Nci 2015 / 1

ISSN 2148 - 4902

NORTHERN CLINICS OF ISTANBUL • İSTANBUL KUZEY KLİNİKLERİ

Vol. 2 • No. 1 • Year 2015

Assessment of aberrations and visual quality differences between myopic and astigmatic eyes before and after contact lens application • Frequency of left atrial dilatation in ischemic stroke • A study

INDEXED IN TURKIYE CITATION INDEX.

exploring knowledge, attitudes and behaviours towards autism among adults applying to a Family Health Center in Istanbul • Knowledge levels of and attitudes to organ donation and transplantation among university students

• Management of strangulated abdominal wall hernias with mesh; early results • Participation of people living in rural areas of Eskisehir province in field researches, and factors affecting their rates of participation •

The effect of sociodemographic and clinical features on mortality in patients with diagnosis of aspiration pneumonia • Three years of retrospective evaluation of skin biopsy results in childhood • Serratia marcessens

infection presenting with papillovesicular rash similar to varicella zoster infection: a case report • A prolapsed intraductal papilloma: a case report • Complicated fronto-orbital mucopyocele presenting

with proptosis: a case report • Neurosyphilis: a case report • A rare cause of acute mechanical intestinal obstruction: strangulated obturator hernia • Cancer in the elderly • An overview of Ebola virus disease

NORTHERN CLINICS OF ISTANBUL İSTANBUL KUZEY KLİNİKLERİ

Editor-in-Chief

Vıce Editors

Bekir Durmus, M.D.

Banu Mesci, M.D. Berna Terzioglu Bebitoglu, M.D. Ender Onur, M.D. Levent Doganay, M.D. Tunc Eren, M.D.

Scientıfıc Commıttee Abdullah Aydın, M.D.

Gulendam Kocak, M.D.

Metin Kapan, M.D.

Alaattin Ozturk, M.D.*

H. Muammer Karakas, M.D.

Muhammed Fatih Onsuz, M.D.*

Ali Ihsan Dokucu, M.D.

Hakan Erdogan, M.D.*

Murat Acar, M.D.

Ali Riza Cenk Celebi, M.D.*

Hale Akbaylar, M.D.

Mustafa Calıskan, M.D.

Ali Rıza Odabas, M.D.

Haluk Vahaboglu, M.D.

Nezih Ozkan, M.D.*

Asiye Kanbay, M.D.

Hamit Okur, M.D.

O. Emek Kocaturk Goncu, M.D.*

Atakan Yesil, M.D.*

Handan Isin Ozisik Karaman, M.D.* Onur S. Goksel, M.D.

Ates Kadioglu, M.D.

Hasan Borekci, M.D.*

Orhan Alimoglu, M.D.

Ayse Cikim Sertkaya, M.D.

Haydar Sur, M.D.

Ozge Ecmel Onur, M.D.

Ayten Kadanali, M.D.

Hilmi Ciftci, M.D.*

Ozlem Guneysel, M.D.

Bekir Atik, M.D.

Hulya Apaydın, M.D.

Ozlem Tanriover, M.D.*

Beyhan Cengiz Ozyurt, M.D.*

Huseyin Bayramlar, M.D.

Recep Alp, M.D.*

Birsen Yurugen, M.D.

Ibrahim Akalin, M.D.

S. Tahir Eren, M.D.

Canan Agalar, M.D.

Ibrahim Ali Ozemir, M.D.*

Sabahat Aksaray, M.D.

Derya Buyukkayhan, M.D.*

Ibrahim Ikizceli, M.D.

Sait Naderi, M.D.

Didem Korular Tez, M.D.

Ihsan Karaman, M.D.

Serhat Citak, M.D.

Dilaver Tas, M.D.

Ilknur Aktas, M.D.

Sevki Erdem, M.D.

Ebru Zemheri, M.D.

Kadriye Avci, M.D.*

Seyhan Hidiroglu, M.D.*

Emine Samdanci, M.D.*

Kamil Ozdil, M.D.

Suayip Birinci, M.D.

Eren Gozke, M.D.

Kaya Sarıbeyoglu, M.D.

Sukran Kose, M.D.

Eren Ozek, M.D.

Kemalettin Koltka, M.D.

Tongabay Cumurcu, M.D.*

Eyup Gumus, M.D.

Lutfullah Orhan, M.D.

Tuba Yavuzsen, M.D.

Fahri Ovali, M.D.

Mahmut Durmus, M.D.

Umut Kefeli, M.D.

Fatma Eti Aslan, M.D.

Mehmet Ali Ozcan, M.D.

Volkan Ince, M.D.*

Ferruh Isman, M.D.

Mehmet Doganay, M.D.

Yasar Bukte, M.D.

Filiz Akyuz, M.D.

Mehmet Eren, M.D.

Yuksel Altintas, M.D.

Fugen Aker, M.D.

Mehmet Kanbay, M.D.

Yurdanur Kilinc, M.D.*

Fusun Mayda Domac, M.D.*

Mehmet Tunca, M.D.

Gozde Kir Cınar, M.D.

Melek Celik, M.D.

*For the first issue of NCI.

NORTHERN CLINICS OF ISTANBUL İSTANBUL KUZEY KLİNİKLERİ YEAR 2015 VOLUME 2 NUMBER 1

p-ISSN 2148 - 4902

Ownership and Accountability for Contents on behalf of the Istanbul Northern Anatolian Association of Public Hospitals

Kemal Memisoglu, M.D.

Publicatıon Manager

Bekir Durmus, M.D.

Publicatıon Coordinators

Neslihan Buyukmurat, M.D.

Umut Elmas

Executive Office

Istanbul Anadolu Kuzey Kamu Hastaneler Birligi Genel Sekreterligi

E5 Karayolu Uzeri, 34752 Atasehir, Istanbul, Turkey

Phone: +90 216 578 78 00

Fax: +90 216 577 40 48 http://www.kuzeyklinikleri.com

e-mail: bilgi@kuzeyklinikleri.com Issued by the Istanbul Northern Anatolian Association of Public Hospitals Indexed in Turkiye Citation Index.

Publisher

Press

KARE PUBLISHING

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Tel: +90 216 550 61 11

Fax: +90 216 550 61 12 http://www.kareyayincilik.com e-mail: kare@kareyayincilik.com

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English Editing by

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Northern Clinics of Istanbul (NCI) is a peer-reviewed journal published triannually by the Istanbul Northern Anatolian Association of Public Hospitals.

Materials published in the Journal is covered by copyright ©2015 NCI. All rights reserved.

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CONTENTS Vol. 2 • No. 1 • Year 2015 VI IX

INSTRUCTIONS FOR THE AUTHORS EDITORIAL

ORIGINAL ARTICLES 1-6

Assessment of aberrations and visual quality differences between myopic and astigmatic eyes before and after contact lens application M. Demir, S. Aydin Kurna, T. Sengor, T. Gencaga Atakan, T. Sahin

7-12

Frequency of left atrial dilatation in ischemic stroke H. C. Misirli, H. T. Yanar, S. N. Erdogan, E. Cevizci Akkilic, D. Ozkan, T. Bayram, O. Araz

13-18

A study exploring knowledge, attitudes and behaviours towards autism among adults applying to a Family Health Center in Istanbul A. Surmen, S. Hidiroglu, H. H. Usta, M. Awiwi, A. S. Oguz, M. Karavus, A. Karavus

19-25

Knowledge levels of and attitudes to organ donation and transplantation among university students O. Ozlem Kose, M. F. Onsuz, A. Topuzoglu

26-32

Management of strangulated abdominal wall hernias with mesh; early results M. Ozbagriacik, G. Bas, F. Basak, A. Sisik, A. Acar, I. Kudas, M. Yucel, A. Ozpek, O. Alimoglu

33-40

Participation of people living in rural areas of Eskisehir province in field researches, and factors affecting their rates of participation O. Ozay, E. Ayhan, M. F. Onsuz, B. Isikli, S. Metintas

41-47

The effect of sociodemographic and clinical features on mortality in patients with diagnosis of aspiration pneumonia M. Ozer, M. Uzunlulu, A. Oguz, O. Kostek, E. Akyer, M. Takir

48-54

Three years of retrospective evaluation of skin biopsy results in childhood S. Ozkanli, E. Zemheri, I. Zindanci, B. Kuru, T. Zenginkinet, A. S. Karadag

case reports 55-58

Serratia marcessens infection presenting with papillovesicular rash similar to varicella zoster infection: a case report A. Bahadir, E. Erduran

59-61

A prolapsed intraductal papilloma: a case report T. Atalay, A. Ozturk, Z. Yananli, O. F. Akinci

62-65

Complicated fronto-orbital mucopyocele presenting with proptosis: a case report M. Z. Berkman, E. Akar, M. U. Akmil, S. Gok

66-68

Neurosyphilis: a case report T. Toptan, B. Ozdilek, G. Kenangil, M. Ulker, F. M. Domac

69-72

A rare cause of acute mechanical intestinal obstruction: strangulated obturator hernia D. Erdogan, M. Gulmez, V. M. Kara, M. A. Uzun, O. Yucel

REVIEWS 73-80

Cancer in the elderly D. Cinar, D. Tas

81-86

An overview of Ebola virus disease A. Kadanali, G. Karagoz

INSTRUCTIONS FOR THE AUTHORS Northern Clinics of Istanbul

- NCI is a peer-reviewed open-access international journal published by the Istanbul Northern Anatolian Association of Public Hospitals. NCI printed three times a year. Free full-text articles in English are available at (www.kuzeyklinikleri.com). The NCI is indexed in Turkiye Citation Index. The journal publishes researches, interesting case reports, letters to the editor, review articles, editorial comments, medical news, guidelines. The journal accepts manuscripts written in Turkish, and English. Opinions presented in published articles by no means represent the official endorsement of the Istanbul Northern Anatolian Association of Public Hospitals.

Manuscripts should be prepared in accordance with the Uniform Requirements for Manuscripts Submitted to Biomedical Journals regularly updated by the International Committee of Medical Journal Editors, available at http:// www.icmje. org.

ARTICLE TYPES Northern Clinics of Istanbul accepts miscellaneous types of articles which will be briefly described below.

Research Articles: NCI accepts original clinical (conducted with healthy subjects or patients) or experimental (human, animal or in-vitro trials) research articles performed in all fields.

Case Reports: NCI publishes reports on interesting, instructive or rarely seen cases.

Review Articles: Reviews are usually invited by the Editors. NCI publishes clinical review articles related to natural course of diseases, updated diagnostic, and therapeutic approaches concerning clinicians, and specialists in basic sciences which encompass genetic, physiologic, and pharmacologic aspects of underlying mechanisms of diseases, and also current reviews about state-of-the art treatment strategies, technologic advancements, and also newly approved drugs.

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Articles in press: Roten L, Derval N, Sacher F, Pascale P, Wilton SB, Scherr D, et al.

Ajmaline attenuates electrocardiogram characteristics of inferolateral early repolarization. Heart Rhythm 2011 Sep 19 [E-pub ahead of print], doi:10.1016/j.hrthm.2011.09.013.

2. Book: Brown AM. Physiology of the liver. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2003.

3. Chapter in book: Anderson JL, Muhlestein JB. The role of infection. In: Theroux P, editor. Acute

coronary syndromes: a companion to Braunwald’s Heart Disease. Philadelphia: W.B. Saunders; 2003. p. 88107.

4. Web page: Nainggolan L. New salt paper causes controversy. Heartwire.

May 3, 2011. Available at: http:// www.theheart.org/article/1220043. do. Accessed: June 12, 2011.

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EDITORIAL

Dear Readers of the Journal of Northern Clinics of Istanbul, We are reuniting with you, our dear readers, with the release of the first issue of the second volume of NCI. I think that we have made an important accomplishment by publication of 3 issues in our first year without any delay. Our achievements within the previoÄąus year further reinforced our self-confidence.

Increasing number of scientific papers have been submitted to us for publication. Peer-reviewers of our journal are also more numerous. I think that we have been rewarded for the efforts, and the resolution of the editorial board, and our staff. As a dedicated team, I hope we will sustain our determination. This year we have also planned to release 3 issues.

Because of increasing number of manuscripts submitted to us, we increased the number of articles of this year’s first issue. With this issue, we are presenting to our readers 8 original articles, 5 case reports, and 2 review articles. Among original articles, evaluation of aberrations, and quality of retinal images before, and after contact lens application in myopic, and astigmatic eyes; incidence of left atrial dilation in ischemic stroke; evaluation of knowledge level, attitudes, and behaviours of the adults related to autism who consulted to a family health care center in Istanbul; knowledge level of university students about organ donation, and transplantation; early-phase outcomes of mesh application for the repair strangulated abdominal wall hernias; factors effective on the participation of the people living in the rural area of Eskisehir in field researches; factors effective on sociodemographic, and clinical features, and mortality in patients hospitalized with the diagnosis of aspiration pneumonia in clinics of internal medicine, and finally skin biopsy results in children can be enumerated.

Original images concerning Marfan syndrome, and giant non-coronary sinus of Valsalva, and skin manifestations emerging as a side effect of imatinib mesylate have been presented to your liking.

Interesting case reports about A case of Serratia Marcessens which progresses with skin rashes resembling varicella infection; a case of prolabed intraductal papilloma; a case with complicated fronto-orbital mucopyelocele who presented with proptosis; a case with neurosyphilis, and a case of strangulated obturator hernia leading to acute mechanical obstruction have been discussed.

Besides 2 review articles, one about cancer in elder people, and the other presenting a general outlook on Ebola virus disease which is a current issue on the agenda have been included in this issue.

We congratulate our authors who contributed to the contents of this issue, as an editorial board, we express our gratitude to our reviewers for their dedication of their valuable time for the evaluation of submitted manuscripts.

Hope to see you in our next issue.

Bekir Durmus, Assoc. Prof. M.D.

Editor-in-Chief

Orıgınal Article

Ophthalmology

North Clin Istanbul 2015;2(1):1-6 doi: 10.14744/nci.2015.87487

Assessment of aberrations and visual quality differences between myopic and astigmatic eyes before and after contact lens application Mustafa Demir1, Sevda Aydin Kurna1, Tomris Sengor2, Tugba Gencaga Atakan1, Tayfun Sahin1 Department of Ophthalmology, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey

1

Department of Ophthalmology, Bilim University Faculty of Medicine, Istanbul, Turkey

2

ABSTRACT OBJECTIVE: To evaluate the aberration and visual quality differences between myopic and astigmatic eyes before and after contact lens application by using corneal aberrometer and low- contrast sensitivity chart.

METHODS: Eighty eyes of 40 patients were included in this study. Patients were divided into two groups as myopic (40 eyes, n=20) and astigmatic groups (40 eyes, n=20). We used aspheric Balafilcon A (Purevision and Purevision Toric Bausch&Lomb, Rochester, USA) lenses for each group. Corneal aberrations and low-contrast sensitivity values were measured and compared for each patient in both groups.

RESULTS: There were no statistically significant differences between myopic and astigmatic groups when we compared low-contrast sensitivity values for both on- and off-eyes. Mean total higher-order aberration (HOA) values for off-eye, were 0.29±0.10 μm, and 0.33±0.10 μm for on-eye in the myopic group, while they were 0.42±0.14 μm in off-eye and 0.37±0.23 μm in on-eye in the astigmatic group. Off-eye mean coma, irregular astigmatism and total higher-order aberration RMS (root-mean-square) values were significantly higher in the astigmatic group compared to the myopic group (p=0.006, p=0.001, p=0.001) but mean on-eye RMS values were not.

CONCLUSION: Myopic and astigmatic patients differ in terms of high-order aberrations and these differences cannot be equalized after contact lens application, but visual quality can be improved in both patients by using contact lenses.

Key words: Astigmatism; contact lens; corneal aberrations; myopia; visual quality.

E

xpansion of wavefront-sensing techniques redefined the meaning of refractive error in clinical ophthalmology [1]. Apart from conventional lower- order aberrations (such as defocus and astig-

matism), retinal images can be degraded by other higher-order aberrations (spherical aberration, coma, and trefoil) [2]. Third order aberrations and upper levels are called as higher-order aberrations

Received: September 23, 2014 Accepted: February 24, 2015 Online: April 24, 2015 Correspondence: Dr. Mustafa Demir. Bartin Devlet Hastanesi Goz Klinigi, Merkez, Bartin, Turkey.

Tel: +90 378 - 227 72 58 e-mail: mustafademir2002@hotmail.com © Copyright 2015 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com

2

and cannot be corrected by spherocylindirical correction [3]. Since introduction of wavefront sensing and other ray tracing technologies, higher-order aberrations can be measured more accurately even in highly aberrated eyes [4, 5]. It is important to quantify higher-order aberrations because they effect visual acuity and retinal image quality [6].

Wearing contact lenses causes changes in the wavefront aberrations of the eye. The changes in wavefront aberrations vary substantially from eye to eye [7]. Developing contact lens technology promises much better retinal image quality by reducing higher-order aberrations [8]. The type and design of contact lens can influence the patient’s quality of vision, as the lens modifies the overall optical characteristics of the visual system and the total amount of astigmatism [9]. Different studies reported different results for both myopic and toric contact lenses about their effects on higher-order aberrations. Hong et al. [10] suggested that soft contact lenses produce significant spherical aberrations,but some other studies reported that aspheric soft contact lenses provide better vision by reducing spherical aberrations [11, 12]. It is important to note that correction of higher-order aberrations is supposed to improve retinal image quality but in practice lack of aberration does not mean best visual performance. For instance Chen et al. reported that visual system works better with its adapted higher-order aberrations which means that it is useless to change aberration at all [13].

In our study, our aim was to evaluate the aberration and visual quality differences between aspheric Balafilcon A spherıc and toric lenses after lens application in the myopic and astigmatic eyes, by using corneal higher-order aberrometer and low- contrast sensitivity chart.

MATERIALS AND METHODS Forty eyes of twenty myopic patients and forty eyes of twenty astigmatic patients were examined in our study and all patients were chosen from the cornea clinic of Fatih Sultan Mehmet Training and Research Hospital between the years 2010 and 2011.

Patients with anterior surface problems, dry eye,

North Clin Istanbul – NCI

retinal diseases, glaucoma and strabismus were excluded. We divided patients into two groups as myopic and astigmatic according to their cylinder value. Patients with more than 0.75 diopters of corneal astigmatism were accepted as astigmatic. All patients were older than 18 years and checked for contrandications for using contact lenses, ocular surface disease, retinal disease, cataract, glaucoma and any eye disease which can compromise retinal image quality. The study protocol followed the tenets of the Declaration of Helsinki. We used aspheric Balafilcon A (Purevision Bausch&Lomb Purevision in the myopic group and Purevision Toric in the astigmatic group) lenses for each group (Table 1).

Corneal wavefront aberrations were measured by dynamic skiascopy type wavefront sensored Nidek Magellan Mapper® corneal topographer. Spherical aberration, coma, trefoil, irregular astigmatism and total higher-order aberrations of mean Root Mean Square (RMS) values were measured and recorded.

Low- contrast sensitivity values were measured as letters which patients could read on Bailey-Lovie chart. In first visit we made full eye exam and determined the best visual refractive correction and best fitting contact lenses for each patient.

After one week usage of best fitting contact lenses, we measured and recorded higher-order aberrations and maximum letter numbers that patients could read on Bailey-Lovie low-contrast sensitivity chart with and without contact lenses. We measured higher-order aberrations in mezopic conditions without dilation and in 5 mm sized pupil for each patient.

Table 1. Features of contact lenses Contact lens

Purevision

Purevision toric

Lens material Balafilcon A Balafilcon A 36% 36% H2O Base curve 8.6 mm 8.7 mm Diameter 14 mm 14 mm Dk/t 112 at -3.00 D 101 at -3.00 D Lens design Aspheric Aspheric

Demir et al., Assessment of aberrations and visual quality differences between myopic and astigmatic eyes

“Statistical Package for Social Sciences for Windows 17.0” (SPSS v 17) program was used to examine the data obtained in this study. Descriptive statistical methods (mean, standard deviation, proportional distribution) were used. Qualitative chi-square test was used when assessing variables.

When assessing the quantitative variables independent samples t-test and paired samples t-test were used. Results were evaluated within 95% confidence interval, and at a significance level of p<0.05.

RESULTS Subjects included in the myopic group (n=20) were between 18 and 36 (24.55±4.63) years of age. In the astigmatic group (n=20) mean age of the patients was 25±4.94 (18-37 yrs) years. The myopic group consisted of 3 male (15%) and 17 female (85%), and astigmatic group comprised of 4 male (20%) and 16 female (80%) patients. Mean spherical refractive errors (not the spheric equivalent) in the myopic, and astigmatic groups were -2.66±1.4 vs -0.37±0.12 diopters, while corresponding mean cylindrical refractive errors were -1.91±1.73, and -1.39±0.50 di-

opters, respectively (p>0.05). Best corrected visual acuity after contact lens fitting was logmar 0.0 both in myopic and astigmatic patients (p>0.05).

The mean number of letters read on Bailey Lovie low- contrast sensitivity chart with, and without contact lenses were 48.82±4.98 vs 12.37±10.66 letters in the myopic group (p=0.001). In the astigmatic group the respective mean low- contrast sensitivity values were 47.22±4.41, and 17.0±13.94 letters, respectively (p=0.001). Statistically significant differences were not detected between myopic and astigmatic groups when we compared low- contrast sensitivity values for both on- and off-eyes, (p>0.05) (Table 2).

The mean corneal wavefront aberration values without contact lenses are shown in Table 3.

The mean spherical aberration RMS values were 0.11±0.14 µm in the myopic, and 0.18±0.22 µm in the astigmatic groups (p=0.111). Mean trefoil values were 0.11±0.07 µm in the myopic, and 0.10±0.05 µm in the astigmatic group (p=0.460).

Mean coma values were 0.14±0.06 µm in the myopic, and 0.19±0.09 µm in the astigmatic groups

Table 2. Comparison of low-contrast sensitivity values off-eye and on-eye according to the groups

Off-eye

On-eye p

Myopic group 12.37±10.66 letters 48.82±4.98 letters Astigmatic group 17±13.94 letters 47.22±4.41 letters p 0.100* 0.132*

0.001** 0.001**

**Paired T Test; *Independent T Test.

Table 3. Comparison of off-eye aberration values according to the groups SPH AB1

3

Coma Trefoil Total HOA’s2

Myopic group 0.11±0.14 µm 0.14±0.06 µm 0.11±0.07 µm 0.29±0.10 µm Astigmatic group 0.18±0.22 µm 0.19±0.09 µm 0.10±0.05 µm 0.42±0.14 µm p 0.111* 0.006* 0.460* 0.001* SPH AB1: Spherical aberration; HOA’s2: High-order aberration; *Independent T Test.

4

North Clin Istanbul – NCI

(p=0.006). Mean total higher-order aberration values were 0.29±0.10 µm in the myopic, and 0.42±0.14 µm in the astigmatic group (p=0.001).

With contact lens the mean corneal wavefront aberration values were as follows (Table 4). The mean spherical aberration RMS values were 0.10±0.17 µm in the myopic, and 0.10±0.23 µm in the astigmatic groups (p=0.85). Mean trefoil values were 0.13±0.09 µm in the myopic, and 0.17±0.12 µm in the astigmatic groups (p=0.20). Mean coma values were 0.16±0.06 µm in the myopic, and 0.20±0.13 µm in the astigmatic groups (p=0.120). Mean total higher-order aberration values were 0.33±0.10 µm in the myopic, and 0.37±0.23 µm in the astigmatic groups (p=0.278).

When we compared the mean RMS values of spherical aberration and trefoil values, we did not observe any statistically significant difference between myopic and astigmatic groups as for on- and off-eyes (p>0.05). Off-eye mean coma and total higher-order aberration RMS values were significantly higher in the astigmatic group relative to the myopic group (p=0.006, p=0.001) but on-eye mean RMS values did not show any statistically significant difference between two groups (p>0.05).

DISCUSSION Myopia and astigmatism constitute major classes of refractive errors [14]. Patients usually suffer from blurred vision and astenopic complaints due to their uncorrected refractive errors. Reducing higher-order aberrations is a new currently entertained phenomenon in ophthalmology aiming at increasing the retinal image quality [3, 8]. Previ-

ous studies showed that HOAs had significant negative correlations with visual performance, and coma-like aberration of the eye significantly influences contrast sensitivity function in normal human eyes [15].

Levy et al. investigated higher-order aberrations in patients with supernormal vision without any correction and found no difference between myopic and normal eyes [16]. In our study we found significantly higher values in coma and total higher-order aberration in astigmatic patients, without contact lens fitting. But after contact lens application, there was no significant difference between myopic and astigmatic groups. Richdale et al. studied low to moderate astigmatic patients wearing toric and spheric equivalent contact lenses and found better results in visual acuity values with toric lenses than spherical lenses [17].

Several studies reported different results about relationships between contrast sensitivity and contact lens which can be attributed to different conditions including contact lens material, contact lens type, adequate fitting of contact lens, and pupil size of the patients. For instance Cox et al. [18] reported in their study that soft contact lenses may induce spherical aberrations which could be the reason of contrast sensitivity loss in 6 mm- sized pupils, Grey et al. [19] reported reductions in contrast sensitivity in the previous soft contact lens wearers whose lenses were made of hydrogel material. Also Wei et al. [20] reported that rigid gas permeable lenses improved visual acuity significantly but contrast sensitivity was reduced in keratokonic patients. We have found a significant increase in low- contrast sensitivity values after contact lens application in

Table 4. Comparison of on-eye aberration values according to the groups SPH AB1 Myopic group Astigmatic group p

Coma Trefoil Total HOA’s2 0.10±0.17 µm 0.16±0.06 µm 0.13±0.09 µm 0.33±0.10 µm 0.10±0.23 µm 0.20±0.13 µm 0.17±0.12 µm 0.37±0.23 µm 0.847* 0.120* 0.202* 0.278*

SPH AB1: Spherical aberration; HOA’s2: High-order aberration; *Independent T Test.

Demir et al., Assessment of aberrations and visual quality differences between myopic and astigmatic eyes

both groups However when we compared on-eye and off-eye results there were no significant differences between the two groups and after contact lens fitting the contrast sensitivity values were sufficient and satisfactory for both goups.

Roberts et al. investigated higher-order aberrations in myopic patients and found that soft contact lenses induced relatively higher-order aberrations, and Lu et al. reported similar results on monochromatic aberrations in human eyes with contact lenses [21, 7]. The induction of wavefront aberrations for soft-CL lenses has been explained by several factors including decentration of the soft-CL relative to the pupil center, surface deformation due to the too-steep base curvature, and a complex interaction between the tear film and the contact lenses on the irregular corneal surface [22, 23]. Lu et al. [7] has also showed that contact lenses induce relatively higher-order aberrations on the eyes that have low wavefront aberrations. Our findings support their findings because we also observed a slight induction of higher-order aberrations in the myopic patients with low level of aberrations while we found a decrease in corneal higher-order aberrations in the astigmatic group with a higher level of baseline corneal higher-order aberrations. In our study, visual acuities and contrast sensitivity values were satisfactory for all of the patients with both aspheric and toric soft lenses.

Our study has several limitations. Firstly, we only evaluated aspheric Balafilcon A lenses in comparison with the toric lenses of the same brand in the astigmatic eyes. Other types of spheric and toric lenses could have yielded different results. Another limitation of our study is our small sample size. Prospective and large- sized studies comparing different types of contact lenses may be helpful in the future.

CONCLUSION Myopic and astigmatic patients differ in terms of high- order aberrations and these differences cannot be equalized after contact lens application, but visual quality can be improved in both patients by using contact lenses.

5

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

REFERENCES 1. Lombardo M, Lombardo G. Wave aberration of human eyes and new descriptors of image optical quality and visual performance.

J Cataract Refract Surg 2010;36:313-31.

2. Marcos S. Aberrometry: basic science and clinical applications.

Bull Soc Belge Ophtalmol 2006;302:197-213.

3. Yoon GY, Williams DR. Visual performance after correcting the monochromatic and chromatic aberrations of the eye. J Opt Soc Am A Opt Image Sci Vis 2002;19:266-75.

4. Liang J, Williams DR. Aberrations and retinal image quality of the normal human eye. J Opt Soc Am A Opt Image Sci Vis 1997;14:2873-83.

5 Moreno-Barriuso E, Marcos S, Navarro R, Burns SA. Comparing laser ray tracing, the spatially resolved refractometer, and the Hartmann-Shack sensor to measure the ocular wave aberration.

Optom Vis Sci 2001;78:152-6.

6. Berntsen DA, Merchea MM, Richdale K, Mack CJ, Barr JT. Higher-order aberrations when wearing sphere and toric soft contact lenses. Optom Vis Sci 2009;86:115-22.

7. Lu F, Mao X, Qu J, Xu D, He JC. Monochromatic wavefront aberrations in the human eye with contact lenses. Optom Vis Sci 2003;80:135-41.

8. Edwards G. Soft lens correction of higher-order aberration Contact Lens Spectrum, Issue: July 2006.

9. Torrents A, Gispets J, Pujol J. Double-pass measurements of retinal image quality in monofocal contact lens wearers. Ophthalmic Physiol Opt 1997;17:357-66.

10. Hong X, Himebaugh N, Thibos LN. On-eye evaluation of optical performance of rigid and soft contact lenses. Optom Vis Sci 2001;78:872-80.

11. De Brabander J, Chateau N, Bouchard F, Guidollet S. Contrast sensitivity with soft contact lenses compensated for spherical aberration in high ametropia. Optom Vis Sci 1998;75:37-43.

12. Harvey B, Long B. The optics of soft toric fitting; vision through contact lenses. Optician 2003;226:20-5.

13. Chen L, Artal P, Gutierrez D, Williams DR. Neural compensation for the best aberration correction. J Vis 2007;7:9.1-9.

14. Rohul J, Maqbool A, Hussain SA, Shamila H, Anjum F, Hamdani ZA. Prevalence of refractive errors in adolescents in out- patient attendees of the preventive ophthalmology Clınıc Of Communıty Medıcıne, Skıms, Kashmır, Indıa. NUJHS 2013;1:17-20.

15. Oshika T, Okamoto C, Samejima T, Tokunaga T, Miyata K. Contrast sensitivity function and ocular higher-order wavefront aberrations in normal human eyes. Ophthalmology 2006;113:1807-12.

16. Levy Y, Segal O, Avni I, Zadok D. Ocular higher-order aber-

6 rations in eyes with supernormal vision. Am J Ophthalmol 2005;139:225-8.

17. Richdale K, Berntsen DA, Mack CJ, Merchea MM, Barr JT. Visual acuity with spherical and toric soft contact lenses in low- to moderate-astigmatic eyes. Optom Vis Sci 2007;84:969-75.

18. Cox I, Holden BA. Soft contact lens-induced longitudinal spherical aberration and its effect on contrast sensitivity. Optom Vis Sci 1990;67:679-83.

19. Grey CP. Changes in contrast sensitivity during the first hour of soft lens wear. Am J Optom Physiol Opt 1986;63:702-7.

20. Wei RH, Khor WB, Lim L, Tan DT. Contact lens characteristics

North Clin Istanbul â&#x20AC;&#x201C; NCI and contrast sensitivity of patients with keratoconus. Eye Contact Lens 2011;37:307-11.

21. Roberts B, Athappilly G, Tinio B, Naikoo H, Asbell P. Higher order aberrations induced by soft contact lenses in normal eyes with myopia. Eye Contact Lens 2006;32:138-42.

22. He JC, Gwiazda J, Thorn F, Held R. Wave-front aberrations in the anterior corneal surface and the whole eye. J Opt Soc Am A Opt Image Sci Vis 2003;20:1155-63.

23. Artal P, Guirao A, Berrio E, Williams DR. Compensation of corneal aberrations by the internal optics in the human eye. J Vis 2001;1:1-8.

Orıgınal Article

neurology

North Clin Istanbul 2015;2(1):7-12 doi: 10.14744/nci.2015.83007

Frequency of left atrial dilatation in ischemic stroke Handan Cemile Misirli1, Havva Tugba Yanar2, Serife Nese Erdogan1, Elvan Cevizci Akkilic3, Duygu Ozkan4, Tamer Bayram1, Ozkan Araz1 Department of Neurology, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey

1

Department of Neurology, Erzurum Horasan State Hospital, Erzurum, Turkey

2

Department of Neurology, Bingol State Hospital, Bingol, Turkey

3

Department of Neurology, Duzce State Hospital, Duzce, Turkey

4

ABSTRACT OBJECTIVE: The study aimed to evaluate the frequency of left atrial dilatation in cases of first-ever acute ischemic stroke with or without atrial fibrillation in a cohort of patients hospitalized for ischemic stroke.

METHODS: Files of 120 patients admitted to our hospital with the diagnosis of acute ischemic stroke were investigated. All patients had at least one brain imaging. Etiology of stroke was categorized according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. Transthoracic and/or transoesophageal echocardiography was used to measure left atrium size. Optimal cut-off value of left atrial diameter was determined as 4 cm. SPSS 11.5 was used for statistical analyses.

RESULTS: In 40% of the patients, left atrial dilatation was detected. Nineteen patients with left atrial dilatation had atrial fibrillation, which was statistically significant (p<0.05). Ninety-four (30.8%) patients with no atrial fibrillation had left atrial dilatation. In the TOAST classification trial, as a statistically significant finding, left atrial dilatation was detected 68.9% of the patients with cardioembolic infarcts. The most frequently encountered risk factor in patients was hypertension.

CONCLUSION: Left atrial dilatation is an important marker for cerebrovascular diseases, and if accompanied by atrial fibrillation becomes even more significant.

Key words: Atrial fibrillation; echocardiography; ischemic stroke; left atrial dilatation.

A

lthough established risk factors for ischemic stroke are well-known, a specific cause remains undefined in up to 12% of the patients who experienced an acute event, even with a full diagnostic evaluation [1, 2]. Echocardiographically determined

left atrial dilatation (LAD) has been shown to be a significant predictor of cardiovascular and cerebrovascular outcomes. It is strongly associated with an increased risk of atrial fibrillation (AF), which is a major risk factor stroke [3, 4]. It has been also as-

Received: December 05, 2014 Accepted: December 30, 2014 Online: April 23, 2015 Correspondence: Dr. Handan Cemile Mısırlı. Haydarpasa Numune Egitim ve Arastirma Hastanesi, Noroloji Anabilim Dali, Istanbul, Turkey.

Tel: +90 216 - 542 32 32/1423 e-mail: handanmisirli@yahoo.com © Copyright 2015 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com

8

sociated with hypertension (HT) and thrombus formation. In this study, we aimed to echocardiographically evaluate the frequency of LAD in patients with first-ever acute ischemic stroke with or without atrial fibrillation.

MATERIALS AND METHODS Files of 865 patients who were admitted to the Neurology Department of our hospital with a first-ever in life acute ischemic stroke experienced between the years of 2009 and 2012 were investigated. Of those, 120 patients aged above 45 were included in the study. We excluded the patients if they had a previous ischemic or hemorrhagic stroke, vasculitis and sinus thrombosis. Ischemic stroke was defined as clinical signs of focal cerebral dysfunction of presumed ischemic origin lasting more than 24 hours [5].

Clinical information including age, sex, history of smoking, alcohol consumption, dyslipidemia, diabetes mellitus, cardiac disease, presence of hypertension, peripheral artery disease, history of stroke in the family, obstructive sleep apnea syndrome and prestroke use of antiaggregants and/or statins were noted.

Hypertension (HT) was considered to be present if at the time of the diagnosis subjects had a systolic blood pressure (BP) 140 Mm Hg or a diastolic BP 90mmHg, and if treatment for high blood pressure was administered previously. Diabetes mellitus (DM) was considered to be present if the subjects had a serum level of glucose >110 mg /dl or if treatment had been previously initiated for hyperglicemia. Patients with abnormal levels of total cholesterol (≥200 mg/dl), HDL-C (men, ≤40 mg/ dl; women ≤50 mg/dl), LDL-C (≥130 mg/dl), and triglyceride (>150 mg/dl), and those on antihyperlipidemic treatment were accepted as having dyslipidemia (DSL). Cardiac disease was considered to be present if cardiac pathology had been observed at the time of the diagnosis or if the subjects had a history of atrial fibrillation, myocardial infarction, angina pectoris, by-pass surgery and severe (>50%) coronary artery stenosis.

Patients were assessed by a complete physical and neurological examination, routine hematological,

North Clin Istanbul – NCI

biochemical and microbiological analyses, chest Xrays, 12-lead electrocardiography, Doppler ultrasonography and echocardiography. In patients without any risk factors, transoesophageal echocardiography was performed after transthoracic echocardiography. All patients had at least one brain imaging.

Brain computed tomography, and MRI scan scans were performed in 100, and 46% of the patients, respectively.

Stroke subtypes were determined based on a modified Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification system [6].

Standard transthoracic echocardiography was performed in all patients using Vivid Three System within 72 h of their admissions. Standard views in the left lateral decubitus and supine positions, were obtained [7].

Echocardiography results of the patients were analyzed to determine the presence of LAD. Left atrial diameters were assessed statistically. LADs were classified as mild (men, 4.1-4.6 cm or women, 3.9-4.2 cm), moderate (men, 4.7-5.1 cm or women, 4.3-4.6 cm) or severe dilated (men, >5.2 cm or women, 4.7 cm) in accordance with the recommendations of the American Society of Echocardiography [7, 8].

The cut-off threshold value was found to be 4 cm, and diameters above that threshold were considered to represent LAD. The study protocol was presented to the regional ethics committee and the board gave approval for the study.

SPSS 11.5 was used for statistical analyses. Continuous variables were represented as mean ± standard deviation and median, while categorical variables were represented as numbers and percentages.

Mann-Whitney U Test, and Kruskal-Wallis Test were used to compare continuous, and categorical variables, respectively.

Chi–square test was used to define the differences between groups. Level of statistical significance was set at p<0.05.

RESULTS In this study, 120 patients (65 male, 55 female) eval-

Misirli et al., Frequency of left atrial dilatation in ischemic stroke

DISCUSSION Cerebrovascular diseases are the second leading cause of death in our country, accounting for 15% of all deaths. Loss of ability is the third one with a rate of 5.9% [9].

Predicting outcome and mortality is important in acute ischemic stroke for optimizing care and treatment decision. The etiology of ischemic stroke effects its prognosis, outcome and management [9, 10]. Despite significant achievement in the diagnosis and treatment of stroke, it is still difficult to diagnose ischemic stroke subtypes at admission and predict mortality [11, 12].

Table 1. Distribution of risk factors Risk factors

Left atrial dilatation

Hypertension

DM*

AF≠

Smoking§

Dyslipidemia

Thrombosis

Secǁ

Heart disease

n

%

Yes No

86 71.7 34 28.3

Yes No

40 33.3 80 66.6

Yes No

26 21.0 94 78.3

Yes No

42 35.0 78 65.0

Yes No

29 24.0 91 75.8

Yes No

2 1.6 118 98.3

Yes No

5 4.1 115 95.8

Yes No

24 19.9 216 81.1

Diabetes mellitus; ≠Atrial fibrillation; §Smoking; ǁSpontaneous echo contrast.

*

Mean age of the patients (years)

uated in our department without any statistical significance between genders (p>0.05). The mean age was 68.7 years (standard deviation 10.9). The most common risk factor was HT (71.7%), followed by diabetes mellitus (DM) (66.6%).The other risk factors are shown in Table 1.

Patients were distributed into two groups as those with or without LAD. Of 120 patients, 48 (40%) had LAD. Patients with LAD composed of 26 men (54.2%) and 22 women (45.2%) with no statistical significance between them. Mean ages of male, and female patients were 67.8, and 75.6 years, respectively with a statistically significant difference between genders (p<0.05).

Nineteen patients with LAD had AF which was statistically significant (p<0.05) (Figure 1). On the other hand, 94 (30.8%) patients without AF had LAD (Table 2).

According to the investigation done based on TOAST classification, large-artery atherosclerosis (LAAS) (n=20), cardioembolic infarcts (CE) (n=45), lacunary infarcts (LAC) (n=28) and LAD of undetermined origin (n=27) were identified.

LAD was found in patients with LAAS (20%), CE (68.9%), LAC (28.5%), and diseases yet undetermined origin (18.5%) (Figure 2). According to TOAST classification the frequency of LAD in the CE group was significantly higher (p<0.01) compared to the other groups.

9

76 74 72 70 68 66 64 62

Male

Female

Figure 1. Mean age of male and female patients with atrial dilatation.

10

Table 2. Relationship of left atrial dilatation and af Left atrial dilatation Yes No AF* Yes n 19 7 % 39.58 9.72 No n 29 65 % 60.42 90.28 Total n 48 72 % 100 100 Atrial fibrillation.

*

Number of patients with left atrial dilatation

Twenty percent of ischemic strokes have cardiological origin and their clinical status is more severe and has a higher risk of recurrence in the short term follow-up compared to the other stroke groups [12, 13]. Even in 50% of those people who die from a heart disease, cerebral infarction has been found in the autopsy findings. Based on this strong evidence, echocardiography is a preferred method for evaluating patients who may have had a cardioembolic stroke [14, 15]. In our study, cardioembolic group had the highest number of patients and LAD had the significantly higher incidence (68.9%) in the cardioembolic group.

Besides many other cardiovascular risk factors, left atrial dilatation also increased stroke and AF risks as reported in some recent studies [16, 17].

The etiology of stroke risk is not so clear, but there are some potential mechanisms that have been proposed. One of them is that LAD is a strong risk factor for AF or paroxysmal AF and this relationship increases the occurrence of stroke. Another probable explanation is that in the existence of LAD, left atrial mean velocity is decreased and spontaneous echo contrast (SEC) or development of thrombosis may be seen in the left atrium [18, 19, 20]. In this study, we found four SEC and two thrombi in the echocardiograms of our patients with no statistical significance. Another study showed that the association of LAD with premature ventricular heart beats increased the stroke risk [21].

Atrial fibrilation is a frequently encountered arrhytmia associated with increased morbidity and mortality. Several large population-based studies have shown a strong association between LAD and the risk of new-onset AF [4, 22, 23]. In the Framingham Heart Study, every 5 mm increase in the left atrial diameter increased the development of AF by 39%. Cardiovascular Health Study showed a fourfold increase in the risk of AF with left atrial diameter of >0.5 mm. In our study, 19 (39.5%) patients with LAE had AF and the result was statistically significant (p<0.05).

In many studies, it was considered that there could be a relationship between left atrial dilatation and HT. It is not so clear if this relates to left ventricular hyperthrophy or there is a direct rela-

North Clin Istanbul â&#x20AC;&#x201C; NCI

35 30 25 20 15 10 5 0

Large artery Cardioembolic atherosclerosis

Lacunary

Undetermined origin

Yes 4 31 8 5 No 16 14 20 22

Figure 2. Distribution of left atrial dilatation according to TOAST classification.

tionship between HT, and left atrila dilatation [24].

Left atrial dilatation, left atrial volume indexes and the distance between left atrium and aortic root were found to be significantly higher in the hypertensive patients than the normotensive people [16, 23, 25]. With its thin wall, left atrium dilates easily. As a result of this, LAD in echocardiography may be evaluated as an early finding of hypertensive heart disease [3, 7, 26]. Although the Framingham Study risk profile is useful and includes well-recognized stroke risk factors- like age, HT, DM, smok-

Misirli et al., Frequency of left atrial dilatation in ischemic stroke

ing- many people have suffered from strokes despite low risk profile score. In our study, 38 out of 86 patients with HT had LAD and this result was not statistically significant (p=0.01). Other known risk factors also didn’t have any significance. In another study, it was shown that HT with diastolic dysfunction causes chronic left ventricular filling pressure and left atrial remodeling [18, 27].

Bouzas-Mosquera and colleagues described an independent association between left atrial size on echocardiography and stroke risk solely in women [28]. However prior studies reported a similar relationship between left atrial size and ischemic stroke risk only in men [3, 29, 30]. In our study, there was no relationship between the gender and the stroke risk with LAD. On the other hand, mean age of the women who had stroke risk was higher than men, carrying a risk for stroke without any statistical significant difference between genders. Ninety-four patients with LAD didn’t have AF which indicates that apparent relationship between left atrial size and stroke does not invariably involve AF [31]. In our study, we detected significant involvement of AF in cardioembolic strokes. In our country Takoğlu, et al. observed also the same result in the undetermined LAD group (p<0.038) [32].

Some studies using left atrial volume-instead of left atrial dilatation-have predicted AF in elderly patients [22, 33]. Recently, in elderly patients without AF at baseline, left atrial volume indexes >32mL/ m2 were independently predictive of a first ischemic stroke. A recent prospective study has found that not only the maximum but also the minimum left atrial volume were independent predictors of first AF [33]. We couldn’t measure the left atrial volume in our study.

Our study has some limitations. Firstly, the number of stroke patients included in the study was relatively small, and the patients were randomly selected. Secondly, we couldn’t investigate paroxysmal AF with at least 24-hour ECG monitoring, so AF frequency may be lower than expected in our study.

Thirdly, we didn’t evaluate left atrial volume indexes relative to body surface area or body height, since recent literatures concerning left atrial size have emphasized the importance of the left atrial volume

11

rather than the left atrial dilatation. In conclusion, LAD is poorly linked with risk factors of stroke.

Atrial fibrillation is seen at a large extent in cardioembolic strokes and LAD is associated significantly with AF, but AF is not a prerequisite for stroke development. We haven’t found any relationship between gender of the patients and the stroke risk. It would be ideal to perform these studies with larger number of ischemic stroke patients in the future with special emphasize on atrial volume.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

REFERENCES 1. Amarenco P, Bogousslavsky J, Caplan LR, Donnan GA, Hennerici MG. Classification of stroke subtypes. Cerebrovasc Dis 2009;27:493-501.

2. D’Agostino RB, Wolf PA, Belanger AJ, Kannel WB. Stroke risk profile: adjustment for antihypertensive medication. The Framingham Study. Stroke 1994;25:40-3.

3. Benjamin EJ, D’Agostino RB, Belanger AJ, Wolf PA, Levy D. Left atrial size and the risk of stroke and death. The Framingham Heart Study. Circulation 1995;92:835-41.

4. Sanfilippo AJ, Abascal VM, Sheehan M, Oertel LB, Harrigan P, Hughes RA, et al. Atrial enlargement as a consequence of atrial fibrillation. A prospective echocardiographic study. Circulation 1990;82:792-7.

5. Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S, et al. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011;42:517-84.

6. Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke.

Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993;24:35-41.

7. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005;18:1440-63.

8. Lerakis S, Nicholson WJ. Part I: use of echocardiography in the evaluation of patients with suspected cardioembolic stroke. Am J Med Sci 2005;329:310-6.

9. Ozturk S. Epidemiology of cerebrovascular diseases and risk

12 factors-perspectives of the world and Turkey. Turk J Geriatr 2009;13:51-8.

10. Ferro JM. Cardioembolic stroke: an update. Lancet Neurol 2003;2:177-88.

11. Biteker M, Ozden T, Dayan A, Tekkeşin AI, Mısırlı CH. Aortic stiffness and plasma brain natriuretic peptide predicts mortality in acute ischemic stroke. Int J Stroke 2013.

12 Murtagh B, Smalling RW. Cardioembolic stroke. Curr Atheroscler Rep 2006;8:310-6.

13. Lee LJ, Kidwell CS, Alger J, Starkman S, Saver JL. Impact on stroke subtype diagnosis of early diffusion-weighted magnetic resonance imaging and magnetic resonance angiography. Stroke 2000;31:1081-9.

14. Michel P, Odier C, Rutgers M, Reichhart M, Maeder P, Meuli R, et al. The Acute STroke Registry and Analysis of Lausanne (ASTRAL): design and baseline analysis of an ischemic stroke registry including acute multimodal imaging. Stroke 2010;41:2491-8.

15. Rauh R, Fischereder M, Spengel FA. Transesophageal echocardiography in patients with focal cerebral ischemia of unknown cause. Stroke 1996;27:691-4.

16. Kim BS, Lee HJ, Kim JH, Jang HS, Bae BS, Kang HJ, et al. Relationship between left atrial size and stroke in patients with sinus rhythm and preserved systolic function. Korean J Intern Med 2009;24:24-32.

17. Nagarajarao HS, Penman AD, Taylor HA, Mosley TH, Butler K, Skelton TN, et al. The predictive value of left atrial size for incident ischemic stroke and all-cause mortality in African Americans: the Atherosclerosis Risk in Communities (ARIC) Study.

Stroke 2008;39:2701-6.

18. Giménez DM, Torres F, Franco M, Vivancos R, Anguita M, Granados AL, et al. An analysis of the factors and phenomena associated with the formation of a spontaneous echo contrast in the left atrium. [Article in Spanish] Rev Esp Cardiol 1994;47:181-6.

[Abstract] 19. Rossi A, Cicoira M, Zanolla L, Sandrini R, Golia G, Zardini P, et al. Determinants and prognostic value of left atrial volume in patients with dilated cardiomyopathy. J Am Coll Cardiol 2002;40:1425.

20. Chimowitz MI, DeGeorgia MA, Poole RM, Hepner A, Armstrong WM. Left atrial spontaneous echo contrast is highly associated with previous stroke in patients with atrial fibrillation or mitral stenosis. Stroke 1993;24:1015-9.

21. Cozma DC, Mornos C, Ionac A, Petrescu L, Tutuianu C, Dragulescu SI. Institute of Cardiovascular Medicine-Timisoara-

North Clin Istanbul – NCI Romania. Left atrial dilatation and shape remodeling in frequent premature ventricular contraction: a possible explanation for stroke risk. Eur J Echocardiography Abstracts Supplement 2011;12:2.

22. Barnes ME, Miyasaka Y, Seward JB, Gersh BJ, Rosales AG, Bailey KR, et al. Left atrial volume in the prediction of first ischemic stroke in an elderly cohort without atrial fibrillation. Mayo Clin Proc 2004;79:1008-14.

23. Tsang TS, Barnes ME, Bailey KR, Leibson CL, Montgomery SC, Takemoto Y, et al. Left atrial volume: important risk marker of incident atrial fibrillation in 1655 older men and women.

Mayo Clin Proc 2001;76:467-75.

24. Gerdts E, Wachtell K, Omvik P, Otterstad JE, Oikarinen L, Boman K, et al. Left atrial size and risk of major cardiovascular events during antihypertensive treatment: losartan intervention for endpoint reduction in hypertension trial. Hypertension 2007;49:311-6.

25. Patel DA, Lavie CJ, Milani RV, Shah S, Gilliland Y. Clinical implications of left atrial enlargement: a review. Ochsner J 2009;9:191-6.

26. Pritchett AM, Mahoney DW, Jacobsen SJ, Rodeheffer RJ, Karon BL, Redfield MM. Diastolic dysfunction and left atrial volume: a population-based study. J Am Coll Cardiol 2005;45:87-92.

27. Vaziri SM, Larson MG, Benjamin EJ, Levy D. Echocardiographic predictors of nonrheumatic atrial fibrillation. The Framingham Heart Study. Circulation 1994;89:724-30.

28. Bouzas-Mosquera A, Broullón FJ, Álvarez-García N, Méndez E, Peteiro J, Gándara-Sambade T, et al. Left atrial size and risk for all-cause mortality and ischemic stroke. CMAJ 2011;183:65764.

29. Di Tullio MR, Sacco RL, Sciacca RR, Homma S. Left atrial size and the risk of ischemic stroke in an ethnically mixed population.

Stroke 1999;30:2019-24.

30. Goldstein LB. Left atrial enlargement: a cause of stroke? CMAJ 2011;183:1129-30.

31. Khidhir AJ, Al-Shimmery EK, Alwan MH. Are left atrial abnormalities a risk for stroke? Neurosciences (Riyadh) 2010;15:21-6.

32. Takoğlu A, Can U. Left atrial dilatation in undetermined group according to TOAST classification: echocardiographic assessment of stroke patients. Turk J Med Sci 2013;43:957-62.

33. Fatema K, Barnes ME, Bailey KR, Abhayaratna WP, Cha S, Seward JB, et al. Minimum vs. maximum left atrial volume for prediction of first atrial fibrillation or flutter in an elderly cohort: a prospective study. Eur J Echocardiogr 2009;10:282-6.

Orıgınal Article

Public Health

North Clin Istanbul 2015;2(1):13-18 doi: 10.14744/nci.2015.83723

A study exploring knowledge, attitudes and behaviours towards autism among adults applying to a Family Health Center in Istanbul Aysen Surmen1, Seyhan Hidiroglu1, Hamide Hande Usta1, Muhammed Awiwi1, Ahmet Saki Oguz1, Melda Karavus1, Ahmet Karavus2 Department of Public Health, Marmara University Faculty of Medicine, Istanbul, Turkey

1

Department of Otorhinolaryngology, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey

2

ABSTRACT OBJECTIVE: The aim of this study was to assess knowledge, awareness, behavior and attitudes towards autism among applicants to a Family Health Center (FHC).

METHODS: This descriptive study was performed at a Family Health Center (FHC) in Istanbul in August 2013.

Data was obtained via face-to-face interviews with participants older than 18 years who were admitted to the FHC. The questionnaire consisted of questions on sociodemographic characteristics, applicants’ knowledge of autism and their approach to autism.

RESULTS: 160 applicants participated in our survey of which 38.8% had heard the word ‘autism’. Knowledge and awareness of autism, and attitudes and behaviours towards this disorder differed significantly with the educational level of the study participants (p<0.05) However, these parameters did not change with gender and income level of the participants (p>0.05).

CONCLUSION: The most important outcome of our study is that awareness, or even having knowledge of the word autism is significant in breaking down stereotypes. Despite the low level of awareness of the disease, the majority of the participitants had a positive attitude towards autism.

Key words: Autism; awareness; education; knowledge.

A

utism disorder was first described in 1943 by the American child psychologist, Leo Kanner.

He presented 11 children whose behaviours were obviously different from those of others. Kanner suspected that they had an inborn feature which had prevented their regular social contacts. Autism disorder is sometimes referred as early infantile au-

tism, childhood autism or Kanner’s autism [1].

Autism is a disorder of neural development, characterized by impaired social interaction, communication, and by restricted, repetitive behaviors.

This condition onsets at birth or within the first two-and-a-half years of life [2]. Even though behavioural differences become manifest before the age of

Received: December 05, 2014 Accepted: March 16, 2015 Online: April 24, 2015 Correspondence: Dr. Aysen Surmen. Marmara Universitesi Halk Sagligi Anabilim Dali, Maltepe Basibuyuk Kampusu, Maltepe, Istanbul, Turkey.

Tel: +90 216 - 421 22 22 e-mail: aysurmen@hotmail.com © Copyright 2015 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com

14

2, diagnosis is usually made at 3 years of age or above [3]. Although etiology, and pathogenesis are not fully acknowledged, and completely elucidated, various genetic, prenatal, early postnatal, microbiological, biochemical, and environmental factors have been implicated in the etiopathogenesis of autism [4, 5].

In the last decade, the prevalence of autism had risen dramatically. Based on CDC (Centers for Disease Control, and Prevention) estimates from 2009 autism is seen in 1 of every 110 children. The CDC has recently reported an increase in the estimates up to 1 in every 88 children, acknowledging that “the extent to which these increases reflect better case ascertainment whether as a result of increases in awareness and access to services or true increases in the prevalence of autism spectrum disorder (ASD) symptoms is not known” [6].

Probable causes of increases in prevalence include expanded diagnostic criteria, and increased awareness of the disease [7]. Knowledge and awareness of the condition have grown exponentially at all levels among general public, parents, health professionals, research community and more recently, at a parliamentary level [8]. The World has begun to recognize the scope of this problem and acted internationally and locally to improve the lives of the growing number of individuals and families affected by this devastating disorder [1].

Nowadays, diagnosis of autism has been more frequently made. Early diagnosis is quiet important with respect to rehabilitation alternatives, and longterm responses [6]. In the early diagnosis, knowledge level, and awareness of the public carry utmost importance. Our aim in this study is to evaluate knowledge levels, attitudes, behaviours and awareness of adults about autism who consulted to FHC for any symptom.

This study was carried out on 160 adults applying to a Family Health Center in Istanbul aiming to investigate their awareness about autism.

MATERIALS AND METHODS The study was designed as a descriptive study. This questionnaire study was realized in a FHC in a

North Clin Istanbul – NCI

county of Istanbul in August 2013 after approval from the Ethics Committee was obtained. Patients, their intimates, and attendants aged over 18 were informed about the study, and those volunteered to participate in the study were enrolled in the study after their verbal approvals were obtained. Data were gathered during face-to-face interviews. The questionnaire forms applied for participants contained a total of 62 questions aiming at determination of sociodemographic characteristics (n=5 questions), knowledge levels of the participants about autism (n=49 questions prepared based on DSM-IV diagnostic criteria), and their attitudes towards autism (n=8 questions).

For statistical analysis of data SPSS 17.0 program was used. In descriptive analysis, data were expressed as frequencies, ratios and means. In intergroup comparisons for categorical variables, Kolmogorov-Smirnov and chi-square tests were used. The results were evaluated at accepted level of significance of p<0.05, and within 95% confidence interval.

Since our study was performed within a limited time period on adult patients applied to only one FHC, we can not generalize the results obtained for the population in general.

RESULTS A total of 160 individuals (female, n=99; 61.9%, and male, n=61; 38.1%) with a mean age of 34.5±12.5 years participated in the study. The participants were illiterate (28.2%), primary (28.8%), secondary school, and high school (42.5%), and university (11.9%) graduates. Monthly income of the participants was 0-1000 (11.9%), 1001-3000 (73.6%), and ≥3001 (14.4%) Turkish liras. Four participants had autistic patients in their families, while 18 participants had close friends with autism. Sixtytwo (38.8%) participants heard the word ‘autism’ (female, 37%, and male, 41%). A statistically significant correlation was not found between gender, income level, and the number of participants who heard the word ‘autism’ (p>0.05). A statistically significant correlation was found between educational level, and the number of participants who heard the

Surmen et al., A study exploring knowledge, attitudes and behaviours towards autism among adults

word ‘autism’ (p<0.05) (Table 1).

When participants who heard the word ‘autism’ were asked about the diagnosis of autism, they described autism as a kind of mental retardation (46.8%), a social communication gap (27.4%), a speech disorder (12.9%), weird repetitive movements (8.1%), and 4.8% of them said that they had no idea about it.

Having heard about the word ‘autism’, and knowing its characteristics were compared, and those who heard the word ‘autism’ frequently responded affirmatively to the questions about autism, while participants who hadn’t heard this word responded on the contrary. The difference between these two groups was statistically significant (p<0.05). The participants who heard the word ‘autism’ (48.4%) were asked to choose the accurate definition of autism”. The individuals with autism had distinct nonverbal behavioural disorders involving eye contact with people, facial gestures, and expression, body postures, and body language they use during their social interactions’. However a statistically significant difference was not detected between participants who heard or didn’t hear the word ‘autism’ regarding responses to the questions concerning etiology of autism, potentially related health problems, subjective field, gender difference and curability of autism with treatment.

In our investigation, statistically significant differences were not found between opinions of participants about patients with autism, and either gender or income level (p>0.05).

When responses to questions inquiring attitudes towards autism including ‘Do you feel anxious when your neighbour next door is an autistic patient?’ were compared, participants who heard about autism (p=0.304), and those with higher level of education (p=0.001) responded more frequently as ‘No, I don’t mind (Table 2).

The response ‘I don’t feel uneasy if an autistic person is working in my workplace’ was given by 50, and 29.6% of the participants who heard, and did not hear the word ‘autism’ respectively (p=0.045).

The question ‘Do you mind if your child share the same classroom with an autistic child?’ was responded negatively by 36 participants, while a statistically significant difference was not found between responses of the study subjects who heard, and did not hear the word ’autism’ (p=0.282). As educational level increases, the number of people who responded affirmatively also increases statistically significantly (p<0.001) (Table 3). Higher number of people who heard the word ‘autism’ said that if an autistic person sits next to them in the bus, they would not change their place or scare when compared to those who didn’t know this word (p<0.05).

Table 1. Awareness of autism according to the educational level of the participants Educational level

Yes

Awareness of autism No

Total

n % n % n %

Illiterate Literate Primary school Secondary school High school University Total

0 0 9 100.0 9 100 ap<0.001 5 27.8 13 72.2 18 100 ax2 10 21.7 36 78.3 46 100 12 33.3 24 66.7 36 100 19 59.4 13 40.6 32 100 24.456 16 84.2 3 15.8 19 100 62 38.8 98 61.2 160 100

: Kolmogorov-Smirnov test was used; Dmax: 0.401.

a

15

16

North Clin Istanbul – NCI

Table 2. Approach to autism according to educational level of the participants, and autism awareness

Do you worry if your neighbour were an autistic individual?

Yes

Have you heard of autism?

Yes (n=62)

No (n=98) Educational level

Illiterate (n=9)

Literate (n=18) Primary school (n=46) Secondary school (n=36) High school (n=32)

University (n=19)

Partially

No

I don’t know

n % n % n % n %

14 22.6 14 22.6 31 50.0 3 4.8 ap=0.304 22 22.4 32 32.7 27 27.6 17 17.3 ax2=2.377 0 6 14 9 4 3

0.0 3 33.3 2 22.2 4 44.4 bp=0.001 33.3 3 16.7 5 27.8 4 22.2 b 2 30.4 13 28.3 15 32.6 4 8.7 x =22.680 25.0 14 38.9 7 19.4 6 16.7 DF=6 12.5 9 28.1 17 53.2 2 6.2 15.8 4 21.1 12 63.2 0 0.0

a : Kolmogorov-Smirnov test was used and Dmax: 0.125; b: Chi square test was used, p value and x2 values were estimated by integrating illiterate vs literate, primary vs secondary education, and High school vs university groups in a table with 3 rows.

In our investigation, study participants who heard the word’autism’ responded affirmatively to the questions about their attitudes towards autistic persons, and most of these responses were

statistically significant. This outcome can be interpreted as even having heard the word ‘autism’ effects the attitude towards autistic individuals positively (p<0.05).

Table 3. Approach to autism according to educational level of the participants, and awareness about autism

Have you heard of autism?

Yes (n=62)

No (n=98) Educational level

Illiterate (n=9)

Literate (n=18) Primary (n=46)

Secondary (n=36) High school (n=32) University (n=19)

Do you mind if your child share the same classroom with an autistic patient?

Yes

Partially

No

I don’t know

n % n % n % n %

13 21.0 10 16.1 32 51.6 7 11.3 ap=0.282 23 23.5 26 26.5 31 31.6 18 18.4 ax2=2.529 0 0.0 3 33.3 1 11.1 5 55.6 bp<0.001 5 27.8 3 16.7 4 22.2 6 33.3 b 2 15 32.6 9 19.6 19 41.3 3 6.5 x =25.693 8 22.2 13 36.1 9 25.0 6 16.7 DF=6 4 12.5 4 12.5 20 62.5 4 12.5 4 21.1 4 21.1 10 52.6 1 5.3

a : Kolmogorov-Smirnov test and Dmax: 0.129; b: Chi square test was used, p value and x2 values were estimated by integrating illiterate vs literate, primary vs secondary education, and High school vs university groups in a table with 3 rows.

Surmen et al., A study exploring knowledge, attitudes and behaviours towards autism among adults

DISCUSSION Only 38.8% of the study participants heard the word ‘autism. In a study performed in France its incidence was 100 percent [9]. In a study, Wilson indicated that 69% of the parents had heard the word ‘autism [10]. Although our study did not evaluate the socioeconomic level of the community fully, in our field of study which might be considered as a region of relatively lower socioeconomic level. Within this context, when compared with other similarly designed studies, relatively lesser number of our study participants who heard the word ’autism’ might be associated with lower socioeconomic level of our study population.

In our study, 37% of women, and 41% of men had heard the word ‘autism’. In a study performed in France, higher incidence of awareness for autism was detected among women [9]. This difference might stem from educational level, and social status of female gender in our country. As educational level of the community increased, incidence of autism awareness significantly rised. Education contributes to the rising trends in autism awareness, and enables early diagnosis, and treatment among educated people, and their environment. Education can prevent prejudice against autistic individuals in the community. Majority of the participants stated that they wouldn’t feel uneasy if an autistic individual was present in their environment, workplace or classroom of their children. This phenomenon might stem from favourable viewpoints of the participants about autism or their higher level of awareness.

The questions which evaluated reactions of the participants when they met autistic individuals including ‘Do you scare or rise, and sit in another place when an autistic person sits next to you?’ were responded as “No, I don’t mind!” At the same time the questions ‘Do you behave them as normal individuals? Do you feel pity for them?’ were responded as ‘Yes, I do’ By higher majority of par ticipants.

These affirmative responses demonstrate positive approaches of the participants. However the proper approach may be to emphatize with autistic individuals, and their families, and contribute to their social development. Indeed treatment of autistic in-

17

dividuals will be possible by reintegrating them into the society. A study which integrates groups with and without autism in sportive, cultural, and art activities were observedly beneficial for both groups, and also contributed to alleviation of social, and communicative difficulties [11].

According to the results of our investigation, the individuals who heard the word ‘autism’ because of the presence of an autistic individual in their close environment, and those with higher educational level because of increased level of consciousness towards all diseases, may be less prejudiced towards autism. Besides they are more inclined to share the same social environment with them.

With these approaches, socialization of especially autistic children, and thus their treatment will be facilitated.

In conclusion, when perspectives and approaches of the participants towards autism were evaluated generally an affirmative outcome has been obtained.

The most important outcome of our study is that even having heard the word’autism’ has been statistically significantly effective in breaking prejudices against autism from many perspectives. This promising situation will cherish our hopes in that programs, and efforts aiming at initiation, promotion, and development of health education, which will be implemented so as to increase awareness, and consciousness towards autism will be welcomed favourably, and yield quick responses.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

REFERENCES 1. J U, M M V, J P, Srinivasan I. Autism Disorder (AD): An Updated Review for Paediatric Dentists. J Clin Diagn Res 2014;8:275-9.

2. Arif MM, Niazy A, Hassan B, Ahmed F. Awareness of autism in primary school teachers. Autism Res Treat 2013;2013:961595.

3. Mandell DS, Novak MM, Zubritsky CD. Factors associated with age of diagnosis among children with autism spectrum disorders. Pediatrics 2005;116:1480-6.

4. Bryson SE. Brief report: epidemiology of autism. J Autism Dev Disord 1996;26:165-7.

18 5. Herbert MR. Autism: A brain disorder or a disorder that affects the brain? Clin Neuropsychiatr 2005;2:354-79.

6. Manning-Courtney P, Murray D, Currans K, Johnson H, Bing N, Kroeger-Geoppinger K, et al. Autism spectrum disorders.

Curr Probl Pediatr Adolesc Health Care 2013;43:2-11.

7. King M, Bearman P. Diagnostic change and the increased prevalence of autism. Int J Epidemiol. 2009;38:1224-34.

8. Dover CJ, Le Couteur A. How to diagnose autism. Arch Dis Child 2007;92:540-5.

9. Durand-Zaleski I, Scott J, Rouillon F, Leboyer M. A first na-

North Clin Istanbul – NCI tional survey of knowledge, attitudes and behaviours towards schizophrenia, bipolar disorders and autism in France. BMC Psychiatry 2012;12:128.

10. Wilson BN, Neil K, Kamps PH, Babcock S. Awareness and knowledge of developmental co-ordination disorder among physicians, teachers and parents. Child Care Health Dev 2013;39:296-300.

11. Günayer Şenel H. Otizmli Bireylerle Akranlarının Spor ve Sanat Etkinlikleri Aracılığıyla Etkileşimde Bulundukları İki Örnek Uygulama. Özel Eğitim Dergisi 2009;10:65-72.

Orıgınal Article

Public Health

North Clin Istanbul 2015;2(1):19-25 doi: 10.14744/nci.2015.58070

Knowledge levels of and attitudes to organ donation and transplantation among university students Onur Ozlem Kose1, Muhammed Fatih Onsuz2, Ahmet Topuzoglu3 Children, Adolescents, Women and Reproductive Health Services Branch, Ministry of Health Istanbul Public Health Directorate,

1

Istanbul, Turkey Department of Public Health, Osmangazi University Faculty of Medicine, Eskisehir, Turkey

2

Department of Psychiatry, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey

3

ABSTRACT OBJECTIVE: The aim of the present study was to determine knowledge levels and attitudes about organ donation and transplantation among university students.

METHODS: This descriptive study was performed with third-grade students of medicine, pharmacy, and law at a university. Samples weren’t selected in the study and it was executed with 145 students who had agreed to participate in the study. The data was collected using a questionnaire of 19 questions. Descriptive statistics were used to analyze the data.

RESULTS: 71.7% of students had positive views about transplantation of their own organs to a suitable recipient, with half of them giving being useful to others as a reason. Among students who had negative views about organ donation, the most important reason given was that it would mean a loss of bodily integrity. 44.1% of participants had positive views about transplantation of their relatives’ organs to another person after death. 51.7% of participants had positive views about transplantation of the organs of a homeless person to another person after death.

CONCLUSION: Students had generally positive views about organ donation. However; organ transplantation and donation should be included in the students’ educational programs in order to increase positive attitudes and organ donations, and transform attitudes into behaviors.

Key words: Attitude; knowledge level; organ donation; transplantation; university students.

O

ne of the important health problems of the human beings is organ failure. Organ transplantation is a process of transferring a healthy and the same duty organ from a living person, a person

with established diagnosis of brain death or a dead person. Organ transplantation is a successful treatment method against irreversible vital organ failures as well as being a second life chance for the patients

Received: December 07, 2014 Accepted: January 08, 2015 Online: April 24, 2015 Correspondence: Dr. Muhammed Fatih onsuz. Eskisehir Osmangazi Universitesi Tip Fakultesi, Halk Sagligi Anabilim Dali, Meselik Kampusu, 26480 Odunpazari, Eskisehir, Turkey.

Tel: +90 222 - 239 29 79 e-mail: fatihonsuz@yahoo.com © Copyright 2015 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com

20

with organ failure [1, 2, 3]. As for organ donation, a person documents and permits with his/her own will that his/her tissues and organs are going to be used for the treatment of other patients after he/ she dies medically [4]. In Turkey, the researches and implementations on organ donation are executed under the Law on Taking, Keeping, Implanting and Transplanting Organs and Tissues enacted in 1979.

According to this law, organs can be taken from dead people including newborns to those aged 60 years, and everybody who is over 18 or sane can donate their organs [3].

In Turkey, the organs to be transplanted are generally provided from close relatives of the patient. Similar to Asian and Middle Eastern countries, cadaver organs havenâ&#x20AC;&#x2122;t been donated in sufficient amounts in Turkey and this leads to widening of the gap between the need and procurement of transplantable organs. While approximately 75% of organ transplantations are performed with the organs taken from healthy people in Turkey, more than 80% of the transplantations are performed with the organs taken from cadavers in European countries. Organ donations are evaluated according to cadaver donors per one-million populations. While organ donation from cadavers is 20-30 per one million in developed countries, it is 33.6 in Spain, 25.2 in Belgium, 14.1 in Canada, 16.2 in France, 4.5 in Greece, and 2 per million in our country [5]. The most important reason for this is that the society remains insensitive against organ donation. Various studies have obtained the views of people about organ transplantation and showed that academic, and cultural background, socioeconomical level, and religious beliefs are significant factors [6]. In order to increase the frequency of organ donation, knowledge level of the community on this issue should be raised, negative attitudes of the society should be eliminated, and obstacles against organ donation should be overcome. To this end, health personnel and all sections of the society, especially trained ones, should have sufficient knowledge and consciousness [3, 7, 8].

This study aims to determine knowledge levels and attitudes about organ donation and transplan-

North Clin Istanbul â&#x20AC;&#x201C; NCI

tation among third-grade university students in different faculties of a university.

MATERIALS AND METHODS This descriptive research was performed in December 2004, with third-grade students in faculties of medicine, pharmacy and law of a university. Any randomized sampling was not done, and the participants were asked to fill the questionnaire forms under surveillance before their classes on a determined day. A total of 150 third-grade students in the faculties of medicine, pharmacy and law were surveyed, and the study was performed with 145 students (96.6%) who had accepted to participate in the research. During the survey, a questionnaire form composed of 19 questions and prepared by the researchers was used. This questionnaire form was composed of the questions about socio-demographic characteristics, and knowledge levels and attitudes of the participants about organ transplantation. Approval from the local ethics committee, and necessary permits were obtained from deanâ&#x20AC;&#x2122;s offices of the relevant faculties. Furthermore, the participants were informed about the purpose of the research, and its performers. They were assured about the confidentiality of their personal information, and that their approvals were obtained. The data was evaluated using descriptive statistics in SPSS statistics program.

RESULTS Study population consisted of 145 participants (female, 66.2%, and male 53.8%). Students were from faculties of law (31.7%) medicine (33.1%), pharmacy (35.2%) A total of 4.1% of the students had a relative who had undergone or had been waiting for organ transplantation, and 9.0% of them had a relative to whom an organ had been donated. Distribution of some descriptive properties of university students are given in Table 1.

When the participants were asked about their organ donors, they indicated living human donors (92.4%), cadaver donors (73.1%), and histocompatible animal donors (9.6%). The responders indicat-

Kose et al., Knowledge levels of and attitudes to organ donation and transplantation among university students

ed kidney (95.9%), bone marrow (91.0%), cornea (89.0%), liver (75.9%), heart (75.1%), gall bladder (6.2%), and brain (3.4%) as transplantable organs.

The students indicated that they had obtained their knowledge about organ transplantation from television/radio (81.3%), newspaper/journals (79.3%), their environment and friends (28.2%), books (21.4%), and internet (15.2%).

Most (71.7%) of the participants stated that they had favourable views about the idea of organ transplantation after death. Half of 104 students emphasized their fovourable views because by donating their organs they would be very helpful for others, and they also stated that in addition to being helpful, they won’t need these organs after death (11.6%). Other reasons for their favourable views included no more need of their body after death (5.8%), acquiring merit in God’s sight (30.7%), while 30.7% gave no reason for their positive views. While 83.7% of the participants with positive views stated that they wished to donate all of their transplantable organs, and 16.3% of them wished to donate some of their organs. Only 20.2% of the students stated that they should ap-

Table 1. Distribution of some descriptive characteristics of university students

Descriptive characteristics Gender Women Men Faculty Pharmacy Medicine Law Having a relative who had undergone or is waiting for organ transplantation Yes No Having a relative to whom an organ had been donated Yes No Total

n

%

96 49

66.2 33.8

51 48 46

35.2 33.1 31.7

6 139

4.1 95.9

13 9.0 132 91.0 145 100.0

21

ply to hospitals and health organizations for organ donation. Only 3.8% (n=4) of the students with positive views about organ transplantation had a certificate showing that they had donated their organs, and only one of them was always carrying this certificate with him/her. The other 2 students stated that their families weren’t aware of their decisions. While,17.1% of 41 students with negative views about organ transplantation indicated that their body integrity would be impaired. Some of them (9.8%) deemed organ donation to be against their religious beliefs or they thought that it would be a sinful act (4.9%) or they would get hurt (2.4%). While 65.8% of them gave no reason for their negative views. A little less than half (44.1%) of the participants had positive views about donating organs of their relatives after their death. A total of 64 students had positive views about organ transplantation because by donating their organs they would be very helpful for others (57.8%), and also they stated that in addition to being helpful, they won’t need these organs after death (7.8%).

Other reasons for their favourable views included no more need of their body after death (5.8%), acquiring merit in God’s sight (30.7%), while 30.7% gave no reason for their positive views. A total of 64 students had positive views about organ transplantation because they wanted to help others in need of transplants (57.8%), and they didn’t need their bodies after death (7.8%). Acquiring merit in God’s sight (1.5%) was another rationale. While 24.7% of them gave no reason for their positive views. Majority (67.9%) of 81 students with negative views responded that right to decide didn’t belong to them, that they would commit a sin (3.7%), that their body integrity would be impaired (2.5%) and that it wasn’t true religiously (1.2%) while 24.7% of them gave no reason for their negative views.

More than half (51.7%) of the participants had positive views about transplantation of organs of a deprived person to another one after death. Moreover, 84.1% of the patients stated that they should make their own decisions about organ transplantation before death, While others responded that their family (31.0%) or their physicians (8.2%) should make decision for organ donation after

22

their death. Knowledge and attitudes of university students about organ transplantation and donation are given in Table 2.

DISCUSSION In the study performed to determine knowledge and attitudes of third-grade students in different faculties of a university about organ donation and transplantation, the students indicated that the most proper donors for organ transplantation were living human donors (92.4%) followed by cadavers (73.1%). In investigations performed with the students of several medical faculties in Turkey, cadaver donors were stated as the most proper donors for organ transplantation [7, 9]. The result of our study is different from literature findings. The reason for this diversity may be that the students from the faculties other than medical faculties were also included in the research. While in European countries cadaveric, and living organ donors consist of 80%, and 20% of the transplantations performed, in Turkey organ donations are made mainly from living donors (cadaveric donors, 25% vs living donors, 75%). As an outcome of recent studies performed in our country, there has been an increase in the number of cadaveric donors [10, 11].

In our research, kidney was stated as the most transplantable organ (95.9%), followed by bone marrow, cornea, liver, heart, gallbladder and brain.

Similarly, kidney is the most known transplantable organ also cited in the literature [2, 7, 9, 12, 13, 14].

This result may lead to the opinion that majority of the patients waiting for organ transplantation are those with renal failure, and this subject creates awareness as it is mentioned in the media more frequently. Furthermore, the first transplanted organ in our country was kidney, and this may have affected the results obtained.

The most important information source of the participants was determined as television/radio, followed by newspaper/journal, environment and friends, books and internet. The result of our research is in parallel with the information in the literature. In both domestic and foreign studies, the most important information sources about organ

North Clin Istanbul – NCI

Table 2. Knowledge levels and attitudes of university students about organ transplantation and donation Knowledge levels and attitudes n of university students

%

Donors for organ transplantation*

Living human donor

134

92.4

Cadaver donor

106

73.1

Suitable animal donor

14

9.6

139

95.9

Transplantable organs

*

Kidney

132

91.0

Cornea

129

89.0

Liver

110

75.9

Heart

109

75.1

Bone marrow

Gall bladder

Brain

9

6.2

5

3.4

Information sources about organ transplantation* Television/radio

118

81.3

Newspaper/journal

115

79.3

Environment/friend

41

28.2

Books

31

21.4

Internet

22

15.2

Positive

104

71.7

Negative

41

28.3

Positive

64

44.1

Negative

81

55.9

Positive

75

51.7

Negative

70

48.3

Opinions of the students on transplantation of their own organs after death

Opinions of the students on transplantation of their relatives’ organs after death

Opinions of the students about transplantation of a homeless person’s organs after death

Decision maker in organ transplantation*

Their own decisions before death

122

84.1

Family’s decision after death

45

31.0

12

8.2

Physicians Participants indicated more than one option.

*

Kose et al., Knowledge levels of and attitudes to organ donation and transplantation among university students

transplantation were determined as television/radio, newspaper and journals [6, 15, 16, 17]. Today, media and especially television are the most important information sources about health. As television is used widely by the people, it can be shown as the most important information source accessed by the people. It has been stated that the media, especially television, should be used actively in order to inform and direct people about organ donation, and related campaigns [18, 19]. However; in the studies to be conducted by means of media, negative views about organ donation, and therefore, disinformation and misdirection of the public should be prevented. It has been stated that the organ donation authorities and organizations should be in closer relationships with the media, and non-scientific, misinformative broadcasts and news should be prevented in this way [10].

Majority of the participants (71.7%) stated that they approved transplantation of their organs to other people after their death. Half of the students with positive views stated that they approved organ transplantation in order to be useful for others and most of them (83.7%) stated that they could donate all of their organs. In a study performed with university students in China, two- third of the students stated that they approved organ donation, and half of the participants had also positive views in this regard in another study [15, 16]. In the studies performed with a medical faculty students in Italy and Iran, four- fifth of the students stated that they had positive views about organ donation [20, 21]. In the studies performed in our country, the rates of positive views about organ donation varied between 21.0% and 91.1% [6, 8, 13, 22]. Although rates of positive views about organ donation reported in studies performed with the students of the faculty of health sciences are generally higher than those of our study, results of our study have similarities with those cited both in domestic and foreign literature.

The fact that the students in medical faculties have more knowledge about the subject matter may have raised their awareness about this issue and led to these favourable results.

The students who had negative views about organ transplantation didnâ&#x20AC;&#x2122;t desire to impair their body integrity, and thought that donating an organ was a

23

profane act. Commitment of a sin and feeling pain were also indicated [6, 7, 13, 23]. In some researches performed in our country, the most important negative reasons about organ donation, and transplantation were stated as personal choice, never thinking about organ transplantation, fear, religious beliefs and lack of trust in physicians [9, 11, 24, 25, 26].

Results similar to our outcomes were also found in the researches performed in other countries. In Europe, the most important reasons asserted against organ donation included abstention from social reaction, being reluctant to impair body integrity, reactions against hospitals and reluctance in decision for organ transplantation [12, 27, 28]. The most important reason for these unfavourable attitudes is lack of knowledge about organ transplantation.

Especially, the matters such as never thinking about organ transplantation, personal choice and religious beliefs which stand in the forefront of the studies support this opinion. Raising awareness about this issue is a must in order to make people think about organ donation, and the most important way to do this is to inform the people through education. Furthermore, although they arenâ&#x20AC;&#x2122;t as commonly held as before, religious beliefs entertained against organ donation show lack of knowledge about Islam. Indeed, Islamic religion doesnâ&#x20AC;&#x2122;t prohibit organ donation. Conversely, it is regarded as beneficial for society. The decree (dated 03.03.1980 and #396/13) issued by Supreme Council of Religious Affairs of Turkish Republic Directorate of Religious Affairs stated that organ transplantation was religiously permissable [29]. All these results show that an education planning is required about organ transplantation which will encompass the entire society In our study, while nearly half of the students had positive views about transplantation of organs of one of their relatives to another person after their death, half of them approved transplantation of the organs of a deprived person to other people after his/her death. The students with positive views stated that being useful to other people was the most important reason for organ donation. In many researches performed in our country, although not at a higher rate, the students had positive views about transplantation of the organs of their relatives or

24

deprived people after their death [9, 11, 17]. These results can be evaluated as that the people aren’t very willing to donate the organs of their relatives.

The most important reason for this unwillingness is that the relatives are not aware of the importance of organ donation after death, Therefore relatives should take initiatives in this respect as the people cannot be a donor without the approval of their relatives. The most important reason for the people to have negative views about donation of organs of their relatives is that they haven’t got the right to decide or they don’t want to take initiative, as seen in the results of our study and the other studies [9]. Again in our study, majority of the students (84.1%) thought that a person should give his/her own decision about organ donation before his/her death which supports our opinion.

In conclusion, organ transplantation is an important problem in our country as is the case all around the world. While the number of people waiting for organ transplantation is increasing day by day, the number of donated organs is insufficient.

It is known that the society should be informed and encouraged to participate in organ donation campaigns in order to increase the number of organ donations. Therefore, arranging campaigns about organ donation and using popular artists, sportsmen and similar people in these campaigns will be significant for informing the society about importance of the subject matter and increasing effectiveness of the campaigns. Furthermore, comprehensive studies should also be performed in order to determine knowledge, opinions, attitudes and negative views of the society in this aspect. Within the framework of these studies, it should be determined, whether or not customs, traditions and beliefs in the society affect organ transplantation and if so to what extent. Involvement of the health personnel in this process shall contribute significantly to the acquisition of comprehensive information. Especially enlightment of the society on these health issues can increase the knowledge level and awareness of the people about organ donation.

Conflict of Interest: No conflict of interest was declared by the authors.

North Clin Istanbul – NCI Financial Disclosure: The authors declared that this study has received no financial support.

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2. Sönmez Y, Zengin E, Ongel K, Kişioğlu N, Oztürk M. Attitude and behavior related to organ donation and affecting factors: a study of last-term students at a university. Transplant Proc 2010;42:1449-52.

3. Göz F, Gürelli ŞŞ. The Thoughts of Intensive Care Nurses Toward Organ Donation. Fırat Sağlık Hizmetleri Dergisi 2007;2:77-88.

4. Akış M, Katırcı E, Uludağ HY, Küçükkılıç B, Gürbüz T, Türker Y, at al. Knowledge and attitude of Suleyman Demirel Unýversity staff About organ-tissue donation and transplantation. S.D.Ü.

Tıp Fak Derg 2008;15:28-33.

5. Yaşar M, Oğur R, Uçar M, Göçgeldi E, Yaren H, Tekbaş ÖF, et al. Attitudes of last grade students of a Vocational School of Health about organ donation and related factors with their attitudes. Genel Tıp Dergisi 2008;18:33-7.

6 Özer FG, Karamanoğlu AY, Beydağ KD, Fidancıoğlu H, Akıncı E, Şanlı İ, et al. Effect of Education on a Group of University School for Health Sciences Students’ Opinions and Knowledge Level about Organ Transplantation and Donation. Kor Hek 2008;7:39-46.

7 Özmen D, Çetinkaya A, Sarızeybek B, Zeybek A. Knowledge and Views of Students of the Celal Bayar University Manisa School of Health Towards Organ Donation. Türkiye Klinikleri J Med Sci 2008;28:311-8.

8. Kılıç S, Koçak N, Türker T, Gürpınar H, Gülerik D. Attitudes of female university students about organ donation and factors affecting these attitudes. Gulhane Med J 2010;52:36-40.

9. Koçak A, Aktaş EÖ, Şenol E, Kaya A, Bilgin UE. Ege University Faculty of Medicine undergraduates’ knowledge level regarding organ donation and transplantation. Ege Tıp Dergisi 2010;49:153-60.

10. Okka B, Demireli O. The Public Attitudes towards Organ Donation in Konya. Türkiye Klinikleri J Med Ethics 2008;16:148-58.

11. Aytaş Ö, Kartalcı Ş, Ünal S. Perspectives on Organ Donation in the Context of Sociodemographic Data and Levels of Burn Out in aGroup of Nurse. İnönü Üniversitesi Tıp Fakültesi Dergisi 2011;18:26-32.

12. Maroof S, Kiyani N, Zaman Z, Gul RK, Nayyar S, Azmat A, et al. Awareness about organ donation especially kidney donation in Nurpur Shahan, a rural community area in Islamabad, Pakistan. J Pak Med Assoc 2011;61:828-32.

13. Doğan P, Toprak D, Sunal N, Doğan İ. Knowledge, attitude and behaviors of university students on organ transplantation, in Turkey. Smyrna Tıp Dergisi 2012;1:16-25.

14. Dutra MM, Bonfim TA, Pereira IS, Figueiredo IC, Dutra AM,

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Lopes AA. Knowledge about transplantation and attitudes toward organ donation: a survey among medical students in northeast Brazil. Transplant Proc 2004;36:818-20.

15. Zhang L, Li Y, Zhou J, Miao X, Wang G, Li D, et al. Knowledge and willingness toward living organ donation: a survey of three universities in Changsha, Hunan Province, China. Transplant Proc 2007;39:1303-9.

16. Chen JX, Zhang TM, Lim FL, Wu HC, Lei TF, Yeong PK, et al. Current knowledge and attitudes about organ donation and transplantation among Chinese university students. Transplant Proc 2006;38:2761-5.

17. Vicdan AK, Peker S, Üçer B. Determination of the Attitudes of Akşehir Health High School Students Concerning Organ Donation. TAF Prev Med Bull 2011;10:175-80.

18. Sato H, Akabayashi A, Kai I. Public appraisal of government efforts and participation intend in medico-ethical policymaking in Japan: a large scale national survey concerning brain death and organ transplant. BMC Medical Ethics 2005;6:1.

19. Alam AA. Public opinion on organ donation in Saudi Arabia.

Saudi J Kidney Dis Transpl 2007;18:54-9.

20. Burra P, De Bona M, Canova D, D’Aloiso MC, Germani G, Rumiati R, et al. Changing attitude to organ donation and transplantation in university students during the years of medical school in Italy. Transplant Proc 2005;37:547-50.

21. Sanavi S, Afshar R, Lotfizadeh AR, Davati A. Survey of medical students of Shahed University in Iran about attitude and willingness toward organ transplantation. Transplant Proc

25

2009;41:1477-9.

22. Goz F, Goz M, Erkan M. Knowledge and attitudes of medical, nursing, dentistry and health technician students towards organ donation: a pilot study. J Clin Nurs 2006;15:1371-5.

23. Akgün S, Tokalak I, Erdal R. Attitudes and behavior related to organ donation and transplantation: a survey of university students. Transplant Proc 2002;34:2009-11.

24. Alat I, Akpinar MB, Eğri M, Aydin N, Aydemir IK, Aldemir M, et al. The conviction of patients and hospital attendants on tissue and organ transplantation. [Article in Turkish] Anadolu Kardiyol Derg 2007;7:316-7.

25. Keçecioğlu N, Tuncer M, Yücetin L, Akaydin M, Yakupoğlu G. Attitudes of religious people in Turkey regarding organ donation and transplantation. Transplant Proc 2000;32:629-30.

26. Naçar M, Çetinkaya F, Kanyılmaz D, Tokgöz B, Utaş C. The Attıtudes Of Medıcal Students To Organ Donatıon. Turk Neph Dial Transpl 2001;10:123-8.

27. Chung CK, Ng CW, Li JY, Sum KC, Man AH, Chan SP, et al.

Attitudes, knowledge, and actions with regard to organ donation among Hong Kong medical students. Hong Kong Med J 2008;14:278-85.

28. Schütt GR. 25 years of organ donation: European initiatives to increase organ donation. Transplant Proc 2002;34:2005-6.

29. Organ nakli, 396 sayılı karar. Türkiye Cumhuriyeti Başbakanlık Diyanet İşleri Başkanlığı, Din İşleri Yüksek Kurulu, 1980. Available at: http://www.diyanet.gov.tr/dinisleriyuksekkurulu/sayfalar/organnakli.aspx Accessed August 06, 2013.

Orıgınal Article

General Surgery

North Clin Istanbul 2015;2(1):26-32 doi: 10.14744/nci.2015.03522

Management of strangulated abdominal wall hernias with mesh; early results Mustafa Ozbagriacik1, Gurhan Bas1, Fatih Basak1, Abdullah Sisik1, Aylin Acar1, Ilyas Kudas1, Metin Yucel1, Adnan Ozpek1, Orhan Alimoglu2 Department of General Surgery, Umraniye Training and Research Hospital, Istanbul, Turkey

1

Department of General Surgery, Medeniyet University Faculty of Medicine, Goztepe Training and Research Hospital,

2

Istanbul, Turkey

ABSTRACT OBJECTIVE: Surgery for abdominal wall hernias is a common procedure in general surgery practice. The main causes of delay for the operation are comorbid problems and patient unwillingness, which eventually, means that some patients are admitted to emergency clinics with strangulated hernias. In this report, patients who admitted to the emergency department with strangulated adominal wall hernias are presented together with their clinical management.

METHODS: Patients who admitted to our clinic between January 2009 and November 2011 and underwent emergency operation were included in the study retrospectively. Demographic characteristics, hernia type, length of hospital stay, surgical treatment and complications were assessed.

RESULTS: A total 81 patients (37 female, 44 male) with a mean age of 52.1±17.64 years were included in the study. Inguinal, femoral, umbilical and incisional hernias were detected in 40, 26, 9 and 6 patients respectively.

Polypropylene mesh was used in 75 patients for repair. Primary repair without mesh was used in six patients.

Small bowel (n=10; 12.34%), omentum (n=19; 23.45%), appendix (n=1; 1.2%) and Meckel’s diverticulum (n=1; 1.2%) were resected. Median length of hospital stay was 2 (1–7) days. Surgical site infection was detected in five (6.2%) patients. No significant difference was detected for length of hospital stay and surgical site infection in patients who had mesh repair (p=0.232 and 0.326 respectively).

CONCLUSION: The need for bowel resection is common in strangulated abdominal wall hernias which undergo emergency operation. In the present study, an increase of morbidity was seen in patients who underwent bowel resection. No morbidity was detected related to the usage of prosthetic materials in repair of hernias. Hence, we believe that prosthetic materials can be used safely in emergency cases.

Key words: Abdominal hernia; emergency treatment; inguinal hernia

Received: November 26, 2014 Accepted: February 11, 2015 Online: April 24, 2015 Correspondence: Dr. Fatih BaSak. Umraniye Egitim ve Arastirma Hastanesi, Genel Cerrahi Klinigi, Elmali Kent Mahallesi, Adem Yavuz Cad., No: 1, Umraniye, Istanbul, Turkey.

Tel: +90 216 - 632 18 18 e-mail: fatihbasak@gmail.com © Copyright 2015 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com

Ozbagriacik et al., Management of strangulated abdominal wall hernias with mesh

I

n studies performed in our country etiologies of bowel obstruction are very diverse. Increase in intestinal adhesions encountered in socioeconomically developed regions is remarkable. Strangulated abdominal wall hernia is one of the frequent referrals to emergency services, and it is a predominant cause of intestinal obstruction in our country [1]. In patients whose hernias are reduced spontaneously, elective surgery is recommended to be performed as soon as possible. Morbidity rates due to emergency surgery can be higher than those of the elective surgery. The most important complications of abdominal wall hernias can be considered as incarceration and strangulation [1, 2]. The safety and reliability of prosthetic mesh usage is still a debatable subject especially in patients who require bowel resection [3]. The objective of our study is to analyse clinical outcomes of patients operated in our clinic with the indication of strangulated abdominal wall hernias.

MATERIALS AND METHODS Patients who consulted to our clinic between January 2009, and November 2011, and operated urgently with the indication of abdominal wall hernia were retrospectively included in the study. Patients’ data were obtained from hospital information system and patients’ files. Demographic characteristics, types of hernias, contents of hernial sacs, hernia repair methods applied were recorded. The patients were categorized based on types of hernia as inguinal, femoral, umbilical, and incisional hernias. Surgical notes were examined in detail, and additional pathologies encountered during operation were evaluated. Additional interventions were examined in detail. Preoperative duration of complaints of strangulation, length of hospital stay, complications developed within postoperative one month, morbidities and mortalities were recorded, and affecting factors were examined. Patients whose medical files were not available, and patients with missing data were excluded from the study.

Statistical evaluation For statistical evaluation of the results obtained, NCSS (Number Cruncher Statistical System)

27

2007&PASS (Power Analysis and Sample Size), and 2008 Statistical Software (Utah, USA) programs were used. Descriptive statistics, means±standard deviations for continious variables, and numbers, and percentages for categorical data were used for analysis of study data. Parametric data with normal distribution were evaluated using t-test, and Anova.

Kruskal-Wallis test was employed for intergroup comparisons of data without normal distribution.

The group which demonstrated differences was determined by using Mann Whitney-U test. Chisquare test, and Fisher’s exact test were used for the comparison of qualitative data. The results were evaluated within 95% confidence interval, and at a significance level of p<0.05.

Results During the study period, among a total of 1367 cases who had undergone elective abdominal wall hernia repairs, 102 (7.4%) patients had been operated urgently for strangulated abdominal wall hernias.

Twenty-one patients were excluded from the study because of missing data. A total of 81 patients were included in the study. Study population consisted of 37 female, and 44 male patients, with a mean age of 52.1±17.64 (range, 20-92) years.

The patients had strangulated inguinal (n=40; 49, 4), umbilical (n=26; 32.1%), femoral (n=9; 11.1 5), and incisional (n=6; 7.4%) hernias (Table 1) In comparisons among types of hernias, differences between male, and female patients were detected, while any difference between age groups was not found (p=0.001, and 0.973, respectively). Especially in inguinal hernias male gender dominancy (male/female=4.7) was remarkable, while in other types of hernias female gender predominance was more frequently seen.

Any difference was not detected between types of hernias as for the preoperative onset of complaints related to strangulation (p=0.079). A total of 31 (38.2%) patients had undergone various organ resections. Small bowel (n=10, 12.3%), and omentum (n=19; 23.4%) resections were performed. In one patient perforated appendix was detected in hernial sac which necessitated appendectomy (1.2%),

28

North Clin Istanbul – NCI

Table 1. Some demographic details of the groups based on hernia types

Number of patients Male/female ratio Age: Mean±SD (range) Preoperative duration of complaints, median (range) Postoperative hospital stay, days; median (range) Bowel resection **n (%) Surgical site infection n (%)

Inguinal

Femoral

40 33/7 51.3±18.07 (22-83) 12 (4-36)

9 3/6 52.4±26.2 (26-92) 8 (4-12)

Umbilical 26 7/19 52.5±15.6 (20-84) 12 (4-24)

Incisional

p

6 1/5 54.8±9.9 (42-68) 6.5 (5-9)

β

0.001* 0.973 γ

0.079

2 (1-7)

2 (1-3)

2 (1-6)

2 (1-2)

γ

7 (58.3) 4 (80)

2 (16.7) 1 (20)

2 (16.7) 0

1 (8.3) 0

α

0.737 1.000 0.321

α

p<0.05; SD: Standard deviation; βAnova test; γKruskal-Wallis test; αchi-square test; **Resection of small bowel, appendix, and Meckel’s diverticulum was evaluated in combination.

*

Table 2. Additional interventions, and their details in diagnostic groups Hernia type

Inguinal (n=40)

Femoral (n=9) Umbilical (n=26)

Incisional (n=6)

Strangulated organ/ Additional intervention

n

Small bowel/Resection Omentum/Resection Meckel’s Diverticulum/Resection Small Bowel/Resection Small Bowel/Resection Omentum/Resection Omentum/Resection Perforated Appendicitis/Appendectomy

and in another patient (1.2%) hernial sac contained Meckel’s diverticulum which required diverticulectomy (Table 2). Median hospital stay was 2 (range, 1-7) days which did not differ among various types of hernias (p=0.737). When all patients who had undergone bowel resection (small bowel, appendix, and Meckel’s diverticulum) were evaluated in combination (total n, 12; 14.8%), any difference between types of hernias was not found, while a significant difference was noted among patients’ age, preoperative duration of complaints of strangulation, and length of postoperative hospital stay (p=1.000,

6 6 1 2 2 11 2 1

%

Contents of the hernial sac

15 15 2.5 22.2 7.6 42.3 33.3 16.6

Small bowel, sigmoid colon, caecum, tuba uterina, appendix, omentum, testis, epididymis Small bowel, omentum Small bowel, omentum Omentum, appendix

0.034, 0.001 and 0.001, respectively) (Table 3).

All patients had received antibiotic prophylaxis with 1 g IV cefazoline sodium. Superficial site infection was detected in 5 (6.2%) patients, and the patients were cured with medical therapy. Any mortality was not seen in our study group. Type of hernia, age of patients, preoperative duration of strangulation complaints did not differ among patients with surgical site infection, while postoperative hospital stay, and frequency of bowel resection differed significantly among these patients (p=0.321, 0.108, 0.051, 0.027, and 0.001, respec-

Ozbagriacik et al., Management of strangulated abdominal wall hernias with mesh

29

Table 3. Statistical evaluation of the patients who underwent bowel resection

Patients who underwent bowel resection (n=12)

Patients who didn’t undergo bowel resection* (n=69)

62±19.7 15 (6-36)

50.3±16.8 9 (4-24)

3.5 (2-7)

2 (1-4)

Age (Mean±SD) Duration of preoperative complaints of strangulation (hr): median (range) Postoperative hospital stay; days: median (range)

p

0.034 0.001**

α β

0.001**

β

*Resection of small bowel, appendix, and Meckel’s diverticulum was evaluated in combination; SD: Standard deviation; αT–test; βMann-Whitney U test; ** p<0.05.

Table 4. Statistical evaluation of surgical site infection

Surgical site infection

Yes (n=5)

No (n=76)

p

Age: years (Mean±SD) Duration of preoperative complaints of strangulation (hr): median (range) Postoperative hospital stay; days: median (range) Patients who underwent bowel resection **n (%)

64.4±20.7 24 (6-36)

51.2±17.2 12 (4-24)

5 (1-7)

2 (1-6)

β

4 (80)

8 (10.5)

γ

0.108 0.051

α β

0.027*

0.001*

SD: Standard deviation; αT–test; βMann Whitney-U test; *p<0,05; γFisher’s exact test; **Resection of small bowel, appendix, and Meckel’s diverticulum was evaluated in combination.

Table 5. Statistical evaluation of patients who underwent hernia repair with or without mesh

Postoperative hospital stay, days, median (range) Surgical site infection n (%)

Repair with mesh (n=75)

Primary repair without mesh (n=6)

2 (1-6) 4 (5.3)

2 (1-7) 1 (16.6)

p

0.232 0.326

α β

Mann- Whitney test; βFisher’s exact test.

α

tively) (Table 4).

Inguinal hernia repair was achieved using polypropylene meshes (n=75, 92.5%) or primary suturing (n=6; 7.5%). Among patients whose hernias

were repaired with meshes, any difference in postoperative hospital stay in days, and development of surgical site infection was not seen (p=0.232 and 0.326, respectively) (Table 5).

30

Forty cases (mean age, 51.3±18.07:22–83 yrs) (male, n=33:82.5%, and female, n=7; 17.5%) with strangulated right (n=23), and left (n=17) inguinal hernias were detected. Indirect (n=32; 80%), direct (n=5; 12.5%), and recurrent (n=3; 7.5%) inguinal hernias were also recorded. Necrotic small bowel segment had been detected in hernial sac of 6 patients who had undergone small bowel resection, and anastomosis, while necrotic omentums of 6 patients had been resected. One patient had undergone diverticulectomy with the indication of Meckel’s diverticulum. Strangulated inguinal hernias of the patients were repaired with polypropylene mesh (n=39; 97.5%) or primarily repair with polypropylene sutures (n=1; 2.5%).

Strangulated femoral hernias were detected in 6 (66.7%) female, and 3 (33.3%) male patients, and mean age of the study population was 52.4±26.2 (26-92) years. Two patients had undergone bowel resection, and anastomosis because of detection of necrotic small bowel segment in the hernial sac.

Strangulated femoral hernias had been repaired either with plug polypropylene mesh (n=8; 11.1%) or using Mc Vay technique in which conjoined (transversus abdominis and internal oblique) tendon is sutured to the inguinal ligament with polypropylene sutures (n=1; 11.1%).

Strangulated umbilical hernias were detected in 19 (73%) female, and 7 (27%) male patients, and the mean age of the study population was 52.5±15.6 (20-84) years. Length of the umbilical hernia defects ranged between 2, and 8 cm. Eleven patients had undergone omentectomy for omental necrosis, while intestinal resection, and anastomosis were performed for 2 patients with small bowel necrosis. Four (15.4%) patients had undergone primary repair or repair with polypropylene mesh (n=22; 84.6).

Strangulated incisional hernias were detected in 6 (female, n=5, and male, n=1) patients with a mean age of 54.8±9.9 (42-68) years. One patient underwent omentectomy because of omentum necrosis, and another patient was appendectomized with the indication of appendiceal perforation detected in hernial sac. All incisional hernias were repaired using propylene meshes.

North Clin Istanbul – NCI

Discussion Strangulated abdominal wall hernias requiring surgery are frequently encountered emergency cases.

Treatment approach in these patients include urgent surgical exploration, reduction of inguinal hernia, and resection of devitalized tissue in case of need [4]. Achievement of lower mortality, morbidity, and recurrence rates are targeted [5]. Delayed referral of the patient to the hospital or delayed diagnosis bring with them increased mortality, and morbidity rates despite surgical intervention. Diagnosis before the onset of strangulation, and hernia repair under elective conditions can decrease these indicated risks [6]. As has been reported in various publications 5-35% of the abdominal wall hernias were operated urgently because of strangulation [7].

As detected in the present study, prolonged interval between the onset of the complaints, and referral to the hospital increased the requirement of bowel resection significantly (p=0,001).

Mortality, and morbidity rates in cases with strangulated abdominal wall hernias have been reported as 1.4-13.4%, and 19-30% respectively.

Mortality, and morbidity are related to the development of bowel necrosis secondary to strangulation [8, 9]. In various studies performed, bowel resection has been reportedly required in 10-15% of the patients with strangulated abdominal wall hernias [2]. Advanced age, and need for bowel resection have been reportedly associated with increased mortality rates. In various studies, authors reported that advanced age, higher incidence rates of concomitant diseases and delayed referrals increased bowel resection and morbidity rates [10, 11]. In studies where patients aged ≤70 years with strangulated abdominal wall hernias were urgently operated, higher mortality rates were reported in the advanced age group [8, 11]. As indicated in various reports, in cases with strangulated abdominal wall hernias, most frequently hernial sac contains small bowel segments [1]. In many studies performed on strangulated abdominal wall hernias which required small bowel resection, a tendency towards increased complication rates was detected [12]. Mean age of our study group was 52.1 years.

Ozbagriacik et al., Management of strangulated abdominal wall hernias with mesh

Most frequently omentum (19 cases), and then small bowel (10 cases) were resected because of their strangulation in the hernial sac. Mean age of the patients who had undergone small bowel resection was 59.4 years. Small bowel resection was performed in 12.3% of all cases with strangulated abdominal wall hernias. Rates of small bowel resection in cases with inguinal, femoral, and umbilical hernias were 15, 22.2, and 7.6%, respectively.

Rate of resection in femoral hernias was detectedly higher, however statistical analysis could not be performed because of scarcity of cases with femoral hernias Therefore, larger series are needed to arrive at a conclusion which suggests that increased rates of bowel resection may be required in cases with femoral hernias. When small bowel, appendix, and Meckelâ&#x20AC;&#x2122;s diverticulum were evaluated as a whole, patients who had undergone bowel resection were in their advanced age (mean age, 62Âą19.7 years).

Besides they stayed longer in the hospital, and experienced higher number of surgical site infections (p=0.034, 0.001 and 0.001, respectively). None of the cases died during perioperative period in our study group. Lack of mortality in our series may be related to the scarce number of our cases.

As reported in studies performed, abdominal wall strangulation is most frequently occurred within inguinal, then umbilical, femoral, and incisional hernia sacs [1, 9, 13]. Still in our study group, in compliance with the literature most frequently (49.4%) strangulation was detected in inguinal hernia sac. Then in decreasing rates strangulations were seen in umbilical hernia (32.1%), femoral hernia (11.1%), and incisional hernia (7.4%) sacs.

In the literature, incidence of postoperative surgical site infection developed after strangulated abdominal wall hernias has been reported as 3.8-5.3 percent [2, 5]. In our retrospective study, surgical site infection was noticed in 5 (6.2%) patients Potential increase in morbidity rates with application of meshes in patients who underwent bowel resection or urgently operated has been discussed in various publications [9]. Risk of contamination in patients especially requiring bowel resection has raised suspicions about safe applicability of meshes.

However on the other hand, higher risk of recur-

31

rence of primary suture technique has been known irrespective of the primary suture technique [4].

In the literature, some authors have advocated use of prosthetic meshes in the repair of strangulated hernias [14, 15]. Based on many relevant medical literature reports, antibiotic prophylaxis decreases surgical site infection in cases with strangulated abdominal wall hernias [16]. In the present study, in cases with strangulated hernias operated under emergency conditions, foreign body reaction secondary to application of meshes was not detected.

However, if we consider our inadequately shorter postoperative follow-up period, we can not overlook foreign body reaction which might develop against meshes. All patients in our study group underwent routine antibiotic prophylaxis. In our series, higher rates (92.5%) of repairs were performed with propylene mesh, which didnâ&#x20AC;&#x2122;t cause any additional morbidity as for duration of hospitalization, and surgical site infection (p=0.232 and 0.326, respectively).

In conclusion, emergency surgery should be performed when strangulated abdominal wall hernia is detected before development of impairment of organ blood supply. Achievement of repair under elective conditions in cases with hernia before development of strangulation can decrease the risks of mortality, and morbidity. We are in the opinion that hernia repair with polypropylene mesh can be also applied safely in cases of emergency.

Ethics Committe Approval: Ethics committee approval was not received due to the retrospective nature of the study.

Informed Consent: Written informed consent was not o tained due to the retrospective nature of the study.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept-M.O., G.B., F.B., A.S., A.A., I.K., M.Y., A.O., O.A.; Design-M.O., G.B., F.B., A.S., A.A., I.K., M.Y., A.O., O.A.; Supervision-M.O., G.B., F.B.; Data collection and/or processing-M.O., G.B., F.B., A.S., A.A., I.K.; Analyse and/or interpretation-M.O., G.B., F.B., A.S., A.A., A.O., O.A.; Literature Review-M.O., G.B., F.B., M.Y., A.O., O.A.; Writing-M.O., G.B., F.B., A.S., A.A., I.K., M.Y., A.O., O.A.; Critical review-M.O., G.B., F.B., A.S., A.A., I.K., M.Y., A.O., O.A. Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

32

REFERENCES 1. Akçakaya A, Alimoğlu O, Hevenk T, Baş G, Sahin M. Mechanical intestinal obstruction caused by abdominal wall hernias. [Article in Turkish] Ulus Travma Derg 2000;6:260-5.

2. Kulah B, Kulacoglu IH, Oruc MT, Duzgun AP, Moran M, Ozmen MM, et al. Presentation and outcome of incarcerated external hernias in adults. Am J Surg 2001;181:101-4.

3. Derici H, Unalp HR, Nazli O, Kamer E, Coskun M, Tansug T, et al. Prosthetic repair of incarcerated inguinal hernias: is it a reliable method? Langenbecks Arch Surg 2010;395:575-9.

4. Nieuwenhuizen J, van Ramshorst GH, ten Brinke JG, de Wit T, van der Harst E, Hop WC, et al. The use of mesh in acute hernia: frequency and outcome in 99 cases. Hernia 2011;15:297-300.

5. Çağlayan K, Çelik A. Strangülasyon nedeni ile ameliyat edilmiş karın duvarı fıtıkları. Tıp araştırmaları dergisi 2011;9:29-33.

6. Ohene-Yeboah M. Strangulated external hernias in Kumasi.

West Afr J Med 2003;22:310-3.

7. Derici H, Unalp HR, Bozdag AD, Nazli O, Tansug T, Kamer E. Factors affecting morbidity and mortality in incarcerated abdominal wall hernias. Hernia 2007;11:341-6.

8. Ezer A, Calışkan K, Colakoğlu T, Parlakgümüş A, Belli S, Tarım A. Factors affecting morbidity in urgent repair of abdominal wall hernia with intestinal incarceration in adults. Ulus Travma Acil Cerrahi Derg 2011;17:344-8.

9. Kurt N, Oncel M, Ozkan Z, Bingul S. Risk and outcome of bowel resection in patients with incarcerated groin hernias: ret-

North Clin Istanbul – NCI rospective study. World J Surg 2003;27:741-3.

10. Alvarez JA, Baldonedo RF, Bear IG, Solís JA, Alvarez P, Jorge JI. Incarcerated groin hernias in adults: presentation and outcome.

Hernia 2004;8:121-6.

11. Martínez-Serrano MA, Pereira JA, Sancho JJ, López-Cano M, Bombuy E, Hidalgo J; Study Group of Abdominal Hernia Surgery of the Catalan Society of Surgery. Risk of death after emergency repair of abdominal wall hernias. Still waiting for improvement. Langenbecks Arch Surg 2010;395:551-6.

12. Kekeç Y, Alparslan A, Demirtaş S, Ezici H, Altınay R. The Effects of Strangulation on Morbidity and Mortality in Irreductible Hernias. Ulusal Cerrahi Dergisi 1993;9:128-31.

13. Rai S, Chandra SS, Smile SR. A study of the risk of strangulation and obstruction in groin hernias. Aust N Z J Surg 1998;68:6504.

14. Legnani GL, Rasini M, Pastori S, Sarli D. Laparoscopic transperitoneal hernioplasty (TAPP) for the acute management of strangulated inguino-crural hernias: a report of nine cases. Hernia 2008;12:185-8.

15. Bessa SS, Katri KM, Abdel-Salam WN, Abdel-Baki NA. Early results from the use of the Lichtenstein repair in the management of strangulated groin hernia. Hernia 2007;11:239-42.

16. Yerdel MA, Akin EB, Dolalan S, Turkcapar AG, Pehlivan M, Gecim IE, et al. Effect of single-dose prophylactic ampicillin and sulbactam on wound infection after tension-free inguinal hernia repair with polypropylene mesh: the randomized, double-blind, prospective trial. Ann Surg 2001;233:26-33.

Orıgınal Article

Public Health

North Clin Istanbul 2015;2(1):33-40 doi: 10.14744/nci.2015.93823

Participation of people living in rural areas of Eskisehir province in field researches, and factors affecting their rates of participation Ozkan Ozay, Emine Ayhan, Muhammed Fatih Onsuz, Burhanettin Isikli, Selma Metintas Department of Public Health, Osmangazi University Faculty of Medicine, Eskisehir, Turkey

ABSTRACT OBJECTIVE: The aim of the study was to determine participation rates of people living in the rural area of Eskisehir in field researches, and the factors influencing this.

METHODS: This descriptive study was performed with 1,482 people aged 18 and above in two districts of Eskisehir. Data were collected with a 16 question questionnaire using the face-to-face interview technique. Data were analysed with descriptive statistics, chi- square test, logistic regression analysis, and factors affecting rates of participation in field researches.

RESULTS: The most important reason (46.9%) given by participating for participant in field researches was the intention of “helping the interviewer”. The other reasons were; believing in the usefulness of the researches (35.0%), contribution to public improvement (14.9%) and taking pleasure in talking with various people (3.2%).

The most important reason (34.6%) for not participating in field researches was “considering field researches a waste of time”. The other important reasons for non-participation were unnecessarily long questions in the research questionnaire forms (32.7%) and being uninformed of the research results (31.9%). In logistic regression analysis, age was found to be an influential factor in participation rates.

CONCLUSION: Lower rates of participation in field researches cause bias. As far as possible high participation in field researches is important. For the achievement of higher participation rates in field researches, training courses must be provided to both research workers and the public.

Key words: Epidemiology; Eskisehir; field research; questionnaire; rural area.

P

ublic health is a branch of science, and art whose objectives can be summarized as follows: protection of individuals from contracting a disease, prolongation of life, improvement of physical, and mental health, and increasing work power by im-

proving conditions of environmental health, providing health care information to individuals, precluding contagious diseases, diagnosing the diseases at their early phases, offering prophylactic therapy, establishing health care organizations, and flourish-

Received: March 27, 2015 Accepted: April 05, 2015 Online: April 24, 2015 Correspondence: Dr. Muhammed Fatih onsuz. Eskisehir Osmangazi Universitesi Tip Fakultesi, Halk Sagligi Anabilim Dali, Meselik Kampusu, 26480 Odunpazari, Eskisehir, Turkey.

Tel: +90 222 - 239 29 79 e-mail: fatihonsuz@yahoo.com © Copyright 2015 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com

34

ing social works so as to ensure healthy life for each individual as an outcome of social works [1]. Generally public health emphasizes collective actions realized to improve community health. Epidemiology is one of the tools used for improving public health, and it is used in various aspects of life [2].

Epidemiology was defined by Last as “investigation of distribution of health-related conditions or events, and their determinants in certain communities, and implementation of the outcomes of these studies for the prevention, and control of health problems” [3]. Epidemiology is not only interested in death, disease, and disability but it also deals with achievement of more favourable health state, and more importantly it concerns with ways of improving people’s health state. A population defined by its geographic location or by other means is the focus of an epidemiological study. Prevalently, for epidemiological studies, a population is selected from a definitive region or country living in a certain period of time [4]. Epidemiology is a science of methodology which encompasses investigation of both the distribution of diseases, and other health-related events in both clinical, and social health disciplines, and also their etiological factors, in addition to determination of research techniques which are benefited to determine optimal methods for their diagnosis, and treatment. Determination of public health state, demonstration of its requirements, and priorities, and planning services which will maintain healthy state of individuals can be only possible by defining the target population to be served. The way of getting acquanted with the community passes through researches, and field studies performed with the targeted community. Field researches are interventional type investigations which are performed with the intention to provide primary prophylaxis, namely to determine the effectiveness of any preventive method or service aimed at healthy people [5].

Field researches are very helpful methods of accumulating additional information which can not be gathered using health information, and surveillance systems as is the case in many developing countries [6]. Using field researches, some criteria concerning rate of effectiveness, relative effectiveness, rates of

North Clin Istanbul – NCI

maintainability, incidence, and complications can be formulated. In field researches, the group to be investigated, in other words, universe of the research is chosen which is called “reference population”. Sometimes all of the reference population is included in the epidemiological studies, occasionally a sample is selected for investigation which is termed as “sampling” [5]. In field researches, most of the time all individuals of a reference population can not be analyzed. Therefore, a sampling in which every individual in the reference population has a equal chance of participating in the study is selected. This method is more prevalently used in field researches. Accordingly, it is possible to refrain from selection bias.

Even if sampling is selected properly, if individuals can not be reached or they don’t participate in the research as a whole, then research studies can yield erroneous results. This phenomenon is called “nonparticipation rate” which can create research bias [6].

Questionnaire survey is the most frequently applied method in field researches. These questionnaire surveys can be performed as face-to-face interviews, by sending mails or phone calls [7].

Many factors which cause inadequate participation or misleading results including characteristics of the people, and individuals, factors specific to questionnaire survey, and surveyors should be considered. Therefore attempts at preparation of the questionnaire forms, and training of the researchers have been made. However very scarce number of studies have analyzed attitudes of the public towards these questionnaire surveys, and their reasons for participation or non-participation [8]. Especially in Turkey very small number of studies have been performed. Particularly, from the perspective of managers of health care organizations, analysis of the factors influential on non-participation rates in field researches which will otherwise provide valuable information about the development of health improvement programs, and determination of their effectiveness, will make significant contributions on the conduction of field researches in the future. The aim of this study is to determine the participation rate of the people living in the rural areas of Eskisehir Province, and relevant effective factors in field researches.

Ozay et al., Participation of people in rural areas of Eskisehir field researches

MATERIALS AND METHODS This is a descriptive study performed on people aged ≥18 years living in the county centers of Mahmudiye and Beylikova of Eskisehir Province in the year 2013. Mahmudiye county is situtaed in the southeastern region of Eskisehir, 53 km away from the city center The county has a population of 8439 people, and 54.7% (n=4622) of them are living in the city center. Beylikova county is 77 km away from the city center, and situated in the eastern part of Eskisehir. The county has a population of 6789, and 48.1% (n=3270) of them [9] participated in the study. During the study period, interviews were made with 1947 accesible individuals living in the city center including those participating from county centers of Beylikova (n=936), and Mahmudiye (n=1011). The research was conducted with 1482 (76.1%) people who volunteered to participate in the study. The research data were retrieved from the implementation of the questionnaire forms containing 16 targeted items, and prepared using responses obtained by face-to-face interviews. The questionnaire form was prepared in two parts by the researchers in line with the literature information. The first part consists of questions related to the participants’ sociodemographic features, whether they participate in the research, and their reasons for and against participation, while the second part constitutes questions about previous participation of the participants in a field search performed in their living place, and their reasons against participation. In the application of the research, the principles of Helsinki Declaration were taken into consideration, and before initiation of the questionnaire survey the aim of the study, the information about the researchers, and confidentiality of their personal information were explained to the participants, and their written, and verbal approvals were obtained.

For statistical evaluation of data, descriptive statistics, and for categorical variables chi-square test was used. In multivariate analysis, age, gender, educational level, marital status, and working status of the participants were evaluated in order to determine the factors effective on their non-participation in previous field researches performed in their

35

districts. The effects of these variables on rates of non-participation in field researchers were analyzed using logistic regression analysis, and estimated relative risks, and their 95% confidence intervals were calculated. In statistical analyses p<0.05 was accepted as the level of significance.

Results The study subjects (n=559/1482; 37.7%) who volunteered to participate in the research did not want to give their names. Fifty-two percent (n=770) of the study participants were men. Mean age of the participants who gave their names was 45.8±15.9 (min. 18, max. 94) years, while 59.6% (n=870) of them were younger than 50 years of age. As indicated by the participants themselves, educational level of most of the participants was secondary school or higher (n=793; 54.9%), and majority of them was married (n=1095; 76.1%). Besides, more than half of them were working in wage-earning jobs. Distribution of study participants based on some of their sociodemographic characteristics is given in Table 1.

Table 1. Distribution of the participants based on some of their sociodemographic characteristics

Sociodemographic characteristics* Age groups (n=1459) <50 years ≥50 years Gender (n=1482) Female Male Educational level (n=1444) Primary school or illiterate Secondary school and higher Marital status (n=1438) Single Married Employment status (n=1424) Working in a wage-earning jom Not working in a wage-earning job

n %

870 589

59.6 40.4

712 48.0 770 52.0 651 793

45.1 54.9

343 23.9 1095 76.1 707 764

49.6 50.4

Only participants indicating their demographic characteristics were included in the analysis.

*

36

North Clin Istanbul â&#x20AC;&#x201C; NCI

Table 2. Distribution of the reasons of the participants

favouring participation in previous field researches Reasons for participation in previously performed field researches (n=671)

n

Helping the interviewer 315 Thoughts about the benefits of the research 235 Thoughts about beneficial contribution of the research to social development 100 Wanting to talk with different people 21

% 46.9 35.0 14.9 3.2

More than half of the participants (n=881; 59.4%) indicated that they had previously encountered field researches conducted by the academicians of medical faculties, and 77.4% (n=682) of them indicated that they had responded to the questions of the questionnaires. The most frequently (26.9%) indicated rationale asserted by participants for their participation in previously performed field researches in their living environment was their intention to help the researchers performing the questionnaire.

(46.9%) followed by presumed beneficial effects of

the research (35.0%), favourable contribution of the questionnaire survey to the social development (14.9%), and taking pleasure in talking with different people (3.2%). Distribution of the reasons of study participants for their participation in field researches performed previously in their environment is presented in Table 2.

The most frequently indicated three reasons of survey responders for not participating in previously perforrmed field researches performed in their living environment were consideration of the questionnaire survey as waste of time (34.6%), longevity of the items of the questionnaire (32.7%), and being uninformed about the results of the research (31.9%). The distribution of the reasons of non-participation in previously performed field researches are given in Table 3.

In multivariate analysis of the study participants, the effect of age, gender, educational level, marital status, and working status on non-participation of the questionnaire responders in field researches was analyzed, and the non-participation rate of the individuals aged above 50 years of age was found to be 7.35 times higher when compared with younger par-

Table 3. Distribution of the reasons indicated by research participants for not participating in previous field researches performed in their region

Reasons for not participating in previously performed field researches (n=364) Field researches are time-wasting attempts Unnecessarily longer questionnaire items Being uninformed about the resuÄąlts of the research Selection of inconvenient timing, and place of the research Time-consuming questions of the questionnaire Unwillingness to talk with strangers Conduction of the survey at home Frequent implementation of research surveys Inadequate explanation of the interviewer Thoughts about the futility of the research questionnaire The interviewer and the participant of the same gender Concerns about the potential use of personal information gathered in the research for other purposes Content of the questionnaire survey irrelevant to the participant Inappropriate approach of the interviewer Inappropriate physical appearance of the interviewer Requirement for other applications

n

%

126 119 116 115 114 111 108 100 98 97 97 97 96 93 90 78

34.6 32.7 31.9 31.6 31.3 30.5 29.7 27.5 27.0 26.7 26.7 26.7 26.4 25.6 24.7 21.4

Ozay et al., Participation of people in rural areas of Eskisehir field researches

ticipants (59% CI; 2.87-18.81, p<0.001). Estimated relative risks (ERRs), and confidence intervals (CIs) of the factors effective on the rates of non-participation of the questionnaire responders based on the results of the multivariate analysis are given in Table 4.

Discussion Generally, investigations performed on participation rates in epidemiological researches have been related to clinical researches, and scarce number of researches have been conducted on rates of participation in field researches. This research will contribute to the literature on the issue of participation in field researches, and relevant effective factors. The participation rate in this field research conducted in the rural area of Eskisehir Province was detected as 76.1 percent. The rate of participation in epidemiological studies reportedly ranged between 48, and 78.5 percent [10, 11, 12, 13]. In a study performed in Turkey, the researchers reported that 11% of the individuals closed the door to the interviewers without listening them, and 57% of the individuals agreed to participate in the research after listening the information given to them [14]. Bias can be created dependent on non-participation in epidemiological researches. Achievement of the lowest pos-

37

sible rates of non-participation is recommended to prevent creation of bias. Any known cut-off value does not exist for rates of non-participation in epidemiological studies. However some authors have advocated that non-participation rate in a research should be above 20 percent [15].

The study participants indicated that the most frequent reason of their participation in the previously perforrmed field researches was their intention to help interviewers. This respond was followed by consideration of benefial aspects of this research, and its contribution to social development. The least frequently asserted reason favouring participation was the desire to talk with different people. In a study performed in Italy, the participants stated their reasons for participation in cohort studies as making contribution to the research, and science [16]. In a study conducted in the USA, the participants expressed their most important reason of participating in clinical researches as their beneficial effects on health [17]. The outcome of our study is different from both of these studies which could be related priorly to different study designs of these two above-mentioned studies. Besides, our field of research was the training, and research area of ESOGU Faculty of Medicine Department of Public Health where department of public health are mak-

Table 4. Distribution of estimated relative risks (ERR), and confidence intervals of the factors affecting on the rates of participation in field researches as assessed in multivariate analysis Characteristics*

ERR

Age (R: <50 years) >50 years Gender (R: Male) Female Educational level (R: Primary school or illiterate) Secondary school and higher Marital status (R: Single) Married Employment status (R: Working in a wage earning-job) Not working in a wage earning-job

p

Min.

Max.

7.354

2.875

18.812

1.687

0.793

3.590

0.175

0.488

0.218

1.094

0.082

2.000

0.826

4.841

0.124

1.021

0.444

2.346

0.961

Only participants indicating their demographic characteristics were included in the analysis.

*

95% CI

<0.001

38

ing frequent research studies. As a matter of fact nearly one third of our study participants indicated that they had been encountered field researches conducted by medical faculty physicians, and great majority (77.4%) of them responded the questions of our survey which also substantiated our assertion.

The most frequently asserted reasons for not participating in previously performed field researches were indicated as consideration of questionnaire survey as waste of time, unnecessarily longer questionnaire items, and being uninformed of the results of the research. In a study performed in the UK, as the most important reasons for not participating in the study were expressed by the participants as their inability to contribute to the researches, their reluctance to entertain strangers at their homes, and their unwillingness to respond to the questions related to their personal life [11]. In an investigation performed in Pakistan, as the most important reasons for non-participation, objections of the family members, and fear from interventional applications of the research outcomes were indicated [13]. In a study realized in Italy, the participants stated their reason for non-participation in cohort studies as unnecessarily long study periods [16]. In an investigation performed in China, the participants indicated their reasons of not participating in cohort studies as longer duration of the study, requirement for more information about the research, and their desire to decide to participate together with their families [18]. In an investigation in our country, the authors reported that brevity or longevity of the questions in the questionnaire forms designed to gather relevant data effected rates of participation in the study, and longer questions restricted participation rates. In the same study, it was demonstrated that if well-trained interviewers asked questions of the survey study, then non-participation rates decreased. It has been also revealed that if the interviewers who gathered data of the research by means of the questionnaires have adequate social skills, then they have a tendency to understand social behaviours, and interactions more fully. Besides, it has been also demonstrated that they can convince the participants to respond to the questions which effect the participation rate favourably [19]. In our research nearly one- fourth

North Clin Istanbul â&#x20AC;&#x201C; NCI

of the participants indicated that the approach of the interviewers was not appropriate, and their physical appearance was not proper which effected participation rates unfavourably. All of these findings also reinforce the above-mentioned argument.

The outcomes of our investigation resemble to those obtained in another study performed in our country, but contrary to the results reported in the foreign literature. This difference might stem from diversities in study designs. Since only a few number of investigations have been performed related to the rates of participation in field researches, outcomes of the clinical, and cohort studies were used to determine participation rates. For this reason different results have been observed. When outcomes of non-participation rates in our research are carefully evaluated, among reasons of not participating in the study, the thoughts of the participants, and content of the questionnaire forms were more predominant, while etiological factors related to the researchers were considered as a less important issues. In the light of our investigation, unnecessarily long questions are among the etiological factors adversely effecting rates of participation in field researches.

Preparation of a questionnaire aiming at gathering data can be thought to be a simple procedure, however in fact it is a very difficult task. Incomplete application of the questionnaire survey for various reasons including unnecessary long questions, presumably boring questions, and types of the questions asked will directly effect rates of participation in the study. Therefore utmost care should be exercised while preparing questionnaire forms. Questions of the survey forms should be simple, clear-cut, and comprehensible. It should not contain inflicting, leading, time-consuming, and long questions. The items of the questionnaire should be prepared using terminologies which can be easily understood by the interviewers, and the participants. Before field researches, the questionnaire forms should be pretested for their applicability [6]. In our research, another important reason for not participating in the field research was participantsâ&#x20AC;&#x2122;being uninformed about the study results. Therefore, after completion of the research, sharing the outcomes with public, and healthcare authorities will carry utmost impor-

Ozay et al., Participation of people in rural areas of Eskisehir field researches

tance for planning, and more effective conduction of healthcare services. Besides, sharing the research outcomes with the population of the region, and at least with the participants will increase rates of participation in field researches, and make important contributions as for community participation in health care services.

As a result of multivariate analysis performed, age was found to be an influential factor on participation. Participants aged 50 and over participated in field researches less frequently. In investigations performed in the USA, and UK, age was also reported as one of the effective factors on non-participation. Decrease in the incidence of participation in researches was associated with advanced age [11, 17]. Literature findings were in compliance with our outcomes which demonstrated decrease in rates of participation in researches with aging [20]. Besides in our research, lower rates of participation among elderly might stem from their unwillingness to talk with strangers. In a study conducted in the UK, as causes of non-participation in researches, inqury of personal, and confidential information, reluctance to entertain strangers at oneâ&#x20AC;&#x2122;s home were put forth which also support our assertions [11]. In addition, mental capacities of the people deteriorate with aging which unfavourably effect their desire to participate in a research with resultant decrease in the number of responses given to the questions of the survey study. Similarly in an investigation performed in the UK, the reasons of not participating in a research were stated by participants as thinking themselves too old for taking part in survey studies, and feeling themselves inadequate as for their personal capabilities [11]. In the literature among other factors precluding participation in researches, gender, educational, and socioeconomical were cited [11, 14, 21, 22]. Any correlation between these variables, and non-participation rates was not found in our investigation which might be explained by the characteristic design of our investigation (field research), and the place where our research was conducted, namely rural are of Eskisehir Province.

Indeed, other similar studies cited in the literature have been more frequently clinical, and cohort studies realized under clinical settings or urban areas.

39

In conclusion, our investigation on the rate of participation in field researches performed in the rural area of Eskisehir Province, and the relevant effective factors determined that the individuals participated in field researches so as to help the interviewer, while those not participating in the research most frequently thought that field researches were timewasting, futile attempts. As an outcome of multivariate analysis, age of the participants was found to be a factor effective on participation in field researches performed in the rural area of Eskisehir Province.

Elder patients are participating less frequently in field researches. Lower rates of participation in field researches induce creation of bias. This phenomenon can lead to erroneous research outcomes, and misleading statistical results. Therefore, it is important to keep rates of participation in field researches at a maximum level as possible. To that end as a priority, the interviewers conducting the research should be informed about the field researches, and field researches should be planned attentively, and accurately. Besides, information about the field researches should be provided to public authorities, and managers of the health organizations living in the region where field researches will be performed.

This approach can effect participation rates in field researches favourably. Still, the people who will be subject to field research should be also informed.

This informing process should encompass sharing the results before, during, and after completion of the research. Preparation, and application of the questionnaire forms which are the most important means of gathering data should deserve meticulous care. On this subject researchers who are the driving force of the field researches, and interviewers who will perform the survey should be trained. For sound conduction of field researches which is a very beneficial epidemiological method so as to gather important information in the field of health, training of especially healthcare managers, and workers carries utmost importance. This research performed in a rural area of Eskisehir Province has a critical importance in that it is one of the rarely performed investigations on this issue. Conduction of further studies on this issue conveys importance for their outcomes, and their contributions on this subject.

40 Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

REFERENCES 1. Öztek Z, Üner S, Eren N. Halk sağlığı kavramı ve gelişmesi. In: Güler Ç, Akın L, editors. Halk sağlığı temel bilgiler. Ankara: Hacettepe Üniversitesi Yayınları; 2012. s. 3-24.

2. Beaglehole R, Bonita R. Public health at the crossroads: achieve ments and prospects. Cambridge, Cambridge University Press, 2004.

3. Last JM. A dictionary of epidemiology, 4th ed. Oxford, Oxford University Press, 2001.

4. Bonita R, Beaglehole R, Kjellström T. Basic epidemiology. 2nd ed. Geneva, World Health Organisation, 2006.

5. Tezcan S. Epidemiyoloji. In: Güler Ç, Akın L, editors. Halk sağlığı temel bilgiler. Ankara: Hacettepe Üniversitesi Yayınları; 2012, s. 95-156.

6. Vaughan JP, Morrow RH. Manual of epidemiology for district health management. Geneva, World Health Organisation, 1989.

7. Groves RM. Survey errors and survey costs. New York, John Wiley & Sons Inc., 1989.

8. Mfutso-Bengo J, Masiye F, Molyneux M, Ndebele P, Chilungo A. Why do people refuse to take part in biomedical research studies? Evidence from a resource-poor area. Malawi Med J 2008;20:57-63.

9. Adresedayalınüfuskayıtsistemisonuçları.Availableat:http://www. tuik.gov.tr/PreTabloArama.do?metod=search&araType=vt. Accessed March 27, 2014.

10. Curtin R, Presser S, Singer E. Changes in telephone survey nonresponse over the past quarter century. Public Opin Q 2005;69:87-98.

11. Williams B, Irvine L, McGinnis AR, McMurdo ME, Crombie IK. When “no” might not quite mean “no”; the importance of informed and meaningful non-consent: results from a survey of individuals refusing participation in a health-related research

North Clin Istanbul – NCI project. BMC Health Serv Res 2007;7:59.

12. Nechuta S, Mudd LM, Biery L, Elliott MR, Lepkowski JM, Paneth N; Michigan Alliance for the National Children’s Study.

Attitudes of pregnant women towards participation in perinatal epidemiological research. Paediatr Perinat Epidemiol 2009;23:424-30.

13. Rohra DK, Khan NB, Azam SI, Sikandar R, Zuberi HS, Zeb A, et al. Reasons of refusal and drop out in a follow up study involving primigravidae in Pakistan. Acta Obstet Gynecol Scand 2009;88:178-82.

14. Erdoğan N, Erdoğan İ. Araştırmalarda veri toplamaya ve bulgulara etki eden kirletilmiş bilinç üzerine bir inceleme. Selçuk İletişim Dergisi 2005;3:5-17.

15. Ay P. Hata: Rastlantısal hata ve yan tutma. In: Topuzoğlu A, Ay P. Kanıta dayalı tıp: klinik epidemiyolojik araştırmaların eleştirel değerlendirilmesi. İstanbul: Ege Yayınları; 2007.

16. Vecchi Brumatti L, Montico M, Russian S, Tognin V, Bin M, Barbone F, et al. Analysis of motivations that lead women to participate (or not) in a newborn cohort study. BMC Pediatr 2013;13:53.

17. Halpern SD, Karlawish JH, Casarett D, Berlin JA, Townsend RR, Asch DA. Hypertensive patients’ willingness to participate in placebo-controlled trials: implications for recruitment efficiency. Am Heart J 2003;146:985-92.

18. Qiu X, He J, Qiu L, Larson CP, Xia H, Lam KB. Willingness of pregnant women to participate in a birth cohort study in China.

Int J Gynaecol Obstet 2013;122:216-8.

19. Alkaya A, Esin A. Item nonresponse reasons and effects. GUJ Sci 2005;18:577-89.

20. Herzog AR, Rodgers WL. Age and response rates to interview sample surveys. J Gerontol 1988;43:S200-5.

21. Goldberg M, Chastang JF, Leclerc A, Zins M, Bonenfant S, Bugel I, et al. Socioeconomic, demographic, occupational, and health factors associated with participation in a long-term epidemiologic survey: a prospective study of the French GAZEL cohort and its target population. Am J Epidemiol 2001;154:373-84.

22. Pedersen P, Nohr EA, Søgaard HJ. Nonparticipation in a Danish cohort study of long-term sickness absence. J Multidiscip Healthc 2012;5:223-9.

Orıgınal Article

internal medicine

North Clin Istanbul 2015;2(1):41-47 doi: 10.14744/nci.2015.41713

The effect of sociodemographic and clinical features on mortality in patients with diagnosis of aspiration pneumonia Mehmet Nuri Ozer1, Mehmet Uzunlulu1, Aytekin Oguz1, Osman Kostek1, Erdal Akyer1, Mumtaz Takir2 Department of Internal Medicine, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey

1

Department of Internal Medicine and Division of Endocrinology, Istanbul Medeniyet University Goztepe Training and Research

2

Hospital, Istanbul, Turkey

ABSTRACT OBJECTIVE: The aim of this study was to evaluate the sociodemographic and clinical chracteristics of patients hospitalized with aspiration pneumonia in internal medicine clinics, and to determine the incidence and parameters of mortality among these patients.

METHODS: Patients over the age of 18 years who were hospitalized in clinics of internal medicine between January 1, 2010 and January 1, 2013 (115 male, 89 female; mean age: 77±13 years; patients aged 65 years and over, 88.2%; average duration of hospitalization, 11±9 days) were evaluated retrospectively and consecutively.

The incidence of mortality, nutritional status at admission, comorbidity frequency, haematological and biochemical data and their relationship with mortality were evaluated.

RESULTS: At admission, 85% of the patients were fed through oral route, while 15% of them were fed through PEG. There was no relation between nutritional status of the patients (oral, nasogastric tube or PEG) at admission, and development of aspiration pneumonia. Commonly seen comorbidities were dementia (49%), hypertension (43%), cerebrovascular accident (42%), and diabetes mellitus (31%) respectively. The mortality rate was 24.5% (in first three days, 56%). A correlation was found between mortality and increase in neutrophil/lymphocyte ratio (NLR) and increased uric acid rate (for both p<0.05).

CONCLUSION: In this study, the mortality rates among patients diagnosed with aspiration pneumonia was found to be increased. The high number of geriatric patients and comorbidities might have played a role in this situation.

Neutrophil/lymphocyte ratio (NLR) and uric acid levels in patients with aspiration pneumonia might be evaluated as factors related to mortality.

Key words: Aspiration pneumonia; comorbidity; internal medicine clinic; mortality.

Received: January 30, 2015 Accepted: April 09, 2015 Online: April 24, 2015 Correspondence: Dr. Mehmet Nuri Ozer. Goztepe Egitim ve Arastirma Hastanesi, Ic Hastaliklari Klinigi, 34710 Istanbul, Turkey.

Tel: +90 216 - 570 91 95 e-mail: drnuri21@hotmail.com © Copyright 2015 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com

42

A

spiration pneumonia is an alveolar infection stemming from inhalation of the pathogenic material in the oropharynx [1]. Demographic factors as advanced age, male gender, comorbidities as dysphagia, diabetes mellitus, severe dementia, deletion of angiotensin -converting enzyme-1, genotype, bad oral hygiene, Parkinson’s disease, malnutrition medications as antipsychotics, proton pump inhibitors, and ACE-inhibitors have been demonstrated as risk factors for aspiration pneumonia [2].

Aspiration pneumonia constitutes 5-15% of community-acquired pneumonia, and it is still responsible for 20% of community-acquired pneumonia among elder people, and ranks second among the most frequently seen nosocomial infections after urinary tract infections [1, 3, 4]. Actuıal incidence of aspiration pneumonia may be higher. As observed by many authors, indeed 50% of healthy individuals, and 70% of the elder population have aspirated something during their sleep [5, 6]. Aspiration pneumonia is one of the most important causes of hospitalization especially of elder people, those with neurological problems or individuals staying in nursing homes.

In the community, the number of geriatric patients increase in parallel with prolongation of mean life span. In addition, higher incidence of comorbidities as dementia, stroke, Alzheimer’s disease, diabetes, and hypertension also increases rates of hospitalization. The objective of this study was to evaluate mortality, nutritional status, sociodemographic characteristics, and factors effective on martality.

MATERIALS AND METHODS Medical files of the patients aged 18 and over who were hospitalized in the Clinics of Internal Medicine of Istanbul Medeniyet University Goztepe Training and Research Hospital between January 1, 2010, and January 1, 2013 with the diagnosis of pneumonia were retrieved from otomation system, and patients’ archives of the hospital and analyzed, and included in the study. The approval (date: January 24, 2013; decision #: 30/H) of the Ethics Committee of Istanbul Medeniyet University Goztepe Training and Research Hospital was obtained.

North Clin Istanbul – NCI

During the study period, principles of Helsinki Declaration were taken into consideration.

Study design: On patient registration forms, age, gender, diagnosis of admission in the Service of Internal Medicine, nutritional status, duration of hospitalization, clinical, and laboratory information, and prognoses (rates of discharge or exitus), comorbidities (chronic obstructive pulmonary disease, diabetes mellitus, heart failure, hypertension, chronic renal disease, chronic ischemic heart disease, atrial fibrillation, dementia, Parkinson’s disease, and cerebrovascular disease) were recorded. Mortality rates, nutritional status, frequency of comorbidities, hematological, and biochemical data, and their relation with mortality were evaluated. Data of the patients discharged, and exited were also compared.

Diagnosis of aspiration pneumonia: Despite lack of defined, and precise diagnostic criteria diagnosis of aspiration pneumonia was made based on witnessed event of aspiration or strong evidence of suspect aspiration (abnormal swallowing function, and dysphagia) and confirmation of findings of pulmonary inflammation [1].

Laboratory parametres: From patients’files, whole blood counts, biochemical data (glucose, urea, uric acid, creatinine, sodium, potassium, phosphorus, aspartate aminotransferase, alanine transferase, total bilirubin, indirect bilirubin, gamma glutamyl transferase, alkaline transferase, lactate dehydrogenase, cholesterol, triglyceride, HDL-cholesterol, LDL-cholesterol, creatinine kinase, CK-MB, iron, iron-binding capacity, amilase, lipase, protein, albumin, sedimentation rate, C-reactive protein, aPTT, INR, HbA1c, TSH, freeT3, free T4, ferritin, folic acid, and vitamin B12) were recorded.

Statistical analyses were performed using SPSS for Windows V.21.0 program. Before analyses, fitness of variables to normal distribution pattern was analyzed using Kolmogorov- Smirnov test.

Continuous variables were expressed as mean±SD. Classified and numerical data were analyzed using chi-square test, Student’s t test, and Mann-Whitney U test, respectively. Independent factors effective on mortality, and results of logistic regression analysis were expressed as levels of significance, and

Ozer et al., The effect of sociodemographic and clinical features on mortality in patients with diagnosis of aspiration pneumonia

estimated relative risks (odds ratio-OR), and 95% confidence intervals (95% CI) Results at a level of significance of p<0.05 within 95% confidence interval were accepted as statistically significant values.

RESULTS A total of 204 (115 male, and 89 female) patients diagnosed as aspiration pneumonia with a mean age of 77±13 years, and duration of hospitalization of 11±9 days were included in the study. Median mortality rate was 24.5 percent. Eighty-eight percent of the patients were older than 65 years of age.

Nearly 56% of the deaths occurred within the first 3 days. At first admission, the patients were receiving their nutrients through oral route (n=174; 85%) or percutaneous endoscopic gastrostomy (PEG) (n=30; 15%). Distribution of demographic data, and comorbidities are given in Table 1. The most frequently associated comorbidities were dementia (49%), hypertension (43%), cerebrovascular events (42%), and diabetes mellitus (31%). Hospitalization rates were higher in discharged patients when compared with exited patients (p=001).

Laboratory data are given in Tables 2, and 3.

43

When compared with survived patients, in exited patients neutrophil/lymphocyte ratio, urea, uric acid, ALP, LDH, phosphorus, prothrombin time were relatively higher (for all, p<0.05), while TSH, and free T3 levels were lower (for all, p<0.05).

In a multivariate logistic regression analysis where factors effective on mortality were evaluated, increased uric acid levels, and neutrophil/lymphocyte ratios predicted mortality. In these patients uric acid levels, and neutrophil/lymphocyte ratios were higher in exited patients when compared with those discharged. Uric acid levels higher than 5.35 mg/ dL (AUC=0.620) have 61.3% sensitivity, and 62% specificity in predicting mortality, however neutrophil/lymphocyte ratios over 10.63 (AUC=0.608) have 44% sensitivity, and 74% specificity in predicting mortality.

DISCUSSION In this study, 88.2% of the cases with aspiration pneumonia were over 65 years of age, and at admission the patients were fed via oral (85%) route or PEG (15%). Development of aspiration pneumonia had no effect on the patients’ nutritional

Table 1. Demographic characteristics and comorbidities of the patients

Age, years Gender, M/F Duration of hospitalization, days Comorbidities

Renal diseases

Diabetes mellitus

Hypertension Congestive heart failure Atrial fibrillatiion Chronic ischemic heart disease

Dementia Parkinsonism

Cerebrovascular disease

Total (n=204)

Discharged (n=154)

Exited (n=50)

p

n % n % n % 77±13 78±13 75±16 NS 115/89 89/65 26/24 NS 11±9 12±7 7±12 0.001 14 6.6 8 4 6 3 64 31 42 21 32 15 91 45 65 33 26 13 27 13 19 9 18 5 26 12 14 7 12 6 34 17 24 12 10 5 104 49 83 42 21 11 20 10 18 9 2 1 89 42 69 35 20 10

NS NS NS NS NS NS NS NS NS

44

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Table 2. Hematological parameters of patients with aspiration pneumonia

Total Discharged Exited (n=204) (n=154) (n=50)

p

Hematocrit (%) 34.5±7.5 34.7±8.1 33.8±5.5 NS 284±140 292±142 258±126 NS Platelet (103/mm3) Leukocyte (103/mm3) 13447±6180 13200±6150 14200±6275 NS Neutrophil (103/mm3) 11380±7670 11196±8160 11950±5960 NS Lymphocyte (103/mm3) 1300 (900-1800) 1300 (900-1800) 800 (700-1400) 0.02 Neutrophil/Lymphocyte 7.6 (4.3-12.3) 7.1 (3.8-11.4) 8.7 (4.5-19.7) 0.05 Neutrophil/Leukocyte 0.82 (0.74-0.88) 0.82 (0.75-0.87) 0.82 (0.76-0.91) NS Lymphocyte/Leukocyte 0.13±0.08 0.13±0.058 0.11±0.08 NS MCV1 (fL) 88 (84-94) 88 (84-93) 84 (82-95) NS RDW2 (%) 15.5±2.5 15.3±2.2 15.7±3.1 NS MPV3 (fL) 9.8±6.9 9.9±7.9 9.4±1.3 NS PDW4 (GSD) 16.3 (15.6-17.5) 16.3 (15.6-17.5) 16.3 (15.8-17.5) NS Iron (µgr/dL) 23 (14-37) 23 (14-35) 40 (18-48) NS Folate (pg/ml) 8.1±5.5 8.1±5.6 7.9±5.2 NS Vitamin B12 (pg/ml) 320 (198-520) 316 (198-542) 542 (270-970) 0.05 MCV1: Mean corpuscular volume; RDW2: Erythrocyte distribution width (%); MPV3: Mean platelet volume; PDW4: Platelet distribution width.

status (oral, nasogastric tube or PEG). The most frequently seen comorbidities were dementia, hypertension, cerebrovascular event, and diabetes mellitus. Mortality rate was 24.5% (56% within the first 3 days). Increase in neutrophil/lymphocyte ratios (NLRs), and uric acid levels were found to be related to mortality (for both, p<0.05).

Demographic characteristics as advanced age, and male gender were known to be risk factors for aspiration pneumonia. In a study where mortality rates in inpatients with aspiration pneumonia were investigated, median age of the patients, and percentage of male patients were reported as 76.7 years, and 50.2%, respectively [7]. In a prospective study on 62 cases performed by Tokuyasu et al. median age of the patients was 86.6 years, and male patients constituted 56.8% of the study population [8]. In their retrospective study by Fidan et al. on 31 cases with aspiration pneumonia, median age of their study population was 61 years, while 55% of their patients consisted of male patients [9]. In our study median age of 204 patients diagnosed as aspiration pneumonia in the clinics of internal medi-

cine was 77 years, and 56% of the study population comprised of male patients. Similar to the literature findings, distribution of aspiration pneumonia was nearly the same in both genders, and medain age of the patients was similar to that encountered during literature reviews.

Aspiration can cause serious problems especially in patients with dementia. In a study by Feinberg et al. the authors performed a study in nursing home patients using modified videofluoroscopy guided swallowing test with barium, and detected events of major, and minor aspiration in 24, and 50% of the patients, respectively [10]. In a study by Metan et al. the most frequent comorbidity in their patients with aspiration pneumonia was neurological diseases (78%) which were detected in 20% of the patients with dementia [11]. Still in our study, great majority of the patients with aspiration pneumonia had a neurological disease (cerebrovascular disease, dementia, Parkinson’s disease), and 49% of the study population consisted of patients with dementia.

Relationship between enteral nutrition, and complication of aspiration is already acknowledged.

45

Ozer et al., The effect of sociodemographic and clinical features on mortality in patients with diagnosis of aspiration pneumonia

Table 3. Biochemical parameters of the patients

Glucose (mg/dL) Urea (mg/dL) Uric acid (mg/dL) Creatinine (mg/dL) Sodium (mEq/L) (Mean±SD) Potassium (mEq/L) (Mean±SD) AST1 (U/L) ALT2 (U/L) T bilirubin3 (mg/dL) I Bilirubin4 (mg/dL) GGT5 (U/L) ALP6 (U/L) LDH7 (U/L) Cholesterol (mg/dL) (Mean±SD) Triglyceride (mg/dL) (Mean±SD) HDL-C8 (mg/dL) (Mean±SD) LDL-C9 (mg/dL) (Mean±SD) CK10 (U/L) Protein (g/dL) (Mean±SD) HbA1c11 (%) Phosphorus (mEq/L) INR12 (%) TSH13 (uIU/mL) FreeT314 (pgr/mL) FreeT415 (ng/dL)

Total Exited Discharged (n=204) (n=50) (n=154) 109 (82-162) 61 (41-113) 5 (3.5-6.5) 0.9 (0.6-1.4) 141±10 4.2 (3.7-4.5) 26 (18-49) 20 (13-35) 0.56 (0.37-0.8) 0.41 (0.28-0.6) 29 (16-62) 79 (64-100) 244 (211-329) 136±45 115±70 33±15 83±37 106 (47-224) 6.1±0.8 5.8 (5.5-6.7) 3.3 (2.8-4) 1.25 (1.18-1.36) 1.12 (0.66-2.26) 2.06 (1.74-2.30) 1.06 (0.87-1.23)

149 (85-178) 79 (46-156) 5.9 (4.1-8.2) 1.3 (0.7-2.6) 140±10 4.3 (3.9-4.9) 30 (22-69) 25 (13-41) 0.64 (0.47-0.89) 0.45 (0.23-0.65) 48 (16-98) 92 (73-114) 262 (227-367) 142±64 129±65 32±18 85±49 77 (29-109) 6.1±0.7 5.8 (5.6-7) 4 (3.2-4.7) 1.32 (1.25-1.45) 0.99 (0.33-1.91) 1.85 (1.59-2.15) 1.08 (0.89-1.23)

108 (82-145) 56 (38-101) 4.9 (3.4-5.9) 0.9 (0.6-1.2) 141±10 4.1 (3.6-4.4) 25 (18-42) 20 (13-32) 0.53 (0.36-0.88) 0.41 (0.27-0.62) 27 (17-53) 76 (61-93) 246 (207-288) 134±39 111±73 33±14 82±33 122 (52-227) 6.2±0.8 5.7 (5.5-6.6) 3.2 (2.7-3.7) 1.23 (1.16-1.3) 1.33 (0.69-2.34) 2.12 (1.81-2.33) 1.06 (0.87-1.23)

p

0.02 0.002 0.003 0.015 NS NS 0.02 0.04 0.02 0.05 0.01 0.003 0.007 NS NS NS NS NS NS NS <0.001 0.008 0.059 0.005 NS

AST1: Acid transferase; ALT2: Alkaline transferase; T. bilirubin3: Total bilirubin; I. Bilirubin4: Indirect bilirubin; GGT5: Gamma glutamyl transferase; ALP6: Alkaline phosphatase; LDH7: Lactate dehydrogenase; HDL-C8: High-density lipoprotein cholesterol; LDL-C9: Low-density lipoprotein cholesterol; CK10: Creatinine kinase; HbA1c11: Hemoglobin A1c; INR12: International normalized ratio; TSH13: Thyroid stimulating hormone; Free T314: Triiodothyronine; FreeT415: Thyroxine.

In patients on tube feeding, and those dependent on others for oral hygiene, the risk of aspiration was observedly 20-fold higher when compared with healthy individuals [12, 13]. Nakajoh et al. investigated one-year incidence of aspiration pneumonia in patients who experienced a cerebrovascular event, and observed its incidence as 54.3% in dysphagic patients on oral intake which was higher than dysphagic cases on tube feeding (13.2%). The incidence of aspiration pneumonia was 64.3% in bedridden patients fed through nasogastric tube [14]. Our patients were fed via PEG (15%) or through oral

route (85%) at admission. This finding suggests that aspiration pneumonia is more frequently seen in elder patients fed through oral route, and alimentation through PEG has not any prophylactic effect in these cases.

Though mortality rates of aspiration pneumonia ranged between 20, and 50%, in some studies higher rates up to 80% have been reported [15, 16, 17, 18].

In our study median rate of mortality was found as 24.5% in compliance with the literature findings.

In cases with aspiration pneumonia, disparities between mortality rates can be attributed to the lack

46

of definitive diagnostic criteria defined for aspiration pneumonia, and higher mortality rates can be associated with advanced age of these patients, and concomitant diseases.

In recent years an index which reflects both acute inflammation, and lymphopenia developing after acute physiologic stress has been started to be used. This index is a neutrophil/lymphocyte ratio which has been reported to be a good marker of the inflammatory state [19]. Duffy et al. divided 1046 patients into 3 groups (mean NLR 1.7±0.5; 3.2±0.6; 11.2±12.9) before percutaneous coronary intervention, and followed them for postoperative 32 months. They reported 144 cases of death, and in patients with increased neutrophil/lymphocyte ratios, higher mortality rates were detected [20]. In a study performed on non-small cell lung cancer patients who had undergone complete resection, Sarraf et al. detected higher mortality rates in patients with increased neutrophil/lymphocyte ratios [21]. Uthamalingam et al. divided 1212 patients with diagnosis of acute decompensated heart disease according to their neutrophil/lymphocyte ratios, and found a positive correlation between mortality, and neutrophil/lymphocyte ratios during a median follow-up period of 26 months [22]. In our study, we also found a correlation between mortality, and neutrophil/leukocyte ratios in patients with aspiration pneumonia which suggests that this parametre can be used as an easily available, simple, and cost-effective marker.

Uric acid is considered as a cardiovascular risk marker [23]. In a study performed by Tomita et al. the authors reported higher risk of all-cause death (from coronary heart disease, stroke, liver disease and/or renal failure) in 49413 patients aged between 25, and 60 years with uric acid levels over 8.5 mg/dl during a median follow-up period of 5.5 years when compared with those with uric acid levels at 5-6.4 mg/dl [24]. In our study relationship between uric acid levels, and mortality supports their outcome.

In conclusion, in this study we found increased mortality rates in patients hospitalized with the diagnosis of aspiration pneumonia. Higher number of geriatric patients, and also higher incidence rates of comorbidities may be responsible for higher mor-

North Clin Istanbul – NCI

tality rates. Neutrophil/lymphocyte ratios (NLR), and uric acid levels can be evaluated as mortalityrelated factors in cases with aspiration pneumonia.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

REFERENCES 1. Marik PE. Aspiration pneumonitis and aspiration pneumonia.

N Engl J Med 2001;344:665-71.

2. van der Maarel-Wierink CD, Vanobbergen JN, Bronkhorst EM, Schols JM, de Baat C. Risk factors for aspiration pneumonia in frail older people: a systematic literature review. J Am Med Dir Assoc 2011;12:344-54.

3. Mylotte JM. Nursing home-acquired pneumonia. Clin Infect Dis 2002;35:1205-11.

4. Langmore SE, Terpenning MS, Schork A, Chen Y, Murray JT, Lopatin D, et al. Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia 1998;13:69-81.

5. Marrie TJ. Community-acquired pneumonia in the elderly. Clin Infect Dis 2000;31:1066-78.

6. Gleeson K, Eggli DF, Maxwell SL. Quantitative aspiration during sleep in normal subjects. Chest 1997;111:1266-72.

7. Heppner HJ, Sehlhoff B, Niklaus D, Pientka L, Thiem U. Pneumonia Severity Index (PSI), CURB-65, and mortality in hospitalized elderly patients with aspiration pneumonia. [Article in German] Z Gerontol Geriatr 2011;44:229-34. [Abstract] 8. Tokuyasu H, Harada T, Watanabe E, Okazaki R, Touge H, Kawasaki Y, et al. Effectiveness of meropenem for the treatment of aspiration pneumonia in elderly patients. Intern Med 2009;48:129-35.

9. Fidan A, Cömert SŞ, Tokmak M, Saraç G, Salepçi B, Kıral N. Retrospectıve Analysıs Of Aspıratıon Pneumonıa Cases. Kartal Eğitim ve Araştırma Hastanesi Tıp Dergisi 2008;19:113-6.

10. Feinberg MJ, Ekberg O, Segall L, Tully J. Deglutition in elderly patients with dementia: findings of videofluorographic evaluation and impact on staging and management. Radiology 1992;183:811-4.

11. Metan G, Bozkurt İ, Yıldız O, Alp E, Aygen B, Sümerkan B. Do We Need Blood Cultures for The Management of Aspiration Pneumonia? Erciyes Tıp Dergisi 2010;32:241-6.

12. van der Maarel-Wierink CD, Vanobbergen JN, Bronkhorst EM, Schols JM, de Baat C. Oral health care and aspiration pneumonia in frail older people: a systematic literature review. Gerodontology 2013;30:3-9.

13. Cogen R, Weinryb J. Aspiration pneumonia in nursing home patients fed via gastrostomy tubes. Am J Gastroenterol 1989;84:1509-12.

Ozer et al., The effect of sociodemographic and clinical features on mortality in patients with diagnosis of aspiration pneumonia

14. Nakajoh K, Nakagawa T, Sekizawa K, Matsui T, Arai H, Sasaki H. Relation between incidence of pneumonia and protective reflexes in post-stroke patients with oral or tube feeding. J Intern Med 2000;247:39-42.

15. Pugliese G, Lichtenberg DA. Nosocomial bacterial pneumonia: an overview. Am J Infect Control 1987;15:249-65.

16. Marrie TJ, Durant H, Kwan C. Nursing home-acquired pneumonia. A case-control study. J Am Geriatr Soc 1986;34:697702.

17. Bosch X, Formiga F, Cuerpo S, Torres B, Ros贸n B, L贸pez-Soto A. Aspiration pneumonia in old patients with dementia. Prognostic factors of mortality. Eur J Intern Med 2012;23:720-6.

18. Dines DE, Titus JL, Sessler AD. Aspiration pneumonitis. Mayo Clin Proc 1970;45:347-60.

19. Gibson PH, Cuthbertson BH, Croal BL, Rae D, El-Shafei H, Gibson G, et al. Usefulness of neutrophil/lymphocyte ratio as predictor of new-onset atrial fibrillation after coronary artery bypass grafting. Am J Cardiol 2010;105:186-91.

20. Duffy BK, Gurm HS, Rajagopal V, Gupta R, Ellis SG, Bhatt

47

DL. Usefulness of an elevated neutrophil to lymphocyte ratio in predicting long-term mortality after percutaneous coronary intervention. Am J Cardiol 2006;97:993-6.

21. Sarraf KM, Belcher E, Raevsky E, Nicholson AG, Goldstraw P, Lim E. Neutrophil/lymphocyte ratio and its association with survival after complete resection in non-small cell lung cancer. J Thorac Cardiovasc Surg 2009;137:425-8.

22. Uthamalingam S, Patvardhan EA, Subramanian S, Ahmed W, Martin W, Daley M, et al. Utility of the neutrophil to lymphocyte ratio in predicting long-term outcomes in acute decompensated heart failure. Am J Cardiol 2011;107:433-8.

23. Niskanen LK, Laaksonen DE, Nyyss枚nen K, Alfthan G, Lakka HM, Lakka TA, et al. Uric acid level as a risk factor for cardiovascular and all-cause mortality in middle-aged men: a prospective cohort study. Arch Intern Med 2004;164:1546-51.

24. Tomita M, Mizuno S, Yamanaka H, Hosoda Y, Sakuma K, Matuoka Y, et al. Does hyperuricemia affect mortality? A prospective cohort study of Japanese male workers. J Epidemiol 2000;10:403-9.

Orıgınal Article

dermatology

North Clin Istanbul 2015;2(1):48-54 doi: 10.14744/nci.2015.99608

Three years of retrospective evaluation of skin biopsy results in childhood Seyma Ozkanli1, Ebru Zemheri1, Ilkin Zindanci2, Burce Kuru2, Tulay Zenginkinet1, Ayse Serap Karadag2 Department of Pathology, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey

1

Department of Dermatology, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey

2

ABSTRACT OBJECTIVE: In our study, we aimed to evaluate retrospectively histopathological diagnoses of children based on their skin biopsies, and determine the prevalence of the disease in question.

METHODS: Among patients who applied to Medeniyet University Goztepe Training and Research Hospital between January 2011 and February 2014, we retrospectively evaluated demographic data and histopathological diagnoses of patients aged between 0-17 years whose skin punch biopsy samples were obtained.

RESULTS: The study population (n=566) with skin biopsy results consisted of 287 (50.7%) male, and 279 (49.2%) female patients with a mean age of 10.04±4.84 years. Biopsy materials were obtained from the various age groups as follows: 0-2 years, n=31 (5.4%); 3-5 years, n=67 (11.8%) 6-11 years, n=165 (29.1%), and 12-17 years, n=303 (53.5%). Among all age groups, we took biopsies mostly from patients with noninfectious erythematous squamous (24%) and vascular (21.2%) diseases. The determined histopathological diagnoses were leukocytoclasis vasculitis (18.9%), psoriasis (7.4%), melanocytic nevus (5.4%), and contact dermatitis (5.1%) respectively.

CONCLUSION: We determined that skin punch biopsy examinations were done most frequently during adolescence and are mostly necessary for diagnosis of erythematous squamous and vascular diseases. If clinical evidence-based prevalence studies are supported with histopathological data, more significant results can be obtained.

Key words: Biopsy; childhood dermatoses; epidemiology.

D

uring pediatric age, skin diseases similar to those seen in adults are observed with different incidence rates. Histopathological examination with diagnostic significance is a frequently resorted method. Epidemiological studies concerning pediatric dermatoses are frequently based

on clinical evidence [1, 2, 3], however only limited number of studies have analyzed histopathological data [4, 5, 6]. In our study we aimed to retrospectively evaluate histopathological diagnoses of pediatric patients with skin biopsy results, and determine their prevalence rates.

Received: November 25, 2014 Accepted: February 23, 2015 Online: April 24, 2015 Correspondence: Dr. Seyma ozkanlı. Istanbul Medeniyet Universitesi Goztepe Egitim ve Arastirma Hastanesi, Patoloji Bolumu, Goztepe, Istanbul, Turkey.

Tel: +90 216 - 566 40 00 e-mail: seymaozkanli@gmail.com © Copyright 2015 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com

Ozkanli et al., Three years of retrospective evaluation of skin biopsy results in childhood

MATERIALS AND METHODS Among patients applied to Medeniyet University Goztepe Training and Research Hospital, between January 2011, and February 2014, those aged less than 18 years who had punch skin biopsy materials were determined. Approval of Ethics Committee of our hospital was obtained. The most diagnostic sample among multiple biopsy materials from the same patient was included in the study. The patients were analyzed in groups of infancy (0-2 years), preschool age (3-5 years), school age (6-11 years), and adolescence (12-17 years) [1]. Histopathological diagnoses were classified based on the criteria indicated in the textbook “Lever’s Histopathology of the Skin” [7].

According to this classification, the disease groups were indicated as follows: Genodermatoses, Non-infectious erythematous-squamous diseases, Vascular diseases, Non-infectious vesiculobullous vesiculopustulous diseases, Non-infectious Granulomas, Infectious Diseases, Pigmented Lesions, Histiocytosis, Nevoid Lesions, Connective tissue diseases, Diseases related to drugs/physical factors/photosensitivity, Degenerative Metabolic Diseases, Inflammatory diseases of epidermal appendix, Tumors of the epidermal appendix, Cutaneous lymphoma/leukemia/mastocytosis, Fibrous/fibrohistiocytic/vascular tumors.

Demographic data of all patients, and histopathological diagnoses were retrospectively evaluated.

Results In our survey lasting for a period of 3 years, skin biopsies had been obtained from 401 (1.8%) of 22.277 patients aged 0-17 years who applied to the dermatology polyclinic. During the same period, skin biopsies had been obtained from 3685 out of 68.240 (5.4%) patients aged over 18.

When all clinics were considered in the evaluation of pediatric age group, punch biopsy materials from a total of 566 patients had been sent to the pathology laboratory for analysis. Study population consisted of 287 male (50.7%), and 279 (39.2%) female patients with a mean age of 10.04±4.84 years. Skin biopsy materials obtained from different age groups had been sent for histopathological evaluation as

49

follows: 0-2 years, n=31 (5.4%), 3-5 years, n=67 (11.8%); 6-11 years, n=165 (29%), and 12-17 years, n=303 (53.5%). These biopsy materials had been sent from clinics of dermatology (n=401; 70.8%), pediatrics (n=158; 27.9%), pediatric surgery (n=5; 0.8%), and plastic, and esthetic surgery (n=2; 0.3%).

Histopathological diagnoses were evaluated according to disease groups, In all age groups, biopsy materials were most frequently obtained from noninfectious erythemato- squamous lesions (24%), and vascular diseases (21.2%), and the most frequently detected histopathological diagnoses were leukocytoclastic vasculitis (18.9%), psoriasis (7.4%), melanocystic nevi (5.4%), and contact dermatitis (5.1%).

When these diagnoses were evaluated according to age groups, most frequently detected diseases in the infantile period were leukocytoklastic vasculitis (12.9%), urticaria (12.9%), contact dermatitis (9.6%), and ichtyosis (9.6%) (0-2 years). During preschool age (3-5 years) leukocytoklastic vasculitis (17.9%), urticaria (5.9%), psoriasis (5.9%), PLEVA (5.9%), calcinosis cutis (5.9%), mastocytosis (5.9%) were detected. During the school age (6-11 years) leukocytoklastic vasculitis (36.3%), psoriasis (10.9%) granuloma annulare (5.4%) were noted.

During adolescent period (12-17 age) melanocytic nevus (10.2%) leukocytoklastic vasculitis (10.2%), and acute folliculitis (6.9%) were found. Among most frequently seen diseases, melanocytic nevus was encountered especially in the 6-11 age group, while melanocytic nevus was predominantly seen between 12-17 years. Histopathological diagnoses, and their incidence rates in all patients according to age groups are indicated in Table 1.

In pediatry clinics, as a striking finding, most frequently, biopsy materials had been obtained from vascular disease group dermatoses. Leukocytoklastic vasculitis was the most frequently encountered diagnosis which was seen in a total of 107 patients, and 89.7% (n=96) of them had been referred from pediatry clinics.

Discussion Histopathological examination has a very important place in the diagnosis of skin diseases It espe-

50

North Clin Istanbul â&#x20AC;&#x201C; NCI

Table 1. Histopathological diagnoses and incidence rates according to age groups Disease groups and histopathological diagnosis

Age 0-2 Age 3-5 Age 6-11 Age 12-17 Total

n % n % n % n % n %

Genodermatoses

5 16.1 0 0 3 1.8 4 1.3 12 2.1

Ichthyosis

3 9.6 0 0 0 0 1 0.3 4 0.7

Epidermolysis bullosa

2 6.4 0 0 0 0 0 0 2 0.3

Keratosis pilaris

0 0 0 0 1 0.6 0 0 1 0.1

Palmoplantar keratoderma

0 0 0 0 2 1.2 1 0.3 3 0.5

Anhidrotic ectodermal dysplasia

0 0 0 0 0 0 1 0.3 1 0.1

Focal dermal hypoplasia

0 0 0 0 0 0 1 0.3 1 0.1

Noninfectious erythematous-scaly diseases

6 19.3 18 26.8 42 25.4 70 23.1 136 24.0

Urticaria

4 12.9 4 5.9 5 3.0 3 0.9 16 2.8

Psoriasis

1 3.2 4 5.9 18 10.9 19 6.2 42 7.4

1

Superficial perivascular dermatitis

3.2

2

2.9

8

4.8

11

3.6

22

3.8

Lichen spinulosus

0 0 1 1.4 0 0 2 0.6 3 0.5

Gianotti crosti

0 0 3 4.4 0 0 3 0.9 6 1.0

PLEVA

0 0 4 5.9 4 2.4 5 1.6 13 2.2

Lichen nitidus

0 0 0 0 4 2.4 3 0.9 7 1.2

Lichen striatus

0 0 0 0 3 1.8 2 0.6 5 0.8

Pityriasis lichenoides chronica

0 0 0 0 0 0 4 1.3 4 0.7

Lichen planus

0 0 0 0 0 0 6 1.9 6 1.0

Erythema dyscromicum perstans

0 0 0 0 0 0 1 0.3 1 0.1

Pityriasis rosea

0 0 0 0 0 0 2 0.6 2 0.3

Pityriasis rubra pilaris

0 0 0 0 0 0 6 1.9 6 1.0

ILVEN

0 0 0 0 0 0 2 0.6 2 0.3

Miliaria profunda

0 0 0 0 0 0 1 0.3 1 0.1

Vascular diseases

6 19.3 14 20.8 65 39.3 35 11.5 120 21.2

Urticarial vasculitis

2 6.4 2 2.9 3 1.8 2 0.6 9 1.5

Leucocytoclastic vasculitis

4 12.9 12 17.9 60 36.3 31 10.2 107 18.9

Pigmented purpuric dermatoses

0 0 0 0 2 1.2 2 0.6 4 0.7

Noninfectious vesiculobullous vesiculopustulous derm. 5 16.1 11 16.4 17 10.3 39 12.8 72 12.7 Allergic/contact dermatitis

3 9.6 6 8.9 10 6.0 10 3.3 29 5.1

Erythema multiforme

1 3.2 2 2.9 0 0 0 0 3 0.5

Infantile acropustulosis

1 3.2 0 0 0 0 0 0 1 0.1

Atopic dermatitis

0 0 2 2.9 0 0 0 0 2 0.3

Bullous pemphigoid

0 0 1 1.4 0 0 3 0.9 4 0.7

Seborrheic dermatitis

0 0 0 0 2 1.2 7 2.3 9 1.5

Nummular dermatitis

0 0 0 0 5 3.0 14 4.6 19 3.3

Lichen simplex cronicus

0 0 0 0 0 0 4 1.3 4 0.7

Dermatitis herpetiformis

0 0 0 0 0 0 1 0.3 1 0.1

Noninfectious granulomas

1 3.2 0 0 9 5.4 9 2.9 19 3.3

Granuloma annulare

1 3.2 0 0 9 5.4 8 2.6 18 3.1

Foreign body reaction

0 0 0 0 0 0 1 0.3 1 0.1

Ozkanli et al., Three years of retrospective evaluation of skin biopsy results in childhood

51

Table 1. Histopathological diagnoses and incidence rates according to age groups (Cont.)

Disease groups and histopathological diagnosis

Age 0-2 Age 3-5 Age 6-11 Age 12-17 Total

n % n % n % n % n %

Infectious diseases

1 3.2 2 2.9 2 1.2 13 4.2 18 3.1

Insect bites

1 3.2 1 1.4 0 0 1 0.3 3 0.5

Tinea

0 0 1 1.4 0 0 2 0.6 3 0.5

Molluscum contagiosum

0 0 0 0 2 1.2 0 0 2 0.3

Verruca vulgaris

0 0 0 0 0 0 3 0.9 3 0.5

Epidermodysplasia verruciformis

0 0 0 0 0 0 1 0.3 1 0.1

Viral rash

0 0 0 0 0 0 3 0.9 3 0.5

Scabies

0 0 0 0 0 0 2 0.6 2 0.3

Bacterial pustulosis

0 0 0 0 0 0 1 0.3 1 0.1

Pigmented lesions

2 6.4 3 4.4 5 3.0 14 4.6 24 4.2

Vitiligo

1 3.2 0 0 1 0.6 1 0.3 3 0.5

1

Postinflammatory pigmented lesions

3.2

3

4.4

4

2.4

12

3.9

20

3.5

Addisonâ&#x20AC;&#x2122;s disease

0 0 0 0 0 0 1 0.3 1 0.1

Histiocytosis

3 9.3 6 8.9 5 3.0 2 0.6 16 2.8

Generalised eruptive histiocytosis

2 6.4 3 4.4 2 1.2 1 0.3 8 1.4

Juvenile xanthogranuloma

1 3.2 2 2.9 3 1.8 1 0.3 7 1.2

Langerhans cell histiocytosis

0 0 1 1.4 0 0 0 0 1 0.1

Nevoid lesions

1 3.2 2 2.9 3 1.8 42 13.8 48 8.4

Congenital nevus

1 3.2 0 0 0 0 0 0 1 0.1

Mongolian spot

0 0 1 1.4 0 0 0 0 1 0.1

Linear whorled hypermelanosis

0 0 1 1.4 0 0 0 0 1 0.1

Spitz nevus

0 0 0 0 2 1.2 1 0.3 3 0.5

Blue nevus

0 0 0 0 1 0.6 3 0.9 4 0.7

Dysplastic nevus

0 0 0 0 0 0 6 1.9 6 1.0

Beckerâ&#x20AC;&#x2122;s nevus

0 0 0 0 0 0 1 0.3 1 0.1

Melanocytic nevus

0 0 0 0 0 0 31 10.2 31 5.4

Connective tissue diseases

0 0 2 2.9 4 2.4 8 2.6 14 2.4

Collagen tissue nevus

0 0 1 1.4 0 0 0 0 1 0.1

Morphea

0 0 1 1.4 0 0 3 0.9 4 0.7

0

Lichen sclerosus et atrophicus

Dermatomyositis

0

0

0

4

2.4

4

1.3

8

1.4

0 0 0 0 0 0 1 0.3 1 0.1

Drug/physical/photosensitive related diseases

0 0 0 0 4 2.4 7 2.3 11 1.9

AGEP

0 0 0 0 0 0 1 0.3 1 0.1

Drug eruption

0 0 0 0 4 2.4 3 0.9 7 1.2

Erythema ab igne

0 0 0 0 0 0 1 0.3 1 0.1

Polymorphous light eruption

0 0 0 0 0 0 1 0.3 1 0.1

Pernio

0 0 0 0 0 0 1 0.3 1 0.1

Degenerative/metabolic diseases

0 0 4 5.9 0 0 7 2.3 11 1.9

Calcinosis cutis

0 0 4 5.9 0 0 1 0.3 5 0.8

Mucinosis

0 0 0 0 0 0 1 0.3 1 0.1

52

North Clin Istanbul – NCI

Table 1. Histopathological diagnoses and incidence rates according to age groups (Cont.)

Disease groups and histopathological diagnosis

Age 0-2 Age 3-5 Age 6-11 Age 12-17 Total

n % n % n % n % n %

Acanthosis nigricans

0 0 0 0 0 0 3 0.9 3 0.5

Confluent reticulated papillomatosis

Anetoderma

0

0

0

0

0

0

1

0.3

1

0.1

0 0 0 0 0 0 1 0.3 1 0.1

Inflammatory diseases of epidermal appendix

0

Acute folliculitis

0 0 0 0 0 0 21 6.9 21 3.7

0

Cronic folliculitis

0 0 0 0 0 0 1 0.3 1 0.1

Eosinophilic folliculitis

0 0 0 0 0 0 1 0.3 1 0.1

Tumours of epidermal appendix

1

Squamous papilloma

0 0 0 0 0 0 1 0.3 1 0.1

Sebaceous nevus

0 0 0 0 0 0 1 0.3 1 0.1

Epidermal nevus

0 0 1 1.4 0 0 2 0.6 3 0.5

Keratoacanthoma

0 0 0 0 0 0 1 0.3 1 0.1

Seborrheic keratosis

0 0 0 0 0 0 2 0.6 2 0.3

3.2

0

1

0

1.4

0

0

0

0

23

13

7.5

4.2

23

15

4.0

2.6

Pilomatrixoma

1 3.2 0 0 0 0 1 0.3 2 0.3

Comedon

0 0 0 0 0 0 3 0.9 3 0.5

Trichoepitelioma

0 0 0 0 0 0 1 0.3 1 0.1

Eruptive vellus hair cysts

0 0 0 0 0 0 1 0.3 1 0.1

Cutaneous lymphoma/leukemia/mastocytosis

0 0 4 5.9 6 3.6 7 2.3 17 3.0

Mastocytosis

0 0 4 5.9 6 3.6 4 1.3 14 2.4

Mycosis fungoides

0 0 0 0 0 0 2 0.6 2 0.3

Lymphomatoid papulosis

0 0 0 0 0 0 1 0.3 1 0.1

Fibrous/fibrohistiocytic/vascular tumours

0

Scar

0 0 0 0 0 0 2 0.6 2 0.3

Dermatofibroma

0

0 0

0 0

0 0

0 0

0 0

9 1

2.9 0.3

9 1

1.5 0.1

Fibrous papule of the face

0 0 0 0 0 0 1 0.3 1 0.1

Angiokeratoma

0 0 0 0 0 0 1 0.3 1 0.1

Pyogenic granuloma

0 0 0 0 0 0 2 0.6 2 0.3

Lymphangioma

0 0 0 0 0 0 1 0.3 1 0.1

Kaposi’s sarcoma

0 0 0 0 0 0 1 0.3 1 0.1

Inflammatory diseases of the fat tissue

0

Erythema nodosum

0 0 0 0 0 0 1 0.3 1 0.1

Total

31 5.4 67 11.8 165 29.1 303 53.5 56 100

cially carries diagnostic importance in atypical lesions whose clinical diagnosis can not be made or mimick other dermatoses. In dermatology polyclinics “punch biyopsi” method is accepted as a practical, and reliable method, and it is used prevalently in patients at every age. It is frequently applied in pediatric dermatology. In our study the incidence

0

0

0

0

0

1

0.3

1

0.1

of biopsy procedures in polyclinics in the pediatric age group was detected as 1.8% which was in compliance with the incidence rate of 1.7% cited in the literature [4]. The rate of performing biopsy procedures was lower in the pediatric age group relative to that indicated in adults. Indeed, some types of dermatoses such as skin neoplasias whose diagnosis

Ozkanli et al., Three years of retrospective evaluation of skin biopsy results in childhood

can be made only with histopathological examination of biopsy specimens are seen especially in the advanced age, and parentsâ&#x20AC;&#x2122; reservations towards biopsy procedures which can be considered as a semiinvasive method can put off biopsy till adulthood. In addition, we think that multiple number of patients who present to the pediatry clinics with skin lesions are treated by pediatricians with the indication of nonspecific diagnoses, and so dermatology consultation is not requested which all can contribute to the lower incidence of biopsy procedures performed. In the literature, limited number of prevalence studies which generally encompassed all age groups have evaluated prevalence of biopsies. Gimbell et al. reviewed 2342 skin biopsies performed in Ethiopia, and reported that biopsy procedures had been most frequently performed for inflammatory dermatoses [6]. Engin et al. [5] evaluated biopsy specimens of 2128 patients aged between 2, and 91 years, and most frequently detected melanocytic nevi (27%).

This phenomenon suggests that nevi are being excised in peripheral hospitals for cosmetic concerns.

Similar to our study AfĹ&#x;ar et al. evaluated 213 biopsy specimens taken from patients in the pediatric age group, and reported that they detected most frequently leukocytoklastic vasculitis, and psoriasis [4]. Especially in tertiary healthcare institutes, even though some dermatoses are clinically diagnosed, for definitive diagnosis histopathological evaluations are performed.

Majority of biopsies sent from pediatry clinics have been apparently obtained from patients with vascular diseases. This phenomenon demonstrates that even patients with vascular diseases demonstrating skin lesions consult more frequently to pediatry polyclinics. Besides especially pediatricians require histopathological confirmation for ruling out dermatoses like cutaneous vasculitis which are considered in the differential diagnosis. Cutaneous vasculitis courses from time to time with systemic findings, and pediatric patientsâ&#x20AC;&#x2122; consultation priorly to pediatry polyclinic for every type of disease can explain the need for histopathological confirmation.

Studies investigating prevalences of pediatric dermatoses are generally based on clinical evidence [1, 2, 3]. Some types of dermatoses have been di-

53

agnosed based on clinical evidence without resorting to histopathological findings. Therefore their prevalence rates do not parallel with those based on histopathological evidence. In studies aiming at determination of incidence rates of pediatric dermatoses in our country, authors reported different rates for various types of most frequently seen diseases (Tekin et al.: eczema/dermatitis [25.9%], and Bilgili et al.: infections, and infestations [24.5%]) [2, 3]. In a survey study which screened the same geographical region as ours eczema group of diseases was the most frequently detected dermatoses [1]. Although we evaluated the population of the same geographical region as indicated by the abovementioned authors, in our study on based on histopathological findings, dermatitis group diseases eczema (contact dermatitis, atopic dermatitis, nummular dermatitis, seborrheic dermatitis, and superfcial perivascular dermatitis) were seen at a rate of 14% which was lower than those reported in the above-mentioned study. This finding indicates that diagnosis of dermatitis is mostly based on clinical manifestations. Biopsies are more often requested for patients referred by pediatricians,and biopsy procedures are not frequently preferred in eczematous diseases which may be the underlying rationale of this attitude.

In our study, contrary to other prevalence studies, the incidence rates of not only disease groups, but also each established histopathological diagnosis in different age groups were determined. Accordingly differences in the distribution of diseases in various age groups were observed.

Evaluation of the biopsies obtained only within the last 3 years, and categorization of biopsy results have constituted limitations of our study. Since histopathological classification was mainly considered in the grouping of biopsy results [7] vasculitis which is clinically a disease group by itself, was analyzed in the category of vascular diseases.

In conclusion, as observed in our study, skin punch biopsies during pediatric age were most frequently performed during adolescent period, and most often it was required for the diagnosis of erythemato-squamous skin lesions, and vascular diseases. Our study emphasizes diagnostic value of

54

histopathological examinations, and its significance in epidemiological studies. Besides, closer cooperation between pediatriticians, and dermatologists will increase the chances of accurate diagnosis, and more precise data can be obtained about the diagnosis of the diseases. It is possible to obtain more elucidative results in larger series based on clinicopathological evaluation.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

REFERENCES 1. Can B, Kavala M, Türkoğlu Z, Zindancı İ, Südoğan S, Topaloğlu

North Clin Istanbul – NCI

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3.

4.

5.

6.

7.

F. Prevalence of Skin Conditions Among Pediatric Patients in the Region of Istanbul. Türkderm 2011;45:10-3.

Tekin N, Sezer T, Altınyazar C, Koca R, Çınar S. Prevalance of skin diseases in childhood. Türkiye Klinikleri J Dermatol 2007;17:92-8.

Bilgili SG, Calka O, Akdeniz N, Karadag AS, Akbayram S. The prevalence of pediatric skin diseases in Eastern Turkey. Int J Dermatol 2014;53:6-9.

Afşar FŞ, Aktaş S, Diniz G, Ortaç R. The Role of Biopsy in Pediatric Dermatopathology. Türkderm 2011;45:137-9.

Engin Ş, Yasemin YK, Karabulut HH, Yasemin D, Nazmiye K. Evaluation of Skin Biopsies in Çankırı Region: A Two-Year Retrospective Assessment. Turk J Dermatol 2014;8:151-3.

Gimbel DC, Legesse TB. Dermatopathology practice in ethiopia. Arch Pathol Lab Med 2013;137:798-804.

Lever WF: Histopathology of the skin. Tenth edition. David E. Elder, Editor –in-chief, Rosalie Elenitsas, Bernett L.Johnson, George F. Murphy, Xiaowei Xu,Lippincot Williams &Wilkins, Philadelphia, 2009.

Case Report

hematology

North Clin Istanbul 2015;2(1):55-58 doi: 10.14744/nci.2015.27928

Serratia marcessens infection presenting with papillovesicular rash similar to varicella zoster infection: a case report Aysenur Bahadir, Erol Erduran Department of Pediatric Hematology-Oncology, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey

ABSTRACT According to the literature, skin manifestations related to Serratia marcessens infections are rarely seen, and observed mostly in immunosuppressed adult patients. Cellulitis, abscess, granulomataus lesions have been reported as skin manifestations of Serratia infections. In our 2 cases with leukemia, papillovesicular rashes were observed resembling those of varicella zoster infection. Serratia marcessens was grown on blood cultures of patients susceptible to meropenem. The patients recovered from the rashes rapidly after treatment. Based on the absence of similar case reports in the literature, we report these two pediatric cases to emphasize that Serratia marcessens infections can present with papillovesicular rash similar to that seen in varicella zoster infections.

Key words: Catheter; leukemia; papillovesicular rash; serratia, varicella.

S

erratia marcessens is a gram-negative, opportunistic and nosocomial pathogen belonging to the Enterobacterieae family. It is often found in intensive care units, and most importantly grown in the digestive, respiratory and urinary systems, and newborn perineums and health workers. The incidence of S. marcessens-derived nosocomial infections is only 1-2%; while the main sources of risk for Serratia infections in hospitals for bacteremia/sepsis are intravenous, intraperitoneal and urinary catheters [1, 2].

Cutaneous manifestations of S. marcessens infections have been reported as ulcer, abscess, granulomatous and nodular skin lesions [2]. S. marcessens

infection-related cutaneous manifestations in pediatric population are rarely reported in the medical literature. Herein, we report two pediatric cases presenting with papillovesicular rash caused by S. marcessens but misdiagnosed as varicella zoster virus (VZV) infections.

CASE REPORTS Case 1 â&#x20AC;&#x201C; A three-year-old female patient was diagnosed with low-risk acute lymphoblastic leukaemia (ALL) in our pediatric hematology clinic, and her treatment was initiated according to the St. Jude

Received: September 23, 2014 Accepted: December 08, 2014 Online: April 24, 2015 Correspondence: Dr. Aysenur BahadÄąr. Karadeniz Teknik Universitesi Tip Fakultesi, Pediatrik Hematoloji-Onkoloji Bilim Dali, Trabzon, Turkey.

Tel: +90 462 - 377 30 00 e-mail: aysenurkbr@yahoo.com Š Copyright 2015 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com

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Total XV chemotherapy protocol. A central venous catheter (CVC) was placed on the 5. day of her hospitalization. Neutropenic sepsis developed on the 5. day of her hospitalization while the patient was on chemotherapy. Blood culture was obtained from the patient, and the patient was put on 100 mg/kg of cefepime and 15 mg/kg of amikacin therapy. Growth of Gram-negative bacilli was observed in her blood culture, and the patient developed antibiotic-resistant fever. As a consequence, cefepime treatment was discontinued on day 2, and 120 mg/kg of meropenem treatment was started.

Growth of meropenem-sensitive S. marcessens was observed in both CVC and peripheral blood cultures. On the third day of antibiotherapy, vesiculobullous rashes originating from the dorsum of the hand and abdomen developed which spred to the scalp the next day. The lesions were not itchy, and didn’t invade the mucosa.

A sample was tested for VZV IgM based on the resemblance of the lesions to those of a VZV infection, and acyclovir (30 mg/kg/d) treatment was started. After the 48th dose, the patient’s body temperature started to decrease, returning to a normal level during the follow-up period. Within 3-5 days rashes diminished and the patient fully recovered.

When VZV IgM test results became negative, acyclovir treatment was discontinued.However, development of a necrotizing abscess in the gluteal region, and nodular skin lesions on the arms and legs necessitated maintenance of vancomycin (40 mg/ kg) treatment. CVC was removed after S. marcessens growth on CVC samples was twice than that observed in the CVC blood culture. Amikacin, and meropenem were discontinued on day 19 after absence of bacterial growth in peripheral blood cultures. Nodular lesions on the arms and legs developed into abscesses, and growth of S. marcessens was observed in the wound cultures collected from these sites. The patient was started on meropenem treatment again, with local care and topical fucidic acid were applied to the abscesses. The skin lesions healed completely by day 20 after hospitalization, and chemotherapy was continued Case 2– A 9-month-old female patient was diagnosed with high-risk ALL at our pediatric hematology clinic, and started on the treatment according

to the St. Jude Total XV chemotherapy protocol. A CVC was implanted on the 10th day of the hospitalization, and neutropenic sepsis developed on day 15. The patient was started on 60 mg/kg of piperacillin-tazobactam and 15 mg/kg of amikacin treatment. S. marcessens growth was observed in both CVC and peripheral blood cultures. Piperacillintazobactam treatment was discontinued 2 days after the patient presented with antibiotic-resistant fever, and 90 mg/kg of meropenem treatment was started.

On the third day of the treatment, vesicular lesions started to appear on the dorsum of the hand and the body, and spread to the scalp and across the entire body the next day (Figure 1a, b). The lesions were not itchy, and mucosal spread was not observed.

Given the resemblance of the lesions to those seen in VZV infections, a sample was sent to test for VZV IgM, and acyclovir (30 mg/kg/d)treatment was started. Her skin lesions diminished and healed within three days. Besides, the patient’s fever began to drop down on the second day of meropenem treatment. Acyclovir treatment was discontinued after negative VZV IgM test results were obtained. CVC catheter was removed after S. marcessens growth on catheter was twice than that observed in the blood culture. Meropenem treatment was discontinued on the 15. day of hospitalization at the time when microorganism growth in the peripheral blood culture was not observed, however chemotherapy was maintained.

DISCUSSION According to the literature, skin manifestations are rarely seen in S. marcessens infections, and they are mostly observed in immunosuppressed adult patients. Skin lesions that develop during serratia infections are classified in two groups. The lesions start as acute cellulitis or abscesses, and may turn into ulcers or even severe necrotizing fasciitis and may take on a chronic form. On rare occasions, granulomatous lesions that start as nodules have been observed in the chronic form [2, 3, 4].

Skin manifestations related to Serratia infections in pediatric cases are rarely reported, although Garcia et al. reported a case of a 10-year-old child diagnosed with S. marcessens, who had skin manifestations in the form of erythematous plaques on

Bahadir et al., Serratia marcessens infection presenting with papillovesicular rash similar to varicella zoster infection

A

57

B

Figure 1. (A) Papillovesicular lesions on the dorsum of the hand. (B) Erythematous macules, fluid filled vesicles and crusting lesions on the dorsum of the hand.

an upper extremity [5].

Both cases discussed in this study were suffering from acute leukemia, and they were not in remission.

On the third day of infection skin rashes in the form of vesiculobullous lesions emerged. Since the skin rashes resembled lesions of VZV infections and the patients had been diagnosed with acute unremitting leukemia, acyclovir treatment was initiated. In the pediatric age group, VZV infections are transmitted via airway or through direct contact. Rashes are firstly seen on the scalp, and from there they spread over the face and the body. VZV infections start as erythematous macules, and later turn into vesicles; and rashes may be detected in the same region in different phases. In a healthy person, rashes tend to continue until day 7. VZV infections are presented with highly severe complications, and can be fatal in patients with hematological malignancies, so it is recommended that intravenous acyclovir treatment be started as soon as suspected lesions are observed [6].

In our cases, the rashes initially emerged on the dorsum of the hand and body, and spread to the scalp. As new lesions started to appear, worms started to emerge from other areas. Unlike VZV infections, the lesions were not itchy and mucosal spread was not seen. The mean recovery time for rashes was 2-5 days. Both had a CVC in situ, and

S. marcessens growth was observed in both of their peripheral and CVC blood cultures. The VZV IgM results in both cases turned out to be negative, and so it was deduced that the patientsâ&#x20AC;&#x2122; rashes were associated with a S. marcessens infection.

However, in immunocompromised patients, VZV antibody test may be false negative [6]. Patients must be followed closely. In our case, acyclovir therapy was discontinued because the serology was negative for VZV and the patientsâ&#x20AC;&#x2122; lesions began to lessen rapidly after meropenem treatment was initiated. Also, Enterovirus can be the cause of vesicular rash in immunocompromised patients [7] However, we examined the oral cavity and couldnâ&#x20AC;&#x2122;t find any lesions, so it was not considered as an Enteroviral infection.

A variety of skin rashes due to drug reactions can be seen. Most frequently antibiotics and anti-inflammatory drugs are causing drug-induced rashes [8]. In our cases, skin rashes began to emerge after meropenem treatment. However, meropenem was previously used in our patients without development of allergic reactions. In addition, the lessions were not itchy and disappeared with meropenem treatment. Therefore, skin rashes were not considered as manifestations of drug allergy.

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In the first case, the rashes started in the vesicular form located on the arms and legs turning into painful nodular lesions with time. The disease of the patient followed a course similar to the cases of Serratia-infection reported in the literature [2].

Some of these nodules developed into abscesses which were drained.

Maybe, this vesicular rash can be considered as an early sign of nodular lesions. However, these nodular lesions were not observed in our second case.

Serratia infections are more frequently observed in cases with immune deficiencies and may have diverse disease courses. Early diagnosis and treatment are vital in cases with both Serratia and VZV infections, as both diseases can be fatal.

Based on the absence of similar case reports in the literature, we report these two cases to emphasize that: i) S. marcessens infections can also lead to development of a papillovesicular rash similar to that seen in VZV infections, ii) S. marcessens infection should be considered, when papillovesicular rashes are observed in immunosuppressive patients with an implanted CVC in situ.

Conflict of Interest Statement: None of the authors of this paper has a conflict of interest, including spesific financial interests, relationships, and/or affilitions relevant to the subject matter or materials included.

Financial Disclosure: The authors declared that this study has received no financial support.

REFERENCES 1. Khanna A, Khanna M, Aggarwal A. Serratia marcescens- a rare opportunistic nosocomial pathogen and measures to limit its spread in hospitalized patients. J Clin Diagn Res 2013;7:243-6.

2. Giráldez P, Mayo E, Pavón P, Losada A. Skin infection due to Serratia marcescens in an immunocompetent patient. [Article in Spanish] Actas Dermosifiliogr 2011;102:236-7. [Abstract] 3. João AM, Serrano PN, Cachão MP, Bártolo EA, Brandão FM. Recurrent Serratia marcescens cutaneous infection manifesting as painful nodules and ulcers. J Am Acad Dermatol 2008;58(2 Suppl):55-7.

4. Langrock ML, Linde HJ, Landthaler M, Karrer S. Leg ulcers and abscesses caused by Serratia marcescens. Eur J Dermatol 2008;18:705-7.

5. García FR, Paz RC, González RS, Ruiz ES, Martín-Neda FG, Rodríguez MS, et al. Cutaneous infection caused by Serratia marcescens in a child. J Am Acad Dermatol 2006;55:357-8.

6. Mattiuzzi GN, Cortes JE, Talpaz M, Reuben J, Rios MB, Shan J, et al. Development of Varicella-Zoster virus infection in patients with chronic myelogenous leukemia treated with imatinib mesylate. Clin Cancer Res 2003;9:976-80.

7. Karadağ Öncel E, Narz I, Özsürekçi Y, Korukluoğlu G, Cengiz AB, Ceyhan M. Demographic and Clinical Findings in Children with Enteroviral Infection Outbreak. J Pediatr Inf 2013;7:97-101.

8. Dincer D. Drug reactions in Dermatology. Turk J Dermatol 2013;7:179-84.

Case Report

General Surgery

North Clin Istanbul 2015;2(1):59-61 doi: 10.14744/nci.2014.18209

A prolapsed intraductal papilloma: a case report Talha Atalay, Alaattin Ozturk, Zuhal Yananli, Omer Faruk Akinci Fatih University Faculty of Medicine, Istanbul, Turkey

ABSTRACT Intraductal papillomas (IP) are benign papillary lesions caused by proliferation of mammary ductal epithelium.

IP occurs in the breast tissue. Prolapse of IP from nipple can be rarely seen. IPs are generally treated with total excision. A 31-year-old female patient was admitted to our clinic because of a protruded lesion from the nipple of her right breast. On her breast examination, an 8 mm- prolapsed mass was seen on the areola of her right breast.

Breast ultrasonography showed no other lesions in the breast. The patient was operated with initial diagnosis of IP. The prolapsed mass, the overlying nipple skin and related ductus were totally excised under local anesthesia.

Histopathological examination of the specimen revealed intraductal papilloma without atypical dysplasia. Herein, we are presenting a rarely encountered case of IP prolapsed from the nipple of a female patient.

Key words: Breast; intraductal papilloma; prolapsus.

I

ntraductal papilloma (IP) develops as a result of papillary proliferation of the ductal epithelium, and constitutes 22% of the benign breast lesions.

They are treated with total excision. IP lesions form in the breast tissue. Rarely protrusion of these lesions from the nipple can be seen. They are treated with total excision. Herein, we are presenting a rarely encountered case of prolapsed IP from the nipple of a female patient.

CASE REPORT A 31-year-old female patient consulted to our outpatient clinic because of a mass protruding from her

right nipple. On her breast examination, an 8 mm prolapsed mass was seen on the right breast areola (Figure 1). During physical examination any abnormality was not detected on other parts of the breast, and her left breast. From her personal and family medical history any evidence of breast disease was not found.

Her breast ultrasonographic (US) examination demonstrated an avascular, hypoechoic prolapsed solid mass measuring 8x5 mm which filled the areolar region completely. Mammograms of the patients were not obtained. Based on physical, and US examination findings surgery was planned with the initial diagnosis of intraductal papilloma. The

Received: July 17, 2014 Accepted: October 02, 2014 Online: December 08, 2014 Correspondence: Dr. Talha Atalay. Yali Mahallesi, SahiĚ&#x2021; lyolu Sokak, No: 16, 34844 Maltepe, Istanbul, Turkey.

Tel: +90 216 - 458 90 00 e-mail: tatalay@hotmail.com Š Copyright 2015 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com

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Figure 2.

Intraductal papilloma, (Hematoxylin & Eosin

x200).

Figure 1.

Macroscopic appearance of the prolapsed intraductal papilloma.

prolapsed mass, minimal portion of the overlying areolar skin and communicating ductus were totally excised under local anesthesia. Histopathological examination of the specimen revealed intraductal papilloma without atypical dysplasia (Figure 2).

Any postoperative complication did not develop, and any recurrence was not seen during 2 years of follow-up.

DISCUSSION Intraductal papillomas (IP) are benign tumours which develop as a result of papillary proliferation of the ductal epithelium. Its incidence is 2-3%, and it is seen between 30, and 77 years of age [1]. IP divides into central, and peripheral types. Central type is a solitary IP which settles in the subareaolar region, and it is observed in perimenauposal women. Peripheral type is situated on the proximal parts of the laciferous ducts of young female patients and

tends to be multiple [2].

Intraductal papillomas are generally smaller than 3 cm. In our patient the diameter of the mass was 8 mm. However, the patient consulted to the physician at an earlier stage because of the protruding characteristics of the mass.

IP can induce hemorrhagic or non-hemorrhagic nipple discharge. On physical examination the mass can be palpated. In one study, hemorrhagic nipple discharge was seen in 72% of the patients [3]. Although it is generally localized in the breast tissue, and subareolar region, in our case, it protruded from the nipple of the patient.

Intramammary masses are detected by US, and the diagnosis is conclusively confirmed by biopsy.

Radiological imaging techniques are helpful in establishing the diagnosis, however for the discrimination between benign, and malign lesions core needle biopsy should be performed.

Treatment of intraductal papillomas consists of total excision. Since the mass lesion of our patient was protruding, total excision was performed both for diagnosis, and treatment.

If intramammary IP lesion can be located using radiological techniques, then excision, without needle biopsy is recommended. Core biopsy is recommended for cases with radiologically suspect malignancy or in the presence of microcalcification, and distorted tissue ultrastructure. If small papillary lesions can be totally excised, and histopathologic examination does not reveal any evidence of atypia,

Atalay et al., A prolapsed intraductal papilloma

then the patient can be followed up with US, and mammographic monitorization [4].

In the differential diagnosis, nipple adenoma, and papillary lesion, Paget’s disease, eczematous dermatitis, and pyogenic granuloma should be taken into consideration Nipple adenoma is a proliferation of the squamous epithelium. It settles immediately under the nipple, and causes rugged scaly nipple with discharge. Advanced lesions protrude from the nipple, and appear as a red granular mass [5]. Histopathological differentiaton of the excised mass can be achieved. If untreated, papillary lesion of the nipple also protrudes. Nipple erosion can cause ulceration, nipple mass or discharge [6]. Paget’s disease, and eczema can be discriminated from other lesions with their characteristic cutaneous incrustrations. Papillary lesions of the breast can be rarely misdiagnosed as intraductal papillary carcinomas. Therefore histopathological examination is important both for diagnosis, and determination of potential malignancy.

IP prolapsed from the nipple is a rarely seen abnormality. For its diagnosis, and treatment, it is

61

sufficient to excise the lesion together with its communicating ductus.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

REFERENCES 1. Ganesan S, Karthik G, Joshi M, Damodaran V. Ultrasound spectrum in intraductal papillary neoplasms of breast. Br J Radiol 2006;79:843-9.

2. Masciadri N, Ferranti C. Benign breast lesions: Ultrasound. J Ultrasound 2011;14:55-65.

3. Poma S, Longo A. The clinician’s role in the diagnosis of breast disease. J Ultrasound 2011;14:47-54.

4. Richter-Ehrenstein C, Tombokan F, Fallenberg EM, Schneider A, Denkert C. Intraductal papillomas of the breast: diagnosis and management of 151 patients. Breast 2011;20:501-4.

5. Ünal G, Gürcan H. Meme Hastalıkları. Nobel Tıp Kitabevleri, 2001.

6. Harris JR. Diseases of the Breast. Philadelphia. Lippincott-Raven, 1996.

Case Report

Neurosurgery

North Clin Istanbul 2015;2(1):62-65 doi: 10.14744/nci.2015.98598

Complicated fronto-orbital mucopyocele presenting with proptosis: a case report Mehmet Zafer Berkman1, Ezgi Akar2, Mehmet Ufuk Akmil2, Sevki Gok2 Department of Neurosurgery, Acibadem Maslak Hospital, Istanbul, Turkey

1

Department of Neurosurgery, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey

2

ABSTRACT Mucoceles are cystic lesions of the paranasal sinuses which develop as a result of accumulation of mucous secretion due to obstruction of the ostium of the sinuses. Despite their benign behavior, they may enlarge progressively and project into adjacent structures by destructing the bony walls of the sinuses. Frontal mucoceles may get infected and extend towards orbital cavity and compress the orbit by eroding the bony walls of the orbital cavity.

Endoscopic and external approaches are performed in the surgical treatment. We report a case of complicated fronto-orbital mucopyocele which eroded the orbital roof and extended into the orbital cavity and discuss the surgical treatment strategy under the light of the current literature.

Key words: External approach; fronto-orbital mucocele; mucocele; mucopyocele.

M

ucoceles are benign, progressive and locally aggressive lesions occurring by accumulation of secretion within the paranasal sinuses [1]. Paranasal sinus mucoceles are usually seen in frontal (65%), anterior ethmoid (30%) and maxillary sinuses (3-10%).

Posterior ethmoid and sphenoid sinuses are rarely involved [2, 3]. Mucoceles extend into the surrounding tissues by eroding the sinus walls and cause pressure effect after reaching a certain size. The patients usually present with displacement of the eyeball in outer or lower direction, diplopia, eye pain, headache, Horner syndrome or panhypopituitarism. Frontal mucoceles can be complicated by infections and extend into the orbital cavity by destroying orbital walls [1, 4].

The treatment of mucoceles is surgical. Mucoceles are treated surgically either with external or endoscopic approaches. Endoscopic approach is recommended in uncomplicated mucoceles due to a low risk of recurrence [5]. However, it is suggested that external approaches will be more convenient in complicated infectious cases extending into the surrounding tissues due to bony destruction [5, 6].

CASE REPORT A 63-year-old male patient presented with complaints of gradually increasing misalignment of the eye, ocular deformity, headache and pain in the left

Received: October 19, 2014 Accepted: December 09, 2014 Online: April 24, 2015 Correspondence: Dr. Ezgi Akar. Haydarpasa Numune Egitim ve Arastirma Hastanesi, Beyin ve Sinir Cerrahisi Klinigi, Tibbiye Caddesi, 34668 Uskudar, Istanbul, Turkey.

Tel: +90 216 - 386 82 63 e-mail: ezgiaycicek@gmail.com Š Copyright 2015 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com

Berkman et al., Complicated fronto-orbital mucopyocele presenting with proptosis

A

63

B

Figure 1. (A)

Preoperative proptosis of the left eye. (B) Proptosis of the patient regressed within hours after surgery.

eye approximately for 5 years. At physical examination, an asymptomatic left eye was detected excepting proptosis (Figure 1). Neurological examination revealed restricted movements of the left eye in both downward and outward directions. Confrontation visual field assessment test of the patient was within normal limits without any visual impairment.

Laboratory values were also within normal limits.

A left fronto-orbital mucopyocele was seen during magnetic resonance 覺maging (MRI) of the patient (Figure 2a). Computed tomography (CT) revealed

a bony defect in the left orbital roof caused by mucopyocele on the left orbital roof (Figure 2b).

After preoperative assessment of the patient, surgery was planned. A modified left pterional craniotomy was performed. After removal of the skull bone flap, it was observed that infected mucocele extended into the extradural region by eroding posterior wall of the frontal sinus. Dark viscous abscess material was aspirated. The culture obtained from the material was negative. After removal of the mu-

A

B

Figure 2. (A) A left fronto-orbital mucopyocele is seen on MRI of the patient. (B) CT image of a bony defect in the left orbital roof caused by mucopyocele localized on the left orbital roof.

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Figure 3. A

bony defect in the orbital roof due to destruction caused by mucopyocele.

copyocele together with its capsule, a bony defect was observed in the orbital roof due to destruction caused by mucopyocele (Figure 3). Dura mater was observedly to be intact. Following cleaning of surgical site, frontal sinus was cranialized with pericranial flap and the sinus ostium was obliterated. Orbital defect was not repaired.

Postoperative follow-up of the patient was uneventful and proptosis of the patient regressed within hours after the surgery (Figure 1b). Postoperative MRI revealed that mucopyocele had been excised (Figure 4).

DISCUSSION Mucoceles are slow-growing cystic lesions developing secondary to obstruction of the sinus ostium [5].

The etiological factors such as mucosal inflammation of the sinus, nasal polyp, anatomical variations of the nasal cavity, tumors or traumas cause mucocele formation by triggering chronic inflammation of the sinus mucosa [4, 5, 6]. Mucoceles occurring due to cystic dilation of the sinus mucosa and retention of secretion are located in the frontal, maxillary, ethmoid and rarely in the sphenoid sinuses with decreasing rates of prevalence [1].

As slow-growing lesions, mucoceles can remain asymptomatic for a long period of time [4, 7, 8].

Mucoceles usually manifest clinical symptoms by eroding the bones of the sinus walls and causing pressure effect on the adjacent anatomical structures after reaching a certain size [7]. Due to anatomical proximity, orbital symptoms are frequently encountered. Mucoceles account for 4-8.5% of the expanding orbital masses [7]. Mucoceles with orbital involvement generally present with a non-infiltrating mass effect resulting in globe displacement, diplopia, proptosis, lid swelling, palpable mass, ptosis and reduced vision [5, 7]. Frontoethmoidal mucoceles often present with swelling in the superonasal and medial canthal regions, ptosis and inferolateral globe displacement. When a mucocele is infected, it is called a mucopyocele [5]. In this case presentation, infected mucocele originating from the frontal sinus extending into the orbital cavity by destroying frontal sinus and orbital roof with resultant symptoms of proptosis and eye pain was presented.

MRI is the gold standard diagnostic tool successful in demonstrating soft tissue lesions. CT is used due to its superiority in the visualization of bones,

Figure 4. Postoperative MRI revealed that mucopyocele had been excised.

Berkman et al., Complicated fronto-orbital mucopyocele presenting with proptosis

providing information about coronal, sagittal, axial planes and enabling three dimensional studies [8, 9]. In our case, mucopyocele was diagnosed using MRI. A CT scan was performed to demonstrate the relationship between mucopyocele and the adjacent bones and bony destruction which canalized our plan of surgical procedure.

The treatment of mucocele is surgical [5]. Although various surgical methods have been defined and performed, there is no consensus about surgical treatment modalities [7, 10]. Traditionally, treatment for paranasal sinus mucocele involved complete resection of the mucosal lining, and obliteration of the sinus. Obliteration of the involved sinus is not recommended if there is erosion of the sinus bony wall with extension of the mucocele either intracranially or into the orbit. Mucoceles are treated surgically either with external approach or endoscopic approach [9, 10]. During long-term follow-up of patients who underwent endoscopic marsupialization, recurrences have been rarely (if any) encountered [7, 10]. Obeso et al. performed endoscopic marsupialization in 48 of 72 cases of mucocele and external approach in the remaining cases and reported lower recurrence rates for the endoscopic approach [9]. However, external approach is recommended in the complicated, and infected mucoceles which destructed the bones severely [5, 10]. Khong et al. treated 15 of 24 cases of mucocele via an endoscopic approach and reported a recurrence rate of 27 percent [10]. Since in our case mucocele was infected and extended into the orbital cavity with destruction of the orbital roof, external approach was preferred.

Since normal histological structure is preserved in most of the cases, excision of the mucocele wall is controversial. It is suggested that the mucocele wall is an ideal lining for the developing cavity, and its removal is not appropriate [9]. However, this suggestion is not valid for the cases of mucopyocele complicated with infection and extending into the surrounding tissues secondary to bony destruction. In these cases, since it reduces the risk of recurrence, removal of mucocele or mucopyocele with its capsule and cranialization of

65

the sinus are recommended [1, 5]. In our case, the mucopyocele was removed with its capsule and frontal sinus cranialization was performed.

In conclusion, removal of mucopyocele with its capsule and cranialization of the sinus is an appropriate treatment choice for the cases of mucocele complicated by infection and extending from frontal sinus into the orbital cavity with resultant widespread bony destruction.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

REFERENCES 1. Chiarini L, Nocini PF, Bedogni A, Consolo U, Giannetti L, Merli GA. Intracranial spread of a giant frontal mucocele: case report. Br J Oral Maxillofac Surg 2000;38:637-40.

2. Palmer-Hall AM, Anderson SF. Paraocular sinus mucoceles. J Am Optom Assoc 1997;68:725-33.

3. Maliszewski M, Ladziล ski P, Kaspera W, Majchrzak K. Mucocoele and mucopyocoele of the frontal sinus penetrating to the cranial cavity and the orbit. Neurol Neurochir Pol 2011;45:342-50.

4. Delfini R, Missori P, Iannetti G, Ciappetta P, Cantore G. Mucoceles of the paranasal sinuses with intracranial and intraorbital extension: report of 28 cases. Neurosurgery 1993;32:901-6.

5. Gall R, Witterick I. Mucocele of the nasal septum. J Otolaryngol 2002;31:246-7.

6. Har-El G. Endoscopic management of 108 sinus mucoceles. Laryngoscope 2001;111:2131-4.

7. Sautter NB, Citardi MJ, Perry J, Batra PS. Paranasal sinus mucoceles with skull-base and/or orbital erosion: is the endoscopic approach sufficient? Otolaryngol Head Neck Surg 2008;139:570-4.

8. Kennedy DW, Josephson JS, Zinreich SJ, Mattox DE, Goldsmith MM. Endoscopic sinus surgery for mucoceles: a viable alternative. Laryngoscope 1989;99:885-95.

9. Obeso S, Llorente JL, Pablo Rodrigo J, Sรกnchez R, Mancebo G, Suรกrez C. Paranasal sinuses mucoceles. Our experience in 72 patients. [Article in Spanish] Acta Otorrinolaringol Esp 2009;60:332-9. [Abstract] 10. Khong JJ, Malhotra R, Wormald PJ, Selva D. Endoscopic sinus surgery for paranasal sinus mucocoele with orbital involvement.

Eye (Lond) 2004;18:877-81.

Case Report

neurology

North Clin Istanbul 2015;2(1):66-68 doi: 10.14744/nci.2015.96268

Neurosyphilis: a case report Tugce Toptan, Betul Ozdilek, Gulay Kenangil, Mustafa Ulker, Fusun Mayda Domac Department of Neurology, Erenkoy Training and Research Hospital for Neurologic and Psychiatric Disorders, Istanbul, Turkey

ABSTRACT Syphilis is a multisystem chronic infection caused by treponema pallidum. It can cause psychiatric disorders including depression, mania, psychosis, personality changes, delirium and dementia. With the introduction of penicillin into practice, the number of cases with syphilis decreased and its incidence increased with AIDS and HIV seropositivity. In this article, we present a case of neurosyphilis that manifested itself with neuropsychiatric symptoms.

Key words: Dementia; general paresis; neurosyphilis; psychiatric manifestations.

S

yphilis is a multisystem chronic infection caused by treponema pallidum support [1, 2]. Although there is a decrease in the number of cases of syphilis with the introduction of penicillin into use, it is still an important cause of the sexually transmitted diseases in developing countries because of the increase of incidence of AIDS and HIV seropositivity in the world [3, 4].

Syphilis progresses into four stages if untreated as primary, secondary, latent and tertiary stages. Primary syphilis is characterized by a typical painless syphilitic ulcer called chancre seen at the inoculation region after an incubation period lasting for 2-3 weeks. Secondary syphilis appears weeks or months later in nearly 25% of untreated patients and lymphadenopathy, gastrointestinal abnormalities and central nervous system alterations are seen.

At the end of the latent period, tertiary syphilis develops in 25% of the untreated patients. Tertiary syphilis is seen 1-30 years after primary infection.

This inflammatory disease progresses slowly as neurosyphilis or gummatous syphilis [5, 6].

Neurosyphilis is classified as early and late syphilis. Cerebrospinal fluid (CSF), meninges and vascular structures are involved in the early stages of neurosyphilis, while in the late stage; cerebral tissue and spinal cord parenchyma are affected [7, 8].

Therefore, neurosyphilis can manifest with many different symptoms.

In this article, we present a case of neurosyphilis with progressive cognitive changes and intractable behavioral and psychiatric problems whose primary and secondary phases were not detected.

CASE REPORT A 40-year-old male patient was admitted to our hospital with amnesia, nervousness, personality changes, hostile attitudes, aggressive behaviors, hallucinations and illusions with a history of one year.

Received: September 04, 2014 Accepted: October 21, 2014 Online: April 24, 2015 Correspondence: Dr. Betul ozdilek. Erenkoy Ruh ve Sinir Hastaliklari Egitim ve Arastirma Hastanesi, Noroloji Klinigi, Istanbul, Turkey.

Tel: +90 216 - 302 59 59/417 e-mail: betulozdilek@yahoo.com Š Copyright 2015 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com

Toptan et al., Neurosyphilis

67

His symptoms started 3 years ago with complaints of unwillingness to move and loss of appetite. He was consulted by a psychiatrist and put on antipsychotic drugs with no benefit. In the following year, urinary and fecal incontinence and speech disorders began. His medical and family history were not remarkable. On his physical examination, necrotic unhealed and deeply seated wounds were detected on his left knee and big toe of his right foot. On neurological examination, his cooperation was poor and he was disoriented to place and time.

He had dysarthria and his comprehension ability was restricted to single commands. On cranial nerve examination, right and left pupil size were 2 and 3 mm, respectively with bilateral decrease in light reflexes. The patient had bilateral bradykinesia. His Romberg test was negative. Blood analyses including complete blood count, hepatic, renal, thyroid function tests, fasting blood glucose, electrolytes, erythrocyte sedimentation rate, C-reactive protein were within normal limits. Markers of vasculitis were negative. Among serum serological tests, Treponema Pallidum hemagglutination assay (TPHA) was positive at 1/2560 dilution. Venereal Diseases Research Laboratories (VDRL) and Rapid Plasma Reagin (RPR) tests were also positive. Cranial magnetic resonance (MR) images were evaluated as global cerebral and cerebellar atrophy and sequela of trauma in subcortical white matter of the right parietal lobe without contrast enhancement (Figure 1). Lumbar puncture was performed.

Cerebrospinal fluid (CSF) analysis revealed the following results. Glucose was 67 mg/dL, protein A

B

Figure 1. Flair-weighted

36 mg/dL, Pandy test positivity and leukocyte 3/ mm3. In serologic examination of CSF, fluorescent treponemal antibody absorption (FTA- ABS) and VDRL was positive at 1/2 and TPHA at 1/10240 dilutions. The patient was diagnosed as neurosyphilis and after consultation with the department of infectious diseases, intravenous crystalized penicilline G (24 million units/day) was administered for 21 days. He was consulted with the department of psychiatry for the behavioral disorders and agitation. He was diagnosed as organic brain syndrome and offered risperidone (3 mg/d), haloperidol (10 mg/d) and carbamazepine (800 mg/d) therapy.

Control CSF tests performed 6 months later were reported as TPHA positivity at 1/64 dilution, VDRL positivity and RPR 27.54 s/co. During his follow-up, we did not observe any improvement in his psychiatric symptoms, cognitive functions, urinary and fecal incontinence.

DISCUSSION Neurosyphilis has been a rarely seen clinical entity within the last decade. It can be encountered in almost all psychiatric disorders including dementia, personality changes, mania, depression, psychosis and delirium.

In our patient, psychiatric manifestations started with introversion followed by gradually worsening cognitive decline, psychotic symptoms, dysarthria, urinary and fecal incontinence. His medical history did not reveal any clinical and dermatological complaints and signs peculiar to primary and secondary C

axial section (A), T2-weighted sagittal section (B) and T1-weighted coronal section (C) of cranial MR images show diffuse cerebral, cerebellar atrophy and ventricular enlargement secondary to atrophy.

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68

stages of syphilis. Differential diagnosis of the patient involved treatable causes of cognitive dysfunction and psychiatric disorders, primary degenerative dementia and vascular disease. Creutzfeldt-Jakob disease was ruled out because of negative radiological and electroencephalographic findings. Primary dementia was discarded because of the patient age and development of cognitive decline within a short time (1-2 years) and severe course. MRI was negative for cerebrovascular disease, space-occupying mass lesion and vascular dementia. There was no sign for substance abuse in his medical history. Normal blood tests results, negative hepatitis and HIV serology ruled out metabolic and infectious causes of dementia. Serologic tests of serum and CSF for syphilis were found positive. Clinical findings and positive serologic results were compatible with general paresis, one of the forms of neurosyphilis.

Tertiary syphilis is a form of progressive dementia, also termed as general paresis, paretic neurosyphilis or dementia paralytica. Generally it develops 10-25 years after onset of the infection. In early phases of the disease, general paresis is associated with amnesia and personality changes. Most frequently problems related to memory and reasoning have been encountered. Less frequently, symptoms as depression, mania and psychosis are seen. Neurological examination may be normal or there are some pathological findings such as dysarthria, Argyl Robertson pupil defects, hypotonia, intentional tremor and reflex abnormalities [9]. Literature reports indicate that outcome of patients with general paresis is poor and death occurred within nearly 2.5 years before the era of penicillin treatment [7].

Effective treatment for neurosyphilis is high dose of intravenous crystallized penicillin. Treatment response should be examined with CSF analyses.

After a treatment period, quantitative evaluation of blood serology is performed at 3-month-intervals and a decrease in the level of positivity in serologic tests can be observed. CSF should be analyzed at 6th and 12th months. Follow-up with neurological examination and CSF analysis can be stopped after the patient is cured, clinical stabilization is achieved and CSF serologic tests return to normal limits [10].

Treatment response is less frequently obtained in patients with general paresis when compared with cases with meningitis and meningovascular syphilis.

Indeed, irreversible neuronal damage is seen in general paresis, while the others reflect types of CNS inflammation [11].

As the case presented here is in the advanced stage of neurosyphilis, no improvement was observed in cognitive functions, psychotic manifestations and symptoms of dysarthria, urinary and fecal incontinence despite penicillin treatment. Nowadays, it should be remembered that syphilis in early stages can be overlooked, left untreated and can lead to irreversible manifestations, especially in developing countries.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

REFERENCES 1. Bharucha NE. Infections of the nervous system. In: Bradley WG, Daroff RB, Fenichel GM (editors). Neurology in Clinical Practice. 3th edition. London: Butterworth - Heinemann 2000;1334-5.

2. Adams RD, Victor M, Ropper AH (editors). Principles of Neurology. 7th edition, New York: Mc Graw-Hill Companies 2000;722-8.

3. Schmidt RP. Neurosyphilis. In: Joynt RJ (editor). Clinical Neurology Vol.2 Revised edition. Philadelphia: Lippincott Williams & Wilkins 1992;1-23.

4. Berger JR. Neurosyphilis in human immunodeficiency virus type 1-seropositive individuals. A prospective study. Arch Neurol 1991;48:700-2.

5. Birnbaum NR, Goldschmidt RH, Buffett WO. Resolving the common clinical dilemmas of syphilis. Am Fam Physician 1999;59:2233-46.

6. Polsky I, Samuels SC. Neurosyphilis. Screening does sometimes reveal an infectious cause of dementia. Geriatrics 2001;56:60-2.

7. Merritt HH, Adams RD, Solomon HC. Neurosyphilis, Oxford, New York 1946.

8. Stokes JH, Beerman H, Ingraham NR. Modern Clinical Syphilology: Diagnosis, Treatment, Case Study, 3rd ed, WB Saunders, Philadelphia 1944.

9. Marra CM. Neurosyphilis. http://www.uptodate.com/contents/neurosyphilis.

10. Stefanis L, Rowland LP. Infectious of the nervous system. In: Rowland LP, Pedley TA (editors). Merritt’s Neurology. Lippincott Williams & Wilkins, Philadelphia 2010;215-2.

11. Saddock BJ, Saddock VA. Klinik Psikiyatri. Aydın H, Bozkurt A (Çeviri ed.) 8. Baskı, Ankara: Güneş Kitabevi Ltd. Şti., 2007;454.

Case Report

General Surgery

North Clin Istanbul 2015;2(1):69-72 doi: 10.14744/nci.2015.46855

A rare cause of acute mechanical intestinal obstruction: a strangulated obturator hernia Dogan Erdogan, Mehmet Gulmez, V. Melih Kara, Mehmet Ali Uzun, Osman Yucel Department of General Surgery, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey

ABSTRACT Obturator hernia is a rarely-seen type of abdominopelvic hernia. It is generally seen in thinner, old, multipara patients. The most frequently seen clinical sign is intestinal obstruction associated with strangulation. Diagnosis is generally made during operation in patients brought into emergency room because of intestinal obstruction. Delay in diagnosis in older patients results in higher rates of morbidity and mortality. Herein, we present a 68-year-old multipara patient who consulted to the emergency service with clinical manifestations of intestinal obstruction, and who was operated with the preoperative diagnosis of â&#x20AC;&#x153;strangulated obturator herniaâ&#x20AC;? established by means of computed-tomography.

Key words: Intestinal obstruction; obturator hernia strangulation.

O

bturator hernia is a rare type of hernia, seen in 0.4% of patients who present with clinical manifestations of intestinal obstruction, and constituting 0.07% of all abdominopelvic hernias [1]. It is generally seen in old and thin multipara patients. It is encountered 9 times more frequently in women because of their wider intrapelvic obturator channel [2]. Most frequently, strangulation is associated with intestinal obstruction. Diagnosis is generally made during emergency operation performed with the indication of intestinal obstruction. Because of its frequent occurrence in older patients, and delayed recognition due to difficulties encountered during the diagnostic process, it causes higher rates of mortality and morbidity. We present a patient

who was referred to the emergency service with clinical manifestations of intestinal obstruction, and operated urgently with the diagnosis of strangulated obturator hernia based on computed tomographic findings.

Case report A 68-year-old female patient presented to our emergency service with inability to pass gas and feces for 2 days, abdominal distension, and vomiting. Her personal medical history was unremarkable, without any previous disease or operation. This multipara patient was 155 cm tall, and weighed 40 kg. Her vital signs were as follows: ABP: 120/70 mmHg,

Received: June 30, 2014 Accepted: November 18, 2014 Online: April 24, 2015 Correspondence: Dr. Mehmet GUlmez. Haydarpasa Numune Egitim ve Arastirma Hastanesi, Genel Cerrahi Klinigi, Tibbiye Caddesi, 34668 Uskudar, Istanbul, Turkey.

Tel: +90 216 - 542 32 32 e-mail: mehmetgulmez86@hotmail.com Š Copyright 2015 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com

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70

pulse rate: 78/min, respiratory rate: 23/min, body temperature: 36.7°C. Physical examination revealed abdominal distension without abdominal guarding, and rebound tenderness. The rectal ampulla was empty on digital rectal examination. Other system examinations were unremarkable. Results of laboratory tests were as follows: Htc: 43.1%; WBC: 11700/mm3, glucose: 125 mg/dL, BUN: 61mg/dL, creatinine: 1.21 mg/dL, sodium: 135 mEq/L, potassium: 4.3 mEq/L. Standing KUB revealed air-fluid level of intestines (Figure 1). On whole abdominal ultrasound, dilated intestinal loops, and free fluid between intestinal loops were detected. Computed tomography (CT) demonstrated obstructive obturator hernia on the left side (Figures 2a, b). The patient was operated urgently with the diagnosis of intestinal obstruction caused by strangulated obturator hernia. On exploration, a strangulated intestinal loop was detected within the left obturator channel, and reduced. Intestinal ischemia, necrosis or perforation were not detected, so additional intervention was not performed. The defect was repaired using a polypropylene mesh placed in the preperitoneal region. The patient was lost on postoperative 3rd day because of acute respiratory failure.

Figure 1. Standing

abdominal radiograph showing dilated intestinal loop, and air-fluid level.

DISCUSSION Obturator hernia is a type of pelvic hernia developed as a result of herniation of the obturator nerve and muscles from the obturator foramen, and is a rarely seen surgical pathology. Obturator hernia is called the “hernia of the small old woman”, because it is generally seen in thin, multipara women of advanced age. Since the intrapelvic obturator channel A

is wider in women, it is seen 9 times more frequently in women [2]. Conditions which increase intra-abdominal pressure predispose to the development of obturator hernia. In compliance with the literature findings, our case was an old, and thin multipara patient. She had a left-sided hernia, and had not been operated previously.

B

Figure 2. Intestinal loop in the left inguinal obturator channel.

Erdogan et al., A rare cause of acute mechanical intestinal obstruction: a strangulated obturator hernia

The clinical findings of obturator hernia are generally not specific. Occasionally, its diagnosis is delayed until diagnostic laparotomy is performed.

The most frequently seen (80%) clinical picture is intestinal obstruction. Usually, acute obstruction is seen in association with strangulation. The most frequently detected second manifestation is the Howship-Romberg sign. This occurs when the anterior branch of the obturator nerve is impinged by hernial sac content, which causes pain at medial aspect of the femur and sometimes knee. It is seen in 15-50% of obturator hernia cases [3]. Other signs of a strangulated obturator hernia include ecchymosis seen on the internal aspect of the femur, and below the inguinal ligament, and a laterally situated tender obturator mass palpated during vaginal examination. If the hernial sac descends below the pectineus muscle, it can be palpated as an inguinal mass. This mass is best palpated when the femur is brought into flexion, adduction, and outer rotation [4]. Another manifestation of an obturator hernia is the HanningtonKiff sign. This signifies preservation of patellar reflex, and simultaneous loss of adductor reflex of the patella. In detection of an obturator hernia, it is more specific compared to the Howship-Romberg sign. Our patient consulted to our emergency service with clinical manifestations of intestinal obstruction identified during vaginal examination.

Patients cannot be diagnosed without development of obstruction. Hip and leg pains are evaluated as neuromuscular pain, and assessed in the departments of neurology, orthopedics, neurosurgery or gynecology and obstetrics, which consequently delays diagnosis. If patients with hip and leg pains carry risk factors for obturator hernia, even in the absence of clinical manifestations of intestinal obstruction, before making a diagnosis of neuromuscular pain, potential diagnosis of obturator hernia should be kept in mind.

In patients who present with abdominal pain suggesting intestinal obstruction, abdominal CT should be done for differential diagnosis [2]. In strangulated obturator hernia with high mortality rates, preoperative diagnosis can rarely be made.

Although ultrasound (US) is a rapid, noninvasive, cost-effective, and easily-available diagnostic method, it is difficult to arrive at a diagnosis of obturator hernia using US. Diagnostic accuracy of preopera-

71

tive abdominal CT has been reported as 90% in cases with obturator hernia [5, 6]. In our patient, preoperative diagnosis of obturator hernia was made using abdominal CT, and the patient was operated with this indication.

In the management of intestinal obstruction, emergency surgery is most frequently preferred [4].

Various types of surgical interventions have been described. If left unrepaired, recurrence rates climb to 10 percent [4]. The defect of the obturator channel or contaminated perforation can be closed primarily or repaired using polypropylene mesh [7].

Because of suspicion of strangulation, we preferred the abdominal approach, and repaired the defect with preperitoneal polypropylene mesh.

Conclusion Obturator hernia is a rare cause of intestinal obstruction. However, because of its higher mortality rates in case of delay in diagnosis and treatment in older, multipara, thin patients who have not previously undergone abdominal operation, and who present to the emergency service with a clinical picture of intestinal obstruction, obturator hernia should be suspected, and contrast-enhanced abdominal CT should be requested for early diagnosis and treatment.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

REFERENCES 1. Yokoyama Y, Yamaguchi A, Isogai M, Hori A, Kaneoka Y. Thirty-six cases of obturator hernia: does computed tomography contribute to postoperative outcome? World J Surg 1999;23:214-7.

2. Chang SS, Shan YS, Lin YJ, Tai YS, Lin PW. A review of obturator hernia and a proposed algorithm for its diagnosis and treatment. World J Surg 2005;29:450-4.

3. Mantoo SK, Mak K, Tan TJ. Obturator hernia: diagnosis and treatment in the modern era. Singapore Med J 2009;50:866-70.

4. Mandarry MT, Zeng SB, Wei ZQ, Zhang C, Wang ZW. Obturator hernia--a condition seldom thought of and hence seldom sought. Int J Colorectal Dis 2012;27:133-41.

5. Wang GY, Qian HR, Cai XY, Fang SH, Shen LG. Strangulated obturator hernia diagnosed preoperatively by spiral CT: case report. Chin Med J (Engl) 2007;120:1855-6.

72 6. Agar NJ, Mooney BM, Nagorcka J. Obturator hernia case report: early diagnosis with the help of computed tomography.

ANZ J Surg 2008;78:508.

North Clin Istanbul â&#x20AC;&#x201C; NCI 7. Agarwal D, Sharma G, Agarwal NN, Rao J, Garg KM. Interstinal obstruction due to obturator hernia {a rarest presentation}.

Indian J Surg 2013;75(Suppl 1):388-90.

REVIEW

Public Health

North Clin Istanbul 2015;2(1):73-80 doi: 10.14744/nci.2015.72691

Cancer in the elderly Derya Cinar1, Dilaver Tas2 Department of Internal Medicine, Balikesir Military Hospital, Balikesir, Turkey

1

Department of Chest Diseases, Balikesir Military Hospital, Balikesir, Turkey

2

ABSTRACT Ageing is a fundamental biological process in all living beings. Nowadays as a result of developments in preventive and therapeutic medicine, and improvements in the quality of life, ageing of the population is one of the most important demographic issues. In the elderly, cancer is one of the predominant causes of mortality and morbidity, and its incidence increases with ageing. Sixty percent of all cases with cancer, and 70% of cancer-related deaths occur in patients aged 65 years and over. For optimal care, and treatment of elderly cancer patients a multidisciplinary approach consisting of physical, psychological, and tumor-related assessments should be pursued.

Because of increased incidence of cancer caused by demographic changes in Turkey and in the world, an increase in the burden of cancer in the population is expected. In the years to come, this expectation will also lead to an increase in cancer-related health expenses.

Key words: Ageing; cancer; cancer incidence.

A

geing is a universal process seen in every living creature which begins mainly from intrauterine life, and continues up to death, and induces changes in physiological functions of organs, and systems under the influence of many factors.

Nowadays, thanks to possibilities brought by scientific, and technological developments, disease, and mortality rates have decreased, birth rates have dropped, and environmental conditions improved which all of them have contributed to the prolongation of life span, and the relatively higher number of elder people in overall population. Based on estimates reported by The World Health Organization (WHO), people aged 65 years and over will be

expected to reach 800 million in the year 2025 [1].

Ageing is defined as irreversible structural, and functional changes in molecules, tissues, organs, and systems of the organism which become apparent with advanced age. Senescent period has been classified from the biological, sociological, economical, and chronological perspectives. WHO defines old age as the period of life starting from 65 years of age. According to this chronological definition, age ranges of young old (65-74 yrs), middle old (75-84 yrs), and very old (â&#x2030;Ľ85 yrs) have been defined [2].

One of the predominant causes of mortality, and morbidity is cancer whose incidence increases with

Revised: December 18, 2014 Accepted: February 03, 2015 Online: April 24, 2015 Correspondence: Dr. Dilaver TaS. Balikesir Asker Hastanesi, Gogus Hastaliklari Servisi, Ali Hikmet Pasa Caddesi, Balikesir, Turkey.

Tel: +90 266 - 239 60 00 e-mail: dilavertas@gmail.com Š Copyright 2015 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com

North Clin Istanbul – NCI

74

age. Although cancer effects each age group, when it is seen from a global perspective, nearly 60% of the cases diagnosed as cancer, and 70% of the cancerrelated mortalities occur in individuals aged 65 or older [3].

Based on the report released by WHO, and International Cancer Research Institute in the year 2012, approximately 14 million new cases were seen in the whole world, while this figure will be expected to rise to 22 million within the next 20 years leading to an increase in the global cancer burden.

As a consequence of growing, and ageing population, an important part of this increase is predicted to concern developing countries. Because of limitations in the application of screening programs, early diagnosis, and access to treatment, further increases in the incidence of cancer, and cancer-related mortality rates have been foreseen [4, 5].

Incidence of cancer in Turkey demonstrates similarities with other developing countries. According to cancer statistics of the year 2009 performed in Turkey, in our country every year nearly 98.000 men, and 63.000 women are contracting cancer [6].

As is seen in the world, and in our country, cancer is a public health problem with increasing importance. Prolongation of overall lifetime leads to increase in the older population in our country. According to 2013 data of Turkish Statistical Institute (TÜİK) the percentage of the elder population was Breast

12.8

Colorectal

Trachea, bronch, lung

22.5 18.8

Bladder

7.5

Trachea, bronch, lung

Most frequently seen cancer types in elder people Nowadays, nearly half of the cases with diagnosis of cancer constitute people aged 70 years and older [9]. Directorate of Cancer Department of Public Health Agency of Turkey reported the statistics of the most frequently seen cancer types in older female, and male population aged 70 years, and over (Figures 1, and 2) [6]. As is seen, the most frequently seen cancer types in population over 70 years are lung cancer, and prostate cancer in men, and breast cancer, and colorectal cancers in women.

Prostate

11.2

Gastric

determined as 7.7 percent [7]. The percentage of the population aged 65 years and over is predicted to increase to 10.2% in the year 2023, and to 20.8% in 2050 [6]. In our country, 27% of the patients diagnosed as cancer are aged 65 years and over [3]. In the United States of America more than 60% of the cancer cases are seen in old individuals aged 65, and over [8].

Prolonged exposure to carcinogenic agents, DNA damage accumulation, tumor suppressor gene defects, impairment of cellular repair mechanisms, oncogenic activation, and attenuation of immunity have been held responsible for higher incidence of cancer in older individuals [3]. Since carcinogenesis is a very long process, emergence of cancer in advanced ages is a natural event.

9.4

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Uterine corpus

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0

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8

10

12

14

Figure 1. Distribution of some of the most frequently seen cancer types in women aged ≥70 years [6].

6.6

0

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5

10

15

20

25

Figure 2. Distribution of some of the most frequently seen cancer types in men aged ≥70 years [6].

Cinar et al., Cancer in the elderly

75

Lung cancer Lung cancer has the shortest survival times among other cancer types, and takes the lead among cancer- related deaths in the whole world [6]. Half of the cases with lung cancer are diagnosed in the advanced stage [6]. More than 80% of the cases with lung cancer constitute non-small cell lung cancer (NSCLC). In the USA, median age of newly diagnosed cases with NSCLC is 68 years, while 40%, and 14% of these cases are over 70, and 80 years of age, respectively [10]. Less than 2% of all cases with the diagnosis of cancer are younger than 45 years of age. According to American Cancer Society (ACS) lung cancer is responsible from nearly 27% of all cancer-related deaths [8]. Owing to the decrease in the rate of smoking in Europe, and USA, decrease in incidence of lung cancer has been observed more frequently in men. Lung cancer -specific mortality rates between genders reflect smoking status, rates of quitting smoking, and historical differences within the last 50 years [11]. According to Globocan 2012 data published by International Cancer Agency, lung cancer ranks on top in men in Turkey, while in the European Union Countries, and in the USA it takes the second place [6]. In smokers the risk is higher relative to nonsmokers [12]. Smoking is the most important predictive risk factor which

Incidence rates standardized to age groups (per 100.000 people)

7

is responsible for nearly 70% of lung cancer-related mortality rates worldwide [13].

In Turkey lung cancer which is more frequently seen in men in Turkey, retains its updatedness as a public health problem. Therefore smoking quitting campaignes should be initiated, and maintained which will consequently lead to decrease in the incidence of lung cancer.

Breast cancer Breast cancer is the most frequently seen malignancy among women aged 65 both in the world, and in our country. Incidence, and mortality rates of breast cancer increase with age (Figure 3) [6]. Among all types of cancer, incidence rates of breast cancer in women are 28% in the world, and 35.47% in Turkey [14].

In our country breast cancer patients are old people aged 51-70 (40.7%), and â&#x2030;Ľ70 (8.2%) years.

In men breast cancer is seen very rarely, and 5-10 years later than women [15]. Based on 2013 ACS statistics, cases with in situ, and invasive breast cancer, and their mortality rates are climbing [11].

Although limited number of studies have been performed on breast cancer in elder population, surgical, and medical approaches do not differ when compared with the younger population. However in

Women

6 5 4 3 2 1

+

4

85

9

-8

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4

9

-7

75

-7

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4

-6

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-5

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-1

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0-

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Figure 3. Distribution of age-specific incidence rates of breast cancer in Turkey [6].

76

patients aged 65 and over, presence of comorbidities, and performance status are preventing optimizaton of the treatment of breast cancer.

Within the frame of breast cancer screening program clinical breast examination, and mammographic methods have been used. ACS recommends annual mammographic controls beginning from 40 years of age on. In Turkey biannual mammographic screening is recommended up to 69 years of age [11].

Regular and organized population-based mammographic screening reportedly decreased breast cancer mortality at a rate of nearly 25-35% in women between 40-69 years of age [16]. In the whole world a total of 1.150.000 newly diagnosed cases in the year 2002 were observed, and in the year 2020 this figure will probably rise to 2.500.000 cases [17].

Cervical cancer Both incidence, and mortality rates of invasive cervical cancer increases with age. Cervical cancer is a very costly disease which has a serious impact on health system, and population. In patients aged 65, and over cervical cancer has mortality rates ranging between 40, and 50%. However regular screening decreases cervical cancer risk at a rate of 80 percent [9]. Every year nearly 500.000 women are diagnosed as cervical cancer, and approximately 80% of them are seen in developing countries [18].

For the early diagnosis of cervical cancer, a very simple but highly sensitive, and specific Pap smear test has been used. Pap smear test which yields very successful outcomes in the early diagnosis of cervical cancer carries vital importance in the reduction, and prevention of mortality [19]. In the developed countries like USA, 85% of the women undergo Pap smear test at least once in their life time, while in the developing countries its rate drops to 5 percent.

Only one negative Pap smear test decreases the risk of development of cervical cancer at a rate of 45 percent. Pap smear tests performed for 9 times during an individual’s’life time decrease this risk at a rate of 99 percent [17]. According to ACS recommendations, screening tests for cervical cancer should be initiated within the first 3 years from the first sexual intercourse or at most at the age of 21. Every year obstetric examination and Pap smear test should be performed. If the last successive 3 screening test results are within normal limits, then screening tests

North Clin Istanbul – NCI

can be done every 2-3 years.

If 3 separate or 10 successive Pap smear tests performed for women aged 70 and over yield normal results, cervical screening tests can be discontinued.

According to National Cervical Cancer Screening Standards, smear, and HPV tests should be performed at every 5 years beginning from 30 years of age. If the last 2 tests yield negative results, screening should be stopped when the patient reaches 65 years of age. Screening tests may not be performed in patients who had undergone hysterectomies [11].

Colorectal cancers Colorectal cancer (CRC) ranks among the first five most frequently seen cancer types in our country in both genders [6]. Prevalence, and mortality rates of CRC increase in individuals aged ≥50 years [9]. Incidence of CRC is 6 –times higher in the 65-84 year age group when compared with the younger individuals [3]. In our country it is most frequently seen in men rather than women (Figure 4). Its incidence rates per one hundred thousand individuals is 21 in men, and 13.4 in women [6]. In the whole world the highest incidence of CRC is found in Northern America, Australia, Northern, and Western Europe, and while in developing countries of Asia, and Africa its incidence is relatively lower [20]. It has been reported that the annual incidence of CRC in individuals aged 50 years and over in the USA decreased at a rate of 3.7%, while in the young population its annual incidence increased, at a rate of 1.8 percent [11].

Even recently developed surgical techniques, and adjuvant treatments could not drop 5-year mortality rates of CRC patients below 50 percent [21].

Ninety percent of newly diagnosed CRC cases, and 93% of CRC-related deaths are seen in patients 50 years and older [8].

According to ACS recommendations all women, and men from 50 years of age should participate in one of the screening programs. Annual fecal occult blood test (FOBT), and at 5–year intervals, sigmoidoscopy, sigmoidoscopy plus annual fecal occult blood tests, barium colonography, and at 10-year intervals colonoscopy have been recommended [11].

In our country CRC Screening program of Ministry of Health is initiated at 50, and terminated at 70 years of age. FOBT at alternate years, and colonos-

Cinar et al., Cancer in the elderly

Incidence rates standardized to age groups (per 100.000 people)

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77

Women Men

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Figure 4.

Distribution of age-specific incidence rates of colorectal cancer in men, and women in Turkey [6].

copy at every 10 years are recommended. As indicated, for cessation of screening in women, and men aged 70 years, fecal occult blood tests should yield negative results [21].

In the USA, it has been estimated that with CRC screening programs, CRC was prevented at a rate of 58-80%, when treated effectively [22]. Limited number of studies have demonstrated the impact of FOBT on the incidence of CRC. In a cohort study lasting for 22 years screened group was compared with a non-screened group, and incidence, and mortality rates of CRC were observedly decreased in the screened group at a rate of 40, and 64%, respectively.

It has been suggested that in FOBT positive cases when these findings were combined with complete colonoscopic follow-up, annual FOBT control can be an effective approach [23].

Prostate cancer Prostate cancer is one of the most frequently seen malignancies especially in the older male population. Majority (75%) of male patients diagnosed as prostate cancer are â&#x2030;Ľ65-years-old [24]. In the USA 64% of newly diagnosed cases are elder people aged â&#x2030;Ľ65 years. It has been estimated that the incidence of

prostate cancer will continue to increase in line with a continual rise in the number of elder population [9].

Patients aged 65 years and over have not been included in drug trials performed in many oncological survey studies. This approach presents difficulties in determining the impact of treatment on an elderly patient. To avoid demographic bias, every age group should be included in prostate cancer survey studies. Recently new agents used in the treatment of prostate cancer patients have widened the spectrum of treatment, and supportive therapy alternatives of prostate cancer patients in every age group [11].

As prostate cancer screening tests, routine use of digital rectal examination (DRE), and prostatespecific antigen tests are recommended. ACS recommends screening programs for prostate cancer including PSA test and DRE to be performed beginning from the age of 50, In patients with higher risk (presence of prostate cancer in one or more than one younger first-degree relatives) these tests should be initiated at an early age. In individuals with very high risk for prostate cancer, tests should be performed at an age of 40, and if normal test results are obtained, then annual tests can be carried on after the age of 45 [11].

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In the USA between the years 2006 and 2010, incidence of prostate cancer decreased at an annual rate of 2.0 percent. The number of newly diagnosed cases will be estimated to rise to 233.000 in the year 2014 [11].

General approach to cancer therapy Ageing is an important risk factor for contracting cancer. However age really represents only number of years. Ageing is a both biological, and chronological phenomenon. Biological ageing begins with fertilization, and progesses all life long, and plays a role in the performance status, and concomitant diseases of the individual. In cancer therapies, biological, rather than chronological age should be taken into consideration. Health state, level of functionality, and expectation from study will differ between individuals. As a consequence, age should not be the only factor to be considered in the determination of cancer treatment alternatives. Other concomitant health problems of elder individuals (cardiovascular diseases, diabetes etc) can effect treatment decisions. Presence of these medical problems, chemotherapy, radiotherapy, and surgery can increase the risk of post-treatment complication rates. Other additional factors as life expectancy, and drug interactions should be also taken into account [8].

International Association of Geriatric Oncology emphasizes the importance of Comprehensive Geriatric Evaluation in old patients [25]. Comprehensive Geriatric Evaluation determines functional state, comorbidities, mental state, nutritional status of the patients, and drugs used by them. It can be used to present treatment alternatives, and in the prevention of treatment complications. In every stage of the treatment, multidisciplinary approach encompassing physical, psychological, and oncological assessments should be pursued for optimal care, and treatment of the elder people with cancer.

As a consequence of physiological changes seen in old age, under the influence of cellular, and vascular factors glomerular filtration rate (GFR) slows down, and renal functions deteriorate. At the same time, hepatic metabolism, intestinal motility, and immunity attenuate. Age-related physiological changes, and presence of comorbidities can increase toxicity of chemotherapy, and also interfere with the effectiveness of the treatment dose. Chemotherapy-relat-

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ed serious complications increase in old people. Myelosuppression, mucositis, nausea, and vomiting in late stages, cardiomyopathy, peripheral neuropathy, and neurotoxicity are more frequently seen. For old people exposure to adverse effects of chemotherapy is the greatest threat to their quality of life Therefore treatment should be individualized. Comprehensive Geriatric Evaluation can identify patients with high risk as for predictive factors for their life expectancies, and chemotherapeutic complications This approach allows for making standard or palliative treatment decisions.

Several studies have demonstrated that most of the cancer patients have been represented in clinical cancer studies, while health state of cancer patients aged 65 years and over has not been adequately revealed [8]. Limited number of studies performed also influence chemoprevention alternatives for the elderly.

Financial burden of cancer In the years to come cancer burden of the nations is expected to rise in line with the increase in the incidence of cancer as a consequence of demographic change in the whole world, and Turkey. This expectation also points out to an increase in cancerrelated healthcare expenditures. National Disease Burden, and Cost-Effectiveness Study conducted in Turkey supports these outcomes.

Financial burden of cancer within the frame of healthcare finance can be calculated with the procurement of effective epidemiological data. Establishment of reliable cancer registration systems is extremely effective in the acquisition of epidemiological data. When Turkey is compared with European countries, it ranks 6th among countries with the highest cancer-related healthcare expenditures.

Since incidence of cancer increases with age, average cancer burden per individual aged over 45 also increases [17]. Anticancer drugs are respondible for 3.8, and 7.2% of all drug expenditures in the years 2003, and 2010, respectively [26].

According to 2014 World Cancer Report, increasing financial burden of cancer are even challenging for economies of countries with higher annual income. Total annual financial burden of cancer in the year 2010 reached to 1.6 trlllion US dollars. According to WHO data 40% of the cases

Cinar et al., Cancer in the elderly

with cancer can be prevented. Increasing incidence of cancer cases is an important obstacle for the development, and prosperity of human beings in the whole world [4]. Lowering incidence rates of cancer will contribute greatly to expenditures incurred by malignant diseases.

In studies performed a marked increase in survival times of breast cancer patients with effective screening programs has been seen, while early diagnosis has apparently directly decreased diseaserelated treatment costs Cervical cancer screening programs included in routine screening programs decrease financial burden of cancer in that these tests do not require advanced technology with their advantages of effectiveness and lower cost. In our country cancer –related morbidities are responsible for nearly 11% of healthcare expenses for the year 2006 17].

Because of the impact of cancer on healthcare expenses, implementation of reliable registration systems should specify srategies for early diagnosis, and screening. As a consequence of ageing in the population an increase in the incidence of cancer is predicted. Population-based effective screening methods enable establishment of early diagnosis, and increase the chance of cure. This approach will have favourable reflections on cancer therapy.

Cancer prophylaxis Prophylaxis seems to have the utmost importance in decreasing cancer burden in society. General opinion in cancer prophylaxis involves taking measures to improve nutrition, physical activity, and also prevent obesity. World Cancer Research Foundation estimates that one-third of the cancer cases in developed countries are overweight or obese which are related to physical inactivity or insufficient nutrition. Recommendations of ACS for cancer prophylaxis are as follows: • Maintain a healthy body weight, • Restrict intake of processed meat or red meat, • Daily intake of at least 2 ½ servings of vegetables and fruits • Prefer wholewheat bread rather than refined cereal products, • Restrict alcohol intake, • Avoidance of using tobacco products

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• Regular engagement in physical activities • Restriction of sedentary life style [11].

Even if we brought nutritional status, physical activity, and other environmental factors completely under control, it is not possible to keep away from cancer by all means. Together with physiological ageing process, mechanisms which control proliferation of cells weaken, repair mechanisms slows down, and cellular destructive changes accumulate.

Within this context, even if healthy individuals have not any complaint, cancer screening tests are performed for early diagnosis of cancer so as to increase chances of cure. Early detection of the disease yields better outcomes for its treatment, and care.

Conclusion Sixty percent of cancers originate from etiological factors related to ageing. Treatment, and care for older patients with cancer should be individualized rather than focusing on age of the patient. With comprehensive geriatric evaluation, risks, and benefits of the available treatment alternatives should be properly determined. Early diagnosis, treatment, and screening programs will also lessen cancer burden imposed on communities thanks to decreasing incidence rates of cancer in elderly.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

REFERENCES 1. Kaptanoğlu AY. Yaşlı Sağlığı. T.C. Aile ve Sosyal Politikalar Bakanlığı. 2. Baskı, İstanbul, Nakış Ofset 2012. p. 1-144.

2. www.turkgeriatri.org/bildiri_uyh.php (Erişim Tarihi: 10.12.2014) 3. Alan Ö, Gürsel Ö, Ünsal M, Altın S, Kılçıksız S. Oncologic Approach in Geriatric Patients. Okmeydanı Tıp Dergisi 2013;29:94-8.

4. World Cancer Report 2014.

5. de Martel C, Ferlay J, Franceschi S, Vignat J, Bray F, Forman D, et al. Global burden of cancers attributable to infections in 2008: a review and synthetic analysis. Lancet Oncol 2012;13:607-15.

6. TC. Sağlık Bakanlığı Türkiye Halk Sağlığı Kurumu. Türkiye Kanser İstatistikleri. Editörler: Murat Gültekin, Güledal Boztaş.

2014.

7. TÜİK, Adrese Dayalı Nüfus Kayıt Sistemi (ADNKS) Sonuçları, 2008-2013 http://www.tuik.gov.tr (Erişim tarihi: 20.10.2014).

80 8. www.asco.org American Society of Clinical Oncology 2012.

(Erişim Tarihi: 10.12.2014) 9. http://www.hasuder.org/anasayfa/index.php/yayinlar/hasuder-yayinlari (Erişim Tarihi: 10.12.2014) 10. Köksal D. Management of Non-Small Cell Lung Cancer in the Elderly. Solunum 2013;15:14-20.

11. http://www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2014/index (Erişim Tarihi: 10.12.2014) 12. http://www.cancer.org/acs/g roups/cid/doc uments/ webcontent/003115-pdf.pdf (Erişim Tarihi: 10.12.2014) 13. http://www.who.int/mediacentre/factsheets/fs297/en/ (Erişim Tarihi: 10.12.2014) 14. Bakar Y, Berdici B, Şahin N, Pala ÖO. Lymphedema after Breast Cancer and its Treatment. J Breast Health 2014;10:6-14.

15. Sözen S, Benderli Cihan Y. Tumor Characterıstıcs, Treatment And Survıval Perıods Of Elderly Patıents With Breast Cancer In Elderly. Turkish Journal of Geriatrics 2012;15:164-70.

16. Kayhan A, Gürdal SÖ, Özaydın N, Öztürk E, Cabıoğlu N, Arıbal E, et al. Fırst Round Results Of A Long Term Populatıon-Based Breast Cancer Screenıng Program From Bahcesehır. Meme Sağlığı Dergisi 2012;8:180-4.

17. T.C. Sağlık Bakanlığı, Kanserle Savaş Dairesi Başkanlığı. Türkiye’de Kanser Kontrolü. Editör: A. Murat Tuncer. Ankara 2010.

North Clin Istanbul – NCI 18. Şahbaz A, Erol O. HPV aşı uygulamaları. Obstet Gynecol 2014;2:126-30.

19. Gümüş AB, Çam O. Kadınların Serviks Kanseri İçin Erken Tanı Tutumları İle Benlik Saygısı, Beden Algısı Ve Umutsuzluk Düzeyleri Arasındaki İlişkiler. Rısk 2011:7;46-52.

20. http://kanser.gov.tr/Dosya/tarama/kolorektal_kanser_tarama_programi.pdf (Erişim Tarihi: 20.01.2015).

21. Kara M, Tanoğlu A. Screening Strategies In A Global Public Health Issue Colorectal Carcinoma and Place of Colonoscopy.

TAF Preventive Medicine Bulletin 2013;12:743-50.

22. Levy BT, Xu Y, Daly JM, Ely JW. A randomized controlled trial to improve colon cancer screening in rural family medicine: an Iowa Research Network (IRENE) study. J Am Board Fam Med 2013;26:486-97.

23 Jin P, Wu ZT, Li SR, Li SJ, Wang JH, Wang ZH, et al. Colorectal cancer screening with fecal occult blood test: A 22-year cohort study. Oncol Lett 2013;6:576-582.

24. Kessler ER, Flaig TW. Geriatric considerations in the treatment of advanced prostate cancer. F1000Prime Rep 2014;6:33.

25. Tuna S. Comorbidity and clinical assessment in geriatric patients with cancer. Türk Onkoloji Dergisi 2007;22:192-6.

26. Pınar N. Ülkemizdeki ilaç harcamaları. İnönü Üniversitesi Tıp Fakültesi Dergisi 2012:19;59-65.

REVIEW

Infectious Diseases and Microbiology

North Clin Istanbul 2015;2(1):81-86 doi: 10.14744/nci.2015.97269

An overview of Ebola virus disease Ayten Kadanali, Gul Karagoz Department of Infectious Diseases and Clinical Microbiology, Umraniye Training and Research Hospital, Istanbul, Turkey

ABSTRACT Ebola virus disease (EVD), formerly known as Ebola hemorrhagic fever, is a severe, often fatal illness in humans.

Ebola virus (EBOV) is transmitted through contact with blood or body fluids of a person who contracted or died from EVD, contaminated objects like needles and infected animals or bush meat. EVD has an incubation period of 2 to 21 days, and the infection has an acute onset without any carrier status. Currently, there is no standard treatment for EVD, so it is important to avoid infection or further spreading of the virus. Although historically the mortality of this infection exceeded 80%, modern medicine and public health measures have been able to lower this figure and reduce the impact of EBOV on individuals and communities. Its treatment involves early, aggressive supportive care with rehydration. Clinicians should consider the possibility of EVD in persons with travel or exposure history with the incubation period presenting constitutional symptoms in order to promptly identify diseased patients, and prevent further spreading of the disease.

Key words: Ebola virus disease; epidemiology; diagnosis; treatment.

E

bola virus disease (EVD) first appeared in 1976 in 2 simultaneous outbreaks in Nzara, Sudan, and in Yambuku, Democratic Republic of Congo. The latter occurred in a village near the Ebola River, from which the disease takes its name. The mortality rate was around 90 percent.

Although medical facilities have improved over the years, case fatality rates have varied from 25% to 90% in past outbreaks. EVD outbreak that began in February 2014 in Guinea, is the most prevalent EVD outbreak recorded in the history which spred to Liberia, Sierra Leone, Nigeria, Senegal, Spain, and the United States. It had common features with the outbreak in 1976. Zaire Ebola virus was isolat-

ed in both outbreaks with the disease onset in rural forest communities. The outbreaks were worsened because critically ill patients with severe systemic symptoms were brought to hospitals which infected hospital staff was unaware of the risks of being exposed to patient blood and body fluids without proper protection. Due to the common travel and general international contacts implicit in globalization, as well as the popularity of tourism, EVD is most certainly a threat to the people all over the world [1, 2, 3, 4]. In this review article, we planned to discuss the epidemiological, clinical and laboratory features and patient management of EVD based on literature.

Revised: February 06, 2015 Accepted: April 09, 2015 Online: April 24, 2015 Correspondence: Dr. Ayten Kadanal覺. Umraniye Egitim ve Arastirma Hastanesi, Enfeksiyon Hastaliklari Bolumu, Istanbul, Turkey.

Tel: +90 216 - 632 18 18 / 1675 e-mail: ayten.kadanali@gmail.com 穢 Copyright 2015 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com

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Virology The virus family Filoviridae includes 3 genera: Cuevavirus, Marburgvirus, and Ebolavirus (EBOV).

There are 5 species that have been identified: Zaire, Bundibugyo, Sudan, Reston and Tai Forest in Ebolavirus. Zaire, Bundibugyo, and Sudan ebolaviruses have been associated with large outbreaks in Africa.

The virus causing the 2014 West African outbreak belongs to the Zaire species. Fruit bats of the family Pteropodidae are the recognized reservoir of the virus. The EBOV genome is a negative-sense single-stranded RNA and contain viral envelope, matrix, and nucleocapsid components. It encodes seven structural proteins: nucleoprotein (NP), polymerase cofactor (VP35, VP40, GP), transcription activator (VP30, VP24), and RNA-dependent RNA polymerase (L) [1]. EBOV is listed as an agent included in WHO Risk Group 4 Pathogen requiring biosafety level 4-equivalent containment requiring Biosafety Level 4-equivalent containment, because of its high mortality rate.

Epidemiology The initial outbreak of EVD occurred in Yambuku in the Northern Zaire. Disease had spred by close personal contact. This was the first recognition of the disease and the subtype was named Zaire Ebola Virus [2]. In the same year, another unrelated virus, which resulted in epidemics in South Sudan, was identified as Sudan Ebola Virus [3]. Of interest, some researchers suggested that EBOV outbreaks might be related to certain confluences of environmental and climatic conditions [4].

Up to date, 25 outbreaks have been reported including the current outbreak (n=4,1976-1979; n=6, 1994-1996; n=9, 2000-2008, and n=6 after 2011 [5, 6]. Current outbreak has been the largest documented outbreak of EVD and involved the Zaire species of the virus. The outbreak has been mostly seen in Guinea, Liberia and Sierra Leone, which together account for over 99% of all cases [7].

It is indicated that the exponential growth phase is over in Liberia, with an expected final attack rate of ~0.1-0.12 percent [8]. The natural reservoir of Ebola virus has not been identified yet. However, it is believed that the first patient became infected through contact with an infected animal like a fruit bat or nonhuman primate. When an infec-

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tion occurs in humans, the virus can be transmitted through direct contact with blood, body fuids of a EVD patient, needles or syringes that have been contaminated with the virus or infected fruit bats or primates. Ebola virus infection does not spread through contaminated air water, food, or by mosquito and other insects bites.

Once people recover from Ebola, they can no longer spread the virus to people through conventional routes. For instance, men who have recovered from the disease can still transmit the virus through their semen for up to 7 weeks after recovery from illness.

One EVD outbreak started in Guinea in late 2013 which was confirmed by the World Health Organization (WHO) in March 2014. As of March, 18 2015, 24.754 suspect cases and 10.236 deaths had been reported [9]. The case-fatality rate is between 20% and 90% depending on the virus species [10, 11].

Zaire Ebola virus species has the highest mortality rate (60%-90%) followed by the Sudan Ebola virus species (40%-60%). The Bundibugyo virus species has caused only one outbreak to date, with a 25% mortality rate. In the current outbreak, when the first 9 months of data were reviewed case-fatality rate was reported as 70.8% [12]. Centers for Disease Control and Prevention (CDC) recommends that travelers to Guinea, Liberia, and Sierra Leone protect themselves by avoiding contact with the blood and body fluids of the diseased people. Nigeria, Cameroon, Central African Republic, Ghana, Angola, Togo, United Republic of Tanzania, Ethiopia, Mozambique, Burundi, Madagascar and Malawi are also at risk for spread of the EVD. Clinical manifestations EVD is an acute hemorrhagic fever, that has an incubation period of 2 to 21 days (mean 4-10) which is characterized by ‘flu-like’ symptoms like fever, chills, malaise, and myalgia. The febrile state may be mild during the initial phase of the illness, but may manifest with an acute, and very worse onset with associated chills and rigors. The most commonly described symptoms are fever in combination with a maculopapular rash around the face, neck, trunk, and arms usually appearing by day 5-7 of the illness. The most common symptoms were fever, fatigue, vomiting, diarrhea, and anorexia in current

Kadanali et al., An overview of Ebola virus disease

outbreak in Africa.

A person who has fever or symptoms as severe headache, fatigue, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage; and an epidemiologic risk factor within the 21 days before the onset of symptoms must be kept under observation.

Viral hemorrhagic fever is the main finding. Because of thrombocythemiamucosal hemorrhage (especially in the conjunctiva), petechiae, ecchymosis, can be observed in patients with EVD. Massive hemorrhage, is usually observed only in fatal cases especially in the gastrointestinal system [13, 14].

Other than the blood system, there are also cardiac, renal, pulmonary, neurological, gastrointestinal, and hepatic involvements. Cardiac manifestations might be due to the hemodynamic changes due to severe hemorrhage or direct viral involvement of the heart.

But the cardiopathy in Ebola virus infection is not clear and needs further study. Profound fluid losses from the gastrointestinal tract result in volume depletion, metabolic abnormalities such as hyponatremia, hypokalemia, and hypocalcemia, shock, and organ failure. The patients who have respiratory, neurological, or hemorrhagic symptoms have higher risk of death [15]. Patients who survive from Ebola infection have been reported to show clinical improvement by the middle of the second week.

Diagnosis EVD usually presents with an acute viral prodrome.

It is difficult to distinguish EVD from other infectious diseases such as malaria, typhoid fever, meningitis, shigellosis, leptospirosis and yellow fever.

Therefore, travel and exposure history is very important when approaching a suspected patient returning from an endemic area.

As laboratory findings, leukopenia with lymphocytes and an increased percentage of granulocytes are common signs at the time of clinical presentation As the disease progresses, leukocytosis can develop with an increase in immature granulocytes.

Thrombocytopenia is a persistent feature until death. Mildly elevated serum levels of alanine and aspartate aminotransferase (ALT, AST) are common findings. Jaundice is not commonly seen, and serum total bilirubin level is either normal or elevated in the early phase of the illness. Elevated blood

83

urea nitrogen and creatinine are observed due to excessive fluid loss from diarrhea and vomiting without adequate volume replacement. Prolonged prothrombin time (PT), partial thromboplastin time (PTT), or bleeding and disseminated intravascular coagulation (DIC) can be seen [16].

Antigen-capture enzyme-linked immunosorbent assay (ELISA) testing, IgM ELISA, polymerase chain reaction (PCR) and virus isolation tests are used as diagnostic tests to confirm infection. Laboratory diagnosis for EVD should be performed in a well-equipped laboratory with up to biosafety level 4 bio- contaminant facilities for viral culturing. WHO Risk Group 4 Pathogen requiring biosafety level 4-equivalent containment requiring Biosafety Level 4-equivalent containment, because of its high mortality rate.

There is no biosafety level 4 bio- contaminant facilities in Turkey so there is a need to establish a biosafety level-4 laboratory for further studies in Turkey.

Case definitions for evd According to the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC), a suspected case was defined as follows: Any person, alive or dead, had or having a sudden onset of high fever and had contact with a patient who is suspected, probable or confirmed or a dead or sick animal from Ebola; or if any person with sudden onset of high fever with at least three of the following findings: severe headache, fatigue, anorexia/loss of appetite, lethargy, breathing difficulties, muscle pain, vomiting, diarrhea, abdominal pain, unexplained hemorrhage or any sudden death without any cause.

A probable case was defined as any suspected case who has had direct contact with the blood and body fluids of an individual diagnosed with Ebola or who has had close physical contact with an individual diagnosed with Ebola or who lived with or visited an Ebola-diagnosed patient while the patient was ill within the previous 21 days with no laboratory confirmation.

A confirmed case was defined as a suspected or probable case with a positive laboratory result.

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On 27 October 2014, the CDC updated the case definitions and included the category of “Person Under Investigation (PUI)” described as: A person who has fever or symptoms, including severe headache, fatigue, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage; and an epidemiologic risk factor within the 21 days before the onset of symptoms.

A confirmed case was defined as a PUI with a positive laboratory confirmation of EBOV [17].

Treatment The main strategies that is being offered to infected patients are symptomatic and supportive care, such as hydration, replacement of electrolytes, nutritional support, maintaining oxygen status and blood pressure and treating other infections. Currently there is no approved vaccine and standard treatment for EVD that has been validated in humans [18, 19].

Up to date there are two notable Ebola vaccine efforts. The first one is cAd3-ZEBOV and the second is the rVSV. Both vaccines are effective in nonhuman primates, but confirmation of effectiveness against the Ebola virus in humans requires further studies [20].

As a result of quick recovery of one of the Dallas (Texas USA) nurses following the transfer of plasma from Ebola survivors; passive immunity has become a potential treatment for EVD [21].

Because of the high mortality rate of EVD, many investigational treatments are underway. ZMapp, is an experimental biopharmaceutical drug under development for treatment of EVD. It contains three “humanized” monoclonal antibodies (mAbs) against the EBOV GP protein. These antibodies are produced in plants, specifically Nicotiana benthamiana [22].

This drug was first used experimentally in humans during the 2014 West Africa EVD outbreak, but there is no randomized controlled trial to determine whether it works or it is safe enough to bring it on the market [20, 23]. In early August 2014, “ZMapp”, was used to treat two American medical workers and one Spanish priest and three African doctors who had contracted the deadly EBOV. Except for the 75-year-old Spanish priest who died despite the ZMapp treatment, the other five were

North Clin Istanbul – NCI

reportedly improved significantly after receiving ZMapp. This is the first time that a drug has shown therapeutic efficacy against EVD in human.

Favipiravir is a new antiviral drug. It can be used for the treatment of patients with Ebola virus, but it is teratogenic, embryotoxic and any clinical trial of favipiravir has not been performed in patients infected with the Ebola virus. It is approved by The Minister of Health, Welfare and Labor of Japan due to the epidemic in West Africa [24].

Melatonin is a natural substance, which is synthesized at night by the pineal gland and intestinal cells among many other cell types. It has no known side effects, even at very high concentrations. Melatonin has significant and curative effects on all the relevant cells and systems and decreases the symptoms and increases the survival of those infected with the Ebola virus. It is expected that melatonin will help maximize the benefit of soon available treatments [25].

Prevention Since Ebola virus infection is highly infectious and there are no standard treatments for EVD, isolation of infected individuals is very important. If a diagnosis of Ebola is being suspected, then, the patient should be isolated in a single room (with a private bathroom or covered bedside commode), and healthcare personnel should follow standard, contact, and droplet precautions, including the use of appropriate personal protective equipment (PPE).

PPE should include double gloves, gown or coverall and apron, face mask, eye protection (goggles or face shield) head cover, and boots. when performing aerosol-generating procedures, the wearing N95 of or higher respirators is also suggested.

Before contact with patients, washing hands with soap and water or an alcohol-based hand sanitizer and wearing appropriate personal protective equipment are recommended. Once exposed to blood or body fluids of the unprotected patient, healthcare workers should thoroughly wash the exposure site with water and soap. Safety needles are recommended for venipuncture or blood samples.

A minimum volume of 4 mL of whole blood preserved with EDTA is preferred for Ebola testing.

Specimens for shipment should be packaged following the basic triple packaging system that consists

Kadanali et al., An overview of Ebola virus disease

of a primary sealable container wrapped with absorbent material, secondary container (watertight, leak-proof ), and an outer shipping package and should be shipped at 2-8°C or frozen on cold-packs.

The defined case should be isolated till two negative results within a single 48 hour period are obtained. If death occurs from a suspect case of EVD, dead body should be burned within 24 hours.

In hospitals, transport and movement of the patients out of the room should be limited to medically-necessary purposes. If transport or movement outside the room is necessary, patients sould wear a surgical mask [26].

After returning from epidemic area, body temperature should be monitored for 21 days.

The Ebola virus is susceptible to many chemical agents. According to the WHO recommendations, environment contaminated with blood spill or body fluid can be cleaned up with 1:10 dilution and for surfaces 1:100 dilution of 5.25% household bleach applied for 10 minutes is required [25].

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

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85 soutbreak-qa.html?_r=1 8. Chowell G, Simonsen L, Viboud C, Kuang Y. Is West Africa Approaching a Catastrophic Phase or is the 2014 Ebola Epidemic Slowing Down? Different Models Yield Different Answers for Liberia. PLoS Curr 2014;6.

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13. Kortepeter MG, Bausch DG, Bray M. Basic clinical and laboratory features of filoviral hemorrhagic fever. J Infect Dis 2011;204 Suppl 3:810-6.

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17. Centers for Disease Control and Prevention. Case Definition for Ebola Virus Disease (EVD). Atlanta, GA, USA: CDC; 2014.

Available at http://www.cdc.gov/vhf/ebola/hcp/casedefinition. html.

18. Kanapathipillai R, Henao Restrepo AM, Fast P, Wood D, Dye C, Kieny MP, et al. Ebola vaccine--an urgent international priority. N Engl J Med 2014;371:2249-51.

19. Butler D. Ebola drug trials set to begin amid crisis. Nature 2014;513:13-4.

20. Bacon J, Owens M. Infected Dallas nurse ID’d; gets transfusion from Ebola survivor. 2014. 2014. Oct 28, [Last accessed on 2014 Oct 28]. Available from:http://www.usatoday.com/story/news/ nation/2014/10/13/ebola-nurse-who/17182599/ 21. Zhang Y, Li D, Jin X, Huang Z. Fighting Ebola with ZMapp: spotlight on plant-made antibody. Sci China Life Sci 2014;57:987-8.

22. Centers for Disease Control and Prevention. Ebola virus disease Information for Clinicians in U.S. Healthcare Settings. CDC USA Website. http://www.cdc.gov/vhf/ebola/hcp/clinician-information-us-healthcare-settings.html#investigational-vaccines.

23. Nagata T, Lefor AK, Hasegawa M, Ishii M. Favipiravir: a new medication for the ebola virus disease pandemic. Disaster Med Public Health Prep 2015;9:79-81.

24. Anderson G, Maes M, Markus RP, Rodriguez M. Ebola virus:

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