Independent risk factors for COVID-19-associated coagulopathy

OBJECTIVE

Past three years since the beginning of the outbreak, we have obtained satisfactory data on COVID-19. However, data on risk factors of COVID-19-associated coagulopathy (CAC) are extremely limited. Prediction of CAC might be a game changer since it is related to poor prognosis. Seeking independent risk factors for CAC was the main aim of the study.

PATIENTS AND METHODS

510 hospitalized COVID-19 patients were retrospectively screened. Forty-eight of them were excluded due to irrelevant D-dimer or ferritin elevation. The remaining patients were stratified into three groups as overt coagulopathy, significant pulmonary microthrombosis, and patients without coagulopathy. The overt coagulopathy group included cases with macrothrombosis or disseminated intravascular coagulation (DIC). The significant pulmonary microthrombosis group covered the cases that had clinical deterioration with simultaneous marked D-dimer elevation. The group of patients without coagulopathy included the asymptomatic patients with normal or elevated D-dimer levels.

RESULTS

Overt coagulopathy developed in 3.2% and significant pulmonary microthrombosis in 10.1% of the patients. In the multivariate analysis, not receiving low molecular weight heparin (LMWH) (p=0.002), a level of D-dimer >15,000 U/ml (p=0.013) were associated with overt coagulopathy. In addition, levels of initial LDH >480 IU/L (p=0.022) and initial ferritin >1,000 ng/ml (p=0.036) were associated with significant pulmonary microthrombosis. Not receiving LMWH (p=0.001) was also associated with significant pulmonary microthrombosis, when multivariate analysis was performed by the parameters with a p-value <0.1 in the univariate analysis. Furthermore, all cases with DIC had Gram-negative bacterial sepsis.

CONCLUSIONS

Not receiving LMWH, high levels of D-dimer, initial LDH, and initial ferritin are independent risk factors for CAC. DIC does not appear to develop based on COVID-19.

Spatial distribution of pyrogenic carbon in Iberian topsoils estimated by chemometric analysis of infrared spectra

Understanding the global carbon (C) cycle is critical to accurately model feedbacks between climate and soil. Thus, many climate change studies focused on soil organic carbon (SOC) stock changes. Pyrogenic carbon (PyC) is one of the most stable fractions of soil organic matter (SOM). Accurate maps based on measured PyC contents are required to facilitate future soil management decisions and soil-climate feedback modelling. However, consistent measurements that cover large areas are rare. Therefore, this study aimed to map the PyC content and stock of the Iberian Peninsula, which covers contrasting climatic zones and has long-term data on wildfire occurrence. A partial least square (PLS) regression using the mid-infrared spectra (1800-400 cm^-1) was applied to a dataset composed of 2961 soil samples from the Iberian component of the LUCAS 2009 database. The values of PyC for LUCAS points were modelled to obtain a map of topsoil PyC by a random forest (RF) approach using 36 auxiliary variables. The results were validated through comparison with documented historical wildfire activity and anthropogenic energy production. A strong relationship was found between these sources and the distribution of PyC. Our study estimates that the accumulated PyC in Iberian Peninsula soils comprises between 3.09 and 20.39% of total organic carbon (TOC) in the topsoil. Forests have higher PyC contents than grasslands, followed by agricultural soils. The incidence of recurrent wildfires also has a notable influence on PyC contents. This study shows the potential of estimating PyC with a single, rapid, low cost, chemometric method using new or archived soil spectra, and has the ability to improve soil-climate feedback modelling. It also offers a possible tool for measuring, reporting and verifying soil C stocks, which is likely to be important moving forward if soils are used as sinks for C sequestration.

Schmallenberg virus affects T-bet, Gata3, RoRrγt, Foxp3 and Eomes in mice brain

Schmallenberg virus (SBV), a neurotropic member of the genus Orthobunyavirus, infects ruminants and causes neurological lesions and fetal malformations including cerebellar hypoplasia, hydranencephaly, and porencephaly. The aim of this study is to establish intracerebral (i.c.) infection of SBV in newborn BALB/c mice and to investigate some of the transcription factors in brain. For this aim, brain samples of newborn BALB/c mice which were infected with SBV i.c. were analyzed by plaque titration and real-time RT-PCR for T-bet, Gata3, RoRγt, Foxp3 and Eomes mRNA levels. Study results showed that SBV can replicate in BALB/c mice brain and cause death of newborn mice with generation of infectious viral particles. Analyses of transcription factor mRNA levels indicated up-regulation of T-bet, Gata3, RoRγt, Foxp3 and down-regulation of Eomes. In this report, we introduce preliminary data of T cell transcription factors affected by SBV infection of BALB/c mice. Keywords: Eomes; Foxp3; Gata3; RoRγt; Schmallenberg virus; T-bet.

Results of the simultaneous measurements of radon around the Black Sea for seismological applications

Results of measurements of radon around of the Black Sea are shown. Radon stations in zones of active faults were placed. Simultaneous hourly measurements of soil radon in 2005 were carried out in the Sivrice Fault Zone that is a segment of East Anatolian Fault System, in the town of Tbilisi (Georgia) and in the South Russia. In 2008 simultaneously hourly measurements of soil radon were carried out in the Western Caucasus (Russia) and in the Mytilene Island (Greece). In 2013 radon in underground waters simultaneously in midday was measuring in Crete (Greece), in the Pamukkale geothermal region (Southwest Turkey) and in the Western Caucasus. Measurements of radon concentration in the points located around of the Black Sea have shown identical regularities in changes of the data. Influence of meteorological, tidal and solar factors on changes of water radon concentrations and soil radon concentrations was observed in all researches points. But this influence was insignificant. Seismological application of observed results also was considered. Various mathematical methods of definition of anomaly in the radon data during earthquakes were considered. During researches in the Black Sea region basically earthquakes with M from 2.0 up to 5.0 and in a depth about 10 km were occurred. For these earthquakes method of daily subtraction of the data of the next and previous day was used. This method has allowed solving a problem with a choice of average value. Probability up to 0.69 (number of earthquakes with radon anomalies/total number of earthquakes) of detection of radon anomalies before earthquakes was achieved applying this method. Changes of radon maps before regional earthquakes were also observed. The frequency analysis of variations of the radon data on the basis of the Wavelet analysis was carried out. Occurrence of the short periods (about 2 days) was observed during regional earthquakes.

Roles of adiponectin and leptin as diagnostic markers in pancreatic cancer

NTRODUCTION

Obesity is one of the most serious public health problem worldwide. Adipose tissue synthetize and secrete many growth factors and several cytokines known as adipokines. Studies demonstrated changes in the levels of these adipokines in many types of cancer associated with obesity. In this study, we aimed to evaluate the possible relationship between adiponectin and leptin levels with pancreas cancer and disease stage, representative of Turkish population.

MATERIALS AND METHODS

The study was conducted between April 2012 - November 2013. Study included 46 patients - 46 control subjects, who had pancreatic carcinoma. Results between the patients and the control group and relationship between the disease stage and results were evaluated.

RESULTS

The comparison of preoperative adiponectin and leptin levels of the study group with the levels of the control group showed that there was no correlation with adiponectin and pancreas cancer. In contrast, leptin levels in the study group were significantly lower than in the control group. There was no correlation between the disease stage and adiponectin and leptin levels.

CONCLUSION

There was a significant correlation between low leptin levels and pancreatic cancer, while adiponectin had no correlation. Differential diagnosis of pancreas cancer can be made by evaluating low leptin levels with elevated tumor markers (Tab. 3, Ref. 17).

Can N-terminal pro B-type natriuretic peptide, neutrophil-to-lymphocyte ratio, C-reactive protein help to predict short and long term mortality?

BACKGROUND

There is limited data about ICU, short and long-term mortality prediction of severe CAP with neutrophil-to-lymphocyte ratio (NLR): N-terminal proB- type natriuretic peptide (NT-proBNP): C-reactive protein (CRP).

AIM

Besides the known severity indexes of ICU, can NLR, NT-proBNP, CRP predict ICU, short and long term mortality?

METHODS

A retrospective cohort study was carried out in a level III ICU of a tertiary training hospital for chest diseases and thoracic surgery.

RESULTS

Over the study period, a total of 143 patients were enrolled in the study. The APACHE II scoring showed a significantly higher predicting performance for ICU mortality (p = 0.002). The performance for predicting short term mortality NLR (p = 0.039) and long term mortality NTproBNP (p = 0.002) had a significantly higher performance. The survival analysis revealed that mortality was significantly higher in patients with CURB65 score ≥ 4 (p = 0.047).

CONCLUSION

NLR, NTproBNP > 2000pg/mL can be used to predict pneumonia severity in ICU alike CURB65 and PSI. Higher NLR, APACHE II and atrial fibrillation can cause an important mortality factor in long term. Consequently, clinicians should take an attention for good cardiac evaluation and cardiac follow-up of patients with CAP (Tab. 4, Fig. 3, Ref. 36).

High hemodialysis vascular access flow and impaired right ventricular function in chronic hemodialysis patients

There are limited data showing right ventricular preload increase due to high-flow arteriovenous fistulas (AVFs). This cross-sectional study investigated whether high AVF flow had an impact on right ventricular function in patients undergoing hemodialysis. Sixty-four patients aged between 18 and 85 years who were on routine hemodialysis with >2 hemodialysis sessions per week for at least 3 months via an AVF were studied. Patients with inadequate flow fistulas, severe chronic obstructive pulmonary disease, history of pulmonary embolism, primary pulmonary hypertension, severe mitral, aortic or pulmonary regurgitation, and/or stenosis were excluded. After an initial evaluation, 44 patients (mean age: 58.50 ± 16.84, male:female = 23:21) were considered eligible. Right ventricular function was assessed by tricuspid annular plane systolic excursion (TAPSE). AVF blood flow was measured with duplex ultrasound. There were 15 patients (34.1%) with a TAPSE of <16 mm. AVF blood flow was significantly higher in patients with impaired versus normal right ventricular function (1631.53 ± 738.17 vs. 1060.55 ± 539.92 min/ml, respectively, P = 0.003). Low left ventricular ejection fraction (odds ratio [OR]: 1.15, 95% confidence intervals [CI]: 1.007-1.334, P = 0.04), high interventricular septum thickness (OR: 1.64, 95% CI: 1.104-2.464, P = 0.01), and high AVF blood flow (OR: 1.00, 95% CI: 1.000-1.003, P = 0.03) were independent predictors of impaired right ventricular function. In addition to known risk factors that predominantly increase right ventricular afterload, excessive AVF blood flow was found to be independently associated with impaired right ventricular function, possibly by increasing right ventricular preload.

What is the neutrophil/lymphocyte ratio in sarcoidosis?

AIM

Information regarding the Neutrophil/Lymphocyte ratio (NLR) in sarcoidosis and the data from studies recommending its use as an indicator of inflammation and in the differential diagnosis and prognosis, are limited. With this study, it was aimed to obtain data regarding the NLR level in the patients at the time of presentation to the hospital and to determine the characteristics of patients in whom the NLR value was > 2.

RESULTS

During the study period, of the 3434 patients with the sub-diagnosis of D86, 1300 cases whose complete blood count values had been recorded at the time of presentation were included in the study. Of the cases, 40 % were pulmonary sarcoidosis, 7 % were pulmonary sarcoidosis with sarcoidosis of the lymph nodes, 8 % were lymph node sarcoidosis, 1 % were sarcoidosis, of other combined areas, and 40 % of the cases were sarcoidosis that were unspecified. The F/M of the cases were 947/353, and the average age of the cases was 44. When the sarcoidosis groups were grouped into NLR < 2 (Group 1) and NLR ≥ 2 (Gorup 2), 27 % were Group 1, 73 % were Group 2, and a significant correlation was found between the two groups. When the inflammatory indicators were compared with NLR, the PLT/MPV was found to be statistically insignificant, and the ACE, ESR and CRP were found to be statistically significant.

CONCLUSION

The Neutrophil/Lymphocyte ratio in the complete blood count, which is an easy and cheap test, can be used as an indicator of inflammation in Sarcoidosis. In clinical practice, wide-based studies comprising the activity and the staging in the prognosis of sarcoidosis are required (Tab. 2, Fig. 2, Ref. 26).

Pressure support ventilation with the I-gel in intensive care unit: case report

BACKGROUND AND OBJECTIVES

The I-gel supraglottic airway has a non-inflatable cuff made from a gel-like thermoplastic elastomer. The use of the I-gel during anesthesia for spontaneously breathing patients or intermittent positive pressure ventilation has been reported. But there are a few published reports about the use of the I-gel with pressure-controlled ventilation.

CONTENTS AND CONCLUSIONS

In this case report we described the use of the I-gel supraglottic airway along 48h in intensive care unit for the management of ventilation in a patient needed mechanic ventilation but in whom tracheal intubation could not be performed.

Effect of hypothermia in patients undergoing simultaneous carotid endarterectomy and coronary artery bypass graft surgery

Purpose

We sought to determine whether hypothermia provided any benefit in patients undergoing simultaneous coronary artery bypass graft surgery (CABG) and carotid endarterectomy (CEA) using one of two different surgical strategies.

Methods

Group 1 patients (n = 34, 88.2% male, mean age 65.94 ± 6.67 years) underwent CEA under moderate hypothermia before cross clamping the aorta, whereas group 2 patients (n = 23, 69.6% male, mean age 65.78 ± 9.29 years) underwent CEA under normothermic conditions before initiating cardiopulmonary bypass (CPB). Primary outcome of interest was the occurrence of any new neurological event.

Results

The two groups were similar in terms of baseline characteristics. Permanent impairment occurred in one patient (2.9%) in group 1. One patient from each group (2.9 and 4.3%) had transient neurological events and they recovered completely on the sixth and 11th postoperative days, respectively. Overall, there was no statistically significant difference between the two groups with regard to occurrence of early neurological outcomes (n = 2, 5.8% vs n = 1, 4.3%, p = 0.12).

Conclusions

This study could not provide evidence regarding benefit of hypothermia in simultaneous operations for carotid and coronary artery disease because of the low occurrence rate of adverse outcomes. The single-stage operation is safe and completion of the CEA before CPB may be considered when short duration of CPB is required.

Saphenous nerve injury after endovenous laser ablation of incompetent greater saphenous vein: An electroneuromyography study

AIM

To determine whether endovenous laser ablation of incompetent greater saphenous vein causes a detectable impairment in saphenous nerve conduction.

MATERIAL AND METHODS

Thirty-five patients (mean age: 44.78 ± 8.6, male/female ratio: 16/19) who were operated on for incompetent greater saphenous veins, underwent electroneuromyography before and two weeks after the operation. Dysesthesia was questioned as to whether having unpleasant abnormal sensation after the operation. Positive electroneuromyography findings for saphenous nerve injury included a sensory nerve action potential amplitude <2 µV or a nerve conduction velocity <48.0 m/s or a latency onset >5.0 ms.

RESULTS

Thirty-four patients were available at two-week follow-up. All patients achieved complete proximal closure. Three patients (8.8%) had dysesthesia at two weeks. Mean electroneuromyography values were not significantly different between preoperative and postoperative period. Postoperatively, none of the patients had abnormal sensory nerve action potential or latency onset, whereas nerve conduction velocity decreased below the lower limit in two patients. These two patients were not among those having dysesthesia and they had no other complaints.

CONCLUSION

Injury to saphenous nerve seems not likely during endovenous laser ablation of incompetent greater saphenous veins, as evidenced by normal electroneuromyography values found after the operation.

Prevalence, presentation and occupational risk factors of chronic venous disease in nurses

OBJECTIVE

In this study involving a group of nurses employed in a number of different medical services with relatively well-defined working conditions, the presence and symptoms of chronic venous insufficiency were screened and their association with work burden and physical working conditions was explored.

METHODS

Of the 294 actively employed nurses during the study period, 232 (79%) were recruited on the basis of their willingness for participation and fulfilment of the inclusion criteria.

RESULTS

Among the study subjects, 62.9% had at least one symptom of chronic venous insufficiency, and 50.4% were found to have chronic venous insufficiency according to Clinical-Etiology-Anatomy-Pathophysiology classification criteria. A significant association was found between the diurnal ankle circumference difference in the left-right ankles and the mean duration of hospital stay.

CONCLUSIONS

Our results have shown that the average duration of hospital stay, which is among the variables used to estimate the work burden of nurses, is associated with an increased frequency of the signs and symptoms of chronic venous insufficiency.

Comparison of Dexmedetomidine and Midazolam in Sedation for Percutaneous Drainage of Hepatic Hydatid Cysts

OBJECTIVE

Hydatid cyst still continues to be a public health problem. The basic treatment for the disease is surgery, but ultrasound-guided percutaneous drainage has become an important treatment alternative. Agents preferred for sedation during drainage performed under local anaesthesia must also preserve respiration and hemodynamic stability while providing adequate sedation. We compared the sedative properties of midazolam, which has a short duration of action, and a selective α2 adrenergic receptor agonist, dexmedetomidine, and the intraoperative complications.

METHODS

After approval by the clinical trials ethics committee, 40 patients with similar demographic data were randomized into two groups. All patients received 10 mg metoclopramide and 45.5 mg pheniramine before the procedure. Then, midazolam (0.07 mg kg(-1) IV bolus followed by 0.01 mg kg(-1) h(-1) infusion) was administered to Group 1, and dexmedetomidine (1 μg kg(-1) loading dose in 10 minutes, followed by 0.2 μg kg(-1) h(-1) continuous infusion) was administered to Group 2 for sedation. Just before the surgical procedure, all patients received IV propofol in a subhypnotic dose of 0.5 mg kg(-1); the dose was repeated if adequate sedation could not be achieved. Observer's assessment of alertness/sedation (OAA/S) scale and Bispectral index (BIS) were used to evaluate the sedation level during the procedure. Heart rate (HR), mean arterial pressure (MAP), respiratory rate (RR), peripheral oxygen saturation (SpO2) and end-tidal carbon dioxide pressure (ETCO2) were monitored before and after induction and every 5 minutes thereafter. Propofol requirement was noted for each group.

RESULTS

Sedation in the dexmedetomidine group was as effective and adequate as that observed in the midazolam group. BIS values were significantly lower in the dexmedetomidine group, especially after 10 minutes and thereafter. RR, SpO2, and ETCO2 were similar in both groups, whereas clinically insignificant decreases in HR and MAP were observed in the dexmedetomidine group. Propofol requirements were similar in both groups.

CONCLUSION

We conclude that dexmedetomidine, providing adequate sedation without respiratory depression, can be considered as an appropriate agent for sedation in surgical procedures performed under local anaesthesia.

Management of hepatic artery aneurysms

BACKGROUND

Hepatic artery aneurysm (HAA) is a rare clinical entity that can lead to potentially life threatening complications. We reported our personal experience of 4 cases, in which we used different procedures.

METHODS

The first case had a pseudo-aneurysm involving the right hepatic artery. The second case had a pseudo-aneurysm, which was localized distal to the accidentally ligated right hepatic artery from the previous cholecystectomy operation. The third case had multiple aneurysms with accompanying dissecting abdominal aortic aneurysm. The fourth case had a pseudo-aneurysm originating from the proper hepatic artery. A covered stent was successfully placed in the case 1. In the second case, the right hepatic artery was ligated distal to the aneurysm. In the third case, vascular structures were not appropriate for vascular reconstruction, and a covered stent placement and embolization were unsuccessful. In the fourth case, ligation of the proper hepatic artery and cholecystectomy was performed.

RESULTS

The third case with multiple aneurysms died from multi-organ failure due to sepsis. The remaining cases (case 1, 2, and 4) are disease free and alive.

CONCLUSION

HAAs are more commonly observed clinical entities, and their treatment should be handled for each patient separately. Computerized tomography-Angiography and intraoperative Doppler ultrasound are useful radio-diagnostics for determination of aneurysm and planning the operative procedure (Fig. 5, Ref. 15).

Treatment challenges in pediatric stroke patients

Aim. In this study we presented our experience of 18 years on the etiology, risk factors, prophylactic and acute treatment, the effect of treatment to recurrence rate of patients with stroke. Methods. The population included 108 patients who had been treated for stroke at Pediatric Neurology Department of Ankara University with the diagnosis of arterial ischemic stroke and sinovenous thrombosis between January 1992 and August 2010. Forty-one girls (38%) and 67 boys (62%) with mean symptom age 3.1 ± 4.04 years, (0–18 years old) were followed up with a mean period of 4.9 ± 3.78 years (0–17 years). Results. 30 patients had no risk factors, 34 patients had only one risk factor and 44 patients had multiple risk factors. Recurrence was seen in three patients. There was no any statistical correlation between the recurrence of stroke and the existence of risk factors (P = .961). Seventeen patients received prophylactic treatment; 2 of them without any risk factors, 3 had one risk factor, 12 patients, who constituted the majority of our patients, had multiple risk factors (P = .024). Conclusion. With this study we showed that the right prophylaxis for right patients reduces the rate of recurrence.

Evaluation of surface contamination with staphylococci in a veterinary hospital using a quantitative microbiological method

OBJECTIVES

To evaluate microbial contamination of the environment in a veterinary hospital using standards recommended for human hospitals and to provide a baseline against which further investigations can be compared.

METHODS

Surfaces were sampled twice daily for five consecutive days using a contact-based counting method to measure the levels of staphylococci in colony forming units (cfu) per cm².

RESULTS

Current recommendations for human hospitals were applied in this study; all samples with <2.5 cfu/cm² staphylococci were considered to have passed and those with ≥2.5 cfu/cm² to have failed. Of all the samples, 55.9% failed. The ICU did not have significantly higher failure rates than other areas of the hospital. The floor as a surface was associated with greater than a threefold increase in odds of elevated cfu concentrations relative to the door handle.

CLINICAL SIGNIFICANCE

This study provides information on the microbiological cleanliness of a veterinary teaching hospital using techniques and standards adopted by the food industry and recommended for human hospitals. This data can be used as a baseline for other hospitals, to evaluate the effectiveness in improvements in hygiene and cleaning measures and to design effective hospital cleaning protocols and assess ongoing hygiene standards.

A new oxidative stress marker in patients with nasal polyposis: advanced oxidation protein products (AOPP)

OBJECTIVES

The aim of this study was to determine whether levels of advanced oxidation protein products (AOPP) can be used a marker of oxidative stress in the etiology of nasal polyposis.

MATERIALS AND METHODS

Twenty-four patients diagnosed with nasal polyposis in Haseki Education and Research Hospital ENT Department between March and June 2008 were included in the study. The AOPP serum levels in NP patients and 24 healthy controls were measured with spectrophotometry and the results were compared statistically.

RESULTS

AOPP levels were significantly higher in the study group compared with the control group.

CONCLUSION

Our findings suggest that AOPP levels can be used as a marker of oxidative stress in patients with nasal polyposis. Future studies are neccessary to evaluate the efficacy of antioxidant therapy.

Predictors of intracytoplasmic sperm injection (ICSI) outcome in couples with and without male factor infertility

AIM

To find out the predictors of ICSI outcome.

METHODS

Forty-three pregnancies in 100 consecutive ICSI cycles.

RESULTS

Every 1,000 pg/ml increase in hCG-day E2 (OR = 0.46, CI: 0.25-0.83, p = 0.01) and 1% decrease in the rate of normal sperm morphology (OR = 0.81, CI: 0.67-0.98, p = 0.03) caused a significant decrease in clinical pregnancy rate and live birth rate (respectively, OR = 0.5, CI: 0.32-0.96, p = 0.03, OR = 0.66, CI: 0.5-0.86, p = 0.002) while every increase in the number of good quality embryos transferred caused a two-time increase in the clinical pregnancy rate (OR = 2.1, CI: 1.2-4, p = 0.01). On the other hand, every increase in the number of four-cell cleavage embryos (OR = 1.02, CI: 1.002-1.04, p = 0.03) and hCG-day endometrial thickness (OR = 1.6, CI: 1.15-2.24, p = 0.005) were found to increase the live birth rate. Implantation rate (m = 8.3 +/- 14.6) was significantly lower in cases with leucocytospermia (n = 33) compared to cases without leucocytospermia (n = 67, m = 17.4 +/- 24.6, p = 0.02).

CONCLUSION

Leucocytospermia, hCG-day E2 level and endometrial thickness, normal sperm morphology, and number of good quality embryos are predictors of implantation, clinical pregnancy and live birth rate following ICSI.

CD40 expression on human pancreatic duct cells: role in nuclear factor-kappa B activation and production of pro-inflammatory cytokines

AIMS/HYPOTHESIS

Human pancreatic duct cells are closely associated with islet beta cells, and contaminate islet suspensions transplanted in Type 1 diabetes mellitus patients. Activated duct cells produce cytotoxic mediators and possibly contribute to the pathogenesis of Type 1 diabetes mellitus or islet graft rejection. As CD40 transduces activation signals involved in inflammatory and immune disorders, we investigated CD40 expression on duct cells and their response to CD40 engagement.

METHODS

CD40 expression on human pancreatic duct cells was analysed by flow cytometry and immunohistochemical analyses. To assess the function of CD40 expression on duct cells, activation of the transcription factor nuclear factor-kappa B was determined using electrophoretic mobility shift assay and ELISA. Cytokine mRNA levels were quantified by real-time RT-PCR, and protein levels by Luminex technology.

RESULTS

Isolated human pancreatic duct cells and Capan-2 cell lines were found to express constitutively CD40. The expression of CD40 on duct cells was confirmed in vivo on human normal and pathological pancreatic specimens. CD40 ligation on Capan-2 cells induced rapid nuclear factor-kappa B activation, and supershift assays demonstrated that p50/p65 heterodimers and p50/p50 homodimers were present in the activated complexes in the nucleus. This activation was accompanied by tumour necrosis factor-a and interleukin-1beta mRNA accumulation. Tumour necrosis factor-alpha protein secretion was confirmed in CD40-activated Capan-2 cells and in isolated human pancreatic duct cells.

CONCLUSIONS/INTERPRETATION

Interaction between activated T lymphocytes expressing CD40 ligand and duct cells expressing CD40 may contribute to the immune responses involved in Type 1 diabetes mellitus and islet graft rejection. Interfering with CD40-mediated duct cell activation could alleviate beta cell damage of immune origin.

Lymph Node Staging in Lung Cancer Using [18F]FDG-PET

BACKGROUND

Mediastinal lymph node staging is essential to determine treatment options in patients with NSCLC. Positron emission tomography (PET) detects increased glucose uptake in malignant tissue using the glucose analogue 2-[(18)F]fluoro-2-deoxy-D-glucose (FDG).

PATIENTS AND METHODS

In the present study were evaluated 155 patients with focal pulmonary tumors who underwent both preoperative computed tomography (CT) and FDG-PET scanning (116 malignant and 39 benign lesions).

RESULTS

Findings in 155 patients included 116 malignant and 39 benign lesions. For N-staging, FDG-PET showed a sensitivity of 88%, a specificity of 91%, and an accuracy of 89%. Corresponding figures for CT were 77%, 76%, and 77%, respectively.

CONCLUSIONS

FDG-PET is an effective, noninvasive method for staging thoracic lymph nodes in patients with lung cancer and is superior to CT scanning in the assessment of hilar and mediastinal nodal metastases. With regard to operability, FDG-PET could differentiate reliable between patients with N1/N2 disease and those with unresectable N3 disease.

Bilateral internal jugular venous thrombosis following successful assisted conception in the absence of ovarian hyperstimulation syndrome

The majority of the venous thromboembolic events seen in patient following gonadotropin administration were associated with the development of ovarian hyperstimulation syndrome (OHSS). However, in this case report, a 29-year-old woman that conceived by controlled ovarian hyperstimulation, intracytoplasmic sperm injection and subsequent embryo transfer without conjunction of OHSS was described. Bilateral jugular venous thrombi were detected by duplex Doppler in the 8th week of pregnancy when she was admitted to the emergency room for difficulty in swallowing and bilateral neck pain. She had unremarkable history and negative results for thrombophilia screening. Full anticoagulation with intravenous heparin was initiated and continued subcutaneously throughout pregnancy. She delivered two healthy babies at 36 weeks of pregnancy. Venous thromboembolism should be taken in account in patients undergoing gonadotropin administration for assisted conception with the complaint of extremity pain regardless of having risk factors for thromboembolism.

Plasma homocysteine and lipoprotein (a) levels as risk factors for atherosclerotic vascular disease in epileptic children taking anticonvulsants

AIM

To assess the effect of anticonvulsant treatment on plasma homocysteine level and lipoprotein (a) in epileptic children.

METHODS

Plasma total homocysteine, folate, vitamin B12 and lipoprotein (a) concentrations were measured in 111 epilectic children taking anticonvulsant drugs for longer than 12 mo. Forty-six healthy, sex- and age-matched children served as controls.

RESULTS

Patients and controls differed significantly in concentrations of homocysteine (p < 0.05) and lipoprotein (a) (p < 0.001). The number of patients with homocysteine concentrations of >9 microM was significantly higher in the patient group than in the control group. A significant inverse relationship was found between vitamin B12 folate levels and plasma homocysteine levels in the patient group; 28.8% of the patient group had lipoprotein (a) concentrations above the cut-off value (30 mg/dl) for increased risk of early atherosclerosis, whereas none of the control patients had concentrations above this value.

CONCLUSION

These data indicate that prolonged anticonvulsant treatment could increase plasma homocysteine and lipoprotein (a) concentrations and that it may be useful to measure the levels routinely in order to prevent atherosclerosis in epileptic children taking anticonvulsant drugs.

Treatment outcome of relapse and defaulter pulmonary tuberculosis patients

SETTING

Tuberculosis clinic in a referral hospital.

OBJECTIVE

To evaluate the effect of risk factors on the outcome of retreatment in relapse and defaulter pulmonary tuberculosis patients.

DESIGN

A total of 57 retreatment tuberculosis patients treated and monitored in our centre between January 1997 and June 1999 were evaluated with respect to treatment outcome. Factors which have on effect on treatment outcome were investigated.

RESULTS

Of 57 patients, 37 (64.9%) were classified as relapse cases and 20 (35.1%) as defaulters. The treatment success rate was 71.9% (68.4% cure rate and 3.5% completion rate). Failure was encountered in 22.8%. Twenty-six patients (45.6%) exhibited resistance to at least one drug, namely rifampicin. The multidrug-resistance (MDR) rate was 18.5%. Treatment success rates were 100% and 50%, respectively, in patients in whom susceptibility to all drugs and resistance to at least one drug were detected. Successful outcome was possible in 68.8% of patients with any rifampicin resistance and in 20% of patients with MDR tuberculosis. Retreatment resulted in failure in 80% and 100%, respectively, of patients whose sputum cultures remained positive at the end of the second and third months.

CONCLUSION

Drug resistance proved the most important factor affecting treatment outcome. Success rates in retreatment of patients with any rifampicin resistance or MDR tuberculosis are low. Conversion to negative sputum results at the end of the second and third months of retreatment seems to be a significant parameter for a successful outcome.

Treatment adherence of 717 patients with tuberculosis in a social security system hospital in Istanbul, Turkey

SETTING

Tuberculosis clinic in a teaching hospital run by the social security system, Istanbul, Turkey.

OBJECTIVE

To determine risk factors associated with treatment adherence.

DESIGN

Seven hundred and seventeen patients who commenced treatment for tuberculosis in our clinic from May 1991 to May 1997 were evaluated retrospectively with respect to treatment adherence. Factors with an effect on treatment adherence were investigated.

RESULTS

Sputum conversion was achieved in 88.9% of the cases within the first 2 months of treatment. Seven patients died during treatment; of the 710 patients remaining, 106 (14.9%) were non-adherent. This rate decreased from 34.4% in 1991 to 2.0% in 1997. In multi-variate logistic regression analysis, only previous treatment history for tuberculosis was related to non-adherence; treatment adherence rate in new cases was 88.9%, while it was 66.7% in previously treated cases (P < 0.001).

CONCLUSION

In new cases, a treatment adherence rate of 88.9% can be considered satisfactory. However, in previously treated cases, an adherence rate of 66.4% must be considered unsatisfactory. Previously treated cases in particular should therefore receive directly observed treatment.

Caffeine intoxication in a premature neonate

Caffeine, which has a wide range between therapeutic and toxic levels, is a widely used medication for prevention and treatment of apnoea of prematurity. Despite its safety, caffeine overdose and intoxication has been previously reported in the literature. We present a 30-day-old 28-week preterm newborn who was exposed to 300 mg.kg-1 caffeine base by mouth accidentally. The patient exhibited agitations, irritability, tachycardia, tachypnoea, diuresis, electrolyte abnormalities, hyperglycaemia and metabolic acidosis, for which he received supportive treatment. No seizure activity was observed. The effects of intoxication lasted for 96 h and then completely resolved.

Tumoricidal activity of monocyte-derived dendritic cells: evidence for a caspase-8-dependent, Fas-associated death domain-independent mechanism

Monocyte-derived dendritic cells (DC) were found to be cytotoxic for several tumor cell lines including Jurkat cells, which were killed through a calcium-independent pathway. K562 cells were resistant, excluding a NK cell-like activity. DC-mediated apoptosis did not involve classical death receptors because it was not reversed by blocking TNF/TNFR, CD95/CD95 ligand, or TNF-related apoptosis-inducing ligand/TNF-related apoptosis-inducing ligand receptor interactions. Fas-associated death domain-deficient, but not caspase-8 deficient, Jurkat cells were killed by DC. Indeed, caspase-8 cleavage was demonstrated in Jurkat cells cocultured with DC, and the use of specific caspase inhibitors confirmed that apoptosis triggered by DC was caspase-8 dependent. Furthermore, the involvement of Bcl-2 family members in the control of DC-mediated apoptosis was demonstrated by Bid cleavage in Jurkat cells cocultured with DC and resistance of Jurkat cells overexpressing Bcl-2 to DC-mediated cytotoxicity. Overall, these data indicate that monocyte-derived DC exert a caspase-8-dependent, Fas associated death domain-independent tumoricidal activity, a finding that could be relevant to their therapeutic use in cancer.

Comparison of agonistic flare-up-protocol and antagonistic multiple dose protocol in ovarian stimulation of poor responders: results of a prospective randomized trial

The management of poor responders in IVF has always been a big problem. The ideal approach has yet to be formulated. In this study we aim to compare two alternative stimulation protocols. A total of 48 poor responder patients described from previous cycles were included and grouped into two: group I consisted of 24 patients in 24 cycles in which leuprolide acetate (40 microg s.c. per day) was initiated on cycle day 2 followed by exogenous gonadotrophins on cycle day 3; group II consisted of 24 patients in 24 cycles in which ovarian stimulation included gonadotrophin-releasing hormone (GnRH) antagonist (cetrorelix, 0.25 mg daily during late follicular phase) administration. While only the oestradiol concentrations on the day of HCG were lower in group II compared with group I, the clinical pregnancy and implantation rates among groups did not show any significance. The impact of these two regimens in ovarian stimulation of poor responders seem to be same and to establish these results further randomized studies with larger sample sizes are required.

The management of anti-tuberculosis drug-induced hepatotoxicity

SETTING

A tuberculosis ward in a chest disease teaching hospital.

OBJECTIVE

To compare the efficacy of two different retreatment protocols on hepatotoxicity recurrence in tuberculosis treatment.

DESIGN

In a prospective, randomised study, 45 patients with new tuberculosis developed hepatotoxicity after anti-tuberculosis treatment. Patients in Group I (n = 20) were retreated with a drug regimen consisting of isoniazid, rifampicin, ethambutol and streptomycin administered by gradually increasing the number and dosage of the drugs. Patients in Group II (n = 25) were retreated with the same regimen (isoniazid, rifampicin, pyrazinamide and ethambutol) in the same dosages throughout.

RESULTS

Hepatotoxicity recurred in respectively zero and six (24%) patients in Groups I and II (P = 0.021). Of the six patients with recurrence of hepatitis, one could not be followed up. The other five received the same retreatment protocol as Group I. By the end of retreatment, all patients were cured.

CONCLUSION

The recurrence rate of hepatotoxicity in the retreatment of tuberculosis is higher in the reintroduction of a full-dose regimen including pyrazinamide, which causes more hepatotoxicity than gradual reintroduction of a regimen without pyrazinamide.

Addition of GnRH antagonist in cycles of poor responders undergoing IVF

Concern about the use of gonadotrophin-releasing hormone (GnRH) agonists in ovarian stimulation of poor responder IVF patients has arisen from the claim that GnRH agonists might have a direct deleterious effect through their receptors on the ovary. In this study, we compared two ovarian stimulation protocols in which no GnRH agonists were used. In all, 40 patients with a poor response in previous treatment cycles were included. They were divided into two groups: group I (n = 20) received ovarian stimulation for 20 cycles, without the addition of either GnRH agonist or antagonist; while group II (n = 20) patients received ovarian stimulation for 20 cycles, including the administration of a GnRH antagonist (Cetrorelix, 0.25 mg daily) during the late follicular phase. There was no statistically significant difference between the groups for mean age, duration of infertility, baseline FSH concentration, cancellation rate, number of ampoules of gonadotrophin used, number of mature oocytes retrieved, oestradiol concentrations on the day of injection of human chorionic gonadotrophin (HCG), fertilization rate and number of embryos transferred. The clinical pregnancy and implantation rates in group II appeared higher than in group I, but were not significantly different (20 and 13.33% compared with 6.25 and 3.44% respectively). The addition of GnRH antagonists to ovarian stimulation protocols might be a new hope for poor responder IVF patients, but this report is preliminary and further controlled randomized prospective studies with larger sample sizes are required.

Expression of c-FLIP(L) and resistance to CD95-mediated apoptosis of monocyte-derived dendritic cells: inhibition by bisindolylmaleimide

To gain insight into the mechanisms controlling apoptosis of dendritic cells (DC), human monocyte-derived DC were analyzed for their expression of CD95 (Fas/Apo-1) and their response to CD95 ligation. Although DC expressed the CD95 molecule on their membrane, they did not undergo apoptosis on CD95 ligation unless sensitized by cycloheximide. In parallel, DC synthesized c-FLIP(L), an inhibitor of the CD95-mediated death-signaling cascade. We also demonstrated that bisindolylmaleimide down-regulates c-FLIP(L) expression in DC and, in parallel, allows CD95-mediated apoptosis in these cells. In contrast, Bcl-2, Bcl-x(L), and Bax levels were not affected by bisindolylmaleimide. We conclude that DC resist CD95- mediated apoptosis in association with c-FLIP(L) expression and that the immunosuppressive potential of bisindolylmaleimide previously observed at the T-cell level also involves facilitation of CD95-mediated DC apoptosis.

Doppler velocimetry of the uterine arteries after hysteroscopic rollerball endometrial ablation

The aim of this study was to document the Doppler indices [pulsatility index (PI) and resistance index (RI)] of the uterine arteries in 30 patients who underwent hysteroscopic rollerball endometrial ablation for dysfunctional uterine bleeding by transvaginal pulsed Doppler sonography, and to reveal whether treatment failures (persistent menometrorrhagia) can be predicted by the blood flow characteristics of the uterine arteries in advance. On the basis of the outcome of patients at the end of the first postoperative year, the Doppler indices of the uterine arteries were meaningful 1 year after the operation when PI (1.32 +/- 0.11; mean +/- SD) and RI (0.71 +/- 0.04) in six menometrorrhagic patients were statistically different from PI (2.19 +/- 0.28; 1.95 +/- 0.36 and 1.82 +/- 0.37) and RI (0.87 +/- 0.06; 0.82 +/- 0.06 and 0.81 +/- 0.04) in normally menstruating, amenorrhoeic and hypomenorrhoeic patients respectively (P < 0.05). On the other hand, the patients who would be menometrorrhagic one year after the operation had a thicker endometrium in the first post-operative month. These findings suggest that the angiogenetic role of the persistent endometrial islands after endometrial ablation needs at some time to be reflected as changes in the Doppler parameters of the uterine arteries.

Evaluation of intrauterine abnormalities in infertile patients by sonohysterography

The purpose of this study was to assess the usefulness of sonohysterography in the detection of abnormalities of the uterine cavity in infertile patients, compared with other diagnostic methods. Transvaginal ultrasonography, sonohysterography, hysterosalpingography and finally hysteroscopy were performed in 37 patients with primary and 25 patients with secondary infertility. Suspected uterine anomalies were also confirmed by laparoscopy. Transvaginal ultrasonography and hysterosalpingography were able to detect 36.3 and 72.7% of uterine pathologies respectively. Sonohysterography was able to detect all the anomalies except for a single endometrial polyp (90.3%). However, there was no significant difference between the diagnostic capabilities of these methods. We recommend the use of sonohysterography as an easy, cheap and noninvasive method for the diagnosis of intrauterine pathologies in infertile patients.

The effect of uterine volume on uterine artery Doppler velocimetry in the myomatous state

This study aimed at testing the hypothesis that lower uterine arterial (UA) Doppler indices are caused by increased uterine volume rather than the presence of myoma. Uterine volumes were calculated and uterine and/or myomal arterial pulsatility index (PI) and resistance index (RI) were obtained by transvaginal color Doppler ultrasonography. The mean uterine volume in the myomatous group (276.2 cm3; range 65-928 cm3, n = 100) was significantly greater than that of the control group (101.4 cm3; range 36-171 cm3; n = 60; p = 0.00). The mean UA PI and RI values in the study group were significantly lower than their corresponding values in the control group (0.77 +/- 0.08 and 1.69 +/- 0.47 vs. 0.82 +/- 0.06 and 1.97 +/- 0.49, respectively, p = 0.01). When the myomatous uterine volumes of the study group were categorized into two subgroups (< 200 and > or = 200 cm2) the UA PI and RI values were lower in the latter group (p = 0.006 and p = 0.015, respectively). However, after analysis of receiver-operator-characteristic curves, none of the UA Doppler indices could differentiate the myomatous uterus from the normal uterus.

Hemodynamic assessment in pelvic inflammatory disease by transvaginal color Doppler ultrasonography

One of the major signs of inflammation is a change in vascular flow and caliber. It is possible to detect these changes with the help of transvaginal color Doppler velocitometry. The purpose of this study was to evaluate the changes in pelvic circulation in cases with pelvic infection and to correlate these findings with other infectious parameters. The study group consisted of 20 cases who had the diagnosis of pelvic inflammatory disease (PID). Resistance index (RI) and pulsatility index (PI) were measured with transvaginal color Doppler ultrasonography in the uterine and ovarian arteries as well as at the tubouterine junction three times in a one-month period. At the same time the body temperature, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and leukocyte counts were recorded. Infectious parameters declined to normal values, following a pattern parallel to clinical improvement from the first until day 30. Infectious parameters revealed significant differences between days 1-7, 1-30 and 7-30. On the other hand, low resistance in all three measurement points exhibited a rapid increase on the day 7 day and plateaued until the day 30 day. Color Doppler velocitometry measurements revealed significant differences between days 1-7 and 1-30 but not between days 7-30. These findings demonstrate that as the infection subsides, the changes in vascular flow return to normal before infectious parameters do. In conclusion, it is possible to detect decreased vascular resistance in acute infection with the help of transvaginal color Doppler ultrasonography. Furthermore, color Doppler ultrasonography can accurately detect regression of the infectious process before body temperature and acute phase reactants do.

Prediction of perinatal outcome by middle cerebral artery Doppler velocimetry

The relationship between pulsatility index (PI) in the middle cerebral artery (MCA) and adverse perinatal outcome was studied in 162 normal and 75 high-risk pregnancies. The intrapartum cardiotocographic (CTG) findings, the mode of delivery, 1 and 5-minute Apgar scores, the pH level of the umbilical artery, admission to the neonatal intensive care unit (NICU) and the incidence of intrauterine fetal growth retardation were recorded. In the low risk group, the PI values in the MCA were only affected in growth retarded fetuses (P = 0.0084). In the high-risk group, there was an association between the MCA PI values and 5-minute Apgar scores (P = 0.0397), umbilical artery pH values (P = 0.0068) and development of IUGR (P = 0.0376). In both groups, an abnormal intrapartum CTG, the 1-minute Apgar score, cesarean section for fetal distress and admission to the NICU were not related to PI values in the MCA. Our present study suggests that Doppler flow measurement of MCA provides useful information about perinatal outcome, especially in the high-risk pregnancies.

[Value of hypertonic media for the isolation of aberrant forms of Candida albicans from women with lower genital tract infections]

Women presenting symptoms and/or signs of lower genital tract infection were examined mycologically and to increase the sensitivity of the culture methods and to estimate the aberrant forms of fungi, hypertonic media was used. 47 yeast species were isolated from 86 patients. On the other hand 8 Candida albicans strains were isolated by using hypertonic culture media in which no growth was observed in any of the media used for routine culture. In relation with this study 8 cases were evaluated and the culture methods that have been used were discussed.

Clostridium perfringens emphysematous cystitis

Emphysematous cystitis is a rare disease and is usually caused by aerobic bacteria, most commonly Escherichia coli. Only rarely have anaerobic bacteria been associated with this condition. We report a case of emphysematous cystitis due to Clostridium perfringens with bacteremia in an elderly diabetic woman.