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Objectives: Diabetes self-management educational (DSME) interventions can vary considerably, and it is unclear what is the operational conceptualization of the ideal delivery to individuals with type 2 diabetes (T2D). Design: From a search conducted concurrently we extracted and evaluated the 50 most recently published DSME intervention studies. Based on an analysis of these studies, we undertook a concept analysis using the Walker and Avant framework. Results: Five attributes describing the concept were recognized and organized into two groups. Group (a): skills related attributes that included (1) decision making, (2) problem solving and (3) taking action. Group (b): information related attributes that included (4) patient-provider interaction and (5) resource utilization. Conclusions: The outcomes of this study make the operational conceptualization of the ideal DSME intervention measurable through its attributes and hence clarifies its delivery. This will improve the implementation of the key attributes in diabetes self-management intervention programs for T2D. The authors thank the Division of Endocrinology, Hamad General Hospital, for support provided during the conduct of this work. Scopus

Background\ud \ud This Commission addresses several priority areas for psychiatry over the next decade, and into the 21st century. These represent challenges and opportunities for the profession to sustain and develop itself to secure the best possible future for the millions of people worldwide who will face life with mental illness.\ud \ud \ud Part 1: The patient and treatment\ud \ud Who will psychiatrists help? The patient population of the future will reflect general demographic shifts towards older, more urban, and migrant populations. While technical advances such as the development of biomarkers will potentially alter diagnosis and treatment, and digital technology will facilitate assessment of remote populations, the human elements of practice such as cultural sensitivity and the ability to form a strong therapeutic alliance with the patient will remain central.\ud \ud \ud Part 2: Psychiatry and health-care systems\ud \ud Delivering mental health services to those who need them will require reform of the traditional structure of services. Few existing models have evidence of clinical effectiveness and acceptability to service users. Services of the future should consider stepped care, increased use of multidisciplinary teamwork, more of a public health approach, and the integration of mental and physical health care. These services will need to fit into the cultural and economic framework of a diverse range of settings in high-income, low-income, and middle-income countries.\ud \ud \ud Part 3: Psychiatry and society\ud \ud Increased emphasis on social interventions and engagement with societal expectations might be an important area for psychiatry's development. This could encompass advocacy for the rights of individuals living with mental illnesses, political involvement concerning the social risk factors for mental illness, and, on a smaller scale, work with families and local social networks and communities. Psychiatrists should therefore possess communication skills and knowledge of the social sciences as well as the basic biological sciences.\ud \ud \ud Part 4: The future of mental health law\ud \ud Mental health law worldwide tends to be based on concerns about risk rather than the protection of the rights of individuals experiencing mental illness. The United Nations Convention on the Rights of Persons with Disabilities, which states that compulsion based in whole or in part on mental disability is discriminatory, is a landmark document that should inform the future formulation and reform of mental health laws. An evidence-based approach needs to be taken: mental health legislation should mandate mental health training for all health professionals; ensure access to good-quality care; and cover wider societal issues, particularly access to housing, resources, and employment. All governments should include a mental health impact assessment when drafting relevant legislation.\ud \ud \ud Part 5: Digital psychiatry—enhancing the future of mental health\ud \ud Digital technology might offer psychiatry the potential for radical change in terms of service delivery and the development of new treatments. However, it also carries the risk of commercialised, unproven treatments entering the medical marketplace with detrimental effect. Novel research methods, transparency standards, clinical evidence, and care delivery models must be created in collaboration with a wide range of stakeholders. Psychiatrists need to remain up to date and educated in the evolving digital world.\ud \ud \ud Part 6: Training the psychiatrist of the future\ud \ud Rapid scientific advance and evolving models of health-care delivery have broad implications for future psychiatry training. The psychiatrist of the future must not only be armed with the latest medical knowledge and clinical skills but also be prepared to adapt to a changing landscape. Training programmes in an age in which knowledge of facts is less important than how new knowledge is accessed and deployed must refocus from the simple delivery of information towards acquisition of skills in lifelong learning and quality improvement.\ud \ud \ud Conclusion\ud \ud Psychiatry faces major challenges. The therapeutic relationship remains paramount, and psychiatrists will need to acquire the necessary communication skills and cultural awareness to work optimally as patient demographics change. Psychiatrists must work with key stakeholders, including policy makers and patients, to help to plan and deliver the best services possible. The contract between psychiatry and society needs to be reviewed and renegotiated on a regular basis. Mental health law should be reformed on the basis of evidence and the rights of the individual. Psychiatry should embrace the possibilities offered by digital technology, and take an active role in ensuring research and care delivery in this area is ethically sound and evidence based. Psychiatry training must reflect these multiple pressures and demands by focusing on lifelong learning rather than simply knowledge delivery.

Aim: Violence in health is an important public health problem that threatens community peace. In our study, it was aimed to examine the state of exposure to violence among employees in our clinic in the last one year and our employees’ opinions and attitudes about violence. Material and Methods: The study was performed cross-sectionally. In this study the Violent Incident Form developed by Arnetz (1998) was used as a data collection tool. Results: A total of 182 healthcare workers were included in the study. Of the participants, 14 (7.7%) were faculty members, 37 (20.3%) were physicians, 24 (13.2%) were interns, 70 (38.5%) were nurses, 10 (5.5%) were medical secretaries, and 27 (14.8%) were ancillary health personnel. The female/male ratio was 143/39. Seventy-nine (43.4%) of the employees had been exposed to violence at least once in the last year. Of those experiencing violence, 57 (72%) were female, 28 (35%) were nurses, 21 (27%) were residents, 16 (20%) were interns, five (6.5%) were faculty members, five (6.5%) were allied health personnel, and four (5%) were medical secretaries. Physicians were exposed to violence with a higher rate (p

Introduction Musculoskeletal system traumas are among the most common presentations in the emergency departments. In the treatment of traumatic musculoskeletal pain, paracetamol and non-steroidal anti-inflammatory analgesics (NSAID) are frequently used. Our aim in this study is to compare the efficacy of intravenous dexketoprofen and paracetamol in the treatment of traumatic musculoskeletal pain. Methods This prospective, randomised, double blind, controlled study was conducted in a tertiary care emergency unit. The participating patients were randomised into two groups to receive either 50 mg of dexketoprofen or 1000 mg of paracetamol intravenously by rapid infusion in 150 mL of normal saline. Visual analogue scale (VAS), Numeric Rating Scala (NRS) and Verbal Rating Scale (VRS) was employed for pain measurement at baseline, after 15, after 30 and after 60 mins. Results 200 patients were included in the final analysis. The median age of the paracetamol group was 34 (24–48), while that of the dexketoprofen group was 35 (23–50), and 63% (n = 126) of them consisted of men. Paracetamol and dexketoprofen administration reduced VAS pain scores over time (p = 0.0001). Median reduction in VAS score at 60 min was 55 (IQR 30–65) for the paracetamol group and 50(IQR 30.25–60) for the dexketoprofen group. There was no statistically significant difference between the paracetamol and dexketoprofen groups in terms of VAS reductions (p = 0.613). Conclusion Intravenous paracetamol and dexketoprofen seem to produce equivalent pain relief for acute musculoskeletal trauma in the emergency department. CLINICALTRIALS.GOV NO: NCT03428503

In October, 2018, the Ministry of Health of Peru approved the sectoral policy guidelines on mental health, which update those published 14 years ago. The five guidelines highlight the transitional framework of public mental health, from tertiary care (psychiatric hospitals) to secondary and primary care. They also call for the inclusion of mental health management in non-specialised centres and for the implementation of new community mental health centres across the country. The Ministry of Health took into account social determinants of health, human rights, and intercultural, intersectional, and territorial approaches for the development of these guidelines...

Background: Obesity is the main obstacle for metabolic control in patients with type 2 diabetes. Turkey has the highest prevalence of obesity and type 2 diabetes in Europe. The effect of obesity on the metabolic control, and the macro-and microvascular complications of patients are not apparent. Objectives: This nationwide survey aimed to investigate the prevalence of overweight and obesity among patients with type 2 diabetes and to search for the impact of obesity on the metabolic control of these patients. We also investigated the independent associates of obesity in patients with type 2 diabetes. Methods: We consecutively enrolled patients who were under follow-up for at least 1 year in 69 tertiary healthcare units in 37 cities. The demographic, anthropometric, and clinical data including medications were recorded. Patients were excluded if they were pregnant, younger than 18 years, had decompensated liver disease, psychiatric disorders interfering with cognition or compliance, had bariatric surgery, or were undergoing renal replacement therapy. Results: Only 10% of patients with type 2 diabetes (n = 4,648) had normal body mass indexes (BMI), while the others were affected by overweight (31%) or obesity (59%). Women had a significantly higher prevalence of obesity (53.4 vs. 40%) and severe obesity (16.6 vs. 3.3%). Significant associations were present between high BMI levels and lower education levels, intake of insulin, antihypertensives and statins, poor metabolic control, or the presence of microvascular complications. Age, gender, level of education, smoking, and physical inactivity were the independent associates of obesity in patients with type 2 diabetes. Conclusion: The TEMD Obesity Study shows that obesity is a major determinant of the poor metabolic control in patients with type 2 diabetes. These results underline the importance of prevention and management of obesity to improve health care in patients with type 2 diabetes. Also, the results point out the independent sociodemographic and clinical associates of obesity, which should be the prior targets to overcome, in the national fight with obesity. (c) 2019 The Author(s) Published by S. Karger AG, Basel, C1 [Sonmez, Alper; Haymana, Cem; Demirci, Ibrahim] Univ Hlth Sci, Gulhane Sch Med, Dept Endocrinol & Metab, TR-06018 Ankara, Turkey., [Yumuk, Volkan] Istanbul Univ, Cerrahpasa Med Fac, Dept Endocrinol & Metab, Istanbul, Turkey., [Barcin, Cem] Univ Hlth Sci, Gulhane Sch Med, Dept Cardiol, Ankara, Turkey., [Kiyici, Sinem] Univ Hlth Sci, Bursa Yuksek Ihtisas Training & Res Hosp, Dept Endocrinol & Metab, Bursa, Turkey., [Guldiken, Sibel] Trakya Univ, Med Fac, Dept Endocrinol & Metab, Edirne, Turkey., [Oruk, Gonca] Izmir Katip Celebi Univ, Ataturk Educ & Res Hosp, Dept Endocrinol & Metab, Izmir, Turkey., [Saydam, Basak Ozgen] Dokuz Eylul Univ, Med Fac, Dept Endocrinol & Metab, Izmir, Turkey., [Baldane, Suleyman] Selcuk Univ, Med Fac, Dept Endocrinol & Metab, Konya, Turkey., [Kutluturk, Faruk] Gaziosmanpasa Univ, Med Fac, Dept Endocrinol & Metab, Tokat, Turkey., [Kucukler, Ferit Kerim] Hitit Univ, Med Fac, Dept Endocrinol & Metab, Corum, Turkey., [Deyneli, Oguzhan] Marmara Univ, Med Fac, Dept Endocrinol & Metab, Istanbul, Turkey., [Cetinarslan, Berrin] Kocaeli Univ, Med Fac, Dept Endocrinol & Metab, Kocaeli, Turkey., [Sabuncu, Tevfik] Harran Univ, Med Fac, Dept Endocrinol & Metab, Urfa, Turkey., [Bayram, Fahri] Erciyes Univ, Med Fac, Dept Endocrinol & Metab, Kayseri, Turkey., [Satman, Ilhan] Istanbul Univ, Med Fac, Dept Endocrinol & Metab, Istanbul, Turkey., [Ayturk, Semra] Trakya Univ, Sch Med, Dept Endocrinol & Metab, Edirne, Turkey., [Yilmaz, Murat] Corlu REYAP Private Hosp, Dept Endocrinol & Metab, Corlu, Turkey., [Asik, Mehmet] Canakkale 18 March Univ, Sch Med, Dept Endocrinol & Metab, Canakkale, Turkey., [Dinccag, Nevin; Cakmak, Ramazan; Turker, Fulya; Idiz, Cemile; Hacisahinogullari, Hulya; Bagdemir, Elif; Yildiz, Busra; Haliloglu, Ozlem] Istanbul Univ, Sch Med, Dept Endocrinol & Metab, Cerrahpasa, Turkey., [Sancak, Seda] Univ Hlth Sci, Sch Med, Fatih Sultan Mehmet Training & Res Hosp, Dept Endocrinol & Metab, Istanbul, Turkey., [Ozsari, Levent; Cagiltay, Eylem] Univ Hlth Sci, Sch Med, Sultanabdulhamit Training & Res Hosp, Dept Endocrinol & Metab, Istanbul, Turkey., [Imre, Eren] Marmara Univ, Sch Med, Dept Endocrinol & Metab, Istanbul, Turkey., [Sait Gonen; Boysan, S. Nur] Istanbul Sci Univ, Sch Med, Dept Endocrinol & Metab, Istanbul, Turkey., [Altuntas, Yuksel; Ozturk, Feyza Yener] Univ Hlth Sci, Sch Med, Sisli Hamidiye Etfal Training & Res Hosp, Dept Endocrinol & Metab, Istanbul, Turkey., [Mert, Meral; Piskinpasa, Hamide] Univ Hlth Sci, Istanbul Bakirkoy Dr Sadi Konuk Training & Res Ho, Sch Med, Dept Endocrinol & Metab, Istanbul, Turkey., [Aydin, Hasan] Yeditepe Univ, Sch Med, Dept Endocrinol & Metab, Istanbul, Turkey., [Ersoy, Canan; Oz Gul, Ozen] Uludag Univ, Sch Med, Dept Endocrinol & Metab, Bursa, Turkey., [Selek, Alev] Kocaeli Univ, Sch Med, Dept Endocrinol & Metab, Kocaeli, Turkey., [Dogru, Teoman; Kirik, Ali] Balikesir Univ, Sch Med, Dept Internal Med, Balikesir, Turkey., [Kebapci, Nur; Efe, Belgin] Eskisehir Osmangazi Univ, Sch Med, Dept Endocrinol & Metab, Odunpazari Eskisehir, Turkey., [Kaya, Ahmet; Cordan, Ilker] Necmettin Erbakan Univ, Sch Med, Dept Endocrinol & Metab, Konya, Turkey., [Kirac, Cem Onur] Selcuk Univ, Sch Med, Dept Endocrinol & Metab, Konya, Turkey., [Capa, Zehra] Univ Hlth Sci, Gulhane Sch Med, Ankara, Turkey., [Capa, Zehra] Gulhane Training & Res Hosp, Dept Endocrinol & Metab, Ankara, Turkey., [Cesur, Mustafa] Private Guven Hosp, Dept Endocrinol & Metab, Ankara, Turkey., [Yetkin, Ilhan] Gazi Univ, Sch Med, Dept Endocrinol & Metab, Ankara, Turkey., [Corapcioglu, Demet; Canlar, Sule] Ankara Univ, Sch Med, Dept Endocrinol & Metab, Ankara, Turkey., [Yildiz, Okan Bulent; Sendur, Suleyman Nahit] Hacettepe Univ, Sch Med, Dept Endocrinol & Metab, Ankara, Turkey., [Cakir, Bekir; Ozdemir, Didem] Yildirim Beyazit Univ, Sch Med, Dept Endocrinol & Metab, Ankara, Turkey., [Corakci, Ahmet] Ufuk Univ, Sch Med, Dept Endocrinol & Metab, Ankara, Turkey., [Kutlu, Mustafa] Private Bayindir Hosp, Dept Endocrinol & Metab, Ankara, Turkey., [Bascil Tutuncu, Neslihan; Bozkus, Yusuf] Baskent Univ, Sch Med, Dept Endocrinol & Metab, Ankara, Turkey., [Cakal, Erman] Univ Hlth Sci, Sch Med, Diskapi Yildirim Beyazit Training & Res Hosp, Dept Endocrinol & Metab, Ankara, Turkey., [Demirbas, Berrin] TOBB Univ, Sch Med, Dept Endocrinol & Metab, Ankara, Turkey., [Ertek, Sibel] Private Mem Hosp, Dept Endocrinol & Metab, Ankara, Turkey., [Altay, Mustafa; Dagdeviren, Murat] Univ Hlth Sci, Sch Med, Kecioren Training & Res Hosp, Dept Endocrinol & Metab, Ankara, Turkey., [Abedi, Amir Hassein] Erciyes Univ, Sch Med, Dept Endocrinol & Metab, Kayseri, Turkey., [Cetinkalp, Sevki; Ozisik, Hatice] Ege Univ, Sch Med, Dept Endocrinol & Metab, Izmir, Turkey., [Yener, Serkan] Dokuz Eylul Univ, Sch Med, Dept Endocrinol & Metab, Izmir, Turkey., [Guney, Engin; Unubol, Mustafa] Adnan Menderes Univ, Sch Med, Dept Endocrinol & Metab, Aydin, Turkey., [Yaylali, Guzin Fidan; Topsakal, Senay] Pamukkale Univ, Sch Med, Dept Endocrinol & Metab, Denizli, Turkey., [Hekimsoy, Zeliha] Celal Bayar Univ, Sch Med, Dept Endocrinol & Metab, Manisa, Turkey., [Akbaba, Gulhan] Mugla Univ, Sch Med, Dept Endocrinol & Metab, Mugla, Turkey., [Aslan, Ibrahim] Univ Hlth Sci, Antalya Training & Res Hosp, Sch Med, Dept Endocrinol & Metab, Antalya, Turkey., [Balci, Mustafa Kemal; Dalkiran, Sefika] Akdeniz Univ, Sch Med, Dept Endocrinol & Metab, Antalya, Turkey., [Akbay, Esen] Mersin Univ, Sch Med, Dept Endocrinol & Metab, Mersin, Turkey., [Gul, Kamile] Kahramanmaras Sutcu Imam Univ, Sch Med, Dept Endocrinol & Metab, Kahramanmaras, Turkey., [Agbaht, Kemal] Private Defne Hosp, Dept Endocrinol & Metab, Antalya, Turkey., [Yilmaz, Muge Ozsan] Mustafa Kemal Univ, Sch Med, Dept Endocrinol & Metab, Antakya, Turkey., [Bozkirli, Emre] Baskent Univ, Adana Training Hosp, Dept Endocrinol & Metab, Ankara, Turkey., [Tetiker, B. Tamer; Cetinkaya Altuntas, Seher] Cukurova Univ, Sch Med, Dept Endocrinol & Metab, Adana, Turkey., [Atmaca, Aysegul; Durmus, Elif Tutku] 19 Mayis Univ, Sch Med, Dept Endocrinol & Metab, Samsun, Turkey., [Mete, Turkan] Univ Hlth Sci, Sch Med, Samsun Training & Res Hosp, Dept Endocrinol & Metab, Samsun, Turkey., [Dikbas, Oguz] Giresun Univ, Sch Med, Dept Endocrinol & Metab, Giresun, Turkey., [Akin, Safak] Recep Tayyip Erdogan Univ, Sch Med, Dept Endocrinol & Metab, Rize, Turkey., [Nuhoglu, Irfan; Ersoz, Halil Onder] Karadeniz Tech Univ, Sch Med, Dept Endocrinol & Metab, Trabzon, Turkey., [Bayraktaroglu, Taner] Bulent Ecevit Univ, Sch Med, Dept Endocrinol & Metab, Zonguldak, Turkey., [Sisman, Pinar] Kars Harakani State Hosp, Dept Endocrinol & Metab, Kars, Turkey., [Sahin, Ibrahim; Cetin, Sedat] Inonu Univ, Sch Med, Dept Endocrinol & Metab, Malatya, Turkey., [Capoglu, Ilyas; Akbas, Emin Murat] Erzincan Univ, Sch Med, Dept Endocrinol & Metab, Erzincan, Turkey., [Ucler, Rifki] Yuzuncu Yil Univ, Sch Med, Dept Endocrinol & Metab, Van, Turkey., [Eren, Mehmet Ali] Harran Univ, Sch Med, Dept Endocrinol & Metab, Sanliurfa, Turkey., [Tuzcu, Alpaslan Kemal; Pekkolay, Zafer] Dicle Univ, Sch Med, Dept Endocrinol & Metab, Diyarbakir, Turkey., [Ozkaya, Mesut] Univ Hlth Sci, Sch Med, Gaziantep Ersin Arslan Res & Training Hosp, Gaziantep, Turkey., [Araz, Mustafa] Gaziantep Univ, Sch Med, Dept Endocrinol & Metab, Gaziantep, Turkey., [Salman, Serpil] Liv Hosp Ulus, Dept Endocrinol & Metab, Istanbul, Turkey., [Dizdar, Oguzhan Sitki] Kayseri Educ & Res Hosp, Dept Internal Med, Kayseri, Turkey., [Gurkan, Eren] Mustafa Kemal Univ, Dept Endocrinol & Metab, Antakya, Turkey., [Kargili Carlioglu, Ayse] Erzurum Reg Educ & Res Hosp, Dept Endocrinol & Metab, Erzurum, Turkey.

SUMMARYThe incidence of nosocomial candidaemia was evaluated in a retrospective study in a Turkish tertiary-care hospital. Over a 12-year period (1996–2007), a total of 743 episodes of candidaemia occurred in 743 patients, accounting for an average incidence of 1·9 episodes/1000 admissions and 2·9 episodes/10 000 patient-days per year. The annual incidence was almost constant during the study period except for 1996 when it was significantly higher in comparison with other years (PCandida albicans (45%), followed by C. parapsilosis (26%), C. tropicalis (7%), C. krusei (7%), and C. glabrata (3·5%). A significant increase in C. albicans isolates causing candidaemia linked to a decrease in C. parapsilosis isolates in adult patients and C. krusei isolates in children was found between the two 6-year study periods. This trend reflects improved infection control at Uludağ University Hospital. Ninety percent of isolates were susceptible to fluconazole (⩽8 μg/ml) and resistance was found only in C. glabrata and C. parapsilosis isolates. Regular local surveillance of Candida spp. is important in order to develop empirical treatment protocols to reduce the incidence and mortality of candidaemia.

SUMMARYWe analysed nosocomial MRSA cases between January 2004 and December 2006 in a retrospective case-control study in a 250-bed tertiary-care teaching hospital. During the study period, 265 nosocomial Staphylococcus aureus infections were identified in 231 patients. There was a significant increase in methicillin resistance in isolates (MRSA) from these infections with frequencies for 2004 of 39/88 (44·3%), 2005 (62/80, 77·5%), and 2006 (75/97, 77·3%) (PPPP=0·023), and male sex (OR 2·000, 95% CI 1·081–3·699, P=0·027). The determination of associated factors for methicillin resistance in nosocomial S. aureus infections in hospitals will play an important role in efforts to reduce MRSA infection rates.

WOS: 000369571000002, PubMed ID: 26860463, Background: Staphylococcus aureus is one of the causes of both community and healthcare-associated bacteremia. The attributable mortality of S. aureus bacteremia (SAB) is still higher and predictors for mortality and clinical outcomes of this condition are need to be clarified. In this prospective observational study, we aimed to examine the predictive factors for mortality in patients with SAB in eight Turkish tertiary care hospitals. Methods: Adult patients with signs and symptoms of bacteremia with positive blood cultures for S. aureus were included. All data for episodes of SAB including demographics, clinical and laboratory findings, antibiotics, and outcome were recorded for a 3-year (2010-2012) period. Cox proportional hazard model with forward selection was used to assess the independent effect of risk factors on mortality. A 28-day mortality was the dependent variable in the Cox regression analysis. Results: A total of 255 episodes of SAB were enrolled. The median age of the patients was 59 years. Fifty-five percent of the episodes were considered as primary SAB and vascular catheter was the source of 42.1 %. Healthcare associated SAB was defined in 55.7 %. Blood cultures yielded methicillin-resistant S. aureus (MRSA) as a cause of SAB in 39.2 %. Initial empirical therapy was inappropriate in 28.2 %. Although overall mortality was observed in 52 (20.4 %), 28-day mortality rate was 15.3 %. Both the numbers of initial inappropriate empirical antibiotic treatment and the median hours to start an appropriate antibiotic between the cases of fatal outcome and survivors after fever onset were found to be similar (12/39 vs 60/216 and 6 vs 12 h, respectively; p > 0.05). High Charlson comorbidity index (CCI) score (p = 0.002), MRSA (p = 0.017), intensive care unit (ICU) admission (p < 0.001) and prior exposure to antibiotics (p = 0.002) all were significantly associated with mortality. The Cox analysis defined age [Hazard Ratio (HR) 1.03; p = 0.023], ICU admission (HR 6.9; p = 0.002), and high CCI score (HR 1.32; p = 0.002) as the independent predictive factors mortality. Conclusions: The results of this prospective study showed that age, ICU stay and high CCI score of a patient were the independent predictors of mortality and MRSA was also significantly associated with mortality in SAB.

Background The aim of this study was to determine the causative agents in early, late- and very late-onset sepsis in preterm infants. The demographic features, risk factors, clinical and laboratory findings in sepsis types were also defined. Methods A total of 151 preterm infants with culture-proven neonatal sepsis were enrolled in this prospective study. The infants were classified into three groups with regard to the onset of sepsis: early onset sepsis (EOS), late-onset sepsis (LOS) and very late-onset sepsis (VLOS). A sepsis screen including whole blood count, blood smear, infection markers and cultures was performed before initiating antibiotic therapy. Results EOS, LOS and VLOS groups consisted of 23, 86 and 42 infants, respectively. Coagulase-negative staphylococci (CONS) was the most common organism in all sepsis groups. The main factors associated with EOS included presence of premature rupture of membranes, antibiotic use in pregnancy and choriamnionitis. Previous antibiotic use was the main factor associated with LOS, while low birthweight was the main factor in infants with VLOS. Although mortality rate due to Gram-negative bacteria and fungi was higher, CONS was an important cause of mortality in infants with LOS and VLOS. Conclusions CONS was found to be the most common causative organism in three sepsis types in preterm neonates. Although the mortality rate due to CONS was lower in EOS, it was an important cause of mortality in LOS and VLOS. CONS seems to be the main pathogen in neonatal sepsis in developing countries, as in developed countries.

Brief Introduction: ST-analysis is a promising method to detect intrapartum fetal metabolic acidosis (FMA). However, many false positives lower its specificity, leading to avoidable interventions and neonatal morbidity. Reducing false positives is preferable to current strict STAN guidelines. Present ST-analysis compares absolute T/QRS ratio rises to its baseline. As fetal heart axis orientation varies, fetal vector ECG parameters vary, resulting in interpatient T/QRS baseline differences. We hypothesize that patients with a higher T/QRS baseline are more prone to exceed absolute thresholds. We suggest analyzing relative rather than absolute T/QRS ratio rises would improve diagnostic accuracy. This study explores whether relative ST-analysis has distinctive value in detecting FMA and compares both methods. Materials & Methods: A retrospective case-control study was performed in a tertiary care teaching hospital with twenty healthy human fetuses during labour at term, of which 10 had an umbilical artery pH 57.05 (cases) and 10 had an arterial pH 47.20 (controls) after birth. Fetal electrocardiogram was recorded with single helix scalp electrode (Goldtrace), a maternal skin electrode and a STAN S31 monitor (Neoventa Medical, Molndal, Sweden). Relative T/QRS values were calculated based on stored data from these registrations. Absolute ST-events were obtained from Event Log of STAN viewer (Neoventa Medical). Absolute ST-events were defined as occurrence of either baseline or episodic ST-events. A receiver operator curve (ROC) of relative ST-analysis was constructed using SPSS Statistics 22. A cut-off value was determined at optimal specificity, which was used to calculate other test characteristics. Sensitivity, specificity, positive likelihood ratio (LR+), negative likelihood ratio (LR-) and diagnostic odds ratio (OR) were calculated for both relative and absolute ST analysis. Primary outcome measures were area under the curve of the ROC curve of relative T/QRS ratio and test characteristics of both relative and absolute ST analysis. Clinical Cases or Summary Results: Relative ST-analysis showed an area under the curve of 0.990 (95% CI 0.958-1.000). The optimal cut-off value of T/QRS ratio rise was determined at 70%. Relative vs. absolute ST-analysis showed specificity of 100% vs. 40% (p = 0.031); sensitivity of 90% vs. 90%; LR+ of infinity vs. 1.5; LR- of 0.1 vs. 0.25; OR of infinity vs. 6, respectively. Conclusions: Relative ST-analysis shows excellent distinctive value in this population. Specificity of this method is better than in absolute STanalysis (without CTG) at comparable sensitivity. However, this study only included patients with extreme pH values at birth; no patients with umbilical artery pH between 7.05 and 7.20 were included. Besides, the occurrence of biphasic events and CTG interpretation were not considered in this study, as we aimed to improve T/QRS baseline dependent aspects of ST-analysis. Nevertheless, relative ST-analysis seems to be a promising method for detection of metabolic acidosis during labour, as its specificity, LR- and OR are better than in absolute ST-analysis. Further research is required to determine whether our cutoff value is also appropriate in a large population that includes the complete clinical range of pH values; followed by external validation. Once validated, this method may improve detection of compromised fetuses during labour, decreasing unnecessary artificial deliveries and improving neonatal outcome.

Importance: The inclusion of data about the presence of metastatic neck nodes with extracapsular spread (ECS) in the neck dissection improves the prognostic classification of patients with head and neck squamous cell carcinoma (HNSCC). Objective: To evaluate the prognostic capacity of ECS in patients with HNSCC, and to analyze the usefulness of including this information in the pathological classification of patients treated with a neck dissection. Design: Retrospective unicenter study performed from 1985 through 2007. Setting: Tertiary referral center. Participants: A total of 1190 patients with HNSCC treated with a neck dissection. Intervention: Unilateral or bilateral neck dissection. Main Outcomes and Measures: Adjusted survival and local, regional, and distant metastases-free survival. Patients were classified according to a recursive partitioning analysis (RPA) method, considering pN cat-egory and number of neck nodes with ECS as the independent variables. Results: Five-year adjusted survival for patients without metastatic nodes in the neck dissection (pN0) was 85.5%, for patients with neck node metastases without ECS (pN+/ECS-) it was 62.5%, and for patients with neck node metastases with ECS (pN+/ECS+) it was 29.9%. There were significant differences in survival between patients with pN0 lesions and pN +/ECS- (P

Güney-Varal İ, Köksal N, Özkan H, Bağcı O, Doğan P. The effect of early administration of combined multi-strain and multi-species probiotics on gastrointestinal morbidities and mortality in preterm infants: A randomized controlled trial in a tertiary care unit. Turk J Pediatr 2017; 59: 13-19. Necrotizing enterocolitis (NEC) is a gastrointestinal emergency of the neonatal period. The aim of this study was to demonstrate the use of multistrain and multispecies probiotic on gastrointestinal morbidities and mortality. The study was organized as a randomized controlled, prospective study in premature infants (≤32 week and ≤1500 gram). The ready commercial preparations which contain multi-combined probiotics of Lactobacillus rhamnosus (4.1x10⁸ cfu) + Lactobacillus casei (8.2x10⁸ cfu) + Lactobacillus plantorum (4.1x10⁸ cfu) + Bifidobacterium animalis (4.1x10⁸ cfu) together with 383 mg of fructooligosaccharides and 100 mg of galactooligosaccharides as the prebiotic content, was administered enterally to the probiotic group (n=70); control group constituted of 40 preterms. Primary outcomes of the present study were ≥ Stage 2 NEC and the mortality. Secondary outcomes were culture-proven sepsis and days to reach full enteral feeding. All cases of NEC were seen in group 2 as 3.6% (n=4) of all infants. The mortality was found to be 1.4% (n=1) in Group 1 and 22.5% (n=9) in Group 2. The incidence of NEC and the mortality rate were found to be significantly lower in Group 1 (p=0.016, p=0.001, respectively). In Group 1, the NEC-related mortality rate and sepsis-related mortality rate were significantly lower than that of the control group (p=0.046, p=0.023). In this study, we showed that using probiotic strains in combined multistrain and multispecies forms at higher doses and for prolonged duration had positive effects on gastrointestinal complications, sepsis and mortality in premature infants.

Objectives: To determine the direct and indirect costs due to rheumatoid arthritis (RA) and ankylosing spondylitis (AS) patients in Turkey. Methods: An expert panel was convened to estimate the direct and indirect costs of care of patients with RA and AS in Turkey. The panel was composed of 22 experts chosen from all national tertiary care rheumatology units (n=53). To calculate direct costs, the medical management of RA and AS patients was estimated using "cost-of-illness" methodology. To measure indirect costs, the number of days of sick leave, the extent of disability, and the levels of early retirement and early death were also evaluated. Lost productivity costs were calculated using the "human capital approach", based on the minimum wage. Results: The total annual direct costs were 2,917.03 Euros per RA patient and 3,565.9 Euros for each AS patient. The direct costs were thus substantial, but the indirect costs were much higher because of extensive morbidity and mortality rates. The total annual indirect costs were 7,058.99 Euros per RA patient and 6,989.81 for each AS patient. Thus, the total cost for each RA patient was 9,976.01 Euros and that for an AS patient 10,555.72 Euros, in Turkey. Conclusion: From the societal perspective, both RA and AS have become burden in Turkey. The cost of lost productivity is higher than the medical cost. Another important conclusion is that indirect costs constitute 70% and 66% of total costs in patients with RA and AS, respectively. Abbott Company

Introduction. Movement disorders are an important part of the activity of a Neurology service, but there are few studies examining their health care demand. Aims. To analyze the first visits of the Movement Disorders Unit of the Hospital de la Santa Creu i Sant Pau in Barcelona and to compare the results with those of previous studies. Patients and methods. Prospective study of the first neurological assessments carried out during 2010. Demographic variables of patients were collected and diagnoses were reviewed 12 months later. Results. 423 first visits were done (application rate of 1.41 per 1000 inhabitants-year): 54% females, median age 68.8 ± 14.2 years-old. 74.3% of referrals came from the family doctor. The most frequent reasons for consultation were tremor (40%) and parkinsonism-motor clumsiness (26%). The most prevalent diagnoses were Parkinson's disease (36%) and essential tremor (19%). After the first assessment, 84% of patients continued controls in the Unit. One year later, in the 8% of cases there was a change in the initial diagnosis. Taking into account the incidence of each disorder, the number of patients seen was fewer compared to the estimated (19,5 times lower), especially marked in cases of restless legs syndrome, essential tremor and Tourette syndrome. Conclusions. In our Unit the most frequent reason for consultation is tremor and the most prevalent diagnosis is Parkinson's disease. The number of patients treated is clearly lower than the estimated according to the incidence of the diseases in the population. © 2012 Revista de Neurología.

Aim: To describe the clinical features of descending necrotizing mediastinitis (DNM) and to outline the diagnostic and therapeutic measures to be taken in its management. Materials and methods: We retrospectively analyzed the data from 13 patients with DNM treated between 2001 and 2012 in 2 tertiary care centers, together with their demographics, diagnostic methods, therapeutic interventions, and clinical outcomes. Results: The patients consisted of 10 males and 3 females, aged from 16 to 72 years (mean age: 44). Odontogenic and tonsillar infections were the probable sources of infection in the majority of cases. Computerized tomography is a crucial imaging modality in the diagnosis and follow-up of patients with DNM. All patients underwent surgical treatment in addition to intravenous broad-spectrum antibiotics. Tube thoracostomy, mediastinal drainage, cervical drainage, and thoracotomy were the therapeutic measures utilized in these patients. Five patients were lost (38%) and 8 survived. Conclusion: DNM is a life-threatening condition that may originate from oropharyngeal infections. Emergency surgical intervention is mandatory in the management of DNM. The 2 most important survival factors are early surgical intervention and adequate drainage.

Background. Infertility is both a clinical and a public problem, affecting the life of the couple, the healthcare services, and social environment. Standard semen analysis is the surrogate measure of male fertility in clinical practice.Objective. To provide information about the relationship between semen parameters and spontaneous conception.Methods. We evaluated retrospectively 453 pregnancies that occurred among 2935 infertile couples evaluated at an infertility clinic of a tertiary-care university hospital, between 2004 and 2009.Results. Normal semen analysis was present only in 158 patients; 295 subfertile patients showed alterations in at least one seminal parameter. A reduction in all seminal parameters was observed in 41 patients. Etiological causes of male infertility were identified in 314 patients.Conclusion. Our data highlights the possibility of a spontaneous conception with semen parameters below WHO reference values. Therefore, we support the importance of defining reference values on a population of fertile men. Finally, we analyzed the related ethical issues.

BACKGROUND Glucose-induced kinetics of bone marrow-derived stem cells in healthy females is presently unknown. The objectives of this study were to determine whether circulating levels of CD133(+), CD34(+) and CD133(+)CD34(+) cells increase in response to glucose load in healthy females and whether the kinetics is altered in amenorrhoeic women. The other objective of the work was to compare the endothelial differentiation potential of peripheral blood-derived endothelial progenitor cells (EPCs) from healthy versus amenorrhoeic women. METHODS In this case-control study, 44 amenorrhoeic subjects and 36 age-matched females with no menstrual disturbance were recruited at Apollo Hospitals, a Tertiary health care center in Chennai, India. Circulating bone marrow-derived stem cells were measured by two color direct flow cytometry. Cultured progenitor cells were characterized at Day 7 and 14 for expression of endothelial markers and production of nitric oxide (NO) via immunofluoroscence. RESULTS The amenorrhoeic subjects were insulin resistant with homeostatic model of assessment of insulin resistance values of 3.33 ± 0.3 versus 1.75 ± 0.148 observed for controls (P< 0.0001). Among the amenorrhoeic subjects, 38 subjects had polycystic ovaries with no signs of hyperandrogenism. Fasting levels of CD133(+), CD34(+) and CD133(+)CD34(+) cells were reduced in amenorrhoeic subjects (P< 0.001). There was a 1.5 to 2-fold increase in the circulating levels of these cells in response to 75 g oral glucose challenge at 1 and 2 h post-load conditions in controls, which was significantly blunted for CD133(+) (P< 0.001) and CD133(+)CD34(+) (P< 0.001) cells in amenorrhoeic subjects. A positive correlation was observed between estrogen and fasting CD133(+) (r= 0.205, P= 0.070), CD34(+) (r= 0.249, P= 0.027) and CD133(+)CD34(+) (r= 0.217, P= 0.055) cell counts. Additionally, fasting counts for CD34(+) and CD133(+)CD34(+) cells positively correlated with FSH and inversely correlated with LH and C-peptide in the polycystic group. Cultured cells from polycystic subjects exhibited reduced adherence to fibronectin and expressed lower levels of endothelial nitric-oxide synthase and NO. CONCLUSIONS Oral glucose-induced increase in circulating numbers of CD133(+) and CD133(+)CD34(+) cells and endothelial differentiation potential of peripheral blood-derived EPCs is attenuated in insulin resistant amenorrhoeic subjects.

WOS: 000285247000004, PubMed ID: 20662635, This study was planned to determine the risk factors of candidemia, and the most common Candida species causing bloodstream infections. A case-control study which included adult patients was conducted over a 1-year period at tertiary-care educational hospitals in Turkey. A total of 83 candidemia episodes were identified during the study period. Candida albicans was the most common species recovered (45.8%) followed by Candida tropicalis (24.1%) Candida parapsilosis (14.5%) and Candida glabrata which was isolated from only four (4.8%) patients. Presence of a urethral catheter (odds ratio [OR] 2.38; 95% confidence interval [CI] 1.09-5.19; P = 0.02), previous use of antibiotics (OR 2.61; 95% CI 1.05-6.46; P = 0.03), RBC transfusions (OR 2.14; 95% CI 1.16-3.94; P = 0.01) and parenteral nutrition (OR 4.44; 95% CI 2.43-8.11; P < 0.01) were found as independent risk factors for candidemia. TPN (Total Parenteral Nutrition) was an independent risk factor for both C. albicans and non-Candida albicans Candida species (P < 0.001). Most of the risk factors were invasive procedures and former medications. We conclude that a great number of candidemia cases are preventable by means of reduction of unnecessary invasive procedures and the use of antimicrobials.

Objective To highlight the clinical role of standard GH replacement treatment on fertility and pregnancy outcomes in four infertile eugonadal women with GH deficiency (GHD). Design Case report. Setting Department of endocrinology and infertility clinic, tertiary-care university hospital. Patient(s) Four normogonadotrophic, normoprolactinemic patients with long-standing infertility, affected by GHD. In two patients (aged 30 and 34 years) GHD was diagnosed after a brain injury. The third patient (age 30 years) had a primary empty sella, documented by magnetic resonance imaging of the pituitary. The last patient (age 28 years) underwent transsphenoidal surgery for Ratke's cyst. The LH and FSH responses to GnRH were normal in all four patients. Two of the four patients also had secondary hypoadrenalism and hypothyroidism. Intervention(s) Patients received recombinant human GH replacement therapy (0.9–1.8 mg/week) for 6–12 months until pregnancy was first indicated by biochemical markers (β-hCG) and later confirmed by transvaginal sonography. The GH therapy was discontinued after confirmation of pregnancy. Main Outcome Measure(s) Pregnancy. Result(s) All patients remained off treatment throughout pregnancy; they had uneventful pregnancies and term deliveries. The babies were healthy and normal in terms of length and weight. Conclusion(s) Our case studies confirm the important clinical role of the GH–insulin-like growth factor I system in oocyte fertilization and the beginning of pregnancy in a selected population of eugonadotrophic infertile women.

The study was designed to investigate characteristics of work-related hand injuries (WRHI) referred to a University hospital emergency department (ED) in an industrialized region as well as to supply data for preventive strategies. All patients with WRHI referred to the University-based ED in the two-year period were investigated. Sociodemographic and injury-related clinical information were analyzed. Out of 746 patients who were admitted to the ED due to occupational injuries within the two-year study period, 244 (32.7%) with isolated wrist, hand and finger injuries were included in the study. Male patients constituted the majority 87.2% (n=213) and 57.0% (n=139) of the patients were between 25 and 34 yr of age. WRHI recorded in industries involving metal and machinery constituted 41.4% (n=101) of all injuries. The sites of injuries were not significantly affected by differences in age, social security status and sectors. The most common types of injury were lacerations, punctures, and abrasions (40.2%, n=98). There was a statistically insignificant rise in amputation injuries with increasing age. Incidences, etiologies and characteristics of WRHI should be highlighted and preventive strategies based on these facts be implemented due to higher level of suffering and more serious consequences attributed to this specific injury.

Objective: Both short- and long-term outcome studies in acute lung injury (ALI) performed thus far were conducted before the implementation of recent advances in mechanical ventilation and supportive care and/or in the context of clinical trials with restricted inclusion criteria. We sought to determine the outcome of consecutive acute lung injury patients after the implementation of these interventions. Design: Prospective cohort study. Setting: Three intensive care units of two tertiary care hospitals. Patients: Patients with acute lung injury treated from October 2005 to May 2006, excluding those with no research authorization or do-not-resuscitate order. Interventions: None. Measurements and Main Results: The investigators collected detailed information about comorbidities, severity of pulmonary and nonpulmonary organ failures, complications, respiratory support, and other interventions. The main outcome measure was mortality 6 months after the onset of acute lung injury. From 142 patents enrolled over a 6-month period, 24 (17%) died in the intensive care unit, 38 (27%) in the hospital, and 55 (39%) by the end of the 6-month follow-up. Median (interquartile range) intensive care unit length of stay, duration of mechanical ventilation, and number of day 28 ventilator-free days were 7.1 (3.6-11.3), 5.7 (2.6-10.3), and, 19.0 (0-24.2) days. Multiple logistic regression analysis identified underlying Charlson comorbidity score (odds ratio 3.11, 95% confidence interval 2.01-5.05) for each point increase, transfer admission from the floor or outside hospital (odds ratio 3.75, 95% confidence interval 1.41-10.99), day 3 cardiovascular failure (odds ratio 3.30, 95% confidence interval 1.19-9.92), and day 3 Pao2/Fio2 (odds ratio 0.94,95% confidence interval 0.88-0.99) as significant predictors of 6-month mortality. Conclusions: With the implementation of recent advances in mechanical ventilation and supportive care, premorbid condition is the most important determinant of acute lung injury survival R01HL087843 - United States Department of Health & Human Services National Institutes of Health (NIH) K23 HL 087843-01A1 - United States Department of Health & Human Services National Institutes of Health (NIH)

Bachground/aims: Hepatic hemangioendotheliomas are rare tumors in childhood. We report our 10-years' experience in a tertiary health center. Methods: This retrospective analysis included eight patients with infantile hepatic hemangioendothelioma. Results: The median age at diagnosis was 24 days (age range: 1 to 70 days) and the female/male ratio was 5/3. The main symptoms were abdominal distention and respiratory distress. Cutaneous hemangiomas were present in four cases. Three infants had Kasabach-Merritt syndrome. Four cases had single hepatic tumors while the others had multiple. The tumor size ranged from 2 cm to 10 cm in diameter. These lesions were located equally in the right and left hepatic lobes, and three babies had bilobar involvement. Most of the multifocal hepatic tumors were associated with skin hemangiomas. Treatment options were assessed individually. Systemic prednisolone therapy (29 mg/kg/d) was commenced in six patients. Five patients responded to corticosteroids. One boy with Kasabach-Merritt syndrome did not respond to this therapy. Interferon-alpha (1 million units (MU)/m(2)/day) was started, and the daily dose of the drug was increased up to 10 MU/m(2), administered 3 times per week, until clinical improvement was achieved. The response was very good and we observed only constitutional adverse symptoms. Two cases were operated; one died from intraoperative bleeding. Other patients were alive and well for 11 to 66 months. Overall survival was 87% in our series. Conclusions: The treatment approaches depend on the centers experience. A multidisciplinary approach is required for the best treatment option.

Objective To establish the frequency of intensive care unit (ICU) admission after esophagectomy and to determine the associated outcomes. Design Retrospective cohort study. Setting Tertiary referral center. Participants Four hundred thirty-two patients who underwent esophagectomy between January 2000 and June 2004. Interventions None Measurements and Main Results Data relating to demographics, patient co-morbidities, perioperative management, complications, and Acute Physiology and Chronic Health Evaluation (APACHE) III variables were abstracted. Statistical analyses were performed to compare survivors with non-survivors and ICU patients with non-ICU patients. Of 432 patients included in the study, 123 (28.5%) were admitted to the ICU. Arrhythmias, new infiltrates on chest radiograph, and documented aspiration were common reasons for ICU admission. Patients admitted to ICU were of high acuity (mean APACHE III score 54.5, mean prediction of ICU death 6.4%). Of 352 patients originally not sent to the ICU, 43 (12.2%) were subsequently admitted to the ICU, often for aspiration. Overall in-hospital mortality was 3.7% (16 of 432 patients). Fifteen of the 123 ICU patients (12.2%) did not survive to hospital discharge. Conclusions A significant minority of patients will require ICU admission after esophagectomy, often for aspiration pneumonitis and arrhythmias. Despite high severity of illness scores, the perioperative mortality rate for patients after esophagectomy at a high-volume center is low.

Submitted by Vitor Silverio Rodrigues (vitorsrodrigues@reitoria.unesp.br) on 2014-05-27T11:22:41Z No. of bitstreams: 0 Made available in DSpace on 2014-05-27T11:22:41Z (GMT). No. of bitstreams: 0 Previous issue date: 2007-12-01 Multiple resistances to antimicrobial drugs arising in Escherichia coli isolates may complicate therapeutic management of urinary tract infection (UTI) by this organism. In order to assess the multidrug resistance (MDR) among urinary E. coli isolates, we have tested 11 antimicrobial drugs against 67 isolates from outpatients attended in a tertiary-care teaching hospital and of 78 isolates from a municipal health unit, respectively in Ribeirão Preto, State of São Paulo, Brazil. Seventy-six percent and 22% of the isolates from the tertiary-care hospital and the municipal unit, respectively, were resistant to three or more different classes of agents, and were considered to present MDR. Among the isolates from the hospital patients, 73.0%, 65.0%, 58.0%, 58.0% and 31.0% were resistant to tetracycline, ampicillin, cephalothin, trimethoprim-sulfamethoxazole (TMP/SMX) and norfloxacin, respectively; resistance from the municipal unit patients were 31.0%, 37.0%, 8.0%, 29.0% and 12.0% respectively, to the same drugs. The predominant phenotype among the MDR isolates presented is ampicillin, TMP/SMX and tetracycline resistance. The high prevalence of drug resistance among UTI patients calls for continuous surveillance to assure effective control of this infection. © 2007 by The Brazilian Journal of Infectious Diseases and Contexto Publishing. All rights reserved. Department of Microbiology Julio de Mesquita Filho University UNESP, Jaboticabal, São Paulo Department of Morphology Stomatology and Phisiology FORP São Paulo University, Campus Ribeirão Preto, São Paulo Department of Microbiology Julio de Mesquita Filho University UNESP, Jaboticabal, São Paulo

This study analyzes the diversity of In60, a class 1 integron bearing CR1 and containing bla(CTX-M-9), and its association with Tn402, Tn21, and classical conjugative plasmids among 45 CTX-M-9-producing clinical strains (41 Escherichia coli strains, 2 Klebsiella pneumoniae strains, 1 Salmonella enterica strain, and 1 Enterobacter cloacae strain). Forty-five patients in a Spanish tertiary care hospital were studied (1996 to 2003). The diversity of In60 and association of In60 with Tn402 or mercury resistance transposons were investigated by overlapping PCR assays and/or hybridization. Plasmid characterization included comparison of restriction fragment length polymorphism patterns and determination of incompatibility group by PCR-based replicon typing, sequencing, and hybridization. CTX-M-9 plasmids belonged to IncHI2 (n = 26), IncP-1alpha (n = 10), IncFI (n = 4), and IncI (n = 1) groups. Genetic platforms containing bla(CTX-M-9) were classified in six types in relation to the In60 backbone and in eight subtypes in relation to Tn402 derivatives. They were associated with Tn21 sequences when located in IncP-1alpha or IncHI2 plasmids. Our study identified bla(CTX-M-9) in a high diversity of CR1-bearing class 1 integrons linked to different Tn402 derivatives, often to Tn21, highlighting the role of recombination events in the evolution of antibiotic resistance plasmids. The presence of bla(CTX-M-9) on broad-host-range IncP-1alpha plasmids might contribute to its dissemination to hosts that were not members of the family Enterobacteriaceae.

PubMedID: 16538424 This study was planned to investigate the economic impact of headache on Turkish headache sufferers attending a tertiary care outpatient headache clinic. A total of 937 headache patients were included in this study and questioned using a questionnaire for the profile of patients and headache, quality of life of patients and economic impact of headache. The median total direct cost was found to be 88.0 USD and the median total cost was 160.7 USD. The drug treatment cost was the highest item followed by the specialist outpatient care cost. The average lost and inefficient work/school days was 1.5 (0-45) and 8.4 (0-100) days for one year. It was shown that loss of productivity was higher for migraine without aura group when compared with the episodic and chronic tension-type headache groups. The results of this nationwide university hospital based study showed that headache, especially migraine, has considerable economic impact on patients. © Springer-Verlag Italia 2006. Acknowledgement Merck Sharpe Dohme, Turkey, provided financial support to this study

OBJECTIVE: Our aim was to find the ratio of multiple diagnosis in dizziness patients and to evaluate the effect of multiple etiologies on handicap level of the patient. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. INTERVENTION: The data of 703 patients (178 men and 525 women) were included in the study. Diagnoses of the patients were made in a multiple-specialty environment including otolaryngology, neurology, cardiology, internal medicine, and rehabilitation medicine. MAIN OUTCOME MEASURES: All patients filled the dizziness handicap inventory and pointed the severity of dizziness on a 10-point visual analog scale. RESULTS: Four hundred thirty-three patients (61.6%) have only one diagnosis, whereas 183 (26%) had two. Three diseases have been found in 34 patients (4.8%), and four diseases were present in eight patients (1.1%). The mean number of diagnosis in one patient was 1.32 ± 0.71. There was a significant difference between two sexes on the number of disease. There was no correlation between age and the number of diagnosis. There was no significant difference in functional scale, but the statistically significant increases are present in both physical (p < 0.05) and emotional (p < 0.01) scales. There was no correlation between age and handicap levels. CONCLUSION: Multiple diagnoses were important factors on physical and emotional handicaps. It was also found that this problem is not limited with older age group. © 2006, Otology & Neurotology, Inc.

Brief Introduction: ST-analysis is a promising method to detect intrapartum fetal metabolic acidosis (FMA). However, many false positives lower its specificity, leading to avoidable interventions and neonatal morbidity. Reducing false positives is preferable to current strict STAN guidelines. Present ST-analysis compares absolute T/QRS ratio rises to its baseline. As fetal heart axis orientation varies, fetal vector ECG parameters vary, resulting in interpatient T/QRS baseline differences. We hypothesize that patients with a higher T/QRS baseline are more prone to exceed absolute thresholds. We suggest analyzing relative rather than absolute T/QRS ratio rises would improve diagnostic accuracy. This study explores whether relative ST-analysis has distinctive value in detecting FMA and compares both methods. Materials & Methods: A retrospective case-control study was performed in a tertiary care teaching hospital with twenty healthy human fetuses during labour at term, of which 10 had an umbilical artery pH 57.05 (cases) and 10 had an arterial pH 47.20 (controls) after birth. Fetal electrocardiogram was recorded with single helix scalp electrode (Goldtrace), a maternal skin electrode and a STAN S31 monitor (Neoventa Medical, Molndal, Sweden). Relative T/QRS values were calculated based on stored data from these registrations. Absolute ST-events were obtained from Event Log of STAN viewer (Neoventa Medical). Absolute ST-events were defined as occurrence of either baseline or episodic ST-events. A receiver operator curve (ROC) of relative ST-analysis was constructed using SPSS Statistics 22. A cut-off value was determined at optimal specificity, which was used to calculate other test characteristics. Sensitivity, specificity, positive likelihood ratio (LR+), negative likelihood ratio (LR-) and diagnostic odds ratio (OR) were calculated for both relative and absolute ST analysis. Primary outcome measures were area under the curve of the ROC curve of relative T/QRS ratio and test characteristics of both relative and absolute ST analysis. Clinical Cases or Summary Results: Relative ST-analysis showed an area under the curve of 0.990 (95% CI 0.958-1.000). The optimal cut-off value of T/QRS ratio rise was determined at 70%. Relative vs. absolute ST-analysis showed specificity of 100% vs. 40% (p = 0.031); sensitivity of 90% vs. 90%; LR+ of infinity vs. 1.5; LR- of 0.1 vs. 0.25; OR of infinity vs. 6, respectively. Conclusions: Relative ST-analysis shows excellent distinctive value in this population. Specificity of this method is better than in absolute STanalysis (without CTG) at comparable sensitivity. However, this study only included patients with extreme pH values at birth; no patients with umbilical artery pH between 7.05 and 7.20 were included. Besides, the occurrence of biphasic events and CTG interpretation were not considered in this study, as we aimed to improve T/QRS baseline dependent aspects of ST-analysis. Nevertheless, relative ST-analysis seems to be a promising method for detection of metabolic acidosis during labour, as its specificity, LR- and OR are better than in absolute ST-analysis. Further research is required to determine whether our cutoff value is also appropriate in a large population that includes the complete clinical range of pH values; followed by external validation. Once validated, this method may improve detection of compromised fetuses during labour, decreasing unnecessary artificial deliveries and improving neonatal outcome.

Brief Introduction: ST-analysis is a promising method to detect intrapartum fetal metabolic acidosis (FMA). However, many false positives lower its specificity, leading to avoidable interventions and neonatal morbidity. Reducing false positives is preferable to current strict STAN guidelines. Present ST-analysis compares absolute T/QRS ratio rises to its baseline. As fetal heart axis orientation varies, fetal vector ECG parameters vary, resulting in interpatient T/QRS baseline differences. We hypothesize that patients with a higher T/QRS baseline are more prone to exceed absolute thresholds. We suggest analyzing relative rather than absolute T/QRS ratio rises would improve diagnostic accuracy. This study explores whether relative ST-analysis has distinctive value in detecting FMA and compares both methods. Materials & Methods: A retrospective case-control study was performed in a tertiary care teaching hospital with twenty healthy human fetuses during labour at term, of which 10 had an umbilical artery pH 57.05 (cases) and 10 had an arterial pH 47.20 (controls) after birth. Fetal electrocardiogram was recorded with single helix scalp electrode (Goldtrace), a maternal skin electrode and a STAN S31 monitor (Neoventa Medical, Molndal, Sweden). Relative T/QRS values were calculated based on stored data from these registrations. Absolute ST-events were obtained from Event Log of STAN viewer (Neoventa Medical). Absolute ST-events were defined as occurrence of either baseline or episodic ST-events. A receiver operator curve (ROC) of relative ST-analysis was constructed using SPSS Statistics 22. A cut-off value was determined at optimal specificity, which was used to calculate other test characteristics. Sensitivity, specificity, positive likelihood ratio (LR+), negative likelihood ratio (LR-) and diagnostic odds ratio (OR) were calculated for both relative and absolute ST analysis. Primary outcome measures were area under the curve of the ROC curve of relative T/QRS ratio and test characteristics of both relative and absolute ST analysis. Clinical Cases or Summary Results: Relative ST-analysis showed an area under the curve of 0.990 (95% CI 0.958-1.000). The optimal cut-off value of T/QRS ratio rise was determined at 70%. Relative vs. absolute ST-analysis showed specificity of 100% vs. 40% (p = 0.031); sensitivity of 90% vs. 90%; LR+ of infinity vs. 1.5; LR- of 0.1 vs. 0.25; OR of infinity vs. 6, respectively. Conclusions: Relative ST-analysis shows excellent distinctive value in this population. Specificity of this method is better than in absolute STanalysis (without CTG) at comparable sensitivity. However, this study only included patients with extreme pH values at birth; no patients with umbilical artery pH between 7.05 and 7.20 were included. Besides, the occurrence of biphasic events and CTG interpretation were not considered in this study, as we aimed to improve T/QRS baseline dependent aspects of ST-analysis. Nevertheless, relative ST-analysis seems to be a promising method for detection of metabolic acidosis during labour, as its specificity, LR- and OR are better than in absolute ST-analysis. Further research is required to determine whether our cutoff value is also appropriate in a large population that includes the complete clinical range of pH values; followed by external validation. Once validated, this method may improve detection of compromised fetuses during labour, decreasing unnecessary artificial deliveries and improving neonatal outcome.

AIM: To investigate prognostic factors of survival following curative, non-palliative surgical removal of lung metastases secondary to colorectal cancer (CRC). METHODS: Between 1999 and 2009, a radical metastasectomy with curative intent was performed on lung metastases in 21 patients with CRC (15 male and 6 female; mean age: 57.4 +/- 11.8 years; age range: 29-74 years) who had already undergone primary tumour resection. RESULTS: The mean number of lung metastases ranged from one to five. The mean overall survival was 71 +/- 35 mo (median: 25 mo). After adjusting for potential confounders, multivariable Cox regression analyses predicted only the number of lung metastases (1 vs >= 2; hazard ratio: 7.60, 95% confidence interval: 1.18-17.2, P = 0.03) as an independent predictor of poor survival following lung resection for metastatic CRC. CONCLUSION: Resection of lung metastases is a safe and effective treatment in selected CRC patients with single lung metastases. (C) 2012 Baishideng. All rights reserved.