The Effect of Ambient Air Pollution on Office, Home, and 24-Hour Ambulatory Blood Pressure Measurements

BACKGROUND

Air pollution has recently been linked to a number of cardiovascular diseases, particularly hypertension (HT). In our study, we aimed to evaluate the association between air pollution and blood pressure (BP) and compare the relationship of BP measurement results obtained using different methods (office, home, and 24-hour ambulatory BP monitoring [ABPM]).

METHODS

This retrospective nested panel study performed with prospective Cappadocia cohort data investigated the relationships between particulate matter (PM) 10 and sulfur dioxide (SO2) and concurrent home, office, and 24-hour ABPM data at each control performed over a 2-year period.

RESULTS

A total of 327 patients in the Cappadocia cohort were included in this study. On the day of office blood pressure measurement, there was an increase of 1.36 mm Hg in systolic BP and 1.18 mm Hg in diastolic BP for every 10 µm/m3 rise in SO2 values. A mean 3-day 10 µm/m3 increase in SO2 was linked to an increase of 1.60 mm Hg in systolic BP and 1.33 mm Hg in diastolic BP. A 10 µm/m3 rise in mean SO2 on the day of 24-hour ABPM measurement was found to be associated with an increase of 1.3 mm Hg in systolic BP and 0.8 mm Hg in diastolic BP. SO2 and PM 10 had no effect on home measurements.

CONCLUSION

In conclusion, increased SO2 levels, during winter months in particular, can be associated with an elevation in office BP values. Our study findings show that air pollution in the setting in which BP is measured may be associated with the results.

COVID-19: booster(s) vs. hospitalization and Intensive Care Unit admission

OBJECTIVE

As the pandemic continues, different vaccine protocols have been implemented to maintain the protection of vaccines and to provide protection against new variants. The aim of this study was to assess hospitalized patients' vaccination status and document the efficacy of boosters.

PATIENTS AND METHODS

The patients that were hospitalized due to COVID-19 were enrolled from 28 hospitals in Turkey for five months from September 2021. 5,331 confirmed COVID-19 patients from collaborating centers were randomly enrolled to understand/estimate the distribution of vaccination status in hospitalized patients and to compare the efficacy of vaccination/booster protocols.

RESULTS

2,779 men and 2,552 women of which 2,408 (45.2%) were admitted to Intensive Care Units participated in this study. It was found that the highest risk reduction for all age groups was found in groups that received 4 doses. Four doses of vaccination for every 3.7 people under 50 years of age, for every 5.7 people in the 50-64 age group, and for every 4.3 people over 65 years of age will prevent 1 patient from being admitted to intensive care. Regardless of the type of vaccine, it was found that the risk of ICU hospitalization decreased in those who were vaccinated compared to those who were not vaccinated. Regardless of the type of vaccine, the ICU risk was found to decrease 1.25-fold in those who received 1 or 2 doses of vaccine, 1.18-fold in those who received 3 doses, and 3.26-fold in those who received 4 doses.

CONCLUSIONS

The results suggested that the addition of a fourth dose is more effective in preventing intensive unit care even in disadvantaged groups.

Does Blood Pressure Variability Affect Hypertension Development in Prehypertensive Patients?

BACKGROUND

Blood pressure variability (BPV) is associated with end organ damage and cardiovascular outcomes in hypertensive patients. Prehypertensive patients frequently develop hypertension (HT). The purpose of the present study was to evaluate the effect of BPV on the development of HT.

METHODS

Two hundred and seven prehypertensive patients from the Cappadocia cohort were monitored over 2 years, and 24-hour ambulatory blood pressure monitoring (ABPM), office BP, and home BP measurements were subsequently performed at 4- to 6-month intervals. BPV was calculated as average real variability (ARV) from 24-h ABPM data, home BP, and office BP measurements at first visit. The relationship was evaluated between baseline ARV and the development of HT.

RESULTS

HT was diagnosed in 25.60% of subjects. Baseline 24-hour ABPM systolic blood pressure (SBP)ARV and diastolic blood pressure (DBP)ARV and home SBPARV were significantly higher in patients who developed HT than the other patients (P 0.006, 0.001 and 0.006, respectively). Baseline 24-hour ABPM SBPARV and home SBPARV exceeding the 90th percentile were identified as parameters affecting development of HT at logistic regression analysis.

CONCLUSION

In conclusion, our prospective observational cohort study showed that short-term BPV in particular can predict the development of HT in the prehypertensive population.

COVID-19: vaccination vs. hospitalization

Objective

Vaccination is the most efficient way to control the coronavirus disease 2019 (COVID-19) pandemic, but vaccination rates remain below the target level in most countries. This multicenter study aimed to evaluate the vaccination status of hospitalized patients and compare two different booster vaccine protocols.

Setting

Inoculation in Turkey began in mid-January 2021. Sinovac was the only available vaccine until April 2021, when BioNTech was added. At the beginning of July 2021, the government offered a third booster dose to healthcare workers and people aged > 50 years who had received the two doses of Sinovac. Of the participants who received a booster, most chose BioNTech as the third dose.

Methods

We collected data from 25 hospitals in 16 cities. Patients hospitalized between August 1 and 10, 2021, were included and categorized into eight groups according to their vaccination status.

Results

We identified 1401 patients, of which 529 (37.7%) were admitted to intensive care units. Nearly half (47.8%) of the patients were not vaccinated, and those with two doses of Sinovac formed the second largest group (32.9%). Hospitalizations were lower in the group which received 2 doses of Sinovac and a booster dose of BioNTech than in the group which received 3 doses of Sinovac.

Conclusion

Effective vaccinations decreased COVID-19-related hospitalizations. The efficacy after two doses of Sinovac may decrease over time; however, it may be enhanced by adding a booster dose. Moreover, unvaccinated patients may be persuaded to undergo vaccination.

Home sphygmomanometers can help in the control of blood pressure: a nationwide field survey

Home blood pressure monitoring (HBPM), which integrates patients into their treatment program, is a self-management tool. The prevalence of home sphygmomanometer ownership and patient compliance with HBPM guidelines are not well known, especially in developing and underdeveloped countries. The aims of this study were to measure the prevalence of home sphygmomanometer ownership among hypertensive subjects through a nationwide field survey (PatenT2), to investigate the validation of sphygmomanometers and consistency of the user arm circumference and cuff size of the upper-arm device owned, as well as to compare blood pressure (BP) readings between hypertensive subjects who have or do not have a sphygmomanometer. Sample selection was based on a multistratified proportional sampling procedure to select a nationally representative sample of the adult population (n = 5437). Of 1650 hypertensive subjects, 332 (20.1%) owned a device, but the percentage of patients who owned a sphygmomanometer was 28.8% among patients who were aware of their hypertension (260/902). The usage of wrist devices and nonvalidated devices is common, and selection of an appropriate cuff size is ignored. Linear-regression analysis showed that owning a BP monitor is associated with decreases of 3.7 mmHg and 2.8 mmHg for systolic and diastolic BPs, respectively. Many patients do not own a sphygmomanometer. The decrease of systolic and diastolic BPs among BP monitor owners is a striking finding. The implementation of a hypertension care program consisting of sphygmomanometer reimbursement and training of patients in its use for HBPM might be cost-effective.

Ophthalmic and Central Retinal Artery Flow Velocities in Patients with Behçet's Disease

Vascular involvement is a well known manifestation of Behçet's disease (BD) and may effect systemic and regional circulation in patients with BD. We evaluated ophthalmic and central retinal artery flow velocities in these patients. Mean ophthalmic and central retinal artery flow velocities were lower in patients with BD than in healthy controls, but the cause and significance of these findings remain to be defined.

Dietary Sources of High Sodium Intake in Turkey: SALTURK II

Previous research has shown daily salt intakes in Turkey to be far above the recommended limits. Knowing the sources of dietary salt could form a basis for preventive strategies aimed towards salt reduction. This study aimed to investigate dietary sources of salt in Turkey. A sub-group (n = 657) was selected from the PatenT2 study population, which represented the urban and rural areas of 4 major cities (Ankara, Istanbul, Izmir, and Konya). A questionnaire inquiring about sociodemographic characteristics, medical histories, detailed histories of diet, and salt consumption was completed. Participants were asked to collect a 24-h urine sample and to record their food intake (dietary recall) on the same day. Of 925 participants selected, 657 (71%) provided accurate 24-h urine collections, based on creatinine excretion data. The mean daily 24-h urinary sodium excretion was 252.0 ± 92.2 mmol/day, equal to daily salt intake of 14.8 ± 5.4 g. Of the 657 participants with accurate 24-h urine collections, 464 (70%) provided fully completed dietary recalls. Among these 464 participants, there was a significant difference between the 24-h urinary sodium excretion-based salt intake estimation (14.5 ± 5.1 g/day) and the dietary recall-based salt intake estimation (12.0 ± 7.0 g/day) (p < 0.001). On the other hand, a positive correlation was obtained between the dietary recall-based daily salt intake and 24-h urinary sodium excretion-based daily salt intake (r = 0.277, p < 0.001). Bread was the main source of salt (34%) followed by salt added during cooking and preparing food before serving (30%), salt from various processed foods (21%), and salt added at the table during food consumption (11%). Conclusively, this study confirmed a very high salt intake of the adult population in four major cities in Turkey. The present findings support the emerging salt reduction strategy in Turkey by promoting lower salt content in baked bread, and less salt use in habitual food preparation and during food consumption in the home.

Effect of Clonazepam on Raynaud's Phenomenon and Fingertip Ulcers in Scleroderma

Objective:

To report the novel finding of a significant improvement in Raynaud's phenomenon symptoms with clonazepam in a patient with systemic sclerosis.

Case Summary:

A 45-year-old female with limited scleroderma and chronic renal failure was admitted to our hospital due to hyponatremia (sodium 103 mEq/L). Her hyponatremia was treated by intravenous infusion of NaCI 3%. Clonazepam, which had been prescribed previously for anxiety and insomnia, was discontinued. Three weeks after she was discharged from the hospital, the patient presented with the complaint of increased severity of Raynaud's phenomenon and digital ulcers. She told us that her fingertip ulcers had been healed while she was taking clonazepam and that episodes of Raynaud's phenomenon had increased after discontinuation of the drug. Clonazepam 1 mg twice daily was restarted, and Raynaud's phenomenon and fingertip ulcers resolved within a month. On 2 occasions after that time, we discontinued clonazepam and replaced it with alprazolam, as the patient believed alprazolam was more beneficial in alleviating anxiety. Episodes of Raynaud's phenomenon and new digital ulcers recurred on both of these occasions, and clonazepam was restarted. At the time of writing, no severe episodes of Raynaud's phenomenon or fingertip ulcers have occurred with clonazepam treatment.

Discussion:

Raynaud's phenomenon and recurrent digital ulcers are a manifestation of vascular disease in patients with systemic sclerosis and lead to pain, impaired function, and tissue loss. Few drugs have previously been shown to affect digital ulcers in the setting of scleroderma. Our patient experienced a significant and sustained improvement in Raynaud's phenomenon and digital ulcers following the initiation of clonazepam. To our knowledge, as of March 2007, this is the first reported use of clonazepam in Raynaud's phenomenon and digital ulcer. While its therapeutic mechanism remains unclear, clonazepam may offer some advantages compared with current agents.

Conclusions:

We report a case of Raynaud's phenomenon and digital ulcers responding to clonazepam. Further research is warranted to test the robustness of this preliminary finding.

The impact of diabetes mellitus on peritoneal dialysis: the Turkey Multicenter Clinic Study

PURPOSE

It is well established that diabetic peritoneal dialysis (PD) patients have a higher mortality rate than the other PD population. This study was designed to determine the overall predictors of survival and compared mortality and morbidity between diabetic and non-diabetic Turkish PD patients.

METHODS

We conducted a multicenter retrospective study with 915 PD patients [217 had diabetes mellitus (DM)]. Serum albumin, PTH, HbA1c, co-morbid diseases, dialysis adequacy (Kt/V), and peritoneal transport characteristics as well as peritonitis episodes and ultrafiltration failure during the follow-up period were recorded.

RESULTS

DM patients were older and had more co-morbidities than non-DM patients. Peritonitis rates were higher in DM patients (one episode per 35.9 patient months) compared to non-DM patients (one episode per 41.5 patient months) (p < 0.001). On Kaplan-Meier analysis, patient survival was significantly lower in DM patients with the 2-, 3- and 5-year patient survival rates of 90.8%, 87.8% and 78.2% in non-diabetics and 80.9%, 70.4% and 61.2% in diabetics, respectively. On Cox regression analysis, DM (HR 1.5, p = 0.022), age (HR 1.03, p < 0.001), baseline serum albumin (HR 0.39, p < 0.001), heart failure (HR 0.038, p = 0.038), peripheral artery disease (HR 1.83, p = 0.025) and amputation (HR 4.1, p = 0.009) at baseline were significant predictors of overall mortality.

CONCLUSIONS

Patient survival is lower in diabetic compared to non-diabetic patients on PD. Peritonitis rates were also higher in diabetic PD patients. DM, older age, albumin level and cardiovascular co-morbidities are predictors of mortality.

Mycobacterium tuberculous peritonitis in CAPD patients: a report of 11 patients and review of literature

BACKGROUND

The aims of the present report were to document our experience of the prevalence of tuberculous peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients, mode of presentation, diagnosis and outcome and to discuss the current published data about catheter removal.

METHODS

A retrospective study of CAPD patients with tuberculous peritonitis was done. A minimum of three specimens of peritoneal fluid were examined for acid-fast bacilli smears. The BACTEC 9000 Blood Culture Series of instruments were used for the culture of Mycobacterium tuberculosis. After 2005, patients were treated with anti-tuberculous treatment, and catheter retention was started in our patients.

RESULTS

There were eleven patients (2.6 %) with tuberculous peritonitis among 414 CAPD patients. M. tuberculosis accounted for 4.47 % of all peritonitis episodes. The incidence of tuberculous peritonitis was 1/794 months. There were eight males and three females. The mean age was 49 years. Intestinal obstruction was reported in two patients, and two patients were treated for antecedent peritonitis. One of them had a simultaneous fungal peritonitis. One patient each developed a peritoneo-cutaneous fistula and ultrafiltration failure. Three were successfully treated without the removal of catheter.

CONCLUSION

Based on the analysis of all published reports of tuberculous peritonitis, there was no significant difference in patient survival between patients in whom CAPD catheter was removed or retained. Tuberculous peritonitis should be considered in patients with neutrophilic 'sterile' peritonitis with no response to antibacterial medications, predominance of lymphocytic peritonitis and in bacterial peritonitis not responding to antibiotics. After an early diagnosis, with close monitoring, an effort to retain the catheter after 5 days of anti-tuberculous therapy may be attempted.

Red cell distribution width and mean platelet volume in amyloidosis

We aimed to determine whether red cell distribution width (RDW) and mean platelet volume (MPV) values differ between patients with reactive amyloid A (AA) amyloidosis due to chronic inflammatory disease and in healthy participants. In this study, 33 patients with AA amyloidosis and 40 age- and sex-matched healthy controls were enrolled. Erythrocyte sedimentation rate (ESR), RDW, platelet count (PLT), and MPV levels were retrospectively obtained from our computerized patient database. We found RDW, ESR, and PLT levels to be significantly higher in patients with AA amyloidosis compared with the controls (P < .0001). Mean platelet volume was significantly lower in patients with amyloidosis (P < .0001). Inflammatory diseases such as AA amyloidosis may demonstrate low MPV and high RDW levels.

Arm circumference: its importance for dialysis patients in the obesity era

PURPOSE

The purposes of this study were to investigate the association between arm circumference and body mass index (BMI) and to discuss problems, mainly arm circumference and cuff size mismatch, that could affect the reliability of home blood pressure monitoring (HBPM) among peritoneal dialysis (PD) and hemodialysis (HD) patients.

METHODS

525 PD and 502 HD patients from 16 centers were included in the study. A two-part questionnaire was used to gather information from the participants. Arm circumferences were categorized into four groups according to the British Hypertension Society cuff size recommendations.

RESULTS

Mean BMI and arm circumference of all participants were 25.0 kg/m(2) and 27.6 cm, respectively. There was a significant correlation between BMI and arm circumference. The mean BMI and arm circumference values were higher in PD patients than in HD patients. Requirement of a large-sized adult cuff was more common among PD patients compared to HD patients (14 % vs 8 %, p = 0.002).

CONCLUSIONS

Since HBPM is a useful tool for clinicians to improve BP control, nephrologists should be aware of the problems related to HBPM in dialysis patients and take an active role to increase the reliability of HBPM.

Use of home sphygmomanometers in Turkey: a nation-wide survey

The purposes of this study were to detect the prevalence of ownership of a home sphygmomanometer among hypertensive subjects through a nation-wide survey, to investigate parameters affecting ownership of a sphygmomanometer, to compare how home blood pressure monitoring (HBPM) was actually used in daily practice with some aspects of the current guidelines, and to discuss what we implemented to increase the reliability of HBPM in a developing country. A total of 2747 hypertensive patients from 34 cities, representative of the Turkish population, were enrolled in the study. A multiple-choice questionnaire was administered to each participant using the computer-assisted telephone interviewing method. Among 2747 hypertensive patients, 1281 of them (46.6%) had a home sphygmomanometer. Most of the patients were using wrist devices. The factors associated with ownership of a sphygmomanometer were female gender, older age, obesity, higher educational status, higher income level, living in urban areas, awareness of hypertension and anti-hypertensive drug usage. Only 16% of the devices were used on the advice of a physician. The patients learned usage of their device mainly from the sellers and their relatives. The ownership of a home sphygmomanometer is common among hypertensive patients in Turkey, but regular monitoring of blood pressure before physician visits is rare despite common ownership of these devices. Daily practice of HBPM in Turkey was far from the recommendations of the current guidelines. More effort is needed to improve the reliability of HBPM.

Renal amyloidosis in children

Renal amyloidosis is a detrimental disease caused by the deposition of amyloid fibrils. A child with renal amyloidosis may present with proteinuria or nephrotic syndrome. Chronic renal failure may follow. Amyloid fibrils may deposit in other organs as well. The diagnosis is through the typical appearance on histopathology. Although chronic infections and chronic inflammatory diseases used to be the causes of secondary amyloidosis in children, the most frequent cause is now autoinflammatory diseases. Among this group of diseases, the most frequent one throughout the world is familial Mediterranean fever (FMF). FMF is typically characterized by attacks of clinical inflammation in the form of fever and serositis and high acute-phase reactants. Persisting inflammation in inadequately treated disease is associated with the development of secondary amyloidosis. The main treatment is colchicine. A number of other monogenic autoinflammatory diseases have also been identified. Among them cryopyrin-associated periodic syndrome (CAPS) is outstanding with its clinical features and the predilection to develop secondary amyloidosis in untreated cases. The treatment of secondary amyloidosis mainly depends on the treatment of the disease. However, a number of new treatments for amyloid per se are in the pipeline.

Obesity, hypertension and home sphygmomanometer cuffs

BACKGROUND

Since the increasing prevalence of obesity leads to a larger mean arm circumferences in the hypertensive population and appropriate cuff size is essential for accurate measurement of blood pressure, overweight and obese patients often require automated home sphygmomanometers with large- or extra large-sized cuffs. The aims of this study were to evaluate the information about cuff size on automated upper arm home sphygmomanometer packing boxes and compare the findings with wrist device boxes.

METHODS

One hundred twelve different device boxes (49 automated upper arm, 5 semi-automatic, and 58 wrist) produced by 40 manufacturers were investigated.

RESULTS

Three different types of information were observed (written, graphical, or a combination of both). There was not any information about cuff size on 49 (44%) device boxes. Most of the information expressed on the boxes was not attractive or informative for the patients.

CONCLUSION

This study showed that the information regarding cuff size on most of the device boxes was obtuse and the patients are not warned sufficiently about appropriate cuff size. Physicians and health care providers should inform and train their patients about appropriate cuff size.

Mild Renal Injury in Behçet's Disease

AIM

The aim of this study is to investigate the frequency of microalbuminuria and abnormal urinary beta2-microglobulin excretion in patients with Behçet's disease (BD).

MATERIALS AND METHODS

Twenty-eight patients and 27 healthy controls were included in this study. Urine albumin/creatinine and beta2-microglobulin/creatinine ratios were calculated.

RESULTS

The frequency of microalbuminuria and abnormal urinary beta2-microglobulin excretion was higher among patients with BD than in control group, but this was not statistically significant (p > 0.05).

CONCLUSION

Microalbuminuria and abnormal beta2-microglobulin excretion are markers of renal injury, which have not been investigated in BD previously. Renal injury in BD is more frequent than has been recognized and it is most often in mild nature.

Ultrasonic Gallbladder Function in Chronic Kidney Disease: Does Predialysis, Hemodialysis, or CAPD Affect it?

BACKGROUND

There are contradictory reports about the prevalence of cholelithiasis in chronic kidney disease (CKD). The pathogenesis of gallstones is associated with the lithogenic changes of bile composition, increased tendency to nucleation, and decreased gallbladder motility. The studies related to these factors can predict the development of cholelithiasis. The aim of this study was to evaluate the ultrasonic gallbladder function in CKD and to compare it in predialysis (PreD), hemodialysis (HD), and continuous ambulatory peritoneal dialysis (CAPD) patients.

METHODS

Age, gender, and body mass index matched 49 CKD patients (14 PreD, 19 HD, 16 CAPD), and 17 control individuals were included in the study. Diabetic and cirrhotic patients were not included. Ultrasonic gallbladder volume was evaluated in pre- and postprandial period, and ejection fraction was calculated. We also measured several biochemical parameters (cholesterol, triglyceride, blood urea nitrogen (BUN), creatinine, calcium, Phosphorus, parathormone, albumin, total protein) in blood.

RESULTS

Preprandial gallbladder volume in PreD, HD, CAPD, and control groups were 26.7 +/-13.6, 20.8+/-10.4, 23.2+/-14.7, and 26.4+/-14.8 mL, respectively (p > 0.05). Ejection fractions were 54.1 +/- 22.9%, 54.9 +/- 23.9%, 48.6 +/- 15.9%, and 51.8 +/- 19.2% in PreD, HD, CAPD, and control groups, respectively (p > 0.05). Serum triglyceride was higher in PreD patients than control group (207 +/- 144 vs. 110 +/-48 mg/dL) (p<0.05). Serum BUN, Cre, P, and PTH levels were higher in CKD groups than the control group, whereas serum total protein and albumin levels were higher in the control group (p<0.05). Serum Ca was lower in PreD and HD patients than in the controls (p<0.05).

CONCLUSIONS

In conclusion, CKD and renal replacement therapy (HD and CAPD) do not affect gallbladder functions, but more studies are needed to evaluate prevalence of gallstones, gallbladder motility, and the composition of bile in CKD.

Evaluation of Hand Functions in Hemodialysis Patients

BACKGROUND AND AIMS

Patients with end stage renal disease (ESRD) have many musculoskeletal abnormalities, including hand dysfunction. The Sollerman test evaluates hand grip function in daily activities. The relationships between Sollerman test (dominant hand) with Duruoz's Hand Index (DHI), Health Assessment Questionnaire (HAQ), and Beck Depression Inventory (BDI) tests have not been investigated previously. The aims of this study are to evaluate hand grip function using the Sollerman test in hemodialysis (HD) patients, correlate this test with other measures evaluating hand function or psychosocial status, and investigate factors that can affect Sollerman test.

METHODS

One-hundred twenty HD patients (64 male, 56 female, mean age 51 +/- 1.4 years, mean duration of HD therapy 5.3 +/- 3.7 years) were included in this study. The HAQ, DHI, and BDI scores were determined by standard techniques. All patients underwent the Jamar grip test and Sollerman test for the dominant (D) and non-dominant hand (ND).

RESULTS

We found a positive correlation between Sollerman test (dominant hand) with Sollerman test-ND, Jamar-D, and Jamar-ND tests. There were negative correlations between Sollerman test with age, HAQ, BDI, and DHI tests.

CONCLUSIONS

The relationships between Sollerman test (dominant hand) with DHI, HAQ, and BDI tests have not been investigated previously. This study showed the correlations between the Sollerman test (dominant hand) and other tests (either positive or negative). Psychosocial problems can affect hand functions.

Tuberculous Peritonitis

Compared with the general population, dialysis patients are at higher risk of acquiring mycobacterial infections. The aim of the present article is to review case reports and studies published since the report by Talwani and Horvath (2000) and to discuss the main problems that arise in daily practice. After a comprehensive review of the literature, cumulative data about peritoneal dialysis and peritoneal tuberculosis from reports of 98 patients in 21 papers were analyzed.

The clinical and laboratory findings of peritoneal tuberculosis are nonspecific. Diagnosis requires a high index of suspicion. The most difficult cases present as culture-negative peritonitis or culture-positive peritonitis resistant to appropriate antibiotics without any additional clues of tuberculosis. The sensitivity of smears and cultures can be enhanced by centrifuging a 50 – 150 mL dialysate sample.

Tuberculous peritonitis

Compared with the general population, dialysis patients are at higher risk of acquiring mycobacterial infections. The aim of the present article is to review case reports and studies published since the report by Talwani and Horvath (2000) and to discuss the main problems that arise in daily practice. After a comprehensive review of the literature, cumulative data about peritoneal dialysis and peritoneal tuberculosis from reports of 98 patients in 21 papers were analyzed. The clinical and laboratory findings of peritoneal tuberculosis are nonspecific. Diagnosis requires a high index of suspicion. The most difficult cases present as culture-negative peritonitis or culture-positive peritonitis resistant to appropriate antibiotics without any additional clues of tuberculosis. The sensitivity of smears and cultures can be enhanced by centrifuging a 50 - 150 mL dialysate sample.

Self-measurement of blood pressure at home: is it reliable?

Self-measurement of blood pressure (BP) at home is more common than 10 years ago and encouraged by current guidelines to increase patient adherence to treatment and reach the goal of target BP. The aims of this study are to evaluate the accuracy of home sphygmomanometers and to investigate behavior/knowledge of the sphygmomanometer owners. A campaign was planned to determine the accuracy of home sphygmomanometers in 2006. Seven hundred and twenty-three home sphygmomanometers were brought by individuals to the University Hospital Hypertension Clinic within 1 year and 693 (96%) of the devices were in adequate working condition and suitable for analysis. Four hundred and thirty-nine (63%) of the sphygmomanometers were automatic. Four hundred and eleven (59.3%) of the 693 sphygmomanometer were inaccurate. About 80% (256/320) of the wrist devices were inaccurate. Most studies evaluating the accuracy of sphygmomanometers are conducted in hospital or primary care settings; studies investigating home sphygmomanometers are rare. High frequency of inaccurate home devices is a major public health problem. In conclusion, inaccurate devices have been used in home BP measurements frequently and frequency of device-related errors can be decreased by awareness and training of the patients. Physicians and healthcare providers should advise the patients to check the accuracy of their home sphygmomanometers regularly.

An unusual presentation of sirolimus associated cough in a renal transplant recipient

Sirolimus-associated pulmonary problems are rare but life threatening. Pulmonary problems due to sirolimus treatment are interstitial pneumonitis, bronchiolitis obliterans organizing pneumonia (BOOP), and alveolar hemorrhage. We present a case of sirolimus-related cough in the absence of any pulmonary radiological findings. A 55-year-old man with a history of 4 years of hemodialysis therapy because of end-stage renal disease of unknown etiology underwent cadaveric renal transplantation in June 2006. Three days following the initiation of sirolimus therapy he complained of dry cough and fever. There were no clinical or laboratory findings compatible with specific pulmonary disease. After switching sirolimus to tacrolimus, the cough improved within 1-2 days and resolved in 5 days. Sirolimus should be considered in the differential diagnosis of pulmonary problems in the early posttransplantation period even in the absence of radiological findings.

MEFV mutations in patients with familial Mediterranean fever in the Black Sea region of Turkey: Samsun experience [corrected]

OBJECTIVE

To investigate MEFV mutations among patients with familial Mediterranean fever (FMF), their relatives, and healthy controls in the Black Sea region of Turkey; to compare 3 different MEFV mutation analysis methods; to evaluate the role of MEFV mutations in the diagnosis of FMF; and to investigate the role of M694V in the development of amyloidosis.

METHODS

In total, 890 subjects (625 patients, 165 relatives, 100 healthy controls) were included in this prospective study. MEFV mutations were studied with the amplification refractory mutation system (ARMS; n = 335), polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP; n = 335), and reverse hybridization assay (FMF StripAssay; n = 693).

RESULTS

All methods were used in 79 patients. The ratio of false negativity was about 2% using ARMS compared to PCR-RFLP. The FMF StripAssay was used to investigate 9 more mutations and detected 17 mutations in 14 patients. The M694V/M694V genotype was more common in patients with amyloidosis (37%) compared to patients without amyloidosis (18%) (p = 0.009). The frequency of MEFV carriers was 27%. The frequency of individuals having 2 mutations among asymptomatic relatives of FMF patients was 6%.

CONCLUSION

The FMF StripAssay is a reliable and time-saving method. In spite of detection of new mutations and developments in MEFV assay technology, there were patients in whom no mutation was detected. Our data, combined with previous studies, show that patients having M694V/M694V carry a risk for amyloidosis.

Clinical and electrophysiologic findings in dialysis patients

The aim of this study was to quantitatively determine the electrophysiologic changes occurring in the peripheral nerves and muscles in patients with chronic renal failure (CRF) treated with haemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD), and to determine which electrophysiologic parameters are most commonly abnormal in uraemic patients. We investigated the relationship between the parameters of neurography and quantitative electromyography (QEMG) and clinical findings. The study included 42 patients with CRF (30 on HD and 12 on CAPD). Nerve conduction studies (NCSs) of the median, ulnar, tibial, peroneal, and sural nerves, and QEMG of the tibialis anterior and biceps brachii muscles were performed. We found axonal and/or demyelinating polyneuropathies in 97.6% of the patients (100% of HD and 91.7% of CAPD patients), but were not able to verify any significant differences between the HD and CAPD patients using NCS or QEMG. Median, ulnar, sural sensory nerve action potential (SNAP) amplitudes, peroneal CV and F-latency were the most common abnormal parameters in sensory and motor NCSs, respectively. The clinical findings only correlated with the parameters of neurography, and not with the parameters of QEMG. Sural SNAP amplitudes, peroneal and tibial CVs, F-latencies also correlated with the severity of the clinical findings in these patients, suggesting that these parameters can be used in follow up studies in these patients. In this study, most of the uraemic patients were found to have already mild or moderate neuropathies in which the objective clinical signs might be absent, even if they have some clinical symptoms. NCS showed abnormality indicating polyneuropathy in 24 out of 25 patients with clinical neuropathy signs and in 17 out of 17 patients with no clinical signs. Thus, in subclinical conditions NCS is useful to detect the abnormalities in peripheral nerves of the ureamic patients under chronic dialysis.

Pulmonary involvement in Behçet's disease

BACKGROUND

Behçet's disease (BD) is a multisystem vasculitis and pulmonary involvement in BD is reported to indicate poor prognosis and high mortality.

OBJECTIVES

The aims of this study were to report on patients with pulmonary involvement and to discuss pulmonary artery thrombus and small-sized vasculitis associated with BD, with respect to previously published cases.

METHODS

Fifteen patients with BD and pulmonary involvement were included in this study. Massive hemoptysis was observed in all patients having pulmonary artery aneurysm (PAA).

RESULTS

Eleven patients had macroscopic pulmonary vascular disease (2 PAA, 3 PAA and thrombi and 6 only thrombi) and 3 patients had microscopic pulmonary vascular disease. The remaining patient had pulmonary cryptococcosis.

CONCLUSIONS

Data regarding treatment and outcomes of patients having BD-related pulmonary emboli/infarct and small-sized vasculitis are limited. Pulmonary vasculitis affects different levels of the pulmonary artery in BD and should be classified as macroscopic and microscopic vascular disease. 'Pulmonary artery thrombosis' should be used instead of 'pulmonary emboli'. Spiral CT angiography is the best radiological tool for evaluation of pulmonary problems in BD. Treatment of vasculitis should be based on the type of vascular disease and may vary among different types of vascular disease. Anticoagulation can be used in patients with microscopic vascular disease and nonaneurysmal macroscopic vascular disease. More studies are needed to clarify this issue.

Garlic, hypertension and patient education

The aims of this study are to investigate the frequency of garlic usage in hypertensive population and to evaluate acute effect of garlic and garlic tablets on blood pressure in patients with hypertension. 4102 of the 7703 patients (53.3%) reported that they were using garlic. No significant effect on blood pressure was observed in any of the three groups (placebo, garlic or garlic tablets). Use of garlic is common among the hypertensive population, garlic and garlic tablets do not have acute blood pressure lowering effect, and a special education program informing patients and public about garlic is required.

SAA1 alpha/alpha alleles in Behçet's disease related amyloidosis

Behçet's disease (BD) related amyloidosis is relatively rare. Serum amyloid A protein (SAA) protein gene polymorphism is one of the factors implicated in the pathogenesis of AA type amyloidosis. The aim of this study is to investigate SAA1 gene polymorphism in different patient groups: (1) BD related amyloidosis, (2) BD without amyloidosis, and (3) healthy controls. One hundred eleven patients from three main groups were included in the study: (1) BD related amyloidosis (n = 9), (2) BD without amyloidosis (n = 39), and (3) healthy controls (n = 63). Homozygous alpha/alpha is present in 78% of patients with BD and amyloidosis. The SAA1 alpha/alpha genotype is significantly more common among patients with BD and amyloidosis. This study demonstrated increased frequency of alpha/alpha genotype in BD related amyloidosis. To our knowledge, the relationship between alpha/alpha genotype and BD related amyloidosis was not studied previously. In conclusion, the SAA1 alpha/alpha genotype is a risk factor for amyloidosis in BD.

Severe vitamin D deficiency in chronic renal failure patients on peritoneal dialysis

The aim of this study was to evaluate the prevalence of vitamin D deficiency in chronic renal failure (CRF) patients on peritoneal dialysis (PD) and to correlate the findings with various demographic and renal osteodystrophy markers.

METHOD

This cross-sectional, multicenter study was carried out in 273 PD patients with a mean age of 61.7 +/- 10.9 years and mean duration of PD 3.3 +/- 2.2 years. It included 123 female and 150 male patients from 20 centers in Greece and Turkey, countries that are on the same latitude, namely, 36-42 degrees north. We measured 25(OH)D3 and 1.25(OH)2D3 levels and some other clinical and laboratory indices of bone mineral metabolism.

RESULTS

Of these 273 patients 92% (251 patients) had vitamin D deficiency i.e. serum 25(OH)D3 levels less than 15 ng/ml, 119 (43.6%) had severe vitamin D deficiency i.e., serum 25(OH)D3 levels, less than 5 ng/ml, 132 (48.4%) had moderate vitamin D deficiency i.e., serum 25(OH)D3 levels, 5-15 ng/ml, 12 (4.4%) vitamin D insufficiency i.e., serum 25(OH)D3 levels 15 - 30 ng/ml and only 10 (3.6%) had adequate vitamin D stores. We found no correlation between 25(OH)D3 levels and PTH, serum albumin, bone alkaline phosphatase, P, and Ca x P. In multiple regression analyses, the independent predictors of 25(OH)D3 were age, presence of diabetes (DM-CRF), levels of serum calcium and serum 1.25(OH)2D3.

CONCLUSION

We found a high prevalence (92%) of vitamin D deficiency in these 273 PD patients, nearly one half of whom had severe vitamin D deficiency. Vitamin D deficiency is more common in DM-CRF patients than in non-DM-CRF patients. Our findings suggest that these patients should be considered for vitamin D supplementation.

What is the optimal dwell time for maximizing ultrafiltration with icodextrin exchange in automated peritoneal dialysis patients?

BACKGROUND

Icodextrin is increasingly being used in automated peritoneal dialysis (APD) for the long dwell exchange to maintain adequate ultrafiltration (UF). However, the UF reported in the literature varies with different dwell times: from 200 to 500 mL with 12 - 15 hour dwells. In order to maximize UF, it is important to know the relationship between dwell time and UF when using icodextrin in APD patients. With this knowledge, decisions can be made with respect to dwell period, and adjustments to the dialysis prescription can be made accordingly.

METHODS

We prospectively studied this relationship in 36 patients from Canada and Turkey. All patients did the icodextrin day exchange manually after disconnecting themselves from overnight cycler dialysis. Dwell period was increased by 1 hour every week, from 10 to 14 hours. Ultrafiltration was noted for each icodextrin exchange. Mean UF for each week (i.e., dwell period) was compared by repeated measures ANOVA.

RESULTS

We found no difference in mean UF with increasing dwelt time: 351.73 +/- 250.59 mL at 10 hours versus 371.75 +/- 258.25 mL at 14 hours (p = 0.83). We also compared mean UF between different subgroups and found that males (p = 0.02 vs females) and high transporters (p = 0.04 vs low) had higher mean UF. Further analysis of maximal UF showed no correlation to age, sex, diabetic status, transport category, creatinine clearance, Kt/V, duration on peritoneal dialysis, or duration of icodextrin use.

CONCLUSION

Icodextrin-related UF in APD patients is not related to demographic factors and does not increase significantly beyond 10 hours.

SAA1 alpha/alpha alleles in amyloidosis

BACKGROUND

Amyloidosis, mainly AA type, is one of the common diseases in nephrology clinics in Turkey. AA type amyloidosis is a complication of various chronic infections or inflammatory diseases such as familial Mediterranean fever (FMF), rheumatoid arthritis (RA), tuberculosis and bronchiectasis. A controversy exists in the literature regarding the relationship between SAA1 genotypes and AA type amyloidosis. This study aimed to investigate SAA1 gene polymorphism in different patient groups: 1) amyloidosis, 2) FMF and 3) healthy controls.

METHODS

Eighty-two patients from the three groups were included in the study: 1) amyloidosis, 2) FMF without amyloidosis, and 3) healthy controls. SAA1 genotypes were studied by the polymerase chain reaction/restriction fragment length polymorphism (PCR-RFLP) method.

RESULTS

The homozygous alpha/alpha genotype is the most common SAA1 genotype among patient groups with amyloidosis, and the alpha/alpha genotype frequency is significantly higher than in healthy controls (68 vs. 38%, p<0.05).

CONCLUSIONS

The SAA1 alpha/alpha genotype is a risk factor for AA type amyloidosis in Caucasoid populations and more studies are needed to investigate why the gamma/gamma genotype is associated with AA type amyloidosis in Japan.

In acute organophosphate poisoning, the efficacy of hemoperfusion on clinical status and mortality

The aims of this study were to report experience in patients with organophosphate poisoning (OPP) and to discuss the potential role for hemoperfusion (HP) in the management of severe OPP. At the emergency service of a university hospital, 52 patients with acute OPP were included in this retrospective study. The patients were divided into 2 groups (Group 1, severe poisoning, n = 25; and Group 2, mild poisoning, n = 27). All patients with mild OPP survived. Seven patients (28%) of the 25 with severe OPP died. This study supports previous data documenting that HP is unnecessary in the management of mild OPP. Although there was not a control group (severe poisoning without HP treatment) in this study, experience suggests that HP can be useful in severe cases. Reports from centers having experience with severe OPP can help clarify this controversial issue. Randomized controlled (prospective) studies investigating the possible beneficial effects of HP on patient survival in patients with severe OPP with control group are needed.