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Background and objective: Epidural volume extension via a combined spinal-epidural is the enhancement of a small-dose intrathecal block by an epidural injection of physiological saline solution. We evaluated the effect of epidural volume extension on the combined spinal-epidural technique of providing spinal anaesthesia for Caesarean section with hyperbaric or plain 0.5% bupivacaine. Methods: Patients (n = 240) with height >163cm received 9mg and patients <163cm received 8mg of bupivacaine. Each study drug was combined with 20 μg fentanyl. Using the combined spinal-epidural technique, Group A (n = 60) received hyperbaric bupivacaine, and Group B (n = 60) received hyperbaric bupivacaine and 10 mL saline epidurally 5 mm after subarachnoid injection. Group C (n = 60) received plain bupivacaine and Group D (n = 60) received plain bupivacaine and 10 mL saline epidurally 5 mm after subarachnoid injection. An anaesthetist blinded to the anaesthetic solution injected examined the level of analgesia by the pinprick method and motor block with the modified Bromage scale for 30 mm after subarachnoid injection, during the intraoperative period and subsequently every 15 mm for 135 mm during the recovery period. Results: Time to reach a sensory block at T4 was significantly shorter in Groups C and D than in Groups A (P = 0.003 and 0.017) and B (P = 0.006 and 0.048), respectively. During the intraoperative period, sensory block levels were significantly higher in Group C than in Group A. Recovery was similar in all groups; only onset was faster in Groups C and D. Conclusion: There was no effect of epidural volume extension on the profile of spinal anaesthesia with the combined spinal-epidural technique for Caesarean section using hyperbaric or plain bupivacaine. [ABSTRACT FROM AUTHOR]

A response by S. Kucukguclu, H. Unlugenc and F. Gunenc to a letter to the editor about their article "The influence of epidural volume extension on spinal block with hyperbaric or plain bupivacaine for Caesarean delivery" is presented.

Pemphigus is a group of rare and life-threatening autoimmune blistering diseases of the skin and mucous membranes. Although they occur worldwide, their incidence shows wide geographical variation, and prospective data on the epidemiology of pemphigus are very limited. Objective of this work is to evaluate the incidence and epidemiological and clinical features of patients with pemphigus in Turkey. All patients newly diagnosed with pemphigus between June 2013 and June 2014 were prospectively enrolled in 33 dermatology departments in 20 different provinces from all seven regions of Turkey. Disease parameters including demography and clinical findings were recorded. A total of 220 patients were diagnosed with pemphigus during the 1-year period, with an annual incidence of 4.7 per million people in Turkey. Patients were predominantly women, with a male to female ratio of 1:1.41. The mean age at onset was 48.9 years. Pemphigus vulgaris (PV) was the commonest clinical subtype (n=192; 87.3%), followed by pemphigus foliaceus (n=21; 9.6%). The most common clinical subtype of PV was the mucocutaneous type (n=83; 43.2%). The mean Pemphigus Disease Area Index was 28.14±22.21 (mean ± Standard Deviation). The incidence rate of pemphigus in Turkey is similar to the countries of South-East Europe, higher than those reported for the Central and Northern European countries and lower than the countries around the Mediterranean Sea and Iran. Pemphigus is more frequent in middle-aged people and is more common in women. The most frequent subtype was PV, with a 9-fold higher incidence than pemphigus foliaceus.

Hermansky-Pudlak Syndrome (HPS) is a rare autosomal recessive disorder presenting with oculocutaneous albinism, bleeding diathesis and lysosomal accumulation of ceroid lipofuscin which leads to interstitial fibrosis in lung. Pulmonary fibrosis which is usually associated with HPS-1 and HPS-4 subtypes usually manifests in the third/fourth decades of life representing with giant lamellar bodies of alveolar type-II-cells and their apparent degeneration causes restrictive lung disease. Pulmonary manifestation of this syndrome may lead to premature death. Pulmonary Alveolar Proteinosis(PAP) is another rare disease characterized by alveolar deposition of surfactant phospholipids and proteins secondary to defective clearance by alveolar macrophages. PAP may occur as autoimmune diseases and/or secondary to toxic inhalation, systemic infections or hematological disorders. None of the cases were reported secondary to HPS according to the best our knowledge. As well, pulmonary involvement of HPS was never reported as PAP. We report the first case of PAP in a patient with HPS.

As psoriasis is a common skin disorder, knowledge of the factors that may induce, trigger, or exacerbate the disease is of primary importance in clinical practice. Drug intake is a major concern in this respect, as new drugs are constantly being added to the list of factors that may influence the course of the disease. We report a patient with a psoriasiform drug eruption associated with the use of sodium valproate. Physicians should be aware of this type of reaction. Early detection of these cases has practical importance since the identification and elimination of the causative drug are essential for therapy success.

Background: In a dermoscopic examination, besides structural components, inexperienced clinicians should also be able to recognize the gross features of the images., Aim: The aim of this study is, whether or not an inexperienced clinician has problems in the recognition of gross features of the images on dermoscopic examination., Methods: Two dermatologists, of whom one was experienced in the field of dermoscopy and the other was not, examined 161 dermoscopic images of melanocytic lesions in the gross features of their borders. Inner and outer borders were defined for each lesion. Both dermatologists separately evaluated the borders of the lesions for irregularity, asymmetry, and wideness of fading. For subjective image analysis they scored each lesion by using the four-point ordinal scale. For computerized image analysis they manually marked borders with dots, by using a computer program. We used quadratic-weighted kappa for interobserver reliability assessments for subjective scores and intraclass correlation coefficients (ICC) for automatically calculated scores., Results: In a subjective evaluation the inexperienced observer used a higher score than the experienced observer and the kappa values were between 0.241-0.286. ICC for the automatically calculated scores were between 0.357 and 0.522. According to both the outer and the inner borders, the concordance between experienced and inexperienced observers was almost perfect in measurements of diameter, perimeter, and area (ICC scores were between 0.948 and 0.990)., Conclusions: An inexperienced person, in comparison with an experienced person, sees lesions in the same sizes, but in different shapes on dermoscopy. Therefore, it is advisable that making learners familiar with the borders of lesions should be included in the training on dermoscopy.

Hair coloring with henna has been popular in Turkey for years. In recent years since the tattoos are applied by the street vendors in most of the beach places in Turkey, skin coloring with henna has also increased. Henna can be used alone or in combination with other coloring agents. Henna alone can be safe but due to additives such as para-phenylenediamine (PPD), p-toluenediamine and various essential oils, allergic contact reactions may occur. We report a 22-year-old man who developed severe inflammatory and keloidal, moderately bullous allergic reaction after henna paint-on tattoo. We did a patch test separately with these painting products (henna powder, PPD) and with the European standard series. PPD was strongly positive (+++) on day 2 and remained positive for following days. After treating with topical clobetasol-17 butyrate, resolution was obtained in two weeks. But some keloidal reaction remained.

The clinical ABCD criteria are still recommended to both physicians and laymen when checking moles. The aim of this study was to determine the level of interrater reliability and therefore objectivity in rating for one of these criteria, namely border irregularity. Five professors, five residents, five nurses, and 10 students rated a set of 54 clinical images of pigmented skin lesions for border irregularity. After a descriptive presentation, rating was again carried out on another set of 54 images. In all groups, the agreement was moderate or substantial before the presentation and increased after the presentation. An almost perfect agreement was achieved by the professors after the presentation. Although both experience and receiving information could increase the level of interrater reliability, the disagreement was usually sufficient to suggest subjectivity in rating for border irregularity.

Background: The purpose of this study was to describe the epidemiological and clinical features, course, response to treatment, and prognosis of pemphigus in the Mediterranean region of Turkey., Methods: All patients with confirmed pemphigus were prospectively enrolled in two major dermatology departments in the cities of Adana and Antalya in the Mediterranean region between March 1998 and March 2004. Details including demography, findings of clinical examinations, treatment, course, and prognosis were recorded., Results: One hundred and forty-eight patients with pemphigus were diagnosed during the 6-year period, with a prevalence of 1.46 and an annual incidence of 0.24 per 100,000 in this region. There was a female predominance with a male to female ratio of 1:1.4. Pemphigus vulgaris (PV) was the most common clinical subtype, identified in 123 patients (83%). The mean age of onset was 43. In 101 (82%) patients with PV, disease began as persistent oral ulcers. The majority of the patients with PV could be managed with middle or high-dose steroids (60-140 mg/day). Complete clinical remission was obtained in 41 (39.4%) patients. The mortality rate was 4.8%., Conclusions: A moderately high incidence of pemphigus was found in the Mediterranean region of Turkey as compared with that encountered in other countries. The commonest clinical subtype was PV with a 9.5-fold higher incidence than pemphigus foliaceus. It is more frequent in middle-aged people and has a female predominance. Although a relatively higher dose of steroid was needed to control the PV, the disease completely remitted in a significant proportion of the patients.