Dapagliflozin utilization following hospitalization for heart failure: real-world insights from EVOLUTION HF, a multinational, observational study

Background

Use of guideline-directed medical therapies (GDMTs) in patients with heart failure (HF) with reduced ejection fraction (HFrEF) – such as renin–angiotensin–aldosterone system inhibitors, beta-blockers, mineralocorticoid receptor antagonists and angiotensin receptor neprilysin inhibitors – is suboptimal, especially after hospitalization for HF (hHF). Dapagliflozin was the first sodium–glucose co-transporter-2 inhibitor approved in patients with HFrEF. In the DAPA-HF study, dapagliflozin decreased the risk of hHF and mortality in patients with HFrEF (with or without type 2 diabetes) compared with placebo. Little is known about the real-world characteristics and treatment profiles of patients initiating dapagliflozin after hHF in clinical practice.

Purpose

EVOLUTION HF aims to describe characteristics and real-world treatment patterns in patients who initiated GDMTs following hHF. Using data available to date, we focused on dapagliflozin use in two countries (Japan and Sweden).

Methods

EVOLUTION HF is a multinational observational, longitudinal cohort study using claims and electronic health record databases, which included 514,869 patients with hHF during the study period. Adult patients who initiated dapagliflozin between December 2020 and September 2021 (Japan) or December 2021 (Sweden) were identified and included if they initiated dapagliflozin 10 mg once daily during hHF or within 12 months after a hHF discharge. Patient characteristics and treatment profile at index (initiation of dapagliflozin) are reported overall and by country.

Results

Overall, 7023 patients were included (3515 from Japan, 3508 from Sweden; Table 1); the mean age was 73±13 years and 70% were male. The median lengths of the hHF leading to dapagliflozin initiation were 16 (interquartile range [IQR] 9–26) days in Japan and 4 (IQR 2–7) days in Sweden. Overall prevalences of atrial fibrillation, chronic kidney disease, diabetes and established cardiovascular disease were 50%, 23%, 34% and 57%, respectively. Of the 7023 patients who initiated dapagliflozin during hHF or within 12 months of hHF discharge, 45%, 62%, 75% and 87% of patients initiated dapagliflozin in hospital/within 7 days of discharge or within 1, 3 or 6 months of discharge, respectively. Japan had a higher proportion of patients who initiated dapagliflozin in hospital/within 7 days of hHF discharge compared with Sweden (64% vs 27%; Figure 1). At dapagliflozin initiation, 37% and 74% of patients in Japan and Sweden, respectively, had three or four other GDMTs.

Conclusions

Patients who initiated dapagliflozin following hHF often had comorbidities associated with increased risk of adverse cardiorenal outcomes. Timing of dapagliflozin initiation and use of other GDMTs at index varied between countries. A large proportion of patients initiated dapagliflozin more than 1 month after a hHF or in addition to three or four other GDMTs, indicating an opportunity for earlier dapagliflozin use in patients with HF.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): AstraZeneca

Lacrimal Function and Ocular Complications in Patients Treated with Systemic Isotretinoin

Purpose

To evaluate the effect on lacrimal function and ocular complications in patients with severe acne vulgaris during systemic treatment with 13- cis -retinoic acid (isotretinoin).

Methods

Forty patients with acne vulgaris were treated with systemic isotretinoin at dosages of 0.5-1 mg/kg per day for two months. Full ophthalmologic examination, Schirmer / test, fluorescein break-up (BUT) and microbiological investigations of the conjunctival flora were done before, during the second month and at least one month after the end of the treatment.

Results

The average Schirmer values before and after the treatment were 21.6 mm/5 minutes (SD ± 7.01) and 18.48 mm/5 minutes (SD ± 7.87) respectively. After the treatment BUT was less than 10 seconds in 50% of the patients and 55% had blepharitis. Subjective symptoms like dryness, itching and contact lens intolerance occurred in 42.5% and colonization of the conjunctiva by Staphylococcus aureus increased significantly during treatment (p = 0.031). All abnormal findings disappeared one month after the cessation of treatment.

Discussion

Isotretinoin causes signs and symptoms of dry eye, probably by reducing meibomian gland function, but ocular complications are generally not serious when low doses are used for a limited time, and are reversible after discontinuation.

Randomized Trial Comparing Resection of Primary Tumor with No Surgery in Stage IV Breast Cancer at Presentation: Protocol MF07-01

BACKGROUND

The MF07-01 trial is a multicenter, phase III, randomized, controlled study comparing locoregional treatment (LRT) followed by systemic therapy (ST) with ST alone for treatment-naïve stage IV breast cancer (BC) patients.

METHODS

At initial diagnosis, patients were randomized 1:1 to either the LRT or ST group. All the patients were given ST either immediately after randomization or after surgical resection of the intact primary tumor.

RESULTS

The trial enrolled 274 patients: 138 in the LRT group and 136 in the ST group. Hazard of death was 34% lower in the LRT group than in the ST group (hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.49-0.88; p = 0.005). Unplanned subgroup analyses showed that the risk of death was statistically lower in the LRT group than in the ST group with respect to estrogen receptor (ER)/progesterone receptor (PR)(+) (HR 0.64; 95% CI 0.46-0.91; p = 0.01), human epidermal growth factor 2 (HER2)/neu(-) (HR 0.64; 95% CI 0.45-0.91; p = 0.01), patients younger than 55 years (HR 0.57; 95% CI 0.38-0.86; p = 0.007), and patients with solitary bone-only metastases (HR 0.47; 95% CI 0.23-0.98; p = 0.04).

CONCLUSION

In the current trial, improvement in 36-month survival was not observed with upfront surgery for stage IV breast cancer patients. However, a longer follow-up study (median, 40 months) showed statistically significant improvement in median survival. When locoregional treatment in de novo stage IV BC is discussed with the patient as an option, practitioners must consider age, performance status, comorbidities, tumor type, and metastatic disease burden.

Diagnostic tools in ocular allergy

Ocular allergy (OA) includes a group of common and less frequent hypersensitivity disorders frequently misdiagnosed and not properly managed. The diagnosis of OA is usually based on clinical history and signs and symptoms, with the support of in vivo and in vitro tests when identification of the specific allergen is required. To date, no specific test is available for the diagnosis of the whole spectrum of the different forms of OA. The lack of recommendations on diagnosis of OA is considered a medical need not only for allergists but also for ophthalmologists. This position paper aims to provide a comprehensive overview of the currently available tools for diagnosing OA to promote a common nomenclature and procedures to be used by different specialists. Questionnaires, sign and symptom grading scales, tests, and potential biomarkers for OA are reviewed. We also identified several unmet needs in the diagnostic tools to generate interest, increase understanding, and inspire further investigations. Tools, recommendations, and algorithms for the diagnosis of OA are proposed for use by both allergists and ophthalmologists. Several unmet needs in the diagnostic tools should be further improved by specific clinical research in OA.

Abstract P6-16-01: The importance of loco-regional tumor burden and surgery on survival in patients with de novo stage IV breast cancer; post-hoc analyses of protocol MF07-01

Background: The MF07-01 trial is a multicenter phase III randomized controlled trial of treatment naive stage IV BC patients comparing loco-regional surgery (LRS) followed by appropriate systemic therapy (ST) versus ST alone.

Aims: To evaluate the importance of loco-regional tumor burden and surgery on overall survival rate in patients with de novo stage IV breast cancer.

Methods: At initial diagnosis patients were randomized 1:1 to LRS group or ST group. The surgery was a lumpectomy (L) or mastectomy (M) and sentinel lymph node biopsy (SLNB) ± axillary lymph node dissection (ALND). After surgery all patients received systemic treatment + endocrine treatment (ET) and Trastuzumab based on pathology results. The demographic, pathologic, and clinical characteristics of the patients were recorded.

Results:274 patients were accrued; 138 in the LRS group and 136 in the ST group. The groups were comparable regarding age, BMI, HER2 neu, tumor type and size, histologic grade, and bone and visceral metastasis (all p>0.05). In the LRS group 36 patients (26%) had L+ALND, 92 patients (67%) had M+ALND and 10 patients (7%) had M+SLNB, respectively.

The patients and tumor characteristicsPatients and Tumors Characteristics and Surgical TreatmentSurgerySystemic TherapyP ValueAge (mean /year±SD)51.8 ±12.651.5±13.6NSMedian follow-up (25%,75%)41.0 (24,54)37 (18,49) Tumor Size (%)   T18.7 (12) NST252.2 (72) NST321.7 (30) NST417.4 (24) NSHistologic Grade (%)   I4.4 (6)9.6 (10)NSII39.9 (55)31.7 (33)NSIII55.8 (77)58.9 (61)NS    Surgical Treatment   Lumpectomy+ ALND26 (36)--M + SLNB7 (10)--M + ALND67 (92)---SLNB17 (23)--ALND92.8 (128)--pN+89.1 (123)--30-day mortality1.4 (2)1.5 (2)0.98SLNB-Sentinel Lymph Node Biopsy; ALND-Axillary Lymph Node Dissection; M-Mastectomy

The axillary positivity rate was 89.1%. There were 76 (55%) deaths in the LRS group and 101 (74%) in the ST group during the median 40 (20-51) month follow-up. Overall survival (OS) was 34% higher in the LRS group compared to the ST group (HR: 0.66, 95%CI 0.49-0.88: p = 0.005).

Overall survival rate was higher in LN (+) (p=0.01), tumor size<5cm (p<0.0001), and high histologic grade (HG III, p<0.008) patients who underwent axillary surgery than ST group ; OS rate was with a marginal significant level in patients without axillary involvement (pN0) in the LRS group compared with ST group (p=0.05).

Conclusion: In this subgroup analysis, we observed that patients with high grade tumor, without skin or chest wall involvement and positive axilla who underwent surgery for primary breast tumor and axilla had better overall survival than ST in de novo stage IV breast. These results can be considered in clinical research design for stratification.

Citation Format: Ozmen V, Ozbas S, Karanlik H, Muslumanoglu M, Igci A, Canturk Z, Utkan NZ, Ozaslan C, Evrensel T, Uras C, Aksaz E, Soyder A, Ugurlu UM, Col C, Cabioglu N, Bozkurt B, Sezgin E, Dagoglu T, Uzunkoy A, Dulger M, Koksal N, Cengiz O, Gulluoglu B, Unal B, Atalay C, Yildirim E, Erdem E, Salimoglu S, Sezer A, Koyuncu A, Gurleyik G, Alagol H, Ulufi N, Berberoglu U, Soran A. The importance of loco-regional tumor burden and surgery on survival in patients with de novo stage IV breast cancer; post-hoc analyses of protocol MF07-01 [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-16-01.

Phyllodes Tumor of the Breast: Analysis of 48 Patients

OBJECTIVE

Phyllodes tumor (PT) is a rare biphasic breast neoplasm that accounts for less than 1% of all breast tumors. The aim of this study was to evaluate the clinicopathologic features, diagnostic difficulties, and therapeutic outcomes of patients with PT.

MATERIALS AND METHODS

A total of 48 female patients who underwent surgery for PT were included in the study. Patient characteristics, clinicopathologic features of tumors, diagnostic findings, surgical outcomes, adjuvant therapies, and follow-up findings were retrospectively evaluated.

RESULTS

The mean age of patients was 35 years. Painless breast mass was the most common (85.4%) presenting symptom. Total excision with at least 1 cm macroscopic clear margins was the most frequently performed (87.5%) surgery. Most patients (n=34, 70.8%) had benign PT; however, borderline and malignant tumors were found in 9 (18.8%) and 5 (10.4%) patients, respectively. During the mean follow-up period of approximately 30 months, local and distant recurrence was detected in three (6.3%) patients and one (2.1%) patient, respectively. Patients with malignant PT had larger tumors than those with benign and borderline PTs (p=0.010). No significant difference in other clinical, diagnostic, and pathologic characteristics was found between the groups.

CONCLUSION

PT can be easily confused with other breast masses such as fibroadenoma due to the non-specific clinical and radiologic findings. Surgical excision with at least 1 cm clear margins is of great importance to reduce the risk of local recurrence. However, recurrence can develop even after appropriate surgery, thus patients should be closely followed up after surgery.

Our First Experience With Negative Pressure Incision Management System Implemented on the Clean Surgical Incision in the Renal Transplantation Recipient: A Case Report

Multiple comorbidities and environmental factors increase the complications of incisional wounds in patients. It was demonstrated in previous prospective and randomized studies that negative pressure wound therapy (NPWT) reduced wound infection and other complications in clean, closed surgical incisions. In this case report, the Prevena incision management system was implemented on the clean, closed surgical incision of a 52-year-old female patient, who was given a renal transplantation from cadaver postoperatively in the operating theater. It was removed from the patient on the fifth day after the operation. Following the removal of Prevena, the wound and surrounding skin of the patient were observed. Wound healing was complete, and no skin lesion or tool-related complication was found around the wound due to NPWT. The Prevena NPWT system can be conveniently and safely implemented on the operational incision in renal transplant recipients in order to prevent surgical wound complications.

A neglected cause for chronic spontaneous urticaria in children: Helicobacter pylori

BACKGROUND

The aetiology of chronic urticaria is usually considered idiopathic. There is a paucity of research both on the prevalence of Helicobacter pylori infection in the aetiology of chronic spontaneous urticaria (CU) in children and also on which patients H. pylori should be investigated.

METHODS

All paediatric and adult patients who presented to the allergy outpatient clinic due to CU between January 2011 and July 2012 were included in this prospective, randomised study. Stool samples from all patients were examined for the H. pylori antigen. Paediatric and adult patients who had a positive stool test for the H. pylori antigen were reassessed following eradication therapy.

RESULTS

Thirty-two children with CU and 35 adults with CU were enrolled in the study. Ten of the 32 (31.2%) children and 18 of the 35 (51.4%) adults were H. pylori positive (p=0.09). All children with positive-H. pylori were older than eight years of age. There was a significant positive correlation between age and the frequency of H. pylori infection (p<0.001; r=0.61). The presence of H. pylori was not significantly associated with the presence of GI (gastrointestinal) symptoms (p>0.05). Following H. pylori eradication, urticarial symptoms recovered in 15 of the adults (83.3%) and 10 of the paediatric (100%) patients (p=0.172).

CONCLUSION

In the current study we found that H. pylori is common among children with CU, particularly after eight years of age. We suggest that CU patients with an unknown aetiology should be routinely screened for H. pylori even if they do not present with GI symptoms and that those with H. pylori-positive results may receive treatment.

Drug allergy in tertiary care in Turkey: results of a national survey. The ADAPT study: adult drug allergy perception in Turkey

BACKGROUND

No data are available on the incidence of drug hypersensitivity (DH) reactions in outpatient settings of tertiary allergy/immunology clinics. Our aims were to document the frequency of outpatient hospital admissions due to DH reactions to allergy/immunology clinics in adults and the management of these reactions in real life. We also investigated whether drug allergy affected social and medical behaviours of the patients.

METHODS

This multi-centre study was performed for one year with the participation of 11 out of 16 tertiary allergy/clinical immunology clinics in Turkey. The study group consisted of the patients with DH reactions. Results of a questionnaire including drug reactions and management were recorded.

RESULTS

Among 54,863 patients, 1000 patients with DH were enrolled with a median of 2.1% of all admissions. In real life conditions, the majority of approaches were performed for finding safe alternatives (65.5%; 1102 out of 1683) with 11.7% positivity. Diagnostic procedures were positive in 27% (154/581) of the patients. The majority of the patients had higher VAS scores for anxiety. A total of 250 subjects (25%) reported that they delayed some medical procedures because of DH.

CONCLUSION

Our results documented the frequency of admissions due to DH reactions to allergy/clinical immunology clinics for the first time. Although physicians mostly preferred to perform drug tests in order to find safe alternatives, considering the fact that DH was confirmed in 27% of the patients, use of diagnostic tests should be encouraged, if no contraindication exists in order to avoid mislabelling patients as DH.

A patient with steroids and antihistaminic drug allergy and newly occurred chronic urticaria angioedema: what about omalizumab?

In this case report, successful use of omalizumab in the treatment of chronic urticarial and angioedema in a 24-year-old female patient with an allergic reaction history to almost every drug including steroids and antihistamines was presented. She also had allergy against a large number of foods, which were confirmed by oral provocation, specific Immunoglobulin E and allergy skin test.

Relationship between skin prick and atopic patch test reactivity to aeroallergens and disease severity in children with atopic dermatitis

BACKGROUND

The immunological mechanism in aetiology of atopic dermatitis (AD) shows significant differences from other allergic diseases. Allergen inhalation exacerbates AD lesions and AD patients' complaints decrease in house dust mite (HDM) low level environments, which reveals the importance of inhalant allergens.

OBJECTIVE

We evaluated the skin prick test (SPT) and atopy patch test (APT) positivity rates with aeroallergens and studied the effect of test results, and aimed to determine the value of allergic test reactivity on the clinical characteristics of children with AD.

METHODS

Forty-five children aged 2-15 years with AD were included to study between May 2006 and May 2007 in GATA Haydarpasa Teaching Hospital, Allergy Department. The reactivity to inhalant allergens using SPT and APT was evaluated. The severity of AD, which was assessed with SCORAD, was compared with aeroallergen hypersensitivity.

RESULTS

The highest positivity of APT was seen against HDM (48.9%). HDM SPT positivity and subjective symptoms score were statistically correlated (P<0.05). Patients with strong SPT positivity to HDM had a higher total SCORAD score (P<0.05). Although there was no statistical correlation between HDM APT and SCORAD parameters, APT positive patients had generally higher SCORAD parameters. The statistical significance was only shown between the extent of the disease and strong APT positive reactions to Dermatophagoides pteronyssinus.

CONCLUSION

HDM allergens play an important role in determining the clinical severity of AD and strong APT positivity could be more meaningful clinically.

Evaluation of necessity for mechanical bowel preparation before Milligan-Morgan hemorrhoidectomy: a randomized prospective clinical study

AIM

In this randomized prospective clinical study, we aimed to evaluate the effect of mechanical bowel preparation (MBP) before Milligan-Morgan hemorrhoidectomy on intraoperative procedures and postoperative complication rates to determine whether MBP is adventageous or not before elective anorectal surgeries.

METHODS

Forty patients who had internal grade III or IV hemorrhoidal disease and who would underwent open hemorrhoidectomy were randomized into two groups: non-MBP group (female:male, 11:9; mean age, 33.8±9.57 years) that would not receive MBP before the surgery, and MBP group (female:male, 12:8; mean age, 34.7±11.37 years) that would be given one Fleet enema on the morning of Milligan-Morgan hemorrhoidectomy. Intraoperative variables and postoperative complications were compared between two groups.

RESULTS

MPB had no effect on both intraoperative and postoperative variables, such as operating time, intraoperative bleeding, visual analogue scale (VAS) score for the comfort of the surgeon during operation, the presence of stool or enema remnants in anal canal, the presence of mucosal edema of the anal canal intraoperatively, the rates of postoperative bleeding and infection, VAS score for the pain on third day postoperatively, time to first stool after the operation, VAS score for the pain during first stool after the operation, and number of analgesics during one week postoperatively (P>0.05 for all).

CONCLUSION

MBP performed before surgery does not provide introperative or postoperative benefit for Milligan-Morgan hemorrhoidectomy, thus MBP is not necessary before elective anorectal surgeries.

Patient and graft survival after pre-emptive versus non-pre-emptive kidney transplantation: a single-center experience from Turkey

OBJECTIVE

We sought to report the graft and patients survival of pre-emptive and non-pre-emptive kidney transplantations performed in our center.

METHODS

The 859 subjects showed a mean age of 36.1 years and included 64.6%; males, who received grafts from living (n = 665) or deceased (n = 194) donors between January 2008 and June 2011. We reviewed their medical records retrospectively, to separately pre-emptive versus non-pre-emptive recipients for year transplant outcomes.

RESULTS

Among the 859 patients, 153 (17.8%) underwent pre-emptive and 706 (82.2%), non-pre-emptive kidney transplantations. The rate of living donors was higher in the pre-emptive group (97.4% vs 73%, respectively). The 1-year graft survivals were 99.3% and 95.8% in pre-emptive and non-pre-emptive transplantation groups, respectively (P > .05). There was no significant difference between groups with respect to patient survival at 1 year (P > .05).

CONCLUSION

In conclusion, graft and patient survival rates between pre-emptive and non-pre-emptive kidney transplantation cases were comparable at 1 year. Pre-emptive kidney transplantation, which eliminates hemodialysis costs and complications, should be preferred as the optimal renal replacement therapy for end-stage renal disease patients.

Correlation of thyroid fine-needle aspiration with final histopathology: a case series

AIM

The aim of this study was to evaluate the correlation between preoperative thyroid fine-needle aspiration result and final histopathology in patients with thyroid nodules.

METHODS

The medical records of 298 patients (mean age, 47.7±12.3 years; 79.5% females) who underwent fine-needle aspiration for thyroid nodules and who were operated and have final pathological diagnosis were retrospectively reviewed. For reporting fine-needle aspiration specimen pathology, the Bethesda thyroid fine-needle aspiration classification was used. Tyroglobulin (Tg) and anti-Tg and anti-thyroid peroxidase (anti-TPO) antibody levels were determined preoperatively.

RESULTS

Thyroid nodules were non-diagnostic, benign or atypia (Bethesda groups 1-3) in 76.8% of patients; and follicular neoplasm, suspicious for malignancy or malignant (Bethesda groups 4-6) in 23.1% of patients. Final pathology of surgery specimen was most commonly nodular goiter (36.6%) and papillary carcinoma (35.6%). Nodular goiter was significantly more prevalent in Bethesda 1 group while papillary carcinoma was more common in Bethesda 3 group (P<0.05). Tg level is significantly higher in the nodular goiter group (90.49±126.93 ng/mL), while anti-Tg and anti-TPO levels are significantly higher in the lymphocytic thyroiditis goiter group (229.77±494.42 U/mL and 282.86±360.77 U/mL, respectively) than the other pathology groups (P<0.05 for all).

CONCLUSION

Papillary carcinoma is more common in Bethesda thyroid fine-needle aspiration classification 3 group. Therefore, preoperative fine-needle aspiration for thyroid nodules is predictive of final pathology and should be applied for diagnosis and follow-up.

Demographic characteristics of SMA type 1 patients at a tertiary center in Turkey

The aim of this study was to demonstrate demographics of 39 consecutive Spinal Muscular Atrophy (SMA) type 1 patients diagnosed genetically in a tertiary center between June 2006 and June 2009. There was history of consanguineous marriage in 27 (69%) patients. The average patient lifespan was 251 days (30-726 days). The average patient age at diagnosis was 129 days (33-297 days). A statistically significant correlation was found between the age at diagnosis and the lifespan (p = 0.00). No significant correlation was found between the time spent in intensive care and the lifespan (p = 0.43). Routine physical therapy was found to have no significant impact on the lifespan average (p = 0.17). The cause of death in all of our patients was respiratory issues. Genetic counseling was given to 35 families. A second child with SMA was born in three out of the 14 families who declined prenatal diagnosis.

CONCLUSION

A national program is needed in Turkey for SMA prevention and creation of expert teams for the management of these patients.

Warburg micro syndrome in two children from a highly inbred Turkish family

Warburg Micro syndrome (WMS) was first reported by Warburg in 1993. The cardinal features are microcephaly, microphthalmia, congenital cataract and intellectual disability. We report on two children from a highly inbred family with microcephaly, congenital cataract, optic atrophy, hypotonia and severe psychomotor retardation. This phenotype is similar to other reported rare entities and especially to the family reported by Warburg. Four other children in the same family may also have been affected. In this report, the symptoms and features of our cases are compared with the Warburg Micro syndrome patients in literature.

The effect of the excisional biopsy in the detection of the sentinel lymph node by lymphoscintigraphy and intraoperative gamma probe in breast cancer

OBJECTIVE

Sentinel lymph node (SLN) scintigraphy is used widespread in breast cancer, but the effect of the radionuclide agent, injection technique, the method of biopsy, tumor localization, breast size remain controversial. We examined the effects of the excisional biopsy in the rate of the SLN identification with lymphoscintigraphy (LS) and intraoperative gamma probe (IGP).

MATERIAL AND METHODS

One hundred patients (age range: 28-79 yr) with breast cancer were included in the study. They consisted of two groups: Group 1; there were 58 patients without excisional biopsy Group 2; there were 42 patients with excisional biopsy LS: 2 hours before the operation, 37 MBq/ ml Tc 99m colloidal rhenium sulphide was injected at the periaerolar region intradermally Anterior and lateral static images were acquired. IGP: The hot spot of greatest radioactivity were marked on the skin during the surgery with IGP and removed. Excised SLNs were examined with frozen section. After that histopathological and immunohistochemical examinations were performed.

RESULTS

SLNs were found in all patients in group 1 (100%), in 39 patients of group 2 (93%) with LS. SLNs were excised in 57 of the 58 patients of group 1 (98%), in 38 of the 42 patients of group 2 (90%) with IGF. Metastases were found in SLNs in 27 patients (28%). Axillary dissection was performed in these patients.

CONCLUSION

According to results of our study the excisional biopsy was not the only factor but also other factors such as breast mass, calcified or metastatic lymph node may be affected the success rate of the SLN.

CONFLICT OF INTEREST

None declared.

Follow-up of lupus choroidopathy with optical coherence tomography

Abstract: A 36-year-old female followed with the diagnosis of systemic lupus erythematosus complained of bilateral visual loss. Ophthalmological examination revealed disc edema with irregular borders, edematous and pale retina with widespread cotton wool spots, intraretinal hemorrhages and serous retinal detachment in both eyes. Optical coherence tomography (OCT) scans showed intraretinal and subretinal fluid creating cystic cavities with central subfield macular thickness values of 994 and 912 µm in the right and left eye, respectively. The follow-up scans after the treatment with systemic steroid, acetylsalicylic acid and cyclosporine documented resolution of this fluid accumulation and a decrease in macular thickness measurements. These clearly demonstrated that OCT, which is a fast, objective and non-invasive technology, may be an adjunctive imaging tool for the diagnosis and follow-up of lupus choroidopathy.

Vernal keratoconjunctivitis--a rare but serious comorbidity of allergic rhinitis and eustachian tube dysfunction

OBJECTIVE

To determine the prevalence of symptoms and signs of allergic rhinitis (AR) in children with vernal keratoconjunctivitis (VKC) and evaluate eustachian tube (ET) function using tympanometry.

METHODS

The patients underwent an otolaryngological examination and symptoms of rhinorrhoea, nasal obstruction, nasal itching and sneezing were evaluated for the diagnosis of AR. Tympanometry was performed by a middle ear analyzer (Impedance audiometer AZ 26, Interacoustics A/S, Assens, Denmark). Blood samples were collected for determination of peripheral blood eosinophil count (PBEC) and serum total immunoglobulin E (IgE). Allergen sensitivity was also determined by skin prick test.

RESULTS

The study included 26 males (96.3%) and 1 female (3.7%) with a mean age of 12.1+/-4.4 years. Eight out of 27 subjects (29.6%) had blood eosinophilia and 11 out of 27 subjects had elevated serum IgE (40.7%). A positive skin prick test was identified for at least one allergen in 40% of patients (10/25 subjects). Symptoms and signs of AR were found in 10 subjects (37%). Median serum IgE level in subjects with AR (262.5 kU/L) was higher than without AR (40.2 kU/L) (p=0.08), whereas there were no differences in PBEC or eosinophilia percentage (p>0.05). Mean middle ear pressures in the right and left ears were -66.4 daPa (range between -268 and 4 daPa) and -57.3 daPa (range between -308 and 0daPa), respectively. The tympanometry results were abnormal in 5 subjects (18.5%) (3 type C and 2 type B tympanogram). Three out of 10 VKC patients with AR (30%) and 2 out of 17 VKC patients without AR (11.8%) had abnormal tympanograms (p=0.33).

CONCLUSION

AR is commonly associated with VKC and subjects with AR are almost three times more likely to have ET dysfunction than those without. Therefore, opthalmologists should refer VKC patients to otolaryngologists to delineate associated AR and ET dysfunction. Conversely, patients with OME and/or AR who have persistent allergic eye symptoms may well benefit from opthalmologic evaluation for seasonal allergic conjunctivitis and VKC.

Uterine contractions: an unusual side effect of venom immunotherapy

Venom immunotherapy (VIT) is an efficient treatment modality for preventing further sting-induced anaphylactic reactions in patients with Hymenoptera venom allergy. The main side effects of VIT include local and systemic allergic reactions with a variable risk of up to 46%. We report the case of a woman who experienced rapid-onset hypocalcemia and regular uterine contractions on 3 occasions within 30 minutes of receiving Apis mellifera VIT. To the best of our knowledge, this is the first report of uterine contractions as a side effect of VIT. The importance of this event is clear, as VIT has now been approved for pregnant women. We provide recommendations to physicians using this modality.

Association of polymorphisms in APOE, p53, and p21 with primary open-angle glaucoma in Turkish patients

PURPOSE

To investigate the association between Apolipoprotein E (APOE), tumor suppressor protein p53 (p53), and cyclin-dependent kinase inhibitor 1A (p21) genes and primary open-angle glaucoma (POAG) in a cohort of Turkish subjects.

METHODS

Seventy-five POAG patients (49 women, 26 men) and 119 healthy subjects (67 women, 52 men) were genotyped with polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). Allele and genotype frequencies between healthy subjects and glaucoma patients were compared by the chi(2) test, and intraocular pressure (IOP), cup/disc ratio (C/D) and visual field indices (MD and PSD) were compared among different APOE, p53, and p21 genotypes in POAG group. A p value <0.05 was considered as statistically significant.

RESULTS

The mean ages were 63.8+/-9.5 and 61.8+/-10.2 years in POAG and control groups, respectively (p=0.18). There were no significant differences in the distribution of APOE, p53, and p21 genotypes between the healthy subjects and POAG patients (p=0.38, p=0.12, and p=0.2, respectively). There were no significant differences in maximum IOP, MD, and PSD values among different groups of p53 and p21 genotypes (p>0.05). POAG subjects with the epsilon2epsilon3 genotype had a worse PSD value (median=2.2) than those with the epsilon3epsilon4 genotype (median=1.77; p=0.01) and POAG subjects with the epsilon3epsilon3 genotype had worse MD and PSD values (median= -7.4 and 3.4, respectively) than those with the epsilon3epsilon4 genotype (median= -4.1 and 1.77, respectively; p=0.034 and 0.028, respectively).

CONCLUSIONS

Our study found no link between polymorphisms in APOE, p53, and p21 genes and POAG in Turkish patients, although a larger sample is required to elucidate the role of these polymorphisms in the pathogenesis and course of glaucoma.

Cardiac remodeling as a consequence and cause of progressive heart failure

Natural history studies in heart failure have shown that increases in left ventricular (LV) volume and LV mass are directly related to future deterioration in LV performance and a less favorable clinical course. Despite the recognized importance of remodeling in heart failure, very little is known about the basic mechanisms that lead to cardiac remodeling. In this review, we will summarize recent clinical and experimental studies that highlight the importance of the remodeling process during the progression of heart failure. The intent of this review is to provide an integrated view of the mechanisms that contribute to LV remodeling at the cellular level, the myocardial level, and the level of the chamber.

Serum allergen specific immunoglobulin E levels in patients with allergic conjunctivitis

PURPOSE

To evaluate serum allergen specific immunoglobulin E (IgE) levels in patients with various types of allergic conjunctivitis.

METHODS

Twenty-five patients with seasonal allergic conjunctivitis (SAC), 17 patients with perennial allergic conjunctivitis (PAC), and 10 patients with vernal conjunctivitis (VC) were included in the study. Specific IgE levels to Dermatophagoides pteronyssinus (Dp), Dermatophagoides farinae (Df), mixed grass pollens, and animal epithelia were measured using Pharmacia CAP system (Pharmacia Diagnostic AB, Uppsala, Sweden).

RESULTS

The percentage of subjects with specific IgE against Dp and Df was statistically higher in VC (30%) compared to PAC (5.9%) and SAC (0%) (p=0.03). Specific IgE against mixed grass pollens was found in 30% of VC and 40% of SAC, whereas 10% of VC and 8% of SAC patients were found to be hypersensitive to animal epithelia.

CONCLUSIONS

Allergic reaction against house dust mites and pollens was common in VC, whereas specific IgE against grass pollens was remarkable in SAC. IgE levels specific to various antigens might be measured by UNICAP system, which is a rapid and practical technology.

Systemic associations and prevalence of exfoliation syndrome in patients scheduled for cataract surgery

PURPOSE

To study the frequency of exfoliation syndrome (XFS) and its association with intraocular pressure (IOP) and systemic diseases in patients with age-related cataract scheduled for surgery.

METHODS

All 1480 cataract patients had a comprehensive systemic and eye examination, including slit-lamp biomicroscopy before and after mydriasis, IOP measurement, gonioscopy, and fundus examination.

RESULTS

The percentage of XFS among patients scheduled for cataract surgery was 16.4, with no gender difference (p=0.833). The mean age of XFS patients (74.3+/-7.0 years) was significantly higher when compared to the ones without XFS (66.5+/-10.9 years) (p<0.001). XFS was unilateral in 41.3% of the subjects and bilateral in 58.7%. The number of subjects with XFS increased significantly with aging (p<0.001) (OR=1.093, 95% CI=1.073-1.14) (p<0.001). The most common type of cataract was nuclear in the XFS group (33.5%) and 24.6% of patients with mature cataract had XFS. In the XFS group, 11.2% of the subjects had glaucoma, which was statistically higher than the non-XFS group (4.6%) (p<0.001) (OR=2.67, 95% CI=1.65-4.32). Eighty-four patients had glaucoma and 27 of them (32.1%) had exfoliative glaucoma. The only systemic disease that was found to be associated with XFS was coronary heart disease with an OR of 1.49 (95% CI=1.068-2.072) (p=0.019).

CONCLUSIONS

XFS is a common problem in the aging cataract population of Turkey and increased IOP, glaucomatous optic neuropathy, and coronary heart disease occur more frequently in patients with XFS compared with subjects without XFS.

Does atopy affect the radiological extent of pulmonary tuberculosis?

BACKGROUND

Th1 cytokines, IL-2 and IFN-gamma , have critical importance in the CD4 cell driven antimycobacterial activity. Th2 type immune response is a characteristic feature of atopic disorders. Th1 and Th2 cells have been reported to negatively cross-regulate each other in vitro and in experimental animals. Our aim in the present study is to determine whether the atopy affects radiological extent of pulmonary tuberculosis (TB) and disease severity.

MATERIALS AND METHODS

A total of 82 male patients with pulmonary TB were prospectively enrolled in the study between March 2005 and March 2006. All patients were evaluated for atopic symptoms and TB related systemic symptoms. Radiological dissemination was scored and cavitation was noted. The skin prick test (SPT) was performed and serum total IgE level was measured.

RESULTS

The SPTs were positive in 28 of 82 (34.1 %) patients. There was no distinction between SPT-positive and negative patients in terms of pulmonary cavitation and radiological dissemination. The median IgE level of moderate-severe radiologically disseminated TB patients was significantly higher than that of mild radiologically disseminated TB patients (130 IU/ml vs. 58 IU/ml). Cavitary TB patients had also significantly higher median IgE levels (78 IU/ml vs. 46 IU/ml) (p < 0.05)

CONCLUSION

This study suggests that SPT-positivity and atopic respiratory phenotype do not affect the formation of cavitation, radiological dissemination and systemic symptoms of pulmonary TB. The high level of IgE in patients with cavitary and radiologically disseminated TB may be a consequence of a dysregulated immune response to infection or reflect disease activity.

Analysis of vascular endothelial growth factor gene 936 C/T polymorphism in patients with familial Mediterranean fever

Vascular endothelial growth factor (VEGF) is a cytokine that promotes endothelial cell proliferation, leucocyte chemotaxis and expression of adhesion molecules and is a major mediator of vascular permeability. It has been demonstrated that VEGF directly activates neutrophils and it could promote acute recruitment of leucocytes. It is known that neutrophils are the major cell population involved in acute inflammation in familial Mediterranean fever (FMF) and the role of VEGF in these cells may be crucial. The aim of this study was to investigate whether the 936 C/T functional polymorphism of the VEGF gene is associated with susceptibility to FMF and its relationship with the main clinical features of the disease. Polymerase chain reaction-restriction fragment length polymorphism technique was used to determine 936 C/T polymorphism within the VEGF gene in 75 patients with FMF and 122 non-related healthy controls. Genotype and allele frequencies of the VEGF 936 C/T polymorphism between patients with FMF and healthy control groups were not significantly different (OR = 0.74, 95% CI = 0.40-1.37, P = 0.335 for CT genotype; OR = 1.11, 95% CI = 0.67-1.83, P = 0.700, for T allele). Although VEGF 936 TT genotype was found to be more frequent in patients with FMF than in healthy controls (6.7% vs. 1.6%, respectively), the difference was not significant (OR = 4.28, 95% CI = 0.81-22.67, P = 0.108). No associations were found between the studied polymorphism and either the clinical features such as arthritis, abdominal pain, pleuritis, myalgia, arthralgia and erysipelas-like erythema of the disease or the four common studied exon 10 mutations (M694V, M680I, V726A, M694I) of the Mediterranean fever gene. Present results suggest that VEGF gene 936 C/T polymorphism does not seem to be associated with susceptibility to FMF and its clinical manifestations.

Does the Atopic Phenotype Prevent Development of Active Tuberculosis Infection?

This study investigated the relationship between the atopic phenotype and the development of active tuberculosis. A total of 82 human immunodeficiency virus-negative males with active pulmonary tuberculosis and 88 healthy controls were enrolled into this prospective study. Serum immunoglobulin E (IgE) levels were measured and skin prick tests performed before initiation of treatment. Skin prick tests were positive in 34.1% of the tuberculosis patients and 39.8% of the controls. Allergic respiratory symptoms were significantly less frequent in skin prick test positive tuberculosis patients (21.4%) compared with skin prick test positive controls (62.9%). Median IgE levels in atopic tuberculosis patients were significantly higher than in atopic controls. The low rate of atopic respiratory complaints seen in the tuberculosis patients, despite having similar allergic skin prick test sensitivities to the controls, could be attributed to a weak T-helper (Th) 2 immune reaction and its effects on Th1–Th2 interaction.

Effect of active tuberculosis on skin prick allergy tests and serum IgE levels

OBJECTIVE

Mycobacterium tuberculosis has been shown to suppress allergic airway disease driven by type 2 helper T cells in animal models. In this study, we investigated the effect of active tuberculosis on skin prick test (SPT) positivity and serum immunoglobulin (Ig) E levels of atopic patients with and without tuberculosis infection.

MATERIALS AND METHODS

Seventeen atopic HIV-negative men with pulmonary tuberculosis and 18 atopic healthy male controls at our military hospital were studied prospectively between March 2005 and March 2006. The sums of all SPT positive tests and positivity to house dust mite alone were calculated before initiation of treatment and after 6 months. Measurement of total serum IgE levels was also performed at the same moments.

RESULTS

The mean (SD) initial serum total IgE concentrations were significantly higher in the tuberculosis patients than in the healthy controls (324.1 [317.67] U/mL vs. 146.7 [75.29] U/mL, respectively; P < .05), The total serum IgE concentrations after 6 months of treatment were also higher in the patients than in the controls. The mean sum of SPT positivity was higher in the tuberculosis patients than in the controls at both testing times.

CONCLUSION

Our study does not support the hypothesis that M tuberculosis suppresses atopy and atopic disorders, but large, prospective experimental studies are needed before excluding the possibility of a relationship.

The effect of ethyl pyruvate on oxidative stress in intestine and bacterial translocation after thermal injury

BACKGROUND

Thermal injury causes a breakdown in the intestinal mucosal barrier due to ischemia reperfusion injury, which can induce bacterial translocation (BT), sepsis, and multiple organ failure in burn patients. The aim of this study was to investigate the effect of ethyl pyruvate (EP) on intestinal oxidant damage and BT in burn injury.

MATERIALS AND METHODS

Thirty-two rats were randomly divided into four groups. The sham group was exposed to 21 degrees C water and injected intraperitoneal with saline (1 mL/100 g). The sham + EP group received EP (40 mg/kg) intraperitoneally 6 h after the sham procedure. The burn group was exposed to thermal injury and given intraperitoneal saline injection (1 mL/100 g). The burn + EP group received EP (40 mg/kg) intraperitoneally 6 h after thermal injury. Twenty-four hours later, tissue samples were obtained from mesenteric lymph nodes, spleen, and liver for microbiological analysis and ileum samples were harvested for biochemical analysis.

RESULTS

Thermal injury caused severe BT in burn group. EP supplementation decreased BT in mesenteric lymph nodes and spleen in the burn + EP group compared with the burn group (P < 0.05). Also, burn caused BT in liver, but this finding was not statistically significant among all groups. Thermal injury caused a statistically significant increase in malondialdehyde and myeloperoxidase levels, and EP prevented this effects in the burn + EP group compared with the burn group (P < 0.05).

CONCLUSION

Our data suggested that EP can inhibit the BT and myeloperoxidase and malondialdehyde production in intestine following thermal injury, suggesting anti-inflammatory and anti-oxidant properties of EP.

Th1?Th2 Interaction: Is More Complex than a See-saw?

Infections, such as tuberculosis, measles and diphtheria, may decrease the risk of developing atopic allergic disorders. Patients with pulmonary TB having similar allergic skin prick test sensitivity as healthy controls but unable to show vigorous atopic phenotype in their healthy period might be a sign for Th1-Th2 immune interaction.

Analysis of CD28 and CTLA-4 gene polymorphisms in Turkish patients with Behcet's disease

In this study we aimed to investigate IVS3 +17T/C single nucleotide polymorphism (SNP) of CD28 gene, +49A/G and -318C/T SNPs of CTLA-4 gene in patients with Behçet's disease (BD) and their potential association to the main clinical features of the disease. These polymorphisms were investigated in a Turkish population of 123 patients with BD and 179 healthy controls, by using PCR-RFLP technique. HLA-B*51 genotype was also studied in both groups by using PCR-SSP. The frequency of IVS3 +17TC genotype of the CD28 gene was significantly increased in BD patients compared to controls (43.6% vs. 31.2%, OR = 1.663, 95% CI = 1.033-2.679, P = 0.039). CTLA-4 +49GG genotype frequency was found to be significantly lower in patients with BD than those of healthy controls (4% vs. 10.6%, OR = 0.357, 95% CI = 0.130-0.983, P = 0.05). Genotype and allele frequencies of the CTLA-4-318C/T polymorphism between the BD and healthy control groups were not significantly different (12.2% vs. 10.6%, OR = 1.170, 95% CI = 0.570-2.402, P = 0.713). There were no associations between the studied polymorphisms and the main clinical features of BD. The frequencies of HLA-B*51 were 60.3% and 30.7% in BD and control groups, respectively (OR = 3.429, 95% CI = 2.115-5.559, P = 0.0001). Association between HLA-B*51 and each studied polymorphism did not reach to significant levels (OR = 0.479, 95% CI = 0.228-1.004, P = 0.064 for CD28 IVS3 +17TT genotype; OR = 2.180, 95% CI = 1.025-4.639, P = 0.061 for TC genotype; OR = 1.570, 95% CI = 0.870-2.836, P = 0.146 for C allele). These results may suggest that CD28 IVS3 +17TC genotype may be a risk factor for the development of BD, on the contrary CTLA-4 +49GG genotype may be protective in the studied Turkish population.

The role of serum inflammatory markers in acute appendicitis and their success in preventing negative laparotomy

Improving the diagnosis of acute appendicitis in order to prevent unnecessary surgery is crucial. This study was intended to identify the role of serum inflammatory markers in patients with preliminary diagnosis of acute appendicitis with a retrospective design. Eighty-five patients with the preliminary diagnosis of acute appendicitis were recruited in this study within the period of November-December 2003. The average age was 31.8 years (ranged from 15 to 85). There were 62 males (72.9%) and 23 females (27.1%). In addition to performing routine tests, preoperative serum samples were obtained from the patients to measure C-reactive protein, interleukin-6, and interleukin-10. All the patients were operated on for a clinical suspicion of acute appendicitis. Depending on the macroscopic evidence during the operation and the histopathological examination of the specimen, the patients were separated into two groups: the ones who did not have acute appendicitis as the cause for acute abdomen (group I; n = 14) and the ones who had acute appendicitis (group II; n = 71). The ones who had acute appendicitis (group II) were further grouped as noncomplicated appendicitis (group IIA; n = 44) and complicated appendicitis (group IIB; n = 27). Being a male with elevated levels of leukocytes (white blood cells, WBC); C-reactive protein (CRP), interleukin-6 (IL-6); and interleukin-10 increased the probability of having acute appendicitis in patients with evidences of acute abdomen. The risk of complication of acute appendicitis significantly increased when patients had increased levels of C-reactive protein, increased erythrocyte sedimentation rate, and increased interleukin-6 levels, had symptoms for more than 24 h, and were female. Interleukin-10 levels within normal range might be helpful in eliminating the possibility of acute appendicitis. Thus, elevated levels of WBC, IL-6 and CRP might be helpful in confirming a potential diagnosis of acute appendicitis. In addition, normal levels of IL-10 might be of additional help to possibly rule out the diagnosis of acute appendicitis.

Relationship between short wavelength perimetry and central corneal thickness values in ocular hypertensive subjects

PURPOSE

To evaluate the results of short wavelength perimetry (SWAP) of ocular hypertensive (OHT) patients and correlate these findings with central corneal thickness (CCT) measurements.

METHODS

Thirty-seven OHT patients with a mean age of 50.2+/-8.2 (SD) years and 30 control subjects with a mean age of 50.3+/-8.5 (SD) years were included in this study. A questionnaire was applied to patients to evaluate the demographic risk factors that may predict glaucoma development. After a detailed ophthalmologic examination, achromatic and short wavelength perimetries and ultrasonic pachymetry were performed and the results were compared between the two groups with Student t test and Mann-Whitney U test. A p value<0.05 is considered as statistically significant.

RESULTS

Mean CCT was higher in the OHT group (right eye; 558.13+/-28.39 microm and left eye; 558.94+/-27.30 microm) when compared with the control subjects (524.66+/-30.53 microm and 525.86+/-30.46 microm, respectively) (p<0.01). A significant positive correlation was found between CCT measurements and intraocular pressure (r=0.5, p<0.001). Four right eyes (10.8%) and five left eyes (13.5%) of OHT patients had defects in SWAP. OHT patients with SWAP abnormalities had significantly lower CCT measurements in right (527.25+/-17.34 microm) and left eye (528.80+/-13.60 microm) when compared with OHT patients without SWAP defects (561.87+/-27.29 microm and 563.65+/-25.92 microm, respectively) (p<0.05). Significant correlations were found between CCT and SWAP MD, PSD, and CPSD (p<0.05).

CONCLUSIONS

OHT patients with SWAP abnormalities had significantly lower CCT measurements than those without. CCT is considered as a risk factor for the development of glaucomatous damage in OHT patients.