Hypophosphatemic osteomalacia: a case simulating anklylosing spondylitis treated with anti-TNF therapy.

In this case, a young male patient diagnosed as hypophosphatemic osteomalacia and ankylosing spondylitis (AS) will be assessed by literature. A 32-year-old male patient who had been previously diagnosed as ankylosing spondylitis and hypophosphatemic osteomalacia was admitted to our clinic. In the beginning of the disease, he complained of pain on the first metatarsal bone and low back. Sacroiliac magnetic resonance (MR) images were interpreted as sacroiliitis. He was diagnosed as AS, and referred to many hospitals and received several therapies. He did not benefit from the treatment and his complaints worsened. The human leukocyte antigen (HLA) B-27 test was negative and alkaline phosphatase level was high. Old femur fractures were reported in the whole body bone scintigraphy. In addition, the patient was diagnosed with osteomalacia. While the patient was receiving vitamin D, oral phosphate, anti-tumor necrosis factor therapy was added. Patient's diagnosis was reevaluated. His final diagnosis was hypophosphatemic osteomalacia instead of ankylosing spondylitis.

Acardiac twin pregnancy: successful intrauterine ablative treatment with alcohol at 14 weeks of gestation.

Twin reversed arterial perfusion (TRAP) sequence is a serious condition of monochorionic twin pregnancy, occurring in approximately one in 35,000 cases. First trimester treatment of TRAP sequence is controversial with higher incidence of procedure related complications. Present case demonstrates a TRAP sequence that was managed by intrauterine treatment with one-ml 100% pure alcohol injection into the abdominal part of the umbilical artery and obliteration of the acardiac twin at 14 weeks of gestation. Antenatal follow-up was uneventful and elective cesarean section was performed at 39 weeks' gestation. Postnatal outcome of the pump twin was excellent at 30 months after birth. Early second trimester elective ablation by alcohol injection can be an inexpensive, alternative, and reasonable minimal invasive treatment option to prevent fetal loss of pump twin before mid and late second trimester in perinatology centers where intrafetal cord occlusive methods are not available.

Healthcare-associated Crimean-Congo haemorrhagic fever in Turkey, 2002-2014: a multicentre retrospective cross-sectional study.

Healthcare-related transmission of Crimean-Congo haemorrhagic fever (CCHF) is a well-recognized hazard. We report a multicentre retrospective cross-sectional study undertaken in Turkey in 2014 in nine hospitals, regional reference centres for CCHF, covering the years 2002 to 2014 inclusive. Data were systematically extracted from charts of all personnel with a reported health care injury/accident related to CCHF. Blood samples were tested for CCHF IgM/IgG by enzyme-linked immunosorbent assay and/or viral nucleic acid detection by PCR after the injury. Fifty-one healthcare-related exposures were identified. Twenty-five (49%) of 51 resulted in laboratory-confirmed infection, with a 16% (4/25) overall mortality. The main route of exposure was needlestick injury in 32/51 (62.7%). A potential benefit of post-exposure prophylaxis with ribavirin was identified.

The reasons for extractions of primary teeth in Turkish children.

AIM: The aim of this study was to determine the current reasons for primary teeth extractions in Turkish children and their relative importance. STUDY DESIGN: retrospective evaluation of patients by analysing dental records of children aged 2-13 years, receiving treatment in different regions in Turkey over a period of five years (2007-2012). Patient's age, gender, any significant medical finding, type of tooth extracted and the reason for the extraction were the parameters evaluated. RESULTS: It resulted that 2,508 primary teeth belonging to 1,755 children aged of 2-13 years were extracted. Extraction due to caries (57,4%) was found to be the most common reason. STATISTICS: Chi-square tests were performed for statistical analysis. Although no differences in the types of teeth extracted were observed between genders, striking differences were noted in the different age groups. CONCLUSION: From this study it can be concluded that caries and subsequent pulpal pathology are the most common reasons for extraction of primary teeth in Turkey. Primary molars were the most common tooth type extracted. Preventive programmes for preschool children should be given importance.

Are behaviour risk factors for traumatic dental injuries in childhood different between males and females?

AIM: Examination of the risk factors for childhood traumatic dental injuries for male and female patients have been elusive. The present study aimed to examine whether males and females are differentially vulnerable to Traumatic Dental Injuries in relation to emotion regulation, attention deficiency hyperactive disorder symptomatology and behaviour problems. MATERIALS AND METHODS: An institutional ethical review board approved the case-control study carried out at the Gazi University, Faculty of Dentistry, Turkey. A total of 80 patients with traumatic dental injuries and 80 patients with other dental problems participated in the study. Patients' parents filled in two scales: Conners' Rating Scales-Revised Attention Deficiency Hyperactive Disorder-Index, Oppositional Behavior, Hyperactivity, Anxious-Shy, Social Problems, Inattentive and Hyperactive-Impulsive subscales; and Emotion Regulation Checklist, with two subscales of Emotional Lability and Emotion Regulation. Multiple logistic regression analyses were performed separately for male and female patients. RESULTS: Oppositional behaviour, hyperactivity and social problems were found to be risk factors for male patients. Being anxious/shy was the protective factor for both males and females. Classification accuracy for males and females were calculated to be 79.2% and 85.2% respectively. CONCLUSION: Several risk factors for childhood traumatic dental injuries were found to differ for male and female patients.

Osteomalacia mimicking spondyloarthropathy: a case report.

Osteomalacia is a metabolic bone disorder characterized by impaired mineralization of bone matrix. Symptoms of osteomalacia can be confused with other conditions such as spondyloarthropathy, polymyalgia rheumatica, polymyositis, and fibromyalgia. In this case, we report a patient with axial osteomalacia who developed low back pain, morning stiffness, and "grade 3 sacroiliitis" in pelvis X-ray, leading to the misdiagnosis as seronegative spondyloarthropathy. Serum biochemical studies revealed low serum phosphorus, low 25-hydroxy vitamin D3, normal calcium, elevated parathyroid hormone, and alkaline phosphatase levels. Her symptoms were relieved with vitamin D and calcium therapy. The diagnosis of osteomalacia should be considered in case of sacroiliitis and spondylitis.

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

BACKGROUND: Crimean-Congo hemorrhagic fever (CCHF) is an acute illness affecting multiple organ systems and characterized by ecchymosis, visceral bleeding, and hepatic dysfunction. In this study, we aimed to investigate the profile of coagulopathy markers (platelet count, activated partial tromboplastin time (aPTT), prothrombin time (PT), international normalized ratio (INR), fibrinogen, protein C, protein S, antithrombin III, activated protein C resistance (APCR), and D-dimer) and their clinical significance in 83 CCHF-infected patients. SUBJECTS AND METHODS: We studied 83 CCHF patients who were admitted to Ankara Numune Education and Research Hospital during the spring and summer of2007. We compared the coagulopathy markers of fatal CCHF patients (n=9) with nonfatal cases (n=74). RESULTS: Platelet count, PT, aPTT, INR, and fibrinogen were prognostic factors associated with mortality for CCHF. Especially, platelet count<20 x 10(9) cells/l and aPTT>60 sec were important. Protein C, protein S, APCR, and antithrombin III levels were not associated with mortality. CONCLUSION: Laboratory tests including classical parameters (platelet count, PT, aPTT, INR, and fibrinogen) of coagulopathy seem to be enough for the followup of CCHF. Protein S, protein C, APCR, and D-dimer levels were not associated with mortality.

In vitro comparison of digital and conventional bitewing radiographs for the detection of approximal caries in primary teeth exposed and viewed by a new wireless handheld unit.

OBJECTIVES: The aim of this study was to compare the diagnostic quality of a new wireless handheld unit (ADX4000; Dexcowin Co. Ltd, Korea) on conventional bitewings and its LCD screen for the detection of approximal caries in primary teeth. METHODS: In total, 108 approximal surfaces of primary teeth were examined in vitro by 3 observers. Conventional films were viewed under subdued lighting conditions on a conventional view box. Digital 3.5 inch images were displayed on the built-in monitor of the ADX4000 and digital 17 inch images were viewed on a 17 inch monitor. The true caries diagnosis was based on histological assessment of the approximal surfaces after sectioning the primary teeth. Receiver operating characteristic (ROC) curve (A(z)) analysis was used to assess the diagnostic quality of imaging modalities. RESULTS: The areas under the ROC curves ranged from 0.786 (digital 17 inch) to 0.813 (digital 3.5 inch). No statistically significant differences were found between the three modalities for detecting approximal caries. CONCLUSIONS: It was concluded that the diagnostic quality of conventional film and digital images, which were exposed and viewed by a new wireless handheld unit, was comparable.

Continuous infusion of subcutaneous compared to intravenous insulin for tight glycaemic control in medical intensive care unit patients.

The aim of this randomised controlled study was to compare continuous subcutaneous insulin infusion using an insulin pump with the traditional continuous intravenous infusion method for tight glycaemic control. Sixty patients admitted to our University Hospital medical intensive care unit with an initial blood glucose level over 6.1 mmol/l, were enrolled and randomised into two treatment groups: the subcutaneous insulin group received continuous subcutaneous insulin infusion and the intravenous group received insulin by traditional intravenous infusion with infusers. Three patients died in the first 24 hours and were excluded from the final analysis. Insulin therapy was administered to both groups according to the previously designed and used protocol in the department. The target glucose level was 4.4 to 6.1 mmol/l. There was no significant difference in mortality between the groups. However mean blood glucose level was found to be lower (6.56+/-0.82 mmol/l vs. 7.85+/-1.6 mmol/l, P=0.00055) in the subcutaneous insulin group. According to Vogelzang's hyperglycaemic index, better glycaemic control was achieved in the subcutaneous insulin group while there was no significant difference in terms of hypoglycaemic events. Daily insulin bolus and infusion requirements were also significantly lower in the subcutaneous insulin group. Despite the small number of patients involved in this study in a medical intensive care unit, strict blood glucose control using a subcutaneous insulin pump was achieved more efficiently than the traditional intravenous infusion method without increasing hypoglycaemic events.

Characteristics and medical management of patients with rheumatoid arthritis and ankylosing spondylitis.

Rheumatoid arthritis (RA) and ankylosing spondylitis (AS) are chronic, progressive, systemic inflammatory rheumatic diseases that lead to serious disability. The objective of this study was to investigate the demographic and clinical characteristics of the patients with RA and AS who were treated in tertiary hospitals in Turkey and to analyze their current medical management. A total of 562 RA and 216 AS patients were evaluated. The mean age of RA patients was 52.1 +/- 12.6 years. The female to male ratio was 3.7:1. Of the RA patients, 72.2% had positive rheumatoid factor (RF), 62.9% had high C-reactive protein, and 75.2% had radiological erosion. The ratio of patients with Disease Activity Score (DAS) 28 >3.2 was 73.9% and of those with Health Assessment Questionnaire (HAQ) > or =1.5 was 20.9%. There was a statistically significant increase in RF positivity and HAQ scores in the group with higher DAS 28 score. Frequency of extraarticular manifestations was 22.4%. The ratio of the patients receiving disease modifying antirheumatic drugs (DMARD) was 93.1%, and 6.9% of the patients were using anti-tumor necrosis factor (TNF) blocking agents. In AS, the mean age of the patients was 38.1 +/- 10.6, and the female to male ratio was 1:2.5. The time elapsed between the first symptom and diagnosis was 4.3 years. The ratio of peripheral joint involvement was 29.4%. Major histocompatibility complex, class I, B 27 was investigated in 31.1% of patients and the rate of positivity was 91%. In 52.4% of the patients, Bath AS Disease Activity Index (BASDAI) was > or =4. The erythrocyte sedimentation rate, Bath AS Functional Index, and peripheral involvement were significantly higher in the group with BASDAI > or =4. Frequency of extraarticular involvement was 21.2% in AS patients. In the treatment schedule, 77.5% of AS patients were receiving sulphasalazine, 15% methotrexate, and 9.9% anti-TNF agents. Despite widespread use of DMARD, we observed high disease activity in more than half of the RA and AS patients. These results may be due to relatively insufficient usage of anti-TNF agents in our patients and therefore these results mostly reflect the traditional treatments. In conclusion, analysis of disease characteristics will inform us about the disease severity and activity in RA and AS patients and could help in selecting candidate patients for biological treatments.

Treatment of tinnitus with transcutaneous electrical nerve stimulation improves patients' quality of life.

OBJECTIVES: Tinnitus can adversely affect patients' quality of life. Transcutaneous electrical nerve stimulation (TENS) may be effective in the management of tinnitus. No study has investigated the efficacy of TENS for the management of tinnitus by means of quality of life measures. In this study, we evaluated the efficacy of TENS for the management of tinnitus symptoms by using the visual analogue scale (VAS), tinnitus handicap inventory test, Nottingham health profile (NHP) and short form-36 (SF-36) questionnaires. METHODS: Twenty-two patients were included in this study (male/female, 16/6; mean age, 48.04 +/- 15.57 years). Nine patients had unilateral and 13 patients had bilateral tinnitus. RESULTS: After TENS, improvement measured by VAS was only marginally significant (p = 0.059). However, after TENS, there were statistically significant improvements regarding tinnitus severity scores, tinnitus handicap inventory scores, NHP fatigue, social isolation and emotional problems scores, and many parameters measured by the SF-36 (physical functioning, general health, vitality, social functioning, role limitations due to emotional problems, and mental health)(p < 0.05). CONCLUSION: Transcutaneous electrical nerve stimulation is a useful method to improve the quality of life of patients with tinnitus.

Glomerulonephritis associating parvovirus B19 infection.

We report a previously healthy, immunocompetent 17-year-old male patient, who developed acute glomerulonephritis during the course of Parvovirus B19 infection and this acute glomerulonephritis did not resolve spontaneously. His renal biopsy showed mild mesangial proliferation and focal segmental sclerosis. Parvovirus B19 DNA was detected in renal tissue by polymerase chain reaction.

Acute fatty liver of pregnancy complicated with disseminated intravascular coagulation and haemorrhage: a case report.

Acute fatty liver of pregnancy (AFLP) is a rare disorder of unknown aetiology that is diagnosed typically in the third trimester or early postpartum period. The incidence is estimated to be 1/6692-1/13,328. The obstetric team must have a high index of suspicion of this pathology, particularly in the presence of clinical and laboratory findings, such as nausea, vomiting, jaundice, increased serum transaminase levels, increased prothrombin time and hypoglycaemia. Early diagnosis followed by prompt delivery and supportive care provides significantly improved maternal and perinatal outcome. Delay in diagnosis of this obstetric emergency may lead to rapid progression to hepatic failure, disseminated intravascular coagulation (DIC), haemorrhage, encephalopathy, multiple organ failure and finally death. The case of a 34-year-old woman, gravida 3, para 2, with AFLP complicated with DIC is presented herein with a review of literature and discussion of its origin.

Risk factors for ICU-acquired imipenem-resistant Gram-negative bacterial infections.

Intensive care units (ICUs) are high-risk areas for infections caused by antibiotic-resistant bacteria. This study investigated the risk factors for ICU-acquired imipenem-resistant Gram-negative infections. It was conducted prospectively in three surgical ICUs and one medical ICU from April to December 2002. ICU-acquired Gram-negative infections were found in 128 patients. Of these, 42 had imipenem-resistant and 86 had imipenem-sensitive Gram-negative bacteria as the cause of infection. According to the univariate analysis results, hospital stay before ICU admission, hospitalization period before ICU admission, length of ICU stay, surgical ICU stay, surgical operation and previous antibiotic use were significant risk factors for the acquisition of imipenem-resistant infections. In the multivariate analysis, length of ICU stay, surgical operation and previous carbapenem use were independently associated with imipenem resistance.

Evaluation of antibiotic use in intensive care units of a tertiary care hospital in Turkey.

The object of this study was to evaluate the appropriateness of antibiotic use in relation to diagnosis and bacteriological findings in the intensive care units (ICUs) of a 1100-bed referral and tertiary care hospital with an antibiotic restriction policy in Turkey. Between June and December 2002, patients who received antibiotics in the medical and surgical ICUs were evaluated prospectively. Two infectious diseases (ID) specialists assessed the antibiotics ordered daily. Of the 368 patients admitted to the ICUs, 223 (60.6%) received 440 antibiotics. The most frequently prescribed antibiotics were first-generation cephalosporins (16.1%), third-generation cephalosporins (15.2%), aminoglycosides (12.1%), carbapenems (10.7%) and ampicillin-sulbactam (8.7%). Antibiotic use was inappropriate in 47.3% of antibiotics. ID specialists recommended the use of 47% of all antibiotics. An antibiotic order without an ID consultation was more likely to be inappropriate [odds ratio (OR)=13.2, P<0.001, confidence intervals (CI)=4.4-39.5]. Antibiotics ordered empirically were found to be less appropriate than those ordered with evidence of culture and susceptibility results (OR=3.8, P=0.038, CI=1.1-13.1). Inappropriate antibiotic use was significantly higher in patients who had surgical interventions (OR=3.6, P=0.025, CI=1.2-10.8). Irrational antibiotic use was high for unrestricted antibiotics. In particular, antibiotic use was inappropriate in surgical ICUs. Additional interventions such as postgraduate training programmes and elaboration of local guidelines could be beneficial.

Effects of carbamide peroxide containing bleaching agents on the morphology and subsurface hardness of enamel.

The purpose of this study is to evaluate the effects of nightguard bleaching agents (Karisma and Yotuel) on the enamel surface of forty anterior teeth. Ten teeth of each group were evaluated with SEM and ten teeth of each group were tested with a microhardness tester Morphologic alterations were observed on the enamel surfaces with SEM. Karisma group showed a significant decrease in enamel hardness (p<0.05) and microhardness values of enamel were increased significantly in Yotuel group (p<0.05).

Bone mineral density and bone turnover markers in a group of male ankylosing spondylitis patients: relationship to disease activity.

Conflicting data have been published about osteoporosis and bone turnover markers in patients with ankylosing spondylitis (AS). The aim of this study was to determine bone mineral density (BMD) of the lateral lumbar spine in a group of male patients with AS and to investigate the relationship between clinical parameters and markers of bone turnover. Thirty-two consecutive AS patients with a mean disease duration of 14.8 years and 32 control subjects were included. Demographic and clinical characteristics were recorded. The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) was used to determine the activity of disease. BMD was determined for the lateral lumbar spine in both patients and control groups. Serum osteocalcin and urinary N-telopeptide were measured as bone turnover markers in patient and control groups. Although the mean values of lumbar BMD in AS patients tended to be lower than in the control group, the difference was not statistically significant. Osteoporosis was observed in 11 (34.3%) of AS patients and in 2 (6.2%) of the control group. Osteocalcin levels were significantly higher in AS patients in comparison with control subjects (p < 0.05). In the subgroup analysis according to the activity of the disease, erythrocyte sedimentation rate and N-telopeptide levels were significantly higher in the severely active group when compared with that in mild or moderate disease groups. Active AS patients compared with the control group had significantly lower BMD and significantly higher N-Telopeptide levels (p < 0.05). The levels of BASDAI scores and N-telopeptide values correlated significantly with each other. The incidence of osteoporosis is high in AS patients, and patients with active disease are especially at risk for developing osteoporosis. The monitoring of bone turnover markers and disease activity indices may help to predict patients at risk. Prophylactic and therapeutic strategies are needed to struggle against bone loss in patients with this disabling condition.

Generalized aggressive periodontitis in a prepubertal patient: a case report.

A 10-year-old boy presented with generalized gingival inflammation, extensive alveolar bone loss, and tooth mobility. Clinical and radiographic examination supplemented by microbiologic investigation led to a diagnosis of classically termed prepubertal periodontitis (now known as generalized aggressive periodontitis). Other than severe periodontitis, the child was systemically healthy. Neither unusual infections nor abnormalities in neutrophil functions were detected. Microbiologic examinations by culture revealed the presence of the periodontal pathogen Actinobacillus actinomycetemcomitans. Treatment consisted of extraction of mobile teeth, supragingival and subgingival debridement, subgingival curettage, and root planing combined with a 1-week prescription of a combination of metronidazole and amoxicillin. Scanning electron microscopy of extracted teeth revealed hypoplastic and aplastic cementum at the periodontally exposed and intact surfaces. Clinical and microbiologic follow-up was continued over a 1-year period. No periodontal lesions have been detected, and A actinomycetemcomitans could not be isolated from the subgingival areas of the remaining teeth at the end of the first year. Since A actinomycetemcomitans was the main pathogen present in the subgingival microflora of the patient, it might play a key role in the etiology of prepubertal periodontitis.