Treatment of ovarian damage induced by chemotherapeutic drugs in female rats with G-CSF and platelet-rich plasma(PRP): an immunohistochemical study correlation with novel marker INSL-3

OBJECTIVE

To assess the impacts of Platelet-Rich Plasma(PRP) and Granulocyte Colony-Stimulating Factor(G-CSF) on a rat model with induced ovarian follicular damage caused by cyclophosphamide(Cy).

MATERIALS AND METHODS

Forty-two Sprague-Dawley rats were randomly allocated into seven distinct groups as; Group 1(control): NaCl intraperitoneal (IP) injection was administered on days D1, D7, and D14. Group 2(Cy):Cy IP injection on D1 + NaCl IP injection on D7 and D14 were administered. Group 3(PRP): PRP IP injection on D1,D7 and D14 were administered. Group 4(Cy + PRP):Cy IP injection on D1 and PRP IP injection on D1, D7 and D14 were administered. Group 5(G-CSF): G-CSF IP injection on D1, D7 and D14 were administered. Group 6(Cy + G-CSF):Cy IP injection on D1+ G-CSF IP injection on D1, D7 and D14 were administered. Group 7(Cy + PRP + G-CSF):Cy IP injection on D1+ PRP IP injection on D1,D7 and D14+ G-CSF IP injection on D1,D7 and D14 were administered. Follicular number, histological scores of AMH and INSL3 stained follicles at different stages of follicular development, and serum Anti-Müllerian hormone(AMH) were evaluated.

RESULTS

The primary, secondary, and antral follicle intensity scores for AMH-positive staining were most prominent in Groups 3 and 5. There was no significant difference between groups 4, 6 and 7 compared to group 1 in terms of follicule counts and AMH staining. The intensity scores of AMH-positive staining follicles were notably reduced in group 2 compared to groups 4, 6, and 7, with a significant difference (p < .01). Among the groups, group 2 exhibited the least intense antral follicle staining for INSL3, displaying a significant difference(p < .01) compared to the remaining groups.

CONCLUSIONS

Autologous PRP and G-CSF might protect ovarian function in the face of ovarian damage caused by Cy-induced effects.

Protective Effect of Glutathione Administration on Ovarian Function in Female Rats with Cyclophosphamide-Induced Ovarian Damage

OBJECTIVES

We investigated the potential of glutathione to protect ovarian function in rats exposed to cyclophosphamide by measuring serum anti-Mullerian hormone (AMH) levels, follicle counts, and related parameters.

DESIGN

Forty-two adult female Sprague-Dawley rats were randomly divided into six groups and treated with various combinations of cyclophosphamide, glutathione, and sodium chloride. On day 21, the rats were anesthetized, and their ovaries were removed for examination.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Histopathological examination, serum AMH concentrations, follicle counts, AMH-positive staining of follicle percentages were analyzed. Statistical analysis was performed using a one-way analysis of variance and Tukey's test, with significance set at p < 0.05. Secondary measures encompassed histopathological examination and percentages of AMH-positive staining of follicles.

RESULTS

Significant differences were observed in follicle counts, AMH-positive follicle parameters, and serum AMH concentrations among the six groups. Group 2 (treated with cyclophosphamide) had the lowest primordial, primary, secondary, and antral follicle counts and the highest atretic count. Group 6, treated with cyclophosphamide and 200 mg/kg glutathione, showed improved follicle counts compared to those in group 2. Reducing the glutathione dose to 100 mg/kg was ineffective.

LIMITATIONS

This was an experimental animal investigation with a comparatively modest sample size. Experimental studies should be conducted to determine the optimal dosage and duration of glutathione therapy. Information gathered from an experimental animal model may not yield precisely similar outcomes in humans; therefore, additional investigations are necessary to examine the impact of glutathione on women experiencing POI.

CONCLUSIONS

The anti-oxidative protective effect of directly administered glutathione was demonstrated for the first time. Low-dose glutathione was ineffective, whereas a high dose yielded significant ovarian protection against cyclophosphamide. Our findings provide valuable insights for supplementing clinical trials on the protective effects of glutathione against ovarian damage.

The Effects of Maternal Smoking on Thyroid Function: Findings from Routine First-Trimester Sonographic Anomaly Screening

AIM

This study aimed to assess the effect of tobacco exposure on maternal thyroid function and investigate its relationship to subclinical hypothyroidism in pregnant women during the first trimester.

SUBJECTS AND METHOD

A comparison of maternal thyroid function was made on 45 smokers, who composed the study group, and 72 non-smokers, pregnant women, who constituted the control group. After determining smokers by questionnaire, carbon monoxide (CO) levels in the expiratory air of the participants in both groups were measured and recorded, and the smokers' exposure was objectively confirmed.

RESULTS

Smoking and non-smoking pregnant women were similar regarding body mass index (BMI). While the TSH and fT4 levels were respectively 1.48 mlU/L and 11.43 pmol/L in pregnant women who smoked, that ratio changed to 1.72 mlU/L and 11.17 pmol/L in the non-smokers' group. But the differences between the groups were not statistically significant (p=0.239, p=0.179). Even though the rate of subclinical hypothyroidism was 8.9% in the smoking group, it was approximately 19.4% in the non-smoker group; the difference was not statistically significant (p=0.187).

CONCLUSION

This study proved that there is no statistically significant difference between maternal serum TSH and fT4 levels and the rate of subclinical hypothyroidism in smokers during pregnancy in the first trimester.

Knowledge levels and community guidance of doctors working in family health centers on HPV screening and HPV vaccination

AIM

Our aim is to evaluate the level of knowledge, compliance with the screening program, and tendency to inform patients of the doctors working in FHCs where HPV testing is performed within the scope of the cervical cancer screening program in our country.

METHODS

This cross-sectional study was performed between June and September 2022 with 113 family physicians working in different FHCs in different provinces in Turkey. Questionnaires prepared by the researchers were delivered to family physicians via online platforms.

RESULTS

When the different age groups were evaluated, in two of the 24 knowledge-level questions (How many types of HPV are there? Can HPV infect men?) the rate of correct answers for participants under the age of 35 years was statistically significantly higher (p = 0.007; p = 0.032). With regard to professional experience, the group with fewer than 10 years of experience gave a statistically significant correct answer to two questions (How many types of HPV are there? Can HPV infect men?; p = 0.008; p = 0.037). It was observed that 107 (94.7%) of the 113 family physicians who participated in the survey recommended that their patients use condoms during intercourse, 110 (97.3%) recommended cervical cancer screening tests to patients who applied for another reason, 105 (92.9%) recommended the HPV vaccine to patients and their relatives and 60 (53.1%) recommended the HPV vaccine to patients who applied for another reason.

CONCLUSIONS

The success of HPV vaccination programs is directly related to the beliefs of health personnel and their recommendations to the general population.

Carbetocin versus Oxytocin with or without Tranexamic Acid for Prophylactic Prevention of Postpartum Hemorrhage after a Vaginal Delivery: A Randomized Clinical Trial

OBJECTIVE

Our study's primary objective was to examine the effects of four different prophylactic protocols on the prevention of postpartum hemorrhage following vaginal birth, including carbetocin only, oxytocin only, and a combination of carbetocin or oxytocin with tranexamic acid.

DESIGN

A multicentric randomized controlled trial.

PARTICIPANTS/MATERIALS, SETTING, AND METHODS

This multicentric center prospective randomized controlled trial was conducted at the Department of Obstetrics and Gynecology of Bezmialem University and Van Health Teaching and Research Hospital from August 2022 to January 2023. The collected data included age, gravidity, parity, gestational age at birth, duration of delivery stages, prepartum hemoglobin and hematocrit concentrations, changes in hemoglobin and hematocrit concentrations, intrapartum blood loss, estimated blood loss after 2 h of vaginal delivery, Apgar scores at 1 and 5 min, birth weight, and neonatal intensive care unit (NICU) admission. Intrapartum blood loss was objectively measured in milliliters using a postpartum drape with a calibrated bag. The amount of bleeding was measured by subtracting the empty weight of the pads placed under the patient in the patient's bed within 2 h after delivery. Group I: carbetocin 100 μg/mL (n = 75), group II: oxytocin 5 IU/mL (n = 75), group III: carbetocin and tranexamic acid 50 mg/mL (n = 75), group IV: oxytocin and tranexamic acid (n = 75).

RESULTS

The hemoglobin concentration decrease significantly differed between groups (1.03 ± 1.04, 1.3 ± 0.85, 1.4 ± 0.85, 1.41 ± 0.87, respectively; p < 0.001). Group 4 has the highest decrease in hemoglobin and hematocrit concentrations. When we investigated the subgroup differences, the decrease in hemoglobin concentration was significantly higher in group 2 than group 1 (1.30 ± 0.85 vs. 1.03 ± 1.04; p = 0.023), in group 2 than group 3 (1.3 ± 0.85 vs. 1.04 ± 0.9; p = 0.013), and in group 4 than group 3 (1.41 ± 0.87 vs. 1.04 ± 0.9; p < 0.001). The decrease in hematocrit level was significantly different between groups (3.07 ± 3.23, 3.55 ± 2.44, 2.13 ± 3.09, 4.25 ± 2.52; p < 0.001, respectively). No significant differences were observed in terms of mean blood loss between the four groups (277.19 ± 208.10, 294.13 ± 198.64, 274.33 ± 199.57, and 283.97 ± 178.11; p = 0.445, respectively). Furthermore, there was no significant difference between the groups in the rate of need for blood transfusion (1.3%, 5.4%, 4%, and 4%, respectively; p = 0.6).

LIMITATIONS

The most important limitation of the study is a relatively small number of participants.

CONCLUSION

In conclusion, our findings suggest that carbetocin may be more successful than oxytocin and oxytocin plus tranexamic acid regimens in terms of postpartum hemoglobin reduction, and there is no difference in terms of the need for blood transfusion when it is used for postpartum hemorrhage prophylaxis after vaginal delivery.

Prevalence of urinary incontinence and anal incontinence: an internet-based cross-sectional study of female Turkish University students

INTRODUCTION AND HYPOTHESIS

The objective of this cross-sectional, epidemiological study was to characterize urinary tract and bowel symptom prevalence and the extent of discomfort/bother associated with them. Additionally, the authors aimed to explore factors associated with both conditions among Turkish female university students. Also, an insight into women's "communication regarding urinary incontinence and anal incontinence" with their family members was sought.

METHODS

This is an internet-based national cross-sectional study. A study-specific 30-item questionnaire containing validated measures of symptom prevalence and bother (Urogenital Distress Inventory questionnaire short form and Colorectal-Anal Distress Inventory) were incorporated into the survey. Out of a total of 2,125 e-mail invitations that were sent, 1,226 responded with data included in this analysis.

RESULTS

The age and BMI of all respondents were 26.53 ± 10.082, 23.45 ± 6.609 respectively. Nine hundred and eighty-five (80.5%) respondents claimed that they did not suffer a UI episode in the last year, whereas 10 people (0.08%) claimed that they had a urinary incontinence episode every day. Three hundred and fifty-seven responders (29.1%) stated that they suffered from "gas incontinence," 6 (0.5%) stool incontinence, and 20 (1.6%) declared that they had episodes of both stool and gas incontinence. Five hundred and forty-four participants (44%) reported that they had family relatives with a problem of "urinary incontinence" and 576 (47%) stated they had a conversation on "urinary incontinence." Seventy-five of the responders (6.1%) stated that they had a family member with "anal incontinence" and 246 (20.1%) responded that they had a conversation regarding "anal incontinence" with them.

CONCLUSION

We have demonstrated that the prevalence of UI was 19.5%. Twenty-nine percent stated they suffered "gas incontinence," 0.5% stool incontinence, and 1.6% declared that they had episodes of both stool and gas incontinence.

The Effect of Upper Abdominal Surgery on Complication Profile in Ovarian Cancer

Introduction: Due to the superficial peritoneal spread of ovarian cancer, upper abdominal surgical procedures are often required to achieve optimal surgical cytoreduction. This study compares the mortality and morbidity rates of patients undergoing upper and lower abdominal cytoreductive surgery in our institution. Material and Methods: Patients who underwent cytoreductive surgery for ovarian malignancies from 2014 to 2020 were retrospectively identified from an institutional database. Upper abdominal cytoreduction was defined anatomically as debulking of disease proximal to the ligament of Treitz. Perioperative and postoperative outcomes were analyzed. Results: A total of 148 operations were performed. A single gynecologic oncologist performed all procedures. When all cytoreductive procedures were evaluated, diaphragm injury, blood transfusion, hospital stay, atelectasis, pneumonia, effusion, wound infection and need for intensive care were found to be statistically significantly higher in patients who underwent upper abdominal surgery compared to patients in the lower abdominal surgery group (p=0.001, p=0.017, p=0.002, p=0.045, p=0.006, p=0.005, respectively). Conclusion: In patients scheduled for cytoreductive surgery with the diagnosis of ovarian cancer, upper abdominal surgery is a viable procedure, although it carries a higher risk of complications compared to lower abdominal surgery alone. Upper abdominal surgery in advanced ovarian cancer can be applied to patients with an acceptable complication profile when the possible survival advantage is considered.

Acute mastoiditis in children: A tertiary care center experience in 2015-2021

Background

Acute mastoiditis is a suppurative infection of mastoid air cells and is the most common intratemporal complication of otitis media.

Aim

This study aimed to evaluate the demographic and clinical characteristics and treatment outcomes of children with acute mastoiditis (AM).

Patients and Methods

We retrospectively reviewed the medical records of hospitalized pediatric patients aged between 1 month and 18 years with a diagnosis of AM between May 2015 and December 2021.

Results

A total of 28 hospitalized children with AM were enrolled in this study, of whom 22 (78.6%) were males and 6 (21.4%) were females with a mean ± standard deviation age of 93.5 ± 53.2 months (range = 6 months-16.1 years). The most common clinical symptoms were postauricular erythema (n = 17, 60.7%), tenderness (n = 16, 57.1%), swelling (n = 14, 50%), fever (n = 14, 50%), and auricular protrusion (n = 7, 25%). Mastoiditis complications occurred in 10 (35.7%) children. The most common extracranial complication was subperiosteal abscess (n = 8, 28.6%). The erythrocyte sedimentation rate (ESR) and the rate of antibiotic use before hospitalization were higher in patients with complicated mastoiditis (P = 0.006 and P = 0.039, respectively). Surgery was performed in 12 (42.9%) patients. Statistically, more surgical interventions were performed in patients who developed complications (P = 0.003).

Conclusion

AM continues as an important disease of childhood. Successful results are obtained with systemic antibiotic therapy and additional surgical intervention as necessary. A careful evaluation of patients with a high ESR and those who received antibiotic therapy before hospitalization is appropriate due to the correlation between these factors and the risk of complication development.

Cannabidiol as a potential novel treatment for endometriosis by its anti-inflammatory, antioxidative and anti-angiogenic effects in an experimental rat model

RESEARCH QUESTION

Can cannabidiol (CBD) be used in the treatment of endometriosis for its anti-inflammatory, antioxidative and antiangiogenic effects?

DESIGN

Endometrial implants were surgically induced in 36 female Wistar albino rats. After confirmation of endometriotic foci, the rats were randomized into four groups. In the leuprolide acetate group, rats were given a single 1 mg/kg s.c. leuprolide acetate injection. The other groups were 5 mg/kg CBD (CBD5), saline solution and 20 mg/kg CBD (CBD20); daily i.p. injections were administered for 7 days. After 21 days, the rats were euthanised, and total antioxidant status (TAS), total oxidant status (TOS), oxidative stress index (OSI), interleukin-6 (IL-6) and tumour necrosis factor-alpha (TNF-α) measurements in blood and peritoneal fluid samples, and immunohistochemical staining for TNF-α, IL-6 and vascular endothelial growth factor (VEGF) of endometriotic tissues were evaluated.

RESULTS

Significant reductions in the endometriotic implant surface area (P = 0.0213), serum TOS (P = 0.0491), OSI (P = 0.0056), IL-6 (P = 0.0236), TNF-α (P = 0.0083) and peritoneal fluid OSI (P = 0.0401), IL-6 (P = 0.0205) and TNF-α (P = 0.0045) concentrations were observed in the CBD5 group when compared with the saline solution group. Compared with the saline solution group, increased TAS concentrations in serum (P = 0.0012) and peritoneal fluid (P = 0.0145) were found in the CBD5 group. The CBD5 and leuprolide acetate groups were similar regarding inflammatory and oxidative stress parameters of serum and peritoneal fluid samples. The CBD5 group showed significantly lower mean intensity in both surface epithelium and stromal cells for VEGF (both P = 0.002) and only in surface epithelium cells for IL-6 (P = 0.0108), when compared with the leuprolide acetate group.

CONCLUSION

Due to its anti-inflammatory, antioxidative and antiangiogenic effects, CBD might be a therapeutic agent candidate for endometriosis.

Sleep, depression, anxiety and fatigue in women with premature ovarian insufficiency

PURPOSE

To assess sleep disturbances, levels of anxiety, depression and fatigue in women with premature ovarian insufficiency (POI).

MATERIALS AND METHODS

The study included 62 women with POI and 62 age-matched controls. Women in both groups completed questionnaires. Pittsburgh Sleep Quality Index, Insomnia severity index, Epworth Sleepiness Scale, Hospital Anxiety and Depression Scale and Fatigue Severity Scale were used.

RESULTS

We found poor sleep quality, higher levels of insomnia in women with POI than in controls. Depression was much more prevalent and severe in POI women. Total anxiety score, the severity of anxiety and fatigue did not differ significantly between the groups. According to the multivariable logistic regression analysis, being married and having POI were associated with worse quality of sleep, and having more children was associated with an increase in depression levels in the whole cohort. Backward analysis showed that when POI status was taken as a reference, married women were at 6.5 fold increased risk of poor sleep quality.

CONCLUSIONS

Women with premature ovarian failure are more likely to suffer from poor sleep quality, insomnia and depression than healthy women.

O-307 Cannabidiol as a potential novel treatment for endometriosis by its anti-inflammatory and anti-oxidative effects in an experimental rat model

Study question

Can cannabidiol (CBD) - a nonpsychoactive constituent of the cannabis plant – be used in the treatment of endometriosis by its anti-inflammatory and anti-oxidative effects?

Summary answer

CBD appears to be a potential novel therapeutic agent in the treatment of endometriosis through inhibiting inflammation and decreasing oxidative stress in a dose-dependent manner.

What is known already

The endocannabinoid system (ECS) consists of various bioactive lipids that are produced endogenously which activate cannabinoid 1-2 receptors (CB1-2). Alterations in ECS are associated with many physiological and pathological conditions throughout the body including endometriosis. The events that play role in the development and growth of ectopic endometriotic implants are proliferation, angiogenesis, and inflammation. By their anti-inflammatory and anti-oxidative effects, phyto and synthetic cannabinoids had been investigated and started being used for diseases with similar mechanisms. CBD is a nonpsychoactive constituent of the cannabis plant which acts indirectly upon the CB-1 receptor and as an inverse agonist of CB-2 receptor.

Study design, size, duration

Endometrial implants were surgically induced in 36 female Wistar-Albino rats in the first surgery. After confirmation of endometriotic foci in the second surgery, the rats were randomized into four groups. Group 1 (leuprolide acetate group) was given a single 1 mg/kg subcutaneous injection of leuprolide acetate. Groups 2,3 and 4 were 5 mg/kg CBD, saline solution (control group), and 20 mg/kg CBD injected groups, respectively, and daily intra-peritoneal (i.p.) injections were applied for seven days.

Participants/materials, setting, methods

After 21 days from the second surgery, the rats were sacrificed and histopathological analysis of endometriotic lesions, total antioxidant status (TAS), total oxidant status (TOS), oxidative stress index (OSI), interleukin 1 (IL-1), interleukin 6 (IL-6) and tumor necrosis factor-alpha (TNF-a) measurements in blood and peritoneal fluid samples, and immunohistochemical staining for TNF-a expression in endometriotic tissue were evaluated.

Main results and the role of chance

After treatment, significant reductions in TOS, OSI, IL-1, IL-6 and TNF-α levels in the blood and peritoneal fluid samples and TNF-α expression of endometriotic implants (p &lt; 0.01) and increased TAS (p &lt; 0.01) were found in the CBD 5mg/kg and leuprolide acetate groups.

Limitations, reasons for caution

The limitation is that this is an experimental rat model study.

Wider implications of the findings

This is the first study in the literature that evaluates the effects of a phytocannabinoid -CBD- on endometriosis in a rat model. With its anti-inflammatory and anti-oxidative effects and favorable safety and tolerability profile, it might be a candidate for a novel treatment in endometriosis.

Trial registration number

not applicable

POS0710 ANALYSIS OF 5-YEAR HOSPITALIZATION DATA OF PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: DAMAGE IS A RISK FACTOR FOR FREQUENT AND LONGER STAYS

Background:

The rates of hospitalization in patients with SLE is around 10% per year.1

Objectives:

In this study, we aimed to examine the hospitalization data of patients with SLE in the last 5 years at our center and determine the factors that affect hospitalization.

Methods:

Hospitalization data of patients with SLE (2012 SLICC classification) admitted to our rheumatology ward between January 2015 and 2020 were analyzed. Cumulative clinical and laboratory findings were retrieved from the existing SLE database and revised. SLICC SLE damage index (SDI), and the disease activity at admission were determined (SLEDAI-2K).

Results:

Eighty-six % (n=138) of 161 hospitalized patients were female. The mean age of the patients was 38 ± 13 years whilst mean duration of disease was 97.3 ±96.9 months. Thirty-eight% of the patients were hospitalized more than once and the mean number of hospitalizations was 1.8±1.5 The mean hospitalization duration covering all stays for each patient was 25±27 days. Active disease followed by infection and damage-related complications ranked the first three among all causes of hospitalization.

Compared to patients hospitalized for active disease or other reasons, patients hospitalized for infection had a significantly higher number of readmissions (p<0.05) and their total duration of hospitalization was longer (p<0.01). Duration of disease was significantly shorter in patients hospitalized for active disease compared to patients hospitalized for infection and damage related causes (p<0.05).

The frequency of patients with damage and the mean SDI score was significantly lower in the group with active disease (68% and 1.9 ± 2) compared to patients hospitalized for infection (90% and 2.7±1.6) and other causes (96% and 3±1.7) (p<0.05 for both). Distribution of damage according to organ/systems is presented in Graph 1. Highest frequency of damage was detected in the cardiovascular (30%), followed by neuropsychiatric (26.7%), renal (23%), pulmonary (23%) and musculoskeletal (20.5%) domains. A positive correlation was found between the mean SDI score and duration of hospitalization (r=0.551, p<0.001) as well as the number of hospitalizations (r=0.393, p<0.001). Regarding disease activity at the time of admission, the mean score of patients hospitalized for active disease was 11.0 ± 6.1 whilst was 3.2 ± 2.8 in patients hospitalized for infection and 2.9 ± 3.3 in patients hospitalized for other reasons (p<0.001). Renal active disease was the most common (44%), followed by hematological (34.8%), articular (21.7%) and mucocutaneous (21%) activity. Ten% of the patients all of whom had damage were admitted to intensive care unit (ICU). Total hospitalization duration (p=0.012), mean SDI (p=0.008), antiphospholipid syndrome (p=0.033), lupus anticoagulant (p=0.010), thrombocytopenia (p=0.015), serositis (p=0.034), pulmonary hypertension (p=0.021), history of alveolar haemorrhage (p<0.001) and cardiac valve involvement (p=0.002) were associated with ICU hospitalization.

Conclusion:

Disease activity, infections and damage are the leading causes of hospitalization in patients with SLE. Damage increases the frequency of hospitalizations, prolongs the duration of stay, and increases the need for follow-up in the ICU. Tight control of disease activity with rational use of immunosuppressive treatment is important to reduce damage and hospitalizations.

Graphic 1.

Distribution of damage according to organs/systems in hospitalized patients

References:

[1]Gu K, Gladman DD, Su J, Urowitz MB. Hospitalizations in patients with systemic lupus erythematosus in an academic health science center. The Journal of rheumatology 2017;44:1173-8.

Disclosure of Interests:

None declared

POS0766 CLUSTER ANALYSIS AND COMPARISON OF CUMULATIVE DAMAGE BY DIAPS IN A SINGLE CENTER COHORT OF APS PATIENTS

Background:

Antiphospholipid syndrome (APS) is a chronic autoimmune disease with significant morbidity and mortality. The recently developed damage index for APS (DIAPS) considers thrombotic APS specific damage.

Objectives:

Herein we aimed to identify disease clusters based on clinical characteristics and compare DIAPS between these clusters in a single center cohort of patients with APS ± systemic lupus erythematosus (SLE).

Methods:

This retrospective study included 237 consecutive patients with APS [114 primary APS (PAPS) and 123 SLE+APS]. Data regarding demographics, clinical and laboratory characteristics and cardiovascular risk factors were retrieved from the existing database and revised. Two-step cluster analysis was performed. Cumulative damage was calculated for all patients by applying DIAPS as described previously.

Results:

237 patients were classified into 4 subgroups by cluster analysis. Cluster 1 (n=74) consisted of older patients with arterial-predominant VT, livedo reticularis and increased cardiovascular risk, cluster 2 (n=70) of SLE+APS patients with thrombocytopenia and heart valve disease, cluster 3 (n=59) of patients with venous-predominant VT, less extra-criteria manifestations and cluster 4 (n=34) of patients with only PM with a lower frequency of extra-criteria features and cardiovascular risk (table 1).

Table 1.

Demographic, clinical and laboratory characteristics of clusters

All (n=237)Cluster 1 (n=74)Cluster 2 (n=70)Cluster 3(n=59)Cluster 4 (n=34)PAge (years), median (range)43 (20-81)51 (20-81)40 (27-72)42 (24-69)40.5 (26-65)<0.001Duration of disease (years), median (range)9.5 (1-37.7)13.1 (1-37.7)10.4 (1-28.7)8.5 (1-32.8)7 (1-22.4)0.028Female, n (%)198 (83.5)56 (75.7)61 (87.1)47 (79.7)34 (100)<0.05SLE, n (%)123 (51.9)31 (41.9)46 (65.7)32 (54.2)14 (41.2)<0.05Vascular thrombosis, n (%)191 (80.6)73 (98.6)59 (84.3)59 (100)0 (0)<0.001Arterial thrombosis, n (%)109 (46)50 (67.6)31 (44.3)28 (47.5)0 (0)<0.001Venous thrombosis, n (%)112 (47.3)36 (48.6)37 (52.9)39 (66.1)0 (0)<0.001Pregnancy morbidity, n (%)117 (49.4)22 (29.7)46 (65.7)15 (25.4)34 (100)<0.001Livedo reticularis, n (%)38 (16)21 (28.4)10 (14.3)5 (8.5)2 (5.9)<0.01Thrombocytopenia, n (%)81 (34.2)4 (5.4)65 (92.9)4 (6.8)8 (23.5)<0.001Heart valve disease, n (%)92 (38.8)32 (43.2)46 (65.7)8 (13.6)6 (17.6)<0.001Arterial hypertension, n (%)101 (42.6)49 (66.2)34 (48.6)18 (30.5)0 (0)<0.001Hyperlipidemia, n (%)103 (43.5)69 (93.2)26 (37.1)0 (0)8 (23.5)<0.001Smoking, n (%)58 (24.5)31 (41.9)7 (10)17 (28.8)3 (8.8)<0.001Lupus anticoagulant, n (%)156 (65.8)53 (71.6)48 (68.6)35 (59.3)20 (58.8)0.36Anticardiolipin IgG/IgM, n (%)155 (65.4)46 (62.2)46 (65.7)38 (64.4)25 (73.5)0.71Anti-β2-glycoprotein I IgG/IgM, n (%)93 (39.2)25 (33.8)33 (47.1)26 (44.1)9 (26.5)0.13Triple aPL positivity, n (%)45 (19)12 (16.2)16 (22.9)13 (22)4 (11.8)0.46

Cluster 2 had the highest cumulative damage (mean DIAPS 2.48 ± 1.67) followed by cluster 1 (2.24 ± 1.44), cluster 3 (1.69 ± 1.27) and cluster 4 (0.32 ± 0.68). Comparison of DIAPS (total and major domains) between the clusters is shown in figure 1.

Patients with SLE+APS had a higher mean DIAPS compared to those with PAPS (2.10 ± 1.61 vs 1.69 ± 1.47, P=0.046). Cardiovascular domain was the most frequently affected DIAPS domain in both groups. Proteinuria and avascular necrosis were significantly more frequent in SLE+APS (9.8% vs 2.2%, P=0.02 and 5.7% vs 0%, P=0.009, respectively). DIAPS was positively correlated with disease duration (r=0.192, P=0.003).

Conclusion:

Elder APS patients with arterial thrombosis and increased cardiovascular risk and SLE+APS patients with extra-criteria manifestations had higher cumulative DIAPS. Longer disease duration, higher frequency of major organ involvement and higher immunosuppressive usage may have contributed to this difference. Therefore, control of cardiovascular risk factors, prevention and effective treatment of SLE flares may help to reduce damage in these subgroups.

Figure 1.

Comparison of mean DIAPS (total and major domains) between the clusters

Disclosure of Interests:

None declared

OP0313 PRELIMINARY CRITERIA FOR MACROPHAGE ACTIVATION SYNDROME ASSOCIATED WITH CORONAVIRUS DISEASE-19

Background:

COVID-19 runs a severe disease associated with acute respiratory distress syndrome in a subset of patients, and a hyperinflammatory response developing in the second week contributes to the worse outcome. Inflammatory features are mostly compatible with macrophage activation syndrome (MAS) observed in other viral infections despite resulting in milder changes. Early detection and treatment of MAS may be associated with a better outcome. However, available criteria for MAS associated with other causes have not been helpful.

Objectives:

To identify distinct features of MAS associated with COVID-19 using a large database enabling to assess of dynamic changes.

Methods:

PCR-confirmed hospitalized COVID-19 patients followed between March and September 2020 constituted the discovery set. Patients considered to have findings of MAS by experienced physicians and given anakinra or tocilizumab were classified as the MAS group and the remaining patients as the non-MAS group. The MAS group was then re-grouped as the cases with exact-MAS and borderline-MAS cases by the study group. Clinical and laboratory data including the Ct values of the PCR test were obtained from the database, and dynamic changes were evaluated especially for the first 14 days of the hospitalization. The second set of 162 patients followed between September-December 2020 were used as the replication group to test the preliminary criteria. In the second set, hospitalization rules were changed, and all patients required oxygen support and received dexamethasone 6mg/day or equivalent glucocorticoids. Daily changes were calculated for the laboratory items in MAS, borderline, and non-MAS groups to see the days differentiating the groups, and ROC curves and lower and upper limits (10-90%) of the selected parameters were calculated to determine the cutoff values.

Results:

A total of 769 PCR-confirmed hospitalized patients were analysed, and 77 of them were classified as MAS and 83 as borderline MAS patients. There was no statistically significant difference in the baseline viral loads of MAS patients compared to the non-MAS group according to the Ct values. Daily dynamic changes in the MAS group differed from the non-MAS group especially around the 6th day of hospitalization, and more than a twofold increase in ferritin and a 1.5-fold increase in D-dimer levels compared to the baseline values help to define the MAS group. Twelve items selected for the criteria are given in Table 1 below. The total score of 45 provided 79.6% sensitivity for the MAS (including borderline cases) and 81.3% specificity around days 5 and 6 in the discovery set, and a score of 60 increased the specificity to 94.9% despite a decrease in sensitivity to 40.8%. The same set provided a similar sensitivity (80.3%) in the replication, but a lower specificity (47.4-66% on days 6 to 9) due to a group of control patients with findings of MAS possibly masked by glucocorticoids.

Table 1.

Preliminary Criteria for Macrophage Activation Syndrome Associated with Coronavirus Disease-19

1.Fever (>37.0 °C)2.Ferritin concentration > 550 ng/mL3.More than 2 times increase of ferritin concentration within 7 days of disease onset4.Neutrophil count > 6000 cell/mm35.Lymphopenia < 1000 cell/mm36.Neutrophil/lymphocyte ratio > 67.D-dimer concentration > 1000 ng/ml8.More than 50% increase of D-dimer concentration within 7 days of disease onset9.CRP concetration > 50 mg/L10.LDH concentration > 300 U/L11.ALT or AST concentration > 50 U/L12.Procalcitonin concentration < 1.2

1 point for each positive item assessed on Days 5-7

Score calculation: Total points / 12 x 100

Possible MAS ≥45 and Definite MAS ≥60

Conclusion:

This study defined a set of preliminary criteria using the most relevant items of MAS according to the dynamic changes in the parameters in a group of COVID-19 patients. A score of 45 would be helpful to define a possible MAS group with reasonable sensitivity and specificity to start necessary treatments as early as possible.

Disclosure of Interests:

None declared.

AB0766 SUCCESSFUL TEATMENT OF ANKYLOSING SPONDILITIS ASSOCIATED AA AMYLOIDOSIS WITH SECUKINUMAB: A CASE SERIES WITH THREE PATIENTS

Background:

Systemic AA amyloidosis is a serious and life-threatening complication of chronic inflammatory diseases such as rheumatoid arthritis, spondyloarthritis (SpA), and periodic fever syndromes. While most common cause of AA amyloidosis is Familial Mediterranean Fever; Ankylosing Spondylitis (AS) is another frequent cause of AA amyloidosis in Turkey.

Objectives:

We aimed to evaluate the response of secukinumab (SEC) treatment in three patients with AS and AA amyloidosis (AS-AA) in our tertiary referral centre.

Methods:

We retrospectively evaluated three AA amyloidosis patients who fulfilled Modified New York Criteria for diagnosis of AS in our AA amyloidosis cohort with 163 patients. Diagnosis of AA amyloidosis was confirmed by Congo red stain and by monoclonal AA-specific antibodies.

Results:

Patient 1: 61-year-old male patient with inflammatory back pain (IBP) and peripheral arthritis for 14 years was evaluated in our clinic. After methotrexate (MTX) failure, he used adalimumab (ADA), etanercept (ETA) and certolizumab (CZP). Nephrotic range proteinuria was detected when he was on CZP, and rectum biopsy documented AA amyloidosis 3 years ago. After the diagnosis, CZP treatment was switched to infliximab (IFX). IFX was ineffective in controlling inflammatory findings. SEC was started 15 months ago and he responded partially. The dose of SEC was increased to 300 mg monthly, which resulted in a sustained improvement in clinical and laboratory findings.

Patient 2: 69-year-old woman was admitted to our clinic with peripheral arthritis in addition to the history of IBP for 19 years in 2005. MTX, NSAID and prednisolone were started. Because of inefficacy to conventional treatments and development of nephrotic range proteinuria, ETA was added to treatment. The patient responded to ETA and was followed-up for 13 years without symptoms of AS and proteinuria. ETA was switched to IFX due to secondary inefficacy two years ago. On the third month of IFX treatment, she developed demyelinating polyneuropathy. IFX treatment was switched to SEC and she is still being followed-up on SEC without any findings of AS and proteinuria.

Patient 3: 49-year-old woman who was on sulphasalasine for 24 years for treatment of ulcerative colitis (UC) was evaluated for recent onset IBP and peripheral arthritis in 2007. After failure of MTX, she started to receive IFX. She did not respond to first IFX and then ADA and CZP, and she developed nephrotic range proteinuria when she was on anti-TNF. Her serum creatinine increased progressively, and haemodialysis (H/D) was started six months later. Due to ongoing IBP and elevated acute phase response with CZP treatment, SEC was started. Significant improvement was observed in both clinical and laboratory findings with no worsening of UC.

Table 1.

Clinical characteristics, laboratory findings and treatment responses of patients

Patient 1Patient 2Patient 3Age (year)616949SexMaleFemaleFemaleAge of AS onset (year)473525Age of amyloidosis diagnosis (year)575046Amyloidosis duration (months)4216830 Family historyNoAS and amyloidosis in siblingsNoHLA-B 27 statusPositivePositiveNot available MEFV statusNegativeNegativeM694V heterozygousOrgan involvement of amyloidosisGIS and kidneyKidney, liver, heart, bone marrowGIS, kidneySecukinumab duration (months)151824 CRP (mg/L) Before271523 After2.44.52.8Creatinine (mg/dl) Before0.51.6H/D After0.51.3H/DProteinuria (g/day) Before4.25.5H/DAfter2.40.9H/DAlbumin (g/dL)Before2.72.53.1After3.14.34.2ASDASBefore4.11.64.6After1.81.11.7

GIS: Gastrointestinal System, ASDAS: Ankylosing Spondylitis Disease Activity Score

Conclusion:

AA amyloidosis is a rare complication of SpA, and SEC treatment was found to be safe and effective in our three patients with AS-AA. Although anti-TNF agents have previously used successfully in treatment of AS-AA, SEC may be a new option especially in patients who are resistant or intolerant to anti-TNFs.

Disclosure of Interests:

None declared

POS1339 MORE FREQUENT AND EARLIER HIP INVOLVEMENT IN SPONDYLOARTHRITIS ASSOCIATED WITH FAMILIAL MEDITERRANEAN FEVER

Background:

Familial Mediterranean fever (FMF) is a hereditary autoinflammatory disorder caused by the MEFV gene variants. Although association between FMF and spondyloarthritis (SpA) has previously been reported, clinical and laboratory features of patients with FMF and SpA have not been defined in detail.

Objectives:

We aimed to evaluate clinical and laboratory characteristics, disease outcome and biologic responses of patients with FMF+SpA compared to patients with only SpA who were followed-up in our tertiary referral center.

Methods:

Database of FMF Clinic was screened for FMF patients with coexistent SpA and 113 patients were identified fulfilling Tel Hashomer and ASAS criteria for FMF and SpA, respectively. A group of patients with SpA without FMF matched for age, gender and disease duration were selected as the control group.

Results:

Thirteen patients were excluded because of missing data, and 100 patients (F/M: 52/48) were included into the analysis. Mean follow-up time was 93.6 ± 77 (range[r]: 3-324) months and mean patient age was 43.3 ± 12 (r: 20-87) years. Mean age of onset for FMF was 12.5 ± 8 (r: 1-36) and for SpA was 25 ± 11 (r: 7-72) years. SpA findings was classified as axial in 35.4%, axial and peripheral in 47.9% and only peripheral in 16.7% in FMF+SpA group. Half (49%) of the patients had hip involvement (70% bilaterally), and 21.5% of them needed total hip joint replacement (TJR), which were significantly more frequent compared to control group. Two exon 10 MEFV variants were found in 69.4%, and most (69.8%) had homozygous M694V. Hip involvement was more frequent in patients with two exon 10 variants (p=0.036; OR=4.4) compared to those with one variant; and TJR was more frequent in those with homozygous M694V compared to other exon 10 variants (p=0.001; OR=10). Radiographic sacroiliitis was less frequent in patients with homozygous M694V (p=0.019; OR=5.48). HLA-B27 positivity was not associated with hip or axial involvement in patients with FMF+SpA.

Biologics were used in 60 patients (anti-TNF in 43, secukinumab in 1, and tocilizumab in 2). Anti-IL-1 drugs were used in 23 patients for refractory FMF. In 9 patients, anti-TNF and anti-IL-1 drugs were tried for refractory joint involvement: 5 switched to anti-TNFs from anti-IL-1, 4 patients switched to anti-IL-1 from anti-TNFs. Biologic DMARD requirement was more frequent in patients with two exon 10 variants (p=0.006; OR=7.4), especially in those with homozygous M694V (p=0.006; OR=7.6). Although anti-IL-1 usage did not differ among MEFV variants, anti-TNF was used more frequently in patients with homozygous M694V (p=0.007; OR=7.2). FMF+SpA patients had higher serum CRP and developed amyloidosis more frequently than those patients with SpA.

Table 1.

Comparison of clinical and laboratory findings between the patients with FMF+SpA and SpA control

FMF + SpA (n=100)SpA (n=217)P valueAge (years)*43.3 ± 1243.4 ± 110.6Sex (n, %) Male48104 (47.9)0.99 Female52113 (52.1)Duration of SpA (monnths)*181.6 ± 108180.2 ± 1120.8Age onset of SpA (years)*25.1±1128.4±80.008Peripheral arthritis (n, %)35/80 (43.8)79/212 (37.3)0.3HLA-B27 positivity (n, %)6/21 (28.6)105/139 (75.5)<0.001 (OR=18.9)CRP (mg/dL)*26.7 ± 25**18.96±290.001ESR (mm/hour)*39.7 ± 2739.4 ± 280.8Hip involvement (n, %)47/96 (49)23/118 (19.5)<0.001 (OR=20.9)TJR (n, %)20/93 (21.5)8/205 (3.9)<0.001 (OR=23.3)Fulfilling mNY criteria (n, %)52/81 (64.2)164/199 (82.4)0.001 (OR=10.8)Biologic DMARD (n, %)6068/214 (31.8)<0.001 (OR=22.5)Anti-TNF (n, %)4668/214 (31.8)0.015 (OR=5.96)Amyloidosis (n, %)165/205 (2.4)<0.001 (OR=19.3)

* mean±standard deviation, **during the attack-free period

Conclusion:

In this group of FMF+SpA patients, hip involvement and need for TJR were more frequent and associated with penetrant MEFV variants rather than HLA-B27 positivity. These patients had higher inflammatory response and risk of developing amyloidosis, and they needed biologics more frequently compared to SpA group. More severe disease course in FMF+SpA patients requires further attention and analysis in larger cohorts.

Disclosure of Interests:

None declared

POS0706 PERFORMANCES OF DIFFERENT CLASSIFICATION CRITERIA FOR SYSTEMIC LUPUS ERYTHEMATOSUS IN A SINGLE CENTER COHORT FROM TURKEY

Background:

Recently developed EULAR/ACR classification criteria for systemic lupus erythematosus (SLE) have important differences compared to the 2012 Systemic Lupus International Collaborating Clinics (SLICC) SLE classification criteria and the revised 1997 American College of Rheumatology (ACR) criteria: The obligatory entry criterion of antinuclear antibody (ANA) positivity is introduced and a “weighted” approach is used1. Sensitivity and specificity of these three criteria have been debated and may vary in different populations and clinical settings.

Objectives:

We aim to compare the performances of three criteria sets/rules in a large cohort of patients and relevant diseased controls from a reference center with dedicated clinics for SLE and other autoimmune/inflammatory connective tissue diseases from Turkey.

Methods:

We reviewed the medical records of SLE patients and diseased controls for clinical and laboratory features relevant to all sets of criteria. Criteria sets/rules were analysed based on sensitivity, positive predictive value, specificity and negative predictive value, using clinical diagnosis with at least 6 months of follow-up as the gold standard. A subgroup analysis was performed in ANA positive patients for both SLE patients and diseased controls. SLE patients that did not fulfil 2012 SLICC criteria and 2019 EULAR/ACR criteria and diseased controls that fulfilled these criteria were evaluated.

Results:

A total of 392 SLE patients and 294 non-SLE diseased controls (48 undifferentiated connective tissue disease, 51 Sjögren’s syndrome, 43 idiopathic inflammatory myopathy, 50 systemic sclerosis, 52 primary antiphospholipid syndrome, 15 rheumatoid arthritis, 15 psoriatic arthritis and 20 ANCA associated vasculitis) were included into the study. Hundred and fourteen patients (16.6%) were ANA negative.

Sensitivity was more than 90% for 2012 SLICC criteria and 2019 EULAR/ACR criteria and positive predictive value was more than 90% for all three criteria (Table 1). Specificity was the highest for 1997 ACR criteria. Negative predictive value was 76.9% for ACR criteria, 88.4% for SLICC criteria and 91.7% for EULAR/ACR criteria.

In only ANA positive patients, sensitivity was 79.6% for 1997 ACR criteria, 92.2% for 2012 SLICC criteria and 96.1% for 2019 EULAR/ACR criteria. Specificity was 92.6% for ACR criteria, 87.8% for SLICC criteria 85.2% for EULAR/ACR criteria.

Eleven clinically diagnosed SLE patients had insufficient number of items for both 2012 SLICC and 2019 EULAR/ACR criteria. Both criteria were fulfilled by 16 diseased controls: 9 with Sjögren’s syndrome, 5 with antiphospholipid syndrome, one with dermatomyositis and one with systemic sclerosis.

Table 1.

Sensitivity, positive predictive value, specificity and negative predictive value of 1997 ACR, 2012 SLICC and 2019 EULAR/ACR classification criteria

SLE (+)SLE (-)Sensitivity (%)Positive Predictive Value (%)Specificity (%)Negative Predictive Value (%)1997 ACR(+) 308(-) 841527978.695.494.976.92012 SLICC(+) 357(-) 352626891.193.291.288.42019 EULAR/ACR(+) 368(-) 242826693.892.990.591.7

Conclusion:

In this cohort, although all three criteria have sufficient specificity, sensitivity and negative predictive value of 1997 ACR criteria are the lowest. Overall, 2019 EULAR/ACR and 2012 SLICC criteria have a comparable performance, but if only ANA positive cases and controls are analysed, the specificity of both criteria decrease to less than 90%. Some SLE patients with a clinical diagnosis lacked sufficient number of criteria. Mostly, patients with Sjögren’s syndrome or antiphospholipid syndrome are prone to misclassification by both recent criteria.

References:

[1]Aringer M, Costenbader K, Daikh D, et al. 2019 European League Against Rheumatism/American College of Rheumatology classification criteria for systemic lupus erythematosus. Ann Rheum Dis 2019;78:1151-1159.

Disclosure of Interests:

None declared

AB0653 COURSE OF COVID-19 INFECTION IN A SERIES OF PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Infection is a remarkable cause of morbidity and mortality in patients with SLE.

Objectives:

We aimed to determine the clinical course of COVID-19 infection in our patients with SLE and the factors affecting this course

Methods:

SLE patients (2012 SLICC criteria) diagnosed with COVID-19 infection by a positive PCR test and/or typical findings of lung involvement in CT (computed tomography) imaging were included. Data regarding cumulative clinical and laboratory characteristics, histopathology results, autoantibody profiles, immunsuppressives and damage (SLICC damage index/SDI)) were retrieved from the existing database and revised. SLE Disease Activity Index (SLEDAI-2K) was determined at the time of infection.

Results:

Sixteen SLE patients with COVID-19 infection were identified. Most (87.5%) of these patients were female. Seventy % (n=11) had lupus nephritis. Twenty-five % had thrombotic antiphospholipid syndrome.

PCR was positive in 70% (n=11) of the patients. Pulmonary parenchymal findings compatible with COVID-19 were observed in 56% (n=9) of those patients. Regarding complaints upon admission, 50% (n=8) had fever, 44% (n=7) cough, 44% (n=7) dyspnea, 19% (n=3) myalgia, 12.5% (n=2) headache, 12.5% (n=2) nausea /vomiting, 6% (n=1) diarrhea, and 6 % (n=1) had anosmia. Eight patients were hospitalized. Six of these patients needed oxygen therapy via nasal cannula. None needed a follow-up in the intensive care unit. The mean hospitalization duration was 14 ± 5 (8-25) days.

Regarding disease activity at the time of infection, 9 had inactive disease with a SLEDAI-2K score of 0 whilst in 5 patients SLEDA-2K score was ≥4. The mean SLEDAI-2K score at the time of infection was 1.7 ± 2.3 (0-6). System/organwise, 1 patient with chronic thrombocytopenia presented with a worsening platelet count accompanied by serologic activity. This patient was a non-adherent to treatment who had stopped taking mycophenolic acid months before COVID19. Three patients 2 of whom had proliferative nephritis experienced nephritic flares.1 patient who had a history of cutaneous lupus and was in remission presented with oral ulcer, leukopenia and hypocomplementemia during infection. Of 16 patients, 7 had system damage at the time of infection. The mean SDI score of the patients was 1.4±1.8. Comparison of patients with and without damage revealed no significant differences in disease activity, symptoms associated with COVID, in the need for hospitalization, hospitalization duration, and the requirement for oxygen therapy. However,CT findings compatible with COVID19, were more common in patients with damage (87% vs.33%,p=0.04) and their mean CRP levels were higher at diagnosis (65 ± 47 vs.22 ± 48 mg/l;p=0.032).

All patients received similar treatment for COVID-19 except active patients who required high dose steroids (2 with active renal, 1 with thrombocytopenia and 1 with oral ulcer, leukopenia and hypocomplementemia).The patient with thrombocytopenia also received intravenous immunoglobulin and 1 with cutaneous active disease received tocilizumab as she developed macrophage activation syndrome. Six patients (37.5%) had received rituximab (RTX) in the last 6 months before COVID. No significant difference, in terms of hospitalization and need for oxygen therapy due to COVID19 was found between patients who had received RTX vs who had not. No hypogammaglobulinemia was detected in patients who received RTX despite lower levels of IgG (998 ± 184 vs 1481± 51 mg/dl, p=0.02)

Conclusion:

Although half of the patients in our series of COVID19 infected SLE patients required hospitalization, there were no mortalities. More patients with damage (none pulmonary) displayed CT findings compatible with COVID19 and further follow up will reveal whether they will suffer from fibrotic lung disease. Patients can experience disease flares during COVID. But it is also important to consider that some manifestations such as thrombocytopenia may also be a sign of severe infection. Immunosupressive agents may not have a negative impact on the course of infection.

*the first two authors contributed equally

Disclosure of Interests:

None declared.

Transvaginal round-infundibulopelvic ligament colposuspension after vaginal hysterectomy in high-grade uterovaginal prolapse: 11-year outcome

OBJECTIVE

To interpret the long-term outcomes of transvaginal round-infundibulopelvic ligament colposuspension after vaginal hysterectomy in patients with stage 3-4 uterovaginal prolapse.

STUDY DESIGN

This retrospective case-control study from 2007 to 2016 analysed patients' medical records and evaluated gynaecological examinations over 11 years of follow-up. One hundred and forty-three patients who underwent transvaginal round-infundibulopelvic ligament colposuspension after vaginal hysterectomy were evaluated. The prespecified primary outcome evaluated at 11-year follow-up was apical prolapse of stage 2 or higher evaluated by the Pelvic Organ Prolapse Quantification System (POP-Q), in combination with bothersome bulge symptoms or repeat surgery for recurrent apical prolapse. The secondary outcome was overall anatomical failure (recurrent prolapse of stage 2 or higher in apical, anterior or posterior compartment). The rate of recurrence of apical prolapse was compared between groups using the McNemar test.

RESULTS

The mean (± standard deviation) follow-up period was 88.15 ± 2.519 months (95 % confidence interval 83.17-93.13). The pre-operative diagnoses were stage 3 uterovaginal prolapse in 23 (16.08 %) patients, stage 4 uterovaginal prolapse in 120 (83.91 %) patients, rectocele in 119 (83.21 %) patients, cystocele in 138 (96.50 %) patients and stress urinary incontinence in 53 (37.06 %) patients. Ten (8.33 %) patients with stage 4 uterovaginal prolapse developed postoperative apical prolapse, whereas none of the patients with stage 3 uterovaginal prolapse developed postoperative apical prolapse. Postoperatively, the POP-Q stages of apical prolapse were significantly lower compared with pre-operatively (p < 0.001). Postoperatively, the apical prolapse rate was 7.0 %, the recurrent cystocele rate was 2.07 %, the recurrent rectocele rate was 5.5 %, and the recurrent stress urinary incontinence rate was 18.87 %. Overall, postoperative anatomical failure occurred in 21 of 143 (14.68 %) women. One (0.69 %) patient developed perioperative bladder perforation, two (1.39 %) patients experienced voiding difficulty, and eight (5.59 %) patients experienced vaginal spotting.

CONCLUSION

Transvaginal round-infundibulopelvic ligament colposuspension during vaginal hysterectomy is an effective and useful method that reduces the rate of postoperative apical prolapse in patients with high-grade uterovaginal prolapse.

SAT0200 RISK FACTORS FOR ADVERSE PREGNANCY OUTCOMES IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS

Background:

Pregnancies of patients with systemic lupus erythematosus (SLE) can be risky both for the mother and the fetus because of disease activity and pregnancy complications.1

Objectives:

In this study, we evaluated the risk factors related to adverse pregnancy outcomes (APO) in our pregnant SLE cohort who were followed up by both Rheumatology and Obstetrics and Gynecology departments at our university.

Methods:

168 pregnancy data were analyzed from 136 patients who fulfilled ACR classification criteria for SLE. The course of pregnancies were monitored and fetal/neonatal outcomes were recorded. Unexplained fetal death after 12 weeks of gestation, neonatal death, preterm birth due to preeclampsia, eclampsia or HELLP and birth of small for gestational age (SGA) infant were defined as APO. Cumulative clinical, laboratory and serological findings, disease activity (SLEDAI-2K) and damage (SLICC/ACR), and conventional risk factors were compared between APO(+) and APO(-) groups.

Results:

The comparison of demographics, conventional risk factors and disease characteristics in APO(+) and APO(-) groups are summarized in Table-1. In APO(+) pregnancies, the duration of disease was longer (p <0.05) and the frequency of chronic hypertension was higher (p <0.05) compared to APO(-) pregnancies. Renal and neuropsychiatric (NP) involvement, thrombocytopenia, antiphospholipid syndrome (APS), lupus anticoagulant and anti-cardiolipin IgM positivity were significantly higher in APO(+) group. Mean SLEDAI-2K scores of three trimesters and postpartum 6 months were higher in APO(+) patients compared to APO(-) patients (2.2 ± 3.6 vs 1.2 ± 2.04, p <0.05; 4.9 ± 6.03 vs 2.7 ± 5.01, p = 0.02, respectively). Percentage of patients with damage at the beginning of pregnancy and the mean SLICC damage score were significantly higher in APO(+) group compared to APO(-) group (1.8 ± 2.1 vs 0.8 ± 1.3, p <0.05). In APO(+) group, damage was significantly higher in neuropsychiatric, renal and cardiovascular and locomotor systems (p <0.05).

Conclusion:

Although an important proportion of SLE pregnancies result in live birth, active disease, especially renal and NP involvement, and presence of damage at the beginning of pregnancy increase the risk of maternal and fetal complications. Furthermore, the presence of APS or antiphospholipid antibody positivity are important risk factors for obstetric complications. In conclusion, pregnancy should be allowed after controlling the disease activity and patients should be closely monitored in coordination with Obstetrics and Gynecology clinics. In case of presence of damage, both the patient and the physician should be aware of a possible adverse pregnancy outcome.

References:

[1]Ann Intern Med. 2015 August 4; 163(3): 153–163. doi:10.7326/M14-2235.

Table 1.

Demographic data of APO (+) and APO (-) groups, comparison of conventional risk factors, cumulative clinical, serological and laboratory features

APO(-)(n=111)APO (+)(n=57)pAge35.1±6.734.9±5.9NSAge at conception30.6±5.628.9±4.2NSDisease duration (months)141.6±70166.9±87.9<0.05Chronic hypertension, n (%)6 (7)11 (19.6)<0.05Photosensitivity, n (%)86 (77.5)43 (75.4)NSMalar rash, n (%)66 (59.5)38 (66.7)NSOral ulcer, n (%)11 (9,9)6 (10.5)NSArthritis, n (%)77 (59.4)42 (73.7)NSSerositis, n (%)17 (15.3)13 (22.8)NSRenal, n (%)39 (35.1)30 (52.6)<0.05Hematologic, n (%)78 (70.3)40 (70.2)NSThrombocytopenia, n (%)37 (33.3)30 (52.6)<0.05AIHA, n (%)16 (14.4)14 (24.6)NSNeurologic, n (%)7 (6.3)9 (15.8)<0.05Anti-cardiolipin IgG, n(%)28 (25.2)18 (32.1)NSAnti-cardiolipin IgM, n (%)18 (16.2)18 (32.1)<0.05Lupus anticoagulant, n (%)26 (23.4)28 (49.1)<0.001Antiphospholipid syndrome, n (%)28 (25.2)30 (52.6)<0.001

(NS=not significant, APO=adverse pregnancy outcome, AIHA=autoimmune hemolytic anemia)

Disclosure of Interests: :

None declared

FRI0160 THE CORRELATION BETWEEN PREGNANCY, DISEASE ACTIVITY AND ADVERSE PREGNANCY OUTCOMES IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Patients with systemic lupus erythematosus (SLE) can present with acute disease flares/exacerbations during pregnancy and postpartum period.1These flares can cause adverse pregnancy outcomes (APO).

Objectives:

In this study, our pregnant SLE cohort, which was under medical surveillance of both our Rheumatology and Gynecology and Obstetrics departments was analyzed. We intended to determine the effects of pregnancy on disease activity and the correlation between disease flares and adverse pregnancy outcomes.

Methods:

168 pregnancy data involving 136 patients with SLE meeting the ACR criteria were examined. Cumulative clinical, laboratory and serological parameters were described and disease activity and flares were calculated using SLEDAI-2K disease activity index during preconceptional six month period, during all trimesters of pregnancy, and during postpartum six month period. Patients with low lupus disease activity scores (LLDAS) during each of these periods were identified. Fetal/neonatal death, premature birth due to preeclampsia, eclampsia or HELLP syndrome, neonates small for gestational age were determined as adverse pregnancy outcomes. Relationship of APO with disease activity was studied and patients with APO were compared to patients without APO.

Results:

Mean SLEDAI-2K scores was 1.3±2.2 (0-16) during preconceptional six month period, 1.3±2.6 (0-16) during conception period, 1.7±3.2 (0-22) during first trimester, 1.4±2.7 (0-16) during second trimester, 1.5±3.3 (0-20) during third trimester and 3.5±5.4 (0-26) during postpartum six month period. Mean postpartum six month period SLEDAI-2K score was higher compared to the mean pregnancy SLEDAI-2K score (p<0.05). LLDAS was sustained in 79% of all pregnancies. 19% of pregnancies resulted in flares. 42% of these flares were severe and 58% were mild or moderate. 49% of severe flares occurred during the postpartum six month period and this percentage was significantly higher compared to each trimester (p<0.05). Most of the flares during pregnancy and postpartum period had mucocutaneous (37%), renal(35%) and hematological(25%) involvement.

APO was observed in 34% of pregnancies (n=57). APO (+) group was characterized by significantly longer disease duration and higher disease activity in all periods compared to APO (-) group (142±70 vs 170±88 months, p<0.05). In APO (-) group, the proportion of patients with severe disease activity during all pregnancy periods and postpartum period was significantly low (%18 vs 35, p<0.05), while the proportion of patients with sustained LLDAS was much higher (%88 vs 70).

Conclusion:

Postpartum six-month period appears to have the highest risk for disease flares during SLE pregnancies. Disease activity during pregnancy increases the risk of APO. Patients with sustained LLDAS have significantly lower APO rates. In order to achieve a positive pregnancy outcome and lower maternal morbidity, regular follow up of patients during pregnancy and postpartum period by Rheumatology and Gynecology and Obstetrics Departments is necessary.

References:

[1]Eudy AM, et al. Ann Rheum Dis 2018;0:1–6. doi:10.1136/annrheumdis-2017-212535

Disclosure of Interests:

None declared

Low indoleamine 2,3-dioxygenase activity in persistent food allergy in children

BACKGROUND

Indoleamine 2,3-dioxygenase (IDO), which degrades tryptophan (Trp) to kynurenine (Kyn), has been demonstrated to contribute to modulation of allergic responses. However, the role of IDO in food allergy has not yet been elucidated.

METHODS

Serum Trp and Kyn concentrations were analyzed by high-pressure liquid chromatography. Expression of IDO gene was measured by real-time PCR. The levels of interleukin (IL)-4, IL-10, and interferon (IFN)-γ in cell culture supernatants were measured by ELISA.

RESULTS

Kyn/Trp (IDO activity) was significantly lower in subjects with food allergy (n = 100) than in aged-matched healthy controls (n = 112) (P = 0.004). Kyn/Trp was decreased from healthy through completely tolerant, partially tolerant, and reactive ones [LN transformation (mean ± SEM) healthy: 3.9 ± 0.02 μM/mM; completely tolerant: 3.83 ± 0.04; partially tolerant: 3.8 ± 0.06; reactive: 3.7 ± 0.04] (P = 0.008). The frequency of genetic polymorphisms of IDO did not reveal a significant association with Trp, Kyn, and Kyn/Trp in healthy and food-allergic cases. Culture of PBMC experiments yielded that IDO mRNA expression was not different between tolerant and reactive groups. IL-4 synthesis when stimulated with casein increased significantly in subjects who are reactive and tolerant to foods (P = 0.042, P = 0.006, respectively). Increase in IL-10 synthesis was observed only in children tolerant to milk, but not in reactive ones. IFN-γ synthesis, when stimulated with IL-2 and β-lactoglobulin in cell culture, was significantly higher in subjects tolerant to milk than in the reactive ones (P = 0.005 and P = 0.029, respectively).

CONCLUSION

Our results imply the probability of involvement of IDO in development of tolerance process, and we presume that high IDO activity is associated with nonresponsiveness to food allergens despite allergen sensitization.

Placental site trophoblastic tumor: report of a tertiary center experience

OBJECTIVE

To analyze the clinical and pathological characteristics of placental site trophoblastic tumor (PSTT) cases and to discuss the diagnosis, treatment, and prognosis of PSTT.

MATERIALS AND METHODS

The clinical and pathological data of eight patients with PSTT at Istanbul Medical Faculty Hospital from 1988 to 2010 were analyzed retrospectively.

RESULTS

The mean age of the patients was 31 years. The antecedent pregnancy was full-term delivery in most of the patients (6/8, 75%). The mean interval from last pregnancy to diagnosis of PSTT was 35 months (range, six to 192). Serum human chorionic gonadotropin (hCG) levels at the time of diagnosis ranged from 0.1 to 2280 mIU/ml (mean, 614). All patients had Stage 1 disease and ultimately underwent hysterectomy. None of the patients received adjuvant chemotherapy. One patient died of an unknown reason, one month after the surgery. The rest of the patients were alive and without evidence of disease after an average of 3.5 years (range, one to 11) of follow-up.

CONCLUSION

Hysterectomy alone can provide long-term survival in early-stage disease.

Course and severity of postpartum metritis cases following antibiotic and PGF2α administration in postpartum metritis cows infected with BoHV-4

Forty cows between day 1 and day 21 post-calving were examined for the presence of postpartum metritis in a dairy herd that had recently experienced an increase in metritis and that had previously tested positive against bovine herpes virus 4 (BoHV-4) by various methods. Antibodies against BoHV-4 were detected in sera from 15 of 22 cows. For the virological study, uterine swab samples of 22 cows with metritis were used and tested for BoHV-4 using polymerase chain reaction (PCR), virus isolation (VI), and immunofluorescence techniques. Twenty-two point seven per cent (5/22) of the vaginal discharge samples obtained from cows with metritis were found positive for BoHV-4 DNA by PCR. All of these samples were also positive in VI and/or immune fluorescence assay (IF). Swab samples were also tested for bacteria. Empirical therapy with a broad spectrum antibiotic (oxytetracycline) was administrated, pending culture and antibiotic sensitivity result. All cows with puerperal metritis or clinical metritis (CM) were treated with intra-uterine (i.u.) administration of oxytetracycline and with intramuscular (i.m.) injections of dinoprost tromethamine (PGF(2)α) for three consecutive days. Concurrently, with the administration of oxytetracycline and PGF(2)α, cows with a rectal temperature >39.5°C received an additional treatment with oxytetracycline (i.m) for three consecutive days. According to the antibiotic test result, on day 3 after the last oxytetracycline and PGF(2)α administrations, all cows were treated with a combination of amoxicillin and clavulanic acid (i.u.) for three consecutive days. All cows with metritis and that were positive for BoHV-4 recovered clinically after the administration of antibiotic and PGF(2)α. In conclusion, postpartum metritis cases in cows infected BoHV-4 recovered clinically following early diagnosis and prolonged treatments with a combination of antibiotics and PGF(2)α.

Non-invasive Indices for the Estimation of the Anaerobic Threshold of Oarsmen

This study compared four common non-invasive indices with an invasive index for determining the anaerobic threshold (AT) in 22 adult male rowers using a Concept2 rowing ergometer. A criterion-standard progressive incremental test (invasive method) measured blood lactate concentrations to determine the 4 mmol/l threshold (La4-AT) and Dmax AT (Dm-AT). This was compared with three indices obtained by analysis of respiratory gases and one that was based on the heart rate (HR) deflection point (HRDP) all of which used the Conconi test (non-invasive methods). In the Conconi test, the HRDP was determined whilst continuously increasing the power output (PO) by 25 W/min and measuring respiratory gases and HR. The La4-AT and Dm-AT values differed slightly with respect to oxygen uptake, PO and HR however, AT values significantly correlated with each other and with the four non-invasive methods. In conclusion, the non-invasive indices were comparable with the invasive index and could, therefore, be used in the assessment of AT during rowing ergometer use. In this population of elite rowers, Conconi threshold (Con-AT), based on the measurement of HRDP tended to be the most adequate way of estimating AT for training regulation purposes.

Preventive effects of a turnover flexor tendon sheath flap on adhesion formation after flexor profundus tendon injury: an experimental study

This study aims to investigate the effects of a proximally-based turnover sheath flap obtained from the tendon sheath on the prevention of adhesion formation in the legs of the chickens whose tendons and sheaths have been injured. The chickens were categorised into 4 groups. Group 1 was chosen as the sham group. In Group 2, a defective area of 0.3 x0.5 cm was created across the sheath, without damaging the tendon. The healthy profundus tendons of the chickens in Group 3 were cut and repaired. Afterwards, a defective area of 0.3 x 0.5 cm was created across the tendon sheath. In Group 4, the healthy profundus tendons were cut and repaired. Then, a defective area of 0.3 x 0.5 cm was created over the reconstructed tendon. This defective area was finally covered with a proximally-based turnover sheath flap of the size 0.4 x 1 cm, which was raised from the distal part of the sheath. The toes were immobilised for 3 weeks before the chickens were sacrificed. Histopathological and biomechanical analyses showed adhesion in the repaired tendons in Group 3, in which movement restriction was shown by biomechanical analyses. The present study showed that covering the defective sheath that was created over the repaired tendon with a proximally-based turnover tendon sheath flap prevented peritendinous adhesion.

Urinary tract infections due to Mycoplasma canis in dogs

Urine samples were obtained from 100 dogs with symptoms of lower urinary tract disease by cystocentesis and were examined for mycoplasmas. Urinalysis, haematological and biochemical analyses were also performed. Bacteria were isolated from urine in 41 of 100 dogs; Mycoplasma canis was isolated from four of 100 (4%) urine samples and three were pure culture. Selective mycoplasma media were used for isolation. In growth inhibition test, propagation of the four M. canis isolates was inhibited by their specific hyperimmune sera and there was no cross reactivity between isolates and hyperimmune sera of other mycoplasmas. Dogs in which M. canis was isolated were azotemic. All dogs were treated with enrofloxacin, furosemide, and supportive therapy (fluid therapy, ascorbic acid). In all animals, clinical improvements were observed after treatment.

Detection of Salmonella spp. in Stray Dogs in Bursa Province, Turkey: First Isolation of Salmonella Corvallis from Dogs

The prevalence and antimicrobial sensitivity of Salmonella spp. in stray dogs in Bursa province, Turkey were determined from a total of 82 faecal samples by bacteriological methods. Of the dogs, nine (11%) were positive for salmonellae-carrying. All Salmonella isolates were serotyped as S. Corvallis, and were sensitive to amoxycillin/clavulanic acid, ampicillin, cephalothin, chloramphenicol, enrofloxacin, gentamicin, kanamycin, nalidixic acid, neomycin, oxytetracycline and trimethoprim/sulphamethoxazole, while 66.7% of them were resistant to streptomycin. It was concluded that stray dogs could be an important carrier of salmonellae as well as a source of human salmonellosis in Turkey. Additional studies are needed to clarify the epidemiological relationship between S. Corvallis isolated from dogs and humans with regard to public health. This is the first report on the isolation of S. Corvallis from dogs in the country.

Chronic groin pain in an amateur soccer player

Chronic groin pain is common in soccer players because of the biomechanics of kicking causing recurrent stress to the abdominal muscles, groin flexors, and adductor muscles. Myositis ossificans in adductor muscles is a rare cause of chronic groin pain in soccer players. Only two cases have been reported and the iliopsoas muscle was involved in both. This case report emphasises the importance of direct radiography for diagnosis in chronic groin pain and is a reminder that the development of myositis ossificans in the adductor muscles may be a cause.

Relation between isokinetic muscle strength and functional capacity in recreational athletes with chondromalacia patellae

OBJECTIVES

To investigate the effects of isokinetic exercise on pain and functional test scores of recreational athletes with chondromalacia patellae (CMP) and to examine the correlation between isokinetic parameters and functional tests or pain score.

METHODS

The functional ability of 30 recreational athletes with unilateral CMP was evaluated using six different tests. Pain scores were assessed during daily activities before and after the treatment protocol. Isokinetic exercise sessions were carried out at angular velocities of 60 degrees /s (25-90 degrees range of flexion) and 180 degrees /s (full range). These sessions were repeated three times a week for six weeks.

RESULTS

Quadriceps and hamstring peak torque, total work, and endurance ratios had improved significantly after the treatment, as did the functional parameters and pain scores. There was a poor correlation between the extensor endurance ratio and one leg standing test. A moderate correlation between the visual analogue scale and the extensor endurance ratio or flexion endurance ratio was also found.

CONCLUSIONS

The isokinetic exercise programme used in this study had a positive effect on muscle strength, pain score, and functional ability of knees with CMP. The improvement in the functional capacity did not correlate with the isokinetic parameters.

Protective effect of fucoidin (a neutrophil rolling inhibitor) on ischemia reperfusion injury: experimental study in rat epigastric island flaps

The objective of this study was to examine whether a decrease in neutrophil-mediated tissue injury using Fucoidin, a nontoxic neutrophil rolling inhibitor, would improve flap survival in an island flap model after ischemia-reperfusion. Myeloperoxidase activity (an indirect index of tissue neutrophil count) and malondialdehyde (an indicator of lipid peroxidation), the degree of neutrophil infiltration by direct counting, and macroscopic flap survival were assessed in the flap after arterial ischemia-reperfusion. Epigastric island skin flaps were elevated in 56 rats. The first group of 21 rats was subjected to 6 hours of arterial ischemia. The second group of 21 rats was subjected to 10 hours of arterial ischemia, and the rest of the rats were used as nonischemic controls (sham flaps). For inhibiting neutrophil rolling, a nontoxic polysaccharide agent-Fucoidin-was used. Each ischemic group was divided further into three subgroups: Subgroup I (control rats) received saline, subgroup II received 10 mg per kilogram Fucoidin, and subgroup III received 25 mg per kilogram Fucoidin before reperfusion. The results were evaluated as tissue neutrophil counts, tissue malondialdehyde content, tissue myeloperoxidase activity, and flap survival. Neutrophil counts and tissue myeloperoxidase activity were decreased significantly (p <0.001) in subgroup III, but lipid peroxidation by means of tissue malondialdehyde content was not affected by Fucoidin administration. The authors conclude that administration of Fucoidin before reperfusion can limit tissue injury apparently by inhibiting neutrophil rolling in a dose-dependent manner.

Arthroscopic fixation of intercondylar eminence fractures using a 4-portal technique

PURPOSE

We report an easy-to-use 4-portal technique for arthroscopic treatment of intercondylar eminence fractures and compare results of 2 groups of cases, adolescents and adults, and 2 types of internal fixation, sutures and screws.

TYPE OF STUDY

Surgical technique and retrospective study.

METHODS

The study was carried on 2 groups of patients, adolescents and adults, with intercondylar eminence fractures who were treated arthroscopically. For internal fixation, sutures were used in 8 adolescents and screws were used in 13 adults. In the technique we describe, anteromedial superior and inferior, and anterolateral superior and inferior portals were used.

RESULTS

The average follow-up period for the adolescents was 27.3 months (range, 11 to 57 months), and for the adults was 19.6 months (range, 7 to 71 months). We did not encounter any cases of nonunion. There were only 3 complications, 1 of arthrofibrosis resulting from a delay of rehabilitation due to a vascular compromise and 2 cases of tenderness over the screw that responded well to its removal. Union occurred earlier in adolescents, but rehabilitation was easier in adults.

CONCLUSIONS

Beside satisfactory results obtained by arthroscopic treatment of intercondylar eminence fractures, arthroscopy also provides the possibility to determine and treat associated pathologies. With the experience we gained, the procedure with the 4-portal technique in treating these fractures became much easier as a routine approach.

Arthroscopic resection of bucket-handle tears with the help of a suture punch: a simple technique to shorten operating time

We describe a surgical technique that has been used successfully for excising bucket-handle tears. The technique is routinely used in our department and has been found to shorten operating time. A suture punch is used to pass the suture through the bucket-handle tear. Manually maneuvering the free suture ends, it is always possible to cut the posterior or anterior attachment of the tear under direct visualization without the need for an additional portal and without the risk of losing the excised fragment in the joint. In our experience, the technique is simple, inexpensive, and reliable, but more importantly, it has shortened operating time significantly.

The effects of saline and plasma on skin graft keratinocyte viability

The viability of human split thickness skin grafts stored in plasma and saline at +4 degrees C had been evaluated by means of viable keratinocytes by trypan blue method. Skin grafts which were stored in plasma showed better percentage of viable keratinocytes at the end of 30 days than saline. It is concluded that plasma is a better storage medium than saline for preservation of skin grafts.

Efficacy of omeprazole plus two antimicrobials for the eradication of Helicobacter pylori in a Turkish population

Omeprazole combined with 2 antimicrobials has been suggested as a first-line option for Helicobacter pylori eradication in recent years. However, controversy exists regarding the efficacy of this protocol. This open-label, prospective clinical study investigated the efficacy of omeprazole-based triple therapy for H pylori eradication in 518 patients with H pylori-positive functional dyspepsia with or without duodenal ulcer. Amoxicillin, macrolides (clarithromycin or roxithromycin), and nitroimidazoles (metronidazole, ornidazole, or tinidazole) were the antibiotics used in the study. Nonulcer patients were randomly assigned to 1 of 8 different treatment protocols and duodenal ulcer patients were randomly assigned to 1 of 4 different treatment protocols consisting of omeprazole (20 mg once daily for nonulcer patients, 20 mg twice daily for ulcer patients for 14 days) with a combination of 2 of the above antimicrobials (for 10 days). H pylori infection was assessed by histologic findings and a rapid urease test before therapy and 4 weeks after therapy ended. Four hundred fifty-nine patients completed their regimens; 327 had functional dyspepsia (180 men, 147 women; median age, 39 years; range, 18 to 70 years) and 132 had ulcers (81 men, 51 women; median age, 40 years; range, 18 to 70 years). Eradication of H pylori was achieved in 58.8% (270 of 459) of all patients, 58.1% (190 of 327) of nonulcer dyspeptic patients, and 60.6% (80 of 132) of duodenal ulcer patients. The eradication rate varied from 47.2% to 69.4% in different treatment protocols. There were no statistically significant differences in eradication rates in any treatment group. All drugs were generally well tolerated in all groups, and no patient discontinued treatment because of side effects. Therapy with omeprazole and 2 antimicrobials for H pylori had limited efficacy in a Turkish population. The reason for these results, which conflict with those of other studies, is not clear. Further investigations of regimens for the eradication of H pylori in our population are necessary.

Serological and haematological diagnosis of enzootic bovine leukosis in cattle in Turkey

A serological study of enzootic bovine leukosis in the Bursa Region of Turkey showed that of 459 cattle (282 Holstein, 127 Brown-Swiss and 50 native Boz breed) 42 (9.15 per cent) were seropositive. The seropositive cattle had higher IgG1 (P < 0.001) and lower IgM (P < 0.01) levels than the seronegative cattle. In addition, the seropositive cattle with persistent lymphocytosis had higher IgG1 levels (P < 0.001), total leucocyte counts (P < 0.001) and lymphocyte counts (P < 0.001), than the cattle in the seropositive group without persistent lymphocytosis and the cattle in the seronegative group. There was a positive correlation (P < 0.05) between the IgG1 levels and the lymphocyte counts of the seropositive cattle with persistent lymphocytosis.

Trace element (Al, Se, Zn, Cu) levels in serum, urine and tissues of burn patients

Trace elements are known to play many important roles in humans. It has also been shown that some of these elements are essential in wound healing. In this study, aluminium, copper, zinc and selenium levels were determined in serum, urine and tissue samples of burned patients and the relationships between wound healing and trace elements were evaluated. Trace element levels were determined using atomic absorption spectrophotometry. During 20 days' treatment, a significant rise in aluminium levels was determined in serum, urine and tissue samples of patients. After day 5 of treatment, copper levels increased significantly only in urine samples. Zinc levels decreased in serum and tissue samples. However, zinc gave high values in urine within the first week then returned to the initial value. There was a significant decrease in zinc in serum and tissue samples taken from burned patients during treatment. Urine selenium levels showed a significant rise within the first 15 days.