[The Importance of Gram-stained Smears in the Diagnosis of Nocardia Infections]. / Nocardia Enfeksiyonlarinin Tanisinda Gram Boyanmis Yaymalarin Önemi.

Nocardia species are low virulence bacteria found in nature. They can be an infectious agent, especially in patients with risk factors such as underlying immunosuppression, chronic lung disease, and malignancy. They can be easily overlooked because they are not seen frequently and has no pathognomonic symptoms. With this study, it was aimed to draw attention to the importance of microscopic examination of Gram-stained smears in the diagnosis of Nocardia infections in routine microbiology laboratories. Cases in which Nocardia spp. were detected in their clinical samples between November 2014-December 2015 in Hacettepe University Medical Faculty Hospital were included in the study. In the direct microscopic examination of Gram-stained smears of the samples arriving to the laboratory, the incubation periods of the cultures of the samples compatible with Nocardia spp. were extended. Then relevant colonies were identified by conventional microbiological methods and also by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS, bioMerieux, France) automated system. Species-level identification of Nocardia isolates was performed by 16S rRNA gene sequence analysis. To demonstrate the genetic relationship between Nocardia isolates, pulsed-field gel electrophoresis (PFGE) was performed. In vitro susceptibility of the isolates against amoxicillin-clavulanate (AMC), linezolid, moxifloxacin, trimethoprim-sulfamethoxazole (TMP-SXT), amikacin, imipenem, clarithromycin, cefepime, cefotaxime, ceftriaxone, and ciprofloxacin was determined using the gradient strip method (E-test). A total of 19 Nocardia spp. strains were isolated from eight patients. Four cases exhibited repeated growth of Nocardia spp. up to a period of nine months. The most frequently isolated species was N.cyriacigeorgica, which was identified in four cases. Other species isolated from patients were N.asteroides, N.transvalensis, N.farcinicia, and N.asiatica/arthritidis. When the results obtained with DNA sequence analysis and MALDI-TOF MS were compared, 16 (84.2%) of 19 isolates were correctly identified to the genus level and 9 (47.4%) to the species level with MALDI-TOF MS, while three (15.8%) isolates could not be identified, and seven (36.8%) isolates were misidentified. According to the PFGE results, it was determined that the strains isolated from the same patient were genetically identical. All isolates were susceptible to amikacin, cefepime, cefotaxime, ceftriaxone, imipenem, linezolid, and except one isolate to TMP-SXT. Among the study isolates, the most common resistance was against ciprofloxacin (62.5%), followed by clarithromycin (37.5%). N.cyriacigeorgica was determined as the most frequently detected and the most resistant species to antibiotics in the study population. Direct microscopic examination of clinical specimens is one of the most valuable methods for the identification of Nocardia-type bacteria, which is difficult to isolate in microbiology laboratories. With this study, the importance of examining Gram-stained clinical samples was emphasized in the identification of Nocardia species, which can emerge with a wide variety of clinical forms and can be easily overlooked. In addition, antibiotic susceptibility profiles of the isolated bacteria were determinedto contribute to species-specific susceptibility profiles. Accurate identification of Nocardia species will contribute to clinical and epidemiological studies.

Factors Associated with Gram-Negative Bacteremia and Mortality in Neutropenic Patients with Hematologic Malignancies in a High-Resistance Setting.

Objective: Patients with hematological malignancies (HMs) have a substantial incidence of febrile neutropenic episodes. Gram-negative bacteremia (GNB) is still the major cause of these episodes. We evaluated the factors associated with GNB and mortality of bacteremic patients with HMs in a high-resistance setting. Materials and Methods: We conducted a prospective cohort study from March 2018 to June 2019 with 66 bacteremic and 132 non-bacteremic patients. Regression analyses were used to identify factors associated with GNB and 30-day mortality. Results: The mean age was 53.83±15.21 years, and 129 (65.2%) of the patients were male. In multivariable analysis, factors independently associated with GNB were male gender, duration of hospitalization and neutropenia before the febrile neutropenic episode, leukemias and allogeneic transplant recipients, radiotherapy, receiving glucocorticosteroids, colonization with resistant microorganisms. All-cause mortality and 30-day mortality were 47.0% and 30.3% in cases of GNB, compared to non-bacteremic controls 25.0% and 10.6%, respectively. Sepsis, duration of hospitalization before the febrile neutropenic episode, carbapenem-resistant GNB, and inappropriate empirical antibiotic treatment was found as factors associated with 30-day mortality. Prior antibiotic exposure particularly beta-lactamase inhibitor combinations and carbapenems during the past 30 days was more frequent in the bacteremic group. An increasing trend was observed in multidrug-resistant (MDR) bacteria (p=0.03) and carbapenem-resistant Enterobacterales (p=0.02) over the years. Conclusion: By considering the risk factors associated with GNB and 30-day mortality that we detected in our study among neutropenic patients, a personalized approach for the management of febrile neutropenic patients can be designed by means of an effective antimicrobial stewardship program including the appropriate use of broad-spectrum antibiotics.

Molecular characteristics of Staphylococcus aureus strains isolated from nasal samples of sixth year medical students during their pediatric services practices.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) strains are prevalent in healthcare services. Medical students are at risk for MRSA carriage, subsequent infection and potential transmission of nosocomial infection.Few studies have examined MRSA carriage among medical students. METHODS: In this prospective cohort study, between July 2016 and June 2017, two nasal swab samples were taken per student 4 weeks apart during their pediatric internship. MRSA typing was performed by staphylococcal cassette chromosome mec (SCCmec) types, Panton Valentine leukocidin (PVL) encoding genes. RESULTS: A total of 239 sixth year medical students, 164 (68.6%) male (M/F:2.1),with median age 25 years (min-max; 23-65 years) were included in this prospective cohort study. Among 239 students, 17 students (7.1%) were found to be colonized with methicillin-sensitive S. aureus (MSSA) at the beginning of pediatric internship. After 4 weeks, at the end of pediatric internship totally 52 students were found to be S. aureus colonized (21.8%). Three of 52 S. aureus isolates were MRSA (1.3%) and the rest was MSSA (20.5%), all were PVL gen negative. Two of three MRSA isolates were characterized as SCCmec type IV, one isolate was untypeable SCCmec. Nasal carriage of S. aureus increased from 7.1% to 21.5% (p < 0.001). Nasal S. aures colonization ratio was higher in students working in pediatric infectious disease service (p = 0.046). Smoking was found to be associated with a 2.37-fold [95% CI (1.12-5.00); p = 0.023] and number of patients in pediatric services was 2.66-fold [95% CI (1.13-6.27); p = 0.024] increase the risk of nasal S. aureus colonization. Gender was not found to increase risk of MRSA carriage. CONCLUSION: MSSA nasal carriage increased at the end of pediatric internship and significantly high in students working in pediatric infectious diseases services. Smoking and high number of patients in pediatric services significantly increase S.aureus colonization.

Bacteriemia por Stenotrophomonas maltophilia en niños: análisis de 10 años / Stenotrophomonas maltophilia bacteremia in children - A 10-year analysis

Stenotrophomonas maltophilia es un microorganismo gramnegativo, multirresistente. La información sobre la bacteriemia por S. maltophilia en niños es limitada. Se revisaron los datos de 10 años de un hospital de niños de alta complejidad. Se incluyó a niños de 0 a 18 años con hemocultivos o cultivos del catéter positivos. Se identificaron 20 cepas de S. maltophilia en 12 niños con infección confirmada, cuya mediana de edad fue 28 meses (intervalo: 3,1-187,3). El índice de antibioticoterapia previa fue 83 %, con una mediana de tres antibióticos (intervalo: 0­7) en los 30 días previos a la bacteriemia por S. maltophilia. La infección relacionada con el catéter fue la principal fuente de infección (8/12). La mortalidad fue de 4/12; y en dos casos, estuvo asociada con neumonía. S. maltophilia puede considerarse un agente muy invasivo productor de bacteriemia en niños con enfermedad preexistente expuestos a antibióticos durante una hospitalización prolongada.

Stenotrophomonas maltophilia is a multidrug-resistant, Gram-negative, and biofilm-forming pathogen. Information is limited concerning S. maltophilia bacteremia in children. Clinical data and microbiological test results collected in a tertiary children's hospital over a ten-year period were reviewed. Children 0­18 years old who had positive clinical specimen, blood and/or catheter cultures were included. We identified 20 S. maltophiliaisolates from 12 pediatric patients with confirmed infections. The median age was 28 months (range: 3.1-187.3). The rate of previous use of antimicrobial therapy was 83 %. The median antibiotic number was 3 (range: 0­7) within 30 days prior to onset of S. maltophilia bacteremia. Catheter related infection was the main infectious source (66.6 %). The mortality rate was 33.3 %. The death of two non-survivors was associated with pneumonia. S. maltophilia should be considered a breakthrough agent for bacteremia in children with underlying disease exposed to broad-spectrum antibiotics during long-term hospitalization

Resistance and heteroresistance to colistin among clinical isolates of Acinetobacter baumannii.

Colistin is one of the most effective alternatives for treating Acinetobacter baumannii infections. The aim of this study was to determine colistin resistance and heteroresistance rates in A. baumannii from clinical samples in Hacettepe University clinical microbiology laboratory between June 2016 and January 2017. A total of 200 isolates were included in the study. In vitro susceptibility to amikacin, gentamicin, ceftazidime, piperacillin/tazobactam, meropenem, ciprofloxacin, and tigecycline were determined by disk diffusion test. Most isolates were multiresistant as they exhibited resistance to aminoglycosides, ß-lactams, and fluoroquinolones. Colistin susceptibility was determined by broth microdilution (BMD) test (EUCAST standards) and was compared with E-test (bioMérieux, France) in 120 isolates. In 14 blood isolates that were susceptible to colistin (MIC ≤ 2 mg/L), heteroresistance was investigated with the population analysis profile (PAP) method. Overall resistance (n = 200) to colistin was 28% by BMD. Among the 120 isolates where the two tests were compared, resistance to colistin was 25.8% versus 4.2% with BMD and E-test, respectively. Three blood isolates (21.4%) were heteroresistant to colistin. With E-test, a majority of the resistant isolates are overlooked and in vitro susceptibility to colistin should be determined with broth dilution method. This is the first study in Turkey reporting heteroresistance in A. baumannii isolates by the PAP method and emphasizes the need to test for heteroresistance in relation to clinical outcome in serious infections due to A. baumannii.

Streptococcus mitis/oralis Causing Blood Stream Infections in Pediatric Patients.

Viridans streptococci are still under investigation concerning epidemiology, pathogenesis and clinical presentations. We aimed to investigate the clinical presentations and outcomes of pediatric patients infected with Streptococcus mitis/oralis. Based on the accumulation of bloodstream infections (BSI) caused by S. mitis/oralis in 4 patients in our Hematology and Bone Marrow Transplantation Department at a particular time, a review of the medical and microbiological records of pediatric patients with positive blood cultures for S. mitis/oralis in the entire hospital was performed. In addition, a retrospective case-control study was conducted. Pulsed-field gel electrophoresis of S. mitis/oralis in 4 patients displayed unrelatedness of the strains. A total of 53 BSI (42 BSI and 11 catheter-related BSI) were analyzed. Thirty-four percent of patients with BSI caused by S. mitis/oralis had febrile neutropenia. Clinical and microbiological outcomes were favorable and infection-related mortality was not observed. Although not significant, previous antibiotic use and trimethoprim-sulfamethoxazole prophylaxis were more common in the case group. S. mitis/oralis seems likely an important agent in bacteremic children who are particularly neutropenic because of the underlying hematologic and oncologic diseases. Prompt management of infections with appropriate antimicrobials, regarding antibiotic susceptibilities of organisms, may facilitate favorable outcomes.

Clinical Strains of Chryseobacterium and Elizabethkingia spp. Isolated from Pediatric Patients in a University Hospital: Performance of MALDI-TOF MS-Based Identification, Antimicrobial Susceptibilities, and Baseline Patient Characteristics.

Our objective was to evaluate the performance of matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) for identification of the Chryseobacterium and Elizabethkingia spp. isolated from pediatric patients at Hacettepe University Hospital using 16S rRNA gene sequencing as the gold standard and to determine the antimicrobial susceptibility patterns of the isolates and baseline characteristics of patients. All stored Chryseobacterium and Elizabethkingia spp. isolated from various clinical specimens (sputum, blood, and urine) of pediatric patients at Hacettepe University Hospital between 2012 and 2016 were included in this study. Minimum inhibitory concentrations of 10 antimicrobial agents were determined by Etest for all isolates. To determine the baseline characteristics of patients, medical records of all patients were retrospectively reviewed. In total, 18 isolates of Chryseobacterium spp. (16 C. indologenes, 2 C. gleum) and 5 isolates of Elizabethkingia spp. (3 E. meningoseptica, 2 E. anophelis) were identified by 16S rRNA sequencing. MALDI-TOF MS correctly identified 19 (82.6%) isolates to the species level. The quinolones (ciprofloxacin and levofloxacin), trimethoprim/sulfamethoxazole and piperacillin/tazobactam showed the highest spectrum of activity against the overall collection of isolates. Cystic fibrosis (CF) was the underlying disease in 81.8% of patients. To our knowledge, this study includes the largest number of Chryseobacterium spp. isolated from clinical specimens of pediatric patients in Turkey. In this study, we also report the first clinical isolate of E. anophelis in Turkey. Since, the majority of strains were isolated from patients with CF; larger, prospective clinical studies are needed to establish whether chryseobacteria could be considered as an emerging opportunistic pathogen in patients with CF.

Vancomycin-resistant Enterococcus bacteremia in a child with acute myeloid leukemia: successful treatment with daptomycin. / Bacteriemia por Enterococcus resistente a la vancomicina en un niño con leucemia mieloide aguda: tratamiento satisfactorio con daptomicina.

Multiple-drug-resistant enterococcal infections canbe a serious problem in pediatric patients particularly concomitance with severe underlying diseases and lead to significant morbidity and mortality. The treatment options in children are limited compared with adults. We report a 3-year old-boy with acute myeloid leukemia (AML)-M7 and vancomycin-resistant enterococcus bacteremia successfully treated with daptomycin. Daptomycin may be an alternative therapy for VRE infections in children; more studies are needed for extended usage.

Las infecciones enterocócicas multirresistentes pueden ser un problema serio en los pacientes pediátricos y causarles complicaciones importantes o la muerte, en particular, en los casos de enfermedades subyacentes graves concomitantes. Las opciones de tratamiento en los niños son limitadas en comparación con las de los adultos. En este artículo, presentamos el caso de un niño de 3 años con leucemia mieloide aguda (LMA)-M7 y bacteriemia por Enterococcus resistente a la vancomicina, que se trató satisfactoriamente con daptomicina. La daptomicina puede ser un tratamiento alternativo para las infecciones por Enterococcus resistente a la vancomicina (ERV) en los niños. Se necesitan más estudios para ampliar su uso.

The Prevalence of Vancomycin-Intermediate Staphylococcus aureus and Heterogeneous VISA Among Methicillin-Resistant Strains Isolated from Pediatric Population in a Turkish University Hospital.

There are limited data regarding the prevalence of vancomycin-intermediate Staphylococcus aureus (VISA)/heterogeneous VISA (hVISA) among pediatric population. Our objective was to determine the distribution of vancomycin and daptomycin minimum inhibitory concentrations (MICs) and explore the phenomenon of vancomycin MIC creep and the VISA/hVISA prevalence among the methicillin-resistant Staphylococcus aureus (MRSA) strains belonging to pediatric population by population analysis profile-area under the curve (PAP-AUC) and Etest macromethod. Vancomycin and daptomycin susceptibilities of 94 pediatric isolates of MRSA were tested by broth microdilution (BMD) and Etest methods. To determine the prevalence of VISA/hVISA, Etest macromethod and PAP-AUC was performed on all isolates. All isolates were susceptible to vancomycin and daptomycin by both BMD and Etest methods. Twenty-eight (29.8%) isolates had vancomycin MICs of 2 µg/ml by BMD. No increase in vancomycin MICs was observed over time. There were no VISA among 94 MRSA tested but 20 (21.3%) hVISA isolates were identified by PAP-AUC. Results of Etest macromethod were compared to PAP-AUC. Etest macromethod was 60.0% sensitive and 90.5% specific. The hVISA isolates represented 53.6% of isolates with vancomycin MICs of 2 µg/ml. Also, 75% of hVISA isolates had vancomycin MICs of 2 µg/ml. To our knowledge, this is the first study investigating the prevalence of VISA/hVISA among MRSA isolated from pediatric patients by PAP-AUC method. Based on our findings, MRSA isolates, which have vancomycin MIC of 2 µg/ml can be investigated for the presence of hVISA. In this study, daptomycin showed potent activity against all isolates and may represent a therapeutic option for MRSA infections.

A potential novel strategy, inhibition of vasopressin-induced VEGF secretion by relcovaptan, for decreasing the incidence of ovarian hyperstimulation syndrome in the hyperstimulated rat model.

OBJECTIVE: To investigate the effects of V1A receptor antagonist through inhibition of vasopressin-induced VEGF secretion in an experimental model. STUDY DESIGN: Thirty rats were randomly divided into five groups. Four groups were given 10IU pregnant mare serum gonadotropin/day (sc) at 8:00-8:30am on days 22-25 of life. They were administered 30IU hCG at 8:00-8:30am on day 26 of life. On days 26 and 27 of life at 8:00am and 4:00pm, (ip) per animal, 50µg/kg/day GnRH antagonist in the GnRH antagonist group, 0.3mg relcovaptan in the high dose relcovaptan group, and 0.15mg relcovaptan in the low dose relcovaptan group were administered. The control group was given the same dosage of 0.9% saline solution (ip) on days 22-26 day of life. The main outcomes were weight gain, ovarian weights, peritoneal fluid VEGF values, corpus luteum count, and atretic follicle count. RESULTS: Weight gain was highest in the OHSS group; it was almost twice as much in the OHSS group than it was in the control group. Ovarian weights were significantly lower in all treatment groups (p=0.03). There was no statistically significant difference in ovarian weights between the GnRH antagonist and relcovaptan groups (p=0.176). The evaluation of peritoneal fluid VEGF-A levels revealed statistically significant differences between levels in the treatment groups and in the OHSS group (p=0.005). Atretic follicle count in the OHSS group was significantly lower (p=0.048). In all treatment groups, CL counts were prominently lower than they were in the OHSS group (p=0.002). CONCLUSION: Relcovaptan may be a novel strategy for decreasing risk of OHSS by inhibition of vasopressin-induced VEGF secretion through V1A receptor antagonist.

Vancomycin and daptomycin minimum inhibitory concentration distribution and occurrence of heteroresistance among methicillin-resistant Staphylococcus aureus blood isolates in Turkey.

BACKGROUND: The aim of this study was to determine the distribution of vancomycin and daptomycin MICs among methicillin-resistant Staphylococcus aureus (MRSA) blood isolates, the prevalence of heterogeneous vancomycin-intermediate S. aureus (hVISA) and the relationship between hVISA and vancomycin MIC values. METHODS: A total of 175 MRSA blood isolates were collected from seven university hospitals in Turkey. All isolates were tested for susceptibility to vancomycin and daptomycin by reference broth microdilution (BMD) and by standard Etest method. BMD test was performed according to CLSI guidelines and Etest was performed according to the instructions of the manufacturer. All isolates were screened for the presence of the hVISA by using macro Etest (MET) and population analysis profile-area under the curve (PAP-AUC) methods. RESULTS: The vancomycin MIC50, MIC90 and MIC ranges were 1, 2, and 0.5-2 µg/ml, respectively, by both of BMD and Etest. The daptomycin MIC50, MIC90 and MIC ranges were 0.5, 1 and 0.125 -1 µg/ml by BMD and 0.25, 0.5 and 0.06-1 µg/ml by Etest, respectively. The vancomycin MIC for 40.6% (71/175) of the MRSA isolates tested was >1 µg/ml by BMD. No vancomycin and daptomycin resistance was found among MRSA isolates. Percent agreement of Etest MICs with BMD MICs within ±1 doubling dilution was 100% and 73.1% for vancomycin and daptomycin, respectively. The prevalence of hVISA among MRSA blood isolates was 13.7% (24/175) by PAP-AUC method. MET identified only 14 of the hVISA strains (sensitivity, 58.3%), and there were 12 strains identified as hVISA that were not subsequently confirmed by PAP-AUC (specificity, 92.1%). CONCLUSIONS: Agreement between BMD and Etest MICs is high both for vancomycin and daptomycin. Daptomycin was found to be highly active against MRSA isolates including hVISA. A considerable number of isolates are determined as hVISA among blood isolates. As it is impractical to use the reference method (PAP-AUC) for large numbers of isolates, laboratory methods for rapid and accurate identification of hVISA need to be developed.

[Evaluation of methicillin-resistant Staphylococcus aureus bacteremia and comparison of prognosis according to vancomycin MIC values: experience of the last ten years]. / Metisiline dirençli Staphylococcus aureus bakteriyemisinin incelenmesi ve vankomisin MIK degerlerine göre prognozun karsilastirilmasi: Son on yillik deneyim.

Hospital acquired methicillin-resistant Staphylococcus aureus (MRSA) infections are important health problems. Mortality and morbidity rates associated with MRSA infections are increasing with mortality rates being higher for MRSA bacteremia than the other clinical presentations of MRSA infections. Initiation of treatment immediately and use of appropriate antibacterial agents may lead to better clinical outcomes in MRSA bacteremia. The aims of this study were to evaluate the treatment and clinical outcomes of patients with MRSA bacteremia in a tertiary care hospital in Ankara, Turkey. Two hundred forty seven MRSA strains isolated from blood cultures at Hacettepe University Faculty of Medicine, Clinical Microbiology Laboratory between January 2000-December 2010, were evaluated retrospectively. Demographic characteristics, duration of bacteremia, types and duration of antibiotic treatment, presence of other pathogens and all other necessary information were collected from patients' registry. One hundred eighty four patients who had clinically significant bacteremia were analyzed. The mean age of the patients was 55 ± 17 years, of them 44.6% were female and 55.4% were male. The median length of hospital stay was 61 days. The median duration for the development of MRSA bacteremia from the time of admission was 23 days. Overall mortality rate was 54.9%, and mortality rate due to MRSA bacteremia was 19%. The rate of treatment success was 81%. There were 3 (1.6%) patients with vancomycin MIC value of 0.5 mg/L, 140 (76.1%) patients with 1 mg/L and 41 (22.3%) patients with 2 mg/L. The median duration from the time of MRSA bacteremia detection to the time of death was shorter in unsuccessfully treated group than successfully treated group (7 days vs. 30 days, p< 0.001). Thirty days mortality rate was higher in unsuccessfully treated group than successfully treated group (94.3% vs. 50.7%, p< 0.001). The median time interval between positive and negative cultures was 9.5 days. Number of patients with MRSA bacteremia had been decreasing for the last five years (36 patients in 2006, 18 in 2007, 16 in 2008, 12 in 2009 and one in 2010). In multivariate logistic regression analysis, it was shown that, intubation (OR: 5.086, 95% CI: 2.094-12.351; p< 0.001) and malignancy (OR: 2.789, 95% CI: 1.185-6.564; p= 0.019) were independent risk factors for mortality. In this study, it was shown that mortality rate was high in MRSA bacteremia and high MIC value was not an independent risk factor for mortality. It was also noted that when there was no clinical response to vancomycin, the therapy should be changed immediately. To decrease MRSA bacteremia rates in the hospital adherence to rules of infection control and prevention proved to be important factors.

Association between osteoprotegerin, fetuin-A, carotid intima media thickness, and urinary albumin excretion in Type 2 diabetes.

AIMS: Vascular calcification and atherosclerosis play a vital role in the development of cardiovascular morbidity and mortality in diabetic patients, especially when complications of diabetic nephropathy occur. Osteoprotegerin (OPG) and fetuin-A are two markers of vascular calcification. We evaluated the association between these vascular markers and urinary albumin excretion in diabetic patients. METHOD: Three groups were arranged containing 40 patients: normoalbuminuric (Group 1), microalbuminuric (Group 2), and macroalbuminuric (Group 3). In addition to the obtained data, levels of hs-CRP (high sensitivity-CRP) and homocysteine were examined. RESULTS: OPG levels of patients in Group 2 were higher than in Group 1 (p = 0.058). OPG levels in Group 3 were lower than in Groups 1 or 2 (p = 0.014 and 0.000, respectively). Levels of fetuin-A in Group 2 were determined to be lower than in Groups 1 and 3 (p = 0.001 and 0.000, respectively). Carotid intima media thickness (CIMT) in Group 3 was higher than in Group 1 (p = 0.002). CIMT in Group 2 was also higher than in Group 1 (p = 0.039). A positive correlation between fetuin-A and OPG was found (p = 0.012, r = 0.393). Additionally, a positive correlation between hs-CRP and fetuin-A in Group 2 (p = 0.020, r = 0.367) and a negative correlation between hs-CRP and OPG in Group 3 (p = 0.036, r = -0.333) were observed. CONCLUSIONS: The differences found between albuminuria and OPG or fetuin-A may be due to the different doses and variety of medications the patients received, in addition to genetic and racial factors. So far, in our country, polymorphisms related to OPG and fetuin-A have not been defined. Further detailed studies about polymorphisms will have additional value.

The use of plasma and urine neutrophil gelatinase associated lipocalin (NGAL) and Cystatin C in early diagnosis of septic acute kidney injury in critically ill patients.

AIM: To assess and compare the roles of plasma and urine concentrations of neutrophil gelatinase associated lipocalin (NGAL) and Cystatin C for early diagnosis of septic acute kidney injury (AKI) in adult critically ill patients. METHODS: Patients were divided into three groups as sepsis-non AKI, sepsis-AKI and non sepsis-non AKI. Plasma samples for NGAL and Cystatin C were determined on admission and on alternate days and urinary samples were collected for every day until ICU discharge. RESULTS: One hundred fifty one patients were studied; 66 in sepsis-non AKI, 63 in sepsis-AKI, 22 in non-sepsis-non-AKI groups. Although plasma NGAL performed less well (AUC 0.44), urinary NGAL showed significant discrimination for AKI diagnosis (AUC 0.80) with a threshold value of 29.5 ng/ml (88% sensitivity, 73% specificity). Both plasma and urine Cystatin C worked well for the diagnosis of AKI (AUC 0.82 and 0.86, thresholds 1.5 and 0.106 mg/L respectively). CONCLUSION: Plasma and urinary Cystatin C and urinary NGAL are useful markers in predicting AKI in septic critically ill patients. Plasma NGAL raises in patients with sepsis in the absence of AKI and should be used with caution as a marker of AKI in septic ICU patients.

The effects of methylene blue on adhesion formation in a rat model of experimental peritonitis.

BACKGROUND: We investigated the effects of methylene blue (MB) on the early and late phases of adhesion and abscess formation in a standard colonic wall injury and fecal peritonitis model in rats. METHODS: There were four groups: Group I (only laparotomy, n=10), Group II (peritonitis + MB, n=15), Group III (peritonitis + saline, n=15), and Group IV (colon incision + saline, n=15). Mortality, morbidity, adhesion scores, histopathologic analyses, serum tumor necrosis factor-alpha (TNF-?) levels, and tissue hydroxyproline (5-HP) levels were evaluated in all animals. Descriptive statistical methods were used with Kruskal-Wallis test. When a statistical difference was obtained between groups, Mann-Whitney U test was used to confirm the difference between two groups. RESULTS: Adhesion scores of Groups I, III and IV were significantly higher than in Group II. TNF-? levels were significantly higher in Groups I, III and IV. 5-HP levels were significantly lower in Groups I and II compared to Groups III and IV. CONCLUSION: Based on these results, it appears that MB may prevent peritoneal adhesions in a peritonitis model, but wound healing could be impaired. MB should be further evaluated because of its dual effect.

Effect of ankaferd blood stopper on hemostasis and histopathological score in experimental liver injury.

AIM: To investigate intra-abdominal, local histopathological and hemostatic effects of Ankaferd (ABS) in an experimental liver injury. METHODS: Forty rats were randomly assigned to the primary suture group (PS) (n = 15), ABS group (n = 15) and control group (n = 10). A wedge resection was performed on the left lobe of the liver. In the primary suture group, the liver was sutured with polypropylene material, while in ABS group the liver surface was covered with ABS. Adhesion, histo-pathological scores and hydroxyproline levels were measured postoperatively on day 3 and day 15. RESULTS: The mean bleeding time was 7.5 sec shorter in the ABS group (6.5 sec-13.5 sec) and 107 sec shorter in PS group. AST, ALT, total bilirubin and ALP values complete blood count (CBC) did not change. Intra-abdominal adhesions were the same in PS and ABS groups on 3rd (2.20 +/- 1.30 vs 2.0 +/- 1.11) and 15th (1.60 +/- 0.54 vs 1.25 +/- 0.7) days postoperatively. Histopathological scores were better in the ABS group than in the primary suture group on 3rd (2.5 +/- 0.5 vs 5.25 +/- 0.2, p = 0.006) and 15th (1.65 +/- 1.7 vs 3.15 +/- 1.0, p = 0.025) days postoperatively. Hydroxyproline levels were higher in ABS group on postoperative 15th day (17.12 microg/tissue vs 13.69 microg/tissue; p = 0.005). CONCLUSION: These data suggest that ABS in experimental liver trauma causes favorable histopathological scores and shorter hemostasis time and higher hydroxyproline levels (Tab. 2, Fig. 2, Ref. 35).

Serum M30 levels are associated with survival in advanced gastric carcinoma patients.

BACKGROUND: Cytokeratin 18 (CK-18) is a cytoskeleton protein of epithelial cells which are released into the circulation during necrotic or apoptotic cell death. M30 detects caspase-cleaved neo-epitope of CK-18; whereas M 65 measures whole length intact protein. We aimed to evaluate the prognostic significance of serum M65 and M30 levels in patients with gastric carcinoma. METHODS: Thirty eight patients with advanced disease were included in the study. Thirty-two healthy people were chosen as control group. Serum M65 and M30 levels were measured by quantitative ELISA method. RESULTS: Serum M65 levels were found significantly elevated in patients compared to control group (385.7+/-280.6 vs. 200.2+/-164.5, p=0.002). Serum M30 levels were significantly increased in patients compared to the control group (204.6+/-245 vs. 106.5+/-17.5, p=0.03). Patients with metastatic disease had significantly higher levels of serum M30 compared to patients with locally advanced disease (267.1+/-296.1 vs. 102.3+/-53.2, p=0.03). Serum M30 and M65 levels were evaluated in respect to survival. Best cut-off value for the prediction of death for M30 antigen level was 83.8U/L. Patients with higher M30 levels had significantly shorter median survival compared to patients' lower serum M30 levels. However, there was no impact of serum M65 levels on survival. Serum M30 levels and clinical stage were found as the strongest variables with independent prognostic value for overall survival. DISCUSSION: These results suggest that serum M65 and M30 levels were elevated in patients with advanced gastric carcinoma patients. Serum M30 levels can be helpful to predict tumor load and also survival.

The effect of bevacizumab on serum soluble FAS/FASL and TRAIL and its receptors (DR4 and DR5) in metastatic colorectal cancer.

PURPOSE: Bevacizumab-based chemotherapy has become the standard of care in metastatic colorectal cancer (MCRC). We aimed to measure the levels of serum soluble FAS, FASL, tumor necrosis factor-related apoptosis-inducing ligand (TRAIL), and its death receptors DR4 and DR5 in MCRC patients and to define prognostic significance of these parameters in response to bevacizumab in these patients. PATIENTS AND METHODS: The levels of these parameters in serum samples were quantified by a commercially available ELISA kit in 31 MCRC patients before and after 2 cycles of therapy and 25 healthy controls. RESULTS: Pretreatment sFAS levels in MCRC patients was significantly lower than the levels of controls (p = 0.043). There was no significant difference in sFAS and sFASL levels in MCRC patients before and after bevacizumab-based treatment. There was no significant difference in sFAS/sFASL ratio in MCRC patients before and after treatment and controls. Soluble DR5 levels were significantly higher in pretreatment serum samples compared with controls (p = 0.008). However, pretreatment sTRAIL and sDR4 levels were similar to the levels of controls. There was no significant difference in sTRAIL, sDR4, and sDR5 levels in MCRC patients before and after treatment. When patients were grouped according to treatment response (responders vs. non-responders), post-treatment sFAS/sFASL ratio was significantly lower in responding patients compared with non-responders (p = 0.029). Significant correlations were observed between post-treatment sFASL and sDR4, sFAS and sTRAIL, sTRAIL and sFAS/sFASL ratio, and sFASL and sDR5. CONCLUSION: Non-significant changes in apoptotic markers with bevacizumab-based chemotherapy showed that they have no prognostic significance in MCRC patients. Significant change in sFAS/sFASL ratio according to treatment response could be an indicator of chemosensitivity.

Increased serum granulocyte colony stimulating factor in Turkish hepatocellular carcinoma patients.

PURPOSE: To evaluate the serum levels of G-CSF in patients with hepatocellular carcinoma and to compare with values in healthy individuals. PATIENTS AND METHODS: Thirty-three patients with hepatocellular carcinoma and 30 controls were included in the study. Histological confirmation of hepatocellular carcinoma (HCC) was performed by core needle biopsy and patients with cirrhosis were classified according to the Child-Pugh score. The serum G-CSF levels of individuals in both groups were calculated as pg/ml and compared for Child-Pugh Class A, B and C patients with HCC. RESULTS: Median ages of patients with HCC and control group individuals were 58 (range:47-78) and 56 (range 45-70), respectively. Sex distributions were approximately equal. The mean serum level of G-CSF in patients with HCC was 199.4-/+112.2, as compared to 24.0-/+8.8 in the controls (p <0.001). In addition, on subgroup analysis, the serum levels of G-CSF were increased with Child-Pugh Class A, B and C, although without statistical significance (p= 0.253). CONCLUSION: Increased levels of G-CSF are observed in patients with HCC. Further investigations are necessary to clarify the mechanism of G-CSF production and its effects on outcomes.

The effect of calcitonin gene-related peptide on healing of intestinal anastomosis in rats with experimental obstructive jaundice.

PURPOSE: Intestinal anastomotic healing is a complex procedure in which several mediators and cytokines play roles. Calcitonin gene-related peptide is an important neuropeptide in inflammation. In this study we aimed to investigate the effect of calcitonin gene-related peptide on healing of intestinal anastomosis in rats with obstructive jaundice. MATERIALS AND METHODS: Obstructive jaundice was induced in rats by the ligation and division of the common bile duct. Four days after the operation, intestinal anastomosis was performed, and either calcitonin gene-related peptide or 0.9% NaCl was administered intraperitoneally to these jaundiced rats and controls. The concentrations of serum tumor necrosis factor-alpha (TNF-alpha) and triglyceride levels of all rats were measured, and healing of the anastomosis was evaluated by measuring the bursting pressure and hydroxyproline content on the 7th postoperative day. RESULTS: Calcitonin gene-related peptide was found to have positive effects on healing of the anastomosis by inhibiting the effects of TNF-alpha and increasing the bursting pressure and hydroxyproline content of the anastomosis. CONCLUSION: Calcitonin gene-related peptide increases anastomotic wound healing in experimental anastomosis in the presence of obstructive jaundice in rats.