Management of gestational diabetes by physicians in Turkey

AimsWe sought to investigate the practice patterns of clinicians (family physicians, internists and obstetricians) in Turkey in screening for gestational diabetes mellitus (GDM), management and monitoring of hyperglycaemia in pregnant women with GDM, and assessment of glucose tolerance in the postpartum state.MethodsBetween January and December 2007, current practices of Turkish physicians (n = 434) were assessed by a questionnaire which was concerned with physician demographics and clinical practice including screening and diagnostic methods for GDM, management of GDM during pregnancy and postpartum assessment of glucose tolerance. The questionnaire was developed in respect to the recommendation of the Fifth International Workshop-Conference on GDM and the standards of the American Diabetes Association (ADA).ResultsAlthough most of the physicians stated that they performed screening for GDM and postpartum screening for glucose intolerance in women with GDM, their screening practices vary. The proportion of women who were provided with a nutrition counselling by a registered dietician and a patient education by a trained nurse was low, especially in women treated by the family physicians. Home glucose monitoring was widely used in the management of GDM, however, postprandial glucose assays were used occasionally. Regular and NPH insulin preparations were the most preferred drugs to treat GDM. Internists were more likely to use insulin analogues. On the other hand, a significant number of physicians stated that they used oral antidiabetics (OADs). A considerable number of family physicians used OADs which have not been proved to be safe in pregnancy.ConclusionsOur results suggest that there is considerable variation in the clinical practice patterns of physicians. An education program to enhance the clinical aptitude of physicians, particularly family physicians, in the medical management of GDM should be designed throughout the country.     

Exogenous subclinical hyperthyroidism impairs endothelial function in nodular goiter patients.

BACKGROUND: Exogenous subclinical hyperthyroidism is associated with cardiovascular and metabolic changes. The aim of this study was to evaluate the effect of levothyroxine (LT4) suppression on endothelial function and insulin sensitivity in euthyroid nodular goiter patients. METHODS: Twenty-two euthyroid patients with multinodular goiter (MNG) and 22 matched healthy controls were studied. LT4 was administered in doses ranging from 50 to 150 microg/day to reach target serum thyroid-stimulating hormone (TSH) levels <0.5 mIU/L. Patients were studied before and after 8 weeks after the target TSH level <0.5 mIU/L. The control group was studied twice, 16 weeks apart. Flow mediated vasodilatation (FMD), insulin sensitivity index (ISI), lipid peroxidation, and high-sensitivity C-reactive protein (hsCRP) were the outcome measures. RESULTS: LT4 treatment significantly suppressed TSH levels to 0.2 +/- 0.1 mIU/L (minimum and maximum range was 0.05-0.3 mIU/L). FMD decreased from 10.7 +/- 2.7% to 5.4 +/- 1.7% (p < 0.001) and mean ISI decreased from 2.56 +/- 1.10 to 1.41 +/- 0.50 (p < 0.001) with LT4 treatment in the MNG group. Lipid peroxidation measured as thiobarbituric acid reactive substances (Tbars) (p < 0.05), and hsCRP (p < 0.001) levels significantly increased compared to the baseline in the MNG group. FMD measurement inversely correlated with free T4 (p = 0.008) and Tbars (p = 0.004), and positively correlated with ISI (p = 0.004). Serum Tbars and hsCRP were independent predictors of FMD (p = 0.004) in multivariate analysis. All results expressed as mean +/- SD. CONCLUSIONS: TSH suppression therapy with LT4 leading to subclinical hyperthyroidism may cause impaired endothelial function, increased oxidative stress, and decreased insulin sensitivity in euthyroid nodular goiter patients.     

Role of endogenous adenosine in atrial fibrillation after coronary artery bypass graft

BACKGROUND: Atrial fibrillation (AF) is the most common complication following coronary artery bypass graft (CABG). The mechanism of AF after CABG is not well defined; however, it is suggested that endogenous adenosine, released in response to tissue hypoxia, may play a mechanistic role in these arrhythmias. HYPOTHESIS: The purpose of this study was to examine whether intravenous theophylline, via adenosine A1 receptor antagonism, would correct or modify new-onset early (<48 h post CABG) atrial fibrillation in patients post CABG, and thereby implicate endogenous adenosine as an inciting agent. METHODS: A prospective double-blind, placebo-controlled study design was applied to 385 consecutive patients with coronary artery disease who had undergone CABG. Any patient who developed AF within 48 h of the operative procedure was randomly assigned to receive 5 mg/kg of intravenous theophylline (Group A) or matched intravenous placebo (Group B). The patients who converted to sinus rhythm within 15 min of drug administration were accepted as showing positive responses. RESULTS: Thirty patients comprised the study group. In Group A, 8 of the 15 patients (53%) converted from AF to sinus rhythm within 15 min of theophylline administration. One patient who converted to sinus rhythm 20 min after theophylline administration was accepted as showing a negative response. In the placebo-treated group, no patient converted to sinus rhythm within 15 min (p<0.007 compared with Group A). CONCLUSIONS: The mechanism of AF after CABG is not well defined and is probably multifactorial. However, this study demonstrated that antagonism of the adenosine A1 receptor can promptly convert many of these patients back to sinus rhythm, and thereby implicates endogenously released adenosine in a mechanistic role for inciting early (<48 h) post-CABG AF.     

Addition of montelukast versus double dose of inhaled budesonide in moderate persistent asthma

BACKGROUND: Although current guidelines suggest the use of inhaled corticosteroids as the first line therapy in persistent asthma, the concerns about high-dose corticosteroids may limit their usage. We aimed to investigate the efficacy of inhaled budesonide plus oral montelukast versus a double dose of inhaled budesonide. METHODOLOGY: Thirty patients with moderate asthma took part in the study. Following a 2-week run in period, the patients were randomized into two groups to receive 400 microg/day of inhaled budesonide plus 10 mg/day of montelukast (BUD + M group) or 800 microg/day of inhaled budesonide (high BUD group). The patients were evaluated at 2-week intervals (during a total treatment period of 6 weeks) for symptom scores, asthma exacerbations, lung function, use of short-acting beta2 agonist, blood eosinophil counts and adverse events. RESULTS: At the end of the study, morning and daytime symptom scores were significantly reduced within the groups. Although there was a significant decrease in the frequency of short-acting beta2 agonist use in the BUD + M group, the decrease in the high BUD group was not significant. During the study period, no patient in either group experienced an asthma exacerbation. Blood eosinophil levels significantly declined in both the BUD + M (0.87 +/- 0.31%) and high BUD groups (0.67 +/- 0.29%) as compared with baseline levels (BUD + M = 2.60 +/- 0.65%, high BUD group = 2.60 +/- 0.47%; P < 0.05). CONCLUSION: Our results suggest that the addition of montelukast to low-dose inhaled budesonide is as effective as a double dose of inhaled budesonide in asthma control.     

Unusual extramedullary relapses under imatinib mesylate treatment in chronic myeloid leukemia

There are at least four distinct African and one Asian chromosomal backgrounds (haplotypes) on which the sickle cell mutation has arisen. Additionally, previous data suggest that the beta(S)/Bantu haplotype is heterogeneous at the molecular level. Here, we report the presence of the (A)gamma -499 T-->A variation in sickle cell anemia chromosomes of Sicilian and North African origin bearing the beta(S)/Benin haplotype. Being absent from North American beta(S)/Benin chromosomes, which were studied previously, this variation is indicative for the molecular heterogeneity of the beta(S)/Benin haplotype.     

Risk factors associated with hospitalizations for asthma attacks in Turkey.

The detection of factors associated with hospitalizations for asthma attacks should have a great value in the development of intervention strategies. However, these factors are unknown in Turkey. Our aim was to investigate the factors associated with hospital admissions by comparing hospitalized patients with the community control asthma patients and the relationships between serum eosinophilic cationic protein (ECP) levels and the disease severity. Eighty-one subjects hospitalized with asthma (69 women and 12 men) and 300 community control asthma patients (227 women and 73 men) were enrolled in this cross-sectional study. A questionnaire including detailed demographic and clinical data was compiled by all patients. Serum ECP levels were measured in 76, 14, and 9 patients of community control, hospitalized asthma patients, and healthy controls, respectively. Hospitalized patients were older and had longer asthma duration (p < 0.001). The significant risk factors for hospital admission for acute asthma attacks were previous severe asthma (odds ratio [OR], 12.26; 95% confidence interval [CI], 5.17-29.0), aspirin (acetylsalicylic acid) and nonsteroidal anti-inflammatory drug intolerance (OR, 3.63; 95% CI, 1.70-7.74), chronic rhinosinusitis (OR, 2.24; 95% CI, 1.16-4.33), lower educational level (OR, 2.24; 95% CI, 1.33-4.18), and lower atopy ratio (OR, 1.99; 95% CI, 1.13-3.50). These parameters were similar in patients who were hospitalized and in patients who had severe asthma of the community control. ECP levels were significantly higher in hospitalized and severe asthma patients compared with healthy controls. In conclusion, the factors associated with hospitalizations were advanced age, prolonged asthma duration, presence of severe asthma, "nonatopy," acetylsalicylic acid-nonsteroidal anti-inflammatory drug intolerance, sinusitis, and lower educational level. Further intervention strategies are needed to address these markers to prevent hospitalizations from asthma attacks.     

Congenital cleft of anterior tricuspid leaflet in adolescent

The diagnostic findings and treatment of an isolated congenital cleft of the anterior leaflet of the tricuspid valve in a 14-year-old boy are described. An atrial septal defect was closed by primary suturing, and the tricuspid valve was successfully reconstructed by De Vega annuloplasty.     

The use of transesophageal echocardiography guidance of thrombolytic therapy in prosthetic mitral valve thrombosis

BACKGROUND AND AIM OF THE STUDY: The aim of the study was to assess the use of transesophageal echocardiography (TEE) to guide thrombolytic therapy in prosthetic mitral valve thrombosis. METHODS: Twenty-nine consecutive cases of prosthetic mitral valve thrombus diagnosed between January 1995 and May 1998 were managed according to data obtained by TEE. Three patients with pedunculated thrombus and five in NYHA functional classes I-II were referred for surgery. Patients who refused surgery or who were in NYHA classes III-IV and had unpedunculated thrombus were selected for thrombolytic therapy. Twenty-one patients (seven males, 14 females; mean age 47 +/- 8 years) received streptokinase for thrombolysis. RESULTS: The mean period from valve replacement surgery was 36 +/- 23 months, and mean time from onset of symptoms 9.2 +/- 14.3 days. Anticoagulant use was inadequate in 18 (86%) patients. Fourteen cases (66%) were NYHA class IV, four (19%) in class III, and three (15%) in class II. Ten patients (48%) were in atrial fibrillation. During the first 24 h of thrombolytic therapy, mean mitral valve peak and mean gradients fell from 25.6 +/- 4 and 13.8 +/- 2.5 mmHg to 11.7 +/- 5.3 and 7.1 +/- 3.1 mmHg respectively (p <0.0001). Five cases with inadequate response to thrombolysis were treated for an additional 24 h. The mitral valve area increased from 1.0 +/- 0.1 cm2 to 2.3 +/- 0.7 cm2 after the first month (p <0.0001). Complete early success in thrombolysis was achieved in 17 (81%) cases, three cases (14%) had partial success, and one case (5%) was referred for surgery on the third day because of failed thrombolysis. Two minor skin bleedings (9%) not requiring transfusion were attributed to thrombolytic therapy. One case (5%) of successful thrombolysis had a non-fatal stroke after therapy and one (5%) was referred for surgery for recurrent prosthetic mitral valve thrombosis at six months' follow up. None of the surgically treated patients died. CONCLUSION: Guidance of thrombolysis by TEE may reduce, but not eliminate, the risk of thromboembolic complications. Response to thrombolysis became apparent within 24 h, but extending treatment beyond this time provided no additional short-term benefit.     

The Influence of Mental and Physical Stress on the Autocapture Function in Children

The Autocapture function detects the evoked response signal (ERS) to verify beat-to-beat capture, and optimizes the output of ventricular pulse amplitude automatically. We had experience concerning the instability of the Autocapture recommendation in some patients. Evoked response is subject to variation as it is a biological event. However, the present knowledge about the Autocapture function lability is very limited. The purpose of this study was to evaluate whether mental stress, body positions or exercise influence the ERS and PS in children.Study was performed in 15 consecutive patients [13.4 ± 4.1 (5–20) year] with VVIR (n = 10) and DDD/VDD pacemakers with the Autocapture function (n = 5), had received ventricular leads including Membrane-E-1450T (n = 6), Membrane-EX-1470T (n = 2), Tendrill-DX-1388T (n = 3), Tendrill-SDX-1488T (n = 1), AV-Plus-DX-1368 (n = 1), Accufix-II-DEC (n = 1) and Vitatron (n = 1), and followed more than six months. Autocapture functions were measured during arithmetic mental stress test (MST), in different body positions, and during symptom-limited treadmill exercise. MST was applied in all except two (5 and 8 year old) who didn't have ability to perform. Activating autocapture was not recommended in only one with Accufix-II-DEC due to high PS.ERS was 10.5 ± 6.3 mV during supine and increased to 11.9 ± 7.5 mV during sitting (p = 0.017) and standing 12.1 ± 7.2 (p = 0.002). However, ERS remained stable before, during and after both exercise and MST, which were 12.6 ± 7.2 mV, 12.8 ± 7.8 mV, 13.6 ± 9.4 mV (p > 0.05) and 10.5 ± 5.5 mV, 10.9 ± 6.7 mV, 10.4 ± 5.5 mV (p > 0.05) respectively. In addition, PS and recommendation about the Autocapture remained unchanged during the study. In conclusion, MST, different body positions and exercise do not have any clinically important influence on the Autocapture function in children.     

The acute cardioprotective effect of glucocorticoid in myocardial ischemia–reperfusion injury occurring during cardiopulmonary bypass

The purpose of this study was to evaluate the acute cardioprotective effect of high-dose methylprednisolone (25 mg/kg) in the controlled in vivo model of myocardial ischemia–reperfusion injury occurring during cardiopulmonary bypass. Forty nondiabetic male patients with three-vessel disease undergoing first-time bypass surgery were enrolled for this double-blind prospective study. Patients were randomized to be given 25 mg/kg methylprednisolone (Group I) and saline (Group II) 1 h before cardiopulmonary bypass. The levels of cardiac troponin-I (cTnI) were used as a marker of myocardial tissue damage in myocardial ischemia–reperfusion injury. The cTnI levels were measured before surgery, at the second hour after cardiopulmonary bypass, at the 6th and 24th hours, and 5th day postoperatively. There was no significant difference between the two groups in respect to the duration of ischemia and reperfusion. The preoperative cTnI levels were 0.22 ± 0.29 ng/ml in Group I and 0.23 ± 0.28 ng/ml in Group II. cTnI levels increased to 2.40 ± 1.0 ng/ml in Group I and 3.19 ± 0.88 ng/ml in Group II at the 2nd hour after cardiopulmonary bypass. When the differences between T1 and T0 level that showed the amount of troponin release occurring due to ischemia–repefusion injury was calculated and then compared, there was a significant difference between Groups I and II (P = 0.024). The cTnI levels measured at 6 h after CPB were 1.98 ± 0.63 ng/ml in Group I and 2.75 ± 1.15 ng/ml in Group II (P = 0.049). cTnI levels decreased to 0.22 ± 0.10 ng/ml in Group I and 0.49 ± 0.25 ng/ml in Group II on the postoperative day 5 (P = 0.0001). Univalent regression analysis showed that preoperative high-dose corticosteroid usage decreased the troponin release in about 12% and this effect was statistically significant (R² = 0.12, P < 0.05). A single dose of intravenous methylpredisolone (25 mg/kg) given 1 h before ischemia reduced myocardial ischemia–reperfusion injury. These results demonstrated that the acute cardioprotective effect of corticosteroids has much potential in the future for reducing ischemia–reperfusion injury occurring during cardiopulmonary bypass when it is inevitable.