The Relationship between Bronchiolitis Severity and Vitamin D Status.

BACKGROUND/AIM: Acute bronchiolitis is mostly caused by viral agents in children under 2 years of age. The disease mostly has a mild clinical course however severe cases are not uncommon. Vitamin D is known to exert immune-regulatory functions. We aimed to examine the association between the clinical severity of acute bronchiolitis and serum vitamin D levels in infants. MATERIALS AND METHODS: A total of 182 children with acute bronchiolitis were prospectively enrolled. The disease severity was assessed using the Modified Tal Scoring System and their vitamin D levels were evaluated. RESULTS: Vitamin D deficiency or insufficiency was as high as 47.8% in infants with bronchiolitis. Infants with low vitamin D levels comprised a significantly larger proportion of patients with severe bronchiolitis (p = 0.002). Infants admitted to intensive care unit had significantly higher degrees of vitamin D deficiency or insufficiency (p < 0.001). CONCLUSION: Vitamin D deficiency is closely linked with severe bronchiolitis and the need for intensive care unit admission in infants. We believe that assessment of vitamin D levels in infants prior to bronchiolitis season and appropriate supplementation may have a protective effect against severe bronchiolitis.

Lean six sigma methodologies improve clinical laboratory efficiency and reduce turnaround times.

BACKGROUND: Organizing work flow is a major task of laboratory management. Recently, clinical laboratories have started to adopt methodologies such as Lean Six Sigma and some successful implementations have been reported. This study used Lean Six Sigma to simplify the laboratory work process and decrease the turnaround time by eliminating non-value-adding steps. METHODS: The five-stage Six Sigma system known as define, measure, analyze, improve, and control (DMAIC) is used to identify and solve problems. The laboratory turnaround time for individual tests, total delay time in the sample reception area, and percentage of steps involving risks of medical errors and biological hazards in the overall process are measured. RESULTS: The pre-analytical process in the reception area was improved by eliminating 3 h and 22.5 min of non-value-adding work. Turnaround time also improved for stat samples from 68 to 59 min after applying Lean. Steps prone to medical errors and posing potential biological hazards to receptionists were reduced from 30% to 3%. CONCLUSION: Successful implementation of Lean Six Sigma significantly improved all of the selected performance metrics. This quality-improvement methodology has the potential to significantly improve clinical laboratories.

Myocarditis and Early Markers of Cardiac Response Associated with Scorpion Stings in Children.

INTRODUCTION: A clinical course ranging from mild local findings to life-threatening systemic findings may occur after scorpion stings. The purpose of this study was to identify priority markers indicating scorpion sting-related cardiac involvement. METHODS: Our study was performed between July 2014, and September 2015 in the Çukurova University medical faculty pediatric emergency department, in Adana, Turkey. Patients admitted with scorpion sting-related cardiac involvement and a control group consisting of patients with no scorpion sting-related cardiac involvement were included in the study. Troponin I at time of presentation and at 6 and 24 h, N-terminal prohormone of brain natriuretic peptide (NTproBNP), ejection fraction as determined by echocardiography at 24 h, and peak and end of T wave (Tp-e) and Tp-e/QTc ratios with echocardiography at 24 h were evaluated. RESULTS: A patient group consisting of 7 cases of scorpion envenomation-related myocarditis and a control group of 30 cases of scorpion intoxication without myocarditis findings were enrolled. Statistically significantly high glucose, white blood cell values, creatine kinase MB, troponin I, and NTproBNP values were identified in the scorpion sting-related myocarditis group (P<0.05). Ejection fractions determined by echocardiography at time of presentation were significantly lower in the patients with myocarditis compared with the control group (P<0.05). A statistically significant difference was identified between Tp-e/corrected QT interval (QTc) ratios investigated in DI and V2 derivations in patient and control group echocardiograms (P<0.05). CONCLUSIONS: We think that use can be made of NTproBNP in addition to echocardiography and troponin I in the early diagnosis of scorpion sting-related myocarditis and that Tp-e and Tp-e/QTc ratios identified via echocardiography can be used as early markers; however, further studies with larger numbers are needed to confirm this.

Comparison of the cardioprotective effects of dexmedetomidineand remifentanil in cardiac surgery

Background/aim: Myocardial protection is an important factor of open heart surgery and biological biomarkers (lactate, CKMB, cardiac troponin I, and pyruvate) are used to assess myocardial damage. This study compares the effects of dexmedetomidine and remifentanil on myocardial protection during coronary artery bypass grafting (CABG) surgery. Materials and methods: Patients scheduled for elective CABG surgery (n = 60) were included in this study. Anesthesia induction was introduced with propofol, fentanyl, and vecuronium bromide. Anesthesia was maintained with remifentanil infusion and sevoflurane in the remifentanil group (Group R) and with dexmedetomidine infusion and sevoflurane in the dexmedetomidine group (Group D). Blood samples for biochemical markers were taken from the coronary sinus catheter before cardiopulmonary bypass (T1), 20 min after aortic cross-clamping (T2), 20 min after removal of the aortic cross-clamping (T3), and 10 min after separation from cardiopulmonary bypass (T4).Results: Demographic data were similar between the groups. Lactate level at the T2 period and CKMB levels during the study period were lower in Group D than in Group R. In both groups, all values except pyruvate significantly increased over time. Conclusion: The dexmedetomidine-sevoflurane combination may improve the cardioprotective effect in comparison with remifentanil-sevoflurane in CABG surgery.

Prognostic Factors Determining Morbidity and Mortality in Organophosphate Poisoning.

OBJECTIVE: Our aim in this retrospective study was to determine the factors affecting poor prognosis and mortality of organophosphate (OP) poisoning by reviewing patient data. We also reviewed present knowledge to make conclusions on certain longstanding debates in light of the literature. METHODS: In this retrospective descriptive study, patients who were admitted to and hospitalized in the emergency department (ED) or intensive care unit (ICU) of a university hospital with the diagnosis of OP poisoning between December 2010 and December 2015 were evaluated. All the data were obtained from electronic and manual patient files. A total of 80 patients were included in the study. RESULTS: The mean age of the study patients was 32.4±15.0 (13-94). Forty-nine (61.2%) patients were female. Twenty-two (27.5%) patients were seriously poisoned and needed mechanical ventilation (MV) support. Low pseudocholinesterase (PChE), high creatinine (Cr), low Glasgow Coma Scale (GCS) scores and long hospitalization durations were all found to be poor prognostics in MV patients. Low PChE and high Cr levels were found to be independent predictors of the hospitalization duration and high Cr was found to be an independent predictor of the intubation duration of MV patients in regression analyses. Ten (45.5%) of the MV patients were unresponsive to medical treatment and Therapeutic plasma exchange (TPE) was performed. Seven patients were discharged healthy. Three patients with low PChE levels and comorbidities died. CONCLUSIONS: Prolongation of respiratory depression necessitating MV support, comorbidities, long hospital stay, elevated creatinine, low GCS scores and low PcHE levels without regeneration in the first 48 hours of admission are all found to be poor prognostic factors for organophosphate (OP) poisoning.

Biological Variation and Reference Change Value Data for Serum Neuron-Specific Enolase in a Turkish Population.

BACKGROUND: Neuron-specific enolase (NSE) is a recognized biomarker for the assessment of cerebral injury in neurological disorders. This study aims to report a definitive assessment of the biological variation (BV) components of this biomarker, including within-subject BV (CVI), between-subject BV (CVG), index of individuality (II), and reference change value (RCV), in a cohort of Turkish participants using an experimental protocol. METHODS: Six blood specimens were collected from each of the 13 apparently healthy volunteers (seven women, six men; ranging in age from 23 to 36) on the same day, every 2 weeks for 2 months. Serum specimens were stored at -20°C until analysis. Neuron-specific enolase levels were evaluated in serum samples using an electrochemiluminescence (ECLIA) immunoassay kit with a Roche Cobas e 411 auto-analyser. ANOVA test was used to calculate the variations. RESULTS: The CVI and CVG for NSE were 21.5% and 28.8%, respectively. Analytical variation (CVA) was calculated as 10.2%. Additionally, II and RCV were calculated as 0.74 and 66% (95% confident interval, CI), respectively. CONCLUSION: As the performance index (PI) was found to be less than 2 (PI = 0.95), it is concluded that the NSE measurements have a desirable performance for analytical imprecision. Since the II was found to be less than 1 (II: 0.74), the reference values will be of little use. Thus, RCV would provide better information for deciding whether a significant change has occurred.

Therapeutic plasma exchange in poisoning: 8 years' experience of a university hospital.

INTRODUCTION AND AIM: This study examined the extracorporeal methods for the elimination of toxic substances in poisoned patients that are used by clinicians taking care of such patients. Here we present our experience in the use of therapeutic plasma exchange (TPE). To the best of our knowledge, this is the largest number of poisoning cases ever reported in a study. PATIENTS AND METHODS: This is a retrospective study conducted at the Çukurova University Faculty of Medicine, Department of Emergency Medicine, with the permission of the ethical committee of the medical faculty. The study includes patients who had undergone TPE because of poisoning between January 2007 and May 2015. We summarize the clinical data and outcomes of the patients with available files. RESULTS: A total of 36 cases among the 42 patients who underwent TPE in this 8-year period were included in the study. More than 20 identified toxic substances, most of which were pesticides, were found to be the causes of poisoning. Twenty-three healthy discharges and 12 deaths are discussed in the study. CONCLUSION: We believe that our study reports the largest ever number of poisoning cases treated with TPE in the literature. When applicable, TPE may be a promising extracorporeal elimination and treatment technique in poisoned patients when performed in selected cases.

Role of calcium metabolism in ADHD: The relationship between parathyroid hormone and ADHD symptom severity.

Background: Vitamin D has been found to be associated with the pathogenesis of attention deficit hyperactivity disorder (ADHD). However, the potential role of parathyroid hormone (PTH) is still unclear. Aim: We aimed to investigate the association between calcium metabolism and ADHD symptomatology. Methods: We included 106 participants aged between 7 and 13 years old (51 ADHD patients, mean age: 9.54 ± 1.77, 55 healthy controls mean age: 9.97 ± 0.94) to this study. K-SADS-PL and Conners' Parent/Teacher Rating Scales, Stroop Test were performed. Blood samples to measure serum levels of Vitamin D, PTH, calcium (Ca), magnesium (Mg), phosphorus (P), and alkaline phosphatase (ALP) were collected in the spring (March-April-May) to prevent seasonal variability. Results: PTH, P, and ALP values were significantly lower and Vitamin D, Ca, and Mg values were significantly higher in the ADHD group (P < 0.05, for all). Both groups had Vitamin D deficiency. Control group has lower Vitamin D levels than the ADHD group (respectively; 17.66 ± 9.07, 21.99 ± 10.99, P < 0.05). There was a negative correlation between PTH and CTRS hyperactivity, CGI-RI and CGI-EL sub-scores, CGI-Total, DSM-IV-Inattention, DSM-IV Hyperactivity/Impulsivity, DSM-IV-Total scores (P < 0.05, for all). Conclusions: We found lower PTH levels in ADHD patients and a strong and negative correlation between PTH and symptom severity. Future studies are needed to clarify if these findings are due to the key role of PTH in ADHD pathology or PTH's function in activating vitamin D.

Relationship of spontaneous subarachnoid haemorrhage and cerebral aneurysm to serum Visfatin and Nesfatin-1 levels.

OBJECTIVES: Visfatin and nesfatin are recently discovered peptides that play a role in various metabolic reactions exhibiting inflammatory and neuroprotective effects, and their levels are known to increase in cerebral ischaemia and haematomas. Inflammation plays a role in the development of aneurysm, and spontaneous subarachnoid haemorrhage (SAH) is typically caused by rupture of the aneurysmal sac because of the increased inflammation. In the present study, we investigated the relationship between serum visfatin and nesfatin levels and the clinical and radiological findings in patients with SAH. PATIENTS AND METHOD: Overall, 62 patients with spontaneous SAH who were followed-up in our clinic between September 2018 and July 2019 and 35 healthy patients who presented to our outpatient clinic with complaints of back, lumbar and neck pain were included in the study. ELISA method was used to study the visfatin and nesfatin levels in the serum samples of both groups. The visfatin and nesfatin levels of patients with spontaneous SAH were compared with the healthy population. In addition, the relationship between visfatin and nesfatin levels and the radiological and clinical findings of patients with spontaneous SAH were also investigated. All findings were evaluated statistically. RESULTS: The median nesfatin and mean visfatin levels were higher in patients with SAH compared with the control group. The median nesfatin and mean visfatin levels were higher in patients with aneurysm than those without aneurysm. A positive correlation was observed between aneurysm length and nesfatin and visfatin levels. In patients with perimesencephalic haemorrhage, the mean visfatin level was determined to be lower compared with patients with classical aneurysmatic SAH, and the median nesfatin level did not differ significantly. The cut-off value of nesfatin for predicting SAH in patients compared with controls was >598.4 with 82.8 % sensitivity and 80 % specificity (P <  0.001). The cut-off value of visfatin for predicting SAH was >10.3 with 85.3 % sensitivity and 91.4 % specificity (P <  0.001). The diagnostic performance of visfatin and nesfatin levels was similar in predicting SAH. CONCLUSION: In the present study, we demonstrated that the presence of aneurysm, size of aneurysm, number of aneurysms correlate with visfatin and nesfatin levels in patients with SAH, and visfatin and nesfatin may be biomarkers for predicting SAH and presence of aneurysm. Nonetheless, future studies can include patients with unruptured aneurysm and investigate their serum visfatin and nesfatin levels to prove whether visfatin and nesfatin can serve as biomarkers in the follow-up of these patients.

eNOS gene intron 4 a/b VNTR polymorphism is a risk factor for coronary artery disease in Southern Turkey.

BACKGROUND: Nitric oxide (NO) plays a major role in the regulation of vascular tone Associations between NO genotypes, coronary artery disease (CAD) and other risk factors have been described by many authors. The aim of this study was to investigate the role of endothelial nitric oxide synthase (eNOS) gene intron 4 a/b variable number of tandem repeats (VNTR) polymorphism and other risk factors in the development of CAD in subjects living in Southern Turkey. METHODS: Two-hundred and sixty-six patients (154 males and 112 females, aged between 30 and 80 years, mean 52.4+/-10.3) whose coronary arteries were evaluated by means of coronary angiography were enrolled in the study. Of the total, 133 had CAD (Group I) and the remaining had normal coronary arteries (Group II). The eNOS gene intron 4 a/b VNTR polymorphism was analyzed by polymerase chain reaction. The plasma lipid levels and other risk factors were also determined in all subjects. RESULTS: The a allele frequencies and genotypes carrying a allele were significantly higher in Group I. Plasma lipids, except HDL-C, were also increased in this group. We found that hypertension (HT), diabetes mellitus (DM), male gender, age and smoking were the independent predictors of CAD. CONCLUSION: a allele of eNOS intron 4 a/b VNTR polymorphism is not an independent predictor of CAD. eNOS intron 4 a/b polymorphism (presence of a allele) is a risk factor in addition to HT, DM, male gender, age and smoking for the development of CAD in Southern Turkey.

Insertion/deletion polymorphism of the angiotensin converting enzyme gene in coronary artery disease in southern Turkey.

Genetic factors are important in the pathogenesis of coronary artery disease (CAD). Angiotensin converting enzyme (ACE) gene insertion(I)/deletion(D) polymorphism is one of the genetic factor found to be related with CAD. We investigated the association between I/D polymorphism of the ACE gene and the presence of CAD. Three hundred and seven patients (187 males and 120 females, aged between 35-80, mean 54.3 +/-9.8 years) who underwent diagnostic coronary angiography were included in the study. ACE I/D polymorphism was detected by polymerase chain reaction. Of the 307, 176 had CAD. The most frequently observed genotype in all subjects was ID (47.9 %). However, in patients with CAD the frequency of II genotype was lower whereas DD genotype was higher compared to the controls (p < 0.05). The number of D allele carrying subjects were also higher (p < 0.05) in CAD patients. The logistic regression analysis indicated that the ACE D allele is an independent risk factor (odds ratio = 1.48, 95 % CI = 1.01-2.18, p < 0.05). In conclusion, the I/D polymorphism of ACE gene (carrying D allele) is an independent risk factor for CAD in the studied Turkish population.

Gene-gene interaction of ACE I/D, endothelial nitric oxide synthase 4 a/b and ApoE does not affect coronary artery disease severity.

OBJECTIVES: Previous studies have shown the impact of angiotensin converting enzyme (ACE) insertion/deletion (I/D), endothelial nitric oxide synthase (eNOS) polymorphisms and ApoE genotypes on coronary artery disease (CAD). The aim of this study is to investigate the relationship between the genetic polymorphisms and the severity of CAD and to evaluate their potential interactions. MATERIAL AND METHODS: All patients underwent coronary angiography; coronary score (CS) and severity score (SS) were calculated for them. ACE I/D, eNOS and ApoE polymorphisms were detected by polymerase chain reaction (PCR). RESULTS: Neither CS nor SS showed a direct relationship with eNOS and ApoE genotypes. CS and SS were found to be high in patients carrying the ACE DD allele (p = 0.034 and p = 0.009). In the gene interactions, there was an increase in the SS only in patients with coexisting eNOS b/b genotype and ACE DD allele (p = 0.043). CONCLUSIONS: The interactions of the gene polymorphisms investigated don't play an important role in determining an individual's risk for the severity of CAD.

Association of eNOS gene intron 4 a/b VNTR polymorphisms in children with nephrotic syndrome.

To investigate the association of endothelial nitric oxide synthase gene intron 4 (eNOS4) polymorphisms with nephrotic syndrome, the eNOS4 genotypes were assessed in 161 children with nephrotic syndrome in comparison with 78 healthy subjects. We classified the children with nephritic syndrome into 2 groups: as steroid-sensitive nephrotic syndrome (SSNS) (n=125) and steroid-resistant nephrotic syndrome (SRNS) (n=36). The eNOS4 polymorphisms were analyzed by polymerase chain reaction. The frequencies of eNOS4 aa, ab and bb genotypes were 3%, 31%, and 66% in all the nephrotic syndrome groups, and 1%, 23%, and 76% in the control group (x(2)=2.87, p>0.05). In addition, the frequencies of eNOS4 aa, ab and bb genotypes were 2%, 33%, and 65% in SSNS group, and 5%, 28%, and 67% in the SRNS group (x(2)=1.13, p=0.567). The present study is the first to investigate eNOS4 gene polymorphisms in children with SSNS and SRNS. Our data show that the eNOS4 gene polymorphisms were not associated with the development, frequent relapse and response to steroid in nephritic syndrome.

ACE gene polymorphism in Turkish children with nephrotic syndrome.

Since 1990, the role of angiotensin converting enzyme (ACE) gene polymorphism in various renal and cardiac diseases is still debated. This study comprised 71 pediatric patients with nephrotic syndrome, 47 males (66%) and 24 females (34%) with a mean age of 57.4 +/- 37.6 months, and a control group of 83 healthy males (59%) and 57 healthy females (41%) with a mean age of 505 +/- 160.5 months. The distribution of the ACE genotype in the control group was II, 11%; ID, 53%; and DD, 36%, and the nephrotic syndrome was II, 4%; ID, 78%; and DD, 18%. Angiotensin-converting enzyme genotypes were significantly different between patients and control groups (p<0.05). The study groups consisted of 52 (73%) with steroid-sensitive nephrotic syndrome (SNSS) and 19 (27%) with steroid-resistant nephrotic syndrome (SRNS). The distribution of the ACE genotype was II, 6%; ID, 75%; and DD, 19% in the SSNS population and ID, 84% and DD, 16% in the SRNS population. No statistically significant difference was found between steroid sensitivity and ACE genotypes (p=0.5). The results show that ACE I/D polymorphism does not contribute to the steroid resistance, even though this study indicates that the presence of the I/D genotype has a much higher risk--approximately 2.8 times--of having nephrotic syndrome. Further studies with a larger number of patients are needed.

Endothelial nitric oxide synthase gene intron 4 a/b VNTR polymorphism in children with APSGN.

The role of endothelial nitric oxide synthase gene intron 4 a/b (eNOS4a/b) variable number of tandem repeats (VNTR) polymorphism in various renal diseases was investigated. We investigated whether the eNOS4a/b VNTR polymorphism is associated with susceptibility to acute poststreptococcal glomerulonephritis (APSGN) and its clinical features. Endothelial NOS4a/b VNTR polymorphism is determined by the polymerase chain reaction in 60 children with APSGN, and 66 healthy controls. The genotype distribution of eNOS4 does not differ between the patients and the controls (X(2)=5.1, p=0.079). However, the frequency of eNOS4a (eNOS4a/a and eNOS4a/b) genotype is higher in the patients than in the controls (X(2)=4.5, p=0.046). In the APSGN group we performed renal biopsy on eight patients because of nephrotic syndrome accompanies acute nephritic syndrome or glomerular filtration rate (GFR) is lower than 50% of normal, and found that to carry a/a and a/b genotypes were a significant risk factor for this type presentation (OR=17.3, 95% CI:1.95-152.67, p=0.03). Mean serum creatinine values are found statistically significantly higher in a/a and a/b genotypes when compared with b/b genotypes (p=0.022). Children carrying the "aa" and "ab" genotype or "a" allele of eNOS4 have a greater tendency to develop and clinical presentation of APSGN.