Pathogens in Pediatric Septic Arthritis: A Multi-Center Study in Turkiye (PEDSART Study)

OBJECTIVES

Septic arthritis (SA) is a serious bacterial infection that must be treated efficiently and timely. The large number of culture-negative cases makes local epidemiological data important. Accordingly, this study aimed to evaluate the etiology, clinical characteristics, and therapeutic approach of SA in children in Turkiye, emphasizing the role of real-time polymerase chain reaction (PCR) techniques in the diagnosis.

METHODS

In this multi-center, prospective study, children hospitalized due to SA between February 2018 and July 2020 in 23 hospitals in 14 cities in Turkiye were included. Clinical, demographic, laboratory, and radiological findings were assessed, and real-time PCR was performed using synovial fluid samples.

RESULTS

Seventy-five children aged between 3 and 204 months diagnosed with acute SA were enrolled. Joint pain was the main complaint at admission, and the most commonly involved joints were the knees in 58 patients (77.4%). The combination of synovial fluid culture and real-time PCR detected causative bacteria in 33 patients (44%). In 14 (18.7%) patients, the etiological agent was demonstrated using only PCR. The most commonly isolated etiologic agent was Staphylococcus aureus, which was detected in 22 (29.3%) patients, while Streptococcus pyogenes was found in 4 (5.3%) patients and Kingella kingae in 3 (4%) patients. Streptococcus pyogenes and Kingella kingae were detected using only PCR. Most patients (81.3%) received combination therapy with multiple agents, and the most commonly used combination was glycopeptides plus third-generation cephalosporin.

CONCLUSIONS

Staphylococcus aureus is the main pathogen in pediatric SA, and with the use of advanced diagnostic approaches, such as real-time PCR, the chance of diagnosis increases, especially in cases due to Kingella kingae and Streptococcus pyogenes.

Evaluation of 601 children with multisystem inflammatory syndrome (Turk MISC study)

PURPOSE

Due to its link with the 2019 coronavirus, the multisystem inflammatory syndrome in children (MISC) has garnered considerable international interest. The aim of this study, in which MISC patients were evaluated multicenter, and the data of the third period of the Turk-MISC study group, to compare the clinical and laboratory characteristics and outcomes of MISC patients who did and did not require admission to an intensive care unit (ICU).

METHODS

This retrospective multicenter observational study was carried out between June 11, 2021, and January 01, 2022. The demographics, complaints, laboratory results, system involvements, and outcomes of the patients were documented.

RESULTS

A total of 601 patients were enrolled; 157 patients (26.1%) required hospitalization in the intensive care unit (ICU). Median age was 8 years (interquartile range (IQR) 4.5-11.3 years. The proportion of Kawasaki disease-like features in the ICU group was significantly higher than in the non-ICU group (56.1% vs. 43.2% p = 0.006). The ICU group had considerably lower counts of both lymphocytes and platelets (lymphocyte count 900 vs. 1280 cells × μL, platelet count 153 vs. 212 cells × 103/ μL, all for p< 0.001). C-reactive protein, procalcitonin, and ferritin levels were significantly higher in the ICU group (CRP 164 vs. 129 mg/L, procalcitonin 9.2 vs. 2.2 μg/L, ferritin 644 vs. 334 μg/L, all for p< 0.001). Being between ages 5-12 and older than 12 increased the likelihood of hospitalization in the ICU by four [95% confidence intervals (CI)1.971-8.627] and six times (95% CI 2.575-14.654), respectively, compared to being between the ages 0-5. A one-unit increase in log D-dimer (µg/L) and log troponin (ng/L) was also demonstrated to increase the need for intensive care by 1.8 (95% CI 1.079-3.233) and 1.4 times (95% CI 1.133-1.789), respectively.     Conclusion: By comparing this study to our other studies, we found that the median age of MISC patients has been rising. Patients requiring an ICU stay had considerably higher levels of procalcitonin, CRP, and ferritin but significantly lower levels of lymphocyte and thrombocyte. In particular, high levels of procalcitonin in the serum might serve as a valuable laboratory marker for anticipating the need for intensive care.

WHAT IS KNOWN

• Lymphopenia and thrombocytopenia were an independent predictor factors in patients with MISC who needed to stay in intensive care unit. • The possibility of the need to stay in the intensive care unit in patients with MISC who had Kawasaki disease-like findings was controversial compared with those who did not.

WHAT IS NEW

• A one-unit increase log D dimer and log troponin was demonstrated to require for intensive care unit by 1.8 and 1.4 times, respectively. • Serum procalcitonin levels had the best performance to predict stay in the intensive care unit stay.

Multisystem inflammatory syndrome in children associated with COVID-19 in 101 cases from Turkey (Turk-MISC study)

AIM

Multisystem inflammatory syndrome in children (MIS-C) may cause shock and even death in children. The aim of this study is to describe the clinical features, laboratory characteristics and outcome of children diagnosed with MIS-C in 25 different hospitals in Turkey.

METHODS

The retrospective study was conducted between 8 April and 28 October 2020 in 25 different hospitals from 17 cities. Data were collected from patients' medical records using a standardised form. Clinical and laboratory characteristics and outcomes according to different age groups, gender and body mass index percentiles were compared using multivariate logistic regression analysis.

RESULTS

The study comprised 101 patients, median age 7 years (interquartile range (IQR) 4.6-9.3); 51 (50.5%) were boys. Reverse-transcriptase polymerase chain reaction (PCR) assay was positive in 21/100 (21%) patients; 62/83 (74.6%) patients had positive serology for SARS-CoV-2. The predominant complaints were fever (100%), fatigue (n = 90, 89.1%), and gastrointestinal symptoms (n = 81, 80.2%). Serum C-reactive protein (in 101 patients, median 165 mg/L; range 112-228), erythrocyte sedimentation rate (73/84, median 53 mm/s; IQR 30-84) and procalcitonin levels (86/89, median 5 μg/L; IQR 0.58-20.2) were elevated. Thirty-eight patients (37.6%) required admission to intensive care. Kawasaki disease (KD) was diagnosed in 70 (69.3%) patients, 40 of whom had classical KD. Most patients were treated with intravenous immunoglobulin (n = 92, 91%) and glucocorticoids (n = 59, 58.4%). Seven patients (6.9%) died.

CONCLUSION

The clinical spectrum of MIS-C is broad, but clinicians should consider MIS-C in the differential diagnosis when persistent fever, fatigue and gastrointestinal symptoms are prominent. Most patients diagnosed with MIS-C were previously healthy. Immunomodulatory treatment and supportive intensive care are important in the management of cases with MIS-C. Glucocorticoids and intravenous immunoglobulins are the most common immunomodulatory treatment options for MIS-C. Prompt diagnosis and prompt treatment are essential for optimal management.

COVID-19 associated multisystemic inflammatory syndrome in 614 children with and without overlap with Kawasaki disease-Turk MIS-C study group

Multisystemic inflammatory syndrome (MIS-C) diagnosis remains difficult because the clinical features overlap with Kawasaki disease (KD). The study aims to highlight the clinical and laboratory features and outcomes of patients with MISC whose clinical manifestations overlap with or without KD. This study is a retrospective analysis of a case series designed for patients aged 1 month to 18 years in 28 hospitals between November 1, 2020, and June 9, 2021. Patient demographics, complaints, laboratory results, echocardiographic results, system involvement, and outcomes were recorded. A total of 614 patients were enrolled; the median age was 7.4 years (interquartile range (IQR) 3.9-12 years). A total of 277 (45.1%) patients with MIS-C had manifestations that overlapped with KD, including 92 (33.3%) patients with complete KD and 185 (66.7%) with incomplete KD. Lymphocyte and platelet counts were significantly lower in patients with MISC, overlapped with KD (lymphocyte count 1080 vs. 1280 cells × μL, p = 0.028; platelet count 166 vs. 216 cells × 103/μL, p < 0.001). The median serum procalcitonin levels were statistically higher in patients overlapped with KD (3.18 vs. 1.68 µg/L, p = 0.001). Coronary artery dilatation was statistically significant in patients with overlap with KD (13.4% vs. 6.8%, p = 0.007), while myocarditis was significantly more common in patients without overlap with KD features (2.6% vs 7.4%, p = 0.009). The association between clinical and laboratory findings and overlap with KD was investigated. Age > 12 years reduced the risk of overlap with KD by 66% (p < 0.001, 95% CI 0.217-0.550), lethargy increased the risk of overlap with KD by 2.6-fold (p = 0.011, 95% CI 1.244-5.439), and each unit more albumin (g/dl) reduced the risk of overlap with KD by 60% (p < 0.001, 95% CI 0.298-0.559).

CONCLUSION

Almost half of the patients with MISC had clinical features that overlapped with KD; in particular, incomplete KD was present. The median age was lower in patients with KD-like features. Lymphocyte and platelet counts were lower, and ferritin and procalcitonin levels were significantly higher in patients with overlap with KD.

WHAT IS KNOWN

• In some cases of MIS-C, the clinical symptoms overlap with Kawasaki disease. • Compared to Kawasaki disease, lymphopenia was an independent predictor of MIS-C.

WHAT IS NEW

• Half of the patients had clinical features that overlapped with Kawasaki disease. • In patients whose clinical features overlapped with KD, procalcitonin levels were almost 15 times higher than normal. • Lethargy increased the risk of overlap with KD by 2.6-fold in MIS-C patients. • Transient bradycardia was noted in approximately 10% of our patients after initiation of treatment.

Active and Latent Tuberculosis in Children Treated with Anti-TNF-α: A Retrospective Multicenter Study

Objective This study aimed to investigate the frequency of latent and active tuberculosis (TB) in pediatric patients receiving anti-tumor necrosis factor (TNF)-α therapy.

Methods Patients younger than 18 years with various inflammatory diseases and treated with anti-TNF-α agents in the past five years were included in the study. The patients' ages, follow-ups, medications received, clinical and laboratory findings, and treatments applied were recorded retrospectively.

Results Of the 160 patients included in the study, 78 (48.8%) were girls. The mean age was 139.54 ± 48.74 (30–226) months. Sixty (37.5%) patients had inflammatory eye disease, 55 (34.4%) had rheumatologic and autoimmune disease, and 45 (28.1%) had inflammatory bowel disease. As anti-TNF-α treatment, 67 (41.9%) patients received adalimumab, 50 (31.2%) received infliximab, and 43 (26.9%) received etanercept. As a result of TB screening performed prior to the treatment, 44 (25.4%) patients were started on isoniazid treatment with the diagnosis of latent TB. During follow-up, latent TB infection was detected in 16 (9.2%) patients and isoniazid treatment was started. The time to develop latent TB under anti-TNF-α treatment ranged from 3 to 28 months. During the treatment, active TB infection developed in two (1.2%) patients and anti-TB treatment was initiated.

Conclusion It is of vital importance to evaluate patients receiving, or planned to receive, anti-TNF-α treatment, for TB infection and to initiate appropriate treatments if latent or active TB infection is identified.

Antifungal consumption, indications and selection of antifungal drugs in paediatric tertiary hospitals in Turkey: Results from the first national point prevalence survey

OBJECTIVES

The aim of this point prevalence survey was to evaluate the consumption, indications and strategies of antifungal therapy in the paediatric population in Turkey.

METHODS

A point prevalence study was performed at 25 hospitals. In addition to general data on paediatric units of the institutes, the generic name and indication of antifungal drugs, the presence of fungal isolation and susceptibility patterns, and the presence of galactomannan test and high-resolution computed tomography (HRCT) results were reviewed.

RESULTS

A total of 3338 hospitalised patients were evaluated. The number of antifungal drugs prescribed was 314 in 301 patients (9.0%). Antifungal drugs were mostly prescribed in paediatric haematology and oncology (PHO) units (35.2%), followed by neonatal ICUs (NICUs) (19.6%), paediatric services (18.3%), paediatric ICUs (PICUs) (14.6%) and haematopoietic stem cell transplantation (HSCT) units (7.3%). Antifungals were used for prophylaxis in 147 patients (48.8%) and for treatment in 154 patients (50.0%). The antifungal treatment strategy in 154 patients was empirical in 77 (50.0%), diagnostic-driven in 29 (18.8%) and targeted in 48 (31.2%). At the point of decision-making for diagnostic-driven antifungal therapy in 29 patients, HRCT had not been performed in 1 patient (3.4%) and galactomannan test results were not available in 12 patients (41.4%). Thirteen patients (8.4%) were receiving eight different antifungal combination therapies.

CONCLUSION

The majority of antifungal drugs for treatment and prophylaxis were prescribed in PHO and HSCT units (42.5%), followed by ICUs. Thus, antifungal stewardship programmes should mainly focus on these patients within the availability of diagnostic tests of each hospital.

Do proinflammatory cytokine levels predict serious complication risk of infection in pediatric cancer patients?

Determination of risk of severe bacterial infection complication in children with cancer is important to diminish the cost of hospitalization and therapy. In this study, children with cancer (leukemia excluded) were evaluated for risk of severe infection complication, success of therapy and the relation between clinical and inflammatory parameters during neutropenic fever attacks. Children who fulfilled the criteria of neutropenic fever with cancer were enrolled in the study. During admission, together with clinical and laboratory parameters; interleukin-6, interleukin-8, soluble tumor necrosis factor receptor II, and soluble interleukin 2 reseptor ve procalcitonin levels were detected. Empirical therapy was started with piperacillin/tazobactam and relation between the inflammatory cytokine levels and therapy response parameters were evaluated. The study population included 31 children and 50 neutropenic attacks were studied. In 48% of the attacks, absolute neutrophile count was >100/mm(3) and infectious agents were shown microbiologically in 12% of the attacks. In the study group with piperacillin/tazobactam monotherapy, the success rate without modification was 58%. In the therapy modified group mean duration of fever, antibiotherapy and hospitalization were significantly longer than the group without modification. Inflammatory cytokines' levels during admission (interleukin-6, interleukin-8, soluble tumor necrosis factor reseptor II) were higher in patients with fever >3 days and in multiple regression analysis, it has been shown that they have a determinative role on fever control time. Other cytokines did not show any significant relationship with risk of severe bacterial infection complication and success of therapy.

Trends in smoking among university students between 2005-2012 in Sakarya, Turkey

Turkey protects its entire population of 75 million people with all the MPOWER measures at the highest level. The aim of this study is to make a comparison of smoking and addiction data obtained from Sakarya University students in 2005-6 and 2012-13. A total of 4,200 (2,500 and 1,700 for each academic year) students at Sakarya University in Sakarya, Turkey, were randomly selected for sampling purposes. The selected participants represented Sakarya University students. Data were collected using a pretested anonymous and confidential, self-completed questionnaire which took 15-20 minutes to complete and Fagerstrom Test for nicotine dependence. Chi-squared, Spearman correlation, and binary logistic regression tests were used to define associations, if any. The level of significance was kept at alpha=0.05. Smoking prevalence dropped by 8.5% (from 26.9% to 18.5%). Male gender, older age, high family smoking index, low self-rated school success, and high peer smoker proportion were common variables that have correlation with smoking status. In the binary logistic regression test the highest contributor to "being a smoker" was found to be the rate of peer smokers. Having all friends smoking puts the student a a 47.5 and 58.0 times higher risk for smoking for males and females, respectively. Our results suggest an admirable diminution of smoking prevalence among Sakarya University students, which can be attributed to MPOWER protection.

Comparison of tubular and panel type photobioreactors for biohydrogen production utilizing Chlamydomonas reinhardtii considering mixing time and light intensity

Two different photobioreactor designs; tubular and panel, were investigated for the biohydrogen production utilizing a green microalgae Chlamydomonas reinhardtii strain CC124 following the two stage protocol. Mixing time and light intensity of the systems were adjusted to compare the productivity of both aerobic culture phase and the following anaerobic biohydrogen production phase. The results showed there was an effect on both phases related with the design. During the aerobic phase bigger illumination area serving more energy, tubular photobioreactor reached higher biomass productivity of 31.8±2.1 mg L(-1) h(-1) which was about 11% higher than the panel photobioreactor. On the other hand biohydrogen productivity in the panel photobioreactor reached a value of 1.3±0.05 mL L(-1) h(-1) based on the efficient removal of biohydrogen gas. According to the results it would be a good approach to utilize tubular design for aerobic phase and panel for biohydrogen production phase.

Microalgal biohydrogen production considering light energy and mixing time as the two key features for scale-up

This study focuses on a scale-up procedure considering two vital parameters light energy and mixing for microalgae cultivation, taking Chlamydomonas reinhardtii as the model microorganism. Applying two stage hydrogen production protocol to 1L flat type and 2.5L tank type photobioreactors hydrogen production was investigated with constant light energy and mixing time. The conditions that provide the shortest transfer time to anaerobic culture (light energy; 2.96 kJ s(-1)m(-3) and mixing time; 1 min) and highest hydrogen production rate (light energy; 1.22 kJ s(-1)m(-3) and mixing time; 2.5 min) are applied to 5L photobioreactor. The final hydrogen production for 5L system after 192 h was measured as 195 ± 10 mL that is comparable with the other systems is a good validation for the scale-up procedure.

The epidemiology and economic impact of varicella-related hospitalizations in Turkey from 2008 to 2010: a nationwide survey during the pre-vaccine era (VARICOMP study)

Varicella can cause complications that are potentially serious and require hospitalization. Our current understanding of the causes and incidence of varicella-related hospitalization in Turkey is limited and sufficiently accurate epidemiological and economical information is lacking. The aim of this study was to estimate the annual incidence of varicella-related hospitalizations, describe the complications, and estimate the annual mortality and cost of varicella in children. VARICOMP is a multi-center study that was performed to provide epidemiological and economic data on hospitalization for varicella in children between 0 and 15 years of age from October 2008 to September 2010 in Turkey. According to medical records from 27 health care centers in 14 cities (representing 49.3% of the childhood population in Turkey), 824 children (73% previously healthy) were hospitalized for varicella over the 2-year period. Most cases occurred in the spring and early summer months. Most cases were in children under 5 years of age, and 29.5% were in children under 1 year of age. The estimated incidence of varicella-related hospitalization was 5.29-6.89 per 100,000 in all children between 0-15 years of age in Turkey, 21.7 to 28 per 100,000 children under 1 year of age, 9.8-13.8 per 100,000 children under 5 years of age, 3.96-6.52 per 100,000 children between 5 and 10 years of age and 0.42 to 0.71 per 100,000 children between 10 and 15 years of age. Among the 824 children, 212 (25.7%) were hospitalized because of primary varicella infection. The most common complications in children were secondary bacterial infection (23%), neurological (19.1%), and respiratory (17.5%) complications. Secondary bacterial infections (p < 0.001) and neurological complications (p < 0.001) were significantly more common in previously healthy children, whereas hematological complications (p < 0.001) were more commonly observed in children with underlying conditions. The median length of the hospital stay was 6 days, and it was longer in children with underlying conditions (<0.001). The median cost of hospitalization per patient was $338 and was significantly higher in children with underlying conditions (p < 0.001). The estimated direct annual cost (not including the loss of parental work time and school absence) of varicella-related hospitalization in children under the age of 15 years in Turkey was $856,190 to $1,407,006. According to our estimates, 882 to 1,450 children are hospitalized for varicella each year, reflecting a population-wide occurrence of 466-768 varicella cases per 100,000 children. In conclusion, this study confirms that varicella-related hospitalizations are not uncommon in children, and two thirds of these children are otherwise healthy. The annual cost of hospitalization for varicella reflects only a small part of the overall cost of this disease, as only a very few cases require hospital admission. The incidence of this disease was higher in children <1 year of age, and there are no prevention strategies for these children other than population-wide vaccination. Universal vaccination is therefore the only realistic option for the prevention of severe complications and deaths. The surveillance of varicella-associated complications is essential for monitoring of the impact of varicella immunization.

Prognostic significance of p63, p53 and ki67 expression in laryngeal basaloid squamous cell carcinomas

BACKGROUND

It is well known that basaloid squamous call carcinoma (BSCC) is more aggressive than the usual form of squamous cell carcinoma. However, current information about the prognostic significance of basaloid squamous cell carcinoma in the larynx is sparse. We investigated p63, p53 and Ki67 in BSCC of the larynx.

METHODS

In a retrospective study conducted from January 2000 to June 2006, we used immunohistochemistry to analyse the protein expression of p63, p53, and Ki-67 in paraffin-embedded tumour samples from 22 BSCC patients and compared the clinicopathological parameters with the survival outcome.

RESULTS

Positive p63 expression was found in 16 of 22 BSCC specimens (72.7%). Expression was higher in cases without lymph node metastasis than in cases with lymph node metastasis. This investigation found an inverse correlation between the expression of p63 and lymph node status in BSCC.

CONCLUSION

To our knowledge, this is the first clinical study of p63 expression in laryngeal BSCC.

Childhood non-Hodgkin's lymphoma arising as a complication early in the course of Crohn's disease

The neoplastic change in patients with Crohn's disease is usually seen in the form of adenocarcinoma. Primary gastrointestinal lymphoma complicating chronic inflammatory bowel diseases is thought to be uncommon. This report describes a case of gastrointestinal lymphoma in a 12-year-old boy with Crohn's disease of one-year duration that initially manifested as an abdominal mass. Although Crohn's disease may present as a palpable abdominal mass, changing symptomatology should always warrant consideration of developing lymphoma complicating inflammatory bowel diseases. It is our hope that this case report gives the clinician an insight into the possibility of lymphoma development, even in the early course of the disease, and stresses the importance of obtaining a reliable histological diagnosis whenever possible.

A case report: gastric adenocarcinoma in childhood

Primary gastric adenocarcinoma is extremely rare in children, and accounts for 0.05% of all gastrointestinal malignancies during childhood. The initial symptoms of epigastric pain, feeling of fullness, belching, and loss of appetite are non-specific and misleading. Nausea, vomiting and weight loss may accompany, which also complicate reaching a prompt diagnosis. In the presented case, a 15-year-old girl admitted with ascites, pleural effusion, right supra-clavicular lymphadenopathy, and back pain. No primary focus of a malignancy was accomplished in radiological evaluation, and the diagnosis of gastric carcinoma was achieved with upper gastrointestinal system endoscopy. We point out the importance of upper gastrointestinal system endoscopy in patients with ascites and uncertain diagnosis of the primary focus of malignancy.

Fournier's gangrene in childhood: a report of 3 infant patients

Fournier's gangrene is uncommon in pediatric age group, and little is known about the disease in the newborn period and infancy. Three patients, aged 10 days, 14, and 17 months, with Fournier's gangrene, were treated in our hospital. The predisposing factors were prematurity, a diaper rash, and varicella infection, respectively. Especially, prematurity and diaper rash are rare predisposing factors in the pediatric population; therefore, high index of suspicion, prompt diagnosis, conservative surgery, and multidisciplinary approach are the mainstays of management in children with Fournier's gangrene.

Recombinant human erythropoietin beta therapy: an effective strategy to reduce transfusion requirement in children receiving anticancer treatment

In recent years erythropoietic agents have become important tools in the management of anemia in cancer patients, improving hemoglobin (Hb) concentrations, reducing the need for transfusion, and enhancing quality of life. In this prospective and historically controlled study, the effects of epoetin beta on Hb concentrations and red blood cell transfusion needs in children with cancer receiving chemotherapy or radiotherapy have been investigated. Epoetin beta (150 U/kg/day, 3 days a week) was given subcutaneously to 22 children with cancer when Hb concentration < or = 10 g/dL. Data from these patients were compared with those from 20 historical control patients. Hb concentrations were studied weekly in the first 9 weeks, then weekly or fortnightly thereafter. Minimum, maximum, and mean Hb concentrations, frequency of red blood cell transfusion, and the number of red cell packs given were noted. Hb concentrations in weeks 6, 8, and 11 were clearly higher in the study group than the controls. The minimum Hb concentration of the study group was significantly higher than than the control group (7.98 +/- 0.73 [6.70-9.68] g/dL and 7.24 +/- 1.40 [5.50-11.20] g/dL, respectively [p = .038]). A total of 8 units of erythrocyte suspension was given to 4 of the 22 patients in the epoetin group (0.36 unit per patient), while 16 of the 20 patients in the control group received 37 units of erythrocyte suspension in total (1.85 units per patient). The red cell transfusion requirement and the units of transfused erythrocytes per patient were clearly lower in the epoetin group (p < .001 for both of the parameters). No drug-related side effects were noted during epoetin therapy. Epoetin beta therapy provides significant increase in Hb concentrations in children with cancer under anticancer treatment, especially after the sixth week of therapy. Administration of epoetin beta prevents profound decreases in Hb concentrations in the course of therapy and effectively reduces the need for red blood cell transfusions. Epoetin beta was found to be safe and effective in the dosage and the scheme it was used in our study.

Comparison of two different pneumatically mixed column photobioreactors for the cultivation of Artrospira platensis (Spirulina platensis)

Internal loop airlift and bubble column photobioreactors (PBR) were compared with respect to their performances during cultivation of Artrospira platensis (Spirulina platensis). Culture conditions were kept the same and different parameters were examined through the experiments. It was observed that a higher dry biomass weight and chlorophyll-a concentration was obtained in the airlift PBR yielding a maximum growth rate of 0.45 day(-1), while 0.33 day(-1) was reached in the bubble column PBR. Subsequently, a 17-day of production was carried out in the selected PBR to fully determine the performance of the PBR. Maximum growth rate of 0.47 day(-1) was reached during long term cultivation.

Caspofungin treatment in two infants with persistent fungaemia due to Candida lipolytica

Candida lipolytica has infrequently been identified as a cause of infection and is associated mostly with vascular catheter-related fungaemia. Patients reported in the literature have been successfully treated with catheter removal or amphotericin B treatment. We report 2 infants with C. lipolytica fungaemia unresponsive to catheter removal and amphotericin B therapy and treated successfully with the addition of caspofungin to amphotericin B.

Successful treatment of Trichosporon mucoides infection with lipid complex amphotericin B and 5-fluorocytosine

Infections in immunocompromised children can stem from bacteria, fungi, viruses, or protozoa, but most importantly, from the host's endogenous bacterial flora. Disseminated infection caused by Trichosporon species is one of the emerging mycoses in neutropenic patients, particularly when they are treated for haematological malignancy with cytotoxic and immunosuppressive chemotherapy. We report a 15-year-old boy with acute lymphoblastic leukaemia, whose Trichosporon mucoides infection was successfully treated with lipid complex amphotericin B plus 5-fluorocytosine.

Influence of surfactant entrapment to dried alginate beads on sorption and removal of Cu2+ ions

The removal of heavy metals has been investigated widely in recent years due to their potential health risk to human beings. In this study, the removals of copper from aqueous phase by alginate and SDBS entrapped alginate was investigated. First, a series of equilibrium sorption experiments were conducted at different initial pH values. Both equilibrium copper concentration and final pH values were observed. Then, a series of kinetic experiments were conducted and a second order rate relationship was fit to the experimental data. Equilibrium sorption experiments showed that the sorption of Cu+2 ions by 2% of SDBS entrapped alginate beads were greater than the plain and 0.5% of SDBS entrapped alginate beads. More H+ ion exchange occurred with the 2% of SDBS entrapped alginate beads, which was attributed to the increased number of the exchange sites on the alginate due to the sorption of surfactant to the beads. Kinetic sorption experiments showed that the equilibrium was reached faster for 2% of SDBS entrapped alginate beads. Results were successfully represented using second order kinetic model. Both equilibrium and kinetic experiments showed that the sorption of Cu+2 ions increased as the pH of the aqueous solution increased.

Characteristics of hyperthermia and its complications in patients with Prader Willi syndrome

BACKGROUND

Thermoregulation problems, resulting in hypo- or hyperthermia, have been infrequently reported in children with Prader Willi syndrome (PWS), yet their clinical details remained unknown.

METHODS

The clinical characteristics of three infants with PWS are reported.

RESULTS

Etiologies of high fever could not be identified in three children with PWS. One of these children was also admitted to the intensive care unit with extremely high body temperature in a life-threatening condition, similar to septic shock, without a plausible explanation.

CONCLUSION

Hyperthermia may be a part of the clinical spectrum in young infants with PWS and should be carefully monitored, since it may cause life-threatening complications.

Bone mineral density in asthmatic patients using low dose inhaled glucocorticosteroids

Inhaled glucocorticosteroids are clearly beneficial in subjects with moderate or severe asthma since they are well tolerated, reduce symptoms, and improve quality of life. Some studies suggest that inhaled glucocorticosteroids can adversely affect bone mineral density. The aim of this study is to determine the effects of inhaled glucocorticosteroid therapy on bone mineral density in female patients. Forty-five asthmatic female patients (36 premenopousal and 9 postmenopausal) and forty-six healthy control subjects were included in the study. Bone mineral density was measured from lumbar spine (L1-4) and femur (neck, trochanter, and Ward's triangle) by dual energy X-Ray absorptiometry. Age, occupation, menopause and smoking status, alcohol consumption, body mass index, previous fractures, family history of fractures, menstrual history, ooferectomy, number of pregnancies, the duration of lactation, physical activity and calcium intake were questioned according to the European Vertebral Osteoporosis Study Group (EVOS) form. Cumulative inhaled glucocorticosteroid dose was calculated. T score of femoral neck and T score and bone mineral density of Ward's triangle were significantly lower in asthmatic patients compared to control group but no statistically significant correlation was found between the disease duration, inhaled steroid treatment duration, cumulative inhaled dose and annual inhaled steroid dose and bone mineral density measurement. These results suggest that in asthmatic patients using low dose inhaled corticosteroids bone mineral density is lower than in healthy controls but it is still unclear if asthma by itself is a risk factor for osteoporosis.

Bilateral hearing loss during vincristine therapy: a case report

Vincristine sulfate is a chemotherapeutic agent used in different cancer therapies. It is also the first choice of treatment for peripheral T-cell lymphoma with cyclophosphamide and adriamycin. Sudden hearing loss during vincristine therapy is a very rare event. This is a case of a 16-year old girl who developed sudden bilateral hearing loss related to vincristine therapy.

An important procedure in ossiculoplasty: autoclaving the ossicles

Autoclaving of the ossicles prior to ossiculoplasty is a very important procedure in surgery of cholesteatomatous chronic otitis media. Autoclaving allows the reuse of the ossicles removed from patients with cholesteatomatous chronic otitis media as an autograft. It also allows utilization of the malleus, incus and stapes taken from cadavers or of the uneroded malleus and incus removed from patients undergoing non-functional middle ear surgery chosen carefully with detailed history and laboratory analysis. The powerful disinfecting effect of the sterilising procedures of the homografts inactivates prion proteins which cause degenerative encephalopathies. In various studies, it has been concluded that autoclaving does not alter the matrix of the bone which is responsiable for its biophysical properties, whereas it removes all viable cells within the bone and dentures the soft tissue attached to the surface of the ossicle. We have also found confirming histological results in our two previous studies published in 1999 and 2001. It is usually recommended that soft tissue on the surface of the ossicles is removed before autoclaving. It is also sufficient to autoclave the ossicles at 134 degrees C, and at 2.5 atmosphere pressure for 5 minutes in a flash autoclave. The autoclaving time of the homograft ossicles must be longer, for 20 minutes. Following the autoclaving, these homograft ossicles should be kept at pH 5.6 for 3 days, then use a solution of 0.5% formaldehyde at pH 7 and 4 degrees C for 21 days and it should be washed with physiologic saline solution three times for 7 minutes before use. Depending on the results obtained from our planned comparative experimental study, there will be no need for additional formaldehyde fixation procedure after autoclaving and the autoclaved ossicles will be used immediately without preservation in formaldehyde solution for 24 days.

Removal of Ni(II) from aqueous solution by adsorption onto hazelnut shell activated carbon: equilibrium studies

Activated carbon prepared from hazelnut shell was used as an adsorbent for the removal of Ni(II) from aqueous solution. Batch mode adsorption studies were carried out by varying initial metal ion concentration, agitation speed, temperature and particle size. A contact time of 180 min was required to reach equilibrium. The equilibrium data were analysed using the Langmuir, Freundlich and Temkin isotherms. The characteristic parameters for each isotherm were determined. The Langmuir isotherm provided the best correlation for Ni(II) onto the activated carbon. Thermodynamical parameters revealed that the adsorption of Ni(II) is exothermic in nature.

Schwannoma (neurilemmoma) of the facial nerve presenting as a parotid mass

A 32-year-old male presented with a mass in the parotid gland. Superficial parotidectomy was performed. Histopathologically the tumour was found to be schwannoma (neurilemmoma) and because this is unusual, the case is presented together with the histopathological findings.

Detection of Alloiococcus otitidis in the nasopharynx and in the outer ear canal

Alloiococcus otitidis has been recovered from the middle ear of children with otitis media with effusion, but its natural habitat is not known. To determine whether the nasopharynx and the outer ear canals are the natural habitats of A. otitidis, 145 swabs (50, nasopharynx; 95 outer ear canal) collected from 50 children were screened by polymerase chain reaction. A. otitidis DNA was detected in seven (4.8%) of the 145 specimens, of which four were nasopharynx, and three outer ear canal. These results indicate that the nasopharynx and outer ear canal may be the body sites for localization of A. otitidis.

Bacterial etiology of otitis media with effusion; focusing on the high positivity of Alloiococcus otitidis

The etiology of otitis media with effusion (OME) is unclear. The bacterial analyses of middle ear effusion (MEE) in OME may reveal important information regarding its etiology. Alloiococcus otitidis, Heamophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis were investigated by using microbiologic culture and a multiplex PCR method in the middle ear fluid of 32 children (54 samples) with chronic OME. PCR yielded positive results in 18 (33.3%) middle ear effusions while culture resulted positive for 3 (5.6%). The PCR method detected A. otitidis in 10 (18.5%) specimens, H. influenzae in 7 (13%), M. catarrhalis in 4 (7.4%) and S. pneumoniae in 2 (3.7%) specimens. The multiplex PCR method enhances the detection rate significantly compared to that of the conventional culture method. A. otitidis is the most common detected pathogen in the MEE of the OME.

Butylcyanoacrylate tissue adhesive for columellar incision closure

Cosmetic outcome of the columellar incision closure in external rhinoplasty patients has been a subject of discussion. This study was conducted to assess whether tissue adhesives provide an alternative option for sutureless closure of columellar skin incisions for cases utilizing open technique rhinoplastic surgery. One hundred and one patients undergoing external rhinoplasty were randomized to either topical application of butylcyanoacrylate or polypropylene sutures for columellar skin closure. The majority of tension on the wound edges was taken up using 5-0 chromic catgut. Cosmetic outcomes were evaluated by two otolaryngologists independently using visual analogue and Hollander wound evaluation scales in a blinded manner. There was no statistically significant difference in cosmesis between the surgeons' evaluation scores for either type or repair of the columellar incision. Since the tissue adhesive forms its own protective barrier, post-operative care is simplified. Closure with adhesives eliminates the need for post-operative suture removal requiring an extra visit that should lead to more efficient use of physician and patient time. Butylcyanoacrylate performs cosmetically as well as standard suture closure of columellar skin incision used for external rhinoplasty.

Does the stapes reflex remain the same after Bell's palsy?

OBJECTIVE

The authors investigated the integrity and function of nervus stapedius 1 year after facial paralysis.

STUDY DESIGN

Patients with Bell's palsy were observed prospectively for 1 year and compared with healthy patients.

SETTING

The follow-up of patients was done in the outpatient clinic and tests were applied in the audiology unit.

PATIENTS

The mean age of 32 patients was 41.03 years. Eight of 32 patients were grade II (25%), 11 were grade III (35%), and 13 were grade IV (40%) according to House-Brackman grading system. The mean age of the control group (10 persons) was 36.5 years.

INTERVENTION

Contralateral stimulus was used in acoustic reflex test at 500 and 1,000 Hz with 80-, 90-, 100-, and 110-dB stimulus intensity. Tests were applied in three ways: normal position, eye-closed position, and grin position. Tests were done in the first 15 days of facial paralysis and repeated at least 1 year thereafter. The millimeter difference in amplitude of impedance recording of middle ear between the normal ear and paralyzed ear was accepted as criterion.

MAIN OUTCOME MEASURES

There were 6- to 9-mm amplitude differences between normal side and healed side of grade IV patients with 100- and 110-dB stimuli.

RESULTS

In the second test (after 1 year), statistically significant differences were present between control group and grade IV patients on 1,000 and 500 Hz frequencies with 100- and 110-dB stimulus intensity (p < 0.05). There were no significant differences between grade II and control group and between grade III and control group.

CONCLUSIONS

A permanent partial denervation is present on the stapedial nerve, especially after grade IV paralysis, and it affects the function of stapes muscle in high decibel sounds. But it does not affect the stapes reflex threshold. No synkinetic innervation was found in the authors' patient group with their test method.

Electroneurography in the late period of Bell's palsy

Our purpose is to investigate the electrophysiological characteristics of Bell's palsy and to obtain clues for estimating prognosis in the late period by using electroneurography. Thirty-three patients were followed by electroneurography over a period of 12 months. They were classified according to House-Brackman system. At the end of the follow-up, 100% of grade II-III patients, and 61% of grade IV patients recovered completely. Thirty per cent of grade IV patients recovered as grade II, and one grade IV (8%) and one grade V (100%) patient had bad prognoses (grade IV). There were significant differences between each group in the time course between the first and third months of onset. We concluded that the amount of non-degenerated synchronous fibres can allow us to estimate prognosis of Bell's palsy, especially between the first and third month of onset, if we make serial tests.

Leiomyosarcoma of the parotid gland

A 36-year-old patient with a primary leiomyosarcoma of the left parotid gland is presented. To our knowledge this is only the second case of a parotid leiomyosarcoma in the world according to the literature review.

The effect of epidural anaesthesia and size of spinal needle on post-operative hearing loss

Forty-five patients who were to undergo elective urological operations were evaluated. In the pre-operative period and on the third or fourth post-operative day audiometry was performed. Epidural anaesthesia was performed in 15 cases, spinal anaesthesia was performed in 15 cases with 25 G needles, and in 15 cases with 22 G needles. No statistically significant hearing loss was observed in the post-operative period compared to preoperative period in the epidural anaesthesia group. In the post-operative period, the hearing loss observed in the 25 G-spinal anaesthesia group was significantly (P < 0.01) less than that seen in the 22 G group. None of the patients had headache after spinal anaesthesia. It was concluded that pure tone audiometry is a more sensitive indicator of cerebrospinal fluid leakage than post-operative headache.