Lamivudine Therapy in Acute Leukemia Patients who are Hepatitis B Surface Antigen Carriers

Background: Reactivation of hepatitis B in patients receiving chemotherapy for acute leukemia may give rise to a variety of clinical patterns including hepatitis, asymtomatic hepatic dysfunction, massive hepatic necrosis and fatal hepatic failure. Lamivudine is a nucleoside analogue which can directly suppress Hepatitis B virus (HBV) replication. We reviewed our combined experience to evaluate the role of lamivudine as prophylaxis in acute leukemia patients who were HBsAg carriers treated with chemotherapy between July 2000 and October 2002 at the Numune Education and Research Hospitals (Ankara, Turkey) retrospectively.

Methods: We investigated 75 acute leukemia patients who received chemotherapy. Thirteen (17.3%) of 75 acute leukemia patients were HbsAg positive and of 7 (53.3%) were HBV DNA positive. Two patients (patients 5 and 6) had a chemotherapy regimen that included corticosteroids and were HBsAg and HBV DNA negative but anti HBc total positive. HBsAg positive patients with or without HBV DNA positivity were treated with a dose of 100 mg/day lamivudine commencing when chemotherapy was initiated. Lamivudine started at the beginning of chemotherapy and was maintained for 6 months following the cessation of chemotherapy. During lamivudine treatment, Aspartate aminotransferase (AST), Alanine aminotransferase (ALT), Gama glutamile transpeptidase (GGT), Alkaline phosphatase (ALP) were followed.

Results: Of the 8 patients who presented with hepatic dysfunction during the first chemotherapy cycle, 4 improved during the second course. After completing chemotherapy, the levels of hepatic enzymes were in the normal range in all but one patient. With lamivudune prophylaxis, HBV DNA positivity did not develop in any of the HBV DNA negative patients. The two patients who received corticosteroids with their first chemotherapy cycle became positive for HBsAg and HBV DNA and were given Lamivudine when the seroconversion was established. Median follow up from the diagnosis of leukemia was 14.5 months. Survival rate at the end of follow up was 5 (38%) for the 13 patients.

Conclusions: As this infection is endemic in our country and the exposure to blood products is high in these patients, HBV infection is more common. Prophylaxis with daily administration of lamivudine to HBsAg carriers who are candidates for chemotherapy seems to be effective and may prevent chemotherapy induced HBV reactivation and hepatic failure.     

Cost of illness among patients with diabetic foot ulcer in Turkey

AIMTo evaluate the annual cost of patients with Wagner grade 3-4-5 diabetic foot ulcer (DFU) from the public payer’s perspective in Turkey.METHODSThis study was conducted focused on a time frame of one year from the public payer’s perspective. Cost-of-illness (COI) methodology, which was developed by the World Health Organization, was used in the generation of cost data. By following a clinical path with the COI method, the main total expenses were reached by multiplying the number of uses of each expense item, the percentage of cases that used them and unit costs. Clinical guidelines and real data specific to Turkey were used in the calculation of the direct costs. Monte Carlo Simulation was used in the study as a sensitivity analysis.RESULTSThe following were calculated in DFU treatment from the public payer’s perspective: The annual average per patient outpatient costs $579.5 (4.1%), imaging test costs $283.2 (2.0%), laboratory test costs $284.8 (2.0%), annual average per patient cost of intervention, rehabilitation and trainings $2291.7 (16.0%), annual average per patient cost of drugs used $2545.8 (17.8%) and annual average per patient cost of medical materials used in DFU treatment $735.0 (5.1%). The average annual per patient cost for hospital admission is $7357.4 (51.5%). The average per patient complication cost for DFU is $210.3 (1.5%). The average annual per patient cost of DFU treatment in Turkey is $14287.70. As a result of the sensitivity analysis, the standard deviation of the analysis was $5706.60 (n = 5000, mean = $14146.8, 95%CI: $13988.6-$14304.9).CONCLUSIONThe health expenses per person are $-PPP 1045 in 2014 in Turkey and the average annual per patient cost for DFU is 14-fold of said amount. The total health expense in 2014 in Turkey is $-PPP 80.3 billion and the total DFU cost has a 3% share in the total annual health expenses for Turkey. Hospital costs are the highest component in DFU disease costs. In order to prevent DFU, training of the patients at risk and raising consciousness in patients with diabetes mellitus (DM) will provide benefits in terms of economy. Appropriate and efficient treatment of DM is a health intervention that can prevent complications.     

Use of polymerase chain reaction in diagnosis of occult tuberculosis of the fibula

An unusual case of tuberculosis of the lower end of the fibula in a young patient is reported. The patient presented with symptoms of pain and swelling over the outer aspect of the right ankle with full range of painless ankle movements. The plain radiographs of the ankle were normal but MRI scan showed increased signals within the lower end of the fibula on T2-weighted images. The histology of the lesion showed only a few Langhans giant cells and culture failed to grow any organism. Polymerase chain reaction analysis of the biopsy specimen, however, showed growth of Mycobacterium tuberculosis. The patient responded to antitubercular treatment with complete resolution of symptoms. Polymerase chain reaction analysis should be considered in atypical presentations with bone pain to rule out an occult infectious pathology.     

Characteristics of daily and occasional smoking among youths

OBJECTIVES: The purpose of this study was to develop a more detailed understanding of the characteristics of occasional smokers, and how the characteristics of occasional smokers differ from those of daily smokers. This information can then be used in youth smoking programmes to better address these differences in a manner that would target appropriate youth with appropriate cessation methods. METHODS: A questionnaire was administered to 976 university students, aged between 18 and 25 years, in Ankara, Turkey. The topics covered included age, sex and tobacco use characteristics. Daily and occasional smokers were defined according to traditional definitions of smoking. RESULTS: Among the 976 students surveyed, 482 (49.4%) reported being active smokers. Among these smokers, 199 (41.3%) were classified as occasional smokers and 283 (58.7%) were daily smokers using the traditional definitions of smoking. Many of the active smokers had relatives or friends who also smoked, specifically, 46.5% had a father who smokes, 13.3% had a mother who smokes, 26.8% had an older brother or sister who smokes, and 69.7% had two or more close friends who smoke. Although more than 51.3% of smokers planned on quitting smoking, only 26.1% had previously tried to quit smoking but 64.7% believed they could successfully quit. Daily smokers reported that they made fewer attempts to quit smoking than occasional smokers. More often than occasional smokers, daily smokers reported that they smoke because they like the image, they are addicted, smoking relieves stress and/or their friends smoke. Occasional smokers reported that they smoke less at home or at the university than in other places, and smoke more often with friends than when alone or with family members. This pattern is encouraged by the family structure in Turkish society, where smoking by adolescents at home in the presence of family members is frowned upon. CONCLUSIONS: This study demonstrates substantial differences between occasional and daily smokers. If effective future smoking prevention and cessation programmes that target youth are going to be developed, data like those gathered in this study are critical. Basic information regarding cigarette consumption patterns, while important, is insufficient to understand behaviour and key factors that trigger smoking among the youth population.     

Risk factors for thrombophilia in young adults presenting with thrombosis

The increased risk for thrombosis is known as hypercoagulability or thrombophilia. Here, we investigated risk factors for thrombophilia which were screened in young adult patients presenting with thrombotic events or with recurrent abortions with unknown etiology. A total of 115 patients aged between 16 and 50 years who were found to harbor thrombophilia were retrospectively evaluated. The laboratory investigations performed for the assessment of thrombophilia included protein C, protein S, antithrombin III deficiencies, activated protein C resistance, factor V Leiden (FVL), prothrombin 20210A (PT 20210) and methylenetetrahydrofolate reductase (MTHFR) gene mutations, factor VIII elevation, lupus anticoagulant and antiphospholipid antibodies (APA). In 66% of the cases a single thrombophilic defect was identified while some of the patients had combined thrombophilic defects. The most common thrombophilic defect was mutation in the MTHFR gene, and was followed by FVL mutation, the presence of APA and PT 20210 gene mutation, respectively. The patients were divided into two different age groups, 16–35 and 36–50 years, and arterial thrombosis was more common in the older age group. Our results indicated that some important thrombophilic defects such as gene mutations may appear in young adult patients presenting with thrombotic events.     

Disability of Arm Shoulder and Hand Questionnaire in rheumatoid arthritis patients: relationship with disease activity, HAQ, SF-36

Rheumatoid arthritis (RA) is a systemic disease that causes disability. Disability and quality of life indexes are used in the assessment and treatment of patients with RA. Disability of Arm, Shoulder and Hand Questionnaire (DASH) is a patient-based outcome measurement developed to evaluate the upper extremities. The aim of this study was to investigate the clinical relevance of DASH in RA patients and the relationship between disease activity and health-related quality of life measurements. One hundred and sixty-six RA patients were included in the study. Disease activity was measured with Disease Activity Score 28 (DAS28), Simplified Disease Activity Index (SDAI), and Clinical Disease Activity Index (CDAI). The DASH questionnaire, Short-Form 36 (SF-36), and Health Assessment Questionnaire (HAQ) were completed by all patients. The DASH score moderately correlated with DAS28 (r = 0.672), SDAI (r = 0.586) and CDAI (r = 0.565). When the patients were grouped according to the activity obtained using the three disease activity measurements, DASH score was statistically significantly higher with higher disease activity (P < 0.001). A high correlation (r = 0.883) was found between DASH and HAQ (r = 0.883). The SF-36 scores were correlated with DASH (r = −0.785 with physical component, r = −0.619 with mental component). DASH scores correlate with disease activity indices, functional disability and QoL and can be used in the assessment of upper extremities in patients with RA.