Salih Emri

Genetic-susceptibility factor and malignant mesothelioma in the Cappadocian region of Turkey

Erionite present in stones used to build the villages of Karain and Tuzköy, Turkey, mined from nearby caves, is purported to cause mesothelioma in half of the villagers. We constructed genetic epidemiology maps to test whether some villagers were genetically predisposed to mesothelioma. Analysis of a six-generation extended pedigree of 526 individuals showed that mesothelioma was genetically transmitted, probably in an autosomal dominant way. This finding should lead to preventive strategies to lower the incidence of mesothelioma in future generations, and close monitoring of high-risk individuals might allow early detection and cure.

A mesothelioma epidemic in Cappadocia: scientific developments and unexpected social outcomes

In Cappadocia, Turkey, an unprecedented mesothelioma epidemic causes 50% of all deaths in three small villages. Initially linked solely to the exposure to a fibrous mineral, erionite, recent studies by scientists from Turkey and the United States have shown that erionite causes mesothelioma mostly in families that are genetically predisposed to mineral fibre carcinogenesis. This manuscript reports, through the eyes of one of the researchers, the resulting scientific advances that have come from these studies and the social improvements that were brought about by both the scientists and members of the Turkish Government.

Lung diseases due to environmental exposures to erionite and asbestos in Turkey

Asbestos deposits have been used locally by the rural inhabitants of Central and Southeastern Anatolia for domestic purposes for many years. Mineralogical analysis revealed that tremolite is the most prominent asbestos type found in the region. There is in addition another mineral fiber found particularly in three villages located in the Cappadocian region of Central Anatolia (zeolite villages). This is a non-asbestos mineral, which has been identified as the fibrous zeolite, erionite. This fiber is present in the volcanic tuffs, which are used as building stone. Hence, exposure to erionite fibers is always possible in the houses, annexes, and streets of the villages. It has been demonstrated that both asbestos and erionite cause a variety of benign and malignant chest diseases. Among the diseases, calcified pleural plaques (CPP) are the most frequently seen and may be used as an indicator of mineral fiber exposure. Asbestos and erionite exposure are the main causes of malignant mesotheliomas in Turkey. In zeolite villages malignant mesothelioma is responsible for more than 50% of the total deaths. A recent study showed that simian virus 40 is not a cofactor in the pathogenesis of environmental malignant mesothelioma in Turkey. An additional recent genetic-epidemiological study showed that there are some families, which are genetically predisposed to mesothelioma.

Treatment of malignant pleural mesothelioma with cisplatin, mitomycin C and alpha interferon.

From October 1990 to September 1991, 20 consecutive patients with histologically proven malignant pleural mesothelioma (MPM), secondary to environmental exposure to asbestos or erionite, were treated with cisplatin, mitomycin C and alpha interferon (cisplatin 50 mg/m2 i.v. on day 1 of a 21-day cycle; mitomycin C 10 mg/m2 i.v. day 1 of cycles 1,3 and 5; alpha-2b-interferon 10 x 10(6) units i.m., 4 h prior to cisplatin and 10 x 10(6) units i.v. immediately prior to cisplatin day 1 of each cycle). Eighty-two treatment cycles were administered to 19 evaluable patients. Two patients attained a partial response. Eleven patients had stable disease and 6 had disease progression. Toxicities included interferon-related fever and flu-like symptoms, and vomiting. Actuarial median survival was 15 months. Three patients are alive at 20+, 21+ and 27+ months. We conclude that while the addition of alpha interferon to cisplatin and mitomycin C did not result in an objective response higher than previously reported with the cytotoxic agents alone, the trend towards an improvement in median survival as compared to a well-matched historical group suggests some benefit from the inclusion of interferon.

Erionite bodies and fibres in bronchoalveolar lavage fluid (BALF) of residents from Tuzkoy, Cappadocia, Turkey.

OBJECTIVES The high incidence of malignant mesothelioma in some villages of Cappadocia (Turkey) is due to environmental exposure to erionite fibres. The aim was to evaluate the fibre burden in bronchoalveolar lavage fluid (BALF) from inhabitants of an erionite village and compare it with Turkish subjects with or without environmental exposure to tremolite asbestos. METHODS Ferruginous bodies (FBs) and fibres were measured and analyzed by light and transmission electron microscopy (TEM) in the BALF of 16 subjects originating from Tuzköy. RESULTS FBs were detected in the BALF of 12 subjects, with concentrations above 1 FB/ml in seven of them. Erionite was the central fibre of 95.7% of FBs. Erionite fibres were found in the BALF of all subjects, by TEM, and these fibres were low in Mg, K, and Ca compared with erionite from Tuzköy soil. The mean concentration of erionite fibres in BALF was similar to that of tremolite fibres in Turks with environmental exposure to tremolite. The proportion of fibres longer than 8 μm in BALF represented 35.6% for erionite compared with 14.0% for tremolite. The asbestos fibre concentrations in erionite villagers was not different from that in Turks without environmental exposure to tremolite. CONCLUSION Analysis of BALF gives information about fibre retention in populations environmentally exposed to erionite for whom data on fibre burden from lung tissue samples are scarce. This may apply to exposed Turks having emigrated to other countries.

A Text Messaging-Based Smoking Cessation Program for Adult Smokers: Randomized Controlled Trial

Background Despite promising data in Western countries, there is a dearth of research into the efficacy of text messaging-based smoking cessation programs in other settings, including the Middle East, where smoking prevalence rates are higher. Objective This paper reports cessation rates observed in SMS Turkey, a text messaging-based smoking cessation program for adult smokers in Ankara, Turkey. Methods This study was a small-scale, parallel-group randomized controlled trial (RCT) conducted in Ankara, Turkey. Participants were adult daily smokers who were seriously thinking about quitting in the next 15 days and living in Ankara, Turkey. The text messaging intervention, SMS Turkey, provided 6 weeks of daily messages aimed at giving participants skills to help them quit smoking. Messages were sent in an automated fashion, except 2 days and 7 days after the initial quit day. On days 2 and 7, the research assistant manually assigned participants to content “paths” based on whether they were still not smoking or had relapsed. The control arm received a brochure that provided similar information about smoking cessation. The main outcome measure was self-reported 3-month sustained abstinence, verified by carbon monoxide (CO) readings. Neither participants nor researchers were blinded to arm assignment. Results The 151 participants were randomly assigned to 1 of 2 groups: 76 to the SMS Turkey intervention group and 75 to the brochure control group. Using intention to treat, all 151 participants were included in analyses. Three-month cessation trends were not significantly higher in the intervention group: 11% intervention vs 5% control had quit (χ2 1=1.4, P=.24; R2=2.0, 95% CI 0.62-6.3). When the sample was stratified by sex, female intervention participants (14%, n=5) were significantly more likely to have quit at 3 months than female control participants (0%, n=0; χ2 1=3.7, P=.05). Among light smokers (ie, those smoking less than 20 cigarettes per day), intervention participants (17%, n=5) also were significantly more likely to have quit compared to control participants (0%, n=0; χ2 1=5.3, P=.02). We noted no difference in cessation rates for males or heavy smokers. Participants experienced significant technology problems during the study. Some participants received duplicate text messages at least once during the trial; others failed to receive some program messages. Neither receiving duplicate messages (χ2 1=0.12, P=.73), or missing 5 or more program messages (χ2 1=0.75, P=.39) negatively affected quitting rates. Conclusions Although the study was not powered to detect statistically significant differences, as the primary aim was to provide estimates of effect size that could be used to better inform a power analysis for a larger trial, findings provide optimism that SMS Turkey may be able to affect quitting rates in environments with high smoking prevalence, such as Ankara, Turkey. The SMS Turkey software program did not work as well as it did 2 years previous. The system will need to be updated to maintain software compatibility with ongoing technology evolution. Trial Registration Clinicaltrials.gov NCT00912795 http://clinicaltrials.gov/ct2/show/NCT00912795 (Archived by WebCite at http://www.webcitation.org/6Ch1cIA8l).

Recognition of cigarette brand names and logos by primary schoolchildren in Ankara, Turkey

OBJECTIVE To assess the smoking behaviour of primary schoolchildren and their ability to recognise brand names and logos of widely advertised cigarettes, compared with other commercial products intended for children. DESIGN Cross-sectional survey in classroom settings using a questionnaire designed to measure attitudes towards smoking and the recognition of brand names and logos for 16 food, beverage, cigarette, and toothpaste products. SETTING Ankara, Turkey. SUBJECTS 1093 children (54.6% boys, 44.4% girls) aged 7–13 years (mean = 10, SD = 1), from grades 2–5. The student sample was taken from three primary schools—one school in each of three residential districts representing high, middle, and low income populations. MAIN OUTCOME MEASURES Prevalence of ever-smoking, recognition of brand names and logos. RESULTS Prevalence of ever-smoking was 11.7% overall (13.9% among boys and 9.1% among girls; p<0.05). Children aged eight years or less had a higher prevalence of ever-smoking (19.6%) than older children (p<0.002). Ever-smoking prevalence did not differ significantly across the three school districts. Ever-smoking prevalence was higher among children with at least one parent who smoked (15.3%) than among those whose parents did not (4.8%) (p<0.001). Brand recognition rates ranged from 58.1% for Chee-tos (a food product) to 95.2% for Samsun (a Turkish cigarette brand). Recognition rates for cigarette brand names and logos were 95.2% and 80.8%, respectively, for Samsun; 84.0% and 90.5%, respectively, for Camel; and 92.1% and 69.5%, respectively, for Marlboro. The Camel logo and the Samsun and Marlboro brand names were the most highly recognised of all product logos and brand names tested. CONCLUSIONS The high recognition of cigarette brand names and logos is most likely the result of tobacco advertising and promotion. Our results indicate the need to implement comprehensive tobacco control measures in Turkey.

Environmental Pleural Plaques due to Asbestos and Fibrous Zeolite Exposure in Turkey

There are many districts in central and south-eastern Anatolia where benign and malignant pleural diseases occur as a result of environmental exposure to mineral fibres. Tremolite asbestos is found in the region and, in addition, in certain areas, there is a unique non-asbestos fibre called erionite which is a fibrous zeolite and which causes pulmonary diseases similar to those produced by asbestos. In this article we would like to report the frequency of calcified pleural plaques in a large-scale epidemiological study in Turkey. The presence of such plaques is considered indicative of mineral fibre exposure. The miner alogy of the region, exposure characteristics of the population and frequency of detection by computerised tomography, thoracoscopy and thoracotomy are also given.

The expanding spectrum of a disease. Behçet's disease associated with amyloidosis.

In this report, we present a series of 6 patients with Behçets disease (BD) associated with amyloidosis whose illnesses date back at least 4 years. In all the cases, nephrotic syndrome heralded the onset of amyloidosis, which was diagnosed by percutaneous kidney biopsies. After the diagnosis of amyloidosis, all subjects received colchicine, and steroids were discontinued. Three patients have benefited from treatment. It was suggested that amyloidosis may be an intrinsic feature of BD or that the suppurative lesions may play a role in the accumulation of amyloid in the tissues. The literature was reviewed and discussed.

Prognostic significance of flow cytometric DNA analysis in patients with malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) due to environmental exposure to asbestos and erionite is a relatively common cancer in Turkey. In this study, we investigated the value of flow cytometric (FCM) DNA analysis and other prognostic factors such as age and etiologic factor in the patients with MPM, treated with surgery+/-combination chemotherapy+/-radiotherapy. A total of 40 patients with a median age of 50 (range 30-68) were included in the study. Twenty-nine patients had asbestos exposure in etiology, while 11 had fibrous zeolite (erionite). Paraffin-embedded tumor specimens were studied by FCM for DNA analysis. Twelve patients (30%) had aneuploid tumors and 28 (70%) had diploid ones. Mean S-phase fraction (SPF; %) was 9.1+/-1.1 and proliferation index (PI, SPF+G2/M phase; %) was 11.3+/-0.9. While the median overall survival (OS) was 10+/-2 months (6-14; 95% CI), 1-year survival rate was 45.2%. Only PI was found to be statistically significant for OS in univariate analysis (P=0.013). PI was also found to be an independent prognostic factor for all patients (P=0.035). Aneuploidy was significantly higher in erionite group compared with asbestos group. Male predominance and poor survival were also prominent in erionite group, though not statistically significant. In conclusion, PI is an independent prognostic factor for patients with MPM and the biologic features of the disease may show differences with respect to different etiologies.