Disease-free survival and the prognostic factors affecting disease-free survival in patients with medullary thyroid carcinoma: a multicenter cohort study

PURPOSE

Despite several factors that may have been associated with poor disease-free survival (DFS) in patients with medullary thyroid carcinoma (MTC), only a few studies have evaluated the prognostic factors affecting DFS in MTC patients. Therefore, this study evaluated the prognostic factors affecting DFS, in a large number of patients with MTC.

METHODS

Patients treated for MTC were retrospectively analyzed. Patients were stratified as having persistent/recurrent disease and no evidence of disease (NOD) at the last follow-up. The factors affecting DFS after the initial therapy and during the follow-up period were investigated.

RESULTS

This study comprised 257 patients [females 160 (62.3%), hereditary disease 48 (18.7%), with a mean follow-up time of 66.8 ± 48.5 months]. Persistent/recurrent disease and NOD were observed in 131 (51%) and 126 (49%) patients, respectively. In multivariate analysis, age > 55 (HR: 1.65, p = 0.033), distant metastasis (HR: 2.41, p = 0.035), CTN doubling time (HR: 2.7, p = 0.031), and stage III vs. stage II disease (HR 3.02, p = 0.048) were independent predictors of persistent/recurrent disease. Although 9 (8%) patients with an excellent response after the initial therapy experienced a structural recurrence, the absence of an excellent response was the strongest predictor of persistent/recurrent disease (HR: 5.74, p < 0.001).

CONCLUSIONS

The absence of an excellent response after initial therapy is the strongest predictor of a worse DFS. However, a significant proportion of patients who achieve an excellent response could experience a structural recurrence. Therefore, careful follow-up of patients, including those achieving an excellent response is essential.

The impact of microscopic extrathyroidal extension on the clinical outcome of classic subtype papillary thyroid microcarcinoma: a multicenter study

OBJECTIVES

Despite the presumed overdiagnosis of papillary thyroid microcarcinoma (PTMC) which has resulted in a new trend toward less-extensive surgery and a preference for active surveillance, the impact of microscopic extrathyroidal extension (mETE) on the clinical outcomes of PTMC is still controversial. This study assessed the impact of mETE on the clinical outcomes of patients with classic subtype PTMC.

METHODS

The data of consecutive patients who underwent thyroidectomy and were histopathologically diagnosed as classic subtype PTMC were analyzed. Cox's proportional hazards model was used to assess the impact of contributing variables on persistent/recurrent disease. Disease-free survival was estimated using the Kaplan-Meier method.

RESULTS

This study included 1013 patients (84% females), with a mean follow-up period of 62.5 ± 35.3 months. Patients with mETE had a significantly higher rate of locoregional persistent/recurrent disease than patients without mETE (9.8% vs 2.1%, p < 0.001). The disease-free survival rate was significantly lower in patients with mETE than in those without (90.2% vs 97%, Log-Rank p < 0.001). Furthermore, mETE and neck lymph node involvement were independent predictors of persistent/recurrent disease in multivariate analysis (HR: 2.43, 95% CI:1.02-5.81, p = 0.043; HR: 4.38, 95% CI: 1.7-11.2, p = 0.002, respectively).

CONCLUSIONS

In patients with the classic subtype of PTMC, mETE is an independent predictor of persistent/recurrent disease and is associated with a lower DFS rate. However, neck lymph node involvement is the strongest predictor of persistent/recurrent disease. Therefore, PTMCs with mETE and neck lymph node involvement are at a higher risk of persistent/recurrent disease than individuals lacking both characteristics.

Do Histologically Aggressive Subtypes of Papillary Thyroid Microcarcinoma have Worse Clinical Outcome than Non-Aggressive Papillary Thyroid Microcarcinoma Subtypes? A Multicenter Cohort Study

Histologically aggressive micropapillary thyroid carcinomas (PTMC) subtypes are thought to be associated with an aggressive clinical course. However, evidence for unfavorable clinical outcomes in patients with aggressive PTMC subtypes is not clear. In this study, we intended to determine the difference in clinical outcomes between patients with aggressive and non-aggressive PTMC subtypes. In this multicenter cohort study, the computer-recorded clinical and histopathological data of patients who underwent thyroid surgery between January 2000 - January 2021 in 9 referral centers and were diagnosed as PTMC were analyzed. A total of 1585 patients [female 1340 (84.5%), male 245 (15.5%), mean age 47.9±11.63 years), with a mean follow-up time of 66.55±37.16 months], were included in the study. Ninety-eight cases were diagnosed as aggressive and 1487 as non-aggressive subtypes. Persistent/recurrent disease was observed in 33 (33.7% )and 41 (2.8%) patients with aggressive and non-aggressive subtypes (p<0.001). Diseases-free survival rates were markedly lower in patients with aggressive than in those with non-aggressive PTMC subtypes (66.3 vs. 94.8%, log-rank p<0.001). Moreover, in multivariate analysis, aggressive histology was an independent predictor of persistent/recurrent disease, after controlling for other contributing factors (HR 5.78, 95% CI 3.32-10, p<0.001). Patients with aggressive PTMC subtypes had higher rates of incomplete biochemical and structural response than patients with non-aggressive subtypes as well (p<0.001). Aggressive PTMC subtypes share many characteristics with histologically identical tumors>1 cm in size. Therefore, the histopathological subtype of PTMC should be taken into consideration to tailor a personalized management plan.

The Importance of DHEA-S Levels in Cushing's Syndrome; Is There a Cut-off Value in the Differential Diagnosis?

The purpose of this study was to determine possible cut-off levels of basal DHEA-S percentile rank in the differential diagnosis of patients with Cushing's syndrome (CS) with ACTH levels in the gray zone and normal DHEA-S levels. In this retrospective study including 623 pathologically confirmed CS, the DHEA-S percentile rank was calculated in 389 patients with DHEA-S levels within reference interval. The patients were classified as group 1 (n=265 Cushing's disease; CD), group 2 (n=104 adrenal CS) and group 3 (n=20 ectopic ACTH syndrome).ROC-curve analyses were used to calculate the optimal cut-off level of DHEA-S percentile rank in the reference interval in the differential diagnosis of CS, and the effectiveness of this cut-off level in the identification of the accurate etiology of CS was assessed in patients who were in gray zone according to their ACTH levels. The DHEA-S percentile rank in the reference interval were significantly lower in group 2 compared to the other two groups (p<0.001), while group 1 and group 3 had similar levels. The optimal cut-off level of DHEA-S percentile rank in the reference interval providing differential diagnosis between group 1 and group 2 was calculated as 19.5th percentile (80.8% sensitivity, 81.5% specificity) and the level demonstrated the accurate etiology in 100% of CD and 76% of adrenal CS patients who were in the gray zone. This study showed that the cut-off value of DHEA-S level less than 20% of the reference interval could be used for differential diagnosis of CD and adrenal CS with high sensitivity and specificity, and it should be taken into the initial evaluation.

Assessment of novel biomarkers: sTREM-1, pentraxin-3 and pro-adrenomedullin in the early diagnosis of neonatal early onset sepsis

BACKGROUND

Early onset bacterial sepsis in neonates (EOS) is recognized as an important health condition. Early diagnosis is crucial. However, blood culture results are released in 48-72 hours. Many biomarkers have been investigated but none have been accepted as the gold standard. This study aimed to investigate the diagnostic value of the molecules: soluble form of triggering receptor expressed on myeloid cells-1 (sTREM-1), pentraxin-3 (PTX-3) and pro adrenomedullin (pro-ADM) in EOS and compare with currently used biomarkers.

METHODS

In this multicenter prospective study, patients were enrolled from different NICUs around the Turkey. Patient data were collected via web-based registry system from attending centers. Neonates, hospitalized with a suspicion of EOS were enrolled. Blood culture and routine blood tests were collected and a serum sample was obtained and kept in - 80°C for studying the molecules. According to laboratory results, patients were divided into three groups as; proven sepsis, clinical sepsis and control group. Groups were compared in terms of demographic, clinical and laboratory findings. The primary outcome of the study was to assess any difference between groups in terms of the diagnostic value of the markers aforementioned.

RESULTS

A total of 130 patients were enrolled; proven sepsis (n = 36), clinical sepsis (n = 53) and control (n = 41) groups. Groups were similar in terms of demographic findings; mean WBC (P = 0.445), procalcitonin (PCT) (P = 0.083) and IL-6 (P = 0.814) levels. Mean C-reactive protein (CRP) level was significantly higher in clinical sepsis and proven sepsis groups compared to control group (P < 0.001). Mean PTX-3 (P = 0.547), pro-ADM (P = 0.766) and sTREM-1 (P = 0.838) levels were similar between groups.

CONCLUSION

These promising molecules failed to help in early diagnosis of EOS. Their relation to correlation with disease progression may make more sense as they seem to be expressed in higher amounts with the progression of the disease in previous studies. CRP was the most frequently used biomarker for detecting the sepsis in our study population.

The effect of gender on response to antithyroid drugs and risk of relapse after discontinuation of the antithyroid drugs in patients with Graves' hyperthyroidism: a multicentre study

INTRODUCTION

The outcome of medical treatment in patients with Graves' disease (GD) is generally difficult to predict. In this study, we examined the hypothesis that gender may affect the outcome of treatment with antithyroid drugs (ATDs).

MATERIAL AND METHODS

This is a retrospective multicentre study including 717 (514 female and 203 male) patients with the first episode of GD treated for at least 12 months. Patients were classified as relapse, poorly controlled (several episodes of hyperthyroidism followed by euthyroidism and rarely hypothyroidism, occurring after titration of ATDs), and remission.

RESULTS

During the mean follow-up time of 26.75 ± 21.25 months (between 1 and 120 months), 269 (37.5%), 176 (24.5%), and 272 (37.9%) patients experienced a relapse, a poorly controlled disease, and remained in remission, respectively. During the follow-up time, 223 (43.4%) of the female and only 49 (24%) of the male patients remained in remission. Relapse and poorly controlled disease (non-remitting GD) were more common in male compared to female patients with GD (hazard ratio 1.26, 95% CI: 1.03-1.53, p = 0.025). Graves' disease in male patients tended to relapse earlier, and male patients tended to have larger goiter sizes at diagnosis as well. The smoking habit was also significantly more frequent in males compared to female patients with GD.

CONCLUSION

Male patients with GD have a markedly higher frequency of relapse and poorly controlled disease, as compared to female patients. Larger goiter sizes and higher frequency of smoking may contribute to the higher frequency of relapse and poorly controlled disease in male patients.

The relationship between participation to social activities, life satisfaction, isolation on aged

Objective

This study was conducted to determine the relationship between the participation of people living in the nursing homes to social activities and their life satisfaction, social isolation and loneliness.

Methods

The study was performed between January 2017 and April 2018 in three nursing homes using the cross-sectional research design. The study population consisted of 310 elderly people in total, 118 women, 192 men, who were over 65 years of age and had no mental and communication problems. Ninety percent of the population was reached. The data were collected by using a questionnaire, Standardized Mini Mental Test, Satisfaction with Life Scale (SWLS), Social Isolation Scale (SIS) and Loneliness Scale for Elderly People (LSEP). Descriptive statistics, Mann-Whitney U test, Kruskal-Wallis variance analysis and Spearman correlation analysis were used in data analysis.

Results

The mean age of the elderly subjects was 74.10 ± 7.57 years, and 61.9% were male and 38.1% were female. Elderly subjects’ SWLS and LSEP scores were below the median, and their SIS score was above the median value. Elderly people without disabilities, who can meet their own needs, do not feel alone, stay in the healthcare facility of their own accord, are satisfied with the services healthcare facility and with life, do sports, go to cinema and theater in their free time and go out more often had high SWLS median values and low SIS and LSEP values (p &lt; 0,05). Examining scale correlations, a moderate and negative correlation between SWLS and SIS (r= -,59; p=,000) a highly significant and negative correlation between SWLS and LSEP (r= -,70; p=,000) and a positive, statistically moderately significant correlation between SIS and LSEP (r=, 65; p=, 00) were found.

Conclusions

Life satisfaction increases and social isolation and loneliness decreases when elderly people living in nursing homes participate in social activities.

Key messages

Loneliness of elderly individuals can be reduced by increasing participation in social activities. Social isolation of elderly individuals can be reduced by increasing participation in social activities.

External Validation of the GREAT Score in Turkish Patients with Graves' Hyperthyroidism Treated with the Titration Regimen Method of Antithyroid Drugs: A Multicenter Study

Recently, the Graves' Recurrent Events After Therapy score (GREAT) was proposed as a useful tool to predict relapse before starting antithyroid drugs (ATD) in patients with Graves' disease (GD). Therefore, we intended to assess the validity of the GREAT score in Turkish patients with GD, including patients who experienced a poorly controlled disease (multiple episodes of hyperthyroidism followed by euthyroidism or rarely hypothyroidism) during ATD dose titration. This is a retrospective multicenter study including 517 patients with the first episode of GD who were treated for at least 12 months. The patients were classified as relapse+poorly controlled disease (non-remission) and remission groups. During a median follow-up time of 35 months (12-144 months), 191 (37%) patients experienced a relapse, 136 (26.3%) a poorly controlled disease, and 190 (36.7%) remained in remission. Patients with non-remission disease tended to have significantly higher serum levels of TRAb, fT4, and fT3, and have larger goiter sizes on palpation at baseline, as compared with the remission group. Non-remission disease occurred in 12, 35, and, 53% of the patients falling into GREAT class I, II, and III, respectively (hazard ratio 2.56, 95% CI 2.02-3.51, p=0.012, and hazard ratio 3.54, 95% CI 2.12-5.91, p<0.001, for GREAT class II and III against class I, respectively). According to our study, the GREAT score is a useful tool to predict the risk of relapse as well as the occurrence of poorly controlled disease before starting treatment with ATDs.

Are serum leptin levels a prognostic factor in advanced lung cancer?

AIM

The aim of the present study was to evaluate pre-treatment concentrations of leptin in patients with advanced lung cancer and to investigate possible associations between their levels and clinicopathological variables, response to therapy and overall survival.

MATERIAL AND METHODS

There are 71 previously untreated patients with cytological or histological evidence of primary lung cancer who were admitted to the oncology department between November 2013 and August 2014. Forty-five healthy individuals with age, sex and BMI matching the lung cancer patients, were recruited to take part in the study as a control group. Leptin levels were measured quantitatively by using a microELISA kit.

RESULTS

The serum leptin levels at diagnosis were significantly lower in lung cancer patients than those in control subjects (4.75±4.91 ng/ml, 9.67±8.02 ng/ml; p<0.001). We did not find any significant difference in leptin values related to clinicopathological parameters such as ECOG PS, weight loss, histological type, disease stage and TNM classification. Nevertheless, we demonstrated a significant correlation between serum leptin levels and BMI in lung cancer patients (correlation coefficient: 0.303; p>0.010). The analysis of serum leptin values did not show any association with the overall survival of the patients.

CONCLUSION

Our results showed that the serum leptin level has no prognostic indications in advanced lung cancer patients. Leptin is decreased in lung cancer, and there is lack of correlation with tumour‑related factors including prognosis. Therefore, leptin is not a useful clinical marker in lung cancer (Tab. 2, Fig. 2, Ref. 22).

Tetanus in adults: results of the multicenter ID-IRI study

Tetanus is an acute, severe infection caused by a neurotoxin secreting bacterium. Various prognostic factors affecting mortality in tetanus patients have been described in the literature. In this study, we aimed to analyze the factors affecting mortality in hospitalized tetanus patients in a large case series. This retrospective multicenter study pooled data of tetanus patients from 25 medical centers. The hospitals participating in this study were the collaborating centers of the Infectious Diseases International Research Initiative (ID-IRI). Only adult patients over the age of 15 years with tetanus were included. The diagnosis of tetanus was made by the clinicians at the participant centers. Izmir Bozyaka Education and Research Hospital's Review Board approved the study. Prognostic factors were analyzed by using the multivariate regression analysis method. In this study, 117 adult patients with tetanus were included. Of these, 79 (67.5%) patients survived and 38 (32.5%) patients died. Most of the deaths were observed in patients >60 years of age (60.5%). Generalized type of tetanus, presence of pain at the wound area, presence of generalized spasms, leukocytosis, high alanine aminotransferase (ALT) and C-reactive protein (CRP) values on admission, and the use of equine immunoglobulins in the treatment were found to be statistically associated with mortality (p < 0.05 for all). Here, we describe the prognostic factors for mortality in tetanus. Immunization seems to be the most critical point, considering the advanced age of our patients. A combination of laboratory and clinical parameters indicates mortality. Moreover, human immunoglobulins should be preferred over equine sera to increase survival.

Assessment of Palliative Care in Lung Cancer in Turkey

OBJECTIVE

To investigate the symptoms of lung cancer in Turkey and to evaluate approaches to alleviate these symptoms.

SUBJECTS AND METHODS

This study included 1,245 lung cancer patients from 26 centers in Turkey. Demographic characteristics as well as information regarding the disease and treatments were obtained from medical records and patient interviews. Symptoms were evaluated using the Edmonton Symptom Assessment Scale (ESAS) and were graded on a scale between 0 and 10 points. Data were compared using the χ2, Student t, and Mann-Whitney U tests. Potential predictors of symptoms were analyzed using logistic regression analysis.

RESULTS

The most common symptom was tiredness (n = 1,002; 82.1%), followed by dyspnea (n = 845; 69.3%), appetite loss (n = 801; 65.7%), pain (n = 798; 65.4%), drowsiness (n = 742; 60.8%), anxiety (n = 704; 57.7%), depression (n = 623; 51.1%), and nausea (n = 557; 45.5%). Of the 1,245 patients, 590 (48.4%) had difficulty in initiating or maintaining sleep. The symptoms were more severe in stages III and IV. Logistic regression analysis indicated a clear association between demographic characteristics and symptom distress, as well as between symptom distress (except nausea) and well-being. Overall, 804 (65.4%) patients used analgesics, 630 (51.5%) received treatment for dyspnea, 242 (19.8%) used enteral/parenteral nutrition, 132 (10.8%) used appetite stimulants, and 129 (10.6%) used anxiolytics/antidepressants. Of the 799 patients who received analgesics, 173 (21.7%) reported that their symptoms were under control, and also those on other various treatment modalities (dyspnea: 78/627 [12.4%], appetite stimulant: 25/132 [18.9%], and anxiolytics/antidepressants: 25/129 [19.4%]) reported that their symptoms were controlled.

CONCLUSION

In this study, the symptoms progressed and became more severe in the advanced stages of lung cancer, and palliative treatment was insufficient in most of the patients in Turkey.

AN UNUSUAL PRESENTATION OF JOUBERT SYNDROME AND RELATED DISORDERS IN A NEWBORN: PANHYPOPITUITARISM

The Joubert syndrome is characterized by hypotonia, ataxia, facial dysmorphism, abnormal eye movement, irregular breathing pattern and cognitive impairment. The molar tooth sign is the pathognomonic midbrain-hindbrain malformation for Joubert syndrome. Joubert syndrome and related disorders (JSRD), are the clinically and genetically heterogen disorders in which the obligatory hallmark is the molar tooth sign (MTS). In this report, it was described the association of the molar tooth sign, absence of pituitary gland and corpus callosum agenesis on an infant with JSRD. To the best of our knowledge, this is the first case diagnosed as JSRD and panhypopituitarism without features of OFD VI.

Patients with normocalcemic primary hyperparathyroidism may have similar metabolic profile as hypercalcemic patients

Primary hyperparathyroidism is well known to be associated with cardiovascular morbidity and mortality. However, it is unclear whether normocalcemic primary hyperparathyroidism (NC-PHPT) and hypercalcemic primary hyperparathyroidism (HC-PHPT) share the same risk factors. We aimed to determine prevalence of metabolic syndrome in NC-PHPT and compare metabolic syndrome parameters and insulin resistance in NC-PHPT subjects with those in HC-PHPT and control subjects. After excluding patients with secondary hyperparathyroidism, the study enrolled 25 patients with NC-PHPT, 24 patients with HC-PHPT and 30 age-gender matched controls. All participants were evaluated using the International Diabetes Federation (IDF)-2006 metabolic syndrome criteria. Compared with HC-PHPT patients, NC-PHPT patients had similar prevalence of metabolic syndrome, glucose intolerance, and previous history of hypertension/anti-hypertensive medications, but compared with controls, NC-PHPT patients had significantly higher prevalence of glucose intolerance and previous history of hypertension/anti-hypertensive medications. Not serum calcium but PTH concentration was found to be significantly higher in those with glucose intolerance. Serum fasting triglyceride concentration and waist circumference were found to be positively correlated only with serum PTH concentration. In conclusion, patients with NC-PHPT may be prone to similar metabolic disturbances linked to higher cardiovascular risk like patients with HC-PHPT. Although NC-PHPT is thought to occur early in the development of the classical disease, it should be monitored regularly because of its metabolic consequences.

Hopelessness and social comparison in Turkish adolescent with visual impairment

The purpose of this study was to determine visually impaired adolescents' level of hopelessness and how they perceive of themselves socially compared to other individuals. Another purpose of this study was to look for relationships between hopelessness and social comparison in adolescents with visual impairment. The research population was comprised of 130 students at a secondary school for the visually impaired in Istanbul, Turkey. Our study demonstrated a weak relationship between social comparison and hopelessness (r=-0.46, P < 0.000). The mean hopelessness score for the adolescents with visual impairment was 4.59 ± 3.12 (girls: 4.23 ± 3.10; boys: 4.83 ± 3.11) and social comparison score was 87.50 ± 11.19 (girls: 88.67 ± 11.62; boys: 86.60 ± 10.85). Hopelessness and social comparison were not affected by being blind from birth compared to later or from being a full-time boarding student compared to being a day student. The hopeless (Beck Hopelessness Scale score ≥ 9) adolescents' social comparison scores were found lower than hopeful ones' scores (P < 000). Factors affecting hopelessness and social comparison were feelings about their father, teacher and school.

Tuberculous meningitis in adults in Turkey: epidemiology, diagnosis, clinic and laboratory [corrected]

A retrospective study was performed to assess the epidemiology, diagnosis, clinic, and laboratory of the patients with tuberculous meningitis (TBM) in a multicentral study. The medical records of adult cases with TBM treated at 12 university hospitals throughout Turkey, between 1985 and 1998 were reviewed using a standardized protocol. The diagnosis of TMB was established with the clinical and laboratory findings and/or microbiological confirmation in cerebrospinal fluid (CSF). The non-microbiologically confirmed cases were diagnosed with five diagnostic sub-criteria which CSF findings, radiological findings, extra-neural tuberculosis, epidemiological findings and response to antituberculous therapy. A total of 469 patients were included in this study. Majority of the patients were from Southeast Anatolia (164 patients, 35.0%) and (108 patients, 23.0%) from East Anatolia regions. There was a close contact with a tuberculous patient in 88 of 341 patients (25.8%) and with a tuberculous family member in 53 of 288 patients (18.4%). BCG scar was positive in 161 of 392 patients (41.1%). Tuberculin skin test was done in 233 patients and was found to be negative in 75. Totally 115 patients died (24.5%) of whom 23 died in 24 hour after admittance. The diagnosis was confirmed with clinical findings and CSF culture and/or Ziehl-Nelson staining in 88 patients (18.8%). Besides clinical criteria, there were three or more diagnostic sub-criteria in 252 cases (53.7%), two diagnostic sub-criteria in 99 cases (21.1%), and any diagnostic sub-criteria in 30 patients (6.4%). Since TBM is a very critical disease, early diagnosis and treatment may reduce fatal outcome and morbidity.

Detection of Brucella melitensis by the BacT/Alert automated system and Brucella broth culture

This study was conducted to evaluate the ability of the BacT/Alert automated blood culture system to detect Brucella spp. in comparison with traditional Brucella broth culture. Overall, 100 (50 bone marrow and 50 blood samples) paired cultures were obtained, and 59 were positive by at least one method. The Brucella broth culture method detected all 59 positive cultures (100%), and the BacT/Alert system detected 30 (50.8%) (P < 0.05). The mean detection times for B. melitensis were 4.5 days in the BacT/Alert system and 5 days in Brucella broth culture (P > 0.05). There is no significant difference between the two methods with respect to growth time of the microorganism, but Brucella broth culture is more sensitive than the BacT/Alert system.

A comparison of high-level aminoglycoside resistance in vancomycin-sensitive and vancomycin-resistant Enterococcus species

The aim of this study was to investigate whether there was a significant difference in high-level aminoglycoside resistance (HLAR) between vancomycin-sensitive enterococci (VSE) and vancomycin-resistant enterococci (VRE). Vancomycin resistance was determined in 116 Enterococcus isolates using brain-heart infusion agar containing 6 micrograms/ml vancomycin. HLAR was determined by both standard agar screening and disk diffusion methods. Streptomycin and gentamicin were used as predictors of HLAR. Vancomycin resistance and HLAR were found in 17 (14.7%) and 41 (35.3%) of the Enterococcus strains, respectively. HLAR was found in 11 of 17 VRE and 30 of 98 VSE strains. HLAR in VRE strains was significantly higher than in VSE. More enterococcal strains were found to be resistant to both gentamicin and streptomycin (29) than to gentamicin (one) or streptomycin (11) alone. The HLAR rate in VRE was two-fold higher than in VSE. The synergistic bactericidal effect of aminoglycosides and beta-lactam or glycopeptide antibiotics is lost if there is high-level resistance to aminoglycosides.

Demonstration of in vitro antagonism between fusidic acid and quinolones

Fusidic acid is an antibiotic active against staphylococci and other bacterial pathogens. It is used in the treatment of staphylococcal infections usually in combination with other antibacterial agents. Reports of the clinical effects of antimicrobial combinations containing fusidic acid have been somewhat inconsistent. The aim of this study was to investigate the in vitro antagonism of fusidic acid and quinolones. Twenty-six staphylococci strains isolated from various clinical samples were tested. After detecting the diameter of the zone of inhibition around fusidic acid, levofloxacin, ciprofloxacin, ofloxacin and moxifloxacin for each strain, in vitro antagonism between fusidic acid and each quinolone was investigated using disk approximation. In all 26 strains, quinolones and fusidic acid were antagonist in vitro. The reason for this antagonistic effect and its clinical implications are not known. However, care should be exercised in prescribing quinolones and fusidic acid in combination.

Anthrax in adults and children: a review of 132 cases in Turkey

In this retrospective study, 132 cases of anthrax observed in a Turkish hospital over a 14-year period (October 1986 to October 2000) were evaluated with respect to clinical features, therapy, and outcome. The results show that anthrax is a disease of significance in the Eastern Anatolian region of Turkey. Preventive measures such as education of the population and vaccination of animals against anthrax would reduce the incidence of the disease.

Predictors of outcome in patients with tuberculous meningitis

OBJECTIVE

To assess predictors of mortality and neurological sequelae in patients with tuberculous meningitis (TBM).

METHODS

Patients with TBM treated at 12 university hospitals in Turkey between 1985 and 1997 were evaluated using a standardised protocol applied retrospectively. Variables associated with hospital mortality as well as with the presence of neurological sequelae at 6 months were determined using logistic regression models.

RESULTS

Four hundred and thirty-four patients between the ages of 13 and 83 years (mean 33 years) were evaluated. Sixty-eight per cent of these patients presented with Medical Research Council Stage II or III. One hundred and one patients (23.3%) died and 67 (27%) of evaluable survivors had neurological sequelae. In multi-variable analysis, convulsion (OR 3.3, 95%CI 1.2-9.0, P = 0.02), comatose mental status (OR 6.0, 95%CI 3.6-10.2, P = 0.01), and delayed or interrupted treatment (OR 5.1, 95%CI 2.4-11.2, P = 0.01) were shown to be predictors for mortality. The presence of extra-meningeal tuberculosis (OR 2.1, 95%CI 1.1-4.2, P = 0.035), cranial nerve palsy (OR 2.6, 95%CI 1.4-4.2, P = 0.01), hemiparesia/focal weakness (OR 9.3, 95%CI 3.8-22.6, P = 0.01), hemiplegia/multiple neurological deficit (OR 7.1, 95%CI 2.14-23.38, P = 0.01) and drowsiness (OR 4.2, 95%CI 2.04-8.82, P = 0.01) were independent predictors of neurological sequelae at 6 months following hospital discharge.

CONCLUSION

The results of this study emphasise the importance of prompt and uninterrupted anti-tuberculosis therapy for tuberculous meningitis. The presence of seizures or coma on admission to hospital are important predictors for mortality, while the presence of focal neurological signs is a predictor for persistent neurological sequelae in survivors.