ISSN: 2149-2247 | E-ISSN: 2149-2549
ERCİYES MEDICAL JOURNAL - Erciyes Med J: 42 (4)
Volume: 42  Issue: 4 - 2020
EDITORIAL COMMENTS
1.Appearance of COVID-19 Pandemic in a Rheumatology Clinic in Turkey
Kemal Nas, Gökhan Koz
doi: 10.14744/etd.2020.58822  Pages 359 - 361
Abstract | Full Text PDF

INVITED REVIEW
2.Bacillus anthracis Evolution: Taking Advantage of the Topology of the Phylogenetic Tree and Human History to Propose Dating Points
Gilles Vergnaud
doi: 10.14744/etd.2020.64920  Pages 362 - 369
This review expands on a talk I gave during the “Biology of Anthrax” meeting held in Bari, Italy (September 3rd–6th, 2019). The talk was a synthesis of recent investigations taking advantage of the topology of the Bacillus anthracis phylogenetic tree to propose tentative dating points and scenarios. Currently available whole-genome sequence (WGS) data allowed identifying single nucleotide polymorphisms (SNPs) among B. anthracis strains and drawing phylogenetic trees. The geographic origin of the strains and the topology of the tree were used to infer spreading events. Five star-like patterns in the tree (polytomies), each containing at least six branches, were detected. The analysis of the geographic distribution of the strains constituting one such polytomy suggests that it emerged not more than a few centuries ago. The key observation allowing this dating is the finding that the polytomy is anchored into Western Europe and that the main North-American lineage emerged from one of its branches, indicative of a post-Columbian export. From this point, I propose additional working hypotheses which may allow dating key nodes along the phylogeny of B. anthracis corresponding to four “Out-of-Africa” events. While trade of contaminated animal products seems to be the predominant driving force underlying modern long-distance spreading of B. anthracis, invasive military operations and more generally borders instabilities may have played an important role in earlier times. The testing of these hypotheses will require the sequencing of a significant number of additional strains from many countries.

3.Reflections on Emerging Technologies in Nanomedicine
Munis Dündar, Adam Mechler, Jean-pierre Alcaraz, Gary Henehan, Satya Prakash, Ratnesh Lal, Donald Martin
doi: 10.14744/etd.2020.68542  Pages 370 - 379
Nanomedicine technologies seem to play an increasing role in modern medicine. Although there are many challenges, it is important to consider emerging technologies that may impact nanomedicine. To establish a rational basis for such consideration in this review, we summarise the present state-of-the-art in nanomedicine based on a bibliometric analysis of the literature that is available in the Clarivate® Web of Science. Then, we build upon that state-of-the-art to highlight the emerging technologies that may have an impact on nanomedicine. We also reflect on these emerging technologies by highlighting examples in areas, such as gene-based biomedicine, the rational design of antimicrobial peptides, and diagnosis and therapy of the gut microbiota. In general, emerging technologies that are based on bioinspired and biomimetic approaches appear to provide important pointers to future improvements in nanomedicine.

ORIGINAL ARTICLE
4.Retrospective Analysis of Meningioma and Alternative Method of Grading
Ismail Saygın, Emel Çakır
doi: 10.14744/etd.2020.69851  Pages 380 - 385
Objective: The current classification of meningioma is based on the mitotic count, brain invasion and atypical histological changes. We re-evaluated the cases of meningioma to make accurate grading and to investigate the effects of morphological parameters and their relationship with each other. We discussed the counting method of mitotic activity. We tried to develop a novel method to determine the most accurate grade.
Materials and Methods: In this study, three hundred nine cases of meningioma were re-evaluated. The number of mitosis in 10 consecutive high-power fields, as well as the total number of mitosis in 1 cm2 area, was found for all cases. Receiver Operating Characteristics curve analysis was performed on the mitotic counts of 304 cases (grade I and II) in both 10 consecutive high-power fields and 1 cm2 for predicting the grade.
Results: In Receiver Operating Characteristics curve analysis, the number of mitoses determining grade II with 99% specificity and 84.4% sensitivity in 1 cm2 was 7 or more. Receiver Operating Characteristics curve analysis for the mitotic count in 10 consecutive high-power fields when the number of mitosis 4 or more, the sensitivity was 84.4%, and it was 100% specific for grade II.
Conclusion: The major cause of the grade change was the number of mitotic activities. We recommend that the mitotic activity count in a large area. Especially, if there is 7 or more mitosis in 1 cm2, the case is to be high-grade. On the other hand, the presence of 1 or more mitosis in 42 high-power fields supports that this case is more likely to be grade II.

5.Pretreatment Metabolic Tumor Volume of Primary Tumor and Total Lesion Glycolysis of Lymph Nodes are Predictive in Nasopharyngeal Cancer
Mete Gündoğ, Ummuhan Abdulrezzak
doi: 10.14744/etd.2020.14564  Pages 386 - 394
Objective: Conventional prognostic factors are not yet sufficient to predict treatment outcomes factors in nasopharyngeal carcinoma (NPC). Parameters from PET/CT are still being investigated as a prognostic factor in nasopharyngeal cancer.
Materials and Methods: We retrospectively analyzed total lesion glycolysis (TLG), metabolic tumor volume (MTV), and maximum standardized uptake value (SUVmax) in patients with non-metastatic nasopharyngeal cancer treated with intensity-adjusted radiotherapy. According to the ROC analysis, we divided the whole cohort into two groups. Kaplan-Meier tests were used to evaluate survival differences between groups. Univariate and multivariate analyzes were performed to find the factors affecting the prognosis. P<0.05 was accepted as statistically significant.
Results: Ninety-one non-metastatic nasopharyngeal cancer patients were enrolled in this study. According to cut-off values, both MTVtumor and TLGnode were found as an independent prognostic factor for overall survival (OS). High MTVtumor (>21.5) and high TLGnode (>186.7) correlated with 4.9 and 4-fold increased mortality risk, respectively. Multivariate analyses showed high MTVtotal (>59.5) was associated with a 3.3 fold increased risk of locoregional recurrence. High TLGtotal (>181.56) was found to be independent prognostic factor for distant metastasis-free survival and it was associated with a 5.4 fold increased risk. The 5-years OS rate was 58.5% in high MTVtotal (>59.5) patients and 82.4% in low MTVtotal (<59.5) patients (p<0.01). The 5-years OS rates were 64.2% in patients with high TLGtotal (>181) and 88% in patients with low TLGtotal (p<0.01).
Conclusion: The results of our study showed that MTVtumor and TLGnode values are significant independent prognostic factors for OS.

6.Effects of ABO/RhD Blood Types and HbA1c Levels on the Postoperative Cardiac Morbidity in Morbidly Obese Patients who Underwent Sleeve Gastrectomy
Özkan Görgülü, Mehmet Nuri Koşar
doi: 10.14744/etd.2020.03443  Pages 395 - 399
Objective: This study was designed to evaluate the impacts of high preoperative HbA1c levels and ABO and Rhesus D antigen (RhD) blood types on the risk of postoperative cardiac morbidity in morbidly obese patients who underwent sleeve gastrectomy.
Materials and Methods: In this retrospective study, 364 morbidly obese patients who underwent elective laparoscopic sleeve gastrectomy operation were included. Data regarding patients’ demographics, preoperative HbA1c levels (low: 4–6%, high: >6%), ABO/RhD blood types, cardiac complaints within the first postoperative week and serum cardiac troponin levels (ng/mL) in patients with postoperative cardiac complaints were recorded.
Results: The findings showed that HbA1c levels were >6.0% in 38.2% of the patients, blood type A (45.9%) was the most prevalent blood type, and postoperative cardiac symptoms were evident in 16.5% of patients. Patients with high and low HbA1c levels were similar concerning ABO/RhD blood type or rate of postoperative cardiac complaints. In patients with postoperative cardiac complaints, a significant positive weak correlation was noted with high troponin levels and high preoperative HbA1c levels (r=0.215, p=0.022).
Conclusion: In conclusion, these findings of a retrospective cohort of morbidly obese patients who underwent sleeve gastrectomy revealed a significant positive weak correlation between high preoperative HbA1c levels and cardiac troponin levels in patients with postoperative cardiac complaints, while ABO/RhD blood type was not associated with preoperative HbA1c levels or the likelihood of postoperative cardiac complaints.

7.Treatment Outcomes and Clinical Evaluation of Upper Extremity Infections Related to Diabetes
Yakup Ekinci, Kaan Gürbüz
doi: 10.14744/etd.2020.76702  Pages 400 - 404
Objective: The most important and common complication encountered in diabetic patients is diabetic infections, which may result in amputation. Herein, we aimed to present the treatment results of rare upper extremity infection related to diabetes at the wound clinic.
Materials and Methods: Forty-two patients who were diagnosed with and treated for upper extremity infection in our diabetic wound clinic between June 2018 and November 2019 were retrospectively screened and the 23 who met the inclusion criteria were included in this study. Drainage, VAC, ray/open amputation, and flap reconstruction were applied either alone or in combination. The preoperative, intraoperative, and postoperative data were recorded.
Results: The mean follow-up time of the 23 patients (4 F/19 M; mean age 55.08±11.83 (28-66) years) was 13.73±4.43 (6–26) months and the mean hospital stay was 18.82±9.31 days. Hypertension was also present in 2/3 of the patients and coronary artery disease in 1/3. The etiological cause was unknown in almost half of the patients. While combined surgical methods were used in some patients, the most common method applied was drainage. Two patients were treated with flap reconstruction.
Conclusion: We think that the treatment of upper extremity infection related to diabetes using a multidisciplinary approach and the dissemination of diabetic wound services will highly likely to make the treatment of complications of this disease more cost-effective.

8.Evaluation of Cerebellar Volume in Adult Turkish Male Individuals: Comparison of three Methods in Magnetic Resonance Imaging
Seher Yılmaz, Adem Tokpınar, Niyazi Acer, Levent Değirmencioğlu, Şükrü Ateş, Halil Dönmez, Serap Baştepe Gray
doi: 10.14744/etd.2020.72593  Pages 405 - 410
Objective: Cerebellum plays quite important in our balance by coordinating the control and synergistic movements of the skeletal muscles. There are many studies in which the volume of the cerebellum is measured and different methods are used. Manual measurements are accepted as the gold standard in these studies, but these measurements are not commonly used due to time and difficulty. The present study aims to compare the cerebellum volume using three different methods.
Materials and Methods: In this study, MR images of 18 men aged between 22 and 30 years were used in the Department of Radiology of Erciyes University Gevher Nesibe Hospital. In the total cerebellum volume measurements, sagittal images were calculated using the Manual (ImageJ), MRICloud and VolBrain (CERES) methods.
Results: Manual and VolBrain measurements were performed to determine the volume of the cerebellum. The total volume of the cerebellum was 136.36±12.36 cm3 in manual calculation 125.46±17.26 cm3 in VolBrain and MRICloud1 46.81±20.16.
Conclusion: In this study, it was seen that the three methods used to measure the volume of the cerebellum were compatible with each other. Because VolBrain volume values are close to the manual method, cerebellum volumes can be obtained by routinely using them.

9.Vitamin D Level and the Association with Morbidity and Mortality in Critically Ill Patients: A Single-center Study
Gülseren Elay, Kürşat Gündoğan, İsmail hakkı Akbudak, Zuhal Özer Şimşek, Şahin Temel, Muhammet Güven, Murat Sungur
doi: 10.14744/etd.2020.40771  Pages 411 - 416
Objective: The present study aims to evaluate vitamin D (Vit D) level in critically ill patients and to assess its level about morbidity and mortality.
Materials and Methods: This study was conducted in an intensive care unit (ICU). Vit D level was measured on admission, third and seventh day.
Results: Of the 62 patients, the median Vit D level at baseline and on the third and seventh days was 12.8 mcg/L, 8.35 mcg/L, and 9.30 mcg/L, respectively. Vitamin D level was low (<30 mcg/L) in 92% of patients at baseline and 97% on the third day. 23% of the studied patients developed a new site infection. No statistically difference in the Vit D level at baseline, or on the third or seventh day based on the presence of infection (p=0.556, p=0.404, p=0.439, respectively). The most commonly seen infections were ventilator-associated pneumonia (VAP) and catheter-related bloodstream infection (CRBSI). The growth of Acinetobacter baumannii was the most frequent. Vit D level (p>0.05) might not have a causal role in mortality (ICU, 30-day, and 6-month), and no correlation was found between them.
Conclusion: The level of Vit D was low. Our study did not show any relationship between mortality rates and Vit D level, but VAP and CRBSI were observed.

10.Comparing Psychosocial Health in Women with and without Risky Pregnancies: A Cross-Sectional Study
Ruşen Öztürk, Özlem Güner
doi: 10.14744/etd.2020.66750  Pages 417 - 424
Objective: This study aims to compare women with risky pregnancy with women with non-risk pregnancies concerning pregnancy-related psychosocial adaptation.
Materials and Methods: This research has a descriptive, comparative and cross-sectional single-centre study. The data were collected from 253 pregnant women who applied to and were followed-up in the gynecology and obstetrics clinic of a university hospital in Izmir, Turkey. The Demographic Information Form and the Pregnancy Psychosocial Health Assessment Scale were used for data collection.
Results: Pregnant with-without risk of Psychosocial Health Assessment Questionnaire (PPHAS) total and subscale mean scores was compared and a statistically significant difference was observed between the two groups. The findings obtained in this study showed that the difference between PPHAS total and subscale mean rank total scores for risky and non-risky subjects was statistically significant (p<0.001). A statistically significant difference was found between the PPHAS score and the occupation, the place/region where the participant lived for the longest time, the family type, previous birth method, the frequency of pregnancy follow-up, the chronic disease presence, the pregnancy type (p<0.05).
Conclusion: There was a significant difference between psychosocial health between risky pregnancies and non-risky pregnancy who participated in this study. The psychosocial health level of the non-risk group was higher and psychosocial health was lower in risky pregnancies.

11.The Relationship between Platelet/Lymphocyte and Neutrophil/Lymphocyte Ratios and Mortality in Intensive Care Patients with Crimean-congo Hemorrhagic Fever
Onur Avcı, Oğuz Gündoğdu
doi: 10.14744/etd.2020.32966  Pages 425 - 430
Objective: This study aims to examine the platelet/lymphocyte ratio (PLR) and neutrophil/lymphocyte ratio (NLR) values in predicting mortality of Crimean-Congo Hemorrhagic Fever (CCHF) patients in an intensive care unit (ICU).
Materials and Methods: This is a retrospective study, and 34 patients diagnosed with CCHF hospitalized in ICU between 1 January 2016–1 January 2020 were included in this study. Demographic data and PLR, NLR, mean platelet volume (MPV), red cell distribution width (RDW), c-reactive protein (CRP) values in their first blood samples taken in ICU were analyzed. Receiver operating characteristic (ROC) curve analyses for the estimation value of the parameters was carried out. The area under the curve (AUC), sensitivity and specificity were used to evaluate the performance of the diagnostic tests.
Results: The mortality rate was 52% (18 exitus). The average length of ICU stay was 10.8±6.6 days. For the value of 8.40 FL for MPV, sensitivity was 83.3%, and specificity was 68.8%. The sensitivity was 88.9% and the specificity was 81.3% for the value of 13.15% of RDW. For NLR, the sensitivity was 83.3%; and the specificity was 87.5% for the value of 2.73. For PLR, the sensitivity was 81.3%, and the specificity was 100% for the cut-off value of 49.94.
Conclusion: PLR and NLR can give the physician an idea about the mortality in patients with severe CCHF; however, studies with a larger number of patients are needed for full validity.

12.The Effects of Art Therapy Techniques on Depression, Anxiety Levels and Quality of Life in the Adolescent with Type 1 Diabetes Mellitus: A Preliminary Study
Elife Başlı, Sevgi Özmen, Esra Demirci, Mustafa Kendirci, Zeynep Uzan Tatlı, Meda Kondolot
doi: 10.14744/etd.2020.45548  Pages 431 - 435
Objective: The incidence of Type 1 Diabetes Mellitus (DM), which is one of the most common chronic diseases of childhood, is increasing all over the world and brings a series of physical, emotional, and social problems. In this study, we aimed to observe the effects of active expressionist art therapy techniques on depression, anxiety, quality of life and diabetes management in adolescents with Type 1 DM.
Materials and Methods: This study included 21 volunteer adolescents with Type 1 DM between the ages of 13-18. All adolescents were evaluated by the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI) and Quality of Life Scale for Children (PedsQL). Then, the program of art therapy techniques was carried out for 12 weeks for 90 minutes a day for every week. Pre-test scales were repeated after the application. HbA1c levels were compared before and after the art therapy techniques program without classification.
Results: In this study, 13 girls (61.9%), 8 boys (38.1%) were included. When the BDI, BAI and PedsQL scores were compared before and after the art therapy techniques in Type1 DM adolescents, a statistically significant difference was found in all scales (p=0.003, p<0.001,p<0.001,p<0.001,p=0.001, respectively). There was no statistically significant difference in HbA1c averages before and after the application (p=0.108).
Conclusion: In this study, after the application of arts therapy techniques, there was a significant decrease in depression and anxiety levels. After the application, improvement in the quality of life scores was found. With this study, it was pointed out that art therapy techniques can be used for diabetic adolescents to self-expression, reduce negative thoughts, express emotions and increase self-esteem.

13.Characteristics and Outcomes of the Patients Infected with SARS-CoV-2 Admitted to Intensive Care Units: Erciyes University COVID-19 Center Experience
Şahin Temel, Kürşat Gündoğan, Birkan Ülger, Hüseyin Arican, Kadir Bulut, Ali Sari, Hilal Sipahioğlu, Ali Yeşiltepe, Ayşim Ertürk, Özgür Karabıyık, Murat Sungur
doi: 10.14744/etd.2020.00907  Pages 436 - 440
Objective: This study aims to investigate the characteristics and outcomes of patients infected with SARS-CoV-2 admitted to the intensive care unit (ICU).
Materials and Methods: This study was performed retrospectively in a medical ICU. All patients admitted to were either laboratory-confirmed or clinically probable COVID-19 patients, and all patients admitted to our ICU during this period were enrolled in the study.
Results: We enrolled 47 patients. The mean age was 68.4±13.4 years and 66% of patients were male. The most common co-morbidities were hypertension (66%) and cardiovascular diseases (40%). The mean APACHE II score was 22.4±8.5, and the first-day median SOFA score was 5 (range: 1–12). Hydroxychloroquine was the most common drug prescribed (78.7%). All patients received at least one antibiotic other than Azithromycin as the most common drug was Piperacillin-Tazobactam (63.8%). Among 47 patients, 55.3% (28 patients) who were admitted to the ICU needed invasive mechanical ventilation. Prone positioning was used in 23% (6 patients) of mechanically ventilated patients. The mean positive end-expiratory pressure (PEEP) was 10±3 cm H2O. The median PaO2/FiO2 ratio was 200 (range, 91–458). The most common ventilator mode was SIMV-PSV volume-controlled mode. ICU mortality rate was 34% (16 patients).
Conclusion: The most common reason to admit SARS-CoV-2 infected patients to our ICU was acute respiratory failure and hypoxemia during the first month of pandemics. COVID-19 patients have a high mortality rate when they develop severe disease.

14.The Role of rs1799889 Genetic Variation in Type 2 Diabetes and Diabetic Nephropathy Risk
Ayşegül Bayramoğlu, Gökhan Bayramoğlu, Halil Ibrahim Güler
doi: 10.14744/etd.2020.04378  Pages 441 - 446
Objective: Type 2 diabetes mellitus (T2 DM) represents a complex metabolic disease with genetic heterogeneity and increasing worldwide prevalence. One of the candidate genes associated with T2 DM and diabetic nephropathy (DN) is the plasminogen activator inhibitor-1 (PAI-1) gene. The present research aimed to reveal the polymorphism frequencies of the PAI-1 gene 4G/5G and to investigate the role of this polymorphism in T2 DM and DN development.
Materials and Methods: The genomic DNA of the 261 individuals was included in this study. The polymerase chain reaction (PCR) method with 4G and 5G allele-particular primers was used to identify the polymorphism of PAI-1 4G/5G. The PCR products were evaluated using a CCD camera after 2% agarose gel electrophoresis.
Results: Although the frequencies of the gene genotypes differed statistically significant between 80 patients and 51 patients with and without DN, respectively, and the control group, no statistically significant difference was detected between those with and without DN. The 5G/5G genotype was found to be significantly higher in the patient group.
Conclusion: The findings suggest that there is a significant correlation between variants of the PAI-1 gene and the risk for T2 DM formation.

15.The Pharmacokinetics of F-18 Fluorocholine in Detecting Breast Cancer Patients
Shazreen Shaharuddin, Hishar Hassan, Shahrun Niza Abdullah Suhaimi, Farida Mustapha, Fathinul Fikri Ahmad Saad
doi: 10.14744/etd.2020.95777  Pages 447 - 451
Objective: The abnormal expression of choline (Cho) metabolism is one of the factors that may contribute to the development of breast cancer. Earlier studies proved that Cho uptakes are varied among the different subtypes of breast cancer. Apart from the ubiquitous 18F-Fluorodeoxyglucose (18F-FDG), the F-18 Fluorocholine (F-18 FCH) has also been proved to be one of the oncologic markers for PET imaging modality. However, it is never been tested on breast cancer patient. Therefore, this study aims to evaluate the distribution of F-18 FCH in breast cancer patient.
Materials and Methods: The biodistribution of 18F-FCH was obtained at two different time points; six minutes and 30 minutes after administration 18F-FCH. The biodistribution data were collected within the first-hour post-injection from the attenuation-correction of whole-body PET scans. The estimation of radiation dosimetry was then calculated using human biodistribution data assuming no redistribution of tracer after one hour.
Results: The F-18 FCH uptake on the malignant tissues was distinguished compared to the uptake in surrounding normal tissue, but much lower than in the liver as the time increases. The 18F-FCH showed a significant difference with high uptake in malignant breast cancer as compared to benign breast cancer with 18F-FCH uptake of (1.66±0.26 vs. 0.56±0.14 (p=0.007).
Conclusion: Although F-18 FCH was never tested on breast cancer patient on PET imaging, the results showed higher SUVmax uptake in the malignant breast tissue as the time increases.

16.Overview of Treatment Methods in Peripheral Major Vascular Injuries: A Retrospective Study
Rıfat Özmen, Muhammet Bozgüney, Tamer Eroğlu, Ali İhsan Tekin, Aydın Tuncay, Deniz Elcik
doi: 10.14744/etd.2020.02800  Pages 452 - 456
Objective: Vascular injuries are observed in 0.2–4% of all traumas and can be life-threatening or difficult when not properly treated. In this study, we aimed to present our experience in the treated vascular injury cases.
Materials and Methods: This retrospective and descriptive study covered the period between May 2014 and December 2018. Medical records of patients with vascular injuries were evaluated concerning demographic and trauma-related parameters.
Results: In this study, 73.1% of 93 patients were male, and the average age was 27.44±6.70 years. In the majority of the patients, it was observed that vascular injuries occurred as a result of penetrating traumas, and mainly radial and superficial femoral arteries were affected. Nerve injuries were found to be accompanied in 16.1% of the patients. The concomitant nerve injuries were also present in 16.1% of the patients. End-to-end anastomosis was used in 73.3% of the injuries. Mortality and amputation rates were 1.1% and 3.2%, respectively.
Conclusion: Demographic and clinical parameters in vascular injury cases were found to be compatible with the previous studies. By collecting the correct data obtained from this study and the other studies, the medical needs of patients with vascular injuries could be better evaluated and clinical services could be planned in advance by conducting a medical approach accordingly.

17.Prognostic Factors in Gallbladder Cancer
Osman Bandırmalı, Zeki Yılmaz, Türkmen Bahadır Arıkan
doi: 10.14744/etd.2020.58897  Pages 457 - 462
Objective: Gallbladder cancer (GBC) is a tumor with poor prognosis, which is rarely seen and challenging to diagnose. Gallbladder cancer is followed by stomach, colon and pancreatic cancers among gastrointestinal system cancers with different geographical distribution. There are different approaches in surgical treatment. Thus, our clinic’s experience of GBC has been evaluated retrospectively.
Materials and Methods: Patients with GBC who were referred to Erciyes University Faculty of Medicine between 2003 and July 2018 were evaluated concerning their demographic characteristics, symptoms, diagnostic methods, surgical treatment, morbidity, mortality and follow-up results.
Results: Of the 1979 cholecystectomy performed in our clinic, 40 (2.0%) had GBC. Of all cases, 21 were male, 19 were female and the mean age was 67 (56–94). The most common symptom was abdominal pain (30%) and jaundice (15%). Abdominal ultrasonography, CT (computerized tomography) or MR (magnetic resonance imaging) were performed for diagnostic purposes. In addition to the diagnosis of cholelithiasis or cholecystitis, 10 (25%) of these patients had asymmetric wall thickness, CA 19–9 height or a tumor mass in the gallbladder, suggesting malignancy in preoperative examinations. Adenocarcinoma and subtypes were found in 33 cases and other malignant types in three cases and dysplasia in four cases after pathologic evaluation. In the follow-up, 31 cases were lost in 0–48 (mean 14.4) months. Nine cases have been monitored for 0–48 (mean 27) months as they are alive.
Conclusion: GBC is a complicated disease with poor prognosis, which is usually diagnosed post-operative, despite surgical treatment.

18.High Mobility Group Box – 1 in Patients with Bacterial Septic Arthritis of the Knee: A Controlled Prospective Study
Alper Öztürk, Yener Bilgetekin, Halis Atıl Atilla, Mesut Emlek, Önder Ersan, Esra Çetin, Ali Yalçındağ
doi: 10.14744/etd.2020.75299  Pages 463 - 467
Objective: High mobility group Box–1 (HMGB-1) is related to inflammation and many kinds of arthritic diseases. Septic arthritis is acute infectious arthritis with potentially devastating outcomes and needs to be diagnosed and treated in an emergent manner. It is not always easy to distinguish septic arthritis from other forms of acute arthritis. In this study, we aimed to find out if serum or synovial HMGB1 can be used for diagnosis and differentiation of septic arthritis.
Materials and Methods: Consecutive patients who were admitted to the emergency department with suspected knee septic arthritis were included in this study. Patients were divided into two groups as septic and non-septic arthritis regarding Newman’s criteria. All patients underwent a laboratory analysis of serum and synovial fluid for white blood cell count, c-reactive protein, sedimentation, cultures, and HMGB1.
Results: There were 23 patients with acute bacterial septic arthritis and 21 with acute non-bacterial arthritis. No difference was observed regarding age and sex. In the septic group, serum WBC, body temperature, sedimentation, CRP and synovial WBC were significantly higher. However, no difference was observed between groups regarding serum and synovial HMGB1 levels.
Conclusion: Although HMGB1 may predict articular damage in any form of arthritis, serum or synovial HMGB1 of patients with bacterial septic arthritis are similar to patients with non-bacterial arthritis.

BRIEF REPORT
19.Estimating COVID-19 Dynamics in Afghanistan
Abbas Ali Husseini, Anton Abdulbasah Kamil
doi: 10.14744/etd.2020.80270  Pages 468 - 473
Little reliable information on novel coronavirus (COVID-19) outbreak is available from war-torn countries, including Afghanistan. The current study estimates the pandemic features based on currently available data to forecasting future challenges of preventive strategies and emergency response using mathematical modeling. The infection fatality and recovery rates were estimated by 1.8% and 20.8%, respectively. The average growth rates of infection, death, and recovery among the Afghanistan population were estimated as 0.2, 0.2, and 0.5, respectively. Also, it was estimated that approximately 6 million people infected in the urban area, which may lead to approximately 11 thousand deaths. However, the features of the pandemic, marks that Afghanistan needs more time to pass the pandemic. Along with this, inadequate community engagement and low abiding to health advice, including social distancing, lack of personnel and testing capacities in the provinces, shortage of laboratory testing supplies, insufficient infection prevention, and control measures in health facilities in some of the provinces, limited access to and response capacities are the main challenges to fight against COVID-19. Therefore, the majority of infected cases and deaths may not be reported, and preventive strategies effectively in Afghanistan could severely be disrupted by several socio-cultural, financial, political, and administrative obstacles.

CASE REPORT
20.A Male Infant with Congenital Chylous Ascites Accompanied by Hypertension
Derya Altay, Ismail Dursun, Zübeyde Gündüz, Duran Arslan
doi: 10.14744/etd.2020.98048  Pages 474 - 476
Background: Congenital chylous ascites is a condition that arises from a disorder of the abdominal lymphatic system.
Case Report: In this case study, a nine-month-old infant diagnosed with congenital chylous ascites in the newborn period presented with hypertension and chylous ascites.
Conclusion: His hypertension was disappeared with the effective treatment of ascites. Patients with chylous ascites should be carefully evaluated concerning hypertension.

21.Brucellosis Presented with Fever and Generalized Maculopapular Rash
Hasan Tahsin Gözdaş, Fatma Sırmatel, Hayrettin Akdeniz
doi: 10.14744/etd.2020.34033  Pages 477 - 479
Background: Brucellosis is a multisystemic zoonosis that can affect all body organs and systems. Musculoskeletal system is the most affected system; however, cutaneous involvement is quite rare.
Case Report: A 31-year-old male who was previously healthy was admitted with fever and generalized maculopapular rash for the last three days before his admission to the hospital. He was eventually diagnosed with brucellosis based on the clinical history and epidemiological features. Brucellosis treatment was administered for six weeks and the patient recovered completely.
Conclusion: In endemic regions, brucellosis should be included in the differential diagnosis of the patients presenting with fever and generalized maculopapular rash.

22.Dyskinesia in a Prepubertal Boy After the First Dose of Methylphenidate and the Association of Focal Epileptiform Activity: A Case Report
Ahmet Çevikaslan, Özgür Duman, Muhammet Gültekin Kutluk
doi: 10.14744/etd.2019.04317  Pages 480 - 482
Background: Methylphenidate is a piperidine derivative stimulant drug. It inhibits the reuptake of dopamine and norepinephrine and improves the primary symptoms of Attention-Deficit/Hyperactivity Disorder. Methylphenidate may cause dyskinesias in children with Attention-Deficit/Hyperactivity Disorder, and concomitant irregularity in Electroencephalography may increase the likelihood of the neuropsychiatric side effects.
Case Report: A case of a 6.5-years-old boy who was admitted to the emergency room with unintended and uncontrolled behaviours after the first dose of this drug was presented. He was diagnosed with acute dyskinesia in the orofacial region and extremities, and then he was cured with biperiden lactate infusion in eighteen hours. Focal biphasic waves at right temporoparietal areas were recorded on his sleep-Electroencephalography.
Conclusion: In our case with both attention-deficit/hyperactivity disorder and epileptiform activity, dyskinesia occurrence after one single dose of 20 mg methylphenidate was discussed with the results of previous studies.

23.COVID-19 in Kazakhstan: A Fatal Case Report
Saule Maukayeva, Alma Tokayeva, Zhanar Issabekova, Aliya Kiyebayeva, Saya Karimova
doi: 10.14744/etd.2020.37630  Pages 483 - 485
Background: COVID-19 is a new severe acute respiratory infection that arises from coronavirus SARS-CoV-2, that has spread around the world, including Kazakhstan. Here, a fatal clinical case with COVID-19 in East Kazakhstan was presented.
Case Report: A 40-year woman complained of severe weakness, fever (39,0oC), body aches, headache, malaise, dry cough, chest pain, shortness of breath, feeling of lack of air for four days. The condition was severe due to acute respiratory and acute cardiovascular failure. She was inhibited; her skin was cyanotic, cold. Her temperature - 35o C, cachexia, breath rate – 39/min, blood pressure - 50\30 mmHg., pulse rate – 122/min, SO2 – 52, weak breathing in auscultation of lungs, moist rales and hepatomegalia. She did not travel outside the city, the history of alcohol abuse. Laboratory examination revealed leukopenia, thrombocytopenia, ESR acceleration, CRP increase, and positive PCR of nasopharyngeal smear on COVID-19. Chest Х-ray showed bilateral focal pneumonia. Acute onset, toxemia, pneumonia, severe course complicated with acute respiratory and acute cardiovascular failure, positive PCR on COVID-19 were supported by a clinical diagnosis of COVID-19, pneumonia, severe course. Complications includedacute respiratory failure II-III, acute respiratory distress syndrome, accompanying disease – alcohol intoxication. Antibiotic therapy with Clavam 1200 mg x 1 time intravenous N1 were started together with intravenous fluid infusions. Tracheal intubation was performed. Although mechanical ventilation and ongoing resuscitation saturation did not rise, cardiac arrest developed and resulted in death.
Conclusion: The physicians should be aware of the clinical presentations of the severe pneumonia as local cases of the COVID-19.

24.Primary Tonsillar Tuberculosis: Is it Really a Rare Entity?
Vinota Paniselvam, Chee Chean Lim, Fong Juen Kiew, Gagandeep Mann
doi: 10.14744/etd.2020.53900  Pages 486 - 488
Background: Oropharyngeal tuberculosis (TB), including tonsillar TB, is rare in an immunocompetent adult. Tonsillar TB is more likely to occur as a result of pulmonary TB causing secondary inoculation of tubercle bacilli. The primary form of tonsillar TB without pulmonary TB has often been described as an extremely rare form of extra-pulmonary TB.
Case Report: In this case study, we aim to illustrate an incidental finding of primary tonsillar TB in an immunocompetent adult presenting with asymmetrical tonsillar hypertrophy. At the same time, we included two other cases of oropharyngeal TB originating from our centre reported in the literature recently to highlight the likelihood that it may be much more common, especially in endemic parts of the world.
Conclusion: Better awareness of this condition would constitute an early referral to the otorhinolaryngology team, which will enable timely treatment and complete recovery.

IMAGE
25.Sudden Hearing Loss Secondary to Cholesteatoma Induced Labyrinthine Fistula
Geng Ju Tuang, Shankar Ramasundram, Abdul Ruhi Ul Azim Liman
doi: 10.14744/etd.2020.04568  Pages 489 - 490
Abstract | Full Text PDF

26.Ranula on the Floor of the Mouth
Satvinder Singh Bakshi
doi: 10.14744/etd.2020.24622  Pages 491 - 492
Abstract | Full Text PDF

LETTER TO THE EDITOR
27.Convalescent (Immune) Plasma Therapy and COVID-19
Viroj Wiwanitkit
doi: 10.14744/etd.2020.09125  Page 493
Abstract | Full Text PDF

28.Effectiveness and Safety of Convalescent (Immune) Plasma Therapy in COVID-19
Öner Özdemir
doi: 10.14744/etd.2020.73483  Pages 494 - 495
Abstract | Full Text PDF

HISTORY OF MEDICINE - ORIGINAL ARTICLE
29.Regimen of elders in Kitāb al-Dhakhīra fī ‘Ilm al-Tibb by Thābit b. Qurra
Gözde Acıduman, Ahmet Acıduman
doi: 10.14744/etd.2020.44788  Pages 496 - 502
Objective: This study aimed to examine the chapter related to regimen of elders in Kitāb al-Dhakhīra fī ʿIlm al-Ṭibb by Thābit b. Qurra (836–901 AD), a renowned translator and scholar of the translation period of Islamic science and medicine.
Materials and Methods: An exact copy of Kitāb al-Dhakhīra fī ʿIlm al-Ṭibb edited by G. Sobhy and printed in al-Ma ba‘at al-Āmīriyye was examined and compared to the manuscript in the Şehit Ali Paşa Collection, nr. 2028, in the Süleymaniye Manuscript Library in Istanbul. The subchapter on regimen of elders was translated and has been discussed.
Results: Information on regimen of elders is the last subheading of the first chapter, which is on health protection. Considering the content, the physiology and pathology of senility and its related regimen are coherent with the principles of the humoral theory.
Conclusion: As Thābit b. Qurra mentioned, the main source of information regarding regimen of elders in Kitāb al-Dhakhīra fī ʿIlm al-Ṭibb seems to be the writings of Galen.

ERRATUM
30.Erratum

Page 503
Abstract | Full Text PDF

OTHER
31.Reviewer List

Page 504
Abstract | Full Text PDF

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