Murat Sert

Piperacillin/tazobactam versus imipenem/cilastatin for severe diabetic foot infections: a prospective, randomized clinical trial in a university hospital.

In this prospective, randomized, open-label clinical trial, we compared the efficacy and safety of two antibiotic regimens for severe diabetic foot infections (DFI). Sixty-two in-patients with DFI received either piperacillin/tazobactam (Pip-Tazo, n = 30) (4.5 g intravenously every 8h) or imipenem/cilastatin (IMP, n = 32) (0.5 g intravenously every 6h). The mean duration of treatment was 21 days for Pip-Tazo and 24 days for IMP. Twenty-two (73.3%) patients in the Pip-Tazo group and 26 (81.2%) patients in the IMP group had DFI associated with osteomyelitis. Successful clinical response was seen in 14 (46.7%) patients in the Pip-Tazo group and in nine (28.1%) patients in the IMP group [relative risk (RR) 1.6 (95% CI 0.84-3.25), p 0.130]. Two patients in the IMP group and none in the PIP-Tazo group relapsed [RR 2 (0.94-4.24), p 0.058]. Eighty-nine microorganisms were isolated: 38 (43%) Gram-positive and 51(57%) Gram-negative. Among patients with positive culture, 47 (96%) had complete and two (4%) had partial microbiological response. Microbiological response rates were similar in both groups (p 1.000). Amputation was performed in 18 (60%) and 22 (69%) patients in the Pip-Tazo and IMP groups (p 0.739) respectively. Side effects were more common in the Pip-Tazo group (30% vs. 9.4%), but they were generally mild and reversible. In conclusion, although the sample size was small and the results did not reach statistical significance, Pip-Tazo produced a better clinical response rate than IMP in the treatment of severe DFI. There was no significant difference between the treatment groups with respect to microbiological response, relapse and amputation rates.

Delay in the diagnosis of SLE: the importance of arthritis/arthralgia as the initial symptom.

Despite the current diagnostic and serologic testing for SLE, the interval between the onset of symptoms and the diagnosis is still long. In this study, we aimed to show the interval between the initial symptoms and the diagnosis of SLE and to investigate the presence of any relationship between the interval and the initial symptoms. One hundred and thirty-six patients were diagnosed with SLE using the 1982 ARA criteria. The mean age of the patients at diagnosis was 29.9 +/- 10.5 years. The mean interval between the onset of symptoms and the diagnosis of SLE was 21.82 +/- 30.32 months. The subjects were evaluated twice, at intervals of < or = 3 and < or = 12 months after the onset of symptoms. Although arthritis and/or arthralgia were the most common initial symptoms (60.3%), only 26.8% of the patients with these symptoms were diagnosed earlier than 3 months after the onset. If the first initial symptoms were butterfly rash or pericarditis, pleuritis, spontaneous abortion or cognitive dysfunction, they led to early diagnosis. In conclusion, since arthritis and/or arthralgia are the most common initial symptoms of the disease, every young woman with these symptoms should be carefully evaluated for SLE.

Rhabdomyolysis and Acute Renal Failure Due to Honeybee Stings As an Uncommon Cause

Saime Paydaş, MD, University of Çukurova, Faculty of Medicine, Department of Nephrology, TR-01330 Adana (Turkey) Dear Sir, Rhabdomyolysis has been implicated as the cause of acute renal failure in approximately 57% of cases [1]. Many cases of rhabdomyolysis associated with acute renal failure have been published, but those due to bee stings are quite rare [2,3]. We present a case of rhabdomyolysis and acute renal failure due to honeybee stings. A 68-year-old man admitted to hospital within 2 h after being stung by thousands of honeybees. He was healthy until this event. His physical examination disclosed an-gioedema, multiple areas marked by erythema and enduring skin lesions due to bee stings on his face, scalp and extremities. Blood pressure and pulse rates were 140/100 mm Hg and 120/min, respectively. ECG was normal except sinus tachycardia. Serum AST and ALT levels were 195 and 9 U/l, respectively. Other laboratory tests were normal. He was treated with intravenous prednisolone, antihistamines and mannitol. On the 3rd day hospital, in urine volume decreased from 1,000 to 300 cc/day. Blood urea nitrogen (BUN) and serum creatinine levels increased to 87 and 6.5 mg/dl, respectively. The color of his urine changed from yellow to dark brown. Serum CPK level was 46,320 U/l (normal: 25-196); AST 899 U/l (normal 5-40); ALT 285 U/l (normal: 5^40), and LDH 3,935 U/l (normal: 150-380). Urinary sodium was 115 mEq/1. Fractional sodium excretion was 3%. Renal failure index was 4%. Myoglobin in the urine was found to be negative by the dipstick test. On the 4th day, the patient was lethargic and BUN was 107 U/l, ALT 310 U/l, LDH 4,110 U/l, Ca 9.6 mg/dl, P 10.4 mg/dl and uric acid 8.5 mg/ dl. Serum fibrinogen was 450 mg/dl; FDP < IO, and prothrombin time 14 s. Kidneys were normal with no obstruction in abdominal ultrasonography. On the 5th day, laboratory data showed BUN 210 mg/dl; creatinine 10.7 mg/dl; K 7.8 mEq/1, Ca 8.3 mg/dl, P 10.8 mg/dl, LDH 4,025 U/l, CPK 50,260 U/l, AST 120 U/l, and ALT 354 U/l. Arterial blood gas analysis disclosed metabolic aci-dosis. The patient died because of sudden cardiac arrest due to hyperkalemia (the last laboratory findings were obtained after the patient died). Rhabdomyolysis and acute renal failure due to bee stings are rare among causes of rhabdomyolysis found in the literature. Although it is not know exactly, both acute intravascular hemolysis and acute myolysis can account for kidney involvement. Nevertheless; direct toxic effects of bee venom on nephrons inducing a tubuler necrosis can not be eliminated [4].

A clinical prospective study on alveolar bone augmentation and dental implant success in patients with type 2 diabetes

OBJECTIVES The objective of this prospective, controlled clinical study was to determine the outcomes of dental implant therapy with staged guided bone regeneration procedures in patients with type 2 diabetes. PATIENTS AND METHODS Twenty-four patients were included in the study. Half of the patients were diagnosed with type 2 diabetes mellitus (group 1) while the other half (group 2) of the patients consisted of patients without diabetes. The edentulous maxillary anterior/premolar regions with sufficient vertical height but inadequate horizontal width were treated with staged guided bone regeneration technique and with one or two implant-supported fixed restorations. The patients were followed up at least for 12 months. The parameters that were evaluated were radiographic evaluations on CBCT images and periapical radiographs, histomorphometric analysis, resonance frequency analysis (RFA) and wound-healing parameters. The data were analyzed statistically. RESULTS A total of 43 implants were placed in 24 patients (22 implants in group 1 and 21 implants in group 2). The survival rates of implants were 100% for both groups. The success rate of implants was 95% for group 1 and 100% for group 2. None of the parameters including CBCT findings, RFA values, success rates and wound-healing scores showed a significant difference between the two groups. CONCLUSION Staged guided bone regeneration is a feasible augmentation procedure for the treatment of horizontal bone deficiencies of the maxillary anterior/premolar regions in well-controlled type 2 diabetic patients.

A large family with Charcot-Marie-Tooth Type 1a and Type 2 diabetes mellitus.

Charcot-Marie-Tooth (CMT) disease is a hereditary demyelinating peripheral neuropathy, and CMT Type 1A is the most common form. In most cases, CMT1A is usually caused by duplication at chromosome 17p11.2–12. Type 2 diabetes mellitus (Type 2 DM) is a common metabolic disorder, characterized by chronic hyperglycemia that can be associated with micro- and/or macrovascular complications. Only a few studies reported CMT1A duplication in association with Type 2 DM. This article explores the characteristics of a large family of 69 members with respect to CMT1A and Type 2 DM. CMT1A was detected in 28 of them. Molecular genetic study was performed in 22, and duplication was detected in all of them. Six of the 22 members with CMT1A also had Type 2 DM based on the American Diabetes Association diagnostic criteria. Association of these two conditions may be coincidental; however, the occurence of these two diseases in this large family may also suggest a genetic basis. More extensive reports and further investigations of such families having this combination will certainly provide a better understanding of this link.

Carotid Intima-Media Thickness as the Cardiometabolic Risk Indicator in Patients with Nonfunctional Adrenal Mass and Metabolic Syndrome Screening

Background Our purpose was to show the association of adrenal incidentaloma and metabolic syndrome in consideration of the studies and to detect the increase in the carotid intima-media thickness which is regarded as the precessor of atherosclerosis. Material/Methods Eighty-one patients who were diagnosed with adrenal mass were included in the study. Hormonal evaluation, insulin rezistance measurement with the HOMA-IR and 1-mg DST were performed of all patients. The patients were classified as follows: mass size <3 cm (K1) and mass size of at least 3 cm (K2). Echocardiography and carotid intima-media thickness of the patients were measured using B-mode ultrasound. Thirty-three healthy individuals were enrolled as the control group. Results Mass size of 64.19% K1, while mass size of the remainder (35.81%) K2 was calculated. Five of the patients with adrenal mass were detected to have subclinical Cushing syndrome. The remaining 76 patients were accepted as nonfunctional. It was seen with regard to metabolic and biochemical parameters that plasma glucose (p=0.01), insulin (p=0.00) and triglyceride (p=0.012) values of all patients were significantly high compared to those of the control group. It was detected that measured heart rate (p=0.00), end-diastolic diameter (p=0.02), end-systolic diameter (p=0.014) and carotid intima-media thickness (p=0.00) values of the patients with adrenal mass were significantly higher than those of the healthy control group. Conclusions We found that the increased insulin resistance, increased risk of cardiovascular disease with the increase in the thickness of carotid intima-media and diastolic disfunction parameters, although the patients with adrenal incidentaloma are nonfunctional.

Is there any relationship between toxoplasma infection and reactive arthritis

BACKGROUND The diagnosis of reactive arthritis is a challenging clinical problem in daily practice. Although there are many triggering infectious agents for reactive arthritis, Toxoplasmosis, a worldwide parasitic infection has not been reported. AIM We investigated the serologic evidence of Toxoplasma gondii ( T. gondii ) infection in patients with newly diagnosed reactive arthritis after six weeks of the onset of the first symptom but no demonstrable triggering agent for reactive arthritis. SETTING AND DESIGN Clinical controlled study. MATERIALS AND METHODS We screened serologically the serum toxoplasma IgM and IgG antibody (Ab) titers which revealed toxoplasma infection in 50 patients with reactive arthritis (40 female, 10 men) and no demonstrable triggering agent and control subjects (32 female, 8 male). STATISTICAL ANALYSIS SPSS 10.0 software package program was used. RESULTS The mean age of the patients and controls was similar (41.3+/- 12.0 vs. 39.6+/-11.8 years) respectively. The prevalence of IgG Ab titers of T. gondii in patients and controls were found to be 52% and 47.5%, respectively. Mean serum Toxoplasma IgG Ab levels were found to be 16.5+/-14.5 IU/ml, and 16.9+/-13.8 IU/ml in patients and control subjects respectively ( P> 0.05). We did not find any Toxoplasma IgM Ab titer demonstrating the acute or sub-acute infection in the serum of patients or controls. CONCLUSION Although past Toxoplasma infection was prevalent in both groups, we did not find any subject with acute Toxoplasma infection in patients with newly diagnosed reactive arthritis and healthy controls. Despite the fact that our study group was small, we suggest that T. gondii does not seem to be a triggering agent for reactive arthritis and past infection may be a coincidental finding.

Review of Two Siblings with Werner's Syndrome: A Case Report

We report the clinical course of two siblings with Werners syndrome (WS) who were diagnosed and followed at our clinics for 12 years. Initial diagnosis of the first sibling (sister) was at age 20, the second (brother) at 16. At the initial diagnosis, the sister had amenorrhea, muscle atrophy at arms and legs, diabetes mellitus (DM), short stature, bilateral cataracts, genital hypoplasia, osteoporosis, and gray hair. During 12 years follow-up period, high-pitched voice, hepatosteatosis, renal parenchymal disease, and urethral obstruction developed. Regarding the brother, DM, cataracts and genital hypoplasia were observed at the initial diagnosis. During the 12 years follow-up period, gray hair, high-pitched voice, steatohepatosis, and osteoporosis developed.

impact of telephonic interviews on persistence and daily adherence to insulin treatment in insulin-naïve type 2 diabetes patients: dropout study

Objective The objective of this study is to evaluate the impact of sequential telephonic interviews on treatment persistence and daily adherence to insulin injections among insulin-naïve type 2 diabetes patients initiated on different insulin regimens in a 3-month period. Methods A total of 1,456 insulin-naïve patients with type 2 diabetes (mean [standard deviation, SD] age: 56.0 [12.0] years, 49.1% were females) initiated on insulin therapy and consecutively randomized to sequential (n=733) and single (n=723) telephonic interview groups were included. Data on insulin treatment and self-reported blood glucose values were obtained via telephone interview. Logistic regression analysis was performed for factors predicting increased likelihood of persistence and skipping an injection. Results Overall, 76.8% patients (83.2% in sequential vs 70.3% in single interview group, (P<0.001) remained on insulin treatment at the third month. Significantly higher rate for skipping doses was noted in basal bolus than in other regimens (27.0% vs 15.0% for premixed and 15.8% basal insulin, respectively, P<0.0001). Logistic regression analysis revealed sequential telephonic interview (odds ratio [OR], 1.531; 95% confidence interval [CI], 1.093–2.143; P=0.013), higher hemoglobin A1c levels (OR, 1.090; 95% CI, 0.999–1.189; P=0.049), and less negative appraisal of insulin therapy as significant predictors of higher persistence. Basal bolus regimen (OR, 1.583; 95% CI, 1.011–2.479; P=0.045) and higher hemoglobin A1c levels (OR, 1.114; 95% CI, 1.028–1.207; P=0.008) were the significant predictors of increased likelihood of skipping an injection. Conclusion Our findings revealed positive influence of sequential telephonic interview, although including no intervention in treatment, on achieving better treatment persistence in type 2 diabetes patients initiating insulin.

An unusual amebic localization on the right hip

We report the history of a 43-year-old man with a histopathologically confirmed invasive amebic abscess in his right hip. CT scan of the liver was normal. The amebic indirect hemagglutination (IHA) test was positive with a titer of 1/1,024. The patient developed acute renal failure and died within 48 h of admission with multiple organ failure due to sepsis. Ein 43 Jahre alter Mann entwickelte in der rechten Hüfte einen Abszeß, der histopathologisch als Amöbenabszeß identifiziert werden konnte. Der indirekte Amöben-Hämagglutinationstest war mit einem Titer von 1/1024 positiv. Der Patient kam in ein akutes Nierenversagen und verstarb 48 Studen nach Einweisung an Sepsis mit multiplem Organversagen.SummaryWe report the history of a 43-year-old man with a histopathologically confirmed invasive amebic abscess in his right hip. CT scan of the liver was normal. The amebic indirect hemagglutination (IHA) test was positive with a titer of 1/1,024. The patient developed acute renal failure and died within 48 h of admission with multiple organ failure due to sepsis.ZusammenfassungEin 43 Jahre alter Mann entwickelte in der rechten Hüfte einen Abszeß, der histopathologisch als Amöbenabszeß identifiziert werden konnte. Der indirekte Amöben-Hämagglutinationstest war mit einem Titer von 1/1024 positiv. Der Patient kam in ein akutes Nierenversagen und verstarb 48 Studen nach Einweisung an Sepsis mit multiplem Organversagen.