Shedding light on the next pandemic path, from outpatient to ICU, the effect of vitamin D deficiency in the SARS-CoV-2 pandemic

Background

Vitamin D insufficiency is named "the pandemic of our era" by some experts. World Health Organization warns against a "deadlier outbreak" than the COVID-19 pandemic. Critical evidence is hereby for future pandemic prevention, with special emphasis on Vitamin D.

Methods

A cross-sectional study was conducted with 172 unvaccinated adult participants, who presented to the emergency department. Blood measurements, radiological findings, and demographic features were evaluated in the four categories of "healthy adults, COVID-19 outpatients, hospitalized inpatients on the wards, and in the ICU."

Results

Results were statistically significant in association with age, gender, weight, Vitamin D, glucose, urea, creatinine, leucocyte, aspartate transaminase, hemoglobin, C-reactive protein, troponin, platelet/thrombocyte, ferritin, D-dimer, triglycerate, glycated haemoglobin, lactate dehydrogenase measurements, and chest computed tomography features (each p < 0.050).

Conclusion

This article presents evidence to support the importance of Vitamin D for global public health. Patients with adequate levels of Vitamin D, glucose, urea, creatinine, leucocyte, aspartate transaminase, hemoglobin, C-reactive protein, troponin, platelet/thrombocyte, ferritin, D-dimer, triglycerate, glycated haemoglobin, lactate dehydrogenase are less likely to be admitted to ICU versus being outpatients. Factors include gender, age, weight, comorbidities, and computed tomography findings. The ultimate goal is to globally minimize preventable burdens of disease and death.

Lymph node density in retroperitoneal lymph node dissection as a novel marker for predicting recurrence in patients with germ cell testicular cancer: A case-control study and long-term clinical experience of a tertiary referral hospital

INTRODUCTION AND OBJECTIVES

In this retrospective study, we aimed to evaluate lymph node (LN) density in retroperitoneal lymph node dissection (RPLND) to analyze whether residual mass after chemotherapy might behave as predicting factor for recurrence in patients with germ cell testicular cancer (GCTC).

MATERIALS AND METHODS

The data of 185 patients that were operated between 12/2004 and 02/2017 because of GCTC were reviewed retrospectively. LN density was calculated. The patients were compared statistically in terms of demographic features, tumor characteristics, serum tumor marker levels, treatment strategies, and pathological results according to GCTC subtypes. Correlation analysis was performed to determine the parameters related to recurrent disease.

RESULTS

The median follow-up was 79 (31-179) months and the median age of the patients was 23 (16-71). The median tumor size was 4 (1-18) cm. Five (2.7%) patients had metastatic disease at initial diagnosis. Seminoma, non-seminomatous-GCT and mix type-GCTC was detected in 62 (33.5%), 60 (32.4%) and 63 (34.1%) patients, respectively. Following inguinal orchiectomy, 48 (25.9%) patients underwent follow-up, 126 (68.1%) patients underwent chemotherapy and 11 (5.9%) patients underwent radiotherapy. A total of 21 (11.4%) patients underwent post-chemotherapy RPLND. Early and late recurrence was seen in 3 (1.6%) and 2 (1.1%) of the patients, respectively. A mild to moderate, negative, but significant correlation was found between the recurrence and the number of LNs containing metastatic deposits and LN density (r= -0.490, P=.024 and r= -0.450, P=.041, respectively).

CONCLUSIONS

There was a negative correlation between the number of LNs containing metastatic deposits and LN density and recurrent disease.

HMGCR and ApoE mutations may cause different responses to lipid lowering statin therapy

Coronary artery disease (CAD) and its complications are the major causes of death in the world. Although statins have been used to lower lipid levels in CAD patients, this goal can not be attained in 1/3 of the patients. The objective of this study was to investigate whether common variations in HMG-CoA Reductase(HMGCR) and Apolipoprotein E (ApoE) genes involved in lipid and statin metabolism modify the effect of statins on serum lipid and lipoprotein concentrations in CAD patients.A hundred  CAD patients were enrolled into the study. At the beginning of the study biochemical measurements were performed to determine the baseline levels performed. Patients were treated with 40 mg atorvastatin for 2 months and biochemical measurements were repeated. According to the post-treatment, LDL-c levels,  patients were divided into 2 groups as non-responders and responders, respectively. The information regarding the risk factors such as smoking, alcohol consumption etc. were also obtained. DNA was isolated from peripheral blood. The presence of rs17244841 ve rs17238540 mutations in HMGCR and ε2, ε3 and ε4 variants of ApoE were determined by using RT-PCR. Results were evaluated statistically. HMGCR mutatations were mostly found in responders and ε4 variant of ApoE was mostly found in non-responders. It was also found that presence of HMGCR mutations causes a significant reduction in total cholesterol and LDL-c levels. Also presence of ε2 variant of ApoE causes a statistically significant increase in trigliseride levels. Our findings should be investigated with other researchers to clarify the mechanism.

The importance of the incidental thyroid gland uptake during Tc-99m MIBI myocardial perfusion scintigraphy

OBJECTIVE

The purpose of study was to investigate whether incidental thyroid gland uptake had an important during Tc-99m sestamibi (MIBI) myocardial perfusion scintigraphy (SPECT).

PATIENTS AND METHODS

In the presented study, 968 consecutive patients were evaluated for the presence or absence of thyroid gland uptake in the raw data of the Tc-99m MIBI SPECT. All of the patients had thyroid gland uptake of the Tc-99m MIBI underwent laboratory evaluation of thyroid function, ultrasonographic imaging, and hystopathological examination.

RESULTS

The thyroid gland uptake was detected in 14 of 968 (1.4%) consecutive patients during the evaluation of raw images of Tc-99m MIBI SPECT studies. Among these 14 patients, 4 had subacute thyroiditis, 7 multinodular goiter, 3 Graves disease by ultrasonographic imaging and hystopathological examination. TSH levels of all of these patients were < 0.01 U/ml.

CONCLUSIONS

Tc-99m MIBI uptake by thyroid gland has been explained with associated clinical thyrotoxicosis. Although the primary goal of myocardial perfusion imaging is the evaluation of myocardial perfusion, the interpretation of myocardial perfusion imaging should not be limited to the heart. Because, it is possible to observe extracardiac radioactivity accumulation, which may then lead to the diagnosis of a noncardiac disease during this detailed examination.

Late coronary stent dislodgement following coronary artery stenting

Recently, coronary artery stenting has been successful when used as an intervention for percutaneous coronary artery disease. However, the procedure may frequently produce complications. Although rare, stent dislodgement is one such complication, which may result in serious problems including coronary artery dissection, myocardial infarction, peripheral embolisation and death. Stent dislodgement is known to be an early complication of the coronary artery stenting procedure. In this case report, we present a 53-year-old male with late coronary stent dislodgement. To the best of our knowledge, no such case has been addressed in the literature to date.

Effect of hypothermia in patients undergoing simultaneous carotid endarterectomy and coronary artery bypass graft surgery

Purpose

We sought to determine whether hypothermia provided any benefit in patients undergoing simultaneous coronary artery bypass graft surgery (CABG) and carotid endarterectomy (CEA) using one of two different surgical strategies.

Methods

Group 1 patients (n = 34, 88.2% male, mean age 65.94 ± 6.67 years) underwent CEA under moderate hypothermia before cross clamping the aorta, whereas group 2 patients (n = 23, 69.6% male, mean age 65.78 ± 9.29 years) underwent CEA under normothermic conditions before initiating cardiopulmonary bypass (CPB). Primary outcome of interest was the occurrence of any new neurological event.

Results

The two groups were similar in terms of baseline characteristics. Permanent impairment occurred in one patient (2.9%) in group 1. One patient from each group (2.9 and 4.3%) had transient neurological events and they recovered completely on the sixth and 11th postoperative days, respectively. Overall, there was no statistically significant difference between the two groups with regard to occurrence of early neurological outcomes (n = 2, 5.8% vs n = 1, 4.3%, p = 0.12).

Conclusions

This study could not provide evidence regarding benefit of hypothermia in simultaneous operations for carotid and coronary artery disease because of the low occurrence rate of adverse outcomes. The single-stage operation is safe and completion of the CEA before CPB may be considered when short duration of CPB is required.

Assessment of atrial electromechanical delay in patients with migraine

Evidence suggests that symptoms of migraine are related to the involvement of the autonomic nervous system. Data on atrial conduction system are limited in migraineurs. We aimed to assess atrial electromechanical delay using tissue Doppler imaging (TDI) in patients with migraine. Forty-five migraine patients and age- and sex-matched 26 control subjects were enrolled in the study. All the patients and controls underwent resting surface electrocardiogram (ECG) and TDI. The maximum P-wave duration (Pmax), minimum P-wave duration (Pmin) and P-wave dispersion (Pd) were measured from the 12-lead ECG. Atrial conduction time was determined from the lateral mitral annulus (PA lateral), septal mitral annulus (PA septal), and lateral tricuspid annulus (PA tricuspid) by TDI. Interatrial (PA lateral-PA tricuspid) and intraatrial (PA septal-PA tricuspid) electromechanical delays were calculated. Pd was significantly higher in migraine patients than in controls (p < 0.05), whereas Pmax and Pmin were not different between both groups (p > 0.05). PA lateral and PA septal durations were significantly higher in migraine patients than in controls (p < 0.001 and p < 0.05, respectively). However, PA tricuspid duration was similar between the groups (p > 0.05). Both interatrial and intraatrial conduction times were delayed in migraineurs as compared to the controls (p < 0.001). Interatrial delay and intraatrial delay variables were found as an independent risk factors separately on predicting atrial conduction abnormalities in migraineurs. An interatrial delay of 18 ms and an intraatrial delay of 5 ms were found to be cutoff values in ROC analysis (p < 0.001). This is the first report to provide a hypothetical suggestion that there is an atrial electromechanical delay in patients with migraine.

Mean platelet volume is associated with myocardial perfusion defect in diabetic patients

Aim

Our aim was to evaluate whether there was a relationship between mean platelet volume and myocardial perfusion defect in diabetic patients using myocardial perfusion imaging.

Method

Forty-four diabetic patients with myocardial perfusion defect (group 1) and 44 diabetic patients without myocardial perfusion defect (group 2), matched for age and gender, were retrospectively examined. Levels of mean platelet volume (MPV) in the two groups were assessed.

Results

MPV was higher in group 1 than group 2 patients (8.76 ± 0.76 and 8.25 ± 0.78 fl), respectively, p = 0.003). Levels of glucose, triglycerides (TG), total cholesterol (TC), low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, haemoglobin (Hb) and glycosylated haemoglobin (HbA_1c), and body mass index (BMI) in the two groups were not statistically significantly different. Multivariate logistic regression analyses showed that MPV was the only variable independently associated with myocardial perfusion defects (OR: 2.401, 95% CI: 1.298–4.440, p = 0.013).

Conclusion

This study showed that higher MPV was associated with myocardial perfusion defects. Higher MPV in diabetic patients was independently related to myocardial perfusion defects and may be an indicator of myocardial ischaemia.

Is there any relationship between RDW levels and atrial fibrillation in hypertensive patient?

BACKGROUND

Atrial fibrillation (AF) is the most common cardiac arrhythmia and increases the risk of stroke and death. Patients with hypertensive have an increased risk of developing atrial fibrillation. RDW (Red blood cell distribution width) levels are elevated in cardiovascular disorders including heart failure, stable coronary disease, acute coronary syndrome, slow coronary flow and stroke.

OBJECTIVE

We aimed to investigate the relation between RDW and AF in patients with hypertensive.

METHOD

We retrospectively examined 126 consecutive hypertensive patients (63 hypertensive patients with AF and 63 hypertensive patients without AF matched with age and sex.

RESULTS

The mean age of the study population was 71,09± 8,50 (af group) and 70,97±8,24 (non-af group) years. RDW level was different among patients with atrial fibrillation and without atrial fibrillation.(15,13±1,58 and 14,05±1,15 p<001) . Logistic regression analysis showed that RDW and left atrial dimension were only independently risk factory associated with atrial fibrillation. (Rdw odds ratio:1,846 CI; 1,221-2,793 p<0,05). Roc curve analyses were applied to determine the cut-off point. Cut-off point was at 14,195 and Sensitive, specificity was %71,4, %56 respectively.

CONCLUSION

RDW levels were higher in hypertensive patients with atrial fibrillation. An increased RDW level in the patient with hypertension may alert physician on developing or presence of atrial fibrillation.

A case of L-2 hydroxyglutaric aciduria presenting as febrile seizure

L-2 hydroxyglutaric aciduria (L2HGA) is a rare, infantile-onset, autosomal recessive organic aciduria affecting exclusively the central nervous system. A case is reported here of L2HGA presenting with macrocephaly and febrile seizure. Although there have been reports of epilepsy associated with L2HGA, to the best of our knowledge this is the second case in literature of febrile seizure in a patient with L2HGA. This report suggests that detailed neurological evaluation of macrocephalic children with febrile convulsion is important. Moreover, metabolic and genetic investigations may be necessary for these kinds of patients.

The effect of nebivolol on internal mammary artery blood flow during coronary artery bypass graft surgery

Background:

During coronary artery bypass grafting (CABG), one of the most important complications related to the internal mammary artery (IMA) is perioperative spasm. Nebivolol causes endothelium-dependent vascular relaxation by increasing nitric oxide (NO) release and prevents endothelial dysfunction in long-term use. In our study, we measured the effect of a third generation beta blocker, nebivolol, on the flow dynamics of IMA grafts.

Methods:

We recruited 90 hypertensive patients undergoing isolated CABG operation, who were divided into three groups and each group included 30 patients: Group 1 patients were under antihypertensive treatment other than beta-blockers (angiontensin-converting enzyme [ACE] inhibitors, calcium channel blockers or diuretics; monotherapy or combination therapy), Group 2 received metoprolol (50 mg/day) and Group 3 received nebivolol (5 mg/day). These antihypertensive therapies were given for at least one week before the operation and continued thereafter. IMA blood flow volume was measured for one minute just before cardiopulmonary bypass (measurement A) and before left internal mammary artery (LIMA)-left anterior descending (LAD) artery anastomosis (measurement B) in the three groups. Cardiac output measurements were also achieved simultaneously.

Results:

The measurement A results were 56.3 ± 36.2, 54.6 ± 28.1 and 66.8 ± 34.2 mL/min in Groups 1, 2 and 3, respectively (p<0.05). The measurement B results were 78.3 ± 29.6, 80 ± 28.8 and 91.1 ± 40.8 mL/min in Groups 1, 2 and 3 (p<0.05), respectively. There were no differences in cardiac outputs among the groups; 5.2 ± 1.4, 5.0 ± 1.6 and 5.3 ± 1.1 L/min (p>0.05). While the cardiac outputs were similar within the three groups, the IMA free flow volume was higher in the nebivolol group after local papaverine use.

Conclusion:

Nebivolol might represent a good choice in hypertensive patients undergoing cardiac surgery by preventing perioperative myocardial hypoperfusion which increases early morbidity and mortality.

The relationship between neutrophil/lymphocyte ratio and the TIMI flow grade in patients with STEMI undergoing primary PCI

OBJECTIVES

ST segment elevation myocardial infarction (STEMI) is an important cause of the morbidity and mortality in coronary artery disease. The aim of this study is to investigate the relationship between hematologic parameters and post primary PCI coronary no-reflow.

PATIENTS AND METHODS

A total of 145 consecutive STEMI patients (mean age=58.2±12.3 years) and healthy volunteer admitted within 6 hours from symptom onset were enrolled to the study in the cardiology clinics. The STEMI patients were divided into 2 groups based on the Thrombolysis In Myocardial Infarction (TIMI) flow grade. No-reflow was defined as post-PCI TIMI Flow Grade 0, 1 or 2 and angiographic success was defined as TIMI Grade 3 Flow.

RESULTS

Diabetes mellitus hypertension and smoking status were similar between groups. With respect to baseline laboratory status, fasting glucose, blood urea nitrogen, creatinine levels were not significantly different between groups. The neutrophil/lymphocyte (N/L) ratio was also significantly higher in STEMI group (7.1±4.6 vs. 2.3±1.7, p < 0.001). Additionally, N/L ratio was also significantly higher in No-reflow group (TIMI Flow Grade 0, 1 or 2) group (13.1±4.5 vs. 5.3±2.7, p < 0.001).

CONCLUSIONS

The N/L ratio, which is cheaply and easily measurable laboratory data is independently associated with post primary PCI coronary no-reflow.

Abnormal heart rate recovery in stable heart failure patients

BACKGROUND

Heart rate decrease after exercise, that is associated with reactivation of parasympathetic system, is important, as it is also associated with mortality. Previous studies have shown that this is an independent mortality predictor in patients having no coronary artery disease and having normal left ventricular function. In our study, we aimed to study heart rate recovery (HRR) after exercise in patients having impaired left ventricular function.

METHODS

One hundred and two consecutive patients (68 males, 34 females) requested to perform an exercise stress test were included in our study. Patients were divided into two groups as those having a normal heart rate reserve (Group1, n = 72) and those having an abnormal heart rate reserve (Group2, n = 30).

RESULTS

In Group1 and Group2, resting heart rate averages were found to be 83.61 ± 18.01/min and 85.10 ± 13.40/min, respectively (P > 0.05), and maximum heart rates during exercise were 141.42 ± 19.70/min and 121.17 ± 19.01/min while those in Group1 had statistically significantly higher heart rates (P < 0.001). A statistically significant positive association was found in the correlation test carried out between the maximum heart rate during the treadmill exercise test and ejection fraction (EF) value (r = 0.201; P < 0.05). Metabolic equivalents of task values obtained during the treadmill exercise test in Group1 and Group2 were 9.48 ± 2.28 and 8.36 ± 2.50, respectively, and the difference between the said values was statistically significant (P < 0.05).

CONCLUSIONS

We believe that the association between low EF and abnormal HRR is worth studying and randomized large-scale studies are needed to determine mortality risk.

What do patients really know about cardiopulmonary rehabilitation: a cross-sectional survey study

BACKGROUND

Although it is known that cardiopulmonary rehabilitation (CPR) reduces mortality and morbidity, it is not widely implemented as is in Turkey. One factor might be lack of demand since the levels of knowledge and awareness among patients who are eligible for CPR seem to be insufficient.

AIM

It is aimed to investigate the level of awareness and knowledge of CPR among patients with cardiopulmonary problems.

DESIGN

Cross-sectional survey study.

SETTING

Outpatient.

METHODS

Knowledge regarding CPR was assessed by questionnaires given to 690 patients recruited in seven university hospitals and six training and research hospitals in which either comprehensive or limited CPR services are available.

POPULATION

Patients who have cardiopulmonary problems

RESULTS

Of the patients, 34.7% were given information on CPR by healthcare staff, and 25.3% reported that their source of information was physicians. Although 49.9% of the patients knew that they needed to exercise for their cardiac/pulmonary problems, only 23.4% and 32.1% of those were aware that fast walking and climbing stairs, respectively, would not pose a risk to their cardiac/pulmonary health. The majority of the patients believed that activities of daily living, which comprise the most important component of exercise-based CPR, were harmful for their cardiopulmonary health. We found that 31.1% of the patients exercised regularly. During their stay at the hospital, certain kinds of exercises were suggested to 62.7% of the patients, and 34.7% of these patients performed various exercises. Of the patients who were given detailed information on cardiopulmonary rehabilitation, 69% stated that they would be willing to participate in a similar program.

CONCLUSION

Although nearly half of the patients stated that they needed CR, it was observed that the ratio of patients who had true knowledge of CPR was low among patients. It is imperative to furnish patients with information on CPR, both in the field of PMR and throughout Turkey, and to put more effort into running those services effectively. Furthermore, we should make an effort to increase the level of liaison between patients and physicians and other healthcare professionals who participate in the treatment of cardiac/pulmonary patients.

Increased γ-glutamyl transferase levels predict early mortality in patients with acute pulmonary embolism

BACKGROUND

Increased γ-glutamyl transferase (GGT) level is associated with increased oxidative stress, all-cause mortality, the development of cardiovascular disease, and metabolic syndrome. However, its role in acute pulmonary embolism (PE) is unknown. In this study, we aimed to investigate the relationship between GGT and early mortality in patients with acute PE.

METHODS

A total of 127 consecutive patients with confirmed PE were evaluated. The optimal cutoff value of GGT to predict early mortality was measured as more than 55 IU/L with 94.4% sensitivity and 66.1% specificity. Patients with acute PE were categorized prospectively as having no increased (group I) or increased (group II) GGT based on a cutoff value.

RESULTS

Of these 127 patients, 18 patients (14.2%) died during follow-up. Among these 18 patients, 1 (1.4%) patient was in group I, and 17 (30.9%) patients were in group II (P < .001). γ-Glutamyl transferase level on admission, presence of shock, heart rate, oxygen saturation, right ventricular dilatation/hypokinesia, main pulmonary artery involvement, troponin I, alanine aminotransferase, alkaline phosphatase, and creatinine levels were found to have prognostic significance in univariate analysis. In the multivariate Cox proportional hazards model, GGT level on admission (hazard ratio [HR], 1.015; P = .017), presence of shock (HR, 15.124; P = .005), age (HR, 1.107; P = .010), and heart rate (HR, 1.101; P = .032) remained associated with an increased risk of acute PE-related early mortality after the adjustment of other potential confounders.

CONCLUSIONS

We have shown that a high GGT level is associated with worse hemodynamic parameters, and it seems that GGT helps risk stratification in patients with acute PE.

Relationship between penile fracture and Peyronie's disease: a prospective study

Peyronie's disease is postulated to be initiated by repetitive minor traumas to the fully or partially erect penis. We investigated Peyronie's disease prospectively in cases treated for penile fracture (PF) within the last 20 years. Medical records of 63 cases treated for PFs were reviewed. Subjects were required to self-assess their current penile morphologies and sexual functions. Penile nodules and Peyronie's plaques were also evaluated with physical examination, ultrasonography and magnetic resonance imaging (MRI), and penile curvatures with auto-photography, and sexual function with international erectile function index (IIEF). Of the 63 cases (mean age 37 years), 46 who had mean follow-up of 63 months were re-evaluated. The mean IIEF-5 score was 23.2±3.1. Painful erections (n=5), penile nodules (n=5) and also penile curvatures <20° (n=2) were investigated. No Peyronie's plaque was palpated in any of the cases. Ultrasound and MRI showed fibrotic nodules of 5 mm in diameter, which extended into the subtunical area in the rupture site in 54% of the cases, although any thickening and Peyronie's plaque were not found in the tunica albuginea and intracavernosal septum of the cases examined. In PF patients treated surgically, the erectile function and penile morphology were preserved. In our cases PFs did not induce the development of Peyronie's disease.

Dyke-Davidoff-Masson syndrome revisited: a didactic case with interesting imaging findings

We present an adult female patient with Dyke-Davidoff-Masson syndrome with distinct features, and discuss neuroimaging findings some of which are unique to this syndrome.

Bone mineral density and bone turnover markers of patients with Behçet's disease

BACKGROUND

Behçet's disease (BD) is a systemic inflammatory disease of unknown aetiology. The pathogenesis of rheumatological findings and the status of bone metabolism in this disease are unknown. Inflammatory diseases may predispose to a decrease in bone mineral density (BMD) and there are many studies concerning osteoporosis in chronic inflammatory diseases.

OBJECTIVE

The aim of this study was to investigate BMD and bone turnover markers in patients with BD.

METHODS

Thirty BD patients (17 male and 13 female patients, mean age 36.9+/-12.6 years) and a total of 30 age- and sex-matched healthy controls (17 male and 13 female controls, mean age 34.9+/-8.95 years) recruited from the general population were enrolled in the study. Bone mineral density was measured at the lumbar spine (L1-4) and the left hip (total hip) using dual energy X-ray absorptiometry. Serum samples were collected between 8 and 10 am after overnight fasting. Serum calcium (Ca), phosphate (P), parathormone (PTH), total alkaline phosphatase (ALP), osteocalcin (OC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were measured. Free deoxypyridinoline cross-links (DPD) in second-void urine and total daily urinary calcium excretion were analysed.

RESULTS

No statistically significant difference in lumbar spine or femoral BMD and bone turnover markers were found between BD patients and control groups (P>0.05).

CONCLUSION

Although it is difficult to draw definite conclusions because of the limited number of patients involved, our study indicates that bone mineral density and bone turnover markers in Behçet's disease were no different than in healthy subjects.

Effect of underground working on vitamin D levels and bone mineral densities in coal miners: a controlled study

The aim of this study was to determine the effect of underground working on 25-hydroxyvitamin D (25-OHD) levels and bone mineral density (BMD) values in coal miners. Fifty coal miners working underground and 50 surface workers as controls, matched for age and body mass index, from Zonguldak, Turkey, were recruited to the study. Levels of 25-OHD, biochemical bone markers, and lumbar spine and femur BMD values were measured in all study participants. Lumbar spine and femur BMD values were significantly higher in underground workers compared with surface workers, but there was no significant difference in 25-OHD levels between the two groups. Duration of underground working, age, 25-OHD levels, cigarette consumption and dietary calcium intake were not correlated with BMD values. Underground physical working does not seem to be a significant risk factor for low 25-OHD levels or low BMD values.

Somatic angiotensin converting enzyme in varicocele

The ACE is found as two isozymes in the body. A somatic isozyme found in blood and several other tissues, and a testis-specific isozyme found only in developing spermatids and mature sperm. In this study, we investigated the ACE activity in left spermatic vein blood samples of infertile patients with varicocele and its correlation to spermatologic parameters. The somatic ACE activities were determined in the peripheral and left spermatic vein blood samples from 31 infertile patients who underwent variococelectomy, and 11 fertile control subjects underwent left inguinal herniorraphy. The somatic ACE activity was measured by kinetic spectrophotometric assay. Semen analyses were performed according to WHO guidelines. The mean somatic ACE activities of peripheral and left spermatic veins of the varicocele group were 60.3 +/- 23.0 and 60.2 +/- 23.2 U/L, respectively. In control group, peripheral and left spermatic vein ACE activities were found as 56.8 +/- 17.1 and 56.5 +/- 15.5 U/L, respectively. There was no significant difference between the ACE activity in peripheral and left spermatic vein blood sample from the varicocele and control group. There was no statistically significant correlation between the spermatologic parameters and ACE activities in the spermatic and peripheral vein in both of varicocele and control groups. As a result, it may be suggested that the somatic ACE has no causative role in pathophysiology of varicocele and varicocele related infertility.

Response to growth hormone with respect to pubertal status on increased dose in idiopathic growth hormone deficiency: an analysis of Turkish children in the KIGS database (Pfizer International Growth Study)

AIM

To compare the growth response to growth hormone (GH) treatment in patients with idiopathic GH deficiency (IGHD) who were prepubertal with the response of those who were pubertal at the onset of GH therapy on an increased GH dose.

PATIENTS AND METHODS

Among the Turkish patients enrolled in the Pfizer International Growth Study (KIGS) database with the diagnosis of IGHD, the growth data over 2 years of GH therapy were analyzed longitudinally of 113 (79 M) prepubertal (Group 1) and 44 (33 M) pubertal (Group 2) patients. Pubertal signs were reported to be present initially or to have appeared within 6 months of GH therapy in Group 2. Mean +/- SD age at onset of therapy was 8.7 +/- 3.5 and 13.5 +/- 1.8 years; height SDS -4.2 +/- 1.4 and -3.2 +/- 1.1 (p < 0.05) in Groups 1 and 2, respectively. Mid-parental height (MPH) SDS did not show a significant difference between the two groups (-1.5 +/- 1.1 vs -1.7 +/- 1.1).

RESULTS

Delta height SDS over 2 years of therapy was significantly higher in Group 1 (1.1 +/- 1.0) than in Group 2 (0.7 +/- 0.6) (p <0.05) in spite of a significantly lower dose of GH (14.6 +/- 3.3 in Group 1 vs 17.0 +/- 3.1 IU/m2/week in Group 2, p < 0.05). Ht--MPH SDS showed an increase from -2.4 +/- 1.7 to -1.4 +/- 1.5 in Group 1 and from -1.5 +/- 1.5 to -0.8 +/- 1.3 in Group 2. Overall delta height SDS showed negative correlations with age (r = -0.32), height SDS (r = -0.41) and height--MPH SDS (r = -0.40) at onset of therapy (p < 0.001).

CONCLUSIONS

These data show that in IGHD the slight increase (15-20%) in the dose of GH during puberty was not adequate to maintain height velocity at the same magnitude as in prepuberty, and thus was not cost effective.

Impact of Ramadan on demographics and frequencies of disease-related visits in the emergency department

Summary The objective of this study was to determine whether Ramadan is changing frequencies and demographics of visits due to certain diseases. Data obtained from the charts of the adult patients admitted into the emergency department (ED) due to 10 predetermined entities between 2000 and 2004 were analysed. Demographic variables analysed separately for certain entities visiting the ED in Ramadan were not found to be different from visits in other times of year. Visit frequencies for hypertension and uncomplicated headache in Ramadan were significantly higher than in non-Ramadan months (chi(2) test, p = 0.015 for hypertension, p < 0.001 for uncomplicated headache). Mean age of the patients admitted to the ED due to diabetes-related conditions in Ramadan was significantly lower than in pre- and post-Ramadan months (59.91 +/- 14.60 and 62.11 +/- 14.61, respectively) (Mann-Whitney U-test, p = 0.032). The patients with diabetes presenting in Ramadan were found significantly younger than their peers in the rest of the year. For other diseases, Ramadan does not appear to be a risk factor.

Analysis of factors affecting pain in intravenous catheter placement: a survey of 925 patients

The aim of the study was to determine some factors affecting pain during intravenous (i.v.) catheter placement in an emergency department (ED). A cross-sectional, observational study was conducted at an academic ED. Nine hundred and twenty five adult patients who had a 20 gauge i.v. catheter placed were enrolled the study. Patients were excluded for the following conditions: more than one i.v. attempt, altered mental status, head trauma, lack of contact due to visual impairment, hearing or speech disorder, intoxication, distracting injury or physical abnormality at the i.v. site. The magnitude of pain of i.v. catheter placement was not related to age, sex, experience of the individual placing the i.v. catheter, site of i.v. catheter insertion and use of analgesic or antidepressive drugs (p > 0.05). Patients with a history of depression reported significantly higher pain than non-depressive patients (p = 0.001). Depressive patients reported higher severity of pain during i.v. catheter placement than nondepressed ones. This may influence the decision on whether or not to use local anaesthesia for catheter insertion.

Factors affecting pain in intravenous catheter placement: role of depression illness

The aim of the study was to examine factors affecting pain during intravenous (IV) catheter placement in an emergency department. A cross-sectional, observational study was conducted at an academic emergency department. Nine hundred and twenty-five adult patients who had a 20-gauge IV catheter placed were enrolled in the study. Patients were excluded for the following conditions: more than one IV attempt, altered mental status, head trauma, lack of contact due to visual impairment, hearing or speech disorder, intoxication, distracting injury or physical abnormality at the IV site. The magnitude of pain in IV catheter placement was not related to age, sex, experience of the individual placing the IV catheter, site of IV catheter insertion and use of analgesic or antidepressant drugs (p > 0.05). Patients with a history of depression reported significantly higher pain than non-depressed patients (p = 0.001). Depressed patients reported higher severity of pain during IV catheter placement than non-depressed ones. This may influence the decision on whether or not to use local anaesthesia for catheter insertion.

Laser-Assisted Fluoroscopic Puncture: A New Technique for Accessing the Kidney

PURPOSE

We developed a laser pointer device that is mounted on the image intensifier of a C-arm fluoroscope. The laser-assisted fluoroscopic puncture technique (LAFPT) is an alternative method of accessing the kidney.

MATERIALS AND METHODS

The LAFPT was assessed both in an in vitro model and in a series of cases. The in vitro model was composed of Foley balloons filled with contrast medium of different volumes (2-6 mL) embedded in silicone pads. The total fluoroscopy times and attempts required for a successful puncture with LAFPT were compared with those of conventional fluoroscopic access.

RESULTS

The number of attempts required to puncture the 2-mL balloons was significantly greater with the conventional fluoroscopic technique than with LAFPT. The fluoroscopy time in vitro was reduced 50% with LAFPT. However, there was no statistically significant difference in the time required for the two techniques in the clinical series.

CONCLUSION

The laser-assisted fluoroscopic puncture technique allows accurate positioning of a needle with reduced radiation exposure.

p53 and bcl-2 overexpression as associated risk factors in patients 40 years old or less with transitional cell carcinoma of the bladder

OBJECTIVES

Transitional cell carcinoma (TCC) of the bladder in younger patients has historically a favourable prognosis. bcl-2 and p53 genes are implicated in cell cycle regulation with roles on programmed cell death. Presence of nuclear accumulation of p53 and cytoplasmic accumulation of bcl-2 were proposed to confer a growth advantage to tumour cells. In this study, we investigated the roles of p53 and bcl-2 as prognostic factors in TCC of bladder in patients younger than 40 years.

PATIENTS AND METHODS

From 1986 to 1998, 25 patients younger than 40 years were treated for TCC of bladder in our hospital. Of the tumour specimens, 24 were adequate for evaluating p53 and bcl-2 oncoproteins (group I). As a control (group II), we randomly selected 30 patients older than 50 years treated for bladder cancer in this period. Two oncoproteins were detected by immunohistochemical analysis in paired tumour tissue specimens in both groups. Retrospectively obtained clinical follow-up data were available, with a mean follow-up of 44 and 25.5 months in groups I and II, respectively. Relations between tumour recurrences and progression with positivity of bcl-2 and p53 were investigated.

RESULTS

Expression of bcl-2 was observed in 13 (54.1%) and 11 (36.7%) and nuclear p53 accumulation in 9 (37.5%) and 17 (56.7%) of groups I and II, respectively. In the presence of p53 expression, tumours showed significantly more progression in group I (55 vs. 6.7%) and group II (41.1 vs. 0%). Recurrence rates were not significantly different in tumours with and without nuclear p53 overexpression in both groups. Also, recurrence and progression rates were not significantly different in tumours with and without cytoplasmic bcl-2 overexpression in both groups. Grade (G) and stage appeared as important prognostic factors in both groups since 60% of GIII tumours showed progression in group I, but none of GI and GII tumours. Similarly, 75% of T3 tumours progressed, while these rates were 25 and 25% for T1-T2 tumours in group I. In group II, 31.2, 25 and 0% of GIII, GII and GI tumours progressed, while 50, 41.6 and 0% of T3, T2 and T1 tumours progressed, respectively.

CONCLUSIONS

Nuclear p53 expression in TCC appears to be associated with a poorer prognosis in both younger and older patients. Although cytoplasmic bcl-2 overexpression is found in the majority of tumours in the younger group, it is not associated with tumour progression and recurrence.

Is Bone-wax an injectable urologic material?

OBJECTIVE

Injection of endoscopic material for reflux and incontinence therapies became popular in urology because of its simplicity and repeatability. Research is going on to develop an ideal injectable material. In this experimental study we investigated whether the bone wax used for osteotomy hemostasis in orthopedic and neurosurgical operations could be used as an injectable material.

MATERIALS AND METHODS

A total of 20 rabbits were included in the study: 6 underwent a sham operation, and in the remaining 14 rabbits, 0.5 ml bone wax liquefied with n-butyl acetic acid was injected submucosally via a 20-gauge needle at three different points on the anterior bladder wall. Cystectomy was performed on the 15th day in 2 rabbits (group I), on the 60th day in 2 (group II) and on the 150th day in 10 (group III). 0.20 ml bone wax was also injected subcutaneously and intramuscularly 7 days before cystectomy in group III. Bladders were examined macroscopically and histopathologically. All animals' lungs, livers, kidneys, spleens and brains were also removed and examined histologically.

RESULTS

Submucosal swellings of bone wax maintained their localizations and shapes in all groups and all of the 42 bone-wax injection sites could be easily identified. Histologically, slight edema around the implant was seen in group I. In group II, collagen was increased around the implants and minimal hyperplasia of the epithelium overlaying bone wax was noted. 150 days after the injections, moderate collagen production and a mild increase in vascularity were seen around the implants. There was no macroscopic or microscopic evidence that implants migrated to locations other than the injection sites.

CONCLUSIONS

When injected to the bladder submucosa, bone wax seems to be inert and biocompatible, encouraging further research to develop it as an alternative agent in the endoscopic treatment of vesicoureteral reflux and sphincteric incontinence.

Boswellic acids inhibit glioma growth: a new treatment option?

Conventional malignant glioma therapy (surgery, radiation therapy and chemotherapy) does not yield satisfying results. The prognosis of the glioma patient depends more on the histological grading of the tumor and patient's age than on the therapy. Especially the adjuvant chemotherapy failed to date to influence survival time in glioma patients significantly. To improve results in malignant glioma therapy additional therapeutic regimes are necessary. In an earlier study we were able to show a significant reduction on perifocal edema by an extract from gum resin (EGR) accompanied with a clinical improvement in patients with malignant glioma. Also a decrease of urinary LTE4-excretion as a metabolite of leukotriene synthesis in brain tumors was observed. Furthermore we had found a proliferation inhibiting activity of the extract form EGR, the boswellic acids in cell cultures. The purpose of this experimental study was to elucidate the effects of the boswellic acids, which are constituents of an extract from gum resin on tumor growth in vivo. Female wistar rats weighing 200-250 g were treated with the drug 14 days after inoculation of C6 tumor cells into their right caudate nucleus and randomization into 4 groups. The treatment groups received different dosages and were compared to a control group without any additional treatment. Survival time of the rats in the highest dosage group (3 x 240 mg/kg body weight) was more than twice as long as in the control group (P < 0.05). In a second experiment the inhibition of tumor cell proliferation was examined. The C6 tumor cells were implanted into the caudate nucleus. Drug treatment was started immediately after implantation and stopped after 14 days. The animals were sacrificed and the brains were examined microscopically. Comparing low and high dosage of EGR treatment a significant difference in tumor volume was detected (P < 0.05). The proportion of apoptotic tumor cells in animals with high dose treatment was significantly larger than in the low dose (treatment) group (P < 0.05). These data demonstrate an influence of EGR in rat glioma growth and might represent a new therapeutic option on glioma treatment in man in future. Further experimental work on human gliomas is needed to definitively answer this question.

Fournier's gangrene: risk assessment and enzymatic debridement with lyophilized collagenase application

OBJECTIVES

Fournier's gangrene (FG) is an abrupt, rapidly progressive, gangrenous infection of the external genitalia, perineum or abdominal wall and is a real urologic emergency. In this study, the risk factors of FG and the effects of enzymatic debridements on wound healing were investigated.

PATIENTS AND METHODS

We reviewed the records of 34 patients with FG to investigate the possible correlation between clinical outcome and infection focus, patient age, number of types of bacteria cultured, delay until presentation, predisposing diseases or accompanying conditions such as diabetes, neurologic deficit, chronic alcoholism and renal failure. Broad-spectrum triple antimicrobial therapy, aggressive and frequent surgical debridement, and if necessary urinary and colonic diversions were performed to control the infection. The effects of enzymatic debridements with topical lyophilized collagenase applications on the wound healing after the control of active infection were evaluated.

RESULTS

The average age of the patients was 55 years. The sources of infections were urogenital in 12 (35.3%), anorectal in 10 (29.4%), dermal in 10 (29.4%) and undetermined in 2 (5.8%) of the patients. The average presentation time was 4.4 days and the number of isolated bacteria was 3.05 per case. The number of isolated bacteria and surgical debridements, the duration of hospital stay and the rate of mortality in patients with anorectal foci were higher than those of the patients with urogenital or dermal foci (p < 0.05). Diabetes, uremia and advanced age did not significantly affect the number of surgical debridements, the duration of hospital stay and control of active infection. Mortality was increased in chronic alcoholism, a finding of undetermined significance. Enzymatic debridements decreased the duration of hospital stay (p < 0.05). Five patients (14.7%) died despite prompt medical and surgical preventive measures.

CONCLUSION

Chronic alcoholism, anorectal infection foci, neurological deficit and delayed presentation were found as risk factors in FG. Diabetes and advanced age did not affect the progression of disease in our cases. Enzymatic debridements decrease the number of surgical debridements and the duration of hospital stay.