Early Prediction of Bloodstream Infection with Complete Blood Count Parameters: an Ex-Vivo Human Whole Blood Model

BACKGROUND

Despite the advanced laboratory technologies available today, blood culture is the gold standard method in the diagnosis of bloodstream infections. Automated blood culture devices give blood culture results for laboratories approximately in 2 - 3 days up to 7 days. Moreover, some microorganisms like nonreproducible bacteria, fungi or viruses cannot be produced in culture. Among all samples taken for blood culture on suspicion of infection approximately 10% are determined as positive whereas the false positive rate due to contamination is 5%. Especially in life-threatening severe conditions such as sepsis early diagnosis and prompt treatment are crucial. Based on this the aim of this study is to investigate complete blood count parameters as potential early markers in Escherichia coli, Staphylococcus aureus and Candida albicans bloodstream infections using an ex vivo whole blood model.

METHODS

Blood samples collected from healthy donors (n = 10) were treated with suspensions containing a certain concentration of microorganisms (107 CFU/mL for both E. coli ATCC 25922 and S. aureus ATCC 29213, 106 CFU/mL for C. albicans ATCC 14053). After bacteremia and candidemia were induced, complete blood count parameters were analyzed hourly in the samples until the end of the 4th hour with a Mindray BC-6800 hematology analyzer. Statistical analysis was performed by Tukey-Kramer post-hoc multiple comparison test and statistical significance was accepted as p < 0.05.

RESULTS

When platelet derived parameter baseline values were compared to hourly values in E. coli and S. aureus induced whole blood samples, it was found that the decrease in PLT, P-LCC and the increase in IPF% was significant from the first hour whereas the increase in IMG% was found to be significant only from the 3rd hour onward. In the experiments with C. albicans, it was observed that the increase in IPF% and IMG% was significant from the 2nd and 3rd hour onward, respectively. There was no relationship between MPV, P-LCR, and NLR baseline and hourly results in any microorganism induced model.

CONCLUSIONS

IPF% can guide clinicians in the early diagnosis and management of treatment of infections caused by S. aureus, E. coli, and C. albicans.

Oxidative stress, apoptosis, inflammation, and proliferation modulator function of visnagin provide gonadoprotective activity in testicular ischemia-reperfusion injury

OBJECTIVE: Visnagin (Vis) is a compound found in the flowers and seeds of the Ammi visnaga plant with promising antioxidant and anti-inflammatory properties. We aimed to investigate the dose-dependent gonadoprotective effects of visnagin in rats while considering oxidative stress, apoptosis, and inflammation-related protein expression levels. MATERIALS AND METHODS: Twenty-eight adult rats were divided into four groups of seven animals each; control, ischemia/reperfusion (I/R), I/R+30Vis, and I/R+60Vis. Animals in control received no surgical application and were sacrificed at the end of the experiment. The rats in I/R, I/R + Vis30, and I/R + Vis60 were exposed to testicular ischemia and the animals in I/R + Vis30, and I/R + Vis60 groups received either 30 or 60 mg/kg visnagin intraperitoneal. At the end of the experiment, testis tissues were used for the measurement of oxidative stress, apoptosis, and inflammation. RESULTS: Our microscopic examinations indicated that I/R resulted in testicular degenerations and morphological alterations, which were improved in visnagin-treated animals. The biochemical analyses demonstrated that oxidative stress in the I/R group increased significantly (p<0.05) compared to the control group. The immunohistochemical examinations showed that pro-apoptotic Bax and Caspase 3 expressions, and pro-inflammatory tumor necrosis factor-alpha (TNF-α) levels were significantly up-regulated (p<0.05) but proliferating nuclear antigen (PCNA) levels in I/R group was significantly (p<0.001) down-regulated compared to the control group. CONCLUSIONS: Ischemia leading to testicular torsion is a reproductive health-affecting problem, and current surgical treatment methods might be insufficient to recover the testis due to the accumulation of reactive oxygen species (ROS). Our observations indicate that visnagin is a potential co-modality along with the surgical interventions for the recovery of ischemia encountered testis, but we believe the requirement of more detailed studies to explore the underlying signaling pathways and the strength of visnagin against testicular ischemia-reperfusion injury.

Graphical Abstract

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Anti-Inflammatory, Antioxidant and Neuroprotective Effects of Niacin on Mild Traumatic Brain Injury in Rats

AIM

To study the effects of niacin, a water-soluble vitamin, on inflammation, oxidative stress and apoptotic processes observed after mild traumatic brain injury (TBI).

MATERIAL AND METHODS

A total of 25 Wistar albino male rats were randomly divided into control (n=9), TBI + Placebo group (n=9), TBI + niacin (500 mg/kg; n=7) groups. Mild TBI was performed under anesthesia by dropping a 300 g weight from a height of 1 meter onto the skull. Behavioral tests were applied before and 24 hours after TBI. Luminol and lucigenin levels and tissue cytokine levels were measured. Histopathological damage was scored in brain tissue.

RESULTS

After mild TBI, luminol and lucigenin levels were increased (p < 0.001), and their levels were decreased with niacin treatment (p < 0.01-p < 0.001). An increased score was obtained with trauma in the tail suspension test (p < 0.01), showing depressive behavior. The number of entries to arms in Y-maze test were decreased in TBI group compared to pre-traumatic values (p < 0.01), while discrimination (p < 0.05) and recognition indices (p < 0.05) in object recognition test were decreased with trauma, but niacin treatment did not change the outcomes in behavioral tests. Levels of the anti-inflammatory cytokine IL-10 were decreased with trauma, and increased with niacin treatment (p < 0.05). The histological damage score was increased with trauma (p < 0.001), and decreased with niacin treatment in the cortex (p < 0.05), and hippocampal dentate gyrus region (p < 0.01).

CONCLUSION

Niacin treatment after mild TBI inhibited trauma-induced production of reactive oxygen derivatives and elevated the anti-inflammatory IL-10 level. Niacin treatment ameliorated the histopathologically evident damage.

Phoenixin 14 ameloriates pancreatic injury in streptozotocin-induced diabetic rats by alleviating oxidative burden

Phoenixin-14 (PNX) is a neuropeptide that has been shown to prevent oxidative damage and stimulates insulin secretion. We investigated the effects of PNX on pancreatic injury induced by streptozotocin (STZ), and nicotinamide (NAD). Male Sprague-Dawley rats, in control (C) and diabetic (STZ) groups, were treated with either saline, or PNX (0.45 nmol/kg, or 45 nmol/kg) daily for 3 days 1 week after STZ injection. Fasting blood glucose (FBG) and gastric emptying rate (GER) were measured. Tissue and blood samples were collected. PNX treatments prevented pancreatic damage and β cell loss. Increased luminol and lucigenin levels in the pancreas, ileum and liver tissues of STZ groups were alleviated by PNX treatment in pancreatic and ileal tissues. PNX0.45 decreased FBG without any change in insulin blood level and pancreatic mRNA. GER increased in all diabetic rats while PNX0.45 delayed GER only in the C group. PNX diminishes pancreatic damage and lowers FBG by reducing oxidative load.

Lymphocyte/mean platelet volume ratio, a new marker; is it effective in predicting the prognosis of COVID-19 cases?

OBJECTIVES

This study aims to determine the prognostic significance of the lymphocyte/mean platelet volume ratio (LMR) in terms of the clinical course of the disease in patients with COVID-19.

METHODS

Patients over 18 who were evaluated for COVID-19 during the period from April 1, to April 30, 2020 were retrospectively scanned. Patients with at least 1 positive PCR test result were as assigned to Group 1 while patients with negative test results were assigned to Group 2. The LMR ratio was calculated by dividing the lymphocyte value by that of MPV. The relationship between LMR, severity of patients' CT findings and 28-day mortality was evaluated.

RESULTS

A total of 938 patients were included in the study. It was observed that the lymphocyte and LMR levels were significantly different in those who died within 28 days (p < 0.001, p ≤ 0.001). In the ROC analysis for the LMR level, the area under the curve (AUC) was found to be 0.737 (95% CI 0.639‒0.834). When the cut‑off value of LMR was 0.045, the sensitivity was found to be 99.0 % and specificity was 15.2 %.

CONCLUSION

LMR can be a guide in multiple cases of care provided to critical patients, as is the case in the COVID-19 pandemic and can be used in recognizing critical patients (Tab. 5, Fig. 1, Ref. 21).

Evaluation of cardiac arrhythmias by electrocardiographic markers in pediatric patients who have tuberous sclerosis without cardiac rhabdomyoma

BACKGROUND

Tuberous sclerosis (TS) is an autosomal dominant and hereditary disorder. Cardiac rhabdomyoma and arrhythmias are the most deleterious risk factors linked to TS. Although arrhythmias in pediatric patients with TS who have cardiac rhabdomyoma have been frequently reported, arrhythmia in patients who have TS without rhabdomyoma is rarely reported in the literature. The study aimed to assess the susceptibility of pediatric patients who have TS without cardiac rhabdomyoma to cardiac arrhythmia using electrocardiographic (ECG) markers.

METHODS

This prospective study included 10 patients who had TS without cardiac rhabdomyoma. The control group was made up of 30 healthy children of the same age and sex as the patient group. P wave, P wave dispersion, QT dispersion, QTc dispersion, TP-e interval, and TP-e interval dispersion were calculated on 12-lead surface ECGs for each patient in both groups and compared.

RESULTS

P wave, P wave dispersion, QT dispersion, and QTc dispersion were found to be significantly higher in the patient group (P<0.001). Furthermore, patients had a greater Tp-e interval and Tp-e interval dispersion than healthy children (P<0.001).

CONCLUSION

Pediatric patients with TS without cardiac rhabdomyoma might be prone to atrial and ventricular arrhythmias according to their prolonged ECG markers. Our findings suggest that patients with TS without cardiac rhabdomyoma need close monitoring for atrial and ventricular arrhythmias.

Peripheral inflammatory biomarkers as predictors of recurrence in surgically-treated anogenital condylomata acuminata patients

The aim of this study was to examine the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) in patients with anogenital condylomata acuminata (CA) and their association with recurrence and squamous intraepithelial neoplasia development. We conducted a descriptive study in 95 patients that had undergone surgical treatment for CA. The descriptive data, disease characteristics, and pre-treatment peripheral inflammatory biomarkers (PIBs) were recorded retrospectively. All parameters were compared in those with recurrent and non-recurrent CA. All PIBs were significantly higher in patients with the greatest genital wart size of >2 cm in the squamous intraepithelial lesion (SIL) group. Human papillomavirus (HPV) types 16, 18, 31 and 33, known to carry high risk for anogenital cancer, were significantly related to higher SII. Greater wart size, high-grade squamous intraepithelial lesion (HSIL), and higher PLR and SII values were highly associated with recurrent disease (p = 0.003, 0.006, 0.005 and 0.000, respectively). Of all recurrences, 34.1% were explained by HSIL and increased PLR and SII values. The prediction of CA recurrence is important to determine those patients at high risk. PLR and SII can be used for risk analysis in selected patient groups.

Nesfatin-1 protects from acute pancreatitis: role of melanocortin receptors

Nesfatin-1, a recently discovered peptide, was shown to have anti-inflammatory effects. Acute pancreatitis (AP) is a life-threatening condition caused by various reasons. Although the etiology of AP is well-known, its pathogenesis is not clear. The aim of this study is to investigate the possible anti-inflammatory role of nesfatin-1 and its probable protective underlying mechanisms in an acute pancreatitis model. Caerulein was applied intraperitoneally to induce acute pancreatitis in Sprague-Dawley female rats. Nesfatin-1 was administered 5 minutes before the application of caerulein to determine its potential anti-inflammatory role on AP. Five minutes before nesfatin-1 injection, in order to investigate the underlying mechanism, oxytocin receptor antagonist (atosiban), melanocortin receptor antagonist (HS024), or ghrelin receptor antagonist (cortistatin) were administered. Five minutes after nesfatin-1 administration, two doses of caerulein were applied one hour apart. The rats were sacrified 12 hours after the first caerulein dose for serum and pancreatic tissue sampling. Microscopic damage scoring, malondialdehyde and glutathione levels, myeloperoxidase activity, luminol and lucigenin chemiluminescence levels in pancreatic tissue and amylase, lipase, trypsinogen-2 levels in serum were evaluated. Oxidative damage was decreased with nesfatin-1 treatment in the acute pancreatitis model (P < 0.05 - 0.001). The administration of HS024 reversed the effect of nesfatin-1, via increasing lipase, amylase, trypsinogen-2, malondialdehyde (MDA), myeloperoxidase (MPO) and lucigenin levels (P < 0.05 - 0.01). Atosiban pre-treatment elevated MPO activity, luminol and lucigenin chemiluminescence levels (P < 0.01 - 0.001) and cortistatin increased lucigenin and luminol chemiluminescence (P < 0.05 - 0.01). Although receptor antagonists reversed the effect of nesfatin-1 on related biochemical parameters, no significant difference was found in histological scoring. Our results indicated that nesfatin-1 had an anti-inflammatory effect on acute pancreatitis via mainly effecting melanocortin receptors.

Presepsin Levels in Experimental Sepsis and Massive Bowel Resection Models in Rats

BACKGROUND/AIM

Presepsin is a useful biomarker for diagnosing sepsis. This study aimed to investigate the relationship between oxidative stress and presepsin levels in animal models.

MATERIALS AND METHODS

Sprague-Dawley rats were used for cecal ligation and puncture (CLP) and to generate massive bowel resection (MBR) models. Trunk blood was collected for analysis of presepsin. Liver and intestinal tissue samples were taken to determine oxidative stress parameters.

RESULTS

Presepsin levels in MBR and CLP sepsis models were higher than those in control groups. Reactive oxygen and nitrogen species (RONS) and malondialdehyde levels were increased in the liver and small intestine of rats in both models, whereas glutathione levels were decreased.

CONCLUSION

Presepsin levels and RONS may be released by the same mechanism which is closely associated with the progression of sepsis and inflammation in both CLP and MBR models.

Myrtus communis leaf extract protects against cerulein-induced acute pancreatitis in rats

In this study, the aim was to examine the potential protective effects of Myrtus communis subsp. communis leaf ethanol extract (MC) treatment against acute pancreatitis (AP) in rats. Thirty-two rats were grouped as the saline-pretreated control (C), MC-pretreated control (MC), saline-pretreated AP (AP), and MC-pretreated AP (MC + AP) groups. To induce AP, cerulein was administered (50 µg/kg) two times. The rats were given MC for 14 days before cerulein injection. Six hours after the final cerulein injection, the rats were sacrificed. Pancreatic damage was associated with an increase in the serum activity of lipase and amylase, the pancreatic activity of myeloperoxidase, and the pancreatic level of malondialdehyde, interleukin-1β, and interleukin-6. AP also led to a decrease in the pancreatic level of anti-inflammatory interleukin-10 and glutathione. Pretreatment with MC before the induction of AP significantly reduced the pancreatic damage observed during the histological examination as well as reversed the biochemical changes evoked by AP. PRACTICAL APPLICATIONS: Acute pancreatitis is characterized by high mortality (average about 5%; severe cases may reach about 30%). The current treatment for acute pancreatitis is mainly symptomatic. The introduction of herbal drugs may lead to the development of a new strategy in the treatment of this disease. This study revealed that MC reduced pancreatic injury by decreasing pro-inflammatory cytokines, increasing antioxidant capacity and anti-inflammatory cytokine, IL-10. To the authors' knowledge, this research is the first report showing that MC inhibits the development of AP. This observation suggests that MC may be useful in the prevention and the treatment of AP in clinical settings.

Structural and spectroscopic properties of LaAlBO3 doped with Eu3+ ions

In this study, we performed X-ray diffraction (XRD) and environmental scanning electron microscope (ESEM) techniques to examine the structure and morphological observation of the samples and thermoluminescence (TL) experiments to extract the trapping parameters and dosimetric properties of LaAlBO₃ phosphors doped with Eu at various doping concentrations. Diffraction patterns of obtained sample were well consistent JCPDS card No 98-009-7945, indicating the formation of pure phase. The TL kinetic parameters were estimated by CGCD software. TL glow curves of LaAlBO₃:Eu³⁺ consist of 12 trap levels and exhibited dominantly first order kinetics. Photoluminescence (PL) emission was observed in the range 400-800 nm for LaAlBO₃ phosphor doped with Eu³⁺. The dominant emission of Eu³⁺ corresponding to the electric dipole transition ⁵D₀ → ⁷F₂ is located at 616 nm. The sharp emission properties exhibited demonstrate that the LaAlBO₃ is a suitable host for rare-earth ion doped phosphor material. It is observed that for the variable concentration of Eu³⁺ on PL studies, the PL intensity augments with increase in the dopant concentration and the concentration quenching was found after 1 mass% of Eu³⁺. The PL experimental results reveal that LaAlBO₃:Eu³⁺ phosphor as an red emitting phosphor may be promising luminescence materials for the optoelectronic applications.

Anti-inflammatory effects of nesfatin-1 on acetic acid-induced gastric ulcer in rats: involvement of cyclo-oxygenase pathway

In order to elucidate the contribution of cycloxygenase (COX) enzymes in the anti-oxidant and anti-inflammatory mechanisms of nesfatin-1, which improves the healing process of chronic gastric ulcers, either acetic acid (80%; ulcer groups; n = 40) or saline (control groups; n = 40) was applied to the serosal surface of male Sprague Dawley rats' stomachs for 1 min. Both the control and ulcer groups were treated daily with either i.p. saline or nesfatin-1 (0.3 μg/kg; for 3 days). Nesfatin-1-treatment was preceded with i.p. saline, COX-2 inhibitor NS-398 (2 mg/kg), COX-1 inhibitor ketorolac (3 mg/kg) or non-selective COX inhibitor indomethacin (5 mg/kg) for 3 days. The rats were decapitated at the end of the third day, and their trunk blood was collected for the measurements of tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β) and IL-10 using ELISA. The induction of ulcers resulted in increased macroscopic scores, along with elevated gastric malondialdehyde, luminol- and lucigenin-enhanced chemiluminescence levels and myeloperoxidase activity. On the other hand, nesfatin-1 treatment abolished these elevations. Depleted glutathione, superoxide dismutase and catalase activity levels in the saline-treated ulcer group were preserved in the nesfatin-1-treated ulcer group. Increased levels of serum TNF-α, IL-1β, IL-10 in the saline-treated ulcer group, as compared to control group, were significantly decreased in the nesfatin-1-treated ulcer group. The inhibition of COX-1, and/or COX-2 reversed most of the alterations induced with nesfatin-1, but COX-2-blockade was consistently more effective to abolish all nesfatin-1-induced changes. Our results suggest that nesfatin-1 ameliorates ulcer-induced inflammatory response through the modulation of oxidant-antioxidant balance. As selective pharmacological inhibition of COX-1 or COX-2 suppresses the antioxidant/anti-inflammatory effects of nesfatin-1, it appears that nesfatin-1 decreases inflammatory mediators and neutrophil migration by a COX-dependent mechanism, especially by a COX-2- dependent mechanism, during the ulcer healing stage.

Factors associated with increased irisin levels in the type 1 diabetes mellitus

OBJECTIVE

The aim of the present study was to determine the irisin levels in patients with the type 1 diabetes mellitus (T1DM) and to examine the relation of irisin levels with the inflammation and autoimmunity.

METHODS

This study included 35 cases diagnosed with T1DM and 36 healthy volunteers. Antiglutamic acid decarboxylase (anti-GAD), islet cell antibody (ICA), and insulin autoantibody levels were measured in patients at the time when they were included into the study and recorded from the patient files. Serum irisin levels were measured by ELISA kit.

RESULTS

The median irisin levels were determined higher in T1DM group compared to the control one (6.8 ng/ml vs. 4.8 ng/ml, p=0.022; respectively). Median irisin levels were higher in anti-GAD (p=0.022) and ICA (p=0.044) positive groups compared to negative groups. In T1DM group, irisin levels displayed positive correlation with glycosylated hemoglobin (HbA1c) (r=0.377, p<0.001) and anti-GAD (r=0.392, p=0.020) and negative correlation with creatinine (r=-0390, p=0.021). In multivariate regression model, HbA1c (B±SE: 2.76±17683, p<0.001), and anti-GAD (B±SE: 2.311±0.610, p=0.001) were determined as independent predictors for predicting the irisin levels.

CONCLUSION

In patients with T1DM, which chronic inflammation and autoimmunity take part in their etiopathogenesis, anti-GAD levels were an independent risk factor for the irisin. Th is may suggest that factors such as inflammation and autoimmunity can be effective in the synthesis of irisin.

The evaluation of renal parenchymal scarring using static renal scintigraphy after percutaneous nephrolithotomy operations

OBJECTIVE

To analyze whether operative techniques and other variables related to patient and renal stone characteristics affect potential renal parenchymal damage.

MATERIALS AND METHODS

The study population comprised 64 patients who underwent percutaneous nephrolithotomy operations (PCNL). Data of the operated renal units, renal stone burden, route and number of entries, dilation techniques, duration of surgery, preoperative and postoperative glomerular filtration rate (GFR) and relative dimercaptosuccinic acid (DMSA) uptakes, as well as the changes in hemoglobin values, were recorded and analyzed for all patients.

RESULTS

The mean age of the patients was 44 years. In 11 (17.1%) cases, renal cortical defects in the 3rd month were detected on DMSA scintigraphy. When the patients with and without renal cortical defect were compared regarding their preoperative and postoperative GFR values, no statistically significant difference was noticed between the groups (P > 0.05). Similarly, when postoperative relative DMSA uptakes were compared with preoperative relative DMSA uptakes of the same kidneys, no statistical significance was seen. When preoperative relative DMSA uptake values between groups with and without renal scarring were compared, no statistically significant difference was observed (P > 0.05).

CONCLUSION

We did not observe any significant difference in scintigraphic parameters and GFR values. Hence, in the current trial, significant loss in renal function after PCNL operations was not observed. Thus, PCNL operations should be regarded as safe, but still, the risk of loss of kidney function should always be considered.

The induction of autoimmune hepatitis in the human leucocyte antigen-DR4 non-obese diabetic mice autoimmune hepatitis mouse model

Autoimmune hepatitis (AIH) is a chronic liver disease characterized by progressive inflammation, female preponderance and seropositivity for autoantibodies such as anti-smooth muscle actin and/or anti-nuclear, anti-liver kidney microsomal type 1 (anti-LKM1) and anti-liver cytosol type 1 (anti-LC1) in more than 80% of cases. AIH is linked strongly to several major histocompatibility complex (MHC) alleles, including human leucocyte antigen (HLA)-DR3, -DR7 and -DR13. HLA-DR4 has the second strongest association with adult AIH, after HLA-DR3. We investigated the role of HLA-DR4 in the development of AIH by immunization of HLA-DR4 (DR4) transgenic non-obese diabetic (NOD) mice with DNA coding for human CYP2D6/FTCD fusion autoantigen. Immunization of DR4 mice leads to sustained mild liver injury, as assessed biochemically by elevated alanine aminotransferase, histologically by interface hepatitis, plasma cell infiltration and mild fibrosis and immunologically by the development of anti-LKM1/anti-LC1 antibodies. In addition, livers from DR4 mice had fewer regulatory T cells (T_regs ), which had decreased programmed death (PD)-1 expression. Splenic T_regs from these mice also showed impaired inhibitory capacity. Furthermore, DR4 expression enhanced the activation status of CD8⁺ T cells, macrophages and dendritic cells in naive DR4 mice compared to naive wild-type (WT) NOD mice. Our results demonstrate that HLA-DR4 is a susceptibility factor for the development of AIH. Impaired suppressive function of T_regs and reduced PD-1 expression may result in spontaneous activation of key immune cell subsets, such as antigen-presenting cells and CD8⁺ T effectors, facilitating the induction of AIH and persistent liver damage.

Diagnosis of fasciola hepatica cases in an operating room

Fascioliasis is a zoonotic disease that is acquired by ingestion of the metacercaria form on uncooked aquatic plants, and humans act as an accidental host. Diagnosis is confirmed by the demonstration of the parasites or evidence of them in faeces and serology. In the absence of these data, delays or misdiagnosis may occur since it may mimic many diseases. In this study, we present three cases, among them two were similar to the above-mentioned statement. The first case, to the best of our knowledge, is the first case with adult-type living fluke in the gall bladder, diagnosed by laparoscopic cholecystectomy.

Association between the neutrophil to lymphocyte ratio and prehypertension

OBJECTIVES

To explore the neutrophil-lymphocyte ratio (NLR) in patients with prehypertension (PHT).

BACKGROUND

Inflammation plays an important role in the development of cardiovascular diseases. A pathophysiological link also exists between inflammation and PHT. NLR is a simple marker for the assessment of inflammatory status. There is a lack of data regarding the association between NLR and pre-hypertensive state.

METHODS

The present cross-sectional study included 33 newly diagnosed PHT patients and 35 normotensive control subjects. Prehypertension was defined as a systolic blood pressure (BP) of 120-139 mm Hg and/or a diastolic BP of 80-89 mm Hg.

RESULTS

Patients were divided into tertiles based on NLR values: 1.17 (0.9-1.42) in tertile 1; 1.57 (1.43-1.78) in tertile 2; and 2.40 (1.82-4.5) in tertile 3. The frequency of PHT was significantly higher for patients in the upper NLR tertile compared to the middle and lower NLR tertiles (21 (91.3%), 7 (30.4%), and 5 (22.7%), respectively; p<0.001). Systolic BP and diastolic BP were significantly higher among patients in the upper NLR tertile than among those in the other NLR tertiles.

CONCLUSION

An association exists between PHT and NLR. NLR measurement, as well as monocyte count, may be used to indicate increased risk of prehypertension (Tab. 2, Ref. 48).

Anti-inflammatory effects of nesfatin-1 in rats with acetic acid - induced colitis and underlying mechanisms

Mucosal balance impairment, bacterial over-proliferation, cytokines, inflammatory mediators are known as responsible for inflammatory bowel disease. Besides known anorexigenic, neuroprotective, and anti-apoptotic effects, the major effect of nesfatin-1 on colitis is unknown. Our aim was to investigate the possible anti-inflammatory effects of nesfatin-1 in acetic acid induced colitis model and potential underlying mechanisms. Male Spraque-Dawley rats were anesthetized by intraperitoneal ketamine (100 mg/kg) and chlorpromazine (0.75 mg/kg). For nesfatin-1 and antagonist applications some of the rats were intracerebroventricularly (i.c.v.) cannulated. In colitis group, intrarectally (i.r.) 4% acetic acid solution (1 ml) and 10 minutes later i.c.v. nesfatin-1 (0.05 μg/5 μl) or vehicle (5 μl) were administered. Treatments continued for 3 days. In control group, physiological saline solution was used intrarectally. To identify the underlying effective mechanism of nesfatin-1, rats were divided into 3 subgroups, 5 minutes following colitis induction; i.c.v. atosiban (oxytocin receptor antagonist), SHU9119 (melanocortin receptor antagonist) or GHSR-1a antagonist (ghrelin receptor antagonist) were administered, 5 minutes later nesfatin-1 was administered for 3 days. On the fourth day, rats were decapitated, and colon tissues were sampled. Macroscopic and microscopic damage scores of distal colon, and colonic tissue malondialdehyde, glutathione, myeloperoxidase, superoxide dismutase, catalase, luminol and lucigenin chemiluminescence measurements were analysed. The increased myeloperoxidase activity, malondialdehyde levels, luminol and lucigenin chemiluminescence measurements, macroscopic and microscopic damage scores with colitis induction (P < 0.05 - 0.001) were decreased with nesfatin-1 treatment (P < 0.05 - 0.001). Nesfatin-1 may show this effect by inhibiting neutrophil infiltration through tissues and by decreasing formation of free oxygen radicals. Atosiban and GHSR-1a administration alleviated the protective effect of nesfatin-1 from microscopic and oxidant damage parameters and lipid peroxidation (P < 0.05 - 0.001). The results of the study suggest that nesfatin-1 had a protective effect from colitis induction, and the anti-inflammatory and antioxidant effects of nesfatin-1 on colitis might occur via oxytocin and ghrelin receptors.

St. John's wort may ameliorate 2,4,6-trinitrobenzenesulfonic acid colitis off rats through the induction of pregnane X receptors and/or P-glycoproteins

It is reported that deficiencies of the pregnane X receptor (PXR) and P-glycoprotein (P-gp), the latter of which is encoded by the MDR1 gene, are important factors in the pathogenesis of inflammatory bowel disease (IBD). It is also known that the activation of PXR is protective of IBD due to the mutual repression between PXR and nuclear factor kappa B (NF-κB) expression and because NF-κB was reported to play a pivotal role in the pathogenesis of ulcerative colitis. The goal of this study was to investigate whether St. John's wort (SJW) and spironolactone (SPL), both known to have strong inducing effects on cytochrome P 450 (CYP) enzymes as well as PXR and P-gp, have ameliorating effects on 2,4,6-trinitrobenzenesulfonic acid (TNBS) colitis of rats through induction of PXR and/or P-gp. Wistar albino rats (250 - 300 g) were divided into control and TNBS-colitis groups. Each group was then divided into a) control (saline), b) SJW (300 mg/kg p.o. bid), and c) SPL (80 mg/kg p.o.) groups. Drugs were given for 7 days. Both treatments ameliorated the clinical hallmarks of colitis, as determined by body weight loss and assessment of diarrhea, colon length, and bowel histology. Plasma levels of NF-κB, tumour necrosis factor-alpha (TNF-α) and tissue myeloperoxidase (MPO) activity, as well as the oxidative stress markers that increased during colitis, decreased significantly after both treatments. The PXR and P-gp expression in the intestinal tissues was diminished in the colitis group but increased after drug treatments. Both drugs appeared to have significant antioxidant and anti-inflammatory effects and ameliorated the TNBS colitis of the rats, most likely through their PXR- and P-gp-inducing properties.

Bridging data models and terminologies to support adverse drug event reporting using EHR data

INTRODUCTION

This article is part of the Focus Theme of METHODs of Information in Medicine on "Managing Interoperability and Complexity in Health Systems".

BACKGROUND

SALUS project aims at building an interoperability platform and a dedicated toolkit to enable secondary use of electronic health records (EHR) data for post marketing drug surveillance. An important component of this toolkit is a drug-related adverse events (AE) reporting system designed to facilitate and accelerate the reporting process using automatic prepopulation mechanisms.

OBJECTIVE

To demonstrate SALUS approach for establishing syntactic and semantic interoperability for AE reporting.

METHOD

Standard (e.g. HL7 CDA-CCD) and proprietary EHR data models are mapped to the E2B(R2) data model via SALUS Common Information Model. Terminology mapping and terminology reasoning services are designed to ensure the automatic conversion of source EHR terminologies (e.g. ICD-9-CM, ICD-10, LOINC or SNOMED-CT) to the target terminology MedDRA which is expected in AE reporting forms. A validated set of terminology mappings is used to ensure the reliability of the reasoning mechanisms.

RESULTS

The percentage of data elements of a standard E2B report that can be completed automatically has been estimated for two pilot sites. In the best scenario (i.e. the available fields in the EHR have actually been filled), only 36% (pilot site 1) and 38% (pilot site 2) of E2B data elements remain to be filled manually. In addition, most of these data elements shall not be filled in each report.

CONCLUSION

SALUS platform's interoperability solutions enable partial automation of the AE reporting process, which could contribute to improve current spontaneous reporting practices and reduce under-reporting, which is currently one major obstacle in the process of acquisition of pharmacovigilance data.

Nesfatin-1 alleviates gastric damage via direct antioxidant mechanisms

BACKGROUND

Indomethacin is a nonsteroidal anti-inflammatory drug, which is known to produce serious side effects, causing ulcerative lesions. Nesfatin-1, a newly identified anorexigenic peptide, was recently shown to have neuroprotective effects. The aim of the study was to investigate the anti-inflammatory effects of nesfatin-1 on indomethacin-induced gastric ulcer.

MATERIALS AND METHODS

After a 24-h starvation period, ulcer was induced in Sprague-Dawley rats by subcutaneous administration of indomethacin (25 mg/kg), whereas control group received vehicle. Fifteen minutes after ulcer induction, rats were treated with either saline or nesfatin-1 (0.1, 0.3, or 1 μg/kg, intraperitoneally). At the fourth hour, all rats were decapitated and their trunk blood was collected for tumor necrosis factor (TNF)-α and interleukin (IL)-6 measurements. Stomach samples were examined microscopically and analyzed for myeloperoxidase (MPO) activity, malondialdehyde (MDA), glutathione (GSH), luminol-, and lucigenin-enhanced chemiluminescence (CL) levels.

RESULTS

Ulcer induction increased serum TNF-α; and IL-6 levels, gastric CL and MDA levels and MPO activity but decreased gastric GSH content (P < 0.05-0.001). On the other hand, 0.1 μg/kg dose of nesfatin-1 reduced microscopic and macroscopic damage scores, decreased MPO activity and MDA levels, CL and IL-6 levels, whereas gastric GSH was replenished (P < 0.01). However, indomethacin-induced increase in TNF-α level was abolished at only 1 μg/kg dose of nesfatin-1 (P < 0.01).

CONCLUSIONS

Nesfatin-1 alleviated indomethacin-induced gastric injury, suggesting that the anti-inflammatory and gastroprotective effects of nesfatin-1 on oxidative gastric damage could be implemented by supporting the balance in oxidant and antioxidant systems while inhibiting the generation of pro-inflammatory mediators.

Healthcare information technology infrastructures in Turkey

OBJECTIVES

The objective of this paper is to describe some of the major healthcare information technology (IT) infrastructures in Turkey, namely, Sağlık-Net (Turkish for "Health-Net"), the Centralized Hospital Appointment System, the Basic Health Statistics Module, the Core Resources Management System, and the e-prescription system of the Social Security Institution. International collaboration projects that are integrated with Sağlık-Net are also briefly summarized.

METHODS

The authors provide a survey of the some of the major healthcare IT infrastructures in Turkey.

RESULTS

Sağlık-Net has two main components: the National Health Information System (NHIS) and the Family Medicine Information System (FMIS). The NHIS is a nation-wide infrastructure for sharing patients' Electronic Health Records (EHRs). So far, EHRs of 78.9 million people have been created in the NHIS. Similarly, family medicine is operational in the whole country via FMIS. Centralized Hospital Appointment System enables the citizens to easily make appointments in healthcare providers. Basic Health Statistics Module is used for collecting information about the health status, risks and indicators across the country. Core Resources Management System speeds up the flow of information between the headquarters and Provincial Health Directorates. The e-prescription system is linked with Sağlık-Net and seamlessly integrated with the healthcare provider information systems. Finally, Turkey is involved in several international projects for experience sharing and disseminating national developments.

CONCLUSION

With the introduction of the "Health Transformation Program" in 2003, a number of successful healthcare IT infrastructures have been developed in Turkey. Currently, work is going on to enhance and further improve their functionality.

A study comparing the efficacy of antimicrobial agents versus enzyme (P-gp) inducers in the treatment of 2,4,6 trinitrobenzenesulfonic acid-induced colitis in rats

The intestinal microflora is an important cofactor in the pathogenesis of intestinal inflammation; and the epithelial cell barrier function is critical in providing protection against the stimulation of mucosal immune system by the microflora. In the present study, therapeutic role of the antibacterial drugs rifampicin and ciprofloxacine were investigated in comparison to spironolactone, an enzyme inducer, in 2,4,6-trinitrobenzenesulfonic acid (TNBS)-induced colitis of the rats. Drugs were administered for 14 days following induction of colitis. All drug treatments ameliorated the clinical hallmarks of colitis as determined by body weight loss and assessment of diarrhea, colon length, and histology. Oxidative damage and neutrophil infiltration as well as nuclear factor κB (NF-κB) and tumor necrosis factor α (TNF-α) expressions that were increased during colitis, were decreased significantly. Rifampicin and ciprofloxacin were probably effective due to their antibacterial and immunomodulating properties. The multidrug resistence gene (MDR1) and its product p-glycoprotein (P-gp) has been implicated in the pathogenesis of inflammatory bowel disease (IBD). In the present study, findings of the P-gp expression were inconclusive but regarding previous studies, it can be suggested that the beneficial effects of rifampicin and spironolactone may be partly due to their action as a P-gp ligand. Spironolactone has been reported to supress the transcription of proinflamatory cytokines that are considered to be of importance in immunoinflammatory diseases. It is also a powerful pregnane X receptor (PXR) inducer; thus, inhibition of the expression of NF-κB and TNF-α, and amelioration of inflammation by spironolactone suggest that this may have been through the activation of PXR. However, our findings regarding PXR expression were inconclusive. Activation of PXR by spironolactone probably also contributed to the induction of P-gp, resulting in extrusion of noxious substances from the tissue.

The role of cholinergic anti-inflammatory pathway in acetic acid-induced colonic inflammation in the rat

The "cholinergic anti-inflammatory pathway" provides neurological modulation of cytokine synthesis to limit the magnitude of the immune response. This study aimed to evaluate the impact of the cholinergic anti-inflammatory pathway on the extent of tissue integrity, oxidant-antioxidant status and neutrophil infiltration to the inflamed organ in a rat model of acetic acid-induced colitis. Colitis was induced by intrarectal administration of 5% acetic acid (1ml) to Sprague-Dawley rats (200-250g; n=7-8 per group). Control group received an equal volume of saline intrarectally. The rats were treated with either nicotine (1mg/kg/day) or huperzine A (0.1mg/kg/day) intraperitoneally for 3 days. After decapitation, the distal colon was scored macroscopically and microscopically. Tissue samples were used for the measurement of malondialdehyde (MDA) and glutathione (GSH) levels, and myeloperoxidase (MPO) activity. Formation of reactive oxygen species was monitored by using chemiluminescence (CL). Nuclear factor (NF)-κB expression was evaluated in colonic samples via immunohistochemical analysis. Trunk blood was collected for the assessment of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-10, resistin and visfatin levels. Both nicotine and huperzine A reduced the extent of colonic lesions, increased colonic MDA level, high MPO activity and NF-κB expression in the colitis group. Elevation of serum IL-1β level due to colitis was also attenuated by both treatments. Additionally, huperzine A was effective to reverse colitis-induced high lucigenin-enhanced CL values and serum TNF-α levels. Colitis group revealed decreased serum visfatin levels compared to control group which was completely reversed by nicotine. In conclusion, modulation of the cholinergic system either by nicotine or ACh esterase inhibition improved acetic acid-induced colonic inflammation as confirmed by macroscopic and microscopic examination and biochemical assays.

Levels of reactive oxygen species in rat tympanic membranes after incisional versus radiofrequency myringotomy

OBJECTIVE

A close relationship between reactive oxygen species (ROS) and myringosclerosis, which is a common complication of myringotomy, was recently reported. The objective of this study was to measure ROS levels directly in rat tympanic membranes using luminol-aided chemiluminescence (CL) in order to compare the levels of ROS after incisional and radiofrequency (RF) myringotomy.

METHODS

Fifteen Sprague-Dawley rats were separated into three groups of five animals each. Bilateral myringotomies were made using an appropriate myringotomy lancet in Group 1 and RF in Group 2. Group 3 served as the control group with no myringotomy. Twenty-four hours after the procedure, all tympanic membranes were inspected with an otomicroscope and then excised for the measurement of ROS using luminol-aided CL.

RESULTS

The mean ROS level in Group 1 was significantly higher than that in Groups 2 and 3 (p<0.05 for both). The difference in mean ROS level between Groups 2 and 3 was not significant (p>0.05). Otomicroscopy revealed increased vascularity and vessel dilation in all tympanic membranes that underwent myringotomy. Vascular dilation was observed in the annular region in the vessels that passed along the long arm of the malleus, in addition to the vessels feeding the anterior and posterior tympanomalleolar folds.

CONCLUSIONS

Although the relationship between ROS and the development of myringosclerosis after myringotomy has been demonstrated, the present study is the first to compare incisional and RF myringotomy based on the measurement of ROS levels. Our results indicate that the increase in ROS due to myringotomy was greater following incisional myringotomy than RF myringotomy.

Protein kinase C activation causes neurite retraction via cyclinD1 and p60-katanin increase in rat hippocampal neurons

Neurons are differentiated postmitotic cells residing in G0 phase of the cell cycle and are unable to proceed through G1 phase, in which cyclinD1 needs to be up-regulated for initiation. Yet, a growing body of evidence has shown that cell cycle re-activation via cyclinD1 up-regulation drives neurons into apoptosis. By contrast, there is also evidence demonstrating cell cycle proteins playing roles in neuronal differentiation. cyclinD1 has been shown to be differently regulated by protein kinase C alpha (PKC-α) in various mitotic cells. Based on these different effects, we investigated the role of PKC-α on cyclinD1 regulation in hippocampal neurons. Neurons were treated with PKC activator, PMA, and analysed for subcellular distributions of PKC-α and cyclinD1. Remarkably, PMA treatment increased nuclear PKC-α and cyclinD1, but not PKC-ε in hippocampal neurons. Increases in nuclear PKC-α and cyclinD1 were accompanied by microtubule re-organisation via increases in tau and retinoblastoma protein phosphorylation levels. Increased p60-katanin and p53 changed the neuronal morphology into neurons with shorter, but increased number of side branches. Since up-regulation of cell cycle is associated with apoptosis in neurons, we also analysed changes in Bax, Bcl-2 early and PARP (poly(ADP-ribose)polymerase), caspase3 late apoptotic markers. However, we did not observe any indication of apoptosis. These data suggest that in addition to their previously known roles in mitotic cells on cell cycle regulation, PKC-α and cyclinD1 seem to be important for differentiation, and nuclear PKC-α and cyclinD1 interfere with differentiation by promoting microtubule re-organisation through PKC signaling without triggering apoptosis.

Detection of reactive oxygen metabolites in malignant and adjacent normal tissues of patients with lung cancer

Background

Different types of reactive oxygen metabolites (ROMs) are known to be involved in carcinogenesis. Several studies have emphasized the formation of ROMs in ischemic tissues and in cases of inflammation. The increased amounts of ROMs in tumor tissues can either be because of their causative effects or because they are produced by the tumor itself. Our study aimed to investigate and compare the levels of ROMs in tumor tissue and adjacent lung parenchyma obtained from patients with lung cancer.

Methods

Fifteen patients (all male, mean age 63.6 ± 9 years) with non-small cell lung cancer were enrolled in the study. All patients were smokers. Of the patients with lung cancer, twelve had epidermoid carcinoma and three had adenocarcinoma. During anatomical resection of the lung, tumor tissue and macroscopically adjacent healthy lung parenchyma (control) that was 5 cm away from the tumor were obtained. The tissues were freshly frozen and stored at −20°C. The generation of ROMs was monitored using luminol- and lucigenin-enhanced chemiluminescence (CL) techniques.

Results

Both luminol (specific for ^.OH, H₂O₂, and HOCl^-) and lucigenin (selective for O₂^.-) CL measurements were significantly higher in tumor tissues than in control tissues (P <0.001). Luminol and lucigenin CL measurements were 1.93 ± 0.71 and 2.5 ± 0.84 times brighter, respectively, in tumor tissues than in the adjacent parenchyma (P = 0.07).

Conclusion

In patients with lung cancer, all ROM levels were increased in tumor tissues when compared with the adjacent lung tissue. Because the increase in lucigenin concentration, which is due to tissue ischemia, is higher than the increase in luminol, which is directly related to the presence and severity of inflammation, ischemia may be more important than inflammation for tumor development in patients with lung cancer.

Protective role of resveratrol against cisplatin induced ototoxicity in guinea pigs

OBJECTIVE

The aim of this study was to evaluate the effectiveness of systemic administration of resveratrol against cisplatin-induced ototoxicity in guinea pigs.

MATERIALS AND METHODS

Healthy guinea pigs (n=24) were randomly divided into four groups. Group 1 (n=6) received resveratrol+cisplatin, group 2 (n=6) received 4% ethanol+cisplatin, group 3 (n=6) received cisplatin, and group 4 (n=6) received saline. Cisplatin was administered at a dose of 10mg/kg/day on days 14 and 15 of the study. Resveratrol (10mg/kg/day), 4% ethanol, and saline were administered throughout the study. Baseline auditory brainstem responses (ABR) (4 kHz, 8 kHz, and click stimulus) were determined for all groups. ABR was repeated 72 h after the last dose of cisplatin in order to record the threshold shifts. The ABR threshold shifts for the click stimulus, 4-kHz- and 8-kHz-frequency stimuli were compared after drug administration. After follow-up ABRs the animals sacrificed under deep sedation and their cochleae were removed. Left cochleae were immediately harvested for measurement of level of reactive oxygen species (ROS). Right cochleae were prepared for histological changes which were observed by scanning electron microscopy (SEM).

RESULTS

For the all stimulus, there was a significant threshold difference among the groups (p<0.01). Group 3 had a significantly higher threshold shift at all stimuli when compared with groups 1 and 4. There was no significant threshold shifts in all stimuli between groups 2 and 3. The resveratrol-treated group 1 showed preservation of threshold in ABR (p ≤ 0.05). SEM showed that inner and outer hair cells were preserved in the group 1. Level of reactive oxygen species (ROS) were significantly higher in groups 2 and 3 compared with groups 1 and 4 (p ≤ 0.05).

CONCLUSION

These results indicated that systemic administration of resveratrol afforded statistically significant protection to the cochlea of guinea pigs from cisplatin toxicity. Experimental dose of resveratrol injections may have a protective effect against cisplatin ototoxicity in guinea pigs.

The effect of phosphodiesterase-5 inhibition by sildenafil citrate on inflammation and apoptosis in rat experimental colitis

AIMS

To investigate the effect of sildenafil citrate (SIL) on the extent of tissue integrity, oxidant-antioxidant status and apoptosis in rats with colitis.

MAIN METHODS

Colitis was induced by trinitrobenzenesulphonic acid (TNBS) in 40% ethanol (30 mg/ml; 0.8 ml) given intrarectally to Sprague-Dawley rats. Sildenafil (25 mg/kg/day) was administered after the induction of colitis and the treatment was continued for 7 days. Other groups received subcutaneously either N(G)-nitro- L-arginine methyl ester (l-NAME; 25 mg/kg) or N(G)-nitro-d-arginine methyl ester (d-NAME; 25 mg/kg) before SIL. After decapitation, the distal colon was scored and stored for the measurement of malondialdehyde (MDA) level, glutathione (GSH) content, myeloperoxidase (MPO) activity and apoptosis. Oxidant generation was monitored by using chemiluminescence (CL). Blood was collected for tumor necrosis factor (TNF)-α and interleukin (IL)-10 assays.

KEY FINDINGS

The macroscopic lesion score of the colitis group was reduced by SIL (p < 0.01) and this effect was abolished by l-NAME (p < 0.01). Increase in colonic MDA along with a concomitant decrease in GSH of the colitis group was reversed by SIL (p < 0.01 and p < 0.001, respectively). l-NAME prevented the effect of SIL on GSH content (p < 0.001). Sildenafil also reduced the elevated MPO of the colitis group (p < 0.001) and this effect was reversed by L-NAME (p < 0.01). Increase in lucigenin CL and serum TNF-α levels in the colitis group were also prevented by SIL (p < 0.001 and p < 0.01, respectively).

SIGNIFICANCE

Sildenafil is beneficial in TNBS-induced rat colitis partially by nitric oxide-dependent mechanisms via the maintenance of oxidant-antioxidant status, prevention of apoptosis, superoxide production and cytokine release.

The effects of Nigella sativa against oxidative injury in a rat model of subarachnoid hemorrhage

OBJECTIVE

The aim of the study was to investigate the putative neuroprotective effect of Nigella sativa oil (NSO) treatment against subarachnoid hemorrhage (SAH) in rats.

METHODS

To induce SAH, rats were injected with 0.3 ml blood into their cisterna magna. Male Wistar albino rats were divided as control, vehicle-treated SAH, and NSO-treated (0.2 ml/kg, intraperitoneally) SAH groups. Forty-eight hours after SAH induction, neurological examination scores were recorded and the rats were decapitated. Brain tissue samples were taken for blood brain barrier permeability, brain water content, or determination of malondialdehyde (MDA) and glutathione (GSH) levels, myeloperoxidase (MPO), and Na(+)-K(+)-ATPase activities.

RESULTS AND DISCUSSION

On the second day of SAH induction, neurological examination scores were increased in SAH groups, while SAH caused significant decreases in brain GSH content and Na(+)-K(+)-ATPase activity, which were accompanied with significant increases in MDA levels and MPO activity. The histological observation showed vasospasm of the basillary artery. On the other hand, NSO treatment markedly improved the neurological scores while all oxidant responses were prevented, implicating that NSO treatment may be of therapeutic use in preventing oxidative stress due to SAH.

Electronic health record interoperability as realized in the Turkish health information system

OBJECTIVES

The objective of this paper is to describe the techniques used in developing the National Health Information System of Turkey (NHIS-T), a nation-wide infrastructure for sharing electronic health records (EHRs).

METHODS

The UN/CEFACT Core Components Technical Specification (CCTS) methodology was applied to design the logical EHR structure and to increase the reuse of common information blocks in EHRs.

RESULTS

The NHIS-T became operational on January 15, 2009. By June 2010, 99% of the public hospitals and 71% of the private and university hospitals were connected to NHIS-T with daily feeds of their patients' EHRs. Out of the 72 million citizens of Turkey, electronic healthcare records of 43 million citizens have already been created in NHIS-T. Currently, only the general practitioners can access the EHRs of their patients. In the second phase of the implementation and once the legal framework is completed, the proper patient consent mechanisms will be available through the personal health record system that is under development. At this time authorized healthcare professionals in secondary and tertiary healthcare systems can access the patients' EHRs.

CONCLUSIONS

A number of factors affected the successful implementation of NHIS-T. First, all stakeholders have to adopt the specified standards. Second, the UN/CEFACT CCTS approach was applied which facilitated the development and understanding of rather complex EHR schemas. Finally, the comprehensive testing of vendor-based hospital information systems for their conformance to and interoperability with NHIS-T through an automated testing platform enhanced substantially the fast integration of vendor-based solutions with the NHIS-T.