Updated S2 K guidelines for the management of bullous pemphigoid initiated by the European Academy of Dermatology and Venereology (EADV)

BACKGROUND

Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering disease of the skin and mucous membranes. This disease typically affects the elderly and presents with itch and localized or, most frequently, generalized bullous lesions. A subset of patients only develops excoriations, prurigo-like lesions, and eczematous and/or urticarial erythematous lesions. The disease, which is significantly associated with neurological disorders, has high morbidity and severely impacts the quality of life.

OBJECTIVES AND METHODOLOGY

The Autoimmune blistering diseases Task Force of the European Academy of Dermatology and Venereology sought to update the guidelines for the management of BP based on new clinical information, and new evidence on diagnostic tools and interventions. The recommendations are either evidence-based or rely on expert opinion. The degree of consent among all task force members was included.

RESULTS

Treatment depends on the severity of BP and patients' comorbidities. High-potency topical corticosteroids are recommended as the mainstay of treatment whenever possible. Oral prednisone at a dose of 0.5 mg/kg/day is a recommended alternative. In case of contraindications or resistance to corticosteroids, immunosuppressive therapies, such as methotrexate, azathioprine, mycophenolate mofetil or mycophenolate acid, may be recommended. The use of doxycycline and dapsone is controversial. They may be recommended, in particular, in patients with contraindications to oral corticosteroids. B-cell-depleting therapy and intravenous immunoglobulins may be considered in treatment-resistant cases. Omalizumab and dupilumab have recently shown promising results. The final version of the guideline was consented to by several patient organizations.

CONCLUSIONS

The guidelines for the management of BP were updated. They summarize evidence- and expert-based recommendations useful in clinical practice.

S2k guidelines (consensus statement) for diagnosis and therapy of dermatitis herpetiformis initiated by the European Academy of Dermatology and Venereology (EADV)

INTRODUCTION

Dermatitis herpetiformis (DH) is a chronic, pruritic, gluten-induced skin disorder characterized by subepidermal granular IgA deposition and a variable degree of enteropathy identical to that seen in coeliac disease. So far, there has been no European consensus about the management of DH.

METHODS

The guidelines were created by small subgroups of a guideline committee consisting of 26 specialists from various medical fields and one patients' representative. The members of the committee then discussed the guidelines and voted for the final version at two consensus meetings. The guidelines were developed under the support of the European Academy of Dermatology and Venereology (EADV) and in collaboration with the European Dermatology Forum (EDF).

RESULTS

The guidelines summarize evidence-based and expert-based recommendations (S2 level) for the management of DH (see Appendix).

CONCLUSION

These guidelines will improve the quality of management of DH and support dermatologists in their diagnostic and therapeutic decisions.

A large cohort of disorders of sex development and their genetic characteristics: 6 novel mutations in known genes

INTRODUCTION

Disorders of sex development (DSD) constitutes a group of congenital conditions that affect urogenital differentiation and are associated with chromosomal, gonadal and phenotypic sex abnormalities.

OBJECTIVE

To evaluate the clinical and genetic features of childhood DSD cases.

MATERIALS AND METHODS

DSD patients followed up between the years of 2002-2018 were evaluated in terms of their complaints, demographic, clinical features and genetic diagnoses.

RESULTS

Out of 289 patients, 143(49.5%) were classified as 46XY DSD, 62(21.5%) as 46XX DSD and 84(29%) as sex chromosomal DSD. Genetic diagnosis was achieved in 150 patients (51.9%). The distribution of the molecular diagnosis of the 46XY DSD patients were; 12 (26.6%) SRD5A2, 10 (22.2%) AR, 7 (15.5%) HSD17B3, 3 (6.6%) WT-1, 2 (4.4%) AMHR2, 2 (4.4%) AMH, 2 (4.4%) LHCGR, 2 (4.4%) HSD3B2, 1 (2.2%) NR5A1, 1 (2.2%) CYP17A1 and 1 (2.2%) SRY mutation. Fifty (80.6%) of the 46XX DSD patients received a diagnosis with clinical and laboratory findings. Twenty-four (38.7%) of them were 21-hydroxylase deficiency, 9(14.5%) Rokitansky-Küster-Hauser Syndrome, 4 (6.5%) 11-β hydroxylase deficiency, 3 (4.8%) gonadal dysgenesis and 2 (3.2%) aromatase deficiency. In 46XX group pathogenic mutations were detected in 21(33.8%) of the patients. Eighty-four (29%) patients were diagnosed as sex chromosomal disorder. Of these 66 (78.5%) were Turner Syndrome, 6 (7.2%) Klinefelter Syndrome and 10 (11.9%) mix gonadal dysgenesis. Gender re-assignment was decided in 11 patients. Malignant and pre-invasive lesions was diagnosed in 8 (2.7%) patients.

CONCLUSION

Many of DSD's are clinically similar and etiology of numerous of them still cannot be established. A multi-disciplinary approach and new rapid genetic diagnostic methods are needed in the process from diagnosis to gender assignment and follow-up.

FRI0369 MIMICKING GLUCOCORTICOID-INDUCED OSTEOPOROSIS USING AN IN VITRO TRABECULAR HUMAN BONE MODEL

Background:

The bone matrix consists of inorganic and organic components and a variety of specialized cells such as osteoblasts, osteocytes and osteoclasts. The bone-forming osteoblasts are responsible for the production of organic matrix components; they differentiate later into osteocytes which is accompanied by matrix mineralization. Osteoclasts are multinuclear giant cells, which resorb bone. Healthy bone homeostasis is characterized by a balanced, dynamic and continuous remodeling process. Glucocorticoids (GCs) are commonly used to successfully treat patients with inflammatory rheumatic and other autoimmune diseases. However, long-term treatment with GC can potentially lead to several adverse effects such as the inhibition of osteoblast proliferation and the increase of osteoclastic activity resulting in osteoporosis.

Objectives:

Hence, the aim of our project is to i) develop anin vitrotrabecular human bone model, ii) integrate this bone model into a perfusion system to accelerate mineralization and provide biomechanical stimuli and iii) applying prednisolone to induce osteoporosis. Here we present our initial results describing the successful differentiation of osteoblasts and osteoclasts in a 3D environment, and the accomplished integration of the bone model into a perfusion system.

Methods:

In a first step, different cultivation conditions were tested to allow optimal osteogenic or osteoclastic differentiation. To this end, a) human bone marrow derived mesenchymal stromal cells (hMSCs) were treated with osteogenic medium, and b) monocytes (isolated from buffy coats) were differentiated into osteoclasts using following protocol: incubation for 3 days with 25 ng/ml M-CSF followed by an 18-day incubation with M-CSF and 50 ng/ml RANKL. Calcification of hMSCs was evaluated via Alizarin Red S staining. Osteoclasts were identified using immunofluorescence staining observing multinucleated (DAPI) giant (ß-Actin) cells with TRAP and Cathepsin K activity. Additional gene expression analyses are currently conducted using qRT-PCR and looking for osteoclast-specific genes. In parallel to the monolayer cultures, cells were transferred on β-tricalcium phosphate (βTCP) – a suitable bony-like scaffold. Furthermore, first experiments in a dynamic bioreactor platform (OSPIN GmH) were conducted to evaluate the influence of shear stress on the cells and model systems.

Results:

We have been able to populate the βTCP scaffold with monocytes, which were differentiated into osteoclasts (morphological changes) without any effect on cellular viability as measured by Live/Dead staining. The morphological changes of those osteoclasts such as formation of filopodia could be demonstrated by scanning electron microscopy. In addition, the cultivation of βTCP populated with hMSCs in a perfusion system showed the upregulation of osteogenic markers (RUNX2, OSX) on mRNA-level.

Conclusion:

These first results of our approach to develop anin vitro3D model for glucocorticoid-induced osteoporosis are promising. Our next step will be the co-cultivation of osteoblasts and osteoclasts under dynamic and optimized cultivation conditions. By combining several cell types, a suitable scaffold and biomechanical stimuli (perfusion), we aim to provide a valid testing platform to study underlying disease mechanisms and for drug development.

Acknowledgments:

The project has been funded by the Elsbeth Bonhoff Foundation.

Disclosure of Interests:

Annemarie Lang: None declared, Karoline Diesing: None declared, Alexandra Damerau: None declared, Sümeyye Uzun: None declared, Moritz Pfeiffenberger: None declared, Timo Gaber: None declared, Frank Buttgereit Grant/research support from: Amgen, BMS, Celgene, Generic Assays, GSK, Hexal, Horizon, Lilly, medac, Mundipharma, Novartis, Pfizer, Roche, and Sanofi.

Oral health related qualıty of lıfe and dısease severıty ın autoımmune bullous dıseases

Background

There is an increased risk of long-term dental and periodontal disease in autoimmune bullous diseases (AIBD).

Aims

In this cross-sectional study, we aimed to determine whether the oral health-related quality of life status (OHRQoL) was associated with disease severity and activity in patients with AIBD.

Subjects and Methods

67 patients with AIBD were enrolled in this study. Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) was used to evaluate the disease severity. The score was categorized as a significant course (≥17) and moderate course (<17). Oral health impact profile-14 (OHIP-14) questionnaire was filled to assess the OHRQoL. Self-reported oral health status and oral lesion related pain score were also evaluated in the study group.

Results

OHIP-14 score was significantly higher in active patients (42.28 ± 13.66) than inactive patients (29.08 ± 12.25) (P = 0.004) and it was correlated with the pain score (6.33 ± 2.78; r = 0.409, P = 0.013). Furthermore, OHIP-14 score was higher in patients with a significant disease course (45.18 ± 15.08) (P = 0.010) than in patients with a moderate course (36.09 ± 9.73).

Conclusions

OHRQoL may be useful in the disease management and treatment. Since it can be affected by both presence of oral erosions and disease severity, a collaboration between dermatologists and dentists could be crucial to the disease management in AIBD.

Serological diagnostics in the detection of IgG autoantibodies against human collagen VII in epidermolysis bullosa acquisita: a multicentre analysis

BACKGROUND

Epidermolysis bullosa acquisita (EBA) is a rare, potentially devastating autoimmune disease of the skin. IgG autoantibodies directed against type VII collagen (Col7), the major component of anchoring fibrils, induce skin fragility leading to cutaneous and mucocutaneous blister formation, which is mostly of a scarring phenotype. Thus, powerful and reproducible diagnostic assays are critical to establish the diagnosis of EBA early to avoid irreversible sequelae.

OBJECTIVES

The present international, retrospective multicentre study included a large cohort of patients with EBA and evaluated the diagnostic power of four different diagnostic assays for the detection of anti-Col7 IgG autoantibodies.

METHODS

Overall, 95 EBA sera and 200 control sera consisting of 100 bullous pemphigoid sera, 50 pemphigus vulgaris sera and 50 sera of healthy controls were tested for anti-Col7 IgG autoantibodies using indirect immunofluorescence (IIF), two commercial enzyme-linked immunosorbent assay (ELISA) systems and Western blot (WB) analysis. EBA sera were taken from patients with positive direct immunofluorescence and IgG reactivity in at least one of the immunoserological assays (IIF, ELISA, WB).

RESULTS

A Col7-NC1/NC2 ELISA (MBL, Nagoya, Japan) showed the highest sensitivity (97·9%), followed by a Col7-NC1 ELISA (Euroimmun, Lübeck, Germany) (89·5%), WB with Col7-NC1 (85·3%), and IIF on saline-split human skin (74·7%). The specificities of both ELISA systems were comparable (NC1 98·7%, NC1/NC2 99·3%). Furthermore, WB was more sensitive than IIF, which was more specific.

CONCLUSIONS

The two commercially available ELISA systems allow for a highly sensitive and specific diagnosis of EBA. The sensitivity of the Col7-NC1/NC2 ELISA is significantly higher compared with the ELISA based on the Col7-NC1 domain only.

Assessment of the relationship between dynamic pupillometry and exercise heart rate recovery among healthy subjects

OBJECTIVE

Dynamic pupillometry (DP) is a simple, non-invasive computerized technique for assessment of pupillary light response which provides data concerning the balance of both branches of the autonomous nervous system (ANS). Heart rate (HR) recovery (HRR) after graded exercise reflects cardiac autonomic activity and predicts cardiovascular events. In this study, we aimed to evaluate the utility of DP as a predictor of cardiac autonomic activity assessed by HRR.

PATIENTS AND METHODS

A total of 62 consecutive healthy subjects (mean age = 33.7 ± 8.6 years, 39 males and 23 females) were enrolled. Pupil diameters (R0, R1, R2 and R%): latency (Lc), amplitude (Ac), velocity (Vc) and duration of pupil contraction (Tc): latency (Ld), velocity (Vd) and duration of pupil dilatation (Td) were measured in DP. HRR indices were calculated by subtracting 1st (HRR1), 2nd (HRR2) and 3rd (HRR3) minute HR from the maximal HR during treadmill exercise stress test.

RESULTS

HRR1 was 32.9 ± 8.0 bpm, HRR2 was 55.1 ± 11.6 bpm and HRR3 was 58.3 ± 12.7 bpm, respectively. Correlation analysis revealed significant positive correlations of HRR1 with Vc (r = 0.660, p = 0.001), Ac (r = 0.559, p = 0.001) and Vd (r = 0.412, p = 0.001). HRR had significant negative correlations with Lc (r = -0.442, p = 0.001), R% (r = -0.384, p = 0.002) and Ld (r = -0.286, p = 0.025). Vc [β = 3.995 (1.040 to 6.951, 95% CI, p = 0.009)] and Lc [β = -0.032 (-0.056 to -0.008, 95% CI, p = 0.01)] were found to be significant independent predictors of HRR1.

CONCLUSIONS

Pupillary autonomic functions assessed by DP correlates with cardiac autonomic functions evaluated by HRR. Among the DP parameters analyzed, Vc and Lc were independent predictors of cardiac autonomic functions.

Ocular blast injuries related to explosive military ammunition

OBJECTIVES

To report the clinical features of ocular injuries associated with explosive military ammunition in insurgent attacks in Turkey.

METHODS

The medical records of 48 casualties who were treated for ocular injuries sustained in insurgent attacks at the Combat Region Hospitals in Turkey were retrospectively reviewed. The reviewed data included initial visual acuity, type of explosive military ammunition (ie, improvised explosive device, mine, hand grenade and rocket-propelled grenade), type of globe injury (open-globe vs closed-globe injury), traumatised globe zones, the presence/absence of an intraocular foreign body, medical interventions, status during the explosion and injuries to other parts of the body. The visual acuity differences between different explosive materials and between 'on-foot' and 'inside-vehicle' casualties were investigated.

RESULTS

A total of 83 injured eyes were analysed. The mean patient age was 24.5±6.6 years. The mean initial logarithm of the minimum angle of resolution visual acuity was 0.60±0.63. The injuries were due to improvised explosive devices in 28 cases (58.3%), land mines in 16 cases (33.3%), and hand grenades and rocket-propelled grenades in 2 cases each (4.2%). Forty-seven eyes (56.6%) had open-globe injuries. The most frequently involved zones were zone 1 (50.0%) in closed-globe injuries and all zones (31.9%) in open-globe injuries. Intraocular foreign bodies were present in 45/47 (95.7%) eyes with open-globe injuries. Twelve (14.4%) eyes with no light perception were enucleated, and two (2.4%) eviscerated. The difference in the visual acuities between the on-foot and inside-vehicle casualties and between the injuries that were caused by the different types of explosive ammunitions was also insignificant (p=0.271 and 0.394, respectively).

CONCLUSIONS

The clinical results for eye injuries caused by explosive military ammunition sustained during insurgent attacks in Turkey are disappointing irrespective of the explosive material. The use of protective eyeglasses might improve the outcomes and should be encouraged.

Pemphigus. S2 Guideline for diagnosis and treatment--guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV)

BACKGROUND

Pemphigus encompasses a group of life-threatening autoimmune bullous diseases characterized by blisters and erosions of the mucous membranes and skin. Before the era of immunosuppressive treatment, the prognosis of pemphigus was almost fatal. Due to its rarity, only few prospective controlled therapeutic trials are available.

OBJECTIVES

For this reason, a group of European dermatologists with a long-standing interest and expertise in basic and clinical pemphigus research has sought to define diagnostic and therapeutic guidelines for the management of patients with pemphigus.

RESULTS

This group identified the statements of major agreement or disagreement regarding the diagnostic and therapeutic management of pemphigus. The revised final version of the pemphigus guideline was finally passed on to the European Dermatology Forum (EDF) for a final consensus with the European Academy of Dermatology and Venereology (EADV) and the European Union of Medical Specialists (UEMS).

The Relationship between Soluble Tumor Necrosis Factor-like Weak Inducer of Apoptosis Levels and Cardiac Functions in Peritoneal Dialysis Patients

Tumor necrosis factor (TNF)-like weak inducer of apoptosis (sTWEAK) levels has been reported to be decreased in patients on hemodialysis (HD) and patients with heart failure. We aimed to study the relationship between sTWEAK levels and cardiac functions in peritoneal dialysis (PD) patients. This cross-sectional study was carried out on patients on chronic PD programs for more than three months. Patients aged under 18 or over 80 years, patients with overt cardiac disease, overt hypervolemia, active systemic infection, malignancy, peritonitis within the last month were excluded. The patient group was compared with the control group including healthy adults aged 24–61 years. Fifty-two PD patients were included in the study (mean age: 52.7±15.4 years; female/male ratio: 30/22). The corresponding data of the control group were 41.3±10.7 years and 17/14. There was no statistically significant difference between demographic parameters of the groups except age. The mean sTWEAK level of the patient and the control groups were similar (564±17 pcg/ml vs 535±126 pcg/ml, p=0.419). No correlation was detected between any of the demographic variables and sTWEAK levels. Among the echocardiographic parameters, only ejection fraction was found to be correlated negatively with sTWEAK levels. Patients with ischemic heart disease (IHD) and heart failure had significantly higher sTWEAK levels compared with the patients without these diseases. With linear regression analysis, only age and the presence of heart failure were found to be the independent determinants of sTWEAK levels. Level of sTWEAK is significantly high in PD patients with heart failure and IHD. sTWEAK may be a marker of cardiac functions in PD patients.

Homocysteine levels and bad obstetric outcome among female operating room personnel occupationally exposed to nitrous oxide

It is known that nitrous oxide (N2O) inactivates vitamin B12 and causes hyperhomocysteinemia. The personnel working at the operating theatres are repeatedly exposed to N2O in the ambient air. This prompted us to investigate the biochemical indices of vitamin B12 metabolic status among female personnel working under various levels of N2O exposure. In this study, the homocysteine and folic acid levels were assessed and bad obstetric outcome was questioned. Sixty operating theatre female personnel were examined. Vitamin B12 and folic acid, total homocysteine level, anticardiolipin IgM, IgG, antiphospholipid IgM, IgG levels were measured in serum. A questionnaire inquiring about obstetric history was given. The serum concentration of folic acid was 10 ± 3.3 nmol liter-1. The vitamin B12 level was 332 ± 134 pmol liter-1, the serum concentration of homocysteine was 9.1 ± 2.4 nmol liter-1 and all were within normal ranges. There was no difference regarding homocysteine, folic acid, vitamin B12 levels and the obstetric history between the subjects who had abortus history and the subjects who had not abortus history. Exposure to N2O in healthcare workers was not associated with alterations of homocysteine, folic acid status and bad obstetric outcome (Tab. 4, Ref. 18).

Horizontal muscle transposition or oblique muscle weakening for the correction of V pattern?

PURPOSE

To report and to analyze the efficacy of horizontal rectus muscle transposition and inferior oblique muscle weakening in terms of pattern correction for patients with V pattern.

METHODS

The review of the medical files identified 55 patients who had esotropia (ET) or exotropia (XT) with V pattern. The primary outcome measure was the amount of V pattern collapse (Δ).

RESULTS

Of the 55 patients (mean age 22.1 ± 9.5 years), 27 (49.1%) were males and 28 (50.9%) were females. The type of deviations was XT in 30 patients (54.5%) and ET in 25 patients (45.5%). Inferior oblique muscle weakening was performed in 43 (78.2%) patients, whereas horizontal muscle transposition was carried out in 12 (21.8%) patients in addition to recession-resection procedures. The amount of pattern was significantly reduced in both groups (P=0.01 for the horizontal offset group and P<0.01 for the oblique muscle weakening group).

CONCLUSION

Oblique muscle weakening surgery and horizontal muscle offset are effective in the correction of V pattern when the amount of pattern is under 30Δ.

Impact of perioperative lidocaine infusion and bis monitorization on remifentanil dosage in hypotensive anesthesia

BACKGROUND

Combination of local and regional anesthetic agents are widely used in emergency and surgical setting and the interaction between the medications used in general anesthesia and these local and/or regional anesthetic becomes a growing concern in current patient management system. The interaction between general anesthetic agents and the local anesthetic agents given epidurally, spinally, intravenously or intramuscularly and the effects of BIS monitorisation on combined propofol-remifentanil anesthesia are examined in several studies. In literature, there is no research investigating the effect of lidocaine infusion on remifentanil and anesthetic dosage used in hypotensive anesthesia. The aim of this study is to examine this effect.

PATIENTS AND METHODS

We studied 39, ASA I-II patients undergoing elective transsphenoidal endoscopic hypophyseal adenoma excision procedure. After preoperative examination and informed consent of the patient, monitorisation with non invasive blood pressure measurement, electrocardiography, pulse oxymeter and Bispectral Index (BIS) was performed. 0.9% NaCl infusion was started via a 20 G route. Lidocaine (1%) was given as 1.5 mg.kg(-1) hour-1 infusion after 1.5 mg.kg(-1) bolus dosage given in 10 minutes. Lidocaine infusion was started at the same time with anesthesia induction and was stopped after surgery. 0.9% NaCl was given as bolus dosage and as infusion in control group. Induction was maintained via propofol (1%) with 10 mg (1 ml) doses given in 5 seconds and it was applied in every 15 seconds until BIS < 45'. During maintenance of anesthesia desflurane-remifentanil-oxygen (50%)-air (50%) mixture was used. Desflurane was titrated by BIS measurement between 40 and 5012. Remifentanil infusion was started after propofol induction with 0.1 µg.kg(-1).min(-1) dosage and it was titrated between 0.1-0.5 µg.kg(-1).min(-1) levels. For intubation, rocuronium with 0.8 mg kg(-1) dosage was given during induction. After the surgical procedure, it was antagonised with neostigmine and atropine. For postoperative analgesia 1 g paracetamole was given IV after the surgery within 15 minutes and it was reapplied with 1 gr doses in every 6 hours. After extubation, the pain of the patients was examined at 15. minute at the recovery room with VRS (VRS; 0-no pain, 1-slight pain, 2-moderate pain, 3-severe pain). If VRS was greater than 2, 50 mg dolantine was given IM. For prevention of nausea and vomitting, 8 mg ondansetron was given IV. Perioperative total doses of remifentanil, desflurane (ml) (anesthesia machine records) and lidocaine (mg) were recorded after the surgery. Perioperative hemodynamic parameters (systolic, diastolic, mean blood pressures, heart rates) were recorded after monitorisation (basal), after intubation, after the start of the surgery and after extubation.

RESULTS

There were no statistically significant difference between two groups with respect to patient characteristics (age, gender, weight, length, Basal Mass Index = BMI) (p > 0.05). The duration of anesthesia and surgery were also not different statistically (p > 0.05). There were no statistically significant difference between two groups with respect to remifentanil dose (p > 0.05). There were no statistically significant difference between two groups with respect to eye opening and extubation times (p > 0.05). When usage rates and amounts of dolantine, paracetamole and novalgine were compared, we found no statistically significant difference between two groups (p > 0.05). Basal mean arterial blood pressure measurements of the patients and mean arterial blood pressure measurements of the patients after induction, after intubation, 1 minute, 5 minutes, 10 minutes, 15 minutes after discharge of surgery and after extubation showed no statistically significant difference (p > 0.05). Basal heart rate measurements and the heart rates after induction, after intubation, 1 minute, 5 minutes, 10 minutes, 15 minutes after discharge of surgery and after extubation showed no statistically significant difference (p > 0.05). Basal BIS measurements and BIS measurements after induction, after intubation, 1 minute, 5 minutes, 10 minutes, 15 minutes after discharge of surgery and after extubation showed no statistically significant difference (p > 0.05).

CONCLUSIONS

We found no statistically significant difference between two groups about different parameters. But new investigations with different local anesthetic agents may show sigificant difference and usage of these local anesthetic agents may be advised.

Is Pentraxin-3 Stronger Than C-Reactive Protein to Determine Inflammation in Peritoneal Dialysis Patients?

Pentraxin-3 (PTX-3) is the prototype of long pentraxins and is produced by many tissues and organs including vascular endothelial cells in response to pro-inflammatory signals. It is thought to be an independent indicator of disease activity. We analyzed the correlation of PTX-3 with other markers of inflammation in peritoneal dialysis (PD) patients. Non-diabetic patients on chronic PD program who meet the dialysis adequacy criteria and who had no active infectious/inflammatory disease were included. Demographic and clinical parameters were recorded as well as hsCRP, fibrinogen, interleukin-6 (IL-6) and PTX-3 levels; and the correlation between them were studied. Twenty-five patients (mean age: 45.7±12.5 years; female/male ratio: 16/9) were included. Mean PTX-3 level was 2.16±2.76ng/ml. PTX-3 was found to be correlated positively with only IL-6 among inflammatory markers (r=0.827; p<0.001) but not with hsCRP. With linear regression model, IL-6 was the only independent determinant of PTX-3 levels. PTX-3 may be a more valuable marker of inflammation than CRP in patients on PD.

Evaluation of muscle fatigue of wheelchair basketball players with spinal cord injury using recurrence quantification analysis of surface EMG

Wheelchair basketball is the most popular exercise activity among individuals with spinal cord injury (SCI). The purpose of this study was to investigate muscular endurance and fatigue in wheelchair basketball athletes with SCI using surface electromyography (SEMG) and maximal torque values. SEMG characteristics of 10 wheelchair basketball players (WBP) were compared to 13 able-bodied basketball players and 12 sedentary able-bodied subjects. Participants performed sustained isometric elbow flexion at 50% maximal voluntary contraction until exhaustion. Elbow flexion torque and SEMG signals were recorded from three elbow flexor muscles: biceps brachii longus, biceps brachii brevis and brachioradialis. SEMG signals were clustered into 0.5-s epochs with 50% overlap. Root mean square (RMS) and median frequency (MDF) of SEMG signals were calculated for each muscle and epoch as traditional fatigue monitoring. Recurrence quantification analysis was used to extract the percentage of determinism (%DET) of SEMG signals. The slope of the %DET for basketball players and WBP showed slower increase with time than the sedentary able-bodied control group for three different elbow flexor muscles, while no difference was observed for the slope of the %DET between basketball and WBP. This result indicated that the athletes are less fatigable during the task effort than the nonathletes. Normalized MDF slope decay exhibited similar results between the groups as %DET, while the slope of the normalized RMS failed to show any significant differences among the groups (p > 0.05). MDF and %DET could be useful for the evaluation of muscle fatigue in wheelchair basketball training. No conclusions about special training for WBP could be determined.

Bupropion in treatment of depression - patient stopped smoking: case report

Aim

To present a case of a patient with depression who stopped smoking during therapy with bupropion.

Case report

Patient, 55 years old, diagnosed with depression, was in psychiatric treatment for two year before she discontined her treatment. She decided to discontinue psychiatric treatment and stopped taking antidepressants because she was feeling better and was functioning at work and in her social environment. For the past one year she was taking only lorazepam occasionally. She came again to our hospital when avolition and fatigue intensified, along with depressed mood. She was not able to function at work any more. She smoked about 20 cigarettes daily and tried to stop smoking on several occasions, but unsuccessfully. Because of worsening of symptoms of depression, treatment with bupropion was initiated in daily dosage of 150 mg. After five days of such treatment daily dosage of bupropion was elevated to 300 mg. The patient reported having headache for the first two days of treatment with bupropion, but after the headache stopped. After ten days of treatment she reported feeling better and was smoking less cigarettes (five per day). She said that didn’t have such pleasurable feeling any more when smoking. Also, after smoking she felt mild nausea. At control examination, after one month of treatment with bupropion, the patient reported feeling well, without symptoms of depression and that she stopped smoking. She continued outpatient treatment regularly and was functioning well again at work and in her social environment.

Comparison of Flexiblade and Macintosh laryngoscopes: cervical extension angles during orotracheal intubation

SUMMARY

The Flexiblade(TM) is a new laryngoscope with a flexible blade, a handle and a lever, allowing gradual flexion over the distal half of the blade. In this study, we aimed to compare cervical vertebral movements during tracheal intubation with the Flexiblade and Macintosh laryngoscope in 32 patients undergoing elective surgery requiring general anaesthesia (n = 16 per group). Fluoroscopic images of cervical movement were captured before, during and after intubation and evaluated by a radiologist. C1-C2 cervical vertebral movement was significantly reduced during the intubation in the Flexiblade group (p < 0.0001). C2-C3 cervical movement was similar in both groups (p = 0.81). No significant differences were noted in success rates for intubation, oxygen saturation levels, haemodynamic variables or intubation-related injury. The decreased extension angle between C1-C2 during Flexiblade laryngoscopy compared with Macintosh laryngoscopy may be an advantage where neurological damage with cervical movement is a concern.

Lamotrigine in Therapy of Patient with Posttraumatic Stress Disorder: Case Report

Patient N-V, with diagnose of PTSD according to DSM-IV-TR, was hospitalized in Vrapce Psychiatric Hospital, Zagreb, during 2008. At admission he reported tension, anxiety, irritability, need for isolation form other people, insomnia and nightmares. He said he was waking up almost every night because of nightmares.

In the beginning of hospital treatment lamotrigine was introduced in therapy, in daily dosage of 25 mg, along with diazepam 10 mg daily and zolpidem 10 mg in the evening. After three days the daily dosage of lamotrigine was elevated to 50 mg. No side effects of treatment were observed and the daily dosage of lamotrigine was elevated to 100 mg after six days and again on 200 mg after ten days of continuous therapy with lamotrigine. The patient reported improvement of sleep - he said he the nightmares were less frequent and he did not wake up as often as before. Also, during second week of treatment he became less tensed. After three weeks of treatment he became even more relaxed and less irritable. Also, he became more active and able to endure conversation. Initial insomnia was reduced, and he was waking up only occasionally during night. The patient was discharged from hospital after six weeks of treatment. Recommended therapy at discharge was lamotrigine in daily dosage of 200 mg, 10 mg of zolpidem in the evening, and diazepam 5 mg in case of tension.

Remifentanil and etomidate for laryngeal mask airway insertion

Etomidate does not depress the upper airway reflexes, making it difficult to insert a laryngeal mask airway (LMA) when using it for anaesthesia. This study investigated the effect of adding remifentanil to etomidate for LMA insertion. Fifty adult patients, undergoing cystoscopy, were randomized to two groups. The propofol-remifentanil group (n=25) received propofol anaesthesia induction (2.5 mg/kg) and a remifentanil bolus of 0.5 microg/kg, followed by a 2-min remifentanil infusion of 0.05 microg/kg per min. The etomidate-remifentanil group (n=25) received etomidate anaesthesia induction (0.3 mg/kg) and remifentanil as described. The LMA was inserted by a blinded anaesthetist who assessed a number of parameters. Only 13 LMAs were inserted at the first attempt in the etomidate-remifentanil group compared with 23 in the propofol-remifentanil group. Gagging, chest rigidity and myoclonus occurred significantly more frequently in the etomidate-remifentanil group. We conclude that the addition of remifentanil to etomidate anaesthesia induction does not improve LMA insertion.

Subhypnotic doses of midazolam prevent nausea and vomiting during spinal anesthesia for cesarean section

BACKGROUND

We aimed to evaluate the efficacy of subhypnotic doses of midazolam and propofol for peripartum nausea and vomiting during regional anesthesia for elective cesarean section in order to prevent emesis in at least 50% of patients.

METHODS

A prospective, double blind, placebo-controlled study was carried out. Patients were randomly allocated to one of three groups to receive placebo (saline, N=28), propofol (20 mg bolus and 1.0 mg x kg(-1) x h(-1) infusion, N=30), and midazolam (1 mg bolus and 1.0 mg x h(-1) infusion, N=30) at subhypnotic doses intravenously (i.v.) immediately after the umbilical cord was clamped. Bupivacaine hydrochloride (8-10 mg) and fentanyl (10 microg) were injected into the intervertebral space for spinal anesthesia. Blood pressure was monitored at 2 min intervals and intraoperative postdelivery emetic episodes and ephedrine consumption were recorded. The study was carried out at the Anesthesiology Department, Hacettepe University, Turkey, hospitalized care. We included 90 parturients with ASA physical status I and II between the ages of 20 and 38 years undergoing spinal anesthesia for elective cesarean delivery to evaluate the efficacy of subhypnotic doses of propofol and midazolam and, in particular, the incidence of nausea, retching, and vomiting intraoperatively.

RESULTS

The incidence of nausea, retching, and vomiting was significantly higher in the control group, compared to the propofol and midazolam groups. Total ephedrine consumption was significantly higher in the control group compared to the propofol and midazolam groups.

CONCLUSION

A subhypnotic dose of midazolam (1 mg x h(-1)) was as effective as the subhypnotic dose of propofol (1 mg x kg(-1) x h(-1)) for the prevention of nausea and vomiting in parturients undergoing cesarean section under spinal anesthesia.

Clinical features and natural course of Behçet’s disease in 661 cases: a multicentre study

BACKGROUND

Behçet's disease (BD) is a systemic inflammatory disease with unpredictable exacerbations and remissions. The natural course of BD is not fully known.

OBJECTIVES

We aimed retrospectively to determine the occurrence of the symptoms in chronological order. We also evaluated the influence of the treatment and follow-up on the clinical severity and tried to identify the factors determining severe organ involvement.

METHODS

Six hundred and sixty-one patients were involved in this multicentre study. The symptoms of the disease were recorded retrospectively in the time order of the manifestations in each patient.

RESULTS

Oral ulcers were the most common manifestation (100%), followed by genital ulcers (85.3%), papulopustular lesions (55.4%), erythema nodosum (44.2%), skin pathergy reaction (37.8%), and articular (33.4%) and ocular involvement (29.2%). Oral ulcers were the most common onset manifestation (88.7%). The mean +/- SD duration between the onset symptom and the fulfilment of diagnostic criteria was calculated to be 4.3 +/- 5.7 years. The clinical severity score was significantly increased in the noncompliant treatment group compared with the compliant group with the passage of time (P < 0.001). The frequency of ocular involvement and genital ulcers was significantly higher in patients whose disease onset was at < 40 years. Genital ulcers, ocular involvement, papulopustular lesions, thrombophlebitis and skin pathergy reaction were found to be significantly more frequent in males.

CONCLUSIONS

Mucocutaneous lesions are the hallmarks of the disease, and especially oral ulcers precede other manifestations. The increase in clinical severity score is more pronounced in patients without regular treatment and follow-up. Male sex and a younger age at onset are associated with more severe disease.

Periocular involvement in cutaneous leishmaniasis

OBJECTIVE

Although cutaneous leishmaniasis (CL) occurs mostly in the facial area, periocular involvement accounts for 2-5% of the facial lesions. CL lesions localized in the periocular region can easily be confused with various other diseases. The aim of this study was to examine the frequency of periocular involvement in CL in the Cukurova region of Turkey, as well as the clinical characteristics, diagnosis and methods of treatment of this disease.

METHODS

Between December 1998 and December 2004, patients who were diagnosed with CL were evaluated prospectively with respect to periocular involvement.

RESULTS

From the 2066 patients evaluated with CL, 2622 lesions were identified. In 59 (2.9%) of these patients, a total of 66 (2.5%) lesions were located in the periocular area. Thirty-two (48.5%) of these lesions were of the papular type, 15 (22.7%) the nodulo-ulcerative type, 10 (15.2%) the plaque type, and nine (13.6%) the nodular type. Dacryocystitis was identified in four patients with periocular involvement. Over the follow-up period, no ocular or periocular deformities or complications developed in these patients.

CONCLUSION

Patients suspected of CL should be evaluated and treated early in the course of their disease to prevent any permanent ocular or periocular deformities.

Perioperative anxiety and postoperative behavioural disturbances in children

BACKGROUND AND OBJECTIVE

This study was designed to determine if subhypnotic propofol reduces postoperative behavioural disturbances in children undergoing sevoflurane induction compared with intravenous propofol induction for elective adenoidectomy and tonsillectomy.

METHODS

Following Ethics Committee approval and parental informed consent, ASA I-II, 120 children (2-10 yr) were recruited. Parents were not allowed to accompany their child. Unpremedicated children were randomly allocated to groups receiving inhalation induction with sevoflurane, 2-2.5 mg kg-1 intravenous propofol induction or inhalation induction with sevoflurane followed by subhypnotic dose of propofol (1 mg kg-1). Anaesthesia was maintained with 2-4% sevoflurane, O2 and N2O. Anxiety on arrival to operating theatre, at anaesthesia induction and 30 min after emergence was assessed. Parents completed a state-trait anxiety inventory test preoperatively and a post hospitalization behaviour questionnaire a week later to assess children's postoperative behavioural disturbances. Kruskal-Wallis test, Wilcoxon signed rank sum test, Bonferroni's test, Paired t-test, t-test, Pearson and Spearman's rank correlation test, chi2-test were used for statistical analysis.

RESULTS

The anxiety level at induction was high in all groups (P < 0.05). There was no difference between groups in respect to anxiety at other measurement times. A relation between preoperative anxiety level and postoperative behavioural disturbances was determined (P < 0.05). Some behavioural disturbances as nightmare/night fear and desire of sleeping with parents were rarely seen in intravenous propofol induction group (P < 0.05).

CONCLUSION

Addition of subhypnotic dose of propofol to sevoflurane induction did not reduce the incidence of postoperative behavioural disturbances.

A case of lupus erythematosus profundus with unusual manifestations

We describe a 16-year old female with lupus erythematosus panniculitis with unusual manifestations. She had noted to have developed erythematous nodules and plaques in the right axilla and inguinal region at the age of one year. These lesions resolved gradually with scar formation. However, new lesions were noted at the same locations in the following years. Some of her lesions at the scalp and the left axillary regions developing within the last two years slowly enlarged showing an annular configuration and subsequently resulted in hair loss. The erythematous border of her lesion in the left axilla consisted of two parallel red lines. Histopathological and direct immunofluorescent findings were consistent with lupus erythematosus panniculitis. Similar clinical findings in the same locations were also observed in the mother.

Histological and immunofluorescence findings of non-follicular papulopustular lesions in patients with Behçet's disease

BACKGROUND

Papulopustular lesions (PPL), the most common type of cutaneous lesions in Behçet's disease (BD), clinically may not be differentiated from ordinary acne. Disagreement exists as to the exact nature of these acneiform and folliculitis-like lesions and whether to include them as a major criterion.

OBJECTIVE

We investigated whether PPL can be a useful tool for the diagnosis of BD when non-follicular lesions over the trunk or extremities were selected, and were correlated with histological and/or immunofluorescence study.

METHODS

Seventeen patients with BD (five women, 12 men; mean +/- SEM age, 32 +/- 7.9 years), were enrolled in the study with blind histopathological and immunofluorescence studies. Biopsies of the PPL and adjacent (approximately 2 cm distant) normal-appearing skin were performed from the extremities and trunk. Follicle-based acneiform lesions and those lesions over face were excluded. Histological evaluation primarily included epidermal and dermal alterations, cellular infiltration and vascular changes. We also performed direct immunofluorescence studies, using polyclonal antibodies for IgA, IgG, IgM, C3 and fibrin.

RESULTS

Lesional specimens of the patients with BD revealed a significant leucocytoclastic vasculitis as compared with non-lesional skin (P<0.05). The vessels of the lesional skin showed a higher IgM deposition than non-lesional skin (52.9% and 17.6%) (P<0.05). IgG, C3 and fibrin deposits on the vessels of the lesional skin were also higher than non-lesional skin (35.3, 11.8%; 41.2, 17.6%; and 47.1, 17.6%, respectively), but the differences were not statistically significant.

CONCLUSIONS

Our findings indicate that non-follicular PPL over the trunk or extremities are more specific, and immune complex-mediated vasculitis is likely to be the main feature of these lesions, as they are in other cutaneous lesions of BD.

Catatonic schizophrenia has a shorter pre-hospitalisation interval than other types of schizophrenia

The time elapsed between the first onset of symptoms and the onset of first hospitalisation was analysed in 355 participants diagnosed with paranoid, simple, hebephrenic and catatonic schizophrenia and shizoaffective disorder. The real onset of the disease was assessed from interviews with reliable relatives and by reviewing medical records in general practices and out-patient psychiatric services. In 184 patients a family history of schizophrenia was identified. A positive family history was found to significantly increase the interval preceding first hospitalisation in all analysed types, except in catatonic schizophrenia. Possible reasons causing this prolongation are discussed, as well as repercussions of the results to studies using age of first hospitalisation as the leading indicator.

Multi-site DNA polymorphism analyses of Leishmania isolates define their genotypes predicting clinical epidemiology of leishmaniasis in a specific region

Leishmania isolates from 57 cases of human cutaneous (CL), human visceral (VL), and canine visceral (CVL) leishmaniasis in Turkey were grouped by multi-site DNA polymorphism analyses into five genotypes. The initial grouping was based on DNA heterogeneity of the faster-evolving mitochondrion (kinetoplast) minicircles and the intergenic regions of two nuclear repetitive genes. Taxonomic affiliation and phylogenetic relationships of the five genotypes were inferred by comparing them with reference species for sequence heterogeneity in a approximately 1.4 kb conserved single-copy gene, encoding N-acetylglucosamine-1-phosphate transferase (NAGT). Alignment of the available sequences revealed no gap, but up to 7% scattered base substitutions, suggesting that this functionally important gene is a suitable marker. Three genotypes are completely identical to the NAGTs of the reference species, identifying them as L. infantum, L. tropica. and L. major, respectively. The remaining two are recognized as L. major NAGT variants with one and four base substitutions, respectively. As expected, Maximum Likelihood analysis of the NAGT sequences separates them into three clades, corresponding to the three species. The majority of the isolates obtained are L. infantum and L. tropica, which have been known to cause infantile VL and anthroponotic CL in western and southeastern Turkey, respectively. Unexpected is the finding of Leishmania major variants and their dispersal, possibly as previously unrecognized clinico-epidemiologic entities of CL and VL.

Cutaneous leishmaniasis: evaluation of 3,074 cases in the Cukurova region of Turkey

A total of 3,074 cases of cutaneous leishmaniasis was evaluated for demography, diagnosis, clinical characteristics and treatment. A peak in the number of cases was observed in 1991 and 1992, with a total of 1,550 cases. There were seasonal differences in frequency, the highest levels being recorded during the period October-December each year. The disease was more frequent in females (59%) and in the age group 10-19 years (41%). More than 80% of 4394 lesions were located on exposed body sites, and most patients (87%) had the acute form of the disease. Diagnosis was made by the smear method in 90% of cases. Treatment was by intralesional injection of antimony compounds in 76% of cases. Cryotherapy was used in most of the remaining cases, either alone or combined with intralesional injection of antimony compounds. The overall healing rate was over 90%.