Symptom prevalence and risk factors for asthma at the rural regions of Denizli,Turkey

Objective

This study was conducted using a standardised method (ECRHS) to identify the prevalence of asthma symptoms and risk factors in adults who lives in the rural regions of Denizli province.

Methods

This study was designed as a cross-sectional study to investigate the prevalence of asthma and asthma symptoms in adults older than 18 years old, around the rural regions of Denizli. Data were collected by personal interview and filling in questionnaires between July 2009 and September 2009.

Results

A total of 1,343 individuals were enrolled. Prevalence of current asthma was 5.9%, having an asthma-like symptom was 34.0% and allergic rhinitis was 2.5%. Most common asthma symptoms were woken by an attack of breathlessness (20.5%, n=275), woken by attack of cough (19.9%, n=267) and wheezing (12.7%, n=171).

Conclusions

Asthma is an important disease that may occur not only in cities but also at country sides. In rural areas risk factors for asthma and asthma-like symptoms compared to urban areas may show some differences.     

Computerised risk scores to guide recognition and diagnosis in patients with possible heparin‐induced thrombocytopenia

The heparin‐induced thrombocytopenia computerised risk (HIT‐CR) score is designed to aid in the diagnosis of HIT. We sought to evaluate its potential clinical utility. In this retrospective cohort study, we collected HIT‐CR scores on all inpatients receiving heparin over a 4‐month period and performed chart reviews on the subset who independently underwent clinical diagnostic testing for HIT to identify patients with HIT. In all, 34 342 patients received heparin, 1744 had high‐risk HIT‐CR scores of ≥3 and 220 had the maximal risk score of 4. Only 6% of high‐risk and 10% of maximal‐risk patients underwent testing for HIT. Conversely, among all 317 patients who underwent independent testing for HIT, 67% had low‐risk HIT‐CR scores (<3). Among patients independently tested, the positive predictive value (PPV) was 6·6% [95% confidence interval (CI) 4·9–8·8%] and the negative predictive value (NPV) was 99·5% (95% CI 97·1–99·9%) at a HIT‐CR score cut‐off of 3, and the PPV was 22·7% (95% CI 12·7–37·4%) and NPV was 99·0% (95% CI 97·6–99·6%) at a cut‐off of 4. This study suggests clinicians fail to test most high‐risk patients and unnecessarily test many low‐risk patients for HIT. A reasonable approach to clinical application of HIT‐CR scores would be recommending no testing for patients with a score of <3 and recommend testing for patients with a score of 4.     

Serious infections in adults due to group B streptococci: Clinical and serotypic characterization

Serious infections in adults due to group B streptococci have been infrequently reported. We describe 24 such patients. Bacteremic pyelonephritis, pneumonitis and endometritis were the most common clinical syndromes observed. Group B streptococcal infections tended to occur in patients with underlying illnesses, particularly genitourinary disorders and diabetes mellitus. Mortality was surprisingly low (8 per cent). Type III was the serotype most commonly isolated, and there was no significant correlation of different serotypes with specific organ-system involvement. Group B streptococcal isolates from these patients were uniformly sensitive to penicillin, ampicillin, cephalothin, chloramphenicol, erythromycin and clindamycin; all were highly resistant to kanamycin. Eighty-seven per cent were resistant to tetracycline. Although consistently sensitive to penicillin, the minimal inhibitory concentrations were significantly higher for group B than group A streptococci (p < 0.0005).     

Exercise-induced bronchospasm in children: comparison of FEV1 and FEF25-75% responses

The response of asthmatic children to exercise has usually been evaluated by forced expiratory volume in 1 sec (FEV(1)). We reasoned that other respiratory indexes derived from the forced vital capacity maneuver such as forced expiratory flow between 25-75% of vital capacity (FEF(25-75%)) would add significant information in the evaluation of the relationship between asthma severity and response to exercise. We studied 164 children with intermittent (n = 63), mild persistent (n = 30), moderate persistent (n = 40), and severe persistent asthma (n = 31). Subjects exercised for 6 min on a cycle ergometer at 80% of their maximum heart rate, and spirometry was performed before and 5, 10, and 20 min after exercise. There was good correlation between changes in FEV(1) and FEF(25-75%) after exercise (r = 0.60, P < 0.001 for intermittent asthma and r = 0.80, P < 0.001 for severe persistent asthma). The presence of a fall in both FEV(1) (>/=10%) and in FEF(25-75%) (>/=26%) when compared to a decrease in only one of these two indexes was significantly greater in children with more severe asthma (60.0% for intermittent asthma and 94.4% for severe persistent asthma, P = 0.022). FEF(25-75%) can decrease in response to exercise without changes in FEV(1), mainly in children with mild asthma. In the evaluation of the response to exercise in children with different asthma severities, more than one maximum expiratory flow-volume parameter should be used.     

Contribution of cross-sectional echocardiography to the diagnosis of right ventricular dysplasia at the asymptomatic stage

The diagnostic accuracy of conventional exercise electrocardiographywas compared with exercise algorithms specifically aimed atapplication in females, with R wave and heart rate adjustedST-segment changes, and with discriminant analysis. A symptom-limitedbicycle exercise test was performed by 189 females without previousinfarction with a normal electrocardiogram (ECG) at rest. Franklead ECG was computer processed. ST-segment amplitudes in leadX were superior to measurements in lead Y, but their sensitivityamounted only to 50% at a specificity of 90%. Correction forR wave amplitude marginally increased sensitivity. It was confirmedthat leads with inferiorly directed vectors such as standardleads II, III, a VF or Frank lead Y should not be used for diagnosticpurposes in females. Exercise-induced increases in R-wave amplitudeof at least 01 mV occurred in only 8% of females with coronarydisease. Previously described discriminant function using attainedheart rate, ST-segment depression and a sex-dependent ST segmentcorrection factor yielded a sensitivity of 60% at a specificityof 90%. Sensitivities of heart rate adjusted ST-segment changesand of a previously proposed discriminant function were greaterthan 70% at a specificity of 90%. It is concluded that the diagnosticyield of exercise testing in females can be improved by useof more sophisticated electrocardio-graphic and exercise variables.     

Selective sphincteroplasty of the papilla in cases at risk due to atypical anatomy

AIM: To analyze the indications, effi cacy and safety of sphincteroplasty in our centre. METHODS: A retrospective study of sphincteroplasty in 53 cases of papilla at high risk was performed in 2004-2006. The procedure consisted of duodenoscopy with Olympus TJF 145 Videoduodenoscope, approach to the biliary tract using a catheter with a guidewire, and dilatation of the papilla with a dilatation balloon catheter using a syringe with a manometer for control of the fi lling pressure. RESULTS: The indications included intradiverticular papilla in 26 patients (49/), stenosis of a previous sphincterotomy in 19 patients (35.8/), small size of the papilla in 4 patients (7.5/), Billroth Ⅱ gastrectomy in 3 patients (5.6/), and coagulopathy in one patient (1.9/). The efficacy was 97.8/, with all the calculi extracted from the common bile duct in 84.4/ of the patients, even though 21 of the patients (39.6/) had calculi with a diameter equal to or greater than 10 mm. Seven patients (13.2/) presented complications: haemorrhage in 1 patient (1.9/) and mild pancreatitis in 6 patients (11.3/). The mean hospital stay in case of complications was of 3 ± 0.63 d. CONCLUSION: Sphincteroplasty is highly effective, with a complication rate similar to that of sphincterotomy, furthermore, the complications are of low clinical importance. The use of the 10 mm balloon makes it possible to extract calculi with a diameter of over 15 mm and to extract more than 3 calculi without increasing the rate of complications and reduces the need to resort tolithotripsy or rescue sphincterotomy.     

Acute bronchiolitis: predisposing factors and characterization of infants at risk

Fifty-one infants hospitalized because of acute bronchiolitis and 24 control children were prospectively followed until 2 years of age. Respiratory syncytial virus was detected initially in 31 index children, parainfluenza virus in two, and rhinovirus in one. More index children were born during the months April through September, and six index children had neonatal respiratory complications. The index children were breast-fed for shorter periods, lived in more crowded homes, and had more siblings. No significant differences were found for atopic background and atopic illness at 2 years of age. The index children had more respiratory infections and episodes of bronchopulmonary obstruction during the follow-up period (60% with three or more episodes). To characterize the hospitalized children, a discriminant analysis was performed. A discriminant function classified 47 of 51 index children as belonging to the index group and 21 of 24 control children to the control group.     

Being a patient with early stage Parkinson disease: reaction to the diagnosis and management

This personal viewpoint, written by a neurologist with Parkinson disease (PD), is to provide a patient's perspective, to accompany the clinical perspective in this issue of the Intenal Medicine Journal entitled 'Approach to the patient with early stage Parkinson disease'. The aim is to provide a personal insight into the numerous issues surrounding early diagnosis and management of PD, from the position of being a physician patient.     

Leisure-time physical activity at weekends and the risk of Type 2 diabetes mellitus in Japanese men: the Osaka Health Survey.

AIMS: To investigate association between leisure-time physical activity at weekends and the risk of developing Type 2 diabetes mellitus (DM). METHODS: Prospective examination of 6,013 Japanese men aged 35-60 years who were free of DM, impaired fasting glycaemia, or hypertension at study entry. Type 2 DM was defined by a fasting plasma glucose level > or = 7.0 mmol/l or a 2-h post-load plasma glucose level > or =11.1 mmol/l. Data on physical activity obtained from questionnaires consisted of overall leisure-time physical activity weekly and leisure-time physical activity at weekends. RESULTS: During the 59,966 person-years follow-up, 444 cases developed Type 2 DM. Regular physical exercise at least once a week was associated with a reduced risk of Type 2 DM. After adjustments for age, body mass index, daily alcohol consumption, smoking habits, blood pressure levels and a parental history of Type 2 DM, men who engaged in regular physical exercise at least once a week had a relative risk of Type 2 DM of 0.75 (95% CI, 0.61-0.93) compared with men engaging in exercise less often. Even vigorous activity only once a week at weekends was associated with a reduced risk of Type 2 DM. Men who engaged in vigorous activity at least once a week at weekends had a multiple-adjusted relative risk of Type 2 DM of 0.55 (95% CI, 0.35-0.88) compared with sedentary men. CONCLUSIONS: Regular physical exercise at least once a week and vigorous activity even only once a week at weekends are associated with a decreased risk of Type 2 DM.     

Septic arthritis due to group C streptococcus: report and review of the literature

A case of polyarticular septic arthritis due to Lancefield group C streptococcus is described and the clinical details of 9 reported cases of septic arthritis due to group C streptococcus reviewed. Several features of the presentation and course of these patients, including polyarticular involvement (4/10), bacteremia (5/10), clinically important dysfunction in other systems (4/10 patients: cardiac, 3; CNS, 2; pneumonia, 1; gastrointestinal, 1), fatal outcome (3/10 patients, 2 during the course of active infection) and poor functional outcome in affected joints (4/7 surviving patients), serve to place group C streptococcus septic arthritis as a syndrome distinct from that usually expected with streptococcal septic arthritis. Specific features of the bacteriology of group C streptococcus are reviewed (including confusion with group A streptococcus when analyzed using nonserologic methods, occasional zoonotic source, and frequency of tolerance to penicillin) in order to emphasize the importance of both the specific identification of this particular streptococcal strain and the initiation of aggressive antibiotic therapy when group C streptococcus is identified as the causative agent in a case of septic arthritis.     

A "new" congenital haemorrhagic condition due to the presence of an abnormal factor X (factor X Friuli): study of a large kindred

Summary Three related patients are presented who show a congenital coagulation disorder with laboratory features intermediate between classical factor-VII and factor-X deficiencies. A woman and two men had suffered from bleeding since early childhood, with epistaxis, bleeding from the gums, post-traumatic haemarthroses, bleeding after tooth extractions and other surgical procedures. Investigation demonstrated a prolonged prothrombin time, prolonged partial thromboplastin time, abnormal prothrombin consumption and abnormal thromboplastin generation corrected by normal serum. Platelet and vascular tests were normal and no hyperfibrinolysis was found. Factors I, II, V, VII, IX, XI and XII were within normal limits in all three patients. Mutual correction was demonstrated with a known factor-VII-deficient plasma but not with Stuart (X-deficient) plasma. Factor-X assay yielded low (4–9%) levels using tissue whole thromboplastin or tissue partial thromboplastin; but the results were normal with a Stypven-cephalin mixture. In agreement with these results, the Stypven-cephalin clotting time, the Stypven clotting time and the factor II + factor X level using a Stypven-cephalin mixture were normal, ‘correction’ being attributable to the Russell's Viper venom. These results were thought to indicate an abnormal factor X rather than a real deficiency. The presence of abnormal factor X was demonstrated by the antibody neutralization technique and by the immunodiffusion studies. The defect, like classical factor X deficiency, is transmitted as an autosomal incompletely recessive trait. The heterozygote population has factor-X levels varying from 32% to 55% of normal and are usually asymptomatic. The term ‘Factor X Friuli’ is proposed for the abnormality, due to a locally common mutant gene.     

The de Quervain's screening tool: validity and reliability of a measure to support clinical diagnosis and management

Background: Studies into the effectiveness of interventions for upper limb soft tissue disorders have been hampered by a lack of consistently used diagnostic criteria, meaning that comparison of research results is a problem. To aid homogeneous recruitment into a study of de Quervain's disease, a de Quervain's screening tool (DQST) was developed. This could also be used to facilitate clinical diagnosis and management in practice. Aims: To provide evidence for the content and construct validity and test–retest and inter‐rater reliability of the DQST. Method: The study was conducted in an acute care, outpatient hand unit in a district general hospital. Three convenience samples of: 59 people with de Quervain's disease; 18 with carpal tunnel syndrome (CTS) and 16 with osteoarthritis (OA) of the carpometacarpal (CMC) joint were recruited. The DQST diagnostic criteria were initially generated from a literature review. Content validity was then established by expert doctors with an interest in upper limb musculoskeletal disorders (n = 7) rating the relevance of the seven items included. The DQST was then tested in people either already diagnosed with, or reported as having some of the symptoms of, de Quervain's disease. Construct validity was tested with people with CTS or OA of the CMC joint. Results: The median DQST score was 5 (Interquartile range IQR = 4–6) out of a possible seven diagnostic criteria. Inter‐rater reliability was excellent (Intra‐class coefficient [ICC] = 0.85; 95% confidence interval [CI] = 0.75, 0.91). Test retest reliability was good (ICC = 0.64; 95% CI = 0.20, 0.87). Sensitivity (Se) and specificity (Sp) testing (Se = 1.00; Sp = 1.00) demonstrated that the DQST discriminated between people with de Quervain's disease, CTS or OA of the CMC joint. Conclusions: The DQST is a valid, reliable tool which could be of assistance in aiding correct diagnosis for recruitment to clinical trials and in clinical practice. Future research is recommended to further examine retest reliability with a larger sample size and to identify the commonest diagnostic criteria required for inclusion. Copyright © 2008 John Wiley & Sons, Ltd.     

Natural and evoked atrial flutter due to circus movement in dogs: Role of abnormal atrial pathways, slow conduction, nonuniform refractory period distribution and premature beats

Natural atrial flutter was discovered In a dog. Two forms of the arrhythmia resembling the human counterparts of typical and atypical atrial flutter were noted. The Observations in this dog led to studies in a series of normal dogs in which the extrastimulus technique was used to evoke runs of repetitive activity simulating but unlike true atrial flutter. Epicardial atrial activation maps were made from 72 to 96 bipolar complexes recorded during the arrhythmias. Multiple effective refractory periods were determined and these values were used to construct maps of the refractory period distribution. Dog 1, with true atrial flutter, demonstrated a complex form of circus motion characterized by unidirectional block and one-way conduction. Abnormal slowing of the unblocked circus wave stabilized and maintained the repetition by permitting more time for recovery of a uniform state of excitability ahead of the wave. The slow conduction in this dog was associated with right atrial hypoplasia and discontinuity in the preferential atrial conduction pathways. The circus activation patterns in the dogs with evoked flutter were similar to those in true flutter; however, the cycle lengths were shorter and the circus wave conducted faster. In evoked flutter the regional differences in refractory period duration determined the one-way block and circus conduction patterns. The circus pattern was caused by a nonuniform bimodal refractory state of the atrium that simultaneously exerted a blocking effect while permitting conduction and complex shaping of the unblocked wave, which was routed back to its site of origin. Thus atrial flutter was the result of three Interacting factors: (1) an atrial premature beat, (2) nonuniform distribution of atrial refractory periods, and (3) slow conduction of the circus wave initiated by factors 1 and 2.