ISSN: 2149-2247 | E-ISSN: 2149-2549
Volume: 44  Issue: 5 - 2022
1.The War Against the Resistance of Acinetobacter Baumannii: A Meta-analysis of Findings in Türkiye
İhsan Hakkı Çiftçi, İmdat Kilbaş, Elmas Pınar Kahraman Kılbaş
doi: 10.14744/etd.2022.94770  Pages 447 - 454
Bacterial resistance to antibiotics continues to be a significant challenge to the global health system. This study was designed to examine changes in the antibiotic resistance of Acinetobacter baumannii (A. baumannii) strains isolated from various clinical samples taken between 2005 and 2020 and to support the development of new antibiotics policies for empirical treatment of multidrug-resistant isolates in Türkiye. This meta-analysis included a data search phase, determination of eligibility criteria, quali-tative analysis of the studies selected, data extraction, and statistical analyses. All of the data were analyzed according to the Pre-ferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. According to Clinical and Laboratory Standards Institute and/or European Committee on Antimicrobial Susceptibility Testing standards and a random effects model, the breakpoint estimate of A. baumannii strain resistance in Türkiye for ampicillin-sulbactam, ceftazidime, imipenem, mero-penem, gentamicin, amikacin, ciprofloxacin, piperacillin-tazobactam, trimethoprim-sulfamethoxazole, netilmicin, colistin, and tigecycline was 90.7%, 92.1%, 86.8%, 87.3%, 72.6%, 63.7%, 88%, 91.2%, 76.7%, 27.1%, 7.9%, and 18.5%, respectively. The reported rates of A. baumannii resistance from different regions demonstrated heterogeneity. Unfortunately, the use of standard antibiotics is unlikely to provide effective therapy throughout Türkiye. New therapy options and protocols are needed.

2.Phytotherapy with Silymarin: A Clinical Trial on Infants with Jaundice
Majid Hamidi, Roya Choopani
doi: 10.14744/etd.2021.57936  Pages 455 - 459
Objective: In this study, we aim to investigate the effects of silymarin in terms of reducing bilirubinemia in infants with hypercholesterolemia and under phototherapy.
Materials and Methods: In this study, 180 infants were randomly assigned to three groups. The intervention was performed with silymarin in the case group. The case, positive, and negative control groups underwent phytotherapy, while the negative control group did not have any treatment; meanwhile, the case group was orally administered with 4 mg/kg silymarin once every 12 h as well. The tests consisted of alanine aminotransferase (SGPT), alanine transaminase (SGOT), albumin levels at baseline and completion of the intervention, and TSB at baseline and then after 24-h intervals up to the infants’ discharge.
Results: As per our findings, a significant difference was noted in terms of the duration of hospital stay between the case and control groups (p<0.001) in favor of the case group. Although there was no significant difference in certain factors such as total albumin, aspartate aminotransferase (AST), alanine aminotransferase (ALT) and bilirubin between the case and positive groups (p>0.05), a significant difference was observed between the case group and the positive control with the negative control group.
Conclusion: Administering silymarin on infants with hypercholesterolemia (bilirubin factor) and under phytotherapy can be effective alongside the main therapies, as a significant difference was observed between the case and positive control groups in terms of length of hospital stay (but not with the control group), which indicates the effect of silymarin on hyperbilirubinuria.

3.The Potential Effect of COVID-19 Lockdown Period on Tinnitus-related Distress
Emre Gürses, Bünyamin Çıldır
doi: 10.14744/etd.2022.71780  Pages 460 - 465
Objective: To determine the tinnitus severity and quality of life of patients with tinnitus followed before and during the COVID-19 lockdown period.
Materials and Methods: Tinnitus-related distress and quality of life were assessed before and during the COVID-19 lock-down period. The primary outcome was the mean change on the Tinnitus Handicap Inventory (THI), the Mini-tinnitus Questionnaire (TQ 12-T), and the Short-form Health Survey (SF-36). Besides, all participants filled out an evaluation form, underwent audiological assessment, tinnitus mapping, and were administered mini-interviews regarding their tinnitus.
Results: We recruited 44 patients with tinnitus (22 females and 22 males, mean age: 50.25±14.51 years). Comparison of changes in mean score from baseline to the lockdown period showed no differences in overall outcomes for THI and TQ 12-T. Catastrophic (p=0.002), physical pain (p=0.020), and general health (p=0.046) subscales were found to be significantly improved. Only emotional subscales (p<0.001) of THI were found to be significantly increased.
Conclusion: Although the COVID-19 lockdown period for patients with tinnitus is a major source of stress, they did not show any increase in their tinnitus-related distress, except for the emotional state.

4.Bacterial Bloodstream Infection in Renal Transplant Recipients: 15 Years of Experience in a University Hospital
Nursel Çalık Başaran, Şehnaz Alp, Abdullah Tarık Aslan, Tural Pashayev, Tolga Yıldırım, Rahmi Yılmaz, Oğuz Abdullah Uyaroğlu, Sevilay Karahan, Banu Sancak, Fazıl Tuncay Akı, Yunus Erdem, Gülşen Hasçelik, Serhat Ünal
doi: 10.14744/etd.2022.63600  Pages 466 - 472
Objective: The epidemiology of a bloodstream infection (BSI) in a renal transplant recipient (RTR) and the resistance pro-files of the isolates provide important guidance for empirical treatment.
Materials and Methods: The medical records of RTRs from a single university hospital during the period of January 2000 to January 2016 were retrospectively evaluated for the presence of a BSI. Blood culture and antibiotic susceptibility results were reviewed in addition to demographic and clinical data. The distribution of causative microorganisms and risk factors for mortality in RTRs with a BSI were analyzed.
Results: In all, 74 BSIs and 76 distinct bacteria were observed in 56 (8%) of 702 RTRs. The mean age of the patients was 43±14 years; 55% were female, and 54% of the transplants were from living donors. Gram-negative bacteria, predomi-nantly Enterobacteriaceae, were the most common (71%) pathogen. One-fifth of all BSIs occurred within the first month of transplantation. Among those that were Gram-positive, there were 5 coagulase-negative staphylococci and 8 Staphylococcus aureus BSIs. The rate of resistance to extended-spectrum β-lactamase, quinolone, and trimethoprim-sulfamethoxazole in Gram-negative enteric bacilli (GNEB) was 36%, 34%, and 50%, respectively. All of the GNEB were susceptible to carbapen-ems and amikacin. The overall mortality rate was 25%. The median length of time from the onset of BSI to death was 8 days (min–max: 2–46 days). The urinary tract was the primary source of infection in 53% of the patients. Delayed graft function significantly increased the mortality risk among RTR patients with a BSI.
Conclusion: Gram-negative bacteria were the leading cause of BSIs and demonstrated high resistance rates, and the most common site of infection was the urinary tract. Awareness of local epidemiology and resistance profiles will enable tailored treatment strategies to manage a BSI in RTRs.

5.Reference Intervals of Hematological Parameters in a Large Sample of the Turkish Population in the Çukurova District of Türkiye
Gizem Gül Koç, Ali Kokangül, Dilek İscan, Şule Menziletoğlu Yıldız, Gülser Karaboğa, Birol Güvenç
doi: 10.14744/etd.2022.97494  Pages 473 - 480
Objective: A complete blood count (CBC) analysis is an essential laboratory test for the diagnosis, treatment, and follow-up of numerous health problems. The aim of this study was to evaluate the reference intervals for CBC parameters of hemoglo-bin (Hb), hematocrit (Hct), white blood cell (WBC), platelet (Plt), and mean platelet volume (MPV) for the adult population in the Çukurova district of southern Türkiye.
Materials and Methods: Data of 117,759 donors (112,557 males) 18–65 years of age who presented at the Çukurova University Blood Center between January 2015 and June 2020 for blood donation were included in the analyses. All of those who met the World Health Organization blood donor criteria were included in the study. Hematological reference intervals, stratified by age and gender, were compared.
Results: The mean age of the donors was 37±9.8 years. The median parameter value was Hb: 15.4 g/dL, Hct: 46, WBC: 7.1x103/µL, Plt: 238x103/µL, and MPV: 8.3 fL. Comparison of the parameters between sexes revealed that Hb (p<0.001) and Hct (p<0.001) levels were significantly higher in males, while WBC and Plt counts were significantly higher in females (p<0.001 for each). The MPV values were similar.
Conclusion: The reference ranges for CBC parameters as evaluated by sex and age group were clinically reasonable and in accordance with the literature data. However, given the single-center design of this study, additional studies with greater detail are needed to more fully assess the reference intervals of the general population in the region.

6.The Impact of Left Ventricle Geometry Patterns on Length of Hospital Stay in COVID-19 Patients
Mehmet Erdoğan, Ayşe Kaya Kalem, Selçuk Öztürk, Mehmet Akif Erdöl, Yunus Emre Özbebek, Hacı Ahmet Kasapkara, Bircan Kayaaslan, Fatma Eser, Imran Hasanoğlu, Hüseyin Ünsal Erçelik, Rahmet Güner
doi: 10.14744/etd.2022.08365  Pages 481 - 489
Objective: The coronavirus disease 2019 (COVID-19) has placed huge strains on medical systems. Therefore, it is essential to determine the predictors of the long hospital stay. We sought to investigate whether alterations in left ventricular (LV) geometry in COVID-19 patients are associated with the length of stay (LoS) and a long hospital stay.
Materials and Methods: 108 consecutive hospitalized COVID-19 patients were incorporated in the study and 89 patients remained for statistical analysis. All participants underwent standard two-dimensional (2D) and Doppler echocardiographic examinations. Patients were classified according to LV geometry characteristics namely normal geometry (NG), concentric remodeling, concentric hypertrophy and eccentric hypertrophy.
Results: Multiple binary logistic regression model adjusted for clinical and laboratory variables yielded significant and inde-pendent association of LV mass index (LVMI) (OR: 1.12, 95% CI: 1.06–1.19, p<0.001), 10 g/m2 increase in LVMI (OR: 3.63, 95% CI: 2.00–6.59, p<0.001), LV geometry patterns (OR: 2.92, 95% CI: 1.46–5.84, p=0.002), and altered geo-metric patterns compared to NG (OR: 3.97, 95% CI: 1.08–14.5, p=0.037) with long hospital stay. Correlation analysis of LVMI and LoS demonstrated significant and moderate correlation (rho=0.58, p<0.001).
Conclusion: LVMI and LV geometric patterns independently predict long hospital stays in COVID-19 patients. The signifi-cant correlation between LoS and LVMI underlies the significance of LV geometry in this infection.

7.Influence of HbA1c Level on Long-term Coronary Artery Bypass Graft Patency
Mürsel Şahin, Savaş Özer, Oğuzhan Ekrem Turan, Yusuf Hoşoğlu, Merih Kutlu
doi: 10.14744/etd.2022.70268  Pages 490 - 494
Objective: Diabetes mellitus (DM) is a very important prognostic factor in patients with coronary artery disease. The precise effects of controlled or uncontrolled diabetes on bypass graft patency in the long term have not yet been determined. The aim of this study was to assess the effect of the glycated hemoglobin (HbA1c) level on bypass graft patency and contribute information about HbA1c targets for patients with diabetes and a history of bypass surgery.
Materials and Methods: A total of 606 patients who underwent coronary bypass surgery and coronary angiography were evaluated. Grafts with any stenosis not causing flow restriction were accepted as patent. The average of all available HbA1c measurements within a year of the angiography was used for analysis. Patients were also analyzed according to the average HbA1c level: well-controlled DM was defined as an average HbA1c level of <7% and uncontrolled DM was defined at an HbA1c level of ≥7%.
Results: In all, 114 patients were included in the study, yielding a total of 289 grafts (venous: 182, arterial: 107). The median HbA1c value of the study population was 7.5 mg/dL. The occlusion rate of arterial and venous grafts was 12.4% and 28.2%, respectively. The median graft age was 8.0 years. The HbA1c level was similar in arterial and saphenous grafts according to the presence or absence of occlusion.
Conclusion: The HbA1c level was not associated with long-term coronary bypass graft patency. Only a graft age of >5 years was significantly associated with long-term venous graft patency. Studies with patients whose HbA1c level is more strictly controlled may reveal different results.

8.Determination of Drug Sensitivity Subgroups in Endometrial Cancer Based on Renin Angiotensin System
Seyhan Türk
doi: 10.14744/etd.2022.45220  Pages 495 - 500
Objective: The renin angiotensin system (RAS) is a prognostic molecular target for a large cancer group and plays an essential role in cancer biology. This critical system affects tumor growth and spread, both directly and indirectly, including endometrial cancer (EC). RAS activation has been strongly associated with the expression of angiogenesis, metastasis, and pro-angiogenic factors. The aim of this study was to identify EC subgroups according to variations in RAS genes and evaluate the prediction of chemotherapy resistance.
Materials and Methods: Hierarchical clustering, variance, t-test, fold change, false discovery rate calculation, and geneset enrichment analyses were performed using microarray and drug sensitivity data obtained from the Genomics of Drug Sensitivity in Cancer Project database and the European Molecular Biology Laboratory-European Bioinformatics Institute ArrayExpress (accession no: E-MTAB-783).
Results: Subgroups of endometrial cancer cell lines were determined based on the RAS gene family. These subgroups were asso-ciated with 2 critical chemotherapeutic agents: vinblastine and epothilone B. Important gene sets were identified in the subgroups.
Conclusion: Pharmacological effects of RAS genes may differ in EC cells, depending on the pathological behavior of genomic subtypes. The results of this study showed that RAS genes were potential biomarkers for drug sensitivity and prog-nosis of endometrial cancer. RAS and NOTCH/autophagosome pathways may be related in EC. If the data of this study are confirmed by in vitro experiments and clinical samples, RAS genes would seem to be robust prognostic biomarkers for vinblastine and epothilone B.

9.Sources of Infection and Risk of COVID-19 for Healthcare Workers at a Tertiary Hospital
Ceyda Şahan, Defne Kalaycı, Hanife Ece Erik, Eray Öntaş, Dilek Yıldırım, Damla Özyürek, Tülin Çoban, Şeyma Aliye Kara, Gulçin Dizman, Nursel Çalık Başaran, Gökhan Metan
doi: 10.14744/etd.2022.22566  Pages 501 - 507
Objective: The aim of this study was to evaluate the exposure and risk of contracting coronavirus disease (COVID-19), the infectious disease caused by severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2), among healthcare workers (HCWs) at a tertiary hospital early in the pandemic.
Materials and Methods: HCWs who presented at an occupational health outpatient clinic for COVID-19 contact tracing or assessment before returning to work between March 30, 2020 and May 31, 2020 were evaluated in this cross-sectional study. The dependent variable used was a COVID-19 diagnosis; the independent variables used were gender, marital status, age, occupation, smoking, presence of chronic disease, symptoms of COVID-19, source of contact, risk classification, and work in a COVID-19 unit. Logistic regression analysis was used to assess factors associated with the risk of COVID-19 and sources of infection.
Results: A total of 603 HCWs presented at the clinic during the study period. The most frequent sources of contact with SARS-CoV-2 were infected co-workers (50.7%) and patients at work (28.2%), followed by household contacts (9.9%). Those who worked in a COVID-19 unit had a 3.55 times greater risk of a COVID-19 diagnosis than other HCWs when adjusted for age, gender, and risk classification.
Conclusion: HCWs frequently face exposure to potential infection. Sufficient support for these workers to ensure adequate awareness of and compliance with protocols is of critical importance to protect public health. The results of this study also suggest consideration of the possibility of another source of contact for HCWs included in the no risk category. Regular screening for COVID-19 may be advisable.

10.Methods of Pain Self-Care Used by Patients with Chronic Musculoskeletal Pain During the COVID-19 Pandemic in Türkiye
Şule Şimşek, Feyza Altındal, Nesrin Yağcı
doi: 10.14744/etd.2022.54889  Pages 508 - 511
Objective: The aim of this study was to determine the methods of pain self-care used by patients in Türkiye with chronic musculoskeletal pain who could not access a healthcare provider during the coronavirus 2019 (COVID-19) pandemic.
Materials and Methods: A total of 255 participants (mean age 40.8±13.2 years) diagnosed with chronic musculoskeletal pain were included in the study. The Nordic Musculoskeletal Questionnaire and a form created by the researchers were used to assess the prevalence of musculoskeletal symptoms and methods of pain management.
Results: The primary site of symptoms during the previous 12-month period was the low back, neck, and upper back re-gions (69%, 64.7%, and 60% respectively). The detailed assessment revealed that in the prior 7 days, patients experienced symptoms most often in the lower back (56.9%), upper back (45.1%), and neck (43.9%). The most frequently used methods of pain self-care were massage (71%), pain relief medication (68.2%), and topical analgesics (55.3%).
Conclusion: Patients most often reported symptoms in the spinal area, and the most used means of self-care for pain man-agement were massaging the painful area, pain medication, and topical analgesics. Self-care initiatives can be very valuable, however, at least some initial guidance from health professionals is advisable. Additional exploration of technological means of intervention and awareness of appropriate self-care could be of substantial benefit individuals and society.

11.Predictive Value of Uterine Sonoelastography on the Outcome of IVF Treatment
Fatih Uzunkaya, Ayşe Zehra Özdemir, Bülent Ayaş, Ayşegül Idil Soylu, Davut Güven, Ayşe Rümeysa Aydoğan Demir
doi: 10.14744/etd.2022.83772  Pages 512 - 517
Objective: The knowledge of factors that influence the outcome of in-vitro fertilization (IVF) has increased significantly over time, yet remains insufficient. This prospective study was designed to evaluate whether uterine sonoelastography could be a tool to predict the outcome.
Materials and Methods: Patients who were to undergo the first cycle of IVF treatment were enrolled for 3 months. So-noelastography using acoustic radiation force impulse technology was performed just before the embryo transfer in patients without a uterine abnormality. The association between the sonoelastography measurements and outcomes was evaluated.
Results: This study included 110 patients, with a pregnancy rate of 33.6%. None of the elastography measurements alone had a significant effect on the outcome, however the ratio between the measurements obtained from each half of the poste-rior uterine wall was significantly higher in the women who conceived compared with those who did not (controls) (1.18 vs. 0.96; p=0.01). Multivariate analysis indicated that the ratio was associated with the outcome.
Conclusion: The preliminary results of the study suggest a possible relationship between the posterior uterine wall elasticity index and the outcome of IVF treatment. Further larger studies are needed to confirm this result and to develop an exami-nation protocol.

12.Retrospective Analysis of Tularemia Cases in Tokat, Türkiye
Emine Türkoğlu, Şener Barut
doi: 10.14744/etd.2022.45793  Pages 518 - 522
Objective: Tularemia is a rare and often overlooked zoonotic infection. While the ulceroglandular and glandular types are observed most frequently in epidemics originating in Europe, the oropharyngeal type is most common in Türkiye. The most common clinical findings are lymphadenopathy, skin rash, and tonsillitis. The aim of this study was to investigate the frequen-cy of tularemia in Tokat, a province located in the Central Black Sea Region of Türkiye.
Materials and Methods: The data of patients diagnosed with tularemia at Tokat Gaziosmanpaşa University Faculty of Medicine Training and Research Hospital between January 2011 and July 2021 were retrospectively analyzed. Laboratory-confirmed cases were included in the study. Sociodemographic characteristics, risk factors, clinical and laboratory findings, treatments, and post-treatment follow-up of the cases were evaluated.
Results: Tularemia was detected in 20 patients. A total of 80% patients lived in a village, 65% were engaged in agriculture as a profession, and 60% in animal husbandry. The most important possible sources of contamination were rodents near the house (40%) and non-chlorinated drinking water (50%). Among 20 cases, 57% were oropharyngeal tularemia, 95% were treated with monotherapy or combinations containing aminoglycosides, and 50% with surgical lymph node drainage.
Conclusion: Tularemia is a rare infection in Tokat Province. But it should be considered in the differential diagnosis of patients living in rural areas who present with fever, sore throat, and cervical lymphadenopathy that is not responsive to beta-lactam agents.

13.Distal Intracanalicular Lipochoristoma: A Rare Case Report
Satesh Kumaran Ganeson, Azwarizan Abd Halim, Norhaslinda Abdul Gani, Asma Abdullah
doi: 10.14744/etd.2021.92844  Pages 523 - 525
Lipochoristomas are benign fatty tumours with rare occurrence in internal acoustic canal and cerebellopontine angle (0.14%). Despite its benign nature and slow growth potential, it poses serious dilemma for neurotologists due to its intimate involvement with the auditory nerve.
Case report
We would like to present a case of distal intracanalicular lipochoristoma in a 60 year male with 5 years radiological follow up and a brief literature review of this rare entity.
Magnetic resonance imaging plays an important role in both diagnosing and surveillance of the disease. Due to limited surgical outcome, conservative surveillance is the best treatment till date.

14.Diarrhea Triggered by Breastfeeding: A Novel Variant Causing Congenital Lactase Deficiency
Ferda Özbay Hoşnut, Gülseren Şahin
doi: 10.14744/etd.2021.26086  Pages 526 - 527
Background: Congenital lactase deficiency (CLD) is a rare disorder that is characterized by severe osmotic diarrhea and malnutrition on the first day of birth. Clinical findings occur due to the defective digestion of the main carbohydrate, lactose, in breast milk. This autosomal recessive disorder is caused by variants in lactase-phlorizin hydrolase (LCT).
Case Report: We report the first genetically confirmed case of CLD in Turkey. The patient suffered from watery diarrhea after breastfeeding, which ceased after feeding the formula containing lactose-free hydrolyzed cow’s milk. The lactose chal-lenge test demonstrated a lactose intolerance pattern. A novel homozygous variant was detected in LCT.
Conclusion: Although genetic analyses are important to highlight underlying etiologies of congenital diarrhea, it should be remembered that clinical findings of patients, fecal characteristics, and the effects of dietary treatment are the primary and most important steps that lead to an accurate diagnosis.

15.Toxic Reaction due to Multiple Wasp Stings in a Child: A Case Report
Yasemin Özkale, Murat Özkale
doi: 10.14744/etd.2021.34545  Pages 528 - 530
Background: Poisoning caused by wasp and bee stings is the most common type of poisoning caused by insects in Türkiye. The wasp belongs to the family Vespidae, a subgroup of the class Hymenoptera (membrane-winged insects). While mild symptoms are frequently observed in response to a single wasp sting, multiple wasp stings can cause severe poisoning and toxic reactions.
Case Report: We present a case of a 7-year-old male patient who died after developing rhabdomyolysis, acute kidney injury (AKI), and multiple organ failure as a result of multiple wasp stings.
Conclusion: The case report of our patient revealed that poisoning from multiple wasp stings can show a fatal course in chil-dren. When the number of wasp stings is 20–200 and when stings occur in the head-and-neck regions, AKI and mortality are high. Therefore, these patients should be hospitalized in the pediatric intensive care unit and monitored closely for toxic reactions.

16.Endotracheal Metastasis of Colon Cancer Presenting as Severe Dyspnea
Furkan Ufuk, Eren Tanrıseven, Gökhan Öztürk
doi: 10.14744/etd.2022.56767  Pages 531 - 532
Abstract | Full Text PDF

17.Incidence of SARS-CoV-2 Infection in Asthma Patients on Omalizumab Therapy
Öner Özdemir, Ümmügülsüm Dikici
doi: 10.14744/etd.2022.28938  Pages 533 - 534
Abstract | Full Text PDF

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