Hasan Yüksel

Septic pulmonary emboli presenting with deep venous thrombosis secondary to acute osteomyelitis

Septic pulmonary embolism (SPE), deep vein thrombosis (DVT) and acute osteomyelitis (AOM) form a triad which is rarely seen in children. The association of DVT, SPE and AOM was first reported as a form of dissemine staphylococcal infection by Gorenstein et al . 1 This clinical syndrome is a life threatening disorder which necessitates urgent diagnosis and treatment. 2–4 SPE is manifested in a large number of patients with fever, cough and hemoptysis. The most common radiographic findings of SPE are the presence of multiple nodules of varying size located in the periphery of both lungs. 5 It is a frequent complication of right-sided bacterial endocarditis, septic thrombophlebitis, osteomyelitis, and urinary tract infections in adults, but there has been no comprehensive studies considering the etiological factors in childhood. 1,5–7 In this article, we report a 3-year-old male patient who was diagnosed with SPE which presented along with the clinical findings of DVT on admission.

Childhood asthma and atmospheric conditions.

Bronchial asthma is the most common chronic respiratory illness in childhood. It is characterized by paroxysmal bronchospastic periods. There are many studies giving reasons to explain the bronchospasm periods. One of the reasons, atmospheric conditions, is effective in creating a clinical picture of asthmatic patients. In the present study, the correlation between atmospheric conditions and asthmatic symptoms in children was investigated using peak expiratory flow rate (PEFR) as the respiratory function test. Twenty‐one children with bronchial asthma were monitored in the study. They were followed as outpatients of the Ege University Medical Faculty, Department of Pediatric Allergy and Pneumotology, between November 1993 and June 1994. Atmospheric conditions were recorded from the local meteorology center. Complaints and the PEFR of children were compared with the meteorological data. Asthmatic symptoms were increased by low temperatures in all asthmatic children. An increase was detected in the extrinsic group by relative humidity and ratio of cloud, but in the intrinsic group only by relative humidity.

Standard dose of inhaled albuterol significantly increases QT dispersion compared to low dose of albuterol plus ipratropium bromide therapy in moderate to severe acute asthma attacks in children

Abstract Background : Beta‐2 agonist therapy has previously shown to increase the QT dispersion (QTd) in asthmatic patients and increased QTd has been well documented in association with cardiac arrhythmias and sudden death. However, the data concerning the effect of low doses of beta‐2 agonist therapy in combination with the anticholinergic agents to potentiate bronchodilatation on QTd in asthmatic children are limited. The objectives of this study was to investigate the changes on QTd during both the standard dose of nebulized albuterol therapy and low dose nebulized albuterol plus inhaled ipratropium therapyn to assess the potential arrhytmogenic risk of these two treatment strategies in children with acute asthmatic attacks.

Effects of allergen-specific immunotherapy on functions of helper and regulatory T cells in patients with seasonal allergic rhinitis.

BACKGROUND Seasonal allergic rhinitis (SAR) is characterized by a helper T (Th)2 cell-mediated immune response at the target site. There is a relative Th1 and/or regulatory T (Treg) cell insufficiency in patients with SAR. It has been demonstrated that there is a change in the balance between these cells after allergen-specific immunotherapy (SIT), which is a curative treatment modality for this disease. However, there are few studies that evaluate the number and function of these cells in the inflammatory area after SIT treatment. OBJECTIVE We aimed to investigate the distribution of Th1, Th2 and Treg cells in nasal biopsies and lavage fluid (NLF) specimens from patients with SAR, before and after SIT. METHODS Twenty-four, symptomatic SAR patients sensitized to Olea europeae, were enrolled in the study prior to treatment. Fifteen, non-allergic subjects with nasal septum deviation, who needed surgical treatment, served as the control group. NLF and inferior turbinate biopsies were obtained from both groups during the pollen season. Conventional, subcutaneous SIT with Olea europeae extract was initiated in patients with SAR. One year after the first biopsy, biopsies and NLF specimens were again obtained for reevaluation. All biopsies were evaluated for Th1, Th2 and Treg cell counts by means of their transcription factors (T-bet, GATA-3 and FoxP3) using an immunohistochemical analysis method. Additionally, all NLF specimens were evaluated for the functions of these cells, by means of their specific cytokines, using an ELISA method. RESULTS When the basal status of those patients with SAR was evaluated based on transcription factors, prior to treatment, Th1 and Treg cells were found to be fewer than in non-allergic controls (p=0.001 for both T-bet and FoxP3). It was demonstrated that numbers of GATA-3-carrying cells, which are a marker for Th2, were not significantly different between the groups (p=0.276), but evaluation of the Th1/Th2 ratio revealed a relative Th2 dominance in patients with SAR prior to treatment. When evaluated on the basis of cytokine levels, it was observed that Th1-originated IFN-γ was lower in patients with SAR compared to the control group, both before and after treatment (p=0.012 for both comparisons), Th2-originated IL-4 levels were not significantly different between the groups either before or after treatment (p=0.649, p=0.855; respectively). Th2- and Treg cell-originated IL-10 levels were higher in patients with SAR before treatment (p=0.033), but this difference was not statistically signifant following treatment compared with controls (p=0.174). Treg cell-originated TGF-β levels were slightly lower in patients with SAR compared to the controls, although the difference was not statistically significant (p=0.178, p=0.296; respectively). None of the above mentioned cytokine levels changed significantly as a result of SIT. CONCLUSION The results of our study indicate that although clinical findings improve after one year of SIT, this duration may not be sufficient to detect changes in cytokine patterns and transcription factors. Further studies that evaluate outcome over a longer duration of treatment would provide valuable information.

Correlation of quality of life with clinical parameters and eosinophilic cation protein levels in children with allergic rhinoconjunctivitis.

Background: Systemic and mucosal roles of eosinophils in the pathogenesis of allergic rhinoconjunctivitis (AR) are known. The aim of this study was to investigate the relationship of clinical parameters and quality of life with eosinophilic cationic protein (ECP) in grass pollen-sensitive children with seasonal AR. Methods: This study included 31 children with AR and 18 healthy controls aged between 5 and 15 years. ECP levels in nasal lavage fluid and serum were measured. AR symptom scores were calculated and the pediatric rhinoconjunctivitis quality of life questionnaire (PRQLQ) was filled in for all patients. Results: Mean serum and nasal ECP levels (ng/ml) were significantly higher in the patient group (p < 0.05 for both). In the AR group, the mean clinical symptom score was 7.3 ± 2.2, while the total PRQLQ score, activity limitation, symptoms and emotional function domains were 2.5 ± 0.9, 3.0 ± 1.1, 2.5 ± 1.2 and 2.6 ± 1.1, respectively. The total clinical symptom score and disease duration showed a significant correlation with the total PRQLQ score (p = 0.00 and 0.003, respectively). However, neither nasal lavage nor serum ECP levels were significantly correlated with symptom score, duration of disease, PRQLQ total score or domains (p > 0.05 for all). Conclusion: These results may indicate the absence of a correlation between clinical status and quality of life and levels of ECP in tissues with allergic inflammation.

Effectiveness of magnetic resonance angiography in the evaluation of lung perfusion in constrictive bronchiolitis obliterans

Childhood constrictive bronchiolitis obliterans (CBO) is characterized clinically by the persistence of obstructive respiratory symptoms following a prolonged episode of lower respiratory viral infection. The diagnosis depends on the clinical, radiological and laboratory findings. Perfusion defects on scintigraphy may predict the severity. This report describes a 2‐year‐old girl who presented with a 15‐day history of respiratory distress despite treatment. Auscultation of the lungs revealed prolonged expiration and bilateral crepitant rales. CXR revealed bilateral paracardiac infiltration. She improved with a treatment regimen of bronchodilators, systemic steroids and antibiotherapy; however, rales were detected again 10 days after discharge. HRCT of the lung revealed an oligaemic‐mosaic pattern, more prominent in the left lung. The diagnosis of CBO was made on the basis of these clinical and radiological findings. Perfusion was normal in the right lung but diffusely decreased in the left lung on perfusion scintigraphy by Tc99m‐MAA. Magnetic resonance (MR) angiography source images of the lungs revealed significant but not diffuse perfusion defects in the left lung, in contrast to radionuclide scintigraphy. There were areas of low perfusion in the right lung, which were not evident in radionuclide scintigraphy. The use of source images of MRI angiography of the lungs may be more sensitive and specific for the detection of perfusion defects in patients with CBO and may assist in determining the prognosis.

Predicting Hospitalization in Children with Acute Asthma

BACKGROUND Acute asthma is one of the most common medical emergencies in children. Appropriate assessment/treatment and early identification of factors that predict hospitalization are critical for the effective utilization of emergency services. OBJECTIVE To identify risk factors that predict hospitalization and to compare the concordance of the Modified Pulmonary Index Score (MPIS) with the Global Initiative for Asthma (GINA) guideline criteria in terms of attack severity. METHODS The study population was composed of children aged 5-18 years who presented to the Emergency Departments (ED) of the tertiary reference centers of the country within a period of 3 months. Patients were evaluated at the initial presentation and the 1(st) and 4(th) hours. RESULTS Of the 304 patients (median age: 8.0 years [interquartile range: 6.5-9.7]), 51.3% and 19.4% required oral corticosteroids (OCS) and hospitalization, respectively. Attack severity and MPIS were found as predicting factors for hospitalization, but none of the demographic characteristics collected predicted OCS use or hospitalization. Hospitalization status at the 1(st) hour with moderate/severe attack severity showed a sensitivity of 44.1%, specificity of 82.9%, positive predictive value of 38.2%, and negative predictive value of 86.0%; for MPIS ≥ 5, these values were 42.4%, 85.3%, 41.0%, and 86.0%, respectively. Concordance in prediction of hospitalization between the MPIS and the GINA guideline was found to be moderate at the 1(st) hour (κ = 0.577). CONCLUSION Attack severity is a predictive factor for hospitalization in children with acute asthma. Determining attack severity with MPIS and a cut-off value ≥ 5 at the 1(st) hour may help physicians in EDs. Having fewer variables and the ability to calculate a numeric value with MPIS makes it an easy and useful tool in clinical practice.

Un)Awareness of Allergy

BackgroundAllergy is associated with considerable morbidity.ObjectiveThe aim of this multicenter study was to provide insight into allergy knowledge and perceptions among the population.MethodsDuring the World Allergy Day, several allergy clinics conducted public meetings to encourage the awareness of and education in allergy. At the beginning, participants filled out a questionnaire to assess their knowledge about what is allergy and to determine by whom those symptoms are cared.ResultsA total of 256 participants (187 women/69 men, mean age, 31.2 ± 12.5 years) completed the survey. Of the 202 participants with symptoms, 58.9% had physician-diagnosed allergic disease. Among the 19 symptoms evaluated, 56.5% of the symptoms were recognized as related with allergy, and this increased in compliance with education level (r = +0.427; P < 0.001) but not with diagnosed allergy (P = 0.34). Sneezing was the most common symptom thought to be related with allergy-related symptom (77.5%), whereas loss of smell was the least one (37.9%). Participants were more likely to be cared by an allergologist (72.9%) followed by other specialties, when experiencing allergy.ConclusionsIncreasing the awareness for allergic symptoms is the key not only for the diagnosis but also for the optimal treatment. Therefore, education is an important component of prevention and control of allergic diseases.

Ailevi Akdeniz Ateşi ile birliktelik gösteren Juvenil Ankilozan Spondilitli bir olgu

Regional anaesthesia has advantages such as, control of postoperative pain, early mobilization, and does not affect respiratory function. In recent years, regional anaesthesia had improved by the application of the peripheral nerve stimulator and ultrasound guided blocks, new local anaesthetic drugs with the use of additional adjunctive agents. Especially in emergency conditions, combination of regional anaesthesia may avoid the complications of general anesthesia in patients with chronic disease who suffer from upper and lower extremity injuries. In this paper, we present two cases who underwent combined regional anaesthesia techniques for the lower and upper extremity surgery.Iki tarafli ses teli felci (ISTF) siklikla tiroid ve paratiroid cerrahisi gibi iyatrojenik bir hasar sonucu olusur. Fakat serebral infarkt sonrasi hava yolu tikanikligina neden olan BVKP nadir olarak bildirilmistir. Bu yazida tekrarlayan serebral infarktin, gec ortaya cikan ve hayati tehdit eden bir komplikasyonu olarak solunum durmasi ile sonuclanan bir ISTF olgusu sunduk. Atmis yedi yasinda erkek hasta, son 3-4 aydir giderek artan solunum yetmezligi sikayetiyle acil servisimize basvurdu. Ozgecmisinde kalp yetmezligi ve kronik obstruktif akciger hastaligi oykusu olmayan hasta, yaklasik bir yil once bir ayda iki kez serebral infarkt gecirmisti. Yapilan solunum sistemi muayenesinde bilateral wheezing ve stridor; norolojik muayenesinde ise sag tarafta kuvvet kaybi mevcuttu. Ust solunum yolu obstruksiyonunu degerlendirilmek uzere endoskopik laringoskopi yapildi. Laringoskopide iki tarafli ses tellerinin orta hatta sabit ve hareketsiz oldugu goruldu. Solunum yetmezliginde artma ve tekrarlayan solunum durmasi nedeniyle hastaya trakeostomi acildi. Operasyon sonrasi hastanin solunum yetmezligi geriledi. Solunum fonksiyonlari normale donen hasta taburcu edildi.Dysphagia aortica is a rare etiological factor of dysphagia resulting from extrinsic compression of the esophagus by thoracic aorta. There is no gold standard diagnostic proscedure for dysphagia aortica. Dysphagia aortica is usually escaped to attention in the differential diagnosis of dyssphagia. Here, we reported compression of the esophagus by thoracic aorta in a 54 years-old male patient who comsplained from dysphagia.

Relationship Between Sleep and Life Quality of Children with Monosemptomatic Nocturnal Enuresis by Assessing Actigraphy

Objective: In this study, it was aimed to compare the sleep quality of healthy children with the actigraphic evaluation and quality of life of monosymptomatic enuresis children of similar age groups. Materials and Methods: This prospective study was conducted in Celal Bayar University Faculty of Medicine and has been submitted to the Department of Pediatric Nephrology. Patients included in the study were suffering from urinary incontinence for two years and only from monosymptomatic enuresis nocturna. The study group consisted of healthy children with monosymptomatic enuresis nocturna who volunteered to participate and those who did not have any systemic disease of similar age and sex. The demographic data, quality of life and activity of all the cases that were taken into the study were tried to be evaluated with sleep quality. Results: Forty children with 40 monosymptomatic enuresis nocturna diagnoses matching the study criteria were included. The control group consisted of 20 healthy children. There were no difference in demographic characteristics between the groups (p>0.05). The Kid-KINDL total score was 59.6±12.9 in children with monosymptomatic enuresis nocturna and 74.8±6.3 in healthy children (p=0.001). The effective sleep duration was statistically lower in children with monosymptomatic enuresis nocturna, and the effective duration of wakefulness, number of naps and fragmentation index were found to be higher in children with monosymptomatic enuresis nocturna (p=0.001). Conclusion: This is the first study in the literature to compare actigraphic analysis and quality of life of healthy children with enuretic children. We think that children with monosymptomatic enuresis nocturna have a significant deterioration in their quality of life compared to healthy children in sleep quality and this leads to an effect on the quality of life.