The course of spinal tuberculosis (Pott disease): results of the multinational, multicentre Backbone-2 study.

We aimed to describe clinical, laboratory, diagnostic and therapeutic features of spinal tuberculosis (ST), also known as Pott disease. A total of 314 patients with ST from 35 centres in Turkey, Egypt, Albania and Greece were included. Median duration from initial symptoms to the time of diagnosis was 78 days. The most common complications presented before diagnosis were abscesses (69%), neurologic deficits (40%), spinal instability (21%) and spinal deformity (16%). Lumbar (56%), thoracic (49%) and thoracolumbar (13%) vertebrae were the most commonly involved sites of infection. Although 51% of the patients had multiple levels of vertebral involvement, 8% had noncontiguous involvement of multiple vertebral bodies. The causative agent was identified in 41% of cases. Histopathologic examination was performed in 200 patients (64%), and 74% were consistent with tuberculosis. Medical treatment alone was implemented in 103 patients (33%), while 211 patients (67%) underwent diagnostic and/or therapeutic surgical intervention. Ten percent of the patients required more than one surgical intervention. Mortality occurred in 7 patients (2%), and 77 (25%) developed sequelae. The distribution of the posttreatment sequelae were as follows: 11% kyphosis, 6% Gibbus deformity, 5% scoliosis, 5% paraparesis, 5% paraplegia and 4% loss of sensation. Older age, presence of neurologic deficit and spinal deformity were predictors of unfavourable outcome. ST results in significant morbidity as a result of its insidious course and delayed diagnosis because of diagnostic and therapeutic challenges. ST should be considered in the differential diagnosis of patients with vertebral osteomyelitis, especially in tuberculosis-endemic regions. Early establishment of definitive aetiologic diagnosis and appropriate treatment are of paramount importance to prevent development of sequelae.

Health-related quality of life in pediatric patients after allogeneic SCT: development of the PedsQL Stem Cell Transplant module and results of a pilot study.

With increased survival after pediatric allogeneic hematopoietic SCT health-related quality of life (HRQL) has emerged as an essential health outcome. The impact of transplant and chronic GVHD (cGVHD)-associated morbidity remains a major obstacle. In 2005, the National Institutes of Health (NIH) Consensus Conference on Criteria for Clinical Trials in cGVHD recommended HRQL tools as an independent measure of the impact of disease burden. The NIH recommendations did not provide a cGVHD-specific tool for HRQOL measures in children. This report focuses on the development of an SCT-specific instrument to assess HRQL in children and adolescents. For the assessment of generic HRQL we chose the PedsQL (Pediatric Quality of Life Inventory) Generic Cores Scales, which have been used in a large number of healthy, acutely ill and chronically ill children and adolescents. To capture SCT- and, specifically, cGVHD-related problems, we developed the PedsQL Stem Cell Transplant module by reviewing the literature, taking over some items/scales of other PedsQL modules, interviewing patients, parents and members of the health-care team, and applying the PedsQL measurement methods. The final PedsQL Stem Cell Transplant module consists of the HRQL domains: pain and hurt, fatigue/sleeping problems/weakness, nausea, worry/anxiety about disease/treatment, nutritional problems, neurocognitive problems, communication about disease/treatment, loneliness, physical functioning and additional somatic complaints (pruritus, skin inflammation, oral problems, eyes or breathing) including patients' and parents' assessment. It was tested in 35 pediatric patients, who were referred to our SCT Outpatient Clinic about 100 days post SCT. Both the generic PedsQL and the SCT-specific scales showed high internal consistency, with Cronbach alpha levels of ⩾0.70 in almost all scales. Most problems were detected within the HRQL domains of physical functioning and pain. The summary scores of the generic PedsQL and the PedsQL Stem Cell Transplant module showed high correlations (r=0.89 in patients' and r=0.81 in parents' assessments). Moreover, both tools discriminated between patients with and without cGVHD. The PedsQL Stem Cell Transplant module is practical for use and suitable across a broad age range (2-18 years) both in patients with and without cGVHD. However, it is still a pilot instrument and needs further development and testing in a larger patient population.

Liver involvement in patients with brucellosis: results of the Marmara study.

Brucellosis is a zoonotic disease that primarily affects the reticuloendothelial system. But, the extent of liver damage in due course of the disease is unclear. This study included 325 brucellosis patients with significant hepatobiliary involvement identified with microbiological analyses from 30 centers between 2000 and 2013. The patients with ≥5 times of the upper limit of normal for aminotransferases, total bilirubin level ≥2 mg/dl or local liver lesions were enrolled. Clinical hepatitis was detected in 284 patients (87.3 %) and cholestasis was detected in 215 (66.1 %) patients. Fatigue (91 %), fever (86 %), sweating (83 %), arthralgia (79 %), and lack of appetite (79 %) were the major symptoms. Laboratory tests showed anemia in 169 (52 %), thrombocytopenia in 117 (36 %), leukopenia in 81 (25 %), pancytopenia in 42 (13 %), and leukocytosis in 20 (6 %) patients. The most commonly used antibiotic combinations were doxycycline plus an aminoglycoside (n = 73), doxycycline plus rifampicin (n = 71), doxycycline plus rifampicin and an aminoglycoside (n = 27). The duration of ALT normalization differed significantly in three treatment groups (p < 0.001). The use of doxycycline and an aminoglycoside in clinical hepatitis showed better results compared to doxycycline and rifampicin or rifampicin, aminoglycoside, doxycycline regimens (p < 0.05). However, the length of hospital stay did not differ significantly between these three combinations (p > 0.05). During the follow-up, treatment failure occurred in four patients (1 %) and relapse was seen in three patients (0.9 %). Mortality was not observed. Hepatobiliary involvement in brucellosis has a benign course with suitable antibiotics and the use of doxycycline and an aminoglycoside regimen seems a better strategy in select patients.

Comparison of colistin-carbapenem, colistin-sulbactam, and colistin plus other antibacterial agents for the treatment of extremely drug-resistant Acinetobacter baumannii bloodstream infections.

The purpose of this investigation was to compare the efficacy of colistin-based therapies in extremely drug-resistant Acinetobacter spp. bloodstream infections (XDR-ABSI). A retrospective study was conducted in 27 tertiary-care centers from January 2009 to August 2012. The primary end-point was 14-day survival, and the secondary end-points were clinical and microbiological outcomes. Thirty-six and 214 patients [102 (47.7%): colistin-carbapenem (CC), 69 (32.2%): colistin-sulbactam (CS), and 43 (20.1%: tigecycline): colistin with other agent (CO)] received colistin monotherapy and colistin-based combinations, respectively. Rates of complete response/cure and 14-day survival were relatively higher, and microbiological eradication was significantly higher in the combination group. Also, the in-hospital mortality rate was significantly lower in the combination group. No significant difference was found in the clinical (p = 0.97) and microbiological (p = 0.92) outcomes and 14-day survival rates (p = 0.79) between the three combination groups. Neither the timing of initial effective treatment nor the presence of any concomitant infection was significant between the three groups (p > 0.05) and also for 14-day survival (p > 0.05). Higher Pitt bacteremia score (PBS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Charlson comorbidity index (CCI), and prolonged hospital and intensive care unit (ICU) stay before XDR-ABSI were significant risk factors for 14-day mortality (p = 0.02, p = 0.0001, p = 0.0001, p = 0.02, and p = 0.01, respectively). In the multivariable analysis, PBS, age, and duration of ICU stay were independent risk factors for 14-day mortality (p < 0.0001, p < 0.0001, and p = 0.001, respectively). Colistin-based combination therapy resulted in significantly higher microbiological eradication rates, relatively higher cure and 14-day survival rates, and lower in-hospital mortality compared to colistin monotherapy. CC, CS, and CO combinations for XDR-ABSI did not reveal significant differences with respect to 14-day survival and clinical or microbiological outcome before and after propensity score matching (PSM). PBS, age, and length of ICU stay were independent risk factors for 14-day mortality.

Effect of severe sepsis on platelet count and their indices.

BACKGROUND: Sepsis is a major disease affecting almost all organs and systems. OBJECTIVES: To examine platelet count and indices (mean platelet volume (MPV) and platelet distribution width (PDW)) in severe sepsis. METHODS: Patients with criteria for sepsis at a first examination by an Infectious Diseases specialist were selected. Consecutive patients who were admitted to the out-patient clinic and who were not diagnosed with any infectious disease were selected as the control group. RESULTS: A total of 145 patients with sepsis and 143 patients as a control group were included in the study. MPV and PDW were significantly differentbetween sepsis patients and control group (P<0.05). Platelet count in sepsis patients was lower than control group but the difference was not significant. PDW was the unique significantly different parameter between survivors and non-survivors (p=0.001). CONCLUSION: Platelet indices are important laboratory findings in the diagnosis of sepsis and severe sepsis. Severe sepsis patients who have greater than 18 % PDW levels have a higher risk of death. Therefore, PDW, which is part of an inexpensive, easily accessible and routinely performed test for almost all patients admitted to health facilities may be used for predicting mortality.

Ferritin concentrations correlate to outcome of hematopoietic stem cell transplantation but do not serve as biomarker of graft-versus-host disease.

Clinical presentation and laboratory data are often too unspecific to distinguish the onset or activity of graft-versus-host disease (GvHD) from infections or toxicity. Antigen-presenting cells such as monocytes/macrophages and dendritic cells are involved in GvHD pathogenesis after allogeneic hematopoietic stem cell transplantation (HSCT). To test whether ferritin, an iron storage marker and macrophage activation-linked acute-phase protein, represents a candidate biomarker for acute or chronic GvHD in pediatric HSCT, we retrospectively evaluated a 2-year follow-up data from 131 eligible consecutive patients with different malignant and nonmalignant diseases who underwent allogeneic HSCT. Thirteen patients (10 %) suffered from acute GvHD II-IV°, 18 (14 %) had limited, and 14 (11 %) had extensive chronic GvHD. In extension of previous studies in adults investigating pre-transplant ferritin, our data show that post-HSCT hyperferritinemia (analyzed on days 0, +30, +60, +100, +180, +360, and +720) was significantly associated with decreased long-term survival (p < 0.001-0.03) in children and adolescents. Increased ferritin concentrations were associated with number and timing of red blood cell transfusions and toxic or infectious multi-organ failure but did not show significant differences between patients without GvHD and with acute grades II-IV, limited, or extensive chronic GvHD. Thus, our data do not identify ferritin as specifically GvHD-linked biomarker; however, they support the prognostic value of ferritin levels for outcome after HSCT in children.

Intracranial epidural abscess secondary to isolated sphenoid sinusitis.

Isolated sphenoid sinus infection, although an uncommon entity, can cause severe cranial complications when left untreated. A case of temporal epidural abscess secondary to isolated sphenoid sinusitis in a 13-year-old boy is presented. Early diagnosis and treatment are critical because the disease can progress rapidly.

Comparison of the tuberculin skin test and the quantiferon test for latent Mycobacterium tuberculosis infections in health care workers in Turkey.

The aim of this study was to compare the efficacy of the tuberculin skin test (TST) and the quantiferon test (QFT) for detecting latent tuberculosis infection (LTBI) in health care workers (HCWs). Seventy-six participants who were working in Duzce University Hospital, where tuberculosis patients were being treated, were included in the study. TST was performed according to the Mantoux technique. QFT was performed in accordance with the manufacturer's instructions. A positive TST result was defined as an induration diameter of > or = 15 mm. TSTs were positive in 41 of 76 participants (53.9%) and QFT was positive in 65 of 76 participants (85.5%). There was a significant difference between the numbers of QFT-positive and TST-positive cases (P=0.02). When the induration diameter of TST was > or = 20 mm, QFT positivity was 100%. Multivariate analysis revealed that there was a significant correlation between the percentage of patients with QFT positivity and the induration diameter of TST (P=0.009). QFT thus seems to be more effective for LTBI diagnosis than TST. However, large-scale trials including quantitative measurement of QFT in subgroups taking into account the division where HCWs are employed and the different results of TST might clarify the usefulness of QFT in LTBI diagnosis.

Pneumosinus dilatans of the ethmoid sinus presenting with exophthalmus: a case report and review of the literature.

Pneumosinus dilatans (PSD) is a rare condition of unknown aetiology in which there is enlargement of the paranasal sinuses by air, where the affected sinus expands beyond the normal boundaries of bone without thinning of its bony walls. The case of a 28 year old male with PSD, who had gradually increasing exophthalmus and diplopia, is presented and characteristics of this condition are reviewed with literature data.

Does topical lidocaine with adrenaline have an effect on morbidity in pediatric tonsillectomy?

OBJECTIVE: To evaluate the efficacy of lidocaine with adrenaline on post-operative morbidity in pediatric patients after tonsillectomy. STUDY DESIGN: A double blind prospective randomized controlled clinical study. METHODS: The study is consisting of two groups of pediatric patients following tonsillectomy performed in a university hospital. One group received lidocaine with adrenaline soaked swabs packed in their tonsillar fossae while the control group received saline-soaked swabs. Chi-square and two-tailed unpaired Student's t-tests were used to compare the two independent groups. p<0.05 was accepted as statistically significant. RESULTS: No significant pain-relieving effect was seen in the lidocaine with adrenaline group (p>0.05) and also the other post-operative parameters such as nausea, fever, vomiting, odor, bleeding, otalgia and trismus were not statistically different between the two groups based on chi-square analysis (p>0.05). There were no complications associated with lidocaine and adrenaline. CONCLUSION: We suggest that application of topical lidocaine with adrenaline seems to be a safe and easy medication for local anesthetic use. However, in our study, lidocaine with adrenaline offered no advantage over placebo in the control of post-operative pain and other morbidity related factors following pediatric tonsillectomy. We therefore do not recommend topical application of lidocaine with adrenaline for reducing morbidity in pediatric tonsil surgery.