Temporal Trends in the Epidemiology of HIV in Turkey

OBJECTIVE

The aim of this study was to analyze the temporal trends of HIV epidemiology in Turkey from 2011 to 2016.

METHODS

Thirty-four teams from 28 centers at 17 different cities participated in this retrospective study. Participating centers were asked to complete a structured form containing questions about epidemiologic, demographic and clinical characteristics of patients presented with new HIV diagnosis between 2011 and 2016. Demographic data from all centers (complete or partial) were included in the analyses. For the cascade of care analysis, 15 centers that provided full data from 2011 to 2016 were included. Overall and annual distributions of the data were calculated as percentages and the Chi square test was used to determine temporal changes.

RESULTS

A total of 2,953 patients between 2011 and 2016 were included. Overall male to female ratio was 5:1 with a significant increase in the number of male cases from 2011 to 2016 (p<0.001). The highest prevalence was among those aged 25-34 years followed by the 35-44 age bracket. The most common reason for HIV testing was illness (35%). While the frequency of sex among men who have sex with men increased from 16% to 30.6% (p<0.001) over the study period, heterosexual intercourse (53%) was found to be the most common transmission route. Overall, 29% of the cases presented with a CD4 count of >500 cells/mm3 while 46.7% presented with a CD4 T cell count of <350 cells/mm3. Among newly diagnosed cases, 79% were retained in care, and all such cases initiated ART with 73% achieving viral suppression after six months of antiretroviral therapy.

CONCLUSION

The epidemiologic profile of HIV infected individuals is changing rapidly in Turkey with an increasing trend in the number of newly diagnosed people disclosing themselves as MSM. New diagnoses were mostly at a young age. The late diagnosis was found to be a challenging issue. Despite the unavailability of data for the first 90, Turkey is close to the last two steps of 90-90-90 targets.

FRI0237 COMPARISON OF DIFFERENT PULMONARY HYPERTENSION SCREENING ALGORITHMS IN PATIENTS WITH SYSTEMIC SCLEROSIS

Background:

Pulmonary hypertension (PH) is an important cause of morbidity and mortality in patients with systemic sclerosis (SSc). Different screening algorithms have been proposed for identifying patients who have a high probability of PH and require right heart catheterization (RHC), which is the gold standard for diagnosing PH.

Objectives:

To compare the performance of PH screening algorithms in our patients with SSc.

Methods:

Sixty-nine consecutive pts fulfilling ACR/EULAR 2013 SSc criteria have been screened for PH until now, using the 2015 ESC/ERS, DETECT and ASIG algorithms. Pulmonary function tests (PFT), diffusing capacity of the lung for carbon monoxide (DLCO), trans-thoracic echocardiography, serum NT-proBNP and uric acid assay and high-resolution computed tomography (HRCT) were performed as needed. Patients with known PH, severe interstitial lung disease and severe left ventricular dysfunction (LVD) were not included. RHC was performed in all patients with positive screening according to any one of the screening algorithms. Pts with PH were classified according to the updated PH classification criteria. Sensitivity and specificity of the 3 screening algorithms were evaluated according to the established cut-off value of 25 mmHg for mean systolic pulmonary artery pressure and for the recently proposed cut-off value of 20 mmHg.

Results:

Among the 69 SSc pts, 27 were excluded due to ILD(n=6), LVD(n=6), already diagnosed PH(n=4) no measurable TRV(n=5), lung cancer (n=2), pulmonary embolism (n=1) and nephrotic syndrome (n=1). Among the remaining 42 patients, 17 required RHC according to at least one of the screening algorithms (Table 1). Number of patients who had suspected pulmonary hypertension and required RHC according to ESC/ERS 2015, DETECT and ASIG were 7 (%17), 13 (%31), and 12 (%29) respectively (Figure 1). Among the 17 pts. who had RHC, PH was present in 3 pts according to the 25-mmHg cut-off (Group 2 in 2, Group 3 in 1) and in 9 pts according to the 20-mmHg cut-off (Group 1 in 5, Group 2 in 3, Group 3 in 1). The sensitivity and specificities were presented in Table 2. ASIG and DETECT had better sensitivity for 25-mmHg cut-off and was better with ASIG for 20 mmHg cut-off. The specificity was better with ESC/ERS for both cut-off values.

Conclusion:

The ASIG algorithm has a better sensitivity and ESC/ERS algorithm has a better specificity for detecting PH in patients with SSc. A limitation of this study was that RHC was not performed in patients who did not fulfill criteria according to any of the screening algorithms. The sensitivities may be lower than what we propose if there are patients with PH who are asymptomatic and not captured with any of the algorithms.

Disclosure of Interests:

Mustafa Erdogan: None declared, Burcak Kilickiran Avci: None declared, Cansu Ebren: None declared, Yagmur Ersoy: None declared, Zeki Ongen: None declared, Gul Ongen: None declared, Vedat Hamuryudan Speakers bureau: Pfizer, AbbVie, Amgen, MSD, Novartis, UCB, Gulen Hatemi Grant/research support from: BMS, Celgene Corporation, Silk Road Therapeutics – grant/research support, Consultant of: Bayer, Eli Lilly – consultant, Speakers bureau: AbbVie, Mustafa Nevzat, Novartis, UCB – speaker

Spread of carbapenem-resistant international clones of Acinetobacter baumannii in Turkey and Azerbaijan: a collaborative study

Epidemic clones of Acinetobacter baumannii, described as European clones I, II, and III, are associated with hospital epidemics throughout the world. We aimed to determine the molecular characteristics and genetic diversity between European clones I, II, and III from Turkey and Azerbaijan. In this study, a total of 112 bloodstream isolates of carbapenem-resistant Acinetobacter spp. were collected from 11 hospitals across Turkey and Azerbaijan. The identification of Acinetobacter spp. using conventional and sensitivity tests was performed by standard criteria. Multiplex polymerase chain reaction (PCR) was used to detect OXA carbapenemase-encoding genes (bla OXA-23-like, bla OXA-24-like, bla OXA-51-like, and bla OXA-58-like). Pulsed-field gel electrophoresis (PFGE) typing was used to investigate genetic diversity. The bla OXA-51-like gene was present in all 112 isolates, 75 (67 %) carried bla OXA-23-like, 7 (6.2 %) carried bla OXA-58-like genes, and 5 (4.5 %) carried bla OXA-24-like genes. With a 90 % similarity cut-off value, 15 clones and eight unique isolates were identified. The largest clone was cluster D, with six subtypes. Isolates from clusters D and I were widely spread in seven different geographical regions throughout Turkey. However, F cluster was found in the northern and eastern regions of Turkey. EU clone I was grouped within J cluster with three isolates found in Antalya, Istanbul, and Erzurum. EU clone II was grouped in the U cluster with 15 isolates and found in Kayseri and Diyarbakır. The bla OXA-24-like gene in carbapenemases was identified rarely in Turkey and has been reported for the first time from Azerbaijan. Furthermore, this is the first multicenter study in Turkey and Azerbaijan to identify several major clusters belonging to European clones I and II of A. baumannii.

Isokinetic Evaluation of Knee Extensor/Flexor Muscle Strength in Behcet's Patients

BACKGROUND

Behçet's disease (BD) is an idiopathic, multisystemic, progressive disease. The purpose of this study is to compare the knee flexor and extensor isokinetic muscle strengths of Behcet's patients with that of healthy subjects.

METHODS

Twenty-five (13 male and 12 female) patients with BD and 25 (15 male and 10 female) healthy individuals were included in the study. Velocities of 90°/sec, 120°/sec, and 150°/sec were used for the isokinetic muscle strength testing. Patients with active inflammatory knee arthritis were excluded. Peak torque (Nm) and peak torque adjusted to body weight (%) were taken into consideration for comparison between study groups.

RESULTS

Compared to healthy controls, there was a statistically significant decrease in both the bilateral knee extensor and flexor muscle isokinetic peak torques(Nm) as well as the peak torques adjusted to body weight (%) at velocities of 90°/sec, 120°/sec and 150°/sec in patients with BD (p < 0.05). However, there was no significant difference in the agonist-antagonist ratio of the isokinetic peak torques of knee muscles between the two groups.

CONCLUSION

In light of these findings, we have concluded that both knee flexor and extensor isokinetic muscle strengths are lower in BD. We therefore recommend careful monitoring of patients with BD in terms of muscle strength.

Outbreak of adenovirus serotype 8 conjunctivitis in preterm infants in a neonatal intensive care unit

BACKGROUND

Adenovirus keratoconjunctivitis outbreaks have rarely been reported in preterm infants. An outbreak of adenovirus conjunctivitis occurred between 15 January and 25 February at a neonatal intensive care unit of a university hospital in Turkey.

AIM

To describe the evolution, investigation and management of the outbreak.

METHODS

Adenovirus type 8 was identified in 14 samples by polymerase chain reaction analysis. A case-control study was performed to determine the risk factors.

FINDINGS

Fifteen preterm neonates, five healthcare workers (HCWs) and four parents suffered from conjunctivitis signs such as lacrimation, swelling and redness of the eye. A retinopathy of prematurity (ROP) examination was found to be the most important risk factor for adenovirus conjunctivitis (odds ratio: 17.5; 95% confidence interval: 1.9-163.0; P=0.012). The eyelid speculum (blepharostat) used during the ROP examination was not sterilized between each patient and was found to be the cause of contamination.

CONCLUSION

The outbreak was controlled by measures such as barrier precautions, hand hygiene, sterilization of the blepharostat, suspending patient transfer to other units, and excluding infected HCWs for at least 15 days.

Can the patient-reported outcome instruments determine disease activity in rheumatoid arthritis?

OBJECTIVES

The aim of this study was to investigate the indicative value of the patient-reported outcome instruments (PROs) on disease activity in rheumatoid arthritis (RA).

METHODS

Three hundred sixty eight patients with RA were included in this cross-sectional study. Disease activity was evaluated using both the Disease Activity Score 28 (DAS 28) and the Clinical Disease Activity Index (CDAI). Patients who had DAS 28 score < 3.60 points and CDAI score <10.00 points were allocated into the "low disease activity" group and those who had DAS 28 score > or = 3.60 points and CDAI score > or = 10.00 points into the "moderate or high disease activity" group. The Health Assessment Questionnaire (HAQ), Nottingham Health Profile (NHP), Rheumatoid Arthritis Quality of Life (RAQoL), and Short Form 36 (SF 36) were used as PROs. Logistic regression analysis was used to find variables, which had an indicative value for disease activity.

RESULTS

HAQ, pain and emotional reaction subscales of NHP, and bodily pain, general health and social functioning subscales of SF 36 had independent indicative values, when DAS 28 was used as dependent variable. On the other hand, HAQ, pain and emotional reaction subscales of NHP, and general health and emotional role limitation subscales of SF 36 had indicative values when CDAI was used as dependent variable. DAS 28 and CDAI both showed HAQ as the parameter with the highest odds ratio (OR). But RAQoL had shown no independent indicative value for projecting disease activity.

CONCLUSION

It was concluded that HAQ could determine disease activity in RA better than other PROs included in this study (Tab. 4, Ref. 36).

Community-acquired acute bacterial meningitis in the elderly in Turkey

This investigation aimed both to delineate the current status of community-acquired acute bacterial meningitis and to produce data on the interrelationships between clinical, laboratory and therapeutic parameters in the elderly. This retrospective cohort study was conducted in 28 Turkish institutions in 159 culture-positive patients over the age of 50 years. Streptococcus pneumoniae was the most common pathogen (69.2%), followed by Listeria monocytogenes (8.8%). For this reason, antilisterial antibiotics such as ampicillin or benzylpenicillin should be added to the therapeutic regimen. Pathogen-specific mortality did not vary between S. pneumoniae and L. monocytogenes. The overall mortality was 2.5% at the third day, 12.6% at the seventh day, 20.1% at the 14th day and 21.4% at the 21st day. The risk factors for fatality were increasing age, the presence of stupor, sepsis and inappropriate antibiotic administration. Cerebrospinal fluid (CSF) leukocyte counts and CSF/blood glucose ratios were lower in patients who died. Fever did not differ between survivors and fatal cases. The mean duration of antibiotic therapy in survivors was 16.3 +/- 6.4 days. One-fifth of the patients had complications, and in 5.7% of the patients sequelae persisted at follow-up.

A comparative ontogenic study of urinary bladder: impact of the epithelial differentiation in embryonic and newborn rats

The present study aimed to show the cellular and subcellular distribution of glycogen content during the differentiation of urothelial cells from simple cuboidal to stratified transitional epithelium. Bladder samples were taken from rat embryos on the 15th to 19th days and newborn at 21st day. During the development of the bladder, the formation of fusiform vesicles, asymmetric unit membrane (AUM) and microridges were examined with staining with haematoxylin-eosin and periodic acid Schiff for light microscope and periodic acid-thiocharbohydrazide-silver proteinate for transmission electron microscope. The topographical changes of luminal differentiation were examined with the scanning electron microscope. The urothelium was simple cuboidal from 15th till the 17th days of gestation. Glycogen content was present in the cytoplasm till the 18th day of gestation. At the early stage (16th day) of gestation, the apical surface contains microvilli that points the undifferentiated cells. The density of microvilli decreased and ropy microridges appeared at the 17th day of gestation. The small discoid vesicles lined with AUM developed at the apical cytoplasm of the surface cells at the 17th day of gestation. After this stage, both the density of microridges and large and elongated fusiform vesicles increased. The differentiation of the urothelium begins with the formation of the round and small vesicles, continues with the formation of the AUM and at the final stage there is a decrease in both glycogen content and the appearance of the microridges at the luminal surface of the urothelial cells.

[Antimicrobial susceptibility and serotype distribution of pneumococci strains isolated from meningitis patients]

Treatment of life threatening pneumococcal infections such as meningitis has recently become problematic due to the emergence of antibiotic resistant strains. Antimicrobial susceptibility data usually derived from the studies that included all clinical pneumococcal isolates. However, resistance patterns of this microorganism isolated from meningitis cases in our country are not exactly known. The aim of this study was to determine the antimicrobial susceptibility and serotypes of Streptococcus pneumoniae strains isolated from meningitis cases. This retrospective study was designed in three university hospitals in Turkey and 72 pneumococci isolated from patients with meningitis were evaluated. In this study disk diffusion test and E-test methods were used to determine the susceptibility of pneumococci to some antibiotics. All S. pneumoniae isolates were serotyped using Quellung reaction. Although resistance for oxacillin was found by disc diffusion method in 11 isolates, only six of them were found to be resistant by E-test. By the latter procedure, no resistance was recorded against ceftriaxone and meropenem, while chloramphenicol resistance was found as 1.4%. In our study, erythromycin, ciprofloxacin and levofloxacin resistance were 2.8%, TMP-SMX resistance was 26.4%, while no vancomycin resistance was detected by disk diffusion. In evaluation of 72 pneumococci, we found 16 different serotypes and four isolates could not be serotyped. The serogroup 23 (n: 19) was the most common one followed by serotype 19 (n: 9) and serotype 14 (n: 7). Of six resistant isolates, three pneumococci were serogroup 23 and the remaining were from three different serotype/serogroups 11, 14 and 19. As a result penicillin resistance in pneumococci isolated from meningitis was low and there was no resistance to ceftriaxone. It seems that ceftriaxone is an appropriate choice for empirical treatment of meningitis in our patients. These findings also revealed that pneumococcal polysaccharide capsule vaccines in use cover most of the invasive pneumococcal serotypes.

Effect of social deprivation on mortality and the duration of hospital stay after a stroke

BACKGROUND

We aim to assess whether social deprivation independently predicts case fatality after a stroke patient has been admitted to hospital, and to assess whether social deprivation affected duration of hospital stay.

METHODS

Cohort study in a tertiary teaching hospital included consecutive patients admitted to hospital within 48 h of their stroke between 1988 and 1994. Outcome measures were case fatality at 1 year and length of hospital stay. The socioeconomic category was derived from the postcode sector of residence for the patients (Carstairs index). Cause of death was determined by data linkage to the Registrar General data for Scotland.

RESULTS

2,042 stroke patients were included. A significant age difference existed between the deprivation categories (76.0 +/- 10.9 years in the affluent cohort vs. 71.4 +/- 10.7 years in the deprived cohort). Smoking was more common in the deprived group. ECG findings and neurological score on admission were similar between the groups. No difference existed between groups for length of hospital stay (p = 0.793), and in the proportions remaining alive at 1 year (p = 0.416). When entered into a multivariate Cox regression analysis, the deprivation categories did not predict mortality. Age, sex, Philadelphia Geriatric Center Instrumental Activities of Daily Living (IADL) Scale Score, Orgogozo neurological score on admission, and ECG abnormalities were the significant predictors.

CONCLUSIONS

Stroke patients living in more socially deprived areas had their strokes at an earlier age but were not at a greater risk of dying or longer hospital stay once they had been admitted to hospital.

Clinical Experience with Three Combination Regimens for the Treatment of High-risk Febrile Neutropenia

Introduction: The objective of this study was to compare the safety and efficacy of ceftazidime (2 g every 8 h), piperacillin/tazobactam (4 g/500 mg every 6 h), and meropenem (1 g every 8 h), when combined with amikacin (15 mg/kg once daily), in the empirical treatment of high-risk febrile neutropenic episodes in patients with haematological malignancy. Materials and Methods : A prospective, comparative study designed in the haematology unit of a university hospital in Turkey. Results: A total of 89 febrile episodes in 60 neutropenic patients were treated; 29 febrile episodes in 23 patients with ceftazidime plus amikacin (group 1), 30 episodes in 25 patients with piperacillin/tazobactam plus amikacin (group 2), and 30 episodes in 25 patients with meropenem plus amikacin (group 3). The 3 groups were comparable in terms of age, sex, underlying malignancy, pretherapy neutrophil counts, duration of neutropenia and types of infections. Neutropenia, since the start of fever, persisted for 10 days in all of the episodes in the 3 study groups. Nearly all of the episodes were seen in patients with acute leukaemia. In 25.8% (23/89) of the febrile neutropenia episodes, an aetiologic organism was isolated, with gram- negative bacteria being the most commonly isolated. The success without modification rates were 34.5%, 30% and 36.7% for groups 1, 2 and 3, respectively (P >0.05). After modification with a different class of antimicrobial therapy, the response rates increased to 65.5%, 63.3% and 70% for groups 1, 2 and 3, respectively (P >0.05). The mean duration of treatment and the time to defervescence were also comparable in all groups. In all arms, side effects were minimal. Conclusions: It is concluded that the 3 regimens were equally effective and safe in the empirical treatment of high-risk febrile neutropenic episodes. Key words: Antibiotic therapy, Haematological malignancy

Clinical experience with three combination regimens for the treatment of high-risk febrile neutropenia

INTRODUCTION

The objective of this study was to compare the safety and efficacy of ceftazidime (2 g every 8 h), piperacillin/tazobactam (4 g/500 mg every 6 h), and meropenem (1 g every 8 h), when combined with amikacin (15 mg/kg once daily), in the empirical treatment of high-risk febrile neutropenic episodes in patients with haematological malignancy.

MATERIALS AND METHODS

A prospective, comparative study designed in the haematology unit of a university hospital in Turkey.

RESULTS

A total of 89 febrile episodes in 60 neutropenic patients were treated; 29 febrile episodes in 23 patients with ceftazidime plus amikacin (group 1), 30 episodes in 25 patients with piperacillin/tazobactam plus amikacin (group 2), and 30 episodes in 25 patients with meropenem plus amikacin (group 3). The 3 groups were comparable in terms of age, sex, underlying malignancy, pretherapy neutrophil counts, duration of neutropenia and types of infections. Neutropenia, since the start of fever, persisted for > or =10 days in all of the episodes in the 3 study groups. Nearly all of the episodes were seen in patients with acute leukaemia. In 25.8% (23/89) of the febrile neutropenia episodes, an aetiologic organism was isolated, with gram-negative bacteria being the most commonly isolated. The success without modification rates were 34.5%, 30% and 36.7% for groups 1, 2 and 3, respectively (P >0.05). After modification with a different class of antimicrobial therapy, the response rates increased to 65.5%, 63.3% and 70% for groups 1, 2 and 3, respectively (P >0.05). The mean duration of treatment and the time to defervescence were also comparable in all groups. In all arms, side effects were minimal.

CONCLUSIONS

It is concluded that the 3 regimens were equally effective and safe in the empirical treatment of high-risk febrile neutropenic episodes.

NK-1 antagonist CP99994 inhibits stress-induced mast cell degranulation in rats

Mast cells are implicated in stress-induced inflammatory skin diseases such as psoriasis. Mechanisms of stress-induced mast cell degranulation however, are not entirely clear. Here we explore the role of activation of a Substance P (SP) receptor (NK-1) on mast cell degranulation upon exposure to stress in rats. A specific nonpeptide NK-1 antagonist, CP99994 was used to treat the rats either peripherally or intracerebroventricularly. Because increased SP activity in the brain may mediate the stress response, we also examined cutaneous mast cell degranulation after central injection of SP. Stress, as well as SP injected centrally, increased mast cell degranulation. Both central and peripheral injection of CP99994 prevented stress-induced mast cell degranulation. Surprisingly, the combination of stress with SP decreased mast cell degranulation, suggesting that high levels of SP may counteract the stress responses. Results in this animal model suggest that NK-1 antagonists may be used therapeutically to treat stress-induced inflammatory skin diseases; however, drug doses should be chosen carefully.

Cytokine profile and nitric oxide levels in sera from patients with brucellosis

The aims of this study were to investigate the serum levels of some cytokines [tumor necrosis factor-alpha (TNF-alpha), interleukin 1beta (IL-1beta), IL-2R, IL-6, and IL-8] and nitric oxide (NO) levels in patients with untreated brucellosis and to test the correlation of these parameters with each other. The study was conducted on 67 subjects, 37 patients with brucellosis and 30 healthy individuals with no history of Brucella infection. Brucellosis was identified by a positive blood culture and/or increased Brucella antibodies in serological tests in addition to compatible clinical symptoms. Cytokine profile analysis was performed by the immulite chemiluminescent enzyme immunometric assay whose inter- and intra-assay coefficients of variance were 2.6-3.6 and 4.4-8.5%, respectively. The levels of nitrites/nitrates, which are representative of NO levels, were measured by the Griess method. Patients with brucellosis had significantly elevated serum levels of nitrites/nitrates, IL-2R, IL-6 and IL-8 (mean +/- SD, 102.8 +/- 23.8 micromol/l, 806.1 +/- 58.5 U/ml, 21.1 +/- 2.3 pg/ml, and 8.8 +/- 1.6 pg/ml, respectively) compared to healthy controls, whereas TNF-alpha and IL-1beta levels were unchanged. No statistically significant correlation was detected between any of the studied cytokine levels and nitrate/nitrite concentrations according to Pearson's linear correlation test. We conclude that only IL-6, IL-8 and IL-2R are elevated in brucellosis and the extent of elevation depends on the severity and clinical pattern of the disease. Moderate elevation in serum NO was comparable to that observed in previous studies. This explains the absence or very rare occurrence of septic shock in brucellosis.

Serum and gastric fluid levels of cytokines and nitrates in gastric diseases infected with Helicobacter pylori

This case control study presents data on the concentrations of nitrite and nitrate and a variety of pro-inflammatory cytokines such as interleukin-1 beta (IL-1 beta), interleukin-2R (IL-2R), interleukin-6 (IL-6), interleukin-8 (IL-8) and tumor necrosis factor TNF-alpha in gastric fluid and serum. Patients with gastritis, gastric ulcer and gastric cancer are studied and grouped according to infection by Helicobacter pylori. The 208 patients who underwent upper gastrointestinal endoscopic examination were classified as follows; H. pylori-positive gastritis (n = 32), H. pylori-negative gastritis (n = 32), H. pylori-positive ulcers (n = 34), H. pylori-negative ulcers (n = 34), 43 patients with H. pylori-positive gastric cancer in addition to 33 H. pylori-negative healthy control individuals. Gastric fluids and blood samples were taken concomitantly. Cytokines and nitrite and nitrate determinations were attempted as soon as possible after collection of the samples. Nitrite and nitrate levels of serum and gastric fluids of H. pylori-positive gastritis and ulcers were higher than H. pylori-negative gastritis and ulcers. The concentrations of total nitrite and nitrate and cytokines (TNF-alpha, IL-2R, IL-6, and IL-8) in gastric fluids and sera of H. pylori-positive gastric cancer patients were higher than H. pylori-negative control groups. IL-1 beta level was significantly elevated in gastric fluid of infected cancer patients but not in serum. Taken together, the results suggest that an increase in cytokine-NO combination in gastric mucosa previously reported by many studies is not restricted to local infected gastric tissue but also detected in gastric fluid and sera of H. pylori-positive subjects and may have an important role in the pathogenesis and development of common gastric diseases.

Stump appendicitis and generalized peritonitis due to incomplete appendectomy

Stump appendicitis is a rare clinical situation when there is incomplete appendectomy. A wide spectrum of diseases in the differential diagnosis of right lower quadrant pain of the abdomen and presence of appendectomy operation in a patient's history delay the diagnosis. We report such a case of perforated stump appendicitis and generalized peritonitis occurring eight months after appendectomy.

Isolated thrombocytopenia: the presenting finding of typhoid fever

Thrombocytopenia is generally seen as a complication in typhoid fever. However, it can also be encountered as a presenting sign on admission. A 29-year-old man with complaints of fever and diarrhoea was hospitalized because of isolated thrombocytopenia encountered on routine complete blood count examination. The diagnosis of typhoid fever was established when Salmonella typhi was isolated from the blood cultures. The platelet count returned to normal level within the first week of ceftriaxone therapy. Possible mechanisms of thrombocytopenia were discussed.

Serum nitrate and nitrite levels in patients with rheumatoid arthritis, ankylosing spondylitis, and osteoarthritis

OBJECTIVE

To assess and compare serum nitrate and nitrite levels in patients with ankylosing spondylitis (AS), rheumatoid arthritis (RA), and osteoarthritis (OA).

METHODS

Thirty five patients with RA, 32 patients with AS, and 36 patients with OA were entered into this study. In addition, 30 healthy volunteers acted as a control group. Concentrations of nitrate and nitrite in serum were determined by direct and indirect Griess reactions. C reactive protein and erythrocyte sedimentation rate levels were determined as markers of systemic activity of disease (SAD) in RA and AS groups.

RESULTS

Serum nitrate and nitrite levels were found to be higher in patients with AS and RA than in the OA group (p<0.01). In addition, serum nitrate and nitrite levels were higher in all three groups than in the control group (p<0.01). Moreover, serum nitrate and nitrite levels were higher in patients who had SAD than in those who had not in the RA and AS groups (p<0.01 and p<0.05, respectively), and there was a correlation between serum nitrate and nitrite concentrations and SAD variables in patients with RA (Spearman's r(s)=0.414, p<0.05 and r(s)=0.408, p<0.05, respectively) and AS (r(s)=0.421, p<0.05 and r(s)=0.412, p<0.05, respectively).

CONCLUSION

The findings suggest that nitrate and nitrite production is enhanced in patients with inflammatory arthritis compared with OA. In addition, serum nitrate and nitrite levels are enhanced in patients with RA, AS, and OA compared with healthy subjects. Furthermore, there is a correlation between the SAD variables and serum nitrate and nitrite levels in patients with RA and AS.

Cerebral Haemorrhage. Parenchymal intracranial haemorrhage

While there have been substantial improvements in the management of patients with cerebral infarction and there are likely to be further improvements over the next decade, the same may not be true for cerebral haemorrhage. Diagnostic facilities and neurosurgical techniques have improved but not all patients are benefiting from these. The current literature is reviewed. Further controlled trials of the utility of modern neurosurgical techniques are urgently required as at present no therapeutic intervention holds out hope for these patients other than optimum medical management. The main focus must be on prevention.

Pitfalls in the diagnosis of complicated pulmonary hydatid disease

The aim of this study was to present the pitfalls in the diagnosis of complicated pulmonary hydatid disease and to discuss the unusual radiological presentations of this endemic disorder in Turkey. We retrospectively evaluated 34 patients (12 females) aged between 8 and 64 years, who were operated on at our centre between 1991 and 1998 and diagnosed with complicated pulmonary hydatid cyst histopathologically. Computerized tomography (CT) scans of these patients were reviewed double-blind by two radiologists. The patients were then divided into two groups: group 1: initial radiological impression is pulmonary hydatid cyst and group 2: initial radiological impression is not pulmonary hydatid disease. These two groups were evaluated in terms of symptoms, radiographical presentation and laboratory tests. The presence of cystic appearance, water-lily sign, ring enhancement concomitant with intact cysts unanimously led the radiologists to the diagnosis of complicated pulmonary hydatid cyst, whereas solid appearance and presence of bronchial obliteration made the diagnosis unlikely. In such circumstances patient history, laboratory findings and bronchoscopic evaluation helped the diagnosis. In conclusion, in endemic regions like Turkey, atypical radiological presentation of complicated pulmonary hydatid disease should be considered in the differential diagnosis of solid pulmonary lesions.

The Dundee Stroke Register: experience of the first ten years

The objective to establish a register of all patients admitted to Dundee hospitals with acute stroke has been achieved. To do this a computerised database system has been established and a prospective survey has been conducted of clinical data of patients at time of admission, with follow-up at one and three years. All patients with a WHO diagnosis of acute stroke (excluding patients with subarachnoid haemorrhage), from January 1988 have been recorded. By the end of 1998, 3222 patients had been registered. The Dundee Stroke register database is the largest in Scotland and one of the largest in the world. The establishment of the register and database has required substantial investment of resources and the collaboration of the NHS, universities and the private sector. The operation of the register has heightened interest in stroke. It also provides present and future opportunities for clinical research and audit studies and the monitoring of outcomes.

CT brain scans after acute stroke: how far are we from meeting the Scottish intercollegiate guidelines network (SIGN) recommendations? Results from the year prior to guideline publication

OBJECTIVE

To determine what proportion of patients admitted to Ninewells Hospital & Medical School in 1996 with acute stroke underwent CT brain scans and in what time frame. To decide if the targets set by the SIGN guidelines can be met, and if not, the reasons for this.

DESIGN

Data from the Dundee Ninewells Stroke Register and the Computerised Radiology Information System were used to determine the timing of CT scanning in relation to stroke and admission. Notes were also reviewed to determine why CT scans had not been done in some patients.

SETTING

Departments of Medicine and Radiology, Ninewells Hospital & Medical School Dundee.

SUBJECTS

All patients admitted with acute stroke in the calendar year 1996.

RESULTS

Two hundred and eighty six patients presented with acute stroke in 1996. Of these patients, 250 patients (87%) had a CT brain scan. Eighty three (29%) underwent CT brain scanning within 48 hours of the acute event. A total of 163 (57%) were scanned within a week. Two hundred and thirty three (81%) were scanned within three weeks. Thirty six patients were not scanned after their acute event and the reasons recorded are reviewed.

CONCLUSIONS

Less than two-thirds of patients were scanned within the time interval of seven days recommended in the SIGN Guidelines for stroke management. Implementation of the current SIGN Guidelines will therefore, require reorganisation of the service to ensure that all patients receive scans within seven and preferably within two days and may have resource implication.

Cervical myositis ossificans traumatica: a rare location

An unusual case of myositis ossificans traumatica lesion located in the paraspinal region is reported. Despite the contiguity of the lesion with the cervical vertebrae and ominous appearance of the biopsy material, the history of antecedent trauma and computed tomography findings allowed preoperative accurate diagnosis. To our knowledge, myositis ossificans traumatica located in the cervical paraspinal region is very rare.