Hypomagnesemia Among Outpatient Long-Term Proton Pump Inhibitor Users.

Proton pump inhibitors (PPIs) are extensively prescribed drugs usually used for a long period. Recent reports linked PPI use with development of hypomagnesemia. However, there is still uncertainty regarding risk of hypomagnesemia in outpatients who were on long-term PPI use. Thus, we aimed to evaluate frequency of hypomagnesemia among a well-defined outpatient patient cohort with no other possible risk factors affecting serum magnesium levels. This was a case-control study carried out at the outpatient gastroenterology clinic of a University hospital. Patients who were on PPI therapy for at least 6 months without diuretic use and chronic kidney disease were included. Patients who were subjected to the same inclusion and exclusion criteria and not using PPI were included as control subjects. One hundred fifty-four patients and 84 control subjects were included. The mean duration of PPI use was 27.5 ± 2.5 months. Mean serum magnesium levels of PPI users and nonusers were 2.17 ± 0.20 mg/dL and 2.19 ± 0.15 mg/dL, respectively. None of the patient had a serum magnesium level below laboratory lower range of 1.7 mg/dL. Our results showed that for typical gastroenterology outpatient clinic patients with no other risk factors affecting serum magnesium levels, long-term PPI use did not affect serum magnesium levels.

IgE-Mediated Reaction to Metamizole: Evaluation of a Patient with Severe Anaphylaxis.

Metamizole, a non-steroidal anti-inflammatory drug with weak anti-inflammatory and spasmolytic effects, is used as an analgesic and antipyretic agent. Many adverse reactions to metamizole, such as early or late-onset systemic reactions and bone marrow suppression, have been identified. In this report, we present a case of systemic reaction after the application of parenteral metamizole (Novalgin(®) ampoule; Sanofi Aventis, Istanbul, Turkey) and discuss the mechanism underlying the reaction.

Rectal or intramuscular diclofenac reduces the incidence of pancreatitis afterendoscopic retrograde cholangiopancreatography.

BACKGROUND/AIM: Acute pancreatitis is the most common adverse event of endoscopic retrograde cholangiopancreatography (ERCP). We aimed to evaluate the efficacy of intramuscular diclofenac sodium for prophylaxis of post-ERCP pancreatitis (PEP) in comparison to the rectal form. MATERIALS AND METHODS: One hundred and fifty consecutive patients who underwent ERCP were enrolled in this single-center, prospective, randomized controlled study. Patients were randomized into three groups. The first group received 75 mg of diclofenac sodium via intramuscular route and the second group received 100 mg of diclofenac sodium rectally 30-90 min before the procedure. The third group served as the control group. Patients were evaluated for post-ERCP pancreatitis with serum amylase levels and abdominal pain 24 h after the procedure. RESULTS: The overall incidence of PEP was 6% (n = 9) and 2% (n = 1) in the intramuscular (IM) and rectal groups, respectively, and 14% in the control group (P = 0.014). Nineteen (12.7%) patients developed post-ERCP abdominal pain (8% in IM, 10% in rectal, and 20% in control group; P = 0.154). Twenty-five (16.6%) patients developed post-ERCP hyperamylasemia (10% in IM, 12% in rectal, and 24% in control group; P = 0.03). CONCLUSION: Prophylaxis with diclofenac given rectally or intramuscularly is an effective option for the management of post-ERCP pancreatitis.

Common variable immunodeficiency in adults requires reserved protocols for long-term follow-up.

BACKGROUND/AIM: The aim of this study is to establish follow-up protocols for adult patients with common variable immunodeficiency (CVID) in a recently founded adult immunology clinic in the Central Anatolia Region of Turkey, where a clinical immunology center for adults was not available previously. MATERIALS AND METHODS: A total of 25 patients with CVID aged 18 years and older were included in this study. The file format consisted of 13 pages and was developed for the purpose of the study. Separate sections were designated for identity information, medical history, disease course, previous and current laboratory and imaging studies, follow-up plans, detection and management of complications/comorbidities, and treatment results. RESULTS: The mean age of the patients was 36.6 ± 13.4 years. The delay in diagnosis was 107 ± 95.6 months. In 92% of patients, initial symptoms resulting in admission to healthcare facilities were infections. Seventeen of 25 patients (68%) had bronchiectasis at the beginning of follow-up. CONCLUSION: Early identification of complications and comorbidities in patients with CVID will significantly improve quality of life and survival. Close observation and standardized protocols for follow-up are essential components of management.

The Predictive Value of Platelet/Lymphocyte Ratio in Hemodialysis Patients With Erythropoietin Resistance.

The most important cause of anemia in CKD is relative deficiency of erythropoietin (EPO) secretion from the diseased kidney and EPO therapy has become the standard treatment for anemia of CKD. However, some patients do not respond well to erythropoiesis stimulating agent (ESA), so-called ESA resistance. One of the most important causes of ESA resistance is chronic inflammation in hemodialysis (HD) patients. ESA hyporesponsiveness index (EHRI), calculated as the weekly dose of EPO divided by kilograms of body weight divided by the hemoglobin level, and has been considered useful to assess the EPO resistance. Neutrophil/lymphocyte (NLR) ratio and platelet/lymphocyte ratio (PLR) were also found to be associated with inflammation in HD patients. However, the relationship between NLR, PLR and EHRI has not been investigated before. HD patients underwent medical history taking, physical examination, calculation of dialysis adequacy and biochemical analysis and calculation of EHRI. Logarithmically converted EHRI (logEHRI) was correlated only with hemoglobin (r -0.381, P < 0.0001) and PLR (r = 0.227, P = 0.021) but not with NLR. Comparison of PLR among 25th, 50th and 75th percentile of EHRI showed that PLR levels increased going from the 25th to 75(th) percentile (P = 0.032). Posthoc analysis revealed that 25-75th percentile (P = 0.014) and 50-75th percentile (P = 0.033) were different with respect to PLR. In linear regression analysis, PLR (standardized ß = 0.296, confidence interval: 0.000-0.001, P = 0.003) was independently associated with logEHRI. We found that PLR was independently associated with EHRI in HD patients. PLR, which is quite a simple and cheap method, may guide clinicians for detecting EPO resistance.

Difficulties encountered in the emergency department by patients with hereditary angioedema experiencing acute attacks.

BACKGROUND: Hereditary angioedema (HAE) is a rare, potentially life-threatening disease characterized by recurrent angioedema attacks. Abdominal symptoms of HAE typically mimic numerous abdominal emergencies, which may result in a delay of correct diagnosis and inappropriate treatments. OBJECTIVE: We aimed to evaluate the difficulties experienced by patients with HAE in Turkish emergency departments (ED). METHODS: We conducted face-to-face interviews with patients with HAE by using a questionnaire regarding the clinical and demographic data of the patients and difficulties encountered during ED admissions. RESULTS: The mean (standard deviation) age of 34 patients with HAE (25 women, 9 men) was 36.2 ± 11.5 years and the mean (standard deviation) delay in diagnosis was 17.2 ± 9.7 years. Inappropriate treatment for HAE attacks was administered to 88.2% (n = 30) of patients in the ED, despite their diagnosis of HAE. The most frequent difficulty was "not knowing how to administer C1 inhibitor concentrate" (n = 11 [32.4%]). Other difficulties encountered were as follows: ED staff being unaware of HAE (n = 6 [17.6%]), lack of C1 inhibitor concentrate in the ED (n = 3 [8.8%]), and kept waiting for the appropriate treatment in triage despite their having angioedema in the head-and-neck region (n = 2 [5.9%]). CONCLUSION: Patients with HAE encounter difficulties in the ED, and the delay in diagnosis could be due to a low level of awareness regarding HAE. Therefore, the management of HAE in EDs requires improvement.

Renal artery embolization in severe nephrotic syndrome.

Introduction Severe nephrotic syndrome is associated with increased morbidity and mortality. Renal artery embolization (RAE) has been used in a number of renal diseases such as renal tumors, arteriovenous fistulas etc. However, data regarding benefits of RAE in patients with symptomatic severe proteinuria is limited. We decided to evaluate role of RAE in the setting of severe symptomatic nephrotic syndrome. Methods Eight patients who had undergone transcatheter renal artery embolization with polyvinyl alcohol (PVA) were included. Clinico-demographic characteristics as well as baseline laboratory data including level of proteinuria, serum albumin, C-reactive protein and LDL cholesterol levels were recorded for each patient. After RAE, outpatient clinic control laboratory values were also assessed. Findings All patients except one underwent bilateral RAE (four simultaneous or three sequential). Two patients experienced postembolization syndrome characterized by flank pain, fever, and leukocytosis, which was self-limited and responded to analgesics in all patients. There was no technical complications associated with RAE procedure. All patients became anuric except one. Serum albumin levels increased and serum LDL-cholesterol levels decreased considerably in treated patients. Discussion Renal artery embolization with the purpose of amelioration in nephrotic syndrome complications was effective and free of major technical complications in our patients.

How effective are the 6 European Society of Immunodeficiency warning signs for primary immunodeficiency disease?

BACKGROUND: The European Society of Immunodeficiency (ESID) developed 6 warning signs to promote the awareness of adult primary immunodeficiency disease (PID). OBJECTIVE: To screen adult patients for the presence of PID using these 6 warning signs to determine the effectiveness of this protocol. METHODS: Questions related to the ESID warning signs for adult PID were added to the standard outpatient clinic file system and asked of 3,510 patients who were admitted to our clinic for any reason. Patients with signs and/or suspicion of PID based on their medical history underwent immunologic investigation. RESULTS: In total, 24 patients were diagnosed as having a PID. The most common reason that patients with PID were admitted was frequent infection (n=18 [75%]), and the most common PID subgroup was common variable immunodeficiency (n=12 [50%]). Twenty patients with PID had at least one positive finding according to the ESID warning signs. Two patients with gastrointestinal concerns and 2 with dermatologic symptoms were also diagnosed as having a PID, although they did not have any of the ESID warning signs. CONCLUSION: The ESID warning signs do not specify the need for symptoms to diagnose a PIDs and do not include a comprehensive list of all signs and symptoms of PIDs. As a result, more than infection-centric questions are needed to identify adult patients with immunodeficiencies.

Magnetic Resonance Imaging May Be a Valuable Radiation-Free Technique for Lung Pathologies in Patients with Primary Immunodeficiency.

PURPOSE: In some primary immunodeficiency (PID) patients, especially in the subgroup with common variable immunodeficiency (CVID), radiosensitivity is a concern and avoidance of repeated radiation exposure has been recommended. To investigate the use of lung Magnetic resonance imaging (MRI) instead of Computed Tomography (CT) for the diagnosis and follow-up of various lesions in the lung parenchyma and airways, especially in PID patients in whom x-ray exposure should be limited. METHODS: The study enrolled 23 patients with PID who underwent thorax CT within the last 3 months and/or who will undergo initial radiological assessment. Lung MRI was performed in all patients to compare the pulmonary findings with CT images. RESULTS: MRI performance was weaker at detecting bronchiectasis extension, and a low concordance was found between MRI and CT in the assessment of the number of bronchial generations. CT better identified peripheral airway abnormalities, while CT and MRI gave similar results for detecting the presence and extension of consolidation, bullae, mucus plugging, bronchial wall thickening, bronchiectasis severity and nodules. CONCLUSIONS: Despite the low spatial resolution, higher cost, and low availability, we suggest MRI as a possible radiation-free alternative to CT in selected patients with PID.

Accelerated atherosclerosis in patients with common variable immunodeficiency: Is it overlooked or absent?

Common variable immunodeficiency (CVID) is a heterogeneous primary deficiency characterized by hypogammaglobulinemia, recurrent infections, and an increased risk of autoimmune disease and malignancy, and so chronic inflammation. Cardiovascular disease is the leading cause of mortality in the general population. Recent studies have suggested that chronic inflammation is an important player in the pathogenesis of CVID. Accelerated atherosclerosis due to ongoing inflammation from recurrent infections and autoimmunity is an expected clinical entity in patients with CVID. However, cardiovascular mortality as a cause of death in CVID series is either absent or minor. We hypothesized that accelerated atherosclerosis and cardiovascular disease are overlooked by clinicians, or atherosclerosis is really lower than that in the general population that may be prevented by some factors such as life-long immunoglobulin replacement treatment.

Current Status of Five Different Regimens for Empiric First-Line Helicobacter pylori Eradication in Turkey.

BACKGROUND/AIMS: This study aimed at comparing the efficacy and tolerability of 5 different regimens for Helicobacter pylori eradication in recent years. METHODS: H. pylori-positive patients with dyspeptic symptoms were included and separated into 5 groups. The 'PAC group' was given pantoprazole, amoxicillin and clarithromycin for 14 days. The 'PAM group' was given pantoprazole, amoxicillin and metronidazole for 14 days. The 'bismuth-containing group' was given pantoprazole, bismuth subsalicylate, tetracycline and metronidazole for 14 days. The 'sequential group' was given pantoprazole and amoxicillin for 5 days, followed by pantoprazole, tetracycline, and metronidazole for the next 5 days. The 'concomitant group' was given pantoprazole, amoxicillin, tetracycline, and metronidazole for 10 days. Eradication was assessed through the urea breath test on 6 weeks after eradication therapy. RESULTS: The eradication rate of intention-to-treat/per protocol were 42/48.3% in the PAC group, 52/54.2% in the PAM group, 62/77.5% in the bismuth group, 71/80.7% in the sequential group and 72/83.7% in concomitant group. The frequency of mild and moderate side effects was similar between groups. CONCLUSION: The concomitant and sequential therapies are an effective treatment for H. pylori. Bismuth-containing therapy is superior to conventional triple therapies; however, the eradication rate is not satisfactory. In our country, conventional triple therapies are not effective for eradication.

Common variable immunodeficiency and pulmonary amyloidosis: a case report.

Common variable immunodeficiency is the most common symptomatic primary immune deficiency characterized by hypogammaglobulinemia, recurrent infections, and increased risk of autoimmune disease and malignancy. Secondary amyloidosis develops from chronic inflammatory conditions. The co-existence of CVID (especially in patients with bronchiectasis) and secondary amyloidosis has been reported rarely. We describe the first case of pulmonary hypertension secondary to pulmonary amyloidosis in a patient with CVID.

Contact dermatitis to cobalt chloride with an unusual mechanism.

BACKGROUND: Contact dermatitis is a frequent inflammatory skin disease. A suspected diagnosis is based on clinical symptoms, a plausible contact to allergens and a suitable history of dermatitis. Therefore, careful diagnosis by patch testing is of great importance because the patch testing is important to find out which allergen/material causes the complaints. Metallic allergens such as cobalt are among the most common causes of allergic contact dermatitis, but frequencies of contact dermatitis to these allergens may vary in different skin areas. Here, we report an unusual case of cobalt allergy on the skin contact with the prosthetic leg of a 30-year-old female patient. CASE DESCRIPTION AND METHODS: The patient developed maculopapular and vesicular lesions on her contact region of residual limb to prosthetic leg. FINDINGS AND OUTCOME: She underwent standard patch testing, which resulted in a strong positive reaction to cobalt chloride. CONCLUSION: This case report may serve to remind doctors to be aware of potential allergic reactions to prostheses and to enable them to recognize a metal allergy if it appears. Prosthetists should also be reminded of potential allergic reactions. CLINICAL RELEVANCE: Cobalt can be used as an accelerator in making a prosthetic socket. Several cases have been reported concerning allergies to components of the prosthetic socket. This is the first report of sensitization to cobalt which is used in making a prosthetic leg.

External hemorrhage from a portacaval anastomosis in a patient with liver cirrhosis.

Variceal bleeding is the major complication of portal hypertension in patients with liver cirrhosis. Hemorrhage mainly occurs in gastrointestinal lumen. Extraluminal hemorrhages are quite rare, such as intraperitoneal hemorrhages. We aimed to present a variceal bleeding case from the anastomosis on the anterior abdominal wall, as an extraordinary bleeding location, in a patient with portal hypertension in whom there were no esophageal and gastric varices.

A Cases of Near-fatal Anaphylaxis: Parsley "Over-use" as an Herbal Remedy.

The use of herbal products in patients with allergic diseases is a special problem and still controversial. But, many people often use herbs to maintain good health. The patients use self-prescribed remedies as medications but do not inform their physicians about herbal use. Unfortunately, some herbal self-medications may have unexpected effects and interactions which may lead to fatal complications. In this report, we describe a female patient who suffered near-fatal anaphylaxis to parsley.

Familial Mediterranean Fever.

Familial Mediterranean Fever is an autosomal recessive inherited disease with a course of autoinflammation, which is characterized by the episodes of fever and serositis. It affects the populations from Mediterranean basin. Genetic mutation of the disease is on MEFV gene located on short arm of Chromosome 16. The disease is diagnosed based on clinical evaluation. Amyloidosis is the most important complication. The only agent that decreases the development of amyloidosis and the frequency and severity of the episodes is colchicine, which has been used for about 40 years. In this review, we aimed to discuss especially the most recent advances about Familial Mediterranean Fever which is commonly seen in our population.

Thrombotic thrombocytopenic purpura secondary to ABO group incompatible blood transfusion in a patient after cardiac surgery.

The triggers of secondary thrombotic thrombopcytopenic purpura (TTP) include drug toxicity, radiation and high-dose chemotherapy, angioinvasive infections, surgery and acute graft versus host disease. TTP secondary to surgery have been reported in a number of cases. Most of the cases have been occurred after open heart surgery. Extensive endothelial damage is held responsible as the initiating mechanism in postoperative TTP cases. However, there is no report of secondary TTP describing development owing to ABO incompatible blood transfusion. Here, we describe a patient who developed TTP after transfusion of ABO incompatible blood during hospitalization for bypass surgery. We also propose a hypothesis which may account for the possible underlying mechanism.

Alström syndrome with liver cirrhosis: first case from Turkey.

Alström syndrome is a rare autosomal recessive genetic disorder characterized by cone-rod dystrophy, hearing loss, childhood truncal obesity, insulin resistance and hyperinsulinemia, type 2 diabetes, hypertriglyceridemia, short stature in adulthood, cardiomyopathy, and progressive pulmonary, hepatic, and renal dysfunction. Alström syndrome is a very rare cause of liver cirrhosis. Postmortem biopsies of patients with Alström syndrome show relevant fibrosis in multiple organs especially in the liver, kidneys, heart, and lungs. We report the case of a patient with Alström syndrome who presented to emergency department with esophageal variceal bleeding and who was not known to have hepatic cirrhosis before.