Evaluating systemic immune-inflammation index in patients with implantable cardioverter defibrillator for heart failure with reduced ejection fraction

Background

Pro-inflammatory pathways play a serious role in the follow-up of patients with intracardiac defibrillator (ICD) for heart failure reduced with ejection fraction (HFrEF). A newly defined index, which is named as systemic immune-inflammation index (SII), has been recently reported to have prognostic value in patients with cardiovascular disease.

Purpose

The aim of this investigation is to evaluate the value of SII in terms of its association with long-term mortality and appropriate ICD therapy during in 10-year follow-up.

Methods

This retrospective study included 1011 patients with ICD for HFrEF. The study population was divided into two groups according to optimal cut-off value of SII to predict long-term mortality. The long-term prognostic impact of SII on these patients were evaluated in terms of mortality and appropriate ICD therapy.

Results

A receiver operating characteristic curve analyses of systemic immune-inflammation index, platelet-to-lymphocyte ratio and neutrophil-to-lymphocyte ratio in long-term mortality and appropriate intracardiac defibrillator therapy for patients intracardiac defibrillator for heart failure reduced with ejection fraction were presented in Figure 1A and 1B respectively. The patients with higher SII had significantly higher long-term mortality and appropriate ICD therapy. After adjustment for all confounding factors, the long-term mortality had 5.1 higher rates at higher SII. (95% CI: 2.9–8.1). The long-term appropriate ICD therapy also had 2.0 higher rates at higher SII (95% CI: 1.4–3.0). Kaplan Meier survival analysis of patients according to the systemic immune-inflammation index was presented in Figure 2.

Conclusion

SII, calculated using neutrophil, platelet, and lymphocyte counts, may be an independent predictive marker for both long-term mortality and appropriate ICD therapy in patients with HFrEF.

Funding Acknowledgement

Type of funding sources: None.

Comparison of mortality prediction scores in elderly patients with ICD for heart failure with reduced ejection fraction

Background

This investigation aimed to examine and compare the predictive value of MADIT-II, FADES, PACE and SHOCKED scores in predicting 1-year and long-term all-cause mortality in implantable cardioverter-defibrillator (ICD) implanted patients who were 75 years and over since there has been an area of uncertainty about the utility and usefulness of available risk scores in such cases.

Methods

In this observational, retrospective study, ICD implanted 189 geriatric patients are divided into two groups according to the presence of long-term mortality in follow-up. The baseline characteristics and laboratory variables were compared between the groups. MADIT-II, FADES, PACE and SHOCKED scores were calculated at the time of ICD implantation. 1-year and long-term predictive value of these scores were compared by a receiver operating curve (ROC) analysis.

Results

A ROC analysis showed that the best cut-off value of the MADIT-II score to predict 1-year mortality is 3 with 87% sensitivity and 74% specificity (AUC: 0.83; 95% CI: 0.73–0.94; p<0.001) and long-term mortality is 2 with 83% sensitivity and 43% specificity (AUC: 0.68; 95% CI: 0.60–0.76; p<0.001) The predictive value of MADIT-II was superior to FADES, PACE and SHOCKED scores in ICD implanted patients who are 75 years and over.

Conclusion

MADIT-II score has a significant prognostic value compared to FADES, PACE and SHOCKED scores for the prediction of 1-year and long-term follow-up in geriatric patients implanted ICD for heart failure with reduced ejection fraction.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

The value of c-reactive protein to albumin ratio in predicting long term mortality among hfref patients with implantable cardiac defibrillators

Funding Acknowledgements

Type of funding sources: None.

Background

Patients with heart failure with reduced ejection fraction (HFrEF) who received implantable cardiac defibrillator (ICD) still remain at high risk due to pump failure and comorbid conditions. C-reactive protein to albumin ratio (CAR) may be of value for identifying those with high risk for mortality despite ICD implantation.

Methods

Those who were implanted ICD for HFrEF in our institution between 2009 and 2019 were included. CAR was calculated as ratio of C-reactive protein (CRP) to serum albumin concentration. Patients were grouped into tertiles in accordance to CAR at the time of implantation. After follow up of 48 ± 35 months, survival times of tertiles were compared by using Kaplan-Meier survival method.

Results

Thousand and eleven patients constituted study population. Ischemic cardiomyopathy was primary diagnosis in 92.3%. Of those 14.5% had died after discharge. Patients in tertile 3 (T3) had higher risk of appropriate shock (19.3% vs 23.7% vs 38.0%) and mortality (4.2% vs 11.0% vs 28.5%) compared to those in other tertiles. Multivariable analysis revealed that when patients in T1 were considered as reference, both those in T2 and T3 had independently higher risk of appropriate shocks and mortality. These effects were consistent in the unadjusted and adjusted multivariable models.

Conclusion

Among patients with HFrEF and ICD, elevated CAR increased the risk of appropriate device shock and mortality at long term. Table 1Admission C-reactive protein/Albumin ratio (n = 1011)T1 (n = 337)T2 (n = 337)T3 (n = 337)Mortality, %4.211.028.5Mortality, HR (95% CI)Model 1: unadjusted1[Reference]3.85 (2.12 - 11.20)8.14 (2.46 - 28.56)Model 2: adjusted for age, sex1[Reference]3.20 (1.90 - 9.48)6.32 (2.12 - 20.12)Model 3: adjusted for comorbiditesa1[Reference]4.85 (2.06 - 14.12)10.86 (4.12 - 44.82)Model 4: adjusted for covariatesb1[Reference]2.72 (1.66 - 7.12)5.72 (2.04 - 18.05)Frequency, %19.323.738.0Appropriate shock, HR (95% CI)Model 1: unadjusted1[Reference]1.38 (0.44 - 6.88)2.48 (1.34 - 5.82)Model 2: adjusted for age, sex1[Reference]1.42 (0.48 - 7.24)3.02 (1.52 - 6.24)Model 3: adjusted for comorbiditesa1[Reference]1.34 (0.38 - 6.66)2.74 (1.40 - 7.28)Model 4: adjusted for covariatesb1[Reference]1.30 (0.34 - 5.68)2.28 (1.16 - 8.28)Cox proportional analysis and logistic regression models for the appropriate shock and the long-term mortality by CAR.Abstract Figure 1

Predictors of all-cause mortality among patients with implantable cardiac defibrillators for nonischemic heart failure with reduced ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Background

Implantable cardiac defibrillators (ICD’s) are recommended in patients with heart failure with reduced ejection fraction (HFrEF) of nonischemic etiology. Determining patients who are at high risk despite ICD implantation is of clinical value.

Methods

Between 2009-2019 patients who were implanted ICD due to nonischemic HFrEF were included to the present analysis. Baseline characteristics, laboratory parameters and echocardiographic findings were obtained from the electronic database. The primary outcome was all-cause mortality. Appropriate and inappropriate device therapies were also extracted from the database and was confirmed with patients’ reports. Predictors for long term all-cause mortality was determined by using Cox regression analysis.

Results

Overall, 1199 patients were screened and 238 were eligible for the analysis. ICD’s were implanted for primary and secondary prevention in 68 (28.6%) and 170 (71.4%) of patients respectively. Multivariate analysis revealed that increased pro-BNP [Hazard ratio (HR): 1.001, 95% Confidence interval (CI): 1.000 – 1.001, p = 0.024] and reduced left ventricle ejection fraction (HR: 0.950, 95% CI: 0.907 – 0.994, p: 0.026) predicted all-cause mortality during long term follow up. Pro-BNP > 425 pg/ml has sensitivity and specificity of 74% for each in predicting all-cause mortality.

Conclusion

Among patients who were implanted ICD for HFrEF of nonischemic etiology, higher pro-BNP prior to the implantation and lower LVEF predicted all-cause mortality during long term follow up. Table 1Univariate analysisP valueHR (95% CI)Multivariate analysisP valueHR (95% CI)Diabetes mellitus0.0062.587 (1.315 - 5.090)Diabetes mellitus0.1441.837 (0.812 - 4.153)Atrial fibrillation0.0023.080 (1.531 - 6.195)Atrial fibrillation0.1811.738 (0.774 - 3.903)NYHA > 20.0172.394 (1.168 - 4.908)NYHA > 20.2531.642 (0.701 - 3.847)RDW0.0441.191 (1.005 - 1.412)RDW0.6461.046 (0.862 - 1.270)Lymphocytes0.0220.616 (0.408- 0.932)Lymphocytes0.1650.683 (0.399 - 1.170)Blood urea nitrogen0.0381.015 (1.001- 1.030)Blood urea nitrogen0.1521.015 (0.995 - 1.036)Pro-BNP<0.0011.001 (1.000 - 1.001)Pro-BNP0.0241.001 (1.000 - 1.001)Albumin<0.0010.252 (0.143 - 0.444)Albumin0.0790.525 (0.256 - 1.079)Ejection fraction<0.0010.921 (0.885 - 0.959)Ejection fraction0.0260.950 (0.907 - 0.994)LVEDD0.0011.408 (1.017 - 1.079)LVEDD0.1521.078 (0.973 - 1.194)LVESD0.0041.038 (1.012 - 1.065)LVESD0.2890.957 (0.883 - 1.038)Appropriate shock in follow-up0.0102.407 (1.237 - 4.684)Appropriate shock in follow-up0.1561.768 (0.805 - 3.883)Univariate and multivariate Cox regression analyses for long-term mortality after ICD implantation Abstract Figure 1

Prognostic Nutritional Index as the Predictor of Long-Term Mortality among HFrEF Patients with ICD

Funding Acknowledgements

Type of funding sources: None.

Background

The benefit of implantable cardiac defibrillator (ICD) in patients with heart failure and reduced ejection fraction (HFrEF) could be limited in a particular group of patients. Low prognostic nutritional index (PNI) indicates malnutrition and pro-inflammatory condition. We sought to investigate the value of PNI in predicting long-term mortality among HFrEF patients with ICD.

Methods

Electronic database was searched for identifying patients with HFrEF who were implanted ICD in our institution between 2009 and 2019. Demographic and clinical characteristics of included patients were recorded. PNI was calculated according to the formula: 10 x serum albumin (g/dL) + 0.005 x total lymphocyte count (per mm3). Patients were divided into the quartiles according to PNI values. Differences between the groups were analysed by the log-rank test. A forward Cox proportional regression model was used for multivariable analysis.

Results

One thousand and hundred patients were included to the study. The underlying heart failure etiology was ischemic and non-ischemic in 77.3% and 22.7% of patients respectively. Mortality rate in Q1 (5.1%) was considered as the reference. In the unadjusted model the mortality rate was 9.5% [hazard ratio (HR) 1.76, 95% confidence interval (95% CI) (0.92 – 3.38)] in Q2, 10.2% (HR 1.88, 95% CI 0.99 – 3.58) in Q3 and 39.6% (HR 8.12, 95% CI 4.65 – 14.17) in Q4. The same trend was consistent in the age- and sex-adjusted, comorbidities-adjusted and covariates-adjusted models.

Conclusion

Among patients who were implanted ICD secondary to HFrEF, lower PNI value predicted all-cause mortality during long-term follow up. This is the first study demonstrating the value of PNI in this population. Table 1Admission Prognostic Nutritional Index (n = 1100)Q1 (n = 275)Q2 (n = 275)Q3 (n = 275)Q4 (n = 275)Long-term mortalityNumber of deaths142628109Mortality, %5.19.510.239.6Mortality, HR (%95 CI)Model 1: unadjusted1[Reference]1.76 (0.92 - 3.38)1.88 (0.99 - 3.58)8.12 (4.65 - 14.17)Model 2: adjusted for age, sex1[Reference]1.70 (0.90 - 3.48)1.79 (0.94 - 3.42)7.76 (4.42 - 13.61)Model 3: adjusted for comorbiditesa1[Reference]1.85 (0.96 - 3.55)1.89 (0.99 - 3.60)9.02 (4.34 - 14.12)Model 4: adjusted for covariatesb1[Reference]1.66 (0.88 - 3.21)1.60 (0.80 - 3.05)6.45 (3.61 - 12.5)Cox proportional analysis and logistic regression models for the long-term mortality by the prognostic nutritional indexAbstract Figure 1

Determination of anomalous pulmonary venous return with high-pitch low-dose computed tomography in paediatric patients

BACKGROUND

In this study, we aimed to image pulmonary venous return anomalies and associated cardiovascular and pulmonary abnormalities by high-pitch low-dose computed tomography (CT) in children.

MATERIALS AND METHODS

Forty-one patients with total or partial anomalous pulmonary venous return anomalous between May 2012 and June 2019 were retrospectively reviewed. The anomalies were determined using high-pitch low-dose CT. The patients' mean age was 3 years (6 months to 15 years), and 24 of them were female.

RESULTS

There were 10 patients with total pulmonary venous return anomalies (TPVRA) and 31 patients with partial pulmonary venous return anomalies (PPVRA). Six (60%) patients with TPVRA had the supracardiac type, 2 (20%) had the cardiac type, and 2 (20%) had the mixed type. All patients with TPVRA had a large atrial septal defect (ASD), 1 patient also had patent ductus arteriosus, and 1 patient had right cardiac hypertrophy. Forty cases of PPVRA were found in 31 patients. Twenty-seven (67%) of them were right-sided, and 13 were left-sided (33%). Twenty (65%) patients also had an additional cardiovascular anomaly (ASD in 12 patients, persistent superior vena cava in 4 patients, patent ductus arteriosus in 3 patients, and aortic coarctation in 2 patients). Of the 27 patients with right-sided PPVRA, it drained into the superior vena cava in 19 patients, the right atrium in 5 patients, and the inferior vena cava in 3 patients. In left-sided cases, the anomalous pulmonary vein drained into the left innominate vein in 9 patients, and in 4 patients, there were accessory pulmonary veins that drained into the left innominate vein. Many of the patients had additional lung anomalies, including pneumonic infiltration (n = 12), atelectasis (n = 8), and lobar emphysema (n = 5), and some of these findings coexisted.

CONCLUSIONS

Anomalous pulmonary venous drains and associated cardiac and extra-cardiac anomalies can be detected reliably and quickly with high-pitch low-dose CT without sedation in paediatric patients.

Surgical outcome of bronchiectasis in children: long term results of 60 cases

BACKGROUND

Bronchiectasis is described as destruction and the irreversible dilatation of bronchial structure. We wanted to demonstrate our surgical practice and outcome of surgical treatment in bronchiectasis.

METHODS

We studied records of 60 pediatric patients who underwent surgical resection in our clinic between January 2000 and January 2013. The results were analyzed regarding factors influencing the outcome.

RESULTS

There were 32 boys and 28 girls with a mean age of 9.45 years (range 2-15). The most common cause was childhood infection in 25 (41.66%). The mean duration of the symptoms was 42.93 months. Patients underwent 64 operations including 2 staged thoracotomies and 2 re-thoracotomies. Atelectasis was the most frequent complication. Longer duration of symptoms related to postoperative complication. The morbidity and mortality rates were 20% and 3.33%, respectively. The outcome was optimal in 92%. Forced expiratory volume in 1 s less than 60% of the predicted value, hemoptysis and duration of symptoms were found prognostic variables for postoperative morbidity with high ratios of odds coefficients by using Binary Logistic Regression Method.

CONCLUSIONS

Complete and early resection of bronchiectasis provides a successful outcome. Duration of symptoms and timely intervention have a major impact on the management and prognosis.

Coagulopathy parameters in patients with Crimean-Congo hemorrhagic fever and its relation with mortality

BACKGROUND

Crimean-Congo hemorrhagic fever (CCHF) is an acute illness affecting multiple organ systems and characterized by ecchymosis, visceral bleeding, and hepatic dysfunction. In this study, we aimed to investigate the profile of coagulopathy markers (platelet count, activated partial tromboplastin time (aPTT), prothrombin time (PT), international normalized ratio (INR), fibrinogen, protein C, protein S, antithrombin III, activated protein C resistance (APCR), and D-dimer) and their clinical significance in 83 CCHF-infected patients.

SUBJECTS AND METHODS

We studied 83 CCHF patients who were admitted to Ankara Numune Education and Research Hospital during the spring and summer of2007. We compared the coagulopathy markers of fatal CCHF patients (n=9) with nonfatal cases (n=74).

RESULTS

Platelet count, PT, aPTT, INR, and fibrinogen were prognostic factors associated with mortality for CCHF. Especially, platelet count<20 x 10(9) cells/l and aPTT>60 sec were important. Protein C, protein S, APCR, and antithrombin III levels were not associated with mortality.

CONCLUSION

Laboratory tests including classical parameters (platelet count, PT, aPTT, INR, and fibrinogen) of coagulopathy seem to be enough for the followup of CCHF. Protein S, protein C, APCR, and D-dimer levels were not associated with mortality.

Characterıstıcs of cutaneous anthrax ın Turkey

BACKGROUND: Incidence of anthrax is diminishing in developed countries; however, it remains a public health problem in developing countries, especially those whose main source of income is farming. METHODOLOGY: Charts of patients hospitalized between 1992 and 2008 in the Infectious Diseases and Clinical Microbiology Department of Ankara Numune Education and Research Hospital were reviewed. RESULTS: Fifty-eight cases with cutaneous anthrax were reviewed. The mean age was 49.8, and 36.2% were female. The most common professions were farmers (62%), butchers (19%), and housewives (15%). The mean incubation period was eight days. Most cases (62%) were exposed to bacteria when butchering sick animals. Eighteen patients used an antibiotic before admission to hospital (31%). The predominantly affected sites were hands (39%) and fingers (29%), followed by forearms (12%), eyelids (7%) and necks (3%). All cases initially had painless ulcers with vesicles; dissemination of the lesion was seen in 27.5% of patients. Gram stain was positive in 11 cases; culture was positive in 7 cases for Bacillus anthracis. All patients except one were discharged and treated with penicillin and/or ciprofloxacin or imipenem. One patient with a disseminated lesion on the neck died even though a steroid was used with the antibiotic. CONCLUSIONS: Cutaneous anthrax should be considered as a possible diagnosis in cases with a painless ulcer with vesicles, edema, and a history of exposure to animals or animal products. Despite previous antibiotic use, taking smears and cultures should be encouraged. Treatment with penicillin G or penicillin procain alone is effective for cases with cutaneous anthrax without severe edema and superinfection.

Characteristics of cutaneous anthrax in Turkey

BACKGROUND

Incidence of anthrax is diminishing in developed countries; however, it remains a public health problem in developing countries, especially those whose main source of income is farming.

METHODOLOGY

Charts of patients hospitalized between 1992 and 2008 in the Infectious Diseases and Clinical Microbiology Department of Ankara Numune Education and Research Hospital were reviewed.

RESULTS

Fifty-eight cases with cutaneous anthrax were reviewed. The mean age was 49.8, and 36.2% were female. The most common professions were farmers (62%), butchers (19%), and housewives (15%). The mean incubation period was eight days. Most cases (62%) were exposed to bacteria when butchering sick animals. Eighteen patients used an antibiotic before admission to hospital (31%). The predominantly affected sites were hands (39%) and fingers (29%), followed by forearms (12%), eyelids (7%) and necks (3%). All cases initially had painless ulcers with vesicles; dissemination of the lesion was seen in 27.5% of patients. Gram stain was positive in 11 cases; culture was positive in 7 cases for Bacillus anthracis. All patients except one were discharged and treated with penicillin and/or ciprofloxacin or imipenem. One patient with a disseminated lesion on the neck died even though a steroid was used with the antibiotic.

CONCLUSIONS

Cutaneous anthrax should be considered as a possible diagnosis in cases with a painless ulcer with vesicles, edema, and a history of exposure to animals or animal products. Despite previous antibiotic use, taking smears and cultures should be encouraged. Treatment with penicillin G or penicillin procain alone is effective for cases with cutaneous anthrax without severe edema and superinfection.

Methicillin-resistant Staphylococcus aureus on hospital admission in Turkey

A total of 900 patients were screened for methicillin-resistant Staphylococcus aureus (MRSA) on hospital admission, and 11 MRSA strains (1.2%) were detected. All 11 MRSA strains were positive for the mecA and PVL genes. Eight of the 11 MRSA-positive patients (72%) had a history of hospitalization within the previous 12 months.

Epidemiologic and clinical characteristics of HIV/AIDS patients in Turkey, where the prevalence is the lowest in the region

The authors describe the epidemiologic and clinical characteristics of 97 human immunodeficiency virus (HIV)-infected patients, who were followed between 1993 and 2006. Seventy-two percent of the patients were male, and median age at diagnosis was 36 years (range, 13-71 years). The mean years of survival was 3, and maximum length of life after diagnosis was 9 years. The most common professions were truck drivers, workers, and housewives. Forty-six percent of the males had a history of working abroad. Heterosexual intercourse was the most common (84%) route of transmission. Seventy-four percent of the women acquired infection from their husbands. In Turkey, less educated or uneducated and poor men are the primary target of the HIV infection usually by sexual contact with foreign women. Considering the low education status of the patients, appropriate education programs should be developed to prevent the dissemination of HIV infection. Because a significant number of patients were diagnosed at very late stages, the physicians and other health care workers should be educated on the clinical pictures of HIV/AIDS.

A sporadic abdominal desmoid tumour case presenting with intermittent intestinal obstruction

Desmoid tumours, also known as aggressive fibromatosis, are rare lesions with an intermediate biological behaviour between benign fibrous lesions and fibrosarcomas. Although abdominal desmoids have an increased incidence in Gardner's syndrome, they are rarely found in an isolated form. We report the findings of a barium study, ultrasound, computed tomography and magnetic resonance imaging in a nine-year-old boy with intermittent nausea and vomiting, diagnosed as having a desmoid tumour. Although intra-abdominal desmoids are usually detected as a solitary lesion in sporadic cases, the presented case had two mesenteric lesions in the left upper quadrant. There was intestinal obstruction and the masses had invaded the colon wall.

Measles, rubella, mumps, and varicella seroprevalence among health care workers in Turkey: is prevaccination screening cost-effective?

BACKGROUND

To investigate the immune status of health care workers (HCWs) against measles, rubella, mumps, and varicella zoster (MMRV) in Turkey and to define an appropriate vaccination program among HCWs.

METHODS

Voluntary HCWs from a children's hospital and a general hospital were included in the study between March and May 2005. The specific IgG antibodies against MMRV viruses were screened by ELISA.

RESULTS

Three hundred sixty-three HCWs participated in the study; 186 (51%) were physicians, 118 (33%) were nurses, 36 (10%) were housekeeping staff, and 23 (6%) were medical technicians. The proportion of HCWs who had antibodies against measles was 98.6%; rubella, 98.3%; mumps, 92.2%; and varicella, 98%. No association was found between the susceptibility to at least 1 of MMRV virus infections and gender, age, duration of work, profession, and department of work in analysis either among the whole study group, or each hospital. The positive predictive value for the history of varicella was 100%, whereas it was 92% for MMR. The cost of vaccination for varicella was significantly expensive without screening before vaccination. However, there was not much difference for MMR infections.

CONCLUSION

A policy based on obtaining the history of varicella infection from the staff and then screening the ones with negative history and vaccination of only seronegative HCWs was found to be appropriate.

Synchronous cervical and vulvar malign melanomas: metastasis or multifocality of the disease? A case report and review of the literature

Vulvar melanoma is rare and has a worse prognosis and higher recurrence rate than cutaneous melanoma. Multifocality is also more common in vulvar melanomas. A case having synchronous cervix and vulvar malign melanoma is presented and discussed in the light of the literature whether it is a metastasis of vulvar malign melanoma to cervix or multifocal originated disease. In conclusion, it is important to evaluate the whole genital system in vulvar melanomas as it is in squamous cancers.

Cognitive and emotional changes in neurobrucellosis

OBJECTIVE

To determine cognitive and emotional changes among neurobrucellosis patients.

METHODS

The patients with neurobrucellosis and controls with brucellosis without neurologic involvement were included in the study. Neurobrucellosis was diagnosed by the following criteria: (i) symptoms or clinical findings compatible with neurobrucellosis, including headache, confusion, mental and emotional changes; (ii) isolation of Brucella spp. from CSF and/or demonstration of antibodies to Brucella > or = 1/4 in the CSF; (iii) the presence of lymphocytosis, increased protein and decreased glucose levels in the CSF; and (iv) clinical improvement with appropriate treatment. Two psychiatrists interviewed the patients, and performed the Hamilton Depression Rating Scale (HDRS) tests and Mini-Mental State Examination (MMSE) tests.

RESULTS

Thirty-four neurobrucellosis cases and 30 patients with brucellosis without neurological involvement were studied. The mean age was 41 years, 12 (41%) patients were female, 13 (46%) patients were farmers, and 7 (25%) patients were housewives. Among the neurobrucellosis cases, before the antibiotic therapy, the mean MMSE test score was 21.6, one week after the therapy 22.7, and two weeks after the therapy 24.3 (p=0.024, and p<0.001, respectively). At the day of admission before therapy, the mean of HDRS test was 9.9, one week after therapy it was 7.8, and two weeks after therapy it was 5 (p=0.014, and p<0.001, respectively).

CONCLUSION

The cognitive and emotional disturbances among neurobrucellosis patients were documented by MMSE and HDRS tests. These disorders improve by antibiotic therapy, without any anti-depressive or anti-psychotic therapy.

Imaging of diaphragmatic rupture after trauma

Traumatic rupture of the diaphragm usually results from blunt or penetrating injuries, or iatrogenic causes. Most cases are initially overlooked in the acute phase because they present with variable clinical and radiological signs. An overlooked diaphragmatic injury presents as a hernia many years later with potentially serious complications, therefore selection of the most appropriate radiological technique and accurate diagnosis of traumatic diaphragmatic hernias (DH) on the first admission is important. Although the diagnosis of diaphragmatic injuries is problematic, various investigations may be used for diagnosis. We describe the imaging findings of 19 traumatic DH cases with various imaging techniques. The patients were acute trauma cases or cases with prior trauma or thoraco-abdominal surgery with clinical suspicion of DH. An evaluation of the imaging techniques used in the diagnosis of DH is presented.

[Malaria in Turkey and 14 years of clinical experience]

In this retrospective study, the epidemiologic and clinical characteristics of 105 adult malaria patients, who had been hospitalized between the period of 1992 and 2006 were evaluated. Nineteen percent of the patients were female, and the mean age was 28 +/- 10 years. Fifty percent of the patients acquired the infection in Southeastern Anatolia, while they were on military duty. The most common complaints were rigor (93%), fever (90%), sweating (90%), headache (76%), nausea (45%), and fatigue (38%). The most common physical examination findings were splenomegaly (86%) and hepatomegaly (62%). Anemia was detected in 23%, leukopenia in 47%, thrombocytopenia in 73%, two fold increase in ALT or AST enzyme levels in 32% of the patients. Plasmodium vivax was detected in 101 (96%) patients, whereas P. falciparum was detected in 4 patients (4%). Although the number of malaria cases in Turkey is declining in recent years, the febrile patients with a history of travel to the endemic regions should raise the suspicion of malaria.

Analysis of risk-factors among patients with Crimean-Congo haemorrhagic fever virus infection: severity criteria revisited

The aim of this study was to determine the predictors of mortality among patients infected with Crimean-Congo haemorrhagic fever (CCHF) virus. Among patients with acute febrile syndrome, characterised by malaise, bleeding, leukopenia and thrombocytopenia, who were admitted to hospital during the spring and summer of 2002-2004, 54 had positive IgM and/or PCR results for CCHF virus in blood or tissue. The overall case fatality rate was 7.4%. Among the fatalities, haematemesis (p 0.009), melaena (p 0.001) and somnolence (p 0.022) were more common, the median platelet count was significantly lower (10,600/mL vs. 20,000/mL; p 0.038), the mean prothrombin time (27 s vs. 16 s; p 0.002) and mean activated partial thromboplastin time (73 s vs. 44 s; p < 0.001) were longer, and the mean alanine transferase (ALT) level (1,125 vs. 331; p < 0.001), the mean aspartate transferase (AST) level (3,118 vs. 913; p 0.004) and the mean fibrinogen level (119 vs. 340; p 0.012) were higher. Serum IgM and IgG against CCHF virus was detected in 25% and 0%, respectively, of fatal cases, compared with 94% and 62%, respectively, of cases with favourable outcomes. Oral ribavirin was prescribed to 22 (41%) patients. Of the four fatal cases, it was the intention to prescribe ribavirin to three patients, but this was not possible because of haematemesis and melaena. Higher levels of AST (>or= 700 U/L) and ALT (>or= 900 U/L) are suggested for use as severity criteria. Oral ribavirin was not effective for patients with haematemesis, and intravenous ribavirin is necessary for treatment of CCHF.

Combined administration of misoprostol in the first and second trimester missed abortion cases

OBJECTIVE

We aimed to investigate the effectiveness and adverse effects of combined (vaginal + oral) administration of misoprostol in missed abortion cases.

MATERIAL AND METHODS

48 missed abortion cases between 8 and 20 weeks of gestation were enrolled in this study. Misoprostol-induced medical abortion was planned; the first dose (200 microg) was administered intravaginally and subsequent doses (200 microg each) orally every following hour. A maximum of six doses (1200 microg) were used. Revision curettage was performed on all subjects who aborted.

RESULTS

The mean time interval from the first dose of misoprostol until the abortion was 6.27 +/- 3.02 hours. The success rate was 95% for the whole group. We observed misoprostol-related trembling in one patient and fever in two patients.

CONCLUSION

We believe that our low-dose combined misoprostol protocol is a safe, effective and well-tolerated method with minimal adverse effects for the termination of both first and second trimester pregnancy losses.

Maternal zinc and cord blood zinc, insulin-like growth factor-1, and insulin-like growth factor binding protein-3 levels in small-for-gestational-age newborns

PURPOSE

To determine the relationship between maternal serum zinc (Zn) levels and birth weight of the offspring and their correlation with cord blood Zn, insulin-like growth factor (IGF-1) and insulin-like growth factor binding protein-3 (IGFBP-3) levels.

METHOD

22 term small-for-gestational-age (SGA) and 34 term appropriate-for-gestational-age (AGA) infants and their mothers were included. Maternal and cord blood Zn levels and cord blood IGF-1 and IGFBP-3 levels were measured.

RESULTS

Eighteen percent of mothers had Zn deficiency (< 75 mcg/dl). No significant difference between IGF-1 and IGFBP-3 levels and birth weight of infants of the mothers with and without Zn deficiency was found. Maternal and neonatal Zn levels correlated (r = 0.38, p < 0.01). Mean IGF-1 and IGFBP-3 levels were significantly lower in the SGA group compared to the AGA group (42.3 +/- 16.8 ng/ml, 1.2 +/- 0.2 mcg/ml, and 62.4 +/- 22.7 ng/ml, 1.5 +/- 0.4 mcg/ml, p < 0.001). A correlation was found between birth weight, IGF-1 and IGFBP-3 levels, and weight gain of the mother during pregnancy (p < 0.01).

CONCLUSIONS

Zn deficiency was not observed to be a risk factor for low birth weight. The significant difference between the SGA and AGA babies' IGF-1 and IGFBP-3 levels emphasizes function of the IGF system in intrauterine growth.

[Two leptospirosis cases and review of the national literature]

In this report, two cases of leptospirosis admitted to our clinic in the same periods, have been presented. The first patient was a 29 years old male farmer, and the other was a 44 years old male prisoner. Both of them were from Middle Anatolian Region with the similar clinical findings (subfebrile fever, gastrointestinal complaints, ichterus in sclera, leucocytosis, and increased levels of liver enzymes, urea and creatine). The diagnosis was based on the antibody positivities against Leptospira with microscopic agglutination test which performed in the Etlik Central Veterinary Control and Research Institute. The first case was positive for L. grippotyphosa, and the second was positive for L. australis serovar bratislava at the titers of 1/800. Both of the patients were given empirical antibiotic treatment (ceftriaxone 2 x 1 gr, and ampicillin-sulbactam 4 x 1 gr, respectively), and discharged with complete healing. These cases led us to review the other leptospirosis cases in our country.

A sporadic abdominal desmoid tumour case presenting with intermittent intestinal obstruction

Desmoid tumours, also known as aggressive fibromatoses, are rare lesions having intermediate biological behaviour between benign fibrous lesions and fibrosarcomas. Although abdominal desmoids have an increased incidence in Gardner's syndrome, they are rarely found in isolated form. We report a barium study, ultrasound, computed tomography and magnetic resonance imaging findings of a case in a nine-year-old boy with intermittent nausea and vomiting. Although intraabdominal desmoids are usually detected as a solitary lesion in sporadic cases, the case presented here had two mesenteric lesions in the left upper quadrant. Intestinal obstruction and invasion of colon wall had occurred.

Crimean Congo hemorrhagic fever infection simulating acute appendicitis

An unusual cause of acute abdominal pain simulating acute appendicitis is presented. The patient was admitted with complaints of fever, malaise, headache, nausea, vomiting, diarrhoea, and severe bleeding. Based on the clinical and epidemiological findings, a diagnosis of Crimean Congo hemorrhagic fever virus infection was suspected, and ribavirin therapy was started. While her clinical condition was improving, she experienced a sudden pain at her right lower quadrant of the abdomen. Explorative laparotomy revealed haemorrhage within the abdominal muscles. Her CCHF IgM was found to be positive.

Risk of tuberculous infection among healthcare workers in a tertiary-care hospital in Ankara, Turkey

OBJECTIVE

To determine risk factors for tuberculin skin test (TST) positivity among healthcare workers (HCWs).

DESIGN

Two-step TST was performed in 2002.

SETTING

Tertiary-care hospital in Ankara, Turkey.

PARTICIPANTS

A sample of 491 hospital HCWs were included. Information related to demographics, profession, work duration, department, and individual and family history of tuberculosis (TB) was obtained by a structured questionnaire.

RESULTS

Four hundred eight (83%) had two-step TST positivity. On multivariate analysis, male physicians (relative risk [RR], 1.5; 95% confidence interval [CI95], 1.23-1.69; P = .001), nurses (RR, 1.5; CI95, 1.29-1.66; P = .005), radiology technicians (RR, 1.7; CI95, 1.35-1.73; P = .002), laboratory technicians (RR, 1.6; CI95, 1.3-1.74; P = .007), and male housekeepers (RR, 1.6; (HCWs). CI95, 1.38-1.7; P < .001) had a higher risk than did female physicians. Among laboratory technicians, radiology technicians had the highest TST positivity (85%). HCWs working for less than 1 year (RR, 0.8; CI95, 0.72-0.98; P = .027) had a lower risk of infection. The HCWs having bacille Calmette-Guerin vaccination (RR, 1.12; CI95, 1.08-1.45) had higher TST positivity.

CONCLUSION

Male physicians, nurses, and laboratory technicians had increased risk of Mycobacterium tuberculosis infection in this setting, but community exposure likely accounted for most infections.

Characteristics of B. melitensis versus B. abortus bacteraemias

OBJECTIVE

To determine the epidemiological and the clinical characteristics of bacteremic brucellosis.

METHODS

A prospective study, performed in the First Infectious Diseases Clinic of Ankara Numune Education and Research Hospital. All the patients had positive culture result for Brucella spp.

RESULTS

Fifty-four acute bacteremic brucellosis cases were included. The majority of patients (76%) were from rural Anatolia. Brucella melitensis serotypes were more common than Brucella abortus (83% versus 17%). Fever and arthralgia were the most common symptoms. The number of patients with back pain and arthralgia was higher in B. abortus infected group (p = 0.014 and p = 0.009).

CONCLUSIONS

B. melitensis is the most common subtype of Brucella infection in Turkey. The infections with B. abortus spp. are not less severe than the infections with B. melitensis.

Evaluation of cytologic screening results of the cervix

The aim of this study was to evaluate retrospectively cytologic screening for cancers and precancerous lesions of the cervix and to research whether biopsy is overused among women with a cytologic diagnosis of atypical squamous cells of undetermined significance (ASCUS). We examined 28 469 smears obtained over 5 years. The patients were referred when the result of the smear was abnormal for a colposcopic biopsy, endocervical curettage, or a repeat Papanicolaou smear. The results of the screening of 28 469 smears are as follows: 699 (2.45%) ASCUS, 67 (0.23%) low-grade squamous intraepithelial lesions (LGSIL), 43 (0.15%) high-grade squamous intraepithelial lesions (HGSIL), 1 epidermoid carcinoma, 31 (0.10%) atypical glandular cells, and 1 adenocarcinoma. Histologic examination of the cervix was done in 119 patients (17.0%) of ASCUS, 13 patients (10.9%) of LGSIL, and 15 patients (12.6%) of HGSIL and cervical carcinoma. In the 119 women with histological examination, histologic examination was generally performed in patients with ASCUS neoplastic Papanicolaou smear, and histologic diagnosis of low-grade, high-grade, or invasive lesion of the cervix was made in 23.5% of women with ASCUS; in these patients, 46.4% were cytologic LGSIL and 53.5 % were cytologic HGSIL and cervical carcinoma. In the aspect of these findings, we concluded that for patients with a cytologic diagnosis of ASCUS, more aggressive interventions should be performed.

A whistling face syndrome case with bilateral skin dimples

The whistling face syndrome (Freeman-Sheldon Syndrome) is a rare disorder characterized by typical face and limb abnormalities. A wide range of clinical findings have been reported. We report unusual skin dimples in a sporadic case with the whistling face syndrome.

Evaluation of cytologic screening results of the cervix

The aim of this study was to evaluate retrospectively cytologic screening for cancers and precancerous lesions of the cervix and to research whether biopsy is overused among women with a cytologic diagnosis of atypical squamous cells of undetermined significance (ASCUS). We examined 28 469 smears obtained over 5 years. The patients were referred when the result of the smear was abnormal for a colposcopic biopsy, endocervical curettage, or a repeat Papanicolaou smear. The results of the screening of 28 469 smears are as follows: 699 (2.45%) ASCUS, 67 (0.23%) low-grade squamous intraepithelial lesions (LGSIL), 43 (0.15%) high-grade squamous intraepithelial lesions (HGSIL), 1 epidermoid carcinoma, 31 (0.10%) atypical glandular cells, and 1 adenocarcinoma. Histologic examination of the cervix was done in 119 patients (17.0%) of ASCUS, 13 patients (10.9%) of LGSIL, and 15 patients (12.6%) of HGSIL and cervical carcinoma. In the 119 women with histological examination, histologic examination was generally performed in patients with ASCUS neoplastic Papanicolaou smear, and histologic diagnosis of low-grade, high-grade, or invasive lesion of the cervix was made in 23.5% of women with ASCUS; in these patients, 46.4% were cytologic LGSIL and 53.5 % were cytologic HGSIL and cervical carcinoma. In the aspect of these findings, we concluded that for patients with a cytologic diagnosis of ASCUS, more aggressive interventions should be performed

[Case report: cutaneous tuberculosis and tuberculous osteomyelitis]

In this report, a 27 years old male patient diagnosed to have skin and bone tuberculosis (TB) has been presented. The patient admitted to the hospital with the complaints of fever, weight loss and night sweats. Patient's history revealed that following a trauma a skin lesion in the right ankle was developed and this was followed by the development of many lesions in different parts of the body. The lesions persisted despite the use of various antibiotics since a year. It has been recorded that his father has already been receiving anti-tuberculosis treatment. Osteomyelitis was detected in the distal part of right tibia by computerized tomography, and Mycobacterium tuberculosis was isolated from the specimens of skin lesion. The patient was immunocompetent, and there was no pulmonary involvement. Isoniazid (INAH), rifampin (RIF), ethambutol and morphozinamid therapy has been started and completed to 12 months with INAH and RIF. In the post-treatment follow-up of patient for one year, no relapse was detected. As a result, tuberculosis should be considered in patients with persistent skin lesions especially in endemic countries.

Spinal Brucellosis with Paraspinal Abscess Formation Treated with CT Guided Percutaneous Abscess Drainage

SUMMARY

Although brucellosis may be present in various systems, osteoarticular brucellosis is a serious complication of human brucellosis. We present two cases of Brucellar spondylitis (BS) having paraspinal abscess with epidural extension. The first case of non-complicated paraspinal abscess was treated effectively with percutaneous abscess drainage and antibrucellar chemotherapy. However, the second case with disseminated BS and multiseptated large abscess did not respond to needle drainage with medical treatment. Because of the persistence and re-growth of the abscess, he was treated with percutaneous catheter drainage using the Seldinger technique. They showed adequate radiological and clinical response to drainage and antibrucellar chemotherapy.

[A case report: Kikuchi-Fujimoto disease]

Kikuchi-Fujimoto disease (histiocytic necrotizing lymphadenitis) which presents with fever and lymphadenopathy, should be considered in differential diagnosis of fever with unknown origin. We presented a 19 years old male patient with complaints of fever and lymphadenopathy. The case was diagnosed as Kikuchi-Fujimoto disease by histopathological evaluation.

Characteristics of Patients with Crimean-Congo Hemorrhagic Fever in a Recent Outbreak in Turkey and Impact of Oral Ribavirin Therapy

We describe the epidemiological, clinical, and laboratory findings and the role of ribavirin therapy for 35 patients who received a diagnosis of Crimean-Congo hemorrhagic fever (CCHF). All patients had immunoglobulin M antibodies and/or PCR results positive for CCHF virus in blood or tissue specimens. Eighty-six percent of the patients were considered to have severe cases of CCHF. The overall case-fatality rate was 2.8%. Eight patients were given ribavirin, and all 8 survived. We suggest using ribavirin to treat patients with CCHF, particularly those with severe cases.

Comparison of CT and MRI for the diagnosis recurrent esophageal carcinoma after operation

Despite an increase in radical surgery for esophageal carcinoma, many patients continue to develop recurrent disease. Some reports have suggested that recurrent tumors should be treated aggressively with a combination of chemotherapy and radiotherapy. The aim of this study was to assess the comparative utility of computed tomography (CT) and magnetic resonance imaging (MRI) for the evaluation of recurrence after curative resection of cancer of the esophagus and gastroesophageal junction. To maximize survival benefit, detection of tumor recurrence as early and accurately as possible is important. Twenty-three patients who developed recurrent tumors after curative transthoracic esophagogastrectomy for esophageal carcinoma were analyzed retrospectively. The CT and MRI findings were correlated with pathology or with endoscopic and clinical follow-up. Primary tumor recurrence was detected at the anastomosis side in 19 patients (intraluminal mass in 13 and as diffuse or focal wall thickening in six). Distant recurrence was seen in the liver (n = 5), lung (n = 4), bone (n = 3), abdominal lymph node (n = 4), pleural effusion (n = 2) and pericardial effusion (n = 1). CT and MRI were found equal in showing the intraluminal mass, liver metastasis, pleural and pericardial effusion. Thickening of esophageal wall was demonstrated in nine patients using CT, but only seven of these tumor recurrences were confirmed by MRI, the remaining two were related to secondary fibrosis. Both CT and MRI showed diffuse gastric wall thickening determined as false tumor recurrence due to severe gastritis in one case. There were two (50%) false negatives for lung metastasis in MRI and one bone metastasis (33%) false negative in CT. CT was found superior in the demonstration of lung metastasis and MRI was superior in the evaluation of wall thickening and bone metastasis.

In vitro antimicrobial susceptibility of Brucella species

MIC50 and MIC90 values of doxycycline, rifampicin, ciprofloxacin, trimethoprim-sulphamethoxazole and ceftriaxone for 42 blood isolates of Brucella species were determined using the Etest. Thirty-seven isolates were identified as B. melitensis and five as B. abortus. Doxycycline had the lowest and rifampicin the highest MIC50 values. Four strains were non-susceptible to rifampicin, and one strain was resistant to trimethoprim-sulphamethoxazole. There is no significantly important resistance problem for antibiotics targeted against Brucella species in Turkey. However, since rifampicin is commonly used for prevalent diseases such as tuberculosis, the regional susceptibility pattern of rifampicin should be assessed periodically.

Pleural tenting in complicated primary spontaneous pneumothorax

AIM

To assess the efficacy of pleural tenting in patients with complicated primary spontaneous pneumothorax (PSP).

METHODS

From 1988 through 2001, 43 patients underwent operations. Mean age was 30.4 years; the male/female ratio was 9.7. Twenty-one (48.8%) underwent pleural tenting in addition to bulla excision (experimental group, EG). Twenty-two (51.2%) underwent bulla excision plus pleural abrasion (11 patients), apical partial pleurectomy (9 patients) and complete apical pleurectomy (2 patients) (control group, CG). The most frequent symptom was chest pain (37.2%). Surgical indications were recurrence in 21 (48.8%), prolonged air leak in 12 (27.9%), failure of expansion without air leak in 6 (13.9%), high risk occupancy in 2 (4.6%) and empyema due to air leak in 2 (4.6%).

RESULTS

Air leak time was decreased by tenting (1.9 days vs 3.7 days) as well as time of drainage (4.8 vs 6.9) and hospital stay (5.8 vs 7.9). Morbidity was 9.5% in EG and 9.1% in CG. Causes of morbidity were postoperative hematoma, prolonged air leak, expansion failure and blunt posterior sinus one of each. Re-operation needed for postoperative hematoma in CG. Mean follow-up was 5.1 years and 1 (4.5%) recurrence observed in CG.

CONCLUSION

Tenting of the dependent lung from the apical pleura after bullectomy via axillary thoracotomy lessens air leak time without recurrence and low morbidity.

Hyperplastic mesothelial cells in pelvic and abdominal lymph node sinuses mimicking metastatic ovarian microinvasive serous borderline tumor

Hyperplastic mesothelial cells within pelvic and abdominal lymph nodes were encountered in the staging procedure of a 32-year-old woman with a left ovarian microinvasive serous borderline tumor. Mesothelial hyperplasia was noted in the pelvic and abdominal peritoneum. Intranodal mesothelial cells occupied the subcapsular sinus with subadjacent interfollicular sinuses involved less strikingly. These mesothelial cells were originally misdiagnosed as a metastatic serous borderline tumor. Histologic review and immunohistochemistry confirmed mesothelial origin. This case represents the second reported example of mesothelial cells within the lymph nodes of patients with ovarian serous tumors. Similar involvement of the mediastinal, cervical and internal mammary lymph nodes has been described in several patients with pleural effusions without neoplastic cells. Intranodal mesothelial cells should be distinguished from metastasis--an error ending in upper staging of a case.