Tamer Tetiker

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.

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].

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.

Thyroid hormone levels as a predictor of mortality in intensive care patients: A comparative prospective study

ZusammenfassungHINTERGRUND: Die Mortalität von Intensivpatienten ist ziemlich hoch. Ziel dieser Studie war es, die Rolle beziehungsweise den Wert verschiedener Marker bei der Vorhersage des Überlebens von Intensivpatienten zu erheben. Bezogen auf die Zahl der Patienten ist die vorliegende Studie die größte ihrer Art. Überdies versucht sie das Ausmaß der bei Intensivpatienten beobachteten Suppression der Schilddrüsenhormone mit dem Anstieg des Procalcitonins (pCT) zu korrelieren. PATIENTEN UND METHODEN: In die endgültige Analyse wurden 417 Patienten (235 Männer = 56 %; 182 Frauen = 44 %)) aufgenommen. Folgende Parameter wurden hinsichtlich ihrer Wertigkeit als Prädiktoren der Mortalität geprüft: Alter, APACHE II Score, pCT, freies Trijodthyronin (fT3), freies Thyroxin (fT4) und Thyreoidea stimulierendes Hormon (TSH). ERGEBNISSE: Bei unseren Intensivpatienten waren hohe APACHE II Scores und niedrige pCT Konzentrationen, sowie Suppression von fT3, fT4 und TSH Konzentrationen alle mit einer höheren Mortalität assoziiert (p < 0.001). Außerdem war die Erniedrigung der Schilddrüsen-hormone reziprok mit einem hohem APACHE II Score und pCT Konzentrationen korreliert (p < 0.05). SCHLUSSFOLGERUNG: Die Erhebung des APACHE II Scores, sowie die Messung der Konzentrationen von pCT, fT4, fT3 und TSH sind möglicherweise als Prädiktoren der Mortalität nützlich.SummaryBACKGROUND: Mortality rates of intensive care patients are quite high. The aim of this study was to determine the role, as well as to compare the value of several markers in predicting mortality in intensive care patients. Patient-wise, this is the largest study of its kind and the first that attempts to correlate the degree of thyroid hormone suppression with elevations in procalcitonin (PCT) levels. PATIENTS AND METHODS: In this study, a total of 417 patients were included in the final analysis, 235 of which were men (56%), and 182 were women (44%). Predictors of mortality that were investigated include age, APACHE II score, PCT, free triiodo-L-thyronine (fT3), free tetraiodothyronine/thyroxine (fT4) and thyroid stimulating hormone/thyrotropin (TSH). RESULTS: High APACHE II score and low PCT levels, as well as suppression of fT3, fT4 and TSH levels were all found to be associated with higher mortality in our intensive care patients (p < 0.001). Suppression of thyroid hormones was also found to be reciprocally correlated with high APACHE II scores and PCT levels (p < 0.05). CONCLUSION: Calculation of APACHE II score as well as measurement of PCT, fT3, fT4 and TSH levels may all be useful as predictors of mortality in intensive care patients.

Effects of rosiglitazone on altered electrical left ventricular papillary muscle activities of diabetic rat

The action potential configuration of the left ventricular papillary muscle as well as the rosiglitazone-dependent changes in ventricular papillary muscle action potential amplitude were studied, and the duration was studied and compared in both healthy and diabetic rats. In this study, we used four groups: (1) nondiabetic control animals (C), (2) rosiglitazone-treated nondiabetic control animals (C+RSG), (3) diabetic animals (D), and (4) rosiglitazone-treated diabetic animals (D+RSG). Diabetes was induced by a single intravenous (i.v.) injection of streptozotocin (STZ). Conventional microelectrode techniques were applied to record action potentials after the establishment of diabetes (8 weeks after STZ treatment). Resting membrane potential (RMP) was decreased significantly in both RSG-treated C and D rats (from −70.2 ± 0.7 to −63.2 ± 0.7 and from −69.2 ± 0.4 to −61.2 ± 0.4). C+RSG and D+RSG groups showed increase in action potential amplitude compared with C and D groups (from 67.1 ± 0.8 to 68.2 ± 0.5 and from 67.1 ± 0.8 to 80.1 ± 0.8 and from 68.2 ± 0.5 to 79.3 ± 0.3) Depolarization time was significantly prolonged in diabetic rats (12.1 ± 0.4 to 27.5 ± 0.9). However, this prolongation in D+RSG group was significantly lower according to D group (from 27.5 ± 0.9 to 19.2 ± 0.7). There was no difference between C and C+RSG rats (12.1 ± 0.4 to 11.6 ± 0.2). Half repolarization time was also prolonged in diabetic rats (17.5 ± 0.6 to 59.9 ± 1.0). Moreover, D+RSG rats showed a slight and statistically insignificant difference according D rats (59.9 ± 1.0 to 55.9 ± 1.7). C+RSG rats showed a slight significant increase in half repolarization time compared with C group (17.5 ± 0.6 to 29.4 ± 0.7). Treatment of rats with RSG markedly decreased insulin resistance and also increased insulin sensitivity of the heart. Our data suggest that the beneficial effects of RSG treatment on the electrical activities of the diabetic rat papillary appear to be due to the diminished K+ currents, partially related to the decrease of hyperglycemia.

Apoptosis and Proliferating Cell Nuclear Antigen in Lupus Nephritis (Class IV) and Membranoproliferative Glomerulonephritis

Background: The role of apoptosis in the pathogenesis of renal diseases has not been clearly established. Proliferating cell nuclear antigen (PCNA) is also a proliferation marker. In this study, we investigated the relationship between clinical course and PCNA apoptosis on baseline renal biopsy in patients with Lupus nephritis (LN) and membranoproliferative glomerulonephritis (MPGN). Methods: Thirty-nine patients with proliferative glomerulonephritis [lupus nephritis (LN)[21] and MPGN[18]] were included in this study. PCNA and apoptosis on renal biopsies were detected by immunohistochemical and terminal deoxynucleotidyl transferase mediated dUTP nick end labelling TUNEL methods, respectively. We calculated the ratios of intraglomerular apoptotic cells and PCNA positive cells per glomeruli, and total numbers of apoptotic tubular cells and PCNA positive tubular cells among the 100 tubular cells, and PCNA positive cell and apoptotic cell on two different tubulointerstitial areas (40 × 10). Results: In LN: Apoptotic indexes of glomerulus and tubulus were 1.08 ± 0.49 and 3.71 ± 1.38, respectively. PCNA positivities were found at 16.76 ± 11.34%, 46.57 ± 22.54%, and 40.28 ± 23.14% on glomerulus, tubulus, and interstitium, respectively. The activity index was 11.23 ± 3.41, and the chronicity index was 3.81 ± 1.99. In MPGN: Apoptotic indexes were found at 0.83 ± 0.25 and 3.55 ± 1.75 on glomerulus and tubulus, respectively. PCNA positivities were found at 21.33 ± 18.42%, 35.5 ± 25.99%, and 34.66 ± 26.84% on glomerulus, tubulus, and interstitium, respectively. In controls, apoptosis was not found. In LN: PCNA positivity on tubulus and interstitium were correlated with the activity index (r = 0.768, p < 0.001, r = 0.721, and p < 0.001, respectively). Glomerular PCNA and apoptosis on interstitium and glomerulus were not correlated with the activity index. The activity index also was not correlated with creatinine clearance and daily proteinuria (p = 0.35 for both). At the end of the first year, patients with recovered or stabilized renal function had higher interstitial and tubular PCNA than others in G1 and G2. Conclusion: It can be said that expression of PCNA on renal biopsy was correlated with activity indexes in LN. PCNA may be a prognostic indicator in MPGN and LN. However, apoptosis does not have a predictive value for MPGN and LN.

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.

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.

Multidisciplinary approach for patients with functional and non‐functional adrenal masses and review of the literature

Adrenal incidentalomas are adrenal masses that are discovered by imaging tests performed for other reasons.

An international survey on hypoglycemia among insulin-treated type I and type II diabetes patients: Turkey cohort of the non-interventional IO HAT study

BackgroundLimited real-world data are currently available on hypoglycemia in diabetes patients. The International Operations Hypoglycemia Assessment Tool (IO HAT) study was designed to estimate hypoglycemia in insulin-treated type I (T1DM) and type II (T2DM) diabetes mellitus patients from 9 countries. The data from Turkey cohort are presented here.MethodsA non-interventional study to determine the hypoglycemia incidence, retrospectively and prospectively, in Turkish T1DM and T2DM patients using a 2-part self-assessment questionnaire.ResultsOverall, 2348 patients were enrolled in the Turkey cohort (T1DM = 306 patients, T2DM = 2042 patients). In T1DM patients, 96.8% patients reported hypoglycemic events (Incidence rate [IR]: 68.6 events per patient-year [ppy]), prospectively, while 74.0% patients reported hypoglycemic events (IR: 51.7 events ppy), retrospectively. In T2DM patients, 95.9% patients (IR: 28.3 events ppy) reported hypoglycemic events, prospectively, while 53.6% patients (IR: 23.0 events ppy) reported hypoglycemic events, retrospectively. Nearly all patients reported hypoglycemia during the prospective period.ConclusionsThis is a first patient-reported dataset on hypoglycemia in Turkish, insulin-treated diabetes patients. A high incidence of patient-reported hypoglycemia confirms that hypoglycemia remains under-estimated. Hypoglycemia increased healthcare utilization impacting patients’ quality of life. Hypoglycemia remains a common side effect with insulin-treatment and strategies to optimize therapy and reduce hypoglycemia occurrence in diabetes patients are required.Trial registrationClinicaltrials.gov,NCT02306681 (Date of registration: 12 Nov 2014; retrospectively registered).