Ayşen Akıncı

Bone mineral density in premenopausal women with major depressive disorder.

This cross-sectional study investigated whether a group of unmedicated patients with major depressive disorder, single episode, had decreased bone mineral density (BMD). The BMD at the lumbar spine and proximal femur in 25 premenopausal women with major depressive disorder and 15 normal women was measured by dual-energy X-ray absorptiometry. Bone turnover markers and serum cortisol levels were also evaluated for each subject. As compared with values in the normal women, the mean BMD in the depressed women was significantly lower at the lumbar spine and at all sites of the proximal femur. There was no statistically significant difference between serum cortisol levels and bone turnover markers except for significantly higher urinary excretion of deoxypyridinoline cross-links in the patients compared with the controls. In conclusion, depressed women may have decreased BMD even at the very early stages of the illness, and this possibility should be taken into consideration in treatment.

A Comparison of the Benefits of Sonography and Electrophysiologic Measurements as Predictors of Symptom Severity and Functional Status in Patients With Carpal Tunnel Syndrome

OBJECTIVES To clarify whether sonography or electrophysiologic testing is a better predictor of symptom severity and functional status in carpal tunnel syndrome (CTS) and to assess the diagnostic value of sonography in patients with idiopathic CTS. DESIGN Cross-sectional. SETTING University hospital physical medicine and rehabilitation clinic. PARTICIPANTS Thirty-four hands with CTS and 38 normative hands were evaluated. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The Boston Carpal Tunnel Questionnaire, which comprised symptom severity and functional status scale, was applied to CTS patients. Bilateral upper-extremity nerve conduction studies of median and ulnar nerves and sonographic imaging of the median nerve were performed in all participants. Sonographic evaluation was performed by a physician blinded to the physical and electrophysiologic findings of the subjects. RESULTS Cross-sectional areas (CSAs) of the median nerve at the carpal tunnel entrance and proximal carpal tunnel were 12.5+/-2.6 and 10.6+/-2.6 versus 15.6+/-4.2 and 11.5+/-3.2 in CTS patients versus controls, respectively. Increased CSA of the median nerve at the carpal tunnel entrance (P<.002) and at the proximal carpal tunnel (P<.000) were detected in the hands with CTS. Flattening ratios did not differ in a statistically significant manner between the groups (P>.05). The best predictor of symptom severity was median nerve sensory distal latency and that of functional status was median nerve motor distal latency. The optimum cutoff value for median nerve CSA was 11.2mm(2) at the carpal tunnel entrance and 11.9mm(2) at the proximal carpal tunnel. Sensitivity, specificity, and positive and negative predictive values at the proximal carpal tunnel (88%, 66%, 71%, 80%, respectively) were higher than those at the carpal tunnel entrance (68%, 62%, 65%, 66%, respectively). CONCLUSIONS The best predictors of symptom severity and functional status in idiopathic CTS seem to be the electrophysiologic assessments rather than sonographic measurements. On the other hand, sonography may be helpful in the diagnosis of idiopathic CTS.

Elevated levels of nitrate in rheumatoid arthritis

Abstract. Nitric oxide (NO) is a free radical that plays important roles in many physiological and pathological processes. Evidence suggests that NO participates in the pathogenesis of inflammatory reactions in many autoimmune and inflammatory diseases such as rheumatoid arthritis(RA). The purpose of this study was to evaluate serum concentrations of NO in patients with RA and to determine whether they correlate with clinical and laboratory parameters of RA disease activity. Twenty-seven RA patients were recruited for the study and compared with 20 healthy subjects. Serum NO concentrations were measured indirectly in terms of nitrate using colorimetric assay. Disease activity was determined by laboratory and clinical findings. Mean serum concentrations of nitrate were significantly higher than those of healthy controls (P<0.05). Among the disease activity parameters, C-reactive protein, number of swollen and tender joints, Ritchie articular index, and disease activity scores correlated significantly with serum NO levels. Our results suggest that these levels can serve as a reliable parameter of disease activity in patients with RA. Further knowledge about the precise role of NO may lead to better understanding of the pathogenesis of RA. Furthermore, modulation of NO synthesis may represent a new approach to the treatment of inflammatory and autoimmune conditions.

Effects of Different Strength Training on Muscle Architecture: Clinical and Ultrasonographic Evaluation in Knee Osteoarthritis

Different strengthening exercises are generally prescribed to overcome the undesirable effects of decreased muscular function on the osteoarthritic joint. Although a few studies have shown the effects of strengthening on the muscle structure in healthy individuals, the literature lacks relevant data concerning knee osteoarthritis.

Ultrasonographic evaluation in symptomatic knee osteoarthritis: clinical and radiological correlation.

To explore the relationship among clinical, radiological and ultrasonographical findings in knee osteoarthritis (OA).

Rapid subcutaneous desensitization for the management of local and systemic hypersensitivity reactions to etanercept and adalimumab in 12 patients

Etanercept and adalimumab are first line therapies for the treatment of inflammatory and autoimmune diseases. However, local and systemic hypersensitivity reactions preclude their use in sensitized patients. Immune-mediated adverse reactions to etanercept and adalimumab reported in the literature include injection site reactions (ISRs) and immediate systemic hypersensitivity reactions such as pruritus, urticaria, angioedema, and anaphylaxis. ISRs are thought to be T lymphocyte-mediated delayed type IV hypersensitivity reactions, which may preclude subsequent medication administration. Rapid drug desensitization protocols have been developed for the delivery of a variety of parenteral chemotherapeutic agents, including monoclonal antibodies, to sensitized patients. However, desensitization protocols have not been standardized for the treatment of ISRs and systemic reactions following subcutaneousmedication injections.We have previously reported 2 patients who experienced an ISR to etanercept and adalimumab and were successfully desensitized to allow subsequent medication administration. On the basis of this experience, we standardized the protocols for subcutaneous administration in patients sensitized to etanercept and adalimumab. We report the successful desensitization of 7 patients who experienced adverse reactions to etanercept (6 ISRs and 1 systemic reaction), and of 5 patients with reactions to adalimumab (4 ISR and 1 urticaria).

Quantification of the Effects of Transcutaneous Electrical Nerve Stimulation With Functional Magnetic Resonance Imaging: A Double-Blind Randomized Placebo-Controlled Study

OBJECTIVE To evaluate the effects of transcutaneous electric nerve stimulation (TENS) by using functional magnetic resonance imaging (fMRI) in patients with carpal tunnel syndrome (CTS). DESIGN Randomized controlled trial. SETTINGS University medical center and an outpatient imaging center. PARTICIPANTS Female patients with CTS (n=20) were randomized into 2 groups receiving either TENS (n=10) or sham TENS (n=10). In both groups, an initial baseline fMRI session was performed via stimulating digits 2, 5, and 3 in turn, 1 scan run for each. TENS versus sham TENS treatment was given, and a repeat imaging was performed starting 20 minutes after the treatment as follows: second finger on the 20th minute, fifth finger on the 25th minute (ulnar nerve innervated control finger), and third finger on the 30th min. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Differences in fMRI activation between the 2 groups were evaluated. RESULTS Our results demonstrated that 20 to 25 minutes after TENS treatment-but not in the sham TENS group-a significant fMRI signal decrease for digit 2 (post-TENS vs baseline) was observed in the secondary somatosensory regions, ipsilateral primary motor cortex (M1), contralateral supplementary motor cortex (SMA), contralateral parahippocampal gyrus, contralateral lingual gyrus, and bilateral superior temporal gyrus. Measurements on the 25th to 30th minutes for digit 5 were similar between the groups, with presence of activities in areas other than generally activated regions because of painful stimuli. Thirty to 35 minutes after TENS treatment, a significant fMRI signal decrease for digit 3 was detected in the contralateral M1 and contralateral SMA only in the TENS group. CONCLUSIONS Our findings showed that TENS treatment significantly decreased the pain-related cortical activations caused by stimulation of the median nerve-innervated fingers up to 35 minutes after treatment.

Osteoporosis In Turkish HIV/AIDS patients: comparative analysis by dual energy X-ray absorptiometry and digital X-ray radiogrammetry

Recently, osteoporosis has attracted concern among physicians treating patients with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS). Many confounding factors are assumed to play a role in its pathogenesis. The discussion has increased dramatically since the introduction of highly active antiretroviral therapy (HAART), and, in fact, the pertinent data have become much more contradictory. In this study, we have evaluated the BMD of our HIV/AIDS patients, comparatively by two methodologies: dual energy X-ray absorptiometry (DXA) and digital X-ray radiogrammetry (DXR). The study comprised 27 HIV/AIDS patients (15 males, 12 females). Bone mineral density measurements using DXA (Hologic QDR-4500) were performed at the lumbar spine (L1–L4), femur and distal radius. DXR evaluations were done by Pronosco X-posure system (Sectra Pronosco, Denmark) using the X-ray graphs of the patients’ non-dominant hands. Nine patients (33.33%) were found to have osteoporosis. Fourteen (51.85%) had osteopenia and four (14.81%) were normal. Estimated BMD and cortical thickness measurements obtained from DXR significantly correlated with lumbar, femoral and radial DXA measurements. Whether disease-related or drug-related, the tendency to a decline in the bone mass of these patients exists, and future studies are awaited to unravel the clinical significance of osteopenia, risk of fracture and the individual differences between HAART regimens in HIV/AIDS. We also believe that launching screening and treatment guidelines for osteoporosis in these patients will then become reasonable. Last but not least, DXR appears to be a promising tool in this regard.

Sonographic evaluation of sciatic nerves in patients with unilateral sciatica.

OBJECTIVES To evaluate the sciatic nerves of patients with unilateral sciatica by using an ultrasound, and to determine whether ultrasonographic findings were related to clinical and electrophysiologic parameters. DESIGN Cross-sectional study. SETTING Physical medicine and rehabilitation departments of a university hospital and a rehabilitation hospital. PARTICIPANTS Consecutive patients (N=30; 10 men, 20 women) with complaints of low back pain and unilateral sciatica of more than 1 month of duration were enrolled. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES All patients underwent a substantial clinical assessment, and they were also evaluated by electromyogram and magnetic resonance imaging. Pain was evaluated by a visual analog scale and the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) Scale. A linear array probe (7.5-12MHz) was used to scan sciatic nerves bilaterally in the prone position. Sciatic nerve diameters-thickness (short axis) and width (long axis)-and cross-sectional areas were measured bilaterally at the same levels, proximal to the bifurcation and midthigh. The values pertaining to the unaffected limbs were taken as controls. RESULTS When compared with the unaffected sides, mean values for sciatic nerve measurements-long axis at bifurcation level (P=.017) and cross-sectional area at midthigh level (P=.005)-were significantly larger on the affected sides. Swelling ratios negatively correlated with symptom duration (r=-.394, P=.038) and LANSS scores (r=-.451, P=.016) at only midthigh level. CONCLUSIONS Sciatic nerves seem to be enlarged on the side of sciatica in patients with low back pain. Our preliminary results may provide insight into better understanding the lower limb radiating pain in this group of patients.

Liaison between rheumatoid arthritis and ulcerative colitis

To the editor, In the year 2000, a 36-year-old lady was seen in our internal medicine department with the complaints of mucoid and bloody diarrhea for the previous 2 weeks. She also reported abdominal discomfort accompanying her symptoms. Her frequency of defecation was allegedly about 7–10 times daily and she never had fever during that period. She denied having had any concomitant diseases other than hypertension for the previous 6 years, which started after an episode of ectopic pregnancy. In physical examination, the only pathological finding was left lower quadrant tenderness. Subsequent laboratory investigations revealed normal complete blood count (CBC), liver, and kidney function tests. Erythrocyte sedimentation rate (ESR) was 53 mm/h. Stool samples demonstrated excessive amounts of red blood cells (RBC) and white blood cells (WBC) without evidence of parasitic infection. No pathogenic bacterial growth was detected in the stool cultures. Colonoscopy showed rectal mucosal inflammation—edema and hyperemia—up to the sigmoid colon with no involvement of the rest of the large intestine. The simultaneous biopsy results were in agreement with the diagnosis of ulcerative colitis (UC). Accordingly, an ongoing regimen of 3 g/day of sulfasalazine and mesalazine fleet enema twice daily was started. The patient’s complaints subsided gradually and she was completely in remission after 6 months. One and a half years later (2002), despite a daily regimen of 1.5 g of sulfasalazine, the patient came back with attacks of bloody diarrhea 2–3 times daily. She had recently started to suffer from painful and swollen wrist, ankle, metacarpophalangeal (MCP), and metatarsophalangeal (MTP) joints and also had morning stiffness lasting for 2 hours. When carefully examined, she was found to have symmetrical arthritis in the aforementioned joints bilaterally. Immediate laboratory evaluation revealed significant rheumatoid factor positivity (1/128), WBC 12,500/ll, hemoglobin 11 g/dl, ESR 47 mm/h, albumin 4 g/dl, and normal C-reactive protein. Radiological evaluation illustrated no abnormalities in wrist, ankle, MCP, MTP, and sacroiliac joints. The patient was then put on a therapy of 3 g/day of sulfasalazine, 7.5 mg/week of methotrexate, and 7.5 mg/day of prednisolone with the likely diagnosis of rheumatoid arthritis (RA). Her symptoms started to improve before the end of first week of treatment. Peripheral arthritis is not an uncommon finding in UC and is oligoarticular and asymmetric, affecting predominantly the lower extremity joints [1, 2, 3]. It is always seronegative and usually subsides with control of the bowel inflammation [1]. Involvement of the MCP, MTP, wrist, and ankle joints is observed quite rarely. The differential diagnosis of RA—especially when there is also seropositivity—becomes quite challenging, in case these types of joint involvements are present. To the best of our knowledge, there are two reports in the literature mentioning about patients in whom RA and UC were seen concurrently [4, 5]. One describes a patient with a flare of both diseases after delivery without explaining details of the proceedings of either disease, and one mentions about a patient in whom the RA had preceded UC. In our patient, the diagnosis of UC was established 1.5 years before the onset of RA. According to the criteria of the American College of Rheumatology, in our Rheumatol Int (2003) 23: 47–48 DOI 10.1007/s00296-002-0264-1