The effect of oxcarbazepine on bone metabolism.

OBJECTIVE: Long term use of several antiepileptic drugs is known to cause alteration in bone metabolism. Therefore, we investigated the effect of new antiepileptic drug, oxcarbazepine, on bone metabolism. METHODS: Twenty eight patients who were on oxcarbazepin therapy (18 female, 10 males; mean age: 27.82 +/- 10.98 years (range: 15-45)) with no additional antiepileptic drug use history in one year period prior to the study and 28 control subjects were involved in the study. Measurement of calcium, phosphate, alkaline phosphatase and Vitamin D3 levels and bone density measurements with DEXA method were performed in patient and age-matched control groups. The baseline parameters were compared with the control group and with those measured at the end of one year. RESULTS: The biochemical (calcium, phosphate, alkaline phosphatase and Vitamin D3) parameters and densitometry values after one year of therapy were not different than the baseline values indicating that those were not affected by the therapy (P > 0.05). CONCLUSIONS: In previous studies, anticonvulsant drugs that induce enzymes increase bone degradation by causing vitamin D deficiency. According to the results of this study, oxcarbazepin with little effect on enzyme induction was shown not to affect bone mineral metabolism.

Combined effects of ACE and MMP-3 polymorphisms on migraine development.

Migraine is a primary headache disorder which involves both genetic and environmental components. Since angiotensin-converting enzyme (ACE) and matrix metalloproteinase (MMP) share the same homology, we investigated whether the MMP-3 and ACE I/D gene variants are involved in migraine risk and whether the ACE variant might act in combination with the MMP-3 genetic variant in patients with migraine. This is the first study to evaluate the association between MMP-3 and ACE polymorphisms, and migraine. Genotypes were determined by polymerase chain reaction. The frequencies of 5A5A genotypes of the MMP-3 and D allele of ACE were significantly elevated, but II genotypes of the ACE and 6A allele of MMP-3 significantly decreased in all patients. The combined DD/5A5A and ID/5A5A genotypes increased the risk of migraine. Individuals who were homozygous for the deletion (D) allele showed increased ACE activity. Subjects with the 5A5A genotype and/or D allele or with the combined DD/5A5A or ID/5A5A might be more susceptible to migraine development. In contrast, subjects with the II and/or 6A6A genotypes may be protected from migraine development. The greater activity of the 5A5A and DD genotypes might result in vascular reactivity that is more pronounced in migraine. Taken together, our data suggest that numerous genes may influence ACE activity. Discovery of new genes might better clarify the pathogenesis of migraine and open an avenue to therapeutic strategies against migraine.

Tonsillar abscess formation due to herpes simplex type-1 in a severely immunocompromised stem cell transplant patient with chronic myeloid leukemia.

Herpes simplex virus (HSV) causes life-threatening infections in immunocompromised patients such as transplant recipients and patients with hematologic malignancies. We herein describe the case of a patient with chronic myeloid leukemia blastic transformation who developed severe herpetic tonsillitis complicated by tonsillar abscess formation. Abscess formation was determined by computed tomography, whereas tonsillitis due to HSV was confirmed by pathologic and immunohistochemical examinations of the tonsillar biopsy. For molecular confirmation, HSV DNA was amplified by LightCycler PCR and type (HSV-1) determined by melting point analysis. The patient responded promptly to antiviral treatment and there were no signs of recurrent infection at the follow-up. To our knowledge, this case is unique for being the first case of tonsillar abscess formation due to HSV-1, also emphasizing the importance of herpetic infections in the differential diagnosis of oropharyngeal small-sized lesions in the immunocompromised patient population.

Change in the amputation profile in diabetic foot in a tertiary reference center: efficacy of team working.

Diabetic foot is a serious complication of diabetes mellitus and the risk of lower extremity amputation is very high in this population when compared with people without diabetes. We have previously reported the lower-extremity amputation rate and significant factors in determining the risks for patients who had been admitted to Hacettepe University Hospital, a tertiary reference center for Turkey, between the years 1992 and 1996. In January 2000, a diabetic foot care team including an infectious diseases specialist, orthopaedic surgeons, endocrinologists, a plastic and reconstructive surgeon, a radiologist, and a diabetic foot nurse was assembled. To determine whether a change has occurred in the rate and the risk factors of lower extremity amputations after the establishment of this team, medical records of 66 patients (39 men, 27 women) with diabetic foot who had been admitted to Hacettepe University Hospital between 2000 and 2002 have now been retrospectively analysed. The grade distribution of diabetic foot according to Wagner classification was quite similar in the two studies (grade 1: 0 % vs. 4.5 %, grade 2: 15.6 % vs. 19.7 %, grade 3: 48 % vs. 33.3 %, grade 4: 24.4 % vs. 30.3 %, grade 5: 11.5 % vs. 12.1 % in the former and current study, respectively). The overall amputation rate in the current study was 39.4 % (36.7 % in the former study). Ray amputation (35 %) and below-knee amputations (30 %) were the two most commonly applied procedures. The rates of Syme, above knee, other amputations (i.e., Boyd, talonavicular amputations and partial calcanectomy) were 8 %, 8 % and 19 %, respectively. These data suggest that amputation is still a frequently encountered outcome for our patients with diabetic foot, but the amputation profile has changed. The implementation of a diabetic foot care team has relatively decreased the rate of major amputations in an attempt for limb salvage to improve the quality of life of the patients. Presence of osteomyelitis, peripheral vascular disease and gangrene still remain as significant predictors of amputation in our population.

Comparison of the effect of closed versus open endotracheal suction systems on the development of ventilator-associated pneumonia.

The aim of this study was to compare the effect of closed versus open endotracheal suction systems on the development of ventilator-associated pneumonia (VAP). A prospective, randomized, controlled trial was performed in a medical intensive care unit (MICU) of a university hospital in patients who received mechanical ventilation for more than 48 h. Patients were randomized to receive endotracheal suction with either closed catheters (closed suction group; N-41) or single-use catheters (open suction group; N=37). Cultures were taken from the ventilator tubing of 42 patients to determine the rate of colonization. There was no difference between the groups in terms of the frequency of development of VAP, mortality in the MICU, length of MICU stay and duration of mechanical ventilation. Thirteen patients in the open suction group and 16 patients in the closed suction group became colonized (P=0.14). The colonization rates by Acinetobacter spp. and Pseudomonas aeruginosa were more frequent in the closed suction group than in the open suction group (P<0.01 and P=0.04, respectively). In conclusion, closed endotracheal suction resulted in increased colonization rates of ventilator tubing with multi drug-resistant micro-organisms but did not increase the development of VAP and MICU outcome compared with open endotracheal suction.

Septic arthritis caused by Nocardia asteroides in a renal transplant recipient.

Although articular complications are common following renal transplantation, septic arthritis is not frequent. Previous bacterial infection in an another site is a consistent finding and the knee is the most often affected joint. We present a 30-year-old female renal transplant recipient with recurrent pulmonary infiltrates preceding septic arthritis of her left knee. Cultures of the aspirated synovial fluid yielded a gram-positive, rod-shaped bacterium later identified as Nocardia asteroides. The patient was treated with oral trimethoprim-sulfamethoxazole without any side effect. Nocardia is a rare but serious cause of infection in renal transplant recipients but there is no well-known predisposing factor. Recently mycophenolate mofetil has been implicated as a factor associated with Nocardia infections. Prolonged courses of treatment with sulphonamides are recommended.

A retrospective review of 228 episodes of infective endocarditis where rheumatic valvular disease is still common.

Two hundred and twenty-eight episodes of infective endocarditis in adult patients (mean age 36 years) were reviewed retrospectively. There were 183 episodes (80%) of native valve, 15 (7%) early prosthetic valve and 30 (13%) late prosthetic valve endocarditis. The most common predisposing factor was rheumatic valvular disease (65%). None of the patients were intravenous drug users. According to the Duke criteria, the number of definite, probable and rejected episodes were 121 (53%), 94 (41%) and 13 (6%), respectively. Additional minor criteria increased the number of definite endocarditis to 82%. The Duke criteria are not primarily intended to influence treatment decisions but are helpful in standardising research activities. The choice of the level of sensitivity or specificity of the criteria may be adjusted according to the aim of the study and prevalence of disease in a particular area. More sensitive criteria may be valuable in those countries where the prevalence of rheumatic valvular disease is still high.

Comparison of cefepime and ceftazidime in combination with amikacin in the empirical treatment of high-risk patients with febrile neutropenia: a prospective, randomized, multicenter study.

A total of 208 adult patients with cancer and febrile neutropenia from 5 medical institutions were randomized to receive either cefepime (2 g b.i.d.) or ceftazidime (2 g t.i.d.) in combination with amikacin (15 mg/kg/o.d.). Ninety-seven patients in the ceftazidime (CEZ) group and 98 in the cefepime group (CEF) were evaluable for efficacy. In 68 patients (35%), infection could be documented. The average duration of antibiotic therapy was 11 and 12 d and response rates to the empirical regimen were 36 and 30% for the CEZ and CEF groups, respectively (p > 0.05). The average time of defervescence in responders was 3 d for both groups. Modification of the initial regimen with antivirals and/or azole antifungals raised the number of responders to 44% and 35%, respectively (p > 0.05). Vancomycin was additionally given to 29 patients in the CEZ group and to 27 patients in the CEF group. Twenty-six patients in each group received empirical amphotericin B. Mild, reversible study drug-related side-effects were observed in 12 patients (12%) in the CEZ group and 13 patients (13%) in the CEF group (p > 0.05). Cefepime in combination with amikacin seems to be as effective, safe and tolerable as ceftazidime + amikacin in patients with high-risk neutropenia and fever.

Vancomycin-resistant enterococci.

After they were first identified in the mid-1980s, vancomycin-resistant enterococci (VRE) spread rapidly and became a major problem in many institutions both in Europe and the United States. Since VRE have intrinsic resistance to most of the commonly used antibiotics and the ability to acquire resistance to most of the current available antibiotics, either by mutation or by receipt of foreign genetic material, they have a selective advantage over other microorganisms in the intestinal flora and pose a major therapeutic challenge. The possibility of transfer of vancomycin resistance genes to other gram-positive organisms raises significant concerns about the emergence of vancomycin-resistant Staphylococcus aureus. We review VRE, including their history, mechanisms of resistance, epidemiology, control measures, and treatment.

Analysis of a mini-outbreak of methicillin-resistant Staphylococcus aureus in a surgical ward by using arbitrarily primed-polymerase chain reaction.

In November 1995, an increase was noticed in the number of methicillin-resistant Staphylococcus aureus (MRSA) isolates from a surgical ward at Hacettepe University Hospital. All MRSA isolates obtained from clinical specimens in this ward (14 MRSA isolates from wound cultures of 10 patients) were collected prospectively for 10 weeks. Surveillance cultures were taken from ward personnel (nose cultures from 4 physicians, 7 nurses, 1 secretary, 1 waiter), 2 surgical dressing containers and 1 nebulizer. MRSA was isolated from one of the surgical dressing containers, the nebulizer and nose cultures of 3 physicians, 3 nurses and the ward secretary. Arbitrarily primed polymerase chain reaction (AP-PCR) analysis showed that most MRSA isolates belonged to 2 major clones (pattern A, pattern B). Pattern A was the most frequent one and was present in 4 clinical isolates, surgical dressing container-1. Pattern B was identified in 3 clinical isolates and nose culture of physician-3. AP-PCR analysis revealed that this mini-MRSA outbreak was caused by contamination of surgical dressing container with MRSA and nasal MRSA carriage in ward staff. AP-PCR seems to be a valuable typing method for analysis of nosocomial MRSA outbreaks because of its simplicity and rapidity.

In vitro activity of a new echinocandin, LY303366, compared with those of amphotericin B and fluconazole against clinical yeast isolates.

The in vitro activity of LY303366, a new echinocandin derivative, was evaluated with 191 yeast isolates by a broth microdilution method. The MICs at which 50% of the isolates were inhibited were 0.125 microg/ml for Candida albicans and C. tropicalis, 0.25 microg/ml for C. krusei, C. kefyr, and C. glabrata, and 2.0 microg/ml for C. parapsilosis.