Screening for functional gastrointestinal disorders in preterm infants up to 12 months of corrected age: a prospective cohort study

Functional gastrointestinal disorders (FGIDs) are characterized by a variety of symptoms that are frequently age-dependent, chronic, or recurrent and are not explained by structural or biochemical abnormalities. There are studies in the literature reporting different results regarding the relationship between prematurity and FGIDs. The main objective of this study was to compare the frequency of FGIDs between preterm and term infants. The secondary objective was to evaluate whether there was any association between neonatal characteristics and development of FGIDs. A multicenter prospective cohort study that included preterm infants born before 37 weeks of gestation and healthy term infants was carried out. At 1, 2, 4, 6, 9, and 12 months of age, infants were assessed for the presence of FGIDs using the Rome IV criteria. In preterm infants, an additional follow-up visit was made at 12 months corrected age. 134 preterm and 104 term infants were enrolled in the study. Infantile colic, rumination syndrome, functional constipation, and infant dyschezia were more common in preterm infants. Incidence of other FGIDs (infant regurgitation, functional diarrhea and cyclic vomiting syndrome) were similar among preterm and term infants. Preterm infants who are exclusively breastfeed in the first 6 months of life have a lower incidence of infantile colic (18.8% vs 52.1%, p = 0.025). In terms of chronological age, FGIDs symptoms started later in preterm infants; this difference was statistically significant for infantile colic and regurgitation (median age 2 months vs 1 month, p < 0.001).   Conclusions: Preterm infants have a higher prevalence of FGIDs compared with term controls. Therefore, especially if they have gastrointestinal complaints, they should be screened for FGIDs. Possibly due to maturational differences, the time of occurrence of FGIDs may differ in preterm infants. Infantile colic incidence decreases with exclusive breastfeeding. What is Known: • The functional gastrointestinal disorders are a very common in infancy. • Data on preterm infants with FGIDs are currently very limited. What is New: • Preterm infants have a higher incidence of infantile colic, rumination syndrome, functional constipation and infant dyschezia when compared to term infants. • Preterm infants who are exclusively breastfed during the first 6 months of life experience a lower incidence of infantile colic.

Lung cancer from suspicion to treatment: An indicator of healthcare access in Turkey

BACKGROUND

Lung cancer is the leading cause of cancer-related deaths worldwide. Before beginning lung cancer treatment, it is necessary to complete procedures such as suspecting lung cancer, obtaining a pathologic diagnosis, and staging. This study aimed to investigate the processes from suspicion of lung cancer to diagnosis, staging, and treatment initiation.

METHODS

The study was designed as a multicenter and cross-sectional study. Patients with lung cancer from various health institutions located in all geographic regions of Turkey were included in the study. The sociodemographic and clinical characteristics of the patients, the characteristics of the health institutions and geographic regions, and other variables of the lung cancer process were recorded. The time from suspicion of lung cancer to pathologic diagnosis, radiologic staging, and treatment initiation, as well as influencing factors, were investigated.

RESULTS

The study included 1410 patients from 29 different medical centers. The mean time from the initial suspicion of lung cancer to the pathologic diagnosis was 48.0 ± 52.6 days, 39.0 ± 52.7 days for radiologic staging, and 74.9 ± 65.5 days for treatment initiation. The residential areas with the most suspected lung cancer cases were highly developed socioeconomic zones. Primary healthcare services accounted for only 0.4% of patients with suspected lung cancer. The time to pathologic diagnosis was longer in the Marmara region, and the wait time for staging and treatment initiation was longer in Eastern and Southeastern Anatolia. Patients who presented to chest disease referral hospitals with peripheral lesions, those with early-stage disease, and those who were diagnosed surgically had significantly longer wait times.

CONCLUSION

The time between pathologic diagnosis, staging, and treatment initiation in lung cancer was longer than expected. Increasing the role of primary healthcare services and distributing socioeconomic resources more equally will contribute to shortening the time to diagnosis and improve treatment processes for lung cancer.

Genetic Investigations in Turkish Idiopathic Pancreatitis Patients Show Unique Characteristics

BACKGROUND/AIMS

Pancreatitis is one of the leading causes of digestive system-related hospital admissions, and it has a genetic background in a considerable portion of the patients. In this study, we aimed to investigate the genetic risk factors of idiopathic pancreatitis in Turkish patients and the contribution of copy number variations to the pathogenesis.

MATERIALS AND METHODS

Idiopathic pancreatitis is defined as failure to detect risk factors despite comprehensive clinical assessments. Next-generation sequencing and multiple ligand-dependent probe amplification of PRSS1, SPINK1, CTRC, and CFTR were performed. For further genotype-phenotype correlations, patients were also questioned for the age of onset, family history, and pancreatic divisum.

RESULTS

A total of 68 idiopathic pancreatitis cases were enrolled. Variants with potential clinical significance of PRSS1 were identified in 13.4%, SPINK1 in 6.3%, CTRC in 4.7%, and CFTR in 26.5% of the patients. No copy number variants were seen in any of these genes. At least 7.4% of the participants had complex genetic etiology involving 2 genes.

CONCLUSIONS

At least 42.6% of the participants had a potential genetic risk factor. Five novel genetic variants were identified, and distinctive genetic risk factors of Turkish population were shown. The results showed that genetic etiology was frequent in pancreatitis and it was even more prominent in patients with early-onset disease. Considering that genetic risk factors may be informative for decisionmaking in the treatment options in addition to providing extensive prognostic value and familial genetic consultation; clinicians need to be more eager to offer genetic tests to pancreatitis patients.

Evaluation of Patients with COVID-19 Followed Up in Intensive Care Units in the Second Year of the Pandemic: A Multicenter Point Prevalence Study

OBJECTIVE

A 1-day point prevalence study was planned to obtain country data by determining the clinical characteristics, follow-up and treatment methods of coronavirus disease 2019 (COVID-19) cases that required intensive care unit (ICU) treatment in the second year of the pandemic.

MATERIAL AND METHODS

All patients who were hospitalized in the ICUs due to COVID-19 between March 11, 2022, 08.00 am, and March 12, 2022, 08.00 am, were included in the study. Demographic characteristics, intensive care and laboratory data, radiological characteristics, and follow-up results of the patients were recorded.

RESULTS

A total of 811 patients from 59 centers were included in the study, 59% of the cases were male, and the mean age was 74 ± 14 years. At least one comorbid disease was present in 94% of the cases, and hypertension was the most common. When ICU weight scores were examined, Acute Physiology and Chronic Health Evaluation-II: 19 (15-27) and Sequential Organ Failure Assessment: 7 (4-10) were seen. Sepsis was present in 37% (n = 298) of cases. PaO2/FiO2 ratios of the patients were 190 the highest and 150 the lowest and 51% of the cases were followed via invasive mechanical ventilation. On the study day, 73% bilateral involvement was seen on chest x-ray, and ground-glass opacities (52%) were the most common on chest tomography. There was growth in culture in 40% (n = 318) of the cases, and the most common growth was in the tracheal aspirate (42%).

CONCLUSION

The clinical course of COVID-19 is variable, and ICU follow-up was required due to advanced age, comorbidity, presence of respiratory symptoms, and widespread radiological involvement. The need for respiratory support and the presence of secondary infection are important issues to be considered in the follow-up. Despite the end of the second year of the pandemic and vaccination, the high severity of the disease as well as the need for follow-up in ICUs has shown that COVID-19 is an important health problem.

Assessment of the clinical features of rheumatoid arthritis-related interstitial lung diseases: a retrospective evaluation

OBJECTIVE

Rheumatoid Arthritis (RA) stands as the most prevalent form of inflammatory arthritis, affecting approximately 1% of the population. Among individuals diagnosed with RA, a notable proportion, ranging from 10% to 40%, also experience Rheumatoid Arthritis-Associated Interstitial Lung Disease (RA-ILD). This coexistence of RA and ILD has been identified as a detrimental factor contributing to increased mortality rates. Furthermore, RA-ILD often exhibits an insidious nature, posing challenges in its timely detection and management. Hence, our objective was to conduct a retrospective analysis of the clinical characteristics observed in patients who underwent evaluation for RA-ILD.

PATIENTS AND METHODS

A total of 87 patients who were evaluated for RA-ILD within one year were included in the study. This study was conducted retrospectively using a cross-sectional and descriptive approach to analyze the demographic and clinical data of the included patients.

RESULTS

Among the 87 patients, eight were diagnosed with RA-ILD, with four being male and four being female. Of the eight patients, two had non-specific interstitial pneumonia, five had usual interstitial pneumonia, and one had nodules consistent with RA. Subpleural fibrosis increased the likelihood of RA-ILD by 6.9 times. In the group with ILD, the residual volume and total capacity were found to be lower compared to the other group. Among the eight patients diagnosed with RA-ILD, five had used methotrexate before the diagnosis.

CONCLUSIONS

In order to mitigate the risk of delayed diagnosis of RA-ILD, which can lead to increased mortality and has a subtle onset, it is recommended that patients with RA who possess certain risk factors undergo regular monitoring. It is advisable for RA patients to undergo annual assessments involving carbon monoxide diffusion capacity and spirometry function tests. In cases, where deemed necessary, more advanced investigations such as high-resolution computed tomography should be conducted.

HMGB1 is related to disease activity in children with celiac disease

INTRODUCTION

We aim to evaluate of the relationship between high mobility gene box-1 (HMGB1) levels and clinical, laboratory and histopathological findings at diagnosis and in remission in children with Celiac Disease (CD).

MATERIAL AND METHODS

The study included 36 celiac patients at diagnosis, 36 celiac patients in remission, and 36 healthy controls. Patients with intestinal pathologies other than CD, and accompanying inflammatory and/or autoimmune diseases were excluded. Relationship between HMGB1 levels and clinical, laboratory and histopathological findings were evaluated.

RESULTS

A total of 72 celiac patients [36 (18 girls, 18 boys, mean age 9.41±3.9 years) in group 1 and 36 (18 girls, 18 boys, mean age 9.91±3.36 years) in group 2] and 36 healthy controls in group 3 (19 girls, 17 boys, mean age 9.56±4 years) were included. The HMGB1 level was significantly higher in group 1 compared to group 2 and group 3 [36.63 (17.98-54.72) ng/ml vs 20.31 (16.89-29.79) ng/ml, p = 0.028 and 36.63 (17.98-54.72) ng/ml vs 20.38 (17.54-24.53) ng/ml p = 0.012, respectively]. A serum HMGB-1 level of 26.553 ng/ml was found to be a cut-off value for the CD with 61% sensitivity, 83% specificity, 78% positive predictive value, and 68% negative predictive value. Higher HMGB1 values were seen in patients with intestinal findings, anemia, anti-tissue transglutaminase IgA levels that were greater than 10 times upper limit of normal, and patients with a higher degree of atrophy as classified by Marsh-Oberhuber.

CONCLUSIONS

In conclusion, it was thought that HMGB-1 might be a marker that reflects the severity of atrophy at the time of diagnosis and could be used to control dietary compliance in the follow-up. However, there is need for larger population studies in order to evaluate its value as a serological marker for the diagnosis and follow-up of CD and to find a more reliable cut-off value.

Characteristics of our hypoxemic COVID-19 pneumonia patients receiving corticosteroids and mortality-associated factors

BACKGROUND

COVID-19 is a disease associated with diffuse lung injury that has no proven effective treatment yet. It is thought that glucocorticoids may reduce inflammation-mediated lung injury, disease progression, and mortality. We aimed to evaluate our patient's characteristics and treatment outcomes who received corticosteroids for COVID-19 pneumonia.

METHODS

We conducted a multicenter retrospective study and reviewed 517 patients admitted due to COVID-19 pneumonia who were hypoxemic and administered steroids regarding demographic, laboratory, and radiological characteristics, treatment response, and mortality-associated factors.

RESULTS

Of our 517 patients with COVID-19 pneumonia who were hypoxemic and received corticosteroids, the mortality rate was 24.4% (n = 126). The evaluation of mortality-associated factors revealed that age, comorbidities, a CURB-65 score of ≥ 2, higher SOFA scores, presence of MAS, high doses of steroids, type of steroids, COVID-19 treatment, stay in the intensive care unit, high levels of d-dimer, CRP, ferritin, and troponin, and renal dysfunction were associated with mortality.

CONCLUSION

Due to high starting and average steroid doses are more associated with mortality, high-dose steroid administration should be avoided. We believe that knowing the factors associated with mortality in these cases is essential for close follow-up. The use of CURB-65 and SOFA scores can predict prognosis in COVID-19 pneumonia.

Secondary bacterial infections in patients with coronavirus disease 2019-associated pneumonia

OBJECTIVE

The vast majority of patients who hospitalized with coronavirus disease 2019 are given empirical antibiotic therapy. However, information on the frequency, microorganism species, and resistance rates of secondary bacterial infections in coronavirus disease 2019 patients are insufficient. We aimed to show the frequency of secondary infections and resistance conditions in patients with coronavirus disease 2019 hospitalized in the intensive care unit.

METHODS

The results of tracheal aspirate culture, blood culture, and urine culture obtained from coronavirus disease 2019 patients - at least 2 days after their admission to the intensive care unit - were examined microbiologically.

RESULTS

A total of 514 patients hospitalized in intensive care unit were included in our study. Tracheal aspirate, blood, or urine cultures were collected from 369 patients (71.8%). Bacterial reproduction was detected in at least one sample in 171 (33.3%) of all patients. The rate of respiratory tract infection and/or bloodstream infection was found to be 21%. Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa in tracheal aspirate culture; Coagulase-negative staphylococci, K. pneumoniae, and A. baumannii in blood culture; and Escherichia coli, K. pneumoniae, and Enterococcus faecalis in urine culture were the most common microorganisms. A. baumannii was resistant to most antibiotics except colistin and P. aeruginosa strains were resistant to most antibiotics except amikacin, colistin, cefepime, and imipenem. In K. pneumoniae, the highest meropenem sensitivity (73%) was observed; there was a strong resistance to most of the remaining antibiotics.

CONCLUSIONS

We think that our study can be useful in choosing empirical antibiotic therapy in the coronavirus disease 2019 pandemic and reducing the mortality that may occur with secondary infection.

Investigation of In-vitro Efficacy of Intravenous Fosfomycin in Extensively Drug-Resistant Klebsiella pneumoniae Isolates and Effect of Glucose 6-Phosphate on Sensitivity Results

BACKGROUND

The aim of this study was to determine the in vitro efficacy of intravenous (IV) fosfomycin against extensively drug-resistant Enterobacterales strains and the effect of glucose 6-phosphate (G6-P) on sensitivity results.

MATERIAL METHOD

Thirty-two extensively drug-resistant Klebsiella pneumonia strains were included in the study. Detection of the carbapenemase genes was performed using the Gene-Xpert® System Carba R® kit. Susceptibility of IV fosfomycin was assessed using the agar dilution method. The agar dilution method was repeated using Muller-Hinton Agar medium without G6-P to assess the effect of G6-P on sensitivity results.

RESULTS

All strains in the study produced carbapenemases and were resistant to all drugs tested, including carbapenems, piperacillin-tazobactam, ceftriaxone, and ceftazidime. Fosfomycin resistance was detected in 3 (9.3%) strains. When the sensitivity test was repeated without G6-P, fosfomycin resistance was detected in 82.7% of the fosfomycin-susceptible strains. The Gene-Xpert® System showed NDM-1 in 46.8%, OXA-48 in 18.7%, KPC in 3.1%, and NDM-1 + OXA-48 in 21.8% of the strains. OXA-48 was detected in one of the resistant strains, and none of the viable genes were detected in two of the resistant strains.

CONCLUSION

This study shows that IV fosfomycin is a potentially important treatment alternative for infections caused by common resistant strains. Accurate results may not be obtained unless G6-P is used in the agar dilution method for in vitro susceptibility studies of fosfomycin.

Assessment of swallowing function in pediatric patients with Wilson's disease: Results of a videofluoroscopic swallowing study

BACKGROUND AND STUDY AIMS

Wilson's disease (WD) is a complex disorder related to copper metabolism and neurological involvement may lead to swallowing disorders. The purpose of this study was to evaluate swallowing function in pediatric patients with WD by using videofluoroscopic swallowing study (VFSS).

PATIENTS AND METHODS

A total of 21 patients were included in the study, prospectively. The VFSS was conducted to evaluate swallowing function of the patients. The penetration-aspiration scale (PAS) was used to assess penetration-aspiration severity.

RESULTS

According to the VFSS, abnormal results were detected in nine patients (42.9%) with WD. Of these nine patients, oral phase dysfunction was present in one patient, laryngeal penetration was present in one patient and moreover, abnormal esophageal body function was detected in all nine patients. Of these nine patients, five had neurological presentation at the time of diagnosis, and remaining four patients had hepatic presentation. Mean PAS score of the patients was 1.

CONCLUSION

The current study results suggest that subclinical swallowing dysfunction may be observed in patients with either neurological or hepatic WD. Further studies are necessary to reveal the real incidence of esophageal phase problems of swallowing function in pediatric patients with WD.

Evaluation of coagulation parameters: Coronavirus disease 2019 (COVID-19) between survivors and nonsurvivors

OBJECTIVE

This study aims to investigate and compare the coagulation parameters of coronavirus disease 2019 (COVID-19) patients with mortal and nonmortal conditions.

METHODS

In this study, 511 patients diagnosed with COVID-19 were included. Information about 31 deceased and 480 recovered COVID-19 patients was obtained from the hospital information management system and analyzed retrospectively. Whether there was a correlation between coagulation parameters between the mortal and nonmortal patients was analyzed. Descriptive analyses on general characteristics of the study population were performed. Visual (probability plots and histograms) and analytical methods (Kolmogorov-Smirnov and Shapiro-Wilk test) were used to test the normal distribution. Analyses were performed using the SPSS statistical software package.

RESULTS

Out of 511 patients, 219 (42.9%) were females and 292 (57.1%) were males. There was no statistically significant difference between males and females in terms of mortality (p=0.521). In total, the median age was 67 (22). The median age was 74 (13) in the nonsurvivor group and 67 (22) in the survivor group, and the difference was statistically significant (p=0.007). The D-dimer, prothrombin time, international normalized ratio, neutrophil, and lymphocyte median age values with p-values, in the recovered and deceased patient groups were: 1070 (2129), 1990 (7513) μg FEU/L, p=0.005; 12.6 (2.10), 13.3 (2.1), p=0.014; 1.17 (0.21), 1.22 (0.19), p=0.028; 5.51 (6.15), 8.54 (7.05), p=0.001; and 0.99 (0.96), 0.64 (0.84), p=0.037, respectively, with statistically significant differences.

CONCLUSIONS

As a result of this study, D-dimer, prothrombin time, and international normalized ratio increase were found to be associated with mortality. These parameters need to be closely monitored during the patient follow-up.

Vitamin D deficiency negatively affects both the intestinal epithelial integrity and bone metabolism in children with Celiac disease

BACKGROUND AND AIM

We aim to evaluate serum vitamin D levels, vitamin D receptor (VDR) expression in the intestinal epithelium, and their relation with epithelial barrier proteins and bone metabolism in children with Celiac disease (CD).

METHODS

Immunostaining for VDR, Claudin-2 and E-cadherin was performed in duodenal samples of the patients with CD and controls. H-score [∑Pi(I+1)] where I is the intensity score and Pi is the corresponding percentage of stained cells was calculated for each samples. The clinic, laboratory and histopathological findings were compared between patients and controls.

RESULTS

Thirty-six patients with CD and age and sex matched 36 controls were enrolled. 25-OH vitamin D levels were significantly lower in the patient group compared to the control group. The mean bone mineral density (BMD) value was significantly lower in patients with vitamin D deficiency compared to patients with normal vitamin D level. H-scores for both VDR and Claudin-2 were significantly lower in patient group when compared to the control group. H-scores for VDR, Claudin-2 and E-cadherin were significantly lower in patients with vitamin D deficiency compared to patients with normal vitamin D level. There were positive correlations between 25-OH vitamin D level and H-scores for VDR, E-cadherin and Claudin-2 in patient group.

CONCLUSIONS

Our findings showed that vitamin D deficiency is common among children with CD. Expression of VDR and epithelial barrier proteins Claudin-2 and E-cadherin which have important roles in paracellular pathway, was decreased in children with CD in correlation with histological findings of disease severity. Furthermore, deficiency of vitamin D was related to decreased expression of VDR and epithelial barrier proteins E-cadherin and Claudin-2. These findings indicate that paracellular pathway structures responsible for calcium absorption are disturbed in CD which is aggravated by vitamin D deficiency.

The relationship of extent of initial radiological involvement with the need of intensive care, mortality rates, and laboratory parameters in Covid-19

Background/aim

It is very important for the efficient use of limited capacity and the success of treatment to predict patients who may need ICU with high mortality rate in the Covid-19 outbreak. In our study, it was aimed to investigate the value of the radiological involvement on initial CT in demonstrating the ICU transfer and mortality rate of patients.

Materials and methods

All PCR-positive patients were included in the study, whose CT, PCR, and laboratory values were obtained simultaneously at the time of first admission. Patients were divided into 4 groups in terms of the extent of radiological lesions. These groups were compared in terms of intensive care transfer needs and Covid-related mortality rates.

Results

A total of 477 patients were included in the study. Ninety of them were group 0 (no lung involvement), 162 were group 1 (mild lesion), 89 were group 2 (moderate lesion), and 136 were group 3 (severe lung involvement). A significant relationship was found between the extensiveness of the radiological lesion on CT and admission to intensive care and mortality rate. As the initial radiological involvement amounts increased, the rate of ICU transfer and mortality increased. The mortality rates of the groups were 0%, 3%, 12.3%, and 12.5%, respectively, and the difference was significant (p < 0.001). Similarly, the ICU transfer rates of the groups were 2.2%, 5.6%, 13.5%, and 17.7%, respectively, and the difference was significant (p < 0.001).

Conclusion

In conclusion, in our study, the strong relationship between the initial radiological extent assessment and the need for intensive care and mortality rates has been demonstrated, and we believe that our results will make a significant contribution to increase the success of the health system in predicting patients who may progress, helping clinicians and managing pandemics.

[Mortality prediction ability of phycians in intensive care units of Turkey (MOPAP)]

Introduction

Intensive care physicians are increasingly involved in decision making about the prognosis of intensive care unit ICU patients. With this study; we aimed to evaluate the power of clinician foresight at prediction of mortality in patient at triage to intensive care and patient follow-up.

Materials and Methods

This study was conducted in ICUs located in various geographical regions of Turkey between January 1, 2017-April 30, 2017.The clinical research was planned as observational, multicenter, cross-sectional.

Result

A total of 1169 intubated patients were followed in 37 different ICU. At the beginning of the follow-up we asked the physician who will follow the patient in the ICU to give a score for the probability of survival of the patients. Scoring included a total of 6 scores from 0 to 5, with the "0" the worst probability "5" being the best. According to this distribution, only 1 (0.9%) of 113 patients who were given 0 points survived. Three (6.1%) of 49 with the best score of 5 died. Survival rates were significantly different in each score group (r: -0.488; p<0.001). After the combined mortality estimation scores based on the clinical observations of the physicians (0 and 1 point score was combined as non-survive, 4 and 5 score was combined as survived) 320 of the 545 patients were estimated to be dead and 225 were predicted survival. Sensitivity and spesifity of scoring system to predict mortality was 91.56% (95% CI: 87.96-94.37), 76.89% (95% CI: 70.82-82.23) respectively.

Conclusions

In this study, we concluded that the physicians who follow the patients in the ICU can predict the poor prognosis at the time of admission and the high mortality rate. The physician's opinion on mortality estimation should be considered in intensive care mortality scoring in addition to other laboratory and clinical parameters.

The effect of video presentation showed in the outpatient clinic waiting area on the success of inhaler device use in chronic respiratory diseases

BACKGROUND/AIM

Nonadherence to inhalation therapy and incorrect inhalation technique is an important problem for optimal disease management in patients with chronic respiratory disease. The aim of the study is to investigate the effectiveness of an inexpensive and effortless method which would be able to improve the inhalation technique of patients.

MATERIALS AND METHODS

The video showing the correct use of inhaler devices was played continuously for 3 months in the waiting room of the chest diseases polyclinic, on the big screen TV. The patients, who were not prompted to watch the video, were divided into two groups, as those who visited the outpatient clinic before (n = 300, Group 1) and after (n = 300, Group 2) the video playback began. Patients' ability to use their own inhaler devices was observed without intervention, scored according to the standard 'Ability of Inhaler Device Use' scale and the two groups were compared.

RESULTS

The inhaler use skill of the patients in the second group was significantly higher except for the Turbuhaler. In Group 2, among the "video watchers" subgroup, there was significant improvement in all device types.

CONCLUSION

Presentation of the use of inhaler devices on the screens in the waiting area of the outpatient clinics of health facilities will provide significant benefits and allow reducing the failure of treatment due to incorrect/incomplete device usage.

Enhanced Collagen Deposition in the Duodenum of Patients with Hyaline Fibromatosis Syndrome and Protein Losing Enteropathy

Hyaline fibromatosis syndrome (HFS), resulting from ANTXR2 mutations, is an ultra-rare disease that causes intestinal lymphangiectasia and protein-losing enteropathy (PLE). The mechanisms leading to the gastrointestinal phenotype in these patients are not well defined. We present two patients with congenital diarrhea, severe PLE and unique clinical features resulting from deleterious ANTXR2 mutations. Intestinal organoids were generated from one of the patients, along with CRISPR-Cas9 ANTXR2 knockout, and compared with organoids from two healthy controls. The ANTXR2-deficient organoids displayed normal growth and polarity, compared to controls. Using an anthrax-toxin assay we showed that the c.155C>T mutation causes loss-of-function of ANTXR2 protein. An intrinsic defect of monolayer formation in patient-derived or ANTXR2KO organoids was not apparent, suggesting normal epithelial function. However, electron microscopy and second harmonic generation imaging showed abnormal collagen deposition in duodenal samples of these patients. Specifically, collagen VI, which is known to bind ANTXR2, was highly expressed in the duodenum of these patients. In conclusion, despite resistance to anthrax-toxin, epithelial cell function, and specifically monolayer formation, is intact in patients with HFS. Nevertheless, loss of ANTXR2-mediated signaling leads to collagen VI accumulation in the duodenum and abnormal extracellular matrix composition, which likely plays a role in development of PLE.

As a Novel Procalcitonin Assay is Architect B∙R∙A∙H∙M∙S PCT; Comparison of Two Commercial Systems

BACKGROUND

Procalcitonin (PCT) is the precursor structure of the calcitonin hormone with 116 amino acids. The measurement of serum procalcitonin is currently being safely used in community-acquired pneumonia, bacterial peritonitis and sepsis in the diagnosis, decision on the initiation of treatment, and follow-up of the response to treatment. In this study, it is aimed to compare PCT results obtained by the VIDAS PCT that makes measurements by the enzyme-dependent fluorescence (ELFA) method and Architect PCT method, a chemiluminescent microparticle immunoassay (CMIA) that has just been put into use, both of which are B∙R∙A∙H∙M∙S licensed and have method differences.

METHODS

Serum samples of 109 patients from different clinics with a PCT request were included in the study. The sera were divided into two groups and the samples were immediately studied with two methods. Cohen's Kappa (κ) coefficient was used to determine concordance between the two methods. Other parameters were analyzed by the paired t-test, and their concordance was evaluated.

RESULTS

In the concordance analysis study carried out by considering the significant cutoff value of 0.5 ng/mL in the clinical diagnosis of bacterial infections, the κ value was found to be 0.930, p < 0.001. Concordance was at an excellent level. Upon pairing and analyzing all the results regardless of the cutoff value, the Concordance Coefficient was found to be 0.958 (p < 0.001). It was observed that concordance was at an excellent level.

CONCLUSIONS

Upon comparing the patient results obtained as a result of the study, it was observed that the concordance of the methods with each other was excellent. Larger and more comprehensive studies on this issue will be helpful.

Diaphragmatic thickness in chronic obstructive lung disease and relationship with clinical severity parameters

Background/aim

Sonographic assessment of diaphragm structure and function would be a useful clinical tool in patients with chronic obstructive pulmonary disease (COPD). Our aim was to determine the muscle thickness of the diaphragm and the usefulness of clinical practice in patients with COPD.

Materials and methods

The diaphragmatic thickness of 34 COPD patients and 34 healthy subjects was measured during tidal volume (Tmin) and deep inspiration (Tmax) on both sides using a B-mode ultrasound. The body mass index and the modified Medical Research Council (mMRC) index values were reported.

Results

There was no correlation among TminR (P = 0.134), TminL (P = 0.647), TmaxR (P = 0.721), and TmaxL (P = 0.905) between the patients with COPD and the control group. There was also no significant difference between diaphragmatic thickness and COPD severity, respiratory function (P = 0.410), and frequency of exacerbations (P = 0.881) and mMRC (P = 0.667).

Conclusion

Diaphragmatic dysfunction in COPD is related to mobility restriction rather than muscle thickness.

Comparison of oxidant/antioxidant balance in COPD and non-COPD smokers

BACKGROUND/AIM

Oxidative stress plays an important role in the pathogenesis of chronic obstructive pulmonary disease (COPD). Smoking is the leading source of oxidants in lungs. However, it is currently unknown why some individuals are more resistant to the detrimental effects of smoking and do not develop COPD. The aim in this study is to measure and compare the oxidant/antioxidant balance between in non-COPD individuals who smoke and COPD patients who smoke.

MATERIALS AND METHODS

Included in the study were 137 patients with COPD and 102 healthy individuals. Participants were divided into groups as COPD patients (former and current smokers), non-COPD individuals who smoke and non-smokers healthy persons. In the following stage, the total antioxidant status (TAS), total oxidant status (TOS) and oxidative stress index (OSI) levels were measured in serum for all participants.

RESULTS

In the current-smoker COPD group, the level of oxidant status were significantly higher than the former-smoker COPD group (p < 0.001). Similarly, oxidant levels were significantly high in current-smoker healthy group than never smoker healthy group. According to these results TOS was associated with especially smoking status rather than COPD. Antioxidant status were similar between former-smoker COPD group and current-smoker COPD group. The antioxidant levels were found significantly low in current-smoker COPD patients, compared to the current-smoker non-COPD individuals (p = 0.007). Nevertheless, no significant difference was found in OSI levels between two groups. Briefly, high TOS and OSI values were correlated with only smoking, independently from COPD.

CONCLUSION

It was concluded that there are complex pathogenetic mechanisms, including genetic and individual variations other than oxidant/antioxidant balance, involved in the development of smoking-related COPD. TOS and OSI values are not predictive parameters for the development of COPD, but high level of TAS in non-COPD smokers is promising for future studies.

Clinical and histopathological features of immunoglobulin G4-associated autoimmune hepatitis in children

BACKGROUND AND AIM

We aimed to examine the frequency and the characteristics of immunoglobulin G4 (IgG4)-associated autoimmune hepatitis among pediatric patients with autoimmune hepatitis.

METHODS

Immunostaining for IgG and IgG4 was performed in liver biopsies of 40 pediatric patients with autoimmune hepatitis. The patients with more than 10 IgG4-positive plasma cells/high-power field were defined as IgG4-associated autoimmune hepatitis. Clinic, laboratory, and histopathological results were compared between groups.

RESULTS

Among the 40 pediatric patients, 34 patients were type 1 and 6 patients were type 2 autoimmune hepatitis. Six patients (15%), four of the type 1 and two of the type 2 autoimmune hepatitis patients, were diagnosed with IgG4-associated autoimmune hepatitis. Clinical, laboratory, and histopathological data were initially similar in both forms. There was a positive correlation between IgG4-positive plasma cell count and degree of portal (r: 0.406, P: 0.009) and lobular inflammation (r: 0.37, P: 0.019), grade of interface hepatitis (r: 0.33, P: 0.03), and fibrosis (r: 0.318, P: 0.046). Time required for normalization of liver transaminases and serum IgG level was significantly shorter in IgG4-associated autoimmune hepatitis (3.3 ± 0.5 vs 6.6 ± 3.5 for alanine aminotransferase, 3.7 ± 0.8 vs 6.7 ± 1.2 for aspartate aminotransferase, 4.3 ± 1.2 vs 7.1 ± 2.7 for gamma-glutamyl transpeptidase, and 7.2 ± 3.1 vs 12.8 ± 4.5 for IgG).

CONCLUSIONS

Immunoglobulin G4-associated autoimmune hepatitis can be found in pediatric age group and also in type 2 autoimmune hepatitis patients. As steroid response may be better in IgG4-associated autoimmune hepatitis, biopsy specimens should be evaluated for this entity at diagnosis.

Factors affecting TST level in patients undergoing dialysis: a multicenter study

INTRODUCTION

The risk of TB is increased in patients with chronic kidney disease (CKD) when compared with individuals with normal renal function. We aimed to determine tuberculin skin test (TST) response and the factors which might affect the response in patients with CKD undergoing dialysis in this study.

METHODS

The purified protein derivative solution was administered to the patients and the diameter of induration was measured. Additionally, the age, gender and smoking status of the patients were interrogated. Comorbidities were recorded both by patients' self-reports and data from the hospital files. The number of Bacille Calmette-Guerin (BCG) scars was recorded by checking both shoulders.

FINDINGS

The study was conducted with a total of 371 patients (194 men and 177 women). The mean age was 60.09 ± 15.88, TST was 6.99 ± 6.9, duration of dialysis was 4.44 ± 4.5 (3.8-0.1,24). A total of 229 patients have comorbodities (61.7%, the most frequent was hypertension). Logistic regression model was performed. Gender, vitamin D treatment and high parathormone (PTH) levels remained in the final stage of the analysis and vitamin D intake and PTH levels were detected to be statistically significant (P = 0.002, 0.007, respectively).

DISCUSSION

This study is the first study which showed a correlation between TST negativity and increased PTH levels and receiving vitamin D treatment. Starting from this point, it was concluded that PTH may suppress the immune system and especially cellular immunity.

Current Statement of Intensive Care Units in Turkey: Data obtained from 67 Centers

OBJECTIVES

We aimed to obtain information about the characteristics of the ICUs in our country via a point prevalence study.

MATERIAL AND METHODS

This cross-sectional study was planned by the Respiratory Failure and Intensive Care Assembly of Turkish Thoracic Society. A questionnaire was prepared and invitations were sent from the association's communication channels to reach the whole country. Data were collected through all participating intensivists between the October 26, 2016 at 08:00 and October 27, 2016 at 08:00.

RESULTS

Data were collected from the 67 centers. Overall, 76.1% of the ICUs were managed with a closed system. In total, 35.8% (n=24) of ICUs were levels of care (LOC) 2 and 64.2% (n=43) were LOC 3. The median total numbers of ICU beds, LOC 2, and LOC 3 beds were 12 (8-23), 14 (10-25), and 12 (8-20), respectively. The median number of ventilators was 12 (7-21) and that of ventilators with non-invasive ventilation mode was 11 (6-20). The median numbers of patients per physician during day and night were 3.9 (2.3-8) and 13 (9-23), respectively. The median number of patients per nurse was 2.5 (2-3.1); 88.1% of the nurses were certified by national certification corporation.

CONCLUSION

In terms of the number of staff, there is a need for specialist physicians, especially during the night and nurses in our country. It was thought that the number of ICU-certified nurses was comparatively sufficient, yet the target was supposed to be 100% for this rate.

Evaluation of central and peripheral neuropathy in patients with chronic obstructive pulmonary disease

Background

The aim of the study was to investigate the frequency and characteristics of peripheral nervous system (PNS) and central nervous system (CNS) involvement in COPD.

Methods

The study included 41 COPD patients and 41 healthy volunteers. Electrophysiological studies were carried out: electromyography (EMG) and visual evoked potentials (VEPs). The median nerve, ulnar nerve, common peroneal nerve, and tibial nerve were evaluated for latency, amplitude, and conduction velocity.

Results

The mean age of patients with COPD was 61.8 years and disease duration 10.3 years. There was no difference between patient and control groups in terms of age, BMI, smoking status, or biochemical parameters. Upon VEP examination, latencies were significantly prolonged and amplitudes shortened in the patient group compared to the control group. In EMG measurements, conduction velocity and amplitudes in all nerves were low in the patient group. Similarly, latencies in all nerves were higher in patients with COPD.

Conclusion

Central and peripheral nervous system involvement could develop in patients with moderate-severe COPD, and these patients should be monitored for neuropathic changes in combination with neurological examination.

Polyposis deserves a perfect physical examination for final diagnosis: Bannayan-Riley-Ruvalcaba syndrome

Hızarcıoğlu-Gülşen H, Kılıç E, Dominguez-Garrido E, Aydemir Y, Utine GE, Saltık-Temizel İN. Polyposis deserves a perfect physical examination for final diagnosis: Bannayan-Riley-Ruvalcaba syndrome. Turk J Pediatr 2017; 59: 80-83. Bannayan-Riley-Ruvalcaba syndrome (BRRS) is a rare autosomal dominant inherited polyposis syndrome characterized by macrocephaly, lipomatosis, hemangiomatosis, intestinal polyposis and pigmented macules on penis. The mutation of the PTEN gene that is responsible for controlling cellular proliferation, migration and apoptosis clarifies the reason of tissue overgrowth in BRRS. Gastrointestinal tract involvement is seen 35-45% of the patients. Histologic features of polyps in BRRS resemble juvenile polyps. In this report, we describe a boy presenting with hematochezia and aggressive polyposis and finally was diagnosed as BRRS due to extra intestinal findings.

The relationship between restless legs syndrome and bronchial asthma

INTRODUCTION

Restless legs syndrome (RLS) is associated with sleep disorders. However, although sleep disturbance is prevalent in people with asthma, an insufficient number of studies have investigated the relationship between asthma and RLS.

OBJECTIVES

We aimed to determine the extent of the presence of RLS, and the factors related to RLS, in people with asthma.

METHODS

A total of 84 people with asthma and 51 healthy volunteers were enrolled. The diagnosis of RLS was made according to the criteria determined by the International Restless Legs Syndrome Study Group, and the Beck Depression and Beck Anxiety scales were used to assess both groups. The Asthma Control Test™(ACT) was carried out to determine asthma control status.

RESULTS

RLS was detected in 27 (32.1%) of the asthma group and in 8 (15.7%) of the control group. The frequency of RLS was significantly higher in the asthma group than in the control group (P = .034). Although no significant relationship was observed between the presence of RLS and the use of an inhaled steroid, use of a β2 agonist and age; a significant relationship was found between the presence of RLS and, ACT score, symptoms of depression and anxiety and gender (P < .05).

CONCLUSIONS

RLS was more frequent in people with asthma than in healthy individuals, and as asthma control decreased, frequency of RLS increased. It was concluded that it would be useful to evaluate people with asthma, particularly those with symptoms of depression and anxiety, with regard to RLS in order to address, and ultimately improve, their quality of life.

The effects of depression, anxiety and sleep disturbances on cognitive impairment in patients with chronic obstructive pulmonary disease

The purpose of this study was to investigate the effects of depression, anxiety and sleep disturbances on cognitive functions in chronic obstructive pulmonary disease (COPD) patients. In this prospective case-control study, demographic data, smoking history, depression, anxiety, sleep quality and cognitive status of 48 COPD patients and 36 healthy volunteers aged 40-90 years were recorded. The Beck depression inventory (BDI), the Beck anxiety inventory (BAI), and Pittsburgh Sleep Quality Index (PSQI) were used to assess depression, anxiety and sleep quality, respectively in COPD patients. Cognitive performance was studied by the mini-mental state examination. The mean age of patients with COPD was 65.3 ± 9.4 years, and disease duration was 9.6 ± 7.8 years. Male sex ratio, smoking, BDI score, BAI score, total PSQI score, sleep latency, sleep duration, average use of sleep aids and sleep disturbances in patients with COPD were significantly higher than the control group (p < 0.05). When cognitive impairment was compared by age, FVC, FEV, FEV/FVC, PEF values and smoking, no statistically significant relationship was found (p > 0.05). A statistically significant relationship was established between cognitive impairment and severity of disease, presence of anxiety, presence of depression and sleep quality. In our study, we found that sleep disorders, depression and anxiety comorbid with COPD increased cognitive impairment as well as the severity of disease. We believe that this finding is important in terms of reducing the risk of cognitive impairment, preventing misdiagnosis and treatment of the aforementioned comorbid diseases.

Effects of aspiration pneumonia on the intensive care requirements and in-hospital mortality of hospitalised patients with acute cerebrovascular disease

INTRODUCTION

In this study, we aimed to evaluate the effects of the development of aspiration pneumonia (AP) on the intensive care unit (ICU) requirements and in-hospital mortality of patients hospitalised in the neurology ward due to an acute cerebrovascular accident (CVA).

MATERIAL AND METHODS

Five hundred and three patients hospitalised in the neurology ward following an acute CVA were retrospectively analysed. The patients were divided into two groups: those with AP (group 1) and those without AP (group 2). Demographic characteristics and physical and radiological findings, including the localisation, lateralisation and aetiology of the infarction, in addition to ICU requirements and mortality, were evaluated.

RESULTS

Aspiration pneumonia was detected in 80 (15.9%) patients during the in-hospital stay. Transfer to the ICU for any reason was required in 37.5% of the patients in group 1 and 4.7% of those in group 2 (p < 0.001). In-hospital mortality occurred in 7.5% and 1.4% of the patients in group 1 and group 2, respectively (p = 0.006). The incidence of AP was highest in patients with an infarction of the medial cerebral artery (MCA) (p < 0.001). The AP was associated with older age (p < 0.001), hypertension (p = 0.007), echocardiography findings (p = 0.032) and the modified Rankin Scale (mRS) score (p < 0.001).

CONCLUSIONS

Our findings suggest that the requirement rate for transfer to the ICU and the mortality rate appear to be significantly higher in patients with a diagnosis of AP. Precautions should be taken, starting from the first day of hospitalisation, to decrease the incidence of AP in patients with acute CVA, focusing especially on older patients and those with a severe mRS score.

Evaluation of central nervous system in patients with glycogen storage disease type 1a

We aimed to evaluate structure and functions of central nervous system (CNS) in children with glycogen storage disease (GSD) type 1a. Neurological examination, psychometric tests, electroencephalography (EEG), magnetic resonance imaging (MRI), visual evoked potentials (VEP) and brainstem auditory evoked potentials (BAEP) were performed. The results were compared between patients with good and poor metabolic control and healthy children. Twenty-three patients with GSD type 1a were studied. Twelve patients were in poor metabolic control group and 11 patients in good metabolic control group. Five patients had intellectual disability, 10 had EEG abnormalities, seven had abnormal VEP and two had abnormal BAEP results. MRI was abnormal in five patients. There was significant correlation between the number of hypoglycemic attacks and MRI abnormalities. Central nervous system may be affected in GSD type 1a even in patients with normal neurologic examination. Accumulation of abnormal results in patients with poor metabolic control supports the importance of metabolic control in GSD type 1a.

Protective Effects of Alpha-Lipoic Acid on Methotrexate-Induced Oxidative Lung Injury in Rats

OBJECTIVE

Oxidative stress is one of the major causes of methotrexate induced lung injury (MILI). Alpha-lipoic acid (ALA), which occurs naturally in human food, has antioxidative and anti-inflammatory activities. The aim of this study was to research the potential protective role of ALA on MILI in rats.

METHODS

Twenty one rats were randomly subdivided into three groups: control (group I), methotrexate (MTX) treated (group II), and MTX+ALA treated (group III). Lung injury was performed with a single dose of MTX (20 mg/kg) to groups 2 and 3. On the sixth day, animals in all groups were sacrificed by decapitation and lung tissue and blood samples were removed for histological examination and also measurement the levels of interleukin-1-beta (IL-1β), malondialdehyde (MDA), glutathione (GSH), tumour necrosis factor-alpha (TNF-α), myeloperoxidase (MPO), and sodium potassium-adenosine triphosphatase (Na+/K+ATPase).

RESULTS

In MTX group tissue GSH, Na+/K+ATPase activities were lower, tissue MDA, MPO and plasma IL-1?, TNF-? were significantly higher than the other groups. Histopathological examination showed that lung injury was less severe in group 2 according to group 3.

CONCLUSIONS

Oxidative damage of MTX in rat lung is partially reduced when combined with ALA.

Value of multiplex PCR to determine the bacterial and viral aetiology of pneumonia in school-age children

BACKGROUND

Conventional methods for the aetiological diagnosis of community-acquired pneumonia (CAP) are often insufficient owing to low sensitivity and the long wait for the results of culture and particularly serology, and it often these methods establish a diagnosis in only half of cases.

AIM

To evaluate the most common bacterial and viral agents in CAP using a fast responsive PCR method and investigate the relationship between clinical/laboratory features and aetiology, thereby contributing to empirical antibiotic selection and reduction of treatment failure.

METHODS

In children aged 4-15 years consecutively admitted with a diagnosis of CAP, the 10 most commonly detected bacterial and 12 most commonly detected viral agents were investigated by induced sputum using bacterial culture and multiplex PCR methods. Clinical and laboratory features were compared between bacterial and viral pneumonia.

RESULTS

In 78 patients, at least one virus was detected in 38 (48.7%) and at least one bacterium in 32 (41%). In addition, both bacteria and viruses were detected in 16 (20.5%) patients. Overall, the agent detection rate was 69.2%. The most common viruses were respiratory syncytial virus and influenza and the most frequently detected bacteria were S. pneumoniae and H. influenzae. PCR was superior to culture for bacterial isolation (41% vs 13%, respectively). Fever, wheezing and radiological features were not helpful in differentiating between bacterial and viral CAP. White blood cell count, CRP and ESR values were significantly higher in the bacterial/mixed aetiology group than in the viral aetiology group.

CONCLUSION

In CAP, multiplex PCR is highly reliable, superior in detecting multiple pathogens and rapidly identifies aetiological agents. Clinical features are poor for differentiation between bacterial and viral infections. The use of PCR methods allow physicians to provide more appropriate antimicrobial therapy, resulting in a better response to treatment, and it may be possible for use as a routine service if costs can be reduced.

Clinical factors and comorbidities affecting the cost of hospital-treated COPD

Purpose

We aimed to assess the effects of comorbidities on COPD costs and to investigate the relationship between comorbidities and clinical variables.

Patients and methods

All patients hospitalized with a diagnosis of COPD exacerbation between January 1, 2014, and December 31, 2014, at all state hospitals of Aydın province, a city located in the western part of Turkey, were included in this study. The costs examined in the study pertained to medications, laboratory tests, hospital stays, and other treatment-related factors, such as consumption of materials, doctor visits, and consultation fees.

Results

A total of 3,095 patients with 5,237 exacerbations (mean age, 71.9±10.5 years; 2,434 males and 661 females) were evaluated. For 880 of the patients (28.9%), or 3,852 of the exacerbations (73.1%), at least one comorbid disease was recorded. The mean cost of each exacerbation was $808.5±1,586, including $325.1±879.9 (40.7%) for hospital stays, $223.1±1,300.9 (27.6%) for medications, $46.3±49.6 (0.9%) for laboratory expenditures, and $214±1,068 (26.5%) for other treatment-related factors, such as consumption of materials, doctor visits, and consultation fees. The cost of each exacerbation was $1,014.9 in patients with at least one comorbidity, whereas it was $233.6 in patients without comorbidity (P<0.001). Age >65 years, female gender, hospitalization in an intensive care unit, invasive or noninvasive mechanical ventilation, and a long duration of hospitalization were all found to be significant factors in increasing total costs during the exacerbations requiring hospitalization (P<0.05 for all).

Conclusion

Comorbidities have an important role in the total costs of acute exacerbations of COPD. Strategies for the prevention, diagnosis, and effective management of comorbidities would decrease the overall financial burden associated with acute exacerbations of COPD.

Consider Behcet's disease in young patients with deep vein thrombosis

Behcet's disease is a multi-systemic and chronic inflammatory vasculitis of unknown etiology characterized by recurrent oral and genital ulcers, uveitis, arthritis, arterial aneurysms, venous thrombosis, skin lesions and GIS lesions. Although pulmonary artery aneurysms are rare, it is a critical condition due to high risk of rupture. Venous involvement of Behcet's disease primarily occurs in the lower extremities. In the presence of deep vein thrombosis(DVT) and pulmonary embolism, the mainstay of treatment in Behcet's disease is immunosuppressant therapy. Anticoagulants can be used only after initiation of immunosuppressant therapy and suppression of the disease. Anticoagulant therapy alone may lead to fatal hemoptysis. We report the case of a 24 year-old patient who presented to the emergency service with complaints of shortness of breath, general condition disorder and hemoptyhis while using warfarin for DVT and whose thoracic CT angiography showed pulmonary embolism and pulmonary artery aneurysm and diagnosed with Behcet's disease.

Relative hypoaldosteronism in a patient with Wolcott-Rallison syndrome

BACKGROUND

Wolcott-Rallison syndrome is an autosomal recessive, multisystem disorder with onset of diabetes in the neonatal period or early infancy.

CASE REPORT

A 9-year-old girl with diabetes and growth failure from 2 months of age presented with ketoacidosis and multiple organ failure. Evaluation for short stature revealed epiphyseal dysplasia. A homozygous mutation in the EIF2AK3 gene confirmed the clinical diagnosis of Wolcott-Rallison syndrome. She was euthyroid. Biochemical evaluation for potential adrenal dysfunction because of persistently elevated serum potassium (range 5.9-6.3 meq/l) and low serum sodium levels (range 128-130 meq/l) 2 weeks after resolution of ketoacidosis yielded normal findings with respect to basal corticotropin (31 pg/ml) and cortisol (18.7 μg/dl) levels. Estimated GFR-Schwartz (36.9 ml/min/1.73 m(2) ) was consistent with stage 3 chronic renal failure. The transtubular potassium gradient was 1.39 (normal value in hyperkalemic states: > 4.1). The plasma aldosterone (upright: 241.3 pmol/l) was within normal ranges, and plasma renin [39 pg/ml (range 5.41-34.53 pg/ml)] was slightly elevated. The patient was diagnosed as having relative hypoaldosteronism and was started on a sodium-rich diet and low potassium. Failure to respond to the dietary intervention prompted a trial of oral fludrocortisone with subsequent normalization of electrolyte levels.

CONCLUSIONS

This is the first case report of Wolcott-Rallison syndrome complicated with relative hypoaldosteronism. Further research is needed to probe the causal inference of relative hypoaldosteronism with chronic renal failure in patients with Wolcott-Rallison syndrome.

Severe Hypokalaemia, Hypertension, and Intestinal Perforation in Ectopic Adrenocorticotropic Hormone Syndrome

Ectopic adrenocorticotropic hormone (ACTH) syndrome is a rare cause of the Cushing's syndrome. The occurrence of the ectopic ACTH syndrome presenting with severe hypokalaemia, metabolic alkalosis, and hypertension has been highlighted in case reports. However, presentation with lower gastrointestinal perforation is not known. We report the case of a 70-year-old male patient with severe hypokalaemia, metabolic alkalosis, hypertension, and colonic perforation as manifestations of an ACTH-secreting small cell lung carcinoma. Ectopic ACTH syndrome should be kept in mind as a cause of hypokalaemia, hypertension, and intestinal perforation in patients with lung carcinoma.

Knowledge Level of Family Physicians about Tuberculosis and their Attitudes and Views Regarding their Willingness to Work at a Tuberculosis Dispensary

OBJECTIVES

Upon transitioning to the family medicine system in Turkey, the number of tuberculosis dispensaries (TDs) was reduced, and important responsibilities have been given to family physicians in tuberculosis (TB) control. Furthermore, with the new system, the incomes of doctors working at TDs remained quite lower than those of family physicians. The primary aim of this study was to examine whether family physicians possess the necessary level of knowledge regarding TB, and the secondary aim was to evaluate the attitudes and views of primary care physicians regarding working at TDs because of this economic inequality.

MATERIAL AND METHODS

A questionnaire consisting of 15 questions that measures the basic knowledge regarding TB and that evaluates the role of family health centers in TB control and the willingness of doctors to work at TDs was presented to family physicians in the city of Sakarya.

RESULTS

Of the 84 family physicians that participated in the study, 43% did not have sufficient knowledge about diagnosis, 56% about medicine information, and 77% about transmission and duration of treatment. In addition, 74% of family physicians stated that TD workers run the risk of infection and that their chances of contracting TB are higher, 90% stated that TD workers should be provided with the same economic conditions as family physicians, and 68% stated that TD workers should be positively discriminated. Half of the participants stated, as it stands, that they do not want to work at a TD, and 31% stated that they would definitely not work at a TD even if TD workers are provided with the same economic conditions as family physicians or they are positively discriminated.

CONCLUSION

To take the national fight against TB to a higher level, we reached the conclusion that it is important that the lack of knowledge of family physicians should be remedied, that TB should be included in their job descriptions, and that TD workers should be provided with the same economic conditions as family physicians.

Factors affecting successful treatment outcomes in pulmonary tuberculosis: a single-center experience in Turkey, 2005-2011

INTRODUCTION

We aimed to describe the treatment outcomes in patients with bacteriologically confirmed pulmonary tuberculosis (PTB) and identify factors associated with successful treatment outcome.

METHODOLOGY

The medical charts of patients with smear and/or culture-positive PTB who were treated between 2005 and 2011 at the Kocaeli Tuberculosis Dispensary, Turkey, were reviewed. Patients were categorized as having a successful (cured or with a completed treatment) or poor (treatment default, treatment failure, death) treatment outcome. The association of demographic and clinical factors, including gender, age, education, occupation, insurance, family size, living area, smear and culture positivity, retreatment, comorbidity, drug resistance, and cavity on radiography, with the success of treatment, was evaluated by univariate and multivariate analyses.

RESULTS

Of 738 patients (258 females, 480 males) with bacteriologically confirmed PTB, 683 (92.6%) had successful treatment outcomes. Of those with a poor outcome, 29 (3.9%) had treatment default, 18 (2.4%) died, and 8 (1.1%) had treatment failure. Young age, no previous treatment, no comorbidity, no drug resistance, and high education level were factors significantly associated with successful PTB treatment outcome (p < 0.05 for all).

CONCLUSIONS

Treatment outcome was successful in young and educated PTB patients who had drug resistance, previous treatment history, and no comorbidities. Knowledge of the factors affecting treatment success will lead to the undertaking of specific measures in the management of PTB, which may help to decrease treatment failure.

Assessment of the factors affecting the failure to use inhaler devices before and after training

BACKGROUND

Inhaler devices used for the treatment of chronic respiratory diseases are frequently incorrectly used by the patients. The effects of training on the correct use of these devices are unquestionable. However, despite the training provided on the correct technique of using the inhaler device, some patients still continue using the device incorrectly. The aims of the present study are to determine the rate of incorrect use of the inhaler devices, assess the parameters that affect the incorrect use, demonstrate the contribution of training, and determine the characteristics of the patients who use the devices incorrectly despite training.

METHODS

342 consecutive patients were included in the study. The patients' ability to use the devices correctly was scored before and after face-to-face trainings. The parameters affecting incorrect use, the impact of training, and characteristics of the patients who continued the incorrect usage after training were evaluated.

RESULTS

The rate of correct usage was 58.9% for dry powder inhalers (DPI) and 31.1% for pressurized metered dose inhalers (pMDI) before the training. The parameters affecting correct usage were educational status, gender, living in rural areas, duration of disease, and being diagnosed and followed-up by a chest diseases specialist. The rate of correct usage increased to 92.6% for DPI and 45.2% for pMDI after the training. The factors affecting continued incorrect usage after standard training were old age and the type of the pMDI device.

CONCLUSIONS

The technique for using the inhaler device should be described to the patients in a face-to-face session by the prescribing physician. Device selection should be done on a "trial" basis and it should be considered that particularly older patients and those using pMDIs continue using the devices incorrectly despite training; hence, alternative treatment options should be reviewed for these patients.

The relationship between allergy and asthma control, quality of life, and emotional status in patients with asthma: a cross-sectional study

Background

Psychiatric comorbidities are prevalent in patients with chronic somatic disorders such as asthma. But, there is no clear evidence regarding the effect of atopic status and the type of sensitized allergen on emotional status. The aim of the present study was to investigate the effects of house dust mites and pollen allergies on emotional status, asthma control and the quality of life in patients with atopic asthma.

Methods

The study included 174 consecutive patients who were diagnosed with asthma accoring to the GINA criteria and who did not receive therapy for their allergy. All patients underwent a skin prick test. The asthma control, quality of life, and emotional status were evaluated using the ACT (asthma control test), AQLQ (asthma-specific quality of life questionnaire), and HAD (hospital anxiety depression questionnaire).

Results

Atopy was detected in 134 (78.7%) patients. Of those patients: 58 (33.3%) had anxiety and 83 (47.7%) had depression. There was no relationship between emotional status, atopic status, and the type of indoor/outdoor allergen. Furthermore, there was no relationship between atopy and asthma severity, asthma control, and the quality of life. The anxiety and depression scores were significantly higher and the quality of life scores lower in the uncontrolled asthma group. The ACT and AQLQ scores were also lower in the anxiety and depression groups.

Conclusions

It was concluded that anxiety and depression are prevalent in patients with uncontrolled asthma, and atopic status did not affect the scores in ACT, AQLQ, and emotional status tests.

Relationship between the GOLD combined COPD assessment staging system and bacterial isolation

Background

Acute exacerbations, which are a significant cause of mortality and morbidity, adversely affect chronic obstructive pulmonary disease (COPD) prognosis by accelerating loss of lung function. It is important to know the microorganisms that commonly cause exacerbations in the patient groups classified according to clinical and functional characteristics for fast and accurate treatment of acute exacerbations.

Objectives

The last Global Initiative for Chronic Obstructive Lung Disease (GOLD) publication recommended a new staging system containing obstruction degree, frequency of exacerbations, and quality of life questionnaires. This study is designed to analyze the relationship between the bacteria isolated in acute exacerbations and new GOLD stages.

Methods

Potentially pathogenic bacteria (PPB) isolation with culture and polymerase chain reaction methods were obtained from 114 acute exacerbation COPD patients, classified into A, B, C, and D groups by analyzing the forced expiratory volume in 1 second (FEV₁) value, COPD Assessment Test (CAT) score, and exacerbation frequency according to the new GOLD staging system.

Results

There was a significant correlation between exacerbation frequency and PPB isolation (P=0.002). There was no relationship between GOLD stage, FEV₁, and CAT score with PPB isolation. The isolated bacteria diversity and mixed infection frequency were higher in the GOLD stage D group. Pseudomonas aeruginosa, Escherichia coli, and Acinetobacter baumannii were isolated only from D group patients.

Conclusion

Bacterial infection may cause an acute exacerbation equally in each stage for COPD. The difference in bacterial etiology is more related to exacerbation frequency than FEV₁ and CAT scores for an acute exacerbation. Determining exacerbation frequency is significant for treatment success in empirical antibiotic selection.

The role of multiplex PCR test in identification of bacterial pathogens in lower respiratory tract infections

Objectives: Lower respiratory tract infection is one of the most important causes of morbidity and mortality. However establishing a microbial diagnosis for patients with lower respiratory tract infection is still challenging and is often achieved in only half of cases by conventional methods. This study was designed to compare the fast responsive PCR method with the culture method in lower respiratory tract infections and to evaluate the reliability of multiplex PCR method.

Methods: One hundred ninety seven patients with the symptoms of acute lower respiratory tract infection, and diagnosed with community-acquired pneumonia, acute exacerbation of chronic obstructive pulmonary disease and exacerbations of bronchiectasis were included in the study. Both culture and PCR methods was performed for the isolation of most commonly seen bacteria, from sputum, nasopharyngeal swabs and bronchoalveolar lavage fluid samples.

Results: While at least one bacterial isolation was determined in 62 (31.5%) of all patients with culture method, this number increased to 125 (63.5%) with multiplex PCR. The bacteria most commonly identified by PCR were S. pneumoniae (32%) and H. influenzae (31%). There was a significant difference between PCR and culture in terms of multi-factor detection rates (p<0.005). Multiple bacteria were detected in only two cases in cultures; however, multiple pathogens were detected in 47 cases with PCR.

Conclusions: Conventional methods, such as culture and serology are not always adequate to detect the pathogens in lower respiratory tract. Real-time PCR assays proved highly sensitive and rapid. The prevalence of bacteria and multiple agent detected by real-time PCR compared with culture was substantially higher. Widespread use of PCR methods, by providing the immediate and appropriate ''agent specific antibiotic treatment'' of LRTI, will help reduce failure and contributes to a reduction in antibiotic resistance.

A Rare Cause of Elevated Chitotriosidase Activity: Glycogen Storage Disease Type IV

Human chitinolytic enzyme named "chitotriosidase" takes part in the defense mechanism against pathogens and the homeostasis of innate immunity. Chitotriosidase was firstly reported to be markedly high in plasma of patients with Gaucher disease. Abnormal lipid laden macrophages are thought to be responsible for stimulating the secretion of chitotriosidase in Gaucher disease. Subsequently, various disorders have also been found to be associated with elevated levels of chitotriosidase. Chronic liver diseases that are also related with macrophage activation may have elevated chitotriosidase activity. We report the second case of the literature with glycogen storage disease (GSD) type IV that presented with high chitotriosidase levels. GSD type IV should be taken into consideration in case of elevated chitotriosidase levels, stigmas of chronic liver disease, and inconsistency of lysosomal storage diseases.

Esophageal stricture due to recurrent mucositis in a patient with acute lymphoblastic leukemia

An esophageal stricture is one of the complications that may develop during cancer treatment in children. Although more commonly associated with radiotherapy, recurrent mucositis has also been implicated. Presented herein is a case of a patient with acute lymphoblastic leukemia who suffered recurrent attacks of severe mucositis. Initial management of ensuing dysphagia included antifungal treatment for candida esophagitis. A subsequent upper endoscopy due to persistence of dysphagia revealed the presence of an esophageal stricture. Our aim in presenting this case is to emphasize the importance of considering a diagnosis of esophageal stricture in patients receiving anti-cancer treatment; early endoscopic intervention may be warranted in some patients.