Identifying and verifying causes of death in Turkey: National verbal autopsy survey.

OBJECTIVES: The aim of this study was to identify the national, rural, and urban mortality rates, and to define the medical causes of death for the 0-28 days and 29 days-5 years age groups, as well as adult mortality in Turkey. STUDY DESIGN: A cross-sectional survey, which identified the causes of death using the verbal autopsy(VA) method, and a methodological study, which determined the validity of the verbal autopsy method was used in conjunction with each other. METHODS: The verbal autopsy method, based on a representative sampling according to age and gender in Turkey, was used. A methodological study was additionally used, which determined the validity of the VA method. RESULTS: The crude death rate calculated from the VA survey was 0.51% with rates of 0.60% in males, 0.42% in females, 0.48% in urban areas, and 0.56% in rural areas. Life expectancy at birth was 72.6 years for males and 77.2 years for females. The mean life expectancy at birth for both sexes together was 74.8 years. The VA form has a high degree of validity although no study or form can take the place of a records-based surveillance system with accurate information; the VA form is a useful tool for collecting data during certain periods or specific areas. However, healthcare providers must work towards establishing a well-designed, routine surveillance system in the long term. CONCLUSIONS: The mortality rates and life expectancies were consistent with other similar studies in the country and the Turkish VA method may be safely used to determine causes of death in countries with inadequate record and registry systems.

Radioimmunoassay for colchicine in plasma and urine.

A radioimmunoassay for the measurement of colchicine (in quantities as small as 0.05 nanogram) in plasma and urine was developed with the use of an antibody from immunized rabbits. After the intravenous injection of 2 milligrams of colchicine in seven subjects, the calculated zero-time concentration in the plasma was 2.9 +/- 1.5 micrograms per deciliter, and the mean half-time in the plasma was 58 +/- 20 minutes. Declining, but measurable, amounts of colchicine could be detected in urine up to day 9 after the drug was administered.

Median sternotomy for an unexpected complication of permanent hemodialysis catheters: "stuck catheter".

Cuffed tunneled venous access catheters are commonly used for temporary and permanent access in patients undergoing hemodialysis. These catheters play an essential role in providing permanent access in patients in whom all other access options have been exhausted. However, they are prone to several complications like catheter thrombosis, catheter fibrin sheating and infection. Herein, we report two uncommon cases of stuck hemodialysis cuffed tunneled catheters causing stenosis and thrombosis in central veins which needed to be removed by median sternotomy.

Hyperparathyroidism and coexisting diabetes mellitus. Altered carbohydrate metabolism.

Hyperparathyroidism was diagnosed in a 67-year-old diabetic man treated for 20 years with isophane insulin suspension, 40 to 45 units/day. It was also diagnosed in a 64-year-old diabetic with severe retinopathy and vascular disease, who was not dependent on insulin. In the first case, removal of a parathyroid adenoma resulted in frequent hypoglycemic attacks, which led to a reduction of the administration of insulin isophane suspension to 20 units/day. In the second case, there was a notable improvement in the glucose tolerance testing that followed surgery, accompanied by a decrease in total plasma insulin response from 17,838 to 5,605 units, by planimetry. These observations suggest that hyperparathyroidism worsens coexisting diabetes mellitus and that one must be aware of increased insulin sensitivity and the possibility of severe hypoglycemia in cases that require insulin after surgical correction of the hypercalcemic state.

A comparison of carbohydrate metabolism after sucrose, sorbitol, and fructose meals in normal and diabetic subjects.

Sucrose, sorbitol, and fructose (35 g) were fed to normal and diabetic subjects as a component of a 400-calorie breakfast. In both normal and diabetic subjects, the mean peak increment in plasma glucose was highest after the sucrose meals (44.0 mg/dl for normal subjects; 78.0 mg/dl for diabetic subjects); lowest after sorbitol meals (9.3 mg/dl for normal subjects; 32.3 mg/dl for diabetic subjects); and intermediate after the fructose meals (29.0 mg/dl for normal subjects; 48.0 mg/dl for diabetic subjects). In normal subjects, the mean peak increment of plasma immunoreactive insulin followed a similar pattern, but in diabetic subjects there was no significant difference between the three groups. We conclude that fructose or sorbitol, given as part of a meal, results in lower glucose levels in both normal and diabetic subjects, but that the latter is not related to a difference in insulin release.

The effects of sucrose, fructose, and high-fructose corn syrup meals on plasma glucose and insulin in non-insulin-dependent diabetic subjects.

We have previously shown that fructose and sorbitol given with a standard meal cause less increment in plasma glucose than sucrose and high fructose corn syrup (HFCS) in patients with NIDDM. However, there was no direct comparison of sucrose with HFCS. Sixteen men and one woman aged 54-67) with NIDDM were given either 35 g sucrose, 35 g fructose, or 43.75 g HFCS containing 35 g carbohydrate as part of a 400-calorie test meal. Blood samples were obtained at frequent intervals up to 3 h and were analyzed for glucose and insulin. As compared with a fructose meal, the mean increment in plasma glucose (delta PG) after a sucrose meal was significantly higher at 45 min and after an HFCS meal it was significantly higher at 30 and 45 min, but sucrose and HFCS meals did not differ. When delta PGs were compared in nine patients with basal PG greater than 140 mg/dl and in eight patients with basal PG less than 140 mg/dl, differences in delta PG after sucrose and HFCS versus fructose meals became more significant but still did not differ from each other. The integrated total areas under the delta PG curves after sucrose, HFCS, and fructose meals were not statistically different. However, the areas under the curves up to 90 min after sucrose and HFCS meals, which did not differ, were greater than the fructose meal. The mean delta IRI after sucrose meals was markedly elevated at 45, 60, and 75 min (P less than 0.05) and after HFCS meals at 45 min as compared with fructose meals.(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma glucose and insulin after fructose an high-fructose corn syrup meals in subjects with non-insulin-dependent diabetes mellitus.

The impact on plasma glucose of 35 g of fructose or an equicaloric amount (43.75 g) of high-fructose corn syrup (HFCS) (as part of a 400-calorie meal) was measured in six patients with non-insulin-dependent diabetes mellitus (NIDDM). Blood samples were collected periodically at all points for all patients for 3 h for plasma glucose (PG) and insulin (IRI) determinations. The mean peak PG increment was higher after the HFCS meal (66.5 mg/dl) than after the fructose meals (45.5 mg/dl). When increase in the mean plasma glucose concentration (delta PG) after the fructose meals were compared with the delta PG after the HFCS meals, there was statistical significance at 15 min (P less than 0.02) and 30 min (P less than 0.05). The total areas under the 3-h curves of mean delta PG showed a highly significant (P less than 0.001) difference between the fructose meal (5601 planimetry U) compared with the HFCS meal (8023 planimetry U). Mean changes in IRI after meals with either sweetener were comparable. These findings suggest that fructose is superior to HFCS as a sweetening agent in patients with NIDDM.

The identification of 5 alpha-reductase-2 and 17 beta-hydroxysteroid dehydrogenase-3 gene defects in male pseudohermaphrodites from a Turkish kindred.

Male pseudohermaphroditism (MPH) is characterized by incomplete differentiation of male genitalia in the presence of testicular tissue. Enzymatic defects involving androgen synthesis or action are causes of MPH. We studied the molecular genetics of a large isolated inbred Turkish kindred with MPH due to either 5 alpha-reductase-2 (SRD5A2) or 17 beta-hydroxysteroid dehydrogenase-3 (17 beta HSD3) gene defects. Using single strand DNA conformational polymorphism analysis and DNA sequencing, a new mutation in exon 5 of SRD5A2 gene was detected in certain male pseudohermaphrodites from this kindred. This single base deletion (adenine) resulted in a frame shift at amino acid position 251 resulting in the addition of 23 amino acids at the carboxyl-terminal of this 254-amino acid isozyme. Transfection expression of the mutant isozyme in CV1 cells showed a complete loss of enzymatic activity in the conversion of [14C]testosterone to dihydrotestosterone, without a change in the messenger ribonucleic acid level compared to that of the wild-type isozyme. Analysis of the 17 beta HSD3 gene in other male pseudohermaphrodites from this kindred revealed a single point mutation (G-->A) at the boundary between intron 8 and exon 9, disrupting the splice acceptor site of exon 9. In this kindred, in addition to the identification of male pseudohermaphrodites with either a homozygous SRD5A2 or 17 beta HSD3 gene defect, other male pseudohermaphrodites were found to be genetically more complex: e.g. homozygous for the SRD5A2 defect and heterozygous for the 17 beta HSD3 defect, or homozygous for the 17 beta HSD3 defect and heterozygous for the SRD5A2 defect. Also, phenotypically normal carriers were identified with either one or both gene defects. Homozygous male pseudohermaphrodites with SRD5A2 or 17 beta HSD3 gene defects were phenotypically distinguishable by the presence of mild gynecomastia in the latter. Hormone data were consistent with the particular homozygous gene defect. In summary, we show 1) the novel existence of two gene defects, SRD5A2 and 17 beta HSD3, each causing MPH within a large isolated Turkish kindred; 2) that the two defects segregate independently and may be inherited from two different progenitors; and 3) analysis of a new mutation in exon 5 of SRD5A2 gene, supporting the functional importance of the carboxyl-terminal of 5 alpha-reductase-2 isozyme.

Familial male pseudohermaphroditism due to 5-alpha-reductase deficiency in a Turkish village.

Twelve persons with sexual ambiguity were identified in an isolated village in southern Turkey. Eleven were examined and had pseudovaginal perineoscrotal hypospadias; eight were studied. Serum and urine samples from five affected males and urine samples from three affected children were analyzed. Urine samples from another 26 villagers, mostly parents and siblings, were also analyzed. In all but one of the affected adult subjects, serum testosterone levels were either normal or increased, and in all adults, the dihydrotestosterone levels were low (8 to 20 ng/dl) and the testosterone/dihydrotestosterone ratios were elevated (to 36 or more); the levels of 4-androstenedione were normal. Thirty-four urine samples were analyzed for etiocholanolone/androsterone, 11-beta-hydroxyetiocholanolone/11-beta-hydroxyandrosterone, tetrahydrocorticosterone/5-alpha-tetrahydrocorticosterone and tetrahydrocortisol/5-alpha-tetrahydrocortisol ratios. In affected persons, all 5-beta/5-alpha urinary C19 and C21 steroid metabolite ratios measured were elevated. These findings are compatible with the diagnosis of male pseudohermaphroditism due to 5-alpha-reductase deficiency. In parents and some of the siblings of the affected subjects, the 5-beta/5-alpha urinary ratios were between affected and normal levels. The intermediate 5-beta/5-alpha ratios of the parents who were phenotypically normal, together with documented consanguinity, confirm an autosomal recessive mode of inheritance and are useful in identification of the carrier state. The urinary tetrahydrocortisol/5-alpha-tetrahydrocortisol ratios provided the highest index of discrimination between homozygotes (mean +/- SD, adults: 35.80 +/- 20.10; children: 15.48 +/- 7.91), heterozygotes (parents: 4.56 +/- 1.61; siblings and other relatives: 5.97 +/- 3.68), and normal subjects (1.07 +/- 0.36). Thus, this study identified a second community with inherited male pseudohermaphroditism due to 5-alpha-reductase deficiency, confirming the autosomal recessive inheritance of this condition and the generalized abnormality in both C19 and C21 steroid 5-alpha metabolism.

Decreased 3 alpha-androstanediol glucuronide levels in plasma and random urines in male pseudohermaphroditism caused by 5 alpha-reductase deficiency.

Concentrations of 3 alpha-diol glucuronide (3 alpha-diol G) in plasma and/or random urine samples were determined in seven subjects with familial male pseudohermaphroditism (FMP) due to 5 alpha-reductase deficiency (5 alpha-RD). All subjects were natives of an isolated Turkish village with a high incidence of consanguineous marriage. A specific and sensitive antibody to 3 alpha-diol was used for radioimmunoassay of 3 alpha-diol G after hydrolysis and chromatographic purification. The mean plasma 3 alpha-diol G in three subjects (31 ng/dL) was much lower than the normal male concentration (516 +/- 50) (+/- SE) and was even lower than normal female values (119 +/- 10.9 ng/dL). In five subjects, mean urinary 3 alpha-diol G in random urine samples was 7.6 (range 2.1 to 12.7) ng/mg creatinine. This was considerably decreased compared with the mean adult male concentration of 65.4 +/- 9.4 and even lower than normal age-matched nonhirsute female values (19.6 +/- 2.1 ng/mg Cr). To validate the use of 3 alpha-diol G/creatinine ratios in random urine samples, correlations of three consecutive eight-hour samples with 24-hour values were determined in 8 male and 3 female age-matched controls. There was an excellent correlation (r = .95) and the linear regression line (y = 0.51x + 2.58) indicates that the 24-hour excretion of 3 alpha-diol G in microgram/24 h is approximately twice the random urinary concentration in ng/mg Cr.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiovascular mortality patterns in Turkey: what is the evidence?

In Turkey, reliable cause-specific mortality data are not available. It is thus unknown whether ischaemic heart disease (as in western Europe and the US) or stroke (as in the Far East) is the prevailing cause of cardiovascular death. This information, however, is required for planning cardiovascular prevention programmes. We analyse available Turkish national cause-of-death data as well as patterns of cardiovascular mortality in a hospital in Ankara and among Turkish migrants in Germany. According to national statistics, the ischaemic heart disease-to-stroke ratio would be 0.3 among men aged 45-64 years, lower than that in Japan. Hospital and migrant data show this ratio to be 2-4. We demonstrate the implausibility of the national data by assessing the precision of cause-of-death assignment. We then discuss to what degree mortality experience among migrants is representative for their country of origin. Our findings suggest that the pattern of cardiovascular mortality in Turkey is closer to that in western Europe and the US than to that in the Far East. Finally, we discuss options for improving cardiovascular surveillance in Turkey.

Evaluation of two different hand hygiene procedures during routine patient care.

In this study, the antimicrobial efficacy of hand washing (HW) and hand washing plus rubbing with an alcohol-based solution (HWR) on numbers of total and transient flora colonies on the hands of healthcare workers (HCWs) during routine patient care was assessed. Samples were collected, using a standard bag broth technique, from the hands of 154 HCWs, before and immediately after carrying out a hand hygiene procedure. The numbers of total and transient flora colonies per plate were counted and transient pathogens were identified. A significant statistical difference between ward speciality was detected with respect to the isolation rate of transient flora. Transient hand flora were recovered from 25.3% of HCWs before carrying out the hand hygiene procedure. With respect to the disappearance and prevention of regrowth of transient flora after hand hygiene, the HWR technique was significantly more effective than HW. In conclusion, a disinfectant should be added to the hand washing process to achieve optimum protection against nosocomial infections in routine hospital practice.