Change in the Frequency of Diabetic Ketoacidosis in Children with Newly Diagnosed Type 1 Diabetes in the Central Anatolia Region of Turkey over the Years Before and After the Coronavirus Disease 2019 Pandemic: A Single-Center Experience

OBJECTIVE

The number of admissions for severe diabetic ketoacidosis (DKA) in children with newly diagnosed type 1 diabetes (T1D) increased during the coronavirus disease 2019 pandemic. We aimed to investigate whether there has been a change in this situation in recent years.

MATERIALS AND METHODS

All children with T1D who were diagnosed in our tertiary hospital between 2019 and 2023 were included. Plasma insulin, C-peptide, hemoglobin A1c (HbA1c), and antibodies against thyroid peroxidase, thyroglobulin, insulin, islet cell, glutamic acid decarboxylase, tissue transglutaminase IgA, and endomysium IgA were measured.

RESULTS

The frequency of moderate-severe acidosis at admission, which increased after pandemic period compared to the pre-pandemic period, returns to its previous levels over time but still shows a statistical difference compared to the pre-pandemic period (P = .012). Age, blood gas pH and HCO3 level, C-peptide, HbA1c, and length of stay of children at the time of admission were compared year by year (years 2019-2023). No statistical differences were observed (P = .509, P = .181, P = .069, P = .469, P = .346, P = .946), respectively. A significant difference was observed in venous glucose (P .001) and insulin (P = .001) according to years. Also, no significant difference was found about the degree of acidosis according to age (P = .334).

CONCLUSION

Although the frequency of DKA in children with newly-diagnosed T1D increased in the first years of the pandemic, it has been decreasing over t.

Postoperative pancreatic fistula after pancreaticoduodenectomy: if you lack knowledge of what to search for, you will be unable to locate what you desire

OBJECTIVE

Postoperative pancreatic fistula (POPF) is the most common and critical complication of pancreatoduodenectomy (PD). In this study, we aimed to define preoperative, perioperative, and postoperative conditions that may cause POPF and examine the predictive value of drain fluid amylase (DFA) values in showing the clinical severity of POPF.

PATIENTS AND METHODS

Between December 2018 and December 2019, 49 patients who underwent PD for malignant reasons by a single team were retrospectively analyzed. Patients with benign indications, vascular reconstruction, preoperative biliary drainage catheterization, resectable liver metastases, POPF that occurred after reoperation, and patients undergoing neoadjuvant oncological treatment were excluded from the study. The patients were divided into two groups developing (FP) and non-developing (FN) POPF.

RESULTS

There was no difference between the groups in terms of gender (p=0.781), age (p=0.219), American Society of Anesthesiologists (ASA) score (p=0.338), and comorbidity status (p=0.219). The mean body mass index (BMI) kg/m2 values of the patients in the FN and FP groups were 25.2±4.0 kg/m2 and 27.4±2.6 kg/m2, respectively (p=0.042). An increased BMI increases the risk of POPF. Preoperative prognostic nutritional index (PNI) score (p=0.588), preoperative total bilirubin level (p=0.707), pancreatic duct diameter (p=0.334), pancreatic texture (p=0.334), operation time (p=0.659) do not pose a risk for POPF. Increased perioperative bleeding amounted to a risk for POPF (123.8±46.7 ml, 244.7±66.3 ml in FN and FP groups, respectively, p=0.024). Drain fluid amylase (DFA) values (p<0.001, p=0.043, p=0.019, respectively) were found to be high in patients with POPF on postoperative days 1, 4, and 7.

CONCLUSIONS

Increased BMI and excess perioperative blood loss increase the risk of POPF. DFA level is an easily applicable method that provides early diagnosis for POPF.

Mortality risk factors among critically ill children with MIS-C in PICUs: a multicenter study

BACKGROUND

This study evaluated of clinical characteristics, outcomes, and mortality risk factors of a severe multisystem inflammatory syndrome in children admitted to a the pediatric intensive care unit.

METHODS

A retrospective multicenter cohort study was conducted between March 2020 and April 2021 at 41 PICUs in Turkey. The study population comprised 322 children diagnosed with multisystem inflammatory syndrome.

RESULTS

The organ systems most commonly involved were the cardiovascular and hematological systems. Intravenous immunoglobulin was used in 294 (91.3%) patients and corticosteroids in 266 (82.6%). Seventy-five (23.3%) children received therapeutic plasma exchange treatment. Patients with a longer duration of the PICU stay had more frequent respiratory, hematological, or renal involvement, and also had higher D-dimer, CK-MB, and procalcitonin levels. A total of 16 patients died, with mortality higher in patients with renal, respiratory, or neurological involvement, with severe cardiac impairment or shock. The non-surviving group also had higher leukocyte counts, lactate and ferritin levels, and a need for mechanical ventilation.

CONCLUSIONS

In cases of MIS-C, high levels of D-dimer and CK-MB are associated with a longer duration of PICU stay. Non-survival correlates with elevated leukocyte counts and lactate and ferritin levels. We were unable to show any positive effect of therapeutic plasma exchange therapy on mortality.

IMPACT

MIS-C is a life-threatening condition. Patients need to be followed up in the intensive care unit. Early detection of factors associated with mortality can improve outcomes. Determining the factors associated with mortality and length of stay will help clinicians in patient management. High D-dimer and CK-MB levels were associated with longer PICU stay, and higher leukocyte counts, ferritin and lactate levels, and mechanical ventilation were associated with mortality in MIS-C patients. We were unable to show any positive effect of therapeutic plasma exchange therapy on mortality.

Respiratory-gated 18F Fluorodeoxyglucose Positron Emission Tomography/Magnetic Resonance Imaging in Evaluation of Primary Gastric Lesions and Gastric Lymph Nodes in Patients with Gastric Cancer

AIMS

To evaluate the added value of respiratory-gated positron emission tomography (PET) in ¹⁸F fluorodeoxyglucose (FDG) PET/magnetic resonance imaging (MRI) in the visual and semi-quantitative assessment of primary gastric lesions and gastric lymph nodes for patients with gastric cancer.

MATERIALS AND METHODS

In total, 102 upper abdominal respiratory-gated and whole-body ¹⁸F FDG PET/MRI of 88 patients with gastric cancer were evaluated visually and semi-quantitatively. For 41 patients who underwent surgery, histopathological and PET findings were compared. Three PET images were obtained from upper abdominal PET data: non-Q static (non-QS) PET from all counts, respiratory-gated Q static (QS) PET from counts in the end-expiration phase of breathing, shortened 4 min (S4min) PET that was reconstructed to obtain similar counts to QS PET. The semi-quantitative parameters (standardised uptake values, metabolic tumour volume, total lesion glycolysis) of primary lesions for each PET image, the sizes of primary lesions and the patient's body mass index were recorded. According to lymph node stations, the presence and numbers of positive lymph nodes and visual scores of lymph nodes for each PET image were recorded.

RESULTS

The patients with smaller gastric lesions (≤30 mm) or higher body mass index (>30) had significantly higher standardised uptake value percentage changes in QS PET compared with non-QS PET (all P < 0.05). The third (lesser curvature), fourth (greater curvature) and sixth (infra-pyloric) lymph node stations had significantly higher visual scores in the QS PET than in the others. The fourth lymph node station had a significantly higher number of FDG-positive lymph node in the QS PET than in the non-QS and the whole-body PET images. In the fourth station, sensitivity, positive predictive value, negative predictive value and accuracy increased in the QS PET compared with the others.

CONCLUSION

Respiratory-gated PET/MRI was found to be significantly superior in the evaluation of especially the fourth lymph node station, smaller gastric lesions and in the patients with a higher BMI compared with the non-respiratory-gated PET images.

GRANULYSIN PEPTIDE AND GENE POLYMORPHISM IN THE PATHOGENESIS OF HASHIMOTO THYROIDITIS

Background

Hashimoto thyroiditis (HT) is an autoimmune disease and the most common cause of hypothyroidism. The widespread lymphocyte infiltration in the thyroid gland and intolerance of the body against its thyroid antigens leads to the destruction of thyroid cells and impaired thyroid function. Granulysin (GNLY) is a cytolytic antimicrobial peptide that has been associated with a wide range of diseases such as various infections, cancer, transplantation, and skin problems. However, there are a few studies investigating the relationship between HT and granulysin.

Aim

Our study aims to investigate whether granulysin levels and GNLY gene polymorphism contribute to the damaged immune response leading to HT.

Material and Methods

100 unrelated patients diagnosed with HT and 140 healthy individuals were included in our study. Frequencies of GNLY rs10180391 and rs7908 gene polymorphisms were determined using PCR- RFLP method and serum granulysin levels were determined using ELISA.

Results

There is no statistical significance between patient and control groups in terms of genotype and allele frequencies of GNLY gene polymorphisms and serum levels of granulysin.

Conclusion

In conclusion, granulysin and GNLY gene polymorphisms do not appear to relate to HT disease.

Therapeutic Plasma Exchange in Pediatric Intensive Care Unit: A Single-center Experience

Aim and objective

To examine the clinical characteristics, indications, and complications of patients undergoing therapeutic plasma exchange (TPE) in our pediatric intensive care unit (PICU).

Materials and methods

Patients who underwent therapeutic plasma exchange between January 2018 and January 2020 in the PICU were included in the study. Demographic, clinical, and laboratory data of patients were obtained retrospectively from medical records. A venous catheter was placed into subclavian, femoral, or jugular veins. The number of plasmapheresis sessions for each patient was determined by observing the course of the disease and clinical improvement. Patients were monitored for vital signs during the plasmapheresis process. Complications directly associated with TPE were recorded.

Results

During the 2-year study period, 105 TPE sessions were performed in 25 patients (15 males/10 females). The median age was 84 months (6–204), and the median body weight was 32 kg (8–75). Renal disorders and sepsis were the most common group, and about 48% of patients were in these groups. The most common diagnoses were sepsis with multi-organ dysfunction syndrome in seven patients and followed by hemolytic uremic syndrome (five patients) and Guillain–Barre syndrome (three patients). Nausea (6.7%) and hypocalcemia (6.7%) were the most common complications of patients associated with the procedure. Premature discontinuation of the procedure were not seen due to complications. Complications were treated with symptomatic therapy.

Conclusion

TPE is an effective treatment that can be safely used for pediatric patients with developments in PICUs. Nevertheless, TPE should be performed by experienced staff at a specialized center to minimize the risk of complications.

How to cite this article

Özsoylu S, Dursun A, Çelik B. Therapeutic Plasma Exchange in Pediatric Intensive Care Unit: A Single-center Experience. Indian J Crit Care Med 2021;25(10):1189–1192.

Association Between IL28B, IL29 Gene Polymorphisms and Clinical Manifestations of Behçet's Disease

BACKGROUND

Behçet's disease (BD) is a chronic, multisystemic, inflammatory disease characterized by relapsing episodes of a wide spectrum of clinical findings. The role and mechanism of IFN-λs in BD remain unknown. The aim of this study was to investigate the relationship between IL29 and IL28B gene polymorphisms and BD or clinical manifestations.

METHODS

Using the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method, single-nucleotide polymorphisms of IL28B rs8099917 (IL28 G/T), rs12979860 (IL28 C/T) and IL29 rs30461 (IL29 T/C) were studied in 94 patients with BD and 90 healthy controls.

RESULTS

Our study did not show any relationship between Behçet Disease and genotype or allele frequencies of IL28B (rs8099917, rs12979860) and IL29 (rs30461) gene polymorphisms (p > .05). We found that the TT genotype of rs12979860 (IL28 C/T) polymorphism is higher in healthy controls and patients without central nervous system (CNS) involvement compared to patients with CNS involvement (p = .014 and p = .022).

CONCLUSIONS

As a result, although the relationship was found between IL28 and IL29 gene polymorphisms with some clinical manifestations of BD, it was not directly related to the predisposition of the disease. The relationship between IL-28 and IL-29 which act as regulators in inflammatory processes, with Behçet disease, needs to be investigated in further studies.

Impact of Anaemia on the Severity of Acute Bronchiolitis in Infants

Introduction: Although anaemia is a predisposing factor in the occurrence of lower respiratory tract infections, there is limited data about the relationship between anaemia and acute bronchiolitis in infants. The aim of this study is to determine whether anaemia is an independent clinical condition increasing the severity of acute bronchiolitis in infants. Methods: This retrospective study was conducted on 163 infants (101 acute bronchiolitis and age and sex matched 62 controls), aged between one month to two years. According to the clinical severity of the disease, patients were divided as having mild, moderate and severe acute bronchiolitis. Haemoglobin (Hb) level was considered low when below 11 gm/dL, which is less than 2 standard deviation (SD). Results: Median Hb and mean cell haemoglobin concentration (MCHC) levels were significantly lower in acute bronchiolitis patients than controls {10.1 gm/dL (9.6 - 10.6 gm/dL) vs. 11.2 gm/dL (10.6 - 12.1 gm/dL); p < 0.001)}, and {33.6 (32.5 - 34.1 gm/dL) vs. 34 gm/dL (33.1 - 34.5 gm/dL) p = 0.012}. Conversely, median red cell distribution width (RDW) was higher {14.4% (13.5 - 15.6%) vs. 14.1% (13.1-15%)}. When evaluated by logistic regression analysis, the risk of severe bronchiolitis increased 10 times in acute bronchiolitis patients with a Hb value ≤ 10 gm/dL. Also, there was a significant negative correlation between Hb level and bronchiolitis severity (r :- 0.423, p < 0.001). Furthermore, the patients who had Hb value under 9.95 gm/dL had risk of more severe bronchiolitis with 73.7% sensitivity and 83.3% specificity than other patients. Conclusions: Anaemic infants are more susceptible to acute bronchiolits and as the degree of anaemia increases, they are more severely affected.

Efficacy of therapeutic plasma exchange in patients with Crimean-Congo hemorrhagic fever

OBJECTIVE

To examine the efficacy of therapeutic plasma exchange (TPE) in patients critically ill with Crimean-Congo hemorrhagic fever (CCHF).

METHODS

Patients with CCHF received supportive treatment (ST) or TPE. After laboratory and clinical evaluations, the patients were divided into mild, moderate, and severe CCHF groups according to the severity score index (SSI). To assess the efficacy of TPE, the incubation period, time of admission to hospital, hospitalization duration, mortality rate and times to recovery of the platelet count and aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were compared between patients receiving ST and TPE.

RESULT

A total of 119 confirmed CCHF cases was analyzed. The median SSIs were 7 in the TPE group and 5 in the ST group. The SSI stages, median incubation times and admission times were similar in the two groups. However, the duration of hospitalization was longer in the TPE group. The overall mortality rates were 9% (3 of 33 patients) in the TPE group and 16% (5 of 31 patients) in the ST group; the difference was significant. The platelet count recovered after a median of 6 (4-7) days in the ST group.

CONCLUSION

The mortality rate was lower in the TPE group than in the ST group, but the duration of hospitalization and the time to platelet recovery were longer in the TPE group than in the ST group. TPE did not contribute significantly to the prognosis of patients with intermediate-severity CCHF. However, TPE might be efficacious in patients with severe CCHF.

Epidemiological, Clinical, and Laboratory Features of Children With COVID-19 in Turkey

Objectives: The aim of this study is to identify the epidemiological, clinical, and laboratory features of coronavirus disease 2019 (COVID-19) in children. Methods: A retrospective study was conducted by pediatric infectious disease specialists from 32 different hospitals from all over Turkey by case record forms. Pediatric cases who were diagnosed as COVID-19 between March 16, 2020, and June 15, 2020 were included. Case characteristics including age, sex, dates of disease onset and diagnosis, family, and contact information were recorded. Clinical data, including the duration and severity of symptoms, were also collected. Laboratory parameters like biochemical tests and complete blood count, chest X-ray, and chest computed tomography (CT) were determined. Results: There were 1,156 confirmed pediatric COVID-19 cases. In total, male cases constituted 50.3% (n = 582) and females constituted 49.7% (n = 574). The median age of the confirmed cases was 10.75 years (4.5-14.6). Of the total cases, 90 were younger than 1 year of age (7.8%), 108 were 1-3 years of age (9.3%), 148 were 3-6 years of age (12.8%), 298 were 6-12 years of age (25.8%), 233 were 12-15 years of age (20.2%), and 268 cases were older than 15 years of age (23.2%). The most common symptom of the patients at the first visit was fever (50.4%) (n = 583) for a median of 2 days (IQR: 1-3 days). Fever was median at 38.4°C (38.0-38.7°C). The second most common symptom was cough (n = 543, 46.9%). The other common symptoms were sore throat (n = 143, 12.4%), myalgia (n = 141, 12.2%), dyspnea (n = 118, 10.2%), diarrhea (n = 112, 9.7%), stomachache (n = 71, 6.1%), and nasal discharge (n = 63, 5.4%). When patients were classified according to disease severity, 263 (22.7%) patients were asymptomatic, 668 (57.7%) patients had mild disease, 209 (18.1%) had moderate disease, and 16 (1.5%) cases had severe disease. One hundred and forty-nine (12.9%) cases had underlying diseases among the total cases; 56% of the patients who had severe disease had an underlying condition (p < 0.01). The need for hospitalization did not differ between patients who had an underlying condition and those who do not have (p = 0.38), but the need for intensive care was higher in patients who had an underlying condition (p < 0.01). Forty-seven (31.5%) of the cases having underlying conditions had asthma or lung disease (38 of them had asthma). Conclusions: To the best of our knowledge, this is one of the largest pediatric data about confirmed COVID-19 cases. Children from all ages appear to be susceptible to COVID-19, and there is a significant difference in symptomatology and laboratory findings by means of age distribution.

Outcomes and prognostic factors for pediatric cancer patients admitted to an intensive care unit in a university hospital

BACKGROUND AND OBJECTIVES

The aim of this study was to investigate the factors predicting Pediatric Intensive Care Unit (PICU) mortality and the outcomes in cancer patients admitted to PICU.

METHODS

We conducted a retrospective study in 48 consecutive cancer patients admitted to the PICU between January 1, 2015 and January 1, 2018. A total of 48 patients (21 males and 27 females) were enrolled in this study.

RESULTS

The median age was 77 (33,5-149) months. The median duration of PICU stay was 5 (2-9) days. Patients were classified according to their stage of disease. Ten (20.8%) patients were in the remission group, 9 (18.8%) patients were in the induction period and 29 (60.5%) patients were in the progressive diseasegruops. Thirtynine patients (81.2%) had hematological malignancies, 6 (12.5%) had extracranial solid tumors and 3 (6.3%) had intracranial solid tumors. Thirty-seven patients died and the mortality rate was found to be 77.1%. mortality rates were 11%, 88% and 93% for patients in remission,during induction period and in the progressive disease group, respectively (p < 0.01).The most frequent reasons of PICU admission were respiratory failure in 29 (60.4%), sepsis in 12 (25%), circulatory collaps in 2 (4.2%), and other reasons in 5 patients (10.4%). The median PRISM III among survivors was significantly lower than non-survivors (13.1 ± 6.4; vs. 20.7 ± 5.2; p < 0.001). At a cut-off value of 13, the sensitivity of the PRISM III was 94.4% and the specificity was 58.3% (AUC: 0.821). OSDwas present in 41 (85%) patients, 82% of them died (34/41). The presence of MOF, the use of mechanical ventilation and inotrop support were significantly related with mortality. Univariate logistic regression analysis showed that male gender [odds ratio (OR)=5.588, P= 0.041, 95% confidence interval (95%CI) 1.070-29.191], presence of organ system dysfunction[OR=12.143, P= 0.008, 95%CI 1.947- 75.736], need for mechanical ventilation[OR=34.000, P= 0.001, 95%CI 5.272-219.262], IS [OR=8.5, P= 0.001, 95%CI 1.318-54.817]were the predictors ofhigh mortality in pediatric cancer patients. PRISM III score ≥ 13 was a predictive criteria of PICU mortality.

CONCLUSION

We conclude that the key to improving survival rates is to pick up on this group of patients as soon as possible.We, believe that cancer patients could be saved by earlier evaluation and intervention by the PICU team when they have a less severe disease.

Prevalence of the extensor digitorum, extensor digiti minimi and extensor indicis tendons and their variations

We aimed to investigate tendon variations of the extensor digitorum (ED), extensor digiti minimi (EDM), and extensor indicis proprius (EIP) muscles. Our study was performed on 43 fetal cadavers (86 extremities), aged between 17 and 40 weeks of gestation. The number of ED tendons varied from three to six, proximal to the extensor retinaculum (ER), and from three to eight, distal to the ER. The ED most often had four tendons, both proximally and distally from the ER. The ED tendons of the fourth finger were observed to be most frequently duplicated. The most common juncturae tendinum (JT) was type 1 in the second intermetacarpal space (IMCS), type 2 in the third IMCS, and type 3r in the fourth IMCS according to von Schroeder classification. The number of EIP and EDM tendons varied from one to two and from one to five, respectively. The EIP double tendons inserted both into the ulnar and palmar sides of the extensor digitorum of the second finger, which had not been reported in the literature. In our study, 7% of hands had variant muscles. In 4.7% of hands, the extensor indicis et medii communis was observed, while the extensor medii proprius and the extensor digitorum brevis manus were observed in 1.2% and 1.2% of hands, respectively. Knowing the prevalence of the ED, EDM and EIP tendons and their variations in the fetal period should help to treat partial loss of hand function or injury after birth and to correct congenital hand deformities.

Could you say that was an atrial flutter or not?

Özsoylu S, Akyıldız BN, Dursun A, Pamukçu Ö. Could you say that was an atrial flutter or not? Turk J Pediatr 2019; 61: 608-610. Muscle-tremor artefact is a potential cause of misdiagnosis of atrial arrhythmias on electrocardiography (ECG) monitoring. Such errors may lead to inappropriate and potentially dangerous therapies in some patients. We present a case of a patient with uncontrolled seizures whose bedside electrocardiogram monitor analysis appeared to demonstrate atrial flutter with 4:1 conduction through the AV node. The ECG monitor and ECG rhythm strip additionally showed a regular ventricular rate of 94 bpm with an underlying regular `saw-tooth` baseline. We applied cardioversion to convert to sinus rhythm. Amiodarone was loaded and added to the patients therapy who had atrial flutter after cardioversion. Echocardiogram was performed by a pediatric cardiologist and they noted that the atrial rate and ventricular rate were equal. After this, we began to suspect this situation might be a pseudoflutter due to his muscle contractions. We applied rocuronium to the patient to understand whether this was a pseudo-flutter or not. We saw that the ECG returned to normal sinus rhythm. Physicians especially working in intensive care units should be aware of artifact to avoid unnecessary therapeutic procedures. As Hippocrates said centuries ago `First, do no harm.`.

Primary Langerhans Cell Histiocytosis in Thyroid

Background

Langerhans cell histiocytosis (LCH) is a rare group of neoplastic diseases resulting from Langerhans dendritic cells. The most common site (80%) is bones. Thyroid gland involvement is exceedingly rare and usually expected to be seen as a part of multisystemic disease.

Case Report

We present a 45 year old male patient operated due to multinodular goiter and neck pain, and diagnosed with LCH in his postoperative pathologic examination. As a result of the systemic screening performed after the pathological diagnosis, the disease was interestingly localized to the thyroid gland. Systemic involvement did not develop in the two-year follow-up of the patient who did not receive additional chemotherapy treatment.

Conclusion

It is difficult to diagnose LCH in the thyroid gland before surgery. Although surgical treatment with or without chemotherapy is recommended, surgery is not recommended alone since it is generally systemic involvement. However, in primary thyroid LCH cases limited to the thyroid gland, we recommend that only total thyroidectomy treatment should be kept in mind.

The morphological investigations on the heart and some vessels of bovine foetus between the 15th and 25th weeks of gestation

BACKGROUND

The aim of this study was to define the morphological and morphometric development of the foetus heart obtained from the domestic cattle in the gestation period of 15-25 weeks.

MATERIALS AND METHODS

For this purpose, a total of 30 hearts belonging to cattle foetuses (15 males, 15 females) were used. The ages of foetuses were calculated according to the forehead-to-tail length and examined in three different groups. After dissection; biometric, macroanatomic, morphometric and histological findings were obtained from the foetal hearts according to the groups. In addition, mean values of the morphometric findings were determined.

RESULTS

As a result of the study, it was found that with the advancing age the convexity of margo ventricularis dexter increased and margo ventricularis sinister transformed from a convex-concave shape to a flat shape. The heart-to-body weight ratio was determined as 0.08% for Group II female foetuses and 0.09% for all other groups. The heart heights for Groups I, II, and III females were identified as 26.21, 41.00, and 46.27 mm, respectively, and for the males 26.45, 34.89, and 47.15 mm, respectively. In the statistical analysis, it was determined that all the morphometric values measured from the heart correlated significantly with the forehead-to-tail length.

CONCLUSIONS

The data obtained as a result of the study is thought to help understand the morphological and morphometrical development of the heart, pioneer the attempts to create a foetal cattle heart model, and thus help in the diagnosis of the foetal heart pathologies.acielecka.

Ogilvie syndrome presenting with septic shock

Özsoylu S, Akyıldız BN, Dursun A. Ogilvie syndrome presenting with septic shock. Turk J Pediatr 2018; 60: 225-227. Acute colonic pseudo-obstruction (ACPO) is also known as Ogilvie`s. We report a 10-year-old child with an unremarkable past history who presented with septic shock including hypotension, prolonged capillary refill time, decreased urine output ( < 0.5 ml/kg/h), metabolic acidosis, liver failure, respiratory failure. The symptoms resolved with supportive therapy. In our patient septic shock contributed to Ogilvie syndrome. Although it is a rare condition in pediatric population, pediatricians should be aware of children with abdominal distention; supportive management is successful and morbidity/mortality is minimal.

A case of DRESS syndrome associated with carbamazepine treatment

Fever and rash associated in a wide clinical spectrum, drug rash with eosiophilia and systemic symptoms syndrome (DRESS) is a potentially life-threatening hypersensitivity reaction. Early diagnosis and treatment and removal of the offending agent can be life-saving. Physicians should be aware of DRESS syndrome, particularly in patients receiving antiepileptic medication and admitted with a symptoms of fever and skin rash. In this study, a girl aged three years who had been under carbamazepine therapy for one month was admitted to our hospital with symptoms of fever and rash and was diagnosed as having DRESS syndrome, is presented to increase awareness of DRESS syndrome among physicians.

Neutrophil-to-lymphocyte ratio and mean platelet volume can be useful markers to predict sepsis in children

Objectives

Neutrophil-to-Lymphocyte Ratio (NLR) and Mean Platelet Volume (MPV) have been found to be useful indexes for the diagnosis of sepsis in adults. However, the knowledge of their roles and cut-off values in pediatric patients is limited. The primary objective of this study was to assess the ability of NLR and MPV to predict sepsis in children. A secondary aim was to evaluate the comparison of these parameters with C-reactive Protein (CRP).

Methods

The study was conducted on pediatric patients, who had two or more of the following criteria were included in the study: tachycardia, tachypnea, temperature change, leukocytosis, or leukopenia for age. Patients were classified into sepsis and non-sepsis groups. The sepsis group was defined as the presence of two or more age specific Systemic Inflammatory Response Syndrome (SIRS) criteria and increased Procalcitonin (PCT) level (>0.5 ng/ml).

Result

The median age of the study population was 18 (6-169) months. Two hundred-sixty four episodes of sepsis were recorded in 125 patients. Eighty two were classified as sepsis and 182 as non-sepsis. CRP level and MPV value were significantly higher in the sepsis group compared to non-sepsis group. The median CRP level was 47.8 mg/dl (10.2-119.5) in the sepsis group and 18.6 mg/dl (4.9-66.1) in the non-sepsis group (p=0.006). In the sepsis group, the median MPV value was 8.4 (7.6-9.5) and it was 7.8 (7.1-8.5) in the non-sepsis group (p=0.001). Significant correlations were found between the procalcitonin (PCT) and CRP level (p<0.001; r = 0.279), NLR (p=0.02; r = 0.186) and MPV (p<0.001; r = 0.243). MPV had the highest specificity for predicting sepsis (75.8%). The largest AUC was 0.629 with a cut-off value 8.5 for MPV, while the AUC was 0.557 with a cut-off value 1.97 for NLR and 0.606 with a cut-off value 38.9 for CRP.

Conclusions

NLR and MPV values should alert clinicians to the possibility of sepsis and to initiate or change antibiotic treatment.

Comprehensive Analysis of Liberal and Restrictive Transfusion Strategies in Pediatric Intensive Care Unit

BACKGROUND

We prospectively compared restrictive and liberal transfusion strategies for critically ill children regarding hemodynamic and laboratory parameters.

METHODS

A total of 180 children requiring packed red blood cells (PRBCs) were randomized into two groups: the liberal transfusion strategy group (transfusion trigger < 10 g/dL, Group 1) and the restrictive transfusion strategy group (transfusion trigger ≤ 7 g/dL, Group 2). Basal variables including venous/arterial hemoglobin, hematocrit and lactate levels; stroke volume; and cardiac output were recorded at the beginning and end of the transfusion. Oxygen saturation, noninvasive total hemoglobin, noninvasive total oxygen content, perfusion index (PI), heart rate and systolic and diastolic blood pressures were assessed via the Radical-7 Pulse co-oximeter (Masimo, Irvine, CA, USA) with the Root monitor, initially and at 4 h.

RESULTS

In all, 160 children were eligible for final analysis. The baseline hemoglobin level for the PRBC transfusion was 7.38 ± 0.98 g/dL for all patients. At the end of the PRBC transfusion, cardiac output decreased by 9.9% in Group 1 and by 24% in Group 2 (p  < 0.001); PI increased by 10% in Group 1 and by 45% in Group 2 (p  < 0.001). Lactate decreased by 9.8% in Group 1 and by 31.68% in Group 2 (p < 0.001).

CONCLUSION

Restrictive blood transfusion strategy is better than liberal transfusion strategy with regard to the hemodynamic and laboratory values during the early period. PI also provides valuable information regarding the efficacy of PRBC transfusion in clinical practice.

Evaluating the basic life support knowledge among schoolteachers: A cross-sectional survey in Kayseri, Turkey

Dursun A, Özsoylu S, Emeklioğlu B, Akyıldız BN. Evaluating the basic life support knowledge among schoolteachers: A cross-sectional survey in Kayseri, Turkey. Turk J Pediatr 2018; 60: 702-708. Children spend a significant proportion of their day in school when they are not with their families.Therefore they might experience medical emergency situations due to injuries, complications of chronic health conditions, or unexpected major illnesses that occur in school. In cases of emergencies, school teachers are expected to play a key role in performing basic life support (BLS) on school children. Very limited data are present in the literature that address the knowledge of the schoolteacher regarding BLS. The primary objective of this study was to asses the BLS knowledge, training status and attitude towards pediatric BLS among schoolteachers. The study had a cross-sectional research design and was conducted between January and March 2017. A self administered questionnaire was used for data collection to assess the knowledge of teachers. The questionnaires were filled in by 541 teachers (243 male and 298 women). The median age of the study population was 39 (34-45) years. One-third of the respondents reported having taken a BLS class in the past (33.1%). The mean for the correct answers for the study population was 5/14 (4/14-7/14). For trained teachers, it was 6/14 (4/14-8/14) and for untrained teachers, it was 5/14 (3/14-7/14)(P < 0.001). There were no differences between teachers who had attended different BLS courses. Significant differences between teachers were observed: 62% of teachers with previous BLS training felt capable of providing cardio pulmonary resusitation (CPR) to their students compared to 48% in the group without previous training (P =0.001). Ninety- five percent of the teachers were eager to attend a BLS course and 92% reported that BLS training should be mandatorily given for teacher certification. Teachers are aware of the importance of BLS and they are willing to attend BLS training programs and improve their knowledge. Despite the fact that the knowledge of trained teachers was found to be better than those of untrained teachers, school teachers in Turkey have a low level of knowledge and skills regarding BLS.

The Diagnostic Value of SCUBE1 in Acute Appendicitis

BACKGROUND

SCUBE1 has recently been studied as a diagnostic biomarker for acute coronary syndrome, ischemic stroke, and acute mesenteric ischemia. The aim of this study is to evaluate the value of SCUBE1 and routine parameters used in patients diagnosed with acute appendicitis.

METHODS

Of the 150 patients admitted to the emergency department whose initial diagnosis were acute appendicitis (AA), 103 patients were excluded from the study for various reasons. Forty-seven patients with a definitive diagnose of AA and 43 volunteers were enrolled in the study. SCUBE1, Alvarado scoring (ASK), C-reactive protein (CRP), and routine tests were compared between the two groups.

RESULTS

SCUBE1 was not statistically significant between the patient and the control groups (p = 0.209). SCUBE1 was significantly higher in the CRP (+) group (p = 0.048). Both the diameter of the appendix on computerized tomography (CT) and SCUBE1 levels increased proportionally (p = 0.043). CRP was significantly higher in the perforated appendicitis (PA) compared to non-perforated appendicitis (NPA) (p = 0.007). White blood cell (WBC) count was not differential for perforation (p = 0.06).

CONCLUSIONS

Although SCUBE1 was significantly higher in CRP (+) patients, it was not a diagnostic biomarker for AA. There was a positive correlation between SCUBE1 values and the diameter of appendix measured on CT.

Angiotensin-converting enzyme gene polymorphism (insertion/deletion) and liver fibrosis in Turkish patients from the western Black Sea region, Turkey

Chronic viral hepatitis B, chronic viral hepatitis C, non-alcoholic steatohepatitis, alcoholic liver disease, autoimmune hepatitis, primary biliary cirrhosis, and secondary biliary cirrhosis are important health issues worldwide. While an association between angiotensin-converting enzyme gene insertion/deletion (ACE gene I/D) polymorphism and liver fibrosis has been demonstrated in rat studies, the results of clinical studies area have been contradictory. The aim of this study was to assess the possible association between ACE gene I/D polymorphism and liver fibrosis in a large group of Turkish patients from the western Black Sea region. In 418 patients with different etiologies, ACE gene I/D polymorphism and serum ACE levels were investigated. The distribution of the "DD", "ID", "II" genotypes of the ACE gene were 32.5, 48.8, and 18.7% in the mild to moderate fibrosis group (N = 246, F:1-3 according to Ishak's score) and 39.0, 44.2, and 16.9% in the advanced fibrosis group (N = 172, F:4-6 according to Ishak's score). A significant correlation between serum ACE levels and ACE gene alleles was identified (P < 0.001): serum ACE levels of patients with D alleles were higher than those of patients with I alleles [44 (min 7-max 101) versus 29 (min 7-max 96)]. Patients with advanced fibrosis were also found to be older than those with mild to moderate fibrosis (P < 0.001). No significant association was noted between the patient gender and fibrosis severity. We conclude that ACE I/D polymorphism is not associated with the degree of liver fibrosis.

The effects of nitrous oxide on vitamin B12 and homocysteine levels in methyltetrahydrofolate reductase gene mutation

BACKGROUND

We aimed to investigate the effects of nitrous oxide on plasma total homocysteine and vitamin B12 levels in patients with or without methyltetrahydrofolate reductase (MTHRF) gene mutation.

METHODS

After obtaining the ethics committee approval and written informed consents of patients, 93 patients between 18-70 years of age scheduled for surgery anticipated to last 1-4 hours were enrolled in the study. Patients with contraindications for nitrous oxide use were excluded. Preoperatively, blood samples were obtained from all patients for the determination of MTHFR gene mutation. Anesthesia induction was achieved with 3 mg.kg-1 of propofol and 1 µg.kg-1 of fentanyl. Anesthesia maintenance was performed with sevoflurane and with a carrier gas composed of 40 % O2 and 60 % N2O. Venous blood samples were obtained after venous canulation, and 24 hours after extubation for the analysis of plasma total homocysteine, vitamin B12 levels.

RESULTS

Eighty-one patients were included in the study. Postoperative vitamin B12 levels were found to be significantly lower when compared with their preoperative levels (p<0.05). It was found that MTHRF gene polymorphism had no significant effect on postoperative plasma total homocysteine and serum vitamin B12 levels (p>0.05). Postoperative plasma total homocysteine levels were found to be significantly different between patients with operation times under and over 3 hours (p=0.028).

CONCLUSIONS

We conclude that MTHRF gene polymorphism had no significant effects on postoperative plasma total homocysteine levels. However, we found that homocysteine levels might rise in patients who received general anesthesia with nitrous oxide for longer than 3 hours (Tab. 7, Ref. 26).

Methylmalonic acidemia mimicking diabetic ketoacidosis in an infant

Methylmalonic acidemia (MMA) is an inherited organic acidemia usually present with recurrent episodes of acute illness. A typical episode is ushered in with ketonuria and vomiting, followed by acidosis, dehydration, and lethargy, leading, in the absence of aggressive treatment, to coma and death. We report an infant with MMA presented with diabetes symptoms. A 13-month-old girl complained of polydipsia, diuresis, and loss of weight. She had clinical signs of diabetic ketoacidosis such as dehydration, deep sighing respiration, smell of ketones, lethargy, and vomiting. Laboratory analysis showed hyperglycemia with acidosis and ketonuria. She was treated with parenteral fluid, electrolyte, and insulin infusion. Two days after her discharge, after having a meal rich in protein, she was brought unconscious with hepatomegaly, severe acidosis, ketonuria, and mild hyperammonemia. The absence of hyperglycemia and the presence of neurologic findings suggested organic acidemia. MMA was diagnosed because of methylmalonic aciduria and elevated C3 carnitine esters. Cranial magnetic resonance imaging (MRI) showed increased uptake of radiocontrast material in the basal ganglia bilaterally. A homozygous mutation in exon 4 of the MMAA gene was found in mutation analysis and confirmed the diagnosis of cblA-deficient MMA. Neurologic regression was improved with treatment of low-protein diet, vitamin B12, and l-carnitine. In patients born to consanguineous parents who admit during infancy with severe acidosis refractory to treatment, organic acidemias should be kept in mind, even they have high blood glucose. The definitive diagnosis is important because it may allow a specific treatment and a favorable evolution to prevent the sequelae.

Secondary hemophagocytosis in 3 patients with organic acidemia involving propionate metabolism

Hemophagocytic lymphohistiocytosis (HLH) may develop secondary to infections, malignancies, immune deficiency syndromes, and rheumatologic and metabolic disorders. Associations between HLH and inborn errors of metabolism, including lysinuric protein intolerance, multiple sulfatase deficiency, galactosemia, Gaucher disease, Pearson syndrome, and galactosialidosis, have previously been reported in the literature. In this report the authors present 3 children with disorders of propionate metabolism--1 with methylmalonic acidemia and 2 with propionic acidemia--who developed secondary HLH during their metabolic attacks. All patients fulfilled the 5 HLH criteria of the Histiocyte Society. Familial HLH was ruled out by molecular analysis. Plasma exchange was performed for 2 of them. Unfortunately 1 died of multiorgan failure despite intensive therapy. This is the first report of such an association.

Identification of mutations and evaluation of cardiomyopathy in Turkish patients with primary carnitine deficiency

Primary systemic carnitine deficiency (SCD) is an autosomal recessive disorder caused by defective cellular carnitine transport. Patients usually present with predominant metabolic or cardiac manifestations. SCD is caused by mutations in the organic cation/carnitine transporter OCTN2 (SLC22A5) gene. Mutation analysis of SLC22A5 gene was carried out in eight Turkish patients from six families. Six patients presented with signs and symptoms of heart failure, cardiomyopathy, and low plasma carnitine levels, five of them with concurrent anemia. A patient with dilated cardiomyopathy had also facial dysmorphia, microcephaly, and developmental delay. Tandem MS analyses in siblings of the patients revealed two more cases with low plasma carnitine levels. SCD diagnosis was confirmed in these two cases by mutation screening. These two cases were asymptomatic but echocardiography revealed left ventricular dilatation in one of them. Carnitine treatment was started before the systemic signs and symptoms developed in these patients. Mean value of serum carnitine levels of the patients was 2.63±1.92μmol/L at the time of diagnosis. After 1year of treatment, carnitine values increased to 16.62±5.11 (p<0.001) and all responded to carnitine supplementation clinically. Mutation screening of the OCTN2 gene study in the patients revealed two novel (p.G411V, p.G152R), and four previously identified mutations (p.R254X, p.R282X, p.R289X, p.T337Pfs12X). Early recognition and carnitine supplementation can be lifesaving in this inborn error of fatty acid oxidation.

A Zinc Sulphate-Resistant Acrodermatitis Enteropathica Patient with a Novel Mutation in SLC39A4 Gene

Acrodermatitis enteropathica (AE) is a rare autosomal recessive disorder of zinc deficiency due to an abnormal intestinal zinc transporter. It is characterized by the triad of acral dermatitis, alopecia, and diarrhoea. Once AE is correctly diagnosed, patients are treated with orally administered zinc sulphate. In some patients, relapses occur during adolescence, despite the regular treatment. Here, we discuss the clinical and molecular features of a 13-year-old adolescent girl with acrodermatitis enteropathica who was resistant to high-dose zinc sulphate therapy. We successfully treated the patient with zinc gluconate and vitamin C, and we detected a novel homozygous c.541_551dup (p.Leu186fsX38) mutation in the exon 3 of her SLC39A4 gene.

Mutation spectrum of fumarylacetoacetase gene and clinical aspects of tyrosinemia type I disease

Tyrosinemia type I (OMIM 276700) is a rare, autosomal recessive disorder caused by a deficiency in the fumarylacetoacetate hydrolase (FAH) enzyme. This study examined the spectrum of FAH gene mutation in 32 patients with tyrosinemia type I. In addition, clinical and biochemical findings were evaluated to establish a genotype-phenotype relationship in the patients. Mutation screening was performed using a 50K custom-designed resequencing microarray chip (TR_06_01r520489, Affymetrix) and sequencing analysis. Of the 12 different mutations found, 6 are categorized as novel. Three of the mutations-IVS6-1G>A, D233V, and IVS3-3C>G-are the most common in Turkish patients, comprising 25%, 17.1%, and 12.5% of mutant alleles, respectively.Clinical evaluations suggest that the spectrum of symptoms observed in the patients with very early and early disease were of the more nonspecific form, whereas the patients with late-presenting disease had more of the distinctive form over the course of the disease. This study adds support to the notion that the D233V mutation is specific to the Turkish population.

Angiotensin-converting enzyme insertion/deletion polymorphism has no effect on the risk of atherosclerotic stroke or hypertension

BACKGROUND AND PURPOSE

Stroke is a heterogeneous multifactorial disease. Hence, a large number of candidate genes are involved in stroke pathophysiology, such as blood pressure regulation and atherosclerosis. Although angiotensin-converting enzyme insertion/deletion (ACE I/D) polymorphism is considered to have a role in hypertension, coronary artery disease, and myocardial infarction, its relationship with cerebrovascular disease and hypertension in stroke in different ethnic populations is still inconsistent.

METHODS

ACE I/D polymorphism, detected by polymerase chain reaction (PCR), was studied in 97 patients with large-vessel and 60 patients with small-vessel atherosclerotic stroke (44 asymptomatic, 16 symptomatic lacunes) and 85 healthy subjects with normal brain imaging. The demographic data, lipid profile and risk factors of patients and controls were obtained retrospectively.

RESULTS

ACE genotypes were in Hardy-Weinberg equilibrium in both patients and controls. Prevalences of DD, ID and II genotype were 41%, 40%, and 19%, respectively, in the stroke group. Differences in ACE I/D polymorphism distribution were statistically insignificant between the groups. This lack of association between stroke and ACE I/D polymorphism did not change in the presence of traditional risk factors (hypertension, diabetes mellitus, smoking, and dyslipidemia). Although hypertension was significantly more common in the patient groups, ACE I/D polymorphism showed no effect on hypertension risk. This lack of association also did not change according to groups or in the presence of diabetes mellitus, male gender or smoking.

CONCLUSION

ACE I/D polymorphism did not predict the risk of stroke or hypertension in our population living in the western Black Sea region of Turkey.

Four novel PDHA1 mutations in pyruvate dehydrogenase deficiency

The pyruvate dehydrogenase (PDH) complex is a mitochondrial multienzyme that catalyses the irreversible oxidative decarboxylation of pyruvate to acetyl-CoA. We report four novel PDHA1 mutations in patients with pyruvate dehydrogenase deficiency. Analysis of PDH activity showed decreased activity in fibroblasts from all four patients, around 16-52% of mean control, similar to what has been found in previous studies. Two of the mutations were missense mutations: c.616G>A (p.Glu206Lys) and c.457A>G (p.Met153Val), one was a 3 bp in-frame deletion: c.429_431delAGG (p.Gly143del), and one was a 65 bp duplication: c.900-6_958dup65. cDNA analysis of the 65 bp duplication showed a small amount of normal transcript in addition to the transcript corresponding to the duplication. The small amount of normal transcript likely explains the survival of the patient, who was a boy. The duplication and one of the missense mutations were associated with decreased amounts of E(1)α And E(1)β protein on western blot analysis, whereas the other two mutations were associated with normal amounts. This study adds four novel mutations to the around 90 reported mutations in PDHA1 (HGMD PDHA1 mutation database). The phenotypes of patients with PDH deficiency have been divided into three groups: a neonatal form with severe lactic acidosis, a form observed only in males and characterized by episodes of ataxia with relapses associated with hyperlactataemia, and an infantile form with hypotonia, lethargy, onset of seizures or dystonia, psychomotor retardation, in some cases Leigh-like lesions and mild to moderate hyperlactataemia. The four patients reported here all belong to the latter group, which is the largest.

MEFVgene is a probable susceptibility gene for Behçet's disease

OBJECTIVE

Behçet's disease (BD) is a rare, chronic, multisystem inflammatory disorder. The prevalence of BD is higher in the Middle Eastern and Mediterranean populations. Another chronic inflammatory disease, familial Mediterranean fever (FMF), is also known to be highly prevalent in these populations. The prevalence of BD is higher in the FMF patient population than in populations known to be rich in BD . Both BD and FMF have some pathophysiological features in common and they result from inappropriate activation of neutrophils. Clinical manifestations of both diseases can mimic each other and the coexistence of both diseases in the same patient has been reported. Given that BD and FMF have similar pathophysiological, epidemiological, and clinical features, we hypothesized that the gene responsible for FMF, MEFV, may also play a role in the pathogenesis of BD.

METHODS

Forty-two BD patients who had no symptoms and family history for FMF and 66 healthy controls were screened for common MEFV gene mutations (E148Q, M680I, M694V, and V726A).

RESULTS

Fifteen patients (36%) displayed MEFV mutations (nine M694V, five E148Q, and one M680I) and mutation rates were significantly elevated compared to 66 (11%) healthy controls (p = 0.0034).

CONCLUSION

The occurrence of frequent MEFV mutations in BD patients suggests that the MEFV gene is involved in the pathogenesis of Behçet's disease.

Does maternal knowledge impact blood phenylalanine concentration in Turkish children with phenylketonuria?

The aim of this study was to compare the level of maternal knowledge and the blood phenylalanine (Phe) control in phenylketonuria (PKU; OMIM 261600). The study was conducted on 144 children (81 boys, 63 girls) with PKU, aged between 1 and 15 years, at Hacettepe University Ihsan Dogramaci Children's Hospital, Metabolism and Nutrition Unit. All subjects were treated with a low-Phe diet using a Phe-exchange system. A 20-question multiple-choice questionnaire was applied to the mothers to determine their knowledge about PKU and its dietary treatment. Questions in the test consisted of the knowledge about the disease (6 questions), general dietary knowledge (14 questions) and knowledge about specific exchange within the dietary questions (6 questions). The median blood Phe concentration for the previous 3-year period was used as an indicator of metabolic control. Eighty-seven children had a median blood Phe concentration above the MRC Working Party Guidelines. There was a negative correlation between maternal knowledge about exchange and median blood Phe concentration in the child (p<0.05). Maternal knowledge about a standard 15 mg Phe exchange system is correlated with dietary compliance as measured by blood Phe concentrations in our subjects. We would like to implement an easier method of measuring Phe exchanges to improve dietary knowledge in the mothers.

Relationship of apoE polymorphism with lipoprotein(a), apoA, apoB and lipid levels in atherosclerotic infarct

BACKGROUND AND PURPOSE

Apolipoprotein E (apoE) polymorphism is suggested to be a risk factor in stroke in some populations, either by affecting lipid parameters or independently. Its effect on lipoprotein(a) [Lp(a)] is not known. The roles of apoE polymorphism and of high Lp(a) levels in atherosclerotic stroke (AS) in the Turkish population are unclear. Our aim was to investigate the relationship of apoE alleles and Lp(a) level with AS and the relationship of apoE alleles with Lp(a) and other lipid parameters.

METHODS

ApoE polymorphisms and lipid parameters were prospectively evaluated in 85 patients and 77 controls with normal brain imaging.

RESULTS

Only hypertension, diabetes mellitus, associated vascular diseases and decreased high-density lipoprotein cholesterol levels were found to be independent risk factors for stroke. However, in the presence of apoE/E4 allele, increased low-density lipoprotein cholesterol (LDL-chol), apolipoprotein B (apoB) and Lp(a) levels and in the presence of apo E/E3 allele, only Lp(a) levels were determined as risk factors.

CONCLUSION

This study showed that while apoE polymorphism was not a risk factor itself, high Lp(a), LDL-chol and apoB were determined to be risk factors in E3 or E4 carriers.

Audiologic findings in children with biotinidase deficiency in Turkey

OBJECTIVE

Biotinidase deficiency is an autosomal recessively inherited disorder characterized by neurological and cutaneous features, including sensorineural hearing loss. Although many features of the disorder are reversible following treatment with biotin, the hearing loss appears to be irreversible. In the present study, hearing status of patients with biotinidase deficiency is characterized in a Turkish population.

METHODS

Subjective and objective audiologic tests were performed on 20 children with profound biotinidase deficiency.

RESULTS

Sensorineural hearing loss occurs in approximately 55% of the children with biotinidase deficiency. The hearing loss varies in severity from mild to profound hearing loss. In children diagnosed immediately after birth because they had an older sibling with the disorder, statistically significant differences were found between ABR results and age of diagnosis (p<0.05). Greater prolongation in ABR latencies were observed in the late-diagnosed children compared to that in the early-diagnosed children (p<0.05).

CONCLUSION

Early diagnosis is important to prevent peripheral and central hearing loss. Children with biotinidase deficiency who have hearing loss are likely at increased risk for having speech and language problems. If hearing aids do not provide sufficient amplification, cochlear implantation may be indicated in these children. Therefore, it is important to test the hearing thresholds of these children with hearing aids and evaluate their language development.

A Turkish case with molybdenum cofactor deficiency

Molybdenum cofactor deficiency (MIM 252150) is a rare progressive neurodegenerative disorder with about 100 cases reported worldwide. We have identified a male with molybdenum cofactor deficiency and analyzed the molybdenum cofactor synthesis (MOCS)1 gene, MOCS2 gene, MOCS3 gene and GEPH gene. We homozygously identified the CGA insertion after A666 of the MOCS1 gene which produces arginine insertion at codon 222 of MOCS1A. The parents, his brother and his sister who did not have any symptoms were heterozygous for the same mutation. This region was highly conserved in various species. The N-terminal part of MOCS1 a protein is suggested to form the central core of the protein and be composed of an incomplete [(alpha/beta)6] triosephosphate isomerase (TIM) barrel with a lateral opening that is covered by the C-terminal part of the protein. The insertion is located in the loop connecting the fifth beta strand to the sixth alpha helices of the TIM barrel structure. This arginine insertion would induce the conformation change and the lack of the activity.

The effects of calcipotriol and methylprednisolone aseponate on bcl-2, p53 and ki-67 expression in psoriasis

OBJECTIVE

The decrease of physiological apoptosis in the psoriatic lesions is thought to be involved in the pathogenesis of psoriasis, and induction of apoptosis was shown to contribute to the regression of psoriatic hyperplasia. In the present study, we compared the effects of calcipotriol and methylprednisolone aseponate (MPA) treatments on bcl-2, p53 and ki-67 expressions in psoriatic patients in order to define a relationship between regulation of apoptosis and healing process in psoriasis.

METHODS

Thirty psoriatic patients with stable and moderate chronic plaque psoriasis applied either calcipotriol or MPA ointment for 6 weeks twice daily. Evaluation of bcl-2, p53 and ki-67 positivity was performed at baseline and was repeated at sixth week for each therapy.

RESULTS

The mean percentage of positive keratinocytes was 8.63 +/- 7.15% for p53, 20.66 +/- 14.45% for ki-67, and 3.74 +/- 2.83% for bcl-2 in psoriatic skin at baseline. Normal skin values were 3.27 +/- 3.21% for p53, 4.93 +/- 4.77% for ki-67, and 1.80 +/- 0.41% for bcl-2. The psoriatic skin showed higher ki-67 (P < 0.05) and bcl-2 (P < 0.05) expression rates when compared to normal skin. The p53 positivity observed in psoriatic skin and normal skin was not significantly different (P > 0.05). Following calcipotriol and MPA treatments, there was a significant reduction in p53 and ki-67 positivity accompanied by an increase in bcl-2 positivity (P < 0.05 each). No significant differences were found at sixth week between calcipotriol and MPA groups with respect to p53, ki-67 and bcl-2 positivity (P > 0.05). The post-treatment psoriatic skin showed lower expression of p53, higher expressions of ki-67 and bcl-2 when compared to normal skin (P < 0.05 each).

CONCLUSION

The results of this study provide evidence that both calcipotriol and MPA decrease the p53 and ki-67 expression and increase bcl-2 expression. However, it should further be elucidated if these changes were the common behaviour of psoriatic keratinocytes to any antipsoriatic medication.

Neurocutaneous melanosis associated with Dandy-Walker malformation

Neurocutaneous melanosis is an uncommon congenital disorder consisting of benign or malignant melanocytic tumors of the leptomeninges with large or numerous cutaneous congenital melanocytic nevi. The Dandy-Walker malformation occurs as an enlarged posterior fossa with high insertion of the tentorium, hypoplasia or aplasia of the cerebellar vermis, and cystic dilatation of the fourth ventricle. To our knowledge, the association of these two conditions has been reported only 14 times. In this article, we present a newborn patient with neurocutaneous melanosis associated with Dandy-Walker malformation, which was diagnosed by magnetic resonance imaging.

Three-field lymph node dissection in the treatment of thoracic esophageal carcinoma: the Turkish experience

The role of extended lymphatic dissection on the prognosis and outcome of thoracic esophageal carcinoma is still controversial. The aim of this study was to determine the impact of three-field lymphatic dissection on the survival and recurrence rates of patients with thoracic carcinoma of the esophagus. Forty-six patients with primary squamous cell carcinoma of the thoracic esophagus underwent esophagectomy with three-field lymphatic dissection between 1992 and 2003. Recurrence and survival rates were examined as well as complications. Overall survival for the patients was 45.6 months and 5-year survival rate was 56%. Five-year survival rates for patients with Stage 2A, 2B, 3 and 4 were 68%, 0%, 53% and 33%, respectively. There was no Stage 1 patient. Mean disease-free survival was 41.4 months. Sixty three percent of patients had node-negative disease (5-year survival rate, 68.9%) and 37% had nodal metastases (5-year survival rate, 33.7%) (P = 0.002). Surgical morbidity was seen in 35 patients (76.1%). Conclusively, lymph node involvement in patients with thoracic esophageal carcinoma is the major determinant of prognosis and survival. Extended lymphatic dissection provides higher disease-free and overall survival rates and our study revealed the highest survival rate for thoracic esophageal carcinoma, to best of our knowledge.

Uterine lipoma and coincidental cervical cancer: a case report

Pure lipoma of the uterus is a rare clinical event, and only a few cases have been reported in the literature. Clinical symptoms and physical signs are similar to those found in leiomyomas. The histogenesis of these lesions is still unclear. However, adipose metaplasia of stromal cells or smooth muscle cells of leiomyoma were accepted hypothesis that explain histogenesis of lipomas of uterus. We report the case of a 55-year-old woman with pure uterine lipoma and coincidental cancer of uterine cervix.

Vascular endothelial growth factor, c-erbB-2 and c-erbB-3 expression in colorectal adenoma and adenocarcinoma

AIM

To analyze vascular endothelial growth factor (VEGF), c-erbB-2 and c-erbB-3 expression and to evaluate their relation to clinicopathologic parameters and pathogenesis of colorectal carcinoma.

METHODS

Sections of adenoma, intramucosal carcinoma and adenocarcinoma were evaluated by immunohistochemistry in 85 malignant and 37 benign colorectal neoplasms for the expression of VEGF, c-erbB-2 and c-erbB-3 considering clinicopathological variables.

RESULTS

VEGF was detected in comparable percentages of all neoplasm types while c-erbB-2 expression was detectable more frequently in adenoma than adenocarcinoma cases (65% vs 43%). Except for the correlation of c-erbB-3 expression with Dukes' staging, there was no correlation between the studied markers and grade of differentiation, Dukes' stage and localization of colorectal adenocarcinoma. c-erbB-3 expression was seen more frequently in tubular adenomas, while c-erbB-2 expression was higher in tubulovillous and villous types. These differences were not statistically significant. The presence of distant metastasis and angiolymphatic invasion were identified as independent predictors of survival. A positive correlation was found between VEGF expression and lymphatic vessel invasion and regional lymph node involvement.

CONCLUSION

These results suggest that VEGF, c-erbB-2, c-erbB-3 expression does not have prognostic value in colorectal cancer. VEGF expression may be implicated in the lymph node metastasis.