Effect of serum vitamin D levels on the severity of acute pancreatitis: A prospective study.

Acute pancreatitis (AP) is a serious and complex disorder with varying disease course and severity. Early and prompt interventions are crucial in management of AP. Vitamin D, being a prominent actor in calcium metabolism, also takes part in immunity and thus in immune-system related disorders, ranging from infections to cancer. In this study, the role of vitamin D status of a patient on the severity of AP was investigated. This study was conducted between June 2021 to August 2022 with a total of 315 patients. Blood samples were obtained upon admission. A 25-(OH)D3 level less than 10 ng/ml was defined as vitamin D deficiency. 10-19 ng/ml was defined as vitamin D insufficiency whereas 20 ng/ml or above was considered to be sufficient. Scoring systems (Ranson score, CTSI, BISAP, Revised Atlanta Classification (RAC) were applied. Serum 25-(OH)D3 levels of patients with AP were found to be negatively correlated with severity of the disease according to RAC (p < 0.001). In concordance to this finding, both Ranson score and BISAP were found to be statistically significantly related to 25-(OH)D3 levels. Both scoring systems revealed higher scores in patients with insufficient or deficient levels of 25-(OH)D3. Serum 25-(OH)D3 levels were not found to be related to intensive care unit admission or mortality. This study revealed that serum 25-(OH)D3 level is related to the severity of AP. In the future, interventional studies with vitamin D therapy in otherwise serum 25-(OH)D3 deficient AP patients might reveal a new potential therapeutic agent in this mechanically complex, burdensome disorder.

Hepatitis B Reactivation in Patients Treated with Direct-Acting Antivirals for Hepatitis C.

INTRODUCTION: There is limited research about HBV reactivation (HBVr) due to direct-acting antivirals (DAA) for HCV and most are limited by short duration of follow-up, small sample size, and absence of baseline HBV DNA. We aimed to determine the incidence and clinical course of HBVr in HBsAg and/or anti-HBcIgG positive patients treated with DAA for HCV. METHODS: Seven centers retrospectively analyzed their database on HCV patients treated with DAA between 2015 and 2019. Patients with HBV coinfection or resolved HBV infection were enrolled. Serum transaminases, HBsAg, HBeAg, and HBV DNA were followed every 4 weeks during DAA treatment and every 12 weeks 1 year after treatment. Entecavir or tenofovir disoproxil fumarate was started in case of HBVr. The development of HBVr, HBV flare, liver failure, and mortality were determined. RESULTS: 852 patients received DAA treatment for HCV. Among them, 35 (4.1%) had HBV coinfection and 246 (28.9%) had resolved HBV infection. 257 patients (53.3% male, mean age: 63 ± 9) constituted the study group (29 with coinfection and 228 with resolved infection). Three patients with coinfection were HBV DNA positive. HBVr developed in 10 (34.5%) HBsAg positive patients, either during (n = 3) or 12-48 weeks after finishing DAA treatment. HBV flare and acute liver failure developed in 1 patient (3.4%), each. Two patients with resolved infection developed HBVr (0.87%) and one (0.44%) had HBV flare. Overall, none of the patients died or underwent liver transplantation due to HBVr. CONCLUSION: Patients with HBV/HCV coinfection have a high risk of HBVr after DAA treatment and should receive antiviral prophylaxis. Patients with resolved infection have a low risk of HBVr and can be monitored by serial ALT measurements.

Role of Pernicious Anemia in Patients Admitted to Internal Medicine with Vitamin B12 Deficiency and Oral Replacement Therapy as a Treatment Option.

BACKGROUND: To determine the role of vitamin B12 deficiency in pernicious anemia and the efficacy of oral vitamin B12 replacement therapy given regardless of the etiology, and to compare the endoscopic and pathological findings in patients diagnosed with vitamin B12 deficiency. METHODS: The study included 216 patients, aged 18 - 65 years, diagnosed with vitamin B12 level < 200 pg/mL between May 2015 and May 2016. Evaluation was made of the demographic characteristics of the patients, diseases, drugs used, dietary habits, previous use of vitamin B12 replacement therapy, family history of vitamin B12 deficiency, laboratory test values, and neurological symptoms present at the time of presentation. Endoscopy was applied to all the patients included in the study. Anti-parietal cell antibody (APCA) and anti-intrinsic factor antibody (AIFA) analyses were applied to all patients. RESULTS: Evaluation was made of a total of 216 patients diagnosed with vitamin B12 deficiency, comprising 145 (67.1%) females and 71 (32.9%) males. The mean vitamin B12 level of the patients was determined as 127 pg/mL at the time of presentation and 334 pg/mL after treatment. APCA positivity was determined in 40 (18.5%) patients, and AIFA positivity in 5 (2.3%) patients. Atrophy was determined endoscopically in 53 (24.5%) patients and pathologically in 90 (41.7%). Helicobacter pylori positivity was determined in 196 (90.7%) patients. A diagnosis of pernicious anemia (PA) was made in 4 (1.9%) patients (patients with AIFA positivity or APCA accompanied by corpus atrophy). APCA positivity was determined but not corpus atrophy in 36 (16.7%) patients and these cases were accepted as suspected pernicious anemia. In this study of 216 patients with vitamin B12 deficiency, stomach pathologies which could cause vitamin B12 deficiency (atrophic gastritis, HP, PA) and the responses to oral replacement therapy were investigated. As vitamin B12 absorption plays a role in the pathogenesis. Vitamin B12 deficiency can lead to atrophic gastritis, and this was determined with biopsy in 41.7% of the patients. APCA positivity was determined in 18.5% of the patients investigated with respect to autoimmune atrophic gastritis (pernicious anemia) and AIFA positivity in 2.3%. A diagnosis of PA was made in 4 (1.9%) patients from autoimmune marker positivity and the presence of corpus atrophic gastritis. HP was determined in 90.7% of the patients with vitamin B12 deficiency, and although no correlation was determined between HP and atrophy, HP positivity was determined in 84 (93.3%) of the patients with pathological atrophy. From the time of diagnosis, the patients in the study were prescribed 1,000 µg/day vitamin B12. At the 40-day follow-up examination, a significant increase was observed in the vitamin B12 levels of 92.5% of the patients. At the end of the study, as oral replacement therapy was seen to be effective to a great extent, even in patients with PA, it was concluded that for patients not responding to oral replacement therapy, it would be appropriate to apply parenteral vitamin B12 treatment. CONCLUSIONS: In developing countries such as Turkey, the role of HP infection in vitamin B12 deficiency must be kept in mind. The incidence of atrophic gastritis and pernicious anemia is higher than expected in vitamin B12 deficiency. Thus, it can be concluded that it is appropriate to investigate patients with vitamin B12 deficiency with respect to atrophic gastritis and PA, and oral replacement therapy should be the first stage in the treatment of vitamin B12 deficiency.

Clinical characteristics of haematological malignancy patients diagnosed with leukaemia cutis: Experience of a single centre.

BACKGROUND/OBJECTIVES: We evaluated the clinical characteristics of patients with haematological malignancies at our centre who were diagnosed with leukaemia cutis (LC). In addition, we describe the spectrum of other skin lesions, including, secondary skin malignancies and nonspecific benign skin lesions in haematological malignancy patients. METHODS: We defined 58 skin lesions that developed in 54 inpatients hospitalised in the Department of Haematology, Trakya University Medical Faculty, Turkey. All skin lesions that developed in inpatients between 2006 and 2012 had been evaluated by a dermatologist. The patients' clinical features, skin biopsy results and therapies were obtained from hospital files. The diagnosis of LC was based on clinical features and histopathological examinations of the skin biopsy. RESULTS: There were 11 patients with LC. Six (54.5%) had acute myeloblastic leukaemia. In nine patients (82%), LC was present at the initial presentation. Secondary skin malignancy was detected in 11 patients (five basal cell carcinoma, four Kaposi's sarcoma, one squamous cell carcinoma, one malignant melanoma); and malignancy was present in two patients (18%) at the initial presentation. Nonspecific benign skin lesions, the most frequent of which were drug eruptions, were determined in 32 of our patients. LC had a significantly higher likelihood of being present at initial presentation than other skin lesions (P < 0.01). The median survival in LC patients was quite short (4.5 months). CONCLUSIONS: LC was usually diagnosed at the initial presentation of the patient or during the early course of the disease. Having LC was a poor prognostic factor.

Peripheral blood lymphocyte dynamics and viral kinetics in patients with chronic active hepatitis B virus infection treated by tenofovir.

BACKGROUND/AIMS: We investigated serum viral kinetics and peripheral blood lymphocyte dynamics in chronic hepatitis B patients during the first year of tenofovir therapy. METHODOLOGY: Fifteen patients, naive to any kind of previous antiviral therapy, were included in this study. The patients received tenofovir daily 245mg for 48 weeks. Fifteen age and gender compatible healthy subjects were enrolled as the control group. Clinical, biochemical, immunological and virological parameters were assessed at baseline, then at the first, third, sixth and twelfth months. RESULTS: CD4+CD25+FOXP3+ nTregs percentages were significantly higher in the study group than that of healthy controls, CD4+CD28+ and CD4+CD38+ T cell percentages were significantly lower in the study group than those of control group (p<0.001). Twelve cases had undetectable HBV DNA levels after the one year therapy. We determined that there was an increase of the CD28+co-stimulator molecule on both the CD4+ and CD8+ T cells while a decrease of the CD8+CD38+ T cells, CD4+CD38+ T cells and CD4+CD25+FOXP3+ nTregs, in patients with tenofovir treatment, but only CD4+CD25+FOXP3+ nTregs were statistically significant. CONCLUSIONS: We found that both viral load and CD4+CD25+FOXP3+ nTreg percentages decreased significantly in patients with chronic hepatitis B virus infection during 1 year course of tenofovir treatment.

Helicobacter pylori eradication lowers serum asymmetric dimethylarginine levels.

INTRODUCTION: Microbial pathogens, one of them is Helicobacter pylori (H. pylori), have frequently been implicated in the atherogenesis. Endothelium-derived nitric oxide (NO) is synthesized from L-arginine by nitric oxide synthase (NOS) and plays a pivotal role in the regulation of vascular tone. Asymmetric dimethylarginine (ADMA) is the most potent endogenous NOS inhibitor. Elevated levels of ADMA have been reported in many circumstances associated with a high cardiovascular risk. The aim of the present study was to investigate whether the eradication of H. pylori infection affects serum ADMA levels. MATERIALS AND METHODS: Forty-two H. pylori-positive patients were enrolled in the study. Triple therapy for 14 days were given to all patients. Serum ADMA levels were measured at baseline and 2 months after therapy. RESULTS: Eradication was achieved in 34 (81%) patients. The mean serum ADMA levels before and after therapy were 1, 77 ± 0, 30 and 1, 67 ± 0, 29 ng/mL in the group with H. pylori eradicated and 1, 63 ± 0, 28 and 1, 56 ± 0, 32 ng/mL in the noneradicated, respectively. We detected statistically significant decreased serum ADMA levels after therapy in H. pylori eradicated group. CONCLUSION: These findings have indicated that eradication of H. pylori infection may decrease the risk of atherosclerosis and cardiovascular events.

Patients with iron deficiency anemia have an increased prevalence of gallstones.

We determined the frequency of gallstones (GS) in iron deficiency anemia (IDA) patients and evaluated factors that could affect GS formation-like lipid levels and gallbladder (GB) motilities of the patients. One hundred and eleven IDA patients (88 females, 23 males; median age, 42) and 81 healthy controls (68 females, 13 males; median age, 42) were included into our study. The clinical findings of all IDA patients were recorded down; biochemical values and body mass index (BMI) were determined; and abdominal ultrasonography was performed. In addition, GB emptying was monitored by ultrasound at 30-min intervals for 2 h after a mixed meal in randomly chosen, age-matched 25 IDA patients and 26 controls. Fasting volume (FV), residual volume (RV), and ejection fraction (EF) for all GBs were determined. The frequency of GS plus cholecystectomy was significantly higher in IDA patients (15 cases, 13.5%) than in the control group (five cases, 6.2%, p = 0.048). IDA patients with GS plus cholecystectomy were older than those without GS plus cholecystectomy (p < 0.001). FV and EF did not differ between IDA and control groups (p > 0.05). On the other hand, RV was significantly higher in IDA group than in controls (p = 0.035). The frequency of GS in IDA patients was significantly higher than in controls. The increased prevalence of GS in IDA might be explained with impaired GB motility.

The role of Blastocystis hominis in the activation of ulcerative colitis.

BACKGROUND/AIMS: Several studies have shown that a change in microbiota plays an important role in the pathogenesis of inflammatory bowel disease (IBD). Furthermore, with the emergence in recent studies of differences according to the subtype of IBD and whether the disease is active or in remission, there has started to be research into the relationship between IBD and several microorganisms. Blastocystis hominis is primary among these organisms. The aim of the present study was to determine the role of B. hominis in the acute flare-up of ulcerative colitis (UC). MATERIALS AND METHODS: A total of 114 patients with UC were included in the study, with 52 in the active phase. The Mayo scoring system was used for the activity index. Patients determined with a flare-up agent other than B. hominis were excluded from the study. Fecal samples of the patients were examined by the polymerase chain reaction method for the presence of B. hominis. RESULTS: B. hominis positivity was determined in 37 (34%) patients with UC. Of the patients, 17 (32.6%) were in the acute flare-up phase, and 20 (32.2%) were in remission (p=0.961). In 11 (64.7%) of the B. hominis positive patients, the disease severity was determined as mild-moderate (p<0.001). CONCLUSION: The results of the present study showed that while there was no difference between the active and remission phases in respect of B. hominis presence, there was milder involvement in those determined with B. hominis.

Importance of target calorie intake in hospitalized patients.

BACKGROUND/AIMS: To evaluate the feasibility and clinical outcome of a nutritional algorithm based on target calorie intake commenced as enteral nutrition (EN) alone or in combination with supplemental parenteral nutrition (SPN) among hospitalized patients. MATERIALS AND METHODS: In total, 301 hospitalized patients who were provided with nutritional support, including EN (n=125) or EN+SPN (n=176), due to various medical conditions during their hospitalization were included in this study conducted at Antalya Training and Research Hospital. All the patients were evaluated during their hospitalization under nutritional support until discharge or in-hospital death. Data on the length of stay (LOS) and serum pre-albumin and C-reactive protein (CRP) levels and records for feeding days considering nutritional risk screening (NRS) 2002 scores were collected. RESULTS: Overall, 85.7% of patients achieved the target calorie intake within a median of 4.0 days, while discharge and in-hospital death rates were 58.1% and 41.9%, respectively. Of the 5719 feeding days recorded during follow-up, 1076 (18.8%) days were associated with failure to achieve the target calorie intake with hemodynamic instability (33.3%), procurement problems (33.3%), and oral reluctance (23.0%). CONCLUSION: Our findings emphasize the role of keeping the intake closer to the target calorie intake and immediate use of SPN whenever full EN fails to achieve the target calorie intake for improving the adequacy of clinical nutrition in the early phase of critical illness. The EN and EN+SPN groups were found to be similar in terms of rates of target achievement, mortality, and discharge, while a lower mortality rate and improved nutritional status were evident in achievers than in non-achievers of the target calorie intake regardless of the type of nutrition.

Use of probiotics as an adjuvant to sequential H. pylori eradication therapy: impact on eradication rates, treatment resistance, treatment-related side effects, and patient compliance.

BACKGROUND/AIMS: To evaluate the effect of probiotics administered as an adjuvant to sequential Helicobacter pylori (H. pylori) eradication therapy on treatment outcome and patient compliance. MATERIALS AND METHODS: In total, 159 patients with H. pylori infection receiving sequential H. pylori eradication therapy were included in this randomized placebo-controlled study. Starting from day 0 of sequential eradication therapy (ERA), patients in the ERA+probiotic group [n=53, mean (SD) age: 47.7 (14.0) years, 54.7% were females] also received a probiotic supplement with Bifidobacterium animalis subsp. lactis B94 (1 capsule/day), patients in the ERA+placebo group [n=52, mean (SD) age: 46.4 (13.4) years, 51.9% were males] received placebo treatment (1 capsule/day), and patients in the ERA-only group [n=54, mean (SD) age: 46.3 (11.9) years, 55.6% were females] received no additional treatments. Eradication rates, patient compliance, and side effects of eradication therapy were recorded in each treatment group. RESULTS: Significantly higher eradication rates were noted in the ERA+probiotic group (86.8% vs. 70.8%, p=0.025) than in the combined ERA (ERA-only and ERA-placebo) group. Non-compliance with anti-H. pylori treatment was noted in 24 (15.1%) of 159 patients. Lower rates of first week treatment non-compliance due to diarrhea (1.88% vs. 12.26%, p=0.036) were noted in the ERA+probiotic group than in the combined ERA (ERA-only and ERA-placebo) group. Treatment resistance (p: 0.389) was similar between the groups, indicating pure antibiotic resistance without any compliance problems. The number needed to treat for an additional beneficial outcome (NNTB) was 6.2 (CI 95%, 3.5 to 28.9) for probiotic use. CONCLUSION: In conclusion, adjuvant administration of probiotic (B. animalis subsp. lactis) in 2-week sequential H. pylori eradication therapy is associated with a higher H. pylori eradication rate, lower first week diarrhea-related treatment discontinuation rates, less common self-reported side effects, and higher treatment compliance.

Cirrhotic Ascites management via procalcitonin level and a new approach B-mode gray-scale histogram.

BACKGROUND/AIMS: To determine the role of serum procalcitonin levels and ascites/subcutaneous echogenicity ratio (ASER) in predicting ascites infection in hospitalized cirrhotic patients. MATERIALS AND METHODS: A total of 50 patients hospitalized because of cirrhosis-related ascites were included in this study. In these patients, 44% of ascites were infected (peritonitis), whereas 56% of ascites were sterile. These two groups were compared in terms of procalcitonin levels and ASER for predicting ascites infection. Receiver operating characteristic (ROC) curves were used to evaluate the diagnostic performance of ASER, and the predicting outcome of ASER was compared with procalcitonin levels. RESULTS: The ASER values of the patients with the diagnosis of infected ascites were significantly higher than in those with the diagnosis of sterile ascites (p<0.001). ROC analysis was performed to determine the diagnostic ASER value for infected ascites. An ASER greater than 0.0019 determined peritonitis with 95.5% sensitivity and 100% specificity. A procalcitonin level greater than 0.05 determined peritonitis with 86.4% sensitivity and 75% specificity. Using ROC analysis, an ASER greater than 0.0019 [area under curve (AUC): 0.974, 95% confidence interval (CI) (0.884-0.999, p<0.001)] was a significantly better diagnostic marker than a procalcitonin level >0.5 mg/dL [AUC: 0.860, 95% CI (0.884-0.999, p<0.001) (p<0.045)]. CONCLUSION: According to our findings, the determination of ASER and serum procalcitonin levels seems to provide satisfactory diagnostic accuracy in differentiating ascites infections in hospitalized cirrhotic patients. ASER values significantly differentiate ascites infections better than procalcitonin levels.

Assessment of Aortic Elasticity in Patients with Celiac Disease.

BACKGROUND AND OBJECTIVES: Celiac disease (CD) is a chronic autoimmune disorder induced by dietary gluten intake by individuals who are genetically sensitive. Many studies report an increased risk of cardiovascular diseases in such patients. The aim of this study is to assess aortic elasticity properties in patients with CD that may be associated with an increased risk of cardiovascular disease. SUBJECTS AND METHODS: Eighty-one patients diagnosed with CD by antibody test and biopsy and 63 healthy volunteers were included in this prospective study. Electrocardiographic and echocardiographic examinations were performed. RESULTS: The CD group did not have any differences in the conventional echocardiographic parameters compared to the healthy individuals. However, patients in the CD group had an increased aortic stiffness beta index (4.3±2.3 vs. 3.6±1.6, p=0.010), increased pressure strain elastic modulus (33.6±17.0 kPa vs. 28.5±16.7 kPa, p=0.037), decreased aortic distensibility (7.0±3.0×10(-6) cm(2)/dyn vs. 8.2±3.6×10(-6) cm(2)/dyn, p=0.037), and similar aortic strain (17.9±7.7 vs. 16.0±5.5, p=0.070) compared to the control group. Patients with CD were found to have an elevated neutrophil/lymphocyte ratio compared to the control group (2.54±0.63 vs. 2.24±0.63, p=0.012). However, gluten-free diet and neutrophil/lymphocyte ratio were not found to be associated with aortic elasticity. CONCLUSION: Patients with CD had increased aortic stiffness and decreased aortic distensibility. Gluten-free diet enabled the patients with CD to have a reduction in the inflammatory parameters whereas the absence of a significant difference in the elastic properties of the aorta may suggest that the risk of cardiovascular disease persists in this patient group despite a gluten-free diet.

Implementation of screening colonoscopy amongst first- degree relatives of patients with colorectal cancer in Turkey: a cross-sectional questionnaire based survey.

OBJECTIVE: To evaluate the implementation of screening colonoscopy amongst first-degree relatives (FDRs) of patients with colorectal cancer (CRC) in Turkey. MATERIALS AND METHODS: A total of 400 first-degree relatives (mean(SD)age: 42.5(12.7) years, 55.5% were male) of 136 CRC patients were included in this cross-sectional questionnaire based survey. Data on demographic characteristics, relationship to patient and family history for malignancy other than the index case were evaluated in the FDRs of patients as were the data on knowledge about and characteristics related to the implementation of screening colonoscopy using a standardized questionnaire form. RESULTS: The mean(SD) age at diagnosis of CRC in the index patients was 60.0(14.0) years, while mean(SD) age of first degree relatives was 42.5(12.7) years. Overall 36.3% of relatives were determined to have knowledge about colonoscopy. Physicians (66.9%) were the major source of information. Screening colonoscopy was recommended to 19.5% (n=78) of patient relatives, while 48.7% (n=38) of individuals participated in colonoscopy procedures, mostly (57.9%) one year after the index diagnosis. Screening colonoscopy revealed normal findings in 25 of 38 (65.8%) cases, while precancerous lesions were detected in 26.3% of screened individuals. In 19.0% of FDRs of patients, there was a detected risk for Lynch syndrome related cancer. CONCLUSIONS: In conclusion, our findings revealed that less than 20% of FDRs of patients had received a screening colonoscopy recommendation; only 48.7% participated in the procedure with detection of precancerous lesions in 26.3%. Rise of awareness about screening colonoscopy amongst patients with CRC and first degree relatives of patients and motivation of physicians for targeted screening would improve the participation rate in screening colonoscopy by FDRs of patients with CRC in Turkey.

Precut sphincterotomy: a reliable salvage for difficult biliary cannulation.

Even experienced endoscopists have 90% success in achieving deep biliary cannulation with standard methods. Biliary cannulation may become difficult in 10%-15% of patients with biliary obstruction and precut (access) sphincterotomy is frequently chosen as a rescue treatment in these cases. Generally, precut sphincterotomy ensures a rate of 90%-100% successful deep biliary cannulation. The precut technique has been performed as either a fistulotomy with a needle knife sphincterotome or as a transpapillary septotomy with a standard sphincterotome. Both methods have similar efficacy and complication rates when administered to the proper patient. Although precut sphincterotomy ensures over 90% success of biliary cannulation, it has been characterized as an independent risk factor for pancreatitis. The complications of the precut technique are not limited to pancreatitis. Two more important ones, bleeding and perforation, are also reported in some publications as being observed more commonly than during standard sphincterotomy. It is also reported that precut sphincterotomy increases morbidity when performed in patients without dilatation of their biliary tract. Nevertheless, precut sphincterotomy is a good alternative as a rescue method in the setting of a failed standard cannulation method. This paper discusses the technical details, timing, efficacy and potential complications of precut sphincterotomy.

A case of cervical spine meningioma following etanercept use in a patient with RA.

BACKGROUND: A 70-year-old female with active rheumatoid arthritis (RA) was administered etanercept to treat active disease that persisted despite therapy with conventional DMARDs. After 18 months of etanercept therapy, her RA symptoms had improved; however, she developed quadriparesis. She presented to a specialist rheumatology clinic with weakness and numbness in her arms and legs; she also had difficulty in standing up and walking. INVESTIGATIONS: Physical examination, neurological examination, nerve conduction studies, measurement of serum inflammatory markers and autoantibodies, MRI of the cranium and cervical spine, and X-rays of the chest and hands. DIAGNOSIS: The patient underwent neurosurgery to resect a 1 x 2 cm mass in the cervical spine at C6-C7. Histopathologic examination of the excised mass revealed it to be a meningioma. MANAGEMENT: Etanercept was discontinued because of a possible association between the drug and development of meningioma; however, shortly afterwards the patient experienced a flare of RA symptoms. High-dose NSAIDs and prednisolone were administered, but the patient died because of gastric perforation. To our knowledge, this is the first report in the literature of meningioma developing following use of tumor necrosis factor inhibitor therapy, and the first to suggest a cause-effect relationship.