Excision of Aortic Vegetation in Brucella Endocarditis

A 19-year-old man with brucella endocarditis was treated by antimicrobial therapy and surgical excision of vegetation with preservation of the native aortic valve.

Surveillance, control and management of infections in intensive care units in Southern Europe, Turkey and Iran--a prospective multicenter point prevalence study

OBJECTIVE

We aimed to compare the features of intensive care units (ICUs), their antimicrobial resistance patterns, infection control policies, and distribution of infectious diseases from central Europe to Mid-West Asia.

METHODS

A cross-sectional point prevalence study was performed in 88 ICUs from 12 countries. Characteristics of ICUs, patient and antibiotic therapy data were collected with a standard form by infectious diseases specialists.

RESULTS

Out of 749, 305 patients at least with one infectious disease were assessed and 254 patients were reported to have coexistent medical problems. When primary infectious diseases diagnoses of the patients were evaluated, 69 had community-acquired, 61 had healthcare-associated, and 176 had hospital-acquired infections. Pneumonia was the most frequent ICU infection seen in half of the patients. Distribution of frequent pathogens was as follows: Enteric Gram-negatives (n = 62, 28.8%), Acinetobacter spp. (n = 47, 21.9%), Pseudomonas aeruginosa (n = 29, 13.5%). Multidrug resistance profiles of the infecting microorganisms seem to have a uniform pattern throughout Southern Europe and Turkey. On the other hand, active and device-associated infection surveillance was performed in Turkey more than Iran and Southeastern Europe (p < 0.05). However, designing antibiotic treatment according to culture results was highest in Southeastern Europe (p < 0.05). The most frequently used antibiotics were carbapenems (n = 92, 30.2%), followed by anti-gram positive agents (vancomycin, teicoplanin, linezolid, daptomycin, and tigecycline; n = 79, 25.9%), beta-lactam/beta lactamase inhibitors (n = 78, 25.6%), and extended-spectrum cephalosporins (n = 73, 23.9%).

CONCLUSION

ICU features appears to have similar characteristics from the infectious diseases perspective, although variability seems to exist in this large geographical area.

Withdrawal of Staphylococcus aureus from intensive care units in Turkey

BACKGROUND

In the past, Staphylococcus aureus infections have displayed various patterns of epidemiologic curves in hospitals, particularly in intensive care units (ICUs). This study aimed to characterize the current trend in a nationwide survey of ICUs in Turkey.

METHODS

A total of 88 ICUs from 36 Turkish tertiary hospitals were included in this retrospective study, which was performed during the first 3 months of both 2008 (period [P] 1) and 2011 (P2). A P value ≤.01 was considered significant.

RESULTS

Although overall rates of hospital-acquired infection (HAI) and device-associated infection densities were similar in P1 and P2, the densities of HAIs due to S aureus and methicillin-resistant S aureus (MRSA) were significantly lower in P2 (P < .0001). However, the proportion of HAIs due to Acinetobacter was significantly higher in P2 (P < .0001).

CONCLUSIONS

The incidence of S aureus infections is declining rapidly in Turkish ICUs, with potential impacts on empirical treatment strategies in these ICUs.

Emergence and co-infections of West Nile virus and Toscana virus in Eastern Thrace, Turkey

The objective of this study was to identify the impact of West Nile virus (WNV) and Toscana virus (TOSV) in febrile diseases of unknown aetiology in Eastern Thrace, Turkey; this study was conducted during August-October 2012, and included 18 clinical cases and 296 blood donors for local serosurveillance. Antibodies were determined via commercial assays and further tested for specificity via neutralization assays (NA). Viral RNAs were sought via specific and/or generic primers. WNV infections were diagnosed in seven patients (38.8%), detected via RNA+IgM in four, RNA in one and IgM and low avidity IgG in two cases. The most common symptom was fever (>38°C), followed by headache, malaise/fatigue, myalgia/arthralgia, muscle stiffness/lower back pain, anorexia, nausea/vomiting, diarrhoea, supraorbital/retrobulbar pain and abdominal pain. Neurological symptoms were noted in one individual. WNV strains in RNA-detectable patients were characterized as lineage 1. TOSV RNA or IgM were identified in two individuals with confirmed WNV infections and in one patient without evidence of WNV exposure. The clinical and laboratory findings in individuals with WNV/TOSV co-infection were comparable to those in WNV-induced disease. The TOSV strain in the patient with detectable viral RNA was characterized as genotype A. In local blood donors, seroreactivity for specific WNV and TOSV immunoglobulins was observed in 1.7% (5/296) and 14.4% (26/180), respectively. These findings indicate the emergence of WNV and TOSV-associated diseases in Eastern Thrace. WNV/TOSV co-infections were documented for the first time.

[Evaluation of epidemiological characteristics and risk factors of candidemia in adult patients in a tertiary-care hospital]

Candida species which are currently the fourth most common cause of nosocomial bloodstream infections, are associated with a significant morbidity and mortality. The aim of this retrospective case-control study which included adult patients was to determine the epidemiology of candidemia and to evaluate risk factors for the development of candidemia and mortality at a tertiary-care education hospital over a 1-year period. A total of 38 candidemia cases (23 were male; age range: 17-82 yrs; mean age: 61.4 ± 13.5 years) were identified among 22.507 patients hospitalized during the study period (January 1-December 31, 2008) and the overall incidence was found as 16.8 per 10.000 hospital admissions. Control group (n= 36; 22 were male; mean age: 60.9 ± 16.3 years) was selected among patients who had no signs and symptoms of candidemia and had negative blood cultures during the study period. Thirty-six (95%) patients with candidemia were identified as nosocomial infection. The most frequently isolated species were C.albicans (55.2%) and C.parapsilosis (28.9%) and the primarily identified origin of infection was central venous catheter use (39%). Candida spp. İsolation was most frequent in patients hospitalized in intensive care units (13/38; 34.2%), followed by surgery (n= 8; 21%) and chest diseases (n= 5; 13). Univariate analysis revealed that presence of a central venous catheter [odds ratio (OR): 4.33; 95% confidence interval (CI): 1.63-11.47, p= 0.003] and the length of hospitalization (OR: 0.97; CI: 0.94-1.00, p= 0.01) were the most frequently associated factors with an increased risk of candidemia compared to controls. However, multivariate analysis exhibited presence of a central venous catheter (OR: 2.90; CI: 1.04 8.11, p= 0.04) as the only independent risk factor for the development of candidemia. Therapy was initiated with intravenous fluconazole (mean duration of therapy 13.2 ± 6.25 days) and in three patients following fluconazol use step-up therapy was initiated. Total mortality rate was 58% (22/38) in our case series. Risk factors for mortality due to candidemia in the univariate analysis were detected as no response to antifungal treatment (OR: 0.23; CI: 0.11-0.51, p< 0.001), underlying disease other than trauma (OR: 0.06; CI: 0.003-1.24, p= 0.02), and high Charlson index (OR: 0.60; CI: 0.38-0.93, p= 0.03), however those factors were not found significant by multivariate analysis. There was also a statistically significant correlation between Charlson index and treatment response (mean Charlson index was 3.5 ± 1.9 in therapy-responded patients and 4.8 ± 1.8 in non-responders; p= 0.03). Since the risk of developing candidemia was significantly higher in severely diseased patients using central venous catheter or with prolonged hospitalization, response to antifungal therapy may be insufficient, leading to higher mortality.

[Staphylococcus aureus hepatic abscess associated with cervical lymphadenitis]

Pyogenic liver abscesses usually develop secondary to biliary tract and intraabdominal infections and members of the Enterobacteriaceae family are usually implicated as the etiologic agents. In this report a case of hepatic abscess devoloped secondary to cervical lymphadenitis caused by Staphylococcus aureus, was presented. Twenty-one years old male patient was admitted to the hospital with complaints of fever, swelling and pain at the right side of the neck and difficulty in swallowing. Physical examination revealed painful submandibular lymphadenopathy with hyperemia. Upon demonstration of cystic lymphadenopathy by magnetic resonance imaging of the neck, the mass was aspirated. Gram-positive cocci with abundant leucocytes were detected in Gram stained smears of the aspiration material and methicillin-susceptible S. aureus (MSSA) was identified in the culture. Treatment with ampicillin/sulbactam (4 x 1.5 g/day) was initiated. However, since patient still had fever and abdominal pain, nausea and vomitting were also added to his complaints, abdominal ultrasonography and computerized tomography (CT) were done and abscesses were demonstrated in liver. The abscesses were drained under CT guidance and the fever of the patient resolved. Treatment with ampicillin/sulbactam was continued for 6 weeks. Although it was considered that the hematogenous spread of MSSA that led to cervical lymphadenitis caused the hepatic abscesses, the agent was neither isolated from the blood culture nor from the hepatic abscess material. It should always be taken into consideration that liver abscesses might accompany distant infections and antibiotic therapy alone might not be sufficient for the complete resolution of such infections.

[Retrospective evaluation of the cases prediagnosed as viral encephalitis in Trace University Hospital between the period of 2000-2005]

In this study, a total of 17 adult patients ((> or =18 years old; 12 male, 5 female) with encephalitis followed up in neurology and infectious diseases clinics of Trace University Hospital between the years 2000-2005 were retrospectively analyzed. The most common signs and symptoms were confusion (n: 13; 76.4%), nausea and vomiting (n: 13; 76.4%), disorientation (n: 12; 70%), fever and headache (n: 11; 64.7%), amnesia (n: 10; 58.8%), convulsions (n: 9; 52.9%), agitation (n: 7; 41%), dysphasia and aphasia (n: 6; 35.2%), nuchal stiffness (n: 5; 29.4) and focal neurological signs (n: 1; 5.8%). Six of the patients were admitted to the hospital during summer, six during winter, four during spring and one during autumn. Eleven (64.7%) of the patients had electroencephalographic signs compatible with encephalitis. Encephalitis related signs were detected in 83.3% (10/12) of the patients by cranial magnetic resonance imaging and in 58.3% (7/12) by computerized tomography. Cerebrospinal fluid (CSF) examination revealed low glucose levels in 17.6% (3/17), high protein levels in 47% (8/17) and increased white blood cells with a predominance of lymphocytes in 41.2% (7/17) of the cases. CSF findings were within normal limits in 23.5% (4/17) of the patients. Empirical acyclovir treatment was given to all patients. One patient died at the acute phase of the infection while all the other 16 recovered. Since none of the CSF samples yielded bacterial growth, all of the patients were diagnosed as viral encephalitis. However, no investigation was performed to identify the viral etiology and this was the major limitation owing to the inadequacy of laboratory facilities during the study period and/or unawareness of the physicians about viral identification methods.

[Short communication: Evaluation of the flu vaccine administered to health care workers in Trakya University Hospital in 2006]

After the detection of human cases of highly pathogenic avian influenza A (H5N1) virus in Eastern Turkey in January 2006, Turkish Ministry of Health has had declared "National Plans of Activity for Pandemic Influenza". All health-care facilities were recommended to develop contingency plans. Then the essential activities were started in August 2006 in Trakya University, Faculty of Medicine (Edirne, Trace region of Turkey), and institutional education about pandemic influenza and preventive measures was implemented to health care workers (HCWs). In November 2006, health care workers were offered inactivated flu vaccine (Vaxigrip, Sanofi Pasteur, France) supplied by the Ministry of Health. The aim of this questionary survey was to evaluate the visions and conceptions of health care workers about influenza vaccination during the vaccination campaign. All the participants were informed by using an information form including the indications, contraindications and possible adverse reactions of flu vaccine, and were requested to complete the questionnaire about influenza vaccination according to their own perception before vaccination. Vaccine recipients were also invited to the vaccination unit if they had any adverse reaction. A total of 1041 HCWs (560 female, 481 male; mean age: 32.8 +/- 8.2 years) completed the questionnaire. Of them 884 subjects (85%) have accepted to be vaccinated, while 157 subjects (15%) have not. It was determined that 72 HCWs (6.9%) had been administered flu vaccine in 2005, and 38 (3.7%) have had an underlying chronic disease requiring medical therapy. Six subjects (16%) with an underlying chronic disease were vaccinated in 2005, while 66 HCWs (6.6%) without any chronic disease received vaccination voluntarily. Seven workers (0.7%) declined vaccination as they defined hypersensitivity to egg, and 84 workers (8%) had influenza vaccine voluntarily before the campaign in 2006. Sixty six workers (6.3%) have refused to be vaccinated as they considered influenza vaccination ineffective to protect against flu. Two workers (0.2%) had allergic skin reactions such as erythema and itching after vaccination. It can be concluded that influenza vaccination of the health care workers is a part of infection control policies and it is also a matter of patient safety. The implementation of necessary education programmes and attempts to emphasize the importance of vaccination of health care workers especially dealing with high risk patients, would be of crucial importance to decrease the morbidity and mortality due to influenza infections.

Prospective Evaluation of Rickettsioses in the Trakya (European) Region of Turkey and Atypic Presentations of Rickettsia Conorii

In 2004 between the months of May-November, 11 patients with spotted fever group (SFG) rickettsioses were admitted to the Trakya University Hospital in Edirne, Turkey. SFG rickettsioses were diagnosed clinically. Before treatment, punch biopsy from skin lesions, especially from the eschar, was performed. Serum specimens were tested by IFA using a panel of nine rickettsial antigens, including SFG rickettsiae and R. typhi. Western blotting and standard PCR were also performed. The average age of the 11 patients (4 male and 7 female) was 51 years. All the patients had high fever; 10 (91%) had maculopapular rash; 8 (73%) had rash in the palms or on the soles. Five patients had a unique eschar; two had double eschars (64%). Two patients presented with multiple organ failure and one of them died. All the patients had significant antibody titers against SFG rickettsiae. PCR experiments of skin biopsies were positive in six (60%) of 10 skin biopsy samples and DNA sequencing of the positive PCR products gave 100% homology with Rickettsia conorii Malish 7 for opmA and gltA. Trakya Region in an endemic area for rickettsioses. In this series, three patients presented with life-threatening diseases and one of them died. This patient was the first fatal case (2.8%). Atypic and serous life-threatening presentations of rickettsioses must be kept in mind for the differential diagnosis of febrile disease in Turkey.

[Evaluation of brucellosis patients in Trakya University Hospital]

Human brucellosis is an endemo-epidemic disease in the Trakya Region of Turkey. The aim of this retrospective study was to evaluate the clinical, laboratory findings, therapeutic features, and prognosis of the 47 patients (49% were female, age range: 17-76 years, mean age: 45 years) with human brucellosis followed up in Trakya University Hospital between 2001-2005. The patients were categorized as acute (64%), subacute (28%) and chronic (9%) brucellosis. Complications were detected in 51% of the patients and spondylodiscitis was the most common (30%) complication. Twenty-seven percent of patients with spondylodiscitis were classified as acute, 46% were subacute, and 27% were chronic brucellosis. Other complications were sacroileitis (9%), arthritis (4%), meningitis (4%), endocarditis (2%), and orchitis (2%). Positive blood cultures were detected in 80% and 54% of acute and subacute cases, respectively, however, blood cultures were all negative in the chronic cases. Overall positive blood cultures were observed in 68% of cases. Fifty-one percent of the patients were treated with doxycycline+streptomycin, and 40% with doxycycline+rifampicin. Two patients with meningitis were treated with doxycycline+rifampicin+ceftriaxone, and one patient with endocarditis was treated with doxycycline+rifampicin+cotrimoxazole combinations. Relapse was observed in two (4%) of the patients. Since serious complications were observed in half of the brucellosis patients, combination therapies were prolonged. Complete evaluation of patients with human brucellosis requires investigation of osteoartricular complications and modification of the duration of therapy according to the existing complication.

Exposure time to hepatitis B virus and associated risk factors among children in Edirne, Turkey

Hepatitis B virus (HBV) infection is endemic in Turkey, but the main routes of transmission were not well established. This study aims to detect the exposure time to HBV and associated risk factors among children. In a sampling group of children aged 0-19 years living in Edirne, antiHBc, antiHBs and HBsAg were screened by the microELISA method. A questionnaire was also completed for each child. In 717 children that were included in the study, the total antiHBc seropositivity was 5.4% and was 1.8, 0.8, 1.7, 6.8, 11.8% in 0-1, 2-5, 6-10, 11-14, 15-19 years age groups respectively. The overall HBsAg seropositivity was 1.7%. The risk of HBV infection increased after the age of 10 years (OR 7.79, 95% CI 3.01-20.16). Collective circumcision was the only independent factor according to regression analysis. Children living in Edirne should be vaccinated against HBV before reaching 11 years of age.

Meningitis due to bacillus anthracis

The first case of haemorrhagic meningitis due to Bacillus anthracis in the European part of Turkey is reported here. B. anthracis, sensitive to penicillin, was isolated from the cerebrospinal fluid and blood cultures. Although appropriate therapy was administered, the patient died two days after hospitalization.

First isolation of Rickettsia conorii from humans in the Trakya (European) region of Turkey

In the Trakya region of Turkey, located in the European part of the country, presumptive cases of Mediterranean spotted fever have been diagnosed and treated every summer since the beginning of the 1990s. The aim of this prospective study was to isolate and identify the rickettsial strains from blood samples of 11 patients and from skin biopsies of 10 of these 11 patients with the diagnosis of spotted fever in the Trakya region of Turkey in 2003. Immunofluorescence assay was performed with acute-phase and convalescent-phase serum samples of 11 patients. All patients had significant antibody titers against spotted fever group rickettsiae. Rickettsia conorii was isolated from the skin biopsies of three of ten patients and was also demonstrated by polymerase chain reaction in skin biopsies of nine of ten patients. In southeastern Europe, the Balkan Peninsula (including the Trakya region of Turkey) is an area where arthropods are endemic and where new arthropod-borne infections can be detected.

The epidemiology of hepatitis a virus infection in children, in Edirne, Turkey

Turkey is a middle endemic area with respect to Hepatitis A virus (HAV) infection. However, the frequency of this infection varies due to socio-economic differences in various regions. The aim of this study was to detect the most likely age of exposure to HAV and factors affecting infection rates among children living in Edirne. A sample of 645 children between the ages of 0-19 living in Edirne were tested for total anti-HAV levels using ELISA method. A questionnaire on socio-economic status (SES), possible risk factors, and place of residence was completed for each child. Anti-HAV seropositivity was found to be 4.4, 25, 37.3 and 43.2%, in 2-5, 6-10, 11-14 and 15-19 age groups, respectively. Seropositivity was found to be increasing with age (p < 0.05). According to logistic regression analysis results; mother's education, SES of family, history of hepatitis in primary family members and the number of brothers or sisters were determined as factors increasing the seropositivity of HAV. Furthermore, HAV infection risk was found to be a decreasing function of income that is higher the income less likely the infection. These results showed that HAV infection rate in Edirne is in middle endemicity and the most likely way of exposure is transmission from family members. Although it requires further cost-effectiveness studies, our results indicate that applying the HAV vaccination in early childhood would be beneficial to decrease the prevalence of the infection and prevent HAV epidemics.

Antituberculosis drug resistance and associated risk factors in the European section of Turkey

BACKGROUND

We carried out this study in order to establish the prevalence of antituberculosis drug resistance in Mycobacterium tuberculosis strains and to determine risk factors for the development of resistance in Trakya region of Turkey.

METHODS

Pattern of drug resistance in 214 M. tuberculosis isolates from patients with tuberculosis treated at the regional tuberculosis dispensaries were included in the study.

RESULTS

Isolates of 105 (49.1%) were resistant to only one drug, and 62 (29.0%) were resistant to more than one drug. The total resistance rates to streptomycin, isoniazid, rifampicin, ethambutol and isoniazid + rifampicin were 29.0%, 27.1%, 21.5%, 10.3% and 11.6%, respectively. The secondary resistance rates in all drugs and combinations were higher than primary resistance rates (p<0.001). Step wise logistic regression revealed that (i) non-compliance with treatment increases the chances of development of resistance by 15 times [p<0.00001, 95% confidence intervals (95% CI) : 4.16 to 56.70], and (ii) a regimen of inadequate treatment increases the chance of development of drug resistance by 10.5 times (p<0.01, 95% CI=2.66 to 49.80).

CONCLUSIONS

We propose that specially trained physicians should institute antituberculosis therapy and medication should be practiced under direct observation in this region.

[Species and biovar distribution of Brucella isolates in Trakya University Hospital between 1997-2002]

The aim of this study was to evaluate the species and biovar distribution of Brucella spp. isolated from blood cultures in Clinical Microbiology Laboratory of Trakya University Hospital, between 1997-2002. A total of 48 Brucella spp. have been isolated from 14.815 patients (0.3%), and the strains were identified according to CO2 requirement, H2S production, basic fuchsin and thionin sensitivity, lysis by Tbilisi phages, and presence of agglutination with monospecific A and M antisera. As a result, 47 (97.9%) isolates were identified as B. melitensis, and one as B. abortus (2.1%). Forty two (89.4%) of B. melitensis isolates were biovar 3, and five (10.6%) were biovar 1, while the single isolate of B. abortus was identified as an atypical strain.

Prevalence of extended-spectrum beta-lactamases produced by nosocomial isolates of Enterobacteriaceae in Trakya University Hospital, Turkey

The prevalence of extended-spectrum beta-lactamase (ESBL) production by 194 nosocomial isolates of Enterobacteriacea recovered from 1995 to 1999 was investigated. The ESBL production was determined by the double-disk synergy test and was confirmed by the E-test ESBL strip. Twenty-three isolates (21 Klebsiella pneumoniae, one Escherichia coli, one Providencia rettgeri) were found as ESBL-producers (11.8%). These isolates were also usually resistant to non-betalactam antibiotics. Most of them contained a beta-lactamase with a pI of 7.6. All the strains conjugally transferred their ESBLs to recipient E. coli. Contrary to others, ESBL-producing K. pneumoniae strains isolated in 1999 were resistant to ciprofloxacin, and had the identical plasmid profiles suggestive of an outbreak. Ciprofloxacin resistance in these strains could not be transferred. In conclusion, K. pneumoniae was the main ESBL-producing species among nosocomial isolates of Enterobacteriacae in our hospital.

A food-borne outbreak caused by Salmonella enteritidis

This study was designed to define the epidemiology of a food-borne outbreak caused by Salmonella enteritidis that affected only one squadron of a military battalion located in the vicinity of the city of Edirne in Turkey. The outbreak was analyzed by a standard surveillance form of the Centers for Disease Control and Prevention. The relationship between the eaten foods and cases was analyzed by Fisher's exact chi-square test, and odds ratios were calculated by a case-control study. The outbreak affected 60 of 168 soldiers in the squadron, 16 of whom were hospitalized. S.enteritidis was cultured in stools from 13 of the hospitalized soldiers and from 3 soldiers who had prepared the food. All strains were completely susceptible to antibiotics; their plasmid profiles were also identical. The highest attack rate detected was 55.7% in an omelet eaten 24 hours before (p < 0.001). Furthermore, it was the riskiest food according to the case-control study (OR=7.88; 95% CI=3.68-16.89). The food samples were unobtainable because they had been discarded. All of the hospitalized cases recovered, and none of the control cultures of stools yielded the pathogen after three weeks. In conclusion, although our results didn't indicate the exact source of the outbreak microbiologically, the omelet was considered to be the source based on the epidemiological proofs.

Resistance to macrolides in Group A streptococci from the European section of Turkey: genetic and phenotypic characterization

The aim of this study was to determine the susceptibilities to macrolides of Group A streptococcal isolates from the European section of Turkey. In the case of resistant isolates, the patterns and genetic mechanisms of erythromycin resistance were studied. Seven (2.7%) of the 260 isolates were resistant to erythromycin. Four of them showed the M phenotype and harboured mefA genes whereas three isolates showed the inducible macrolide, lincosamide and streptogramin B resistance phenotype and harboured ermTR genes. In the European section of Turkey, the current resistance rate of Group A streptococci to macrolides remains low.

Antibiotic Resistance Patterns and Plasmid Profiles of Salmonella typhimurium Isolates in Turkey

To understand the resistance mechanisms present in 75 isolates of Salmonella typhimurium derived from clinical infections in Turkey, antimicrobial resistance patterns and associated plasmids were investigated. Among the 22 strains that produced extended-spectrum beta-lactamase (ESBL), 20 were resistant to aminoglycosides and 12 to trimethoprim-sulfamethoxazole. Strains that did not produce ESBL did not express aminoglycoside or trimethoprim-sulfamethoxazole resistance, although 27 of them were ampicillin resistant. None of the strains were resistant to imipenem or fluoroquinolones. Nineteen strains producing ESBL carried a plasmid of >100 MDa. Seven ESBL-producing strains conjugally transferred their ESBLs and trimethoprim-sulfamethoxazok resistance. No correlation was found between the resistance patterns and plasmids in non-ESBL-producing strains.

Photorefractive keratectomy for post-penetrating keratoplasty myopia and astigmatism

PURPOSE

To determine the safety, effectiveness, and predictability of photorefractive keratectomy (PRK) for the correction of myopia and astigmatism after penetrating keratoplasty.

SETTING

Gazi University, Medical School, Department of Ophthalmology, Ankara, Turkey.

METHODS

Photorefractive keratectomy was performed in 16 eyes of 16 patients with postkeratoplasty myopia and astigmatism who were unable to wear glasses due to anisometropia and were contact lens intolerant. They were examined for uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), and corneal transplant integrity before and after surgery.

RESULTS

The mean follow-up after PRK was 26.0 months +/- 15.7 (SD) (range 12 to 63 months). The mean preoperative spherical equivalent refraction of -4.47 +/- 1.39 diopters (D) was -3.39 +/- 1.84 D (P >.05) at the last postoperative visit and the mean preoperative cylinder of -5.62 +/- 2.88 D was -3.23 +/- 1.70 D (P <.05); refractive regression correlated with the amount of ablation performed. The BSCVA decreased in 3 eyes (18.8%), and the UCVA decreased in 2 (12.5%). Six eyes (37.5%) had grade 2 to 3 haze, which resolved spontaneously in 4 eyes within a relatively long time but caused a decrease in BSCVA in 2 (12.5%). Two of the eyes (12.5%) had a rejection episode after PRK and were successfully treated with topical steroids.

CONCLUSIONS

Photorefractive keratectomy to correct postkeratoplasty myopia and astigmatism appears to be less effective and less predictable than PRK for naturally occurring myopia and astigmatism. Corneal haze and refractive regression are more prevalent, and patient satisfaction is not good.

Effects of perfluorophenanthrene on the human corneal endothelium

PURPOSE

To evaluate long term effects of perfluorophenanthrene (C12F24), a perfluorocarbon fluid, in the anterior chamber of the human eye, where residual perfluorophenanthrene was retained in the eye postoperatively.

METHODS

Slit-lamp microscopic and specular microscopic examinations of 4 eyes of 4 patients were performed. All the eyes were operated for complicated retinal detachment and they were aphakic at the end of the operations. Mean follow-up period was 10 months (6-16 months).

RESULTS

Perfluorophenanthrene was seen in the anterior chamber in the first or second day postoperatively as a single drop. In the third week, postoperatively, the first signs of splitting the perfluorophenanthrene (fish egging phenomena) was observed. There was no sign of corneal or anterior segment toxicity with the slit lamp microscopic examinations and the intraocular pressure was within normal limits during the follow-up period in all eyes. However, some structural changes of the corneal endothelium were shown by specular microscopy. Decreased endothelial cell density, a reversed illumination pattern in which the normally dark cellular boundaries appear bright and intracytoplasmic light reflecting bodies were signs of cellular damage at the contact sites whereas no significant changes were seen at non contact sites.

CONCLUSION

Residual perfluorophenanthrene in the anterior chamber does not induce gross corneal damage or ocular inflammation, although structural changes indicating the damage of the corneal endothelium, can be shown by specular microscopy at the contact sites. Corneal endothelial changes seem to arise from a contact-dependent effect of the perfluorophenanthrene.

Results of Photorefractive Keratectomy in Keratoconus Suspects at 4 Years

PURPOSE

We studied the long-term results of photorefractive keratectomy (PRK) in keratoconus suspects detected by videokeratography (TMS).

METHODS

Bilateral inferior corneal steepening was detected in 6 candidates for PRK presenting with moderate myopia or astigmatism. Mean follow-up was 44.5 +/- 4.4 months (range, 38 to 54 mo). Mean spherical equivalent refraction was -5.18 +/- 1.60 D (mean sphere, -4.73 D; mean cyclinder, -0.92 D) which was stable for at least the preceding year. The quantitative measurement of inferior corneal steepening (I-S value) was greater than +1.60 (mean, 1.83 +/- 0.11) in all eyes. An Aesculap Meditec Mel 60 excimer laser was used for the PRK procedures and mean follow-up was 44.5 months. Postoperative pachymetric measurements were also performed in 6 eyes.

RESULTS

Postoperative uncorrected visual acuity was 20/20 in 8 eyes (66.6%) and 20/32 or better in all eyes with a mean postoperative spherical equivalent refraction of -0.70 +/- 0.74 D (mean sphere, -0.63 D; mean cyclinder, -0.39 D). Five eyes (41.6%) were within +/- 0.50 D spherical equivalent refraction. Inferior steepening was associated with thinning of the inferior cornea which was statistically significantly thinner than the superior thickness (Student's t-test, P < .05). There were no wound healing problems or any sign that the excimer laser adversely affected the cornea during follow-up.

CONCLUSIONS

Photorefractive keratectomy seems to be a safe procedure for reducing or eliminating myopia or astigmatism in keratoconus suspect eyes-most probably forme fruste keratoconus-with a stable refraction, but this may be different in eyes with early keratoconus, known to be a progressive disease.

Scanning laser polarimetry in corneal topographic changes after photorefractive keratectomy

PURPOSE

To examine whether, or not, corneal topographic changes after excimer laser photorefractive keratectomy (PRK) for myopia and myopic astigmatism have any influence on measurements of the retinal nerve fiber layer (NFL) with scanning laser polarimetry.

METHODS

Retinal NFL thicknesses were determined by scanning laser polarimetry in 17 eyes of 13 patients with myopia and myopic astigmatism before and after PRK. Total ablation depth ranged from 26 to 71 microm. We used the relative ratios for superior and inferior NFL thicknesses which were calculated by dividing the NFL values of respective regions by the nasal value.

RESULTS

The mean superior NFL ratio measured was 3.02 +/- 0.92 preoperatively, and 3.00 +/- 0.76 postoperatively. The mean inferior NFL ratio was 2.95 +/- 0.75 preoperatively, and 2.99 +/- 0.66 postoperatively. There was no statistically significant difference between preoperative and postoperative NFL measurements (Wilcoxon signed rank test, p > 0.05).

CONCLUSIONS

Corneal topographic changes after PRK have no significant influence on NFL measurements by scanning laser polarimetry. Our results suggest that scanning laser polarimetry can be used as a reliable method for retinal NFL thickness measurements even after excimer laser PRK.

Corneal iron ring after hyperopic photorefractive keratectomy

PURPOSE

To report the incidence and course of corneal iron deposition after hyperopic photorefractive keratectomy (PRK).

SETTING

Gazi University, Medical School, Department of Ophthalmology, Ankara, Turkey.

METHODS

Between January 1995 and December 1997, 62 eyes had PRK to correct hyperopia.

RESULTS

Nine eyes developed corneal iron ring 5 to 8 months (mean 6.25 months +/- 1.3 [SD]) after PRK for hyperopia. The rings persisted during the mean follow-up of 19 +/- 11.09 months.

CONCLUSION

The ring-shaped iron deposition after PRK for hyperopia must be differentiated from the Fleischer ring. Our results suggest that the slitlamp findings of peripheral corneal iron deposition in hyperopic PRK patients correlate with achieved correction.

Photorefractive keratectomy in refractive accommodative esotropia

Photorefractive keratectomy (PRK) was performed on a 19-year-old man with hyperopic astigmatism and refractive accommodative esotropia. The patient was orthophoric while wearing spectacles, but had an esotropia of 30 prism dioptres at near and distance vision without spectacles. The best corrected visual acuity of the right eye was 20/50 and of the left eye was 20/20. The excessive accommodative convergence of the patient was eliminated by correcting the hyperopic refractive error by performing PRK, and the patient became orthophoric after the treatment.

Fluorometholone-induced cataract after photorefractive keratectomy

The use of topical corticosteroids following photorefractive keratectomy (PRK) is widespread. The major complications of potent corticosteroids are glaucoma and cataract formation; in order to decrease these complications, 0.1% fluorometholone administration is usually preferred after PRK. We report here a case of lens opacification which was induced by 0.1% fluorometholone administration after PRK in a period of 4 months. To our knowledge, this is the first reported case of 0.1% fluorometholone-induced cataract after PRK.

The molecular epidemiology of trimethoprim-sulphamethoxazole- resistance of Shigella flexneri in the Trakya region of Turkey

Trimethoprim-sulphamethoxazole (SXT) resistance increased among Shigella flexneri isolates in 1995 relative to previous years, in the Trakya region, the European part of Turkey. Since this region is the entrance to Turkey from northern countries, a heavy traffic of travellers passing through should have been importing or exporting the resistant isolates. We studied the genetic basis and epidemiology of this resistance and monitored the clonal changes which have taken place in the meanwhile. During the study period, a total of 70 Shigella spp. were isolated. Of these 58 were S. flexneri, 10 were S. sonnei and two were S. boydii. S. dysenteriae was not isolated. Of S. flexneri isolates 32 were SXT, ampicillin, chloramphenicol and tetracycline resistant (pattern I), while two isolates were found to be resistant only to SXT (Pattern II). Transconjugation experiments revealed that an approximately 80 Kbp self-transmissible plasmid carried the SXT resistance genes in both groups. However, EcoRI and HindIII restriction patterns of the plasmids from resistance pattern I and resistance pattern II were different. Ribotypes of three randomly selected isolates from pattern I were identical and were distinguishable from the ribotype of the isolate from pattern II. We concluded that at least two different clones with different plasmids and resistance patterns were spreading in our territory.

Effects of hyper- and hypo- thyroidism on oxidative stress of the eye in experimental acute anterior uveitis

Glutathione peroxidase activities and malondialdehyde levels were measured in the homogenated anterior segment of rat eyes with endotoxin induced acute anterior uveitis in euthyroid, hyperthyroid and hypothyroid rats. Malondialdehyde concentrations were found to be significantly increased (p < 0.0005) and glutathione peroxidase activities significantly decreased (p < 0.01) in the hyperthyroid group when compared with controls. Malondialdehyde concentrations of the hypothyroid rat eyes were higher than the control group (p < 0.05), but glutathione peroxidase activities of the same group showed no difference with controls (p > 0.05). These results suggest that excess or deficiency of the thyroid hormones cause alterations in the malondialdehyde levels and glutathione peroxidase activities of the rat eyes in endotoxin induced uveitis, and hyperthyroidism may increase the oxidative stress in endotoxin induced acute anterior uveitis.