation. Samples were run according to the instructions of TIMP-2, ILGF-7, KIM-1, and IGFBP-7 ELISA kits. Diuretic treatments were then administered with intravenous administration of at least 80 mg furosemide per day. Follow-up biochemical and spot urine specimens were taken after 72 hours. For statistical analysis, SPSS version 21.0 statistical software was used. Significance was evaluated at p<0.05.

RESULTS

The baseline creatinine level was measured as 1.33 ± 0.39 mg/dL in the heart failure group. It was seen that 67% (75) of the patients had increased creatinine levels and developed type 1 CRS. ILGF-7, TIMP-2, and (ILGF-7 * TIMP-2) values were significantly higher in patients with cardiorenal syndrome when we separated the two groups as patients with and without cardiorenal syndrome (0.40 (0.25-0.71), p1: 0.049/2.40 (1.42-3.70), p2: 0.003/1.15 (0.29-2.43), p3: 0.001).

CONCLUSIONS

Renal tubular markers reveal promising developments in the pathophysiology of cardiorenal syndrome in light of recently obtained data. Renal tubular biomarkers may have the potential to be a predictor of heart failure and cardiorenal syndrome.

The Effect of Pre-emptive Dexketoprofen Administration on Postoperative Pain Management in Patients with Ultrasound Guided Interscalene Block in Arthroscopic Shoulder Surgery

Background: Postoperative pain is an important problem for patients undergoing shoulder surgery. Our study investigated analgesic efficacy, duration of analgesia, postoperative analgesic use and patient satisfaction with the use of preemptive intravenous dexketoprofen for interscalene block in addition to general anesthesia in arthroscopic shoulder surgery. Methods: 60 patients, scheduled for arthroscopic shoulder surgery were randomized (30 patients each) into either: - control group (Group1) or dexketoprofen group (Group 2). Patients were followed for 48 hours to compare both groups for; post-operative pain scores, effectiveness of postoperative analgesia, duration of analgesia, and analgesia consumption. Duration of postoperative sensory block of the shoulder joint was defined as time to onset of pain at the incision site. Duration of postoperative motor block of the shoulder joint was defined as time to onset of first shoulder movement. Results: While no significant difference was determined for motor block time, sensory block time was significantly longer in the dexketoprofen group (p < 0.05).VAS scores were significantly lower at all times in the dexketoprofen group (p < 0.05).Total PCA fentanyl consumption was 274.16 ± 314.89 (μg) in the dexketoprofen group, and 490.00 ± 408.98 (μg) in the control group, the difference was statistically significant (p < 0.05). No significant difference was observed between the groups' demographic and hemodynamic data. Conclusion: Pre-emptive IV dexketoprofen may be a good option for arthroscopic shoulder surgery and provides effective analgesia.

Serum vitamin D concentrations in young Turkish women with primary dysmenorrhea: A randomized controlled study

OBJECTIVE

This study aims to investigate the possible role of vitamin D deficiency in primary dysmenorrhea by assessing serum 25-hydroxyvitamin D₃ levels in a cohort which includes young Turkish women with primary dysmenorrhea and healthy controls.

MATERIALS AND METHODS

A total of 683 women who were aged between 18 and 25 years and who were consecutively admitted to the study center were eligible. After the exclusion of 55 women, 184 women with primary dysmenorrhea were randomly assigned into the dysmenorrhea group and 184 women without dysmenorrhea were randomly allocated into the control group.

RESULTS

The dysmenorrhea group had significantly less consumption of dairy products (p = 0.001), lower serum calcium (p = 0.001), lower serum vitamin D (p = 0.001) and higher serum parathyroid hormone (p = 0.001) than those of the control group. Hyperparathyroidism was significantly less frequent whereas vitamin D deficiency was significantly more frequent in the dysmenorrhea group (p = 0.001 for each). The dysmenorrhea patients with vitamin D deficiency had significantly higher visual analogue scale (VAS) scores (p = 0.001). Depression, irritability, mood swings, fatigue, headache and breast tenderness were significantly more frequent in the vitamin D deficiency group (p < 0.05 for all). The VAS scores of the dysmenorrhea patients correlated positively and significantly with serum parathyroid hormone levels (r = 0.666, p = 0.001) whereas these VAS scores correlated negatively and significantly with serum vitamin D levels (r = -0.713, p = 0.001).

DISCUSSION

The significant and positive correlation between vitamin D levels and VAS scores and the significant reduction in serum vitamin D levels of the dysmenorrhea patients designate the possible role of vitamin D deficiency in the primary dysmenorrhea.

Two-Year Follow-Up Results of Transobturator Tape Procedure with and without Concomitant Vaginal Surgery

OBJECTIVE

This study aims to evaluate the subjective and objective outcomes of the transobturator tape (TOT) procedure performed to treat stress urinary incontinence and to determine the efficacy and safety of the TOT procedure when used along with vaginal surgery.

METHODS

This is a prospective review of 24 women who had the TOT procedure done only due to stress incontinence; 22 women who underwent concomitant TOT and pelvic floor repair; and 20 women who received concurrent TOT, transvaginal hysterectomy, and sacrospinous ligament fixation.

RESULTS

When compared to the patients who had TOT with pelvic floor repair, the patients who underwent TOT with hysterectomy declared to have more dyspareunia (p = 0.008) and they were found to have significantly higher post-void residual volume (p = 0.014). When compared to the patients who had only TOT, the patients who underwent TOT with hysterectomy claimed to have more pelvic pain (p = 0.012) and significantly higher post-void residual volume (p = 0.020).

CONCLUSION

The TOT procedure results in moderately high objective cure rates, and concurrent application of pelvic floor repair or transvaginal hysterectomy does not affect these rates. The relatively higher incidences for voiding problems and pelvic pain in women who underwent TOT, hysterectomy, and sacropinous fixation simultaneously suggest that the extent of surgery directly correlates with the severity of postoperative complications.

Rare complication of needleless mini-sling procedure: Case report

The mini-sling procedure is a widely used, minimally invasive treatment for stress urinary incontinence. While bladder perforation and stone formation over the mesh is not an expected complication of the mini-sling procedure, in this case, we report on the management of bladder calculi formed over the mesh, which was passed through the bladder while applying the mini-sling procedure, and was eventually removed using holmium laser. Performing cystoscopy in patients with irritative and obstructive symptoms after the sling procedure will help confirm bladder perforation, and an endoscopic approach using holmium laser is an effective treatment.

Plasma L-carnitine levels of obese and non-obese polycystic ovary syndrome patients

It is well-known that plasma L-carnitine concentrations are significantly decreased in obese individuals. A study showed that L-carnitine concentrations are significantly lower in lean PCOS patients than in lean healthy women. Thus, it has been suggested that lowered L-carnitine is associated with PCOS. This study also showed that the women with PCOS had significantly lower L-carnitine levels than those of the healthy controls. In addition, this study hypothesised that low L-carnitine levels in PCOS patients were associated with obesity and/or insulin resistance. Moreover, plasma L-carnitine concentrations were found to be statistically similar in PCOS patients and healthy controls, when controlled for obesity. This study implied that L-carnitine could be used as an adjunctive therapy in the management of insulin resistance or obesity in women who have PCOS. Further research might be planned to clarify the clinical effects of L-carnitine administration in PCOS patients with insulin resistance and/or obesity.

Cesarean section: requested mode of delivery?

AIM

To constitute accurate policies for reducing the cesarean section (C/S) the authors evaluated the attitudes and knowledge of health workers and public population towards the mode of delivery, C/S on demand, and delivery complications in a large population.

MATERIALS AND METHODS

1,892 female volunteers in reproductive age were enrolled in the study and 589 of them were health workers. Patients were evaluated with questionnaire about their delivery mode and their answers were analyzed.

RESULTS

The overall cesarean rate of the study population was 45.4%. This rate were 51.4% and 28.2%, respectively, for the health workers and public group (p < 0.001). Medical indication ratio ivere 57.7% and 40.1% for the healthcare group and the public population respectively and 20.2% of health workers and 13.9% of the public group had C/S by their preference without any medical indications (p < 0.001).

CONCLUSION

C/S rate is high in Turkey and an action plan is needed to decrease the rate. When a patient's preference towards the mode of the delivery is C/S on demand, obstetricians, in their capacity as patient advocate, should help guide their patient through the sophisticated detailed medical information toward a decision that respects both the patient's attitude and the physician's obligation to optimize the health of both the mother and the newborn.

A novel parameter for the diagnosis of acute pulmonary embolism: the T-wave peak-to-end interval

OBJECTIVE

Acute pulmonary embolism (APE) is a very common disease that must be diagnosed and treated quickly and accurately to reduce significant morbidity and mortality rates. Acute pulmonary embolism is associated with numerous electrocardiographic (ECG) changes including prolonged QT interval with global T-wave inversion. The aim of the study was to investigate the relationship between the T-wave peak-to-end interval and diagnosis of APE, which has never been investigated in the literature.

PATIENTS AND METHODS

Seventy-three patients who were suspected of having APE took part in the present study. The Local Ethics Committee of Istanbul University, Turkey, approved the study protocol. Forty-one of the patients were diagnosed as having APE using computed tomography. Surface ECGs were taken in the initial assessment at admission. The Tp-Te interval was identified as the interval from the peak of the T-wave to the end of the T-wave. The measurements of the Tp-Te interval were taken using precordial leads. All measurements were compared using appropriate statistical tests. Statistical analysis was performed using SPSS version 22.0.

RESULTS

We enrolled 73 patients to the study, 41 of which were diagnosed as having APE. Men comprised 54% of the APE group. The mean ages in the APE (+) and APE (-) groups were 59.5 ± 14.5 years and 61±9.2 years, respectively. There was a significant increase in Tp-Te results in V1 (p<0.01). The Tp-Te interval was 74.21 ± 20.81 in the APE (+) group, whereas it was 59.73 ± 12.82 in APE (-) group (p<0.01).

CONCLUSIONS

Acute pulmonary embolism (APE) is a mortal condition and as such, rapid and accurate diagnosis is very important. Surface ECG can be used to measure Tp-Te in patients admitted to the emergency room with suspected APE in the differential diagnosis as a fast and easily accessible tool.

Could the platelet-to-lymphocyte ratio be a novel marker for predicting invasiveness of cervical pathologies?

PURPOSE

To determine whether the preoperative platelet to lymphocyte ratio (PLR) could predict invasiveness of cervical pathologies.

MATERIALS AND METHODS

Patients with preinvasive and invasive diseases were reviewed retrospectively, over a nine-year period, 2005-2014. The pathological records and completed blood counts of the patients were collected and recorded in the SPSS program. Patients were divided in two groups, preinvasive and invasive.

RESULTS

The median PLR was significantly higher in the invasive group than in the preinvasive group (p=0.03). There was a correlation between invasion of cervical cancer and white blood cell count, red cell distributing width (RDW), neutrophil-lymphocyte ratio (NLR), and PLR.

CONCLUSIONS

This study showed that patients with uterine cervical cancer may present with leukocytosis, increased RDW, NLR and PLR. These cheap and easily available parameters, especially PLR, may provide useful information about the invasiveness of cervical lesions.

Is Intracytoplasmic Sperm Injection Success Affected by the Testicular Histopathology in Nonobstructive Azoospermic Patients?

OBJECTIVE

To investigate whether the histological changes observed in testicular tissue might be correlated with pregnancy outcome in intracytoplasmic sperm injection-testicular sperm extraction (TESE) cycles in nonobstructive azoospermic patients. Embryo quality was also tested in various types of histology.

STUDY DESIGN

We retrospectively analyzed the pathology results of 209 testicular biopsies from nonobstructive azoospermic patients in our assisted reproductive technologies clinic. According to the final pathology reports, the study group was divided into the following categories: Group A (Sertoli-cell-only), Group B (maturation arrest), Group C (hypospermatogenesis), Group D (normal spermatogenesis), and Group E (mixed pattern).

RESULTS

Spermatozoa were identified in 114 of 209 cases (54.5%). Sperm retrieval and presence of motile spermatozoa after TESE was highest in normal spermatogenesis and lowest in Sertoli-cell-only groups. Fertilization rate was highest in the normal spermatogenesis and hypospermatogenesis groups. Embryo grades on day 3 were comparable between groups. Clinical pregnancy per embryo transfer was also similar. Both fertilization and clinical pregnancy rates were statistically higher in favor of motile spermatozoa group.

CONCLUSION

Testicular histopathology not only gives information regarding the probability of retrieving sperm at TESE, but also is a good predictor of fertilization. Once a motile spermatozoon is identified, the chance of clinical pregnancy might improve probably due to relatively good optimal microenvironment within the testis.

121 EXPRESSION OF HYALURONAN SYSTEM COMPONENTS IN THE EARLY PREGNANT OVINE ENDOMETRIUM

Hyaluronan (HA; hyaluronic acid), a member of glycosaminoglycans (GAG) family, is the main polysaccharide and is expressed in almost all tissues including those of the reproductive tract. Three different hyaluronic acid-synthase (HAS) enzymes, HAS1, HAS2, and HAS3, synthesise HA. The action of HA depends on its molecular size and its cell surface receptor (CD44). Hyaluronidases (HYAL) are a group of enzymes, HYAL-1 and HYAL-2, that degrade HA. Roles of the HA system in reproductive events include oocyte maturation, fertilization, and implantation. It is also known that ovarian steroids, specifically progesterone, regulate the HA system in the endometrium. Moreover, HA-mediated cell signalling participates in embryonic development. The aim of this study was to evaluate expression of the HA system at the mRNA level in the early pregnant ovine endometrium at pre-implantation stage. Therefore, endometrial tissue samples were collected on Day 13 of the oestrous cycle (n = 10) and pregnancy (n = 14). Relative mRNA expression levels of HA system genes were quantified using quantitative RT-qPCR. Data were analysed using one-way ANOVA and l.s.d. test. All of the studied components of the HA system (HAS1, HAS2, HAS3, HYAL1, HYAL2, and CD44) were expressed in the ovine endometrium. Steady-state mRNA levels of HAS1, HYAL1, HYAL2, and CD44 were not significantly different between cyclic and early pregnant ovine endometrium on Day 13. However, expression of HAS2 and HAS3 appeared to be down-regulated in early pregnancy. Considering that both cyclic and pregnant endometrium on Day 13 is under the influence of progesterone, detected differential regulation of some components of HA system in the ovine endometrium may be directly related to the effects of the presence of an embryo. The role of the HA system in ovine endometrium at later stages of pregnancy warrants further investigation. Partially funded by TUBITAK-112R022 to ZK and SUBAP to AG.

116 EFFECT OF EXOGENOUS PROGESTERONE AND GONADOTROPIN-RELEASING HORMONE APPLICATION ON MAINTENANCE OF PREGNANCY IN EARLY PREGNANT EWES AFTER PROSTAGLANDIN F2 ALPHA INJECTION

In this experimental study, we tested the hypothesis that exogenous progesterone and GnRH applications would prevent the detrimental effect of prostaglandin F2α (PGF2α; a) on early pregnancy in ewes by sustaining high plasma progesterone level. For this purpose, 9 pregnant ewes (mating day = 0) were divided into 2 groups on Day 18 as follows: (1) PGF2α group (125 μg of d-cloprostenol injection on Day 18, n = 5); (2) PGF2α + progesterone sponge group (125 μg of d-cloprostenol injection on Day 18 + 20 mg flugestone acetate for 7 days, n = 4). Moreover, gonadotropin-releasing hormone (GnRH; 10 μg of buserelin acetate, n = 4) was injected intramuscularly to PGF2α + progesterone sponge group ewes on Day 22 after mating to induce luteinization in dominant follicles. The progesterone sponge was withdrawn on Day 25. Plasma progesterone (P4) concentration was measured on Days 18 and 19 by ELISA. Pregnancies were examined by using transrectal ultrasonography on Days 18, 22, 25, and 35 after mating. Statistical difference between groups was analysed by Chi-squared test. P4 concentration declined to below 1 ng mL–1 on Day 19 in both groups. While all pregnancies were terminated (5/5) in the PGF2α group by Day 25, progesterone sponge application prevented pregnancy loss (4/4) in the PGF2α + progesterone sponge group (P < 0.02). When the progesterone sponge was withdrawn on Day 25, half of the pregnancies (2/4) continued after GnRH application in the PGF2α + progesterone sponge group until birth. In conclusion, results suggest that exogenous progesterone application is sufficient for maintaining early pregnancy in ewes, even if the corpus luteum is regressed. Furthermore, GnRH application on Day 22 after mating might luteinize dominant follicles and could be sufficient to maintain pregnancy after exogenous progesterone is removed.

Congenital IL-12R1β receptor deficiency and thrombophilia in a girl homozygous for an IL12RB1 mutation and compound heterozygous for MTFHR mutations: A case report and literature review

Interleukin-12 (IL-12) plays an important role in the production of interferon gamma from T cells and natural killer cells and is essential for protection against intra-macrophagic pathogens such as Mycobacterium and Salmonella. Here, we describe a 16-year-old girl with homozygous mutation in exon 12 of the IL12RB1 gene, which causes complete IL-12Rβ1 deficiency in association with heterozygous mutation (C677T and A1298C) in the methylenetetrahydrofolate reductase gene. She presented with disseminated Mycobacterium tuberculosis complex infection, retroperitoneal fungal abscess and also thrombosis in the superior mesenteric-portal vein junction. This is the first case report of a primary immunodeficiency associated with a genetically determined venous thrombosis.

Association of genetic polymorphisms with endothelial dysfunction in chronic heart failure

OBJECTIVES

Endothelial dysfunction can be shown very early in the cardiovascular disease. In the present study the association between congestive heart failure (CHF), endothelial function and 3 gene polymorphisms was investigated.

PATIENTS AND METHODS

In 104 healthy controls and 104 CHF patients, endothelial constitutive nitric oxide synthase (ecNOS), angiotensin converting enzyme (ACE) and angiotensin II type 1 receptor (AT1R) gene polymorphisms were assessed. The cause of CHF was ischemic in 68 patients and dilated cardiomyopathy (DCMP) in 36 patients. High resolution brachial artery ultrasound was used in 37 CHF patients and 37 healthy controls to assess the endothelial function. Endothelium-dependent vasodilation (EDD) and endothelium-independent vasodilation (EID) were determined.

RESULTS

There no was difference between controls and CHF patients for the ACE, ecNOS, and AT1R genotype frequencies. Compared to controls CHF patients had significantly impaired EDD (9.0+5% vs 16±7%, p < 0.001) and EID (13±6% vs 19+8%, p = 0.001). EDD (7±4% vs 12+6%, p = 0.005), but not EID, was significantly impaired in ischemic CHF as compared to DCMP patients. In the CHF group ecNOS a allele and AT1R C allele influence the EDD.

CONCLUSIONS

Endothelial dysfunction was present in CHF group and the presence of ecNOS a allele and AT1R C allele further impaired EDD.

Endothelial constitutive nitric oxide synthase, angiotensin converting enzyme, angiotensin II type 1 receptor gene polymorphisms and endothelial functions in healthy individuals

INTRODUCTION

Endothelial dysfunction is recognized as an early and initiating event in the pathogenesis of coronary artery disease. Gene polymorphisms of endothelial constitutive nitric oxide synthase (ecNOS), angiotensin converting enzyme (ACE) and angiotensin II type 1 receptor (AT1R) have been found to be associated with atherosclerosis.  We aimed to investigate the possible effects of ecNOS, ACE and AT1R gene polymorphisms on endothelial functions in healthy population.

MATERIALS AND METHODS

In 255 healthy subjects (male/female: 119/136 mean age 35.1±2.3 years)  ecNOS, ACE and AT1R gene polymorphisms were assessed by polymerase chain reaction (PCR). Endothelium dependent (EDD, flow-mediated) and endothelium independent vasodilation (EID) were measured by high resolution brachial artery ultrasound and 0.5 mg sublingual nitroglycerine respectively.

RESULTS

ecNOS and ACE genes had no significant effect on EDD and EID. However, subjects with AT1RAC+CC genotypes had lower EDD compared to subjects with AT1RAA genotype in females (19.4 ± 6.6% vs 21.5 ± 7.8%, p = 0.041). EDD and EID were significantly negatively associated with  age, body mass index, serum creatinine, glucose, uric acid and hemoglobin levels. When the data on age, uric acid, BMI, glucose, creatinine, and hemoglobin were split into 3 as low-1/3, mid-1/3 and  high 1/3, there was significant graded decrease in EDD and EID with these parameters. In multiple regression analysis, age and presence of AT1RAC+CC genotype  retained as significant independent factors predicting endothelial functions.

CONCLUSIONS

Gene polymorphisms of endothelial constitutive nitric oxide synthase and  angiotensin converting enzyme had no effect on endothelial functions. However, the presence of angiotensin II type 1 receptor polymorhism (AT1RAC+CC genotype) seemed to adversely affect the endothelial functions as reflected by impaired endothelium dependent and independent vasodilatation in healthy individuals.

Interferon-gamma assays for the diagnosis of tuberculosis infection before using tumour necrosis factor-alpha blockers

OBJECTIVES

Patients who receive tumour necrosis factor-alpha (TNF-alpha) blockers are mostly immunosuppressed. A study was performed to investigate whether an interferon-gamma (IFN-gamma) assay could represent an alternative approach to the tuberculin skin test (TST) for the diagnosis of latent tuberculosis infection (LTBI) in these patients.

DESIGN

We prospectively enrolled 106 individuals into the study in two groups. Group 1 consisted of 38 healthy individuals and Group 2 included 68 patients with chronic inflammatory diseases evaluated for LTBI before the use of TNF-alpha blockers.

RESULTS

Of all participants, nine had indeterminate IFN-gamma test results. Agreement between the two tests was poor in both groups (kappa values respectively -0.54 and 0.18). In a total of 97 subjects, 10 (10.3%) were positive by the IFN-gamma test and 49 (50.5%) by TST.

CONCLUSION

We found poor agreement between TST and the IFN-gamma test in our study. Our limited preliminary data should be accepted as a basis for designing future studies that will be helpful for physicians to decide whether the IFN-gamma test is more sensitive than the TST test in detecting LTBI before the use of TNF-alpha blockers.

A retrospective review of metastatic or recurrent uterine sarcomas treated with ifosfamide and doxorubicin (IMA)

15053

Background: The prognosis of metastatic uterine sarcoma is poor with median survival reported between 4 to 26 months. We evaluated the efficacy and toxicity of ifosfamide (I) mesna (M) and doxorubicin (A) (IMA) chemotherapy regimen retrospectively in patients (pts) with metastatic, or recurrent uterine sarcomas. Methods: Eligible patients had measurable recurrent or metastatic disease, ECOG PS < 2, had adequate renal, hepatic and hematologic functions. The IMA regimen was ifosfamide 2500 mg/m2 days 1–3, mesna 2500 mg/m2 days 1–3, doxorubicin 60 mg/m2 day 1, repeated every 21 days. Patients were evaluated for response for each two cycles. Results: Thirty-five pts (17 leiomyosarcoma [LMS], 6 malignant mixed mesodermal tumor [MMMT], 5 endometrial stromal sarcoma, 4 carcinosarcoma, and 3 adenosarcoma) were enrolled in this study. The median age was 49 yrs (range, 18–72). Two pts were lost to follow up after the first cycle; one patient had ifosfamide encephalopathy on the third day of the first cycle. Thirty-two pts were assessable for response, toxicity, and survival. Nine pts had prior chemotherapy and 4 pts had radiotherapy. Most frequent metastatic sites were peritoneum, lung and liver. Median period of time from the diagnosis to starting IMA regimen was 14.5 months. A total of 132 cycles of chemotherapy were introduced and for each patient median number of chemotherapy cycles were 4 (range, 1–6). We observed CR in 2 pts; PR in 15 pts. Objective RR was % 48.6 (95% CI, 32% to 67%). Of 17 pts with LMS, 1 CR and 6 PRs were observed. The median progression-free survival time of the responders was 12.0 months. The median progression-free survival time of all patients was 7.0 months. NCI-CTC grade 3 or 4 leucopenia, neutropenia, thrombocytopenia, and anemia occurred in 40%, 55%, 12%, and 13%, respectively. There was no significant nausea/vomiting, nephrotoxicity. Febrile neutropenia was encountered in 6 pts. Dose modifications were required in 4 pts due to myelotoxicity. CNS toxicity was observed in one pts. Conclusions: IMA regimen has moderate anti-tumor activity (48.6%) with acceptable toxicity in pts with recurrent or metastatic uterine sarcomas.

No significant financial relationships to disclose.

An analysis of continent-wide patterns of sexual selection in a passerine bird

Patterns of selection are widely believed to differ geographically, causing adaptation to local environmental conditions. However, few studies have investigated patterns of phenotypic selection across large spatial scales. We quantified the intensity of selection on morphology in a monogamous passerine bird, the barn swallow Hirundo rustica, using 6495 adults from 22 populations distributed across Europe and North Africa. According to the classical Darwin-Fisher mechanism of sexual selection in monogamous species, two important components of fitness due to sexual selection are the advantages that the most attractive males acquire by starting to breed early and their high annual fecundity. We estimated directional selection differentials on tail length (a secondary sexual character) and directional selection gradients after controlling for correlated selection on wing length and tarsus length with respect to these two fitness components. Phenotype and fitness components differed significantly among populations for which estimates were available for more than a single year. Likewise, selection differentials and selection gradients differed significantly among populations for tail length, but not for the other two characters. Sexual selection differentials differed significantly from zero across populations for tail length, particularly in males. Controlling statistically for the effects of age reduced the intensity of selection by 60 to 81%, although corrected and uncorrected estimates were strongly positively correlated. Selection differentials and gradients for tail length were positively correlated between the sexes among populations for selection acting on breeding date, but not for fecundity selection. The intensity of selection with respect to breeding date and fecundity were significantly correlated for tail length across populations. Sexual size dimorphism in tail length was significantly correlated with selection differentials with respect to breeding date for tail length in male barn swallows across populations. These findings suggest that patterns of sexual selection are consistent across large geographical scales, but also that they vary among populations. In addition, geographical patterns of phenotypic selection predict current patterns of phenotypic variation among populations, suggesting that consistent patterns of selection have been present for considerable amounts of time.

Sexual selection for white tail spots in the barn swallow in relation to habitat choice by feather lice

Many bird species have white spots in their tails or wing feathers, and such characters have been hypothesized to be either reliable signals (handicaps) or amplifiers that facilitate the message of a signal. In barn swallows, Hirundo rustica, the size of the white spots in the tail feathers is sexually dimorphic and positively correlated with feather length. We tested whether such spots act as handicaps or amplifiers. These white spots affect sexual selection in barn swallows, as shown by an experiment in which we randomly subjected males to (1) a considerable reduction of the size of all the spots by the use of a black permanent marker pen, (2) a small reduction of the size of the spots, or (3) no reduction. There was a positive association between spot size and the number of offspring produced per season. The white tail spots were preferred by feather-eating Mallophaga as a feeding site: holes made by Mallophaga were more abundant in the white spots than expected by chance. A habitat choice experiment with Mallophaga on barn swallow tail feathers revealed that they preferred white spots over black parts of the tail feathers. We therefore expected long-tailed male barn swallows to have more Mallophaga than short-tailed males. However, the opposite relationship was observed, indicating that long-tailed males may reliably signal their quality by the presence of large white tail spots without parasite damage. Thus white tail spots in barn swallows appear to be a reliable signal of phenotypic quality. Copyright 1999 The Association for the Study of Animal Behaviour.