[A Case of Intra-abdominal Tuberculosis Due to Mycobacterium bovis Mimicking Ovarian Cancer: Importance of Microbiological Diagnosis]. / Over Kanserini Taklit Eden Mycobacterium bovis Kaynakli Intra-abdominal Tüberküloz Olgusu: Mikrobiyolojik Taninin Önemi.

Mycobacterium bovis causes gastrointestinal tuberculosis by being transmitted through consumption of infected milk and dairy products, mostly in developing countries, and can spread to the other neighbourhood intra-abdominal tissues and organs. In addition to the symptoms such as weight loss, weakness, abdominal pain, and chronic diarrhea in female patients with abdominal tuberculosis, findings such as pelvic mass, ascites and CA-125 elevation may be encountered. Patients with these symptoms usually preliminary diagnosed as having ovarian cancer. It is very important to distinguish between these two diseases quickly, which have different treatment protocols. In this case report, a case of intra-abdominal tuberculosis caused by M.bovis, whose diagnosis was confirmed by microbiological methods with the findings mimicking ovarian cancer such as weight loss, ascites, pelvic mass and increased CA-125 was presented. Tuberculosis was considered in the differential diagnosis of a 23-yearold female patient with abdominal pain, weight loss, ascites, pelvic mass, and elevated CA-125 (643.9 U/ml) findings and a mass in the left tubaovarian region on abdominal CT. The ileum biopsy sample taken during colonoscopy and ascitic fluid sample taken with paracentesis were sent to our laboratory for acid-fast bacilli (AFB) staining and tuberculosis culture. In our laboratory, samples were incubated in both liquid culture system [BACTEC MGIT 320 Mycobacteria Culture System (Becton Dickinson,USA)] and solid culture medium [Lowenstein-Jensen Medium (Becton Dickinson,USA)] and AFB smears were performed. While AFB smears were negative, ileum biopsy material showed growth on day 14 and ascitic fluid sample on day 11 in liquid culture medium. AFB smear was prepared from broth and red bacilli were seen on a blue background that formed cord factor. The bacillus was identified as Mycobacterium tuberculosis complex by the immunochromatographic rapid test [BD MGIT TBc Identification Test (BD,USA)]. The anti-tuberculosis drug treatment was initiated with the diagnosis of intra-abdominal tuberculosis. The isolated bacillus was found to be sensitive to isoniazid, rifampicin, ethambutol and resistant to streptomycin, according the drug susceptibility test results. Subspecies identification of M.tuberculosis complex was investigated by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) but could not be determined by this method. Genotyping was performed with the GenoType MTBC VER 1.X (Hain Lifescience, HardwiesenstraBe, Germany) kit. The isolate was identified as M.bovis. In the follow-up of the patient three months later, it was determined that tumor markers, ascitic fluid and intra-abdominal lymph nodes regressed significantly and the mass in the left ovary completely disappeared. In this report, we presented a case with intra-abdominal tuberculosis whose clinical, radiological and laboratory findings mimic ovarian cancer to imply the importance of microbiological diagnosis.

[COVID-19 pandemic and sleep disorders: COVID-somnia]. / COVID-19 pandemisi ve uyku bozukluklari:COVID-somnia.

As a pandemic sweeping over the world, COVID-19 has led to significant changes in daily routines and lifestyle. People closed to their homes to reduce their contact with each other and socialization took place with telecommunication facilities. Moreover, factors like an extended period of isolation, fear of infection, uncertainty, disappointment, insufficient supplies, and economic damage also negatively impacted individuals' psychological wellbeing. Psychosocial stressors affected the pattern of sleep and caused worsening of sleep quality in individuals. As a result of all this, sleep disorders have emerged. Sleep disturbances during pandemic have been referred as COVID-somnia. In this review, the relationship of COVID-19 infection and sleep, and sleep disorders during COVID-19 pandemic are presented in the light of the literature.

Evaluation of pulmonary involvement in systemic rheumatic diseases with high resolution computed tomography and pulmonary function test: A single-center experience.

INTRODUCTION: The objective of this study was to investigate the clinical and radiological features and pulmonary function tests (PFTs) in patients with the pulmonary involvement of systemic rheumatic diseases (SRDs). MATERIALS AND METHODS: This study was conducted as a retrospective and single-center study. Patients diagnosed with an SRD and admitted/referred to the department of chest diseases of our hospital between January 2015 and June 2019 were enrolled. All patients were evaluated using High Resolution Computed Tomography (HRCT) and PFT. RESULT: This study included 68 patients (15 males, 53 females) with a mean age of 62.38 ± 12.4 years. Forty-one (60.2%) patients had diagnosis of rheumatoid arthritis (RA), 10 (14.7%) patients had sjögren's syndrome (SS), 8 (11.7%) patients had systemic lupus erythematosus (SLE), 6 (8.8%) patients had systemic sclerosis (SSc), and 3 (4.4%) patients had mixed connective tissue disease (MCTD). While RA, SLE, MCTD patients were more commonly symptomatic, most of the SS patients were asymptomatic. Overall, 30 (44.1%) patients had normal PFT. Although 30 (%44.1) patients were asymptomatic and 30 (%44.1) patients had normal PFTs, at least one imaging finding was found in all patients according to HRCT imaging. "Bronchiectasis" was the most common HRCT finding in RA, followed by "chronic fibrotic changes" and "peribronchial thickening". "Chronic fibrotic changes" and "peribronchial thickening" were the most common changes in SS. Similarly, "peribronchial thickening" was the most common radiologic finding in SLE. As for SSc, "chronic fibrotic changes", "interlobular septal thickening", and "pleural effusion" were the most common radiologic findings. CONCLUSIONS: Pulmonary involvement in systemic rheumatic diseases can occur with various radiological images even in asymptomatic patients. PFTs can be normal as well as an obstructive, restrictive or mixed pattern can be seen. Heterogeneous and combined HRCT findings can be seen in SRD patients.

The effect of tocilizumab on severe COVID-19 infection: Review of current evidence.

The COVID-19 outbreak that spread in December 2019 has caused the death of millions of people in a short time. Many studies published recently have shown that many cytokines (interleukin (IL) IL-1, IL-2, IL-6, TNF and IFN-) are significantly increased in COVID-19 patients with pneumonia, and especially IL-6 in combination with other cytokines has shown to be the main cause of the cytokine storm. Since IL-6 level is associated with clinical worsening in COVID-19 patients, anti-IL-6 therapy is seen as a promising treatment. Tocilizumab, a widely used IL-6 antagonist, was approved by the FDA in 2017 for Cytokine Storm Syndrome (CSS). Its addition to the treatment in COVID19 patients with increased blood IL-6 levels and oxygen saturation.

Importance of Anthropometric Measurements to Determine Cardiometabolic Diseases in Obstructive Sleep Apnea Syndrome.

OBJECTIVE: Obesity is considered a major risk factor for obstructive sleep apnea syndrome (OSAS). This study aimed to examine the correlation between anthropometric measurements, which have been recently defined and are indicative of abdominal obesity and cardiometabolic diseases, OSAS severity, and polysomnography (PSG) parameters in patients with OSAS. MATERIAL AND METHODS: This retrospective cohort study included patients who underwent all-night polysomnography with a prediagnosis of OSAS. These patients were categorized as having mild (5-15), moderate (15-30), and severe (>30) OSAS according to the apnea-hypopnea index (AHI). The anthropometric measurements used in the study consisted of waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), (waist/hip)-to-height ratio (WHHR), a body shape index (ABSI), body adiposity index (BAI), abdominal volume index (AVI), and conicity index (CI). RESULTS: A total of 410 individuals were enrolled in the study (31 control subjects and 129 with mild, 101 with moderate, and 149 with severe OSAS). A significant difference was observed between groups in terms of all anthropometric measurements (p<0.05). The difference between the groups was significant in terms of diabetes mellitus, hypertension, and cardiovascular disease (p<0.05). There was a significant correlation between each of the anthropometric measurements and the PSG parameters. In the receiver operating characteristic analysis, cutoff values that predicted severe OSAS were ABSI>0.08, BAI>28.29, AVI>25.54, and CI>1.37. Multiple regression analyses demonstrated that age, sex, and AVI were independent predictors that determine OSAS presence. CONCLUSION: Anthropometric parameters that are indicators of abdominal obesity were found to be robustly correlated with cardiometabolic diseases and the severity of OSAS.

[Mortality prediction ability of phycians in intensive care units of Turkey (MOPAP)]. / Türkiye'de yogun bakim ünitelerinde hekimin mortaliteyi öngörebilme gücü.

INTRODUCTION: Intensive care physicians are increasingly involved in decision making about the prognosis of intensive care unit ICU patients. With this study; we aimed to evaluate the power of clinician foresight at prediction of mortality in patient at triage to intensive care and patient follow-up. MATERIALS AND METHODS: This study was conducted in ICUs located in various geographical regions of Turkey between January 1, 2017-April 30, 2017.The clinical research was planned as observational, multicenter, cross-sectional. RESULT: A total of 1169 intubated patients were followed in 37 different ICU. At the beginning of the follow-up we asked the physician who will follow the patient in the ICU to give a score for the probability of survival of the patients. Scoring included a total of 6 scores from 0 to 5, with the "0" the worst probability "5" being the best. According to this distribution, only 1 (0.9%) of 113 patients who were given 0 points survived. Three (6.1%) of 49 with the best score of 5 died. Survival rates were significantly different in each score group (r: -0.488; p<0.001). After the combined mortality estimation scores based on the clinical observations of the physicians (0 and 1 point score was combined as non-survive, 4 and 5 score was combined as survived) 320 of the 545 patients were estimated to be dead and 225 were predicted survival. Sensitivity and spesifity of scoring system to predict mortality was 91.56% (95% CI: 87.96-94.37), 76.89% (95% CI: 70.82-82.23) respectively. CONCLUSIONS: In this study, we concluded that the physicians who follow the patients in the ICU can predict the poor prognosis at the time of admission and the high mortality rate. The physician's opinion on mortality estimation should be considered in intensive care mortality scoring in addition to other laboratory and clinical parameters.

Ultrasonographic measurement of the diaphragm thickness in patients with obstructive sleep apnea syndrome.

PURPOSE: The aim of this study was to evaluate the diaphragm thickness in patients with obstructive sleep apnea syndrome (OSAS). METHODS: This prospective study included patients who underwent polysomnography evaluation for the first time with a clinical suspicion of OSAS. All patients underwent polysomnographic evaluation with a 55-channel Alice 6 computerized system (Respironics; Philips, IL). Diaphragm thickness was measured as the distance between the peritoneum and the pleura using electronic calipers with a 7-12-MHz linear probe (PHILIPS EPIQ 5G). RESULTS: A total of 108 patients (67 males, 41 females) were enrolled in the current study. The mean age of the patients was 48.92 ± 11.47 years. The diaphragm thicknesses were significantly higher in OSAS patients both at end-inspirium and end-expirium compared with the normal group (p < 0.05). No significant difference was observed regarding the change level and thickening ratio (%) (p > 0.05). When the patients were allocated into OSAS subtypes; diaphragm thicknesses at the end of inspirium and expirium on both sides were significantly higher in the severe OSAS group and OSAS+OHS group compared with the other groups of normal, mild OSAS, and moderate OSAS subgroups (p < 0.05 for all). There was no significant difference between the groups regarding the thickening ratio (p > 0.05 for all). There was a positive correlation between the severity of OSAS and diaphragm thickness. CONCLUSION: Diaphragm thickness seems to be increased in OSAS patients and the thickness correlates with the severity of OSAS. However, the thickness ratio of OSAS patients does not differ from that of normal subjects.

Association Between 25-Hydroxyvitamin D and Bone Mineral Density in People With Obstructive Sleep Apnea Syndrome.

The aim of this study was to evaluate the association between bone mineral density (BMD) and 25-hydroxyvitamin D [25(OH) D] levels in patients with obstructive sleep apnea syndrome (OSAS). This study was designed as a cross-sectional and observational study. Patients who underwent polysomnography evaluation were classified as normal, mild, moderate, severe, or position-dependent OSAS, and OSAS + obesity hypoventilation syndrome (OHS). BMD was measured with the dual-energy X-ray absorptiometry method at the femur and lumbar spine. The chemiluminescence microparticle immunoassay was used for the measurement of 25(OH) D levels. A total of 126 patients (73 males, 53 females) with a mean age of 48.55 ± 11.8 years were included. Body mass index was significantly higher in the OSAS + OHS group than in the other groups (p < 0.01). There was no statistically significant difference between the groups in terms of total BMD, T-scores and Z-scores of the lumbar spine, femural neck, and total femur (p > 0.05 for all). Post hoc analyses showed that OSAS + OHS subgroup had lower level of 25(OH) D compared to the normal subjects (p = 0.006). Yet no significant difference was observed between the other OSAS groups. No significant correlation was observed between the apnea hypopnea index, the Epworth Sleepiness Scale scores, desaturation index, and BMD parameters (all for p > 0.05). While 25(OH) D levels were lower in OSAS + OHS patients, there was no statistically significant relationship between OSAS and BMD values.

Body surface area: a new anthropometric measurement for obstructive sleep apnea syndrome.

INTRODUCTION: We aimed to explore the possibility of using body surface area (BSA) as a new anthropometric measurement in evaluation of OSAS. MATERIALS AND METHODS: Obesity was defined as having a BMI ≥ 30 kg/m2. BSA were calculated using the Mosteller and Boyd formulas. Totaly 426 (306 male) cases were included in this study. RESULT: The mean BMI was 33.0 kg/m2. The mean BSA was 2.06 m2 and 2.11 m2 respectively. BMI, AHI, oxygen desaturation, ODI and oxygen saturation were found different between the groups. Both BMI and BSA correlated positively with AHI, oxygen desaturation and ODI and negatively with oxygen saturation. There was no difference between BMI and BSA in mild cases in both gender. However, in moderate and severe cases, BMI and BSA were higher in males. We dedected that BSA and BMI display similar sensitivity and specificity values for the prediction of severe OSAS. CONCLUSIONS: To the best of our knowledge, this is the first study to examine the potential association between BSA and the severity of OSAS. As a result, we determined that BSA correlated with polisomnographic parameters as BMI. In severe OSAS BSA can be used as a predictor parameter like BMI.

Monocyte Count/HDL Cholesterol Ratio and Cardiovascular Disease in Patients With Obstructive Sleep Apnea Syndrome: A Multicenter Study.

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) is an independent risk factor for cardiovascular disease (CVD). Although monocyte to high-density lipoprotein cholesterol ratio (MHR) is increasingly being implicated in cardiovascular morbidity and mortality, no study has attempted to determine the role of MHR in cardiovascular morbidity of patients with OSAS. We aimed to investigate the association between MHR and CVD in patients with OSAS and the relationship between severity of OSAS, polysomnographic parameters, and MHR. METHODS: In this cohort study, patients who had undergone a full-night polysomnography for the diagnosis of OSAS were recruited. Included patients were grouped according to the apnea-hypopnea index (AHI) as mild (5-15), moderate (15-30), and severe (>30) OSAS. Patients with AHI < 5 served as the control group. The presence of heart failure, coronary artery disease, or arrhythmia was defined as CVD. RESULTS: A total of 1050 patients were included (131 controls, 222 mild, 228 moderate, and 469 severe OSAS). The severe group had higher MHR compared with the control and other OSAS groups (9.99, 12.11, 13.65, and 20.67 in control, mild, moderate, and severe OSAS groups, respectively, P < .001). The MHRs were significantly correlated with AHI, oxygen desaturation index, and minimum O2 saturation values ( P < .001). Values of MHR were significantly higher in patients with CVD compared with those without ( P < .001). Multiple regression analysis demonstrated that MHR is an independent predictor of CVD. CONCLUSION: The MHR is strongly associated with CVD and the severity of OSAS and might be used as a biomarker to predict CVD in patients with OSAS.

Obstructive sleep apnea is a risk factor for osteoarthritis.

INTRODUCTION: Obstructive sleep apnea (OSA) syndrome is closely associated with cardiovascular and metabolic disorders. Recent studies reported that osteoarthritis (OA) is associated with cardiovascular disease as well as inflammation defined as "metabolic disorder". Due to the strong association of metabolic disorders with both OA and OSA, we aimed to investigate the association between severity of OSA and osteoarthritis grade based on X-Ray. MATERIALS AND METHODS: Patients who underwent polysomnography due to suspicion of OSA were recruited in a cross-sectional study. Included patients were grouped according to apnea-hypopnea index (AHI) as mild (AHI between 5 and 14.9), moderately (AHI between 15 and 29.9), and severe OSA (AHI ≥ 30). Patients with AHI p< 5 served as the control group. Kellgren-Lawrence scoring system was used to express OA severity, which was graded as Grade 0, 1, 2, 3 and 4. RESULT: One hundred twenty patients were enrolled into the study. Mean age was 52.4 ± 11.5 years and 56% (68/120) of the patients were male. A strong correlation was present between severity of OSA and severity of OA. Among those with Grade 4 OA group (33 patients), all patients had severe OSA and this association was independent from body-mass index. In the Grade 1 OA group, none of the patients had severe OSA (p< 0.05). A positive correlation was also seen between severity of OSA, OA and hs-CRP. CONCLUSIONS: There is a strong association between OSA and OA. OSA might be a novel risk factor for the development OA. Further studies should evaluate the effect of OSA treatment on OA.

[Where do we perform sleep test: In the laboratory or at home?] / Uyku testi nerde yapilmali; laboratuvarda mi, evde mi?

Obstructive sleep apnea syndrome (OSAS) is an important public health problem seen in 14.3% of male, and 5% of female population which leads to higher morbidity, and mortality rates because of its outcomes effecting many organ systems including cardiovascular, and cerebrovascular systems. Despite its higher prevalence in community, sleep laboratories both in our country, and in the world remain incapable of diagnosing these patients, and 80-90% of the cases with OSAS can not be diagnosed. As an alternative to gold standard polysomnographic examinations this desperate condition revived the use of more practical, and less expensive portable monitorization devices which can be used at home without the need for help of a technician. In this article we will discuss whether application of sleep test on a patient with suspect OSAS in the laboratory or at home will be more appropriate regarding effectiveness, and reliability of the test in the light of the scientific data.

[An important concomitancy: interstitial lung diseases and sleep related breathing disorders]. / Önemli bir beraberlik: interstisyel akciger hastaliklari ve uyku iliskili solunum bozukluklari

Interstitial lung diseases (ILD), are a group of diseases which can involve pulmonary interstitium, small airways, and vessels, and diffusely affect pulmonary parenchyma as a consequence development of inflammation, and fibrosis leading to respiratory failure, and finally death. Obstructive sleep apnea syndrome (OSAS) is a disorder which courses with its systemic outcomes, and increasing morbidity, and mortality when accompanied with other respiratory system diseases. Concomitancy of OSAS with other lung diseases including chronic obstructive pulmonary disease, asthma, ILD, cystic fibrosis is termed as ''overlap syndrome''. Because of characteristic feature of OSAS ie. recurrent oxygen desaturations during night hours, ILD-OSAS concomitancy accelerates progression of underlying lung disease. Therefore, in cases with ILD, early diagnosis, and treatment of comorbid OSAS conveys vital importance in that this approach improves quality of life of the patients, and slows down progression of the disease. In this review ILD-OSAS concomitancy will be analyzed from its various aspects.

The opinion of catering sector about the smoking ban and the evaluation of establishments.

INTRODUCTION: We aimed to evaluate the knowledge and perspective of employees/employers in the catering sector in our city regarding the smoking ban, as well as to determine the changes in the number of customers and income after the bans implementation. MATERIALS AND METHODS: In this two phased cross-sectional study 337 and 310 adults were evaluated respectively. Before the smoking ban was implemented we visited 84 workplaces in city center, after 18 months later 97 workplaces were visited in the same region. In both phases, the participants' opinions about the necessity/applicability of the ban were evaluated. In the second phase, they were also asked whether they had any changes in their income. RESULTS: In both phases, participants' general characteristics were similar. When all participants were evaluated, we determined that their knowledge and belief in the necessity/applicability of the ban did not change over time. It was determined that non-smokers more strongly believed in the necessity/applicability of the ban. Thirty-eight participants were included in both phases; 44.7% of them reported a decrease in the number of customers, and 60% of employers reported an increase in their income. CONCLUSION: The smokers were less convinced about the applicability/necessity of this ban than non-smokers. According to our results it could be said that smoking can also adversely affect implementation of the related ban. Employers should be informed that the ban will not affect their income.

[The treatment of central sleep-apnea syndrome, updated information, and review of the literature]. / Santral uyku apne sendromu tedavisi, güncel bilgiler ve literatürün gözden geçirilmesi.

Central sleep-apnea syndrome (CSAS) is a disease state characterized by respiratory arrest as a result of decrease or lack of respiratory drive originating from respiratory center. Although it is seen in less than 5% of the casses who consult to the sleep disorders center, incidence of CSAS increases in the presence of congestive heart and/or renal failure, and central nervous system abnormalities. Treatment of CSAS which has been analyzed under six headings in the last version of International Classification of Sleep Disorders (ICSD-2), differs among each type of CSAS. In this review, our aim is to analyze treatment alternatives for CSAS in the light of currently updated information.

[Nicotine addiction and environmental tobacco smoke exposure]. / Nikotin bagimliligi ve çevresel tütün dumani maruziyeti.

In present study it was aimed to determine the general characteristics of cases who cause environmental tobacco smoke (ETS) exposure. One hundred and forty five cases (53/92, F/M) who admitted to smoking cessation clinic were asked about general demographic characteristics, the history of ETS exposure in childhood and whether they cause of ETS exposure or not. Also Fagernström test for nicotine dependence (FTND) and hospital anxiety depression test (HADT) were performed. The mean age of the cases was 42.2 years. It was determined that 71% of cases exposed ETS in childhood and 69% of cases cause ETS exposure. There was no effect of the number of cigarette smoked per day and the amount of packet/years on to cause ETS exposure. The cases who cause ETS exposure to be forced more than others in places that it is forbidden smoking (p= 0.045), FTND score was higher (mean= 5.9) than others (mean= 4.8) (p= 0.009). The FTND score was ≥ 5 in 72% of cases who cause ETS exposure and in 53.3% of others (p= 0.045). 117 of cases were performed HADT, symptoms related with anxiety and depression were detected in 45 and 54 of cases respectively. The mean anxiety score was higher in cases who cause ETS exposure (p= 0.025). The symptoms related with anxiety and depression were determined similar in cases who cause ETS exposure or not. It was identified that there was no effect of gender, education, business status, another smoker at home, history of ETS exposure in childhood, socioeconomic status and to have knowledge about passive smoking on to cause ETS exposure. Prevention of nicotine addiction to be developed by starting smoking precludes the onset of the diseases related to smoking, and also enables inhibition of ETS exposure especially at home.