Comparison of stiffness, elasticity and resilience values of ACL with autografts used instead of ACL in terms of texture analysis

Background

Anterior cruciate ligament (ACL) ruptures are one of the most extensively studied injuries in the field of orthopedics, but despite the extensive research, graft selection for ACL reconstruction remains a matter of debate. The present study aims to evaluate the stiffness and elasticity of native ACLs using texture profile analysis and compare results with those of autografts used in ACL reconstruction.

Methods

Included in the study were dissected 12 cadavers from which grafts were recovered. The graft characteristics, such as stiffness, elasticity and resilience, were measured using a TA.XT Plus Texture Analyzer.

Findings

Among the grafts studied, Achilles' tendon graft (0.70; 0.64) had the highest resilience in both males and females, while the greatest elasticity was identified in the patellar tendon graft (Male: 93 %; Female: 94 %) in all subjects. The highest stiffness value in males was recorded for the quadriceps tendon graft (2928.76 N), while the highest stiffness value in females was recorded for Achilles' tendon graft (2204.61 N).

Interpretation

According to the study data, the autografts that may be considered as an alternative to ACL were, listed in order of strength from high to low, the quadriceps, Achilles', patella and hamstring tendons in men, and the Achilles', quadriceps, patellar and hamstring tendons in women. It is worthy of note that the hamstring tendon graft, which is the most frequently preferred autograft in ACL reconstruction, was found to be the lowest in all parameters in both groups.

Potential benefits of combining two long-acting injectable antipsychotic: a retrospective study

OBJECTIVE

The aim of this study was to evaluate the efficacy and tolerability of the combination of two long-acting injectable antipsychotics (LAIA) in psychiatric disorders, especially in schizophrenia.

PATIENTS AND METHODS

Eighty-three patients treated with dual LAIA were included in the study by retrospective screening from the hospital registration system. The present study was designed as an observational, retrospective, naturalistic mirror-image study. The number of hospitalizations before and after switching to dual LAIA was compared in patients who received oral antipsychotics and single LAIA during the study period. In addition, it was analyzed which was the preferred dual antipsychotic combination.

RESULTS

Of the patients, 44.6% had schizophrenia, 41.0% had schizoaffective disorder, and 14.4% had other psychiatric disorders. The number of patients receiving oral treatment prior to dual LAIA use was 80 (96.4%). Data on dual LAIA regimens showed that 31.3% were receiving paliperidone and aripiprazole, 24.1% were receiving paliperidone and flupenthixol, 18.1% were receiving paliperidone and zuclopenthixol, and 26.5% were receiving the other combinations. After dual LAIA treatment, there was a significant decrease in the number of hospitalizations compared to before (from 5.95 to 0.99, p<0.001). In addition, while the number of patients who did not require hospitalization in the pre-treatment period was 10.8%, it reached 48.1% in the post-treatment period (p<0.001). No significant adverse effect related to the use of dual LAIA was observed in any patient during the treatment period.

CONCLUSIONS

The use of dual LAIA instead of oral antipsychotics or single LAIA in chronic psychotic patients with poor social support and irregular medication use is thought to reduce hospitalization and related treatment costs and regularize medication use.

COMPARATIVE ANALYSIS OF OPEN AND CLOSED FLOATING KNEE INJURIES

Objective

To compare the functional outcomes between floating knee injuries with open femur and tibia fractures and closed floating knee injuries.

Methods

Floating knee injuries (followed up and treated in our clinic) were retrospectively analyzed. Patients were divided into two groups: floating knee injuries with open femur and tibia fractures (Group 1) and floating knee injuries with closed femur and tibia fractures (Group 2). Patients were compared according to their demographic characteristics and clinical and functional outcomes.

Results

Of 52 study patients, 28 had Group 1 injuries and 24, Group 2 injuries. We found a statistically significant difference in length of hospital stay between the two groups (p = 0.01) and a statistically significant difference in Karlström-Olerud functional scores between the groups (p = 0.02). We found osteomyelitis in five (17%) patients in Group 1 and in one (4%) patient in Group 2.

Conclusion

Patients with floating knee injuries and open fractures showed poorer outcomes than those with closed fractures. Those with open floating knee injuries show complications more often and longer hospital stays. Level of Evidence III, Therapeutic Studies Investigating the Results of Treatment.

Assessment of the diagnostic accuracy of noninvasive scoring tools in predicting moderate-to-severe steatohepatitis via ultrasonography in asymptomatic healthy subjects admitted to family medicine outpatient clinics

OBJECTIVE

Efficacies of the noninvasive scoring tools in screening and diagnosing nonalcoholic fatty liver disease (NAFLD) remain controversial. Aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio, AST-to-platelet ratio index (APRI), and fibrosis-4 (FIB-4) index are the most frequently used parameters for differentiating moderate and severe steatohepatitis. In this context, the objective of this study is to evaluate the diagnostic accuracy of noninvasive tools in predicting moderate-to-severe steatohepatitis via ultrasonography in asymptomatic healthy subjects admitted to family medicine outpatient clinics.

PATIENTS AND METHODS

The population of this retrospective study consisted of healthy individuals tested within the scope of a medical check-up program between January and July 2021. All participants included in the study underwent relevant laboratory tests and liver ultrasonography (US). Steatohepatitis was graded using the US images as normal (grade 0), mild (grade 1), moderate (grade 2), and severe (grade 3). The participants with grade 0 and 1 steatohepatitis were categorized as Group 1, whereas those with grade 2 and 3 steatohepatitis (NAFLD) were categorized as Group 2. Any relationship between the aminotransferase/alanine aminotransferase (AST/ALT), AST-to-platelet ratio index (APRI), and fibrosis-4 index (FIB-4) parameters and the diagnostic powers thereof were analyzed based on the collected data.

RESULTS

The mean age of the study sample (n=408) was 46.1±12.7 years. There were 352 (86.3%) and 56 individuals in Groups 1 and 2, respectively. Platelet-to-lymphocyte ratio (PLR) and AST/ALT values were significantly higher, whereas APRI values were significantly lower in Group 1 than in Group 2 (p=0.004, p<0.001, and p<0.001, respectively). There were significant correlations between the presence of NAFLD and PLR values of ≤90.78 [area under the curve (AUC)=0.619, 95% confidence interval (CI): 0.570-0.666, p=0.007], AST/ALT values of ≤0.91 (AUC=0.802, 95% CI: 0.760-0.840, p<0.001), and APRI values of >0.22 (AUC=0.687, 95% CI: 0.640-0.732, p<0.001).

CONCLUSIONS

The composite noninvasive indices, including PLR, AST/ALT, and APRI, can be beneficial in predicting NAFLD in healthy individuals.

Evaluation of Autografts Used in Anterior Cruciate Ligament Reconstruction in Terms of Tensile Strength

Introduction Anterior cruciate ligament (ACL) injuries increase the likelihood of chronic knee problems in later years, including early onset osteoarthritis. Therefore, ACL treatment is important in preventing knee problems from developing. The treatment of choice for ACL tears is surgery (ACL reconstruction), and the most popular tendons for ACL reconstruction are the patellar tendon, hamstring tendon (semitendinosus and gracilis tendons), and bone-patellar tendon-bone. The present study compares the tensile strength of autografts used in ACL reconstruction to identify the optimum autograft for ACL in terms of mechanical properties. Methods Cadavers were dissected, and the Achilles tendons, quadriceps tendons, hamstring tendons (semitendinosus and gracilis tendons), patellar tendon grafts, and ACLs were harvested. Tensile tests of each tendon graft were performed using a Shimadzu Autograph AG-IS 100 kN tester (Shimadzu, Kyoto, Japan). Results The mean difference in tensile strength between ACL and other grafts was lowest for the quadriceps in both males and females (p ˂ 0.001), meaning that ACL and quadriceps grafts are more compatible than other tendon grafts in terms of tensile strength. Conclusion The present study found the lowest mean difference in tensile strength to be between the ACL and the quadriceps tendon, suggesting that the use of the quadriceps tendon in ACL reconstruction will yield more positive outcomes.

Enhanced dataset synthesis using conditional generative adversarial networks

Biomedical data acquisition, and reaching sufficient samples of participants are difficult and time ans effort consuming processes. On the other hand, the success rates of computer aided diagnosis (CAD) algorithms are sample and feature space depended. In this paper, conditional generative adversarial network (CGAN) based enhanced feature generation is proposed to synthesize large sample datasets having higher class separability. Twenty five percent of five medical datasets are used to train CGAN, and the synthetic datasets with any sample size are evaluated and compared to originals. Thus, new datasets can be generated with the help of the CGAN model and lower sample collection. It helps physicians decreasing sample collection processes, and it increases accuracy rates of the CAD systems using generated enhanced data with enhanced feature vectors. The synthesized datasets are classified using nearest neighbor, radial basis function support vector machine and artificial neural network to analyze the effectiveness of the proposed CGAN model.

Can neutrophil-to-lymphocyte, platelet-to-lymphocyte and monocyte-to-lymphocyte ratios be useful to the diagnosis of aseptic loosening after total knee arthroplasty?

BACKGROUND

The aim of this study is to determine the role of hematological parameters - neutrophil/lymphocyte, platelet/lymphocyte, and monocyte/lymphocyte ratios - in the diagnosis of aseptic loosening after total knee arthroplasty.

METHODS

This study retrospectively analyzed the data of 244 patients who had primary total knee arthroplasty and 66 patients with aseptic loosening developed after total knee arthroplasty. The white blood cell counts, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, monocyte/lymphocyte ratio and c-reactive protein levels in both groups were determined using the results of venous blood samples collected during preoperative preparation and compared between the groups.

RESULTS

Our study findings reveal that the monocyte/lymphocyte ratio of the group with aseptic loosening was statistically significantly different from that of the patient group who had primary total knee arthroplasty (p=0.02). Furthermore, although c-reactive protein levels are not high enough to suggest systemic inflammation, the difference between the groups is statistically significant (p=0.01).

CONCLUSIONS

No hematological parameter that could be used in the diagnosis of aseptic loosening has been defined in the literature so far. This study demonstrated that the monocyte/lymphocyte ratio could be a helpful parameter in the diagnosis of aseptic loosening (Tab. 1, Fig. 1, Ref. 28).

Residual Symptoms After Carpal Tunnel Decompression and Treatment With Gabapentin: A Multicenter Study

Objectives

To identify postoperative residual symptoms of carpal tunnel syndrome (CTS) and to investigate the effectiveness of gabapentin in the treatment of residual symptoms.

Materials and methods

Of a total of 412 patients who underwent surgery for CTS in four centers over a four-year period, 14 who had residual symptoms after CTS release and did not receive gabapentin (Group A) and 14 patients with postoperative residual symptoms and received gabapentin were included in this retrospective study. Postoperative residual symptoms were defined as persistent nocturnal numbness and tingling with or without occasional daytime pain. Tinel’s and Phalen’s tests were performed for the diagnosis of residual symptoms. Functional Severity Score (FSS), Symptom Severity Score (SSS), and Visual Analog Scale (VAS) were used to evaluate functional outcomes, severity of symptoms, and numbness and sleep quality, respectively at six and 12 weeks postoperatively.

Level of Evidence: III, therapeutic study

Results

There was no statistically significant difference in the mean postoperative FSS (p=0.845) and VAS-numbness scores (p=0.367) between the groups. However, there was a statistically significant difference in the mean postoperative SSS (p=0.025) and VAS-sleep quality scores (p<0.001) between the groups.

Conclusion

Gabapentin treatment can be a treatment of choice for residual symptoms after CTS surgery and clinical improvement can be achieved owing to its relieving effect, particularly in nocturnal symptoms of patients having neuropathic pain.

Plasma and Breast Milk Pharmacokinetics of Tenofovir Disoproxil Fumarate in Nursing Mother with Chronic Hepatitis B-Infant Pairs

Tenofovir use is associated with lower risk of mother-to-infant transmission of the virus, and discontinuation of the treatment is not safe. However, the safety of the drug during pregnancy and breastfeeding is not clear. In this study, we aimed to determine the tenofovir concentration in plasma of mother-infant pairs along with breast milk in chronic hepatitis B patients during the lactation period. A total of 11 mother-infant pairs were enrolled in the study. All the mothers received tenofovir disoproxil fumarate (TDF) 245 mg/day for at least 1 month because of chronic hepatitis B infection. Maternal blood, breast milk, and infant blood samples were obtained concomitantly. Tenofovir concentrations were determined by liquid chromatography-tandem mass spectrometry. The median concentrations of tenofovir in maternal plasma and breast milk samples were 88.44 (interquartile range [IQR], 62.47 to 116.17) ng/ml and 6.69 (IQR, 4.88 to 7.03) ng/ml, respectively. Tenofovir concentrations were undetectable (<4 ng/ml) in all of the infant plasma samples. The ratio of tenofovir concentration in breast milk to that in maternal plasma was 0.07. Tenofovir disoproxil fumarate passes through the breast milk in a small amount. Infants had no detectable tenofovir level in their plasma. Our study suggests that tenofovir disoproxil fumarate treatment is safe during the breastfeeding period in chronic hepatitis B patients.

Emotion recognition using time-frequency ridges of EEG signals based on multivariate synchrosqueezing transform

The feasibility of using time-frequency (TF) ridges estimation is investigated on multi-channel electroencephalogram (EEG) signals for emotional recognition. Without decreasing accuracy rate of the valence/arousal recognition, the informative component extraction with low computational cost will be examined using multivariate ridge estimation. The advanced TF representation technique called multivariate synchrosqueezing transform (MSST) is used to obtain well-localized components of multi-channel EEG signals. Maximum-energy components in the 2D TF distribution are determined using TF-ridges estimation to extract instantaneous frequency and instantaneous amplitude, respectively. The statistical values of the estimated ridges are used as a feature vector to the inputs of machine learning algorithms. Thus, component information in multi-channel EEG signals can be captured and compressed into low dimensional space for emotion recognition. Mean and variance values of the five maximum-energy ridges in the MSST based TF distribution are adopted as feature vector. Properties of five TF-ridges in frequency and energy plane (e.g., mean frequency, frequency deviation, mean energy, and energy deviation over time) are computed to obtain 20-dimensional feature space. The proposed method is performed on the DEAP emotional EEG recordings for benchmarking, and the recognition rates are yielded up to 71.55, and 70.02% for high/low arousal, and high/low valence, respectively.

Analysis of the involvement of the thyroid gland using computed tomography in patients with suspected SARS-CoV-2 infection: a retrospective study

OBJECTIVE

SARS-CoV-2 primarily infects the respiratory tract and leads to severe pneumonia by binding to the ACE-2 receptor. The virus can also interact with ACE-2 receptors expressed in other tissues as in thyroid. This study predicted the complications involving the thyroid in patients with suspected SARS-CoV-2.

PATIENTS AND METHODS

Patients with suspected SARS-CoV-2 infection between March 11, 2020-May 31, 2020 were retrospectively evaluated. Sixty-nine patients who were radiologically diagnosed as COVID-19 according to thoracic CT and had previously performed thoracic CT before November 2019 were included in the study according to the exclusion and inclusion criteria. Age and gender-matched controls (No. 69) were selected with normal thoracic CT whose PCR tests were also negative. Thyroid densities of participants were calculated and compared from the previous and current thoracic CTs. Results were also compared with the control group.

RESULTS

Participants were composed of 69 patients (39 male, mean age 64.35 years). Thyroid densities were significantly decreased from 89HU to 76HU for whole gland, from 88HU to 76HU for right lobes and from 87.5HU to 75.5HU for left lobes at current thoracic CTs performed during COVID-19 (p<0.001, p<0.001, p<0.001 respectively). The decrease in densities of the whole thyroid gland, both left and right lobes, was correlated with mortality (p<0.001). The changes in thyroid densities were not correlated with age nor gender. The decreases in HU values of thyroid densities for whole gland, left and right lobes, were correlated with mortality (p<0.001, p<0.001, and p<0.001 respectively).

CONCLUSIONS

COVID-19 is a multi-systemic disease that threatens vital organs, including the thyroid. Future studies are needed to investigate the association between SARS-CoV-2 and other complications.

Quality and Content Analysis of Carpal Tunnel Videos on YouTube

INTRODUCTION

Carpal tunnel syndrome is a disease that reduces the quality of life, and it is characterized by numbness, tingling in the fingers, and weakness in the hand, which we frequently encounter in our daily clinical practice. In this study, we aimed to evaluate the videos in terms of quality and reliability by watching the first 50 YouTube videos most relevant to the carpal tunnel in the YouTube video channel, which is often the first reference point as a source of information.

METHOD

Among the videos that appear after typing "carpal tunnel" in the search tab of the YouTube, we eliminated those with advertisements and those that are not in English and evaluated the top 50 most relevant videos about the carpal tunnel. A specific YouTube channel was not selected during the search; however, the most relevant videos on carpal tunnel syndrome were determined. The duration, the number of views, the number of likes, dislike numbers, upload times, and upload sources of the videos were recorded and evaluated. The content, quality, and reliability of the videos were evaluated according to the GQS, JAMA, and DISCERN scales.

RESULTS

The average length of the 50 videos included in the study was 315.18, the average number of views was 150,977.4, and the average number of likes was 1410.86. The average number of days when the videos were uploaded to the internet was calculated as 1259.62 days. The GQS average of 50 videos included in the study was calculated as 2.7, the JAMA score average as 2.14 and the DISCERN score average as 33.62, and the video quality, content, and reliability were low. There was no statistically significant relationship between uploading sources of videos to the internet and video content, quality, and reliability (p > 0.05). The number of views, the number of days uploaded to the internet, the number of views, the number of likes and dislikes, like rates, and the video power index of the videos showed no statistically significant relationship with JAMA, DISCERN, and GQS.

CONCLUSION

Social media is one of the easiest methods to access information today. The high number of contents, quality, and reliability of social media videos are crucial for patients to obtain accurate information, gain awareness about diseases, and receive guidance on treatment. This study found out that the quality, content, and reliability of the existing videos on the carpal tunnel were at a low level. We propose that the videos' content and quality should be improved and become more beneficial for patients.

Which frequency is better for pediatric shock wave lithotripsy? Intermediate or low: a prospective randomized study

PURPOSE

Shock wave lithotripsy (SWL) is the first option in the treatment of pediatric kidney stones; however, optimal frequency is still uncertain. The aim of this study was to compare low frequency [60 shocks per minute (SWs/min)] and intermediate frequency [90 SWs/min] in terms of lithotripsy success, complications, cardiac arrhythmia, anesthesia time, secondary procedures, and efficiency quotient (EQ) in children.

METHODS

Seventy-eight consecutive children who received SWL for radiopaque renal stones between July 2016 and January 2020 were randomly divided into two groups: Group 60 (SWL frequency: 60 SWs/min) and Group 90 (SWL frequency: 90 SWs/min). After exclusion (remaining 71 children), Group 60 (n = 38) and Group 90 (n = 33) were compared using univariate analysis.

RESULTS

The median age of children (37 girls, 34 boys) was 5 (1-16) years. Patient demographics and stone features were similar between the groups. Success rate after the last SWL session was 81.6% (n = 31) for Group 60 and 87.9% (n = 29) for Group 90 (p = 0.527). Stone-free rate after the first, second, and third sessions was 42.1%, 18.4%, and 21.1% for Group 60 and 48.5%, 27.3%, and 12.1% for Group 90, respectively. Additional treatment rate was similar between the groups. In Group 60, the EQ was 57.83, and it was 64.07 in Group 90. Median total anesthesia time was significantly longer in Group 60 (74.5 min) than in Group 90 (32 min; p < 0.001).

CONCLUSION

Intermediate frequency and low-frequency pediatric SWL have similar success rates; however, intermediate-frequency SWL has a shorter anesthesia time.

Evaluation of factors affecting the association between thickening of sinus mucosa and the presence of periapical lesions using cone beam CT

AIM

To evaluate the effect of various parameters of periapical lesion(s) on the amount and type of mucosal thickening using cone beam CT images.

METHODOLOGY

CBCT scans of 1000 patients were evaluated retrospectively for the presence of apical lesions in maxillary posterior teeth associated with sinus mucosal thickening. The number of cases with pathological mucosal thickening was recorded and classified according to the amount and type of mucosal thickening. The parameters evaluated as the cause of mucosal thickening were the type and number of posterior teeth, number of root(s), diameter of the periapical lesion and distance between maxillary sinus and lesion. Descriptive statistics and multiple logistic regression was used for data analyses. Spearman's correlation coefficient was used for pair-wise comparisons. Intrarater reliability was tested by Cohen's kappa.

RESULTS

Mucosal thickening associated with periapical lesions was determined in 48% of 202 cases. The most frequently detected extent of mucosal thickening was type 3 (42%), whereas flat type thickening (59%) was the most frequent type. The tooth most frequently associated with mucosal thickening was the maxillary first molar (44%). Parameters significantly affecting the extent of mucosal thickening were gender, number of roots, number of teeth with periapical lesions and diameter of periapical lesions (P < 0.05). The single parameter with an association with the type of mucosal thickening was the number of roots with an apical lesion (P < 0.05).

CONCLUSION

Mucosal thickening associated with periapical lesions was observed in almost 50% of all mucosal thickening cases. Therefore, collaboration amongst endodontists and otolaryngologists is mandatory to provide successful treatment and prevent recurrence of maxillary sinusitis.

Non-HACEK Gram-negative bacillus endocarditis

PATIENTS AND METHODS

Retrospective analysis of clinical data using 26 diagnosed non-HACEK Gram-negative infective endocarditis cases from nine hospitals in Turkey.

RESULTS

Mean age of patients was 53 (28-84) years, with a 23% case fatality. Nineteen (73%) of the 26 patients had at least one predisposing factor. The presence of a central venous catheter was the most common predisposing factor (7/26 patients). Pseudomonasaeruginosa (7/26 patients) and Escherichiacoli (7/26 patients) were the most common pathogens. The median duration of the antibiotic therapy was 42 days (range 3-84 days). Surgical procedures were performed in 10 patients. The case fatality was similar in patients who did or did not undergo surgery (20% vs. 25%).

ECG feature extraction based on the bandwidth properties of variational mode decomposition

It is a difficult process to detect abnormal heart beats, known as arrhythmia, in long-term ECG recording. Thus, computer-aided diagnosis systems have become a supportive tool for helping physicians improve the diagnostic accuracy of heartbeat detection. This paper explores the bandwidth properties of the modes obtained using variational mode decomposition (VMD) to classify arrhythmia electrocardiogram (ECG) beats. VMD is an enhanced version of the empirical mode decomposition (EMD) algorithm for analyzing non-linear and non-stationary signals. It decomposes the signal into a set of band-limited oscillations called modes. ECG signals from the MIT-BIH arrhythmia database are decomposed using VMD, and the amplitude modulation bandwidth B AM, the frequency modulation bandwidth B FM and the total bandwidth B of the modes are used as feature vectors to detect heartbeats such as normal (N), premature ventricular contraction (V), left bundle branch block (L), right bundle branch block (R), paced beat (P) and atrial premature beat (A). Bandwidth estimations based on the instantaneous frequency (IF) and amplitude (IA) spectra of the modes indicate that the proposed VMD-based features have sufficient class discrimination capability regarding ECG beats. Moreover, the extracted features using the bandwidths (B AM, B FM and B) of four modes are used to evaluate the diagnostic accuracy rates of several classifiers such as the k-nearest neighbor classifier (k-NN), the decision tree (DT), the artificial neural network (ANN), the bagged decision tree (BDT), the AdaBoost decision tree (ABDT) and random sub-spaced k-NN (RSNN) for N, R, L, V, P, and A beats. The performance of the proposed VMD-based feature extraction with a BDT classifier has accuracy rates of 99.06%, 99.00%, 99.40%, 99.51%, 98.72%, 98.71%, and 99.02% for overall, N-, R-, L-, V-, P-, and A-type ECG beats, respectively.

Comparison of community-onset healthcare-associated and hospital-acquired urinary infections caused by extended-spectrum beta-lactamase-producing Escherichia coli and antimicrobial activities

OBJECTIVE

We aimed to compare community-onset healthcare-associated (CO-HCA) and hospital-acquired (HA) urinary tract infections (UTIs) caused by extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli in terms of epidemiology, clinical outcomes and antimicrobial activities.

METHODS

Patients from both groups with ESBL-producing E. coli detected by urine culture between January 2009 and January 2011 were included in this retrospective study. Relevant demographical, microbiologic and clinical data were obtained from case records.

RESULTS

A total of 173 patients (mean age of 58 years, 74% female) were included, of whom 75 (43.4%) had a CO-HCA UTI and 98 (56.6%) had an HA UTI. Eighty (46.2%) patients had more than one comorbid disease, of whom 57 (32.5%) had urological problems. The most common clinical manifestations were pyelonephritis (43.9%) and urosepsis (16.2%). An age of > 65 years (p = 0.005) in addition to urinary catheterisation (p = 0.001), urosepsis (p = 0.001) and mortality (p = 0.001) were significantly more common in the HA UTI group. Acute cystitis (p = 0.027), complicated cystitis (p = 0.001) and non-urologic neoplasm (p = 0.032) were significantly more common in the CO-HCA UTI group. No isolate was resistant to carbapenems or fosfomycin. Sensitivities to nitrofurantoin, amikacin, trimethoprim sulfamethoxazole-trimoxazole and quinolones were 97.6%, 89%, 29.4% and 17.9% respectively. Both groups showed similar rates of antibiotic resistance.

CONCLUSION

ESBL-producing E. coli should be taken into consideration in patients with a CO HCA UTI, not only in hospital settings but also in outpatient settings. We suggest ertapenem as a first-line empirical treatment for patients with an upper UTI and fosfomycin and nitrofurantoin for those with a lower UTI when ESBL-producing E. coli is suspected.

Modeling and mapping potential distribution of Crimean juniper (Juniperus excelsa Bieb.) using correlative approaches

Modeling and mapping potential distribution of living organisms has become an important component of conservation planning and ecosystem management in recent years. Various correlative and mechanistic methods can be applied to build predictive distributions of living organisms in terrestrial and marine ecosystems. Correlative methods used to predict species' potential distribution have been described as either group discrimination techniques or profile techniques. We attempted to determine whether group discrimination techniques could perform as well as profile techniques for predicting species potential distributions, using elevation (ELVN), parent material (ROCK), slope (SLOP), radiation index (RI) and topographic position index (TPI)) as explanatory variables. We compared potential distribution predictions made for Crimean juniper (Juniperus excelsa Bieb.) in the Yukan Gokdere forest district of the Mediterranean region, Turkey, applying four group discrimination techniques (discriminate analysis (DA), logistic regression analysis (LR), generalized addictive model (GAM) and classification tree technique (CT)) and two profile techniques (a maximum entropy approach to species distribution modeling (MAXENT), the genetic algorithm for rule-set prediction (GARP)). Visual assessments of the potential distribution probability of the applied models for Crimean juniper were performed by using geographical information systems (GIS). Receiver-operating characteristic (ROC) curves were used to objectively assess model performance. The results suggested that group discrimination techniques are better than profile techniques and, among the group discrimination techniques, GAM indicated the best performance.

A Strain ofSalmonella entericaserovar Virchow Isolated in Turkey and Carrying a CTX-M-3 Extended-Spectrum Beta-Lactamase

A multiply resistant strain of Salmonella enterica subsp. enterica serovar Virchow was isolated in November 2002 from a catheterized patient admitted to the SSK Training Hospital in Ankara, Turkey. This isolate showed an antimicrobial susceptibility pattern compatible with the presence of a CTX-M-type ESBL, namely resistance to cefotaxime, aztreonam and cefepime, and intermediate susceptibility to ceftazidime. On checking for the presence of the bla(TEM), bla(SHV), and bla(CTX-M )resistance genes by PCR, negative results were obtained with the primers specific for SHV and TEM genes, while positive results were obtained with those specific for CTX-M-type genes. After sequencing, the beta-lactamase was identified as CTX-M-3. This is the first report of this enzyme in Salmonella Virchow and represents a further disquieting threat to the therapy of infections caused by Salmonella isolates.

Hierarchical land classification and mapping of Aglasun forest ecosystems in the Mediterranean region, Turkey

Hierarchical Land Classification of forest ecosystems is an attempt to classify the territory considering hierarchical distinctions of plant communities. Ecological land classification is especially crucial for semi natural or degraded forest ecosystems. In this study, a hierarchical land classification was generated for Aglasun forest ecosystems where urban and agricultural developments and non-stop human activity for fuel wood and timber have caused extensive degradation to native plant communities. Data obtained from 153 sample plots consisting of environmental characteristics and vascular plant species were evaluated by using cluster analysis, stepwise discriminate analysis, and chi-square test. Interspesific correlation analysis was applied to define the indicator species at each distinction level. Two sections, two subsections and four units were finally determined for the Aglasun forest district. The results of the stepwise discriminate analyses showed that the fundamental variables for classifying the district are altitude, exposition, latitude and longitude.

Pelvic and retroperitoneal hydatid cysts superinfected with Brucella sp. and review of infected hydatid cysts

Hydatid disease is a zoonotic infection resulting from the tissue infestation of the larval stage of the parasite Echinococcus granulosus. Hydatid cysts superinfected with pyogenic organisms have been reported previously. Brucellosis is more prevalent in people with close contact to animals and those consuming fresh milk or fresh milk products. Although these two disorders have some similar epidemiological features, we did not encounter any hydatid cyst cases superinfected with Brucella species (sp.) in a search of medical literature (Pubmed). Here, we present a case of hydatid cyst disease superinfected with Brucella and review the literature on other hydatid cyst cases superinfected with pyogenic organisms. We conclude that in regions where brucellosis and hydatid cysts are endemic, cysts may be infected with Brucella sp.

The effect of delayed scanning of storage phosphor plates on occlusal caries detection

OBJECTIVE

The aim of this study was to determine (1) the effect of various scan delays on pixel intensity measurements and (2) the diagnostic accuracy of occlusal caries detection.

METHODS

72 non-cavitated extracted human permanent molar teeth with sound and carious occlusal surfaces were radiographed using the DIGORA® storage phosphor plates (SPPs) (Soredex Corporation, Helsinki, Finland). Plates were scanned immediately and 10 min, 30 min, 60 min and 120 min after exposure. Three different plates were used for each scan delay. An aluminium (Al) wedge was used to evaluate the change in mean grey values (MGVs) for scan delays. Diagnostic accuracy for occlusal caries detection was performed by scoring all the digital images. The true presence of caries was determined by stereomicroscopy. Comparison of MGVs of the Al wedge for immediate and delayed scans was made using repeated measures analysis of variance (ANOVA) and Tukey-Kramer tests. The accuracy was expressed as the area under the receiver operating characteristics curves (A(z)). A(z)s were compared using two-way ANOVA and t-tests. Kappa was used to measure inter and intraobserver agreement.

RESULTS

The mean A(z)s of immediately scanned plates were higher than the A(z)s of plates scanned with four different delays (p < 0.05). The A(z) of immediately scanned images was significantly higher than the A(z)s of images with 60 min and 120 min scan delays (p < 0.05) but not for 10 min and 30 min delays (p > 0.05). MGVs of immediately scanned plates were significantly higher than the plates scanned with four different delays (p < 0.05). Agreement decreased with increasing scan delays.

CONCLUSION

Scanning of DIGORA SPPs should not be delayed beyond 30 min for accurate occlusal caries diagnosis.

Diagnostic accuracy of proximal enamel subsurface demineralization and its relationship with calcium loss and lesion depth

OBJECTIVE

The aim of this study was to determine the relationship between the amount of calcium loss, lesion depth, and the accuracy of storage phosphor plate (SPP) and film radiographs for the detection of artificial proximal demineralization.

METHODS

Standard enamel windows of extracted premolars were exposed to a demineralizing solution for 60 h, 80 h, 100 h and 120 h. Solutions were analysed for calcium concentration by atomic absorption spectrometer and the lesion depths were calculated by a specific formula. All teeth were radiographed with SPPs and F-speed films before and after acid application. Images were evaluated by five observers. Stereomicroscopic and scanning electron microscopic (SEM) observations were carried out to visualize enamel surfaces after acid exposure. Receiver operating characteristic analysis was used for diagnostic accuracy (A(z)). A(z)s were compared with factorial analysis of variance and t-tests. The relationship between A(z)s and lesion depths was determined with Pearson's correlation test.

RESULTS

Strong positive correlation was found between A(z)s of both radiographic methods and lesion depths. No difference was found between the A(z)s of two radiographic systems for any of the demineralization durations (p > 0.05). Pair-wise comparisons revealed no significant difference in A(z)s of SPPs (p > 0.05), while significant differences were obtained for the A(z)s of films for different demineralization periods (p < 0.05). Stereomicroscopic and SEM observations confirmed demineralizations from superficial to deeper layers of enamel.

CONCLUSION

Subsurface enamel demineralization was not accurately detectable with either storage phosphor plates or F-speed films. The amount of calcium loss and the depth of demineralization have a strong relationship with diagnostic accuracy with a significant effect particularly on F-speed films.

Perception of anatomical structures in digitally filtered and conventional panoramic radiographs: a clinical evaluation

OBJECTIVES

The aims of the study were to compare subjective image quality of clinical images obtained with a storage phosphor plate (SPP)-based digital and conventional film-based panoramic system for the visualization of various anatomical structures and to evaluate the effect of various processing algorithms on image interpretation.

METHODS

Panoramic radiographs were taken in 42 patients both with film and with a SPP system. SPP images were treated with shadow, sharpen, negative, greyscale sigma and greyscale exponential filters. Four observers subjectively evaluated films and unfiltered and filtered SPP images for the visibility of anatomical structures with various radiodensities as well as for overall image quality on a three-point rating scale. The statistical methods used were Kruskal-Wallis, odds ratio analysis and Cohen's kappa.

RESULTS

No statistically significant difference was found between film and unfiltered digital images except for low-contrast structures (P > 0.05). Film images were preferred for the visibility of low-contrast structures (P < 0.05). Best overall image quality was obtained with sharpened images (P < 0.05) followed by films and unfiltered digital images. Among all filtered images, sharpened ones received the highest ratings for the visibility of all anatomical structures (P < 0.05). The intra- and interobserver agreement ranged between moderate and substantial and between fair and moderate, respectively.

CONCLUSIONS

Film and unfiltered SPP-based panoramic images performed equally well in terms of overall quality; however, films were best for the perception of low-contrast structures. The sharpening filter may be recommended for enhancing SPP panoramic images to improve the visual perception of most of the anatomical structures as well as overall quality.

Plant distribution-altitude and landform relationships in karstic sinkholes of Mediterranean region of Turkey

The purpose of this study was to investigate the relationships between the plant distribution and the altitude-shape-size characteristics of sinkholes, and the landform characteristics inside sinkholes in the Mediterranean region of Turkey. Block kriging, Factor analysis, Cluster Analysis and Detrended Correspondence Analysis were performed. The sinkhole type and altitudinal zone were found to be the significant factors affecting the plant distribution. However, the sinkhole type was more important than the altitudinal zone. Hence, the sinkholes were first subdivided into groups according to types and then the groups were divided into subgroups according to the altitudinal zones. Consequently, 4 groups were defined; A-type sinkholes [1400-1550 m (A1), 1550-1700 m (A2)] and B-type sinkholes [1400-1550 (B1), 1550-1700 m (B2)]. The B-type was wider vertically and shorter horizontally than A-type sinkholes. Significant differences were found between the plant distribution and slope position inside the sinkholes. Plant distribution in the lower slopes was different from that in the flats and ridges in the B1 sub-type of B-type. Plant distribution in B2 subtype was different among the slope positions (ridge, middle slope, lower slope, and flat). Although distribution of plants is different in different parts (ridges, upper slope, middle slope, lower slope and basal flats) of A sinkhole, the differences between the parts of intermediate slope position are not significant. A high plant variability along short distances in the sinkholes was observed in the study area. That is why the site of sinkholes have a big potential for the distribution of many species. Hence, the area must be separated as strictly protected zone.

Estimation of Tree Size Diversity Using Object Oriented Texture Analysis and Aster Imagery

This study investigates the potential of object-based texture parameters extracted from 15m spatial resolution ASTER imagery for estimating tree size diversity in a Mediterranean forested landscape in Turkey. Tree size diversity based on tree basal area was determined using the Shannon index and Gini Coefficient at the sampling plot level. Image texture parameters were calculated based on the grey level co-occurrence matrix (GLCM) for various image segmentation levels. Analyses of relationships between tree size diversity and texture parameters found that relationships between the Gini Coefficient and the GLCM values were the most statistically significant, with the highest correlation (r=0.69) being with GLCM Homogeneity values. In contrast, Shannon Index values were weakly correlated with image derived texture parameters. The results suggest that 15m resolution Aster imagery has considerable potential in estimating tree size diversity based on the Gini Coefficient for heterogeneous Mediterranean forests.

Chronic hepatitis C responds poorly to combination therapy in chronic hepatis B carriers

BACKGROUND

The effect of conventional interferon-based therapy of hepatitis B virus (HBV) and hepatitis C virus (HCV) dual infection is controversial. Yet, no studies have been carried out into pegylated interferon treatment for chronic HBV/HCV coinfection. We aimed to evaluate the response rate and side effects of conventional or pegylated interferon combined with ribavirin on chronic HBV/HCV coinfection therapy.

METHODS

The study included 36 chronic hepatitis patients (M/F: 28/8, mean age 47+/-12 years) who were positive for HBsAg and anti-HCV. They were tested for the presence of HBV-DNA by hybridisation assay, and the samples giving negative results were retested by polymerase chain reaction (PCR). All patients were tested for HCV-RNA using PCR, and the HCV genotype was determined.

RESULTS

Nineteen patients were given standard interferon either alone or in combination with ribavirin, whereas 17 were given pegylated interferon and ribavirin combination therapy. None of the patients had HBV-DNA positivity; however, all had HCV-RNA detectable by PCR. All the patients had HCV genotype 1b. The mean alanine aminotransferase and aspartate aminotransferase levels were 118+/-65 U/l and 90+/-95 U/l respectively. Five patients in each group discontinued the treatment due to side effects. Only two patients (one from each group) reached sustained virological response.

CONCLUSION

Neither pegylated nor conventional interferon based regimes were effective for HBV/HCV coinfection, in which the dominant virus was HCV. Pegylated interferon and ribavirin therapy was not superior to conventional interferon based regimes in the treatment of HBV/HCV coinfection.

Candida krusei Arthritis in a Patient with Hematologic Malignancy: Successful Treatment with Voriconazole

Here, we report a case of disseminated Candida krusei infection in a patient who presented with arthritis. The infection was successfully treated with voriconazole after amphotericin B deoxycholate therapy had failed.

Erythema nodosum: an evaluation of 100 cases

OBJECTIVES

In this study, we investigated the clinical features, etiology, and also predictive factors of secondary erythema nodosum (EN) in patients with EN.

METHODS

A total of 100 patients (mean age: 37 years) diagnosed with EN between 1993 and 2004 in our clinic were included in the study prospectively. A skin biopsy was performed in 46 of the patients. Patients were considered to have secondary EN when an underlying condition was found, and to have primary EN when no such condition was found. For the diagnosis of the underlying diseases, the pertinent diagnostic criteria and/or diagnostic methods were used. Categorical and continuous variables were compared by using chi-square and Mann-Whitney U tests respectively. Multiple regression analysis was applied to the significantly different variables.

RESULTS

The majority of the patients were female (female/male: 6/1) and nearly half (47%) of the cases had a determined etiology. The leading etiology was poststreptococcal (11%), followed in decreasing order by primary tuberculosis (10%), sarcoidosis (10%), Behçet's syndrome (BS) (6%), drugs (5%), inflammatory bowel diseases (IBD) (3%), and pregnancy (2%). Fifteen (15%) patients complained of cough; the diagnosis was primary tuberculosis in eight cases and sarcoidosis in seven. Four patients with arthritis were diagnosed as having BS (in 3) and Crohn's disease (in 1). All the patients were followed for a mean duration of 4.5 years. The nodosities relapsed annually in 62% (33/53) of idiopathic EN patients but in only one (BS) in the secondary EN group. The histology was consistent with EN in all biopsied patients. Our study revealed that fever, leukocytosis, elevated CRP level, accelerated ESR, presence of cough, sore throat, diarrhea, arthritis, and pulmonary pathology were predictors of secondary EN. Recurrence in EN significantly predicted primary EN. All of the patients had bed rest and the majority was given an anti-inflammatory agent (naproxen sodium). The outcomes were usually favorable within 7 days. The patients with an underlying disease were given the specific treatment.

CONCLUSION

EN has been associated with numerous diseases. In order to reduce cost and duration of diagnosis, every centre should determine its own most frequent etiologic factors. Predictive variables for secondary EN should also be determined and an optimum management for such patients should be clarified. Our study revealed streptococcal pharyngitis, primary tuberculosis, sarcoidosis, IBD, and BS as the main etiologies of EN.

Abdominal actinomycosis: a report of two cases

Actinomyces spp. cause a chronic suppurative, granulomatous disease which is characterized clinically by extensive abscess formation, recurrent draining of sinuses and fistulae and histologically by the presence of the so-called "sulphur granules". Colonic actinomycosis is a relatively rare infection and its diagnosis is difficult. We report the case of a female patient who was operated on for ovarian cyst and the case of another female patient operated on for a mass in the transverse colon. In both cases the pathology of the excised tissues revealed actinomycosis. Actinomycosis must be considered in the differential diagnosis of patients who present with abdominal pain, fever, leucocytosis and intestinal wall thickness and/or abdominal mass.

Cellulitis as a manifestation of miliary tuberculosis in a renal transplant recipient

Cutaneous involvement is an unusual presentation of tuberculosis (TB) and is rarely reported in renal transplant recipients. We describe a 37-year-old renal transplant recipient with disseminated Mycobacterium tuberculosis infection that presented as cellulitis. The organism was isolated from tissue and blood cultures. The patient was treated with quadruple anti-TB therapy for 12 months. Anti-TB therapy led to a complete resolution of TB lesions. We also provide a review of the literature on cutaneous TB in renal transplant recipients. Skin TB in renal transplant recipients usually occurs with nontuberculous mycobacteria. The spectrum of the skin lesions can be quite different and can mimic bacterial infections. Mycobacteriosis should always be included in the differential diagnosis of a skin lesion in renal transplant recipients.

Is laparotomy necessary in the diagnosis of fever of unknown origin?

Fever of unknown origin (FUO) is a diagnostic challenge for the practising physician. Detailed medical history, physical examination, non-invasive laboratory tests, and radiologic examinations compose the first level in the diagnostic approach to the FUO. When a diagnosis cannot be established with these procedures, some invasive diagnostic techniques and finally exploratory laparotomy are performed. Although advanced diagnostic measures and imaging-guided less invasive procedures have decreased the need, laparotomy remains as a final diagnostic method for FUO cases. In this study we evaluate the role and importance of laparotomy in the diagnosis of our FUO cases. In 17 out of 126 patients (8 male, 9 female, the median age 35.8 years) hospitalized in our clinic between 1982 and 2002 with the diagnosis of FUO, the diagnosis was established by laparotomy. The diagnosis was made directly in 13 patients, and indirectly (by excluding other diseases) in 2 patients. In several FUO series, the contribution of laparotomy to the diagnosis of FUO was reported as 27-100%. This rate was found to be 88% in the present study. During laparotomy on 17 cases, tissue samples were taken from spleen, liver, intra-abdominal and mesenteric lymph nodes. Pathologic examination of these tissue samples revealed miliary tuberculosis in 4; non-Hodgkin's lymphoma in 3; Hodgkin's lymphoma in 3; liver tumour in 1; hairy cell leukemia in 1; peritonitis carcinomatosis in 1. In the patients with miliary tuberculosis, the liver (3) and/or spleen (2), and/or lymph node (3) revealed caseating granulomas. Laparotomy diagnosed 3 of 5 cases whose abdominal ultrasonography and computerized tomography were normal. In conclusion, although advanced diagnostic methods decreased the need for laparotomy in FUO, if non-invasive and invasive diagnostic measures fail, laparotomy may contribute to the diagnosis. The selection of the patient and the timing are important for laparotomy.

PER-1 production in a urinary isolate of Providencia rettgeri

A Providencia rettgeri strain resistant to extended-spectrum cephalosporins and intermediate to aztreonam was isolated from the urine of a patient hospitalized in the urology clinic of SSK Educational Hospital in Ankara. Clavulanic acid restored the activity of extended-spectrum cephalosporins, suggesting that the strain was harboring an extended-spectrum beta-lactamase. Since the PER-1 enzyme is widespread in Turkey, and had been already detected in a related species such as Proteus mirabilis, the Providencia strain was suspected of harboring a PER-1 enzyme, which was indeed detected by PCR. This is the first description in a P. rettgeri isolate of a PER-1 enzyme which is widespread among Acinetobacter baumanni and Pseudomonas aeruginosa strains in Turkey.

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.

Malaria in Turkey: a review of 33 cases

AIM

To evaluate epidemiologic and clinical features of the patients with malaria followed in our clinic, and to review current status of malaria in our country.

PATIENTS AND METHODS

Epidemiologic, clinical, diagnostic, and therapeutic features of 33 patients with malaria (4 female, 29 male, mean age: 28 +/- 11 years, range: 15-60) followed in our clinic between 1981 and 2000 were evaluated retrospectively. Malaria data of our country for 1926-2000 were obtained from Health Ministry.

RESULTS

Diagnosis was established by thin smears of blood preparations obtained in the febrile period in all cases. Plasmodium vivax was detected in 26 patients (25 domestic and one imported), and P. falciparum in seven (two domestic and five imported). Sixty-one percent of the patients had the prodromal symptoms of the disease and used various antibiotics. All cases demonstrated the typical pattern of fever with chills. Fever (100%), splenomegaly (91%), hepatomegaly (55%), anemia (70%), leukopenia (48%), thrombocytopenia (48%), a rise in sedimentation rate (100%), and abnormalities in hepatic enzymes (30%) were determined in the patients. Chloroquine + primaquine were given to all patients with P. vivax, chloroquin (for three) or mefloquin (for four) alone were given to the patients with P. falciparum. One patient with P. falciparum died soon after admission, all the remaining recovered. Data from Health Ministry revealed that the most common (approximately 100%) species in our country is P. vivax. Although an eradication program against malaria initiated in 1926 achieved success, it still remains as an important health problem.

CONCLUSION

Every febrile patient with a history of travel to the regions where malaria is endemic (tropical regions for the world, southeast regions for our country) should raise the suspicion of malaria. Every country should fight against malaria and global cooperation is essential.

Fever of Unknown Origin in Turkey

BACKGROUND

The etiology of fever of unknown origin (FUO) includes primarily infectious, collagen-vascular and neoplastic diseases. The distribution of the disorders causing FUO may differ according to the geographic area and the socioeconomical status of the country. Moreover, the developments in radiographic and microbiologic methods have changed the spectrum of diseases causing FUO.

MATERIALS AND METHODS

We reviewed 117 cases that fulfilled the criteria of FUO followed in our department during the period 1984 to 2001.

RESULTS

The etiology of FUO was infectious diseases in 34% of the patients, collagen-vascular diseases in 23%, neoplasms in 19% and miscellaneous diseases in 10%. In 14% of the cases the etiology could not be found. The three leading diseases were tuberculosis (24%), lymphomas (19%) and adult-onset Still's disease (11%). Tuberculosis was found to be a more common cause of FUO than reported in studies in developed countries. Invasive procedures helped to establish the diagnosis in 50 out of 92 patients (43%). As a final diagnostic procedure, laparotomy aided the establishment of a diagnosis in 15 out of 20 patients (75%).

CONCLUSION

Although the relative rate of infectious disease as etiologic category is less commonly encountered, infectious disease, especially tuberculosis, remains a common cause of FUO. Although several diseases may lead to FUO, lymphomas, adult-onset Still's disease and particularly tuberculosis should be considered in the differential diagnosis of a patient admitted with FUO.

Fever of unknown origin: a review of 20 patients with adult-onset Still's disease

In this study we aimed to investigate the findings in patients with adult-onset Still's disease (AOSD) admitted with fever of unknown origin (FUO) during the last 18 years in our unit, in order to discover the ratio of such patients to all patients with FUO during the same period, and to determine the clinical features of AOSD in FUO. The number and the aetiologies of the patients with FUO diagnosed between 1984 and 2001, and the clinical features of those with AOSD, were taken from the patient files. The diagnosis of AOSD was reanalysed according to the diagnostic criteria of Cush et al. [11]. The presumed diagnoses before a diagnosis of AOSD was established were also noted. The chi(2) and Fisher's exact tests were used for statistical analysis. We studied 130 patients with a diagnosis of FUO, 36 (28%) of whom had collagen vascular diseases. Of these 36 patients, 20 (56%, 12 female, 8 male, mean age 34 years, range 16-65) had AOSD. Clinical and laboratory findings were as follows: fever (100%), arthralgia (90%), rash (85%), sore throat (75%), arthritis (65%), myalgia (60%), splenomegaly (40%), hepatomegaly (25%), lymphadenopathy (15%), anaemia (65%), neutrophilic leukocytosis (90%), increased erythrocyte sedimentation rate (100%), elevated transaminase levels (65%), a negative RF (100%), and a negative FANA (80%). Antibiotics had been prescribed in 18 (90%) of cases. The presumed infectious diagnoses were streptococcal tonsillitis/pharyngitis (50%), infective endocarditis (four patients), sepsis (two patients) and acute bacterial meningitis (two patients). The presumed non-infectious diagnoses were acute rheumatic fever (three patients), seronegative rheumatoid arthritis (two patients) and polymyositis (two patients). Sixteen patients were followed for a mean duration of 30 months (range 2-59). A remission was obtained with indomethacin in three cases (19%), and with prednisolone in the remainder. Relapse was detected in three cases (19%). AOSD is one of the most frequent aetiologies of FUO. During the diagnostic course of a patient with FUO, a maculopapular rash and/or arthralgia and/or sore throat should raise the suspicion of AOSD. Because the disease has heterogeneous clinical findings, certain bacterial infections (e.g. streptococcal pharyngitis and sepsis) are generally considered and the prescribing of antibiotics is common.

Sarcoidosis after use of interferon for chronic hepatitis C: report of a case and review of the literature

Although interferon has not been classified in the pathogenesis of sarcoidosis, it may rarely lead to this disease during treatment of chronic hepatitis C. The case of a 36-year-old woman with chronic hepatitis C who developed sarcoidosis within 10 weeks of treatment with recombinant interferon-alpha2a and ribavirin is described and all seven similar cases published in English from 1989 to 2001 are discussed.