Turkish inappropriate medication use in the elderly (TIME) criteria to improve prescribing in older adults: TIME-to-STOP/TIME-to-START.

PURPOSE: To improve prescribing in older adults, criterion sets have been introduced from different countries. While current criterion sets are useful to some extent, they do not meet the need in some European countries. Turkish inappropriate medication use in the elderly (TIME) criteria was planned to meet this need. METHODS: In phase 1, the user friendly sets: STOPP/START version2 and CRIME criteria were combined. National experts composed of geriatricians and non-geriatricians were invited to review and comment. In phase 2, thorough literature review was performed and reference-based revisions, omissions, and additions were made. Explanatory additions were added to some criteria to improve application in practice. In phase 3, all working group members reviewed the criteria/explanations and agreed on the final content. RESULTS: Phase 1 was performed by 49 expert academicians between May and October 2016. Phase 2 was performed by 23 working group academicians between October 2016 and November 2018 and included face-to-face interviews between at least two geriatrician members and one criterion-related specialist. Phase 3 was completed between November 2018-March 2019 with review and approval of all criteria by working group academicians. As a result, 55 criteria were added, 17 criteria were removed, and 60 criteria were modified from the first draft. A total of 153 TIME criteria composed of 112 TIME-to-STOP and 41 TIME-to-START criteria were introduced. CONCLUSION: TIME criteria is an update screening tool that differs from the current useful tools by the interactive study of experts from geriatrics and non-geriatrics, inclusion of practical explanations for some criteria and by its eastern European origin. TIME study respectfully acknowledges its roots from STOPP/START and CRIME criteria. Studies are needed whether it would lead improvements in older adults' health.

Turkish doctors' cohort: healthy despite low screening.

OBJECTIVES: We aimed to determine the prevalence of chronic diseases and unhealthy lifestyle behaviors of Turkish doctors as compared with the general population and the frequency of compliance with preventive clinical practices among doctors. METHODS: This was an observational, prospective cohort study that enrolled graduates between 1975 and 2004 from six medical schools in Turkey. Data on demographics, disease conditions, and unhealthy lifestyle behaviors were gathered. Preventive care practices were analyzed with regards to age and gender. RESULTS: A total of 7228 doctors participated in the study. Comparison with the national data revealed higher hyperlipidemia and coronary artery disease rates. While 54.5% of the doctors had a doctor visit in the last 12 months, only 31.5% of those over 40 years of age reported a recent blood pressure measurement. Colon cancer screening rate over 50 years of age with any of the acceptable methods was only 3%. One-fourth of the female doctors over 40 years of age underwent mammography within the last two years. Only 7.1% of the doctors over 65 years of age and 10% of the doctors having an indication for a chronic disease had a pneumococcal vaccine, while nearly one-fifth had no hepatitis B vaccine. CONCLUSION: In this cohort of mainly middle-aged Turkish doctors, the age-standardized rates of chronic diseases were lower than the rates in the general population except for the rates of hyperlipidemia and coronary artery disease. However, doctors did show quite low rates of receipt of screening practices. These results might provoke questions about how to use Turkish doctors' health behaviors to further improve doctors' and, relatedly, patients' health.

Acquired FVIII and FIX Inhibitors after Pregnancy: A Case Report.

Acquired hemophilia is a relatively rare clinical presentation, and most cases present with acquired FVIII inhibitor. The co-occurrence of inhibitors to multiple coagulation factors is uncommon. These autoantibodies may induce spontaneous life-threatening bleeding in patients who have had no previous bleeding disorder. Herein, we present a patient with postpartum acquired FVIII and FIX inhibitors who developed intramuscular hematoma and hemothorax during follow-up. She was then treated with activated prothrombin complex concentrate and methylprednisolone.

[Turkish Hypertension Consensus Report]. / Türk Hipertansiyon Uzlasi Raporu.

Hypertension is a common and important public health problem in Turkey and worldwide. Recommendations on the diagnosis and treatment of hypertension have been presented in many nationally and internationally agreed European and American guidelines. However, there are differences among these guidelines, and some of the recommendations are not consistent with clinical practice in our country. Consensus report preparation, with the participation of relevant associations, was considered necessary to merge recommendations by evaluating hypertension guidelines from the perspective of Turkey and to create a joint approach in the diagnosis and treatment of hypertension in adults. For this purpose, it was aimed to prepare a practical text in Turkey in which all physicians dealing with hypertensive patients, from family practitioners in primary care to specialists in tertiary care, could come to agreement on common concepts, and which would be used as a basic reference guideline. Considering health care practices and sociocultural structure in Turkey, this report aimed to enhance awareness on hypertension, provide a common basis for different definitions and values as well as therapeutic options in various guidelines, and establish a practical reference guide to improve clinical practices in Turkey. This report is not a document describing hypertension in every aspect, but a reference, including basic recommendations with outlines. Care was taken to ensure that recommendations were evidence-based and valid for a majority of patients in clinical practice. However, it should be kept in mind that an approach assessment should be made on an individual basis for each patient.

A Case Study: Rare Lepiota brunneoincarnata Poisoning.

Amatoxin poisoning from the genus Lepiota may have a deadly outcome, although this is not seen as often as it is from the genus Amanita. In this report, we present a patient who was poisoned by a sublethal dose of Lepiota brunneoincarnata mushrooms. The patient was hospitalized 12 hours after eating the mushrooms. The patient's transaminase levels increased dramatically starting on day 4. Aspartate transaminase peaked at 78 hours. Starting at 1265 IU/L, alanine transaminase peaked at 90 hours at 5124 IU/L. The patient was discharged on day 8 to outpatient care, and his transaminase levels returned to normal ranges in the subsequent days. A toxin analysis was carried out on the mushrooms that the patient claimed to have eaten. Using reversed-phase high-performance liquid chromatography analysis, an uptake of approximately 19.9 mg of amatoxin from nearly 30 g of mushrooms was calculated. This consisted of 10.59 mg of α-amanitin, 9.18 mg of ß-amanitin, and 0.16 mg of γ-amanitin. In conclusion, we present a patient from Turkey who was poisoned by L. brunneoincarnata mushrooms.

High sensitivity C-reactive protein in spontaneous bacterial peritonitis with nonneutrocytic ascites.

BACKGROUND/AIMS: Diagnosis of spontaneous bacterial peritonitis in cirrhotic ascites is based on a polymorphonuclear leukocyte count of ascitic fluid equal or greater than 250/mm3 in the presence of clinical signs. There is a small number of patients with positive ascitic fluid culture whose polymorphonuclear leukocyte count is less than 250/mm3. In this study, we assessed the diagnostic value of serum high sensitivity C-reactive protein in spontaneous bacterial peritonitis with nonneutrocytic ascites. METHODOLOGY: Patients with decompensated cirrhosis were enrolled in three groups. Group 1: Signs and symptoms of peritonitis plus a polymorphonuclear leukocyte count of ascitic fluid equal or greater than 250/mm3. Group 2: Signs and symptoms of peritonitis, but polymorphonuclear leukocyte count of ascitic fluid less than 250/mm3. Group 3: No signs and symptoms of peritonitis and polymorphonuclear leukocyte count of ascitic fluid less than 250/mm3. Ceftriaxone was started in Groups 1 and 2. Serum level of hsCRP was repeated after the 2nd day of the antibacterial treatment. RESULTS: Mean levels of serum hsCRP were 68.4 mg/dl, 68.3 mg/dl and 6.5 mg/dl in Groups 1, 2 and 3 respectively. Those levels were significantly higher in Groups 1 and 2 compared to Group 3 (p < 0.0001). After the 2nd day of ceftriaxone, serum hsCRP decreased to a mean level of 9.0 mg/dl in Group 1 and to 9.1 mg/dl in Group 2. CONCLUSION: These findings indicate that elevated hsCRP levels may discriminate patients with and without spontaneous bacterial peritonitis even in the presence of nonneutrocytic ascites, and may have utility in the assessment of treatment response.

Lens opacities in Bloom syndrome: case report and review of the literature.

Bloom syndrome is an autosomal recessive disorder characterized by proportionate short stature, photosensitivity, immunodeficiency, hypogonadism and a tendency to develop various malignancies. The greatly increased frequency of sister chromatid exchanges (reciprocal exchange of homologous segments between the two sister chromatids of a chromosome) is regarded as pathognomonic for BS. We describe an 18-year old girl who presented with short stature. She was diagnosed with BS based on an extremely increased frequency of sister chromatid exchanges. Ophthalmological examination revealed mild lens opacities bilaterally, which, to our knowledge, has not been previously reported to be associated with BS.

Comparison of rheological parameters in patients with post hepatitic and alcoholic cirrhosis.

It is well known that various constituents of blood, especially lipids and proteins, and hematological parameters are altered in chronic liver diseases. These alterations have been shown to affect rheological parameters in various studies. However, it is not clear whether the etiology of chronic liver has any specific influence on flow dynamics of blood. In the present study, we analysed erythrocyte rigidity (ER), whole blood and plasma viscosity, and other factors related to blood rheology (including hematological parameters, plasma lipids and proteins) in healthy controls (n=20) and patients with post hepatitic and alcoholic cirrhosis (n=15 in each group). ER was significantly higher (p<0.05) in both groups compared to controls. Although blood viscosity was found to be low in both groups, the difference reached statistical significance only in patients with alcoholic cirrhosis. On the other hand, when compared to controls, plasma viscosity was significantly lower in patients with alcoholic cirrhosis and significantly higher in patients with posthepatitic cirrhosis (p<0.05). When we compare post hepatic and alcoholic cirrhosis with each other, there was no significant difference in ER between the two groups.

Suicide attempt with clopidogrel.

We report the case of a 49-year-old male who took an overdose of 1650 mg of clopidogrel with suicidal intent. The patient developed abnormalities of platelet aggregation, but never developed symptoms. Clopidogrel is a commonly prescribed drug. Reports of overdose of clopidogrel were very rarely reported in the literature.

Sister chromatid exchange and mitotic index in patients with cirrhosis related to hepatitis B and C viruses and in chronic carriers.

BACKGROUND/AIMS: It is controversial whether hepatitis B or C viruses induce liver cancer through non-specific mechanisms (inflammation and cell renewal) or direct genotoxicity. Considering that both viruses infect peripheral lymphocytes, studying sister chromatid exchange frequency and mitotic index in peripheral lymphocytes is a reasonable experimental approach to investigate their genotoxic potential separately. In the present study we investigated sister chromatid exchange frequency and mitotic index in the peripheral lymphocytes of patients with cirrhosis and chronic carriers with positive serology for HBV or HCV infections. METHODOLOGY: The study population consisted of 3 groups: group I involved 23 HBsAg positive chronic carriers; group II involved 30 HBsAg positive patients with cirrhosis and group III involved 9 HCV-positive patients with cirrhosis. The control group involved 30 healthy individuals. RESULTS: Sister chromatid exchange frequency was significantly higher in all the study groups than the control group (p < 0.05). The mitotic index was significantly lower in all the study groups than the control group (p < 0.05). CONCLUSIONS: The increased sister chromatid exchange frequency and low mitotic index may be reflecting a direct genotoxic effect of HBV and HCV in peripheral lymphocytes. We suggest that the same genotoxicity may also operate in the liver and contribute to hepatocarcinogenesis.

Acute wood or coal exposure with carbon monoxide intoxication induces sister chromatid exchange.

OBJECTIVE: The object of this study was to investigate the genotoxic effect of acute overexposure to combustion products originating from coal or wood stoves in patients presenting with acute carbon monoxide intoxication. STUDY DESIGN: In a prospective study, we analyzed the frequency of sister chromatid exchange and the carboxyhemoglobin concentration in 20 consecutive patients without a history of smoking or drug use who had been treated in the Emergency Care Unit of Istanbul Medical Faculty due to acute carbon monoxide intoxication. All of these cases were domestic accidents due to dysfunctioning coal or wood stoves. The results were compared with a control group of 20 nonsmoking, nondrug-using healthy individuals matched for age, sex, and absence of other chemical exposure. RESULTS: The mean sister chromatid exchange frequency per metaphase was significantly higher in the study group compared to the control group: 8.11 +/- 2.39 vs. 6.33 +/- 1.60 (p = 0.008). We found that there was no positive correlation between the blood carboxyhemoglobin concentration and sister chromatid exchange frequency. CONCLUSIONS: These results suggest that acute exposure to combustion products of wood or coal is genotoxic to DNA. Potential causes of genotoxicity include known mutagenic compounds present in coal or wood smoke and ash, oxygen radicals formed during combustion, as well as hypoxic and reperfusion injury mechanisms initiated by carbon monoxide intoxication. Additional studies on separate carbon monoxide exposure from smoke and ash are needed to understand individual genotoxic contributions and mechanisms.